1: 5000 in place of boric acid. He considers that antiseptic bladder washings before the introduction of such an instrument as a cystoscope will sometimes obviate the necessity of resorting to antiseptic bladder washings after the removal of the instrument. His suggestions as regards the sterilization of instruments before performing lithotrity are of value. He recommends that the pumps be sterilized and placed in bottles filled with bichlorid solution, where they should be left until required. Just before operation the bichlorid can be removed and boric acid solution substituted as a washing-out fluid. He quotes Guyon as advocating silver nitrate 1: 5000 for sterilizing the pumps. Kraus has invented a glass pump that is now on the market that should be easily rendered sterile.

The measures advocated by Zuckerkandl for preparing the patient for the operation of litholapaxy are as extensive as those followed when a serious operation is to be performed. Beginning with the usual bichlorid solution, soap poultices, etc., disinfection of the hands of, and the wearing of sterile clothes by, the operator, he recommends the prolonged washing-out of the urethra and bladder with the boric-acid solution before the lithotrite is introduced; his general recommendation as regards the frequent washings of the bladder during litholapaxy are somewhat at variance with the recommendations of Chismore, quoted elsewhere. Zuckerkandl, who has written extensively on asepsis in connection with surgery of the urinary organs, recommends that, even for so simple an operation as urethrotomy, the antiseptic details should be the same as in operations of greater consequence.

Anesthesia. Ether is the safest for the more serious operations on the urinary organs. It is preferably given by the drop method. When possible, the services of a professional anesthetist should. be procured. We operated on the perineum several times under spinal anesthesia about ten years ago, but discontinued the procedure on account of a serious secondary hemorrhage occurring in one case some four hours after an external urethrotomy, due apparently to the after-effects of the anesthetic. Local anesthesia with 2 per cent. cocain and a chlorid of ethyl spray has been used, when necessity required, for the radical operation for the cure of double hydrocele and for perineal section. We

advise against the use of some of the more recently exploited local anesthetics on account of reports that have reached us of necrosis following after their use.

PREPARATION OF THE SURGEON

In private practice, if the work to be done is at all extensive, the precautions as regards asepsis are carried out with some difficulty. The frequent changing of sterile clothing during consultation hours is not a very practicable method. It is well, however, for the surgeon to wear a sterile gown; this need not, however, be when its use is indicated by the requirement of any particular case. It is a good plan to use sterile rubber gloves in all examinations, even for so simple an operation as the instrumental examination of the urethra or bladder. The general practitioner may find some of the foregoing

in accord with the directions laid down in the text-books on modern surgery, reference to which may furnish many valuable hints. A thorough asepsis and the use of antiseptic methods in the surgery of the urinary organs has undoubtedly done much to lessen the frequency and the severity of catheter fever. If the necessity for taking proper aseptic and antiseptic precautions in the surgery of the urinary organs is sufficiently borne in mind, benefit will accrue in two ways: first, by reducing the number of infectious conditions that may occur after urethral and vesical instrumentation; and second, because of the detail required for the proper carrying out of such precautions, by placing a curb on those who are overzealous in introducing instruments into the urinary canal.

CHAPTER IV

EXAMINATION OF THE URINE AND URETHRAL

EXUDATE

EXAMINATION OF THE URINE

The technic of urinary examination is now so fully discussed in numerous special text-books that, with the limited space at our disposal, it seems unnecessary to consider this subject in detail; our attention will, therefore, be devoted, instead, to a consideration of the value and application of urinary diagnosis.

There is, perhaps, no field of diagnosis in renal disease in which greater error may result than from the making of isolated urinary examinations, though they may seem to afford the most accurate and direct evidence as to the action of the kidneys. This possibility of error is largely the result of the fact that not only does the normal constitution of the urine vary markedly in different subjects, but it may vary also in the same subject under many differing physiologic as well as pathologic states. The urinary characteristics are also very largely and directly dependent upon the nature of the food and drink, a fact that is too frequently overlooked in estimating the significance of any urinary examination. Finally, it should not be forgotten that a diagnosis should never be based solely on the urinary findings, and that these findings are to be looked upon only as symptoms and considered with all the clinical aspects of the case. It must not, moreover, be overlooked that just as marked variation exists in the urinary picture as in any other of the symptomatic manifestations of diseases of the urinary passages.

