Curettage was performed at Kings County Hospital, Brooklyn, from
which she was discharged after six weeks. Had lost much flesh.
On admission, September 2, 1901, the following facts were noted .
Patient emaciated; internal organs apparently normal. In the right
lumbar region a mass the size of a child's head could be felt. It Avas
movable, liard, non-fluctuating, tender, and kidney-shaped. Bi-
manually it could be ballotted between loin and anterior parietes.
Rectal and vaginal examination yields negative results. Pulse and
temperature normal. Urine pale, 1006 ; albumin ; mueli pus and epi-
thelia ; no casts ; urea 1 per cent. ; daily quantity of urine, 20 ounces.
Attempt was made to determine the kidney sufficiency of the left
side, but no positive result of the examination followed. Cystoscopy.
Turbid, purulent urine descending from both ureters.
September 6 : Nephrectomy. Lumbar aspiration of the tumor
yielded seropui'ulent fluid. Lumbar incision. Peritoneal reflection
exposed, peritoneum opened, and other kidney felt and paljiated.
Difficult development of the kidney, which being delivered, the pedicle
was secured by a rubber ligature and the organ ablated. Mikulicz
tamponade: drainage and usual closure of wound. Duration of
operation, forty minutes.
166 MOUNT SINAI HOSPITAL REPORTS.
September 7 : Patient very restless. Has not reacted well from the
operation. Great thirst; tongue dry; pupils dilated. Temperature
103.6°, pulse 144. Quantity of urine, 21 ounces, heavily charged
with pus, containing also hyaline and granular casts; urea 1 per
cent. The condition declined continuously in spite of energetic
stimulation.
September 10 : Died.
Postmortem.— heh kidney markedly lobulated; capsule not ad-
herent ; marked degeneration ; acutely congested ; cortex swollen and
contained numerous hemorrhages. Peritoneum normal.
Comment. ~lt was evident that in this patient we had to deal with
a bilateral kidney affection, as punilent urine was seen descending
from both ureters. The right kidney appeared to be the more seri-
ously involved, and, as the patient was daily losing ground, some-
thing had to be done to radically relieve her. It was impossible
from urea estimation and amount of urine to determine the separate
kidney sufficiency. In the attempt to relieve the patient by removing
the right suppurating organ, the left kidney proved itself insufficient,
and death resulted.
1901, vol. iii., page 186. — Clara S., married, 21 years old, one child.
Was perfectly well until six months ago, when she began to suffer
from what was declared to be malaria. She has missed her last
three periods. Had morning nausea and vomiting, and frequent
micturition, considering herself to be pregnant. Three days ago
developed severe pain over left hypochondriac region; the following
morning had chill with rise of temperature to 102° ; a second chill
the following night. During this the right lumbar pain was very
acute. Felt continuously nauseated: vomiting frequently. Had
passed no urine voluntarily for three days. Had been twice catheter-
ized ; both times one ounce of pure pus was withdrawn.
On admission, March 5, 1901, a very pale and anemic body was
observed ; facial expression anxious ; patient exhaling a urinous odor.
Uterus about the size of a large fist; position that of normal ante-
flexion. To the right of the uterus a painful mass of the size of a
hen's egg can be felt. The left hypochondrium and lumbar regions
occupied by a large, rounded mass, which was also painful on
handling. Pain is elicited on bimanual pressure over the opposite
loin, though it is not as acute as on the other side. Dry pleural
friction sounds at bases of both chests. Bladder absolutely empty.
A preliminary diagnosis of acute suppression of urine was made, its
presumable cause being a pyonephrosis of the left side and a reflex
anuria of the right kidney.
Immediate double nephrotomy. Operation commenced under local
anesthesia and was continued and finished under chloroform. After
infusing the skin and deeper tissues with eucaine and Schleich solu-
GERSTER: REPORT OF THE FIRST SURGICAL DIVISION — 1901. 167
tion, the left loin was opened by a four-inch incision ; the patient
complained bitterly, and chloroform was given ; the kidney being
exposed, it was found enlarged, its pelvis dilated. An incision through
its convexity permitted the escape of two pints of turbid urine.
