mass.

dulness in the flank, and bimanual palpation reveals a swelling or indurated The urine is clear unless pyelitis is also present. In doubtful cases the use of the aspirating needle may be necessary for the diagnosis, and when pus is found the tumefaction must be incised and treated like any other abscess. A perinephritic abscess may be mistaken for appendicitis, empyema of the gall bladder, psoas abscess, or lumbago. When free drainage can be established the prognosis is good.

MOVABLE KIDNEY; FLOATING KIDNEY (NEPHROPTOSIS)

We recognize various degrees of abnormal kidney mobility. We speak of palpable kidney, movable kidney, floating kidney, and fixation of the kidney in an abnormal position. Floating kidney is rather common in women and is generally acquired, owing to the wasting of fat around the kidney or the relaxation of abdominal walls in consequence of repeated pregnancies and as an element of that general relaxed condition known as enteroptosis. The condition is recognized by means of bimanual palpation in the lying or standing posture. The patient aids in the examination by taking a deep inspiration, and when a kidney is quite out of place we notice a distinct flattening of the lumbar region on the side on which the kidney is loose or mobile. The recognition of a movable kidney in moderately nourished women, when a part or the whole organ can be palpated, does not present a difficult problem; but when the abdominal wall is thick, when the symptoms point to gallstones, impacted in the cystic or common ducts, or to a false or dislocated lobe of the liver, if the spleen or pancreas has become loosened, if the kidney is but slightly movable, if a third kidney is present, or if a congenital kidney presents, whether freely movable or attached to the false or true pelvis, when associated with gastroptosis, enteroptosis, uterine displacements, or other pelvic disorders, the diagnosis demands careful study. The displaced kidney can usually be felt as a tumor which can be replaced. The diagnosis of floating kidney should be made by palpation and never by the symptoms. The hepatic flexure of the colon has been mistaken for movable kidney.

Symptoms. Dyspepsia, with motor, sensory, and secretory neuroses of the various abdominal viscera, is noticed in cases of floating kidney, but it is also a common complaint of hysterical and neurotic individuals. Painful crises, mucous colitis, hydronephrosis, and intermittent albuminuria have disappeared after fastening a movable kidney. The relation of movable kidney to Bright's disease and to appendicitis is of interest. According to the experience of Edebohls chronic appendicitis is the chief symptom and most important complication of movable right kidney. A dragging sensation and a feeling of weakness are the general symptoms in movable kidney.

Treatment. When kidneys have become displaced from loss of fat in general emaciation, the patient may with benefit adopt the rest cure. Ordinary degrees of mobility can be benefited by wearing a plain abdominal supporter, or belt, which encircles and sustains the lower two thirds of the abdomen. All forms of apparatus with special kidney pads are useless or injurious. In lieu of a bandage a straight front corset which comes

SUMMARY OF DIAGNOSTIC POINTS IN KIDNEY LESIONS

485

low down and properly supports the lax abdomen can be worn to advantage. Such a corset is best applied when the woman lies on her back. A floating kidney may be anchored in its proper place by operative means (nephropexy), and torsion symptoms are the principal indications for operation.

SUMMARY OF DIAGNOSTIC POINTS IN KIDNEY LESIONS

Tumors. Tumor, pain, hæmaturia, cachexia, sarcoma in early life, carcinoma in later life.

Cysts. Tumor, pain, discomfort, cloudy urine, cyst fluid on aspiration. Cysts are congenital or acquired.

Hydronephrosis.-History of torsion or blocking of ureter; painless, fluctuating unilateral tumor may be bilateral.

Floating Kidney.-Pain, neurasthenia, recognition of displacement by examination.

Pyelonephritis (Surgical Kidney).-Irregular low fever, occasionally chills and high temperature, pyuria, cystitis, sometimes enlargement and tenderness to touch. History of obstruc

UE

FIG. 154.-SACCULATED PROLAPSE OF THE
RIGHT URETER.

