Some Recent Important Advances in the 
Diagnosis and Treatment 
/ 
OF 
Urinary Diseases in Women, 
BY 
Howard A. Kelly, M. D. 
PROFESSOR OF GYNECOLOGY AND OBSTETRICS, 
IN THE 
JOHNS HOPKINS UNIVERSITY, 
H^fcTlMORIr. 
Reprinted from the Pittsburg Medical Review, January, 1896. SOME RECENT IMPORTANT ADVANCES IN THE 
DIAGNOSIS AND TREATMENT OE URI- 
NARY DISEASES IN WOMEN. 
By HOWARD A. KELLY, M. D., 
Professor of Gynecology and Obstetrics in the Johns 
Hopkins University, Baltimore. 
I need only briefly mention before this 
body of men, so closely in touch with all 
that is most recent in medicine and surgery, 
a discovery which I made over two years 
ago, and first described in The Bulletin of 
the Johns Hopkins Hospital, November, 
1893, and with more detail in the American 
Journal of Obstetrics, in January, 1894, and 
still more fully in the first volume of the 
Twentieth Century Practice of Medicine, in 
February, 1895. 
By means of this discovery diseases of 
the bladder in women were rescued from 
the obscurity which had previously en- 
veloped them, and by one stroke made 
accessible to simple means of diagnosis, 
ing also the little ureteral slits communi- 
cating with the ureters and the kidneys 
above. 
Upon this last fact, the ability to see and 
get at the ureteral orifices, which seems so 
trifling in its bare statement, I wish to dwell 
to-night, speaking to you of some of the 
more important consequences which I have 
been able to develop from it. 
In order that you may fully realize just 
where we stand in taking up this part of the 
subject, I will ask you to keep in mind some 
facts in connection with the ordinary meth- 
ods of diagnosis and treatment of surgical 
affections of the kidneys in women. 
In the first place, recall the obscure posi- 
Fig. I. Ends of renal and ureteral Catheters Nos. 1% and 2 
and the way made easy for simple 
and certain methods of treatment, to re- 
place difficult and haphazard procedures. 
The principles of this method, you will 
recall, are briefly the following: 
1. An atmospheric distension of the blad- 
der secured by posture. 
2. The inspection of the inner walls of 
the distended bladder through a simple 
straight tube, by means of a light reflected 
by a head-mirror. 
By turning this tube or speculum in vari- 
ous directions all parts of the bladder walls 
are successively brought into view, includ- 
tion of the kidneys, concealed in the loins, 
protected by the ribs, and beyond the reach 
of touch. Remember that the function of 
the kidneys is one of such vital importance 
that each individual is provided with two 
of them, so that one may supplement the 
other in case of injury. 
The ordinary way of making a diagnosis 
of disease affecting them is, as you know, 
(a) by a consideration of the symptoms, 
notably obscure; (b) by an attempt at pal- 
pation through the entire thickness of the 
abdominal walls; and (c) by examination 
of the urines secreted from the two sides 
and thoroughly mixed in the bladder be- 
fore they are collected. 
* Address delivered before the Academy of Medi- 
cine, Pittsburg, December 2, 1895. Note further the uncertainty which at- 
tends every diagnosis, as to which side is af- 
fected, and then if a site of the disease is deter- 
mined, the doubt as to the exact condition 
of the other kidney. Note also, if the ques- 
tion is raised in the course of an operation, 
as to the advisability of sacrificing a kidney, 
how vital the query, “What is the state of 
the other kidney?” “ Is it sound?” “Is the 
other good enough to do the work of both 
if one is taken away?” 
It is my good fortune to have found sim- 
formation is wanted is short; it comprises 
the various infections due to the presence 
of micro-organisms in the pelvis of the kid- 
ney, e. g.: tubercle bacillus, colon bacillus, 
staphylococcus pyogenes, streptococcus py- 
ogenes, and gonococcus; neoplasms, cancer 
and sarcoma, hydronephrosis, and renal cal- 
culus. 
