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The Year in Urology Volume 3 1st Edition John L.
Probert Digital Instant Download
Author(s): John L. Probert, Hartwig Schwaibold
ISBN(s): 9781904392828, 1904392822
Edition: 1
File Details: PDF, 2.02 MB
Year: 2006
Language: english
(A) Clinical Urology prelims 12/6/06 12:11 Page iii

THE YEAR IN
UROLO GY
VOLUME 3

EDITED BY

J O H N L P R O B E R T, H A R T W I G S C H W A I B O L D

CLINICAL PUBLISHING
OX F O R D
(A) Clinical Urology prelims 12/6/06 12:11 Page iv

Clinical Publishing
an imprint of Atlas Medical Publishing Ltd
Oxford Centre for Innovation
Mill Street, Oxford OX2 0JX, UK
Tel: +44 1865 811116
Fax: +44 1865 251550
E mail: [email protected]
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© Atlas Medical Publishing Ltd 2006

First published 2006

All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted, in any form or by any means, without the prior permission in
writing of Clinical Publishing or Atlas Medical Publishing Ltd

Although every effort has been made to ensure that all owners of copyright material
have been acknowledged in this publication, we would be glad to acknowledge in
subsequent reprints or editions any omissions brought to our attention

A catalogue record for this book is available from the British Library
ISBN 1 904392 82 2
Electronic ISBN 978 1 84692 570 2
ISSN 1479-5353
The publisher makes no representation, express or implied, that the dosages in
this book are correct. Readers must therefore always check the product information
and clinical procedures with the most up-to-date published product information and
data sheets provided by the manufacturers and the most recent codes of conduct
and safety regulations. The authors and the publisher do not accept any liability for
any errors in the text or for the misuse or misapplication of material in this work

Project Manager: Rosemary Osmond, Helimetrics Ltd, Chipping Norton, Oxon, UK

Typeset by Hope Services (Abingdon) Ltd, Abingdon, Oxon, UK
Printed by T G Hostench SA, Barcelona, Spain
(A) Clinical Urology prelims 12/6/06 12:11 Page v

Contents
Editors and contributors vii
Foreword xi

Part I
Diagnostic and general urology
1. Paediatric urology 3
Oliver Gee, Guy Nicholls, Mark Woodward

2. Advances in uroradiological imaging 15

Conor Corr, Mark Thornton

3. Quality of life 27
Katherine Kennedy, Ruaraidh MacDonagh

4. Trends in diagnostic uropathology 47

Jon Oxley

Part II
Urological oncology
5. Renal cell carcinoma 67
Sivaprakasam Sivalingam, Hartwig Schwaibold

6. Prostate cancer 87
Jonathan Osborn, Kieran Jefferson

7. Locally advanced and advanced prostate cancer 109

Heather Payne, Omar Al-Salihi

8. Phytotherapy in urology 129

Paul Crow, Mark Stott

9. Bladder cancer 143

Steve Williams, Hartwig Schwaibold, John Probert
(A) Clinical Urology prelims 12/6/06 12:11 Page vi

VI CONTENTS

Part III
Non-malignant conditions of the lower urinary tract
10. Urinary incontinence 171
Hashim Hashim, Paul Abrams

11. Lower urinary tract symptoms and suspected benign

prostatic obstruction in the ageing man 191
Alun Thomas, Mahmood Shafei

12. Andrology and erectile dysfunction 207

Chi-Ying Li, David Ralph

Part IV
New techniques and experimental developments
13. Trends in investigative urology 229
John Probert

14. New developments in cancer biology 249

Marto Sugiono, Toby Page, Malcolm Crundwell

15. Cryotherapy 267

Ulrich Witzsch, Anthony Koupparis

16. New minimal invasive techniques in urology 285

Evangelos Liatsikos, Jens-Uwe Stolzenberg

Acronyms/abbreviations 301
Index of papers reviewed 305
General index 321
(A) Clinical Urology prelims 12/6/06 12:11 Page vii

Editors
John L Probert, BMEDSCI, DM, FRCS(UROL)
Consultant Urological Surgeon and Senior Clinical Lecturer in Surgery,
Department of Urology, Western General Hospital, Weston super-Mare,
Somerset, UK
Hartwig Schwaibold, MD
Head of Urology Department, Kreiskliniken Reutlingen GmbH, Klinikum am
Steinenberg, Reutlingen Teaching Hospital, University of Tübingen, Tübingen,
Germany

Contributors
Paul Abrams, MD, FRCS
Professor of Urology, Bristol Urological Institute, Southmead Hospital, Westbury-
on-Trym, Bristol, UK
Omar Al-Salihi, BSC, MRCP, FRCR
Locum Consultant Clinical Oncology, Meyerstein Institute of Oncology,
University College London Hospitals, London, UK
Conor J Corr, FRCSI, FRCR
Specialist Registrar Radiology, Department of Radiology, Bristol Urological
Institute, Southmead Hospital, Westbury-on-Trym, Bristol, UK
Paul Crow, MD
Specialist Registrar, Torbay Hospital, Torquay, Devon, UK
Malcolm C Crundwell, MA, MD, FRCS(UROL)
Consultant Urologist, Department Urology, Royal Devon and Exeter NHS
Hospital, Exeter, UK
Oliver Gee, MBCHB, MRCS
Specialist Registrar in Paediatric Urology, Bristol Royal Hospital for Children,
Bristol, UK
(A) Clinical Urology prelims 12/6/06 12:11 Page viii

