Qlnllf gp of Pl|g0irtan0 an& ^urgMna iAtUnntt ffitbrarg ■ I UROLOGY VOLUME I Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/urologydiseaseso01guit UROLOGY THE DISEASES OF THE URINARY TRACT IN MEN AND WOMEN A BOOK FOR PRACTITIONERS AND STUDENTS BY RAMON GUITERAS, M.D. (Harv.) PROFESSOR OF GENITO-URINARY SURGERY, NEW YORK POST-GRADUATE MEDICAL SCHOOL; VISITING SURGEON TO THE COLUMBUS AND POST-GRADUATE HOSPITALS; CONSULTING SURGEON TO THE CITY AND FRENCH HOSPITALS; FORMERLY PROFESSOR OF ANATOMY, OPERATIVE SURGERY AND GYNECOLOGY. POST-GRADUATE MEDICAL SCHOOI<, AND VISITIN& SURGEON^ IN THE DEPART- MENT OF GENITO-URINARY CiSEASfiS AND GYNECOLOGY, NEW YORK CITY HOSPITAL ; MEMBER OF THE AMERICAN MEDICAL ASSOCIATION, THE AMERICAN UROLOGICAL ASSOCIATION, THE FRENCH UROLOGipAL ASSOCIA-TION, THE AMERICAN-PUBLIC HEALTH ASSOCIATION, THE AMERICAN ASSOCIATION OF "GENITO-URINARY SURGEONS, THE AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNE- COLOGISTS, THE ASSOCIATION OF MILITARY SURGEONS OF THE UNITED STATES, THE AMERICAN SOCIETY OF TROPICAL MEDI- CINE, THE NEW YORK ACADEMY OF MEDICINE, AND THE HARVARD MEDICAL SOCIETY WITH NINE HUNDRED AND FORTY-THREE ILLUSTRATIONS IN TEXT AND SEVEN PLATES VOLUME I NEW YORK AND LONDON D. APPLETON AND COMPANY 1912 PRINTED IN NEW YORK, V. S. A. Copyright, 1912, by D. APPLETON AND COMPANY TO MY TEACHERS HENRY J. BIGELOW THEODOR BILLROTH ERNEST FINGER FELIX GUYON JAMES E. KELLY PRINCE A. MORROW FESSENDEN N, OTIS FREDERICK R. STURGIS ROBERT W. TAYLOR ROBERT ULTZMANN LEOPOLD VON DITTEL ERNEST VON BERGMANN THIS WORK IS DEDICATED AS A TOKEN OF RESPECT, ESTEEM AND GRATITUDE PKEF ACE This work on Urology includes all the diseases of the urinary tract, both medical and surgical, in men and women. The upper part of the urinary tract, the kidneys and ureters, is practically the same in both sexes. The middle part, the bladder, is also the same, although its relations are different, and, whereas bladder troubles in men are principally due to intravesical causes and obstructions in the prostate and urethra, the troubles in women are gen- erally due to extravesical causes in the pelvis. It is obvious, therefore, that it is the lower third of the urinary tract, the urethra, which principally differs in men and women. In men it has been thought advisable to consider the diseases of the genital tract together with the urinary, as the genital tract empties into the prostatic urethra and from this point to the external urinary meatus the two tracts are in common. In women, on the other hand, the urinary and genital tracts are separated from each other throughout their entire extent, meeting externally at the urogenital sinus in the vestibule. The internal genital organs are, how- ever, in close enough contact with the bladder to give rise to many disagreeable urinary symptoms, most of which have been carefully considered. If an attempt were made to consider the genital tract of the female as thoroughly as that of the male, it w^ould necessarily embrace gynecology, wdiich is not within the scope of this work. It has been my aim in writing the text to consider principally cause, diag- nosis and treatment and not to go as deeply into pathology as many writers do. The illustrations were chosen to show certain pathological conditions and to illustrate the steps of operations, and, excepting the purely anatomical and pathological drawings of specimens, they are principally diagrammatic and schematic. The first part of the book is preparatory to the second. It contains the anatomy of the urinary organs in the male and female and the laboratory methods of examining the urine, discharges and blood. The dift'erent varieties of offices for this kind of work are then considered with their equipment, the instruments and apparatus recommended and the methods of sterilization of the apparatus and instruments. The technique employed in using the apparatus and the general instruments that compose the armamcutariiim of the urinary surgeon as well as the special instruments, such as the urethroscope and cysto- viii PREFACE scoiie, is carefully described. A lengthy description of the general and special uriiiarv symptoms and disturbances of urination are then entered into, and urinary fever is thoroughly discussed. The history and examination of the patient, showing the manner of arriv- ing at a diagnosis, are then taken up. This is followed by a chapter on uro- looical therapeutics in which drugs, exercise, diet and the use of water, inter- nally and externally, as w^ell as by rectum, intravenous injections and hypo- dermoclysis, are fully considered. Asepsis and antisepsis and general and local anesthesia, such as are used in the various urological operations, are also care- fully described. A small section on the diseases of metabolism is here brouglit in and is a valuable addition to the work. The second part of the work is principally clinical and operative, and the diseases of the various organs of the urinary tract, the kidneys, ureters, bladder, prostate, urethra and the genital organs in the male have been taken up seriatim; and finally a chapter on lues was added. The most modern methods of exami- nation of the patient and diagnosis are here described in great detail. The med- ical and palliative treatment of diseases have, however, been gone into as care- fully as the surgical, and the details of such treatment are thoroughly explained. Lengthy historical data have been omitted and statistics have not been recorded and (pioted fully. As the object of the book has been to make it a comprehen- sive w^ork for the practitioner, the bibliography has not been given gTeat promi- nence. Most of the teachings in the book are the same as I have advocated in my lectures during the last twelve years. They are my own views on the subject, some original and others taken from the teachings and wa-itings of others that appeal to me as sound and worthy of recommendation. Having tauciit in the jSTew York Post-Graduate Medical School and Hos- pital for over twenty years, I believe I understand the requirements of the gen- eral practitioner, and therefore, after repeated requests from many students, I have endeavored to present the subject in a way which I believe will be satisfac- tory to them. I wish to thank Dr. H. T. Brooks, Dr. Faxton Gardner, Mr. K. Iv. Bosse, Dr. David Geiringer and Dr. F. Bobbins for their assistance in the text, and Dr. David Geiringer for the illustrations he has made. For the remaining illustrations I wish to thank the various authors whose names appear on the legends. If in any case I have not given credit w^here it is due, it is on account of being doubtful whose name to inscribe. I wish par- ticularly to thank Drs. Ashton, Corner, Deaver, Kelly, Lewis, Lydston, Luys, Manson, Wallace, Watson and Cunningham and White and Martin for the kind permission to use their illustrations. Ramon Guiteras. 80 Madison Avenue, New York City. CONTENTS VOLUME I CHAPTER PAGE I. — History of Diseases of the Urinary Tract 1 II. — The Anatomy of the Urinary and Genito-Urinary Tract .... 9 III.— The Urine 70 IV.: — Discharges • 117 V. — The Blood in Relation to Urology 132 VI. — Urological Equipment 137 VII. — Sterilization of Instruments and Apparatus 153 VIII. — Technique of Instrumentation 163 IX. — Urethroscopy 188 X. — Cystoscopy 198 XI. — Special Urinary Symptoms 239 XII. — Urinary Fever (Catheter Fever), Urinary Infection 289 XIII. — The History of the Case 297 XIV. — General Symptoms 304 XV. — Examination of Patients 308 XVI. — Urological Therapeutics 323 XVII. — Anesthesia in Urology 350 XVIII. — Diseases of Metabolism 358 XIX. — Methods of Examining the Kidney 369 XX. — Anomalies of the Kidney 383 XXI. — Kidney Injuries 390 XXII. — Movable Kidney 403 XXIII. — Nonsuppurative Nephritis . 418 XXIV.— Uremia . '. 440 XXV. — Chronic Suppupative Diseases of the Kid.ney 453 XXVI. — Tumors of the Kidney 480 XXVII. — Cysts of the Kidney 492 XXVIII. — Nephrolithiasis 499 XXIX. — Tuberculosis of the Kidney . 525 XXX. — Hydronephrosis 560 XXXI. — Operative Surgery ok pjik Kidney 570 XXXII. — The Ureters 622 XXXIII. — Operations on the Ureter 646 ix LIST OF PLATES VOLUME I FACING PAGE Plate I. — Indican Color Reaction in Ubine 80 Plate II. — Bacteria Found in the Urine 110 Plate III. — Bacteria, Showing the Opsonic Action Increased by Proper Adminis- tration OF Bacterial Vaccines 112 Plate IV. — Urethroscopic Conditions 192 Plate V. — Urethroscopic Conditions 194 Plate VI. — Shreds and Formations Passed in the First Urine without Massage . 310 Plate VII. — Formations Coming from the Vesicles after Massage .... 318 LIST OF ILLUSTEATIONS IN TEXT VOLUME I FIG. PAGE 1. — Anterior view of the opened genito-urinary tract in the male 10 2. — Posterior view of the genito-urinary tract in the male 10 3. — Posterior view of the relations of the genital and urinary organs in the male at the back of the bladder 11 4. — Anterior view of the genito-urinary tract in the female 12 5. — Posterior view of the genito-urinary tract in the female 12 6. — Upper and middle portions of the virinary tract of the kidney 13 7. — Lower urinary tract in the male on sagittal section, and also the internal and external genital organs 13 8. — Genital organs and lower urinary tract in the female on sagittal section . . 14 9. — Genito-urinary sinus in the male 15 10. — Genito-urinary sinus in the female 15 11. — Anterior view of the bony skeleton of the part of the body in which the urinary tract is lodged 16 12. — Posterior view of the bony framework enclosing the urinary tract .... 17 13. — Space occupied by the urinary tract after it has been lined with its muscular layer . . ' 18 14. — The ligaments and muscles helping to form the pelvic floor 19 15. — View of the right side of the pelvic cavity as seen after a sagittal section . . 21 16. — The pelvic floor looking in from above 22 17. — View of the internal genitals and the pelvic fascia in the male as seen from be- hind 23 18. — Extraperitoneal sagittal section of the body to the left of the median line . . 24 19. — jMuscular layer of the perineum on the right side after the removal of the super- ficial fascia and on the left side after removing the muscular layer ... 26 20. — Anterior perineal triangle after the removal of the muscles, the corpus spongeosum and the corpora cavernosa covering it 27 21. — The outer layer of the triangular ligament of the right side, and on tlie left the space between the two layers of the ligament . .28 22. — The male perineum after the removal of the deep layer of the triangular ligament 29 23. — The perineum in the female after the removal of the labia 30 24. — Anterior layer of the triangular ligament in the female, after the removal of the external genitals, the superficial fascia and muscles 31 25. — The deep layer of muscles forming the fioor of the pehis in the feiiialo from the outside 32 26. — The posterior surfaces of the kidneys and their relations to the ribs .... 33 27. — The relation of the kidneys and suprarenal capsules to the soft tissues in front of them 34 28. — The relation of the kidneys to the soft tissues behind them 35 29. — Median vertical (sagittal) section of the right kidney 35 30. — The renal fascia after a sagittal incision through the kidney 36 xiii xiv l^lST OF ILLUSTKATIONS IN TEXT I'l^- PACK 31. — The renal fascia after a liori/.oiilal iiu-iwioii tlirougli tlie kidney 37 32. — Sagittal section of the kiiliicy 37 33. — Malpighian corpuscle 38 34. — Scheme of the renal tubes and blood vessels 38 35. — The renal artery and its branches 39 30. — Schematic drawing showing the theory of the anangenient of the vascular arches over the pyramids 40 37. — The relations of the ureter to the inferior pole of the kidney and to the blood ves- sels of this region 41 38. — A sagittal section of the pelvis to the left of the median line showing the ureter outside of the peritoneum 42 39. — The relations of the ureter to the pelvic tissues 43 40. — Ureter passing through the wall of the bladder 43 41. — Schematic drawing of the relations of the ureter to the neck of the uterus and its vessels. 44 42. — Shape of the right ureter 44 43. — Bladder on sagittal section, showing its apex and base 45 44. — Bladder on vertical transverse section, showing the trigone and the urethral orifices. 46 45. — The peritoneal reflection on the side of tlie bladder 47 46. — Diagrammatic drawing of the upper surface of the bladder in the male ... 47 47. — The upper surface of the bladder in the female as seen from above . . . • . 48 48. — Diagrammatic drawing showing the base and sides of a dilated bladder from below 49 49. — Change in the shape of the bladder while filling 49 50. — Longitudinal muscular fibers of the bladder wall 49 51. — Middle or circular layer of the muscular wall of the bladder 50 52. — Deep layer of the bladder wall 50 53. — ^Veins in the, male pelvis connected with the bladder 51 54. — Veins about a female bladder 52 55. — Male urethra from the neck of the bladder to the external urinary meatus . . 52 56. — Curves of the urethra when the organ is flaccid, also the fixed portion of the canal 53 57. — Curve of the urethra when the penis is erect or held in jjosition for the passage of instruments 53 58. — Membranous urethra arid its relation to the triangular ligament .... 54 59. — Genito-urinary sinus in the male, the prostate having been opened anteriorly into the urethra and its lateral lobes retracted '.54 60. — The natural dilatations and narrowings of the urethra 55 61. — Transverse vertical (coronal) section through the female urethra .... 56 62. — Cowper's glands 57 63. — Vertical transverse (coronal) cut through the scrotum and penis (schematic) . . 57 64. — The tunica vaginalis opened, exposing the testis 58 65. — Schematic drawing, showing the anatomical arrangement of the tubules in the testicle and the epididymis 59 66. — Vertical section (sagittal) of the testis and epididymis, showing the line of reflec- tion of the visceral layer of the tunica vaginalis, the timica albuginea with its septa, the rete testis mediastinum, the epididymus and vas deferens ... 60 67. — Blood supply of the testis and cord 60 68. — Coverings of the testicle, seen from in front 61 69. — The A'as deferens extending through the inguinal canal and along the side of the bladder to the ejaculatory ducts 62 70. — Profile view of the side of the unopened prostate 64 71. — The lobes of the prostate and the perineal fascias 65 72. — Sagittal section through the prostate, a little to the left of the median line . , 66 73. — Penile urethra in the state of repose and erection 67 74.— Roots of the penis 67 LIST OF ILLUSTRATIONS IN TEXT xv FIG. PAGE 75. — Manner of union of the anterior end of tlie cor2)ora cavernosa with the glans . 08 76. — The end of the penis 68 77. — Urine analysis chart 72 78. — Squibbs urinometer with thermometer and cylinder 74 79.— Saxe's urinopyknometer and cylinder 75 80. — Esbach's albuminometer 77 81. — The Laurent i^enumbra polarizing saccharometer - . . .80 82. — Lohnstein's saccharometer for undiluted urine 82 83. — Einhorn's saccharometer 82 84. — Doremus ureometer 84 85. — Doremus ureometer, improved form 84 86. — Ruhemann's uricometer for the rapid estimation of uric acid 85 87. — Hand centrifuge 92 88.— Water centrifuge 92 89. — The Purdy electric centrifuge 93 90. — Crystals of uric acid 94 91, 92. — Unusual forms of uric acid 95 93. — Crystals of ammonium urates 95 94. — Calcium oxalate crystals 96 95. — Crystals of ammonium magnesium phosphate 96 96. — Feathery form of triple phosphates 97 97. — Crystals of calcium sulphate 97 98. — Leucin crystals 98 99.— Leucin and tyrosin crystals 98 100.— Crystals of cystin 99 101. — Blood cells in the urine 99 102. — Pus cells in the urine 99 103. — Epithelial cells of genito-urinary tract . . . 101 104. — Hyaline casts 105 105. — Granular casts 105 100.— Epithelial casts 106 107.— Blood casts 106 108.— Pus casts 107 109. — Fatty and other casts 107 110. — Types of casts with a waxy matrix 107 111. — Cylindroids or false casts 108 112. — Manner of holding the slide in taking a specimen of urethral discharge in the male 117 113. — Method of obtaining a specimen from the male urethra 118 114. — Platinvim wire to be passed down the urethra to take some discharge from its walls 118 115. — Forcing the discharge out of the female urethra 119 116. — Smears on slides 119 117.— The slides together 119 118. — Spermatic or Bottcher's crystals 120 119. — Spirocheta pallida 122 119. — A spirocheta as seen by Goldhorn stain 122 120. — Reflecting condenser 123 121. — Reflecting condenser 124 122. — Electrical arc lamp with hand feed for a current of 4 amperes 124 123. — Plan of an office of one room with waiting room 137 124. — Plan of an office of two rooms with waiting room 138 125. — Plan of an office of three rooms with waiting room 139 120. — Tabic in the examining room with glassware used in examinations .... 143 127. — Counterbalance table in the position for examination of male patients . . . 144 128. — Different positions in which the patient can be placed in examining the abdominal organS;, especially in kidney cases 145 xvi LIST OF ILLUSTKATIONS IN TEXT FIG. PAGE 129. — Counterbalance table with a douche-pan on it 145 130. — Allison table in the cystoscopic position 147 131. — Appointment form 148 132. — Three vertical liles in which the envelopes containing the patients' histories and correspondence are kept 149 133. — Plan of the clinic at the New York Post-Graduate Medical School . . . 1.50 134. — Willy Meyer steam sterilizer for the sterilization of dressings and instruments . 154 135. — Rochester sterilizer, steam and dry heat 154 13G. — Schering-Glatz formalin sterilizer, used principally for woven catheters, piston syringes and cystoscopes 155 137. — Snell's formalin sterilizer for sterilizing all catheters, but especially ureteral . 157 138. — Method of flushing out catheters employed in author's office 158 139. — Catheter and catheter tube 159 140. — Glass sterilizing tubes with hollow rubber stoppers containing formalin . . 159 141. — Straight catheter with single eye 163 142. — Elbowed catheter with the eye on the side 163 143. — Curved catheter of the woven variety 163 144. — Straight olive-tipped woven catheter 103 145. — Bi-coud6 woven catheter . . . 163 146. — Straight rubber catheter with velvet woven eye 164 147. — Elbowed soft rubber catheter with eye on the side 164 148.— Metal catheter 164 149.— Nelaton catheter 165 150. — Retained catheter . 167 150a. — A more secure method of holding a retained catheter 167 151. — Malecot's catheter. 167 152. — Another type of Malecot's catheter 167 153. — Pezzer's catheter 167 154. — Another type of Pezzer's catheter 167 155. — Glass urinal between legs 168 156. — Relative position of meatus and nozzle of the syringe 169 157. — Manner of holding the nozzle of the syringe in the urethra 169 158. — How the solution is held in the urethra 169 159. — A large piston syringe (bladder syringe) used for washing out the bladder through a catheter 170 160. — Cut-off, nozzle tip and shield with a tube passing to a douche jar .... 170 161. — ^Author's methods of suspending douche jars for irrigations in office, hospital and clinic 171 162. — ^Author's apparatus for irrigating urethra and bladder by hydrostatic pressure . 172 163. — Irrigating Kollmann dilator 173 164. — Guyon's instillating syringe 174 165. — Manner of giving an instillation of the urethra with the Guyon instillator . . 174 166. — Ultzmann's instillating syringe 175 167. — Manner of injecting the posterior urethra by means of the Ultzmann instillator . 175 168. — Curves of sounds recommended 176 169. — French (Charrifere) sound scale, compared with English measurement . . . 176 170. — Sound curve preferred by author ' . . .177 171. — First step of passing a sound 177 172. — Second step of passing a sound 178 173. — Third step of passing a sound 178 174. — Benique sound with and without filiform guide 179 175. — First step of passing a Benique sound 179 176. — Second step of passing a Benique sound 180 177. — Third step of passing a Benique sovmd 181 178. — Fourth step of passing a Benique sound 181 LIST OF ILLUSTRATIONS IN TEXT xvii ma. PAOB 179. — Oberliinder dilators 182 180. — Kollmann's dilators 183 181. — Blades of a Kollmann dilator, opened and closed 184 182, 183. — Rubber sheaths drawn over the dilators 185 184. — Kollmann irrigating dilator 185 185. — Guiteras urethroscope. 188 18G. — Light carrier for the Guiteras urethroscope 189 187. — Portable battery for the Guiteras urethroscope 189 188. — Wappler's controller for urethroscopy and cystoscopy 100 189. — Case of intraurethral instruments 191 189a. — Urethra probe 191 1896. — Cannula used for injecting glands and follicles 191 189c. — Urethral knives 191 189ri. — Gruenfell's polypus snare 191 190. — Swinburne's posterior urethroscope 192 191. — The Braun-Buerger cysto-urethroscope 192 192. — Manner of introducing the urethroscope 193 193. — Swabbing out the urethra 193 194. — Position in examining the anterior urethra 194 195. — Position in examining the posterior urethra 195 196. — Brenner's observation and catheterizing eystoscope 200 197. — Nitze's observation eystoscope 201 198. — Nitze's irrigating eystoscope 201 199. — Nitze's operating eystoscope, showing the snare and lithotrite 202 200. — Nitze-Albarran catheterizing eystoscope 203 201. — A direct air eystoscope of American make . . . 204 202. — The Brown direct eystoscope 205 203. — BierhoflF's indirect catheterizing eystoscope 205 204. — Bransford Lewis eystoscope 206 205. — Guiteras teaching eystoscope 208 206. — Portable table used for cystoscopy in the clinic and at private houses . . . 211 207. — Patient's position for cystoscopy on Allison table 213 208. — Washing out the bladder through the urethroscope, first step 214 209. — Washing out the bladder through the urethroscope, second step 214 210. — Looking into the bladder 215 211. — Air cystoscopy 215 212. — The eystoscope introduced into the bladder 219 212a. — Inspection of the bladder with the indirect eystoscope 219 212&. — Inspection of the bladder with the direct eystoscope 220 213. — Phantom bladder for practicing cystoscopy and ureteral catheterization . . . 228 214. — Catheterization of the ureters 228 215. — The same position as in Fig. 214, to show the position of the hands in catheteriza- tion 229 216. — Catheterization of the ureters by the direct method 230 217. — Catheterization of the ureters by the indirect method 231 218, 219. — Catheterization of the ureters, the catheters in situ . . . . . . 232 220. — Diagrams of bladder used for keeping records 236 221. — The outline of the abdomen in a case of retention 258 222. — The Blasucci catheter, first step of catheterization 261 223. — The Blasucci catheter, second step of catheterization 262 224. — The Blasucci catheter, third step of catheterization 263 225. — Paracentesis of the bladder 264 226. — The method of wearing a urinal 270 227.— Chart of acute urinary fever 292 228. — Chart of acute recurring urinary fever 292 xviii LIST OF ILLUSTEATIONS IN TEXT via. PAGE 229. — Chart of chronic urinary fever 293 230.— Male history card 298 231.— Female history card 299 232. — Patient lying at full length, first step in the examination of the male . . . 309 233. — Examination of the kidneys, the patient lying flat 310 234. — Examination of the kidneys, the patient in the sitting posture 310 235. — Examining the kidney, with the patient lying on the healthy side . . . .311 236. — Position for examining the female genitals and urethra 313 237. — Male patient urinating in a glass cylinder 313 238. — The preparation of the finger prior to rectal examination 314 239. — Rectal examination of the prostate and vesicles 315 240. — Massage of the prostate 316 241. — Examining the urethra with the bougie a, boule 319 242.— Filiform bougies 319 243. — The examiner looking through the urethroscope 320 244. — Method of obtaining specimens of urine from female patients 321 245, 246. — Abdominal exercise 330 247. — Back exercises 331 248. — Front exercises 332 249-252. — Chest and arm exercise 333, 334 253. — Loin exercises 335 254. — Recto-genital tube 341 255. — Rectal irrigations, patient in bath tub 342 256. — Rectal irrigations, patient reclining in chair 342 257. — Hypodermoclysis 347 258.^Intravenous injection, first step 348 259. — Intravenous injection, second step 348 260. — Intravenous injection, third step 349 261. — Syringe for local anesthesia 354 262. — Method of holding the syringe ■ 355 263. — Method of making the blebs in intradermic injections 355 264. — The subcutaneous method of anesthetizing an area to be operated upon . . 356 265. — Minute tubercular abscesses of a single asymmetrical kidney 386 266. — Single asymmetrical kidney, 8-^ inches long, removed at autopsy .... 388 267. — Single asymmetrical kidney, markedly convoluted, removed at autopsy . . . 388 268. — Shape of the abdomen in the case of a ruptured kidney 395 269. — The rent in the kidney proper and pelvis of a ruptured kidney 397 270. — Displacement of the kidney, showing the first, second, and third degrees of dis- placement 404 271. — Kinking of the ureter in displacement of the kidney 405 272. — Anterior view of the body divided into three zones, the upper, middle and lower, in people with movable kidney, as determined by Harris 408 273. — Side view of the body and the lines corresponding to the antero-posterior diam- eters of the body index, predisposing to movable kidney 408 274. — Pomeroy's elastic abdominal support for patients with movable kidney . . . 415 275. — Straight-front corset for movable kidney 416 276. — How the corset should be put on in movable kidney 416 277a. — Wide strips of adhesive plaster for supporting abdomen 416 2776. — The adhesive plaster strips applied 417 278. — Kidney pad to be buttoned on the back of a vest as a protection for nephrctics 432 279.— Southey's tubes 437 280. — Bleeding the patient in uremia 451 281. — Pyelo-nephritis 457 282. — Pyonephrosis, showing enlargement of the kidneys and their pelvis and kinked ureters 460 LIST OF J LLUSTKATIONS IN TEXT xix via PAGE 283. — Cross section of a calculus pyonephrotic kidney, 7i inches long 4G1 284.— Bulge in perinephritic abscess in left side of loin, front view 468 285. — Characteristic bulge in a perinephritic abscess on the left side, back view . . 4G9 286.— Posterior surface of left kidney in a case of a tubercular perinephritic abscess . 470 287. — Posterior surface of tuberculous kidney in a case of perinephritic abscess . . 471 288. — Longitudinal section of same kidney, showing contracted pelvis now not much larger than the vu-eter 471 289. — A bulging of pus in the groin and an opening in the thigh and groin made to drain a perinephritic abscess 472 290. — A sharp-pointed calculus that v^^as found sticking through the wall of the kidney in a case of perinephritis 473 291. — Multiple disseminated abscesses of kidney 475 292.— Chronic parenchymatous nephritis with acute exacerbation and suppurating foci 477 293. — Chronic interstitial nephritis, the other kidney in the case 477 294. — Carcinoma of the kidney 482 295. — Sarcoma of the kidney 483 296. — Hypernephroma, outside view 485 297. — Hypernephroma, view on section 485 298. — Papilloma of the renal pelvis 490 299. — Large serous cyst of the kidney "... 493 300. — Two large polycystic kidneys in the same individual . 494 301. — The larger kidney in Fig. 300 on section 495 302.— Hydatid cyst of the kidney 497 303. — Some large calculi removed from a pyonephrotic kidney 501 304. — A pyonephrotic kidney in a state of acute renal retention 503 305. — The renal pelvis of a pyonephrotic kidney filled with five stones of large size . 504 30G. — A cluster of stones in one kidney 510 307. — A cluster of stones in both kidneys 511 308. — A calculus concealed in the thick mass of fibrous tissue held open by the hook and not detected by nephrotomy 518 309. — A renal calculus that was discharged through the wall of the kidney . . . 519 310. — Clusters of tubercles on the outside of the kidney 528 311. — The same kidney as in Fig. 310, shown in section 528 312. — A ease in which the tuberculous abscesses have broken into the pelvis, giving rise to pyelonephritis 529 313. — Tuberculous pyelonephritic kidney 530 314. — Tuberculous pyonephrotic kidney 531 315. — A case of urinary tuberculosis involving both ureters and both kidneys . . 532 316. — Tuberculous kidney in which the functionating renal tissue has been entirely de- stroyed by the disease 533 317. — A vertical section of a tuberculous kidney removed by a secondary nephrectomy 549 318. — Kidney with hydronephrosis 561 319. — Hydronephrosis, first stage 563 320. — Hydronephrosis, second stage 563 321. — Hydronephrosis, third stage 563 322. — Instruments used in operations on the kidney 571 323. — Posterior kidney angle and triangle 572 324. — Anterior kidney angle and triangle 572 325. — Posterior vertical incision seeri on the left and the short-curved iiu-ision on llic right 573 326. — Anterior vertical incision seen on the right side and the " modified "' incision on the left 573 327. — Transverse incision 574 328. — Long curved lumbar incision, the position preferred in renal surgery . . . 574 329. — Oblique lumbar incision 574 XX LIST OF ILLUSTRATIONS IN TEXT FIG. PAGE 330. — Operating table with a transverse iron plate running across it that can be elevated to any distance for regulating the patient's position 575 331. — Body holder for preventing the patient from rolling when lying on the side . . 576 332. — The body holder on the patient 57G 333. — Incision through the skin and superficial fascia, revealing Pctit's triangle . . 577 334. — Incision through latissimus dorsi muscle, showing the tissues beneath it . . 578 335. — Muscles cut through down to the lumbar fascia 578 336. — Deep lumbar fascia cut through, showing the fatty capsule of the kidney . . . 579 337. — Freeing the kidney 579 338.— Delivery of kidney 580 339. — Delivery of the kidney, the lower pole first 580 340. — Delivery of the upper pole of the kidney . . . ' 581 341. — Delivery of the kidney by inserting the entire hand in the wound . . . .581 342. — Examination of the kidney by pyelotomy 583 343. — Operation for movable kidney; the fixation sutures are passed through the ab- dominal wall 584 344. — Operation for movable kidney; the kidney is delivered and the whole of the fatty capsule behind the kidney is cut away 585 345. — Operation for movable kidney; the capsula propria of the kidney slit through . 585 346. — Operation for movable kidney; the kidney capsule on the back of the kidney is reflected halfway to the hilum 585 347. — Operation for movable kidney; the posterior fixation sutures are passed through the doubled capsule of the kidney 586 348. — Operation for movable kidney; the anterior fixation suture is passed between the capsule and cortex 587 349. — Operation for movable kidney; the kidney is pushed back again into the renal fossa and the fixation sutures are again passed through the abdominal wall 587 350. — Operation for movable kidney; the muscles and fasciae of the abdominal incision are closed by interrupted sutures, the fixation sutures are hauled taut and tied 588 351. — Side view of the convexity after anchoring the kidney 589 352. — Posterior view after anchoring the kidney 589 353. — Anterior view after anchoring the kidney 589 354. — Nephrotomy; showing position of patient and loin incision 591 355. — Nephrotomy; the long incision from pole to pole 592 356. — Nephrotomy; the short incision between the poles 592 357. — Nephrotomy; catheterization of the ureter from above 593 358. — Method of passing sutures in closing the nephrotomy incision in the kidney . . 594 359. — Appearance of the kidney after closure 594 360. — Drainage tube in position 594 361a. — Four-tailed bandage for controlling renal hemorrhages 596 3616. — Four-tailed bandage in place 596 362. — Nephrostomy; this is nephrotomy plus fixation of the sides of the kidney incision to those of the abdominal wall 598 363. — Drainage in nephrostomy 599 364. — Drainage by siphonage 599 365. — Cup-shaped shield of Watson's apparatus for permanent renal drainage through the loin 600 366. — The metal receptacle of Watson's apparatus 601 367. — Method of clamping the pedicle and passing the pedicle ligatures in nephrectomy 602 368. — Nephrectomy; ligatures in place ready to tie 603 369. — Nephrectomy ; second ligature 603 370. — Albarran's method of securing the pedicle in a subcapsular nephrectomy . . 609 371. — Retraction of the capsule, allowing the operator to ligate the pedicle outside of it 609 372. — Partial nephrectomy 610 LIST OF ILLUSTKATIONS IN TEXT xxi Fia. PA«B 373a — Nephrectomy by morcellcment ; the lower pole amputated 611 3736. — Nephrectomy by morcellcment; the upper pole amputated 611 373c. — Nephrectomy by morcellement; the remains of the istlimus between the two poles 612 374. — Closing of the wound in nephrectomy by morcellement 612 375. — Nephrectomy by the transverse incision; the kidney delivered 613 376. — Nephrectomy by the transverse incision; the vascular pedicle clamped . . . 614 377. — Anterior or transperitoneal nephrectomy; the peritoneal cavity opened and the incision made in the mesocolon 614 378. — Anterior or transperitoneal nephrectomy ; the kidney being freed from the fatty capsule 615 379. — Anterior or transperitoneal nephrectomy ; the kidney delivered and pedicle clamped and ligated 615 380. — Anterior or transperitoneal nephrectomy; the kidney removed and the wound closed 616 381. — Hydronephrosis 616 382. — Resection of kidney pouch below the ureter 617 383. — Capittonage; the part of kidney pouch below the ureter is drawn up by a series of tucks or reefs 618 384. — Albarran's method of suturing in capittonage 618 385. — Cutting down the ureteral spur 619 386. — Cutting down the ureteral spur; sutures passed uniting pelvic and ureteral walls on either side 619 387. — Uretero-pyeloplasty ; the incision 619 388. — Uretero-pyeloplasty; sutures placed so as to leave a transverse wound . . . 620 389. — Uretero-pyeloplasty; sutures ligated 620 390. — Lateral pelvic-ureteral anastomosis 620 391. — Lateral pelvic-ureteral anastomosis; the wound united 620 392. — Kinked ureter with adhesions amputated below 621 393. — Two ureters emptying into the bladder, coming from a single unsymmetrical kid- ney on the right side 622 394. — A double ureter coming from the left kidney, as seen by radiography . . . 623 395. — Vesical ends of the ureters prolapsing into bladder 624 396. — A diverticulum of the part of the ureter passing through the bladder wall . . 624 397. — Ureteritis and associated pyonephrosis 629 398. — Dilatation of the renal pelvis and ureter in a case of acute ureteritis .... 630 399. — Papilloma of the ureter 631 400. — Cervix with a cancerous growth that has involved the ureter and bladder . . 631 401. — Positions of ureteral calculi 633 402. — Actual size of a stone giving rise to calculous anuria 635 403. — Case of double ureteral calculus 638 404. — Tuberculosis of the ureter 640 405. — Thickening, dilation, ulceration and strictures of the ureter that are seen in Fig. 404, more clearly shown 642 400. — Instruments for ureter operations 647 407a. — Ureterotomy for stone; delivery of the ureter below the kidney .... 647 4076. — Ureterotomy for stone; method of enlarging the field prior to operation . . 647 408. — Ureterotomy for stone; exposing the ureter as it crosses the pelvic brim and iliac vessels 648 409. — Ureterotomy for stone in the Trendelenburg position. The same incision is seen and two ligatures about the epigastric artery . . . . . . . . 648 410. — Ureterotomy for stone; shows a deep-seated calculus 649 411. — Ureterotomy for stone; the delivery of the calculus, the clamping of the iireter, and the suturing of the ureteral wall 650 412. — Ureterotomy for stone; a ureteral catheter as an aid in suturing the ureter . 651 413. — Incision through the broad ligament, exposing the ureter on one side . . . 652 xxii LIST OF ILLUSTRATIONS IN TEXT FIG. PAGE 414. — Perineal ureterotomy; the vesicle and the vas pulled to one side and ureter hooked up and incised over the calculus 053 415. — Patient in the gj-necological position. An incision is seen in the vaginal wall, the ureter hooked up and incised over the calculus 654 41G. — Intravesical ureterotomy. The bladder opened suprapubically ; the part of the bladder wall through which the ureter passes and the stone are clearly seen . 655 417. — Ureterotomy for stricture 656 418. — Ureterorrhaphy 658 419. — Poggi's operation for a ureteral anastomosis 658 420. — Van Hook's operation of lateral anastomosis 659 421. — Bov^e's method of end-to-end anastomosis 659 422. — Transperitoneal method of uretero-cystotomy 661 423. — Uretero-colostomy 663 424. — Ileo-lumbar incision for nephro-ureterectomy 664 425. — !Nephro-ureterectomy 665 426. — Showing Kelly's method of removing the ureteral stump through the vagina in nephro-ureterectomy 666 UROLOGY • VOLUME I CHAPTER I HISTORY OF DISEASES OF THE URINARY TRACT Ancient Urology. — Diseases of the urinary tract have been known and treated, both in a medical and surgical wav, for many centuries. Medical treat- ment was first recorded in the Papyrus of Ebers, written 1550 years b.c, in which were given many prescriptions for their cure. From this time until the present, various remedies have been used internally and externally by medical men, and by the monks during the Middle Ages, when the practice of medicine was principally in their hands. The history of the progress of surgery has been interesting, although noth- ing was written upon it until the time of the " Ayurveda of Sucrutu," the great work of the Hindoos in India, which was brought out about one thousand years after the first recorded manuscript. The first operation spoken of in this later work was perineal lithotomy, which was then performed in practically the same way as it is to-day. The Hindoos at this time were also treating strictures by gradual dilation with sounds of metal or wood, and were treating diseases of the urethra and bladder by injections. Hippocrates (about 400 b.c.) was the next great writer. Among other sub- jects, he was interested in vesical calculi, and described accurately how a stone grows gradually from a nucleus. He thought that lithotomy should be per- formed only by a lithotomist. He was the first to be interested in the surgery of the kidney, and taught that, as soon as a swelling appeared in that region, it should be cut down upon, lie also wrote on the subject of urethral abscess and cystitis, and was the first to point out the change in the urine in diseases of the kidney and bladder. Cornelius Celsus, the gTeat Poman medical writer who lived at the licgin- ning of the Christian era, was the next to write extensively on urinary dis- eases. He wrote on urethrotomy for impacted urethral stone; catheterization for retention of urine, especially in old men; vesical calculus and lithotouiy, iut'ludiug after-treatment; and the care of wounds and fistuhv. Perineal ure- throtomy was also performed for stricture by the Poman surgeons cue hundred and fift}^ years later. 1 y'^' HISTORY OF DISEASES OF THE URINARY TRACT Galen was the next writer of consequence. lie wrote upon incontinence and retention of urine, and described an " S-sliaped " or curved catheter which he used for the relief of the latter trouble. Ca.'lius Aurolianus, at the beoinning- of the fourth eenturv, was the next to interest hiuisclf in diseases of the bladder. He used a stone searcher for the diagnosis of vesical calculus. Mediaeval Urology. — We thus see that, in the beginning of the Middle Ages, diseases of the urinary tract had bfeen treated medically for two thousand years, while surgical interference had been going on for a thousand years. Diseases of the urethra, prostate, bladder and kidney were already known, and many of them had been operated ujion. It was strange therefore that at such a time a de- cadence should have taken place, that the practice of medicine should have fallen into the hands of the monks, and that surgery was attended to by the barber and charlatan. This condition existed until the fourteenth century, when scientific surgery again started up in Paris, at the College of Saint Come, founded by Jean Pitard, and thence slowly extended over Europe. The ad- vances along the urological line w^ere evidenced by the discovery of movable kidney in 1497 by Mesure of Venice; the improvement in the technique of stricture operations by Ambrose Pare and Richard Wiseman ; the works of Git- tler of Leipsic on wounds of the kidney ; the rescue of lithotomy from the hands of the layman and the variation of its technique by Pierre Franco. Changes of the urine had been spoken of since the time of Hippocrates, but the first w-ork of any scientific importance was that of Protospathori in the seventh century ; for he not only described normal urine, but also, in a clear way, the various changes that took place in the urine of disease. Actuarius, a Turk, wrote the first extensive work on this subject in the twelfth century, and it remained an authoritative treatise for five hundred years. During the heyday of the Salernian School, near Xaples, all the physicians were practically urologists, as they depended largely upon the urine for diag- nosis and prognosis, and the urinal became the insigTiia of the physician and the emblem of medicine. At this time, the examination of the urine was re- sorted to, not only by the regular practitioner and the university graduate, but also by the school of quacks, known as uromancers or uroscopists, who gravely inspected urine passed into a glass flask, guessed the illness and temperament of the patient, and dispensed miraculous cures. Paracelsus and Van Helmont, in the latter part of the sixteenth century, introduced the spagiric or so-called analytic methods of the diagnosis of dis- ease, which depended on the proportion in which the three elements of man's nature — mercury, sulphur, and salt — occurred in the urine. Boerhaeve and Bellini, in the seventeenth century, added to the study of urine. Boerhaeve distilled the urine and weighed the vapors. When the vaj)or occupied a certain part of the still, it pointed to disease in a certain part of the body. He was MODERN TTROLOGY 3 tlio first, to discover tlio si)ccific i>,Tavity of urine. Px'llini advocated the study of llui uN'crage urine of the healthy individual, llic amount pAssed and the specific gravity as a standard witli which the unhealtliy urine slioidd he coni- jini'cd. In the latter part of the eighteenth century, there Avas a decided advance in urinary analysis. Cotugno discovered albumin in the urine of diseased kidneys l)y boiling it. Roulle and Cadet discovered urea and isolated many .salts of the urine, and Schule discovered uric acid. It will thus be seen that, at the dawn of the nineteenth century, a good working basis existed in the study of urinary diseases, especially in the line of urinai'v examinations and the treatment of urethral and bladder diseases. Modern Urology. — Modern urological history may be divided into two periods, the first and second halves of the nineteenth century, the first of which was preparatory to the second. During the first half of the century the work was principally confined to improving and elaborating urethral and bladder work, urinary examination, and the study of pathology. In 1805, Bozzini of Frankfort, invented an apparatus for illuminating the urethra and bladder, which was the first of a series of crude attempts that led to our present knowledge of urethroscopy and cystoscopy. In urethral work, Desormeaux in 1853 improved the endoscope. Later a cooling apparatus was added, which finally was supplanted by the mignon or cold lamp introduced l)y Preston, an electrician of Rochester, jST. Y., at about the dawn of the twen- tieth century, thus giving ns the practical instrument of to-day. Maisonneuve in 1853 invented the first of the modern urethrotomes, which is still used in internal urethrotomy to cut through small strictures from the front backward, and in 1872, Otis invented his dilating urethrotome for cutting strictures of large size from behind forward. Both of these, although there have been many modifications, exist to the present day. The dilation of urethral strictures by the dilators of Oberliinder and Kollmann have since then superseded the use of sounds with many practitioners. The method of treating urethritis by the irrigation of Janet, and numerous new ren^edies for hand in- jections, have entered into our urethral therapeutics. In bladder work, the efforts to improve the diagnosis of pathological con- ditions by vision, led to the gradual development of the illuminating instru- ments, the first marked improvement being that of Briick, a dentist, who called his instrument a diaphanoscope. Improvements were slow and nnimportam: until 187G, when ISTitze, Brenner and Leiter perfected their cystoscopes, giving us our present knowledge of cystoscopic diagTiosis. These were rendered more practical three years later (18Tl>) by introduction into them of the incan- descent lamp, which enabled the urologist to employ it instead of the hot and less luminous platinum wire hitherto used, with a cooling apparatus. 4 illSTORY OF DISEASES OF THE rPJNARY TRACT Further iiii])rovement, due to the use of smaller aud colder lamps, ren- dered the use of cooling devices — irrigation with water while exauiining — unnecessary. In bladder surgery, Civiale (1817) performed the first successful lithotrity, the crushing of a vesical calculus, with an instrument wdiicli served as a pro- totype for the modern lithotrite. His lithotrite was modified by Weiss, Hodg- son, Ferguson and Sir Henry Thompson, and finally by Bigelow fl.STT) who combined the operation with evacuation of the fragments of stone by means of an aspirator in one operation, litholapaxy. His evacuator for emptying the bladder of the last fragment of stone consisted of a very large hollow sound, with a large eye in its concavity, connected wdth a rubber bulb, between which and the sound was a bottle into which the fragments fell wdien sucked out by squeezing and releasing the bulb. While suprapubic lithotomy in this country has largeh^ superseded Bigelow's operation, his method stands to this day in all parts of the world as the j)rocedure best employed for the removal of stone in the bladder in a selected class of cases. In the work on the kidney, that of Richard Bright (1827) was the founda- tion of our present knowledge of the medical diseases. Bright's investigations showed that many patients with dropsy and albumin in the urine had diseased kidneys, and although Catu'gno, the discoverer of albumin, had made it known a century before and Allison in 1823 had reported the occurrence of dropsy with albuminuria in kidney disease. Bright found the profession more recep- tive to scientific advances than did Catugno, and through his w^ritings received such recognition that the name of Bright's disease w^as applied to pathological conditions of the kidney accompanied by albuminuria. In 1823, Scudmore of London had found that the urine of patients with albuminuria contained less urea than that of normal persons. The discovery of urinary casts by Viglia, some ten years after Bright's publication, added another important link to the chain of our present knowledge of urinary findings in nephritis. From these early studies sprang the elaborate researches of later years, as recorded in the text-books of Johnson ("Diseases of the Kidneys," London, 1852), Jo- hann Fogel (1856), Rosenstein (18G3), Senator (1896) and others. In renal surgery, Paeslee performed the first nephrectomy (1868) by ac- cident, in a case the diagnosis of which had been an ovarian tumor. Simon, the following year, removed the first kidney purposely in a case of calculous pyonephrosis, and took advantage of this step to write his important monograph on the kidney, in which he gave a definite classification of the surgical affections of the organ, thus stamping them formally for the first time as surgical. Catheterization of the ureters, which now is one of the most important urological procedures, owes its birth to the efforts of Pawdik and Bozeman, who were the first to catheterize the ureters in women. The development of MODERN UROLOGY 5 this important prorodnro was, liowevor, due to the cystoscopists. They added a eoinpartiiient to their cystoscopes for the passage of a small woven catheter, tlien, hy looking at the month of the nreter, they conld pnsh the catheter into the bladder nntil its end entered the nreter. The first catheterizing cystoscopic instrument was that of Brenner (1892), then followed tliose of Xitze (1805), Casper (ISilf)), Albarran (1897), etc. Later they addc(] to their iiistrmnents a double catheterizing apparatus which enabled them to cathctcrize both ureters at the same time. One of the most important discoveries in urology, as in all other diseases, was the rule of the microorganism as the causative agent of fermentation, de- composition and disease, by Louis Pasteur, described in a work called " La Generation Spontanee," which appeared in 1859. He took up in particular the Micrococcus nrea^, which causes urinary decomposition by splitting up urea into ammonia and other by-products, and suggested that the bacteria enter the bladder with dust particles that adhere to unclean instruments. In 1879, IN'eisser announced the discovery of the gonococcus, a microorgan- ism which has since then been found as the constant cause of blennorrhagic in- fection. Then followed rapidly the discoveries of the several important specific germs: The tubercle bacillus by Robert Koch, in 1882; the staphylococcus, the chief germ of suppuration, by Rosenbach, in 1884; and the colon bacillus — so often found in cystitis, pyelitis, etc.— by Escherich, in 1885. These dis- coveries changed many of our previous etiologic concepts and created entirely new therapeutic view points — antisepsis and asepsis. The development of a plate-culture method by Koch had a great deal to do with the later and more accurate studies on the bacteriology of cystitis, pyelitis, etc. The amalgamation of the diseases of the urinary tract into the modern specialty has taken place through the combination of the work of numerous internists, surgeons, pathologists and bacteriologists at different times and in different ways. A knowledge of diseases of the urethra and bladder and their treatment has existed since the earliest writings, and of diseases of the kidney since the days of Hippocrates. The diseases of the kidney, however, were not considered in conunon with those of the bladder and the urethra, but were rather in the hands of internists and general surgeons. Bright was the first thoroughly to consider diseases of the kidney frcnn tlie point of view of an internist, and Raver and Simon as surgeons; while Civiale, Thompson, Mercier, Guyon, Maisonneuve, Ricord, and others were working on the bladder and urethra in both a medical and surgical way. Tlie laboratory men were principally engaged in the work of urinary anal- ysis until Pasteur's discovery of bacteria and microbic infection, followed later by the discovery of the gonococcus, the tubercle bacillus and streptococcus, colon bacillus and others of the important forms of infection. 6 HISTORY OF DISEASES OF THE URINARY TRACT Cystoscopy in the hands of Kitze and Brenner was perhaps the final step of an amalgamation; for it allowed the surgeon who had examined and passed through the urethra to see with certainty the condition of the bladder wall, and to diag-nosticatc in many cases between bladder and kidney hematuria and pyuria, and in case of renal origin to see from which side the pathological urine had come. The further investigations of the microbic causes of disease showed that the same germs that give rise to infectious bladder diseases were also the cause of suppurative renal disease: also that practically the same diseases existed in both organs ; that is, tumors, tuberculosis, stone and suppurative inflammations. Furthermore, it Avas then learned that in cases of disease of the urethra, pros- tate and bladder, the infection may pass to the kidney directly up the ure- ters, or by the blood current or the lymphatic channels. The catheterizing cystoscopes then came as another step in the relation between the two kidneys. In urinary cases, the analysis could tell us of disease of the bladder, or kidney, or both. The cystoscope could show us, in a bladder case, the degTee of disease in this organ ; while in a kidney case, the urine, withdrawn by the ureteral catheters, could tell us which of the kidneys ex- creted the urine that gave the pathological appearances to the general specimen. By this means, direct connection between the bladder and the kidney was es- tablished, and the study of the urinary tract from the bladder up was consid- ered just as important, if not more so, than from the bladder down. Conse- quently, the direct reason for including the entire urinary tract from the capsule of the kidney to the external urinary meatus in both sexes can be better understood. Having considered some of the principal direct steps taken in modern urol- ogy toward its advancement and development into the present specialty, we must consider a few imi^ortant factors in general and special surgery that have an important bearing on the subject. The acceptance of the fact that germs are the cause of surgical infections led to the consideration of the best way to be rid of them in surgical work; that is, the study of antisepsis and asepsis. In 1859, Lemaire found that carbolic acid was the active constituent of coal tar and advocated it as the best antiseptic. It w^as thought that fermenta- tion and putrefaction were due to the access to the wounds of particles from the air that could be destroyed by boiling, heat and chemical agencies. Among the latter the best agents were carbolic acid and bichlorid of mercury, iu which wounds could be Avashed and dressings soaked. The title " antiseptic method " was given by Lister to a form of wound treatment founded on certain definite principles and commenced by him in 1865. His studies were founded on the results of Pasteur's researches on spontaneous generation, which served as a guide in systematizing his investiga- MODEKN UROLOGY 7 tion. "Working on the liypotliesis that the particles of dust-borne germs en- t('r('<] the wounds at the time of operation, he devised the carbolic spray as a uicnns of rendering- aiitis('])tic the operative field in surgical operations. Asep- sis then succeeded antise^jsis, as it became apparent that it is better to exclude germs by having everything connected with the operation sterile, than to have germs present at the time of operation and tlien try to render them inert by the use of strong solutions. The sterilization of instruments, dressings, gowns, etc., beforehand, and the wearing of rubber gloves, proved more simple and effective than the more cumbersome methods of trying to sterilize after the operation had begun. For the technique of asepsis we are much indebted to another English surgeon, Lawson Tait. Anesthesia was another great discovery for urinary surgery. In the years 1844—47, the three chief methods were discovered in rapid succession and at once began to exert an important influence upon the development of painless major urological operations. The discovery of nitrous oxid gas as an anes- thetic by Wells gave us an invaluable aid for brief operations and for examina- tions that require perfect relaxation. The discoveiy of ether anesthesia by Morton in 1846, and of chloroform anesthesia by Simpson in 1847, gave us the most useful means of rendering patients unconscious that have yet been discovered. Ethyl chlorid and cocain, as brought out by Koler, are of great value as local anesthetics, and the great majority of urological operations can be performed imder the influence of the latter. In 1895, Conrad Roentgen discovered the X-ray, the perfection of which has brought to the urologist another valuable means of diagnosis in suspected cases of stone in the kidney, the ureter and bladder. Laboratory experiments through the inoculation of small animals, have also been of great service to us in determining the presence or absence of tubercu- losis in disease of the kidneys. A few years ago, the determination of the relative efficiency of both kid- neys, and especially of each kidney separately by various methods, was consid- ered as one of the important diagnostic and prognostic criteria by surgeons and urologists in the study of renal diseases. The first of these methods employed to test the functional capacity of the kidney was cryoscopy, which consisted of freezing the urine. This was introduced in 1897 by Koranyo of Budapest, but has been little used in this country. The methylene blue test, popular with the French School, came next, the function of the kidney depending upon the early or late appearance in the urine of the blue or chromogen color after its injection into the body. The phloridzin test was advocated by Casper and Richter in 1900 and was the favorite method of the German School, but re- quired more care on account of the frequent necessity of testing the urine for sugar. It is difficult at the present time to see along what lines the progress in HISTORY OF DISEASES OF THE URINARY TRACT urology will extend. The steps in diagnosis at present seem to be qnite com- plete, and I think that progress will probal^ly be along the lines of improved technique. At present, what is most needed is better cooperation between the patient and the surgeon in the study of the cases, and the continuation of medi- cal treatment and careful observation before resorting to operation, except in urgent cases. CHAPTEK II THE ANATOMY OF THE URINARY AND GENITO-URINARY TRACT The urinary tract in both sexes is arranged in a series which begins at the kidneys and ends at the external nrinary meatus. The various parts are the kidney, ureter, bhidder and urethra. The kidneys and ureters are the same in both sexes, while the bladder is practically the same, differing only in re- gard to its external relations. It will thus be seen that the urethra is the part Avhich differs the most in the two sexes. In women it is short and entirely in- dependent of the genital tract in its functions and in its relations until it reaches the external meatus in the sinus uro-genitalis. In men, from the open- ing of the common ejaculatory ducts to the external meatus, the genital and urinary canals form a single passage. In both the male and the female the urinary organs meet the genital organs at the sinus uro-genitalis, which is found in the prostatic portion of the urethra in men and in the vestibule in Avomen. At this point in the male the urinary tract communicates with the ejaculatory duct, the vesiculffi seminales, the vasa deferentia and the testes; while in the female it communicates at the sinus with the clitoris, the vulva, the vagina, the uterus, tubes and ovaries. In men the combined relations and functions of the urinary and genital tracts in the urethra, where they are in common, has given rise to the expression genito-urinary tract in their combined consideration. In women, on the other hand, except in foetal life, the genito-urinary organs are divided into two distinct tracts, the genital and the urinary. These are separated from each other throughout their entire course, and although they are in close contact with each other, they are never in connnon in a nor- mal condition ; for which reason they are not spoken of as the genito-urinary tract. In the female the genital and urinary organs bear a delinite relation Id each other, the urinary being in front of the genital except where the ureter passes behind the broad ligament. In the male, the urinary tract is also placed anteriorly as far as the urethra, but from the internal to the external meatus the urinary tract is sur- rounded by j)arts of the genital tract — namely, the prostate, the corpus spon- giosum, and corpora cavernosa — the urethra being the common canal for the discharges from each. 10 ANATOMY OF THE URINAEY AND GENITO-UKINARY TRACT Tliu fulluwiiig illii.stratiuii.s will give an idea of the relation of the genital and urinary tracts to each other when removed from the body : Fig. 1. — Anterior View of the Opened Genito- urinary Tract in the Male. pe, the pelvis of the kidney. cor, the cortex, the part between the cortex and the pelvis being the medullary portion. pyT, pjTamid. ca, the calices. m.r, the medullary rays. V, the ureters. B, the bladder. o.u, the ureteral openings. i.u.m, the internal urinary meatus. o.e.d, the openings of the ejaculatory ducts in the prostatic urethra. g.u.s, the genito-urinary sinus. v.m, the veru niontanum. b.u, the bulbous urethra. d.c, openings of the ducts of Cowper's glands. c.c, corpus cavernosum. c.s, corpus spongiosum. u, urethra. /, fossa na\'icularis. e.u,7n, external urinary meatus. Fig. 2. — Posterior View of the Genito-uri- nary Tract in the Male. K, kidney. pe, peh-is. U, ureters. B, bladder. V, vas deferens. a, ampulla. s.v, seminal vesicles. P, prostate, c, Cowper's glands. T, testicles. E, epididymis. b.u, bulb of urethra, c.s, corpus spongiosum. c.c, corpus cavernosum. G, glans penis. ANATOMY OF THE URINARY AND GENITO-URINARY TRACT U I'lg'. 1 gives (lie niitcrior view of the genito-urinary tract in the male, and Fig. 2 the ]X)sterior. In Fig. 1 it can be seen how the nrine excreted into the tubules of the kidney is carried down through the calices, the renal pelvis and the ureter into a reservoir, the bladder, where it accumulates and from which point it enters the urethra through which it is discharged from the body. In examining the first part of the urethra as it passes through the pros- tatic gland, we see the openings of the ejaculatory ducts that bring the secre- tions of the testes and seminal vessels into the urethra ; also the openings of the prostatic ducts that discharge the prostatic fluid ; while lower down the bulbous pcn-tion will be seen the mouth of the ducts of Cowper's glands, that are the last to contribute to the formation of the combined fluid known as semen at the time of its ejaculation. In Fig. 2 it can be seen how the spermatozoa formed in the testes are carried up through the epididymis and vas deferens to the seminal vesicles where they are stored and from which point, mixed with the secretion of the vesicles, prostate and Cowper's glands, they are discharged from the urethra, as has already been shown in Fig. 1. Fig. 3. — Posterior View of the Relations of the Genital and Urinary Organs in the Male. 1, ureters. 2, vasa deferentia. S, right seminal vesicle laid open. 4, right vas deferens laid open. 5, prostate. 6', left seminal vesicle. 7, bladder. A, outer muscular lai'er of liladder. B, middle muscular layer of bladder. C, inner muscular layer of bladder. D, mucous membrane of bladder. Fig. 3 is a view of the posterior aspect of the bladder prostate, seminal vesicles, ureters and vasa deferentia. The right vesicle and vas have been laid open. 12 ANATOMY OF TTTE TRTNAKY AND GENITO-URINARY TRACT Fig. 4 rc])rosents an interior view of the genito-iirinarv ti-aet in the female- tlic kichicv and ureter cii riglit side are split, and lhe liUuhlcr and urethra below. Fig. 5 represents a posterior view. The tubes, uterus and vagina are split. Here the genital tract is seen to be behind the urinary, excepting where the ureters pass behind the adnexa. Fig. 4. — Interior View of the Genito-urinart Fig. 5. — Posterior View of the Genito-uri- Tract in the Female. nary Tract in the Female. Fig. 6 shows the side view of the kidney, ureter and bladder in an an- terior posterior section as it is found in either man or -woman. If this is placed aboA'e either the male or the female urethra chart in such a way that the urethral opening of the bladder is placed at the beginning of the urethral canal, it will be seen that the Idadder answers for either sex as well as the kidneys and ureters. Fig. 7 represents a central anterior posterior vertical section through that ANATOMY OF THE URINARY AND GENITO-URINARY TRACT 13 1 ■'■ \ Fig. 6. — Upper and Middle Portions of the Urinary Tract, the Kidney, Ureter and Bladder of Either Sex on Sagittal Sec- tion. S, supra renal capsule. K, kidney. p, papillae. pr, pyramids. c, cortex. h, hilum. pe, pelvis. U, ureter. B, bladder. a, apex. n, neck. b, base. CM, cystic orifices of ureter. Fig. 7. — Lower Urinary Tract in the ]\L\le on Sagittal Section, and also the Internal and External Genital Organs. V, vas deferens. S.V., seminal vesicle. a, ampulla. e.d, ejaculatory duct. E, epidid.vmis. g.77i, globus major. g.min, globus minor. b, body of the epididymis. T, testicle. P, prostate. T.L., triangular ligament. C, Cowper's gland. U, urethra. p.u, prostatic urethra. b.u, bulb of urethra. f.n, fossa navicularis. c.c, corpus cavernosum. C.S., corpus spongiosum. gl, glans penis. cor, corona. p, prepuce. m, meatus. 14 ANATOMY OF TTTE URINARY AND GENITO-IJRINARY TRACT V. part of the g-eni to-urinary apparatus of the male that is in common, namely, the penis, prostate and urethra; besides which it shows the male adnexa on one side, that is, the seminal vesicles, vas -.;';'=«.-.., ■'■} deferens, epididymis and testis. /'' ^,: \"y If Fig. 6 was placed on Fig. 7 in / Y'^T' 1 such a way that the opening of the blad- 1 \"' X' der was to fit that of the urethra, and i iij ,.v ^ t^6 seminal vesicles and the vas deferens \ A/'""' ]\ j with their ampullae were properly ad- justed, they would he seen to lie on the back of the bladder as in Fig. 2. Fig. 8 depicts an anterior posterior vertical section through the central part of the female genitals, namely, the vesti- bule, clitoris, vulva, vagina and uterus. There is also a similar section through the urethra in the same line. The Fal- lopian tube and the ovary are also sho^^^l, although somewhat out of position. The place for a dilated bladder corresponding in size with that of Fig. 6 is indicated by dotted lines. If Fig. 6 was placed over Fig. 8 in such a Avay that the blad- der would fit in the space indicated by the dotted lines, it would be seen that the uterus would lie in a plane posterior to the bladder, and that the tubes and ovaries, in case the bladder were empty or but moderately distended, would also lie in a j)Osterior plane. Fig. 8. — Genital Org.\ns and Lower Uri- nary Tract in the Female on Sagittal Section. F, fallopian tube. f.e, fimbriated extremity. O, ovary. U, uterus. C, cervix. B, bladder. ur, left ureter passing alongside uterus. R, rectum. A, anus. S, symphysis pubis. V, vagina. cl, clitoris. Ve, vestibule. e.u.o, external urethral orifice. L.M, labium major. L.Min., labium minor. I.V, introitus vaginae. P.B, perineal body. These figures show the great similar- ity in the upper three quarters of the uri- nary tract in the two sexes and also how much closer related the lower quarter of the urinary tract is to the genital in the male than in the female. This intimate relation in the male has been the reason why the troubles of the genital tract have been called " genito- urinary " in men, instead of " andro- logical," which would correspond to the term ^' evnecoloeical " in women. LOCATION OF THE GENITO-URINARY TRACT 15 The iTrogenital sinus is the point where the urinary tract joins the genital and is differently located in the two sexes. Fig. 9 shows the urogenital sinus in tlie male. It is situated in the prostatic urethra at the point wliere the ejaculatory ducts open into the canal about one inch below the vesical open- ing. wmm Fig. 9. — Genito-tjrinary Sinus in the Male, THE Prostate having been Opened Ante- riorly AND its Lateral Lobes Retracted. (Testut.) At this point, the posterior urethra is seen in direct communication with the bladder, and with the ejaculatory ducts. 1, the bladder. 2, urethra. S, prostate. 4, veru montanum. 5, frenum of the veru rnontanum. 6, urethral crest. 7, prostatic utricle. 8, orifices of the ejaculatory ducts. 9, prostatic fossette. 10, lateral depressions of the veru monta- num. Fig. 10.- -GENITO-tlRINARY SiNUS IN THE Female. The labia minora of the external genitals are seen to be retracted, showing the urethral meatus, the termination of the urinary tract, and just below and behind it the vaginal opening, the termination of the genital tract. Fig. 10 shows it in the female. It is situated in the vestibule of the vulva, where the urethra and the vagina open. LOCATION OF THE GENITO-URINARY TRACT The genito-urinary tract in its whole course has an extensive location, being partly within the body cavity and partly without. The inside part extends from the costal diaphragm to the pelvic diaphragm (levator ani muscle) below, while the outside part is a continuation of the part within through the pelvic diaphragm and the perineum, to end in the external meatus in the male and the vestibule in the female. The bony framework wliich incloses it may be said to consist of tlie two lower ribs, the last dorsal and the lumbar vertebra^, and the bones entering into the formation of the pelvis. These are bound together by ligaments, especially important in assisting to make a smooth, pelvic cav- ity out of an irregular bony framework. (See Figs. 11 and 12.) 16 ANATO^rY OF TTTE T'RTXAKY AND GEXITO-T'KIXARY TRACT Fig. 11.— Anterior View of the Bony Skeleton of the Part of the Body in Which the Urin.\ry Tract is Lodged. 1 , anterior common ligament. £, ilio-lumbar ligament. 3, greater sacro-sciatic ligament. 4, lesser sacro-sciatic ligament. 5, obturator foramen and membrane. 6, anterior pubic ligament. LOCATION OF TTTE GEXTTO-URINARY TRACT 17 l)()t]i kidneys and the upper five and one half inches of tlu; nrctcr are Avitliin llic abdominal cavity. The bladder, seminal vesicles, the hjwer four Fia. 12. — Posterior View of the Bony Framework Enclosing the Urinary Tract. 1, posterior ilio-lumbar ligament. 2, posterior sacro-iliac ligament. 3, lesser sacro-sciatic ligament. 4, greater sacro-sciatic ligament. and one half inches of the ureter, the prostate gland, and part of the vas defer- ens arc ^vithin the pelvic cavity ; while the penis, testicles and part of the 18 ANATOMY OF THE URINARY AND GENITO-URINARY TRACT Fig. 13.-SPACE Occupied by the Urinary Tract after It has been Lined with Its Muscular Layer. 1, diaphragm. 2, inferior vena cava. 3, right cms of diaphragm. 4, pectineus. 6, esophagus. 6, aorta. 7, left cms of diaphragm. 8, quadratus lumborum. • 9, transversalis fascia. 10, psoas par^a^s. 11, iliacus. 12, psoas magnus. 13, pyriformis. H, coccygeus. 15, obturator externus. 16, obturator membrane. 17, obturator internus. tttf; pelytr 19 uretlirn arc outside the bod)' cavity. Tlic kidneys are on tlie posterior abdom- inal \vall on cither side on the last dorsal and npper three lumbar vertebra;. They are behind the peritoneum, and rest behind on the twelfth rib, crurse of the dia])hrai!,-m, psoas and qnadratns lumljornm muscles (Fig. 13). The ab- dominal portion of the ureter is also behind the peritoneum, lying npon the psoas and running downward and inward as far as the brim of the pelvis. The intrapelvic and extrapelvic portion of the tract is so intimately re- lated to the various structures in the pelvic cavity and perineum, that, in order to give an adequate idea of their location and relations, a brief description of the joelvis and perineum as a whole must be given. THE PELVIS The pelvis consists of a surrounding framework of bones and ligaments, the inner surface of the bones being covered, for the most part, by muscle, while a sheet of muscle arising from either side of the bony wall meets in the middle 1 7 8 9 Fig. 14. — The Ligaments Helping to Form the Pelvic Floor on the Right and on the Left, the First Layer of the Muscles Above Covering Them and the Spaces About Them. 7, obturator membrane. 1, anterior common ligament. 3, ilio-lumbar ligament. S, anterior sacro-iliac ligament. 4, greater sacro-seiatic ligament. 5, lesser sacro-sciatic ligament. 6, Y ligament of Bigelow. 8, levator ani. 9, obturator internus. 10, pyriformis. 11, coccygeus. 20 AXATOMV OF THE URINARY AND (JENITO-URIXARY TRACT lino, to close the space below. I'lie iiinscles are covered with fascia, constitiit- iiiii' the various layers described as pelvic fascia. Tliis has attachments to the prostate, bladder, vagina, vesiciilic seniinales and rectum, and forms folds Avhicli are descril^ed as ligaments of these organs. The whole cavity so formed is lined by a complete layer of peritonenm. The bony wall consists of the sacrum behind and the os innominatum on either side, meeting in front at the symphysis pubis. The ligaments and struc- tures "which complete the framework of the pelvis are the sciatic ligaments which extend over the sciatic notch, the obturator membrane closing the ob- turator foramen, and the triangular ligament wliich bridges across the space between the rami of the ischium and pubes. These cover the irregular open- ings in the bony framework, and transform the lower part of the interior into a cylindrical cavity witb more or less complete walls, as already mentioned. The muscular structures which pad the inner surface of this framework are the pyriformis and obturator internus. They cover the inner surface of the bones on their lateral and posterior aspects, and obliterate the irregularities of the bony wall, thus rendering the interior a comfortable location for delicate organs. The space inclosed by these various structures is known as the jielvic cav- ity, and may be likened to the short segment of a liollow cylinder, deeper be- hind than in front. It is closed in below by the levator ani and coccygeus muscles, which are known as the pelvic diaphragm, but the coccyx and trian- gular ligaments must also be looked upon as forming part of the true floor of the space. Levator Ani. — This arises from the back part of the pubic bone from a line of fascia (white line. Figs. 15-16) extending from the back part of the pubes and from the inner surface of the ischial spine. The anterior fibers extend do-wnward and inward by the side of the prostate, meeting those of the opposite side. The intermediate fibers slope downward and inward and sup- port the rectum and bladder. At the junction of the rectum and anal canal, they form a collar round the gut, wliich extends downward on its lateral walls as far as the external sphincter. The posterior fibers are inserted into the ano- coccygeal raphe and the sides of the coccyx (Fig. 15). In the female, that portion of fibers which surrounds the prostate in the male are attached on either side to the vaginal wall. The nerve supply for this muscle comes from the fourth and fifth sacral, some branches of the same nerves going to the coccygeus. Coccyg"eus Muscle. — This is a small fan-shaped muscle which arises from the spine of the ischium, extending backward and inward to be attached to the sides and anterior surface of the coccyx. The levator ani and coccygeus thus form one continuous sheet of muscle, which make, as it were, a bed and support for the viscera (Fig. 16). They are both the remains of the tail THE PELVIS 21 iiinscles. In quaflnipeds the various components of tlie levator ani arise from the hi'iin of ilie pelvis, and are inserted into the coccyx or caudal vertebra*. / y 10 11 l:i IS 14 15 Fig. 15. — View of the Right Side of the Pelvic Cavity as Seen aftek a Sagittal Section. The sacrum is seen above and the pubis below, while between are the muscles and fascias going to make up the pelvic walls and floor. The urethral orifice is seen just behind the pubis and behind this the stump of the rectum; extending from the coccyx to the pubic bone the levator is seen. 1, cut surface of the sacrum. 2, pyriformis. 3, ilio-pectineal line. 4, obturator internus. 5, obturator foramen. 6, urethral opening. 7, bulbo-cavernosus muscle. 8, corpus spongiosum. .9, deep layer of triangular ligament. 10, superficial layer of triangular ligament. lU Cowper's glands. 12, transversus perinei muscle. 13, sphincter ani externus. 14, rectum. 15, levator ani cut through. 16, gluteus maximus. 17, pyriformis. 18, coccygeus. 19, levator ani. With the assumption of the upright posture, the muscles become modified to form one sheet, their origin sinks downward, while they acquire their various 22 ANATOMY OF THE URINAKY AND GENITO-TJRINARY TRACT insertions and increase in strength, to support the viscera wliicli tend to sink downward from gravity, the effect of gravity being markedly increased in tlie upright position. In man, traces of the former attachment of these muscles 1 Fig. 16. — The Pelvic Floor Looking in from Above. The pubis is seen in front, the vertebra behind and the ilium and pubes on cither side. 1, symphysis. 6, obturator internus. 2, prostatic urethra. 7, levator ani muscle. 3, seminal vesicles. 5, coccygeus. 4, rectum. 9, pyriformis. 6, cut surface of Uiac bone. 10, prostate gland. can often be found. The coccygeus and small sciatic ligaments arc the rcin-c- sentatives of the ischio coccygeus, the lateral flexors of the tail in lower ani- mals (Keith's "Embryology"). Pelvic Fascia. — This can be best understood by considering the develo])- ment of fascia in general. This structure is never developed in sheets, as is so commonly described, but is merely the portion of mesoblast left over after structures have formed within it. Thus w^e see that fascia must form a con- tinuous attenuated spongcAvork, in which the interstices are filled with struc- tures which have become differentiated. We can now understand the intimate relations of the fascia covering the levator and its connections with the pros- tate gland, bladder, the vesicular seminalis, uterus, vagina and rectum. With the above considerations in mind, we see that the parietal layer of pelvic fascia, so called, is merely the internal sheath of the pyriformis and obturator in- ternus muscles. The visceral layer, laterally and behind, is the upper portion of the sheath of the levator ani, while in front the visceral layer is really the THE PELVIS 23 posterior layer of tlie triangular ligament, which is itself the posterior portion of the sheath of the compressor urethra. The fibrous covering of the prostate, bladder, vesicult:. — This arises from the inner side of the ischio- pubic rami on either side, the two muscles meeting in the mid line and inclos- ing the urethra. The larger body of the muscle is inserted behind the urethra. THE PERINEUM 31 Just below this muscle is a group of muscle fibers arising from the ramus of the ischium and continuous with the compressory urethra at its insertion; this is called the transversus perinei profundus. Sometimes muscular fibers (com- pressor venffi dorsalis) from the anterior portion of the bulbo-cavernosus mus- cle pass obliquely outward and forward, inclosing the entire circumference of the root of the penis and the dorsal vessels. Internal Pudic Artery. — The internal pudic artery arises from the an- terior division of the internal iliac, passing out of the pelvis through the small Fig. 24. — Anterior I^ayer of the Triangular Ligament in the Female, after the Removal of THE External Genitals, the Superficial Fascia and Muscles. The urinary and vaginal passages are seen. It corresponds to Fig. 20 in the male. 1, urethral opening. 6, levator ani. 2, vagina. 7, sphincter ani externus. 3, tuber ischii. S, gluteus maximus. 4, adductor muscles of thigh. 9, coccyx. 6, superficial layer of triangular ligament. sciatic notch ; it crosses over the spine of the ischium and enters the perineal space, running along the ischial tuberosity in the fascial sheath known as Al- cock's canal. This is situated about an inch and a half from the lower border of the ischial tuberosity. It ascends to the inner surface of the ramus of the pubes, and about one half inch below the symphysis pubis pierces the triangular liga- 32 ANATOMY OF THE URINARY AND GENITO-URINARY TRACT ment and is continued onward to the dorsal artery. Its branches are inferior hemorrhoidal, superficial and transverse perineal, artery to the bulb, and artery to the corpus cavernosus. IxTEKXAL PuDic Xekve. — Tliis arises from the sacral plexus and follows the same course as the artery, the nerve being situated usually above. As it passes over the ischium, it divides into two branches, the perineal, and dorsal nerves of the penis. The perineal nerve breaks up to supply the small perineal muscles previously described, and the two superficial perineal nerves supply the skin over the part as far forward as the scrotum. The dorsal nerve of the penis is contin- 5 6 7 8 Fig. 25. — The Deep Layer of Muscles Forming the Floor of the Pelvis in the Female from THE Outside. The urethral and vaginal openings are seen. 1, urethra. 2, adductors. 3, tuberosity of iscliium. 4-, obturator internus. 5, gluteus maximus. It resembles Fig. 22 in the male. 6, coccjrx. 7, sphincter ani. 8, levator ani. 9, great sacro-sciatic ligament. ued onward with the internal pudic artery and dorsal artery of the penis. Fig. 22 shows a deep dissection of perineum after removal of triangular ligament. Female Perineum. — In the female the perineum is divided into urogenital and rectal triangles, as in the male. The rectal triangle does not differ in any THE KIDNEYS 33 way from that found in the male. In the urogenital triangle the vagina makes some alteration in the relation of the parts. The ischio-bulbosus muscle is found in two separate parts covering over the bulb as it lies at the sides of the vagina (Fig. 23). The vagina also makes a cleft in the triangular ligament, which structure in the female is of less density than in the male (Fig. 24). Fig. 25 shows a deep dissection of female perineum after removal of tri- ano'ular ligament. THE KIDNEYS The kidneys are the glands which secrete the urine. They are situated on the jjosterior abdominal wall behind the peritoneum, between the upper border Fig. 26. — The Posterior Surfaces of the Kidneys and their ReLu\tions to the Ribs. (Recamier.) of the- twelfth dorsal and middle of tlie third lumbar vcrtebriTp (Fig. 2G). The right kidney extends to the lower border of the eleventh rib; the left is placed somewhat higher, and its upper pole may rest on the eleventh rib. Below, they are both separated by a short interval from the crest of the ileum. The kidney is a bean-shaped body, four and one half inches (11.2 cm.) in length, two and one half inches (6.2 cm.) in breadth, and one and one half inches (3.7 cm.) in thickness. Its weight is about four and one half ounces. 34 ANATOMY OF THE URINARY AND GENITO-T^RIXARY TRACT Relations of the Kidney. — Tlie kidney has an anterior or visceral surface, a posteridr or niuscuhir surface, an internal border or hilus, and an external border. The upper and lower ends of the kidney are called respectively tlie upper and lower poles. The anterior surface of the kidney looks forward and slightly outward, and is jDartly covered by peritoneum. On the right side, it is in relation above with 27. — The Relation of the Kidxets axd Suprarenal Capsitles to the Tissues ix Front of Them. caval area. gastric area (peritoneal). hepatic area (nonperitoneal). gastric area of spleen. duodenal area (nonperitoneal). splenic artery. hepatic area (peritoneal). pancreatic area (nonperitoneal). (Morris.) 9, duodenal area (nonperitoneal). 10, coUc area of spleen. 11, mesocolic area. 12, colic area (nonperitoneal). 14, mesocolic area. 16, ureter. 18, aorta. 20, vena cava. the right suprarenal body, which extends farther down the anterior surface on the right than on the left (Fig. 27). The outer three fourths of the upper half of the kidney lies behind the liver and is covered by peritoneum. The outer three fourths of the lower half, just below the hepatic area, is behind the ascending colon and the mesocolic area and is not covered by peritoneum be- neath the colon. The inner quarter of the organ is behind the duodenum, and is nonperitoneal as is its colic area. The small area on the internal aspect of the anterior surface of the upper third of the kidney is in relation with the inferior vena cava. The anterior surface of the left kidney is in relation above, for a small space, with the left suprarenal (Fig. 27). The upper fifth of the anterior sur- face lies behind the stomach, and is covered by peritoneum. The middle two fifths is behind the pancreas, nonperitoneal. The lower two fifths lies behind the colon and mesocolon, the latter being peritoneal. A narrow strip of the THE KIDNEYS 35 anterior surface in its outer part is in apposition with tlie renal surface of the s})]e('n, and connected to this organ hy the lieno-renal liuaiiient. The posterior surface on both sides in its upper third rests upon the diaphragm, the twelfth rib crossing behind this (Fig. 28). Between the dia- pliragni and the lower ribs, the pleura extends for a considerable distance be- hjntl llio kidney. The inner third of the lower two thirds lies upon the psoas, the middle third on the quadratus luniborum, and the outer third rests upon the tendon of the transversalis. The last dorsal ilio-hypogastric and ileo-in- guinal nerves pass in a direction downward and outward behind tlie kidney on both sides. The external arcuate ligament and transverse processes of the upj^er three lumbar vertebra^ lie immediately behind the muscular bed of the kidney. OUTLIWE OF 12Xi! RIB Pelvis Ureter - - PapillcE Urirn'f- Calyx FiG. 28. — The Relation of the Kidneys TO THE Tissues behind Them. (Morris.) 