[Reprinted from the New York Medical Record, September 15th, 1888.] 
URETHRITIS, ACUTE CYSTITIS, OBSTRUCTION OF 
THE URETER, HYDRONEPHROSIS, ULCERATION 
THROUGH THE PERITONEUM, DIAPHRAGM, 
PLEURA, AND LUNG-TISSUE, AND DISCHARGE 
OF FLUID THROUGH BRONCHI-RECOVERY. 
BY Z. T. SOWERS, M. D., 
WASHINGTON, D. C. 
The patient, white, male, aged nineteen years, scientific 
plumber, when two years old began to have periodic attacks 
of pain, which were presumed to be "stomach-ache" or 
" colic." The application of clothes wrung out in hot water 
usually afforded relief in the course of an hour or so. These 
paroxysms of pain would occur three or four times a year. 
After the child had experienced three or four of these 
attacks his mother began to notice that his side would swell 
each time these recurred, " like a ridge between the hip and 
lower ribs." Under these conditions, an hour or so after 
the use of the hot applications, he would urinate freely, the 
ridge would disappear, and he would be free from pain. 
When the patient was six years old he was seen by a 
homceopathist, who pronounced the trouble "inflammation 
of the spleen." He was under homoeopathic treatment for 
some time. 
After coming to Washington he was brought under the 
observation of a regular practitioner, who pronounced the 
trouble " neuralgic pains in consequence of the large vein 
passing through the kidney becoming congested." 
Hot applications, in addition to morphine and camphor 
internally, were prescribed, which always gave great relief. 
But the relief was only temporary, and desiring a permanent 
cure they consulted another physician-this time a homce- 
opathist again. Finally the patient drifted into my care, 
with such results as are indicated in the following lines: 
On November 20th the patient called at my office, and 
was found to be suffering from an attack of specific urethritis. 
The usual well-known remedies were administered, and 
with the usual result. Rest had been particularly urged. 
Nothing out of the ordinary routine of such cases occurred 
until the 29th of this same month. On the 29th of Novem- 
ber, being summoned to see the patient at his home, I found 2 
him suffering from cystitis and also bronchitis. Simultane- 
ously with the appearance of the cystitis the urethral dis- 
charge ceased. 
At this time pain in the region of the spleen and along 
the course of the ureter (left) was complained of, and, in 
consequence, hot applications were ordered. 
The pain persisting, morphine was administered, and the 
patient subjected to dry-cupping, and this, in turn, followed 
by blistering. The granular effervescent lithiated potash 
was administered very freely. 
The quantity of urine being passed during this time 
amounted to one quart in the twenty-four hours. 
A microscopical and chemical examination of the urine 
at this time, by Dr. D. K. Shute, showed the presence of a 
very large number of leucocytes, triple phosphates, bladder 
epithelial cells, and granular debris; also the presence of 
albumen; no tube-casts; no epithelial cells from pelvis of 
kidney; no sugar. 
In consequence of necessity, the patient had not been 
able to comply with my recommendation as to rest. He 
was compelled to work at his occupation-scientific plumb- 
ing-in a rather damp place, which latter especially induced 
his bronchitis. The ordinary remedies for bronchial and 
vesical inflammation were administered, and followed by 
satisfactory results. The patient was visited daily. On De- 
cember 10th a slight fusiform enlargement was noticed in 
the left lumbar and inguinal regions. 
The patient was seen daily by me until December 19th. 
During this time the tumor was continuing to enlarge very 
much. The mere fusiform shape of the tumor during this 
time was becoming less and less noticeable, but on the 19th 
there was present a large bulging tumor extending from the 
crest of the ilium to the ribs, and from the lumbar around 
through the left inguinal and the hypogastric regions to 
the median line, even encroaching, to some extent, upon 
the right segment of the abdomen. Fluctuation at this 
period was easily detected. The constitutional symptoms 
at this time, as throughout the whole period of illness of the 
patient, were very slight. No chills, no sweats, scarcely any 
elevation of temperature. 
On December 19th Dr. S. C. Busey was called in as con- 3 
suiting physician, when it was decided to use the aspirating 
needle for purposes of exploration. 