VIII EDITORS AND CONTRIBUTORS

Hashim Hashim MBBS, MRCS

Urology Specialist Registrar, Bristol Urological Institute, Southmead Hospital,
Westbury-on-Trym, Bristol, UK
Kieran P Jefferson, MA, FRCS(UROL)
Locum Consultant Urologist, Department of Urology, North Bristol NHS Trust,
Southmead Hospital, Westbury-on-Trym, Bristol, UK
Katherine P Kennedy, MBCHB, MRCS(EDIN), DTMH
Research Registrar, Department of Urology, Taunton and Somerset Hospital,
Musgrove Park, Taunton, Somerset, UK
Anthony Koupparis, BSC, MD, MRCS
Specialist Registrar in Urology, Royal United Hospital, Bath, UK
Chi-Ying Li, MB BS, MRCS(ENG)
Clinical Research Fellow, Institute of Urology, St Peter’s Andrology Centre,
London, UK
Evangelos N Liatsikos, MD, PHD
Lecturer of Urology, Department of Urology, University of Patras Medical School
Rio, Patras, Greece
Ruaraidh P MacDonagh, MBBS, FRCS, MD
Consultant Urologist, Department of Urology, Taunton and Somerset Hospital,
Musgrove Park, Taunton, Somerset, UK
Guy Nicholls, BSC, MD, FRCS(PAEDS)
Consultant Paediatric Urological Surgeon, Department of Paediatric Urology,
Bristol Royal Hospital for Sick Children, Bristol, UK
Jonathan R Osborn, MBCHB, MSC, MRCS
Research Fellow, Bristol Urological Institute, Southmead Hospital, Westbury-on-
Trym, Bristol, UK
Jon D Oxley, BSC, MD, MRCPATH
Consultant Histopathologist, Department of Cellular Pathology, North Bristol
NHS Trust, Southmead Hospital, Westbury-on-Trym, Bristol, UK
Tobias Page, MBBS, BSC, MRCS, PHD
Specialist Registrar, James Cook University Hospital, Middlesbrough, UK
Heather Payne, MD
Consultant in Clinical Oncology, Meyerstein Institute of Oncology, University
College London Hospitals, London, UK
(A) Clinical Urology prelims 12/6/06 12:11 Page ix

EDITORS AND CONTRIBUTORS IX

John L Probert, BMEDSCI, DM, FRCSUROL

Consultant Urological Surgeon and Senior Clinical Lecturer in Surgery,
Department of Urology, Western General Hospital, Weston super-Mare,
Somerset, UK
David Ralph, BSC, MS, FRCS(UROL)
Consultant Andrological Surgeon, Institute of Urology, St Peter’s Andrology
Centre, London, UK
Hartwig Schwaibold, MD
Head of Urology Department, Kreiskliniken Reutlingen GmbH, Klinikum am
Steinenberg, Reutlingen Teaching Hospital, University of Tübingen, Tübingen,
Germany
Mahmood Shafei, MCH, FRCSI
Specialist Registrar in Urology, Department of Urology, Royal Gwent Hospital,
Cardiff Road, Newport, UK
Sivaprakasam Sivalingam, MB, BCH, BAO, BMEDSCI, MRCS
Research Registrar, Bristol Urological Institute, Southmead Hospital, Westbury-
on-Trym, Bristol, UK
Jens-Uwe Stolzenberg, MD, PHD
Associate Professor, Department of Urology, University of Leipzig, Leipzig,
Germany
Mark Stott, MD, FRCS
Consultant Urologist, Royal Devon and Exeter NHS Hospital, Exeter, UK
Marto Sugiono, MBCHB, FRCS
Specialist Registrar, Royal Devon and Exeter NHS Hospital, Barrack Road, Exeter,
UK
Alun W Thomas, FRCS
Specialist Registrar in Urology, Bristol Urological Institute, Southmead Hospital,
Westbury-on-Trym, Bristol; Department of Urology, Royal Gwent Hospital,
Newport, UK
Mark J Thornton, MRCP, FRCR
Consultant Radiologist, Department of Radiology, Bristol Urological Institute,
Southmead Hospital, Westbury-on-Trym, Bristol, UK
Steve Williams, MRCS
Research Registrar, Department of Urology, Southmead Hospital, Westbury-on-
Trym, Bristol, UK
(A) Clinical Urology prelims 12/6/06 12:11 Page x

X EDITORS AND CONTRIBUTORS

Ulrich K Fr Witzsch, MD
Department of Urology and Paediatric Urology, Krankenhaus Nordwest der
Stiftung Hospital zum Heiligen Geist, Frankfurt/Main, Germany
Mark N Woodward, MD, FRCS(PAED)
Consultant Paediatric Urologist, Department of Paediatric Urology, Bristol Royal
Hospital for Sick Children, Bristol, UK
(A) Clinical Urology prelims 12/6/06 12:11 Page xi

Foreword
PAUL ABRAMS, MD, FRCS
Professor of Urology
Bristol Urological Institute
Southmead Hospital
Westbury-on-Trym
Bristol, UK

Welcome to the third volume of The Year in Urology.

Each of the volumes produced so far in this series has reviewed what the editors
of each individual chapter consider to be the best, most pertinent and most inter-
esting papers published in the academic urological literature during the year. The
contents list has deliberately been varied from volume to volume. In some years
more papers are published on a particular topic than in others; if this series were to
have identical chapter headings each time, then there would be the danger of mate-
rial becoming repetitive. This is why stone disease has not been included this time,
but there are chapters on Quality of Life and Phytotherapy, topics which have not
been covered before but which are increasingly becoming recognised as important
in the field of urology, with a considerable quantity of good quality research
appearing in the literature to reflect this.
The first part of the book also includes reviews by the regular expert contribu-
tors in the fields of paediatric urology, radiology and uropathology. As well as deal-
ing with phytotherapy, the uro-oncological section provides updates on bladder
cancer, renal cell carcinoma and prostate cancer, including a review of the treat-
ment options in advanced disease.
The third part of the book covers a similar brief to the previous volume, with
chapters on urinary incontinence, lower urinary tract symptoms with specific ref-
erence to benign prostatic hyperplasia, trauma and reconstruction, and andrology.
Finally, the ‘New Techniques’ section once again takes a look at the disparate
world of the basic sciences in the investigative urology chapter, and the more com-
plex world of molecular oncology in a chapter devoted to new developments in this
field.
Cryotherapy was a subject touched upon last year in a brief chapter that also
dealt with radiofrequency ablation and photodynamic therapy. This current vol-
ume is rounded out by a chapter devoted entirely to cryotherapy that covers the lit-
erature dealing with the use of this technique in treating both prostate and renal
tumours.
The aim of this series of books is to provide an up-to-date review of the latest
developments and findings in the world of urology, and the authors hope that they
are also giving the reader a taste as to which of these are going to be of greater
(A) Clinical Urology prelims 12/6/06 12:11 Page xii

XII FOREWORD

importance in the years to come. Only time will tell. The feedback for this series of
books has been excellent, and if anyone has any comments or has anything they feel
deserves greater coverage in future volumes, then the editors would be more than
happy to hear from them via the publisher.
(B) Clinical Urology Ch1 25/5/06 16:46 Page 1

Part I
Diagnostic and general urology
(B) Clinical Urology Ch1 25/5/06 16:46 Page 3

1
Paediatric urology
OLIVER GEE, GUY NICHOLLS, MARK WOODWARD

Introduction
A key systematic review concerning the role of circumcision in preventing urinary
tract infection (UTI) has been published among other papers. The late David
Gough was senior author on an important paper that looked objectively at the
results of hypospadias surgery. A series of papers looking at multicystic dysplastic
kidney (MCDK), the risk of hypertension and the outcome of nephrectomy for
renally mediated hypertension have also been considered. Finally, a number of key
papers on the undescended testis, varicocele and intersex are reviewed.

