rOLUMBIA LIBRARIES OFFSITE '^HEALTH SCIENCES STANDAHD HX64064344 RD571 T38 surgical diseases an \ 1 I RECAP . ll!ir.i:'t!'i.;:;ii:!!Hiiilfi.tllliI!IIHUli:!:ill!'.i!IM!lllli!ii;;ll!i H|ll:[:,|:i!IHl r i-i o M s oN,:„:,„„;^VAL k e r Kps-y/ Tse intl)fCttpoflfttigork CoUese of $t)?s>ictan£( anb ^urgeond Hibrarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/surgicaldiseasesOOthom SURGICAL DISEASES AND INJURIES OF THE GENITO-URINARY ORGANS Surgical Diseases and Injuries of the Genito -Urinary Organs By J. W. Thomson Walker M.B., C.M.Ed., F.R.C.S.Eng. Hunterian Professor of Surgery and Pathology, Royal College of Surgeons of England (1907) ; Surgeon to the Hampstead General and North-West London Hospital; Assistant-Surgeon to St. Peter's Hospital for Stone; Urinary Surgeon to the Radium Institute. With 24 Colour and 21 Black-and-White Plates, and 279 Illustrations in the Text NEW YORK FUNK & WAGNALLS COMPANY t .z- 3: T PREFACE In the following pages I have given an account of the diseases and injuries of the urinary system, and of the male genital system, which I hope will prove of value to members of the profession engaged in general practice, and may also assist those on the threshold .of a surgical career. A textbook should reflect the current opinion of the day, and should at the same time bear the impress of the experience and individual views of the author. I have endeavoured to give each its proper place in this volume. For the benefit of those anxious to obtain a more extensive knowledge of any subject, a few references to recent articles from the literature of different countries have been provided. Many valuable articles have of necessity been omitted from these lists, but references to these may be obtained through the channels I have quoted. In writing these pages I have drawn largely on my own expe- rience and have referred to many personal cases. Many procedures which are of merely historical interest have been omitted, and space has thus been found for a more adequate discussion of modern methods. The claims of a pathological as opposed to an anatomical classification of diseases have received full consideration. I decided to retain the anatomical classification for the reason that this work lays no claim to be a purely scientific treatise on VI PREFACE the diseases of tlie genito-urinary organs, but is intended to serve as an aid to clinical work; and my personal experience of using textbooks arranged in the anatomical and in the pathological classification is that it is easier to refer to the former in an obscure case than to the latter. In recent works there is observable a tendency to slur over the science and to make prominent the art of urinary surgery. With this I am not in sympathy. It is, I believe, impossible to carry out good work on a superficial knowledge of the patho- logical conditions with which the surgeon has to deal. The pathology given in the following pages is not the pathology of the post-mortem room. It is the Hving pathology met with by the surgeon in the operating theatre, and, as such, is of vital importance to proper treatment. Special attention has been paid to both the immediate and the late results of operation, and, whenever possible, reliable statistics in regard to these have been given. This will, I hope, prove of value to the practitioner in considering the question of prognosis. The illustrations, with very few exceptions, are from cases that have been imder my care, or from specimens that have been removed by operation. Professor A. K. Ferguson, of Cairo, generously provided a series of beautiful microscopical sections illustrating bilharziosis, from which Pigs. 121, 122, and 123 were drawn. To him and to Professor F. C. Madden, who also helped me in this section, I wish to express my warmest thanks. The cystoscopic drawings are, I believe, of exceptional value. They were obtained direct from the patient, and are chosen from a large collection made during a number of years. For these and for manv other illustrations I have to thank the PREFACE vii patience and skill of Mr. Thornton Shiells. To Dr. G. Dupuy my thanks are due for his skilful realism in drawing the ilhistrations of operations. I have to express my gratitude to my friend Sydney G. MacDonald, F.R.C.S., who undertook the arduous task of reading proofs, and to whom I am indebted for many valuable suggestions. To my publishers I ofier my especial thanks for the generous enthusiasm with which my suggestions in regard to the illustra- tions of the volume were adopted, and for their forbearance in many delays. J. W. THOMSON WALKER. Jantiary, 1914. CONTENTS Part I. — The Kidney CIIAP'TER 1. Surgical Anatomy ....... 2. Physiology and Pathology of the Renal Function 3. Examination of the Kidneys ..... 4. Abnormal Conditions of the Urine 5. Congenital Abnormalities of the Kidney and Ureter 6. Movable and Floating Kidney .... 7. Injuries of the Kidney ...... 8. Aneurysm of the Renal Artery . . . . .9. Perinephritis and Perinephritic Abscess 10. Surgical Inflammation of the Kidney and Pelvis 11. Surgical Inflammation of the Kidney (concluded) ..... 12. Hydronephrosis .... 13. Tumours of the Kidney and Ureter 14. Cysts of the Kidney 15. Perirenal and Suprarenal Tumours 16. Infective Diseases .... 17. Renal Calculus .... 18. Calculous Anuria .... 19. Oper.\tions on the Kidney ix AND Pelvis I 10 31 47 67 78 96 109 III 116 138 164 186 207 220 226 249 278 284 X CONTENTS Part II.— The Ureter CHAPTER 20. Surgical Anatomy — Physiology — Examination 21. Injuries of the Ureter . . . . . . 22. Congenital Abnormalities of the Ureter — Prolapse — Fistula ........ 23. Stone in the Ureter . . . . . 24. Operations on the Ureter ..... PAGE 299 ^.08 312 334 Part III.— The Bladder 25. Surgical Anatomy and Physiology 26. Examination of the Bladder . z^j. Methods of collecting the Urine THE Function of each Kidney 28. Vesical Symptoms of Disease . 29. Congenital Malformations 30. Cystocele — Prolapse — Diverticula 31. Injuries of the Bladder 32. Cystitis ..... 33. Tuberculous Cystitis 34. Other Infections of the Bladder 35. Tumours of the Bladder 36. Vesical Calculus 37. Foreign Bodies in the Bladder 38. Pericystitis and Perivesical Abscess 39. Fistula of the Bladder and Perivesical Hydatid Cysts . . . . . . . 40. Nervous Diseases of the Bladder . . . . 41. Operations on the Bladder , . . . . AND examining 344 352 367 374 392 405 416 423 437 445 454 490 514 517 522 531 541 CONTENTS Part IV.— The Urethra CHAI'TEK 42. Surgical Anatomy . . . • . ... 43.- Examination of the Urethra — Urethral Shock- Urethral Fever ..... 44. Congenital Malformations of the Urethra 45. Prolapse of the Urethra — Urethrocele 46. Injuries of the Urethra 47. Urethritis ..... 48. Urethral Calculus — Foreign Bodies 49. Stricture of the Urethra 50. Periurethritis — Urethral Fistula . 51. Growths of the Urethra 52. Tuberculosis of the Urethra and Penis XI I'Acnc 555 569 585 588 595 618 623 647 656 665 Part v.— The Prostate 53. Surgical Anatomy — Examination — Congenital Mal- formations ..... 54. Prostatitis ..... 55. Tuberculosis of the Prostate 56. Simple Enlargement of the Prostate 57. Atrophy of the Prostate 58. Malignant Disease of the Prostate 59. Calculus of the Prostate 667 677 685 690 728 731 739 Part VI. — The Seminal Vesicles and Cowper's Glands 60. Anomalies and Affections of the Seminal ^^esicles — Cowper's Glands ...... 744 xii CONTENTS Part VII.— The Testicle CHAPTER 6i. Anatomy and Malformations — Injuries and Wounds — Torsion . . ... 62. Congenital Malposition — Imperfectly Descended Testicle — Ectopia Testis .... 63. Inflammation of the Epididymis and Testicle 64. Syphilis of the Epididymis and Testicle 65. Tuberculosis of the Epididymis and Testicle 66. New Growths of the Testicle 67. Impotence and Sterility . 753 761 771 778 781 789 797 Part VIII. — The Tunica Vaginalis 68. Hydrocele and Hematocele — New Growths . . 800 Part IX. — ^The Spermatic Cord 69: Volvulus — Hydrocele and Hematocele — New Growths — Varicocele . . . . . . 819 Part X. — The Scrotum 70. Elephantiasis — New Growths 828 Part XL— The Penis 71. Anatomy — Congenital Malformations — Injuries— Preputial Calculi ...... 834 72. Balanitis— Herpes Preputialis — (Edema of Penis — Priapism — Fibrous Cavernositis — ^Tumours . 844 INDEX . . . 863 LIST OF PLATES FACING I'AHK Plate 1 .......... 38 Fig. I. — Shadow thrown by Gall-Stone in Renal Area. Fig. 2. — Shadows thrown by Bismuth-covered F^ces. Fig. 3. — Shadow thrown by Intra-Abdominal Cal- careous Glands. Plate 2....... -..42 Fig. I. — Pyelography : Injected Pelvis showing DicHOTOMOus Outline and Calyces. Fig. 2. — Pyelography : Collargol which has regurgi- tated INTO Bladder. Fig. 3. — ^Pyelography in Movable Kidney. Plate 3 . . . . . . .. . > -44 Fig. i. — Dilated Calyces in Ureteral Calculus. Fig. 2. — Hydronephrosis caused by Aberrant Renal Vessels. Fig. 3. — Hydronephrosis (Pelvic Type) in Movable Kidney. Plate 4 . . . . . . . . . .45 Fig. I. — ^Double Hydronephrosis. Fig. 2. — Pyelography : Normal Trumpet-shaped Pelvis and Calyces. Fig. 3. — Pyelography : Normal Trumpet-shaped Pelvis AND Calyces. Plate 5 (Colour) ......... 58 Fig. I. — Hematuria: Blood-stained Efflux from Left Ureter. Fig. 2. — Semi-solid Pus issuing from Ureter in Case of Chronic Suppurative Pyelonephritis. Plate 6 [Colour) . , , , . . . . .128 Ascending Pyelonephritis in Case of Enlarged Pros- tate. * xiii xiv LIST OF PLATES FACING PAGE Plate 7 {Colour) . . . . . . . . ' . 132 Dilatation of Renal Pelvis, Pyelitis, and Suppurative Nephritis in Enlarged Prostate, Plate 8 .......... , 156 Fig. I. — Shadows of Large Calculus in Kidney and Number of Small Calculi lying in Sponta- neously-formed Fistula. Fig. 2. — Hydronephrosis due to Adhesions round Vertebra in Scoliosis. Plate 9 ' . . . . . . . . . . 176 Fig. I. — Author's Method of determining Normal Extent of Renal Areas on Radiographic Plate. Fig. 2. — Method of measuring Shadow of Kidney. Fig. 3. — Shadows thrown by Metastatic Deposit in Mediastinal Glands and in Lungs in Case of Malignant Growth of Kidney. Plate 10 [Colour) . ....... 192 Hypernephroma of Kidney. Plate 11 {Colour) ........ 192 Section of Hypernephroma of Kidney. Plate 12 {Colour) . . . . . . ... 222 Hypernephroma of Suprarenal Capsule invading Kidney. Plate 13 {Colour) . . . . . . . . 228 Tuberculosis of Kidney, Ulcero-Cavernous Type. Plate 14 {Colour) ........ 228 Acute Tuberculosis of Kidney with Mixed Infection Plate 15 {Colour) ........ 230 Tuberculosis of Kidney, Final Stage : Tuberculous Hydronephrosis. Plate 16 {Colour) ........ 234 Fig. I. — Ureteric Orifice in Chronic Pyelitis. Fig. 2. — Tuberculous Ulceration of Ureteric Orifice. Fig. 3. — Dragged-out Ureter in Chronic Tuberculous Ureteritis. Plate 17 . . . . . = . . . . 236 Shadow thrown by Caseous Tubercle of Left Kidney. LIST OF PLATES xv r-ACING TAtiK Plate 18 (Colour) 254 Multiple Calculi of Kidney. Plate 19 (Colour) 256 Renal Calculus ; Dilatation of Renal Pelvis and Pyelitis ; Invasion and Destruction of Kidney by Hypertrophy of Fat in Renal Sinus. Plate 20 264 Fig. I. — Shadows of Large Branching Calculus and OF Two Smaller Calculi in Kidney. Fig. 2. — Shadow of Calculi in Right Kidney, with Clear Field in Left Kidney Area. Plate 21 306 Fig. I. — Opaque Bougie in Ureter. Fig. 2. — Shadow of Calculus in Ureter at Brim of Pelvis. Fig. 3. — Shadows of Opaque Bougies lying in Double Ureter. Plate 22 (Colour) . . 328 Fig. I. — Prolapse of Ureters. Fig. 2. — Right Ureteral Orifice in Descending Ure- teral Calculus (Infected). Fig. 3. — Descending Ureteral Calculus (Non-Infected). Fig. 4. — E version of Ureteral Orifice Twenty Minutes AFTER Expulsion of Calculus into Bladder. Fig, 5. — Uric- Acid Calculus partly extruded from Ureteral Orifice. Fig. 6. — Acute Ureteritis in Descending Calculus. Fig. 7. — False Ureteral Orifice produced by Ulcera- tion OF Calculus from Ureter into Bladder. Plate 23 ......... . 330 Fig. i. — Two Calculi in Right Ureter. Fig. 2. — Oval Calculus in Pel\t:c Segment of Right Ureter. Plate 24 . . . . . . . . . . 331 Fig. I. — Shadows in Pelvis due to Calcareous Glands. Fig. 2. — Shadows thrown by Calcareous Glands in Region of Pelvis and Ureter on Right Side. Fig. 3. — Shadow thrown by Calcareous Gland outside Line of Right Ureter. xvi LIST OF PLATES FACING PAGE Plate 25 ......... . 332 Fig. I. — Shadows thrown by Calcareous Glands below AND internally TO LeFT KiDNEY. Fig. 2.— Shadow of Large Oval Calculus in Pelvic Segment of Left Ureter, and of Opaque Bougie lying beside it. Fig. 3. ^Calculus in Pel\t:c Segment of Ureter, and Opaque Bougie lying in Ureter. Plate 26 ......... . 333 Fig. i. — Ureteral Calculus lying in Pelvic Segment, Cystoscope in Bladder, and Opaque Bougie IN Ureter. Fig. 2. — ^Two Calculi lying at Lower End of Right Ureter. Plate 27 360 Fig. i. — Shadow thrown by Partly Distended Healthy Bladder. Fig. 2. — Shadow of Greatly Distended Bladder and of Diverticulum ; Catheter lying in Urethra. Fig. 3. — Shadow of Ureteral Calculus in Middle Line OF Bladder. Plate 28 361 Fig. I. — Shadow of Phosphatic Calculus in Bladder pushed to Right of Middle Line by Large Growth on Left Side of Bladder. Figs. 2, 3. — Calculus in Bladder which was moved to Left of Middle Line from Patient lying on Left Side. Plate 29 362 Fig. I. — Shadow of Large Phosphatic Calculus in Diverticulum of Bladder. Fig. 2. — Shadows in Pelvis. Fig. 3. — Diverticulum of Bladder. Plate 30 {Colour) ......... 412 Fig. I. — Orifice of Diverticulum and Trabeculation ON Posterior Wall of Bladder. Fig. 2. — Orifice of Large Diverticulum of Bladder CLOSE TO Right Ureteral Orifice. Fig. 3. — Partial Rupture of Bladder : Appearance of Mucous Membrane Six Days after Accident. LIST OF PLATES xvii FACING PACE Plate 31 (Colour) ......... 426 Fig. i.^ — Acute Cystitis. Fig. 2. — Cystic Cystitis. Fig. 3. — Ulcer of Bladder in Cystitis due to Bacillus coLi communis. Fig. 4. — Tuberculosis of Bladder : Group of Caseous Tubercles. Fig. 5. — Tuberculous Ulcer with Caseous Tubercles in Vicinity. Plate 32 (Colon i^) 446 Fig. i. — Bilharzial Nodules in Bladder. Fig. 2. — Bilharzial Granulations in Bladder. Fig. 3. — Villous Papilloma of Bladder. Plate 33 ......... . 472 Figs, i, 2, 3. — Views of Operation Specimen of Malig- nant Growth of Bladder (Nodular Papilloma). Fig. 4. — Recurrence of Malignant Growth of Bladder IN Scar of Resection Wound. Plate 34 . ......... 473 Operation Specimen of Squamous Epithelioma of Bladder. Plate 35 (Colour) ........ 47S Fig. I. — Nodul.ar Malignant Growth of Bladder. Fig. 2. — Nodular Malignant Growth of Bladder with Necrotic Surface. Fig. 3. — Small Nodular Malignant Growth of Bladder. Plate 36 (Colour) ........ 500 Fig. i. — Large Phosphatic Calculus with Cystitis. Fig. 2. — Uric- Acid Calculi covered with Thin Layer OF Phosphates. Fig. 3. — OxALATE-OF-LiME Calculi in Bladder. Plate 37 504 Fig. i. — Shadow of Calculus in Grasp of Lithotrite. Fig. 2. — Shadow of Evacuating Cannula. Plate 38 (Colour) . . . . . . . -514 Fig. i. — Stud - Buttoner covered with Phosphatic Deposit in Male Bladder. Fig. 2. — DouBLED-up Piece of Wax in Male Bladder. Fig. 3. — Atrophy of Bladder Wall in Tabes Dorsalis. xviii LIST OF PLATES FACING PAGE Plate 39 . . . . . . . ... 590 Fig. I. — Pelvic Shadow after Fracture of Pelvis and Rupture of Urethra. Fig. 2. — Stone in Fossa Navicularis of Urethra. Plate 40 {Colour) ........ 626 Fig. I. — ^Lacun^ and Striation of Roof of Normal Urethra. Fig. 2. — Scar Tissue in Urethra in Old-standing Stric- ture. ■ Fig. 3.^Urethroscopic View of Stone behind Stricture OF Urethra. Fig. 4. — Urethroscopic View of Stricture with Large False Passage on Floor and another on Roof of Urethra. Plate 41 {Colour) ........ 660 Fig. I.— Papilloma of Anterior Urethra. Fig. 2. — Polypus of Posterior Urethra attached to Premontanal Ridge. Fig. 3. — Urethroscopic View of Polypus of Urethra. Fig. 4. — Malignant Growth of Anterior Urethra appearing through a Stricture. Plate 42 ......... . 742 Fig. I. — Shadow of Large Single Prostatic Calculus. Fig. 2. — Shadows of Small Irregular Scattered Pros- tatic Calculi. Plate 43 {Colour) ........ 778 Gumma of Testicle ulcerating on Surface of Scrotum. Plate 44 {Colour) . . . . . . . . 782 Tuberculosis of Epididymis with Tuberculous Abscess under Skin of Scrotum and Miliary Tubercle OF Testicle. Plate 45 {Colour) ........ 792 Solid Embryoma of Testicle ; Operation Specimen. SURGICAL DISEASES AND INJURIES OF THE GENITO-URINARY ORGANS PART L—THE KIDNEY CHAPTER I SURGICAL ANATOMY Situation of the kidney. — The kidneys lie obliquely on the posterior wall of the abdomen, the upper end of each being 2| cm., the hilum 3J cm., and the lower pole 4 cm. from the middle line. The anterior surface has an antero -external aspect. The upper border of the kidney corresponds to the middle of the 11th dorsal vertebra, and the lower border to the lower border of the transverse process of the 3rd lumbar vertebra about 5 cm. above the iliac crest. The left kidney reaches to the upper border of the same process. The hilum of the kidney corresponds to the 2nd lumbar vertebra. The upper two-thirds of the kidney lies under cover of the 11th and 12th ribs, the lower one-third descends below them. The 12th rib may, rarely, be absent ; it may be short and only come into relation with a small part of the posterior surface of the kidney, or it may be long and project beyond it. A short 12th rib, less than 7 cm. long, is always horizontal ; a longer rib is oblique. Relations of the kidney (Figs. 1, 2). — The posterior rela- tions are the diaphragm, and the anterior layer of the trans- versalis aponeurosis which separates it from the quadratus lumborum muscle. A strong process of this aponeurosis, the costo-vertebral ligament, reaches from the tips of the transverse processes of the 1st and 2ud lumbar vertebrae to the 12th rib. Between the fibres of origin of the diaphragm from the external arcuate ligament and the r2th rib the pleura is uncovered and comes into relation with the kidney. The psoas muscle is . also THE KIDNEY [chap. related to a small part of the kidney at its lower pole. The more important structures met with in exposing the kidney from the lumbar aspect are as follows : the skin, subcutaneous fascia and fat, the latissimus dorsi muscle and the external oblique, the serratus posticus inferior, internal oblique, the lumbar fascia, the 12th intercostal nerve and vessels, the perirenal fascia and perirenal fat. The anterior surface of the right kidney is covered by peri- toneum along the outer border and upper part of its surface. At the upper part it is in relation to the under surface of the right SHORT /Z'^^RIB £XT£RN/iL /^RCU/^TE LIG/iMENT QU/iDRATUS I UMBO RUM ILIAC CREJT 'ERE.CTOR SPINA E Fig. 1. — Diagram of the general relations of the kidneys. lobe of the liver and internally to the vena cava. The hepatic flexure of the colon crosses the lower one-third and is adherent to it. In this situation a nephro-colic ligament has been de- scribed. The descending part of the duodenum is in direct contact with an area along the inner border, and the common bile-duct is in close relation to the inner border of the organ. In relation to the anterior surface of the left kidney, and separated from it by peritoneum, are the stomach and spleen, the former lying in con- tact with the upper pole and the latter with an area along the outer border. Below the stomach area the tail of the pancreas and the splenic artery are in contact with the kidney. The duodeno-jejunal junction is related to the inner border at the region of the hilum. Below this the splenic flexure of the colon Ij SURGICAL ANATOMY crosses the kidney and passes down its outer border, and tlie left colic artery lies upon its anterior surface. It is attached to the diaphragm above and outside the kidney by the phreno-colic ligament. At the lower pole, iu' the angle formed by the flexure of the colon, the coils of small intestine are separated from the kidney by peritoneum. The suprarenal capsules are in contact with the upper pole of each kidney and attached to it by areolar tissue. The con- nection is not very firm in normal kidneys, and diminishes with age ; in disease of the kidney it may be densely adherent. Diagram of the anterior relations of the kidneys. 1 and 2, Peritoneum-covered surface of right kidney in apposition with liver and with small intestine ; 3 and 5, peritoneum-covered surface of left kidney in apposition with stomach, with spleen, and with small intestine ; 6, duodenum ; 7, duodeno-jejunal junction ; 8, hepatic flexure of colon; 9, ascending colon; 10. splenic flexure; 11, descending colon; 12, attachment of transverse mesocolon; 13, suprarenals ; 14, gastric surface of spleen; 15. splenic vessels; 16, pancreas ; 17, inferior vena cava ; 18, aorta ; 19, superior mesenteric artery ; 20, superior mesenteric vein ; 21. ureters. Investment of the kidney. — The kidney lies embedded in a layer of fine fat, the fatty capsule, contained in a fascial en- velope, the fascia propria or perirenal fascia. (Figs. 3, 4.) The perirenal fascia appears between the transversalis fascia and peri- toneum, and divides into an anterior and a posterior layer at the border of the kidney. The anterior layer covers the front of the kidney and crosses the middle line to join the corresponding layer of the opposite side, passing in front of the abdominal aorta and inferior vena cava. A thin layer splits off at the hilum and covers the renal blood-vessels. The posterior layer, or fascia of Ziicker- kandl, lies behind the kidney, and, after sending a layer to the THE KIDNEY [chap. PLEURA ■DMPHRAdM renal vessels, passes on to be attached to the sides of the bodies of the vertebrae. At the upper pole of the kidney the layers unite after having enclosed the suprarenal capsule, and are attached to the under surface of the diaphragm, forming a suspensory ligament. At the lower pole the anterior layer is continued onwards, lining the peritoneum, and the posterior layer is gradually lost in the extraperitoneal fat without uniting with the anterior layer. The perirenal fascia thus forms an envelope which is open on its internal and inferior aspects. It is strengthened by an additional covering of fascia, the fascia of Toldt, which is dis- tributed between the fascia propria and the hepatic flexure of the colon and the de- scending part of the duodenum on the right side, and the splenic flexure of the colon on the left side. The kidney is im- mediately surrounded by a fine layer of fibrous tissue in which are some non-striped muscle fibres. This capsule passes in at the hilum to become continuous with the outer layer of the pel- vis of the kidney, and also invests the renal SUPRARENAL CAPSULE POSTERIOR. LAYER Of PERIREHAL FASCIA ILI^C CREST PERITONEUM ANTERIOR LAYER OF PERIRENAL FASCIA KIDNEY Fig. 3. — Diagram of the arrangement of the perirenal fascia in vertical section. vessels. The capsule is easily stripped from the kidney as far as the hilum. From the outer surface of this capsule a network of fine fibres passes out in all directions to the perirenal fascia. In the meshes of this is deposited a layer of fine yellow fat — the fatty capsule — forming a bed in which the kidney lies. This layer is thicker over the posterior and outer aspects of the kidney. It does not exist before the tenth year. Structures at the hilum. The renal pelvis (Fig. 5). — At the level of the lower end of the kidney the ureter begins to expand into a trumpet-shaped extremity which passes the hilum Ij SURGICAL ANATOMY and enters the sinus of the kidney. This is the renal pelvis. At the junction with the urc^ter a narrow part may frequently be POSTERIOR. L/^YEH OF P£R/R£N/tL FASCIS Fig. 4. — Diagram of the arrangement of the perirenal fascia in transverse section at the level of the 2nd lumbar vertebra. seen. As it passes upwards the pelvis usually separates into two primary divisions — a smaller upper and a larger lower branch — and each of these separates into three or more subdivisions, /INTERIOR CALYX POSTERIOR C/^LYX POSTERIOR. BRANCH OF ARTERY VEIN ARTERY Fig. 5. — Diagram of the arrangement of the structures at the hilum in transverse section of the kidney. called calyces (average number, nine), which receive the apices of the pyramids of the kidney on which open the large collecting THE KIDNEY [CHAr. Fig. 6. — Tracings from collargol shadow- graphs showing different types of renal pelvis and variation in calyces. {See Plate 2, Fig. 1, and Plate 4, Figs. 2, 3.) «, Dichotomous pelvis ; 6, simple pelvis ; c, compound branching pelvis. tubes. Each calyx surrounds two or sometimes tliree papillie. The calyces are arranged in an anterior and a posterior series. Modifications of the primary division are not uncommon. (Fig. 6.) The average capacity of the renal pelvis is about 3| drachms. Distension of 2 drachms or less in the living subject causes pain {see p. 176). ^^^^ ^L^ The renal artery ,^^K ^tL ^^^- 7). — The left ^^^^M ^k ^^^ artery is 1 cm. shorter ^^Bw ^^^^^ ^L^^^k than the right. Small ^V ^^^^^^^ yH^^^^^ branches are given o:S ^^ ■ . ^^1^^^^ ^^^^^^ from the main trunk |fl^^ ^^^ I Ti ■ or the primary divi- i^^w WT I I sions, which pass to a h , the fatty capsule and form a network round the kidney. At the hilum the renal artery divides into three or four branches. Two or three of these pass into the sinus in front of the pelvis, and one passes behind it : one of the anterior branches passes to the upper pole and may reach it directly without entering the hilum. The retropelvic branch passes over the upper border of the pelvis and runs down- wards under the edge of the posterior lip of the hilum. The branches further subdivide and enter the kidney at the columns of Bertini between the pyramids, each pyramid being surrounded by four or five arteries. These run alongside the pyramids and curve towards the base of the pyramid. The arteries do not anastomose either at the base or around the pyramids. The arterial supply is divided into an anterior and a posterior system, which are independent, and each branch of which is a terminal artery. The anterior system is larger than the posterior, which is formed by the single posterior primary branch. The arteries of the kidney communicate on the surface of the organ with those of the adipose capsule, and through these with the diaphragmatic, lower intercostal, and lumbar arteries. This anas- tomosis with parietal arteries is not sufficient to carry on an adequate blood supply if the renal artery is blocked. An additional renal artery is present in about 20 per cent, of bodies. The accessory artery may arise from the trunk of the renal artery, from the aorta, or from one of the parietal arteries, such as the inferior phrenic. The vessel may pass into the kidney 1] SURGICAL ANATOMY at the hiluni, or it may enter the surface of the kidney at the upper or lower pole on either the anterior or posterior surface. Such a vessel is more frequent on the left side and above the normal renal artery. An abnormal renal artery may pass in front of or behind the ureter. When the kidneys are abnormal in shape and position an abnormal blood supply is very common. Irregu- larities in the veins are also common. The surgical importance of these abnormalities lies in the facts that in nephrectomy an abnormal vessel may escape ligature and cause serious hsemor- ANTERIOR REN/^L y£/NS ANTERIOR. BRANCHES Of RENAL ARTERY FAT IN SINUS OF KIDNEY POSTERIOR POSTERIOR BRANCH OF RENAL ARTERY PELyiS OF KIDNEY Fig, 7. — Diagram of the relations of the veins, arteries, and pelvis at the hilum of the kidney. A cornice of kidney tissue has been cut away to display these structures. rhage, and that hydronephrosis may result from pressure of the vessel on the ureter. In my experience, an aberrant artery, the size of a crow-quill, passing to the upper pole, is very commonly met with in performing uephrectom3^ The artery is derived from the suprarenal or phrenic artery. On the surface of the kidney the area corresponding to each pyramid is usually marked out by lines of paler colour, and a depressed line can be seen running parallel to the convex border a little in front of its most prominent part. This is BrodeFs THE KIDNEY [OHAP. line, and, with the other pale areas, it indicates the lines along which the arteries course. Brodel's line is the most vascular part of the kidney, and should for this reason be avoided in incising the organ. The least vascular line is that which separates the anterior and posterior arterial systems and runs parallel to and a little behind the curved border. This is the exsanguine line of Hyrtl, and is the best line for nephrotomy incision. The rena! veins (Fig. 7). — The small renal veins are col- lected by large anastomosing venous arches running parallel with the surface of the kidney. The veins emerge from the kidney Fig. 8. — Diagram of the lymphatic vessels and glands of the kidneys, showing their relations to the blood-vessels. substance between the papillye of the pyramids and anastomose between the calyces. Numerous branches then combine to form two large trunks in front of the pelvis. These and a smaller posterior branch unite to form the renal vein. The left renal vein receives the spermatic or ovarian vein. Lymphatics of the kidney (Fig. 8). — The lymphatics are col- lected into four to seven large trunks, which emerge at the hilum. They pass partly in front of the vein and partly behind it, to glands lying in front of and behind the vena cava on the right side, and alongside the aorta on the left side. In their course they run in a sort of mesentery between the layers of the fascia to the glands. This extends from the inner border of the kidney and the ureter I] SURGICAL ANATOMY 9 on the outer side to the aorta on the left and the inferior vena cava on the right (Gregoire). They do not anastomose with neigh- bouring lymphatic plexuses. The glands earliest aft'ected in malignant di.sease of the kidney are found at the hilum and lying along the side of the aorta between it and the spermatic vein, and along the vena cava. These glands lie in small numbers above the renal vessels and in larger numbers below them. The mediastinal glands are then the seat of deposit. The renal pedicle. — The pedicle of the kidney consists of the renal vein, the renal artery, the lymphatic vessels, and the nerves, together with a varying amount of fat. The pedicle is about 4 cm. long. It is shorter on the right side than on the left. It is longer in kidneys which lie low down and in those which show foetal lobulation. When the kidney is abnormally movable the pedicle becomes elongated, and the organ in its excursion swings downwards and towards the median line round the attachment of the artery and the vein. When the kidney is raised into a lumbar wound the artery and vein are increased in length by stretching. On the right side the wall of the inferior vena cava is dragged outwards, but on the left side the aoi-ta is more resistant. The pedicle is seldom transverse. Usually it passes obliquely upwards towards the middle line. When the kidney is brought into a lumbar wound this obliquity is increased. The circumference of the pedicle varies greatly. It is increased by an early branching of the renal artery, and in diseased kidneys may be greatly thick- ened by masses of fibrous fatty tissue. Attachments of the kidney.— The following structures combine to support the kidney. They prevent the organ from being displaced, but allow it to move freely (3 to 5 cm.) with respiration . 1. The renal vessels. 2. The peritoneum. 3. The attachment of retroperitoneal surfaces of the duo- denum, colon, pancreas. 4. The adhesion to the suprarenal capsule. 5. The perirenal fascia and the supporting network of fibres that pass to it from the renal capsule. 6. The perirenal fat. 7. The fascia of Toldt. 8. The intra-abdominal pressure. CHAPTER II PHYSIOLOGY AND PATHOLOGY OF THE RENAL FUNCTION The following functions are combined in the kidney : — 1. The kidneys separate from the blood a fluid of different molecular composition, namely the urine. 2. They exercise a selective power by which certain sub- stances are removed from the blood. These substances, if allowed to accimiulate in the blood, produce uraemia. 3. They have a synthetic action which places them in a line with other- glandular organs. Hippuric acid is built up and secreted by the kidneys. 4. An internal secretion which affects nitrogenous meta- bolism is suggested by certain experiments. The urine differs from the blood in reaction, in the absence of the proteins of the blood, in the presence of hippuric acid in the urine, and in the different percentage of its constituents. The most important factor in producing variations in the renal secretion is the velocity of the blood flow through the organ. This is affected by variations in the general blood pressure. When the aortic blood pressure falls below 40 cm. of mercury the flow of urine stops. Constriction of the renal arteries by stimulation of the renal nerves, or pressure upon the renal artery so as to obstruct its flow, and obstruction to the renal vein, diminish the blood flow and reduce the secretion of urine. EXAMINATION OF THE RENAL FUNCTION An estimate of the function of the kidneys in disease of these organs may be formed (1) by the discovery of symptoms of renal failure, (2) by an examination of the urine, or (3) by certain tests of the renal function. 1. Signs and Symptoms of Renal Failure Pain is a sign that the kidneys are diseased, but it is not a reliable indication of interference with the renal function. The 10 ciiAi III KHNAL FAILURIt H kidneys may hv the seat ol" a . ».. > 1 ^ / >»■ f^ ^ S,- o> Ci ^ ^ CO ( V (^ r ■0 JNJ J 1 / >*• .^ V w 00 O s V o N >L 1 o O) ^ (O ^ O 03 y ^ ^ ^^ K ^ *^ "O ^ x^ lO -'^ <» ^ f \ % I o n <. 0) "^ ^ ^^ N N <0 — 1 \ (O ^ 1 ' 2 qOOOOOOO (J ■^OOjeoKto'O^ * a ^ - o O) o u a O o 0) ;i C3 X. U u THE KIDNEY [chap. and the percentage of the urinary constituents is reduced. No albumin or other abnormal constituent is present. The patient complains of frequent micturition and scalding as the urine passes. 5: 2 ti •c ::^ - ' i ', 5^ 1 5 ^ ►; ^ 1 5 < \ ■ 1 ^ 5 ^ 5 >i ,,' f ^ 1 5 j • ^ 1 K !:i ( V''7 ^ 1 \ / : 1 • ^ 1 < ** / J ^ 1 ^ •^ «» \ <^ •^ ^ ^ ^ <- 00 ^ , ^-5 ^ 1 ■0 v. N < •: #' _} ^ 1 VI "^ ^-v s ; 1 ^ •0 N V ) ' ^ 1 ■* <* > \ ,^ ^ 1 ^ •^ •^ y' ^' "') ^ ^ ^ ■ C ./ 1 ■? >» » --•r- *,1.. ^ N 1 ^ .AH0133yHd3f/ < •1 '1 1 • ^ § ^ \ V 1 a ^ Si > ) 1 5 § ^ ^ K <, \ ^ ^ <^ ^ > • 1 ^ ^ 1^5 5^ { « { ? N Si N > ,.* \ 1 9 Q ^ < f,'' k M 1 03 . \ ■§■■■ •5i •^ 1 »3 >*^ C> »0 ^ «J *5 ^ i;? >o xh "* "n «- ^ ^ !5 ^ ^ < 5i 5 5 ^ ^ 1 i <3 O N < > ID < n CM N O 0) •• CO N IS in -» » m ^ ,^' N •< p > - /» •« p o ' •oil lO J — < >. ^ ^ •J ^ru T ■^ w*~ ^" - ■^ • > s 1 k < • >• « £ ^ ■> « "^ o _ - - - - C 4> .9.S o 3 c (J. 2 In a prolonged attack the urine is increased by one or two pints in the twenty-four hours. Thirst is not a marked feature of the malady. There are usually obscure abdominal pains which are never severe or definitely localized. Oliguria and anuria. — Oliguria is a diminished secretion of urine ; anuria is a total cessation of the se- cretion. The agencies which bring about oliguria and anuria may be classified in the following manner : — (1) Hysterical anuria. (2) Anuria due to changes in the general circulation of the body. (3) Reflex anuria : (a) Urethra. (6) Bladder, (c) Ureter. {d) Kidney. (4) Infective anuria : (a) Hsematogenous (i) Toxic, (ii) Bacterial. (6) Ascending urin- ary. (5) Urinary- tension anuria : 1. Obstruction — (a) Gradual. (6) Sudden. 2. Sudden relief of tension. * (6) Anuria from de- struction or re- moval of renal tissue : («) Gradual de- struction. (6) Sudden com- plete destruc- tion or removal. -^^ •00 . J; ^ ^ S o ^^ 0) " CS'O us A O a i2 a A c o< o 4> ,-1-' o a >> ^ 0) I- c X D 5 fl O o « c a> 0) o 2 " o Hue ^M *j O o 16 THE KIDNEY [chap. (1) Hysterical anuria. — There may b suppression in cases of severe hysteria, several hours, or even for some days. r^ .^ ^ ,•' '^ *' . i^ =^ ~" ■;■ n 'N - — ^ jr' e «5 • z. ■^ ^ J--* K m cCl. <, 1 **■ ".-■J- s •t; — <> 5 "•« ..^ T 5 V v^ ^ •^ >'' ■• ^ J i ■->. 0\ ■^ ^ V y> ^ ., ■^ ~ ■ ^ fo ^ "^ N Ai^xa yffo 3N vo/iyyjt Jt^ ••'• ^ ^ rJL_ ^ f' — ■-«, f^ ^ > ^, > ♦ .^ ^ - !«i - — — ■ !^ <: ^ ,-•'' i ,,•-' ^ <' i^ \ ..A • ^ 95 1 t;' > ■"•--J ir> '"7 '^> l. '» s 5 ,«^ ^ 5 4 !Nj %* '_ 5; ■--• .._ < ^ i 21« "" ^ a^ • --** ;s. 03 "N J^ M '-A^ '""•^ •« ~ ^ r h >o »' 3-* > •*'-- . — % N ■^ •< •.^^ ^ -- ■ ■ V, ■- , 5^ 1 •»- .. , 1 >s «1 ^ ^ ■■ 5^ ""= — _ » ^ i^ *9 ~ -^^ It! 5 ° " "lO V V) °M °— °0 °m °m °|s 9292222 of o^S^ '0 ^-' O -"0 O -^j p o O ? o C S s ^ -Ah c O t/5 _^ o O t3 -o'C .S'o tM . O cc CI >> o *"5 =^ fin . =3 s se «3 OJ c _, -w C3 C O S3 § ?: o '■M '-4-1 .tn (u c S o 3^ J 5 U le diminution or complete Anuria has lasted for Apart from continuous vomiting, no symp- toms of uraemia have been observed in such cases. A copious poly- uria immediately fol- lows the anuria. (2) C i r c u I atory anuria. — After severe and prolonged opera- tions the secretion of urine is temporarily reduced or suspended. This may last for several hours, and is due to the low blood pressure of shock and collapse. The effect of the anaesthetic, and perhaps the absorption of antiseptics, may play a subordinate part. Where the kid- neys are diseased and the active renal tissue much reduced this may be the exciting cause of continuous and fatal anuria. Usually the function is restored when the blood pres- sure again rises. In shock following grave injuries to the body, in the collapse of cholera, and in other conditions of extreme lowering of the blood pressure, anuria is present. (3) Reflex anuria. — The passage of an instrument along the II] ANURIA 17 urethra may be followed by suppression of urine. In such a case the urethra may be healthy, or it may be the seat of stricture or other disease. In some cases no blood follows the passage of the instrument, and post-mortem examination of the urethra fails to reveal the slightest abrasion. The kidneys are sometimes the seat of chronic interstitial nephritis or chronic septic nephritis, and they have been found deeply congested ; but in some cases nothing abnormal has been discovered. Suppression of urine is more likely to occur when an instru- ment has been roughly passed, and where the disease for which it is used is in the deeper part of the urethra. In the majority of cases there has been difficulty in passing an instrument, and this has been followed by some bleeding. Some hours later, usually immediately after the first passage of urine, the patient has a rigor, and the temperature rises to 103° or 104° F., after which no urine is secreted. The majority of these cases are due to septic absorption. Some are apparently due to a combination of septic absorption and a reflex effect on the circulation of the kidneys, while a few are purely reflex in nature. Surgical interference with the bladder may be followed by suppression of urine, especially if the kidneys are already diseased. Reflex impulses from a ureter, started by a stone or the catheter, may inhibit the secretion of the corresponding kidney. The function of the second kidney may be inhibited, and com- plete anuria result, by reflex impulses from a stone in the ureter. The corresponding kidney is affected partly by blocking of its ureter and partly by reflex impulses from the ureter. The second kidney may be healthy in such a case, but almost invariably it is impaired by disease. Sudden kinking of the ureter by torsion of the pedicle in a case of movable kidney may bring about a temporary diminution in the secretion, or a complete suppression. The function is re- established when the torsion is relieved. There is a reflex depressant effect exerted by one diseased kidney on its healthy or less diseased neighbour. In cases of pyonephrosis, unilateral suppurative pyelonephritis, and other irritative conditions, the total quantity of urine is usually much reduced. On removal of the diseased kidney the activity of the remaining kidney, relieved of the depressant reflex, is greatly increased. Surgical interference with one kidney is said to produce a reflex inhibition of the acti\dty of its neighbour. Although it appears probable that some such effect may be temporarily c 18 THE KIDNEY [chap. produced, it can only last during the time of the operation, and if the second kidney is adequate before the operation this cause will not induce postoperative anuria. Other factors which are much more potent in producing anuria after a kidney operation are the effect of the anaesthetic and of absorbed antiseptics on the remaining kidney and the low blood pressure of shock. Further, the remaining kidney may have been inadequate before the opera- tion, and the removal of its neighbour only makes this evident. Irritation of the kidney pedicle by a drainage tube after nephrec- tomy has been found to produce reflex anuria (Israel). (4) Infective anuria, {a) Hcematogenous. — In acute nephritis caused by a hsematogenous infection in septicsemia, influenza, pneumonia, typhoid fever, and in auto-intoxication from gastro- intestinal infections, suppression of urine is frequently present and may be fatal. Anuria following urethral operations where the kidneys are healthy and no ascending infection has occurred is probably toxic in nature in many cases. (6) Ascending. — An acute ascending affection of the kidneys from the bladder, arising from an old-standing cystitis or induced by means of septic instruments, may cause complete and rapidly fatal anuria. Chronic septic pyelonephritis secondary to disease of the lower urinary organs is accompanied by oliguria, which becomes more pronoimced with acute exacerbations of the disease. and complete anuria may supervene. (5) Urinary-tension anuria. — {a) Gradually increasing ob- struction to the outflow of urine, such as is met with in enlarged prostate, produces a slight dilatation of the kidney and chronic interstitial nephritis, and in this way the secreting tissue of the kidney is slowly destroyed. The onset of anuria in these cases is referred to under the heading of Anuria from Destruction of Eenal Tissue {see below). (6) Rapid occlusion of both ureters is met with in malignant growths of the bladder involving both ureteric orifices, and in other pelvic growths such as carcinoma of the uterus. Where a calculus suddenly blocks the lumen of the ureter of , a solitary kidney, or where both ureters become simultaneously blocked, obstructive anuria results. The calculous anuria is partly obstruc- tive and partly reflex. (c) Anuria may follow the sudden relief of urinary hyper- tension. When the urine has been secreted under increased tension for some time, as in enlarged prostate, and the kidneys are the seat of interstitial changes, the sudden emptying of an over-distended bladder is frequently followed by suppression of urine. This suppression is probably due to sudden engorgement 11] ANURIA: TREATMENT 10 of the renal vessels. It is more likelv to occur in old than in young men. (6) Anuria from destruction or removal of renal tissue. — The removal of a solitary kidney, or a working kidney whose neighbour is destroyed by disease, is followed by anuria and death in a few days. When nephrectomy has been performed, and the second kidney is active, but incompetent from disease to perform the total renal function, the patient may survive the operation and gradually sink Avith symptoms of increasing renal failure, and die some months after the operation. Where disease, such as stricture, enlarged prostate, or calculus or tuberculosis of the kidney, has gradually destroyed the tissue of the kidney, there is usually polyuria. This is inter- rupted from time to time by attacks of oliguria or anuria brought on by shght causes. (Chart 5.) Finally an attack of anuria proves fatal. Treatment of anuria. — The follomng measures should be adopted in cases of anuria : Di- uretics are administered, such as caffeine (5 gr.), diuretin (10 gr.), theocin sodium acetate (5 gr.), hot Contrexeville water, and citrate of potash (25 gr.). Hot fomentations and poul- tices are applied over the loins. The patient is placed in a hot pack or a vapour bath. A saline infusion of several DATE 4- i 5 i 6 i 7 8 9 iiolll 1 OZS. 1 1 100 90 00 70 60 50 4-0 30 20 1 C F° 107 106 105 104 103 102 101 100 39 93 07 1 • >' i / ' . 1 ■? 1 1 1 1 1 •S 1 1 1 • 1^ V I 1 V o i „ r r«i*l l/\. /\ !^ :/i ; Chart 5. — Urine and tempera- ture in obstructive anuria, showing subnormal tempera- ture and practically com- plete anuria, interrupted by a copious polyuria. pints (sodium chloride, 1 dr. to the pint) is slowly introduced into the rectum. In severe cases the introduction of one to two pints or more of saline solution into a vein has a powerful diuretic effect. It has recently been pointed out that the kidneys are embarrassed by the introduction of chlorides, and these should be replaced by sugar solutions, which are powerfully diuretic. In urgent cases a pint of glucose solution (25 per cent.) is infused into a vein. This solution is hypertonic, and increases the molecular content of the blood. 20 THE KIDNEY [chap. Ill less urgent cases the injection may be given subcutaneously or intramuscularly. Jeanbrau recommends an isotonic solution of glucose (47 grm. per 1,000), or of saccharose or lactose (90 grm. per 1,000). A solution of 5 per cent, of glucose is isotonic, and I use this in preference to saline solution in anuria. Nephrotomy is followed by re-estab- lishment of the secretion in some ap- parently desperate cases. This will be discussed in connection with the dis- eases causing anuria. Hysterical anuria is treated by bromides, valerian, etc. Diuretics should be administered, and care exercised that the patient has no opportunity of fraudu- lently disposing of urine that may be passed. In circulatory anuria the treatment is directed to raising the blood pressure by means of strychnine, ergot, adrena- lin, and pituitary extract, and by saline infusion. In reflex anuria the cause of the reflex inhibition should be removed {see Calculous Anuria, p. 279, and Pyelone- phritis, p. 127). In infective anuria it may be neces- sary to incise one or even both kidneys (see Pyelonephritis, p. 135). Sudden r.elief of long-established se- vere obstruction— as, for example, the complete emptying of a chronically over- distended bladder in a case of enlarged prostate — should be avoided. Fig. 9. — Beckmann's ap- paratus for estimating the freezing-point of the urine. A, Glass jar ; B, stirring rod ; C, outer glass tube ; D, inner glass tube for urine ; E, platinum stirring rod ; F, Beckmann's thermometer. 3. Tests of the Renal Function (1) Cryoscopy.^ — For details of the method of cryoscopy of the urine and blood the reader is referred to special works dealing with this subject.^ By estimating the freezing-point (Fig. 9) the molecular con- centration of a fluid is ascertained, and as the molecular concen- tration is proportional to the osmotic pressure the latter may thus ^Thomson Walker, "The Estimation of the Renal Function in Urinary Surgery." 1908, II] CRYOSCOPY 21 be measured. The osmotic piessure of tlic mine is constantly higher than that of the blood, and the work of extracting this fluid of greater osmotic pressure from one of lower osmotic pres- sure is performed by the kidney. If these organs are diseased their power of bringing about a change in the osmotic pressure of the fluid passing through is reduced. The osmotic pressure therefore falls, and approaches more nearly that of the blood. When the kidneys are diseased the molecular content of the urine is reduced, and the freezing-point of the urine is raised. The freezing-point of the urine is indicated by the sign A) o^) to avoid confusion with other fluids, A U may be used. In the healthy state this is liable to considerable variations. It is usually between —1-30° and —2-20° C, but after copious libations it may rise to —1° C, and when the urine is concentrated by profuse sweating the figure may be —2-30° C, or lower. In nervous polyuria the point may be reduced to —0-46° or —0-17° C. A fallacy is introduced by the precipitation of urates in many urines when the temperature is lowered. The variations in the point A U are so considerable in healthy individuals that cryoscopy of the urine alone has little value as an indication of the renal function. Cryoscopy of the blood. — The freezing-point of the blood is remarkably constant at —0-56° C, and the point A of the serum is practically the same as that of the blood. Where one kidney is inefficient no change is found in the point /\, but when the Eimction of both kidneys is reduced the point A is lowered. A point A of —0-57° or —0-58° C. indicates a reduction in the total renal function, and a point A of —0-60° C. is a contra- indication to nephrectomy. Lowering of the point A to —0-60° C. or under may be observed apart from disease of the kidney in cardiac and respiratory affections, and in diabetes, epilepsy, and other conditions. Further, the normal point A of the blood does not prove that the kidneys are efficient, for the blood may have been hydrsemic and the point A raised, and the renal lesion only succeeds in reducing the point A to normal. This method is not always trustworthy, although it may give useful information when it is impossible to separate the urines of the two kidneys for examination. Comparative cryoscopy of the urine and the blood. — The freezing-point of the normal urine is —1-5° to —2° C, and that of the blood serum —0-56° C. The quotient of these will be 2-3° to 3-5° C, and when this figure diminishes we may conclude that there is a diminution in the permeability of the kidney. There is, however, too wide a range of variation in the freezing-point 22 THE KIDNEY [chap. of the urine in the normal individual for reliable information to be obtained by this means. If the volume of the urine be taken into account, this fallacy will be corrected. Thus the quotient is multiplied by the number of c.c. of urine secreted in twenty- four hours. The figures thus obtained vary in healthy individuals from 3,000 to 5,000. The remarkable tendency of the blood to remain at a constant molecular concentration under any condi- tion reduces the value of this test. Cryoscopy of the urine and estinnation of the chlorides. — Koranyi believes that the glomeruli of the kidney filter through a solution of sodium chloride from the blood, and as this passes down the tubules water is absorbed and molecules of sodium chloride are removed, and replaced by molecules of urea, uric acid, etc., from the blood. He therefore proposes to estimate the renal Fig. 10. — Apparatus for measuring the electrical conductivity of urine. A, Induction coil ; B, vessel containing fluid ; C, rheostat ; D, movable contact ; E, telephone. function by noting the relation between the point A U (the total molecular content) and the sodium chloride content in 100 c.c. of urine. This is expressed by the formula ^ry— pi- In the normal state this does not exceed 1-7. The result depends, however, not upon the permeability of the kidney, but upon the rapidity of secretion, which affects the time allowed for interchange of the sodium chloride molecules. This again depends upon the rate of circulation through the kidney. In order to overcome such fallacies the formula has been corrected by adding to it the volume of urine in cubic centimetres for twenty-four hours and the total body-weight in kilogrammes. The formula becomes so compli- cated that the figures obtained are of very doubtful value. Wright and Kilner have suggested a method by which the molecular content of the blood is measured by means of dilution Ill METHYLENE-BLUH TEST 23 with a staiulai'd solution of sodium chloride. At a certain point of dilution destruction of the red blood-corpuscles (htemolysis) takes place, and the amount of dilution required to produce this is an index of the molecular concentration of the blood. Estimation of the electrical conductivity of the urine has been used to estimate the molecular content, and the figure compared with that of salt solution. (Fig. 10.) Further, the electrical resist- ance of the urine has been compared with that of the blood and a haemo-renal index obtained ; but neither this method nor the estimation of the surface tension of the urine, which has also been used, has been widely adopted. It may be said of all these methods of estimation of the mo- lecular content of the urine, that the delicacy of the instruments required and the skill necessary for their observation preclude them from general chnical use, and that the results they have given could equally well and much more easily be obtained by testing the specific gravity by means of the ureometer. (2) Methylene-blue test. — The methylene blue should be pure and free from arsenic, and must dissolve completely in water. Methylene blue is absorbed from the intestine or from an intramuscular injection into the blood, and excreted by the kidney, and to a less extent by the liver. Some of the latter is reabsorbed from the intestine. The blue cannot be recognized in the blood. It appears in the urine partly as blue and partly in the form of a chromogen or colourless body which is transformed into blue by boiling with acetic acid. After cleansing the skin, 15 minims of a 5 per cent, aqueous solution are slowly injected into the muscles of the buttock. Chromogen appears in the urine in from fifteen to twenty minutes, and a trace of blue is detected half an hour after the injection. The urine rapidly becomes olive green and then emerald green bluish green, prussian blue, and finally a deep blue colour. The colour may not, however, pass beyond emerald green. During the first four or five hours of the elimination chromogen is present in greater quantity than blue, and may be detected by extracting the blue with chloroform and then boihng the cleared urine with acetic acid. (Chart 6.) The excretion of blue is at its height in four or five hours, remains stationary for several hours, and then gradually decHnes. In from forty to sixty hours it has usually disappeared. The chromogen disappears from the urine some hours before the methylene blue. In pathological conditions of the kidney, such as chronic interstitial nephritis, tuberculous kidney, or hydronephrosis (Charts 7, 8), the appearance of methylene blue is delayed for one, two, or more hours. An early onset and rapid ^16 - 1 dIXf A iVAd3iNi synoH zi diiixxxji 4r§ C8 Z9 IS 08 Li. 9L SL 3XVMUS3 01 \y nn/s 001 3ma 3N3Uhi3h jo AiiiNvnb^ IX? tx? dIXf / y / \ ; iVAdSiNi StinoN ZI xnxil 09 6S 89 /S 95 €S zs 'NOU3dOX3 IVIQI IXE Al£ IIIAXS IIA£ XC AIX2 X£ dillA? Xlf' Xl£ IXf -dif A.f^ H3NNia ,1* < ^s >, 1 s. S \/31 Y "* / f ^ / >•, HONm * •v s. *♦ s _ — = = — r=t ^ £ s = m — MoaisrNi 1 5: to 3 u o 1 to u * to i 5 2 5 o i O ■g-i l.s C >.« d ^•- ^^ .S s ^& o I? o SB (11 ,^ •00 o O w 2 « 3 o 0) D 3 0) u 6 S c '=' a* ■" C3 •S 3 e: g crcs 1 2 S CS V30 24 CllAI'. II INDIGO-CARMINE TEST eliiuinutioii liavc been obscrvctl in pareischyinatous nephritis. In surgical disease of the kidneys elimination of blue may be pro- longed for several days. I have observed the excretion during a period of eight days and seventeen hours in a man of 67 y^ars who suffered from eidarged prostate and interstitial changes in the kidneys. After the first twenty-four hours only traces of blue are passed in such cases, and the total quantity of blue eliminated is usually much reduced. The quantity of blue may bo estimated bv a colorimetric method, but it is usually sufficient ^>Nron>>0 s v^ r ^, s ^ FAINT GREEN 1 [i ^> s li 1 •*, k V SHADOW U 1 ^ '> I ZERO W Chart 7. — Elimination of methylene blue (continuous line) in tuberculous kidney. Delayed commencement and rapid short elimination. to note the varying depth of colour, and from this to judge of the quantity eliminated. Intermittent elimination may occur, and is said to result from an inhibitory action on the kidney of bodies produced in the liver in hepatic disease, but I have observed it in the healthy. (3) Indigo -carmine test, — An injection of 20 c.c. of 0-4 per cent, solution of indigo carmine is made into the muscles of the buttock. The urine becomes tinged in five minutes, the excretion reaches its highest point in half to three-quarters of an hour, and then falls gradually and disappears in about twelve hours. Delay in the commencement and a diminution in the quantity of dye eliminated are indications of a reduced renal 26 THE KIDNEY [chap. function. The quantity of fluid which must be injected is a drawback to this method. The solubihty of indigo carmine does not permit of more concentrated solution being used. 09 9S- ZS Si' Oi' 9£ Z€ 9Z ■kz oz Zl 6 9 r 96. ^ff ZZ 09 95- Z£ 9^ Oi' 9€ Z£ 9Z PZ OZ Zl 6 9 € V,Z Z V,l 1 V, ~ r J^ ^ ■^ f*) ^ « •^ ^ ■ *. ' > \ X ^ . 1 1^ *• 1 / ^* J "^ J * f 1'' "^ 11 -^ « ' ^ p^ Q "■ — — - - .^ «- ^^ • ^ >i « < ^« in - ^ ' / -* 4 c^ ,. • ■•« 1 i. "*H - J p»- "" " ^j -1 ^ 1 ^ »«* "" / — — "** ^ •^ / 5^ : 4 < u. "«» 4 '*■ > > \' I •30 ^ \- y lo 1 ■^ ; X «^ ^ J ^ ■« - \ '- *■ — — ^ STRONG MEDIUM FEEBLE MINIMUM ZERO ^ 5 Rosaniline, iodide of potassium, and salicylic acid have been tried as tests of the renal function, but have not been found satisfactory. iij TESTS OF RENAL FUNCTION 27 (4) Phenol-sulphone-phthalein test.' A cubic ceiitinietic of a solution coutaiuiut!; <> ui s / f A \s QUANTITY C.C. 1-2 168 19 21 50 368 UREA % 1-9 SUGAR % ■20 ■5 ■18 Chart 9. — Stricture of the urethra. Delayed, shortened, reduced elimination of sugar. ENLARGED PROSTATE. HOURS '/* 1 '/2 ^U 1 \/'/z 2 2/2I 3 3'/2 4- 4-'/i\ C. 8 7 1 ! 6 i TOTAL 1 1 ■303GRMS 1 I I'll 5 1 1 ■^ j 3 1 1 1 2 -»v ,.. V 1 !>^ t^T^ > ■'>' --UU-iJ^^^^J4^'' /I 111') QUANTITY C.C. 6 15-5 20 // 23-5 /9 20 10 29 19 13 UREA % 21 1-6 1-75 /■9 1-95 1-9 2-2 -as 1-7. 135 8 SUGAR % ■08 •// ■25 ■19 -10 -l^- 1 ■■* 15 2 -08 Chart 10. — Prolonged diminished phloridzin glycosuria <5) in enlarged prostate. /^IGHT KIDNEY LEFT KIDNEYiDI5EASEDJ HOURS 'A\y.2\%\/ \i'/z 2 'A '/2 ^A / //2 2 a TOTAL SUGAR ' * ■S/O GRMS ^ 7 \ \ 6 5 *s V "X^ ^-■4 r ^ ^ \ -^u -^ -^ U / \ •< QUANTITY C.C. /2-5 13 15 28 98 £6 20 /8 /o 34 88 56 UREA % /■7 /■/s I-7S /■I ■S5 ■8 ■75 ■88 ■7 ■6 \-45\-3 SUGAR % TH/ICL ■5 •5 J-0 ■09 T^Kt mc^ -^vi| 1 Chart 11. — Calculous hydronephrosis. Traces of sugar on diseased side. 29 30 THE KIDNEY [chap. II function which is usually due to disease of the kidney, and com- plete absence of sugar should be regarded as a sign of advanced renal disease. Compared with the urea output and the general symptoms of renal inadequacy, the phloridzin test is more delicate. The fallacy RIGHT KIDNEY. iPYONEPHROSIS LEFT KIDNEY. HOURS '/-» Vz Vf 1 l'/2 2 % 5 o + 1/4 '/2\^/4-\ 1 l'/2 Z F.J. 8 i 7 TOTAL SUGAR ■ 395 GRM?. TOTAL SUGAR 1-623 GRM?. 6 \ '' 5 1 ^ /! 3 A^ \ ^/ / 1 Z •-■ -•'' \ % ; • 'Q '/ -^ aI', U L, A ■^ K >^ \ 'q \ k:j :?^ ^ ^ V*' r V^ \ \ ^ QUANTITY C.C. ?7 25 34\25 10 9 30 40\60\22 25 3 UREA % 1-38 •71 -3 \h5 ■4 1 /■6\ -9 ■7 -e \ -9 •5 SUGAR % •?4\-06\-3Z\-6Z ■50 trace 2-6\-3l ■IZ\l-55\hlZ (race Chart 12. — Calculous pyonephrosis. Diminished elimination of sugar on diseased side. to which it is especially liable is the pronounced effect which minor renal changes may produce upon the glycosuria. The test, which we owe to Casper, is especially useful for unilateral renal disease, and is used with catheterization of the ureters, each kidney being drained for two and a half hours. CHAPTER III EXAMINATION OF THE KIDNEYS I. INSPECTION AND PALPATION Inspection. — A kidney which has attained a large size becomes prominent on the surface of the abdomen. The prominence is more readily seen in the recumbent than in the erect posture. There is usually well-niarked fullness in the flank on the affected Fig. 11. — Bilateral hydronephrosis. The left kidney is distended ; the right has been the'subject of a plastic operation. side, but the greatest prominence is on the anterior surface of the abdomen (Fig. 11). With the patient lying on the back, a large, rounded swelling will be seen to one side, or a little above the level, of the umbiUcus. If the abdominal wall is thick and the tumour very large,' only a general fullness of one side of the abdomen is apparent. In some 31 32 THE KIDNEY [chap. cases of hydronephrosis the pelvis of the kidney is greatly distended with fluid, while the kidney itself is less prominent. A vertical groove will frequently be observed on the swelling, and indicates the division between pelvis and kidney. Palpation. — The patient lies on his back on a high couch, the abdomen fully exposed, the shoulders raised on a pillow, and the knees flexed, with the feet planted on the table. I usually dispense with the flexion of the knees, or, at most,, place a pillow beneath them. The surgeon either sits on the edge of the couch, or stands alongside it, about the level of the patient's pelvis on the side to be examined. To examine the right kidney, he places the finger-tips of the left hand beneath the patient's loin and presses gently upwards in the angle formed by the last rib with the erector Fig. 12. — Palpation of right kidney, with patient recumbent and thigh extended. spinse mass of muscles. The right hand, well warmed, is placed flat upon the surface of the abdomen, with the tips of the fingers a little above the level of the umbilicus and about midway between this and the margin of the ribs (Fig. 12). With the knees fully flexed the axis of the surgeon's hand lies almost transverse (Fig. 13). With the knees slightly flexed or fully extended the hand can be placed with its long axis in the long axis of the patient's body — a position more favourable for palpation of the kidney. The patient is directed to take deep inspirations, but not to force expiration. As the abdomen recedes at each expiration the fingers sink in, and the deeper position is maintained during the next inspiration, and at each succeeding expiration the fingers sink deeper. There should be no plunging with the tips of the fingers. When the fingers have sunk deeply, the posterior hand should try to raise the kidney at each inspiration. To examine the left kidney, the position of Ill] RENAL PALPATION 33 the surgeon and his hands are changed to the (;ther side of the patient, the left hand being used for the front of the abdomen and the right hand being behind. Fig. 13. — Palpation of right kidney : dorsal position with knee flexed. Note interlocking of thumbs. The patient may also be examined lying upon the side with the knees flexed. The uppermost loin is palpated, the surgeon standing behind the patient (Fig. 14). Fig. 14. — Palpation of kidney with patient lying on sound side. In thin patients and in children the whole loin may be grasped just below the last rib by placing the hand behind and the thumb 34 THE KIDNEY [chap. in front. Additional pressure may be applied to assist the sinking- in of the thumb by pressing upon it with the fingers of the other hand. The same method may be practised with the patient standing Fig. 15.— Palpation of kidney in erect posture. (Fig. 15), but it is more difficult to get relaxation of the abdominal muscles in this position. By palpation the size, outhne, shape, and movements of an CDlarged or otherwise abnormal kidney will be ascertained. The Ill] SIGNS OF RENAL TUMOUR 35 difficulties in examining a renal tumour are stoutness of the patient and rigidity due to contraction of the abdominal muscles. Con- traction of the muscles may be caused by pain and tenderness of the kidney, or by rough handling or the application of a cold hand, or by nervousness on the part of the patient. A general anaesthetic may be necessary to overcome this. Signs of renal tumour. — The following are the characteristic signs of an abdominal tumour formed by the kidney (tumours caused by movable kidneys will be specially described under that heading) : The borders of the kidney are all rounded ; there are no sharp edges. The reniform shape can frequently be distin- guished. Kidney tumours project forwards into the abdomen, and although the depression of the loin may be obliterated, there is no projection of a definite tumour laterally or backwards. The tumour passes backwards into the kidney area at the angle formed by the ribs with the spinal muscles, and the fingers pressed in here do not sink in behind the tumour. With the fingers in this position and the other hand on the front of the abdomen, the kidney tumour, if a small one, can be projected against the anterior hand by a sudden push, and gives a characteristic sensation, called by French surgeons " ballottement." When the tumour is a large one, and already in contact with the abdominal wall in front, the hands in these positions can so grasp the tumour as to move it backwards and forwards between them. Renal tumours descend with inspiration unless they are fixed by adhesions. They move rather less freely with respiration than tumours of the spleen, liver, or suprarenal body. Unless the renal tumour is very large it does not reach the middle line, but it may, when of exceptional size, cross the middle line, and even fill the whole abdominal area. When of moderate dimensions it can usually be separated from the liver. The edge of the liver may sometimes be felt on the surface of the enlarged kidney. Renal tumours rarely extend into the iliac fossa. A renal tumour due to a large growth is usually tense and elastic to the touch. Sometimes the tumour is hard and nodular, or the consistence may vary in different parts, being soft and fluctuating at one part and hard at another. Kidneys dis- tended wdth fluid are tense and elastic. It is seldom possible to detect fluctuation in these tumours. Occasionally large masses of calculi may be felt in the kidney as very hard, irregular nodules. The colon can often be felt crossing the tumour vertically. On percussion the tumour is dull, and the dull note merges into that of the spinal muscles behind. Anteriorly there is a zone of com- parative resonance when the colon is pressed forwards in front of the tumour ; or if the colon is collapsed, and dull on percussion, 36 THE KIDNEY [chap. it can be rolled beneath the fingers. An enlarged right kidney may push the ascending colon downwards and inwards. On the right side percussion will usually show an area of resonance between the renal dullness and that of the liver, which can be demonstrated when the patient is standing. Differential diagnosis of renal tumour. — Tumours of the kidney may be confused with enlargements of the liver or spleen, ovarian tumours, suprarenal tumours, malignant growths of the large intestine, and perinephritic tumours and inflariimations. (1) An enlarged liver has no intestine in front of it, and does not give the sensation of ballottement. The outline of the dullness may be characteristic, and the sharp lower edge may be felt, or there is an absence of roundness at the edge. Jaundice and biliary colic, when present, point to disease of the liver and gall-bladder, while urinary symptoms may give the clue to urinary disease. A floating lobe of the liver may be confused with a movable kidney. In all cases where there is difficulty in diagnosis, pyelography gives invaluable information in regard to the position of the kidney and the presence of dilatation of the organ (p. 42). (2) The S'pleen has no bowel in front, and is therefore absolutely dull on percussion. It has a sharp, well-defined edge, and a notch in this which may be distinguished. There is usually resonance between the posterior edge and the spinal muscles, and there is frequently hollowing in this position if the tumour is large. Ballottement cannot be obtained. The enlargement of a splenic tumour takes a downward and inward direction ; that of a renal tumour extends downwards, not inwards. The lower end of a large splenic tumour crosses the middle line ; that of a renal tumour does not, although a very large renal growth may cross the middle line at its point of greatest circumference. The history of the case and examination of the blood may help. Urinary symptoms, such as hgematuria, are very important when present. (3) Ovarian tumours are dull in front, and there is reson- ance in the flanks. The enlargement has taken place from below upwards. The tumour can be felt in the pelvis from the vagina or rectum, and there are changes in the position of the uterus. A small ovarian tumour with a long pedicle has been mistaken for a renal tumour. (4) Suprarenal tumours are seldom distinguished from those of the kidney. The kidney may be recognized as a reniform swelling on the surface of the mass, but if felt at all will probably be indistinguishable from a round nodule of growth. (5) Maligyiant growths of the large intestine may simulate renal growths. In position and in distribution of the dullness they may be similar, and the out- line of the intestinal tumour may be rounded on palpation. Mobility may be a feature of intestinal growths, and it may be possible to Ill] RADIOGRAPHY OF KIDNEY 37 reduce such a growth into the loin in a manner similar to a renal tumour. The presence of changes in the urine or of intestinal symptoms will influence diagnosis in one or other direction. In- testinal growths are not reniform in outline. (6) Perinephritic growths may closely simulate renal tumours in all respects, and the diagnosis may only be made by exploration. Perinephritic iyiflammatiofi and suppuration may originate above a malignant growth of the intestine, or may result from appendicitis or other causes. The diagnosis of the cause of the inflammation will be made by the history of the case. II. RADIOGRAPHY OF THE KIDNEY AND RENAL PELVIS The Rontgen rays were first used in the diagnosis of renal calculus by Macintyre in. 1896, and have proved of immense value in urinary surgery. In examining a kidney by this means the plate should show both kidney areas, the last two ribs on each side, the transverse processes of the vertebrae, and each iliac crest, and it should be possible to trace clearly the shadow of the psoas muscle. If these landmarks are not seen the plate must be classed as of poor quality, and the value to be placed upon the reading of it is reduced. In a plate of good quality the shadow of a normal kidney can be distinguished. The outline of the lower pole and the outer border are most definite ; the inner border can sometimes be seen, but the upper pole can seldom be distinguished unless the organ is displaced downwards clear of the ribs. The left kidney throws a more definite shadow than the right, which is frequently obscured by the liver. Stoutness of the patient and a loaded bowel give rise to diffi- culty in obtaining a good radiogram. It is possible to obtain a negative of first quality even in very stout subjects. Careful preparation of the bowel is of the utmost importance. A loaded bowel will produce a cloudy opacity which obscures the kidney. It is equally important to avoid over-purgation, as the large in- testine becomes distended with air and reduces the value of the plate. A mild aperient, such as a dose of hquorice powder, should be given on two successive nights previous to the examination. The patient should eat very sparingly on the day before, and should fast on the day of the examination. It is important for purposes of localization and comparison that the radiographer should be able to reproduce with mathe- matical exactness the position and the relation to each other of the patient, the tube, and the plate at any subsequent time, and in 38 THE KIDNEY [chap. order to do this a fixed position must be used. The radiographer must clearly indicate on the plate which is the right and which the left side of the patient. At the first examination both kidney areas should be examined, and the light should be centrally placed in relation to the patient. Should more detailed information be required to elucidate some point, oblique rays may be used, or one spot may be examined by means of a diaphragm. Inspection with the fluorescent screen may be used as a preliminary to the production of a radiogram, but it is an unreliable method of examination and cannot replace radiography. The photographic negatives should be examined in preference to prints in doubtful cases. It cannot be too strongly insisted that every radiographic ex- amination in urinary disease must include the whole urinary tract. Both kidneys, both ureters, the bladder, and the urethra must be examined. Radiography in Eenal Calculus Radiography is used for the following purposes in renal cal- culus : — 1. Diagnosis of the calculus. 2. Examination of the condition of the calculous kidney. 3. Localization of the calculus. 4. Examination of the second kidney. 1. Diagnosis of renal calculus, (a) Position of the shadow. — In the radiogram the bodies of the vertebrae and transverse processes, the last two ribs, and the iliac crests will be visible, and these act as landmarks. The following points in regard to the normal relations of the kidney to the bony skeleton are therefore extreniely important. The upper part of the kidney lies under cover of the last two ribs, the upper border corresponding to the middle of the 11th dorsal vertebra and being covered by the shadow of the 11th rib. This rib may therefore be taken as representing the upper limit of the renal area. The lower border reaches the level of the lower border of the transverse process of the 3rd lumbar vertebra. The right kidney lies a little lower than the left. In radiograms the lower border of the kidney usually comes a little lower than this, and the upper border scarcely so high. The outer border usually lies well beyond the tip of the 12th rib, but the varying length and obliquity of this rib make it an unreliable guide. I have adopted the following method of measurement by which the outer border of the normal kidney can be indicated and any increase in size demonstrated. If the narrowest transverse measure- ment of the 1st lumbar vertebra be taken, and this measurement Fig. 1. — Shadow thrown by gall-stone in renal area (upper arrow) ; shadow of right lobe of liver (lower arrow). (P. 39.) Fig. 2. — Shadows thrown by bismuth-covered feeces during adminis- tration of bismuth. (P. 41.) Fig. 3. — Shadow thrown by intra-abdominal calcareous glands. The shadow lies on the psoas-muscle shadow at the level of pelvis of kidney, but just internal to it. (P. 39.) Plate l. ni] RADIOGRAPHY IN RENAL CALCULUS -'^'-^ doubled and projected transversely tVoni the middle? of the outer edge of the vertebral body, a point will be found. If the same measurements be made in regard to the 2nd and 3rd lumbar vertebrae, two other points are found. By joining these three points the outer border of the kidney is roughly in- dicated. The kidney does not, however, lie flat on an even bed of muscle. The inner border is tilted so that the hilum and pelvis face forwards and inwards. As a result, shadows of calculi lying in the pelvis of the kidney may appear in the kidney area as if embedded in the substance of the organ. The inner border of the kidney corresponds with fair accuracy to the outer border of the psoas shadow, and the hilum lies in this line at the level of the 2nd lumbar vertebra. The pelvis of the kidney lies at this area and over- laps the psoas shadow. In full ex- piration and in full inspiration, in the supine and in the erect posture, the kidney shadow lies higher or lower respectively, and in some cases the excursion is considerable. Shadows in the renal area are, so far as position is concerned, most probably calculi embedded in the kidney (Plate 20, Figs. 1, 2) ; those in the pelvic area are stones in the renal pelvis. Lying outside and pjg^ 16.— Gall-stone which below the kidney is the colon, and threw a radiographic this also passes in front of the shadow in renal area. kidney, so that opaque bodies in the colon may give shadows in the renal area. This difhculty more frequently arises on the left side, where the colon covers a larger area of the kidney, than on the right. This does not affect the pehdc area, but in this area calcified glands in the lumbar chain or in the mesentery may throw shadows (Plate 1, Fig. 3). Immediately outside the renal area on the right side at the level of the 1st lumbar vertebra are the gall-bladder and ducts. Rarely, a shadow may be throwii by a gall-stone and appear in this area. Plate 1, Fig. 1, shows- the shadow of a gall-stone which I re- moved from the cystic duct ; Fig. 16 shows the gall-stone itself. The patient had been unsuccessfully explored for renal calculus in South Africa. The kidney which contains a calculus may be movable or dis- placed. When the outhne of the kidney is seen in the negative the relations of the suspected stone shadow to it will be evident. • 40 THE KIDNEY [chap. The displacement is usually vertical ; seldom, if ever, outward. A stone in the pelvis of a horseshoe kidney is much nearer the middle line than the normal pelvis, and is usually at a lower level. After an operation upon the kidney the organ is usually found displaced downwards, and may be partly' hidden behind the shadow of the iliac crest. Distension of the renal pelvis with coUargol solution (Pyelography, p. 42) may give valuable assistance in localizing a doubtful shadow. (b) Size, shape, and number. — Small stones usually throw a round or oval shadow. Stones the size of a split pea may be recognized unless composed of pure uric acid. The size of the shadow is several times greater than that of the stone, if the stone be opaque throughout. Move- ment of the stone due to deep breathing will cause a round stone to throw an elongated shadow. When a pro- longed exposure has been given, some very small stones, which are eventually passed through the ureter, do not cast a shadow on even a good plate. Large stones are usually branched, and the main mass throws an extensive, heavy shadow (Plate 20, Fig. 1, and Fig. 17). The branches which are connected by a narrow neck may appear isolated. In the larger masses of stone the shadows extend down- wards beyond the kidney area, and may be partly hidden by the iliac crest. A collection of stones may throw a single shadow. (c) Density of the shadow. — The density of the shadow depends upon the size and composition of the calculus. A large mass of calculus will throw a heavy, uniform shadow, whatever its composition may be ; a small calculus will throw a shadow whose definition and opacity depend upon its composition. , Oxalate- of-lime stones are the least permeable to the rays and throw the densest shadow, the rare cystin and xanthin calculi throw a shadow slightly less dense, calcium phosphate is next, and triple phosphate is much less opaque. Pure uric-acid stones throw little, if any, shadow, and are not recognizable in the body. Calculi are seldom Fig. 17.- -Branched calculi removed from kidney. in] RADIOGRAPHY IN RENAL CALCULUS 41 composed of a single ingredient, and a coating of phosphates will occasionally render a uric-acid calculus opaque. Fallacies. — Fallacies due to the size and composition of a cal- culus have already been noted. Opaque substances in the bowel may closely simulate renal calculi. A shadow of very irregular shape is unlikely to be caused by a calculus. Sometimes the shape is that of some recognizable object, such as a coin. A long, opaque body lying transversely is not renal, and is usually in the bowel. In a patient who has been taking bismuth, shadows which are indistinguishable in size, shape, position, and density from those of renal or pelvic calculi may be thrown by bismuth-covered faeces. The bismuth shadows shown in Plate 1, Fig. 1, remained for several months, in spite of repeated purgation. Calcified glands belonging to the lumbar group or Ipng in the mesentery, or the deposit of phosphates upon silk ligatures used in a previous operation, may simulate renal or pelvic calculi. In- definite shadows are sometimes found in the kidney or pelvic area, which have proved to be due to thickened scars in the kidney or to phosphatic deposit in an inflamed or tuberculous renal pelvis. Fallacy due to gall-stones has already been mentioned. In an aseptic case the absence of a stone shadow after two or more examinations, when a plate of first quality has been obtained, excludes all but a pure uric-acid calculus. When the urine is alkaline the absence of a stone shadow excludes calculi of any composition, for it is certain that phosphates will have been deposited upon a uric-acid calculus and render it opaque. 2. Condition of the kidney.— In slight dilatation of the kidney the measurement given above will serve roughly to demon- strate the change. I have introduced a more accurate method of measurement of the kidney shadow. A ureteric catheter, alter- nately opaque and translucent in segments of half an inch, is passed up the ureter of the diseased kidney ; on the plate the shadow- value of half an inch is obtained, and by using this the shadow of the kidney can be measured in half-inches. In a greatly enlarged calculous kidney the shadows extend downwards and outwards beyond the normal limits. The stone shadows may merge with, and be partly hidden by, the iliac shadow. The upper limit does not, however, extend higher than the normal kidney at the level of the 11th rib. Where a very large branched shadow or many stone shadows are observed, the kidney will be found practically destroyed. Isolated stone shadows widely separated indicate that the kid- ney is dilated with pus or urine, and a large kidney outline will confirm this. 42 THE KIDNEY [chap. The use of collargol in the diagnosis of hydronephrosis will be described later (p. 176). 3. Position of the calculus. — Several cases are recorded in which symptoms of stone were present in one kidney, and radio- graphy showed that this kidney was free from calculus, but that the second kidney was the seat of calculi. Shadows lying far out in the kidney area are cast by calculi embedded in the calyces, and the position of the shadow will indicate whether the stone lies at the upper or the lower pole of the kidney. A stone shadow lying over or above the 12th rib shadow and far out, in a short, stout patient, is likely to give rise to difficulty in its removal. Pyelography is valuable in accurately localizing the position of the calculus. 4. Examination of the second kidney. — When a stone shadow has been found in one kidney, information in regard to the second kidney may be obtained by examination of the plate. If the outline of this kidney is seen and is normal, this will demon- strate the presence of a second kidney, although it will not indicate functional power. The most frequent disease of the second kidney, when one organ is the seat of calculus, is the formation of calculi, and the absence of stone shadows in the kidney will exclude this. Radiogeaphy in Hydronephrosis and Pyonephrosis A large, dense shadow is thrown by a distended kidney. The upper and inner parts are difhcult to define, but there is a sharp and easily distinguishable outer and lower border. It is impossible to distinguish, in a radiograph, between a hydro- and a pyonephrosis. Pyelography (Plates 2, 3, 4). — Voelcker and Lichtenberg introduced a method by which the early stages of dilatation of the renal pelvis can be recognized. These observers inject a warm solution (2 to 5 per cent.) of collargol, an innocuous preparation of silver, through a ureteric catheter into the renal pelvis. A radio- gram is now made, and the size and shape of the renal pelvis can be seen. Lime-water, argyrol, and other solutions have also been used, but are less opaque. I have used this method in a large number of cases, and have obtained striking pictures of the renal pelvis which clearly demonstrate the position of the pelvis and the presence or absence of dilatation. A catheter is passed up the ureter so that the eye enters the renal pelvis, and the contents are allowed to run off. The bladder is emptied and the cystoscope removed, leaving the ureteric catheter in position. The collargol solution is heated and slowly introduced. I use a 10 or a 20 per cent, solution, and introduce it by means Fig. 1. — Pyelography : Injected pelvis showing dichotomous out- line and calyces. Note axis of upper end of ureter and of pelvis are in line. (P. 42.) Fig. 2. — Pyelography : Collargol which has regurgitated into bladder (arrow). Opaque catheter in ureter, (P. 42.) Fig. 3. — Pyelography in movable kidney: Kinking of ureter and dilatation of upper calyx. The lowermost arrow points to the upper end of ureter, the middle one to the kinked pelvo-ureteral junction, and the uppermost one to the dilated calyx. (Pp. 79, 176.) Plate 2. Ill] PYELOGRAPHY 43 of an all-glass syringe of 20 c.c. capacity. The barrel of the syringe, filled with solution and with the piston in place, is attached to the catheter by means of the needle, and held 6 in. to 1 ft. above the level of the body. The fluid passes slowly in, and is assisted by an occasional touch on the piston. No force is used, and the injection is stopped whenever the patient feels the pain of dis- tension of the pelvis ; the syringe is removed, the catheter plugged, and the radiograph is taken. The ureteral catheter should be opaque to the X-rays. The fluid is now allowed to flow oii. The catheter is removed in ten minutes. Pain is usually only present when, the pelvis is fully distended, but occasionally there is an attack of renal colic. In the radiographic plate the uretero-pelvic junction should be examined for kinking, and the pelvis and calyces for dilatation. The earliest stage of dilatation is shown by club- bing of the calyces. . Later, the calyces become much- enlarged and approach the surface of the kidney, and the kidney tissue between them is reduced (Plate 3, Fig. 1). The angle formed between the lowest calyx and the ureter and pelvis becomes more and more acute as dilatation proceeds, and eventually there is only a narrow slit remaining (Plate 3, Figs. 1, 3). A hydronephrosis shows as a mass of opaque nodules separated by thin, clear lines — renal type (Plate 4, Fig. 1) ; or as a large opaque mass with small bosses projecting from its surface— pelvic type (Plate 3, Figs. 2, 3). In the normal kidney the point of the ureteric catheter enters the upper calyx of the renal pelvis, and can be seen here in a collargol plate (Plate 4, Fig. 3). In hydronephrosis the catheter impinges on the upper wall of the dilated pelvis (Plate 3, Fig. 3). Braasch has recorded cases of renal tumour, tuberculosis, and other renal diseases in which he has used the method. Radiography in Renal Tuberculosis Clark, Brown, and others have shown that radiographic shadows are thrown by chronic tuberculous " abscesses " of the kidney. The opacity depends in part upon the presence of phosphatic salts in the milky or putty-like substance found in these " abscesses," but also upon the greater bulk of the kidney which contains these collections. In Plate 5, facing p. 58, are shown the outhne and details of structure of a tuberculous kidney converted into a multi- locular sac filled with putty-like material. Radiography in New Growths of the Kidney Large growths of the kidney cast a dense, ill-defined shadow which extends beyond the normal limits of the kidney. 44 THE KIDNEY [chap. Dangers of Radiography All possible care must be exercised by the radiograpber in avoiding undue exposure of the patient, rough handling, or too severe pressure upon the kidney. I have seen a severe attack of haematuria with an increase in all the symptoms follow a radio- graphic examination of a tuberculous kidney, and a serious crisis of fever and reduced renal function supervene in bilateral calculous disease. The collargol method must be used with the greatest possible care and gentleness, and is only safe and reliable in the hands of an expert. LITERATURE Blum, Amer. Journ. Derm, and Gen.-Urin. Dis., March, 1912, p. 136. Braasch, Ann. Surg., Noy., 1910, p. 645. Brown, New York Med. Journ., March 31, 1906, p. 683. Clark, Med. News, Dec. 9, 1905. Keyes, Trans. Amer. Urol. Assoc, 1909, p. 351. Macintyre, Lancet, July 11, 1896. Voelcker und Lichtenberg, Miinch. med. Woch., Jan. 16, 1906 ; Beitr. Hin. Chir., 1907, lii. 1. Walker, Thomson, Lancet, June 17, 1911 ; Travis. Med. Soc. Lond., 1912. III. EXAMINATION OF THE BLADDER IN SURGICAL DISEASES OF THE KIDNEY The examination of most surgical diseases of the kidney is incomplete without examination of the bladder with the cystoscope. The method of performing cystoscopy will be described in the section dealing with diseases of the bladder. The cystoscope may be required to localize the disease. There may be disease of the bladder which has caused no vesical symptoms but has given rise to symptoms pointing to disease of the kidney. When a papilloma of the bladder is seated at one ureteric orifice there is often pain in the kidney on that side, and this, combined with haematuria from the papilloma, may cause a diagnosis of renal heematuria to be made if the cystoscope is not used. This is especially the case when the ureter and kidney are dilated from obstruction by a growth in the bladder. In such a case there is a painful enlarged kidney with haematuria, and with- out cystoscopy the kidney may be regarded as the source of the haematuria. In tuberculosis and other diseases of the kidney there may be signs of cystitis with no symptoms of disease of the kidney. The secondary nature of the vesical disease will be demonstrated by the condition of the ureteric orifice and area surrounding it and the efflux. j.ii.-m^^ ^^^^K£^^___ Fig. 1. — Dilated calyces in ureteral calculus. (Pp. 43, 176.) Fig. 2. — Hydronephrosis caused by aberrant renal vessels. Dilated renal pelvis shown by oval collargol shadow. (Pp. 43, 176.) Fig. 3. — Hydronephrosis (pelvic type) in movable kidney. Three arrows point to ureter ; the upper and lower to segments filled with collargol, the middle to an empty segment, probably a descending wave of contraction. The outer arrow points to the dilated kidney, the uppermost one to the greatly dilated pelvis. (Pp. 43, 176.) Plate 3. Fig. 1. — Double hydronephrosis. On the left is a hydronephrotic kidney filled with collargol. The clear bands (lower arrow) I indicate the fibrous septa. On the right is a very large hydronephrosis, the arrows pointing to shadows of widely separated calculi in the kidney. (Pp. 43, 176.) Fig. 2. — Pyelography : Normal trumpet-shaped pelvis and calyces. Arrows point to catheter in ureter, open angle between this and lower calyx, upper and lower calyces. (Pp. 43-6.) Fig. 3. — Pyelography: Normal trumpet-shaped pelvis with calyces. The point of the opaque catheter (arrow) is lying in the upper calyx. An arrow points to the lower calyx, and another to the open angle between this and the ureter and pelvis. (P. 176.) Plate 4. Ill] CYSTOSCOPY IN RENAL DISEASE 45 In many cases of pyuria and hseraaturia there are no definitely localizing symptoms, and cystoscopy is necessary to exclude disease of the bladder. In these cases a blood-stained or purulent efflux will indicate the kidney as the source of the haematuria or pyuria, and show which side is diseased. Information may bo obtained as to the state of the diseased kidney by observing the ureteric orifice. An open, rigid ureteric orifice denotes dilatation of the ureter and renal pelvis. A " dragged-out " ureteric orifice (Fenwick) is present in cases of advanced tuberculosis of the kidney or ureter. Here the orifice is displaced outwards and upwards, and resembles a tunnel. In cases where- the efflux is a semi-solid pipe of pus the kidney is functionally destroyed and is converted into a thin- walled sac. Large quantities of purulent urine are poured out of the ureteric orifice in cases of acute and subacute pyelonephritis. A cloudy efflux is present in the minor grades of pyelitis. Where no efflux is present on one side, and the cause is not some temporary cessation of the renal function, the kidney may be absent on that side, or the ureter may be blocked by kinking -or some other cause, or there may be a fistula of the ureter. When the kidney is absent or totally destroyed, there will be no movement at the ureteric orifice. When the kidney is present and secreting, and the ureter blocked, there will be an occasional • sluggish movement at the orifice, although there is no efflux. In the case of a fistula of the ureter the rhythm and force of the movements at the ureteric orifice may be normal, although there is no discharge of urine into the bladder. Lastly, information may be gained in regard to the presence and condition of a second kidney when one is diseased. The absence of a ureteric orifice on one side will usually denote the absence of the kidney on that side. The muscle of the trigone on the side corresponding to the congenitally absent ureter is often absent. Rarely, the ureter may open in some abnormal situation, such as the prostatic urethra. The presence of a normally placed ureter and the observation of an efflux from it mil in all but the rarest cases demonstrate the presence of a kidney on that side. In very rare cases two normally placed ureteric orifices lead to the ureters of a solitary kidney, one of the ducts crossing the middle line. In such a case the condition may be demonstrated by passing an opaque bougie into the ureter and obtaining a radiogram, or by pyelography. When there is disease, such as tuberculosis of one 'kidney and the bladder, the area of bladder mucous membrane around the ureteric orifice of the second kidney, and the orifice itself, may be 46 THE KIDNEY [chap, in free from disease. This is strong evidence but not absolute proof that the second kidney is not tuberculous. If the eflELux is clear on this side, this is further evidence, but it is necessary to examine the urine of this kidney separately in order to make certain of the health of the organ. Examination of the urine of each kidney.— In rare cases when there is known to be complete blocking of one kidney, or when a fistula drains away the urine from one kidney, it may be assumed that the urine passed through the bladder is derived from the other kidney, and examination of this urine will demonstrate the condition of the kidney. In all other cases the urine which is passed is a blend of that secreted by the two kidneys. In order to examine the functional activity of one kidney, and frequently to locahze disease to one kidney, it is necessary to examine the secretion of each organ separately. The urine of each kidney is obtained by means of separators or ureteric catheters (p. 367). Exploration of the kidney.— Exploration of the kidney by operation may be necessary in the following cases : — 1. To make a diagnosis in an abdominal tumour of doubtful nature. Laparotomy will be the best method. 2. To ascertain the nature of disease already localized to the kidney. An oblique lumbar incision and extraperitoneal examina- tion of the kidney is the method best suited to this purpose. 3. To ascertain the extent and connections and the condition of the lymphatics in a malignant growth of the kidney which has reached a considerable size. Either a combined lumbar extra- peritoneal examination of the kidney with an extraperitoneal exploration through an opening in the peritoneum in front of the colon, or a laparatomy alone, may be used. 4. To ascertain the presence and condition of the second kidney when one is diseased and nephrectomy is proposed. Exploration of the kidney for this purpose can only be necessary in the rarest cases. Cystoscopy and catheterization of the ureters have taken the place of this operation, and it is only when these methods are rendered impossible by inflammation of the bladder that this opera- tion is required. In some cases of tuberculosis of the kidney and bladder, when the bladder has been too irritable to permit of catheter- ization of the ureters, a course of tuberculin injections lasting three months has caused sufficient improvement to allow of ureteral catheterization. Exploration of the kidney in such cases is carried out through a lumbar incision, and the kidney is examined by inspection, 'palpation, and incision, and a shp of the kidney substance is examined microscopically. The abdominal route only permits of palpation, and has been proved to be worthless. CHAPTER IV ABNORMAL CONDITIONS OF THE URINE OXALURIA About 0-0172 grm. of oxalic acid is passed daily in the urine as calcium oxalate. This is derived from the food, and partly also from the tissues. It is -held in solution by the acid phosphate of sodium of the urine. Calcium oxalate is deposited in the form of octahedra or dumb-bell crystals, which are visible to the naked eye as sparkling particles in clear urine. The urine is usually pale and faintly acid. When calcium oxalate appears in a high-coloured urine it is said to result from the decomposition of urea, and is of no clinical importance. Crystals of calcium oxalate are some- times passed persistently for years with occasional attacks of severe oxaluria. Small masses of crystals clinging loosely together may be passed, and larger masses bound together with a colloid sub- stance form calculi. Increased excretion of oxalic acid has been observed in jaundice, diabetes, gastritis, enteritis, and pancreatitis, but is not constant in any disease. A deposit of these crystals may take place after eating certain vegetables, such as rhubarb, spinach, tomatoes, sorrel, and gooseberries. In many cases persistent oxaluria is accompanied by symptoms of dyspepsia and mental depression, or even neurasthenia. The exact relationship of these symptoms to the oxaluria, whether they are the cause or the effect, is not decided. The symptoms which are directly caused by the presence of large quantities of oxalate-of-lime crystals in the urine are due to irritation of the kidneys and urinary tract. Renal aching is frequently present, and is usually bilateral. It may, however, be more marked on or even confined to one side. Aching along the line of the ureter may also be felt. Unilateral renal colic may result from the passage of large quantities of oxalate crystals. The colic may be severe, and is indistinguishable from that caused by the passage of a calculus down the ureter. Heematuria may accom- pany the colic, and the blood is present in considerable quantities. 47 48 THE KIDNEY [chap. In less pronounced cases of oxaluria, blood discs are frequently found microscopically, when no staining of the urine is perceptible to the naked eye. Some vesical irritation is usually present in oxaluria, and fre- quency of micturition may be the prominent symptom. When an oxalate- of -lime stone is present, oxaluria may be pronounced ; but, on the other hand, there may be only a few crystals or none at all. All the symptoms of a calculus of the kidney, ureter, or bladder may be simulated by oxaluria. Exercise does not, however, affect the symptoms in the latter condition. Cystoscopy will show that no calculus is present in the bladder, and the X-rays fail to demon- strate a stone in the kidney or ureter. , Treatment. — The diet should contain little oxaUc acid and lime, and plenty of magnesia, for the latter favours solution of calcium oxalate. The bowels should be regulated, and all causes of intestinal fermentation removed. Articles of diet that are rich in oxalic acid, and therefore contra-indicated, are rhubarb, spinach, tomatoes, sorrel, gooseberries, strawberries, tea, coffee, pepper, haricots, beetroot, and dried figs, much milk, quantities of carbo- hydrates in the form of sugar and sweets. Calcium is in excess in the following foods, which should therefore be avoided, viz. veal, milk, eggs, fresh vegetables such as radishes, asparagus, spinach, cereals (especially rice), and hard water. Foods poor in lime, and therefore suitable, are meat (except veal), fish, bread, fruit, potatoes. Magnesium is abundant in meat, bread, potatoes, peas, apples, and beer, and these articles may be taken. Mineral acids, such as dilute nitro-hydrochloric, should be given, combined with strychnine. The acidity of the urine should be increased by the administration of acid phosphate of sodium, which is the natural solvent of the oxalate of lime in the urine. It should be dissolved in a large quantity of water and taken between meals in a dose of | oz. to 1 oz. daily. It occasionally causes troublesome diarrhoea, and the quantity may have to be reduced on this account. When much irritation is present, sandal- wood oil in capsules (10 minims thrice daily) and a diluent water such as barley water may be given for a week at first, and the acid treatment commenced after the most acute symptoms have subsided. Mineral waters which contain little lime, or such as are rich in magnesium and sodium phosphates, should be given. To the former belong Contrexeville and Vittel, and to the latter Kissingen. Hard water should be avoided, and also such mineral waters as contain lime (Rosbach, Apollinaris, Kronthal). IV] ABNORMAL CONDITIONS OF URINE 49 PHOSPHATURIA This term is applied to the presence of undissolved earthy phosphates in the urine. The phosphates form a flocculent deposit, or the urine may be milky and deposit a thick white layer. Occa- sionally in a clear, well-coloured urine numerous sparkling crystals of triple phosphate are seen. Phosphoric acid to the extent of 2-6 grm. is excreted daily in the urine in the form of phosphates of potassium, sodium, cal- cium, and magnesium. It is derived largely from the food, but partly from the tissues. The acidity of the urine is due to acid phosphate of sodium. The phosphates of lime and magnesium are only soluble in acid urine, and when the urine is faintly acid, neutral, or alkaline these salts are precipitated. -When the alkalinity is due to ammonia from decomposition of the urine, ammonio-magnesium phosphate is formed and is deposited. The phosphatic salts of sodium and potassium, which form about two-thirds of the total phosphates, remain in solution, whether they are acid, neutral, or basic. A temporary phosphaturia occurs after a meal from the diges- tion of food rich in salts of vegetable acids or alkaline carbonates, and partly from the withdrawal of hydrochloric acid for the gastric secretion. Phosphaturia is sometimes observed in children, and is here due to an increase of the calcium in the urine and deposit of calcium phosphate, without actual increase in the total phosphatic excre- tion. This increased calcium output in the urine coincides with a diminution in the calcium in the faeces, and is supposed to be due to an inflammation of the intestinal mucosa. This phos- phaturia may be the cause of scalding during micturition, and increased frequency of the act. In certain individuals of a nervous type, and in others during a period of nervous strain, a copious precipitate of earthy phos- phates may be present, so that the urine is milky when passed. Nervous dyspepsia is frequently present, and is said to cause the phosphaturia. The total daily excretion of phosphates is not increased in these cases. The phosphaturia is often intermittent in character, and occurs after a period of unusual anxiety. I have known patients, whose urine was continuously phosphatic at first, improve under treatment, so that the phosphaturia appeared only on the day on which their attendance was expected at hospital or in the consulting-room. These patients not infrequently . suffer from intermittent attacks of polyuria, or more strictly " hydruria." I have met with a patient whose urine varied in the course of one 50 THE KIDNEY [chap. day from a milky phosphaturia to a highly acid urine which deposited urates on cooling. Pronounced phosphaturia accompanied by dyspepsia and pro- longed intestinal derangement has been the prelude to bacteriuria in several patients under my observation. Patients aiTected with this type of phosphaturia usually com- plain of symptoms of dyspepsia, and frequently suffer from con- stipation. There is constant, dull aching over the kidneys, most marked in the morning on rising. The urine scalds when passed, and there is a feeling of dissatisfaction after micturition, and often some increased frequency of the act. The urethral mucosa is reddened, and the trigone red and congested, while the rest of the bladder is healthy in appearance. Such cases usually respond readily to treatment. A more serious form of phosphaturia has been called " 'phos- fJiatic diabetes.''