CHAPTER XLVIII (Part 2)

inflammation or congestion of the prostate, or calculus. The history of the case, particularly the existence of ui'ethritis or of stricture, the examination of the prostate or, the passage of a sound, wiU decide the diagnosis. In extensive bleeding from the p-ostaie the blood flows back into the bladder, and it is not then to be distinguished from vesical hfemorrhage except by other signs of prostatic disease. When the blood is not intimately mixed with the mine, but becomes more abundant towards the end of the act, or when the urine contains flat or irregular-shaped clots, or is reddish m colour, it is fi'om the rroslate or bladder. . , The causes of vesical hccmorrhagc are stone m I lie bladder, vesical tumours, acute cystitis, tuberculous and cancerous ulceration of the bladder, schistoso- miasis (bilharziosis), rupture of a vesical vanx, XLVIIl] H/EMATURIA 683 and perhaps hfemopliilia, purpura, and scurvy. The hsemorrhage from stone is often small in amount, intermittent, especially excited by exercise, and accompanied by the characteristic pain, etc. Hajmorrhage from villous tumour comes on sud- denly without obvious cause, is often exceedingly profuse, and after continuing for a while ceases equally abruptly and may not recur for a long time. In some cases the bleeding occurs during the act of micturition, and as the urine is passed it becomes more and more bloody until at last pure blood flows when the bladder is comjDressuig the very vas- cular growth. In malignant tumour of the bladder the hfemorrhage is more frequent but less abundant, and pain, frequency of mictui'ition, and cachexia are marked. The hfemorrhage of acute cystitis is moderate in amount and accompanied by intense pain and frequency of micturition, and the urine contains mucus and pus. In tuberculous ulceration the blood is small in amount and mixed with pus, and there may be signs of tubercle in the kidney, prostate, testicle, or vesiculte seminales. The tubercle bacillus must be sought in the urine — it is not easily found. The haemorrhage due to the schistosoma is usup,lly sUght in amount and frequently recurring ; the ova of the parasite are found in the urine. Vesical varix is a very rare condition characterized by occasional profuse hfemorrhages, and is only to be diagnosed when the varix is seen through the cj^stoscope. Other signs of purpura, scurvy, and hcemo'philia accompany bleeding from these causes. Where the blood is intimately mixed with the urine, or the urine has a smoky thit, or there are long narrow clots (" casts " of the ureter), it is certainly rcjial in origin. The cysto.scope must be used to determine whether the bleeding is from one 684 SURGICAL DIAGNOSIS [chap or both kidneys. Very profuse renal or prostatic hsemorrhci ge may closely simulate vesical bsemor- rhage, and is only to be distinguished by other signs of disease of these organs. Renal heemorrhage may be due to injury, acute inflammation, infarction, stone, tubercle, growths, parasites, or blood changes. The history of the case decides whether it is due to injury. When due to inflammaiion it is accompanied by excess of albumin, by tube casts, and is usually associated with oedema and other signs of blood change. Ha3morrhage due to stone is chiefly characterized by its being increased by exercise or movement, by the pain, and some- times by the passage of gravel. Hajmorrhage due to tubercle is recognized by the detection of tubercle bacilli in the urine, by the presence of tuberculous disease elsewhere, by fever, and by the admixture of pus with the blood ; the hsemorrhage is usually slight. The haemorrhage of renal tumour may be very profuse or very slight ; in papilloma of the pelvis it is profuse as in the similar disease of the bladder, and there are abundant epithelial cells in the urine ; there may be no renal tumour to be felt, and in any case the palpable swelling is but slight. The signs of hcBmofhilia, scurvy, furjmra, fever, ajid the causes of renal congestion are so apparent that the diagnosis of haemorrhage from these sources is easy. Hsemorrhage as a part of chyluria is recognized by the fibrinous coagula, the milky colour due to fat, and possibly by the detection of tilai-ia^ in the blood. In all cases of hsematuria, in which ju'ithor the history, e.g. of an injury, nor tlic result of a ,sim]ih' physical examination, e.g. the