✍
Circumcision for the prevention of urinary tract infection in
boys: a systematic review of randomised trials and
observational studies
Sing-Grewal D, Macclessi J, Craig J. Arch Dis Child 2005; 90: 853–8

B A C K G R O U N D . Circumcision remains the commonest surgical procedure carried out

on boys worldwide. Although the absolute indications for circumcision are limited, a
number of urologists recommend circumcision to prevent UTI. This important
systematic review compared the rate of UTI in circumcised and uncircumcised boys.

I N T E R P R E T A T I O N . A total of 402 908 children, with 1953 separate UTI episodes,

were identified from the 12 studies analysed (one randomized control trial [RCT], four
cohort studies and seven case–control studies). Circumcision was associated with a
significantly reduced risk of UTI (odds ratio [OR] 0.13; 95% confidence interval [CI]
0.08–0.20; P <0.001) with the same odds ratio (0.13) for all three types of study
design. The authors identified weaknesses in this review: its reliance on observational
studies of variable quality, the single small RCT failed to achieve significance, and the
majority of studies measuring UTI episodes rather than number of patients experiencing
UTI. The authors used the risk ratio with estimates of UTI incidence and circumcision
complication rate to construct a harm-vs-benefits table (Table 1.1). They concluded that
circumcision should be considered in those boys with recurrent UTI or significantly
increased risk of UTI.

© Atlas Medical Publishing Ltd

(B) Clinical Urology Ch1 25/5/06 16:46 Page 4

4 I.DIAGNOSTIC AND GENERAL UROLOGY

Table 1.1 Benefit versus harm for circumcision in preventing urinary tract infection in
boys at different levels of risk for UTI per 1000 boys, assuming a complication rate of
2% and odds ratio of 0.13

Patient group Risk of UTI in un- UTI in UTI prevented Complications

UTI (%) circumcised circumcised by circum- of circum-
(n) (n) cision (n) stances (n)

Normal 1 10 1 9 20
Past UTI 10 100 13 87 20
High-grade VUR 30 300 39 261 20
UTI, urinary tract infection; VUR, vesicoureteric reflux.
Source: Sing-Grewal et al. (2005).

Comment
Circumcision, as a prophylactic measure for ‘medical conditions’, remains contro-
versial. This stringent and well-structured review finds that circumcision leads to a
decreased rate of urinary tract infections in boys. The authors acknowledge that it is
let down by the poor quality of the studies analysed, but few would disagree with
the paper’s findings. The interpretation of these findings, and how this should
influence clinical practice, is a more interesting topic.
This is well demonstrated by the conflicting perspectives published with the
article. Schoen’s |1| interpretation, a US author, is that this study backs routine
newborn circumcision for all boys, suggesting that the author’s summary is
‘analogous to postponing immunization of an infant until the child is exposed to
the pathogen or is diagnosed with the disease’. In contrast, Malone |2|, a UK author,
agrees with Sing-Grewal et al. that circumcision should be reserved for those boys
with recurrent UTI or those at increased risk of UTI.

✍
Inguinal hernia in female infants: a cue to check the sex
chromosomes?
Deeb A, Hughes IA. BJU Int 2005; 96: 401–3

B A C K G R O U N D . Complete androgen insensitivity syndrome (CAIS) arises from

target tissue androgen resistance and results in a female phenotype in a genotypical
XY male. This study reviews the clinical presentation of CAIS and assesses the
current practice of considering this diagnosis in female infants presenting with an
inguinal hernia.

I N T E R P R E T A T I O N . Patients were identified from the Cambridge Intersex Database,

and details of presentation, presence of hernia, hernial contents and family history of
CAIS were recorded. A questionnaire considering the diagnosis of CAIS, in female infants
with a hernia, was distributed to paediatric surgeons and endocrinologists. The intersex
database identified 120 cases of CAIS, and the presentation mode is shown in Fig. 1.1.
(B) Clinical Urology Ch1 25/5/06 16:46 Page 5

PA E D I AT R I C U R O L O G Y 5
Number of patients

80

70

60

50

40

30

20

10

0
IH FH PA AD
Fig. 1.1 The mode of clinical presentation of CAIS. IH, inguinal hernia; FH, positive
family history of CAIS; PA, primary amenorrhoea; AD, antenatal diagnosis. Percentages
of total number in each category are shown on the bars. Source: Deeb and Hughes
(2005).

There was an equal distribution of hernia side and half were bilateral. Gonads were
palpable in the hernial sac in a third of cases. The questionnaire response is shown in
Table 1.2, with most considering the diagnosis of CAIS in any female patient presenting
with inguinal hernia. The authors conclude that, as an inguinal hernia is the commonest
presentation of CAIS, it should be considered in all females with inguinal swellings. They

Table 1.2 Response to the questionnaire

Response, n

CAIS should be considered in: options Surgeons (87) Endocrinologists (64)

1 All female infants presenting with an 54 52
inguinal hernia
2 Only in female infants with bilateral 5
inguinal hernias
3 Only for inguinal hernias containing gonads 6 4
4 In female infants with a family history of 0 0
inguinal hernias (female sibling/cousin)
5 In infants with a family history of CAIS 6
(female sibling/cousin)
2 and 5 4 8
3 and 5 6
Other options chosen by surgeons:
Inspection of gonads and internal genitalia 4
CAIS diagnosis not worth considering as 2
association with hernia presentation is low
Source: Deeb and Hughes (2005).
(B) Clinical Urology Ch1 25/5/06 16:46 Page 6

6 I.DIAGNOSTIC AND GENERAL UROLOGY

felt investigation was justifiable, but the method should be decided upon by the
individual clinician.

Comment
This study reaffirms that CAIS should be considered in all girls who present with
inguinal hernias. The options of assessment by gonadal inspection, gonadal biopsy,
ultrasound and karotyping are all considered, without reaching any real conclusion
or suggestions. Common practice is to attempt to visualize the ovary or fallopian
tube in all females undergoing inguinal herniotomy. If this is not possible, blood
would be routinely sent intra-operatively for a subsequent karyotype to be
performed.