The clinical history of the patient revealing the fact that 
previous enlargements had suddenly disappeared simultane- 
ously with copious discharges of urine, it was decided in 
consultation to await developments for awhile. 
Consequently, on December 20th and 21st, consultations 
of observation, if I may use such an expression, were held. 
On the 22d the parts had become so much distended that, 
after consultation with Drs. S. C. Busey and D. K. Shute, 
aspiration was deemed imperative. 
Even at this time there was scarcely any constitutional 
disturbance. The patient being anaesthetized I introduced 
one of Dieulafoy's large-sized aspirating needles (after a 
preliminary incision had been made through the integu- 
ment and fasciae) midway between the umbilicus and the 
anterior superior spine of the ilium, carrying the point of 
the needle obliquely upward, outward and backward. The 
needle penetrated the sac of the tumor with great difficulty, 
in consequence of its great toughness and unyielding nature. 
One gallon of bloody fluid was withdrawn, which, when 
subjected to examination by chemical analysis and the mi- 
croscope, revealed the following characters: A trace of al- 
bumen; alkaline reaction; sp. gr. 1.020; a large number of 
blood-corpuscles; a few spindle-shaped epithelial cells, etc. 
Unfortunately no examination was made to detect the pres- 
ence or absence of urea. 
On December 22d, prior to the aspiration, the urine was 
normal in color. That voided after the operation was 
bloody-looking-resembling very much the fluid drawn by 
aspiration. This latter fact inspired the hope that, probably, 
the obstruction being removed, the sac would not refill, 
and this hope was still further strengthened, inasmuch as 
there was no apparent increase in the size of the sac, and 
the amount of urine now being voided amounted to three 
pints (one pint in excess of what it was previous to the 
operation). These favorable conditions obtained for four 
days. During all this time, again, there were no constitu- 
tional symptoms. On the fourth day, however, there was a 
very perceptible refilling of the sac. The amount of urine 
passed this time amounted to over one quart-still bloody. 4 
On December 26th, after consultation with Drs. S. C. Busey, 
D. W. Bliss, and D. K. Shute, it was decided again to aspirate 
the patient. Local anaesthesia, by means of cocaine, being 
very satisfactorily induced, the sac was again aspirated, and 
one gallon of bloody fluid removed, resembling that previ- 
ously withdrawn, but being much richer in blood corpuscles, 
as revealed by the examination made by Dr. Shute. After 
the tapping a large compress was applied over the sac, and 
retained in position by Martin's elastic bandage, with the 
hope that they would aid the expulsion of the fluid and 
prevent its reaccumulation. 
On December 27th consultations were held, and the 
patient found in excellent condition. On the 28th there 
was no consultation. On the 29th a consultation was held. 
No reaccumulation of fluid apparent. Patient in excellent 
condition. 
On January 1, 1888, the fluid was evidently accumulat- 
ing again, presenting a swelling about the size of an orange, 
which gradually increased until January 5th, when it 
reached the dimensions of a small cocoa-nut and remained 
stationary until January 12th. No pain or fever during 
this time. Scarcely any soreness in the region of the 
"tapping" or of the spleen. 
On January 11th I saw the patient about six o'clock in 
the evening, and found him suffering with symptoms of 
acute indigestion-flatus causing dyspnoea, palpitation of 
the heart, and a pronounced hacking cough, which were 
greatly relieved for a time by the application of turpentine 
stupes and the administration of stomachics. 
The symptoms continued to some extent until 12 p. m., 
when the cough became very violent and was accompanied 
by the sudden expectoration of about half a pint of frothy, 
bloody fluid, very similar in appearance to the fluid that 
had been drawn by aspiration previously, as indicated by 
microscopic examination. Simultaneously with this ex- 
pectoration was the complete disappearance of the cocoa-nut 
swelling and the unpleasant symptoms, such as dyspnoea, 
etc. The patient, to use his own expression, " thought he 
had coughed the lump up;" no pain during all this time. 