^ In this there is an actual increase in the quantity of earthy phosphates, their proportion to the alkaline phosphates being as much as 5 to 2, or even more, instead of the normal 1 to 2. The quantity of urea may be normal, or may be increased, though in a less proportion than the earthy phosphates. The symptoms consist in extreme nervous irritability, dyspepsia, and aching pain in the back and suprapubic area. There are increased frequency of micturition and scalding, and these symptoms may be very distressing. Cystitis is caused by the presence of masses of phosphates loosely held together in the bladder. There is no de- composition of the urine, which is neutral or faintly alkaline and non -bacterial. Some of my patients have dated the onset of their symptoms from the day on which they entered the cold atmosphere of the temperate zone on returning from the tropics. There may be extreme emaciation. With a tuberculous heredity such cases as these may eventually develop phthisis, in others diabetes mellitus or insipidus has fol- lowed. A proportion of these cases recover and the symptoms disappear. In many patients suffering from chronic, posterior urethritis a slight degree of phosphaturia is present, and varies with the changes in the inflammation. In moderate cystitis without decomposition of the urine, phosphates may be present and powder the surface of the bladder mucous membrane. In these cases the phosphaturia is probably due to the local inflammation further reducing the acidity of a faintly acid urine. Decomposition of the urine with liberation of ammonia causes a deposit of ammonio- magnesium phosphate in cases of severe and old-standing cystitis, ulcers, malignant growths, and papilloma, and foreign bodies be- come encrusted with phosphatic deposit. IV] PHOSPHATURIA-BAGILLURIA 51 Treatment. — Children suffering from phosphaturia should sub- sist on a diet poor in calcium salts, and a milk diet should be replaced by one consisting partly of meat. In adults the slighter cases are treated by the administration of tonics and mineral acids, such as nitro-hydrochloric acid and strychnine, quinine, phosphorus, and cod-liver oil. Acid phosphate of sodium in doses of 10-20 gr. thrice daily speedily cures some cases, but in others is less efficacious than mineral acids. The two may be combined. Where the phos- phaturia is the cause of severe irritation and cystitis, belladonna and hyoscyamus, and occasionally sandal- wood oil, are useful. Opium may be given in full doses in the same forms of phospha- turia, but should hot be long continued. Alcohol, coffee, and tea should be avoided. Moderate exercise and relief from worry and anxiety should be recommended. Where the urine is decomposing the treatment is that of chronic cystitis. Sodium acid phosphate is especially valuable in these cases. Its use for increasing the acidity of a faintly acid urine, or for rendering an alkaline urine acid, was first advocated by Dr. Robert Hutchison. BACTERIURIA— BACILLURIA Bacteriuria or bacilluria is a condition of the urine in which bacteria are present in such abundance that they render the fluid cloudy to the naked eye. In bacteriuria inflammatory products cannot be detected by the naked eye, or at most are seen in very small quantity. It is also a characteristic of bacteriuria that symptoms of inflammation of the urinary organs are either absent or very slight. It is difficult to separate some cases of bacteriuria from cases of infection of the urinary tract where there is excessive bacterial growth combined with definite inflammatory reaction. The phenomenon of bacteriuria represents, however, a special type of urinary infection in which there is excessive bacterial growth and minimal reaction. Etiology. — Bacteriuria is found in infants and children, as well as in adults. Women are more frequently affected than men. Pathology. — The bacterium coli is present in pure culture in over 80 per cent, of cases. It is frequently atypical in its cultural characters. The bacillus of typhoid is next most frequent. The staphylococcus albus is sometimes present, and more rarely the proteus vulgaris, a streptococcus, or the bacillus subtilis. These bacteria are usually present in pure culture. Bacteriuria may arise spontaneously, or it may supervene in the course, or follow in the wake, of some urinary disease. In the cases which are spontaneous a history of constipation, diarrhoea, or indigestion can usually be 52 THE KIDNEY [chap. obtained, and in several cases I have observed pronounced phos- phaturia immediately preceding the bacteriuria. Other predis- posing causes are chronic septic conditions of the mouth and throat, operations upon the rectum and anus, and boils and carbuncles. Typhoid fever precedes the form known as typhoid bacilluria, and other fevers such as smallpox, diphtheria, scarlet fever, and measles may be accompanied by bacteriuria. The bacillus coli is frequently the bacterium present in the urine in these cases of bacteriuria associated with the acute fevers. Bacteriuria may supervene during the course of a subacute or chronic urethritis of the prostatic urethra, or a chronic prostatitis, or chronic seminal vesiculitis. It may immediately follow the passage of a sound or catheter. It may follow an acute attack of pyelitis, and I have observed a case in which it complicated a movable kidney with intermittent hydronephrosis. In such cases the growth of bacteria is strictly localized to the diseased area. In a prostatic case clear sterile urine may be drawn from the bladder, and in a pyelitic case the ureteric catheter demonstrates that the culture ground is confined to the renal pelvis. In a boy with stone in the ureter whose urine was previously clear and sterile, I have seen a bacteriuria suddenly appear, last for three days, and then as suddenly disappear. The bacteria gain admission to the urinary tract through the kidneys (haematogenous infection), or are intro- duced into the urethra or bladder by the passage of instruments, or may be deposited at the urethral opening in women and female children and ascend to the bladder (urinary or ascending infection). It has been stated that the bacteria may pass directly from the rectum through the rectal and bladder walls, but of this there is no reliable evidence. In most cases of hsematogenous infection the bacteria become implanted in some part of the urinary tract, and continue to pro- liferate there ; but there are other cases, I believe, where repeated infections from the bowel take place, the bacteria rapidly dis- appearing after each infection. In cases of uncomplicated bacteriuria post-mortem examination has failed to discover any lesion of the mucous membrane of the urinary tract. The nidus of bacterial growth in women is the renal pelvis in the great majority of cases ; in males it may be either ' the renal pelvis or the prostate. When the renal pelvis is affected the condition is frequently unilateral. The urine is hazy when passed, from the suspension of myriads of bacteria. Frequently an opalescent appearance is observed. On rotating a glass beaker containing the urine, so as to circulate IV] BAGILLURIA 53 the urine, and holding it to the light, a peculiar appearance is seen, like drifting mist or smoke, that is characteristic of the condition. This phenomenon is due to the suspension of fine particles (the bacteria) in fluid. It is to be seen also in the fluid obtained from a spermatocele, where the spermatozoa form the suspended particles. The reaction is usually acid, occasionally neutral, and rarely alka- line. On centrifuging it, no deposit, or only a very small quantity of deposit, is obtained, and the fluid remains cloudy. In most cases the urine has a peculiar strong fishy odour. It is never ammoniacal. There is usually a trace of albumin, and protein can be detected in most cases. Under the microscope the field is crowded ^vith bacteria, usually the motile bacterium coli. A few leucocytes may be found, and epithelial cells from the renal pelvis, ureter, and bladder or prostatic urethra. The only constant sign is the bacterial emulsion in the urine. The urine may be constantly cloudy for months or years, or it may clear and the bacteria disappear with almost startling suddenness. Just as suddenly the bacteria may reappear in as great quantity as before. I have seen the urine milky with bac- terium coli in the morning, and clear in the afternoon of the same day. There may be no symptoms at all, but signs of localized inflammation are seldom entirely absent. In cases of chronic prostatitis or posterior urethritis the symp- toms of these diseases are already present, and the bacterial con- dition of the urine is superadded. In bacteriuria arising without previous urinary disease there may be slight increase in the fre- quency of micturition, and some urgency or heat and burning on passing water. These symptoms are aggravated by cold and by dietary indiscretions. In children, nocturnal enuresis may result from bacteriuria. Here there is urgency and sometimes frequent micturition during the day ; in severe cases there may be diurnal incontinence. In cases where the prostatic urethra or prostate is the seat of the bacterial growth the last few drops of urine are often milky with bacterial emulsion, while the rest of the urine is merely hazy. In other cases the focus of bacterial growth is confined to the renal pehds. If the bacteriuria be superadded to some disease the symptoms of that disease will be present. In cases arising spon- taneously there may be some aching in the kidney and along the course of the ureter, and the kidney and ureter may be slightly tender. There are, however, cases where there is pronounced bacilluria with recm'rent attacks of high fever, but no symptom referable to the minary organs is present. 54 THE KIDNEY [chap. Prognosis. — In some cases bacteriuria is transient and appears for a few days only, disappearing under treatment. It may, how- ever, be more persistent, and frequently it continues with exa- cerbations and remissions for months and sometimes for years. During this time the condition may have no influence on the health of the patient. In all cases there is the danger that a period of lowered resistance from some other cause may be the signal for a virulent bacterial inflammation of some part of the urinary tract. Where bacteriuria is superadded to some disease already present, such as stone in the ureter or movable kidney, it is the precursor of inflammatory complications. Diagnosis. — The diagnosis is made by the observation of the characteristic appearance of the urine and bacteriological examina- tion. It is imperative to ascertain whether the bacilluria is the sole condition present, or whether it is superadded on stone, growth, chronic inflammation, or other pre-existing disease. Where bacil- luria is an independent condition it is necessary to find out where the focus of infection has commenced (e.g. appendix, bowel), and what part of the urinary tract is affected (e.g. prostate, renal pelvis). The latter can only be ascertained by examination of the prostate, by cystoscopy, and by examination of the urine obtained from each kidney by the ureteric catheter. Treatment. — The treatment consists in the administration of urinary antiseptics and diluents, local treatment of the focus of inflammation, and removal of the source of bacterial infection. Of urinary antiseptics the best are urotropine (15-30 gr. daily), oil of turpentine (15-30 minims daily) in capsules, hetralin or helmitol (30 gr. daily), and salol (30 gr. daily). The administration of diuretics and alkaline waters with these antiseptics appears to render the urine less suitable for bacterial growth. Contrexeville, Vichy, or Evian water may be given, or the patient directed to drink large quantities of distilled or barley water. Rovsing advises that in bacterial infection of the urinary tract a catheter should be retained in the urethra for a week or more while salol is administered by the mouth and large quantities of distilled water are drunk. An alternative treatment to urinary antiseptics is the adminis- tration of large doses of alkalis together with diuretics. Citrate or acetate of potash (60-90 gr. daily) is given with the diuretic waters already mentioned. Where the focus of bacterial growth is confined to the prostatic urethra and bladder, washing the bladder and urethra by Janet's irrigation method may quickly relieve the symptoms and suppress the bacterial growth. The solutions suitable for this irrigation are IV] BACILLURIA-H/EMATURIA 55 permanganate of potash (1 in 1(),()()0 to 1 in 5,000), oxycyanide of mercury (1 in 10,000), or nitrate of silver (1 in 10,000). When the bacterial nidus is situated in the renal pelvis, this may in some cases be washed with weak nitrate of silver solution (1 in 10,000) through a ureteric catheter. It is of the utmost importance to empty the bowel and prevent further absorption. A mercurial pill followed by a saline purge should be given, and attention paid to obtaining a regular and free action of the bowel. Small doses of calomel {j\—l gr.) may be given regularly after meals, or a larger dose (1-2 gr.) may be given once a week. In order to reduce the growth of the bacterium coli in the intestine a course of milk soured with the Bulgarian bacillus (B. Caucasicum) may be advised, and continued for several months. Anti-coli horse serum has been administered with some success in acute cases of bacterium coli infection of the urinary tract, and may be tried. A dose of 25 c.c. of the serum should be injected subcutaneously on three successive days. If improvement has not taken place at the end of that time the treatment should be abandoned. Calcium lactate (20 gr. thrice daily) should be admin- istered by the mouth to prevent the unpleasant effects of the serum. Treatment by vaccines gives varying results. In some cases the bacteria in the urine rapidly diminish in quantity, and in a few cases disappear, when the bacteriuria has been uninfluenced by other methods of treatment. In cases apparently cured by vaccines recurrence may suddenly take place. In cases treated by vaccines, and also in those treated by serum, the opsonic index of the blood may rise while the state of the urine remains unchanged. Vaccines should be prepared from cultures taken from the patient's urine. In bacterium coli infections small doses of vaccine up to 10 or 15 millions are less efficacious than higher doses from 30 millions and upwards. These should be given in graduated series up to 100 millions, or even higher, at intervals of a week. Where the bacteriuria is superimposed on some pre-existing disease of the urinary tract, the latter must be suitably dealt with as a preliminary to treatment of the bacilluria. The onset of bacteriuria in a case of movable kidney or ureteric calculus should be the signal for operative measures. HEMATURIA In haematuria the amount of blood in the urine may be so small that the microscope is required for its detection, or there may be so great a quantity that the fluid appears to consist wholly of blood. 56 THE KIDNEY [chap. An appearance resembling blood is given to the urine in hsemo- globinuria, and after the ingestion of some drugs, such as senna, rhubarb, sulphonal, etc. The final test for hsematuria is the dis- covery of red blood-corpuscles by the microscope. The urine in hsemoglobinuria has a peculiar purple colour ; it contains no clots, and there are no blood corpuscles even after centrifugalizing. Heematuria may take origin in any part of the urinary tract, and may be caused by a large number of surgical diseases. In examining a case of heematuria it is necessary first to localize the bleeding to one part of the urinary tract, and then to diagnose the disease which causes it. 1. Localization of hpematuria. — The discharge of blood from the meatus, apart from micturition, will indicate that the source of haemorrhage is anterior to the compressor urethrse muscle. At any part of the urinary tract behind the compressor urethree blood will mix with the urine and will only be discharged with it. RcBmaturia with other symptoms. — Hsematuria may be the solitary symptom, or it may be accompanied by other symptoms which indicate the source of the haemorrhage. Heematuria with fain. — Severe pain in one kidney and ureteric colic will localize the haemorrhage to this kidney, the renal pelvis, or the ureter. Dull aching in one kidney is not so reliable a symp- tom. A papilloma or malignant growth of the bladder at one ure- teric orifice may give rise to hsematuria with unilateral renal aching. Pain at the end of the penis on micturition points to the base of the bladder or the prostatic urethra as the source of the blood ; while pain at the base of the sacrum, in the rectum or perineum, will point to the prostate. Hwmaturia with frequent micturition. — Frequent micturition suggests the localization of the point of haemorrhage to the prostatic urethra or bladder. Copious bleeding which has come from the kidney may, however, cause irritation of the bladder, and this is more likely when clots are present in the urine. In some diseases of the kidney, such as tuberculosis, reflex irritation of the bladder is a prominent feature. It follows that haematuria with frequent micturition may be caused by disease of the kidney when the bladder is healthy. Heematuria with obstruction. — Urethral obstruction may be temporarily produced by the impaction of a clot in the urethra, but the combination of obstruction and haematuria is most fre- quently due to prostatic or urethral disease, A papilloma of the bladder situated near the internal meatus, or one provided with a long pedicle, may cause haematuria with attacks of obstruction. IV] Hv^MATURIA 57 Examination of the urine. — The colour of the urine may be of some assistance. The longer the blood remains in contact with the urine the more likely is it to be discoloured. The higher the source of blood in the urinary tract the more likely is it to be well mixed with the urine. Blood in a highly acid urine is brownish in colour, and in an alkaUne urine bright red. When much pus is mixed with the blood, and the urine is decomposing, a dirty- brownish, muddy appearance is given to the urine. The urine may have a brownish or smoky appearance. This indicates that the blood is small in quantity, well mixed with the urine, and the reaction acid. Such bleeding is usually renal in origin. In renal hsematuria the blood precipitates very slowly, so that a sediment forms only after several hours. In coffee-coloured urine the source of bleeding is frequently the kidney or kidney pelvis, but the blood- may come from the bladder or prostate, especially if there be urethral obstruction. Purple urine denotes venous bleeding, which may be derived from any part of the urinary tract. If the urine has a dehcate pink colour the blood usually comes from the bladder or the prostatic urethra. Bright-red blood indicates copious bleeding from an arterial source, and may be discharged from any part of the urinary tract. Disease of the bladder or prostate is the most frequent cause of such bleeding. Tyye of hcematuria. — The blood may be present at the beginning or at the end of micturition, or thoroughly mixed with the urine. Blood appearmg at the beginning of micturition (initial hsematuria) has a urethral origin, and usually comes from the prostatic urethra. Terminal hsematmia may mean that the first urine is clear and blood appears at the end of micturition, or that the earlier part of the stream is blood-stained and the last part pure blood. The blood in this type is derived from the prostatic urethra or the bladder. No inference can be drawn as to the source of blood which is mixed with the whole of the urine (total haematuria). Presence of clots. — The formation of clots depends largely upon the proportion of blood in the urine. Blood poured out in large quantities from the kidney or renal pelvis may clot in the ureter. Slender worm-like clots, 10 or 12 in. in length, are sometimes passed in such cases, and are diagnostic of the source of the bleeding. More frequently, however, the clots passed from the ureter are small plugs, | in. in length. The blood may be rapidly passed into the bladder and clot, there forming irregular masses or flat clots which indicate the position of the clotting but not the source of the hsemorrhage. Vesical hsemorrhage vdW produce these flat or irregular clots. Urethral bleeding may form a clot 58 THE KIDNEY [chap. which lies in the urethra and is discharged with the urine. This will form a long worm-like clot, not unlike that derived from the ureter, but it is thicker and shorter, and frequently shows en- largements and contractions corresponding to the varying calibre of the urethra. Albumin can be demonstrated in the urine in haematuria, even where the amount of blood is very small. In cases of renal hsema- turia, however, the quantity of albumin is in excess of what might be expected to be present from the admixture of blood. If on estimation the proportion of albumin to haemoglobin prove to be more than 1*6 to 1, this points to a renal affection as the cause of the hsematuria (Newman). In renal hsematuria the corpuscles often appear as pale discs, almost devoid of colouring matter, while the corpuscles that are added to the urine in the lower urinary tract are less changed. Epithelial and other elements may be found in the urine, and give an indication of the source of the bleeding. Casts of the renal tubules, if present, indicate a renal source of the hsematuria. Epithelial cells from the kidney, pelvis and ureter, bladder or urethra, may be discovered and help to localize the source of the haemorrhage. Examination of the patient. — This may reveal signs of dis- ease which point to the source of bleeding. The kidneys, ureters, and bladder should be examined by abdominal palpation, and the prostatic and membranous urethra, the prostate, seminal vesicles, bladder base, and lower ureters examined from the rectum. Cystoscopic examination. — The cystoscope is the means by which the source of the hsematuria can be localized with certainty. On cystoscopy, some disease of the bladder, such as papilloma, may be discovered ; or the bladder may be found healthy, and the hsematuria will be known to originate in the kidney, or kidney pelvis. On examining the ureteric orifices, changes may be observed, such as ulceration or tuberculous deposit, which will assist in the localization of the haematuria. Where no gross changes are present at the ureteric orifices there is sometimes a slight staining of the lips of the orifice on the side whence the hsematuria is proceeding. Examination of the efflux from the ureters may show blood-stained urine issuing from one or both sides. (Plate 5, Fig. 1.) When the quantity of blood is small it may be extremely difficult to detect any change in the efflux. The haematuria may sometimes cease suddenly before the cystoscopy, so that the examination must be repeated. Finally, the ureters should be catheterized and a sample of urine obtained from each kidney for microscopical examination. This examination should only be carried out by an expert, for the- Fig. 1. — Heematuria. Blood-stained efflux from left ureter. (P. 58.) Fig. 2. — Semi-solid pus issuing from ureter in case of chronic sup- purative pyelonephritis. Acute cystitis. (Pp. 65, 125.) Plate 5. IV] ESSENTL4L RENAL H/EMATURIA 59 technique is difficult, and bleeding is easily produced in passing the ureteric catheter, and thus the object of the examination is Ukely to be defeated. 2. Diagnosis of the cause of haematuria. — Haematuria may appear in almost any disease of the urinary organs. The character of the haematuria and the position it occupies in the symptomatology of each disease will be fittingly described under the various diseases. There is, however, one form of haema- turia which cannot be referred to any single disease, and it must therefore be dealt with in this place. Essential renal hsematuria. — This name has been given to a group of cases in which hsematuria has been localized to one kidney, and nephrotomy, with, in some cases, an examination of the kidney after removal, has failed to reveal the cause of the haemorrhage. More careful examination of these kidneys, however, shows that in most of them a partial chronic nephritis exists, and in a few there is a varicose condition of one or more of the renal papillae. The partial chronic nephritis which is present in these cases gives rise to no changes visible to the naked eye, so that the condition is readily overlooked when the kidney is examined by nephrotomy. Further, it is not found in every microscopic section of the kidney substance, so that it may be overlooked unless careful search be made in a number of such sections. In sC section of the renal cortex the tubules and glomeruh are normal in appearance, except at one part where there is a patch of fibrous tissue separating the renal tubules. The fibrous tissue may be poor in nuclei, or there may be an abundant infiltration of small round cells. Frequently the fibrous tissue forms a streak radiating towards the capsule ; occasionally it is subcapsular. The capsule is frequently thickened, and there may be a patch of thickening at the spot where an intertubular streak of fibrous tissue reaches the surface of the kidney. One or several completely sclerosed and atrophied glomeruli may be seen ; sometimes there is only a thickening of the capsule of Bowman. The walls of the vessels do not appear changed, but occasionally I have found the veins dilated, and there may be some perivascular infiltration of round cells. The tubules are frequently found filled with blood. The epithelium of the kidney is unchanged. A few cases have been recorded in which haematuria without other symptoms and without albuminuria has been caused by a more extensive unilateral chronic nephritis (Poirier, Loumeau). The characters of essential renal haematuria are as follows : It is spontaneous, and no cause can be assigned for the onset ; it is not afiected bv rest or movement. The blood is abundant and 60 THE KIDNEY [chap. well mixed, and the urine has a dark port-wine colour. Clots are very rarely formed. The heematuria is strictly unilateral ; it may suddenly cease after some weeks or months, and may as suddenly reappear and become persistent. In the intervals of clear urine no albumin can be detected and no tube casts found. No bacteria are found in the urine. There is occasionally a dull aching pain on the side from which the hsematuria proceeds : this is unaffected by movement. The kidney is not tender or enlarged. In thirteen cases of unilateral symptomless hsematuria in which I explored the kidney and removed a portion for examination the microscope showed patches of fibrosis of varying size in the cortex in all. The capsule was frequently thickened, solitary sclerosed glomeruli were sometimes found, and there was blood in the con- voluted tubules in seven cases. It is possible that the cause of these changes may be the excretion of bacteria by the kidneys in constipation and other conditions {see p. 120). A varicose condition of one or more of the renal papillae has been described by Fenwick and by Whitney and Pilcher. The origin of this varicose condition appears to be doubtful, and it may possibly result from a patch of interstitial nephritis similar to the condition described above. The type of haematuria and absence of other symptoms are similar. Profuse unilateral renal hsematuria which is unaccompanied by other symptoms is sometimes met with as a premonitory or early symptom of chronic Bright's disease. Roy, Harmonic, and Israel have described cases in which the symptoms of chronic Bright's disease developed several years after a spontaneous, symptomless hsematuria. Newman has recorded a case of severe renal hsematuria which preceded other symptoms of tubercular disease by two years. " Symptomless " hsematuria is a symptom of some growths of the kidney from a very early stage of their development. Treatment of essential hsennaturia. — Exploration of the kidney by operation is necessary in such cases of unilateral hsema- turia. If a papilla of the kidney shows congestion it may be cut away with a sharp spoon. Where no such appearance is observed and nephrotomy fails to discover any lesion in the sub- stance of the kidney, the wounds in the kidney and renal pelvis should be closed with catgut sutures. The hsematuria in the majority of cases ceases after the exploration, apparently as a result of pressure upon the bleeding vessel by the sutures. For this reason, and also because bilateral nephritis may give rise to unilateral hsematuria, nephrectomy should not be performed. Very rarely haemorrhage commences again and necessitates a second operation. IV] H/EMATURIA: TREATMENT 61 Hale White describes five cases of renal hsematuria in wKich the kidney was explored by nephrotomy and no lesion found. Two of these cases had a recurrence of haemorrhage, in three there was none. Decapsulation may be combined with nephrotomy, but the results are similar to those of nephrotomy alone, the haematuria recurring in rare cases. Treatment of hzematuria. — It is only in exceptional cases that treatment of haematuria apart from operative measures is required. The following drugs may be used, viz. morphia, ergot, ergotine, tincture of hamamelis, and calcium chloride or lactate. Of these, morphia and calcium lactate are the best. A hypodermic injection of morphia is given, and the patient placed on calcium lactate, 10 gr. in cachets being given every four hours for forty-eight hours. After this period the calcium lactate should be omitted. Local treatment. ^In renal hsematuria, dry cupping over the loin, and icebags over the kidney, may be employed. Adrenahn has been injected into the renal pelvis through a ureteric catheter, 1 drachm of a l-in-5,000 solution being used. Vesical haematuria. — A catheter should be passed and the bladder washed out with hot boric solution, or with a hot, very weak solution (1 in 15,000) of silver nitrate. Large quantities of these solutions must be used, the stream being supplied from an irrigatoi' or a large glass hand-syringe. A double-way catheter with continuous irrigation is often useful. After washing the bladder, 10-12 oz. of a solution of antipjrrin (10 per cent.) are introduced and left in for a few minutes, or 1 or 2 drachms of adrenahn solution (1 in 2,000) are injected into the bladder, left for a few minutes, and then run out. If clots are present in the bladder they may be washed out through a large catheter, or, better, through a large evacuating catheter such as is used in lithotrity. The rubber lithotrity bulb may be attached and the clots sucked out. 1) These methods should ^not be persisted in for long, and, if the clots are of large size and the bladder has become distended with them, suprapubic cystotomy should be performed, the clots cleared out, and a stream of hot boric solution (115° to 120° F.) passed through a catheter in the urethra, and allowed to well out of the suprapubic opening. A large drainage tube (1 in. diameter) should then be placed in the bladder, and the foot of the bed raised on blocks. LITERATURE Albarran, Prcssc Med., 1904, p. 657. Fenwick, Clinical Cystoscopy. London, 1904, Graff, Folia Urol., 1908, p. 274. 62 THE KIDNEY [chap. LITERATURE— co7itinued Israel, Deuts. med. Woch., Feb. 27, 1902 ; Mittheil. aus d. Grenzgeb. d. Med. u. Chir., 1899, p. 471. Klotzenberg, Zeits. /. Urol., 1908, p. 125. Kretschner, Zeits. f. Urol., 1907, S. 490. Legueu, Ann. d. Mai. d. Org. Gen.-Urin., 1891, p. 564. Pilcher, Ann. Surg., 1909, p. 652. Rovsing, Brit. Med. Journ., 1898, ii. 1547. White, Hale, Quart. Journ. Med., 1911, p. 509. Whitney, Boston Med. Surg. Journ., 1908, p. 797. PYURIA The presence of pus in the urine is, except in a few rare cases, a sign of inflammation of some part of the urinary tract. The inflammation may be confined to one segment of the urinary tract, such as the urethra, the bladder, or the renal pelvis, or it may be more widely spread, and affect the bladder and pelvis of the kidney. While pyuria is always due to inflammation, the ultimate cause of the inflammation varies. There may be a bacterial infection of an otherwise healthy urinary tract, or there may be bacterial infection superadded to stone, stricture, growths, or other gross lesions. Further, one bacterial inflammation may be superimposed or follow upon another of a different character : thus, a staphylo- coccal or streptococcal inflammation may be added to a tuber- culous inflammation. It is necessary to localize the origin of the pus as a preliminary to making a diagnosis of the cause. 1. Examination of the urine, {a) Quantity. — Apart from acute inflammation of the urethra, the distribution of which will be evident from the discharge of pus at the meatus, the largest quantities of pus are derived from purulent collections in the kidney. In cases of long-standing bladder inflammation the quantity of deposit may be large, but the proportion of pus is not so great. (6) Character of the pus. — Pus in small quantities makes the urine cloudy and opaque, and in large quantities milky. This may be equally produced by a copious urethral discharge and a pyelonephritis, but the clinical features of the cases are so obviously different that no question of differential diagnosis need arise. Pus from the urethra is mixed with a certain amount of mucus, so that the deposit, which settles quickly to the bottom of the glass, has a fluffy, feathery appearance. The urine in inflammation of the bladder gives a deposit which is billowy and fluffy, and occupies a large part of the glass without sinking heavily to the bottom. The urine is generally high-coloured and has a high specific gravity. In severe grades of old-standing cystitis the urine may be like coffee to which a large proportion of milk has been added. The sedi- IV] PYURIA 63 ment, after standing for an hour or two, is thickly viscous, and clings like slime to the bottom of the vessel. Renal pus — that is, pus which is produced in the renal pelvis or in a dilated kidney — gives a milky urine when passed, and a characteristic deposit on standing. A heavy solid layer of yellow or yellowish-green pus with a flat, even surface lies at the bottom of the vessel and rolls heavily to the lowest part when the vessel is canted. The supernatant fluid is cloudy with suspended pus or bacteria. The urine is usually pale in colour and of low specific gravity. When a suppurative renal disease is combined with cystitis, there is the solid layer of pus at the bottom of the glass, and above this is a layer of billowy, fluffy muco-pus. (c) Odour and reaction of the urine. — There is no unusual odour in the pyuria of a purulent urethritis. In bacteriuria, when the bacterial growth is excessive and the pyuria in minimal amount, the odour of the urine is " fishy." In chronic cystitis the urine becomes decomposed and has a pungent, ammoniacal odour. As a rule, purulent urine from the kidney has no strong or characteristic odour, but a purulent col- lection in a dilated kidney may be offensive, and a pyelitis mth excessive bacterial growth may possess a very strong, penetrating smell. That " acid pyuria is from the kidney and alkaline pyuria from the bladder " is no longer accepted as accurate. The following bacteria produce acute cystitis in which the purulent urine remains acid, viz. the bacillus coh, gonococcus, and bacillus typhosus ; while the tubercle bacillus produces a subacute or chronic cystitis Avith an acid urine. The bacillus coli is the most frequent cause of cystitis. The staphylococcus, streptococcus, and proteus are the bacteria of alkaline cystitis. These bacteria cause the ammo- niacal decomposition of the urine found in chronic non-tuberculous cystitis. The pyuria of pyelitis is usually acid, but not invariablv so. Ammoniacal decomposition may take place from the same causes as in the bladder. A slightly alkaline urine from the kidney is mixed with the acid urine from the second kidney, and the blended urine is acid. Catheterization of the ureters separates the alkaline and acid urines in these cases. (d) Type of pyuria. — The urine should be passed into two glasses. Pus appearing at the begimiing of micturition has a urethral origin. When the urine is clear at the beginning of micturition and purulent at the finish, the pus comes from the prostate or bladder. Intermittent pyuria is the special characteristic of the discharge 64 THE KIDNEY [chap. from an inflamed dilated renal pelvis. The urine is clear, or almost clear, for days or weeks, and during this time renal symptoms are present and increase in severity. Then the urine suddenly becomes thick with pus and the renal symptoms disappear. This is repeated at varying intervals. Intermittent pyuria may also be observed when an abscess sac repeatedly discharges into the bladder or urethra, or there is a diverticulum of the bladder which has become infected. (e) Chemical and microscopicai character of the urine. — Albumin is present in pyuria in a small amount, which is pro- portional to the quantity of pus present. When nephritis is pre- sent, as in pyelonephritis, the quantity of albumin is greater. In catarrhal pyelonephritis the albumin will only give a cloud, while in suppurative pyelonephritis it may be present in large quantity. If the albumin appears to be present in excessive quantities, renal complication may be suspected. The proportion of albumin to the number of pus corpuscles per cubic millimetre may assist the diagnosis. The albumin should bear the relation of 1 in 1,000 when the pus corpuscles number 100,000 per c.mm. In a urine which contains 40,000 per c.mm. and shows 2 per 1,000 of albumin, the albumin must be derived from another source than the pus. Epithelial elements may be present in the urine, but have rather less significance in regard to localization here than in hsematuria. Tube casts are found in the slighter forms of pyelonephritis, and are of importance in localizing the process where symptoms are absent or slight. 2. Presence of localizing symptoms. — The symptoms of prostatic disease and disease of the seminal vesicles, and rectal examination, will clearly distinguish pyuria which proceeds from these organs from that derived from the bladder and kidneys. In these cases clear urine may be drawn by catheter from the bladder, while the urine which is passed is purulent. The symp- toms of inflammation of the bladder will demonstrate that that organ is diseased, but the cystitis may be produced by secondary infection of the bladder from the kidney by way of the ureter, or there may be reflex bladder symptoms from the kidney without actual vesical disease. The renal symptoms in these cases are frequently minimal, while the bladcler symptoms are prominent. 3. Other methods of examination, {a) Cystoscopy. — The cystoscope is a means of localizing disease causing pyuria in a large number of cases which would otherwise remain obscure. When the cause of the pyuria lies in the bladder the disease will be diagnosed at the same time. When the kidney is at fault the source of the pyuria will be localized to one or both organs. IV] PYURIA— GHYLURIA 65 The examination of the ureteric orifices should not be neglected, even when all the symptoms point to cystitis and the cystoscope lends support to the view. Disease of the bladder exclusively surrounding one ureteric orifice, changes at the orifice itself, and the observation of murky or purulent^ urine coming from one ureter will show that there is disease of the kidney, whether renal symptoms are present or not. When the quantity of pus in the urine is small and the bladder inflamed, it may be very difficult to distinguish the pyuria by exam- ining the ureteric efflux. In such cases catheterization of the ureters will become necessary. A urine with a moderate quantity of pus and shreds is readily distinguished as purulent at the ureteric orifice ; when the pus is present in quantity the appearance of the efflux is unmistakable. Pipes of semi-sohd pus are observed issuing from the ureteric orifice in some cases of advanced sup- purative disease of the kidney. (Plate 5, Fig. 2.) (6) Catheterization of the ureters. ^When cystitis is pre- sent, catheterization of the ureters may be difficult. A general anaesthetic will be required, and a good deal of patience must be exercised. The various forms of separator are quite unsuitable for use in such cases. The urine collected from each ureter is com- pared, each urine is examined microscopically and chemically, and cultures are made. Very important information may thus be gained which cannot be obtained by other methods. In a case of chronic cystitis it may be possible to show by this means that purulent urine comes from one kidney and contains tubercle or colon bacilli, while the urine collected from the other ureter is healthy. (c) Radiography. — In cases of long-standing pyuria radio- graphy may show the presence of stones in one or both kidneys when no symptom of their presence has been observed. CHYLURIA In chyluria there is fat in emulsion in the urine so finely divided that no globules of fat are found with the microscope. The urine is milky, and on standing a layer like cream separates and rises to the surface. Shaking with ether extracts the fat and clears the urine. The condition is found in filariasis, in which the lymphatics are blocked with the filaria worms above the entrance of the lacteals. The obstruction causes dilatation of the lymphatics of the renal pelvis, ureter, and bladder, and eventually rupture of these vessels and mixture of chyle with the urine. The urine is clear in the morning after fasting. 66 THE KIDNEY [chap, iv PNEUMATURIA Gas is discharged with the urine and appears usually at the end of micturition, producing a gurgling, bubbling, or whistling noise and a peculiar sensation. Pneumaturia may result from the introduction of air into the bladder by means of a catheter or during evacuation after lithotrity. The gas may come from the intestine, escaping into the bladder by a vesico-intestinal fistula. There may rarely be spontaneous development of gas in the urinary tract. In some of these cases sugar is present in the urine, and the pneumaturia results from fermentation of the sugar and the formation of alcohol, setting free carbonic acid gas. This results from the action of organisms^ usually the Bacillus coli communis, but occasionally the Proteus vulgaris. Where sugar is not present in the urine the spontaneous formation of gas has been said to be derived from the blood or to be due to the action on the urine of gas-producing bacteria, such as the B. coli and the B. lactis aerogenes. Treatment. — When no fistula exists, treatment consists in removing the cause of the fermentation by washing the bladder and administering urinary antiseptics. Glycosuria should be treated. The treatment of fistula of the bladder will be discussed later (Chap, xxxix). LITERATURE Luetscher, Johns Hopkins Hosp. Bull., Oct., 1911, p. 261. Schnitzler, Internat. klin. Rundschau, 1894, pp. 265, 306. Wildbolz, Correspond. Bl. f. Schweiz. Aerzte, 1901 p. 683. CHAPTER V CONGENITAL ABNORMALITIES OF THE KIDNEY AND URETER FcETAL lobulation of the kidneys occasionally persists throughout life. The only clinical importance of this foetal form is that these kidneys, according to the view of some authorities, are specially vulnerable to disease. Kiister and Wagner state that they fre- quently become tuberculous. Complete absence of both kidneys is most frequently found in acephalic foetuses and other monsters. The condition has no clinical importance. Supernumerary kidneys are rare. A third kidney has occasion- ally been found post mortem, and very rarely on operation. CONGENITAL ABSENCE OR ATROPHY OF ONE KIDNEY —FUSED KIDNEYS These conditions are of extreme practical importance. I col- lected 93 cases of death from uraemia or anuria commencing within the first few days after an operation on one kidney, and found that there was no second kidney in 10 of the cases, and that the second kidney was " completely atrophied " in 8. In over 19 per cent, of these cases, therefore, the fatal result was due to the absence or atrophy of one kidney. Congenital Absence of One Kidney — Unsymmetrical Kidney The frequency with which unsymmetrical kidney or extreme congenital atrophy of the kidney occurs is about 1 in 2,400 bodies (Morris). The left kidney is more frequently absent than the right, and male subjects are more frequently affected in the pro- portion of two to one (left 127, right 97 — Mankiewicz). The renal vessels of the side on which the kidney is wanting are usually absent, or are quite rudimentary, being represented by a few small twigs which ramify in the retroperitoneal fat. The ureter is usually absent (93 per cent.). When present, it is repre- sented by a solid fibrous cord of varying length which finds 67 68 THE KIDNEY [chap. attachment to the bladder at its lower end and disappears in the retroperitoneal fat at its upper end. There may be no trace of the ureteric opening, and this half of the trigone of the bladder may be atrophied. A small dimple may sometimes mark the situation which the ureteric orifice would occupy, and sometimes an orifice is actually present opening into a lumen which extends for 1 to 2 cm. along the fibrous cord. The suprarenal gland is absent on the same side in 27-7 per cent, of cases. Associated with congenital absence of one kidney there is some congenital malformation in the genital system in 70-8 per cent, of cases, almost without exception found on the same side as the renal defect. Thus, in the female subject there has been uterus bicornis with imperfect development of the horn of the uterus on the side of the absent kidney, absence of the uterus, ovary, and Fallopian tube, formation of a septum in the vagina, and absence of the vagina ; in the male, absence or atrophy of the testis, vas deferens, and seminal vesicle have been observed. Other congenital malformations have also been noted, such as hare-lip and cleft palate, accessory auricles, double thumbs, web fingers and toes. The single kidney is usually larger than the natural size, but there are cases in which it is not increased in size. Sometimes the organ may be as much as twice the size of a normal kidney, or even larger. Such excessive growth cannot be regarded as due to compensatory hypertrophy. It may occupy the natural position in the loin, or it may sometimes be misplaced and lie in the iliac fossa or over the lumbar vertebrae or the sacrum. The kidney is sometimes lobulated, and may have lost its reniform outline and become rounded or globular or even irregular, but more frequently it retains its natural shape. The ureter is single and enters the bladder in the usual position. Occasionally the ureteric orifice in the bladder may be misplaced towards the middle line, or it may open in some abnormal position such as the urethra or vas deferens. Congenital Atrophy op One Kidney Congenital atrophy to the extent that the affected kidney is almost obliterated is very rare. Morris found only 3 such cases in 15,904 post-mortem examinations. Less complete atrophy of the kidney is more frequently observed. The atrophy may be due to chronic Bright's disease, to blocking of the ureter, or to embolism. The chief difference between cases of extreme congenital atrophy and congenital absence is that in the former some rudiment of the kidney is always found and the ureter is present, though some- times merely in the form of a fibrous cord. V] UNSYMMETRICAL KIDNEY 69 The rudinicntaiy kidney may be a fibro-fatty nodule, or it may be a fibrous nodule with cysts and traces of renal tissue. The shape and appearance may be that of a foetal kidney with the well- marked lobulation. Clinical facts relating to congenital absence or atrophy of one kidney. — To the surgeon, complete atrophy and total absence are synonymous terms. A single kidney is prone to be attacked by disease. Calculus is especially frequent in these kidneys. Newman collected 8 cases of single kidney affected with calculus ; Mosler found that 9 out of 12 cases of single kidney had calculi. Malignant growths have also been observed, while cases of tuberculous disease, hydro- and pyonephrosis, and chronic nephritis are recorded. Such diseases are rendered more serious by the fact that they develop in' a single kidney. Apart from this, however, the absence of one kidney does not of itself shorten life. This condition is found in bodies from infancy to old age. Newman collected 17 cases aged over 60 years. In the great majority of cases of single kidney the condition has been found accidentally post mortem. A few cases of nephrec- tomy of a single kidney are recorded. I have collected 18 such cases. It is imperative, therefore, that proof of the presence of a second kidney should be obtained whenever nephrectomy is proposed. The presence of some congenital abnormality of the genital organs, or even some congenital malformation elsewhere, should put the surgeon on his guard when dealing with a case of kidney disease. In 103 cases of congenital absence of the kidneys col- lected by Ballowitz, where the state of the genital organs w^as mentioned, there were 73 (70-8 per cent.) in which some mal- formation was present, and the majority of these were females (28 male and 41 female). The following means may be used to obtain proof of the presence of a second kidney, viz. (1) cystoscopy, (2) catheteriza- tion of the ureters, (3) lumbar exploration. 1. Cystoscopy. — In those cases where a kidney is congenitally absent the ureter is also absent, and there is, in many cases, no ureteric opening in the bladder. The ureteric orifice is absent in 33-3 per cent, of such cases (73 in 234 cases — Mankiewicz). It will therefore be possible, to make a diagnosis of congenital absence of a kidney by cystoscopy in one-third of the cases. Rarely the half of the trigone is absent or rudimentary on the side of the absent kidney (Fig. 18). This has been observed on the left side (4 cases) but not on the right. In some 70 THE KIDNEY [chap. cases a dimple may be seen in the position of the ureteric orifice. In a small number of cases there is a normal ureteric orifice which leads into a short tunnel in a rudimentary ureter extending upwards for a few centimetres. In such a ureter the normal rhythmic con- tractions of the functioning ureter are absent, and there is no efflux. It does not follow, however, that every ureter that is motionless under observation lacks a functional kidney. It fre- quently happens that while the surgeon is examining the ureteric orifice the ureter ceases to contract, and there may be a pause of several minutes' duration. 2. Catheterization of the ureters. — By this method there is pro- vided a means of proving that a patent ureter exists, and that a Fig. 18. — Bladder and prostatic urethra in a case of solitary kidney, showing absence of left half of trigone and of left ureteric orifice. functionally active kidney is present, and the functional value of the kidney may be tested by the various methods which have already been described (p. 20). If the catheter passes 12 or 13 in. along the ureter without hindrance, the patency of the duct is demonstrated ; but if the catheter is arrested at some point near the bladder orifice, it does not follow that the lumen ends here. The point of the catheter may be arrested by catching in a fold of mucous membrane, especially where there is over- or under-distension of the bladder, or a loaded rectum. A catheter with a smooth, rounded end is the best for use where such a fold is encountered, and various degrees of dis- tension of the bladder and elevation of the pelvis should be tried, and, if necessary, the rectum should be unloaded with an enema. A general anaesthetic may give assistance. V] SOLITARY KIDNEY 71 There are also pathological causes for the catheter being arrested at some point in the ureter, but these need not be discussed here, for their presence will already have led to the conclusion that a kidney exists on this side. The withdrawal of urine from a catheter lodged in a ureter is an almost certain proof that a kidney exists on this side. There are, however, rare cases in which two ureters arise from one kidney, and open into the bladder in the normal position {see p. 75). Pyelography (p. 42) will give valuable in- formation in such cases. 3. Lumbar exploration of the kidney. — A preliminary operation may be performed to demonstrate the presence of the second kidney. The organ is exposed by a lumbar incision, and, if a kidney be found, the size, appearance, consistence, and the microscopical character of a sUp cut from its substance are examined. Unless there is some suspicion as to the absence or atrophy or disease of a second kidney, this method is not likely to be used, but should the other methods already described fail, and a sus- picion of such a condition be raised, the use of lumbar exploration is fully justified. Operative interference in a single kidney has been frequently undertaken, in most cases without previous knowledge that the kidney attacked was a single organ. Winter records 4 cases of nephrolithotomy for calculous anuria in a single kidney where the patients recovered. In 18 cases of death from anuria after opera- tion upon a kidney, where the other kidney was completely atrophied or absent, I found that nephrotomy had been performed for tuber- culosis once and for stone once. In the remaining 16 cases nephrec- tomy of the single kidney was performed for the following condi- tions : Tuberculosis 3, calculus 3, hydronephrosis 4, displaced and floating kidney 3, cystic and hydatid cyst 2, carcinoma 1. Solitary or Fused Kidney Fusion of the kidneys into one mass gives rise to an organ pre- senting great variety in shape and size. The lowest degree of fusion is found where two kidneys are united by a fibrous band, and the highest where the two kidneys are indistinguishably fused in a single mass. Different names have been conferred upon some of the varieties. There are the horseshoe kidney, the S-shaped kidney, the long kidney, the shield-like kidney, etc. Some of these merit further notice. The horseshoe kidney. — This represents the most common and the smallest degree of fusion. Morris found the frequency of horseshoe kidney to be 1 in 1,000. The horseshoe is formed bv a union of the lower ends of the 72 THE KIDNEY [chap. kidneys by means of a band passing across the aorta and vena cava. More rarely the upper ends of the kidneys are united so that the concavity is downwards. The fused kidneys He nearer the middle line than normal, and they are usually misplaced downwards. The misplacement is never so great as in the more complete forms of fusion, but the uniting band frequently lies as low as the bifurcation of the aorta. The bond of union may be merely a fiat band of fibrous tissue, or it may be composed of renal tissue, which is spread out into a thin layer, or forms a bulky mass uniting the lateral organs. The traces of a median division have sometimes been observed on the anterior surface of the isthmus. The uniting mass Fig. 19. — Horseshoe kidney and abnormal renal vessels, ureters pass in front of the uniting band. The has taken the form of a third kidney, to each pole of which the lower pole of an abnormally placed kidney was welded (E,ayer) ; or the kidneys may be united by a large quadrilateral mass. One kidney may be much smaller than the other. The blood-vessels of each kidney may be normal in number, but abnormalities of character and distribution have frequently been recorded (Fig. 19), and are found in the more complete degrees of fusion rather than in the more perfectly formed kidneys. They may be asymmetrical. An increase in the number of arteries is frequent, and the isthmus may receive a special artery. The prin- cipal artery of each kidney arises from the aorta above the level of the renal pelvis and passes downwards in front of the pelvis. A V] HORSESHOE KIDNEY 73 smaller artery arises at each side from the aorta or iliac artery below the kidney and ascends to the lower pole of each kidney. Considerable variation is observed in the renal pelvis and ureter. Each kidney has usually a single pelvis and ureter, the ureter passing over the front of, very rarely behind, the uniting band (Fig. 19). The pelves may be increased in number and irregular in form, and are turned more to the front than normal. Very rarely the isthmus possesses a special ureter, which opens into the bladder in the position normally occupied by one ureter, while the ureter belong- ing to one of the kidneys is misplaced and opens into the bladder in some unusual position. Diagnosis. — The clinical diagnosis before operation of a diseased horseshoe kidney has only once been made, and that by Israel, in a student of medicine aged 23 years. The patient had suffered for four years from attacks of pain in the back and right side, recurring every fourteen days and accompanied by diminution of the urine. During an attack there was an ill-defined swelUng in the gall-bladder region, which reached as low down as the umbihcus. It was tender, and did not move with respiration or in varying positions of the body. The kidneys could not be felt in the normal position. The diagnosis of a horseshoe kidney depended upon the median position of the swelhng and the impossibility of feeling the kidneys in the normal position, and this was confirmed by operation. Suggestions have been made by different authors for the diagnosis of disease in horseshoe kidneys. According to Konig, one may suspect a horseshoe kidney if one feels a horseshoe-like swelling in front of the lumbar vertebras. In a case in which Kiimmel operated for stone and hydronephrosis in one half of a horseshoe kidney, the shadows in the radiograph were situated immediately adjacent to the bones of the 2nd and 3rd lumbar vertebrse, obscur- ing the transverse processes ; and he suggests that the median position of the shadows should raise the suspicion of a horseshoe kidney. Burghart regards as supremely important the detection of a large, pulsating, somewhat elastic tumour with irregular con- tour in front of and below the abdominal aorta, and over which a systolic bruit is audible, while there is no delay in the pulse in the peripheral arteries. Davidsohn found hypertrophy of the heart from compression of the aorta by the transverse band. This malformation of the kidney and also the fixed misplaced kidney have been mistaken for a mahgnant gro^Ai:h. Oliver relates such a case. Pyelography with an opaque catheter in the ureter should enable a diagnosis to. be made in such cases (p. 42). 74 THE KIDNEY [chap. The long simple kidney and the S-shaped kidney. — In both these varieties there is an end-to-end. fusion of the kidneys, and the combined organ is situated on one side of the vertebral column. In the simple long kidney the hilus of both the component kidneys is turned in the same direction. The ureter of the upper kidney passes to the opposite side of the bladder and opens in the normal position, and there is thus no crossing of the ureters. Both ureters have been known to open on the same side of the bladder. In the S-shaped kidney, or sigmoid kidney, the pelves of the component kidneys face in opposite directions (Fig. 20). The ureters may run parallel, or they may cross and open into opposite sides of the bladder. The shield-like or discoid kidney. — The kidneys are completely fused, and form a large, flat, lobulated mass, which usually lies in the middle line of the body, low down about the bifurcation of the aorta. There are usually two ureters, very rarely one. Another form of fused kidney is quite irregular in shape and in the number and distribution of the vessels. I have recorded an example of this form of kidney, for which I am indebted to Prof. Johnston Symington of Belfast. (Fig. 21.) This occurred in a female subject aged 19. There was no kidney on the left side. On the right side a kidney was situated in the right iliac fossa, and extended upwards to the level of the intervertebral disc between the 3rd and 4th lumbar vertebrae. The lower por- tion was bent nearly to a right angle with the upper part, and dipped into the pelvis, extending as low as the 3rd sacral vertebra. The kidney mass was supplied by three renal arteries, one from the right side of the aorta, one from the right common iliac, and a third from the bifurcation of the aorta. There were two ureters, which passed down and opened into the bladder in the usual situations. MISPLACED KIDNEYS Fixed misplacements are almost invariably congenital, movable displacements are usually acquired. Fixed misplacements only will be discussed in this place. The movable displaced kidney will be considered later. Fig. 20.— Sigmoid kid- ney. {After Br OS ike.) V] MISPLACED KIDNEY 75 III the inalformation of the kidney described above it was noted that in the slighter degrees of fusion of the organs the kidneys were either normally placed or were misplaced downwards to a slight degree, whereas in the more severe degrees of malformation the misplacement was considerable. It follows, therefore, that when Fig. 21. — Solitary misplaced kidney with two ureters, each of which opened in the natural position in the bladder. we consider fixed misplacements of the organs, many of the kidneys are malformed. A few fixed misplaced kidneys are normal in size and contour, but there is considerable malformation of the misplaced organ in the great majority of cases. The remaining kidney, if not fused, may be normal in structure and position ; but occasionally 76 THE KIDNEY [chap. there is no second kidney, or it is atrophied. The position of the misplaced kidney is at the bifurcation of the aorta, on the pro- montory of the sacrum, over the sacro-iliac synchondrosis, in the ihac fossa, or in the hollow of the sacrum. The suprarenal capsule is misplaced with the kidney in 9 out of 24 cases (Newman). Both kidneys may be misplaced. If only one kidney is misplaced, it is more frequently the left. The frequency with which fixed mis- placements of the kidney occur is about 1 in 1,000 bodies (Morris found 13 in 12,768). Where the left kidney is misplaced the descending colon crosses the middle line, and the first part of the rectum is on the right side of the sacrum. The vessels are usually abnormal in origin, number, and distribution. The renal artery may spring from the bifurcation of the aorta or from the iliac artery. Genital malforma- tions are as frequently found with malplaced as with malformed kidneys. Symptoms. — The pelvic kidney (Beckenniere) is more frequent in men than in women, but it is more likely to cause trouble in women. It gives rise to disturbances of menstruation, of preg- nancy, and of parturition. Apart from disease, to which these kidneys are unduly liable, most cases of renal misplacement cause no clinical symptoms. As Israel points out, disease of a misplaced kidney frequently gives rise to pain in the corresponding lumbar region, and is apt to distract attention from the real cause of the symptom. Persistent interference with defsecation has been noted as a symptom. Wehmer considers the following points important in the diagnosis of a misplaced kidney : — ■ 1. The discovery of a tumour lying upon the promontory or sacrum. 2. The absence of the kidney from the same side. 3. Together with these, the presence of pyuria or hsematuria, and of spasm of the bladder, especially connected with menstruation in women. 4. The demonstration of an abnormal course of the rectum by means of air inflation. 5. Exclusion of origin of the tumour from the pelvic organs. Ovarian cysts and hydatid cysts are most difficult to distinguish. Hochenegg felt the pulsation of several arteries on the anterior surface of the tumour, which corresponds to the hilum, and found a very short ureter on catheterization. Psychic disturbances are noted by Hochenegg and Israel as accompanying congenital mis- placement of the kidney. The only published clinical preoperative diagnosis of a pelvic V] MISPLACED KIDNEY 77 kidney has been made by Miillerheim. Israel suggested such a condition as extremely probable in a patient sent to him as a case of malignant growth of the rectum, and his suggestion proved correct. When a doubtful tumour is found in this situation, an exploratory laparotomy has been necessary to make a diagnosis. Catheterization of the ureter with an opaque bougie and pyelo- graphy would make the renal nature of such a tumour clear. Treatment. — When the nature of the tumour has been recog- nized it will be necessary to have certain proof of the presence and activity of a second organ before removing the misplaced kidney. When this is obtained, Wagner recommends the removal of the misplaced organ, even if it is normal, where profound psvchic disturbances are present, or where interference with the bowel causes general symptoms. Frank found a peh^c left kidney and a malformed uterus on laparotomy, and displaced the kidney upwards above the brim of the pelvis, and fixed it there. Nephrectomy has frequently been performed. Israel removed the kidney extraperitoneally by a lateral incision, after allowing an exploratory laparotomy wound to heal. Cragin removed a misplaced kidney through the vagina, and Hochenegg another by a sacral route. Two cases are on record in which a solitary misplaced kidney was removed from the pehas (Buss and Polk). In both cases there was maldevelopment of the genital organs. The patients died, on the seventh and eleventh days respectively, of uraemia. LITERATURE Ballowitz, Virchows Arch., 1895, clxi. 309. Buss, Zeits. f. Min. Med., xxxviii. 4, 5, 6. Heiner, Folia Urol., Oct., 1908. Israel, Nierenkrankkeiten, 1901 : Berl. klin. Woch., 1889, xsvi. 71.5. Kiimmel, Arch. /. klin. Chir., 1901, vol. Ixiv. Manby, Lancet, 1885, i. 161. Mankiewicz, Centralhl. f. d. Krankh. d. Hum- u. Sex.-Org., 1900, v. 513. Morris, Surgical Diseases of the Kidney and Ureter, vol. i. 1901. Miillerheira, Deuts. mcd. Woch., 1902, xxviii. 46. Newman, Scot. Med. Surg. Joitrn., vol. i., Xo. 1, p. 53 ; Movable Kidney, Oliver, Brit. Med. Journ., Feb. 26, 1898. [1907. Owen, Med. Press and Circ, May 10, 1899. Polk, Xew York Med. Journ., Feb. 17, 1883. Preindlsberger, Wien. klin. Rundschau, 1901, p. 197. Walker, Thomson, Renal Function in Urinary Surgery, p. 155. 1908. Ward, Brit. Med. Journ., 1908, 1. 978. Winter, Arch. /. klin. Chir., 1903, vol. Ixix. CHAPTER VI MOVABLE AND FLOATING KIDNEY The normal kidney descends with inspiration and ascends with expiration, the excursion varying from |- to 1| in. In many normal individuals where the abdominal wall is not thick or resistant, the lower pole of the right and sometimes of the left kidney can be felt. Where one-half or more of the kidney can be felt and grasped between the fingers on inspiration the organ is unduly movable. Anatomy of movable and of floating: kidney. — A floating kidney is entirely surrounded by peritoneum, which also clothes its pedicle and forms a mesonephros. A floating kidney is a con- genital malformation, and is very rare. It cannot be diagnosed from a movable kidney without operation, and an intraperitoneal operation is required for its relief. A movable kidney moves behind the peritoneum and remains an extraperitoneal organ. The movable kidney moves within the perirenal fascia. The perirenal fascia is often greatly thickened, and the perirenal space enclosed within its layers is elongated. The delicate perirenal fat immediately surrounding the organ is usually diminished in amount, and sometimes is entirely absent ; it is occasionally present in considerable quantity. The fine fibrous threads which normally connect the fibrous capsule of the kidney with the perirenal fascia and cross the fatty envelope are thicker, tougher, and longer than in the normal state. The fibrous capsule may present no change, but milky patches of thickening are frequently observed and often the whole capsule is thicker and tougher. It strips easily from the cortex of the kidney. The renal vessels are elongated, the artery more so than the vein, as a result of the rigidity of the aorta com- pared with the vena cava. The walls of the renal vessels are usually thickened. There is no inflammatory matting of the vascular pedicle. Except in the rarest cases, the suprarenal capsule retains its normal position. The attachments of the kidney to the duodenum and ascending colon on the right side and the pancreas and descending colon on 78 VI] MOVABLE KIDNEY 79 the left are usually separated. Thick bands of adhesions between the kidney and the colon may, however, be found, and adhesions may form between the right kidney and the duodenum. The kidney mav become adherent to the structures surrounding it in an abnormal position, such as the iliac fossa. The kidney has been found in a congenital lumbar hernia and in a diaphragmatic hernia. I have met with a case in which a kidney could be completely projected by straining or coughing into a thin-walled lumbar hernia which had resulted from a badly repaired lumbar incision. The kidney could be grasped in the fingers and its outline and pedicle traced. Changes in the kidney substance may be referred either to interference with the blood supply or to obstruction of the out- flow of urine, and they may be acute or chronic. Torsion of the pedicle may occur even when a movable kidney has but a moderate range of mobility. The renal vein obstructed, the organ becomes engorged with blood. The kidney is enlarged and dark purple in appearance, and the fibrous capsule may be raised up by subcapsular haemorrhages. The urine is partly, and may be completely, suppressed. It contains blood and blood casts. After a time the torsion is relieved and the kidney returns to its normal condition. Kinking or twisting of the ureter may be caused by rotation of the kidney on its transverse axis and twisting of the ureter over the renal vessels, or by the kidney swinging at the end of its vascular pedicle and causing the ureter to become folded so that its lumen is occluded. The normal ureter is extremely mobile, and some degree of fixation by adhesions is necessary before kinking or test- ing of the tube can produce obstruction. (Plate 2, Fig. 3, facing p. 42.) The urine is pent up, and the pelvis distended. By pres- sure the pyramids of the kidney become flattened and the kidney is hollowed out, until eventually only a thin layer of kidney sub- stance remains. This condition is brought about by repeated attacks of obstruction of the ureter, which give rise to intermittent hydronephrosis. The upper end of the ureter is frequently found adherent for an inch or more to the surface of the dilated pehds. Chronic interstitial nephritis may be present in a movable kidney, and is due either to interference with the circulation or to pressure from obstruction of the ureter. Occasionally the undue mobility of the kidney is accompanied by enteroptosis. The stomach is frequently dilated. The movable kidney may be the seat of stone, tuberculosis, or new growth, or there may be hydronephrosis, caused by folding of the ureter oyer an abnormal blood-vessel. 80 THE KIDNEY [chap. Statistics of frequency, sex, age, and side affected. — The frequency of movable kidney is variously stated as from 44 per cent, to 56 per cent, in women, and 0-48 per cent, to 6 per cent, in men. At most, from 5 to 10 per cent, of women and from J to 1 per cent, of men have an abnormally movable kidney. A smaller number suffer from symptoms caused by the undue mobility. The average age is 33 1 years (Mc Williams). The right kidney is affected in 8 of every 10 cases, and both kidneys in 5 per cent, of cases. Etiology. — ^No one cause will satisfactorily explain the occur- rence of abnormal mobility of the kidneys in all cases. Three facts must be explained by any fundamental cause of movable kidney : (1) the preponderance of the condition in women (8 in 9 cases) ; (2) the frequency with which the right side is affected (8 in 10 cases) ; (3) the prevalence of the condition between the ages of 20 and 50. The following factors are of importance : — 1. Congenital mobility. — Congenital nephroptosis has been observed by Dr. W. R. Stewart and others, but the cases were examples of floating kidney. It is exceptional to meet with movable kidneys in children, and the condition develops at some period after puberty. 2. Anatomical factors. — The kidneys lie in a shallow recess on each side of the vertebral bodies, the paravertebral fossa. Wolkow and Delitzen state that in those persons with abnormally movable kidneys the paravertebral fossae are shallow and more .widely open at their lower ends than in normal individuals. In women they are shallower and more open than in men, and on the right side more than on the left. According to Mansell Moullin there is a slight rotation of the vertebrae to the right in a large number of right-sided people, and this makes the right lumbar recess shallower. The liver does not cause downward displacement of the right kidney. Becker and Lennhof look upon the build of the trunk as an important predisposing factor. Women with a long trunk and narrow waist more frequently have movable kidney than those with a short trunk and broad waist. These authors constructed a body index as follows : The distance in centimetres from the supra- sternal notch to the upper margin of the symphysis pubis is divided by the narrowest circumference of the abdomen and multiplied by 100. The normal quotient is 75. Where the quotient is above 75 one kidney will be movable ; where it is below this figure there is no movable kidney. This method has been elaborated by Harris, VI] MOVABLE KIDNEY: ETIOLOGY 81 who used the level of the tip of the 10th costal cartilage as a more exact transverse measurement. He also used a series of lateral and antero-posterior measurements made with calUpers to show that there was a diminution in the size of the zone at the level of the 10th rib in cases of movable kidney. 3. Atrophy of the perirenal adipose capsule. — In rapid emaciation the perirenal fat frequently disappears, and the kidney becomes unduly movable. This can only be a factor in the causa- tion of a few cases of movable kidney. 4. Weakness of the abdominal walls. — Glenard states that general enteroptosis always accompanies movable kidney, and results from weakness of the abdominal walls. This has been dis- proved by several observers. Grodard-Danhieux examined 131 cases of movable kidney without finding enteroptosis. Einhorn observed 27 cases of enteroptosis in which the kidneys were not movable. Where enteroptosis and nephroptosis coexist, they do not bear the relation of cause and effect. The relaxation of the abdominal wall after repeated pregnancies probably explains some cases, but movable kidney is frequently found in young nulliparae with strong abdominal muscles. In 61 cases of movable kidney, 38 of the patients were married, and of these only 22 had borne children (Mc Williams). 5. Injury and pressure. — In 11-4 per cent, of cases there is a distinct history of a blow, severe muscular strain, or other injury in the region of the kidney, which preceded the discovery of the movable kidney. The wearing of corsets has been stated to cause movable kidney. The waist line is, however, below the lower pole of the kidney, and, unless undue pressure is exerted at the upper part of the abdomen, the corset gives support to the kidney rather than causes its displacement. In races in which the corset is not worn movable kidney is observed. 6. Drag of adhesions between the kidney and bowel. — Bands of adhesions, probably secondary to chronic constipation, pass between the caecum and ascending colon and the right kidney, and the drag of these is a cause of movable kidney (Arbuthnot Lane). Adhesions may also be observed between the descending colon and the left kidney. 7. Pathological conditions of the kidney. — Tumours of the kidney, hydronephrosis, renal calculus, or other disease may coexist with movable kidney, and in some cases may appear to be a contributory factor in the causation of the mobility. Symptoms. — A movable kidney may have a wide range of movement and be unaccompanied by symptoms. When a patient 82 THE KIDNEY [chap. with a movable kidney discovers the abnormahty subjective symp- toms frequently develop, and it is generally accepted as unwise to inform a patient of the presence of undue mobility of the kidney if no symptoms exist. The symptoms which accompany movable kidney may be directly connected with the kidney, or they may be referred to other organs. 1. Symptoms referred to the kidney. — These are (a) pain and discomfort, (b) undue mobility, (c) enlargement of the kidney, and (d) changes in the urine. (a) Pain and discomfort. — The patient is often conscious of the movement of the kidney within the abdomen. Renal pain is felt in two positions — posteriorly, at the angle formed by the last rib with the erector spinse mass of muscle ; and anteriorly, at a point about 2 in. below and internal to the tip of the 9th costal cartilage. This corre- sponds to the position of the pelvis and vascular pedicle. The anterior area is that most frequently affected, and the pain is usually of a heavy aching character. There may also be attacks of severe pain on the side of the abdomen on which the kidney is mov- able, and this pain is most severe at the point indicated above. These attacks are followed by tenderness and sometimes by enlargement of the kidney. The pain of movable kidney is initiated or aggravated by move- ment and relieved by rest. It is sometimes first experienced on turning in bed, and may be felt on lying in certain positions. The aching is increased during the menstrual period. (b) Undue mobility of the kidney. — In examining the kidney the patient should be placed in the recumbent position described on p. 32. The examination should be made with gentle, firm pres- sure, the fingers of the examining hand sinking into the abdomen at each expiration and holding their position at inspiration. She should also be examined standing up facing the surgeon. If the loin can be grasped with the hand, the thumb should be placed in front above the upper pole of the displaced kidney with the fingers Fig. 22. — Chart of areas of mo- bility in three cases of movable kidney. The dotted lines show limits of excursion. VI] MOVABLE KIDNEY: SYMPTOMS 83 behind the loin. The fingers of the other hand are used to palpate the organ. The kidney can sometimes be made prominent on the surface of the abdomen in this way, and its outline distinguished with the eye. Three grades of mobility of the kidney are described: (1) where the kidney can be readily grasped below the ribs ; (2) where the fingers can be inserted above the upper pole ; (3) where the kidney moves freely about the abdominal cavity. (Fig. 22.) In slight degrees of abnormal mobility the kidney usually moves in a line parallel with the vertebral column, but sometimes it swings Fig. 23. — Movable kidney swinging on its vascular pedicle. round so that the lower pole approaches the bodies of the vertebrae. The latter has been called the " cinder sifting " movement (Morris). It is difficult or even impossible to detect this movement without the help of a general anaesthetic. In another form of abnormal movement the upper end of the kidney falls forward while the lower end remains in contact with the posterior abdominal wall. In the wider ranges of movement the kidney descends below the costal margin. At first the direction is vertical, and then the lower pole swings towards the vertebral column at the full length of its' vascu- lar pedicle, and the hilum, which at first faces towards the middle line, swings round to face directly upwards. (Fig. 23.) The lower 84 THE KIDNEY [chap. pole passes transversely and may cross the middle line by 1 or 2 in. Finally, there are cases where the vascular pedicle is so long that it exerts no control on the excursions of the kidney, and the organ may be found in almost any part of the abdomen and may descend into the true pelvis. Where the mobility of the kidney is marked, the organ is un- influenced by the respiratory movements, but many kidneys which are abnormally movable and of which the mobility is causing symptoms move with respiration. A movable kidney of normal size presents the following char- acters : The organ has a smooth, rounded surface, and the reniform shape can frequently be detected. The tumour escapes from the grasp of the fingers with a sudden slip that is characteristic. The patient experiences a sickening sensation when the organ is squeezed. The tumour can be reduced into the loin, and in this position may no longer be palpable. The kidney will usually drop again when the patient sits or stands. A kidney may be found freely movable at one examination while at the next it cannot be felt. It is therefore unwise, where movable kidney is suspected, to base a negative diagnosis on a single examination. (c) Enlargement of the kidney. — Intermittent hydronephrosis is an occasional result of abnormal mobility. The enlargement of the kidney may follow some muscular effort. In two cases under my care an attack of pain and distension of the kidney was in- variably brought on when the patient was confined to bed. There were numerous bands of adhesion between the movable left kidney and the descending colon in these cases, and the obstruction prob- ably resulted from the drag of a loaded colon. In the earlier attacks the hydronephrosis is small, but after several attacks it becomes large and forms a prominent swelling in the abdomen. After remaining for a variable time the swelling disappears and there is a marked transient polyuria. The hydronephrosis does not completely disappear between the attacks of acute distension, although it is so soft as to be unrecognizable on abdominal palpa- tion. A loose, partly filled, hydronephrotic sac will be found on operation in the interval between attacks of acute distension. (d) Changes in the urine. — Hsematuria may occasionally follow muscular effort and be accompanied by attacks of pain. It is not a frequent symptom. Very rarely there is moderate continuous hsematuria, which ceases when the patient is confined to bed. Albuminuria is frequently observed, and disappears on resting. Tube casts may be present in the urine. These are due to venous congestion ; they are present in 8 out of 180 cases of vij MOVABLE KIDNEY: SYMPTOMS «5 movable kidney (Newman). They disappear after the operation of nephropexy. Transient polyni'ia coinci(h'S with the relief of an attack of hydronephrosis. Anuria may result from torsion of the renal pedicle, and has been known to last nine days without ill after- effects. Frequent micturition may be observed during an attack of pain, and is due to reflex impulses from the kidney, or it may follow the relief of a hydronephrosis, and is due to the increased quantity of urine. 2. Symptoms referred to other organs. — These consist of (a) gastro-intestinal, (6) nervous symptoms. {a) Gastro-intestinal symptoms may be referred to the stomach. There is epigastric pain and burning unconnected with taking food. A sensation of sinking is complained of, and there is loss of appetite and nausea. Eructation, a feeling of distension of the stomach, and vomiting are frequent symptoms. In these cases the stomach is usually distended, and may be displaced. The patient becomes thin and emaciated. The right kidney is the one which is movable in these cases, and the condition is probably due to the drag of adhesions on the second portion of the duodenum (Frank), or of a thickened band of peritoneum upon the pylorus (Bramwell). Symptoms which are referred to the large intestine are consti- pation and flatulent distension of the colon. The attacks are recurrent, and so severe as to lead to a suspicion of intestinal obstruction from malignant growth or other cause. The symp- toms are probably caused by adhesions between the kidney and large intestine. Jaundice may be prominent. There are recurrent attacks com- mencing with severe epigastric pain, and the gall-bladder may be distended. These attacks cease after fixation of the kidney. They have been ascribed to pressure of the kidney on the common bile- duct, but are more probably due to dragging of the kidney upon the second part of the duodenum. (6) Nervous symptoms. — A varying degree of neurasthenia accompanies movable kidney in many cases. There are depression and irritability, giddiness, palpitation, neuralgic pains, loss of appetite, and sometimes loss of weight. It is held by Suckhng that some forms of insanity are due to movable kidney, and are cured by fixation of the organ. Acute attacks, or DietVs crises. — The patient suffering from mov- able kidney is liable to acute attacks or crises which may be due to the kidjuey dragging on the pylorus or bowel by adhesions, or to torsion of the vascular pedicle, or kinking of the ureter. Such an attack may follow some muscular efiort. 86 THE KIDNEY [chap. If the stomach or bowel is affected there is epigastric or general abdominal pain. The patient lies with the knees drawn up, or sits with the thighs acutely flexed on the abdomen, clasping the knees (Newman). Vomiting and collapse are usual. The abdominal muscles are rigid, and the rigidity may be most marked on the side of the movable kidney. Later the abdomen becomes distended and tympanitic. The stomach may be found distended, or the colon prominent. The bowels are constipated, and the temperature may be raised one or two degrees. In cases in which the ureter is obstructed there is no distension of the stomach or bowel, but on one side of the abdomen a large tender swelling rapidly develops. The swelling has the characters of a renal tumour. The urine is diminished, and there may be complete anuria. After lasting a few hours or some days, the swelling subsides and the symptoms disappear. If torsion of the renal vessels is the cause of the crisis the symp- toms are again those of an acute abdominal condition. In addition the urine becomes scanty, albuminous, and sometimes bloody, and complete suppression may supervene. The pain is most severe in the region of one kidney, and this organ is found to be enlarged and tender if it can be felt through the rigid abdominal muscles. When the attack passes off the secretion of urine is re-established, and polyuria may follow. The urine contains blood, and hyaline, granular, and blood casts. Diagnosis. — The great majority of cases of movable kidney occur in patients of moderate or slight build, in whom the abdomen is easily palpable, and the kidney readily felt and the condition diagnosed. The following conditions may give rise to difficulty in the diagnosis of a movable kidney : — 1. A distended gall-hladder. — There may have been an attack of jaundice or of haematuria which will point to the swelling being gall-bladder or kidney respectively. A distended gall-bladder is always palpable, whereas a movable kidney sometimes disappears completely. The range of movement of the gall-bladder is more restricted. When a movable kidney is reduced into the loin it only reappears on the patient breathing very deeply or sitting up. A distended gall-bladder reappears whenever the pressure of the examining fingers is removed. The kidney may be felt apart from the enlarged gall-bladder. The area of dullness over a dis- tended gall-bladder is continuous with that of the liver, and there is never bowel in front of it. The two conditions may coexist. 2. RiedeCs lobe of the liver. — The swelling moves with the liver in respiration, and the movement is greater than that in a VI] MOVABLE KIDNEY: DIAGNOSIS 87 kidiioy. The diilliiess is continuous with that ol: tlie liver, and the edge of the swelling is sharp. The right lobe of the liver dragged down by an adherent contracted gall-bladder may resemble an en- larged movable kidney. The edge is hidden by adherent bowel, but there is an absence of roundness of the outer border and lower pole. I have had a case of splenic leukaemia with enlarged spleen and liver referred to me as a case of bilateral movable kidney wdth anaemia. 3. A small ovarian tumour with a long pedicle. — The tumour can be reduced into the pelvis, but not into the loin. Careful examination will usually show that the pedicle of the ovarian cyst is attached below. Vaginal examination may demonstrate the pelvic attachment of the swelling. 4. A malignant growth of the large intestine may simulate a movable kidney. If may be possible to reduce the swelling into the loin in a manner similar to a movable kidney. Symptoms of intestinal obstruction are occasionally produced by a movable kidney, and this makes the diagnosis more difficult. A prolonged history of intestinal disturbance and the absence of urinary symp- toms will point to a tumour of the bowel. Where difficulty arises as to the nature of a swelhng in the region of the kidney, the introduction of collargol into the renal pelvis through a ureteric catheter, followed by radiography (pyelography), should be used to show the position of the renal pehas and calyces. By this means the relation of the kidney to the tumour will be demonstrated. (Plate 2, Fig. 3.) Radiography after a bismuth meal will further demonstrate the relation of the intestine to the tumour. While the recognition of a movable kidney is essential for the diagnosis, and a movable kidney is frequently the cause of symp- toms which are referred to other organs, it does not follow that where symptoms such as neurasthenia are present with a movable kidney the nervous symptoms result from the renal mobility. If the neurasthenia is known to have been present before the kidney became movable, and if the replacement of the kidney and its retention by lying in bed or the application of some mechanical support have no effect in allaying the symptoms, it is likely that the two conditions are independent. But if movement aggravates the symptoms and rest or support affords relief, there is a relation of cause and effect between the undue mobility of the kidney and the neurasthenia. Treatment. Selection of cases. — The careful selection of cases for the different methods of treatment is the only means of obtaining satisfactory results. In cases where no symptoms are 88 THE KIDNEY [chap. present and there does not appear to be any change taking place in the kidney itself, as shown by enlargement or tenderness of the organ or changes in the urine, it will only be necessary to limit violent exercises, such as horse-riding, and to warn against lifting heavy weights. The bowels should be carefully regulated. Should symptoms appear, active treatment of the mobility will become necessary. In such cases a choice will have to be made between palliative and operative treatment. In certain cases 'palliative treatment is contra-indicated and operative treatment is imperative : 1. Where there are signs that the mobihty is causing disease of the kidney. This includes cases in which the kidney is tender or enlarged, cases of intermittent hydronephrosis, cases in which heematuria or albuminuria is present, or there are tube casts in the urine, or slight or severe attacks of torsion of the renal pedicle have occurred. 2. Where the kidney is exerting harmful traction upon other organs. This includes cases where there are gastric and intestinal crises and attacks of jaundice. 3. Where the kidney lies below the waist line and is uncon- trolled by any mechanical apparatus, and the use of a mechanical apparatus causes pain and aggravates the symptoms. 4. Where the patient is going to reside in tropical or uncivilized countries. 5. Where the patient has to perform manual labour, and the expense of maintaining an apparatus in good order cannot be borne. In all other cases palHative treatment may be tried before resorting to operation. In certain cases operative treatment is contra-indicated, because doomed to failure : Where general enteroptosis is present. Where severe neurasthenia is present and no symptoms can be referred to the kidney. In a few cases of movable kidney with neurasthenia, control of the renal movements by a mechanical apparatus will alleviate or cure the neurasthenia, and in these cases also fixation of the kidney by operation will be followed by a similar result. This view is generally held, but a few writers go further and advocate operation in all cases of neurasthenia with movable kidney. Palliative treatment. 1. Treatment by rest and in- creasing the body fat. — It is claimed by a very few writers that this method can bring about a cure of the renal mobility. They hope by increasing the general fat of the body to produce a simulta- vi] MOVABLE KIDNEY: TREATMENT 89 .iieous deposit around the kidney, which will fix it in ]josition. Such a result is not obtained in practice. The method is, hcnvever, useful in treating cases of movable kidney in which neurasthenic symptoms are present. In these cases a " rest cure " should be the first resort and an operation the last. The patient is strictly confined to bed, and in severe cases full Weir-Mitchell isolation should be exacted. The bowels are care- fully regulated, and the food is chosen with the view of increasing the bocly-weight. Milk is given in large quantities, graduated according to the digestive powers. General massage is adminis- tered, but the kidney areas are not subjected to manipulation. The treatment extends over a month or six weeks. This is a useful preliminary to treatment by means of mechani- cal apparatus. 2. Treatment by mechanical apparatus. — Treatment by this means is especially indicated when enteroptosis is present. It is suitable for any case of movable kidney, with the exceptions already mentioned. Three forms of apparatus will be described : {a) Kidney truss. — The truss made by Ernst consists of a thin, carefully padded metal plate which exercises pressure upon the abdominal wall by means of two springs. The pressure concerns the lower and inner margins of the plate, so that the kidney is forced upwards and outwards. It must of necessity be applied when the patient is lying down. The truss must be very carefully fitted, and the patient trained and practised in its proper adjust- ment. She is able to take active exercise. (6) Kidney belt. — A kidney belt is an abdominal belt which is specially adapted for the relief of movable kidney. It consists of a broad band of jean or coutil which surrounds the waist and comes down over the iliac crests and is accurately moulded to the hips. The lower border follows the curve of the groin along Poupart's hgament, and in the middle line in front it slightly overlaps the pubic bones. The upper border is about the level of the umbilicus. The belt is stiffened by whalebone or light steel busks. It is laced in front and behind. At each side there is a broad inset of silk elastic. There are two perineal straps to prevent the belt from riding upwards. A kidney pad is added with the view of exerting pressure upon the movable kidney and retaining it in place. This may be horse- shoe-shaped or oval. The pad may be fixed in the lining of the belt, and consists of a rubber bag with a fine tube which pierces the belt and has a turncock. Or it may be a closed air sac or rubber bag containing glycerine, which fits into a pocket in the 90 THE KIDNEY [chap. lining of the belt. The belt must be put on when the patient is recumbent, and is worn over a silk or fine woollen under- vest. A belt of similar construction can be fitted to the lower part of a corset, and by this means the perineal straps, which are irksome, become unnecessary. The pads which are used in these belts do not control the move- ments of the kidney ; were they sufficiently large and firm to do so they would exert injurious pressure upon the bowel. Their use appears, however, to give a feeling of security to the wearer, and for this reason they may be worn. (c) Corset for movable kidney {Gallant). — The corset is made from measurements taken from the patient. At the bottom the front steels must overlap the upper half-inch of the symphysis pubis and fit very snugly over the hips, stretching tightly from one to the other to flatten and reduce the hypogastrium. The circumference must be equal to the natural waist, but there should be well-marked incurving of the sides, so that the clothing is supported, the corset prevented from slipping upwards, and a fashionable outUne afforded to the figure. At the back and sides the upper portion must accurately fit the thorax, while in front ample room must be provided for the replaced stomach. Below the waist the corset must be inflexible and inelastic, and the portion above the waist must permit free play to the trunk and thoracic walls. If the hips are poorly developed, pads should be stitched inside the lower part of the corset to give rotundity to the figure and avoid painful pressure on the iliac crests and anterior spines. One lace begins at the eyelet above the waist line, and is con- tinued down to the bottom of the corset. In the upper part a thin, flat hat-elastic is loosely threaded, so as to keep the corset in contact with the thorax but not to cause pressure. The following directions must be followed in putting on the corset : The lower lacing is freely loosened and the corset applied to the body over a fine woollen or silk vest. The patient lies on her back on a bed, and the legs are flexed to a right angle. The abdomen is massaged, by stroking upwards, for ten minutes. The corset is then drawn well down over the hips and fastened in front, beginning with the lowest hook. Without lower- ing the thighs the lace behind is drawn as tight as possible and tied. The corset must not be drawn down after the front has been fastened. The lower part above the pubes must flt so snugly that the VI] NEPHROPEXY 91 fingers can barely be inserted between the corset and the piibes when the patient is lying down. On rising, sitting, or walking the corset should not slip upwards. Uallant holds that from 90 to 95 per cent, of movable kidneys with symptoms are cured of the symptoms by wearing this corset. Operative treatment. — The preparation of the patient is similar to that in other kidney operations. The position depends upon the incision employed : for the oblique posterior incision the patient lies on the side with a pillow beneath the loin ; for the vertical posterior incision she lies prone with an air pillow beneath the abdomen ; and for the anterior incision the dorsal position is adopted. 1. The incision. — The usual incision is the oblique posterior, passing downwards and forwards from the angle formed by the last rib and the erector spinse mass of muscle for 4 or 6 in. The advantage of this incision is the good exposure and the possi- bility of unlimited extension. In it the latissimus dorsi and the three layers of abdominal muscles and the lumbar aponeurosis are cut. A vertical posterior incision along the outer border of the erector spinse muscle is used by Edebohls. The latissimus dorsi is pushed aside, and the external oblique pulled forwards. The lumbar aponeurosis is split vertically. The advantage of this incision is the slight disturbance of muscles. A disadvantage is that the exposure is limited. An anterior incision has been used by some surgeons (Harlan, Stanmore Bishop, Watson Cheyne). It runs from the anterior edge of the latissimus dorsi forwards for 4 in. parallel with the costal margin. Stanmore Bishop opened the peritoneal cavity ; Watson Cheyne pushes the peritoneum inwards and exposes the front of the kidney. This incision is less suitable for dealing with disease of the kidney which may accompany the undue mobihty. The advantage claimed for it is that it allows of the kidney being replaced and fixed in its normal position, whereas the posterior incision necessitates the fixation in an abnormal position. 2. Removal of the fatty capsule. — All authorities are agreed that the adipose tissue immediately surrounding the kidney should be carefully removed. The perirenal fat, the posterior layer of perirenal fascia, and the fat between this and the quadratus Imn- borum and psoas muscles must be dissected away, and the muscles laid bare. This can only be carried out satisfactorily through a free incision. 3. Methods of fixation. — i. By sutures passing through the kidney capsule or kidney substance. The suture material may be 92 THE KIDNEY [chap. catgut, silk, kangaroo tendon, or a strip of tendon from the erector spinse muscle of the patient left attached at one end. Strong catgut and kangaroo tendon are the best of these. If the suture is to be passed through the capsule alone, a small slit is made in it and a director passed along underneath, stripping it up for a varying distance and ending at a second small slit. The suture material is threaded along this tunnel and passed through the muscles of the abdominal wall. Several such sutures may be passed, and they may be placed at the convex border of the kidney or on the posterior surface. The sutures may be passed through the kidney substance about | in. from the convex border, and then through the muscles of the abdominal wall at the upper edge of the wound. ii. By stripping the capsule of the kidney (decortication). An incision through the fibrous capsule of the kidney is made along the convex border, and the capsule seized with dissecting forceps and stripped from both surfaces as far as the hilum, where it is clipped away. This is done with the view to producing adhesions between the stripped surface of the kidney and the surrounding structures. iii. By stitching the stripped capsule to the parietes. Many variations of this method have been introduced. The stripped capsule may be rolled up on the anterior and posterior surfaces of the kidney without carrying it as far as the hilum, and stitches introduced through the rolled capsule and the muscles of the abdominal wall. The capsule may be stripped in a number of wedges, each of which is stitched to the abdominal wall. The kidney may be slung by passing a strip of capsule through a slit in the ligamentum arcuatum externum (Foulerton). iv. By partial stripping and suture through the substance of the kidney. It may be necessary to explore the kidney, and the incision is placed along the convex border of the kidney. The nephrotomy wound is closed by four or five thick catgut sutures passed through the kidney substance. These are tied and left long. An elliptical incision through the fibrous capsule leaves an area of unstripped capsule, which contains the nephrotomy incision and the sutures closing it. The capsule is stripped from the anterior and posterior surfaces of the kidney. The ends of the catgut sutures are passed through the upper and lower muscular edges of the wound, and are tied after the wound has been closed. Or the highest suture is passed through the muscles of the last intercostal space and tied. V. By methods designed to promote granulation. Long strips of gauze are placed below the lower pole of the kidney to promote VlJ NEPHROPEXY 93 granulation and the formation of a fibrous sling to support the kidney (Jaboulay). vi. The formation of a shelf of peritoneum or fibrous capsule. Stanmore Bishop opened the peritoneal cavity by an anterior incision and replaced the kidney in its proper position. The peritoneum covering the lower third of the kidney was divided transversely, and the capsule stripped downwards and inwards from the anterior surface of this portion of the kidney. The divided peritoneum was replaced and sutured. Sutures were passed directly backwards through the peritoneum, detached capsule, and posterior abdominal Fig. 24. — Method of fixation of kidney. The kidney has been delivered from the lumbar wound and its posterior surface decapsulated. Three catgut sutures (A, A') are passed through the substance of the organ. B, Last rib ; C, quadratus lumborum muscle. wall, so as to form a chain of sutures extending from immediately below the renal pelvis along the internal and inferior edge of the kidney and a short distance round the external edge. The sutures were tied behind after division of the skin and subcutaneous fat over the muscular layer. Watson Cheyne exposes the kidney by an anterior incision and pushes aside the peritonemn. The muscles of the posterior abdominal wall are cleared of fat. The fibrous capsule is stripped from the posterior surface of the lower pole of the kidney, and another flap of capsule from the outer half of the remaining part of the posterior surface, and the capsule is stripped as far as the 94 THE KIDNEY [chap. convex border. The kidney is replaced, and the flaps of the cap- sule are stitched down to the muscles of the posterior abdominal wall, so that the raw surface is kept in contact with the muscles. I use a free oblique lumbar incision, and prepare the posterior abdominal wall carefully by dissection of the fascia and fat. Only the posterior surface of the kidney is stripped of capsule, as it is undesirable that the anterior surface should become adherent to the colon. Three catgut stitches are passed through the kidney an inch from its convex border. The upper suture is passed through the intercostal muscles ^of the last space, and the lower two are Fig. 25. — Method of fixation of kidney. The upper suture is passed through the last intercostal space, the other through the quadratus lumborum muscle. A, A', Catgut sutures ; B, last rib ; C, quadratus lumborum muscle. passed through the outer edge of the quadratus lumborum. (Figs. 24, 25.) The patient is confined to bed for four weeks. Results. — The operative mortality is stated at 1 per cent., but it is lower than this in the practice of most surgeons. The statistics in regard to the success of operation vary. Keen found that of 116 cases examined not less than three months after operation 57-8 per cent, were cured, 12-9 per cent, improved, and in 19-8 per cent, the operation failed. Failure may consist in recurrence of the mobility or the persistence of pain. Of 42 cases examined by Mc Williams, 22 were cured, 8 greatly benefited, 7 somewhat reheved, and 5 unrelieved of symptoms. Improvement in many cases was only seen some months after the operation. vij RESULTS OF NEPHROPEXY 95 There were 48 per cent, of cures where parenchymatous sutures were used, and 52 per cent, of cures where no parenchymatous sutures were employed. Wilson and Howell examined 41 cases after nephropexy had been performed at St. Bartholomew's Hospital, and found 12 cured, 8 greatly improved, 12 improved, and 9 unaffected by the operation. Failures, are, I believe, due to incomplete removal of fat, want of stripping of the kidney, tearing out of sutures too tightly tied, and too short confinement to bed. It is immaterial whether the kidney is fixed in normal position or lower down, so long as the pedicle and ureter are not twisted. LITERATURE • Barling, Brit. Med. Journ., 1908, i. 972. Billington, Brit. Med. Journ., May 1, 1909. Bishop, Stanmore, Lancet, July 6, 1907, vol. ii. Cheyne, Watson, Lancet, April 24, 1909. Gallant, Journ. Amer. Med. Assoc, Nov. 7, 1908. Glenard, Les Ptoses Viscerales. Paris, 1899. Guiteras, New York Med. Bee, 1903, p. 561. Keen, A^m. Surg., Aug., 1890. Lane, Arbuthnot, Lancet, Jan. 17, 1903. M.QTT\S, Surgical Diseases of the Kidney and Ureter. 1901. Moullin, Mansell, Brit. Med. Journ., March 10, 1900. Newman, Movable Kidney. 1907. Treves, PracL, Jan., 1905. Walker, Thomson, Lancet, Aug. 11, 1906. Walkow und Delitzen, Die Wandemierc. Berlin, 1899 Wilson and Howell, Movable Kidney. 1909. CHAPTER VII INJURIES TO THE KIDNEY I. WITHOUT EXTERNAL WOUND The kidney is well protected by the lower ribs and the spinal muscles, and injuries of this organ are comparatively rare. In 7,741 injuries found post mortsm, 10 (0-12 per cent.) were injuries of the kidney, and in only one of these was there an open wound. The relation of injuries to surgical diseases of the kidney is 7-81 per cent. (Kiister). The right side is more frequently affected than the left, and the injury is rarely bilateral (142 right, 118 left, 12 bilateral). The usual age is from 10 to 30 years. There is a great preponderance of male subjects. Of 299 cases, 281 (93-9 per cent.) were male and 18 (6-1 per cent.) were female. Etiology. — The form of injury which produces the rupture may be a direct blow on the loin or over the lower ribs, such as a kick or a fall across a beam or cart-wheel, or the passage of a wheel over the loin, or compression between buffers ; or the violence may be indirect, such as a fall from a height on the buttocks or forcible acute flexion of the body. In these cases of indirect violence Tuffier holds that the kidney is injured by impact against the 12th rib or the transverse process of the 1st lumbar vertebra. In cases where the body is acutely flexed from a fall or muscular exertion the laceration of the kidney arises from flexion on its transverse axis. Kiister ascribes an important role to hydrostatic pressure within the kidney in the production of laceration. He experimented by distending the veins, arteries, and renal pelvis, and applying vio- lence to the surface of the organ, and produced deep transverse lacerations which extended into the pelvis. The part of the kidney adjacent to the hilum is that most frequently torn. The most friable part of the kidney substance is at the junction of the cortex and medulla. The mobility of the kidney is some protection against rupture. Pathology. 1- Lesions of the kidney. — The fatty capsule 96 CHAP, viij RENAL INJURIES 97 alone may be torn, without injury to the renal parenchyma. Around the kidney there is an accumulation of blood, which later becomes organized and eventually constitutes a layer of fibrous tissue. Less frequently a cyst containing blood is formed. From a slight subcapsular rupture of the kidney, blood may be poured out and accumulate beneath the fibrous capsule of the organ. In a more severe degree the fibrous capsule is ruptured and there is extravasation of blood in the substance of the kidney, especially at the base of the pyramids, and at the same time blood is effused into the renal pelvis. The lacerations are usually transverse or slightly oblique, and radiate from the hilum. There is commonly one large tear with several smaller lacerations, and there is always bruising of the parenchyma in the neighbourhood. Lacerations are more frequent on the anterior than on the posterior surface of the kidney, and at the lower than at the upper pole. In severe degrees of rupture the rent passes from the surface to the pelvis in a transverse or oblique direction. The whole of one pole of the kidney may be detached. The kidney may be broken up into several fragments and the substance pulped. Some- times a large branch of the renal artery is ruptured, and the ureter may be torn. Earely the organ may be split along its convex border, or it may be torn from its pelvis and vessels. When the kidney is ruptured, blood is poured out and collects in considerable quantity within the fatty capsule. With extensive laceration and pulping of the kidney there is sometimes compara- tively little effusion of blood. The blood may track along the spermatic vein and cause discoloration of the skin at the external abdominal ring, and of the scrotum or labium. In most cases there is laceration of the renal pelvis or of a calyx, so that urine is mixed with the effused blood. A large collection of urine and blood may be formed which becomes limited by adhesions (pseudo-hydronephrosis). Blood is also poured into the renal pelvis and passes into the bladder. The ureter may be ruptured or a clot may block its lumen, so that no blood reaches the bladder. 