✍
An objective assessment of the results of hypospadias
surgery
Ververidis M, Dickson AP, Gough DCS. BJU Int 2005; 96: 135–9

B A C K G R O U N D . A number of different hypospadias repairs are used by paediatric

urologists worldwide. Recently, the Snodgrass repair has gained widespread
acceptance as it is reputed to have an excellent cosmetic outcome. However, there
are very few published reports of objective cosmetic outcome data, which was the
purpose of this paper.

I N T E R P R E T A T I O N . Five independent heath professionals used post-repair

photographs to compare the cosmesis of different hypospadias repair techniques. The
Snodgrass technique was used for both distal (10) and proximal (6) hypospadias by one
surgeon. A second surgeon performed the Mathieu repair for distal hypospadias
(10) and an onlay preputial island flap for proximal hypospadias (6). Cosmesis was
graded as poor, unsatisfactory, satisfactory or very good (1–4) for different aspects of
penile appearance: meatus, glans, shaft and overall appearance. One author assessed
the incidence of a vertical slit-like meatus.
The mean assessment score of the panel for each cosmetic variable is shown in
Table 1.3. The score for any aspect of cosmesis was significantly higher for the

Table 1.3 The mean assessment scores for the S and M/D groups

Meatus Glans Shaft Overall

Assessor S M/D S M/D S M/D S M/D

1 3.56 2.94 3.43 2.88 3.38 2.88 3.44 2.88

2 3.00 2.44 3.13 2.69 2.81 2.67 3.06 2.88
3 3.38 2.38 3.25 2.56 2.94 2.38 3.06 2.38
4 2.81 2.25 2.94 2.31 2.88 2.60 2.88 2.31
5 3.63 2.56 3.63 2.56 3.53 2.87 3.64 2.57
Source: Ververidis et al. (2005).
(B) Clinical Urology Ch1 25/5/06 16:46 Page 7

PA E D I AT R I C U R O L O G Y 7

Table 1.4 Comparison between the S and M/D onlay techniques

Feature Mean difference (95% CI) (SD) P

Meatus 0.76 (0.45–1.10) (0.25) 0.002
Glans 0.67 (0.38–0.97) (0.24) 0.003
Shaft 0.42 (0.16–0.69) (0.21) 0.01
Overall 0.62 (0.24–1.00) (0.30) 0.01
Source: Ververidis et al. (2005).

Snodgrass technique (Table 1.4). The incidence of vertically orientated meatus was
significantly higher for the Snodgrass repair (88%) than for the other technique group
(38%), P = 0.009. The horizontally orientated meatus, reported previously with the
Mathieu repair, was not found, and this technique could reproduce a vertical meatus
with minor modification. The authors note that this is a method for assessing the
outcome of hypospadias repair techniques by healthcare professionals. However, they
comment that this does not always equate with the patient’s or parents’ own
perceptions.

Comment
This interesting study strengthens the evidence that the Snodgrass repair can
produce a very good cosmetic result, perhaps even better than other techniques.
This study’s strength lies in the use of independent assessors, blinded to surgical
technique, to objectively evaluate cosmesis. However, this is only one facet in the
evaluation of penile appearance post hypospadias repair. A complete assessment
would include complication rates and, ideally, the patient’s own assessment of the
appearance. Most of the children undergoing this surgery would have been
circumcised as part of the repair, and there was no discussion as to the potential role
of the foreskin in cosmetic outcome. As the authors conclude, an ideal study to
compare cosmesis would be a multicentre, randomized, prospective trial involving
several surgeons, which is probably not feasible.

✍
Predictive factors of ultrasonographic involution of
prenatally detected multicystic dysplastic kidney
Rabelo EAS, Oliveira EA, Silva GS, Pezzuti IL, Tatsuo ES. BJU Int 2005; 95:
868–71

B A C K G R O U N D . Antenatal ultrasound (US) has resulted in a substantial increase in

the detection of asymptomatic MCDK. The authors of this study aimed to evaluate
possible predictive factors for the involution or disappearance of MCDK.

I N T E R P R E T A T I O N . Forty-five children with prenatally detected unilateral MCDK were

managed conservatively. US was performed 6-monthly for the first 2 years and yearly
(B) Clinical Urology Ch1 25/5/06 16:46 Page 8

8 I.DIAGNOSTIC AND GENERAL UROLOGY

thereafter. Variables analysed were: gender, affected side, palpability at first

examination, initial MCDK length (US) and contralateral kidney length. The mean (range)
follow-up was 50 (12–167) months with a mean of six ultrasounds per patient (3–10).
US showed partial involution in 30 (67%) children and complete involution in nine (20%).
The mean (95% CI) time to complete involution was 121 months (99–142). Twenty-two
(49%) were reduced by half the initial renal length, with a mean (95% CI) time of
76 (62–92) months. The MCDK length remained unchanged in six (13%) children. The
only factor predictive of complete involution was a renal length at diagnosis <62 mm
(hazard ratio 8; 95% CI 0.98–68; P = 0.05). Two children (4.5%) developed hypertension
during follow-up.

Comment
There is an increasing incidence of diagnosis of many conditions, such as MCDK,
by antenatal US, and it is therefore important to understand the natural history of
such conditions. This study has shown similar rates of complete involution of
MCDK to those reported previously, although at a slower rate. The only factor
apparently predictive of involution was length at diagnosis, but this finding needs to
be reproduced in larger studies if it is going to be used to counsel parents more
effectively.

✍
Risk of hypertension with multicystic kidney disease: a
systematic review
Narchi H. Arch Dis Child 2005; 90: 921–4

B A C K G R O U N D . Children with MCDK are usually managed conservatively in the first

few years of life. Blood pressure is monitored, as a number of reports have highlighted
a risk of hypertension, even after apparently complete MCDK involution. The authors
have conducted a systematic review of all published cohort studies, in order to
estimate the probability of a child with a conservatively treated unilateral MCDK
developing hypertension.

I N T E R P R E T A T I O N . In the follow-up period, six out of 1115 eligible children from

29 studies developed persisting hypertension (excluding four patients who developed
transient hypertension). The mean probability of a child with unilateral MCDK developing
hypertension was therefore 5.4 per 1000 (95% CI estimated at 1.9–11.7 per 1000). The
follow-up period, in the 15 studies in which it was stated, varied between 0.2 and
13 years (range of means 3–5.3 years). The authors commented on weaknesses in their
review: hypertension was not uniformly defined and the older studies would have missed
antenatal diagnosis.