Rubber tube drainage, and packing. The patient being turned over,
a similar incision exposed the right kidney, with the intention of
splitting its capsule. It was found contracted, exhibiting a softened
area, from which a quantity of pus was voided by incision. There-
upon the entire kidney was split, permitting the escape of pus from
several cavities. Rubber tube drainage, packing, and large external
dressing. Time of operation, one hour ; chloroform anesthesia, thirty-
five minutes. The patient bore operation very well.
March 6 : No urine found in bladder. Escape of bloody mucus
from vagina. Incomplete abortion. Nine a.m., curettage under chlor-
oform. Intravenous infusion. Temperature almost normal, pulse
about 100. Very copious urinous discharge from both wounds.
March 10 : Packings renewed. No urine passed from bladder.
March 11: Temperature 103°. Urinous discharge still copious.
The urinous discharge from the wounds continued to be very copious.
On account of the continued fever, on March 18 right nephrectomy
was done. The previous incision being sufiEiciently enlarged, the
kidney was, on account of dense adhesions, developed with consider-
able difficulty ; elastic ligature around pedicle ; ablation of kidney ;
drainage and usual dressing. The removed organ consisted almost
entirely of fatty and fibrous tissue. Of the parenchyma, only the
rudiments of a few papillae could be identified. Intravenous infusion
following operation.
March 19 : Passed for the first time 3 ounces of urine from bladder,
then passed 5 ounces. Urine contained a thick sediment. The healing
of both wounds progressed satisfactorily.
March 31 : Passed small amount of urine voluntarily.
April 1 : Passed urine voluntarily four times, each time 3 ounces ;
the rest of the urine passing through the wound.
April 7 : Ligature cast off. Out of bed. Passed 39 ounces of urine
which was fairly clear; reaction neutral; 1014; trace of albumin; no
sligar; 1.6 urea; no casts; a few pus and epithelial cells.
April 14 : Tube withdrawn from left kidney.
April 21 : Wound healing rapidly. No urinary leakage from sinus.
Passes between 30 and 40 ounces of urine daily.
Discharged cured May 8 in excellent condition.
1901, vol. iii., page 191. Actinomijcosis of Kidney with Secondary
Perforation into Perinephritic Tissues and Descending Colon; Ne-
phrotomy and Drainage of Perinephritic Tissues: Death.— Helen S.,
18 years old; lady's maid. Was ill seven weeks; during the first
four she was in bed on account of fever, which was declared to be
typhoid. Had been suffering with a dull pain in the back, especially
marked on left side. During the remaining three weeks she felt better
168 MOUNT SINAI HOSPITAL REPORTS.
and was out of bed. Three days ago she had a sharp attack of pain on
left side with fever and chill. Noticed nothing abnormal about urina-
tion.
On admission, May 12, 1901, temperature was 102°. pulse 108. Her
condition was fair, somewhat anemic. Internal organs apparently
normal. In the left loin a rather superficial fluctuating tumor was
observed, extending so far forward as to be visibly raising the an-
terior abdominal parietes. This mass was not influenced by respira-
tion, and the transverse colon was occupying its lower border.
May 10 : Large perinephritic abscess was opened, containing
granules which proved to be actinomyces. By means of usual oblique
incision, a very large quantity of extremely fetid fecal pus was
evacuated. The cavity being widely opened and cleansed, the kidney
was exposed and aspirated, pus of the same character being gained.
The kidney Avas widely opened and a drainage tube was inserted.
A communication with the descending colon was also noticed, and
the entire Avail of the abscess cavity was gangrenous. The subse-
quent course of the illness was characterized by extensive necrosis
of the connective tissue and a continued sepsis. An extremely fetid,
fecaloid, and seropurulent discharge gradually undermined the
patient's strength, and she succumbed June 16. Actinomycosis
granules were continuously dischai^ged in the pus.