2. Lesions of other organs. — Rupture of the kidney is fre- quently complicated by other lesions. The peritoneum may be torn, when blood and urine are poured into the peritoneal cavity. This happens more frequently in children than in adults, since the perinephritic fat is not developed before the tenth year, and the peritoneum is therefore in more intimate relation with the kidney up to that age. Fracture of one or more ribs occurs in 5 per cent, of cases (Tuffier). The spinal column may be injured, H 98 THE KIDNEY [chap. and the pelvic girdle is occasionally fractured (2 per cent.). There may be injuries to the bowel, liver, spleen, bladder, and lungs. In 36 post-mortem examinations of subcutaneous renal lesions Giiterbock found fracture of the ribs in 21, laceration of the liver in 20, of the spleen in 13, of the suprarenal capsule in 9, and of the bowel and mesentery in 3. Repair. — In the slighter degrees of rupture the process of repair takes place very rapidly. A clot forms between the edges of the wound, and the surrounding parenchyma is infiltrated with blood lying between and within the tubules. In this zone the epithelium of the tubules degenerates, the area thus affected taking the wedge shape of an infarct with the broadest part at the surface of the kidney. Outside this area there is a zone where the inter- tubular connective tissue proliferates, and the round-cell infiltration thus produced invades the clot and eventually forms fibrous tissue. The tubules nearest the edge of the wound degenerate and are hidden by the round-cell infiltration. In the less damaged tissues regeneration of the damaged epithelium takes place, but there is no new formation of tubules. The glomeruli atrophy slowly, and persist for a long time in the cicatrix. The wound in the kidney may be firmly healed in three weeks. Occasionally healing may be delayed for many months, and debris and clots are found in the wound with little attempt at cicatrization. Wounds of the renal pelvis leave a fibrous scar which does not cause narrowing of the receptacle. Occasionally a fistula remains, and if this heals there is pocketing in the interior of the renal pelvis. When the kidney has been extensively lacerated and pulped the whole organ may be converted into a fibrous mass in which little kidney tissue remains. The blood which was effused is either absorbed (rarely it remains as a cyst), or it may become infected and suppuration occur. Infection and suppuration in the form of perinephritic abscess, suppurative nephritis, pyonephrosis, and peritonitis occur in 11 '8 per cent, of cases. Symptoms. — Shock is present to a varying degree in all the more severe grades of rupture. The symptoms may not appear immediately on receipt of the injury. I have seen a gamekeeper fall heavily on his shoulder while dragging a shot stag down a steep hillside, pick himself up, resume his part in dragging the animal for another mile, and then take his turn in trundling the 16-stone weight in a wheel- barrow for another mile and a half. There were no signs during that evening or throughout the night, but next morning he noticed blood in his urine and then became faint. When I saw him he was VII] RENAL INJURIES 99 pale and sweating, with a rapid, feeble pulse and a drawn, anxious face, and he had been sick. He passed a large quantity of blood, and the hsematuria continued for a week. There was tenderness over the left kidney with rigidity of the abdominal muscles on this side. He made a good recovery. The symptoms which are characteristic of rupture of the kidney are pain, tumour, haematuria, and variations in the quantity of urine. Pain. — Pain after an injury to the loin may result from the bruising of the tissues, or it may be due to fracture of the ribs. The pain which points to an injury of the kidney radiates along the line of the ureter and is accompanied by retraction of the testicle. This pain is severe, and is present especially when the haemorrhage is copious and clots are passed down the ureter. There is also a dull heavy pain, deeply seated in the loin, which is increased by palpation, by movement, coughing or sneezing. The abdominal muscles are rigidly contracted, and palpation of the loin is difficult and painful. The pain may last for a week or more. Tumour. — Even in slight lacerations of the kidney there may be perirenal swelling. When a large quantity of blood and urine is effused it forms a prominent swelling in the loin, which may be found soon after the injury, or its appearance may be delayed for some days. The swelling is dull on percussion and very tender on palpation, and may be slightly movable. It is usually diffuse and obscured by the rigidity of the abdominal muscles or distension of the bowel (pseudo-hydro-hsematonephrosis). If the swelling be smooth and clearly outlined and ballottement can be obtained the renal pelvis has been distended with blood and a haematonephrosis formed. The condition is very rare. Haematuria. — There is blood in the urine in nearly all cases of rupture of the kidney (91-5 per cent.). In shght cases it may be the only symptom. Haematuria may be absent in cases of shght cortical rupture when the injury does not affect the renal pelvis, or it may fail to appear when the kidney is completely pulped and the ureter torn across, or when the ureter is blocked with clot. In slight injuries the microscope may be required to detect the blood. In other cases the first urine passed after the accident is blood-stained, and then the bleeding ceases. In severe cases blood is present in large quantity. It usually appears immediately after the injury, but it has sometimes been delayed for several days. In about 50 per cent, of cases the haematuria has disappeared in a week ; in other cases it persists for several weeks, and may 100 THE KIDNEY [chap. be the cause of death at the end of a fortnight or three weeks. Rarely the hsematuria is intermittent, the urine remaining clear for ten days at a time. The blood is bright at first, but later a large quantity of dark disintegrated blood may be discharged from the rupture of a collection of blood into the kidney pelvis {hcematuria tardive — Tuffier and Levi). Clotting of the blood in the renal pelvis may block the ureter and prevent haematuria. Clots may be passed down the ureter and give rise to ureteric colic. If there is clotting of the blood in the bladder, retention of urine may be caused by blocking of the urethra with clot, or the bladder may become distended with masses of clot. Secondary haemorrhage may occur on the sixteenth or eighteenth day, the primary hsematuria having ceased a few days after the injury. This is due to suppuration and sloughing of the injured kidney. Changes in the quantity of urine. — Oliguria or anuria may follow injury to the kidney, and may be due to injury affecting both kidneys, or to injury to one kidney when the second kidney is diseased or atrophied. More frequently the uninjured kidney is healthy and the suppression of urine is dae to a depressant reflex exercised upon it by the injured organ. Marsius has described fibres in the vagi and splanchnic nerves, stimulation of which contracts the renal vessels and suspends the secretion of urine. Stimulation of either vagus stops the secretion of both kidneys. The interference with the renal function may be temporary, lasting for twelve or twenty-four hours after the injury, or it may persist and cause death. Polyuria frequently follows upon the oliguria, appearing in twenty-four or thirty-six hours, or later up to the twelfth or fifteenth day, and lasting for several days. Polyuria persisting beyond this time is usually due to traumatic nephritis. Discoloration of the skin in the lumbar region appears four or five days after the injury. In two or three weeks discoloration may be found at the external abdominal ring, passing down into the scrotum or labium. Blood may pass down behind the peritoneum into the pelvis, and on rectal examination can sometimes be felt behind the bladder. Intraperitoneal effusion of blood may be detected in the pouch of Douglas when the peritoneum has been torn. Complications and sequelae. — Anuria, retention of urine, and pseudo-haematonephrosis have already been referred to in describ- ing the symptoms. VII] RENAL INJURIES 101 Intraperitoneal haemorrhage. — Intraperitoneal haemorrhage occurs when the peritoneum is lacerated, and is most frequently observed in children under the age of 10 years. It occurs in cases of severe injury, and other organs — such as the liver and spleen — are frequently injured, so that it is impossible to say with certainty that the intraperitoneal haemorrhage comes from the kidney. Such haemorrhage is usually rapidly fatal. Septic complications. — When the peritoneum is lacerated there is the further danger of septic peritonitis from infiltration of urine into the peritoneal cavity. It is seldom possible to make a diagnosis between peritonitis due to rupture of the kidney and that due to rupture of some other organ, such as the bowel. Infection of the damaged kidney is usually the result of an ascending infection from the bladder, and in a large number of cases results from septic catheterization. There are cases, how- ever, in which no instrument has been passed and infection of the perirenal haematoma must have been due to bacteria carried by the blood stream.- This has been reproduced experimentally by Albarran. The infection usually occurs soon after the accident, but may be delayed for some weeks or months. It has been said to occur some years after the injury. When the perirenal effusion of blood and urine is infected, suppuration takes place and injured portions of the kidney slough, so that a large collection of blood, urine, pus, and disintegrated kidney tissue is formed. Suppuration may extend beneath the diaphragm and affect the pleura. Septic inflammation may be confined to the kidney substance and cause pyelonephritis or an abscess of the parenchyma. Symp- toms usually develop soon after the use of a catheter, and are ushered in by a rigor. The quantity of urine secreted diminishes, and complete suppression may supervene. There is a high, swinging temperature and an increase in the local tenderness and swelling. The uninjured kidney may also be affected by the ascending in- fection (pyelonephritis) at the same time as the injured kidney or at a later date. Traumatic hydronephrosis. — Hydronephrosis sometimes follows upon injury to the kidney. The number of undoubted cases recorded is not great ; Wildbolz has collected 17. The obstruction may be due to blocking of the ureter with blood clot, rupture of or injury to the ureter, or to pressure upon it of scar tissue. The true hydronephrosis thus formed is sometimes indistinguishable clinically from traumatic pseudo-hydronephrosis, in which a cyst 102 THE KIDNEY [chap. containing blood and urine limited by adhesions is formed outside the kidney. A swelling appears in the loin in from two to six weeks after the injury, and may attain a very large size. The parenchyma is destroyed in a comparatively short time. Hydronephrosis may develop some months or years after an injury, and is probably due to undue mobility of the kidney, the result of the injury. Movable kidney. — To traumatism is ascribed an important role in the causation of movable kidney. It has already been stated that 94 per cent, of cases of laceration of the kidney are in the male sex, and the figures relating to sex in movable kidney are reversed, namely, 94 per cent, female. From this Kiister has inferred that " the result of a lumbar injury in the male is a subcutaneous contusion of the kidney, in the female a movable kidney." The number of cases in which a movable kidney follows an injury to the loin cannot, however, be very great, for Tuffier exam- ined a large number of patients who had previously suffered from such an injury without finding a single case of movable kidney. Traumatic nephritis. — Nephritis is a rare sequela of injury to the kidney. The nephritis is insidious, and usually takes the form of a chronic interstitial nephritis, with secondary vascular changes. Less frequently a parenchymatous nephritis develops. After the haematuria has ceased, albumin continues to be present in the urine and there is continuous polyuria, and epithelial and granular casts are found. There is sometimes a rapidly appearing oedema of the feet and face, or of the entire body. The oedema is said occasionally to be confined to the side of the body corresponding to the injury (Potain). In some cases the symptoms disappear, but in others they per- sist, and in the latter cases there may have been chronic nephritis present before the injury. It is possible that an injury to the kidney may rarely be the cause of calculus, for a portion of blood clot has been found as the nucleus of a renal calculus. The relation of trauma and calculus is, however, very rare. Injury is said to have been the cause of cysts in the kidney and of malignant growths, but in support of this there is no clear evidence. Diagnosis. — The history of the case and the presence of bruis- ing or abrasion in the kidney region will point to an injury of the kidney; and if there is renal and ureteric pain, and especially if there is blood in the urine, rupture of the kidney may be diagnosed. Pain and hsematuria may be absent, from causes already mentioned, VII] RENAL INJURIES 103 and the diagnosis must depend upon the history, local swelUng, and rigidity of the abdominal muscles on the affected side. It is impossible to judge accurately as to the extent of the injury from the amount of blood or pain. A large, rapidly formed swelling in the region of the kidney is a sign of severe laceration. It is necessary to inquire very carefully into the previous his- tory of the patient, and to examine doubtful cases with the view of excluding disease antecedent to the injury, such as stone, growiih, or chronic nephritis. Course and pro^^nosis. — In favourable cases the urine clears in three or four days, and the symptoms pass off and disappear in a week or ten days. In severe cases the immediate dangers are shock and haemor- rhage, and the more remote septic complications and anuria. During the period of shock the appearance of a large rounded swelling in the region of the kidney, or of free fluid in the peritoneal cavity, denotes progressive perirenal or intraperitoneal haemorrhage respectively. When shock has passed off, if there be no signs of progressive anaemia and the swelling in the loin be moderate and show no sign of increase, it may be concluded that the haemorrhage is not immediately progressive. Profound anaemia, an increasing lumbar swelling, and signs of free intraperitoneal fluid denote con- tinued haemorrhage. The danger from haemorrhage may continue for fourteen or twenty-one days after the injury. There is a remote danger of recurrent haematuria at intervals of some months, and this may continue for years and eventually necessitate nephrectomy. Septic complications may supervene a few days after the injury, and may follow catheterization, or occur apart from it. Sepsis may be delayed for some weeks or months, and suppuration has been known to occur in a kidney injured some years previously. The later the onset and the less acute the progress of the septic process, the better is the prognosis. Prognosis is chiefly affected by haemorrhage and injury to other organs. Recovery takes place in 70 per cent, of uncomplicated cases. G-rawitz found in 108 cases of injury to the kidney that 58 recovered. Of 50 cases, the fatal result was caused by injury to other vital organs in 18, immediate haemorrhage in 14, delayed haemorrhage in 8, suppuration in 7, and failure of the renal func- tion in 3. The mortality is much higher in children than in adults, owing to the greater frequency with which the peritoneum is ruptured. Treatment. — In cases of slight and moderately severe uncom- plicated rupture of the kidney the treatment is non-operative. 104 THE KIDNEY [chap. The side is strapped with adhesive plaster reaching to the middle line in front and behind to prevent movement, and a broad bandage may be applied over this to give pressure. Icebags should be placed over and under the loin, and the patient kept absolutely quiet in the recumbent position. The food should be fluid. Hsemostatics are of little value, and those which raise the blood pressure, such as ergot, are harmful. Calcium lactate in doses of 10 to 15 gr. every four hours may be tried ; it should not be continued longer than forty-eight hours. Morphia should be given hypodermically, and serves the double purpose of relieving pain and quieting the circulation. Shock, if not profound, should not be too energetic- ally treated lest bleeding be encouraged. Warmth to the extremi- ties and the recumbent position will usually suffice. If the patient cannot pass water the bladder should be emptied by catheter under the most rigid aseptic precautions. Clots, if numerous, may be washed out. If the bladder is distended, and on passing a catheter only a little bloody urine is drawn, there is an accumulation of clot in the bladder, which cannot be removed by catheter. An attempt may be made by means of a large evacuating cannula and bulb, such as is used after the operation of lithotrity, to remove the clots by suction, but this method should not be persisted in if it be not quickly successful. The bladder should, in case of failure, be opened suprapubically, the clots cleared out, and a large rubber drainage tube introduced. The operation should be rapidly carried out. Should no complications supervene, the patient should be kept in bed for a fortnight after the haemorrhage has ceased and all local tenderness and swelhng have disappeared. Operative interference may be required for the following conditions : — 1. Immediate severe haemorrhage. 2. Delayed severe haemorrhage. 3. Suppuration of the injured kidney. 4. Septic peritonitis. 5. Hydronephrosis, pyonephrosis. Where there is a rapidly increasing swelling in the region of the kidney, or free fluid in the peritoneum, or severe persistent haema- turia, and especially where there is progressive anaemia, operation is necessary to control the bleeding. An oblique lumbar incision should be made and the damaged kidney exposed. Clots should be cleared away and a careful search made for the bleeding-point. It may be necessary when the haemorrhage is free to compress the renal pedicle with the thumb and fingers. A single tear in the kidney substance should be closed by cutgut sutures passed through the substance of the kidney. If one or several portions are partly Mil RENAL INJURIES 105 detached by a number of lacerations, packing with strips of steril- ized gauze should be resorted to, and will successfully control the bleeding. When a large branch of the renal artery is the source of haemorrhage, it should, if possible, be picked up in long artery- forceps and tied with a silk ligature. It may be necessary to underrun the vessel with a curved needle and silk in order to tie it securely. A distended renal pelvis should be incised and the clots turned out. If this be followed by considerable haemorrhage, the pelvis may be packed with gauze. Detached portions and shreds of kidney tissue should be re- moved, and rents repaired as far as possible. When the kidney is injured so that repair does not appear possible, primary nephrectomy should be performed. All operative measures should be carried out with the utmost dispatch ; and when the haemorrhage has been controlled, rectal and intravenous infusion of glucose solution (1 per cent.) should be given. When there is free, fluid in the peritoneum and the diagnosis of injury to the kidney is clearly established, the kidney should first be exposed and dealt with, and the peritoneal cavity cleared of clots and blood by an extension of the lumbar incision. When the diagnosis of injury to the kidney is uncertain, an exploratory laparotomy will be necessary, the abdomen being opened in the middle hne. Nephrectomy is called for when there are recurrent attacks of haemorrhage after injury to the kidney. Suppuration of the damaged kidney necessitates lumbar ex- ploration. Free incision, irrigation, and drainage may be all that is necessary, but nephrectomy should be performed if there is extensive destruction of the kidney tissue. Laparotomy and drainage of the peritoneal cavity will become necessary if septic peritonitis supervene. Persistent anuria should be treated by nephrotomy and packing. The treatment of Hydronephrosis and Pyonephrosis will be dis- cussed under those headings (pp. 177, 150). Results. — The results of operative treatment in injuries of the kidney have greatly improved in recent years since the necessity of early aseptic operation has been recognized. Haemorrhage accounted for 80 out of a total 190 deaths, septic complications for 41, anuria for 34, and shock for 11 (Watson). Of 13 cases of nephrectomy performed on account of dangerous haemorrhage only 4 died, and the 6 patients most recently operated upon all recovered (Giiterbock). W^ilhs collected 14 cases of 106 THE KIDNEY [chap. nephrectomy for injury to the kidney, with 9 recoveries and 5 deaths. Albarran collected 6 cases of operation in which packing of the injured kidney was resorted to, and all recovered. The operative interference in septic complications is . frequently postponed until too late, and the already exhausted patient suc- cumbs. Of 7 nephrectomies of this nature, 4 resulted fatally. Nephrotomy also has a high mortality. Of 8 cases, 4 died after the operation, and another after a second nephrotomy (Giiterbock). The following general statistics may be quoted with Riese : Of 490 cases of uncomplicated subcutaneous injuries to the kidney, 93 (18-9 per cent.) died. There were 327 treated by expectant treatment, and of these 69 (21-1 per cent.) died, 40 of the deaths being due to haemorrhage. In 85 cases a conservative operation was performed (46 times on account of bleeding), and 10 died (11-7 per cent.). In 78 cases nephrectomy was performed (54 on account of bleeding), and 14 died (17-9 per cent.). II. WITH EXTERNAL WOUND Etiology. — Wounds of the kidney are much less frequent than subcutaneous injuries. They are produced by stabs with a dagger, sword, bayonet, hayfork, etc., or by bullets. Pathology. — The external wound may lie in the loin, or on the anterior surface of the abdomen, or over the ribs, and accord- ing to the site and direction of the wound the intestine, liver, spleen, or pleura may be wounded. Any part of the organ may be affected, and portions may be detached by bullet wounds. With the older forms of bullet the ball and portions of clothing might be embedded in the organ and remain for considerable periods. A bullet may have a burst- ing action on the kidney and cause extensive destruction of its substance. The blood escapes by the external wound, and, if the calyces or the pelvis of the kidney are wounded, urine escapes along with it. There is no perirenal accumulation of blood, except in rare cases in which the wound is a long, sinuous track. The kidney may partly prolapse from a large wound. The wound is almost invariably infected, so that primary union is very rare, and prolonged suppuration common. The organs which may be wounded at the same time as the kidney are seen in the diagram illustrating the anterior relations of the kidneys (Fig. 2, p. 3). Urinary fistulse occur, but seldom persist. In the American Civil War there was only one permanent fistula in 74 cases of bullet wounds of the kidney. VII] RENAL INJURIES 107 When healing has taken place the kidney is usually largely destroyed, and presents irregular depressed scars and extensive adhesions to neighbouring parts. Symptoms. — The symptoms differ in several particulars from those of subcutaneous lesions of the kidney. There is no perirenal swelling of blood and urine. There are external haemorrhage and escape of urine by the wound, and occasionally prolapse of the kidney. The pain is persistent, but does not radiate along the ureter. Haemorrhage from stab wounds may be severe and rapidly fatal. In bullet wounds the external haemorrhage is seldom severe, but it may be intermittent, recommencing after an interval of about five days. The escape of urine seldom takes place at first. It usually occurs when the bleeding is diminishing after a few days. Occa- sionally flatus from a wound in the intestine is passed with the blood and urine from the external wound. Septic complications occur on the fourth or fifth day after the injury. Haemorrhage has usually ceased at this time, but it may continue. With the pus, fragments of slough, portions of clothing, and other materials are discharged. The track of the wound may become blocked by debris, and pus and urine collect aromid the kidney. Diagnosis. — The diagnosis is made from the position and direction of the wound, the escape of urine, and the occurrence of haematuria. Prognosis. — In wounds of the kidney the prognosis is com- paratively good, and operation is frequently undertaken with success. Wounds of other organs increase the gravity of the prognosis. TujSier found that in 31 cases 8 died, and in 6 of these the fatal result was due to complicating injuries. The mortality of incised wounds of the kidney is as low as 15 per cent. (Albarran), but bullet wounds have a high mortality — namely, 53 per cent. (Klister). The mortality of bullet and other wounds of the kidney in the American Civil War was 66-2 per cent. The statistics are all compiled from cases treated before the development of aseptic wound treatment and abdominal surgery. The duration of healing varies from three weeks to three months ; rarely it may be prolonged to two years. After healing of the womid, sequelae such as inflammation in the urinary tract, fistulae, etc., may cause chronic invalidism. Of 52 recently healed wounds of the kidney Tuffier found 22 with sequelae. Treatment. — If the external haemorrhage is moderate and 108 THE KIDNEY [chap, vii diminishing, it will suffice to clean and dress the wound. A careful watch is kept for recurrent haemorrhage and septic complications. If there is any reason to suspect that a foreign body is lodged in the wound, the track should be freely opened up and the kidney exposed and examined. If the haemorrhage is severe and persistent the kidney should be exposed by an oblique lumbar incision. A single wound in the kidney may be closed with catgut sutures. Detached portions of the kidney may require removal, or, if the kidney is extensively lacerated, nephrectomy may be necessary. When a large vessel is wounded at the hilum it may be very difficult to control the haemorrhage, and clamps must be placed upon the pedicle. If the blood supply of the kidney is entirely cut off in this way, it will be necessary to remove the kidney. Kiister advises that, when a doubt exists as to the blood supply being sufficient to nourish the kidney, the clamps be left on for a day and then removed on the operating table. If the kidney now bleeds when it is pricked, it may be left and packed with gauze ; if it fails to bleed, nephrectomy is performed. A kidney prolapsed into a large lumbar wound is cleansed, examined, and replaced if necessary, being fixed in position by means of catgut stitches. The wound is then cleansed and partly closed, and a large drainage tube inserted. In complicated cases in which it is probable that other organs are wounded an exploratory laparotomy will be necessary LITERATURE Curschmann, Munch, med. Woch., 1902, xlix. 38. Belhet, Ann. d. Mai. d. Org. Gen.-Urin., 1901, xix. 669. Keen- Spencer, ^?iw. Surg., Ang,., 1896, xxiv. Klippel et Chabrol, Presse Med., 1900, p. 265. [vol. ii., pt. ii. Medical and Surgical History of the War of the American Rebellion, Riese, ylrc/t. /. Uin. Chir., 190.3, vol. Ixxi. Tuffier, .4rc;^. Ge7i. de Med., 1888, cxxii. 298, cxxiii. 335. Waldvogel, Devts. Zeits. f. Chir., 1902, vol. Ixiv. Watson, Boston Med. Surg. Journ., July 9, 1903, p. 16. Wildbolz, Zeits. f. Urol., 1910, iv. 241. CHAPTER VIII ANEURYSM OF THE RENAL ARTERY This is a rare condition. Only 25 cases were found by Skillern in the literature. Etiology. — The condition is usually due to traumatism, but it is sometimes spontaneous (12 traumatic. 7 spontaneous — Morris). In traumatic cases the majority are men in the most active period of life ; in spontaneous cases the sexes are about equally divided, and the majority are over 40 years of age. The form of injury which causes the aneurysm is similar to that which produces rupture of the kidney, such as a fall across a cart-wheel. In spontaneous cases endocarditis or arterial degeneration is usually present. Pathology. — The aneurysm is formed in relation to the main trunk of the renal artery or one of its large branches. It may be fusiform or sacculated, and it may be associated with a false aneurysm formed either by rupture of a branch of the renal artery at another part or by rupture of the aneurysm itself. The aneurysm may vary from the size of a hazel-nut to a large swelling occupying the whole of the loin and extending inwards as far as the middle line. A small aneurysm may press upon the kidney and cause atrophy of the parenchyma adjacent to it. When the aneurysm is large, and especially when a false aneurysm has been formed, the kidney tissue is extensively destroyed by pressure. The blood may track along the renal vessels and accumulate within the capsule of the kidney, which is greatly distended. Rupture may take place into the renal pelvis, which becomes distended with blood, and the kidney is dilated to form a hsematonephrosis. Rupture of the wall of the sac and the overlying peritoneum will be followed by escape of blood into the peritoneal cavity. When the aneurysmal sac increases in size it displaces the colon forwards and inwards, and the liver or spleen upwards. Adhesions are formed mth neighbouring structures, which vary in density and thickness. The sac is lined by, and most of its cavity filled with., laminated clot, so that it contains only a small quantity of fluid blood. 109 no THE KIDNEY [chap, vm Symptoms. — Some of the smaller aneurysms recorded have been discovered post mortem, and have caused no symptoms during life. With large or with false aneurysms there is a tumour situated in the region of the kidney which has, in most cases, followed upon an injury to the loin. The tumour may appear some days or weeks after the injury, but two years, or even fourteen years, may elapse before a swelling is noticed. It is smooth, slightly movable or fixed, and does not move with respiration. It is not painful or tender, unless in a few exceptional instances. Hsematuria is an early symptom, and usually precedes the discovery of the swelling. It may immediately follow the injury and be continuous, or there may be an interval of months or years, or the hsematuria may be recurrent. Profuse and rapidly fatal haemorrhage may be caused by the rupture of an aneurysm into the renal pelvis. Pulsation has rarely been observed. It was present in one case, and very indistinct in two others. In Morris's case there was a loud systolic bruit, best heard in front, over the tumour. Diagnosis. — The condition has been diagnosed once, and suspected in two other cases. When pulsation is absent the only means of diagnosis is exploratory operation. The conditions with which aneurysm of the renal artery is most likely to be confused are ruptured kidney with hsematuria, and hsematonephrosis. Prognosis. — Albert, Hahn, and Keen have each operated successfully in one case. All the other patients in whom the aneurysm caused a tumour died. Aneurysms cause no symptoms and are discovered accidentally post mortem. Treatment. — The condition will usually be discovered in the course of an exploratory operation undertaken for a swelling in the loin which has followed an injury. The sac should not be opened up more than is sufficienib to recognize the laminated character of the contents. In breaking down adhesions severe hsemorrhage has taken place and necessitated plugging with gauze. In such a dilemma, and in a case where diagnosis has previously been made, the peritoneal cavity should be opened in the semilunar line. The peritoneum is divided along the outer side of the colon and reflected inwards. The pedicle of the kidney is exposed and ligatured. The aneurysmal sac and kidney are then removed. LITERATURE Barnard, Trans. Path. Soc, 1901, lii. 254. Hahn, JDeuts. med. Woch., 1894, xx. 32. Keen, Philad. Med. Journ., 1900, p. 1038. Morris, Lancet, 1900, ii. 1902. Skillern, Journ. Amer. Med. Assoc, 1906, xlvi. 37. Ziegler, Gentralbl. f. Grenzgeb. d. Med. ti. Chir., 1903, vi. 2. CHAPTER IX PERINEPHRITIS AND PERINEPHRITIC ABSCESS PERINEPHRITIS Chronic perinephritis leads to the formation of a layer of inflam- matory tissue aromid the kidney. Two forms are observed : a fibrous or sclerotic and a fibro- lipomatous form. They both result from long-continued inflam- mation which has not reached the stage of suppuration, and it is seldom that a purely fibrous or a purely lipomatous form can be distinguished. The kidney is invariably diseased. Any form of chronic in flammatory disease may be present, such as pyelonephritis, pyo- nephrosis, calculus, tuberculosis. The change takes place in the fatty capsule of the kidney, and in old-standing cases tough adhesions are formed with the sur- rounding structures, especially the diaphragm, liver, colon, duo- denum, and peritoneum. In the sclerotic form the fatty capsule of the kidney is replaced by a dense layer of fibrous tissue which binds the organ to the surrounding structures. The kidney is usually small and shrunken, and may sometimes be difficult to find at operation. I operated upon a child of 9 years with subacute pyelonephritis and a renal calculus, and found a mass of perinephritic fibrous tissue, | to f in. in thickness, that cut like cartilage and was fused with the ribs, diaphragm, and peritoneum. On cutting a window through this the kidney was found and the stones were removed. In the more common fibro-lipomatous form the delicate peri- renal fat is replaced by coarse nodular fat with a tough fibrous stroma, the whole mass being adherent to the neighbouring struc- tures. The fibrous capsule of the kidney is firmly adherent to this fibro-lipomatous envelope, but is easily stripped from the kidney itself, so that a subcapsular nephrectomy may, if required, be quickly and easily performed. The mass is closely adherent around the hilum to the pedicle of the kidney, and there may be difficulty in securing the vessels in such an operation. Ill 112 THE KIDNEY [chap. When the pelvis of the kidney is the chief seat of disease the fibro-hpomatous mass is developed principally in this situation. When one pole of the kidney contains an abscess, this part only may be surrounded by an adherent fibrous or fibro-lipomatous mass. Symptoms. — The symptoms of chronic perinephritis are slight, and are merged in those of the underlying renal disease. Some part of the aching and tenderness in the loin and the local rigidity of the abdominal muscles in cases of pyelonephritis and pyonephrosis, etc., may be referred to perirenal inflammation. At the same time a tuberculous kidney may become surrounded by a thick layer of chronic inflammatory tissue without ever having given rise to pain or discomfort. The volume of the kidney is increased on palpation, but it is impossible to say what part of the increase is perirenal and what renal. The movements of the kidney are not appreciably limited. The treatment of perinephritis is that of the renal disease which has caused it. PERINEPHRITIC ABSCESS A perinephritic abscess may occur at any age, and may be primary or secondary. In 230 cases collected by Kiister the age was from 25 to 40. Recently, Townsend has described cases of 5 and 15 years, and Gibney collected 28 cases of children aged from 1| to 15 years. Men are more frequently affected than w;omen (140 men to 68 women — Kiister), and the right side more often than the left. The abscess is very rarely bilateral. Etiology. — The primary form may follow injury to the kidney, suppuration occurring immediately, or sometimes after months or years. More frequently it develops during the course of some fever such as typhoid, scarlatina, measles, or pneumonia ; or it may appear when the patient is suffering from tonsillitis, car- buncle, boils, or even eczema. The secondary form complicates suppuration in some neigh- bouring organ, such as the kidney (about 25 per cent.), liver, gall- bladder, appendix, pelvic organs, or vertebrae, or duodenal ulcer. Tuberculous perinephritic abscess is very rarely secondary to tuberculosis of the kidney. It is especially found in tuberculous disease of the vertebrae. Pus from an empyema or an abscess of the lung may track through the costo-lumbar hiatus of the diaphragm and form a perinephritic abscess. Bacteriology. — The following bacteria are found, and are IX] PERINEPHRITIC ABSCESS 113 given in their order of frequency, viz. bacterium coli commune, streptococcus, staphylococcus. The gonococcus and pneumo- coccus are rare. Pathology. — The abscess is usually unilocular, but occasion- ally there are multiple abscesses. It is situated outside the fibrous capsule, and may lie inside or outside the perinephritic fascia. In the former case the pus will tend to spread down the ureter into the bony pelvis, while in the latter it will appear on the surface of the body over the iliac crest, or pass into the iliac fossa. There is a tendency to the formation of fibrous tissue in the early stages of the suppuration, so that the pus becomes shut in and tends rather to rupture in one direction than to spread widely in the retroperitoneal tissue. Four varieties are distinguished according to situation : — 1. Above the kidney, or subphrenic, which is frequently con- nected A\T.th intrathoracic suppuration. The kidney is pushed downwards, and may be felt below the subphrenic mass. 2. Below the kidney, which tends to pass downwards to the iUac fossa, and may rupture into and pass .along the psoas sheath and appear in Scarpa's triangle, or may pass into the pelvis and escape at the sciatic notch. 3. In front of the kidney, hmited by peritoneum. This form is very rare ; it may rupture into the peritoneal cavity, bowel, bladder, or vagina. 4. Behind the kidney — a much more common variety, which may pass through the muscles of the loin at the triangle of Petit. Symptoms. — When the perinephritic abscess compUcates some other disease the symptoms are superadded to those of the primary disease. When the perinephritic suppuration is primary the onset is usually insidious and the pain slight and insignificant. The general condition of the patient is bad, and there is fever of the high remittent type. The temperature rises to 102° or 103° F. at night, and falls to normal or a little above it in the morning. In rare cases the temperature is not raised. Occasionally the onset is sudden and is heralded by a rigor. It is often difiicult to find the cause of the illness at this stage. Pain and tenderness over the kidney become marked. The pain may radiate to the shoulder or arm, but more frequently it passes downwards to the scrotum or labium. It is increased by movement and by respiration, coughing and sneezing. There is increasing tenderness on palpation of the loin, and the abdominal muscles of that side are rigid, so that examination is difficult without an ansesthetic. 114 THE KIDNEY [chap. The patient complains of stiffness of the corresponding thigh, which becomes flexed and rotated sHghtly outwards. There is restricted extension, but no hmitation of flexion. The position is that of contraction of the psoas. There may be transient paralysis of the lower limb. A characteristic tumour forms in the loin. The waist line is obliterated, and the whole loin bulges outwards and backwards. The anterior swelling is less than appears in cases of enlarged kidney. The tumour does not move with respiration. It may be moved a little between the hands, but it does not give the sensation of ballottement. There may be oedema of the overlying skin. Very rarely fluc- tuation can be detected. Some variation in symptoms may be observed according to whether the abscess is situated mainly above or mainly below the kidney. In the variety above the kidney, in addition to the symptoms of involvement of the pleura and lung there may be jaundice, ascites, and oedema of the legs, and persistent vomiting when the right side is affected. These symptoms are caused by the relation of the abscess to the gall-bladder, inferior vena cava, and duodenum. An abscess below the kidney is characterized by constipation from the colon being affected, symptoms of involvement of the psoas muscle {see above), neuralgic pain referred to the groin and genital organs, and retraction of the testicle. The swelhng invades the ihac fossa and may pass under Poupart's hgament. Pyuria will be present in the cases where the kidney is the cause of the perinephritic abscess, unless the ureter is blocked. In acute cases pus forms in ten or twelve days, while in less acute cases pus may not be detected for three or four weeks. In tuber- culous cases the abscess is usually secondary to disease in the vertebra, acute symptoms are absent, and pain and tenderness are slight. If no operation is performed the patient either dies of septicaemia or the abscess ruptures into some neighbouring organ or on the surface through the muscular triangle of Petit. Kiister gives the following statistics of rupture : Pleura and bronchi, . 18 cases ; intestine (colon), 11 cases; peritoneum, 2 cases; bladder, or bladder and vagina, 3 cases. Diagfnosis. — The condition has been mistaken for typhoid fever or malaria in the early stage, and disease of the hip-joint or pyonephrosis at a later period. When only fever and general symptoms are present, leuco- cytosis suggests that suppuration is taking place in the body ; a negative Widal reaction will exclude typhoid fever, and exam- IX] PERINEPHRITIG ABSCESS 115 ination of the blood will eliminate malaria. Against hip-joint disease there is the freedom of flexion and rotation of the thigh, and the absence of local tenderness. A pyonephrosis is regular and well defined. It moves with respiration, projects forwards rather than laterally or backwards, and does not cause oedema of the skin. A pyonephrosis may be present and concealed by a perinephritic abscess. Prognosis. — Spontaneous cure is very rare and cannot be hoped for. Good results are obtained by prompt operation in primary cases. The longer the operation is delayed the worse is the prognosis. The prognosis in secondary perinephritic abscess depends upon the original cause. Kiister collected 230 cases at a period when the importance of early operation was imperfectly understood, and found 151 (65-6 per cent.) recovered. Fistulse persisted in 6 of these cases. Treatment. — Early operation is the only successful method of treatment. The kidney is exposed by an oblique incision, and the abscess drained. The lumbar muscles are found oedematous, and the abscess lies immediately under the lumbar fascia. The cavity should be explored in all directions, so that no pockets are left undrained. Subphrenic collections of pus and those in the iliac fossa are searched for and opened up. Counter-openings may be necessary in the loin or elsewhere to ensure free drainage. If the kidney is the seat of abscess, pyelonephritis, or pyo- nephrosis, it should be freely incised and drained. If nephrectomy be necessary it should be postponed to a later date. When the abscess has originated in an empyema, this should also be drained. In old-standing cases, when sinuses have persisted, a diseased kidney or an imperfectly drained empyema may necessitate nephrec- tomy, resection of portions of ribs, or other secondary operations. Watson compared two series of cases where perinephritic sup- puration had followed injuries to the kidney. Of 21 cases treated without operation 17 died (80 per cent.), while in 28 cases treated by operation 2 died (7*1 per cent.). LITERATURE Albarran, Soc de Biol., 1889. Guiteras, New York Med. Journ., 1906, Ixxxiii. 169. Kiister, Chirurgie der Nieren. 1902. Maas, Volkmanns Sammlung klin. Vort, 1897, p. 605. ' Townsend, Journ. Amer. Med. Assoc, 1904, xUii. 1626. Watson, Boston Med. Surg. Journ., 190.3, cxlix. 29, 64. Zuckerkandl, Wien. klin. Woch., Oct. 13, 1910. CHAPTER X SURGICAL INFLAMMATION OF THE KIDNEY AND PELVIS Classification and nomenclature. — The inflammations of the kidney and pelvis met with in surgical practice may be either non-bacterial or bacterial. The non-bacterial inflammations are caused by the excretion of irritants or by mechanical means. The bacterial diseases are divided for convenience into those pro- duced by the ordinary pathogenic bacteria and those due to the tubercle bacillus, the fungus of actinomycosis, and the spirochsete of syphilis. When the kidney is affected alone the term " nephritis " is used, and when the kidney substance contains scattered abscesses the condition is named " suppurative nephritis." When a single abscess or several large abscesses are present, then the disease is termed " abscess of the kidney." When the kidney and pelvis are affected " pyelonephritis " is present, and when the pelvis alone is inflamed " pyelitis " exists. If obstruction to the outflow of urine compli- cates pyelitis or pyelonephritis the kidney becomes distended with pus and urine, and a " pyonephrosis " is formed. Bacteriology of renal infections. — The bacillus coU communis is the most common cause of renal infection, occurring in 75 per cent, of cases. The next most frequent are the staphylococcus (especially the aureus), the streptococcus, the proteus of Hauser, and the bacillus pyocyaneus. The pneumococcus and gonococcus are rare. The bacillus coli is usually found in pure culture, but occasionally in a mixed infection with the proteus, staphylococcus, or streptococcus. Anaerobic bacteria are occasionally found, especially in pyonephrosis. The staphylococcus and proteus vulgaris cause decomposition of urea, and the urine rapidly becomes ammoniacal. In the rare pure streptococcal infections and the common bacillus coli infec- tions the urine remains acid. Where the urine of the infected kidney is alkaline the blended urine of two kidneys may be acid. 116 CHAP. X] SURGICAL INFLAMMATION 117 ASEPTIC PYELONEPHRITIS L Due to Acute Retention op Urine Guyon and Albarran have described a form of pyelonephritis observed experimentally in acute retention of urine. There is acute congestion of both kidneys, which may go on to interstitial and intratubular haemorrhages with desquamation of the epithelium of the tubules. Clinically there is lessened secretion of urine. The urine contains a reduced quantity of salts, and blood, renal cells, blood casts and epithelial casts are present. When the retention is relieved there is polyuria, and the urine contains casts for some days. If the obstruction is completely relieved and no sepsis is present, the symptoms entirely disappear. 2. Due to the Excretion of Irritants A mild catarrhal pyelonephritis may be set up by the elimina- tion of certain balsamics such as sandal-wood, copaiba, turpentine, etc. There is pain in the renal region and often increased fre- quency of micturition; The urine contains a little albumin, and cells derived from the renal pelvis. The symptoms disappear when the drug is withheld. The excretion of cantharides produces nephritis, at first catar- rhal, then interstitial ; there are also catarrhal pyelitis and cystitis. The urine is scanty, high-coloured, and contains blood, albumin, mucus, and fibrin. Microscopically, the urine contains cells from the urinary tract, and also hyaline and epithelial casts. The oliguria may become anuria. The condition may subside when the elimination of cantharides ceases and the patient is placed upon a milk diet ; but it may pass into chronic interstitial nephritis. 3. In Chronic Urinary Obstruction In long-standing obstruction to the outflow of urine, such as stricture, enlarged prostate, or the pressure of malignant- pelvic growths, the ureters become dilated and thickened and lose their contractile power, and the pelvis of the kidney is dilated. The apices of the pyramids become flattened, the sinus of the kidney is hollowed and more spacious, and the calyces are dilated. The lining membrane of the pelvis becomes opaque and tough and loses its brilliancy. The kidney is enlarged, and when not dis- tended with fluid is flabby. The kidney substance is narrower, both cortex and medulla being reduced in width. The differentiation between the layers remains distinct, but the fine structure is lost. The substance is tough and leathery. Microscopically there is chronic interstitial 118 THE KIDNEY [chap. nephritis in an advanced degree. The interstitial connective tissue is increased, is moderately cellular, and the tubules and glomeruli are widely separated. The tubules become distorted and broken up, the glomeruh fibrous and their vessels occluded. (Fig. 26.) Both kidneys are affected, but usually to an unequal degree. Symptoms. — Those of renal disease are generally slight, and may easily be overlooked. There is dull aching pain in the posterior renal area on both Fig. 26. — Chronic interstitial nephritis due to obstruction from enlarged prostate. sides, rarely on one side only (25-3 per cent.), with constant thirst, sometimes more marked at night (26-7 per cent.). The tongue is dry (12-9 per cent.), at first along the centre, and later over its whole surface. Loss of appetite is present in 5 per cent., and frontal headache in 22 per cent. There may be appreciable loss of weight. The temperature is shghtly subnormal. There are no cardiac or vascular changes. The kidneys cannot be felt on pal- pation, and are not tender. Polyuria is a constant symptom. The urine is pale and clear. The percentage of urea and other urinary constituents is much reduced, and the specific gravity is X] PYELONEPHRITIS 119 low (1005 to 1010). The total quantities of these bodies passed in twenty-four hours may be only slightly below the normal standard, or may be much reduced. The polyuria amounts to 80-100 oz. in twenty-four hours ; it is often more marked at night. No tube casts or other cellular elements are found in the urine. Treatment. — Operation in advanced cases is fraught with extreme danger. Suppression of urine may immediately follow the operation ; more frequently there is gradual failure of the renal function, with thirst and drowsiness alternating with sleeplessness and restlessness, gradual loss of flesh, and mild delirium at night ; and the patient dies of syncope after gradually increasing cardiac failure, a few days or some weeks after the operation. Chronic aseptic pyelonephritis may also be caused by calculus and by new growths of the kidney. If the obstruction to the outflow of urine is complete and intermittent, the kidney becomes distended with urine and a hydronephrosis forms (p. 164). In calculus of the ureter a very pronounced polyuria may be present, which disappears when the calculus is removed, and is apparently due to reflex influences on the kidney of the affected side {see Chart, p. 327). INFECTIVE PYELONEPHRITIS There are two forms of pyelonephritis, which differ according to whether the infection occurs without previous disease of the urinary tract, or is secondary to some pre-existing urinary disease. The first form, primary pyelonephritis, is believed to be caused by blood-borne bacteria, and is therefore termed " haematogenous " ; while the second form is secondary to infection of the lower urinary tract, and is termed " ascending " pyelonephritis. These two forms will be described separately. 1. Primary or Hematogenous Pyelonephritis Haematogenous pyelonephritis is a less common form than ascending pyelonephritis, but it has been shown within recent years to occur with greater frequency than was at one time sup- posed. The disease is met with in infants, children, and adults. In infants and young children it occurs with comparative frequency. At this age the pelvis is more severely affected than the kidney, and the condition will be more conveniently described under the heading of Pyelitis of Infancy and Childhood (p. 141). Adults are most frequently affected in the most active period of life. The disease also occurs in pregnant women, and presents special fea- tures, which will be described under the heading of Pyelitis of Pregnancy (p. 142). 120 THE KIDNEY [chap. Of my personal cases 56 per cent, were female and 44 per cent, male ; while the right kidney was affected in 50 per cent., the left in 42 per cent., and both in 6 per cent. Legueu found the right kidney affected in 93 per cent, of cases. Etiology. — The large intestine is the chief source of bacteria. A history of chronic constipation can be obtained in a number of cases, and occasionally an attack of diarrhoea has preceded the onset of renal symptoms. Tonsillitis, boils, and carbuncle are sometimes the primary foci. The renal infection may occasion- ally complicate influenza and typhoid fever. It is now recognized that bacteria are constantly entering the lymphatics from the intestine and other sources in healthy in- dividuals. The bacteria may be destroyed at the point of entry or at the lymphatic glands, or they may pass through the lymphatic system into the blood stream, in which they circulate. The endo- thelium and cells of the liver destroy bacteria which are introduced by way of the portal system, and bacteria are excreted in the bile. Similarly a function of the renal parenchyma, especially of the con- voluted tubules, is to remove the bacteria present in the systemic circulation. It has been proved that the virulence of these bacteria is not reduced in their passage through the body. The excretion of bacteria in this way does not give rise to any symptoms which show that the kidneys are damaged. It is stated, however, as the result of experiments on animals, that the secreting membrane is injured by the passage of the bacteria. The damage is probably slight, and is repaired partly or completely by the regenerative powers of the kidney. In some cases long-continued excretion of bacteria or their toxins may be the cause of patches of interstitial nephritis in the kidney. It is held that the excretion of bacteria does not cause pyelo- nephritis unless some additional factor is present. Predisposing causes of pyelonephritis are traumatism, excessive functional activity, the elimination of toxic bodies such as cantharides, pre- vious disease of the kidney such as urinary obstruction, calculus, new growth. It is exceptional, however, to find any of these factors present, and it is more likely that chronic toxsemia from consti- pation, an excessive dose and an exceptionally virulent strain of bacteria, are the decisive factors. Pathologfy. i. Hyperacute or fulminating pyelonephritis. — The kidney is large, plum-coloured, and engorged with blood. The vessels at the base of the pyramids are distended with blood. The cortex is dark, the pyramids are paler. Microscopically, the large vessels and a few glomeruli are engorged with blood, and a X] Hy^MATOGENOUS PYELONEPHRITIS 121 few of the pyramids show dilated vessels. The glomeruli and tubules are healthy in appearance, and the nuclei of the renal epithelial cells may be well stained. (Fig. 27.) There may be a few ecchymoses, and sometimes a slight degree of cloudy swelling of the epithelium. ii. Acute pyelonephritis. — The organ is enlarged and con- Fig. 27. — Microscopical section of kidney in postoperative suppression of urine. There is engorgement of blood-vessels. The nuclei of the renal epithelium are well stained. gested. Scattered over the surface are bosses varying in size from a millet-seed to a large pea. On section the cortex shows con- gestion, and dots and patches of greyish yellow, some of which are wedge-like in shape and correspond to the bosses on the surface of the organ. Ecchymoses are frequently observed. The epithe- lium of the convoluted tubules shows cloudy swelhng and some- times desquamation, and there is proliferation of the endothelium of the glomeruli. The greyish patches and wedges are densely 122 THE KIDNEY [chap. infiltrated areas, where the tubules and glomeruli are obscured by round cells. Here and there the centre of these may have broken down so as to form a tiny abscess. The infiltration may surround a glomerulus or a small blood-vessel. The pelvis shows prolifera- tion and desquamation of the epithelium with ecchymoses. iii. Subacute and chronic. — The kidney is small, very tough, and densely adherent to the sclerosed perirenal tissue. The sur- face is irregular and the capsule adherent. The substance of the organ is tough and fibrous, the cortex and medulla are poorly defined. The colour is either uniformly greyish, or is pale red with grey areas. Sometimes there are small cysts, which may be filled with pus. Microscopically there is advanced chronic inter- stitial nephritis with sclerosis of glomeruli and destruction of tubules, and the fibrous tissue is infiltrated with densely packed round cells, either uniformly distributed or in patches. The pelvis shows thick- ening of the mucous membrane and great proliferation of epithe- lium. There may be phosphatic debris or calculi in the pelvis. Symptoms. Prodromal symptoms. — The patient frequently has headache, lassitude, and want of appetite for a few days before the onset of the acute symptoms. Habitual constipation may have become more pronounced, or there may have been an attack of diarrhoea. In 6-25 per cent, of cases (5 out of 80 — Lenhartz) there is a sudden desire to pass water, followed by great frequency of mic- turition and even strangury. These symptoms may last for an hour or two, or for one or two days. There are several degrees of severity of the symptoms : — (a) Mild attack. — After a rigor the temperature rises to 101° or 102° F. The vesical irritation continues, and there is usually aching across the loins, sometimes more marked on one side. Theire is tenderness over one kidney, but the organ is not enlarged. The urine is usually abundant and pale, with a low specific gravity and a stale-fish odour. It is hazy, and on swinging the glass a drift- cloud appearance or shimmering, is seen, which is characteristic of bacilluria. The bacillus coli communis is present in pure culture. In a few days the temperature begins to subside, and in ten or fourteen days it is normal. The tenderness of the kidney dis- appears. The urine may clear and become sterile, or it may remain hazy with bacteria. In rare cases haematuria is an early symptom, and persists for many weeks after all other symptoms have subsided. (6) Acute attack. — The initial rigor is severe and the tempera- ture rises to 102° or 103° F. The patient is prostrate, often drowsy, and may be delirious. There is at first general abdominal pain or X] Ht^MATOGENOUS pyelonephritis 123 a X 3 O c "OO o C c3 4) o ■4-1 ^ — O <+5 .S 0) a^. -*r r»- * z/* h^ =~- [^ .^_ - k < ' "0 ^ -^ •0 r ^ ' * <. > "5 « :> fN 2/ • - -- - .*^ »~ ■^ „ ^ 2> •- ■- — -=• f— — 1 Si " y» -T ^ F" — 1 ;_^ ^ ^ •^ — — — 1 -_ ^ ^ 2 '• • - — ^ - < K "N s i^ •^ ■>>> pi 5^ < > ^ J X ;^ M -^ >, !^ y - ■ - ■- !> fN y -- ^ ■w. -*1 ^ ^ 5 < 5 y -- j^ ■=^ — \ — - k N / 10 V -- -' -- -- -^ . — ' -t* ><) &-• -- ... -- -^ ^ • rf < > 5 i/ ,-- -- -- ;^ -> 5! •< "-. , W 5 "K °io '") °^' °r> "'^ °>: °Q "Ol °* °f^ 4) ^ cs'C S c H 124 THE KIDNEY [chap. weeks the acute symptoms may subside ; the temperature falls> gradually or quickly. When the patient is allowed to get up the symptoms may all reappear. The recurrent attack is due either to infection of the second kidney or to recrudescence of the disease in the organ first attacked. After the second attack has subsided, convalescence may be established, but sometimes recurrent attacks are brought on each time the patient gets up, for several months. Instead of taking a benign course after a fortnight or so, the rigors may be frequently repeated, the temperature rising to 105° or 107° F. after each, falling occasionally to normal, but usually keep- ing above 100° F. There is often a lull, during which the patient appears to improve, and then another series of rigors follows. The kidney remains large and tender, and the urine scanty and bacterial. The tongue becomes dry and brown, the appetite is. lost, and the patient rapidly emaciates. Hiccough appears occa- sionally, and, then grows more persistent and distressing. The- mind becomes dull and clouded, and the patient gradually sinks, and dies in from three to six weeks after the onset of the illness. (c) Fulminating attack. — The patient, previously in good health, is seized with a severe rigor, and the temperature mounts to 104° or 105° F. He becomes heavy, drowsy, or even comatose. Vomiting occurs, and there is abdominal pain and sometimes, backache, and the abdomen is rigid. The urine is scanty and con- tains bacteria, casts, epithelia, and sometimes blood. There may be complete suppression of urine. The patient may die comatose without developing any symp- toms which point to the kidney, except the condition of the urine. Clironic pyelonephritis (hsematogenous). — When the acute stage of pyelonephritis has subsided, chronic pyelonephritis fre- quently follows, and recurrent subacute or acute attacks occur from time to time. The renal symptoms are very slight. There may be aching in one kidney, but the organ is not tender or enlarged. The urine is abundant, pale, faintly acid, and hazy with pus, and contains small shreds. The pus settles in a fiat, creamy, or dead- white layer at the bottom of the glass. Bacilluria is seldom present in the milder forms of chronic pyelonephritis, but bacteria are plentiful. The chief complaint is of chronic vesical irritation. There is. increased frequency of micturition, partly from the polyuria and partly from cystitis. Micturition is either equally frequent night and day, or the nocturnal frequency is the greater. This nocturnal polyuria is very characteristic of chronic pyelonephritis. On cystoscopy the general surface of the bladder is healthy, or there X] Hy^MATOGENOUS pyelonephritis 125 may be a patchy cystitis. The trigone is red and often puffy, and the inflammation is chiefly confined to, or more marked on, one side. On this side, which corresponds to the diseased kidney, the ureteric orifice is surrounded by a zone of inflammation, and not infrequently an irregular greyish patch may be seen below it, repre- senting a delicate film of necrosis of the surface epithehum. In the more chronic conditions these appearances may be absent, there is congestion at the bladder base, and the opening of the ureter appears a little thickened and reddened. The efflux from the ureter of the diseased side is abundant and cloudy with pus. In very chronic cases it is often scanty and thick, and occasion- ally it is reduced to a putty-like pipe of pus which is squeezed out of the ureter at long intervals. (Plate 5, Fig. 2.) In other cases the vesical symptoms are prominent, and the case is frequently regarded as one of chronic cystitis. There is frequent and painful micturition. The urine contains mucus and bladder epithelium, bacilluria is usually present, and the urine has a fishy and sometimes an ammoniacal smell. In these cases recurrent attacks of subacute or acute pyelonephritis fre- quently occur. In some cases there are recurrent attacks of urethritis. In another class of cases the bladder is healthy, there is a long history of renal aching but no enlargement or tenderness. The urine contains a few bacteria and some pus, and the ureteric catheter shows that these come from one kidney. The quantity of urine is continuously lowered (8 to 10 oz. in twenty-four hours), and there are recurrent attacks of complete anuria lasting for twenty- four to thirty-six hours. Diagnosis. — In fulminating cases the symptoms are those of a sudden and profound toxgemia. Infective endocarditis, acute influenza, the onset of lobar pneumonia, and malaria have been diagnosed in such cases. Examination of the urine usually makes the diagnosis plain. In acute cases the abdominal pain and rigidity of the muscles have led to the mistaken diagnosis of cholecystitis, subphrenic abscess, abscess of the liver, appendicitis -with retrocoHc abscess. The discovery of a large tender kidney, together with changes in the urine, will lead to a correct diagnosis. Rarely an exploratory laparotomy may be necessary to clear up the diagnosis. In chronic pyelonephritis the most frequent mistake in diag- nosis is to regard the chronic cystitis as primary and to overlook the renal infection. The diagnosis is made by the cystoscope and by examining the urine dra^vTi from each kidney by the 126 THE KIDNEY [chap. ureteric catheter. All subacute and chronic cases of pyelonephritis should be examined with the X-rays for calculus. Prognosis. — In mild cases of acute pyelonephritis the prognosis is good. Recovery without operation is the rule. Recurrent attacks occur, however, and in a large percentage of cases bacilluria and slight chronic pyelitis or pyelonephritis persists. This may dis- appear, or it may continue for many years, and may be the cause of an acute attack ten or twelve years after the first. In acute cases the prognosis is very grave, and operation will frequently be necessary. In fulminating cases the issue is often fatal. If the diagnosis has been made, an early operation gives a more hopeful outlook. Chronic pyelonephritis persists for many years, and eventually destroys the kidney. There is the danger of secondary stone formation in the kidney and bladder, and of ascending pyelonephritis of the second kidney. Treatment. — The treatment is medicinal, serum, vaccine, or operative. Medicinal treatment consists in confining the patient to bed and applying hot fomentations to relieve pain, and turpentine stupes or dry cupping over the loins to reheve congestion. Urinary antiseptics should be given, such as urotropine, metramine, hetra- lin, or helmitol in doses of 5 or 10 gr. every four hours. Alkalis and diuretics should be freely administered, such as potassium citrate in doses of 50 or 60 gr. daily, Contrexeville water and dis- tilled water. The bowels should be freely opened, and calomel given in doses of ^V ^o i g^- thrice daily. This treatment is suit- able for mild cases and the early stage of acute cases. If bacteria persist in the urine when the acute symptoms have subsided, urinary antiseptic treatment should be continued and vaccine treatment adopted. Serum treatment. — This consists in the injection of serum, usually anti-colon-bacillus serum, since in the great majority of cases the infection is due to the bacillus coli. A dose of 25 c.c. is injected hypodermically each day for three days, and at the same time calcium lactate in doses of 20 gr. thrice daily is given by the mouth in order to prevent the joint-pains and rashes which may result from the serum. Should no effect be produced in three days, the treatment should be abandoned. Dudgeon obtained satisfactory results in most instances by this treatment in 12 cases of acute pyelonephritis. In 5 of his cases the effect was rapid and permanent, in 4 there was considerable benefit, in 3 there was no benefit. In chronic cases the treatment has no effect. Vaccine treatment. — This consists in injecting graduated doses of dead bacteria obtained from cultures of the patient's urine, X] H.^MATOGENOUS PYELONEPHRITIS 127 or of a stock vaccine should there not be time for the preparation of an autovaccine. Small doses of two or three million colon bacilli should be used at first, and repeated in four or five days, rising rapidly to 10, 15, 20, 25. 30 millions, and so on to 100 millions, then to 150 millions for six doses,, then 200 millions for six or twelve doses. The injection should be made once a week after the first three doses ; and should any reaction, shown by a rise of temperature, malaise, and headache, occur^ the dose should be reduced and a longer interval allowed. In acute cases the results of the vaccine treatment have been unsatisfactory. In 10 cases-only one showed a change in tempera- ture (Williamson) ; in a large number of patients treated by Dudgeon there was " no material improvement except in a very few in- stances." In chronic cases, with or without acute exacerbations, where no complication, such as growth or stone, is present, the treatment may be of great service and bring about a cure when all other methods have failed. The treatment is a long and tedious one, and may last for six months or a year or even longer. The doses must be carefully graduated and sudden large increases avoided, as an overdose is frequently followed by a recurrence of symptoms, and if this has occurred the vaccine appears to have less effect. In several cases under my care the urine has been rendered sterile after six or twelve months' treatment. Operative treatment. — The operations that have been per- formed are nephrotomy, decapsulation and opening of surface abscesses, partial resection, and nephrectomy, but only nephrotomy and nephrectomy need be considered. I have collected 40 cases of operation in acute hsematogenous pyelonephritis from the literature, with the following results : — Unilateral Operations Cases Recovered No change Died Nephrotomy 12 . . 3 . , 2 . . 7 Decapsulation and opening of surface abscesses ..6 .. 6 .. .. Partial resection .. ..2 .. 2 .. .. Nephrectomy . . . . 17 . . 17 . . . . Bilateral operations Nephrotomy .. .. ..2 .. 2 .. .. Nephrectomy and nephro- tomy 1 .. 1 .. .. 40 31 2 7 The results of nephrotomy are even less satisfactory than this table shows. I have performed the operation twice in the acute stage, and seen three cases in which it had previously been 128 THE KIDNEY [chap. performed. All these patients survived. This makes 20 cases of nephrotomy with 7 deaths. The after-results of nephrotomy are unsatisfactory. Chronic pyelonephritis persists, and nephrectomy may be required at a later date. The best results in acute cases have been obtained by nephrec- tomy. This should not be too long delayed. If at the end of five or seven days the acute symptoms persist and the patient is beginning to lose ground, nephrectomy should be performed. In chronic cases operation will be called for on account of recurrent exacerbations of acute inflammation, or of persistent cystitis, or for secondary calculus, or sometimes for anuria If the second kidney is shown to be healthy by examination of its urine, nephrectomy should be performed. I have found nephro- tomy sufficient when reflex oliguria and attacks of anuria were caused by chronic unilateral pyelonephritis. LITERATURE Adams, Joum. Amer. Med. Assoc, 1899, xxxiii. 1512. Barnard, Lancet, Oct. 28, 1905. Brewer, A7in. Surg., Dec, 1904, p. 1010 ; Surg., Gyn., and Obst., June, 1908, p, 699. Dudgeon, Lancet, 1908, i. 616. Finkelstein, Jahrb. /. Kind., 1896, xliii. 148. Guyon et Albarran, Arch, de Med. Exper., 1897. Herringham, Clin. Joum., 1910, xxxv. 241. Legueu, Ann. d. Mai. d. Org. Gen.-Vrin., 1904, xxii. 1441. Lenhardt, Milnch. med. Woch., 1907, Nr. 16. Pawlowsky, Zeits. f. Hyg. u. Infect., 1900, xxxiii. 261. Pousson, Ann. d. Mai. d. Org. Gen.-Urin., 1902, p. 514. RoUeston, Pract., April, 1910, p. 439. Sampson, Johns Hopkins Hosp. Bull., 1903, No. 153, p. 336. Walker, Thomson, Pract., May, 1911 ; Renal Function in Urinary Surgery. 1908. 2. Secondary or Ascending- Pyelonephritis This disease results from an extension of infection from the lower urinary organs. It is the last phase of many chronic dis- eases of the bladder and urethra, such as malignant growths^ stone, enlarged prostate, stricture. It frequently follows surgical interference in the bladder or urethra, such as the passage of instru- ments, or operations upon stone, and for this reason has been termed " surgical kidney." Ascending pyelonephritis usually, but not invariably, attacks kidneys which are already the seat of chronic aseptic pyelonephritis due to obstruction in the lower urinary tract. (Plates 6, 7.) Etiology. — The bacteria already mentioned are the active agents in the production of ascending pyelonephritis. They are introduced into the bladder by a sound or other instrument Ascending pyelonephritis in case of enlarged prostate. (Pp. 128, 130.) Plate 6 x] ASCENDING PYELONEPHRITIS l^'J wliicli has not been sterilized, or they may be carried from an infected nrethra on a sterilized instrument. Infection from the bladder may reach the kidney by the following paths : — 1. Blood-vessels. (a) General circulation. (6) Anastomosis between the vesical, uterine, ovarian, and renal arteries (Sampson), (c) Along the blood-vessels of the ureter. 2. Lymphatics of the ureter in the muscular and outer coats, 3; Ureter. Infection ascending along the ureter is the most frequent method. It spreads either by chrect continuity of the inflam- matory process or by ascent of motile bacteria against the stream of urine. The presence of organisms in the bladder, or even in the ureter, is not necessarily followed by an ascending infection of the kidney, Albarran injected cultures of virulent organisms into the blad.der and ureter without producing ascending pyelonephritis. There are natural barriers to the ascent of infection. The lower end of the ureter penetrates the wall of the bladder very obliquely, and its longitudinal layer of niuscle passes into the trigone. When the bladder is distended the trigone is pushed down and the bladder wall stretched so that the intramural por- tion of the ureter becomes more oblique and flattened by stretch- ing, and the intravesical tension further closes the lumen by pres- sure. When the bladder is contracted the intramural portion becomes shortened and less oblique, but the mucous membrane is thrown into folds, which prevent a reflux of fluid. The condi- tion under which a reflux is most likely to occur is during a powerful contraction of the bladder when the organ contains a small quan- tity of fluid. The downward flow of urine is a further protection against the ascent of bacteria. The predisposing causes of ascend- ing infection are urethral obstruction, long-continued cystitis, new growths of the bladder, operations on the bladder involving the ureteric orifice, and stone in the bladder or ureter, all of which destroy the natural barriers. Pathology. — In the early stage ascending pyelonephritis is frequently unilateral ; in the later stages it is invariably bilateral, although one side is more diseased than the other. The disease is bilateral in 83 })er cent, of cases. 'i'hree types of ])athological change are found : 1. Recent acute pyelonephritis. — The kidney is enlarged, tense, and deeply congested. Scattered over the surface are small J 130 THE KIDNEY [chap. groups of greyish-yellow spots the size of a pin's head or a split pea, or larger, and shghtly raised. The kidney substance is dark and congested, and greyish streaks radiate outwards through the pyramids and cortex. A greyish-yellow patch underlies the raised surface nodule. Ecchymoses are observed here and there. 2. Old-standing, diffuse, subacute, and chronic pyelo- Fig. 28. — Microscopical section of kidney in suppurative pyelonephritis. The field shows the edge of the affected area and illustrates the spread of inflammation along the line of the tubules. nephritis. — The kidney is enlarged, and has a mottled dull-red and greyish-yellow surface. Section shows either a uniform dull greyish-yellow appearance or patches of this colour scattered on a dull-red surface. (Plates 6, 7.) Small points of softening may be found in the cortex. The grey streaks and patches consist of dense round-cell infiltration. (Fig. 28.) Bacteria are found in the straight and convoluted tubules and passing through the walls. ASCENDING PYELONEPHRITIS l.U •i. Old-standing sclerotic pyelonephritis.— The kidney is of iiatinal size or smaller than iioniial. It is surrouiHled by a dense tliick layer of fibro-lipomatous tissue firmly adherent to the capsule. The capsule is usually adherent to the kidney. The surface is irregular and granular. The kidney substance is tough and fibrous. Microscopically there is diffuse chronic interstitial fibrosis. The tubules are widely separated, some foiniing small cysts and others being broken up and disintegrated. Patches of round-cell infiltration are found here and there. Many sclerosed glomeruli are seen. The ureter may be almost normal, or may be dilated, thickened, and thrown into folds. The pelvis is thick- ened and may be slightly dilated, and contains purulent urine. Symptoms. — During the course of chronic cystitis or some obstructive disease, and usually as a direct consequence of surgical intervention, such as the passage of instruments or the removal DATE 4 5 6 7 6 9IOIll2l3l4>l5l6l7rai9 20 2l22 23 2 4|2526272829303l 1 2 "^*-33 g _ i / : vV\/ "^-^^.K .^t^^^A^..^^-^^r\^J Chart 14. — Continuous subnormal temperature in chronic ascending pyelonephritis in vesical calculus. of an enlarged prostate, symptoms of acute infective pyelonephritis supervene. The onset of chronic pyelonephritis is insidious, and the symptoms may be insignificant, so that it is usually impossible to say when the disease commenced. Occasionally the onset is marked by an acute attack, which subsides. 1. Acute ascending pyelonephritis. — A few hours after surgical interference, or sometimes after exposure to cold, there is a rigor, and the temperature rises to 102° or 104° F. (Chart 3, p. 15). The temperature may, however, be continuously sub- normal (Chart 14). The patient is drowsy, and complains of backache, sometimes more marked on one side. The skin is dry and harsh, the face heavy and apathetic. There is burning thirst, the mouth is dry and parched : the toiiguc is dry, red, and glazed ; later it becomes coveicd with a brown or black fur C' parrot tongue "). Nausea and vomiting are frequent symptoms, and there is absolute constipation. The abdomen becomes tense 132 THE KIDNEY [chap. and distended with flatus. Hiccough sets in and becomes in- creasingly troublesome. Rigidity of the abdominal muscles is usually present, and often more marked on one side. There is tenderness over both kidneys at first, but after twenty-four hours this usually becomes confined to one side. The tender kidney is enlarged, the second kidney is not palpable. There has frequently been polyuria before the attack, and now the urine suddenly be- comes scanty, or there is complete suppression. The temperature may remain at 102° F. or over, or it may fall, and rise again after another rigor, and then become high and swinging while the rigors are repeated at irregular intervals. Herpes of the lips is frequently observed. The patient becomes more and more drowsy, the abdominal distension increases, vomiting grows more frequent, and hiccough is constant. The pupils are small and react sluggishly to light. Convulsions are extremely rare. Ursemic dyspnoea may be present and is occasionally paroxysmal. Cheyne-Stokes breathing may be observed in the last stages. Muttering delirium supervenes, and the patient passes into coma and dies. Occasionally the mind remains clear and the patient is restless and anxious ; the temperature is high (105° F.) and swinging, the urine absolutely suppressed. Later there is dehrium, and eventually coma. In less severe cases the excretion of urine becomes re-established. It is scanty at first and may contain blood. The temperature falls, flatus is passed and the abdominal distension disappears, and the symptoms subside. In other acute cases the urine continues to be secreted in good quantity, but there are recurrent attacks of very severe haemorrhage. In mild cases the temperature rises to 102° or 103° F. after a slight chill, the quantity of urine is reduced, and there are slight tenderness over the kidneys, headache, nausea, and sometimes vomiting. The bowels are constipated. The urine becomes purulent. In some cases the urine becomes foul and there are signs of cystitis without any rise of temperature. As the cystitis subsides, blood begins to appear in the urine, and on cystoscopy the haemorrhage is found to be renal. In this type severe haemor- rhage may continue until relieved by operation. 2. Chronic suppurative pyelonephritis. — An acute attack of septic pyelonephritis which subsides is usually followed by chronic septic pyelonephritis. In rare cases, where the obstruction ill the lower urinary tract is relieved, the kidneys may return to their normal state. The onset of chronic suppurative pyelonephritis is frequently Dilatation of renal pelvis, pyelitis, and suppurative nephritis in en- larged prostate. Same kidney as shown in Plate 6. (Pp. 128, 130.) Plate 7. x"l ASCENDING PYELONEPHRITIS 133 insidious. I ( is ciii^rat'tcd on chronic ascpl ic pycloncpliiil is (p. II 7), anil it. is ollcn impossible to state; when the septic coniphcation ensued. Wlieii the syndrome is fully developed, the condition is known as urituiry scpticn'mui. The patient has a sallow, earthy appearance, the skin is dry and harsh and seldom sweats. There is gradual, persistent loss of weight. The lips are dry ; the tongue is at first dry along the middle, then over the whole surface, and it becomes glazed, red, and cracked; the mouth and throat also become dry. There are loss of appetite, dyspepsia, and occasion- ally nausea. The bowels are constipated. The patient suffers from frontal headache, and is frequently drowsy. There is polyuria, amounting to 80-100 oz. in twenty-four hours. The urine is pale, neutral or faintly acid, has a specific gravity of 1008-1010, or NOyEMaEK DATE a 5 /o // /2 13 11- 15 16 '^ ja 19 20 21 22 23 24- 25 26 27 f I03° I02° lO 1 ° IOO° 9 9° SB° 3 7° 96° A ( \ ^ r^ t V '•-v \ ^»^ 1 \ / v-.- \ •^/ ^ y *-V A \/^ ^ v. Chart 15. — Continuous subnormal temperature in case of bladder growth with chronic septic pyelonephritis. even less. It is hazy and contains flakes, and may occasionally give the characteristic drift-cloud appearance of bacilluria. There is a trace of albumin, and a small deposit of pus which settles as a thin creamy layer. The urine contains pus, sometimes a few casts, and bacteria. There may be slight renal aching, but the kidneys are not enlarged or tender. There is frequent micturition, in increased quantity, more marked at night (nocturnal polyuria), but this symptom may be masked by the symptoms of previously existing prostatic or bladder disease. The temperature varies from 97° to 97'6° or 97*8° F., occasionally rising to 98° or to normal. (Charts 14, 15.) An injection of methylene blue either fails to colour the urine or the elimination is delayed, reduced, and prolonged. After the injection of phloridzin, either no sugar is produced by the kidneys, or only a trace. 134 THE KIDNEY [chap. The course of chronic septic pyelonephritis may be interrupted by acute or subacute attacks at long or short intervals. (Chart 4, p. 16.) These are brought on by the passage of an instrument or by injudicious exposure to cold and fatigue, or may come on apparently without exciting cause. Such an- attack resembles the acute attacks already described, but is usually milder in character. During the attacks the quantity of urine diminishes, and there may even be a period of temporary suppression, lasting some hours, and the patient rapidly emaciates. After the attack improvement takes place, the urine is secreted in as great quantity as before, but the patient has lost ground. Sometimes the patient dies during an acute exacerbation. Chronic septic pyelonephritis may last several years, and its progress apart from acute exacerbations is slowly progressive. In the later stages the quantity of urine diminishes, and the headache, thirst, anorexia, drowsiness, and other symptoms increase. There are seldom^ if ever, ursemic convulsions. The patient may die almost suddenly without an increase in the symptoms, or may gradually sink with a failing renal function. Diagnosis. — The occurrence of acute symptoms such as those detailed above, after the passage of an instrument in a case of obstructive urinary disease, presents no difficulty in diagnosis. If the urine becomes clear while the temperature remains high and swinging and the kidney large, it is likely that a pyonephrosis has developed. The diagnosis of chronic suppurative pyelonephritis is of high importance in diseases of the urethra, prostate, and bladder. The symptoms are insidious and slight, and must be carefully investi- gated. The condition of the urine is very important in diagnosis. The tests for the renal function are also invaluable. Where opera- tive treatment of the renal disease is proposed, it will be necessary to catheterize the ureters and examine each urine separately. Prognosis. — Many patients die during the acute attack of ascending pyelonephritis, and of those that recover the majority suffer from chronic pyelonephritis. Should the urinary obstruc- tion be removed,, the further progress of the disease will probably be arrested, but the kidneys are permanently damaged. Chronic ascending pyelonephritis is usually slowly progressive, and is eventually fatal after some years. Treatment. 1. Acute ascending pyelonephritis. — Prophy- lactic measures include the sterilization of all urethral instruments and of all basins, syringes, lotions, etc., and the cleansing of the surgeon's hands and of the patient. They consist also in prac- tising the utmost gentleness in all manipulations. Koughness X] asgi:nding pyeloni:fhkitis 155 nicjiiis hi'uisiiit,' jiiid liicci'alioii, and Ibis, togctlici" witli lln" damage produced by ohsl ruction., paves Mie way for sepsis. Non-operfUwe tredtment consists in dry cupping, hot fomenta- tions, turpentine stupes, or poultices applied to the loin to relieve the renal congestion. A hot pack or hot vapour bath should be given to induce sweating. Pilocarpine may be injected hypodermic- ally, but should be carefully watched. It is important to get the bowels opened and to relieve the abdominal distension. A large dose of castor oil or a strong saline purge should be given, but it is frequently returned if the patient has commenced vomiting. Turpentine and soap-and-water enemata, to which 20 minims of oil of rue are added, help to bring away flatus, and a rectal tube should be introduced high up in the rectum. If the patient is able to keep fluids down, large draughts of warm Contrexeville water should be given, and may be combined with theocin sodium acetate 3-8 gr. every four hours, or theobromine sodiosalicylate (diuretin) 10 or 15 gr. every four hours. Pituitary (infundibular) extract (20 per cent., B., W. & Co.) may be used in a dose of 0-5 c.c. This has the advantage of being given sub- cutaneously, but its powerful effect in raising the blood pressure necessitates great caution in its use; I combine it with atropine. Glucose solution should be introduced into the subcutaneous tissues in large quantities, several pints being injected slowly. Infusion of glucose solution (2| per cent.) into a vein (median basihc) is the most rapid and powerful means of re-estabhshing the renal secretion. Two or three pints are infused. Operative treatment. — There are two indications for operative treatment : i. The rehef of urinary obstruction, if present, ii. The relief of congestion and drainage of the kidney. Should the measures detailed above prove ineffectual and no improvement be apparent in two or three days, or if the patient appear to be failing before this, operation will become necessary. If there is unrelieved urinary obstruction, this should first receive attention. The operation which is performed for the relief of the obstruction is not necessarily that which would have been chosen had no kidney complication developed. The operation should give the freest drainage with the least amount of shock. Suprapubic cystotomy and drainage with a large tube are the best means of carrying this out. It is a temporary measure. Opera- tion for the permanent cure of the obstruction can be performed later if the patient survives. , For relief of the renal congestion and sepsis nephrotomy should be performed. The kidney is freely incised along the convex border, 136 THE KIDNEY [chap. and a large rubber drain introduced into the pelvis. If there is free hseniorrhage a mattress stitch may be inserted to control it, the rest of the kidney wound being left open or packed with anti- septic gauze. Another large drain is placed outside the kidney before uniting the edges of the parietal wound. As a result of this operation the temperature falls to normal, and within a few hours the dressings are flooded with urine. The temperature may remain normal and the progress to complete recovery be iminter- rupted, or the temperature may rise again to 100° or 101° F. for a few days and then gradually fall. The secretion of urine, however, is re-established, and the crisis is over. It is of vital importance that these operations be carried out with the utmost celerity. The operation for obstruction and that for relief of the renal congestion and sepsis are done at one sitting. Saline infusion, rectal and intravenous, should be given on the return from the operation. There is some danger of haemorrhage from the kidney about the seventh or tenth day after operation. Should this occur, the tube is removed and the kidney rapidly plugged with gauze. I have operated in this manner with suc- cessful results on patients who were weakened by over-long delay, on others in the final unconscious stage of the disease, and on a patient mth one kidney, anuric for three days and with a tempera- ture of 106°. F. Nephrectomy is not indicated in these cases, since nephrotomy suffices to tide over the crisis ; the shock in nephrectomy is greater, the disease is not cured by it, and the second kidney, if it is not acutely septic, is damaged to an unknown degree by back pressure. Nephrectomy may, however, be necessary in the hsemorrhagic type of pyelonephritis on account of the severe and continuous haemorrhage. 2. Chronic ascending pyelonephritis. — In the majority of cases chronic ascending pyelonephritis is bilateral, one kidney, however, being more seriously damaged than the other. The prophylaxis of chronic ascending pyelonephritis consists in the early removal of enlarged prostate, the efficient treatment of stricture, the removal of calculi, and other measures directed against the existence of chronic obstruction and chronic sepsis in the lower urinary organs. When chronic pyelonephritis has become established, operative interference in the bladder and urethra' must be undertaken with the utmost caution. When an operation for enlarged prostate is proposed the bladder should be opened suprapubically and drained for a week or more before the prostate is removed. In a case of stricture, external urethrotomy with drainage of the bladder would X] ASCENDINCi PVFLONHPHKITIS 137 be prclci'icd to iii((MiKil uid lirofoiiix' or dilatation with in.slruiiients. Urinary antiseptics {sec uikUh- Ha'niatogeiious Pyelonephritis, p. r2()) and dinrctics should be freely administered. If the disease is proved to be unilateral and the second kidney ascertained to be healthy by means of the ureteric catheter and tests for the renal function, the kidney may. after removal of all lower urinary obstruction, be incised or removed. It is seldom, however, that these circumstances combine to make surgical inter- vention possible. Vaccine treatment has not given encouraging results. The administration of renal extract has been tried in these cases and in chronic aseptic pyelonephritis. It does not influence the cause, or, in the cases I have seen treated by it, modify the progress of the disease. LITERATURE Albarran, Tmite de C'himrgie (Le Dentu et Delbet), iii. 7G0. Israel, N ierenhrayikheiten. Berlin, 1901. Legueu, Bull, de la Soc. de C'hir., 1901. Pousson, Folia 'Urol., Jan., 1909, p. 445. Sampson, Johns Hopkins Hosp. Bull., Dec, 190,3. Walker, Thomson, Pract., June, 1903. Weir, Med. Bee, 1894, xl. 32,'j. Wilms, Miinch. med. Woch., 1902, Xr. 12, p. 470. CHAPTER XI SURGICAL INFLAMMATION OF THE KIDNEY AND PELVIS (Concluded) PYELITIS The intimate relation between the kidney and its pelvis makes it impossible for severe inflammation to be wholly confined to one or the other. At the same time there are cases where the brunt of the inflammation falls upon the pelvis, and the kidney is but slightly involved, so that clinical evidence of nephritis cannot be obtained. These are cases of mild subacute or chronic inflamma- tion, which may either follow upon an acute attack of pyelo- nephritis or arise de novo. Etiology. — -Mid-adult life is most frequently affected in either sex. The infection may be blood-borne (haematogenous), or it may ascend from the lower urinary organs by the ureter or the lymphatics of the ureter. As in p yelonephritis, diseases of the lower urinary organs which cause obstrucFion and inflammation are the most frequent causes. Thiis, enlarged prostate, stricture, stone in the bladder, gonorrhoea (T8~ per cenK— Finger), Hadder growths, etc., are predisposing causes. " in one class of cases a calculus is present in the pelvis. This may be either the cause or the result of the pyelitis. Pathology. — The mucous membrane in slight catarrhal forms is hypereemic, and in more severe forms is thickened and velvety, and sometimes shows petechise and superficial ulceration. In old- standing pyelitis, especially where calculi are present, the wall of the pelvis is thick and leathery, the mucous membrane dull and opaque, sometimes there are small colloid-filled cysts {'pyelitis cystica), or tiny sago-grain lymph follicles {pyelitis granulosa). Pyelitis, whether ascending or hsematogenous, may be unilateral. In the later stages of ascending pyelitis the condition is usually bilateral. Symptoms. — In cases of non-calculous pyelitis the symptoms are usually insignificant, if the cases of acute pyelonephritis, already 138 CHAP. x[] PYELITIS : SYMPTOMS 139 described, arc cxcliidcd. Tlicic may hr a sliiflil, ri,s(! of teniperatiirc to 100' F. at Jii<,'lii, hut i\w tcnipciuturt' is oltcii uiiaft'ected. Slight constant renal achirifr is complained of, either at the angle formed by the last rib and the erector spina? mass of muscles, or anteriorly a little below and internal to the tip of the 9th rib. There may be a little tenderness on pressure at this point, but often this is absent. The kidney is not enlarged. Urine. — Changes in the urine form the most important signs of pyelitis. There is polyuria, most marked at night. The urine is pale and opalescent, the specific gravity low (1008 or 1010). It is acid and usually odourless, but sometimes there is the stale- fish smell of bacilluria. On standing the urine deposits a fiat, creamy layer of pus, which moves heavily when the glass is tilted. The supernatant fluid is pale and cloudy, and there may be the characteristic drift-cloud appearance on making the urine circulate in a glass. There is a slight cloud of albumin. Microscopically, tailed cells and over- lapping epithelial cells. (see under Pyuria, p. 147) are present, but no tube casts. Bacteria are present and may be abundant. With the cystoscope the ureteric efflux is copious, frequently repeated, and cloudy to a varying degree. The movements at the ureteric orifice are vigorous. The edges of the orifice may be healthy, but are frequently reddened and sometimes thick. (Plate 16, Fig. 1, facing p. 234.) A halo of congestion or inflam- mation may surround the orifice in an otherwise healthy bladder. Where cystitis is present these appearances may be obscured, and there may be nothing apart from the efflux to distinguish one orifice from the other when the disease is imilateral. In slight degrees of pyelitis the urine shows only a faint haze and a few flakes, and the cystoscopic changes consist in a faint blush around the orifice, which is open and with sHghtly thickened lips. It will sometimes be found on examination of the urine of each kidney, drawn by a ureteric catheter, that the urine of the diseased pelvis is alkaline, while that of the healthy side is acid. The blend of the two urines is acid if alkaline cystitis is not present. In cases where pyelitis is secondary to cystitis, the symptoms of the latter may obscure those due to the pyelitis. In this case the urine may be alkaline and stinking and ammoniacal. It con- tains pus and mucus, giving the deposit a billowy appearance. Diagrnosis. — In making a diagnosis the following questions must be answered : — 1. In a case of cystitis from any cause is pyelitis present ? 2. Where pyelitis is present is the kidney involved ? 3. Is there a calculus in the renal pelvis ? 140 THE KIDNEY [chap. 1. Where the signs of pyeHtis are obscured by cystitis the diagnosis depends upon the cloudy efflux from the ureteric orifice, the appearance of the orifice, and the examination of the urine of each kidney obtained by the ureteric catheter. 2. It is often extremely difficult to state whether the kidney is involved in a slight chronic pyelitis. The history of a severe acute onset points to renal inflammation, and so do tenderness and enlargement of the organ, an excessive quantity of albumin, the discovery of tube casts, and proofs of an inadequate renal function as shown by symptoms {see under Chronic Pyelonephritis, p. 117) and by the methylene-blue and phloridzin tests. 3. There, may be difficulty in the diagnosis of a pelvic calculus when there has been no pain or hsematuria and no history of stone. The X-rays will settle the diagnosis. Treatment. — The first indication for treatment is to remove any local irritant or any cause of back pressure or sepsis in the lower urinary organs. The removal of a calculus from the renal pelvis may suffice to cure the pyelitis. Enlarged prostate and stricture must be treated. If the pyelitis is of long standing and there is reason to suspect that the kidney is involved, it may be necessary to drain the bladder by suprapubic cystotomy for a fortnight or more before proceed- ing to the operation for radical cure of the prostatic obstruction. The treatment of the pyeHtis consists in the administration of urinary antiseptics (urotropine, hetralin, helmitol, metramine, etc.) and diuretics (Contrexeville, Evian, Vittel, and other alkaline diuretic waters). Vaccine treatment should be tried in chronic cases {see under Pyelonephritis, p. 126). Instillations of argyrol and other silver preparations have been made through a ureteric catheter passed along the ureter into the renal pelvis. The method is not free from the danger of obstruction resulting from swelling of the mucous membrane at the outlet of the pelvis, and should be used with the utmost caution, and not practised if the temperature be elevated. Kelly and Casper have employed this method in cases of chronic gonorrhceal pyelitis, and Stockmann recommends it in all cases of chronic pyehtis. From 10 to 15 c.c. of a 1-2 per cent, solution of nitrate of silver are instilled into the renal pelvis on several successive days or on alternate days, or a solution of 1 in 2,000 to 1 in 1,000 may be used in larger quantities. My experience of this method has been favourable. I reserve it for cases where medicinal and vaccine treatment have failed. XI] PYELITIS OF INFANCY Ml It should only be used by those who are experienced in ureteral catheterization. Should these methods fail in chronic cases, and diuretics and urinary antiseptics fail in more severe and acute cases, the kidney should be exposed and opened, and the pelvis washed out and drained through the wound. A small rubber tube may be fixed in the pelvis by a catgut stitch through the renal capsule, and the pelvis washed with silver nitrate solution daily for ten days, when the wound is allowed to close. The cystitis should then be treated by bladder-washing. Pyelitis of Infancy and Childhood A form of acute pyelitis which occurs in infants and children merits separate discussion. Many of the cases are met with in infants under 2 years, but the disease also occurs in older children. Dr. J. Thomson records 8 cases at the ages of 7i, 10, 10, 12, 14, 14, 18, 20 months. The majority are girls, but cases in boys have been recorded, and Morse found that 40 per cent, of his 50 cases were boys. Constipation is very frequently present, and there may have been occasional attacks of diarrhoea. There is frequently a history of soreness around the anus, painful defsecation, or blood in the motions. The symptoms begin suddenly with a rise of temperature and a chill or rigor, which may be severe and repeated. Delirium, squinting, and vomiting follow, and the child is restless and dis- tressed. The temperature is high, 104° or 106° F., and remittent in type. There is pallor and anorexia. Emaciation is slow. The local symptoms may be slight and insignificant. Attacks of screaming — due to colic — occur, and tenderness on palpation in the region of the kidney has been suspected in some cases. Increased frequency of and pain on micturition is . sometimes observed, but this symptom may be wanting, and occasionally the urine is held for an unusually long time to avoid pain on passing it if there is soreness of the vulva. The first indication that there is any urinary trouble is often given by a yellowish staining of the diapers. The urine is strongly acid. There is a little albumin (usually less than 0"1 per cent.), while pus is present in considerable amount. Hyaline and finely granular tube casts are occasionally found. Red blood-corpuscles may be seen in the early stage. Some epithelial cells from the kidney pelvis or quantities of squamous cells from the bladder are ])resent, and bacteria in large numbers, which are found to bo the bacillus coli in the majority of cases, but occasionally the staphylo- or streptococcus. U2 THE KIDNEY [chap. Diagnosis. — This depends upon the presence of pus and bacteria in the urine. Thomson looks upon pyrexia " and extreme distress without any other symptoms sufficient to produce them," and the occurrence of rigors, in a child under 2 years, when malaria can he excluded, as important points in diagnosis. The condition has been mistaken for malaria, irregular typhoid, and general tuberculosis. Prognosis. — There is a tendency to spontaneous recovery, but the condition sometimes ends fatally. The cases improve rapidly under treatment. The temperature falls and the symptoms subside in a week or ten days. The pus may remain for several weeks and the bacteria for longer. Treatment. — Acidity of the urine is reduced by the adminis- tration of alkalis, and the urine is kept neutral. Citrate of potash is given in doses of 24 gr., or in severe cases 36 to 48 gr., per day in infusion of digitalis, and continued till danger of a relapse is past. Urotropine, 5 or 10 gr. daily, and salol may be given in addition to the alkaline treatment. The nurse should be warned not to wipe soiled diapers against the urethra. Operative measures are very rarely necessary. If the child is steadily losing ground under medicinal treatment, and the symp- toms are unilateral, nephrotomy may be performed. Pyelitis (Pyelonephritis) of Pregnancy When pyelonephritis is already present the effect of pregnancy is to aggravate the disease. Pyelonephritis not infrequently develops during the early months of pregnancy, and the pregnancy is the predisposing cause of the disease. Pathology. — The bacteriology is similar to that of other renal infections. Albeck found the bacillus coli in 131 out of 159 cases. The right kidney is almost always attacked (65 in 70 cases — Legueu), and the condition is unilateral. The disease most fre- quently appears about the fourth month of pregnancy. It has been ascribed to compression of the ureter by the gravid uterus, but this is doubtful, since the uterus is not likely at this early stage to cause pressure. Mirabeau holds that it is due to hypergemia of the vesical mucous membrane and the altered rela- tions of the ureters and bladder to the urethra causing urinary obstruction. When an instrument has been passed the infection is usually looked upon as ascending. In other cases when no infection of the lower urinary tract has occurred, it is considered to be a hsematogenous infection. xij PYELITIS OF PREGNANCY 143 Symptoms. — Bar describes a latent presuppurative stage during which there is bacilhiria with continuous fever, but Legueu found a sudden onset in 12 out of 70 cases. There are a rigor and rise of temperature, together with severe unilateral renal pain in paroxysms and frequent painful micturition. The vesical irritation may be the first and most distressing symptom. The urine contains pus and bacteria. The quantity of pus is not a gauge of the severity of the infection, and Legueu states that the urine may be almost clear even with grave symptoms. The general condition usually remains good, although the temperature is high and swinging. In a few cases the disease is bilateral and there is rapid emaciation, with drowsiness, burning thirst, dry tongue, and other signs of uraemia. In the later stages of pregnancy palpation of the abdomen is difficult owing to the large volume of the uterus. There is some rigidity on one side, and the kidney is tender ; it may be felt slightly enlarged. Diagnosis. — The diagnosis depends upon the examination of the urine and the situation of pain and tenderness. A mistaken diagnosis of appendicitis has been made. Course and prognosis. Effect on the pregnancy and puerperium. — Of 52 untreated cases, premature labour occurred in 13 (25 per cent.) (Legueu). When the acute attack occurs early in the pregnancy and there is an interval of normal tem- perature before jparturition takes place, the puerperium is usually apyretic. If, however, the acute attack is late in the pregnancy there is usually fever during the puerperium, but puerperal infec- tion does not occur. Effect on the child. — If the pregnancy be interrupted the child is usually ill-nourished, and dies in one-third of cases (Legueu). If the attack occur late, and the pregnancy go on to full term, the child is usually healthy and well-nourished. Effect on the kidney. — After parturition the pyelonephritis may subside and the urine clear and become sterile, but more frequently bacilluria and some degree of pyelonephritis persist and exacerbations occur during succeeding pregnancies. Treatment. — Prophylaxis consists in careful asepsis in catheter- ization and in the treatment of constipation during pregnancy. If bacilluria exists or there is chronic pyelonephritis, this should be energetically treated, and the patient warned of the danger of becoming pregnant. The production of abortion or the induction of premature labour is seldom necessary, but it may be called for in a severe case. Urinary antiseptics tiiid vac<;ine treatment should be given, and in the great majority of cases these yield satis- factory results. {See Pyelonephritis, p. 126.) 