An outline of genito-urinary surgery

Front matter

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Foreword

This book has been written ^Yith the idea of presenting to students and to general practitioners the important points in the symptomatology and pathology of genito-urinary diseases. The treatment of these conditions, in so far as it deals with medicine or with minor surgery, is given in full; when m^jor surgery is indicated, enough of the technic is described to give the medical reader an intelligent opinion as to the nature of the operation, its aims and its dangers.

The methods and technic described are by no means the only ones possible, but they are measures w^hich I in my own experience have found practicable. The case histories are almost entirely from my own cases, either in private practice or at the Massachusetts General Hospital.

The articles referred to at the end of each chapter have been selected because of their value as original contributions, or because they represent the views of men of authority upon the subject under discussion.

The drawings were made by Mr. H. F. Aitken from actual operations and from pathologic specimens. I take this opportunity to express my great appreciation of his interested and intelligent cooperation.

George Gilbert Smith.

99 Commonwealth Avenue, Boston, Mass., April, 1919.

CHAPTER I PAGE Introduction 17

Asepsis in Urethral Instrumentation, 20 — Equipment, 22.

Endoscopy and Cj'stoscopy 24

Endoscopy, 24 — Anterior Urethroscopy, 26 — Posterior Urethroscopy, 26 — Cystoscopy, 27.

CHAPTER II Urinary Axtiseptics 33

The Balsamics, 33 — Hexamethylenamin, 34 — Other Drugs, 38.

CHAPTER HI

Urinalysis. Tests of Rexal Fuxctiox 39

Urinalysis 39

Albumin, 40 — Sugar, 40 — Sediment, 40 — Specimens Stained for the Tubercle Bacillus, 41 — Urethral and Prostatic Secretion, 42 — Gonococcus Complement-fixation Test, 43.

Renal Function Tests 44

CHAPTER IX Infections of the Prostate and Seminal Vesicles 107

Acute Infections, 107 — Subacute and Chronic Prostatitis and Vesiculitis, 114 — Chronic Non-specific Prostatitis and Vesiculitis, 118 — Cure of Gonococcus Infections, 120 — Tuberculosis of the Prostate and Vesicles, 123.

Chapter X

Symptoms, 125 — Diagnosis, 128 — Management of Prostatics, 132 — Cystotomy, 138 — Prostatectomy, 146 — Postoperative Treatment, 155 — After-treatment of Prostatectomy, 156 — The Small Fibrous Prostate, 157 — Cancer of the Prostate, 158.

CHAPTER XI Hydrocele; Spermatocele; Hematocele 163

Diseases of the Spermatic Cord ..." 1 74

Hydrocele of the Cord, 174 — Varicocele, 175 — Torsion of the Spermatic Cord, 176.

Diseases of the Testicle 178

Trauma of the Testicle, 178 — Epididymo-orchitis of Mumps, 178 — Abscess of Testicle, 181 — Tuberculosis of the Testis, 182— Syphilis of the Testicle, 182— Neoplasm of the Testicle, 183 — Epididymitis, 183.

CONTENTS 15

CHAPTER Xn

Cystitis, 189— Encrusted Bladder, 195— Chronic Cystitis, 196 Syphilis of the Bladder, 203 — Bilharzia Infection, 203 — Tumor, 204 — Vesical Calculus, 212 — Rupture of the Bladder, 213.

CHAPTER Xni

Urinary Abnormalities, 216 — Pyuria, 219 — Pain, 219 — Disturbances of Urination, 220 — Fever, 220 — Abdominal Tumor, 220 — Renal Insufficiency, 225 — Essential Hematuria, 226 — Decapsulation in Nephritis, 228 — Nephroptosis, 228— Renal Infections, 232 — Pyelitis of Pregnancy, 235— Pyelitis of Childhood, 237— Sequelae of PyeUtis, 238 — Renal Retention, 243 — Renal and Ureteral Stone, 245 — Renal Tumor, 255 — Rupture of the Kidney, 257.

CHAPTER XIV

Kidney and Bladder, 261 — Tuberculous Epididymitis, 265.

CHAPTER XV

GoNOCoccus Infection m the Female 272

Vulvovaginitis of Little Girls, 272 — Vulvovaginitis in Adult, 276.

CHAPTER XVI

Sterility, 282.