detection of an en- larged prostate, nor a reiial tumour, renders the cause of the bU'cdiug obvious, a cystoscopic examiiuitiou must be made at the eiirhest possible moment. XLVIIT] PYURIA fiPf) If postpoiiod until the hlocding has coasod, tho diagnosis may be rendered more difficult. Pyuria. — Pus is a frequent addition to urine, and is recognized by turbidity of the urine, by the pre- sence of albumin and pus cells, and, when the pus deposits in quantity, by the fact that liquor potassaa converts this deposit into a very ropy, tenacious fluid. The addition of ozonic ether to purulent urine causes free and continued efTervescence. If the pus escapes from the penis independently of micturition, it is urethral, due either to urethritis or to abscess opening into the urethra. A sudden dis- charge of pus in the urine indicates the bursting of an abscess, the seat of which will be shown by swell- ing and pain ; if the act of micturition ends in the passage of a small quantity of pus, it points to sup- puration in the prostate. The passage of very ropy muco-fus in alkaline, fovd-smelling urine shows that there is cystitis. Pus in large quantity in acid urine is derived Iiom the pelvis of the kidney, or more rarely from an abscess opening into the bladder or ureter. B.-coli bacilluria may be recognized by the char- acteristic opalescence of acid urine ; the bacillus, like other organisms, must be identified by bacterio- logical methods. The mucus of urine is increased in inflammation of any part of the urinary tract. Semen may be found in urine, especially after a seminal emission. The passage of flatus or of f cecal matter, the latter recognized by the animal and vegetable fibres and cells as well as by its colour, consistence, and odour, shows that there is a communication between the nlimentary canal and the bladder ; this condition is usually attended with extreme pain, and it generally leads on to cystitis. The surgeon must endeavour to determine what part of tlje intestine opens into 686 SURGICAL DIAGNOSIS [chap. I ho bladdei- by the amount, the coluur, and the coii- .sisteaee of the iivx-nl matter, ui' l)y tlie rapidity with wJiieh such a suhstanee as cliarcoal given by the Jiiouth i.s recognized in the mine. The communica- tion may be a congenital malformation, but it i.s more often due to cancerous idceration, to typhoid ulcera- tion, or to pelvic abscess; the history of the case clears np the dia-gnosis. As a, secpiel to an attack of appejidicitis the appendix Jnay form a communication with (he l)huhler, and intermitteJitly — perhaps at vej'v h>ng ijdci'vals — discharge a small amount of fa-cal matter into tlie bladder. For tiie fliagnostic sig- nificance of bile or siij/ar in the urim^ and of the various cri/slalliHe depusils, the reader must refer to other worivs. The passage of hair or of masses of sebaceous matter indicates the ojjening of a (Irnnnnl cijd \\io some part of the urijiary apparatus. EcJiiiio- coLXUti hooJyicts and hydaiid vesidci; have been found in the urine. Examinaliou oi Ihc urethra.— For malforma- tions of the urethra, see Chap. XLIII. The size and condition of the orifice, and the presence of discharge, if any, are to be noticed. The orifice may be too small [driclure). A cyst or a wart may project fi'om it, or its edges may be the seat of chancre or of cpiUuiioma. Should the orifice be swollen and covered with a gummy dis- charge, and be the seat of itching, and these signs have appeared two to seven days after coitus, it is the initial stage of acute urethritis. If there is an abundant thick yellow or greenish discharge, and the penis is swollen, and the urethra feels firm and tender, there is acatc urethritis ; when the dischaigc becomes milky in colour, and the pain and swelling subside, It is chronic urethritis ; and if the discharge consists only of shreds voided in the iirst portion XLVin] EXAMINATION OF URETHRA 687 of the mine, or of a drop of gummy discliarge at the meatus, seen perhaps only in the morning, it is cjleeL In all these cases the gonococcus must be sought for in the discharge. If the discharge is sanious, and an ulcer is seen just within the orifice, it is a soft chancre. A sero-purulent discharge with little or no pain, associated with a firm lump in the urethra near the orifice, and multiple enlargement of the inguinal glands, and followed by sore throat and