Urology

“ So long as this sheath is not cut where it covers the sides of the prostate, urinary infiltration of the pelvis{258} is impossible, the urine being carried forwards and fairly out of the pelvis in this urine-tight funnel.
Fig. xxxiv. [150]
But it may now be said, If this be the case, we are very much limited in the size of the incision we may make into the bladder. We cannot remove a large stone, for the prostate ought not to be larger than a good-sized chestnut, and any cut we might make through a chestnut without cutting out of its side must be very small. Very true ”

“ In a person prepared for the operation the rectum is emptied by purgative medicine and an enema; and the bladder, which in a stone patient seldom contains more than eight ounces of urine, occupies the hollow of the flaccid or contracted rectum. Care has been taken not to distort these parts by the introduction of an instrument into the urethra, nor by more distention than was sufficient to preserve a general outline. ”

“ When urine contains a larger amount of chemical constituents than it can conveniently hold in solution, a certain quantity crystallizes out, and may be deposited in the kidney or in the bladder. If the crystals run together in the kidney the resulting concretion may either remain in that organ or may find its way into the bladder, where it may remain to form the nucleus of a larger vesical calculus, or, especially in the case of females, it may, while still small, escape from the bladder during micturition. ”

“ Use the steel catheter, insert it in the bladder through the urethra, and draw off the urine, or use the trocar and insert it through the abdominal wall in the median line just above the pubic bone, directing the end of the trocar into the bladder which lies just below the pubic bone and draw off the urine. It is seldom necessary to inject the bladder with fluid, as after the urine has been removed, we find from general experience that it is well supplied with fluid from the arterial injection. ”

“ The hinder part of the kidney is the predominant renal organ. There is a common uro-genital duct, into which a seminal vesicle, which is especially large in early spring, opens. This is the permanent condition of the frog. In the rabbit, for urogenital duct, we have ureter and vas deferens; the testes and that anterior part of the primitive kidney, the epididymis, shift back into the scrotal sacs, and the ureters shift round the rectum and establish a direct connection with the bladder, carrying the genital ducts looped over them. ”

“ When the stone falls into the neck of the bladder a sudden retention of urine takes place. Of those cut for the stone, children to the age of fourteen are the best subjects for the operation, on account of the softness of their bodies: old men are difficult to cure because ulcers of their bodies do not readily heal; and the intermediate ages have an intermediate chance of recovery. And again, those who have larger stones recover best because they have become habituated to the inflammation, whereas those who have smaller recover with difficulty for the opposite cause. ”

“ The urinary apparatus (consisting of the kidneys, ureters, bladder, and urethra) is known to be the principal emunctory for eliminating and voiding the detritus formed by the continual decay of the parts comprising the animal economy. The urine is this detritus in a state of solution. The components of urine are chemically similar to those of calculi, and as the components of the one vary according to the disintegration occurring at the time in the vital alembic, so do those of the other. ”

“ This done, he draws the penis gently along the catheter as the point is lowered to the perinæum, but without raising his right wrist until the instrument has travelled 5 or 6 inches along the passage and reached the triangular ligament. The surgeon then carries his right wrist to the middle line of the patient’s body, and while pushing the point onwards, raises the hand round a curve till it again sinks between the patient’s thighs. When the bladder is reached he withdraws the stylet that the urine may escape. ”

“ The kidneys. 2. Ureters. 3. Bladder. 4. Aorta. 5. Inferior vena cava. 6. Renal arteries. 7. Renal veins. Structure of the Kidneys.—Each kidney is a compound tubular gland and is composed chiefly of the parts concerned in secretion. The ureter serves as a duct for removing the secretion, while the blood supplies the materials from which the secretion is formed. On making a longitudinal section of the kidney, the upper end of the ureter is found to expand into a basin-like enlargement which is embedded in the concave side of the kidney. ”

“ The nucleus, or kernel, of these concretions is always formed in the kidney, as above described; and passing down the ureter into the bladder, is there perpetually increased by the mucus and salts secreted from the arterial system, or by the mucus of the bladder, disposed in concentric strata. The stones found in the bowels of horses are also formed on a nucleus, and consist of concentric spheres ”

“ This collection takes place in the kidney, the ureters (the vessels that convey the urine to the bladder) , the bladder, and sometimes in the urethra. The stone so formed varies in its composition and size, and is one of the saddest ills that can befall human nature. Hence the importance of watching, and attending to every urinary disturbance, of which gravel forms a prominent feature, the treatment of which has been already stated; but which, as it involves more practised judgment than a non-professional invalid can be supposed to possess, had better be intrusted only to professional hands. ”

“ While, therefore, a calculus is only as urine precipitated and solidified, and this fluid only as calculous matter suspended in a menstruum, it must appear that the lithic diathesis is as natural and universal as structural disintegration is constant and general in operation. As every individual, therefore, may be said to void day by day a dissolved calculus, it must follow that its form of precipitation within some part of the urinary apparatus alone constitutes the disease, since in this form it cannot be passed. ”

“ When in the perinaeum it approaches the anus we must bend the penis with the instrument in it down to its natural position, for from the perinaeum to the bladder the passage is upwards, and we must push the instrument onwards till we reach the cavity of the bladder. ”