Comment
This study demonstrates that the risk of developing hypertension in childhood
secondary to MCDK is low, at approximately 1 in 200. This figure can be used for
(B) Clinical Urology Ch1 25/5/06 16:46 Page 9

PA E D I AT R I C U R O L O G Y 9

counselling parents if an MCDK fails to involute in infancy. However, the available

data do not indicate whether MCDK involution is associated with a reduced risk of
hypertension, and further longer-term studies are vital to quantify the risk of
hypertension in adulthood.

✍
The role of unilateral nephrectomy in the treatment of
nephrogenic hypertension in children
Johal NS, Kraklau D, Cuckow PM. BJU Int 2005; 95(1): 140–2

B A C K G R O U N D . Paediatric hypertension is most commonly secondary to renal

disease, with a prevalence in children of 0.5 –1.5%. This study aimed to define the
efficacy of unilateral nephrectomy in patients presenting with benign renal disease
and hypertension and a normal contralateral kidney.

I N T E R P R E T A T I O N . Twenty-one children undergoing nephrectomy for hypertension

(defined as a systemic blood pressure [BP] >95th centile for age and height) between
1968 and 2003 were reviewed retrospectively. Blood pressure and medication
requirements were compared before and after surgery.
The median age at presentation was 5 years (birth–12 years) with all patients
having persistent hypertension, despite treatment with between two and four
anti-hypertensives. The time from diagnosis to surgery was 11 (0–105) months, with
a follow-up of 39 (1–169) months. After nephrectomy, 76% (16/21) stopped
anti-hypertensives and became normotensive. Four patients were able to reduce the
number of anti-hypertensives, and only one patient had no response to nephrectomy.
The median time to BP normalization was 7 (1–120) days, which varied with different
histological groups.

Comment
Paediatric hypertension secondary to unilateral renal disease occurs reasonably
frequently, and lifelong medical treatment is potentially necessary. The authors
concluded that nephrectomy is successful in normalizing nephrogenic hyper-
tension in most cases, and that children may benefit from early nephrectomy to
reduce the potential morbidity from this condition.

✍
Apoptosis and proliferation in human undescended testes
Ofordeme KG, Aslan AR, Nazir TM, Hayner-Buchan A, Kogan BA. BJU Int
2005; 96: 634–8

B A C K G R O U N D . Cryptorchidism is associated with decreased fertility and reduced

sperm counts. Animal data suggest that this may arise as a result of a decrease in
germ cell proliferation or an increase in apoptosis. In this study, testicular biopsies
taken at orchidopexy from a consecutive series of patients were studied using
immunohistological techniques.
(B) Clinical Urology Ch1 25/5/06 16:46 Page 10

10 I.DIAGNOSTIC AND GENERAL UROLOGY

Table 1.5 Apoptosis rates according to age at orchidopexy and testicular location at
operation

Testicular location Mean (SD) no. of

at operation apoptotic cells

Inguinal (n = 83) Abdominal (n = 18)

Orchidopexy <1 year (n = 29) 25 4 1.35 (1.56)

Orchidopexy >1 year (n = 72) 58 14 0.68 (1.40)
Mean (SD) no. of apoptotic cells 0.71 (1.31) 1.63 (1.95)
Source: Ofordeme et al. (2005).

I N T E R P R E T A T I O N . Biopsies were taken from 101 undescended testes from children

between 2 months and 15 years of age (median age 23 months). The numbers of cells
undergoing apoptosis or proliferation, per 50 seminiferous tubules, was recorded. Five
testicular biopsies from autopsy cases were used as controls (age range
26–156 months).
Apoptosis was identified in all specimens (Table 1.5). Rates were generally low, but
were higher in the controls (mean [SD] 10.6 [1.34] per 50 seminiferous tubules). There
was less apoptosis in children >1 year than in children <1 year (P <0.03), and in the
inguinal testes compared with the intra-abdominal testes (P <0.02). Proliferation was
very limited in all the biopsies and again more common in the autopsy controls, although
no data were supplied in the paper.

Comment
This study showed that the reduced fertility associated with undescended testes
cannot be explained by either reduced proliferation or increased apoptosis of
testicular germ cells at the time of surgical intervention. It remains possible that the
testis simply has fewer germ cells, or that abnormalities in germ cell turnover occur
before 6 months of age.

✍
Managing varicoceles in children: results with microsurgical
varicocelectomy
Schiff J, Kelly C, Goldstein M, Schelgel P, Poppas D. BJU Int 2005; 95:
399– 402

B A C K G R O U N D . Varicocele in childhood may be associated with symptoms or growth

arrest of the ipsilateral developing testis. A number of different surgical procedures
are used, with the majority of surgeons favouring the Palomo procedure. The authors
in this retrospective study describe their experience of microsurgical varicocelectomy
(MSV) in boys <18 years old, over a 4-year period in a single institution.

I N T E R P R E T A T I O N . Subinguinal varicocelectomies were performed assisted by an