144 THE KIDNEY [chap. Operative treatment. — This is very rarely necessary. Nephrotomy has given good results, and is specially indicated when the pyelo- nephritis is unilateral. In severe bilateral pyelonephritis premature labour should be induced. Nephrectomy is a more severe operation. It may be necessary in unilateral pyelonephritis, and does not affect the course of the pregnancy in most cases. Cova collected 21 cases of nephrectomy, and found that the pregnancy went on to term in 15 and was 5 times interrupted spontaneously and once artificially. The mortality is 9-5 per cent. According to this observer nephrectomy is well borne in the early months of pregnancy, but less so after the fifth month. LITERATURE Albeck, Zeits. f. Geb. u. Gyn., Ix. 466. Ayres, Amer. Journ. Urol., 1906, p. 480. Bar, Soc. d'Obst. de Paris, June 16, 1904. Box, Lancet, 1908, i. 77. Casper, Wien. med. Press, 1895, p. 1417. Cova, Soc. d'Obst. e di Gin., 1903, p. 692. Cumston, Amer. Journ. Med. Sci., 1908, p. 87. Johnson, Amer. Journ. Urol., 1906, p. 566. Legueu, Ann. d. Mai. d. Org. Gen.-Urin., 1904, p. 1441. Morse, Amer. Journ. Med. Sci., 1909, p. 313. Pousson, Folia Urol., 1909, p. 445. Sampson, Johns Hopkins Hasp. Bidl., 1903, p. 336. Sellei und Unterberg, Berl. Min. Woch., 1907, p. 1113. Smith, Bellingham, Gui/s Hosp. Repts., 1906, p. 227. Thomson, Scot. Med. Surg. Jour7i,, 1902, p. 7. PYONEPHROSIS Pyonephrosis is distension of the kidney and its pelvis with pus or purulent urine. In the description of pyelonephritis it was pointed out that obstruction in the lower urinary organs was a frequent predisposing factor, and that some dilatation of the renal pelvis was almost constant in these cases. The degree of dilatation is, however, very slight, and the destruction of renal tissue by intrapelvic pressure is minimal. In pyonephrosis the kidney tissue is destroyed by intrapelvic pressure, and the presence of sepsis may be accidental. There are two distinct forms of pyonephrosis : 1. Pyonephrosis secondary to uronephrosis (hydronephrosis), or uro-pyonephrosis. 2. Pyonephrosis developing from acute pyelonephritis. Etiology. — The etiology of uro-pyonephrosis is that of uro- nephrosis. The condition is unilateral, it occurs more often on the right side, it is more cDmmon in women, and it is in most cases related to movable kidney, stone, or pregnancy. The actual obstruction is usually situated high up in the ureter, and is due XI] PYONEPHROSIS 145 to a stone, or to strictiu'o oi- duplicatioii of tlie ureter. The super- added infection may })e a.scendiii*,', from leceiit cystitis, or it may be lianuatogenous. Pyonephrosis developing in acute pyelonephritis occurs especi- ally in cases of old-standing disease of the lower urinary organs, such as enlarged prostate, stricture, and growths of the bladder and prostate, and is therefore more frequent in men. The infec- tion is almost invariably ascending. There is frequently bilateral disease, but the second kidney is not necessarily pyonephrotic. The obstruction which gives rise to the dilatation of the kidney is at any part of the ureter, and is due either to stricture or to swelling of the mucous membrane consequent upon the septic inflammation. The bacteria are those of other renal suppurations. Anaerobic bacteria are sometimes found. A pyonephrosis is '' open " when the obstruction is incomplete and pus escapes, and " closed " when the block is complete. Pathology. — The dilated kidney forms a globular or elongated mass. It frequently r-eaches the size of a child's head and fills the flank and one side of the abdomen. The pelvis may be greatly dilated and form a large globular swelling, which is capped by a slightly enlarged kidney. This form is said to occur especially where the pyonephrosis is of ascending origin. The kidney may be greatly distended, form- ing the pouch, while the pelvis is small and hidden. The surface shows rounded grey or dark bosses corresponding to saccules in the pouch and separated by grooves corresponding to septa between these. The kidney is firmly adherent to its surroundings, and is frequently hidden by a thick fibro-fatty layer. There is a single large cavity in the centre formed by the dilated pelvis or the greatly distended sinus of the organ, and with this numerous pouches com- nninicate. These pouches are separated by firm fibrous septa of varying thickness, and frequently communicate with each other. Sometimes the communication of a pouch with the main cavity is very small, and occasionally a pouch may become completely shut off from the central cavity. In the walls of the secondary pouches there may be small abscess cavities. The lining membrane of the primary and secondary pouches is smooth and tough, and is occasionally covered with a rough greyish false membrane, which may be gritty with calcareous deposit. The distension of the kidney is brought about by pressure upon the pyramids, which become flattened and then pouched, while the colunms of Bertini form the fibrous septa. These septa may become thinned out so that one pouch communicates with another. Microscopical examination of the wall of the sac shows remains of 146 THE KIDNEY [chap. the renal parenchyma. The glomeruli are fibrous, and the tubules undergoing atrophy. There is widespread fibrosis, and scattered through this are patches and areas of recent leucocytic infiltra- tion. Albarran has described areas of compensatory hypertrophy. Partial pyonephrosis may occur, and is due to the blocking of one section of a dichotomous renal pelvis. A small portion or one pole of the kidney may be converted into a pyonephrosis by the blockage of one or several calyces with a stone. The content of a pure pyonephrosis is pus, and this is sometimes thick and almost cheesy. Traces of urea may be found, but are occasionally absent. In a uro-pyonephrosis the contents are urine with a varying admixture of pus. Calculi may be present in the sac, and may be primary and cause the obstruction, or secondary. When the pyonephrosis is secondary to disease of the lower urinary organs the ureter is large, elongated, tortuous, greatly dilated and pouched, and usually adherent to the surrounding cellular tissue ; the wall is thick and tough, and there are folds and strictures which may be so narrow as to admit only a fine probe. When the pyonephrosis follows a uronephrosis or a descending infection, only the part of the ureter above the site of obstruction is damaged. The ureter is inserted into the dilated pelvis at a point high above the lowest part of that receptacle, and may be adherent to the surface of the sac. The functional power of the renal tissue of a pyonephrotic kidney may have been entirely destroyed, and only pus is discharged on nephrotomy. Usually, however, a certain quantity of urea (Albarran states 2 to 4 gr. per litre) is found in the fluid discharged by the fistula, and most pyonephrotic kidneys have some amount of functional power. The second kidney. — When the pyonephrosis is due to old- standing disease of the lower urinary organs, both kidneys are usually affected, although in different degrees. Gosset has shown that the lesion is occasionally unilateral in these cases. When bilateral disease is present, the second kidney usually suffers from chronic pyelonephritis, and there is seldom any marked develop- ment of compensatory hypertrophy. In uro-pyonephrosis the second kidney is usually healthy, and shows compensatory hypertrophy. Symptoms. — When the pyonephrosis is secondary to lower urinary disease, the symptoms of cystitis or obstruction ma;y obscure those of the renal complication. Usually, however, there are symp- toms of ascending pyelonephritis. It may be difficult or impossible to say when obstruction converts the pyelonephritis into pyo- XI] PYONEPHROSIS H7 nephrosis. When the condition settles down into a less acute state, the diagnosis is more readily made. The advent of suppuration in a case of hydronephrosis is heralded by a rigor, rise of temperature, and other signs of infection. The symptoms of pyonephrosis are pain and tenderness of the kidney, tumour, and pyuria. Pain. — At the outset pain is usually pronounced. It is con- stant, heavy, and boring, and is occasionally severe. When the pyonephrosis is more fully developed pain may be absent, and may occur only when the outlet of the pyonephrosis becomes blocked and the kidney fills up with pus. It may then be severe and radiate down the ureter, causing renal colic. The thigh is often flexed to relax the psoas muscle. Tenderness on palpation is pronounced at first, but later it may be absent, and only appear during a crisis of retention. When present the abdominal muscles are contracted. Guyon found tenderness absent in "17 out of 26 cases. Tumour. — The tumour has the characteristics of a renal tumour. It projects below the costal margin, but, as Albarran points out, it is more likely than a hydronephrosis to form adhe- sions and remain bound down and concealed beneath the ribs. It forms a large, smooth, regular, non-fluctuating, firm tumour from which ballottement can be obtained. During an attack of retention it becomes tense, larger, and tender. The ureter may occasionally be felt as it crosses the brim of the pelvis, and it may be detected as a thickened band in the lateral fornix of the vagina in the female, or in the rectum in the male. Pyuria. — This is the cardinal symptom of pyonephrosis. The pus forms a thick, heavy deposit, and the supernatant urine remains cloudy. The pyuria is abundant, and is subject to shght variations in quantity from day to day, and to intermissions lasting a few days. These variations are dependent upon the ease with which the pus escapes from the pyonephrosis. There are recurrent attacks of complete retention of pus, during which the urine becomes clear, the tumour increases in size and becomes painful, tender, and more tense, and the temperature rises. The attack lasts two or three days, and then the tempera- ture falls suddenly, the symptoms subside, and a large quantity of pus appears in the urine. Even in the crises of acute retention the urine may still con- tain pus derived either from the bladder or from a diseased second kidney. 148 THE KIDNEY [chap. Cystoscopy. — If the infection has been ascending there will be chronic cystitis and evidence of urethral obstruction or of bladder growth. The orifice of the ureter may be lost among the trabeculse and pouches of the bladder. It may be discovered on a thick ridge and show nothing abnormal, even when the ureter and renal pelvis are widely dilated and their walls greatly thickened. (Edema and thickening of the lips will denote inflammation of the ureter. The orifice is occasionally found open, round, and immobile, and surrounded by a rigid, thickened margin, or with a thick, oedematous, sometimes ulcerated edge. In a closed pyonephrosis there is no efflux, but there may be an occasional feeble gaping movement at the orifice. In an open pyonephrosis the efflux varies according to the contents of the pyonephrosis. It may consist of thick worm-like masses of semi- solid pus slowly expressed from the ureter, or there may be a copious intermittent stream of watery pus or of purulent urine. A forcible jet rapidly repeated denotes that the ureter has retained its muscular power, while a slow, continuous stream or a lazy welling of fluid at long intervals shows that the ureter is dilated and atonic. Catheterization of the ureters will determine whether an obstruction exists, and at what level, and also give information in regard to the presence, health, and function of a second kidney. Course and prognosis. — In rare cases the pyonephrosis diminishes in size. It is compressed and invaded by the peri- nephritic inflammatory tissue from between the calyces and from the surface, and gradually shrinks, being eventually replaced by a fibro-fatty mass. The ureter becomes obliterated and atrophies. More frequently there is perinephritic suppuration, and this burrows in various directions {see Perinephritic Abscess, p. 112), and may rupture into the lung, stomach, peritoneum, or on the surface. The patient eventually dies of exhaustion from long-continued suppuration. Diagnosis. — If the pyonephrosis is closed the diagnosis will depend upon the history of pyuria, the presence of cystitis, symp- toms of septic absorption, and the presence of a renal tumour. Occasionally cases may be met with in which there has never been renal pain or other urinary symptom. When there is pyuria alone the characters of the pyuria and cystoscopy will lead to a diagnosis. When cystitis is superadded the large quantity of pus in the urine will suffice to distinguish the renal disease. When the pus reaches one-fifth to one-sixth of the whole urine it must come from the kidney. In two other conditions there may be very large quantities of XlJ pyoni:piirosis Ml) ])ii.s ill I he iiiiiit! ;ii iiilcrvals, iiaiudy, ( I ) a suppiiral iii>,' di vert iculuin of tlu; bladder, and (2) a piiiulcnt collcftioii rouiniuiiicatinf^ witli a ureter. The use of the cystoscope, and if necessary the ureteric catheter, will distinguish a diverticulum of the bladder. The second condition is only diagnosed on operation, unless some point in the history of the case reveals its nature. The differential diagnosis must be made from — (1) Pyeh)nephritis without retention. The large quantity of 23US points to pyonephrosis, and catheterization of the ureter will show no obstruction. (2) Tuberculous pyonephrosis. The presence of tubercle bacilli in the urine and of tuberculous lesions elsewhere in the genital system, and the general tests for the presence of tubercle in the body, will distinguish this from pyonephrosis. In such cases there is usually a thick tuberculous ureter which will be diagnosed by abdominal, vaginal, or rectal palpation and with the cystoscope. The functional value of the pyonephrotic kidney and the pre- sence of disease in the second kidney and the functional power of this organ are estimated by catheterization of the ureters. The urine of each kidney is examined, the quantity, naked-eye and microscopic characters, and the presence of albumin and the quantity of urea being noted. The tests for the renal function (phloridzin, indigo carmine, etc.) are used (p. 20). The following table gives the results of the examination of the urines in a case of calculous pyonephrosis : — Right Kidney Left Kidney (Pyonephrosis) . (Healthy) Quantity 206-5 c.c. 107 c.c. Specific gravity 1004 1011. Freezing-point (A) -0-18° C. -0-76° C. Colour . . Pale, limpid Fairly coloured. Urea 0-4 per cent. 1-3 per cent. Uric acid 0-0067 per cent. 0-0150 per cent. Chlorides 0-0977 per cent. 01 112 per cent. Phosphates 0-08 per cent. 0-03 per cent. Methylene lilite . . No change in colour Delayed 1 hour 50 min.. of urine diminished, pale green, and lasted only 18 hours. Chromogen Appeared 25 min., Appeared 25 min.. small amount large amount. Phloridzin glycosuria . . 0-395 grm. 1-623 grm. 150 THE KIDNEY [chap. An X-ray examination for stone should be made of the whole urinary tract, including the bladder, lower ureters, and second kidney. Treatment. — The following methods of treatment will be dis- cussed : — 1. Drainage by ureteral catheter. 2. Plastic operations. 3. Nephrotomy. 4. Partial nephrectomy. 5. Nephrectomy. 1. Drainage by ureteral catheter. — Pawlik and Albarran have advocated this method in selected cases. The ureter is catheterized daily or less often, according to whether a reaction occurs. The pelvis is washed at the same time. The catheter may be progressively increased in size until No. 13 Fr. is reached. Albarran has left the ureteral catheter in place for several weeks, changing it when it became blocked. He uses boric acid, silver nitrate (1 in 1,000), and permanganate of potash (1 in 4,000 to 1 in 500) for washing the kidney. Pawlik recom- mends massage of the kidney and the application of a firm bandage afterwards. He claims a cure in a pyonephrosis of 150 grm., and Albarran another in one of 60 grm. Many circumstances combine to limit the application of this method — an intolerant bladder, febrile reaction, strictures of the ureter, subdivision of the pyonephrotic pouch, the presence of calculi, thick caseous contents, etc. — and there can be very few ' cases where it will possess an advantage over an open operation. 2. Plastic operations. — In cases of uro-pyonephrosis plastic operations have been undertaken with the object of re-establishing the outlet by the ureter. These operations will be discussed under Uronephrosis (p. 179). It is necessary to ascertain first the nature of the obstruction and the functional power of the kidney, and in order to do this a preHminary nephrotomy is necessary. Usually the functional power is so far destroyed that it is not worth while doing such an operation, and the choice will lie between nephrot- omy and nephrectomy. 3. Nephrotomy. — This may consist only in incision of the kidney, or an attempt may be made to re-establish the lumen of the ureter. The pyonephrotic sac is opened by an oblique lumbar incision. The contents are evacuated, and septa between saccules are broken down. Careful search is made for interstitial abscesses and the main cavity, the upper portion of the ureter and the subsidiary cavities are carefully examined for stone, and the perinephrit:ic xr] NEPHROTOMY FOR PYONEPHROSIS 151 tissue around llio kiducy, and especially at the upper and lower poles, should he explored for possihle extrarenal collections of pus. Guyon reconnuends that the edges of the sac should be stitched to the skin in order to avoid perinephritic suppuration. This is not necessary if free drainage be established by large rubber tubes placed both inside and outside the kidney. This operation is rapid, causes no shock, and preserves the remains of the secreting tissue. It may therefore be performed in the very worst cases, where the patient is weak from severe or prolonged suppuration, and in cases where it is impossible to esti- mate the value of the second kidney or where this organ is known to be the seat of advanced disease. The mortality of the operation is from 17 (Kiister) to 23-3 per cent. (Tuffier). After the operation an improvement in the work performed by the second kidney is usually observed, and is due to the relief from the depressant reno-renal reflex, and also to the removal of toxins which were being absorbed from the pyonephrosis and excreted by the second kidney. The general health, for similar reasons, greatly improves. In 27 per cent. (Kiister) of cases the wound closes, the sac shrinks, and the patient is cured. In a certain number of cases septicaemia persists, and the work of the second kidney is still poorly performed. This is due to continued suppuration in the thick, fibrous-walled cavity, to un- opened pouches, to abscesses in the walls and partitions, to stones being left in the sac (16 per cent, of cases), or to the persistence of the ureteric block and ureteritis. A fistula remains in from 45*6 per cent, (calculous pyonephrosis 34-2 per cent., non-calculous 57-1 per cent. — Tuffier) to 56 per cent. (Kiister). Various means have been adopted to obviate this or to cure the fistula when it has persisted. At the nephrotomy Bazy intro- duced a bougie along the ureter, and Doyen used a metal sound to dilate the ureter. There is difficulty, however, in finding the opening of the ureter in a large multilocular sac, and Albarran has used the following method : Before the nephrotomy he passes a catheter up the ureter by means of the cystoscope. At the operation this is easily found, and to the end of it is attached a catheter of No. 10 Fr. size. By withdrawing the first catheter the No. 10 catheter is drawn down to the bladder. This second catheter is fixed to the skin of the loin vnth a thread, and the nephrotomy is finished in the manner described. The ureteric catheter is left in place for four or five days and then changed. A light pliable stilette is passed along the catheter, and a metal conductor screwed on the end of it. The catheter is now withdrawn, and replaced by another which is threaded over the guide. The ureteral drainage 152 THE KIDNEY [chap. is continued for a month. By this means the number of cases of fistula has decreased. A fistula may be cured by excision of its fibrous wall, the opening up of the sac, removal of calculi, and the estabhshment of free drainage. Should these measures fail, the patient has the choice of retaining the fistula or having the kidney removed. The presence of a renal fistula does not of itself necessarily shorten life. Watson has described a bilateral renal fistula persisting for thirteen years, and Legueu has seen women become pregnant and parturition proceed naturally when such fistulae were present. Watson fits a tube and metal reservoir to collect the urine dis- charged. A small celluloid box the shape of a straw hat may be used for this purpose. It is held in position by a rubber waist- band, and drains into a receptacle. (Fig. 32, p. 159.) Secondary nephrectomy is indicated when septicaemia persists ; when it is believed, from the inadequate secretion of the diseased kidney and the absence of disease in the second kidney, that a depressed renal function in the latter will improve after nephrec- tomy ; and when the patient is gradually losing ground from prolonged suppuration. The mortality of secondary nephrectomy is only 5*9 per cent. (2 in 25 operations, 8 calculous and 17 non-calculous — Tuffier). If this is added to the mortality of nephrotomy (23-3 per cent.) the total mortality of nephrotomy followed by nephrectomy at a later date is 29-2 per cent. Nephrectomy. — This operation may be either partial or total. Partial nephrectomy is only possible when there is a partial pyonephrosis with a separate pelvis. This condition is rare. Nephrectomy is performed by the lumbar route. The abdominal route has been abandoned owing to its high mortality (57 per cent. — Kiister). Subcapsular nephrectomy should be performed. The kidney will usually shell out of the great perinephritic fibro-fatty mass with comparative ease, whereas the removal of the thick fibro- fatty capsule with the kidney is fraught with extreme difficulty and some danger. It may be necessary to puncture a very large pyonephrosis with a trocar and cannula, and to remove a large part of its contents, so as to deal with the pedicle more easily. The wound should be protected with pads, and the patient turned almost on his back while the purulent fluid is being withdrawn through a rubber tube attached to the cannula. The ureter should be dissected out separately, and as much of it removed as possible. The mortality of this operation is 17 per cent. (Kiister). , Death may take place from shock in patients exhausted by XI I ri:nal abscess i>3 severe or prolonged suppiiiatioii, hut the ])rii)cipal danger is in- adequacy of the second kidney from disease (40 per cent. — Legueu). Nephrectomy should not, therefore, be undertaken until the con- dition of the second kidney has been ascertained by catheteriza- tion of the ureters and the use of the phloridzin, indigo-carmine, or methylene-blue test. By this means only those cases are sub- mitted to nephrectomy in which there is a functionally adequate second kidney, and the mortality is thereby greatly reduced. In the remaining cases nephrotomy is performed, and at a later date improvement in the condition of the second kidney may render nephrectomy practicable. As to the time when operation should be performed in a case of pyonephrosis, Bazy, Pousson, and recently Morris have urged the importance of early nephrotomy in all cases with the view to preventing irreparable damage to the kidney. LITERATURE Albarran, Traiti de Chirurgie (Le Dentu et Delbet), viii. 800. Bazy, Xlle Congres fran9. de Chir., Paris, 1898, p. 'i(\. Cahn, Milnch. med. Woch., 1902, xlix. 19. Casper, Wieii. med. Presse, 1895, xxxvi. 38. Fouguet, These de Paris. Gosset, These de Paris, 1900. Greaves, Brit. Med. Journ., July 13, 1907. Halle, These de Paris, 1897. Meyer, Med. News, Sept. 12, 1900. Morris, Lancet, 1910, i. 1597. Watson, Ann. Surg., 1908, No. 3. ABSCESS OF THE KIDNEY Under this term will be described a rare condition in which there is circumscribed suppuration in the renal parenchyma, form- ing a solitary abscess of considerable size. From this category are excluded an abscess formed in a calyx plugged by a stone or other obstruction {partial pyonephrosis), and scattered points of suppuration in the kidney substance {suppurative nephritis). Etiology and pathology. — According to Morris, a renal abscess may be formed by {a) the fusing together of a number of miliary abscesses, or (6) the plugging of a large artery with a septic embolus. The infection may be hsematogenous in cases of ulcerative endo- carditis or pyaemia, or it may be ascending from the lower urinary tract. Injury by wounds or contusions and lacerations and cal- culus of the kidney are other causes. The abscess may rupture into the renal pelvis and the pus be discharged from the ureter or on the surface of the kidney and form a perinephritic abscess. Symptoms. — The abscess may give rise to acute or chronic 154 THE KIDNEY [chap. symptoms. In acute cases the temperature rises after a rigor, and there are severe renal pain, a)3dominal rigidity and tenderness. The kidney is not sufficiently enlarged to form a tumour, and, unless the abscess is secondary to infection of the urinary tract or bursts into the renal pelvis, there is no pus in the urine. Morris states that hsematuria often precedes the formation of abscess, and, when it does, partial suppression of urine may be expected. Symptoms may be entirely absent in chronic abscess of the kidney, or they may resemble those of stone. Treatment. — The abscess will not infrequently be found during an exploratory operation, but if a diagnosis has been made the kidney should be exposed without delay. The abscess should be freely incised, and the kidney carefully searched for other col- lections of pus and for calculi. Morris has excised portions of the kidney in such cases. If the kidney is extensively destroyed it must be removed, but nephrectomy should be reserved for cases Avhere the destruction of renal tissue is widespread. EENAL AND PERIRENAL FISTULiE Eistulse which open on the lumbar region may take origin in the kidney or ureter, or they may be unconnected with the urinary tract. In a small number of cases fistulae connected with the kidney appear spontaneously or follow an injury. The great majority of renal and perirenal fistulse follow upon an operation. 1. Peeieenal Fistula unconnected with the Ueinaey Oegans Perinephritic abscess, if untreated, ruptures on the skin, having reached the surface by the triangle of Petit ; or it may be incised and a postoperative fistula persist. The origin of perinephritic abscess, when the kidney is not diseased, has been discussed (p. 112). The subsequent fistula may be single, and open in the lumbar region, or there may be several openings, which are often connected by subcutaneous tracks. A large inflammatory mass may surround or displace the kidney (Fig. 29). There is frequently a perinephritic cavity. Beyond this the sinus may lead by a tortuous track through the diaphragm into the pleural cavity, into the iliac fossa, or else- where, according to the origin of the abscess. The quantity of pus which escapes varies at different times in the same individual. From time to time retention of pus may cause an attack of pain and fever, relieved by the discharge of a large amount of pus from the fistula. XI] PERIRENAL FISTULA 155 Diagnosis. TIk' <>ii,^iiiiil scat ot suppiiratioi) may Ix'- .sliowii hy tlic hibtoiy of the cusc or hy (lie presence ol' ,seai\s (Fig. :}0). Much PLRI NEPHRITIS HIDN£Y PUSHED DOWH 6INUS OPEHIHC INTO OLD EMPYEMA CAiflTy JIN US IN. PERINtPHnhlC W/2£/4 3IHUS CONNECTED WTH PERJHEPHRntC ^REA Fig. 29. — Diagram of area of perinephritic suppuration following empyema. information can be obtained by the injection into the sinus of an emulsion of bismuth and then taking a radiogram. Examination /t/iEA Of PERINEPHRITIC ;'i?f;: o. V- \ iUPPURj^ TIOH SC/iR OF OLD OPERATION Fig. 30. — Diagram of area of perinephritic suppuration in case of dermoid of kidney. Note the fistulous track passing beneath the iliac vessels. 156 THE KIDNEY [chap. of the urine, cystoscopy, and catheterization of the ureter on the fistulous side demonstrate that there is no urinary infection, and that the ureter on this side is patent and the kidney active. Treatment. — The treatment is surgical, and may require extensive operations, such as the exploration of the perinephritic tissue, the search for a retrocaecal appendix, or the obliteration of a cavity in the pleura by resection of ribs. Before resorting to operation the effect of injections of bismuth paste (vaseline 20, paraffin 10, lanoline 10, subnitrate of bismuth 10) may be tried. The injections are made twice a week with a glass syringe. 2. Spontaneous Eenal Fistula In this category are placed a small group of fistulse which do not follow operation on the kidney. Wounds of the kidney cause a urinary fistula only when the renal pelvis or calyces are injured. A fistula persists for some months and sometimes for years, but is rarely permanent {see under Wounds of the Kidney, p. 107). An untreated pyonephrosis ruptures into the perinephritic tissue, and the pus either finds its way to the surface of the body or opens into the pleural cavity, a bronchus, the stomach, duodenum, or elsewhere, giving rise to a reno-cutaneous, reno-pulmonary, reno-intestinal, or reno-gastric fistula. The discharge is purulent or uro-purulent. There may be con- siderable difficulty in diagnosis. To symptoms of pyonephrosis there are superadded those of rupture of a large abscess into a bronchus or elsewhere. The opening of the fistula is usually small, so that the escape of pus into the bronchus or elsewhere is intermittent. In the intervals there is retention of pus in the kidney or around it, causing fever and recurrent rigors. A small number of cases have been re- corded in which calculi have been discharged Fig. 31. — Gollec- from a spontaneous renal fistula. Fig. 31 tion of calculi shows a number of small calculi discharged ISC argea trom fj-Qj^^ g^ spontaneous sinus in a man aged 78. tula of kidney. ^ small abscess formed on the right side, 1 J in. below the iliac crest and the same distance external to the posterior superior iliac spine ; this was incised, and the sinus persisted and discharged small calculi. The radio- gram (Plate 8, Fig. 1) shows a large calculous mass in the right kidney with a number of small shadows of calculi lying in the sinus. There was a history of litholapaxy ten years previously, ^/^ ^m^^ Fig. 1. — Shadows of large calculus in kidney and number of small calculi (arrow) lying in spontaneously formed fistula. A number of calculi were discharged through the fistula. (Sec p. 156 and Fig. 31.) Fig. 2. — Hydronephrosis due to adhesions round vertebrae in scoliosis. Arrows point to lateral curvature of spine, to opaque catheter in ureter, and to three of the dilated calyces. (P. 168.) Plate 8. XI] RENAL FISTULA 157 and of bladder symptoms, but no renal symptoms, and the general health was unimpaired. 3. Postoperative "Renal Fistul/E These fistulse are cutaneous and open in the lumbar region, generally at the posterior end of the operation sear. There is commonly a single fistula ; occasionally two or more exist, and communicate by subcutaneous tracks. The latter are most fre- quently found in tuberculous disease. The orifice of the fistula is often retracted and hidden in folds of skin. If placed far back in the lumbar region it is more likely to be on the level of the surface. It is narrow and the edges are smooth. In tuberculous disease and in some septic cases there may be granulations sprouting from the fistula, and tags of scar tissue around it. The discharge may be urine, urine mixed with pus, or pus. The track of the fistula is narrow, and it usually passes in a straight course down to the kidney. The walls consist of thick, dense fibrous tissue. The state of the kidney and ureter varies according to the disease for which the operation was performed. The factors which cause a temporary fistula to persist or become permanent are various. The fistula may give exit to pus or urine, which would accumu- late under tension if it closed. Disease, such as tuberculosis, may spread along the track, or concretions form in the lumen and prevent healing. The wall of the fistula may become so thick, hard, and callous from prolonged use of drainage tubes, or from continued discharge of urine and pus, that spontaneous healing is impossible. After nephrolithotomy there is seldom a fistula, unless urinary obstruction is present, or unless there are infected calculi remaining in the kidney. Pyelotomy for stone has been followed by a fistula, but this is rare, unless some collateral condition, such as ureteritis or narrow- ing of the ureter, exists, or unless the drainage by rubber tubes or other means is unduly prolonged. Nephrotomy in hydronephrosis w^here the obstruction has not been removed is followed by a fistula which discharges w^atery urine. In pyonephrosis a uropurulent fistula persists, which is chiefly due to the ureteral obstruction, but partly also to the thick fibrous w^alls being too rigid to collapse. xA_fter nephrectomy a fistula may persist and may be due to necrotic portions of the kidney or renal pelvis forming part of 158 THE KIDNEY [chap. the stump of the pedicle, to an infected Hgature of thick silk on the pedicle, to infection of the wound from a septic ureter, or to tuberculous infection of the wound. In these conditions a purulent discharge issues from the fistula. After nephrectomy considerable quantities of urine may be discharged from the wound, derived from fragments of kidney tissue remaining on the stump of the pedicle. These portions of kidney tissue lie on the distal side of the ligature, and are appar- ently cut of? from their blood supply. In a few days they necrose and the secretion of urine ceases. A permanent fistula discharging urine may be caused by a patent dilated ureter allowing the urine of the remaining kidney to ascend from the bladder. Finally, there are permanent urinary fistulse made by nephros- tomy to effect drainage in a ureter blocked by irremediable disease. Diagfnosis. — In many cases the cause of the fistula and the condition of the kidney are well known, but in others it is uncer- tain whether the copious purulent secretion contains urine. The discharge should be examined for urea, which can be detected if even a small quantity of urine is present. After an intramuscular injection of methylene blue, a urinary discharge will be tinged with blue. By catheterization of the ureters or separation of the urines in the bladder, it is found either that the fistula drains away all the urine secreted by the kidney, or that it drains away only a part of it, the remaining urine, usually a small quantity, passing down the ureter. Catheterization of the ureter on this side will also give informa- tion in regard to the presence of stricture. Treatment. — In some cases nephrostomy has been performed with the view of producing a permanent fistula. In such cases the treatment consists in devising an apparatus which will drain away the discharge and prevent it from soaking the clothes. A modification of Irving's suprapubic drainage apparatus is the best for this purpose (Fig. 32). In purulent non-urinary fistulse it will be sufiicient to dissect out the fistulous track and expose the kidney by a free incision, opening up pockets and tracks and providing free drainage. In- jection of a bismuth paste as in non-urinary perirenal fistulse may be tried (p. 156). Before undertaking radical treatment in urinary fistulse it is necessary to know (1) if the ureter is patent, (2) the functional power of the fistulous kidney and of the second kidney. This information is obtained by catheterization of the ureter, by examin- ation of the discharge from the fistula and that from the ureter of XI RENAI. FISTULA 150 the fistulous kidney, and of the urine from the ureter of the second kidney, and by usinf^ the tests for the renal function. If the ureter is found to be patent, Albarran recommends drainage by a catheter en demeure in the ureter. In order to get a large catheter into the ureter, he introduces, by means of the cystoscope, a long stilette (70 cm.) which is flexible for the first 6 cm. Over this stilette a catheter with a terminal eye is passed and ascends the ureter to the renal pelvis. The catheter is held in place and the stilette removed ; the catheter is left in the ureter for four or five days and then changed after passing the stilette l\ li Outlet Fig. 32. — Watson's apparatus for collecting urine in permanent renal fistula. as a guide. Eventually a No. 13 Fr. catheter may thus be passed. The renal pelvis is washed daily with silver nitrate solution (1 in 1,000). This continuous catheterization is maintained for three weeks {see also under Pyonephrosis, p. 151). Should it fail, a plastic operation should be performed upon the renal pelvis. If the ureter is impassable and the kidney has been shown to retain a considerable part of its function, then also a plastic opera- tion on the renal pelvis will be necessary. But should the func- tional value of the kidney be low, and that of the second kidney adequate, nephrectomy should be performed. LITERATURE Albarran, XH'' fonf^res franc, de Chir., Paris, 1898, p. So. Heitz-Boyer vt Moreno, Ann. d. Mai. d. Org. Gen. Urin., 1910, Xo. 11, Pouquet, These de Paris, 1901. IGO THE KIDNEY [chap. SURGICAL TREATMENT OF NON-SUPPURATIVE NEPHRITIS Acute Nephritis In 1896, Reginald Harrison suggested operative interference in certain cases of acute nephritis. He operated on " cases of scar- latinal nephritis, nephritis complicating influenza, traumatic nephri- tis, and nephritis which had followed a chill." The operations were undertaken on account of one or more of the following symptoms, viz. diminished secretion of urine, pain, haematuria. He recom- mended operation in cases of acute nephritis where convalescence was delayed, and albumin and casts did not disappear from the urine ; also in cases such as the malignant type of scarlatinal nephritis with suppression, and lastly where cardiac and circulatory complications were present. The operation was performed with the object of setting aside the dangerous symptoms and also of preventing the sequence of chronic nephritis. Harrison suggested incision of the renal capsule and puncture of the kidney to relieve the renal tension in these cases. Other observers (Pel and Rosen- stein) recommended nephrotomy in acute nephritis when oliguria was present and medical treatment had failed. Confusion in regard to statistics has been caused by the publication of cases of suppura- tive nephritis in the same category as those referred to above. All Harrison's cases recovered, but the after-history is unre- corded. Chronic Bright' s Disease Acute exacerbations in chronic Bright's disease. — Edebohls, Pousson, Casper, and others have treated the acute exacerbations of chronic Bright's disease by operation. In these cases surgical interference is supplementary to medical treatment. Where there are symptoms of uraemia, diminished secretion of urine, and oedema, operation may be of service when medical treat- ment has failed. Cases with advanced cardio-vascular changes and pulmonary complications are unsuitable for operation. Decapsulation and nephrotomy are the operations recommended. Except in the rare cases when the disease can be proved to be unilateral, decapsulation should be rapidly performed on both sides. Pousson recommends that nephrotomy be performed on one side, and only decapsulation on the other. The immediate results give a mortality of 25 per cent. (Pousson), some part of which is due to the patient being moribund when the operation is performed. Of 92 patients Avho survived the operation, 8 were considered as cured. The others died after a XI] CHRONIC BRIGHPS DISEASE 161 temporary relief lasting from some months to one or two years in a few cases. In my experience of decapsulation and nephrotomy in these cases and in large white kidney very striking improvement may be observed. OEdema and ascites disappear, and the patient, who has been rapidly losing ground under medicinal treatment, regains some measure of health and vigour. This improvement is, how- ever, only temporary, and after some weeks or months relapse occurs and the disease pursues its course. Chronic interstitial nephritis with haematuria. — These cases have already been discussed under the term Essential Haema- turia (p. 59). Chronic nephritis with pain.— Legueu described these cases as neuralgia of the kidney. In a few cases the renal condition is that of chronic Bright' s disease, but in many cases there has been a renal calculus at some previous date, while in others there is a history of traumatism. The kidney shows cJironic nephritis, and there are thickening and adhesion of the fibrous capsule and fibrosis of the fatty envelope. The pain may be localized to the kidney, and be spontaneous, constant, and unaffected by movement, or there are attacks of renal colic. There may be a trace of albumin with hyaline and granular casts. Nephrectomy, nephrotomy, capsulotomy, decapsulation, and simple freeing of the kidney from surrounding adhesions have been practised. The operation, like that for haematuria in partial nephritis, usually takes the form of an exploratory nephrotomy, and to this decapsulation may be added. The great majority of patients have been relieved by operation, and the relief is known to have lasted for some years. If there have been a diminution in the quantity of urine and albuminuria, these symptoms disappear. Decapsulation in chronic Bright's disease. — In 1899 Edebohls suggested nephrotomy as a method of treatment of chronic nephritis in cases of chronic nephritis in movable kidney. Newman, of Glasgow, had previously treated two cases of this nature by nephropexy. In 1901 Edebohls proposed decapsulation of the kidney with the object of curing chronic Bright' s disease. He held that the thickened fibrous capsule prevented the establishment of a col- lateral circulation, and that if this barrier were removed a free flow of blood through the kidney, which the diseased vessels were unable to supply, was provided by anastomosis with the parietal 162 THE KIDNEY [chap. vessels. By this means the increased interstitial tissue would be absorbed, pressure on the tubules removed, and a regeneration of renal epithelium take place. Experimental inquiry into this hypothesis has shown that no damage is done to the kidney by decapsulation, and that although the fibrous capsule invariably re-forms in a few weeks the new capsule is composed of loose connective tissue which does not compress the kidney. A parietal anastomosis has actually been observed, which was not strangled by contraction of the new capsule. On the other hand. Hall and Herxheimer have shown that a thick, strong connective tissue capsule is formed in from eight to fourteen days, and they did not find anastomotic vessels passing through the new capsule. Conflicting statements have been made in regard to the results found post mortem after decapsulation in human beings. The kidney has also been transplanted into the peritoneal cavity and formed adhesions with the serous membrane or with the omentum. Results. — Pousson gives a mortality of 5 per cent. Of 55 cases, 36 survived more than three months after the operation. Of 10 cases of nephritis with nephroptosis, there were 9 greatly improved, 3 of which were said to be cured; while of 16 cases of nephritis without nephroptosis 3 were improved, 4 much im- proved, 4 greatly improved, and 5 cured. The 5 cases of cure were under observation for 11 years, 6| years, 5| years, 2 years, and 1 year. It will be seen, therefore, that although the course of the disease is uninfluenced in a considerable proportion of cases, improvement is undoubted in some, and it is claimed that a cure has been brought about in a few cases. The cases of movable kidney with albuminuria and tube casts should be carefully separated from the others, for the prognosis without operation is very diflerent from that of chronic Bright's disease, and the effect of nephropexy alone is to cure most of these cases. In cases of chronic Bright's disease the results might be improved by operation performed at an earlier date than is usual. LITERATURE Edebohls, Med. News, April 22, 1899 ; Med. Bee, May 4, 1901. Hall and Herxheimer, Brit. Med. Journ., 1904, i. 821. Harrison, Lancet, 1896, p. 19. Legueu, Ann. d. Mai. d. Org. Gen.-Urin., 1891. Lehmann, Berl. klin. Woch., Jan., 1912, p. 158, Newman, Trans. Clin. Soc, 1897. ■' Pousson, Chirurgie des Nephrites. Paris, 1909. Walker, Thomson, Pract., June, 1903. XI] PUERPERAL ECLAMPSIA 163 SURGICAL TREATMENT OF PUERPERAL ECLAMPSIA Although the modern views on the pathology of puerperal eclampsia are not yet settled, it is undoubted that there are changes in the kidneys, amounting to great engorgement or even to acute nephritis, and symptoms are present which result from interference with the renal function. On these grounds decapsulation of the kidneys and nephrotomy have been practised in this fatal malady, with the object of relieving the renal engorgement and allowing the escape of poisons. In some cases the convulsions cease and the symptoms dis- appear, the secretion of urine becoming re-established. Kehrer collected 26 cases with a mortality of 36 per cent. The general opinion is not, however, favourable to decapsulation. The state of the kidneys, de Bovis holds, plays but a secondary part in the disease, and even if the renal function is resumed it does not prevent the development of hepatic necrosis, or the pete- chial haemorrhages of the encephalitis found in eclampsia. There may, however, he believes, be cases where the renal lesions exceed the other morbid changes in the body, and these cases explain certain striking successes which are too numerous to be mere coincidence. LITERATURE De Bovis, Semaine Med., Jan., 1912, p. 3. Kehrer, Zeits. /. Gyn. u. Urol., 1909, ii. HI. "^ ' [i. 561. Pousson et Chambrelent, ^?i?i. d. Mai. d. Org. Gen.-Urin., 1906, CHAPTER XII HYDRONEPHROSIS Hydronephrosis is chronic aseptic retention of urine in the kidney and renal pelvis due to obstruction. Etiology. — Hydronephrosis is slightly more frequent on the right side and in the female sex. It is frequently bilateral when the obstruction is urethral^ and occasionally when it is ureteral. Of 665 cases, 217 were unilateral and 448 bilateral (Newman). The obstruction may be ureteral or urethral. 1. Ureteral obstruction may be caused by — (a) Changes in the wall of the ureter, such as valves, folds, strictures. (b) Obstruction of the lumen by calculi, tumours, foreign bodies, clot. (cj Pressure from without by tumours, fibrous. bands, puru- lent collections, an aberrant renal vessel. {d) Kinking of the ureter due to undue mobility of the kidney. (e) Torsion of the ureter. 2. Urethral obstruction may be caused by a congenital fold or diaphragm, or obliteration, or more frequently by stricture and enlarged prostate. There are two principal categories into which the cases of hydronephrosis fall, namely : (1) Congenital. (2) Acquired. 1. By congenital hydronephrosis is understood cases of hydro- nephrosis occurring in the foetus or new-born, or appearing soon after birth. Cases of hydronephrosis occurring in adults and ascribed to congenital malformation are not included in this category. In congenital hydronephrosis one or both kidneys may be affected. When the condition is unilateral it is due to an abnormal renal artery, to valves or folds, or to stenosis of the orifice of the ureter, or bending or kinking of the duct, which is malplaced in the bladder, urethra, ejaculatory duct, seminal vesicle, vas deferens, vagina, or urethro-vaginal septum. More frequently congenital 164 CHAP. XII] HYDRONEPHROSIS 165 hydronephrosis is bilateral, and is due to obstruction in the urethra by a complete or an incomplete septum or imperforate portion, a cyst, torsion of the penis (Morris), or phimosis. In some cases no obstruction can be found, but the bladder, both ureters and kidneys are greatly dilated. 2. There are two classes of acquired hydronephrosis : i. Hydronephrosis due to obstruction in the lower urinary organs or to disease in the pelvic organs. These cases are almost invariably bilateral. Those due to disease of the lower urinary organs occur most frequently in the male, and are due to urethral stricture and enlarged prostate, and less frequently to growths of the bladder. Those due to disease of the pelvic organs occur more often in the female, and are caused by new growths of the uterus and ovaries, less frequently by carcinoma of the rectum in either sex, or carcinoma of the prostate in the male. In this group of cases the distension of the kidneys is seldom great, and may not be detected clinically. When the lower urinary organs are diseased, infection is frequently superadded and pyo- nephrosis may develop. ii. Hydronephrosis due to obstruction of the ureter. In these cases the narrow point is usually situated at the upper end of the ureter, at the junction of the ureter and renal pelvis; less frequently the middle or lower end of the ureter is the seat of obstruction, and the ureter is dilated. Pathology. 1. Hydronephrosis due to valves, folds, tor- sion, and stenosis. — The ureter and renal pelvis are developed as an outgrowth from the Wolffian duct. As development pro- ceeds the new-formed tube rotates around the Wolffian duct, and, its lower end being fixed, becomes twisted upon its axis. This twisting is said to be the cause of torsion of the ureter, which has been described in rare cases. In the foetus the ureter has a very irregular lumen, some parts being dilated and others contracted. The narrowing is due to folds formed either by the mucosa or by the mucosa and muscular layers ; these are most common at the uretero-pelvic junction, at the vesical end of the ureter, and in the middle of its course. These folds are constant in the foetus, and occur at the upper end of the ureter in 20 per cent, of new-born children (Wolfler). If anything interferes with the normal growth of the ureter, these valvules persist, and are the cause of hydro- nephrosis at a later date. (Fig. 33.) English found that of 65 ureteral strictures, 3 occurred in the middle, 34 at the upper, and 28 at the lower end — a distribution which corresponds very closely with that of the physiological valves in the foetus. 166 THE KIDNEY [chap. Folds or valves of mucous membrane may be found at the uretero-pelvic junction in hydronephrosis developing in adult life, and may have a congenital origin or may result from other causes, such as stone or the drag of adhesions outside the pelvis and ureter. Acquired stricture of the ureter may be caused by external injury, operations on the ureter or on the pelvic organs, lacera- Fig. 33. — Hydronephrosis in boy of 7, due to multiple congenital strictures of the ureter. Nephro-ureterectomy specimen. tion from the passage of calculi, or irritation from the presence of calculi or from chronic ureteritis. 2. Hydronephrosis due to bands and adhesions outside the ureter. — The most frequent site of obstruction is in the region of the uretero-pelvic junction. The bands may affect only the pelvis and ureter, or the ureter, or there may be adhesions between these structures and neighbouring organs. XII] HYDRONEPHROSIS : PATHOLOGY 167 In the most frequent form the ureter is bound down for the first inch or two of its course by fibrous adhesions to the surface of the distended pelvis (Fig. 34). Occasionally there is narrowing of the lumen at the pelvo-ureteral junction (Fig. 35), and it is possible that the ureter may have become adherent to the already distended pelvis. Usually, however, the lumen is found to be free Fig. 34. — Hydronephrosis due to bands of adhesion between ureter and renal pelvis. after dissecting away the bands whichTwere j[evidently the cause of the obstruction. The ureter is less often afiected alone, but may sometimes show distortion from adhesions. The cause of these adhesions may be obscure, as, except for the distension of the kidney and pelvis, there is no disease of that organ or of neighbouring structures. In a few cases stone is present with extensive perinephritis and periureteritis. 168 THE KIDNEY [chap. Disease of 'neighbouring organs is sometimes present and is obviously the cause of the adhesions. In one case an early hydro- nephrosis was shown by pyelography (Plate 8, Fig. 2) to be due to adhesions around a spinal curvature. In another case the descend- ing colon was adherent to the surface of a hydronephrosis binding the first 2 in. of the ureter down to the sac in a thick hard plaque the size of the palm of the hand. A faecal fistula, lasting a week, followed dissection of this adhesion and nephrectomy. J' Fig. 35. — Hydronephrosis (pelvic type) due to stenosis of uretero-pelvic junction. In Other cases the bands apparently originated in appendicitis and perityphlitis or duodenal ulcer, or followed peritonitis. 3. Hydronephrosis due to abnormal blood-vessels.— The ab- normal vessels which are important are those which pass to the lower pole of the kidney. Such an artery may be derived from the main renal artery or from the aorta, and it passes in front of or behind the ureter in the proportion of 3 to 1. The vessel may be as large as the radial artery. Mayo found that anomalous blood-vessels were present in 20 out of 27 cases of hydronephrosis, and the obstruction in each case was at the point at which the vessels crossed the ureter. XIl] HYDRONEPHROSIS : PATHOLOGY 169 The importance of aberrant vessels as the cause" of ob- struction has been disputed, for in some specimens which have been described the dilatation commences above or below the aberrant vessel, and is evidently independent of it. The relation of the hydronephrosis to the vessels in these cases is said to be accidental. There are, however, cases in which no other cause for obstruction is present, and in which division of the vessels Fig. 36.— Hydronephrosis due to aberrant renal vessels. Operation view : aneurysm needle under normal ureter. suffices to relieve the obstruction. This was the case in a boy of 13, in whom I found an aberrant artery and vein the size of the ulnar vessels crossing in front of the uretero-pelvic junction to the anterior surface of the lower pole of the left kidney. The obstruction was caused not so much by the vessels as by the fibrous tissue around them, which formed a strong, flat band. (Fig. 36.) There was no stenosis or other cause of obstruction, and the con- dition was cured by section of the vessels and fibrous band. 4. Hydronephrosis due to movable kidney. — In a large number of cases of hydronephrosis the kidney is abnormally movable. In these cases the hydronephrosis is intermittent. The hydro- 170 THE KIDNEY [chap. nephrosis has been said to be caused bv the undue mobility kinking a ureter which has become rigid from periureteral adhesions, but it is also held that the undue mobility is secondary to the increased size of the kidney, hydronephrotic from some other cause. The former hypothesis is probably the correct explanation of the origin of the dilatation. 4. Traumatic hydronephrosis. — Hydronephrosis may be found a few days after an injury to the loin, or it may develop several months or years after the injury. In the majority of the former the fluid collects around the kidney (pseudo-hydronephrosis) and not in the pelvis. Gardner points out that the severe pain caused by rapidly distending the renal pelvis is completely absent in these cases. In a few cases of tense hydronephrosis found soon after an injury the distension of the kidney has preceded the injury. Late traumatic hydronephrosis results from stricture caused by injury to the ureter. 5. Hydronephrosis due to calculus. — The degree of obstruc- tion does not correspond to the size of the calculus. A very large calculus (7 in. by 1 in.), or numerous calculi (sixteen), may cause no dilatation, while a small solitary stone may cause a hydronephrosis. The stone may be situated at the outlet of the pelvis, or it may lie at the vesical end of the ureter (Fig. 37). At the upper end of the ureter the calculus is often wedge-shaped, and usually fixed ; at the lower end it is frequently round or oval, and freely movable upwards. Stenosis of the ureter on the vesical side of the stone usually becomes superadded if the case is of long standing. 6. Relation of diuresis to hydronephrosis. — Diuresis plays an important part in the production of hydronephrosis. There are many cases of congenital valves and narrowings of the ureter, of pressure of aberrant vessels, or of strictures following injury, in which the lumen is sufficient for the escape of the urine under ordinary conditions, but is too narrow to drain a sudden diuresis. From the comparative obstruction thus established hydro- nephrosis begins to develop, and the pressure it exerts upon the ureter increases the obstruction. It is only thus that I can explain the delay in the development of hydronephrosis until adult life, where the cause is evidently congenital. A young Canadian con-ij suited me with regard to recurrent attacks of renal pain and enlargement due to the intermittent blocking of a congenitally narrowed pelvic outlet. Early in life he learnt that he could not take whisky or beer without inducing an attack. A hydronephrosis is said to be "closed" when the obstruction is complete, and "open" when urine escapes. XIl] HYDRONEPHROSIS : PATHOLOGY 171 Sudden complete obstruction such as is caused by ligaturing the ureter produces either shrinking and atrophy of the kidney or hydronephrosis in about an equal number of cases. According to Lindermann the accumulation of fluid depends upon the develop- ment of a compensatory anastomosis being established through capsular vessels as the intrapelvic pressure blocks the renal vessels. The obstruction in hydronephrosis is only complete at inter- Fig. 37. — Hydronephrosis (renal type) with dilatation of ureter caused by smooth oval calculus. Nephro- ureterectomy specimen. vals. Even in the largest hydronephrosis the obstruction is rarely complete. A small amount of fluid escapes, but a slightly larger quantity is secreted and the kidney is slowly distended. The ten- sion never becomes sufficient to arrest the renal secretion. Where a very large hydronephrosis becomes completely closed atrophy does not take place, for the absorption from the sac is very slight. In an open hydronephrosis there may be attacks of retention from kinking of the ureter, an excess of polyuria, or other causes, 172 THE KIDNEY [chap. and the hydronephrosis is " intermittent." In the intervals the sac which disappears clinically is partly collapsed, and still con- tains a considerable quantity of fluid. When the attack of re- tention occurs the sac again becomes tensely filled with fluid. After a varying period the outflow is re-established. Pathological anatomy. — In the early stage of hydronephro- sis there is a slight increase in the capacity of the renal pelvis. The normal pelvis is said by Luys to hold from 2 to 3 grm. of fluid (about 30-50 minims) ; but Bazy regards a pelvis as normal that contains ten times this amount of fluid. According to Legueu a capacity of from 30-40 grm. (about 1-1^ oz.) indicates the first stage of hydronephrosis. The kidney is not increased in size at this stage, but the pelvis is sac-like and the kidney hollowed. The apices of the pyramids are flattened and the calyces dilated. This stage is frequently met with at operations upon movable kidney, stone in the ureter, and in aseptic urethral obstruction. In the last the dilatation seldom passes beyond this stage. In the fully developed hydronephrosis either the pelvis (" pelvic type") or the kidney ("renal type") may form the greater part of the sac, and even in advanced cases the pelvis and kidney are distinguishable. When the pelvis is chiefly affected the subdivisions and branches of the normal pelvis have completely disappeared. (Fig. 35.) There is a large single chamber, one part of which is capped by the kidney. The kidney itself is hollowed, and, if viewed from the inside, the calyces form large round secondary chambers. The thickness of kidney substance is reduced to half an inch or less. There is a groove between the kidney and the dilated pelvis. The wall of the pelvic sac may be as thin as brown paper, and consists of fibrous tissue, the muscular elements having disappeared. The lining is smooth, opaque, white. When the kidney alone is distended the pelvis is small and hidden by the cyst, and may contain a stone. (Fig. 37.) The surface shows rounded bosses corresponding to the sacs of the hydro- nephrosis. These are formed by the atrophy of the pyramids and destruction of the renal cortex. Between them are septa show- ing as depressions on the surface and formed by the sclerosed columns of Bertini. There is a small central cavity with numerous rounded chambers leading from it, often communicating laterally with each other. In the pelvis, or at the junction of the pelvis and ureter, will be found the narrowing, valve, kink, calculus, or other cause of the hydronephrosis ; occasionally no cause for obstruction can be discovered. XII] HYDRONEPHROSIS 173 If the obstruction is situated at the lower end of the ureter this tube is dilated and tortuous, and its wall is thick and has lost its elasticity and contractile power. There may be very little perirenal inflammation, but fre- qu?ntly there are tough adhesions between the hydronephrosis and its surroundings. A partial hydronephrosis may be formed by the blocking of one segment of a double pelvis or the malformation of a calyx. Hydronephrosis has been observed in a horseshoe kidney ; about a dozen cases are on record. Morley describes an interesting case operated on by Wright in which hydronephrosis was pro- duced in one part of a horseshoe kidney by a papilloma at the uretero-pelvic junction. In rare cases of extreme distension the kidney tissue has entirely disappeared from the wall, but there is usually a con- siderable layer of renal parenchyma, which shows an increase in the interstitial connective tissue, with scattered areas of round- cell infiltration. The tubules are distorted, and the lining cells partly or totally destroyed. The glomeruli are crowded together and sclerosed. The walls of the blood-vessels are considerably thickened. The hydronephrosis may hold from 1 or 2 oz. to as much as 26 pints of urine of the specific gravity of 1005-1010, and con- taining traces of urea, phosphates, and chlorides. Occasionally as a result of injury, and sometimes spontaneously, the fluid becomes mixed with blood, and the cyst is transformed into a haematonephrosis. The second kidney is usually normal and hypertrophied. Occasionally chronic inflammatory changes are observed in it. The secretion of this organ is often reflexly depressed, and com- plete anuria, may supervene during a crisis of retention in the hydronephrotic sac. Symptoms. — There are two clinical stages of hydronephrosis, (1) an early stage, before a tumour can be detected, and (2) a stage when an enlarged kidney is found. The first of these is the more important therapeutically. 1. Early stage. — When the enlargement of the kidney is not recognizable on palpation the hydronephrosis is latent. Thus, in a malignant growth of the prostate, bladder, or uterus, anuria may suddenly set in without any previous warning, and the kidneys are found dilated ; or again, in urethral obstruction from enlarged prostate, or in a movable kidney, or in obstruction from valves, adhesions, aberrant vessels, etc., though there may be no symptoms directly pointing to dilatation of the kidney, yet dilatation is taking 174 THE KIDNEY [chap. place. In other cases symptoms are present at this early stage : they are pain and polyuria. The pain is a constant dull aching, is situated at the costo- muscular angle over the lower pole of the kidney, and is bilateral or umlateral according to the cause. In movable kidney it is indistin- guishable from the pain caused by constant dragging on the renal pedicle. In other cases there are recurrent attacks of renal colic. Polyuria is an important sign. The specific graAdty of the urine is diminished and the percentage of urea and salts reduced. In bilateral obstruction this may be very marked, but in unilateral hydronephrosis it is frequently obscured by the urine from the second kidney. The polyuria may, however, be remarkable in early unilateral hydronephrosis. 2. Late stage. — In the late stage the symptoms are tumour, pain, and changes in the urine. The tumour is situated in the loin, or it may fill a large part of the abdomen. It is rounded and moves with respiration. If it is moderate in size the sensation of ballottement can be obtained, but if very large it will be in contact with the anterior abdominal wall and ballottement will be lost. Fluctuation cannot be obtained. The tumour is not tender. A partly tympanitic note can be ehcited in front of the tumour, while the outer and lateral parts are dull on percussion. The collapsed colon can frequently be felt passing vertically over its anterior surface. Where the pelvis is greatly dilated a vertical groove may be felt, and even seen, between this and the enlarged kidney. There are two clinical types of hydronephrosis : 1. Constant hydronephrosis. 2. Intermittent hydronephrosis. 1. In constant hydronephrosis the tumour varies little in size, the urine is normal in quantity or may be reduced, and, beyond some aching pain, there are no symptoms. The hydro- nephrosis in such cases is " closed." 2. In intermittent hydronephrosis there are periods during which the tumour completely or almost completely disappears. From time to time there are attacks of retention, during which the patient has severe pain in the kidney and sometimes renal colic, the urine diminishes in quantity and may become com- pletely suppressed, the tumour can be felt and is large, tense, and sometimes tender. After some hours or some days the patient suddenly passes a large quantity of pale urine, the pain subsides, and the tumour rapidly vanishes. These attacks may follow some unusual exertion or the drinking of some diuretic such as tea, whisky, or beer. XII] HYDRONEPHROSIS 175 Cystoscopy. — Where the obstruction is situated at some part of the ureter the ureteric orifice is unchanged. In the early stages of hydronephrosis when polyuria is present, contractions of the ureter are more frequent on the diseased side. In advanced cases when a small quantity of urine escapes there is a slower and less frequent contraction of the orifice on the diseased side. When the obstruction is complete, but some muscular power is retained by the renal pelvis and ureter, an occasional gaping movement of the orifice is seen at long intervals, although no efflux takes place. When the kidney and the muscular structure of the pelvis are completely destroyed the orifice is still, and there is no efflux. The injection of methylene blue or indigo carmine will assist in the observation of the efflux. Catheterization of the ureters. — The catheter is arrested at some part of the ureter, but usually it will move on after gentle manipulation, and the urine passes in hurried drips, or it may spout from the catheter in a continuous stream. Pressure upon the hydronephrosis increases the stream. I have with- drawn 16 oz. from a tense hydronephrotic sac in this way. The quantity of urine which drains from the ureter of the diseased side is greater than that from the healthy side when polyuria is present. I have observed a secretion of 82-6 c.c. on the diseased side to 68-4 c.c. on the healthy side. In advanced cases a small quantity of urine is collected by the catheter from the diseased side. In one of my cases 45 c.c. passed from the dilated kidney and 213 c.c. from the healthy kidney. Finally, no urine at all may pass. In one case I observed 158-5 c.c. with 1-3 per cent, of urea, and in another 150 c.c. of urine with 2 per cent, of urea, from the healthy kidney, while no urine appeared on the diseased side. In an open hydronephrosis the eHmination of methylene blue is delayed, diminished, and prolonged on the diseased side, and the glycosuria produced by phloridzin is reduced or suppressed. After relief of the obstruction by operation the functional value of the kidney greatly increases, even when the outflow has been completely blocked. Diagnosis. — Diagnosis in the early stage before the develop- ment of a tumour is important therapeutically. The symptoms may sometimes lead to a diagnosis. Occasionally, when a stone is situated at the lower end of the ureter, the X-rays will show the outline of a thickened dilated ureter and an enlarged kidney. Recently other methods have been introduced for the early diagnosis of hydronephrosis : 1. Estimation of the capacity of the renal pelvis. — This is carried out by the passage of a ureteral catheter into the renal 176 THE KIDNEY [chap. pelvis. The urine is withdrawn and warm boric solution is slowly injected from a graduated syringe until pain is felt. The quantity of fluid injected shows the capacity of the pelvis ; A capacity of 30 to 40 c.c. shows a slight degree of hydronephrosis. This method is open to some objections. It may be uncertain whether the fluid has reached the pelvis of the kidney, and some of it may flow back into the bladder alongside the catheter. If the fluid is coloured with methylene blue, the latter objection may be obviated. If more than 150 c.c. can be injected without pain, but little secreting substance remains (Braasch). There is frequently polyuria of the diseased kidney, so that the pelvis will be partly filled with urine, and the capacity is then under- estimated. 2. Injection of metallic solutions and photography by the X-rays (pyelography). — Volcker and Lichtenberg introduced this method. After passing a ureteral catheter to the pelvis of the kidney and allowing any accumulated fluid to run off, a warm solution of collargol (10 per cent.) is slowly injected with a syringe, A radiogram is now taken, and shows a shadow of the renal pelAds. If dilatation is present it is demonstrated by the shape and increased area of the shadow. (Plate 2, Fig. 3; Plate 3; Plate 4, Fig. 1.) There is usually pain in the renal pelvis, which may amount to renal colic. The fluid is aspirated off after examination, and the pelvis may be washed with warm boric solution. Volcker and Lichten- berg employed this method in 17 cases without harm resulting. They obtained 9 good shadows, 4 that were less defined, and 4 were failures. I have used this method in a large number of cases, and have found no difficulty in obtaining a clear outline of the pelvis and calyces. A catheter opaque to the X-rays, or one opaque in alternate half-inches, should be used. The fluid should not be injected, but is allowed to run in by hydrostatic pressure from a glass receptacle attached to the end of the ureteric catheter and held about 6 or 8 in. above the external meatus. The utmost gentleness should be used, and forced injection must be avoided. The injection is stopped whenever pelvic pain is felt. No morphia or other anaesthetic is used before or during the examination. The abnormalities that can be shown are kinking at the uretero-pelvic junction, dilatation of one or more calyces, hydronephrosis of pelvic or of renal type. Where an abdominal tumour is suspected to be a hydronephrosis, pyelography will demonstrate the position of the renal pelvis and its relation to the tumour. 3. I have recently introduced two methods of measurement of the X-ray shadow thrown by the kidney (Plate 9, Figs. 1 and 2), as follows : — Fig. 1. — Author's method of determining normal extent of renal areas on radiographic plate. (P. 176.) Fig. 2. — Method of measuring shadow of kidney. AAA, opaque 4-in. segments of catheter ; B, points in outline of kidney ; C, ^-in. shadow values placed across kidney shadow. (P. 176.) Fig. 3. — Shadows thrown by metastatic deposit in mediastinal glands and in lungs in case of malignant growth of kidney. (P. 199.; Plate 9. XII] HYDRONEPHROSIS 177 (a) The narrowest transverse measurement of the body of the 1st lumbar vertebra is doubled and projected transversely from the middle of the outer edge of the vertebral body and a point is found. The same measurements are made in regard to the 2nd and 3rd lumbar vertebrae. By joining the three points the normal outer border of the kidney is roughly indicated. (6) A ureteric catheter alternately opaque and translucent in segments of half an inch is passed up the ureter. On the plate the shadow value of half an inch is obtained, and by using this the shadow of the kidney can be measured. Diseases that have been mistaken for hydronephrosis are appendicitis and gall-stones. The diagnosis depends upon the position of the pain and tenderness, the absence of fever and of jaundice, and the changes in the urine. If a tumour is present it has the characters of renal tumour. {See also p. 35.) Course and prognosis. — These depend upon the cause. In urethral or vesical obstruction sepsis is frequently superadded, and the prognosis becomes very grave. In ureteric obstruc- tion infection is less frequent and later. It may take place by the blood-stream, and a pyo-hydronephrosis is formed. Rupture of the sac spontaneously or from an injury is very rare. Car- stair and Muir -describe a fatal case of rupture of a hydronephrotic kidney followed by suppression. The second kidney was also hydronephrotic. Where the second kidney is hydronephrotic or otherwise diseased the ultimate prognosis is grave, suppression of urine eventually taking place. Treatment. 1. Congenital hydronephrosis. — Congenital hydronephrosis is more frequently of interest to the obstetrician than to the surgeon, on account of the difficulty in parturition to which it may give rise. The condition is frequently associated with other congenital malformations, such as hare-lip, imperforate anus, etc., and the child seldom survives birth for more than a few hours, but occa- sionally lives a few months and very rarely four or five years. Morris performed bilateral nephrostomy on a male child within twenty-foiu: hours of its birth, and the child survived ninety- four days. 2. Hydronephrosis due to urethral, vesical, or pelvic obstruction. — In cases of urethral obstruction from stricture or enlarged prostate operations will be undertaken for the relief of the obstruction. The presence of dilatation of the kidneys in these cases and in cases of growths of the pelvic organs, such as uterine and ovarian tumours, increases the gravity of such operations. In growths of the bladder which involve one ureter M 178 THE KIDNEY [chap. causing a moderate degree of hydronephrosis, but wliich are in other respects suitable for operation, removal of the growths with transplantation of the ureter to some part of the bladder should be undertaken. No direct operative treatment of the hydro- nephrosis will be necessary in these cases. In nearly all these cases the formation of a hydronephrosis can be prevented by early operation, and this is especially true of cases of urethral obstruction and of bladder growth, 3. Movable kidney with hydronephrosis. — In cases where hydronephrosis is combined with undue mobility of the kidney the mobility is not always, at the time of the operation, the cause of the obstruction. Strictures, valves, and adhesions may be found, the removal of which is necessary for the relief of the obstruction. But in many instances the mobility is the direct cause of the ureteric obstruction. In cases of movable kidney hollowing of the organ with slight distension of the pelvis is fre- quently discovered. In these cases nephropexy will be suflicient to cure the hydronephrosis. The early diagnosis of these cases is possible by the methods described, and early operation should be insisted upon in order to prevent destruction of the kidney tissue. In more advanced cases, even when no sign of narrowing or adhesion or permanent kinking is found on exposure of the kidney, the renal pelvis must be opened and the patency of the outlet and the ureter examined. When a plastic operation has been found necessary in such cases, nephropexy must also be performed. 4. Hydronephrosis with calculus. — ^When calculus in the ureter or renal pelvis is combined with hydronephrosis the dis- tension of the kidney has frequently arisen from this cause, but n some cases strictures of the ureter are present, and have either preceded the formation of calculus or have developed secondarily. In addition to the removal of the calculus, the ureter must there- fore be examined for the presence of stricture. 5. Hydronephrosis with aberrant vessels. — In cases where an aberrant vessel is found, which bears no close relation to the point of obstruction, it need only be divided if it interferes with the plastic operation for the relief of the obstruction. In other cases it lies in close relation to the point of obstruc- tion and is evidently the cause of the obstruction. If it is an unimportant vessel passing to the hilum or to the perirenal tissues, or an additional vessel arising from the aorta, it should be divided between two ligatures and the patency of the ureter then exam- ined, and if necessary a plastic operation performed. If, how- ever, the aberrant vessel is an important artery passing to the XIl] HYDRONEPHROSIS : TREATMENT 179 lower pole of the kidney, and it is not proposed to perform nephrec- tomy, the vessel should be preserved and some form of plastic operation carried out which will circumvent the obstruction caused by it. Helferich divided such a vessel between ligatures, and necrosis of a part of the kidney followed, necessitating nephrec- tomy. In a case in which I divided an aberrant artery and vein of considerable size the lower pole of the kidney at once became blanched. Before the end of the operation, however, it had become dark purple from the establishment of collateral blood supply. No ill effects followed. Operations for congenital and acquired malformations of the ureter and renal pelvis. 1. Operations which modify the form of the renal pelvis. — i. Nephro- fexy in intermittent hydro- nephrosis. The kidney is not only raised and fixed, but the pelvis resumes its old form, provided that the distension has not been so long established as to lead to a weakening and sagging of the sac wall. ii. To remove the pouch- ing Israel introduced an operation, pyeloplication, by which the redundant part of the wall is folded inwards after emptying the sac by puncture. A row of Lem- bert sutures fixes the fold. (Fig. 38.) In addition, an operation may be performed to correct any malformations of the uretero-pelvic junction. iii. My own plan is to resect a large triangular portion of the posterior wall of the renal pelvis, the apex of the triangle being at the uretero-pelvic junction and the base at the margin of the kidney. A plastic operation for rehef of any malformation of the uretero-pelvic junction is then performed, and the wound closed by Lembert's sutures. A flap of renal capsule is reflected and stitched over the pelvic wound, the kidney drained through a nephrotomy wound and fixed to the posterior abdominal wall. (Fig. 39.) iv. ''^ Ortho'pcBdic resection'''' or " cafitonnage.'''' — Albarran Fig. 38. — Pyeloplication ( Israel's operation) in pelvic type of hydro- nephrosis. 180 THE KIDNEY [chap. removes the pouch consisting of the portion of the pelvis and kidney which lies below the level of the outlet of the pelvis, and sutures the opening. (Fig. 40.) Fig. 39. — Resection of the renal pelvis (author's operation) in pelvic type of hydronephrosis. a, Triangular flap of posterior wall of pelvis turned down, b. Triangular flap removed, closing wound in pelvis ; area of decapsulation marked with dotted line, c, Pelvic wound covered with flap of capsule and fatty tissue ; tubes draining kidney and in ureter through nephrotomy wound. 2. Anastomosis, i. Uretero-ureteral anastomosis. — This may be — [a) End-to-end anastomosis with transverse or oblique section Fig. 40. — Orthopaedic resection (Albarran's operation) in hydronephrosis. ^, Portion of pelvis and kidney below dotted line to be resected. ''', Closing wound in pelvis and kidney. of the ends, or by invagination of the upper into the lower end (Pozzi). (Fig. 41.) (6) End-to-side anastomosis by ligaturing one cut end and XIlJ HYDRONEPHROSIS : TREATMENT 181 implanting the other end in a lateral slit below the ligature. (Fig. 4lA.) (c) Lateral anastomosis without section or after section of Fig. 41. — End-to-end anastomosis of ureter. Ends cut obliquely. Fig. 41a. — End-to-side anasto- mosis of ureter. '■, Two primary sutures in position ; ''s primary and secondary sutures tied. the ureter. The edges of two lateral incisions are brought together by interrupted sutures. (Fig. 42.) ii. Pyelo-ureteral anastomosis. — (a) Lateral anastomosis. This is the oldest plastic operation for hydronephrosis, and was per- formed by Trendelenburg in 1886. The ureter is spht longitudinally on a level with the lowest part of the hydronephrotic sac, and a transverse incision is made in the sac wall. The edges of these wounds are sutured, and the kidney is then drained and fixed. (Fig. 43.) (6) Transplantation of the ureter into the lowest part of the sac (uretero-pyelo-neostomy). The ureter is cut across trans- versely or obliquely, and in addi- tion it may be split longitudinally to prevent stenosis. An incision is made into the lowest part of the sac, a small triangular por- tion excised, and the ureteral mucous membrane is sutured to a pelvic mucous membrane. (Fig. 44.) (c) Nephro-cysto-anastomosis. This is the direct anastomosis of a hydronephrotic sac with the bladder, and has been done in cases of displaced hydronephrotic solitary kidney. The operation Fig. 42. — Lateral anastomosis of ureter. 1, One half of outer continuous suture in position; /', one half of inner continuous suture in position. 182 THE KIDNEY [chap. Fig. 43. — Lateral pyelo-ureteral anasto- mosis, showing incisions and details of stitching. is performed intraperitoneally. The sac is emptied by puncture, and the peritoneum over its lowest part incised and brought into contact with an incision in the upper posterior peritoneal surface of the bladder, and the edges sutured, iii. Plastic opera- tions on strictures and valves. — -{a) Incision of a valve. This is per- formed through a ne- phrotomy wound or a large opening in the posterior wall of the dilated sac. The py- elo-ureteral opening is found, and one blade of a pair of scissors introduced into^^it. The valve is then cut downwards. If it is thin and formed only of mucous membrane, this will sufl&ce ; usually, however, the thickness of the pelvic and ureteral walls is cut through, and these are sutured to each other. (Fig. 45.) (6) Uretero-pyeloplasty. This consists in making a longitu- dinal incision through a stricture at the uretero- p el vie junction and uniting the edges of the wound transversely. It is similar to the operation of pyloro- plasty for narrowing of the pylorus. The operation is frequently combined with one of the methods of re- ducing the sac of the hydro- nephrosis. General observations. — 1. These operations are performed on aseptic or on mildly infected hydronephrotic sacs. 2. When infection is present a preliminary nephrotomy with drainage for some weeks should be carried out. 3. The lumbar extraperitoneal route is used in all except nephrocystostomy. Fig. 44. — Uretero-pyelo-neostomy, showing details of stitching. XIl] HYDRONEPHROSIS : TREATMENT 183 4. Adhesions of the hydronephrotic sac and ureter should be removed before commencing the plastic operation. 5. Operations on the renal pelvis are performed on the posterior surface. The renal vessels are usually adherent to and stretched over the anterior surface. 6. Before commencing the operation a catheter should be passed up the ureter from the bladder to ascertain the position of the obstruction and assist in the operative measures. 7. The pelvic outlet may be examined through a nephrotomy or pyelotomy wound, and the examination is rendered simpler by everting this part of the sac through the wound. \\ v^ 8. The sac should be drained through a ne- /K\ \\V phrotomy wound. Some surgeons leave a ureteric Fig. 45, — Plastic operation on a valve. rt, Section of spur consisting of pelvic and ureteral walls, b. Stitching cut edges of pelvis and ureter, c, Stitching completed- catheter in situ, but this is not necessary, and may be a source of irritation. 9. Nephropexy is an important part of many of these operations. 10. Catgut should be used as suture material. Functional value of a hydronephrotic kidney. — In the early stages of hydronephrosis the functional power of the kidney is impaired, but if the obstruction is relieved the organ will secrete urine almost as well as the normal kidney. The early diagnosis and operative treatment of hydronephrosis are therefore of ex- treme importance. In the fully developed hydronephrosis, where the layer of kidney tissue is reduced to half an inch, the organ still retains a considerable degree of functional power. I have operated on both kidneys for the relief of obstruction in bilateral advanced hydronephrosis, and the patient was well two and a half years later. There are cases of bilateral advanced hydro- nephrosis in which the patient has lived for many years, and there are other cases where a solitary kidney was converted into 184 THE KIDNEY [chap. Operations Deaths Faihires . . 12 -, i. 3 ..18 1 4 ..19 2 6 ..13 r.1 2 3 al .. 1 ..4 ..8 — 1 1 . 11 . — — . 86 I 17 a hydronephrotic sac and yet carried on a function sufficient to maintain life. In the hydronephrotic sac the renal tissue, although greatly damaged, persists even when the wail is only a few milli- metres thick, and it very rarely completely disappears. After relief of the obstruction the kidney does not return to the normal state, and if regeneration takes place it is not the invariable rule. Results of plastic operations. — Schloffer collected 86 opera- tions with the following results : — Section o£ valves Uretero-pyeloplasty . . Uretero-pyeloneostomy Lateral anastomosis Plastic operations on pelvis Pyeloplication Orthopaedic resection Combined operations ! Total .. To this I can add three personal cases treated by my method, with two successes, and one failure due to haemorrhage into the resected pelvis. This patient was submitted to nephrectomy and recovered. I can also record a successful result in a case of pyelo- ureteral anastomosis. In a fourth case there was bilateral hydro- nephrosis, and the operation was performed on each pelvis with an interval of three weeks. The patient died, two months later of renal failure, which had commenced some months previously and slowly progressed. Nephrostomy. — Incision and drainage of the sac without any attempt to overcome the cause of the obstruction is some- times performed. This has been followed in between 30 to 45 per cent, of cases by re-establishment of the flow of the urine through the ureter and healing of the nephrotomy wound. In the remaining cases a fistula persists. Nephrectomy. — Primary nephrectomy is only indicated when the sac is very large and its wall so thin and fibrous that no renal tissue is present, and only in cases when it can be proved that a second kidney is present and efiicient. Secondary nephrectomy is required when nephrotomy and plastic operations have failed. LITERATUEE Albarran, Bull, de VAcad. de Med., 1898, p. 59. Albarran and Legueu, Congres frang. de Chir., 1892, p. 561. Braasch, Joiim. Amer. Med. Assoc, 1909, p. 1386. XII] HYDRONEPHROSIS 185 LITERATURE— co?i*^'' Fig. 69.^ — Delivery of the kidney from the lumbar wound. is opened, or during the isolation of the kidney. The extremities of the peritoneal wound are immediately picked up in forceps and the rent closed by means of a continuous catgut suture. Occasion- ally a rent very high up under the liver in a prolonged and difficult nephrectomy must be left unsutured. I have never had after- trouble from wounds of the peritoneum even in septic' diseases of the kidney. Nephrotomy and nephrostomy. — When exploration of the kidney is the object of the operation the kidney is incised along its convex border. The surgeon grasps the vascular pedicle of the kidney between the thumb and forefinger of the left hand, and incises the kidney in the exsanguine line of Hyrtl, parallel to and a little behind the curved border. (Fig. 70.) The knife is entered vertically to the surface, and the size of the incision varies. xix] NEPHROTOMY 291 The object of the nephrotomy is to examine the kidney substance and also to explore the calyces. It is necessary, therefore, to open the calyces, and for this purpose I prefer two incisions, one at the lower pole and the other at the upper pole, to a single larger incision in the middle of the kidney. This double incision is suited for the exploration of the bifid form of renal pelvis. Keeping up pressure on the renal pedicle, the lips of the wound are parted and the kidney tissue is examined. The forefinger is inserted and Fig. 70. — Nephrotomy. The left hand is grasping the pedicle. carefully explores the calyces, care being taken not to rupture the attachment of the pelvis to the kidney by rough manipulation. In short, thick-set individuals, in whom the renal pedicle is short and inelastic, it may be difficult or impossible to bring the kidney into the wound or to deliver it on the loin. In such cases full use must be made of the additional space given by detaching the muscles and arcuate ligament from the lower border of the r2th rib. It may further be necessary to excise a portion of this rib, or to cut it with bone forceps and mobilize it. The kidney must be incised in situ, and the operation becomes much more difficult. The nephrotomy wound is closed by means of thick catgut 292 THE KIDNEY [chap. sutures (No. 3 or 4) on round-bodied needles. One or even two mattress sutures may be required where the bleeding is profuse ; they are placed 1 or IJ in. from the edge of the incision, and tied carefully so as not to cut the kidney capsule and tissue. The wound is closed with interrupted catgut sutures, three or four in number. (Fig. 71.) The kidney is returned to its fatty bed and a drainage tube placed in the upper extremity of the lumbar wound. Before commencing to suture the muscles, the skin and subcutaneous Fig. 71. — Methods of suturing nephrotomy wound. A, Mattress sutures. B, Superficial sutures to bring edges of wound together over mattress suture. C, Interrupted sutures deeply placed. fat should be freed for an inch or so from the cut edge of the muscles. The muscular wound is closed by means of a single or a double row of interrupted sutures of thick catgut. The sutures are all introduced, and clipped with artery forceps. The air is now allowed to escape from the cushion under the loin, and the edges of the wound fall together. The sutures are then tied. The skin wound is closed with interrupted silkworm-gut sutures, care being taken that the upper lip, which slides forwards as much as an inch or more on the lower one, is brought into its proper position. The scratches made before commencing the incision indicate the proper relations of the two lips. xix] LUMBAR NEPHRECTOMY 293 In nephrostomy the Iddiioy is drained temporarily or per- manently. This is p(!rl'()rnied usually for hydronephrosis or i)yo- ncplirosis. The kidney is exposed, but is not raised from its bed. The most prominent part is incised with a knife, and a large drainage tube inserted, a stitch being introduced through the kidney tissue and the tube. A second tube may be placed along- side this to drain the perinephritic tissue. When permanent drainage is desired, an apparatus for collect- ing the urine is applied {see p. 159). Lumbar nephrectomy. — When nephrectomy is proposed Fig. 72. — Lumbar nephrectomy. Ligature of ureter previous to section. the preliminary steps are the same as those already described. The incision may be prolonged as far as the anterior iliac spine, and it may occasionally be necessary to excise the 12th rib in order to gain access to the upper part of the kidney and to the renal pedicle. In doing so care must be taken to avoid damaging the pleura. Wounds of the pleura have frequently been recorded, but they do not appear to have been followed by collapse of the lung or other untoward results. In operating for malignant growths of the kidney which are adherent at the upper pole it is wise to open the peritoneum out- side the colon, and introduce the hand in order to palpate the upper pole of the kidney and ascertain whether the growth has 294 THE KIDNEY [chap. spread to the peritoneum and surrounding structures, and is therefore inoperable. Modifications of the operation in malignant growths are described elsewhere (pp. 200-2). In lumbar nephrectomy for stone, tubercle, growth, or other disease, the separation of adhesions may be a long and tedious process. The adhesions are clamped and tied as the operation proceeds. The ureter is cut across between two ligatures (Fig. 72), and the lower pole of the kidney moves more freely. The kidney is freed on its posterior and convex surfaces and the upper pole Fig. 73. — Lumbar nephrectomy. The ureter has been ligatured and cut, the vascular pedicle clamped, and ligatures are . being placed on each vessel separately. reached. The pedicle is now reduced by dissection to its vascular elements, the pelvis being freed from its posterior surface. A clamp is placed on the pedicle close to the kidney but avoiding the pelvis. The kidney is cut away, leaving the pedicle in the grasp of the clamp. Attention is now turned to the ligature of the pedicle (Fig. 73). If the vessels are readily separated by dissection a strong catgut suture is placed upon each and the clamp carefully removed. In some cases it is impossible, from the short, thick, rigid con- dition of the pedicle resulting from chronic inflammation, to do this, and the pedicle must be transfixed with a double silk thread XIX] NEPHRECTOMY 295 (No. 4 or 5) and tied in two portions, cure being taken to draw the knots tight and to plaee the hgatures as far behind the clamp as possible. The clamp is now cautiously removed, the stump being held with a jniir of Kocher's forceps until it is evident that all is secure. Difhculty in dealing with the pedicle may arise from the unexpected discovery of tuberculous or malignant glands adherent to it and to the aorta or vena cava. Careful dissection is required in such cases. The treatment of the perirenal fat and lymphatic area and of the ureter is described under the different diseases for which nephrectomy is required. A large rubber tube is placed in the upper angle of the wound and leads to the neighbourhood of the stump of the pedicle, and another leads downwards into the iliac fossa. These tubes are removed on the fourth day. The wound is closed in the same manner as in nephrotomy. Subcapsular nephrectomy. — Where there is excessive peri- nephritis with the formation of dense adhesions and a large mass of fibro-fatty tissue the kidney may be removed by subcapsular nephrectomy. The incision is carried down to the perirenal fat, which is freely incised in a vertical direction, grasped with sponge forceps and held aside. The forefinger is now introduced between the kidney and the capsule, and swept first round the lower pole and then round the upper. A broad pedicle is isolated, consisting of the renal pelvis, vessels and a mass of fibro-fatty tissue. This is clamped and the kidney removed. The broad pedicle may now be tied in sections with stout silk and the clamp cautiously removed. Great care is taken to get a good grasp with the ligatures. If the pedicle is not too broad it should be transfixed and tied in two portions. Another method which may be successful is to make an incision in the capsule round the pedicle and isolate it beyond the fibro-fatty mass. Nephrectomy by morcellement. — This is seldom rec|uired, but it may be necessary in removing a kidney the seat of long- standing suppurative pyelonephritis. The organ is removed in portions, large clamps being used to control the bleeding. These should be placed as near the pedicle as possible, and will usually have to be left in situ. They are removed in forty-eight hours, the wound being rapidly and firmly packed if bleeding should follow their removal. Partial nephrectomy has been advocated in the treatment of tuberculosis and new growths of the kidney, but has now been 296 THE KIDNEY [chap. abandoned as it is impossible to define the limits of these diseases and remove the whole disease by this method. Ligature of the renal vessels. — In a few cases, where ne- phrectomy has been judged too formidable an undertaking owing to previous unsuccessful operations and to extensive adhesions, transperitoneal ligature of the renal artery and vein has been practised as a substitute for nephrectomy. According to Kellock, who has recorded a case and has made observations on the cadaver, the operation on the right side is more difficult than that on the left, owing to the position of the duodenum and pancreas. Aberrant arteries may give rise to difficulties. Difficulties in lumbar operations. — The chief difficulties encountered in lumbar operations on the kidney are — (1) great adipose development ; (2) narrow ilio-costal space, which is found in short, thick-set individuals ; (3) high position of the kidney and short vascular pedicle ; (4) adhesions and excessive development of the perinephritic fat ; (5) distension of the colon due to over- purgation or to want of preparation ; (6) deformities of the spine or hip-joint. Abdominal nephrectomy. — The patient lies on his back. A vertical incision is made either in the semilunar line on the affected side or through the rectus sheath parallel to the median line. In the latter case the rectus muscle is displaced towards the median line, and the posterior layer of the sheath and the peri- toneum are incised. The colon is exposed and the small intestine packed off. An incision is made through the outer layer of the mesocolon, and the bowel displaced inwards. The kidney is ex- posed by incising the anterior layer of perinephritic fascia. The procedure is now similar to that adopted in the lumbar operation. After removal of the kidney a stab wound is made in the loin and a large rubber drain passed through it. The wound in the mesocolon and the abdominal wound are then closed. Dangers of nephrectomy. — Wounds of the pleura and peri- toneum have been referred to. They are treated by immediate suture, and do not give rise to further trouble. Shock. — Shock is the most frequently fatal complication. It occurs in a pronounced degree in kidney operations compared with operations on other organs. Traction on the renal pedicle during removal of the kidney has an immediate and powerful effect on the pulse and respiration. In prolonged operations the shock may be profound. It may commence towards the end of the operation or after the patient is returned to bed, and it is frequently observed three or four hours after nephrectomy. Saline XIX] DANGERS OF NEPHRECTOMY 297 subcutaneous infusion may bo administered durin<^ the operation if the pulse begins to fail. Rectal saline infusion (enteroclysis) should be commenced when the patient is returned to bed, and continued for several hours, and repeated if necessary. Brandy or strong coffee may be added to the rectal infusion. Hypodermic injections of strychnine (irV^aV gr.) and intramuscular injection of camphor (|-3 gr.), or of camphor (J gr.) with ether (17 min.), may be required. Haemorrhage. — During the operation haemorrhage may be due to a number of causes. An aberrant artery may be torn during separation of perirenal adhesions. These arteries enter the upper or lower pole of the kidney, and may give rise to severe haemorrhage. Care should be taken to clamp all suspicious bands before cutting them across. Long artery forceps are useful for seizing the artery when it has been inadvertently torn. The in- ferior vena cava has been torn during the removal of a malignant growth. The tear is usually lateral, and is followed by very serious venous bleeding. When the wound is small and can be picked up with a pair of forceps a lateral ligature should be placed on it, and this has resulted in recovery in several cases. When the wound is more extensive lateral suture has been practised, and where a severe transverse tear has been produced double circular ligature of the vena cava below the renal veins is recommended. Haemorrhage from the pedicle during the operation is frequently due to carelessness or flurry in tying the ligature, resulting in the ligature, from being too loosely applied, shpping after removal of the clamp. A renal vein may be injured in passing the ligature through the pedicle. Good exposure, careful dissection, and care in tying the ligature prevent such accidents. Should bleeding occur, the pedicle is at once seized with pres- sure forceps and the individual bleeding-point, if possible, secured, or a new ligature placed more firmly around the whole pedicle. Finally, in a difficult case where the condition of the patient does not permit of much time being spent in again securing the pedicle, a clamp should be applied, and left in position for three days, when it is cautiously removed. Haemorrhage after the operation may be due to oozing from unligatured vessels or to slipping of the pedicle ligature. If it is severe the wound must be opened up, the clots removed, and the bleeding-point secured, or, this failing, the cavity is firmly packed with strips of gauze, which are removed in two days. Anuria. — Anuria may occur immediately after nephrectomy, or there may be gradual failure of the renal function. This is due to inadequacy of the second kidney. Before nephrectomy 298 THE KIDNEY [chap, xix the state of the second kidney should be examined by catheter- ization of the ureters and the use of the tests for the renal func- tion. The value of these methods in discriminating cases which are inoperable is strikingly demonstrated by the statistics of nephrectomy for tuberculosis of the kidney previous to their use, and recent statistics since these methods have been employed. Anuria and oliguria are treated according to the directions given at p. 19. Remote dangers are sepsis and pulmonary embolism. Sepsis is avoided by care in preventing the soiling of the wound with pus or tuberculous material when cutting the ureter and removing the kidney, and in general aseptic technique. Should the muscular layers of the wound be infected, this may necessitate the opening up of the wound and entail a prolonged and tedious convalescence. Peritonitis is a danger in transperitoneal oper- ations for septic diseases of the kidney. The operations of nephrolithotomy, pyelotomy, pyelolithotomy, nephropexy, and decapsulation are described in other chapters. PART IL—THE URETER CHAPTER XX SURGICAL ANATOMY-PHYSIOLOGY EXAMINATION Surgical anatomy. — The ureter extends from the pelvis of the kidney to the bladder. The upper end commences at the lower pole of the kidney at the level of the 2nd lumbar vertebra, and there is a slight narrowing as it joins the renal pelvis. From this point the ureter passes vertically downwards to cross the iliac vessels at the brim of the bony pelvis, descends into the pelvis, and turns forwards and then inwards to pierce the wall of the bladder. (Fig. 74.) The ureter has several curves (Fig. 75). The first or lumbar part is vertical, inclining . slightly inwards at the upper part. It forms a slight, very long curve with a postero-external concavity. There is a second, more pronounced curve, with the concavity postero-external, as the ureter crosses the iliac vessels and drops into the pelvis ; a third, wider but well-marked curve, with the concavity forwards ; and finally the duct curves inwards towards the middle line to pierce the wall of the bladder. At the upper end the ureters are about 10 cm. apart, at the level of the iliac crests 7 cm., at the level of the brim of the pelvis 5 cm., at the widest part of the pelvic curve they lie 10 cm. apart, and at the point of entry into the bladder wall 4 cm. The ureter is 30 cm. (12 in.) long, and has a varying calibre. Gelatin casts show that there are certain narrow points in the normal ureter. According to Poirier there are two types. In the first there are two contractions — the first at the junction of the ureter and pelvis, the second at the point of entrance into the bladder. In the second type there is, in addition to these narrow points, a third contraction at the brim of the pelvis. Between these points there are two " dilatations " — the lumbar dilatation, which is the larger, and the pelvic dilatation. 299 300 THE URETER [chap. The relations to the skeleton as seen in radiography are very important, and are fully described in the section dealing with examination of the ureter. Relations of the ureter. — The lumbar portion of the ureter lies upon the sheath of the psoas muscle and crosses the genito- crural nerve. Anteriorly it lies in close relation with the peri- toneum, and is crossed by the spermatic or ovarian vessels at the level of the 3rd lumbar vertebra. On the left it is crossed by the Fig. 74. — Diagram of renal pelvis and ureter, showing relation to spine, pelvic girdle, and great vessels. Drawn from radiograms. left colic and sigmoid branches of the inferior mesenteric artery, and on the right by the right colic and ilio-colic branches of the superior mesenteric artery. If the vermiform appendix passes upwards and inwards it crosses in front of the lower part of this segment of the ureter. At the brim of the pelvis the duct crosses the common ihac vessels near their bifurcation, or the external iliac vessels, and is covered by peritoneum. The ureters are intimately related to the peritoneum, and when this membrane is raised the duct remains attached to it. XX] RELATIONS OF URETER 301 Iiitcnially the ri<,'ht ureter is in contact with tiie inferior vena cava ; the left ureter is in relation to, but not in contact with, the aorta. The relations of the pelvic portion vary in male and female. In the male the ureter crosses the brim of the pelvis and passes downwards, backwards, and a little outwards, lying in front of the spine of the ischium and crossing in front of the internal iliac vessels. External to it is the parietal layer of the pelvic fascia covering the obturator inter- nus, and it crosses internally to the obliterated hypogastric artery and the obturator vessels and nerve. Internally it lies in relation to the peritoneum. The duct now turns forwards and inwards on the upper sur- face of the levator ani and beneath the peritoneum, and is crossed by the vas deferens before it enters the muscular wall of the bladder. In the female the relations of the first part of the pelvic portion are the same as in the male, except that the ovarian vessels and the ovary lie in relation to it. The second part turns inwards on the upper surface of the levator ani and crosses beneath the broad liga- ment and alongside, and then in front of, the lateral fornix of the vagina and the cervix uteri, and enters the wall of the bladder. In this part of its course it is surrounded by a dense plexus of veins belonging to the uterine and vaginal plexuses, and it crosses below and behind the uterine artery. The ureter opens into the bladder at the level of the upper one- third with the lower two-thirds of the vagina, and it is adherent to the vaginal wall at the lateral fornix. The ureters pass very obliquely through the muscular wall of the bladder, lying beneath the mucous membrane for some part of this intramural course, which extends altogether for | in. The Fig. 75. — Diagrams showing curves and dilatations of ureter. a, Lateral curves ; i', antero-posterior curves. 