CONTRIBUTORS TO VOL. I. BARNEY, J. DELLINGER, M.D. BARRINGER, B. S., M.D. BEER, EDWIN, M.D. BUERGER, LEO, M.A., M.D. CORBUS, B. C., M.D. DODD, WALTER J., M.D. FOWLER, H. A., M.D. KEYES, EDWARD L., JR., M.D. LEWIS, BRANSFORD, M.D., B.Sc., F.A.C.S. OSGOOD, ALFRED T., M.D. PILCHER, PAUL MONROE, A.M., M.D. QUINBY, WILLIAM C., M.D. SANFORD, HENRY L., M.D. SMITH, GEORGE GILBERT, M.D. STEVENS, A. RAYMOND, M.D. WARREN, GEORGE W., M.D. WATSON, FRANCIS S., M.D. YOUNG, HUGH HAMPTON, M.D. IN ORIGINAL CONTRIBUTIONS BY AMERICAN AUTHORS EDITED BY HUGH CABOT, M.D., F.A.C.S. CHIEF OF THE GENITO-URINARY DEPARTMENT OF THE MASSACHUSETTS GENERAL HOSPITAL; ASSISTANT PROFESSOR OF GENITO-URINARY SURGERY IN THE HARVARD MEDICAL SCHOOL, BOSTON, MASSACHUSETTS VOLUME I GENERAL CONSIDERATIONS - DISEASES OF PENIS AND URETHRA -DISEASES OF SCROTUM AND TESTICLE- DISEASES OF PROSTATE AND SEMINAL VESICLES ILLUSTRATED WITH 368 ENGRAVINGS AND 7 PLATES UJ . o O I) (o't if;? COPYRIGHT LEA & FEBIGER 1918 DEDICATED TO WHOSE SKILL AND INTEGRITY AS A' SURGEON AND TO WHOSE WISDOM, GENTLENESS AND FORCE OF CHARACTER I DESIRE TO EXPRESS MY DEBT OF GRATITUDE CONTRIBUTORS. J. BELLINGER BARNEY, M.D., Genitourinary Surgeon to Out-Patients in the Massachusetts General Hospital ; Consulting Genito-urinary Surgeon to the United States Marine Hospital, Chelsea, Mass.; Assistant in Genito-urinary Surgery at the Harvard Medical School, Boston, Mass. B. S. BARRINGER, M.D., Instructor in Urology in the Cornell University Medical School; Assistant Urologist in the Bellevue Hospital; Assistant Surgeon in the Memorial Hospital, New York. EDWIN BEER, M.D., Visiting Surgeon to the Mt. Sinai Hospital; Assistant Visiting Surgeon to the Bellevue Hospital, New York. LEO BUERGER, M.A., M.D., Instructor in Clinical Surgery in the Columbia University; Associate Visiting Surgeon and Associate in Surgical Pathology in the Mt. Sinai Hospital, New York. B. C. CORBUS, M.D., Instructor of Genito-urinary Surgery in the Rush Medical College, Chicago, 111. WALTER J. DODD, M.D., Instructor in Roentgenology in the Harvard Medical School; Roentgenologist at the Massachusetts General Hospital, Boston, Mass. H. A. FOWLER, M.D., Professor of Genito-urinary Surgery in Howard University Medical School; Genito-urinary Surgeon to the New Emergency and Freedmen's Hospitals, Washington, D. C. EDWARD L. KEYES, JR., M.D., Professor of Urology in the Cornell University Medical School; Urologist to the Bellevue Hospital; Surgeon to St. Vincent's Hospital, New York. BRANSFORD LEWIS, M.D., B.Sc., F.A.C.S., Professor of Genito-urinary Surgery in the Medical Department of the St. Louis University; Genito-urinary Surgeon to St. John's Hospital; Con- sulting Genito-urinary Surgeon to the Frisco Railway Hospital, St. Louis, Mo. ALFRED T. OSGOOD, M.D., Professor of Genito-urinary Surgery in the New York University and Bellevue Hospital Medical College; Associate Urologist in the Bellevue Hospital; Consulting Genito-urinary Surgeon to the Presbyterian Hospital, New York. PAUL MONROE PILCHER, A.M., M.D., Consulting Surgeon to the Eastern Long Island Hospital; Surgeon at the Pilcher Private Hospital, Brooklyn, New York. WILLIAM C. QUINBY, M.D., Assistant in Surgery in the Harvard Medical School; Urologist to the Peter Bent Brigham Hospital, Boston, Mass. (vii) 3*2. % 74- viii >\TRIBUTORS HENRY L. SANFORD, M.D., Instructor in Surgery in the Medical Department of the Western Reserve University; Assistant Visiting Surgeon in the Department of Genito- urinary Surgery in the Lakeside Hospital; Visiting Surgeon to the City Hospital in charge of Genito-urinary Surgery, Cleveland, Ohio. GEORGE GILBERT SMITH, M.D., \~istant in Genito-urinary Surgery in the Harvard Graduate School; Genito- urinary Surgeon to Out-Patients in the Massachusetts General Hospital, Boston, Mass. A. RAYMOND STEVENS, M.D., Instructor in Genito-urinary Surgery in the New York University; Assistant Attending Surgeon, Urological Service, Bellevue Hospital; Chief of the Urological Clinic in the Presbyterian Hospital, New York. GEORGE W. WARREN, M.D., Urologist at the Lutheran Hospital of Manhattan; Associate Genito-urinary Surgeon to St. Mark's Hospital, New York. FRANCIS S. WATSON, M.D., Late Lecturer in Genito-urinary Surgery in the Harvard Medical School; Late Surgeon-in-Chief in the Boston City Hospital, Boston, Mass. HUGH HAMPTON YOUNG. M.D., Clinical Professor of Urology in the Johns Hopkins University; Director of the James Buchanan Brady Urological Institute; Visiting Urologist to the Johns Hopkins Hospital, Baltimore, Aid.; President of the Alaryland State Lunacy Commission. PREFACE. UROLOGY as a specialty is still young. It is not more than a genera- tion since there have been in America men of eminence who devoted themselves exclusively to this subject. The surgeons who contributed to the great System of Genito- urinary Surgery, by the late Prince A. Morrow, M.D., were none of them, properly speaking, specialists. They were general surgeons whose interests had attracted them to this branch of surgery but who still devoted most of their time to general work. The development of the specialty has been due to refinements in diagnosis and particularly to the introduction and development of the cystoscope, which though it was introduced by our foreign col- leagues, has been brought to its highest development in this country. It is today quite impossible for the general surgeon to master thor- oughly the details of urological diagnosis, and though he may be expert in the refinements of operative treatment, he of necessity fulfils the function of the therapeutist rather than that of the diagnostician. The development of the last generation has added much to the dig- nity of urology. More and more the care and management of venereal disease has fallen in the background. Syphilis with its many develop- ments has become almost a specialty in itself and largely separated from urology. It is for this reason that it has seemed wise to abandon the heretofore common joint consideration of genito-urinary diseases and syphilis and consider this disease only insofar as it effects the genito-urinary apparatus. This separation I believe is certain to become more rather than less marked. The relation of syphilis to genito-urinary diseases is purely incidental. Many of its develop- ments belong far more truly to the realm of the internist and the neurologist and its importance in the community justifies its being allowed to develop unhampered by its purely accidental relationship. An important reason for the production of this book at this time is that there have developed in the last generation in this country a large group of urologists, many of whom are authorities, not only (ix) X PREFACE here but in the world, on their particular subjects, and there can be no doubt that this specialty stands today in America at least on a par with the position which it has made for itself abroad. No longer must recourse be had to foreign clinics to learn the refinements of diagnosis and treatment, and it is owing to this group of men that they should find adequate expression here. All composite works have an inherent weakness in that they lack the smoothness and balance of works produced by a single author. There is always a certain lack of proportion; there is always obvious difference of opinion where two men approach the same subject from slightly different angles. This, while perhaps objectionable in a book intended solely and chiefly for the use of students, is not in fact objec- tionable for the use of the profession at large. Such a work as this is in fact a correlated set of monographs and makes up in vigor what it may lack in detail. I am not tempted, therefore, to make any apology for a certain degree of disjointedness, since I do not regard it as a cogent objection. Our intention has been to give articulate expression to American urology, and if in this we have been successful the object has been achieved. H. C. BOSTON, MASS. CONTENTS. SECTION I. CHAPTER I. HISTORICAL SKETCH OF GENITO-URINARY SURGERY IN AMERICA 17 BY F. S. WATSON, M.D. CHAPTER II. THE CYSTOSCOPE AND ITS USE 58 BY LEO BUERGER, M.A., M.D. CHAPTER III. METHODS OF DIAGNOSIS IN LESIONS OF THE URINARY TRACT 107 BY BRANSFORD LEWIS, M.D. CHAPTER IV. THE ROENTGENOLOGY OF THE URINARY TRACT .... 147 BY WALTER J. DODD, M.D. CHAPTER V. SYPHILIS OF THE GENITO-URINARY ORGANS 161 BY B. C. CORBUS, M.D. SECTION II. THE PENIS AND URETHRA. CHAPTER VI. ANATOMY, ANOMALIES AND INJURIES OF THE PENIS . . 193 BY H. A. FOWLER, M.D. (xi) xii CONTENTS CHAPTER VII. DISEASES OF THE PENIS 223 BY GEORGE W. WARREN, M.D. CHAPTER VIII. GENITAL ULCERS 240 BY B. C. CORBUS, M.D. CHAPTER IX. INFECTIONS OF THE URETHRA AND PROSTATE OTHER THAN TUBERCULOSIS . .' 286 BY B. S. BARRINGER, M.D. CHAPTER X. DISEASES OF THE URETHRA IN THE FEMALE 336 BY A. T. OSGOOD, M.D. CHAPTER XI. STRICTURE OF THE URETHRA 384 BY EDWARD L. KEYES, JR., M.D. SECTION III. DISEASES OF THE SCROTUM AND TESTICLE. CHAPTER XII. ANATOMY AND PHYSIOLOGY, MALFORMATIONS, INJURIES AND TORSION OF THE TESTICLE 417 BY GEORGE GILBERT SMITH, M.D. CHAPTER XIII. DISEASES OF THE SCROTUM 447 BY A. RAYMOND STEVENS, M.D. CHAPTER XIV. HYDROCELE, HEMATOCELE AND VARICOCELE 461 BY HENRY L. SANFORD, M.D. CONTENTS xill CHAPTER XV. INFECTIONS OF THE TESTICLE 485 BY J. BELLINGER BARNEY, M.D. CHAPTER XVI. GENITAL TUBERCULOSIS 498 BY J. DELLINGER BARNEY, M.D. CHAPTER XVII. TUMORS OF THE TESTICLE 534 BY EDWIN BEER, M.D. SECTION IV. THE PROSTATE AND SEMINAL VESICLES. CHAPTER XVIII. ANATOMY AND PHYSIOLOGY OF THE PROSTATE AND SEMINAL VESICLES 541 BY WM. C. QUINSY, M.D. CHAPTER XIX. PROSTATIC OBSTRUCTIONS 553 BY PAUL MONROE PILCHER, A.M., M.D. CHAPTER XX. CANCER OF THE PROSTATE '657 BY HUGH HAMPTON YOUNG, M.D. CHAPTER XXI. SARCOMA OF THE PROSTATE 720 BY HUGH HAMPTON YOUNG, M.D, CHAPTER XXII. CALCULUS DISEASE OF THE PROSTATE 723 BY HUGH HAMPTON YOUNG, M.D. MODERN UROLOGY. SECTION I. CHAPTER I. HISTORICAL SKETCH OF GENITO-URIXARY SURGERY IN AMERICA. BY F. S. WATSON, M.D. IT is but ten years since genito-urinary surgery, or, as it is usually called today, "urology," has become an established specialty of the medical profession in America. Before that time nearly all who con- tributed to the advance of knowledge of this branch of surgery were general surgeons. Previous to 1890 there were but three or four clinics in the country devoted to the care of patients having maladies of the genito-urinary tract. The first recognition of genito-urinary surgery in the title of a teacher of medicine in this country was that given to Dr. Van Buren, of New York, who, in 1877, held the position of professor of the principles of surgery, with diseases of the genito-urinary system, and clinical surgery in the Bellevue Hospital Medical College (Fig. 1). Prior to 1877 there was but one treatise in America dealing with the subjects which are included in this field. This was the work of the elder Gross, 11 of Philadelphia, the first edition of which appeared in 1851 and the last in 1876. It was the third work of its kind in the English language at that time, the other two being those of the dis- tinguished English surgeons, Brodie and Coulson. The contrast offered by the status of genito-urinary surgery today with that which has been indicated above may be seen by the large number of medical men who confine their attention exclusively to the study and care of the diseases of the genito-urinary system; by the recognition of the importance and growth of this special branch by medical schools, in many of which departments with professors at their heads, have been created for the teaching of it; by the organization of several associations for the purpose of discussing MU j2 (17) 18 SKETCH OF GENITO-URINARY SURGERY IX AMERICA subjects included in urology and of advancing our knowledge of them. Finally, there have been published in the last twenty-two years eleven exhaustive treatises upon diseases of the genito-urinary system, besides many important monographs concerning certain parts of it as compared with the two works which were produced in the course of the preceding forty years. FIG. 1. Doctor W. H. Van Buren, professor of the principles of surgery, with dis- eases of the genito-urinary system and clinical surgery, in Bellevue Hospital Medical College, New York. The data set forth above are evidence that in the wonderful progress which has characterized the growth of surgical science in the last half-century this branch of it has had its full share and kept pace with it. THE ORGANIZATION OF ASSOCIATIONS OF UROLOGISTS. The first association of American urologists, which bore the name of the American Association of Genito-urinary Surgeons, came into being at the home of Dr. Edward L. Keyes, of New York, on the THE ORGANIZATION OF ASSOCIATIONS OF UROLOGISTS 19 evening of October 16, 1886. When the organization of the new association was complete, the gentlemen who had been invited to meet there elected Dr. Keyes as its first president. The list of the original members is as follows: John H. Brinton, Philadelphia; John P. Bryson, St. Louis; Arthur T. Cabot, Boston; George Chismore, San Francisco; Algernon Garnett, Hot Springs; Francis B. Greenough, Boston; Gilbert C. Greenway, Hot Springs; Samuel W. Gross, Philadelphia; Moses Gunn, Chicago; William H. Kingston, Montreal; J. Xevins Hyde, Chicago; Edward L. Keyes, New York; Claudius Mastin, Mobile; Christian Fenger, Chicago; Prince A. Morrow, New York ; Fessenden N. Otis, New York; Roswell Park, Buffalo; Frank W. Rockwell, Brooklyn; Nicholas Senn, Chicago; Frederick Sturgis, New York; Robert W. Taylor, New York; J. William White, Philadelphia. This association was one of a number which were the component parts of a larger general body, to which the name Association of American Physicians and Surgeons was given, which was formed at about the same time and meets triennially in Washington in congress. The membership of this special branch of that body was limited to the number of thirty until recently, and it was the intention of its original members to admit into it only those who should have demonstrated unusual ability by their work and who were of high character. Within the next fourteen years the field of urology had been so greatly extended that a far larger number of men than hitherto had been drawn into it and devoted themselves exclusively to the study of the subjects which are included in it. Owing to this there was a demand for the formation of another and larger association, and in 1900 the American Urological Association w r as organized, and has been an active and useful body since that time. In 1913 a third association of urologists was formed as one branch of the American Medical Association. In 1907 a few distinguished French surgeons took steps for the organization of an international body of urologists, and in 1908 there 20 SKETCH OF GEN J TO-URINARY SURGERY IX AMERICA came into existence 1'Association Internationale d'Urologie. The most renowned specialist of his time, Professor Felix Guyon, was its first president. The officers of the first congress, which met September 30-October 3, 1908, in Paris, were: President, Professor J. Albarran. Vice Presidents: Professor Karl Posner, of Berlin; Dr. F. S. Watson, of Boston. Secretaire- general, Dr. E. Desnos, of Paris. Tresorier-general, Dr. O. Pasteau, of Paris. A committee composed of Drs. F. S. "Watson, of Boston (chairman), John Vanderpoel, of New York (secretary and delegate), and Hugh II. Young, of Baltimore, manages the affairs of the American branch of the international association. Full recognition of the share that American surgeons have had in contributing to the progress of surgical science in this branch of the profession was given by the members of other countries to America's representatives at the first congress. Summary of the More Important Steps of Progress in Genito-urinary Surgery in the Last Forty Years. It would seem appropriate to intro- duce a short statement of steps of progress at this point in the chapter, and therefore those which have occurred during the last forty years or so are briefly summarized below: 1. The revolutionizing of the method of treatment of vesical calculus^ by the crushing operation Litholapaxy. 2. Practically speaking, all the knowledge we possess with regard to the nature and treatment of vesical tumors. 3. The radical surgical treatment of the hypertrophied prostate by removal of the gland. 4. The introduction of the cystoscope and the great extension of knowledge secured by its use. 5. The introduction of the ureteral catheter and the opportunity supplied by it to study the functional capability of each kidney separately. 6. Numerous and valuable tests to determine the functional con- dition of the kidneys. 7. Radiography and the knowledge gained by it, more especially of renal and ureteral calculus, of certain conditions of the kidneys, of the renal pelvis and the ureter. 8. The devising and employment of numerous new surgical pro- cedures and contrivances, among which may be noted: The operations of nephrolithotomy, nephropexy, operations upon the ureters, partial resection of the bladder, total cystectomy, the removal of vesical diverticula, the operation of prostatectomy, plastic operations upon the penis, urethra, and bladder, the discoveries con- cerning the normal caliber of the male urethra, the operation of litholapaxy, etc. Each and all of these have resulted in great saving of human life and sparing of human suffering. BRIEF SKETCHES OF SOME OF THE MORE NOTABLE MEN IN THE FIELD OF UROLOGY. The group of surgeons in whose hands rested the early development of Urology in America, was composed of men of unusually high char- acter and distinction. Among them were some whose work has secured for them international recognition and fame, and has marked them as among the most distinguished medical men of their time. It has seemed to the writer that greater interest would be lent to this chapter if there should be included in it something of personal reference to a few of the most notable members among the contributors to Urology in this country, and he feels confident that in making the selection of them he will be in accord with the views of the greater number of his colleagues, and that his choice will meet with their approval. The following six surgeons are the subjects of the brief sketches that follow: SAMUEL 1). GROSS, Professor of Surgery in the Jefferson Medical College of Philadelphia. HENRY J. BIGELOW, Professor of Surgery in the Harvard Medical School of Boston. EDWARD L. KEYES, Professor of Genito-urinary Surgery, Syphil- ology and Dermatology in the Bellevue Hospital Medical College of Xew York. ARTHUR T. CABOT, Lecturer in Genito-urinary Surgery in the Harvard Medical School, and Fellow of the Corporation of Harvard University, Boston and Cambridge. JOHN P. BRYSON, of St. Louis. SAMUEL ALEXANDER, Professor of Genito-urinary Surgery in the Medical School of Cornell University of New York. Dr. Samuel D. Gross, of Philadelphia (Fig. 2). The elder Gross, as he was usually called, was one of the most distinguished citizens of Penn- sylvania as well as the most distinguished surgeon of that State of his or other times. He stood forth from his fellows by virtue of his rare personal attributes, his broad sense of humanity and w r arm heart, and because he bore the stamp of a master and leader of men. He was the most authoritative writer on surgical matters in America in his day, the most masterly teacher, one of the most finished operators, and was the highest type of medical practitioner. In character he was absolutely upright, of decided though just temper, and a man of great human kindness. In an admirable address upon Dr. Gross, delivered some years ago by another distinguished physician of Philadelphia, Dr. John Chalmers Da Costa, many interesting details concerning the elder Gross are recounted. The following quotations are taken from this address: "Dr. Gross was the most illustrious graduate of Jefferson Medical College. He was the most celebrated man who ever taught there. He was the leading surgical writer of his day. He was among the most notable of the great men of the nineteenth century who really 22 SKETCH OF GENITO-URINARY SURGERY IN AMERICA created the magnificent science of modern surgery, and many of his views influence us still. "Dr. Gross was tall, well made, and moved with a dignified gait. He had a noble head, a broad, high forehead, and snow-white hair. He was the embodiment of professional and professorial dignity, the beau ideal of a wise and learned surgeon. FIG. 2. Dr. Samuel D. Gross, professor of surgery in Jefferson Medical College, Philadelphia^ "As a teacher, Dr. Gross was magnificent. . . . He was animated, profoundly interested in what he was doing, absolutely convincing. " Now and then he liked to tell an anecdote in order to fix a point in the memory. He used to say : 'A mere statement is a nail driven into a board. A story bends the point of the nail and holds it fast in place.' "As an operator, Gross was calm, painstaking, careful. He was rapid, but not hurried, and always proceeded so that students might see and understand what he was doing." Two little incidents are told in the course of Dr. Da Costa's address which throw a side-light upon Dr. Gross's character, and are worthy to be recorded here: SKETCHES OF NOTABLE MEN IN THE FIELD OF UROLOGY 23 "On one occasion a patient was brought into the clinic and was found to require a small operation on the foot. Gross determined to do it at once. He directed one of the junior assistants to wash the foot. The young man declined to do so, saying that he had not come there to do such work. The professor called for soap and water and scrubbing brushes and did it himself. He dismissed the assistant from his place and told the class that there was nothing dirty in surgery." "On another occasion he walked into the out-patient department, where a junior assistant was speaking in a very imperative manner to one of the poor patients. Gross said: 'Young man, you speak as one having authority, but the basis of all authority here must be kindness.' ' Dr. Gross left an excellent record of lithotomy operations performed by him. It consisted in 69 operations of lateral lithotomy upon children, with but 2 deaths. He was a general surgeon, and not in any sense a specialist. Among his other writings, however, is that to which reference has already been made, which treats of the diseases of the urinary organs, and which was for many years the standard authority upon the subjects of which it treats. In the last edition of this work the elder Gross 11 had the assistance of his son, another surgeon of remarkable attributes, and in that book we find references to some of the subjects which we are wont to regard as being essentially of modern origin such, for example, as the removal of vesical tumors and partial prostatectomy. In the chapter on Yesical Tumors in the last edition the methods for their removal are described as avulsion, ligature of the pedicle and excision, curetting, and cutting off with snare, these being done through the dilated female urethra or through a perineal boutonniere in the male. In the chapter in which the surgical treatment of the hypertrophied prostate is spoken of the following passage occurs (p. 114): "When the obstruction to micturition is complete and the capacity of the bladder is greatly diminished, so that resort to the catheter becomes necessary every hour . . . the permanent retention of a tube in the bladder above the pubes may be advisable to avert impending death. . . . When the obstacle to the passage of urine depends upon enlargement of the middle lobe and the patient is in fair general health, I can see no objection to excising it. ... I should certainly prefer it, in such an event, to the formation of an artificial fistule above the pubes. In executing the operation the incisions would have to be the same as in the lateral operation of lithotomy, and the enlarged lobe could be easily cut away with probe-pointed bistoury or a pair of probe-pointed stout scissors." Dr. Gross's activity continued throughout a very long, most valuable, and distinguished career. He held the chair of surgery in no less than four medical colleges in America during his life. He wrote some 24 SKETCH OF GEN I TO-URINARY SURGERY IN AMERICA of the most important surgical works of his time. He exercised a strong and most beneficial influence upon the profession of this country, and was an example of all that is of the best and highest in the physician. Few men have been held in so high esteem as he. Few have better deserved to be thus regarded. Dr. Henry J. Bigelow, of Boston (Fig. 3). Of the men who added luster to this special field of surgery, Dr. Henry J. Bigelow, was in the eyes of many of his contemporaries the most striking figure and had the most dominant personality. FIG. 3. Dr. Henry J. Bigelow, professor of surgery, Harvard Medical School, Boston. His career was one of almost unexampled brilliancy and success. He made the most important single contribution to genito-urinary surgery that has been made in this field. He was vitally instrumental in causing the adoption by the profession of the greatest boon that has perhaps been given to man anesthesia by the inhalation of sulphuric ether which was first administered in public by Dr. Morton, of Boston, in 1846, in the amphitheater of the Massachusetts General Hospital to a patient of the elder Warren (Fig. 4). Dr. Bigelow was at that time a young man, just beginning his professional career. His promotion in the ranks of medical men was extraordinarily rapid. Two years after he had begun his practice he was appointed visiting surgeon to the Massachusetts General Hospital, and three years later was given the position of professor of surgery in the Medical School of Harvard University. Much of his medical education was received in France, and he possessed, whether by nature or by his early association with the French people, a large share of their finesse and mental acumen. His first contributions to surgical literature were published when he had been but two years in practice, and whatever he made public thereafter was of high quality and value. Dr. Bigelow was tall, handsome, graceful, of polished manners, a thorough man of the \vorld, and a patrician. FIG. 4. The first administration of ether in the old amphitheater of the Massa- chusetts General Hospital, 1846. If one recalls the gatherings of medical men of one or another of the international medical congresses, those who are most clearly stamped on the memory, among their members, are: Pasteur, Lister, Virchow, von Langenbeck, Bigelow, Sir William Macewen, Sir William MacCormac, and Sir James Paget. All of them truly remarkable, most of them great men. Bigelow was not the least among them. Bigelow's mental qualities were such as to place him in the class of men we call geniuses. The chief characteristic of his mind was that of seizing with extraordinary rapidity and in unerring fashion upon the vital point of the problem presented to him and of remaining absorbed in it until he had established it to his satisfaction in all its bearings. One might liken the working of his mind to the swift plunge of a fish haw r k when it drops into the water and fixes its talons in the submerged prey. As an operator his coordination of mind and hand were more perfect, 26 SKETCH OF GENITO-URIXARY SURGERY IN AMERICA the delicacy, deftness, and precision of movement more remarkable than it has ever been the fortune of the writer to see exhibited by any other surgeon. He added grace and finish to all his work. His hands never made groping motions, but went direct to and from the objects they sought with swift, single movements. His sense of touch was so keen that it often gave him the power to make almost instantaneous and correct diagnoses which other men failed of doing. As a teacher he was equally remarkable. The value of his lectures was enhanced by his power of graphic, often dramatic and epigram- matic expression, and by a tendency, which may have been in part unconsciously exercised, in part done with intent, to stage in the most telling manner if one can apply such a phrase to the surgical amphitheater of a hospital the scene of his operations and teaching. One little example of his way of summing up a part of a subject may be given as an illustration of the indelible impression which he so often made upon his students. In a lecture upon dislocations of the joints of the arm he concluded his remarks thus : " A great many pages have been written and many illustrations have been made to describe and to represent numerous complicated bandages, apparatuses, or whatever, employed for the purpose of retaining the arm in its proper position after reduction of a dislocation of the shoulder-joint has been effected. The whole thing consists in this: pad in the axilla, elbow to the side, arm in a sling. Good morning, gentlemen." He would have been as successful in diplomacy, or in a number of other walks of life, had he followed any one of them, as he was in his chosen profession. He was many-sided and his mind reached out in many directions. As a consequence he became interested from time to time in a number of subjects other than those included in his professional work. Among these outside excursions if one may so call them may be mentioned : fancy breeds of pigeons, gems, the restoration of pictures, soil ferti- lizers, the facial expression of the monkey. " Another anecdote of Dr. Bigelow may be appropriately told here. He was walking through the Boston Art Museum with the curator of the institution. As they passed a small repository in which some of the valuables of the museum were placed for safe keeping, the doctor's eye fell upon its lock. He stopped, and after contemplating it for a moment, turned to the curator and told him that he did not think the lock was safe. The curator did not agree with him. " Very well," said Bigelow, "I'll bet you that I can come down here in the course of the next few days and pick that lock in ten minutes." The wager was taken. A day or two later a visitor calling upon the doctor discovered him seated at his desk with a basket filled with all manner of locks beside him, while locks of various patterns were scattered freely about the room. "What on earth are you doing?" asked the visitor. "Oh," replied the Doctor, "I am merely getting ready to pick one of the locks at the Art Museum." In the course of the next four days he came to the museum and SKETCHES OF NOTABLE MEN IN THE FIELD OF UROLOGY 27 picked the lock in two minutes in the presence of the curator. The incident illustrates one of the doctor's mental qualities which was that of becoming absolutely absorbed in the study of a problem until he had reached the solution of it. After having done so he would frequently cast the whole matter aside as though it had never interested him at all. Sometimes he turned over the finishing of the detail of his problem to another, after he had solved the chief point of interest in it; yet no one ever carried detail to more complete and finished consummation than he, if he desired to do so. He was the author of the most important single contribution that has been made to the field of genito-urinary surgery. This was his operation known as litholapaxy, of which more extended description will be given farther on in this chapter. On entering the surgical amphitheater Bigelow would sometimes find a colleague who had encountered a check in the course of the performance of an operation, such, for example, as that which is offered at times by the difficulty of finding the posterior end of a ruptured or tightly strictured urethra. Bigelow would watch his colleague's efforts, for a moment, then say to him, "Want to let me have a try at that?" Assent being given, he would take the instru- ment in his hand, and, presto! the thing was done in one movement. Nature had gifted him with rare attributes; he developed many of them to a high degree of perfection. Possessed of a mind that was constant in its inquiry into the nature of various phenomena, gifted with clear vision and accurate powers of observation, these qualities being enhanced by a striking power of expression, by an impressive bearing and dominating personality, he stands out in one's memory as the most remarkable figure in the profession of medicine in this country in his day. Edward L. Keyes, of New York (Fig. 5). One of the admirers and followers of the teachings of Dr. Keyes placed in a treatise which he published, many years after first meeting him, the following inscription as a dedication to the volume: To Edward L. Keyes surgeon, author, teacher, and master in his field of the profession the author dedicates this work as a token of his respect and esteem. Far too brief a summary to address to one of the foremost masters of his day in the- medical profession in America. Dr. Keyes won a conspicuous place in surgery, and especially in urology, at a very early period of his career. He first became known to the medical public as the junior author of a work on Genito-urinary Diseases and Syphilis, the senior author of which was Dr. Van Buren, of New York. This work and its succeeding edition, the later ones of which have been the work of the younger Keyes, has held its place as the most popular text-book in this field of surgery from 1874 to the present time. The chapters on Calculus in the first edition were the work of Dr. Van Buren, the rest of the volume being entirely written by Keyes. In a private letter to the writer, Dr. Keyes says that Dr. 28 SKETCH OF GEN 1 TO-URINARY SURGERY IN AMERICA Van Buren revised the whole work, and speaks in terms of highest praise and with warm gratitude of his own indebtedness to his senior associate who was a widely known surgeon in New York. Dr. Keyes had scarcely started in the practice of his profession when he undertook this work, and it is a great tribute to his powers. The work is remarkable for its direct, terse, lucid style and for the practical manner in which the subjects are treated, thus giving to it an especial value to the students of medicine. FIG. 5. Dr. Edward L. Keyes, professor of genito-urinary surgery, syphilography, and dermatology in the Bellevue Hospital Medical College, New York. For more than twenty-five years Dr. Keyes was the highest authority in what we call an "all-round" sense, in this country, in the field of urology. He was not, however, a specialist, but a general surgeon. Dr. Keyes was a teacher of rare power, and the writer well remembers the strong impression made upon him by his teaching when he had the good fortune to hear his lectures during a winter passed in New York many years ago. He presented his subject in a terse, forceful, and practical manner, and caught and absolutely held the attention of his students as few teachers are able to do. He was masterful, a natural leader of men, filled with a super- SKETCHES OF XOTABLE ME\ IX THE FIELD OF abundant energy, capable of doing an enormous amount of work day in and day out. One recognized in Dr. Keyes at first glance the integrity, directness, and honesty of the man, and saw a look of determination that was an index of character that must have meant much in the building of - iccessful career. His influence and his work have been of great value to surgical science and to his col nd have won for him universal respect and esteem most well deserved. FIG. 6. Dr. Arthur T. Cabot, instructor in penito-urinary sureery. Harvard Medical Sehool, Fellow of the Corporation of Harvard University, Boston. Dr. Arthur T. Cabot, of Boston (Y\g. (>>. and Dr. John P. Bryson, of St. Louis.- One instinctively associates these t\vo men in one's memory because of their having possessed certain sterling and high qualities in common and because of the nobility and manliness of their char- acters. No one possessing mean, dishonest, or underhand traits of human nature, it may be believed, ever came into the presence of either without being conscious of a rebuke to those qualities. Both stood for what they believed to be right, and were uncompromising in advocating it and in condemning what they believed to be wrong. 30 SKETCH OF GEN I TO-URINARY SURGERY IN AMERICA The value of their service was greater by virtue of their character as men rather than for the originality of the work which they con- tributed to this field of the profession. Few, if any, medical men exercised a stronger influence for good in their profession than these two. With Dr. Cabot its effect reached far beyond his profession, indeed, for he rendered distinguished service in other fields of public work as well. His most notable services of this kind were those rendered by him in his positions as a member of the corporation of Harvard University, as trustee of the Boston Art Museum, and as chairman of the board that was organized to limit the spread of tuberculosis in the United States. In these offices as well as in those of teacher in the medical school of Harvard University for several years, as visiting surgeon to the Massachusetts General Hospital, and as one of the best practitioners of medicine in his town, he rendered great public service, and the value of all of it was enhanced by the fact of his being a thorough gentleman and high-minded man. The first recognition of urology as a special department of the medical profession given by Harvard University was in its appoint- ment of Dr. Cabot as an instructor in genito-urinary surgery in the Medical School of Harvard in the year 1880. As an operator, Dr. Cabot was careful, deliberate, calm, thorough; as a surgeon, he was wise and conscientious; as a man, humane, upright, straightforward and honorable. His temper was sharp but just. Apart from his profession and the public works already mentioned, he displayed unusual capabilities in his diversions, for he was as an amateur an uncommonly good painter of pictures in water color, and a very keen and admirable sportsman. He was one of the best shots in the community. He was fond of the country and of animals, a good cross-country rider, and a polo player. These were his principal diversions, and he enjoyed them and exhibited in them a capability of character similar to that displayed in his professional work. John P. Bryson, of St. Louis. An exponent of manliness and honesty! These are the qualities of which one first thinks when recalling Dr. Bryson and his work. The first of them was put to the test, and doubtless fortified, when, at the age of seventeen, as a private soldier in the army of the South, during the Civil War in America, he was in the thickest of the fighting in the two days' battle at Gettysburg. It was a rough initiation to life that he received on that field, but it stood him in good stead throughout a most useful and valuable life, in which all his efforts were directed to relieving human suffering. Reliable, strong, and honorable always dealing telling blows for good causes, and always ranging himself against all that was less worthy in human nature, warm of heart and of tender humanity. He, too, exercised a strong and beneficent influence in his profession. Dr. Bryson was a general surgeon, though in the later years of his life he was identified chiefly with the field of genito-urinary surgery, and SKETCHES OF NOTABLE MEN IN THE FIELD OF UROLOGY 31 for a number of years contributed to it work of high, though not strikingly original, character. Dr. Samuel Alexander, of New York (Fig. 7). A man possessed essentially of the temperament and nature of a genius, one who unaided by the physical traits that often play so important a part in the effect produced by certain men, none the less dominated in remarkable degree those who came in contact with him. His nature, his manner and speech may be designated without exaggeration as fervid. His enthusiasm for his work, for his teaching, in his researches, was hot and seemingly FIG. 7. Dr. Samuel Alexander. inexhaustible; moreover it was contagious, and owing to this he was a teacher who, so to speak, gripped his students by the throat. He held them in closest attention and inspired them with his own en- thusiasm more perhaps than any other teacher of his day. As a lecturer he was rapid of speech, vitalized to the finger-tips, lost in his subject, oblivious of self; intent only on lodging the information which he desired to impart in the minds of his listeners, and succeeding in so doing as it is given to but few men to succeed. Dr. Alexander was not a general surgeon, and is the only one of 32 SKETCH OF GEN I TO-URINARY SURGERY IN AMERICA those of whom these short sketches have been written who was definitely a specialist, for he confined his work entirely to genito- urinary surgery and syphilis. His mind was of a distinctly original quality, although the actual original work that he produced was not so much in amount as he doubtless would have contributed but for his early death, and being hampered for several years by serious illness. His contributions to genito-urinary surgery were, however, all of them, of distinctive character, and all of them marked by original expression and thought. They were always thorough, carefully pre- pared, beautifully illustrated, and presented without thought of any personal advantage that might be derived from them. He was more notable as a teacher than as an operator, though he did not lack skill in that capacity. It was doubtless true of the other members of the association, to which the writer and Alexander both belonged, that they looked forward, as he did, to meeting Alexander at each of its annual gatherings with greater pleasure than was anticipated from any other feature of them. He was an excellent fighter, hit hard and straight, never skirmished for a technical advantage in a discussion, but fought vigorously to establish his views, always in the open. It was delightful to become involved in a good hot discussion with Sam; Alexander. The following sketch of Dr. Francis S. Watson is written by Dr. Edward L. Keyes, Jr., of New York, at the request of the editor of this work, who desires to include its subject in this chapter: "Among the circle of men who have maintained the high standard of urology in Boston during the past forty years, Dr. Francis S. Watson is unique (Fig. 8). " As a pupil of Bigelow, he inherited the best traditions. As surgeon of the Boston City Hospital, he cultivated his inheritance. As the author of many monographs upon urological topics, he evinces his lucidity of thought and keenness of observation. But in his case, as in that of all memorable men, the peculiar force of his personality is what stands foremost in the memory of those who know him. To say that his wit is as lucid as his intelligence, or that his tireless energy drives both to incessant display, suggests only the most salient of his characteristics, mellowed as these are by a great gentleness and intense feeling for art and music, and above all a whole-hearted and generous love and loyalty for his fellows. "As an informal teacher (for we can speak with no knowledge of his work with the undergraduates) at medical societies and elsewhere such a personality scintillates with suggestions; even more perhaps in its obiter dicta than in the direct topic. This casual brilliancy is permanently illustrated in that work which he would be the last to wish placed at the head of his achievements, a three-act travesty on medical foibles and New England rusticity, entitled 'A Day with the Specialists.' " But to turn from the gay to the grave, his important contributions to medical literature are numerous. SKETCHES OF NOTABLE MEN IN THE FIELD OF UROLOGY 33 "In 1888 he published a volume entitled Operative Treatment of the Hypertrophied Prostate, which both by its textual and its pictorial illustrations of pathological conditions has been the foundation for much subsequent work. "He performed his first perineal prostatectomy in the following year. This was apparently the first time that the operation was performed in America. FIG. 8. Dr. Francis S. Watson, lecturer on genito-urinary surgery, Harvard Medical School, Boston. "Among his more recent contributions we may mention his original method of nephropexy, described in the Boston Medical and Surgical Journal, July, 1896. "An exhaustive study of Subparietal Injuries of the Kidney, Boston Medical and Surgical Journal, July 9 et seq., 1903. "Operative Treatment of the Hypertrophied Prostate (Annals of Surgery, June, 1904) and his contributions to the subject of vesical tumors, Annals of Surgery, 1905 and 1907, reviewing the disastrous surgical history of this condition, and urging bilateral preliminary nephrostomy followed by total cystectomy for certain cases of malig- nant neoplasms. "In 1909 he urged unilateral nephrolithotomy in the treatment of M tJ I 3 34 SKETCH OF GEN I TO-URINARY SURGERY IX AMERICA certain cases of calculous anuria before the International Urological Congress, of which he has been vice-president since the inception of the International Association of Urology, and the bilateral operation in a small class of other cases of the same condition. "The summing up of Dr. Watson's literary contributions and surgical experience is a two-volume work on genito-urinary surgery, written with the assistance of Dr. John H. Cunningham, Jr., and published by Lea & Febiger in 1908. This will long stand as a monument to the genius of its author." THE EVOLUTION OF UROLOGY IN AMERICA. The year 1851 is selected as that in which the specialty of genito- urinary surgery had its birth in this country, because it was in that year that the elder Gross published his work dealing with the maladies of the urinary organs. This was the first work of this character in America, and the third one in the English language, the other two being the treatises of the noted English surgeons, Brodie and Coulson. From 1851 until 1877 the treatise of Gross was the only one available to students of this special branch of surgery in this country. It had great literary value and, so far as it went, was a full and thorough exposition of the subjects of which it treated. It held its place in medical literature and in the world of medical students until the year 1876, when its last edition appeared. In 1877 the first edition of its rival and successor, the work of Van Buren and Keyes, already referred to, was published, and before long superseded its predecessor. Mention has been made of the comparatively large number of exhaustive treatises upon genito-urinary surgery and venereal diseases which have appeared since 1879, and they may be appropriately named at this point as follows: 1880. Otis: Stricture of the Urethra. 1893. P. A. Morrow: System of Genito-urinary Diseases and Syphilis. 1895. White and Martin: Genito-urinary and Venereal Diseases. 1898. Bangs and Hardaway: American Text-book of Genito- urinary Diseases, etc. 1900. Fuller: Diseases of the Genito-urinary System. 1902. Morton: Genito-urinary Diseases and Syphilis. 1905. Deaver: Monograph on the Prostate. 1907. Greene and Brooks: Diseases of the Genito-urinary Organs and Kidneys. 1908. Watson and Cunningham: Diseases and Surgery of the Genito-u rinary System . 1910. New Edition of Keyes. Written by Edward L. Keyes, Jr. 1910. Part of Keen's Surgery on Genito-urinary Diseases. 1912. Guiteras: Urology. 1912. Garceau: Monograph on Tumors of the Kidney. 1913. Chetwood: Practice of Urology. CONTRIBUTIONS OF AMERICAN SURGEONS TO UROLOGY 35 Translation by Bonney of the work of Casper, of Berlin, 1910. The work of Bumstead and of Taylor, of New York, are not included in this list, as they deal only with venereal disease. In general, it may be said that all of these works are of high merit and of great value. In addition to them there have been published many important and admirable monographs upon special subjects included in the field of urology. CONTRIBUTIONS OF AMERICAN SURGEONS TO UROLOGY. The members of the medical profession whose works are cited in this sketch are, with three or four exceptions, those who are no longer living or who have retired from active participation in the work of their profession. The author of this chapter recognizes that in thus limiting its personal history he does not render full justice to the part that American sur- geons have taken in the advancement of knowledge of Genito-urinary Surgery, but he has been advised to follow this plan by those having the publication in hand, and as he thinks, wisely advised. He trusts to be excused for having made the obvious omissions of important work done by his colleagues who are still among the active workers in the profession, and believes that they will readily forgive his failure to give them mention. Among those whose works receive notice below there are three still living: Drs. W. H. S. Gouley and Edward L. Keyes, Jr., of New York, and Francis S. Watson, of Boston. The names of those who have died are as follows: John Ashhurst, Jr., Philadelphia. Samuel Alexander, New York. Henry J. Bigelow, Boston. L. Bolton Bangs, New York. Tilden Browne, New York. Dr. Byford, Chicago. John P. Bryson, St. Louis. Arthur T. Cabot, Boston. George Chismore, San Francisco. George M. Edebohls, New York. Dr. Gilmore. William Ingalls, Boston. A. Jackson, Chicago. Fessenden N. Otis, New York. Dr. Peasely, New York. Dr. Pyle. Dr. Peters, New York. Alex. Stein, New York. Robert Taylor, New York. Robert Weir, New York. J. William W'hite, Philadelphia. 36 SKETCH OF GEN I TO-URINARY SURGERY IN AMERICA RENAL SURGERY IN AMERICA. Nephrectomy. Transperitoneal. The first performance of the operation of nephrectomy is credited by Albarran to the American surgeon Walcott in 1861. The operation was transperitoneal. The patient was a woman, aged fifty-eight years. She had cancer of the kidney. She succumbed on the fifteenth day following the operation. Peasely. The second nephrectomy, also a transperitoneal operation, was done by an American surgeon in 1868. The patient was believed to have an ovarian tumor, and the operation was undertaken under that impression. The tumor was found to have its seat in the kidney, and that organ was removed, together with the neoplasm. This patient also died. Gilmore performed, in 1870, one of the earliest nephrectomies, and his patient recovered. This, too, was a transperitoneal operation. The patient was a woman who was five months pregnant. Peters, of New York, in 1872, did another nephrectomy, the patient in this case dying subsequent to it. Byford, of Chicago, in 1878, performed the first successful nephrec- tomy in a case of cancer of the kidney. This operation was also a transperitoneal one. The patient recovered. The first lumbar nephrectomy was, as is well known, done by Simon, of Heidelburg, in 1869. The patient recovered. The same operation was done by the same surgeon again in 1871. This patient died. The first nephrectomy in England was done by Durham in 1872. The first one in France by Le Fort in 1880. Nephrolithotomy. The first performance of the operation of nephrolithotomy is of uncertain date. Dr. Desnos, of Paris, in a recent and admirable historical chapter written as a part of the Encyclopedic Francaise d' Urologie, quotes from the Memoire of Hevin, in which it is stated that this operation was performed, in 1633, by a surgeon named Domonique Marchettis, the patient being an English consul. The patient insisted upon having the operation done. The procedure was carried out in two stages, the kidney being exposed on one day and entered on the second one. Three small calculi were extracted from its interior and a fourth one was passed spontaneously into the dressings later. The latter is said to have been the size of a date stone. The patient suffered the inconvenience of having a permanent renal fistula, but recovered. A similar operation is said to have been done by Lafite in 1734. The operation thereafter was condemned and passed out of sight for more than one hundred years. In modern times one of the first, if not the first, surgeon to do this was an American. William Ingalls, of Boston. Dr. Ingalls, a member of the surgical staff of the Boston City Hospital, removed a large calculus from one of the kidneys of a woman by a lumbar operation which he had deliber- RENAL SURGERY IN AMERICA 37 ately planned. The operation was done October 8, 1872. It was not reported until 1882. 13 In consequence of this delay the English surgeon Mr. Morris received the credit of being the originator of the procedure in modern times. He published his first cases in 1881. Nephropexy. The operation of attaching the kidney to the loin in cases in which the organ has an abnormal mobility and more or less serious symptoms are being produced by it originated with the German surgeon Hahn in 1881. Hahn's operation was inadequate, and it was not until the following year, 1882, that Bassini for the first time passed sutures through the capsula vera of the kidney for the purpose of fixing it to the posterior wall of the abdomen. FIG. 9. Edebohls's modification of the operation of nephropexy. Cunningham.) (Watson and Robert Weir, of New York (1882). The method employed by Bassini was also carried out by Weir, of New York, in the same year (1882) . This operation, so far as we can learn, was the first nephropexy performed in America. Numerous modifications of the technic of the operation have been introduced since that time. Among them are two by American surgeons. The first of these is that of Edebohls, of New York (Fig. 9). In this method of doing the operation the kidney is decapsulated and the sutures are applied on either side of the organ through the fibrous capsule which they traverse twice in order to give a more firm holding ground for the stitches. 38 SKETCH OF GEN I TO-URINARY SURGERY IN AMERICA F. S. Watson, of Boston (Fig. 10). In the method devised by Watson the sutures are passed, four in number, through the substance of the kidney, two in the long, and two in the tran s verse axis of the organ. The capsule is split through the length of the posterior border of the kidney. FIG. 10. Watson's modification of the operation of nephropexy. Cunningham.) (Watson and Bilateral NephroUthotomy at one Sitting in Certain Cases of Obstructive Anuria. F. S. Watson, of Boston, at the first Congress of I'Association Internationale d'Urologie, held in Paris, in October, 1908, made, as one of the reporters en the subject of anuria, a plea for the employ- ment of bilateral nephrolithotomy, or ureterolithotomy, at one sitting in certain cases of calculous anuria. The communication forms a part of the reports of that congress issued in Paris during the same year. Edward L. Keyes, of New York (New York Medical Journal, June 16, 1894). In this number of the journal is a valuable communi- cation made by Dr. Edward L. Keyes, of New r York, on the subject of nephritis in its surgical aspects. SURGERY OF THE BLADDER 39 SURGERY OF THE BLADDER. Vesical Calculus. Henry J. Bigelow. 3 Litholapaxy, 1878. The most noticeable achievement of an American surgeon in the field of urology is that to which its author gave the name of litholapaxy, intending thereby to indicate an operation for crushing vesical calculus and entirely removing it from the bladder in one and the same sitting. The first account of Dr. Bigelow's method was published in the American Journal of the Medical Sciences in 1878. Dr. Bigelow sub- sequently demonstrated it before the International Medical Congress in London in 1881. Before the introduction of the operation of litholapaxy the method employed when treating vesical calculus by the crushing operation of lithotrity was to crush the calculus for as short a time as possible and to leave the resulting fragments to be passed out by the natural acts of micturition. The calculus was finally disposed of by a series of successive crushings varying in number according to the size and hardness of the stone. Five minutes was the longest time which was thought to be safe to continue the crushing procedure at any one sitting. The operative mortality at the best as, for example, that which occurred in the hands of the most skilful lithotritist of his day, Sir Henry Thompson, of London was nearly 6 per cent., w r hile in the hands of less adroit operators it was nearly 10 per cent., and in the case of patients having prostatic obstructive conditions it rose to 15 per cent., and even higher. Bigelow based his operation of litholapaxy upon the belief that the bladder would tolerate far better even the prolonged manipulations in it of smooth round-ended instruments than the irritation produced by fragments of calculus left in it at a series of successive sittings. If he w r ere correct in this supposition, and if the means could be devised for emptying the bladder entirely of fragments immediately the stone had been crushed, the operative mortality should be greatly lessened. There remained, in order to test his theory, therefore, the devising of the instruments and apparatus by which these things could be accomplished. The discoveries of Otis already described, with respect to the large size of the normal male urethra, had opened the way for Bigelow to devise instruments of greater power for the crushing of vesical calculi and for the making of tubes to evacuate the fragments of stone rapidly and effectually. Availing himself of the discoveries of Otis, Bigelow devised a lithotrite of novel form and greater power than was pos- sessed by the instruments then in use, and contrived an apparatus of most cleverly planned and beautifully executed character for evacu- ating the fragments. The special features of Bigelow's lithotrite are as fellows: (1) The form given to the tip of the female blade which is such as to permit it to pass over obstructions offered by an hypertrophied prostate more 40 SKETCH OF GENITO-URINARY SURGERY IN AMERICA I FIG. 11. Bigelow'a evacuating apparatus. (Watson and Cunningham.) FIG. 12. Jaws of Dr. Bigelow's lithotrite. (Watson and Cunningham.) SURGERY OF THE BLADDER 41 readily than any other. (2) The form given to the distal or crushing end of the male blade of the instrument, which is that of a series of FIG. 13. Handle of Bigelow's lithotrite, showing locking mechanism by which the blades are locked upon the stone or released from it. diverging planes which prevent the blades from becoming clogged with the debris of the calculus during the crushing of it (Fig. 12). (3) The FIG. 14. Bigelow'a evacuating apparatus withdrawing fragments of calculus from the bladder. (Watson and Cunningham.) mechanism of the handle of the instrument which is such as to avoid the necessity of changing the operator's hands when he has caught the 42 SKETCH OF GEM TO-URINARY SURGERY IX AMERICA calculus and desires to crush it (Fig 13). This was necessary with the previously constructed lithotrites, and the innovation of Bigelow in this detail was of great value. (4) Greater strength given to the blades; this is such as to make it impossible to break them, no matter how hard they are screwed together upon the stone. The features of the evacuating apparatus are the following: (1) The placing of the glass trap below the bulb and in such a way that the fragments of the stone which have once entered it cannot be washed out of it again by the returning current of water into the bladder. (2) The large caliber of the tubes and the location and large size of the eyes of them at their distal ends. Also the raised lip on the posterior end of the eye which prevents the slipping past it of the fragments which are drawn toward it by the current of water that sets them in motion. (3) The straight as well as the curved form of tube, the former permitting, when it can be introduced into the bladder, a more rapid evacuation of the fragments than does the curved tube. The caliber of the tubes is 28 and 30 of the Charriere scale (Figs. 1 1 and 14). A comparatively short time of its employment was enough to make abundantly clear that the conception of the author of this new opera- tion had been absolutely correct. The operative mortality grew at once markedly less with its adoption and the abandonment of the former practice of successive sittings. A glance at the records of this operation and at those of the method of performing lithotrity previously and also of the results of the cutting operations at once demonstrates the superiority of litholapaxy, even in the case of children who were the most favorable subjects for the lateral lithotomy operation. Two series of American surgeons may be taken as examples of this fact. They are those of Drs. Edward L. Keyes and of Arthur T. Cabot. Edward L. Keyes's series of litholapaxy operations: Number of cases, 157. Operative deaths, 7. Recurrences, 25. In none of the fatal cases was the patient less than fifty-eight years of age. Arthur T. Cabot's series of litholapaxy operations: Number of cases, 179. Operative mortality, 4.3 per cent. Recurrences, 21. In none of the fatal cases was the age of the patient less than sixty years. In four of them the ages of the patients were eighty-four, seventy, seventy, and seventy years respectively. A glance at the large number of cases and the results of the different methods of operation will give a just idea of the relative value of Bigelow's operation as compared with other methods. Operative mortality of lithotrity prior to the introduction of Bigelow's operation of litholapaxy: In elderly people, from 15 per cent, to 20 per cent. In patients aged less than fifty years, about 9 per cent, to 10 per cent. The following statistics are taken from Watson and Cunningham's Diseases and Surgery of the Genito-urinary System, 1908. Litholapaxy Operations. Number of cases, 17,736. Operative mor- tality, 2.4 per cent. Patients of all ages. In 2518 patients under fifteen years of age the operative mortality was 1.7 per cent. In 719 SURGERY OF THE BLADDER 43 patients between fifteen and fifty years of age it was 1.6 per cent. In 2395 patients over fifty years of age it was 4.04 per cent. Lateral Lithotomy. Number of cases, 11,963. Irrespective of age, operative mortality was 9.8 per cent. In 94 patients over fifty years of age it was 20.2 per cent. Suprapitbic Lithotomy.- Number of cases, 3302. Operative mor- tality, irrespective of age, was 13.2 per cent. In 378 patients over fifty years of age it was 25.4 per cent. These figures speak too strongly of the value of Bigelow's method of treatment to require comment. There are several factors, however, which militate against the employment of litholapaxy today which did not oppose its use at the time of its introduction. These are: (1) The marked lessening of the operative mortality of the suprapubic lithotomy operation as com- pared with former times. (2) The establishment of the operations of total prostatectomy which allow the surgeon to remove the stone from the bladder when there is one present at the same time that the prostate is taken away, and thereby there is secured the freedom of obstruction to the escape of urine and also the freedom from recurrence of calculus. Finally, there is the fact that many surgeons cannot or do not acquire the delicacy and skill which are requisite for the success- ful performance of litholapaxy. Transperitoneal Partial Resection of the Bladder. Dr. Frank Harrington, of Boston. This method of treatment in certain cases of disease of the bladder was first practised by Rydygier in 1887. In 1893 Harrington first performed the operation in America. It was but little employed until revived by the Mayos and Judd in the famous clinic of the Mayo brothers in Rochester, who have used the procedure in a number of cases of vesical tumors, and with marked success. Vesical Tumors. The date of the first operation performed for the removal of a vesical tumor is somewhat uncertain. The earliest mention that has been found of such an operation is that performed in 1635 by Covillard. 4 In this case it is doubtful whether or not the tumor removed was a lobe of an hypertrophied prostate. In 1750 Warner removed through the female urethra a large polyp of the bladder. The patient made a perfect recovery. In 1890 the most complete exposition of the subject of vesical tumors that has up to the present time been published was written by the most brilliant surgeon of France in the field of genito-urinary surgery, Professor Albarran, in his classic work, Tumeurs de la Vessie. In America the first important monograph is that published by: Alex. W. Stein, of New York. 20 In this volume there are set forth among much else that is of interest the cases of vesical tumor in which operations had been done prior to that time. Watsoji, of Boston, 1884. 24 Watson published an article on the subject of vesical tumors in which he added 10 cases to those collected by Stein and reported 1 in which he had operated through the perineal boutonniere. 44 SKETCH OF GENITO-VRINARY SURGERY IX AMERICA The earliest operations published in America were the following: A. R. Jackson, of Chicago. 14 Ashhurst, of Philadelphia. 2 Ransohoff, of Cincinnati. Watson, of Boston. 25 Jackson's case has some unusual features, and seems worthy of special notice. While visiting a female patient one day he found a fleshy mass protruding from her urethra. As he was examining it it was withdrawn into the bladder. Jackson directed the patient's husband to watch for its reappearance, and told him should it again be protruded to seize it with a pair of forceps and hold it until he the doctor should arrive. During the absence of the surgeon the tumor was again pushed into view through the urethra. The husband in his eagerness to observe the doctor's orders seized upon it too forcibly and tore a part of it off. The piece that was thus removed was of the size and shape of the forefinger. Subsequently the surgeon arrived and dilated the urethra. This enabled him to reach and extract, by avulsion, a second portion of a fleshy mass eight inches in length and of considerable thickness. The patient made an excellent recovery, was freed from her former symp- toms, and reported that there had been no return of them one year after the performance of the operation. Total Cystectomy (1887-1915). The first operation for total removal of the urinary bladder was performed in 1887 by Bardenheuer. The patient did not survive. In 1888 the first successful operation of the kind was done by Pawfik, of Vienna, in the case of a woman having vesical carcinoma. This patient survived and was free from recurrence during the ensuing fifteen years or more. From 1887 to the present time 1915 there have been approxi- mately 80 total cystectomies reported in cases of vesical tumor. The operative mortality of this series is about 40.5 per cent. The operative mortality prior to 1909 was over 50 per cent. The number of cases then reported was approximately 60. In the last twenty operations performed since then there has been a striking diminution of the operative mortality, which is sufficient to have reduced it for the total number of the cases to 40.5 per cent, in place of 50 per cent. Ureteral Implantation. Until 1895 the ureters were either implanted in the rectum, in the vagina, or abandoned in the wound; and with but two or three exceptions this was the practice until 1905. In 1895 Vasilief seems to have been the first surgeon to make an implantation of the ureters to the skin in connection with the operation of total cystectomy. This patient recovered. In 1905 Watson, of Boston, 23 proposed a radical change in the method of performing total cystectomy in cases of vesical tumor. Previous to that time it was almost the invariable custom to implant the ureters in one or the other of the locations mentioned above, and to do this at the same time as that at which the bladder was removed. Study of the causes of the remarkably high mortality attending this SURGERY OF THE BLADDER 45 FIG. 15. Cup-shaped hard-rubber shield of Watson's apparatus for permanent renal drainage through the loin. (Wataon and Cunningham.) 