Int)EX 291

AN OUTLINE OF GENITO-UKINAEY SUEGEEY

Introduction

The management of genito-urinary disease presents to the medical profession many problems. Not least of these is the problem of bringing about between. the general practitioner and the specialist that co-operation which is so essential to the welfare of the patient. Obviously, the man in general practice cannot be expected to make those diagnoses which require special instruments and the skill necessary to their use. No more can he be expected to send all his genito-urinary cases to the specialist; indeed, in many smaller communities the services of a urologist may be quite difficult to obtain.

Certain conditions, such as hematuria, clearly require these services, no matter how inaccessible they may be; other conditions may be treated with perfectly satisfactory results by the general practitioner, provided he will make use of those measures of diagnosis and treatment which are within his powers. In this he is aided by his knowledge of the patient's temperament, general health, and social and economic condi- 2 17 tions, and in many instances his advice is more seriously accepted because of the confidence which past relations with the patient have engendered. Yet all of these advantages, valuable though they are, become as nought if he is ignorant of the actual pathology underlying his patient's condition.

Not only must he know the pathology, but he must have a very definite idea of the object of treatment and the ends which he may hope to attain. In the management of these cases, particularly when they are ambulatory and not incapacitated by severe symptoms, there is considerable temptation to slip into an aimless, visit-to-visit policy. This must be guarded against, first, by the establishment of an exact diagnosis, then by the institution of definite measures to correct whatever is wrong. If one feels himself unable to achieve either of these aims, he should seek help from someone more experienced in this department of surgery, and perhaps under the guidance of expert advice carry on the details of treatment.

The following pages are an attempt to simplify the rather complex subject of genito-urinary disease, to describe in detail the diagnostic and therapeutic measures accessible to every medical man, and to state definitely the boundary at which the province of general medicine ends and that of

urology begins.

In the manipulation which constitutes so large a part of genito-urinary therapeusis gentleness is all essential. The intact mucous membrane of bladder and urethra is really very resistant to infection. This fact is strikingly proved by the excellent condition which the bladder mucosa may show in spite of a stream of pus constantly pouring over it from a damaged kidney. If the mucous membrane be torn or abraded, however, infection by the bacteria which are necessarily introduced or which are already present will take place and set up an inflammatory reaction. Usually mild, this reaction may be enough to cause peri-urethral abscess, prostatitis, and even septicemia. Careful attention to asepsis is necessary, but even more important is absolute avoidance of trauma to the lining of the urinary tract.

Care in manipulation, therefore, is the first consideration in the avoidance of infection. There is another rule which must always be observ-ed; that is, instrumentation must be followed by lavage. If the posterior urethra has been entered, the lavage must include the bladder; if only the anterior urethra, an anterior wash will suffice. If the bladder is to be included, 8 ounces of the solution are left in that viscus and are voided after the catheter is removed. The solution used consists of one of the mild antiseptics, such as boric acid 2 per cent., potassium permanganate i : 3000 to I : 10,000, or silver nitrate i : 5000 or weaker.

The antiseptic solution, flowing with considerable force over the mucous membrane of the urethra, carries out with it bacteria which may have been deposited along the canal. The strict observance of this rule is imperative.

The value of urinary antiseptics in the prevention of infection from instrumentation I believe to be greatly exaggerated.

That they are of the greatest importance in certain conditions of the genito-urinary tract goes without saying; used as a prophylactic measure they certainly do no harm. The administration of one of them previous to instrumentation of the lower urinary tract is a safe precaution, but is not essential, provided instrumentation is properly done.

Asepsis in Urethral Instrumentation. — In urethral instrumentation there are certain minimum requirements of asepsis which must be observed. The hands should be carefully washed with soap and hot running water, and dried with a clean towel. A sterile catheter lubricant, preferably one of the sea-moss preparations put up in collapsible tubes, is dropped upon the tip of the instrument. The hands, even though washed, are not sterile, and should not touch that part of the instrument which will enter the posterior urethra — that is, they should not come in contact with the instrument within 3 or 4 inches of the tip.

The instrument itself may be sterilized in one of several ways; the cleansing process should start at the time the instrument was last employed. Immediately after use, before the adherent mucus dries, all metal and rubber instruments should be washed in hot running water, boiled for at least two minutes, dried with a clean towel, and put away in a closed drawer or case until used. If their container is reasonably dust-proof and the instruments are employed frequently they may be used without further sterilization. If there is doubt of their cleanliness, they should be again boiled before being used. Complicated instruments, such as the KoUmann dilator and those with electrically lighted bulbs attached, should not be boiled, but can be cleaned by washing wdth lukewarm water and soap, followed by alcohol. They may then be further sterilized by formalin gas.