a rash, is due to a hard chancre. Gonorrhcea is dis- tinguished from other forms of urethritis by the presence of the gonococcus in the discharge. A painless muco-purulent discharge is sometimes seen in secondary syphilis. Gouly urelhrilis is to be dis- tinguished by the history and concomitant affections and by the absence of the gonococcus. Gleel may be caused by chronic urethritis or prostatitis, by a stricture, or by a urinary fistula. Now let the surgeon pass his fingers back along the urethra to the perineum : it may be swollen and tender in acute urethritis, or hard and knotty in severe stricture ; if a painful and tender, ill- defined firm swelling is felt in the anterior perineum, it is a perineal abscess ; in its later stages fluctuation may be felt. A similar swelling with much surround- ing oedema may be found over the urethra where it is covered by the scrotum, the pus being under the eiaculator urinte muscle; sucli an abscess will point at the root of the penis. An examination of the urethra with the urethro- scope enables the surgeon to note the presence and exact position of granulations, ulcers,- erosions, dis- tended follicles, and of liyperaimia of the mucous membrane, and so to determine the site and character of the lesion responsible for the persistence of a chronic uretliiitis. 688 SURGICAL DIAGNOSIS [chap. If a youiig or middle-aged man complains of difficulty in micturition, with loss of force of the stream, forking of the stream, or dribbling at the end of micturition, or of retention, and there is a history of a previous attack of gonorrhoea or of injury, there is probably a stricture of the urethra. This may be due to spasm of the extrinsic muscles of the urethra, congestion of the mucous membrane, or organic narrowing of its lumen. Any two of these causes may be present together. Pure spasmodic stricture is rare ; cases of retention of urine after rectal or perineal operations are said to be due to this con- dition. The more probable cause is inhibition of the bladder. Congestive stricture may be diagnosed if a patient during the early stage of gonorrhosa is sud- denly seized with retention, and examination of the prostate is negative. It is unnecessary and bad practice to pass a catheter or bougie in this case. Organic stricture may be suspected if the patient gives a history of gonorrhoea some years previously, or of injury to the perineum, and of progressive diffi- culty in passing urine, characterized by having to strain to commence the act, and also by enfeeble- ment and distortion of the stream, culminating perhaps in retention or dribbling of urine, the ac- companying retention being unrecognized by the patient. The diagnosis is confirmed by passing a catheter or bougie and demonstrating an actual narrowing of the urethra. An attempt should first be made to pass a full- sized instrument. If obstruction is cncoimtered within 6 in. of the meatus a stricture is present. The surgeon has to determine the position, size, and number of the narrowings. This examination is best made with " acorn " or " bullet-headed " in- stnnuents, successively smaller sizes behig used midl XLViii] EXAMINATION OF PROSTATE 689 the largest is foiuid which can be passed through the stricture or strictures into the bladder. If in passing a catheter a coarse grating is felt, it shows that there is a urethral or prostatic calculus, and the exact position at which the grating occurs, as measured by the stem of the catheter, distinguishes between these two. The soft grating felt in passing an instrument through an old tough stricture must not be mistaken for a calculus. If, as the catheter is jiasscd, a sudden flow of pus occurs, it shows that a periurethral abscess has been opened ; these are most commonly prostatic, but the position of the abscess is easily ascertained by the detection of swelling. If on passing a catheter the shaft is found to deviate from the middle line, or the instrument passes in to its full length without reaching the bladder (except in cases of prostatic hypertrophy), pass the finger into the rectum, and if the catheter is felt to be very super- ficial, or to one or other side of the middle line, it has entered a false passage. If, when the surgeon is trying to overcome an obstruction, the catheter suddenly slips on with a soft grating sensation, and blood escapes, he knows that he has