1, transverse processes of the first and sec- ond lumbar vertebrae. 2, line indicating outer border of quadratus lumlDorum. Fig. 29. — Median Vertical Section of the Right Kidney. (Poirier.) The renal artery and vein, the interior of the pel- vis, calices, the ureter, the papillae and pj-ramids are seen. The inner horder of the kidney in its middle part consists of an anterior and posterior lip, forming a fissure Avhich is known as the hilum. In a space between these lips, which extends into the kidney substance for a short dis- tance, is the renal sinus, and here the blood vessels and ureter enter the kidney (Fig. 29). These vascular structures are known as the ikmHcIc. The relations from before backward are vein, artery, ureter. From above downward the relation is artery, vein, ureter. The upper pole of the kidney supports the suprarenal body posteriorly. It is in relation v;ith the inner sur- 36 ANATOMY OF THE URINARY AND GENITO-URINARY TRACT —13 face of the twelfth rih, or on the left side may lie in front of the eleventh. The diaphragm and pleura intervene between the kidney and the bone. The lower pole reaches abont two inches from the iliac crest and is situated farther from the median line than the upper pole. The external harder of the kidney is formed by the meeting of the anterior and posterior surfaces, and rests upon the tendon of the transversalis. The kidney is closely in- vested by a fibrous capsule, which, winding round the lips of the hilum, lines the renal sinus and also sends prolongations over the vessels and ureter. The Pelvis of the Kidney. — This arises from the kidney sinus by a series of small tubes, eight to twelve in number, called calices, surrounding one or more papillae. These fuse into one, two or three larger ducts, whicb in turn unite to form the pelvis. This cone- shaped duct extends inward and downward, decreasing rapidly in size to become continu- ous with the upper end of the ureter (Fig. 29). Perirenal Tissue. — When the kidney de- velops, it grows out as an evagination from the Wolffian duct. This diverticulum extends into the surrounding mesoblastic tissue, a por- tion of which becomes differentiated to form the kidney cortex. The part of the mesoblast that remains outside tlie cortex forms the peri- renal tissue. This remaining spongework be- comes filled with fat and surrounds the kidney, being thickest above, behind and externally. As we see from this mode of formation, no special ligaments are developed to hold the kid- ney in place, although by special dissection some of the fibrous tissue may be described as such. This surrounding tissue above is car- ried upward to the diaphragm (Fig. 30), internally over the spinal column (Fig. 31) to the opposite kidney, while below^ it extends on the posterior abdominal wall as far as the iliac fossa. Fig. 30. — The Renal Fascia after A Sagittal Incision Through the Kidney. (Testut and Jacob.) 1, kidney with its sinus. 2, suprarenal capsule. 3, perirenal fascia in front of kidney. 4, perirenal fascia behind kidney. 6, common insertion of its two leaves into the diaphragm. 6, fatty capsule. 7, pararenal fascia. 8, opening below the two layers of perirenal fascia. 9, diaphragm. 10, twelfth rib. 11, quadratus lumborum muscle. 12, crest of ilium. 13, parietal peritoneum. 14, adipose and cellular tissue in the iliac fossa. THE KIDNEYS 37 Below it (Iocs not form so markedly a closed sac as it does over the upper part of the kidney. This is due to the fact that the kidney originates below and travels upward as it develops. The chief agents in maintaining the kidney in its normal position are the intra-abdominal pressure, the attachments to the various vis- cera, and to some extent the perirenal tissue. Fui. 31. — The Renal Fascia after cisioN Through the Kidney A' A', the median line. 1, the kidney. 2, aorta. 2', inferior vena cava. 3, perirenal fascia. 4, po.sterior leaflet of perire- nal faseia. 5, anterior leaflet of perire- nal fascia. Horizontal In- (Testut.) 6, 6, fatty capsule. 7, pararenal fat. 8, parietal peritoneum. 9, vertebra. 10, psoas muscle wit hits apo- neurosis. 11, quadratus lumborum with its aponeurosis. Fig. 32. — Sagittal Section of the Kidney. (Henle.) u.t, uriniferous tubes. c.t, cortex with pyramids of Ferrein. m, pyramids of Malpighi. i, column of Bertini. p, papilla. c, calyx embracing papiUa. m.r, medullary rays. P, pelvis. u, ureter. a.a, artery. Structure. — The kidney on section shows an outer cortical layer called the cortex, and an inner called the medulla (Fig. 32). The medulla consists of pyramidal masses, eight to twenty in number, with their base toward the cor- tex, called pyramids of Malpighi. Their apices form small prominences (renal ])apillie) which project into the renal calices, and contain the orifices of the kidney tubules. Between the pyramids are found the columns of Bertini ; these are processes from the cortex and contain blood vessels, lymphatics and nerves. At the bases of the j)yramids in the cortex, are seen the medullary rays which are made up of the cortical portions of the straight collecting tubules, the descending and ascending limb of Henle and blood vessels. The areas of cortex between these raj's are known as the labyrinth. The pyramids of Ferrein are seen at the perijihery of the cortex and lie external to the medullary rays and labyrinth. 38 ANATOMY OF THE URINARY AND GENITO-URINARY TRACT The kidney siihstauce is iiindc ii]> of siiial] fnl)ii]('s, wliieli consist of a l)ase- ineiit nienibranc lined with epillieliiini and separated one from the other by connective tissue. The tubules ■Ef'pEHENT Vessel begin as blind dilated extreni- ~AFr£f^eNr V ^^^^^ "^ ^^'^ labyrinths and form what is called the cap- sule. This is surrounded by looped capillary blood vessels, which in turn are covered by a thin reflected layer of the capsule. The capillaries are thus inclosed between the two layers and tlie whole is GIoMeyulus, CApsu/e^ of Fiu. 33. — Malpighian Corpuscle. ur/f* WTW Fig. 34. — Scheme of the Renal Tubes and Blood Vessels (from ^^■ilson: modified from Klein). On the left of the figure the arrangement of the Ijlood vessels of the kidney is shown, on the right the course of the uriniferous tubules. v.s, venae stellatse of Verheyen. v.i, interlobular veins. ■y.r, vense rectse. m.v, veins of medullary part. «.p, veins of papillae. a.i, interlobular artery. g, glomerulus. a.r, arteriae rectae. a.m, arteries of medullary part. A, cortex. B, boundary zone. C, papillary zone of medulla. a.a' , superficial and deep layers of cortex, free of glomeruli. 1, Malpighian capsule. 2, neck. •S, first convoluted tubule. 4, spiral tubule of Schachowa. 5, descending limb of looped tubule of Henle. 6, bend. 7, 8, 9, ascending limb. 10, irregular tubule. 11, second convoluted tubule. 12, junctional tubule. 13, H, collecting tubule. 15, excretory tubule. THE KIDNEYS 39 called a ]\Ialpii;liian corpusele (Fig. S-'Jj. Tlic first part of tlie tuUiilo Icad- iiii;' from the capsule is the first convoluted tubule; it passes through the labyrinth to the medullary ray and becomes the spiral tubule. Thence it passes into the intermediate zone, then straight through the pyramid toward the apex. This part is known as the descending limb of Plenle's loop. Near the apex it bends around, forming the loop of Ilenle, and passes npward through the pyramids, through the intermediate zone into the medullary ray, as the ascend- ing limb of Ilenle's loop. It now continues its course to the labyrinth as the irregular tubule, becoming more uniform within the labyrinth ; this portion is known as the second convoluted tubule. - 2 1 This ends in the jnnctional tubnle which, ];)assing into the medullary ray, joins the collecting tubule. The collecting tu- bule is made up of several renal tubules and pursues a straight course to the apex of the pyramid. Here several unite to form one excretory duct, which opens at the renal papillae in the kidney sinus (Fig. 34). Blood Supply. — The kidney is sup- plied with blood by the renal artery. The chief function of this artery, however, is not to nourish the gland but to allow the various products of metabolism in the systemic circulation to be acted upon by the kidney. The Renal Artery. — In the sinus, the artery subdivides into a fan-shaped plexus, as seen in Fig. 29, and the ter- minal branches enter the projections pro- duced by the columns of Bertini (Fig. 35). On entering these, at their cen- ters, the arteries at once bifurcate, so that each division skirts the boundary of a ])yrauiid. Faeh pyramid is supplied with four or five arteries which travel along its surface until the base is reached (lobar or peripyramidal arteries). At the bases, they give transverse arched branches which anastomose with similar branches from other lobar arteries, and form the su]irapyramidal arch or plexus. The meshes of this network surround the base of a ])vramid transversely like a collar. From this network arise a nund)er of arteries directed toward the fibrous capsule, usually between two pyramids of Ferrein (Fig. 30). 2. i Fig. 35. — The Renal Artery and Its Branches. (Testut.) Right kidney. Sagittal section seen from the front. 1, capsule. 2, pyramids of Malpighi. 3, 3, columns of Bertini. 4, renal artery. 5, its posterior branch. G, its anterior branch bifurcating. 7, peripyramidal arteries. 8, renal pelvis. ■9, ureter. 40 ANATOMY OF THE URINARY AND GEN I TO-URINARY TRACT These arterioles, known as the interlobular vessels, end in the capsule in " capsular branches," some of which perforate into the perirenal fat. The in- terlobular vessels, however, give off lateral branches all along their route through the parenchyma, which end in the afferent ves- sels of numerous ]\lalpighian tufts. The glomerular capillaries are twisted around each other, forming the lobulated tuft de- scriljed above, and end in an efferent arterial capillary. Leaving the glomeruli, the efferent capillaries pass toward the convoluted tubules and the pyramids of Ferrein, and form a network which sur- rounds and supplies all the cortical tubules. In the me- dulla, the straight tubules are found accompanied by parallel capillaries — the arteria* recta? — which are probably also de- rived from the efferent capil- laries of the glomerulus. The arterise rectne form a rectangu- lar network about the papillary orifice of the collecting tubule. Abnormalities of the Kidneys. — (1) Complete absence of one kidney. (2) One kidney very small and atrophied, the other hypertrophicd and very large. (3) Lobulation, such as is seen in the foetus and in some of the lower animals. (4) Horseshoe kidney, the two kidneys being fused together at the lower pole. (5) Abnormal position, one kidney, usually the left, luay be ])laeed very low, opposite the sacro-iliac synchondrosis, this being the location of its early origin, (6) More than one renal artery may be present, or the main artery may break \\-p before it enters the sinus. Fig. 36. — Schematic Drawing Showing the Theory of THE Arrangement of the Vascular Arches over the Pyramids. (Testut.) 1,1, two Malpighian pyramids. £, sinus of the kidney. 3, columns of Bertini. 4, arterial arches. 5, venous arches. 6, branches of the renal artery. 7, branches of the renal vein. 8, interlobular arteries. 9, interlobular veins. 10, direct (straight) veins. THE UEETER 41 THE URETER The ureter is a fibro-mnsciilar canal, wliich conducts the urine from the kid- ney to the bladder. When in situ it measures about fifteen inches (37 cm.) (Fig. 37). Fiu. 37. — Showing the Relations of the Ureter to the Inferior Pole of the Kidney and to THE Blood Vessels of This Region. (Hartmann.) On both sides, it lies on the psoas muscle behind the peritoneum (Fig. 38), and is crossed obliquely by ovarian or spermatic vessels. The genito-crural nerve passes behind it on both sides, in a direction from within downward and outward. On the right side, the duodenum lies in front of its commencement. Lower down it is crossed by the ileo-colic artery and the root of the mesentery. On the left side, the left colic artery and the mesentery of the pelvic colon pass in front. 42 ANATOMY OF THE URINARY AND GENITO-URINARY TRACT Crossing the pelvic brim at the bifurcation of the common iliac or at the commencement of the external iliac (Fig. 39), it passes down from the side Avail of the pelvis in a curved direction, the convexity of the curve being back- ward. It passes over the obturator nerve and artery and obliterated hypogas- tric artery, as they riui forward on the side wall of the pelvis. At the spine of the ischium, it crosses inward over the floor of the pelvis and is crossed In* the vas deferens near its termination. As it enters the bladder, it lies in front of the vesiculce seminales and is surrounded by veins continuous with the vesical and prostatic plexus. As they enter the bladder, the two ureters are Fig. 38. — ^A Sagittal Section of the Pelvis to the Left of the Median Line. (After Hartmann.) On the right the peritoneum is seen intact with the ureter outside of it, whereas on the left the extra peritoneal tissue and the common iliac branching into the external and internal iliac branches are seen. If the two sides were brought together the ureter would occupy the space at the bifurcation of the common iliac. placed about two inches (5 cm.) apart. They run from the bladder wall in an inward direction for three quarters of an inch (1.87 cm.) (Fig. 40), and open on the internal surface by two valvular slitlike orifices which in the empty bladder are about one inch (2.5 cm.) apart. In the female, the pelvic portion of the ureter has somewhat different relations. As it runs down on the side wall of the pelvis, it produces a ridge in the peritoneum, Avhich forms the pos- terior boundary of a small fossa (fossa ovarica) in which the ovary lies. The upper and anterior boundary of this fossa are formed by the external iliac. It then passes inward underneath the broad ligament, passing over the vault of THE ■ URETER 43 in 11 13 18 14 19 20 21 YiQ, 39._The Relations of the Ureter to the Pelvic Tissues. (After Duval.) The ureter is seen to pass just below the bifurcation of the common iliac. 1, ascending colon. 2, end of ileum held up. 3, appendix held up. Jf, common Uiac. 5, superior hemorrhoidal. G, right sigmoidal. 7, middle sigmoidal. 8, internal iliac. 9, external Uiac. 10, right ureter. 11, vena cava. 12, aorta. 13, inferior mesenteric artery. IJ^, left ureter. 15, psoas muscle. 16, left sigmoidal artery. 17, internal Uiac. 18, colon. 19, anterior layer of pelvic mesocolon. 20, posterior layer of peritoneum. 21 , posterior layer of pelvic mesocolon. f^UCOUS CofiT. /^uscuIar Coat Fig. 4f). — Ureter Passing through the Wall OF the Bladder and Opening into Its Cavity. Ureter: 44 ANATOMY OF THE URINAKY AND GENITO-URINARY TRACT the lateral fornix of the vagina about a quarter of an inch (0.6 em.) from the lateral border of the cervix uteri. Near its termination it is crossed by the uterine artery (Fig. 41). Its course within the bladder is the same as in the male. Structure. — The wall is composed of an outer librous layer, then a middle muscular layer, the muscular coat being in three strata. Ute.ru-vaginal plexus Uterine vein L. Posterior uterine vein Ureteral artery - Ureteral artery Vesico-vaginal plexus Anterior uterine vein -•■-' Cervico-vaginal artery Vaginal artery _ Ureter Fig. 41. — Schematic Drawing of the Relations of the Ure- ter TO THE Neck of the Uterus and Its Vessels. (Poirier.) L.L, is a line drawn just below the uterine isthmus. The striations below this represent the vaginal wall. The outline of the cervix uteri is indicated in this area by a dotted line. An arch in front of the cervix and vagina represents the outline of the bladder wall through the sides of which the ureters are seen to extend. On the right side of the cervix about the ureter, the uterine and vaginal arteries and veins are seen. The uterine artery and vein pass in front of the ureter. The middle fibers are circular, the outer and inner longitudinal. Inside of the muscular coat is the mucous membrane, the epithelium of which is the same as that found in the bladder. Caliber of the Ureter. — The caliber of the ureter is not uniform throughout its extent. At its junction with the pelvis, its diameter is about 3.2 mm. From this point on it gradu- ally dilates until it reaches a diameter of 8 mm. As it passes from the abdomen into the pelvis, its diaiiiotor is abdut 4 iiiiii. From that point to its termination there is a slight gradual decrease in 'its caliber (Fig. 42). Variations. — The ureter is sometimes double at its commencement; some- times it is double throughout its course. In rare cases, one ureter may ojien into the vagina or urethra. Fig. 42. — Shape of the Right Ure- ter AFTER It has been INJECT- ED WITH Tallow. (Testut.) 1, pehas of kidney. 2, infundibulum. S, narrowing. 4, wide or abdominal portion. 5, bend at pelvic brim. 6, narrowing at brim. 7, widening in pelvic portion. 8, 9, external iliac artery and vein. 10, vesical orifice. THE BLADDER 45 THE BLADDER The bladder is a muscular pouch which acts as a temporary reservoir for the urine. Its capacity varies in different individuals, but an average is about twelve ounces. It is situated in the anterior part of the pelvic cavity, beliind tlio symphysis pubis and the retro-pubic pad of fat, and in front of the rectum, from which, in the male, it is separated by the vesiculse seminales and the ter- minal portion of the vas deferens. In the female, it is separated from the rec- FiG. 43. — Bladder But Slightly Dilated on Sagittal Section, Showing Its Apex AND Base. (Poirier.) 1, vas deferens. 5, seminal vesicle. 2, Retzius space. 6, prostate. 3, plexus of Santorini. 7, transverse deep perineal muscle. 4, retro-vesical fold. 8, transverse superficial perineal muscle. tum by the uterus and upper part of the vagina (Fig. 47). It presents varying forms and relations according to whether it is distended or empty. Relations. — The bladder has an aj^ex and five surfaces ; they are a superior or abdominal, a postero-inferior or basal, antero-inferior or pubic and two lateral (Figs. 43 and 44). The. apex looks upward and forward and is connected to the abdominal wall by a fibro-muscular cord, the urachus. On either side of it are the obliterated h^'pogastric arteries which pass upward from the sides of the bladder. TJie superior or abdominal surface is entirely covered by peritoneum and extends antero-posteriorly from the apex to the base. Laterally it is separated from the sides of the bladder by the obliterated hypogastric arteries (Fig. 45). The antero-inferior or puhic surface (Figs. 46 and 47) is that part of the bladder in relation with the symphysis pubis, the triangular ligament, internal obturator muscles and the anterior portions of the levator ani. It looks down- ward and forward, and is not covered by peritoneum. 40 ANATOMY OF THE UUl.XAliV AM) OEXITO-rRINAKY TRACT The hose or fundus (diagrammatic view) looks do^\Tiward and backward (Fig. 48). In the male, it is in relation to the rectum, from which it is sepa- rated by a reflection of the recto-vesical fascia. In the female, the base lies in contact with the ii])per part <»£ the aiitci-jor wall is fixed in ils lower jiart Ijv the fascia siir- roiiiKlinu' llie vcsicula' seiiiinalcs and tennination of the vas deferens. This Fig. 48. — Diagrammatic Drawing Showing the Base and Sides of a Dilated Bladder in a Pelvis from Which THE Floor and the Tissues Constituting the Perineum ' Have Been Removed. The lower part of the anterior surface is just seen. The pelvis is in the lithotomy position. P, antero-inferior or pubic surface. L, lateral surfaces. B, base. contains some mnscnlar fiber and extends back- ward, gaining- attachment to the rectum and the front of the sacrnm. Structure of the Bladder. — The serous or ])eritoneal coat, as we have seen, only gives a partial covering to the viscns. The muscular coat is very thick and is disposed in three layers, which are somewhat irregular. The outer coat is disposed for the most part in a longitudinal or vertical direction, some of the fibers from the inferior surface being continuous with the mus- cidature of the prostate, while in front they are continuous with the muscle fibers in the pubo- l)rostatic ligament (Fig. 50). The middle coat is not found as a complete layer, some of the fibers being horizontal (Fig. 51) and some longi- tudinal. Over the trigone it forms a continuous layt'v, the fibers running transversely, while near the urethral orifice they are dispersed in a cir- FiG. 49. — Change in the Shape OF THE Bladder while Filling. (Poirier.) Fig. 50. — Longitudinal Muscular Fibers of the Anterior Layer OF the Bladder Wall. (Sappey.) 1, longitudinal fibers of the anterior wall. 2, 2, the same fibers which are continu- ous at the top of the bladder with those of the opposite side. 3, the urachus surrounded by the middle anterior fibers. 4, group of fibers detaching themselves from the principal bundle to spread over the lateral vesical wall. 6, lateral fibers extending out from the longitudinal. 6, antero-latcral longitudinal fibers. 7, aponeurosis by which the longi- tudinal medium fibers attach themselves to the inferior part of the symphysis pubis. 50 ANATOMY OF THE URINARY AND GENITO-URTNARY TRACT cular nunnier. The inner coat is a tliin stratum, the fibers of which imui htn^i- tndinally, forming the internal sphincter (Fig. 52). The submucous coat separates the mucous membrane from the inner muscular layer. This forms a definite layer, except over the trigrme of the bladder, whcix- the mucous layer is firudy adherent to the underlying muscular surface. Fig. 51. — Middle or Circular Later of the Muscular Wall of the Bladder. (Sappey.) 1, 1, circular or transverse fibers of the bladder forming bundles which fit into one another. 2, muscular fibers of the urachus. 3, 3, sphincter of the bladder embracing the be- ginning the prostatic portion of the urethra. 4, cut through the vesical sphincter showing its thickness. Fig. 52. — Deep Layer of the Bladder "\Y.\ll. (Sappey.) i, 1, 1, streaked bundles of fibers extending from the top toward the neck of the bladder divid- ing and uniting with one another. 2, 2, 2, elliptical meshes in the longitudinal axis re- sulting from the union of these bundles. 3, muscular fibers at the urachus separating below and continuous with the other fibers. 4, fibers of this layer forming a cylindrical sheath wliich extends along the urethral mucosa. 5, sphincter of the bladder. 6, cut section of the prostatic portion of the ure- thra. The mucous layer is a continuous membrane lining the "whole internal sur- face of the bladder, and is continuous with that of the ureters and urethra ; it is disposed in folds and is loosely attached to the bladder wall, e.xcejit over the region of the trigone. The epithelium is a transitional stratified tyj)e, the same as that lining the ureter. Cavity of the Bladder. — In the empty bladder, this is said to assume the shape of the letter " Y " (Fig. 43). The stem of the Y is represented by the beginning of the j^rostatic urethra in the male. Normally in the living body, the interior of the bladder probably never possesses this shape, but would b(; better represented as a slitlike cavity extending from the a}K'X almost directly THE BLADDER 51 backward to the internal meatus. In the distended bladder, the cavity assumes an oval shape (Fig'. 40). The Orifices. — On the inner surface, three openings may be seen: Above and behind, the two o])enings of the ureters, while at the lowest part is the urethral internal meatus or urethral orifice (Fig. 44). Lines joining these orifices \\(»uld form the boundaries of an equilateral triangle, the sides measuring about an inch (2.5 c.c.) in the empty bladder. This triangular area is called the trigone. Vessels and Nerves. — The blood supply of the bladder comes from the su- perior and inferior vesical arteries. The veins (Figs. 53 and 54) form a dense Tiu. 53. — Veins in the Male Pelvis after the Rectum has Been Removed and the Bladder Pulled Down. (Henle.) 1, vena cava. 7, plexus of Santorini. 2, external iliac. 5, vas deferens. 5, internal iliac. 9, dorsalis penis. 4, gluteal. 10, internal pubic. 6, obturator. . 11, liladder. 6, sciatic. plexus about the base of the bladder just above the prostate and surrounding the entrance of the ureter. This ])lexus communicates freely with the pros- tatic plexus and empties into tributaries of the internal iliac veins. The lymphatics go to the iliac glands. 52 ANATOMY OF THE URINARY AND GENITO-URINARY TRACT The nerve supply is derived from the ] .civic plexus of the sympathetic and the third and fourth sacral nerves. T\n- former supi-lics the upper jx.r- tion and the latter its neck and hase. Fig. 54. — Veins about a Female Bladder as Seen fkom THE Front. (Poirier.) They empty into the internal iliac principally through the vesical and internal pudic vein. THE URETHRA Fig. 55. — Entire Length of the The male urethra is a canal extending from Male Urethra from the Neck , -, T . 1 , 1 , T ii ^ ,1^ ;+ OF the Bladder to the External the bladder to the external meatus, in the male it Urinary Meatus. (Taylor.) measures about eight inches in length, and passes through the prostate, compressor urethra? muscle and corpus spongiosum of the- penis"(Fig. 55). In its course from the bladder as far as the suspensory liga- ment, the urethra forms, a continuous curve with the convexity backward. At this point a reverse curve appears when the penis is flaccid. The whole course TITK rRKTIIRA 53 of flic cniiiil tlius resembles the letter "" S " (Fig. 56). When the penis is erect (ir hcM in position for the j^assage of an instrument, the reverse curve is Fk;. 56. — Curves of the Urethea When the Organ is Flaccid, also the Fixed Portion of the Canal. (Testut.) 1, symphysis pubis. 2, neck of bladder. 3, lowest point of the bulb the urethra. 4, angle of the penis. 6y bladder cavity. 6, prostate. 7, vas deferens. On the right of the figure out rapidly the distance in a 5, ejaculatory duct. 9, veru niontanum. of 10, bulb of urethra. a, a, the plane of the superior strait of the pelvis. b, b, axis of the symphysis. c, c, horizontal line drawn through the neck of the bladder, is to be found a scale in the metric system which permits the reader to make vertical line which separates different parts marked on the cuts. d, d, horizontal line passing through the lowest edge of the sym- physis. e, e, horizontal Kne drawn through the penile angle. /, /, horizontal line drawn through lowest part of the membranous canal. (il>] iterated, the anterior limb of the posterior curve being prolonged f c r w a r d and upward (Fig. 57). The urethra is di- vided into three portions for descriptive purposes: the prostatic, the mem- branous and the spongy portion. The Prostatic Ure- thra. — This part extends Fig. 57. — Curve of the Urethra When the Penis is Erect or Held in Position for the Passage of Instruments. (Taylor ) 54 ANATOMY OF THE URINARY AND GENITO-URIXARY TRACT throngli the prostate jiland, niid is sliohtly curved in direction, the convexity of the curve being backward (Fig. 58). It is one and one quarter inclies (3.1 ciii.j ill length, and is somewhat s])indle-shaj)ed. Tlie dilated middle por- tion is the widest part of the whole urethra. On cross section it is horse- shoe-shaped, with the con- v exit y forward . The posterior wall or floor contains a median ridge, C.S. ^- ^^^^^^^^^^^k^^Z^i^T^ \ \ the veru montanum, on the summit of which is a small depression. This depression is the opening Fig. 58. — Membranous Urethra and Its Relation to THE Triangular Ligament. M. U, limits of membranous urethra. D.T, deep layer triangular ligament. S.T, superficial layer of triangular ligament. c.c, corpus cavernosum. C.S, corpus spongiosum. C.F, Colles' fascia. B. U, bulbous urethra. P, prostate. E.D, ejaculatory duct. S, symphysis. of the sinus pocularis, a small cul-de-sac which extends into the jirostate for about one quarter of an inch, and is analogous in the male with the nterns in the female. On either side of its opening into the nrethra, are the openings of the common ejaculatory ducts. Abont the veru montanum, are the openings of the ducts of the prostate, while on either side is a groove called the prostatic sinus. The Membranous Portion. — This part extends from the prostate to the bulb of the Fig. 59.— Genito-urin.^ry Sinus in the Male, the Prostate H.wing Been Opened Anteriorly .vnd Its Lat- eral Lobes Retracted. (Testut.) At this point, the posterior urethra is seen in direct communication with the bladder and with the ejaculatory ducts. 1, the Ijladder. 2, urethra. S, prostate. 4, veru montanum. 5, frenum of the veru montanum. 6, urethral crest. 7, prostatic utricle (sinus pocularis). 8, orifices of the ejaculatory ducts. 9, prostatic fossette. 10, lateral depressions of the veru mon- tanum. THE UKETHRA 55 -.— 2 penis. Tt is about an inc-li (2.5 cm.) from the symphysis pubis, and lies liclwcc'U tlic two layers of the triangular ligament. The anterior wall is abmil one half inch in length, while the posterior wall is a little more. This is (hio to the fact that the urethra opens into the bnlb by an oblique opening. It is completely surrounded by the compressor urethral muscles, while on either side are (^owper's glands. At its commencement, it is immediately in front of the rectum, but in its course it curves forward while the rectum curves back- ward ; hence at its termination there is an interval of about half an inch be- tween the two. At its termination the antericn- portion has passed through tlie triangular ligament be- fore entering the bulb, and here there is a small area with no im- mediate covering and it can be eas- ily punctured by an instrument (Fig. 58). The Spong-y Portion. — The s])()ngy portion extends from the an- terior layer of the triangular liga- ment to the meatus and is about six inches (15 cm.) in length. It is sur- rounded by the erectile tissues of the corpus spongiosum, the greater part of the tissue being behind the urethra in the bulb, and in front and on the side of the glans. The caliber of this part is not uniform through- Fig. 60. — The Natural Dilatations and Nar- ROWINGS OF THE UrETHRA. (Testut.) out (Fig. 60), thus it is larger in tlie part surrounded by the bulb, be- comes smaller in the corpus spongi- osum, and as it enters the glans it becomes markedly dilated, the di- lated portion being known as the fossa navicular is. The external meatus is vertical in direction, and is the narrowest and least dilatable por- tion of the wdiole canal. Therefore, 1, the bladder. 2, neck of bladder. 3, eoUar of the bulb. 4, meatus. The natural dilatations are: 5, of the prostate. 6, of the bulb. 7, of the fossa navicularis. The narrowings are: 5, of the membranous urethra. 9, of the penile portion. it will be seen in Fis;. 0(1 that the three dilatations of the canal are the fossa navicularis, the bulb and the prostate. The Structure. — The urethra consists of a muscular, submucous and mucous layer. The external coat is a thin layer of unstriped muscle, continuous with the musculature of the bladder and prostate. The submucous layer consists 56 ANATOMY OF THE URINARY AND GENITO-URINARY TRACT of vascular and erectile tissue. This is found not only in the spongy portion bnt also in the niemhranous and ])i'ostatic portions. The mucons membrane is a thin delicate layer lined by transitional epithelia continuous with the bladder and urethra. The superficial epithelium of the mucous mendn-ane is columnar, except at the meatus and fossa navicularis, Avlierc; it becomes squamous. The meudu'ane is disposed in folds during the flaccid condition of the organ, and on the internal surface are the orifices of numerous glands. Some of these in the mend)ranous and the first part of the spongy portion are called the glands of Littre. The ducts of Cowper's glands open into the bulbous portion near its commence- ment. The urethra in the female ( Fig. 61) is a short canal about one and one half inches (3.7 cm.) in length, im- bedded in the anterior vaginal wall. The external meatus is situated be- neath the clitoris and has the shape of an inverted " V." The whole urethra in the female morphologically repre- sents that portion of the prostatic ure- thra in the male which is situated be- tween the bladder orifice and the sinus pocularis. The Blood Supply. — The prostatic portion is supplied by branches of the middle hemorrhoidal artery, the membranous portion by the inferior hemor- rhoidal and transverse perineal arteries, the spongy portion by the arteries which go to the penis. The venous return is in part by the dorsal vein of the penis, and in part directly by the prostatic plexns. The lymphatics of the membranous and spongy portion go to the inguinal glands, while those of the prostatic portion go to the iliac glands. The nerve supply of the urethra is from the superficial perineal and dorsal nerves of the penis, and also branches from the hypogastric plexus. Fig. 61. — Transverse Vertical Section THROUGH THE FeMALE UrETHRA. Skene's glands are near its end. Compare it with Fig. 55, the male urethra. COWPER'S GLANDS These are two small bodies about the size of a pea, placed on either side of the membranous urethra, between the apex of the prostate and the bulb of the corpus spongiosum (Fig. 62). The gland consists of numerous branching tubules, which are arranged in small lobules. The excretory duct SCROTUM 57 of each gland passes forward between the urethra and the substance of the bnlb for about an inch (2.5 cm.), opening by a minute orifice on the floor of the iiretlira. The glands of IJniiholiii, in the female, arc I he analogues of the glands of ( 'owper in the male. They are slightly larger than the latter glands, and open outside of and external to the hymen just be- neath the labia minora. 10 ~ Fig. 63. — Schematic Vertical Trans- verse Cut through the Scrotum, Showing the Formation of the Sac. (Poirier.) 1, skin, integument. 2, outer layer of dartos. S, inner layer of dartos. 4, areolar (cellular) tissue. 5, middle spermatic or cremasteric layer. 6", internal spermatic or fibrous tunic. 7, cellular tissue between the two sides of the scrotum. recipitate that gradtndly blackens. On adding ferric chlorid, the nrine turns gray ; if enough be added, the phosphates will precipitate, carrying the coloring matter with them. The nrine containing melanin is normal in appearance when freshly voided, bnt on exposnre to the air becomes brown or black. Organic Constituents of Minok I:mportance Leucin and tyrosin are f otnid in the nrine, chiefly in destructive diseases of the liver (acute yellow atrophy, phosphorous poisoning) and in acute infec- tions (smallpox, typhus). Leucin and tyrosin usually occur together ; they may be deposited in the sediment when present in large amounts. Usually the urine contains an excess of bile and a deficiency of urea. The crystals may be obtained by evaporating the urine and, if the crystals are extracted with alcohol, leucin dissolves and tyrosin is left. Inorganic Constituents The principal inorganic constituents of the urine are the chlorids, phos- phates and sulphates occurring in combination with sodium, potassium, am- monium, calcium and magTiesium. The total amount of inorganic substances excreted in twenty-four hours varies between nine and twenty-five grams. Chlorids The chlorids rank next to urea in importance among the solid constituents of the urine. The greater part of the chlorids exist as sodium chlorid, while smaller amounts of potassium and annnonium chlorids are found. The chlorids in the urine are derived from the food, and most of the salt ingested is elim- inated in the urine as such. The nornuil amotnit of chlorids excreted in twenty-fotir hours varies frcnn ten to twenty grams, but if much salt is taken with the food, the amount may reach fifty grams. Chlorids are diminished especially in all acute affections, in which there is a serous exudation or transudation, vomiting, or diarrhea. Chlorids are diminished or absent also in cholera, septicemia, pyemia, puer- peral fever, and acute artictdar rheumatism. The chlorids may be absent in 90 THE URIXE the urine in a chronic disease, if accompanied by dropsy (chronic nephritis, heart disease), and as the dropsy is absorbed, the chlorids gradually are in- creased. In pneumonia, the chlorids are low or absent in the acute stage, but as the exudate becomes absorbed, they increase, and may become normal. In lueningitis (acute) the chlorids are also increased, so that by testing for them, we may differentiate between meningitis and typhoid. In nephritis, the amount of chlorids eliminated as compared to the amount of urea, is of considerable iniportaiico. Detection and Approximate Estimation. — Sit.ver Xitrate Tkst. — De- fore applying this test, if more than a trace of all)uniin is present, it should be removed by heat, as albuminate of silver forms and interferes with the reac- tion. One half ounce of urine is laid upon an equal amount of pure nitric acid in the same manner as in the test for albumin. Then one drop of a 1 : 8 solu- tion of silver nitrate in water is added. A jDrecipitate of silver chlorid is formed, which, if normal or increased in amount, appears as a compact, solid mass which falls to the surface of the nitric acid. If the amount is diminished, the silver chlorid becomes more or less diffused through the layer of urine. Carbonates Minute quantities of carbonates and bicarbonates of sodium, ammonium, calcium, and magiiesium, are found in fresh urine of alkaline reaction. Am- monium carbonate may occur in large amounts, owing to alkaline decomposi- tion. The carbonates in urine are derived from the food, especially from vege- table acids, such as lactic, tartaric, malic, succinic, etc. They are, therefore, most abundant in the urine of herbivora. An excess of carbonates renders the urine turbid when passed or on standing and, as a rule, the sediment is mixed with phosphates. Detection, — On the addition of an acid, the presence of carbonates is de- tected by the evolution of gas bubbles, and this gas, wdien passed into baryta water, renders the latter turbid. The determination of the amount of carbonic acid will be found described in the larger text-books. Phosphates Earthy Phosphates. — Render half a test-tubeful of filtered urine alkaline with ammonia and warm gently. Earthy phosphates, in the form of a wliirish cloud, settle to the bottom of the tube. The precipitate is dissolved by the addition of acetic acid. Approximate Quantitative Estimation (Ultzmaiin). — A test-tube 2 cm. wdde is filled with urine to the depth of 5-j cm., and a few drops of strong ammonia are added. The mixture is w'armed over an alcohol lamp until the earthy phosphates separate. The depth of the sediment is measured after CHEMICAL EXAMINATION OF THE URINE 91 staiidinii; for fiftcon iiiinutes. IS^ornially, the layer Avill be 1 cm. liiuli: ;i <;reater depth indicates an increase, while a less abundant precipitate means diminution. Alkaline Phosphates. — After the earthy phosphates have been separated, as shown above, the mixtui'c is filtered. To the filtrate is added one third of its volume of niai!,nesinm fluid (magnesium sulphate, ammonium hydrate, am- monium chlorid, of each one part; water eight parts). The white precipitate consists of alkaline phosphates. To make this test available for approxinuite estimation, according to Ultzmann, 10 c.c. of the urine are treated with 3 e.c. of the magnesium fluid. A precipitate of crystalline ammonio-magiiesium ])hosphate is found, together with an amorphous mass of calcium phosphate. If a milky turbidity permeates the entire fluid, the alkaline phosphates are normal in amount. If an abundant precipitate gives the fluid the appearance of cream, they arc greatly increased ; and if a slight turbidity follows, or if the fluid remains transj)arent, they are decreased. Sulphates The ethereal sulphates have already been considered. There are in addition in the urine the ordinary alkaline sulphate of sodium and potassium, the sodium salt being present in larger quantities. The amount of sulphates excreted by healthy adults ranges from 1.5 to 5.0 grams daily. About one tenth of this 11 mount is represented by the ethereal sulphates, about nine tenths represented by the potassium and sodium salts. The sulphates in the urine are derived partly from food and partly from the decomposition of proteid substances in the tissues. The sulphur from the foodstuffs and from the tissue elements is oxidized to sulphuric acid, the lat- ter in turn combining with sodium and potassium to form a sulphate of these bases. The amount of sulphates in the urine is increased after taking sulphuric acid or suljjhates ; after active exercise ; after the inhalation of oxygen ; in acute fever, in meningitis and in rheumatism. As a rule, the amount of sulphates is parallel to that of urea. Sulphates are decreased in most chronic diseases when metabolism and appetite are diminished ; also after carbolic-acid poisoning or after the use of large doses of salol, etc. In such cases the ethereal sulphates are increased. Detection. — For ordinary purposes, the following test is sufficient: To a test-tube one half full of filtered urine, add one or two inches of barium solu- tion (barium chlorid, 4 parts; concentrated hydrochloric acid, 1 part; distilled water, 10 parts). A white precipitate occurs which normally fills one half the concavity of the test-tube. A larger amount indicates an increase, a smaller amount a decrease. 92 THE UKINE IV. MICROSCOPICAL EXAMINATION General Coksidkuatioxs To obtain the sediment of a specimen of urine for microscopical examina- tion, we can use either the okl-fashioned gravitation method or the centrifuge. If the former is used, the specimen must bo aHowed to stand in a well-co\'ercd, conical glass, preferably in a cool, dark place, from six to twelve hours. This method has the obvious disadvantages of delay in examination and more or less disintegration of the organic elements. Centrifugal sedimentation permits the inunediate examination of the urine microscopically and produces a concentrated sediment from freshly voided urine before cells and easts can be destroyed by the alkalinity of the stand- ing urine and before the development of bacteria. This is the only method by which crystals, formed in the urine before it is passed, can be dis- tinguished from those formed after- wards. By the old methods in urine of high specific gravity, the lighter forms of casts might float and thus be overlooked. This does not happen with the centrifuge. Fig. 87. — Hand Centrifuge. (From Kny-Scheerer.) Fig. 88. — Water Centrifuge. The Centrifuge. — Three types of centrifuge are on the market: the hand (Fig. 87), water motor (Fig. 88), and the electric centrifuge (Fig. 89). Of the three, the hand centrifuge is the least expensive and answers the purpose MTCEOSCOPICAL EXAMINATION 93 wliere it is impossible or iinpractieal)lo to use eitlicr a water or electric centri- fii<;e. The labor and time re(iuired in using it, owing to the limited speed ob- tainable, are obvious disadvantages. The water motor is in many ways the most practical. It can be used wherever I hero is a faucet of running water under ordinary city pressure and it is so simple that it never gets out of order. The electric centrifuge has some ad- vantages, and is joreferred by laboratory workers on account of the greater speed ol)tainable. It can be run with ordinary in- ciindeseent lighting currents of 110 volts, direct or alternating, or even by currents of K'ss voltage. Aluminum shields protect the tubes from all danger of breaking, no matter wdiat the s])eod may be. The tubes have conical tips in which the sediment collects, and it is not disturbed by sudden stopping of the instru- ^ _ ^ ^ ^ •^ , . Fig. 89. — The Purdt Electric Centri- ment or by decanting the urine. fuge. Methods of Examining the Sediment A pipette, consisting of a single glass tube, drawn to a moderate point, is held with its upper opening tightly closed with the index finger and dipped to the bottom of the sediment glass of the centrifuge tube. The finger is then released and the sediment is allowed to rush in from below upward. A speci- men should include portions of all strata of the sediment, mixed with a little urine, especially if the sediment is very dense. The sediment is dropped upon a slide and covered with a large cover glass. The excess of urine is taken up with filter paper. When the low power (only I objective) is used, no cover glass is needed, but for the high-power lens a cover glass is essential to prevent soiling the lens, the microscope and the ex- aminer's fingers. It is best to go over a slide with the low-powerTens (Leitz Xo. 3, Zeiss A A, Bausch & Lomb §). With this, most of the larger elements can be made out. For the fine study of epithelia, casts, etc., however, the higher power (Leitz Xo. (i, Zeiss D, Bausch & Lomb \^) is necessary. For the routine examination ot a large uuud)er of specimens without a cover glass, the lower ]iower with a stronger eyepiece (Zeiss No. 12, Achromatic or Leitz Ko. 3, Ocular 5) will be found sufficient. In fact this combination offers a rapid, cleanly way of ex- 94 THE l^KIXE aiiiining' urine, wliieli will appeal to the busy practitioner. For differentiating epithelia and the liner structures, however, it cannot serve in all instances. In searching for casts, especially of the hyaline variety, the diaphragm of the microscope should be closed so as to admit the least possible amount of light. The micrometer screw of the microscope should be freely used in looking for casts, as these structures are cylindric and often so trocated that one turn of the screw brings one part into view, while the rest remains hazy. The flat mirror should be used when looking for casts. The Abbe condenser should not be used when looking at urinary sediment. UlS'OROANIZEI) SeDIMEIs^T Uric-Acid Calculi. — In uric-acid calculi in the kidneys or elsewhere in the urinary tract, considerable masses of uric-acid crystals, with jagged outlines, may be found in the urine. Detectiox. — Uric-acid crystals (Figs. 90, 91, 92) vary greatly in shape, but the typical forms are the rhom1)ic, or six-sided plates, the whetstone shape 4 .*:'V ^ Fig. 90. — Crystals of Uric Acid. (From Wood.) in stellate groups and crystals resembling a comb with teeth on both sides. All these are more or less yellow in color, though occasionally some of them appear colorless. They dissolve on adding a few drops of alkali and reappear on add- ing acetic acid. MICROSCOPICAL EXAMINATION 95 Urates. — The mixed sodium, potassium, ammonium, calcium and mag- ne?iuiii urate deposit is a granular sediment of a rcddisli color, varying from piiik to l)ri('k-red, and usually sinks (prickly, tliougli it uiiiy make the urine turbid. Tiie ])r('('ipitate redissolves on gently heating the urine. Fig. 91. — Unusual Forms of Uric Acid. Fig. 92. — Unusual Forms of Uric Acid. K ^ ■^ Sodium Ur.vte. — This forms the greater bulk of the mixed urate deposit, and is usually amorphous. It is generally found in mosslike masses of mi- nute granules which easily adhere to larger masses of sediment. When crys- talline, it is seen in the form of fan-shaped groups, pointed at the center, or arranged like sheaves of wheat. These crystals show characteristic striation. Potassium Ueate. — This occurs always as an amorphous sediment, forming a part of ^■ the mixed urate deposit. It is soluble in hot water, insoluble in cold water. Calcium Urate. — It is a rare deposit and is found as a part of the amorphous mixed urate sediment. Ammoxium Urate. — It is said by some that this is in reality sodium urate in modi- fied form, marking a transition of an acid sediment into an alkaline. Ammonium urate is characteristic of alkaline fermentation, and is usually associated with triple phosphate and calcium phosphate. It occurs in the form of yellowish-red or dark-brown spher- ules, studded with fine sharp thorns which have given rise to the term " thorn-apple " crystals (Fig. 93). These crystals may be massed in clum])s or chains and are soluble in hot water or in acids ; they emit the odor of am- monia on adding alkalies. It is the onlv urate found in alkaline urine. \ Fig. 93. — Crystals of Ammonium Urates. (From Wood.) 96 THE URINE Calcium Oxalate. — Xormally the greatest part of the oxalic acid taken in the food is coinerled by oxidation into nrea and carbonic acid. When for some reason (disease) this oxidation is inter- fered with, this change (h)es not take jjUico, then the oxalic acid is excreted as such in- combination with calcium (from the blood, also derived from food and tis- sues). Detection. — The crystals of calcium oxalate may be found in acid urine when they may accompany crystals of uric acid, or in alkaline urine w^hen they accompany triple phosphates. Two typical forms of calcium oxalate crystals are distinguished Fig. 94. — Calcium Oxalate Crystals (Fio". 94). The octahedral crystals consist of two four-sided pyramids placed base to base and appear like squares crossed like envelopes, or, if turned with their long axes toward the observer, like long- FiG. 95. — Crystals of Ammonium Magnesium Phosphate. (From Wood.) pointed octahedra. Sometimes these crystals coalesce with larger masses. The dumb-bell crystals are not so common and look like two crossed dumb-bells. They must be distingiiished from the yellow or brown dumb-bells of uric acid. MTCKOSCOPICAL EXAMINATION 97 Fig. 96. — Featheey Form of Triple Phosphates. The (]uinl)-l)('ll.s of ealciuni oxalate are solul)lc in hydrochloric acid, those of uric acid in alkalies. Phosphates. — In the sediment the earth}' j)liosj)hates are represented hy cal- cium |)li()S|)hate and by ammonio-magnesia phos- ])liate (tri})le phosphate, so called). The alkaline ])hosphates are not represented in the sediment. Calcium Phosphate. — Calcinm phosphate is either amorphons (the normal salt), or crys- talline (the acid salt), the latter consisting jiartly of magnesium phosphate. The amor- phous form occurs in feebly acid urines and is seen in small, highly refractive granules, in elnni])s or adhering to other parts of the sedi- ment. The crystalline form is found in urine about to undergo alkaline fermentation, but Avliieli is still weakly acid. They are prismatic and arranged in either single or in star-shaped, often in fanlike, groups. Acetic acid rapidly dissolves them, whereas it slowly affects sodium- urate crystals similarly shaped. Teiple Phosphate Crystals. — Ammonio-magnesium phosphate occurs either as the coffin-lid crystals or the feathery crystals. The former is more common and consists of a triangular prism with one of the three angles wanting. They are large in size and at times shortened into squares which may be mistaken for calcium oxalate. The stellate crystals are feathery stars or parts of stars. The phosphate crystals are soluble in acetic acid, while the oxalate crystals are insoluble in this acid. Carbonates and Sulphates. — (a) Calcium Carbonate. — Calcium car- bonate is found rarely in the urine of man, but in large quantities in the urine of some lower animals. It occurs in the form of small squares. On adding acetic acid, an effervescence of carbon dioxid results. (h) Calcium Sulphate. — Calcium sul- phate is a very rare deposit ; it occurs in highly acid urine with high specific gravity, in the form of needlelike prisms which often are grouped in radiating fanlike arrange- ments (Fig. 97). Leucin and Tyrosin. — (a) Leucix occurs in the form of yellowish, highly refractive s])heres, looking like oil drops (Fig. 98), which show radiating or concen- tric stripes. They are often arranged in masses or groups of three or more Fig. 97. — Crystals of Calcium SuL' PHATE. 98 THE I^RINE spheres. Unlike oil, leucin is not soluble in other, but is soluble in alka- lies. They are larger than the spheres of anniioiiiuui urate and have no spikes. Fig. 98. — Leucin Crystals. (From Jacob.) Fig. 99. -Leucin and Tyrosin Crystals. (From Wood.) (h) Tykosust occurs as very fine needles arranged in sheaves or rosettes (Fig. 99). They are colorless, but when arranged in masses, they appear quite dark. They are insoluble in ether, but soluble in alkalies. Blood and Bile Pigments; Fat; Cholesterin. — (a) Bilirubin. — In urine containing bile, bilirubin may be found as amorphous masses, or as needles in stellate formations, often adherent to cells, or in yellow or ruby-red rhombic plates. They show a green rim on adding nitric acid. (h) Hematoidin. — Crystals of hematoidin occur in nrine containing blood, e. g., after an extensive hemorrhage, in pyonephrosis, renal stone, etc. The crystals are identical with those of bilirubin and probably hematoidin is iden- tical with the former. (c) Fat Globules. — Fat globules may be seen in the urine as extraneous matter from unclean bottles, or from ointments in the genitals. "When enough fat is present to be seen with the naked eye, the term " lipuria " is used. When the fat makes the urine milky, the term " chyluria " is used. The latter is usually due to the presence of a parasite, the Filaria sanguinis. Fat in small amounts may occur in healthy urine after a fatty diet, also in pregnancy and in phosphorous poisoning. j\Iany minute fat globules are found in the urine of chronic nephritis in which the fat granules are derived from disintegrated fatty epithelia. They are found also in other chronic inflamma- tions, such as cystitis, pyelitis, prostatitis, urethritis and vaginitis, in cystic kidney, and in abscesses opening into the ureter. (d) Cholesterin. — Cholesterin is a monatomic alcohol, normally present in the blood, the nerve tissues, the bile, etc. It occurs in gall-stones, in pus, tu- mors, etc., but is a rare deposit in the urine in extensive fatty changes in the kidney as a result of acute or subacute or chronic nephritis. Still more rarely I MICROSCOPICAL EXAMINATION 99 Fig. 100. — Crystals of Cystin. (From Jacob.) it occurs in choosy (loi>'oncration of cystic kidnoys. It crystallizes in large ])lates, is insoluble in Avater, l)ut soluble in alcohol, etlier, chloroform, etc. If a mixture of five parts of sulphuric acid is allowed to act on a cholesterin plate, a bright carmine-red color appears, which changes to violet. Cystin. — Cystin is seldom found as a urinary sediment and ])i'<»l)ably never in normal conditions. Its origin in the econ- omy is not clearly nnderstood, but the liver is regarded as the seat of its formation. It is a crystalline compound and occurs in two forms; either as hexagonal tablets with an opalescent luster, or as four-sided prisms. It is soluble in caustic alkalies, oxalic and strong mineral acids, insoluble in boiling water, acetic acid, ether and alcohol. These crystals may be distinguished from uric acid by treat- ing them with strong acid — which dissolves them but not uric acid — and from triple ])hosphates by the solubility of the latter in acetic acid (Fig. 100). Clinical Significance. — But little is known as yet of the interpretation of cystin in the urine. It is found in typhoid fever, in renal degeneration, in chlorosis, and acute rheumatism. It occasionally forms calculi. Okganized Sediments 1. Blood Cells. — As a urinary sediment, blood cells are always pathological. Their form depends upon the source of the bleeding and the reaction of the urine ; when the typical biconcave disks are preserved, it is easy to recognize them by the microscope and in acid urine they retain their shape for a long time, gradually shriveling and becoming crenated (Fig. 101). They seldom form rolls as when drawn from a blood vessel, except in cases of great hemorrhage from bladder or urethra. If the urine be concentrated, the biconcave form is exaggerated and the corpuscles shrink and become crenated ; when the urine is of low specific gravity, they swell and may be- come spherical. 2. Pus. — Pus cells may be derived from any part of the urinary tract. The urine containing pus is usually turbid and gives the albumin reactions. Under the microscope, the pus cells appear as circular, pale, finely granular disks, about twice the size of the red blood cell ; they contain distinct nuclei, often two or three (Fig. 102). \Yater swells the pus cell, renders it paler and ob- m ©a @ Fig. lOL — Blood Cells in the UlUNE. Fig. 102.— Pus Cells in the Urine. 100 TTIK URINE sciires its outlines ; acetic acid produces the same effect, more quickly, and, causing the granular condition to disap^jear, renders the nuclei very distinct. Pus cells resemble the white cells of the blood and lymph, and in the fresh state present the glistening appearance of living protoplasm and also ameboid move- ments ; seen in the urinary sediment, the cells are dead. The chief constituent of pus cells are albuminous bodies ; especially nucleo- albumin, which is insoluble in water, but expands into a tough slimy mass when treated by sodium-chlorid solution. Pus in the urine is usually accom- panied by tissue elements or bacteria, which aid materially in determining its anatomical and pathological source. 3. Epithelia. — In normal urine, a few epithelial cells from the superficial layers of the urinary tract are always seen and have no special significance. When these cells are altered by disease and are found in considerable num- bers, accompanied by pus or red blood cells, a pathological process exists in some part of the genito-urinary tract. Theoretically, each separate portion of the urinary tract has a type of epithelium peculiarly its own, but in actual j^ractice there are so many transi- tional forms in every portion of the tract, that it is not always possible to specify the origin of a given cell. Inasmuch, however, as the recognition of the differ- ent characteristic epithelia is absolutely essential to a localization of diseases of the tract by urinary examination, the problem of distinguishing the epi- thelia of each portion of the trac^ is of great importance. Most authorities maintain that, while histologic preparations of the dif- ferent urinary organs show that the epithelial lining of each has well-marked characteristics, the epithelia shed by these organs during life and appearing in the urine are radically altered in aspect, and their characteristics to a large extent obliterated. Moreover, the same school of clinical pathologists holds that the cells of the deeper layers of the bladder, for example, are identical in ap- pearance with cells from other parts of the urinary tract. The chief characteristics of epithelia found in the urine are their form and size. By comparing the size of the different epithelia with that of the leucocyte or pus cell, we have, because the latter varies so little, a fair idea of the relative magnitude of the epithelial structures. Three chief types of epithelia occur in the urine, viz., the flat or squamous, the round or cuboidal, and the columnar or caudate. All these epithelia have one or more distinct nuclei, and are more or less gTanular. When the epithelia in the urinary tract are stratified, the outer layers are usually flat, the middle layers cuboidal, the inner columnar. The tubules of the kidney, tlie prostatic acini and ducts, and the ejaculatory ducts are lined with a single layer of cuboidal or columnar epithelium. The pelvis of the kidney, the ureters, the bladder, the urethra and the vagina are lined with stratified epithelia. £ HiSTolooicAl f^ppenRnNCE ;?* ip © Es They Occuii iNTne Uf^we. # Tf.C. Fig. 103. — Epithelial Cells from Different Parts of the Genito-urinary Tract. I. — The different varieties of these cells as seen histologically. /?', convoluted tubules. R^, spiral tubules. R^, descending and ascending limb of Henle. /?', loop of Henle. R'\ distal convoluted. R>, arched collecting tubules. R', straight collecting tubules. P, pelvic cells. U , ureteral cells. Bs, superficial layer of bladder cells. Bd, deep layer of bladder cells. S. V, seminal vesicle. P.U, prostatic urethra, V.D, vas deferens. U.R, penile urethra. F.N, fossa navicularis. II. — The groups of these cells recognized in the urine. R.C, epithelial cells from renal B, superficial bladder cells. C, cells belonging either to pel- tubules. Ur, penile urethra. vis, deeper layers of bladder, P, cells from renal pelvis. F.N, fossa navicularis. prostate or ureter. III. — Comparative size of epithelium found in the urine. /, blood cell. 4, renal pelvis, ureter, prostate 5, superficial layers of bladder. 2, pus cell. and deeper layers of blad- f>\ the penile urethra. S, cellsfromthcreualparenchyma. dcr. 7, the vagina. 101 102 THE URINE Tlie largest epithelia in the urine are the flat superficial cells from the male anterior urethra, the vagina, vulva and female urethra. Xext in size are the superficial squamous layers of the bladder. Xext come the cells from the renal pelvis, the ureters, the prostate and the tubules of the kidney. The average size and the average shape should always be taken into consideration, not the many transitional sizes which are confusing, (See Fig. 103.) (a) Eenal Epithelium. — These cells are the most difficult, yet the most important, to identify in the urine. They do not occur in normal urine, save in such small numbers that they may be disregarded. Their presence in any numbers is indicative, at least, of renal irritation ; when accompanied by or ad- hering to casts, they mean nephritis. The chief diagnostic characteristic of renal cells is that they are at least one third larger than the pus corpuscles. This relation is constant. If the renal epithelia are small in a given case, the pus corpuscles will also be small. The illustration shows the comparative sizes of pus corpuscles and renal epi- thelia. The smallest group is that of red corpuscles, which are the smallest cellular elements in the urine. The next group is composed of pus cells. Then follow the smallest epithelia, the renal, which are one third larger than the pus cell. The next group shows cuboidal cells twice the size of the pus cell. These may be either from the ureter or from the prostate. The epithelia from the straight collecting tubules are not frequently seen. They are about the same size as the epithelia from the convoluted tubule, but narrower and columnar in shajDe. Renal epithelia, pus and pelvic epithelia, especially when accompanied by casts, are indicative of a pyelonephritis. It is important to look for epithelial casts and to compare the size and appearance of the epithelia on these casts with other renal epithelia found free in the urine. In this way we often con- firm our opinion that a given set of round cells are from the kidney. It is al- ways important, however, to compare the tubular e2:)itlielia with the pus cell. (6) Epithelia from the Rexal Pelvis. — These cells are of two types. The superficial layers shed a characteristic caudate, pear-shaped or lenticular cell. The deeper layers are represented by round or cuboidal cells, smaller than the bladder epithelia. The caudate cells of the pelvis are distinguished from those of the ureter and from the columnar cells of the bladder l)y various features. The pelvic cells are twice the size of a pus cell; they have more distinct nuclei; their granules are well marked and they often have jointed or bifurcated tails. They are smaller than those from the bladder and slightly larger than those from the ureters. The presence of these caudates is characteristic, when present in large numbers and accompanied In- pus, of pyelitis. The round cells from the pelvis are not so characteristic, and fortunately are not so frequently seen, as they may be confused with renal cells. They MICROSCOPICAL EXAMINATION 103 often occur in clumps of considerable size, are always accompanied by pus, and indicate chronic pyelitis. (c) Epitiielia from the Ureters. — These occur in the urine of uretero- pyelitis, stone in the ureter, etc. They are also found in normal specimens ob- tained by the ureteral catheter. There are two forms of ureteral cells. The majority of epithelia from the ureters are round or cuboidal, smaller than those of the pelvis but of the same size as those of the prostate. They rarely occur without pelvic epithelia, and can be differentiated only when the renal and ])elvic cells are present. The ureteral epithelia are twice the size of a pus cell and are comparatively rarely seen. They resemble a small narrow caudate s})in(lk', having a small bright nucleus. These cells are rarely found in sedi- ments and are very similar to those of the deepest layers of the bladder, but are much smaller. (d) Epithelia from the Bladder. — The upper layers of the bladder strata are flat. They occur in moderate numbers in normal urines, but in cys- titis and other bladder diseases are greatly increased and modified. They occur either free or as fragments of cells irregular in size and shape. The largest of these flat cells are found near the neck of the bladder, and are apt to be confused with vaginal cells. The average superficial bladder cell, however, is smaller and has more rounded outlines than the vaginal cells. The latter also often contain bacteria. The middle layers are composed of cuboidal epithelia. These are present in moderate or in large numbers in acute cystitis, in conjunction with cells from the upper layers. When chronic cystitis is present, the middle layers are represented by a majority of the bladder cells found in the urine, as by this time the superficial layers have been to a marked extent destroyed. In addition, in chronic cystitis, the cells present are found filled, with fatty granules of various sizes, and many of them are in a state of partial dis- integration. The deepest layers of the bladder are composed of columnar cells which are rarely found in the urine, save in ulcerative processes, in tumors, and in cases of intense inflammation. (e) Epithelia from the Ejaculatory Ducts and the Seminal Vesi- cles. — Epithelia from the ejaculatory ducts are elongated cylindrical and cili- ated, though the cilia may be broken off. These cells are easily recognized by their shape. Epithelia from the seminal vesicles are colunniar, nouciliated, and some- times contain a yellow pigment. They are rather larger, broader and less ri'gular than the epithelia from the ejaculatory ducts. Epithelia from the ejaculatorv ducts and from the seminal vesicles occur in the urine in cases of seminal vesiculitis, and vesiculo-prostatitis. They are often associated with pus cells, urethral cells and prostatic cells. 104 THE URINE (/) Prostatic EriTiiELiA. — There are two types of epithelia from the prostate. The ducts of the gland are lined with columnar, tlie acini with cu- hoidal cells. The cuboidal epithelia are twice the size of pus cells, and are identical with the epithelia from the ureter. Prostatic epithelia, however, do not occur in association with renal and pelvic cells. They are apt to be asso- ciated with pus, with spermatozoa and amyloid bodies from the prostate. (g) Epithelia fkom the Urethka. — The stratified lining of the urethra is represented in the urine by cells of a great variety of shapes. The super- ficial cells are present in the milder grades of inflammation and are squamous or cuboidal. They are always smaller than the bladder cells and larger than any other cells from the tract. The deeper layers of the urethra, with their smaller cylindrical cells, are less frequently represented, appearing in the deeiDer and more chronic processes. In such cases they show numerous fat granules and are often fragmented. (^h) Epithelia from the Vagina. — The largest cells in the urine come from the vagina. Usually the superficial squamous cells are represented ; in fact, they are present in the urine of most women in health. In vaginitis, they are increased in number, accompanied by bacteria, mucus and pus. These cells may be found wrinkled or folded and show fine granules or fat globules. The cuboidal epithelia from the middle strata of the vagina are found in severe, especially in chronic, vaginitis ; and may contain fat granules. The col- umnar epithelia from the deepest layers are seen only in very extensive ulcera- tions. All vaginal cells are larger than those of the corresj)onding layers of the bladder. (i) Epithelia from the Uterus. — These do not often occur in the urine. They cannot be differentiated from urethral epithelia. The mucosa of the uterus itself sheds cylindrical ciliated epithelia, the- presence of which indicates endometritis. 4. Urinary Casts. — Three views are held as to the fonnation of casts: (1) That they are the result of the disintegTation of the epithelium of the renal tubes, the resulting products being packed into molds by the pressure of the urine and at last forced out. (2) That they consist of a morbid secretion from the renal epithelium similarly caked into molds. (3) That they are formed from the coagulable elements of the blood (serum) albumin which gain access to the renal tubes through pathological lesions of the latter, and that any de- tached portions of the tubules become entangled in this coagulable product, assisting to form the mold which afterwards appears in the urine. This latter view is the one most generally accepted. Casts may be conveniently divided for purj^oses of study, into ten kinds, viz. : (a) Hyaline casts, whose origin and nature are still a matter of discussion, appearing as narrow hyaline, broad hyaline and composite casts. MICROSCOPICAL EXAMINATION 105 (h) Granular casts, iiiadc iij) oi' a hyaline basis, (*<»ii1;iiiiiiia,' lirainilcs of dis- iiitcg-rated leucocytes, and red and epithelial cells. (c) Epithelial casts, made of unchanged anatomical elements, including red blood cor})uscles, leucocytes, eiDithelial cells, or hactcria. ((I) ]jlood casts. {h) Amyloid casts, ((') Pus casts. (i) Mixed casts. (/') Fatty casts. (j) Cylindroids. {(j) Waxy casts. (a) Hyai-ine Casts (Fig. 104). — These are the pale structures of variable but usually considerable length, sometimes very difficult to detect in the sedi- ment. Sometimes they are transparent and free from granules; more fre- quently they present fine granulations of a very light color. They may also have a few drops of fat or fragments of epithelium adhering to the surface. The origin of the hyaline cast has been variously explained as a result of secre- tion from the epithelia of the kidney, or as a coagulation of the albumin or its derivatives excreted with the urine. In support of the latter view it is stated that they are found only when the urine is albuminous, or has lately been so. The occurrence of albumin and casts may not be simultaneous. It is a mistake to regard the presence of very small narrow hyaline casts as of no great importance, as is sometimes done, for they are often the chief urinary sign of the existence of a very grave disease of the kidneys, namely, chronic interstitial nephritis in which the albuminuria may be slight or absent. Fig. 105. — Granular Casts. (Ogden.) Fig. 104. — Hyaline Casts. , , i i x a, granular cast. c, coarsely granular cast. b, finely granular cast. d, brown granular cast. (7; ) GkAXULAU Casts ( Fi"". ^' granular cast with normal and aianormal blood adherent. „ ' ^ f, granular cast with renal cells adherent. JO.) ). 1 Ins lorm 01 casts, g^ granular cast with fat and a fatty renal cell adherent. resulting from the metamor- phosis of anatomical elements, such as epithelium, pus, or blood, is found in the urine in great variety. The casts vary much in shape and appearance and are most often seen in fragments. They are irregular, in both fine and coarse outline, with ragged ends, the granules varying from those which 106 THE URINE require the highest powers to discover to a relatively coarse size which gives it8 name to the cast. They are of various colors — yellow, gray, or brown — and may have scattered over their surfaces epithelium, leucocytes, fat globules, or fatty crystals. Granular casts have generally been regarded as evidence of pathological changes in the kidney of a chronic degenerative nature. (c) Epithelial Casts (Fig. 106). — This form is due to patliological con- ditions wdiich cause the exfoliation of the renal epithelium. At times this is thrown off intact for short distances, resulting in cylinders with lumens ; or the cast may be solid, the body being hyaline and the epithelia adherent to it. The cells when seen imder the microscope appear more or less swollen and gTan- ular, with ill-defined margins. Sometimes the epithelial cells appear as rows or patches scattered over the surface of the cast. In other cases the epithelia have undergone degeneration and present dots of fat, significant of chronic inflammation of the kidney and consequent fatty change. Finally, some casts consist of epithelial cells alone, glued together. Casts of epithelial variety are usually of medium size and length, refracting light to a marked degree and therefore easy to find with the microscope. They resist the action of chemical reagents more than most varieties. Epithelial casts always signify inflamma- tion of the kidney and are therefore of gTeat diagnostic worth. Fig. 107. — Blood Casts, Composed Wholly of Red or W'hite Corpuscles or Hyaline Sub- stance Covered with Blood Corpuscles. Fig. 106. — Epithelial Casts. (d) Blood Casts (Fig. 107). — Blood casts appear in the urine under conditions which cause hemorrhage in the renal tubules. The corpuscles may be well preserved and glued to- gether to form perfect molds of the renal tubes, usually short and of uniform diameter with rounded ends. These casts are found in nephritis, especially acute, in hemorrhages, acute renal congestion and hemorrhagic infarction of the kidney. They do not in themselves furnish positive proof of organic renal disease, but, on the other hand, blood casts are positive evidence of renal hemorrhage. These casts are among the rarer kinds and are usually hard to find, since a large sediment of blood corpuscles is apt to accompany them and obscure the microscopic field. MICKOSCOPICAL EXAMINATION 107 (e) Pus Casts (Fig. 108). — Casts composed altogether of pus are very rare. Compound casts, however, may present a few corpuscles here and there Fig. 108.— Pus Casts. Fig. 109. — Fatty and Other Casts. (Ogden.) 1, epithelial cast. S, pus cast. 2, blood cast. 4> fatty cast. 5, fatty cast with compound granules and fatty renal cells adherent (crystals of the fatty acid protruding) . on their surface. They signify puru- lent intlammation in the kidney itself — i. e., pyonephritis or pyonephrosis. Bacteria are present in pus casts. (/) Fatty Casts (Fig. 109). — Oil globules are often found adherent to many varieties of casts, whereas others are frequently seen which seem wholly made up of fatty material, including crystals of the fat- ty acids. These fatty acids indicate fatty changes in the kidneys and are found in their most typical form in the large white kidney. They suggest pathological states of the kidney whose chief feature is chronicity, since they are the result of complete destruction of the cell protoplasm, which is re- placed by fatty elements. (fj) Waxy Casts (Fig. 210). — Waxy casts reseni- l)lo somewhat hyaline easts. Tliey are more refractive, and are yellow or grayish- 3'ellow in color and differ fnrthermore in presenting a cloudy appearance. Unlike hyaline casts, they are not attacked by acetic acid. Tliongh they resemble amy- FiG. 110. — Types of Casts with a Waxy Matrix from a Case of Subacute Parenchymatous Nephritis. ("Wood ) Some of the casts are quite transparent, others are granular at one end and clear at the other. Some are composed partly of granular matter and partly of waxy material. The casts vary greatly in .size, but are all drawn to the same scale. One very small cast in the center is of the hyaline variety. 108 THE ITRINE loid casts in appearance, yet their presence does not indicate amyloid disease of the kidney. It is possible that they were originally hyaline casts which have remained in the nriniferons tubules for a long time and have there undergone certain chemical changes analogous to " amyloid metamorphosis." (h) Amyloib Casts. — Amyloid casts resemble in appearance waxy casts. They can be differentiated, however, by the addition of dilute iodopotassic iodid solution (Lugol's solution), when they assume a mahogany color which changes to a dirty violet uj^on the addition of dilute sulphuric acid. Waxy casts do not give this reaction. The presence of amyloid casts is indicative of amyloid degeneration of the kidney. (i) Mixed Casts (Fig. 110). — The various kinds of casts are sometimes found in the same specimen, depending on the stage of pathological process in the kidney. (_/") Cylindroids (Fig. 111). — In addition to the varieties of casts men- tioned, the urine may contain what are called cylindroids. These are long, wavy, ribbonlike structures, Avhich often divide and sub- divide at their ends. The ends may be folded or twisted. They are pale, colorless and of greater length than casts, and seldom have cells adher- ent to them. They appear flat and do not give the im- pression of being solid struc- tures like the true renal casts. It seems probable, however, that these cylindroids come from the renal tubules. They occur in nephritis, cystitis and in renal congestion, and may be present in urine which contains no albiunin. They are not characteristic of kid- ney disease, but rather of irritations of the lower urinary tract, Avhich have extended to the kidney. Fig. 111. — Cylindroids or False Casts. (After Peyer.) ISToTE. — To find casts Avith the least delay, the urine should be voided freshly, immediately centrifuged for three minutes, and four to six drops of the sediment taken up with the pipette and placed on a perfectly clean slide, a cover glass laid on, the excess urine removed by blotting paper, and the speci- men examined with a quarter-inch objective in not too bright a light. Fly aline MICROSCOPICAL EXAMINATION 109 casts may be overlooked, but wlien the focus has been carefully adjusted, if the field be darkened gradually till perhaps one third of the illumination is cut off, and the slide be moved slowly about, the contents of the field arc viewed in different liiihts and the outlines or shadows of the hyaline casts may be de- tected. If doubt exists as to the nature of a cast, slight pressure on the cover glass will cause currents under it and cause the cast to turn. 5. Shreds. — Under the Microscopical Examination of Sediment, something should be said of shreds voided with the urine in an acute or chronic process of the genito-urinary tract. If they are derived from destructive processes in the bladder, prostate, or the kidney, they contain connective tissue. Shreds not due to destructive lesions are the result of subacute or chronic urethritis, prostatitis, pyelitis, or cystitis. Several varieties of shreds may be distinguished: (1) Pus shreds, (2) mucous shreds, (3) muco-pus, and (4) epithelial shreds. The characteristics of these four varieties are sufficiently well marked to be readily recognized by the microscope. Examination of Sheeds. — They are carefully removed from the urine with a platinum loop and spread upon a slide with a few drops of water, teased apart with a needle if they are thick, and a cover glass placed over the speci- men, after which their composition can be determined. Eor a bacteriological examination, the shreds can be stained like tissue sections. For this purpose the following method can be employed. 1. Fix with alcohol and ether for ten minutes. 2. Stain for one or two minutes with Unna's polychrome methylene blue. 3. Wash in distilled water. Dry. 4. Dehydrate for a few seconds in ninety-fivc^per-cent alcohol. Dry with filter paper. 5. Clear in xylol or in clove-thyme mixture. 6. Mount in balsam. Massage Pkoducts in the Urine. — After massage of the prostate and vesicles, certain products may be voided with the urine and these should, there- fore, be mentioned under Examination of Sediment. In chronic inflammations and infections of the prostate and vesicles, the urine contains many pus cells and red blood cells, together with shreds. In seminal vesiculitis after massage, large masses of the secretion of the seminal vesicles, together with inflammatory detritus, are thrown off, looking like meal in the water, and sometimes like a thick white lump. These are often so large and thick as to block the urethra for an instant. In addition to these elements, the urine, after massage of the prostate and vesicles, very frequently contains other products, the significance and pathology of which are not quite so clear. 1 call them tapioca, sugar granules, skin flakes, and snowflakes. 