46 SKETCH OF GEN I TO-URINARY SURGERY IN AMERICA operation led Watson to the conviction that it was due to three factors, these being: (1) Shock produced by the prolongation of the operation, rendered necessary if the urine was to be diverted at the same time at which the bladder was removed. (2) Renal infection due chiefly to implanting the ureters in the bowel or vagina, but though in far less degree, liable to be invited if the ureters were implanted on the surface. (3) Delaying the operation until the patient's powers of resistance were lowered too far to permit them to sustain its effects and until -there was every probability that metastases had already occurred. FIG. 17. Watson's apparatus for permanent drainage of the kidney, showing manner of wearing it. (Watson and Cunningham.) He therefore proposed that: (1) Ureteral implantation in all its forms be abandoned, (2) That the operation be applied to those patients only in whom malignant disease of the bladder had not advanced to a late stage, but was in its early development, and in whom the powers of resistance were still good. (3) Above all, he proposed that the operation of total cystectomy be divided into two stages, the first of which should deal with the diverting of the urinary secretion into its new channel and that step alone, for accomplishing which he stated his preference for bilateral nephrostomy as the HGERY OF THE PROSTATE 47 preliminary step; and that the second operation should be the removal of the bladder at whatever time it might be appropriate to perform it. He further described and illustrated in the Annals of Surgery, September, 1907, an apparatus designed by him for the purpose of keeping a patient with bilateral renal fistula 3 in the loins dry and allowing him to pursue an active life while wearing it. (Figs. 1 5 and 17.) In this article is the report of a case in which one of his patients has worn such an apparatus with entire comfort during seven- teen years, and has been actively at work during the whole time and in excellent condition, draining all the urine from both kidneys into the reservoirs direct through nephrostomy channels. In only one instance known to the writer has the plan above described been adopted exactly as it was set forth in 1905, for almost all who have done the operation have employed ureterostomy. But there have been a number of cases reported in w-hich the operation has been done in accordance with the most important feature of that plan, namely, the two-stage operation; and so far as the writer has learned, there has been no operative death in any of them. It would therefore appear that his claim that the operative mortality would be markedly lessened, if his proposal were adopted, had been justified. SURGERY OF THE PROSTATE. The share that America has had in developing the surgery of the prostate has been a large one, and it was in this country that it was kept alive during a short interval in which it had been abandoned elsewhere in the world. The first total prostatectomy done through the perineal approach was performed in America. The suprapubic operation of prostatectomy also had its origin in America almost simultaneously with its birth in England, and some of the best modifications of the perineal operation have originated here. Some of the earliest writings upon the operative treatment of the hyper- trophied prostate are by American surgeons; later, some of the most important monographs upon the surgery cf the prostate were published by Americans. Development of the Surgical Treatment of the Hypertrophied Prostate. The earliest instances of operations by which parts of the obstructing prostate were removed were those in which they were taken away either accidentally or incidentally to lithotomy operations. The first intentional attempts to overcome this obstruction to the exit of urine from the bladder were made in a few cases by tunneling or cutting through the median lobe of the enlarged gland. Among these may be cited, as examples, the operations of John Hunter, in 1805. of Sir Everard Home in 1S35, and of Brodie in 1865. In 1830 Chopart cut through the median lobe with a sharp-pointed lance blade passed through a catheter with an open distal end. In 1795 and in 1800 Dessault and Sir William Blizzard respectively removed a median lobe and a lateral lobe in the course of lateral lithotomy operations. 48 SKETCH OF GEN I TO-URINARY SURGERY 7.V AMERICA Sir William Ferguson, 5 in the London Lancet, January 1, 1870, makes the following interesting comment upon the removal of the prostate: "I have ventured to put on record what some of my profes- sional brethren may have hesitated to do for fear that they may have been guilty in performing their operations of perpetrating some rough mechanism not in accord with the nicety of manipulation which is thought so essential in the performance of the master handi- work of surgery lithotomy." This remark of Ferguson was applied to his proposal to remove the obstructing parts of an enlarged prostate in the course of the operation of lateral lithotomy. Amussat removed a mass from the prostate when doing a suprapubic lithotomy in 1830. In 1830 Guthrie 11 definitely proposed division of the bar at the neck of the bladder. In 1856 the operative treatment of the hypertrophied prostate was definitely begun by the French surgeon Mercier. 16 Merrier urged the adoption of the operations of division of the bar at the neck of the bladder and of obstructing median lobes, or the removal of the obstruction to urination by punching out a piece of the median lobe by means of instruments, devised especially for the purpose by him, and which he passed through the whole length of the urethra. W. H. S. Gouley, 9 of New York (1873) .The operative treatment of the hypertrophied prostate began in America with Gouley, of New York. In 1881 the writer of this sketch had several talks with him, during which Gouley showed him specimens of parts or the whole median lobes of enlarged prostates which he had removed by an operation which was a modification of that of Mercier, whose pupil Gouley had been. The modification consisted in applying the method of Mercier through a perineal boutonniere incision instead of through the whole length of the urethra. More important yet, however, was Gouley's description of the operation of perineal median total endo-urethral finger enucleation prostatectomy which he sets forth in his work entitled Diseases of the Urinary Organs, 9 as follows (he has been describing partial pros- tatectomy through a boutonniere incision in the urethra): "The surgeon should endeavor to give permanent relief by a procedure which will not add materially to the dangers of the preceding steps. He should explore the prostate through the artificial opening, and if he should discover a median enlargement, or isolated tumors (lobes), he should dilate the prostatic sinus, or incise it laterally, and enu- cleate the lateral tumors, and, if there be a median enlargement, excise it," etc. In 1874 Bottini, of Padua, introduced his operation of division of the median obstruction formed by a middle lobe of an hypertrophied prostate by means of a galvanocautery blade passed through the whole length of the urethra. In 1836 Parish, of Philadelphia, describes a case in which Dr. Wistar, SURGERY OF THE PROSTATE 49 of Philadelphia, had made a suprapubic fistula and established per- manent drainage of the bladder through a gold tube worn in the fistula. In this case urinary obstruction by an hypertrophied prostate existed. Sir Henry Thompson, of London, later advocated the same plan. In 1881 and 1883 Billroth and Leisrink respectively performed total prostatectomy, each in a case of cancer of the prostate. These operations were carried out through the perineal approach. In 1886 Belfield, of Chicago, performed his first suprapubic pros- tatectomy. This operation was a partial prostatectomy. In 1887 McGill, of Leeds, England, reported several prostatectomies in which in some instances one lateral lobe alone, or with the median lobe, were wholly removed by finger enucleation through a suprapubic cystotomy wound. To Belfield and to McGill the suprapubic operation properly should be credited. In the following year, 1888, Watson, of Boston, published a mono- graph, which was privately distributed among his colleagues, in which he advocated partial prostatectomy either by the suprapubic or the median perineal route by removal of the median or lateral lobes, w T hen they were the obstructing parts of the gland, and illustrated a galvano- cautery instrument devised by him which he had used both through the suprapubic and the perineal median incisions for the purpose of burning through the median obstruction bar at the neck of the bladder or lateral enlargement of the gland. He discarded the latter method after that year, having done it in the course of his first partial suprapubic prostatectomy in 1889, 26 and also a total perineal median endo-urethral prostatectomy. The last-named case was not published until some years later. In 1889 Zuckerkandl 31 described his total perineal prostatectomy through a perineal transverse crescentic incision and separation of the rectum from the prostate and finger enucleation through an incision in the posterior surface of the fibrous sheath of the gland. In 1890 Goodfellow, of San Francisco, performed his first total prostatectomy through the median perineal external urethrotomy incision and endo-urethral finger enucleation. His first report of his method of doing this operation was made before the California Academy of Medicine in April, 1902. He read other communications upon this operation and reported a remarkably successful series of cases in which he had done the operation on 78 patients, with an operative mor- tality of but 2.5 per cent. In 1892 Pyle 19 describes the operation of Zuckerkandl and advocates its employment. In 1894 Nicoll 17 describes the removal of the entire gland by finger enucleation through a perineal incision in combination with the employment of the suprapubic cystotomy incision for the purpose of exercising downward pressure on the prostate to bring it near the perineal surface. Alexander 1 advocated the combined high and low operation and M IT I 4 50 SKETCH OF GEN I TO-URINARY SURGERY IX AMERICA removal of the gland through the lower route after freeing it from its attachments by finger enucleation through the sides of the prostatic urethra. Subsequently he abandoned the upper incision and employed the median perineal avenue of approach only. Fuller, of New York, 7 described fully the suprapubic total pros- tatectomy. Also in his treatise, Diseases of the Genito-urinary Organs, 1900. The operation described by Fuller, in 1900, Freyer, of London, without the slightest justification, endeavored to appropriate as being original with him in the following year, 1901. 6 His claims to priority have been too completely disproved to call for further notice. Thus stood the history of the development of the operative treat- ment of the hypertrophied prostate in the year 1900. One of the interesting features connected with it is the fact that despite the able and vigorous advocacy of the above-named radical procedures by a number of distinguished surgeons, before the year 1900 the profession turned a deaf ear to their counsel and would have none of it. In some instances, indeed, they withdrew their patients from the care of certain of the advocates of such rash measures. Sir Henry Thompson and Guy on, the two highest authorities upon all matters relating to genito-urinary surgery, pronounced against attempts to relieve patients with prostatic hypertrophy by removal of the gland, and it seemed as though the radical surgical treatment might be doomed to failure. There was another reason for this delay in the establishment of the operation of total prostatectomy. This was the proposal of J. William White, of Philadelphia. 30 Dr. White reported at the meeting of the association cited above the results of experiments which were conducted in order to study the effects of castration upon the prostate in dogs, and advocated partly upon the basis of the resulting atrophy of the prostate- in these animals as a sequence of castration, his proposal to treat hypertrophy of the prostate in the human being by castration. In the same year Mears, of Philadelphia, proposed ligature and resection of the vasa defTerentia for the same purpose. These two operations were presently practised on a large scale here and in England. The introduction of this method drew r the attention of the profession for a number of years from the more radical methods of direct attack upon the prostate itself, and hence delayed total prostatectomy for a good while. The castration and vas resection operations were after awhile abandoned because of having been found far less certain and reliable in their results than total prostatectomy, and because they were shown by Drs. Arthur Cabot and Wood to have a surprisingly high mortality and to be followed in a certain proportion of cases by mental disturbances of more or less severity. It was not until the period between the years 1900 and 1904 that the operations of suprapubic and perineal total prostatectomy became fully established, after a more or less persistent but unavailing effort SURGERY OF THE URETHRA 51 to bring them into use had been made, as recounted above, by a number of surgeons. The final establishment of the low and the high total prostatectomy operations came through the advocacy of the perineal operation by two brilliant surgeons in France, Albarran and Proust, and later by the able and skilful advocacy of Young, of Baltimore, in America, and in England by the advocacy of Freyer (1901) and others of the supra- pubic method. SURGERY OF THE URETHRA. Fessenden N. Otis, ls of New York. One of the most notable con- tributions made by American surgeons to genito-urinary surgery is that of Dr. Otis, of New York. Before the investigations of Otis with regard to the normal caliber of the male urethra there was no standard by which its size could be estimated. Various assertions were made with regard to its normal caliber, but always there was a difference between them. One esti- mated it by the size of the meatus, another gave without any reason this or that number of millimeters for its normal caliber. There was no accord in the various estimates, nor any data by which to deter- mine what the normal caliber actually was. In the journal cited above and in other publications subsequently, of which the most important is his work entitled Practical Clinical Lessons on Si^hiUs and Genito-urinary Diseases, published in 1883, Dr. Otis gives his views concerning the normal caliber of the male urethra, the relation of stricture of wide caliber, as he termed narrow- ings of slight extent, to gleet, and the treatment of stricture of the urethra. With regard to the latter, he believed strongly in the opera- tion of internal urethrotomy properly performed, and devised a new instrument for its performance which is superior to other forms of urethrotomes in all cases of strictures of a caliber not less than 16 of Charriere scale of measurement (Fig. 18). For those of lesser caliber he advised the employment of the instrument of Maisonneuve. He also designed an instrument for estimating the size of strictures. It resembles that which was introduced by the French surgeon Leroy d'Etiolles. Otis laid down the following rules with regard to the caliber of the urethra and the treatment of stricture by the cutting operation: 1. That the meatus cannot be taken as a guide to the size of the urethra behind it. 2. That the normal caliber of the male urethra is much larger than was previously believed. 3. That the caliber of the average urethra is 32 mm. of the Charriere scale of measurement. 4. That there is a correspondence between the circumference of the flaccid penis and the caliber of the urethra in each person and that both these measurements differ considerably in different individuals. 5. That there are but very few urethra? that are of a caliber less 52 SKETCH OF GEN I TO-URINARY SURGERY IN AMERICA FIG. 18. Otis's urethrotome and steel sound. (Watson and Cunningham.) SURGERY OP THE URETHRA 53 than 28 of the Charriere scale. That there are a considerable number of a calibers larger than 32 of that scale. That there are some that are as large as 40 of that scale. 6. That the caliber of the urethra of a penis which has a circum- ference of 3 1 inches is 32 mm., and that for every quarter of an inch of increase in the circumference of the penis there is a corresponding increase in the caliber of the urethra of 2 mm. Thus in the penis measuring 3| inches in circumference the caliber of the urethra would be 34 mm., and so on. So, too, if the penis measures less than 3j inches in circumference, there is a correspondingly smaller caliber of the urethra of 2 mm. for each quarter of an inch in the circumference of the penis. 7. That it is essential to completely divide strictures if one is to secure a permanent result by the operation of internal urethrotomy. That if the division is made in correspondence with the caliber of the urethra in each case, this caliber being established by carefully taken measurements beforehand, and if the incision made by the operation with a dilating urethrotome, such as that of Otis, in such a way as to ensure the restoration of the strictured parts of the canal to the normal caliber of the special urethra in which it is made, and furthermore, if the incisions thus made are kept open subsequently by the passage- of a sound of the caliber of the normal urethra every second day after the operation until no blood appears after the withdrawal of the sound, that a large percentage of the patients will be permanently cured. The view of Otis concerning strictures of w r ide caliber were shown by Keyes, Weir and others, of New York, to be erroneous. It was demonstrated that the narrowings, to which Otis gave this name, were in most instances anatomical folds of the inner lining of the canal and that they existed in every urethra. Apart from the last-named factor the views of Otis have been shown to be in the main correct and their establishment produced a decided and very beneficial eft'ect in the treatment of stricture of the urethra. His discoveries also opened the way, as has already been said, to Bigelow to construct his instruments for the performance of the operation of litholapaxy. Arthur T. Cabot. Cabot was among the earlier American surgeons to urge the employment of the operation of resection of dense strictures of the urethra in the region of the perineum, and reported some cases in which he had practised this operation with successful results. Opposition to the Treatment of Stricture by Electrolysis. Edward L. Keyes. Keyes rendered valuable service by his opposition to the method of treating stricture by electrolysis, advocated by Newman, of New York. Operations upon Varicocele. Edward L. Keyes. Subcutaneous Ligature in Cases of Varicocele. Keyes modified the operation of subcutaneous ligature of the veins of varicocele by a clever device which is described in his second edition of the original Van Buren and Keyes, which was published in 1888 (p. 453). 54 SKETCH OF GENITO-URINARY SURGERY IN AMERICA SURGICAL INSTRUMENTS AND DEVICES INTRODUCED BY AMERICAN SURGEONS. IF. //. S. Gouley. The Tunnelled Sound to Secure Immediate Dilatation of Stricture (Fig. 19). Gouley devised and describes FIG. 19. Gouley's tunnelled sound with filiform guide. (Watson and Cunningham.) SURGICAL INSTRUMENTS BY AMERICAN SURGEONS 55 this instrument in his work, Diseases of the Urinary Organs, 1873. 8 It is a tunnelled sound which may be threaded onto a filiform bougie, and using the latter as a guide, can be passed safely through a tight FIG. 20. Cabot's tampon. (Watson and Cunningham.) stricture and thus secure a considerable degree of dilatation of the stricture in any case in which it is so narrow as only to allow the passage of the filiform. The Keyes-Cabot Tampon. To Arrest Hemorrhage after Supra- pubic Prostatectomy (Fig. 20). FIG. 21. Watson's scissors cautery. (Watson and Cunningham.) Watson introduced several surgical devices which are as follows: A curette to fit the finger for the purpose of curetting vesical tumors through a perineal boutonniere incision. 24 50 SKETCH OF GEN I TO-URINARY SURGERY IX AMERICA A hard-rubber drainage tube to be temporarily worn through a perineal boutonniere and which permits tamponing to arrest hemor- rhage after perineal prostatectomy. 29 FIG. 22 FIG. 23 FIGS. 22 and 23. Watson's bladder speculum closed and open. (Watson and Cunningham.) A scissors cautery to remove vesical tumors through a suprapubic cystotomy incision. 27 A bladder speculum. 28 A galvanocautery prostatectatome to be applied either through a perineal boutonniere or suprapubic incision. 29 VENEREAL DISEASES 57 Apparatus for receiving urine from permanent renal fistulse in the loins; already mentioned earlier in the chapter (Figs. 21, 22 and 23). Tilden Browne's Modification of the Cystoscope. VENEREAL DISEASES. The most important single contribution to the treatment of syphilis contributed by an American surgeon is that of Dr. Edward L. Keyes, of New York. To the effective advocacy of Dr. Keyes the profession in America owes more than to anyone else the plan of employing mercury in small tonic doses during long periods instead of the method of treatment by large doses of the drug which formerly prevailed and to which practice much of the opposition to its use was due. Dr. Keyes was a persistent advocate of the tonic dose mercurial treatment of syphilis, and established its value in the face of strong opposition. 22 Robert Taylor, of New ^foYk.Genito-urinary and Venereal Dis- eases. 111 In this excellent volume Dr. Taylor includes the surgical diseases of stricture and of the prostate and other organs of the genito- urinary system, but 470 out of 732 pages of which the volume is com- posed are devoted to venereal diseases, or nearly two-thirds of the whole volume. The work is far more a treatise on venereal disease than on the surgical maladies of the genito-urinary system, and has usually been so regarded. BIBLIOGRAPHY. 1. Alexander: New York Mod. Jour., 1896, Ixiii, 171. 2. Ashhurst: Phila. Med. Times, April 15, 1872. 3. Bigelow: Am. Jour. Med. Sc., 1878. 4. Covillard: Obs. latro-chir., p. 93. 5. Ferguson: Lancet, January 1, 1870. 6. Freyer: Brit. Med. Jour., 1901, ii, 125. 7. Fuller: Jour. Cut. and Genito-Urin. Dis., 1895, ii, 239; also treatise, Dis. of Genito-Urin. Organs, 1900. 8. Gouley: Dis. of the Urin. Organs, New York, 1873. 9. Gouley: Dis. of the Urin. Organs, 1873. 10. Gross: On the Urinary Organs. 11. Guthrie: Anat. and Dis. of the Neck of the Bladder, 1830. 12. Harrington: Ann. of Surg., October, 1893. 13. Ingalls: Boston Med. and Surg. Jour., March 25, 1882. 14. Jackson: Boston Med. and Surg. Jour., August 25, 1870. 15. Keyes: New York Med. Jour., June 16, 1894. 16. Mercier: Recherches sur les Maladies des Organes Urinaries, Paris, 1856. 17. Nicoll: Lancet, April 14, 1894. 18. Otis, Fessinden N.: Calibration of the Male Urethra and its Influence on the Treatment of Stricture, New York Med. Jour., 1872, xv, 152. 19. Pyle: New York Med. Rec., 1892, xlii. 20. Stein: A Study of Tumors of the Bladder, 1881. 21. Taylor: Genito-Urin. and Ven. Dis., 1904, ^d ed. 22. Van Buren and Keyes: Genito-Urin. Dis. and Syph., 1877. 23. Watson: Ann. of Surg., December, 1905. 24. Watson: Boston Med. and Surg. Jour., October 30, 1884. 25. Watson: Boston Med. and Surg. Jour., October, 1884, p. 414. 26. Watson: Boston Med. and Surg. Jour., March 7, 1889. 27. Watson: Lancet, October, 1890, p. 808. 28. Watson: Lancet, October, 1890, p. 809. 29. Watson: The Oper. Treat, of Hypertro. of Pros., 1888. 30. White: Trans. Am. Surg. Assn., 1893, xl, 167. 31. Zuckerkandl: Wiener med. Presse, 1889, xxx, 857-902. CHAPTER II. THE CYSTOSCOPE AND ITS USE. BY LEO BUERGER, M.A., M.D. THE interior of the bladder can be brought into view either with the cystoscope or with the endoscope. A cystoscope is a tube carrying a system of lenses (telescope) by virtue of which a field much larger than the lumen of the tube can be seen. An endoscope is a simple metal tube through which light can be thrown to allow of inspection by direct vision. Cystoscopes may be classified, according to the lens system em- ployed, into two types: the direct, in which the plane of the field or view is perpendicular to the axis of the telescope or cystoscope, and the indirect or prismatic, in which the field is deflected 90. The Direct Cystoscope. Through the work of Nitze, an optical system was developed, by means of which a comparatively large portion of the vesical interior can be visualized through a very small tube, the field of view being many times greater than that obtainable with the endoscope. Fig. 24 illustrates the actual field of vision (x y) through an endoscopic tube, and that (a b) of a Nitze telescope, and shows how they are projected by the eye to X Y and A B respectively. Properties of the Nitze (Direct) Optical System. Enclosed in a narrow tube there are three essential lenses: an objective lens or lenses, a middle or inverting lens, and an ocular or eye-piece (Fig. 25) . The chief physical properties of such a system are (1) amplification of the field of vision, the picture being in correct or upright position, and (2) magni- fication of objects as they approach the telescope, the focus being practically correct at all distances (universal focus). 1. Amplification of the Field. The objective is a lens of very short focal distance, which produces a minute, real and inverted image of a comparatively large field (Fig. 25, a 6) at the distal end of the tube (Fig. 25, a B). This image, which is too small to be seen by the naked eye, is transplanted by the middle lens to the eye or ocular end of the telescope, where it can be enlarged by the ocular lens. The eye sees an enlarged, virtual image, whose apparent size depends upon the diam- eter of the telescope and the magnifying power of the ocular (Fig. 25, A B). In short, a field much larger than the capacity of the tube is brought into view. The illuminated disk that is seen when the objective of the telescope is held toward the sky may be called the "inner field," or apparent or virtual image. The size of the true " outer field," or object, varies with the distance of the objective lens from the plane upon which the tele- (58) THE DIRECT CYSTOSCOPE 59 scope looks. The virtual capacity of such a system can be represented by a cone whose base is at infinity and whose apex is at the centre of the objective lens (Fig. 25, a c b). 2. Magnification. If such a telescope be held toward the sky and a small object be interposed, the following facts will be noticed: (1) that the illuminated disk or inner field remains the same ; (2) that the size of the interposed object varies, becoming larger as it approaches the FIG. 24. Comparison of actual field inspected with a simple endoscopic tube (x y = X Y) and with a direct telescope (a b = A B). objective, and smaller as it recedes; (3) that when the object is made to approach closely but a small portion of it can be seen, and, conversely, at greater distances more and more of it comes into view. Fig. 26 will illustrate: Let be a telescope, the objective lens of which produces an inverted image (a /3) of the field, a b (a a, b b in full- face view) and a c b the visual angle of the system. Given an ocular of such power that the size of the object (a 6) and of the enlarged image or FIG. 25. Direct telescopic system, a b, outer field; AB inner field; angle acb visual angle aB = small inverted image produced by the objective lens. virtual image (A B} will be identical. In other words, let a b be situated at a point (7) where it appears as large as it really is (a b = A ft). At II only a portion (a' &') will be seen. This, however, takes up the same space in the tube (a 0) , and therefore will also be seen as large as A B-, therefore a' V is equal to A' B'. At 777, a" b" = A" B"; at IV, a'" b'" = A'" B"'. The virtual image (A B}, or "inner field," seen through the telescope always remains the same, but the size of the 60 THE CYSTOSCOPE AND ITS UXE outer or actual field rapidly diminishes as it approaches the lens. A small field at a short distance is made to occupy the same amount of space in the virtual (inner) field as a large one, and is therefore enlarged. bb atab ata'b FIG. 26. Diagrammatic explanation of the magnifying power of the telescope. This system (the direct, non-prismatic) is employed in all direct telescopic cystoscopes, such as the modifications of Brenner, Brown, Lewis, and in Buerger's universal urethroscope. The Prismatic (Indirect) Optical System. In order to bring the trigone of the bladder more readily into view a right-angled prism is placed in front of the objective. The prism's silvered hypothenuse acts like a mirror, deflecting the whole field 90, and inverting the \ FIG. 27. The effect of the right-angled prism in inverting the far (north) and near (south) points of the field. upper (north) and lower (south) parts of the picture, no change taking place as far as left and right are concerned (Figs. 27 and 28). This optical system was first used in the N'itze cystoscope (Figs. 28 and 29) . Resembling a metallic catheter, this consists of a shaft, a beak, CORRECT VISION SYSTEMS 61 and an ocular portion. The shaft contains the optical system.* At the point A there is a window through which the rays from the object or field enter. The beak carries a detachable electric lamp for illumina- tion of the bladder. Near the ocular is the apparatus for attaching the electric coupling B. The current is transmitted through the shaft to the beak by way of an enclosed wire, the circuit being completed by the metal wall of the instrument itself. This instrument is known as the Xitze examining or observation cystoscope (Fig. 29). ->* N FIG. 28. Nitze cystoscope in longitudinal section viewing the arrow in the floor of the bladder, the picture seen by the eye being inverted. Correct Vision Systems. To overcome the disturbing effects of the inversion of the picture E. R. Frank 7 added a second or rectifying prism to the ocular. The most improved methods are those of Ringleb (used in some Continental instruments) and Buerger. In most of the American cystoscopes the system described by Buerger 5 has been FIG. 29. Nitze cystoscope, showing sheath with lamp, prism (A), contact (B), and fork coupling (C) for electric connection. adopted. A modified Wapplerjprism (a hemispherical lens with one plain side) is the objective, and six middle achromatic lenses and an ocular make up the rest of the system. The objective lens brings about one reversal of the picture, the middle lenses two additional reversals. In the sense of north and south (Fig. 30) the prism causes another inversion, so that we have a total of four reversals for the north and * Note that two lenses are employed in the objective instead of one as in our diagrams. The second lens tends to overcome spherical aberration. 62 THE CYSTOSCOPE AND ITS USE south points and three reversals for the east and west points (Fig. 31). This naturally results in the production of an image whose north and south poles are upright and correct, and whose east and west points are reversed. The interchange of these points is then brought about by a FIG. 30. The course of the rays from north and south points through the corrected lens system, showing four reversals of the arrow, the result being an upright picture. simple reversing prism of 90 (Fig. 31) that is placed in front of the ocular. This system gives a larger field of vision and a great deal more light than is obtainable in any other telescopic system. Hi* looking.daKn at Object FIG. 31. The course of the rays in the same telescope from east and west, showing three reversals through lenses, one reversal by the prism, the final result being non- inversion. Since a corrected or upright picture greatly facilitates cystoscopic work, the above optical system has been almost universally adopted in the United States. In all future descriptions, therefore, the use of this system will be understood. CYSTOSCOPES. In addition to the classification into direct or indirect varieties, cystoscopes may be grouped as examining (observation) and catheter iz- ing instruments, according to their special function. Direct Cystoscopes. This type had been used by Nitze for purposes of examination before he had improved the cystoscope through the addition of a prism. Brenner, by adding a catheter channel, was the first to employ this instrument for catheterization of the ureters. F. Tilden Brown improved this by separating the telescope from the sheath, the former carrying channels for two catheters for synchronous ureteral catheterization (Fig. 32). Later, Brown modified this instru- ment by cutting an additional fenestra into the concave aspect of the beak and by rearranging the lamp. This permitted of the introduction and the application of a telescope of the indirect type for ureteral CYSTOSCOPES 63 catheterization. To this instrument he applied the name composite cystoscope. Bransford Lewis developed a similar instrument, calling it universal cystoscope. The field of vision of the cystoscope illustrated in Figs. 23, 24 and 25 will be seen to encompass a cone whose apex is at the objective and whose base lies in planes perpendicular to the axis of the telescope. "When introduced into the bladder such a cystoscope would look directly FIG. 32. The beak of the Brown direct catheterizing cystoscope showing lamp, objective end of telescope and two catheters projecting. at the posterior wall. For a thorough inspection of the bladder it has certain disadvantages which have resulted in its being gradually sup- planted by the prismatic type of instrument. Thus, it is necessary to make wide excursions with the instrument to inspect the interior of the bladder. Although this is feasible without much distress to the patient in the female, it is almost impossible to make adequate excur- sions in the case of the male. Fig. 33 illustrates the wide sweep that FIG. 33. Wide excursion of the direct cystoscope in order to bring the posterior wall of the bladder into view with a direct cystoscope. must be made with the shaft of the instrument in order to bring a con- siderable portion of the bladder interior into view. The prismatic cystoscope is not open to this objection, since by rotation about its long axis (Fig. 34) an annular band, including roof, lateral walls, and floor of the bladder, can be seen. By an inward or outward movement along its long axis combined with rotation, almost the whole of the bladder interior can be inspected. 64 THE CYSTOSCOPE AND ITS USE FIG. 34. Annular band around the whole bladder brought into view by rotation of the prismatic cystoscope on its long axis, very slight rotation bringing the fields /, //, and /// into view. B :iii\mwtvnf fim FIG. 35 FIG. 36 FIG. 37 FIG. 38 FIGS. 35, 36, 37 and 38. Diagrammatic drawings demonstrating that only objects lying in planes perpendicular to the axis of the direct cystoscope suffer no distortion. CYSTOSCOPES 65 Another disadvantage of the direct system is the fact that only objects that lie in planes perpendicular to the long axis of the telescope escape the effects of distortion. Figs. 35, 36, 37 and 38 demonstrate this fact, the hair-pin having a grotesque appearance when telescope and object are parallel. When the most important portion of the bladder is viewed, namely, the trigone and ureteric orifices, the ocular end of the instrument must be raised so as to depress the objective against the floor of the bladder (Fig. 66). Under these circumstances the plane of the trigone is almost parallel to that of the long axis of the instrument. The trigone and ureters, therefore, will come but poorly into view. The prismatic telescope will give a perfect picture of this region. The Prismatic or Indirect Cystoscope. Here the eye of the observer may be regarded as transferred from the region of the ocular to the objective, where it looks in a direction perpendicular to the shaft of the instrument (Figs. 28 and 50). FIG. 39. Otis-Brown-Nitze cystoscope. For a long time the prismatic cystoscopes were unpopular in the United States because of the difficulty in interpreting the inverted picture. Since the introduction of the corrected systems 1 the advan- tages of the prismatic type have become evident to most all cysto- scopists, so that the indirect system is most widely used today. The most generally useful examining cystoscopes are the Buerger, Otis-Nitze, or Nitze (Fig. 39). The first will be described under Catheterizing Cystoscopes. Otis-Nitze Cystoscope. The Nitze evacuating cystoscope for pur- poses of observation was improved by Otis and Brown by the use of a Wappler hemispherical lens and a change in the pattern of the beak. The Otis-Nitze consists of a sheath carrying a lamp, a fenestra through which the objective looks, two irrigating faucets at the ocular end, and an observation telescope. After removal of the tele- scope the sheath can be employed for irrigation of the bladder. Where an examining cystoscope of smaller caliber than the Buerger instrument is desired, this cystoscope will be found serviceable. Catheterizing Cystoscopes. In order to provide for the collection of urine from each kidney separately, the examining cystoscopes had to 5 66 THE CYSTOSCOPE AND ITS USE be modified so as to carry catheters that could be inserted into the ureteral orifices under the guidance of the eye. Direct Catheterizing Cystoscopes. Brenner converted the direct cysto- scope into a catheterizing instrument in 1887 by placing a channel for one ureteral catheter below the telescope. F. Tilden Brown improved the Brenner cystoscope by separating the sheath and the telescope, the latter carrying the catheter bed or channels (Fig. 32). The sheath carries the lamp and provisions for electric contact, and is closed with an obturator before introduction into the bladder. Indirect Catheterizing Cystoscopes. All instruments of this type are based upon the Nitze instrument, in which it was found necessary to add a mechanism for deflecting the catheters so that they would have the proper direction for insertion into the ureters. Albarran's deflector, or finger, which could be elevated or depressed by a mechanism situated at the ocular end of the instrument, is the most useful device of this kind, and, in somewhat modified form, is still in use today. The Nitze- Albarran Cystoscope. In America this instrument possesses merely historical interest. It is the Nitze observation instrument with provision for the introduction of one or two ureteral catheters that may be passed through a separate channel in the shaft of the instru- ment. Because of many mechanical disadvantages this instrument has been discarded almost completely in the United States, and has been supplanted by the Buerger cystoscope. The Buerger Catheterizing Cystoscope.* This instrument (Fig. 40) consists of four parts, the sheath, the obturator, the observation tele- scope, and the catheterizing telescope. The sheath is circular on cross- section, bears a very short lamp at its end, and possesses a large fenestra or window behind the lamp. Its caliber is about 24 French, f The obturator closes the working aperture perfectly. The observation telescope is large, but does not completely fill the sheath, room being left for irrigation. The catheterizing telescope combines in one piece the optical apparatus, the mechanism for deflection and the catheter grooves or beds. At the objective end the catheters may be fastened by a clip; at the ocular end there are two catheter channels through which the catheters emerge. These are provided with rubber tips or nipples that firmly grasp the catheters and prevent the escape of fluid from the bladder. A large deflector or catheter lift is implanted near the objective. This instrument presents the following advantages: the employ- ment of a catheter for washing the bladder is unnecessary, the sheath serving this purpose; because of its small size, its round shape, the smoothness in the region of the beak and window, the introduction of this instrument is easy, and injury to the deep urethra is avoided; synchronous ureteral catheterization with two No. 6 French catheters is * Sold under the name of Brown-Buerger Cystoscope, because the sheath principle popularized in the United States by Brown was adopted. (This principle had been intro- duced by Nitze in his "Evacuation Cystoscope.") t Recently, Buerger has devised a smaller (21 Fr.) double catheterizing cystoscope carrying 2 No. 6 French ureteral catheters. The design is the same as that of the above. CYSTOSCOPES 67 possible, and the telescope and sheath may be removed, leaving the catheters in the ureters; irrigation of the bladder may be very rapidly effected, through the sheath after removal of the telescope, or more slowly through the faucets, even while the process of catheterization is going on; the separation of the catheters in their grooves avoids friction FIG. 40. Buerger catheterizing cystoscope:* 1, concave sheath; 2, convex sheath; ,?b, extra lamps; 3, observation or examining telescope; 4. obturator; 5, catheterizing telescope; 6, clip to hold catheter against telescope. between them, and a new catheter can be inserted at any time without removing the telescope; the relation of the lamp to the objective lens gives the best illumination and prevents burning of the bladder wall; inasmuch as the catheter-bearing mechanism is separable from the sheath, and is not introduced until the bladder is cleaned, the likelihood * For children, Buerger has constructed a single catheterizing cystoscope of 15 French caliber, and recommends a 12 French observation cystoscope of the Otis-Nitze type for observation cystoscopy. 68 THE CYSTOSCOPE AXD ITS USE of carrying infection into the ureters is reduced to the minimum ; if the lens becomes soiled, the telescope may be removed without disturbing the sheath, or a larger observation telescope may be substituted. The typical sheath carries the lamp on the concave side of the instru- ment (Fig. 40, No. 1) and is called the concave type of sheath, the fenestra and lamp being on the same side. An additional sheath is provided (Fig. 40, Xo. 2), in which the convex portion of the beak en- closes the lamp. This allows of very close approximation of instrument and bladder wall, and is applicable in contracted bladders, where dis- tention of the bladder is impossible, when a very close view is essential, whenever work must be done at close range, and when the sphincter and posterior urethra are to be examined, particularly in prostatic adenoma (hypertrophy) . Composite or Universal Cystoscope. A number of workers have at- tempted to make the direct and indirect methods of procedure appli- cable in one sheath. For this purpose the sheath is provided with two fenestrse, one on the concave side of the lamp for the indirect telescope, the other at the convexity for the projection of the objective of the direct telescope. Because of the larger size of the beak, the inadequacy of illumination for indirect vision, the weakness of the mechanism in the region of the beak, and many other mechanical disadvantages such instruments are not recommended. F. Tilden Brown and Brans- ford Lewis have both devised instruments of this type. Endoscopic Tubes. These are simple tubes of varying diameters, and are called urethroscopes when employed for inspection of the urethra. They are of two types, male and female. Gruenfeld introduced these in 1881 for use in the urethra, and both Pawlik and Howard Kelly, of Baltimore, demonstrated that, at least in the female, the ureters could be catheterized with comparative ease through a mere tube, into which light could be reflected from a forehead mirror from a lamp situated near the eye portion of the tube or from a small light carrier inserted into the tube itself. The Elsner-Braasch Cystoscope. This is a modified endoscope con- sisting of a sheath carrying a beak and lamp, an obturator and a small glass window to close the eye-end of the tube. When used in a water medium, a direct view is obtained without the intervention of any lenses, the observer looking through the window down the water-filled sheath. Ureteral catheters may be passed through special channels, no deflector being necessary, the technic being similar to that employed with the direct cystoscopes. Because of the restricted field of vision the wide excursions necessary to bring the bladder interior into view, and the difficulty of finding the ureters, particularly in pathological bladders, the instrument will scarcely find general adoption. In the hands of a very few experts it may answer in the majority of cases. The Kelly Endoscope. A simple tube (Fig. 41) provided with an obturator and handle is successfully used by many for ureteral cathe- terization in the female and also for inspection of the bladder. Light is thrown into the bladder with a forehead mirror. In certain modified TOSCOPIC ACCESSORIES 69 models of this instrument a small lamp is attached either to the eye-end of the tube or carried inward on a small light carrier. The Kelly- Pawlik method is not recommended for observation cy^toscopy. since the field obtained is too limited. In the female, however, it has a sphere of usefulness for purposes of ureteral catheterization. FIG. 41 . Kelly speculum or endoscope, The Luys Endoscope. Luys employs a simple endoscopic tube for catheterization of the ureters even in the male, and has modified the instrument by the addition of a small magnifying lens in front of the eye-end of the instrument and a small canal through which the urine can be aspirated and the field kept dry. CYSTOSCOPIC ACCESSORIES. The Lighting Apparatus. The source of electricity is preferably the street current, but a dry cell, storage or other battery may be employed. The requisite amount of current is obtainable through a controller* that can be attached to any universal lamp socket. Current should be turned on gradually until the outlines of the lamp filament become blurred and the light becomes white, the instrument being tested and the proper amount of current determined before its introduction into the bladder. Dry-cell batteries (single or six-cell pocket battery with rheostat) are often serviceable, though larger portable batteries con- taining two to six cells will last longer and give more satisfaction in an office not equipped with electric light.! Sterilization. After cleansing with green soap and water, then alcohol, tbe cystoscope may be sterilized either in pure carbolic acid or in formaldehyde vapor. A carbolic acid sterilizer may be improvised by placing two large tubes or cylindrical vessels in a wooden stand, one containing carbolic acid and the other 95 per cent, alcohol. The eystoscope is plunged into carbolic acid for five minutes, then immersed in alcohol, and finally washed with sterile water. * The Wappler controller. Xo. 3, is one of the best instruments for this purpose, t Wappler Catalogue, No. 59, p. 19. 70 THE CYSTOSCOPE AND ITS USE A formaldehyde sterilizer* in which there is provision for the develop- ment of formaldehyde is even more reliable. Formaldehyde vapor is developed by allowing a tablet of paraform to be vaporized over a lamp. The instruments should be kept in this vapor for several hours, pre- ferably overnight, and must be rinsed off with sterile water before using. Cystoscopic Table.- A table suitable for cystoscopic work should per- mit the patient to be comfortably placed in the following positions: lithotomy position, the modified lithotomy position with legs hanging down, Trendelenburg, and knee-chest position, f Anesthesia. Although an anesthetic may be dispensed with in many cases, it is a good plan to employ novocain or alypin as a routine in males, and occasionally even in the female. A 2 and 4 per cent, solution of novocain and a l-grain tablet of alypin or novocain should be at hand. Lubrichondrin or K Y,J to which 4 per cent, novocain or alypin has been added (Barringer), is a good preparation. The following is a useful method of obtaining local anesthesia : After cleansing of the foreskin and meatus, the patient voids, and the urethra is irrigated with a 2 per cent, boric acid solution. The anterior urethra is then distended with a 2 to 4 per cent, novocain solution and closed with a penis clamp. After five minutes have elapsed, about 15 c.c. of the novocain solution are injected into the urethra in such a manner that the greater part of this solution enters the bladder, the urethra remaining distended for an additional five minutes. Some recommend the introduction of a tablet of alypin or novocain (1| gr.) into the pos- terior urethra by means of a special tablet depositor (Bransford Lewis), or the injection of a 4 per cent, alypin-lubrichondrin into the urethra for five minutes, the instrument being then anointed with the same preparation. Suppositories containing 1 grain of codein or \ grain of the extract of belladonna with \ grain of the extract of opium may be administered an hour before the examination in irritable patients. In rare instances nitrous oxide gas anesthesia or epidural injection of 10 c.c. of a 0.5 per cent, novocain solution will be necessary. Solutions. Since cystoscopy with telescopic instruments necessitates the distention of the bladder with a clear fluid, a warm 2 per cent, boric acid solution must be at hand. It is best employed in an irrigator, but may also be injected with a 5- to 6-ounce syringe. Indigo-carmin (0.08) mixed and boiled in 15 to 20 c.c. of sterile normal salt solution may be injected into the buttocks, if selected as a functional test; or phenolsulphonephthalein (vial of 1 c.c.) is intro- duced either into one of the arm veins or under the skin. Ureteral Catheters. The French silk- woven catheters^ are the best. They vary in size and in the shape of their tips or collecting ends. They * Hospital Supply Company, New York. t Buerger-Hyman table made by the Hospital Supply Company, was especially designed for this work; or the Buerger combined cystoscopic and radiographic table. J Van Horn & Sawtell, New York. Hynson & Westcott, Baltimore, Maryland, f Eynard make is recommended. CYSTOSCOPIC ACCESSORIES 71 may terminate in an olivary point with one or two lateral openings, in a whistle-shaped tip, with lateral holes, in a single terminal opening without any lateral holes, or with a rounded, closed end with a lateral opening. The most serviceable are the olive-tip and the whistle-tip catheters; the former are preferred for routine work since they more easily surmount obstruction in the ureter ; the latter have the advantage of giving a somewhat more copious flow. Although the No. 6 French catheter is recommended for routine use, it will be necessary occasionally to employ one of 4 or 5 French caliber. In pyelography where reflux of the injected argyrol or collargol must be prevented, or in estimating the total output of a kidney, or in order to collect thick purulent secretions, etc., a larger catheter from 7 to 12 French may be introduced through an operating cystoscope.* Lubricants. A lubricant containing tragacanth put up in tubes has given us satisfaction.! Four per cent, novocain or 4 per cent, alypin may be added to aid local anesthesia. Sterile glycerin or liquid petro- latum may also be employed. Syringes. A complete outfit includes a 1-ounce syringe with rubber tip for injection of novocain solution; a small 5 to 10 c.c. syringe for washing the pelvis of the kidney, injecting fluid, oil, or glycerin into the ureteral catheters and provided with a special conical blunt needle to fit into any ureteral catheter; a 20-c.c. syringe for indigo-carmin injection; a small hypodermic syringe for injection of phenolsulphonephthalein; and a 5-ounce syringe for injecting fluid into the bladder when an irri- gator is not at hand. Other Accessories. Other accessories are rubber tips or nipples, with or without perforation, to occlude the catheter outlets; clips to hold catheters in their beds in the telescope; cystoscope holder, especially valuable in females to grasp the cystoscope and to hold two test-tubes for collecting specimens. Preparation for Cystoscopy. Although a complete armamentarium for the use of the specialist includes a larger number of instruments, a satisfactory set would include a Buerger observation and catheterizing cystoscope, J an Otis-Xitze examining cystoscope, a cysto-urethro- scope,^[ an operating cystoscope,** and a Kelly endoscope.ft The cystoscope selected for use, after sterilization, is laid out on a sterile towel and the lamp tested. Preparation of a male patient includes the cleansing of the external parts, the irrigation of the urethra with a 2 per cent, boric solution with a hand syringe followed by the application of the local anesthetic. After ten minutes have elapsed * Buerger or Brown or Bransford Lewis instruments. t So-called "K-Y," Van Horn & Sawtell, New York. j Manufactured by Wappler Electric Mfg. Company, catalogue 59, p. 2, Brown- Buerger combination cystoscope. Wappler Electric Manufacturing Company. If Wappler catalogue 59, pp. 9, 10 and 11 (Buerger cysto-urethroscopes) . ** Ibid., pp. 6 and 7, Buerger operating cystoscope. ft Manufactured by all surgical instrument makers under the name of Kelly speculum or Kelly endoscope. 72 THE CYSTOSCOPE AXD ITS USE the patient may be put in the position for cystoscopy. In the case of the female, after irrigation of the vagina and thorough cleansing of the external parts, a tablet of novocain or alypin may be introduced into the urethra with forceps. A slightly modified lithotomy position will be found to answer in most cases, except for the Kelly and Luys methods, which require either the knee-chest posture or an exaggerated Trendelenburg. The Introduction of the Instrument. In the case of the female this requires no special comment, but in the male the technic is as follows: The operator standing in front of the patient holds the penis in the left hand, puts it on the stretch, everts the lips of the meatus, and is ready to pass the well-lubricated cystoscope through the urethra. The sheath with the obturator in place is allowed to slip into the urethra as far as the bulb, by its own weight whenever possible, until it meets the resist- ance of the bulbomembranous junction. Here it is allowed to rest for a second or more. The ocular end of the instrument is then depressed until a sensation of penetration begins to make itself manifest. A slight rotation of the beak from one side to the other may facilitate in this maneuver, and a finger of the left hand (which has now released the penis) may aid by pressing the beak of the cystoscope upward against the pubic arch. The instrument will then suddenly plunge through the posterior urethra and into the bladder, while the right hand con- tinuously depresses the ocular end. The obturator is then removed, the urine collected in a sterile vessel, and the bladder is irrigated with a 2 per cent, boric solution from an irrigator until the return flow is perfectly clear. Either the observation or the catheterizing telescope is now inserted, locked in place, and the boric acid allowed to flow into the instrument through one of the lateral faucets until 150 to 200 c.c. have entered. Technic of Observation Cystoscopy. Four motions of the cysto- scope must be mastered : motions of translation, rotation, a pendulum or rocking motion, and a motion of circumduction. By the motion of translation we mean an inward and outward move- ment of the instrument (introduction and withdrawal). In Fig. 42 the positions A , B and C bring into view the greater portion of the an- terosuperior wall, vertex and posterosuperior region. When associated with rotation around the long axis of the shaft, the lateral walls and floor also are visualized (Fig. 34). A motion of translation alone, when the beak is turned down, gives a survey of a band of the floor of the bladder, whose width depends upon the distance of the objective lens from the floor, it being remembered that the nearer the objective, the smaller the field. Complete rotation affords a view of an annular band extending around the whole bladder. Therefore the two motions of rotation and translation demonstrate practically the whole of the bladder except a small area of the posterior wall and the immediate neighborhood of the sphincter. The combined motions of introduction, withdrawal, and rotation do not suffice, since the illumination is scarcely adequate at all distances, CYSTOSCOPIC ACCESSORIES 73 and since details will not be sufficiently magnified until the objective is brought nearer to the bladder wall. Therefore the rocking or pendulum motion is useful. By this we mean the elevation and depression or side-to-side movement of the ocular with consequent conjugate motions of the beak. These are appropriate to exhibit the posterior wall (Fig. 43), and the juxta- FIG. 42. Inspection of (A) anterosuperior, ((7) posterosuperior, and (B) vertex, by motion of translation; in a similar manner the floor of the bladder (Z>) is brought into view. sphincteric portions of the anterior wall ; for the purpose of magnifying objects, and for special conditions, as in cystocele, diverticula, adenoma of the prostate, etc. FIG. 43. Rocking or pendulum motion to demonstrate the posterior wall. Motions of circumduction combine the rocking motion with rotation and offer the possibility of a more comprehensive view of larger objects, such as stones or tumors. The Routine of Inspection. The following is a useful scheme : First: Obtain a superficial view of the superior wall with the beak turned up, introducing and withdrawing until the air-bubble comes into 74 THE CYSTOSCOPE AND ITS USE view (Fig. 44) . The air-bubble occupies the highest point of the bladder, being air introduced into the bladder upon insertion of the sheath. Do not tarry in this examination, since the inspection of the floor of the bladder is most important and should be executed first. Second: Examine the floor (including trigone and ureteric orifices) after having rotated the instrument so that the beak looks down. (Fig. 42, D.) FIG. 44. Air-bubble seen with the beak turned upward when vertex is inspected. Third: Finding of the ureters. Carry the cystoscope well into the bladder (Fig. 45) and the field becomes dark, for the lamp has impinged against the posterior bladder wall, leaving the greater part of the field dark (Fig. 46) ; withdraw slightly and the retrotrigonal region appears. If the illumination is imperfect, you are probably too far away from the FIG. 46. View obtained with the cystoscope as seen FIG. 45. Finding of the ureters; first position. in Fig. 45. Upper part of field illuminated, lower por- tion dark. If cystoscope is pushed still farther in, the whole field may become dark. floor, and the ocular must be raised. Continue the recessive motion (withdrawal) until the interureteric bar or ridge, a fold running trans- versely between the ureters, comes into view (Figs. 47 and 48). This is distinguished by its marked vascularity, darker color, and prominence in the male, although in the female the markings may be less distinc- tive. Even here, however, the change in the color of the mucous mem- brane, fascicles of prominent vessels, running sagittally, will indicate CYSTOSCOPIC ACCESSORIES 75 its presence. Allow the bar to occupy the centre of the field ang! rotate about 20 degrees to either side and the ureters will come into view FIG. 47. Finding of ureters. Second position. The interureteric bar o'ccupies the middle of the field. FIG. 48. View obtained with the cystoscope as in Fig. 47 ; the interureteric bar runs across the field; above, the retro trigonal region; below, the more vascular area of the trigone. The ureteral orifices lie outside of the field. (Fig. 49) . Examine the ureters carefully, both with the instrument in the position of lateral rotation and also with the shaft carried into the line of the course of the ureter, a position which is obtained by bring- ing the beak toward the opposite side of the patient. By raising the ocular the details of the ureteric orifices will be brought distinctly into the field. Note the intermittent vermicular contractions of the ureteral orifices and the character of the efflux or urinary jet. Fourth: Study the trigone itself. Fifth: Proceed to the inspection of the superior wall by turning the beak upward. Sixth: View the lateral walls by combining the motion of translation with rotation, and with the cradle motion so as to bring the beak nearer to the wall. Seventh: Examine the posterior wall with the beak down or up by a rocking motion (Fig. 43) . Eighth: Inspect the sphincter by rotation after having drawn the objective into the urethrosphincteric margin, so that the prism lies partly within the urethra, partly within the bladder. FIG. 49. Finding the ureters. Third position. /, cystoscope in the midline looking at the interureteric bar; //, cystoscope turned to the patient's right to see the right ureter; III, to the left, to see the left ureter. 76 THE CYSTOSCOPE AND ITS USE Ninth: Remove the instrument with the light turned off, the tele- scope removed, and with the obturator reinserted. Elementary Principles of Observation Cystoscopy. For a thorough comprehension of the field of view (outer field) of the indirect cysto- scope, certain elementary physical principles must be known: (1) we must study the relation of the inner field to the position of the cystoscope; (2) the movements of this field induced by the motions of the instrument; (3) the problem of magnification; (4) the observation of the internal sphincteric region; and (5) the question of illumination. FIG. 50. Viewing the floor of the bladder, far point (north) occupies the upper portion of the field, near point (tail of the arrow) the lower part of the field. Relation of Field and Cystoscope. It is necessary to remember that the eye of the observer is transferred to the objective of the cystoscope and looks in a direction perpendicular to the shaft of the instrument. With the objective looking down upon the floor of the bladder the field is that of a swimmer headed in the same direction as the beak. The view obtained by the cystoscope as it is pushed inward is comparable to that of such a swimmer (Fig. 50) . When the anterior and superior walls are inspected the view is that of one swimming on his back and looking upward at the vertex of the bladder (Fig. 51). When the right wall is examined, the swimmer is treading water and looking to the patient's right, so that a "far"* point will be on the examiner's right ; conversely, for the left wall, the swimmer looks to the left and the far points will be on his left. * Far points in the anteroposterior direction are away from the cystoscopist, hence nearer the posterior wall. CYSTOSCOPIC ACCESSORIES 77 Induced Movements of the Field. One of the most disturbing phe- nomena is the apparent movement of the interior of the bladder con- sequent upon motion of the cystoscope. The up-and-down motions that attend movements of translati6n are easily comprehended by keeping the positions of the swimmer in mind. But when the cysto- scope is rotated on its long axis, or when a rocking motion is carried out, the changes in the field are somewhat more confusing. On rotating the cystoscope with the beak down, toward the patient's right (clockwise), the field will seem to travel in a similar direction. Thus, when the right ureter is being viewed the interureteric bar and right border of the trigone w^ill be seen to rotate about the ureteric orifices as a centre, although this centre will travel toward the obser- ver's right.* FIG. 51. Inversion of the field when the beak is turned upward; the near point occupies the upper portion of the field. With the cystoscope looking at the floor of the bladder (Fig. 52), depression of the ocular (cradle movement in a sagittal plane) imparts a downward motion to the object. This is tantamount to advancing the instrument, except that the details of the field will become smaller, and the illumination will become poorer (Figs. 53, 54 and 55). Magnification. To produce enlargement the ocular must be moved so as to approximate objective and outer field. The ocular must go upward in viewing the floor, downward for the roof. Such rocking motions tend also to throw objects out of the field, depression of the * The opposite motion will be conferred upon the field by rotation of the instrument to the left, 78 THE CYSTOSCOPE AND ITS USE beak toward the floor having the effect of withdrawing the instrument. Hence, to compensate, slight intrusion of the cystoscope is necessary. The Problem of the Sphincter. Here, three disturbing factors are encountered; the proximity of lens and field, the great enlargement, and the difficulty of obtaining adequate illumination. The concave FIG. 52. Induced movement of the field by depressing the ocular when a stone on the floor of the bladder is being inspected. sheath is inferior to the convex here, since the lamp of the latter can be brought into better relation with the juxtasphincteric and urethro- sphincteric regions. The cysto-urethroscope gives the best picture here. The roof and sides of the internal sphincter normally present a concave line, that portion of the bladder occupying the concavity being darker because the illumination is inadequate (Fig. 56). The floor is FIG. 53. Stone is in the centre of the field. FIG. 64. Stone has moved downward and is smaller. FIG. 55. Stone is almost out of the field and is still smaller. somewhat convex. ' These concave and convex lines represent the margin of the sphincter in the direction of an approximately horizontal plane. Any abnormality in this plane, such as intravesical intrusion due to prostatic adenoma (hypertrophy) will alter the concave to a convex line. In the vertical plane outgrowths are difficult to estimate, since they will have no other effect than one of magnification, URETER AL CATHETER1ZATION 79 Light. The quality, intensity, and position of the light will vary according to type of lamp, three forms being in use: with the lamp in the concave sheath , in the convex sheath, and in the cysto-urethroscope. The illumination varies also with the distance of the lamp from the field; and finally it will depend upon the relation of the lamp to the mucous membrane, being modified by the presence of tumors, foreign bodies (calculi, etc.), and the displacements produced by extravesical causes. ROOF FIG. 56. Diagrammatic drawing showing the view obtained at the sphincter, the roof, the floor, the right and left side being shown. Up to a certain point approximation enhances the intensity of the light, but when the lamp comes too close to the mucous membrane, illumination diminishes, particularly when the lamp is in contact with the mucous membrane. Then transillumination and shadow formation occur. When the cystoscope is too far back in the bladder (Fig. 45) the lamp becomes covered by mucous membrane and the light is shut off. A tumor may throw a shadow by obscuring the light, so also a calculus, as well as an enlarged uterus, a myoma, or a tumor outside of the blad- der. Prostatic adenoma ("hypertrophy") leads to the formation of a retroprostatic pouch and prevents the approximation of the beak and mucous membrane so that light is diminished. So also do prolapse of the uterus and cystocele interfere with illumination. Some of these conditions can be overcome by compensating movements of the instrument by pressure over the abdominal wall or by manipulation of the vaginal wall in the case of cystocele. URETERAL CATHETERIZATION. Technic with the Indirect Cystoscope. The technic with the Buerger cystoscope will be described, since this is commonly employed. * In the majority of cases, synchronous ureteral catheterization is ad- vised, since the collection of urine simultaneously from both kidneys is * In the United States. 