On January 12th I saw the patient, in consultation with 
Drs. Busey, Bliss, and Shute. We found him in a comfort- 
able condition ; temperature, 99° F.; pulse, 100; no pain 5 
Physical exploration revealed absolute flatness over the 
entire lower lobe of the left lung and half of the upper lobe. 
Entire absence of vesicular murmur. No bronchial breath- 
ing. A very large number of moist rales were audible in 
the upper lobe. 
The first urine voided after these occurrences was now 
found to be perfectly clear, and the quantity voided in the 
twenty-four hours became very large, averaging more than 
half a gallon, and was normal in appearance. 
The fluid expectorated was subjected to chemical and mi- 
croscopical examination, and found to be like that drawn 
from the sac by aspiration in all essential respects. A fact 
of special interest to note is that this fluid was slightly al- 
kaline in reaction. 
On January 13th the expectoration continued, still bloody, 
though much diminished, and the constitutional symptoms 
continued to be insignificant. The lung gradually cleared 
up from above downward. There were a large number of 
moist rales throughout the whole lung. 
January 14th.-Gradual improvement; less cough and 
sputa; less blood in the sputa; lungs were clearing up very 
rapidly. 
January 16th.-Improvement very marked. Lungs en- 
tirely clear except at a very small portion of the lower part 
of the lobe. 
January 19th.-Consultation for "scientific inquiry." 
Lung entirely normal. 
January 22d.-Patient called at my office. He had been 
out riding for one hour in a cab. 
January 25th.-Patient went to a ball and danced several 
hours. 
March 7th.-Slight irritation about the neck of the 
bladder. Passed a slight concretion of uric-acid crystals. 
Lithiates were administered. 
March 10th.-Patient entirely well. 
April 12th.-Left for Denver, Col., to reside. 
In commenting upon the clinical history of this case, the 
first inference that necessarily thrusts itself upon my mind 
is that there must certainly be a congenital constriction of 
the left ureter, low down toward the bladder. 
The frequent attacks of pain and swelling in childhood, 6 
which were, upon the use of hot and counter-irritant appli- 
cations, relieved, with the simultaneous discharge of large 
amounts of urine, point, in my judgment, quite surely to 
this conclusion. 
The constriction must have been of such a nature that 
ordinary "colds," by inducing internal congestion, must 
have so engorged the mucous membrane of this left ureter 
as to cause complete occlusion of this small channel of exit 
for the urine. 
In explanation of the tremendous enlargement present in 
the patient during this last attack, we have the two potent 
factors-cold, causing congestion, and therefore great swell- 
ing of the mucous membrane of the ureter in the neighbor- 
hood of the constriction, and, probably a more efficient 
cause, extension of the inflammation to the congenitally 
weak point, in consequence of the acute cystitis. 
The simultaneous occurrence of these two factors pro- 
duced such intense inflammatory swelling that the procedure 
which had been formerly so successful now utterly failed; 
so that the three influences-continued excretion of the 
urine (to be referred to shortly), complete obstruction of the 
channel of exit, and thirdly, both of these conditions ob- 
taining for several days-all conjoined to bring about the 
tremendous enlargement present at the time of aspiration. 
It will be noticed from the clinical history that the color 
of the urine previous to the operation was normal where, 
after the operation, the urine became bloody-very much 
resembling the aspirated fluid. How is this to be accounted 
for? I think as follows: 
The inflammatory swelling of the ureter in the neighbor- 
hood of the constriction had very much subsided at the time 
of the operation, so that, as far as this factor was concerned, 
the urine (bloody) in the dilated ureter (dilated above the 
point of constriction, of course) was capable of flowing on- 
ward into the bladder; but, prior to this subsidence, the 
bloody urine had accumulated to so great an extent in the 
dilated ureter that now the element of mechanical pressure 
was superadded as an obstructing cause. 
Of course, when the mechanical pressure was relieved by 
aspiration the bloody urine from the left ureter was allowed 
to flow down into the bladder and discolor the clear urine 7 
in the vesical organ which had been coming from the right 
(and healthy) ureter. 
