MEDICAL GAZETTE VOL. XLIX FEBRUARY, 1914 No. 2 ORIGINAL COMMUNICATIONS. A GROUP OF CASES DIAGNOSED BY THE CYSTOSCOPE.* BY LOUIS RENE KAUFMAN, M.D., Asst. Attending Surgeon Flower Hospital; Attending Physician French Day Nursery: Lecturer on Surgery, New York Hom. Medical College and Flower Hospital Lecturer on Surgery, New York Medical College and Hospital for Women. Cystoscopic procedures in the study of most kidney and bladder diseases as well as in the diagnosis of certain other obscure cases offer us a large field of observation. In reviewing certain cases I have omitted detailed discussion of the technic involved in diagnosis except for a more complete description of the plan followed in the case of vesico-utero-vaginal fistula because in this case it was necessary to adopt an original method, which I have not seen described. In reviewing some of these cases we are struck by the fact that the urinary tract may provoke reflex symptoms as well as the other great organs of the abdomen and pelvis, and that the abdomen. contains the kidneys and ureters, in close proximity on the right side to the appendix. At least two of the cases show the necessity of care in diagnosing appendicitis because of pain and abdominal rigidity, an error which is so well-known and yet not uncommon. In these cases if the diagnosis is at all uncertain the urinary tract should be investigated if there are any symptoms referable to it, such as disturbances of micturition or frequency, even though these symptoms may seem secondary. We have met a number of these cases in the female sex, especially, and there is no doubt in my mind that we should have been unable to make a diagnosis without the cystoscope in many of them. I know of no way to recognize stricture of the ureter other than by operation, and without operation through the cystoscope. The early symptoms of tuberculosis in this part of the body are indefinite. and vague, as the abundant literature on the subject shows. In all Presented with skiagrams and drawings before the Homœopathic Medical Society of the State of New York at Syracuse, October 14, 1913. these cases the cystoscope offers us invaluable assistance with its procedures for urological diagnosis, and we may often come to a definite conclusion by simple tests. Case 1. Miss M. M., 27 years of age, had a sharp attack of pain in the right lower abdomen with a dull, heavy ache running through to the back; seat of maximum pain at McBurney's point, accompanied by slight abdominal rigidity, more marked on right side, some nausea; for a few hours a temperature of 99 or 100; normal blood count. History negative except that she stated that two years before she had fallen down a few steps in a sitting position, at which time for a week she had a slight increase in the frequency of urination, and since, now and then a slight pain in her side. Examination was negative except for a slightly movable right kidney. She was relieved by lying down, and any straining exertion produced intense pain. A diagnosis of appendicitis was made by another physician, who advised operation, but I insisted on delay, for I was suspicious of kinking of the ureter produced by traumatic movable or a dislocated kidney. An immediate cystoscopy demonstrated a right ureter which would not admit any instrument but a fine whalebone bougie; it was readily dilated by the Blasucci catheter, the kidney previously having been manually replaced and strapped; the symptoms were instantly relieved. She still suffers from backache but refuses operation. The diagnosis was not appendicitis, but a dislocated kidney with kinking of the ureter. In this case the obstruction was functional. It may, however, be organic in type. It may be complete, with definite signs of hydronephrosis, or partial and slight enough to cause vague symptoms without any palpable hydronephrosis. In our cases presenting this lesion we have failed to measure the capacity of the renal pelvis which Schmidt of Chicago has shown may be done to good advantage. At any rate we are certain that some of our cases must have had, from our study of the ureter, such a paroxysmal hydronephrosis as to cause symptoms without any physical signs. Case 2. Miss K. S., aged 16, was admitted Feb. 3, 1912, to the Flower Hospital, service of Dr. Bishop; complained of abdominal pain and tenderness. She had suffered intermittently from this pain for several months; it was worse on any exertion, requiring rest in bed; it extended to the lumbar region posteriorly, radiated down and across the abdomen and had its maximum intensity at McBurney's point. The rest of the history was negative. I operated three hours after admission for acute appendicitis through a right rectus incision. The notes made by the anesthetist state that the appendix did not seem sufficiently inflamed to account for the symptoms and that the abdomen and pelvis were explored without discovering any lesion. Patient's convalescence from the operation was uneventful; but the pain and some other notes made then show that we had not the least idea of her condition. She was discharged in three weeks as neurotic. She returned on April 10, 1912, complaining of pain now almost continuous, and we failed to relieve her by various efforts made on the basis of a possible spinal condition, gastro-intestinal, etc. All examinations were negative, till finally the urine one day was found to contain a few red blood cells, some pus and a moderate number of cuboidal epithelia. I was asked by my senior, Dr. Bishop. to cystoscope her. The bladder was normal. and the left ureter easily catheterized, but I was unable to locate or penetrate the right ureter; Dr. Sprague Carleton had the same experience a few days later. A second attempt by Dr. Carleton was successful in locating the ureter, but the catheter was arrested an inch and a half from the mouth