Postmortem not permitted.
1901, vol. iii., page 192. Sarcoma of Aberrant Suprarenal Body;
Neplirectomy ; Cure. — Yetta E., 56 years old. Present trouble began
four months ago Avith sharp pains in right lumbar region, radiating
doAvnAvard to groin, accompanied by the Avoiding of bloody urine.
She had to stay in bed for se\^eral days during this attack. Since
then similar seizures have appeared at shortening intervals, the patient
losing strength and flesh A'isibly.
Admitted June 2. 1901. General condition aa^cII nourished: some-
Avhat anemic. Temperature and pulse normal. Skin slightly icteric.
Internal organs normal, except the heart, AA-hich shoAved a soft-bloAAung
murmur at apex, extending oA'er pulmonic area. In the abdomen, and
occupying the right loin, and extending forAvard to Avithin one inch
of the umbilicus, Avas a large, nodular mass. It could be easily man-
ipulated bimanually, AA'as fairly moA^able, and occupied evidently the
retroperitoneal space. Per A^agiuam and rectum nothing abnormal.
The urine betAveen 25 and 35 ounces in daily amount; contained al-
bumin, many red cells, no pus, no elemeiits suggestive of neoplasm.
June 3 : Multiple aspirations Avere made, but blood only AA^as ob-
tained. Temperatures normal, pulse normal. Diagnosis: Neoplasm
of kidney.
June 7: Nephrectomy, gas and ether anesthesia. Oblique lumbar
incision on right side. A large hematoma Avas found occupying the
place of the exploratory aspirations. In liberating the kidney the
peritoneum Avas accidentally opened and immediately closed. On
GERSTER: REPORT OF THE FIRST SURGICAL DIVISIOX — 1901. 169
account of the necessity of giving the tumor a wide berth, the perito-
neum was injured a second time. The pedicle being exposed, its
vessels were separately deligated with silk. Then the whole mass was
firmly withdrawn, and a rubber elastic mass ligature was placed as
high up as possible and well away from the kidney, which was then
cut away. Mikulicz packing and closure of anterior angle of wound
with button sutures.
Uneventful recovery followed ; urine was bloody until June 10 .
after that it became perfectly clear. Ligature came away June 28.
Discharged cured July 28.
1901, vol. iii., page 183. N ephroptosis ; Declined Operation; Unim-
proved. — Josephine G., farmer's wife, 48 years old. Had three chil-
dren. Operated on four years ago for polypus uteri. Had suffered
for past nineteen years from dragging pains in right side of abdomen,
where she noticed a movable mass. This dragging pain is occasionally
augmented to paroxysmal severity and is then accompanied by
vomiting.
On admission, June 4, there was found a poorly nourished body,
markedly anemic, internal organs all apparently normal. Abdomen :
In right hypochondrium and iliac region a smooth, kidney-shaped,
and movable mass is to be felt ; this can be pushed back well into the
loin, where it remains until the patient assumes the upright posture.
Eectal and vaginal examination negative. Pulse and temperature
normal. Evidently we had to deal with a condition of nephroptosis,
accompanied by the usual neurasthenic symptoms. As we could not
give an assuring prognosis as to complete recovery, the patient de-
clined surgical treatment and on June 7 Avas discharged unimproved.
DISEASES OF THE MALE
GENITAL AND
DIED, 3.
URINARY ORGANS. TOTAL, 36;
Gonorrheal cystitis and urethritis 1
Cystitis; retention of urine; enlarged prostate.. 1
Perivesical and perirectal abscess 1
Periureteral abscess; prevesical abscess; ischio-
rectal abscess; sepsis 1
Foreign body in bladder 1
Vesical calculus.* 1
" " and hemorrhoids 1
Hematuria (tumor of bladder?) 1
Papilloma of bladder (renal calculus?) 1
Torsion of undescended testicle; congenital in-
guinal hernia 1
Varicocele 4
" atrophy of testicle 1
Hydrocele 1
Epididymo-orchitis, traumatic , 1
170
MOUNT SINAI HOSPITAL REPORTS.