110 THE URINE ' *S'a\ germs transmitted from the normal urethra does not occur in man, owing t(^ the fact that the vesical sphinc- ter shuts off the bladder from the urethra. On the otlier hand, in women, hhid- der infection may occur through the healthy urethra. In addition to an infection from the urethra upward, the urine may become contaminated also by the entrance of bacteria into tlie kidney through the cir- culation (especially of the tubercle bacillus), and by the passage of bacteria into the bladder through the intestinal wall. The question of a descending infection has been demonstrated both experi- mentally and clinically. It is difficult to understand at first how bacteria can infect the kidney from the bladder when the stream of urine apparently tends to prevent this by opposing the ascent of the germs. Anim'al experiments, however, have shown that under certain conditions, the contents of the bladder regurgitate into the pelvis of the kidney. When the germs reach the pelvis, they may enter through the lymphatics of the kidney, less frequently through the urinary tubules, and more rarely through the capillaries of the kidney. The entrance of germs from the blood through the kidneys into the urine has been repeatedly demonstrated. Germs may enter the bladder directly from the intestine in cases in wdiich the bladder is damaged, or from the intestine into the blood and thence into the kidney. The Gonococcus in the Urine. — To avoid repetition, we have grouped all data on the gonococcus in the chapter on the Examination of Urethral Dis- charges. The gonococcus is usually found in the urine in urethritis, sometimes in prostatitis and vesiculitis after massage, and occasionally in cystitis, pyelitis and pyelo-nephritis in ascending infections of gonorrheal origin. The germ is much more difficult to detect in the urine than in smears of discharge. In the urine, it is always accompanied by pus and is to be looked for within the cyto- plasm of the pus cells, or upon the epithelia of the sediment. The methods of obtaining and precipitating the sediment for such examination has been given in the preceding pages. The Tubercle Bacillus. — The tubercle bacillus occurs in the form of a small rod, one quarter to one half as long as the diameter of a red blood corpuscle. The rods are delicate, straight, slightly bent or curved, and somewhat beaded. They occur either singly or in groups, especially in the form of tufts which are commonly found in the urine. At times they are found also within the body of the pus cell. In some specimens, the ends of the rods are somewhat clubbed or branched, or present swellings at different points. In stained preparations, the bacilli show alternation of stained and colorless portions. Method of Staining. — The detection of the tubercle bacillus depends upon its characteristic behavior toward anilin dyes and decolorizing agents. The penetrating power of the dye used must be increased by the addition of PLATE III Fig. 1. Fig. 2. BACTERIA, SHOWING THE OPSONIC ACTION INCREASED BY THE PROPER ADMINISTRATION OF BACTERIAL VACCINES. Fig. 1. — Tubercle Bacilli in Sputum. The tul:)ercle bacilli are stained red with carbol- fuchsin. At A the bacilli are inside the leukocytes, showing phagocytosis, or that the bacteria have been prepared for inges- tion by the opsonins. B shows the bacilli outside the leukocytes not prepared for in- gestion by the opsonins. Fig. 2. — Gonococci in Urethral Pus. The gonococci are stained with methylene blue. At A the cocci are inside the leukocytes, showing phagocytosis, or that the bacteria have been prepared for ingestion by the opsonins. B shows cocci outside the leukocytes not prepared for ingestion by the opsonins. C shows the cocci haAing prob- ably been ingested by the white blood- corpuscles, but the toxins of the gonococci have destroyed the leukocytes. BACTEEIOLOGY OF THE URINE 113 either carbolic acid or anilin oil and by the application of heat. Once stained ill this way, the bacilli resist acids, and npon this depends the differentiation frmii other bacteria in the same specimen. Ziehl-Ncclscn Method. — This is the method in common nse for staining tu- lierele bacilli in the nrine. Tlie sediment is obtained in as concentrated a form as possible, and spread in a thin layer npon a slide or cover glass and allowed to dry in the air. The ])reparation is then fixed in the nsnal way in the flame of a Bunsen bnrner. The s})ecimen is then covered with some filtered Ziehl-iSTeelsen carbol-fuchsin solution (five-per-cent aqneons solution carbolic acid, ninety parts; saturated alcoholic solution of fuchsin, ten parts) and held over the flame of a Bunsen burner, allowing the solution to steam for one or- two minutes without bringing it to the boiling point. The specimen is then washed in a stream of running water and immersed in five-per-cent sulphuric or thirty-per-cent nitric acid. The film turns yellow or brown, but, on washing again in water, the red color reappears. The operation is then repeated until only a very faint tinge is left and no more of the stain is given off. The specimen is now washed for from ten to fifteen minutes in strong (ninety-five per cent) alcohol, folloAved by rins- ing in water. In staining a urine specimen, the use of alcohol is an important step as a means for excluding the smegma bacillus, which is decolorized by alcohol. The specimen is now covered with a weak, watery solution of methy- lene blue, which is allowed to remain for from one to two minutes. After wash- ing and drying, the specimen is ready for examination with an immersion lens. Differentiation. — The tubercle bacillus may be confounded morphologic- ally with two different germs : the smegma bacillus and the leprosy bacillus. The smegma bacillus is most often confounded with the tubercle bacillus. It occurs in the decomposing secretion around the genitals. In obtaining speci- mens of urine for examination for tubercle bacilli, care must be taken, first, to wash the external genitals with soap and hot water, so as to remove any smegma germs, and then to draw off the urine with a sterilized catheter. If, in addi- tion to these precautions, the specimens are washed in alcohol after decolorizing, as previously mentioned, there is very little danger of error in the microscopical diagnosis. The lepra hacillus resembles the tubercle bacillus both in shape and stain- ing properties, but is somewhat shorter, thicker, and stains unevenly. It oc- curs, however, so rarely, that its differentiation from the tubercle bacillus need not be discussed here. Animal Inoculation. — In case of doubt as to the nature of the bacillus and in instances in which repeated examinations of urinary sediments do not show any tubercle bacilli, although clinically tuberculosis is suspected, recourse may lie had to inoculation of animals and to cultures on artificial media. The ma- terial should be introduced subcutaneously or into the peritoneum, the former 114 THE URINE method taking from four to ten weeks, the latter from ten to twenty days for tnbereular lesions to develop when tubercle bacilli are present. If smegma bacilli only are present, no lesions develop. At tlie end of the time stated, an antopsy is performed upon the animal, and the site of puncture, the peritoneum, the lungs, and other organs are examined for tubercles. The Colon Bacillus. — The colon bacillus occurs normally in the intestine of man, bovines, dogs, and other domestic animals. Its close resemblance to the typhoid bacillus makes it an object of interest. Certain features, however, distinguish it from the typhoid bacillus, and it is regarded as a distinct species of germ. The colon bacillus may under favorable conditions produce serious disease. It is the cause of local suppuration in a gTeat variety of organs, and also produces at times general septic infection. The colon bacillus plays an important role in urinary affections, as it is one of the chief germs concerned in the causation of cystitis, and is found also in the urine and the purulent sediment in cases of infection of the kidney, the pelvis, and ureter. MoKPHOLOGY. — The colon bacillus occurs in the form of rods, with rounded ends, which may vary in two directions : they may be either so short as to ap- pear almost like cocci or so long as to resemble threads. ISTo spores have been demonstrated, but flagella may be shown by Loeffler's method. It is motile in most cases, but often its movements are very slow. Staining Properties. — It stains with ordinary anilin dyes and is decolor- ized by Gram's method. Streptococcus Pyogenes. — The Streptococcus pyogenes is the cause of local inflammatory and suppurative processes and of general infections such as sep- ticemia. In the urinary tract it is found in inflammatory conditions of the urethra, bladder, kidney, pelvis, and ureter, either alone or more generally in comjjany with other germs of suppuration, as the tubercle bacillus, with which it is very frequently associated. The Streptococcus pyogenes occurs in the form of chains of minute round or oval cocci resembling strands of beads. Sometimes two or more cells in the chains coalesce to form a somewhat longer segment. The chains may be short, consisting of a few cells, or very long. Sometimes the cocci composing a chain divide simultaneously, so that a chain of diplococci may be seen. The strepto- coccus stains easily with anilin dyes and usually stains with Gram's method. Staphylococcus Pyogenes Aureus. — The Staphylococcus aureus is the most common of the germs of suppuration. It occurs in abundance everywhere, and is the usual cause of wound infection. It is present in the normal as well as the diseased urethra, is frequently found in the bladder in cystitis, and plays a prominent part in infections of the kidney, either alone or accompanying other germs, as the colon bacillus, the streptococcus, etc. In tuberculosis of the urinary tract, it is often present as a complicatory organism, along with other germs of suppuration. BACTERIOLOCiY OV TITE URTNE 115 Tt oocurs in the form of round or oval cocci arranged typically in clusters, Itiit often in pairs. In preparations from pns, they are found outside the pus cells, rarely within these bodies. It stains readily with the basic anilin dyes and is not decolorized by Gram's method. Staphylococcus Pyogenes Albus. — Microscopically, this variety cannot be (lilfcrcutiated from the Stapliylococcns pyogenes aureus. The difference be- tween the two lies in the appearance of the cultures. The occurrence and sig- uilieance of the two varieties are very similar. Bacillus Proteus Vulgaris. — The Bacillns proteus frequently occurs in cys- titis. It occurs as short and long bacilli, and also in the form of threads. It is markedly motile and shows numerous flagella. It stains well wdth basic iiiiilin dyes and is not decolorized by Gram's method. It forms grayish-white, minute colonies upon agar, which later coalesce into a dirty-gray translucent tihii. On gelatin it gi'ows in the form of grayish-white colonies and liquefies the medium rapidly. The proteus is frequently found in suppurative conditions in the urinary tract, especially in cystitis. Experimental cystitis has been produced by in- jecting cultures into the bladder in animals. Bacillus Pyocyaneus. — The Bacillus pyocyaneus, or bacillus of green pus, is mentioned here as a germ occasionally found in cystitis. It is found in fetid pus from wounds. It is a delicate rod with rounded or pointed ends, actively motile and does not form spores. It occurs in irregular masses or singly ; grows on all the ordinary media, giving a characteristic green color to tlie same, which becomes blackish in old cultures. The bacillus stains with the ordinary anilin dyes. Other Microorganisms of Minor Importance. — The rays or granules of Actinomyces may be found in the urine wdien this infection affects the genito- urinary tract or when this fungus is present in the system and finds its way into the urine. The Micrococcus urece is the germ which occurs in long chains consisting of large cocci. It occurs in urines undergoing ammoniacal fermentation and de- composes urea into ammonia. Yeast cells and molds of various kinds are very often found in the urine, entering either from the air or as a result of contamination from the vessels in which the urine is collected. Methods of Examining the Ukine for Bactekia Specimens of urine which are to be examined bacteriologically should be obtained from the bladder by means of a sterile catheter (introduced after copi- ous washing of the urethra wntli boric-acid solution), collected in a sterilized bottle, and handled thereafter only with sterile apparatus. Before introducing 116 THE URINE tlie catheter, the external genitals in either sex should be thoroughly cleansed Avith soai5 and hot water and tlie smegma removed from the neighborhood of the orifice of the uretliia. 'Ilie urine should be examined, as a rule, as soon as obtained, especially "when looking for tubercle bacilli, so as to prevent decompo- sition and multij^lication of extraneous germs. Centrifugation is a rapid and most satisfactory method of obtaining bac- terial sediments. The centrifuge sediment is drawn u\> liy a slender pipette, and spread on slides and allowed to dry. The spread preparations are then fixed by immersing in alcohol and ether, equal parts, or by passing slowly through the Bunsen flame. Care must be taken always to spread the film very thinly. The successful fixation of the sediment depends upon the presence of a certain amount of pus containing coagulable proteid substances. AVhen these are absent in the urinary sediment, as sometimes is the case, fixation on the slide is not easily aceomplislied without tlie addition of egg-albumen. The sediment is taken up with a platinum loop and spread upon a slide, upon which a drop of a mixture of egg-albumen and glycerin has previously been placed, and then fixed as already described. Shreds from the urethra, clumps of fibrin, masses of epithelium and other tissue elements which may be found in the urine, may be examined for bacteria after being fished out with a platinum loop and spread on the slide and stained. They are fixed and stained in the same manner as the other smears from the urinary sediment, but especial care should be taken to spread them very thinly by means of a platinum needle. It is difficult to detect germs in these shreds of tissue under the best conditions. When the bacteria looked for are absent from the sediment on microscopical examination of stained preparations, cultures and inoculations into animals may be resorted to — methods to be employed when the importance of the diag- nosis requires them. The details of cultivation and animal inoculation are given under the headings of the respective germs. CHAPTER IV DISCHARGES Under tins heading wo shall consider the character of all discharges frEt.N BY Goldhorn Stain. SYPHILITIC URETHKITIS 123 METHODS OK STAININO THE SI'IKOCII KTA J'ALLIDA I. Goldhorns Method: Goldhorn's S]3irocheta Stain is used. 1. Cover unfixed preparation Avitli dve. (The Goldlidrn Spiroclieta Stain.) 2. Pour off excess of dye in three or four seconds and immediately plunge the whole slide gently face downward into water to pi-e- vent precipitation of the stain. 3. Hold in water for three to four seconds and wash. 4. Dry. (Do not let the slide lie flat while drying, but stand it up or shake in the air.) 5. The specimen is then mounted by dropping on a drop of Canada bal- sam and placing a cover glass over it. It is examined microscopic- ally with a tV oil-immersion lens. II. Giemsas Method: 1. Clean a test-tnbe by boiling in soda solution, after which wash thor- onghly and dry. 2. Put thirteen drops of Giemsa's Solution II in the test-tube and add 10 c.c. of a 0.5-per-cent solution of chemically pure glycerin in distilled water. 3. Warm this solution in flame. 4. Cover fixed preparation with stain, and after five minutes pour off and cover again with fresh solution ; after five minutes wash, dry and mount, and examine with V3- oil-innnersion lens. The reflecting condenser under dark-ground illumination offers a rajiid and accurate method for the observation of the living spirocheta. This ap- paratus (Fig. 120) can be attached to the stage of any microscope and held in position by the ordinary clips. The condenser is pro- vitled with two reflecting surfaces, as shown iii Fig. 121 on next page. The jiarallel rays of light com- ing from below (that is, from the plane mirror of the microscope), are almost completely united in one point " P." An intense ilhnnination of the spirocheta and other organ- Fig. 120.— Reflecting Conde.n^eu. 124 DISCHARGES isms is thus obtained. The light diffused by the bacteria, as represented by dotted lines, enters the objective and thus produces an image of the bacteria. The best source of light for dark-ground illumination is furnished by a small arc light (Fig. 122). But whore this is not available, a Xernst lamp or an in- candescent gas lamp may be used, in which case, it is necessary to employ a bull's-eye lens on a stand, so placed that it is betAveen the source of light and the reflecting mirror of the microscope ; the distance between the light and the lens should be 17 em. and between the lens and mirror reflector of the micro- scope 40 cm. Fig. 121. — Reflecting Condenser. Q, glass slide with cover glass. a, b, reflected raj's meeting at P. C, condenser apparatus. O, objective. P, point of concentration of the rays. Fig. 122. — Electrical Arc Lamp with Hand Feed FOR A Current of 4 Amperes and an Illumi- nating Lens Mounted on a Stand. The specimen to be examined is taken on a slide, but the serum is not al- lowed to dry; a drop of distilled water is added to it and a cover glass placed over it, and the specimen is examined in the wet state. The slide is now placed on the condenser and, the source of light having been adjusted, it is then ex- amined either with a dry or an oil-immersion lens. The object slide and cover glass must be thoroughly clean, as dust particles interfere with the observation ; the preparation itself should be very thin and the specimens must not contain any air bubbles. Chancroidal Urethritis. — This is the result of infection of the meatus by chancroidal virus and an extension of a few millimeters do^m the canal. The discharge is moderately profuse in amount and muco-purulent or muco-san- guinolent or puro-sanguinolent in character. Microscopically, mucus, epi- thelium, pus cells, pus-producing organisms. Bacillus of Ducrey and sometimes blood are found. The infective agent in chancroid is the Bacillus of Ducrey. The Bacillus of Ducrey is a short, thick bacillus with rounded ends, some- what like a dumb-bell. It is about 1-J micromillimeters in length. It is found both within the cells and between them. CHEONIC GONOCOCCAL URETHRITIS 125 The specimen is taken on a slide and prepared in the usual way, and then stained for one half hour in the following solution : Sol. acid horic five per cent oSS ; Sat. sol. methvlene-hlue acpieous .Iv ; 1 )istillc(l water .Ivj. Tt is sometimes very difficult to demonstrate the Ijacillus in stained speci- mens, owing to the extremely small number compared to the enormous numbers of other bacteria present. Acute Gonococcal or Specific Urethritis. — This condition is the most fre- (pu'ut cause of urethral discharge. The constituents of the discharge are mucus, epithelial cells, pns cells and diplococci, which are the infective agents called gonococci. Other germs existing normally in the urethra or complicating the original infection may be present. At the onset of the disease, the discharge is mucoid or muco-purulent, ap- ])caring as a slight moisture or a drop at the meatus when the gonococcal in- vasion has as yet not penetrated farther than the fossa navicularis. If very acute or moderately acute, the discharge becomes more abundant, i:)urulent or muco-sanguinolent, and the gonococcus is found in the discharge. The char- acteristic discharge of acute urethritis contains but very few epithelia as com- pared to the enormous number of pus cells present. As the acute infection licgins to subside and as a proliferation of epithelia goes on in the process of healing, the number of epithelial cells in the discharge gTOws larger, while the relative number of pus cells is less. Thus we are able to gauge with fair ac- curacy by the microscopical examinations, the acuteness of the urethritis, by the number of epithelia as compared with the number of pus cells. An excep- tion must be noted, however, during the first few hours of an acute attack when the discharge is mucoid and when there are more epithelia than pus cells, the e]utlielia coming largely from the anterior region of the canal, that is, of tlie large, flat tj'pe, irregular or polygonal in shape. Gonococci are present until the discharge has ceased or is a simple moisture. Chronic Gonococcal Urethritis. — The discharge of chronic urethritis differs from tliat of the acute conditions in that it is scanty, mucoid or muco-purulent, sometimes absent during the day, but present in the morning. It contains mu- cus, uretliral epithelia, especially many squamous cells and usiuilly but a small auiount of pus. Gonococci are usually, but not always, found. Gonococci are coffee-bean-shaped micrococci, grouped in pairs, the flattened surfaces facing each other. For this reason the gonococcus is generally spoken of as di])lococcus. It is usually found in the pus cells, that is. intra-eellular, occupying the ju'otoplasm, but never penetrating the nuclei. It stains deeply with anilin dyes and can readily be distinguished upon the paler background 126 DTSCIIAKGES of the pus cells or epitlielia. Examined under high magnifications, the longi- tudinal slit between the two cocci constituting the pair, can be very distinctly nuide out. The gonococcus varies somewhat in size, the average being 1.25 microns in length and from O.G to 0.8 microns in diameter. The well-developed and full- sized germ is found in acute conditions, while in some chronic cases, the smaller form may sometimes be seen, showing possibly an attenuated state. A variety of sizes may be noted in some pure cultures. The pairs of cocci are grouped usually in small masses; occasionally, how- ever, a cell will contain but a few pairs. In acute urethritis, on the other hand, when the process is virulent, numerous pus cells will be found so closely packed with gonococci, that the cell protoplasm is entirely masked. Often, also, the gonococci are found grouped about the nuclei of a cell, but the cell body seems to be absent, because it is either very faintly stained or has been obliterated in the course of the inflammatory process. When epithelial cells occur in the urethral discharge, the gonococci are often grouped about them or seem to lie upon the cells or within them. The intra-cellular position of the gonococcus in the pus cells, however, is so characteristic, that its recog-nition is made a condi- tion for the morphological diagiiosis of this germ. The important part of the examination of the discharge in gonococcal in- fection is naturally for the gonococcus. The number of gonococci found in a specimen of gonorrheal pus varies gTeatly, according to the stage of the disease and the virulence of the infection. There is also a variation in the number of gonococci found within the pus cells in different stages of the inflammation. They are most numerous in the creamy discharge. A large number of other cocci and bacilli are also found in some cases of gonorrheal urethritis (secondary infection). It is said that when these are present, complications are more apt to occur. In chronic cases accompanied by very little mucoid discharge and by some shreds in the urine, it is difficult and sometimes impossible to detect gonococci either in the discharge emitted in the morning (morning drop), in the shreds or in the urine. In cases of relapse or of exacerbations of a chronic gonorrhea, the gonococci reappear, although occasionally they are not found. Methods of Staixixg ajs^d Examixatiox. — The first step in this exam- ination is the fixation of the smear upon the slide by means of heat. This is done by taking the slide between the thumb and forefinger and passing it slowly, smear side up, three times through the flames of an alcohol lamp. The next step is to stain the smear with one of the anilin dyes, which suffices in routine work. In case of doubt as to the identity of the germ, it can be determined by Gram's stain. It is advisable, in important cases, to take several smears, so as to have material for confirmatory examinations. CHRONIC PROSTATITIS 127 The gonococciis stains readily with the basic anilin dyes, but loses its color when treated with Gram's method — in other words, it is Gram-negative. 1. Methylene Bine.- — A great variety of staining methods have been nsed for staining the gonococcns. The simplest method, which at the same time is perfectly satisfactory for ordinary clinical work, is with a dilute solution of methylene bine, which is dropped npon the smear by a medicine dropper in sufficient quantity to cover the slide and allowed to remain for five minutes ; it is then washed thoroughly with distilled water. Such is the differentiating action of this basic dye, that the nuclei of the cells are stained a pale blue, while the cell bodies are stained a still paler tint, forming a background against which the gonococci appear distinctly. If the preparation has been carefully and thinly spread, if the light and the optical conditions are perfect, the morpliology of the germ appears sharply defined with this method of staining. (The for- mula for the methylene-blue solution is a matter of individual choice.) 2. Grams Differential Method. — The most important method of differen- tiating the gonococcns from other germs which resemble it, and which may occur in urethral discharges, is the method of Gram, to which reference has al- ready been made above. This method consists in treating the smears with a staining solution known as ^^ anilin water gentian violet." The anilin water is dropped on the fixed smear in the same way as the methylene blue and allowed to remain five minutes. It is then transferred to Gram's solution (composed of 1 gram of iodin, 2 grams of potassium iodid, and 300 c.c. distilled water), in which it remains for about two minutes. It is next rinsed thoroughly in absolute alcohol until no trace of violet can be seen. If tliere is still some violet color, the iodin solution is again used, followed by rinsing in alcohol, and this is repeated until no trace of violet is visible. The specimen is next washed in water, and then counterstained for about two min- utes in a solution of 1 part of Bismarck brown, 10 parts of alcohol and 100 parts of distilled water. The specimens are then dried and examined with the oil-immersion lens. The characteristic feature of the gonococcns in specimens thus stained is that it loses its color when treated with the decolorizing solution of Gram, and takes the brown counter stain. The other bacteria in the preparation, including other diplococci, which may resemble the gonococcns, retain the purple color of the gentian violet. Gram's method is, therefore, useful in the diagnosis of the gonococcns in smears. It should be employed whenever there is any doubt as to the identity of a diplococcus found in urethral discharges, especially in medico-legal in- vestigation. Chronic Prostatitis. — Chronic prostatitis is an inflammation of the jiros- tate usually following gonorrhea or some other urethral infection. The dis- charge is generally seen in the morning, having passed the cut-off muscle dur- 128 DISCHARGES a CO «i > c 11 1 1 I I .3 .« G m ' 1 1 1 c 'r; r^ ^0 C O X JD _j_; . C 1 I K 1 1 :0 1- M '^ Ph Is •+^ >.g I o >," I 1 1 1^ 1 1 1^ rt 1 1 1 Ph '^ a ■ a; a C 7: o o ^ N o ^ "S a ' o G ' 1 1 o > 3 a o fa ^ 1 1 . ^ 72 • ^ 01 o o o 3 o o G O 1 - ^ S -f c3 ■cfi o O r-C^ ■T. aj CO cc 72 72 7; 3 ^ 23 3 3 3 o o 3 3 ^ ^ 3 3 § ^ § § 1 S 1 i I J, »j P ^ ^ _a; CO o o >> 5R 72 5 ^ 71 a o 11 o 3 S SS-3 ^ fajl O 73 72 c-3 a 3 ^ s "5 -^ c ■p. u ^ II _; £3 '' M "0 pHpHoiU C ^^ :2 ^ j.'--^ 3 c P tC (u •-r^ d ^"3 ■>• -s rs H "3 ^ ■; "2 S 3 1 rt o S ^.2S 3 •- u -3 3 3 ^ H--3 ? X 'f -i ^• <^ a H a .u • -v* " CO < i2 00 Hl^ )-u fa 1-1 c; K d " H Jr H P H rr» tj M o r^ 5 H « C - 3 S H 04 e- 3 /v> 2 " ? cc H Z a a c a ^5 D ^ DISCHARGES 129 CO , ? Ol 03 -1-^ a -^i OJ fl 11 1 1 1 o O o3 <^s .« -t^ u—i 3 X a 1 1 1 73 1 Ph TS . ^ 3 '3 o 1 1 1 0; 1 (1< • rt i. d o . S . o o 1 1 1 IS 1h a p^-^ Ul 02 1^ >> o c QJ (H e3 .2 C3 «*- 3 2 O 'o o o o o o o c 3 -^ 1| 3 -^ pq 13 ^< " fl r;3 oj 3 H CG O o O o o O ^ ■ »i tc m c^ 3 3 :=! 3 3 o « o o o 3 3 3 3 3 <. S § S § s O ^ .^§L in OQ ^ +D >..- c3 1 CC "Tj ^ tn cc tc 3 3 o a 3 3 3 a o PU Pm PL, O § -3 . s 3 . "^"^S 1^11 5. 3 c O ^1 ^3 rf •5 02 O " ^§^^ 2| £ S g w P >, (-i o o § ? ^ ^ iP p>£ i_H c c^ o 3 2SS e3 O 1^ t! B CUPh&h CO O ^fi. ij « . J . as g g cc O O £i W H w g O p w ii " ^ -, £ « ?5 « s s ^§p S 3 us 130 DISCHAKGES ing morning erections, as in prostatorrliea. The discharge is similar to that of prostatorrhea, plus pus and infection. It is scanty and viscid, and con- tains prostatic and urethral epithelia, leucocytes (pus), mucus, few or no sjicrmatozoa, amyloid Ixxlies and Bijttcher's crystals, gonococci or other bacteria. Chronic Vesiculitis. — Chronic vesiculitis is an inflammation of the seminal vesicles, due to gonorrheal or other infection. The discharge is scanty and viscid, and resembles that of spermatorrhea. It contains urethral, vesicular and frequently prostatic epithelia, pus corpuscles, mucous and colloid material, gono- cocci or other microorganisms, usually many spermatozoa, well developed and in different stages of disintegration. The condition is characterized by the dis- charge oozing out in nocturnal erections, the same as in prostatitis. DISCHARGES IN THE FEMALE In men the discharges come from the meatus, as the urogenital canal com- mences in the prostatic urethra, where the secretions of the prostate and those coming from the ejaculatory ducts first meet the urinary flow. From here to the external meatus, the genital and urinary tract are in common. In women, the urinary and genital tracts first meet at the vulva and therefore the dis- charges from the urinary and genital tracts would reach this jDoint in case they are sufficiently profuse. A discharge found on the vulva may come from the vulva itself, the urethra, Skene's glands, the glands of Bartholin, the vagina, the cervical or uterine canals or the Fallopian tubes, under the following conditions : jSTonspecific ure- thritis, acute gonococcal urethritis, chronic gonococcal urethritis, gonorrhea of Skene's glands. Bartholinitis, nongonococcal, gonococcal, tubercular, syphilitic and malignant disease of the vagina, chancroids, in endocervicitis or endome- tritis due to nongonococcal or gonococcal infection or to tumors, benign or ma- lignant, tuberculosis or salj)ingitis. A smear should be taken from the vulva by touching it with a glass slide. This smear may, therefore, contain a combination of discharges from various points, consisting of mucus, pus and blood cells, epithelia from the mucous membrane of the vulva, urethra, vagina, glands of Bartholin, uterus and the Fallopian tubes ; also gonococci and various other cocci and bacilli. The vulva should then be wiped with a piece of moist gauze and the dis- charges from the various other contributing jjarts should be taken in the man- ner previously described. Urethral discharges occur in gonococcal and nongonococcal inflammations, just as in the male. The appearance varies from a thin, scanty, transparent or turbid drop to a thick yellow or greenish-yellow discharge. In nonspecific in- flammations, microscopic examination shows mucus, pus cells, urethral epi- DISCHAKGES IN THE FEMALE 131 thelinm and tlie various kinds of cocci and bacilli normally present in the urethra. Blood cells may also be present, but no gonococci. The gonorrheal discharge from the urethra differs only on account of the relatively greater number of pus cells, plus gonococci, both intra- and extra- ('(•Ihilar. In chronic gonococcal urethritis, the discharge is often very scanty or iibscut, in Avliicli case a specimen should be obtained by introducing a plati- num wire into the ui-cthra. Skene's glands should then be pressed upon and any discharge coming from them should be taken. Very often in latent cases these glands harbor gonococci. Discharges due to chancre or chancroid are the same as in the male, and liave to be determined by the presence of the Spirocheta or the Bacillus of Dncrey. Bartholin's glands should next be gently squeezed, and the discharge from their ducts examined. Bartholinitis is due in nearly all cases to gonor- rheal inflammation, and the microscopic examination of the discharge shows mucus, pus cells, columnar epithelium from the gland's duct and gonococci, both intra- and extra-cellular. The discharge coming from the vagina is then examined. This may come from the vagina itself or from the cervix, uterine canal or the Fallopian tubes. 'J'liis discharge is known as leucorrhea, although the gynecologist in whose field it belongs, seems to use the name less than formerly. A speculum is inserted into the vagina and the sides of its walls explored. The vaginal discharge is usually thin and creamy, although in chronic cases, it may be thick and ad- herent. The examination may also show a chancre, chancroid, tuberculosis, cancer or an inflammation due to gonococcal or other infection. Smears or scrapings are taken and the microscoj)ical examination is made as already de- scribed in the first part of the chapter. The cervix is then examined for lacerations or malignancy. If there are no evidences of either of these conditions, but a thick opaque discharge, white or yellow in character, is seen coming from the cervical canal, the patient has an endocervicitis due to a gonococcal or other infection; wdiereas, if it is very liurulent, it probably comes from the tubes. In case it is due to a gonorrheal ])rocess, gonococci are present. If they are not present, it is due to some other infection, and has as a predisposing cause uterine displacement, or subinvolu- tion or new growth. Besides mucus, pus and the germs of infection, the dis- charge from the uterus occasionally contains ciliated epithelia. CHAPTER V THE BLOOD IN RELATION TO UROLOGY Blood examinations are especially useful in differentiating septic or sup- purative conditions from other fevers, as, for example, typhoid or malarial fever. They also give a clew as to the degree of resistance to be expected from an anemic patient before operation ; while blood counts, periodically made after operations, show us the progress of our patients on the road to recovery. The degree of coagulability of the blood, determined before operation, gives us con- fidence to operate in certain cases, while it warns us not to in certain grave conditions of the kidneys or the prostate. In this brief chapter I shall confine myself to those clinical facts which should be known in order to interpret properly the blood examinations fur- nished by the laboratory. Blood comprises a fluid, liquor sanguinis or plasma, in which float certain specialized cellular bodies known as corpuscles. The plasma is a solution of various salts and of proteid materials (fibrinogen, serum albumin, serum globu- lin), and is the fluid medium which acts as a recipient and carrier of metabolic, eliminative and nutritive substances. The Percentage of Hemoglobin. — In healthy men, the percentage of hemo- globin is from eighty-five to ninety-five per cent. In robust persons, it may, however, reach above one hundred per cent. A percentage below eighty-five per cent indicates anemia. The determination of the hemoglobin percentage is a most important feature in blood examinations in both general and urological surgery. All chronic surgical conditions generally produce some secondary anemia, which grows more profound as the case progresses. This is especially so in septic conditions and in malignant growths. In this secondary anemia, the decrease in the hemoglobin percentage is the first change noted in the blood, except in septic conditions, and frequently the hemoglobin is diniinishcMl in disproportion to the comparativel}^ slow or moderate decrease in the blood cells. Corpuscles. — The corpuscular elements of the blood are divided into three classes: (1) The red blood cells, or erythrocytes; (2) the white cells, or leuco- cytes and (3) the blood platelets. Other minute particles of irregular-shaped bodies, kno^vn as blood dust or hemokonia, will not be considered. 132 LEUCOCYTOSIS I33 Blood Count. — The blood count means determininfi:; l)y count the nmn- ber of red and white blood cells contained in a cubic niillinieter of blood. The Red Cells. — 'I'lie normal number of I'ed cells is 5,000,000 to the cubic millimeter of blood in men and 4,500,000 in women. They contain about ninety per cent of oxyhemoglobin and a small amount of nucleo-proteid. Their function is to carry oxygen from the lungs to the tissues in loose combination witli hemoglobin. Leucocytes. — The white cells or leucocytes in fresh blood appear as color- less, highly refractive bodies, containing one or more nuclei, and sometimes granular matter in their cell bodies. They number from 5,000 to 10,000 to the cubic millimeter, an average being Y,500. A differential blood count means an estimation of the percentage of the different wdiite cells, which is of great importance in urological diagnosis. The four varieties of leucocytes found (Ehrlich) are: (1) Small mononuclear leucocytes — lymphocytes, twenty-two to twenty-five per cent. (2) Large mononuclear and transitional leucocytes, two to four per cent. (3) Polynuclear (neutrophile) leucocytes, seventy to seventy-two per cent. (4) Eosinophile (polynuclear or bilobed nuclei) leucocytes, two to four per cent. Blood plaques and blood dust need no mention here, as they are not of in- terest in surgical conditions. Leucocytosis. — When the number of leucocytes is markedly increased, we have a leucocytosis. Simple leucocytosis affects chiefly the polynuclear leuco- cytes and is sometimes styled " polynuclear leucocytosis." When the lympho- cytes (small mononuclear) are increased, the term " lymphocytosis " is used. When the eosinophile cells are increased we speak of " eosinophilia," and when several varieties of leucocytes are increased, we have a " mixed leucocytosis." A physiological leucocytosis may occur in pregnancy, during digestion, after exercise, hot or cold baths, massage or electric treatment. . A moderate leucocytosis means from 10,000 to 15,000 ; a marked leucocy- tosis from 20,000 to 25,000 ; and a very marked one may reach 85,000 or even 90,000. Leucocytosis in disease may be temporary in acute and permanent in chronic conditions. Inflammatory leucocytosis is the infective type. The theory of this is, that, when infectious agents (bacteria, etc.) enter the system, they generate chemical substances which have the property of attracting leucocytes into the blood out of their hiding places in the spleen, the marrow, etc. In addition, however, the influence of germs seems to favor the formation of new leucocytes in the mar- row, spleen and lymphatic glands, and it is from these sources that we have leucocytosis in the blood — emigrated and newd}^ formed leucocytes. 134 THE BLOOD IN RELATION TO UROLOGY Leucocytosis and Infectious Diseases. — The importance of leiicocytosis in an infectious process can be realized when we consider that the leucocytes attack bacteria and eni>-ulf them within their prf)toplasm, where the germs are digested by a special ferment or killed by a bactericidal substance which exists in the white cells. The leucocytes are, therefore, the body's army of defense, sent out to annihilate the enemy, which is the germ, and this process is called 'phagocytosis. Blood serum and lymph also contain bactericidal substances which take part in the fight against the germs and their poisons. A person wdth strong resistance to infection will develop a marked leucocy- tosis when a virulent germ enters the system. A person with poor resistance, on the other hand, will have a slight or no leucocytosis when the same germ enters. In a person with good resistance, even a mild infection will produce moderate leucocytosis. We see at once how leucocytosis may be employed to gauge the constitution of the patient in a septic case before a serious operation. The importance of blood examination is shown in the following diseases, occurring in or with diseases of the urinary tract : Septicemia, Malaria, ] >-r , rr. 1 1 . c^ ^ '^^ C ^^ IcUCOCytOSlS, luberculosis, feyphilis, ) Gonorrheal Infection, Hemorrhage, Peritonitis, Malignant Growths. (a) Septicemia. — In septicemia, patients with a slight resistance to infec- tion have no leucocytosis. The prognosis of those cases is, as a rule, unfavor- able. In most patients, however, there is a distinct pohjnuclear leucocytosis. The prevalence of polynuclear cells in septicemia, in fact in any septic condi- tion, serves to differentiate these affections from typhoid fever, Avhere the whole number of polynuclear leucocytes is diminished, but the lymphocytes are mark- edly increased. When typhoid is complicated by suppurative conditions, this rule does not hold good and a leucocytosis is present. In such cases, one must rely upon the Widal test. (&) Tuberculosis. — In tuberculosis, no inflammatory leucocytosis results unless a mixed infection is present, Avhen a polynuclear leucocytosis occurs. (c) Gonorrheal Infection. — In gonorrheal infection, a moderate leucocy- tosis of the polynuclear type is found, especially in acute gonorrhea when ac- companied by fever and complicated by epididymitis, orchitis, etc. The gouo- coccus can be isolated from the blood in gonorrheal endocarditis and other gonorrheal metastases. (d) Peritonitis. — All forms of peritonitis, except the tuberculous, produce a leucocytosis, unless the patient is very weak. A sudden rise in the number of leucocytes indicates a spread of the process. Chronic cases are associated with increasing anemia. BACTERIA IN THE BLOOD I35 (e) Cachectic Leucocytosis. — In malignant tnmors there is leucocytosis which becomes more marked as the disease advances, and which is due to the local inflammation (that is, nlceration and necrosis) and the chronic toxemia. The blood is nsnally normal in the early stages. A profound anemia with a dis- tinct leucocytosis follows later, due to toxemia. Usually the ratio of the poly- nuclear cells is increased, but occasionally there is an increase in the mononu- clears, or myelocytes may be present. The anemia becomes profound as the cachexia advances. In some cases of sarcoma, there is a marked lymphocytosis, the blood looking like that of lymphatic leukemia. (/) PostJieniorrhagic Leucocytosis. — Great loss of blood is followed by a nuirked increase in the white cells. This leucocytosis rapidly disappears before tlie red cells reach their normal level and is due to the pouring in of the lymph to take the jilace of the lost blood. The Degree of Coagulability. — The degree of coagulability of the blood is of great interest to the surgeon. In urology, it is of special importance in cases of tumor of the bladder and kidney, and also when such operations as prosta- tectomy and nephrectomy are contemplated, where much bleeding and oozing may be expected. Koughly stated, the blood normally clots within five minutes. If the clotting is delayed to ten or fifteen minutes, one may look for a danger- ous oozing or hemorrhage in the patient. A number of conditions, chief among them hemophilia, purpura and jaundice (cholemia), produce a deficient coagu- lal)ility. Wright's coagulometer is an instrument used to measure this physical property of the blood. If the coagulability is found deficient, the usual treat- ment with calcium chlorid, gelatin, etc., may be employed. Bacteria in the Blood. — The discovery of specific bacteria in the blood is not an easy matter, and requires the most rigid aseptic technique and the utmost Avatchfulness and skill in the preparation and use of the various media. But few germs occur in the blood in such numbers that they can be detected in ordinary smears. The principal microorganisms which are found in the blood are : (1) Streptococcus and Stapliylococcus. — In septic conditions, malignant en- docarditis, etc., their presence in the blood always means a bad prognosis, but care must be taken to exclude accidental contamination by the Staphylococcus a] bus always present in the skin. (2) Tubercle Bacilli. — This has been found in the blood in acute miliary tuberculosis and is difficult to detect, but it exists probably oftener than is supposed. (3) Gonococcus. — The gonococcus has been isolated from the blood in a number of cases, principally in maligiiant endocarditis due to gonorrheal in- fection. (4) Bacillus Coli. — The bacillus coli can be often detected in the blood in some form of septicemia in urological cases. 136 THE BLOOD IN RELATION TO UROLOGY (5) Typhoid Bacillus. — Typhoid bacillus is always present in the blood in typhoid fever and is not difficult to detect. An important point to remember is that the absence of a germ from the blood is not to be regarded as a negative diagnostic factor. (6) Protozoa in tlie Blood. — Among these are the Plasmodia malaria^ and the embryos of Filaria sanguinis and the spirilla of European and African re- current fever. . CHAPTER VI UROLOGICAL EQUIPMENT Iisr considering nrological equipment, we will discuss the space that the physician uses for his office work, his office furniture, apparatus, instruments and dressings. In case he has a clinic or hospital service, it should also be taken into consideration. The methods of conducting his private and institu- tional work should also be spoken of. Space Required for Office Work. — In order to do good work in urology, it is not necessary to have an elaborate plant; efficient urological work can be done and is done in a very limited space. This usually consists of one room in which the patients wait, called a re- ception room, and another in which to attend them, called the office, situated TJ OO o V Q D o a n Fig. 123. D n D on the same floor. The office proper, in case it consists of but one room, is a combined consultation and treatment room. Such was my office for many years. (See Fig. 123.) 137 138 UROLOGICAL EQUIPMENT Here it will be seen tliat the waiting room faced the patient on entering, while the office opened into the hall on the left. The office was a large one, hav- ing two windows facing the street, on the opposite side to which were two doors, one opening into the hall, the other into the waiting room. Tlie two re- maining sides of the room with their corners were used for my library and ecpiipment. On the side of the room extending from the hall door to the front, was an open bookcase with hanging curtains on the shelves. In the corner of this, near the adjacent window, was placed my microscope with its accessories. On the opposite side of the room, was the fireplace in the center and a cabi- net with shelves, resembling a bookcase, extending from it to the wall on either side. The space between the fireplace and the window contained everything required in the office for urological work — the examining table, the instrument table and an open cabinet on the shelves of which were all the apparatus, instru- ments and dressings used for the examination and treatment of patients. In a corner corresponding to the space between the fireplace and the reception- room door, was kept my sterilizing and throat apparatus. The fourth corner was unavailable on account of the presence of the hall door. In my one-room office, everything that was used for my microscopical and throat examinations was kept on the shelves of the bookcase or cabinet and just before office hours was placed on the tables in the corners, ready for use ; and they were put away again after office hours. The corner where the examining and instrument tables and the urological apparatus and instruments n rr / Fig. 124. were kept, was hidden by a screen. Within a few minutes, this room was trans- formed from a library into an office and vice versa twice a day. Everything pertaining to my work was kept in this one room and there was no running about, no looking for things that were in some other room. The only disad- APPARATUS AND INSTRUMENTS FOR OFFICE 139 A'niitnii'c of this liniited spaeo was that T conld only do a certain niiionnt of work in the time allotted to otHee hours. In the course of time it became necessary to add more space. The first step AViis to convert the adjoining reception room into a treatment room and to place ill it a similar equipment to that which I already had in my single office be- hind the screen. I took an adjoining room for my patients to wait in, thus mnkiug a consultation, treatment and reception room. (See Fig. 124.) This enabled me to have a patient in the consultation room and another in the treat- ment room at the same time. It also permitted me to have an assistant to handle the old cases while I was examining the new ones. As my practice increased, I added another room as a laboratory, thus mak- ing a complete suite of offices. (See Fig. 125.) Fig. 125. Office Furniture.— The consultation room in a urological office can be fur- nished in any way that the practitioner desires, but it is desirable to have strong, heavy furniture, preferably of a dark color, covered with leather. It should consist of a table-desk, a number of chairs and a couch ; also a book- case, if it contains the library. Besides this, if the patients are to be treated in the same room, it should have additional office furniture indicated for a one-room office, such as an examining table for the examination and treatment of patients; an instrument table; a small table for microscope, or for whatever other purpose the practitioner might desire ; a cabinet for apparatus and in- struments and a lamp — electric or gas (probably both). Small stools and tables are always convenient and take up but little space. Apparatus and Instruments Recommended for Office. — Tables. — For ex- amination and treatment of patients ; for instruments ; for microscope and ac- cessories. Lamp. — With a reflector — electric, gas or oil. Sterilizer. — Steam, formalin, a pan for boiling instruments. KuBBEK Goods. — Rubber tubing for irrigating jars ; hard-rubber irrigating tips, shields and cut-offs ; finger cots. 140 UKOLOGICAL EQUIPMENT Glassware. — Irrigating jars; jars for dressings; jars for solutions; glass graduates ; urine tubes ; medicine droppers. Graniteware. — Basins for solutions ; douche pan ; pus basin. Piston Syringes. — Large and small urethral; bladder; hypodermic. Dressings. — Assorted bandages; T-bandages; cotton balls; tampons; sani- tary pads ; gauze compresses — 3 by 5 ; 5 by 6 ; 8 by 10 ; gauze compresses with cotton-combined dressings — 5 by 6 ; 8 by 10 ; adhesive plaster. Miscellaneous. — Instrument tray ; galvanic and f aradic battery ; small water barrel (for hot water) ; tub for bichlorid solution in which to sterilize utensils requiring chemical disinfection ; stirrups and lithotomy uprights for examination and treatment tables. Cocain tablets ; bichlorid tablets ; peroxid ; Holzien solution ; silver solu- tion ; boric acid ; alcohol ; lubricants (glycerin, gommenol) ; green soap ; brushes. Instruments. — Special. — Catheters — soft rubber^ straight or elbowed; woven, straight with olivary tip and elbowed; metal. Filiform bougies ; bougies a boule. Cystoscope. Sounds. Prostatic douche tubes. Stone searcher. Instillating syringe. Dilators — Kollmann and Oberliinder. Applicators. Urethroscope. Tunneled sound and catheters. Perineal grooved probe, director, cannula and gorget; perineal drainage tube. Rectal bag. Prostatic forceps and depressor. General. — Retractors, dull with rounded edge, large and small; sharp with short teeth. Probe, grooved director. Scissors, dull curved, sharp curved ; dull straight. Knives, straight scalpels, large and small ; straight and curved bistouries. ^Needles, large and small Hagedorn's, short round, surgical and straight, ^Needle holder. Forceps, thmnb; artery, curved with long slender blades; bullet. Sponge forceps. Vaginal speculum, depressor, dressing forceps. Throat mirror and tongue depressor. Sutures, ligature material, catgut jDlain and chromic, ISTos. 1, 2 and 3 ; braided silk. Ligature carrier. Kelly pad. Paquelin cautery. Extra Equipment for Outside Work. — Besides the office equipment, little is needed for outside visits. The following list will show what is generally used for operations and cystoscopy outside of the office. EXTRA EQUIPMENT FOR OUTSIDE WORK 141 For Cystoficopy Rheostat. Two cystoscopes and cords. Bougies a bonle ; sounds. Assorted catheters. r Bladder. Syringes i UrethraL '- Fountain. Glycerin, BAGS FOR OUTSIDE WORK Foi' Operation Portable metal table. Rubber sheeting and Kelly pad. Basins. Sterilized towels. Green-soap tincture. Brushes and nail file. Alcohol. Bichlorid tablets. Test glass. Cocain solution. Syringes r Fountain and piston. 1 Hypodermic. Bichlorid tablets. Assorted catheters, knives, scissors. Silver solution. Lubricant. Medicine dropper. Cocain. Rubber tubing. Peroxid. Suppositories of morphin and quinin. ■ r Thumb. Kelly pad. Artery. Rubber sheeting. Forceps < Sponge. Table and lithotomy leg rest. Bullet. Sterilized towels. - Prostatic. Cotton balls. Assorted retractors. Gauze pads. Assorted needles. Battery, if no electric light. l^eedle holder. Sutures 1 r Plain. and I C'-^tgut 1 Chromic. Ligatures J Braided Silk. Sounds. Bougies a boule. Gouley tunneled sound and catheter Filiforms. TT . fOtis. Urethrotomes i -,r • (^ JNlaisonneuve. ' Grooved probe. Perineal Grooved director. < Grooved cannula. . Gorget. Bandages, assorted dressings. Lare-e catheter drain tubes. Portable sterilizer. Pedicle clamp. Infusion jars. 142 UROLOGICAL EQUIPMENT Office Dressing- Equipment. — Towels. — A large supply of office towels, 18 by 36 in size, must be kept on hand. The variety known as " glass " towels are the best for general use. They are kept wrapped in an outer towel, or preferably in a piece of muslin, in packages of ton for office work and six for outside operating. The packages of towels should be kept in a tin box as stock. Cotton Balls. — These are convenient in office work for sponging the meatus and glans in men, and the vulva, meatus and vagina in women, before instrumentation. They are kept in glass jars on a treatment table. Before us- ing, they should be dipped into a bichlorid solution, which should always be kept in a jar close at hand. The solution should be changed daily. Gauze. — This is a most useful surgical dressing, and much care sliould be given to its j)reparation and sterilization. The following varieties of gauze dressings are useful. They should be kept in separate jars and a supply should be in each room, while a sufficient supply should be kept in tin boxes for office and outside work. Gauze sponges, 3 by 6 inches, for absorbing blood, etc., during an operation and for use with probangs or sponge holders, are folded from pieces of gauze 9 by 16 inches. They are also useful unfolded to wrap about the forefinger in making a rectal examination. Sponges or compresses, 5 by 6 inches, are made of pieces of gauze, 15 by 18 inches, folded three times each way, with the cut edges inside. They can be stitched at their free borders or left free as the surgeon prefers. They are packed in tiers in jars, or are tied up in packages containing four pads each, wrapped and pinned in pieces of muslin. Some of these packages may contain in addition a number of cotton balls, as these are better adajDted for use in a minor operation. Large gauze compresses for abdominal pads are gauze pieces, 18 by 21 inches, folded to make pads, 6 by 8 inches. For abdominal sponges these gauze pads should have their edges sewed and provided with tapes. Gauze packing strips should be an inch wide and three yards long. A thread is pulled from a piece of gauze of this length and the strip is cut along the line indicated. These strips are kept in eight-inch tubes plugged with cotton, the tubes being in turn kept in jars. When the dressing is needed, it is pulled out with sterile forceps and cut with sterile scissors. Strips of gauze, an inch wide and a yard long, saturated with five- or ten- per-cent iodoform and others of the same size, saturated with Balsam of Peru, are also kept in stock for packing wounds. Other Dressings. — Bandages, both gauze and muslin, from 1 to 4 inches wide, are used for office work and outside operating. They can be wrapped in sets of from two to four in pieces of muslin. EuBBER tissue in assorted sizes is scrubbed with green soap and is kept in 1 : 500 solution of bichlorid. OFFICE DRESSING EQUIPMENT 143 SuRGiCAT. PLASTER ((Hacliylon or zinc oxid) is kept in convenient rolls. For small dressings, pieces of diachylon })laster, 1 inch wide by 4 to 6 inches long, arc kept in readiness in a small jar and are known as dressing holders. They are heated for a moment over an alcohol lamp before being applied. Ordinary adhesive plaster is nsed for strapping on dressings of large size. Forceps for taking dressings and gauze ont of jars and tubes are sterilized by dipping into pnre carbolic and alcohol, or are kept, during office hours, in a ghiss jar containing five-per-cent carbolic. Glass hand syringes, irrigator tips and shields, couplings of glass OR HARD RUBBER are kept on the treatment table in alcohol or bichlorid solution. Infusion jars are rarely nsed in office work, but they are an important part of the outfit for an outside operation and should be provided with a thermometer. Needles, threaded with silk or unthreaded, are put through pads of gauze in assorted sizes and varieties. The pads with their needles are wrapped in small pieces of muslin and sterilized by dry heat or formaldehyd. The packages are thus ready for operations. Ordinarily, needles of assorted sizes are kept in covered glass dishes containing a mixed powder of boracic acid and lyco- podium. The suture material is all kept in tubes ready for use. A /^ ^ /^ Ci A 3 ^ b o Fig. 126. — Table in the Examining Room. On the top are kept in jars, gauze cotton balls, lubricants, syringes in alcohol, applicators, catheters, urethral speculum, sterile water, magnifying glass. On the lower shelf, urine cylinders, finger cots, vaseline, material for quick urinary tests, two dishes, and cases for instruments. 144 UROLOGICAL EQUIPMENT HYroDERMic SYRINGES are kept with their needles, etc., in a small glass tray. The needles should always have wires in them when not in use. Arrangement of Author's Present Offices. — In arranging my rooms for office work, it was necessary for me to convert the basement, situated imme- diately under my consultation room, into a reception room. This was easily done and it was connected with the offices and treatment rooms above by a private staircase. The arrangement of the office floor still remains as it was then planned. Room No. 1 is the consultation room, containing bookcases for the larger part of the library, a table, a desk, a letter file, two easy chairs, two arm- chairs, two ordinary chairs and a couch. It opens into the examining room CNo. 2) by one door and into the hall by another. Boom No. 2, the first examining and treatment room, is painted and fur- nished entirely in white. It contains an examining table, an instrument table (Fig. 126), a tray table, two stools, a chair, a commode, a screen and a cabinet for apparatus and instruments. The examining table is of the counterbalance variety, with a drain pan below (Fig. 127). The seat section of this table, on which the buttocks of the Fig. 127. — Author's Counterbalance Table in the Position for Examination of Male Patients. patient rest, is made of two pieces of glass with a slit between them, which allows the fluids used in treatment to drain into the pan. The head or back section can be raised to any position (Fig. 128) for facilitating the examina- tion of the abdomen, or increasing the comfort of the patient; while the leg part of the table, for supporting the lower extremities, can be removed and the hip portion elevated for cystoscopy. With the leg section removed, this table makes an ideal table for treating women, as the solutions run into the pan below. Care must be taken, however, to see that the patient, when lying on the table, ARRANGEMENT OF AUTHOR'S PRESENT OFFICES 145 sits on the middle part first, as seating oneself on either of the end pieces might result in falling to the floor. The patient must also be instructed in moving about on th(^ table to take hold of the side bars, as, if the top of tlie table is Fig. 128. — Different Positions in Which the Patient Can be Placed in Examining the Abdominal Organs, especially in Kidney Cases, by Raising and Lowering the Shoulder Piece of the Table. grasped when the shoulder part is elevated, the fingers might be crushed in case that part of the table were to slip from the cog in which it is caugkt. Over the examining table is placed a large tray table on an adjustable stand, which is exceedingly convenient for holding close at hand the various instruments used in the examination of the patients while on the table. Fig. 129. — Counterbalance Table with a Douche-pan on It. This counterbalance table is probably the best antiseptic metal table that has ever been placed on the market. The slit in the seat part, however, does 146 UROLOGTCAL EQUIPMENT not prevent the solutions from wetting the patient during urethra and bladder washings, when it is covered by the leather pad, and the glass or metal is too cold for the bare buttocks. I have personally found an ordinary wood table of my own designing more convenient for treatment than these more modern ones and they are more pleasing to the patient. I have consequently gone back to first principles, in that I do not depend on the slit in the modern tables for draining away solutions during medication, but prefer to place a dcniche pan under the patient's buttocks, finding that in this way the buttocks and clothing are kept dry (Fig. 129). In the instrument closet are kept all the instruments and supplies necessary for a thorough examination and treatment of a patient in the office and outside, as well as for an operation. On the top of the closet is a row of glass jars for dressings. Behind the screen, near the washstand, the commode is placed, for the use of the female patients when they void urine for specimens. Room No. 3 is the next room and has communicating doors with Room Ko. 2 as well as with the corridor. In the little passage between Rooms jSTo. 2 and Xo. 3, on shelves, are bottles containing sterile water and solutions, also irrigators and other appliances kept in reserve. Room 'No. 3, also finished in white entirely, with an impermeable floor, contains a counterbalance table of the same pattern as that in ISTo. 1. It is also surmounted by an instrument tray with a stand (adjustable). One or more irrigators are hoisted on pulleys over the table from the ceiling, in a manner described farther on. A glass table in this room serves for dressings and solu- tions, while in the corner is an instrument closet. On the top of this closet is the massage vibrator, properly connected with the electric current ; the flexible shaft of this instrument is sufiiciently long to reach the treatment table. In a recess of this room is an electric outfit for high-frequency current, for X-ray work and for cautery and for other electrical appliances. A closet over the washstand holds the stock for the solutions and medicines that are used in the daily work in the treatment of cases. The scales, on which patients are weighed from time to time, are also included in the furnishings of this room. Besides the examining table and tray stand for the instruments, there is an- other glass-top table for the apparatus and instruments used in the examination and treatment of patients. This stands just beside the examining table. Room No. 4, the next in order, is of the same size as Xo. 3 and com- municates with the latter as well as with the corridor. It connects also Avith the room behind it by means of folding doors. It serves as the second examin- ing and cystoscopic room and is used principally for treating women and for urethroscopy, cystoscopy and ureteral catheterization in both sexes. The gen- eral arrangement is the same as Room Xo. 2, in that it contains an instrument cabinet, washstand, examination and instrument tables. The table for examining and treating patients is known as the Allison (Fig. 130), which I find unequaled AERANGEMENT OF AUTHOR'S PRESENT OFFICES 147 for cystoscopic work. It seems to afford a better position for this purpose than any other, as the seat part of it is shorter than that of other tables. The illustra- tion shows the position of the hips when this table is nsed in cystoscopic work. Each of the examining tables is provided with a detachable and adjustable pair of leg and knee rests, as seen in the illustrations. The choice of these is a matter of individual preference, the knee rests having the advantage that the patient can be more quickly placed in position than with the straps attached to the leg holders. Fig. 130. — Allison Table in the Cystoscopic Position, with Shoulder and Buttock Pieces Elevated. Knee rests or lithotomy uprights are used when cystoscopy is performed. In the corner of Room ISTo. 4 is a washstand over which is a closet for solu- tions, etc., the entire corner being screened by a wdiite, washable curtain swing- ing upon a hinged rod. An instrument case with glass shelves contains all the instruments used in this room. A glass table with a shelf underneath contains all the necessary articles for conducting cystoscopy and other examinations the same as in Room l\o. 2. The next room, No. 5, separated from ISTo. 4 by folding doors, is known as the back office, and is the assistant's room, in which correspondence is looked out for and office work attended to which is not accomplished in the main office. The files for histories and records are kept in this room. Doctors who call with their patients often wait here. It is used as a second consultation room in which to take histories and interview patients when the front office is in use. A ])art of the library is here and easy chairs, and a couch for patients who may want to rest. It forms wath Room No. 4 a second consultation and treatment room corresponding to Rooms ISTos. 1 and 2. 148 UROLOGICAL EQUIPMENT The last room of the series is the hiboratory, No. 6. Tn tliis room the lu'ines are examined. All the equi])ment needed for the examination is found here. The room contains waslistand, draining boards, closets for chemicals and re- agents, the microscopes and laboratory accessories, A desk serves for keeping" the records and filing the laboratory cards. Some of tlie interesting ulceration specimens are also kept here. APPOINTMENT IVO. ADDRESS DIAGNOSIS WILL COME ON. APPOINTMENT ^VITII DK. BAMON GUITEBAS 80 Madison Ave. New Yokk M. HOUR A. M., N. B. — Office visits are not expected to last more than a quarter of an hour No special appointments are given in the afternoon. Patients are seen in tlie order in which they arrive. TELEPHONE MADISON SQUARE, 5798 OFFICE HOTJES: 0-13 A. M. Fig. 131. — Appointment Form. Office Management. — A patient, calling for the first time, on entering the reception room is handed a card bearing the date of his or her visit and is in- structed to write the name and address. All old patients write their names on a similar card at each visit. Whenever a patient arrives, the attendant at the door telephones upstairs announcing the arrival, which is immediately regis- OFFICE MANAGEMENT 149 t(M'('(] l)y (lie nurse in attendance on the office floor on a list that I have always before nie. The card which has been received in the reception room is then brought np and placed on a table in the hall. New patients are shown up to the cousultation room and their histories are taken by one of the assistants, wlio also makes arrangements regarding the fees. The patient is then brought t(i me for examination, and any specimens requiring examination are sent to llio laboratory. When the examination is finished, the diagnosis made, the treat- incut outlined and an opinion given, if the patient is in need of further treat- ment in the office, an appointment is given for the next visit. (See Fig. 131.) The old patients, on arriving, are called up and assigned to one of the as- sistants with whom treatment is continued until they are discharged. All pa- tients are seen by me personally at each visit or as often as necessary. At the expiration of office hours, the cards of new patients are placed in the file index of ]iatients. A card with the name of the physician recommending the case is put in another file, and cards with the name of the disease written on them are placed in the third file. The history is put in an envelope and placed in a large vertical file. This gives a very thorough record of the case. Very often histories used to lie about in tlio office pending the writing (if tlu' urine analysis or other data and consequently no diagnosis of the case was written, no treatment out- lined and no diet prescribed. The •following rules were therefore for- mulated and posted over the mi- croscope tables in the laboratory. Arrangement of the Rules roR THE History of Patients. — (1) The history of each patient should be taken by an assistant. (2) The patient should be ex- amined physically and the find- ings written down. The one Avho makes any part of the examina- tion should write it down with his initial after it. (3) The urine goes to the laboratory and is examined by the laboratory man who writes the urine report on the examination card. It is then sent to me for the diagnosis and should not be filed until the diagnosis is written upon it. Fig. 132. — Three Vertical Files in Which the En- velopes Containing the Patients' Histories and Correspondence are Kept. 150 UROLOGICAL EQUIPMENT If tliere is an opinion to be given, it should be written out by me and under no circumstances should the history be filed without this having been done. When these letters of opinion and diet are writ- ten, a carbon copy should be made and they should be submitted to me before they are sent out. All correspondence is kept in the history en- velope. The management nf the office is entirely in the hands of the nurse who is also secretary. She has care of the correspondence, the appointments for vis- its and operation, the pa- tients' accounts, the laun- dry, the purchase of office supplies, the making of the dressings, the steriliz- ing of the instruments and dressings and the lists of instruments and ap- paratus that leave the office for outside opera- tions. Equipment for Clinic and Hospital. — The work in the clinic corresponds to that in the office on a large scale, although the equip- ment and records are not kept so carefully. There are generally plenty of as- sistants, most of whom are there to learn the routine of the work of the clinic and who are generally not so well trained as are office assistants. The clinic records are, therefore, but about a quarter as valuable, except Fig. 133. — Plan of the Clinic at the New York Post- graduate Medioal School. 1, waiting room for old patients. 2, waiting room for new patients. S, passage to Rooms 4, 5, 6, and 7. In the corner of Room 3 is seen a table and chair where the history file is kept by the historian. The room to the left of Room 4 is for the acute cases. Room 5 is the room for chronic cases. Room 6 is the cystoscopic room. Room 7 is the amphi- theater. Each of these rooms has two treatment tables, an in- strument table and a sterilizer. EQUIPMENT FOR CLINIC AND HOSPITAL 151 so far as a record for tlie number treated is concerned. Tlie greatest difficulty is fonnd in obtaining assistants with the true scientific spirit who are willing to give their time to tabulating statistics, to investigating new methods and to doing research work outside of the clinic. The plan of the clinic (Fig. 133) is that of a semicircle and is arranged as follows : No. 1 is the general waiting room. No. 2 is the waiting room for new pa- tients. No. 3 is the passage in which the records are kept. No. 4 is the first- treatment room. No. 5 is the second-treatment room. No. 6 is the cystoscopic room and No. 7 is the amphitheater or lecture room. The old patients enter in tlie basement Room 1 — the new ones are brought into Room 2 where they wait for the lecture. Room 3 is the passage and here is the table at which the card index is kept. The clinic filer, w^ho sits at this point, directs the new patients to enter from Room 2 for the lectures and the old patients come in from Room 1 to be treated in the other rooms. The card filer hands the cards to the patients as they come in and replaces them when they pass out. The first assistant investigates the new patients before they go to the lecture room, writing down their names and l)rincipal symptoms, and brings the list into the lecture room (No. 7). The lec- turer reads over the list and has the cases sent in as chosen. The patient, on entering, is placed on the table, his history is taken aloud by the lecturer, and recorded by the historian. The local examination is then made by inspection and palpation. If the patient is an acute case, there is usually but little difficulty in making a diagnosis. If the case is chronic, however, the patient is instructed to leave the table and pass his urine in two glasses. The first and second specimens are inspected and the appearance noted, after which the patient leans over the table and the prostate gland and seminal vesicles are examined. The patient then passes the remainder of his urine, containing any debris that has been expressed from the internal genitals during examination. The three specimens are then handed to the microscopist, seated at the table, for examination. While he is attending to this, the patient is again placed on the table and the lecturer pro- ceeds to examine the urethra with the instruments at hand. As the instruments are used, they are handed to an assistant, Avho attends to the sterilization. After the patients have been examined and the diagnoses made, they are each referred to a certain clinical assistant outside, whose patients they then become and who are treated by him until cured, unless some complication oc- curs or the assistant in charge of the case desires him to come again before the lecturer. All the acute cases are sent to the first-treatment room (No. 4) and are placed in the care of the two assistants in charge of this room. All chronic cases are sent to the second-treatment room (No. 5), in which there are also two assistants working. When an acute case becomes chronic, the physician in 152 UKOLOGICAL EQUIPMENT charge can either continue treating him or else refer him to the room for the chronic cases. In both these rooms, there are two treatment tables, an instru- ment and a sterilizing table and some chairs. The instruments are of the same variety as those used in the office. Room 6 is the cjstoscopic and bladder room. In this are two tables, on one of wdiich the patients are prepared for cystoscopy, while on the other they are examined by the cystoscopist. As the preparation for cystoscopy takes some time, the case lectured on is not prepared in the amphitheater, but outside, after wdiich the patient is wdieeled into the lecture room wdth the cystoscope in the bladder, ready for examination. This is the usual routine, but in cases in which the fluid medium becomes rapidly turbid, as in marked pyuria and hciua- turia, the last Avashing is given in the lecture room and the cystoscope is then introduced. The clinic is managed by a chief of clinic, who goes about from room to room and gives help and advice to the clinical assistants. Clinic patients are in charge of the first assistant. One man is at the head of the cys- toscopic room, and two in each of the treatment rooms, the man Avho has had the longest duty outranking the other in each of the rooms. The rec- ords are in charge of two men, one in the lecture room who takes all the his- tories, the other on the outside who makes notes, at each lecture, of the inter- esting cases that are kept under observation, such as the kidney, bladder and stricture cases, as well as those who are to be operated or have already been operated upon. The new men coming to assist the clinic go through a regular circle of serv- ices before they are permanently appointed clinical assistants, serving in each for at least three months. The rotation is as follows: Historian in the aiiii)hi- theater; first-treatment room, treating the acute cases; second-treatment riKHu, treating the chronic cases ; third-treatment room, working in cystoscopy. When they have finished cystoscopy, if fitted for it, they go on the microscope, other- wise they go on the book and around the circle again, as the head man of the different departments. The development of the clinic and of the clinical assistant has been very satisfactory of late, owing principally to the formation of an Alumni Society, that meets once a month, at each of which meetings one of the assistants reads a thesis on some subject that has been assigned as a special w^ork. The hospital is connected with the clinic, inasmuch as the patients requiring operation are referred to the hospital for the operation clinic, which takes place once a w^eek. After they recover, they are again sent to the clinic for observa- tion and treatment. Patients are also referred to the hospital for treatment, although it is principally for an operative service. The same instruments and apparatus are used at the hospital and for outside work, as have already been indicated under Equipment for the Office. CHAPTEK VII STERILIZATION OF INSTRUMENTS AND APPARATUS The methods of destroying germs applicable to urological instruments are : Disinfection by means of chemicals, by boiling, by steam, and by the vapors of bactericidal snbstances. It is important to know the particular method which is suitable for each special class of instruments, as some appliances are injured by subjecting them to the wrong process. Probably the most efficient method of disinfecting an instrument that can be sterilized by any method is by boiling or steam. The least effective of the methods at our disposal is disinfection in chemical solutions, a method which is used chiefly in emergencies. Disinfection with chemical vapors is more thorough and more trustworthy than with solutions, and the vapors of formalin have now been adopted very generally in the dis- infection of urological instruments which do not bear the application of heat. Chemical Solutions. — Formerly it was considered sufficient, for all practical purposes, to disinfect certain urological instruments, such as catheters, by im- mersing them in solutions of carbolic acid or bichlorid of mercury. It has been shown, however, that these methods are untrustworthy, and that even when catheters are immersed for half an hour in a 1 : 1,000 solution of bichlorid, living microorganisms have been found within their lumen. Of the solutions which are employed with more or less safety in the steril- izations of urological instruments, we may mention formalin and mercuric oxycyanid, the latter 1 : 1,000 to 1 : 500. Formalin is probably the better of the two, and can be used in a strength of from two to five per cent. The most convenient solution of formalin is that recommended by Holtzein, which serves for the disinfection of cystoscopes, urethroscopes, woven catheters, etc. The stock solution consists of sixty parts of formalin and forty parts of alcohol. Two drachms of this solution are added to each pint of distilled water for im- mediate use. ]\[ercuric oxycyanid is employed in the strength of 1 : 200 for the dis- infection of delicate instruments, such as cystoscopes, etc. The value of this sidistance is rather questionable. Boiling. — Boiling is one of the best ways of attaining absolute asepsis. The material to be boiled, however, must be carefully selected. Metallic instru- ments, consisting entirely of metal or of glass or the two combined, may be 153 154 STERILIZATION OF INSTRUMENTS AND APPARATUS l)oilc(l with impunity. It is always liest to add some soda to the water, so as to prevent rnsting and to preserve the nickel plating. Soft-rnbljer catheters may also be boiled, Ijut plain Avater should be used. The time required for boiling any of these classes of instruments is five minutes. Any instrument boiler, fish boiler, or common agate or enameled pan, can be used. Special long and nar- row pans with covers are useful for boiling soft rubber, glass or metal instruments in the office or the treatment room. Steam. — When employed correctly, steam under pres- sure disinfects with the same efficiency as boiling. The steam must penetrate through every part of the material to be disinfected, and the time of exposure must be sufficient to kill the most resistant germ ; that is, about twenty- five minutes. Disinfection with steam requires special apparatus, although in an emergency an ordinary fish kettle, with a perforated pan hanging over the boiling water, can be employed. One of the best all-round steam sterilizers is that known as the ''Willy Meyer" (Fig. 134). This can be used for both dressings and instruments, and is very convenient for carrying to an operation at the patient's house. Another of about the same size, though a more complicated sterilizer, is the type known as " Rochester Combina- tion " (Fig. 135). In this sterilizer, we can use alternately steam and dry heat, so that the steamed articles can be dried by heat without removing them from the trays. Both these sterilizers have an arrangement for boiling instruments in the water which produces the steam. I Fig. 134.- -WiLLY Meyer Sterilizer for the Sterilization OF Dressings and Instruments. Fig. 135. — Rochester Sterilizer. FORMALIN VAPORS 155 Formalin Vapors. — Formalin vapors offer a very convenient, and at the same lime very ettieieut, way of disinfecting all kinds of urological instruments, especially cystoscopes, Avoven catheters, etc. The most convenient apparatus for this pur])ose is Schering-Glatz's formaldehyd sterilizer (Fig. 136). This apparatus consists of a box of japanned tin, measuring 18 x 11-| x 8 inches. It has two shelves upon which the instruments may he placed, and a small compartment for the formahlehyd lamp. One side of this box swings on hinges, forming a door of sufficient size for the introduction of the longest Fic 136. — Formalin Sterilizer, Used Principally for Woven Catheters, Piston Syringes and Cystoscopes. instruments that the box will hold. The lamp is about eight inches high, con- sisting of a body for the alcohol and a chimney, in the top of which is a cup or receptacle for formalin pastilles, white tablets which by heat are com- pletely converted into formaldehyd gas. The strength of each pastille is five grains. Two of these tablets are sufficient for ordinary disinfection in this apparatus. The instruments are placed on the wire shelves. Two five-grain paraform pastilles are put into the cup or receptacle. The lamp is now" lit and the door closed. A small glass window in the door permits us to watch the flame of the lamp. An outlet at the top of the box allows the escape of gas when steriliza- tion is complete. The lamp will burn for twenty minutes in the air of the box, when empty. About ten minutes are needed to burn a five-grain pastille of })araform in the sterilizer. Ten minutes' exposure to the amount of gas obtained by vaporizing two five-grain pastilles will kill anthrax, diphtheria, tubercle and typhoid germs, as well as those of suppuration. At my suggestion. Prof. H. T. Brooks, of the Post-Graduate Hospital, made a series of experiments with this 156 STERILIZATION OF INSTRUMENTS AND APPARATUS sterilizer to determine its efficiency. The following is an extract from his report, which was sent to me in December 17, 1899. Woven catheters were injected with dilutions of live cultures of the typhoid, colon and prodigiosus bacilli, and the Staphylococcus aureus. The catheters were then drained, dried, and placed in the Schering formalin sterilizer. Two pastilles were burned for ten minutes, after which the lamp flame was spon- taneously extinguished. The door of the sterilizer was then opened, two new pastilles placed in the cup above the lamp chimney, the lamp relighted, and the door closed. The lamp Avas then allowed to burn for an additional ten minutes. The door was not oj3ened until a third ten minutes had elapsed — i. e., thirty minutes from the beginning of the exposure. The catheters were then removed from the chamber with sterile forceps, cut with sterilized scissors, and portions placed on gelatin plates, in tubes of alkaline bouillon, and also in surface and submerged agar tube cultures. jSTo growth of any of the above-mentioned organ- isms occurred after three days in the incubator at 98^ F. Control cultures were made from the original dilutions used for injecting the catheters, and all grew. Subsequent experiments showed that the tubercle bacillus and the strepto- coccus also were killed by exposure to the formalin fumes for half an hour. Detailed Methods of Sterilization and Disinfection: 1. Water. 2. Surgeon's hands, 3. Rubber gloves. 4. Packages of dressings and tubes of gauze. 5. General care of instruments. 6. Catheters. 1. Cystoscopes, urethroscopes, etc. 8. Piston syringes. 9. Glass hand syringes. 10. Instillation syringes. 11. Hypodermic syringes and needles. 12. Glass and agate ware, etc.; infusion jars; irrigator jars and tips; pans, pus basins, pitchers, dishes, trays and glass jars. 13. Catheter lubricants. Snell's formaldehyd sterilizer is recommended for catheters (Fig. 137). 1. Water. — The quality of the water used in the office for making our solutions was found unsatisfactory. It was ordinary boiled city water and at times was discolored and often formed some chemical combination with silver or other salts used for solutions. Besides this, the enamel was burned off the bottom of the kettle, giving rise to a certain amount of mineral deposit in the water. When this occurred in the instrument sterilizer, which was of the same METHODS OF STERILIZATION AND DISINFECTION 157 constrnction as the kettle, a gritty substance climg to the instruments, while a. scum floated on the water. For a long time we used filtered water, which had been boiled, but even filtered water formed a chemical combination or gave rise to precipitates. We then began to use distilled water, which has proved iiiost satisfactory. In the smaller towns, this can be made in the oflico with the aid of a still, such as are now used for its rapid manufacture. In the large cities we simply buy distilled water in five-gallon bottles. The water is heated in a large tea kettle, which should be changed for another as soon as it is burned in the least (legTce. After the distilled water has been heated, it is poured into an aseptic pitcher and thence into an earthenware jar with a faucet in the lower part. The Fig. 137. — Snell's Fokmalin Sterilizer for Sterilizing all Catheters, BUT especially URETERAL. The catheters are pushed over hollow posts leading to the formalin chamber. sterilized water is drawn, as needed, from this jar. The kettle is always kept full of hot water in order to replenish the treatment-room jar whenever neces- sary. The cooled water is drawn off into a second jar, which is kept beside the one for hot water in order to mix the two for solutions at a proper temperature. An extra supply of cold sterilized water is kept in sterile flasks, stoppered with cotton or gauze. 