The new methods of making a diagno- 
sis are chiefly of two kinds, by using short 
ureteral or long renal catheters, and by 
means of hard rubber bougies. I have had 
two series of catheters made, varying a quar- 
ter of a millimeter in diameter, from 2 to 3 
mm, respectively 30 and 50 cm. long. They 
are of woven silk, coated many times with 
varnish and polished smooth. The lumen 
of the catheter and an oval eye 2 cm. back 
of the conical end, allow fluid to pass freely 
in or out. 
The bougies are used as sounds to de- 
tect and overcome resistance, and to diag- 
nose a blockade in the ureter, such as a stone 
or a stricture. 
The catheters are sterilized by boiling in 
pure water for two minutes, and are kept for 
use in glass tubes plugged at the ends with 
cotton. ' ■ 1 
A wire stylet stiffens the catheter during 
its introduction and prevents it from coil- 
ing up in the bladder. 
The ureteral catheter is introduced by ex- 
posing the ureteral orifice through the spec- 
ulum, and then, as the assistant holds the 
outer end of the catheter over the shoulder 
of the examiner, the latter introduces the 
conical end within the ureteral orifice and 
simply pushes the catheter steadily on up 
the ureter, gradually pulling it off from its 
stylet, the end of which is firmly held by the 
assistant. 
The catheter is introduced up the other 
ureter by taking the speculum out and re- 
introducing it alongside the first catheter. 
The opposite ureteral orifice is then exposed 
and catheterized in the same way as the 
first. 
The ends of each of these catheters are 
now introduced into separate test tubes 
Fig. II. Renal catheter in place on right side, ureteral ca- 
theter in place in left. 
pie answers to all these difficult and here- 
tofore unanswerable questions. 
I have repeatedly made diagnoses 
which but a short time ago seemed beyond 
the range of possibility, and I have even 
been able to give entire relief to some pa- 
tients without operation, and by very simple 
plans of treatment, when under any other 
plan they must inevitably have undergone 
a severe surgical operation. 
The list of diseases where diagnostic in- plugged with sterilized cotton where the 
separated urines from right and left kidneys 
are collected. 
A chemical, microscopic and bacteriolog- 
under the microscope that I might know 
what kind of a peritonitis I had to deal with; 
it contained abundant pus corpuscles, and 
in the cells were numerous colonies of gon- 
Fig. III. Urine draining through ureteral catheter into tube held in block. 
ical examination of these urines collected in 
the course of from a few minutes to several 
hours or more, will reveal any differences 
existing between the two kidneys. 
DIAGNOSIS IN PYURIA. 
As an example of the utility of these new 
diagnostic methods I will cite some of my 
cases of pyuria, covering briefly the whole 
range of the subject* to show you how well 
the field has been cleared up. You are all 
aware from your practical experience that 
when pus is found in the urine it is dif- 
ficult to know certainly just where it 
comes from. To support this assertion I need 
only refer you to the vague and unsatisfac- 
tory treatment of pyuria in your text-books. 
I recall also, out of a large personal experi- 
ence, the long series of women who have 
come to me with a pyuria of years stand- 
ing, who have been constantly under treat- 
ment, without the slightest advance towards 
a diagnosis. 
Here are some illustrations: In a patient 
with small quantities of pus in her urine, 
at intervals, I found nothing abnormal in the 
urinary tract until I squeezed the under 
surface of the urethra against the pubic 
arch, when a large drop of yellow pus ex- 
uded from the right Skene’s gland, and the 
difficulty was cleared up. 
Only last week I operated on a woman 
who was ill with an acute peritonitis. On 
opening the abdomen I first took up with 
sponges from among the intestines a lot of 
milky serum. This was put immediately 
ococci. As I lifted the Fallopian tube out 
of its bed of adhesions thick pus oozed 
from the fimbriated extremity; this also 
contained innumerable colonies of gono- 
cocci. The grade of inflammation was so 
intense and adhesions so extensive, that 
tubes, ovaries and uterus all had to be re- 
moved. Coverslips taken from the interior 
of the amputated uterus also showed pus 
cells containing gonococci. I took cover- 
slips from the vaginal cervix, and from the 
vagina; I emptied Bartholin’s glands on the 
vulva and took coverslips, and finally 
I squeezed a little milky fluid out of the 
urethra, and found in every specimen abun- 
dant pus cells and everywhere the same 
colonies of gonococci; the whole pelvis of 
the patient was saturated with a gonorrhoeal 
infection from urethral orifice up into peri- 
toneal cavity. 