operating microscope (× 10 –15). The technique involves mobilizing the spermatic cord at
Other documents randomly have
different content
 This idea is not hypothetical; the injections of which I have spoken
are the most evident proof of it. Let it not be said that it is a
transudation after death, analogous to that of the bile through the
gall-bladder: if it were so, not only the fine fluids injected would go
out by the excretories and the exhalants, and return by the veins;
but in oozing through the pores, they would fill the whole cellular
texture. On the contrary, nothing escapes into the cellular texture,
around the vessels by which the injection passes; there is then a
continuity of tubes from the artery which has received the fluid, to
the excretory, the exhalant, or the vein which transmits it.
These are the communications of the capillary system that explain
how the skin becomes livid on the place on which a dead body has
for a long time lain, as on the back, for example; how by turning a
dead body, so that the head may hang down, it becomes full of
fluid; how, on the contrary, by placing upright the body of one dead
from apoplexy, asphyxia, &c. the capillary system of the face is freed
in a great measure from the blood it contained; how an erysipelas
disappears on a dead body, when the blood, arrested during life on a
part of the skin, by the vital action, is spread after death to all the
surrounding parts; how every kind of analogous redness of the skin,
and even of the serous surfaces, disappears because the blood goes
by the communications of the capillary system to the neighbouring
organs. During life the tonic action retains the fluid in a determinate
part; abandoned to its gravity, and other physical causes, after
death, it soon disappears from the part in which it was accumulated,
on account of the innumerable communications of the general
capillary system.
I would observe to those who examine dead bodies, that these
considerations are very important. Thus we must not judge of the
quantity of blood which penetrated the inflamed peritoneum or
pleura, by what is seen twenty-four hours after death; local irritation
was a permanent cause that fixed the blood in the part; this cause
having ceased, it escapes from it. A serous membrane may have
been very much inflamed during life, and yet exhibit almost its
natural appearance after death; as it is in erysipelas. I should have
been often tempted from opening dead bodies, to deny the
existence of an affection which had been real. The same remark
applies to the inflamed cellular texture, the mucous surfaces, &c.
Examine a subject that has died of angina, which during life gave
the deepest red colour to the pillars of the velum pendulum pelati, to
the velum itself and the whole pharynx; after death, the parts
assume nearly their natural colour.
I would observe that in this respect it is necessary to distinguish
acute from chronic affections. In the chronic inflammations, for
example, of the pleura, of the peritoneum, &c. the redness continues
after death, because the blood is combined, as it were, with the
organ; it makes a part of it, as it makes a part of the muscles in a
natural state. So the chronic affections of the skin, of the mucous
surfaces, retain after death nearly the same blood, that they had
during life; whereas in acute affections, the blood retained for a time
by irritation, escapes when life has ceased, upon which this irritation
depended. These principles can be applied to many diseases; I
repeat it, they are of great importance in examining bodies. The
neglect of them has often led me into an error, upon the degree and
even the existence of acute inflammations, of which the organs that
I examined had been the seat.

V. How, notwithstanding the general communication of

the Capillary System, the Blood and the Fluids differing
from it, remain separate.

Since in the dead body, and consequently during life, there is in

the capillary system no organic obstacle to the communication of the
fluids through its small branches; since the general net-work that
these vessels form is everywhere free, how does it happen that the
blood does not pass into the part destined to the white fluids? how
is it that these do not enter where the blood is to circulate? Why
does not this fluid go out by the exhalants and the excretories, since
these tubes communicate with the arteries by the anastomoses of
the capillary system? This depends wholly upon the relation which
exists between the organic sensibility of each part of the capillary
system, and the fluid that it contains. That which carries the blood,
finds in all the other fluids irritants that make it contract at their
approach; and reciprocally, where the other fluids belong, the blood
would be a foreign fluid. Why does the trachea admit air, and reject
every other fluid? Why do the lacteals choose only chyle from the
contents of the intestines? Why does the skin absorb certain
substances, and repel others, &c.? It all depends upon this, that
each part, each portion of an organ, every organic particle, has its
own sensibility, which is in relation only with one substance, and
repels others.
But as this kind of sensibility is remarkably subject to vary, its
relation to substances foreign to the organ changes also; thus the
part of the capillary system which rejected blood, admits it at the
moment when its sensibility has been increased. Irritate a part of the
skin, it reddens in an instant; the blood flows there; while the
irritation continues, it remains; when it ceases, it disappears.
Whatever be the external means which raise the cutaneous or
mucous sensibility, we observe the same phenomenon. We can in
this way bring more or less blood into some parts of the capillary
system. Bring the hand to the fire, the heat exalts the sensibility of
its system, more blood enters it; take it away, this property resumes
its natural type, and the blood is brought back to its ordinary
quantity. The internal organs which are subjected less to the causes
of excitement, have less varieties in their capillary system; yet,
however, there are many, and all arise from the same principle.
A series of organized tubes are unlike an assemblage of inert
ones. These last require mechanical obstacles to prevent the
communication of fluids with each other; where there is a
communication between the tubes, there is a communication in the
fluids. On the contrary, in the living economy, it is the peculiar
vitality with which each tube is animated, which serves for an
obstacle and a limit to the different fluids; this vitality performs the
part of different machines that we place in the communicating tubes,
to separate them from each other. Every organized vessel is then
truly active; it admits or rejects fluids which enter there, according
as it is able or not to support their presence. Disproportion of
capacity has nothing to do with this phenomenon; a vessel may have
mere than four times the capacity of the particles of a fluid, and yet
refuse to admit them, if this fluid is repugnant to its sensibility. It is
in this point of view that the theory of Boerhaave has a great defect.
At the period in which this physician wrote, the vital forces had
not been analyzed. It was necessary to employ physical forces to
explain vital phenomena; hence it is not astonishing that all his
theories are so incoherent. In fact, theories in the vital phenomena
borrowed from physical forces, exhibit the same inadequacy, as
those would in the physical phenomena borrowed from vital laws.
What would you say, if in explaining the motion of the planets,
rivers, &c. they should talk of irritability and sensibility? you would
think it absurd; it is equally absurd, in explaining the animal
functions, to talk of gravity, impulse, inequality of the capacity of the
tubes, &c.
Observe, that the physical sciences made no progress until they
analyzed the simple laws that preside over their innumerable
phenomena. Observe also, that medical and physiological science
was not accurately explained, until the vital laws were analyzed, and
it was shown that they were everywhere the principles of the
phenomena. See with what ease all those of the secretions,
exhalations, absorptions, inflammation, capillary circulation, &c. are
referred to the same principles, flow from the same data, by deriving
them all from their real cause, the different modifications of the
sensibility of the organs which execute them. On the contrary, see
how each presented a new difficulty, when the mechanical causes
were employed to explain them.
From what has been said, it is then evident, that in the
innumerable variations of which the fluids of the capillary system are
susceptible, in the different portions of the system which they fill,
there is always antecedent variations in the sensibility of the vascular
parietes; these varieties produce the first.
It is especially in the capillary system and its circulation, that the
variations of the organic sensibility of the vessels produce varieties in
the course of the fluids; for as I have observed, in the great arterial
and venous trunks, in the heart, &c. the fluids are in too large
masses, and they are agitated by too strong a motion, to be thus
immediately subjected to the influence of the vascular parietes. Thus
when nature wishes to prevent the fluids from communicating in the
trunks, it places among them valves, or other analogous obstacles,
which become useless in the capillary system.
Though the anatomical arrangement be the same in the living and
the dead body, there is then a very great difference in the course
through the capillary system, in one and the other. Push, into the
aorta of an animal in whom you destroy life by opening this artery to
fix in it a syringe, different fine fluids; you will never see them fill the
capillary system, pour out by the exhalants, the excretories, &c. as
when the subject has been some hours deprived of life. The organic
sensibility inherent in the parts repels the injection; it can only
circulate in the great trunks, in which there is a large space. I have
injected, with other views, a great number of times, fluids by the
arteries and the veins; now, the capillary system is never filled with
these fluids; they circulate only in the great vessels, when the
animal can bear them. Mr. Buniva has also made comparative
experiments with injections upon living animals and those deprived
of life; he has experienced in the first a resistance which he has not
found in the other; now this resistance is in the capillary system,
whose vessels refuse to admit a fluid to which their organic
sensibility is not accommodated.