2. Surgeon's Hands. — The care of the hands is one of the most important details in a urological office. It is a problem how to keep the hands clean, as they are constantly touching septic matter. Each treatment room should be provided with soap, brushes, nail cleaners and jars of bichlorid for the hands. 3. Rubber Gloves. — At intervals I have worn rubber gloves, but have never become accustomed to them in office work. There is so much changing 158 STERILIZATION OF INSTRUMENTS AND APPARATUS of clothes, telephoning, handshaking, prescription writing and other matters of a business and social nature transacted during office hours, that the changing of gloves becomes a difficulty and involves a great loss of time. The surgeon should, however, wear rubber gloves in the treatment of all cases which tlireaten infection. In the office, they are washed with soap and water, wrapped in a towel, and boiled for ten minutes after using them, then dried, powdered and wrapped in gauze and put away until next needed. 4. Packages of towels^ gauze compresses, sponges or pads, gauze band- ages, cotton balls, sanitary pads, muslin table covers and sheets should be sterilized by steam. Strips of j)lain gauze, for packing, should be sterilized in the tubes in which they are kept. 5. General Care of the Instruments After Using. — After use, all instruments should be washed in hot water and green soap with a soft brush or piece of gauze, thoroughly dried and put away. Special care should be taken, in the case of cystoscopes, not to sub- merge the entire instrument in cleaning or other solutions. Metal instruments should be cleaned in the same manner as house silver, when they begin to tarnish. All instruments should be kept free from dust in closed cabinets, or between towels if on open shelves. 6. Catheters. — It is very difficult to clean catheters and other hollow instru- ments, as the remnants of pus, mucus and blood are apt to remain adherent to their interior. This is especially true when greasy lubricants have been used. A catheter must be flushed out, after using it, with soapsuds, by means of a piston syringe, or by attaching to a sink faucet a small nozzle which will iit into the lumen of the catheter. In this way, a strong jet of water can be made to flow tlirough it (Fig. 138). This is most important especially in woven catheters, which are usually sterilized by means of gas or chemical solutions that do not penetrate a coat of dried albuminous matter containing infection that adheres to their inner walls. Soft-rubber catheters are best sterilized b}' boiling for ten minutes in Fig. 138. — Method of Flushing out Cathe TERS Employed in Author's Office. METHODS OF STERILIZATION AND DISINFECTION 159 ])lain water after a thorougli cleansing. They should be wrapped in ganze or a towel and put into the boiler so that they do not come in contact with the wall of the boiler and become burned. In the office, we boil our catheters in bags Fig. 139. — Catheter and Catheter Tube. and then put the bags into glass tubes. In this way they are handled more easily than in the wet bags alone (Fig. 139). Woven urethral and ureteral catheters cannot be boiled or placed in carbolic acid. They may be sterilized either by immersing them for thirty minutes in a solution of silver nitrate or of mercuric oxycyanid (1:1,000), or else by exposing them to the vapors of formaldehyd in the formalin sterilizer. The last-named method is the best and is the one used in the office. Another way of sterilizing woven catheters by formaldehyd, consists in placing them in a glass tube, in the stopper of which is a rubber receptacle containing formalin tablets (Fig. 110). The lower part of the stopper is perforated and through these perforations the vapors of formalin are constantly passing into the tube. They can also be placed in boxes in the center of which is a piece of gauze containing tablets or a j)Owder of formalin. The formaldehyd gas is spontaneously generated and sterilizes the catheters in twenty- four hours. Special boxes are constructed for this ])iirpose, although any ordinary flat air-tight tin box will do as well. 7. Cystoscopes, urethroscopes and other delicate instruments of this type are sterilized in the fornuilin sterilizer. After being used, the outer surface of the shaft is washed with tincture of green soap and water by means of a piece of gauze, then with alcohol, after which they are laid away in their cases, or, better still, wrapped in gauze, ready any moment. 8. Piston syringes of large size that is, holding from four to six ounces. Fig. 140. — Tubes with Hollow Rubber Stoppers Containing Formalin. he sterilized at 160 STERILIZxVTIOX OF INSTRUMENTS AND APPARATUS such as are used for washing out the bladder, are usually made of hard ruhber, metal or glass and metal. They are best sterilized with formalin gas in the Schering sterilizer. The metal syringes and those of glass and metal can also be boiled. They may be sterilized in clieiiiical solntitms the same way as the woven catheters, but they are better sterilized in the chemical vajjor (formalin). 9. Glass hand syringes are usually kept in jars with cotton in the Ijottom, partly filled with five-per-cent carbolic or a 1 : 500 bichlorid solution and ])laced nozzle down. I keep mine in alcohol and rinse them with sterile water, as then no deposits form on the instruments that will make chemical combinations with the salts in the solutions used. Another good way is to keep them in water and boil before using them, 10. Instillation Syringes, Aspirators, etc. — These are sterilized in the same way as the large piston syringes. The instillation metallic catheters are boiled before being used. 11. Hypodermic Syringes and jSTeedles. — Hypodermic needles should be boiled before using. The needles are kept in a small glass box con- taining a powder made of equal parts of boric acid and lycopodium, always with their wires passed through their lumen. Two small glasses, one f(jr a five-per-cent carbolic solution, the other for sterile water, are kept on a tray on a shelf, called the emergency shelf, during the office hours ; also one- ounce bottles of atropin solution (10 drops equal to yxo of a gTain) ; of camphor in oil (10 drops equal to 2 gTains) ; of strychnin sulphate (10 drops equal to yV of a grain) ; and pearls of amyl nitrate, each containing 3 grains, in a cotton-lined box. These should also be kept at hand on a table in hospitals and outside operations in case of emergency. A little glass receptacle with a cover contains cotton balls in ninety-five-per-cent alcohol. For local anesthesia, special solutions, which are prescribed in the appro- priate chapter, are kept on a tray with special syringes and needles, arranged in a similar manner to the hypodermic tray just described. (See chapter on Anesthesia.) 12. Miscellaneous Articles of Hard Rubber, Glass, Porcelain and Agate Ware. — Irrigator tijJS and couplings of glass Or hard rubber, to be used with rubber tubes and catheters, are kept in glass jars containing bichlorid solution. Irrigator jars should be washed out daily and flushed out with 1 : 1,000 bi- chlorid solution. Infusion jars are an important part of the operative outfit and should hold two quarts ; a thermometer is provided for each. They are kept filled with bichlorid solution and are cleansed with sterile water before using. The tubes, cannulas, etc., are kept wrapped in a towel, sterile and ready for instant METHODS OF STERILIZATION AKD DISINFECTION 161 use. Two bottles of sterile salt solution, one drachm to the pint, are kept at hand for use with this apparatus. Pans, pitchers, pus pans, dishes, basins, trays and glass jars should be divided into classes, those for aseptic cases and those for septic. Pitchers, basins for solutions or sterile water, instrument pans, trays, glasses for solutions, etc., sliould be thoroughly washed and cleaned with soap and water, rinsed out and \)ut into a tank, or an unpa luted waslitul^, wliero tliey are kept STdjmerged in 1 : .500 bichlorid solution. If they are not to be used immediately, they are kept bottom up on glass shelves or wrapped in sterile towels. Glass jars in which dressings are kept are cleaned in the same way and should be kept in the l)iehlorid solution, with their covers on, for an hour, and then dried with a sterile towel. Pans for the reception of dressings which have been removed, pus j^ans or basins, urine tubes and all other soiled articles of this order should be scrubbed with soap and water, rinsed with bichlorid and kept in their customary places without further attention. 13. LuBRicAiSTTS FOR I]srsTKrME]\"Ts. — The lubricants generally employed for urinary instruments include petroleum bases (vaselin), oils, glycerin and vegetable bases. Vaselin should never be used, except for rectal examinations. Olive oil should be used only after sterilizing it thoroughly by allowing the un- corked bottle to stand in boiling water until the oil itself boils. The only cases in which olive oil is useful is in examination for a supposedly impassable stric- ture. Certain oils are prepared with an antiseptic, as gommenol, which is a preparation of olive oil and eucalyptol. The usual lubricant employed in both hospital and office work is. 'glycerin. This is kept in tall jars, into which sterilized instruments can be easily dipped. Glycerin is easily kept sterile, as germs do not thrive in it. Some surgeons use boro-glycerid, which is a compound of boric acid and glycerin, containing thirty per cent of the former. Personally, I do not care for it, as it sometimes irritates. The vegetable bases, which have of late years been employed for lubricants, are composed chiefly of tragacanth, or of Irish moss (chondrus, carragheen). These bases have the advantage of being soluble in water and sufficiently slip- pery to be an efficient lubricant. They are easily washed off from the instruments or washed out of the canal. Most of the lubricants now on the market contain such a base, and have added to them either boric acid, eucalyptol, thymol, formalin, etc., as antiseptics. They are usually put up in collapsi])le tubes with a nipple-shaped nozzle which can be used to introduce the lubricant into the urethra before ]")assing sounds. The nozzle can be sterilized In' boiling, or each patient should have his own tube of lubricant. The lubricant that I use in the office is nuide according to the following formula : 162 STERILIZATION OF INSTRUMENTS AND APPARATUS I> Tragacantli oss ; Glycerin ovijss ; ITydrarg. Oxjcyanid ors. i j ; Aqiise oiij- The objection to oil and vaselin in urethral work is that they leave a coating over the mucous membrane of the urethra and thus prevent the thorough medi- cation of the canal afterwards. CHAPTER VIII TECHNIQUE OF INSTRUMENTATION CATHETERS A CATHETER IS a hollow tube with an opening at one end the size of its himen, while at the other end the opening is smaller and called the " eye." This is either in the tip or near it. Shape of Catheters. — The shape of the catheter is either straight (Fig, 141), or elbowed (Fig. 142) or curved (Fig. 143). The straight has the same caliber throughout, or else it tapers into the neck and then widens out at the end forming a small olive-shaped dilatation (olivary tip) (Fig. 144). Fig. 141. — Straight Cath- eter WITH Single Eye, USUALLY OF THE SoFT- RUBBER Variety. Fig. 142. — Elbowed.Coude OR Mercier Catheter WITH THE Eye on the Side, usually of the Woven Variety. Fig. 143. — Curved Catheter of the Woven Variety. Not much used. The neck is the narrowest part of the instrument, while the olive-shaped end, though larger than the neck, is smaller than the shaft. Elbowed catheters have a curved beak, somewhat similar to that of a sound, but shorter and more angular. They are also called coude or Mercier catheters. When the beak has a double curve, it is called bi-coude (Fig. 145). Curved catheters are shaped like sounds. Fig. 144. — Straight Olive-tipped Woven Catheter. Fig. 145. — Bi-coude Woven Catheter. 163 164 TECHNIQUE OF INSTRUMENTATION Catheters are made of soft riibLor, of a woven material with a varnish fin- ish, or of metal. Those made of other material are not recommended. The Eye of the Catheter. — The eye of the catheter is the openinjij through which the water escapes into the urethra or bladder. It is more frequently on the side, the end o])ening be- ing confined principally to instillating and large peri- neal drainage catheters. Openings on the side may be either single or mul- tiple. The single opening is most common, usually oval in shape and, especially in the soft-rubber variety, situated about a quarter of an inch from the tip (Fig. 146). The edges are rounded, so they may not give rise to traumatism of the canal. Such a finish is frequently spoken of as the " velvet eye." Straight catheters, whether they are soft rubber or woven, usually Fig. 146. Fig. 147. have but one eye. In the olivary type of woven catheter, the eye is situated in the body of the catheter, and may be one inch or more from the tip. In the elbowed catheter, when made of soft rubber, the opening is usually made in the concavity of the elbow, although, when the catheter is of a r Fig. 148. — Metal Catheter. Now rarely u^ecl. large size, it may be on the side, between the convexity and the concavity (Fig. 147). Side openings are generally found in the woven catheters, in which ease two or more may be present. In the single-elbow catheter, there CATHETERS 165 are rarely more than two, one on each side. Metal catheters are also better when they have the openings on the side (Fig. 148). Catheters for giving a general irrigation of the urethra may have multiple eyes — a dozen or more small round openings, through whicli the water spurts against the urethral walls (Fig. 149). They are generally of soft rubber in texture. Perineal drainage catheters, to be used after opera- t « a « »•■ ■ « ©''■•'^ tion usuallv have an openino' in servation and three with the catheterizing instrnment. Descriptiojt of the Cystoscope. — The teaching cystoscope is a com- bination of Xitze, Brenner and Boissean dn Rochet instruments, or, more prop- erly speaking, of F. Tilden Brown, Bransford Lewis and William K. Otis, with modifications that have seemed to me practical, the principal one being the elimination of the obturator as an unnecessary attachment. My cystoscope consists of four parts (Fig. 205) : (1) A hollow shaft with a lamp in its beak; (2) a combined obturator and indirect-observation telescope; ^d er Fig. 205. — Guiteras Teaching Cystoscope. 1. Straight, hollow shaft for reception of the 3. Direct telescopic tube. telescopic tube. 4. Direct telescope ^vith grooves for the 2. Indirect telescopic tube. catheters. (3) a direct-observation telescope; and (4) a direct-observation telescope with catheterizing attachment. To go into the separate parts more in detail : (1) The first is a straight tube with curved beak, in which there is an electric light tliat tlirows its rays both from the convexity and concavity. It has an open space on the straight part of CONSTDEKATTON OF MODERX CYSTOSCOPES 209 the shaft near tlie concavity, servinii; as a window llii'diiiih A\liic1i one can look from the indirect visnal part of the telescope that tits directly beliind it. (:2) The second is a combined telescope and obturator with a visnal ap- ])aratns, the window of which is abont one third of an incli from its end. The end is solid, cnt obliquely and of an angle that exactly fits in the distal ex- tremity of the hollow tube which it fills, thus serving both as an obturator and for indirect examinations. (3) The third is a telescope similar to those in all the direct Wappler cys- toscopes for the direct examination of the bladder, which, wdien pushed through the hollow shaft, protrudes through the opening in its convexity. (4) The catheterizing part closely resembles the direct telescopic portion, excepting that it has on its surface a fin with a groove on either side of it. These two grooves connect with the nozzles on the proximal end, through which the catheters are inserted. The catheters then pass along the grooves to the end of the instrument, being held in place by the inner wall of the hollow shaft as far as its distal end, from which point they are pushed out into the ureters when the instrument is in the bladder. This instrument is very practical, as, with the indirect visual apparatus in- serted, it answers the same purpose as a Nitze observation cystoscope. After the bladder has been thoroughly examined by the indirect method, the indirect apparatus is removed and the direct telescope of the instrument is introduced for the corresponding examination. The cystoscope stands for my teachings in cystoscopy during the last ten years : First, that a bladder should always be ex- amined with the indirect cystoscope before the ureters are catheterized ; second, the ureters are more easily catheterized by the direct cystoscope. This instrument combines these two important principles. The straight, hollow shaft with a curved beak can hold either the indirect or direct telescopes (i^o. 1). When the indirect telescope is introduced, the solid beveled end of the telescope fills the opening in the end or convexity of the shaft and they enter in the same way as the former shafts did with the solid ends. At the same time, the mirror near the end of the indirect telescope fits into the window near the convexity, on the straight part of the shaft, in such a way that a most satisfactory indirect examination can be made. Having thorougldy examined the bladder, the indirect telescope (Xo. 2) is withdrawn and the direct telescope (Xo. 4) containing the catheters is in- troduced into the shaft (xvTo. 1) and its end protrudes from the opening in the end of the shaft. The ureters are then catheterized. No. 3, the direct- observation telescope, is only used in teaching the student to find the ureters. There is an irrigating apparatus connected with the shaft (Xo. 1), into which the direct telescope has been introduced. The bladder can consequently be washed clean, examined thoroughly and the ureters catheterized without removing the outer part of the instrument. 210 CYSTOSCOPY The bladder can be waslK^l out tlii-(Mii!,li I lie sliaft (jf tlie instnniicnt b_v al- lowing the solution to run through the opening in one of the posts when neither the direct nor indirect telescope is inserted, or through the same opening when the direct telescope is in place. TECHNIQUE OF CYSTOSCOPY The following practical part of this chapter has been the result of experience gained in twenty years of cystoscopy. The work was principally done in the Post-Graduate, Columbus and City hospitals. In my clinic at the Post-Gradu- ate, w^e have done over 3,000 cystoscopies and ureteral catheterizations. The following instruments and apparatus are required in cystoscopy : ( 1 ) Cystoscope. (2) Table with knee or leg rests. (3) Battery; or, if street current is used, a controller. (4) Soft-rubber and woven coude catheters, Nos. 12 to 16 French scale. (5) Piston syringe, holding six ounces; or a fountain syringe. (6) Ultzmann syringe for injecting cocain. (7) Antiseptics: Bichlorid solution, 1:2,000; silver solution, 1:4,000; boric-acid solution, 1 : 30. (8) Cocain solution, 1:100. (9) Glycerin as a lubricant. (10) Test glass. (11) Douche pan or Kelly pad to catch fluid. (12) Slop jar at foot of table. For sterilization of the cystoscope, catheters and above apparatus, see the chapter on Asepsis and Antisepsis. The cystoscope should never be boiled or j^laced in hot water. It may be sterilized in an emergency by placing it for fifteen minutes in a two-per-cent solution of formalin. This solution we prepare by adding two drachms of our stock office solution, called Tlolzien's solution-, to one pint of water. (Holzien's solution is composed of formalin, sixty parts, and alcohol, forty parts.) Cystoscopes in the office are always kept sterilized and ready for use. After using them, they are cleaned on the outside with soap and water and then alcohol, wrapped in gauze and placed in Schering- Glatz formalin sterilizer for ten minutes and allowed to remain in the gauze until the next examination. The catheters used for washing out the bladder should have been previously sterilized. This is done by boiling the rubber ones, while the woven ones are sterilized in the same manner as the cystoscopes. The author keeps the rubber catheters in a muslin bag, in which they have been boiled, while the woven cathe- ters are kept wrapped in the gauze in which they have been sterilized. TECHNIQUE OF CYSTOSCOPY 211 Just ])ri(>r to the exiiiiiiiiatioii, all iiistrnnicnts should be laid out on a sterile towel, where they will be within easy reach of the examiner. Before doing a cystoscopy, the instrument and the light should always be tested to see if they work properly and to determine how much light will be necessary; the op- tical ]iart should be wiped with alcohol and dried with gauze. The urethra should also be examined to see if it will aduiit the cystoscope. jSTothiug is so exasperating as to prepare a patient for cystoscopy and find that the hnii]) is burned out or that the cystoscope cannot pass through the urethra. It is well to have everything in readiness before the patient is brought into the room. The table generally used in this country is one which will admit of a certain position, that is, the body part at an angle of 135° witli that part Avliich supports the thighs. There should be supports on each side, either upright lithot- ouiy bars or knee rests. If cystoscopy is to be performed in a private house, it is advisable to send a port- able metal table, w^hich can be adjusted to the position already referred to ; the appa- ratus referred to should also be sent. The patient, if a male, is placed upon the table in a reclining position, with his Fig. 2O6.— Portable Table Used for head and shoulders slightly elevated and Cystoscopy in the Clinic and at , , Private Houses. feet extended. The clothing is removed from the lower limbs, which are covered with clean towels, a sheet or flannel stockings. The external genitals are thoroughly washed with soap and water, followed by bichlorid solution 1 : 2,000 as for an ordinary surgical operation. The operator prepares his hands by scrubbing and immersing them in bichlorid solution. In the case of a female patient, she is immediately placed in the gynecolog- ical position, with her feet on the sides of the upriglit lithotomy bars, or else her legs are supported by knee rests. Washing the Bladder. — The first step is to determine the bladder capacity by the amount of urine voided, plus the amount of residual present; or else by measuring the entire amount of fluid that can be tolerated when injected into the empty bladder. A solution of boric acid, in the strength of one part of boric acid to thirty of water, is used for washing out the bladder. In cystoscopic Avork I usually have small packages consisting of half an ounce of boric acid wrapped in a piece of sterile gauze, and in making my solution I put one of these into a pint of hot water, or two into a quart. The solution is injected through the outer cylinder of the cystoscope from a fountain syringe, after removing the indirect telescope, or through a catheter from a six-ounce piston 212 CYSTOSCOPY syringe, until the patient's bladder begins to feel full. This marks the subjec- tive capacity of the bladder in a given case, and the amount so injected should be noted for future reference. The more fluid a bladder holds, the more easily it can be examined. When the bladder feels full, the fluid is allowed to escape into the test glass, its clearness or turbidity is noted and a fresh quantity is injected into the bladder until the viscus is filled. This is repeated until the boric-acid solution flows into the test glass perfectly clear. At times, this is not possiljle Avhen there is much pus in the bladder ; in such cases, we wash until we get as clear a washing as possible, and then hasten the examination for fear the blad- der fluid will become clouded again before we see its interior. I have fre- quently washed out a bladder for an hour and a half without obtaining a fluid medium sufficiently clear for an examination. This usually occurs in cases of I^us kidney or sacculated bladder. The. test glass is a small glass such as is used for mineral water, or else an ordinary tumbler. Filling the Bladder. — When the washing of the bladder results in the dis- charge of a clear fluid through the catheter, the organ is filled with as much fluid as can be introduced without causing hematuria. The desired amount of distention for cystoscopy is 150 to 200 c.c. (5 to 6 oz.) of fluid in male cases, and 200 to 300 c.c. (6 to 10 oz.) in female. Introducing the Cystoscope. — The instrument, having been well lubricated with glycerin, is then passed into the bladder, practically the same tech- nique being used as in introducing metallic sounds. Very often the in- strument glides into the urethra down to the cut-off muscle, where it meets resistance, due to a certain amount of spasm which takes place if the posterior urethra is involved and tender. The cystoscopist must not attempt to push the cystoscope through this muscle, for if he does it may be attended by a certain amoimt of hemorrhage which would blur the vision; therefore, he should hold the instrument against the muscle, exerting gentle pressure, and soon it will be felt to relax and the instrument will glide through into the posterior urethra and then through the sphincter into the bladder. Sometimes, however, it is not the cut-off which resists, but the vesical sphincter, in which case the same tac- tics are pursued and the cystoscope passes the rebellious sphincter and enters the viscus. A small amount of two-per-cent cocain, injected by means of an Ultzmann syringe or through a very fine catheter into the posterior urethra and the neck of the bladder just before the final filling, will prevent the spasm. This is usually caused by an inflammatory condition beyond the cut-off muscle or the bladder sphincter, which sensitive areas these muscles try to protect through their contraction. Changing the Patient's Position.— The foot board of the table is then low- ered to the full extent, and the patient, if a male, has his legs supported in TECI-miQUE OF CYSTOSCOPY 213 lithotomy iipriglits, or kiieo rests (Fig. 207), after Avliicli liis buttocks are brought to within six inches of the edge of the talAe, the surgeon meanwhile keeping the cystoscope in place by a gentle grasp upon the handle of the in- FiG. 207. — The Patient's Legs Supported by Knee Rests, and the Seat Portion of the Table SLIGHTLY Elevated, the Position usually Employed in the Office. The table is the Alli- son model. striiment. In the case of a female patient, she is already in such a position from the first, and, therefore, does not require to have it changed. The patient's hips may be slightly elevated, as this helps the cystoscopist to examine the bladder more easily. Should the bladder contents become too cloudy before the examination is completed, the cystoscope, in case it is a simple observation cystoscope, should be withdrawn, the bladder once more washed, filled with clear fluid and the instrument reintroduced. The irrigating cystoscope has an arrangement for washing the bladder while the instrument is in place. In order to do this, there must be a small piece of rubber tubing on the nozzle of the irrigating opening, and water should be forced into this through a piston syringe. This not only cleanses the bladder wall, but also the Avindow of the instrument and thus washes away any deposits of blood, mucus or pus, that may have collected there. The fluid escapes from a nozzle on the other side of the instrument. Thus a thorough lavage of the bladder can be made. In my own cystoscope, the lavage can be made through an irrigating apparatus by connecting the tube from a fountain syringe with the nozzle and allowing; the solution to run into the bladder and. Qii.t of the hoi- 214 CYSTOSCOPY low shaft (Figs. 208, 209). The quickest way to cleanse the bladder is tlirouiih the shaft of the instrument, as a larger quantity of solution can quickly run in and out again. The Light. — The power for the light is taken either from the street current by means of a Wappler electric controller, or else from a storage battery on the left side of the patient. One end of the cable is then connected with the cystoscope and the other with the electric controller or the storage bat- tery, after which the operator turns on the current by means of a switch or screw in the handle of the cysto- scope. And here the technique dif- fers according to whether a direct or indirect instrument is being used. If the instrument is indirect, as in the observation part of my own cystoscope, turning on the current is sufficient to allow the cystoscopist to examine the bladder ; whereas, in di- rect cystoscopes of American make, it is necessary to withdraw the ob- FiG. 208. — Washing Out the Bladder. The wa- turator, place the tlinmb quicklv ter is running in from the fountain syringe , . j? ;i i r-. \c through a tube attached to the irrigating nozzle O^er the Opening of the shaft 0± of the instrument; the thumb is held over the end the instrument to prevent the es- of the hollow shaft. The force of the fluid can be £ 'i -Q ' ^ 11 changed by raising or lowering the irrigating jar. Cape 01 tiie nUlU ailU tlieil llltrO- FiG. 209. — Washing Out the Bladder. The bladder has been dilated to its point of tolerance (see dotted lines), the thumb has been removed from the end of the shaft and the fluid rushes out through its lumen, the bladder quickly emptying. TECHNIQUE OF CYSTOSCOPY 215 Fig. 210. — Looking into the Bladdeb. The patient's feet are in lithotomy upright, the position usually used in the clinic. Fig. 211.— AirCystoscope. Patient in partial Trendelenburg position. Bladder being inflated with air from tank on the table. (From Luys.) 216 CYSTOSCOPY duce tlie telescope before the interior of tlie l)la(l(ler can he examined l)y the cjstoscopist. In either case, after the instrument lias liecn introduced and everything is in readiness for examination and the cable connection is made, the examiner sits between the legs of the patient and turns on tlie power until the light is suffi- ciently bright for him to see plainly the interior of the bladder, before pro- ceeding to examine it (Fig. 210). The storage battery, freshly recharged at regular intervals, is generally used for outside work in private houses and in the office or in hospitals, unless electric illumination is present, in which case a controller is preferable. The position of the patient with air cystoscopy is different as, in this case, the patient is in a partial Trendelenburg position which allows the bladder to balloon out to better advantage and the urine coming from the ureter to gravi- tate toward the apex of the bladder and away from the instrument (Fig. 211). DIFFICULTIES IN CYSTOSCOPY Stricture of the Urethra. — The first difficulty encountered in cystoscopy is organic stricture of the urethra. Very few cystoscopes that give a good view of the bladder are less than No. 2-1 of the French scale in size. Therefore, the urethra should be g/: least 25 French in caliber, in order to allow free admission of the cystoscope without causing traumatism or hemorrhage. If the meatus is smaller than this number, it should be cut up to 28 or 30 French and should be treated as any other case of meatotomy for a few days, until it has healed to a larger size, sufficient to admit the instrument easily. If there are strictures along the canal, they should be dilated, if soft and dilatable ; if not, they should be cut to a sufficient size to admit the instrument before cystoscopy is performed. Spasmodic strictures are also common, but they usually yield to instilla- tions of a two-per-cent solution of cocain, given through a small catheter, or by means of an Ultzmann syringe. In case, however, that local cocain anesthesia is not sufficient, a general anesthetic should be administered, preferably nitrous- oxid gas alone or followed by ether. An enlarged prostate that bleeds easily should be treated by a deep urethral instillation composed of equal parts of a two-per-cent solution of cocain and a 1 : 1,000 solution of adrenalin. Pelvic exudates, uterine displacement and pelvic tumors, of sufficient size to interfere with the function of the bladder and to make cystoscopy difficult, are of enough importance to call for a vaginal operation in the first instance and an abdominal operation for the other two conditions. Small, Intolerant and Sensitive Bladders.^Sometimes a few irrigations of the bladder will dilate it sufficiently to allow of a satisfactory cystoscopy, for DIFFICULTIES IN CYSTOSCOPY 217 which 150 to 200 t'.c. (5 to (5 oz.) is usually necessary. Examinations oan, how- ever, he made with two ounces of fluid in the bladder, and I have made them with hut one ftunce and a half, by means of an indirect instrument. In case a bladder is very sensitive, cocain or a general anesthetic should be used, as many blad- ders that will hold but from one to two ounces under other circumstances will, Avhen anesthetized locally or generally, retain four ounces or more. Twenty grains of antipyrin and ten minims of laudanum in an ounce of water, injected into the rectum forty-five minutes before cystoscopy, will often relieve the patient sufficiently to permit a cystoscopic examination. If tlie bladder is found intolerant and will not hold enough fluid, it should be emptied and half an ounce of a one-per-cent solution of cocain, or a two-per- cent solution of eucain, should be injected into the bladder through a catheter. Chismore, of San Francisco, in doing lithotomy in old men, used to inject two or three ounces of a three-per-cent solution of cocain into the bladder as a mat- ter of routine, with no ill effects. Surgeons differ so much as to the strength of cocain used, that it is really a matter of individual experience. In the ordinary case, ten one-half -grain cocain tablets in two ounces of water, making a one-half- per-cent solution, is sufficiently strong for cystoscopic use. In cases of severe tubercular cystitis, a solution of the maximum strength cannot be relied on. If cocain does not produce sufficient anesthesia, nitrous-oxid gas should be used during the introduction of the instrument; and if anesthesia has to be continued, ether should be administered. Distention Hematuria. — Under ether, patients are supposed to hold more fluid in the bladder than when examined without anesthetics. If, under anes- thesia, the bladder holds two ounces and you try to insert three for cystoscopy, you may have a. pinkish discoloration of the fluid, due to the bladder wall being stretched and some capillary leakage resulting, or else bleeding from ulcera- tions, tumors or erosions. Such bladders can often be dilated, under anesthetics, better by means of the fountain syringe than by the piston variety. In this way, after a quarter of an hour of washing, during which time the hematuria may increase somewhat, perhaps five ounces can be introduced into the bladder. In these cases, the time that it takes for this amount of fluid to enter should be noted, and at the next filling a certain number of seconds under this time should be allowed the fluid to run in, to see if hematuria is caused. If hema- turia is caused, then, the next time the bladder is filled, allow still less time for its filling; and so on until a point is reached where, in a certain time, the amount of water entering the bladder is not sufficient to cause a pink discolora- tion of the fluid. On the following injection of the bladder, if five seconds less are allowed, you will be sure to have a clear fluid for cystoscopy. To make this clear, I will cite one or two cases. A patient with a cystitis dependent upon a hypertrophied prostate had a maximum bladder capacity of two ounces of urine. Under an anesthetic, his bladder held three ounces. The 218 CYSTOSCOPY three ounces ran in tlirouoh flic catlictcr in forty-five seconds. The next time, fluid was allowed to run in for one minute; four ounces were then introduced, whicli in escaping was found to be tinged with blood, being slightly pink in color. At the next filling of the bladder, a minute and a quarter was allowed and five ounces entered. The escaping fluid was tlien of a more reddish color. The next time it was allowed to run in for about a minute and a half, and six ounces entered. This on escaping was no more bloody than wlien the five ounces had been injected. The next time four ounces were put in in one minute and the fluid was clear. Five ounces were again put in, which showed on escaping a pinkish tinge, but not as marked as before. It was then felt that a little under four ounces would be the sure capacity of the bladder for cystoscopy without hcnuituria while Tni(U'r an anesthetic. This was accordingly carried out by allowing the fluid to run in for fifty-five seconds. Another patient with tuberculosis of the bladder could hold but an ounce and a half of fluid when his bladder was washed out. Under an anesthetic two ounces entered in half a minute, producing no hematuria. Three ounces entered in forty-five seconds, producing hematuria. On introducing two ounces again, there was no hematuria. Several trials were made with three ounces both through fountain and piston syringe, and each produced hematuria. It was found that two and one half ounces could be put in the bladder in thirty-eight seconds without making the urine bloody. The cystoscopic examination was then made with this amount in the bladder. It must always be remembered that a very sensitive bladder, particularly in tuberculosis, will not dilate to its full capacity, even under general anesthesia, unless it is pushed to a point at whicli it is dangerous to life. Ether is the best general anesthetic to use. NORMAL AND PATHOLOGICAL FINDINGS WITH THE CYSTOSCOPE After the cystoscope has been introduced and the light has been turned on, it is always advisable to pursue a certain routine in the order of examination, so that one may not miss any part of the bladder in the survey and yet may per- form the examination with as few movements of the instrument as possible. We will now speak of the indirect cystoscopes used for observation which are the best for diagnostic purposes. As the field of the cystoscope is limited, we must form a picture of the entire interior of the bladder by means of a series of partial pictures which should so follow each other as the instrument moves that we gain a very accurate knowledge of the entire organ. The rules that Nitze gave for this purpose may be set down here for reference, although each observer will necessarily vary his method somewhat, according to his own prac- tical experience. Nitze advised that the anterior and upper portions of the bladder be in- spected first and the fundus and trigone last. After the cystoscope has been in- FINDINGS WITH THE CYSTOSCOPE 219 trnducod, Avitli tlie mirror ])oiiiliiin- upward and the iiistriiiiient parallel with the tahle, its beak is turned at an angle of 22.5° toward the right side of the j^atient and the instrument is now passed slowly backward until the beak touches the posterior wall. The field of the cjstoscope thus sweeps over a section of the an- terior and upper vault of the bladder, and covers part of the posterior wall. The strip of the illuminated bladder corresponds in width to the angle of the prism which defines the width of the field. As soon as the beak touches the posterior wall, it is turned still farther to the right (i. e., at an angle of 45° from the median line), and is swept for- FiG. 212. — The Cystoscope Introduced INTO THE Bladder. ward, illuminating a strip paral- lel to the first, but lying to the right of the latter, sweeping the beak from behind forward and thus covering the right lateral portion of the bladder. ISText the left half of the bladder is in- spected. This is done by placing the instrument again in the me- dian line with the beak at the internal opening and turning it 22.5° to the patient's left, sweep- ing it slowly from before back- Avard in this position until it touches the posterior wall ; then turning it to 45°, i. e., still more to the patient's left, and sweep- ing it from behind forward, thus covering the two zones lying to Fig. 212a. — Inspection of the Bladder with the Indirect Cystoscope. The excursion made on the right side of the bladder at an angle of 22.5° from the median line of the bladder, aA, and the excursion made at an angle of 45°, Dd. hB and Cc show similar excursions on the left side of the bladder. The cysto- scope turned down in a similar position would easily show the trigone. (From Morrow, after Nitze.) 220 CYSTOSCOPY the left of the nicdian line. With tliese four motions, two to the h'ft and two to the right, practically the entire upper and lateral j)ortion.s of the lihiddcr are inspected {Fig. 212«). There remains to be seen now the fundus and the neighborhood of the in- ternal meatus. For this purpose the instrument is turned so that the beak points directly downward and is swept from side to side from behind forward, or from before backward, until every portion of the posterior wall of the bladder and the trigone has been covered. It is needless to say tliat all these manipulations must be gentle to avoid injuring the bladder wall. Burning the bladder woidd not be liable to occur with the cold lamp now generally used in this country, although it was common when the hot lamp was in use. The direct cystoscope is not so good for observation purposes. It is introduced with its obturator, Avhich is then withdrawn and the direct telescope inserted. It is then pushed well back into the bladder and its beak is tilted up and swept from side to side, in this way showing some of the roof of the bladder with the adjoining part of the anterior wall ; the lat- eral and posterior walls are then examined and the instrument is drawn for- ward until the interure- teral band and the trigone are seen. This applies to direct-air or water cystoscopes, while another telescope, made by Wappler, with an opening in the side near the end, allows us to look back at an acute angle at the neck of the bladder and the prostatic base. Normal Cystoscopic Pictures. — It is necessary for the practitioner to be familiar with the appearance of the normal bladder before he can understand Fig. 2126. — Inspection of the Bladder with the Direct Cystoscope. The beak of the direct cystoscope is moved from right to left and vice versa in examining the floor and roof of the bladder, and from above downward in examining its sides. FINDINGS WTTTT THE CYSTOSCOPE 221 tlio coiulitions seen in a pathological organ. The interior of I he Madder as illii- ininated by the cystoscope has a pale-yellow, orange or a pink tinge, depending for its exact color upon the lamp and prism used. A number of branching blood vessels are seen outlined upon it in darker red, which in healthy bladders are clear-cut and finely drawn. The upper hemisphere of the healtliy bla0,00() inhabitants in which there was no one who could do cystoscopy or cathe- terize the ureters, cut both ureters in doing a hysterectomy. He concluded that if the patient had had catheters in the ureters, the accident would not have lia])p('ucd and lie accordingly l)()ught an air-cathetcrizing cystoscopc. He exam- ined bladders religiously for one year before he could see the ureters. He was then able to find them and he catheterized fifty successive cases before doing hysterectomy. He accomplished his purpose and for a long time was the only- thorough cystoscopist in his city. 230 CYSTOSCOPY The Instruments. — At present all the models of cathGtorizinf>: cystoscopes made in this country have the double canal and can be nscd for observation as Avell ; therefore, in considering- the subject of catheterizing the ureters, only the double-cathetcrizing instruments will be mentioned. The ureteral catheters should be Nos. C to 8 French scale, the latter being the better size to prevent the leakage of urine along the sides. A catheter with a tip No. 6 French gradually increasing in size toward the proximal end is most desirable. The Direct Instrument. — The nreters having been seen as outlined under cystoscopy, a catheter is first passed up the ureteral opening on one side and then the instrument is moved along the interureteral band to the other ureter, and the remain- ing catheter is pushed up in the same way (Figs. 215, 216). The same method applies to the air cystoscope, which is also direct. When the ure- teral orifice cannot be seen, more water should be added by the piston syringe, in the case of water cystoscopy ; or more air by means of a pump, if the air cystoscope is used. The Indirect Instru- ment. — The Bierhoff instru- ment is the one used in this description, and presents more difiiculties in ureteral catheterization than does the direct instrument, as it is necessary to move the cathe- ter toward the ureter in an angle instead of in a straight line. In other words, one must dip the end of the cathe- ter into the opening instead of pushing it straight in. It must be remembered that, as the image is inverted, the movement is liable at first to appear ataxic, and the examiner must consequently learn to turn the wheel on the side of the shaft in what seems to be the wrong way, in order to make the point of the catheter move in the right direction. The ureters are Fig. 216. — Catheterization of the Ureters. The right ureter has been eatheterized by the direct method and the beak of the instrument moved across the interureteral band with the catheter in the left ureter. CATHETERIZATION OF THE URETERS 231 at tlio extremities of the hypothemise of a triangle represented by the inter- urctcral band, the apex of which is the internal urinary meatus. In looking for the ureters, the floor of the bladder must be compared to the dial of a watch, the central point of which should be that from which the catheter protrudes from the instrument, in which case the opening of the right ureter should correspond to twenty-five minutes before the hour and the left ureter twenty-five minutes after. When the catheter is in place and the examiner, looking at the ureteral mouth, endeavors to in- sert the tip of the catheter, he finds that it tends to catch on the side of the trigone, or reach over it. The wheel on the side of the shaft of the instrument is then turned, which projects a knee or finger on the concave surface of the instrument near its base in such a way that it moves the end of the catheter in front of the ureter mouth. When the catheter tip has reached this position, the fingers are removed from the wheel and grasp the catheter and gently push it into the ureter. The finger is then turned down again and the other ureter is lo- cated. During this latter pro- cedure, the first catheter moves entirely out of the field of vision, and may be entirely disregarded by the operator. The second ureter is now catheterized (Fig. 217), the knee again tTirned down and the instrument turned so that the operator may assure himself, before with- drawing it, that both catheters are in situ (Figs. 218 and 219). The cystoscope is then turned within the catheterizing portion, so that the beak points toward the median line of the abdominal wall, the catheterizing portion meanwliile being held, and continuing to jioint downward. The instrument is then slowly withdravv-n, its removal being compensated for by a gradual insertion of more Fig. 217. — Catheterization of the Ureters. The catheter in the left ureter, and on the other side, in dotted lines, the movement of the catheter before entering the right ureter in catheterization by the indirect method. 232 CYSTOSCOPY of the catheters into the cannnljr. When the knees of the instrument, Avith the catheters, appear at the meatus, the catheters are fixed at the urethral orifice M-ith one liand, and the cystoscope steadily withdrawn with the other. In performing cystoscopy, the catheters should be of different colors, so that they Figs. 218-219. — Catheterization of the Ureters. The Catheters in situ. In the first figure the ureteral catheter points to " twenty-fi.ve minutes before the hour," and in the second to " twenty-five minutes after." can be easily distinguished from one another, as a black and a brown, or a black and a striped catheter. The collecting bottles should also be marked right and left. It is thus an easy matter to distinguish and collect the separated urines. With the present system of lenses in the Wappler cystoscopes the image is not inverted and the catheters can easily be introduced without resorting to the maneuvers just described. Should the urine become turbid during the course of the examination, the catheters should be withdrawn and rubber tubes attached to the irrigating noz- zles connected with the cannula^, after which the solution should be forced through one of the tubes from a fountain or piston syringe. The streams then, flowing through separate tubes, are kept distinct, and the one tube may be used for the inflow, the other for the outflow. In refilling, after irrigation, one stopcock is closed, and the bladder filled through the other tube. The Rhythm of Ureteral Secretion — How to Remedy It When Interfered with. — After the catheters are inserted, the plugs, if used, are removed from the ends and the urine is collected in different test-tubes or bottles. Xormally the urine will be seen to come in dribbles, interrupted periodically, each dribble consisting of about ten or twelve drops. If the urine does not flow from one side, it is probable that the catheter is blocked with pus or mucus, and should be aspirated. If this is not successful in reestablishing the flow, a small but measured amount of boric-acid solution should be injected to clear the cathe- CATIIETEKIZATION OF THE URETERS 233 tcr, l)y iiicaiis of u liaiul syringe iiiscrlocl info tlic end of tlic catheter. It nmst be noted whether this all comes away or not and its appearance after it comes away as compared with the solntion before injection, A clear fluid in- jected and a turbid one coming away wonld indicate pus ; a bloody one coming away, hemorrhage ; a less amount of turbid fluid coming away would show that some debris has plugged the catheter. If the fluid comes away clear, it shows that the pelvis is normal. If no fluid enters, it shows that the catheter was l)lugged before using it and it should be withdrawn and cleaned, or else an- other one used. This shows the importance of testing the catheters always before using them and w^ashing them out immediately afterwards. If but one iireler can be catheterized, a soft-rubber catheter should be left in the emptied bladder to collect the urine from the other kidney. The catheterization of both ureters at the same time is very important, as it shows us the comparative secreting activity of the kidneys. We know that the kid- neys secrete normally about forty-eight ounces of urine in twenty-four hours ; or that each organ will average an ounce an hour. This gives a certain standard for us to compare the urines with, although we know that there are certain conditions depending upon ureteral catheterizations wdiich influence in a way the secre- tion of urine. Changes in the rapidity of secretion of the two specimens, of the color and the clearness are also noted, as well as the appearance of the coloring matter in case it is given for testing the function of the respective kidneys. If, on inserting a ureteral catheter into the pelvis of the kidney, a few drachms of urine of normal appearance pours down from that side, it is a case of renal retention ; whereas, if it be of a whitish, turbid flow, pyonephrosis is probably present in that kidney. The primary purpose of ureteral catheterization is the determination of the presence of both kidneys, their function and a comparative examination of the urine from each. After the urines from each side have been collected, they should be examined separately, and the examination recorded on blanks marked ri(j]i( and left l-idney. Diagnostic Value of Ureteral Catheterization in Ureteral Diseases. — Ure- teral catheterization, furthermore, is useful to recognize the presence of and to locate obstruction in the ureter due to strictures, bends or kinks (movable kid- ney), valvular formation, stones and the pressure of bands of adhesions or adjacent tumors. Furthermore, this procedure may be employed for the diagnosis of inflammation, distention or suppuration in the pelvis of the kidney. Ureteral Catheterization as a Therapeutic Procedure. — As a therapeutic pi'oeedure, catheterization may be resorted to lor the purpc^se of increasing kid- ney drainage by dilating the narrowest parts of the ureter; for the ]iurpose of irrigating and treating the ureters and the pelvis when they are inflamed. A 234 CYSTOSCOPY catheter in tlie ureter can also be employed as a guide in some abdominal and pelvic operations, and as a means of permanent drainage. By introducing a catheter, provided with a silver or lead mandrel, and then exposing the abdomen to X-rays, the course of the ureter can be accurately mapped out and strictures, calculi or displacements of the renal pelvis can he detected. The Importance of Ureteral Catheterization in Pelvic Operations. — Ure- teral catheterization is also an important step, prior to hysterectomy, in cases of malignant growths of the uterus, as the independent tumors in the abdomen, not connected with the kidneys or ureters, can thus be made out. Dangers and Complicatons of Ureteral Catheterizations. — These are gen- erally slight, provided two conditions are fulfilled. The first is not to work too long on any one occasion, but, if unsuccessful after working a short time, to have the patient call again and to repeat the calls imtil the catheterization is successful. The second important point is to be careful not to use undue vio- lence in the introduction of the instrument. It is needless to mention the im- portance of as perfect asepsis and antisepsis as possible, both in the preparation of the bladder for the eucain or cocain, and in every manipulation connected with the procedure. It is remarkable how rarely infections of the pelvis and ureters occur if proper precautions are taken in catheterizing the ureters. At the Post-Gradu- ate Clinic, where several hundred cystoscopies and ureteral catheterizations have been performed in the past few years, no distinct cases of renal or pelvic infection following ureteral catheterization have been noticed, although numer- ous attacks of urinary fever have followed in patients whose urethra, bladder or kidneys were already infected. The prophylactic injection of solutions of silver nitrate, 1 : 2,000, with a syringe through the ureteral catheter and into the pelvis of the kidney, and the washing of the bladder with the same solution after every ureteral catheterization, has been carried out in these cases as a mat- ter of routine. This has proved to be a useful precaution against the exten- sion of existing infections and the prevention of a new infection. It must be remembered that a certain amount of blood and a certain number of ureteral epithelia are often found in the catheterized specimens of urine, sim- ply as a result of the mechanical effect of the catheters upon the mucous mem- branes. This should be borne in mind in judging the results of the urinary examinations of the separate urines. Ureteral catheterization has now become so universally recognized as a method of diagnosis and treatment, that it is no longer necessary to plead in its favor or to refute the attacks which have been made upon it by surgeons who were so conservative that they did not care to employ this procedure. The technique is difficult to acquire, but with practice, patience and perseverance, there is no reason why anyone possessed of moderate dexterity, cannot become expert. CYSTOSCOPY IN AUTIIOli'S CLINIC 235 EVOLUTION OF CYSTOSCOPY IN THE AUTHOR'S CLINIC For a loii^- time, altliouiili tlicro Averc assistants in the clinic who Lad studied cystoscopy and ureteral catheterization abroad, the cystoscopy was ])erformed by me alone and none of thoni coidd catheterize the ureters. To remedy this state of affairs, I accordingly established a cystoscopic room, which was probably the first one in this country, connected with a clinic for routine cystoscopy. ISTow every assistant coming to the clinic has to go through a certain course of service — three months in each department of the clinic — so that it requires from one to two years for him to reach the cystoscopic room. Here he is on duty for three months, washing out bladders and preparing patients for cystoscopy, and then for three months more in per- forming cystoscopy and in catheterizing the ureters, at the end of which time he has become very proficient. The result has been that we have developed a cystoscopic school and some of the most expert cystoscopists in this country have served terms in our clinic. It requires about six weeks for each man to become acquainted with the bladder, and six weeks more for him to be able to catheterize the ureters. For- merly, physicians returning from Europe were constantly telling us about the dexterity with which certain surgeons abroad, who taught them, could cathe- terize the ureters. When they attempted to show their technique, however, they usually failed. At present, they find that our methods of catheterization are the simplest and that our cystoscopists have more speed than those in Europe. On one occasion when the question of quickness was being discussed by a body of men visiting the clinic, I requested the cystoscopist in charge of the room to illustrate the speed of our American method. He filled the patient's bladder with solution, inserted the cystoscope and catheterized both ureters in twenty- nine seconds. I do not approve of these trials of speed and it was the only time in our work of ureteral catheterization in the clinic that it has been indulged in, as I feel that, while showing the dexterity of the operator, it detracts from the care- ful and conservative methods which it is our endeavor always to carry out in bladder Avork. After the cystoscopic examination, cither for observation or ureteral cathe- terization, is finished, the patient is again placed in the horizontal position, a catheter is introduced and the bladder, is emptied, after which it is washed out with a 1 : 4,000 solution of nitrate of silver, as is also the urethra. Fifteen grains of urotro])in in a glass of Avatcr is given by mouth, and a suppository is inserted containing ten grains of quinin and one quarter of a grain of morphin to prevent an attack of urethral fever. Fig. 220 is a chart showing bladder laid open, used by me in depicting blad- der lesions seen by cystoscopy. 236 CYSTOSCOPY Reaction after cystoscopy is due to the ])iitient's spasmodic resistance to the passai»'e of the instrument through the urethra, which causes a traumatism and consequently a urethral fever in case the urine or the canal is infe('t(!d. This is intensified in a damaged condition of the kidneys. A slight reaction may Fig. 220. — Diagrams of Bladder used for Keeping Records. Shows, on the left, the base, posterior and part of lateral walls, and on the right, the anterior and lateral walls. occur even though asepsis and antisepsis is perfect, and the bladder and nrethra are washed out after it by silver solution, and morj^hin and quinin solution is given. QUESTIONS REGARDING CYSTOSCOPY In concluding this chapter, I will consider the questions that have been so frequently asked me regarding cystoscopy : (1) Which is the better instrument, the direct or the indirect? (2) Which is the better instrument, the air or water cystoscope ? (3) Which is the easier to catheterize, a man or a woman ^ (1) As to the question, which is the better instrument, the direct or in- direct, I will say that the indirect is the better. This is especially true in the hands of the cystoscopist who is an exjiert in the use of both instruuients^ as with an indirect you can examine the interior of the bladder better, which is the object of cystoscopy. You can also see and pass the catheter into any ureter that can be catheterized by the direct instrument, besides introducing it into many ureters that cannot be catheterized by the direct cystoscope on account of an enlarged prostate, a displaced or deformed bladder, or a cystocele. QUESTIONS REGARDING CYSTOSCOPY 237 With the direct instrnnieiit, it is iinicli easier to catheterize the ureters of ninety-five j)er cent of the patients, if this percentage can be catheterized ; I feel quite certain that they cannot be, the first time, in patliological cases. Once the ureters are seen, the catheters can easily be introduced, as they are simply pushed straight into the openings. The direct cystoscope, however, does not give the examiner as good a view of the entire bladder and, therefore, is not such a good instrument for observation. This led me to bring out the cystoscope that I have described, as it stands for the teaching in the clinic — ^namely, ex- amine the bladder with the indirect telescope ; withdraw it, introduce the direct- catheterizing apparatus and catheterize the ureters. ( 2 ) Which is the better instrument, the air or the water cystoscope ? The Avater cystoscope is certainly better, as the indirect instrument, which is the best general cystoscope, can only be used successfully in a water medium. There is, consequently, remaining for discussion, only that part of the ques- tion as to the relative merits of direct-air and w^ater cystoscopes, and here again I believe that, in the great majority of cases, the direct-water cystoscope is prefer- able. A bladder dilated with water is more tolerant than when dilated with air, and it is less liable to traumatism, as the maneuvers are made in a field full of an antiseptic solution. Formerly the air cystoscope could not be used, as the cystoscopic lamps were too hot and ^vould burn the bladder, and cystoscopy had to be performed in a water medium. The advent of the Mignon cold lamp, brought out by Pres- ton of the Electro-Surgical Company of Rochester, and introduced into the instruments devised by Dr. Koch and Dr. Lewis, made air cystoscopy practical, on account of the bladder being able to tolerate the cold lamp. There are advantages that an air cystoscope has in certain cases, as, for in- stance, when a large amount of pus is coming down the ureter from a kidney and clouding the fluid in the bladder or when blood coming from the kidney renders the fluid medium difficult to see through, in either of which cases the diseased kidney would be determined and the ureters easily catheterized by the air instrument. It is also valuable in certain cases of cystitis with bladder sac- culation. In the treatment of certain conditions, it should be more suitable than the water instrument, as in curetting or cauterizing ulcers of the bladder. It is, however, a more difficult instrument to use than the water cystoscope, as the jiatient complains of pain, and is kept in position with difficulty ; while the leaking of air, and the bubbling up of air and urine disturbs the composure of the examiner. These causes have been sufficient to make the majority of the practitioners who have purchased the instrument put it away, and its use is limited to the specialist with an abundance of material. There is, however, a great field for the air cystoscope if alterations can be made by which the patho- logical field in the bladder can be kept sufficiently smoothed out by air dilatation to allow operative work to be done through the instrument. A cystoscopist 238 CYSTOSCOPY should, therefore, be able to use the direct and indirect water, air and catheter- izing cystoscoije equally well, in order to be proficient in his specialty. (3) Which are the easier to catheterize, men or women? This may be an- swered by stating that it is easier to introduce the instrument into the fenuile bladder than into the male, but once introduced it is more difficult to make the examination in the female. This is because, in the female bladder, the land- marks are not so clearly defined, and also because, in women, the pelvic con- tents are not always normal, especially the internal genitals. Uterine displace- ments change the shape of the bladder and its relations, as do fibroid tumors, the adhesions of exudates about the tubes, the presence of ovarian tumors and the prolapse of the posterior wall in cystocele. CHAPTEK XI SPECIAL URINARY SYMPTOMS I. DISTURBANCES OF MICTURITION Frequency of Ueinatiok (Pollakiuria) rREQUENCY of iirination is perhaps the most common form of urinary dis- turbance. The normal frequency of urination varies somewhat in different individuals and at different times. A healthy person, with a normal urinary tract not pressed upon or interfered with by anything outside of its walls, passes urine five times a day without any difficulty or pain, and with a stream of good size which can be started or stopped at will. At the end of the act, the bladder is empty and no sense of discomfort will be felt in any part of the tract. Urina- tion usually takes place on arising ; at the time of the stool ; before the midday meal ; before the evening meal and on retiring. The temperature plays an important role in the frequency of urination. During the hot weather when the skin is active, much fluid is taken from the body in the perspiration and the amount of urine and the frequency tend to diminish, excepting when the individual is in bathing, when the desire is much increased. In the autumn, the skin becomes less active, additional work is thrown upon the kidneys and the frequency is increased. Wetting the feet in the fall of the year or chilling of the legs increases the amount of fluid voided by producing a congestion of the internal urogenital tract and, therefore, an irritability of the urinary organs bringing on the desire. Autumn frequency is often caused by sitting or standing quietly watching some game or other object of interest, when the circulation is active and the extremities, on account of not being well covered, are chilled. This tendency disappears during the winter when the extremities are better protected by heavier clothing and over- coats. The frequency, perhaps, returns in the spring from a different cause — the sudden begimiing of active perspiration which takes a certain amount of fluid from the urine and renders it more concentrated and irritating. The amount of exercise has the same effect as heat, in that it increases the activity of the circulation and consequently perspiration, when the quantity of urine is temporarily diminished. 239 240 SPECIAL T'RTXARY .SY]\IPTOMS ^Mental emotions i»ive rise to many varieties of frequenev^ -wliifli may nliow themselves in an unexpected desire to nrinate, as in the case of sudden fright. At other times frequency is increased wlien waiting to take part in some event, competition or game, in which the participant is especially interested; in which case, before l)eginning, it may he necessary to urinate three times in an hour, whereas perhaps a few minutes after the affair is over, tlie desire is gone and will not occur again for several hours. Mental association or continuous thought centered upon tlio urinary organs may have the same effect, as students working on the sulijoct eitlier in a literary or clinical way, hut especially the former. Pathological frequency of urination or bladder irritability is a condition in which the urine is not only voided more frequently than normal, l)ut in which the desire to urinate is present again soon or immediately after voiding it. The frequency of micturition observed in disease is variable, ranging from six urina- tions in the daytime and one at night, to an almost continuous desire, or a mic- turition every few minutes. Etiology. — Frequency of urination is due to troubles independent of the urinary tract ; to diseases of the urinary tract ; to affections outside of the urinary tract that interfere with its (the urinary tract's) function. (1) Diseases iNDEPEiiTDENT of the Urinaky Tract. — The diseases inde- pendent of the urinary tract causing frequency of urination are those of me- tabolism, as diabetes mellitus and insipidus, giving rise to overproduction of urine ; nervous disorders, as hysteria, neurasthenia and hypochondriasis pro- ducing an increased amount of urine ; or the character of the urine itself, as a highly acid urine or one containing an increased amount of uric acid, oxalate of lime or indican, the results of faulty metabolism through irritation of the kidney and the consequent polyuria. Frequency may also follow certain articles of diet, as pepper and other con- diments; an abundance of spring water; mineral diuretics, alcoholic drinks, especially gin and beer; certain foods giving rise to intestinal fermentations, as sweets, fried food, onions, radishes, cabbage, tomatoes; also a diet too rich in meat which may give rise to intestinal jDutrefaction. These articles of food, if not properly digested, give rise to the products of faulty metabolism already mentioned: indican, uric acid, diabetes, oxaluria, etc. (2) Diseases of the Uria^aky Tract Giviis-^g Eise to Frequency of Urination. — The diseases of the urinary tract causing this trouble are situated above and below the middle zone of the bladder, principally in the latter. Above this zone, we have the kidney, which causes pollakiuria, owing to a polyuria. The polyuria is generally due to an interstitial nephritis, to a tubercular nephri- tis in its early stages and sometimes to the irritation of a renal calculus. An intermittent pollakiuria is sometimes jDresent in the ease of a movable kidney that has become displaced, wdiere there is an intermittent hydronephrosis, which DISTUKBANCES OF MICTURITIOX 241 on its return to position pours ont a sufficient amount of nrine to give rise to frequency for a brief period. The bladder is, however, usually responsible for frequency of urination, due to a congestion or inflanniiation of its wall as a result of the irritation from a foreign body, as a calculus in its cavity, from tubercular deposits or ulcers in its wall, from tumor, or indirectly from the back pressure owing to some obstruc- tion in the tract below, as the prostate or the urethra; or from an extension oi' an inflammation from the urethra. Most of the troubles in the bladder giving rise to frequency, are those situ- ated in the part below what would correspond to the middle zone of an organ in health Avhcn full of fluid. This would include the base or fundus from the intei-nal meatus to a line above the interureteral band, thus including the trigone. A caJcuhis in this position when the patient is standing, sitting or moving ab(iut, would give rise to irritation and consequent congestion of the bladder nearest the internal meatus; while at night, when he. is sleeping, it would fall away from the posterior wall of the bladder and the patient would be compara- tively comfortable. The shape and surface of the calculus influences frequency, as calculus with a smooth surface that does not come in close contact with the internal meatus produces a less degree of frequency. Vesical tuberculosis resembles closely vesical calculus in the day frequency, excepting that the stream is not interrupted, as it often is when stone is present ; but at night the frequency continues in about the same degree. The frequency in this disease is very great when there is an ulcer near the internal meatus and consequently over the vesical sphincter ; whereas, when ulcers are farther away from it, the urgency is much less marked. In vesical tuberculosis, before ulcers have formed, the frequency is not so great. Vesical tumor does not usually cause such marked frequency as either cal- culus or tuberculosis, as it is not generally situated near the vesical outlet. In all three of these conditions, there is congestion, in the first due to the irritation of the stone, in the second about the tubercular deposits and in the third in and about the tumor. In all these conditions, the closer the contact of the pathogenesis with the internal meatus, the more marked the frequency. The symptoms are also more severe after a cystitis has developed. Impediments to urination also give rise to frequency in different ways and in different degrees. When a bladder has to force urine through a canal in which there is a nar- rov.'ing in some locality, or where its shape has become changed through pres- sure, an extra strain is brought upon it and consequently an extra amount of blood is brought to its walls, resulting in congestion. If this inqiediment is temporary, the bladder quickly regains its normal condition, after it has sub- sided, and the frequency is consequently of short duration and of a varied de- 242 SPECIAL URINARY SYMPT0:MS gree. Tf the impediment is slight at the start and increases slowly, then the bladder becomes accustomed to it and slowly hypertrophies ; tlie congestion is then not marked and the frequency develops slowly and insidiously. If the impediment interferes with the in-ination to such a degree, owing to a mechan- ical obstacle or a weakened state of the bladder wall, that the bladder cannot completely empty itself and a certain amount of residual urine is always pres- ent, occupying a part of the bladder space, then the remainder of the space for the transient urine is consequently lessened and the patient must urinate more frequently on account of this diminished space being filled more fre- quently. Temporary impediments to urination are due, first, to an acute prostatitis, principally of the parenchymatous form ; next, to that of the follicular type, or to an abscess resulting from either of these forms, or to a chronic prostatitis. In an acute parenchymatous prostatitis, when one or both lobes are involved, the inflamed gland grows up into the prostatic urethra, toward the bladder, the same as in prostatic hypertrophy. This gives rise to frequency of urination on account of the inflammation near the bladder neck, and also on account of the residual urine resulting from the impediment itself and the consequent dimin- ished transient capacity of the bladder. If the prostatitis is follicular, then there is simj^ly a bulging into the urethra of a sufficient degree to give fre- quency, due to an increased strain being brought upon the bladder to pass the urine through the narrowed canal. In either of these conditions, an abscess may form, giving rise to an increased effort of the bladder to force urine by the impediment, to residual urine or even to complete retention. When the inflammation subsides or the abscess breaks or is evacuated, the frequency dis- appears or subsides. If it disappears, the disease is probably cured ; but if it subsides and the urine is not clear or shreds are j)resent or prostatic leakage, then the disease is not cured and the slight frequency remaining is the result of a chronic prostatitis. In tuberculosis of the prostate, there is frequency in a varied degTee due to the associated prostatitis and urethritis. This is more marked if it extends to the bladder. When confined to the prostate alone, in time it usually subsides. In prostatic calculus, the frequency also varies in degree and is often very marked, due to an associated i^rostatitis and sometimes to incomplete retention. This subsides slowly after the stone has been removed. Exudates about the urethra in any part w^hich may or may not result in a periuretJnril ahscess, often give rise to temporary frequency of urination, due to the narrowing from the outside pressure, which disappears when the abscess has been incised or broken. If tliere is great pressure in the urethra in these cases, there may be comj^ilete retention of urine. Posterior urethritis occurring during an attack of acute urethritis will also give rise to frequency, often in a very marked degree. DTSTFKBANCES OF MTCTTJRITTON 243 It is easy to imderstand llic inoelianisni of frequency of uriiuitioii in acute posterior urethritis. Normally, the pressure of a few drops of urine in the posterior urethra, as the result of a slight leakage through the sphincter when the bladder is sufficiently distended, is said to be the real cause of the desire to urinate. The desire to urinate is a physiological phenomena, initiated by a cen- ti'iiK'tal irritation of the posterior urethra and the neck of the bladder, by a small (piantity of urine. When the posterior urethra is inflamed, the irritability of its mucous membrane is increased to a high potential and thus the patient is obliged to pass water frequently. Frequency of urination slowly increasing is caused by a chronic impediment to urination, as in the case of stricture or prostatic hypertrophy. A sfridure may be congenital, acquired or traumatic, and the nearer to the bladder it is situated the more marked Avill be the frequency. Congenital strictures are usually linear and situated at the meatus or just in front of the fossa navicularis. The frequency of urination in children is principally due to this condition and there is generally a history of nocturnal incontinence. If these patients develop a urethral inflammation, the frequency becomes more marked. Acquired strictures, resulting from a urethral infection, are the most fre- quent. The frequency in these cases until the stage "when residual urine begins, is due to vesical congestion or cystitis, usually the latter. The frequency is more nuirked, in proportion, during the day than during the night, and increases after dissipation or exposure. Traumatic stricture is due to a fall and the pressure of the urethra between the triangular ligament of the pubis and the impinging body. This is often severe, giving rise to retention and later, perhaps, to overflow incontinence, or to extravasation of urine. In cases of moderate degree with no com- plications, however, a mild but steadily increasing frecpiencv will probably result. Impediment, with residual urine, causes frequency of urination by the vesical congestion resulting from the impediment, and also on account of the lessened bladder space for the transient urine, due to so much of the bladder cavity being taken up by the residual. The frequency will continue to increase in proportion to the amount of bladder space that becomes occupied by the residual urine, and often initil complete retention or overflow incontinence results. In prostatic hypertrophy, the frequency occurs in the same way as it does in cases of acquired stricture and is at first duo to congestion from the extra amount of work thrown upon the bladder in its effort to overcome the obstruc- tion. As the prostate increases in size and the venous return flow from the l)Uiddcr is interfered with, a passive congestion takes place. This is more marked at nialit : for then the circulation is less active than durino- the dav when 244 . SPECIAL URIXARY SYMPTOMS the patient is up and about. The more marked frequency at night thus differs from the frequency of stricture. Later, as the prostate continues to increase in size and pushes up into the bhidder, the residual urine increases, and, as the bladder is more encroached upon by it, the space for the transient urine, therc^ fore, is consequently diminished and frequency increases. This increased fre- quency increases as in stricture, until complete retention or overflow incon- tinence takes place. In prolapse of the uterus, cystocele and vaginal hernia, there is also a poucli of the posterior wall of the bladder, giving rise to residual urine and conse- quently less room for the transient urine ; the patient, therefore, passes urine more frequently, just as he would in case of prostatic hypertrophy. (3) Feequency of IlRiNATioisr Due to Disease Outside of the Uri:n^art Tract Interfering w^th its Function. — First among these, are the injuries and diseases of the spinal cord and brain (usually the latter), as the sclerosis or tumors press upon them, increasing pressure slowly and causing an inter- ference with their circulation. Here the innervation of the bladder is interfered with, there is loss of power in its wall, the desire is not so imperative, but the patient feels the neces- sity of passing urine more frequently in order to avoid dribbling of urine. This increased frequency, the result of mental calculation, increases until there is a larger amount of residual urine and a consequent overflow retention. Interference from without, when there is no disturbance of the innervation of the bladder, is due to the pressure or pulling of some perivesical tissue with which it is in close relation or to which adhesions have formed. Seminal vesiculitis causes frequency w'hen the vesicles are enlarged, tense, acutely inflamed or adherent to the bladder. The seminal vesicles are at times very large, the size of the finger, which gives rise to a sense of fullness of the bladder when a small amount of urine has accumulated in it. At other times, the tense feeling of the seminal vesicles is transmitted to the bladder, which lies in front and above them. Adhesions to the bladder, if the walls of the vesicles are thick and inelastic, give rise to a sense of discomfort when the bladder is stretched a little. In these cases, the feeling of discomfort or fullness is transmitted to the suprapubic region. The frequency in seminal vesiculitis, as in stricture and stone, is more marked in the day than in the night. The uterus, when misplaced, causes frequency of urination. This is espe- cially annoying when it is displaced forward in such a way as to rest on the bladder, and by its position causes a feeling of discomfort to such a degree, when a small amount of urine has accumulated in it, that, in order to be relieved, the patient must empty the bladder. Again, when the uterus has fallen back and pulls the bladder with it, there is a feeling of discomfort from pressure on the pelvic plexus of nerves, from interference with the function of the bladder, and perhaps from residual DISTURBANCES OF MICTURITION 245 urine that accumulates in the back of the bladder, resulting in a desire to urinate. An inflammation of the tubes also interferes with the function of the blad- der, through holding it to one side by adhesions and interfering with its dilata- tion and contraction, and consequently causing frequency. An exudate, infiltration or abscess, due to a pus tube or to a torn or septic uterus, may press upon the bladder from without so as to prevent it from dilat- ing, except to a limited degree, and thus, by diminishing its capacity, neces- sitate voiding wdien but a small quantity is present. Tumors in the pelvis pressing upon the bladder, on account of their weight, shape or size thus interfering with its dilatation, may give rise to frequency. This condition creates a sensation of fullness before the bladder is actually full, or it may be that pressure only allows the bladder to fill partially. Instances of this are fibroids of the uterus, hydatid in the recto-vesical space and appen- diceal abscess in the pelvis. Cancer of the uterus, involving the bladder wall, may also give rise to fre- quency of urination, through the congestion it causes ; through interfering with the vesical contractibility ; through the infiltration of its wall ; or through the irritation of an ulcerating area. Malignant tumors of the rectum produce much the same result. A loop of atonic dilated sigmoid, in case of fecal retention or a sigmoiditis, may press upon the bladder sufficiently to give rise to frequency or even to re- tention. This is a much more frequent cause than is generally realized. In women, this loop is often caught dow^n and held by adhesions resulting from salpingitis. The omentum, when adherent to the bladder, may pull it in any direction, thus interfering with its function. This is generally due to pelvic inflammation starting as a salpingitis. It may also pull other tissues or organs against the bladder, TABLE OF FREQUENCY OF URINATION A, Causes Independent of Diseases of the Urinary Tract Temperature Mental emotions In hot weather, due to prolonged bathing in cold watei,*. In autumn, due to diminished perspiration and extra work thrown on the kidneys. In winter, due to wetting of the feet, chilling of the extremities. In spring, when the sudden active perspiration begins, it is due to concentrated urine charged with irritant properties. Fear, anxiety, excitement, or thoughts regarding urinary troubles or brought about by clinical or literary work on the subject. 