A third case was one of sub-urethral ab- 
scess, of years’ standing, associated with in- 
tense pain in urinating. The endoscope in- 
troduced into the bladder and gradually 
withdrawn from the urethra, showed a fine 
opening on the floor of the urethra, through 
which pus at once welled up and filled the 
lumen of the speculum. 
A case occurring last Wednesday, Nov. 
27th, was one of peculiar interest. An old 
woman constantly discharged large amounts 
of pus in the urine, and there was nothing 
in her history or a digital examination 
throwing any light upon its source; a cys- 
toscopic examination showed tit-like protu- berances at the base of the bladder, sur- 
rounded by a localized high-grade inflam- 
mation. Up in the vaginal vault I found 
a little opening in the midst of some nod- 
ular scar tissue, which I at first took for the 
cervix, but in order to exhaust every possi- 
ble avenue of investigation, I forced the 
tip of my finger into this orifice; it encoun- 
tered a hard body, which proved to be the 
handle of a cup and stem pessary put in 
many years ago; this had been lost in the 
vagina and had become pocketed by closure 
of the vagina below it, and the handle 
ulcerated through the vaginal walls, and 
the cup part through the base of the bladder. 
The suppuration from the ulcerated area dis- 
charged by both bladder and vagina. After 
the removal of the pessary a sound passed 
into the bladder readily entered the vagina 
also. 
Another patient had a pyuria of years’ 
standing and of uncertain origin; I found 
a little further in when it suddenly cleared 
an obstruction and the urine began to es- 
cape rapidly in a continuous stream, filling 
the beaker in a few minutes, with a pale 
lemon-colored alkaline urine, containing 
abundant pus cells and tubercle bacilli. The 
diagnosis of tuberculosis of the right kid- 
ney and ureter was at once made, and the 
patient relieved, March 30, 1893, by the extir- 
pation of both kidney and ureter—Nephro- 
ureterectomy. 
An instructive case in the diagnosis of py- 
uria is that of Mrs. S., who came to me two 
years ago with a marked pyuria, which the 
most careful investigation had failed to clear 
up. I found, on examination with a cysto- 
scope, that the region about the left ureteral 
orifice was puffy, red, and oedematous, and 
so covered with papillae that I was only able 
to find the opening after repeated prolonged 
searches, and even after finding it I could 
not get a catheter well into the ureter. One 
Fig. IV. Metal ureteral catheter, for stricture of ureter low down. 
by a cystoscopic examination an inflamed 
patch on the right side of the bladder pos- 
teriorly, and located a fistulous orifice in 
the midst of some oedematous granulations. 
I passed in a searcher and saw the pus and 
air escape from it. I then found an old con- 
tracted, hitherto unsuspected tubercular 
abscess discharging through the base of the 
right broad ligament into the bladder. 
A young woman of about twenty-five 
years of age came to me with a pyuria of 
nine years standing. In the course of the 
investigation I passed a catheter into the 
right ureter and left it there, and a little 
clear, acid, dark brown urine was discharged 
into the beaker drop by drop. On the left 
side it was difficult to introduce the cathe- 
ter far up the ureter owing to some re- 
sistance within the ureter itself, and after 
waiting about ten minutes there was no 
discharge of fluid. I then took hold of the 
catheter, and with some difficulty and deli- 
cate manipulation succeeded in coaxing it 
day, however, I was more fortunate, and it 
slipped in with a peculiar twisting move- 
ment, which I was a long time in imitating 
again, until I finally learned the corkscrew 
twist of a tight stricture of the vesical end 
of the ureter, when I had no more trouble. 