80 THE CYSTOSCOPE AND ITS USE invaluable in determining the relative function of the two organs, aided with the use of such tests as the phenolsulphonephthalein and indigo-carmin and the chemical microscopic and cultural examination of the separated specimens. The catheterizing telescope is armed with two Xo. 6 French ureteral catheters; the sheath, observation telescope, and obturator having been FIG. 57. Normal ureteral catheterization. First move. position. Cystoscope in normal also prepared. After observation cystoscopy has been completed, we proceed to the catheterization of the ureters as follows: 1 . The ureteral opening is found and the ocular end of the cysto- scope is brought slightly to the opposite side of the patient. By raising the shaft the ureteral slit is made to occupy a point just above the FIG. 58. Cystoscopic view in first move: the ureter slightly above the centre of the field. centre of the field. This position must be rigidly maintained during the next two steps. The ureter orifice should be about normal in size, or but slightly enlarged, which can be expected at a distance of about three quarters to one inch (Figs. 55 and 58). 2. After the deflector has been slightly raised (just sufficient to prevent the catheter from hugging the lens) the catheter is pushed for- URETERAL CATHETERIZATION 81 ward almost 1 cm. beyond the limit of the field. Now the catheter appears enlarged, for it lies close to the prism (Figs. 59, 60 and 61). 3. The deviation is gradually increased by raising the deflector, the movement of the catheter in the field being observed during the pro- FIG. 59. Normal ureteral catheterization. Second move. beyond the field. The tip of the catheter lies cedure. The tip of the catheter now comes into view, first appearing at the top of the field and gradually traveling downward, its size dimin- ishing at the same time. When its tip is a short distance below the ureter, it is usually in the proper position; in reality it then lies in front FIG. 60. Cystoscopic view. The catheter is being pushed across the field. FIG. 61. Cystoscopic view: the catheter lies beyond the field; view seen in Fig. 59. < nearer the neck of the bladder), below and slightly to the inner side of the ureteral mouth (Figs. 62 and 63). 4. By now raising the shaft of the instrument, and at the same time passing it farther into the bladder, the tip of the catheter is made to M u i 6 82 THE CYSTOSCOPE AND ITS USE enter the mouth of the ureter. Therefore the cystoscope and catheter as a whole travel toward the opening and not the catheter alone (Figs. 64 and 65) . In the picture we see the ureter descend to meet the cathe- FIG. 63. Cystoscopic view. The catheter tip lies just below the ureteral FIG. 62. Normal ureteral catheterization. Third move, opening; view seen in Fig. Catheter has received its full inclination. 62. ter at about the middle of the field. When the catheter has engaged the ureteral opening, it is pushed a short distance forward, the deflector is depressed somewhat, and, by still further raising the ocular, the FIG. 64. Normal ureteral catheteri- zation. Fourth move. The tip of the catheter is made to enter the ureter. FIG. 66. Cystoscopic view. Catheter has entered; view seen in Fig. 64.* introduction of the catheter becomes easy. The lid (deflector) is now turned upward, the other ureter sought, and the method repeated. Although the above may be considered as a "normal" method, cer- tain variations in technic will be required in difficult or anomalous cases. * Note that through an error the ureteral orifice has been drawn too high in the field, since it must occupy a lower position than in Fig. 57 after the instrument has been pushed inward. Cf. with Figs. 51, 52, 53 and 54. 83 Thus we may find it advantageous to change the amount of deflection or to retain the maximum deviation while pushing the catheter along the ureteral canal. If we see that the bladder wall is being raised con- siderably by the entering catheter, we know that the anterior wall of the ureter is being lifted up by the catheter. This occurs especially when stiff catheters are used and when the deflector has been turned down too far, for in both instances the catheter has a tendency to seek a higher level, one approaching the plane of the shaft of the instrument. To overcome this, three maneuvers are permissible, either raising the ocular so as to bring the catheter more nearly in the direction of the uretheral canal or increasing the deflection, or a combination of both. If carefully carried out, this procedure is far superior to that by which the catheter is "aimed" at the opening and pushed out to meet it. It affords a more certain way of hitting the mark, avoiding scraping of the bottom of the bladder, and is easy of execution. * FIG. 66. Catheterization with the direct cystoscope. Technic with the Direct Cystoscope. In our experience the direct method of catheterization is far inferior to the indirect. The direct cystoscope will practically never be found necessary for ureteral catheterization. After introduction of the instrument, the obturator is removed and the bladder irrigated. The telescope armed with two catheters is then introduced and boric acid solution allowed to enter. The trigone is then inspected, it being remembered that the instrument looks directly forward and that the intravesical portion of the instrument necessarily comes into contact with the trigone. The latter, therefore, appears considerably enlarged and is distorted by virtue of the fact that the plane of the field lies in the axis of the instrument (Figs. 35 to 38). When the ureter is recognized, the ocular end of the instrument is raised somewhat and the catheter introduced into the direction of the * For those who catheterize at close range, particularly when the convex sheath is used, the method described need not be followed. 84 THE CYSTOSCOPE AND ITS USE canal (Fig. 66). The instrument is then turned to the opposite side, an attempt being made to follow the interureteric bar, and the other ureter recognized and catheter ized. Technic with the Elsner-Braasch Cystoscope (or Endoscope).* In the hands of a few experts this method still finds application, but is not recommended for the average cystoscopist because the view is too limited; thorough inspection of the bladder is impossible; observation cystoscopy necessitates wide excursion of the ocular end of the instru- Retro pubic (5) Vertex Right cornu (3) Sacral ar'ea (?) Base 0) FIG. 67. The position of the Kelly endoscope in viewing the bladder. and Burnam.) (After Kelly ment ; the procedure is much, more painful and disagreeable than the indirect method; in difficult cases the finding of the ureters takes a great deal more time and is not as certain as with the indirect method; the acquisition of the requisite technic is painstaking and success with the method is relegated to a very few. As for the technic, the instrument is introduced with the obturator removed, the bladder irrigated, and the ocular end is closed with a glass window. Through an irrigating cock a continuous flow of boric acid solution bathes the telescopic tube and enters the bladder. The * For those who occasionally use this method, the Buerger universal cysto-urethro- scope will be found just as serviceable. OPERATIVE CYSTOSCOPY 85 operator looks through the glass window, inspecting the trigone, and by a lateral motion brings the ureteric orifice into view. The catheter is then put into the corresponding catheter canal and introduced into the orifice under the guidance of the eye. With the Kelly-Pawlik Endoscope. A method for direct examination of the bladder first adopted by Kelly and Pawlik was described by H. A. Kelly as the rerocystoscopic method 9 (Fig. 67). In this method, distention of the bladder with air is induced by posture. A simple speculum or urethroscopic tube is introduced and located by with- drawing the speculum until the internal urethral orifice is seen. It is then carried in a short distance and pointed from 20 to 30 to one or the other side, the base of the bladder being viewed. With the orifice in view a ureteral catheter provided with a stylet is held in the right hand for catheterization of the left ureter, in the left hand for entering into the right ureter. The stylet is then removed. If we wish to catheterize both ureters, the speculum is withdrawn, reinserted, and the same maneuvers carried out for catheterization of the other ureter. Luys's Method. Luys recommends his modified endoscopeor urethro- scope for catheterization of the ureter of the male, employing an exaggerated Trendelenburg posture. The bladder is kept dry by con- tinuous suction through a special canal in the endoscope. This method will be found too difficult and uncertain for anyone but the expert. OPERATIVE CYSTOSCOPY. In this we include all those special diagnostic and therapeutic man- ipulations that can be carried out through a catheterizing cystoscope or through an operative cystoscope. The Buerger and Lewis operating cystoscopes are the simplest and used most widely in the United States. The Nitze and Kuttner cystoscopes are employed on the Continent. FIG. 68. Buerger operating cystoscope with forceps of the recessive type in place. The Buerger Operating Cystoscope. The instrument resembles the catheterizing cystoscope, but its sheath is elliptical and its telescope provided with but a single outlet (Fig. 68). Concave and convex sheaths are provided and telescopes for giving either a right-angled 8G THE CYSTOSCOPE AND ITS USE view, an obliquely forward view, or a slightly retrograde view, depend- ing upon the region to be attacked. The right-angled telescope will suffice for almost all cases. The Buerger Combination Operating Cystoscope. This instrument at first glance indistinguishable from the others, offers the possibility of introducing examining, catheterizing and operating telescopes into the same specially designed sheath. As far as the requirements of ob- servation and operating cystoscopy are concerned, it is identical with the catheterizing cystoscope. For operating purposes it is usually adequate, although it carries slightly smaller operating devices. FIG. 69. Working ends, operating forceps and snare. The Operating Instruments. Two varieties are available, the recessive* and non-recessive or scissors type. In the first the general assembly includes a shank carrying the special working ends or jaws (Fig. 69), a flexible spiral cannula and a handle. The distal extremity of the cannula is reinforced, serving for the closure of the jaws of the instru- ment. By means of a universal scissors type of handle the jaws are drawn into the cannula and thereby made to close (Fig. 70). In the second type of operating instrument the closure of the jaws is brought about by a scisssors mechanism which obviates recession of the jaws as they shut (Fig. 71). Grasping, cutting, biting forceps and scissors for cutting the ureteral orifices are provided. A very useful and simple instrument is a snare, which comprises a spiral cannula whose distal end is capped with a solid metal knob con- * This type has been found less generally useful than the scissors type, the latter being recommended. OPERATIVE CYSTOSCOPY 87 taining two perforations for the emergence of the wire loop and whose proximal end is fitted with a catheter channel which may be closed by a rubber tip. FIG. 70. Operating forceps in telescope. Besides, bougies for dilatation of the ureter a special bougie through which the d'Arsonval current may be applied will be found useful. A No. 9 French silk ureteral catheter serves to insulate a wire conductor, the proximal end of which has a coupling for attachment to the high- FIG. 71. Scissors type of operating forceps. frequency machine, the distal end being provided with a screw thread. To the latter, metal olives of various sizes are attached in sizes from 6 to 16 French. 88 THE CYSTOSCOPE AXD ITS USE The Technic of Operative Cystoscopy. In the Buerger instrument it is possible to employ operative instruments of much greater size than the catheter outlet would seem to allow by a retrograde insertion of the working devices. All of the larger instruments must be intro- duced somewhat in advance of the telescope so that they may pass through the telescope alone, emerging through the fenestra before the telescope is locked home. 1. Technic with the Recessive Type of Instrument. The operating telescope is prepared as follows : The cannula provided with a rubber nipple is introduced into the telescope through the catheter outlet until its extremity lies about 1 cm. beyond the lens prism. A suitable work- ing end with its shank is now inserted in reverse fashion and the handle securely attached. After introduction of the sheath and thorough inspection with an observation telescope, fitted to the operating sheath, the operating telescope armed with the instrument selected is introduced as follows : The working end with jaws closed enters in advance, and, if it is some- what too large to escape at the fenestra in all possible positions, may be made to emerge by slight motions of rotation or with the aid of slight deflection of the lid. With the bladder filled, the lesion or foreign body is located. The cannula is pushed inward for the requisite dis- tance, the jaws are opened, and by a combination of movement of the cystoscope and deflector the part to be attacked is readily seized. To overcome recession of the jaws the cystoscope or cannula must be pushed inward slightly as the jaws are made to close. Small bodies, tissue, and tumors are easily extracted through the sheath, the tele- scope and operating device being removed together. In extracting larger bodies, such as a ureteral calculus or foreign bodies, the cysto- scope is withdrawn first, the forceps following. If it is desired to replace the particular operating device just used with another, the telescope is withdrawn, the jaw with its shank removed and another inserted, the cannula and handle remaining undisturbed 2. Technic with the Scissors Type. After being provided with a suit- able tip or nipple the operating instrument (forceps or scissors) is adapted to the sheath by being passed through the catheter outlet. Larger jawed instruments must be inserted in the manner described as suitable for the recessive instruments. The technic is the same as recounted above, except that it is unnecessary to move cystoscope or cannula while the jaws close. It is best to open the jaws before deflec- tion, since bending of the cannula interferes with easy working of the instrument. Whenever small devices are needed the scissors type is recommended; when larger forceps for removal of foreign bodies, as ureteral calculi, are required, the recessive type is preferable. Methods in Operative Cystoscopy. The Diagnosis of Ureteral Cal- culi by Means of Wax-tipped Catheters. This method of detecting a calculus in the ureter through scratch marks left upon the surface of a wax-tipped catheter was first suggested by Kelly, of Balti- more. In females there will be no danger of producing adventi- tious scratch marks, if the Kelly endoscope is used. In the male, 89 when the direct cystoscope is employed, the following special technic must be observed: Either the catheterizing cystoscope or the opera- ting cystoscope is selected, preferably the latter. A No. 5 French olive-tipped ureteral catheter* is prepared by dipping the tip into a mixture of equal parts of paraffin and beeswax. On withdrawal from the mixture a small fusiform mass of hardened wax remains. The fol- lowing technicf is to be followed in the male. After irrigation of the bladder with a catheter a sterile wax-tipped catheter is introduced through the urethra and made to coil up in the bladder. The sheath of the cystoscope is then threaded over it and then the catheterizing tele- scope is inserted, the butt end of the catheter being passed in retrograde fashion through the catheter outlet. The bladder is then filled and, under the guidance of the eye, the redundant portion of the wax-tipped catheter is slowly withdrawn, care being taken that the wax portion does not come into contact with metal or with the deflector. Catheteri- zation of the ureter and exploration of the same are then done. Finally, the instrument is withdrawn first, the catheter following. A search for scratch marks is then made with a pocket lens. Hinman has recently described an ingenious rubber sheath which protects the wax-tipped catheter as it glides through the operating cystoscope. 8 In the female it will be found easiest to insert the wax-tipped bougie through the urethra, thread the sheath over it, and then follow with the catheterizing telescope. Or if the operating cystoscope be not at hand, the following technic is applicable: After introduction of the sheath the wax-tipped bougie protected with a rubber tube (which projects 1 cm. beyond the wax tip), is made to enter and manipulated until tube and bougie emerge through the fenestra. The bougie is then pushed a little farther into the bladder, the rubber tube withdrawn and the telescope inserted. Special Catheterization. The synchronous employment of three cathe- ters or bougies is possible in the operating cystoscope, and useful in cases of reduplication of the ureters. A very large catheter of the Gar- ceau type may be useful in pyeloradiography and for drainage of a pyonephrotic kidney. Special catheters with bulbous enlargements to prevent reflux can be introduced through the operating cystoscope, and are valuable in pyelography. High-frequency Treatment of Tumors. This can be carried out through the catheterizing cystoscope, operating cystoscope or cysto- urethroscope. For the employment of this method of treatment which has been variously termed desiccation, fulguration, electro-coagulation, cauterization, intravesical cauterization, Beer made use of an insulated wire electrode which can pass through the cystoscope and be made to discharge the current from a high-frequency machine.! Although the * Long whalebone filiforms are useful but more rigid and less easily handled. t Since the introduction of the Buerger operating and combination cystoscopes, it is an easier procedure to guard the wax-tipped bougie with a rubber tube placed in the operating telescope. J Standard Nos. 2 and 3 made by Wappler Electric Manufacturing Company, cata- logue No. 56, pp. 41 and 42. 90 THE CYSTOSCOPE AND ITS USE exact nature of the effect of the electric sparks upon the tissues is not clearly understood, we may regard destruction of the tissues that ensues as equivalent to cauterization. Two types of current, the Oudin or monopolar, and the d'Arsonval or bipolar current give almost identical results. This procedure is applicable only in benign growths, particularly to papillomata, and must not be carried out until the exact diagnosis has been made with the microscope. For this purpose a por- tion of the tumor should first be removed with the snare or with the punch forceps through the operating cystoscope. Carcinomata do not respond, except perhaps for those small papillomata in which a change into carcinoma is just beginning to take place. When used through the cysto-urethroscope and operating cystoscope, special electrodes covered with silk and shellac insulation will be found more durable than the rubber-insulated wire first suggested. Dilating of the Ureters and Facilitating the Descent of Ureteral Calculi. For strictures of the ureter, abnormally narrow ureteric orifices, occa- sionally inflammatory conditions of the ureter due to calculus, and particularly for the purpose of expediting the descent of descending ureteral calculi, the dilatation of the ureter may be practised. With the operating cystoscope, we begin with a small catheter or small bougie, No. 5 French or less, then insert a larger one, or two or more catheters or a large bougie. Somewhat more certain and effectual is the employ- ment of graduated metal olives at the end of a bougie electrode, through which the d'Arsonval current may be applied. 1 Detachable metal olives are screwed on the end of an insulated wire electrode. These can be introduced after the fashion of a ureteral catheter. With a large indifferent electrode over the lower abdomen, the second pole being the metal olive, a current of 200 to 400 milliamperes is allowed to pass, while gentle pressure is exerted against the point of ureteral obstruction. Often the obstruction gives way after a few seconds' contact. The small olive (beginning with No. 5 or 6) is then removed, and a larger one inserted, the process being repeated until adequate dilatation has been produced. When using the larger olives, it is important that the olive protrude beyond the objective and enter the sheath first, or else introduction into the sheath will fail. In many cases of descending ureteral calculi a small stone will be made to pass shortly after dilata- tion by this procedure. This may be combined with the injection into the ureter of olive oil or glycerin and the employment of the current is not always essential. When the ureteric orifice is not too small, the procedure may be preceded by meatotomy of the ureter. The Removal of Foreign Bodies, Calculi and Phosphatic Encrustations. The technic of the removal of foreign bodies with the operating cysto- scope will depend upon their size, structure and shape. We must be guided in the selection of the type of forceps by these considerations. When the body is too large to pass through the sheath, which is often the case with descending ureteral and also vesical calculi, the forceps with body in its grasp is first pushed farther into the bladder beyond the beak. The cystoscope is then rotated so that its beak points up- 91 ward,* and the cystoscope, forceps, and body are removed simultane- ously, the foreign body being the last to appear from the urinary meatus. For the removal of phosphatic encrustations in alkaline and ulcerative cystitis, the operating punch forceps or a special curette will be found invaluable in clearing up an otherwise intractable cystitis. The sheath must remain in situ while the encrustations are removed piecemeal. Ureteral Meatotomy. This may be necessary as a preliminary pro- cedure before dilatation of the ureter to facilitate the passage of a cal- culus; also in cases of congenital stenosis of the ureter. Special scissors are used to cut the upper ureteral lip. Exploratory Excision (Intravesical Biopsy). We are not infrequently confronted with alterations of the vesical mucous membrane, whose exact nature is doubtful. For the diagnosis of certain cases, excision of lesions followed by microscopic examination may be indicated. In the case of suspected carcinoma the removal of adequate pieces, prefer- ably from the periphery of the growth, is absolutely imperative. In the cases of suspected renal tuberculosis when there are early changes, such as edema and polypoid protuberances in the neighborhood of one ureteral orifice, excision of tissue from the ureteral lip will disclose miliary tubercles under the microscope. When tubercle bacilli are not found, we often can make a diagonsis in this way. Snaring of Papillomata. Experience 6 has shown that carcinoma must be ruled out in the case of all papillomata by means of histological ex- amination. Whenever feasible, therefore, a large part of the growth should be removed w r ith the intravesical snare. This can be readily accomplished when the tumor has attained sufficient size and lies in accessible portions of the bladder. In certain positions, such as the immediate neighborhood of the sphincter, the snare is not applicable. Here the removal of material by means of the punch forceps through the operating cystoscope or operating cysto-urethroscope must be substi- tuted. The snare is provided with a loop of No. 00 piano wire, which is developed by pushing out one and then the other of the wires. The tumor is encircled, the end of the cannula being carefully held against the pedicle lest the papilloma elude the grasp of the loop as it is being drawn tight. Because of the peculiar villous nature of these growths, tumors of considerable size can be forced through the sheath of the operating cystoscope. Excision of Ulcers. Callous ulcers of the bladder, particularly in females, and foci that are covered with phosphatic encrustations, when these cause an irritable bladder, should be treated with excision with the punch forceps. Operations on Ureterocele and Cystic Bodies. When there is an anoma- lous or congenital stenosis of the ureter ic orifices, or when there is a condition of cystic dilatation of the lower end of the ureter, incision with a special intravesical knife or with cystoscopic scissors, combined with the use of the punch forceps, may completely abolish the cause of the obstruction and make for drainage of the kidney. 4 * Rotation is unnecessary if a convex sheath is employed. 92 THE CYSTOSCOPE AND ITS USE URETHROSCOPE AND URETHROSCOPY. Urethroscopy deals with the inspection of the male and female urethra in their entirety. In the male we may arbitrarily divide the urethra for purposes of urethroscopy, into the anterior urethra, the posterior urethra and the urethrovesical or sphincteric portion. In the female we may divide the canal into the urethra proper and the sphincteric or urethrovesical portion. The anterior urethra may be brought into view in two ways : directly with the urethroscope, also called endoscope, and indirectly with tele- scopic instruments. The posterior urethra may be viewed directly by endoscopes of the straight or curved variety, indirectly by means of a cysto-urethroscope. The sphincter or urethrovesical portion in the male may be poorly and inadequately viewed by means of the direct method, thoroughly inspected by the indirect method through the cysto-urethroscope. THE URETHROSCOPE. The simplest and most useful instrument for viewing the anterior urethra is a tube into which light can be thrown either from without by means of a small electric lamp or from within by means of a light carrier introduced into the tube (Fig. 72). A small magnifying lens is invaluable to enlarge the picture. A set of tubes in sizes of 20, 22, 24, 26, 28, and 30 French should be available, Nos. 24, 26, and 28 being the most frequently used. Although this instrument will suffice for routine work in the anterior urethra, the cysto-urethroscope is em- ployed by many for a study of those finer details that may escape observation by direct vision. Technic of Urethroscopy. The patient is placed either in the dorsal decubitus with the operator standing on his right or in a modified lithotomy position with the thighs horizontal, the legs vertical, and the feet supported upon a rest, in which case the operator stands between the patient's thighs. The former position will be found convenient for the inspection and treatment of the anterior urethra. The set of urethroscopes having been boiled, the lamp having been tested, the operator selects a tube of ample size, preferably 24, 26, or 28 French. If the meatus is too small, meatotomy may be done. After cleansing the foreskin and meatus the left hand holds the penis, while the endoscope with the obturator in place, previously lubricated, is allowed to find its way into the urethra, until it is arrested at the bulbomembranous junction. The obturator is removed, the urethra and tube mopped dry by means of sterile cotton applicators, the light applied, the lens adjusted, and the urethra is ready for view. The left hand continues to hold the penis while the right hand gradually with- draws the endoscope. In most cases local anesthesia is not recommended for simple observa- tion urethroscopy, because it may produce anemia of the mucous mem- THE URETHROSCOPE 93 brane, and may wash away secretions whose source is to be determined. If painful operative procedures are to be done, a 2 per cent, or 4 per cent, novocain solution is injected and allowed to remain in contact with the urethra for five minutes. FIG. 72. Urethroscope for viewing the anterior urethra: 1. obturator; , light carrier with small lens attached; 3, electric coupling and cable; 4< endoscopie tube. Urethroscopic Picture. The essential features of the urethroscopic view are the character of the central figure and of the mucous mem- brane. The central figure is that artificial termination of the urethral canal produced at the far end of the urethroscope. By virtue of the distending effect of the endoscope the urethral walls are symmetrically separated at the level of the end of the tube and present, in their gaping condition, a funnel whose outlet is made up of the centre of the urethral canal (the central figure) and whose walls are the mucous membrane immediately in view. The shape of the central figure will vary in different parts of the canal, being a vertical slit in the region of the glans, being punctiform in the penile urethra, and becoming a more or less transverse crevice farther down in the canal. 94 The surface of the mucous membrane presents for consideration the longitudinal folds, longitudinal striae, the lacunas of Morgagn i, and the glands of Littre. The longitudinal folds by virtue of their disposition may be likened to the spokes of a wheel and become considerably altered by patho- logical changes in the mucous membrane. The longitudinal striations are the consequence of vascular ramifica- tions, and are seen as red converging markings on a paler, yellowish-red background. The surface of the mucous membrane is smooth and shiny, any loss of brilliancy being evidence of pathological change. The lacuna? of Morgagni are crypts situated on the superior roof of the penile urethra, and their orifices can be seen as minute depressions whose color does not vary from the surrounding mucous membrane in the normal state. The larger lacunae have orifices that are Y-shaped, the point being turned toward the central figure. The glands of Littre are very numerous and hardly recognizable except when they have undergone pathological change. The Cowper's glands are rarely visible in the floor of the bulbous urethra. The Pathological Anterior Urethra. As a result of gonorrheal inflammation, two broad types of lesions in the mucous membrane may result, "soft infiltration" and "hard infiltration." Soft Infiltration. This is characterized by a turgid condition of the mucous membrane, histologically by infiltration of the submucosa with round cells and increased vascularization. This condition results or accompanies acute urethritis, also the earlier stages of chronic urethritis. The mucous membrane is hyperemic, inflamed, turgid, and not unlike a group of hemorrhoids. The central figure is closed, the longitudinal strise disappear, and the longitudinal folds are effaced. The lacuna? of Morgagni and glands of Littre are usually involved, their glandular secretions being increased. The mucosa in the imme- diate neighborhood is a deeper red and slightly swollen, and the excretory ducts of the Littre glands are more prominent than normal. Hard Infiltration. This is distinguished by pallor of the mucosa, histologically by connective-tissue proliferation, the end-result of an exudative cellular inflammation. This corresponds to the condition of " stricture of large caliber" described by Otis. The urethroscopic tube meets with a certain resistance in its passage through such a urethra. The walls present a characteristic rigidity, having lost their normal suppleness. When the endoscope is withdrawn the central figure gapes and the eye may look down much farther than in the normal case. There is notable diminution in the coloring of the mucosa, pallor, a grayish-yellow color or even a whitish-gray appearance. Lesions in the Lacunae of Morgagni and Littre's Glands. Two types of lesions must be recognized, the glandular form, or open lesion, and a dry or follicular form, the closed lesion. Glandular Open Lesions. Here the orifices of the glands of Littre are enlarged and surrounded by an inflammatory zone. A drop of secre- tion, sometimes purulent, sometimes clear, may be seen emanating from THE URETHROSCOPE 95 the orifice. Similar changes are seen about the lacunae of Morgagni. Their orifices are crater-like, and mucoidal or purulent secretion escapes. The Dry or Follicular Form. When the excretory ducts are closed, the glands become shut off and secretion accumulates so as to form cystic bodies which may harbor the gonococcus. For the more rare lesions, such as ulceration, leukokeratosis, leuko- plakia, syphilitic lesions, chancroid, varices, new growths, papillomata, polyps, sarcoma, tuberculosis, etc., special works on urethroscopy should be consulted. Urethroscopy of the Posterior Urethra. The posterior urethra can be brought into view in two ways : directly, through a straight or curved urethroscopic tube, and indirectly, through a cysto-urethroscope carrying a telescopic lens system (Goldschmidt or Buerger). With Endoscopes.- Two types of instruments may be used for this puspose: The straight tube employed for inspecting the anterior ure- thra, or the curved tube w r ith a beak as suggested by Lowenhardt and modified by Swinburne. These instruments were much in use before the development of the cysto-urethroscope, and, although they still have a sphere of usefulness in the hands of those who frequently make topical applications, they may be regarded as being so greatly inferior to the cysto-urethroscope, that, in our experience, they need rarely be employed. A useful type is that in which the lamp is carried in a special groove and does not encroach upon the lumen of the tube. When it is desired to look into the bladder also by direct vision, the Luys endoscope is recommended since the field can be kept dry by aspiration. Some urologists find an attachment for air inflation of the urethra of value. Technic: W r ith the bladder empty and after the application of the local anesthetic, the patient is placed in either the lithotomy or modified lithotomy position, with the inclination of the Trendelenburg posture if the Luys tube is employed. In the female the knee-chest position is preferred by many. After the patient has voided, the urethroscope is introduced, the urine aspirated either through a special aspirator or through the canal in the urethroscopic tube or mopped out with cotton applicators, the lamp applied, and inspection is begun at the internal vesical sphincter. The urethroscope is withdrawn gradually, the pos- terior urethra being inspected as it prolapses into the lumen of the tube. It is difficult to avoid traumatism in these manipulations. With Cysto-urethroscopes. Since the introduction of the telescopic variety of instrument for viewing the posterior urethra the direct method has been discarded by a large number of urologists. In our own opinion a cysto-urethroscope is to be preferred both for routine examinations and for therapy, for the following reasons: it produces no trauma, may be easily introduced, and is very well borne by the patient; the view of the ureters, trigone, sphincteric, and juxta- sphincteric regions and posterior urethra is immeasurably superior to that obtained with any other system ; by the use of a constant flow 96 THE CYSTOSCOPE AND ITS USE of irrigating fluid that dilates the posterior urethra the to-and-fro as well as the rotatory motions of the instrument are facilitated, trauma- tism is obviated, pain is dispelled, the urethra is unfolded, and the thoroughness of inspection is enhanced; even the region of the neck of the bladder, almost inaccessible in a therapeutic sense through other instruments, can be attacked with ease; in the diagnosis of prostatic hypertrophy the cysto-urethroscope gives exact data obtainable with no other instrument. The Goldschmidt Instrument. This is made up of a sheath with a large fenestra whose width corresponds to the diameter of the sheath, necessitating the cutting out of one-half of the circumference of the tube. A non-prismatic telescope is introduced, the source of illumina- tion being situated either in the beak or in the roof of the sheath. Al- though a fairly good view of the urethra is obtained with this instru- ment, objects must necessarily suffer considerable distortion, owing to the fact that the part to be seen is parallel with the axis of the telescope. Then, too, the source of illumination takes up a portion of the field, disturbing the picture. Wossidlo has modified this instrument so that the view and accessibility of the parts for treatment are enhanced. The Buerger Cysto-urethroscope. T\vo types of instrument are avail- able, one for simple observation and another for special operative work, the optical principle involved being the same in both. In the Buerger cysto-urethroscope a true picture of the interior of the posterior urethra is obtained by a special lens system, which produces scant augmentation in the size of near objects, and looks downward at right angles upon the field. The observation instrument (Fig. 73) consists of a sheath with a curved detachable beak, an obturator, and telescope. In the sheath there is a small fenestra, two irrigating cocks, and the source of illumina- tion is a small lamp behind an obliquely set window, illumination com- ing from above. The telescope is provided with a single catheter outlet and deflector. Technic of Cysto-urethroscopy.* The sheath with obturator in situ is introduced into the bladder, the obturator removed, and if the contents of the bladder are cloudy, irrigation is carried out through the sheath. Otherwise the telescope may be inserted at once, an irrigator attached to one of the lateral faucets, and a constant flow of boric acid solution is allowed to pass through the sheath, being controlled with the finger of the left hand at the stopcock. The light is then turned on, the beak turned up, the lens looking downward. The trigone is first inspected; then the sphincteric margin is brought into view, the instrument being rotated on its long axis. The instrument is then gradually withdrawn and the posterior urethra examined as far as the membranous urethra. The instrument is then introduced again beyond the sphincter and the bladder emptied, if it is too full, either through the irrigating cock or by withdrawing the telescope. By rotation of the instrument the superior * With the Buerger cysto-urethroscope. THE URETHROSCOPE 97 and lateral walls of the posterior urethra are now viewed. Finally, the membranous urethra and bulb are examined, and upon withdrawing the instrument the left hand firmly grasps the penis, so that an inspection of the anterior urethra can also be carried out. In order to facilitate localization of the findings obtained with the cysto-urethroscope, it is expedient to divide up the posterior urethra in an arbitrary way, taking certain well-defined landmarks, such as the annulus urethralis, or margin of the internal sphincter of the bladder, and the colliculus seminalis, in determining the extent of each portion. The subdivisions that are most useful in practice are the following: FIG. 73. Buerger observation cysto-urethroscope. The sphincter margin with superior (roof), inferior (floor), and lateral ]x>rtions (sides); the pars prostatica (C r ) and the pars membranacea (B) (Fig. 74). We divide the prostatic urethra into : (1) Supramontane portion between the sphincter margin and veru- montanum, with a roof, lateral walls (sides), and floor ( U}. (2) Mon- tane portion with a roof, sides and floor ( 7"). The floor of the supramontane portion shows the fossula prostatica (F P) and the floor of the montane portion contains the colliculus (verumontanum or urethral crest) and lateral sulci (sulci laterales). If we regard the complete ridge or verumontanum as the urethral crest (crista urethralis) it seems best, for topographical reasons, to distinguish the following parts : posteriorly (toward the bladder) there are usually a number of small bands that lie in the fossula prostatica and pass into the crista urethralis, namely, the posterior frenula. They, belong both M U I 7 98 THE CYSTOSCOPE AND ITS USE to the supramontane portion and to the montane. The crista shows a posterior gradual inclination or declive (S), a central prominence, or summit, and the anterior distal slope, the acclive (R). We shall drop the term urethral crest and speak only of a verumontanum or colliculus FIG. 74. Diagrammatic subdivision of the posterior urethra, the membranous urethra, and bulb. showing a summit, acclive (anterior crista), and declive (posterior crista) . The valleys on either side of the colliculus are the sulci laterales. The membranous urethra (B) receives the terminating fold of the acclive and also has a roof, side walls and floor. Normal Urethroscopic Picture (Posterior Urethra). The Supramon- tane Region. The markings of the floor are prolongations of those of FIG. 75. Floor of the sphincter and supramontane urethra. the trigone. The floor descends toward the periphery and terminates in the fossula prostatica. The mucous membrane of this region is of a deeper red than that of the roof and sides of the sphincteric margin. As for the markings, we usually find longitudinal vessels which show a THE URETHROSCOPE 99 tendency to converge toward the periphery, taking their source from the sphincteric margin and passing toward the fossula prostatica (Fig. 75). The side walls and roof present nothing worthy of note. The supra- montane region contains a proximal and a distal portion. The proximal part corresponds to the true internal sphincter. Distally the floor of the pars supramontana contains the fossula prostatica, in which lie the FIG. 76. Normal type of colliculua Fu;. 77. -Normal colliculus, showing (verumontanum) , with large utricle. three vertical slits, the utricle in the centre and the ejaculatory ducts on either side. posterior frenula, tiny ridges which pass backward from the foot of the declive, diverging as they are traced backward toward the sphincter and varying both in number, in size and inclination. At the level of the fossula prostatica we begin to meet with the larger, plainly visible prostatic ducts, that hide in the depression between the posterior frenula and at the foot of the declive. FIG. 78. Normal colliculus, showing the utricle, the ejaculatory ducts, the declive above, and the posterior frenula. The Montane Region. The verumontanum has a summit, a posterior portion or declive, and an anterior portion or acclive. The size of the verumontanum varies greatly. The general shape of the region, too, is subject to variation, insofar as it may sometimes show a deep concavity, and at other times seems to be almost filled by the verumontanum . Types of verumontanum are illustrated in Figs. 76, 77 and 78. In 100 THE CYSTOM'OPE AXD ITS USE most the orifice of the utricle can be distinctly seen. It takes a median position not far from the summit, varying in general appearance, some- times being punctiform, slit-like (Figs. 76 and 77), umbilicated, even of bizarre form. Commencing by a fine tapering extremity in the mem- branous urethra the urethral crest broadens in a triangular fashion as it ascends, becoming the acclive of the colliculus. In most cases the ejaculatory ducts can be made out as two symmetrically situated ori- fices somewhat below, distal and to either side of the utricle. They may be vertical slits or may resemble the prominent eyes of a frog when they occupy a more lateral position. In the. contracted state the color of the colliculus is a pale yellowish red. A change in color takes place when upon artificial irritation, traumatism, or psychical excitation this body becomes congested. The Sulci Laterales. Their depth varies considerably in different cases. It is in these sulci that we find a number of prostatic ducts varying from 2 to 6 sometimes in the form of tiny slit-like openings, and more frequently having a punctate shape. The mucous membrane here is also of pale reddish yellow and the vascular markings are in the form of irregular longitudinal streaks and tortuous delicate vessels. As for the side walls, these offer very little of interest. In most cases there is a fairly abrupt rise from the sulci, and in other cases there is a concavity w r hich is of a somewhat deeper red than the floor. The Pars Membranacea. As the instrument is withdrawn from the montane region with the fenestra turned downward the acclive can be followed by its tapering crest into the membranous urethra. The longi- tudinal markings are very distinct, as a rule, parallel or slightly con- verging vascular striations running distally on either side of the crest and gradually becoming lost in the floor of the membranous urethra. The delicate median ridge of the acclive, as it becomes lost in this portion of the urethra, often shows a striking pallor at its summit or middle, due partly to the pressure effect of the instrument and possibly also to an avascular condition of the part. The Bulbous Urethra. The pars bulbosa may be so large that when distended with fluid its distance from the fenestra and lamp is considerable and illumination becomes diminished. The floor presents a corrugated appearance with occasional transverse folds. The roof and the sides do not present these plica?. A useful and interesting distal land- the F buibo 9 us7nd U p n enZous f mark is afforded by the junction of the bulbous urethra; the bulb is not and penile urethra (Fig. 79). The transverse properly illuminated. margin with the illuminated mucous mem- brane below presents the beginning of the penile urethra. On either side the folded lateral wall and part of the floor of the bulbous urethra are seen, and the central upper dark region represents the poorly illuminated distended bulb. THE URETHROSCOPE 101 The Sphincter Margin. Three parts may be considered: the vesical part, which also belongs to the realm of the right-angled and retrograde cystoscope; the true margin, or ring; and the urethral portion. Owing to anatomical conditions it is impossible, in the male, to obtain a satis- factory view of a small zone adjoining the roof of the sphincter (the juxtasphincteric part of the bladder roof). The sphincteric margin, however, can be perfectly seen throughout. Our inability to depress the ocular of the instrument sufficiently makes it impossible to approxi- mate the window of the instrument near enough to obtain a proper view of an area adjoining the roof of the sphincter. At the sides, how- ever, this is easier, particularly if we allow the bladder to collapse. In examining the inferior aspect of the vesical portion of the sphincter we encounter no difficulty, for the transition from trigone to floor of the vesical sphincter is a gradual one, and there is no sudden drop or sudden concavity such as is characteristic for the roof and sides. In the female these obstacles do not obtain, the urethra being short and the instrument having perfect freedom of motion. In the picture of the floor (Fig. 75) there is an upper portion which is relatively dark and represents the poorly illuminated bladder. Below this is the beginning of the floor of the pars supramontana with its slightly convex margin, the internal orifice or floor of the sphincteric margin. The color of this part is a fairly deep red admixed with yellow, and the vascular markings run in a longitudinal direction with a tendency to converge toward the urethra. I n the picture of the sides of the sphincter we note the absence of vascular markings and a relative pallor as compared with the floor. A slight concavity is the rule. The sides are usually counterparts (Fig. 80), but the roof of the sphincteric margin often represents a more acute angle. Pathological Lesions. Just a bare mention of some important lesions can be made here. A more complete description may be sought in special monographs. 2 Sphincteric or Urethrovesical Lesions. Cystitis colli, lesions of gonor- rheal urethrocystitis, edema, leukoplakia, urethritis cystica (Fig. 81), cystitis proliferans, papillomata, anomalies, early incisure, and lobe formation indicating hypertrophy of the prostate, the tabs following healed proliferative processes all these can be distinctly made out. The supramontane region is the favorite site of urethritis proliferans, which is characterized by hypertrophy of the mucous membrane, bul- bous knobs, thickenings resembling small cysts. Widely dilated crypts occur as a sequel of gonorrhea. In urethritis chronica cystitica the formation of cysts or edematous bodies is common, and these may involve any portion of the supra- montane or montane urethra. The cystic changes may be so extensive as to involve the whole of the fossula, even converting the verumon- tanum into a cystic or edematous mass (Fig. 82) . In the montane region the lesions of the verumontanum are important : hyperemia, swelling, distortion, excrescences, enlargement, a velvety appearance, absence of vascular markings, disappearance of the open- 102 THE CYSTOSCOPE AND ITS USE ings of the ejaculatory ducts, while the utricle remains visible, etc. As a result of posterior urethritis, the mucous membrane of the verumon- tanum loses its smoothness, often developing cock's comb-like vegeta- tions. Intense changes with conversion of the summit of the verumon- tanum into a deep crater (Fig. 83) and other distortions result from the rupture of abscesses. FIG. 80. Right margin of the sphincter. FIG. 81. Cystic changes at the right margin of the sphincter. In our experience, enlargement, hyperemia, and inflammation of the colliculus are not as frequent as one would suppose from the writings of those who have relied upon direct endoscopic examination. As a result of repeated instrumentation, traumatism, or chronic urethritis the verumontanum suffers marked alterations. A number of knob-like masses may be all that is left of it ; peculiar bands may divide it into irregular portions, or it may almost completely disappear through atrophy. FIG. 82. Cystic changes in the verumontanum. FIG. 83. Atrophy of the verumon- tanum with crater formation due to rupture of an abscess. Deep scars in the montane (Fig. 84) and supramontane urethra are the sequels of instrumentation, perforation, and rupture of prostatic abscesses, traumatism and operations for stricture. Papillomata are not uncommon, particularly near the summit of the colliculus, and polyps of the lateral walls and membranous urethra are not rare. In the membranous and bulbous urethra strictures of large caliber THE URETHROSCOPE 103 with their transverse bands and ridges are frequently demonstrable. Stricture usually form shelf-like projections in the floor, sometimes extending over either lateral wall, with white crow's foot-like lateral offshoots. In prostalic hypertrophy the cysto-urethroscope will demonstrate the very earliest submucous adenoma formations. The outline of the FIG. 84. A deep scar and large crypt in the right sulcus lateralis and distor- tion of the colliculus. Fus. 85. Floor of the sphincter in so-called lateral lobe hypertrophy (prostatic adenoma). sphincter will present either an intrusion at the site of the submucous adenoma, or a distinct incisure, often at the floor, roof, or sides of the sphincter. Such clefts indicate the convergence of two contiguous adenomata or "lobes." As a rule, in cases of so-called "lateral lobe hypertrophy" the normal convex line at the floor of the sphincter, is replaced by two distinct rounded bodies (Fig. 85). These can be traced into the supramontane urethra where they look like two FIG. 86. Lateral lobe hypertrophy in the supramontane region viewed with the cysto-urethroscope. FIG. 87. Lateral lobe hypertrophy: view just above the verumontanum; the latter is small. large vocal chords, separated by a deep cleft (Fig. 86). Even the termination of these lobes in the membranomontane region can be found, and the verumontanum will appear much reduced in size (Fig. 87). A middle lobe may be combined with the lateral or may be present alone. Its presence is easily recognized at the floor of the sphincter. 104 THE CYSTOSCOPE AXD ITS USE Operative Urethroscopy. This includes all therapeutic procedures that are applicable through either a urethroscope or cysto-urethroscope. In the Anterior Urethra. Very few instruments will suffice to do all the necessary therapeutic work in the anterior urethra. Cotton appli- cators, preferably on wooden handles, a fine probe, an electrolytic needle, a high-frequency applicator and an operat've punch and alli- gator forceps should be available. The lacunae of Morgagni and glands of Littre may be destroyed either with the electrolytic needle or with the high-frequency electrode, the aim being to burn through the inner wall of the lacuna? or glands, so as to leave a wide avenue of communication with the urethra! lumen, or to completely destroy the glands. Under special circum stances a small Kollmann knife may be of value in incising closed inflammatory foci. 10 In the Posterior Urethra. The straight urethroscope, the Swinburne, the Goldschmidt,Wossidlo, or the Buerger instruments may be employed. Through urethroscopes (endoscopes) the following manipulations have been suggested: the application of silver nitrate in the strengths of 5, 10, 15 and 20 per cent, to lesions in the posterior urethra; cauteri- zation of polypi and papillomata with galvanocautery or the high- frequency current; incision of cysts or closed suppurative foci with a knife; the injection of the utricle with silver solutions through a special cannula; and the removal of foreign bodies with forceps. All of these procedures can be carried out by experts, but will be found difficult of execution through mere endoscopes. Practically all necessary manipu- lations can be more easily learned and more precisely executed with the operating cysto-urethroscope. Operating Cysto-urethroscopes. * These are of two types, the indirect (prismatic) and direct (non-prismatic). The general construction (Fig. 88) of- the indirect type is the same as that of the observation cysto- urethroscope, except that the fenestra and the catheter outlet are larger, both being ample for the insertion of operating devices. The lamp is arranged to give adequate illumination in the bladder as well as in the urethra. Synchronous catheterization of the ureters is possible, either through the operating telescope or through a special telescope f pro- vided with two smaller outlets, and a fin to separate the catheters. Technic and Application. With the operating punch forceps the following thera- peutic and diagnostic procedures are possible: (1) the removal of excrescences, inflam- matory hypertrophies, and inflammatory polypi at the vesical sphincter and in the urethra; (2) the ablation of polypi and papillomata in the urethra of the male (this can be carried out in a few seconds and will be found much easier technically than through a straight tube); (3) the removal of pieces cf tissue for diagnosis; (4) the opening of the superior wall of the utricle when this harbors inflammatory exudate, the injection of silver solutions being less efficacious; (5) the application of the high- frequency current through a special electrode! (the d'Arsonval current is preferred). One of the most useful fields for the application of the operating cysto-urethroscope is in the treatment of papillomata at the sphincteric * Buerger Operating Cysto-urethroscope, Wappler Electric Manufacturing Company, catalogue 59, p. 11; and Buerger universal cysto-urethroscope. t This may be obtained by special order from the Wappler Electric Mfg. Co. J Bugbee electrode, Wappler Electric Manufacturing Company, catalogue 59, p. 16. THE URETHROSCOPE 105 margin and for the diagnostic removal of pieces of tumor in this region. The application of medicaments to the posterior urethra through the operating cysto-urethroscope is carried out as follows: After the lesion is recognized the sheath is firmly held with the left hand in the position in which the lesion was found, while the telescope is removed and the fluid aspirated or mopped out of the sheath. Then the medi- cated applicator is introduced. Fie. 88. Buerger's operating cysto-urethroscope. This instrument has recently been constructed according to Buerger's specifications of a caliber equivalent to 21 French, a useful instrument in -case of stricture and prostatic adenoma. Buerger's Universal Cysto-urethroscope. This instrument employs the Goldschmidt- Xit/.o typo of direct non-prismatic telescope in a specially designed endoscopic tube, and is so constructed that by interchange of its parts it is available either as a cysto-urethro- scopi-f )[ the anterior urethra, an air-inflating or aero-urethroscope, a posterior urethro- scope or cysto-urethroscope of the irrigating type, a Kelly cystoscope, an Elsner-Braasch cystoscope, and a direct catheterizing cystoscope and operating cystoscope. It consists of FIG. 89. Buerger's universal urethroscope with Philip's filiform bougie for treatment of strictures of the urethra. a straight endoscopic tube (Fig. 89), an obturator for the anterior urethra, a curved obtu- rator for the posterior urethra and bladder, a light-carrying tube, a telescope, and a magni- fying window. The endoseopic tube carries a large catheter outlet for the introduction of operating devices, applicators, catheters, etc., and permits of the introduction of either of the two obturators and also the light-carrying tube. Either the direct non-prismatic telescope or the magnifying window fit into the ocular end of the light-carrying tube. 106 THE CYSTOSCOPE AND ITS USE Ter,hnic. The sheath fitted with the curved obturator for the bladder and posterior urethra or the short obturator for the anterior urethra is introduced, and when the bladder and posterior urethra are to be inspected the obturator is removed, the bladder emptied and irrigated through the sheath. The light-carrying tube and telescope are then locked into place, and the irrigating fluid is allowed to flow. The trigone and ureters come into view and the ureters may be catheterized according to the direct method. The instrument is withdrawn, the trigone, the sphincteric region, the supra- montane, montane, membranous, bulbous, and penile urethra are inspected, a sort of perismjiir view being obtained of the neck of the bladder and urethra. This instrument will be found particularly useful in the recognition and treatment of filiform strictures of the urethra. Urethroscopy in the Female. The Kelly type of .endoscope answers for work in the urethra itself. For the juxtasphincteric margin, how- ever, the operating cysto-urethroscope is to be preferred. Selection of Cystoscopes, Urethroscopes, and Cysto-urethroscopes. In the vast majority of cases (more than 99 per cent.) the Buerger com- bination cystoscope with two sheaths will suffice for observation and ureteral catheterization. A No. 18 French single catheterizing and a 21 French Buerger catheterizing cystoscope are useful when small cali- ber is desirable. In children a small Nitze or Otis-Nitze (10 or 12 French) for observation, a single catheterizing (17 or 18 French), and Buerger's smallest 15 French single catheterizing have their sphere of application. In special cases, such as contracted bladder, in prostatic hypertrophy for study of the sphincteric region, and when the posterior urethra, too, must be attacked, the operating cysto-urethroscope is to be used. It combines the possibility of operative work with synchronous ureteral catheterization either through its operating telescope or through a special telescope carrying a fin and two catheter outlets. \Yhenever we desire to combine ureteral catheterization with any endovesical operative procedure, an operating cystoscope, or the combination operating cystoscope (p. 86) should be selected. For inspection of the anterior urethra the straight tubes (Valentine, Squier, Luys, or Young) are admirable. For the posterior urethra the Loewenhardt, Swinburne, or Luys find adherents. The cysto- urethroscope is best in our opinion. In treating the posterior urethra the two types of Buerger operating cysto-urethroscope are recom- mended. For Buerger's method of treating filiform strictures of the urethra the direct non-prismatic universal cysto-urethroscope should be employed. BIBLIOGRAPHY. 1. Buerger: Am. Jour. Surg., April, 1913. 2. Buerger: Am. Jour. Urol., January, 1911; loc. cit., January, 1912. 3. Buerger: Ann. Surg., February, 1909. 4. Buerger: Med. Rec., June 21, 1913. 5. Buerger: New York Med. Jour., April 1, 1911; Am. Jour. Urol., September, 1911. 6. Buerger: Surg., Gyn. and Obst., August, 1915. 7. Frank: Med. Klinik, 1907, No. 12. 8. Hinman: Jour. Am. Med. Assn., June 26, 1915. 9. Kelly: Johns Hopkins Hosp. Bull., 1893, iv, 101; Am. Jour. Obst., xxix, 1. 