302 THE URETER [chap. ureteric orifices open from J to 1 in. apart as fine slit-like orifices on a low muscular ridge. Blood-vessels.— The sources of the arterial supply are numer- ous. From above downwards the ureter receives branches from the renal artery, the spermatic or ovarian, the aorta, the common iliac, the hypogastric, the uterine in the female and the vesical in the male. The arterioles anastomose along the whole length of the duct. The veins empty into the renal, spermatic or ovarian, and hypogastric veins. The blood supply of a small area of vesical mucous membrane surrounding the orifice of the ureter is intimately connected with the ureteric vessels. The area is inflamed in ureteral inflamma- tions, and congested when obstruction to the ureteric vascular drain is present. The nerves are derived from the renal, spermatic or ovarian, and hypogastric and vesical plexuses. Physiology. — The urine descends from the renal pelvis to the bladder, propelled by waves of vermicular contraction which pass down the ureter. The exposed ureter can be stimulated to contract by touching it with a pair of forceps or other instrument. Two forms of contraction are observed — a contraction of the circular muscle fibres, and a writhing movement due to contraction of the longitudinal muscle. The natural waves of contraction are initiated by contractions which commence in the renal pelvis and sweep the whole length of the duct, and are further stimulated by the passage of the urine along the duct. If the ureter is blocked or fistulous at its upper end, so that no urine travels along it, only a feeble contraction reaches the bladder. If the fistula is low down near the bladder the contraction at the vesical orifice is as powerful as if urine were discharged. These facts show that the passage of the urine along the tube is not necessary for the contraction, but that the stimulus of the passing urine greatly increases its vigour. Continuity of the duct is necessary for the passage of the wave of contraction. If the tube is partly severed and fistulous the contraction passes on to the vesical end ; but if it is completely severed the lower segment no longer contracts. The oblique insertion of the vesical end in the bladder wall gives it a valve action and prevents the regurgitation of fluid from the bladder. When the bladder becomes distended the trigone is pushed downwards and the rest of the bladder wall is stretched. As the lower end of the ureter is inserted into the trigone the ureter becomes stretched and more oblique. As a result the anterior and posterior walls are approximated, and XX] EXAMINATION OF URETER 303 the intravesical tension presses the anterior against the posterior wall, further occluding the lumen. Examination. 1. Inspection. — I have once seen a greatly distended ureter form a swelling on the abdominal surface (Fig. 76). The patient was a girl of 9, admitted to my ward as a case of intussusception. The abdomen was not distended or rigid, and on the left side, extending from the left lumbar into the iliac region and disappearing in the hypogastric region, was a large sausage- like swelling, very evident on inspection and easily traced on Fig. 76. — Prominence on surface of abdomen in a child caused by greatly distended left ureter. palpation upwards into the left hypochondrium and downwards into the pelvis. On rectal examination a large tense mass bulged into the rectum. On opening the abdomen a swelling was found to the outer side of the descending colon, and proved to be the greatly distended and thickened left ureter, leading to a small hydronephrosis. The ureter was drained, and a nephro-ureter- ectomy performed later. 2. Palpation. — (a) On deep palpation of the abdomen in a favourable subject a thickened ureter can be felt lying alongside the spinal column. It is most readily detected as it crosses the 304 THE URETER [chap. brim of the pelvis. In order to palpate the abdominal portion of the ureter (Fig. 77) the surgeon stands on the same side of the patient and places the hands fiat on the abdomen, the lower hand reaching as low as the line between the umbilicus and the middle of Poupart's ligament, the upper one above this hand. The patient may lie flat, or with the knees flexed, and respires slowly and deeply. With each expiration the fingers sink into the abdomen in the line of the ureter, and at inspiration they hold the ground already gained. After two or three expirations the fingers have sunk to the back of the abdomen and are slowly drawn outwards. Fig. 77.- — Palpation of right ureter. The fingers are sunk deeply into the right side of the abdomen and are palpating the ureter at the brim of the pelvis. palpating the structures which roll under them. No attempt should be made to plunge or poke the fingers into the abdomen against the inspiration of the patient. The ureter is most readily felt in tuberculosis of the duct, when it may resemble a leaden gas-pipe, and can be felt alongside the vertebral bodies and traced over the brim of the pelvis. Occasion- ally, after an attack of renal colic, it can be felt thick and very tender, and when it is dilated and thickened in urethral obstruc- tion it may be felt on careful palpation. (6) On rectal 'palfotion in the male the ureter is felt above and outside the base of the prostate, and can sometimes be hooked down with the tip of the finger. The finger is pushed far up XX] EXAMINATION OF URETER 305 beyond the base of tlie prostate and then passed outwards towards the lateral wall of the pelvis. (c) In the female the ureter may be felt in the vagina in the normal state, but frequently it cannot be detected. It commences near the middle line on the anterior vaginal wall and passes along the lateral wall at the junction of the middle and upper thirds of the vagina. About 3 in. of a thickened ureter may thus be palpated. The tuberculous ureter is readily felt as a thick, hard, and tender cord which can be rolled beneath the fingers, and it may also be felt in other conditions of chronic ureteritis. 3. Cystoscopy. — On cystoscopy the vesical end of the ureter can be examined and important information obtained. The vesical mucous membrane surrounding the orifice, the shape and appearance of the orifice itself, the condition of the lips, the absence or presence of ureteric contractions and their frequency and character, the presence of an efflux and its char- acters, should all be noted. An account of these will be found in the sections dealing with Cystoscopy (pp. 58, 364). 4. Catheterization and sounding of the ureters. — By passing a catheter up each ureter into the renal pelvis, the urine derived from the corresponding kidney is obtained without blend- ing with that of the other kidney and without passing over the surface of a diseased ureter or bladder. The tests for the func- tion of each kidney can be carried out, and the urines examined for changes due to disease or loss of functional power. The ureter may be sounded by passing a ureteric catheter or a wax-tipped bougie. Information in regard to the presence or absence of stricture or calculus is thus obtained. When a stone is present the catheter may be arrested, or it may hesitate and then pass on. The size of the calculus is not important in regard to the passage of the instrument ; a very large calculus may per- mit the catheter to slip past, while a small calculus may arrest it. Wax-tipped bougies are only useful in the female subject, in whom Kelly's open cystoscopic tubes can be used. These methods are referred to in the chapter on Stone in the Ureter (p. 328). 5. Radiography. — The X-rays may in rare cases show the shadow of a greatly distended and thickened ureter. Calculi in the ureter throw a shadow in the line of the duct. It is very important to define the course of the ureter in cases of suspected calculus, and this is done by passing up the ureter a bougie opaque to the X-rays, and obtaining a radiogram. The line of the ureter shown by radiography. — In examining the ureter by the X-rays it is of the utmost importance, as Ironside Bruce has shown, to use a fixed position of the relations of the u 306 THE URETER [chap. patient to the source of light. For this there are two reasons : (1) The line of the ureter is shown in its relation to the bony skeleton, and variation in the position of the source of light causes changes in the relations of the shadow of the ureter with those of the bones. (2) When a stone is descending the ureter slight changes in the position can only be detected by reproducing with mathematical exactness at subsequent visits the previous posi- tions of the patient and of the source of light. The fixed positions suggested by Ironside Bruce are — (1) In the abdominal and sacral segments " the anode of the X-ray tube is placed immediately below the spine of the 2nd lumbar vertebra." (2) In the pelvic and sacral segments the source of light is opposite the upper border of the pubic symphysis. There are three segments of the ureter which are important in reading a radiographic plate : — 1. The abdominal segment, which extends from the renal pelvis to the upper border of the shadow cast by the bones of the pelvis, here the lateral mass of the sacrum. 2. The segment in the broad band of shadow thrown by the lateral mass of the sacrum. 3. The pelvic segment of the ureter. 1. Abdominal segment. — The ureter commences in the renal pelvis at the tip of the transverse process of the 2nd lumbar ver- tebra. From this point the duct passes inwards and downwards upon the psoas muscle, crossing the tip of the transverse process of the 3rd lumbar vertebra and inclining inwards to cross the transverse process of the 4th lumbar vertebra near its base and the transverse process of the 5th lumbar vertebra close to the body. (Plate 21, Fig. 1.) 2. Sacral segment. — The ureter then passes vertically along the lateral mass of the sacrum as it crosses the brim of the pelvis, well internally to the sacro-iliac synchondrosis. 3. Pelvic segment. — After crossing the brim the ureter curves outwards across the outer border of the sacrum, and now lies within the ring of the shadow thrown by the brim of the pelvis. It crosses the tip of the spine of the ischium and, keeping just internally to the shadow of the pelvic ring, swings inwards. It may then become hidden behind the horizontal ramus of the pubic bone, but more frequently it passes above the upper border of this bone, and reaches almost to the middle line. (Plate 21, Fig. 2.) This is the appearance most commonly found, but there are cases where the course is different. This variation in the course of the ureter as shown in a radiogram does not depend upon 2 ^ o .S -c 5 " c o - ^ O "oc si «^fc^ 3 a 2 IS — 3 cB o ■^ E S ^ >. O. 'OC in m o n XX] URETERAL RADIOGRAPHY 307 changes in the position of the source of the rays or the patient, as these radiograms were taken in the " fixed position." (i.) The ureter may lie nearer the middle line, and is partly obscured by the shadow of the vertebral bodies, (ii.) It may lie farther out beyond the tips of the transverse processes and pass outwards from the shadow of the psoas muscle at the level of the 3rd lumbar vertebra, (iii.) It passes upwards and outwards away from the vertebral colunm at the level of the 4th lumbar vertebra. These variations may be partly accounted for by an abnormally placed or movable kidney, and it is likely that the less pronounced changes in the line of the ureter result from temporary outward displacement of the kidney by the compressor used during the radiography. The varying tilt of the pelvis also shghtly affects the radiographic position of the pelvic ureter. CHAPTER XXI INJURIES OF THE URETER From its protected position and the comparative thickness and elasticity of its wall the ureter is less liable to injury by violence than the kidney or other abdominal organs. In 1901, Morris could find only 12 probable cases in the literature, and but 3 of these were actually proved to be ruptures of the ureter. With the progress of modern surgery a new and more numerous class of cases has appeared, namely, injury to the ureter during surgical operations upon the ureter or on neighbouring structures. 1. Subcutaneous Injuries and Penetrating Wounds Etiology. — Compression between hard bodies, kicks, falls on the loin, and being run over by a wheel are the forms of Adolence which have caused rupture of the ureter. Rowlands records the case of a young man who, walking with his left hand in his pocket, fell upon the left elbow and ruptured the left ureter at its upper end. Impaction against the transverse processes of the lumbar vertebrae and overstretching of the ureter are the mechanisms which are believed to produce the rupture. Only a few cases of bullet wounds and punctured wounds by a rapier are on record. Pathology. — In 1 out of 12 cases the peritoneum over the ureter was ruptured (Morris). The ureter may be bruised and cicatricial contraction follow ; or it may be torn longitudinally, or be torn across. If the ureter be partly or completely torn an accumulation of urine forms in the retroperitoneal space, which may later rup- ture into the colon. If the peritoneum be torn, urine leaks into the peritoneal cavity. Symptoms. — If the ureter alone be injured there is sHght haemorrhage, or this may be completely absent. There are pain and tenderness, which, however, are difficult to distinguish from those which may follow a blow without rupture of the ureter, and which usually pass off in a few days. If the patient survive the injury a swelling forms in the loin. This may appear a few 308 CHAP. XXI] INJURIES OF URETER 309 days after tlic iiijuiy, or it may bo delayed for several weeks. It is rounded or elongated and well defined, and may assume a large size. This is due to accumulation of urine and blood in the retro- peritoneal tissues. Sui)purati()n takes place, and the symptoms of extensive suppuration develop. It is impossible to diagnose between rupture of the ureter and rupture of the renal pelvis. If the patient recovers after receiving a penetrating wound of the ureter a urinary fistula forms. Prognosis. — When early operation is performed the prognosis is good. When the peritoneum is ruptured it is more serious. Treatment. — In most of the cases recorded, puncture of the swelling and incision and drainage were the methods of treatment adopted. The real difficulties are met with in making an early diagnosis and in finding the ruptured ureter in a large mass of inflammatory tissue. A swelling of the loin following an injury in this region should be freely exposed by a lumbar or a lumbo- abdominal incision, when the presence of urine in the fluid will lead to a careful examination of the renal pelvis and ureter. Should the history of haematuria, however shght, or the position of the swelling have led to a suspicion of the nature of the injury, a catheter should be passed up the ureter before the operation, and vidll help in the identification of the tube. When the ruptured ends are found, one of the methods of ureteral anastomosis should be practised. In a case recorded by Vaughan of a gunshot wound of the ureter, an implantation of the end of the ruptured ureter into the bladder was successful. Nephrectomy may be required in rare cases for septic com- plications or for the cure of an intractable fistula. LITERATURE Allingham, Brit. Med. Journ., 1891, i. 699. Barker, Lancet, Jan. 17, 1885. Morris, Hunterian Lectures, 1908. Page, Ami. Surg., 1894. Rowlands, Med. Press Circ, April 21, 1909. Vaughan, Amer. Journ. Med. Sci., 1905, p. 499. 2. Surgical Wounds Injury to the ureter is occasionally caused by forceps during delivery, but the most frequent form of surgical wound of the duct is made during pelvic operations, and above all in gynae- cological operations. The removal of mahgnant growths of the uterus by the extensive operations now in vogue is a prolific source of accidental wounds of the ureter. 310 THE URETER [chap. The ureter may be partly or completely cut, or its wall or blood supply may be damaged by extensive stripping or by pressure or by rough handling, so that it sloughs and a fistula forms after some days. The fistula may open in the vagina, or, if a subtotal excision of the uterus has been performed, in the cervix or on the skin surface at the abdominal wound. Spontaneous closure of such a fistula has taken place, but it is so rare as not to be looked for. Treatment. — The treatment of such accidents is either imme- diate at the time of the operation, or remote when a fistula has formed. The treatment of fistula will be described later. 1. Partial laceration or incision of the ureter.— The ureter heals well if the blood supply has not been damaged by extensive strip- ping and rough handling. The edges of the wound should be carefully sutured with fine catgut. A ureteral catheter may be passed up the ureter to the renal pelvis from the bladder, and retained for a week. A covering of fatty or areolar tissue or even of peritoneum should be applied over the ureter wound to assist healing. Provision should be made for drainage of the urine should leakage occur. If there be an irregular tear of the ureter it is better to resect a portion of the tube and perform one of the operations for anastomosis. 2. Complete laceration or section of the ureter. — Ureteral anasto- mosis should be carried out. The varieties of anastomosis are as follows : — ■ (1) End-to-end anastomosis, {a) The ends are cut transversely (Schopf) ; (b) the ends are cut obliquely (Bovee). The objection to this is that it leaves a ridge in the lumen which promotes stricture formation. (2) End-to-end anastomosis with invagination (Poggi). This is facilitated by splitting one end and invaginating the other (D'Antona). (3) The employment of a button (Boari) or a tube of magne- sium over which the ends are drawn and invaginated. The tube is dissolved by the urine in twenty days (Taddei). (4) End-to-side anastomosis, in which one end is ligatured and the edges of the other end sutured to the edges of a longi- tudinal wound in the lateral wall of the first, or cut obliquely and invaginated into it (Van Hook). (5) Lateral anastomosis, in which both ends are ligatured and the edges of a longitudinal lateral wound in each ureter are united in a manner similar to that used in intestinal anastomosis (Monari). The peritoneum should be closed outside the junction to prevent extraperitoneal extravasation. The junction may be covered with XXI] WOUNDS OF URETER : TREATMENT 311 a litxp of peiitDiK'uiu or a j^rai't of oiiicntiim. A ureteial catheter may be passed from the bladder up the ureter, but this is likely to cause irritation and is better omitted. When a portion of the ureter has been torn away, one of the following procedures may be carried out : — (1) Uretero-cysto-neostomy, the upper end of the ureter being implanted into some part of the bladder. Here the rupture must be low down and the upper segment sufficiently long to reach the bladder (Novaro). (2) Uretero-ureteral anastomosis, the two ureters being exposed by reflecting the peritoneum on the front of the promontory, and the end of the damaged ureter ligatured and brought across the middle line and united to the uninjured ureter by lateral anasto- mosis (Bernasconi and Colombino). (3) The formation of a cutaneous fistula by suture of the severed end to the skin. (4) Implantation into the intestine. (5) Immediate nephrectomy. (6) Ligature of the upper end of the ureter has been suggested, with the object of causing atrophy of the kidney. Results. — Alksne collected all the published records of ureteral anastomosis since 1886, and found 43 complete recoveries in 60 cases, 9 recoveries after temporary fistula, and 8 deaths (11-6 per cent.). Poggi's invagination method gave the best results, yielding 12 per cent, of fistulas in 28 cases, while the circular method gave 24 per cent, of fistulse. LITERATURE Alksne, Folia Urol, 1908, p. 280. Baja, These de Paris, 1908. Bernaseoni et Colombino, Ann. d. Mai. d. Org. Gen.- TJrin., 1905, ii. 1361. Boari, 11 Polidinico, July 15, 1899 ; Ann. d. Mai. d. Org. Gen.- Urin., 1908, ii. 1761. Bovee, Ann. Surg., 1900, p. 165. Hein, Jahresh. d. Urogen. Afptirates, 1906, ii. 126. Markoe and Wood, ^«m. Surg., 1899. Poggi, XlXe Congres de Chir., Paris, 1906, p. 188. Scharpe, Ann. Surg., 1906, p. 687. CHAPTER XXII CONGENITAL ABNORMALITIES OF THE URETER PROLAPSE— FISTULA CONGENITAL ABNORMALITIES Anomalies of number. — The ureter is sometimes divided so that there are two ducts, and this may extend from the pelvis to the bladder (Fig. 78). The two tubes may unite to form a single lumen just before entering the bladder, or two distinct ureters may pierce the bladder wall and open separately. The ureter which drains the upper part of the kidney usually crosses that from the lower part and opens lower on the trigone. In such a case there are two physiologically separate kidneys on one side, although no anatomical division may be apparent. Sometimes a deep groove on the surface of the organ indicates the division. One portion of the kidney may be diseased and the other remain normal. In routine cystoscopy the discovery of two ureteric orifices lying side by side on the horn of the trigone is comparatively frequent (Fig. 79), and an efflux may be seen from each opening. An opaque bougie can be passed up one, or sometimes both, and the double ureter demonstrated by means of the X-rays. The illustration of a double ureter (Plate 21, Fig. 3) was derived from a patient who had been treated for a urethral stricture, and subsequent cystoscopy revealed the double ureter. The frequency of double ureter is about 4 per cent, of cases (Lessig). Calculus is often found in kidneys which have a double pelvis and ureter. Bilateral double ureters are less frequent than unilateral. Five or even six ureters have been observed in one individual. Absence of a ureter is combined with absence of the kidney. In a case of fused kidney with two ureters one duct may cross the middle line and open on the opposite side of the trigone. Abnormalities of position. — When a single ureter is present and opens into the bladder the orifice is frequently misplaced, usually towards the middle line. I have seen a single ureter, in the lower end of which a stone was impacted, open in the middle line of the trigone. The ureter may open into the prostatic urethra 312 CHAP. XXII] ABNORMALITIES OF URETER 313 in the male or the urethra in the female. It has been found to open into the seminal vesicles, the vagina, or the rectum. The displaced opening is frequently that of a supernumerary ureter. Fig. 78. — Double right ureter draining upper and lower halves of kidney. Case of septic pyelonephritis complicating vesical, ureteral, and renal calculi ; chronic cystitis and hypertrophy of bladder. Lower half of right kidney destroyed by calculus, upper half shows recent pyelonephritis ; calculus in left ureter ; commencing distension of left kidney. Out of 9 cases recorded by Schwarz where the ureter opened into the prostatic urethra, there were double ureters in 7. The 314 THE URETER [chap. abnormally placed orifice is frequently narrowed so as to cause dilatation of the ureter and corresponding kidney. Sometimes a misplaced ureter ends blindly in the bladder wall and forms a cyst. Nebel has recorded the termination of the ureters on the surface of the abdomen between the umbilicus and the pubes. According to Schwarz the diagnostic sign of a ureter opening into the female urethra is incontinence of urine — the urine dribbling away from the urethra, while the patient can pass a quantity of urine voluntarily. The ureter has been transplanted into the bladder in such cases. Congenital narrowing of the ureter. — I have observed congenital narrowing of the ureteric orifices in a man whose urinary system was otherwise normal. The finest ureteric cath- eter or bougie would not pass through the orifices. The lu- men of the ureter may be nar- rowed or completely blocked by a valve or congenital stricture. As a result, either hydrone- phrosis develops or atrophy of the kidney ensues. Rarely the ureter immediately above the stricture dilates without disten- sion of the renal pelvis and kidney. The ureter may be compressed by an artery or vein which takes an abnormal course {see under Hydronephrosis, p. 168). LITERATURE Blumer, Johns Hopkins Hosp. Bull., 1896, p. 175. Israel, Bed. klin. Woch., Feb. 27, 1900. Lessig, Charite. Ann., xxx. 452. Lewis, Brandsford, Med. Bee, 1906, p. 521. Meyer, Vir chows Arch., 1907, p. 408. Schwarz, Beitr. z. Idin. Chir., 1895, Bd. xv. Walker, Thomson, Renal Function in Urinary Surgery. 1908. Zondek, Zur Chirurgie der Ureteren. Berlin, 1905. Fig. 79. — Double ureteric orifice on left side. PROLAPSE OF THE URETER ' Under the term prolapse of the ureter two conditions are included which it is impossible to distinguish clinically. In one there is prolapse of the whole thickness of the ureteral wall, ana- logous to prolapse of the rectum ; in the other there is prolapse of the mucous membrane alone. XXII] PROLAPSE OF URETER 315 Pathology. —The tumour is a "^'lohulai' oi' sausage-shaped cyst attaclicd by a narrower base in the positujii of the ureteric orifice. It varies in size from a pea to a wahiut, or even larger. The cyst consists of a double layer of mucous membrane, the bladder mucosa externally and the ureteral mucosa internally. At some part of the surface, usually the summit of the swelling, the ureteric orifice can be found. It is small, and may be stenosed or completely obliterated. In some cases one or several small calculi have been found in the cavity. The cyst is usually single, but Portner found that of 40 cases 5 were bilateral. I have examined two cases with the cystoscope ; in one both ureteric orifices were affected, one to a greater degree than the other, and in the second case the condition affected both orifices equally. (Plate 22, Fig. 1.) In some cases the cyst has prolapsed into the urethra and appeared at the external meatus in the female. Neelsen described a case in which the cyst was strangulated by the vesical sphincter and became necrotic. The condition may result from a congenital narrowing of the ureteric orifice or an acquired stenosis from ureteritis. Calculi may be present in the cystic ureter. In a number of cases there has been a double ureter on the diseased side. Symptoms. — The symptoms are irregular. In some cases renal symptoms have been present, such as lumbar pain and pain in one or both ureters. More frequently there are symptoms of vesical irritation or obstruction, such as frequent micturition, scalding pain along the urethra, terminal haematuria, difficult mic- turition, and occasional intermittent passage of urine or attacks of complete retention. Attacks of hsematuria may be the only symptom. The ureter and kidney are frequently dilated on the affected side. Infection of the kidney may supervene. The con- dition may be latent for a considerable period. The cyst may appear at the external meatus in the female, and can be distin- guished from prolapse of the bladder by passing a catheter into the bladder and drawing off the urine. The diagnosis is made with the cystoscope. In the position of the ureteric orifice a rounded, globular, or sausage-shaped swelling is seen, pink and semi-translucent in appearance. In a prolapse of the mucosa alone delicate blood-vessels can be seen coursing over the cyst, while in a prolapse of the whole thickness of the wall the vessels are abruptly arrested at the base (Kapsammer). In two cases that I have seen, the cysts gradually filled up under observation, becoming pale and more transparent until they reached a large size, and then slowly subsiding like an air balloon ; and this was repeated in slow, regular rhythm. 316 THE URETER [chap. In one of these cases the condition was equally developed on both sides, the left cyst being covered with small translucent cysts. On removal of the cysts I found both ureters dilated. Treatment. — Before operation the kidneys and ureters should be searched with the X-rays for stone. The pouch is cut off at the base with scissors and removed, with any calculi it may contain. Operation by the urethra with cutting forceps or the cautery in the female has been successful. Removal by suprapubic cyst- otomy is preferable. LITERATURE Englisch, Centralhl. f. Kranlch. d. Ham- u. Sex.- Org., 1898, ix. 7. Fenwick, Obscure Diseases of the Kidney. 1903. Freyer, Trans. Roy. Med. and Chir. Soc, 1897. Grosglik, Zeits. f. Urol, 1901, p. 577. Kapsammer, Zeits. f. Urol., 1908, p. 800. Kolisko, Wien. Bin. Woch., 1889, No. 48. Portner, Monats. f. Urol., 1904, ix. 5. FISTULA OF THE UEETEE, Fistula may follow an operation for stone in the ureter, the external opening being in the scar of the operation. Uretero- vaginal fistula is more common. Rarely it is congenital ; fre- quently it is acquired and follows parturition, in which case it involves the bladder, ureter, and vagina (uretero-vesico-vaginal fistula) ; or it may result from a surgical operation on the uterus and involve the ureter and vagina only, the opening in the ureter being at some distance (5 cm. — Bazy) from the bladder. The ureter may be partly or completely severed. On the vesical side of the fistula there is almost invariably stenosis of the ureter. Above the fistula the ureter may be dilated, and the kidney is also dilated. The fistula very rarely closes spontaneously. Infection of the fistula, ureter, and kidney is the rule. Before operating upon a ureteral fistula it is necessary to ascertain — (1) Is the duct partly or comfletdy severed ? On examination of the bladder with the cystoscope the ureteric orifice shows no move- ment where the ureter is completely severed, but there is rhythmic contraction of the ureteric orifice if the ureter is only partly severed. (2) 7s the fistula vesical or ureteral? By injecting methylene- blue solution into the bladder the blue fluid escapes by the fistula if the fistula communicates with the bladder, but not if the fistula is purely ureteral. Examination with the cystoscope will show a healthy bladder when the ureter is fistulous. xx.i] FISTULA OF URETER 317 (3) Which ureter is fistulous ? Where the ureter has been completely severed, cystoscopic examination will show one ureter motionless and without efflux, and the subcutaneous injection of 4 c.c. of a 4 per cent, solution of indigo-carmine is followed by the appearance of a coloured efflux at the healthy ureter and no efflux at the other. Regular powerful contractions of the ureteric orifice are observed when the fistula is low down and the duct is not completely severed. There is, however, no efflux from the orifice. (4) What is the position of the fistula ? This is ascertained by sounding the ureter with a bougie opaque to the X-rays. The bougie is arrested at the stricture below the fistula, and the dis- tance from the bladder ascertained by observing the markings on the bougie and by obtaining a radiogram. Treatment. 1. Introduction of a catheter en demeure. — This is impossible in a large proportion of cases on account of the stricture of the ureter. It has been practised in a few cases, but the ultimate result has not been successful. The stricture recontracts and the fistula opens after the catheter has been re- moved, or the fistula may heal permanently and the recontraction of the stricture brings .about atrophy of the kidney. 2. Suture of the ureter. — This is not feasible. The patent segments of the ureter are widely separated by a mass of fibrous tissue, and it is impossible to approximate them. 3. Transplantation of the ureter, i. Implantation into the bladder {uretero-cysto-neostomy). — This may be done by a trans- peritoneal operation or by the extraperitoneal route. Legueu recommends that the abdomen be opened and the position of the ureter ascertained. The peritoneum is then closed and the operation performed extraperitoneally. The urine is invariably infected in these cases, so that the extraperitoneal route is to be preferred. The ureter is followed downwards as low as possible and cut across above the fistula.' An opening is made in the most accessible part of the bladder, and the union of the ureter and bladder made at this point. It is essential that no traction be exerted on the newly formed union, and the ureter and bladder should be freed. Ricard sutures the wall of the bladder to the pelvic peritoneum to prevent traction. Many varieties of implantation have been used (p. 339). Results of uretero-cysto-neostomy. — ^Primary miion is occasion- ally obtained, but frequently there is leakage of urine. A few cases have been recorded in which by catheterization of the implanted ureter a successful result has been confirmed after 318 THE URETER [chap, xxii considerable periods, but in other cases the kidney has been found atrophied post mortem. ii. Implantation into the bowel. — On the right side the caecum or ascending colon is selected, on the left the pelvic portion of the colon. (For a description of the operation, see p. 342.) Results of implantation into the bowel. — Successful results have been published. The mucous membrane of the colon does not resent the action of the urine, and the fluid is passed with the faeces. The dangers of the operation are shock, peritonitis, and ascend- ing pyelonephritis from infection. Papin found a mortality from the operation of 58 per cent, where bilateral implantation was performed, and 29 per cent. where one ureter only was implanted. A few cases have been recorded in which the patient continued in good health, but many patients die within a comparatively limited period of ascending pyelonephritis. iii. Lateral anastomosis of the upper segment of the injured ureter with the opposite ureter has been performed experimentally by Bernasconi and Colombino for injuries of the ureter. The ureters are exposed by reflecting the peritoneum over the promontory, and lateral anastomosis carried out. The method has not yet emerged from the experimental stage. 4. Where the fistula opens high up in the vagina an operation may be performed which turns a small portion of the vagina into the bladder. The fistula is enlarged, and an opening made into the bladder close to it. This part of the vagina is then closed off so that the fistula and bladder become continuous. 5. The vagina may be obliterated after first establishing a large vesico- vaginal fistula. 6. Ligature of the ureter with the object of producing atrophy of the kidney was suggested by Guyon. 7. Nephrectomy has until recently been resorted to by a large number of surgeons. It should not be performed until a plastic operation has been tried, or unless septic pyelonephritis is present. LITERATURE Bernasconi et Colombino, Ann. d. Mai. d. Org. Gai.-Urin. 1905, ii. 1361. Boari, Ann. d. Mai. d. Org. Gen.- Urin., 1909, ii. 1232. Budinger, Arch. f. klin. Ghir., 1894, p. 639. Legueu, Traite Chir. d' Urol., 1910, p. 1172. Payne, Journ. Amer. Med. Assoc, 1908, p. 1321. Scharpe, An7i. Surg., 1906, p. 687. Tuffier et Levi, Ann. de Gyn. et d'Ohst., 1895, p. 382. CHAPTER XXIII STONE IN THE URETER The great majority of calculi in the ureter are formed in the renal pelvis and passed into the ureter. Very rarely a calculus is formed in the ureter itself. In a man from whose right ureter I had removed a calculus impacted at the brim of the pelvis, I closed the ureteric wound with fine silk. Six months later he passed a smooth oval calculus with one silk suture and a facet, and after another six months he passed a second calculus articulating with the first and containing the re- maining ■ three silk sutures I had placed in the ureter. (Fig. 80.) Primary calculi have also been found on other forms of foreign body, such as a catheter or a pin (Boyer), or on an ulcerated surface. The etiology of secondary ureteric calculus is that of renal calcuH (p. 249). Pathology. — Ureteral cal- culi are either impacted or migrating. A stone migrating from the renal pelvis may pass without halting, and sometimes with little pain, into the bladder. It may pass after repeated attacks of renal colic, having remained in the ureter for a considerable time. It may be arrested in the ureter, and, in spite of repeated attacks of colic, remain impacted. (Plate 23, Figs. 1, 2.) The calculus becomes arrested in the ureter on account of its large size, irregular shape, or rough surface, or from a part of 319 Fig. 80. — Two articulating ure- teral calculi formed on fine silk sutures introduced after uretero- lithotomy. 320 THE URETER [chap. the ureter being too narrow, or from the presence of a fold or valve, or of a stricture caused by injury from the previous passage of a calculus, or from laceration or rupture of the ureter, or from the pressure of a tumour from without. Position of impac- tion. — The calculus is usually arrested at one of the three narrow parts of the ureter, namely, at the outlet of the renal pelvis, at the brim of the bony pelvis (Figs. 81, 82, 83, 84), or at the entrance of the ureter into the bladder (Fig. 86). Out of 204 collected cases, Jeanbrau found the calculus in the lum- bar portion of the ureter in 46 (22-8 per cent.), in the iliac portion (just above the iliac vessels) in 15 (7"4 per cent.), in the pelvic portion in 105 (52 per cent.), and in the intramural portion in 36 (17-8 per cent.). In rare cases the position of the calculus changes with the posi- tion of the patient. In a patient on whom I operated, a round calcu- lus the size of a marble travelled from the lower part of the pelvic ureter, in which position it was radiographed, into the lumbar segment of the ureter at the level of the iliac crest, on the patient being placed in the Fig. 81. — Faceted ureteral calculi re- moved from ureter at brim of pelvis (upper stone) and at vesical end (lower stone). Actual size. {See Plate 23, Fig. 1.) Fig. 82.^ — Calculus removed from pelvic portion of ureter. Actual size. (See Plate 25, Fig. 2.) XXII 1 J URETERAL CALCULUS 321 Trendelenburg position. (Fig. 87.) In another patient two stones threw shadows, one at the pelvic brim and the other at the bladder, and were found in this position at operation ; they were faceted and articulated with each other. (Fig. 8L) Number, shape, and size of calculi. — There is usually only one calculus (90 per cent.), but there may be two, three, or as many as twenty-seven. The calculi are bilateral in a small number of cases (3-6 per cent.). In shape they resemble a date or oHve-seed, or a cofiee-bean, or they may be round, or, when large, oval or sausage-shaped. The surface may be smooth and polished, or granular, or covered with small basses, or very frequently they show a spiculated surface of sharp, glis- tening crystals. Large calculi have been re- moved from the ureter. Bloch removed one weighing 816 gr., Carless one weighing 803 gr., and Federoff one of 780 gr. In composition they resemble renal cal- culi. A small calculus impacted in the ureter increases in size by deposits which are greatest at its upper end — that nearest Fig. 83. — Calculus removed from ureter at brim of pelvis. Note original calculus at lower end. Fig. 84. — Calculus removed Fig. 85. — Ureteral cal- from ureter at brim of cuius removed by pelvis (actual size) previ- operation, ous to formation of calculi shown in Fig. 80. the kidney — and the nucleus will be found at the lower or vesical end of a large stone. (Fig. 83.) The wall of the ureter may be unchanged, or there may be a V 322 THE URETER [chap. stricture below the stone, or a diverticulum in which the stone lies. In old-standing cases the ureter above the calculus is dilated Fig. 86. — Ureteral calculus. The small cone-like end projected into the bladder, and the narrow neck was grasped by the ureteric orifice. Fig. 87. — Calculus which travelled up a dilated ureter. (Fig. 87) and the walls are greatly thickened, so that the duct is the size of the small intestine. When the stone occupies the intramural portion of the ureter Fig. 88. — Types of ureteral calculi. it forms a rounded swelling in the bladder to the outer side of the ureteric orifice, and it may project into the bladder. (Fig. 86, and Plate 22, Fig. 5.) The stone may ulcerate through this part of Fig. 89. — Oxalate-of-lime calculi passed from kidney. the ureter into the bladder, leaving a ragged opening to the outer side of the normal orifice. The edges of this eventually become XX 1 1 1 URETERAL CALCULUS 323 smooth and rounded, and act as the functional ureteric orifice. (Plate 22, Fig. 7.) Rarely a prolapse of the ureter is caused. In the corresponding kiduev there are calculi in 13 per cent. Fig. 90. — Areas of fixed pain in slowly descending ureteral calculus. The uppermost spot represents anterior renal pain ; the lowest spot, pain when the calculus had reached the lower end of the ureter. The intervening spots were pain areas at intervals of from six months to one year. of cases, and there are bilateral renal calculi in 3 per cent. (Jean- brau). Hydronephrosis occurs in 11 per cent., pyelonephritis and pyonephrosis in 12 per cent. In rare cases the kidney becomes sclerosed and atrophied. Fig. 91. — Position of pain in ureteral calculus at brim of pelvis, marked by black spot. The scar of operation for extraperitoneal removal of the calculus is visible. Symptoms. — In some cases of ureteric calculus there is a his- tory of the passage of a calculus at some previous time. When 324 THE URETEK [chap. a stone descends into the ureter there is an attack of renal cohc, and this is repeated either at frequent or at long intervals. The cohc has the same character and distribution as that caused by Fig. 92. — Pain-history in case of ureteral calculus which became impacted at brim of pelvis. a, b. Severe fixed anterior and posterior renal pain, August, 1901. c, d, Attacks of renal colic, October, 1901 . a stone in the renal pelvis, and there may be nothing to distin- guish the two conditions. Frequently the cohc commences at some spot lower than the Iddney, and shoots downwards. There XXIII] PAIN IN URETERAL CALCULUS 325 may be attacks of pain which does not radiate, at some spot in the line of the ureter. (Figs. 90, 91, 92, 93.) Apart from tlie attacks of colic, there may he fixed pain of a Fig. 93. — Continuation of pain-history (sir Fig. 92). c, Discomfort, 1901 to 1903. /, g. Attacks of pain, June, 1904. /', Fixed pain, July. 1904. dull aching character over some part of the line of the ureter on the anterior surface of the abdomen. Occasionally there is fixed pain in the back just above the crest of the ilium and outside the erector spinae mass of muscles. The fixed pain is 326 THE URETER [chap. worse on inovcjiient or straiiiii)g, and is increased by taking diuretics. The attacks of colic may be frequent and severe until the calculus is expelled into. the bladder. The patient frequently feels something drop into the bladder, and the pain ceases. After an interval of one or several hours or of a few days the calculus is expelled, either easily or with pain and strangury. In other cases, after a period of frequent attacks of renal colic the attacks become less frequent and less severe, and may entirely cease. During the attacks of colic there may be frequent attempts at micturition and very little urine passed, or the bladder may re- main undisturbed. When the stone has descended to a point just outside or within the wall of the bladder, certain symptoms are often super- added. Symptoms of bladder irritation become prominent. There is frequent micturition day and night with strangury and pain referred to the end of the penis. Genital symptoms also appear. There are' painful nocturnal emissions, pain at the moment of ejaculation, hsemospermia, and intermittent pain in the correspond- ing testicle. Genital symptoms are explained by the relations of the lower end of the ureter to the seminal vesicles (Young). There is also constant pain in the rectum, aggravated during defaecation. These symptoms, however, are often entirely absent. Changes in the urine are very common. Haematuria may be pronounced, and in rare instances is the only symptom. It usually follows an attack of renal colic, and lasts a few hours or one or two days, and is aggravated by movement. It may, however, be absent or microscopic. During an attack of colic there may be temporary diminution or complete suppression of urine. Under certain circumstances anuria becomes established. Sometimes an increased quantity of urine is passed after the crisis is over, or the quantity may gradually return to normal. In rare cases there may be continuous polyuria. In a man of 38 years, with a small calculus in the pelvic portion of the left ureter, the quantity of urine varied from 120 to 165 oz. in twenty-four hours, with a specific gravity of 1006. After uretero- lithotomy the quantity of urine fell to from 40 to 50 oz. in twenty- four hours, with a specific gravity of 1010 to 1024. (Chart 16.) The urine may contain pus and bacteria, crystals, and tube casts. Phosphaturia may occasionally be present without other changes in the urine. Course and progfnosis. — In addition to calculous anuria, which is a rare accident, two complications occur, both of which XXIII] PALPATION IN URETERAL CALCULUS 327 are alniosi. iiicsilahlc in ait irnpack'd calculus; tlicv are iufectiou and chronic urinary ohsi ruction, infection is usually ha,'mato- genous in origin, hut may he introduced hy a sound or catheter. Pyelonephritis or pyonephrosis results. Obstruction takes place insidiously, and may not cause pronounced symptoms until a large hydrono])hrosis is found. Examination of the patient. 1 Palpation. — There may be tenderness on palpation at some part of the abdomen along JUNE JULY SEPTEMBER. DATE a 10 12 14- 16 18 20 2 4- 6 a 10 12 14- 16 la 20 22 24. 15 /6 20 21 oz:. 180 I70 /60 /SO /■4-0 I30 I20 no /oo so so 70 60 so f-O JO 2.0 /■a K V y A \ r \ ^ \ 1 1 1 t \ \ / 1 I \ f v § Hi 1 1 1 A A 1 A \/ A 1 V V- y^ ^ /v s N '. i 1 s ■^^ y ;/ Chart 16. — Polyuria in ureteral calculus, showing drop to normal quantity after uretero-lithotomy. the line of the ureter. If this is due to a stone in the right ureter at the level of the brim of the pelvis the tender spot is close to the appendix, and may lead to confusion. A stone is seldom of sufficient size to be palpable in the abdo- minal part of the ureter. On rectal examination in the male a stone at the lower end of the ureter may be felt above and outside the base of the prostate as a small, buried, tender nodule. A large stone is distinctly felt alongside the rectum. In a favourable subject I have felt a stone as high as the brim of the pehas on rectal examination. In the female subject a small stone 328 THE URETER [chap. can usually be felt in the lower end of the ureter by the finger in the vagina. 2. Cystoscopy. — The symptoms may be similar to those of vesical calculus, and the X-rays throw a shadow in the bladder area when the stone is still in the lower end of the ureter. By cystoscopy the presence of a calculus in the bladder is excluded. In descending calculi the ureteric orifice may show no change even where the stone is large and low down. More frequently, however, changes are observed : the ureteric area is congested, the lips are thick and the orifice is gaping (Plate 22, Fig. 2). There may be fine ecchymoses around the orifice, or a flame-like haemorrhage outside the opening (Plate 22, Fig. 3). In some cases one or both lips are bright-red and partly evertfed. When the stone has reached the lower end of the ureter, but has not entered the intramural part of the duct, the orifice may be open and puckered and surrounded by heaped-up, dark, velvety mucous membrane (Plate 22, Fig. 6), or the mucous membrane at the mouth of the ureter may be converted into a rosette of beautifully transparent cedematous bullse or into delicate transparent clubs. Sometimes the oedema spreads to the base of the bladder, and large cedematous fingers and bosses hide the trigone from view. In other cases the stone has reached the intramural portion of the ureter, and appears as a rounded swelling to the outer side of the ureteric orifice, which is red and gaping. The brown or white tip of the stone may project from the ureteric orifice (Plate 22, Fig. 5). Sometimes it is crystalHne and sparkles in the cystoscopic light. When the stone has passed into the bladder a mushroom-shaped projection of mucous membrane may prolapse into the viscus (Plate 22, Fig. 4) like a prolapse of the rectum, or the orifice is open and lacerated. The efilux when a calculus is descending may be rapid and forcible, and may be tinged or stained with blood or cloudy with pus. With an impacted stone low down in the ureter the move- ments at the orifice are frequently slow and lazy, and the efflux feebly wells out. 3. Sounding the ureter. — The ureter may be sounded by a ureteral catheter or solid ureteral bougie passed by means of a catheter cystoscope. The bougie may be arrested by the calculus, or it may hitch and then pass on. Stenosis of the ureter, or some- times a fold of mucous membrane, or angling of the ureter from a loaded rectum or a poorly filled bladder, may block the passage of the catheter, and the value of this method, if used alone, is Fig. 1. — Prolapse of ureters. The partly distended prolapse of right ureter and a small part of prolapse of left ureter are seen. (P. 315.) Fig. 2. — Right ureteral orifice in descending ureteral calculus (in- fected). The orifice is open and the lips are rigid, thick- ened, and warped. (P. 328.) Fig. 3. — Descending ureteral calculus (non-infected). Round open left ureteral orifice with ecchymosis near edge. (P. 328.) Fig. 4. — Eversion of ureteral orifice twenty minutes after expulsion of calculus into bladder. (P. 328.) Fig. 5. — Uric-acid calculus partly extruded from ureteral orifice (P. 328.) Fig. 6. — Acute ureteritis in descending calculus. Note cedema of ureteral orifice and patch of ecchymosis. (P. 328.) Fig. 7. — False ureteral orifice produced by ulceration of calculus from ureter into bladder. True ureteral orifice seen on right. (P. 323.) Plate 22. Plate 22. xxiii] RADIOGRAPHY IN URETERAL CALCULUS 329 limited. Kelly has used wax-tipped ureteric bougies, which are passed up the ureter and may show scratches on the surface of the wax if a calculus is present. The method can only be used in the female and with a Kelly's tube, as the bougies do not pass freely along the tunnel of the catheter cystoscope, and are scratched by the rigid orifice of the instrument. Newman has introduced a fine metal sound, which is attached to a small air balloon, and this to an ear-piece. The contact of the point of the sound with a calculus is heard by the operator. The application of this method is limited to female patients,' and only a calculus in the lower end of the ureter could be safely reached with the metal sound. Separation of the urines of the two kidneys by the separators or by the ureteral catheter will show changes such as blood, pus, casts, etc., on the diseased side, but does not give information in regard to the diagnosis of stone. 4. Radiography. — Radiography is the most accurate and reliable method by which ureteric calculus is diagnosed. The radiographer may be unable to show very small calculi or those formed entirely of uric acid, but stones the size of a split pea or even less can be demo^istrated. Pure uric-acid calculi mthout the admixture of oxalates or phosphates are very rare. It is necessary that the whole urinary tract should be examined in every case, irrespectively of symptoms localized to a point in one ureter. A negative should always be obtained and examined : • the screen is not sufficient. A ureteric calculus throws a shadow in the line of the ureter (Plate 23, Figs. 1, 2, and Plate 25, Figs. 2, 3). This hne crosses several bone shadows — the transverse processes of the 3rd, 4th, and 5th lumbar vertebrae, the sacrum internally to the sacro-iUac synchondrosis, the spine of the ischium, and frequently the hori- zontal ramus of the pubes — and in a doubtful case these parts should be carefully searched, and, if necessary, several plates taken at slightly different angles, as well as stereoscopic photographs. In small stones the shadow is usually oval, with the long axis in the line of the ureter, and they are generally single. Large calculi form round, or elongated rod-like, or sausage-shaped shadows. Shadows thrown by other conditions may lead to difficulty in diagnosis of the shadow. Of these the most important are calci- fied lymph-glands (Plate 24, and Plate 25, Fig. 1), appendices epiploicse, atheromatous patches in arteries, phleboliths, calcareous deposits in old scars or chronic inflammatory tissue or on hgatures from a previous operation, or calcareous deposits in the seminal vesicles, intestinal contents such as scybala, foreign bodies in the 330 THE URETER [chap. bowel (Blaud's pills, etc.), fsecal matter coated with bismuth, calcuU in the appendix, and enteroliths. A differential diagnosis is made by the position of the shadow, the shape, the numbers, by stereoscopic photographs, and by the clinical history {see also p. 305). Radiography with an opaque bougie as a guide. — Although a shadow,, from its size, shape, and density, falls within the sup- posed path of the ureter, some further method of diagnosis will be necessary should the clinical symptoms not clearly point to the presence of a calculus. This is provided by the passage up the ureter of a bougie opaque to the X-rays. These instruments may be obtained in the form of a solid bougie or a catheter. Lead and antimony are metals frequently used in their manufacture. The method of introducing an opaque bougie into the ureter and obtaining a radiogram in order to define the position and trace the course of the duct was first used in the living subject by Tuffier (1897). Tilden Brown published observations on the method in 1898, but it was first placed on a certain and practical basis by an important article by Kolischer and Schmidt in 1901. In 1905, Fen wick drew attention to the value of the method in ureteric calculus. The bougie may be arrested by the stone, and the radiogram shows the stone shadow at the tip of the bougie shadow ; or the bougie may hitch and pass on, and the close relation of the two shadows is then evident. The combination of this method with stereoscopic radiograms gives very accurate information; (Plate 25, Figs. 2, 3, and Plate 26.) Radiography and the injection of collargol. — In the life-history, of a ureteral calculus there comes a time when dilatation of the kidney commences, and from this time onwards the renal tissue is steadily destroyed by expansion. The clinical symptoms give no indication as to when expansion is commencing, and when the kidney is found large and hydronephrotic the renal tissue is already destroyed. By the passage of a ureteric catheter and the injection of collargol (10 per cent.) a shadow of the contour of the renal pelvis is obtained and early dilatation is diagnosed {see p. 176). Treatment. 1. Diuretic treatment. — The cases suitable for diuretic treatment are those of small stones recently engaged in the ureter with recurring attacks of renal colic, and especially where a calculus has previously been pased. Potassium citrate and acetate (15 or 20 gr. thrice daily), theocin sodium acetate (3-8 gr. twice daily), Contrexeville (Pavilion), Evian, and Vittel water, are some of the diuretics which may be given. Antispas- modics may be administered at the same time, such as atropine and belladonna. A visit to one of the spas, such as Contrexeville or Vittel, may prove successful when diuretic treatment at home Fig. 1. — Two calculi in right ureter. The lower round calculus lies just outside the bladder, the upper long oval calculus lies obliquely in the shadow thrown by the sacrum and ilium, and was impacted at the brim of the pelvis, lying upon the iliac vessels. (Pp. 319 and 320, Fig. 81.) Fig. 2. — Oval calculus in pelvic segment of right ureter. (P. 329.) Plate 23. Fig. 1. — Shadows In pelvis due to calcareous glands. There is also a calculus In left ureter (double arrow). (P. 329.) Fig. 2. — Shadows thrown by calcareous glands in region of pelvis and ureter on right side (arrows). Opaque catheter In left ureter (arrow). (P. 329.) Fig. 3. — Shadow thrown by calcareous gland (lower arrow) outside line of right ureter. Edge of psoas muscle shown by upper shadow. (P. 329.) Plate 24. xxiii] URKTFRAL CALCULUS: TREATMENT 331 lias failed. The I rcat^iuciit should he liiuitt'd to four or six luoiilJis, ut the (.'ud of wliicli time an openilioii sfiould bo rccoiniueiidcMl if there is no sign of the stone passing. If coUargol examination of the renal pelvis and calyces shows commencing dilatation, or bacteriological examination of the urine shows infection to have occurred, iinniediate o])erati()n should be undertaken. 2. Instrumental treatment. — The passage of a bougie up the ureter is sometimes followed by the expulsion of the stone. Oil has been injected and eucaine introduced along a ureteric catheter to assist expulsion and relieve spasm. Nitze and Jahr have passed a ureteric catheter with a mem- branous balloon which, when distended, dilated the ureter below the calculus. These methods are only successful in a small number of cases, and safe only in the most expert hands. 3. Operative treatment. — Operation is indicated — i. In calculous anuria {see p. 278). ii. When medicinal treatment has failed. iii. When infection has occurred. iv. When dilatation of the kidney is commencing. When the calculus .is situated in the lumbar segment of the ureter it is exposed by an oblique lumbar incision similar to that used for exposing the kidney, and the ureter found at the lower end of the kidney and traced down to the stone. When the stone is impacted at the brim of the pelvis the ureter is exposed by a curved incision commencing at the level of the anterior superior iliac spine and passing downwards and inwards parallel to Poupart's ligament and about 2 in. above it. The incision passes through the abdominal muscles, care being taken at the inner end not to wound the veins of the spermatic cord. The deep epigastric artery is ligatured. The transversalis fascia is carefully divided to the full length of the wound, and the patient is then placed in the Trendelenburg position. The peritoneum is now reflected along the external iliac vessels. The ureter adheres to the peritoneum, and should be searched for at the level of the bifurcation of the iliac artery. An opaque line or a leash of vessels on the peritoneum will show its position if the stone cannot at first be felt. The ureter is separated by blunt dissection (Fig. 94), but should not be extensively isolated or roughly handled. A fine catgut suture is introduced before removing the stone, and the incision in the ureter should be accurately longitudinal. The ureteral wound is closed with fine catgut on fine rounded needles. The abdominal wound is very carefully closed with stout catgut and a rubber drainage 332 THE URETER [chap. tube introduced, care being taken to keep the tube high up to avoid contact with the iliac vessels. Calculus of the pelvic portion of the ureter may be removed by several methods. By an extraperitoneal route, using the Trendelenburg position and the same curved incision, and tracing the ureter over the brim into the pelvis. In a small movable calculus the ureter Fig. 94. — Operation view of exposure of ureter at brim of pelvis. The ureter is being detached from the peritoneum by blunt dissection. should be opened above the iliac vessels, and a fine scoop (Fig. 95) or long ureteral forceps passed down and the calculus removed. A large fixed stone must be removed by an incision through the ureter directly over it, the abdominal muscles being strongly retracted inwards, and a good light being directed into the wound from a head-lamp. Fig. 1. — Shadows thrown by calcareous glands below and internally to left kidney. (P. 329.) Fig. 2. — Shadow of large oval calculus in pelvic segment of left ureter, and opaque bougie lying beside it. At lower end of calculus is seen denser shadow of nucleus. This cal- culus produced the hydronephrosis seen in Plate 4, Firf. 1. (Pp. 329, 330.) Fig. 3. — Calculus in^ pelvic segment] of ureter (arrow), and opaque bougie lying in ureter. (Pp. 329, 330.) Plate 25. Fig. 1. — Ureteral calculus lying In pelvic segment, cystoscope in bladder, and opaque bougie in ureter. (P. 330.) Fig. 2. — Two calculi lying at lower end of right ureter (arrows). Cystoscope is seen in position, and opaque bougie passed into ureter and arrested by calculi. (P. 330.) Plate 26. xxiii] OPERATIONS FOR URETERAL CALCULUS 333 Other inetliocls of exposing the ureter are described in the Chapter on Operations on the Ureter (Chap. xxiv.). For stone in the pelvic portion of the ureter the sacral, the transperitoneal, the vaginal, or the transvesical route may be used. Calculus in the intramural portion of the ureter is removed from within the bladder after suprapubic cystotomy. The bladder must be drained by a tube in the suprapubic wound. After all operations on the ureter for stone the duct should be examined by passing a bougie downwards into the bladder to search for other stones or for stricture. If a stricture be present it should be incised in the long axis of the duct, and if the lumen be much contracted it may be necessary to perform a plastic operation. Dr. R. Dos Santos has introduced a uretero- tonie which consists of a concealed knife in a flexible ureteric catheter. This is of use in cases of stricture of the ureter. Apart from cases of calculous anuria, extraperitoneal uretero- lithotomy has an operative mortality of under 2 per cent. (1-66 1^ Fig. 95. — Author's pliable scoop for ureteral calculus. per cent. — Jeanbrau). When other operations are combined with uretero-lithotomy the mortality rises to 13-11 per cent. Trans- peritoneal uretero-lithotomy has a mortality of 5-5 per cent. Late restdts. — Urinary fistula results from stenosis of the duct, and is rare (3 per cent.). Recurrence is, I believe, also rare {see p. 319). Patients on whom I have operated have remained well seven years, five years, three years after the operation. In the early stage of dilatation of the kidney the organ may completely recover, but in the later stage recovery of the renal tissue is only partial. LITERATURE Bloch, Folia Urol., April, 1909. earless, Proc. Roy. Soc. Med., Jan., 1910. Dos Santos, Med. Contemp., Dec. 31, 1911. Fenwick, Obscure Diseases of the Kidney. 1903. Jeanbrau, Iks Calculs de VUretere. 1909. Kelly, Opcrdlirc dyncEcology, vol. i. 1898. Kolischer and Schmidt, Jonm. Amrr. Med. Assoc, Nov. 9, 1901. Morris, Siiri/ical Diseases of the Kidney and Ureter. 1901. Rigby, Ann. Snnj., Nov., 1907. Tuffier, Traite de Chiriirrjie (Duplay et Reclus), 1899, vii. 418, Young, Trnns. Amer. Assoc. Gen.- Urin. Surg., 1907, vol. ii. CHAPTER XXIV OPERATIONS ON THE URETER An operation upon the ureter may be required to complete some operation upon the kidney or upon the bladder, or it may be called for to remedy some injury or disease of the duct itself. • In operat- ing upon the ureter the greatest delicacy and gentleness in manipu- lation is necessary. The muscular wall of the tube is easily torn, the blood supply readily damaged. The penalty of rough handling is the formation of stricture and fistula of the ureter, and the ultimate fate of the kidney is often nephrectomy. If present, sepsis of the bladder and urethral obstruction should be effectually treated before the operation is embarked upon. In some cases cystotomy may be necessary for the pur- pose of drainage, apart from any question of intravesical operation upon, the ureter. Renal sepsis usually takes the form of pyonephrosis, which should be treated by temporary nephrostomy before the plastic ureteral operation. When the infection is mild this may not be required, but in such cases, and even when no infection is present, the question of draining the kidney as a temporary measure to spare the line of union in plastic operations on the ureter should be considered. Extensive stripping of the ureter is to be avoided. The adhesion to the peritoneum should be preserved as far as is compatible with the freedom required for a plastic or other operation. This is especially important when the duct is to be or has been cut across, and the continuity of the anastomosis of blood-vessels severed. The ureter can be cut across, or it may be stripped for a considerable distance, without any untoward result ; but if it is both cut across and stripped, sloughing is likely to follow. In manipulating the ureter delicate-toothed forceps should be used, and care taken not to include in the grip the blood-vessels, which are usually quite evident. Incisions into the tube should be made longitudinally. If the tube is to be cut across it is usually best to cut it obliquely, so as to obtain a larger Imnen, although this is not necessary in a dilated ureter. 334 ciiAi'. XXIV] EXPOSURE OF URETER 335 The finest round-bodied needles should be used if the ureter- is of normal size. A cutting needle causes a considerable amount of damage to the wall. Fine soft catgut wliich is not impregnated with strong anti- septics such as iodine, or stiffened with chromic acid, should be used for suturing. Silk, even of the finest size, should be avoided, as a stone will form on the suture {see p. 319). It is seldom possible to suture the wall without including mucous membrane, nor do I consider that this matters in the least if proper catgut be used. Stitches should not be placed too near together, and should not bo tied too tightly, lest the line of suture slough. Wherever it is possible some covering for the line of suture should be provided. A fold of peritoneum or a tag of fatty tissue is invaluable as soldering material for the woimd. A drain should be placed as near the line of suture as possible, with the view of avoiding accumulation of urine should leakage take place. A leak during the first two or three days does not mean failure of the suture line, and perfect union may follow if no accumulation of urine be permitted. Exposure of the Ureter The ureter may be exposed by a transperitoneal or an extra- peritoneal operation. The four regions in which the ureter is exposed are the lumbar or abdominal, at the brim of the bony pelvis, in the pelvis, and in the wall of the bladder. 1. Extraperitoneal exposure of the lumbar segment of the ureter. — This operation is generally part of an operation upon the kidney. The usual oblique kidney incision is made and the lower pole of the kidney exposed. This is pushed up under the ribs, making the ureter tense, and the retroperitoneal surface of the colon is displaced forwards. In the areolar tissue behind or to the inner side of the colon the ureter is found and is isolated by blunt dissection. By carrying the lumbar incision forwards just above the anterior superior iliac spine the ureter can be traced as far as the brim of the pelvis where it crosses the iliac vessels. •2. Extraperitoneal exposure of the whole length of the ureter. — Extraperitoneal exposure of the ureter commences as an oblique lumbar incision at the angle between the erector spin* muscles and the last I'ib, and sweeps roimd the anterior supeiior iliac spine about 1 in. above and internally to it. The incision then runs parallel and about 2 in. above Poupart's ligament to 336 THE URETER [chap. the outer border of the rectus muscle near its insertion. In this incision the epigastric vessels are ligatured and cut. The incision has been used for ureterectomy, especially in tuberculous disease of the ureter. It is not, however, necessary to make so extensive an incision. If the upper wound be carried almost to the anterior superior iliac spine, a second small incision may be made above and parallel to Poupart's ligament and the pelvic portion of the ureter treated through this. The mutilation of the abdominal wall is much less by this method, and a more satisfactory scar is obtained. 3. Extraperitoneal exposure of the ureter at the brim of the pelvis and in its pelvic portion. — An incision about 4 in. in length is made 1| in. above and parallel to Poupart's ligament, commencing a little internally to the middle of that liga- ment, and curving upwards at its outer extremity to pass 1 in. internallv to the anterior superior iliac spine. The muscles are partly cut through and partly split, and the transversahs fascia exposed. This is incised for the whole length of the wound, and the extraperitoneal fat and peritoneum are exposed. In the male, care should be taken at the inner end of the incision to avoid the veins of the spermatic cord. The deep epigastric vessels usually require hgature. After exposure of the peritoneum the patient is placed in the Trendelenburg position and the peritoneum raised. The external ihac vessels are followed and the ureter searched for at the level of the bifurcation of the common iliac vessels, about 4 in. from the surface in an average body. The ureter hes on the peritoneum and is raised up with it. If it be normal it may be difficult to find. A faint whitish track on the peritoneum or a fair-sized blood-vessel pursuing a long straight course may be the only guide. (Fig. 94.) The spermatic or ovarian vessels should not be mistaken for those around the ureter. The normal ureter cannot be detected on palpating the peritoneum. Good retraction and a powerful head-light are important aids to the search. When the ureter is dilated it is found as a large greyish tube, sometimes the size of the small intestine, with a tough wall ; but even when it is of considerable size it may not present more than a greyish band on the perito- neum until a few strokes of the dissecting forceps make it stand out. I have had great difficulty in exposing a ureter in this position in a case where there had been chronic appendicitis with retroperitoneal adhesions. A hard tuberculous ureter or a ureter containing a stone can be readily detected by the touch. Having been exposed by blunt dissection, the ureter may be XXIV] EXPOSURE OF URETER 337 followed over the brim of the pelvis, and the pelvic portion explored. The portion of the duct below the pelvic brim alongside the rectum may be difficult to reach. Beyond this the ureter passes forwards and is more easily accessible until it approaches the bladder, when it is surrounded by numerous vessels and in the female runs below the uterine artery. After the operation a rubber drain is placed in the iliac fossa, and great care should be taken to keep it from touching the iliac vessels. It must not be allowed to lie over the brim into the pelvis, for it will certainly press upon the iUac artery and cause sloughing and hsemorrhage from that vessel. Several fatal cases of this accident are on record. If the ureter has been opened in the pelvic segment the lower end of the bed should be raised, so that any leakage of urine may pass into the iliac fossa and be drained by the tube. I have not had any trouble with pelvic cellulitis even in septic cases. Should a doubt exist in the case of a female patient, a small incision should be made through the vaginal wall and a tube placed in it for a few days. The route indicated in this section is the safest and most satisfactory for operation upon this part of the ureter. 4. Transperitoneal exposure of the ureter at the brim of the pelvis and in its pelvic segment. — A median incision is made, commencing just above the symphysis pubis; the perito- neum is opened, the patient is placed in the Trendelenburg position, and the intestines are packed off. The ureter is seen appearing just internally to the caecum, and passes over the brim of the pehis, crossing the bifurcation of the ihac vessels. It can be traced in the pelvis imtil it disappears beneath the broad ligament in the female and the seminal vesicles in the male. By incising the peritoneum over it the duct is exposed in any part of the pelvic course. The intraperitoneal route has the disadvantage that in septic cases there is a grave danger of infecting the peritoneum. 0. Parasacral extraperitoneal route for exposure of the pelvic segment of the ureter. — A nimiber of operations have been described by Delbet, Cabot, and others for the exposure of the portion of the ureter by a sacral route. That used by Morris will be described. A straight incision 5 in. in length is made 1 in. from and parallel with the median line, commencing 2 in. above the border of the gluteus maximus muscle, and extending nearly to the level of the anus. The edges of the gluteus maximus and great sciatic ligament are divided, the rectum and vagina are pished aside, w 338 THE URETER [chap. and the ureter is found as it crosses the tip of the spine of the ischium. The advantages claimed for this incision are the absence of bleeding, the avoidance of the peritoneum, and the dependent drainage. Morris advocates it especially in women. The dis- advantage is the narrow, cramped field of operation. 6. Vaginal route. — An incision is made transversely through the upper part of the lateral vaginal wall. The ureter is exposed by blunt dissection and isolated, care being taken to avoid the uterine artery, which crosses above and close to it. The ureter is incised, the stone removed, and the wound closed with catgut sutures. The vaginal route is used when a stone can be felt in the ureter and the exposure of the duct is made without difficulty. When the duct is not thickened or contains a stone, it may be very diffi- cult to find. An unduly large percentage of urinary fistulae have followed this operation, due probably to mistakes in technique. 7. Vesical route for calculi in the intramural portion of the ureter. — Suprapubic cystotomy is performed and the patient placed in the Trendelenburg position. The edge of the ureter is seized with long forceps, the mucous membrane slit up with long curved scissors, and the stone removed. The bladder should be drained suprapubically, and not closed, as there is a danger of ascending pyelonephritis even in a mildly infected bladder. 8. Transvesical route for calculi lying in the lower two inches of the ureter outside the bladder wall. — I have performed the following operation where great difficulty was experienced in exposing the lower part of the ureter by the iliac extraperitoneal route. After suprapubic cystotomy the patient is placed in the Tren- delenburg position and the wound well retracted. A curved incision with the concavity towards the trigone is made Ih in. outside the ureteric orifice on the affected side. A flap of bladder wall is turned down, and by pulling on this the ureter is made tense and exposed. It is surrounded by a number of blood-vessels which may require ligature. After removal of the stone the duct is stitched, and the curved wound in the bladder closed with catgut stitches on a rubber tube which drains the extravesical space and is brought out of the cystotomy and suprapubic wounds. The bladder is also drained. A perineal route has been used, but this and the rectal route have both been abandoned. Choice of route. — For the lumbar segment of the ureter the lumbar extraperitoneal route is the only one available. To expose XXIV] URETERECTOMY 330 the ureter at the brim of the ))elvis the iUac extraperitoneal route is the })est, and this route is also the most satisfactory for the great majority of cases in which the pelvic portion of the ureter is to be exposed. The transperitoneal route may be useful in some cases for the pelvic segment of the duct, and the transvesical for difficult cases of impacted stone lying just outside the bladder. The vaginal route is also a useful method of approach, but rough handling should be avoided and the ui-eter carefully stitched. Ureterectomy Partial ureterectomy. — This may be performed as part of the operation of nephro-ureterectomy. The kidney with a part of the ureter is removed for tuberculous or other disease {see p. 293). The operation may in rare instances be required for the treat- ment of stricture or other disease of the ureter. Here a portion of the ureter is resected, and the ends of the tube are united by one of the methods of anastomosis. Total ureterectomy. — This is part of the operation of nephro- ureterectomy which is described elsewhere. It is performed for tuberculosis of the kidney and ureter, suppuration and dilatation of the ureter, and new growths. The ureterectomy may be carried out at the time of the nephrec- tomy (primary ureterectomy), or it may be deferred to a later date (secondary ureterectomy). In the latter case the upper end may have been fixed in the lumbar wound, or it may have been re- turned to the retroperitoneal space. In primary ureterectomy, after the renal pedicle has been tied, the patient is turned on his back and the lumbar wound con- tinued forwards so as to form the iho-lumbo-iliac incision already described. The ureter, with the kidney attached, is stripped from the peritoneum and traced into the pelvis. It may be difficult to remove the last two inches of the duct, and this is usually liga- tured and left, no harm resulting. The surgeon may, however, persist if the condition of the patient warrants it. The patient is placed in the Trendelenburg position, and the ureter traced up to the wall of the bladder and ligatured there. In the female subject Kelly has employed an incision in the vaginal wall to expose and remove the lower end of the ureter. Separate lumbar and iliac incisions may be made {see p. 336). Plastic Operations on the Ureter 1. Anastomosis of ureter and kidney. — These operations are used in hydronephrosis, where the seat of the obstruction at the renal pelvic outlet is inaccessible owing to adhesions or 340 THE URETER [chap. perinepHritic fat, or where the obstruction is irremediable. The operations consist in lateral anastomosis, transplantation of the ureter into the lowest part of the sac. Incision of valves and uretero-pyeloplasty are methods of dealing with obstruction at the outlet of the renal pelvis. These operations are described under Hydronephrosis (p. 182). 2. Uretero -ureteral anastomosis. — This operation is used when the ureter has been torn or cut across, or when a portion of the tube has sloughed as a result of blows, stabs, injuries during childbirth, or when it has been injured during pelvic operations. Immediate suture should be performed. If a portion of the tube be damaged it should be excised before commencing the anastomosis. The methods of performing uretero-ureteral anastomosis are described at p. 180. 3. Anastomosis between ureter and bladder. — This opera- tion is performed for fistula of the ureter near its lower end, usually caused by injury during a pelvic operation such as hysterectomy or ovarian operations in the female, and removal of the rectum by the abdomino-perineal method in the male. It is also neces- sary in resections of portions of the bladder wall for maHgnant growth when the operation involves the lower end of the ureter. In cases of fistula following extensive pelvic operations the relations of the pelvic organs are usually completely changed, and there may be very extensive development of scar tissue. On this account the transperitoneal method of approach is preferred to the extra- peritoneal route. r <4 The operation is facilitated by passing a catheter up the vesical end of the ureter by means of the catheter cystoscope. The abdomen is opened, the patient is placed in the Trendelenburg position, and the intestines are packed off. The ureter is defined at the brim of the pelvis and traced downwards to the seat of the fistula if possible. Should there appear to be a prospect of obtain- ing union of the two ends of the severed tube, a ureteral anasto- mosis should be carried out. If this be not feasible, the upper end of the ureter should be dissected free for as far as is neces- sary and implanted in the bladder. An incision is made in the bladder, and the tube pushed through and stitched from the inside of the bladder to the mucous mem- brane. A second set of sutures is introduced between the outer surface of the bladder and the ureter, and the first inch of the ureter buried by folding the bladder wall over it by means of a row of Lembert's sutures. All traction on the sutures must be avoided, and Ricard stitches XXIV] PLASTIC OPKRATIONS ON URKTKR 'Ml the bliiddcr to tli(^ purietal pcrit.oiicmii on llic sidi^ of tlio aiiasto- luosis, to prevent tension. The bladder should be drained supra- pubically by a large rubber drain. There are many variations in the iin|)luntation of the ureter, Ricard turns back a cuft" of ureter after splitting the tube, and stitches it. A portion of the ureter is made to project into the bladder, and the bladder and ureteral wall are sutured above this. Payne splits the ureter to form two flaps. A U -suture is introduced through each flap and carried through the vesical wall from the inside. Transvesical operations are sometimes used, but are rarely successful. In a case in which the abdomino-perineal operation for rectal carcinoma had been performed by another surgeon a urinary fistula followed, arising from the right ureter about 2 in. from the bladder. After opening the bladder I made a free incision in the bladder wall near the right ureteric orifice, and stitched a large drainage tube through this at the lower end of the upper segment of the severed ureter, in the hope that a permanent fibrous track would result and form a new communication between the ureter and the bladder. For a few weeks this worked admir- ably, but contraction took place, and eventually nephrectomy became necessary. The operations for implantation of the ureter in the bladder in resection of the bladder wall will be described in connection with malignant growths of the bladder (p. 481). 4. Implantation of the ureter on the skin (dermato- ureterotresis. — This operation is chiefly employed where the urine must be diverted in cystectomy. It may also be used when a ureter is injured and ureteral anastomosis is impracticable in a case where the second kidney is absent or inadequate. The ureter is exposed in the loin and isolated. It is cut across, and the lower end tied and dropped into the retroperitoneal tissue. The upper end is brought up to the surface of the skin, care being taken not to kink or twist it. The cut end is split, and the flaps are stitched to the skin at the edge of the wound, supporting stitches being placed at the level of the subcutaneous fascia. A rubber tube is placed alongside the ureter and pierces the abdominal wall. This forms a weak spot in the wall and obviates the strangulation of the ureter which sometimes takes place. The results of this operation are rather better than those of implantation of the ureter into the intestine, but stenosis of the orifice and ascending pyelonephritis cause a very high late mortality. An apparatus similar to that worn in nephrostomy is used. 342 THE URETER [chap. 5. Implantation of the ureter in the intestine. — The operations performed for extroversion of the bladder are described elsewhere (p. 398). The following operations are suitable for cases of ureteral fistula, as a preliminary to total cystectomy, or for wounds of the ureter : The ureter may be implanted into the caecum, the pelvic colon, or the ascending or descending colon. In the majority of cases the transperitoneal method is used, but in a few cases the operation may be performed extraperitoneally. The abdomen is opened either in the middle line or over the por- tion of bowel in which it is proposed to implant the ureter. The ureter is exposed by cutting through the peritoneum over it, and, the peritoneum being protected from the septic urine, is cut across and the lower end ligatured and cauterized. The upper end is cut obliquely if it be of normal calibre. The extraperitoneal aspect of the bowel is exposed and the obliquely-cut ureter implanted into it. This may be done by a double layer of continuous catgut sutures, the first layer uniting one half of the outer layer of the ureter to that of the intestine, and the next the whole circumference of the mucous lining, and then the second half of the outer layer in a manner similar to that used in intestinal anastomosis. A third row of sutures may be inserted for ad- ditional security. In order to prevent the actual contact of faecal matter with the ureteric orifice. Fowler has introduced the following method : The peritoneum is split and the ureter dissected up and divided. The upper end is displaced towards the bowel beneath the peri- toneum and fixed to the surface of its wall by a few stitches. A rectangular flap of the bowel wall is now raised, and the mucous membrane dissected from the muscular coat. The flap of mucous membrane is doubled on itself and stitched so that a fold with a mucous covering on both sides is formed. Between this and the rectangular flap of the muscular wall the end of the ureter is placed and secured in position. The muscular flap is now replaced and stitched. Uretero-appendicostomy, — In a case of very extensive papilloma of the bladder which recurred after four operations I made an anastomosis between the right ureter and the appendix. An incision similar to that for appendicectomy was made, and extended for 4 in. The patient was placed in the Trendelenburg position, and the appendix found lying close to the dilated ureter at the point at which it crossed the iliac vessels. The peritoneum over the ureter was incised and the duct freed for 2 in. and then cut across between two ligatures. A longitudinal incision was xxiv] URETERO-APPENDICOSTOMY 343 iiuulo ill the uj)p('r .scfjjinciit. The jippendix was cut across obliquely and two catgut stitches were passed tlirough its wall and up inside the ureter, drawing about an inch of appendix into its lumen through the longitudinal opening. The sutures were passed through the wall of the ureter from within outwards, and tied. The longi- tudinal incision was carefully closed around the appendix, and sutures united the serous surface to the surface of the ureter. A flap of fat from the meso-appendix was stitched over the line of suture, and the wound in the peritoneum closed. For three days the urine passed by the colon, but sloughing occurred, and the patient died of ascending pyelonephritis. PART III— THE BLADDER CHAPTER XXV SURGICAL ANATOMY AND PHYSIOLOGY Surgical anatomy. — The adult bladder is a pelvic organ when it is empty or moderately full ; when distended, it is partly abdominal. The physiological capacity of the bladder is from 8 to 10 oz., but it may be so distended as to contain several pints, or even quarts. There are an anterior, a posterior or postero-superior, and two lateral walls, a base, and an apex. The apex is the highest, conical portion of the bladder, and to this is attached the urachus. The extent of the base is indefinite. It is frequently looked upon as the portion of the lower segment of the bladder which is uncovered by peritoneum. In cystoscopy the term is used to indicate the trigone and an undefined area of bladder wall around this. The lateral walls are concave, and a recessus lateralis on each side is sometimes described. The internal meatus of the urethra is on a level with and about 2 cm. behind the middle of the symphysis pubis. This is the most fixed part of the bladder. The peritoneum covers the postero-superior wall, and descends to cover half the seminal vesicles within 1 cm. of the prostate. On each side it covers the greater part of the lateral wall. When the bladder is empty the peritoneum passes directly from the abdominal wall on to the bladder ; when the viscus is full the postero-superior wall is pushed up to form the apex, and the peritoneum dips down on the front of the bladder for a short distance. The area of bladder wall uncovered by peritoneum above the level of the symphysis pubis is about 1 or 1| in. with moderate distension of the bladder (10 to 12 oz.) ; frequently it is less, and 344 (HAi. xxv| RHLATIONS OF BLADDER 345 with the l)hi(l(h'r I'lilly distciKh-d the pciitroncal fold may lj<^ loiiiid as low as the iqiiK'L' boi'der of tlie syiiii)hysis i)ut)is. The perito- neum is loosely attached to the bladder by ai'eolar tissue, and is readily stripped from its anterior surface. At the apex around the attachment of the urachus and at the upper part of the pos- terior wall it sometimes adheres firmly ; but below this and on the lateral walls it is readily detached. In front of the bladder, behind the symphysis pubis, is a space filled with aret^lar tissue, the space of Retzius. Relations of the bladder. — The moderately distended blad- der lies behind the symphysis pubis and pubic bones, and above these it comes in contact for a very short space with the posterior surface of the anterior abdominal wall. The posterior wall in the male is covered with peritoneum, and in relation to this are coils of small intestine. The lateral wall is in relation to peritoneum as low as the obliterated hypo- gastric arteries, and below this it comes into relation with the obturator internus muscle covered by the parietal layer of pelvic fascia, and then with the levator ani muscle covered by the visceral layer of pelvic fascia. The base in the male is in relation to the prostate, which extends rather more than half-way from the urethra to the base of the trigone, and passes out laterally beyond the ureteric orifices. Behind this the ampulla of the vas deferens is in relation to the bladder wall on each side, and then to the peritoneum of the pouch of Douglas. The base of the female bladder is in relation to the anterior vaginal wall, which extends backwards for more than an inch behind the base of the trigone. The trigone is firmly adherent to the vaginal wall, but above this the vagina and bladder are loosely attached. The bladder wall then comes into relation to the anterior surface of the uterus almost to the apex. At the apex the peritoneum covers it for a short distance before being reflected on to the uterus. " In the new-born child the orifice of the urethra is about the level of the upper border of the pubic symphysis. In front of this orifice the bladder extends forwards and slightly upwards in close contact with the pubis until it reaches the anterior abdominal wall, against which it lies until within about 1 cm. of the umbilicus " (Symington). The anterior surface is entirely uncovered by peri- toneum, which posteriorly reaches as low as the level of the orifice of the urethra. At birth the organ is described as being essentially an abdominal organ. According to Symington, however, if a line be drawn from the promontory of the sacrum to the upper edge 346 THE BLADDER [chap. of the symphysis, fully one-half of the bladder will be found below this line, or, strictly speaking, within the cavity of the true pelvis. The organ is pear-shaped ; it has no base and no lateral recesses. As the child grows older the bladder dilates and sinks into the pelvis, so that at the age of 10 it is a pelvic organ with the same relations as in the adult. The bladder wall consists of three coats — mucous, muscular, and serous. In the contracted male bladder the posterior wall is thicker than the anterior. There are an outer and an inner longitudinal muscular layer and a middle interlacing layer. In the lateral walls the longitudinal muscle is less developed or absent. The trigone is a separate structure from the rest of the muscular wall of the bladder. From the internal longitudinal layer of one ureter muscular bundles pass to join those from the other ureter, and these form a muscular ridge called the interureteric ridge or bar of Mercier. Other strands of longitudinal muscle pass from the ureters towards the urethra, and flow over the posterior edge of this orifice to join the internal longitudinal muscular layer of the urethra. These form the sides of the trigone. In the centre of the triangular space the muscle bundles interlace irregularly. The sphincter of the bladder is formed as follows : Beneath the surface layer of the trigone is a thick layer of non-striped muscle lying on the upper surface of the prostate. This is con- tinuous with the circular layer of bladder muscle, but distinguished from it by being thicker and the bundles being more closely set. As this layer approaches the urethra it becomes thicker and forms a thick wedge behind the opening of the internal meatus. Thence it is continued as a thin layer of circular muscle surrounding the urethra. Along the front wall of the prostatic urethra is a thick band of circular muscle similar in its compact arrangement to that lying upon the base of the gland, and extending as a gradually thinning layer to the apex of the prostate. The sphincter of the bladder is a fan-shaped muscle the posterior part of which is formed by the deep circular layer of the trigone muscle, while the anterior part is spread out along the anterior surface of the prostatic urethra. The mucous membrane consists of transitional epithelium, the superficial cells of which are characteristic, having several nuclei, and protoplasm which stains less deeply on the surface than on the deeper layer. The surface is smooth and rounded ; the deep aspect shows prickles. There are no papillae. In the normal submucous tissue there are round cells either diffusely distributed or grouped in nodules, and it is unsettled whether or not these represent lymphoid tissue. xxv| ARTr:RIES OF BLADDER 347 Leiidorl' describes j^Haiulular structures around the urethral orifice and at the base. These are solid or hollow epithelial down- growths and glands consisting of froni one to five lacuna) which open into a single excretory duct. In the body of the bladder only the epithelial ingrowtJis are found, and the apex is free from glandular structures. The mucous membrane is smooth and delicate, and freely movable upon the underlying muscular layer over the whole bladder surface. Over the trigone it is coarser and firmer, and is adherent to the underlying structures. At each angle of the trigone, set on the ureteric ridge, is the opening of a ureter, which appears as a fine pink slit. In the mucous membrane at the apex there is frequently a trace of the urachus in the form of a dimple. The urethral orifice is a half-moon-shaped slit, concave back- wards. The shape is due to the prominence of the uvula vesicae on the posterior lip, which passes down into the postmontanal ridge and to the verumontanum. Arteries. — The arterial supply is derived from branches of the internal iliac arteries. The superior vesical and middle vesical are derived from the unobliterated portion of the hypogastric artery ; the inferior arises from the anterior division of the internal iliac, frequently in common with the middle hsemorrhoidal. The superior supplies the apex and upper part of the body of the bladder, the middle supplies' the rest of the body and base of the bladder, and the inferior supplies the trigone. The branches perforate the muscular wall and form a sub- mucous plexus from which proceed fine branches that penetrate the mucosa. On the surface of the mucous membrane fine twigs can be seen with the cystoscope. They penetrate the mucosa at irregular intervals and break up into fine branches. There is no regular arrangement of these vessels, and they vary very considerably in numbers in healthy individuals. When the vessels are engorged from some pathological cause the fine branches can be seen to anastomose with each other and with branches of neighbouring vessels. In many bladders deep-blue branching vessels, three or four times the breadth of the surface vessels, are seen coursing deeply in the mucous membrane. The fine surface vessels cross these. One of these large vessels may be seen rising to the sur- face and splitting into two or more fine surface vessels. One or two vessels emerge from the ureteric orifice and pass outwards and backwards, breaking up into fine branches. In an area the size of a threepenny-piece around the ureteric orifice the circulation is intimatelv connected with that of the ureter. In 348 THE BLADDER • [chap. health there is no indication of this, but in many diseases of the ureter this area shows a halo of congestion. The vascular supply of the trigone, as seen with the cystoscope, is distinct from that of the rest of the bladder. The vessels, which are much larger, run for the most part in a fan shape from the urethra backwards over the trigone area, overlapping it a little at each side and at the base. The fine twigs on the surface anastomose, and at the angles of branching there are frequently small dilatations. Veins. — The vesical veins do not correspond to the arteries. Numerous veins pass downwards on the surface of the front of the bladder (anterior vesical veins) and join the large veins which pass backwards on each side at the base of the prostate. The posterior vesical veins collect the blood from the apex and peritoneal sur- face of the bladder by a vertical trunk, and by a horizontal trunk which collects the blood from the lateral wall and communicates with the anterior plexus. These veins form several large trunks which communicate with the hsemorrhoidal plexus and open by a single trunk into the internal iliac vein. The veins of the trigone pass into those of the prostatic urethra. Lymphatics (Fig. 96). — No lymphatics have been described in the mucous membrane. In the submucous tissue there is a net- work of lymphatic vessels from which numerous branches pass into the muscular coat vertically to the surface, with free lateral anastomoses. From this network spring large trunks. On the posterior surface two parallel trunks course from the apex to the base and drain the lateral walls. The basal lymphatics communi- cate with those of the prostate and seminal vesicles in the male, and the anterior vaginal wall in the female. On the anterior face of the bladder there are one or two collecting trunks situated on each side of the middle line. A few small lymphatic glands are found on the outer surface of the bladder. The lymphatics from the anterior surface pass to glands along the external iliac, those of the upper part of the bladder pass to the external iliac and to the hypogastric glands, while those of the lower part of the posterior wall pass alongside the rectum to the sacral ganglia lying at the bifurcation of the aorta. Nerves. — From the 3rd, 4th, and 5th lumbar nerve roots nervi communicantes pass to the sympathetic chain and run with- out interruption by the three mesenteric branches to the inferior mesenteric ganglion. From this ganglion the two hypogastric nerves emerge, forming the hypogastric plexus, and pass to the wall of the bladder. A second set of nerves originate in the 2nd and 3rd sacral nerves (nervi erigentes or sacral nerves), and pass to the hypogastric plexus, where they are interrupted by ganglia, xxv] PHYSIOLOGY OF BLADDER 349 from which they pass to the fundus, anterior part, and neck of the bladder. Physiology. — In the healthy individual the urine collects in the bladder and is passed four or five times during the day, and not at all at night. About 8 or 10 oz. are passed at each act of micturition. Zuckerkandl and Frankl-Hjochwart have shown that in normal individuals there is slight desire to micturate when 100-500 grm. of fluid are introduced into the bladder and the pressure varies Fig. 96. — Lymphatics of bladder. E.I.A., External iliac artery; I.I. A., internal iliac arter>' ; O.N., obturator nerve ; H.A., hypo- gastric artery ; U, ureter ; B, bladder ; R, rectum ; X, apex of bladder when distended ; 1 to 6. lymphatic trunks. from 10 to 30 cm. of water. When 400-700 grm. are introduced there is a powerful impulse and the pressure rises to from 13 to 53 cm. of water. When the bladder is slowly filled the intravesical pressure very gradually rises, apart from any contraction of the bladder, giving a pressure of from 3 to 4 cm. In the living subject the gradual rise is followed by a rapid increase synchronous ^nth a contraction 350 THE BLADDER [chap. of the bladder. The urine is retained in the V^ladder partly by mechanical conditions and partly by the tonic contraction of the vesical sphincter. In the cadaver fluid does not escape from the bladder when in the recumbent or the erect posture, and a con- siderable quantit}' can be injected into the bladder through the ureter without any escape from the urethra. Some amount of force is required to separate the elastic walls of the urethra at the vesical orifice. The compressor urethrae forms a second sphincter, partly volun- tary and partly involuntary. After suprapubic prostatectomy the vesical sphincter does not resume its f miction in 50 per cent, of cases, and the compressor acts as the sphincter. Micturition is performed by relaxation of the sphincter and contraction of the detrusor muscle. Two theories are advanced to explain the initiation of the act : 1. It is said to arise in gradually increasing waves of contrac- tion caused by distension. This can be demonstrated by artificially distending the bladder \\^th fluid. When the distension reaches a certain point contraction of the detrusor takes place. If during the expulsion of the fluid through the urethra fluid is run in as rapidly through a suprapubic wound the contraction is not prolonged, but the detrusor relaxes after a regular period of contraction, and this is followed by an interval of relaxation and then another contraction. 2. When the bladder is distended to a certain degree, contrac- tions of the wall occur which force a few drops into the sensitive prostatic urethra, from which the reflex is initiated. The reflex can be produced artificially by injecting a few drops of silver nitrate solution into the prostatic urethra, which produces intense desire to micturate. The injection of cocaine into the prostatic urethra may cause retention of urine when the bladder is full>' distended. On the other hand, I have shovai that the prostatic urethra is removed in the operation of suprapubic prostatectomy and the act of micturition is unimpaired. The act of micturition consists in the accumulation of urine, ^\■ith slow rise of intravesical pressure to 15 cm. of water (Starling), followed by rhythmical contractions of the bladder increasing in force. Afferent impulses pass to the spinal centre, and eft'erent impulses cause contraction of the bladder with rise of intra- vesical pressure to 20 or 30 cm. of water, when the sphincter re- sistance and adhesion of the urethral walls are overcome and the urine is discharged. The act of micturition can be voluntarily initiated by relaxing the perineal muscles, and perhaps also the sphincter of the bladder, and contracting the abdominal muscles. XXV] PHYSIOLOGY OF BLADDER 351 The passage of the urine can be voluntarily interrupted hy contraction of the voluntary perineal muscles, and perhaps also of the sphincter vesicae. There is a centre for micturition in the lumbar spinal cord which in the adult is subject to control from the cerebrum. Reflex micturition can be carried on when the cord is cut across above this centre. Complete destruction of the lumbar centre is followed at first by retention of urine and overflow, and later the bladder acts re- flexly and is continent. The reflex centres here are apparently the inferior mesenteric and hypogastric plexuses of the sympathetic. Finally, some power of causing contraction is possessed by the scattered nerve ganglia in the bladder wall itself. When the organ is completely isolated from the nervous system, stimulation will produce contraction of its wall. LITERATURE Frankl-Hochwart und Zuckerkandl, Die Nervdsen Erkrunkungcn der Blase. 1898. Goltz und Treusberg, Pfliigers Arch., vols, viii., ix. Goltz und Ewald, Pflugers Arch., vol. Ixiii. Jarjavay, Recherches Anatomique sur V Uretere de V Homme. Paris, 1856. Kalischer, Die Urogenitalmuskulatur des Dammes. Berlin, 1910. Lendorf, Anatomie. 1901. MUller, Deuts. Zeits. f. N-ervenheilkunde, 1901, S. 886. Rehflsch, Virchows Arch., Bd. cl. Symington, The Anatomy of the Child. 1887. • Walker, Thomson, Journ. Anat. and Phys., April, 1996, vol. xl. von Zeissl, Wien. ined. Bldtt., 1902, Nr. 10. Zuckerkandl, E., Handbuch der Urolojie (von Frisch und 0. Zuckerkandl), Bd. i., 1904. CHAPTER XXVI EXAMINATION OF THE BLADDER 1. Inspection. — When the bladder becomes greatly distended it forms a prominent rounded swelling between the pubes and the umbilicus. When the patient is standing there is only a general prominence ; when he is lying on his back the rounded swelling appears. (Fig. 97.) 2. Palpation. — ^With the patient lying on his back, the shoulders raised and the knees drawn up, the surgeon places his hand flat upon the suprapubic region. The distended bladder is felt as a firm rounded swelling rising out of the pelvis. The apex can be distinctly felt. Sometimes a large diverticulum can be recognized on palpation, especially when it is surrounded by inflammatory thickening. The distended bladder is dull on percussion ; pressure upon it usually gives a heavy aching sensation in the perineum or at the end of the penis. 3. Rectal examination. — Examination of the rectal surface of the bladder is made with the patient in the knee-elbow position on a couch, or in the lithotomy position. The portion of the male bladder which can thus be examined is about l^ in., commencing just behind the interureteric bar. In front of this the seminal vesicles and prostate intervene between the finger and the blad- der base. With the fingers of the other hand above the pubes a bimanual examination is made. The distended bladder fills up the space above the prostate and bulges downwards so as almost to bury the gland. This may be simulated by a collection of pus in the peritoneal pouch of Douglas. Thickened ridges of hypertrophied bladder muscle can sometimes be felt. The thickening of an advanced infiltrating growth at the base of the bladder can be felt in this situation. Calculi are very seldom detected by this method of examination, but a very large calculus may be felt on bimanual examination. The lymphatics of the bladder base pass out along with those of the prostate at the upper and outer angle of the prostate. A sling containing blood-vessels and lymphatics can be felt on each side in this position. In this lie the first lymph-glands of the CHAP. XXVI] EXAMINATION OF BLADDER 353 chain which passes to the internal iliac vessels. Enlargement of these glands can be detected on rectal palpation. 