Kummel has made a study of the freezing-point of the blood in 265 persons, including 137 subjects with normal renal functions. If the freezing-point remains within normal limits, .55 to .57, in a case of unilateral nephritis, the kidney can be removed without apprehension; that is to say, the other kidney is doing compensatory work. In 40 such cases recovery was uneventful and the renal function undisturbed, while every case in which the freezing-point was .59 exhibited a sluggish renal function afterward and also albuminuria.

These facts are further established by the results in the cases in which the freezing-point was .58 to .81. The assumed renal insufficiency was confirmed in every instance by the autopsy or operation. Nephrectomy is still possible at .59, but .60 is the extreme limit of permissible nephrectomy. It has been found in nearly all the cases when the freezing-point of the blood is low, that of the urine will be high. Urinocryoscopy with ureteral catheterization and urine separation has been of the very greatest aid in the clinical experience of the writer.

The freezing of the urine is a comparatively simple matter. At least sufficient urine to cover the bulb of the thermometer should be used. The Beckmann apparatus is probably the best instrument. The freezing should be done while the urine is fresh.

In two cases of tubercular pyonephrosis, in one case of a suppurating cyst of the kidney, in one of pyelitis and infected hydronephrosis, the functionating capacity of the supposed healthy kidney was ascertained by urinocryoscopy. All of these cases showed a renal sufficiency. Nephrectomy was done in each case, and all made good recoveries. An equally good result was obtained in a case of nephrotomy.

In two cases, one of hemituria and one of pyuria, operation was advised against because of renal insufficiency. The justification of this advice was demonstrated when both cases succumbed to uremia, one 10 days and the other three weeks after the examination.

In a goodly number of cases pus has been demonstrated in one or the other kidney, but in all the cases a good functionating capacity was present. The kidney substance was probably not much involved, the infection being in the pelvis. In such cases the administration of urinary antiseptics and washing of the pelvis have been of very great benefit.

The writer does not offer this method of cryoscopy as a substitute for the other methods of examination, for it in no way determines the anatomic condition as shown by the presence of pus, albumin, casts, red corpuscles, and microorganisms, but offers it only as an important supplement, and as the best known way at present of determining the functions of the kidney.

The deductions from a previous paper on the same subject are submitted in concluding:

Before doing a cutting operation upon the kidney, especially before doing a nephrectomy, the presence of a second functionating kidney should be established.

2. The best and safest method for ascertaining the presence of a kidney is by the aid of cystoscopy and ureteral catheterization.

3. The function of the kidney is best determined, in order of importance:

(a) By the freezing-point of the urine.

(b) By phloridzin glycosuria.

(c) By the freezing of the blood.

(d) By the quantity of urine excreted.

4. The most reliable method of obtaining the sepa

rate urines is by the ureteral catheter.

Prostatic Surgery

(Historic and Experimental)
(ABSTRACT)

BY BENJAMIN MERRILL RICKETTS, PH. B., M. D., CINCINNATI

PROSTATE

Anatomy: Two lateral and a middle lobe constitute the prostate which was first described by Home in 1806. The gland is not constant and is of many variations. Normally it is about one and one-half to two inches in its transverse diameter; one inch anteroposterior in diameter and one inch in depth. It is composed of Cowper's glands (each the size of a pea), numerous follicles and vascular tissues arranged to form about 20 channels lined with columnar epithelium (excretory ducts) through which a milky, slightly acid, fluid passes to dilute the semen. All vertebrates fecundate in the

same way.

The blood-supply is from the internal pudic artery. The venous blood enters the internal iliac vein through the dorsal vein.

The nerve-supply is from the hypogastric plexus, and the filaments of the sympathetic.

Etiology: Man is the only animal that has hypertrophy of the prostate. No definite cause is as yet assigned. Habits, disease and evolutionary changes from quadripedal to bipedal state is probably the most important factor.

"Prostatic hypertrophy is not found in Japan, India or China." (Otis.)

Surgery of Prostate: Ammonius Lithotomus, B. C., 460-357; Johnnesde Romanes, in 1555; Ran of Leydon and Frere Jean, in 1700, in operating for stone, no doubt contributed much to advance the various subsequent operations for prostatic hypertrophy.

Cystotomy may be said to have been inaugurated when the bladder was first opened for any purpose.

Both perineal and suprapubic drainage have been successfully accomplished with more or less benefit in hypertrophy of the prostate.

Massage was first employed by Estlander in 1878. Hogge claimed priority in the use of electric massage. Lewis in 1899 employed the finger and condemned instruments for this purpose. Neiswanger in 1900 employed cataphoric applications of iodin in hypertrophy of prostate.

Injection of various solutions, such as argentinitras, iodin and cocain, into the prostate, was done by Hall in 1887 with no special effect. Haurate in 1896 injected testicular extracts into the prostate.

Ligation of cord was done by Mears in 1894 without

effect.

Ligation of iliac arteries was done by Bier in 1893, and Meyer in 1894, while Loze, in 1898, removed the vesicovenus plexus.

Vasectomy was employed by Lonmean in 1895, since which time there have been several hundred such operations.

Steinart, in 1896, showed by experiments on rats that the removal of the seminal vesicles and prostate gland does not lessen the sexual passion or ability to perform the sexual act, with a discharge of spermatozoa, but that fertilization is prevented. The ability of the semen to fertilize is lessened by the removal of their vesicles. The operation of vasectomy has become obsolete.

Castration was first performed for prostatic hypertrophy by Mercier, in 1857, but was not again performed until 1893, when White, Ramm and Cabot did it. Removal of one testicle is supposed to cause its corresponding prostatic lobe to undergo atrophic changes while the removal of both testicles will cause atrophy of all the lobes. The operation was based upon the fact that Eunochs do not have prostatic. hypertrophy. Several hundred cases of prostatic hypertrophy have been subjected to emasculation with more or less benefit. It should be done in but a few selected cases, such as extreme age or lessening of vitality or before more radical

measures. The operation is seldom considered since the inauguration of prostatectomy.

Prostatotomy consists in incising the prostate by knife, cautery or otherwise for abscess, cysts, foreign bodies, injuries or pathologic conditions.

Tenotomy of Levator Prostate was first done by Wyman in 1885, and again by Andrews in 1902, with much beneficial result.

Urethral Prostatotomy: Incising the prostate through the urethra by knife, catheter and various other devices dates from Home in 1817, since which time many such operations have been done by as many different devices. Much benefit has been obtained from this method, but it is no longer considered rational.

Galvanocautery has been employed since 1875, when Rabitsch and Bottini reported the result of their work. The cautery was very seductive and attended by much mortality and uncertainty in its results. It is applicable, if at all, in but a few cases of a selected type. It cannot be considered a rational procedure as the cautery cannot be seen.

Perineal Prostatectomy is the removal of a part or all of the prostate gland through a median, transverse or lateral perineal incision.

Gibb's question, in 1857, was "cannot enlargement of the middle lobe of the prostate gland be removed by the lateral operation, for lithotomy?" This is one of the earliest suggestions for the removal of the prostate gland through a perineal incision.

Since this time many such operations have been made for this purpose, and there can now be no question as to this route and method being the most acceptable and beneficial operation for hypertrophied prostate.

RECTUM FOR URINARY RECEPTACLE

Ricketts, in 1902, in removing the prostate gland in two cases of emergency succeeded in diverting the urine into the

rectum.

L