10. Oberlander-Kollmann : Die chronische Gonorrhoe der mannlichen Harnrohre, Leipzig, 1910. CHAPTER III. METHODS OF DIAGNOSIS IX LESIONS OF THE URINARY TRACT. BY BRAXSFORD LEWIS, M.D. Introduction. The following general remarks on genito-urinary diagnosis may be looked on by some as an innovation not sanctioned by custom, and one hardly appropriate to a scientific treatise for urologists. But when it is understood that they are written for the advancement of the scientific aspects of urology to bring up and straighten out the irregular marching lines where they are hesitant and lagging; when it is understood that they are written from the stand-point of the earnest student of facts and causes; and that the conscientious hope exists that they may throw some light on the vital and glaring question, why so many failures in genito-urinary diagnosis continue to appear, not- withstanding that this is an era of ample instrumental equipment and well-organized technic for the successful practice of urology it is hoped that these remarks may seem timely and appropriate. But especially is it desired that they may be received in the spirit in which they are tendered, as having the sincere purpose of being serviceable and practically beneficial to all concerned to patient, specialist, and practitioner. In further explanation, it might be said that the writer esteems diagnosis as the most important, by far, of all the subjects of urology; and he believes that anything that contributes to a better under- standing of its general principles, its successes or its failures, should promote the interests of urology from its foundation up. SOME VITAL TRUTHS REGARDING GENITO-URINARY DIAGNOSIS. Diagnosis in urology has experienced mutations and phases of evolu- tion just as have other departments of medicine and surgery. While in ancient times Hippocrates and Cornelius Celsus pursued logical though primitive methods in reckoning diagnoses and applying their deductions to the treatment of urinary retention, stone, and other genito-urinary affections, it remained for the later period of medi- evalism to witness the most extreme exploitation of the urine as an index of disease. Guiteras 1 relates that at this period (about the fifteenth century) examination of the urine was resorted to not only by the regular practitioner and the university graduate, but also by the school of quacks, known as uromancers or uroscopists. These (107) 108 METHODS OF DIAGXOHIH I\ LEMOXX OF I'RIXARY TRACT quacks would gravely inspect urine passed into glass flasks and imme- diately guess the illness and temperament of the patient, and then base a miraculous cure thereon. While the modern trend is hardly so materialistic as this, it is, nevertheless, a fact that there have been marked changes in that direction in methods of investigation for devel- oping diagnoses, even during the last quarter-century. Previous to that time investigators of greatest acumen had, perforce, to resort to and rely on the evidences then attainable in genito-urinary diseases, which consisted mainly of symptomatology plus the external evidences observable and an examination of the urine. Under the stress of neces- sity urologists became most skilful in refined analysis of symptoms, weighing at its full value every deviation from the normal either as detected by them or as related by the patient; the art of deduction doubtless reached its ultimate degree of perfection in the hands of Ricord, of Fournier, Guyon, Sir Henry Thompson, and Ultzmann. The contributions of Guyon fairly scintillate with logic and acumen as they relate the diagnostic estimate to be placed on the symptoms of urinary tuberculosis, urinary lithiasis, "painful cystitis," etc. But the trouble came when there were no symptoms to analyze; when there were kidneys destroyed by stone and never a backache; when there was pus in urine and little to indicate its source; hematuria and no index of its causation or its point of origin. The difficulties of the situa- tion were enhanced by reason of the fact that the genito-urinary organs, hidden more or less in the body, were inaccessible to the means of research then available; and reliance was limited to the examination of the only factor that was at hand, namely, the urinary excretion. There can be no doubt that accurate and comprehensive diagnosis has been the most influential factor in the establishment of urology on the scientific and satisfactory plane on which it rests today. It was the turning of the patient inside out, so to speak, and the plain demon- stration of the cause and nature of his complaints by means of the various instruments of diagnostic precision, that has accomplished the miracle of evident progress; that has developed urology from venere- ology; that has won this field from the domain of obscurity and empiri- cism to one of science and accomplishment. Nevertheless, while urology as a specialty has progressed in the man- ner and extent mentioned, it cannot be said that the general profession has kept pace with its progress. The chief basis for this remark lies in the countless number of genito-urinary patients who suffer needlessly from month to month and year to year ten, twenty or more years, often w r hile under the care of practitioners who go no further in efforts at relief than to supply various "favorite prescriptions" for urinary symptoms or complaints. Instead of giving undivided attention to efforts at learning the source and causation of a hematuria, they supply drugs and measures for stopping the bleeding, which is the worst object that could be accomplished by them at that time. Instead of learning the origin and nature of an infection, they are industriously and empirically supplying "internal antiseptics," vaccines, or urinary VITAL TRUTHS REGARDING GEN ITO-URI NARY DIAGNOSIS 109 soothing syrups, that palliate, perhaps, but incidentally postpone the day of definite diagnosis and effectual relief. The patient may, indeed, have cause for self-gratulation if he is not incidentally conducted, mean- time, from a benign into a malignant period of gro"wth in the bladder, passing from a condition amenable to treatment into one beyond relief or ho'pe. When he is finally referred for the examination that has been long deferred or ignored, he is found to be beyond all human aid save that of palliating his progress to the grave. The failure of relief in an infinite number of such cases is due, not to obscurity of the disease or difficulty in diagnosis, but to the fact that no effort to attain a real diagnosis is systematically or methodically made or even advised. The precious time is spent on so-called treatment, and a wonderful oppor- tunity is wasted. If members of the profession could collectively realize the truth and import of these facts they could better appreciate the incalculable importance of genito-urinary diagnosis as compared with immature and ill-based therapy, and would oftener refrain from the reversed action alluded to. It is believed that so great is the importance of this matter that an awakening and reformation of the profession in this respect would not only redound to its benefit in scientific progress, but would markedly subtract from the sum total of human misery as well as add materially to the span of human life. There is one thought in this connection that cannot be suppressed or overlooked: Whenever a practitioner of medicine, either general or special, undertakes the care of a patient, he assumes responsibilities that he cannot avoid ; he takes on the moral obligation to supply or to have supplied to that patient all means and mechanisms at the disposal of the profession that are necessary for securing the relief desired, and this whether the practitioner is himself capable of using them or not. Lack of familiarity with the use of the a*-ray machine, or failure to possess one, does not excuse him for depriving his patient of the advan- tages of such a machine when needed. The same reasoning applies to the ophthalmoscope, or the cystoscope or any other of the parapher- nalia so useful and often so essential in modern medicine and surgery. Another broad fact of importance in this connection is that no prac- titioner who undertakes the care of such cases has the right to disclaim knowledge of the appliances used in the various specialties, and on that account justify himself for emitting the false doctrine that "nothing else can be done" in a given case. No one, in the author's humble opinion, has the right to make any such ex-cathedra statement, and many a poor patient has, doubtless, been assisted to his grave on account of it. A better, truer, and more serviceable axiom would be: Some- flung can always be done. And, it might be further remarked, mainly through diagnosis. As to the causes of backwardness and inadequacy in genito-urinary diagnosis, it is probable that a part of the difficulty lies in the fact that the methods and technic of genito-urinary examinations, being of 110 METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT comparatively recent development, are not yet familiar to the pro- fession at large, or that they assume formidable proportions in the perspective of infrequent use or lack of practical experience. As a matter of fact, for most genito-urinary diseases the demands of serviceable diagnosis are easily met and may be carried out by anyone who possesses a logical mind and a reasonable acquaintance with labora- tory technic. This remark, of course, does not apply to the more re- fined and difficult steps of investigation, such as those of endoscopy, cystoscopy, etc. But for the ordinary investigation the greatest lapse seems to be in the lack of a formulated plan for pursuing the examina- tion. Relative Value of Symptoms and of Physical Examination for Diagnosis. There should be no denial of the value of a well-rounded and carefully studied history of a genito-urinary case. Symptoms are often typical and characteristic of certain maladies, and lead to ready deductions that prove correct on applying the steps of investigation without which no genito-urinary diagnosis should ever receive con- sideration. But in many instances urinary symptoms are not typical, are not regular, do not conform to what would be expected of them or harmonize with the actual pathological conditions as later demonstrated by postmortem examination or otherwise. In many such cases the symptoms are unconventional and misleading. In renal cases, for in- stance, pain may arise apparently from the healthier of two diseased kidneys; or, indeed, acute and severe pain may be thus transposed from a totally diseased to a healthy kidney of the opposite side. If symptoms were to be accredited in such cases without the test of search- ing physical examination, it would readily lead to disastrous conse- quences. In fact, it has led to disastrous consequences in actual experience. These are facts well-known to all practitioners of experi- ence in urology. Method in the Quest for Diagnosis. A certain prescribed plan of investigation should be carried out in every case of chronic urinary disorder, and all the steps should be included up to the point at which the diagnosis is not only made but completed. In a given case of urethritis, for instance, it is necessary to learn, not only the nature of the infection as to whether gonococcal or not but also whether the posterior urethra is involved, and the prostate, and seminal vesicles, and all other parts of the body subject to such microbic invasion. The omission of either one of these features of diagnosis would be as serious an oversight as the omission of the other. To find gonococci in a urethral discharge and then treat the anterior urethra only, failing to recognize and treat the infected posterior urethra as well, would be like putting a splint on one of two broken legs and neglecting the other. That very tendency of many to ignore the post- urethral infection has probably been the most prolific source of failure in the treatment of gonorrheas, as was pointed out by the author as early as 1893 ; 2 and, similarly, with the diagnosis of prostatic obstruc- tion, certain factors are absolutely essential to a serviceable diagnosis VITAL TRUTHS REGARDING GEN I TO-URINARY DIAGNOSIS 111 and nothing short of them all will suffice. They must include definite information as to whether: 1 . The prostate is hypertrophied or atrophied ? 2. Whether there is obstruction to urination? 3. If so, the relative amount of obstruction? 4. The form, physical characteristics and nature of the obstruction? ">. The physical condition and functional activity of the allied organs (especially heart and kidneys). To illustrate why it is necessary to learn all of these individual features in prostatic obstruction, it may be mentioned that no one could determine the proper measures for relieving such a case without first learning the several points of diagnosis mentioned and then acting on that precise information. And if, for instance, he learned the correct answers to the first four of these diagnostic points, operated skilfully but ignored investigation of the fifth point (with reference to the con- dition and functional activity of the allied organs), it might very readily prove to be another case of "successful operation, but the patient died;" because renal involvement with unrecognized suppression of urine, uremia and death may follow on the heels of the "successful" operation, a result that should readily be avoided by attention in diag- nosis to the point under discussion, together with appropriate prepara- tory treatment. Hence it is evident that diagnosis, to be efficient, must be not only analytical but comprehensive and inclusive. But to show that in the given instance of prostatic obstruction it is within the ability of any practitioner of ordinary skill to acquire the information desired in the five diagnostic points, it may be mentioned that the first point is determined by rectal palpation, the finger detect- ing whether the prostate is unduly large, unduly small, or of approxi- mately normal size. The second point is determined by the passing of a soft-rubber catheter into the bladder directly after the patient has finished voluntary urination, which shows whether there is residual urine or not ; and the quantity of residuum thus obtained is the answer to the third point. The fourth point is not so easily settled, but, never- theless, should be settled in every case that has been proved by the steps above mentioned to be the subject of prostatic obstruction. It is most advantageously accomplished by means of the cystoscope, and especially the retrospective lens of the cystoscope, showing the confor- mation and character, etc., of the vesical neck and prostate. The fifth point is determined by examination of the urine and physical examina- tion of the heart, together with the application of such functional tests as are appropriate. It is therefore apparent that if carried out methodically and judi- ciously, the essential requirements for a working diagnosis of such a case, with the exception of one point only (cystoscopy), are within the ability of every practitioner of even ordinary skill and experience; and nothing has been demanded in the technic that was either unreasonable or ultra-scientific. As to the cystoscopy, every town of self-respecting ambition now possesses a cystoscopist of sufficient ability to resolve that question. 112 METHODS OF DIAGNOSIS IN LESIONS OF UIUXAIiY TRACT Hence the difficulties have proved, when fairly attacked, neither insurmountable nor appalling. Which may be said to be true, also, of diagnostic endeavors with reference to other diseases of the urinary organs. Difficulties melt down and disappear in the face of method and system, and repeated endeavor brings success. PLAN OF INVESTIGATION. So much depends on method and system in developing genito-urinary diagnosis that some definite plan should always be followed. The field of investigation being more or less limited, it is feasible, therefore, for those following this work as a specialty to formulate and have printed in the history book a series of questions relating to the several genito- urinary organs or diseases, with a blank for the response, which may be filled by an affirmative or negative sign for reply. This markedly shortens the time and labor in getting and recording the history. Cur- rent and additional events, treatments, reactions, and responses may be recorded on cards that are indexed and filed after the usual card-index filing system. Intricate and time-consuming bookkeeping may be avoided in this manner and all necessary records continued and kept indefinitely and always available. The diagnosis should be based on the following three kinds of evidence : 1. History and symptoms of the case. 2. Physical examination of the patient. 3. Examination of the secretions and excretions, pathological and physiological, of the organs in question; and of the blood (complement- fixation tests). I. History of the Case. The questioning should cover the family history, the previous personal history, and the history of the existing complaint. In the family history information that would have a bear- ing on hereditary influences and stigmata should be learned. The bale- ful effect of inherited syphilis is discovered with surprising frequency when definite search is made for it. This is especially true now that the Wassermann blood-test has come into frequent use. The writer has found syphilis to be the underlying factor in a number of instances in which there had been obstruction at the vesical neck from childhood to manhood. 3 While a positive history of hereditary syphilis might be of great significance, one should not place too much reliance on a failure to acknowledge such a history if there is reason to suspect the contrary. It is like the Wassermann blood test in this respect; while the positive test is of great import, the negative is of relatively little significance and must not weigh heavily in the final estimate. Neurologic, neurotic, and other tendencies should be inquired into as related to family traits. Previous Personal History. In both chronic and acute affections of the urinary tract antecedent infections frequently have a dominant influence, and failure to discover them in developing the history may PLAN OF INVESTIGATION 113 seriously handicap one's understanding of the case. Chronic and recurrent urethral discharges often are only exacerbations of uncured but apparently inactive urethritis; subacute vesiculitis may persist for years after active urethral discharge has ceased to be an outward sign of trouble. The insidious evidences of urethral stricture come on when the patient has but a dim remembrance of his former infection. Even at the risk of a seeming insistence the questioner should tactfully learn about all such "accidents" and conditions of the patient's former life. Habits and customs have a bearing that is unrealized by individuals, sometimes; such as habitual postponement of the act of urination until long after the desire has been felt, either from occupational causes or undue modesty. Permanent damage to the bladder, ureters, and kid- neys is occasionally the price of such heedless practices. Habits of eating and drinking may have a bearing on obscure cases. Evidences of rheumatism, tuberculosis, defective metabolism, dyscra- siiv, loss of weight or strength, should be developed in the history. Focal points of irritation and infection at distant parts of the body are now recognized as having a preeminent bearing on the urinary tract, notably the kidneys in connection with nephritis. Special inquiry should be made about pain; frequency or urgency in urination; changes in the urine; changes in the stream. Undoubtedly pain, though irksome, is a great conservator of the human kind. It is unfortunate that a larger proportion of genito- urinary maladies are not ushered in with pain. A larger proportion of sufferers would thereby be impelled earlier to seek medical assistance. Many accept even a bloody urine complacently for a long time just because there is no pain accompanying this portentous sign. A patient who possessed a growing hypernephroma held a letter of introduction from a physician to the writer for over six years before finally presenting it; there was pronounced hematuria all of that time. Pain may be primary or secondary in the genito-urinary organs. Originating in a diseased or strictured urethra, the irritation may be reflected into the rectum, presenting the whole complaint, so far as the patient knows it, at that point. Or ascarides vermicularis may display their vicious effect by reflected irritation from the rectum into the ure- thra, producing inordinate frequency or troublesome difficulty in urina- tion. Therefore, although one must learn what he can about pain, in getting the history, he must refrain from making deductions concerning it until physical examination is able to set him right. Pain in the back is ordinarily ascribed by the laity to " kidney dis- ease," and on so slight a piece of evidence do they often take cures and courses of treatment at the spas of repute. The profession is well a \vare that pain in the back seldom has such a significance, but the pro- fession is not so well aware of the fact that an actual renal pain is often transposed from one kidney into the region of its fellow; and it often requires the more exact findings of physical examination to establish the real origin of the complaint. 114 METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT The pain of prostatic inflammation is frequently reflected into the glans penis; that of the ureter into the cord and testis; that of the vesicles into the back, the rectum, or the testis. Frequency and urgency in urination are standard indications of irritation of the posterior it ret lira, not of the bladder. Inflammation of the posterior urethra is in itself a source of irritation and arouses the undue desire to urinate; hence undue frequency results. A healthy person should urinate from three to four times in twenty-four hours, and should not have to get up in the night for that purpose. It is practicable, therefore, to draw a fairly distinct line between normal and abnormal frequency of urination. Undue frequency in the daytime usually means an irritative or inflammatory causation, such as posturethritis or vesical stone; whereas, nocturnal frequency is more likely to indicate an obstructive causation (prostatic obstruction). Changes in the Urine. The changes in the urine most liable to impress themselves on the attention of the patient relate to the appearance of blood, of pus, or of precipitated urates or phosphates. Information based on the time of appearance of any of these may be of great im- portance, as showing whether an infection or disease is of recent or remote origin. Patients have been able to establish that the clouding of their urine, for instance in an obstructive condition in an adult, had existed since childhood, which would at once eliminate ordinary pros- tatic hypertrophy or gonorrheal infection as the originators of the trouble and give the investigator quite a different view-point from the one that might be forming. The most effective use that can be made of information that the urine is bloody is immediately to start the train of real diagnostic endeavor to put into motion the arrangements for systematic examination of the whole urinary tract and not only trace the blood to its origin, but also to learn the reason for its appearance in the urine. Until both of those objects are accomplished no effort should be made to stop the bleeding, unless it is of menacing proportions. In the presence, then, of hematuria, the first duty of the practitioner is one of diagnosis, not of treatment. Changes in the Urinary Stream. Much significance has been attached by some to the description of changes in the stream as given by patients, but in view of the lack of information or observation powers in many patients, and their proneness to see the same things differently, the writer has seldom found their impressions in this regard to be of much service. Some patie.nts with a normal stream complain that it has been twisted latterly ; and others with well-defined obstruction from stricture or congenitally narrow meatus, say that they have never had any impediment in urination. It is hardly justifiable to place reliance in such an insecure basis. If, however, the investigator himself has the opportunity to observe the stream, its description may be worth while in the record. II. Physical Examination. Nowhere in medicine or surgery do method and system count for more than they do in pursuing the PLAN OF INVESTIGATION 115 physical examination of genito-urinary cases. Many times this will save the investigator from overlooking conditions that have a vital bearing; conditions that, without method and system, would assuredly go undiscovered. On a number of occasions the writer has seen crystal- clear urine passed by patients which might have led to the inference that there could be no such thing as gonorrheal infection present; yet massage of the vesicles made directly afterward has brought out pus and gonococci, leading to a vastly different conclusion and furnishing the required revelation for diagnosis and proper treatment. Physical Examination. Following the taking of the history the uro- logic patient should be conducted through certain prescribed steps of physical examination, and without regard to whether diagnoses have been made of his case before or not. The only exception to this rule should be that in which the infectiousness or acuteness of the trouble indicate a postponement of instrumentation until a period in which it will not in itself cause injury or extension of infection. Physical examination in genito-urinary cases may be divided into general and local. The local examination naturally takes precedence over the general from the nature of the conditions. The steps of local examination may be subdivided into (a) those preceding instrumentation, and (b) those including instrumentation. Local Examination. (a) Steps Preceding Instrumentation, 1. In- spection. Obtain good exposure of the external genitals for complete inspection: Coat and vest off and clothing widely open. Inspect the external genitals, including especially the prepuce and urethral meatus for pathological secretions. If present, make smears on three glass slides for microscopic investigation : one for methylene-blue stain, one for Gram stain, and a third for reserve. 2. Have the patient urinate into two clean, clear glasses, for inspec- tion and chemical and microscopic examination:* Microscopic and Chemical Examination. 1. Centrifugalize the two glasses of urine for microscopic and chemical examination. The first portion is better for detecting infecting organisms, pus that is sparse, red blood cells, etc.; while the second part is preferable for chemical examination and study of the condition of the kidneys, as indicated by the urine: Albumin, casts, red blood cells, urates, phosphates, specific gravity, etc. 2. Palpation. Prostatic and vesicular palpation and massage. While the urine is undergoing sedimentation step No. 2 may be carried out. With the patient well exposed, bending forward over a chair, the hand of the operator protected with a finger cot or rubber glove, lubri- cated preferably with one of the iceland moss or gum tragacanth * If from the interview a suspicion of urinary tuberculosis is aroused, a specimen should be taken, by catheter only, at a subsequent time or at least after completion of the several steps now being described. Urine passed voluntarily should never be used for tubercle bacillus investigation (except for guinea-pig inoculation) because of the likeli- hood of confusion with the smegma bacillus. The only safe method is to exclude the smegma organisms by aseptic catheterization, either in males or females. 116 METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT preparations, palpation of prostate and seminal vesicles is carefully executed ; after which gentle massage of these organs is also carried out. At the same time a sterile butter platter or saucer is held under the penis and catches the drops of secretion expelled by the massage. This also furnishes material of value for microscopic examination, both in the stained and unstained ("fresh") condition. Gonococci that were undiscoverable in the urinary specimens may be plainly evident in the massage specimens, and if such proves to be the case, one can readily understand why it is worth while to be persistent and searching in such examinations. There may have been no discharge at the meatus, in a given case; there may be nothing of importance (pus, organisms) found in the sedi- mented urine passed after the inspection, and there may be no dripping into the butter platter on massage; and yet means are still available for gathering, at this time, gonococci-laden secretion from prostate or vesicles. With this object in view, following the massage and before any instrumentation is undertaken, the patient is directed to pass water again, .this time into a third glass; and even though he urinated only a short while previously and he now r passes but a few r drops of urine, that amount suffices; for it brings out with it the massage effect (pus, mucus, leukocytes, organisms, spermatozoa, etc.) that up to that time had been retained in the posterior urethra by mere lack of sufficient volume to flow out. It has now been washed out by the additional drops of urine, and is at our disposal for examination just as if it had been obtained in the more usual way. If the patient proves unable to pass the additional urine into the third glass, we have still another mode of obtaining the desired massage effect: without a catheter, inject two or three ounces of warm distilled water into the bladder and allow the patient to pass it into the third glass. It is then sedimented and ex- amined as previously described. Microscopic Examination. See Examination of the Urine. Instrumentation. (a) Of the urethra; (6) of the bladder; (c) of the ureters and kidney pelves. I XSTROIEXTAL EXAMINATION OF THE URETHRA. This Step is for chronic cases, not for acute. It should be conducted without pain or disturbance to the patient, leaving with him not even an unpleasant memory; and yet sad experiences with instrumentations may keep patients away from needed medical service for years at a time, so painful and shocking sometimes are they. lineal Anesthesia. Fifteen to twenty minims of 5 per cent, alypin solution properly used at this time are worth their weight in gold giving contentment to the patient and blessings to the doctor. A rubber-tipped anterior urethral syringe is used to inject the solution into the urethra, a cushion of air following the fluid serving to distend the urethra and diffuse the solution as far as desired. The cushion is made by injecting the air with the same syringe (Fig. 89). The early burning effect is soon replaced by effective local anesthesia, whereupon bulb sounds (the largest possible size first, smaller ones next) are passed PLAN OF INVESTIGATION 117 as far as the cut-off muscle, to learn if there are strictures in the anterior urethra; or an air-inflation urethroscope of Mark is used for the same Fio. 89. Anesthetizing the anterior urethra. FIG. 90. Anesthetizing the posterior urethra: Depositor dropping alypin tablets in prostatic urethra. purpose, disclosing at the same time any erosions, granulations, cicatri- cial deposits, etc., of chronic urethral processes. A full-sized urethral 118 METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT steel sound may be used for determining the permeability of the poste- rior urethra ; or it may be replaced by use of the posterior endoscope of McCarthy or Buerger, which give a distinct view of the verumontanum and its varying pathological conditions. Lastly, the steps of ordinary instrumentation are completed, in cases in which urinary obstruction or retention is suspected, by the passage into the bladder of a soft-rubber catheter for determining the amount, if any, of residual urine left after the voluntary urination of a few minutes before. (XoTE. A dram or two of urine thus found would be negligible; whereas, forty ounces would mean severe obstruction, and the several points for diagnosis previously mentioned (page 111) would then have to be solved.) Tubercle Bacilli. If there is reason to suspect urinary tuberculosis, this is the stage at which investigation with this in view should be pursued. In certain cases the bacilli of tuberculosis are numerous and easily found in the urine ; in other cases they are scarce and are then demon- strated microscopically only with difficulty. An expedient that serves for their easier detection, to which attention was called by Bryson, is that of utilizing for examination the small amount of urine (a dram or two) that may be drawn by catheter shortly after the patient has uri- nated voluntarily. It is supposed that this serves to collect the bacilli which have settled in the bas-fond, remaining and accumulating there in spite of successive urinations. The custom of catheterizing after voluntary urination may, then, have a double object: The determination of residuum, and the detec- tion of tubercle bacilli. The importance of this is reenforced by reason of the belief, long held by the writer, that voluntarily passed urine should never be used for searching for tubercle bacilli. The chance of finding the acid-fast smegma bacilli in such urine is too great and of differentiating them from tubercle bacilli too precarious to place reliance on such a measure. The only means that affords reliability, both in men and women, is to draw the urine by aseptic catheterization, avoid- ing the possibility of including smegma bacilli in the specimen. The writer has personal knowledge of several instances in which failure to carry out such precautions led to erroneous diagnoses and disastrous consequences, reliance having been placed on the accuracy of the bacteriologists' unsupported reports. Summary. The steps thus presented may seem from description elaborate and ponderous; but they are much more so in description than in practice, and take much longer in the telling than in the execu- tion. One might readily elaborate a more complicated plan of investi- gation, but the writer believes the one submitted to be simple, definite, and practicable; and no one who endeavors to do good work in this department can afford to minimize or ignore them. Xor should the sequence of the steps be reversed. The passing of any instrument before the voluntary urination or the massage would, from traumatism, superinduce the presence of blood and other cellular elements in the 119 urine that might wholly change and disguise the actual conditions pre- vailing and lead to erroneous conclusions. INSTRUMENTATION OF THE BLADDER. Sounds; stone-searchers. From time immemorial reliance has been placed on sounds, bougies, and stone-searchers for detecting foreign bodies, tumors and other patho- logical entities within the bladder. The sharp contact of a metal sound or searcher with a stone in the bladder elicits a click that is distinctive and of definite value for diagnosis when attained. But in a large pro- portion of cases in which vesical stone is present the click is not ob- tained. The stone may be coated with soft, sticky mucus that softens or prevents the expected contact; or it may be ensconced in a pocket under an overhanging prostate (Fig. 91), or in a diverticulum, prevent- ing the approach of the searcher within striking distance of the stone. Positive evidence only is of value with this method. But many a surgeon and patient, relying on its negative evidence, have been soothed into false security against the presence of stone and have failed utterly FIG. 91. Enlarged prostate rendering stones inaccessible to sound, but evident to retrospective universal cystoscope. in their efforts at diagnosis. A diagnostic appliance or method to be efficient must be reliable; one that gives a large proportion of failures is not reliable and should be replaced by others affording reliability. Cystoscopy. Cystoscopy outweighs all other methods and measures for diagnosis of affections of the bladder and upper urinary tract. It is analytical, comprehensive, and convincing. A discussion of cystoscopes and cystoscopic methods is presented elsewhere, but it is deemed appropriate to consider the logic and pro- priety of cystoscopy here. Indications for Cystoscopy. The indications for cystoscopy in con- nection with disturbances of the upper urinary tract are many; the contra-indications are few. Cystoscopy should be performed in practically all cases of chronic urinary disturbance in which no definite centra-indication is present. It is often the case that an existing seminal vesiculitis or prostatitis appears quite sufficient to account for the persistence of an infection, 120 METHODS OF DIAGXOSIS IX LEMOXX OF I'RIXARY TRACT and treatment is expended solely on them without result, until finally, discouraged by lack of success and merely as an experimental measure, cystoscopy and ureteral catheterization are carried out, whereupon a flood of light is unexpectedly thrown on the case. It is found that the infection involves one or both pelves of the kidney as well, and that explanation might never have been attained without the cystoscopy and catheterization. Hematuria, pyuria, microbic infection, when demonstrable as coming from the upper or middle urinary tract, symptomatology that is in- veterate or is apparently referable to the kidneys or ureters, no matter of what character, demand cystoscopy with insistence that should never be denied. The definite indication in many of these is for diagnosis first, not treatment; and cystoscopy, together with ureteral catheteri- zation and radiography, are the means above all others for meeting that indication. Therefore, with chronic or obscure or unsatisfactory con- ditions of the urinary tract, it is advisable not to be too punctilious in awaiting the positive indications for cystoscopy, but rather to withhold it only in the face of definite contra-indications opposing it. Contra-indications to Cystoscopy. Acute inflammatory conditions of the urinary tract, together with exacerbations of chronic inflamma- tions, form contra-indications for cystoscopy. This does not apply to anuria from renal or ureteral stone, which sometimes is relieved by ureteral catheterization. The same measure has been known to start up urinary secretion, for a time at least, in anuria from nephritis; so that cystoscopy need not be feared in these conditions where there is reason to apply it. Urinary tuberculosis has by some been considered a dangerous field for cystoscopy. It would more properly be termed a dangerous field with- out cystoscopy. The outcome of neglected urinary tuberculosis is not only unpromising but almost assuredly fatal. Urinary tuberculosis in the earlier periods means infection of one kidney only so far as the urinary tract is concerned. In other words, the discovery of the nature and location of the infection clearly the province of the cystoscope is the vital, pivotal step to be taken at a time when such a discovery is of service at a time when it may lead directly to removal of the origi- nating focus of infection from the body and reclamation to health of the patient. No means other than the cystoscope can compare with it in the performing of this function. On the other hand, experience with thousands of cases of urinary tuberculosis, in the hands of many operators, has failed to show that cystoscopy is injurious. Such patients are usually inordinately tender and demand the liberal use of local anesthetics, but they recover from the transient effects of instrumentation quite satisfactorily. Some ob- structive phases of urinary tuberculosis are even improved by instru- mentation and local medication. Prostatism. It is well known that prostatics may go for long periods with considerable obstruction and no infection until some form of instrumentation is undertaken; and whether this be done with or with- PLAN OF INVESTIGATION 121 out careful aseptic precautions it is liable to precipitate the long-deferred urinary infection and bring about conditions more painful and irritative tli ;in any that previously existed. Yet the claim that a prostatic should never be instrumented because of these facts would hardly receive general support. Like catheterization, cystoscopy is one of the disa- greeable necessities, temporarily objectionable, perhaps, but having the ultimate object of permanent relief and restoration. As mentioned previously, prostatic obstruction is of such multi- farious production that it cannot be adequately coped with except on a basis of accurate diagnosis. Contracture, hypertrophy, cyst formation, all may produce obstruc- tion, but do so in different ways; and it requires cystoscopic inspection to differentiate between them. It is as illogical to expect to accomplish this object without cystoscopy as it would be to expect to determine the amount of obstruction present without using a catheter. And the use of either is as liable to be fol- lowed by infection as the other. But their use paves the way to re- covery and is therefore amply justified. Urethral stricture, prostatic inflammation, or abscess and other obstructive conditions militate against or interfere with the use of the cystoscope; but under such circumstances they themselves are the con- ditions demanding attention, and there is seldom any need for cystos- copy in connection with them. But if such a need were found, the obstructing factors could be attended to first, opening the channel for the introduction of the cystoscope. A narrow meatus should be incised for the same purpose when necessary. It must be remembered, too, that there are small-calibered cystoscopes on the market (No. 17 or 18, French) which, though sacrificing certain features of the larger instruments, are advantageous for such exceptional conditions. Urine Segregation. The separation of the urines of the two kidneys by means of segregators for a time was held in favor by some, but further experience with such instruments has proved that they are quite unreliable for diagnostic service in that they give false returns and lead to erroneous conclusions. In working with them the oper- ator is working in the dark and must take for granted that such exacting conditions are fulfilled as that of obtaining an effective water- shed between the ureteral orifices, and that each tube of the instrument is draining from its respective side and from this side only. That the instrument is unreliable was proved by Kummel, 2 who found that in a case in which he had previously removed one kidney, the only urine that flowed came from the side on which the nephrectomy had been done. Aside from its incompetence for diagnosis, the segregator suffers when compared from the therapeutic stand-point with cystoscopy and ureteral catheterization. It offers no possibility of sounding ureters or of administering irrigations to kidney pelves. URETERAL CATHETERIZATION. Ureteral catheterization is so closely associated with cystoscopy that what has been said may well refer, for 122 METHODS OF DIAdXOXIS IX 7,/i.sYO.Y.s OF URINARY TRACT the most part, to this procedure also. But when, by cystoscopy, the pathological condition is clearly demonstrated to be in the bladder, such as a tumor, stone, simple ulcer, etc., and there are no indica- tions of further trouble above, ureteral catheterization may be deemed unnecessary. Some authors place much reliance on meatoscopy as a guide to con- ditions in the upper tract. They watch the urine as it issues in jets from the ureteral orifices, and inspect the orifices themselves, alleging that reliable evidence may thus be obtained as to the presence of pus or blood in the respective urines or pathological conditions in the ureters. It is but another instance of positive evidence being valuable and negative evidence worthless, or worse. If the ureteral orifice displays ulceration or the funnel-shaped de- pression characterizing tuberculous ureteral contraction, the evidence is of value; but it is established that many kidneys are tuberculous without the corresponding ureteral orifice showing any deviation from the normal. And to await the ureteral demonstration would be indefinitely postponing required action and seriously endangering the chances of the patient. As to the other claim, if it is impossible to say whether there are pus or blood cells in a glass of fairly clear urine without examining by the microscope, one can readily appreciate how much greater the difficulty of making the determination by macroscopic observation of urine while it is being ejected from ureteral orifices. The claim is preposterous except for pathological conditions that are very pronounced. There would be no objection to the claim did it not incline to mislead inexperienced cystoscopists who may not realize the fallacies of the situation. It is advisable, therefore, not to forego the many advantages of ureteral catheterization on too slight provocation. Many pathological conditions of the ureter are not discoverable by meatoscopy. Ureteral strictures, kinks or dilatations may betray no evidence at the meatus of their existence. Wax-tip Bougies. The wax-tip bougies of Kelly have been tested by wide usage in the profession but have not found favor to the extent that exists with their illustrious author. That is probably explainable by the difference in the form of cystoscopes used. Kelly has never given up the use of his very simple pattern of cystoscopic specula, which he uses with women in the knee-chest position. This permits the use of the wax-tip bougies with more or less freedom from danger of con- tact with the instruments, thereby producing a false scratch. Most practitioners now use one of the several forms of lens cystoscopes on the market. With these it is difficult or impossible to prevent the scratching of the tip by the cystoscope itself, and thus casting doubt and confusion on the findings. Obstructions in Ureteral Catheterization. Obstruction to the passage of a ureteral catheter may occur either in a healthy or a diseased ureter. The axis of the channel may be such that the catheter impinges against RADIOGRAPHY IN GENITO-URINARY DIAGNOSIS 123 the wall and hangs there until dislodged by a twist or movement that enables the catheter to follow the curve of the channel, when it may pass easily. In other instances the presence of the catheter excites spasmodic contractions for a time of the muscles of the ureter, which clamping down on the catheter effectually oppose its passage until the spasm is relieved, when the catheter passes promptly and without further difficulty. Obstructed ureteral catheterization, therefore, does not always point to a pathological condition. Organic pathological conditions, such as narrow ureteral meatus or stricture of the ureter, impacted calculus, kink, or an anomalous vessel crossing the ureter, may obstruct the passage of a ureteral catheter, and when met with must be differentiated by the various methods dis- cussed. Through the influence of a strictured ureter it often happens that from the resulting or coincident pelvic infection mucopus plugs cause colics, persisting pain, and backward pressure by coming in contact with and plugging up the narrowed orifice of such a constriction. The author has seen prolonged invalidism result therefrom, relieved promptly and permanently by widening the contraction to physiological proportions. Lack of Drainage after Ureteral Catheterization. It occasionally happens that after an especially irksome and difficult essay at cathe- terization success is finally attained and the fruits of victory are natu- rally expected, but none appear. In other words, the urine does not flow through the catheters, notwithstanding their introduction well up to the kidney pelves. Such a disappointing failure may result from any one of several causes. The catheter itself may be stopped up, or it may be too high in the pelvis, thus failing to locate the eye of the catheter where it can draw the contents by siphonage or otherwise. A little mucopus plug caught in the eye of the catheter may close the outlet and defeat drainage for the time being. Another prolific cause for lack of drainage is the temporary discontinuance of renal activity in the presence of catheters in the ureters, one or both. The resulting "shock" to the kidneys seems to superinduce a temporary anuria or oliguria. The drinking of a glass of water usually restores activity and the expected drainage. RADIOGRAPHY. ITS POSITION IN GENITO-URINARY DIAGNOSIS. Value of Radiography. In connection with cystoscopy and ureteral catheterization, radiography is invaluable for genito-urinary diagnosis. It has helped tremendously to bring urinary diagnosis to its present satisfactory state. But it must not be considered as all-sufficient or free from liability to err. It indulges in errors both of commission and of omission. Its shadows must be attested and controlled lest they betray us into diagnosing stones that are not present, and its occasional failure to delineate a shadow where one ought to be is one of its lament- able shortcomings. 124 METHODS OF DIAGNOSIS IN LESIONS OF CRINARY TRACT Nevertheless, when these failings are met and controlled by appro- priate action, radiography becomes the wheel-horse of service men- tioned. The corollary to the above is that radiography in urology should not be relied on without the control of cystoscopy and possibly ureteral catheterization. It may also be admitted that for diagnosis of stone in the upper tract, cystoscopy and ureteral catheterization should not be relied on without the control of radiography. In other words, they are mutually interdependent and should be utilized together. It is mere waste of time to speculate on which is the more important of the two. Radiography in Diseases of the Middle Urinary Tract. For diseases of this part of the tract, radiography is less important, though not without marked value in certain conditions. It serves well in the detection of stone in the prostate. With oxygen gas distending the bladder Kelly has taken good negatives, showing the size and con- formation of enlarged prostates. Used with collargol distention of the bladder, radiography dilineates diverticula of that organ, and shows the shape and size of the bladder to advantage. The size of a vesical tumor is often made appreciable by the same means, but without the use of the collargol. Kelly used bismuth suspension in tragacanth, and later, a suspension of argentide, for this purpose. Information regarding the size, number, and location of vesical stones and foreign bodies is afforded. Radiography in Diseases of the Upper Urinary Tract. It is especially in this part of the tract that the supreme advantages of radiography are made manifest. It is found to be most serviceable and reliable when used in connection with such control appliances as radiograph catheters (opaque to .r-rays), ureteral sounds, or the injection of colloidal silver solutions (ureteropyelography) . While certain precautions are re- quired to avoid accident or injury to the kidneys in this work, it may be said that these are easily carried out, and, with them in effect, the pro- cedures are safe. Dangers of Pyelography. There are certain elements of danger in injecting the renal pelves with collargol solution in that it has been shown that even under very moderate pressure the solution passes up the urinary tubules and permeates the kidney tissues to make infarcts 1 and infiltrations that have proved highly injurious or even fatal. In applying this method stringent precautions must be taken to obviate this fault. It should not be applied in a case in which drainage from the pelvis is seriously interfered with unless provision is made for prompt artificial evacuation (drainage by ureteral catheter, for in- stance). The injection should be made, not with a piston-syringe, which may prove too forcible in its effect, but by a simple hydrostatic apparatus such as that of Thomas. The necessity for using radiograph catheters is brought about by the fact that calcified glands or phleboliths in the abdomen or pelvis often give shadows to .r-rays that resemble those of ureteral stones, and it is RADIOGRAPHY IN GEN I TO-URINARY DIAGNOSIS 125 desirable to provide some method of differentiating between them. The opaque catheter in the ureter shows the exact line of the ureter, a shadow widely separated from that line is at once recognized as having no relation to the ureter or ureteral stone. A shadow in the line of the catheter shadow is differentiated by filling the ureter with collargol solution and then making the exposure (Braasch). If it is a ureteral stone shadow, a distinct difference in the caliber of the ureter above and below the shadow is seen; the ureter is relatively dilated iihare the site of the stone. Whereas, if it is only a phlebolith shadow, there is no difference in ureteral caliber above and below the shadow, as indicated by the pyelogram. Another means of differentiation is that of stereoscopic radiogram, also with the opaque bougie in the ureter (Kelly) . The stereoscopic view removes the shadow from the plane of the ureter, either forward or backward, showing it is not in the ureter. It is safe not to put too much faith in the ability of the radiologist to make the differentiation by the characteristics of the shadow itself. This has proved fallacious in many instances. Nevertheless, certain characteristic differences in shadows have been noted, as pointed out by Fenwick. Shadows that are clean cut, round and grouped near the outer or ischial portion of the open pelvic space in an ar-ray picture are likely to be those of phleboliths, while the ureteral stone shadows are inclined to be oval, with the long axis in the line of the ureter, and located near the median line of the body. Capacity of the Kidney Pelvis. The question is important for differ- entiation between a normal pelvis, a dilated one, and hydronephrosis or pyonephrosis. Injecting fluid through a ureteral catheter to the point of exciting pain, Kelly allows 8 c.c. capacity as the normal maxi- mum; whereas Braasch considers 15 c.c. as compatible with physio- logical capacity. Indications for Radiography of the Upper Urinary Tract. Radiography and pyelography are applicable to cases in which there is ground for suspecting stone, stricture, kink, obstruction of any sort, or dilata- tion at any point in the ureter; or duplicated ureter; hydronephrosis or pyonephrosis; calculus, benign or malignant tumor, tuberculosis or abscess formation in connection with the kidney. Modern radiograms made with "soft" tubes are capable of showing shadows of abscess pockets, tuberculous and like conditions, that are of much service when correctly interpreted. Interpretation of Radiograms. It must not be thought that this is an easy matter or one requiring only indifferent ability. Much experience and refined judgment are really necessary; and these must be backed with the repeated testings and the various methods of control available. Preparation of the Patient. In anticipation of radiography the patient should be prepared so as to eliminate extraneous factors as much as possible. The bowels should be emptied, including flatus, by a brisk cathartic; and a light diet should be observed for a day or two before- hand, when permissible. 126 METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT Technic and Mode of X-ray Examination. This will be considered elsewhere. It may be remarked, however, that, as with ureteral cathe- terization, if one is guided solely by the symptoms and takes a radio- gram only on the side complained of, one is liable to overlook evidence of great value that may exist on the opposite side. Unless the opposite side has been definitely excluded by ureteral catheterization as a source of trouble, it is advisable to take both the kidney and ureter of that side always remembering that a shadow without the control of the radiograph catheter merely indicates the taking of another radiogram with such a catheter in place. Kelly suggests that it is well to take a verifying plate a day or two following the positive finding or before a contemplated operation for stone; not only for verification but also for indicating a change in the position of a stone. Stereoscopic Radiography. This refinement of .r-ray photography serves to place the shadow of. a stone or foreign body with reference to the horizontal planes of the body. Used in connection with a radio- graph catheter in the ureter it gives an attractive elucidation of con- ditions not otherwise rendered. FUNCTIONAL TESTS. The integrity of the kidneys is universally recognized as being of great moment in its bearing on the risk involved by a given surgical operation. But this risk relates not so much to the anatomicopatho- logical condition of the kidneys as to their functional activity. Conse- quently, while the information obtained by chemical and microscopic tests of urine is valuable, it is not the kind of information that is most useful in the case at hand. The pathological condition does not always parallel the functional activity. Some kidneys badly degenerated give urine that shows good excretion by reason of adequate compensation; while others apparently little involved may give urine very inferior in quantity and quality. Individuals with albumin and casts in their urine have been known to live for many years without apparent progress in the renal condition or decrease in the kidney activity. But the menace comes when the function is inefficient even in the face of a sufficient quantity of urine and of fair quality. So insignificant an operation as a urethral catheterization may disturb the equilibrium that has existed, and be followed by suppression of urine and death. Such sequences have occurred even where the volume and quality of urine seemed to be satisfactory. Variability of Renal Function. This is marked in both health and disease; and depends on many influences. A glass of beer in a healthy person may double or quadruple the urinary output in the space of a few minutes. Functional activity that is lessened through disease may be restored by removal of the disease (acute nephritis) or its cause (a prostatic obstruction). Therefore the estimate should include not only the actual renal activity but also the potential capa- FUNCTIONAL TESTS 127 bilities of the kidneys under better or worse conditions for instance, in the face of an operation, especially a nephrectomy. With the exception of hippuric acid the kidneys do not manufacture any of the waste products that issue from them. They simply extract them from the blood. It is the measure of this faculty of extraction that is desired. If the renal function is adequate, the waste products are excreted sufficiently and the blood is kept in its proper and healthy condition. If kidney activity is below the requirements of the individual, such products accumulate unduly in the blood or tissues of the body. To determine whether this function is being properly attended to, it would seem proper to investigate either (a) the state of the blood, with reference to retention of waste products in it, or (6) the product of the kidneys (the urine), with reference to completeness of excretion. These tests would resolve themselves, then into (a) tests of retention and (6) tests of excretion (Hinman). The tests of retention (cryoscopy of the blood, electrical conduc- tivity) have so far not proved their efficiency or reliability. The nitrogen content of the blood has been found by some (Widal, Folin, Ovisannikova) to have mucji prognostic significance. When the blood urea, in a case of nephritis, rises to one or two grams per liter, the prognosis is considered a grave one; if above three grams, impending uremia and dissolution are expected. The normal limits are from 0.1 to 0.55 gram per liter. The tests of excretion have found most favor because of their greater convenience and reliability. Apparently realizing the supreme value that would attach to the finding of an efficient test of tbis kind, students of the subject have submitted many different tests during the past decade. They have aimed at measuring the rapidity and completeness with which in a given case the test drugs were eliminated through the kidneys, and the relative activity of the two kidneys as tested sepa- rately ; this, mainly to learn whether, if the diseased kidney were oper- ated on or removed, the remaining one could fulfill the requirements of elimination and sustain life. Endeavors at gauging functional activity or insufficiency by measur- ing the amount of the physiological waste products of the urine have proved unreliable. The chlorides, the phosphates, uric acid, the urates, urea, the total solids, etc., vary so much in health and the variations depend on such multifarious causes that they cannot be interpreted as having any relationship to operative risk or renal potentiality. The same thing may be said for the total quantity of urine. While it is of material value and definitely advisable to make use of these (urea, total solids, total quantity of urine, etc.) there yet remains something to be desired for determining functional activity. For reckoning permeability, the following products have been found of most service: Phloridzin, methylene blue, indigo-carmin, phenol- sulphonephthalein (reduced for convenience to "phthalein"). Phloridzin. The discovery by von Mehring that phloridzin renders the kidney very permeable to sugar led to its use as a test of renal func- 128 METHODS OF DIA(;\OXIS L\ LESIOX* Of L'RIXARY TRACT tional activity, and it seemed at first to promise much in this respect; but it was found that there was occasionally no elimination of sugar at all in perfectly healthy kidneys, while in others with only slight deteri- oration the test would apparently indicate serious degeneration. It has therefore not held the position at first hoped for it. The manner of using the phloridzin test is as follows : An injection of 0.01 to 0.05 gm. of the drug in aqueous solution is made subcutane- ously, intramuscularly or intravenously, the solution being freshly prepared and slightly alkalinized with bicarbonate of soda, which favors complete solution. After ten minutes the urine is tested every minute with Fehling's solution until the appearance of the sugar is indicated in the usual way. Fifteen- or thirty-minute estimates of the output are then recorded. The sugar should make its appearance in from ten to fifteen minutes with normal conditions; reaches its maxi- mum in one hour and gradually disappears in from two to three hours, with a total excretion in that time of one or two grams (Geraghty and Rowntree). Indigo-carmin, methylene blue, and other anilin dyes have been praised in this light. The first is used by intramuscular injection of 20 c.c. of a 0.4 per cent, solution freshly prepared in sterile distilled water at room temperature (warmed before using). In about nine to twelve minutes after the injection is made, a greenish-blue tinge appears in the urine, with normal kidneys, and continues until about 25 per cent, of the injected drug has returned through the kidneys. But only 10 to 12 per cent, returns in an hour, and it continues showing for the next day or two. B. A. Thomas 9 puts much faith in this test, but in addition to marking the promptitude of its appearance after injection, be seeks, as he terms it, the index Cff elimination of the drug; that is, he divides the quantity of indigo-carmin eliminated during the first hour by the quantity excreted during the third hour after injection. He found that the index for normal individuals in a series of cases averaged 5.1. If the amount eliminated during the third hour equals or exceeds that excreted the first hour, the patient's kidney function centra-indicates serious operative intervention. The conclusions are based on the theory that disease of the renal parenchyma delays the onset of elimination and diminishes the early output as well, while the duration of excretion is prolonged; it there- fore seemed to the author that the relative excretion for the first and third hours was of greater value than 'the mere quantitive output for the first two hours. Thomas considers this to be the safest guide to renal functionation of all the tests that have been proposed. Methylene blue has been held in much the same esteem by its spon- sors, Kutner and Casper, and later Achard. But by others it is rated of inferior merit. Investigation showed that in certain forms of neph- ritis there was none of the expected delay in the appearance of the green tint (normally nine to twelve minutes) after injection nor any inter- ference with the rapidity of its excretion; while in some normal cases FUNCTIONAL TESTS 129 the drug did not appear in the urine at all after the injection. Its unreliability condemned it. Methylene blue is given by intra-muscular injection, fifteen minims of a 5 per cent, aqueous solution being used. Fifty per cent, of the drug comes back in the urine; the remainder is supposed to be con- verted in the body. The blue-green color should make its appearance in the urine within twenty to thirty minutes after injection, and may continue to show for one or two days thereafter. In some cases of nephritis it has been observed as persisting for fifteen days. In inter- stitial nephritis its initial appearance may be delayed for five or six hours, whereas in parenchymatous nephritis there may be no marked delay (Albarran; Bond; Hinman). These instances serve to indicate the difficulty of finding a functional renal test that furnishes accuracy, reliability and innocuousness. Nevertheless one closely approaching the fulfillment of these exacting requirements has been found. Phenolsulphonephthalein. This agent ("phthalein," for conveni- ence) possesses certain properties and reactions, as described by Ger- aghty and Rowntree (1910-1912), that make it more nearly ideal than anything heretofore proposed. It is innocuous, even in large doses. It is secreted entirely by the kidneys and, in health, with punctilious uniformity, both as to time of appearance and rate of excretion. And this rapidity is so great that within two hours after it has made its appearance in the urine (beginning ten minutes after injection) from 00 to 85 per cent, of the drug passes out in the urine. This fact is doubly valuable, both for an estimate of the total function of the two kidneys, and for determining the relative functioning power of the two organs. The rapidity of elimination shows variations dependent on the method and location of introduction of the dose. The response is slowest and least certain after subcutaneous injection; more prompt with intramuscular injection and most prompt with intravenous use. It is therefore advisable to use either the intramuscular or intra- venous. The latter is particularly useful in connection w r ith ureteral catheter drainage, the test being completed in fifteen minutes and permitting a snorter retention of the catheters in the sensitive ureters. While it is practicable to determine the promptitude of appearance of phthalein in the urine after injection, it is not essential, and this is not nearly so important as the measurement of the amount of the drug excreted in the first and the second hour taken separately. After intramuscular use, the time of appearance is from five to ten minutes ; the output for the first hour from 40 to 60 per cent.; for the second hour, 20 to 25 per cent, (making from 60 to 85 per cent, for the two hours) . When administered intravenously in connection with ureteral catheterization, it appears in from two to eight minutes. The collection of urine for the fifteen-minute or half-hour period should begin with the appearance of color in either urine. To make the drug visible, a few M u i 9 130 METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT drops of sodium hydrate solution are placed in the test-tubes or vessels intended for receiving the urine drainage. Then, at the moment when excretion begins, a pinkish tinge appears, merging into a definite Bordeaux red by the additional flow. In order that there may be no inhibition of urinary secretion from the presence of the ureteral catheters, it is advisable to have the patient drink one or two glasses of water before the beginning of the test. Schmidt and Kretchmer 7 advise the collection of urine for three successive hours, believing that the excretion for each of three hours of the same amounts of phthalein indicates that the kidneys are working at top speed all the tune because they are badly damaged. Relative Functional Activity. Where the quantity of urine, merely, is measured and the collection is made for ten minutes only, there may be a marked difference in the amount excreted by two healthy kidneys. But if the time of collection be prolonged for an hour or two, or per- haps if repeated at another time, this discrepancy is made up and the account balanced. Excretion of phthalein, however, does not depend on the quantity of fluid excreted, whether large or small, and its relative findings are positive indications of functional activity, whether taken at long or short intervals. This, indeed, is one of the vital advantages of the test, making it both useful and reliable. Technic of Applying the Phthalein Test. Intramuscular. Ampules containing about 20 minims of standard solution of Phenolsulphone- phthalein are supplied by Hynson & "\Yestcott, of Baltimore, Md. Exactly one cubic centimeter is injected by hypodermic syringe deeply into the gluteus or any muscle of the lumbar region, the time of injec- tion being noted. A soft-rubber catheter in the bladder drains the urine as it enters that organ from the kidneys. The drainage is caught in a white enamel vessel containing a few drops of sodium hydrate solution, which renders the phthalein visible on the instant of its arrival in the vessel. The appearance of the pink color marks the beginning of the first hour of the quantitative phthalein estimate. The catheter is withdrawn and is reinserted an hour from that time for obtaining the first hour's specimen. Sixty minutes later the second hour's specimen is obtained in the same way (unless the patient can be depended on for completely emptying his bladder by voluntary urina- tion, default of which vitiates the result). The phthalein percentage of the two hours' excretion is then determined by adding to each speci- men respectively enough water to make 1000 c.c.; placing a few cubic centimeters of this diluted specimen in the cup of the colorimeter of DuBoscq, which by comparison with a standard solution at once gives the required percentage. The same is then done with the diluted specimen from the second hour's excretion and its reading recorded. When ureteral catheterization is employed for determining the relative functional activity of the two kidneys, the intravenous method should be used and the time lessened as previously suggested. Fifteen minutes (one-fourth of an hour) is the customary period used, and its result EXAMINATION OF THE URINE 131 is multiplied by four for the full hour. This represents the output of each kidney, which, added together, gives the output of both kid- neys. In the first fifteen minutes a normal kidney should put out half of about 30, or 15 per cent. (G. G. Smith). If one kidney is diseased and putting out less than the normal (less than 15 per cent.), the other may be compensating and putting out more than 15 per cent. Hence the value of making the comparative functional test by ureteral cath- eterization. In women the average output is slightly lower than in men. In summing up, it may be said that no one test should be relied on as all-sufficient, but that a working combination of two or three should be utilized. The daily output of urine-urea and solids, the quantity of urine, together with phthalein estimate, repeated as necessary, should be prominent among the factors determining the question of operation and prognosis. According to Cabot, the stability of renal functionation, established by successive tests, is of greater moment than a high functional per- centage. Patients who under strains of exercise, changes of diets or alterations in quantity of water vary markedly in their renal output are less favorably considered than those having a lower index which is well maintained under these influences. EXAMINATION OF THE URINE. While the conventional steps of urine examination will not be con- sidered here, it may be profitable to express some thoughts on the subject that clinical experience has indicated as of frequent and prac- tical importance. Examination of the urine may be of incalculable service in tracing the location and nature of a genito-urinary affection. But it must be made understandingly and not in the stilted, routine fashion ordinarily carried out. Many think that if they have learned whether a patient's urine contains albumin or not their full obligation in that direction has been discharged. As a matter of fact, such a return may offer no enlightenment on the case, one way or another. Aside from the evidence on renal functional capability, considered elsewhere, the pertinent questions to be answered are, what pathological elements does the urine contain; and from w r hence do they come? Eminently practical questions, both, and answerable by definite methods of investigation. Volumes have been written in the endeavor to make the source of urinary disturbance recognizable by means of the particular shape or other characteristics of epithelia formed in the urine; that caudate epithelia mean pyelitis, etc. To the mind of the writer this is mere waste of time ; and illusory. More exact methods are those which trace the epithelia or pus cells or other pathological findings to their source by the definite means of cystoscopy, ureteral catheterization and radi- ography. Mark Twain said that when he dined at a boarding house he always called for hash because he wanted to know what he was eating. 