VI. Consequences of the preceding principles, in relation to

Inflammation.
 From what has been said thus far, it is easy, I think, to understand
what takes place in the inflammatory phenomena, considered in
general.
If a part be irritated in any manner, immediately its organic
sensibility is altered, and increased. Without previous connexion with
the blood, the capillary system is then placed in relation with it; it as
it were calls it there; it flows there and remains accumulated until
the organic sensibility returns to its natural type.
The entrance of the blood into the capillary system is then a
secondary effect of inflammation. The principal phenomenon, that
which is the cause of all the others, is the local irritation which has
changed the organic sensibility; now this local irritation may be
produced in different ways; 1st, by an irritant immediately applied,
as a straw upon the conjunctiva, cantharides upon the skin, acrid
vapours upon the mucous surface of the bronchia or the nasal
cavities, atmospheric air upon any internal organ laid bare, as we
see in wounds, &c.; 2d, by continuity of organs, as when a part of
the skin, of the pleura, &c. being inflamed, those that are near it are
also affected, and the blood flows there, as when one organ is
diseased, that which is near it becomes so by the cellular
communications; 3d, by sympathies; thus the skin being seized with
cold, the pleura is sympathetically affected; its organic sensibility is
increased, the blood immediately enters it from every part. When
this property is raised in one of these three ways in the capillary
system, the phenomena that result from it are the same. For
example, when in the pleura it is raised because the air is in contact
with this membrane, because the lungs that it covers have been first
affected, or because coin has seized upon the skin in sweat, the
effect is nearly analogous, as it respects the entrance of the blood in
the capillary system.
It is then the change that takes place in the organic sensibility,
that constitutes the essence and the principle of the disease; it is
this change which makes a pain more or less severe soon felt in the
part; then the sensibility that was organic, becomes animal. The part
was before sensible to the impression of the blood, but did not
transmit this impression to the brain; then it transmits it, and this
impression becomes painful. Irritate the healthy pleura in a living
animal; it does not suffer; irritate it on the contrary during
inflammation, and it gives signs of the most acute pain. Who does
not know that most often and almost always, a pain more or less
acute is perceived in the part, some time before it becomes red?
Now this pain is the indication of the alteration that the organic
sensibility undergoes; this alteration exists some time, often without
producing an effect; this effect, which is especially the afflux of
blood, is subsequent.
It is the same of heat. I shall say hereafter how it is produced. It
is sufficient now to show that it is, like the passage of the blood in
the capillary system, only an effect of the change that has taken
place in the organic sensibility of the part; now this is evident, since
it is always consequent upon this change.
There happens then in inflammation exactly the reverse of what
Boerhaave thought. The blood accumulated according to him, in the
capillary vessels, and pushed à tergo by the heart, as he termed it,
was truly the immediate cause of the affection, whereas, from what
I have said, it is only the effect.
If we reflect a little upon the innumerable varieties of the causes
which can alter the organic sensibility of the capillary system, it will
be easy to understand of what infinite varieties inflammation is
susceptible, from the momentary blush that comes and goes in the
cheeks, to the most serious phlegmon and erysipelas. We might
make a scale of the degrees of inflammation. By taking the
cutaneous, for example, we should see at the bottom the redness
that arises and disappears suddenly by the least external excitement
upon the dermoid system, which we can produce at will, and in
which there is only an afflux of blood; then those that are a little
more intense, which occasion cutaneous efflorescences of some
hours, but without fever; then those that continue for a day, with
which there is some fever; then erysipelas of the first order; then
that which is more intense, and which gangrene soon terminates. All
these different degrees do not suppose a different nature in the
disease; the principle of them is always the same; there is always,
1st, an antecedent increase of organic sensibility, or alteration of this
property; 2d, afflux of the blood only if the increase is not great,
afflux of the blood, heat, pulsation, &c. if it is. As to fever, it is a
phenomenon common to every severe, acute local affection; it
appears to depend on the singular relation which connects the heart
with all parts; it has nothing peculiar in inflammation, but the
particular modification it receives from it.
The afflux of the blood in an irritated part takes place in
inflammation, as in an incision. In this the divided point has been
irritated by the instrument; soon the whole blood in the
neighbourhood flows there and escapes by the wound. This afflux is
so evident a result of irritation, that in a slight incision, the blood
scarcely flows at the instant of the division of the integuments,
because there is but little of this fluid at the divided place; but a
moment after, the irritation which has been felt, produces its effect,
and it flows in a quantity disproportioned to the incision.
When the alteration of the organic sensibility which produces
inflammation, has no varieties except in its intensity, the
inflammation itself differs only in degree. But the nature of the
alteration is oftentimes different; a feeble character is frequently
united with it; the part has then less redness, heat, &c. Other
modifications are also observed; now all these depend upon the
difference of the alterations that the organic sensibility experiences;
at least these alterations always precede them.
The influence of these alterations is not less evident when
inflammation terminates, than when it begins. If the organic
sensibility has been so raised, that it is as it were exhausted, then
the solid dies, and the fluid, which is no longer in a living organ,
soon becomes putrid. Examine the phenomena of every gangrene;
putrefaction is certainly only a consequence; there is always, 1st, a
desertion of the solids by the vital forces; 2d, putrefaction of the
fluids. The first is never a consequence of the second. When the
organic sensibility begins to diminish, the blood brought there by
inflammation is already susceptible of putrefaction; but the defect of
tone in the solid always precedes. There is this local phenomenon,
as well as the general, in putrid fever. It is incontestable that in this
fever, the blood has a tendency to be decomposed, to become
putrid; I will say further, that it often exhibits a commencing
putrefaction. The index of the alteration of this fluid is always the
general state of the forces of the solids; these have first lost their
spring; the symptoms of weakness are evident before those of
putridity. All the animal fluids tend naturally to putrefaction, which
takes place inevitably when life abandons the solids in which they
circulate. In proportion as the forces diminish in the solids, this
tendency is manifested. A commencement of putrefaction in the
fluids during life, is not a general phenomenon more improbable
than the local phenomenon of which we have spoken, viz. that the
blood of an inflamed part begins to putrefy and the part
consequently becomes fetid, before the organic sensibility has
entirely abandoned the solid. It is only when this ceases, that this
putrefaction becomes complete; but then it is extremely rapid,
because it had commenced during life. So bodies that have died of
putrid fevers decompose with a rapidity far surpassing those that
have died of other diseases, because putrefaction had really
commenced before death.
Inflammation with a livid colour, small degree of heat, prostration
of the forces in the part, and termination by gangrene, is evidently
to well marked adynamic fever, what phlegmon is to inflammatory
fever, what irritation of the primæ viæ, which is called bilious
affection, is to the meningo-gastric fever, &c. I think if we examine
attentively local affections and general fevers, we shall always find a
particular kind of fever corresponding in its nature to a particular
kind of local affection. But let us return to inflammation.
If it terminates by suppuration, it is evident that there is a new
alteration of the organic sensibility to produce pus. The same thing
in scirrhus. The termination by resolution takes place when this
sensibility returns to its natural type. Examine well the inflammatory
phenomena in their succession; you will see, that always a particular
state in this property, precedes the changes they exhibit.
When our medicaments are applied upon an inflamed part, it is
not upon the blood that they act; it is not by lessening the heat, or
relaxing. The expressions to soften, unbend and relax the solids, are
inaccurate, because they are borrowed from physical phenomena.
We relax, we soften dry leather by moistening it; but we only act
upon the living organs, by modifying their vital properties. Observe
that though we already begin to recognize the empire of these
properties in diseases, medical language is still wholly borrowed
from theories which employ physical principles in the explanation of
morbid phenomena. We have arrived at a period when the manner
of expressing ourselves upon these phenomena should be changed;
I do not here speak of the names of diseases. Certainly every
emollient, astringent, discutient, relaxing, tonic, medicament, &c.
employed with different views upon an inflamed part, only acts by
modifying differently from what it was, organic sensibility. It is thus
that our medicaments cure or often aggravate diseases.
From what has been said, it is evident that the solids perform the
first part in inflammations, and the fluids only the second. Modern
authors have perceived this truth, and they have immediately
assigned an important part, in this respect, to the nerves; but we
have seen that these appear foreign to organic sensibility, that they
are so even after the most rigorous observation. The nervous
influence, that at least which we know in other parts, is, in
inflammation, as in secretion, exhalation and nutrition, almost
entirely wanting. There is in this affection, unalteration of the
organic sensibility, and this is every thing.
The kind of blood varies in inflammation, and in this respect, I
think the following rule is generally uniform; whenever the organic
sensibility is much raised, the life augmented and there is an
increase of forces in the inflamed part, then it is the red blood that
remains in the capillary system; then there is always great heat
there. On the contrary, when the inflammation approaches the putrid
character, the part becomes of a dull and livid colour; the capillaries
appear to be filled with black blood; the heat is less. In general, a
bright colour, in all eruptions analogous to inflammatory tumours,
announces the increase of the organic sensibility. A livid colour, on
the other hand, indicates its prostration; petechiæ are livid;
scorbutic blotches are so; a livid colour in tumours is the forerunner
of gangrene. Do you wish to know when cold acts as a stimulant? It
is when it reddens the end of the nose, the ears, &c. When these
parts become livid, other phenomena announce at the same time,
that its action is sedative. This is supported by my experiments upon
life and death, which have proved that the black blood everywhere
interrupts the functions, weakens, annihilates even the motion of the
parts, when it is brought to them by the arteries.