No sooner was the stricture passed than a 
large amount of pale yellow urine escaped, 
with an abundant pus sediment, 160 cc. in 
all, showing that the ureter above the stric- 
ture was extremely dilated. A bacteriolog- 
ical investigation showed that the gonococ- 
cus was the cause of the infection and the 
stricture. In this way the diagnosis was 
cleared up. 
Mrs. B. came to me from Washington 
with high fever, prostrated by a long con- 
tinued intense pain in the right side, where 
a tumor could be felt between the rib mar- 
gins and the iliac crest, very sensitive to 
touch. I put her in the knee-breast posi- 
tion and introduced a speculum, sought 
out the ureteral orifice and passed a renal 5 
catheter up into the pelvis of the kidney. 
After waiting some minutes and seeing no 
flow from the catheter, I sent her to bed in 
the ward, leaving the catheter in place. Dr. 
Clark in making his rounds afterwards and 
finding that nothing had escaped from the 
kidney, connected the end of the catheter 
expecting to die shortly; she not only re- 
covered entirely from an extensive pyelone- 
phrosis, but regained her health and left 
the hospital having gained 15 lbs. in weight. 
I could multiply these cases, but enough 
has been said to show the facility with which 
pyuria, one of the most difficult subjects in 
with the aspirator bottle and put on suc- 
tion and was rewarded by the escape of 
280 cc. (over half a pint) of thick yellow 
pus, and the diagnosis was made—Pyone- 
phrosis. 
The same thing occurred in the case of 
another woman brought in on a stretcher, 
Fig. V. Washing out pelvis of kidney; fluid running in. 
medicine, has been cleared up. 
TREATMENT OF URETERAL AND RENAL 
PYURIA. 
Any active treatment of ureteral or renal 
pyuria has up to now always been sur- 
gical, but the ease with which we can now 
invade this whole tract with our instruments 6 
of precision also opens up fruitful avenues 
for treatment, curing many cases without 
operation. 
There are three ways of treating the 
pyuria by our new methods: 
1. By evacuating the pus; 
2. By washing out the abscess cavity 
with a simple salt solution or with medica- 
ted fluids; 
3. By dilating a stricture or removing 
a calculus. 
The treatment actually begins with the 
first evacuation of the abscess when the ca- 
theter is passed in to make the diagnosis, 
and is kept up by leaving the catheter in 
situ for drainage, or by introducing it and 
emptying the pus at intervals of from one to 
three or four days. In my last case I left 
it in from Wednesday morning until Sun- 
day afternoon, but I do not think this is 
wise as a rule. 
For washing the kidney out the most ser- 
viceable solutions, I have found, are a weak 
one of bichloride of mercury (1-10,000) and 
boric acid in a solution half the saturated 
strength. The boric acid solution may be 
used regularly and the mercury at longer in- 
tervals, judged by the effect. 
To do this one of the best plans is a sim- 
ple gravity apparatus, a piece of fine rubber 
tubing with a funnel at one end connected 
with the end of the catheter is as good as 
anything for conveying fluids into the kid- 
ney. Any one seeing the kidneys washed out 
for the first time is surprised to observe the 
fluid as it rapidly falls in the elevated tunnel, 
and wells up in it again as soon as the funnel 
is depressed below the level of the kidney. 
An equally simple plan, where the quantity 
of pus is small and but a small quantity of 
fluid is to be injected into the renal pelvis, 
is to throw it into the catheter with a small 
syringe, not more than an ounce (30 cc) or 
two in capacity, connected with the catheter 
by means of a short bit of fine rubber 
tube. I make it a point after evacuating 
large accumulations from the kidney, never 
to inject more than 2-3 or 3-4 of the amount 
taken out. Once when the rule was inad- 
vertently broken the patient suffered from 
an intense renal colic. 
When the pus is too thick to flow, the 
syringe serves an excellent purpose by 
throwing in a watery fluid and thinning the 
pus which then escapes readily. If the kid- 
ney can be handled, the water should be well 
mixed with the matter in the pelvis by suc- 
cussion and kneading with the hands. If 
this is not done the injected water often re- 
turns almost as clear as it was thrown in and 
does little good. 