The ureters are liable to become obstructed by calculi or constricting bands or by the pressure of tumors. They may participate in the ulcerative tuberculous processes of the genitourinary tract. Torsion and kinking of the ureters sometimes take place in floating kidneys and give rise to painful crises, known as Dietl's crises. In such cases one sided pain or colic is usually present. By means of the Harris segregator or catheterism of the ureters we may definitely ascertain which side of the urinary tract is involved. Injury to the ureters is possible in major pelvic and abdominal operations. Prolapse of the inverted

lower portion of the right ureter into the bladder and through the urethra, in a child two weeks old, was reported by the writer in the American Journal of the Medical Sciences for May, 1888.

Total extirpation of the ureter has been done in connection with extirpation of the kidney for malignant growths or calculous and tuberculous diseases (see case of Dr. Willy Meyer in the Jacobi Festschrift, 1900).

AILMENTS OF THE URINARY BLADDER

General Remarks.-The empty bladder lies behind the symphysis pubis. When the bladder is extremely full and distended, its percussion dulness may reach to and above the umbilicus. The neck of the bladder is surrounded by the prostate, and both are immovable. Suprapubic and rectovesical and vaginovesical palpation are readily performed. The introduction of the sound will determine the condition of the vesical walls or the absence or presence of calculi and foreign bodies.

Visual inspection is possible by means of the cystoscope. Digital exploration is possible through a suprapubic or perineal incision and in the female through the dilated urethra. Direct visual inspection of the bladder in women is best accomplished by Kelly's method with the patient in the knee-chest position.

Patent urachus, the remains of a foetal structure (see section on Pædiatrics).

Exstrophy of the bladder is an absence of its anterior wall with deficiency in the corresponding abdominal wall. This condition can be remedied by a plastic operation described in special surgical works.

Vesical diverticula are sometimes met with. Various injuries, such as contusions and perforating wounds, resulting in rupture of the bladder, are met with and are of a serious nature when extravasation of urine results. When rupture is suspected, a soft catheter should be introduced into the bladder. If the urine comes away bloody, a measured quantity of boric acid solution should be injected into the bladder. In case of rupture, the full quantity of liquid cannot be regained by catheterism, and immediate surgical treatment may become necessary. Inversion of the bladder through the female urethra has been observed. In such cases the viscus presents in the form of a bluish pink sac.

Vesical hypertrophy is seen in cases in which an obstruction to the flow of urine has developed gradually. When a fistulous opening between the bowel and bladder exists, foul gas and fæcal matter will be expelled with the urine. Vesicovaginal fistula may occur from childbirth and from injury.

Vesical neuroses and irritability of the bladder are usually of a reflex nature, depending upon disease of neighboring organs. A marked irritability of the bladder is occasionally observed in cases of appendicitis. Neurotic individuals, adults as well as children, urinate frequently. On the other hand, neurotic retention of urine is not uncommon. Retention is often observed after childbirth or following operations on the rectum and penis. The inhibitory effort is due to the dread of exciting pain. In such cases the application of a hot water bag is often efficacious. Noc

ACUTE CHRONIC AND ULCERATIVE CYSTITIS AND PERICYSTITIS 487

turnal incontinence in children is discussed in the section on Pædiatrics. In some neurotic individuals there may be a local irritation due to the deposit of crystals in the urine. When a cystoscopic examination is made in a case of irritable bladder, a localized hyperæmia of the trigonum is often found. In protracted cases of this nature a few applications of a 5 per cent solution of nitrate of silver directly to the red patches will have a curative effect.

Paralysis and atony of the bladder, with retention or incontinence, are met with in serious lesions of the central nervous system, as in locomotor ataxia and spinal sclerosis. The treatment for such conditions must be directed to the underlying cause, and when syphilis of the nervous centres is suspected, energetic antisyphilitic treatment is indicated. In cases of incurable incontinence a rubber urinal may be worn by the sufferer.