132 METHODS OF DIAGNOSIS L\ LESIONS OF URINARY TRACT In this work one wants to know one's evidence, putting doubt and speculation as far behind one as possible. One should never assume an ability to name the contents of urine by viewing it macroscopically; yet this assumption is practised habitually by some. Many a speci- men of urine looks limpid clear and innocent, yet contains blood cells, pus corpuscles or tubercle bacilli; and these spell pathological conditions. Cloudy Urine. The clouding of urine, apparent to the naked eye as viewed in the urine glasses, may come from the admixture in it of precipitated urates or phosphates, of spermatozoa, pus cells, blood cells, epithelia, bacteria, parasites of various sorts, and foreign material (dirt), and crystalline formations. It should be the first object of the investigator to learn the cause of the clouding. This is accomplished to best advantage by means of the microscope after sedimentation. To propose a sequence, then, of steps of urinary examination, it is well to begin with the double-glass urine specimens that have been passed voluntarily by the patient and described on page 115. In inflam- matory conditions the second portion is usually the clearer of the two and the one less influenced by disturbances in the anterior urethra. In passing outward, the first part of the urine carries not only the materials it has collected in the bladder and upper urinary tract, but has added to it products from the urethra; hence its greater cloudiness. Exceptions to this occur when, in the final contractions of the vesical and post- urethral muscles, blood is squeezed from an acutely inflamed vesical neck; or incidental to the same act, there is the passage of spermatozoa from the seminal vesicles into the second part of the urine. Then the second part is bloodier or cloudier, as the case mav be, than the first. If the clouding be due to precipitated phosphates , it may be cleared by the addition of a few drops of acetic acid; if due to precipitated urates, warming the specimen over a Bunsen burner will cause them to redissolve. But if these simple measures do not at once succeed in clearing the urine, resort must be had to the more definite plan of seeing what is earning the clouding; and this should be done while the specimen is fresh and unchanged by decomposition or bacterial in- vasion. It is to be accomplished by microscopic demonstration, to which no chemical test or other method is comparable in accuracy or completeness. The specimen of urine is sedimented by centrifuge; the sediment is placed unstained ("fresh specimen") under the micro- scope, enabling the investigator to see whether motile bacteria, pus cells, crystals, blood cells or what not produce the clouding. Stain- ing of the same sediment brings bacteria, when sparse, into more prominent view, and permits their differentiation; so that it should be the next step of the investigation. Naturally the staining must accord with the requirements of bacteriology and must be varied accord- ing to the kind of organisms suspected to be present; but methylene blue is a convenient and serviceable stain to begin with. If, in a sus- EXAMINATION OF THE URINE 133 pected gonorrheal case, this dye demonstrates diplococci that appear to be gonococci, they must invariably be proved to be such by means of the Gram stain. If the fuchsin stain appears to demonstrate tubercle bacilli they must be proved to be such by measures that leave no room for doubt. These include methods of acquiring the urine specimen that at the same time exclude the possibility of contamination with smegma bacilli, and may include inoculation tests, as welL The question of differentiating between tubercle and smegma bacilli by processes of staining alone has been discussed elsewhere (page 118) with the conclu- sion that no such possibility should be entertained. In both sexes the urine for tubercle bacilli demonstration should be obtained by cathe- terization and after careful cleansing of the external genitals. With but few exceptions it may be said that the finding of tubercle bacilli in the urine means tuberculosis of one or both kidneys. That truth, the deter- mination of which has been w r ithin-the past decade, has been of immeas- urable service to sufferers from urinary tuberculosis leading the surgeon to disregard, as of secondary import, the tuberculous implica- tion of the bladder and go straight to the source of trouble, one or the other kidney; remove it and reclaim the patient to health and the enjoyment of living. It is true that tubercle bacilli have been found in the urine of patients who had no renal involvement, but were tuberculous elsewhere, the bacilli apparently having been filtered through the sound kidneys after being conveyed by the blood from the original focus. But the dis- covery of tubercle bacilli under such circumstances is so rare that it should be viewed more as a pathological curiosity than a reality to be reckoned with in the clinic. Practically, then, tubercle bacilli in the urine means renal tuberculosis. The next question is, which kid- ney ? As mentioned elsewhere (page 1 22) , ureteric meatoscopy through the cystoscope, though relied on by many, should be supplanted by the surer method of ureteral catheterization, by which means is learned not only which kidney is to blame for the tuberculous infection, but also the condition of health and functional activity of the other organ. The answer to both of these questions is absolutely demanded in a complete diagnosis. The Absence of Tubercle Bacilli. The inability to find tubercle bacilli in a suspected urine should not at once lead to false hopes of their absence and to what may later prove an erroneous diagnosis of non- tuberculous infection. While latter-day methods have increased the ability to find the bacilli when present, it must be remembered that even with active and severe renal tuberculosis there are periods in which the bacilli do not appear in the urine. They seem to be pent up for the time being in the suppurating pockets, to escape periodically in the so-called showers of the organisms, easily demonstrable then in countless numbers. The necessary deduction is that in a suspected case a failure to find tubercle bacilli should count for nothing and should be followed by many repetitions, if necessary, of the endeavor. 134 METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT Guinea-pig Inoculation. A measure that often proves successful in the face of failure by direct microscopic investigation is that of inocu- lating a guinea-pig (or two) with the sediment of suspected tuberculous urine. Too few to be detected by the microscope, the bacilli are numerous enough to respond positively to this more refined method and develop tuberculosis in the animal, showing within two to four weeks. But this also is not absolutely reliable as to negative evidence, since it is established that failure to inoculate has happened with urine that later was proved to be tuberculous by postmortem demonstration. A failure of this sort may be due to the fact that the attempted inocula- tion is made during a quiescent period, between showers of bacillary excretion, or to some other cause. At any rate, because of the unre- liability of the various phases of negative evidence, one is reduced occasionally to make a diagnosis instinctively, so to speak: Feeling, from the several aspects of the case, that it is tuberculous at bottom, even though the ultimate proof, demonstration of the presence of the tubercle bacillus, be lacking. Tuberculin Tests. Tuberculin tests may be used in cases of suspected urinary or genital tuberculosis, and occupy the same position as when the focus of infection is located elsewhere in the body. Its positive reactions are similar, consisting of the well-recognized chill or chilliness, temperature, aching sensations; and in urinary infection, local reaction of various sorts: Increased pain during urination, increased frequency, occasionally hematuria or increase in a hematuria already present. Radiography can be of assistance only in the late stages of a renal tuberculosis when it demonstrates the shadows of caseous masses in a badly damaged kidney. AYhen this condition is reached, the diagnosis has doubtless already been made by other methods. Examination of Urine Drawn by Ureteral Catheters. It is not always practicable or desirable to draw a considerable quantity of urine for examination after ureteral catheterization. Both the time of the surgeon and the safety of the patient militate against this. Fortu- nately, it is not necessary. Two or three drams of urine are usually sufficient for practical purposes. The separated urines should be put through the same processes of examination as have been applied to the other specimens. Albumin due to the presence of the catheter in the ureter will nearly always be found, and is therefore a negligible element. Sometimes casts appear for the same reason. Blood cells often are present from the same cause. But as these may all have been absent in the specimens previously examined, they are recognized as having no significance. If there are sufficient blood cells present to interfere with steps of the examination, they may be at once dissolved and eliminated by adding a few drops of acetic acid to the specimen, or, better, a drop of the acid to the sediment on a slide. This also clears up the pus corpuscles and leaves their multinuclei plainly discernible as compared with leukocytes, white blood cells, etc. Round epithelia are usually present in abundance in the specimens acquired by ureteral catheterization, and do not always indicate pathological conditions, EXAMINATION OF THE VRINE 135 especially if unaccompanied by pus, bacteria or other evidence of dis- ease. Specific gravity of small quantities of urine is obtained by using gravity beads in small test-tubes ; but this, also, is of lesser import, influenced as it is by many accompanying conditions, excitation or inhibition of renal excretion from instrumentation. Aside from the determination of the relative functional activity of the two kidneys (discussed elsewhere), the chief objects to be attained in examining ureteral catheterized specimens are: Learning whether pus or bacteria (including tubercle bacilli) are present, and making the differential recognition of the organisms found; learning the exact source of bleeding which is present before the catheterization; compar- ing the relative activity of the two kidneys w r ith regard to quantity of urine secreted in a given time. (For insuring against error in this, precautions must be taken with reference to leakage on one side or the other alongside the catheter into the bladder, instead of draining through the catheter); and relative functional activity. Complement Fixation Test. In inflammatory conditions of the urinary tract, when intracellular groups of diplococci are found by methylene blue or other of the anilin dyes and they are decolorized in the Gram stain, the diagnosis of gonococcus infection is fixed irrefutably. But if in the face of symptoms and history simulating those of gonor- rhea, or if there is a question of recovery from gonorrhea and none of the organisms can be found, the question as to whether the gonococcal element prevails may be a momentous one, yet difficult of solution. The tests of irritation (beer, nitrate injection, use of urethral sounds) may all fail and leave the investigator in the dark. Cultural methods are not always satisfactory or available. To meet this dilemma the complement-fixation blood test was devised by Miiller and Oppenheim in 1906, the efficacy of which was confirmed by Schwarz and McNeil 8 whose contribution on the subject was highly appreciated by the profession. Others investigated the efficiency and reliability of this test and reports of Swinburne, Schmidt, Gardner and Clowes, Gradwohl and others gave strong support to the favorable estimate early placed on it. The test is somew r hat analogous to the Wassermann test. It is based on the fact that microorganisms, when mixed with their homologous antisera, are capable of rendering complement inactive or fixed, as shown by the absence of hemolysis W 7 hen sensitized erythrocytes are added to the mixture. The antibody is produced in the patient by the gonococci, and the antigen is a preparation of the gonococci. The fixation of complement is a result of the specific interaction between the two. For details of preparation and use, see the papers by the authors alluded to (Trans. Am. Urolog. Assn., 1911-1912). The test is now available in practically all modern laboratories, and should be used whenever the other modes of diagnosticating suspected gonococcal infection prove unsatisfactory or uncertain, Wassermann Tests : Blood and Spinal Fluid. That the Wassermann blood and spinal fluid tests have great practical value in assisting in the 136 METHODS OF DIAdXOMX /A" LKSIOXS OF I'KIXARY TRACT solution of obscure cases of urinary obstruction and other chronic genitourinary disturbances, is becoming widely recognized. These tests should be applied without hesitation in all cases, young or old, whose etiology is not traced or understood. The writer has found syphilis to be the basic and controlling factor in a number of cases of prostatic obstruction, urinary retention and vesical atony cases in which there had never been the slightest suspicion of such infection, although it had evidently been present for years. Even hereditary syphilis has been observed in the same light, causing chronic and severe urinary obstruction from infancy to adolescence, the patient meantime being put through a number of operative measures and treatments that served only to aggravate his suffering^. This topic is discussed at greater length in a paper by the writer, "Studies in Obscure Forms of Prostatic Obstruction and Vesical Atony." 3 The chronic retention of urine from locomotor ataxia is but a similar manifestation of syphilis and its late effects on the spinal cord. The modus operandi of the production of retention in these and similar cases has been expressed by the writer 1 as follows: The normal filling and emptying of the bladder is accomplished by a well-balanced relationship between the detrusor and sphincteric muscular systems of the bladder. If there is incoordination or loss of balance between these two systems, there is derangement of the function of urination. If the sphincteric function be weakened or abolished, there is leakage or incontinence; if the sphincteric energy be excessive, as compared with detrusive power, there is retention. Sphincteric energy is rela- tively stronger when the detrusors are weakened from any cause. In atony, for instance, while the sphincters may not actually have gained any strength through the establishment of that condition, they offer sufficient resistance to the now weakened detrusors to interfere with the discharge of their function; a certain amount of urine is left over after each urination. The insertion of a catheter removes the effect of the sphincters, opens the outlet and restores the original balance between the two opposing systems. The detrusors demonstrate their remaining, though weakened, power and readily empty the bladder. It is incumbent on the diagnostician to differentiate between these conditions, and also to trace the cause of the disturbances described. CARDIOVASCULAR EXAMINATION. As suggested under a previous heading, an examination of the allied organs, the kidneys and cardiovascular system, is of the utmost importance in its bearing on the outcome of a contemplated major surgical operation; and may have much to do with success or failure in non-operative plans of treatment in certain affections, especially of the kidneys. Cardiac functionating is intimately associated with renal activity and competence. Nothing shows this more plainly than the success that frequently follows the prescribing of efficient heart tonics in the presence of lagging kidneys. The heart grows energetic, DIAGNOSIS OF OBSTRUCTIONS IN THE URINARY TRACT 137 circulation becomes better, the kidneys respond with more and better urine and improvement becomes manifest in every respect. In determining the condition and efficiency of the heart and vascular system, besides the methods of examination regularly employed, the blood-pressure should be accurately taken. Some operators consider this to be as important as the urinary findings as a gauge on the physical condition and powers of resistance to the shock of operation. A press- ure unduly high or low may well be considered as directly suggestive of the propriety of postponing a contemplated operation until such time as various corrective measures may bring about a more favorable condition. DIAGNOSIS OF OBSTRUCTIONS IN THE URINARY TRACT. Obstructions in the urinary tract must be diagnosed with reference to (a) location; (b) form and nature; and (c) severity. They occur at any point between the preputial orifice, and the urinary tubules of the kidneys. There are definite and well-conceived methods of attaining the above-mentioned objects in diagnosis. Urethral Obstructions. Obstructions located at the preputial or external meatal orifice are patent to observation and require no com- ment other than a gentle expression of regret that physicians do not always make even the cursory inspection of these parts that w r ould locate the source of trouble, which is often on that account severe and unnecessarily prolonged. In children kidneys have been destroyed through backward pressure from so simple a cause as a narrow meatus or a tight prepuce. The tissues surrounding a narrow meatus gradually merge into a dense fibrous ring, producing, through backward pressure, insidious but disastrous effects on the organs above. Invalidism and a shortened life may be the consequence. Obstruction of the urethra at any point offers little difficulty of detection. Suspicious symptoms or history should lead to direct examination of the urethra by bulb sounds, which, the larger sizes being used first, will demonstrate the "hitch" of a stricture, its size and extent; or the obstructive presence, and possibly the grating feel of a foreign body. The bulb sounds are useful for the anterior urethra, but the large size conical steel sounds are preferable for the posterior part of the canal. A tight stricture at this point will obstruct a steel sound with- out the objectionable grasping of the bulbs. E. G. Mark 1 expresses his belief that one of the most satisfactory methods of diagnosticating urethral stricture is that by means of the aero-urethroscope. This gives a plain and clean-cut view of the constricted area, as well as of the adjacent healthier portion. Such a view also leads to more definite indications as to the treatment, it is claimed. Obstruction at the Vesical Neck. The demonstration of obstruction located at the vesical neck rather than at some point in the urethra is 138 METHODS OF DIAG.\OXIX IN LKXIOXX OF I'RIXARY TRACT made in the following way: In a given case the symptoms of which point to obstruction somewhere, the patient is instructed to pass his urine (all that he can) by voluntary effort; after which a soft-rubber catheter is passed if possible into the bladder. This immediately shows whether or not residual urine has been leftover after the volun- tary urination. Five, ten or twenty ounces residual urine thus obtained is clear evidence of marked obstruction; and also that the obstruction is located at the neck. So marked an obstruction as this (5 to 20 ounces residuum) if in the form of a urethra! stricture, would stop the passage of a soft catheter before it arrives at the neck; whereas, prostatic obstruc- tion, in the first place, does not make itself evident to a catheter until the depth of the vesical neck is reached ; and, in the second, prostatic obstruction is usually surmounted by a soft-rubber catheter of good size and quality. In brief, therefore, the drawing off, by means of a good sized rubber catheter (Xo. 18), of a pronounced amount of residual urine after voluntary urination indicates obstruction at the neck. If, on the other hand, the progress of the soft catheter is suddenly stopped before reaching the vesical neck, we know the obstruction is urethral; and in all probability is either a stricture or a manifestation of the obstructing influence of the cut-off muscle (compressor urethrse). The differentiation between these is made by means of the bulb and conical steel sounds. TJie muscle offers obstruction to the bulbs but not to the steel sounds. Pronounced stricture offers obstruction to both. By these tests, then, is learned (n) whether there is obstruction; (6) the severity of the obstruction; and (c) its location. If the obstruction is thus found to be located at the neck, the problem resolves itself into the determination of the remainder of the diagnostic points previously described, namely, the form, character and other physical characteristics of the obstructing factor at the neck; and the determination of the condition, functional activity, etc., of the allied organs, the heart and kidneys. Prom the view-point of obstruction, the vesical neck is undoubtedly the most interesting part of the urinary tract. While many forms of obstruction here met with are readily differentiated under the plans of examination already described, there are many others in which the cause is not easily determined. It may be obscure and may never be identified. The patient then is either classed as incurable or joins the host of "journeymen patients" who go unrelieved through the hands of physicians, thence to quacks, to osteopaths, "scientists" and down the line of fakery. With its importance and far-reaching influence in mind the writer, in discussing this subject at length elsewhere, 3 expressed himself as follows: "The causation of urinary obstruction should always be found in one of two factors, namely, (a) physical obstruction of some kind or (6) disturbance of the nervous mechanism controlling urination (tabes, spinal or cerebral lesions, etc.). There is no such thing as 'unaccountable' atony or urinary retention; such a term represents incomplete diagnosis. The most frequent and important DIAGNOSIS OF OBSTRUCTIONS IN THE URINARY TRACT 139 of the obscure, unrecognized causes of obstruction are: (a) Ill-defined contracture at the vesical neck demonstrable sometimes only by palpation through the opened bladder or urethra; (6) unrecognized syphilis, acquired or hereditary, affecting the spinal centres. Such con- ditions are by no means confined to adult life, and should be looked for at any age, from infancy up; diagnosed and treated in accordance with the refined diagnosis always demanded in cases of urinary obstruction. A final, but too late recognition is but poor solace for a lifetime of suffering due to delinquencies in diagnosis." Causes of Obstruction at the Vesical Neck. The causes of obstruction at this point are multifarious. They include disturbances both local and general or internal , primary or secondary , congenital or acquired, and are capable of being subdivided as to etiology as follows: Local causes: 1. Prostatic overgrowths (adenoma); 2. Contracture; 3. Cyst formation; 4. Abscess; 5. Congestion or Inflammation; 6. Neoplasm, benign or malignant; 7. Calculus; 8. Foreign body; 9. Valve formation in prostatic urethra; 10. Cyst or tumor of verumontanum ; 11. Inflammation of seminal vesicles; 12. Infection (colon bacilluria of little girls); 13. Hemorrhage (clot formation). Internal or systemic causes: 1. Cerebral (meningitis, hemorrhage); 2. Spinal (paresis, tabes, spinal syphilis) ; 3. Habit (deferred urination of teachers and others) ; 4. Fatigue (Peyer); 5. Neurotic (hysteria, nymphomania) ; 6. Psychic (fixed idea) ; 7. Reflex (secondary to irritations originating elsewhere; post- operative; shock). 8. Toxic (alcoholism, diabetic coma; acidosis, effect of drugs). The number and variety of causes of obstruction at the vesical neck afford no excuse for not making the required recognition and differ- entiation. Indeed, these must be made in order to choose an appro- priate treatment. Aside from an intelligent study of symptoms and signs, the cystoscope and posterior urethroscope afford the greatest assistance in arriving at diagnostic conclusions. These instruments are not interchangeable. A lens appropriate for the close-vision work of urethroscopy is inefficient and inappropriate for cystoscopy; and the relatively long distance focus of the cystoscope lens is inappropriate for intra-urethral vision. For discussion of diagnostic instruments see page 118. 140 METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT Obstruction in the Bladder. Obstruction and urinary retention sometimes occur from causes located within the bladder itself; such as foreign bodies, stones, tumors, etc.; or diverticula, whose lack of muscular equipment prevents them from contracting and emptying their contents into the bladder cavity. Cystoscopy is the chief agency for determining the diagnosis in such cases, although much may be done with radiography, using collargol or silver iodide solutions for distending the bladder. Deviations from normal size and form are thus to be recognized. Obstruction in the Ureter. Ureteral stricture is not as rare a condition as its lack of recognition in general would indicate. Occur- ring independently, or in connection with ureteral stone, the symptoms of both are often intertwined. Mucopus plugs passing down a ureter and becoming impacted in a strictured area act like stones and are followed by similar consequences of distention, pain, colic, chills or fever and infection. The effects resemble those of stone colic so closely that the differentiation is often made only with difficulty and with the aid of ureteral catheterization and radiography. A catheter is usually obstructed or stopped in its passage up the ureter on coming in contact with a stricture ; and is frequently, though not always, obstructed by the presence of ureteral stone. But the progress of a catheter may be stopped from too great angulation of the ureter channel or from spasm of the ureteric muscles, to be overcome in both instances by appropriate measures: Changing the course or direction of the catheter, in the first, and making steady pressure with the catheter and awaiting relaxation of the spasm, in the second will usually overcome the abstacle. A ureteral band, pressure from an anomalous vessel or adhesions, are other causes of ureteral obstruction whose differentia- tion is assisted by catheterization and pyelography. The efficiency of these measures in diagnosis has gradually lessened the utility and necessity of the old stock reliance, exploratory operation, in surgery of the upper urinary tract. Time was when surgeons opened the bladder to see whether or not the prostate was enlarged, but such a pro- cedure would hardly be countenanced now except in the presence of very complicated conditions. Obstruction in the Renal Pelvis. This is produced by stone forma- tion, constriction from stricture, adhesions, kink, anomalous vessel, or malignant growth, and sometimes from plugging of the outlet by the products of inflammation, crystalline sedimentation, or hemor- rhage. The typical characteristic distress-signal of Nature indicating any of these conditions is pain, intense, repeated, horrid; described by some as possessing all the tortures conceivable. Where the stone forms in the kidney tissue, especially in the cortical portion, the pain is less insistent; indeed, it may be insignificant or even absent throughout the progress of destruction of the organ. But this well-established fact should not justify a failure to trace and find the offending stone, no matter how insidious its development nor retired its situation. Investi- SYMPTOMATOLOGY IN GEN I TO-URINARY DISEASES 141 gation along the lines of comprehensive physical examination should divulge the secrets of all eases and evoke relief before the period when decreptitude and participation of the opposite kidney preclude chances of reclamation. Pathological evidences of obstruction in the pelvis consist in hydro- nephrosis, pyonephrosis, thinned, sacculated and destroyed kidneys, the latter being sometimes nothing but a thin-walled sack, incapable of excreting real urine, but perhaps carrying on a process of filtration of thin, worthless fluid incapable of performing the renal scavenger service required for life and health. SYMPTOMATOLOGY IN GENITO-URINARY DISEASES. The writer has always considered the extended discussion of urologic symptomatology as detrimental to the attainment of correct and useful diagnosis, rather than the contrary. Such symptomatology is inexact and often illusory, as has been previously shown, and cannot be given much credence even by the initiated. How much less reliance, then, can be placed on it by those who are doing general practice and do not possess experience in this special work that would keep them out of the pitfalls ever present. The symptoms under such circumstances assume more the character of will-o'-the-wisps, leading practitioner and patient on and on from one erroneous assumption to another, the while postponing the day of definite reckoning, exact diagnosis and correct treatment until the arrival of the unhappy time when everyone realizes that it is too late; that opportunity has fled from the poor sufferer, leaving in its wake only the miserable duty of palliation until death relieves. The betrayal has been made through the guile of plausible but illusory symptoms. Used in their proper light, however, urinary symptoms are valuable and serviceable for paving the way to recovery. They should be received as pointing the way, not to diagnosis, but to appropriate methods and steps of physical examination, on which must rest the development of the diagnosis. This is "a real situation in' urology and is met with every day of the year, the country over. Its considera- tion, therefore, and its reiteration are worth while. Whatever is said of symptomatology, in this or any other review, should be said with those thoughts ever in mind. Symptoms of Urethral Affections in the Male. The anatomico- physiological division of the male urethra into anterior and posterior portions markedly influences the symptomatology of this tract. Be- tween the placid progress of an anterior urethritis and the urgent and impetuous invasion of the posterior urethra there is a wide difference. Frequency and urgency of urination usually mark the transition; and inspection of the urines confirms the suspicion: The two (or three) glasses are found to be cloudy, instead of the clouding being confined to the first glass, as has been the case up to that time. With subsidence in the intensity of the posterior inflammation there 142 METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT is usually decrease in the unwonted frequency until often, even with persistence of a low-grade inflammation and moderate infection there may be no greater frequency than normal. Also, under the same circumstances, there may be no purulent discharge at the external meatus; and if one were guided by symptoms alone, he might pro- nounce such a patient well and permit him to resume intercourse though he were as infectious as during the more active stages. In the misconception that undue frequency of urination means cystitis, the irritative symptoms of posterior urethral infection are often ascribed to the bladder. As a matter of fact, the sensation of desire to urinate arises in the posterior urethra, and excessive frequency is an indication of irritation of the posterior urethral membrane. \Vere the bladder mucosa the seat of the sensation, desire to urinate would be aroused practically all of the time, as the bladder nearly always contains some urine even shortly after urination, when it is refilling. Vesical Symptoms. Pain deep in the pubic region and a disagreeable feeling of fulness are often present with cystitis. In connection with the presence of a stone in the bladder there is described by the patient the sudden interruption of the urinary stream and, after a pause, the resumption of the flow. These are the most characteristic symptoms pointing to disturbances within the bladder. But they are not to be relied on for differentiation, even with the addition of blood in the urine, as the same conditions and interruptions may be brought about by the presence of a pedunculated tumor in the bladder, intermittently plugging the outlet and interrupting the stream as does the stone. Prostatic and Seminal Vesicular Symptoms. A symptom almost con- stantly attendant on prostatic inflammation, either from abscess forma- tion or in connection with acute retention from hypertrophy, is pain in the glans penis. Complaint of such pain, in the absence of apparent disturbance of the glans, should arouse suspicion of prostatic disturbance and lead to the rectal palpation that should determine the question. Active irritation in the vesicles often produces an uncomfortable " bear- ing-down" feeling in the perineum with a sensation of fulness there; or, the pain may be transmitted down the spermatic cord into the testicle of the side affected. Chills or elevation of temperature in connection with any of these conditions depend on the acuteness and intensity of the process, and may or may not be present. A sign of atonicity of the ejaculatory ducts is given in the recurrent escape with urination of spermatozoa from the seminal vesicles. Sig- nificant evidence of this appears in the two-glass urine test: In this case the second glass is cloudier than the first, an exception to the rule as already mentioned. The clouding, on microscopic examination, is found to be from numbers of spermatozoa. Ureteral Symptoms. Ureteritis sometimes presents symptoms, some- times not. If present, they may show as a fixed or intermittent pain in the line of the ureter, extending downward into the scrotum and testis of the corresponding side; to which may be added an irritation reflected into the posterior urethra that evokes frequency of urination or even SYMPTOMATOLOGY IN GEN I TO-URINARY DISEASES 143 strangury. Tenderness in the line of the ureter is also characteristic of ureteritis. This is accentuated when one comes to catheterize that ureter through the cystoscope; and further confirmation is obtained in the contents of the urine drawn from that side : pus, bacteria, epithelia and blood cells. Ureteral Stone. By blocking the ureter and damming the urine back into the kidney, and also by arousing spasmodic contractions of the ureteral muscles, ureteral stone often becomes one of the most painful conditions aft'ecting the human body; and such attacks may recur at irregular intervals for many years, subjecting the patient to the mortal dread, as \vell as the realization of their horrors. When the stone is smooth and oval, and leaves room for the passage of urine beside it, there may be no more than an occasional dull ache in the vicinity of its location; and this, notwithstanding that the kidney above it may be undergoing damage and gradual destruction through infective and insidious back-pressure influences. Nausea and vomiting often occur in connection with such ureteral crises. Renal Pelvic Symptoms. Chronic backache that has, by the laity, been ascribed to "kidney disease" is more closely and typically con- nected with pyelitis than with nephritis, of the chronic form. The amount and intensity of pain caused by a stone in the pelvis depends largely on whether it falls into the ureteropelvic outlet and blocks the escape of urine. But even aside from that it may be said that a stone moving about in a pelvis and thereby irritating it arouses much more pain than does the stone that grows while fixed immovably in the cortex, even though the destructive effect may be as great with the latter. Many cases have been observed in w r hich kidneys had been utterly destroyed found so at postmortem examination without any complaint of backache having been made during life. Probably the most typical sign of severe pyelitis is the persistent loading of the urine with pus, continuing perhaps over many years. The very absence of other symptoms in the presence of excessive pyuria is in itself sufficient to cause a suspicion of pyelitis and call for the cystoscopy and ureteral catheter ization that are needed to solve the question. Of course the determination of pyelitis by such means is only one step in the procedure, and the cause of the pyelitis is also to be learned: Whether from stone, tumor or infection; and if the latter, what kind (colon bacillary, tuberculous, gonococcal, etc.). It is sur- prising how long such pelvic suppuration may go on without making marked inroads on the general health of the patient. A patient of the writer showed urine that by bulk was almost a third pus on settling, and declared that the same thing had been going on for twenty years; and without apparent detriment to his general health. Movable and displaced kidneys produce symptoms of pain and systemic reaction, nausea and vomiting harmonizing with the occur- rence of displacement and obstruction to circulation and urine escape incidental thereto. Such attacks are called Dietl's crises, a term given in recognition of their graphic description and explanation in 1864, by Diet). 144 METHODS OF DIAGXUSIX IX LESIONS OF URIXARY TRACT Genital Symptoms. Symptoms of pain connected with diseases of testis or scrotum are sufficiently localized to disclose their identity, with certain exceptions. The writer recalls an instance in which a bed- ridden patient was crying out with plaints of pain in the back and could give no clue to the cause until an extended search disclosed the existence of acute swelling and inflammation of one testicle, of which the patient was not aware until it was shown to him. It showed where the reflexes of ttsticular pain might be looked for: Up the cord and into the back. Disturbances of the cord tend to reflect pain in the same direction. Urologic Symptomatology in Women. Urethral Symptoms. In women the short urethra is undivided by a cut-off muscle, and the symptomatology presents no such variations according to location of in- volvement as are found in the male. The female urethra, nevertheless, is the source of much suffering and intensely painful symptomatology, which, curiously enough, is nearly always ascribed to the bladder by the sufferers. Designated as "cystitis," such urethra! irritations, inflam- mations and contractures go for years, often with no better treatment than some internal medicine and perhaps an occasional washing of the bladder an organ that is merely an innocent bystander in multitudes of such instances. The symptoms complained of, then, are undue frequency and urgency of urination, often painful urination, accompanied with straining or incomplete emptying of the bladder; and all with or without clouding or infection of the urine. Some patients show crystal-clear urine yet complain strenuously from adolescence to middle life. Some relate that the same conditions have prevailed since childhood. Others give the birth of their first child as the date of beginning; while still others note the close and suspicious relationship between marriage and the begin- ning of their "bladder trouble." At any rate, like the poor, it seems ever present with them. A recent patient of the writer was certain that she had had the same symptomatology for thirty-eight years; yet she became well within a month after appropriate treatment, based on a correct diagnosis, had been applied. In this case the urethra only was involved, in the form of a narrow stricture at the meatus, causing obstruction and urethritis behind it. In these conditions, as well as in those in which the female vesical neck is particularly involved, the symptomatic expression is chiefly frequency of urination and an inability to retard urination when once the desire is felt. It occurs in the young, the middle-aged and the old. Yesical symptoms, pain and aching feelings often originate from disturbances in the uterus or malpositions of that organ, causing it to impinge on or distort the bladder. Cystoscopically, one may often see the dome-shaped body of the fundus uteri as it encroaches on the bladder cavity. The symptomatology of the remaining urinary organs of women do not differ materially from that described for men, and requires no further special mention. Hematuria, pyuria, bacteriuria when sufficiently pronounced are evi- SYMPTOMATOLOGY IN GEN I TO-URINARY DISEASES 145 dent to the naked eye, and on being thus observed should always impel the practitioner to make or have made the definite investigation that should disclose their source and causation. Under no circumstances a hurt of actual danger from /o.v.v of blood should an endeavor be made by medicines, etc., to check hematuria until opportunity is had for cysto- scopic diagnosis of the source and causation of the bleeding. It is of greatest importance to have the cystoscopy done while the bleeding in- going on. When it stops, the urine may be as clear as crystal and give no tangible evidence of whence came the alarming hematuria of a few days previously. To bring about a temporary clearing of the urine of blood is no real accomplishment and postpones the making of a definite diagnosis; so that the more successful the practitioner is in that endeavor, the more he is liable to injure the prospects of his patient. To depend on the color of the blood as indicating whether it has come from bladder, ureters or kidneys, is fallacious in the extreme and should not be entertained for a moment. The crucial test is the use of cystoscopy and ureteral catheterization, with possibly the addition of radiography. Phosphaturia, oxaluria, uric acid excess and other like conditions are indicative of disturbances of metabolism. Their irritating influ- ences sometimes excite an irritation of the urethra that may become quite an active urethritis, not easily controlled unless the causation is recognized and is eliminated at the source. The writer has seen cases in the males that, excepting for the absence of gonococci in the dis- charge, closely resembled gonorrheal urethritis. These are among the so-called "simple urethritis" cases. The diagnosis is arrived at by examination of the urine and identifying the causal element therein. Physical Examination of Women. The patient should be cautioned against taking a douche or urinating shortly before undergoing exami- nation something that prospective patients are prone to do. Such action only washes out the inflammatory products and disguises the real situation. If the woman is being examined because of a suspicion of gonococcal infection, inspection of the external genitals should be the first step, a little pressure with the finger being made under the meatus to express any urethra! discharge that may be present. If none is found, the meatus may be cleaned with moist cotton and the patient requested to urinate in a sterile vessel, both for macroscopic and micro- scopic examination. Such a urine specimen will contain vaginal epi- thelia in abundance; and if urethritis be present, evidence of it will be shown in the pus and other inflammatory products, possibly with gonococci, attained by sedimentation and staining. If it is desired to examine for tubercle bacilli, the specimen for this purpose should be drawn by catheter directly from the bladder. Continuing the physical examination, a vaginal speculum is intro- duced and the cervix is inspected. Some of its secretion may be mopped up with a small cotton swab and transferred to glass slides for staining. It is scarcely worth while to take secretion from the vaginal wall, as the bacteria are naturally so numerous in the vagina that no particular M U I 10 146 METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT forms can be identified in this way. The cervical canal and uterine cavity may be sounded by the uterine probe, for information as to depth and conformation. The remainder of the physical examination is to be made by bimanual palpation, with the patient on the back and legs and thighs flexed to the degree of affording most relaxation to the abdominal muscles. Bimanual palpation gives information not only as to the size, shape, mobility and position of the uterus, but often gives valuable informa- tion regarding the bladder and ureters: As to whether they are thick- ened, tender, severely inflamed, etc.; and sometimes a ureteral stone may be felt in the lower part of the ureter. Bimanual palpation of the kidneys should be made with the patient in three successive positions : Lying down, semireclining and standing up. These changes give opportunity of detecting the mobility of loose kidneys as well as outlining the shape and size of the organs, and elicit- ing any tenderness that may be present. BIBLIOGRAPHY. 1. Guiteras: Urology, i. 2. Kummel: Trans. 32d Congress of German Surg. Soc. 3. Lewis: Ann. Surg., March, 1915. 4. Lewis: Keen's Surg., iv, 300. 5. Lewis: Trans. Am. Assn. of Genito-Urin. Surg., 1893. 6. Lewis and Mark: Cystoscopy and Urethroscopy, 1915. 7. Schmidt and Kretchmer: Trans. Am. Urolog. Assn., 1911, p. 233. 8. Schwarz and McNeil: Am. Jour. Med. Sc., May, 1911. 9. Thomas: Jour. Am. Med. Assn., November 28, 1914. CHAPTER IV. THE ROENTGENOLOGY OF THE URINARY TRACT. BY WALTER J. DODD, M.D. IN order to make a successful examination of the urinary tract, certain conditions are necessary. The patient must be prepared and the proper technic used. It is absolutely essential that a distinct out- line of both kidneys should be seen and the entire course of the ureter and bladder must also be examined. It has been stated that a good .r-ray plate must show the transverse processes of the lumbar vertebra, the eleventh and twelfth ribs and outline of the psoas muscle. Some years ago, roentgenologists had to be content with the above, but today there is no reason why a distinct outline of both kidneys cannot be clearly revealed, even in stout individuals. Preparation of Patient. When possible, the patient should be given a good cathartic, preferably a sufficient dose of castor oil, and for twenty-four hours preceding the examinations liquids without solids should be the diet. Enemata should be given only in emergencies, owing to the fact that particularly if there is much delay before the examination is made, the intestines are apt to become distended with gas and the kidney outlines may be obliterated. Calomel or prepara- tion containing heavy metalic salts should not be used as a cathartic. The above conditions we realize are ideal and frequently cannot be followed. In fact, hundreds of cases are examined every year in a large out-patient clinic and the known error is still only 5 per cent. It would seem from this that, if a thorough technic on the part of the roentgenologists is complied with, the Roentgen examination of the urinary tract for the detection of urinary calculi must be considered extremely successful. Under ideal conditions, roentgenologists agree that probably 2 per cent, would be an excusable error. We must remember that there are certain types of renal calculi, fortunately extremely rare, such as zanthin, cystin, and pure uric acid calculi, which are detected only with great difficulty. Pure uric acid calculi are rare in adults. Although many have been reported as being revealed by the Roentgen methods, if a perfect chemical analysis had been made of these stones, enough calcium salts would have been found present to explain the reason of their detection by this method. Sources of Error. It has been stated by various writers that the percentage of error in locating renal calculi varies from 5 to over 30 per cent. Five per cent, is almost an excusable error in a large out- patient clinic where the patients are not properly prepared and are (147) 148 THE ROENTGENOLOGY OF THE URINARY TRACT often apprehensive and many times cannot be made to understand the very essential point that they must hold their breath during the exposure. FIG. 92. Patient sent in for examination of spine. Old Pott's disease. Plate reveals stone in kidney. This plate shows the great importance of not only examining spine in such cases, but also the renal area. It is also wise to examine spine when making renal examination, as not infrequently pathological processes may be revealed in the spine. FIG. 93. Stone in the pelvis of the kidney. No symptoms. Patient sent in for other examination. X-ray examination of kidney made owing to presence of pus in urine. SOURCES OF ERROR 149 \ Cry frequently calcified glands are present. Sometimes singly and, in other cases, numerous glands are seen. As a rule, it is easy to BB FIG. 94. Shadows seen over fifth lumbar transverse j >!<>< catheter to he calcined glands. >roved by radirtyraphic distinguish between calcified glands and renal calculi. The writer has found that the best method to differentiate these shadows from calculi was to take separate plates, one in forced inspiration and the other in Fie. 95. Radiographic catheter proves that shadow seen over fifth lumbar transverse process is not in ureter. forced expiration. Usually it will be seen that the shadow does not bear the same relation to the kidney in these two plates, as the kidney 150 probably moves to a much less degree than the glands. Stereoscopic plates are also of great value in such cases. Pigmented Moles. Pigmented moles on the back of the patient, which sometimes lie in the course of the ureter or in the renal area, may also be mistaken for calculi. Here, again, stereoscopic plates would be of greatest value, or if a wire ring is put around the mole and a piece of adhesive plaster fastened over the ring on the skin, it will be seen that the shadow changes its position. When the adhesive strap is pulled to one side, its relation to the transverse processes of the lumbar vertebra may be changed considerably. FIG. 96. Large phlcbolith adherent to the ureter causing symptoms. (Case of Dr. Lincoln Dodge.) Concretions in the Appendix. These may be mistaken for ureteral calculi, particularly following a bismuth meal. Osteophytes. Osteophytes of the transverse processes of the lumbar vertebrae not infrequently look like small, round ureteral calculi, but ureteral catheters impervious to the x-rays and stereoscopic plates will enable one to readily differentiate this shadow from a calculus. Phleboliths. Phleboliths which are so frequently found in the large veins of the pelvis, and oftentimes lie right in the course of the ureter, can invariably be distinguished by means of the ureteral catheter and stereoscopic plates. Intestine Shadows. Intestine shadows, as a rule, can be readily recognized, but not infrequently small masses of bismuth, following a SOURCES OF ERROR 151 bismuth meal,. may lie in the renal area or in the course of the ureter. As a rule, however, these shadows are of such a nature that this need FIG. 97. Numerous stones in right kidney. Might be mistaken for gall-stones. One large stone in left. not be considered a serious source of error. Calomel tablets or other pills or tablets containing heavy metal salts may give rise to mistakes. FIG. 98. Same case after removal of stones from right kidney. Gall-stones. Gall-stones not infrequently closely resemble renal calculi and may lie in the renal area. As a rule the shadow changes its Io2 THE ROENTGEXOLOdY OF THE I'RIXARY TRACT relation in full inspiration and forced expiration more than the kidney outline changes. The best way to differentiate gall-stones from renal stones, however, is to take a plate of the patient in the prone position as well as in the supine position. In the prone position the shadows will appear much clearer than when in the supine position. Technic. We have seen that a good Roentgen plate of the urinary tract must show the outline of both kidneys, as well as the transverse processes of the lumbar vertebrae, psoas muscle, and the eleventh and twelfth ribs, and that part of the bones of the pelvis, i. e., sacrum and ilium, which the ureter crosses. In order to obtain such a plate, cer- tain points of technic must be observed, and as already stated, if pos- sible, the patient should be properly prepared. FIG. 99. Multiple renal calculi in boy, aged eleven years. For a number of years the writer has used a pure rubber bag covered with canvas in order to get the necessary compression. Some form of compression must be used. The compression cylinder is extremely valuable, but he has found the rubber bag, first suggested by Cald- well, far superior. The compression when applied by this means is more bearable to the patient and is more uniform. Small -compression cylinders can be used and separate plates taken of each kidney: one of the middle portion of the ureter and another plate of the lower portion of the ureter and bladder. He has found, however, that both kidney outlines can be distinctly seen on one plate when the proper compres~ sion is applied with the inflated rubber bag, and that another plate TECHN1C 153 taken of the lower portion of the ureter and bladder will give the entire urinary tract. Thus it is necessary to take only three plates : two of the renal area, one in forced expiration and one in forced inspiration, and another one of the bladder and the lower portion of the ureter. After the plate is properly under the patient, making sure that the top of the plate is at least as high as the tenth rib and the lower edge of the plate is just below the crest of the ilium, the tube is carefully f ocussed in the median line ; the compression bag or cylinder is then placed on the abdomen ; the patient is requested to take a long breath FIG. 100. Illustrating position of patient when taking plate of kidney. Notice that the shoulders and legs are elevated and that the back is flat on plate. Patient's arm elevated to show plate. Should be at the side when plate is taken. and slight compression is applied. The cylinder or bag will thus be forced down slightly under the costal margin and the focal point of the tube will be practically between the ensiform and the umbilicus. The patient is requested to take another full breath and then forcibly exhale it. When the lungs are completely empty, full compression is applied. The tube is locked in place after being tilted upward about 5 degrees so that the central rays cut upward, thus enabling one to get a picture of the upper portion as well as the rest of the kidney outline. The legs are flexed in order to correct the lordosis which is so commonly present, thus bringing the back of the patient close to the 154 THE ROENTGENOLOGY OF THE URINARY TRACT plate. When necessary, the shoulders are elevated. The elevation of the shoulders and flexion of the legs should, of course, be done before compression is applied. After these essentials are complied with, it is only necessary to make the exposure, but the patient should be instructed not to breath during the exposure and to keep perfectly still. The length of the exposure varies from a fraction of a second to two seconds, according to the size of the patient. After this exposure has been made, another plate is taken in forced inspiration. The third plate of the lower portion of the ureter and bladder is now taken. Compression FIG. 101. Position of tube when plate of bladder and lower portion of ureter is taken. cylinder with the rubber bag can be used. The focal point for this plate should be exactly in the median line of the body and the central rays should pass through a point just below the anterior superior spine, but always in the median line. This will give us that portion of the bony pelvis and the sacral synchondrosis over which the ureter passes, as well as the bladder. The tube should be tilted about 10 degrees. Not infrequently ureteral stones lie in the ureter as it crosses the sacrum and may lie right at the brim of the pelvis. A good plate will usually show these calculi even without tilting the tube, but if the stone is not sufficiently dense, it may be overlooked unless the tube is tilted. PYELOGRAPHY 155 Stones near the brim of the pelvis with this technic will be thrown off the bony structures and the shadows appear in the true pelvis. Pyelography. This term has been applied to that part of roentgen- ography in which the pelvis of the kidney and ureter is made apparent on the plates by injecting into the renal pelvis some solution that is opaque to the .r-rays, such as collargol, solution of thorium nitrate or a suspension of argentide. The writer has found the argentide suspension very satisfactory and not so irritating as a collargol solution. This method is of extreme importance in some cases, for when the renal pelvis is properly injected, abnormalities in contour as well as size can be quite readily determined. FIG. 102. Collargol injection showing evidence of renal tumor, distorted. Kidney lower than normal. Pelvis large and Uric Acid Stones. Another valuable use of this method is in cases where clinical evidence points very positively to the presence of a stone and the stone has not been revealed on the .r-ray plate, the injection of an opaque solution will frequently coat the stone which by the ordinary method was invisible. The writer believes that when such stones are revealed by this method, that they are probably pure uric acid or stones that do not contain sufficient lime to demonstrate their presence. Nephroptosis. Another use for the opaque solution is to determine whether the patient has a very freely movable kidney. This is best determined by taking the regular compression picture and then without shifting the position of the tube in relation to the patient, simply with- draw the original plate, insert a fresh one, and then tip the table into the upright position; an exposure being made, of course, in this position. This technic requires a special table and it is better to use one in 156 THE ROENTGENOLOGY OF THE URINARY TRACT which the tube is under the table and moves with the table as it is tipped. This requires that the patient be in the prone position instead of in the supine position. This is an extremely valuable method and FIG. 103. C'ollar-rol injection showing kink in ureter. FIG. 104. Stone in ureter. PYELOGRAPHY 157 FIG. 105. Large stone in ureter. Removed by Dr. Horace Binney. FIG. 106. Ureteral calculi one at vesicle orifice and one just above the bladder. 158 THE ROENTGENOLOGY OF THE URINARY TRACT FIG. 107. Same case eighteen hours later. Very important, as this case shows, the great necessity of making the examination as near the time of operation as possible, as the stones may change their position. FlG 108 _stone in left ureter appears just below brim of pelvis. Was not revealed in original plate which was uot clear enough to differentiate the stone from the bony structures. PYELOGRAPHY 159 fluoroscopy can be combined with roentgenography in such cases with such a table. Ureteral Calculi. The use of the opaque solution in determining the presence of ureteral calculi is also of value. When the roent- genologist makes the diagnosis of a stone in the ureter or when the diagnosis is doubtful owing to the presence of phleboliths or calcified glands or shadows in the region of the appendix, this method will fre- quently give confirmatory evidence. It is not at all uncommon for the catheter to pass freely through the entire course of the ureter without obstruction even when a stone is present, as the ureter may be greatly dilated. FIG. 109. Large prostatio calculus weighing 60 grams. When the opaque solution is injected, the stone, as a rule, will be surrounded by the collargol shadow. The opaque solution also is of great use in revealing kinks and tortuosities of the ureter. Prostatic Calculi. The same technic is used as was described tor stones in the lower portion of the ureter and bladder. That is, the tube is tilted from 5 to 10 degrees, the focus of the tube being in the median line, midway between the symphysis and the anterior superior spine. This will throw the symphysis off the field and prostatic calculi may be revealed providing they contain sufficient lime salts. 160 THE ROENTGEXOLOGY OF THE L'RIXARY TRACT Diverticula. Another use for the opaque solution is in demonstrating cliverticula of the bladder. The writer has found the best method to be the following: About one ounce of a 20 per cent, solution of collargol is injected into the bladder and allowed to remain for a few minutes. The bladder is then evacuated and in most cases the diverticuli will retain sufficient solution to be well defined on the plates. Stone in the Bladder. Most stones in the bladder can be readily re- vealed, but soft phosphatic stones are not infrequently missed. If the bladder is distended, a distinct outline can usually be seen, but the stone itself may appear very faint. In such cases it is wise to have the bladder evacuated and take another plate. Xot only will the stone appear more distinct but not infrequently its position will have changed. Faint shadows often appear in the region of the bladder and these shadows are usually due to intestinal contents. Calcification in the walls of the uterus may resemble a stone, also calcification of the ovary. As a rule these sources of error can be readily eliminated. The intestinal contents can be eliminated by means of an enema and the shadows in the uterus and ovaries by palpation. Exposure. The length of the exposure depends upon two factors: the power of the machine and the size of the patient. In such an article as this it is unnecessary to go into details regarding apparatus. It is only necessary to say that with the modern transformer, so-called interrupterless machines, the exposure varies from one-half second to four seconds, according to the size of the patient. The penetration of the tube should be equivalent to 6 or 7 degrees on the Benoit penetrometer. Dark-room Technic. Absolute cleanliness in the dark-room is essen- tial and nothing should come in contact with the film of the plate. The author has found the tank system of developing the ideal method. The formulae for developing and the fixing solutions are usually furnished by the plate manufacturer, any of which are perfectly satisfactory. A normal plate will be developed in from six to ten minutes. It should be thoroughly washed in running water before being placed in the fixing bath. It is wise, as a rule, to leave the plate in the fixing bath for about fifteen minutes after all signs of unaffected silver salts have disappeared. Otherwise the plates will slowly become blackened and the image almost disappear. The plates should, of course, be thoroughly washed in running water for about one-half hour and interpreted when dry. CHAPTER V. SYPHILIS OF THE GENITO-URINARY ORGANS. BY B. C. CORBUS, M.D. SYPHILIS OF THE URETHRA. THE Spirochaeta pallida may invade the urethra in either the primary, secondary, or tertiary periods, and provoke lesions which on account of their site, form, and evolution may produce a variety of more or less obscure symptoms. In 1897 appeared the first review of syphilis of the urethra, by Faitout, 5 followed later (1898) by the thesis of Bellet, 22 and still later (1905) by the general review of "Syphilis of the Urethra," by Simionescu. 15 More recently (1908) the thesis of Rougier, 14 "Tertiary Syphilis of the Urethra," followed by the general review of " Syphilis of the Urethra," by Tanton/ 6 have added materially to our knowledge of these conditions. Primary Syphilis. 1. Frequency. Fournier 8 reports that out of 414 indurated chancres, 32 occurring at the meatus, 17 were deep and could easily have escaped notice. In women urethral chancre is much more infrequent than in men. According to Fournier, 7 the order of frequency in women is as follows : Entrance to the vagina, region of the clitoris, uterine neck, and urethra. 2. Location. Urethral chancre is located either at the meatus (chancre of the meatus) or more deeply in the interior of the urethral canal (end o- urethral chancre). A. CHANCRE OF THE MEATUS. Chancre of the meatus may make its appearance in the following w'ays: 1. Round chancre embraces all of the free extremity of the canal. This form presents itself under the aspect of a small rose-colored circle, hemming in the meatus and leaving the urethra projecting like a beak on the surface of the glans. 2. Left or right hemilateral chancre occupies the corresponding lip of the meatus; it appears under the form of a projecting nodule which provokes a deformation of the meatus by retraction of the correspond- ing lip or side on which the chancre is located. 3. Superior or inferior commissural chancre occurs in the form of a crescent, the corners of which descend or ascend more or less on either of the two lips of the meatus or on both. These three types of chancre during the course of their evolution may lose the primitive characteristics which differentiate them from each other, particularly when phagedena is a complication. MU I 11 (161) 102 XYI'lULIX OF THE GEN I TO-URINARY ORGANS Symptoms. - -Syphilitic chancre of the meatus may be of either erosive or ulcerative type. Induration is marked and often diffuses toward neighboring structures. ^ hen the chancre is situated exactly on the meatus, whether or not it extends itself into the canal, the orifice presents itself as swollen, deformed, red and gaping, bleeding on pressure and offering to the touch a sharply circumscribed, indurated area. In women, syphilitic chancre of the meatus usually has its site at the inferior angle of the orifice. Simionescu 15 cites an observation where the chancre, primarily located at the meatus, sank into the urethra up to the vesical neck. B. ENDO-UBETHRAL CHANCRE. While endo-urethral chancre is not common, it is far from uncommon. Occurring in the fossa navicularis portion of the urethra, as it does, many times it is unrecognized. Often it is so near the meatus that it can be seen by forcibly separating the borders of the urethral orifice. Du Castel 4 observed one situated 2 cm. behind the fossa navicularis. Fasoli 6 cites one situated 2| cm. from the meatus on the inferior wall of the urethra. Endo-urethral chancre occurs in the following ways: 1. From a chancre at the meatus, extending by continuity. The endo-urethral chancre of the anterior portion of the urethra is only an extension of the chancre of the meatus. 