4. Vaginal examination. — The short urethra can be felt in the anterior vaginal wall, extending backwards from the outlet of the vagina for Ih in., when it expands into the trigone. The trigone can sometimes be detected on palpation of the anterior vaginal wall, and the ureters may be felt passing out- wards from each lateral horn. Behind the trigone the bladder base can be palpated in the anterior fornix. 5. Examination by catheters and sounds. — The passage of a catheter is required to withdraw the urine in atony of the bladder or obstruction of the urethra. It may be necessary in order to Fig. 97. — Distended bladder. ascertain the presence and quantity of residual urine after the patient has passed all he can voluntarily, or it may be used to obtain a specimen of urine from the bladder for examination so as to avoid contamination by the urethra or the external genital organs. Occasionally it may be necessary to drain the bladder continuously by tying the catheter in position in the urethra. Sometimes on passing a catheter a calculus may be felt in the bladder, or the filling up of one part of the bladder with a growth ; or fragments of a growth may be caught in the eye of the catheter on withdrawing the instrument. Catheters. — Three varieties of catheter are in use — the metal catheter, the flexible catheter, and the rubber catheter. 354: THE BLADDER [CAHP. Metal catheters have a curve corresponding to that of the urethra, a blunt conical end, and two small metal loops at the proximal end to assist in fixing the instrument in the urethra should it be desired to drain the bladder continuously. A " pros- tatic " catheter has a large curve and a much longer beak. Flexible catheters have a basis of finely woven silk, which is coated without and within with a flexible preparation. They may be straight and taper to a point which has a bulb or olive tip, or they may be of the same calibre throughout and have a blunt rounded end, or the end may be bent upwards (coude catheter), or there may be a double bend (bicoude catheter). (Fig. 98.) The tip of the catheter beyond the eye should be sohd. The proximal end of these catheters should be trumpet-shaped so as to admit the nozzle of a syringe or a glass nozzle. There should be no ornamental bone attachment. Fig. 98. — Silk-wove catheters. From above downwards : Olivary, coude, and bicoude varieties. Gum-elastic catheters are less flexible than those just described, and can be bent into the required shape for use. They have a mandarin. Rubber catheters are soft and very supple. The tip of the catheter beyond the eye should be solid, and the proximal end should be trumpet-shaped. Cleansing and sterilization of catheters. — Metal catheters are boiled before use. After use they should be syringed through with antiseptic fluid or attached to an apparatus which is fixed to the water-tap. The grease is removed from the surface, and the instruments are boiled, dried, and laid aside. Well-made -flexible catheters can be boiled in water. Additions to the water have been suggested, such as chloride of soda (40 per cent.) and ammonium sulphate (10-12 per cent.), with the view of preserving the surface of the catheter. They should be boiled from two to five minutes and then carefully placed in cold sterile water, or l-in-80 carbolic, or l-in-4,000 biniodide of mercury, or after removal from the sterilizer they may be placed upon a dry xxvi] STERILIZATION OF CATHETERS 355 sterile towel and allowed to cool. They must not be grasped with forceps in removing them from the sterilizer. A convenient form of sterilizer is that introduced by Zucker- kandl (Fig. 99). Tiiis compact apparatus is portable and durable. Another sterilizer for flexible catheters has been introduced by Herring. In this the catheter is boiled in liquid paraffin in a straight tube, which is then detached and the ends closed, so that the tube acts as a carrier. After use, flexible catheters should be washed inside and out to remove grease, blood-clot, etc., then boiled for two minutes, and carefully dried and put away dry. It is better to leave catheters exposed on a tray until they are thoroughly dry than to store them at once. Grlass tubes for storing and carrying catheters should be open Fig. 99. — Zuckerkandl's catheter sterilizen at both ends, to facilitate cleaning and drying. Flexible catheters should be wiped with a little oil or dusted with lycopodium powder before being put away. Formalin vapour is employed for the sterilization of flexible catheters, and is especially useful when a large number of instru- ments must be sterilized. At St. Peter's Hospital a large oblong copper box is used. This contains perforated trays which hold several hundred catheters. On the floor of the box is a cup-shaped depression in which fluid formalin is placed. The box is closed and a lamp burns under the cup until the formalin has evaporated. The box is kept closed for two hours, and then air, filtered through cotton-wool, is pumped through to remove the irritating fumes. Boxes on a smaller scale can be obtained for formalin sterilization. For single catheters, a glass-stoppered tube, within which is a box perforated on the inside and containing a granular preparation of formalin, may be used. The efficiency .of these tubes as sterilizers 356 THE BLADDER [chap. ig very doubtful, and moisture tends to collect on the catheter and destroys its surface. Rubber catheters can be boiled, and should be stored dry after carefully removing any oil or grease. For the convenience of patients who are compelled to pass a catheter upon themselves, small round sterilizable metal boxes with a receptacle for oil or vaseline are constructed. (Fig. 100.) Lubricants should be sterile and non-irritating. Liquid paraffin, sterilized olive oil, and vaseline are the best. Impregnation with powerful antiseptics should be avoided. Many elegant preparations are manufactured. In using metal bougies, especially those of large size, vaseline is the best lubricant. The following formula may be employed : Cocainae hydrochloridi 5 gr., olei eucalypti 10 minims, adrenalin (1 in 1,000) 20 minims, olei ricini J oz., olei olivee | oz. Method of passing cath- eters. — The passage of a catheter must be regarded as an opera- tion of the first magnitude. The danger to the patient of infection introduced by the catheter is as great as that incurred by the infection of the peritoneum in an abdominal operation. The disastrous effects may not have their full fruition at once, but the ultimate result is none the less certain. It is true that a healthy bladder is able to deal with bacteria introduced in large numbers by a dirty catheter, no harm ensuing, or only a transient cystitis ; it is also true that some patients with enlarged prostate use no antiseptic precautions and go for many years unscathed — most rural practitioners are able to relate such a case from experience or hearsay. These facts give a sense of false security, and are the cause of many surgical dis- asters. In the. bladder obstructed by an enlarged prostate, or the seat of tuberculosis or other disease, bacteria find a ready soil, and the prognosis in these cases becomes immeasurably graver if sepsis is introduced. It is impossible to ascertain the remote mortality of septic catheterization ; but the rate is very high. Passage of a metal instrument. — The patient is recumbent in bed or on a couch, with the abdomen and thighs well exposed and Scale z Fig. 100. — ^Sterilizable catheter box. XXVI] PASSAGE OF CATHETER 357 sterilized towels placed across the knees and thorax. The surgeon stands on his left side. The penis is washed with antiseptic solu- tion and the meatus carefully cleansed. An instrument is selected and well lubricated. The penis is grasped behind the glans with the forefinger and thumb of the left hand, and the tip of the in- strument inserted into the meatus. The shaft of the instrument lies transversely across the patient's left Scarpa's triangle. The handle of the instrument is now carried gently towards the patient's abdomen and onwards to the middle line so that the point drops downwards and backwards. (Fig. 101.) During this manoeuvre the left forefinger and thumb draw the penis on to the instrument like a glove. The handle is lightly held between the right forefinger and thumb and gently raised, and the shghtest hitch receives instant attention. (Fig. 102.1 As the point passes down the bulbous urethra the left hand leaves the penis and the fingers are used to support the perineum. The point passes into the membranous urethra as the handle becomes vertical (Fig. 103) and swings downwards, and the left forefinger and thumb replace the right while the handle is gently depressed between the thighs and pushed onwards (Fig. 104), The point of the instrument should move freely from side to side if it is in the bladder. Instead of swinging the handle of the catheter to the middle line, it is sometimes easier to carry it in the opposite direction so that it crosses the middle line below the scrotum, and then to carry it across the right Scarpa's triangle to the middle line of the abdomen, gradually raising it so that the point drops downwards along the urethra. Passage of a flexible catheter. — In passing flexible catheters it must be remembered that the surgeon has little power of changing the direction of the point of the instrument, and the passage of a straight instrument into the membranous urethra depends upon its pliability. The penis is grasped behind the glans by the thumb and forefinger of the left hand, and kept on the stretch to render the urethra straight and obhterate the folds in its walls. The instrument is introduced vertically, and lightly held by the corresponding digits of the right hand and pushed carefully onwards until it reaches the bladder, which is recognized by the escape of urine. Sounding the bladder. — Six ounces of sterile fluid are intro- duced into the bladder through a catheter. The instrument is passed in vertically until the beak reaches the membranous urethra, when the handle is slowly lowered in the middle line until it drops between the thighs, and then pushed onwards. It may assist the passage of the instrument to raise the patient's 358 THE BLADDER [chap. Fig. 101. — Passing metal instrument. Position 1 : Beakiin anterior urethra, shaft lying parallel to left Poupart's ligament. Fig. 102. — Passing metal instrument. Position 2: Shaft swung to middle line, beak in bulbous uiethra. XXVI] PASSING METAL INSTRUMENT 359 Fig. 103. — Passing metal instrument. Position 3 : Shaft vertical, fingers of left hand on perineum, beak engaged in membranous urethra. ^ I Fig. 104. — Passing metal instrument. Position 4 : Shaft depressed between thighs by left hand, beak in bladder, right hand pressing on pubes to relax suspensory ligament. 360 THE BLADDER [chap. pelvis on a sand pillow. The sound should be passed as far as possible in the middle line, and the handle, held lightly in the right thumb and forefinger, turned on one side and again upwards ; and this is repeated, gradually drawing the instrument out until it reaches the internal urethral orifice, on which it hitches. It is now passed in again in the middle line, and the other side of the bladder searched in the same way. Finally, the beak is turned downwards and the post-trigonal or post-prostatic area searched. In manipulating the instrument the grating or click of a stone in the urethra or projecting from the prostate may be felt. 6. Exploration. — Exploration of the female bladder with the finger after dilatation of the urethra is an unsatisfactory method of examination. Only the terminal phalanx of the finger can ^e introduced, and by pushing the bladder down from above the pubes with the other hand a part of the superior wall can be palpated. Permanent incontinence of urine has frequently followed this procedure, which has now been entirely superseded by cystoscopic examination. It is sometimes necessary, when the bladder has become filled with blood clot and cystoscopy has been found impossible, to explore the bladder by a cutting operation. In growths of the bladder information is also gained respecting the base of the growth which may not be obtainable by cystoscopy. In such cases the bladder should be opened suprapubically and the patient placed in the Trendelenburg position. By means of full exposure, by bladder retractors and the use of a head-lamp, the interior of the bladder can be thoroughly searched. The perineal route in the male and the vaginal route in the female are unsatis- factory and inadequate methods of exploration. 7. Radiogfraphy. — For the radiographic examination of the bladder, as of the kidneys and ureters, it is necessary to employ a fixed position which can be repeated with mathematical exact- ,ness at a future examination. Estimation of the position of the pelvic organs depends entirely upon the relation to the pelvis, a bony ring tilted at an angle. Unless some means of obtaining 'uniformity be employed the variation in different individuals, and in the same individual in different examinations, will be very great {see pp. 37, 305). In the radiographic plate the brim of the bony pelvis should be shown. A normal bladder and prostate sometimes throw a shadow in a good plate. The prostatic shadow lies behind the pubic sym- physis and the pubic bones. It does not project below the symphysis, but may rise very slightly above it. The lateral extent of the prostatic shadow varies, but it seldom extends laterally Fig. 1. — Shadow thrown by partly distended healthy bladder. (P. 361.) Fig. 2. — Shadow of greatly distended bladder (uppermost arrow) and of diverticulum (middle arrow) ; catheter lying in urethra (lowest arrow). (P. 361.) Fig. 3. — Shadow of ureteral calculus in middle line of bladder. (P. 361.) Plate 27. Fig. 1, — Shadow of phosphatic calculus In bladder pushed to right of middle line by large growth on left side of bladder. (P. 361. ) Figs. 2, 3. — Calculus in bladder which has moved to the left of middle line from patient lying on left side. (P. 361.) Plate 28. XXVI] RADIOGRAPHY OF BLADDER 361 beyond the middle of the pubic bones. The shape of the shadow thrown by the bladder varies according to its distension. The lower border of the shadow nearly corresponds to the upper margin of the pubic portion of the pelvic girdle. In moderate distension the bladder has an oval shape with the long axis placed trans- versely. (Plate 27, Fig. 1.) In full distension the shadow is more rounded and extends farther back towards the promontory of the sacrum. The lateral limits of the bladder in moderate distension do not pass beyond a vertical line drawn through the middle of the obturator foramen, and the posterior limit rather more than half-way to the promontory. If the bladder is distended with air a clear area appears on the plate. Radiographic examination of the bladder is chiefly useful in stone and in diverticula of the bladder. A stone shadow in the bladder area may be thrown by a stone in the bladder, a stone in a diverticulum (Plate 29, Fig. 2), or a stone in the lower ureter. It is seldom possible by a radiographic examination alone to distinguish between these conditions. In Plate 27, Fig. 3, the round shadow in the middle line was thrown by a calculus which the cystoscope showed lay in the lower end of a solitary ureter opening in the middle of the distorted trigone. At a later date a radiogram showed the shadow in the middle line, and after water had been passed another radiogram showed that the shadow had moved considerably to the left, demonstrating that the calculus was free in the bladder. (Plate 28, Figs. 2, 3.) In another case (Plate 29, Fig. 1) the shadow appears in the bladder area, but the calculus lay in a large diverticulum that opened into the bladder by an aperture which would admit a lead pencil. In a third case a large shadow lay on the left side of the bladder area, and on cystoscopy there was a stone on the left and a papillomatous growth on the right side of the bladder. (Plate 28, Fig. 1.) A stone shadow constantly found in one position, not in the middle line, on several examinations, with varying distension of the bladder, is more likely to be thrown by a stone in the ureter or in a diverticulum than in the bladder, or the stone may be pushed to one side by a growth. Even when the shadow lies in the middle line it is not certain that the stone lies within the bladder, as the cases quoted above show. Diverticula are demonstrated by filling the bladder with an emulsion of oxychloride of bismuth. The catheter, filled with the bismuth emulsion, should be left in the urethra during the radio- graphic examination to act as a guide, as the bladder is frequently distorted in these cases. (Plate 27, Fig. 2, and Plate 29, Fig. 3.) 362 THE BLADDER [chap. 8. Cystoscopy. — There are two methods of cystoscopy — (1) indirect, (2) direct. 1. Indirect cystoscopy. — The indirect method is carried out by means of a cystoscope after distension of the bladder with fluid. (a) Simple cystoscope. — The simplest form of cystoscope, of which Nitze's was the original model, consists of a telescope and a lighting apparatus combined. The instrument is 20 cm. long and has a calibre of 21 Charriere. At the distal end there is a short beak formed by a small detach- able electric lamp which may have a metal or carbon filament. The shaft of the instrument consists of a double tube, between the layers of which is an insulated wire carrying the current and returned along the body of the instrument. At the proximal end is a double slot for the movable attachment which carries the Scale 3 Fig. 105. — Author's irrigation cystoscope. current and on which is the switch. The ocular apparatus con- sists of a prism window and a mirror that reflects the image along the tube, in which is a series of lenses. The proximal end is expanded, and on to this may be screwed an eye-piece. For use in children a small-calibre (15 Fr.) cystoscope is used. The current is supplied by a small accumulator or a dry cell giving about 4J volts. The image is inverted. (6) Irrigation cystoscope. — In the irrigation cystoscope the outer tube acts as a catheter and carries the lighting apparatus. At the proximal end of this there is a valve to prevent the fluid escaping. The telescope is separate, and is pushed along the lumen of the catheter. In the author's pattern (Fig. 105) the outer catheter and lighting tube can be boiled. At the proximal end of this is a valve which acts by a spring placed outside the lumen and may also be used as a turncock. The telescope, which is made by Zeiss, gives an erect image. The advantages of an irrigating "O w W T3 ■T3 c '5 a '■5 C ^^ o c u ■^ r* o 'x o -a « •OC ■" "5 ■a ■a c E s c o c; « '"' a > c ■*-• o o o 3 E T3 -a 2 3 E « u <*< o u C3 e o ,^ j: ^ 3 ro S 3 "5 p u "B '5 ^ •^ 3 .s c o u nO X c ^ (T) >■ V 0) « d Q ■^ 0) O 3 0^ fc g O 3 §• i's 2 1 i 'Z O 4) CS o o — . -a ^• .S "B 'E g "rt • - fe o ^- c/5 'C X •a si u 3 2 r5 a CO « ^1- Si a ft -a ^ 3 JO o v< CS d) J3 C« XXVI] CYSTOSCOPY 363 cystoscope are that only one introduction of the instrument is necessary, and that the bladder can be washed repeatedly by with- drawing the telescope and without removing the outer tube from the urethra. (c) In the catheter cystoscope provision is made for catheterizing the ureters. In the simplest form a tunnel is placed on the upper surface of the simple cystoscope. This opens just short of the window, and at the end is provided with a small movable gutter which can be raised by turning a screw at the proximal end of the cystoscope and serves to project the point of the ureteric catheter away from the line of the cystoscope, facilitating its introduction into the ureter. Either one channel or two are provided, for single or double catheterization of the ureters. The more recent models combine the catheterizing and irrigat- ing cystoscope, and a very useful instrument is thus obtained. Method of performing indirect cystoscopy. — The cystoscope is cleansed with ether soap and carbolic lotion, or, if the author's pattern is used, it is boiled. The patient either lies on a couch with a sand pillow beneath the hips, or sits in a special chair with the knees and hips flexed and the thighs widely apart. The urethra is anaesthetized • by instilling 15 minims of a 4 per cent, solution of novocaine into the prostatic urethra by means of a Gruyon's syringe, or by a combination of alypin with suprarenin — tablets of alypin 0-02 grm. (| gr.), suprarenin boric 2 minims of solution in 1,000. A catheter, or the catheter portion of the irrigation cystoscope, is lubricated with glycerine and introduced, and the bladder filled with 10 or 12 oz. of warm boric solution or sterile water. The " telescope " is now introduced, the light switched on, and the window turned to the base of the bladder. Air or oxygen has been used instead of water, but both have many disadvantages. There may be difficulty in obtaining a clear medium owing to haemorrhage from the bladder or the prostate. Careful washing with sterile water or very weak nitrate of silver solution (1 in 10,000) will usually overcome this. In persistent bleeding adrenalin may be used. I inject J drachm of quarter-strength 1 -in- 1.000 solution of adrenalin, and leave it in for a half to one minute, and then wash it out. If the urine be purulent, prolonged washing may be necessary before a clear medium is obtained. Spasm of the bladder may prevent a full distension ; this may be due to using cold solution or injecting it too rapidly, or to cystitis. If it be due to cystitis, local anaesthesia may be obtained by washing the bladder with a 5 per cent, solution of antipyrin. A general anaesthetic may be necessary. 364 THE BLADDER [chap. 2. Direct cystoscopy (the open method). — This method was perfected by Kelly,, and has been modified by Luys and others. Kelly's specula (Fig. 106) are plated metal cyHnders, 3J in. long, and of the same diameter throughout. There is a funnelr shaped expansion at the outer end of the speculum, and a handle 3 in. long is attached to the funnel. The specula are made in various sizes, from 5 to 20, each number representing the diameter in millimetres. Each instrument has an obturator, which is used during introduction. A dilator is used to enlarge the orifice of the urethra (Fig. 107), and an evacuator to remove the urine which accumulates in the bladder during a prolonged examina- tion. It consists of a rubber exhausting bulb and 14 in. of fine Fig. 106. Kelly's speculum. Fig. 107. Kelly's dilator. rubber tubing, and at the bladder end a small hollow perforated metal ball. The lower bowel is emptied, and immediately before the exam- ination the bladder is emptied in a sitting or standing position. General anaesthesia is necessary in nervous individuals. Local anaesthesia is obtained by cocaine introduced on pledgets of wool. Two positions are used — (a) the elevated dorsal, (6) the knee- chest, (a) The dorsal position is the less trying to the patient, but it is only of service in thin patients, and the atmospheric expansion of the bladder is not so good. The bladder of stout patients will rarely distend at all in this position. The buttocks are raised 8 or 12 in. above the table level, the speculum is introduced, the obturator is withdrawn, and the atmospheric pressure distends the bladder. (6) In the knee-chest position the patient kneels, with the knees slightly separated, close to the end of the table, and lets the back curve in with the buttocks well xaised. XXVI] CYSTOSCOPY 365 If an anaesthetic is required the patient may be held by assist- ants, or a slinging apparatus may be used. The speculum is introduced, the obturator withdrawn, and light projected through it from a forehead mirror reflecting lamp, or from an electric lamp held over the sacrum. After an examina- tion the bladder is emptied by introducing a catheter and gently lowering the patient to the horizontal. Kelly's method is only applicable to the female, and the posi- tion is an exhausting and embarrassing one. Luys has modified this method, and uses it in the male also. His instrument consists of a metal tube of 10 cm. for the female and 18 cm. for the male. On the floor of the tube is a fine tunnel leading to a small tube to which a rubber tube and aspirator bottle are attached, and which prevents the accumulation of urine in the bladder. The plunger that closes the tube during introduction is straight in the instrument for the female, and angled in that for the male. The patient is placed in the Trendelenburg position, with local or, preferably, general anaesthesia. It is not always possible to obtain complete distension of the bladder, and there are folds and depressions in the mucous mem- brane. An area at the apex, the anterior and part of the lateral walls, are inaccessible to examination. As a method of examination, direct cystoscopy is inferior to indirect. With the tube a small area of the bladder wall is seen, and the instrument must approach it closely in order to get a good view. With the indirect cystoscope an extensive field is displayed and a broad bird's-eye view can be obtained. The advantage of the direct or open method is the facility it presents for topical applications in cystitis, for operations on small papillomas, and for the removal of foreign bodies from the bladder. Cystoscopic appearance of the normal bladder. — When the cystoscope is introduced the beak is turned downwards and the trigone comes into view. This is examined, and the inter- ureteric bar at the base of the trigone recognized and followed out on either side, and the ureteric orifices noted. Then the posterior wall and the lateral walls, and finally the anterior wall and the apex, are examined. A portion of the posterior wall near the apex is difficult to see, and the ocular end of the instrument must be fully depressed so as to tilt the window upwards and bring it into view. The ante- rior wall rises almost vertically from the urethral orifice, and the window of the cystoscope looks along it. The mucous membrane is smooth and sandy-yellow, and it 366 THE BLADDER [chap, xxvi reflects the light so that the whole viscus is easily illuminated. Fine vascular twigs appear here and there, and branch freely. Their number varies greatly in different healthy individuals. Larger vessels of a blue colour are usually seen here and there shining through from the deeper layers of the mucosa. The mucous membrane of the trigone is coarser and darker in hue. The vessels are larger, and pass in a fan-shaped arrangement from the urethral orifice, overlapping the sides and the base of the trigone. The ureteric orifices are seen as fine pink slits on the ridge at the base of the trigone, and are found by following this ridge (the bar of Mercier) outwards on either side. One or two small blood-vessels emerge from the ureteric orifice and pass outwards and backwards. At the apex of the bladder there is usually a small bubble of air which has been introduced during the washing of the bladder. The urethral orifice is seen by withdrawing the window until it is partly in the prostatic urethra. It has a slightly concave, even contour all round. CHAPTER XXVII METHODS OF COLLECTING THE URINE AND EXAMINING THE FUNCTION OF EACH KIDNEY At the present time two methods are available for collecting the urine of each kidney separately : L The use of separators. 2. Catheterization of the ureters. L Intravesical separation of the urines. — Two models of separator are in use, those of Luys and Cathelin. Lulls' separator (Fig. 108) consists of a shank and a handle. The shank has a central metal stem, mth a metal catheter fitted on each side. The distal end of the shank is curved to the extent of about half a circle, the curve lying below the straight portion of the shank. Attached to the end of the central flattened stem is a fine chain, which, when loose, lies snugly in the concavity of the curve. When drawn tight by a screw in the handle this chain bridges across the half-circle curve like the string of a bow. A fine rubber tube fits over the whole of the median stem. With the chain slack the rubber-covered central stem retains its pecuhar curve ; with the chain taut the half-circle curve is filled in by a rubber membrane, forming a septum which divides the bladder in two parts. The metal catheters fit on each side of the central stem, and open one on each side of the membrane at the depth of the curve. At the handle of the instrument they curve out- wards as fine tubes over two movable glass receptacles. In Cathelin' s separator the shaft is straight with a small curved beak. Concealed within the shaft is a membrane stretched on a spring hasp. When the membrane is projected by pushing in the shank the spring frame expands and a membranous di\asion is formed. On each side small catheters project and drain each compartment of the bladder thus produced. IVIethod of using separators. — The instrumeiit is prepared by adjusting the membrane and lubricating it. The patient lies on the back on an operating chair. The bladder is washed until the fluid returned into a glass vessel is clear. From 6-8 oz. of 367 368 THE BLADDER [chap. fluid are allowed to remain in the bladder. A 1 per cent, solution of cocaine hydrochlorate, 15 or 20 minims, is injected into the urethra. In the female the instrument is readily passed into the bladder ; in the male the Luys separator passes easily until the Fig. 108. — Luys' separator. A, Shank and handle ; the rubber membrane has been drawn over the curve and shank, conceal- ing the chain in the concavity of the curve. B, B, Metal catheters. C, Cap to unite shank with catheters. D, Component parts adjusted ready for introduction. E, Curve of instrument with chain drawn taut and separating membrane expanded. curve lies in the prostatic urethra. The handle is now depressed deeply between the thighs and pushed gently onwards. The patient is gently raised into a sitting posture, and the instrument is drawn towards the surgeon and held in the median line of the xxviij CATHETERIZATION OF URETERS 309 body with a slight upward inclination. The screw is now turned and the chain rendered taut, forniing the membranous septum in the bladder. A rectal or vaginal examination is made, to ensure that the instrument is in position. The first fluid is discarded, the tubes are placed in position, and the examination is continued Fig. 109. — Author's catheterizing cystoscope. for twenty-five minutes. In the case of Cathelin's instrument the introduction is easier, and the instrument is pulled towards the operator until the beak fits against the pubes. The membranous septum is then projected. 2. Catheterization of the ureters. — Many catheter cysto- scopes are in use. Those of Nitze, Casper, Albarran, Freudenberg, Ringleb, and Israel are well known and reliable. The instruments have already been described. My pattern (Fig. 109) has the same valve as my irrigation cystoscope. Ureteral catheters are 30 in. long, and are of different sizes, varying from No. 5 to No. 8 Charriere. The end may be blunt or conical, or may have a fine Fig. 110.^ — -Author's ureteral catheters. olivary bulb. There are two lateral eyes, or the eye may be terminal. Albarran's catheter has a slightly thicker part proximal to the second eye, to prevent the escape of urine alongside the catheter. My own catheters (Fig. 110) are graduated in divisions of black and brown of | in. each, and a narrow red band marks each 6 in. The end is blunt or olivary, the eyes are lateral. Y 370 THE BLADDER [chap. There is a slight thickening proximal to the second eye. The proximal end is obliquely cut, but is not trumpet-shaped, as it must pass through the tunnel of the cystoscope. The catheters are sterilized by cleaning them with biniodide of mercury solution (1 in 1,000) and thoroughly syringing with the same solution before and after use with a special fine nozzle syringe which fits the catheter (Fig. 111). Before laying the catheter aside it is rubbed with a trace of sterile oil, and a little oil is injected through it to prevent cracking. The catheters should be kept in enamelled tin trays or in long glass tubes open at both ends. A general anaesthetic is unnecessary unless in the case of a con- tracted tender bladder, such as may be met with in tuberculous disease. Local ansesthesia and the preparation of the bladder are the same as for cystoscopy. The amount of distension of the bladder for catheterization of the ureters is the same. It is some- times necessary in an irritable contracted bladder to catheterize s sg. L LM' _ AKiJJl Y c Fig. 111. — Author's syringe for washing out ureteral catheters. the ureters with a small quantity of fluid in the bladder. I have occasionally had to be content with between 2 and 3 oz. of fluid. The cystoscope should be loaded with a catheter before it is introduced, but the point of the catheter must not project from the tunnel. On the bladder being reached, the beak is turned downwards, the light switched on, and the interureteric bar comes into view. This is followed outwards on one or the other side by rotating the instrument, when the slit-like opening of the ureter comes into view. The ocular end of the instrument is now carried towards the opposite thigh, and the window and catheter opening travels towards the ureteric orifice. (Fig. 112.) The catheter is projected so that the point lies about the middle of the field of vision. The catheter is then manoeuvred as close to the orifice as possible, and finally the elevating gutter raised by a touch of the screw, the point of the catheter sinking between the lips of the opening and being slowly and gently pushed on. (Fig. 113.) When the catheter has passed a few inches up the ureter the elevator is lowered, and the catheter glides more easily. The catheter should be passed into the renal pelvis. xxvii] CATHETERIZATION OF URETERS 371 which is reached when the double red band indicating 12 in. hes at the ureteric orifice. If it is intended to catheterize both ureters and a double-barrelled cystoscope is being used, the second catheter is now introduced ; or if a single-barrelled cystoscope is being used, this is withdrawn — leaving the first catheter in posi- tion — reloaded, and introduced, and the second ureter catheter- ized. Each catheter is fixed with a piece of adhesive plaster to the thigh of the side to which it belongs, and it drains into a sterilized bottle labelled " right " or " left." By Kelly's open method the ureteric catheters are introduced direct through the large tube. The ureter may also be sounded by passing a catheter to ascer- tain if any obstruction exists ; or a solid opaque bougie may be Fig. 112. — ^Gatheter approach- Fig. 113. — Catheter lying in ing ureteric orifice. ureter. passed up the . ureter in order to differentiate by means of the X-rays between stone in the ureter and extra-ureteral shadows. Kelly has suggested the passage of a bougie tipped with wax which will receive scratches apparent to the naked eye from the rough surface of a calculus. This method cannot be used with the indirect method of catheterization of the ureters, as the wax would be scratched in the tunnel of the cystoscope. Difficulties, such as temporary cessation of function of the kidney due to the catheterization, blocking of the catheter with blood clot, thick pus, or even gravel, inaccessibility of the ureter, smallness of the ureteric orifice, or enlarged or tuberculous pros- tate, may be met with, but are less formidable as greater expe- rience is gained. With proper precautions there is no danger of infecting the ureter and kidney. 372 THE BLADDER [chap. Choice of an instrument for separation of the urines. 1. Ease of application. — The separator is more easily introduced than the ureteral catheter. It is imperative, however, to make a cystoscopic examination before using the separator, so as to ascer- tain that the bladder is healthy. 2. Danger of infecting the kidneys. — In proper hands there is no danger of infection of the renal pelvis and kidney by a catheter. 3. Accuracy of separation. — The ureteral catheter is more accurate than the separator in obtaining the uncontaminated urine from one kidney. The results of the examination are so important that the surgeon cannot accept any report on which a doubt can be cast. 4. Duration of the examination. — The separation can only be borne for twenty minutes or half an hour, and cannot, therefore, be used for the majority of the tests for the renal function. The ureteric catheter can be left in position for four or five hours without discomfort. Catheterization of the ureters is the method which has been most widely adopted. Its accuracy is greater and its sphere of usefulness far wider than that of the separator, which it has now entirely superseded. Examination of the urine of each kidney. — In cases of slight pyuria or hsematuria,, where the bladder is healthy and there is no indication as to which side is aiiected, it is often impossible to detect a slight cloudiness of the efflux with the cystoscope. Examination of the urine drawn by catheter from each kidney will localize the disease in these cases. In disease of one kidney, when nephrectomy is proposed, the presence of a second kidney and its health and functional power are ascer- tained by the same method. In examining the urines of the two kidneys, one may be normal and act as a standard of comparison for the other, or there may be signs of disease in each. The quantity of urine is occasionally reduced by the presence of the catheter in the ureter. This is usually temporary, and can be avoided by giving a diuretic before the examination. The quantity may be reduced or the urine be absent on one side from blocking of the ureter or advanced disease of the kidney. There may be polyuria on the diseased side in conditions of cystitis such as early renal tuberculosis. The urine should be examined for blood, pus, epithelial elements, and crystals, and also for bacteria. The renal function is tested by the methods already described. Those suitable for the examination of one kidney are the quanti- XXVII] EXAMINATION OF EACH URINE 373 tative estimation ot urea, Casper's phloridzin test, Albarran's ex- perimental polyuria test, and the pJK'nol-sulj)liono-phthaleiii test. I use the phloridzin and phenol-suiphone-phthalein tests, and retain the catheters for two or three hours. The details of the tests of the renal function have been already described (p. 20). The following table gives the results of the examination of the urine of each kidney in a case in which nephrectomy was performed for advanced calculous disease of the right kidney : — BIGHT KIDNEY LEFT KIDNEY Quantity 206-5 c.c. 107 C.C. Specific gravity 1004. 1011. Freezing-point (a) -018 C. -0-76 C. Colour . . Pale, limpid. Fairly coloured. Urea 0-4 per cent. 1-3 per cent. Uric acid 0-0067 per cent. 00150 per cent. Chlorides as chlorine . . 0-09777 per cent. 01 112 per cent. Phosphates as P2O5 . . 0-08 per cent. 0-034 per cent. Methylene blue . . No change in colour. Appeared in 1 hour 50 minutes, green colour, duration 18 hours. Chromogen Appeared in 25 min- Appeared in 25 min- utes, faint green. utes, deep green. Phloridzin glycosuria . . 0-395 grm. 1-623 grm. The following is a report on a case in which nephrectomy was performed for tuberculosis of the left kidney : — EIGHT KIDNEY LEFT KIDNEY Total quantity . . Specific gravity Urea Phloridzin glycosuria 3 oz. 1018. 1-4 per cent. 2-81 grm. No tubercle bacilli. 8 oz. 1006. 0-3 per cent. Absent. Tubercle bacilli LITERATURE Albarran, Exploration des Fonctions Renales. 1905. Casper und Richter, Functionelle Nierendiagnostik. 1901. Kapsammer, Nierendiagnostik und Nierenchirurgie. 1907. Walker, Thomson, Renal Function in Urinary Surgery. 1908. CHAPTER XXVIII VESICAL SYMPTOMS OF DISEASE HEMATURIA and pyuria have already been discussed [see pp. 55, 62). Frequent Micturition Increased frequency of micturition may be a symptom in almost any disease of the bladder, and is observed also in many extra vesical diseases. The normal frequency of micturition varies in different indi- viduals, and in the same individual under varying conditions. The female bladder, by habit, is emptied less frequently than the male. The average number of micturitions during the day is three or four in the female and four to six in the male. During the night there is no call to micturate, partly from training and partly from the smaller quantity of urine secreted. Some healthy individuals, however, rise once during the night to pass water. This may be the continuation of a habit acquired in early life, or it may be the functional sequence of some pathological condition of the bladder, the organic disease having long passed off. The senile bladder is less sensitive, and micturition is usually performed less frequently than in earlier life. In old men increased diurnal frequency and the necessity for nocturnal micturition are signs of disease. In the tropics urine is passed less frequently than in cold climates, owing to the smaller quantity secreted. On return- ing from the tropics to the temperate zone, frequent micturition is usually observed. It may be distressing, and occasionally persists for some years. An Indian civil servant has told me that for over two years after returning to England from India he and his wife were unable to accept an invitation to dinner on account of frequent micturition. For convenience of de- scription, frequency of micturition will be considered under four headings : 1. Frequency of polyuria. — In diabetes mellitus, diabetes insipidus, chronic Bright' s disease, chronic interstitial nephritis from obstructive disease, nervous polyuria, and in the transient forms of polyuria such as those due to diuretics (tea, etc.), there 374 CHAP. XXVIII] FREQUENT MICTURITION 375 is increased frecjuency of inicturitioii. The increased frequeocy is nocturnal as well as diurnal. In nephritis from obstructive dis- ease the nocturnal frequency is especially marked. The quantity of the urine and the presence of abnormalities such as sugar or albumin render the diagnosis obvious. 2. Frequency with normal urine and bladder. — The mental state may affect the frequency of micturition. Fear and excite- ment may, apart from the production of polyuria, cause frequency. Prolonged intense concentration may reduce frequency. When disease of the bladder is present mental influences still affect the frequency of micturition. A patient with frequent micturition due to disease may have prolonged intervals when his attention is fully occupied, and shorter intervals when there is nothing to distract his attention from the calls to micturate. Reflex frequency may be caused by disease of the kidneys. It is difficult to dissociate this from irritation of the bladder by descending ureteritis or by irritating urine. In early tuber- culosis of the kidney, as well as in some cases of movable kidney and calculus, there is ground for believing that an increased fre- quency of micturition may be reflex, for the cystoscopic appear- ance of the bladder and .ureteric orifices is normal. In other and advanced diseases of the kidney and ureter, such as pyelonephritis, stone, tuberculosis of the kidney and ureter, inflammation of the bladder base is present and is the cause of the frequency. In such cases the diagnosis as to the presence or absence of bladder disease is made by means of the cystoscope. Reflex frequency of micturition may have its source in rectal irritation caused by worms, a condition which is often the cause of enuresis in children. In cases of rectal, anal, or vulvar irrita- tion increased frequency of micturition is often due, not to reflex influences, but to a mild form of cystitis, with or without bacilluria, or there may be some disease such as diabetes. Pressure on a normal bladder from without causes frequent micturition by reducing its capacity. Frequency is sometimes a marked and distressing symptom in the later months of preg- nancy, and is generally associated with an abnormal position of the foetus (retroversion). I have been consulted in regard to persistent frequency in a young lady which I found was due to the pressure of a large ovarian cyst. 3. Frequency due to irritating urine. — Apart from other causes the urine may cause irritability in a healthy bladder. Blood poured out suddenly and in quantity may cause frequent micturition ; usually, however, no change is caused by hsema- turia in the frequency of micturition. Where clots are formed 376 THE BLADDER [chap. they may act as foreign bodies and give rise to frequency. It is more usual to find that, beyond a temporary difficulty during the passage of the clot along the urethra, the patient is unaware of any irritation. When the urine is highly acid, when it contains abundance of oxalate-of-lime crystals, or is milky with phosphates, extreme irritability of the bladder is present. In any of these states of the urine, but especially in phosphaturia, the irritability of the bladder is intermittent. It is more pronounced at certain times of the day ; in phosphaturia it is often worse after dinner. Bacil- luria may be the cause of persistent frequency without other symptoms. 4. Frequency from disease of bladder, prostate, or urethra. — The frequency in mild cystitis is diurnal, but in severe cystitis it is also nocturnal, and the patient passes water at regularly spaced intervals of half to one or two hours day and night, accord- ing to the intensity of the inflammation and its distribution in the bladder. The frequency is unaffected by movement, but the intervals may be longer when the attention of the patient is held by other matters. In new growth frequent micturition, if present, is due to cystitis and has the characters already described. The frequency due to stone in the bladder is characteristic. It is present during the day and disappears at night or on resting. Movements and exercise, or travelling by train or motor-car, increase the frequency. If there be severe cystitis the frequency is present at night as well as during the day. In enlarged prostate there is an increase in the diurnal frequency, and the patient rises once or several times during the night. The first four or five hours of the night are usually undisturbed, and then the patient wakes at three or four o'clock and passes water, and this is repeated several times at short intervals. Movement and exercise have no effect upon prostatic frequency. The frequency which results from urethritis of the prostatic urethra usually accompanies a urethral discharge. It is diurnal, and occasionally nocturnal, in character. Frequent micturition due to nervous disease will be considered later. Treatment. — The treatment of frequent micturition depends upon the cause, and the reader is referred to the various diseases which produce increased frequency of micturition for the lines along which treatment should be conducted. When the frequency is unconnected with any pathological condition of the urine or bladder, the prognosis for complete recovery is good only in mild cases. Washing the bladder with weak nitrate of silver solution XXVIII] INCONTINENCE OF URINE 377 (1 in 10,000) or with a 5 per cent, solution of antipyrin, or gradual dilatation by the injection of progressively increasing quantities of fluid, may be tried, or instillations of silver nitrate solution (1 or 2 per cent.) into the deeper part of the urethra, or of cocaine (1 per cent.) or other local anaesthetic, may be given at intervals of a week. Gomenol may be instilled in small quantities (1 or 2 drachms of 5 or 10 per cent.) once or twice a week. Electricity in the form of X-rays or high-frequency currents or radiant heat has been employed, but is rarely successful. Treat- ment by suggestion may be tried in severe cases. The following drugs, which should be given with caution when urethral or prostatic obstruction is present, are valuable in reducing frequency, viz. camphor (2 gr. in pill) or camphor monobromide (2-4 .gr. in suppository), cannabis indica (tincture in doses of 5-10 minims, or extract in doses of | gr. in pill), belladonna (tincture, 5-10 minims, extract, i gr., in suppository), coUinsonia canadensis (tincture, |-1 drachm, liquid extract, 1-2 drachms, or as suppository 20 gr.), sandal-wood oil (10 minims in capsule), oil of copaiba (5-15 minims in capsule), hydrastis canadensis (tinc- ture, 30-60 minims), kava-kava (liquid extract, 30-60 minims), argopyrum (decoction, .^1 oz., or liquid extract, 1-2 drachms), hyoscyamus (tincture, 10-15 minims), lupulin (pill containing 2-5 gr., or suppository 5 gr.), lycopodium (tincture, 15-60 minims). When the urine is highly acid, diuretics and alkalis should be administered, such as Contrexeville, Vittel, or Evian waters, acetate or citrate of potash (15-20 gr.), liquor potassse (5-10 minims), and sodium bicarbonate (5-30 gr.). If phosphaturia is present, sodium acid phosphate (20 gr.) and mineral acids should be prescribed {see p. 49). Incontinence of Urine Incontinence consists in the involuntary escape of urine from the bladder, and is due to very widely differing causes. The urine is retained in the bladder by the combined action of the involuntary sphincter at the outlet of the bladder and the voluntary compressor urethras or external sphincter. In infancy the bladder acts in an automatic reflex manner. After a certain quantity of urine has accumulated it is expelled. Towards the end of the first year mental control by inhibition is becoming established, and at the end of the second year the child has learned to intimate the desire to micturate and to exert an inhibiting influence for a certain time during the waking hours. Inhibition of micturition during sleep becomes gradually estab- lished, and under normal conditions and surroundings is complete, 378 THE BLADDER [chap. except for an occasional accident, at the end of the second year. During adult life the voluntary power of inhibiting micturition during waking hours and the unconscious inhibition exercised during sleep are much more powerful and less easily disturbed. Incontinence of urine may be (1) false, (2) true. (1) False incontinence. — ^Here the bladder is full of urine, and the escape is the overflow from the over-distended organ. This is observed in cases of chronic retention due to prostatic or urethral obstruction. (2) In true incontinence the urine which escapes is the entire content of the bladder. Two types can be distinguished : (a) A fassive type, in which the urine dribbles away without distending the bladder and without contraction of the bladder assisting the expulsion. Here the sphincter is paralysed, and to this type belong cases of paralysis of the bladder involving the sphincter, or paralysis of the sphincter by mechanical means. (6) An axitive type, in which the urine is expelled by contraction of the bladder. Here there is sphincter action, but it is either too weak to resist the normal contractions of the bladder or the contractions are so strong as to overcome a normal sphincter. 1. Incontinence due to mechanical causes. — This occurs more frequently in women than in men. A slight occasional escape of urine on coughing, sneezing, or lifting weights, or on exertion of any kind such as playing golf, is sometimes observed in women. In slight cases it may be difl&cult to assign a cause, but it is probably traumatic, for it frequently follows parturition. In older women more serious incontinence occurs in combination with cystocele. When the now obsolete method of examination of the female bladder by dilatation of the urethra and introduction of the finger was in vogue, incontinence of urine from overstretching of the sphincter was commonly observed. Injury sustained during child- birth may cause incontinence. In men perineal prostatectomy may produce incontinence of urine. I have also known it follow perineal drainage of the pros- tatic cavity after suprapubic prostatectomy, being caused by cutting through the compressor urethrae muscle, which acts as the vesical sphincter in these cases. In a few cases (5 per cent.) of malignant disease of the prostate there is incontinence of urine without distension of the bladder. In these cases there is extensive infiltration of the bladder base, and the prostatic urethra is open and rigid. Treatment. — In slight cases in women medicine may suffice. Strychnine (liquor, 5 minims) and ergot (liquid extract, 10-20 XXVIII] INCONTINENCE OF URINE 379 luinims) are the best drugs. The introduction of a pessary may control the escape l)y pressure upon tfie uretlira. In some severe cases operation is necessary. When cystocele is present an ellip- tical portion with the long axis vertical should be removed from the anterior vaginal wall and the edges united. Duret has freed the urethra and excised the mucous mem- brane around its orifice, and transplanted the urethra forwards to the neighbourhood of the clitoris. Gersuny dissects the female urethra with as much surrounding tissue as possible, twists it on its own axis for a complete turn, and fixes it in this position. The urethra is thrown into spiral folds in its whole length. This surgeon has also injected paraffin around the urethra and bladder orifice in incontinence of urine in the female, but the method has not been widely adopted. Where incontinence in the male follows prostatectomy, recovery or improvement may take place by the perineal muscles assuming control. If not, the patient will have to wear a urinal. 2. Incontinence due to nervous disease. — This form of incontinence is considered at p. 532. 3. Incontinence due to bladder spasm. — The somewhat rare form of uncontrollable bladder spasm met with in disease of the spinal cord has already been mentioned. In acute inflammation of the bladder uncontrollable spasm may give rise to active incontinence. This is usually nocturnal, as the patient, worn out by frequent micturition, sleeps heavily and the urine is passed involuntarily. Tuberculosis of the bladder in its advanced stage is the most frequent cause, but other forms of cystitis which persist in a subacute condition may also cause incontinence of this type. Diurnal incontinence from uncontrollable spasm is also met with in the acute stages of cystitis and in acute inflammation of the prostate and prostatic urethra. Treatment. — Means of soothing the bladder should be adopted. In acute cases hot fomentations should be applied suprapubically and on the perineum, and morphia and belladonna suppositories given. The rectum may be washed out with hot water, followed by a small enema of hot water containing anti pyrin (30 gr.) to be retained. The urine should be diluted and rendered less irri- tating by large draughts of Contrexeville or Vittel water, and by the administration of sandal-wood oil (10 minims in capsule). Hot sitz-baths (106°-108° F.) are sometimes useful. In chronic cases diuretics and sandal-wood oil should be ad- ministered and belladonna and hyoscyamus with small doses of opium given in mixture. Gomenol (5 per cent.) may be used as an 380 THE BLADDER [chap. ingtillation (30 to 60 minims) in the bladder and given by mouth in capsules. The treatment of the cystitis is carried out simulta- neously with these measures. In tuberculous cystitis the bladder should not be washed. 4l. Incontinence of childhood (nocturnal enuresis, essen- tial enuresis). — Up to the end of the first year the bladder acts automatically. About that time, as mentioned above, mental con- trol of the act of micturition begins, and by the age of 18 months or at most 2 years it is fairly established. At first the control is feeble and the inhibition can only be exercised for a very short time, and during sleep the automatic action continues. Gradually the control grows stronger and becomes a habit, so that it is exercised during the hours of sleep, although there may still be occasional lapses up to the age of 3 years. After that, constant or frequent bed-wetting must be regarded as abnormal. The period during which the incontinence of childhood occurs extends from the age of 3 to puberty. In 60 per cent, of Still's cases the onset was observed between the ages of 5 and 8 years, when the second dentition commences. Enuresis is usually nocturnal, sometimes it is diurnal as well, rarely it is diurnal only. There may have been a period of a year or more of complete control before the enuresis develops, or the nocturnal control may never have become established. In 142 cases examined by Still, 67 had been incontinent since birth, and in 75 the incontinence began some time after infancy. Boys and girls are about equally affected. Etiology. — i. The cases first to be considered are those in which a source of irritation is found, such as threadworms, anal fissure, vulvitis, phimosis, and balanitis. These cases are looked upon as due to reflex irritation. The relation of phimosis to enuresis is doubtful. The great majority of cases that have come under my notice have already been circumcised in the hope of curing the enuresis, but without any effect upon it. In some cases there are enlarged tonsils and adenoids, and the enuresis is ascribed to partial asphyxia during sleep. The import- ance of this as a causal factor is disputed, but most authorities are agreed that where enlarged tonsils and adenoids are present their removal, or, if small, the use of breathing exercises, should form an adjunct to the treatment of the enuresis. ii. The next group of cases are those in which there is some abnormality in the urine or disease of the bladder. In young children the urine may be highly acid and contain large quantities of uric acid. Phosphaturia also occurs at this age. Bacilluria due xxvin] INCONTINENCE OF CHILDHOOD 381 to the bacillus coli is a common disease of childhood, and explains a small number of cases. Cystitis, stone in the bladder, and tuber- culous cystitis may be found. iii. Finally, there are cases in which no source of irritation and no alteration in the urine or disease of the bladder can be found. These form a class that has been named essential enuresis. There is frequently an heredity of nervous disease which may take the form of epilepsy, neurasthenia, alcoholism, insanity, or other disease. The child may be nervous, quiet, sensitive, and furtive. This is largely, however, due to a feeling of shame, and sometimes to the well-meaning but cruel and utterly futile attempts of parents or guardians to bring about a cure by chastisement. Stuttering and habit spasms are frequently observed, and betray a lack of co-ordination in the nerve centres. In some children there is a slight escape of urine on coughing or exertion, together with nocturnal enuresis. The enuresis is always worse after excitement. It may occur when the child is at school and cease during holidays. In a small number of cases the enuresis occurs during a minor epileptic seizure ; and the possibihty of the patient suffering from fetit mal must .always be remembered. Thursfield points out that in these cases the interval between the bed-wettings is much greater, and may be one or two months, and then several wettings occur in succession. Prognosis. — In cases where an abnormality is found which is amenable to treatment the prognosis for immediate recovery is good. In the great majority of cases of essential enuresis, continence becomes complete with or before the advent of puberty. Most cases get well after two or three months' treatment, but some- times treatment for a year or even longer is required. In a small percentage enuresis persists into adult life. Treatment. — In cases where some reflex influence, such as threadworms, is a factor, this should be treated. The prognosis should, however, be guarded, for the removal of a source of irrita- tion may not be attended by the disappearance of the enuresis. Circumcision is often disappointing in this respect. This operation, and also that for the removal of enlarged tonsils and adenoids, should, nevertheless, always be done as a preliminary to other treatment. Hyperacid urine with uric-acid or oxalate crystals should be treated with alkalis (potass, citrate, 5 or 10 gr. for a child of 3 or 5 years), and the intake of carbohydrates should be cut down. Sugar, starch, green vegetables, potatoes, and fruits should be 382 THE BLADDER [chap. restricted. This is more important than interdicting nitrogenous foods. Phosphaturia is treated with acids and sodium acid phos- phate, and attention to the diet and bowels. Bacilluria, cystitis, and stone should receive appropriate treatment. In cases where all such causes of irritation are absent, treat- ment along the following lines should be adopted : All sources of mental excitement should be excluded. Late hours, theatres, parties, entertainments of all kinds, should be interdicted. The efEect of removing the child from school and reducing, or for a time intermitting, book-work should be tried. If, as sometimes happens, the enuresis ceases when the child is withdrawn from school, a three or six months' holiday should be prescribed. Country life in the open air is to be preferred to town life. The principal meal should be taken in the middle of the day, and no fluids should be allowed after five o'clock. Tea and cofiee, ginger beer and ginger ale should be interdicted. Meat may be taken, but in moderate quantities. All highly seasoned foods, with sugars' and pastry, should be avoided. The nurse should train the child to hold water at longer periods during the day, and the child should be made to pass water before going to rest. He should be wakened for the same purpose once during the night. The enuresis usually occurs during the first two hours of sleep, and the nocturnal micturition should be arranged to take place after about one and a half hours' sleep, shortly before it is due. The mattress should be firm, and the clothing light but warm. The air of the bedroom should not be too cold. Belladonna is largely used in the form of the tincture. The dose varies Math the age and idiosyncrasy of the patient. It should commence with 3 minims of the tincture thrice daily for a child of 5 years or over, and slowly increase up to 30 or 40 minims, or even 1 drachm, three times a day, unless symptoms of dryness of the throat, flushing, dim vision, and commencing delirium appear. During the period in which this drug is being administered the child should be under daily medical supervision. Symptoms of poisoning with these large doses may set in rapidly. If the enuresis is controlled the dose should be kept a little beyond this point for a fortnight and then very gradually reduced. Tincture of lycopodium is also useful and may be combined with belladonna. The dosage should commence with 5 or 10 minims thrice daily, and may rise to 20 minims. The tincture of nux vomica in doses of 3 or 4 minims thrice daily for a child of 5, and the liquid extract of ergot in doses of 10-20 minims thrice xxviii] INCONTINENCE OF CHILDHOOD 383 daily, are sometimes successful. I have found them most useful in cases where an occasional leak on laughing, sneezing, or other muscular effort shows weakness of the sphincter. Potassium bromide and antipyrin have been found useful, and the fluid extract of rhus aromatica in doses similar to bella- donna is recommended (Still). Hyoscine hydrobromide has also been used. Leonard Williams and Firth have used thyroid extract. The latter observer found that of 28 cases 16 showed a marked improve- ment or were cured, and 12 showed no improvement. The initial dose was J gr., and this was cautiously increased to 1 gr. or even 4|- gr. in twenty-four hours. The treatment was most successful when the child was backward, slow at school, lethargic, and under weight. Local treatment should, if possible, be avoided, but in some cases it may be used and be successful. Instillation of 10 or 15 minims of silver nitrate solution (1 per cent.) into the prostatic urethra once a week for three or four weeks may be followed by cessation of the enuresis. I have, however, known relapses occur after this treatment when it was completely successful for a time. Treatment by the continuous current is applied by means of a urethral electrode introduced into the prostatic urethra and a pad applied over the suprapubic region. Two or three seances are given for five or ten minutes, with a week's interval between. Cathelin has suggested the injection of fluid into the sacral canal with the object of causing pressure upon the sacral nerves. The method, which is employed also for adults, is carried out in the following manner : The patient is placed upon the side with the back bent and the thighs well flexed upon the abdomen. With the tip of the forefinger the opening at the lower end of the sacral canal is defined. This opening is covered with a membrane and lies a short distance above the lower end of the sacrum. On each side of it is a tubercle, and the bony arch surrounding the small opening can be felt. The skin is carefully cleaned and a hypo- dermic syringe sterilized and filled with 30 minims of saline solu- tion. The needle is passed through the membrane and easily introduced into the sacral canal. The fluid is slowly injected and the needle removed. The procedure is painless. Cathelin claims 80 per cent, of cures by this method. I have used it in a few obstinate cases, but have had no success with it. Care should be devoted to training the child, and when the confidence is once gained much may be done by persuasion. Good 384 THE BLADDER . [chap. results have been claimed for control by suggestion, employed during waking hours and also during sleep. LITERATURE Dudgeon, Lancet, 1908, i. 616. Firth, Lancet, 1911, ii. 1619. Still, Diseases of Children. Williams, Lancet, 1909, i. 1245. Difficult Mictueition Difficult micturition results from obstruction to the outflow of urine, or from reduced power of expulsion. In difficult micturition there is delay in the commencement of the act amounting to from a few seconds' hesitation to a wait of two minutes or more. The stream is feebly projected, and may drop vertically from the end of the penis. It may commence feebly, and gain in power, and then fall away again, or it may dribble throughout. The stream may be intermittent, one or several pauses occurring during the act. Occasionally the flow ceases, and only recommences after a pause of several minutes, or even a quarter of an hour. The abdominal muscles are brought forcibly into action to assist the expulsion of the urine. After- dribbling is usually observed. The most frequent cause of difficult micturition is stricture of the urethra. Here the obstruction usually commences in young men, or below the age of 45. The onset is insidious, and the increase is gradual and persistent. Attacks of retention of urine following alcoholic excess or exposure to cold or wet supervene when the stricture has become narrow. Eventually there may be chronic retention with- overflow. Diseases of the prostate frequently cause difficult micturition. The commonest of these is simple enlargement of the gland. Here the symptoms commence at or after the age of 50 years. The difficulty is combined with frequency of micturition, which is most troublesome at night and especially during the early hours of the morning. Complete retention may occur without the patient being aware of previous difficulty in micturition. Malignant disease of the prostate causes difficult micturition which closely resembles that of stricture ; it is insidious and persistent and is not com- bined with frequent micturition unless cystitis is present, but it appears in middle or late life. Tuberculous disease and calculi of the prostate, subacute chronic inflammation of the prostatic urethra, post-gonorrhoeal or due to bacillus coli, may cause difficulty of mic- turition. Acute urethritis, prostatic abscess, impaction of a stone in the prostatic urethra, may cause difficulty and even retention. XXVIII] RETENTION OF URINE 385 Atony of the bladder, apart from obstruction, is usually due to disease of the spinal cord. The patient complains of increas- ing difficulty of micturition, or sometimes there is sudden com- plete retention. Tabes and Erb's " syphilitic spinal paralysis " are the most frequent causes of this form of atony. The symptom is often combined with nocturnal incontinence without over- distension of the bladder. I have described a form of atony of the bladder without obstruction and without signs of nervous disease ; it occurs at any age, but most frequently in young men ; the cases do not at a later date develop symptoms of spinal disease. Functional difficulty of micturition. Stanhnnering blad- der. — It is well known that micturition may be difficult or impossible when there is urgent necessity that it should be quickly performed, or when it is attempted in the presence of others. There are many patients who pass water after considerable hesitation, or are unable to pass it at all, when called upon to do so in the surgeon's consulting-room. These are the minor phases of the condition described by Sir James Paget as the " stammering bladder." In its more severe forms it is found that otherwise healthy individuals cannot pass water in a public urinal, and may get complete retention of urine (hysterical retention). Complete retention from this cause occurs more frequently in women. Treatment. — The treatment of difficult micturition can only be initiated after the cause has been ascertained. Urethral obstruction due to stricture is treated by dilatation or operation, enlarged prostate by operation. The obstruction of malignant disease of the prostate is much benefited by the careful passage of metal instruments at regular intervals. The treatment of atony of the bladder due to nervous disease will be discussed later (p. 538). In any case of difficult micturition where obstruction has been relieved, or where a paralysed bladder is being emptied by catheter, the administration of small doses of ergot (liquid extract, 15-20 minims) and- strychnine (liquor, 5 minims) is beneficial. In " stammering bladder " ergot and strychnine are the most useful drugs, and they may be combined with bromides. Ketention of Urine Etiology. — The causes of retention of urine may be classi- fied in the following manner : — 1. Retention with obstruction. (a) Prostate. (1) Simple enlargement. (2) Malignant disease. 386 THE BLADDER [chap. (3) Stone. (4) Acute prostatitis and prostatic abscess. (6) Urethra. (1) Rupture of urethra. (2) Acute urethritis. (3) Stricture. (4) Stone and foreign bodies. (5) Pressure from without, pelvic tumours, etc. 2. Retention due to atony. [a) With symptoms of nervous disease. Tabes, etc. (b) Without symptoms of nervous disease. Idiopathic atony. 3. Retention in acute or chronic intoxications, such as appendicitis, typhoid, salpingitis, or arsenical, mer- curial, belladonna, or lead poisoning, or syphilis. 4. Retention from inhibition or spasm. (1) Hysterical retention. (2) Retention after anal and rectal operations. Diagnosis. — It is necessary to distinguish between anuria and retention, and between retention due to atony and that due to obstruction, and, in the latter, to ascertain the form of obstruction. A patient Avith anuria refers to previous attacks of renal colic,, haematuria, or other signs pointing to progressive renal disease, and the cessation of periodic micturition may have followed immediately upon such an attack. Symptoms of bladder trouble are absent, and have been absent or insignificant during the course of the disease. The patient is in no pain, there is no distension of the bladder, and an instrument passes readily along the urethra into the bladder but draws no urine. In retention of urine there is usually a history of gradually increasing difficulty in micturition, the stream has become progressively smaller and more feeble, and there may be some involuntary dribbling of urine. The bladder is distended and appears as a smooth, rounded swelling above the pubes, firm on pressure and dull on percussion. In retention from atony of the bladder muscle there is no pain and no desire to empty the distended viscus. In acute retention due to obstruction, recurrent spasmodic attempts of the bladder to overcome the obstruction usually double the patient up with cramp-like pain. In some patients, however, pain is remark- ably absent, and this is especially the case in old men when the obstruction results from enlargement of the prostate. Here the retention is chronic and slowly progressive, and some urine is XXVIII] RETENTION OF URINE 387 passed, voluntarily or involuntarily. The patient may be unaware that the bladder is distended even when the organ reaches above the umbilicus. Diagnosis is made by the passage of a large-sized instrument, which enters the bladder easily if retention is due to atony, but is arrested if obstruction is present. The presence of signs of spinal disease clinches the diagnosis. In young men the most frequent cause of acute retention is gonorrhoea, and there will be a history of an acute discharge. In adult life retention is usuallv due to stricture, and there is a history of gradually increasing difficulty of micturition, culminating in retention after alcoholic excess or exposure to cold. The passage of an instrument confirms the diagnosis. In old men enlargement of the prostate is the most frequent cause of retention of urine. There is a history of noc- turnal frequency and increasing difficulty, and rectal examination shows that the prostate is enlarged. Treatment. — The follo\\nng is the treatment suited to the chief t\'pes of cases met with in practice : — 1. Acute inflammation of the urethra {gonorrhcea, etc.). — Every means should be tried to relieve the retention without the passage of a catheter. Suprapubic puncture should not be performed. It has been recommended with the view of avoiding infection of the bladder by the catheter passing along the urethra. Retention does not, however, take place unless there is posterior urethritis or prostatitis, and in such cases the base of the bladder is already infected. The patient should be placed in a hot bath or made to sit in a hot sitz-bath and directed to pass his water in it. A large hot- water injection should be introduced into the rectum ; should this fail, a suppository containing extract of belladonna (i gr.) and aqueous extract of opium (f gr.) should be given. If relief is not obtained in half to three-quarters of an hour a catheter must be passed and the urine withdrawn. An anaesthetic will usually be necessary, for the urethra is intensely sensitive. The canal is first thoroughly washed with a solution of permanganate of potash (1 in .5,000) or protargol (1 in 10,000) from a douche can, a glass nozzle and bell shield being used to allow the fluid to rush in and out of the canal without splashing. To this 20 or 30 minims of cocaine solution (2 per cent.) may be added and may suffice to numb the urethra for the passage of the instru- ment. A soft rubber catheter is passed very gently and the urine withdrawn. The bladder should be washed out with protargol solution before the catheter is removed. If a morphia and bella- donna suppository has not already been given, it should now be inserted into the lectum and the patient returned to bed. If 388 THE BLADDER [chap. acute prostatitis and a prostatic abscess be present, operation as soon as possible is indicated. 2. Blocking the urethra hy stone, foreign todies, 'pedunculated bladder growths, blood clot, etc. — The diagnosis is made by the his- tory, and relief by catheter should be given without delay. There is sometimes difficulty in introducing a catheter, due to intense spasm of the compressor urethree muscle caused by impaction of the stone or foreign body. A metal catheter passes most readily. It may be necessary to pass several metal sounds before the catheter can be introduced. The distension of the bladder with blood clot from a sudden copious haemorrhage in a case of bladder growth will cause re- tention of urine. The condition is serious on account of the grave danger of septic infection of the clot. An attempt may be made with a large metal catheter to break up the clot and wash it out ; or a lithotrite may be used, and an evacuating cannula. Very little time should be spent in these attempts, and the bladder should be opened suprapubically without further delay, the masses of clot removed, and a large rubber drain placed in the bladder. Treatment of the growth or other cause of bleeding will have to be postponed until a more convenient time. 3. The distended atonic bladder of spinal disease. — This should be relieved by catheter with the same precautions as are adopted in enlarged prostate. The introduction to regular catheterization is similar to that in enlarged prostate. 4. Retention from reflex spasm in disease of or after operation on the rectum, anus, testicles, etc., and hysterical retention. — In operation cases the catheter is passed without delay, to avoid distress. In other cases hot baths and other means of relieving spasm, such as are used in retention due to acute inflammation, should be tried before resorting to the catheter. A metal catheter is the best form of instrument in these cases. After relief of the retention the cause of the spasm should be treated. 5. Retention with enlarged prostate. — The diagnosis is made by the history of the case, by the age at which the symptoms com- menced, and by rectal examination. The preliminary measures which are detailed above may be tried, but recourse to the catheter will nearly always be necessary. Three points must be insisted upon : (i) The most rigid asepsis ; (ii) the delicate handling of instruments ; and (iii) all the urine of the over-dis- tended bladder must not be withdrawn at once, or it must be drawn off very slowly. The catheters, whether gum-elastic or metal, must be boiled, the hands carefully cleansed, the penis washed with antiseptic, XXVIII] RETENTION OF URINE 389 and the uretlnu with sohition of oxycyanide of niercuiy (1 in 5,000) or permaiifraiiiite of j)otash (1 in 4,000). The instrument shoukl be of gum-elastic or metal. Coude and bicoude catheters are useful, and may pass easily. Where a difficulty is encountered it may be due to the distorted shape of the prostatic urethra, and the greatest gentleness should be exer- cised in pushing the instrument onwards. Sometimes twisting it gently one way or another during the passage will make it ride over an obstacle. Occasionally false passages have been made by previous instrumentation. It may be necessary to withdraw the instrument one or two inches, and then push it on, so as to avoid being caught in the cul-de-sac. When the prostate is very large the urethra is greatly elongated, and it is necessary to push the catheter very deeply before the urine begins to flow. Bicoude catheters are made specially long to allow for the additional length of the urethra in these cases. A very frequent cause of failure is the use of a catheter which is too small or too pointed. The obstruction to the catheter is not due to narrowing of the canal but to distortion of its lumen. A No. 18 or No. 20 Fr. is the best size for routine use. If the coude and bicoude catheters fail, a metal instrument may be tried. Special prostatic catheters which possess a very long curve are found in every set of metal catheters. A method that may be adopted when other methods have failed is to bend an English gum-elastic catheter containing its stilet into a very complete curve which commences by dropping down from the plane of the shaft. If this does not pass, it has been recom- mended to pull the stilet out while holding the catheter in the urethra, so that the beak of the instrument bores forwards and enters the bladder. These manoeuvres failing, it may be necessary to puncture the bladder suprapubically with an aspirator needle. Three dangers attend the rapid emptying of an over-dis- tended bladder — haemorrhage from the vessels of the bladder or kidney ; acute urinary infection, either autogenous or introduced with the catheter ; and suppression of urine. In order to avoid these the following procedure is adopted : The patient is in bed and in a warm atmosphere. Only 10-15 oz. should be dra^ai off, and an interval of half an hour or one hour should elapse before a similar amount is again mthdrawn, and so on until the bladder is empty, the catheter being retained in the urethra meanwhile. Another method is to withdraw a pint of urine and substitute half a pint of warm boric solution, and repeat this at intervals until only boric solution is left. 390 THE BLADDER [chap. Or, again, a catheter of very small calibre is introduced and the urine allowed to dribble slowly away. When the bladder is empty a few syringefuls of silver nitrate solution (1 in 10,000) should be injected and allowed to escape. The catheter should be tied in. Stimulants are usually necessary in these cases. A mixture containing urotropine 10 gr., liquor strychninee 5 minims, liquid extract of ergot 5 minims, citrate of potash 20 gr., and infusion of buchu 1 oz. should be given every four hours. After several days' continuous bladder drainage, the decision will have to be made whether " catheter life " is to be commenced or an operation performed. 6. Retention with stricture. — A hot sitz-bath and hot rectal injection followed by a suppository of morphia (^ gr.) may be tried, but recourse to instruments will in most cases be necessary. The method of passing instruments through a narrow stric- ture is described elsewhere (p. 631). In cases where a No. 7 or No. 8 Fr. bougie can be passed it should be withdrawn and a catheter of this size introduced. If only a filiform bougie will pass, it should be tied in place with a piece of silk, the ends of which are carried along the sides of the penis and fixed by means of strapping. After half an hour the urine begins to trickle alongside the bougie, a few hours later the stricture will allow of a larger instrument being passed, and eventually a catheter is introduced. A more rapid method is to use a special instrument consist- ing of a metal catheter with a conical end which screws on to a filiform bougie. The bougie acts as a guide, and the catheter is forced through the stricture. Harrison's whip bougies are some- times useful. They consist of a gradually tapering gum-elastic bougie 20 in. in length, the end of which is filiform, while the shaft rises to the size of 18-20 Fr. These may be made with a groove along one side, by which the urine trickles away. Another special instrument is a tunnelled catheter which can be threaded upon the filiform bougie and pushed through the stricture. There is less danger in completely emptying a distended bladder in a case of stricture than in enlarged prostate, for the age of the patient is less, and the kidneys are usually not so extensively diseased as the result of obstruction and arterio- sclerosis. At the same time diuretics and stimulants should be administered to guard against suppression of urine. If instrumentation fail, the bladder should be emptied with an aspirator needle. The most suitable point for the puncture is an inch above the upper margin of the pubic symphysis in the XXVIII] RETENTION WITH STRICTURE 391 middle line. The percussion note should be dull. The skin is cleansed, and incised with a sharp scalpel, and the aspirator needle introduced. The urine will flow from the cannula with- out a negative pressure being produced. The dangers connected with aspiration of the bladder are puncture of the peritoneum with subsequent peritonitis, leaking of the wound in the bladder, and the formation of a prevesical abscess, or in more vimlent infectious a spreading pelvic cellulitis. There is little risk of wounding the peritoneum when the bladder is distended and the percussion note dull. The aspirating needle should not be a large one, lest leakage at the point of puncture of the bladder take place. Usually, after a single aspiration an instrument can be intro- duced through the stricture and tied in, but rarely the puncture must be repeated several times. In such a case operation for the relief of the stricture should be performed as soon as possible. The operation ^^^ll take the form of a Wheelhouse operation. CHAPTEK XXIX CONGENITAL MALFORMATIONS Development of the bladder and urethra. — In order to explain malformations of the bladder and urethra it is necessary to make a brief note in regard to the development of this part of the urinary tract. The allantois, a hollow tube of hypoderm with a covering of mesoderm, opens posteriorly into the hindgut. A septum de- velops between the allantois and the hindgut, and both come to open into a common cloaca. As the septum descends, the cloaca is divided into a dorsal or anal portion and a genital or urogenital sinus. The sinus and allantois form a tube on which a dilatation (the bladder) appears at the second month, implicating the portion belonging to the sinus, and probably also a part of the allantois. The remainder of the allantois is obliterated and forms the urachus. The Wolffian ducts, the progenitors of the vasa deferentia and ejaculatory ducts in the male, open into the sinus by a common opening with the ureters. Further growth leads to separation of these ducts from the ureters, so that the ureters come to open into the bladder dilatation and the Wolffian ducts into the urogenital sinus. The sinus eventually comes to form the prostatic and membranous urethra in the male, and the whole of the urethra and the vestibule in the female. The Wolffian ducts open on an eminence, and between them the fused Miillerian ducts end. This eminence persists as the crista urethrse in the male, and when the ureters become separated by elongation of this portion and diverge from each other the upper part forms the trigone of the bladder. It can thus be realized how malposition of the ureteric orifice in the prostatic urethra or into the seminal vesicle may take place by persistence of the foetal condition. The cloaca at first extends from the umbilicus to the root of the tail, and is covered by the cloacal membrane. On either side the mesoderm encroaches upon this until it meets in the median line from the umbilicus backwards for some distance. This union ends behind in an eminence, the genital tubercle, which lies at the anterior end of the reduced cloaca, and is at first con- 392 CHAP. XXIX] DEVELOPMENT OF URETHRA 393 tained in it. On each side of the cloaca ridges appear, forming the outer genital folds, which eventually form the labia majora or the scrotum. A groove forms on the under or posterior surface of the genital tubercle, the urethral groove. The edges of this groove constitute the inner genital folds, which form the labia minora in the female, and in the male unite to form the floor of the bulbous and penile urethra. At the surface the septum which divides the cloaca into anal and urogenital segments forms the perineum. In the female the urogenital sinus becomes the vestibule, the inner genital folds form the labia minora, and the outer genital folds the labia majora. The genital tubercle forms the clitoris. In the male the inner genital folds unite from behind forwards in the middle line, and as the penis becomes extruded from the cloaca this union passes forwards so as to close in the groove on the under surface of the genital tubercle, and the bulbous and penile parts of the urethra are formed. The orifice of the urethra is now on the under surface of the penis at the base of the glans penis, and this opening represents the orifice of the urogenital sinus. The end of the tubercle forms the glans penis, and the portion of the urethra which traverses this is formed separately by folding over the edges -of the groove on its mider surface. Berry Hart believes that this part of the urethra is formed by the ingrowth and hollowing of a rod of epithelium, but the above description is generally accepted. The last part to be completed is the junction of this part of the urethra with the rest of the penile urethra. It is interesting to note how closely the various forms of hypospadias correspond to the stages of development of the urethra. The prepuce is formed by an ingrowth of solid ectoderm. The outer genital folds unite in the middle line to form the scrotum, and the median scrotal raphe represents their line of union. ABSENCE OF THE BLADDER The bladder is rarely absent, except in cases where there are extensive congenital deformities of the pelvic organs which are incompatible with life. A few cases have been observed clinically (Fleury, Benninger) in which the bladder was the only organ afiected, and the ureters opened into the urethra. The bladder was represented by a small pocket, the size of a bean. Incon- tinence of urine is present, and ascending pyelonephritis occurs. CONGENITAL DILATATION The dilated bladder may be a cause of difficulty in labour. Urethral obstruction may be present in the form of atresia, folds 394 THE BLADDER [chap. or valves or cysts of the urethra, or torsion of the penis. Rarely, no obstruction of the urethra is present, and the condition is probably due to changes in the sympathetic ganglia. The ureters are usually dilated, and the kidneys greatly distended, and there is also congenital dilatation of the colon. The bladder may be greatly thickened and hypertrophied in congenital hydronephrosis. FISTULA OF THE UEACHUS When the whole of the lumen of the allantois remains patent a urachal fistula results. Urethral obstruction is frequently the cause of the persistence of the lumen. In these cases the bladder is often dilated. In infants a membrane or fold in the urethra may cause the condition. The allantois may close and the fistula appear in adult life, when it may be due to urethral stricture or enlargement of the prostate. In some cases no urethral obstruc- tion is present and it is supposed that a temporary obstruction has been present in foetal life and has disappeared. The fistula opens at the umbilicus, sometimes on a small, raspberry-like tumour. It is usually narrow, but it may admit a filiform bougie. The opening into the bladder may be minute, or it may be so large as to admit three fingers (Marshall). Urine escapes from the opening during micturition or constantly. There may be a leakage in drops, or a tiny jet may escape. Any doubt as to the nature of the fistula is settled by examination of the fluid for urea, or by injecting methylene blue into the bladder, when the fluid discharged from the fistula becomes coloured. A malignant growth may develop at the umbilical orifice. A portion of the urachus at the vesical end may remain unobliterated and form a diverticulum at the apex of the bladder. Dykes reports a case in which there was a calculus in such a diverticulum. Pressure and cauterization are uncertain methods of treat- ment. The track of the fistula should be excised from the umbilicus to the bladder, and the bladder wall repaired. It may be necessary to open the peritoneum, but this should be avoided if possible. URACHAL CYSTS The majority of these cysts are found in women in adult life. They vary in size from a chestnut to large cysts occupying a large part of the abdominal cavity and containing many pints of serous or blood-stained fluid. The cysts are thin-walled and lined with mucous membrane, and the wall contains non-striped muscle. In large cysts the XXIX] DOUBLE BLADDER 395 wall is thin and the layers are indistinguishable. There may be a fine communication with the bladder or with the exterior at the umbilicus. Frequent micturition or incontinence of urine may be present. Infection of the cyst has been observed. In small cysts the position, and sometimes adhesions to the umbilicus, are relied upon for diagnosis. In large cysts diagnosis may be impossible. Excision of the cyst is the proper treatment, but in some cases dense adhesions have prevented this being done and the cyst was drained. MEMBRANES AND DOUBLE BLADDER There may be incomplete division of the bladder cavity with a membrane or fold. This may be longitudinal and sickle-shaped, or transverse, and the bladder is partly divided into two unequal compartments, an hour-glass bladder being formed. Cathelin and Sempe collected 32 cases of double bladder. The bladder is divided by a vertical septum into two compartments which open into the urethra. Abnormalities in the ureters or other congenital malformations are sometimes present. Von Frisch describes a case of double bladder in a man of 34 years. On cystoscopy there was a high septum in the middle line with transverse folds and covered with reddened oedematous mucous membrane. The patient had complained since childhood of delayed and difficult micturition, and eventually suffered from complete retention. The double bladder was demonstrated by the X-rays after collargol injection. Primrose records a case of a man aged 50 with the following malformations, viz. patent peri- cardium, solitary kidney, and septum in the urinary bladder. The septum was incomplete and formed two partly separated com- partments, into one of which the ureter opened. LITERATURE Cathelin ct Sempe, Ann. d. Mai. d. Org. Gen.- Vrin., 1903, p. 339. Delbet, Ann. d. Med. d. Org. Gen.- Urin., 1907, p. 641. Doran, Lancet, May 8, 1909. Dykes, Lancet, 1910, i. .566. Fortescue-Brickdale, Repf. Soc. Dis. Child., 1904, p. 94. von Frisch, Verhandl. d. deuts. Gesell. f. Urol, III. Kongress, 1912. Hart, Berry, Journ. Anat. and Phys., 1903, p. 330. Holt, Diseases of Injancy and Childhood. Marshall, Journ. Obstet. and Gyn., 1907. Pommer, Wien. kiin. Woch., 1904, Bd- xvii. Primrose, Glasg. Med. Journ., Sept., 1909. Schlagenhaufer, Wien. kiin. Woch., 1896. Schytzer, Arch. /. Gyn., Bd. xliii. Vaughan, Trans. Amer. Surg. Assoc, 1905. Weiser, Ann. Stirg., 1906, p. 529. White, Hale, Guy's Hosp. Repts., Iv. 17. 396 THE BLADDER [chap. EXTKOVERSION OF THE BLADDER (ECTOPIA VESICAE) There is congenital absence of the anterior wall of the bladder, so that the mucous membrane is exposed and the urine is dis- charged on the surface. The condition is rare, and male infants are more often affected than female. Hoenow found that one-quarter of the cases were female, two-thirds male, and in the rest the sex was uncertain. Wood found that only 2 out of 20 cases were females. The condition appears at birth as a dark-red swelling the size of a plum at the lower part of the abdomen. It is pear-shaped with the narrow end downwards. The eversion of the bladder wall is due to the intra-abdominal pressure. The upper, broader part of the mucous membrane is folded, irregular, and excoriated, bleeding readily when touched, while the lower part, which is somewhat triangular in shape and corresponds to the trigone, is smooth and partly hidden. At the margin of the mucous membrane there is a zone of scar tissue which forms a rigid border at the upper margin, the " hypogastric fold," and from the skin there are irregular ingrowths of epithelium into the mucosa. The epithelium of the mucous membrane is transitional in character with islands of squamous epithelium near the cutaneous margin. Columnar epithelium is frequently observed. The umbilicus may be normal or displaced downwards and containing a hernial sac ; it is separated from the extroverted bladder by healthy skin, or the bladder may fill the entire space from the umbilicus to the root of the penis. On raising the prominent swelling a moister area of mucous membrane is seen, with two nipples on which the ureters open. These are closer together than in the normal condition, and the trigone is undeveloped. The ureters are frequently dilated. The muscular wall of the ectopic bladder is thicker than that of the normal bladder. The penis is a tubercle 1-1^ in. long, \vith un- developed corpora cavernosa and glans. Along the dorsum there runs a median groove which represents the urethra (epispadias). At the base of the penis in a small pocket are the sinus pocularis and ejaculatory ducts. The foreskin is well developed in the form of an apron. The scrotum is split or rudimentary, and rarely con- tains the testicles, which are usually fomid in the inguinal canals. The prostate is absent or rudimentary. The pubic bones do not unite in the middle line, and are sometimes separated as much as 3 in. or more ; a fibrous band has been stated to pass across the middle line, uniting the pubic bones, but this is now disputed. The ureters, owing to the absence of the bladder from the abdominal XXIX] EXTROVERSION OF BLADDER 397 cavity, have a longer course than normal ; they descend into the deep pocket between the rectum and the bladder, and then ascend to the bladder. Associated deformities, such as harelip, cleft palate, and spina bifida, are sometimes observed. The perineal muscles may be defective and the anal sphincter ill developed — an important point when the operation of transplantation of the ureters into the rectum is proposed. The condition described above is the most common form, but other less extensive lesions are occasionally found. There may be scarring of the suprapubic region without separation of the pubic bones or defect of the abdominal wall or bladder. In other cases the pubic bones are separated, and there is scarring of the skin. In a still more advanced form there is a defect of the abdominal wall with exposure and thinning, but without perfora- tion of the bladder wall. In a further stage a fistula of the bladder above or below the pubic symphysis exists. Finally, a more extensive congenital defect than the common variety of extro- version described above may rarely be observed : in this the bowel below the lower ileum or the caecum is wanting, and the ileum opens behind the ureters in a common cloaca. Etiology. — The cause of the malformation is unknown. Two theories have been advanced to explain the anatomical conditions present. According to one, there is an arrest at an early period of development. It has been pointed out, however, that at no period of development is the bladder open on its anterior wall. This, with the frequent coincidence of dilated ureters and kidneys, has led to the second suggestion, that there is an intra-uterine rupture of the bladder following obstruction and back pressure. More recent work on embryology shows that the cloaca extends at first from the umbilicus to the base of the tail, and that the bladder is largely, if not entirely, formed from the cloaca. In- growths from mesoderm on each side reduce the size of the cloaca from before backwards {see p. 392). It is evident, then, that a failure of these lateral folds to meet on each side at the lower part of the abdomen, and the destruction of the cloacal membrane, sufficiently explain the anatomical conditions found in extro- version of the bladder. There is a difficulty in accounting for the presence of the urethra as a gutter on the dorsum of the penis. Symptoms and prognosis. — The thighs are widely separated owing to the cleft symphysis, and the body is bent forwards so as to protect the sensitive mucous surface. A peculiar w^addling gait and bent attitude are thus developed. The conditions of existence are extremelv miserable. There is 398 THE BLADDER [chap. the constant escape of urine, saturating the clothes and leading to inflammation and excoriation of the skin. The child lives in the pungent atmosphere arising from decomposing urine, and his life is a burden to himself and to those around him. Pro- gressive dilatation of the ureters and kidneys occurs. The mor- tality from ascending pyelonephritis is very high, but occasionally the patients attain adult life and even old age. A malignant growth may develop in the exposed bladder, and may take the form of an adeno-carcinoma. Treatment. — Many operations have been suggested and practised for ectopia vesicae. The following are the chief types : — I. Formation of a reservoir in tlie body. A. From the bladder. \ 1. Closure of the defect by osteoplastic operations. ' 2. Closure of defect by flaps, (a) Autoplastic methods, (i.) Of skin, (ii.) Of intestine. (6) Heteroplastic methods. B. From the rectum. 1. By transplantation of the ureters. 2. By vesico-rectal fistula, c. From the sigmoid flexure. D. From the vagina. II. No reservoir formed in tlie body. 1. Implantation of the ureters. (a) In urethra. * (b) In skin. 2. Nephrostomy. A few of the more important of these operations will be described. Trendelenburg's operation (osteoplastic operation). — This consists in opening the sacro-iliac synchondrosis, which allows of the approximation of the separated pubic bones and subsequent closing of the defect in the bladder wall. The patient is placed in the prone position, and a longitudinal incision made over one sacro-iliac synchondrosis. Its posterior ligaments are cut through and lateral pressure is applied to the iliac bones, so that the pubic bone on the operated side swings towards the middle line. A similar operation is performed on the opposite side. The patient is placed on a special couch. Round the pelvis is passed a leather girdle, the ends of which cross in front and are attached to cords and weights acting over pulleys on each side. The pelvic bones are fixed in position for some XXIX] OPERATIONS FOR EXTROVERSION 399 weeks. Three or four moiiths later an attempt to close the bladder is made by separating the bladder wall and uniting it, and bringing the component parts of the abdominal wall together in front of it. A later attempt may be made to reconstruct the urethra. Results. — Katz collected 23 cases, with a mortality of 21-7 per cent. Improvement in rectal incontinence has been noted after these operations, and three patients were stated to have gained control of the urine. This must be exceptional, how- ever, for no provision is made for sphincteric control, and an apparatus must be worn in almost all cases. The opened syn- chondrosis fills with clot and granulation tissue, and fibrous tissue is formed which contracts and drags the bones into their original position. Wiring the pubic bones together does not prevent this, for the wire cuts through the cartilage. There is some danger of injuring the sacral nerves and causing paralysis of the rectal sphincters. Wood's operation (autoplastic skin method). — The defect is closed by skin flaps (Fig. 114), and the operation should be done about the age of 4 or 5 years. Several operations are usually required, and they should be completed before puberty, when hairs grow upon the skin flap and erections of the penis interfere with the success of the operation. If puberty be already passed some method should be adopted to remove the pubic hairs. Three flaps are used — a median superior flap from the abdominal wall above the bladder, broad above and narrow below, which is turned down over the defect skin inwards ; and two lateral flaps from the abdominal wall on each side, which remain attached at their lower ends, are swung inwards to meet in the middle line, and are stitched in this position with the skin outwards. The trefoil surface thus laid bare is either covered at once with skin grafts or allowed to granulate and grafted later. The objections to this method are that there is no control and a urinal must be worn, and phosphatic deposit takes place on the skin surface which forms the anterior wall of the bladder. Segond's operation. — The bladder is dissected from the abdominal wall and turned downwards so that the upper portion forms a roof for the urethra. The ample prepuce is now unfolded so that the upper surface is raw, and this is reflected backwards on the surface of the bladder flap, a hole being made through which the penis projects. implantation of the ureters into the rectum. — The dangers of implantation of the ureters into the bowel are slough- ing of the womid and ascending pyelonephritis. 400 THE BLADDER [chap. Fowler endeavoured to protect the implanted ureters from contact with the faeces. He cut the ureters obliquely and formed a flap valve of mucous membrane from the anterior wall of the rectum. To the under surface of this he attached the cut ends of the ureters in the hope that the descending faeces would press upon the valve and close the ureteric orifices. Gersuny made an artificial anus at the sigmoid flexure and '^ ■nf^ ^^^^'^^'^^'^^ Fig. 114. — Wood's operation for extroversion ot bladder. A, B, C, Raw surface left after cutting skin flaps. A', Central flap turned downwards (dotted line) with skin surface inwards. B', C, Lateral flaps swung inwards and stitched across back of A'. D Covering for urethral gutter formed from foreskin. closed the upper end of the rectum. He then transplanted the ureters into the rectum. Peters introduced catheters into the ureters, which he dis- sected from the wall of the bladder, leaving a collar of bladder mucous membrane round each. The catheters and ureters were passed through two small openings in the anterior rectal wall, each ureter projecting about 3 cm. into the cavity. The catheters were removed after three days. Soubottine's operation (Fig. 115). — The coccyx is excised XXIX] OPERATIONS FOR EXTROVERSION 401 and the posterior rectal wall slit up longitudinally, cutting through the anal sphincter. A fistula is now made between the rectum and the bladder. A horseshoe incision is made with the con- vexity upwards round the recto-vesical fistula, including one- third of the rectal wall, the limbs of the horseshoe passing down to the skin at the anus. The edges of the portion of rectal wall included within this horseshoe are now united, and a reservoir formed. Finally, the rectal wall is united over this and the pos- Flg. 115. — Soubottine's operation for extroversion of bladder. The posterior wall of the rectum has been slit, a vesico-rectal fistula formed, the incision for the rectal pouch made, and the stitches introduced. terior rectal wall repaired. The neck of this urinary receptacle is within the grasp of the anal sphincter. The suprapubic gap in the bladder wall is closed by a skin- flap operation. One patient operated on in this manner obtained complete continence and held urine for four hours. Maydl's operation (Figs. 116, 117). — The trigone of the bladder, together with the ureteric orifices, is transplanted into the sigmoid flexure of the colon. A catheter is introduced into 402 THE BLADDER [chap. each ureter, and the bladder separated completely from the abdominal wall. The bladder wall is cut away, leaving an oval area on which the ureters open. Care is taken not to injure the vesical arteries. A knuckle of sigmoid flexure is isolated and incised longitudinally, and the bladder base is implanted into it and carefully sutured. Maydl fixes the bowel in the abdominal Fig. 116. — Maydl's operation for extroversion of bladder. Stage 1. The bladder is being separated from the abdominal wall. Catheters are lying in the ureters, and the dotted line shows the portion of the bladder base that will be transplanted into the intestine. wound on account of the danger of peritonitis from the line of suture giving way. This method has proved the most successful of the bowel- implantation methods owing to the retention of the sphincter action of the lower end of the ureters. Moynihan dissected up the whole bladder and implanted it into the colon. Kocher brings out a knuckle of sigmoid, implants the XXIX] OPERATIONS FOR EXTROVERSION 403 bladder base at the apex of the loop, and short-circuits the bowel at the base of the loop. The immediate mortality of Maydl's operation varies from 5-5 per cent. (Josseraud, 18 cases) to 26-7 per cent. (Katz, 57 cases). In Petersen's collection 31 patients recovered from the operation ; of these 2 died of pyelitis within a year. In the Fig. 117. — Maydl's operation. Stage 2. The portion of the bladder base surrounding the ureteric orifices is implanted into the sigmoid flexure of the colon. The double row of stitching is seen. -other cases the control of the anal sphincter was good in every case but one. In 6 cases the operation was followed by fistula, which in every instance subsequently closed. Before embarking on this most satisfactory operation, the surgeon should ascertain if the anal sphincter retains fluid motions. In Sonnenberg's operation the bladder is excised and the ureters implanted in the urethra. This allows of the fitting of .a receptacle which will collect the urine. 