Collection of Specimen. It is best, whenever practicable, for the physician to secure the specimen himself, receiving the same in a clean vessel, and, when desired for bacteriologic examination, under sterile precautions. Very serious errors in diagnosis and in subsequent treatment have followed a lack of attention to these manifestly important details. Unusual foreign substances in the urine should always be looked upon as contaminations until they can definitely be shown to have actually been voided by the

patient. When considerable importance is to be attached to the urinary analysis, a statement of the patient's diet should be furnished with the specimen. In every case the specimen selected for examination should, if possible, be taken from the entire twentyfour hours' urine, the total quantity of which should further, of course, have been determined.

Only

When considerable time must elapse between the collection of the specimen and the examination, the urine should be kept in the ice-box or a few grains of chloral should be placed in it. Chloroform or formalin may also be added for the same purpose. Amount. The amount of urine passed should always be considered in conjunction with the quantity of liquid nourishment taken and also with the water excreted by the bowels and skin. when these factors have been considered may the quantity of urine passed be regarded as a means of pointing out possible disease. In important cases a fluid and urine chart is very useful, since it graphically demonstrates any gross retention and at the same time is a most excellent control of the effects of treatment in local or general edemas. The amount of urine may vary normally between 800 c.c. and 3000 c.c. in twenty-four hours, this being dependent somewhat on the sex and the body weight; a fair statement of the average amount would be about 1500 c.c. Pathologic polyuria occurs in diabetes, both with and without glycosuria, and in interstitial nephritis. A temporary polyuria is a frequent accompaniment of many nervous and mental disorders, of shock, and of like conditions.

Decrease in the amount of urine is found in practically all conditions where blood pressure is lowered, as, for example, in various types of cardiac insufficiency. It is a very marked symptom of acute nephritis, where it may amount to actual suppression, and it is also seen in many nervous conditions, as in some cases of hysteria, epilepsy, and the like. As has been stated, it is of the greatest importance always to consider the quantity of urine excreted in connection with the amount of liquid ingested and that excreted by other emunctory organs.

Specific Gravity. The specific gravity of urine is very closely associated with the amount excreted and with the total solids thus thrown out of the body. It may, therefore, be taken more or less accurately as a measure of the solids excreted. In order

that conclusive data as to the excretion of solids may be drawn from an examination of the urine, by any method, it is absolutely necessary that the entire twenty-four hours' amount be collected and the specific gravity determined from this.

Reaction. The reaction of the urine is normally acid. It may, however, become amphoteric, neutral, or alkaline under the influence of medication, from the use of certain foods, and under some physiologic as well as in many pathologic conditions. In itself the reaction of any individual specimen has but little importance. When, however, the reaction of the fresh entire twentyfour hours' specimen is altered, the cause for this change must be ascertained. For example, after severe nervous strain, especially if prolonged, the urine may become intensely acid, due to excessive excretion of acid phosphates. A diet almost purely vegetarian leads, in many cases, to the excretion of an amphoteric or alkaline urine, whereas a diet rich in animal food, as a rule, gives rise to a highly acid urine. Frequently the reaction of the urine may cause more or less marked disturbances. Thus a highly acid urine may account for vesical irritation and for frequent and painful urination. Less often a strongly alkaline urine may cause similar manifestations. Where the reaction of the urine only is at fault, the condition is usually easily corrected by giving attention to the diet or by simple corrective medication.

URINARY CONSTITUENTS

Urea. The amount of urea present in the urinary output should be determined as a matter of routine in all urinary examinations, for this substance is the most important element given off as a result of nitrogenous decomposition in the human body. Unfortunately, the amount of urea excreted under various physiologic as well as pathologic states varies, being largely associated with the amount of nitrogen thrown out in the form of other nitrogenous compounds, such as uric acid, kreatinin, xanthin bases, and the like; the total nitrogenous metabolism of the body can therefore be accurately estimated only when the presence of all these are determined, as by the method of Kjeldahl. For comparative clinical use the methods of urea determination as obtained by the Doremus or the Einhorn ureometer are sufficiently accurate in most cases. The amount of nitrogen ingested and the relative