Another important use of the injection 
syringe is to start the flow by clearing the 
catheter of any clots which choke its lumen. 
I have definitely cured three cases by this 
treatment—the improvement takes place in 
the following order: 
a The amount of the pus becomes less; 
b The pus becomes thinner, more mix- 
ed with watery elements from the kidney 
which begins to secrete; 
c The pus becomes scant and a hydrone- 
phrosis of low grade (small amount) is sub- 
stituted for the pyelonephrosis; 
d The hydronephrosis disappears and 
the patient is cured. 
I have had one opportunity of testing the 
usefulness of the renal catheters in a large 
hydronephrosis. 
A patient came to my consulting room 
for the purpose of finding out the nature 
of an obscure abdominal tumor, as big as a 
quart measure lying low down in the right 
side of the abdomen. The tumor was 
moveable, elastic and not sensitive, and 
might have been a large kidney, a tumor of 
the bowel, a retroperitoneal sarcoma, or an 
ovarian tumor. To decide whether it was 
a kidney or not I put her in the knee- 
breast posture, exposed the right ure- 
teral orifice, and passed in a long renal ca- 
theter. There was a little escape of fluid 
which increased on squeezing the tumor be- 
tween two hands, as suggested by my 
associate, Dr. Ramsay, until the whole 
thing collapsed completely, demonstrat- ing the fact that the case was one of hy- 
dronephrosis of high grade. 
A woman with a large tumor in the right 
side of the abdomen was obliged to stop 
her work in a reformatory institution near 
Baltimore on account of rapidly failing 
health. The mass was evidently renal but 
a deceptive sense of fluctuation made the 
diagnosis between a vascular malignant 
growth and a hydro or pyonephrosis doubt- 
ful. I passed a renal catheter up and got 
down at once about 10 cc. of urine and some 
black specks, shown by the microscope to 
be pieces of stone, but the large resilient 
examination showed them to be masses of 
uric acid. 
Operation and removal of a calculus nx 
16 mm. in diameter from pelvis of right 
kidney. 
Case II. Mrs. W., Pyonephrosis; small 
black pieces of stone brought away by suc- 
tion, a large piece caught in the eye of the 
catheter, black and mammilated on one sur- 
face, sharp crystalline and buff color on 
other surface. The end of the catheter dis- 
figured and scratched by contact with a hard 
body in the kidney. 
Diagnosis, renal calculus with pyone- 
Fig. VI. Washing out pelvis of kidney: fluid running back again. 
mass remained the same. The diagnosis 
was carcinoma or sarcoma of the kidney, 
with calculus and hydronephrosis of low 
grade. 
Finally in the diagnosis of a renal cal- 
culus the catheters have been of the great- 
est service. In evidence of this I will brief- 
ly cite two cases just published in detail in 
the Medical News, Nov. 30, 1895. 
Case I. Miss S., pyelitis; colon bacillus 
infection. Several black specks withdrawn 
from pelvis of kidney by suction through 
renal catheter. Microscopic and chemical 
phrosis. 
In conclusion I would present to the pro- 
fession the following data to serve as guides 
in future investigations of renal diseases in 
women: 
1. In all cases of pyuria from urethral 
orifice to the renal pelvis the location of the 
infected surface can be easily determined. 
2. The presence of a calculus in the 
pelvis of the kidney may be determined by 
the renal catheter or bougie. 
(a) Either by bringing down bits of the 
stone, or (b) By the scratches on or change in 
form of the end of the catheter or bougie. 
3. Strictures in the ureter may be pre- 
cisely located. 
4. Hydronephrosis can be diagnosed 
and differentiated from soft malignant 
growths. 
5. Strictures of the ureter may be treat- 
ed by dilating catheters or bougies. 
6. Infection of the ureter and renal pel- 
vis can, by emptying and washing out with 
medicated solutions, be cured without sur- 
gery- 
7. We have at our command a precise 
way of estimating the functional value of 
each kidney, judged by the amount of urine 
discharged and its constituents, a fact of the 
highest importance in forming a prognosis 
and deciding upon operation; it is therefore 
incumbent upon the surgeon in all cases to 
give the patient the benefit of this analysis 
before operating. 
fiUkfyrtc-W'yifo. proceedings 
THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY. 