404 THE BLADDER [chap, xxix LITERATURE Connell, Journ. Amer. Med. Assoc, 1901, p. 637. Fowler, Amer. Journ. Med. Sci., 1898, p. 270. Frank, Ann. Surg., 1903, p. 291. Gersuny, Wien. Min. Woch., 1898, No. 43. Hager, 3Iunch. med. Woch., 1910, p. 2301. Hoenow, Inaugural Dissertation, Berlin, 1884. Josseraud, Gaz. Hebdom. de Med. et de Chir., 1895, p. 117. Katz, These de Paris, 1903. Keith, Brit. Med. Journ., 1908, ii. 1858. Lendon, Brit. Med. Journ., 1906, i. 961. Maydl, Wien. med. Woch., 1894, 1896, 1899. Moynihan, Ann. Surg., 1906, p. 237. Newland, Brit. Med. Journ., 1906, p. 964. Peters, Brit. Med. Journ., June 22, 1901 ; 1902, ii. 1538. Petersen, Med. News, Aug. 11, 1911. Segond, Ann. d. Mai. d. Org. Gen.- Urin., 1890, p. 193. Soubottine, Wratsch, 1901. Trendelenburg, Gentralhl. f. Chir., Dec, 1885 ; Ann. Surg., 1906, p. 281. Watson, Ann. Surg., 1905, p. 813. Wood, Brit. Med. Journ., 1880. Zuckerkandl, Handbuch der Urologie (von Frisch und Zuckerkandl), 1905. CHAPTER XXX CYSTOCELE— PROLAPSE-DIVERTICULA HERNIA OF THE BLADDER (CYSTOCELE) Hernia of the bladder is comparatively rare. Moynihan found 23 bladder hernias in 2,543 collected cases of hernia operations, or about 1 per cent. It is much more frequent in men than in women (115 in 144 — Alessandri), and is most common in advanced life, although cases occurring in children have been described. The average age in males is 51 and in females 44 (Moynihan). The great majority of bladder hernias are inguinal ; femoral are much less common, but are more frequent in women than in men (27 to 2). A few rare records of obturator, sciatic, and perineal hernia and of hernia in the linea alba exist. Etiology. — A thin-walled bladder placed in close relation to a weak inguinal or femoral ring is either drawn through or forced into it. The following are recognized causes : — 1. Urethral obstruction with distension of the bladder (stric- ture, enlarged prostate, pelvic growths). The wall is usually thinned and its muscular power weak, but in a few cases there has been hypertrophy with thickening of the wall. 2. Weakness of the abdominal wall, such as is found in old age and other contributory causes of hernia. 3. Intermittent increase in intra-abdominal pressure, which may be caused by coughing, straining to pass water, etc. 4. Traction upon the bladder drawing it through the weak abdominal wall. This may be the traction (a) of an extraperi- toneal lipoma, (b) of extraperitoneal fat on the sac of a hernia upon adherent perivesical fat, (c) of the peritoneum of a large hernial sac on the peritoneum covering the bladder, or {d) adhesions between the omentum or intestine and the intraperitoneal por- tion -of the bladder dragging this into the hernial sac. A number of these factors unite to produce a bladder hernia. Bland-Sutton relates a case in which there was an enlarged prostate and dis- tended thinned bladder and the inguinal canal contained a fibro- fatty tumour of the spermatic cord, a fat-covered " diverticulum " of the bladder, and a hernial sac in which there was omentum. 405 406 THE BLADDER [chap. Varieties. — Three varieties are found (Fig. 118) : 1. Paraperitoneal, in which a sac of peritoneum is present, and adherent to this is the bladder. The large majority of vesical hernias are of this variety. Usually only a small portion of the bladder is involved, but a large part of the ^dscus, together with the ureters and even the prostate, has been foimd in the hernia. 2. Eoitraperitoneal, in which there is prolapse of the bladder without a hernial sac of peritoneum. 3. Intraperitoneal, in which the peritoneum-covered portion of the bladder is drawn into a hernial sac together with bowel and omentum. Intraperitoneal cystocele lies outside the deep epigastric artery (obhque hernia). Extraperitoneal cystocele lies internally to this vessel (direct hernia), while paraperitoneal cystocele may PBRITOHEUH BLADDER. -PERITONEI Fig. 118.— Hernia of bladder. A, Paraperitoneal variety. B Extraperitoneal variety. C, Intraperitoneal variety. be oblique or direct. The communication between the prolapsed portion of the bladder and the main cavity may be temporarily narrowed, but there is never a diverticulum in the true sense, and after the prolapsed portion is returned to the pelvis no change can be found with the cystoscope. Hernia of the bladder occurs most frequently in an inguinal hernia which has recurred after operation. One of Gifford's two cases of extraperitoneal bladder hernia was that of a child aged 5, on whom a previous operation had been performed. Cystitis may be present, and a phosphatic stone has been known to form in the prolapsed portion of the bladder. Symptoms. — There is an inguinal or femoral swelling having the characteristics of an ordinary hernia. The swelling increases in size in the erect posture. It has the following characteristics : XXX] GYSTOCELE : SYMPTOMS 407 (1) It is irreducible. (2) When the bladder is distended it is large, and when the bladder is emptied it subsides and only an indefinite thickening is left, or an ordinary hernia may persist. (3) Pressure upon the swelling causes a desire to micturate. (4) Fluctuation may be detected if the hernia is large. (5) The swelling is dull on percussion. Symptoms pointing to implication of the bladder in the hernia may be present, but, as the prostate is enlarged or other urethral obstruction is present in many of these cases, the significance of the symptoms may be overlooked. Micturition in two parts is a common symptom. Urine is passed, and then after a pause a second quantity is passed, some- times after pressure upon the hernia or by assuming some par- ticular position. There is difficulty in micturition, and some- times complete retention, and the patient may only be able to pass water by pressing on the swelling or in a certain posture. Cystitis may complicate the condition. Urinary symptoms may be completely absent. In a case under my care there were no urinary symptoms, but only constant deep-seated peMc pain, which was unrelieved by operation. Cystoscopy after operation showed no abnormahty of the bladder. On introduction of a catheter it may pass into the hernial sac and be felt through the skin. Injection of fluid into the bladder distends the hernial swelling. Strangulation of a bladder hernia has occurred in several cases. The svmptoms are those of strangulation of an intestinal hernia, but constipation is absent. Bladder symptoms are frequently wanting, but there may be strangury. Hiccough is sometimes a prominent svmptom. Diagnosis. — The diagnosis is usually made for the first time at operation, for there are frequently no symptoms to point to the presence of the bladder in the hernia. If suspicion of the nature of the swelling is aroused, some of the characteristic symp- toms may lead to a diagnosis, and cystoscopy will help. The diagnosis of the condition is made at operation on hernia in 67 per cent, of cases, and unintentional wounds of the bladder or inclusion in the ligature of the hernial sac seldom occur if due care be taken in clearing and inspecting the neck of the sac in a radical ciu'e of hernia. The discovery is made when the sac is being freed, and the bladder in the most frequent form of vesical hernia (paraperitoneal) is found adherent to the median aspect of the surface of the sac. It is covered by perivesical fat, and when this is removed the muscular wall, on which veins course, is exposed. When the perivesical fat is wanting and the 408 THE BLADDER [chap. bladder wall is thinned by distension, it may not be possible to recognize the organ until its cavity is opened. When this has occurred the nature of the case is demonstrated by the escape of urine, the appearance of the mucous membrane, and the free- dom with which a probe passes behind the pubes, and, if necessary, the passage of a metal instrument through the urethra into the bladder can be felt from the inguinal cystotomy wound. When the bladder alone forms the hernia (extraperitoneal) the same features assist in the diagnosis. If the bladder has passed unnoticed at a hernia operation, and has been included in or pierced by a ligature, hsematuria and strangury follow the operation, and sometimes the escape of urine from the hernia wound. Fatal peritonitis usually supervenes. The significance of these symptoms is frequently overlooked. I have made an autopsy on a child who died of peritonitis following operation on an inguinal hernia. The bladder had been mistaken for the muscles of the abdominal wall and sutured to Poupart's ligament. Prognosis. — There is danger that the surgeon may not recog- nize the bladder at the operation, may puncture it, or include it in a ligature, and fail to appreciate the significance of the symp- toms which follow. If the bladder be recognized and treated at the operation the danger is not great. Hermes found the mor- tality of hernia operations involving the bladder to be 19-5 per cent. ; when the bladder was uninjured it was 6-5 per cent., and when it was injured 26-5 per cent. Treatment. — When urethral obstruction is present this should be removed, and in some cases when the cystocele is intra- peritoneal it may be controlled by p, truss. In the great majority of cases, however, the hernia is irreducible and an operation is necessary. When the bladder is found within the hernial sac it is reduced with the other contents, adhesions to bowel or omentum being first separated, and the radical cure of the hernia carried out in the usual manner. If the prolapsed bladder is recognized outside the sac it should be dissected off and returned to the abdomen without being opened. If a considerable portion of the bladder is covered by peritoneum, this may be left adherent to the bladder and excised from the sac. Great care is necessary to avoid tearing the bladder wall during the dissection. After radical cure of the hernia, care should be taken to remove urethral obstruction, if such exists. If the bladder be opened during the operation, it should be carefully dissected off the sac and the opening closed by a double layer of catgut sutures. The bladder is then returned to the pelvis, the hernia operation completed, and a caijieter tied in XXX] PROLAPSE OF BLADDER 409 the urethra for a week. Should any sign of pericystitis super- vene, a median suprapubic incision should be made and the perivesical extraperitoneal space drained through this. LITERATURE Alessandri, Ann. d. Mai. d. Org. Gin.- Urin., 1901. Bland-Sutton, Arch. Middx. Hosp., 1910, p. 10. Brunner, Deuts. Zeits. f. Chir., Bd. xlvii. Curtis, Brit. Med. Journ., 1903, ii. (59. Foy, Brit. Mid. Journ., 1897. Hamilton- Whiteford, Lancet, 1900. Hermes, Deuts. Zeits. /. Chir., Bd. xlv. Malcolm, Trans. Med: Soc. Lond., 1908, p. 26. Martin, Deuts. Zeits. /. Chir., Bd. liv. Monod et Delageniere, Rec. de Chir., 1889, p. 701. Moynihan, Brit. Med. Journ., 1900, i. 503. Noall, Pract., 1910, Ixxxiv. 842. Zuckerkandl, Handhuch der Urologie (von Frisch und 2uckerkandl), 1905, ii. 589. INVERSION AND PROLAPSE OF THE BLADDER (URETHRAL CYSTOCELE) There are two forms of urethral cystocele. In one, inversion of the bladder, the whole thickness of the bladder wall, including the peritoneal investment, is inverted through the urethra, while in the second the mucous membrane is prolapsed through the urethra. The condition occurs in women and female children. (Gross collected 7 cases of complete inversion, 5 in girls between 14 months and 4 years, and 2 in adult" women.) Etiology. — Except in one or two cases in which the urethra was destroyed, little is known in regard to the causation. But the exciting causes are straining from crying, coughing, sneezing, constipation, and diarrhoea. Hirokawa has described a case following pertussis. Varieties and diagnosis. — Inversion of the bladder, which is very rare, varies in degree, (i) The whole bladder may be inverted into the urethra and appear at the external meatus as a round swelling, the size of a walnut or an orange, covered with reddened, easily bleeding mucous membrane. The tumour is tender, elastic, increases in size on crying or straining, and is felt to consist of several layers. It is reducible with difficulty or not at all. If it project well beyond the urethral orifice it appears to be pedunculated, and a probe passed along the urethra beside the pedicle enters the bladder and can be swept round the pedicle on all sides. Rarely the ureteric orifices are carried down with the prolapsed bladder, and can be recognized emitting drops of urine on the surface of the tumour. The patient complains of incontinence of urine. 410 THE BLADDER [chap. (ii) In an incomplete form of inversion the bladder wall is folded inwards into the cavity of the viscus, but is not prolapsed through the urethra. This variety is said to occur in men as well as in women. The diagnosis is only made by cystoscopy. Symp- toms resembling those of stone in the bladder are usually present. There are increased frequency, pain on micturition and tenesmus^ intermittent micturition, and the stream may only be initiated or recommenced by lying on the back. Heematuria is rare. Prolapse of the vesical mucous membrane is more frequent than inversion. An area of mucous membrane is prolapsed through the urethra. According to Malherbe a glandular cul-de-sac in the neighbourhood of the internal meatus becomes distended with urine so that a ridge of mucous membrane is raised, and this, becomes pedunculated. A small tumour of mucous membrane appears at the external meatus. It has a translucent appear- ance and is compressible. The diagnosis from inversion of the bladder wall is made by the sensation of greater thickness and the presence of the ureteric orifices on the surface of the tumour in the inversion. A tumour of the bladder which has prolapsed through the urethra is firmer^ does not vary in size, and is not compressible. In prolapse an instrument passes alongside the tumour into the bladder, and can be swept round it, but is not free in the cavity when it has passed the urethra. When it has been reduced, cystoscopy shows that there is no growth or prolapse of the ureter. Polypi of the urethra may protrude from the meatus, but they are small, and the attachment of the base to the urethral mucous membrane can be demonstrated by a speculum or urethroscope tube. Prolapse of the ureter has appeared at the external meatus in the female subject, but the thin, transparent appearance of the tumour and cystoscopic examination will make the diagnosis plain. Treatment. — There are few cases recorded on which to base statements in regard to treatment. The tumour has been reduced and has not recurred (Leech). Leedham- Green reduced the inversion in his case and injected melted paraffin in a ring around the urethra ; the hardened paraffin gave support to the urethra, and recurrence did not take place. Cysto-uteropexy has been performed, the upper part of the bladder being fixed to the anterior surface of the uterus. This was successful in a case recorded by Peigne. Plastic operations on the urethra are necessary when prolapse has recurred. When the mucous membrane is prolapsed the polypoid portion should be removed by suprapubic cystotomy. XXX] DIVERTICULA OF BLADDER 411 LITERATURE Carrel, Ann. d. Mai. d. Org. Gen.-Urin., 1900, p. 299. Hirokawa, Denis. Zeits. f. Chir., 1911, p. 575. Leech, Brit. Med. Joiirn., 189G, ii. 1128. Leedham-Green, Brit. Med. Journ., 1908, i. 970. Lowe, Arch. j. IcLin. Chir., v. 305. DIVERTICULA OF THE BLADDER A diverticulum is a pouch lined by vesical mucous membrane which communicates with the bladder by a narrow opening. Diverticula should be distinguished from the pouches or sac- cules of a sacculated bladder, which is commonly seen in prostatic obstruction, where there is widespread or universal trabeculation, and between the trabeculse are innumerable shallow and deep depressions, open, without contraction of the orifice, to the bladder cavity. Pathological anatomy.^Diverticula may be single or mul- tiple, small as a pea or as large as the bladder cavity, or even larger. Small diverticula may be solitary, but they are frequently multiple, and when multiple are frequently arranged in groups of two or three, or even six or seven sometimes, symmetrically arranged on each side of the bladder. The orifice is small. It may barely admit a crow-quill, but more frequently will pass a pencil, or even the forefinger. The size of the orifice has no relation to the capacity of the diverti- culum. The edges are sharply defined. The opening frequently appears as a round hole punched out in an absolutely healthy bladder wall. An oval or slit-like orifice is sometimes found, but is rare.. General trabeculation of the bladder wall is seldom if ever present. Trabeculation limited to an area around the orifice of the diverticulum is frequently found, and may be confined to the wall at one part of the circumference of the orifice. The mucous membrane frequently shows puckerings and ridges which radiate from the orifice at one part of the circumference or all round. They resemble the puckering of the peritoneum at the neck of a hernia when viewed from within the abdomen, and give "the impression that the mucous membrane is being dragged upon from without the bladder. (Plate 30, Figs. 1, 2.) When situated in the neighbourhood of the ureter the interureteric bar is usually hypertrophied on that side. The ureteric orifice may open in the wall of the diverticulum or on the margin of the mouth of the diverticulum. In the former case the ureter has probably become dragged into the cavity in the process of development of the sac. 412 THE BLADDER [chap. Diverticula may be found at any part of the bladder. They are most frequently found on the lateral walls, in the neighbour- hood of the ureteric orifice, and next on the posterior wall. Less frequently they are found at the apex. Rarely they open on the trigone. I have seen the opening of a very large diverticulum in the middle line near the posterior part of the trigone. The structure of the wall varies. The cavity is lined by mucous' membrane continuous with and similar to that of the bladder, and is surrounded by fibrous tissue and usually by a consider- able quantity of coarse fat. In some diverticula there is a layer of non-striped muscle, while in others this is wanting. Virchow, Englisch, and others hold that when the muscle is present the diverticulum is congenital, and when absent the diver- ticulum is acquired. Young was always able to find muscle in the walls of diverticula, although the layer might be very thin. Diverticula may have secondary pockets, and they are usually extensively adherent to the pelvic viscera. Etiology. — The great majority of diverticula are found in men, but they sometimes occur in infants. They are frequently met with in young adults or in middle age. While many of the diverticula are congenital, some are appar- ently due to urethral obstruction, and are met with in cases of stricture and enlarged prostate. In some cases I have found a history of pelvic cellulitis (from appendicitis, salpingitis, etc.), and traction from without by adhesions may have been a factor. Diverticula at the apex of the bladder result from incomplete obliteration of the urachus. Symptoms. — These, apart from the symptoms of obstruction due to stricture or enlarged prostate which are present in some cases, and the symptoms of such complications as cystitis or new growth, are usually puzzling and irregular. In a young man with clear urine there may be attacks of frequent micturition at varying intervals, or continuously. In other cases there are attacks of complete retention, relieved by catheter, or there may be gradually increasing difficulty in mic- turition, culminating in complete retention. In these cases I have usually found spasmodic contraction of the compressor urethrse. In many cases there are no symptoms which can be ascribed to the diverticulum, and it is discovered accidentally during examination of the bladder for some other disease. Micturition in two parts is a symptom which has been described, but is rarely seen except in very large diverticula. Sometimes the second supply is purulent when the first was clear. On passing a catheter a somewhat similar phenomenon is -h' ^' "O S u OS « b h .2 § S c3 -a i-l cu 6 r -g .2 3 O O XXX] DIVERTICULA OF BLADDER 413 observed. The bladder is apparently emptied, when the point of the catheter slips onwards and a large quantity of urine, some- times purulent, is passed. With a sound it is sometimes possible to feel the edge of the aperture with the beak. One or several ounces of residual urine may be drawn of! by catheter after the patient has passed all he can. Small diverticula cannot be felt on abdominal or rectal palpa- tion. A large diverticulum can be felt as a tumour in the lower part of the abdomen. In an extensive diverticulum on the right side of the bladder I could feel a large fluctuating mass in the right iliac fossa when the bladder was distended with fluid, and this almost disappeared when the bladder was emptied. The diverti- culum was apparently adherent to the caecum. Eventually a malignant growth developed in the diverticulum, and the patient died of pyelonephritis. Diagnosis. — The symptoms are frequently those of cystitis with residual urine which is purulent. The only certain method of diagnosis is cystoscopy. The extent of the diverticulum cannot be gauged by the cystoscopy A stone lying in a diverticulum is sometimes seen cystoscopically. Usually, however, the orifice is so small that even a large stone cannot be seen. Drawings of the orifices of diverticula are seen in Plate 30, Figs. 1, 27, and the skiagram of a large stone which one contained is shown in Plate 29, Fig. 1. The stone could not be seen by cystoscopy. To demonstrate the dimensions and position of a diverticulum, the bladder should be distended with an emulsion of bismuth and a skiagram obtained. (Plate 27, Fig. 2, and Plate 29, Fig. 3.) Complications.' — 1. By pressure or dragging upon the ureter dilatation of the kidney may be produced. Both kidneys may be affected. 2. Infection is a common and very serious complication, and is usually due to septic catheterization. There may be acute general cystitis lasting for many weeks and finally subsiding, but recurring from time to time, or there is continuous subacute cystitis with recurrent exacerbations. A collection of purulent urine, sometimes decomposing, is lodged in the diverticulum and pours out into the bladder from time to time. Pericystitis and peritonitis may occur. Ascending pyelonephritis is the usual termination in these cases. 3. A calculus may form in the diverticulum, and may follow long-standing infection of the diverticulum, but it also forms where a very mild infection is present. 4. A malignant growth may develop on the edge or in the neigh- bourhood of the orifice, or may arise within the diverticulum. 414 THE BLADDER [chap. I have seen instances of each of these, and operated upon three cases of the former. Prognosis. — The presence of a diverticulum is not in itself dangerous, but when infection has taken place the prognosis is extremely grave. Ascending pyelonephritis supervenes in these cases. Malignant growth occurs in a small percentage of cases. Treatment. — The grea,t danger of infection should render the Fig. 119. — Operation specimen of resection of bladder wall. The upper portion shows the excised part of the bladder wall, on which is set a malignant growth. Below this is the orifice of a diverticulum with the diverticulum itself. To the left is the lower end of the ureter, in which lies a bristle. The ureter was transplanted ; perineal prostatectomy three weeks later ; recovery. surgeon doubly careful in regard to asepsis. Where infection has occurred, washing the bladder has little effect upon the contents of the diverticulum. In the female subject a Kelly's tube may be passed and a catheter introduced through this into the orifice and the diverticulum washed out, A number of operations have been performed : 1, Drainage outside the bladder. — This may be tried in XXX] DIVERTICULA OF BLADDER 415 large diverticula, but is impossible in small pockets and in those at the base of the bladder. This method leads to a permanent urinary fistula. It may, however, be combined with the next method. 2. Closure of the orifice. — After suprapubic cystotomy the edges of the orifice are cut away and the raw surfaces brought together. The diverticulum must previously have been aseptic. 3. Drainage into the bladder. — The walls of the bladder and diverticulum are split upwards or downwards and the edges stitched together so that the cavity of the diverticulum is thrown into that of the bladder. This permits of free drainage of the diverticulum into the bladder, and the cavity is more readily cleaned by washing the bladder. 4. Excision of the sac and repair of the bladder wall. — This has been performed by several surgeons, and I have carried it out in six cases. In the upper part of the bladder the operation does not present great difficulties, but it may be extremely difficult, owing to extensive adhesions, in diverticula deeply situated in the pelvis. A urinary fistula has persisted in some recorded cases and necessitated secondary operations. In one of my cases a small pocket deeply placed in the pelvis had been left and caused a purulent discharge for some time, but the communication with the bladder closed at once. In another case (Fig. 119) I removed a large malignant growth by resection of the bladder wall, and with it a diverticulum full of stones, and the lower part of the ureter, transplanting the ureter into the wound. A fortnight later an enlarged prostate was removed from the perineum. The patient, aged 73, made an uneventful recovery. In order to facilitate removal of the sac, Lerche introduced a small collapsed rubber bag on the end of a fine catheter into the diverticulum, and then distended it with fluid. LITERATURE Berry, Proc. Eoy. Soc. Med., Surgical Section, 1911, p. 158. Chute, Boston Med. and Surg. Journ., Sept., 1912, p. 316. Durrieux, These de Paris, 1901. Englisch, Wien. Min. Woch., 1894, p. 91. Lerche, Ann. Surg., Nov., 1911, p. 593; Feb., 1912, p. 285. Pagenstecher, Arch. f. Uin. Chir., 1904, p. 186. Targett, Trans. Path. Soc., 1896, p. 155. Young, Johns Hopkins Eosp. Repts., 1906, p. 401. CHAPTER XXXI INJURIES OF THE BLADDER RUPTURE In rupture of the bladder the outer coat may remain intact, or more commonly the whole thickness of the vesical wall is torn. The great majority of cases (90 per cent.) take place in male sub- jects, and usually during the most active period of life (20 to 40 years). The injury is said to occur more frequently in England and America, owing to the greater prevalence of field sports and boxing. The bladder is invariably full at the time of rupture, some- times it is over-distended. A considerable proportion of cases (35 per cent. — Bartels) occur during alcoholic intoxication. The injury is usually direct, as from kicks, blows with the fist or knee, falls upon furniture or boulders, crushes between buffers or from machinery. In fracture of the pelvis a splinter of bone may penetrate the bladder. The injury may also be due to indirect violence, such as falls from a height or being thrown from a vehicle. The bladder may be ruptured by the muscular effort of lifting heavy weights, or by straining under an ansesthetic. Rupture has taken place from the effort of blowing a trumpet (Fenwick), and from leaning over the edge of a barrel (Zuckerkandl). Over-distension of the bladder has caused rupture from great intravesical pressure. This usually occurs from the forcible injection of fluid by the surgeon into the bladder. It has been known to occur from the action of the evacuating bulb after the operation of litholapaxy. It is very doubtful if the bladder can be ruptured by intravesical tension from the collection of urine when the organ is healthy. Cases have, however, been described to show the possibility of such an occurrence. In a bladder the seat of malignant or other ulceration rupture may take place spontaneously. Pathology. — A few cases of incomplete rupture have been recorded, but they are very rare. In a case described later, only 416 ( iiAi. xxxij RUPTURE OF BLADDER 417 the iiuicous membrane was torn. The rupture is most frequently oil the postero-superior wall, and opens the peritoneal cavity. Extraperitoneal rupture occurs exceptionally, and affects the anterior wall. Rupture of the base and lateral walls is usually the result of fracture of the pelvis. The rupture is vertical, and in or near the middle line ; it is single, and is usually small in size, with clean-cut or bruised edges. Later, inflammatory reaction is found around the wound. Rarely the tear is trans- verse or irregular. When the peritoneal cavity is opened, coils of intestine may exceptionally become adherent and limit the extravasation of urine and peritonitis. Usually, urine escapes into the peiitoneal cavity, and general peritonitis supervenes. When the urine is already septic this appears rapidly. Aseptic urine does not cause peritonitis, but it is toxic when absorbed, and even if aseptic at the time of the accident it very readily becomes infected. In extraperitoneal rupture the urine infiltrates the pelvic cellular planes, and infianmiation and suppuration follow. Fracture of the pelvis is present in 38 per cent, of cases (Bartels), the pubic bones being the most frequent seat of frac- ture, then the ischium, ilium, and sacrum. The mechanism by which the rupture is produced is open to discussion. It is stated that contact of the distended bladder with the pubic bone or with the promontory of the sacrum is the cause, and that the greater liability of the posterior wall to rupture is due to its being unsupported when compared with the anterior wall, and to the more frequent occurrence on it of saccules and diverticula. When the bladder is fully distended above the pubes the danger from an antero-posterior blow is rupture of the postero- superior wall, while a partly distended bladder is more likely to be driven down into the pelvis and sustain injury to the base. The slower forms of violence are said to be more likely to produce a partial rupture. Symptoms. — Shock is present as in other abdominal injuries, and is pronounced and frequently prolonged, but it may be absent, and when the rupture is uncomplicated by other injuries some time may elapse before other symptoms appear. These are pain, great desire to micturate, and straining, but inability to pass water. The spasms come on at intervals, and may be very severe. The abdomen is rigid, and tender on palpation. There is no dull- ness corresponding to a distended bladder, and the patient has not passed water for several hours. Per rectum there is bulging in the pouch of Douglas. On a catheter being introduced a little bloody urine is with- 2 b 418 THE BLADDER [chap. drawn. Rarely the catheter passes through the rent in the bladder wall into the peritoneal cavity, and a very large quantity of urine can be drawn off. If a catheter is passed several times within a short space it is -found that the quantity of urine in the bladder is always the same, for any excess of fluid escapes into the peritoneum. If, after emptying the bladder, the patient be set upright for a very short time, a quantity of urine will be found to have filled the bladder again, having passed in from the peri- toneal cavity (Morel). When the rupture is extraperitoneal, dullness appears above the pubes, and there are tenderness and rigidity. The infiltration spreads in the pelvis and escapes by the sciatic notch into the buttock, by the obturator foramen, into the upper part of the thigh, or along the inguinal canal into the scrotum. Abscess formation and the development of fistulae follow, and then thrombosis of veins and septicaemia. In intraperitoneal rupture, peritonitis appears within the first twelve hours, the abdomen becomes distended, there are vomiting, hiccough, a rapid pulse, and other signs of severe peritoneal infec- tion. Death may rarely take place without signs of peritonitis, and is then probably due to the toxic effect of the urine. In a case of partial rupture of the bladder which I was asked to see by my colleague Mr. Jackson Clarke, a boy aged 5 was knocked down by a motor car, but it was doubtful if the wheels had passed over him. Soon after the accident he passed urine containing bright blood. Seven hours after the accident he was suffering from shock, there was a hsematoma over the left iliac crest, left loin, and left inguinal region. The abdomen was slightly rigid, and there was tenderness to the right of the umbilicus and in the hypogastrium. The pelvic girdle was intact. On passing the catheter, clear urine flowed at first and was followed by bright blood. The blood disappeared from the urine in twenty-four hours. Cystoscopy six days after the accident showed the whole mucous membrane of the bladder dotted with tiny petechiee like a rash ; in some places they were grouped. On the right side of the bladder near the apex there was a gutter -like tear of the mucous membrane about | in. in length. The edges were sharp, raised, and slightly everted. The base was red and granular. (Plate 30, Fig. 3.) Convalescence was uneventful. Diagnosis. — The diagnosis depends upon the history of an injury and the feeling of something having given way, followed by strangury and the inability to pass urine, and by the bladder being found empty with the catheter, or only a small quantity of blood-stained urine being withdrawn. xxxij RUPTURE OF BLADDER 419 From rupture of the urethra the diagnosis is made by the absence of blood at the meatus and of perineal swelhng, both of which are characteristic of injuries to the urethra. In rupture of the kidney there may be symptoms similar to those of rupture of the bladder. The history of the blow in the lumbar region, the comparative absence of bladder irritation, and the absence of pain in passing water, together with tenderness in the loin, are characteristic features of renal injury. In cases of fracture of the pelvis it is often doubtful if the bladder is ruptured, and the more so that retention of urine is frequently present. In these cases the bladder will be found distended. On rectal examination the pouch of Douglas is not filled with fluid. On passing a catheter the urine is drawn off, while in rupture of the bladder a small quantity of blood-stained urine dribbles feebly away. The injection of fluids into the bladder in order to ascertain if a smaller quantity is returned, and thus assist in the diagnosis of rupture, is to be deprecated, for there is very grave danger of carrying infection and increasing the extravasation of fluid. The inflation of the bladder with air, which will escape into the peritoneal cavity and obliterate the liver dullness, is equally dangerous. Cystoscopy is only of service in partial rupture ; in complete rupture it is not of diagnostic value, as distension of the viscus cannot be obtained. When there is a fracture of the pelvis the rupture is more likely to be extraperitoneal. Here also there are no signs of peri- tonitis and no rigidity of the abdominal muscles. In the rectum the finger can feel a tender swelling, and there may be ecchymoses around the anus. Exploration of the bladder by suprapubic cystotomy is the most satisfactory method of making an exact diagnosis, and is a preliminary to treatment. Treatment. — In complete rupture operation should be per- formed as soon as the diagnosis is made, unless the shock is very profound, when a few hours' delay is permissible in order to allow the patient to rally. When the diagnosis of intraferitoneal rupture is clearly estab- lished, the abdomen is opened in the middle line below the umbilicus, and the urine and blood mopped up. The patient is then raised into the Trendelenburg position, the intestines packed aside, and the peritoneal surface of the bladder carefully examined. If the opening is within reach its extent is examined and brought up as near the surface as possible, and sutured in two layers, and Lembert's sutures added. A catheter should be tied in the urethra and a drain placed in the peritoneum. If the wound, from its 420 THE BLADDER [chap. position, is inaccessible, it will only be possible to drain the peri- toneum and to tie a catheter in the urethra. When the rupture is extraferitoneal a suprapubic incision is made down to the bladder and the anterior face examined. If the rupture is easily accessible it is sutured and a suprapubic drain inserted in the bladder. If the rupture is inaccessible — a very rare condition when the Trendelenburg position, good re- traction, and proper lighting are used — the bladder is drained suprapubically, and if necessary a counter-drain is inserted in the perineum. Results. — Dambrin and Papin found that the mortality of operations in intraperitoneal rupture was 43-5 per cent, in 78 cases, and when only the last six years were taken the mortality fell to 20-5 per cent. Death, when it occurred, was due to peritonitis, shock, Urinary toxaemia, and haemorrhage. The earlier operation is performed in intraperitoneal rupture the better the prognosis. Of 13 cases operated on within the first twelve hours after the injury, 8 recovered ; while of 21 cases operated on after this limit, 15 died (Zuckerkandl). At the same time it is never too late for operation, for recoveries have been recorded when six days have elapsed (Blumer), and Quick successfully operated on a case ten days fourteen hours after the injury. In non-operated cases of extraperitoneal rupture Zuckerkandl gives a mortality of 27 per cent. Collected cases in which there was urinary extravasation show a high operative mortality. Mitchell collected 90 cases with a mortality of 83 per cent, in 1898. Of 49 collected cases of extraperitoneal rupture, Wolfer found that 6 were fatal, and of 18 cases of intraperitoneal rupture 9 were fatal. WOUNDS Bullet wounds of the bladder are not common, but Bartels could collect 285 cases from the literature. Both in civil and in military practice they are usually incurred when the bladder is distended. Stab wounds of the bladder from a bayonet or dagger are rare. Accidental wounds during surgical operations are met with when the bladder is drawn into a hernial sac, in operations on the uterus, and in symphysiotomy. Falls upon sharp objects on which the patient is impaled are not infrequent. Puncture of the bladder base during attempts at abortion has been recorded. The wound is almost invariably complete, and frequently double. It may be intra- or extraperitoneal. Bladder wounds are usually complicated by injury to the xxxi] WOUNDS OF BLADDER 421 I)()iiy pelvis, I'ccfun), utciiis, va<^iiia, or iiiciJira. Foicij^ii bodies are fre(|U('iitly cai'ried into the wound, with ('(xiscMuieut infection. Ill intraperitoneal wounds a small opening may rarely be plujrfied by omentum or adherent bowel. Usually there is extravasation of urine, followed by acute peritonitis. In extraperitoneal wounds there are extravasation and suppuration, leading to urinary fistulae. Symptoms. — Shock is usually present, and may be profound. There are pain, tenesmus, and frequent desire to pass water, with inability to do so ; often a few drops of blood are passed after much straining. Rectal spasm may also be present. Urine mixed with blood may escape by the wound, especially when it is extensive. The escape of urine may be prevented by plugging of the wound with bowel, or by the urine escaping into the peritoneal cavity through a second wound. In other cases, in which the wound is small and the track oblique, urine may only escape during attempts at micturition. Occasionally there is profuse haemorrhage from the external wound. Faeces and flatus may escape from the wound with the urine when the rectum is wounded. Spontaneous closure of a small intraperi- toneal wound has been observed (Makins), but this is rare, and peritonitis almost invariably supervenes. The peritonitis may be delayed until the separation of sloughs on the seventh or eighth day. In small, oblique extraperitoneal wounds there is perivesical and periurethral extravasation of urine which becomes infected. This is followed by thrombosis in the vesical and prostatic veins. Fistulae are very common, especially after bullet wounds. Recto-vesical and vesico-vaginal fistulae, and surface fistulae on the abdomen, scrotum, perineum, thighs, and buttocks, result from suppuration and urinary infiltration. Bartels found that 23 cases out of 67 had a fistula for from six to twelve months, and in 5 the fistula was permanent. In many cases foreign bodies, such, as bullets, fragments of bone, etc., are found in the bladder, and phosphatic calculi containing foreign bodies are frequent. Diagnosis. — The escape of urine from the wound and the presence of blood in the urine passed or drawn by a catheter, and tenesmus of the bladder, are sufficient to establish the diag- nosis. Examination of a perineal wound with a metal instru- ment in the bladder will assist. The diagnosis as to whether the wound is extra- or intraperitoneal may be impossible at first, _ and it is important not to wait until symptoms of peritonitis appear before operating. Prognosis. — Intraperitoneal wounds are grave from the cer- tainty of infection and the frequency of injury to other organs, 422 THE BLADDER [chap, xxxi such as the bowel. Extraperitoneal wounds have a much better prognosis. Treatment. — The treatment is that of penetrating wounds of the lower abdomen. Laparotomy should be performed as early as possible, and the peritoneal surface of the bladder exam- ined and any wound closed. Wounds of the intestine are searched for and sutured. If the bladder wound is not found on the peri- toneal surface the peritoneum is closed and the anterior surface of the bladder examined. If a wound is found it may, if the position is suitable, be used to drain the bladder, or the wound may be closed and a catheter tied in the urethra. When the bladder has been wounded from the perineum the wound should be carefully examined and free drainage provided. If symptoms of peritonitis supervene the abdomen should be opened. The treatment of fistulse is described later (p. 523). LITERATURE Ashurst, Amer. Journ. Med. Sci., July, 1906. Bartels, Arch. f. hlin. Chir., 1878, p. 519. Berndt, Arch. f. hlin. Chir., 1899. Blumer, Brit. Med. Journ., Dec. 22, 1900. Dambrin et Papin, Ann. d. Mai. d. Org. Gen.-Urin., 1904, p. 641. Goldenberg, Beitr. z. hlin. Chir., 1909, p. 356. Makins, Surgical Experiences in South Africa. Mitchell, Ann. Surg., 1898, p. 157. Morel, Ann. d. Mai. d. Org. Gen.-Urin., 1906, p. 801, Murray, Liverpool Med.- Chir. Journ., 1906, p. 159. Quick, Ann. Surg., 1907, p. 94. Seldowitsch, Arch. f. hlin. Chir., 1904, p. 859. . Treves, Brit. Med. Journ., 1900. Wolfer, Theraf. Gaz., Dec. 15, 1910 CHAPTER XXXII CYSTITIS Etiology. — Inflammation of the bladder is due to the combina- tion of a bacterial infection with some factor which produces lowered resistance. An injury will cause cystitis, and repeated injuries, such as are produced by the presence of a stone in the bladder, will lead to the persistence of the cystitis ; but if the injury is not repeated the inflammation is transient, and if the cause of repeated in- juries (such as the stone) is removed the cystitis spontaneously disappears. In some cases the presence of bacteria of most virulent type in the urine without any known local cause of diminished resistance gives rise to cystitis. On the other hand, if bacteria reach the healthy bladder by the urethra or through the kidneys, cystitis is not produced in the majority of cases. Urine which is swarming with bacteria may be passed through the bladder for years without producing cystitis. Pure cultures of bacillus coli and other bacteria have been injected in experimental work on animals, without producing cystitis. When, however, the penis has been ligatured, in addition to the injection of bacteria, cystitis is produced. The predisposing causes of cystitis, such as masturbation, affections of the female genital organs, pregnancy, stricture, enlarged prostate, calculus, foreign bodies, malignant growths, operations upon the bladder, atony from nervous disease, etc., may act by producing congestion or injury to the bladder wall or stagnation of the urine. They vary at different ages and under different conditions. In childhood and infancy cystitis is the frequent complication of vulvo- vaginitis, enteritis, and stone. In young men gonorrhoeal urethritis and stricture, in adult men stricture and atony of the bladder from nervous disease, in old men enlarged prostate, in women pregnancy and diseases of the uterus and ovaries, are the usual predisposing causes. Bacteriology. — A large variety of bacteria are found in the urine in cystitis, and a mixed infection is frequent. Cystitis due 423 424 THE BLADDER [chap. to the tubercle bacillus will be discussed separately. The bacillus coli communis occurs more frequently than other bacteria, and is often found in pure culture. Other bacteria that occur alone, or in mixed infections, are the staphylococcus, streptococcus, proteus, gonococcus, the pneumococcus of Fraenkel and of Fried- laender, the bacillus pyocyaneus, and the typhoid bacillus. In chronic cystitis anaerobic bacteria are frequently found. The streptobacillus fusiformis, bacillus ramosus, micrococcus fcetidus, and others may be found alone or with aerobic bacteria. The bacteriology of cystitis varies during the course of an attack, whether acute or chronic. At one time there may be a mixed infection, at another a pure culture. There is a tendency for certain bacteria to predominate, while others may be found in small numbers and have a feeble culture growth. When a dominant bacterium has been reduced in virulence or destroyed by vaccines, by bladder-washing, or by other means, other bacteria may be found to increase in numbers. Thus, in a case of almost pure bacillus coli cystitis the decline of this bacillus is not infre- quently marked by the appearance or increase of staphylococcus. The bacillus coli has a tendency to persist and to dominate the bacteriology of a mixed infection ; the strepto- and staphylo- cocci are readily displaced by other bacteria, while the pyocyaneus tends to persist. The urine remains acid in cystitis due to the bacillus coli and the gonococcus, and also in about half the cases of cystitis due to bacteria which decompose urea. Method of infection. — The bladder may be infected from the kidney, the bacteria being borne by the urine. The kidney may or may not participate in the inflammation, and the bacteria are usually blood-borne, and in the majority of cases bacillus coli is the infecting agent. Infection may be introduced by way of the urethra either by continuity of inflammation as in gonorrhoea or by the passage of an instrument. Bacteria may also reach the bladder through a cystotomy wound or a fistula, or from the rupture of an abscess or the formation of a fistula with the bowel. Pathological anatomy and cystoscopic appearances. — Except in the most severe varieties of cystitis, little or no change is found post mortem. It is, therefore, necessary to take advantage of the cystoscope in studying the appearances presented in cystitis. In the majority of cases of cystitis the inflammation does not affect the whole surface of the bladder mucous membrane. The base is most frequently involved, while the rest of the bladder may escape ; less frequently there is an area of cystitis at some xxxn] CYSTOSCOPY IN CYSTITIS 425 pail, ol l.lic orf^an, soincliiiics at the apex, while the base is slightly aft'ected. Occasionally there are patches ol' cystitis distributed over the bladder. In the more severe varieties of acute cystitis, and also in chronic cystitis, the whole of the mucous surface is usually inflamed. The earliest appearance of inflammation is engoigement of the capillary vessels, which appear as a fine intri- cate network. The mucous membrane becomes reddened and spongy or woolly, and the outline of the vessels grows less and less distinct until they are completely obscured. The sur- face is now bright red, and the mucous membrane thrown into stiff folds and ridges, with shreds of muco-pus or desquamated epithelium adhering to it. (Plate 31, Fig. 1.) Haemorrhages may occur into the subepithelial tissues and appear as dark-red or black spots or blotches surrounded by a halo of intense inflam- mation. If there are numerous haemorrhages the condition is known as haemorrhagic cystitis. In bullous cystitis the surface is covered with closely-set yellow semitransparent bullae. This appearance is usually confined to some part of the bladder, such as the orifice of a diverticulum, the neighbourhood of the ureter in a virulent descending inflam- mation, or the area arCund a malignant growth, or it may extend over the whole base. It may be quite evanescent. Small, closely grouped granules in the inflamed mucous membrane are character- istic of follicular cystitis. In cystic cystitis there are yellow sago-grain-like follicles which may be scattered or grouped together, and may be surrounded by a halo of inflammation, or by only a few injected vessels. (Plate 31, Fig. 2.) Groups of small cysts may form in inflamed areas and project from the surface in masses like bunches of grapes, or there may be solid projecting masses. In these cases there may be cysts in the ureter and renal pelvis. Stoerk and Zucker- kandl have found that the cysts result from the closure of the orifices of small invaginations of epithelium, or by the fusion of papillary excrescences on the surface. Adeno-carcinoma may take origin in these cysts. Extensive deposit of phosphatic salts may take place in patches, along the ridges of inflamed mucous membrane or over large areas of the bladder. This may be heaped up into irregular projecting masses. Necrosis of the superficial layers of mucous membrane mixed with fibrin forms a membrane which is cast off, and the con- dition is named croupous or diphtheritic cystitis. The infection in these cases is usually streptococcal. In very virulent infections exfoliation of the bladder mucous 426 THE BLADDER [chap. membrane may take place, and the necrosed membrane is passed as a cast of the bladder. Emphysema of the mucous membrane has been described. Ulceration is usually confined to the superficial layers. It is frequently found along the summit of ridges and folds, and may extend more widely. Less frequently there is a circumscribed deep round or oval ulcer, with a heaped-up, sharply defined edge. (Plate 31, Fig. 3.) I have also seen a spreading ring-like ulcer commencing at the apex and advancing to the base. Leucoplakia is found in stone and other conditions of chronic irritation, and there may be a single patch or several patches. The surface is dry, greyish or yellowish white, and parchment- like. The edges are irregular, and the surrounding mucous mem- brane is deep red and intensely inflamed. The epithelium becomes transformed into squamous epithelium, which is heaped up in thick masses. In chronic cystitis there are infiltration and sclerosis of the submucous tissue and muscular layer, and a great increase in the perivascular fat, which becomes fibrous and adherent. The bladder becomes contracted and the cavity permanently diminished. When cystitis complicates urethral obstruction there is thicken- ing of the bladder wall from hypertrophy of the muscle. In stricture, trabeculation is always less marked and saccu- lation less pronounced than in enlarged prostate. In the latter, sacculation with thinning and atrophy of the muscular layer is frequently present. Calculi often form in the bladder in chronic cystitis, especially when there are sacculi or residual urine. Symptoms. — The symptoms of cystitis are frequent micturi- tion, pain, and changes in the urine. Increased frequency of micturition usually draws attention to the condition. The frequency varies with the intensity of the cystitis. In slight cases the urine may be passed every two hours, and there is some urgency when the call to micturate is felt. In severe cases a few drops of urine are passed every few minutes, and necessity to pass water is uncontrollable, so that a form of active incontinence is produced. In the lesser grades the patient sleeps throughout the night, but in severe cystitis the call to mic- turate is powerful and frequent during the night as well as the day. The bladder may be so sensitive that spasm is induced by jarring the bed, or a breath of cold air, or a hot or cold drink. Polyuria frequently accompanies the frequent micturition, and is said to be due to a reflex influence on the kidney. It diminishes as the frequency subsides. Pain is present to a varying degree. There is scalding pain Fig. 1. — Acute cystitis. (P. 425.) Fig, 2.— Cystic cystitis. (P. 425.) Fig. 3. — Ulcer of bladder in cystitis due to Bacillus coli communis. (P. 426.) Fig. 4. — Tuberculosis of bladder ; group of caseous tubercles. (P. 439.) Fig. 5. — Tuberculous ulcer of bladder with caseous tubercles in vicinity. (P. 439.) Plate 31. xxxn] CYSTITIS: SYMPTOMS 427 aloii!^ lilic iiicl.Iira on passiiiif wat.cr, and inl.ciisc desire and pain when au at.tein])t is made to hold the urine. In niodenitely scivere cases there is diseonilort at the end of micturition, and a feeling that the bladder has not been emptied; and in severe cases a cramping pain at the neck of the bladder, in the rectum, along the urethia to the end of the penis, and sometimes radiating down the thighs. Pyuria is always present, but varies greatly in amount. The pus is mixed with mucus in varying proportion. It may form a haze which settles to the bottom of a glass as a billowy semitrans- lucent mass, or in more severe or chronic cases it forms a slimy tenacious deposit which clings to the bottom of the receptacle. The quantity of mucus and pus is not subject to sudden variation unless the cystitis is complicated by sacculation or diverticula of the bladder, pyelitis, or some other disease which permits of accumulation and sudden discharge of pus. The urine is mixed with blood in severe cases ; in less severe cases there may be terminal hsematuria. In most cases no blood is seen with the naked eye, but very frequently blood corpuscles are found with the microscope in the acute stage. Fever is not present unless cystitis is complicated by renal, prostatic, or some extravesical inflammation. There is tender- ness on pressure above the pubes and on rectal and vaginal exam- ination. The bladder wall can be felt from the rectum thickened and contracted. The capacity of the bladder is reduced to a degree corresponding to the intensity of the inflammation. In acute cystitis the bladder may not retain more than |^ oz. of fluid ; in less acute cystitis the organ may hold 1 oz. or several ounces. Cystoscopy is difficult and may be impossible in acute cystitis, and it is advisable to wait until the acute stage has passed before using the cystoscopy There is difficulty in obtaining adequate distension of the organ or a medium clear of pus and blood. Cystoscopy shows that in a large proportion of cases of cystitis the inflammation affects a small area of the bladder, usually at the base. When the inflammation is descending and mild, an area surrounding one ureter and involving the trigone is alone affected ; when inflammation has reached the bladder by ex- tension from the urethra (urethro-cystitis) the trigone is most acutely inflamed. In other cases cystitis consists of scattered patches of inflammation over the mucous surface or of an inflamed area at the apex or elsewhere. The illumination is more difficult in cystitis than in a normal bladder, for the reflecting property of the mucous membrane is diminished by desquamation of the surface epithelium. 428 THE BLADDER [chap. The appearances seen on cystoscopy have already • been described (p. 424). / Complications. — Retention of urine may occur as a compH- / cation of cystitis, usually in cases of stricture of the urethra or of enlarged prostate, but also in atony of the bladder from neryous" disease. Ascending infection of the kidneys is a (.onstant danger, V especially wFeii' obstnrciroFTi''^present, and is the cause of "dSa^ in most of the fatal cases of cystitis. —- """"Abscess of the wall of the bladder, or surrounding a saccule, or in the perivesical tissue, may complicate chronic cystitis. Diagfnosis. — The diagnosis of cystitis involves a number of questions : 1. Are the symptoms due to cystitis or to some con- dition outside the bladder? (a) Extra-urinary causes of vesical symptoms. — Pain in the bladder of a dull constant aching char- acter, sometimes also in acute attacks, may occur in tabes, and reflex pain is observed in, cases of haemorrhoids and anal fissure, and there is a condition known as " neuralgia " of the bladder in which pain is present without recognizable cause. In these con- ditions there is pain but no pyuria. Frequent micturition may also be caused by extravesical con- ditions, such as pregnancy, ovarian or fibroid tumours, prolapse of the uterus. Here also pyuria is absent. (b) Urinary causes of vesical symptoms without cystitis. — Frequent micturition may be due to the passage of large quan- tities of urine in diabetes mellitus, diabetes insipidus, hysterical polyuria, etc. In such cases pain is usually absent, but there may be dull aching vesical pain. In highly acid urines and urines containing oxalate crystals, and in phosphaturia, frequent and urgent micturition with pain is often present. The condition of the urine, the absence of pus, and the effect of treatment distinguish these cases. Occasionally frequent micturition due to urethral obstruction in stricture may be ascribed to the effect of the obstruction on a sensitive bladder, apart from cystitis. In enlarged prostate frequent micturition is an early and pro- minent symptom when no cystitis is present. This is due partly to the pressure of the enlarging prostate on the base and sphincter of the bladder, and partly to the exposure to the urine in the bladder of the sensitive mucous membrane of the prostatic urethra, which is dragged up through the vesical sphincter by the intra- - vesical projection of the prostate. Urethral polypi in the male or female urethra may cause fre- quent painful micturition. Reflex bladder pain and frequency of xxxn] PRIMARY AND SECONDARY CYSTITIS 12') micturition are coininoii in coitaiii diseases of the kidney, notably in tuberculous disease, calculus, and pyelitis. In these cases the ureter of one side may show congestion and other slight changes, and the trigone be infected, but usually no changes referable to cystitis can be found in the bladder. In pyelitis the frequency is principally nocturnal. The diagnosis is made by the discovery of pus and bacteria in the urine and by the use of the cystoscope. 2. Is the cystitis primary or secondary ? — This question only applies to the condition at the time of the examination, for the bladder is an internal organ at which bacteria arrive by the urethra, the ureter, or the blood stream, or from the bursting of an abscess through the bladder wall ; and primary infection in the strict sense only occurs in cystotomy or other wounds of the bladder. In a secondary cystitis the removal of the primary extravesical focus is followed by disappearance of the cystitis. The bladder may be infected from the kidney in cases of renal calculus, pyonephrosis, pyelonephritis, renal tuberculosis, etc., or there may be infection from the urethra (urethro-cystitis) in acute, subacute, or chronic urethritis. The source of infection in subacute and chronic -cases is the prostatic urethra, and there is usually chronic prostatitis as well. In renal suppuration there may be symptoms of disease of the kidney, such as pain, tenderness, enlargement of the kidney ; and if no cystitis is present, tenderness of the bladder and pain on distension with fluid are absent. The urine sometimes con- tains cells from the renal pelvis, and tubules, and occasionally tube casts, while vesical epithelium is absent. The reaction of the urine in renal affections is usually acid from the blending of acid urine from the second kidney ; but this is not a reliable point in diagnosis, for the urine may be alkaline in renal disease and acid in some forms of cystitis. The pus in pyelitis or pyelonephritis, and especially in pyonephrosis, is greater in quantity than in cystitis, and forms a heavy, flat layer at the bottom of the glass ; and it is liable to sudden and marked variations in quantity. In cystitis the pus is mixed with mucus, and forms an irregular deposit which is slimy and tenacious. Variations in quantity do not occur. When cystitis complicates suppurative renal disease, the combination of a heavy substratum of pus with an upper layer of muco-pus is observed. The diagnosis of cystitis secondary to renal disease is made by the cystoscopic inspection of the ureteric orifices. The inflam- matory area may surround one ureter, or it may affect the whole bladder surface. The orifice shows inflammatory changes, and 430 THE BLADDER [chap. the efflux is purulent. In slight cases the ureteral catheter may be necessary to ascertain the origin of the infection. In urethro-cystitis there are signs of urethral inflammation, and the use of the urethroscope and cystoscope confirms the diagnosis. Entero-vesical fistula may be the cause of acute cystitis, and of chronic cystitis with acute exacerbations. The diagnosis is made by examination of the urine and by cystoscopy. 3. In primary cystitis, what is the cause ? — Acute sponta- neous cystitis is most frequently due to the bacillus coli, but also to other bacteria. Subacute and chronic cystitis may be purely bacterial, or there may be a diverticulum, stone, or growth of the bladder with secondary infection. Of cases of malignant growth of the bladder, 40 per cent, come under observation as cases of chronic spontaneous cystitis. The urine in all subacute chronic cases should be carefully examined bacteriologically and histo- logically, and the bladder inspected with the cystoscope. Prognosis. — In acute cystitis without complications the prog- nosis is good. The attack lasts from two to four or five weeks, and, if there is no focus of recurrent infection inside the bladder, recovery is usually complete. When a diverticulum or sacculi of the bladder are present, recurrent attacks, and eventually chronic cystitis, may be expected. Cystitis complicated by urethral obstruction rarely disappears unless the obstruction is completely removed. Cystitis in an atonic bladder in nervous disease usually becomes permanently established, and the chronic inflammation is subject to acute exacerbations from time to time, usually as the result of infection from outside sources. When suppuration in the kidney is the primary disease and cystitis is secondary, the latter will not be relieved until the renal infection is removed. Ascending pyelonephritis is the flnal stage of most of the fatal cases of cystitis. The infection may ascend spontaneously or may follow upon bladder-washing. Treatment. Acute cystitis. — In acute cystitis the patient should be confined to bed and treatment chiefly directed to sooth- ing the inflamed bladder. The diet should consist mainly of milk, eggs, custards, soups, and light farinaceous foods. Alcohol should be interdicted. Diuretics such as Contrexeville, Vittel, Vichy, and Evian waters, barley water, buchu and parsley tea are administered to render the urine less irritating. When the urine is acid the administration of alkalis is of great value. Citrate of potash 20 gr., pot. bicarb. 20 gr., magnesium sulphate 30-60 gr., and liquor potassae 5 minims, may be given, and sandalwood oil has a soothing eft'ect (10 minims in capsule or emulsion). To XXXII] CYSTITIS: TREATMENT 431 reduce the painful spasm of the bladder the following are useful, viz. : tincture of belladonna 5 or 10 minims, tincture of hyoscyamus 15 minims, tincture of opium 5-15 minims, and bromide of cam- phor 5 gr., by the mouth ; and lupulin 4 gr., extract of belladonna J gr., and morphia l-^ gr., given singly or in combination as sup- pository, and repeated twice or thrice in the twenty-four hours provided morphia and belladonna are not being administered by the mouth. Hot sitz-baths are given twice or thrice a day, the patient being well covered up during the bath, which lasts for ten or twenty minutes, and thoroughly rubbed down afterwards. Hot fomentations, to which laudanum may be added, are applied to the lower abdomen and perineum, and when intense strangury is present a small enema of hot water containing antipyrin 20-30 gr., or a vaginal douche of similar composition, may be given. Two teaspoonfuls of starch and 15 or 30 minims of tincture of opium may be added to the enema. Occasionally a hypodermic injection of morphia J gr. with atropine jljy gr. may be necessary. The bowels should be freely opened by a smart saline purge, and a daily aperient such as Apenta, Hunyadi Janos, or cascara given. No attempt should be made to wash the bladder at this stage. In very painful cystitis an instillation of a few drachms or ounces of distilled water containing antipyrin 2 per cent., and laudanum | to 1 per cent., or of orthoform 5 to 10 per cent., in oil, may be cautiously introduced. Subacute cystitis. — The acute stage lasts from three to ten days, and is followed by a subacute stage. In subacute cystitis the patient may be allowed up and a less restricted diet per- mitted, but all highly spiced foods, cm'ries, much meat, coffee, and all alcoholic drinks are forbidden. Urinary antiseptics should be administered by the mouth, such as urotropine, hetralin, or helmitol 10 gr. of each, urodonal 1 drachm, and salol 5-15 gr. ; and sometimes benzoate of soda or ammonia 10 gr., and boric acid 15 gr., will be found valuable. If the cystitis is due to the bacillus coli or to other bacteria which flourish in an acid urine, alkalis should be given. If, on the other hand, the urine becomes alkaline from ammoniacal decomposition owing to the presence of the bacillus ureae lique- faciens in mixed infections, alkalis should be withheld, and dilute mineral acids, benzoate of soda and ammonia, and boric acid given. Sodium acid phosphate 20-30 gr. is especially useful, together with large doses of urotropine or other urinary antiseptics. Bladder-washing should be commenced when the acute symptoms 432 THE BLADDER [chap. have passed off. Vaccine treatment with an autogenous vaccine will be found of use in this stage. Chronic cystitis. — In chronic cystitis a very careful examina- tion with the cystoscope is necessary to ascertain whether there is some factor such as renal suppuration, stone, enlarged prostate, or diverticula which may act as a contributory cause and prevent resolution of the cystitis. Should any such complication be present it must be dealt with before the cystitis can be cured. The treatment is similar to that of subacute cystitis. The only restrictions of diet that are necessary are the avoidance of articles such as curries and all highly spiced foods and alcohol. Alkalis or acids and urinary antiseptics are administered as in subacute cystitis. Bladder-washing plays a prominent part in the treatment ; a visit to one of the Continental spas, such as Wildungen, Contrexe- ville, or Vittel, is frequently of great service. Vaccine treatment is occasionally beneficial, while drainage of the bladder with daily flushing or continuous irrigation may become necessary. Bladder-washing. — This is suitable for subacute or chronic cystitis. A large rubber or silk-wove coude catheter with a trumpet-shaped outer end is sterilized and carefully passed into the bladder. An irrigating can hung 2 or 3 ft. above the level of the recumbent patient contains the solution selected, the tempera- ture of which is about 100° F. A glass bladder syringe with metal fittings and asbestos plunger may be used to replace the irrigator. The fluid is allowed to flow through the catheter slowly until the patient begins to feel slight discomfort, when the nozzle is removed and the fluid run off. Several pints of solution are used in this way, and the mechanical action of free washing with large volumes of fluid plays an important part. A double-way catheter does not wash the bladder so thoroughly as a single-bore instrument. In some cases masses of tenacious muco-pus adhere to the bladder wall or obstruct the lumen of the catheter. In acid cystitis a preliminary washing with a weak alkali such as bicarbonate of soda, 1 or 2 per cent., is useful, while in very alkaline cystitis with deposit of phosphates I have found much benefit from the use of a weak solution of acetic acid, ^ per cent. Solutions that may be used for washing the bladder are potassium permanganate 1 in 5,000 or 10,000, oxycyanide of mercury 1 in 1,000 or 5,000, biniodide of mercury 1 in 10,000 or 20,000, tincture of iodine i-1 drachm to the pint, nitrate of silver 1 in 10,000 or 20,000, peroxide of hydrogen 1 in 10 or 1 in 20 of the twenty volumes, lysol |-1 per cent., protargol | per cent. xxxii] DRAINAGE IN CYSTITIS 433 Instillations. — The instillation of small quantities (-|-2 drachms) of more powerful solutions is sometimes useful. These are introduced by means of a small syringe and catheter such as Gruyon's syringe. Iodoform in sterilized liquid paraffin (5 per cent.) is a useful solution ; the oil floats in the urine, and, if the patient is careful to stop micturition before he has completely emptied his bladder, some of the solution may be retained in the bladder for several days. Gomenol is analgesic as well as antiseptic ; it is used in oil solutions of 5 to 20 per cent., and may also be given internally in capsule. Silver nitrate 2 per cent., protargol 2 per cent., and acid picric |-1 per cent., may also be used. In chronic alkaline cystitis instillations of lactic acid bacillus in the form of trilactine may be beneficial. I have instilled ^-1 drachm of freshly prepared trilactine daily after washing the bladder with sterile water, with marked improvement in the condition of the urine. Bladder drainage. — Drainage of the bladder is very excep- tionally required in acute cystitis, and then only in the rare cases of fulminating cystitis with sloughing of the mucous membrane. It is chiefly of use in intractable subacute or chronic cystitis, and may be carried out through the urethra, or by the perineal or the suprapubic route. In urethral drainage a catheter is " tied in." A silk-wove coude catheter (No. 10 Fr.), a Jacques rubber catheter, or a Pezzer's self-retaining rubber catheter is used. In the female subject the last is most suitable, and is introduced with a stilette. In the male subject the catheter is passed until the eye is just within the internal meatus, and its position is tested by injecting a little fluid with a syringe and allowing it to flow off, gradually withdrawing the catheter until the flow becomes arrested, and then pushing the catheter in again until the flow is re-established. Two strands of silk or two short strips of narrow tape are tied firmly around the catheter, without constricting its lumen, ^ in. beyond the external meatus, and if there is any tendency for them to slip a small safety-pin is oiled and passed through the tape and catheter at this point. The four tails of silk or tape are laid along the penis, and a strip of adhesive plaster 1 in. broad is wound round the penis over these, just behind the corona glandis, care being taken not to apply it so tight as to cause constriction. The ends of the tape may be turned back under a second round of plaster. The adhesive plaster may be applied longitudinally to avoid causing oedema of the foreskin. A short length of rubber tubing is attached 2c 434 THE BLADDER [cHAr. to the end of the catheter and carried into a bottle between the patient's thighs. If the catheter becomes blocked, this may be due to tenacious mucus or blood clot, or to gravel, or there may be a kink of a silk-wove catheter, or the instrument may have sHpped so that the eye is in the urethra. Perineal drainage is carried out by opening the membranous urethra on a staff by a median incision and introducing a rubber perineal drainage tube through the prostatic portion of the urethra into the bladder. A stitch through the edges of the wound fixes the tube, and a length of tubing carries the urine into a vessel. When a stiff gum-elastic tube is used, metal loops are provided for perineal tapes passing anteriorly in the fold of the groin and posteriorly in the fold of the buttock to a waist-band. The mor- tality of this operation is high — 25 per cent. — as it is frequently practised in severe cases, and often at a late stage. Suprapuhic drainage is carried out by distending the bladder with fluid and opening it by a vertical median suprapubic incision. The bladder should be thoroughly explored, and any cause for the persistence of the cystitis ascertained and, if possible, removed. In the case of a middle-aged woman whose bladder was encrusted with phosphatic deposit heaped up in parts so as to resemble a large phosphate-covered growth, I applied pure acetic acid to the interior, and afterwards washed the bladder with a weak solution of acetic acid for a fortnight. The recovery from a long-standing and intractable cystitis was rapid and uninterrupted. A large rubber drainage tube (f-1 in. diameter) is introduced, and the bladder wound closed around this with catgut stitches. A smaller tube is placed in the prevesical space. Both tubes are removed on the fourth day, and a smaller tube is introduced into the bladder. An alternative method is to stitch the edge of the bladder wound to the skin, but there is often diflficulty in obtaining healing later and a fistula persists. The mortality of suprapubic drainage is 10 per cent. (Joubert). In the female subject a fistula may be created between the bladder and the vagina for the purpose of draining the bladder. This is frequently successful in curing cystitis, but a fistula remains in 50 per cent, of cases. Comparative value of methods. — Urethral bladder drainage may suffice, but it is less thorough than either of the other methods. Suprapubic drainage is preferable to perineal unless there is a stricture of the urethra, when perineal drainage can be com- bined with external urethrotomy. In other cases the bladder can be more thoroughly explored by the suprapubic route, and drain- age and washing can be more easily carried out. The perineal XXXII] VACCINES IN CYSTITIS 435 tube does not drain the lowest part of the bladder, since the end of the tube projects into the bladder at the internal meatus, which is the highest part of the fixed portion of the bladder when the patient lies on his back. The suprapubic drainage tube passes to the bottom of the bladder, and this part is more readily drained and washed. Continuous irrigation. — This is carried out by the supra- pubic route, and can conveniently be arranged by using an Irving suprapubic drainage apparatus. Through the small hole in the lid of the apparatus a rubber catheter passes, and descends through the rubber tube in the suprapubic wound to the lowest part of the bladder. To the outer end of this catheter rubber tubing is attached, and leads from a reservoir placed above the level of the patient. The flow is regulated by screw clips so as to allow of a gentle continuous stream, and arrangements must be made for keeping the fluid in the reservoir warm. Serum and vaccine treatment. — Serum-thera'py consists in supplying the patient with antibodies contained in the serum of an animal artificially immunized by inoculation with bacteria. In acute cystitis this method may be useful. Antistreptococcic serum is obtained from animals inoculated either with one strain of streptococcus or with several strains from different sources (poly- valent). Anti-colon-bacillus serum has not yet been widely used. The serum is injected subcutaneously, and a large initial dose (20 c.c.) is given, followed by smaller doses (10 c.c). Calcium lactate should be given at the same time as the serum in order to prevent serum rashes and joint troubles. Care must be taken not to continue the treatment too long, lest the state of hyper- sensitiveness to the serum, known as anaphylaxis, be produced. Vaccine treatment is most suitable for cases of subacute and chronic cystitis. It consists in the inoculation of the patient with graduated doses of vaccine with the object of increasing the resist- ance to the special bacteria by the production of antibodies. The vaccine should be prepared from cultures of the patient's urine. Stock vaccines are of much less value. The bacteriology of the urine is investigated, and if the infection is by a pure culture a vaccine from that strain is obtained. If several varieties of bac- teria are present the dominant species is selected, or if more than one grows luxuriantly a mixed vaccine is prepared. The vaccine consists of a measured number of the bacteria sterilized. For a period of forty-eight hours after the inoculation the resistance of the patient is lowered (negative phase), and then it rises, and remains high for several days, falling again to its previous level or a little above it. For the earlier inoculation it is often 436 THE BLADDER [chap, xxxii necessary to examine the opsonic index, so that too large a dose may not be given and a second dose may not encroach upon the negative phase of a previous inoculation. In the majority of cases, however, it is possible to dispense entirely with this exam- ination, and to rely upon experience and clinical observation as guides to dosage. The inoculations should begin with small doses at intervals of three or four days,- the doses rising continuously, and the interval being extended to a week or longer. The more acute the disease the smaller the dose of vaccine. If possible^ a reaction should be avoided. It is shown by a feeling of malaise, pains in the back and head, and a slight rise of temperature, with increased irritability of the bladder. The most frequently used vaccine is that of the bacillus coli, and this may be employed alone when the culture is pure, or in combination with other vaccines when it is mixed. The inoculations can usually be commenced with a dose of 3 milUons given every three or four days, the dose being raised to 4 and 5 millions with extension of the interval to a week, and then to 10, 15, 20, 30, 40, 50, 60, 80, 100, 150, and eventually to 200 millions, and even higher. The staphylococcus is given in doses commencing at 100 to 250 millions, and rising to 500 or 1,000 millions ; the streptococcus in increasing doses of 2, 3, 5, 10, 20 millions, and more. The treatment may extend over several months. Vaccine treatment is frequently successful in reducing and causing the disappearance of cystitis, but in many cases bacilluria remains and resists all treatment, and at a later date relapses of the cystitis occur. LITERATURE Brown, Johns Hopkins Hosp. Repts., 1901, p. 1. Faltin, Ann. d. Mai. d. Org. Gen.- Urin., 1902, p. 176. Halle et Motz, Ann. d. Mai. d. Org. Gen.- Urin., 1902, p. 17. Joubert, VII^ Sess. de I'Assoc. frang. d'UroL, Paris, 1903, p. 7, Lichtenstein, Wien. Bin. Woch., 1904; ibid., 1907, Nr. 40. Melchior, Monats. f. d. Krankh. d. Ham- u. Sex.-Apparat., 1898, p. 581. Motz et Denis, Ann. d. Mai. d. Org. Gen.- Urin., 1903, p. 898. Motz et Montfort, A7in. d. Mai. d. Org. Gen.- Urin., 1903, p. 1211. Newman, Lancet, 1912, i. 490, 570. ' Raskai, Monats. f. Urol., 1905, p. 1. Stoerk, Zieglers Beitr. z. path. Anat., 1911, 1. 361. Stoerk und Zuckerkandl, Zeits. f. Urol., 1907, p. 3. Suter, Zeits. /. Urol., 1907, p. 97. Zuckerkandl, Monats. f. fjroL, Bd. vii. CHAPTER XXXIII TUBERCULOUS CYSTITIS Tuberculous cystitis is said to be primary or secondary, accord- ing to whether it is the original focus in the genito-urinary organs, or is dependent upon a tuberculous focus in the kidney or the male genital system. Primary tuberculosis in the strict sense that the vesical tuber- culosis is the primary focus in the body does not exist. Etiology. — Vesical tuberculosis occurs in youth and early adult life, and is more common in men than in women. Cases of senile vesical tuberculosis are occasionally observed. Primary tuberculosis invades the mucous membrane of the bladder by the blood stream. At the present time there is con- siderable doubt as to whether this form of tuberculosis ever occurs. The evidence for it is clinical and cystoscopic. The clinician finds that symptoms of vesical tuberculosis are present without symp- toms of renal or genital infection, and the cystoscopist sees tuber- culosis of the bladder mucous membrane while the orifices of the ureters are healthy. Neither of these observations is reliable, for it can be proved by catheterization of the ureters that under these conditions tuberculosis of the kidney may exist. Since I have relied upon the ureteral catheter in every case for a decision on this point, I have not met with a single case of primary tuberculosis of the bladder. In cystitis secondary to renal tuberculosis there is either direct spread by continuity along the ureter to the bladder, or the deposit of tubercle from the infected urine. In cystitis secondary to genital tuberculosis the tuberculous process either passes directly through the bladder wall from the seminal vesicles or prostate, or spreads from a dilated and tuberculous prostatic urethra into the bladder. In cases in which the bladder and kidneys are tuber- culous, much discussion has arisen as to whether the tuberculous process is primary in the kidney and the infection of the bladder a descending one, or the tuberculosis of the bladder is primary and the infection of the kidney ascending ' and secondary. At one time the ascending theory was universally held, and 437 438 THE BLADDER [chap. was based upon (1) the early appearance of vesical symptoms in urinary tuberculosis, (2) some post-mortem records, and (3) experimental work. Cystoscopy has proved that the early symptoms of cystitis in urinary tuberculosis are, in the majority of cases, reflex ; that the bladder is healthy, or at least non-tuberculous ; and that the kidney may be totally destroyed by tuberculosis without giving rise to renal symptoms. Post-mortem records which are quoted in support of the ascending view show the tuberculous process surrounding the ureteric orifice of the affected kidney, and might equally be quoted in proof of secondary descending infection of the bladder. Apart from cases of genital tuberculosis, tubercu- losis of the bladder is almost without exception accompanied by tuberculosis of the kidney ; whereas tuberculosis of the kidney, or kidney and ureter, is frequently present without tuberculosis of the bladder. The experimental production of ascending tuber- culosis of the kidney in animals by Albarran, Wildbolz, and others has proved that by injecting tubercle bacilh into the bladder and ligaturing the urethra, or into the ureter and ligaturing the ureter, a tuberculous infection of the kidney can be produced. In all these experiments the element of obstruction, temporary or permanent, is superadded to the introduction of the tubercle bacillus, a condition not found in tuberculosis in the human subject. Baumgarten has demonstrated that the tuberculous infection cannot spread against the stream of the secretion in which the bacilli are suspended. Not only does he deny the possibility of ascending infection of the kidney, but he holds that tuberculosis of the prostatic urethra cannot affect the epididymis by spreading back along the vas deferens. In the female the combination of urinary tuberculosis with genital tuberculosis is very rare, and the infection of the urinary from the genital tract does not occur. Pathology. — The distribution of the tuberculous process is frequently significant of its origin. It surrounds one ureter in cases in which the infection has spread along the ureter from the kidney. When the process has commenced in the seminal vesicle it is found immediately behind the trigone ; when a tuber- culous collection has ruptured through the bladder wall from the prostate a crater -like ulcer is foimd on one side of the trigone. In tuberculosis of the prostate tubercles may be found in the prostatic urethra, and tuberculous ulceration extending from this part of the urethra into the bladder. A tuberculous collection of the prostate may rupture into the prostatic urethra and spread xxxTTT] TUBRRGULOUS CYSTITIS 439 thence into the bladder, the outlet of the bladder and the prostatic urethra being sometimes indistinguishable. The tuberculous process commences in the mucous membrane as greyish tubercles surrounded by inflammation. (Plate 31, Fig. 4.) These become yellow from caseation and break down, forming a tiny superficial ulcer, the size of a pin's head, with sharply cut edges, and sometimes covered with blood clot. (Several of these fuse and form larger ulcers. Very extensive superficial ulceration may be present, covering a large area of the bladder wall. The exposed surface is pinkish- red and granular, and to it adhere numerous small white flakes. Deep ulcers may also be found. (Plate 31, Fig. 5.) They are round, oval, or serpiginous. The base is greyish-red and granular, the edge deeply undermined, and often with a thin, frayed margin of necrosing mucous membrane. The edge is not heaped up above the mucous membrane, and, where the condition is chronic, yellow tubercles are dotted around with little surrounding inflam- mation. Evidence of .healing may be found at one part of the ulcer, and of spreading at another. In chronic tuberculous cystitis where there is no infection by other bacteria the lesions are discrete, the intervening mucous membrane being healthy. If infection with other bacteria is superadded these characteristics are lost, but the serpiginous outline is retained. Irregular masses of granu- lation tissue may be found. Widespread infiltration of the sub- mucous tissue and of the muscular coat takes place. In long- standing tuberculosis the bladder becomes contracted and fibrous. The perivesical fat is thickened and fibrous, and the bladder becomes adherent to the rectum and intestine and, in the female, to the genital organs. The pelvic lymphatic glands are tuberculous, but the formation of a tuberculous abscess is very rare. In a few cases the bladder cavity remains large and the wall is trans- formed into a thin fibrous layer, the contractile power of which is lost. Together with these changes there is tuberculosis of the kidney on one or both sides, or tuberculosis of the seminal vesicles or prostate. Genital tuberculosis in the female is rarely found com- bined with vesical tuberculosis. Symptoms. — The symptoms are those of spontaneous cystitis in a young man or woman. The onset is insidious, and the pro- gress gradual but persistent. Variations in intensity of the symp- toms frequently follow dietetic indiscretions and chmatic changes. Frequent micturition is the earliest symptom. At first this is diurnal and moderate, the call coming every two or three hours, but it is progressive and becomes nocturnal and sleep is disturbed. 440 THE BLADDER [chap. Small quantities of urine are passed every quarter- or half-hour during the day, and slightly less frequently at night. Micturition is urgent, and if the patient sleeps heavily the urine is passed in- voluntarily. Pain and intense desire are felt at the neck of the bladder when the patient attempts to hold water too long. There is scalding along the urethra during micturition, and cramp-like pain in the bladder and pain at the end of the penis, or at the external meatus in the female. Hsematuria is a frequent symptom, a few drops of bright blood passing at the end of micturition. In some cases there are occasional attacks of more severe heematuria at long intervals. The urine is pale, faintly acid, of low specific gravity, and contains numerous fine dots and shreds, and a small quantity of pus well mixed, which gives it an opalescent appearance. Poly- uria is present, and may be ascribed to the reflex effect of the frequent contractions of the bladder, but is probably the result of tuberculous changes in the kidneys. The quantity of pus is small, but it is constant. The symptoms are unaffected by move- ment, but are influenced by dietetic indiscretions and cold damp weather. Complications. — Severe hsematuria is rare. Retention of urine is an unusual complication. It may occur when there is tuber- culosis of the prostate, and I have met with it twice as a post- operative complication lasting several days after nephrectomy for renal tuberculosis in women. The most serious complication is septic infection. The bacillus coli, staphylococcus, and strepto- coccus are the bacteria most frequently present, and are almost invariably introduced by the passage of instruments or by wash- ing the bladder. With the advent of a mixed infection the symp- toms increase in intensity. The cystitis, which may have been localized to one part of the bladder, becomes general, and septic pyelonephritis may be superadded to the tuberculous process in the kidney. Course and prognosis. — The course of tuberculous cystitis when instrumental interference is withheld is slowly progressive, with periods of improvement and periods of relapse, dependent partly upon changes of diet and climate. There may be a period of acute cystitis at the commencement, which subsides, a slight subacute cystitis persisting. More frequently, however, the onset is insidious and the progress very gradual. After some years the nocturnal calls to micturate become very distressing, and the patient is worn out with loss of sleep. If septic complica- tions are avoided, death takes place after some years from renal failure due to bilateral renal tuberculosis. More often there are xxxm] TUBERCULOUS CYSTITIS: DIAGNOSIS 441 septic coinplicatioiis, occasionally with secoiidaiy stone foniiatioii and subacute or chronic septic pyehMiephritis. Where vesical tuberculosis is secondary to renal tuberculosis which is unilateral, and nephrectomy is perfor)ned, the tu))erculous disease of the bladder may entirely disappear without further treatment. The same may occur when the lumen of the ureter becomes perma- nently obliterated without operation {closed renal tuberculosis). When the tuberculous process is secondary to disease of the pros- tate or seminal vesicle the prognosis is less favoura?jle, owing to the difliculty of eradicating the primary focus. Diagnosis. — The spontaneous development of slight persistent and progressive vesical irritation in youth or early adult life, when venereal disease can be excluded, should raise the suspicion of tuberculosis of the bladder. On cystoscopy the presence or absence of cystitis is definitely ascertained. If it is present, the following questions must be answered : — 1. Is the cystitis tuberculous ? — (a) Examination of the urine. The urine is pale, faintly acid, opalescent, with a small quantity of suspended pus, and contains small white dots and shreds. The discovery .of the tubercle bacillus in the urine is conclusive. The bacilli are more easily found when slight haemor- rhage is in progress. Failure to discover the tubercle bacillus on one occasion should not be accepted as final, and repeated exam- inations may be necessary. Inoculation of animals with the suspected urine should, if necessary, be carried out. (b) Tuberculous disease may be found in the epididymis, seminal vesicles, or prostate, or in the lungs or elsewhere in the body. (c) The cystoscope shows characteristic appearances. There are greyish-yellow opaque tubercles distinguished by being small, discrete, opaque, and having the appearance of pushing through the inflamed mucous membrane, which distinguishes them from the small cysts of cystic cystitis — semitransparent, often closely grouped, and set upon the surface of the mucous membrane, which is seldom much inflamed. Chronic deep ulceration with undermined edges, heahng at one part and spreading at another, is characteristic of tubercu- losis. There may be general acute cystitis, or extensive super- ficial ulceration, or heaping-up of granulation tissue, none of which is characteristic of tuberculosis. 2. Is the tuberculous cystitis secondary to renal or to genital tuberculosis ? — Basal grouping of the tuberculous cyst- itis behind or on one side of the trigone, together with nodules 442 THE BLADDER [chap. in the seminal vesicles or prostate, shows that the primary focus is in these organs. The presence of tuberculosis of the kidney is ascertained by Fig. 120. — Specimen of bladder, ureters, and prostate in case of urinary tuberculosis. Universal tuberculous ulceration of bladder, the wall of which is much thickened ; right ureter normal, left ureteric orifice dragged upwards and outwards and ureter thickened and dilated. There was advanced tuberculosis of the left kidney, examining the orifice of the ureter. Changes at the orifice and grouping of tuberculous inflammation round it show disease of xxxm] TUBERCULOUS CYSTITIS: TREATMENT 113 Mh'. corri'spoiidiiiif kidney. (Ki^j. l-<».) The Absence of cliaiiges ut (he secoiul ureteral oiifiee doe.s not exclude tuberculous disease of that kidney, and when both ureteric orifices are healthy renal tuberculosis may still be present. The only i-eliable test is the passage of the ureteric catheter and examination of the urine withdrawn by it for pus and the tubercle bacillus. Treatment. — When tuberculous cystitis is secondary to renal tuberculosis, the kidney, if one only is affected, should be removed, and in the majority of cases the cystitis diminishes and completely disappears. When bilateral renal tuberculosis is present, when the cystitis is secondary to tubercle of the prostate or seminal vesicle, when an active focus of tubercle exists elsewhere in the body, when no renal or genital tuberculosis can be demonstrated, or when the cystitis does not disappear after nephrectomy, other treatment is necessary. General treatment. — Residence in a warm, dry climate, such as Egypt and Algiers, has a very beneficial influence. Arcachon, Biarritz, and the French or Italian Riviera are also suitable resorts for these tuberculous patients. The food should be plain and nourishing. Articles known to irritate the urinary tract, such as curries and highly spiced foods, and all alcoholic drinks, should be avoided. Plenty of milk and eggs and cod-liver oil in suitable quantity should be taken. If the infection is mixed, urinary antiseptics should be used, but in pure tubercle they have no effect. Guaiacol, 5 minims in capsule, thrice daily, has been recom- mended, and cacodylate of soda, i-1 gr. hypodermically, or guaiaco- cacodylate, J-2 gr. hypodermically, and disodium methylarsenate, r-3 gr. hypodermically, have also been used. Sandalwood oil, 10 minims in capsule, should be given for its soothing effect on the bladder, and belladonna and hyoscyamus to reduce the spasm of the bladder. Tuberculin should be given in all cases, and very striking results are frequently obtained. The pain, frequency, and irrita- bility diminish, the blood disappears from the urine, and the patient increases in body weight. When the cystitis is secondary to renal tuberculosis marked improvement is observed in early cases, sometimes "with the disappearance of pus and tubercle bacilli for varying periods. The tuberculous disease of the bladder may completely disappear, and the ureter of the diseased kidney is found to be occluded. Relapses, however, occur, and observa- tions extending over a few months are worthless in regard to the permanence of the cure. In genito-urinary tuberculosis the re- sults are less favourable, but amelioration of the symptoms may 444 THE BLADDER [chap, xxxiii be anticipated, and ' occasionally the genital tuberculosis heals under the treatment. The method of administration has been described elsewhere (p. 238). Local treatment. — I am opposed to the local treatment by means of bladder-washing and instillations. Temporary improve- ment is observed in many cases, but septic complications almost invariably supervene and the patient is placed in a much worse condition. As, however, this view is not universally held, the following details of these methods are given: The bladder has been washed with boric acid and other solutions containing anti- pyrin or opium to soothe the pain. Instillations of |-1 drachm of various drugs have also been given with a small syringe under strict aseptic precautions. Corrosive sublimate is used in strengths of 1 in 10,000 up to 1 in 5,000, the injections being repeated every two or three days and continued for a long time. With iodoform in liquid paraffin, 5 per cent., may be combined guaiacol, 5 per cent., which has the advantage of being analgesic. Gomenol, 10 or 20 per cent., in oil, has been instilled daily, or given in alter- nation with the corrosive sublimate instillations. Picric acid, J-l per cent,, and carbolic acid, 5 per cent., have also been used. Treatment by direct appHcations may be made in either sex through Luys' direct cystoscopy In this way ulcers may be scraped or cauterized with the electric cautery, with nitrate of silver, or lactic acid. Cystotomy may be performed either for drainage alone or for drainage after treatment of the tuberculous ulcers. In the extremely rare cases where a single ulcer is present it is excised. In other cases the ulcers are curetted, cauterized, or treated with silver nitrate, chloride of zinc, or other caustics, and the bladder is drained. Suprapubic cystotomy is prefer- able to perineal cystotomy, for it permits of local applications. Temporary relief may be obtained by these methods, but in a few months the condition relapses, and sepsis is invariably super- added, so that the condition of the patient is worse than before the operation. LITERATURE Casper, Deuts med. WocJi., 1900, p. 661. Fenwick, Trans. Med. Soc, 1905, xxvii. 242. Halle et Motz, Ann. d. Mai. d. Org. Gin.- JJrin., 1904, p. 161. Karo, Med. Bee, Oct. 2, 1909. de Keersmackers, CentralU. f. d. Kranhh. d. Earn- u. Sex.-Org., 1906, p. 413. Pardoe, Lancet, 1905, ii. 1766. Rovsing, Arch. f. Bin. CMr., 1907, p. 1. Suter, CentralU. /. d. Kranhh. d. Ham- u. Sex.-Org. , 1901, p. 657. Walker, Thomson, Pract., May, 1908. CHAPTER XXXIV OTHER INFECTIONS OF THE BLADDER BILHAEZIOSIS Etiology. — Bilharziosis is caused by a trematode worm named the Bilharzia hcematohia or Schistosomum hcematohium. The disease is endemic in certain countries. In Africa, in- cluding Egypt, it is most prevalent, especially in Lower Egypt, where it is found in about one-third of the autopsies. Ferguson states that about one-half of the agricultural population of Egypt are shedding blood and bilharzia ova in their urine and faeces daily — a very serious drain on themselves, and a constant menace to their neighbours as a source of infection and re-infection. He found the disease present post mortem in 40 per cent, of 600 male subjects from 5 years of age upwards. Madden found that 10 per cent, of 11,698 patients had bilharziosis. It occurs also in Tunis, Algiers, on the west coast of Africa (Nigeria, etc.), and on the east coast (Abyssinia, Zanzibar, Madagascar). In South Africa it is common in Delagoa Bay, Natal, the Eastern Province of Cape Colony, and the Transvaal. The disease has been met with in Japan and China. In England a large number of cases were imported after the South African War. Major Smith, R.A.M.C., reports : "In ordinary times soldiers serving in South Africa were little subject to the disease, and it seems to have been of very minor importance as a cause of ill-health in former cam- paigns in that country. The Army Medical Department Reports for the period 1890 to 1898, when the garrison had an average numerical strength of 4,164, made no mention of bilharzia, while the reports dealing with the sick statistics of the Zulu and first Boer Wars contain no reference to it." The actual number admitted to hospital during the South African campaign (1899- 1902) was 187, but the slighter cases were probably unnoticed or disregarded. All the cases that came under observation were mild (Simpson). Mode of infection. — Infection takes place after bathing or prolonged immersion in infected rivers or pools, and, it is also 445 446 THE BLADDER [chap. stated, from the constant soaking of the bare feet in the rice fields. The incubation period is about three to six months. Males are much more frequently affected than females in the proportion of 93-2 males to 6-8 females (Madden). The disease is very common in boys ; Kautsky found that 79 per cent, of boys in a school near Cairo had bilharziosis. Agricultural labourers and dwellers in the country are more frequently affected than town dwellers. Looss found that 30-5 per cent, of boys in a school in Cairo, and 80 per cent, in a school in the outskirts of the same town, had hsematuria. The path by which invasion takes place is disputed. (a) The stomach. — ^The embryo is supposed to be swallowed in the water during bathing or in drinking water. Against this theory is the fact that the embryo is killed by a much weaker solution of hydrochloric acid than is present in the normal stomach. (b) Through the urethra or anus. — Allen holds that the parasite enters the urethra during prolonged immersion in infected water, and that it is more likely to do so if there is a long prepuce and care is not taken to dry the parts thoroughly after bathing. Cir- cumcision he regards as a valuable preventive measure. (c) Penetration of the skin. — This is held by most authorities to be the probable path of invasion. It is chiefly male earth- workers in country districts and their children who are affected. Life-history of the trematode. — The male worm is 1 cm. long, flat, and with the lateral margins incurved to form a canal, and the female 2 cm. long ; they are thread-like, and possess two suckers. The sexes are separate in the early stage, and at this time they occupy the portal vein. With sexual maturity they unite and find their way against the blood-stream to the veins of the submucous tissue of the bladder and rectum. (Fig. 121.) The eggs deposited by the female penetrate the mucous mem- brane, and are shed and appear in the urine and faeces. The ova are elliptical, and are contained in a thin yellow envelope which has a spine at the posterior end. Larger ova with a lateral spine are also found, most frequently in the liver or the rectum, and are probably deformed. If the ovum is placed in fresh water a ciliated embryo (Miracidium) escapes from the envelope and swims vigor- ously, and can be kept alive for twenty-four to forty-eight hours. The length of life of the worms is unknown. When they die the supply of ova ceases and the symptoms subside and disappear. The severe cases met with in Egypt are probably the result of often- repeated infection. Pathology. — The disease affects the ureter (Fig. 121), bladder (Figs. 122, 123), urethra, and rectum, and rarely other parts of the body. Only urinary bilharziosis will be considered here. Fig. 1, — Bilharzial nodules in bladder. (P. 447. J Fi^. 2. — Bilharzial granulations in bladder. (P. 447.) Fig. 3.— Villous papilloma of bladder, (P. 461.) Plate 32. XXX IV] BILHARZIOSIS : PATHOLOGY 447 The mucous membrane becomes red and injected, and then inflamed and (Edematous in patches. In these areas small yellow- ish-grey nodules the size of a millet-seed appear, and these rupture and leave ulcers, sometimes of considerable extent, which become covered with gramilation tissue. (Plate 32, Fig. 1.) The mucous membrane has a brownish, sandy appearance in patches. Irregular excrescences of granulation tissue spread from the surface, forming o^S'' ,Vv.' '■•.•.;•; „ •,■■.■■.■■.■ •■.■<'7'^ ■■■<>-'■ ■'.-•■•"■.•• '.•'•:■••■•.•.■•■■•" Fig. 121.