The apparatus generally used for this purpose consists of a metal box long enough to hold sounds and catheters, with a tightly fitting lid. At one end is a shelf; upon this a pastil of formalin is placed. The compartment beneath this shelf has a separate opening at the end of the box, and contains a small alcohol lamp. The heat of the flame liberates formaldehyd from the pastil, and fills the sterilizer with the gas. The in^struments are left in this for twelve hours or more.

Catheters and bougies made of woven fabric coated with varnish should be washed w^ith soap and water, dried and sterihzed with formaldehyd gas; some kinds, such as those made by certain French firms, may be boiled. They must not be allowed to cool while in contact with other instruments or with the sides of the sterilizer, for the varnish, softened by heat, will lose its smoothness if touched.

Finger-cots for rectal examination should be boiled after each case. The infectious organisms to be especially guarded against in genito-urinary practice are the gonococcus and the Spirochaetae pallida. Both organisms are easily killed by heat ; the gonococcus is said to be killed by exposure to a temperature of 1 20° F. Immersion of instruments in boiling water for two minutes is sufficient therefore to insure against their carrying these micro-organisms from one patient to another.

Equipment. — For the practice of genito-urinary surgery there are certain things which are practically essential and others which are not essential, but which are very useful. In the following list will be given the essential equipment. In a supplementary list will be given the equipment which is desirable, but not necessary.

Necessary Equipment General:

Hot and cold running water.

Sterilizer for boiling instruments. (At least 1 2 inches long.)

Examining table. (32 or 34 inches high.)

Irrigating reservoir, glass, capacity at least 24 ounces, with rubber tube, glass nozzle, and cut-off.

Glass graduate or enamel pitcher (capacity 16 ounces).

Stirring rod, glass pipet.

Enamel basin.

Urinometer. Two conical urine glasses.

Finger-cots.

Instruments:

Soft-rubber catheters about Nos. 14, 16, or 18 French.

Woven bougie catheters, sizes 12, 14, and 16 French.

Woven coude catheter, size 14 French.

Stylet of substantial character and a soft-rubber catheter to fit it.

Bougies, filiform and alternate sizes from Nos. 6 to 20 French.

Bougie catheter with fiUform which screws to its tip.

Metal sounds, sizes 20 to 32.

Metal or woven bougies a boule, sizes 16, 20, 24, and 28. Drugs:

Catheter lubricant. (The kind made of sea-moss and dispensed in collapsible tubes is very convenient.)

Acetic acid, ;^T) per cent.

Potassium permanganate (3-grain tablets. One in 16 ounces makes a i : 2500 solution).

Silver nitrate (tablets, i grain each. One in 8 ounces makes a i 14000 solution).

Boric acid crystals (saturated solution equals 4 per cent.).

Nitric acid (concentrated) .

Fehling's solutions A and B.

Oxalic acid crystals (for removing stains of potassium permanganate) .

Alcohol, 95 per cent.

Litmus paper.

Stains:

Loffler's methylene-blue.

AnUine oil gentian violet.

Gram's solution (IKI).

Bismarck brown.

Equipment Desirable, But Not Necessary

Large syringe for bladder irrigation. (The all metal and

the glass and metal kinds are the best.) Kollmann dilator.

Keyes' instillator.

Centrifuge.

Formaldehyd sterilizer.

Various catheters with prostatic curves and tips.

Straight electrically lighted endoscope.

Endoscopy. — Actual inspection of the urethra, anterior and posterior, is a procedure which at times yields information of much value. According to some writers it should be performed in every case of persistent urethral discharge. It is their contention that by means of the urethroscope one will detect many lesions otherwise overlooked, and that by apphcations and manipulations through the urethroscope these lesions can be cured.

Views such as these, which may be found in many text-books and articles upon the management of urethritis, seem to me to place far too much emphasis upon the operation of endoscopy. In eight years' experience in clinic and private practice I have seen only a few cases in which endoscopy contributed information of any importance. The ruling out of a definite lesion is sometimes helpful, and in this direction lies the chief value of endoscopy.

Papillomata or condylomata of the urethra can be accurately diagnosed by this measure, and can be treated only by fulguration or excision through the endoscope. Small granulating areas of the urethra will heal up as quickly when treated by dilatation and massage of the urethra upon a sound as when touched with caustic. Lesions of the mucosa of the posterior urethra are, as a rule, due to infection of the prostate or vesicles. Treatment of the surface alone will not suffice — the underlying cause must be removed by prostatic or vesicular massage.