A very interesting fact to be noted from the clinical his- 
tory of this case is that, previous to the aspiration on De- 
cember 22d, the patient had been passing two pints of clear 
urine and after the aspiration three pints of bloody urine, 
which suggestive fact seems to indicate that the left kidney 
was not only not destroyed by pressure, but, on the contrary, 
w'as performing its function quite effectively. Moreover, 
since one gallon of fluid was withdrawn by the second as- 
piration, which occurred four days after the first one, the 
kidney was secreting daily one quart of urine. 
Another interesting fact to account for is the presence of 
blood in the aspirated fluid as well as in the urine after the 
operation. Evidently, again, the clinical history furnishes 
a very satisfactory explanation. 
On the night of January 11th the patient, after a paroxysm 
of violent coughing, expectorated a considerable amount of 
bloody fluid, closely resembling that drawn by aspiration- 
there occurring at the same time a complete disappearance 
of the swelling in the side. Evidently an ulcerative process 
had been going on for some time in the sac as well as through 
the diaphragm and related structures, in consequence of 
pressure, which ultimately permitted the contents of the di- 
lated ureter to break through the diaphragm into the lungs. 
This ulceration was the source of the blood which discolored 
the urine in the diseased ureter. 
Now what explains the fact, noted in the clinical history, 
that after this occurrence on the night of January 11th, the 
first urine voided was perfectly clear? It must be this: 
Simultaneously with the progress of the ulcerative process 
there occurred localized adhesive peritonitis as well as 
pleuritis, which prevented the pouring of the contents of 
the sac into the cavity of the peritoneum or that of the 
pleura. When the sac ruptured the ulcerated portion was 
carried by the force of the escaping fluid a sufficient dis- 
tance into the perforation to subject it to considerable 
pressure. This pressure was sufficient to control the flow of 
blood from the open blood-vessels into the fluid contents of 
the sac; consequently there was no more blood to discolor 
the urine in the dilated ureter or in the bladder; the bloody 8 
expectoration, which continued for a few days, with slight 
coughing, being accounted for by the ulcerated tissue. 
Probably the most interesting fact to observe in the clin- 
ical history of this patient is the entire absence of pneu- 
monia after the contents of the dilated ureter had broken 
into the lung. We know that normal urine is a most irri- 
tating fluid. In extravasation of urine from any cause, the 
most violent inflammation is excited in parts reached by 
this fluid. It is this fluid that prevents successful plastic 
operations upon the penis where the mucous membrane of 
the urethra is involved, etc. Why is it, then, that the urine 
in this left diseased and dilated ureter did not excite in- 
flammation in the delicate tissue of the lungs? We confi- 
dently expected pneumonia of a violent type to occur. How 
could we do otherwise a priori? But neither pneumonia 
nor any other inflammatory condition arose. 
I think the following is the explanation: 
It is a well-known fact that all the nutritive processes of 
the body take place in alkaline fluid. The tissues of the 
lungs are constantly bathed in alkaline fluid-the plasma 
of the blood-a fluid which is bland, soothing, and life-sus- 
taining. We have already noted that there was hemorrhage 
into the contents of the dilated ureter. This hemorrhage 
was quite profuse, entirely sufficient to impart to the urine 
a pronounced alkaline reaction. Therefore the fluid that 
came in contact with the delicate lung-tissue was not the 
acrid, irritating, acid, normal urine, that does so much 
harm, but urine that had become perfectly harmless and 
soothing by being made alkaline in consequence of the large 
amount of blood contained in it. 
I have already stated that the ulcerated portion of the sac 
was forced into the opening in the diaphragm, and subjected 
to pressure by which further hemorrhage was prevented. 
It was by this same means that any of the after-forming 
acid urine was prevented getting in contact with the lung- 
tissue. 
Very plainly, the clinical history of this case will exclude 
the presence of pyonephrosis or pyelitis, and just as plainly 
points to hydronephrosis. Moreover, it indicates a case of 
hydronephrosis the pathological conditions of which are of 
long standing, and one in which, strange to say, the kidney 
had not been destroyed by long-continued (though inter- 
mittent) pressure.