Epididymo-orchitis, gonorrhoic 2 2
" " seminal vesiculitis, gonor-
rhoic 1 1
Tuberculosis of testicle 4 3
" " " seminal vesicles and
prostate 1 1
Complete denudation of skin of penis 1 1
Periurethral abscess 1 1
" " prostatic abscess 1 1
Urethral calculus 1 1
Stricture urethrae (deep) 3 3
Hypertrophy of prostate gland; catheterism. . . . 1 1
" " " " retention of urine;
sepsis 1
Prostatic abscess: gonorrhea 1 1
Epithelioma of glans penis: stricture urethrae;
scrotal fistulae; pyelitis, bilateral; cystitis... 1
Operations on Male Urinary and Genital Organs— 29 ; 3 Deaths
Cystoscopies:
Incision and drainage of perivesical and peri-
rectal abscesses 1 . . 1
Incision and drainage of prevesical, periureteral,
and ischiorectal abscess 1
Incision and drainage of periurethral abscess... 2 2
" " " " prostatic abscess 1 1
Suprapubic cystotomy for foreign body in
bladder^ 1 1
Suprapubic cystotomy for calculi' 2 2
" " " cauterization of dif-
fuse vesical papilloma 1
Suprapubic cystotomy for retention of urine; en-
larged prostate 1
Suprapubic cystotomy for drainage V
Median perineal section for calculus lodged in
posterior urethra 1 1
Ablation of twisted undescended testicle; Bas-
sini's operation for hernia 1 1
Ablation of atrophic testicle 1 1
" " tubercular testicle 3 3
" " " " with removal of
vas deferens, vesicle, and one-half of pros-
tate 1 1
Resection of veins for varicocele 5 5
Plastic operation for restoring skin of penis. ... 1 1
External urethrotomy for stricture urethrae 1 1
" and internal urethrotomy for stricture
urethrae 2 1^
Bottini's operation for hypertrophic prostate... 1 1
Partial amputation of penis for epithelioma. ... 1'
'Closure of bladder by Kader's method, with drainage.
-In one case the bladder was at once closed by suture.
'In the same patient three operations were performed at one sitting; the
fatal issue is recorded under the "partial amputation for epithelioma."
GBRSTER : REPORT OF THE FIRST SURGICAL DIVISION — 1901. 171
Suprapubic cystotomy was performed six times, lii two cases the
wound in the bladder was at once closed by three rows of buried
catgut sutures, passed Lembert fashion through all the coats but the
mucosa. Our experience has been that this method of suture serves
as well as any to bring about primary healing of the bladder wound.
In the two eases in which it was employed during the past year,
primary union occurred in one ; an infection of the suture line in the
other interfered Avith faultless primary union. In those cases where
only temporary drainage of the bladder is required, the wound in the
bladder is closed in the usual fashion, except at one angle where suffi-
cient space is left for the introduction of a good-sized drainage tube.
Around this tube the margins of the opening are inverted, Kader
fashion, by two or three purse-string sutures of chromicized catgut.
After withdrawal of the tube, the walls of the cylindrical channel
thus created collapse and so prevent escape of urine.
Bottini's operation for hypertrophic prostate was performed once.
The case affords a brilliant example of the beneficial effects that can
be accomplished by this operation. Thus far our experience is too
limited to permit of drawing any conclusions as to the special indi-
cations calling for its performance in preference to prostatectomy, or
as to the comparative merits of these two operations.
The history of this patient follows :
1901, vol. iii., page 225. Hypertrophic Prostate; Bottini Opera-
tion; Cured.— J. B., 72 years old, admitted February 27, 1901. Had
been leading a catheter life for six months. Catheterization had
become so very difficult during the three weeks before his admission
that the patient himself begged for something to be done.