“ Perhaps the practitioner may be very anxious to discover a stone and have the glory of removing it, and is satisfied with feeling a rubbing or grating of the instrument; he cuts into the bladder, and to his dismay and discomfiture nothing is found. No foreign body may have existed; or perhaps some small particles of sand which gave rise to the feeling may have escaped detection, being carried off along with the urine and blood. ”

“ In some diseases the lustre of the eye increases, as in consumption. But if it decreases with the attack of violent disease, it indicates great debility and prostration.
Examination of the Urine. All medical authors and physicians of education, freely admit and even insist upon the importance of critically examining the patient's urine, in all cases in which there is reason to suspect disease of the kidneys or bladder. In chronic affections it is particularly serviceable, especially in derangements of the liver, blood, kidneys, bladder, prostate gland, and nervous system. ”

“ Fortunately this substance is rarely found in the urine. When present however it indicates liability to, or the actual presence of, a calculus or stone in the bladder. In division C is a representation of the deposits seen in the urine of those who are greatly debilitated. In division D are seen epithelial cells mixed with mucus.
Fig. 8.
In Fig. 8, division A, are represented the caudated cells from the deep structure of the bladder. The cells represented in division B are amyloid concretions, found where there is an enlarged prostate gland. ”

“ But in man and other animals furnished with incisors in both jaws, and in whom the allantois is wanting, the size of the urachus is so diminished, that although it rises from the fundus of the bladder as a single tube, it afterwards splits into innumerable fibres, which pass beyond the umbilicus together with the vessels, and carry the urine into the chorion, although the exact mode in which it does so cannot be demonstrated. ”

“ The part of the ureter itcpated in the hilum is dilated, and is named the pelvis of the 1 ney. In minute structure the kidney is the most complex gland in the body. Each of the papillae consists of a large number of straight tubes—collecting tubules-which open by pores on its surface. When these are traced into the pyramid, they are seen to divide several times, their line end-branches projecting in little tufts into the cortical matter at the base of each pyramid. ”

“ When a stone has advanced into the ureter from the pelvis of the kidney, it is sometimes liable to be returned by the retrograde motion of that canal, and the patient obtains fallacious ease, till the stone is again pushed into the ureter. ”

“ When the part becomes morbidly enlarged, it acts as a mechanical impediment to the passage of urine from the bladder, but from this circumstance we cannot reasonably infer, that while of its normal healthy proportions, its special function is to facilitate the egress of the urine, for the female bladder, though wholly devoid of the prostate, performs its own function perfectly. ”

“ Again, a general oozing may often appear a few hours after the operation, when the patient is warm in bed, apparently from the substance of the prostate. If raising the breech and the application of cold fail to arrest it, it may be necessary to plug the wound. This is done by stuffing it with long strips of lint round the tube. Great care must be then taken lest the tube become occluded.
3. Infiltration of urine may occur as a result of a too free incision of the vesical fascia (in adults) , and still more frequently of a too small external wound. ”

“ Had the ancients solid bladder sounds? They must have been well aware of the characteristic grating sensation conveyed to the skilled hand on striking a stone with a metal instrument, for we have several references in the classics to the manœuvre of pushing back, by means of a catheter, a stone impacted in the urethra. Rufus of Ephesus (Περὶ λιθιώσης κύστεως) says of impacted urethral calculus: ‘Those that are stuck fast push back with the catheter if you prefer not to do lithotomy’ (ἐρείδοντας οὖν εἰ μὴ θέλοις τέμνειν ἀπῶσαι τῷ αὐλίσκῳ) . ”

“ Operation.—A preliminary incision, varying in length according to the amount of fat, should be made above the pubis exactly in the middle line; the edges of the recti should be separated, the peritoneum pushed out of the way and upwards by the finger, and a curved trocar plunged into the distended bladder obliquely backwards. The canula should be retained for a day or two, and then a flexible catheter with a shield inserted instead. Such instruments have been worn for years. ”

“ The effete, nitrogenous and more solid matters of the urine are probably eliminated by these glandular appendages, which take upon themselves the function of the urinary tubules of the kidneys of the higher animals; while the other great chamber, the genital, receives the fluid, perhaps little more than water, that may be supposed to flow from the arterial capillaries of the various organs placed within it. Assuming this to be the case, then this chamber will be related functionally to these capillaries as the capsule of the malphigian tuft is to the capillaries of the tuft itself. ”

“ The kidney is enclosed in a rigid metal box, the arrangement being such that while the organ can freely expand or contract, and while the changes in volume are recorded by a lever writing with a light glass pen upon the kymograph paper, no obstruction is offered to the entrance and exit of blood by the renal vessels nor to the outflow of urine by the ureter. ”

“ Stain other specimens with hæmatoxyline or alum carmine to reveal the nuclei.
Stratified squamous epithelium.—Specimens from skin of various parts, finger, groin, lip, tongue should be prepared. Harden in Müller’s fluid.
Transitional epithelium.—Occurs in the pelvis of the kidney, ureter and bladder. It is very readily detached, especially if not hardened immediately after death. Remove as early as possible. If the bladder is taken it should be cut open and pinned out as flat as possible. Harden in osmic acid, or Müller’s fluid and spirit. ”