The discovery of congestion of the verumontanum in a case of sexual or urinary disturbance does not materially aid in relieving the symptoms, and in my experience the application of silver nitrate to the posterior urethra is more successful when made with the Keyes' instillator than when applied by a swab through the endoscope.

In the management of diseases of the female urethra endoscopy is really essential, and should be used much more frequently than at present. There are many cases of so-called '^cystitis" in which the lesion is not in the bladder, but in the urethra. The most effective treatment is by means of applications through the urethroscope.

The technic, both in male and female, is not difficult. The simplest instruments are the best. A straight, electrically lighted endoscope, consisting of sheath, obturator, and a lamp carrier which passes through a small channel separate from the main lumen, is the most generally useful. It can be used in making applications both to the anterior and to the posterior urethra. For inspection of the posterior urethra dilation of the canal by water gives a much better picture, and can be carried out best by means of a cysto-urethroscope or close-vision cystoscopy

For endoscopy of the anterior urethra no anesthesia is necessary. For manipulations in the posterior urethra local anesthesia secured by the instillation of 2 or 3 ex. of 4 per cent, cocain solution is desirable.

Anterior Urethroscopy. — The penis is drawn out so as to eradicate folds in the urethra. The urethroscope is passed as far as the triangular ligament (cut-off muscle), the obturator is removed, and the instrument is slowly withdrawn by the right hand, while the left hand keeps the penis taut. The mucosa appears reddish pink, with longitudinal striae of deeper red. Granulating areas appear as dull red spots which bleed easily. Papillomata and condylomata are easily identified. The incision of the orifices of peri-urethral glands is mentioned by some writers as a possibility, but is a procedure which can be carried out only by operators of unusual deftness.

Endoscopy in the female is best done with the patient in the knee-chest position. The bladder must be empty. The endoscope is passed into the bladder; the obturator is removed and the instrument withdrawn until the diaphragm of the sphincter closes over the tip. The walls of the urethra are inspected and, if necessary, applications are made with a cotton-tipped probe as the endoscope is withdrawn.

Posterior Urethroscopy. — When the cysto-urethroscope is used the instrument is passed into the bladder and then withdrawn so that the window is between the sphincters. A stream of boric acid solution (2 per cent.) is gently injected by an assistant or by means of an irrigator. The fluid distends the urethra and enables one to inspect the walls and the verumontanum. Between the internal sphincter and the verumontanum is a depression. The floor of this is frequently streaked with red and may show ribs of mucous membrane. Then the verumontanum rises abruptly and fills the field of vision. Its surface should be smooth and pink; when pathological it may be congested, cystic, or papillomatous. The anterior aspect of the verumontanum contams the opening of the utricle, which, if infected, may exude pus. In this connection it is easy to let the imagination run away with one's surgical common sense. Such procedures as washing out the utricle and catheterizing the ejaculatory ducts sound very effective, but unless one is an expert cystoscopist he should not attempt them. The case of gonorrhea that cannot be cured by the simple measures of dilatation, lavage, and massage is a rarity. The chances of doing harm by more complicated treatment are many. In making applications to the verumontanum either the straight endoscope or the posterior urethroscope, with window on the side, may be used. After the field is wiped dry it is swabbed with silver nitrate solution in strength varying from i to 10 per cent. Too strong solutions will excite too great reaction.

Cystoscopy. — The value of cystoscopy admits of no argument. Without it diagnosis of genito-urinary disease is in many cases impossible. Today the practice of renal surgery without preliminary study of each kidney by itself amounts to malpractice.

As to the advisability of the man in general practice attempting to do cystoscopy there is some difference of opinion.

The actual performance of cystoscopy is not difficult. The difficulty lies in interpreting what one sees. It stands to reason that the opinion of a man who does only ten or twelve cystoscopies a year cannot be as reliable as that of the man who does several hundred. It would seem better, therefore, for each district to support one cystoscopist, whose opinion, by reason of his experience, would become of very definite value.

Technic— In our experience the Brown-Buerger cystoscope has proved to be the most generally useful. It consists of a sheath bearing upon its tip a hooded electric light, an obturator which closes the window in the sheath during its introduction, and observation and catheterizing telescopes. These latter contain the system of lenses which enable one to inspect a surface which lies parallel to the long axis of the instrument. The principle is the same as that of the now famous periscope. The catheterizing telescope is smaller in diameter and has two grooves for ureteral catheters, and a lever with which the tips of the catheters are directed into the ureters. Two types of sheath are furnished with each instrument. One has the window upon the convex side, the other has it upon the concave side. The latter is better for '.observation alone; the former is used especially in catheterizing ureters in a contracted bladder.