The Treatment of Pyo-ureteritis and Pyonephrosis by Ure- 
teral and Renal Catheters.—Dr. H. A. Kelly. 
I want to give this evening a brief resume of some import- 
ant work going on in the gynaecological department during the 
past year, namely, the treatment of pyo-ureteritis and pyo- 
nephrosis by the renal catheter. In the first place, a word or 
two as to diagnosis; by means of my cystoscopic apparatus, 
shown to this society in October, 1893, and the renal catheters 
first used in April, 1893, I have been able, in all cases with 
great facility and sometimes in a few minutes, to trace to its 
source the pus found in the urine of women. 
Judging by the number of cases I have met with, pyuria 
in women appears to be common, and as a rule its source is 
utterly unknown to the practitioner in charge. 
I have found pus in all parts of the urinary tract, from the 
external urethral orifice up to the kidney. In one case there 
was an abscess in one of Skene’s tubules at the orifice; in two 
other cases a suburethral abscess discharged into the urethra 
and filled the vesical speculum with pus as it was drawn out. 
In another instance a contracted pelvic abscess opened into 
the bladder through the right broad ligament; by my cysto- 
scope I could see the opening and run in a sound, and by 
pressure cause pus to ooze out. 
In other cases I have been able to locate the affection in the 
urinary tract above the bladder by getting separated urines from 
both sides, and examining it bacteriologically and microscop- 
ically; a careful examination of the urea will determine the 
working coefficient of each kidney, a valuable point in the 
judgment as to the safety of operating. 
I want to dwell now more particularly on the treatment of 
ureteral and renal pyuria by the renal catheter. There are 
two ways of treating accumulations of pus in the kidney by the 
renal catheter: a) by evacuation; b) by washing out. 
a) The treatment actually begins with the first evacuation when the pus is drawn off by the catheter, and may be continued 
either by leaving the catheter in the kidney for several hours 
(as in one of the first cases, where it was left in from 12.30 p. m. 
till late in the same evening), or for several days (from Wednes- 
day morning until Sunday evening, in a case now in the house). 
By leaving the catheter in for a length of time I have been able 
to evacuate and drain an abscess, and then by introducing the 
catheter at intervals of one to five days I can keep it well 
drained. In several patients I have introduced it as often as 
once daily, in one woman over 120 times in all. 
b) Washing out the kidney. In each case the kidney has 
been washed out after evacuating the pus, by a syringe con- 
nected to the catheter. I first used simple gravity for this 
purpose, by connecting the catheter with a funnel by means of 
a rubber tube. As the funnel was held high or lower, the 
fluid ran in or out (v. Johns Hopkins Hospital Bulletin, 
February, 1895). 
I have used solutions of 1-150,000 bichloride of mercury and 
gradually increasing to 1-2500 and in one case_evenJ;oJ^T00. 
“ som'e'msicihces I nave used boric acid, and in one nitrate of] 
silver. I find that the occasional use of the bichloride solution 
with the regular use of boric acid solutions gives good results. 
Sometimes it only seems necessary to let the pus out to start' 
an improvement. A case in point was that of Miss D., sent to 
me by Dr. Norment of Baltimore. She had an abscess in the 
pelvis of the kidney, and another just below the pelvis in the 
ureter. The lower pocket contained 45 cc. of pus. I evacu- 
ated these in my office, and she improved so much that she 
returned to work and abandoned further treatment. 
The washing out may be repeated at intervals of 1 to 4 days, 
according to the condition of the patient and the way she 
stands it. This little procedure does not call for anaesthesia. 
The quantity injected is usually not more than two-thirds that 
of the fluid withdrawn. In one instance, in using the force- 
bottle of the aspirator, a quantity was accidentally forced in 
larger than that which came out, and ihe patient at once had' 
a severe renal colic. Three women had ureteral chills and 
fever in the course of the treatment, with nausea and general 
malaise; there were two or three chills, and a sharp rise in 
temperature, highest on the second day, gradually subsiding 
and disappearing by the fourth or fifth day; the initial chill 
was more marked than the subsequent ones. The tempera- 
ture went as high as 104 in one case and 103 in another, but 
no harm resulted, and treatment was continued. 