2. Sometimes, in patients afflicted with gonorrhea, the mucous mem- brane in the fossa navicularis becomes eroded a producing an atrium of entrance for the spirochetes. 3. It is possible, but highly improbable, that infection may take place by the passage of sounds into the urethra. Such things have been reported, but in this day of asepsis and antisepsis, it is almost beyond belief. Ki/DiptoiHx. The three principal symptoms are: 1. Pain. 2. Discharge. 3. Induration. 1. Pain. This is slight, always accompanies micturition and occurs in the majority of cases toward the end of urination ; this is due to the expansion and contraction of the base of the lesion. 2. Discharge. This is the first symptom noticed by the patient and causes him to consult a physician. In every case a discharge is the initial symptom. It begins slowly after variable periods of incubation. In the beginning it is seldom accompanied by pain at the time of mic- turition; it is very watery at first, later slightly seropurulent, easily becoming blood-tinged, especially if the urethra is palpated roughly. At times the discharge is thick and purulent, but this is always a sign of mixed infection. 3. Induration. This is perceptible only by palpating the glans from behind and in front; the chancre is situated in the substance of the urethra, following an anterior-posterior direction, and, as a consequence, is lamellate in form. Often in the fossa navicularis the induration SYPHILIS OF THE URETHRA 163 manifests itself as a mass of cartilaginous consistency and of variable dimensions. In women the endo-urethral chancre is situated in the anterior part of the canal; in order to locate the induration, the index finger of the left hand is introduced into the vagina in contact with the suburethral region, while the right index finger examines the meatus from before backward. Sometimes this forms a veritable indurated cylinder, a peri- urethral muff, around the canal. At other times it is limited to the inferior segment of the canal and to the lateral surfaces. Syphilitic chancre of the urethra is accompanied by indolent inguinal adenitis, the same as any other chancre situated on the penis; at times the dorsal lymphatic vessels appear as an indurated cord. Diagnosis. Chancre of the meatus should not be difficult of diagnosis from the character of the induration, appearance, and lastly and most important, from the microscopic examination of the secretion for Spirochseta pallida. In endo-urethral chancre, most patients present themselves on account of a discharge; this should be immediately examined for gonococci, as this is the most frequent condition that produces a "ure- thral running." Failure to find any organism either of a specific or non-specific variety should arouse suspicion. Chancre of the meatus may be confounded with simple chancroid of the meatus, on account of induration caused by the irritating effect of the urine; however, in chancroid there is more discharge and extreme pain, and the lesion may be covered by a membrane with a dirty, moth- eaten appearance. Superficial erosions due to gonorrhea may simulate chancre of the meatus, or both may exist together. Herpetic eruptions are multiple, the borders are polycyclic, and, if recent (vesicle stage), clear serum can be expressed from the lesion. Syphilitic chancre of the meatus may be confounded with epithelioma of the glans; here an error in diagnosis might lead to unnecessary operation. The epithelioma may be accompanied by infiltration and adenopathy, the same as a chancre. In women the error may be still more easy, as the periphery of the meatus is the place of election of urethral epithelioma; cancerous induration is more extended, but less hard and less resistant than the syphilitic induration. The adenopathy is less tardy in the neoplasm, and the neoplasm does not tend toward cicatrization. However, in all cases a careful history should be noted, together with a complete physical and careful microscopic examination. In examin- ing for Spirochseta pallida there is no better way of obtaining the material than by capillary attraction, as illustrated on page 251, under Genital Ulcers. Complications. The evolution of urethral chancre is slower than that of other syphilitic chancres; this is due, in a measure, to the constant passage of urine and secondary infection, with poor drainage. 164 SYPHILIS OF THE (iEMTO-UKIX ARY O/.Y/.l.YN Ukeration. Often in the male and female, syphilitic chancres of the meatus may form extensive ulcerations, the edges become uneven, the base grayish, and a pseudomembrane may form, giving the condition, as a whole, a formidable appearance. Phayedena. Occasionally, in practice, more especially in dispensary work, chancre of the meatus isseen complicated by phagedena. This condition, occurring in endo-urethral lesions, is not so common. When occurring at the meatus, it may form extensive cavities, extending deeply; it may even decapitate the glans penis or enlarge the meatus considerably. Extensive mutilation may later cause complete closure of the orifice, calling for surgical interference. Strictiiir. Chancre of the meatus or endo-urethral chancre may at times cause stricture. Two varieties may occur: 1. A diminution of the caliber due to the syphilomatous neoplasm. 2. True cicatricial stenosis. The first variety occurs at the time of the specific induration and is of little importance; the stenosis disappears with the reabsorption of the induration. The second variety follows ulcerated or phagedenic chancres, espe- cially of the meatus and fossa navicularis. These strictures follow the general law of cicatricial strictures. They develop with great rapidity and offer great resistance to dilatation. Secondary Syphilis. Urethral Mucous Syphilides. Numerous French authors recognize the possible existence of a specific secondary urethritis. It is characterized by a more or less viscous, transparent, slightly opalescent discharge, rarely creamy or purulent. This is scarcely perceptible during the day, but is always present in the morning, after the urine has been held all night. Inflammatory symptoms are absent. Microscopic examination without the dark-field condenser shows nothing characteristic; mucus and epithelial cells predominate. However, the Spirocha?ta pallida may be found if the proper appa- ratus is used. Antisyphilitic treatment rapidly clears up the con- dition. It is this secondary specific urethritis that is the means of contagion through the semen, which, during this period, in its passage through the urethra at the time of ejaculation becomes saturated with the urethral discharge and the spirochetes that it contains, thus acting as a carrier of the infection. An interesting case of Rochon is cited by Tanton, 15 the details of which are as follows : A woman presented on the abdomen excoriations caused by her corset; the syphilitic husband, afraid of having syphilitic children, had the habit of ejaculating on the abdomen. A gigantic chancre developed at the site of the excoriations. The author con- cluded that urethral mucous syphilides existed. Tertiary Syphilis. In 1901 Fournier 8 reported nineteen cases of tertiary syphilis of the urethra; Mauriac, 11 Gaudier, 10 Renault, 12 and Rougier" have observed and reported cases; recently Drs. Dey and Kirby-Smith 3 in this country have reported two interesting cases. SYPHILIS OF THE URETHRA 165 Time of Appearance. Often they are late, making their appearance eight, ten, or even fifteen to twenty years after the primary symp- toms. Modes of Invasion. 1. Primary. These lesions make their appear- ance by way of the canal. 2. Secondary. These lesions appear in the canal from an extension by continuity. In the case of primary localization these lesions may appear under two forms. (a) Primary ulceration. (6) Syphilitic gumma. The latter is the most common form and may be presented under two clinical aspects : 1. Circumscribed infiltration. 2. Diffuse infiltration. Circumscribed infiltration appears as a small gummatous tumor, often resembling a small tumor or core, forming a slightly rounded or hemispherical projecture. In the diffuse infiltration the gumma grows on the surface, infil- trating the tissues to a variable extent, often appearing as a sheet-like induration. Both of these forms may contract the canal, causing symptoms of obstruction in a greater or less degree. However, these forms often undergo softening and ulceration, thereby eliminating, for the time being, obstructive symptoms. Hemorrhage following such a condition may be severe. These gummata may break down and ulcerate in either one of two ways: toward the urethral canal or on the under surface. If the gumma breaks down on the surface which is in connection with the urethral canal, it often forms internal blind fistulae which act as reservoirs and collect urine during the act of micturition. Later, these foci may be the starting-points of urinary infiltration and abscess. Symptoms. Tertiary syphilitic lesions of the urethra have the fol- lowing characteristics: 1. Insidious invasion, indolent, often remaining for a long time unnoticed. 2. Slow evolution : It is necessary for these lesions to attain compara- tively large proportions before the patient seeks surgical advice. 3. The local reaction is generally insignificant or absent. There is no inguinal adenopathy. In general, these lesions do not pass the balanitic region, for which they seem to have a specially marked predilection. Cylindroid Syphiloma of the Urethra. Cylindroid syphiloma is a gummatous infiltration, regular, cylindric, occurs in a segment of the canal and may lead to stricture. It occurs under two forms: (a) Sclerotic. (6) Sclerogummatous. The sclerotic form is rare, severe, and resistant to treatment. 166 SYPHILIS OF THE CKMTO-rRIXARY OflG.-l.Y.s' The sclerogummatous form is benign and yields rapidly to specific treatment; the guminata disappear, the islands alone persisting.' This FIG. 110. Extensive cununatous destruction of the jilans penis involving the urethra. Date of primary infection three years. Wassi-rmann positive. Xetrlected treatment One salvarsan injection made in May, 1911. (Author's <-. FIG. 111. Beginning gumma of the glans penis involving the urethra. Previous treat- ment none. "Wastfermaun positive. (Author's case.) condition may exist at the same time as other gummatous lesions of the canal, from which it seems only a prolongation. SYPHILIS <>i' nil-: I-RKTIIRA 167 Complications following Tertiary Urethral Syphilis. Phagedenism, according to Foumier, is the most serious and coni])licatioii that can occur. He says that one should be imp: with the fact that genital phagedenism occurs as a complication in tertiary syphilitic lesions more frequently than in simple chancres. Here phagcdena of the urethra may destroy not only the meat us, hut also may extend extensively into the glans portion of the urethra. This is particularly noticeable inferiorly where gummata are most often encountered. From this extensive destruction hypospadias of the glans portion may occur to a greater or less degree. fixtnla. As a roult of this extensive destruction, fistulas are very frequent. They may be in the following locations: fistulas of the balaiiopreputial groove, of the fo>si navicularis, or of the body of the penis, causing destruction of the penile portion of the urethra to a greater or less extent. Albarran 1 says: "It is probable that certain fistulas are veritable urinary abscesses with secondary infection, the microorganisms gaining entrance into the lesions through the canal, thus acting as a great open portal for entrance into peri-urethral tissue." Str/rf/irr. Strictures may be of two kinds, false or pseudostrictures, and true strictiir* False strictures occur during the formation of the gumma and, once they ulcerate or dissolve, empty their contents either into the urethra or externally, and the strict ure disappears. True or cicatricial strictures occur secondary to ulcerated urethral gummata or following phagedenic ulceration, or as a sequel to cylin- droid syphiloma. The site of the obstruction depends on the form of syphiloma from which it is derived. It is most frequently found at the meatus or in the balanitic region. The diagnosis of this form of stricture must be made on the particular history of the patient. Diagnosis may be considered under the follow- ing headings: Wassermann reaction, microscopic examination of the discharge, and a careful physical examination. The Wassermann reaction here, as in other forms of tertiary syphilis, if performed by a careful serologist, should be positive in 100 per cent. The urethral discharge is very characteristic. The diagnosis is made by exclusion. If one cannot find any predominating organism, one should be suspicious and a careful search continued until the diagnosis is positive. Erosive and gangrenous balanitis may produce destructive symptoms at times, greatly simulating a broken-down gumma; however, micro- scopic examination will rapidly settle the question. Epithelioma, while comparatively rare, must be thought of. Glan- dular enlargement, however, occurs early. Gummata here, as elsewhere, grow very slowly and ulcerate only after some time. They are only slightly painful, and, as a rule, are attended by no constitutional symptoms; however, both gumma and neoplasm have the common 168 SYPHILIS OF THE GENITO-URINARY ORGANS characteristic of being indurated. The cancerous discharge is purulent, foul-smelling, often streaked with blood and the pain at micturition is severe. If the urethra is explored with a sound or bougie there is abundant bleeding. Often the sound will bring away particles of the tumor. These should be microscopically examined immediately. Xeoplasmic induration often adheres to the deeper parts, ulcerates the skin and produces fistula surrounded by neoplasmic offshoots. In the neoplasm the edges of the ulceration are projective, thick and resistant; the surface bleeds easily, with a characteristic fetid discharge. In. syphilitic gumma there is no adherence to subjacent parts, the base is unequal, and if seen early, there often exists a yellowish adherent scab with central necrosis. The base is indurated but not painful; secretion is not marked. The Wassermann reaction is always negative in epithelioma, and a biopsy will rapidly clear up the diagnosis. Occasionally urinary abscess may be mistaken for gumma. Here the history either of traumatism or of previous stricture should be sufficient to make the picture plain. Prognosis. The prognosis of primary lesions, whether occurring at the meatus or endo-urethrally, depends on a prompt diagnosis. If treatment is beirun early, before there is any secondary infection and destruction, these lesions cause no further symptoms. However, in tertiary syphiloma the prognosis varies according to the character of the lesion. In simple, uncomplicated cases, ulcerations scar over rapidly and gummata dissolve. But if there is great destruc- tion of tissue, with resulting strictures, treatment may be prolonged and unsatisfactory. Treatment. In chancre of the meatus and endo-urethral chancre the treatment is the same as described under primary lesions elsewhere. (See Chapter VIII, p. 257, under Genital Ulcers.) In tertiary lesions of the urethra the treatment is the same as that described under Tertiary Lesions of the Bladder. For the treatment of stricture following tertiary lesions of the meatus and urethra the reader is referred to the chapter on Strictures. SYPHILIS OF THE PROSTATE. The small number of reports in the literature up to the present would seem to indicate that syphilis of the prostate is extremely rare. Unlike the bladder, infections in the prostate only manifest themselves in the destructive lesions of tertiary syphilis. In this condition a reliable Wassermann report is the best aid in diagnosis. When we stop to consider that syphilitic infection can occur in any part of the human organism, it is only natural to suppose that now and again it would involve the prostate. Consequently, if we hope to recognize this condition in the future, it will be necessary carefully to examine all cases that are at all typical for prostatic involvement. Among the cases in the literature heretofore published are one by M. Drobney 17 (1906), another by F.R. Wright 19 (1912), and a third by SYPHILIS OF THE BLADDER 169 J. O. Rush 18 (1913). A study of the symptoms in these cases shows that it is extremely difficult to diagnose this infection from hypertrophy of the prostate, as they both occur in the later period of life and are attended by the same symptoms. SYPHILIS OF THE BLADDER. By syphilis of the bladder is meant only those diseases which involve the bladder mucous membrane itself. All those affections which ex- tend from the surrounding tissues to the bladder, whether they come from syphilis of the rectum in man or syphilis of the uterus and vagina in woman, are not considered. Syphilitic lesions of the bladder are at present scarcely known and most of the works on urology and syphilology fail to make mention of the subject. However, observations are being published and numerous articles have appeared in the foreign literature describing the clinical picture in detail, so that now that attention has been brought to this subject, it is highly probable that numerous cases will be reported in the future. The history of this affection is divided into three distinct periods: In the first period there is almost complete obscurity. There is cited only an occasional observation of autopsy findings in syphilitics, dying on account of their urinary lesions, ulcers, perforations and tumors, which were discovered on opening the bladders. This extends down to the year 1 Ml', at which time Tarnowsky 41 reported a case which is described later on in this chapter. In the second period are related some clinical observations, the diagnosis being based solely on the result of treatment; some of these observations lack accuracy. However, a sign of our advance in understanding this condition is the fact that the cases published during the second period were all diagnosed in life and many of the patients recovered under specific treatment. In the third period diagnosis was made by the cystoscope, with the addition, many times, of the Wassermann reaction. FIRST PERIOD, FROM 1767 TO 1872. During this period 9 cases of syphilis of the urinary bladder were reported; all diagnoses w r ere made at the autopsy table. Of these 9 cases, 5 were undoubtedly gummata and 4 were secondary lesions. Fol- lowing is a brief history of the vesical findings, arranged in chronological order: Morgagni, 33 in 1767, at the autopsy of a patient who presented scars on the surface of the penis and syphilitic lesions of the tongue and epiglottis, found a bladder hollow r ed out by ulcerations, and made the diagnosis of syphilis of the bladder. This observation is especially of historic interest, but on authority is doubtful. 170 SYPHILIS OF THE GEN1 TO-URINARY ORGANS Follin, 24 in 1849, found in a woman with destructive lesions of the bony and soft palate and syphilitic lesions of the liver, the vesical mucous coat covered with twelve small tumors about the size of lentils, making slight projections, in appearance similar to vulvar syphilitic papules. Ricord, 10 in 1851, reports 2 cases: The first of a patient, aged fifty-two years, without special antecedent history, who for two months presented a urethral discharge, which was very abundant, persisting, and a little painful. At the end of fifteen days a right epididymitis appeared, with hydrocele; a month afterward the discharge was still very abundant and tinged with blood; the hydrocele had disappeared; the epididymis was still indurated. Soon a left epididymitis with hydro- cele manifested itself. Then, in spite of the cure of the lesions, the discharge persisted, the general condition was aggravated, and death followed four months after the beginning of the infection. At the autopsy the membranous and prostatic portions of the urethra were hollowed out by deep ulcers, presenting the character of primary phagedena. The prostate was in part destroyed. In the bladder there existed several round ulcerations, with borders cut into peaks. On the left side the seminal vesicle, the vas deferens, and even the testicle, showed abscesses. On the right side these organs were normal. The next observation dealt with a young man, aged eighteen years, who some days after a suspicious coitus had contracted a chancre of the frenum which spread from place to place, encroaching on the meatus. A little later an abundant discharge appeared, with painful urination. A phimosis formed, the constriction of which was removed by incision, but the edges of the wound ulcerated and the ulceration encroached on the glans and destroyed it almost completely. During three months the discharge persisted, with pain and incontinence of urine; death followed from marasmus. There was found at the autopsy an ulcera- tion of the meatus which had encroached on the urethra, and a second ulceration much elongated on the surface of the membranous urethra and in the prostatic region. The vesical neck was in part destroyed. The vesical cavity was filled with elevated tumors, reposing on an ulcerated mucous coat; the vesical wall was hypertrophied. Virchow, 44 in 1852, at autopsy found ulcerations of the bladder and urethra in a woman, aged fifty-four years, who for fifteen years pre- sented periosteal pains and syphilitic ozena, with destruction of the nose and pharynx, and who, during the first month, had had incon- tinence of urine. Vidal, of Cassis, 43 in 1853, reported the case of a patient, aged twenty- six years, who had had a chancre three years previously, and who, having presented urinary troubles, urethral discharge, abdominal pains, hematuria after micturition, and retention of urine, succumbed to a generalized peritonitis. At the autopsy there existed a vesicoperitoneal fistula. The vesical mucosa presented an elevated ulceration with edges cut into peaks, rounded, with a vascular periphery surrounded with disseminated plaques. SYPHILIS OF THE BLADDER 171 Tarnowsky,' 1 in 1872, reports the case of a child, aged four years, infected by its foster-mother. The diagnosis of syphilis not having been made at the beginning, and the child having been treated for eczema, entered the hospital in a deplorable condition. The body was covered with oozing and ecchymotic papules. The mouth and throat were covered with ulcerations and mucous plaques separated by dee]) fissures. The general condition was not favorable. The respiration was difficult and anorexia complete. This child was subjected to mercurial treatment, baths and rubbings. Four days after its entrance to the hospital it was noticed that at each micturition the child was extremely agitated and experienced pains in the genital region. On examination it was found that the prepuce was very much tumefied and inflamed, that the urethra was indurated and painful; puncture of the preputial sac allowed a purulent greenish- yellow liquid to escape. The patient died the twelfth day after his entrance to the hospital. At the autopsy the mucous coat of the urethra and, in part, that of the bladder were covered with superficial syphilitic ulcerations. The pharynx and throat were sprinkled with ulcerated papules; the liver was syphilitic. Fenwick, 23 * in 1879, reported the case of a twenty-three-year-old man who was admitted to the London Hospital for a stab wound; he died of the injury. Autopsy showed, beside this injury, a hard chancre of the penis and adenitis of the inguinal and lumbar glands. Elevated spots were seen on the mucous membrane of the bladder, which looked like condylomata. Neumann,* 5 f in 1899, reported a case of gumma of the bladder observed by him in a forty-four-year-old working woman, who pre- sented in the bladder numerous round whitish nodules the size of a millet-seed, some of them isolated and some in groups. SECOND PERIOD, FROM 1872 TO 1900. Morris, 34 in 1897, reported the case of a woman who had bladder hemorrhage for months ; she had lost thirty pounds in weight. Morris made a cystoscopic examination, but reports nothing definite; specific treatment caused a rapid subsidence of symptoms. Griwzow, 27 in 1899, presented observations on two patients attended by urinary troubles of a doubtful nature; the diagnosis of syphilitic cystitis was admitted, because of the action of the mercurial treatment, which was instituted for the specific lesions in other organs. In the first case, a woman, aged forty-two years, syphilitic for ten years, presented urinary troubles, pain, and intermittent retention of urine. The diagnosis of chronic catarrh of the bladder had been made, but the mercurial treatment instituted for three years gave no results. At this time, on palpation, a compact, rounded tumor could be felt * These authors' cases, while appearing in publications as cited, belong to the first period, 1767 to 1872. t Ibid. 172 SYPHILIS OF THE CEXITO-i'RIXARY ORCA\S below the pubis, also palpable by the vagina: the diagnosis was not definite. At the same time the particular symptoms pain in the region of the liver, with palpable hepatic nodes, diarrhea and vomiting, caused a diagnosis of gunima of the liver to be made, and in several months the mercurial treatment caused not only the hepatic symptoms to disappear but the vesical condition and the subpubic tumor as well. The second observation by Griwzow is that of a man, aged thirty years, who had contracted syphilis six years before. The vesical symp- toms and the pain on micturition, which he had for two years, per- sisted in spite of all local treatment. A perforation of the bony palate had appeared. Mercurial treatment was given, which brought about a cure not only of the soft palate, but also the disappearance of the vesical pains. Griwzow had in these 2 cases discovered accidentally the specific nature of the vesical lesions. Chezelitzer,' 2 " 2 in 1901, presented a case similar to that of Griwzow. He treated a patient, afflicted with vesical pains and retention of urine for a long time, for catarrhal cystitis and prostatitis. He did not obtain any result, when, one day, he found the presence of syphilitic lesions of the testicle and psoriasis of the palms of the hands. Mercurial treat- ment brought about the cure of the testicular lesions and the disappear- ance of the vesical phenomena, which, indeed, seemed to have been of syphilitic nature. Margoulies,' in 1002, reported a case of vesical phenomena, hema- turia, incessant desire to urinate, diminution of vesical capacity, in a man, aged fifty-five years, a tabetic, who besides had a nephritis (albumin and edema). Margoulies made the diagnosis of syphilitic cystitis, and mercurial treatment caused the vesical symptoms to disappear. Unfortunately cystoscopic examination had not been made before treatment, and when made, it showed only a bladder rich in trabecula?, which occurs often in tabetics. Towbien, 42 in 1904, reported a case, probably a gumma, the record of which, however, is incomplete. THIRD PERIOD, FROM 1900 TO 1916. The rapid progress made, coincident with the development of the cystoscope, in the diagnosis of vesical lesions is particularly noticeable during this period; while the first authentic reports of Matzenauer 31 appeared in 1900, others were still using the older therapeutic diag- nostic test and reporting their cases (Chezelitzer, Margoulies and Towbien). It is interesting to note how, in the first years of the second decade 1^72 to 1900), the syphilitic nature of the bladder infection was only occasionally discovered, and how later physicians came to consider the possibility of bladder syphilis more and more, and how, at last, Mat- zenauer, 31 in 1900, opened the modern period by publishing the first case of syphilitic ulcerations of the bladder, as observed by means of the SYPHILIS OF THE BLADDER 173 cystoscope. Since then the serum reaction of Wassermann has been added as strong supporting evidence in diagno- Syphilitic lesions of the bladder may be of two kinds: 1. Secondary. 2. Tertiary/ Secondary Bladder Syphilis. In 1S93 Neumann called attention to the fact that secondary lesions of the bladder were undoubtedly not so rare as was previously thought. Ernest Frank, in 1909, presented at the Congress of Urology in Berlin a number of plates of cystoscopic examinations of secondary lesions of the bladder before, during, and after treatment. In all he reported 5 cases that had never been published before. Unfortunately I have not been able to find a description of Frank s cases. Paul Asch,-' J in 1911, reported the case of a woman, aged twenty-eight years, who presented all the signs of an acute cystitis which several doctors had diagnosed as gonorrhea. At the time of examination the patient urinated during the day every half-hour and at night every ten minutes. There was persistent and severe strangury, accompanied by terminal hematuria. Tuberculosis having been excluded by inoculation and microscopic tests, a cystoscopic examination was made which showed the following picture : The whole of the bladder mucous membrane was very much swollen and red, and scattered over it at irregular intervals were hard, superficial, round, and oval defects in the mucous membrane, with small undermined edges and whitish ba>e.->. They looked like syphilitic patches such as are found in the mouth in the secondary stages of syphilis. Examination of the inguinal glands showed them to be large, hard, and painless on both sides. The patient now admitted that one year and three months before, she had had a small ulcer on the left labium that had recovered under local treatment, and had not been followed by any other symptoms. Mercury inunctions were ordered. During the first week of the treatment the symptoms seemed rather to increase, which was probably the result of irritation from the cystoscopic examination, but may also have been a reaction from the treatment itself. At the end of the second week the symptoms began to improve. The urine cleared up, the general condition improved, and in the fourth week the picture was very different. The patient had increased fourteen pounds in weight ; she could retain her urine two to three hours in the day, and only had to get up once during the night. The urine was almost clear, contain- ing only a few red blood cells and leukocytes. The cystoscope, at the end of the fourth week, showed the mucous membrane only a little reddened, with small white flecks of mucus. In the sixth week the bladder was completely normal, so that treatment could be given up. A year later the patient came for examination, and bladder and urine were both normal. This case is undoubtedly one of those rare ones, not previously reported in the literature, of secondary syphilitic disease of the bladder corresponding to the patches in the mouth and sexual organs. 174 SYl'IlILIS OF THE GENITO-URINARY ORGANS Pereschiwkin, 37 in 1911, published o cases of "papulous exanthema of tlie vesical mucous coat;" all these patients showed lesions on the skin and mucous surfaces, together with vesical symptoms. In the first patient the cystoscopic examination showed a normal vesical mucous coat with the exception of the base of the bladder, which was edematous and hyperemic. On the periphery of the left ureter one saw several ulcerations with edges elevated and infiltrated. The base was very red, the ureteral orifices were normal. In the second there existed in the region of the summit of the bladder seven small ulcerations with infiltrated edges. In the third patient the vessels of the mucous coat were strongly injected and the ve-ical sphincter was edematous; on all the mucous coat, especially at the base of the bladder, there existed small arc-as of ulcerations of variable forms and dimensions, some with edges infil- trated, others with flat edges. The ureteral orifices were a little edema- tons. Mercurial treatment brought about a rapid disappearance of the symptoms. (Plate I, Figs. 1 and \ Michailoff, 32 in 1912, published a case of a woman, aged thirty-nine years, who complained of bladder pain radiating into the hips; hema- turia was periodic over a period of five years. Gradually the hematuria increased in amount and frequency. There were no pains during the hematuria, and the temperature was normal. The details of the cysto- scopic picture were as follows: On the lateral and superior wall of the bladder, characteristic rows of vesicles covered by yellowish-gray crusts were visible; each vesicle was surrounded with small areas of the color of red raspberries which sharply contrasted with the normal coloring of the neighboring mucous coat. Here and there injected vessels were seen, the rows of circles, which were surrounded by little "coronas," looking like the papules which we are accus- tomed to see on the epidermis. Later on, at a second cystoscopic ex- amination, catheterization showed that the hemorrhage came from the left kidney. In secondary affections of the bladder and upper urinary tract hemorrhage has never been observed. It is possible that the hemorrhage came from the renal papilla or from minute bloodvessels. It resembled that form of hemorrhage that is spoken of as "essential hematuria." The diagnosis in this case was based entirely on the cystoscopic examination, afterward confirmed by the Wassermann reaction, with prompt disappearance of local and general symptoms as a result of specific therapeusis. Mucharinsky, 35 in 1912, reported the case of a patient who a year before had had a hard chancre; later roseola and treatment. There were no objective signs of syphilis; glands not palpable; no urethral discharge; there was painful urination by day and night ; a catheter had been used for two weeks. Cystoscopic examination showed diffuse bluish-red hyperemia of the neck of the bladder and trigone; middle lobe of the prostate protruded considerably into the bladder; bladder tense; on the mucous membrane flakes of mucus; on the fundus of the bladder an ulcer the size of a copper coin, with jagged, strongly hyperemic PLATE I FIG 1 FIG. 2 Secondary Syphilis of the Bladder Mucous Membrane as described by Pereschiwkin. Fiy. 1 shows the vessels of the mucous coat strongly injected with some edema around the internal sphincter. All over the mucous membrane, especially on the base, are ulcerations of various forms and dimensions, some flat, others with infiltrated edges. Fig. 2 shows complete disappearance after mercurial treatment. SYPHILIS OF THE BLADDER 175 edges; on the base of the ulcer a blood clot. Complete healing took place under specific treatment. This case belongs to the secondary erythemata of the bladder with ulcer formation. The author has had the opportunity to examine cystoscopically one case of secondary syphilis in a young man with a diffuse macular erup- tion, without any bladder symptoms. The mucous membrane was diffusely hyperemic; the vessels were injected, with numerous islands of mucus adherent throughout. Urine from both kidneys showed a large number of leukocytes, but no organisms. Tertiary Bladder Syphilis. Matzenauer, 31 in 1900, heretofore men- tioned as the first to publish a case of syphilitic lesion of the bladder ascertained by the cystoscope, describes a case of a girl, aged twenty- two, a syphilitic for four years, whose vesical neck was covered with papilloma-like projections resembling villosities; the rest of the mucous coat of the bladder was normal. On the superior wall of the urethra a superficial ulceration existed, with edges cut into peaks, reaching the internal orifice. Matzenauer made a diagnosis of gummata of the urethra and bladder. MacGowan,* 9 in 1901, reported a case of a patient, syphilitic for ten years, who presented urinary troubles and, in particular, vesical pains, with frequent desire to urinate and with retention of urine. The local treatment brought no amelioration; he made a cystoscopic examina- tion. He found on the posterior part of the vesical mucous coat numerous papilloma-like projections and behind the right ureteral orifice several concentric ulcerations, with hard edges, infiltrated, the syphilitic nature of which could not be doubted. While syphilis of the bladder is not so frequent in this country as it is abroad, and as a consequence not so easily diagnosed, MacGowan deserves credit for his pioneer report of a case diagnosed by means of the cystoscope. Graff, 26 in 1906, mentions a case in a fifty-six-year-old man, who, thirty-five years before, had had a gonorrhea and small ulcers on the penis, and who was admitted to the hospital because of repeated hemorrhages from the bladder. For some months there had been pain in the perineum and limbs, extending sometimes to the glans penis. Urination was difficult. Both testicles showed a moderate doughy swelling, but no pain. Catheterization was rendered difficult by a contracted external urethral orifice. Cystoscopy could not be per- formed on account of the bladder hemorrhage. The urine was bloody and purulent. No tubercle or other bacilli could be demon- strated in the urine. The general condition improved under irrigation of the bladder with weak silver nitrate solution and the hemorrhage and other symptoms decreased, so that the patient thought of leav- ing the hospital; cystoscopy was now possible and it showed, at the summit of the bladder, a tumor-like new r growth with a defect in the centre and papillary proliferation of the edges, so that papilloma was suggested, or several small papillomata. Suprapubic cystotomy was performed. At the summit of the bladder 176 SYPHILIS OF THE GBNITO-UBINABY OflGV there was an ulcer extending into the muscular layer, from the K which white particles could easily be removed. The ulcer was cauter- ized, the bladder closet! by suture, with drainage through a catheter. The wound healed uneventfully. After opening the bladder, the nature of the tumor could be better recognized. In connection with the swell- ing of the testicle, it suggested syphilis. Syphilis had been thought of before, but the history alone did not give sufficient grounds for it. The diagnosis of gumma of the bladder and bilateral gummatous orchitis onfirmed by the results of the antisyphilitic treatment, which was now begun. Six weeks after the operation the patient was discharged, completely cured. The excised piece consisted chiefly of necrotic cell masses and bladder epithelium, which did not show any tumor-like degeneration. Le Fur,- s in 19(>2. reported the case of a patient who had never had gonorrhea, but eight years before had had syphilis, which was treated very irregularly. Two years before hematuria had appeared, which lasted throughout the act of urination. This occurred several times at irregular intervals, but without pain and without any other bladder symptoms. A few months before a more severe hematuria than usual had appeared, which caused urinary retention by the formation of clots in the bladder. The aspiration of these clots stopped the hemorrhage, but it must have been profuse, for the patient's mucous membrane was very pale. The urine was turbid, contained numerous red blood cells and leukocytes, but no bacteria. The capacity of the bladder was good. The prostate was very hard and irregular, and in the right lobe a large, hard nodule could be felt. The author suspected, therefore, that the hemorrhage was caused by chronic prostatitis and began treatment for that. As this treatment had no effect he made a cysto- scopic examination. lie found a group of three ulcers in the region of the trigone, one of which was of some depth, had fissured edges and a gray base. From these findings he suspected an infection of the bladder from the dis- ea-ed prostate and irrigated the bladder with a solution of silver nitrate. Since the urine remained turbid even after this treatment, and as syphilitic patches developed in the pharynx, the author concluded that syphilis was the cause of the bladder disease, and antisyphilitic treat- ment brought about complete recovery in a short time. The urine became clear and free of blood, the prostate soft and the nodules disap- peared, (.'ystoscopy showed white scars in place of the ulcers in the bladder. Margoulies, in 1912, reported the case of a woman, aged forty-one years, who presented intermittent hematuria, with pains in the left hypochondriac region, radiating toward the bladder, with frequent desire to urinate: cystoscopic examination showed a little behind and to the left of the left ureteral orifice a neoplasm formed of three tumors, each the size of a bean; these three excrescences were very close to each other and the sides turned toward the summit of the bladder were covered with a visible membrane; all around the mucous coat was SYPHILIS OF THE BLADDER 177 hyperemic. Having made the diagnosis of cancer of the bladder, Margoulies, in proposing ablation, noticed that the patient bore on her whitish scars and had in her previous history a miscarriage. He had her take potassium iodide. To his great surprise it produced a rapid amelioration, and a month later the vesical tumors had disap- peared, leaving on the mucous coat little insignificant scars. Yon Engelmann, 45 in 1911, reported the following 3 cases: His first case was in a sixty-year-old woman who had had bladder hemorrhages for six months, without any other bladder symptoms. ( Ystoscopic examination showed, above the right ureter, a tumor about 3 cm. long, with ulcerated surface covered with a purulent mem- brane, and, in places, encrustation. The author thought the tumor was a carcinoma and proposed an operation; then he found that the patient had acquired syphilis twenty years before and ordered mercury treatment. The ulcerations healed rapidly and the entire tumor disap- peared in a few weeks. The second case was that of a man, aged forty-six years, who had suffered from hematuria at times during the preceding three months. He had had syphilis fifteen years before and a mercury and potassium iodide treatment. A year before paralysis of the left leg had developed, which disappeared after mercurial treatment. The urine was turbid, and at the end of urination there was slight pain. Cystoscopic ex- amination showed, beneath the opening of the right ureter, a round, prominent tumor about the size of a hazel-nut, with surface partly ulcerated and covered with purulent membrane and with papillary characteristics in places. At that time there were no other syphilitic symptoms. The author made a diagnosis of gumma of the bladder and advised antisyphilitic treatment. Cystoscopic examination, after thirty mercurial inunctions, showed that the tumor had disappeared and there was a red spot in place of it. Xo local treatment had been given. The third case was that of a woman, aged forty-seven years, who had had paralysis of both legs for a year. She had had painful urination for a month. There was a history of three abortions twenty years before. Examination showed syphilitic myelitis, ulcerated papules of the labia majora, swelling of the inguinal glands, paresis of the detrusor vesicae and also of the extremities. The urine was turbid, contained much pus, streptococci, and Gram-positive diplococci; tubercle bacilli could not be demonstrated. Cystoscopy showed reddening of the bladder, and in the region of the opening of the left ureter, completely surrounding it, a large ulcer covered with encrustations which pro- jected into the bladder. Similar encrusted ulcers were found in the summit, and on the lateral and anterior wall. They were all of dif- ferent sizes, up to 5 cm. The encrustations could hardly be separated with the catheter; when separated, hemorrhages occurred. The sur- faces of the ulcers were papillary in appearance. Antisyphilitic treatment, combined with bladder irrigations, brought slow but progressive improvement in all the symptoms. The paresis M U 112 17* >F THE (if-: MT<>-riU\ARY ORGANS disappeared and cystoscopic examinations, repeated at regular inter- vals, showed progressive improvement of the cystitis as well as of the uleers. The encrustations gradually came off and were discharged with the irrigations. After two months the bladder mucous membrane was normal. In some places, where the larger ulcers had been, there were white scars on the mucous membrane, a sign that they had not been superficial erosions, but deep ulcers. i says that we will probably not err in saying that the ulcers and encrustations in von Engelmann's third case were only indirectly caused by syphilis. : i.- 1 in 1911, reported the case of a man, aged forty-five years. who had suffered for three months from bloody urine; no other symp- toms. General condition good. Previous treatment had not affected the disease. Suddenly a hemorrhage appeared without explainable cause. Its duration from the beginning to the end of urination, and the failure of previous methods of treatment, caused Aschto suspect a tumor. The lack of other symptoms indicated that it was probably in the summit of the bladder. Cystoscopic examination showed papilla? the size of a hazel-nut about 0.5 cm. externally from the open- ing of the left ureter, and directly above, partially covered by the papillu\ an ulcer about 1 cm. in diameter with hard, infiltrated edges and grayish-yellow purulent masses covering its base. This ulcer aroused a suspicion of syphilis. The patient admitted that he had had syphilis about twenty years previously, and that he had hardly been treated at all. Bacterial examination of the urine showed that there were no gonocooci or tubercle bacilli. This shows that syphilis may produce papillomata which are very similar to the ordinary papillomata in appearance. i reports a second case of a man, aged thirty-five years, who, for three months, had had severe bladder hemorrhages and, for six weeks, painful desire to urinate. The urine hail recently become turbid and contained many leukocytes and a considerable number of red cells. There was an ulcer on the right thigh which had persisted for five months, and which had had all the characteristics of a gummatous ulcer. Twenty years before the patient had had a hard chancre which was only superficially treated, but no other symptoms until the gummatous ulcer developed. Cystoscopic examination showed a large gummatous ulcer in the fundus. It was 2 or 3 cm. in diameter, had edges very much infiltrated, and projected 1 cm. into the bladder. The base of the ulcer was yellowish and projected above the mucous membrane. There was no doubt of the diagnosis. The patient received an intra- venous injection of sal varsan, 0.5 gm. ; the result was excellent. After four days the gummata of the thigh and the bladder had completely disappeared. ( 'ystoscopy showed a normal bladder. Picot, w in 1912, gives the details of one case of vesical syphilis in a patient, aged fifty-three years, who denied all venereal disease. The patient began to have urinary symptoms eight years previously, apparently without cause; at the end of two years he was operated on ."////./.< Of-' THE BLADDER for vesical calculi. One clay, a year afterward increased and brown masses appeared in the urine; later most of the urine passed through the rectum. 1 the left ureteral orifice round, large, and gaping. A little below this orifice the vesical wall rotif. I>argeprr> : - were visible, intersected by longitudinal furrows on which finer -anched. This aspect recalls that of a parquetted floor. The right ureteral orifice was elongated tra . The bladder mucous coat which surrounded it wa> pal<-. This pallor 1 with the deep coloration of the region of the trigone. Abr>ve and below the ureteral orifice, almost touching it, were found small irregular plaques of a clearer red, sur- rounded by a sort of halo. The edges were irregular, and a little I>olycyelic. It was above this region that the more characteristic ele- ments w<-r- di-< ..vered. At thi> point the vesical wall was covered by numerous ulcerations of some depth; they were very variable a- to dimensions and some were confluent. Their border was lar and polycyclic, the ba^e was red at the periphery, paler at ntre. These elements had the aspect of ulcerous syphilides. The po-terior part of the bladder on the right side presented the same parquettcd n>pe<-t a- that which has been described of the left ureter. In the midst of the projections, in a cavity, a fistula was found. It was an irregular orifice, the borders of which were cut into peaks. It appeared to be about 0.25 cm. in diameter. Below this orifice, floating in the liquid were two blackish bodies (debris of fecal matter). The .summit of the bladder was occupied by small tuberculous me of which were massed together, others isolated, slightly ulcerated at their apices. At the left posterior part of the bladder, at a point where the preceding formations were found there was a large vari 1, emerging into the bladder like a temporal arterio- >clern>ir.. Papulo-ulcerative element < in a fistula, the edges of which are cut into peak>. suggest syphilis. The patient denied having contracted a chancre, but the Wassermann reaction was found to be positive. R. Picker.** in 1913, reported the case of a solitary gumma of the bladder in which he maintains that the diagnosis is the earliest on record for this class of ca-e-. The Wassermann examination was negative. This, however, was before the ulcer had broken down. There was no hemorrhage. The clear urine and the normal adnexa pointed to the localization of the condition in the bladder. Complete healing took place under specific treatment. ( ysto-copy showed the vault thoroughly smooth and pale yellow. Both ureteral folds were clearly defined throughout their whole course. The openings of the ureters appeared at the end of the ureterai folds in the form of small, papilhe-like protuberances. The stream of urine from both sides was strong. At the posterior end of the trigone, the mucous membrane appeared entirely normal and smooth, while on the infernal side of the right ureteral fold, there was a cystoscopic picture of a prominence about the size of a quarter of a dollar, which was sur- 180 SYPHILIS OF THE GEN I TO-URINARY ORGANS rounded by a narrow but livid red border which gradually passed over into the normal neighboring mucous membrane. The surface of the prominence itself appeared yellowish, tinged with red, and was demar- cated from the livid border by a margin formed of five segments coming together at an obtuse angle. In the middle of this formation there was a depression covered with a thick whitish eschar about the size of a five-cent piece. The entire formation was like a pansy in shape. Healing took place under specific treatment. Gayet and Favre, 25 in 1914, reported under this heading 3 cases. The first had the following history : A tabetic, aged sixty-six years, whose urinary symptoms began fifteen months previously with a pollakiuria, most frequent at night, gradually growing worse; repeated attempts at cystoscopy were not successful. Later, however, the following picture was visible. On December 9, 1913, the patient continued to bleed; ureteral orifices clearly visible. Medium prostatic projection; at its site an ulcer with irregular contour. Two other ulcerations were found on the upper side of the left ureteral orifice, in the form of papules, covered over with a greenish-white exudation. This suggested the specific nature of the lesion and the patient who had been until then treated by washings only, was subjected to weekly injections of calomel and potassium iodide. The \Yassermann was positive at this time. After the first week of treatment, the hematuria ceased, not to reappear, but incontinence persisted. January 17, 1914, after six months of treat- ment, cystoscopy showed a little vesicular vascularization, especially in the prostatic region, but there the preexisting ulceration was no longer to be seen. The neighboring ulcerations of the left ureter were in process of cicatrization; there was a sort of gray edematous covering. They conclude as follows: "An old syphilitic, tabetic, attended with chronic retention, with ordinary cystitis, had suddenly a hemorrhage; the hemorrhage repeated itself in capricious manner, without provoca- tion, recalling the hemorrhage of neoplasms. It persisted until the day when mercurial treatment was begun and then disappeared rapidly. The cystoscopy, which at this time was not clear, gave the impression that there were ulcerations of specific nature. In ten weeks, under the influence of mercury, iodides, and finally neosalvarsan, these ulcerations completely scarred over. " The only objection which could be made to the diagnosis of vesical syphilis is that it might have been a question of ulcerous cystitis, occurring by ordinary infection in a tabetic bladder during retention, or the result of trophic lesions of medullary origin." Gayet and Favre's second case is that of a patient, aged fifty years, who denied venereal history. Seven years previously there was per- foration at the junction of the hard and soft palate. The patient suddenly had very intense hematuria, accompanied by pains at micturition and with pollakiuria; these functional symptoms dimin- ished soon; the hematuria was pronounced from the moment of ,sT/'///L/S OF THE BLADDKI! 1M entrance to the hospital and did not quiet down under the influence of rest. The first cystoscopy was not satisfactory on account of the hemorrhage. Salvarsan treatment was instituted. Later cystoscopic examination showed the following (five days after the first injection and one month after the patient's entrance): The base of the bladder was red, the remainder of the mucous coat less red, but there existed numerous papfllomata around the neck and the general aspect of a cerebral convolution still persisted, but with ridges and folds less pro- nounced. Later, the patient, who had quit the service, returned for a cy^toseopy. She had not had the least trouble or the least hematuria since the last examination. Her bladder was entirely normal, except at the boundary of the neck, where several ridges still persisted, with the mucous coat a little irritated. The third case was that of a woman, aged thirty-five years. Eleven years previously she had had a chancre on the lip; fifteen days before her admittance to the hospital she suddenly, without premonitory symptoms, began to urinate blood. The first hematuria was of terminal character and accompanied by pain with the last drops. There was pollakiuria, especially on standing. Cystoscopy showed the bladder white throughout; the ureteral orifices presented nothing abnormal. The trigone was, on the other hand, somber red, with a median pro- jection recalling a prostatic lobe. The periphery of the neck was red, the folds much affected. No ulcerations were seen. Vaginal examina- tion was negative. Simple rubbings brought about complete cure. Pathology. The pathology of vesical syphilitic lesions is the same as that found in syphiloma in other parts of the body. Symptoms. SECONDARY SYPHILIS. Age. It . generally occurs in early adult life. During" the period of secondary eruption, if the infection is severe, there frequently occurs a diffuse syphilitic cystitis. If one stops to consider that during the period of secondary invasion the spirochetes localize in every organ of the human body, it is not sur- prising that at times there should be vesical lesions during this period; however, in the majority of cases, they are overshadowed by the general infection and rapidly lose their identity once specific treatment is instituted. In the more severe infections there are all the symptoms of acute and chronic inflammation of the bladder, i. e., pyuria, pollakiuria, pain, and tenesmus. It must not be forgotten that secondary lesions, no matter where located, are not destructive, and as a consequence the accompanying symptomatology may be insignificant, compared with that of gumma. During this period secondary symptoms, such as mucous plaques, condylomata and secondary skin eruptions are common. Cystoscopic Examination. During this period the vesical mucosa often shows an increased vascularization, or more or less congestion. Scattered diffusely over the mucosa are little islands of mucus. In the more severe forms the exact duplicate of the mucous patch may isj SY i'n / us <>{ mi': <;I-:MTO URINARY ORGANS occur; this may he multiple and become so extensive as to form distinct ulcers. TI.KTI \i;v SVIMIH.IS. . dji . (lunima of the bladder occurs especially in iniddie life, thirty-five to fifty year- of a ire, but may occur earlier or later. 1. rains are variable, intermittent or continued, or radiating at times, increased on dee]) pressure, little marked if the lesions lie on the ba>e of the bladder; much more marked at the time of micturition if they lie at the vesical neck. I'. Ilematiiria is the most constant and important symptom. There may be a terminal hematuria, intermittent, hematuria, or a con-taut hematnria, lasting from the beginning to the end of urination. This may be scant or profuse, repeating at irregular intervals, often acting in a peculiar manner, capricious at times, as in hemorrhages due to ueoplasms. :'.. 1'ollakiuria is a frequent symj)toin; the urine almo-t always con- tains a large quantity of red cells and leukocytes rarely have any organisms been found. As a rule the general ])hysical condition is little affected. CystofCOpic F..ra initiation. Tertiary syphilis manifests itself on the vesical mucous coat in two ways: ricerations. (6) Papillomata. The diagnosis of liberations is not difficult; they may be rounded, more or le-s extended, isolated or multiple; they make projections into the vesical cavity, the edges are infiltrated, cut into peaks, and the ba-e is generally covered with a yellow, ])urulent in Sometimes these lesions appear as veritable tumors. sessile or pedun- culated, capable of simulating absolutely the character of a fringed polypus or a series of unequally enlarged papillomata; they may In- found in the region of the triu'oin-. around the \e-ical neck, seemini; at times to continue into the urethra. It must not be forgotten that syphilis of the bladder may have its course quite independent of other syphilitic manifestations. The most varied forms will be ob-erved, from Simple hyperemia of the mucous membrane to extended breaking down of ^ummatoiis tissue. Diagnosis. Srcotularti and Trrfiart/ Si/j>hilix. Syj)lulis may a fleet the bladder as well as any other part of the body, but there is no .such thing as chancre of the bladder. Syphilitic affections of the bladder that produce severe destructive symptoms belong to the tertiary period. Syphilitic nlceration of the bladder mucous membrane may be soli- tary or appear at the same time with syphilis of the skin and other mucous membranes. During the secondary stage of the disease on the mucous membrane of the bladder may be found a general or localixed eruption, which may be in the form of ulcerous processes resembling mucous patches. It is easy to mistake their etiology, particularly gummas that simulate .N Y I'll I us r THI-: />/.. !/>/;/./,' 183 papilloma and single ulcer-. beeau-e a gumma may he transformed into ningly .single ulcer l>y central necr Jt is often difficult to distinguish gummas from papilloma, so that their syphilitic nature can only l>e recogni/ed by simultaneous appearance of syphilitic ulcers either in the bladder or other part- of the body, or by the prex-nce. of M.IIIC other tertiary legion. These ulcers may extend deep and lead to perforation of the bladder peritoneum or to ve-ieo\ aginal fistuhe. It is well in every case of papilloma to get a thorough history of the patient, and make careful and thorough examination of the skin and other organ-. Simple solitary ulcers >hoiild arouse suspicion of syphilis, especially if tuberculosis can be excluded by bacteriological examination. Syphil- itic ulcers can be distingui.-hed from ordinary or tuberculous ulcers by the infiltrated edges which project more or le-s into the ulcer cavity. As MM, ii as a Mi-picion of syphilis is aroii>ed a \Va-sermann examina- tion should be made by a reliable serologist, all local treatment should be discontinued ami specific treatment instituted. The gummas generally cau>e symptoms of new growth and hemor- s which are not influenced by re-t or ot her treatment. Hemorrhages from gumma may last from the beginning to the end of urination, while hemorrhages in ulcers of the bladder, even if syphilitic, are terminal. 1 leers are more apt to cause pyuria than gumma. The number, si/e and loca t ion of the lesions, either gummas or ulcers, greatly influence the accompanying symptomatology. Treatment. It must not be forgotten that vesical syphilis, whether secondary or tertiary, is only an incident in the course of a general syphilitic infection and that after the \ e-ical lesions are healed, every effort known to modern medicine should be made to safeguard the patient from a relapse in other organs. The Wassermann reaction offers the best and most efficient guide in the management of syphilitic cases. Unfortunately, the tendency is to give too little treatment and to stop when the first negative reaction is reached. I nder the new therapy (salvarsan and mercury) all cases that come under observation should be treated at least nine months after the negative goal is reached, giving during this period 150 rubbings of mercury and at least two intravenous injections of salvarsan. It must be distinctly understood that treatment should be continued vigorously during the " negative phase," in order to secure permanent results. Salvarsan given every week or ten days for four or five doses, then every month, with mercury rubbings, controlled by biological examina- tions, constitute the best method of treating the patient. It should be borne in mind that dilatory and haphazard treatment, while healing the lesions, often produces both a salvarsan- and mercury-fast spirochete which when localized in other regions (spinal fluid) may never be dislodged. Spinal fluid examinations, while appearing superfluous, are as much 184 SYPHILIS ni' THE cKMTu r/,'/.\ .l/.T ORGANS indicated here as in other forms of visceral syphilis, and a physician with the patient's best interests at heart should certainly in>i>t on making them. Spinal Cord Affections Simulating Bladder Disease. Besides these secondary and tertiary syphilitic diseases of the' bladder there are considerable number of ca>es that come under observation on account of spinal cord disease (progressive paralysis and tab' Unfortunately a Wassermauu reaction on the blood is not the last word in diagnosis, as it is often negative in this class of infections; unless a spinal fluid examination is made the true cause of the trouble may be overlooked until the degeneration has gone so far that restora- tion of function is not possible. While it is true that trabeculization of the bladder without other known cause of obstruction should eau>e a strong suspicion of syphilis, especially in the absence of other nerve degeneration findings, a spinal puncture should not be neglected. Many of tin . on account of treatment and catheteri/.ation. proent mild grades of cystitis; the cy>toscopi<: picture is therefore altered and a diagnosis is impossible with the cystoscope. Treatment. While practically hopeless in the advanced cases, much can be done if the condition is diagnosed early. Here, as in other forms of syphilitic lesions, regular, persistent treatment by the Swift-Kllis method, or the combined method of salvarsin and mercury, if given intensively after the method of ( 'ollins, is most satisfactory, the treat- ment being controlled by serological examination of the blood seruin and the spinal fluid. SYPHILIS OF THE URETER. Syphilis of the ureter i> rare. A case has been described by 1 hidden, as mentioned by Osier and (Jibsoii. While involvement of the ureter has been observed in conjunction with bladder syphilis, it is impossible to recogni/e this condition alone except at autopsy. Essential Hematllria. While a great deal of speculation has been brought forward in regard to the etiological factors in essential hema- turia, few have considered the possibility here of secondary ulcers or gununatous formation, and it might be well in this class of cases to thoroughly eliminate this form of infection before ascribing some doubtful etiology. SYPHILIS OF THE KIDNEY. Syphilitic nephritis manifests itself in the following forms: 1. Acute parenchymatous syphilitic nephritis. 2. Chronic interstitial nephritis. 3. Amyloid kidney. 4. Gummatous kidney. S 01' Till': KtDM'Y 185 Under this heading will be considered only those forms of syphilitic infection in which the symptoms and pathology can he actually attributed to the Spirocha-ta pallida, the first and the fourth. Acute Parenchymatous Syphilitic Nephritis. Synonyms. Acute early syphilitic nephritis; nephritis syphilitica pra-cox. The first to acknowledge syphilitic kidney diseases was Bayer. 17 lie wrote as follows: " I liave seen cases in which the influence of con- stitutional venereal diseases seemed so striking that I did not hesitate to attribute, at least to a great extent, the development of kidney diseases to the venereal cachexia." The first description of kidney syphilis was given by Virchow. 63 lie observed that simple nephritis is often found in syphilitics, but that does not justify considering them specific, because they have no characteristic signs. (lniol :>l) published the first report of syphilitic albuminuria and Perodu 57 the first description of early acute syphilitic nephritis. Karvonen - and Neumann 15 are among the writers on the subject. More recently, Bauer, 1 ' 1 Habetin, Erich Hoffmann, 61 Osthelder, 56 Welz, 64 Tach/' 2 Morit/' 5 and I>ama-k ' have written communications, while the excellent monograph of Mnnk ' ranks as an authority on the subject. Owing to the fact that the causative airent in syphilis was so long misunderstood, few realize that during the period of secondary localiza- tion (secondary eruption), the spirochetes are actually present in every organ of the human body to a greater or less extent, and the fact that syphilis may cause disease of the internal organs during the eruption of the first exanthem or even for some time before, is recognized possibly by syphilologists alone. Hoffmann lias shown that transmissible spirochetes circulate in the blood three weeks before the outbreak of the eruption. For a long time there has been a great deal of doubt concerning the specific nature of the nephritis appearing in the early stage. Sena- tor, 59 co an expert himself on kidney diseases, did not admit the real nature of this condition in 1902. We are astonished to find that today a great number of cases of disease of the heart, bloodvessels, liver, kidney and joints in syphilitics are due to the Spirochaeta pallida, yet more surprising is the number of syphilitics who do not know that they are affected. It has only been in the last ten years that the syphilitic etiology in many cases of aortic aneurysm has been recognized. In Munk's clinic, among 260 cases of visceral syphilis with a strongly positive Wassermann, 38 per cent, of the men and 84 per cent, of the women did not know that they had the infection. Notwithstanding the advance in our knowledge of visceral syphilis, the subject has been more clearly understood only since the introduction of the Wassermann reaction in practice. Etiology. This form of nephritis is a hematogenous injury, not a tissue process, and it is caused by the presence of the Spirochseta pallida. ISC. SYPHILIS OF THE GEN I TO-URINARY ORCAXS By most authors, therefore, syphilitic nephritis, as well as nephritis caused by scarlet fever and other infectious diseases, is attributed to a toxic cause. The idea that the continued administration of mercury in syphilitics causes a nephritis has long been held. The question of whether the kidney injury in these cases is due to syphilis or to mercury is decided at once by the lipoid findings in the urine, reference to which will be made later. In the nephritis caused by mercury there is never lipoid degeneration, therefore no lipoid casts are found in the urine. Naturally there are all sorts of transitional forms, from very severe cases of nephritis to slight and quickly passing albuminurias, which many syphilographers, especially the French, maintain are very fre- quent, but according to Hoffmann, are rare in Germany. Since the discovery of the Spirochseta pallida we are in a position to test its relation to the kidney. In these investigations it has been frequently found in the kidneys of congenitally syphilitic children. They have been reported as having been found in the urine in cases of acquired syphilis. Recent syphilis can generally be demonstrated by the clinical symp- toms; however, these may be so masked by severe edema that they are not apparent. It is more difficult to palpate the glands, and even the eruption is not so easy to recognize on an edematous skin. There- fore it is particularly important to make a diagnosis either by finding the spirochetes in the urine or by the Wassermann reaction. From Hoffmann's experience in determining the syphilitic etiology in a given case, and from the recent advances in syphilology, he formu- lated the following signs as an indication of early syphilitic nephritis: 1. The demonstration of recent syphilis by clinical symptoms, finding the Spirochseta pallida in primary or secondary lesions, and a positive Wassermann reaction. 