246 SPECIAL URINARY SYMPTOMS Diet Polyuria Vesical congestion or cystitis Interference- temporary Urethral Interference- slowly increasino- Condiments, mineral waters, alcoliolic drinks. Certain vegetables giving rise to intestinal fermentation. Too much meat giving rise to intestinal putrefaction. The faulty metabolism from this diet giving rise, through in- dicanuria, uricacidemia, oxaluria and diabetes, to renal irri- tation. Diseases of ]\Ictabolism : — Diabetes insipidus and mellitus. IsTervous Disorders : — Hysteria, neurasthenia and hypochondriasis. B. Dependent on Diseases of the Urinary Tract Interstitial nephritis. Tubercular nephritis. Calculous nephritis. Movable kidney (temporary polyuria). Vesical calculus. Vesical tuberculosis. Vesical tumor. Prostatic impediment. Urethral impediment. Parenchymatous prostatitis. Follicular prostatitis. Suppurative (abscess) prostatitis. Chronic prostatitis. Tubercular prostatitis. Calculous prostatitis. Acute posterior urethritis. Exudates about the urethra. Urethral calculi. Periurethral abscess. Stricture, frequency due to vesical congestion or inflammation until residual urine begins. Prostatic hypertrophy, due to vesical congestion or inflamma- tion until residual urine begins. Stricture and prostatic hypertrophy, due to lessened bladder space to hold the transient urine after residual urine has begun to be present. Prolapse of uterus, due to lessened bladder space to hold the transient urine. Vaginal hernia, due to lessened bladder space to hold the tran- sient urine. Cystocele, dne to lessened bladder space to hold the transient urine. Interference with residual urine DISTURBANCES OF MICTURITION 247 C. Dependent on Diseases Outside of the Urinary Tract Interfering with its Function Interference — temporary Interference- slowly increasing Interference with residual • urine ' Seminal vesiculitis. Salpingitis. Abscess, exudates, infiltrates. , Appendiceal abscess. ' Hydatid cyst of pelvis. Tumor of rectum. Sigmoiditis or sigmoid retention, Displaced uterus. Uterine fibroids. Sclerosis of the cord Tabes dorsalis. Lateral sclerosis. Tabes dorsalis. Lateral sclerosis. Injuries and diseases of the brain. Sclerosis of the cord Consecutive Cases of Feequency of Urination. — In 2-iO cases coming to my clinic during the winter of 1907, frequency was found to be due to a single cause in 127 cases. Mixed causes, namely, two or more pathological con- ditions tending by their combined action to cause this, occurred in 113 cases. List 1 Cases of frequency in which a single condition was found as a cause at the time of the visit. Urethritis 46 Stricture 25 Prostatitis (including 1 case of tuberculosis) 23 Seminal vesiculitis (including 1 case of tuber- culosis) 10 Cystitis (including 3 tubercular) 7 Prostatic hypertrophy 5 Movable kidney 2 Tumor of bladder 2 Stone in bladder 2 Contracted bladder (frequency from dimin- ished capacity) 1 Dilated bladder (transient capacity or di- minished space left for urine over the amount of residuum) 1 List 2 Cases of frequency in which a number of pathological conditions were found as contributing causes at the time of the visit. Urethritis 43 Stricture 38 Prostatitis (including 2 cases of edema and 2 cases of tuberculosis) 80 Vesiculitis (including 2 cases of perivesic- ulitis) 73 Cystitis 46 Prostatic hypertrophy 6 Prostatic abscess 5 Tumor of bladder 3 Nephritis 5 Pyelitis 4 Pyelonephritis 3 Renal calculus 3 Ulcer of bladder 1 Sarcoma of prostate 1 Note. — In looking at this table, we will see that urethritis was present in 89 cases of frequency, stricture in 63 cases, cystitis in 53 cases, prostatic hypertrophy in but 11 cases, while prostatitis was present in 103 cases and vesiculitis in 93 cases. This can be explained by saying that ure- thritis, stricture, cystitis, and prostatic hypertrophy are the principal active causes of frequency; whereas, prostatitis and vesiculitis, excepting in the real acute attacks or in tubercular cases, are usually contributory causes. This list was compiled by Dr. Nelson of Cincinnati, 248 SPECIAL URINARY SY:\IPT0:\IS In the list of cases in Avliicli we could ascribe the frequency to one cause, the largest number occurred in the following order : Urethritis, stricture, prostatitis, seminal vesiculitis, cystitis and prostatic hypertrophy ; whereas, in the remain- ing cases, there was no marked number under any one disease. Of the com- bined causes, we will also see that these six conditions were more or less present in the majority of the cases. This list embraces 2-1:0 consecutive cases of fre- quency coming to the clinic during the -winter session. In my hospital work, the causes are different singly and combined ; stricture is the most common cause, next acute prostatitis, posterior urethritis, vesical tuberculosis, vesical calculus and prostatic hypertrophy. Of these, stricture, prostatic hypertrophy, vesical tuberculosis and vesical calculus are generally accompanied by cystitis, while acute prostatitis and pos- terior urethritis are usually complications of acute anterior urethritis. Treatment of Frequency of Urination. — Treatment of frequency of urina- tion varies largely according to the cause, and is considered in the various chap- ters dealing with each of the conditions involved. This leaves but few words to be said regarding the general treatment of functional frequency of micturition. It is imjDortant to keep the feet warm and dry during the fall and winter, to increase the clothing in accordance with the temperature of the air. All excitement which would tend to cause local irritation should be avoided. The diet should be simple mixed animal and vegetable, taking a small amount of a variety of food rather than a large amount of any one kind. Uried foods and sweets should be j)artaken of sparingly. Condiments, salted and pickled food, should be avoided. Alcoholics should be avoided or restricted. Spirits, ale, beers and champag-ne, are the worst drinks, whereas red wines are the least harmful. About three pints of water should be taken in twenty-four hours. In the therapeutic line, hot Turkish baths should be taken twice a week, hot sitz baths before retiring. If there is any fecal retention or trouble witli the pros- tate gland or seminal vesicles, hot rectal douches are better than hot sitz baths. Massage of the prostate and vesicles is of value in diseases of these organs, unless they are tubercular. If the urine is very acid, alkalines should be given, preferably acetate or citrate of potash. Of the mineral waters, the most satisfactory in my judg- ment is Celestine vichy. If much pus is present, urotropin, salol, benzoic acid and benzoate of soda, are the best urinary antiseptics. If there is acute inflam- mation, santal oil is the best. For relieving the frequency, especially if spasm is present, the antispas- modics, as belladonna and hyoscyanms, codein, morphin and the bromids are the best. For bladder irrigation, solutions of boric acid, nitrate of silver or protargol are the best. Tor bladder injections, small quantities of argyrol, ten to twenty- five per cent, gommenol or iodoform emulsion, are the most efficacious. DISTT^^BANCES OF 1\rTrTFKITIOX " 249 Tlie bowels slidiild Itc kept npcii by cascara sagrada, salines, such as phos- phate of soda, Apeiita or some mild mineral laxative waters, and should be as- sisted if necessary by glycerin sn])])ositories or rectal enemas. Moderate exercise should be taken. Dysuria ok Isciiukia Dysuria, or ischuria, is a term which, Avhcn correctly used, ajjplics to dif- ficulty in voiding urine and may be accompanied by pain and a spasmodic condi- tion of the bladder at its neck, known as tenesmus. Dysuria does not mean painful micturition, pure and simple. Just as dyspepsia stands for an inabil- ity to digest food, so dysuria stands for a difficulty to pass the water. Dysuria may occur suddenly as an unforeseen event ; for example, when a stone becomes jammed in the neck of the bladder or Avhen a papilloma of the bladder suddenly twists in such a way as to block the orifice. In other condi- tions, as, for example, in hypertrophied prostate, in tumors of the prostate and in strictures of the urethra, dysuria often conies on gradually, the difficulty in passing water becoming more and more pronounced. In the milder forms of dysuria, the act of urination is merely accompanied by a slight amount of exertion in which the accessory muscles, the abdominal and the perineal, are brought into action. In severe forms, the individual may be unable to pass water, except in certain positions, as squatting or leaning over and bracing against stationary objects. In these severe cases, the face may be- come agonized, red with swollen veins ; pers]3iration appears in beady droj^s on the forehead, the breath is held and the lips are compressed in the effort at expulsion, which is repeated periodically with intervals of rest and is accompanied often by an involuntary discharge of gas and feces. When the patient is in the squat- ting position, a prolapse of the rectum of two inches or more may take place. This is the clinical description of the symptom dysuria as such. Of course, a number of other disturbances of micturition and of allied clinical signs are very frequently associated wdth this particular manifestation. Among these, frequency of micturition, retention and overflow incontinence, pain during, before and after the act of urination may be grouped in a syn- drome, each element of which can be analyzed and set down by itself as having its own significance. Dysuria being present, the question arises to what cause it should be at- tributed ? Our first thought, of course, will be the presence of some obstruc- tion which prevents a free and normal outlet of the stream. The chief causes of such an obstruction have already been mentioned. They are stricture of the urethra ; prostatic hypertrophy ; stones in the bladder or the urethra ; tumors of the bladder or the prostate ; or acute inflammatory swelling of the mucous membrane of the neck of the bladder or the prostatic urethra. A form of dvsuria depending only upon a spasmodic contraction of the 250 SPECIAL rlllXARY SYMPTOMS sphincter may bo styled a nervous dysnria. It may ho followed later hy in- continence and is characterized hy an ahsence of all local evidences of disease of the urinary organs. Whenever such adysuria is present, a suspicion arises as to the j)resence of a spinal disease. Dysuria of inflammatory origin is simple in its mechanism, depending upon the congestion and swelling of the parts, and is usually fairly easy to recognize by the history and symptoms. In the presence of an acute urethritis, the onset of dysuria with painful and frequent micturition is the signal of the involve- ment of the jDOsterior urethra. It occurs in an intense degree, especially if ac- companied by fever, when an acute involvement of the prostate should be feared, unless excluded by rectal examination. When dysuria and other disturbances of micturition occur in tlie course of a chronic urethritis, we are led to suspect stricture. If the patient is advanced in age, and if the dysuria has been coming on gradualh', increasing apace with frequency of urination, we naturally look for hypertrophy of the prostate. A characteristic of the dysuria of prostatics is that the symptom is aggravated at night. Rest in bed, a horizontal position of the pelvis, a sedentary life and the presence of constipation, are all factors Avhich increase the dysuria of prostatics. One of the most interesting forms of dysuria is that due to stone in the bladder. In this form, patients, instead of being aggravated when lying in bed, are relieved by the horizontal position, while the upright position and any jars or jolts, as in walking or running, in which the stone has a chance to become lodged in the vesical orifice, increases the discomfort. A temporary dysuria frequently occurs after urethro-vesical instrumenta- tion — as after the passage of a cystoscope, sounds, or other dilating instruments —and after irrigations by the Janet method, or deep instillation of strong solu- tions of silver nitrate. This should be termed a false dysuria, as it is simply due to irritation and not to a pathological condition, and is usually of very brief duration. All varieties of dysuria are frequently accompanied by more or less pain, or at least by a sensation of pressure and burning which is quite distinct from that of an exaggerated desire to urinate. The latter is a sensation of pressure or burning, which cannot exactly be called a pain, in fact, can scarcely be anal- yzed, yet it forms part and parcel of the mixed sensations experienced by patients afflicted with dysuria. In certain conditions, the contraction of the bladder walls in trying to overcome the obstacle, whatever that may be, gives rise to a colicky pain. This vesical colic may be an accompaniment of dysuria. It is characterized usually by a gTadual onset, a rapid rise to a climax, followed by a remission. Usually it is located in the body of the bladder, accompanied by intense desire to urinate, and may radiate to the perineum, the rectum or the urethra, or into the hypogastrium, the groin, or even the loin. Vesical colic is an accompaniment also of retention, especially of the acute DISTURBANCES OF MTCTTTRTTTON 251 form. It is dwc to Iroiihlos aecf)iii]iiini(M| liy residual iiriiic, to lesions seated in the upper zone of the bladder or to that covered by })eritoneuni ; to deep-seated lesions and to perivesical troubles. Bladder Extra- vesical causes Prostate \"esical tumors < CONDITIONS GIVING KISE TO DYSURIA ''Vesical calculus, especially if it obstructs the neck of the bladder. Papillomas, if they obstruct the vesical neck. Intiltrated or malignant, if they interfere with, dilatation and contraction of the bladder. Acute inflammation of the bladder neck, the congestion of the mucous membrane imparting the sensation that the bladder is not entirely emptied. ' \^esiculitis. Appendicitis with bladder adhesions. Salpingitis. ' Uterine displacement. ' Uterine. Ovarian. Kectal. Hydatids. Inflammatory exudates. Pressure of sigmoid. • 1 f In Retzius' space. Abscess J ^ Inflanunation outside of the bladder Extravesical pressure Pelvic tumors < Pelvic. Adhesions of omentum. Extravesical -J Adhesions of tubes. traction Adhesions of large intestines. 'Calculus in prostate. Tumors of prostate. r Parenchymatous. Acute prostatitis J Follicular. iHypertrophy. [ Abscess. Calculus in any part of the urethra, but most marked in the pros- tatic portion. Acute posterior urethritis, the sensation of obstruction being due to intense congestion. ^Stricture accompanying chronic urethritis. Periurethral exudates. Periurethral abscess. Urinary extravasation. Nervous difficulty due to lesions of the spinal cord. Urethra Extra- urethral 252 SPECIAL URINARY SYMPTOMS Painful Micturition Under this headino;, we shall discuss pain which either precedes, accompanies, or follows the act of micturition. This symptom is of the greatest imjjortance in urological diagnosis, as it often enables us to localize and to define the char- acter of urinary diseases. Micturition is made jDainful in the presence of congestion, inflammation, ulceration, new growths, calculi, foreigTi bodies or traumatism, either in the bladder, the jDrostate or the urethra. There is, however, a group of conditions of the kidneys and the ureter which indirectly give rise to painful micturition. Of these, perhaps, the most prominent is due to stone in which small calculi pass down the ureter and stick just above or at the opening into the bladder, giving rise to a sensation akin to those in the bladder, the prostate, or the urethra. Painful micturition is a prominent accompaniment of cystitis. In the milder degree, especially of the chronic type, it is not very pronounced. In the acute form, the pain is very distressing and the same may be said of the tuljer- cular form, especially when accompanied by ulceration. In tumors of the bladder, painful micturition is also one of the important symptoms, becoming marked when the new growth involves a large portion of the organ and Avhen it ulcerates. Stones or foreign bodies in the bladder, especially if they be rough or pointed, may cause intense pain during the act of micturition. The rule is, so far as the time of occurrence of the pain is concerned, that, in bladder conditions, the acme of intensity is reached at the end of the act of expulsion — that is, when the greatest amount of vesical contraction takes place. The character and the position of the pain during micturition, when due to bladder conditions, is not distinctive. It may present itself as a tenesmus or burning sensation at the neck of the bladder, or it may be located in the hypo- gastrium, radiating to the end of the penis, the groin or even the loin. The pain of stone in the bladder is characteristically located at the end of the urethra. In posterior urethritis and in inflammations of the prostate, painful urina- tion, accompanied by dysuria, and frequency, constitute a very frequent and important set of symptoms. Usually the pain is felt at the beginning of urina- tion, when the posterior urethra is distended by a rush of urine. The contrac- tion of the posterior urethra at the end of micturition causes an exacerbation of the pain at that time. Painful micturition may also be present without any organic affections of the urinary organs, when the character of the urine is such as to irritate the lower passages. Among these conditions may be mentioned phosphaturia, oxaluria, nricacidemia and other conditions in which there is an excess of crys- talline elements in the urine. DISTITKEANCES OF MICTURITION 253 (2) Congestion or inflammation of the bladder (cystitis) dne to PAINFUL MICTUKITION (!) Ureter: — Calculus near or at the opening into the bladder. Vesical calculus, especially if rough or pointed. Vesical tuberculosis with ulcer near the urethral opening. Vesical tumor, especially when ma- lignant or ulcerating, or if it comes in contact with the urethral open- ing. Vesical ulcer. Impediment from below, pressure from without, displacement or an interference with its functions. Gonorrhea, giving rise to an acute prostatitis. Tuberculosis. Calculus. Tumors (especially malignant). Gonorrhea ^ • m • i Jiispecially m the posterior portion. (3) Congestion or inflammation of the prostate (prostati- tis) due to (4) Congestion or inflammation of the urethra (urethritis) Stone Crystals For treatment, see the treatment of the trouble under the special chapters. Changes in the Urinary Stream Changes in the urinary stream include alteration in the shape, caliber, force and rhythm of the stream. The form and direction of the stream is altered in epispadias, hypospadias, fistula, abnormalities of the meatus and other anomalies. There are certain changes in form that are transient and depend upon the gluing of the meatal lips by discharge. In such cases, the stream may be twisted, flattened or split for a few seconds, but wdien the meatus has been washed by it, the stream again becomes normal. Persistent changes in the form of the stream indicate the presence of strictures. They may consist of a special tM'isting, a flattening, or a splitting of the stream into several smaller jets, depending on the distribution, size, or amount of thickening forming the stricture. In stricture, these changes may be accompanied by difficulty in passing water. The caliber of the stream varies greatly according to the size of the meatus, 254 SPECIAL URINAET SY]\rPTOMS i. e., the nozzle tlirontih wliicli the stream iinist ])ass. If tlie iiientus is narrow, the stream is fine, hut when the nieatns is normal and the stream is very small, the presnmption is that there is a stricture farther back. The force of the stream depends npon the force of contraction of the de- trusor muscle of the bladder and tlie amount of the obstruction or interference. The force normally depends upon a variety of circumstances. If the bladder muscle is tired by long retention in normal conditions, the stream is weaker. It is also weaker in old people. Any condition which injures the bladder mus- cles or interferes with free circulation, will cause the force of the stream to be diminished. The stream loses its force in a variety of nervous conditions, notably in scleroses of the cord (tabes and lateral sclerosis), and in other diseases of the brain and cord in which the action of the detrusor is impaired. In the pres- ence of any obstruction of the stream, there is usually a period of compensa- tion at first, during which an increased muscular action overcomes the re- sistance, and the stream remains normal in force. Later, however, an atonic condition of the bladder develops and the force of the stream is diminished. This is especially the case in hypertrophy of the prostate, in stricture of the urethra, etc. In prostatic hypertrophy the bladder wall may be strong and the urethra of large size, as is evidenced after the passage of a large-sized catheter and the escape of a forceful stream of urine through it, and yet if no catheter is passed, the prostatic obstruction will be found sufficient to slow and diminish the force of the stream. The force of the stream is also lessened when the bladder contractions are interfered with, \vhere there are adhesions of the omentum, tubes or intestines to the bladder, displacements of the uterus, pressure of pelvic tumors and inflam- matory exudates. The rhythm of the stream means its normal uninterrupted flow, beginning with a strong, steady stream and gradually diminishing. The last drops are then expelled by a contraction of the accessory muscle. In old people, the last part of the act is considerably less forceful and the same may occur in people who retain their urine for a long time. Interruption in the stream of urine, known sometimes as urinary hesitancy, or urinary stammering, occurs in a variety of conditions. These include many in which there is dysuria, the interruption then being due to a necessary relaxa- tion of the auxiliary muscles of micturition. Another cause of interruption of the stream is a spasmodic contraction of the vesical sphincter, such as occurs in acute inflammations in and about the neck of the bladder, as, for example, in acute prostatitis. Finally, the stream of urine may be interrupted in cases in which the bladder itself is free from disease, as in spinal diseases in which the vesical reflex is increased, causing a contraction of the sj^hincter during the DISTURBANCES OF MICTURITION 255 act, wliicli interrupts the streniii. Infiauiiiiations of tlie rcctinn, acting- reflexly upon the bladder, may also produce the same effect. When small stones, pediculated growths, or tonguelike projections of pros- tatic tissue are present, the stream may be interfered with. RETENTIOISr OF TJrINE This term designates an inability on the part of the bladder to empty itself, because of loss of power or obstruction. It is variously classified as complete or incomplete, according to the degree of retention ; acute or chronic, depending upon the duration and severity of the attack ; and traumatic, paralytic or ob- structive, referring to the nature of the cause. ^ Complete retention, from whatever cause, is a condition in which the pa- tient cannot pass any urine from the bladder ; it is incomplete when he can empty it only in part, a certain residuum of an ounce or more, remaining in the bladder. The urine which passes represents the excess over this residuum, or the transient urine. Acute retention occurs when the patient suddenly finds that he cannot pass any urine, though he may never before have had any diflfi- cult}^ It is chronic when for a long time he has not been able to empty his bladder ) and paralytic when his inability to void urine is due to paralysis of the bladder wall, owing to disease of either brain or cord. Retention is obstructive when, owing to some growth or impediment in or about the neck of the bladder or at some point of the urethra, either no urine or not all of it can be forced out. It is traumatic when some wound gives rise to an impediment, either within the urethra itself or on the outside, which presses upon it. Occasional acute attacks of retention may be due to operations, alcoholism, profound temporary stupor, or voluntary refraining from urinating. The loss of power is variously referred to as paralysis, paresis and atony. There is really very little difference between certain degrees of these conditions. Complete paralysis of the bladder is found when, on account of some brain or cord lesion, it is incapable of expelling any urine; partial paralysis, when the bladder is not able to empty itself fully. Paresis is another name for partial paralysis, and atony is a condition where, through lack of power, the bladder wall cannot force out all the urine. Both in atony and paralysis, the bladder may be constantly distended by urine to a certain extent, perhaps to its utmost limit, as a passive sac,_and the excess of this residuum may dribble away in- voluntarily (overflow incontinence) ; or it may be expelled in small quantities by repeated acts of urination in the ordinary way, accompanied by great strain- ing and assisted by the voluntary contractions of the muscular wall of the abdomen. ' Guiteras, "Retention of Urine," A''. Y. Medical Journal, May 20-27, 1899. 256 SPECIAL URINARY SYMPTOMS The causes of atony arc: Ovcrdistcntion Ly neglecting to urinate, invuliin- tary retention in cases of fever and coma, and nretliral obstructive conditions. The muscular coat of the bladder may be paralyzed from any cause that will induce loss of muscular power in other parts of the body, and the paralysis may aifect either the detrusor urina', or the sphincter vesica^ or both at the same time. Power may be diminished or wholly lost, and this impairment of func- tion may be temporary or permanent. The muscles of the bladder which expel or retain the urine are only ]iai'tially under control of the will. Thus the contraction of the detrusor is involun- tary, being occasioned as a reflex from the stimulus of the urine in the bladder. When sensibility is diminished and the presence of urine no lf)nger acts as a stimulus on the detrusor, the result is urinary retention. The com- pressor urethras must relax under the influence of the will before the contents of the bladder can escape. It is well to remember also that the bladder muscle may be directly paral- yzed by overdistention, as already stated, or by inflammation extending fr(jm either its mucous or its serous coat. Causes. — Acute Retention. — Acute or temporary retentions may be due to operations on or about the external genitals, anus or rectu^ii, or upon parts of the body quite distant from this locality, bringing about a spasmodic inability to urinate. It may also be due to acute alcoholism ; to large doses of opium, belladonna or hyOscyamus, especially when given by rectum ; or to profound temporary stupor, such as occurs in typhoid fever or other adynamic diseases. Voluntary refraining from urinating until the bladder is so full that its walls are unable to contract, as when one is in company where no opportunity is af- forded, is also at times a cause of retention. It may also be found in pregnant women, due to some displacement of the uterus, which presses upon the bhuhh^'. If it occurs after delivery, it is due to displacement of the bladder or to the effect of long pressure upon its neck during delivery. Acute attacks may also occur during chronic obstructive conditions, such as stricture or enlarged prostate from various causes. In the majority of cases, retention is due -either to organic nervous lesions or to obstructions involving the urethra or prostate. Chronic Retention (Complete or Incomplete). — Certain organic nervous diseases cause retention. In paraplegia, in hemiplegia, in locomotor ataxia and in lateral sclerosis, w^e may have complete or partial retention due to motor paralysis. In Pott's disease, we may have retention with incontinence, due to paralysis by interference with the vesico-urethral nerve centers. In injuries of the brain and spinal cord the same applies. These are at- tended by important changes in the urinary system as well as in the urine. These changes do not seem to be connected with the particular locality of the DISTURBANCES OF MTCTITRTTTON 267 injury. They occur almost uiiifonnly, wlicther the injury affects the Inmbar, the dorsal or the cervical region. In the varions forms of spinal sclerosis, there may be more or less complete retention, in tlie earlier stages of a spasmodic natnre (dnring the stage of ex- citement ), and, later, dne to paralysis. The OhstrudlcG Causes. — They are principally situated in the prostate or the urethra, although vesical calculi may enter the neck of tlie bladder and lodge there. Displacement and fracture of the pelvic bones, especially of the ]uibes, may also cause obstruction. Prostatic causes of obstruction are acute prostatitis, prostatic hypertrophy, tumors, cysts, calculi or tuberculosis. The urethral cause is usually a stricture. The retention may be due to an acute congestion of the mucous membrane or of the submucous tissue about this lesion, or it may be a late symptom dependent upon the great obstruction offered by the stricture itself. In either case, it is apt to be preceded by a his- tory of fatigue, cold or alcoholic excesses. Spasm of the urethra aids in closing the canal. Foreign bodies or calculi in the urethra may also cause retention. Atresia is another cause. This may give rise to complete retention in the new born, if the urethra is impervious ; or, if it is slightly pervious, the trouble will come on gradually. This latter condition is really a congenital stricture. Wounds of the urethra also give rise to retention, either by causing a con- gestion or an exudate which narrows its caliber, or by pressing upon its walls on the outside and thus rendering it impervious. Extravasation of urine, due to rupture of the urethra from an injury or wound, or to rupture of a urethral follicle, may allow of sufficient leakage of urine into the surrounding tissues, either in the pendulous portion of the iiretlira or the perineum, to block completely the canal by its pressure. Abscesses or cellulitis starting in the urethra or surrounding tissue may also exert enough pressure upon the urethra to shut it off. Symptoms. — The symptoms of retention vary in a marked degree. In an acute attack of retention, such as occurs after an operation or during a fever, the patient complains of pain steadily increasing in the suprapubic region, and of a sense of fullness and inability to micturate, associated with a constant de- sire. On palpation over the pubes, there is a feeling of tenderness and disten- tion, and perhaps a globular tumor can be seen (Fig. 221), extending up toward the thorax. Eectal examination may reveal a tumor filling the pelvis like a gravid uterus. Chronic complete retention rarely occurs, as an overflow incontinence usu- ally renders it incomplete. It may be observed, however, in certain cases of paralysis or obstruction. In complete retention, such as occurs in some cases of paralysis, tlie jiatient nmy not have been able to void a drop of urine for 258 SPECIAL URINAEY SY:MPT0MS months. There is, however, when the hladder is full, a sensation, or, in cases of paralysis, where sensation is not perfect, a knowledge of how long it takes the bladder to fill, so that the individual knows when the time has arrived to have recourse to the catheter. In chronic incomplete retention, the symptoms are different, as all eases have residual urine, and the condition often develops so slowly that the pa- FiG. 221. — The Outline of the Abdomen in a Case of Retention. tients do not know that they cannot empty their bladders until they have been so informed by the physician after an examination. A patient with a weak bladder may carry for many years about a pint or more of clear urine as a residual deposit, w^hich its weakened walls cannot throw off. An excess of the fixed residuum produces a desire to urinate, and the patient, mainly by volun- tary contraction of the abdominal muscles, is able to void this excess. In chronic incomplete retention, acute attacks of complete retention occur principally when there is obstruction to the escape of urine in the form of stricture or enlarged prostate. A patient with prostatic hypertrophy suffers from chronic incomplete re- tention, in addition to which his bladder is usually atonic and chronically inflamed. The usual symptoms are those of congestion, pain, frequency of mic- turition, in addition to which the urine is thick and foul-smelling if cystitis has developed. After overeating or drinking, or exposure to wet or cold, these patients suddenly find that they cannot pass urine. As the bladder dilates, they have a feeling of pain and a sense of retention, which is usually relieved by the methods wdiich we shall mention under Treatment. Cases of acute attacks of retention due to stricture are also common. Here also there is usually a certain aiuount of residual urine in the bladder. In bad cases, the urethra behind the stricture is dilated, at times even as far back as the neck of the bladder, which itself becomes dilated and no longer acts as a sphincter, giving rise to an overflow incontinence. In such cases, it is often difficult to expel any of the remainder of the urine. Great straining and pro- lapse of the rectum may accompany the efforts. In chronic incomplete retention, where the bladder cannot emj)ty itself, cys- DISTURBANCES OF MICTURITION 259 titis iisiiallj develops, after which sufficient bacteria remain in the residuum to contaminate the fresh urine flowing' into it. Diagnosis. — When one is caRed to see a case of suspected retention of urine, it is necessary to ascertain first if it is really retention, and then inquire care- fully into the history of the case : whether it is complete or incomplete ; and if complete, whether it is an acute attack or not; and if an acute attack, whether the ])atient has had others of a simihir nature. It is then important to know if there is any other symptom, g'eneral or local, which may give us some clew as to the cause of retention; also to ascertain age and family history. To be sure of an attack of retention, there are certain other conditions that must be excluded, as anuria, rupture of the bladder and extravasation of urine. It is strange how generally anuria and retention are confounded with one another. Anuria is a condition where either the function of the kidney has ceased or the urine is prevented from entering the bladder, whereas, in reten- tion, the bladder contains urine, but cannot empty itself. If no urine can be passed by the urethra, and it is a question between anuria and retention, a bi- manual examination per rectum and suprapubically will usually disclose the presence of a large fluid tumor if it is retention, and a catheter inserted into the bladder will draw off a quantity of urine in vesical retention and none in the case of anuria. Rupture of the bladder can be distinguished from retention, as in the former case there is no well-defined globular tumor present, and a catheter passed by the urethra will bring away only a slight amount of urine and blood. The patient will complain of great pain and tenderness in the suprapubic region and perhaps of strangury. If the rupture extends into the peritoneal cavity, general abdominal pain, an elevation of temperature, and rajjid pulse will soon follow. In extravasation of urine, vesical retention may also be present on account of the pressure of the exuded urine on the urethra and it may be impossible to pass an instrument into the bladder on this very account. The extravasation can be seen as a swelling in the perineum, external genitals, or even extending to the abdominal wall. The history of a case of retention will reveal a great deal, as will a survey of the symptoms. For instance, if there is history of an operation on tlie geni- tals or about the rectum, an acute attack of retention can be ascribed to that source. If the patient has had a stroke of apoplexy, a fracture of the skull, or is suffering from a disease of the cord, or other evidences of paralysis, we can assume that the retention is due to one of these causes. To show that injury to the cord is followed by bladder dilatation, I will quote an experiment of Budge, who found that division of the cord in the lower dorsal region was fol- lowed by increased reflex action of the sphincter and a greater degree of dis- tention of the bladder than could be produced after death. 260 SPECIAL URINARY SYMPTOMS It is rarely tliat retention is so complete tliat not a drop of nrine can he passed, bnt we do at times observe cases in comi)lete and partial paraplegia in which not a drop can he voided without the catheter. Having excluded paralysis as a cause of retention, we should then look for some local trouble to account for it. If the patient is a man over fifty-five years of age, with a history of trouble in urinating, the stream coming tardily, and if ho has sufi^ered from such frequency of urination as to be obliged to get up often at night, and if, on certain occasions, he was imable to pass his urine except when aided by a hot bath or by hot local applications, we can assume that he has some prostatic trouble, and can examine him per rectum and per urethra to see if obstruction is present there. If an enlargement is found, it is prob- ably occasioned by senile prostatic hypertrophy. Of course, there are other prostatic troubles that may give rise to enlargement, as acute prostatitis, malig- nant tumor, tuberculosis and cystic conditions, but these are rare. If the patient is a man between twenty-five and fifty years of age, has had several attacks of urethritis, and has recently urinated with increased frequency and wdth some difficulty and pain, his urethra should be explored for stricture, and if one of small caliber is found, it is probably the cause of his retention. Treatment, — The treatment in retention of urine varies and depends upon the cause, form and degree of the trouble, and may be divided into temporary, palliative and radical methods. It is my intention to consider the different forms from the standpoint of degree and cause. Acute Attacks of Complete Retention. — In acute attacks of complete retention, such as occur after operations in toxic, comatose conditions, or fevers, the surgeon should insert a soft-rubber catheter into the bladder and draw off one pint of the urine. If then hot applications are made over the pubes, the patient will probably be able to pass urine, after an hour, without difficulty. If not, the catheter should again be introduced at the end of two hours, and again every three hours, until spontaneous urination has been reestablished, drawing off each time only a pint of urine. This will usually take place after a few catheterizations, although sometimes it requires a longer period. Acute Attacks of Complete Retention Occurring in Cases of Chronic Incomplete Retention. — Attacks of this nature, occurring in people who have a certain amount of residual urine habitually, are those most commonly encountered. They usually occur in men suffering from stricture or enlarged prostate and are generally caused by exposure to cold or wet, dissi- pation, or by excesses in eating or drinking. Here the patient suddenly finds that he cannot urinate, although he has been able to pass a fair amount at fre- quent intervals, for some time. This is a critical moment for him, as it is often here that his future woes begin. A case in this condition should be handled with the greatest care, as the bladder and, perhaps, the ureters and jDelves of the kidneys are more or less DISTURBANCES OF MICTURITION 261 distended or congested and in a favorable condition to Lc infected. The cathe- terization should, therefore, l)e made under the strictest asepsis or antisepsis, and care must be taken to avoid lacerating, wounding or bruising. (See chapter on Asepsis and Antisepsis.) The treatment of these attacks, or exacerbations of chronic ones, is the same as that of an acute attack independent of a chronic condition ; namely, to pass a catheter and draw off a pint of urine, another pint in two hours, and then a pint every three hours until the patient can urinate spontaneously, as has just been mentioned. Frequently, however, a catheter will not enter, in which case the patient should have a hot sitz bath, which may enable him to pass a small amount of urine while seated in the water. If, however, he is unable to pass any urine in this way, he should then have a hypodermic injection of a quarter of a grain of morphin, hot applications over the pubes and perineum, and should lie down for about an hour, when another attempt should be made to catheterize him, at first with a small soft-rubber cathe- ter, and, if unsuccessful with such an in- strument, then with a woven one with an olivary tip. If the patient is an old man, an elbowed woven catheter should be used. In case these measures do not meet with success, he should be given another hot sitz bath and another attempt at catheterization should be made. Fig. 222.— The Blasucci Catheter. Contains a mandrin with a pliable filiform guide at its end, seen in the bladder. 262 SPECIAL URINARY SYMPTOMS Sometimes, when other catheters fail, the Blasiicei instrument can be passed (Figs. 222, 223 and 224). If this attempt fails and he cannot i)ass Fig. 223. — The Blasucci Catheter. The mandrin and filiform are being -nathdrawn from the catheter. nrine, he should be aspirated suprapubically and a pint of urine with- drawn, after which he should be aspirated every four hours until he is able Fig. 224. — The Blasucci Catheter. The mandrin has been withdrawn and the urine is seen flowing into a basin. DISTURBANCES OF MICTURITION 263 to urinate spontaneously, or a catheter can be passed. In case such a re- sult is not obtained, an operation should be performed, preferably a perineal section. It is very rarely, however, that an immediate operative procedure has to be resorted to, as these patients are almost always able to pass sufficient urine to be relieved if a catheter cannot be inserted. In case it is difficult to pass the catheter at any time, when one finally enters, it is prudent to tie it in for twenty- four hours and insert a plug, which can be withdrawn every two or three hours, until the bladder is empty. In twenty years of the most active practice in bladder surgery, I cannot recall having had to aspirate more than three patients. The best lubricant is glycerin ; next to this, Casper's prescription : I^ Hydrarg. oxycyanat gr. iijss ; Glycerini f ovss ; Tragacanth gr. xlvj ; Aquse dist. sterilizat f^iij- The mixture is put up in tubes. In case a catheter does not easily pass with such lubricants, half an ounce of sterile olive oil, which is more than the anterior urethra will readily hold, should be injected and held in for several minutes in the hope that some of it will pass through the stricture and lubricate its walls. Before allowing any oil to escape from the meatus, while the urethra is still somewhat dilated, an attempt should be made to pass a catheter or filiforms. If a catheter can be introduced into the bladder, it may be allowed to re- main as a retained catheter. It should be plugged, and every two hours, until the bladder is empty, twelve ounces of urine should be withdrawn. In case neither a soft-rubber nor woven catheter can be introduced, an en- deavor should be made to pass a filiform. If successful and some urine escapes by its side, it may be left in place, in the hope that the urine will drain off by its side ; or a metal tunneled catheter may be forced over it into the bladder, thus allowing as much urine to be drawn off as Ave desire. I do not advocate this latter procedure, however, unless it is considered desirable to operate immediately afterwards. If a patient cannot pass urine and an instrumcut cannot be introduced that will allow the escape of urine, then there are but two things to do. One is to perform paracentesis (aspiration), ancl the other a radical operation. It is probable that by keeping the patient in bed and resorting to the palli- ative methods already referred to, he will be able to urinate spontaneously in a few hours, but only in small quantities ; or else the congestion will go down sufficiently to allow the catheter to be passed. Patients may be aspirated fre- quently, each time but a pint of urine being withdrawn ; I have known a patient to be aspirated over one hundred times without any ill effects. 264 SPECIAL URINARY SYMPTOMS Paracentesis should always be performed by tlie suprapubic route. The point for the introduction of the instrument should be in the median line, just above the symphysis. The trocar should be pushed inward and downward for about two inches, the stilet should then be taken out and a certain amount of urine withdrawn (Fig. 225).' A piece of plaster should be placed over the puncture and the patient put to bed. Fig. 225. — Paracentesis. The grooved cannula or an aspirating needle is thrust through the ab- dominal and bladder walls, just above the pubes toward the tip of the forefinger, which is in the rectum just above the prostatic base and acts as a guide. The complete emptying of the bladder at once may produce a distention of the blood vessels of the urinary tract and a consequent engorgement of its sur- face. Within a few hours, the urine may contain a little blood (hematuria), in- dependent of mechanical injury. If the urinary tract was infected before or during the catheterization, the temperature may rise, the tongue become dry and DISTURBANCES OF MICTURITION 265 brown, and the patient may develop a condition known as nrinary fever. If the ]iatient's kidneys are damaged, even if no infection is present, the kidneys may l)ecome congested, resnlting in nremia and death. The renal congestion may even give rise to death in a few lionrs from suppression. The conservative method recommended of gradually evacuating the bladder may be used with advantage in cases of retention. It consists, first, in evacuat- ing about one pint of urine by catheter, which should be plugged and retained. At intervals of two hours, until the bladder is empty, the plug should be with- drawn and twelve ounces of urine allowed to escape. CirRo:xic Complete RETENTioisr Due to Paralysis. — In chronic complete retention due to paralysis, such as occurs in cases of transverse myelitis, the patient should be catheterized every six hours. CHROisric Complete Retention Due to Obstruction. — In chronic com- plete retention due to obstruction, the treatment should be the same as in chronic eases due to paralysis, if this is possible. These cases are, however, almost al- ways due to hypertrophy of the prostate or to stricture, so that, in the former condition, w^e should be obliged to use an elbowed soft-rubber or woven catheter. In such cases, pain, irritation and tenesmus are often so great that the catheter may have to be passed more frequently in order to give the patient relief. In- ternal urinary antiseptics, bladder irrigations of antiseptic solutions by means of the catheter, and antispasmodics by the mouth or rectum, should be given. Chronic Incomplete Retention Due to Paralysis. — In chronic incom- plete retention due to paralysis, the bladder w^all is partially paralyzed, residual urine is present, and cystitis is apt to occur. Here the frequency of catheteriza- tion should depend on the amount of residual urine present; if four ounces, once a day; four to eight ounces, twdce a day; eight to twelve ounces, three times a day ; over twelve ounces, four times a day. If, in addition to this, cystitis is present, we should wash out the bladder every day or two through the catheter with some antiseptic solution, as one of boric acid or silver nitrate, and give internally a urinary antiseptic. In all cases of chronic incomplete retention, the treatment of the inftamed and atonic ivall of the Ijladder is to be considered. A patient may live for years with a chronic cystitis, if his bladder is treated properly. This trouble is gen- erally not curable, but few inflammatory conditions yield to treatment with more gratifying results to both the physician and the patient. The methods of toning up an atonic bladder are: By using remedies which will excite contraction of the bladder wall, such as strychnin, cold sponging, or douching over the pubes, and counterirritation to the spine. Civiale recommended cold-water injection into the bladder, beginning with tepid w-ater and gradually decreasing the temperature to 60° F. This should be done after emptying the bladder. Two or three of these injections may be given one after another. These generally excite contractions, which, once hav- 266 SPECIAL UrvlNAKY SYMPTOMS ing begun, will bring about favorable results. The daily injections for a fort- night will usually cause marked improvement. The faradic current given by placing one pole over the lumbar or hypogas- tric region, and introducing the other into the bladder in the form of a hard- rubber sound, with a metallic tip, is often of great service. This should be moved around until it comes in contact with the different parts of the bladder wall for five minutes at a sitting. Various preparations, such as those of iron, strychnin and other tonics, are recommended. Chronic Incomplete Retention Due to Obstruction. — In chronic in- complete retention due to obstruction, we have a very common condition, such as is usually seen in cases of enlarged prostate or tight stricture. The treat- ment of the bladder in these cases should depend very much on the amount of residual urine. The bladder should be catheterized as often as indicated and irrigated with an antiseptic solution. A urethral stricture, if present, should be dilated. Radical Treatment. — The causes of complete or incomplete retention, when obstruction is due to mechanical interference, should be treated by opera- tion, as recommended in the respective chapters on these subjects : urethrotomy for urethral stricture and prostatectomy for prostatic hypertrophy. The classification of retention of urine is as follows : (1) According to the degree of retention (3) Cause (2) Degree of intensity and dura- tion Comj^lete — when no urine can be passed. Incomplete — when not all the urine can be passed. Acute Chronic Obstructive. Traumatic. Paralytic. When the patient suddenly finds it impossible to urinate. An acute attack taking place during chronic incomplete retention, is really an acute exacerbation. When the patient habitually, for a considerable time, has not been able to empty his bladder. In the following table I classify them according to acute and chronic, speak- ing first of the purely acute ; then those purely chronic, which will be divided into complete and incomplete. DISTURBANCES OF MICTURITION 267 Acute attacks of complete reten- tion may be due to Chronic retention (complete or incomplete) Acute parenchymatous prostatitis. Follicular prostatitis. Stricture or prostatic hypertrophy. Alcoholism. Temporary stupor. Voluntary refraining from urinating. Fever, as typhoid. Pregnancy. Urethral calculus. Extravasation of urine. Periurethral abscess or cellulitis. Fracture of the pelvis. ' Paraplegia ^ ^ .. T-T- . n . ^Jcrom disease or miury. Hemiplegia J Tabes and lateral sclerosis. Pott's disease. Prostatic hypertrophy. Prostatic tumors or cysts. Urethral stricture. Atresia in the newborn. In chronic cases of partial retention (that is, when there is residual urine present), the patient may suddenly find that he cannot urinate, thus making an acute attack of retention. In paralytic and chronic obstructive cases, there may be an overflow retention or incontinence. Incontinence of Urine Definition. — True incontinence is the involuntary discharge of urine through the urethra. False incontinence is a condition in which an irresistible desire to urinate occurs, causing the patient to void every few minutes, or giving rise to precipitate urination. Varieties and Causes. — The following table shows the varieties of true in- continence and their causes: I. Retention with Incontinence or Overfeow Incontinence. (1) Due to an obstruction in the vesico-urethral path f (a) Strictures of the urethra, trau- matic or acquired. (J)) Chronic enlarged prostate. (c) Foreign bodies, stones, tumors blocking the path; outside pressure ; or cystocele. 268 SPECIAL URINAKY SYMPTOMS (2) Due to a change in the nerr oiis mechanism of the blad- ^ der (3) Due to a loss of muscular tone of the bladder (a) Locomotor ataxia ; myelitis ; pa- ralysis. (Bladder paralyzed.) (h) Comatose conditions; apoplexy; cerebral concussion ; narcotic poisoning. (Consciousness of desire abolished.) Senile atrophy of the bladder. II. Without Retention. — Due to insufficiency of, or interference with, the sphincter mechanism from the following causes : (a) Enuresis nocturna in children. (1) Idiopathic or functional (2) Mechanical (&) i^ervous and physical incon- tinence in adults ; hysteria ; neurasthenia. Stone or foreigTi body or tumor in the neck of the bladder, partly holding the sphincter open. (3) Tuberculosis of the neck of the bladder, giving rise to loss of tissue from ulcerations that prevent its uniform closing.^ For prostatic abscess. For stricture. For perineal p r o s t a - tectomy. (4) Traumatic," after (a) Perineal section (5) Atonic, affecting the sphinc- ter only I (h) Bottini operation. (c) Forcible dilatation of sphincter, (d) Fracture of the pelvis affecting sphincter. (a) Aiter childbed, with subinvolu- tion of the uterus. (b) In old women, with atrophy of the genito-urinary organs. 1 This condition described by many authorities is probably rare, as the author has never seen a case of true incontinence in vesical tuberculosis that he could prove to be such either by clinical methods or post-mortem findings. Many cases of false incontinence in vesical tuber- culosis resemble true incontinence so closely as to be mistaken for it. ^ Childbirth, with tearing of the vesical sphincter usually given as a cause of incontinence, has been omitted from this table, as in fifty-five thousand (55,000) cases in one of the largest ly- ing-in hospitals in the world, no such case has been recorded. Its presence on the list together with the usual causes might mislead the practitioner for whose use this table has been prepared. DISTURBANCES OF MICTURITION 269 Clinical Features. — The clinical types which can be distinguished are as follows : (1) Dribbling. (2) Sudden discharge of entire contents of the bladder at intervals, giving bladder time to fill up. (3) Discharge of the contents of bladder by steady pressure over it. (1) Dribbling. — This is characteristic of overflow retention in true in- continence. In most cases the accumulation of urine gradually overcomes the resistance of the sphincter and the urine begins to dribble out. As the bladder keeps filling up, there being usually polyuria in these cases, the dribbling continues, with interruptions. Usually the overflow dribbling of retention appears at night, but later continues through the tM^enty-four hours. Dribbling may occur without retention in those cases of incontinence in which the sphincter is interfered with. (See Table II, 2, 4.) Sometimes in these cases the discharge of small amounts of urine may be brought about by sudden jars, such as occur in coughing, sneezing, etc., while the bladder may retain its contents during sleep. Slight dribbling is also due to a few drops of urine collecting in dilations behind strictures, in cases in which the bladder sphinc- ter holds. (2) Sudden Discharge of the Entiee Contents of the Bladder at Intervals, Giving the Bladder Time to Fill up Again. — The involuntary discharge of large amounts of urine in a steady stream, from time to time, while the fluid is retained in the intervals, is characteristic of enuresis nocturna in children ; of cerebral conditions accompanied by coma ; of narcotic poisoning, concussion, epilepsy, etc., in which cases the patient does not feel any desire to urinate, though the bladder be full. (3) Discharge of Urine by Steady Pressure on the Bladder. — This is a symptom indicating the reverse of the above, namely, a lowered reflex sus- ceptibility of the organ, and occurs when the reflexes are generally lowered in locomotor ataxia, myelitis, etc. This form of incontinence is characterized by the fact that the contents of the bladder can be readily expressed when pressure is made upon the suprapubic region. The pressure on the bladder, however, that usually causes such incontinence, is a fibroid or subinvoluted uterus, an abdominal or pelvic tumor, or, in some cases, the weight of the intestines in ptosis, or of the omentum when standing. Diagnosis. — True incontinence is distinguished from false by the subjective presence in the latter of the desire to urinate. We must be sure, of course, to exclude cases of willful discharge of urine in bed, etc., for the purpose of nuilin- gering. If an examination, general and local, fails to reveal the causes of true incon- tinence, we can assume that the case is one of false incontinence. Among the causes of false incontinence are the followino-: Acute inflannua- 270 SPECIAL URINARY SYMPTOMS tion of the posterior urethra in verv nervous iii(livi(hials; any of the causes of true incontinence which have not reached ihc jioint where they are beyond the control of the will ; acute prostatic trouhles ; and tuberculosis of the bladder. The last-mentioned is the most common and typical of all causes and should always be suspected. Treatment of Incontinence. — Strictures, where there is bnt slight dribbling after urinating', due to dilatations behind them, are nsually situated anteriorly, and dilatation or internal urethrotomy should be resorted to. In cases in which there is overflow incontinence, the stricture is usually deep-seated and of long standing, and would reqnire an exter- nal urethrotomy. When due to enlarged prostate, the gland should be enucleated, or a Bottini opera- tion performed, or catheter life resorted to. For- eign bodies and stones holding the sphincter open and occluding to a sufficient degTee, to cause re- tention, should be removed. Tumors should also be removed if the growth has not involved too much tissue. In locomotor ataxia, myelitis and paralysis, the bladder should be emptied four times in twen- ty-four hours, and should be washed with silver solution and a urinal be worn (Fig. 226). Some- times in cerebral lesions, the condition improves somewhat, but in diseases of the spinal cord there is rarely any improvement. Cases in which the bladder is atonic should be treated by uitrate-of- silver irrigations, by electricity to the inside of the bladder, injections of cold water and internally by iron and strychnin. In enuresis nocturna in children, the child, if a male, should be circumcised. He should be ex- amined for a congenital urethral stricture, which should be cut if present. He should sleep with a knotted towel about him and with the knots behind his back. He should be awakened at a certain time to empty his bladder. Internally, he should have hyoscyamus and bromid before retiring. If five years of age hyoscyamin, gr. •g^; bromid, grs. v. In cases of hysteria and neurasthenia, bromid, belladonna and hyoscyamus should also be given. Fibroid tumors pressing on the bladder should be removed. A uterus press- ing upon it should be fixed in place by shortening the ligaments or by anchoring Fig. 226. — The Method of Wear- ing A Urinal. The rubber urinal is strapped about the hips. The external genitals fit in the pouch below the pubes, from which a tube runs down to a reservoir on the inner side of the leg. CHANGES IN THE AMOUNT OF URINE ' 271 it to the abdominal \vall, well u]). Bad tears of the bhadder sphincter during childbirth should be immediately repaired. Extensive cuts through the sphinc- ter at the time of operations for stricture or prostatic abscesses, in the Bottini prostatotomy, or in perineal prostatectomy, may give rise to an incontinence, for the treatment of wliich no satisfactory remedy has yet been devised. Time, electricity, prostatic and vesical douches, and tonic remedies may benefit them; but many of the bad cases are never cured. Subinvolution of the uterus after childbirth should be treated by curettage and ventral suspension. In many cases of incontinence, the cause of which cannot be discovered by the history, examination, or urinary analysis, the patients are relieved by symp- tomatic treatment. In women cystocele is a frequent cause, in which case they are readily cured by an anterior coljDorrhaphy and repairing the perineum. A prolapsed uterus should be suspended, and an anterior colporrhaphy or perineorrhaphy performed, if indicated. There is no other condition in urinary diseases so trying to the patient as urinary incontinence; therefore, every means should be taken to discover and remove the cause. Cystoscopy should give us a clear idea of the condition -of the bladder. If no cause is seen and if no disease of the nervous system is discovered, an exploratory laparotomy should be performed with the object of seeing if there is any interference with the bladder function from the outside. A large gynecological service leads me to believe that, in women, such inter- ference is due to adhesions of the bladder to the neighboring structures, and that the consequent displacement and interfered function of the bladder is more com- mon than was formerly supposed. II. CHANGES IN THE AMOUNT OF URINE POLYIJKIA The term polyuria indicates an increased secretion of urine and is a symp- tom, not a disease. There is, however, a form of polyuria which seems to exist independently of any other condition and is known as " essential polyuria " or polyuric diabetes. The term polyuria is usually applied to cases in which the amount of urine exceeds two liters in twenty-four hours. It must be carefully distinguished from frequency of urination, because, as we have seen, the latter may exist with a normal amount of urine. The amount of urine for twenty-four hours should be accurately measured before making a diagnosis of polyuria. Malin- gering by the patient who may add water to his urine should be excluded. Etiology. — Transient polyuria may exist from extraneous causes in health, and can usually be made out without difficulty, as in people who drink large 272 sPE(^rAL URTXARY SY:\rPTo:\r?; anioniits of cold Avatcr and coiisciiiicntlv have a polyuria of rciiiai'kalilo (lo;Lir('o within a few hours. Warm enemas, and warm Huids drunk give rise to a poly- uria. The same is true of a cold bath, while a hot bath diminislies the auiouut of urine secreted. The ingestion of diuretics and other tliera])eutic measures also transiently increases the urinary secretion. Other imporiaut causes of polyuria are sudden emotions, epileptic seizures, nervous strain, mcutal ai)pli- cation occurring especially in those not accustomed to it, causing a ])olyiiria wliic'h disappears as soon as the mental work is discontinued. This uuiy be termed " nervous polyuria." The polyuria of convalescence is another type of the transient form. This includes the increase in the amount of urine noted at the end of many diseases. The object of this is to rid the system of certain products which are excreted in large amount, as, for example, the chlorids in pneumonia. A convenient division of the polyurias occurring from organic diseases is into the moderate polyuria, reaching up to four liters, and the marked polyurias, reaching as high as ten liters and over. The moderate type, according to Merck- len, indicates disease of the urinary organs, while the marked polyurias are seen in diabetes mellitus and diabetes insipidus. The causes of polyuria may be thus tabulated, after Castaigne's description : A. MODERATE POLYURIAS I. Due to Renal Disease. (a) Chronic interstitial nephritis, (b) Amyloid kidney. (c) Reflex congestion of the kidney. (d) Pyelonephritis. (e) Tuberculous kidney, II. Due to Heart Disease. Permanent in persons with cardiosclerosis, III. Due to Liver Disease, Cirrhosis (sometimes). IV, Due to Nervous Causes. Hysteria. Epilepsy. Exophthalmic goiter. Cerebral hemorrhage. Reflex from ]\Ieningitis. Sclerosis of the cord. General paresis. Sciatica. Mental strain. CTTANCES TN TTTE AlVfOT^NT OV T^RIXE 273 B. iMARKED rOLYlIKIAS I. Glycosuria — diabetes mellitus. II. Uricacideiiiia — nitrogenous diabetes. III. Phosphaturia — phospliatic diabetes. IV. Diabetes insipidus — hydruria. The urologist is especially interested in the first group of polyurias, due to renal disease. Even if interstitial nephritis and amyloid kidney have been excluded, there may be a polyuria due to trouble further down in the urinary tract. The urethra, bladder, prostate and ureter should be examined to make sure of their integrity. Frequently strictures, chronic cystitis and hypertro- phied prostate are reflex causes of a polyuria, or else the ascending infection to which they give rise produces a pyelonephritis and so gives rise to a polyuria. (See Table A, I, a, b, c and d.) With the latter there will be purulent urine from the pelvis of the kidney on ureteral catheterization, while wdth the reflex form of polyuria in these conditions the urine will be clear. Anuria Definition. — The word anuria is derived from an, without, and ouron, urine. It means, therefore, literally a total absence of urinary secretion, although, clin- ically, we understand by anuria the absence of urine from the bladder, which is ascertained by the introduction of a catheter into this organ after the patient has failed to urinate for some time. Etiology. — Anuria may be due either to an arrest of secretion of urine (nonobstructive anuria) or to an obstruction in the ureters (obstructive anuria). A. NoNOBSTRiJCTivE Anuria — A SUPPRESSION OF Urine. — A ccssatioii of the secretion of urine may be induced (1) by disease of the secretory apparatus of the kidney, (2) by circulatory disturbances affecting the renal circulation, (3) by certain nervous affections, or (4) by toxic agents. (1) Anuria due to lesions of the kidney may occur in either acute or chronic nephritis. In acute nephritis due to scarlet fever or other causes, there may be suppression of urine due to a degeneration of the epithelium of the tubules, with or without involvement of the glomeruli. In chronic nephritis the kidney may become so atrophied and sclerosed that it no longer contains sufficient secre- tory elements to maintain the process of excretion. The anuria of chronic nephritis, however, is more frequently the result of a complicating passive con- gestion, or an edema of the interstitial tissue which so compresses the urinary tubules that secretion is arrested. (2) Anuria due to circulatory disturbances is produced by a venous stasis in diseases of the heart, or else by large double infarcts of the kidney. In the 274 SPECIAL URIXARY SYMPTOMS former type, the chief factor is the dilatation of the right ventricle, which pro- duces venous stasis of the kidney. There is always a disease in the kidney in such cases, and the venous stasis suffices to produce edema of the interstitial tissue and thus to choke the tubules. Cases of double plugging of the ureters by desquamation, as in scarlet fever, or by suppuration products, in cases like nephritis, or of other origin are reported. Such cases must, however, be very rare, the lesion existing by far more commonly as unilateral. (3) Anuria due to nervous causes may depend on a variety of conditions. Complete suppression of urine has been noted in some cases of hemiplegia from fracture of the skull. More frequently, however, anurias are due to reflex in- hibition of secretion. It appears that an irritation in one kidney can so aifect the other organ reflexly, that anuria may follow\ Thus may be explained the anuria of renal colic, following operation upon the kidney or injury of that organ. Extensive burns may also produce reflex anuria, although the absorp- tion of toxins may have something to do with these cases (Castaigne). In hysteria, the anuria is probably also reflex, although the exciting cause is not always apparent. (4) Toxic anurias may occur in the course of infectious diseases such as cholera, scarlet fever and in acute peritonitis and affections of the colon and small intestines. The toxins probably act by affecting the renal tissue, as well as by disturbing the circulation. B. Obstructive A:s^urias. — The second group, the obstructive anurias, are of great interest to the modern surgeon, particularly because they can be reme- died by timely intervention. They result either from the blocking of the lumen of the ureter or from its compression or kinking. Among the obstructive causes w^e have, foremost, renal calculi. The mechanism and pathologA- of this form of anuria has been described in the chapters on calculus of the kidney and of the ureters, respec- tively. It has been said that it is not necessary to have a stone in both ureters, but that the presence of stone on one side often acts reflexly by inhibiting the secretion of the opposite kidney. This is a course of events which Guyon has described, but it is probably of rare occurrence. In most instances, the anuria due to stone on one side arises because the opposite kidney had not been working for some time, and when the calculous kidney, which alone was capable of excreting urine, was blocked, a total suppression of urine resulted. Albarran has gone so far as to say that calculous anurias may exist without the actual presence of a calculus in the ureter at the time when the symptoms occur. Compression of the ureter may produce anuria in such conditions as cancer of the bladder, the prostate, the uterus or the kidney. Kinking of the ureter in floating kidney may be accompanied by obstructive retention on one side and arrest of secretion on the other. CHANGES IN THE AMOUNT OF URINE 275 Symptoms. — Amiria can exist for a long time witliont giving rise to any symptoms. Jt also occurs at times with astonishingly few symptoms. The phenomena of renal insufficiency and of uremic poisoning, which are described elsewhere under the heading of Uremia, come either slowly or suddenly, ac- cording to the type of uremia, acute or chronic, which develops as the result of the suppression of urine. Usually the first symptoms are gastro-intestinal in character, including nausea, anorexia, vomiting, eructations and either consti- pation or diarrhea. Headaches, restlessness and other nervous phenomena of uremia are also among the early symptoms. Patients with anuria may die within a few hours, showing the acute form of uremia in its most pronounced type. They may also live for days and even weeks without showing any acute symptoms and linger on toward a slow death with the manifestations of chronic uremic poisoning. The occurrence of a nonfunctionating kidney on one side is more common than it is generally thought to be. I have occasionally seen such an organ, both larger and smaller than normal, due to some suppurative process, calculus, tu- berculosis or some other cause, where the parenchyma had been destroyed and nothing but a sclerosed mass or shell remained. I have cut into such kidneys at operation and had little or no bleeding. In a case where such a kidney is present, if the remaining organ is suddenly incapacitated, an attack of anuria would occur. Diagnosis. — It is comparatively easy to recognize the existence of anuria by passing a urethral catheter, which at once differentiates this condition from retention. The important point, however, is to determine the cause. The first thing to do, if possible, is to determine the presence and seat of the ob- struction. This may be done by palpation and by ureteral catheterization. The presence of obstruction will at once suggest the treatment of the con- dition. If the anuria be transient it may be preceded by or accompanied with a clinical picture of renal colic ; or there may be a history of traumatism, or of an operation either on the abdominal organs or upon the kidney. If the anuria is more or less permanent, we should first exclude the pres- ence of chronic diseases, such as affections of the kidney or of the heart or of acute infectious or toxic conditions. If the anuria comes on suddenly, it is usually due to calculi, though hysterical anuria should not be lost sight of. A word should be said of the hysterical type of anuria. Usually the pa- tient presents some of the peculiarities or stigmata of hysteria. Charcot noted also a certain compensation between the anuria and the vomiting which seemed to alternate ; thus, when the patient, who was a woman, urinated 3 grams of urine, she had 1 liter of vomitus. When the urine increased to 206 grams, she vomited only 362 grams. Hysterical anuria is a tissue anuria and not ii'laudu- 276 SrKCIAL UlMXAIiY SY.MPT():\rS lar. Til other words, there is a more or less complete suspension of the proteid kataholic function of the digestive epitheliuni of the organism. A very inter- esting and rather puzzling feature of these cases is that hysterical subjects may liave anuria for a number of days or even for several weeks without showing any uremic symptoms whatever. Treatment. — The medical treatment of anuria is the same as that described elsewhere under the heading of Uremia. Treatment of Obstructive Anurias. — In case the history of anuria points to a surgical cause — such as an attack of renal colic on the one side, the passing of calculi, pain in the loin on one side for a considerable time, a puru- lent urine without symptoms of frequency, or a hematuria following exertion — the case should be immediately examined, not only by palpation, but also by cystoscopy and catheterization of the ureters. If one ureter is found obstructed, even though the other catheter enters the kidney, an incision should be made in the loin of the obstructed side, a nephrotomy performed, the pelvis examined and a catheter passed down the ureter to the seat of obstruction. The kidney should then be drained and the treatment of the ureteral obstruction postponed until the patient has recovered from the attack of anuria, in case this tem- porary operation is successful. The result of the hemorrhage accompanying the operation will benefit the patient the same as bleeding in uremia, and saline solutions can be given by the rectum, or into the tissues or a vein, as indicated. Oliguria Oliguria, or diminution in quantity of urine, is noted in a variety of patho- logical conditions, affecting either the urinary .tract or the general system. Temporary diminution is noted in health, and should be carefully distinguished from true oliguria. This term should not be employed unless the change in the amount of urine is well marked and continues for several days, and unless all extraneous causes can be excluded. The conditions under which the urine is diminished in quantity in health have already been considered under the heading of Urine Analysis. They are briefly: Exercise, free perspiration and not drinking sufficient water. In dis- ease the urine is diminished in acute nephritis, especially after scarlet fever, in acute congestion of the kidney, in the acute stages of chronic nephritis and often in the last stages of chronic nephritis, accompanied by uremia. The urine is also diminished in conditions of stasis of the kidney due to heart disease. Among the general conditions which produce oliguria and which are important to the urologist, are shock after anesthesia or after operations on the genito- urinary organs. Oliguria is also noted in fevers, where it is accompanied by a concentration of the urine. Other causes of oliguria are prolonged diarrhea CHANGES IN THE ClIAKACTEK OF TIIK lUINE 277 and voinitiui;', such as occiii's in some diseases as cholera or yellow fever. The urine is markedly diminished in quantity in all diseases in the last stages be- fore death. III. CHANGES IN THE CHARACTER OF THE URINE Hematukia Definition. — Hematuria means the admixture of blood in the voided nrine, no matter from what source the blood is derived. Clinically, the term is ap- ])lied only to cases in which the amount of blood is such as to be perceptible to the naked eye on inspection. The presence of a microscopic amount of blood is not clinically styled hematuria. Hematuria must be carefully distinguished from hemoglobinuria. The lat- ter means the direct passage of the blood-coloring matter into the urine without any red blood corpuscles, the urine being acid and of lower specific gi-avity than in hematuria. Etiology. — The causes of hematuria are many, the determination of which is one of the most important procedures in the clinical study of urinary diseases. The etiologic factors may thus be briefly summarized : ETIOLOGY OF HEMATURIA {Tabulated after Castaigne with Modification) I. Traumatic Hematuria. (a) Wounds and Injuries of Any Part of the Tract. Rupture. Urethrotomy. Fracture of pubis. Wounds. Injuries to pelvis. Wounds. Injuries to loin. (6) Stone in Any Part of the Tract: Foreign Bodies. Pelvis of kidney ; ureter. Bladder. Posterior urethra, (c) Sudden Change of Pressure in Bladder. When a bladder is emptied too suddenly or too completely, in a case of re- tention, we may have bleeding from the bladder or even from the kidneys, due to congestion. 