Before passing the cystoscope the urethra should be anesthetized by the instillation of 4 per cent, solution of cocain. In most cases this will suffice; in very irritable bladders, such as the contracted, ulcerated bladder of tuberculosis, a more extensive anesthesia is necessary. For this purpose spinal anesthesia is ideal. There is no spasm of the bladder, and renal secretion does not diminish as it does when the patient is etherized. Before introducing the cystoscope always test the light. If that is satisfactory, pass the cystoscope into the bladder. Sometimes meatotomy is necessary to allow of the passage of the instrument, the caliber of which is 22 or 24 French. When the tip is in the bladder the obturator is removed and the bladder is washed with boric acid solution through the hollow sheath until the water returns clear. If there is persistent bleeding the addition of adrenalin to the solution will be of great assistance. The observation or catheterizmg telescope is then introduced and the bladder filled with solution through a tube attached to one of the side cocks. The light switch is then turned on and inspection begins.

A routine method of inspection should be followed. First the roof is examined, then each lateral wall, and finally the base. The condition of the bladder musculature — whether trabeculated or not— the presence of diverticula, stones or tumors, should be noted. The color and quality of the mucous membrane— whether pale and shining, and marked by fine capillaries, or whether light-absorbing and of a uniformly reddish color— are important. The character of the ureteral jets and of the ureteral orifices should be studied next. Lastly, the condition of the bladder neck is examined. If the patient is a man, the prostatic outline should be mapped out. In cases with obstruction at the bladder orifice the presence of the anterior cleft, denoting enlargement of the lateral lobes, or the elevation of the posterior lip by the middle lobe or bar, is especially important.

The search for the ureters is commenced by passing the cystoscope as far in as it will go and locating the bubble on the roof of the bladder. The instrument is then rotated half a circle, so that the window looks directly downward. The instrument is then withdrawn until one notices that the lax, wrinkled mucosa of the base has changed into a smooth, white, elevated area. This is the trigone. By following the upper line of the trigone to either side, the eye is carried on to the ureteric ridges which run obliquely upward away from the observer. Upon the crest of each ridge a short distance above its junction with the trigone lies the ureteral orifice. In certain instances the orifices are visible only when they open to emit urine.

In bladders distorted by long-standing infection, especially that of tuberculosis, the ureters may be impossible to find unless the urinary jet is artificially colored. This is best done by the intravenous injection of 5 c.c. of 4 per cent, solution of indigocarmin in water, which has been sterilized by boiling. Within five minutes after the injection the jet from a normal . kidney should be colored a deep blue and will make easy the location of the ureteral orifice. The relative intensity of color of the jets from the two ureters will give an idea as to the relative functions of the kidneys.

The passage of the ureteral catheter is a matter of technic which is readily learned by one who has a chance for frequent practice. Occasionally the ureteral orifice is easily visible, but is hard to catheterize. It is helpful to change the amount of fluid in the bladder. Further distention will flatten the base and may make catheterization a great deal easier.

Cystoscopy in Children. — Boys of ten or more and girls of six may be cystoscoped if an instrument of 16 or 18 French is used. Such a cystoscope is made on the Brown-Buerger style, but with only one catheterizing channel. General anesthesia is necessary.

Operative Cystoscopy. — Elaborate operating cystoscopes have been invented. Hugh Young's model has a pair of jaws which can be used to pick up small stones or foreign bodies, or to nip off small tumors. Leo Buerger has devised several instruments which may be worked through his operating cystoscope. There are scissors, a pair of nippers, and a dilator. These are intended chiefly for aiding the passage of stones low in the ureter. With the scissors the ureteral orifice may be slit, with the dilator it may be stretched. The nippers can be used to grasp the stone if it is in sight, or to bite out a bit of mucous membrane for diagnosis. Hugh Young has devised ingenious appliances which can be operated through the cystoscope for applying radium to bladder tumors.

These intravesical manipulations should be left to the expert cystoscopist. They are applicable only in exceptional cases, and their usefulness is distinctly limited.

Cabot, H.: The Training of the Urologist, New York Med. Jour., May

25, 1912.

Schmidt, L. E. : Why Urology Should be Considered a Specialty, Trans.