made a false passage ; an instrument is never grasped by a false passage as it is by a stricture or by the compressor urethras muscle. Examination of the proslalc. — The condition of the prostate can be investigated (a) by digital ex- amination with the finger in the rectum, (b) by the passage of catheters or bougies, (c) by the cystoscopc, and (d) by the X-rays. The facts to Ijc noted are its size, shape, and consistence, its mobility in the pelvis, its tenderness, and its opacity to X-rays. The following affections of the prostate can be diagnosed : Acute prostatitis is diagnosed if a patient who has or has recently liad acute urethritis complains of 690 SURGICAL DIAGNOSIS [chap. deep-seated perineal pain, and a finger in the rectum finds the prostate to be uniformly enlarged, hot, and tender. If in a similar case the swelling of the prostate is soft and fluctuating, there is a frosiatic abscess. Retention of urine may occur in eitlier of tliosii conditions. Acute jirostatitis may also follow clumsy instrumentation. Chronic prostatitis is a common cause of gleet. It is to l)e diagnosed if in a patient with a chronic urethral discharge the pi'ostate is felt to be slightly enlarged, and massage of the gland with the finger in the rectum causes a diminution in size, and the first few ounces of urine passed immediately after contain flakes of dischai'ge from the prostatic crypts. Prostatic calculi rarely give rise to marked symp- toms. The diagnosis is usually made either by their being felt by the finger in the rectum or by the characteristic gratmg on passing a catheter. Their presence can l)c shown by the X-rays. Chronic enlargement of the prostate. — If a patient over 50 years of age complains of difficulty of mic- turition, delay in starting the act, and of frequency more marked by night than during the day, and the passage of a catheter, other than a large coude, is difficult and reveals increase in length of the urethra, and the presence of more or less residual urine, chronic enlargement of the prostate is to be suspected. The diagnosis is confirmed if the pros- tate is felt to be definitely enlarged, or if the cysto- scope I'eveals a projection into the bladder just behind the internal meatus. If the enlarged glaud has a smooth surface and is movable in the pelvis, it is an iidenomalous or simple enlargement. If, on the olli.T hand, the prostate is very firm, irregular, and nodular, and the lateral limits of the gland xLviii] EXAMINATION OF BLADDER 691 are ill dclined and it is Hxcd, the eniargeuient is due to carcinoma of the prostate. One or iTiore of the following complications of enlarged prostate are commonly present, and their symptoms are then added to those enumerated above, viz. ha;maturia, cystitis, retention, and vesical calculus. It is to be noted that haiiiiaturia occurs earlier and is more profuse in simple tluui in malig- nant enlargement of the gland. Exsiniiiiatioii of Ihc bhithler.— In addition to the oidiiiary methods of examination by palpation, percussion, etc., the condition of tiic bladder may be investigated by the passage of instruments, especi- ally the sound, by the X-rays and the cystoscope. The proper use of this latter instrument is attended by no risk to the patient, and the information it is capable of yielding is so important that its use should be a routine measure in the diagnosis of vesical and also of renal affections. The following affections of the bladder may be met with : Ectopia vesicse is a congenital abnormality charac- terized by failure of development of the anterior vesical wall, and separation of the pubic bones. The bladder appears as a raw red surface discharging mucus, on which the two ureteric orifices are to be seen dribbling urine. The external genitals are always grossly abnormal. Sacculus of the bladder may be a congenital con- dition or may be acquired secondarily to stricture of the urethra or other condition. It may be found in a hernial sac, or appear as a dull cystic swelling above the pubes, not altered when the bladder is emptied by a caJheter, but discharging urine by the catheter when pressure is made on it; or it may be seen in a cystoscopic examination. In cases of fi02 SURGICAL DTACtNOSTS [citap. doubt the bladder should be filled with collargol or sodium bromide solution and then examined with the X-rays. Acute cystitis is diagnosed when the