278 SPECIAL UKINARY SYMPTOMS II. Infammatory II ematuria. Anterior urethritis. Posterior urethritis. Cystitis. Pyelitis, acute. Acute nephritis. Hemorrhagic nephritis. Chronic nephritis. Some types in which vessels are changed. III. Due to Tumors. (1) Prostate. (2) Bladder. (3) Kidney. IV. Due to Tuberculosis. (1) Prostate. (2) Bladder. (3) Kidney. V. Due to Parasites. Kenal parasites ; Bilharzia ; Filaria, etc. VI. Due to General Changes in the Blood. Smallpox Yellow fever Hemophilia Typhoid Plague Leukemia Purpura ["Phosphorus Malaria l^poisoning Detection of Hematuria. — This has been considered in the chapter on The Urine, so far as chemical and microscopic tests are concerned, but there are certain gross characteristics to hematuria which aid in its detection and lo- calization. If bloody urine is allowed to stand for a little w'hile, it deposits a more or less abundant sediment. Over this there remains a clearer, but still cloudy, fluid. This may be bright red in color, showing that the blood has been freshly shed and that it probably comes from the lower part of the tract — from the bladder usually. The amount of blood wall determine in such cases the exact tinge. The more dilute the bleeding, the paler the tint, but fresh blood is al- ways red. Renal hematuria is characterized by a pale, reddish-brown, cloudy urine, the sediment containing no clots, unless they are wormlike casts of the ureters. If retained for a long time in the pelvis or in the bladder, in hematurias asso- ciated with obstruction, there may be a dark-brown or even black color to the fluid. The sediment of bloody urine varies in amount, color and consistency. The CHANGES IN THE CHAKACTER OF THE URINE 279 first thing that strikes one is the presence or absence of clots. When the bleed- ing is from the kidney or ureters, the clots sometimes assume the appearance of dark-red worndike masses. Next to clots, the urine may sometimes contain a bloody sediment mixed Avith fragments or masses of tumors. These may be fibrinous or shaggy, or they may appear more regular, villous. The deposit may, of course, be also mixed with fragments of crystalline substance, particles of calculi, etc. When, as very often happens, the blood is mixed with pus, the deposit as- sumes peculiar stratifications. In some cases, the deposit of yellowish-gray pus is arranged in strata separated by bright-red streaks. This means that a layer of pus alternates with a layer of blood cells. In other cases, the purulent (usu- ally muco-purulent) sediment is thick, glairy and tenacious, and is tinged a distinct red color. These are cases of alkaline urines, in which pus has under- gone the glairy change into a viscid mass, as the result of the action of the alkali. In these cases, the urine itself is but feebly tinged. There is finally another class of cases in wdiich the urine is bright red and the sediment is gray- ish or gelatinous. These are usually cases of cystitis, prostatic abscess, or other purulent infection of the tract, in which a fresh hemorrhage has taken place as the result of some existing cause. Diagnosis of the Cause. — The diagnosis of the cause of a hematuria is very important and often a puzzling problem. The question is easily solved when there is a blood disease manifesting itself in other hemorrhages, as in purpura ; when the urine shows signs of acute nephritis, oliguria, high specific gravity, albumin, casts, etc. Hematurias due to stone are often characterized by an intermittence or a remittence; they may be accompanied by pain, and are worse after any form of exertion or jarring motion, while hematurias due to tumor and to tuberculosis usually occur independent of either pain, exertion or jarring. To sum up: — The cause of hematuria must be determined after a careful study of the history of the case, a thorough examination of the patient and a complete analysis of the urine. If these precautions are taken, one will seldom err in determining the pathological process which gives rise to the bleeding. Localization of the Bleeding. — Bleeding fkom the Ukethea. — When there is bleeding from the anterior urethra the blood oozes or drips from the meatus independently of micturition. But when the blood is beyond the cut-off muscles, the blood does not ooze from the meatus, but is voided with the urine. The two-glass test shows blood in both glasses, the second more than the first, because the muscular effort of expulsion brings out any residue of blood that may be present in the posterior urethra. Bleeding fkom the Prostate. — Bleeding from the prostate is also char- acterized by the same features. In bleeding, either from the prostate or the prostatic urethra, the bladder urine may also be bloody, owing to the regurgi- 280 SPECIAL URINARY SYMPTOMS tation of the blood into the bladder. The di fife rout ial diagnosis will depend on age, history, clinical and urinary examination. By washing the bladder through a soft-rnbber catheter until it is clean and then filling it with water, if the fluid escaping through the instrument is free from blood while the remainder voided is mixed with blood, the source of the hemorrhage is below the vesical sphincter. Hemorrhage from the Bladder. — Hemorrhage from the bladder, if pro- fuse, gives a red color to the urine, although, if collected in three glasses, the last glass will contain the most blood. If the bladder is washed clean by cathe- ter and the instrument is allowed to remain in place for a short time, the blad- der contents will again become bloody. At times, the last drops alone contain fresh blood. Cystoscopy will usually show us the source of the bleeding if there is a bleeding point in the bladder or if it comes from one or both ureters. Bleeding from the Ureter. — Bleeding from the ureter is characterized by the elongated clots already described, unless it comes from the vesical end close to the bladder. Bleeding from the Kidney. — Bleeding from the kidney is diagnosed by excluding all other sources. The blood is thoroughly mixed with the urine in these cases and there is no separate quantity of fresh blood, as in the hemor- rhage farther down. In the three-glass test, the patient voids a uniformly tinged urine in all three cases. Microscopically, in renal hematuria, we have blood casts and renal epithelia, besides the fact that the red blood cells " are washed " out and appear as swollen shadow disks scarcely perceptible. Having located the bleeding in the kidney, we must next try to find out the cause of the symptom. In stone, we have the history of colic, the aggravation of the bleeding after exertion or jarring, and the subsidence of it after days of perfect rest, while fragments of crystalline masses in the urine will often clinch the diagnosis. In tumor of the kidney, we have bleeding which appears and disappears without apparent cause ; emaciation ; a tumor in the loin ; increasing pain ; a feeling of weight ; and symptoms of pressure and a varicocele when on the left side. Cancer cells and tumor fragments in the urine would complete the diagnosis. In tuberculous K-idney, a polyuria is very suggestive. When it is accom- panied by renal hematuria, the bleeding recurs without apparent cause. Tu- bercle bacilli may sometimes be found in the sediment. It is difficult, however, to assigTi a definite cause for the early hematurias which come in renal tubercu- losis before any marked changes have occurred in the kidneys. In nephritis, large numbers of red blood cells always indicate the acuteness of the condition. In some cases, renal bleeding occurs without previous signs of acute or chronic nephritis. (Perhaps the term '' essential hematurias " is justified, but in all probability there is some basis for the occurrence of the bleeding.) Thus a number of cases have been found, after nephrectomy, to be CHANGES IN THE CHARACTER OP^ THE URINE 281 early stages of renal tuberculosis, and in certain cases there were found the signs of a chronic interstitial ne])hritis with arterial changes. Castaigiie emphasizes the value of studying the arterial tension in such cases. If the tension is high, we may suspect the presence of interstitial changes in the kidney in cases of otherwise unexplainable bleeding. The presence of even slight uremic symptoms point to interstitial nephritis rather than to other causes of renal bleeding. Which of the two kidneys is bleeding is usually determined nowadays by cystoscopy and watching the urine coming from the ureters, and also by ureteral catheterization. ORDER OF FREQUENCY OF CAUSES OF HEMATURIA In the Clinic. In the Hospital, Stricture. Stone in bladder. Prostatitis. Stone in kidney. Renal calculus. Tuberculous bladder. Tuberculous cystitis. Tuberculous kidney. Tumor of bladder. Tumor of bladder. Prostatic hypertrophy. Stricture. ]*^ephritis. Prostatic hypertrophy. Ulcer of bladder. Rupture of kidney. Carcinoma of prostate. Retention of urine. Seminal vesiculitis. JSTephritis. These two lists simply show the order of frequency in my clinic and hos- pital. The causes would have been very different if taken from other hospitals with which I am connected. Pyuria Pyuria means pus in the urine from whatever source. Pyuria may be due to any suppurative inflammation in the urinary tract, or to a suppuration in some communicating or adjoining organ. It is one of the most frequent symp- toms encountered in urologieal practice. We must always satisfy ourselves that pus is actually present and that we are not mistaking anything else for it, for urine passed as a cloudy fluid may be free from pus, the cloudiness being due to either mucus, bacteria, plios- phates or urates. Differential Diagnosis. — Every practitioner, therefore, should be familiar with the rough clinical tests which are necessary to determine the presence of pus immediately after the urine has been passed. Mucus. — formally a faint mucous cloud, which very slowly settles, is pres- ent in the urine. It consists of mucus mixed with a few epithelial cells from the bladder. It is much more pronounced in women, on account of the admix- 282 SPECIAL URINARY SYMPTOMS ture of vaginal imR'u.s. It is markeclly iiicroasod in catarrhal cfinditions of the nrinary tract, especially in cystitis, prostatitis and nrethritis. A rough test for mucin, which is the proteid substance contained in the mucous cloud, consists in diluting the urine with equal parts of water and add- ing acetic acid, until a precipitate of mucin is formed which is soluble in an excess of acetic acid. As a general rule mucus may be distinguished from pus in the urine by the fact that it floats longer, is less dense and more evanescent than pus. Phosphates. — Phosphates, when present in excess, or when the urine is slightly alkaline, create a diffuse turbidity, which gradually settles on standing. A few drops of acetic acid added to such a urine will almost immediately clear it up, while, if the turbidity be due to the presence of pus or mucus, it would be increased by the addition of the acid. Bacteria. — Bacteria, when growing in large numbers in the urine (see Bacteriuria), give rise to a faint cloud wdiich has a tendency to float in the mid- dle part of the vessel. This cloud remains practically unchanged by the addi- tion of acetic acid. Urates. — Urates, when present in excess, form a turbidity wdiich rather rapidly deposits as a sediment. The lower the temperature of the urine and the greater the acidity (wdthin certain limits), the more apt are urates to pre- cipitate. Simply heating a test-tube containing such a urine gently over the flame will dissolve the turbidity and clear the urine. If pus w^ere present heat would increase the turbidity instead of decreasing it. Chyluria. — Chyluria may be mistaken for pyuria. In this condition the urine is milky, yellowish-white and shows a iilm of fat on standing. On shaking with ether, the fat is dissolved and the urine becomes normal in ap- pearance. Pus. — Pus in the urine is characterized usually by a cloudy appearance immediately after passing. The cloudiness is usually in proportion to the amount of pus. Small amounts of pus may be present in the form of clumps or shreds, the urine reaiaining comparatively clear at the time of passing. There is not much difference in the appearance of purulent urines accord- ing to the locality of the affection. Urine, clear or slightly turbid, with thick threads, points to the urethra ; urine which is thick and turbid and tends to become gelatinous on standing, points to the bladder ; urine which is opaque and not thick, but ^viih pus held in suspension, points to the kidney. If it is of a light color, a lemonade or even whiter, it is probably from a tubercular organ, w^hile if it is darkly colored, it points more to a calculous kidney. The light-colored pyuric urine usually occurs when there is considerable polyuria wdth pus and points to a pus kidney, the darker when the urine is more con- centrated or bloody. The color of the urine is not much affected by the presence of pus, unless CHANGES IN THE CHARACTER OF THE URINE 283 there is a large amount, in wliich case it appears whitisli-yellr should stand on the side of tlie patient adjacent to the kid- ney he is examining. If on the right side, he should have his right hand in front on the onter side of the rectus muscle and the left hand on the back below the twelfth rib. The position of the examiner and his hands should be exactly reversed in examining the other side. If the examination in the doi'su] ])osition is not satisfactory, the patient is placed on the healthy side with the knees slightly flexed, thus allowing the organs to fall toward the healthy side (Fig. 235). The object of bimanual palpation is to feel the kidneys between the Fig. 235. — Examining the Kidney, with the Patient Lying on the Healthy Side. fingers of the two hands. Therefore, the patient should be instructed to breathe deeply, thus increasing the extent of the renal excursion. With every expira- tion, the fingers are pressed more deeply in until the kidney region is reached. The examiner must not press hard when examining for a movable kidney, as it will slip away without his being able to detect it. If the kidney is enlarged, it should be ballotted between the hands, as in this way its size, sbape and con- sistence can be better determined. Sometimes it is advisable to have the patient stand during examination. In my experience, the variety of kidneys that we are more often called on to treat are the movable, the tuberculous, the calculous and the so-called surgical, pyelo-nephritis following cystitis. In these cases, the organ is often tender and increased in size. In marked cases of hydronephrosis, pyonephrosis and cys- tic kidney, the mapping out of the organ is even easier. In the loiver zone of fJie abdomen, we may encounter tumors, appendicular or intestinal fecal accumulations, an enlarged bladder, with residual urine, and,' in women, a gravid uterus, tumors of the uterus and adnexa, exudations and abscesses due to diseases of the tubes, periurethral and extraperitoneal suppu- ration. 312 EXAMINATION OF PATIENTS Examination of the External Genitals. — .Mai^e Genitals. — I notice fir.st the size and shape of the organs, whether they are well fonned or misshapen (epispadias, hypospadias, etc.). The condition of the prepuce, the presence or absence of snch lesions as nodules or ulcerations, verruca', abscesses, lymphan- gitis are noted. The meatus is next inspecteil, it being noted Avhether it is large or small, normal or distorted. An induration at the meatus, with the lips pressed together, may indicate the presence of an initial lesion of syphilis, or if ulceration is pres- ent, a chancroid infection may be suspected. The presence of urethral discharge is also noted at this inspection and a smear should be taken for microscopic examination. This is done by sterilizing a iDlatinum wire loop by heating it red hot over an alcohol lamp, cooling the loop and taking a drop of the discharge from the meatus upon the loop. The discharge is quickly smeared very thin upon a clean glass slide, bearing a label with the patient's name or munber. In each of the examining rooms, a compact equipment is provided for taking smears, etc. Slides are kept in a wide-mouthed bottle. A glass rod with a platinum loop and an alcohol lamp are also on hand on each table. The loo]5s are used for obtaining urethral, cervical, vaginal or other discharges which are smeared on the slides in a thin layer. The platinum loop is heated to a red glow before and after taking each smear. If the discharge is very scanty, it is sometimes possible to obtain a sufficient amount by milking the urethra from behind forward and exj^ressing its contents into the fossa navicularis, where it can be taken up with a loop. Caution must be observed in drawing hasty conclusions as to urethral inflam- mations in the presence of a discharge, as many cases of persistent urethral dis- charge are due to the presence of an initial lesion or other infection which we do not yet understand. The urethra is further examined by external palpation along its entire length, the presence of nodules, indurations, swellings, abscess formations or fistulne being noted. The testes are next palpated, tenderness, enlargements, nodules, etc., of testes, epididymis or cord being noted, indicating the existence of inflam- mation, tuberculosis or syphilitic processes, the beginning of malignant tumors, etc., as well as the presence of hydrocele, varicocele or hernia. Female Genitals. — In order to examine the external female genitals, the patient must be brought down to the edge of the table in the gynecological posi- tion (Fig. 236) and the same conditions must be looked for as in the male, viz. : deformities, swellings, nodules, ulcerations, verrucse, abscesses and lym- phangitis. The glands of Bartholini are pressed upon to see if there is a purulent discharge from the ducts. The presence of vaginal discharge is noted and a smear taken if it is present. The labia are then separated and the vesti- bule sponged with a bichlorid solution, 1 : 5,000. The forefinger of the left hand is then inserted into the vagina against the urethra at the point where it leaves EXAMINATION OF THE MALE PATIENT STANDING 313 Fig. 236. — Position for Examining the Female Genitals and Urethra. the bladder aud is then drawn down toward the meatus, making pressure all along the canal. In case discharge is seen, it is taken on a slide if there is sufficient quantity, otherwise a })latinum loop is inserted into the meatus and an effort made to secure a specimen (see chapter on Discliargcs). XoTE. — So far the exam- inations have been on the table in both sexes ; but they must now be considered sepa- rately on account of the dif- ference in the anatomy of the sexes. I will, therefore, first give the procedure in the case of the male and then take up that of the female. Examination of the Male Patient Standing. — The First Urine. — The patient is next directed to stand up and is handed a glass cylinder by the exam- iner. Into this he is instructed to pass a portion of his urine (Fig. 237). Fre- quently in the embarrass- ment caused by the exam- ination, or for some other psychical reason, the patient is unable to urinate prompt- ly at this moment. In order to aid him as much as pos- sible, two measures may be adopted. The first is to leave him to himself, the second is to allow a thin stream of water to trickle from a fau- cet in the room in which he is being examined. This acts on the motor centers of the bladder through the mental impression which suggests urination through the very sound of the stream of water. The size, shape and force of the stream is noted, if possible, when the patient passes water. A healthy man with a normal urethra and bladder passes a fairly large stream, projecting from his body at a distance of from three to five feet Fig. 237. — Male Patient Urinating in a Glass Cylinder. 314 EXAMINATIOX OF PATIENTS when standing up. A man with a small meatus has a smaller, but usually a forcible stream. A sudden in1ci'ru])tiun of the stream which begins normally, often points to the presence of stone in the bladder. On the other hand, a stream which slowly becomes smaller and less forcible points to either some obstruction, siich as stricture, prostatic enlargement, acute congestion of the prostate, acute or chronic prostatitis, or to a lack of tone of the bladder. Further details as to the character of the stream will be found in the chapter discussing the subject of urination. After the first urine is passed, it is held up to the light to see if it is light or dark, clear or turbid, and examined for pus, shreds and mucus. The signifi- cance of these various elements is considered more in detail under the subjects of urine and discharges. Second Ukine. — The patient is then handed a second glass cylinder, of the same size and shape as the first, and is asked to void a second portion of his urine, but is warned not to pass the entire contents of his bladder. The second urine is inspected in the same way as the first, any cloudiness, shreds or a dej)Osit of pus, etc., being noted. Pkostate axd Vesicles. — The patient is then told to bend forward. lie leans over, resting on his hands placed on a table. The body is at an angle of A A, finger cot unrolled. B, finger cot rolled up. C D Fig. 238. — The Finger Cot. C, piece of gauze to wind about the finger. D, the hand with the finger cot on the forefinger and the piece of gauze wound about it. 135 degrees to the perpendicular. The examiner places a finger cot on his fin- ger (see Fig. 238) and winds a piece of gauze about the base of it to keep his finger clean. He then sits behind him and inserts the forefinger of the right EXAMINATION OF THE jMALE PATIENT STANDING 315 luuid into the rectiiiii and cxaiiiincs tlic ])r()sratc. lie tlieii presses the fore and middle ting-er of the left hand into the groin of the patient, thus pushing the vesicle down against the examining finger (Fig. 230). It is strange that much experience is necessary to examine well the internal genitals, but snch is the case. The examiner notes the outline of these organs, the presence <.f nodules, Fig. 239. — Examination by Rectum. The patient leans over the table and the examiner inserts his right forefinger into the rectum, presses the fingers of the left hand into the groin, and palpates the vesicles bimanually. depressions, as well as the general consistence and tenderness of the parts. A hard prostate, either normal or small in size, may give rise to frequency of uri- nation from a cause which cannot as yet be determined, though probably owing to pressure exerted by a very tense external capsule. A prostate which is soft and boggy indicates a chronic prostatitis, in which case the gland has become atonic. Modules in the prostate show local areas of follicular inflammation or simple chronic or tuberculous prostatitis. An intensely tender, hot, swollen, en- larged turgid gland, with one or both lobes involved, is characteristic of acute prostatitis. An enlargement of the gland in young men without the acute signs just mentioned, but usually with nodular swellings, points to a tuberculous proc- ess. In elderh^ men, an cnhirgement usually indicates prostatic hypertrophy, or 316 EXAMINATION OF PATIENTS else malignaut growth. A shrunken prostate, with an irregular outline and with depressions or softened areas, shows the seat of former abscesses which have destroyed a part of the prostatic tissue. Engorged, thick, tender vesicles point to an acute vesiculitis. Moderately distended vesicles with the walls not so thick, although tender, point to a sub- acute process, or to congestion, ^vith some retention of vesicular secretion. When the vesicles are tender and cannot be outlined, they are probably simply con- gested. In the chronic condition, vesicles have thickened, atoidc walls perhajis full of vesicular secretion and inflammatory products, due to a subacute inflamma- tion probably associated with a thickening of the neck of the vesicle or pressure on the ejaculatory duct by the prostate. The vesicles often have a pasty feeling and dent in when pressed with the flnger as if full of cheesy matter. Xodular, irregular vesicles are the result of chronic inflammation, in consequence of which there has been a retention of vesicular secretion. Localized thickenings in cer- tain parts of the vesicles are due to stricture or scar tissue ; they may also be due to tuberculosis. Small vesicles, hard and irregular, are the result of chronic inflammation and partial destruction. If this destructive process goes on still further, they will probably atrophy until they cannot be felt. Third Urine. — During the examination of the prostate and vesicles, the organs are gently massaged with the finger (Fig. 240). When the finger is withdrawn, the patient is instructed to void the remainder of his urine in a third cylinder. This third urine represents the con- tents of the bladder plus the material massaged from the prostate and the vesicles into the pos- terior urethra. W^e are now ready, with the three cylinders of urine before us, to compare them and to draw such conclusions as may be warranted from their appearance. The first urine contains the -washings of the urethra plus any elements from the kidney, ure- ter and bladder that may be present. The sec- ond urine represents that from the bladder, ureter and the kidney alone, as all the products of inflammation that were present in the urethra were washed out by the first urine. The third urine, as we have seen, contains, in addition to the second urine, the elements massaged from the prostate and vesicles. The urines are then sent to the laboratory for examination. Fig. 240. — Massage of the Pros- tate. The arrow shows the di- rection in which the tip of the forefinger moves in this maneu- ver. ? -2 ll^ o 03 ^ CO CO p W O o 35 a, ^ 3 p o _o -3 a QJ H co" "^ c/^ g CO 02 .a a rt ■g d 03 3 •-J 1 < '^ -C 'Ti 1 >i 02 5 § ifi p > P =3 0; o ^3 3 bC 6 C o 5^ S E. 3 •X Eh 1— I '5 O o 0) bil c ^ 5 Q .3 o W t*-! ■+^ g rt p ci 1— 1 O 03 03 s p o -i-j o +3 to p 3 'EH .22 "p 0' m rt of ^ 0) '3 _g IS 1— 1 •S 02 H ^ p "C p H 3 '^ .2 CO 'g "ffi "^ CO .2 bjO r\ 'SI 02 p .s c >-J d S 2 "o 'o +^ .3 fe 1— 1 c3 O o +3 02 ■ ^ +3 o '■+3 c3 02 5 '^ CO CO s o 4: p _g ^ ^ 02 CO a. +3 bC rt o o s g '0° c c£ -£ O 'S -g c2 "+3 _c 3 l-H g 15 CO c3 02 "-i3 'C +3 p 3 p 3 '■+3 02 c 6 O Q bjO _g JO 3 02 ■^ "5 02 CO O a s 3 -5 p 02 p 02" _g CO 1 -/2 Pi p tS u ■^ 3 ;_ 02~ ■ P 'S CO 13 15 02 "03 "m 02 tC K p p C 3 rt .23" l-H O o; p o C 02 p "02 _g g" _3 3 bC _g "43 f^ H h5 1 f I-H cH f^ f=< fe £ Eh EXAMINATION OF THE URINES 317 Examination of the Urines. — The followiiii^' table represents tlie chief pos- sil)ilities encountered in examining the three urines at the time the patient passes them and indicates in each case the significance of the findings. First Urine. (1) Clear. (2) Clear. Second Urine. Third Urine. {After massaye of the prostate.) Clear. Clear. Clear. (3) Clear (small float- ing mass, clear) (4) Clear, with heavy! Clear. shreds. (5) Turbid, heavy'Clear. shreds. [ (6) Clear, heavyClear. shreds. | (7) Turbid, heavy;Clear. shreds. j (8) Turbid, no shreds. iTurbid Clear. Cloudy, with debris Opaque, debris. Turbid, no debris. (9) Turbid, with No shreds or flocculi. No debris, turbid. Clear. Slightly opaque, with debris. Slightly opaque, with debris. Clear. shreds (10) Turbid, shreds. (11) Turbid, slireds. turbid. Turbid, shreds and flocculi. Turbid, shreds. No debris, turbid. Turbid, with debris. Summa.y. ( What they show ; parts in- volved.) Normal urine. Prostate. Prostate and vesicles. Chronic urethritis. Chronic urethritis. Urethra, prostate and vesicles. Chronic urethritis, pros- tatitis, vesiculitis. Pyuria, bladder kidney or both. Urethra, bladder, kid- ney or both or phos- phaturia. Urethra, bladder or kid- ney. Urethra, bladder pos- sible, kidney possible, prostate or vesicles, phosphaturia. This table is quite difficult to understand. We should first eliminate phos- phaturia. If the urine is turbid, therefore, a small amount is poured into a test-tube and a little acetic acid is added. If the turbidity is due to phosphates, it will at once disappear. This test should be performed whenever both the first and second urines are opaque. If the urine does not become clear with the acid, another portion of it is poured into a test-tube and is shaken with some liquor potassa?. If the turbidity is due to pus, a thick coagulum will form and sink to the bottom, leaving a clearer upper portion. In order to differentiate between inflammatory ])ro(lucts massaged from the vesicles and those obtained in the third urine from the prostate, we should note the following points : — Urethra : Urethral shreds. Prostate : (1) Plugs or comma-shaped bodies are from the mouths of the ducts. (2) White thick masses in turbid urine, coming from the dilated and chron- ically inflamed ducts. Vesicles : (1) 8ago hodics consist of the coagulated secretion of the vesicles that have become molded in the convolutions of the vesicles. 318 EXAMINATION OF PATIENTS (2) Sugar granules^ amber C(jlorc(l (or colorless) bodies resoin])liiig sn O Pi O o o o I— I Pi o M c OJ "^ H >> _ > o 3 5 p > S .5 > p ■^ r1 c o fcJD P 'o S _o u r/2 c ^ ■? — -2 ^ > oT r; F? o a iS •r ^■ Tc .S ^^ S o 5P S C to tc .S o -C ^ SsC O — rf q3 oj • S M cri bfl a 3 7J bfl bfl C Ll O ^ "c 'r^ o - -= s s s M CC OD CQ S c c c O O O o O -t2 -t; -^ -1^ O rt rt :3 rt ^ I 2 £ S O O C O fe (^ fe fa o 6 6 6 6 fa fa fa fa fa URETHEAL EXAMINATION 319 mont that passes the narrowest point oi- ])oiiits of the canal and the distance of these narrowings from the meatus. I then take a sound corresponding in size to the bougie a boule, with a short heak, and pass it into the urethra following the upper wall. If this glides easily into the 1 (ladder, I register " Ure- tlira No. — at meatus " or whatever dis- tance from it the narrowing may be and add " Sound No. — passes easily into bladder." In case the smallest bougie a boule (No, 6 French) does not pass to the bulb or that a sound of that size does not pass through the remainder of the urethra, the locality of the impediment must be registered. It will then be necessary to pass a smaller instru- ment^ — a filiform bougie No. 1 or No. 2 (Fig. 242). If the filiform passes the point of nar- rowing at which the larger instrument failed to pass, it will be spoken of as a fili- form stricture. In case the filiform fails to pass, the impediment will be spoken of as an impassable stricture. When the patient passes a fairly good stream and yet a filiform cannot be passed, the location of the impediment must be con- sidered. If it is in the deep or bulbous portion of the urethra, the instrument may have entered a pocket, in which case, by in- serting a filiform with a spiral end like a No. 2 and rotating it slowly during its in- troduction, the end may pass along the ure- thra by the pocket without sliding into it. In case the impediment is in the posterior ure- thra and the remainder of the canal is larger, it is probably not a stricture, but an enlarged or deformed prostate. If the patient is an did man, the condition is Fig. 241. — The Bougie a Boule Mov- ing DOWN THE Urethra through a Strictured Area. No. 1 ' No. 2 Nu. 3 ^ No. 1, straight. Fig. 242. — Filiform Bougies. No. 2, with a spiral end. No. 3, with a bend near the end. 320 EXAMINATION OF PATIENTS probably hypcrtrojiliy and a small eoiidc' catlietor would pass over the impedi- iiieiit and into the bladder : wliile if tbe patient is a ycnmg man who has had a bad attack of jirostatitis, the im})ediment would probably be the result of a prostatic abscess, a cavity or an irregnlarity which j)revents the entrance of the instru- ment. As these conditions are nsnally in the floor of the nrethra, a coude cathe- ter which tends to hug the roof of the canal may pass throngh into the bladder. At times the anterior urethra is of large size with smooth walls and the sound goes up against an impediment at the bulb or at the neck of the bladder. In such a case, we must think of a spasmodic stricture of the cut-off muscle, de- pendent on an inflamed condition of the prostate or prostatic urethra in the first instance, whereas, in the second instance, of spasm of the vesical sphincter due to an inflammation of the bladder neck. In such cases, an instillation of cocain solution, or nitrous-oxid anesthesia, may be used in the examination. If noth- ing can be passed through a urethra under anesthesia and the patient is able to pass some urine although he has symptoms of urinary obstruction, no further ex- amination can be made in his case excepting of his urine, and he should be sent to the hospital or home for further observation. A few days' rest in bed under a treatment of hot sitz baths, diluents, a liquid diet and a large amount of water, will probably so change the character of the imj)ediment as to allow some instru- ment to pass. Such cases rej)resent, however, a minority of those which come to our office. The majority of the cases have urethras of a fair size, that is, over 15 French. Fig. 243. — The Examiner Looking through the Urethroscope at the Urethral Bulb. If the patient has but a slight chronic urethral discharge and the canal is over 20 French in size, the urethroscope is frequently used at the first visit, especially with patients from out of town or those who are accompanied by their physicians. COMPLETION OF THE EXAMINATION IN WOMEN 321 1 n this case, tlu; ui'C'tlirosco])e ( I^'ii!,'. 24-'5 ) is dippcil into Ji^ The muscles brought into actiou are those of tlie front of tlie chest and arms, the back and the muscles around and between the shoulders. Fourth. — Stand with one side toward the pulley weights, as before. Ex- tend both arms toward the pulley weights (Figs. 251 and 252). The arm next to tlie weights will be at full extension and at right angles to the body. The arm away from the pulleys will be slightly l)owed over the chest. Then swing the arms held straight with no bend to the elbows around the front of the body, at right angles to the body, to the other side. The arm farthest from the weights will then be extended straight and the nearer one will be bowed over the chest. Repeat as many times as de- sired and then turn the other side to the weights and make similar movements. This exercises the chest and abdominal muscles, the back, the muscles of the arm and under the arm. Fifth. — Stand with the back to the pulleys and the feet about half a yard apart. The arms should be slightly flexed, the hands extending back toward the machine. One hand is then swung around in a circle in such a way that it passes by the front of the body at about the level of the shoulder, while, as it swings farther, it passes around the body to the other side until the knuckles point toward the wall behind. In making this swing, the body is raised on the ball of the foot on the same side, while the body turns at the waist (Fig. 253). This is the best movement that can be used by walking urological patients in good condition. It exercises the muscles of the legs, thighs, buttocks, abdomen, loins, chest, shoulder, the muscles about the shoulder and the upper arms. Outdoor Exercises. — Of the outdoor exercises, walking in the fall and win- ter, and rowing and swinuning in the sunnuer are the best. lu walking, five miles is sufficient at a gait of from three and a half to four miles an hour. Golf, when one is properly clothed, is an excellent exercise, as it keeps one walking in the open air. In the city, walking to and from business each day is like- wise beneficial. Fig. 253. — Loin Exercises. 336 rnOLOOTCAL THERAPET'TTrS^ Rowing and swinniiiuji- arc of i>,reat licnctit:, provided they iii-(! not too vio- lently indulged in, or ])rolongehate and magTiesiuiii sulphate, hut also magnesium and calcium carbonate. Few of these contain carbon dioxid. They are purgative waters and are taken in small doses (3 to 8 ounces) in the morning before breakfast. They arc of great value in emptying the intes- tines before operations and in keeping the bowels clear in varions condi- tions in which this is desirable, as in prostatics, etc. The principal Ijitter waters arc : Bohemia: Pull n a. ITungary: Alap, llnnyadi Janos, Franz J(ise})li, Apenta, Victoria. Spain : Carabana. Germany : Friedrichshall. United States : Crab Orchard Springs, Kentucky. All my urological cases, while bed patients after an operation, are given either Ajoenta or Carabaila water every morning. USE OF WATER IN UROLOGY The Use of Water Introduced into the Passages of Excretion, Beneath THE Skin and into the Blood Vessels Rectal Irrigations. — Rectal irrigations with saline solution are employed in a variety of diseases of the urinary organs. They secure a thorough cleansing of the bowels ; in shock, they supply heat ; in uremia and other toxic conditions, they remove intestinal toxins and secure the absorption of a certain amount of salt solution into the blood. Locally, that is, applied to the lower part of the bowel, they relieve pain and discomfort in the prostate, the neck of the bladder, the vesicles and the posterior urethra. They allay spasm of the vesical sphincter and they counteract acute in- flammation in the pelvic organs both in tlie male and female. The tube wliich 1 eni])loy is called the recto-<>enital tube. It is a double-current tube with a Fig. 254.— Recto-genital Tube. curved end (Fig. 254). The inflow part of the tube is attached by a nozzle to the rubber tubing coming from the douche bag, and extends to the opening in its concavity. The outflow part begins in an o])ening on either side of the tube a little farther from the tip than the inflow aperture and ends in a nozzle at the distal eutl where it is attached to a piece of tubing carrying away the fluid into a basin or douche pan. The fluid flows into the bowel through the oi^ening in the concavity and flows out through the side openings. 342 UEOLOGICAL THERAPEUTICS Technique. — For douching the lower bowel, the patient lies in the hath tub in a reclining position (Fig. 255), or sits on a chair iu a similar position (Fig. Fig. 255. — Rectal Irrigations. Patient in bath tub. 256). A gallon douche bag is suspended so that its bottom is just on a level with the tojD of the head, or two feet above the pubes. The douche bag is tilled Fig. 256. — Rectal Irrigations. Patient reclining in chair. USE OF WATER IN UROLOGY 343 Avitli a aalldii of salt solution containing a tablespoonfnl of salt to the gallon, the teinpci-nlurc of which, ronghly speaking, is as high as can be borne by the hand, that is, about 105° to 130° F. Before iutrodncing the tnbe, its tip should be lubricated and the air should be expelled from it by allowing some of the solution to pass through. The tip of the left forefinger is then introduced just inside the front part of the anal orifice and serves as a guide to the tnbe, the tip of which is gently introduced into the rectum, at first with a slightly forward and rotary motion. When it has passed u}) for an inch and a half, it comes in contact with the apex of the prostate. The tip should then be tilted back toward the hollow of the sacrum and the tube should be pushed up for another inch and a half if the prostate is to be treated ; or for three inches if the seminal vesicles are to be douched. When treating the vesicles, the tube should be tilted from side to side, so that its inflow opening lies over one or the other of the vesicles. After the tube has been inserted, the solution is allowed to enter the rectum. Should the flow seem sluggish, or be arrested, the tube is probably blocked by fecal matter and it should be removed and thoroughly flushed out, when it can be reattached and reintroduced. In case the sigmoid and colon are to be irrigated, the pelvis should be ele- vated and the patient should lie on the left hip. If then the outflow tubing be compressed, the solution will run up to the splenic flexure. Turning onto the right hip will then allow it to gravitate to the hepatic flexure and sitting up will allow some of the fluid to gravitate into the cecum. In urology, douches of the lower part of the large intestine are generally used and it is rare that one is called upon to wash out the entire colon. Vaginal Irrigation. — This should always be given to the patient on her back with the hips elevated and a douche pan under the buttocks. The nozzle should always be of sufficient length to reach well behind the cervix of the uterus and the tip should be introduced along the posterior vaginal wall. Although many eminent gynecologists maintain that vaginal irrigations are of no benefit in pelvic diseases, my experience has been quite to the contrary. I am now speaking of bladder troubles in women which are associated with afl^ec- tions of the internal genitals. There is a close relationship between the uterus and its adnexa and the bladder, and pressure upon this viscus as the result of inflammations or malposition of the female pelvic organs, gives rise to a variety of disturbances of the bladder functions. Hot vaginal douches of salt solution, ])rolonged and repeated daily, are very useful in the treatment of inflammatory conditions of the uterus and its appendages and have a good eft'ect in relieving the bladder symptoms associated with these conditions. In treating cases of cystitis depending on or associated with gonorrheal and tuberculous affections, I have derived the greatest help from hot vaginal irrigations, especially when the internal female "■enitals were involved. 344 UROLOGICAL THERAPEUTICS Irrigations of the bladder and the urethra in women are the same as in men, although the catheter is used in preference to hydrostatic pressure. EXTEKXAT. APrLlCATlOXS OF WaTKR The urologist should he familiar with the effects of water at different tem- peratures, applied externally in the form of baths, douches, etc., as these meas- ures form an important feature of treatment in urinary diseases. A very bi-icf outline of the general principles of hydrotherapy will be given here. Cold water when applied externally in the form of a tub shower or tub bath, is a vasomotor stimulant which produces contraction of the superficial, and re- flexly of the deep blood vessels. Cold baths increase the blood pressure and stimulate the activity of all the organs of the body ; but if too greatly prolonged the action is reversed ; muscular activity is decreased and circulation is retarded. It is of value in treating patients suffering from genito-urinary conditions who need a general stimulation, as well as increasing the function of the pelvic organs. Heat applied externally through the medium of baths, local or general, acts as a sedative, dilates the vessels and produces a hyperemia of the skin and con- sequent anemia of the vessels of the internal organs. Hot sitz baths, in this way, tend to lessen congestion of the pelvic organs. Hot baths also promote sweating and favor the radiation and abstraction of heat. Baths. — Baths are divided into general and local. General Baths. — General baths may be classified according to temperature as cold, from 50° to 75° F. ; tepid, from 75° to 95° F. ; and hot, from 105 = to. 115° F. The temperature of the bath room should be about 70° F. The hot tub bath acts as a sedative and should be given for from five to twenty minutes, with the patient in a recumbent position. The best time to take these baths is before retiring and the bath should never be prolonged suf- ficiently to make the patient feel weak or dizzy. The cold tub bath is a stimulant to metabolism and to excretory activity, as well as an excellent general hygienic measure. It should be taken in the morn- ing and followed by a bi-isk rub. Its use is contraindicated in very weak patients. The cold tub bath may be u'^ed in septic conditions accompanied by a high fever, as it is employed in typhoid fever. The bath is begun at a tem- perature about 10° lower than that of the patient's body and the body is rubbed vigorously while the patient is in the water. The temperature is reduced to about G8° F. within fifteen miniites. The duration of the bath should be between twenty and thirty minutes. The head should be ^vrapped in a towel immersed in cool water before the patient is placed in the tub and after the bath the patient is to be thoroughly dried and placed in a warm bed. Tepid baths are to be taken by those who do not react properly to cold baths and cannot stand the strona' stimulation of the latter. USE OF WATER IN UROLOGY 345 Sea Baths. — Sea bathing' is one of the best adjuvants to other treatments in chronic urinary diseases of the urethral canal and in all cases in which we desire to ])roniote the general health as well as stimulate the nervous system. They are especially indicated in neurasthenic patients, provided they are strong enough to bear them. Surf bathing, aside from its stimulant thermic influence, constitntes a general massage of the body. Swimming is one of the best exercises that can be indulged in. In order to insure the fnll benefit of a sea bath, a full reaction mnst be obtained and the bath shonld not be pro- longed nntil the chilly sensations appear. It shonld be followed by a vigor- ous rnb. Salt baths made by adding sea salt (2 to 5 ounces to the gallon) to an ordi- nary tub of water are in a measure substitutes for sea baths and are stimu- lants to nervous and glandular activity. They are indicated in weak patients who cannot take sea baths. Local Hydrotiiekapeutic Measures. — Of the local measures, we must first mention the douche or shower. This may be a vertical rain douche, or a movable sjiray. Tlie temperature used varies from the lowest to the highest employed in baths, while in the '' Scotch douche " the temperature is alternately hot and cold. A cold shower is a powerful stimulant and is applied for about one minute, at from 50° to 60° F. Warm douches are used as sedatives in neurasthenia. The " Scotch " douche applied to the genitals is useful in sexual depression. Sitz Baths. — Sitz baths may be either hot or cold. They are very useful in many urological conditions. They are taken in a special tub holding five to six gallons, or enough to reach the patient's navel as he sits in it. Ordinary washtubs may also be used. The hot sitz bath is sedative, antispasmodic and anodyne, and should be given for from ten to fifteen minutes twice a day as hot as can be borne. It is indicated in all acute inflammatory troubles of the pelvis, especially in the bladder, posterior urethra, prostate and vesicles. Cold sitz baths act as a stimulant to muscular contraction, if not too prolonged. They are employed in impotence, sexual debility, spermatorrhea, atonic condi- tions of the bladder and passive congestion of the pelvic organs. They should last for from two to five minutes only and are contraindicated in acute inflam- matory conditions of the bladder, prostate, etc. Wet Pads. — A method of reducing temperature and inducing profuse sweating is kno-wn as the " wet pack."' A woolen blanket is i^laced upon the bed and over this is spread a linen sheet immersed in cool water and well wrung out. The patient is placed upon this sheet with his head wrapped in a towel wet with water at about 60° F., his arms are raised above his head and the sheet is tucked in all around his body ; the woolen blanket is then carefully folded and tucked over the shoulders and entire body of the patient. A hot- water bag is then placed at the feet. The pack is left on until it becomes very 346 UKOLOGICAL THERAPEUTICS ^val■m and a second pack, or several successive packs, can be applied until tin; temperature is reduced. In urology the wet pack is indicated in febrile states, such as septicemia, and in cases of pelvic inflannnations. In diseases of the kidneys, the hot pack is useful for promoting perspiration and elimination. They are contraindicated in patients with weak hearts. Sponge Balks. — The cold sponge bath is used as an antipyretic measure in place of the cold tub bath, when less active treatment is sufficient, or when the condition of the patient is such that it is not advisable to move liim about. When frequently repeated, it reduces temperatures to a considerable degree. The sponge bath should be followed by an alcohol rub, or some alcohol should be mixed in with the water. Local Use of ('old }Vater and Ice. — Local inflammatory conditions arc fre- quently treated by the external application of cold or ice water, either in coils or ice bag, while the combined part of the genito-urinary tract is treated by cold water indirectly applied l)y means of tul)es called psychrophores. There are two varieties of psj'chrophores, a urethral and a rectal. They are both hollow metallic tubes, closed at one end, with no outlet through which water. can escape into the urinary or rectal passages. After the psychropliore has been introduced into the urethra or rectum, the nozzle is connected with the pipe from the douche bag and the cold water flows into the tube in a con- tinuous stream, filling the tube, and escapes by an adjoining nozzle through a piece of tubing into a douche pan or basin. The metallic surface of the instru- ment is cooled and communicates the cold to the tissues with which it lies in contact. The psychrophore is used either in the rectum or urethra for passive hyperemia of the prostate and posterior urethra, especially in chronic inflam- mation of these organs associated with sexual debility, nocturnal emissions, spermatorrhea and prostatorrhea. Ice bags are used principally in cases of epididymitis complicating gonococcal urethritis. Saline Infusion Salt solution in the " physiological proportion," that is, 1 drachm to the pint, is introduced into the body in such a way as to combat shock, to supply loss of fluid due to hemorrhage, or to cleanse the blood from various poisons, as, for example, in uremia. The solution is introduced into the rectum or cellular tissues, from which it is taken up into the circulation; or else it is injected directly into the vein. The three methods of introducing saline solutions are called: (1) enteroclysis, (2) hypodermoclysis and (3) intravenous injection. (1) Enteroclysis. — This is the simplest of all methods and should always be first resorted to in an emergency until the apparatus for the other methods can be prepared. It consists in the introduction of a soft-rubber rectal tube USE OF WATER IN UROLOGY 347 of sufficient caliber liigli up into tlic bowel and tbe slow introduction of a salt solution, at 105° to 110° F., containing a teaspoonful of table salt to a pint of water. The fluid may be introduced through a funnel or with the aid of an ordinary douche bag and, in either case, the bottom of the reservoir should not be raised more than a foot above the pubes so as to avoid the forcible introduc- tion which might be followed by reflex expulsion. The patient's pelvis should be elevated or he may be placed in the Trendelenburg position, unless it inter- feres with a surgical operation. The saline enema is an excellent measure during or after operations to counteract hemorrhage and shock, and some surgeons employ it as a routine jiroeedure in operating. One pint of this solution at a time is sufficient and, in case strong stimulation is required, two ounces of whisky can be added. (2) Hypodermoclysis. — This consists in the introduction of the salt solu- tion sterilized. It is recommended that a small amount of calcium chlorid and potassium chlorid be also added (making what is known as Ringer's Solution) into the cellular tissues through a hollow tube. The temperature of the solution should be 105° to 110° F. The apparatus needed is a sterile reservoir of any kind connected by rubber tubing to an asjnrating needle. The patient is pre- jjared as for a surgical operation, the skin being scrubbed and disinfected with alcohol and bichlorid. The apparatus is prepared and all the air is expelled from the needle before it is inserted. The place selected for the puncture should always be one where there is a great deal of loose subcutaneous tissue. In "svomen, the space between the breast and the chest wall will be found con- venient; in men, the fold of skin at the edge of the pectoral muscle at the border of the axilla. The fluid should be introduced very slowly and should be supplied only as fast as absorption takes place. Xot too much pressure should be used at any time and the vessel should be raised only enough to cause a constant flow. The amount of fluid in- troduced at one time varies. About six ounces can be intro- duced in an hour and from one to two quarts have been introduced within twelve hours (Fig. 257). Hypodermoclysis is especially useful in septic conditions, in uremia Fig. 257. — Hypodermoclysis. (From Ashton.) 348 UROLOGICAL THERAPEUTICS and anuria, but, heinc; slowor tliaii otlicr inothods, is less useful in lu'iiiorrlin^c and shock. (3) Intravenous Injection. — In this method the sterile saline solution is introduced into a vein at the Ix'nd of the ell)o\v through a special cannula. The •^CMe«— ^^^^^^^ )))"' W))l«liiilil))l)j})))))))))))))ll"'"' Fig. 258. — Intravenous Injection. The arm is compressed above the elbow, thus making veins prominent. apparatus required is very similar to that for hypodermoclvsis, excepting that it is advisable to have the jar graduated to determine better the amount of fluid entering the circulation. The rubber tubing and cannula must be ster- ilized bv boiling, pinned in a sterile towel and allowed to remain there until needed. The skin is prepared as for operation, a firm bandage is placed over the upper arm and tied on the side selected, thus impeding the venous flow and Fig. 259. — Intr-wenous Injection. Shows the median basilic exposed and the ligatures passed beneath it. causing the veins of the forearm and bend of the elbow to bulge out (Fig. 258). The median basilic is the vein usually selected because of its large size. It is a branch of the median vein and passes obliquely inward across the bend of USE OF WATEPt TX UROLOGY 349 the elbow joiniua,' with the eoiiiiiinii ulnar on the inner side of the elbow to form the basilic vein. The incision is made over its middle portion. The tissues over it are dissected awav by blunt dissection and two lio;atures are placed around the vein (Fig. 27>i)). Tlie distal ligature is tied, the proxi- mal remains loose. A trans- verse incision is then made in tlie vein and the cannula is inserted into its lumen (Fig. 260, A, B), while the solution is running out of the tube, in order that no air shall enter the vein. The bandage is now loosened, al- lowing the solution to run into the vein, and if neces- sary the proximal ligature can be tied around the can- nula so as to avoid leakage. From one to three pints is allowed to run into the vein. The elevation of the douche jar should be from three to six feet above the table. The flow should be at the rate of a pint in a half hour. The amoinit necessary to inject depends on the pulse of the individual, which should be carefully watched. After the injection is finished, the tube is withdrawn and the proximal ligature is tied. The temperature of the solution should be kept constantly at least 105° F. in the jar, so as to secure a temperature of over 08° F. as the fluid enters the vein. This may be aecom])]ished by the addition of fresh hot solution. A sterile thermometer is kept in the jar for tlic purpose of regu- lating its contents. Fig. 260. — Intravenous Injection. A shows the cannula in the vein and the tube extending from it to the reservoir con- taining the solution. B shows the opening in the vein, the cannula inserted and the vein ligated above and below the opening. CHAPTEE XVTI ANESTHESIA IN UROLOGY There are two varieties of anesthesia, general and local, the former of which will probably always be nsed in most of the major operations, while the latter will without donljt be employed more and more as the technique of its administration develops. General Anesthesia. — The materials nsed in general anesthesia are liquids which are rapidly diffusible and therefore are readily transformed into gases that are inhaled and have a narcotic effect upon the patient. Of these, the ones generally employed are ether, chloroform and nitrous-oxid gas. Ether is probably the best and safest in all major surgical operations. It is administered through inhalers which are usually about six inches in length, three inches in width, and five inches in height. Those that are sold as the most up-to-date appliances are made wholly or partially of metal with various mechanisms for holding gauze and cotton. The}^ can also be constructed from paper folded in a strip five inches wide and fifteen inches long, this to be enveloped in a towel and then rolled up in oval form of the same dimensions already given. In this inhaler, ordinary absorbent cotton or gauze is placed and it is pinned together at the top, in this way forming a truncated cone. The in- haler is placed over the nose of the patient and the fluid is ])(iiircil into the inhaler from above, or from l)elow, either directly into the cone or through some apparatus leading to it. Ether is also given by the drop method through a special or a chloroform inhaler, a process which takes a longer time, but which is considered safer for the patient, as he does not receive such a large dose suddenly. Chloroform is administei-ed by the drop method. The chloroform inhaler is spoon-shaped, made of a wire frame covered with gauze or flannel, and the liquid is dropped upon it very much as in the last method described for the administration of ether. Of the two anesthetics, ether is safer on account of being a heart stinmlant, although it is supposed to be contraindicated in diseases of the kidney, in which case, chloroform is considered advisable. The latter is, however, a cardiac depressant, and many deaths have occurred from its use. In a large operative service covering many years and many urological operations, I have never had a death that I could ascribe directly to ether. 350 GENEEAL ANESTHESIA 351 ISTitrous oxid is of value for exaiiiiiiiilioiis in iiroloiiy and is also used for brief operations, altliougli ])atienls can and have been kept under its influence for an hour or more. The i>,as is contained in a cylinder in a coin])ressed form, from which it escapes, on the turn of the valve, into a collapsed rubber balloon. When this is tilled, the gas slowly passes through, the irdialei- and is breathed in by the patient. It is the safest of all anesthetics. It can be taken on a full or an empty stomach. No preparation for the anesthetic is required. There are no toxic symptoms following, such as vomiting and nausea. It may be con- sidered harmless. Dr. C. S. McjSTeille, the dentist at Cooper Union, who has had unusual experience -with this variety of anesthesia, in speaking of its action as an anes- thetic, says : " All statements in relation to this matter can only be approximate. In this office we have given it 259,000 times since 1SG3 with no deaths. Very few deaths in nitrous-oxid anesthesia have been reported, and those usually came from asphyxia. We have never had a death during an anesthesia. As to the advisability of administering the gas on a full or an empty stomach, I would say that, in my experience patients have never vomited during an anesthesia if the operator or his assistant held the chin well down on the chest of the patient and thus let the saliva run forward. I , also find that the patients who come with an em])ty stomach are the only ones who have a headache after taking gas. Hence I am in the habit of advising them to take a light repast before the oper- ation. As far as the time during which we can keep the patient under gas is concerned, I would say that I have kept a patient under gas for a surgeon for two and a half hours without intermission. The principal thing in keeping a ]:)atient under prolonged gas anesthesia is to watch the respiration and to give the gas so slowly as to prevent the system from being crowded with the vapor. "As long as the rate of respiration is satisfactory, in fact as long as the ])atieut is breathing, I do not care what the pulse may be doing. A man who kn(.)ws how to give gas, will rarely produce the slightest degree of asphyxia. Should marked asphyxia occur, then artificial respiration must immediately be applied. As a rule, the patient recovers in from a half to two minutes, but it may be necessary to continue for a longer time. I believe that the stage of excitement in gas anesthesia is produced by a too rapid administration of the gas, and that in giving ether, this stage is the more severe and violent, the more we croAvd the anesthetic in the first stage. The usual time for producing a narcosis for a tooth extraction is one minute. In administering gas, we are guided purely by the physiological effects and not by the pressure indicator on the reservoir.'" The increasing poiJularity of niti-ous-oxid gas as a general anesthetic has brought about its use as a forerunner to ether and chloroform in general anes- thesia, so that now, especially in the administration of ether, gas is frequently given first, which renders the ])atient unconscious in a few seconds. Then the ether is continued liy ])()uring it intct a separate section of ilie inhaler made for 352 ANESTHESIA IX UROLOGY this purpose, and the patient passes from the influence of one anesthetic to that of the other quickly and with but slight disturbance. The method of com- bined anesthesia was introduced by Dr. Thomas Bennett, of Xew York, who be- came a specialist in this branch of work. IJy his well-devised apparatus and his "skillful manipulation, he is able to give anesthesia, starting with nitrous-oxid gas, continuing with ether or chloroform and administering oxygen, if necessary, in such a way that the operator feels safe and his composure is never disturbed while operating. The result of Dr. Bennett's pioneer work in combined general anesthesia has been the development of anesthesia as a specialty, which has been taken up by a number of the younger men throughout the country. The ease of operating under nitrous-oxid gas has been one of the chief in- centives to find other easy methods of using anesthesia and especially to produce analgesia without rendering the patient unconscious, a condition which no one looks upon favorably and every patient dreads nearly as much as the operation. An analgesic condition can be brought about generally and locally by certain drugs. The best general analgesic is scopolamin, generally spoken of as the scopolamiu-morphin injection; but drugs which render the body analgesic are rarely used, as they are considered dangerous to the life of the patient. Local analgesia or anesthesia is, therefore, preferable. SpI^^Ax, AjStesthesia. — Spinal anesthesia has been used considerably in the surgery of the genital tract, especially in women. Personally, I have never used spinal anesthesia in urological operations, and, judging froiu what I have observed of its effect in the hands of other surgeons, I do not feel inclined to advocate its use, although Goodfellow, of San Francisco, and Boyd, of Panama, have found it most satisfactory in their work of prostatic surgery. This method was introduced in 1885 by Corning, of Xew York, and Avorked out by Bier, Quincke and Sicard. It consists in the injection of a solution of eocain (or another anesthetic) into the subdural s])ace in the spinal canal. The effect of this is to render the entire lower part of the body anesthetic through the action of the drug upon the s})inal nerve roots in the cauda equina. The puncture is made with a long strong hypodermic needle beneath the second lumbar vertebra (in children, the third ) a little to one side of the median line. The patient lies on his side with legs drawn up. The skin is disinfected as for an operation ; then it is anesthetized with a 0.1-per-cent solution of eocain, or with the ethyl-chlorid spray. The needle, syringe and solution are sterilized. The dose of eocain is 0.01 to 0.02 gram in a syringeful of physiological salt solu- tion with one drop of adrenalin. The needle is first introduced and a sufii- cient amount of spinal fluid allowed to escape. The syringe is then attached and the solution is slowly injected. The needle is withdrawn and the punc- ture closed with plaster. Anesthesia occm-s in ten minutes. Local Anesthesia. — Local anesthesia occupies a very important position in urology, as it renders the examination and treatment painless in many cases, LOCAL ANESTHESIA 353 iuid oporatioiis can be perforuicJ without pain, or with a iiiiniinuiu ainouiit of siiircriiii;'. The methods of applying local anesthesia are by freezing; by application to the mucous membrane or skin ; by intra- or hypodermic injections or infil- trations; and by injections into the urethra, bladder and tunica vaginalis. Freezing Methods. — Freezing methods have been popular since the intro- duction of the ether spray by Richardson in 1860. In the following year, lioth- cnstein introduced the ethyl-chlorid spray, which supplanted it and has been extensively used in minor surgery. Ethyl chlorid is a colorless liquid which is sold in glass tubes provided with a stopcock. When grasped in the hand and the valve is opened, the warmth of the hand suffices to vaporize the fluid. The tube is held at a distance of ten to fifteen inches (25 to 40 cm.) from the spot to be operated, the fine s])ray striking the surface, giving it a frosty appearance when it is frozen and anesthetized. A number of other freezing substances have been introduced since ethyl chlorid, but this is as eifective as any of the newer preparations. The spray must be interrupted when freezing takes place, as permanent damage to the tissues may be brought about by prolonged freezing. Personally, I rarely use the freezing method, as it is not as practical, nor as far reaching as other local anesthetics. The AppLiCATioisr or Iisf jection of Anesthetic Solutions. — Cocain. — Of the large number of anesthetic drugs now known, the preferable one in routine work is cocain. Cocain is an alkaloid from the leaves of the coca plant. The salt used in local anesthesia is cocain hydrochlorate and is spoken of in this chapter as cocain. It is a white crystalline powder, soluble in water and alcohol. It has an anesthetizing power when placed upon mucous or serous membranes or when injected into the tissues, which was first discovered by Ivoller, of ]N^ew York, who utilized it in anesthetizing the eye in his operations on tliat organ. It paralyzes the nerve terminals of the sensory nerves in the skin, the subcutaneous and other tissues, and also paralyzes, in a less marked degree, the motor peripheral nerves. Domge of Cocain.- — The dose of cocain internally is 1 grain (or cgm.) ; in- jcclcd intradermically, or into the deeper tissues, the dose is from 1 to 2 grains (or () to 12 cgm.); while, on the skin or mucous membrane or the external genitals, grains (or -Tt! cgm.) or more can be used. The dose according to the strength of the solution is as follows: Of a lOper- cent solution, di-ops 10 are used; of a 4-})er-ceut solution, drops 25; of a 2-per- cent solution, drops 50 ; and of a 1-per-cent solution, drops 100. The quantity generally used in this country for urethral and bhidder injec- tions is ^ ounce of a 1-per-cent solution. Chismore, of San Francisco, used in his office practice for several years a 3-per-cent solution, of which he was in the 354 ANESTHESIA m UEOLOGY liabit of injecting 3 ounces into the bladders of his patients as a matter of rou- tine in crushing vesical calculi. Method of Administration. — In the hospital, for intradermic injections, wet use Bodine's tubes put up by Squibb, each tube containing 1 grain of sterilized cocain and a certain amount of salt. The solution is made by breaking the tube and adding its contents to 1 ounce of sterile water. The proportion of salt in the tube is sufficient to make a solution corresponding to 1 gi-ain of cocain in 1 ounce of normal salt solution. We can, therefore, see that : Tube 1 (gr. 1), added to water 1 ounce, makes a 1: 500 or i of 1-per-ccnt solution ; the strength and dose for intradermic injections. Tube 1 (gr. 1), added to water 2 ounces, equals a 1: 1,000 or iV of 1-per- cent solution ; to be used for injections into the deeper tissues. For urethra and bladder solutions \ of 1-per-eeut strength is used. It, there- fore, follows that : Tubes 5 in number (grs. 5), added to 2 ounces of water, makes a 1: 200 or ■J-per-cent solution. Generally, however, the tablets of cocain are used for preparing these solu- tions, especially in all exploratory and cystoscopic work. Five -J-gi-ain cocain tablets to 1 ounce of water, would make a 1 : 200 solution, or ^ per cent. Pow- ders of similar strength can be used in place of tubes or tab- lets in making these solutions. Sterilization of Cocain Solutions. — In the Squibb's tubes, the contents are sterile, and it is simply necessary to break the tube, letting the powder fall into the sterile water. After making solutions from tablets or powder, they should be held over a flame and brought to a boil once, as prolonged boiling weakens the solution. The solution should be freshly made be- fore operating, as cocain solutions spoil quickly. Each powder of cocain can contain incorporated in it the proportion of salt sufficient to make a solution, corresponding to 1 grain of cocain in an ounce of normal salt solution for a i-of-1- per-cent solution, or by adding .5 grains to 2 ounces of water a 1 : 200 solution will be obtained. The syringe used for intradermic and deeper injec- tions is one holding cither 5 c.c. or 10 c.c. of the solu- tion. The barrel and piston are both made of glass. Both the syringe and needles are sterilized by boiling. The syringe with a finger brace is preferable. The needle and syringe should have a simple socket joint. For infiltration work, needles bent at right angles to the barrels are useful (Fig. 261). Technique of Injection: Intradermic and Suhdermic. — The syringe should be held with the thumb on the piston, and the first and second fingers should be Fig. 261. — Steinge for Local Anesthesia. Needle bent at right angles. LOCAL ANESTHESIA 355 on the cross piece of the barrel. (See Fig. 262.) Care should be taken that the pressure is used only in the axis of the instrument with a free wrist, so as not to break the needle. A method at our disposal for incising or excising diseased, inflamed or suppurating tissues is, first, to isolate this area by surrounding it with an anes- FiG. 262. — Method of Holding the Syringe. thetized region carefully mapped out ; second, to anesthetize a strip of skin and then gradually work deeper, to render anesthetic all the tissues to be included in the field of operation. The first principle to be observed is that the needle should not be pushed forward or reintroduced, save through an already anesthetized field. The skin and subcutaneous tissue is best anesthetized by the following method (Fig. 263). The needle is pushed into the skin (not subcutane- ously) just far enough to cover the beveled jioint. Then a little pressure is ap- plied to the piston and a small white wheal or bleb is raised which renders the skin anesthetic. The needle is withdrawn and the point is now reintroduced at the distal margin of the bleb where a new bleb adjacent to the first is made, continuing in this way until a strip of anesthetized skin is obtained for an incision. If a larger area of skin is to be anesthetized, we can use a modification of Reclus and Schleich's infiltration motluxls on the griMind that, if the subcu- taneous tissue under an area of skin be anesthetized, the surface will also be- come anesthetic after a few minutes. Two points at o]iposite sides of the area are marked on the skin by raising blebs (Fig. 204). From these points, a Fig. 263. — Method of Making the Blebs in Intradermic Injections. A shows the punc- ture of the first bleb. The crosses (x) show the introduction of the needle for the succeeding blebs. Only the first puncture is felt. 356 ANESTHESIA IN UROLOGY long needle is introduced in a radiating- direction into the siihcntaneons tis- sne, injecting eocain always ahead of the needle and lollowing with the point. The diagram shows how the area is coN'ered suhcntaneously. After a few minutes, the entire skin surface over this area is anesthetized, which is espe- cially applicable in excising nlcerated or diseased lesions of the skin, and in ol)tain- ing skin grafts. Other forms, as the oval or the diamond, can be injected in a simi- lar way, depending on the shape and loca- tion of the area to be operated. When it is desired to cocainize a sec- tion of skin and a mass of tissue beneath it, the oval or diamond may first be Fig. 264. — The Subcutaneous Method of -, -, , i j> i i i mi ^i Anesthetizing AN Area TO BE Operated marked OUt by four blebs. Then the CO- Upon. Numbers 1 and 2 show the points cain is injected deeply into the tissues to at which the needles are introduced in ra- t i ^ t • ^ • • ^ i i i diating Unes. the de^ijth to wnich it is thought that the operation will extend, and while i)roceed- ing with the operation, an injection can be made from time to time into the deeper tissues to be invaded. It is well to remember that 1 : 500 solution is used intradermically and 1 : 1,000 subdermically. The oi^erations that are performed under eocain are usually those of a minor type, although many of a major nature are equally successful. It is principally indicated in circumcision, meatotomy, internal urethrotomy, external urethrot- omy, vesical lithotomy and operation on any suppurative condition from the external urinary meatus to the mouths of the ureters. In kidney work, with the exception of cases of perinephritie abscess, a gen- eral anesthetic should be used. It is very difficult to keep the parts sufficiently relaxed under eocain anesthesia to deliver a kidney, unless it is very small or freely movable. I will take up the technique of local eocain anesthesia more in detail under the operations in which it is used. Cocain Foifioning. — Cocain jioisoning is usually manifested suddenly by an attack of vertigo. Often there is a partial or actual collapse, irregular, weak or fluttering pulse, and cold perspiration on the surface of the body. The attack may be followed or accompanied by vomiting; sometimes syncope occurs and may last for a few minutes. In a certain class of cases, there is a feeling of excitation, the result of irrita- tion by the drug of the brain cortex. It resembles somewhat the period of excitement of chloroform anesthesia, excepting that consciousness is not so deeply affected. The patient becomes excited, noisy, laughing and chattering in incoherent delirium. There is frequently dryness of the throat, a heavy feeling over the heart and disturbances of sensation, as a tingling or numbness LOCAL ANESTHESIA 357 of tlic iiiiilis, oi" I lie los^ of sense of slight (»r iiejiriui;'. The pupils m.-iy lieeome \vi(lel\' (lil;ile(l and iiisensihle to li^lit. Soiiiel i nies there is t wilchi iiii' ol 1 ho iimseles, or loss of reliexes, wliik^ in fatal cases there is usually eonia and death due to ])ai'al_vsis of the res])iratory system. J'rcrcnilrc ami Palliative Treabnent uf Cocain- rui.soniny. — We should always be on our guard against poisoning, as cases hav^e been reported in which slightly over one grain used hypoderniically or injected into the serous and nuicons cavities has proved fatah The following precautions are reconnnended by Eeclus : The iiatient shonld lie horizontally while being cocainized and should re- main in this position from twenty minutes to three hours, according to the grav- ity of the case. Before the injections are made, the part should be compressed by a band above the locality to be anesthetized, and this compression should con- tinue for a half hour after the operation. If symptoms of cocain poisoning come on at any time, the patient should be made to lie flat; the heart should be stimulated by injections of strychiun, digitalis or atropin, one or all, according to the pulse ; besides which, friction of the body and the extremities should be resorted to. Artificial respiration may be needed if breathing threatens to stop. Drops of amyl nitrate should be imme- d lately used if at hand. In case the trouble is due to a solution in the bladder, the viscns should be emptied and washed with saline solution. If there are con- vulsions, ether inhalations are indicated. In conclusion, I will say that in all uncomplicated cases of urethral surgery and in cases of vesical calculus, cocain can be used ; but it is important to have an assistant to give the injections and infiltrations, who is accustomed to the tech- nique of the administration. For prostatectomies, extirpation of vesical tumors, nephrotomies and nephrectomies, it is important to have a special anesthetist of the highest possible grade if the operator desires to feel at ease during the oper- ation, as in that latter group of cases in my j)ractice, the hemorrhages are often alarming. CHAPTER XVIII DISEASES OF METABOLISM URIC ACIDEMIA Uricacidezniia is tlic condition in which an excess of nric acid in the hhjod is characterized Lj various nervons symptoms and freqnently bv the local phenomena known as gout. This does not mean that an excess of nric acid in the nrine as shown Ijv its analysis indicates the uric-acid diathesis or gout, as is supposed by many. These conditions are the result of nric acid retained in the blood and tissues, and not of that eliminated with the urine. It may be said, and at times it is no doubt true, that the amount of nric acid and urates contained in the urine is in proportion to that retained in the body. The formation of uric acid in the body and its role in disease are still sub- jects of discussion. Formerly it was thought that uric acid was a product of nitrogenous changes, an intermediate between the foodstuffs and the final product of urea. It is thought at present that uric acid is formed by oxidation of nucleic acid and that foods rich in nuclei, such as meats, give rise to its formation and elimination in large quantities. It is impossible to know, how- ever, whether or not uric acid is also derived from some other constituent of the food. Excessive accumulation of uric acid in the blood and tissues is more frequently the result of imperfect elimination than of increased formation. Uric acid is a very insoluble substance and a slight decrease in the alkalinity of the blood may cause its retention and accumulation in the tissues. AVe hold at present that uric acid is not formed in tlie kidney, but in the tissues, in the liver and in the spleen. The normal amount of uric acid in the urine is from 0.4 to O.o2 grams ( (3 to 8 grains) in twenty-four hours. The proportion of uric acid to urea is as 1 to 45. A deposit of uric acid and urates in the urine does not necessarily indicate an excess of uric acid. Such a deposit may occur on cooling, as the result of acid fermentation. Urines of high acidity may deposit uric acid, irrespective of the absolute quantity of the latter in the specimen. Whether uric acid is really increased or not, we can only know by quantitative analysis. Uric acid is increased in the urine by an abundant meat diet, containing 358 URICACIDEMIA 359 iimcli nuclear siil)staii('C' and by a sedentary life, often the nse of tea and coffee, c'ciTain dru^s, as the salicylates and also in the following diseases: 1. In acute fevers and in most acute diseases. 2. After an attack of rheumatism and gout, when noi-mal elimination has been reestablished. '). In diseases of the lungs and heart accompanied by diminished oxida- tion (pneumonia, hydrothorax, chronic heart diseases). 4. In large abdominal tumors, ascites, respiratory insufficiency. 5. In diseases of the liver and spleen. 6. In pernicious anemia and leukemia, due to the destruction of the nuclei of the leucocytes. 