ACUTE CHRONIC AND ULCERATIVE CYSTITIS AND PERICYSTITIS Causes. Cystitis is due to chemical or mechanical irritation combined. with infection. Calculi, foreign bodies, unclean catheters, foul urine, tumors, and syphilitic and tuberculous ulcers are causative factors. Cystitis may be due to the extension of a neighboring inflammation, as in gonorrhoeal urethritis. Cystitis is occasionally a complication in the course of infectious fevers. In some instances an examination of the bladder shows nothing more than redness at the trigonum. In other cases the cystoscope will reveal ulceration or a bullous oedema of the mucous lining of the bladder. In chronic cystitis the vesical walls are usually very much thickened.

Ulceration in the bladder may be due to traumatism, thrombosis of veins, pus infection, syphilis, tuberculosis, or carcinosis. Hæmaturia is generally observed in such cases.

Symptoms. The symptoms of cystitis are characteristic; dysuria, pain on pressure over the pubic region, and cloudy urine loaded with bladder epithelia and pus cells or blood. The urine soon acquires an ammoniacal odor and may become putrid. Fever is usually present, and in a severe form the patient has chills. A vesical neurosis is often taken to be cystitis; in the former the urine is free of pus.

Differential Diagnosis of Cystitis and Pyelitis.-The reaction of the urine in pyelitis not associated with cystitis is acid. The white blood corpuscles in cystitis have a rounded contour, those from the kidney pelvis have distorted forms. In cystitis with marked pyuria the albumin rarely exceeds from 0.1 to 0.15 per cent. In pyelitis with little pyuria the albumin ranges from 0.15 to 0.3 per cent.

Treatment. The treatment is radical or palliative. In catarrhal cystitis with superficial simple ulceration, in which palliative treatment is of no avail, local cauterization may be indicated. Tuberculous ulceration may require direct local treatment in cases in which bladder irrigation with boric acid solution or with iodoform emulsion fails to give relief.

The radical treatment is directed to the primary cause. The palliative treatment consists of rest in bed, opium and belladonna suppositories, subcutaneous injections of morphine, and the free administration of warm drinks (flaxseed tea or peppermint tea). If the symptoms are urgent, it

may be well to irrigate the bladder by means of a fountain syringe and a soft rubber tube once or twice a day with some mild antiseptic solution, such as boric acid solution (2 per cent) or formalin solution (5 to 10 minims to a pint). In chronic cystitis vesical drainage and direct local treatment in conjunction with hygienic measures may be called for. Drainage may be effected through a perineal incision a suprapubic incision, or, in the female, through the vaginal fornix.

STONE IN THE GENITOURINARY TRACT

Concretions, or stones, are found in both sexes and at all ages in the kidneys, ureters, bladder, urethra, and occasionally the prostate gland and the seminal vesicles. The general symptoms of stone in the urinary

FIG. 155. FOR BLADDER IRRI

GATION.

nosis positive.

quire time, a good history, a physical and urinary examination, and possibly cystoscopy, radiography, ureteral catheterism, and exploratory incision.

Stone in the Kidney

In addition to the general symptoms just mentioned, the urine shows albumin and casts, the pain is often paroxysmal and intense, accompanied by nausea and fainting, and radiates downward into the thigh and the pubic region. Frequent micturition is generally present. A positive diagnosis is often impossible, unless the patient has been under observation for some time. Therefore surgical interference should not be hastily carried out except in cases of urgency and complete obstruction. Fine gravel may be passed for years without giving rise to marked symptoms, and gravel is occasionally found in the diapers of infants. An attack of renal colic is usually followed by a feeling of general prostration, and an aching pain is complained of in the region of the affected kidney.

Differential Points.-In biliary colic the pain is localized more toward the middle line and is apt to radiate into the back, and frequently there is jaundice. A floating kidney is made out by a physical examination. In some instances appendicular colic or intestinal colic may be confounded with renal colic, particularly in fat individuals. In such cases the correct diagnosis is made after a small stone is found to have passed with the urine. A stone in the ureter can occasionally be felt through a lax abdomen, particularly when the patient is examined under ether. Calculi in the ureter give the usual colicky and retention symptoms on one or on both sides. Impacted stones may cause ulceration and perforate through the ureters.