2. Characteristic signs in the urine, such as enormous albumin con- tents, and the finding of the Spirochseta pallida in the sediment of the urine removed by catheterization. 3. The influence of specific treatment, which is almost always evident if mercury and salvarsan are correctly used. According to Hoffmann, acute syphilitic nephritis may develop in two ways: either gradually, without any specific symptoms, so that it may be overlooked unless the urine is examined, or in a more or less stormy fashion, with marked edema and fluid in the body cavities. However, most patients seek the physician's advice on account of general edema and weakness; this gradually progresses and anemia may be marked. The principal and most characteristic symptom is the anemic appear- ance of the patient, with a more or less severe edema; the patients complain of a great weariness and weakness; sometimes there is difficulty in breathing; headaches are not very frequent; vomiting, as a rule, appears late, as well as other uremic symptoms. As long as there is no complication, fever rarely goes higher than 38 PLATE II mm Acute Parenchymatous Syphilitic Nephritis. (Munk.; SYPHILIS OF THE KIDNEY 187 to 38.5 C. ; chills are not present. The only symptom that the patient complains of is that on urinating he notices a small amount of urine. Urinary Findings. These are especially characteristic. The vol- ume varies from 300 to 1200 c.c.; the color is normal yellow, reaction acid, specific gravity very high; albumin contents generally high, up to 28 per 1000. Microscopically, examination of the urinary sediment shows a small number of red cells, fairly numerous white cells, many epithelial, and a few hyaline, waxy and granular casts, but most of them lipoid casts. Under the polarizing microscope, in fresh specimens the whole field may be strewn with double refracting drops, some of them in crystalline form and some of them cylindrical. Recently, Stengel and Austin, 61 in this country, have examined the urine with a polarizing microscope fifty-eight times in 46 cases. Of the 46 cases, 23 showed nephritis with an abundance of albumin and casts in the urine. Of these 23 cases, 6 had positive Wassermanns; 3 had strong presumptive evidence of syphilis, but not positive Wasser- mann. Fourteen had not the slightest evidence of syphilis. The 6 cases with the positive Wassermann all showed lipoids in the urine, whereas, in the 14 non-syphilitic cases only 5 showed lipoids in the urine. Pathology. According to Munk, the pathological anatomy of this form of syphilitic kidney, at the height of the disease, corresponds to the co-called large white kidney, which name has been given it on account of its macroscopic appearance. The color is really not white, but a grayish yellow, due to the lipoid contents and the cloudy swelling of the cortical substance. The kidney for the most part is flaccid and soft. On the surface of the kidney it is possible to see, at times, individual groups of convoluted tubules appearing as yellow flecks standing out from the remaining grayish-yellow turbid ground substance. On cross-section the cortical substance seems increased in breadth and so swollen that it stands out over the medullary substance. The medullary rays may be recognized as gray, watery stripes, often com- pletely transparent and gelatinous, while the cortical pyramids appear turbid, intersected by bright yellow stripes and flecks which are the convoluted tubules which have undergone fatty degeneration. The vessels are not w r ell filled, while the vasa recta of the medullary substance are, so that there is a sharp contrast in the coloring of the two substances. Plate II gives a picture of a frozen section of such a kidney colored with sudan hamalaun. The lipoids are colored yellowish red ; w r e see the convoluted tubules chiefly attacked by the lipoid degeneration. Besides the lipoid degeneration, some parts of the convoluted tubules show a somewhat indistinct appearance. These are in a state of cloudy swelling. The glomeruli, are, on the contrary, completely intact. The nucleus stains well and the interstitial tissue does not show any changes which indicate inflammatory processes, either cellular infiltration or productive proliferation. We have, therefore, an organ which has undergone a purely degenerative change. The cloudy swelling itself is a degenerative stage which may pass over into 188 SYPHILIS OF THE GEN I TO-URINARY ORGANS fatty or lipoid degeneration. A noteworthy fact is the rapid appear- ance of primary lipoid degeneration of the kidney epithelium, without any further degenerative or later inflammatory changes. Clinically, this type of syphilitic kidney is an acute nephritis, but from the point of view of pathological anatomy, it is a degenerative, non- inflammatory change of the organ of a chronic character, and can be set in a group by itself as a form of degenerative kidney disease peculiar to syphilis (Munk). Symptoms. The leading symptoms of nephritis following infectious diseases are: marked anemia and a considerable degree of dropsy, which is a dropsy of the body cavities rather than a general anasarca, as in syphilis. Headache and rise of temperature are only exceptionally observed in uncomplicated cases. Marked uremia is unusual if there is not a considerable degree of stasis; the liver and spleen are involved only moderately, if at all. Murmurs may be demonstrated in the heart from time to time, but they are generally due to anemia. Accentua- tion of the second aortic sound is rare, at least in the beginning, and at that time there are no signs of increased blood-pressure. The symptoms of nephritis may appear in a few months, or not until some years after the infection. The Wassermann reaction may be strongly positive or only weakly positive. However, a positive Wasser- mann reaction is not sufficient to decide the question whether in a given case we have a syphilitic nephritis or merely nephritis in a syphilitic patient, but it fills the gap in the history of patients who do not know that they have the disease, and it increases the number of demon- strable syphilitic cases in which the nephritis is observed. Urinary Findings. These are of the greatest importance. The daily amount is small, sometimes as little as 300 c.c. The urine is turbid, yellow or brown in color and macroscopically only rarely shows blood. The reaction is always acid, specific gravity high, sediment abundant. Its chief constituents are double refracting lipoid sub- stances which are sometimes free in individual droplets or clumped together, or they may appear as fine droplets in the numerous epithelial cells, but a more characteristic formation is that of large opaque casts. Pure hyaline and granular casts are found, but they are rare. There are also considerable numbers of leukocytes, the mononuclear form predominating. It is true that lipoid substances occur in the urinary sediment in secondary contracted kidney, but not in such amount as in parenchy- matous syphilitic kidney, and the albumin contents also are lower. Munk says that greater difficulties lie in differentiating this form of kidney from large white amyloid kidney. The urinary findings are quite similar, but the amyloid kidney is distinguished by the fact that in addition to lipoids it has relatively numerous single refracting fat elements. These two forms of disease are different also in the time of their appearance. While amyloid kidney generally develops slowly, still it leads to severe clinical symptoms; syphilitic disease appears early with very severe symptoms, especially marked dropsy. Within SYPHILIS OF THE KIDNEY 189 ten days after the first appearance of albumin in the urine, the condition may become threatening. Munk hopes that this form of acute parenchymatous degenerative kidney will be more often recognized in the future, since it can be recog- nized only by means of examination of the sediment by the polarizing microscope. Unfortunately, most cases that come to the medical clinics have severe symptoms, and as a consequence this makes the number of cases appear relatively small, but there is no doubt that there are a large number of cases with mild symptoms that are observed and treated by syphilographers. Differential Diagnosis. Differential diagnosis can be made between acute parenchymatous syphilitic nephritis and nephritis resulting from other infectious diseases. Prognosis. In most cases, with proper treatment and care, the patients recover from the first stage, even when there has been high- grade edema and weakness of .threatening character. The edema may last two or three weeks, or may disappear earlier, sometimes very rapidly. The quantity of urine increases, the formed constituents in the urine decrease, but the albumin contents remain rather high. As soon as the edema disappears completely, the patient usually regains his strength and appetite and normal conditions return. The headaches gradually pass away. The amount of urine may vary for awhile in the formed elements; especially lipoids may be observed from time to time, but it is the high albumin contents that may persist for months afterward, rising and falling indefinitely. The relatively benign course of acute parenchymatous syphilitic nephritis is surprising, and like all other forms of syphilitic infection, the prognosis depends on the prompt diagnosis, for the longer the kidneys remain jammed with spirochetes with their attending sys- temic symptoms, the more difficult will it be to bring about permanent resolution. According to Munk's views, a fatal outcome in the acute stage is very rare in spite of the severe symptoms, such as dropsy, anemia, weakness, and so forth. Hoffmann says: "The prognosis of early acute syphilitic nephritis, which was good before, has become even better since the introduction of salvarsan." We have two powerful remedies, both without danger if properly used. In the majority of cases the albuminuria is completely overcome. Death is rare and when it occurs is perhaps due to improper treatment. The quick cure is due to the double action of salvarsan and mercury against the spirochetes through the blood and urinary tubules. Treatment. In every case of syphilis which is presented for examina- tion and treatment a careful urinalysis should be made, and if later on an albuminuria presents itself, its etiology will not be so obscure. If a patient comes for treatment at the height of his disease, it is generally 190 SYPHILIS OF THE GEXITO-URIX ARY ORGANS extreme dropsy and oliguria that demand attention. As this condi- tion is caused by the presence of the Spirochseta pallida within the substance of the kidney, as soon as specific remedies can be applied (salvarsan and mercury), thecondition should improve. Unfortunately, diuretics do harm; the chemical irritation caused by them causes the degenerated epithelium to be discharged suddenly and in large quantities. Such a considerable desquamation of kidney elements is not without danger for future restoration of the kidney. Diuretics, if used at all, should be of the mildest form; diuresis should be taken care of in a compensatory manner by free saline catharsis. Whenever the anasarca has advanced to a considerable degree, skin drainage may be resorted to. As soon as possible small doses of salvarsan should be given. It is perhaps best not to give over 0.2 gin. or 0.3 gm. at a dose, and, as soon as the dropsy has disappeared, rubbings may be combined. Hoffmann gives salvarsan the preference in nephritis. It does not cause irritation of the kidneys, except in very rare cases. Some authors hold that it is sufficient to cure. The dietetic management in this class of cases deserves some little attention. Eggs, milk and carbohydrates are used as an exclusive diet in the beginning. Munk recommends some form of malt extract to be added to the milk, and, on account of the severe anemia, iron is given as soon as the intestinal tract will stand it. Meat should not be withheld long. The use of baths and hot packs is contra-indicated in this form of nephritis, because the advantage to be gained from them is not in proportion to the bad effects they have in increasing the general weakness. The general specific treatment for the syphilitic condition must, of course, be carried on, regularly controlled by the ^Yassermann reaction. CONCLUSIONS. Munk's conclusions are the following: In the clinical diagnosis of nephritis more attention must be paid than heretofore to the different degenerative processes in the kidney. The examination of the urine may give valuable information on this point. The demonstration of fat and fat-formed elements in the urine points to a fatty degeneration of the organ in the different forms of cachexia. The presence of a greater or less amount of fat-formed elements shows the destruction of kidney parenchyma in acute forms of nephritis. The demonstration by means of the polarization microscope of double refracting lipoids in the sediment of the urine is a reliable criterion for differential diagnosis between acute inflammatory and chronic degenerative kidney diseases. GUMMA OF THE KIDNEY. Gumma of the kidney is rarely recognized except at autopsy. It w T as Arnold Beer 48 who gave the first description of gumma of the GUMMA OF THE KIDNEY 191 kidney. Gummatous disease of the kidney generally appears in the form of circumscribed miliary nodules varying in size from that of a grain of millet to that of a hazel-nut, which, as a rule, are limited to one kidney. They generally occur, in the cortical substance, extending at times more or less deeply into the medullary substance, even as deep as the papillae. Occasionally a single gumma occurs, but usually they are multiple. On section these gummata show a peripheral part which is gray and transparent. They may be either soft or hard, with a necrotic centre consisting of caseous masses undergoing fatty degeneration. The periphery consists of tissue which is rich in cells and vascular tissue. In this tissue, or sometimes surrounded by it, there are atrophied urinary tubules, together with shrunken Malpighian bodies. When these gummata have evacuated their contents, they may be resorbed by the lymphatics of the kidneys, and, when superficial, leave in their places cicatrices with corresponding deformities. Symptoms. As in gummata elsewhere, gummata of the kidney manifest themselves from seven to twenty years after the chancre first appears. The evolution of the gumma is slow and insidious and only exceptionally gives symptoms which permit of a diagnosis during life. In some cases, however, gummata that open into the pelvis of the kidney may soften and discharge their contents into the urine. As soon as this elimination of the contents occurs, the urine again be- comes macroscopically clear, the condition remaining undiagnosed, thus leaving the true cause unsuspected. Gummatous kidney, when greatly enlarged, may simulate a malignant tumor. In such instances, even in the absence of positive symptoms of syphilis, a Wassermann reaction may clear up a doubtful diagnosis. The possibility of a tuberculous kidney should be constantly kept in mind. Prognosis. Unless the attending interstitial nephritis is advanced, the prognosis is good. BIBLIOGRAPHY ON SYPHILIS OF THE URETHRA. 1. Albarran: Sem. mod., 1894, xiv, 489. 2. Bellet, Charles: Contribution a 1'etude du chancre syphilitique de 1'urethre, These de Paris, 1898. 3. Dey, W. P., and Kir by Smith, J. L.: Southern Med. Jour., 1913, vi, 21. 4. Du Castel: Jour. d. pract., 1894. 5. Faitout, P.: Gaz. d. hop., 1897, Ixx, 1045. 6. Fasoli: Ann. d. rnal. d. orj;. gen. ur., 1900, xviii, 954. 7. Fournier, Alfred: Lecons sur la syphilis tertiaire, Paris, 1899. 8. Fournier, Alfred: Traite de la syphilis, Paris, 1898-1901. 9. Gaucher and Druelle: Bull. soc. franc, de dermat. et syph., 1909, xx, 122. 10. Gaucher and Rostaine: Ann. de dermat. et syph., 1904, xxxv, 149. 11. Mauriac: Syphilis tertiaire et hereditaire, Paris, 1890. 12. Renault, Alex.: Ann. de dermat. et syph., 1903, xxxiv, 932. 13. Renault, Alex.: Bull. Soc. franc, de dermat. et syph., 1905, xvi, 215. 14. Rougier: La syphilis tertiaire de 1'urHhre, These, Paris, 1908-1909. 15. Simionescu, F.: La syphilis de 1'urethre, Geneve, 1905. 16. Tanton, J.: Progres med., 1910, xxvi, 007, 619. 192 SYPHILIS OF THE GEXITO-URIXARY ORGANS BIBLIOGRAPHY ON SYPHILIS OF THE PROSTATE. 17. Drobny: Med. Obozr., Ixv, 7; Ref. Ann. d. mal. ven., 1906, i, 376. 18. Rush, J. O.: Med. Rec., 1913, Ixxxiv, 1028. 19. Wright, F. R.: Syphilis of the Prostate. Reported at a Meeting of the Am. Urol. Assn., November, 1912. BIBLIOGRAPHY ON SYPHILIS OF THE BLADDER. 20. Asch, Paul: Ztschr. f. Urol., 1911, v, 504. 21. Asch: Loc. cit. 22. Chezelitzer: Zentralbl. f. d. Krankh. d. Ham- u. Sexualorgane, 1901, p. 6. 23. Femvick: Casper's Handbuch der Cystoskopie, Leipzig, 1898. 24. Follin: Soc. de biol., April, 1849; Gaz. mod. de Paris, 1849, p. 492. 25. Gayet, G., and Favre: Jour, d'urol., 1914, vi, 35. 26. Graff, Karl: Beitrag zur Kenntnis der Blasensyphilis. Diss., Freiburg, 1906; also reported by Kraske, Chirurgenkongress, 1904. 27. Griwzow: Monatsber. f. Krankh. d. Harn- und Sexualorgane, 1899, p. 449. 28. Le Fur: Ann. d. mal. d. org. gen.-Ur., 1902, xx, 1519. 29. MacGowan, G.: Jour. Cut. and Gen.-Ur. Dis., 1901, xix, 326. 30. Margoulies: Ann. d. mal. d. org. Gen.-Ur., 1902, p. 384. 31. Matzenauer: Arch. f. Dermat. u. Syph., 1900, p. 112. 32. Michailoff, N. A.: Ztschr. f. Urol., 1912, vi, 215. 33. Morgagni: De sedibus et causis morborum per anatomeii indagatis. Lovanni, 1767. Cited by Proksch, J. K. Vierteljahrschr. f. Dermat. u. Syph., 1879, p. 555. 34. Morris: Indiana Med. Jour., 1897-98, xvi, 5. 35. Mucharinsky, M. A.: Ztschr. f. Urol., 1912, vi, 376. 36. Neumann, Isidor: Syphilis. Nothnagel's spezieller Pathologic and Therapie, vol. xxiii, 2d ed. Wien, 1899, p. GS:;. 37. Pereschiwkin, N.: Ztschr. f. Urol., 1911, v, 732. 38. Picker, R.: Ztschr. f. Urol., 1913, vii, 192. 39. Picot, G.: Jour, d'urol. med. et chir., 1912, ii, 693. 40. Ricord, Philippe: Traite complet des maladies veneriennes, Paris, 1851. 41. Tarnowsky: Vortriige iiber venerische Krankheiten, Berlin, 1872, p. 199. 42. Towbien: Vrach. Gaz., 1904, No. 9. Ref. Monatsber. f. Urol., 1904, p. 494. 43. Vidal (de Cassis) : Traite des maladies veneriennes, Paris, 1853, p. 169. 44. Virchow: Verhandl. der physikalisch-medizinischen Gesellsch. zu Wurzburg, 1852, iii, 366. 45. Von Engelmann, G.: Fol. urol., 1911, p. 472. BIBLIOGRAPHY ON SYPHILIS OF THE URETER AND KIDNEY. 46. Bauer, Richard, and Habetin, Paul: Wien. klin. Wchnschr., 1913, xxvi, 1101. 47. Bayer: Traite des maladies des reins, Paris, 1840. 48. Beer, A.: Die Eingeweide Syphilis, Tubingen, 1867. 49. Damask: Mitt. d. Gesellsch. f. inn. Med. u. Kinderheilk. in Wien, 1912, xi, 119. 50. Guiol, V. F. : Sur 1'albuminurie syphilitique, These, Paris, 1867. 51. Hoffmann, Erich: Deutsch. med. Wchnschr., 1913, xxxix, 353. 52. Karvonen, J. : Die Nierensyphilis, Berlin, 1901. 53. Moritz, Alfred: Beitrag zur Kenntnis der Nierensyphilis. Diss., Heidelberg, 1912. 54. Munk, Fritz: Zeitschr. f. klin. Med., 1913, Ixxviii, 24. 55. Neumann, Isidor: Syphilis. Nothnagel's spez. Path. u. Therap., Wien, 1896, xxiii, 436. 56. Osthelder, F.: Vereinsbl. d. pfalz. Aerzte, 1913, xxix, 200. 57. Perodu: De l'albuminurie dans la periode secondaire, de la syphilis, Mem. et compt. rend, de la Soc. d. sc. med. de Lyon, 1867, vi, 88, 196. 58. Power and Murphy: System of Syphilis, London, 1901, iii, 79. 59. Senator: Ueber die acut-infectiosen Erkrankungsformen der constitutionellen Syphilis, Berl. klin. Wchnschr., 1902, xxxix, 482. 60. Senator: Erkrankungen der Nieren. Nothnagel's spez. Path. u. Therap., Wien, 1896, xix. 61. Stengel and Austin: Am. Jour. Med. Sc., 1915, cxlix, 12. 62. Tach, Jean: A propos de deux observations de nephrite precoce ch6z des syphili- tiques, These, Bordeaux, 1913. 63. Virchow: Virchows Arch., 1858, xv, 217. 64. Welz, A.: Deutsch. med. Wchnschr., 1913, xxxix, 1201. SECTION II. THE PENIS AND IJEETHEA. CHAPTER VI. ANATOMY, ANOMALIES AND INJURIES OF THE PENIS. BY H. A. FOWLER, M.D. ANATOMY OF THE PENIS. THE penis is the male organ of copulation. 'It is also concerned with urination. It therefore has a double function: genital and urinary. Its anatomical structure is peculiarly adapted to subserve these two functions. It is composed chiefly of erectile tissue separated into three parallel, cylindrical segments, by tough fibre-elastic investments. The two larger segments, the corpora cave*rnosa, lie side by side on the dorsal surface and make up the main bulk of the organ. In the groove on their under or ve'ntral surface is placed the third or smaller segment, the corpus spongiosum, w r hich surrounds the urethra and expands distally to form the free end of the penis. These three bodies are bound together by a common sheath of dense fibro-elastic tissue, called Buck's fascia, and the whole covered by integument and subcutaneous layers. The size of the penis varies greatly in different individuals and bears no constant relation to general physical development. A large robust man may have a small penis, while a small undersized man may present an organ of unusual proportions. The average length of the penis, when it is flaccid, is from three to four inches; when erect, from five to seven inches. Its circumference is about three inches. Corpora Cavernosa. The corpora cavernosa, composed of erectile tissue, are closely united in the greater part of their extent. They arise, one on each side, in the form of a dense, flattened, tendinous attachment from the ascending ramus of the ischium. They converge rapidly and meet just in front of the arch of the symphysis pubis. These two extremities form the root of the penis, and are called the crura penis. The anterior extremities are separated slightly and terminate in rounded, blunt ends which fit into corresponding depressions on the under surface of the glans penis. The average length of the corpus cavernosum is six inches; its diameter one-half inch. M u. i13 (193) 194 AX ATOMY, AXOMALIES AXD IX JURIES OF THE PEXIS They are invested by a dense fibre-elastic sheath or tunica albuginea. This sheath, according to Henle, is 2 mm. thick when the penis is flaccid, hemispheres of bulb of urethra corpus cavernosunt - of urethra glans penis *- valve of navicular fossa' external orifice of urethra ' fossa navicularis FIG. 112. The male urethra -with the corpora cavernosa of the penis, the bulbo-urethral glands, and the prostate. (Sabotta.) and only 0.25 mm. thick during erection. It is, however, remarkably tough and strong, being capable of supporting the entire weight of the A. \* ATOMY OF THE PENIS 195 body. It consists of two layers: an outer, of longitudinal fibers com- mon to both bodies; an inner, of circular fibers surrounding each body separately and forming a median partition, the septum pectiniforme. This septum is incomplete; numerous perforations allow free inter- communication between the two corpora, thus ensuring symmetrical distention during erection. While this sheath is very strong it is also very elastic, due to the predominance of elastic tissue. This allows for the great variation in size during repose and erection. There are no muscle fibers in the tunica albuginea. The angle between the rounded, anterior extremities of the cavernous bodies is filled with a dense fibrous expansion which projects forward into the glans in the form of a central stalk called the anterior ligament of the corpora cavernosa. The inner layer of the tunica albuginea gives off numerous fibrous septa, some thick and lamellated, others fine and filament-like, which anastomose freely and divide the inclosed space into innumerable irregular spaces or areolse. These trabecula contain unstriped muscle fibers in addition to connective tissue and elastic fibers, and form the supporting framework for the bloodvessels. The areola spaces thus formed communicate freely with each other and with those of the opposite body through the medium of the septum. They are lined by endothelial cells and represent dilated capillaries, communicating with the afferent artery on the one hand and the efferent veins on the other. There is no direct vascular communication between the corpora caver- nosa and the corpus spongiosum or glans. Corpus Spongiosum. This is composed of erectile tissue similar in structure to the corpora cavernosa. It presents a central shaft and two expansions, one at either extremity. The posterior dilated ex- tremity, called the bulb, lies in front of the triangular ligament in the angle formed by the converging crura. The anterior extremity is expanded into a cone-shaped body, the glans penis, which caps the corpora cavernosa. The glans presents at its posterior border a flange- like expansion, the corona glandis. Behind this is a deep sulcus, the coronary sulcus or neck of the penis. The urethra perforates the corpus spongiosum axially, terminating in a slit-like opening at the tip of the glans, the meatus urinarius. Within the bulb the urethra is not cen- trally placed, but lies nearer the dorsal surface, hence a greater thick- ness of spongy tissue covers the lower or ventral aspect of the urethra at this level. In the glans these relations are reversed, there is little or no erectile tissue below or ventral to the urethra. The fibro-elastic sheath surrounding the corpus spongiosum is separate and distinct from the fibrous investments of the cavernous bodies, which permits the easy dissection of the former from the latter. The glans is usually described in the text-books of anatomy as the expanded extremity of the corpus spongiosum, hence anatomically and morphologically a part of this body. The studies of Retterer (1892) upon the development of the penis in embryos and in the human fetus of different ages led him to quite different conclusions. According to 196 ANATOMY, ANOMALIES AXD IN JUKI EX OF THE PENIS this author the spongy body surrounded by its fibrous elastic sheath accompanies the urethra as far as the meatus, but does not present any expansion at its anterior extremity. The central or axial portion of the glans is formed, therefore, of the anterior extremities of the corpora cavernosa and the corpus spongiosum. This is surrounded by a per- ipheral layer, much like a muff, particularly well developed dorsally, which represents the cutaneous and fibrous coverings of the penis at this point. Within this layer the terminal branches of the dorsal arteries and nerves of the penis end. At a later stage of development this per- ipheral layer takes on the structure of true erectile tissue and forms the peripheral portion of the glans in the adult. Free anastomosis takes place between the spongy body and the peripheral layer of the glans, while the vascular connections wifli the cavernous bodies are small and insignificant. Coverings of the Penis. The coverings of the penis are disposed in four layers. From without these are: (1) skin; (2) dartos; (3) areolar tissue; (4) fascia of the penis. The skin covering the penis differs from the general body integument in its freedom from fat, the absence of smooth muscle fibers, the rudimentary character of its sebaceous glands, and the absence of hair except at or near the base. It is remarkably mobile, and after puberty is pigmented, resembling the skin of the scrotum. Extending beyond the glans it folds back on itself, forming a hood-like covering of the glans, called the prepuce. The inner semimucous layer of this duplicature is closely adherent to the neck of the penis and passes forward intimately covering the glans, to meet the mucous membrane of the urethra at the meatus. A tri- angular fold, the frenum, attaches the prepuce to the glans just below the meatus. Tearing or rupture of the frenum is often accompanied by severe hemorrhage from the frenal artery, which is controlled only by ligature. This artery must also be tied whenever the frenum is severed during circumcision. The two layers forming the prepuce are separate and distinct, thus permitting obliteration of the preputial sac and uncovering of the glans by retraction of the skin. Xumerous glands on the inner layer of the prepuce, particularly about the frenum and coronary sulcus, secrete a white cheesy material, smegma, with a characteristic offensive odor. Immediately beneath the skin is a layer composed of smooth muscle fibers continuous with the dartos of the scrotum. The fibers run for the most part longitudinally, others have an oblique direction. This layer extends forward to the preputial orifice, and follows the inner layer of the prepuce as far as the neck of the penis. These fibers, by their contraction, are supposed to assist in erection by producing stasis in the superficial veins. Beneath the dartos is a layer of loose areolar tissue rich in elastic fibers. Within this layer run the superficial vessels and nerves. It is to this layer that the skin owes its extreme mobility. Its loose texture favors the excessive accumulation of fluids seen in massive edema of the penis. ANATOMY OF THE PENIS 197 The sheath of the penis, already referred to as Buck's fascia, is com- posed almost exclusively of elastic tissue. It forms the common sheath of the erectile bodies to which it intimately adheres. It is attached posteriorly to a triangular bundle of fibers, the suspensory ligament of the penis, which surrounds the penis and is inserted into the symphysis pubis, and to the superficial perineal fascia. Anteriorly it is inserted into the base of the glans. It is this disposition of Buck's fascia which protects the cavernous bodies from invasion in ulcerative lesions of the glans, and also by confining periurethral inflammation and cellulitis within its limits for a long time protects the glans from involvement. Muscles. The paired muscles of the penis are the ischiocavernosus, or erector penis, and the bulbocavernosus or accelerator urinse. The ischiocavernosus arises from the tuberosities of the ischium, and running obliquely forward and upward is inserted into the lateral fascia! covering of the corpora cavernosa. By their contraction they compress the cavernous bodies and thus aid in erection. The bulbocavernosus arises from the central tendon of the perineum, and passing forward and inward completely surrounds the bulb. By its forcible contrac- tion the fluid, urine and semen, which collects in the bulbous urethra, is expelled, thus assisting in the muscular effort concerned in ejaculation and in expelling the last drop of urine. Both muscles are innervated by branches of the internal pudic nerve and receive their blood supply from the branches of the internal pudic artery. Vessels. The dorsal arteries of the penis, terminal branches of the internal pudics, pierce the suspensory ligament, and running along the dorsal surface beneath the fascia of the penis (Buck's fascia), on either side of the deep dorsal vein, terminate in anastomosing branches about the corona glandis. These two arteries supply the coverings of the penis and give off branches to the corpora cavernosa. External to the dorsal arteries and the dorsal nerves courses the external pudic branch of the common femoral artery. This also supplies the integuments of the penis. The artery to the bulb, a branch of the internal pudic artery, pierces the anterior layer of the triangular ligament close beside the urethra and enters the bulb. It supplies the erectile tissue of the corpus spongiosum. The artery of the crus, also a branch of the Internal pudic, pierces the anterior layer of the triangular ligament close to the ramus of the pubis and enters the crus. They furnish the main blood supply to the corpora cavernosa. In detaching the crura from the bone in the operation for the complete removal of the penis, the close proximity of these arteries to the bone may give rise to diffi- culty in controlling hemorrhage. It will be noted that the arteries of the penis supplying the erectile tissue and the envelopes are all branches of the internal pudic, except the small external pudic branches of the common iliac, which supply blood to the envelopes only. Veins. The veins of the penis are divided into a superficial and a deep venous network. The superficial veins situated in the subcutane- ous tissue and collecting the blood from the integument unite to form the superficial dorsal vein of the penis. This passes back to the root 198 ANATOMY, ANOMALIES AND INJURIES OF THE I'ENIS of the penis, anastomoses with the venous network of the abdominal wall and empties into the saphenous vein. The deep veins comprising the branches from the erectile tissue, and situated beneath the fascia of the penis, unite to form the deep dorsal vein of the penis. This vein forms the main venous trunk of the penis and, passing back, between the two layers of the triangular ligament, bifurcates and empties into the prostaticovesical plexus or plexus of Santorini. Lymphatics. The lymphatics of the penis, like the veins, are divided into a superficial and a deep network. The superficial system drains the prepuce, skin and subcutaneous tissue. Some unite to form a common trunk, the superficial dorsal lymphatic trunk, *which empties into the superficial inguinal glands. Others maintain their independence and empty separately into the inguinal glands. The deep lymphatics, like the deep veins, lie beneath the fascia of the penis. They drain the glans penis and communicate freely with the lymphatics of the prepuce and the urethra. Running along the groove of the dorsum of the penis as a single or as multiple (2 to 4) trunks, they form a plexiform network in front of the symphysis, at which level one some- times encounters two or more small glands. According to Cuneo and Marcille the deep lymphatics empty for the most part into the deep lymphatic glands along the femoral and iliac arteries and only excep- tionally into the superficial inguinal glands. This course and termina- tion of the lymphatics is important to bear in mind in the operation for carcinoma of the penis, which disease practically always involves the glans first. It is necessary not only to remove the superficial inguinal glands on both sides along with the nodes in front of the symphysis, but also the deep glands along the femoral vein, under Poupart's ligament and the retro-iliac glands. Nerves. The nerve supply of the penis is extremely rich, receiving filaments from both the cerebrospinal and the sympathetic systems, the former supplying the integument while the latter pass to the erectile bodies. The glans is particularly rich in nerves which termi- nate in free extremities and in special nerve endings, the genital nerve corpuscles of Krause. The erectile bodies receive filaments from the hypogastric plexus through the nervi erigentes which accompany the arteries to the cavernous and spongy bodies. CONGENITAL MALFORMATIONS. Congenital malformations of the penis, as a whole, are extremely rare. They have little clinical interest and are referred to merely as curious errors of development. They are usually associated with developmental defects of other organs, as the bladder, kidneys, ureters, and rectum. Congenital deformities of one or more of the constituent parts of the penis are, on the contrary, relatively common, and certain of these represent well-known types; for example, hypospadias, congenital phimosis. The penis may be double, absent, concealed, twisted, adherent, or cleft. CONGENITAL MALFORMATIONS 199 Double Penis. Double penis, penis duplex, diphallus verus, is an extremely rare anomaly but by no means as rare as generally sup- posed. Lebrun 16 recently collected 13 cases of double penis with double urethra and omitted 4. About double that number, including all cases of this anomaly, have been recorded. Several varieties have been described: supernumerary glans, 3 cases; double glans with a single shaft, diphallus partialis, 3 cases; and two separate well-developed penes. These are either superimposed, placed side by side, or separated for a greater or less distance. The two urethras are separate and dis- tinct, communicating with a common bladder, or they unite in the prostatic region (Kiittner's case 15 ). In 4 cases the bladder was double, FIG. 113. Velpeau and Gorre's case. and each urethra opened separately into the bladder of the correspond- ing side. In the frequently quoted case of Alan P. Smith 29 a stone formed in one of the bladders and was successfully removed. This man could void from either bladder at will. One of the most remark- able and widely known cases occurred in the person of Jean Battista dos Santos, a native of Faro, Portugal. He was exhibited at several European clinics, where a minute examination and accurate description of the malformation was made. In addition to two well-developed penes he presented a deformed supernumerary lower extremity pro- jecting between the normal thighs. A wax model of the penile malfor- mation is in the Army Medical Museum at Washington. (A descrip- tion of this interesting case together with photographs by Mr. Hart 200 ANATOMY, ANOMALIES AND INJURIES OF THE PENIS will be found in Lancet, London, 1865, ii, 124.) Curious variations in the functions of the two organs have been observed. In 13 cases urine was voided by both urethras, Ollsner's patient 24 voided through the right and ejaculated through the left penis. Two patients (Xie- man, 22 St. Hilaire- 8 ) passed both urine and semen by both urethras. In 2 cases with imperforate anus, feces and urine escaped together. Keppel 14 observed that the right penis of his patient was used for urination only, while the left was the only one capable of erection under excitation. FIG. 114. Lange's case. Reduplication of the penis never occurs alone, but is always associ- ated with other marks of fetal inclusion. A number of cases have been observed in children who presented other abnormalities incompatible with life, such as imperforate anus, and it was for the relief of this con- dition that they came under observation. In adults the condition is nearly always discovered accidentally during examination for some other unrelated malady. It is probable, therefore, that this ab- normality is not as rare as the number of cases reported would indicate, since these unfortunates are careful to guard their secrets and do not come under observation except \vhen compelled to by necessity. Other abnormalities associated with reduplication of the penis are double bladders, hernia, and exstrophy of the bladder, cleft scrotum, imper- forate anus, and hypospadias. Volpe's 32 case is unique; this infant CONGENITAL MALFORMATIONS 201 with imperforate anus had a double penis, urethra, bladder, and scrotum, with a single (horseshoe) kidney and a single ureter opening into the left bladder, a fusion of the organs normally double and a reduplication of the organs normally single. Treatment. Surgical intervention, except in rare cases, is limited to the treatment of associated malformations requiring operation. In 2 cases an operation was performed for atresia of the anus; 1 (Coles) 8 was successful. In a favorable case an accessory penis can be removed, as was done by Lionti 17 and Albrecht, 2 with very good chances for excellent functional results. Except in these rare instances surgical treatment is of no avail, and therefore not indicated. Absence of the Penis. Congenital absence of the penis is exceedingly rare, and unlike reduplication, is not accompanied by other gross malformations of the external genitals or developmental defects in other parts of the body. This condition must not be confused with con- cealed or apparent absence of the organ, or with pseudohermaphro- ditism. The penis is completely wanting, the urethra opens upon the perineum or on the anterior wall of the rectum. The subjects of this deformity are in other respects normally developed with well-marked secondary, sexual characteristics. The scrotum is normal, the testicles are present, but not pendant. The extreme rarity of this anomaly is evident from the fact that only 7 cases have been recorded. Harris 11 collected 5, added 1 of his own but omitted 1 (Revolat). I have not been able to find any others reported since. It is curious that the earlier literature contains no mention of this anomaly. There were two infants, the others w r ere adults, and in three of these the urethra opened into the rectum. Mathews's ls patient, a man, aged thirty years, had been married several years. His secret was known only to his mother and family physician previous to marriage. He died of kidney in- fection following a simple operation for hemorrhoids. In two adults with the urethra opening into the bowel the kidney did not become infected. Concealed Penis. In cases of apparent absence, the penis is dwarfed and concealed beneath the skin of the scrotum or perineum. This condition is easily mistaken for that of true congenital absence. Careful search, however, will reveal a rudimentary organ concealed beneath the skin. Cases have been described by Chopert, Bouteillier, and more recently by Mocquot, and Aievoli. 1 In Mocquot's 20 case, a man sixty-one years of age, the scrotum was normal and both testicles present but not pendant. In the normal position of the penis there was a depression surrounded by a fold of skin, in the depth of which a cylindrical body could be felt. This was a rudimentary penis, 7 cm. long and about the size of one's little finger. In the case recorded by Aievoli the penis was covered completely, even the glans, by the skin of the scrotum. Treatment. The treatment consists in the liberation of the penis by incision and in supplying a covering of integument from the adjacent parts by an appropriate operation. 202 ANATOMY, ANOMALIES AND INJURIES OF THE PENIS In the newborn with retention resulting from this deformity, libera- tion of the penis by dissection must be done at once; the plastic opera- tion may be deferred until later, as was done by Aievoli. Torsion. Torsion of the penis or twisting in its long axis may occur. The frenum then comes to occupy a mid-dorsal position. It is usually associated with hypospadias, epispadias, or other penile defects. Cases have been reported by Jacobson. Very rarely this deformity exists alone and independent of any other deformity, as in Caddy's 7 case. Adherent Penis. Adhesions between the penis and scrotum together with marked incurvation occur as a complication of scrotal hypospadias. Freeing of these fibrous attachments and straightening the penis constitutes the first step in any operation for hypospadias. In the absence of any urethral defect the penis may be enclosed by the scrotal integument throughout its entire length. Such a case of webbed penis is described by Mummery. 21 More commonly the attachment of the scrotum extends forward along the under surface of the penis a varying distance, and may seriously interfere with coitus (Verge palme). The treatment is simple, and consists in severing the attach- ments as far as necessary and suturing the loose skin in the corrected position. Cleft Penis. There is only one case of transverse cleft or splitting of the glans on record. This singular abnormality is described by Hofmokl 12 in a man, aged sixty-eight years, with congenital phimosis. Retracting the prepuce it was discovered that the glans was divided by a deep transverse cleft into a thickened dorsal and a thinner ventral portion. The urethra opened in the midline at the bottom of the deep sulcus. There was a shallow, blind opening on the inner surface of the lower segment. This man had been married twice and was the father of eight children. A vertical cleavage of the glans would appear to be more common, but nevertheless extremely rare. When complete, a double glans results (see above). Trenkler 30 has recently observed a remarkable case of cleft penis in a strong, healthy young man without any other congenital defect. The appearance was that of a double penis in which the left one was rotated slightly under the other. Examination showed that in reality the condition was not that of duplication, but that a vertical cleft involving the corpora cavernosa and the urethra separated the two bodies completely. By drawing the two halves wide apart the urethral opening could be seen at the bottom of the sulcus. On the inner aspect of either half, extending from the urethral opening to the tip, was a narrow band of mucous membrane. These presented numerous pits or lacunae, and represented the lateral walls of the cleft urethra. Hypospadias and Epispadias. Hypospadias is a congenital defect of the anterior urethra, the canal terminating at some point behind the normal position of the meatus. This defect varies in degree from a mere elongation of the meatus to a complete absence of the urethra in CONGENITAL MALFORMATIONS 203 front of the perineum. It never extends beyond this point, hence the posterior urethra escapes, the sphincters are competent, and the patient is always able to control his urine. Eleven varieties of hypo- spadias have been described, but for practical purposes it is necessary to distinguish only three, which are, in the order of their frequency of occurrence, balanitic (glandular) , penile, and perineal (perineoscrotal) . In balanitic hypospadias the urethra opens just behind the glans at a point where the frenum, which is absent, is normally attached. The glandular urethra is either entirely wanting, or there may be a shallow groove, or a deep furrow, lined by mucous membrane which represents the roof of the fossa navicularis. The glans is generally broader than normal, somewhat flattened, and slightly incurved. The malformed prepuce forms a redundant hood-like fold on the dorsal aspect of the glans. This degree of hypospadias causes little inconvenience or inter- ference with function and therefore seldom requires treatment other than the occasional dilatation of a contracted urethra! opening. In penile hypospadias the deformity is much greater. The urethral opening may be situated at any point along the floor of the penile ure- thra, but is usually just behind the glans, midway between the glans and scrotum, or at the penoscrotal juncture. Associated deformities are much more common in this variety and usually are more marked the greater the degree of hypospadias. When the hypospadiac opening is in the anterior portion of the penile urethra the penis may be well formed and its functions quite normal, but in penoscrotal hypospadias the member is usually small, malformed, and markedly incurved upon the scrotum to which it may be partially adherent. The corpora cavernosa are poorly developed. The urethra in front of the abnormal opening is most often obliterated and when an attempt is made to straighten the penis this stands out as a tense fibrous cord. Excep- tionally it may remain patulous up to the meatus, end in a cul-de-sac, or in a secondary fistulous opening. Perineal hypospadias represents the extreme grade of the deformity and is fortunately very rare. The associated malformation of the external genitals is most marked. The scrotum is divided by a deep cleft, each half containing a normal testicle, more often an atrophied testicle, or, when these have been retained, none at all. In any case the cleft scrotum closely resembles the vulva, the two halves represent- ing the labia majora. The penis is dwarfed and may be completely concealed, except for the glans, by a redundant fold of scrotal tissue, and is easily mistaken for an hypertrophied clitoris. The urethral opening forms a funnel-shaped depression lined by mucous membrane and con- cealed under the retracted and incurved penis. Occasionally the ure- thra may continue forward to its tip as a groove on the under surface of the stunted penis. In a pronounced case it may be very difficult to determine the sex of the individual. The functions of the penis are little disturbed in balanitic hypospadias. The stream of urine may be very small on account of the contracted opening, or scattered and directed to one side or downward as a result of the associated penile 2i>4 ANATOMY, AXOMALIES AXD I.\J CRIES OF THE I'EXIS deformity. In the penoscrotal and perineal variety, function is mark- edly interfered with. Coitus is difficult or impossible, and sterility is the rule. In urinating, the patient must sit down to avoid wetting his clothes; the urine bathes the adjacent parts which become excoriated and eczematous. Etiology. Hypospadias is manifestly a congenital defect and is due to an error in development. The posterior, penile, and glandular urethra develop separately. At one stage in its development the urethra is an open gutter or groove, the sides of which unite in the median line to form the floor of the canal. If for any reason the process is arrested at any point, or the separate portions fail to unite properly, closure is incomplete and hypospadias results. The causes underlying the arrest of development are not well understood. The condition is unquestionably hereditary. Kaufmann 13 has proposed an ingenious theory to explain hypospadias and its accompanying deformities. He assumes that there is a failure of the separate portions to unite properly which results in atresia of the urethra. When the kidneys begin to secrete, the urine ruptures the urethral floor behind the point of occlusion and hypospadias results. Treatment. In the treatment of hypospadias one aims to correct deformities and restore normal function. Whether an operation should be advised or not depends upon whether the degree of deformity and the resulting disturbance of functions are sufficient to demand surgical relief. In balanitic hypospadias operation is rarely, if ever, indicated. The deformity is so slight that the disturbance in function is trivial and does not justify any surgical operation. Two operative pro- cedures have been described, those of Duplay and of Beck. Dnplay's Operation for Glandular Hypospadias. This operation is well adapted to cases in which there is a groove on the under surface of the glans representing the glandular urethra. The edges of this groove are freshened and brought together in the midline over a retention catheter by interrupted sutures of fine silk or chromic catgut. When the flaps are too short to come together without undue tension, lateral incisions into the glandular tissue are made which will overcome this difficulty. The retention catheter is retained until complete healing takes place. Beck's Operation. 4 This procedure is said to be suitable for cases in which the hypospadiac opening is just at the margin of or just behind the glans and the latter is not grooved on its under surface. A circular incision is made about the hypospadiac opening and this is extended laterally on either side along the sulcus behind the corona. A longi- tudinal incision is then made, beginning at the hypospadiac orifice and extending along the line of the urethra. The two skin flaps thus marked out are dissected up. The urethra is then mobilized by dissect- ing the spongy body free from its bed for a certain distance. The glans is now tunnelled by passing a long narrow-blade scalpel from be- hind forward through the glans, emerging at its summit. This tunnel must be enlarged by dilatation or crucial incision. A pair of Kocher CONGENITAL MALFORMATIONS 205 forceps are now passed through this new meatus, the end of the liber- ated urethra seized and drawn through the tunnel. The dislocated urethra is sutured in place by interrupted sutures passing through the edge of the urethra and glans. The operation is completed by approxi- mating the skin flaps to cover the raw surface. The distance the ure- thra is dissected free depends upon the amount of forward dislocation necessary. The urethra should not be under any considerable amount of tension when sutured in its new position, otherwise retraction will occur and the result will be a failure either from the sutures giving way or from a pronounced incurvation of the penis. Indeed, the tendency toward the latter deformity seems to be one of the chief objections to an otherwise theoretically ideal operation. The technic is slightly modi- fied when the glans is grooved as shown in Figs. 115, 116, 117 and 118. My personal experience with Beck's operation in a small number of cases has been 100 per cent, failure, due to recontraction of the dis- located urethra and incurvation of the. glans. A. C. Wood, of Phila- delphia, has reported a similar experience. I am of the opinion that the procedure of Beck is faultily conceived for the repair of a defect which should rarely, if ever, be subjected to surgical attack. This operation as well as the preceding one can be carried out in one stage. In penoscrotal and perineal hypospadias an operation is always indicated and its object is twofold : to straighten the penis and recon- struct the urethra. A number of operations have been described and performed which differ in the ingenious methods advised for the repair of urethral defects. The different procedures are all modifications of two fundamentally different methods, namely, urethroplasty by tun- nelling, and by the use of flaps. The operations of No ve- Josser and, Rochet, and Mayo are examples of the first. While those of Duplay and Beck represent the second method. The first step in all operations, and common to all, is to straighten the penis. A transverse incision is made through the fibrous band which holds the penis retracted and incurved on the scrotum. At times multiple incisions must be made to completely free the penis. It may be necessary to carry this incision into the sheath of the cavernous bodies, care being taken not to injure the latter, and if the spongy body is too short and interferes with complete liberation of the penis, it should be dissected up and allowed to retract. All constrictions having been divided, the penis is fully extended and the incision closed by trans- versely placed interrupted sutures. It is maintained in an extended position by appropriate dressings until healing is complete. At the time of the straightening of the penis Pousson advises straightening the glans by his technic of " redressement." A transverse V-shaped wedge of tissue is removed from the dorsal surface just behind the glans. When the edges of the wound are sutured, the incurvation of the glans is overcome. One should wait from four to six months after the first stage before beginning the plastic repair of the urethra in order to be sure no further retraction will occur and to allow the scar tissue to become freely movable. 206 AX ATOMY, AXOMALIES AXD IX JURIES OF THE PEXIX FIG. 115. Beck's operation for hypo- spadias. (Watson and Cunningham.) FIG. 116. Beck's operation, and Cunningham.) (Watson FIG. 117. Beck's operation, and Cunningham.) (Watson FIG. 118. Beck's operation. (Watson and Cunningham.) CONGENITAL MALFORMATIONS 207 DupJay's Operation (Pousson's technic 26 ). In this operation the urethral defect is repaired by flaps taken from the penis itself. This operation or a slight modification is the one most generally used. First Stage. Begins by straightening the penis as already described. Second Stage. A preliminary perineal section is done to divert the urine through a perineal fistula. This is absolutely essential to the success of any operation for hypospadias. An incision is then made on the under surface of the penis parallel to its long axis about 8 mm. from the midline and extending from the summit of the glans to the level of the hypospadiac orifice. At each extremity of this incision, incisions AC and BD are made at right angles extending outward a distance of 6 mm. The flap E thus outlined is then dissected up toward the out- side. Shorter incisions (AF, EG] mark out a narrower, inner flap ( //). FIG. 119 FIG. 120 FIGS. 119 and 120. Duplay's operation for penoscrotal hypospadias. (Pousson's technic.) Similar flaps are made on the opposite side of the midline, an outer and an inner, with this difference, that the longitudinal incision is only 5 mm. from the midline and the inner flap ( 77') is therefore narrower. The two flaps (// and //') are sutured together over a catheter and form an inner layer on the floor of the new urethra. As these two flaps are of an unequal width, the suture line will be at one side and therefore not directly under the outer suture line. Flaps E and E f are then brought together to cover in the raw surface and form the outer layer of the double urethral floor. Third Stage. Closure of the Perineal Fistula. Drainage of the blad- der through the perineal opening should be maintained until complete healing has taken place and one is sure that displacement of the flaps due to faulty suturing or infection will not result in the formation of a fistula. The perineal fistula is then closed in the usual way. 208 ANATOMY, AXOMALIES AXD IXJl'lUKH OF THE PENIS Beck's Operation. This operation makes use of flaps derived from the penis and scrotum. On either side of the midurethral line and several millimeters distant a longitudinal incision is made extending from the summit of the glans to just beyond the level of the abnormal urethral opening. These are joined by transverse incisions at either extremity. FIG. 121. Beck's operation for scrotal hypospadias. Cunningham.) First step. (Watson and The flap thus outlined is dissected up on either side and the edges brought together over a catheter in the midline by interrupted sutures, thus forming a urethra with an epidermal lining. A flap is now marked out on the scrotum with its base at the abnormal urethral opening of proper shape and size to cover in the raw surface left by the first flap. CONGENITAL MALFORMATIONS 209 This is rotated on its base and sutured in place over the new urethra. The scrotal wound is closed by direct suture (Figs. 121, 122 and 123). Nove-Josserand's Operation. 23 This is the best-known procedure in which urethroplasty is made by tunnelling and the use of grafts. The results obtained by the technic originally described were unsatisfactory, ^^^^^^ Fiu. 122. Beck's operation for scrotal hypospadias. Second step. (Watson and Cunningham.) as a fistula at the juncture of the new-formed and normal urethra was practically constant, and the new canal showed a marked tendency to contract. This technic was subsequently modified and the results obtained by the originator of the operation have been recently fully analyzed. M U 114 210 ANATOMY, ANOMALIES AND INJURIES OF THE PENIS Step One. The urine is diverted by a perineal urethrostomy, the edges of the urethra being sutured to the skin. Redressement of the penis is then made. At the same time the hypospadiac urethral open- ing is excised together with 2 or 3 cm. of the urethra, a ligature placed FIG. 123. Beck's operation for scrota! hypospadias. Cunningham.) Third step. (Watson and about the stump and the wound in the penile urethra sutured (Figs. 124 and 125). The penis is immobilized against the abdominal wall by appropriate dressings and one waits for two or three months. Second Step. This consists in tunnelling the new urethra and apply- ing the graft. A trocar is introduced through the urethrotomy wound, CONGENITAL MALFORMATIONS 211 directed along the course of the proposed new urethra and brought out at the position of the new meatus. This tunnel is enlarged by special instruments. A dermo-epidermal graft is taken from the inside of the thigh, an area free from hair, this is wound spirally around a staff and fastened at either end by catgut ligatures. The staff carrying the graft is now introduced into the tunnel from behind forward and fastened into position (Figs. 126, 127 and 128). At the end of about eight days the staff is removed and after an interval of about three or four weeks bougies are passed to dilate the channel. It has been found that contraction will occur, and to overcome this an internal urethrotomy FIG. 124. Nove-Josserand operation FIG. 125. Nov6-Josserand operation for perinoal hypospadias. Formation of for perineal hypospadias. Excision of porincal fistula. Incision around hypo- hypospadiac opening. Sutures in place, spadiac opening. is done after two or three months, just as is done for a stricture in an otherwise normal urethra. Third Step. This comprises the closure of the perineal fistula by the usual technic. The operation of Xove-Josserand is suitable for perineal hypospadias as well as penile. Rochefs Operation. Rochet 31 has proposed the transplanting of a skin flap taken from the scrotum in place of the graft used by Nove- Josserand, while Mayo and Donnet 9 each have described a technic of transplanting a flap taken from the redundant prepuce in cases of penile hypospadias. 212 ANATOMY, ANOMALIES AND INJURIES OF THE PENIS In the plastic repair of urethral defects the transplantation of a section of vein or ureter has been suggested. Tanton has successfully experimented on dogs and more recently operated on a patient, using the saphenous vein for the transplantation. This procedure has also been used by Tuffier, Potel and Leriche, Becker, Stettiner and Schmieden. It is probable that this method of urethroplasty event- ually will come into more general use. It must be said, however, FIG. 126. Nove-Josserand operation for perineal hypospadias. Hypospadiac opening closed. Formation of new urethra by tunnelling with a special instrument. FIG. 127. Nove-Josserand opera- tion for perineal hypospadias. Prep- aration of graft. This is wound spi- rally around a catheter and anchored at either end by ligatures. that any operation for hypospadias is difficult, due chiefly to the failure to get primary union. A fistula often results from infection and breaking down of the wound, which may require a long time and repeated efforts to close. Great care and gentle- ness in handling the tissues is necessary for success. Preliminary perineal drainage is indispensable. At what age should operation for hypospadias be undertaken ? In cases of marked deformity this should be corrected early, otherwise development will be seriously interfered 213 with. About the sixth year is the most suitable time for the first step. It is better, according to Albarran, to wait several years, until the parts are fully developed before attempting the plastic repair of the urethra, about the sixteenth to eighteenth year. According to the experience of some other surgeons, better results are obtained when the operation is completed before puberty. Epispadias. In this deformity the urethra lies above the corpora cavernosa in the mid-dorsal line and the roof of the canal is partly or wholly absent. It is relatively rare. In the department of the Seine one case of epis- padias was found in 6000 recruits, while Marshall did not find a case in examining 60,000 conscripts. Baron observed 300 cases of hypo- spadias for two of epispadias. Three degrees of epispadias occur: balinitic, penile and complete, or penopubic. In the balinitic form the urethra opens upon the upper surface of the glans or at the level of the coronary sulcus, the glan- dular urethra being repre- sented by a groove. In penile epispadias, which is very rare, the urethra opens farther back on the upper surface of the penis and extends forward as a groove to the tip of the glans. Complete epispadias is characterized by complete absence of the roof of the urethra and is nearly always associated with exstrophy of the bladder and separation of the pubic bones. In these cases the penis is deformed; it is short, broad, and gen- erally curved upward against the pubes. The urethral opening is large, infundibuliform, often admitting the examining finger. It is usually concealed by an overhanging fold of pubic tissue above, and below by the penis, which is strongly curved upward against the open- ing. The prepuce is divided and is redundant on the under surface of the glans. In balanitic epispadias the functional disturbances are less marked. Coitus is usually difficult on account of the brevity of the penis, and the stream of urine is spattering. In the more marked FIG. 128. Nove-Josserand operation for perineal hypospadias. Introduction of graft into the newly formed canal, made by transfixing the tissues. 