7. In diabetes mellitus. Uric acid is diminished in the urine by a vegetable diet ; after a diet of milk, eggs and dairy products ; after eating cherries and similar fruits. It is also diminished in chronic diseases of the kidney and in other condi- tions, with a decrease in the amount of urea ; in gout, during acute attacks and in chronic wasting diseases. Symptoms. — Uricacidemia is clinically characterized by a certain group of symptoms, sometimes spoken of as the gouty state. Heredity plays an important part, and in many families various manifesta- tions may be of frequent occurrence. In addition to attacks of gout proper, a tendency to uric-acid diathesis may 1)0 responsible for more or less frequent attacks of headaches, neuralgias, sciatica, biliousness, affections of the skin, such as eczema, etc. Later in life, after the prevalence for many years of uricacidemia, the more serious results of the disorder become evident. Arteriosclerosis frequently develops, leading to a fatal termination by nephritis, apoplexy, or aneurysm. The presence in the urine of an excessive amount of uric acid in crystalline form often acts as an irritant to the genito-urinary tract and always renders the patient liable to renal or vesical calculus. Treatment. — In the treatment of uricacidemia, the fact that gluttony and errors in diet are the most frequent etiologic factors must be constantly kept in mind. The daily amount of meat and fat-producing foods must be reduced, and a vegetable diet suljstituted. Alcohol must be interdicted altogether. Elimina- tion should be favored by the free use of mineral waters, such as ApoUinaris, Vich}^, Selters, as well as by gymnastics and outdoor exercise. The long list of useful therapeutic agents includes the lithium salts, col- chicuni, uricidin, piperazin, the salicylates, etc. URIC-ACID DIET Avoid. — Bisque, cream and tomato soup; corned, dried, smoked, canned, ])rcserved (ir fried meats or tish. Tongue, ham, veal. ])ork, turkev, beef, lob- 360 DISEASES OF METABOLISM sters ami ('ral)S. Iliglily spiced sauces and ])c|i|)crs. Hot rolls, cakes of all kinds; all cereals, as oalniciil, lioininy, etc.; sini])s, sweets of all kinds; every- thing made from corn; potatoes, or vegetables rich in sngar, as beets. (Just suf- ficient sugar to sweeten coffee can be used.) Strawberries, bananas and melons. Spirits — brandy, whisky, gin and rum; good whisky is the least injurious, taken with meals and A\ell diluted with water. One or two Scotch whiskies a day, well diluted, can be taken with meals or after them, if the patient is below l^ar; or a glass of claret with the meah Heavy wines, also champagne, Bur- gundy, beers and ales. May Eat. — Oysters and clams, consomme and thin soups (without tomato), fish, beef, lamb and chicken, roasted, boiled or broiled, never fried. Salads of lettuce, romaine and chicory, with French dressing, consisting of four parts of oil to one of Tarragon vinegar, salt and white pepper. Dry toast and light, unsweetened, dry bread. Green string beans and peas ; spinach occasionally ; cauliflower and Brussels sprouts, if they can be digested. Apple at lunch and grape fruit for breakfast, without sugar, are the least harmful, although no fruits are necessary. Lemon is the least harmful. ]Sr. B. — Iso tea. Coffee wdth hot milk for breakfast. Watei^ Diet. — One glass of water on arising ; one glass at lunch ; one glass at dinner ; one between meals ; one on retiring. Small cup of mild, black coffee ]nay be taken after lunch or dinner. Dietaries. — The following is the dietary which Sir H. Thompson recom- mends in calculous affections : " Fish in all forms, except those containing much fatty matter — i. e., her- rings, mackerel, eels and the thin part of salmon. Game in all forms. Poultry. Lean meat in moderate quantity. Preparations of gelatin, savory jelly, or jelly agreeably flavored, but unsweetened. Butter in moderation (this is the only direct form of fat admitted, fat in some form being necessary). An egg or two on account of their usefulness in all cooking operations. (The ob- jection to eggs applies only to the yolks.) Milk in strict moderation, and <»nly with tea, coffee or cocoa. It is very undesirable and noxious in large quantity, as it contains a large proportion of fat and sugar, and its casein is digested with difficulty. It is less objectionable when thoroughly skimmed. Well-made whole- meal bread. Oatmeal. Pearl barley. Macaroni and other Italian pastes. Some coarse meal is needed to act as an aperient and prevent constipation. Whole-meal bread is improved in flavor and texture by an admixture of fine (not coarse) Scotch oatmeal, in the proportion of about one quarter to one third of the wdieat meal employed. " Dry haricots and lentils are most nutritive vegetables, and should be taken made into iJurees. They are digested with ease and contain much nutri- tious matter. Rice, sago, tapioca and arrowroot are all useful if treated as INDICANURIA 361 savory dishes, iiiid not as swoels. Frosli gr('(3ii ve£2;(!tal)l('s are ('sj)ef'ial]_y f!;ood. Frcsli i;r('('u ])cas and hi'oad beans, well masticated. Lii^lit salads are permis- sible to i)ers()ns who digest them easily, but tliey must not be taken by those who digest them with difticulty. Celery, sea kale, asparagus, tomatoes, potatoes and artichokes are all permitted; so also are api)les, roasted or leaked, witlnnit added sugar. " The following are to be avoided : Rhubarb, gooseberries, currants, strawber- ries, raspberries, grapes, plums, pears and all sweet fruit, fresh or preserved. Saccharin may be substituted for sugar." I INDICANURIA The urine often contains substances, not necessarily indicative of very great departures from health, but rather to be considered as danger signals, not to be ignored altogether. Thus, it may contain those known as chromogens, that is to say, bodies which do not of themselves color the urine, but subse- quently develop a characteristic color under special conditions, either on stand- ing or on the addition of agents that cause oxidation. Indican may be defined as the chromogen of indigo blue. It arises from the absorption on the part of the intestinal canal of the parent substance, indol, which itself results from the decomposition of proteids. In the human intestine in health, indol is formed in small amounts. It is one of the products of the bacterial putrefaction of albuminous compounds, and is 2)liysiologically increased on a diet rich in meats or animal food, containing a large proportion of proteid. The indol thus absorbed by the intestine becomes in the tissues through oxidation a new substance, indoxyl, which is excreted in the urine, as a rule in conjugation with sulphuric acid — as indoxyl-sodium or potassium sulphate — and also it is found in small proportion as indoxyl-glycuronic acid. Pathological Indicanuria. — The clinical importance of the presence of a large proportion of indican in the urine has been exaggerated by some, but is more apt to be underrated. Its significance in the light of recent researches can scarcely be doubted. It affords valuable evidence of excessive proteid decom- position in the presence of bacteria ; these are the agents of processes of putre- faction that lead to disturbances in the liver, to the various forms of gastritis, to constipalidu and diarrhea and those i)rocesses of putrefaction and fei-nienia- tion gathered loosely into the general idea of " toxemia and autointoxication."' Experience shows that an increased output of indican is observed in cases of intestinal obstruction, associated with atony and with a deficiency of acid in the gastric juice, and in not a few intestinal disorders dependent on a dimin- ished flow of bile. According to Simon, the deficiency of hydrochloric acid in the stomach is intimately associated with the development of indican. Thus, indicanuria occurs frecjuently in carcinoma of the stomach, in subacute and 362 DISEASES OF METABOLISM chronic gastritis and in those forms of dyspepsia where the motor power oi the stomach is impaired It is also present in typhoid fever. Examples of excessive albuminous putrefaction and of the bacterial activ- ity leading to the formation of large amounts of indican in conditions to be met with elsewhere than in the alimentary tract, are afforded by cases of putrid empyema, fetid bronchitis and pulmonary gangrene, the importance of which has been fully set forth by Von Jaksch. Symptoms. — The symptoms of indicanuria are various, and are in many cases difficult to trace to their true relation with the output of indol. In general, it may be said that indicanuria is commonly associated with gas- tro-iutestinal disorders marked by flatulence — the sig-n of bacterial growth — and of the nondigestion of fats, prominently disclosed by alternating attacks of constipation and diarrhea. A long train of symptoms, nervous, hepatic and renal, take their origin in putrefying processes in the intestine, which at the same time give rise to the presence in the urine of indigo-yielding substances. It becomes necessary, therefore, to examine the urine for indican whenever the signs of gall-stone disease appear, whenever there is pain or colic, or jaundice; and though the mere presence of indican should not be regarded as pathogenic, it gives a clew to the nature of the disease and its treatment. Thus, a furred tongue, injected eye, loss of appetite, headache, torpor, both mental and bodily, tender- ness over the liver and abdomen, may occur without indicanuria, but they may just as well coexist with it, and such signs should, lead us to examine the urine. Treatment. — The treatment of indicanuria consists of those remedies which are intestinal antiseptics and those which stimulate bile secretion. Xo single drug should be used continuously, more benefit being derived by using different members of these groups from time to time. Salol is the most frequently used and is given in doses of from 3 to 5 grains three times a day after meals, either in tablets or capsules. Beta-naphthol and naphthalene come next in efficiency and. are given in doses of 2 to 5 grains in capsules three times a day, after meals. Sodium iodid is use- ful in cases in which there are accompanying nervous symptoms, 10 to 15 grains in solution being given three times a day after meals. Sodium benzoate is also valuable as a remedy and is given in doses of 10 to 20 grains in capsules or solu- tion after meals. In cases of hyperacidity due to intestinal fermentation, sodium bicarbonate is of value, 10 to 30 grains being given in solution or capsule after each meal. Of the remedies used when fermentation or putrefaction is due to an insufficient flow of bile, the gWcholate and taurocholate of sodium are useful. They may be given in capsules, 3 to 4 grains in a capsule, after meals, or every three to four hours during the day. Phenolphthalein has of late been used when indicanuria is associated with constipation, as it acts as a cholagogue and laxative. It is given in capsules or tablets, in doses of from 5 to 30 grains, before retiring. OXALUKIA 363 OXALURIA Oxalnria mpans the presence of an excessive amonnt of oxalate of calcinm in the urine. When found occasionally in moderate quantity, these crystals are of no clinical significance, as they may appear under normal conditions after eating fruits and vegetables containing comparatively lai-ge amounts of oxalic acid, such as rhubarb, tomatoes, spinach, cabbage, turni]^s and sorrel. Oxalic acid is a product that is formed as an intermediate step in the com- bustion process, and comes between urea and uric acid in the series. It is found in very small quantities in normal urine in the form of calcium oxalate, but it is contained in normal specimens occasionally only, after the urine has been left standing for a time. Urine containing numerous crystals of calcium oxalate for any length of time is not the urine of a healthy individual, and the condition is one that should be treated. Oxaluria is merely a symptom pointing to a debilitated condition of the system. Of the cause of this condition, little is known. Generally, oxaluria is associated with conditions of nervous debility, perhaps especially often with those arising from sexual excesses. This is so frequently the case, that one should always be on the lookout for spermatozoa, if, in examining the urine of a nervous individual, calcium oxalate is found. Oxaluria may also give rise to local irritation in the genito-urinary tract. When the crystals are formed in the kidney as they very frequently are, their passage through the kidney tubules, pelvis and ureters may give rise to lumbar pains or hematuria, or the crystals may collect around epithelial cells and mucus and form into concretions in the kidney or renal pelvis, causing renal colic, or they may irritate the bladder and urethra, bringing on frequency of urination. The urine in cases of pronounced oxaluria is of high specific gravity, often reaching 1.040. Even when there are no subjective symptoms of irritation, the microscopic examination usually shows the presence of red blood corpuscles, mucus and epithelia. Treatment. — Eegulation of the diet, and exercise, are of the greatest im- portance. The diet indicated shoidd be one that limits the amounts of all articles con- taining large amounts of oxalic acid. Water, weak coffee and tea are the most suitable drinks. Alcoholic beverages are not especially forbidden, but should be taken in moderation. In order to dilute the urine, the patient should drink water freely. The carbonated alkaline waters, such as Apollinaris, are especially useful. Many authors, as Klemperer, Tritchler and others favor the bitter waters containing magnesia, such as Friedrichshall, llunyadi, etc. Some cases are greatly benefited by the administration of nitromuriatic acid. 364 DISEASES OF METABOLISM DIET IX OXALURIA From tlie following list of foods, a diet suitable for })atieiit.s having oxaluria may be selected : — • Foods Pebmitted. — Clams and oysters, consomme and thin sonjis without tomatoes, all kinds of meat and jish (baked, boiled or broiled), stale bread and toast. Vegetables: Fresh string and lima beans, gi-een peas, lettuce, chicory and romaine salads ; later on, Brussels sprouts and cauliflower may be added. Fruits: Apples are for lunch, peaches or grape fruit without sugar are the least harmful for breakfast in moderation. Cereals: Oatmeal, well cooked, may be taken in small quantities. Foods Forbidden. — All vegetables not mentioned in foregoing list ; espe- cially injurious are potatoes, tomatoes, spinach, rhubarb, beets, turnips, dried beans. Fruits: Strawberries, plums, figs. All sweets are interdicted. Meats: All glands such as pancreas, thymus, liver and kidneys, on accoimt of the many nucleins contained therein. EXTRA DIET IX OXALURIA A More Bigid Diet Covering a Longer Period First Week. — As purely nitrogenous as possible, may take milk, meat (boiled, broiled or roasted), fish, eggs once a day. Xothing fried, pickled, salted or canned, or preserved in any way. Should drink pure water, at least three quarts a day. Xothing to be taken except those things men- tioned. Second Week. — To above may be added cucumbers, celery, lettuce and asparagus. TuiRD Week. — To above may be added raw oysters, oyster broth, green peas, string beans, any broth or variety of clear soup. Fourth Week. — Grape fruit, lemons and cauliflower may be added, pears, peaches, baked apples, grapes in moderation, melons, well-cooked oatmeal in small amount and well-toasted or stale wheat bread. Interdicted. — Potatoes, spinach, rhubarb, beets, turnips, dried lieans, to- matoes, strawberries, plums, figs, or sweets added to the above. DIABETES AND GLYCOSURIA General Consideration Diabetes and glycosuria are discussed together in this eliai)ter because they are so frequently confused with one another, owing to the fact that, in diabetes mellitus, glycosuria is present. DIABETES AXD GLYCOSUEIA 365 Diabetes. — Diabetes is a disorder of tlie body metabolism, characterized by the passing of excessive quantities of urine. There are two forms of diabetes : Diabetes mellitus and diabetes insipidus. Diabetes mellHus is the most important form. In addition to the polyuria and the intense thirst which characterizes bftth forms of diabetes, we have here the presence of sugar in the urine. When diabetes is spoken of without quali- fication, this form is usually referred to. Diabetes insipidus is a name applied to that form of diabetes which is characterized by the passage of abnormally large quantities of normal urine of low specific gTavity, and by intense thirst. Glycosuria. — Glycosuria means the presence of sugar in the urine, from any cause, in excess of 0.1 per cent. There are three varieties of glycosuria: (1) The alimentary, (2) the toxic, (3) the diabetic. Alimentary glycosuria occurs in healthy individuals in certain disturbed conditions of digestion and elimination ; also in diseases of the liver and of the brain, especially when the latter affects the fourth ventricle ; in goiter and after injuries. Alimentary glycosuria may occur after the ingestion of large amounts of starch. Toxic glycosuria occurs in fevers, after drinking large amounts of alcohol and after poisoning with lead, phosphorus, morphin, atropin, chloral, amyl nitrite, acetone, carbon dioxid, curare and strychnin. Phloridzin glycosuria should be classed under toxic glycosuria. Although phloridzin is a glucosid, the amount of sugar passed after its administration is too great to be accounted for by that derivable from the drug. Phloretin, which is a derivative from jihloridzin, is free from sugar and produces the same result. Diabetic glycosuria constitutes the disease known as diabetes mellitus. DiABKTF.S ^IeLLITUS Pathology and Etiology. — The pathology and etiology of diabetes, like those of other disorders of metabolism, has not been definitely determined. The glycogenic function of the liver is deranged, and an excess of sugar passes into the blood and is eliminated with the urine. The bulk of the sugar thus passed is derived from the carbohydrates in the food ; in severe cases, a certain amount of the sugar seems to be the result of metabolism of the ]u-oteid constituents of proto])lasm. The amount of sugar eliminated in diabetes varies considerably. It ranges from a mere trace up to ten per cent and even twenty per cent ; average two to three per cent. The percentage of sugar in tlie urine is by no means an accurate index of the severity of the pathological process. The total amount of urine passed also varies greatly. In mild cases, the 366 DISEASES OF METABOLISM daily quantity may not exceed six to eiglit pints; in s(!vere cases, thirty to fort}' pints are often passed. The specific gravity is high, varying according to the saccliarine contents of the nrine from 1.025 to 1.060. Diabetic nrine has a sweetish taste and aromatic odor, increasing or dimin- ishing with the amonnt of sngar. Symptoms. — The great prominent general symptom of the disease is in- tense thirst, a large quantity of water being required to keep the sugar in solu- tion. There is also usually a great craving for food; in spite of abnormally large' quantities of nourishment taken and in spite of excellent digestion, the patient may lose weight. The skin is dry and harsh, the temperature frequently subnormal, the pulse frequent and the tension increased. Complications. — Serious complications are frequent, such as acute pneu- monia, tuberculosis, diabetic tabes, hypochondriasis, cataract, diabetic retinitis, impotence ; nephritis is quite common, sometimes due to arteriosclerosis, in other cases probably the result of the strain on the renal structure from the continual passage of abnormal quantities of sugar. Prognosis. — Recovery from true diabetes is very rare. In children, the dis- ease is especially fatal ; so-called galloping cases are often seen which carry the young patient ofp in a few days. With advancing years, the disease runs a slower course. During middle life, diabetes may exist for ten or fifteen years before the fatal termination. In stout individuals, the prognosis is more favor- able than in those of slighter build. Unless one of the many serious complications, to which the patient is ex- - posed, sets in, the disease usually ends with diabetic coma. This condition closely resembles in its onset uremic coma and, like it, is due to the presence in the blood of some toxic agent, which in this case is believed to be acetone. Treatment. — The diet and personal hygiene of the patient are of prime im- portance. The patient should live a quiet life, free from excitement and worry. He must be scrupulously regular in his habits, taking a moderate amount of exercise and bathing daily to promote a free action of the skin. The regula- tion and restriction of the diet is the most essential part of the treatment. The carbohydrates in the food should be reduced and a carefully arranged diet, with due regard for variety, should be given. The substitution of gluten bread for ordinary bread and saccharin for sugar, should be a part of the dietary regime. Among remedies, opium is the one that has specific influence on the progTess of the disease. Codein given in one-half-gTain doses three times a day, gTadu- ally increasing to six or eight gTains during twenty-four hours, will in the ma- jority of cases lessen the amount of sugar in the urine materially. As the amount of sugar diminishes, the opium may be gradually withdrawn. Among other useful remedies, we may mention potassium bromid, arsenite of bromin, arsenic, antipyrin, the salicylates, nitroglycerin and strychnin. PHOSPHATUIIIA 367 DIKT LIST From Friedenwald and Ruhrah, ^^ Diet in TJeaUh and Disease ^^ Foods Allowed. — Meats, eggs, green vegetables, fats. Soups: Chicken, beef, veal, mutton, oyster, turtle, terrapin, clam broth (prepared without flour). Meats: All meats, except liver. Gelatin jellies. Cheese: All varieties, espe- cially cream cheese. Fish: All fish, including oysters, clams, terrapin, lobster, shrimp, salt fish. Farinaceous foods: Gluten bread, cakes, biscuits and por- ridges, almond cakes and bread, soya bread. Vegetables: Green vegetables, spinach, lettuce, romaine, chicory, sorrel, kale, artichokes, endives, pickles, cucumbers, cranberries, truffles, mushrooms. Fruits: All acid fruits, sour ap- ples, sour cherries, sour oranges, lemons, grape fruit, gooseberries, red currants. Nuts: All sorts of oily nuts, such as cocoanut, walnuts, filberts, almonds, butter- nuts, pecans, Brazil nuts. Fatty foods: Cream, butter, olive oil, cod-liver oil, bone marrow. Drinks: Tea or cofPee without sugar, alkaline mineral waters, Rhine wines, claret. Burgundy, brandy, whisky. Foods Forbidden. — Sugars, starchy foods (rice), sweets of all kinds, liver. Vegetables: Potatoes, turnips, beets, carrots, peas, baked beans, cauliflower; also sweet fruits, such as dates, grapes, peaches, prunes, bananas, preserves and jel- lies. Nuts: Peanuts and ckestnuts. Drinhs: Sweet wines, cider, cordials, beer, porter. PHOSPHATURIA This is a condition in which an excess of phosphates is passed in the urine. Two varieties of phosphaturia can be distinguished, the true and the false. True phosphaturia depends upon an absolute increase in the amount of phosphates eliminated in the urine as determined by quantitative analysis. A mere deposit of phosphates in the urine immediately on voiding or on standing, without a relative increase in the total amount of phosphates, consti- tutes false i^hosphaturia. The clinical diagnosis of true phosphaturia can be made only: (1) If there is a quantitative excess of phosphates which is con- stant (the normal amount excreted in twenty-four hours does not exceed three and a half to four grains). (2) If this excess is not controlled by a change of diet. (3) If the deposit of phosphates occurs immediately after voiding the urine. Deposits of phosphates in the urine may occur within the body in cases of inflammation or suppuration of the urinary organs, such as cystitis, pyelitis, etc. ; es}D€cially when there is a decomposition of the urine within the tract, the result of an obstruction, as an enlarged prostate or a stricture. Of course, such cases cannot, in any sense, be called true phosphaturia. This form of phosphaturia is of special interest to the genito-urinary surgeon on account of the frequent formation of calculi under these conditions. 368 DISEASES OF :\rET ABOLISH The iDliospliorus eliiiiinaic'(l with the urine is derived from two sources: from the food and from decomposition ^ Inches Long, Removed at Autopsy. Note the fissures and depressions. (Author's collec- tion.) Fig. 267. — Single Asymmetrical Kidney, Mark- edly Convoluted, Removed at Autopsy. (Author's collection.) was 4 inches long, 2| inches wide and 2 inches thick. Five or six irregular ele- vations could be seen on its surface. The microscopical report of Dr. Noyes showed changes of chronic inter- stitial nephritis, with the production of a moderate amount of new connective tissue, degeneration of tubules in the cortex with exudates, glomeruli filled with leukocytes, proliferation of epithelia. The tubules in the medullary portion were more normal (Fig. 267). ANOMALIES OF THE BLOOD VESSELS Vascular anomalies may exist in cases of abnormal kidneys, but they may also be found in an otherwise perfectly normal gland. Some of these anomalies have a surgical interest, although most are mere anatomical curiosities. The vessels may be abnormal by their origin, by their distribution or by their number. Anomalies of the renal artery are more important, and also more common than those of the vein. The artery may originate much lower than usual ; this is ordinarily coupled ANOMALIES OF THE BLOOD VESSELS 389 with a congenital ectopy of the gland. Among the anomalies of distribution, the most interesting is the premature branching off from the trunk of the renal artery of the branch going to the lower pole of the kidney. This artery then crosses the ureter near its origin, and may become the cause of an hydro- ne])hrosis; in three cases out of four (English), it passes in front of the ureter, whereas in the fourth it passes behind. This artery is not a supernumerary vessel, as is sometiriies stated ; but it is a normal artery of the kidney, which cannot be ligated or cut without necrosis of the corresponding part of the gland. The renal artery itself may be replaced by two, three or even four trunks. There may also be renal supernumerary arteries that are small and may be severed without interfering with the nourishment of the kidney but may give rise to considerable hemorrhage during renal operations. An embryologically interesting anomaly of the left renal vein is that in which, all other things being normal, the vessel ends abnormally low into the vena cava, at the level of the fourth lumbar vertebra, and receives perpendicu- larly the vena azygos minor. CHAPTER XXI KIDNEY INJURIES Broadly speaking, there are two varieties of kidney wounds : First, those that are inflicted without the wall of the body having been opened or pierced ; and second, injuries of the organ by some instrnment, weapon or missile that has passed through the body wall. The former is called a suhparietal (closed) injury, and is usually due to a direct blow, a fall, striking on the kidney region, or a crush from the wheel of a vehicle ; the latter is called an. open wound, and is due to a slash or a puncture with a knife, sword or bayonet, or to a pro- jectile from a firearm. Kidney injuries are rare, if surgical wounds are excluded. In 7,741 cases of injuries reported by Kiister, but 10 were renal. Contusions are the most frequent, next come gunshot wounds and last incised and punctured wounds. I have had 5 cases of suhparietal injury and 1 open wound (a stab). There is an instinctive tendency to consider all injuries involving the kid- ney as dangerous. This idea has been inherited from surgeons who were not •familiar with renal surgery, but at the present writing operative interference has shown us that this fear was not justified and that kidney wounds, like the wounds of all highly vascular organs, often heal quickly. Experimental sur- gery, in the hands of Albarran, Legueu, Paoli, Podvyssotsky, Tuifier and others, has taught us that the mechanism of wound repair in the kidney is essentially the same as in any other parenchymatous organ ; that is, the proliferation of the interstitial connective tissue of the gland bridges the gap between the two edges and then permanently replaces this temporary mending in the natural way with the aid of a clot. The functionating elements of the gland degenerate and are replaced by connective tissue. Scar formation is rapid in the kidney and the process of repair has been shown far advanced after six days. The parenchyma is substituted by common scar tissue, which is slowly permeated by scant, newly formed capillaries. It has been claimed by several that, after the healing of a kidney injury, a regeneration of the epithelial cells and the glomeruli takes place. I do not believe, however, that such a process is possible, as in such a case the kidney parenchyma would have regenerative powers that are not shared by other tissues in the body. The epithelial cells of the kidney are so delicate, that even a temporary ligature of the renal vein is enough to alter them deeply ; 390 SUBPAKIETAL INJUEIES 391 and liig"hl,y sjieeiali/ed cells do not. regenerate. As for glomendi, one docs not understand how sneh a complex formation could regenerate, even in very young people. If the glomeruli appear more abundant near a renal scar, it is prolj- ably because of the shrinkage of the connective tissue in the vicinity. There is undoubtedly a compensatory hypertrophy after any loss of sub- stance of the kidney, but this is not due to the regeneration of renal elements. (\)m])ensation in the remaining kidney, after nephrectomy, for instance, is established not through formation of new elements, but through an increase in size and in functional activity of the surviving elements ; for it must not be overlooked that we have normally in the body a much greater amount of kidney tissue than is necessary for the maintenance of life. Tuffier removed one kid- ney in dogs and had to slice off a large part of the other, before he obtained any symptoms of urinary insufficiency. SUBPARIETAL INJURIES Etiology. — Contusions of the kidney are seen a little more frequently on the right side than on the left (142 to 118). They sometimes have taken place in both sides ; while cases are on record of the rupture of a single asymmetrical kidney, and one case of a ruptured horseshoe kidney. In my series, 3 cases were on the right side. The most susceptible age is from ten to thirty, that is, the age of greatest muscular activity and liability to accident. Men are much oftener affected than women. In my personal cases, eighty per cent occurred in men. Kiister gives even as high as ninety-four per cent in men and six per cent in women. The kidney may undergo rupture as a consequence of a direct violence, such as a blow, fall on the loin, kick from a horse ; or of an indirect compression of the body between two surfaces, as in elevator-shaft accidents, by the pinning of the lumbar region between the buffers of railroad cars, or by the passage of a carriage wheel over the costo-iliac space, the body resting flat on the ground. The latter two accidents and a fall on the loin are the most common. Some claim that a kidney may be ruptured by indirect violence, such as a strong muscular contraction when the body is bent suddenly forward or on one side; but personally I am inclined to doubt the possibility of a rupture of so well-protected and so movable an organ from a mere muscular contractiou, unless the kidney is very much congested or distended on account of some ob- struction to the urinary flow. The theories of the mechanism of rupture do not accoimt for all forms of renal injuries, but the}^ are the best we have at our disposal at ])resent. Pathology. — The pathology of contusions depends on whether the fibrous capsule is torn through or not. If the capsule is not torn through, the hemor- rhage is usually slight, in which case there is a subcapsular ecchymosis or hema- 392 KIDNEY INJUKIES tonia, or irrcgnlarly shaped areas of hemorrhage within the parenchyma near the surface or extending as deep as the pelvis. True rupture exists when the capsule is torn and the laceration is deep enough to communicate with the pelvis of the kidney. Fissures are usually found on the anterior aspect of the organ and are transverse in direction or radiate from the hilus. Infarcts of the usual wedge shape may follow con- tusions of the kidney. In cases of true rupture of the kidney, there is an ex- tensive leakage of blood, or blood and urine, into the surrounding tissue, ac- cording to W'hether the excretory channels are torn or not. If the rupture is very extensive, the two halves of the kidney are held together by the pedicle only, or, in extreme cases, the kidney may be divided into a number of small pieces, some of which may be totally detached. The perirenal extravasation may burrow down along the ureter and collect around the pelvic organs, but it usually collects in the retroperitoneal cellular tissue, Avhere it forms a rapidly growing liquid tumor known as a pseudo- traumatic hydronephrosis. The contents of the tumor resulting from rupture of the kidney consist of a brown-red fluid, which it is said may later change to amber and resemble clear urine. Personally, I have never seen the clear fluid after a rupture of the kidney, and I have cut into these extravasations of very large size some time after the injury. Clear fluid I am inclined to regard as coining from a rupture of the renal pelvis or ureter. Detachment of the kidney from its pedicle is very rare and is accompanied by -severe, generally fatal, hemorrhage. When death does not occur at once, infarction and necrosis of the kidney (extravasation with gangrene of the peri- renal tissues) are liable to follow. Fracture of the ribs is a frequent complication of renal contusion. The peritoneum is torn in some cases of violent injury, an accident more apt to occur in children under ten years on account of the firm connection between the peritoneum and the kidney at this early age. Other abdominal organs nuiy, of course, suffer coincidently wdth the crushed kidney. Symptoms. — The Ukine. — When a kidney is torn, even slightly, it bleeds more or less profusely. Hemorrhage is, therefore, the most important consid- eration in the symptomatology of renal contusions. Of all forms of bleeding, hematuria deserves the first place, because it is the most frequent and the most characteristic. It occurs in the gTcat majority of cases, even in mild injuries, and is lacking only when there is a small tear that does not reach the calices, and vdien the continuity of the kidney with the ureter has been destroyed. It Avill thus be seen that it is not always an alarming symptom per se, and that its absence does not invariably indicate a mild injury. Hematuria^ coming on after injury, does not mean necessarily a contusion of the kid- ney in the sense that Ave are considering; for if a calculus is present, the bleeding may have been provoked by the traumatism of the stone within SUBPARIETAL INJURIES 393 tlic kidney, as aftei' a jar. Blood and urine pressing on the outside of tlie ])elvis or nretcr may prevent licniatnria. The hematuria after an injury to the kidney may be profuse at once, or slight and subsequently increase ; or it may be intermittent. In addition to fresh blood, clots or casts of the ureter may be passed, or the blood clots may accumulate in the bladder and be discharged with difficulty. It lasts from two to eight days in the average cases. In some, it may continue remittently for weeks. In infected cases, secondary hemorrhage may occur. Certain conditions that aifect the character and amount of urine passed occur as the lesion begins to interfere with the function of the kidney. Oliguria and even anuria may result if a blood clot occludes the ureter. Later polyuria may occur, either simply compensatory in character or indicating the presence of a traumatic nephritis. Albumen and pus may also be found in the urine, indicating the j^resence of an infection and renal suppuration. Together Avitli hemorrhage, w^e should look for the general symptoms such as accompany other abdominal injuries, and are summed up by the word " shock," symptoms w^hich are due to injury to the solar plexus and other of the adjoining nerve plexuses as well as the loss of blood. They include pallor, cold extremities, cold perspi- ration, a small and rapid pulse, vomiting, vertigo and prostration. If internal hemorrhage be severe, there are added to this gradual blanching of the skin and mucosae, a thready pulse, anxiety and collapse. If peritonitis comes on later, there are the usual general symptoms associated with this complication. Local Symptoms. — The local symptoms generally come on at once after the injury, although they are sometimes delayed. They include pain of a varying character, usually not severe when due only to the injury of the externfll tissue or to fractured ribs. It may, however, be very severe, radiating like that of a renal colic, and increasing on movement and often upon respiration. Sometimes 2)atients complain of a sensation of something bursting at the moment of injury. Retraction of the cremaster and pain in the testis on the affected side, are regarded as signs of severe renal hemorrhage and of blocking of the ureters by blood clots (Le Dentu). There may also be muscular rigidity over the in- jured organ. The renal pain may last for weeks, and sensitiveness on pressure persist for a long time. Physical Sic4ns. — The skin about the injured loin may be ecchymosed or lacerated. Ecchymosis may also follow the connective-tissue sheaths of the spermatic vessels and thus reach the external abdominal rings. In certain cases, it has been seen to extend over the external genitals. A characteristic feature of these ecchymoses due to renal injuries is that they usually reach the inguinal ring late — two or three weeks, perhaps, after the accident (Sebilleau, Dumenil, Le Dentu) — but it must be remembered that they nuiy also be due to injuries of other vessels in the retroperitoneal tissues. The swelling may be very slight in mild injuries, but it is always distinct 394 KIDNEY INJUKIES in the more severe forms. It usually comes on suddenly in severe cases and depends upon the amount of the effusion of blood and urine. The tumor is usu- ally palpable even in mild cases and is dull on percussion, when the swelling is suthcicutly larae to percuss well. Complications. — The complications are aseptic or infectious in character. Aseptic complications are intraperitoneal hemorrhage, and, rarely, traumatic nephritis. Infectious complications are peritonitis, perinephritic abscess and pyelo-nephritis. Peritoxeal Co:^ir'LiCATioxs. — Effusions of blood into tlie peritoneum occur when the injury includes a rent in that mendjrane, or when the liver, spleen, or some other organ is torn. A septic peritonitis develops within a short time when infected urine flows into the cavity along with the blood. However, this is fortunately not a connnon occurrence, as the peritoneum is fairly resistant to aseptic urine. According to experiments quoted by Wagner, such urine is borne by the peritoneum for forty-eight hours without much damage. As- cending and hematogenous infections may also attack the peritoneum in sub- cutaneous injuries of the kidneys (de Quervain). De Quervain noted that, owing to disturbances in circulation of the colonic flexure on the affected side, a certain degree of meteorism was often present without any peritoneal involvement. This is a point worth remembering, as such tympanites are apt to mislead one into the diagnosis of traumatic peritonitis. Chko]n^ic Traumatic Xepheitis. — Chronic traumatic nephritis, as a com- plication of subcutaneous renal injuries, deserves a few additional words, as it •has been the subject of considerable controversy. It is not certain Avhether a diffuse nephritis can follow such an injury, and it is probable that in the cases in which diffuse renal lesions were found at autopsy after contusions of the kidney, the patient had been suffering from chronic nephritis before the injury. Circumscribed nephritic lesions may occur, however, in the areas immediately involved. In such cases, which are rare, the albuminuria and the casts persist for some time in the urine after the hematuria disappears. Albumin has been found in small amounts for a year or more after the injury. Diagnosis. — The diagnosis of a renal contusion is possible i-n a positive way wdien hematuria is present. All other symptoms may lead us to suspect such a lesion, but none is sufficiently characteristic. This does not mean that they must not be looked for carefully. The existence of a perirenal hematoma, coupled with the history of the case, has, however, gTcat value. The differentiation between a subparietal renal injury and a renal colic due to calculus and preceded by an accidental traumatism, is not always easy. The history of the case and the repetition of the attacks at intervals may help in making this distinction in the limited time at our disposal in these cases. Renal tumors often give rise to pain and hematuria after an accidental blow, SUBPARIETAL INJURIES 395 and, in sncli cases, the diagnosis will have to he reserved until tlio nrino and the cachexia .give a clew to the condition. We liave seen tliat I lie sc^verity of the symptonis is l)y no means a measnre (if the extent of the injury in snhcntaneous renal traumatism. An exception to this, perhaps, is the rajiidity Avith which the renal hematoma develops. This is usually proportionate to the severity of tlie injury. In cases with slight or ahsent swelling and i)ain, hut with persistent hema- turia, the cystoscope will show from which side the bleeding comes. Muscular rigidity on the affected side is of service in doubtful cases. In another class of cases, the l)lceding continnes slowdy until a tumor resembling a small water- melon in shape and size develops on one side of the abdomen, most nuirked in front (Fig. 268). In this case, a lumbar incision should be made in the ileo-costal space be- hind and the contents evacuated. The amount of mixed nrine and blood in such cases is often as- tounding. Prognosis. — The prognosis of renal contusions varies with the severity of the lesion. The chief danger is from complications, and recoveries are on record of patients who have been in an apparently hopeless condition. Death nraj oc- cur within a short time as a result of collapse from hemorrhage. If the patient lingers on, complica- tions may be feared. According to Morris, in rupture of the kidney, its pelvis, or ureter, the prognosis, as far as life is concerned, is less favorable than in rupture of other abdominal organs. Statistics of mortality from subparietal renal injuries vary souiewhat. Edler gives fifty per cent mortality, Kiister forty-seven per cent. Keen thirty- three per cent, but Albarran thinks that these figures are exaggerated, as he saw seven cases without a death and as Le Dentn notes that recovery took place in nearly all cases observed by him. Guyon, at the ISTecker Hospital for the past ten years, does not record a single fatal case. The high mortality figures are due probably to the fact that only the grave cases are published. Hemorrhage Fig. 268. — Shape of the Abdomen in the Case OF A Ruptured Kidney. The rupture extended into the renal pelvis. There was a slow leakage of blood and urine. (Author's case.) 396 KIDNEY INJURIES and siippiiration are the most frequent causes of death. Wagner could find hut three cases on record where the patient recovered from a renal contusion complicated by a demonstrable tear in the peritoneum. Kiister considers these cases as offering the most unfavorable prognosis. The question of prognosis bears directly on the question of treatment. Treatment. — In mild and moderately severe cases, renal contusion heals spontaneously, in -which case there is no place for active surgical interference. In fact, such patients, when kept in bed, with strips of adhesive plaster across the back, recover quite well in a very large proportion of cases. The usefulness of ice bags is doubtful. In complicated cases, rest in bed should be maintained for a week or longer, after the swelling and all traces of bleeding have disappeared. Shock should be treated in the usual way, but cases of rupture of the kidney must be very carefully watched and, if the shock is great, the pulse thready, indicating in- ternal hemorrhage, rapidly increasing, an incision should be made and the wound in the kidney repaired by suture, if not too extensive. If, however, the kidney is badly lacerated, an immediate nephrectomy is indicated. If the renal hemorrhage is found to be active, the kidney must be repaired or removed. In two such cases of my own, after evacuating the contents and packing the cavity, the hemorrhage ceased. Later I removed the kidney in one of these, on account of infection and the great damage done to the kidney. Still another indication for operative intervention is given by the late in- fection and suppuration of a perirenal hematoma. This may require an opera- tion three weeks after the accident. The kidney is sometimes necrotic and has .to be removed. To sum up in a few words : The immediate indication for operation is hem- orrhage ; the late indications are perirenal accumulations and infection. The results of operative treatment as contrasted with the nouopcrative treat- ment, are tabulated thus by Morris (vol. i, p. 198). In twenty-six cases collected from English and American sources from ISSi to 1893 inclusive, he found: One died of other causes. Fourteen treated palliatively, ten died — 70.7 per cent. Eleven treated by operation, three died — 27.2 per cent. This is not absolutely convincing jn'oof of the superiority of the operative method. My personal results to date are: One treated palliatively, no death. Eour treated by operation, one death. Illustrative Cases. — I will give a brief resume of the five eases of sub- parietal injury of the kidney I have had. Case I. — Case of subparietal subcapsular injury of the right kidney. The patient was a laborer, thirty-eight years of age, who one week before seeking SUBPARIETAL INJURIES 397 admission to the liospital had a fall, striking on the right side. This was fol- lowed by pain in the loin and inability to pass urine for twenty-four hours; when he finally ])assed urine, it was red in color. Stains pnvf^ens: A mass the size of a coeoanut, dull on jx-rcussion behind, is felt in the right lumbar region. Local pain and tenderness. No temperature. Urine: Of a Burgundy-red color. S|:>ecific gravity, 1.022. Albumin, twenty-five per cent in bulk. Some leucocytes and abundant red corpuscles. Treatment: Rest in bed; milk and Vichy diet; urotropin and Basham's mixture. Course: The patient remained in the hospital five weeks. At the end of the first week, the urine was straw-colored, specific gTavity 1.019, of acid reac- tion and contained a few blood cells and calcium oxalate crystals. By the end of the second week, three weeks after the accident, all traces of blood had dis- appeared from the urine, and the tumor was diminishing in size. It could scarcely be felt at the time of discharge, five weeks later. Case II. — The patient, a laborer, twenty-two years of age, eleven days before admission fell while dumping a box of dirt, and struck the ground on the left side from a distance of twenty-five feet. He was unable to walk and had to be carried home. A few days later, the painful swelling, that had been gradually increasing in size, occupied the entire left side of the abdomen. The general symptoms increased in severity, and the patient en- tered the hospital. Status 'proesens: There was a swelling in the left side, resem- bling a small watermelon in form, dull on percussion (Fig. 268). Temperature 101° to 106° F. ; pulse, 88 ; respiration, 20. There was no visible hematuria. The local findings led to the diagnosis of splenic rupture. Treatment: Operative. An in- cision was made in front, along the outer border of the rectus muscle, and the peritoneal cavity was opened. The gut Avas found stretched between the anterior and posterior peritoneal walls like pieces of ribbon, due to a retroperitoneal tumor that was pushing forward the ab- dominal contents. The patient was accordingly turned and an incision made in Fig. 269. — Rupture of Kidney. IShows the rent in the kidney proper and pelvis of a ruptured kid- ney. The kidney is turned so as to show the tear. (Author's case.) 398 XTDXEY TX.TT^rJES tlic loin l)cliin(l, wlicii Iwo and onv half lialloiis of a rcddisli-hrown l)]ood_v fluid escajjed. The kidney was found i'U])tui'cd poslcriorly, sliowiiiii- a ti-aiisverse rent in the kidney proper extending into the ijclvis ihat achnitted three fingers. The opening was just ahove and posterior to the ureter. The organ was snrronnded by a dense mass of tissne and very adlierent to tlie adjacent parts. The wound was packed and drained, hnt a week later the drainage became impaired, and there was much pain and distress. Reopening of wound and removal of two and one half quarts of a brownish fluid containing pus. Nephrectomy one month later. The patient recovered (Fig. 2G9). Case III. — The patient was a grocer, thirty-one years of age, who three weeks previously, following a fall, began to suffer from pain, gradually increasing, and swelling in the left lumbar region, with anorexia and constant thirst. Xo irregu- larities of urination. No visible hematuria. Status prwsens: A large tumor, not sharply defined, also shaped like a melon, was felt in the left lumbar region. Temperature, 102° to 103° F. ; pulse, 98. Treatment: Operative. A lumbar incision was made, and a large amount of a brownish fluid like broken-down kidney tissue was removed. The cavity was packed with gauze. Suppuration followed, and the patient remained in the hospital for two months, when he was discharged with the wound in the kidney healed. Case IV.— The patient, a housewife, thirty-six years of age, had complained for eight years of occasional pain in the right lumbar region, with fever, last- ing from a few hours to days. For some time before coming under treatment, she had noticed an increasing fullness in the lumbar region. Examination showed a well-defined tumor on the right side, extending from the costal mar- gin to the iliac fossa, beyond the umbilicus. There was another bulging in the ileo-costal space behind. At this time the patient's temperature was 101° F. ; pulse, 94; respiration, 36. She was sent to the hospital in an ambulance, and at the time of admission, a few hours after the first examination, her tempera- ture was 105° to 10G° F. ; pulse, 130; respiration, 46. No well-defined tumor could be outlined in the examination, but there was a general mass over the en- tire right side of the abdomen. It was evident that the ride in the ambulance had caused rupture of the kidney and leakage into the postrenal space. An in- cision was made the next day, and a large amount of blood and pus evacuated. The temperature dropped at first, but then ran a septic course due to imperfect drainage. The kidney on removal was found to contain a stone. The outcome was death. Case V. — The patient was a man twenty-nine years of age, an ironworker by occupation, who gave a history of many attacks of malaria. Two years ago he had pain in the right loin, lasting four or five days, and this had recurred since at intervals of four or five months, with a little fever, lasting for hours IT^[CISED, PUNCTURED AND GUNSHOT WOUNDS 399 or cla^^s. Four inoiillis Ix'fore coining nndor troatiiicnt, tlio patient, while lifting' a piece of metal, heard something snaj) on the right side; this was followed hy faintness and cold perspiration. There was a strong desire to nrinate, and the nrine passed Avas bloody, remaining tnrhid ever since that time. At the time of admission, the patient had a se])tic temperature, aver- aging 100° F. ; his general condition was bad. A large mass could be felt in the right side. Treatment : Operative. An incision was made in the loin, and three pints of mixed nrine, blood and pus were evacuated. A ragged opening was found in the lower pole from wdiich protruded a fragment of stone, over an inch in length and one third of an inch in width. The wound was packed. The temperature dropped after the operation ; the wound did not heal and a sinus remained, discharging urine and pus. ]^ephrotomy was performed, followed by free drainage of the kidney, and the patient left the hospital one month later in good condition. INCISED, PUNCTURED AND GUNSHOT WOUNDS OF THE KIDNEY Etiology. — Incised and punctured wounds of the kidney are almost always due to a thrust, or to a fall on something sharp, as a pointed weapon. The kid- ney is generally alone aifected, as the wound is usually due to the stab of a knife in the back or side, and the opening of the peritoneal cavity is infrequent. Still rarer is a complete division of the organ. When the kidney wound results from a thrust through the anterior wall of the abdomen, the other abdominal organs are usually injured as well. The wound may vary considerably in depth and direction. As these wounds are often inflicted by septic instruments, it is not surprising that they fre- quently become septic. Gunshot wounds are rarely seen in civil practice, and in war they are al- most always complicated with gunshot injuries of other organs on account of the high velocity of modern firearms. Edler states that these wounds constitute about one twelfth of one per cent of all gunshot injuries. Only tln-ee cases are on record in women. Pathology. — The bullet may remain in the kidney and become encysted there, or it may pass through the organ, or it may graze it and cut oif a ])iece of renal substance, or pass through the renal pelvis. Fragments of cloth, bone, etc., may be carried with the bullet and remain in the track of the projectile. There is alwa^'S a certain amount of contusion along this tract, and an escliar forms in its walls. The kidney may, however, be mashed to a pulp by the projectile. The orifices of entrance and exit are of \mequal size, the latter being usually the larger. Stellate fissures radiate from these openings when- the kidney is flaccid, or a long and wide fissure results when it is distended at 400 TaDXKY INJURIES the time of the injury. Unless the ])_vr:iiiii(ls oi' cnlices l)e \voun(h'(l, no hlood escapes an(] thci'e is but liitU' hematuria at first in the average case, llioniih hlood nuay accumulate in the perineal space. These wounds heal by granulation followed by the formation of cicatricial tissue, after the slough has separated from the tissues and has been discharged. Foreign bodies carried in with the bullet nuiy become encysted in the kid- ney, or pass into the ureter or through the external \v ]t('ar, with the exco])ti(m of some albumin and casts in the urine, in which case the disease usually becomes chronic. Generally, the attacks of subacute nephritis do not reach the stage in which the serous cavities become involved, or in which there are marked uremic symp- toms. The active stage of the attack usually lasts for three weeks, during Avhich time the temperature is but slight or ranges from 90° to 101° F., with a pulse of from 90 to 100. If these gradually subside, the patient will prob- 422 NONSUPPURATIVE NEPHRITIS ably recover by the end of six or eight weeks, or else pass into ihe chronic stage. The blood pressure in acute nephritis is from 130 to 150. Diagnosis. — Acute nephritis occurring in the course of an infectious dis- ease will not be overlooked if we make it a habit to examine the urine for albu- men in every case. The history of the patient will show us whether we are dealing with an acute nephritis or wdth an exacerbation of a chronic condition. In the latter, the urine shows in the sediment hyaline, fatty casts and fatty or degenerated renal epithelia. There is also a history of a previous acute nephritis, or an infectious disease. The presence of thickened arteries and of hypertrophy of the heart, as well as changes in the retina, are also points which show that a chronic nephritis has existed for some time and is now in an acute explosion. The diagnosis between renal hemorrhages from other causes and an acute nephritis with bloody urine is not difficult. In the latter, the urine is dimin- ished in amount and contains renal epithelia, leucocytes and hyaline, granular and epithelial casts. The presence of fever and edema are also signs which help to differentiate the condition from renal hemorrhage. In renal hemorrhage due to tumor, atypical cells and tumor fragments would be found in the urine. If due to stone, crystals would be present, and if due to tuberculosis, tubercle bacilli. The treatment of acute nejohritis wall be considered later. CHRONIC NEPHRITIS As we remarked in the introductory chapters, the terms chronic paren- chymatous and chronic interstitial nephritis are no longer regarded wdth favor •by some modern clinicians. What was formerly known as chronic paren- chymatous nephritis some now style chronic nephritis Avith dropsy, and what was known as chronic interstitial nephritis, they call chronic nephritis wdth uremia. However clinicians may call these two general groups, the autopsy findings show that, although in all cases of chronic nephritis there is more or less evidence of both parenchymatous and interstitial changes, the preponder- ance of the disease is either in the parenchyma or the stroma. In comparing the autopsy findings with the clinical symptoms during life, it is usually found that the cases accompanied by dropsy are of the parenchymatous type and those accompanied by uremic symptoms are of the interstitial type. Chronic PARENCiiYiiAxous iSTEPiiKiTis {Chronic Nephritis iviih Dropsy) Etiology and Pathogenesis. — This form of chronic nephritis frequently follows an acute or subacute renal parenchymatous inflammation, or it may also develop wdthout discoverable reason. In the latter case, the real cause of the chronic nephritis is not known, but it is supposed to lie in some toxic influence CHRONIC NEPHRITIS 423 Avhich acts upon the kidney through the blood. A variety of causes contribute more or less distinctly to its development. Of these, we may mention frequent or protracted exposure to cold or dampness ; overnutrition ; undernutrition ; per- haps abuse of alcohol ; various constitutional diseases, such as tuberculosis, syphilis, gout and chronic malaria ; diseases of the heart, especially ulcerative endocarditis ; and chronic poisoning with lead or mercury. Chronic paren- chymatous nephritis may also be the result of a previous acute infection or in- toxication, which was apparently cured and reappeared afterwards in this chronic form. Among the predisposing causes are unfavorable hygienic sur- roundings, overwork and severe physical strain. Pathology. — U^^on gross examination, the kidneys are generally enlarged and the capsule is adherent in places. The consistence of the kidney may vary greatly. The surface of the organ is pale white or mottled. An incision through the convexity shows the cortex to be narrower than normal, the yellow and white finely striated markings obscured. The medulla is not much changed. The medullary rays are slightly darker than normal. The lesions in this type of nephritis are always scattered through the kidney in patches or foci, and the appearance of the organ depends upon the arrange- ment of these foci and the amount of changes in the parenchymatous and in the interstitial tissues. What is known as the large white kidney, for example, is a parenchymatous or a diffuse nephritis mixed with amyloid kidney (Senator). It is characterized especially by fatty degeneration of the tubules and the glomeruli, and fibrous and hyaline changes in the stroma. The large mottled kidney is the result of lesions in patches, involving both the parenchyma and the stroma. The minute hemorrhages and venous conges- tion in the cortex give rise to the mottled appearance. Microscopically, it has been found that all these differences depend npon quantitative relations of the pathological changes in the various classes of tissues of the organ (Senator). The j)athological changes in parenchpnatous nephritis are found principally in the cortex, especially in the epithelia of the convo- luted tubules and less frequently of the straight tubules. These epithelia are in various stages of degeneration, from cloudy swelling to complete molecular necrosis, and are shed more or less freely into the lumen of the tubules, which contain also leucocytes, fat globules, red blood cells and hyaline, fine or coarse granular, epithelial, fatty and mixed casts. While the type is known as the parenchymatous, there are always some changes in the interstitial tissue (diffuse nephritis). Foremost of these is an edema of the stroma. In the advanced stages, there may be round-celled infiltra- tion or proliferation of the interstitial tissue partly clouding the parenchym- atous elements. The glomeruli are also affected, showing fatty degeneration and necrosis of their epithelia, and an exudate within their capsules. Their capillaries are fre- 424 NONSUPPURATIVE NEPHRITIS queiitly compressed or blocked l)j tlie .swelling' of the eiidothelia. The arterioles siirroinidiiiii,' the glomeruli are also more or less thickened. Symptoms. — The symptomatology of chronic parenchymatous nephritis is quite clearly defined. There may be a prodromal stage, characterized by a fever and lumbar pain, but usually the disease sets in insidiously with slight and transient edema, which leads to an examination of the urine and to the dis- covery of albumin and other evidences of nephritis. The edema first appears on the lower eyelids or on the face, over the sternum or at the ankles. Later, it extends to the legs, the scrotum, the abdomen, the loins and the rest of the body, after which the edema changes its place according to the patient's position. It is greatest in the legs when he stands and greatest in the loins and buttocks when he lies in bed for any length of time. Gradually, effusions may appear also in the pleura, the peritoneum and the pericardium. The extensive edema of chronic Bright's disease is considered by some as a means of defense, that is, that the toxins which are not eliminated are stored np in the edematous fluid and are thus kept out of the circulation. This theory is proved by finding toxic constituents in serous effusions and in edematous fluids in chronic nephritis. The urine in this form of chronic nephritis is always scanty, clear, of high specific gravity and straw or yellow color. The toxins of the urine are composed of 85 per cent of inorganic j^roducts, the princijDal of which is chlorid of potash, and 15 per cent of unknown organic substances. There is usually a considerable amount of albumin — over 2 grams per liter (i to f of 1 per cent by weight). The ordinary urinary salts may be normal or increased, save the chlorids, which are diminished. Their retention in the system when the kidneys are affected with chronic nephritis, especially in the parenchymatous form, has been thor- oughly demonstrated. Renal epithelia, numerous fine and coarse granular, epithelial and fatty casts, leucocytes and a few red cells are found in the sediment of the urine. Cardio-vascular symptoms are not pronounced in this form of nephritis. There may be at the start slight weakness of the heart beats ; the arterial tension may be at first slightly lowered. If the nephritis turns toward the chronic atrophy or interstitial form, we note a rise of blood pressure and a marked hyi^er- troph}^'of the left ventricle. Course. — The course of the disease in this type of nephritis may be either rapid or slow. If it is rapid, there is a steady increase in the edema and a decrease in the amount of urine secreted. The heart becomes seriously affected, the pulse feeble and rapid. Gradually, the other internal organs are involved. The appetite fails, the tongue becomes coated, the breath fetid. There are often attacks of diarrhea and vomiting. These symptoms, according to some writers, are due to the invasion of the gastric walls by edema. The serous cavities are next attacked and the edema spreads, giving rise to a hvdrothorax. I CHRONIC NEPHEITIS 425 When hydrocardiiiiii develops, wc find u diffused apex beat, dyspnea and a tend- ency to syncope. 'J'lic blood pressure is variable. These i)atients with their tense, swollen skin, which is white and dry, present a characteristic appearance. In fatal cases, if death is not due to an intercurrent infection, as, for instance, a broncho-pneumonia, it is the result of gradual exhaustion and finally edema of the lungs or uremia after a hopeless period of disability. When the course of the disease is slow in evolution, the edemas are much more gradual in their development. The patients are often pale, puffy, with a peculiar luster of the eyes (edema of the conjunctiva) and at times complain of headaches and other minor uremic signs. Diagnosis. — The diag-nosis of chronic parenchymatous nephritis is generally not difficult, as edema, pallor and abundant albuminuria are usually well marked. It is distinguished from acute nephritis (or from an acute exacerba- tion of a chronic nephritis) by the history of the case and by the absence of acute symptoms, such as fever and blood and blood casts in the urine. It is at times not easily distinguished from amyloid kidney, as amyloid changes may exist with such a nephritis. The diagnosis of an amyloid kidney can only be made when there is an amyloid enlargement of other organs and when there is a history of some cause for an amyloid kidney. In amyloid kidney the quantity of urine is large and the color pale, although there may be large amounts of albumin. We should, therefore, suspect an amyloid degeneration whenever the amount of albumin in a chronic case tends to exceed ten or twelve grams in twenty-four hours. In amyloid kidneys, the urine does not contain granular casts, save in the very advanced cases. Diffuse ISTepiikitis This represents the case of chronic parenchymatous nephritis with cardiac and vascular changes, which start as a typically parenchymatous type but go on sloMdy toward the atrophic or interstitial form. The urine in these cases is more abundant than in the pure parenchymatous, lighter in color, Avith a lower specific gravity and contains a smaller amount of albumin. As the disease progresses, and as the heart hypertrophies and the artcM-inl tension increases, the edemas grow less marked, but what appears like an im- provement is in reality a transition to the interstitial form. Chronic Interstitial I^epiiritis Etiology. — The development of this disease must be referred to the long- continued action of slight toxic factors, usually of a systemic origin. Concern- ing the relation of arteriosclerosis to this form of nephritis, arteriosclerosis may be the cause of chronic interstitial nephritis, or, on the other hand, it may be 426 no:n'suppurative nephritis the result of it, Liit it is ])rf)l)al)l(' that more often both arteriosclerosis and chronic interstitial nephritis are the result of the same causes, such as chronic poisoning with lead, alcohol, gout or syphilis. Diabetes mellitus may also be mentioned as the cause of this form of nephritis. Senator called attention to the frequency with which arteriosclerosis and the accompanying interstitial nephritis is met with in diabetic patients of advanced age. From what has been said concerning the causes of this condition, it will be understood that chronic interstitial nephritis is rare in childhood and youth, and frequent toward the end of life. The frequency increases with the age of the patient, being greatest between fifty and sixty. Men are more frequently aifected than women, because they are more often exposed to the causes above mentioned. Occasionally, there is an hereditary or family predis- position toward this disease. The condition has also been found present at birth. Pathology. — The essential pathological change in this form of nephritis is a slow hypertrophy of the interstitial tissue, stroma of the kidney, with a gTad- ual disapi^earance of the parenchyma. The appearance of the kidney varies with the duration of the disease. In the early stages, the kidneys, are normal in size or slightly enlarged and mottled. In the advanced stage, they may have shrunken to half their size or even less, one kidney being usually more markedly affected than the other. The capsule is generally adherent in places and con- tains newly formed vessels. The surface of the kidney is covered with minute red or grayish elevations, showing sometimes small cysts among them. On section, the kidneys are hard and tough, their cortex shrunken, sometimes ap- pearing as a narrow border around the medulla. The medullary rays are also shortened, closely packed and darker in color than normal. The visible arteries show thickened, gaping walls, and at times there are infarcts of uric acid or of calcium salts in the renal tissue. On microscopical examination, the changes are found chiefly in the cortex and usually are scattered in patches. The interstitial tissue is greatly increased, with here and there some round cell infiltrations. The tubules are compressed or in places obliterated, their epithelia are in a state of atrophy or fatty de- generation or lying loosely detached in their lumen. The glomeruli are the seat of a cellular proliferation around their capsules, which compress them and render them incapable of functionating. Their loops show increased layers of cells, or else a degeneration of cells, swelling of the epithelia and fatty degeneration of the same. The cavities of the glomeruli may be the seat of an exudate as in the parenchymatous form. Characteristic arterio- sclerotic changes are found in the arteries of these kidneys. Symptoms. — This form of nephritis has always a very slow and insidious onset, and the lesions usually exist for years before the condition is recognized. The disease may be divided into three stages : CHRONIC NEPHRITIS 427 (1) The stage of compensation, (2) The cardiac stage, (8) The uremic stage. (1) Stage of Compensation. — In the first stage of the disease, there is a compensation for the gradually increasing involvement of the kidney. The sys- tem in some way accommodates itself to the altered conditions. During this stage, there are two classes of minor symptoms that may occur : (a) Those due to arterial hypertension and those due to uremic intoxication. The symj)toms due to arterial hypertension are : Swollen and twisted tem- poral arteries ; occasional attacks of anesthesia in the fingers ; slight attacks of epistaxis ; noises in the ears and impaired hearing ; occasional vertigo. Those due to uremic intoxication are : Headaches, which are not relieved by drugs but disappear with rest and diet ; paresthesia, sensation of cold, heat, formication ; cramps in the ankles awakening the patient at night. (h) The urine in this stage of the disease is increased in quantity, and the patient urinates frequently. The urine is pale, clear, usually below 1.010 in specific gravity ; the total solids are diminished. There is either no albumin or merely a trace. (2) The Cardiac Stage. — During the cardiac stage, which follows that of compensation, the system begins to feel the effect of the diseased kidney. The cardiac symptoms of this stage consist in palpitation, attacks of angina pec- toris, an increase of arterial tension, hypertrophy of the heart and a hruit de galop (galloping sound) which is a marked uremic symptom. Complications may set in during this stage, some of which may prove fatal before it has fully developed, such as hemorrhages and infections. The hemor- rhages may be of great severity, as attacks of epistaxis ; retinal hemorrhages that may be followed by more or less permanent blindness ; and hematurias re- sembling those of renal tuberculosis, stone or tumor, during which there may be alarming losses of blood. Hemorrhages into the skin and the mucous mem- branes also occur, although rarely, during this stage. Some of the infections which may complicate this stage are erysipelas, pneumonia, anthrax and abscess formation. (3) The Ukemic Stage. — During the uremic stage, in addition to some of the symptoms that have already been enumerated under the minor symptoms of compensation are nausea, vomiting, diarrhea and, in the more dangerous cases, convulsions, dry tongue, delirium, stupor, coma. Diagnosis. — The diagnosis of chronic interstitial nephritis is usually not difficult when the disease assumes its characteristic clinical type. We should pay special attention to the presence of cardiac hypertrophy, as shown on per- cussion by the increased area of cardiac dullness, by a more diffuse pulsation and by the apex beat being found in the sixth intercostal space, one to three inches to the left of the nipple ; to increased arterial tension, which, instead of 428 NONSUPPURATIVE NEPHRITIS beiiiii; loU to 140, would be found io bo 140 to 180 or liigbcr ; to arterial .sclero- sis, which would show as thick distended tortuous vessels or, later on, as fibrous cords that roll under the fini>ers ; and to a lariio (|uautit_v of urine with a low specific gravity and the presence of albumin and hyaline casts. There are some cases, however, in which the diagnosis is more difficult, Ijc- cause the condition is marked by a predominance of uremic symptoms resem- bling chronic bronchitis, gastro-intestinal affections and cancer of the stomach, owing to the cachexia present. In still others, the marked delirium has been looked upon as a sign of progressive general paralysis. Prognosis. — The prognosis of this form of no])hritis is always gTave. The disease is incurable, but the patients may live for years and die from some other disease. The only consolation is that the course is usually very slow. The prognosis is worse when the symptoms of chronic uremia or heart failure are present. TREATMENT OF NEPHRITIS Treatment of Acute Nephritis. — The first steps to be taken are to have the jDatient kept in bed, as rest is most important both for the heart and the kidneys, after which an attempt should be made to eliminate the toxins by giving a saline purge, such as sulphate of magnesia an ounce, or compound jalap powder half a drachm; some physicians prefer calomel five grains. A diet which will necessitate as little work on the part of the kidney as possible should then be given, such as milk, three pints a day, or milk with one third part of Yichy. Wet cups should be applied over the kidneys. After these first steps, the patient should be kept on a milk diet ; the bowels should be kept open by mild saline laxatives, such as citrate of magnesia, Apenta or Carabafia water ; and hot-water bags should be kept over the kidneys. The patient should be allowed to go on without further treatment, unless severe symptoms set in, and may have an uneventful recovery. In more severe cases, certain symptoms that call for a vigorous treatment occur, such as marked edema with perhaps an involvement of the serous cavi- ties, or those of uremia. A hydragogue cathartic should then be given. Ela- terium is the most efficient of all hydragogue cathartics and of value in uremia, but it must be kept in mind that its action is very exhausting. It is best given in combination with the extract of belladonna one quarter of a grain each. If this is not sufficient to eliminate the toxins, a hot-air bath oi' ])ack should be given later. When this fails after waiting for a sufficient interval, pilocarjiin should be given. This is most useful in the treatment of renal dropsy and gen- erally exerts a marked diaphoretic action when given internally in doses of from one twelfth to one sixth of a grain. If the purge, hot-air bath and pilocarpin, together with tlie saline diuretic, are not sufficient to benefit the Datient, then venesection should be resorted to. TEEATMENT OF NEPHRITIS 429 followed ])}■ nil iiitrax'cnous iiijrctiou of iiorinal salt solution. In ihis ease, 400 to r>()0 e.c. of Mood should lie withdrawn, and the same aiiioniit of salt solution should be injected. When the flo^v of the urine is scanty, it should be stimulated by liivinu- as a diuretic citrate of i)otash, ten to fifteen grains every three hours, by wdiicli the severe edema and uremia just mentioned can often be prevented. After the dangerous symptoms subside by this means, the patient should continue with the milk diet and with saline laxatives if constipation is pres- ent. The saline diuretics should be given again, as soon as the urine Ijegins to become scanty. If dangerous symptoms again set in, the same vigorous measures should be taken to combat them by means of hydragogiie cathartics, hot packs, pilocarpin or intravenous saline injections. Under such treatment, most patients recover in from six to eight weeks; others become chronic ; still others die, especially those developing anasarca and uremia. As the patient's acute symptoms disappear and the urine increases in quantity and elimination is better, the patient can be gradually changed to a more varied liquid or soft diet, as broths, cocoa, bi?ead, crackers, rice and other carbohydrates, and sugar and butter can be adclgd if the digestion permits. Some also allow easily digested vegetables, such as spinach, cauliflower, string beans and peas. In this waj', a variety is furnished and the patient is able to maintain a partial milk diet for some time. As a beverage, the patient may have slightly alkaline table waters, or lemonade, or water slightly tinged with wine. Benzoate of soda and lactate of strontium have been recommended in the treatment of acute nephritis, but they are more suitable for chronic cases. The benzoate of soda acts as a urinary antiseptic and counteracts the causative in- testinal fermentation through increasing the flow of bile. The lactate of stron- tium diminishes the amount of albumin in the urine but does not increase the flow. For the pain in the loin, dry cups or hot compresses are sufficient. . For the hematuria, ergot or tannic acid may be given in the following form (Senator) : Ergot grs. V (0.3 gram) ; Tannic acid grs. ss (0.03 gram) ; Powdered gum acacia grs. viiss (0.5 gram). To be taken every three hours. The constipation which these drugs produce must be counteracted by ap- })ropriate })urgatives, such as Apenta or C^irabaua water. Treatment of Chronic Nephritis. — This includes preventive, specific, di- etetic, hygienic, therapeutic and sym})tomatic measures. Preventive. — The probabilities of a chronic nephritis following an acute attack nuiy be very much lessened by very carefully managing its treatment dur- 430 NONSUPPURATIVE NEPHRITIS ing the acute stage and the period of convalescence. This means keeping the patient qniet and on a bland diet during the acute stage and by not exposing him to bad weather, cold or draught of air while he is convalescing. The diet during convalescence should be very simple and moderate, free from condiments and with a limited amount of animal proteids ; or it may be salt free if there is a tendency to edema, or such a condition is threatening. Specific Treatment. — Most cases of chronic nephritis are incurable. Therefore, the aim of treatment should be to maintain the general health and assist the renal functions so that the patient can continue to live without much inconvenience. Within the last decade, there have been brought forward certain special methods of treatment which are intended to reach the disease itself and to im- jDrove the condition more or less permanently. Organotherapy, the use of renal extracts, is not yet sufficiently known to be recommended. My own personal experience with it has been such as to lead me to prefer the older reme- dies. The second form of treatment under this category is the surgical, and that of the iodids, the former of which is of very little use, except in the case of certain complications. The Iodids. — Sodium and potassium iodids, or their substitutes, have been used in chronic nephritis, especially by the older physicians. I frequently use this remedy in doses of two or three grains, three times a day, as a vaso-dilator in arteriosclerotic and cardiac changes. It is also supposed to modify the de- velopment of the lesions in the kidney and to prevent the formation of inter- stitial tissue. Its principal value is in cases of chronic nephritis, in patients with lead poisoning and syphilis, when from two to five grains, three times a day, should be given. The minor symptoms of chronic interstitial nephritis, due to arterial hyper- tension and appearing in the shape of headache, occasional vertigo, tinnitus and epistaxis, are also combated with potassium iodid, the action of which should be carefully watched. Alternately with the iodid treatment, glonoin (solution of ni- troglycerin) is recommended by Chauffard and may be given in doses of one to two drops. Nitroglycerin has to a large extent taken the place of amyl nitrite in conditions where this drug is indicated. SuKGiCAL Treatment. — About eight years ago, my colleague, Dr. Ede- bohls, noticed that many of his cases of movable kidney had in the urine before operation a slight amount of albumin and a few hyaline and finely granular casts which disappeared after partial decapsulation and fixation of the organ. He accordingly concluded, first, that chronic nephritis could be unilateral or bilateral, and second, that, if the partial decapsulation employed in nephropexy was sufficient to cure nephritis, through the increased blood obtained by the anastomosis between the partially decapsulated surface of the organ and the adjoining tissues, then a more extensive decapsulation would give a greater i TEEATMENT OF NEPHEITIS 431 exposed surface for anastomosis and consequently the recovery would be more certain. He accordingly advocated and began to perform an operation, called renal decapsulation, for the cure of chronic nephritis, which consisted in en- tirely removing the capsula propria of the kidneys and replacing them in their fatty capsules. He claimed that, by this means, an anastomosis of good-siz.ed vessels formed between the kidney and the fatty capsule, resulting in the cure of the disease. I performed a number of these operations, but was not satisfied with- my results, and accordingly wrote to many of the leading surgeons of the country, asking them to send me a report of the results of their operations. In answer, I received reports of 120 cases that had recently been operated upon, 16 per cent of which were reported cured, 40 per cent improved, 11 per cent unimproved and 33 per cent of deaths. The mortality had been greatest in the cases diagnosti- cated as diffuse nephritis, 75 per cent of which had died, whereas in the cases diagnosticated as parenchymatous and interstitial, there had been about 25 per cent mortality in each group. Some time after this, I again wrote to the surgeons who had contributed before and found that, among those of their patients who had survived the operation, 88,5 per cent had since died. The results were accordingly not such as could lead me to advocate renal decapsulation. There was, however, a class of cases that had been very much benefited by operation and this comprised cases of chronic nephritis, associated with hema- turia and nephralgia. These cases were cured of the attacks of hemorrhage or pain by a nephrotomy. The conclusions that I drew from the studies of my own operations and those of my colleagues were, first, that total decapsulation of the kidney is an unwarranted operation which should never be performed ; but that a partial decapsulation of a sufficient area of the surface of the organ to assist in its fixa- tion is helpful in the case of a movable kidney ; second, that, in cases of a non- movable kidney in which there is much tension on account of a tight capsule, this will be removed by simply incising the capsule over the convexity ; third, that, if there are symptoms of unilateral nephralgia or hematuria, a nephrotomy is satisfactory, not only as an approved operation, but also as an exploratory means of determining a possibly existing surgical disease. Geneeal Treatment. — Rest in bed is important whenever an acute exacer- bation occurs, associated with edemas, scanty or bloody urine, or uremic symp- toms, during which time the patient should be treated as a case of acute nephri- tis. If it is found that rest in bed does not improve the condition of the urine, the patient may be allowed to get up and lounge about the h(~)use in reclining postures, especially if the disease is not far advanced. If the heart is hyper- trophied and there is much arterial tension, as from IGO to 200 or over, and cardiac symptoms, such as palpitation and angina pectoris, headaches or diges- 432 NONSUPPURATIVE NEPHRITIS tive distin-Laiices are present, rest in hcd slioiild be maintained until llie pa- tient im})r()ves. Periods of rest in bed, for from two to four weeks at a time, say every four months, are of considerable benefit in many ehronic cases with a tendency to uremia. The patient's general condition is kept up by massage while undergoing this rest treatment. During these periods, the diet should consist of milk or mixed food, whichever agrees better with the patient. Many chronic nephritics go on for years attending to their regular pursuits of life without taking any medical treatment for the disease. Many of these patients would never know they had nephritis unless told so by the physician making the nrinary analysis. It is important to instruct them as to the pro- tection of back and chest by suitable clothing, the avoidance of draughts, or any prolonged exposure to cold and wet. For the protection of the back in male patients, I recommend a kidney pad or protector during the cold weather. It is eas_y to see that the winter vests have thick material in front and thin behind. The kidney pad is made of doubled woolen cloth sewed together, of the size and shape of the vest back. There are nine buttonholes in the pad, and nine corresponding buttons on the vest to which they are fitted. The same pad can be used with a number of vests. Besides the protection it affords the lungs and back, I know of nothing of its size that has ever given me so nnich warmth as has this pad (Fig. 278). It is desirable also that patients should pass a number of hours in the open air every day, if possible, provided the weather is mild and pleasant. Climate. — A change of climate during the winter to a warm, dry, evenly tempered place is of great benefit. Patients are sent to Egypt or Algiers, or to the south of Italy or the Riviera. In this country, Florida and Southern California offer excellent climatic conditions for nephritics. Diet. — The diet of these patients should be moderate, mixed and nonirri- tating. They should learn to estimate how much they can eat without doing themselves harm, or else should regulate the diet according to its calories, Fig. 278. — Kidney Pad to Be Buttoned on the Back OF A Vest as a Protection for Nephretics. TREATMENT OF NEPHRITIS 433 and tliey should know that their longevity depends on eating certain foods and in sncli amounts as they can easily digest, assimilate and eliminate. Milk is the ideal food for the patient with Bright's disease, because it is highly nutritious, contains but few toxic substances and promotes the excre- tion of urine. Yet an absolute milk diet is not necessary except in acute exacer- bations, or in eases in which the major symptoms of uremia threaten to develop. Again, a diet of milk alone is not sufficient in chronic nephritis during the stage of compensation, and, when prolonged, it leads to gastric intolerance and to a general debility with sluggishness in the functions of various organs. Be- sides, if milk diet be instituted too early, it will be difficult to keep it up later on in the disease when it is indispensable. When an absolute milk diet is necessary, it should be given in small quan- tities at frequent intervals. The amount needed for the maintenance of the body weight is about three liters in twenty-four hours, but this is entirely too much fluid and two liters usually mark the degree of tolerance, while one liter daily is sufficient for a short interval or for a longer period, if combined with other food. Milk can be taken hot or cold or flavored wath a little sugar or a small quantity of cocoa. It is more easily digested when mixed with Vichy or some similar alkaline mineral water. If not well borne, it can be given pre- digested by means of pancreatin. Substitutes for milk, such as koumiss, may also be used. Milk diet often causes constipation, thus necessitating the daily use of laxa- tives or cold-water enemas. Sometimes fecal impactions form, so that enemas of oil or even mechanical removal of the masses is necessary. In other patients, a milk diet causes diarrhea for which bismuth should be used internally. A diet free from chlorids has of late years taken the place, in a measure, of the absolute milk diet. This method of treatment is indicated in cases of chronic parenchymatous nephritis with dropsy and has already been spoken of. The dropsy can sometimes be made to disappear in patients by giving them a diet free from chlorids, but will reappear again on adding sodium chlorid to the food. An absolute salt-free diet should not be continued for any length of time, as the system requires six grams of salt a day. This represents the amount of salt in three quarts of milk. The amount of salt to the liter is approximately two grams. The advantage of the chlorid-free diet is that it offers a choice between a number of articles of food. Meat contains very little chlorids, which are lost completely when it is boiled. Eggs, vegetables, potatoes, lentils, rice and farinaceous food contain but small amounts of chlorids. Among the fresh vege- tables, green peas, carrots, turnips and string beans may be chosen as contain- ing little salt. In some cases, after a period of such a diet, the patient can return to ordinary food and can tolerate more salt. In other cases, as soon as salt is given, the symptoms reappear. 