Amer. Urological Assoc, 1912, vi, 1-12.

Thomas, B. A.: The Significance of Specialism with Reference Especially'

to Genito-urinary Surgery, Jour, of Penn. State Med. Assoc, 1916,

Chapter II Urinary Antiseptics

Urinary antiseptics are those drugs which, taken by mouth, are followed by the excretion through the kidneys of a substance hostile to the growlh of bacteria. Experience with various drugs has resulted in the elimination of all but two — i. e., the balsamics and hexamethylenamin. Different preparations of these two are employed, but the value of each depends upon the action peculiar to its parent drug. These two drugs act in widely different ways.

The Balsamics. — These drugs (sandalwood oil, oil of copaiba, and oil of cubebs) are excreted partly by the lungs, but chiefly by the kidneys. Cushny (Pharmacology, p. 7^) says: ^'The products of the oils excreted in the urine appear to have some antiseptic action, for the urine of persons treated with them putrefies more slowly than ordinary urine and the growth of many of the more common germs is somewhat retarded by it. On the other hand, there seems some question as to how far it is destructive to the gonococcus, which sometimes grows readily in culture-media made up with such urine instead of water. Winternitz therefore attributes the undoubted therapeutic efhcacy of these oils to their lessening the inflanmiatory exudate rather than to their antiseptic ac- 3 33 tion, without denying that the latter may also be of some importance."

With these conclusions practical experience closely agrees. Of the balsamics, sandalwood oil is best borne by the stomach, is less likely to produce skin eruption, and is as efficacious as any of the others.

The chief use of sandalwood oil is to allay inflammation of the mucous membrane of the lower urinary tract. In the acute stage of gonococcus infections, in acute cystitis of any origin, and especially in cystitis due to the tubercle bacillus, sandalwood oil best demonstrates its value. Frequency and burning on urination diminish. It is given usually in capsules (lo minims) after or during each meal. In certain individuals this drug will cause hyperacidity and gastric distress, in others its use is followed by severe colicky pain in the kidneys. In these cases the drug had better be discontinued.

With the synthetic products (gonosan, arrhovin, santyl, etc.) we have had no experience. Keyes (p. 213, 191 1) considers them no more and no less potent than the more familiar balsamics.

Hexamethylenamin of the United States Pharmacopoeia is practically the same as urotropin, which is a patented German product. It dissolves rather slowly in water, and should be taken after meals in order to avoid any irritant effect which it might have upon the empty stomach. The drug is inert and has no bactericidal effect until it is broken up into ammonia and formalin, a process which requires an acid

URINARY ANTISEPTICS 35

medium. To the formalin thus set free the drug owes its value as a urinary antiseptic.

In order to get any benefit from its administration the urine must be definitely acid. With an acid urine the process of splitting off formalin begins in the kidney and is continued in the bladder. The value of hexamethylenamin in the treatment of kidney infections has been doubted, on the ground that the drug does not stay there long enough for any important amount of formalin to be set free. In distinctly acid urine warmed to body temperature enough formalin may be liberated in three minutes to give a definitely positive test (Burnam's test) . On theoretical grounds it would seem easily possible for urine to remain this length of time in the kidney, if we include its passage through the various tubules as well as its diffusion through the pelvis. As a matter of practical experience there is ample evidence to show that the administration of hexamethylenamin influences very markedly certain types of renal infection. As the liberation of formalin continues in the bladder, one can easily understand its value in keeping down infection within that viscus.

The greatest value of hexamethylenamin is in combating colon bacillus infections of the urinary tract. The urine is naturally acid in this condition, thereby assisting in the liberation of formalin, and the colon bacillus is very susceptible to a constant bath of formalin. The coccus infections are less responsive to this type of therapy. In acute inflammatory conditions of the lower urinary tract and in infections by the tubercle bacillus hexamethylenamin is contraindicated. The sensitive mucosa is irritated by the formalin in the urine, and the local hyperemia and discomfort are increased.

In order to get the best effect from hexamethylenamin it must be administered with an understanding of its behavior. The urine must be acid and not too dilute. If not definitely acid to litmus paper it may be made more so by the administration of sodium acid phosphate lo to 20 grains three times a day. As monosodium phosphate and disodium phosphate are both constituents of normal urine, the administration of the monosodium phosphate (sodium acid phosphate) does not introduce a foreign substance, but simply swings the balance on to the acid side. Sodium acid phosphate is now supplied in lo-grain tablets, and may be employed to the point of causing diarrhea.