The preparation for the operation consisted in the administration
of urotropin in fifteen-grain doses three times daily. The urine
was acid, 1082, contained a trace of albumin and much pus. It was
impossible to wash out the bladder regularly, on account of the
difficulty in passing a catheter. Residual urine, 16 ounces. The
patient was otherwise healthy; his temperature was normal, pulse
rate 72. The prostate was large, nodular, and firm; the right lobe
more enlarged than the left.
March 1 : Bottini 's operation under ChCl., anesthesia. Air dis-
tension of the bladder. Posterior incision of the prostate, 314 cm.
Two lateral incisions of li/o cm. each. Slight hemorrhage. Irriga-
tion of the bladder. Drainage with large-sized English catheter.
Chill immediately after operation ; repeated twice within the next
twenty- four hours. Temperature rose to 104.4°, pulse 88-90.
March 2: Temperature between 99° and 100°, and never rose be-
vond 100.2°. Passed 86-58 ounces of urine daily. No more chills.
172 MOUNT SINAI HOSPITAL REPORTS. •
March 3 : Several sloughs came away from the prostate.
March 6 : Out of bed. Passes urine spontaneously.
March 7 : Bladder easily entered with Mercier catheter No. 12.
Two ounces of residual urine. Still passing sloughs of prostate in
the urine.
March 15 : Residual urine, Si^ ounces.
March 17 : Discharged cured. Passes urine spontaneously. Since
leaving hospital he has no residual urine. Urine clear, acid ; passes
urine easily, and declares he is as well as he ever was.
The histories of two cases of perivesical suppuration follow. No
positive cause for the abscesses could be ascertained.
1901, vol. iii., page 196. Prevesical, PeHureieral, and Ischiorectal
Abscesses; Sepsis; Incision and Drainage; Death.— F. B., 45 years
old, Avas admitted May 6. Family tubercular. Denied syphilis and
gonorrhea. For ten to twelve years before the present illness he suf-
fered with increased frequency of urination, not accompanied by any
pain. For the last four weeks he has liad to pass urine very fre-
quently; urination was painful, and only a few drops would be voided
at a time. lie also had fever, sweating, and chilly sensations. No
blood or pus in the urine. Three weeks ago he had an infection of the
finger, which had been incised.
On admission, examination revealed numerous crepitant rales at
both apices of the lungs. Spleen much enlarged. In the hypo-
gastric and right inguinal regions was a tender mass, irregular in
shape, extending from one and one-half inches below the umbilicus
to the symphysis. Mass hard, immovable, and slightly fluctuating.
Rectally, the mass could be felt bimanually extending from above the
prostate forward and outward to the right. On the right middle
finger was a. healing incision discharging seropurulent material. The
rectal mass encroached upon the posterior urethra. Urine acid, clear,
1022, few pus cells, few red cells, no casts, trace albumin. Tempera-
ture 102.6°, pulse rate 108.
May 7 : Incision and drainage of the mass in th(> hypogastrium.
Ether and gas anesthesia. Mass proved to be extraperitoneal, lay in
front of bladder in space of Retziiis, and extended laterally to the
right and backward to tlic huso of the bladder. It contained about
four ounces of thick, creamy jms containing in spreads the staphy-
lococcus aureus. Drainage.
The temperature fell after the first twenty-four hours, and con-
tinued between 99.5° and 100.5° for eight days, when it again rose
to 104°. The wound did not clean and granulate, but remained coated
with a grayish membrane. ITrine unchanged. On May 17, the ninth
day, he had a chill, and temperature rose to 108°. Induration found
in ischiorectal space, to the left of the rectum.
May 18 : Incision and drainage of ischiorectal abscess, evacuating
several ounces of nus. Cavity connnunicafed with original abscess
GERSTER: REPORT OF THE FIRST SURGICAL DIVISION — 1901. 173
cavity. Temperature again declined to near the normal and remained
so for a week. The general nutrition failed perceptibly, and the
wounds were pale and covered witli flabby granulations.