434 NONSUPPURATIVE NEPHRITIS There is a class of cases, also, in whicli the salt-free diet does not lessen the edema nor prevent uremia. It is probable that in these cases the exclusion of chlorids from the food is not enough to relieve the system of an excess of chlorids. There are also some patients in whom a chlorid-free diet causes an increased albuminuria. All patients should be carefully watched while on this diet. If the edemas have disappeared, the salt may be g-radually increased while the return of symptoms are watched for. If they return, the amo\int of salt should be reduced again. Quantity of Fluid. — An important rule in chronic nephritis is never to ex- ceed a definite quantity of fluid ingested in twenty-four hours and in this way to avoid overloading the heart. The heart in these cases is already overworked and must not be strained too much. The average daily quantity of fluid should not exceed one and a half liters. It is for this reason that an absolute milk diet is difficult to maintain without impairing the nutrition of the patient. If we wish to give the patient the full amount of nutriment, we ought to give from three to four liters of milk a day ; this is obviously unwise, as we would thus exceed the limit of fluid capacity of the organism. Van ISTorden recommends a liter and a quarter of fluid a day and says that a person taking this amount should pass from one and one third to one and one half liters of urine daily. The liquids besides water allowed in chronic nephritis are milk, lemonades or sour drinks and the alkaline mineral waters, especially Celestine Vichy. Mineral-water cures, as such, cannot be expected to cure the disease, but are sometimes beneficial to the extent to which they improve the patient's general condition. Carlsbad, Vichy and ISTeuenahr are advised when there is not much hypertroj)hy of the heart, and but slight increase of arterial tension and no dropsy. On the other hand, when there is a tense pulse and a markedly hyper- trophied heart, such springs must be avoided and Marienbad or Kissingen may be recommendedo Carhonic-acid baths may be used at home when the patient is no longer able to stand the journey to the watering places, and are beneficial in high arterial tension. They are made by charging the water in a bath from a tank of carbonic-acid gas. The duration of the bath should be from eight to twenty minutes, after which the patient should rest for an hour. By this means, the pulse is slowed and the pressure considerably diminished. Alcohol should not be allowed, or else should be given only in very small quantities in the form of light wines, such as a glass of Bordeaux, or Zinfandelj from California, alone or mixed with plain water or mineral waters. Beer] and champagne and the stronger wines are very injurious, as they either irri- tate or cause fermentation, thus interfering with digestion. Whisky with water, well diluted, is allowed by some on the plea of improvement of the pa- tient's nutrition. Alcoholics are less harmful in chronic parenchymatous than in the interstitial form of nephritis. TREATMENT OF NEPHRITIS 435 Coffee, tea and tobacco are cardinr stiimilants and for this reason should not be allowed, as they tend to overwoik the heart and wear it out. Walking }5atients with a mild degree of nephritis do fre(iuently indulge in all these stimulants, but those with cardiac and vascular changes should be more cautious. Meat can be allowed to nephritics in a certain amount once a day. White meats are usually recommended, as they contain slightly less extractives and proteins. Yeal, pork, lamb and poultry are considered the best, although opin- ions regarding them vary. I do not attach much importance to the color of the meat, and allow beef and mutton with the same frequency as the white meats. Meat should be taken at the midday meal, which should be the principal meal of the day. They are best prepared boiled, broiled or roasted. Fish can be taken prepared in the same way. Fish is not as difficult to digest as meat. It is classed by some among the white meats. Once a day is also sufficient for fish and it should not be taken at the same meal as the meat, except in half quantities of each. Eggs are considered as undesirable food by some and approved by others. In many patients, an egg will increase the amount of albumin in the urine, whereas in other cases it has no effect upon it. Eggs should be boiled, poached or shirred. One egg a day is sufficient for a nephritic and is best taken in the morning. Vegetables are quite freely allowed in chronic nephritis, although physi- cians differ in their choice. The allowed list contains rice, lentils, peas, green beans, asparagus, tomatoes, potatoes, carrots and turnips. Personally, I do not allow asparagus and tomatoes, which are on the list because they do not contain much protein matter. I prefer rice, green peas and green beans. Farinaceous foods are also allowed, as bread, properly toasted, and the cereals, hominy, farina and wheatena. Fats, carbohydrates and fruits are con- sidered by many as valuable tissue builders in these cases, and can be taken in moderation if they are well tolerated. Grapes and apples are probably the best fruits for nephritics. From this list it will be seen that the variety is sufficient but that care must be taken not to eat too much, for overeating is one of the causes of chronic nephritis as well as being one of the chief factors in hurrying the death of the patient who is suffering from this trouble. Condiments, as all pickled and smoked foods, spices, pepper, paprika, catsups, mustard, radishes, horseradish and garlic should be interdicted. Hygiene and Mode of Life. — Persons with chronic nephritis must live strictly according to the ndes of hygiene. Excessive exercise and exertion should be avoided, as giving rise to an overproduction of waste to be excreted by the kidney. Pest is essential during acute exacerbations and in the presence of impending uremia. Chronic nephritics are not fit for excessive mental work, 436 NONSUPPURATIVE NEPHRITIS as this is apt to produce indigestion, which indirectly means extra work for the kidney. The function of the bowels and the skin should he regulated and the patient should avoid extremes of cold and wet. Symptomatic Tkeatment. — This is addressed to the symptoms as they arise in the different types of chronic nephritis. In early cases of chronic parenchymatous nephritis, before cardiac valvular changes have had time to develop, the arterial tension is sometimes so low, that digitalis, caffein and spartein are often used on account of their effect in strengthening and regulating the heart action. Beginning Edemas. — When a patient with chronic parenchymatous nephri- tis complains of lumbar pain, wdiile his eyelids appear puffed up and edematous, his urine should be examined and, if evidences of an acute exacerbation are present, he should be put to bed and treated the same as for an attack of acute nephritis. General edema is threatened when the urine becomes scanty and of a high specific gravity, containing a considerable amount of albumin and casts. A purge of jalap powder or elaterium should be given and diuretic remedies are indicated, selecting those which act upon the glomeruli and promote excretion without irritating the tubules, such as the theobromin preparations. In such cases, the following diuretics should be given until the symptoms have been relieved, when they should be discontinued. Diuretin (salicylate of sodium theobromin) does not irritate the kidney, rarely causes disagTceable symptoms and is a diuretic that I consider most reliable. In the course of the day, from 60 to 120 grains (4 to 8 grams) may be given in divided doses in capsules or solution or hypodermically. Theocin, a synthetic alkaloid of theobromin, has also been found to act as a very reliable diuretic, more so than theobromin itself or caffein, increasing both the excretion of water and solids from the kidney, and useful for the control of dropsy. It is prescribed in small doses, frequently repeated, so as to avoid gastric irritation. Up to 8 grains daily may be given (0.5 to 0.75 gTam) the effect being usually most evident on the second or third day after the administration of the drug. Diuresis cannot, however, be main- tained by means of this drug, as the system soon becomes accustomed to its use. Agurin, a preparation consisting of theobromin-sodium and sodium acetate, is prescribed in cases of renal dropsy in the form of a powder, to be taken in dilute solution or in capsules, in doses of from 5 to 15 gi-ains three to six times daily. Another very useful remedy in oliguria (scanty urine) is potassium acetate, in 5 to 15 grain doses, every three hours. Apocynum, Canadian hemp, assists the elimination of fluid that has accumu- lated in chronic Bright's disease and may be given in doses of 5 to 15 minims (0.3 to 1.0 c.c.) of the fluid extract. If the threatening edema is not relieved by diuretics and other methods of AMYLOID KIDNEY 437 treatment already outlined and the edema extends to the lower extremities and serous cavities, as it frequently does in the later stages of parenchymatous nephritis, internal medication should be assisted by physical measures, such as hot baths, followed by packs to promote sweating and thereby favor the elimina- tion of toxins. It is a noteworthy fact, however, pointed out by Landouzy, that 100 liters of sweat would be required as an equivalent of 1,500 gTams of urine. Hence, the kidney must always be relied upon as the safest cliannel of drain- age for the impurities of the organism. In the general dropsy of chronic nephritis, aspiration of the body cavities affords not only a local relief, but the general condition improves, the uremic sym])toms are lessened and tlie diuresis is increased. This is probably due to uremic poisons in the blood leaving the body with the trans- udating fluid. The use of Southey's tubes (Fig. 279) have been recom- mended for the drainaji'e of edematous areas, including the extremities, to relieve the tension of the overdistended tis- sues. They are made of metal from 3 to 9 cm. long with a lumen of 1 5^ to 3 mm., resembling trocars, but perforated on the sides. Two or more of these tnbes are pushed into the subcutaneous tissue, the stilet withdrawn and a rubber tube attached, leading into a receptacle for drainage. They are left in from twelve to twenty-four hours. The puncture continues to leak for some time after the removal of the tubes. In this way, two quarts of fluid a day will sometimes escape. During the time that operations by renal decapsulation were being performed for the treat- ment of chronic nephritis, the incision in the loin, made in patients suffering from chronic parenchymatous ne- phritis, sometimes did not close, but acted as a drain and large quantities of edematous fluid leaked through the loin continu- ously. Some of the patients operated, who were apparently very stout, having thick abdominal walls, rapidly appeared emaciated after the opera- tion. Fig. 279. — Southey's Tubes. (To be obtained from Tie- man.) AMYLOID KIDNEY Amyloid kidney is a condition of amyloid degeneration in that organ, which usually accompanies amyloid changes in other viscera, such as the spleen and the liver. Amyloid kidney was first described by Eokitansky, in 1842, but the term was introduced l)v Virchow, in 1855. Etiology. — Amyloid degeneration of the kidneys is due to any chronic in- fectious disease which gives rise to a cachexia. Of these, the principal ones are tuberculosis, chronic suj)puration and syphilis, but the condition has 438 NOXSUPPUKATIVE NEPHRITIS also been observed in chronic malaria, in leprosy and in arthritis deformans. Experimentally, amyloid degeneration has been produced by the injection of the bacilli or the toxins of bacillus pyocyaneus. Patholog-y. — At autopsy, the amyloid kidney resembles very closely the large white kidneys of chronic nephritis with dropsy (chronic parenchymatous nephritis), so that the conditions are often mistaken for each other. If the surface of the cut kidney is treated with tincture of iodin, the degenerated por- tions will turn a mahogany brown, while the unaffected portions will remain yellow. If sulphuric acid is then applied, the degenerated zones turn blue. On gross examination, the amyloid kidney is large, pale, firm and non- elastic, waxy in consistence. Its capsule is smooth and easily detached. On section, the tissue is colorless, often glistening, the cortex swollen and yellowish white, the medullary portion dark. On microscopical examination, amyloid tissue assumes peculiar coloring with anilin dyes. Thus, with methyl or gentian violet, the amyloid tissue stains pink; with methyl gTeen, the kidney stains a green color except the amyloid portions, which stain violet. The organ should not be fixed in alcohol previous to staining, inasmuch as alcohol dissolves the amyloid substance. The lesions under the microscope are usually well scattered through the kidney, including the blood vessels, the connective tissue and the epitlielia. The blood vessels are the most frequent seat of degeneration, the glomerular capil- laries showing amyloid degeneration early in the disease ; next, the capil- laries of the cortex and last the straight vessels of the medulla. All these arterial channels become gradually obliterated by the amyloid changes. Occa- sionally, the interstitial tissue is also affected by the amyloid changes. The tubular epithelia themselves, however, are usually free from these changes, although they may be the seat of fatty degeneration. As the result of the amyloid changes in the arteries and coimective tissue, the tubular structures gradually undergo the same changes as are seen in chronic nephritis. Symptoms. — There are always the symptoms of amyloid degeneration of other organs. The kidney is but slowly affected and the disease develops in- sidiously. The chief phenomena are in the urine. A frequent Ijut inconstant symp- tom is the polyuria, w^hich may amount to from 2 to 6 liters in twenty-four hours. The urine is clear, light colored, wuth low specific gravity, and con- tains nothing of importance in the sediment. When there are abundant diar- rheas, the polyuria may be absent and the -same is true sometimes in the last stages of the disease, when there is heart failure. The amount of albumin is usually considerable, increasing gi-adually until it reaches 20 or 30 grams daily. According to Senator, this albuminuria con- sists in great part of globulin. The urea, chlorids, phosphates, etc., are some- AMYLOID KIDNEY 439 ^vliat diininislied in ainoimt. Ilyuliuc and granular casts are sometimes found in the sediment, owing to the presence of a nephritis. But there are never casts having an amyloid reaction. Amyloid kidney does not give rise to edemas or to uremic symptoms. When these are present, they are due to the accompanying nei:»hritis. Diagnosis. — The diagnosis is made by the presence of a polyuria, with a large amount of albumin in cachectic patients suffering from tuberculosis or syphilis or some chronic snppurative condition, particularly if there is a hypertrophy of the liver and the spleen to strengthen the diagnosis. The diagnosis from interstitial nephritis is made bj' the absence of uremic symptoms, of high arterial tension and of cardiac hypertrophy, also because the urine is paler and there is a smaller amount of albumin in interstitial nephritis. Treatment. — The treatment of amyloid nephritis consists in the main- tenance of a mixed diet of milk and vegetables, the administration of iodids in syphilitics and the general care of the primary condition in tuberculosis, etc. When a complicating nephritis exists, it should be treated according to the manner indicated in the chapter on Chronic ISTephritis. CHAPTER XXIV UREMIA Uremia ( ovpov, urine, atfta, l)]oofl) is a toxic condition due to the accumu- lation or retention in the hlood of urine, urinary constituents or excreuientitious substances usually throAvn off by the kidneys. It gives rise to a more or less complex group of symptoms, such as headache, nausea, vomiting, convulsions, coma, visual disturbance, a urinary odor to the breath and sometimes hemiplegia. Etiology. — A variety of theories as to the cause of uremia, each based on more or less experimental evidence, will here be mentioned for their historical interest. The condition that is spoken of as uremia was first made known through the work of Bright on nephritis, but the term itself was first used by Piorry, after Wilson had brought forward the theory that the symptoms were due to a retention of urea in the blood (1833). The j^riucipal theories of uremia may be tabulated as follows : (1) MECHANICAL (Traubc, 1861). — Uremia is due to cerebral edema. (2) toxic: monotoxic theories. (a) Due to the retention of urea in the blood. (Wilson, 1833. ) (b) Due to the formation of ammonium carbonate in the blood by micro- coccus urea. (Frerichs, 1851.) (c) Due to fermentation of ammonium carbonate in the stomach and intes- tines from urea, and the absorption of the former into the blood. (Treitz; confirmed by Landois and Pavloff.) (d) Due to the accumulation of kreatin, kreatinin, uric acid, etc., as result of changes in metabolism, (Schottin; Voit ; Chalvet.) (e) Due to intoxication by the retention of urinary coloring matters. (Thudicum,) (/) Due to intoxication with iwtassium salts, (Feltz and Rittcr. Injec- tion of K. salts in proportion occurring in urine was fatal in animals. ) (g) Due to retention of chlorids causing edema of the brain, etc. (Widal and Javal.) (3) toxic: polytoxtc theory, (Bouchard,) ISTot a single toxic substance, but a number of various poisons retained in the blood cause uremia. Practically all the research work done in uremia since 1881 is based upon 440 ETIOLOGY 441 the theory of Bouchard. Ilis dcfiiiition of the syinptoin complex is that uremia is ail intoxication by poisons, either introduced from without or formed in the body, which are n(.)rmally elimiiuited by the kidneys in the urine, but in c(;rtain conditions are retained, owing to renal impermeability. According to this in- vestigator, forty-seven per cent of the poisonous effects of the urinary cou- stituents are due to potassium salts ; urea, ammonium carbonate, the extractives, the coloring matters, etc., may each play their part in the intoxication. Five distinct poisons, the chemical nature of Avhich is not known, were isolated by Bouchard from the urine. A series of experimental studies on the permeability of the kidney have been published since, especially in France, and some recent investigators doubt the importance of renal impermeability in the production of uremia (Bernard). Insufficiency of the internal secretion of the kidneys and the liver, with failing compensatit>n of the heart and increasing arterial tension, are believed l)v them to be sufficient etiological factors, without any renal impermeal)ility. The significance of toxic retention and renal impermeability is held by other observers, who explain the occasional absence of toxic substances from the blood in uremia by their absorption on the part of the tissues. (Castaigne, Achard.) The retention of chlorids in the body has also been pointed out as a factor in the mechanism of uremia. (Widal and Javal, Bohne. ) According to ^ Castaigne, uremia is due to the retention in the body of multiple toxins from various sources and the retention of chlorids, both being the result of renal impermeability, without which no uremic poisoning can take place. The occurrence of uremia is dependent upon (1) the presence of a renal disease, either acute or chronic nephritis, pyelo-nephritis or pyonephrosis, cystic kidney or renal abscess; (2) upon the presence of renal obstruction, such as calculus in the ureter, ureteral stricture or pressure upon the duct, in the blad- der or somewhere along its course. Patients suffering from an acute affection of the kidney producing anuria, such as acute nephritis or an acute exacerbation of chronic nephritis, are liable to an acute attack of uremia. In the absence of predisposing factors, patients with chronic disease of the kidney may remain free from uremic manifesta- tions for years. The causes that favor or immediately induce the appearance of the uremic symptom complex may be summed up as follows : (1) Increase in the work of the kidneys, due to overeating or drinking. (2) Intercurrent acute nephritis, exposure to cold, wet, fatigue, any cause producing congestion of the kidneys. (3) Complicating extrarenal intoxications: Influenza (in old age) and other acute infectious diseases occurring in chronic nephritis. (4) Arrest or diminution of toxin elimination, by treatment or conditions which arrest sweating, defecation, vomiting and urination. 442 UEEMIA Symptoms. — Tlio symptoms of uremia vary according to the character, strength and degree of the intoxication, as well as the predisposition and re- sistance of certain organs or groups of organs. Clinically, there are two vari- eties of acute and chronic uremia. Acute uremia may occur in acute ne])hritis, or in the course of chronic lesions of the kidney, and may be the first indication of the presence of renal disease. Acute Uremia. — The hyj)eracute form is characterized by a sudden attack, without premonitory symptoms, of faintness, vertigo and coma, which is fol- lowed by death within a short time. As a rule, such patients for months or years have been sufPering from chronic uremia, but the true nature of their ill- ness has remained unrecognized to the end. The acute form also comes on suddeidy, but is preceded by premonitory symptoms, such as headache, vomiting, oliguria or anuria, or disturbances of vision and hearing (contraction of the pupil, double vision, partial or total blindness, noises in the ears, sudden deafness). There may have been also slight delirium and a tendency to aphasia. The acute attack is characterized by convulsions, delirium, somnolence and coma. There may also be intense dyspnea, asthmatic breathing or Cheyne- Stokes respiration, or the dominant symptom may be vomiting and diarrhea. Paralyses have been reported in this connection, especially by French writers. Latent ok Mild Ukemia (Lecorche and Talamon's Attenuated Uremia). — There are cases of chronic disease of the kidneys in which the uremia is so mild and is accompanied by so few typical symi^toms, that it is apt to be mistaken . for some less serious trouble. Only when the urine is repeatedly examined and the case studied thoroughly, may we make out the uremic origin of the mild symptoms complained of by the patient. This mild form of chronic uremia may persist for a long time without be- coming aggTavated, or it may be the precursor of the more severe type known to the French writers as " grande uremie." Headache is the leading symptom in many such cases of mild uremia. It may for a long time be the only symptom present, and may vary greatly in intensity. IvText to headache, there are a variety of muscular and neuralgic pains which frequently accompany mild uremias. Uremic intoxication may give rise to a neuritis like that of alcohol and lead, and one form of such a neuritis is that of the cardiac plexus known as angina pectoris. Facial and other neural- gias may also occur in mild uremia. A variety of aches in the muscles and the joints, and cramplike contrac- tions of the sole of the foot, are also complained of. The patients behave like rheumatics and are frequently given salicylates erroneously. I^umbness, prick- ing sensations in various parts of the body, including the common phenomenon of " dead finger," may also occur. (Dieulafoy.) i SYMPTOMS 443 Finally, the mild form may be accompanied by disturbances of vision and hearing, of which we shall speak further on, and occasionally there are attacks of asthma without any organic cause, due to toxic influence. CiiKONic Ukemja. — In the chronic form, the symptoms are usually rather indefinite. Headaches, neuralgias, respiratory disturbances, attacks of asthma or disturbances of vision or hearing, come on at irregular intervals, provoked usually by exposure to cold, fatigue, or excesses in eating or drinking. Gradu- ally these attacks become more frequent, and the final stage is heralded by a period during which vomiting, diarrhea and loss of appetHe are prominent. The patient loses weight, becomes weak and anemic, and gradually grows som- nolent, apathetic and semicomatose. Death comes on either in deeper coma and exhaustion, or preceded by an acute exacerbation of the symptoms, with convulsions, coma and paralysis. Groups of Symptoms. — Having thus sketched the clinical evolution of the principal forms of uremia, we should now consider more in detail the individual groups of symptoms observed in this condition. Many signs of uremia occur in other conditions and it is for this reason that the diagnosis of uremia is not easy to make. In each case, a careful study of the mass of symptoms is needed. The clinical picture, however, can usually be sub- divided into various groups or classes of symptoms, one or more being repre- sented in the case studied : (1) NERVOUS SYMPTOMS. Headaches. Neuralgias. Disturbances of cutaneous sensation, e. g., tingling, formication, " dead finger." Restlessness, confusion of ideas, partial aphasia, somnolence, disturbed sleep, aj)athy, depression, convulsions, delirium, coma, paralyses. (2) CARDIO-RESPIRATORY SYMPTOMS. Dyspnea. Uremic asthma. Cheyne-Stokes breathing. Bronchitis, pleurisy, pulmonary edema, hydrothorax. Heart symptoms, due to affection of the heart which may coexist. Usu- ally cardiac hypertrophy and increased arterial tension, (3) GASTRO-INTESTINAL SYMPTOMS. (a) Mouth and Pharynx: Dryness, thirst, difiiculty in swallowing. Stomatitis (catarrhal or ulcerative). Salivation. 444 UEEMIA (h) Stomach: Anorexia, djsjx'psia. l^aiisea or vomiting'. (c) Intestines: ])iarrliea (serous or dysenteric), constipation. (■i) SKIN SYMPTOMS. Pruritus. Erythema papulosuni and maculusuni. Urticaria, purjjura. Hyperidrosis. (5) EYE SYMPTO:iIS. Miosis (contracted pui:)ils ), mydriasis. Disturbances of vision, double vision, amaurosis. Optic neuritis. (6) EAR SY'MPTOMS. Tinnitus (ringing) or other noises in the ear. Deafness (sudden). (7) URINAEY" SY'MPTOMS. Oliguria or anuria in acute form. Quantity normal or increased in chronic* forms (but quality suffers). Urea diminished. Albumin usual (not invariably present). Functional efficiency of kidneys low (cryoscopy, phloridzin test, etc.). (8) GENERAL SY'MPTOMS. Emaciation, atrof)hy of muscles, edema. Pulse slow, high tension. Temperature subnormal or febrile. Nervous Symptoms. — Some of these are characteristic of the prodromal period. The uremic headache is one of the early symptoms, and is usually very obstinate, sometimes occurring in the form known as migraine. Headache, ac- companied by apathy and stupor, may also be present during the attack itself. A variety of neuralgias often depend upon incipient uremia. These include particularly occipital neuralgias and angina pectoris. Pains in the limbs and joints and disturbances of sensibility may also occur as prodromal signs. During the attacks of uremia, the serious nervous symptoms may be divided into the signs of excitement and those of depression. The former include con- vulsions which may assume the type of eclampsia or e]ulepsy, general or par- tial clonic contractions, which are the usual types. These convulsions present nothing specially characteristic, and the differential diagnosis from epilepsy, SYMPTOMS 445 etc., must 1)0 made from doliriiim, coma and tlie other symptoms above iiiciitidiicd. Delirium is another symptom of this gronp. The patient may suffer from confusion of ideas, mutter incoherent sentences, and have illusions and hallu- cinations. In other patients, the delirium seems to be more specific in char- acter — they rave about one subject, often 2:)ersecution, or they become moody and melancholy and may attempt suicide. Coma is one of the most typical symptoms of the uremic attack. In the acute form, it comes on rapidly, in the chronic form more gradually, l)ur in both the same features prevail as a rule. It is accompanied by anuria or oli- guria, a subnormal temperature, a slow pulse, slow, irregular breathing (Cheyne- Stokes). The muscles are completely flaccid, the face is pale, the pupils con- tracted and consciousness is entirely lost. Paralyses have been observed in a large number of cases of uremia, espe- cially those due to chronic nephritis. They vary in intensity, and disappear if the patient recovers. The affected muscles, usually those of one arm, are always perfectly flaccid. Occasionally aphasia has been observed in these cases. Bespiraiory Symptoms. — The dyspnea of uremia may be either toxic or pulmonary. The toxic form occurs after exertion and overeating. It is easily cured by simply adopting a milk diet. Typical asthmatic symptoms accompany the dyspnea. The jjatient is unable to lie down in bed, and complains of constant oppression on his chest, breathes srapidly and. emits sibilant rales. The attacks come on at uight, without asphyxia. In another type of cases, there is actual asphyxia associated with the dysp- nea, and the patient may die during the attack. Cheyne-Stokes breathing is an abnormal type of respiration not characteris- tic of uremia, but present during the attacks, in the comatose stage. The extent and rapidity of the respiratory movements are gradually lessened, until the patient's breathing is entirely arrested for several seconds ; it is then resumed again at a gradually increasing rate and depth. It is always a serious symp- tom, pointing to deep involvement of the cerebrum. Bronchitis, pulmonary edema and hydrothorax may accompany uremia and give rise to pulmonary dyspnea. Pulmonary edema is often a fatal complication of uremia. Gasfro-intestinol Symptoms. — In acute uremia, vomiting is a frequent and important symptom, but the chronic uremic state may show many more signs on the part of the gastro-intestinal tract, including all those mentioned in the table. The toxic agents causing uremia are evidently, at least in part, elimi- nated through the mucosa of the gastro-intestinal tract, instead of through the insufficient kidneys, and accordingly the entire tube from mouth to rectum may be affected. Dryness of the tongue and throat and thirst are frequent pre- 446 IJEEMIA monitory symptoms of a uremic attack. (Stomatitis is rare, but must Le looked out for. The vomiting at first occurs after meals; later it is more frequent and occurs independently of eating. The vomited matter contains urea and am- monium carbonate and is alkaline in reaction. Under these circumstances, vom- iting is a grave sign, showing that the toxemia is general and profound, and the renal insufficiency very marked, so that the organism has recourse to emesis to rid itself of the accumulated poisons. Usually, the diarrhea is of the ordinary catarrhal or muco-serous type, fre- quent fetid fluid stools being the chief symptom. There are cases, however, in which intestinal ulceration leads to a dysenteric diarrhea. Alternate consti- pation and diarrhea are often present. Eye Symptoms. — The ocular symptoms of uremia should l)e carefully dis- tinguished from those of chronic nephritis. The former are not accompanied by ophthalmoscopic changes ; the visual disturbances are of sudden onset and transitory in character (double vision, hemiopia, hemeralopia, amblyopia and amaurosis). At the height of a seizure, the pupils are dilated and do not react to light or only feebly so, whereas a chronic uremic poisoning not an attack produces a contraction of the pupil. Edema of the optic sheath has been noted in cases where the pupils fail to react. The presence of an albuminuric retinitis is shown by the ophthalmoscope. Amaurosis, always bilateral, may be the only symptom of uremia in certain exceptional cases, and in conjunction with head- ache is often the forerunner of an attack. Urinary Symptoms. — The urinary symptoms of uremia vary according to the original cause of this condition in a given case. The quantity of urine ex- creted is greatly diminished (oliguria), or there is total absence of urinary se- cretion (anuria) in acute forms, due to acute parenchymatous nephritis, to an acute exacerbation of a chronic parenchymatous nephritis, or to acute obstruc- tion of the urinary tract. In chronic interstitial nephritis, on the other hand, there is an increased amount of urine (polyuria) of low specific gravity. The amount of urea is generally diminished considerably, the daily excretion becoming less and less in the fatal cases until it reaches zero at death. Usually there is some albumin, but this may be absent. The functional efficiency of the kidney as tested by the cryoscope, the phloridzin test and other means is very much impaired, especially in uremias due to interstitial nephritis. Among the clinical urinary symptoms, nothing characteristic of uremia can be noted. There may be frequency of urination, retention with overflow, in- continence and a musty odor of dribbling urine soaking into the bedclothes. These symptoms depend upon the primary condition of the urinary organs, in- ducing uremia, the presence of renal or vesical infection, urinary obstruc- tion, etc. DIAGNOSIS 447 In the comatose condition of uremia, retention of the nrine may occur from inability to feel the impulse to urinate. In such cases, the urine either dribbles away as the bladder overflows, or, if the coma is not so profound, the patient voids the entire contents of the bladder involuntarily at intervals. Of course, this does not refer to the urinary retention due to obstruction which may and fr('([uently does appear with uremia, especially uremia as it comes to the knowledge of the surgeon. (Compare sections on Incontinence and Retention.) General Symptoms. — Acute uremia may occur in apparen1:ly perfectly healthy persons. Chronic uremia, with its attendant renal insufficiency and gastro-intestinal troubles, leads to pallor, emaciation, cachexia and weakness of the muscles, which become atrophied. Edemas may be present, especially in patients with cardiac complications and cirrhosis of the liver. The pulse of uremia is characteristically slow and of higb tension. This is the result of the intoxication and of the condition of the arteries in chronic nepliritis. High-tension pulse in a nephritic is, indeed, considered by some as a sign of impending uremia, although fatal uremias may be accompanied by a comparatively low arterial tension. The temperature during the attack tends to become subnormal as the symp- toms increase in gravity. Fever may, however, be present if there is an infec- tion of the kidney or any other organ, and also in some of the acute cases, due to acute nephritis. Diagnosis. — A correct interpretation of a given symptom as a sign of uri- nary intoxication is not always easy. A symptom may be looked upon as uremic in origin, (a) when it is associated w^ith other signs pointing to uremia; (b) when it occurs without any organic basis of disease in the organ with which the symptom is associated (e. g., the stomach and the intestine) ; (c) when it is associated with renal disease, alone or in combination with lesions of the lower genito-urinary tract. A careful examination of the urinary organs and of the urine is essential for a diagnosis of uremia. If there is no residual urine in the bladder, no obstruction to the discharge of urine, no oliguria or anuria, and if a fresh specimen and a twenty-four-hours' specimen of urine are found to indicate normal function of the kidney, the symptom thought to be uremic in origin must be ascribed to some other cause. On the other hand, uremia is diagnosticated by the presence of the symp- toms or groups of symptoms above described, when the urine shows a deficient renal function. For the purpose of obtaining an estimate of the kidney function, we resort to the methods of functional diagnosis described in detail in the chapter on Examination of the Kidney. Of these, the most valuable in the diagnosis of uremia are the determination of the specific gravity, of the total solids ex- creted, of the percentage of urea of the total nitrogen in the urine and the measurement of the freezing points of the urini' and of the blood (cryoscopy). 448 UREMIA The retention of toxic snbstances in tlie hhnn] and the deficiency of elimina- tion of these substances by the kidneys are expressed in nreinia l)y (1) a hnv- ered specific gravity; (^) a diminished amount of total solids excreted in twen- ty-four hours; (3) a low percentage of urea and of nitrogen; (4) a lowered freezing point of the blood, owing to its greater concentration; and (5) a raised freezing point of the urine (nearer zero, owing to the lowei-ed concentration). Differential Diagnosis of an Attack of Uremia. — Uremic unconsciousness Coming on suddenly, as in chronic interstitial nephritis, may simulate (1) cere- bral hemorrhage, (2) meningitis, (3) epilepsy and (-4) certain intoxications, (1) Cerebral Hemorrhage. — In apoplexy, which is so commonly asso- ciated Avith kidney disease and arteriosclerosis, the sudden loss of consciousness may simulate a uremic attack ; but the mode of onset as well as the existence of complete hemiplegia, with the eyes turned toward the lesion and away from the paralyzed side, suggest cerebral hemorrhage. The distinction is extremely difficult, if not impossible in certain cases. (2) Meningitis. — Meningitis, in which there is deep coma, with rise of temperature, a furred tongue and no localizing symptoms, is also easily con- founded with uremia ; but the mode of onset, the rigidity" of the neck, inco- herence or mild delirium, photophobia and pronounced fever, point to a lesion of the brain. (3) Epilepsy. — The fulminating or eclamptic type of uremia is very sug- gestive of epilepsy. The principal distinctive feature between uremia and epilepsy is that uremic attacks are usually preceded by headache, vertigo and nausea, and occur without an injury to the tongue. The onset of an epileptic attack is sudden, with tonic and then clonic convulsions, beginning generally with biting of the tongue. A history of former seizures is sometimes obtain- able. The urine during and after a paroxysm of epilepsy may contain albu- min. When the convulsions are uremic, albumin and casts may both be present. Edema, especially under the eyes, would point to uremia. The ophthal- moscopic examination of a uremic patient would show degenerative changes in the retina. (4) Intoxications. — Uremic coma may be mistaken for poisoning by opium or alcohol. In opium poisoning the pupils are contracted, whereas, in an attack of uremia, they are dilated. According to the type of uremia, the pupils may be either widely dilated, of mediinn size or contracted, but in a so- called attack of uremia, when a diagnosis is most important, they are dilated, the contracted pupil being characteristic of chronic cases. The examination of the ocular fundus with the ophthalmoscope, to determine the presence or ab- sence of albuminuric retinitis, is a valuable diagnostic adjuvant. The urine should be drawn oif and examined in all suspected cases. In the diiferential diagnosis of uremia from alcoholism (state of drunken- ness), an alcoholic odor of the breath sometimes is a most important point. In PROONOSTS 449 nlroliolip intoxication, tlio pnpils arc soniewliat dilated, l)iit not as markedly as ill iirciiiia. The condition of the heart and arteries must also be taken into account in cases of elderly individuals who may be suffering from arterioscle- rosis. The delirium in alcoholism is not accompanied by convulsions, and the coma is not so deep as in uremic poisouing. Tt may for a time be impossible to determine whether the condition is du(> to uremia or to profound alcoholism, as one of the ])rincipal causes in precipitating an attack of uremia in a nephritic is overindulgence in alcohol. In many of these doid)tful cases, uremia can be identitied by the history given by the family, the age of the patient and the marked arterial tension. The presence of dropsy in some cases is a valuable- indication of the nephritic origin of uremic symptoms. Uremic coma must also be differentiated from diabetic coma. The examina- tion of the urine would show the presence of sugar and further tests with the tinctu.re of the chlorid of iron would show the Burgundj^-red reaction of acetone. Acute Prolonged Uremia. — The differentiation of uremia from certain infectious diseases is sometimes difficult. The uremia may persist for weeks or months, the patient lying in a condition of torpor or even unconsciousness and slight fever, with a heavily coated and also, perhaps, dry tongue, a rapid feeble pulse and muscular twitchings. This state naturally suggests the ex- istence of one of the infectious diseases, such as typhoid fever or acute miliary tuberculosis. There is no absolute rule applicable to the differential signs. The table (page 450) which I have written out is appended, simply as an aid in doubtful cases. Prognosis. — Uremia, once diagnosticated, should always be a source of anxiety to the attendants of the patient, because there is an element of uncer- tainty in the manner in wdiich the intoxication will affect a given case. A peculiarity of uremia, which should not be overlooked in making a prognosis, is that the degree of actual intoxication and the severity of the symptoms do not always correspond with the gravity of the lesions in the renal apparatus. In some patients, the subjective and even the objective symptoms may be quite severe, while the renal function is very fair ; wdiereas, others exhibit remark- ably few and mild symptoms with very much impaired renal functions. The type of uremia has no xerj pronounced bearing on the prognosis, Tlie mild latent form nuiy exist for years, but eventually the grave form develops. The chronic form toward the end may become more and more severe, the at- tacks increasing in frequency, until one of them ends in death. The acute form may either subside and, if its cause be removed, leave the patient in good condition, or it may end fatally, or it may dcvclo]) into llic clirduic fonii. The cause of death may ])c one of the following: ( 1) Hearh in coma, some- times following convulsions ; (2) edenux of the lungs ; (3) asthenia. 450 UREMIA bO M © >1 t< I 3 S3 S . 3 «3 ^ •/3 ?^ 3 c3 i2 3 s •^ ^ .2 2 § i e3 S -s -l-> 1 3 1 of ^ ^ « 3 -C G Q J2 03 Ph 2 C5 •s -a II ^ ~ i .S g 3 ^"Pk -c 3 ^ -. a tc d ;.. a ^1 > 3 3 i 'S. ■ O £i 5 "^ T3 1 ;-i '^ = 1 P hi d "3 g' 2 § ^ 00 g "s -3 s ^ 'rt t£ '^ > 03 J2 £ '-3 ^ w E ^ p ^ >>' • - ^ 3 to ■3 -§■ bO 3 3 3 £ c3 S 13 1 to 3 1 i 3 1 «3 1= c ~ ^ D fe § a; a ^ p <: Sh i n2 i .3 3, 03 ?^ -a &c ;_, -^ '^ si '-C 1 Q 3 to tn a 3 ^3 5r! . ."3 i^ c £ c . 1 •x ^ - 2 jr^ '.4J u . ^ .^ ^ ^ ^ *" s CO -3 £ 3 12 iB 3 3 := Pi < > P 12; C U ^ Q i i 3 J, c >i '0 33 ^ "o 03 r3 £ b£ 3 tJG 3 i a. 'S, 0: 73 a .2 3 Is 3 2 f3 >^ to 13 03 '3 |2 c3 r3 ^ 3 gS-j3 s H 1— 1 H p ;? 3 ^ '2 =^ ^ '-k t ■; 3 S .c > ^ ii ■3. a < 3 q5 -1-3 013 -5 i *" "3 i- p 3 -^ -2 -i =3 .3 ^ •3 " 3 M 3 c 5; ?; 3 ..I >> c 3. >> M ^j ^J K D ^ c < 03 G 3 ■_M ■^ a 3 > 3 ■&, - CO 03 i— ( .2 'B. a t/ c c c . CI 3 3 oi 'C i ii C U P5 Ph flH (^ P 1 ^ N CO -* iT. cc t- oc ) TREATMENT OF UPwEMTA 451 A case which occurred in one of my hospital services was in a boy aged twenty-one years, who had total suppression of urine and lived for eight days after the removal of a large tuberculous kidney. At no time during the post- operative eight days did he show any signs of uremia and was conscious almost to the end. Death occurred from astlienia. The autopsy revealed the absence of a second kidney. Treatment of Uremia. — Wlien convulsions are frequent, the face red and cyanotic, the pulse full, venesection is, in my judgment, the most effective remedy. The causes of the benefit derived from venesection are probably four : (1) Withdrawal of a part of the poisons circulating in the blood; (2) lowering Fig. 280. — Bleeding the Patient in Uremia. (See also Figs. 258, 259, 260.) of the blood pressure; (3) dilution of the blood, i.e., lessening the viscosity, and hence a reduction of the work of the heart and of friction along the vessels ; and (4) the lowering of temperature (Fig. 280). It is usually followed by an intravenous injection of a corresponding quantity of normal salt solution. (See Intravenous Injections of Saline Solution in chapter on the Use of Water in Urology. ) The subject of the lessening of the viscosity of the blood brings us next to the employment and effect of inhalations. By this easy means, agents that enter the blood rapidly may be given, with a notable effect upon the convulsions when present. Chloroform is among the first, a few whiffs lessening the motor symptoms in a marked manner. For the dyspnea, iodid of ethyl may be inhaled with relief, from a small vial held in the hand, or ten to twenty minims on a handkerchief. The internal administration, of morphin and heroin markedly relieves the dyspnea and the convulsions. When the convulsions are marked liy high tcusidu, the vaso-di- lators, glonoin or spirits of nitroglycerin (2 to 5 dro^is every three to four hours), amyl nitrite (trt v from a crushed capsule), cautiously inhaled, is 452 UREMTA sometimes employed, nnd iimst bo regarded witli favor under the proper conditions. Ammonia, a remedy too little nsed, exerts a direct liquefying action upon the blood, reducing its molecular concentration, and contributing to the oxida- tion of other nitrogenous compounds. The aromatic spirits of ammonia (thirty to sixty minims in water) are serviceable, stimulating the movements of the stomach and intestines. In the most pressing cases, ammonia can Ije injected directly into a vein of the leg. In an acute attack of uremia, there often are symptoms of approaching weakness of the heart, a snuill pulse, so small at times as to be imperceptible, and very faint respiration. Under these circumstances, the aromatic spirits of ammonia are very useful, and it may be well to support the heart with injec- tions of digitoxin, yro grain ; camphor, 14 grain in oil ; caifein sodium salicyl- ate, -| to 2 grains ; and etlier, f3ss or more in cold water. After venesection, isotonic injections of warm saline solution into the veins or into the loose cel- lular tissue of the flanks, groin and axilla, are given. In all cases of acute uremia, an effort should be made not to overtreat the patient by too violent purging, which is very exhausting and often not as effi- cacious as the milder methods above mentioned, or the simple diuretics and dieting. As to the convulsions, there are no better remedies, if swallowing is possible, than the bromids. The treatment of chronic uremia is considered under Chronic Xephritis. CHAPTER XXV CHRONIC SUPPURATIVE DISEASES OF THE KIDNEY (Pyelitis, Pyelo-nephritls, Pyonephrosis, PerinepJnitic Abscess, Nephritic Ah- ■ sccss and Suppurative Nephritis) During the last two decades, there have been rapid changes in our views of the pathology and bacteriology of the kidney, due principally to the exhaustive investigation of the French school. Xotwithstanding, however, that much light has been throAvn upon the causes of these diseases, the variety and manner of infection, their scope and line of march, the clinician is still constantly at a loss to know in any case before him whether one of these affections exists alone, or whether two or more are com- bined. The diseases of this variety, however, that have come under my per- sonal observation, were usually combined, instead of existing as one single, well- defined disorder. I may here say, in a general way, that I consider the diseases closely asso- ciated with one another in their line of march to be : Pyelitis — an inflammation of the pelvis of the kidney ; pyelo-nephritis — a pyelitis plus nephritis ; pyo- nephrosis — a pyelitis plus a nephritis, together with enlargement of the pelvic cavity due either to destruction of renal tissue by abscess, or to dilation of the pelvis from obstructions lower down the canal, or to both these causes ; and peri- nephritic abscess — a collection of pus about the kidney. Abscess of the kidney and suppurative nephritis occurring independently of the above group, will he considered later. They are comparatively rare. As the scope of this work is clinical, I will endeavor to consider these dis- eases from a clinical standjioint, whatever may be their etiology. I will, there- fore, include in this consideration tuberculosis and calculus, as they have been in my practice such frequent predisposing causes of renal suppuration. PYELITIS Etiology. — The causes of these sup]iurativc diseases of the kidney arc prac- tically the same, whether the inflannnation begins in the pelvis and extends to the parenchyma, or whether it begins in the parenchynui and extends into the pelvis. They are predisposing and active causes. The former include, in the 453 454 CHRONIC SUPPURATIVE DISEASES OF THE KIDNEY first place, debilitated conditions of the Inxly which favor suppuration; infec- tious diseases; any factor Icadini;- to congestion, as traumatism from direct con- tusion; the irritation of drugs, exposure to cold or wet and displacement of the kidney due to great mobility. Other ])redisposing causes are found in all conditions which interfere with the urinary flow or congest or irritate the kidney ; in the first instance — urethral strictures; enlarged prostate; vesical stone or tumor; ureteral stone, tulierculosis or stricture; or outside pressure upon the ureter due to adhesions or growths: and in the second instance — a stone ; tumor ; tuberculosis of the kidney or its pelvis; or abnormal renal mol)ility. In tuberculosis with suppuration, the pelvis may l)e involved in an ascend- ing process from the bladder or in a descending process from the kidney tis- sues, usually the latter. The tubercles developing in the renal pelvis may break down and suppurate at the same time that a similar process is going on in the kidney proper. Usually pyelitis is a part of a pyelo-nephritis or pyonephrosis, and, in most cases in wdiich the predisposing cause of the pyelitis is not removed or relieved, the disease secondarily affects the kidney, at least in its medullary portion : whereas, on the other hand, in the great majority of cases in which the su})- purative process begins in the parenchyma, the inflammation in turn extends to the pelvis. The active causes of these suppurative conditions are the various pus-produc- ing germs, the most common of which are the colon bacillus, staphylococcus, streptococcus, Proteus vulgaris. Bacillus pyocyaneus. The gonococcus is a pus producer, but it is rarely the active microorganism giving rise to the renal su])- puration. The tubercle bacillus is not considered as a pus producer, but is productive of lesions that are favorable for other infections. The infectious agents that produce renal suppuration may reach the organ either through the Idood (hematogenous infection) or through the lymph (lymphogenous infection), or they may reach the organ by extension of the suppuration from neighljoring structures (infection by contiguity), and finally the infection may travel upAvard from some lower portion of the genito- urinary tract, as the urethra or bladder (ascending infection, or infection by continuity. The ureteral, lymphogenous and heumtogenous routes of these infectious have been carefully investigated by All)arran and others of the Xecker school, who have concluded that the circulatory is the most common. Pus-producing microorganisms in the blood current circulating through the kidney or its pelvis are not likely to give rise to sup})uration without the presence of congestion due to some of the predisposing causes just mentioned ; but if congestion is present, the germs, having passed through the circulation and entered the urinary tract, find the pelvis a soil adaj)ted for their settlement and gTOwth. I PYELITIS 455 We have, therefore, covered the causes of this group of diseases in a general way, and those of pyelitis in particidar. Pathology. — Pyelitis usually begins with a simple catarrhal condition of the mucous membrane of the pelvis, with congestion of the superficial capil- laries and an excess of mucus. As infection takes place, the mucous membrane takes on the appearance of a turbid gelatinous lining, which is rapidly fol- lowed by a purulent exudate and thickening of the wall. The thickening and roughness of the pelvic wall are more marked in tubercular cases and the ulcera- tions are of a more active type. There is also great thickening at times in cal- culous pyelitis, as well as erosions and capillary hemorrhage. When the pyelitis is due to an ascending infection, there is a gi'eater dilata- tion of the pelvis, its surface is smoother and thinner and the capillary conges- tion is less. The amount of urine and pus is considerable and the admixture thinner than in the descending cases. Capillary congestion, engorgement, ero- sions and ulcerations are also less marked. It must be remembered that urinary retention takes place in varying degrees when there is obstruction due to tuber- cular lesions or calculus, but that the retention is greater when there is obstruc- tion due to interference with the urinary flow in the ureter proper. When the pyelitis advances to such a degi'ee that there is retention of urine and pus in the renal pelvis, the parenchyma is also generally involved and the trou1)le l)econies a pyelo-nephritis or pyonephrosis. Symptoms. — The symptoms of pyelitis are few and at times absent when it exists alone and not associated with calculus, tumor, tuberculosis or abnormal renal mobility. There is sometimes slight frequency of urination, due to a polyuria, or there may be a vague pain or a heavy feeling in one or both loins. The pain is more intense and colicky when the pyelitis is due to calculus or to movable kidney. Plematuria is rare in pyelitis unless there is a growth or stone present, when it is common ; whereas, in tuberculosis it is still less frequent. Pyuria exists, but is of a mild degree when the pelvis is alone involved ; but when a cystitis also is present, the pyuria is more marked, owing to the addition of the pus produced in the bladder to that coming from the pelvis and ureter. Marked frequency of urination is due to an associated cystitis, probably tuber- cular. Attacks of nausea, vomiting, chills, fever and sweating are generally due to movable kidney or renal calculus, with attacks of retention and absorption of ])us. Febrile attacks also ])(iiiit to an extension of the inflanunation to the kidne}' substance and we must, therefore, always be on our guard against such an involvement. Examination. — In pali)ating the kidney in ]\velitis, a slight tenderness may be experienced by the patient. There is usually no rise of temperature. There is no enlargement of the organ unless a complication is present, such as retention of ui'iue and ]ius in the pelvis, or an extension to the kidney parenchyma. The urinary examination shows in the chronic cases, such as are usually ob- 456 CHRONIC SUPPURATIVE DISEASES OF THE KIDNEY served, a urine of low specific gravity, somowliat increased in amount, contain- ing considerable pus, scrum and nuclear albumin, pelvic epithelia and a few blood cells and hyaline and granular casts. In case the disease is due to tulier- culosis, the bacilli may be found in the urine ; while if due to stone, crystals may be found in masses of pus and mucus, and the specific gravity is higher. Diagnosis. — In the differentiation of pyelitis and cystitis, there are some rather interesting points. In chronic cystitis, the daily amount of urine and urea are always normal, unless the patient has been given a large amount of water or diuretics. The reaction is generally alkaline, or if u'lt, it soon be- comes so, unless due to the colon or tubercle bacillus. The amount of albumin does not exceed that caused by the pus and blood. There is a muco-purulent sediment which coagulates quickly. ^Microscopically, pus and a large number of bladder epithelial cells are found in the urine. The large amount of ei)i- thelium that is present is striking, rather than any particular type. There is no renal pain, nor tenderness on pressure over the kidney. In chronic pyelitis, there is polyuria, the sediment is more diffuse and does not coagulate, or certainly not so quickly. The urine is usually acid in reaction and contains but few epithelial cells. The importance of the colon bacillus is not sufficiently appreciated ; it is very frequent and its recog-nition is not diffi- cult. A cystoscopic examination will always give information concerning the condition of the bladder. ProgTiosis. — The prognosis of pyelitis depends entirely upon its cause and the j^resence of associated lesions. If the cause is removed, the patient should recover. This may require some time, or it may never take place, in which lat- ter instance the pyelitis ^vould probably slowly extend up into the kidney and develop into a pyelo-nephritis or a pyonephrosis. In many cases, the kidney is involved together with its pelvis, but the couditioint to it as the principally affected kidney. Catheterization of the ureters shows the difference between the two organs, as the urine coming from the ])yo- nephrotic side on which there are no symptoms would show a considerable amount of thin fluid resembling pus and water mixed, containing but a small amount of solids ; whereas, on the side on which the acute symptoms are present, the urine might be comparatively normal in color and would contain a greater amount of solids, as well as the products of inflammation. Diagnosis. — The diagnosis of pyonephrosis depends on finding a urine hav- ing the turbid or starch-water appearance, and finding that it contains albumin, pus, renal epithelia and various kinds of casts, including pus casts. Then, on catheterizing the ureters, it will be seen that the elements of kidney disease found in the general urine can be accounted for by the urine coming from the TREATMENT 403 suspected kidney. A considerable amount of ui-ine from the diseased kidney may run out as soon as the catheter is introduced into its pelvis, perhaps half an ounce or more, which, on examination, will be found to consist principally of a clear fluid with but a small amount of solids, albumin, considerable pus and other pathological kidney elements. In both pyelitis and pyelo-nephritis, the urine is generally of a higher specific gravity than in pyonephrosis and would contain more solids. Pviii-ia is more marked in pyonephrosis than in either pyelitis or pyelo-nephriiis. The diagnosis of the cause of the p3^onephrosis is more difficult and includes all the various steps that have been included in the chapter on Examination of the Kidney. Treatment of Pyelitis, Pyelo-nephritis and Pyonephrosis In case of pyelitis, as soon as the diagnosis has been made and even before the cause has been determined, it is advisable to have the patient drink a con- siderable amount of water, say two quarts a day, to flush the kidneys, and to give three times a day an internal urinary antiseptic, such as urotropin, 10 grains; benzoate of soda, 15 grains; benzoic acid, 15 grains; salol, 5 gTains, or other urinary antiseptics. Lavage and injections of the renal pelvis by means of ureteral catheters have been, practiced for many years and have been advo- cated especially in cases of gonorrheal pyelitis, which condition has been ex- tremely rare in my practice. For several years, lavage and injections of the pelvis through the ureteral catheters have been employed quite extensively by us in the cystoscopic room of the clinic, and several thousand lavages and injec- tions have been made. Most of these cases had but slight symptoms and dis- continued their visits on account of the inconvenience the treatment occasioned them. In one case of gonorrheal pyelitis, due to gonorrheal infection, the pelvic lavage and injections with solution of nitrate of silver and its derivatives were kept up constantly for two years, but the gonococci Avere still present at the last examination and the jDatient was no better ; if anything, he was worse. So far, covering a period of nine years that cases of pyelitis have been treated by lavage of the renal pelvis, there is not a history of a single case that has been cured by this method. The solutions nsed were a silver nitrate, 1 : 4,000 to 1 : 2,000 or milder, alone or combined with boracic acid ; protargol, one half to two per cent in strength ; argyrol, ten- to twenty-five-per-cent solution ; and 1 : 5,000 solution of formalin. But few patients seem to have been relieved by such treatment. Some of these patients have had injections of the renal pelvis more than a hundred times and did not improve. Injections of silver solution and protargol seem to have been the most eft'ective, and doubtless nuiny who have been treated at the clinic recovered later. Pyelitis without a predisposing cause is an cxtvomely rare condition, if it ever exists, and patients suffering from it should never be subjected to such 464 CHROXTO SFPrFKATTVE DISEASES OF THE KTDXEV local troatineiit until tlic ])li_vsician lias discox-crcd ilic f-auso and ro^isidL'V.s pelvic injections indicated. Otlierwisc, he niii:lil inject the ])e]vis of a tuliei-- cnlar kidney, in wliicli case tlie jjassinii' of a catlieter niiiilit aii'O'ravate the con- dition and also ])i'o\'oke tnhei'cnlar lesions in the nretei* throngli catheter tranniatisni. Tlie sni'oical treatment of cln-oii'ic j,j/rjilis consists in the removal of the canse. Sometimes, in ])yelitis dnc to ol)strnction wliicli may exist anywhei-e from the cavity of the pelvis itself to the external nrethral meatns, it may 1)0 easy to locate the canse. These obstrnetions are nsnally nrethral strictnre, prostatic hypertrophy, vesical tnmor, stone in the nreter, or pressnre hy oi-n^vths or adhesions ontside of the nreter ; or stone or growth in the jDclvis of the kidney. In snch cases, the obstrnction shonkl be overcome as follows: Urethral strictnres shonkl be dilated or cnt ; hy])ertrophic prostates shonld be subjected to catheter life or prostatectomy; vesical calcnli shonld be crushed or removed by supra- pubic cystotomy ; vesical tumors should be excised through a suprapubic in- cision or fulgurated ; stone in the ureter should be removed by ureterotomy ;, ureteral stricture should be dilated or ureterorrhaphy or plastic operations per- formed ; adhesions about the ureter should be broken up and the canal stretched out;, growths pressing upon the ureter should be removed; a renal calculus should be removed by nephrolithotomy; obstruction in the pelvic wall should be treated by plastic operations ; while in cases of tumor of the pelvis, the entire organ should be removed (nephrectomy), (See chapters on Operative Surgery of the Renal Pelvis and Ureter.) The treatment of pyeJo-neplintis is either palliative, expectant, or radical, depending upon the symptoms. In case a patient has a chill, followed by a fever, and examination shows tenderness and perhaps a noticeable enlargement of one kidney, it does not necessarily mean that this kidney will develop an abscess that will require immediate operation, for the symptoms often subside with rest in bed, milk diet, diuresis and urotropin. It is also advisable to cup the patient over the kidney, to keep the bowels open and to give quinin, three gTains, three times a day. If the temperature continues high and assumes a septic curve, a nephrotomy should be performed and the kidney drained, although probably, if no operation were performed, the abscess would rupture into the renal pelvis. If the nephrotomy shows the kidney to be extensively diseased and a condition of chronic sepsis which is injuring the patient's health continues after the opera- tion, a secondary nephrectomy should be performed, provided the other kidney is sufficiently healthy to carry on the renal function. A tubercular kidney in a state of pyelo-nephritis shonld always be removed in case the other kidney is capable of carrying on the work. In calculus pyelo-nephritis, nephrolithotomy should be performed, nephrectomy being reserved for those cases in which the renal tissue is almost entirely destroyed. A pyelo-nephritis of any variety may break down and empty into the pelvis TREATMENT 4G5 inilil tlio l8S). If we cannot satisfy our- selves that the source of the troul)le is in the kidney, we should make a thorough and systenuitic examina- tion of the organs in the abcb^ni no- pelvic and thoracic cavities. In mak- ing this examination, we should have in mind the various conditions that may give rise to perinephritic ab- scess, mentioned under Causes. It must be remembered that, when we find a perinephritic abscess that has existed for some time, and there is pus in some other neighboring localities, it is difficult to say whether the pus came from the other point and settled in the perirenal space, or extended from the perirenal space to these localities, or simply accumulated in this space as a depot while traveling from one point to another. It should also be borne in mind that, after opening the abscess and washing Fig. 286. — Posterior Surface of Left Kidney IN A Case of Perinephritic Abscess. Shows opening of a cortical tubercular abscess which communicated with the perinephritic cellular tissues. (Author's case.) PERINEPHRITIC ABSCESS 471 it out, the finger should palpate carefully the entire region for openings, how- ever small, in the surface of the kidney or adjacent structures, or for sinuses running up to more distant tissues. All such openings should be probed and examined with an electric light thrown into the cavity. In the case of the Fig. 287. — Posterior Surface of Tuberculous Kidney in a Case of Perinephritic Abscess. The organ was 4 inches long. Note the open- ing on its surface. (Author's case.) Fig. 288. — Longitudinal Section of Same Kid- ney, SHOWING Contracted Pelvis now not Much Larger Than the Ureter. The renal fistula extends from the pehds to the point where it has broken through the capsule of the kidney as a perinephritic abscess. (Author's case.) tubercular cortical abscess, just referred to, the tip of the finger could just be inserted into the abscess cavity in the kidney. There was no ]nis in the urine. The patient developed shortly after this a tuberculous knee, requiring ex- cision, and thus confirming the clinical diagnosis of a preceding tuberculous abscess. The Course of the Abscess. — The course of the abscess varies. In the first ])lacc, it may be absorbed after being walled off by connective tissue. I have had one such case in which all the symptoms gradually subsided. Again, it may extend through Petit's triangle and ru])ture externally. Very few abscesses rupture externally or into the intestinal or urinary tract ; but the patients die of a slow sepsis unless operated upon. The abscess may break into the pleural cavity or lungs, in which latter case it is coughed up and the pa- tient may recover, although usually he dies of sepsis unless the pleural cavity and the perinephritic space are both opened. Rupture into the peritoneal cav- ity is followed by septic peritonitis and death. 472 CHRONIC SUPPURATIVE DISEASES OF THE KIDNEY When the abscess burrows aloiii!; the psoas, it gives the symptoms of psoas abscess. The tumor is felt as a fluctuatiiig mass at or below Poupart's ligament, and may extend down the thigh. Fig. 280 shows the point of bulging of a peri- nephritic abscess just above Pou part's ligament and the point (.4.) at which it was opened in the inner side of the tliigh. It may extend to the pelvis and break into the gut or urinary tract, or through the saero- sciatic foramen into the sci- atic region, beneath the glu- teal muscles or on the back of the thigh. When peri- nephritic abscesses break externally, it is usually in the loin ; next in frequency, the pleura and bronchi ; and after this, the intestine. Treatment of Perinephritic Abscess. — As soon as the diagnosis of peri- nephritic abscess is ascertained, a lumbar incision should, be made into the perirenal space to allow the escape of pus, after which the cavity is washed out with salt solution and then with peroxid and again with salt solution. The abscess cavity should then be explored with the finger. It is often surprising to note how extensive such a cavity may be, the fingers going up to the dia- phragTn and down into the iliac fossa, or even into the pelvis. In cases in which a pyonephrotic kidney has ruptured, the fingers may find themselves in the pelvis of the kidney. It is very difficult for anyone, who has not an experi- enced touch, to open a lumbar abscess and ascertain the exact source of the pus. For this reason, the kidney should always be palpated carefully to see if there is an opening into it, or if the organ feels pathological. If an opening is found, the finger should be inserted, and in case it enters the pelvis, the cavity should be palpated to discover if calculi are present. In that case, they should be removed. If there is an opening in the kidney that will not admit the finger, a cigarette drain should be inserted down to it and the incision closed, with the idea of opening it again in a few days, when the patient is better able to stand the operation, or when the tissues have again resumed their normal relations. In some cases, the kidney is so pushed to one side that it cannot be located at the time of the first operation and it will be necessary to explore it later. Fig. 289. — A Bulging of Pus in the Groin and an Opening IN THE Thigh Made to Drain a Perinephritic Abscess THAT Had Burrowed Down from the Renal Fossa. (Author's case.) ABSCESS OF THE KIDNEY 473 Duriiiii' tlifsc sccdiidiirv, cxploralory ()])('i';i1 ions, tlic kidney can Ix' more carL'tully examined and an exjiloi'atory or drainage neplii-olomy perfoi'med, or a nephrectomy, as decided upon by existing conditions. In four cases in which a i)erinephritic abscess was dne to a calcnlns, in one ease the calcnhis had been discharged from the kidney with the pns wlien it ruptured. (See chapter on Ivenal Calculus.) In an- other case, the stone was felt ]U'otruding from the kid- ney like a spur and was pulled out (Fig. 290). In still another, there was a small sinus in the kidney and tlie stone was not dis- covered until an explora- tory nephrotomy had been performed. In another in- stance, I could not find the stone at nephrotomy and it was not until later after a nephrectomy had been performed that the cal- culus was discovered in a pocket. In all my opera- tions on tuberculous kid- neys, with one exception, the opening into the kidney communicated directly with the pelvis. In the case in which the abscess burrowed down be- neath Poupart's ligament, it was opened in the inner part ^^^- 290. — A .Sharp-pointed Calculus that Was Found ■ „ , 1 • T / T-i- \ Sticking through the Wall of the Kidney in a Case of the thigh (see ilg. 289). of Perinephritis. (Author's case.) ABSCESS OF THE KIDNEY There are several forms of abscess of the kidney: (1) Those associated wiili renal tuberculosis; (2) those associated with stone; (3) those associated willi obstruction of the urinary flow in the pelvis of the kidney or in the urinary tract below it, coupled with an existing infection in the urinary tract; (4) those in which the abscesses form in the kidney substance, independent of infection of the renal pelvis, that is, it may or may not be infected. 474 CHRONIC SUPPURATIVE DISEASES OF THE KIDXEY Groups 1, 2 and 3 have been discussed in the foregoing part of the chapter under Pyelitis, Pyelo-nephritis and Pyonephrosis, and we have recognized the fact that the course of the affection may he ascending or descending and that the predisposing cause is generally some obstruction or irritation in the renal l^elvis or below, that favors congestion in the kidney, and a diminislied resist- ance. If an abscess develops in the kidney substance proper, the infection may he derived from any part of the body; but it is usually due to infection in the lower urinary tract. Group 4, in Avhicli abscesses form in the renal substance independent of in- fection in the renal pelvis, is the conditidu that will now be considered. In these cases, however, the same causes that favor renal suppuration exist ; namely, some obstruction in the renal pelvis or below, that interferes with the flow of urine and causes renal congestion and consequent diminished resistance on the part of the kidney. An existing nonsupi)urative nephritis, together with a diminished resistance, may also provide this predisposition. These abscesses may then be considered primary, and, if their contents are discharged into the pelvis of the kidney, the condition of the pelvis favoring an infection, a pyelo-nephritis may result ; or a pyone^jhrosis in case there is a large amount of destruction, I will consider these abscesses of the kidney in Croup -i as primary abscesses. There are two varieties: The miliary (disseminated) and the circumscribed. They are of a hematogenous origin and pyemic in character, originating as sep- tic infarcts. The miliary abscesses may invade the entire kidney cortex or only a part of it ; although, when they invade the entire kidney substance, they are much more marked in certain areas than in others. The circumscrihed abscesses may result from the breaking down of one or more areas of the miliary type into one large-sized abscess or into several ; or they may develop as localized abscesses independent of the miliary type. Etiology. — The predisj^osing causes of such kidney abscesses are, as already mentioned, anything that tends to produce congestion or to diminish the re- sistance of the kidney parenchyma, such as urethral stricture ; prostatic hyper- trophy, stone or tuberculosis of the prostate ; stone or tumor of the bladder ; stone, tumor, tuberculosis or kinking of the ureter ; stone, tumor or dilatation of the pelvis of the kidney, with urinary retention ; and stone, tumor, patho- logical mobility of the kidney and also parenchymatous or interstitial nephritis, or congestion due to infectious diseases. The active cause is the introduction of pyogenic germs : The colon bacillus, Staphylococcus aureus. Streptococcus pyogenes, etc. These may come from any focus of suppuration in the body and cause diffuse miliary abscesses of the kidneys, resembling those of miliary abscesses in the lungs in septic pneumonia, that is, of a i^yemic type. Such pus-producing germs enter the kidney and ABSCESS OF THE KIDNEY 475 loflgc in tlio fino r;i]iillarics, foriiiiiig innumerable small septic areas. They may come from apjjendiciilar abscesses, carbuncles, septic metritis or endome- tritis, septic endocarditis, septic phlebitis or many other septic conditions located anywhere in the system. The infectious diseases, by lodgment of the specific germs in the substance of the kidney, also provide an active infection in these cases. Ty])ical disseminated abscesses, varying from a pin point to a large pea, may also develop in very large numbers in patients who have a suppurative con- dition of the loAvcr genital tract, bladder, prostate or urethra. Fig. 291. — Multiple Disseminated Abscesses of Kidney. The kidney was 7li inches long. Nephrectomy. (Author's case.) Pathology. — The kidney is swollen and increased in weight. In the dis- seminated forui, the removal of the capsule ex]ioses, in the cortex, uuiidiers of ju-otruding abscesses frequently surrounded by a hemorrhagic zone. Individual abscesses generally do not exceed the size of a pea. Fig. 291 shows the cortex of the kidney to be riddled with abscesses varying in size from 476 CHROXIC SUPPUEATIVE DISEASES OF THE KTDXEY a pin point to a pea. When grouped, ^vlncll often is the ease, the masses thus formed may occupy a much larger area, the size of a filbert (a circumscribed abscess). On incision of the abscesses (Figs. 292 and 293), a greenish-yellow pus exudes, in which, on microscopic examination, the pyogenic agent can be demonstrated. On section through the convexity of the kidney, the groups of cortical abscesses are found to occupy a wedge-shaped area, the apex directed toward the pelvis. The medulla is generally congested and travei^sed by per- pendicular yellow lines which are continuous above with the wedge-shaped foci in the cortex. Microscopic examination shows areas of necrosis surrounded by dense, round-celled and polynuclear leucocytic infiltration; the tubules are filled with pus and bacteria and not infrequently also the intracapsular spaces and the Malpighian bodies. Circumscribed abscesses may reach a large size involving both the cortex and the medulla and may break into the renal pelvis or externally through the capsule, giving rise to a perinephritic abscess. Symptoms. — The symptoms of miliary abscess of the kidney are mixed of sepsis and later uremia: Chills, fever, sweating, temperature from 100° to 10.5^ F., pulse 90 to 120, headache, pain more or less marked in the loin, pros- tration, loss of appetite, perhaps nausea and vomiting, and later apathy, stupor, delirium, constituting a typhoid state, and occasionally convulsions. Examination. — Upon examination, we find tenderness and perhaps mus- cular rigidity over one or both kidneys. The urine is scanty and shows at first a trace of albumin, a few pus cells, renal epithelia and occasional red blood cells and later casts. The blood shows no indications of typhoid fever or malaria, but signs of sepsis, e. g., a leucocytosis of from 10,000 to 30,000. Ureteral catheterization will usually show that the albumin and cells come from the kidney that is painful. These kidneys are often found to be enlarged on palpation. Brewer has shoA^m that this type of disseminated miliary abscess is usually located in one kidney at the onset. Treatment of Primary Abscess of the Kidney. — From my experience in the treatment of renal aL.scesses occurring when no infection of the renal pelvis is present, I should say that it is exceedingly difficult to tell the type of abscess in the kidney — ^Avhether it be "disseminated or circumscribed, until the organ has been exposed. Also that it makes but little difference whether or not the renal pelvis is diseased. Presumably, however, the disease at the start is usu- ally disseminated. The clinical observations of Brewer, that these disseminated abscesses usually occur in one organ at the beginning and the more favorable results that he had with nephrectomy than Avith nephrotomy in these early cases, would tend to show that it is important to make an early diagnosis and to per- form an early nephrectomy. I think, therefore, that in operating on an acute case of short duration, if considerable kidney area is involved by pyemic ab- scesses, large or small, nephrectomy is preferable, if the other kidney is healthy. If, in operating on a case of some duration, we find circumscribed abscesses I ABSCESS OF THE KIDXEY 477 I < RS X 5 H J O "T" 5 i ^ • s r a =? ^-S I p if I ^ ^ O « I. a H S ^ S H S S S O 478 CHRONIC SUPPURATIVE DISEASES OE THE KIDXEY present instead of tlio iniilliplc miliary I_ypc3 wlirn (•()iisi of 2-1 autopsies on persons in whose ki(hieys calculi were ])rcscnt, that there had been no symptoms whatever during- life referal)h' to Fig. 305. — The Renal Pei-vis of a Pyonephrotic Kidney Filled with Five Stones of Large Size. There was also an attack of acute renal retention present in this case, and the affected kid- ney contained over a pint of pus. nephrolithiasis. I wish, therefore, to emphasize, at the beginning of the clinical part, that the symptoms are not always in proportion to the extent of the dis- ease, and that I have often been surprised to find how few subjective symptoms a patient has had when his kidney has been nearly destroyed by a calculus. In some cases, the existence of renal stone is not suspected because the train of symptoms is obscure, or for the reason that they point to other organs, as the bladder, the uterus, the ovaries, the testicles or to the gastro-intestinal tract. In the majority of cases, however, the subjective symptoms are marked and often most distressing. Pain. — Pain occurs in most cases, and is situated in the lumbar region cor- responding to the affected side or in that side of the abdomen. This had been SYMPTOMS AND DIAGNOSIS 505 ])r('S('iil ill '.)2 per cent, of my ciises for a ])erio(l varyiiii;' from six days to twenty- two years, with an averai^c duration of four years. The right side is most fre- quently aifec'ted, and in my own eases the relative frequency was G5 per cent on the right side and 35 per cent on the left, while the pain was bilateral in l)ut (I per cent. The abdominal pain may run down to the groin or the testis on the affected side. It is of varying degrees of intensity, from a dull ache to the excruciating, sharp, cutting pain of renal colic It may be continuous, l;ut generally follows exercise or jolting, although cases have been reported when it o( ( urrcd at night. It is renal colic that nsually causes the patient to consult a physician, espe- cially if it be associated with or followed by hematuria. In my own cases, thirty-three ])er cent complained of this symptom. Attacks of colic occur when a freely, movable stone begins to engage in the mouth of the ureter, or to descend along the canal. The forces that jDropel a stone along the ureter in such cases are said to be threefold, viz. : The j^ressure of pent-up nrine behind it, the forcible contraction of the nreter under the irritation produced by a foreign body, and the alternating })ositive and negative pressure of the act of vomiting which often accompanies the attack of colic. The clinical joicture of a patient in the throes of renal colic is not easily forgotten when once seen. The facial pallor, the cold sweat, the flexed thighs, the bending of the body during the agony of the paroxysm, are sufficiently ty]ii- cal to direct our attention to the probability of a stone in the pelvis of the kid- ney or passing through the ureter. The pain is acute, paroxysmal, has its chief seat in the loin or in the side of the abdomen, and radiates along the ureter toward the testicles or the labia majora, or into the thigh, according to the course of the spermatic or ovarian plexuses and their communications. The access of pain is frequently preceded- by a chill, and complicated by attacks of nausea and vomiting. The j^aroxysm usually lasts from two to three hours, and, as a rule, terminates more or less abruptly, the patient feeling re- lieved and falling asleep. In milder cases, the pains are not so colicky or paroxysmal, and consist sim- ply of slight pricking sensations along the course of the ureter, accompanied by a feeling of slight nausea. During an attack, the urine may be passed frequently. It may be clear, of low specific gravity, in case the ureter or the uretero-pelvic opening is completely obstructed by the calculus, as it then comes from the healthy kidney. If the ureter is not completely obstructed, the urine may be tinged with blood ; or tur- bid, in case the kidney is infected. The frequent desire to urinate depends upon the locality of the calculus, as the nearer it is to the bladder, the greater is the frequency. Ureteral blood casts are sometimes passed in the urine during the attack, but usually not until after the expulsion of the calculus. 506 XEPHROLITHIASIS The cases in wliifli the stone remains in the kidney or pelvis, withont giving rise to attacks of renal colic, are those that })resent the greatest difficulties in diagnosis. Keflex or referred pains are often met with in nephrolithiasis, and frequently mislead the diagnostician. They existed in twenty per cent of my cases and were situated principally in the groin, testicle and thigh. In such instances, the renal region may be free from pain. The pain may be seated in the lumbar sensory nerves, or in the sciatic nerve, as in lumbar sciatic neuritis. The reflex pains of nephrolithiasis have been classified by Guyon as follows: The reno-renal, reno-vesical, reno-ovarian or reno-uterine and reno-testicular reflex. The reno-renal reflex is a sensation of pain in the kidney that is not sup- posed to contain a stone, and is attributed to its reflex transmission from the affected side, in other words, from one renal plexus to the other. Such a mani- festation is, I believe, rare, and is based upon the idea that the kidney which is not thought to contain the stone is a healthy one. Recent investigation, espe- cially since the development of ureteral catheterization, has shown that this other kidney is generally not a normal one, in fact, that it is usually the seat of a nephritis. The painful symptoms in this so-called healthy kidney can be ac- counted for in various ways. The healthy organ may be the seat of an occasional acute congestion when an extra amount of work is suddenly thro^vn upon it, owing to the calculus in the diseased kidney engaging in its pelvis and thus interfering with its function. The pain may also be more acute in the so-called healthy organ when it is the seat of an inflammation that is much less exten- sive than that of the other organ although more acute in character ; again when it contains a stone, not identified by radiography, which is rougher and conse- quently more irritating; or when there is a stone present of a size just suffi- cient to interfere with the urinary flow and to cause an acute distention of the pelvis. The reno-renal reflex occurred in six per cent of my cases. Eegarding the reno-ureteral reflex, the reno-ovarian and reno-testicular re- flexes, I will say that such pains are due to the pressure of the calculus on the sensory nerve fibers of the spermatic and ovarian plexuses at the beginning of the ureter in the pelvis, or lower do^vn in case it is descending the canal, and are consequently distributed to the organs supplied by these nerves. The reno-vesical reflex can be explained in a similar way, although pain in the bladder can also be due to a stone in the part of the ureter that is contained in the bladder wall. The gastro-intestinal reflex is a more genuine reflex, because in this case the pains are reflected from the urinary to the gastro-intestinal tract through the connection between the renal, spermatic, or ovarian plexuses on the one hand, and the gastric or splanchnic plexuses on the other. This probably accounts for the large number of patients who complain of dyspepsia, by which name they describe an unpleasant feeling in any part of the abdomen, such as can be pro- SYMPTOMS AND DIAGNOSIS 507 diiccd l)_v an iii(lii;csl imi, hv i)i-ossnro of the kidney on tlio adjoining organs, or 1)V a renal ni-inary i-clciil ion. The wf>man with the lai'gc pyoncphrotic kidney containing nnnierous calenli (see Fig. o05) complained only of dyspepsia and attacks of malaria. Hematuria. — If the reason for consulting a physician for this disease is not pain, then it is nsually the presence of blood in the urine. This is one of the most frequent symptoms of renal calculus, and was complained of in thirty- seven per cent of my cases. The bleeding in these cases occurs in sufficient quan- tity in the urine to be detected by the patient. It is aggravated by movements and by prolonged standing, and lessened by rest in bed. It is due both to conges- tiun and. to injury of the tissues caused by friction from the stone, or to conges- tion of the wall of the pelvis, in case it is distended by a stone blocking the ureteral opening. Oxalic calculi are the roughest and therefore especially liable to cause hematuria. The urine and blood are freely mixed, giving the color of porter, and in case clots are present, they are thin and elongated, of a wormlike apj)earance (ureteral clots). I have seen a number of interesting cases of hematuria due to renal stone, occurring w^hile playing ball, riding horseback, boxing aftd indulging in other athletic sports. Hematuria in such cases follows pain in the affected side. In the case of a grocer, the patient stated that when, in his w^ork, he lifted objects from the ground, especially barrels and baskets of gToceries, blood would appear in his urine. I had him come to my office for a cystoscopic examination and put him through the same movements with pulley weights and dumb-bells that he made when lifting in the store, to see if hematuria would be induced ; but it was not, showing that hematuria cannot be brought on at will, or else the patient's statements are not always truthful. Pyuria. — Pyuria, strictly speaking, means that pus can be detected in the urine on microscopical examination; but clinically it means there is a sufficient amount of pus to make the urine appear opaque or turbid, and show a light precipitate on standing. It usually occurs in the course of nephrolithiasis, and the amount may be so abundant as to form twenty-five per cent or more of the urine by volume. In many cases the urine has a milky color, while in others it resembles lemonade. Pyuria occurred in over fifty per cent of the cases under my observation. General Examination. — Palpation, it is said, will in certain cases reveal the presence of stones, if they are of sufficient size. This nuiy be true, and I believe that a kidney that can be sufficiently well palliated to detect undue hard- ness will probably prove to Ix' either a calculous kidney or a nudignant kidney. I have noticed enlargement of the organ in thirty-three per cent of the cases of renal calculus that I have examined, but have never felt the stone. It is often possible to determine the presence of tenderness, the degree of mobility and size of the organ by palpation, which are important points, as an inflamed kidney, 508 NEPHROLITHIASIS especially if it i-ontaiiis a foreign body, is veiy apl to \h_' enlarged and tender and Uriiily attached by inflammatory adhesions. The kidney is tender in nearly all cases in wliicli it is enlarged, but it cannot always be outlined. A normal kidney cann(jt usually be felt and is not tender to the tonch. There are other symptoms that may occur in nc]ilirolitliiasis that may be mentioned as digestive disturbance, snch as nansea and vomiting, abdominal dis- tress and poor appetite. These are nsnally due either to pressnre or dragging on the diiodennm or colon, to an accompanying nephritis, or to a septic condition in case of infection. Headaches are probably