^ — Wall of ureter in case of bilharziosis, showing male and female worms in vein. The worms are cut transversely. The outer body with radiating structure is the male worm, while the female lies enfolded in the genital groove. A fold of the female worm has been cut so that it appears as two bodies. {Section Jtrcsentcd by P>-o/cssor A. R. Ferguson, Cairo.) papilloma-like masses, or in ridges like the comb of a cock. These patches are adherent to the submucous tissue. (Plate 32, Fig. 2.) ' Microscopically there is proliferation of the epithelium, which may grow downwards in glandular and cystic forms. (Fig. 123.) The submucous tissue is infiltrated and adherent. Ova are found in the mucous membrane, especially in the epithelial layer. They are perivascular in their grouping, suggesting a position in the lymphatics. They increase in numbers with the duration of the 448 THE BLADDER [chap. infection, few being seen in children and large numbers in adults. Stained with hsematoxylin, the living ova are blue, and dead ova violet. (Fig. 122.) Old dead ova may become calcified. The granular masses consist of thickened inflamed mucous mem- brane with granulation tissue and numerous ova. True papillo- matous tumours may develop, and malignant growths (carcinoma and sarcoma) are very frequently observed. Ferguson has de- scribed 40 cases of malignant growth associated with bilharziosis mi ^^FOf^ a Fig. 122. — Section of bilharzial nodule in bladder. There is a heaped-up mass of tubes of epithelium, in which are embedded numerous bilharzial ova. {Sectioti presented by P7-ofessor A. R. Ferguson., Cairo^ of the bladder. The posterior wall was most frequently affected, but in many cases the whole bladder was a rigid spherical mass. In 34 cases the growth was carcinomatous — usually squa- mous epitheUoma ; in 6 it was sarcomatous. Lymph-glands were frequently affected. In severe cases sepsis is almost invariably superadded, the urine becomes alkaline, there is widespread ulceration and sloughing of the epithelium and granulation tissue. The interior of the bladder becomes encrusted with phosphatic material, from which portions may be detached, forming the xxxiv] BILHARZIOSIS : PATHOLOGY 449 nucleus of larger calculi. The bladder is contracted, and ascend- ing pyelonephritis combined with dilatation of the ureters and the pelvis of the kidneys is common, and leads to a fatal termina- tion. In a number of cases the urethra also becomes involved ; ulceration of the mucous membrane follows, and a deep crater coated wdth phosphates is formed. Aroimd this an abscess usually develops, which ruptures in the perineum, and sinuses form. Madden, who has described this condition, points out that the bulbous urethra is the Dart affected, and that the sinuses start Fig. 123. — Section of bladder wall in bilharziosis. Down-growths of epithelium into submucous layer. (Section fii-escntcd by Proft-ssor A. R. FcrgKson, Cah-o.) from the urethra either laterally or even from the roof and track round between the corpus cavernosum and corpus spongiosum, opening to one side of the middle of the perineum and sometimes tracking round the anus on to the buttocks, scrotum, or pubes. A characteristic false elephantiasis of the scrotum and perineum may be produced by multiple fistulse. The penile urethra may also be afiected, and when the lesions are confined to the terminal one or two inches there is sohd oedema of the glans and prepuce, sometimes accompanied by purulent urethral discharge. The whole penis may be involved, and there may be numerous fistulse communicatino; with the urethra. Ulceration of the sjlans mav lead to epithelioma. There may be nodules in the subcutaneous 450 THE BLADDER [chap. and erectile tissues of the peiiis. The latter lead to extensive infiltration of the erectile tissue and great distortion of the organ and the urethra. The prostate and seminal vesicles are less fre- quently affected. Symptoms. — Bilharziosis may exist without giving rise to symptoms. Milton found that of 35 cases in which bilharzia ova Avere found in the urine, in only 2 were symptoms of bilharziosis complained of. In bilharzial cystitis the chief symptom is heema- turia. This appears spontaneously, and is persistent, although there may be intervals of clear urine from time to time. The hsematuria is terminal, a few drops of bright blood appearing at the end of micturition. It is unaffected by movement. Rarely more severe haemorrhage occurs. The hsematuria may be un- accompanied by other symptoms. The urine contains shreds of various shapes, and frequently there are shreds with a small terminal blood clot in which an ovum can be found. The ova are readily found on microscopical examination of the urine. Fre- quent micturition and slight pain at the end of the penis are early symptoms in most cases. The irritability gradually increases and becomes distressing day and night. On cystoscopy small yellow bodies about the size of a canary- seed are found projecting from the mucous membrane. They are usually grouped together in colonies, and a colony may have little or no surrounding inflammation. These bodies may closely re- semble tubercles in tuberculous cystitis, but are larger, more prominent, more numerous, and more distinctly grouped. The formation of ridges of infiltrated mucous membrane on which are excrescences of granulation tissue, often with the bilharzial bodies dotted around, is very characteristic of the disease. Larger areas may be raised, and granular and papillomatous new growths may develop. As the disease advances the bladder becomes intensely irritable and cystoscopy becomes more and more difficult. Complications. — In the later stages complications occur. Sepsis is the most constant of these, and leads to an intensely painful form of cystitis with alkaUne urine and phosphatic en- crustation. Madden describes a peculiar grey-green urine charac- teristic of the advanced stages of the disease. Stone is a frequent complication. Of 65 cases, Goebel found stone in 34, and probable stone in 10 others. When the urine is still acid the stones may be composed of uric acid and oxalate of lime, sometimes with alternating layers of phosphates. They have as a nucleus bilharzia ova or portions of papillomas. When the urine has become alkaline they are invariably phosphatic, and may originate in detached portions of the phosphatic encrust- XXXIV] BILHARZIOSIS : TREATMENT 451 ations of the bilhaizial ulcers. Papillomatous tumours develop late and may fill the whole of the bladder. Fistulae appear in the perineum and suprapubically, and track in various direc- tions. Malignant growth in the papillomatous tumours is not uncommon (p. 448). Prognosis. — The type of bilharzial disease met with in South Africa and imported into this country is benign compared with the bilharziosis of Egypt. Colonel Simpson, R.A.M.C, states, in reference to the cases which occurred in the South African campaign, that " secondary changes involving the bladder and other parts of the urinary tract have not come under observation." The virulence and malignancy of the Egyptian form appears to some extent to depend upon the prevalence of the disease and the habits of the agricultural population, which give opportunity for repeated re-infection. In ordinary cases, if the patient leaves the bilharzial country the symptoms disappear in about four years. I have re-examined the bladder in a case of vesical bil- harziosis after an interval of four and a half years, and found the mucous membrane quite healthy. The mortahty of Egyptian bilharziosis or its immediate com- plications is just over 10 per cent. (Madden). Treatment. — The treatment is prophylactic and symptom- atic. No method of destroying the schistosomum is known. Pre- ventive measures consist in forbidding bathing in infected rivers or pools, in thorough drying where a risk of infection has been taken, in circumcision of boys, and in boiling drinking-water. Removal of the patient from the bilharzial country is usually followed by recovery. In the early stages Madden recommends 15 minims of the liquid extract of male fern thrice daily. The treatment of the cystitis is similar to that already described. Urotropine, methy- lene blue, and other urinary antiseptics are usually administered. Washing the bladder with weak solutions of silver nitrate, 1 in 10,000, or quinine, 4 per cent., or other antiseptics, or instillation of stronger solutions, may be carried out, especially where cystitis is present. Treatment of the bladder is, however, unsatisfactory, for the ova in the mucous membrane are constantly being renewed. When stone complicates the disease litholapaxy is to be preferred to cystotomy, and when in advanced disease bladder drainage is necessary the suprapubic route is more suitable than the perineal. Day and Richards have tried salvarsan in the treatment of bilharziosis. and found that it was worthless. 452 THE BLADDER [chap. LITERATURE Allen, Lancet, May 8, 1909, and Aug. 6, 1910. Day and Richards, Lancet, 1912, i. 1126. Elgood, Brit. Med. Joiirn., Oct. 31, 1908. Ferguson, Journ. of Path, mid Bad., 1911, p. 76. Goebel, Deuts. Zeits. /. Chir., 1906, p. 288. Kautsky, Wien. klin. Bunds., No. 36. Looss, Menses Handbuch der TropenkranJcheiten. Madden, Bilharziosis, 1907 ; Lancet, Oct. 23, 1909 ; Journ. of Trop. Med., Dec. 1, 1909 ; Brit. Med. Journ., Oct. 1, 1910. Simpson, Journ. of R. A.M. C, 1910, p. 653. Wilson, St. Bart.'s Hosp. Bepts., xlv. SYPHILIS OF THE BLADDEE Scattered through the literature there are descriptions of syphilitic affections of the bladder. In the majority of cases proof of the syphilitic nature of the affections has been confined to the history of a syphilitic infection and the effect of treatment ; cystoscopic and bacteriological examinations have been wanting. Recently, however, the writings of Frank, von Englemann, Pere- schiwkin, and especially an exhaustive article by Asch, have placed the subject on firmer ground. In secondary syphilis symptoms of an acute or chronic cystitis develop, frequent micturition and the presence of pus being most prominent. On cystoscopic examination there is congestion and swelling of the mucous membrane, and multiple small superficial ulcers with indurated edges may be present. Multiple (twelve) superficial round or oval ulcers with undermined edges and whitish base, resembling syphilitic plaques, have also been •described. In tertiary syphilis there may be gummata or ulcers, or both may be combined. The gummata may form papillomas which are indistinguishable from other forms of papilloma, except that they disappear under antisyphilitic treatment. In other cases a gumma has formed a round, circumscribed, nodular swelling, the size of a walnut, and covered with ulcerated mucous membrane. The ulcers have high infiltrated edges and a grey base. The symptoms resemble those of a new growth. There is hsematuria, sometimes severe and terminal, and uninfluenced by rest. There are also frequency of micturition and pyuria. Diagfnosis. — The urine must be examined for the bacillus coli, tubercle bacillus, and other bacterial causes of cystitis and ulceration. The history, the presence of signs of active syphilis or the scars of postsyphilitic affections, and the effect of antisyphilitic treatment without local treatment are important in diagnosis. Syphilitic papilloma and gumma disappear rapidly under treatment. xxxivj VESICAL ACTINOMYCOSIS 453 LITERATURE Asch, ZcUs. /. Urol, 1911, p. 504. von Englemann, Folia Urol., 1911, p. 472. Frank, Vei-lKnulL d. II. dents, urol. Kongress, Berlin, 1909, p. 356. Heberern, Cculndbl. /. Chir., 1911, p. 063. Hinder, Austral. Med. Gaz., 1901, p. 92. Lefur, Vr .Sess. de I'Assoc. fran9. d'Urol., 1902, p. .'524. MacGowan, Journ. Cutati. and Gen.-Urin. Vis., 1901, p. 642. Margoulies, Ann. d. 2Ial. d. Org. Gen.- IJrin., 1902, p. 384. ACTINOMYCOSIS OF THE BLADDER Actinomycosis very rarely affects the bladder,, and is always secondary to intestinal actinomycosis. The disease reaches the bladder by direct continuity, taking origin either in the appendix or in the rectum. Extensive perivesical inflammation is present and there is usually a perivesical abscess. The symptoms are those of cystitis, and on examination there is an indurated mass in the perivesical tissue and in the region of the appendix or round the rectum. Malignant growth or chronic appendicitis may be diagnosed. The diagnosis can only be made by the discovery of the yellow actinomycotic granules in the urine. The treatment "consists in administering large doses of iodide of potash and in opening collections of pus if they exist. Iodides have not proved so successful as was at one time antici- pated. If the bladder is invaded the cystitis is treated by urinary antiseptics and washing. LITERATURE Ruhrah, Ann. Surg., 1899, p. 417. Stanton, Amer. Med., 1906, p. 401. CHAPTER XXXV TUMOURS OF THE BLADDER Tumours of the bladder form about 3 per cent, of diseases of the urinary organs (Kiister). Men are much more frequently afiected (78 per cent. — Albarran) than women. In children vesical growths are rare, and are usually of the connective-tissue varieties. The age most frequently affected is from 40 to 60 years. Secondary growths of the bladder are uncommon, and result from the spread of malignant growths from the prostate, urethra, or rectum in the male, and from the uterus in the female. In the rare papillo- matous tumours of the renal pelvis or ureter papillomatous new growths may become implanted on the bladder mucous mem- brane or spread from the ureteric orifice. Etiology. — There is little exact knowledge of the origin of vesical neoplasms. The frequent situation of papillomatous growths in the immediate vicinity of the ureteric orifices has led to the view that some irritant in the urine may be the cause of the growth. The usual position is, however, above and to the outside of the ureteric orifice, while the stream of urine is directed downwards and inwards, the current passing just below the orifice of the opposite ureter. Workers in anihne dyes (fuchsin, etc.) are stated (Wendel, Lichtenstein) to be especially liable to the development of papil- loma of the bladder, and this is ascribed to some irritating effect these dyes exert upon the bladder mucous membrane. Malignant growths have been found to develop in a bladder the seat of long-standing cystitis, but in the majority of cases where malig- nant disease and cystitis are combined the cystitis occurs as a complication of the growth. In 40 per cent, of malignant growths spontaneous cystitis is the first sign of disease. A malig- nant growth may develop in a patch of leucoplakia caused by chronic cystitis. In some cases of chronic cystitis papillomatous masses develop. These are cystic or solid (cystitis cystica, cystitis glandularis). Stoerk and Zuckerkandl have traced the develop- ment of glandular carcinoma of the bladder from cystitis glandu- laris. In bilharzial cystitis the development of papillomatous and 454 CHAP. XXXV] VESICAL GROWTHS 455 malignant new growths is so frequent as to indicate an etiological relationship. Classification. — New growths of the bladder are conveniently- divided into the following groups and subgroups : — 1. Epithelial growths. (1) Benign. (a) Papilloma. Villous tumour. (6) Adenoma. (c) Cholesteatoma. (2) Malignant. (a) Papillomatous. Malignant villous growth. Nodular growths. (b) Infiltrating. Epithelioma. Adeno-carcinoma. Alveolar carcinoma. 2. Connective-tissue new growths. (1) Simple. (a) Fibroma. (6) Myoma.. (c) Angioma. (2) Malignant. ( Spindle-celled. Round-celled. Sarcoma \ Melanotic. Rhabdo-myoma. ^ Chondro-sarcoma. 3. Dernnoid cysts, 1. EPITHELIAL GROWTHS Papilloma — Villous Tumour Pathology.— These tumours are covered with villi or tendrils, and are either spread out over the surface of the mucous mem- brane (sessile) or set on a stalk (pedunculated). They vary in size from a split pea to a Tangerine orange, and may be single or multiple (30 to 40 per cent. — Albarran). The great majority are situated at the base, in the neighbourhood of the ureteric orifices, usually behind and to the outer side of these orifices, and frequently concealing them. They are rarely situated on the trigone, but frequently around it, and they may surround the urethral orifice. Other parts of the bladder are also affected, especially the posterior wall. 456 THE BLADDER [chap. On section (Fig. 124) a papilloma shows a central fibrous trunk with branches subdividing in all directions. Microscopically the trunk consists of fibrous tissue containing elastic and plain muscle fibres, and supporting numerous large blood-vessels. Each branch and twig has a fibrous core containing blood-vessels, and is covered bv a thick layer of epithelium (Fig. 125). This consists of layers of cells of the tralisitional epithelium type. The deeper cylindrical cells radiate from the core in characteristic manner, and are regular in arrangement and size. (Fig. 126.) Where the villi are closely .-41m Fig. 124. — Slightly magnified section of operation specimen of papilloma of bladder. Two papillomas are seen with villi closely packed together. The relation to the mucosa and muscular wall of the bladder is shown. pressed together the superficial flat cells disappear and the cylin- drical cell layers unite. The nuclei show karyokinetic figures in abundance. Vacuolation of the cells and the formation of spaces containing colloid material or epithelial debris are frequently observed. (Edema of the stroma of a branch may result from kinking. The tumour may consist of closely set, short finger- like processes (Fig. 127), looking, on surface and section, not unlike a cauliflower. A papilloma may remain solitary and in- crease to the size of a Tangerine orange ; more frequently small villous tumours appear around the parent growth, and others are XXXV] VESICAL PAPILLOMA: PATHOLOGY 457 dotted over the bladder, and finally the cavity may be filled with masses of papillomatous growth. Dilatation of the ureter and kidney on the side corresponding to the growth is not infrequent. The histological appearance of these growths is benign, but they possess certain characters by which they differ from other benign tumours. i. They may spread by implantation. A portion of a papil- loma of the kidney may be detached and implanted at the lower end of the ureter or in the bladder. Small buds of papilloma appear on normal mucous membrane around the parent tumour. Recurrence after an operation shows signs of implantation of papillomas in the track leading from the site of the original growth to the cystotomy scar, and the frequency with which a papilloma, usually the largest of the recurrent growths, is situated at the cystotomy wound. 458 THE BLADDER [chap. ii. Recurrence very frequently takes place after removal, and the recurrent growth is multiple although the primary growth may have been single. iii. The recurrent growths after operation or the multiple papillomas in a non-operated bladder become sessile and irregular in growth, and in a large number of cases eventually infiltrate the bladder wall Symptoms. — Haematuria is the characteristic, and usuallv the Fig. 126. — Highly magnified villus of papilloma of bladder with central capillary blood-vessel and covering of transitional epithelium. only, symptom of papilloma of the bladder. It appears suddenly without ascertainable cause, continues for one or two micturitions or for a day or a week, and suddenly ceases. Rest has little effect on the haemorrhage. The blood is copious, and mixed throughout the urine. Occasionally the first part of the urine is blood-stained, and a few drops of pure blood are expelled at the end of mic- turition. Flat or irregular clots may be present. After an interval of a few weeks, but more often of several months, and occasion- ally of one or two years, another attack of haemorrhage occurs similar in character and duration to the first ; and this recurs with diminishing intervals, and often with increasing duration of the XXXV] VESICAL PAPILLOMA : COMPLICATIONS 459 hajmorrhage. The hsemorrhage comes from a ruptured vessel in a villus, and clot may be seen adhering when the hematuria has ceased. SUght aching pain in one kidney is frequently present if the papilloma is situated in the neighbourhood of one ureter. Occasionally other symptoms are added. A patient under my care had an attack of intense pain and strangury, with the discharge of a few drops of bright blood from the urethra every few minutes. A pedun- culated papilloma had engaged in the prostatic urethra and caused spasm of the bladder. Another patient with a pedunculated papilloma had five at- tacks of retention of urine from plug- ging of the internal meatus. Complications. — Profound anaemia from recurrent haemorrhages is not in- frequent. Spontaneous cystitis is very rare, but cystitis very often follows the introduction of instruments, espe- cially in cases of pedunculated papil- loma, where some degree of urethral obstruction from plugging is usually present. Cystitis leads to sloughing of por- tions of the growth, to the deposit of phosphates on the growth, and occa- sionally to the formation of stone. Retention of clot from excessive haemorrhage is rare. Retention of urine may occur from a pedunculated papil- loma obstructing the internal meatus. Course and prognosis. — The dura- tion of papilloma of the bladder may extend over many years (ten to fif- teen, even twenty-five) ; meanwhile the growth increases in size and forms a large single tumour, or multiplies and covers large areas of mucous membrane. It may very rarely remain quite stationary for many years, and I have seen a case of multiple recurrent papillomas in which the growths slowly diminished in size during seven years and have almost disappeared. The average duration of life after the appearance of symptoms Fig. 127. — Papillomas of bladder, removed by operation. At the upper part of each drawing is a portion of the mucous membrane and muscle of the bladder wall, re- moved with the tumour. 460 ' THE BLADDER [chap. is stated to be about three years. In my experience it is much longer. Recurrence of growth after operation is very common, and is due to (a) new development of papilloma from the original cause, (6) incomplete operation, (c) implantation of fragments in the bladder wall during removal. Malignant transformation is frequent, and may occur in un- operated or in recurrent growths. However benign the histo- logical characters of the original papilloma may be, clinical experience shows that recurrence after removal is very common, and that infiltration of the bladder wall occurs eventually in a large proportion of cases. Papilloma of the bladder cannot, there- fore, be looked upon as a benign tumour, and it is better to regard it as a precancerous condition in all cases. Diagfnosis. — " Symptomless " hsematuria in a young or middle- aged adult is usually due to papilloma of the bladder, to " essen- tial renal heematuria," or to early renal growth. If tube casts are present the condition is renal. The quantity and appearance of the blood may be the same in all three conditions. The passage of fragments of papillomatous growth in the urine is important but rare. It is impossible to distinguish by the microscope be- tween fragments from papilloma of the bladder and from similar tumours in the renal pelvis or ureter, but the passage of papillo- matous masses from the kidney almost invariably gives rise to ureteral colic, and these papillomas are very rare. Evidence may also be obtained by the removal of portions of growth in the eye of a catheter. Histologically there may be nothing to show whether the portion of papilloma has been detached from a benign papilloma or from the surface of a malignant growth. Palpation of the bladder from the rectum and bimanually gives negative results in the great majority of papillomas, but when the growth is large and firm it can be felt in bimanual palpation in favourable cases. The diagnosis can only be certain when the cystoscope is used. Cystoscopy. — Cystoscopy for symptomless hgematuria should be made during an attack of bleeding, for should the haemorrhage prove to be renal it will be seen from which ureter the blood is issuing. When the haemorrhage arises from a vesical papilloma there is seldom difficulty in obtaining a clear medium. A papilloma is seen as a round or irregular tumour with tendrils of varying length which float in the fluid and are stirred by every current or eddy. (Plate 32, Fig. 3.) They may resemble the fronds of a luxuriant fern or ostrich feathers, or they may be short and leaf -like and the tumour may be like a coarse bath sponge. XXXV] VESICAL PAPILLOMA: TREATMENT 461 Each villus has a fine central vessel with lateral branches. The majority of papillomas have a short pedicle (subsessile), some have a long delicate stalk (pedunculated), and others are sessile. The tumour is most frequently situated on the upper and outer aspect of the ureteral orifice, which may be hidden by its branches. Usually a leash of vessels passes up to the growth from the trigone. Small buds of papilloma may be found on the mucous membrane in the neighbourhood, and other papillomas may be scattered about the bladder. Adherent clots appear as dark-red or black masses, and the tumour may be powdered with phosphates. When the growth is very large the beak of the cystoscope may plunge into it, and the light is obscured so that no view is obtained. Treatment. Non-operative. — Prolonged treatment by wash- ing the bladder with solutions of nitrate of silver and resorcin with the object of causing necrosis of the tumours has been advo- cated by Casper, Herring, and others. Daily instillations of 2 oz. of nitrate of silver solution (1 in 3,500 at 100° F.) are made by means of a catheter and retained for a few seconds, and then repeated once. The instillations are best made at night, and the patient feels only a slight warmth for half an hour. The strength of the solution is gradually increased to 1 in 1,000, and the treat- ment continues for six months. Solutions of resorcin (2 per cent, up to 10 per cent.) have also been used bi-weekly. This method has apparently met mth an occasional success or partial success. It may be useful in cases which are unsuitable for operation, or which have recurred and are still small. Radium and the high-frequency current (fulguration) are under trial. Radium is inserted in a catheter into the bladder and a radium plate applied suprapubically, or radium may be suspended in the rubber drainage tube after suprapubic operation as a prophylactic measm'e. For high-frequency treatment an electrode is applied to the growth through a catheterizing cystoscope, a flat electrode being applied suprapubically. Operative treatment, (o) Removal through the urethra. " In- travesical operations.'''' — This is carried out by means of the Nitze operating cystoscope (or some modification of it), or by Luys' direct cystoscope, or in the female through Luys' or Kelly's cysto- scope. A fine platinum wire is projected from a tunnel in view of the cystoscope ^^dndow and is passed over the tumour, which is snared and left in the bladder to be expelled in the urine. If the papilloma is very large, portions of it are removed at several sittings. Hemorrhage is sometimes severe after these opera- 462 THE BLADDER [chap. tions. The growths must be favourably situated. Tumours near the neck of the bladder are unsuitable. Those at the base and on the posterior wall are most suitably placed. With the direct cystoscope the growth can be touched with the electric cautery, or removed with forceps or a snare and the base cauterized. Malignant growths should not be operated on by this method. The advantages claimed for it are the small mortality, the avoid- ince of complications such as sepsis, fistula, phlebitis, or pneu- monia, the ability of the patient to continue work, the avoidance of danger of implant- ing tumour cells, and its greater applicabihty to recurrent tumours. The Open operation applied to cases suit- able for intravesical removal should, how- ever, have no mor- tality ; complications such as those men- tioned should not occur with thorough aseptic operation, and the after-treatment of the bladder {see p. 465) should prevent any possibility of im- plantation. Very small recurrent growths may be treated by intra- vesical removal, but the tendency of recur- rent growths to become malignant must be remembered. Good results in small growths have been obtained by some surgeons. Weinrich found that 71 cases out of 101 oper- ated before 1902 had no recurrence. There were 18 cases of re- currence, and 12 cases were untraced. The mortality was 1 in 150. (6) Removal hy open operation. — This is the most radical form of treatment, and, in view of the pathology, should be adopted in all cases when no contra-indication to an operation exists. If Fig. 128. — Gystoscopic chart of multiple papilloma of bladder. The trigone with ureteric and urethral orifices is shown, and the number and position of the growths. At X a small paoil- loma was concealed from the view of the cystoscope behind the larger growth. XXXV] VESICAL PAPILLOMA: OPERATION 463 multiple papillomas are present a chart showing their number and position must be drawn at a preliminary cystoscopy. (Figs. 128, 129.) Suprapubic cystotomy is performed by a vertical median in- cision 3 in. in length, the peritoneum being pushed aside. The edges of the bladder wound are held by two catgut traction sutures, and the patient is placed in the Trendelenburg position. Suit- able bladder retractors (Fig. 130) are intro- duced, a small re- tractor being placed on the side of the growth and a large one on the opposite side. With a power- ful head-lamp the in- terior of the bladder is thoroughly examined. A solitary peduncu- lated papilloma (Fig. 131) is picked up with forceps, the pedicle put on the stretch, and a double catgut suture passed through it and tied. The pedicle is then cut through, and with it an area of bladder mucous mem- brane which was raised by the traction. In sessile papilloma (Fig. 132) the mucous mem- brane is raised and cut through half an inch from the tumour, and the incision carried round it at this dis- tance, so that a good margin of healthy mu- cous membrane is re- moved with the growth (Fig. 133). The mu- cous membrane is then Fig. 129. — Cystoscopic chart of recurrent papillomas of the bladder. The largest growth is in the position of the suprapubic scar. Fig. 130.— Author's bladder retractors. 464 THE BLADDER [chap. brought together and bleeding controlled by catgut stitches. I use special needles on pliable handles (Fig. 134), long fine for- ceps (Fig. 135), and curved scissors (Fig. 136) for these opera- tions. If a number of papillomas are situated close together the whole area of mucous membrane bearing them is removed Fig. 131. — Removal of pedunculated papilloma of bladder. The patient is in the Trendelenburg position, and the edges of the suprapubic cystotomy wound are widely retracted. The papilloma is grasped with long forceps, and the base of the pedicle is transfixed by a needle with catgut. in one" strip (Fig. 137). I have removed an area as large as the palm of the hand, and in one case half the mucous mem- brane of the bladder was stripped off. When the papilloma lies near the orifice of the ureter a catheter should be passed up the XXXV] VESICAL PAPILLOMA: OPERATION 465 duct in case it may be included in the stitches. Great care is taken not to soil the mucous membrane by contact ^\■ith the papilloma during removal. At the end of the operation I treat Fig. 132. — Removal of multiple sessile papilloma of bladder, A traction suture steadies and raises the mucous membrane on the near side of the papilloma. The mucous membrane is cut round the base of the growth with long curved scissors and dissected up, carrying with it the growth. The cut edges of mucous membrane are united with catgut. On the right is a wound already closed. the bladder with silver nitrate solution 5 or 6 per cent., formalin 1 in 300, resorcin 10 per cent., or other albumin coagulant, with the object of destroying stray cells or microscopic papillomas. 9 w 466 THE BLADDER [chap. The bladder is drained through a large suprapubic tube, and washed daily with weaker solutions of these drugs. The suprapubic wound may be closed at the end of the opera- tion with catgut sutures and a catheter placed in the urethra, but Fig. 133. — Group of papillomas removed from bladder. The tumours are removed with an area of mucous membrane, which shrinks after removal. In two the under surface is shown. An area of mucous membrane bearing eight separate tumours is seen at the upper left-hand corner. if this is done the treatment of the bladder with strong solutions must be omitted. Complete immediate suture of the bladder with catheter drainage may even in the simplest operation for papilloma lead to haemorrhage which necessitates opening up the suprapubic XXXV] VESICAL PAPILLOiMA: OPERATION 467 wound, and I have now abandoned it and diain every case supra- pubically. In removing the papillomas a Guyon's clamp may be used, Fig. 134. — Author's needle on pliable handle for bladder-growth operations. but it is rarely necessary, and may injure the ureteric orifice. After convalescence the bladder should be examined at regular intervals wnth the cystoscope for recurrence. In its earliest stage a recurrent bud of papilloma should be treated by a fine electric cautery applied through a Luys' cysto- BBflllHlpn Fig. 135. — Long toothed and serrated forceps for bladder- growth operations. scope, or instillation of nitrate of silver may be tried. If the recurrent tumour is large or multiple a second suprapubic opera- tion is necessary. When the bladder cavity is filled with large numbers of papillo- matous growths the operations described are inapplicable. The Fig. 136. — Long curved scissors for bladder-growth operations. choice then lies between palliative, non-operative treatment, and operative treatment. Operative treatment consists in (1) open- ing the bladder and clearing out the contents, and stopping the bleeding by means of the cautery, hot douche, nitrate of silver, 468 THE BLADDER [chap. adrenalin, or, better, packing the bladder with gauze round a large rubber tube which leads down to the ureters ; or (2) the total removal of the bladder (cystectomy) after ureterostomy. The latter operation has a high immediate and remote mortality, but it is the only method by which cure can be obtained in these cases. Transperitoneal cystotomy has been advocated (Harrington, Mayo) as an easier method of approach in operating on papilloma Fig, 137. — Papilloma of bladder. Numerous discrete papillomas, and one large area of mucous membrane covered with papillomatous masses. The extent of this portion of mucous membrane was half the posterior and the whole of the left lateral wall of the bladder. of the bladder. This method is unnecessary, as there is no difficulty in obtaining full exposure and room for manipulation by the ordinary extraperitoneal route. Palliative treatment. — In cases in which radical operation is abandoned, certain complications and symptoms may arise which require treatment. Hcemorrhage. — Unless the case is acknowledged to be inoperable, XXXV] VESICAL PAPILLOMA: PALLIATION 469 the proper treatment for hsemorrhage is early removal of the growth, and the less the bladder is interfered ^\^lth before the operation the better. Haemorrhage so severe as to cause acute anaemia seldom occurs. The patient is kept in bed and a morphia suppository (J gr.) or a hypodermic injection of morphia {^-l gr.) given. Calcium lactate in doses of 10 or 15 gr. every four hours is given for two days, but if haemorrhage persists beyond this time it is then omitted. Ergot, iron salts, tannin, acetate of lead, and suprarenal extract given internally have all been used, but in my experience they are worthless. Washing the bladder should be avoided if possible, as there is a very serious risk of intro- ducing sepsis. Should it become necessary, a large coude catheter (10 or 12 Fr.) should be passed under the strictest aseptic pre- cautions and the bladder washed out by means of an irrigator. About 4 or 6 oz. are allowed to run in and to escape, and this is repeated until several pints have been used. The best solution is silver nitrate, 1 in 10,000, and it should be used hot (110° to 120° F.). Another method is to pass a double-way catheter and run a continuous stream of hot silver nitrate solution through the bladder. A weak solution of adrenalin (1 in 100,000) may be used, but it is not so efficacious. Instillations of stronger solutions may be used, such as silver nitrate solution (3 oz. of l-in-1,000 or l-in-500 solution) or adrenalin (1 oz. of l-in-2,000 solution). These are allowed to remain in the bladder for a few minutes and then run off. The following may also be used, viz. 3 oz. of a sterilized solution of gelatin (2 per cent.), or 2 oz. of creolin solution (J-1 per cent.) at a temperature of 105° F., retained for twenty, or thirty minutes. If clotting has occurred in the bladder the clots are extracted with a large evacuating cannula with, rubber bulb, such as is used in litholapaxy. This method should be employed with the utmost caution and under strict aseptic conditions, and should not be persisted in if it is not at once successful. After removal of the clots a large catheter should be fixed in the urethra and the bladder washed frequently with normal saline solution to prevent recurrence of clotting, or a double-way catheter and continuous irrigation with normal saline solution should be installed. Finally, should these methods fail, the bladder should be opened supra- pubically, the clots cleared out, and a large rubber tube inserted. Bladder spasm. — In the later stages of recurrent and inoper- able papilloma and in infected cases there may be distressing frequency of micturition and painful spasm of the bladder. The general and local treatment for cystitis should be carried out. 470 THE BLADDER [cHAr. Instillations into the bladder of a few ounces of distilled water containing antipyrin (2 per cent.) and laudanum (1 per cent.), or of orthoform (5 to 10 per cent.), or the use of suppositories containing belladonna (J gr.) and morphia (^-^ gr.) or lupulin (4 gr.), may give temporary relief. The injection of 20 or 30 minims of sterilized water, or eucaine (2 per cent.) or cocaine (1 per cent.), into the sacral canal may also assist {see p. 383). Permanent suprapubic drainage may become necessary, and the opportunity may be taken to clear out the papillomatous material and apply nitrate of silver solution. In some cases the pain and spasm continue in spite of this, and nephrostomy or permanent drainage of the kidneys, or ureter- ostomy, by bringing the ureters to the surface in the loin or groin; may be necessary in order to direct the urine from the hyper- sensitive organ. Results. — The mortality of open radical operations on papil- loma of the bladder is very small under modern conditions. Rafin found a mortality of 3-8 per cent, in 156 cases operated on in recent years. Recurrence of papilloma after operation is fre- quent. In Rafin's collection there were 33 cases of recurrence out of 115 cases traced (28 per cent.). In 18 cases there was no recurrence for over three years, and non-recurrence was re- ported in periods as long as fourteen and twenty years. Recur- rence four and eight years after operation has been recorded. The recurrent tumours are usually multiple, and may have the same characters as the primary growth. There is a marked tendency, however, for the type to change. The tumour becomes more and more sessile, the villi shorter, and the surface smoother, and finally infiltration of the submucous and muscular coats takes place. Watson found that about 60 per cent, of pedunculated papil- lomas were cured by operation, but only 2 per cent, of sessile and multiple papillomas. The number of cases of recurrence will, I hold, be greatly reduced by careful preoperative charting of multiple growths, by thorough operation, and by treatment of the bladder with strong solutions after the operation. Adenoma Adenoma is a rare tumour so far as the bladder is concerned. It arises in the glands in the region of the base of the bladder, and is found in two forms, a diffuse and a circumscribed (Rochet and Martel). The tumours have a smooth or villous surface. Rafin collected 11 operated cases. XXXV] VESICAL CARCINOMA 471 Cholesteatoma This rare condition was described hy Rokitansky, and 10 cases were collected from the literature by Rafiii. There is great thickening of the epitheUum, which becomes squamous and pre- sents a pearly appearance. Masses of epithelial debris are thrown off and collect on the surface. The whole urinary tract may be affected. Carcinoma A number of malignant growths differing widely in their gross and microscopic characters are grouped under this heading. The following grouping of varieties is cHnical, and will be of greater use to the surgeon than a strictly pathological classification : (1) Malignant Papilloma However benign the macroscopic appearances of a villous growth of the bladder may be, the majority, as already stated, eventually become malignant if untreated. Some papillomas are malignant from their earliest stage of development. Macro- scopically, malignant papillomas may be similar in appearance to those of benign form, but certain characters can usually be detected. The villi are more stunted and less regular in size and shape, the tumour is sessile and irregular in contour. In- filtration of the bladder wall commences, and the mucous mem- brane at the base is thickened and adherent to the submucous tissue. Microscopically the epithelial cells show rapid and very irregular proliferation. The base shows the invasion of lymphatic spaces and veins by irregular masses of cells. Another type of malignant papilloma is malignant from its earliest appearance. The growth is very rapid and irregular, and luxuriant on the surface, so that the bladder is rapidly filled with a friable mass from which portions slough oft' and are discharged in the urine. (2) Nodular Growths These are sessile, or rarely have a short pedicle, and vary in size from a hazel-nut to a chestnut or a Tangerine orange. The surface may be irregular with nodules varying in size, or there may be a large single mass with a regular nodular surface. Occa- sionally there is a round tumour with flat surface, the centre of which is depressed and shows short villi, with sometimes a hard, brown, pigmented, calcareous mass adherent to it. The margin is rounded and vertically ridged. (Plate 33, Figs. 1, 2, 3.) These tumours belong to the papillomatous group. (Fig. 138.) The surface consists of a dense mass of irregvilar villi closely welted 472 THE BLADDER [chap. together, and sometimes necrotic on the surface about the centre. In the deeper part there is a fine stroma of fibrous tissue sup- porting irregular spaces filled with cells. In these spaces papillary ^'M ^m. ^'^f C ^gv-^f'..^ #^i Fig. 138. — Microscopical section of a nodular malignant growth (papillomatous variety). formations are frequently seen. Masses of cells infiltrate the muscular planes passing along the lymphatic vessels. (3) Infiltrating Growths The growth forms fiat nodules on the surface of the mucosa, but its most extensive growth is intramural. Not infrequently it takes the form of a hard, depressed ulcer surrounded by nodules or by a raised, hard ring of growth. (Plate 34.) The histological structure varies. (a) Squamous epithelioma {chancroid). — This takes origin in a patch of leucoplakia (Fig. 139). The greatly thickened and heaped. X Figs. 1, 2, 3. — Views of operation specimen of malignant growth of bladder (nodular papilloma). On surface is a mass of clot encrusted with phosphates. The third figure shows peritoneal surface. (Pp. 473-8.) Fig. 4. — Recurrence of malignant growth of bladder in scar of resection wound. Operation specimen of second operation. Patient well three and a halt years later. Primary tumour, sec Plate 35, Fig. 3. (P. 485.) Plate 33. 3 J= 2" 3 ft O S o- ^ "OO 4> a S fi f^l^' o 2 ^ 2 st# « P OS CO a Vi u « u ^ u "O C C3 2 B J3 3 a C (U u s s as o 9 Vm O o u s a .2 i^ u o ,£ a J3 s - 13 ■£ ^ 'S. P « « -OIJ g S e o* 2 D •OB V c 3 CO '$ o "S; J3 £3 « ^ o xxxv] MALIGNANT GROWTHS 473 up epithelium infiltrates the submucous tissue and a depressed ulcer is formed. The growth has the structure of a squamous epithehoma with cell nests. (Figs. 140, 141, and Plate 34.) (6) Cylindrical epithelioma or adeno-carcinoma consists of round or oval spaces lined with one or two layers of cylindrical epithehum. These tumours develop at the base of the bladder, and are com- paratively rare. Stoerk and Zuckerkandl have shown the close relation between this form of growth and cystitis glandularis. (c) Alveolar carcinoma. — Alveoli of varying sizes, branching and Fig. 139. — Leucoplakia of mucous membrane in neighbourhood of large squamous epithelioma of bladder. Note the presence of papillae and the large, clear, flat nucleated cells. tubular, filled with cells of varying shape and size, many of which are cylindrical and others spheroidal, are set in a stroma of con- nective tissue. The proportion of the cellular elements to the stroma varies. With an excessive development of the former a soft tumour is formed, while a highly developed stroma forms a scirrhus. When stroma and cellular elements are equally balanced it is customary in German literature to term the growth " carcinoma simplex." Spread of growths of the bladder. — Growths remain for a long time localized in the bladder. The spread is intravesical, intramural, perivesical, glandular, and metastatic. The intravesical spread of papillomatous growths may be 474 THE BLADDER [chap. rapid and extensive. It appears to take place by implantation, small papillomas occurring on the mucous membrane around the original tumour. After removal of a papilloma recurrence takes place in a form which also suggests implantation. A track of papillomas is seen from the site of the original growth to the supra- pubic scar, and the largest, and occasionally the only, recurrent tumour is situated on the vesical aspect of the cystotomy scar. Fig. 140. — Section of squamous epithelioma of bladder showing cell nests. {See Plate 34.) Propagation by contact is occasionally seen in malignant growths of the bladder. A small secondary growth develops on the por- tion of the bladder wall which comes in contact with the parent tumour when the viscus is empty. The anterior and superior walls are those affected in this manner. (Fig. 141.) Owing to the peculiar distribution of the lymphatic vessels {see p. 348) malignant growths may spread widely in the muscular coat while their extent is still limited in the mucous and sub- mucous layers. Rapid penetration of the growth through all the XXXV] MALIGNANT GROWTHS: SYMPTOMS 475 coats of the bladder wall is a feature in some tumours which do not spread laterally. The perivesical spread is sometimes as extensive as the intra- vesical growth, and this ])art of the growth is surrounded by dense fibrous fat. Adhesions to the vagina, uterus, rectum, and intestines take place in the later stages, and perforation may occur. The spread along the lymphatics follows the large trunks {see p. 348). The first glands are a few small lymph nodules in the outer coat of the bladder, and then the larger lymph -glands serving the different regions of the bladder are affected. Pasteau states that the glands along the internal iliac arteries are affected Fig. 141. — Small epitheliomatous ulcer (contact growth) on anterior wall of bladder. There was an extensive nodular malignant growth at the base. in 79 per cent, and the lumbar glands in 26 per cent, of cases. This refers to the advanced stage found post mortem. In the latest stages secondary deposits may be found in the lung, pleura, liver, spleen, or kidney. Symptoms. — The onset of symptoms is usually insidious ; occasionally there is a sudden severe attack of hsematuria with- out previous symptoms. Haematuria is the most frequent (90-2 per cent, of cases) and the earliest (61-7 per cent.) symptom. The bleeding usually com- mences gradually. A little blood appears at the end of micturi- tion. This passes off, and reappears and increases till the whole urine is stained. Clots are frequently present (34 per cent.). Persistent slight terminal haematuria may be observed, with occasional attacks of severe haemorrhage. Frequent micturition occurs in 68 per cent, of cases, and may be the first symptom (14-7 per cent.). It is nocturnal as well as 476 THE BLADDER [chap. diurnal, and may increase until urine is passed every ten or fifteen minutes during the day, and every half-hour at night. There is urgency, and sometimes the necessity to empty the bladder is uncontrollable. These symptoms are usually due to cystitis, but may occur without cystitis and with a clear urine. Pain may be due to cystitis, to obstruction by blood clot, or to pressure upon nerves. It is felt along the urethra, at the end of the penis, in the suprapubic region and groin, in the perineum, anus, and down the thighs or along the sciatic nerve. Posterior renal pain may be unilaieral or bilateral, and is due to obstruc- tion of the ureters or to ascending pyelonephritis. Although pain is frequently present (63-4 per cent, of cases) and may be the first symptom (8-8 per cent.), it is never severe. The urine may be clear in the intervals of hsematuria, and contain no abnormal elements. Occasionally a persistent excess of epithehal cells from the bladder may be found. Portions of growth may be passed. These are villi from the surface of the growth, and their structure may be that of a benign papilloma. In some cases the irregularity of cell growth and rapidity of pro- liferation suggest malignancy. When cystitis is present the urine contains pus, mucus, and blood. The urine may be alkaline and stinking. It contains greyish or brownish shreds, which may be blood clot, muco-pus, or necrotic portions of growth. Masses of mucus and phosphatic or more sohd concretions, of flat or hmpet-shell shape, form on ulcerated patches and are discharged with the urine. Difficult micturition (12 per cent, of cases) is due to large luxuriant growths, or to smaller growths situated near the urethral orifice. Emaciation is present in advanced cases. It is not a reliable sign of malignancy, for it may be caused by chronic septic pyelo- nephritis. Diagnosis. — Cases of mahgnant growth of the bladder pre- sent two chief types, a cystitis and a hsematuria type. (1) Cystitis type (40 per cent.). — The onset may be sudden or gradual, and occurs without the passage of an instrument. The following conditions may also give rise to spontaneous cystitis in a man of 50 years or over : — (a) Stone. — Here the onset is less acute. Pain is a much more prominent symptom ; it is sharp, is felt at the end of the penis and at the close of micturition. Hsematuria, if present, is terminal and moderate, and the blood is bright. Frequent micturition only appears during the day ; the patient sleeps throughout the night without waking. All the symptoms of stone are greatly increased by movement and shaking. XXXV] MALIGNANT GROWTHS: DIAGNOSIS 477 (6) Simple enlargement of the prostate. — The onset of frequent micturition is gradual. Nocturnal frequency is pronounced and commences in the early morning after a rest of five or six hours. Hsematuria may be absent, and there is no pain. (c) Malignant disease of the prostate. — In this condition there is gradually increasing difhculty in micturition, pain is a prominent and persistent symptom {72-5 per cent, of cases), hsematuria is rare, and movement has no influence on the symptoms. (2) HaBmaturia type (60 per cent.). — These cases are most likely to be confused with simple papilloma or with tuberculous disease of the bladder. In simple papilloma the patient is usually younger (under 45) than in malignant growth (average, 57 years). The hsematuria is sudden, copious, and intermittent in papilloma ; it is insidious, terminal, persistent, and increasing in malignant growth. The hsematuria of papilloma is usually the only symptom, while frequent micturition and other symp- toms are present in malignant growth. There is no change in symptoms to show when a simple papilloma takes on malignant characters. Tuberculous disease usually occurs in younger patients. It can frec^uently be detected in the genital system (epididymis, prostate, seminal vesicle), or there are tuberculous lesions elsewhere in the body. The tubercle bacillus is found in the urine. Examination. — Discrete, shotty enlargement of the groin glands is occasionally present (12 per cent, of cases). Enlarged lymphatic glands can be detected in the pelvis on rectal examina- tion in the advanced cases. These are found in a band of tissue at the upper and outer angle of the prostate on each side, and are the lowest glands of the lymphatic chain. Palpation of the base of the bladder from the rectum or vagina, and especially by bimanual examination, may detect a thickening of the wall. Cystoscopy. — Hsemorrhage and spasm of the bladder may render cystoscopy difficult. The following are the chief types of malignant growth as seen with the cystoscope : — (a) Villous growth. — In some cases there is nothing to dis- tinguish simple from malignant papillomas. Usually, however, the latter are sessile, the villi are stunted, more closely packed, and less regular. In the same bladder there are pedunculated and sessile growths. Signs of infiltration of the bladder wall may be present. The" pedicle is thickened and more fleshy, the sur- rounding mucous membrane is ridged and puckered, and may have an infiltrated, velvety appearance. Small cedematous tags may 478 THE BLADDER [chap. project from the mucous membrane, and separate nodules may be seen. (6) Nodular sessile or pedunculated growths. — These vary in size from a large pea to a Tangerine orange. The surface is smooth, and may be firmly or coarsely nodular, opaque, and pink or yellowish-pink in colour. (Plate 35.) The surrounding mucous membrane may show signs of infiltration. The centre of the growth is sometimes depressed and covered with a gritty mixture of blood clot and phosphates (Plate 33), or may be necrotic (Plate 35). (c) Infiltrating nodular growths and depressed ulcers. — The appearances have already been described. (Plate 34.) The unaffected portion of the mucous membrane is usually the seat of subacute or chronic cystitis. Phosphatic deposit may take place on the growth. Course and complications. — The average duration of life after the first appearance of symptoms is said to be under three years, but this estimate requires qualification. The duration of symptoms in papilloma of the bladder which eventually becomes, malignant may be ten or fifteen years. Hard infiltrating growths, forming a depressed ulcer are very chronic, although the duration is shorter than that of papilloma. Those of the rapidly growing papillomatous variety have a very short history, death taking place frequently under a year and always under two years. Septic complications usually result from the passage of instru- ments, and if untreated ascending pyelonephritis eventually follows. Obstruction of the ureters is a frequent complication of bladder growths. If one ureter is involved and the obstruction is gradual an intermittent hydronephrosis results. If both ureters are occluded, obstructive anuria supervenes. Anuria may come on suddenly with no previous symptoms, or after symptoms lasting a few hours. Lymphatic glands are involved late, and metastatic deposits in the lungs and liver are rare. Treatment. — The treatment is operative or non-operative, and the operative treatment is radical or palliative. Selection of cases for radical operation. — Of 41 consecu- tive cases under my observation, only 15 (36-5 per cent.) were fit for the operation when first submitted for examination. Cases suitable for a radical operation must fulfil ^he following conditions : (1) The growth must be confined to the bladder. (2) The patient must be sufficiently robust to undergo a severe operation. Evidence of disease of the kidneys or of renal failure, of bron- chitis or emphysema, of a weak or failing circulation, must be held as a contra-indication to radical operation. Fig. 1. Nodular malignant growth of bladder. Fig. 2.' Nodular malignant growth of bladder with necrotic surface. Fig. 3.— Small nodular malignant growth of bladder. Recurrent growth after removal. {See Plate 33, Fig. 4.) Plate 35. (P. 478.) XXXV] MALIGNANT GROWTHS : OPERATIONS 479 The radical operations that may be performed in suitable cases are (1) resection of the bladder wall and (2) cystectomy. Choice of radical operation. — Wherever possible, resection of the bladder wall should be performed in preference to total cystec- tomy, because the mortality of resection varies from 10 per cent. (Thomson Walker, in 30 cases) to 22 per, cent. (Enderlein and Walbaum), while cystectomy has an operation mortality of from 46-1 per cent. (Thomson Walker, collected cases) to 61-5 per cent. (Goldenberg). The cases unsuitable for resection are — (1) Growths covering a very large area of the bladder wall. (2) Rapidly growing malignant papillomas. (3) Growths involving both ureters, or the trigone or urethra. (4) Intractable cystitis. None of these is a contra-indication to cystectomy provided the conditions previously stated are fulfilled. Resection of the bladder wall. — Before operation the posi- tion and intravesical extent of the growth are ascertained by cystoscopy. At the operation the perivesical extent is examined before commencing to resect the bladder wall. Tumours of the lateral wall should be examined from the outer aspect of the bladder. In all tumours of the posterior wall the peritoneum should be opened and the peritoneal surface of the bladder exam- ined. Tumours at the base are examined by palpation after cystotomy. A vertical median suprapubic incision of 3| in. with under- cutting of the rectus muscle on the side of the growth and sub- sequent repair suffices for the majority of resections. In stout patients a transverse curved suprapubic incision may be necessary. The bladder is opened and. the patient placed in the Trendelen- burg position, illumination being obtained from a powerful head- lamp. In tumours of the anterior wall and apex of the bladder the cystotomy wound should be placed well away from the growth. An area of bladder wall extending for at least an inch on all sides of the growth is removed, and the edges of the bladder wall are brought together by catgut stitches round a rubber tube, which is retained for four days. In tumours situated on the posterior wall (Figs. 142, 143, 144) cystotomy is first performed, and then the peritoneal cavity is opened and the peritoneal aspect examined. An area of peri- toneum is marked out behind the growth with scissors, and the edges are stripped ofl, leaving this portion adherent to the bladder. The peritoneal cavity is now closed. The cystotomy wound is 480 THE BLADDER [chap. carried back and surrounds the growth, which is removed with the area of bladder wall and peritoneum on which it is set. When the growth lies in the neighbourhood of the ureters a second wound is made from within the cavity of the bladder. A catgut suture is passed through the bladder wall IJ in. on the near side of the Fig. 142. — Resection of posterior wall of bladder for malignant growth. The bladder has been opened by suprapubic cystotomy, the peritoneum opened, and the intestines packed off, exposing the puckered peritoneal surface of the growth. growth. By traction on this the bladder wall is steadied, and with a long, curved pair of scissors a transverse incision is made through the whole thickness of the bladder wall an inch from the growth. This is carried round the growth, leaving an inch xxxvj MALIGNANT GROWTHS: RESECTION 481 margin of healthy bladder wall. As the section, proceeds catgut traction sutures are inserted every half-inch through the edge of the bladder wound, while traction on the growth is made by a stitch passed through it. Any spouting vessels are readily controlled. Fig. 143. — Resection of posterior wall of bladder for malignant growth. The portion of wall bearing the growth is being removed. If the ureteric orifice comes within the area of the resection the lower end of the ureter must be excised. This is done by continuing the wound down on each side of the growth and raising 2f 482 THE BLADDER [CHAr. the flap thus made. The ureter is exposed on the extra vesical aspect of this flap, secured by toothed forceps, and cut across. The resection having been finished, the cut end of the ureter is raised to the bladder edge of the growth wound at the nearest point, and a catgut stitch passed through the wall of the ureter, and then through the bladder wall, and tied. Bleeding-points having Fig. 144. — Resection of posterior wdll of bladder for malignant growth. Bladder surface of growth shown ; resection nearly completed. been ligatured, the growth wound is stitched with catgut sutures from below upwards, using the traction sutures as stitches. When the level of the ureter is reached a second stitch is passed through its wall and through the opposite edge of the growth wound, to which it is already fixed. I then place a rubber drainage tube with a lateral perforation near the terminal opening alongside the xxxvj MALIGNANT GROWTHS: CYSTECTOMY 483 ureter in the extravesical space, and this passes through the growth wound across the bladder and out of the cystotomy wound. It is fixed in the growth wound by a catgut stitch. The remaining portion of the growth wound is now closed, the bladder mucous membrane treated with nitrate of silver as in papilloma (p. 465), and a large drain placed in the cystotomy wound, which is then closed around the two tubes. The abdominal wall is now repaired. The catgut stitch holds the tube alongside the ureter for seven days. It drains the extravesical space and leaves a weak spot in the bladder wall which prevents constriction of the ureter. I have used this simple method of ureteral transplantation success- fully in ten cases, and prefer it to more elaborate methods. In none of my cases has there been any postoperative pyelonephritis after resection and implantation of the ureter. Cystectomy : treatment of the ureters. — Some method of derivation of the urine must be adopted, and a large part of the high operative mortality of cystectomy is due to the operation for derivation of the urine being performed at the same time as the removal of the bladder. "The two operations should be per- formed at an interval of some weeks. The ureters have been implanted into the rectum, large in- testine, urethra, vagina, or on to the skin in the loin or at the suprapubic wound, or bilateral nephrostomy may be performed. Maydl's operation of transplanting the trigone of the bladder ^\'ith the ureters cannot be done in growths of the bladder. Implantation of the ureters into the rectum is seldom suc- cessful, and in the majority of cases in which the patient has sur\aved operation a fistula has formed on the surface. In cases of implantation into the large bowel there is a grave danger of ascending septic inflammation. Implantation of ureters into the urethra has not given good results. Fixation of the ureters in the suprapubic wound has been successful in several cases. After ureterostomy there is considerable danger of stenosis and of ascending inflammation. In one case I implanted the appendix into the dilated right ureter {uretero-ap'pendicostomy, see p. 342). The most successful operation is one done in two stages, of which the first stage consists in derivation of the urine by vaginal implantation in the female, and nephrostomy or ureterostomy in the male subject. Cystectomy in the male : the combined perineo-abdo- minal nnethod. — The bladder is distended with fluid and the patient placed in the lithotomy position. A curved transverse prerectal incision, concave forwards, is made, and the posterior surface of the prostate and seminal vesicles is exposed. 484 THE BLADDER [chap. The patient is now placed horizontally, and then raised into the Trendelenburg position, and a transverse suprapubic incision made down to the bladder. The peritoneum is then stripped by blunt dissection from the apex and posterior wall until it meets the dissection made from the peritoneum. The vas deferens is separated, the seminal vesicles are detached and pushed back- wards, the bladder is pulled to one side, and the ureter and large vessels on the opposite side are isolated and clamped ; and the same is done on the other side. The bladder is emptied and pulled up, and dissection carried transversely between the front of the base of the prostate and the bladder, and the prostatic urethra is clamped and cut arcoss. The trigone is dissected off the upper surface of the prostate and the bladder removed. The lateral pedicles are now ligatured. The peritoneum may be opened, and, instead of being stripped off, the adherent portion is excised (intraperitoneal method). Cystoprostatectomy. — The preliminaries are the same as already described, but the prostate is completely separated from the perineum, the membranous urethra is cut across, and the anterior surface of the prostate separated from the back of the pubic bones. The patient is placed in the Trendelenburg position and the bladder exposed, the peritoneum stripped off, and the lateral pedicles clamped as before. The bladder is drawn upwards and backwards, the pubo-vesical ligaments are cut across, and the bladder, prostate, and seminal vesicles removed. Cystectomy in the female (Pawlik's operation). — The ureters are exposed from the vagina, cut across, and implanted into the vaginal wall. After some weeks the bladder is exposed and separ- ated from the peritoneum by a vertical suprapubic incision. A vaginal incision is made immediately above the urethra, and the bladder delivered into the vagina and removed after cutting across the urethra. The urethra is then implanted into the vagina and the outlet of the vagina closed by a second operation later, so that the vagina forms a -reservoir for the urine. Results. Partial resection. — In 96 collected cases of partial resection of the bladder for carcinoma there were 21 deaths (21-8 per cent. — Watson). The author has performed (March, 1911) resection of the bladder in 30 cases of malignant growth, with 3 deaths (10 per cent.). In 10 of these cases one ureter was transplanted. Late results. — Of 50 cases of partial resection collected by Watson there was recurrence in 58 per cent, within three years, and in 10 per cent, there was no recurrence. Kiimmel reports that of 47 cases of bladder resection for malignant growth 10 are well XXXV] CYSTECTOMY: RESULTS 485 al'ter sixteen, fifteen, eij^lit, uiid six uiid a half years, and I dicMJ of recurrence ten years after the operation. Ill 25 cases of resection by the author in which late informa- tion was obtained there were 3 deaths from ascending pyelo- nephritis and 6 recurrences, 1 of which was re-operated (Plate 33, Fig. 4) ; in 17 cases the patients were alive and without recurrence (1) six months after the operation in 6 cases, (2) twelve months in 3 cases, (3) eighteen months in 6 cases, (4) two years in 1 case, and (5) four and a half years in 1 case (statistics in March, 1911). Cystectomy.— Oi 39 cases collected from the literature, death occurred after the operation in 18, a mortality of 46-1 per cent. Only 10 cases could be traced, and in only 2 of these was the period after the operation longer than fifteen months. One was well five years afterwards (Hogge) and one sixteen years (Pawlik). Later statistics give an even higher mortality. Verhoogen and de Graeuwe collected 59 cases of total cystectomy, with an opera- tive mortality of 52-7 per cent. Of the 27 cases that survived the operation, 6 died in the first year, 7 died before the third year, and only 2 survived more than three years. In 12 cases the result was unknown. Watson, basing his statistics on collected cases, holds that the only operation that offers reasonable hope of success in carcinoma of the bladder is total extirpation of the organ, and that this operation should be done in every case that is suitable for opera- tive interference. He also holds that cystectomy should be per- formed for benign growths whenever recurrence takes place, " or at least if there is more than one recurrence." With the high operative mortality of cystectomy and the lack of encouraging statistics of the after-results, the views of Watson are not likely to be generally accepted, the more so that the results of partial cystectomy have greatly improved. Cystectomy must at the present time be looked upon as a desperate measure which holds out little, if any, prospect of cure. Palliative treatment. — This is adopted when radical operation is contra-indicated, and consists in treating symptoms as they arise. Hcematuria. — In severe heematuria the patient is confined to bed, the lower end of the bed being raised. Opium and ergot are given hypodermically and calcium lactate by the mouth, the latter in doses of 10 gr. every four hours for forty-eight hours. The bladder should be washed with a large quantity (several quarts) of hot weak silver nitrate solution (1 in 10,000). Con- tinuous irrigation may be arranged with a double-way catheter. This is followed by the instillation of a small quantity of adrenalin solution (1 in 1,000). 486 THE BLADDER [chap. If the bladder becomes distended with clots, an attempt may ■be made to break them up and remove them by means of an evacuating cannula and bulb. If this is not quickly successful the bladder should be opened suprapubically, the clots cleared out, and a large drain inserted. Partial operations involving the removal of the salient portion of a large growth by the suprapubic route and subsequent drainage are sometimes successful in relieving severe bleeding. Pain. — Pain is frequently the result of chronic cystitis, and in such cases the urine is usually ammoniacal, and there may be phosphatic deposits on the bladder wall. Severe pain may, how- ever, be present in infiltrating growths with little, if any, cystitis. Treatment consists in giving suppositories of extract of bella- donna J gr. and morphia J gr., to which cocaine ^-1 gr. may be added. The injection of tincture of opium 20 minims, with antipyrin 30 gr., in a small enema of hot water, frequently gives relief. Washing the bladder with silver nitrate solution (1 in 10,000) may be beneficial, and, if the urine is alkaline and phosphatic material is being deposited, washing with a very weak solution of acetic acid (1 in 5,000) and the administration by mouth of sodium acid phosphate, 20 gr. thrice daily, should be tried. Urinary antiseptics (urotropine, etc.) are also useful. Suprapubic cystotomy may become necessary, and the cyst- itis should be treated by continuous irrigation. A permanent drain should be established, an apparatus being fitted^ and the urine drained into a rubber urinal attached to the thigh (p. 549). Partial operations upon the growth give relief from pain and from serious haemorrhage. They are attended with some danger of septic pyelonephritis where cystitis is present. Nephrostomy, or permanent drainage of the kidney with ligature of the ureter just below the renal pelvis, may be done. Each kidney is treated in this way, and an apparatus applied to the loin to collect the urine (Watson). Harrison suggested the implantation of one ureter on the skin of the loin and the removal of the second kidney. Fenwick has adopted this method, applying it to both sides without nephrectomy. 2. CONNECTIVE-TISSUE NEW GROWTHS FiBEOMA These rare tumours are small, round, pedunculated, covered with smooth mucous membrane, and of a yellowish-white colour. They consist of somewhat loosely-set fibrous tissue containing XXXV] CONNECTIVE-TISSUE NEW GROWTHS 487 few blood-vc'ssi'ls. Tlioy arc likely to be confused with iiiuliguaiit growths. Clado collected 25 recorded cases. The author removed a fibroma the size of a hazel-nut fioni tlic neighbourhood of the right ureter in a man aged 30. Myoma, Fibro-Myoma These tumours, of which about 20 examples are on record, form single, very rarely multiple, round nodules, which project from the outer surface of the bladder (extravesical), or into the interior of the viscus (intravesical or submucous), or are buried in the wall (interstitial). The submucous variety are peduncu- lated or sessile, firm, round, or oval tumours foUnd at the base of the bladder. The growth consists of closely-set non-striped muscle fibres in whorls or irregularly interlacing. The vascular supply is peripheral and abundant. Sarcomatous, rarely epitheliomatous, degeneration of these tumours has been described. Myxoma Pure myxoma of the bladder is rare, and is found almost exclusively in children. The tumours are situated at the base of the bladder, are almost always multiple, and form polypi not unlike those of the nose, but of firmer consistence and darker- red colour. Growth is extremely rapid, and recurrence takes place in a short time after removal. Microscopically there is an abundant granular intercellular substance, in which are round cells and a few branching myxomatous cells. The vessels are large and numerous, and formed of a single layer of endothelium. Sarcoma Sarcoma of the bladder is found in infancy and late adult life, and, relatively to epithelial tumours, is a rare growth. Wilden states that in 50 cases of sarcoma 26 of the patients were over 40, and 14 were under 10 years. Horder found 4 cases in 60 growths, and Targett described 4 in 36 specimens. The proportion is much higher in children. Phocus found that 7 in 15 bladder growths in children were sar- comas. Secondary sarcoma is rare. The sarcoma originates in the submucous areolar tissue, less frequently from the extra- muscular areolar tissue (Targett), and rarely from the connective tissue of the muscular layer (Bernstein). The majority of these tumours arise from the posterior or lateral walls (57 per cent. — Albarran), and the trigone is seldom affected unless with other parts. The tumour may be peduncu- 488 THE BLADDER [chap. lated or sessile, and infiltrating. Not infrequently the bladder wall is widely infiltrated, and projecting into the interior are numerous polypoid bodies. The cavity of the bladder may be filled with masses of these polypi. The surface is smooth and pink, or deep red, and of the consistence of hail. The ureteric orifices may be surrounded without obliterating the lumen. The urethra is sometimes blocked by polypoid bodies which may protrude from the external meatus in the female. The rectum, intestine, and vagina may be involved, and perforation of the bladder wall occasionally occurs. The spindle-celled, round-celled, and rarely the melanotic varieties of sarcoma are found. Myxoma and myxo-sarcoma are also described. Rhabdo-myoma is a very rare tumour, probably arising from the striped muscle of Henle which passes up the anterior surface of the prostate as far as the bladder. Chondro-sarcoma is another rare form. Angioma has been described by Albarran and others ; it is a rare form of tumour, which may become sarcomatous. Two cases of chorion-epithelioma have been described. 3. DERMOID CYSTS Dermoid cysts are occasionally found as pedunculated tumours the size of a pigeon's egg, or buried in the wall of the bladder. Occasionally a perivesical dermoid cyst ruptures into the bladder. Clado described 8 examples, 2 of which were pedunculated and 6 sessile tumours. LITERATURE Albarran, Les Tumeiirs de la Vessie. 1891. Bangs, Med. Bee, 1911, i. 359. Binney, Boston Med. and Surg. Journ., 1911, p. 226. Block and Hall, Amer. Journ. of Med. Sci., 1905, p. 654. Casper, Bed. Min. Woch., 1908, Nr. 6 ; Zeits. f. Urol., 1909, Supfl., 441. Cassanello, Ann. d. Mai. d. Org. Gen.- Urin., 1908, i. 641. Enderlein und Walbaum, Festschr. z. 60 Geburtstage, 0. Ballingers. Wiesbaden, 1903. Gredenberg, Beitr. z. Min. Chir., 1904. Harrington, Ann. Surg., Oct., 1893. Kummel, IP Congres de 1' Assoc. Internat. d'Urol., London, 1911. Liehtenstein, Deuts. med. Woch., 1898, p. 709. Mayo, Ann. Surg., 1908, p. 105. Motz, IIP Sess. de 1' Assoc. Frang. d'Urol., Paris, 1898, p. 347. Paschkis, Folia Urol, 1908, ii. 450. Pawlik, Wien. med. Woch., Nov. 7, 1891. Rafin, Proc.-verb. Assoc. Frang. d' Urol., 1906, p. 1. Rehn, Centralbl. f. Chir., 1904, Suppl, 122. Rochet et Martel," Gaz. Hebdom. de Med. et de Chir., 1898, p. 337. Rovsing, Arch. f. Idin. Chir., 1907, p. 1407. Shattock, Proc. Roy. Soc. Med., Pathological Section, 1909, p. 31, Stoerk und Zuckerkandl, Zeits. f. Urol., 1907, p. 1. XXXV] VESICAL NEW GROWTHS 489 LITERAT UUE (conlinucd) Stump!, Zciijlers Bcitr., I'Jll, p. 171. Treplin, Dc'ut.'^. mcd. Woch., I'.HKi, No. 1!). Verhoogen, de Graeuw^, and von Rihmer, XVI'' Congies Internat. dc Med., Buda- pest, liM)!), p. 118. Walker, Thomson, " Operations on the Bladder," in Burghard's System of Opera- lire Surgeri/, 190!), vol. iii. ; Lancet, Nov. 12, I'JlO ; II. Congres de I'Assoc. Internat. d'Urol., London, 1911. Watson, Ann. Surg., Dec, 1905 ; Diseases and Surgery of the Genito- Urinary System, 1909. Weinrich, Arch. f. hlin. Chir., 1906, p. 887. Wendel, Mitt. d. Grenzgeh. d. Med. u. d. Chir., 1900, p. 15. Wilder, Amer. Joitrn. Med. Sci., 1905, p. 03. CHAPTER XXXVI VESICAL CALCULUS Etiology. — The etiology of stone formation in the urinary tract is discussed under Renal Calculus (p. 249). Stone in the bladder is less frequent in children than in adults, and much more frequent in men — especially old men — than in women. In children vesical calculus is more frequent in the lower class than in the well-to-do. When stone occurs in children it is found in the bladder in the great majority of cases. Bokay found that 1,150 out of 1,621 cases of urinary calculus in children were vesical. Calculi are primary when they are formed in an aseptic urine, and secondary when they result from changes in the urine caused by bacteria. The nucleus of a vesical calculus may be formed by a small oxalate-of-lime or uric-acid calculus which has descended from the kidney, or the stone may form around a portion of blood clot or a foreign body such as a fragment of a catheter, a pin, a silk ligature from a previous operation on the bladder (Figs. 152, 153) or neighbouring organs, a fragment of necrosed bone, etc. The two important predisposing factors in the production of secondary calculi are bacterial action and stagnation of urine. Of these bacterial action is the more important. The following proof of the presence of bacteria in the interior of calculi is of interest. In a woman of 50 years I removed a large phosphatic vesical calculus by litholapaxy. Previous to the operation the urine had been aseptic. The centre of the stone was composed of soft, greyish, stinking material, and cultures made from this gave an abundant growth of bacillus coli. The operation was followed by a smart attack of cystitis due to the bacillus coli released from the interior of the stone at the litho- lapaxy. The patient gave a history of removal of a urethral caruncle, followed by an attack of cystitis, three years before. Calculi are very frequently found in old men with enlarged prostate and infected urine, and they may form in the stagnant urine in a diverticulum of the bladder. 490 CHAP. XXXVl] VESICAL CALCULUS 491 Fig. 145. — Radiogram of pure uric-acid calculi from bladder, taken after removal. These calculi did not throw a shadow when in the bladder. Chemicai composition and physical characters. NCsiciil cuk'iili ;uc coiiqxj.scd of uric acid, pliosplialcs. or oxalulc ol lime, in that order of frequency, and rarclv of cvstiii, xantliin, in- digo, or calcium carbonate. Uric-acid calculi (Figs. 145, 146, 147) may be pure uric acid, or ammonium or sodium urate. They are single or mul- tiple, varying from the size of a split pea to that of a hen's egg. They are rounded or oval and may be flat ; the surface is smooth, or very finely nod- ular, and easily polished. They are sandy yellow to a dark brown in colour, and on sec- tion show a regular concentric lamination. They are hard, but not so hard as oxalate- of-lime calculi. Calculi, com- posed of urates are similar in contour, but lighter in colour and harder in consistence. Oxalate-of-lime calculi (Fig. 148) are round and usually single. They vary from a pea to a chestnut in size and have a dark- brown colour. The sur- face is covered with closely-set conical bosses (mulberry calculus), or there may be a few sharp projecting spines (star form). The calculi are very hard. On section they are composed of closely set, irregularly disposed laminae. Phospkatic calculi (Figs. 149-53) may con- sist of basic calcium phosphate, either alone or mixed with ammonio- magnesium phosphate, and in addition there may be ammonium urate. Fig. 146. — Uric-acid calculi removed from bladder. 492 THE BLADDER [chap. Fig. 147. — Uric-acid calculi removed from bladder. Fig. 148. — Oxalate-of-lime calculi (mulberry calculi) removed from bladder. XXXVlJ VESICAL CALCULUS 493 Fig. 149. — Phosphatic calculus of bladder. These stones vary greatly in consistence. They may be soft and easily crumble, but when composed of crystalline phosphates they are very hard. Sometimes there is a hard outer shell and a soft interior. On section they are granular and rarely show lamination. Cystin calculi are oval, granular, yellowish-brown, and have a soapy appearance. They turn a greenish-yellow when exposed to air. XantJnn stones are smooth and yellow, and indigo are , blue, while calcium-carbonate calculi are greyish- white, earthy-looking, hard stones. Calculi are rarely composed of a single ingredient, and are frequently named uric-acid, oxalate - of - lime, etc., only from their principal ingredient. The nucleus in primary stones is most frequently uric acid, less often oxalate of lime. Around the nucleus the laminae of oxalate of lime or of uric acid are disposed. The layers may alternate. The sur- face is frequently covered with a smooth layer of phosphates. Large calculi are usually single, but there may be one large calculus and many small ones. Multiple hard stones are rounded like peas, while the softer varieties (phos- phates) are angular and faceted. As many as 400 or 500 may be present. Very large stones have been recorded: Preston found one weighing 51 oz., and Earle another of 44 oz., at an autopsy; and Milton re- moved one of 34 oz., and Clive another of 46 oz., by operation. Fig. 150. — Phosphatic calculus removed from bladder. 494 THE BLADDER [chap. The average weight is 200 or 300 gr. Phosphatic stones develop rapidly, and a large stone may form in a few weeks. Uric-acid calculi form less ra- pidly, and oxalate-of- lime very slowly, some years being usually taken to form a cal- culus of moderate size. Vesical calculi are either movable or fixed. A movable stone rolls about in the bladder, and its position varies according to the atti- tude of the patient. With the patient re- cumbent the stone usually lies on the posterior wall, just behind the base of the trigone. Large calculi in an inflamed, sensitive bladder are occasionally found at the apex spasmodically Fig. 151. — Phosphatic calculi removed from bladder. Fig. 152. — Phosphatic calculi formed around silk sutures used in removal of bladder growth. grasped in a partial contraction of the bladder. The lower part of the bladder is not contracted, and contains fluid. Freely movable stones take a. rounded or flat oval form. xxxvij VESICAL CALCULUS 495 Ultzmann holds that the contour of the stone depends upon the crystals of which it is composed. Urates, uric acid, earthy phosphates, and cystin belong to the rhomboidal crystalline form, and produce flat ovoid stones varying in the three axes. Calcium oxalate belongs to the quadrate crystal form, and produces a rounded calculus. Secondary deposits change the contour of the stone : a rounded oxalate stone covered with uric acid becomes egg-shaped, while an ovoid uric-acid imcleus becomes rounded when oxalate of lime is deposited upon it. When a number of calculi are closely packed together they Fig. 153. — Phosphatic calculi formed around silk sutures used to close a cystotomy wound. take a polygonal form with facet-like surfaces ; when freely movable they take a rounded form. A fjxed stone is found in a diverticulum or saccule, or project- ing into the bladder from the lower end of the ureter or from the urethra, or in a diverticulum at the apex of the bladder, the patent lower end of the urachus (Dykes). When a stone lies within the cavity of a diverticulum it is rounded or oval, and it may be movable within the diverticulum or fixed. The opening of the diverticulum may be so small that the stone cannot be seen from the bladder. Stones which project from the prostatic urethra into the bladder increase rapidly in the shape of a mushroom or umbrella. 496 THE BLADDER [chap. Spasmodic contraction of the bladder wall around a large stone may fix the stone in the upper or, in children, in the lower part of the bladder. Such contractions may give the bladder an hour- glass form, one part of the bladder being distended with fluid; while the other is firmly contracted round the stone. In enlargement of the prostate, stones may be wedged in the deep pocket behind the intravesical projection so that they become fixed. Pathology. — Cystitis may precede the formation of stone, or may result from its presence. The inflammation may be con- fined to the base of the bladder, or it may be universal. The bed on which the stone lies frequently consists of a thick, shaggy, greyish-white membrane formed of thickened and necrosed epi- thelium with muco-pus. Papilloma or malignant growth is present in rare cases. Chronic pyelonephritis is found in cases of long-standing calculous cystitis, and is the cause of death in most fatal cases of stone. Spontaneous fragmentation of a vesical calculus has been known to occur, and it has been most frequently observed in uric-acid calculi. Watson, Dabout d'Estrees, Kasarnowsky, and others have described such cases. The phenomenon is ascribed either to mechanical or to chemical action. Ord believed that it was due to the colloid cement substance of the calculus becoming saturated with urine of low specific gravity, such as is produced by diuretic waters. Leroy d'Etoilles regarded a drying and shrinking of the calculus as an essential factor. Heller explained the fracture by supposing that tension was produced within the calculus by decomposition of ammonium urate lying between layers of uric acid. Civiale, and later Kapsammer, held the view that the mechanical action of bladder contractions produced the fragmentation. If the mechanical view were correct, fracture would be expected to occur more frequently in multiple calculi and when the bladder was spasmodically contracted ; but this is not the rule, and Zuckerkandl points out that fragmentation may occur in an atonic bladder. At the present time the factors which govern this rare phenomenon are unknown. Symptoms. — A stone which descends from the kidney may give rise to a varying series of symptoms. There are one or several attacks of renal colic, which may be followed at once by symp- toms of bladder irritation and the immediate discharge of the calculus with the urine. Frequently, however, a period of relief from symptoms follows the discharge of the calculus into the bladder, and this may last for some days, weeks, or even months. Symptoms commence again when the calculus is swept into the xxxvij VESICAI. CALCULUS: SYMPTOMS W7 urethra to be impacted in that tube or passed through it, or when irritation of the bladder is produced by the continual movement of the stone, or finally when infection takes place. Legueu states that calculi which form in infancy may remain quiescent for ten or even twenty years. Fixed calculi give rise to no symptoms directly referable to stone, and very large calculi are frequently " latent." FrequeM micturition. — This is the most common and the earliest symptom. The increased frequency commences gradually and is progressive. There is urgency to pass water, and the desire, once felt, becomes an imperative necessity. After passing water there is discomfort, and a feeling that the bladder has not been emptied. These symptoms are aggravated, and may only be pre- sent, when the patient moves about or is subjected to the jarring of horse-riding, bicycling, or travelling in a railway carriage or a bus. In the recumbent position the stone falls away from the sensitive neck of the bladder, and the desire to pass water is no longer felt. The patient sleeps peacefully throughout the night. Pain. — Pain is a prominent symptom. It is felt at the neck of the bladder and at the end of the penis, either at the external meatus, at the base of the glans on the dorsum, or most frequently beneath the fraenum. The pain occurs at the end of micturition, is sharp and " cutting," and is increased by movement and jarring. HcBmaturia. — Terminal haematuria is a frequent symptom. A few drops of blood are squeezed out at the end of micturition. The blood is bright, and the haemorrhage not severe. Movement and rest influence this in the same manner as the other symptoms. An intermittent stream may be observed. Arrest in the middle of the act, accompanied by severe pain, is due to impaction of the stone at the internal meatus. The arrest may be momentary, or it may be impossible to start the flow for some minutes, or even ■ a quarter of an hour. If the patient lies down the stone rolls away from the internal meatus and water can be passed freely. Continued retention of urine, necessitating the use of the catheter, is rare when the stone is still in the bladder. It may occur when the stone has become impacted in the prostatic urethra, and is usually accompanied by severe pain and strangury. The urine contains crystals of oxalate of lime, uric acid, or phosphates. The urinary deposit for the time indicates the composition of the surface layer of the calculus. Microscopic quantities of blood and an excess of leucocytes and epithelial cells are usually fomid in the urine. In children, screaming on micturition and retention of urine are not infrequent. In other cases there is incontinence from 2g 498 THE BLADDER [chap. frequent involuntary expulsion of the urine caused by the irrita- tion of a stone forced down into the neck of the bladder. In small boys " milking " of the penis is an attempt to ease the pain, and leads to an enlarged, turgid, semi-erect condition of the penis which is very characteristic. When cystitis complicates stone the symptoms are modified. The frequency is increased, and is continued at night as well as during the day ; the pain grows more intense, and pus and mucus appear in the urine, which often becomes alkaline and stinking. In old-standing cases symptoms of ascending pyolonephritis appear, and the patient rapidly loses weight, and eventually dies of " urinary septicaemia " {see p. 133). Pericystitis with perfora- tion into the rectum or vagina is a rare complication. Diagnosis. — Pain similar to that of calculus may occur in other diseases of the bladder, such as cystitis or malignant growth ; but the pain in calculus is a prominent symptom, it is sharp, occurs at the end of micturition, and is markedly affected by movement and rest. The heematuria and frequent micturition are also increased by movement. The gradual onset of frequent micturi- tion, diurnal in character, is very characteristic of stone. When cystitis is present a calculus may be suspected if the pain is unusually severe and all the symptoms are markedly increased by movement and jarring. The previous passage of a calculus is an important aid to diagnosis. Tuberculous cystitis in children or adults may give rise to difficulty in diagnosis. Pain is sel- dom so acute, and the frequency is continued at night as well as during the day, while movement has little effect upon the symptoms. Malignant growth of the bladder may give rise to symptoms closely resembling stone. Here the pain is constant, is not so sharp, and movement has no effect upon the symptoms. Calculus in combination with enlarged prostate may be attended by no distinctive symptoms, and the stone is usually found during an examination of the bladder, or at the operation for enlarged prostate. Has a stone which is known to have been descending the ureter been discharged into the bladder, or is it still in the lower end of the ureter ? The symptoms of stone in both these situa- tions may be similar, but the effect of movement is seldom so marked in ureteral calculus, and symptoms of irritation of the genital system, such as erections and emissions, are frequently observed when the calculus is in the lower ureter. Usually; when the calculus passes into the bladder the symptoms suddenly cease, XXXVI I VESICAL CALCULUS: SOUNDING 499 and they may not recur until the calculus is passed through the urethra or impacted in that tube. The only certain method of distinguishing between stone in the lower ureter and stone in the bladder is by the use of the cystoscope. Examination. — As a rule, it is not possible to detect a stone of moderate size by rectal or vaginal examination. Even large stones may not be palpable from the rectum, on account of the thickened bladder wall. They may, however, be felt on bimanual examination. Sounding: the bladder. — Before sounding a patient it is necessary to exclude urinary tuberculosis by bacteriological exam- ination of the urine and other means. If tuberculosis is present the bladder should not be sounded. The most stringent precautions in regard to asepsis must be exercised in this examination. The instruments are boiled, the hands rendered surgically clean, and the area of operation is sur- rounded by clean towels. The penis is washed with antiseptics. In children a general ansesthetic is usually necessary, but in adults none is required. The patient lies on. a high couch, and the surgeon stands on his right. Four or six ounces of fluid are introduced into the bladder through a catheter, which is then removed. The sound is introduced and pushed on until it is arrested at the apex of the bladder in the middle line. The beak is turned first to one side and then to the other, and the instrument drawn slowly out, tapping the bladder on each side of the middle line by turning the beak from side to side, until it is arrested at the internal meatus. Then the postprostatic area is examined by raising the handle of the sound until it is vertical, and finally by turning the beak down behind the prostate if it is enlarged. As the in- strument is withdrawn the surgeon should pay particular attention to grating or impact with a stone in the prostatic urethra. When the beak of a sound comes in contact with a stone in the bladder a sharp metallic click is heard, and the impact can be felt with the thumb and forefinger lightly holding the instrument. An idea of the size of the stone may be gained by noting the distance to which the sound is withdrawn while the beak still rings upon the stone. Multiple calculi may be detected by the impact taking place when the beak is turned first on one side and then on the other. In children the stone lies at the neck of the bladder, and the sound at once impinges upon it ; in adults in the dorsal decu- bitus the stone falls into the post-trigonal area, and in old men 500 THE BLADDER [chap. the stones are usually found behind an intravesical projection of the prostate (postprostatic pouch). A calculus may not be felt with the sound when it is embedded in the folds of a partially distended bladder, when it is grasped by a spasm of an irritable bladder, when it lies behind an enlarged prostate or in a diver- ticulum, or when it is covered by a thick layer of mucus and pus. The ridges of a trabeculated bladder, or phosphatic deposit on the mucous membrane in chronic cystitis or on a new growth, may give rise to difficulties in diagnosis with the sound ; and the operator should be careful that the handle of the instrument does not come in contact with hard bodies such as a ring or a button. When a small stone cannot be felt with the sound the follow- ing method may detect it (Freyer) : The cannula of a litholapaxy evacuator is passed, a few ounces of fluid are introduced, and the evacuating bulb is applied. At diastole of the bulb the small calculus is sucked against the eye of the metal cannula with an easily detected click. Cystoscopy (Plate 36). — This is the most certain method of detecting a calculus. Movable calculi are found just behind the inter- ureteric bar. Large calculi in a contracted bladder may be difficult to view, as they are pushed aside by the beak of the cystoscope. Calculi lying behind the prostate or in a sacculus or at the mouth of the ureter are readily seen with the cystoscope, while they may escape detection with the sound. When a diverticulum has a small opening it may contain a large calculus which cannot be seen with the cystoscope. The number of calculi present in the bladder and their position and appearance are readily ascertained. I have seen a small spherical growth of the bladder entirely covered with phosphates, which exactly resembled a phosphatic stone, except that the position was constant to the outside of the right ureter in different positions of the patient. In another case where a stone shadow was shown by radiography the cystoscope revealed in addition a large papillomatous growth, and litholapaxy was abandoned for suprapubic cystotomy. Radiography. — A shadow in the vesical area {see p. 360) may be cast by a stone in the bladder, in the lower end of the ureter, or in a diverticulum. A vesical stone shadow is usually in the middle line, and it can be made to change its position by move- ments of the patient. The shadow thrown by a calculus in a diverticulum is more likely to be to one side of the middle line, and this position may also be taken by a shadow thrown by a stone in the bladder pushed aside by a growth. Treatment. — There is no means by which a stone in the Fig. 1.- Large phosphatic calculus with cystitis. Fig. 2. — Uric-acid calculi covered with thin layer of phosphates. Fig. 3. — Oxalate-of-lime calculi in bladder. Plate 36. (P. 500.) XXXVI] VESICAL CALCULUS: TREATMENT 501 bladder can be dissolved, whether by medicines, or waters adminis- tered by mouth, or washes used k)cally. When a stone has been passed in the urine a thorough examin- ation witli tlie cystoscope or X-rays sliouhl t'oUow to make certain that no other calcuh are present in the bhidder, ureters, or kidney. When a stone has been passed down the ureter into the bladder and lias not inmiediately been discharged through the urethra, its removal from the bladder should be proceeded with as soon as possible ; for, although there is a fair probability of the stone passing through the urethra, there is also considerable danger that it may become impacted in that tube — an accident that may give rise to much pain and considerable difficulty in attempting to push the calculus back into the bladder, and may necessitate a perineal operation for its relief. A small calculus may sometimes be removed by means of the cannula and aspirator (Fig. 154) used in litholapaxy. This should Evacuating cannula and stylet. be performed under the same aseptic conditions that are neces- sary in a crushing or cutting operation. A general anaesthetic is preferable, although it may be dispensed with, or local anaesthesia used when the operator is skilful and the patient placid. The largest cannula that the urethra will take is passed and the bladder emptied. Four or five ounces of warm boric lotion are introduced by means of a bladder syringe, and the aspirating bulb, filled with boric solution, is applied to the cannula. The bulb is raised so that the beak of the cannula lies at the lowest part of the bladder, and is compressed and relaxed. At diastole the calculus is felt to click at the eye of the cannula, and it drops into the glass bulb. The aspirating bulb is removed, the bladder emptied and then washed with a few syringefuls of silver nitrate solution (1 in 10,000). This method is only applicable to small stones which have recently descended from the kidney, or to small fragments of phosphatic grit found in the course of chronic cystitis. It should not be attempted- unless the surgeon is skilled in litholapaxy and is prepared at once to proceed to this operation if suction fails. 502 THE BLADDER [chap. The operations which are performed for stone in the bladder are of two kinds — (1) crushing (Utholapaxy or hthotrity), and (2) cutting (lithotomy). 1. Litholapaxy or Hthotrity. — The modern operation of litholapaxy, which consists in crushing a stone and removing the fragments at one sitting, was introduced by Bigelow, of Boston, in Scales Fig. 155. — Thompson's lithotritCi 1878, and became firmly established as the operation of choice for vesical calculus through the work of Freyer, Keegan. and other officers of the Indian Medical Service. Previous to this date the operation consisted in crushing the stone and allowing the fragments to be swept out by the urine. The instruments necessary for litholapaxy are a lithotrite and evacuating apparatus. Lithotrites of shghtly varying construc- tion have been introduced by Weir, Bigelow, Guyon, Thomp- son (Fig. 155), Freyer, and others. The lithotrite consists of two blades, one of which, the male blade, glides in a sunken groove in the other. The beak is set at an angle, and the female portion of it is concave and fenestrated, while the male is convex and toothed. The handle, by which the instru- ment is held in the left hand of the operator during the crushing, is attached to the female blade, and the screw, which is manipulated with the right hand, passes through this and belongs to the male blade. By a mechanical device, controlled either by a movable button on the handle (Thompson) or a screw cap attached to the male blade (Bigelow), the two blades can be locked, and can then only be approximated by means of a power- ful screw worked on the male blade by a wheel (Thompson), or by Fig. 156. — Freyer's aspirator. xxxvi] LITHOLAPAXY )03 a conical serrated handle (Bigelow). The cannula consists of a straight metal tube with a short beak and a large eye, the proximal end of which fits into the tube of the aspirator. The size of the cannula) varies from 12 to 18 English scale. There have been many modifications of Bigelow's aspirator. That of Freyer (Fig. 156) is the simplest and best. It consists of a bulb of thick rubber, on the lower aspect of which is an opening to which a glass bulb is attached ; close to this, and steadied by a metal bridge, is a metal tap and stopcock. This fits on to the proximal end of the Fig. 157. — Litholapaxy : Grasping the stone and locking the blades. Note the angle of the instrument ; the blades are in the most dependent part of the bladder. The stone is grasped between the blades, and the thumb of the operator's left hand is pushing up the locking button. cannula. Pardoe has modified this by replacing the pressure band of twisted wire which holds the rubber bulb and glass bulb together by a metal band with a spring clip. The operation of litholapaxy (Figs. 157, 158, 159, and Plate 37) is carried out as follows : The patient is prepared by the administration for some days of 10 gr. of urotropine thrice daily, the bowels are emptied by an aperient, and the rectum cleared before the operation by an enema. A general anaesthetic is admin- istered. The pelvis is slightly raised on a low, flat cushion. The bladder is thoroughly washed with warm boric solution and the catheter withdrawn, leaving: 4 or 5 oz. of the solution in the bladder. 504 THE BLADDER [chap. If the meatus is narrow it is slit downwards. The surgeon stands on the right side of the patient, and the lithotrite, with the male blade pushed home and well lubricated, is passed along the urethra until the beak is inside the bladder. The handle is then raised so that the beak descends to the lowest part of the bladder (the post-trigonal area in this position), and the blades are separated. The stone, which is lying at the lowest part of the bladder, rolls in between the blades, and is caught when the male blade descends upon it. Should the stone not be grasped by the manoeuvre the Fig. 158. — Litholapaxy : Crushing the stone. The stone having been caught between the blades of the lithotrite and the blades locked, the handle is firmly grasped in the left hand ; the right hand is turning the screw. blades are separated and the instrument turned to the right or left, or pushed well up into the apex of the bladder, or finally turned downwards behind the prostate if this is enlarged. The blades are now locked, the beak raised slightly from the bladder wall, and the screw rapidly turned, the female blade being kept absolutely steady by holding the handle rigid with the left hand. When the blades have closed the screw is thrown out of gear and the blades are separated, a fragment seized as before and crushed. The crushing should proceed with the lithotrite in this position until no more fragments are grasped, then it may be turned on one side, opened, and a fragment (if any are left) grasped, the beak again turned into the erect mid-line position, and the fragment Fi^. 1. — Shadow of calculus (P. 5C4.) in grasp of lithotrite. Fig. 2. — Shadow of evacuating cannula, upper arrow on right ; lower arrow on right points to small fragments of crushed calculus, arrow on left to large fragment that could not pass the eye of the cannula. (P. 503.) Plate 37. XX W I LITHOLAPAXY 505 crushed ; and this maiKjeiivro is repeated until no fragments are left. Tlie beak is now turned to the other side, and the process repeated. All the fragments having been crushed, the blades arc closed and the lithotritc witlidrawji. The largest cannula that the urethra will admit is now passed and the fluid in the bladder allowed to escape. Four or five ounces are again injected, the aspirator bulb is applied to the cannula, and the cock opened. The bulb is now raised in the middle line, so that the beak of the cannula lies at the lowest part of the Fig. 159. — Litholapaxy : Removal of the crushed fragments by evacuator. The beak of the evacuating cannula is at the most dependent part of the bladder. It is supported by the left hand, and the eye has been turned towards the onlooker by pressing the thumb on the flange. The right hand is in the act of squeezing the bulb. bladder, and the bulb is grasped in the right hand and compressed, the cannula being firmly held by the left hand. At diastole of the bulb the fragments of the stone are sucked into the rubber bulb, and, being heavier than water, they fall down into the glass bulb. The aspiration is continued until no further fragments fall, then the beak of the cannula is turned to the right and aspiration repeated, and then to the left, each new position being retained until the supply of fragments is exhausted at that spot. During diastole there may be " stammering " of the suction, which indicates that the beak of the cannula has been applied too close to the wall of the bladder and the loose mucous membrane sucked into the 506 THE BLADDER [chaf. eye. This miigt be avoided, as it is tantamount to dry-cupping the wall of the bladder. If it should happen, the eye is set free by compressing the bulb, and is then turned away from the mucous membrane. Two aspiration bulbs should be in use, to save time by chang- ing them when one is filled or the fluid has become cloudy. The bulb may become fixed and fail to expand. This is due either to aspiration of the mucous membrane, and is freed by squeezing the bulb and turning the eye away from the mucous membrane, or to a fragment of stone too large to pass the cannula becoming fixed in the eye. This may be dislodged in the same way, but will probably necessitate the bulb being detached from the can- nula and a stylet being pushed along the tube, after which the fluid comes away in a gush. When removal of the stones is complete the fragments cease to fall into the glass bulb at diastole, and on listening carefully no click of a fragment against the eye of a cannula can be heard. Frequently at the end of the crushing several large greyish-white shreds of muco-pus and necrosed epithelium fall into the bulb. This is the bed on which the stone has been lying. If the clicking of fragments can still be heard the lithotrite is again introduced, and the fragments are crushed, and removed by the aspirator. The type of fragment which is most difficult to pick up with the lithotrite is a thin shell from the outer part of the calculus. The bladder is now washed out through the cannula with nitrate of silver solution (1 in 10,000), and the cannula removed. If the fluid returns clear on washing the bladder a cystoscope may be introduced and the bladder examined to see that it is clear of fragments. Usually, however, the cystoscopy may be deferred for a few ' days. The operation lasts from five or ten minutes to an hour or more, according to the size of the stone and the condition of the bladder. If cystitis is present, or if the bladder is irritable or the pros- tate enlarged, the bladder should be drained by tying a catheter in the urethra for a few days, and should be washed daily with silver nitrate solution. The patient is kept in bed from two to fourteen days, according to the condition of the bladder and the temperature. Three to five days will suffice when the stone is small and the bladder aseptic. Litholapaxy in children. — There are theoretical objections against the performance of litholapaxy in children. The urethra is very small and narrow, and its mucous membrane delicate and easily torn, and the bladder is small and pear-shaped, so that the space for manipulation is confined. xxxvT] LITHOLAPAXY IN CHILDREN 50? Keegan has shown, Iiowcvcm-. that lithohi[)axy in yoiii)