May 20: Cystoscopie examination showed vesical mucosa normal.
Right ureteral orifice surrounded by deeply congested, slate-colored
mucosa. It appears displaced inward and downward. One-half cm.
external to it is a retracted area, from the bottom of which pus
exuded on pressure. Left ureter appears to be displaced upward
and outward. The position of the ureters would seem to indicate
a displacement of the neck of the bladder to the left and rotated
around a sagittal axis. Blood-tinged, turbid urine was seen to emerge
from the right ureter. It would appear, from this examination and
our previous data, that the suppuration had taken its origin around
the lower extremity of the right ureter, burrowing forward until it
involved the prevesical space.
May 26: Temperature again rose to 104°. There was some reten-
tion in the ischiorectal abscess cavity. After establishing good drain-
age the temperature again fell to 99°-100°. The wounds showed no
tendency to actively heal or granulate.
June 10 : Right kidney to be felt, but not tender. Aspiration
through the loin negative. Temperature occasionally rose to 104°.
From now on the temperatures daily fluctuated between 97.6° and
104 4-°- No chills. The general condition, in spite of forced feed-
ing, grew worse; the wounds were covered with pale granulations;
bedsores formed over the sacrum. Exitus June 25.
Neve)- any tuhcrcic hacilU in urine. Eigld kidney never tender.
No postmortem permitted.
1901, vol. iii., page 195. Perivesical and Perirectal Abscess; In-
cision and. Drainage; Recovery. — 1. T., 15 years old, a ragpicker, was
admitted May 17, 1901. Had typhoid fever two years before. Three
weeks before, he began to have pain in bladder at end of urination.
This was so severe that he had to go to bed. Also felt chilly and had
some fever. No blood or pus in urine. Bowels moved regularly.
On admission there was a large, tender, globular mass extending
from one inch below umbilicus to the symphysis. Rectally a mass
was to be felt above the prostate ; it gave the sense of fluctuation.
Temperature 101.8°.
Immediate operation. Tlirough a median incision above the sym-
physis, an abscess in the prevesical space, containing about two
ounces of thick, non-odorous pus, was evacuated. During rectal
examination a large abscess, not communicating with the previous
one, and containing fetid pus, was burst open. Drainage of both
cavities. Temperature declined to nonnal and remained so. Gradual
closure of both cavities by granulation.
June 9 : Above the pi-ostate. lying lietween the bladder and rectum.
174 MOUNT SINAI HOSPITAL REPORTS.
and extending forward at right side of the bladder, is a brawny mass
about the size of a lemon, non-fluetuating. Discharged to report for
observation. A month later most of this mass had disappeared.
Comments.— Whereas the first of these two cases may have been a
metastatic abscess following the infection of the finger, it impressed
us rather as a tuberculosis Avith mixed infection of the seminal vesicle
and right ureter. The absence of tubercle bacilli in the urine would
seem to point against this assumption.
In the second case we have not been able to assign any cause for
the suppuration. There was no evidence of appendicitis.
A complete denudation of the cutaneous covering of the penis,
caused by an unskilful circumcision, necessitated a plastic operation :
1901, vol. iii., page 216. Complete Cutaneous Denudation of
Penis; Plastic Operation; Cured. — I. S., admitted August 20, 1901.
The patient stated that the phj-sician pulled the foreskin as
far forward over the glans as he possibly could, and then amputated
the skin at level of the glans. On relaxation it was found that the
entire penis was denuded of its cutaneous covering. Came to the
hospital twelve hours later.
August 30 : Plastic transplantation of skin from scrotum. Two
transverse horizontal incisions, separated by a space corresponding
to length of the penis, were made through the skin of the scrotum.
The scrotal skin between these two incisions was raised from the
underlying tissues. Under the flap thus formed the penis was slipped,
and the edges of the flap united to the skin at the root of the penis