TESTICLE - EXAMINATION OF THE PATIENT FOR THE SOURCE OF HEMATURIA OR HAEMATURIA.
The vasa deferentia are to be searched for the bead-like deposit of tubercle, and the epididymis (the globus minor especially) should be examined for a similar infiltration.
Any sudden onset late in life (after forty-five) of a varicocele is to be regarded with suspicion as indicating malignant disease of the corresponding kidney.
Instrumental Examination.—Various methods have been devised to ascertain whether the blood has originated in the kidney or in the bladder, such as those suggested by Pawlik, Silbermann, Polk, Tuchmann, Gliick, Hurry Fenwick. Most of these procedures can only be employed by their originators. Since the introduction of electric cystoscopy those which were accounted as serviceable in the male have been relegated to obscurity. Any instrumental ex ploration of the bladder by means of the catheter, sound, lithotrite* (Thompson), calculus aspirator (Chismore or sharp curved curette (Kuster), is, I am sure, unsurgical and unsafe in all cases of kema turia unaccompanied by other symptoms of urinary disorder. If any instrumental examination is necessary in this class of cases, let it be a gentle, purposive, educated cystoscopy, and let the examination be made with full leave to proceed at once to any operation which the electric light may indicate as being necessary. I would emphasize this statement by asserting that I recognize no disease of the urinary organs in which bleeding is a prominent symptom which necessi tates the routine use of either sound or catheter for its detection, and I know of no urinary disease which may not be materially aggravated by the employment of these instruments. I speak thus strongly be cause the existence of blood in the urine suggests at once to the mind of most practitioners the use of the calculus sound. Now this instrument is useful only in a very limited class of cases, viz., that of stone in the bladder; and, as I shall point out immediately, hmma turia is very rarely the sole symptom evoked by a calculus. Even then sounding had better not be clone until all preparations for simul taneous litholapaxy have been completed.
My reasons for opposing all forms of instrumentation in symp tomless hrematuria are as follows : I have known the use of the cathe ter and washing to cause death in three cases of renal carcinoma in the course of a single week. I have seen it induce fatal suppres sion in renal tuberculosis ; dangerous pyelitis and cystitis in cases of vesical growth; I have known it dangerously aggravate cases of gran ular nephritis, cause acute renal abscess in vesical tubercle, and pro duce death in cases of vesical stone coexisting with advanced but unsuspected renal degeneration; I have known of deaths from sup purative nephritis, and from sloughing of vesical tumor; and I have seen retention and alarmingly profuse hemorrhages follow sounding in cases of tumor of the bladder (severe hemorrhage following upon gentle sounding points to the presence of a new growth)—in fact, my note-books are interspersed with cases in which instrumentation in symptomless hmmaturia has brought discredit upon the practitioner and disaster upon the patient.
It is, however, quite otherwise in those cases of Hematuria in which symptoms of vesical or prostatic disease, pain, frequency of micturition, and obstruction to the stream, have preceded the appear ance of the blood. In these cases instrumental exploration is often absolutely necessary for a differential diagnosis, and if employed skil fully and judiciously it is as free from risk as is any instrumentation through the deep urethra of males. The urethral bougie will elimi nate stricture, the sound determines the presence of stone and the in travesical enlargement of the senile prostate, while the catheter estab lishes at once the presence or absence of residual urine. I may remark, incidentally, that the risk of instrumentation increases after forty-five years of age with every year ; that more danger is incurred in town dwellers than in those who have led healthy out-door lives; that malaria and the various tropical fevers probably leave the kidneys less able to bear any sudden stress of reflex congestion.