of the ureter. I made repeated efforts to dilate the canal, without any results. We demonstrated the point of obstruction by skiagrams taken of the pelvis with a Bismuth catheter in situ and an ordinary one injected with argyrol. (See fig. 1.) It had taken an operation and five weeks of observation during which time she was under the care of two services to make the right diagnosis, which was a stenosis of the right ureter. In May, 1912, Dr. Bishop performed a typical Israel operation befor the Alumni Clinic. Preceding the operation the ureter had been catheterized by Dr. Carleton, and a tight stricture was revealed at Fig. 1. Stenosis of ureter, congenital in type; the ureter would not admit any in strument through the stricture. The skiagram shows the Bismuth catheter arrested at the point indicated by the arrow which was the seat of a definite stenosis beautifully demonstrated by the operation, performed through a curved anterior abdominal incision, stripping the peritoneum off from the ureter for a distance of six inches. the point where the tip of the catheter was arrested. She was discharged cured, but some months later she stated that her pain had returned and I was unable again to penetrate the ureter, so that I think the stricture had returned; and she has since passed out of our observation. Turning now to a different variety of case I want to report two cases which represent forms of reno-vesical tuberculosis, a subject the diagnosis and treatment of which are occupying a great deal of attention. In these cases we may establish a diagnosis by cystoscopic procedures long before the condition can be recognized by the terminal symptoms which mean the later stages of the disease at a time when as in all malignant conditions cure is almost impossible. I have selected these two cases because they are very typical examples of puzzling cases. Case 3. Miss C. L., aged 21, admitted to the Flower Hospital on Feb. 2, discharged cured June 6, 1913, services of Dr. Bishop and Dr. Helmuth, referred by Dr. Fred. Mosser for the relief of pain in the right side of the abdomen, of gradual onset for the last few months. The pain radiated to the back, across the abdomen, with tenderness. She complained of insomnia, anorexia and physical exhaustion, and later we learned that for several weeks she had had some increase in urinary frequency. Family history negative. As a child had scarlet fever and measles, typhoid in 1910; a few months later an appendectomy had been performed, and in the following year had had two mastoid operations. Examination showed an arrested tubercular focus in the upper lobes, a distended abdomen slightly tender over the right kidney region anteriorly, right kidney movable; persistent low lecucocytosis of 14,000, with an average polynuclear count of 67 per cent. Noguchi test was positive (subsequent specific treatment had no effect whatever, including salvarsan). Skiagrams of the kidney and bladder and gastrointestinal tract were negative; the cuti test was negative. Two weeks after admission the urine showed a trace of albumin, increased indican, a few blood and pus cells and epithelial cells from the pelvis and tubules of the kidney; several examinations for T. B. were negative. A guinea-pig was inoculated with urinary sediment, but died too soon to permit of any conclusion. We performed an exploratory laparatomy through a right rectus incision which revealed a Jackson membrane with many enlarged lymph glands throughout the abdomen; after repair of the membrane we excised a gland for diagnosis, and Dr. Heitzmann reported it a typical tubercular lymph gland. Her recovery from the operation was prompt, without any improvement in her symptoms. The absence of any definite signs except proof of a tubercular focus led us to consider early tuberculosis of the kidney and bladder, the more so as she now began to complain of more marked increase in frequency and some dysuria. A cystoscopic examination showed a small, extremely sensitive bladder. The trigone was pale, more yellow than normal, with injected vessels with a cluster of tiny ulcers to the left and in front of the right ureter, as well as behind it. which were greyish white. The mouth of the right ureter was of the Fenwick golf-hole type. (Fig. 2.) The left ureter was normal. She failed to improve under all forms of palliative treatment, and on April 24 she was operated by Dr. Bishop. A typical nephoureterectomy was performed by the method of Lilienthal. The kidney was not grossly affected, but it was the seat of hyalin degeneration, of cloudy swelling, and the ureter contained two well marked ulcerations. She made a somewhat stormy recovery, but on her discharge six weeks after operation she was free of pain, vastly improved and since then has maintained this improvement; the bladder when examined in August was healed and was no longer sensitive. The only functional test made in this case was to examine specimens from the two kidneys, which showed that the urine of the left or presumably sound kidney contained no albumin and no sediment, urea 1.4, while that of the right contained a trace of albumin, blood, pus, epithelia from the kidney, its pelvis, and urea 1.3 per cent. We felt that the left kidney could carry on the work of both, and removal of the right would cure the vesical lesion. 1 Case 4. Mrs. V. V., Italian, aged 28, was admitted June 9, Fig. 2. Tuberculosis of Bladder, secondary to lesion of kidney and ureter, unilateral. From a water color made by Dr. Philip Schmahl of New York from direct view through the cystoscope. The ulcers are seen clustered about the mouth of the right ureter; a catheter is shown in the ureter which has the induration and peculiar pathological change designated as the golf-hole ureter, pathognomic of renal tuberculosis. cured of all vesical lesions by nephrectomy. L'atient |