The progress towards recovery is often as follows: After from 
five to ten catheterizations, the thick creamy pus begins to 
become watery and of low specific gravity, containing a small 
amount of urea (0.3 to 0.7 percent.). Finally the pus disap- 
pears, leaving a hydronephrosis of lesser volume than the 
original pyonephrosis, and later the hydronephrosis too disap- 
pears and the condition becomes normal. 
Case 1. Mrs. B had been in the Hospital about a year 
before for a suspensory operation. At that time she com- 
plained of frequent micturition. The urine was examined 
and the bladder inspected and found normal. She returned 
a year later, suffering extreme pain in the right loin, with 
high temperature, and wretchedly depressed. I put her in the 
I will now briefly cite a few of my cases: knee-breast position, passed a catheter up the ureter into the 
kidney, but nothing came, as the pus was too thick to flow. I 
left the catheter in and sent her to the ward, where Doctor Clark 
attached the aspirator and drew out 280 cc. of thick, greenish 
pus, of fetid odor. Her kidney was then regularly washed out 
with bichloride and boric acid solutions, and the urine became 
clear. One time by mistake a 1-1000 solution was used; she 
suffered a good deal of pain, but made more improvement than 
after any previous treatment. She was finally discharged per- 
fectly well after about 12 washings, with clear urine and with- 
out pain. 
Case 2. Mrs. S. was brought here on a stretcher about four 
months ago, apparently in the last stages of illness and not far 
from death. I introduced the renal catheter, made suction on 
the end, and drew down a large amount of pus, and then 
washed her kidney out. The bladder specimen, examined at 
the time of admission, was reddish in color; thick white pre- 
cipitate; acid ; contained a trace of albumen. 
Microscopic examination showed the entire field filled with 
pus cells. No tubercle bacilli found. Urea, one-half normal. 
Specimen of urine from right ureter, pale lemon color, with 
lower layer of gray thick sediment and an upper layer of 
sediment. Quantity too small for chemical examination. 
Field filled with pus cells. One hyaline cast. Amount of 
urea, one-fourth the amount of the mixed urine. Urine from 
left ureter: slight amount of albumen present; few leuco- 
cytes; few epithelial cells. Urea three times as much as from 
the diseased side. She has been washed out regularly, and 
the kidney, on entrance larger than a child’s head, is now 
quite small; there is no more pus in the urine and she is 
well. She has gained 15 pounds. 
Case 3, Mrs. S., a gonorrhoeal stricture low down in the 
ureter, has been reported in the Bulletin (February, 1895) 
and will, therefore, not be reported in detail. Washed out 
over 120 times, with the result that from containing 150 cc. 
of pus, the kidney and ureter now contain 90-100 cc. of clear 
urine. 1 could not relieve the stricture entirely, and she still 
has a hydro-ureter. 
Case 4, Miss S., was washed out over 100 times. Instead of 
getting better she got gradually worse. One day on applying 
suction to the end of the catheter I brought out a couple of 
black granules which proved to be masses of uric acid. I 
concluded upon this find that the inefficiency of the washing 
was due to a mechanical cause, a stone in the kidney, so I cut 
down and removed a small stone as big as the end of my thumb. 
Case 5 was sent to me from Chicago for diagnosis (v. Med. 
News, Nov. 30, 1895). I was able to settle it by drawing out 
pus and urine through the catheter by suction, together with a 
number of little black specks and some granular debris; but 
the smaller specks were apparently of calculus. On with- 
drawing the catheter, a little calculus, black and mammillated 
on one side and buff-colored and jagged on the other, was 
found in its eye. The microscope showed that this was broken 
off from a larger stone. The end of the catheter also, instead 
of being smooth and round, was hammered down and angular 
and the side scraped off. This patient has not been operated 
on, but there can be no doubt about the correctness of the 
diagnosis.