214 ANATOMY, ANOMALIES AND INJURIES OF THE PENIS cases the associated penile deformity makes coitus impossible, while the constant dribbling of incontinence renders the condition of these unfortunates well-nigh intolerable. Incontinence of urine, absent in some cases of most marked epispadias, is partial or intermittent in others, and is always absolute when the posterior urethra is involved. In the latter case there is usually a separation of the pubic bones and exstrophy of the bladder, or hernia without exstrophy. Etiology. This condition is obviously due to arrested development whereby complete closure of the canal does not take place. Xo satis- factory explanation, however, has yet been offered as to how or why the urethra comes to lie above the corpora cavernosa. The very rare cases of complete separation of the cavernous bodies with the urethral open- ing situated in the angle between them really represents an intermediate stage in the migration of the urethra from its normal position to that occupied in epispadias. Treatment. The treatment is either palliative or radical. Palliative treatment consists in devising some sort of apparatus, which the patient wears constantly, for collecting the urine. The irritation of the urine continually bathing the parts, the odor, and the leakage makes this form of treatment unsatisfactory and insupportable. The surgical treat- ment of epispadias is difficult, tedious, and requires time, patience, and skill. Several successive operations, separated by a considerable interval of time are required, and a successful result is often delayed by the formation of fistulse which are difficult to heal. As in the treat- ment of hypospadias, the preliminary step in any operative procedure consists in establishing drainage through a perineal fistula and the redressement of the penis. Having secured perineal drainage through a perineal fistula, time should be allowed for complete healing of the eczematous condition usually present, before attempting to straighten the penis. This latter is accomplished by severing all constricting bands and bandaging the penis to a splint in the extended position. Several methods have been described for the repair of this urethral defect. The procedure of Duplay is the simplest. The edges of the urethral canal are freshened and brought together by suture over a sound. This simple urethrorraphy is suitable for those cases only where the urethral groove is deep and the edges can be approximated without undue tension. In Thiersch's operation the new urethra is constructed of flaps taken from the penis, prepuce, and pubic region. First Step. The penile urethra is formed of flaps taken from the penis itself. The method has been already described under Duplay's operation for penile hypospadias, which was adapted from Thiersch's operation. Second Step. After several weeks or months one proceeds to recon- struct the glandular urethra. This is done by freshening the edges of the glandular urethra and suturing over a sound. Third Step. This consists in the repair of the deformed prepuce. A transverse incision is made at the base of the prepuce, and through this CONGENITAL MALFORMATIONS 215 FIG. 129. Thiersch operation for epi- spadias. Dissection of flaps and first row of sutures. FIG. 130. Thiersch operation for epi- spadias. Flaps sutured in place, incision of prepuce. Fro. 131. Thiersch operation for epispadias. Prepuce drawn over the glans and sutured in place. A flap from the pubic region covers the pubic opening of the newly formed canal and the raw surface id covered by suturing. AA THE opening the glans i< drawn. The c'ntV of prepuee. thus transferred to the dorsum of the dans, is sutured in this position to a freshened area and serv< - or any fistula remaining between the balanitie and penile urethra. Fourth Step. The epispadiae opening remains to be closed by flaps taken from the pubis. The method of employing these flaps is shown in TJM. i:>0 and 1^1. Nove-To-serand ha< employed his teehnic for the repair of hypospadins in these epispadias witli excellent results. Fu;. 13'_\- ration :i and Cunningham.) Operation* for EjnapaiKiu. In this ingenious operation the new urethra is formed of mueous membrane obtained by dissecting up the tissues alxnit the infundibuliform urethral opening, and forming these into a canal whieh replaees the urethral defect. The floor of the new urethra is made by dissecting up the floor of the urethral groove. the dissection beginning at the eoronary suleus. and extending back to the vesieal orifice. The roof of the urethra is formed from the tissue above the urethral opening. The incision is shown in Fig. 1^2. The flap thus outlined is dissected up in the same manner as dissecting out ' rE\I TA L MALFORMA T! 1 33. Beck's operation for epispadias. Second step. (Watson and Cunningham.) FIG. 134. Beck's operation for eplspadias. Third step. (Watson and Cunningham.) _!ls ANATOMY, .\\OMALIES AXD IX J TRIES OF THE PEXIS a hernial sac, with the left index finger introduced into the urethral opening. In this way one avoids buttonholing the flap. Care must also be taken in making the incision to allow a flap long enough to ex- tend to the tip of the glans without undue tension. The two flaps which are to form the roof and floor of the new urethra are now sutured along their edges into a tube Fig. 133. The glans is then perforated and the end of the new urethra is drawn into this opening and sutured to the margin of the new meatus Fig. 134. The raw surfaces are covered in the usual manner. In suitable cases the operation is rela- tively simple and avoids the formation of fistulas so troublesome in the flap operation of Thiersch. The result in one case by the author of the method was most satisfactory. This patient was able to retain his urine for four hours. WOUNDS AND INJURIES OF THE PENIS. Contusions. Contusion of the penis is characterized by excessive edema and the extravasation of blood into the loose subcutaneous areolar tissue, and is the result of the application of direct violence with- out resulting lesion of the skin. Such injuries are rare and occur when the penis is erect, the flaccid organ generally escaping. They result from any common accident, as a blow, a fall, the kick of a horse, the passage of a wagon wheel, etc. In a personal case the patient was struck by an ear of corn thrown by a companion in play. In the curious case of Dufour, the young man while seated, with his penis erect, received a young woman roughly on his lap. In another case (Voillemier) the man caught his penis in closing a bureau drawer. Dupuytren records the case of a drunken man who had his penis caught under a falling sash while urinating out of the window. The amount of hemorrhage into the tissues depends upon the extent of the injury. This may be slight, amounting to little more than a subcutaneous ecchymosis, or it may be abundant and simulate gan- grene. In one case (Solignac) the dorsal vein was wounded on the edge of the corsets during coitus, producing an abundant hemorrhage, difficult to arrest. If the sheath of the cavernous bodies is injured, hemorrhage may be very abundant. If the urethra is wounded, there is always hemorrhage from the meatus, and the condition is a much more serious one. Treatment. This consists in the application of hot, moist compresses and a supporting bandage to keep the penis elevated. Absorption takes place rapidly, the edema subsides and the discoloration disap- pears. When a hematoma forms and is developing rapidly, an incision should be made to evacuate the blood and ligate any bleeding-point or suture any laceration requiring it. If suppuration occurs, this must be treated by free drainage. Injury to the urethra is more serious and calls for appropriate treatment to prevent extravasation of urine and the formation of a stricture. (See Injuries of the Urethra.) WOUNDS AND INJURIES OF THE PENIS 219 Wounds. The penis may IK- wounded accidentally in a great variety of ways; it may also be wounded maliciously, as in injuries inflicted through jealousy; or intentionally, as for example, the self- mutilation practised by certain sects and by insane patients. These wounds are usually classified as punctured, incised, lacerated, and those resulting from fire-arms. Punctured Wounds. Punctured wounds are very rare, and are caused by bayonet, sword, or foil thrusts. In a case described by Demarquay the injury was due to a fall on a spike. Malgaigne saw a curious case in which an open knife carried in the pocket severed the dorsal artery of the penis. Incised Wounds. Incised wounds are most often seen as the result of self-mutilation by insane patients or criminal mutilation inspired by jealousy. One recalls the custom of the barbarous Abyssinians, of emasculating their enemies when captured, and the practice among the adherents of the cast of Skoptzy of cutting off the penis. Accidental injuries of this kind are rare; the case of Nottingham is an exception. A young sailor received a deep wound of the glans during intercourse from a piece of a glass nozzle which had broken off in the vagina while taking a douche. Lacerated Wounds. These result most often from the bite of an animal, for example a horse, dog, hog, etc. Less often they are pro- duced by machinery. Westbrook's 13 patient was caught in a pulley which tore the skin from the pubis, scrotum, and penis. In Powers's case, a lad of six years, the injury occurred in climbing over a barbed- wire fence. The skin of the penis was stripped off, turned inside out, and hung at the preputial attachment. The nature of the wound depends upon the manner in which it was produced. It may be limited to the integument which is lacerated, torn, and turned inside out like the finger of a glove, as in Powers's 27 case, or the deeper structures may be implicated. According to Biondi, 6 less force is necessary in the pro- duction of lacerated wounds when the penis is erect than when it is flaccid. Gunshot Wounds. These are by no means rare. They are usually associated with injuries to other organs, the bullet passing through the penis or finding lodgment here after passing through neighboring structures. In the Civil War Otis recorded 30 cases. When the cavernous bodies are pierced, hemorrhage is abundant and a large hematoma may result. The scar remaining after healing will interfere with erection. Treatment. In the treatment of wounds of the penis one is guided by the general surgical principles applicable to wounds of other parts. Cleanse the wound and apply an antiseptic dressing. Hemorrhage should be controlled by ligating the bleeding-point or by suture of the torn sheath of the corpora cavernosa. When suppuration supervenes, free incision and drainage are demanded. Healing of wounds of the penis is rapid, owing to the abundant blood supply. Even in apparently hopeless cases an attempt should always be made to save the organ, 220 A\ ATOMY, ANOMALIES AXD INJURIES OF THE PEXIS and amputation is resorted to only when every effort has resulted in failure. In one case we obtained a useful organ when this seemed to be hopelessly gangrenous. ^Yhen the urethra is involved in the injury, this should receive immediate attention to prevent extravasation of the blood and urine and the subsequent development of a traumatic stricture. When the urethra] wound does not communicate with the surface, a retention catheter, if this can be introduced, may be all that is necessary. Open wounds of the penile urethra require closure by suture, and the drainage of the urine through a perineal fistula will be found necessary in most cases for a successful healing of these wounds. Rupture of the Penis. The terms rupture and fracture of the penis are used to designate the same lesion, namely, a tear in the fibrous sheath of the corpora cavernosa. Strictly speaking, fracture of the penis in man does not occur, since there is normally no bone in the penis. Among certain animals, as the bull and the sea lion, there is an os penis, but fracture of this bone is not observed. Calcification some- times occurs in cases of circumscribed cavernitis or Peyrone's disease, and true bone tissue has rarely been found as a pathological product in the human penis, as in Gerster's case. 10 Rupture of the penis always occurs during erection and is usually due to sudden rough bending of the penis downward toward the thighs. It results from a false pass in coitus, masturbation, or a direct blow. In Mott's case this accident was due to striking the erect penis against the bed-post. Merkens 19 describes an unusual case in which complete transverse subcutaneous rupture of the corpus spongiosum was produced by accidental closing of an open door through which the patient was urinating. It is probable that the sudden increase in pressure during erection produced by a blow or sudden bending of the penis is sufficient to rupture the normal fibrous sheath of the erectile bodies, hence the accident plays the chief role. In some cases, however, the corpora cavernosa and their fascial coverings are weakened by areas of degeneration resulting from antecedent disease, arid are therefore much more easily ruptured. At the time of the accident there is sudden pain at the point of rupture, a distinct crackling sound is heard, the penis becomes flaccid, and coitus is interrupted. In a short time the penis begins to swell from the associated edema and attains enormous proportions. The acute pain gives way to a sense of fulness; the penis is bent sharply at the site of the tear toward the uninjured side, hence the rupture is always on the convex side. Under appropriate treatment the swelling quickly sub- sides; the ecchymosis gradually disappears, but a scar often results which interferes with erection and may make coitus impossible. Sup- puration rarely occurs, and hemorrhage is not often alarming. Treatment. Elevation of the penis and the application of cold com- presses suffices in most cases. Incision and suture are rarely required, but should not be deferred when indicated by a progressive hematoma. Dislocation of the Penis. In this exceedingly rare accident the body of the flaccid penis is forced out of its outer sheath of integument and displaced under the skin of the scrotum, pubes, or thigh. The WOU\DS AND INJURIES OF THE PENIS 221 injury has been observed in children as well as adults. The mechanism of its production is not clear from the cases reported, but evidently the body of the penis is squeezed out of its envelope by a force applied to its outer extremity, the separation occurring at the preputial orifice or more commonly along the coronary sulcus. The deformity is not apparent at first, since the skin sheath, filled with a blood clot, may present a normal appearance. Very soon, however, difficult}' in urina- tion attracts attention and examination shows a sheath filled \vith blood and containing no penis. The urethra is usually ruptured in the peri- neum and extravasation of urine with its attending symptoms may supervene. Careful search will always reveal the presence of the organ in its abnormal position. Treatment. In at least two cases (Nelaton and Guth) the penis was easily replaced in its sheath, with happy results. This may be difficult or impossible, however, owing to the edema and infiltration, in which case incision will be necessary to liberate the penis and permit its repo- sition in its proper sheath. In the event of a rupture having occurred, immediate perineal section will be necessary. Strangulation of the Penis. This injury is not at all uncommon. It is seen in children as the result of a nurse tying a string or cord about the penis to prevent the escape of urine in cases of incontinence. In adults, strangulation is produced by rings, bands, the neck of a bottle, etc., used for the purpose of masturbation or other sexual perversions. The extent of the injury will depend upon the degree of constriction, the amount of swelling of the penis, and the length of time the foreign body is allowed to remain. As a result of the constriction, the penis swells rapidly and the constricting band is buried at the bottom of a deep groove; it is soon hidden from view and may be difficult to find. The injury will vary from a superficial lesion of the skin in the simplest case to section of the urethra and even gangrenous destruction of the distal portion of the organ. With the onset of swelling, retention of urine is complete and is relieved only by removal of the foreign body. When this is delayed, the urethra ruptures behind the constric- tion and a fistula results. It is the pain associated with the swelling and especially the retention of the urine which compels the patient to seek relief, which he usually does in a few hours. Shame and fear of detection may delay the visit to a physician and the patient postpones seeking relief for a longer time; three weeks, six months, a year, or even t\velve years in reported cases. The treatment consists in remov- ing the foreign body as soon as possible. This is easily done in the case of a thread or a thin ring. When the foreign body is a thick ring its removal may require considerable patience and ingenuity. In Aylen's 3 case it required two hours to file through a heavy iron ring. When the urethra has been cut into, the resulting fistula must be closed according to the principles laid down in the section on Injuries of the Urethra. 222 ANATOMY, ANOMALIES AND INJURIES OF THE PENIS BIBLIOGRAPHY. 1. Aievoli: Arch. gen. de med., Paris, 1906, ii, 2380. 2. Albrecht: Ztschr. f. Path., 1910, iv, 475. 3. Aylen: St. Paul Med. Jour., 1905, vii, 46. 4. Beck: New York Med. Jour., 1898, Ixvii, 147. 5. Beck: New York Med. Record, March 30, 1907. 6. Biondi: Jahresbericht f. Urog., 1906, p. 251. 7. Caddy: Lancet, 1894, ii, 634. s. Cole: Nashville Med. and Surg. Jour., 1894, Ixxvi, 159. 9. Donnet: Bull, et Mem. de la Soc. de Chir. de Paris, 1906, xxxii, 1002. 10. Gerster: Ann. Surg., 1913, Ivii, 896. 11. Harris: Philadelphia Med. Jour., 1898, i, 71. 12. Hofmokl: Arch. f. klin. Chir., 1897, liv, 220. 13. Kaufmann: Deutsche Chirurgie, L, a, 60. 14. Keppel: New York Med. Jour., 1898, Iviii, 710. 15. Kiittner: Beit, zur klin. Chir., 1895-6, xv, 364. 16. Lebrun: Journal d'Urologie, 1912, ii, 380. 17. Lionti: Deutsche med. Wchnschr., 1914, xl, 393. 18. Matthew: Quoted by Harris. 19. Merkeiis: Deutsche Ztschr. f. Chir., 1911, cxi, 313. 20. Mocquot: Bull, et Mem. Soc. Anat. de Paris, 1904, Ixxix, 344. 21. Mummery: Rep. Soc. Study Dis. Child., London, 1906-7, vii, 99. 22. Neimann: Quoted by Lebrun. 23. Nove-Josserand: Lyon Med., 1897, Ixxxv, 198. 24. Ollsner: Quoted by Lebrun. 25. Papadopoulos: These de Lyon, 1908. 26. Pousson: Ztschr. f. Urologie, 1914, viii, 440. 27. Powers: Ann. Surg., 1909, xlix, 238. 28. St. Hilaire: Quoted by Lebrun. 29. Smith, Alan P.: Transactions Med. and Chir. Faculty of Maryland, April, 1878. 30. Trenkler: Wicn. med. Wchnschr., 1914, Ixiv, 1079. 31. Trillat: Arch. prov. de Chir., 1902, p. 311. 32. Volpe: II Policlinico, fasc., 1903, i, 46. 33. Westbrook: Long Island Med. Jour., 1911, v, 405- CHAPTER VII. DISEASES OF THE PENIS. BY GEORGE W. WARREN, M.D. DISEASE OF THE FRENUM. A SHORT frenum, which may he classed as congenital, occurs in cases where there is no other malformation. This may interfere with com- plete emptying of the urethra. It may cause an incurving of the penis when the organ is erect. I have seen cases where the subject was sterile, due to this marked incurving, and became fertile by simply cutting through the frenum. During coitus these short frenums are torn and the accident frequently results in a marked hemorrhage, the frenal artery being torn. Sexual neurasthenia in some cases is caused by these short frenums. Erections are very painful. Treatment. Cutting through the frenum, and sewing together the cut edges of the wound, which causes a quicker union and prevents hemorrhage, as the frenal artery is caught by the stitch. PHIMOSIS. Congenital Phimosis. The opening or ring of the foreskin in this condition is relatively to the glans so small that retraction of the fore- skin over the glans is impossible. There are necessarily several degrees of this condition, from those cases where the meatus of the penis is seen with difficulty or not at all to those where the foreskin can be retracted, but the blood supply of the glans by this act is cut off or impeded. In the newborn there is a physiological phimosis which continues for a longer or shorter time. The inner leaf of the foreskin, that portion in contact with the glans, is adherent to it by an epithelial deposit. This condition can be relieved by separation with an instru- ment or retraction of the foreskin. If this condition is allowed to remain, inflammatory processes supervene and result in adhesions between the glans and foreskin. As the patient grows older this phy- siological phimosis is relieved by the orifice of the foreskin becoming larger at about the second year, and it generally takes the adult form between the years of nine and thirteen. The normal foreskin can be retracted over the glans easily and pain- lessly when the penis is in erection, and when there is no retardation of blood circulation while it is thus retracted. Congenital phimosis may exist with a prepuce of normal length or (223) 224 DISEASES OF THE 1'EXJS with one very long or short. In cases of long prepuce the glans is covered with an empty sac which lies in folds. Upon urination this bag fills with urine and may balloon out to the size of an egg, and the urinary stream issuing has little force. The opening of the foreskin may be so small that a fine probe cannot enter it. In these cases the frequent ballooning of the foreskin causes it to become tremendously dilated. This great dilatation causes a dis- proportion between the outer and inner leaf of the foreskin. The ring of the foreskin, which is the narrowest portion of the same, seems to be retracted by the overhanging of the outer leaf. In cases of short foreskin (atrophic phimosis) the prepuce is drawn tightly over the glans. Here, again, the opening of the prepuce may be very small and not in line with the meatus. This causes difficulty in urination and may be a serious condition. In both of these conditions, long and short foreskin, there may be an accumulation of epithelial smegma and urinary sediment, preputial stones, and balanoposthitis may occur. These are not, as one would expect, constant sequehe of this condition. In both of these lesions, when the condition has existed for some little time, there is sometimes a trabeculation of the bladder and at times a hydronephrosis with dilated ureters. The urinary act is always difficult, and, as before stated, in those cases of short foreskin where its opening does not correspond to the meatus, the child strains and cries with pain upon urination. The long foreskin may hold urine and dribble after the urinary act. At times the urine retained in the foreskin becomes infected and decomposes, and the resulting inflammation may cause urinary retention. In adults phimosis with short foreskin results in a poorly devel- oped glans penis, and the sexual act is interfered with. Many of these cases are sexual neurasthenics. Retention of urine may sometimes occur in these cases of phimosis, when upon this condition balanoposthitis is superimposed. All the complications of a balanoposthitis are to be found in these cases of phimosis, such as erosion, ulceration and perforation of glans and foreskin, stone formation under foreskin, and ammoniacal urine. The dangerous sequela of impediment of urination, in cases of phimosis, is often underestimated. In cases of marked phimosis of children it is not uncommon to find hernia, prolapsed anus, etc., due to the marked abdominal pressure necessary to empty the bladder. Phimosis in Adults : The impediment of urination exists, though not so apparent as in children. Dwarfing of the glans penis; sexual neuras- thenia may be conspicuous in these cases; balanoposthitis with its complications is common; and most important is the danger of cancer formation. Three-fourths of all cases of cancer of the penis reported occur in cases of phimosis. Preputial stones may be a complication of phimosis. They generally PARAPHIMOSIS 225 occur in children, but rarely in adults. Two types of stone may exist in phimosis : true preputial stones which are formed under the prepuce, and stones which are formed in the kidney or bladder, and in their escape from the body are caught in the preputial sac by its narrow ring. True preputial stones are formed from the smegma, epithelial detritus, bacteria, and the salts of decomposed urine. They are light in weight, soft, brownish bodies without any characteristic shape, often being so soft that they mould themselves over the glans, even to the extent of covering it. When the number of stones is large they may be faceted. Generally they are small in size, but there are exceptions, one being reported the size of an egg. They are multiple, as a rule; as many as a hundred have been reported. Under the microscope they are seen to consist of epithelium, fat molecules, cholesterin crystals, urinary salts, and bacteria. The hard, heavy stones sometimes found in this location are formed in the kidney or bladder. They often gain in size by the accumula- tion of smegma and epithelial deposits from the foreskin. Under this layer of smegma and epithelium is found as a nucleus a urinary stone. This nucleus will show the elements of a true bladder or kidney stone. These stones, as a rule, cause a chronic balanoposthitis, often accom- panied by a thick, purulent secretion. The penis may be swollen and edematous, and the prepuce infiltrated. The patient may suffer from dribbling of urine or difficulty in urination, and may have frequent erections and pollutions. Often they suffer from defective erections, due to pain. Usually these patients are not aware of the presence of a stone, although they often feel a foreign body under the foreskin which at times impedes urination by wedging itself into the ring of the fore- skin. The stone tends to ulcerate through the foreskin in long-standing cases, resulting in fistula formation. There is danger in these cases of bladder and kidney infection. Treatment. Circumcision. PARAPHIMOSIS. Paraphimosis embraces all conditions in which the glans penis is compressed or strangulated by the prepuce. This takes place when the glans penis passes forward through a comparatively small pre- putial ring and the ring in sliding back over the glans drops into, and is held by, the sulcus back of the corona. Paraphimosis can exist only in cases in which there is a relatively moderate degree of phimosis, and the length of the foreskin must be sufficient to allow it to slip back behind the corona. It is impossible for paraphimosis to exist in cases in which the fore- skin cannot be drawn back over the glans, as in cases of high-grade phimosis, or in cases of very short frenum, or where adhesions exist between the glans and foreskin. M U I 15 226 DISEASES OF THE PENIS This lesion occurs, as a rule, when the penis is erect. It can take place with the penis flaccid, but is then usually accomplished by forcibly pulling a tight foreskin back over the glans. As the inner leaf is closely adherent to the shaft of the penis for some little distance back of the corona, one will readily see that the preputial ring cannot be in direct apposition to the shaft of the penis, but is separated from it by this layer of the inner leaf. Only in cases of atrophic phimosis, where the inner leaf hugs the glans closely, does the entire foreskin come back so that the preputial ring lies in direct apposition to the shaft of the penis. In cases of milder paraphimosis there is only a swelling of the glans penis, and behind this is the folded and swollen outer leaf of the prepuce. The preputial ring lying in the sulcus is hidden under this swelling of the outer leaf. The swelling of the glans is, as a rule, far more marked, and it becomes edematous and discolored. Behind, and at times overlying it, is the swollen outer leaf. In the sulcus, and more than filling it, is a second swelling, consisting of the swollen and edematous inner leaf. Only by lifting aside this second swelling can the preputial ring be seen. A long or short frenum may modify the character of a paraphimosis. A long frenum may cause the constriction of the preputial ring to occur behind the sulcus. The sequelae of this condition are rapid swelling, discoloration, and bullse of the tissue, which may go on to necrosis. This takes place just in the region of greatest pressure. Gangrene of the ring is rare. The gangrenous process generally confines itself to the outer and inner leaf, sparing the cavernous tissue. Paraphimosis may relieve itself somewhat by gangrenous process of the preputial ring. There are cases reported in which by numerous inflammatory processes and ulcerations the preputial ring has been enlarged, thereby relieving the tendency to constriction. The systemic symptoms are mild, patients often not presenting them- selves for treatment until the condition has existed for several days. Treatment. In most cases the swollen glans can be compressed between the fingers until it can be pushed back through the ring. When this cannot be done the constriction should be relieved by incision of the preputial ring. Circumcision may be performed after the swelling has subsided. SUBCUTANEOUS INJURIES OF PENIS. Pain may be very intense even in slight injuries, and may cause the patient to faint. The bleeding following these contusions is very noticeable, even in superficial contusions, and the resulting ecchymosis spreads over the pubic region, scrotum and perineum, as well as the shaft of the penis. The discolorations of skin due to this deep extravasation of the blood appear in a cherry or blue red, while the subcutaneous extravasation SUBCUTANEOUS INJURIES OF PENIS 227 appears as a dark blue. This extravasation, as a rule, spreads from the deep to the superficial coverings of the organ, and extends over a large area. The point of most marked extravasation is the point of greatest induration. Subcutaneous tearing of the penis involving the corpora cavernosa takes place only when the penis is erect or when the corpora cavernosa are involved by inflammation, causing a tight- ening of the connective tissue. Formerly this was called fracture of the penis. This is not a true fracture, as sometimes happens in lower animals, in which an os penis exists; but in man a growth of bone occurs only as a rare pathological condition. So-called fracture is a tear of the cavernous tissue. This tear, as a rule, extends through the albuginea (the fibrous covering of the cavernous body), which, when the penis is flaccid, is over 2 mm. in thickness and very tough, and when the penis is erect, is spread out to a thinness of 0.25 mm. (Henle). The force causing the injury, as a rule, is delivered in line of the long axis, rarely in the transverse. The injury is rare during coitus, but may take place if the organ strikes outside the vaginal orifice. It is more often due to a blow by a falling body or the pushing of the penis against some foreign body, or by forcibly bending back the organ. So-called fracture may result when the patient tries forcibly to correct the deformity resulting from chordee, in which case it is almost always limited to the corpus spongiosum. Symptoms. The symptoms of fracture are similar to those resulting from a grave injury to the urethra. Inability to void often exists when the urethra is not injured. This is due to the pressure on the urethra from blood extravasation. The absorption of the blood is rapid. Diagnosis. In this instance diagnosis is apparent. The deformity of the penis, as a rule, is corrected by the patient, but even in these cases where the deformity has been corrected one may feel the break in the albuginea and corpora cavernosa. At this point there is a marked induration and the blood clots creak under the touch. The pain is intense. Prognsois. The prognosis depends upon the presence or absence of complications. In some cases the blood is quickly absorbed from the parts and the blood spaces of the cavernous body are freed. In these cases th.e function of the penis remains normal. In other cases this does not take place and a hard infiltration remains in the cavernous body. This causes either a crooking of the penis or else that part of the organ in front of the fracture remains flaccid when the organ is erect. If, as a complication, we have an infection, gangrene and partial loss of the organ may result. Treatment. In cases in which the urethra is not involved, a simple dressing with a splint is sufficient, care being taken to have a free pas- sage for the urine. Where the extravasation is absorbed slowly, or the blood clot becomes infected, drainage becomes necessary. 228 DISEASES OF THE PEXIS OPEN WOUNDS OF THE PENIS. Tearing and contusions are more often the cause of open wounds of the penis than biting, shot, cut, or stab wounds. The most common tearing wound is of the frenum; also the tear of the prepuce in cases of phimosis is common. In rare cases the whole organ is torn off, as where the parts have been caught in machinery, etc. It is rare to have the skin torn from the organ, but it does occur. In these cases the skin is stripped from the root of the penis and rolled up forward. Luxatio penis is a condition which is frequently described, though not common, but the resulting condition is of serious consequence. The skin of the penis is torn through at the inner leaf of the foreskin at the sulcus coronalis and the denuded penis is liable to slip back from its skin envelope and is lost under the skin of the scrotum or pubis. These cases, as a rule, are due to violence, but may follow ritual circumcision. The condition resembles the so-called congenital anomaly (phimosis scrotalis) in which the penis lies under the skin of symphysis pubis or scrotum. The patient directly after the accident presents a short skin sac, often filled with blood clot, which can be easily emptied by pressure. It is sometimes difficult to find the shaft of the penis. The urine is emptied either through the skin sac or from some neighboring skin wound. Urination is necessarily interfered with and as it takes the path of least resistance the tissues may become infiltrated. After a short time the shaft of the penis becomes fixed in its abnormal position by scar tissue. Wounds in which a portion of the skin has been stripped off, and even when there is loss of tissue, heal readily and rarely lead to death. Nevertheless, the resulting scars often cause contractions and the dis- torted penis may be of little value functionally. Treatment. Fresh wounds of the frenum should be sutured immedi- ately with fine thread. The stitch should include the frenal artery. In older cases which have been infected it is better to clean the part and treat by wet dressings before plastic work is begun, as the swelling which is always present will by these means be reduced and thus the ultimate result is better. The so-called luxatio penis should be reduced at once, the denuded penis placed in the skin sac and held by loose stitching. Urinary fis- tulse should be excised freely and drained, and the whole covered by wet dressing. As a rule these cases require several operations before a satisfactory result is obtained. In those of long standing in which the shaft has been caught and held by scar tissue in its abnormal position one finds great difficulty in locating it. The guide, naturally, is the existing urinary sinus, as it must lead to the meatus of the penis. Thus one opens these sinuses freely and dissects back to the hidden shaft. After the shaft is quite freed it is placed in its skin envelope as in fresh cases. STRANGULATION OF PENIS BY FOREIGN BODIES 229 Healing in these instances is usually good, except when infected or neglected. In those cases in which the skin has been torn it should be united by stitches at once. Drainage should be instituted in those where there has been marked maceration or when a great amount of dirt has been driven into the wound. When there is loss of tissue, plastic work should be instituted at once, as the resulting scars of neglected cases cause marked distortion of the penis, which can be corrected only with the greatest difficulty. Contusions of the penis are similar to subcutaneous contusions already described, but are of greater intensity, and often involve the scrotum and perineum. They are accompanied by shock. The prog- nosis of contusions depends upon how early the case is seen and upon the absence or presence of complications, such as infiltrations and scar formations. When there is injury to the urethra a catheter should be passed into the bladder and retained there. There should be an immediate attempt to repair all wounds. Wounds of the penis resulting from bites are usually severe and are due to attacks by animals. Insect bites are serious only as the resulting swelling and infection may lead to gangrene of the part. BURNS AND FREEZING OF THE PENIS. Burns are treated as elsewhere on the body. Freezing of the penis is very rare. The symptoms are the same as for other parts of the body. The scratching of the patient, due to the intense itching, may cause an infection and consequent chronic inflam- mation. There is, as a rule, a low r -grade urethritis and balanoposthitis in these cases. The part is afterward sensitive to cold and heat, as is seen in cases of frozen ears. STRANGULATION OF PENIS BY FOREIGN BODIES. This is not a very rare condition, and is due to the application of ligatures or other encircling bodies. Hair is the most common, and with children is sometimes applied by the mother or servant with the belief that it will stop bed-wetting. When ligatures are used by older people, which is rather common, they are used with the idea of increasing erection or to prevent nocturnal pollutions. Many tubular articles are used by the weak-minded and mastur- bators. There is a large variety of these instruments. They are applied to the penis before or during erection, and are at times re- moved with the greatest difficulty, as the constriction of the enveloping instruments allows ingress of arterial blood and obstruction to outflow of venous blood. In my experience the ligature, especially the ligature of hair, is by far the most commonly met with. This ligature is generally applied just at the corona and soon causes a marked constriction. In a few days 230 DISEASES OF THE PEXIS it is rather a difficult matter to determine the cause of the strangulation, as the peripheral end of the penis becomes swollen and soon the liga- ture cuts through the skin and underlying connective tissue. The prepuce is inflamed by the resulting infections and takes on a markedly swollen, angry appearance. The edema makes it hard to find a hair ligature, even in an early case; but later, when it has cut into the tissues and is covered with granulations, it is most difficult. The constriction at this time, if a non-elastic ligature is used, is lessened, and a child may carry such a ligature for weeks. If not removed it is at times covered by scar tissue from the healing of the wound of entrance. It may then cause no further trouble and be carried thus in its connec- tive-tissue retainer for years. If the ligature cuts into the urethra there is a resulting fistula. Solid rings applied to the flaccid penis are firmly caught by the result- ing erection. The penis becomes markedly swollen, due to the obstruc- tion to the return flow of the blood. Gangrene of the tissue is the result. Systemic symptoms in these subjects are not marked. ACUTE INFLAMMATORY PROCESSES. Edema of the foreskin accompanies all acute inflammatory affections and local mechanical interference with circulation. This mechanical interference may be due to a tight-fitting dressing, or ligature, or to con- striction due to contraction of scar tissue. In cases of general edema of the organ it is more marked at the prepuce and most marked at the frenum. The under surface of the penis shows the least edema. Edema of the glans is first seen on its under surface in the line of the attach- ment of the frenum to the orifice of the urethra. When this edema continues the glans, being held firmly by the attachment to the frenum, can swell only on its upper surface, and this causes the demarcation of the glans and frenum to be obliterated. The edema is, as a rule, more marked on one side and then the organ is bent in the opposite direc- tion. In cases of marked edema, urination at times is interfered with. After dorsal or lateral incision of foreskin, there often exists a chronic edema of the flaps. Acute inflammation of the glans (balanitis) and foreskin (posthitis) are rarely separate and will be treated together as balanoposthitis. The most common form of this is due to gonorrheal infection. 1 Other infections are divided by some writers into catarrhal, croupous, diph- theritic, and diabetic. The diabetic is a complication of diabetes. All cases of balanoposthitis are due to filth, an irritating foreign sub- stance retained under the foreskin causing inflammation. Men without a foreskin never have balanoposthitis, as the mucous membrane by exposure is converted into epidermis. 1 Although gonorrhea is the exciting cause in this condition there are no gonococci in the secretion from the foreskin, the infection of the foreskin being due to another organism. 231 Etiology. The cause is any form of irritation which may lead to inflammation of the mucosa of the glans and foreskin. The most com- mon is the retention and decomposition of the secretion of Tyson's sebaceous glands; the accumulation of gonorrheal pus; the products of hard or soft chancroidal growth; and eczema or herpes of the glans and foreskin. To all these causes must be added uncleanliness, as one never finds balanoposthitis when the parts are kept clean. Symptoms. The first symptoms are burning and itching. The fore- skin soon becomes swollen, often to such an extent that it cannot be drawn back over the glans. There is an increased secretion, due to irritation. This may be of a purulent nature, and may be so pro- fuse that it drops from the foreskin. The meatus, if it can be seen, appears swollen, as well as the lining of the foreskin and the covering of the glans penis. Lymphangitis is generally present. The dorsal lymphatics are outlined in red lines and are swollen and painful to the touch. As this inflammatory process continues there is erosion of the epithe- lium covering the parts, which may lead to ulceration. In severe cases the foreskin, as a whole, is edematous and swollen, and if retracted over the glans penis and not reduced, may lead to gangrene. Recurrence of balanoposthitis leads to infiltration and increase of connective tissue in the foreskin, which may be so great that it is impossible to retract it. Other complications are the formation of adhesions between the glans and foreskin, as well as preputial stones. Balanoposthitis is more common in children, especially at time of puberty, and, as above stated, is due to lack of cleanliness. In older people, when phimosis is present, a large number will be found to have a keratosis, or so-called venereal warts. The danger of malignant changes in them is very great. (See Carcinomata.) Treatment. Remove the irritating agent and keep the parts clean. Circumcision is advisable in cases of phimosis after the inflammation has subsided. If erosions are present after circumcision, one had better use a salve with boric acid or one containing 0.5 per cent, silver nitrate. As stated above, balanoposthitis is one of the complications of dia- betes, and is often due to the sugar-charged urine remaining under the foreskin. This is a favorable medium for bacterial growth, and when this takes place the itching, edema, swelling, and increased secretion of Tyson's glands are present, as in uncomplicated balanoposthitis. These subjects having a reduced resistance against infection, the cover- ing of the parts soon ulcerates and infiltration of the organ follows. The phimosis and scar retraction are often marked. The diagnosis is at once suggested by finding sugar in the urine. Herpes Progenitalis. Herpes progenitalis manifests itself in an erup- tion of blisters containing a water-like fluid. These blisters may be single or in groups. They occur usually on the retroglandular surface behind the sulcus, but may appear on the shaft of the penis. They have been reported as involving the urethra in their extension. These 232 DISEASES OF THE PEMS water-like blisters soon become infected, and then their contents become white and cloudy. The breaking of the blister causes ulcer formation. The inflammation soon subsides and the ulceration heals. Often there is a painful inguinal adenitis as a complication. Certain of these cases have neuralgic symptoms, as in herpes zoster. In these instances a day or two before the eruption there is marked pain and soreness to the touch of the skin of the penis and scrotum, the pain sometimes radiating to the glans penis. This symptom dis- appears as the vesicles appear. Treatment. Cleanliness, and a saturated solution of argyrol in ichthyol to paint over the eruption, and bandage with dry dressing. Cause is unknown, although the vesicles seem to follow the nerve fibers. Cases show a marked tendency to recurrence. Erysipelas. Erysipelas of the penis is rarely primary. If primary, it is due to infection with a streptococcus through some abrasion in the penis. SKIN AFFECTIONS OF THE PENIS. Skin affections in general may involve the penis and ought to be considered in connection with the original disease. The most common of the skin lesions occurring on the penis are psoriasis, scabies, herpes, a leukoplakia preputialis, described by Schuchardt, and venereal ulcers. PHLEGMONS OF THE PENIS. Circumscribed inflammations of the penis are noted in connection with eczema, erysipelas, variola, typhus, and infectious diseases of severe type. Although the above are to be mentioned, the majority of phlegmons are secondary to traumatism or to extensions from inflammatory processes in the urethra, also after urinary infiltrations, as well as after ulcerations, insect bites, erysipelas, etc. These phlegmons may be accompanied by gangrene of the skin. In such cases the dorsal lymph channels are prominent and painful. There is a painful adenitis in the groin. Of the causes of this gangrene little is known. Symptoms. The condition starts in a typical manner. There is at first slight local pain and redness. In more severe cases vomiting and fever are early symptoms. The penis, and often the scrotum, are swollen. At the end of about twenty hours there appear numerous gangrenous spots on the skin. These quickly coalesce and total necrosis of the skin of the penis and scrotum results. This is not a deep-seated process, but at times results in abscesses of the parts. Often the lymph glands in the neighborhood suppurate and abscesses extend to the abdominal wall. In severe cases the gangrene becomes demarcated in a few days and the symptoms improve. Recovery is the rule, although rarely death occurs due to general asepsis. Treatment. Incision for drainage and wet dressings. PHLEGMONS OF- THE PENIS 233 Acute Cavernositis. Acute cavernositis, an infection localized in the cavernous bodies, must be differentiated from a superficial phlegmon. Etiology. Acute cavernositis is due to injuries, extravasation of urine into the cavernous bodies in cases of stricture and infected thrombosis which occurs in certain blood diseases, as leukemia. Symptoms. At the onset an irregular, hard, painful mass is felt which can be localized in the cavernous body. There is painful and, at times, difficult, urination, due to the extension of the process to the urethra. Suppuration soon occurs and then a fluctuating swelling takes the place of the'hard mass formerly felt. In neglected cases the abscess may break into the urethra or through the skin of the penis. As stated above, traumatism and the complications of stricture are the causes of the infection. (This type of cavernositis is often spoken of as periurethral abscess.) But it may be hematogenous in origin, as it occurs in cases of septicemia. Diffuse Cavernositis. The rarer and much severer type of caver- nositis, the so-called diffuse idiopathic cavernositis, is, in my belief, always hematogenous in origin and is due to pyemic metastasis. These patients rarely recover. Diffuse cavernositis begins w r ith marked systemic symptoms: chills, high fever and marked swelling of the prepuce. Priapism is a char- acteristic symptom and is present by the third day of infection. The erections may be complete or partial, may last for long periods and cause difficulty of urination. Priapism may be due to physio- logical irritation of cavernous bodies or to a thrombosis of the same. The latter is painless and is generally followed by gangrene of the penis. These infections at times go on to abscess formation and they may rup- ture into the urethra. Untreated cases of a few days' standing show symptoms of pyemia. Death is not uncommon. At autopsy the lungs, liver and kidneys contain abscesses. The penis may remain erect after death, held in this position by the thrombosis of the caver- nous bodies. Cases which recover may have nothing of the penis left but a mass of scar tissue. Cases have been reported of diffuse gangrene of the penis which is due to thrombosis of its bloodvessels. This thrombosis may extend from the iliac, femoral, and periprostatic veins. Chronic Cavernositis. Chronic cavernositis may follow acute caver- nositis. In these cases scar tissue replaces that portion of the caver- nous body which previously was the site of inflammation. Another group of these chronic cases never present any acute symptoms. The inflammatory process begins as a small, irregular swelling, generally on the dorsum of the penis and often near the symphysis. The masses vary in size, are generally small and may be multiple. There is a tendency for this chronic process to develop connective tissue. In this manner more or less of the cavernous body is replaced by connective tissue. This naturally causes a bending of the shaft when the organ is erect. The distortion, as well as the pain upon erection, may cause impotency. 234 DISEASES OF THE PENIS Cases reported in literature of bony formation in the human penis are probably the calcification of these connective-tissue masses. Etiology. Causes are many tearing of tunica albuginea, intra- cavernous extravasation, periurethritis, syphilis, and gout. GANGRENE OF THE PENIS. Ordinary gangrene of the penis follows traumatism and inflammatory processes, as before stated. It also is caused here, as in other parts of the body, by loss of blood supply, burns, etc. Infiltration of urine with its resulting infection, deep-seated infections in the perineum are also peculiar causes of gangrene of the penis. There is an acute progressive gangrene of the penis and scrotum described by Fournier, Kellemont and others, which occurs, apparently, without any specific predisposing cause and has no analogue in other organs. It may occur in persons suffering with diabetes, typhus and after cantharides poisoning. At times it occurs without any disease being present. It may follow bandaging of the penis after the bandage has been wet with urine, also after adhesive bands have been used on the penis to hold a retention catheter in the urethra. Treatment. Treatment is the same as for gangrene from other causes incision and drainage. LYMPHATICS AND BLOODVESSELS. Diseases of the bloodvessels and lymphatics are rare. Traumatic aneurysm of the dorsal artery, being the most common of these con- ditions. CARTILAGINOUS AND BONY FORMATION. True bone formation is found in the penis of some of the lower animals. In man, thickened fibrous tissue takes the place of this bone. By careful examination this fibrous tissue can be felt normally. Pathologically, in old people, the tunica albuginea may become infiltrated with a calcareous deposit, which resembles bone. The symptoms accompanying the condition are pain and distortion of the penis when erect. This distortion is similar to a chordee, with the concavity in the direction of the infiltration. Other causes than old age, held by some writers, are injury to the cavernous bodies involving the albuginea, chronic cavernositis, syphilitic lesions of cavernous body, and gout. There is doubt in the minds of many whether these latter so-called etiological factors can be proven. Undoubtedly, senility is the most common cause, as the pathological process in this location resembles senile processes in other parts of the body. TUBERCULOSIS OF THE PENIS. Primary tuberculosis of the penis in adults is very rare. The glans is more often involved than the prepuce. It is a chronic process from GUMMA OF THE PENIS 235 the start and manifests itself by the formation of granulation tissue, which gradually infiltrates the surrounding substance and may invade the whole thickness of the penis. This infiltrate undergoes caseation. The infection may be acquired by coitus with a female having tubercular genitals or by direct infection with tubercular sputum. As the infection progresses, isolated masses can be felt in the caver- nous bodies and urethra. They are often the size of a pea and as they enlarge they extend toward the surface and are felt directly under the skin. On section they are seen to foe masses of caseous tubercles. Their growth is slow, but eventually the skin of "the penis is involved with a resulting ulceration. In this state one may mistake the infection for a hard chancre. Although this infection is undoubtedly autogenous in the great majority of cases, the primary lesion may not be in the genito-urinary tract. The penis may be the seat of a secondary infection in cases where there is a tubercular in- fection of the kidney and bladder. These are rare, but when they occur, the meatus at first presents a swollen, angry appearance, and small miliary tubercles are seen over the surface. The adjacent tissue is slightly infiltrated. There is a seropurulent secretion. The whole picture is very much the same as that presented by the mouth of a ureter which has been infected by a tubercular kidney. Tuberculosis of the penis in young children is far more common and is often due to direct infection at the time of circumcision by the rabbi. The old, orthodox circumcision was performed by tearing the fore- skin free from the penis by the finger-nail, and the resulting hemor- rhage was stopped by sucking the penis with the mouth. This was at times performed by a rabbi with infected sputum. The incu- bation period in these cases is about two weeks. It manifests itself as a tubercle, being the typical yellowish or gray-white speck on a surface of granulation tissue. These infections progress rapidly; the inguinal glands are involved early. The patients always die either by a general tubercular infection or by marasmus. A few cases are reported where the wounds healed, but after two or three years death resulted from tuberculosis of some internal organ. Treatment. Although the tubercular organism is often not found in the tissue, one can, as a rule, demonstrate the organism if a deep section of the tissue is carefully stained. Excision or amputation of the dis- eased tissue is the safest procedure. GUMMA OF THE PENIS. Gumma of the penis may be located in any of its anatomical divisions. When located in the connective tissue just under the skin, it may have the appearance of an enlarged lymph gland, but as there are no lymph glands in the penis, one should be on one's guard. These masses are prone to break down, and may result in urinary fistula and stricture. No pain accompanies this lesion. 236 DISEASES OF THE /'A'.Y/.S ACTINOMYCOSIS. This is a very rare pathological lesion. In the cases reported, pain is an early symptom, and there is a redness of the meatus which is soon followed by a serosanguineous secretion. In the accompanying induration there are small, purulent, knotty masses. These soon ulcerate through the skin so that the glans penis is covered with many small holes. Amputation is the only treatment. ELEPHANTIASIS. True elephantiasis of the penis is due to infection with filaria. Nat- urally these cases occur in countries in which the disease is endemic. Here the only cases which have come to my notice are among emigrants. A great many were from St. Kits, West Indies. The swelling may begin in the foreskin of the penis and then extends to the scrotum. The swelling of these parts, like other swellings inci- dental to the disease, is due to back pressure of the lymph on the parts, due to plugging of its channel which has been occluded by the mother worm. The chronic state of this lesion leads to a thickening of the skin and increase of connective tissue in the parts involved. This is such a rare condition in this country that the cause of the lesions may be overlooked. But, as a rule, by careful examination of the blood both by day and night, the young filaria will be found. Several times each year cases present themselves which have all the ear-marks of true elephantiasis, even to the skin thickening and increase of connective tissue. The prepuce is often markedly swollen, and that part at the frenum stands out with great prominence. The most common cause of these cases is the complete destruction of the inguinal glands, generally by operative removal, or rarely by inflammation. In this way there is a lymph stasis. Strictures, traumatism, syphilis, lymphangitis, as well as filth under the foreskin, all have been reported as causing this lesion. If there is no ulceration or infection of the parts, these patients have no symptoms referable to the lesion, and their general health is not impaired. Ulceration and infection do occur rarely in very marked cases. The size of the organ causes a great deal of discomfort. Amputation, or excision, including when possible all the tissue involved, has proved successful in some instances. EPITHELIAL CYSTS. In clinics which are attended by many Jews, cases at times are seen of epithelial cysts of the remaining foreskin. These are probably due to faulty method of circumcision. From the same cause, cases of tumor-like formation are seen where there has been poor union of the skin, and sebaceous glands have been turned under and in this position continue to secrete. TUMORS OF THE PENIS 237 The secretions of the sebaceous glands at times are retained and cause small but oftentimes numerous tumors of the penis. These are situ- ated more frequently at the hairy portion of the organ. DERMOIDS OF THE PENIS. True congenital dermoid cysts have been reported. They never attain a large size, but contain the ordinary elements of dermoid cysts in other locations. They occur mainly near the raphe. TUMORS OF THE PENIS. Papilloma of the penis is rare and there is some question if true papil- loma does occur. Waldeyer reports a case of nineteen years' standing which was of a very large size. The tumor involved the inner and outer foreskin, as well as the shaft of the penis. He made the diag- nosis of a true papilloma, as its elements did not involve the connec- tive tissue. Fibromata are rare and of little importance. The cases reported are of the neurofibromata type. Chondromata are rarely seen on the penis. Lipomata may occur in the skin. So-called venereal warts (condylomata acuminata) are common. They are present in cases of congenital phimosis and those cases in which the glands at the corona are active and the patient does not keep the parts clean. The tumor masses are true epithelial outgrowths. Treatment is excision. These wart-like growths are prone to malignant degeneration. Carcinomata. Carcinoma of the penis is next to the most common skin cancer. It occurs usually at about fifty, rarely before forty years of age. Congenital phimosis is an important etiological factor. The great majority of reported cases have, or have had, phimosis. Some cases have been published where the exciting cause was a wart, or syphilitic ulcer, and some authorities lay stress upon trauma or inheri- tance. Although the infective theory has been advanced, no cases have been proved where cancer of the penis has been acquired by intercourse with a woman having carcinoma of the cervix. The classification of this newgrowth may be made from a clinical or pathological stand-point. Kiittner divides them from a clinical stand-point into papillary cancer, carcinomatous swelling, and tumors not papillary, but adds that one type can pass into the other. Pathologically, they are all epitheliomata and can, according to some pathologists, arise from the basic or squamous cells. This naturally divides cancer of the penis into two types. This theory is not held by many authorities. The majority of these epitheliomata occur in the form of papillomata and involve, primarily, the glans or inner leaf of the foreskin. Its 238 DISEASES OF THE PEXIS papillae are hard, leaf-like structures in contradistinction to the fine villa? seen in bladder papillomata. The peripheral growth soon fills the space between the glans and pre- puce, and by infiltrating the tissue of the foreskin, breaks through the preputial sac in one or more places. The glans which previously has been covered by the infiltrated foreskin which could not be retracted, may, after this perforation, be seen again. It is rare, even in cases of phimosis, to have the outer leaf of the fore- skin the primary seat of a newgrowth. Small warty growths on the glans may give rise to neoplasm, either by their malignant degene- ration or carcinoma may develop near them. The foreskin in these cases is soon distended by the swollen glans and cannot be retracted. This is due to the disproportion of the size of the glans and the fore- skin, while in those cases where the growths occur on the foreskin the inability to retract the foreskin is due to the infiltration of the same. All newgrowths which are situated under the foreskin are soft and moist, but if uncovered, are hard and dry. The papillary branches spring from one stem, but this is often overlooked on account of the great mass of these branches. Like all epitheliomata, the surface cells tend to degenerate, filling the interstices with a white, smegma- like, foul-smelling paste. These tumors may grow to be several times the size of the glans. The growth is often so rapid that large pieces are cut off from their blood supply, die and fall off. The many ulcerations of the penis, caused by the infiltration of its tissue, lead to fistula, and where these enter the urethra, they discharge urine. By the invasion of the penis by the growth and the subsequent death of this tissue the organ wastes away. A cauliflower growth perforated by many urine-delivering fistula 3 , connected to the pubis by a short stem, the remains of the penis shaft, is often the condition of the patient when he presents himself for treatment. The whole penis is eventually sloughed off by the continuation of this process. The pubis and scrotum may be involved. The patient urinates through sinuses in the newgrowth, which connect with the eroded and shortened urethra. Kiittner describes a form of carcinoma which he says is rare. It appears as an ulcer with raised edges, either on the glans or at the sulcus. The growth is slow at first, but from the start the connective tissue of the part is involved. The other form described by him he claims is the rarest and is char- acterized by a grayish-white discharge. It does not have a papillary structure and may become very large. The tissue of the tumor has a tendency to undergo cystic degeneration. Newgrowths of the penis, by extension, may involve the scrotum, testicle, prostate, bladder, rectum, and pelvic cavity. The cavernous bodies are not involved early, as the albuginea offers an obstruction to invasion, but when involved there is an advance of the growth along the cavernous tissue. The inguinal glands are the first lymph glands TUMORS OF THE PENIS 239 to be involved, then the retroperitoneal. Metastases are common, although they take place late in the disease. Symptoms. Carcinoma of the penis begins without pain. In cases in which a phimosis exists there is itching of the parts, and as ulceration takes place it is accompanied by a discharge which may be profuse. Urination may be impeded either by the newgrowth obstructing the outlet of the foreskin, or by ulceration of the urethra. As the condition advances, erections are painful and later disappear. Pain, when present, is due usually to the growth invading the glans. The advance of the growth is slow, as a rule, often a year elapses before the patient presents himself for treatment. Diagnosis. The diagnosis is difficult to make in early cases without microscopic sections of the tumor. It may be mistaken for a condy- loma. The differential points are: condyloma tissue is soft and cancer is hard; the attachment of condyloma is superficial, while cancer is deep. It is wise to make microscopic sections of the tissue in all cases. This is especially easy to do, as most cases have a phimosis which must be relieved when they present themselves for diagnosis. Treatment. Treatment is amputation with radical removal of the lymph glands, which drain the field of operation. Sarcoma. Sarcoma of the penis is very rare. It may occur as a round or spindle-celled tumor which infiltrates the tissue of the penis. Myxomatous types are very rare, while the melanosarcoma are somewhat more common. These growths develop fast and the lymph glands are soon involved. Prognosis. The prognosis is very bad even in cases of early operation. Diagnosis. The diagnosis may or may not be hard, but rarely is a case diagnosticated early enough for a cure. CHAPTER VIII. GENITAL ULCERS. BY B. C. CORBUS, M.D. Historical Review. The Bible is the most ancient as well as most reliable source from which early knowledge in regard to genital ulcers can be obtained. The plague which fell upon the men who frequented the altars of Baal is supposed to relate to ulcerations of the penis, while the lamenta- tions of King David over the sharp pains in his bones doubtless refers to the effects of venereal disease. Changes in the throat and soft palate are mentioned by St. Paul in his epistle to the Romans. From all these it is fair to infer that genital ulcers with their accompanying effects existed in ancient days. Hippocrates, among the early medical writers, speaks of ulcerations of the genital organs, of tumors of the groin, of ulcerations of the mouth, and of extensive pustular eruptions on the body. Later, Celsus describes two varieties of ulcers on the penis, which he calls "ulcera sicca" and "ulcera humida." This division fits admirably well the description of today the soft chancre, which suppurates freely, and the hard, which scarcely suppurates at all. Celsus also describes the phagedena which may invade the ulcers at times. Aretaeus describes the destruction of the uvula and soft palate. Cribasius, like Celsus, divides the ulcers into dry and moist. Galen speaks of ulcers of the scrotum, which he divides into two classes, deep and superficial. Aretaeus and Paul of Aegina both make mention of ulcerations of different kinds that develop on the genital organs. During the latter part of the fifteenth century (1496) syphilis was conveyed by sailors of Columbus to the inhabitants of Seville and Barcelona. From this date authentic transmission is well chronicled. For want of a name the disease was called morbus gallictus, and on account of the primitive character of domestic relations at that time, hardly a family in Spain was free from it in 1494. The cases became so numerous in Seville that special hospitals were opened to cope with the situation. During 1494 the whole of Italy was infected, progress being noted from town to town. In 1495 France, Germany, and Switzerland became the seats of virulent outbreaks. Holland and Greece in 1496. England and Scotland in 1497. Russia and Hungary in 1499. (240) SYPHILIS 241 In 1490 the Decree of the Parliament of Paris required all infected persons to leave the city. In Scotland, during Cromwell's time in the seventeenth century. In Norway in 1720. In Prussia in 1757. In Sweden in 1762. In Holland in 1789. In Uganda (Africa) in 1896. At present syphilis exists everywhere in the world, being less frequent in the rural districts and most frequent in the large cities. No historical sketch, however brief, should close without a reference to John Hunter and Philippe Ricord. In 1767 John Hunter inoculated himself on the prepuce and glans with the pus from a virulent gonorrhea, and produced a chancre as well as constitutional syphilis. From this he concluded that the secretion from a case of gonorrhea was capable of producing all three diseases gonorrhea, chancroid, and syphilis. This unfortunate theory was not disproved