Differences of Inflammation, according to the different Systems.

From what has been said upon inflammation, it appears that it has
for its seat the capillary system, for its principle an alteration in the
organic sensibility of this system, for its effect the afflux of blood
into vessels in which it did not before circulate, a consequent
increase of caloric, &c. Now where the capillary system is more
developed, where the organic sensibility is greater, inflammation
ought to be more frequent; and this is the case. It is especially in
the cellular, serous, mucous and dermoid systems that we observe
it; fine injections demonstrate in these systems a capillary net-work
infinitely superior to that of the others. Besides, as if there is not
only nutrition, but also exhalation and oftentimes secretion in these
systems, there must be more organic sensibility, a property from
which all these functions are derived.
On the contrary, inflammation is rare in the muscular, osseous,
cartilaginous, fibrous, arterial, venous systems, &c. where there are
but few capillaries, and where the organic sensibility presiding only
over nutrition, is necessarily found in a less degree.
 Besides, as the capillaries make an integral part of the system
where they are found, and as each system has its peculiar kind of
organic sensibility, it is evident that they ought to partake of this
kind; now as it is upon this property that all the inflammatory
phenomena depend, they ought to present an aspect wholly
different in each system. This is what we shall be convinced is the
case by an examination of each. I shall only present here generally,
that essential point of view, upon which authors have not insisted.
Let us take first the systems most exposed to inflammation; we
shall see that phlegmon is the inflammatory kind of the cellular,
erysipelas that of the dermoid, and catarrh that of the mucous. We
have not yet a general name to express that of the serous; but who
does not know how it differs from the others?
In the systems rarely subject to inflammation, we know this
affection infinitely less than in the preceding; but there is no doubt
that it differs essentially. Compare the length and permanency of
that of the bones, with the rapidity and disposition to change of that
of the muscles, or rather of the fibrous bodies, in rheumatism.
The results of inflammation do not vary less than its nature; if
resolution does not take place, each has its own mode of
suppuration. Compare the pus of erysipelas, that of phlegmon, the
milky or flocculent fluid of the serous membranes, the whitish or
greyish humour, of a mucous consistence, that escapes from the
membranes of the same name after catarrh, the blackish sanies of
the bones in suppuration, &c. We shall see that some organs, as the
fibrous bodies, do not suppurate.
Gangrene once taken place, is everywhere the same, since it is
only the absence of life, and all dead organs have the same
properties. But according to the sum of organic sensibility which
each system has, it is more or less disposed to die after
inflammation, in the midst of others which retain their life. Who does
not know that the carbuncle which soon kills the part it seizes, only
attacks certain systems; that the osseous, the cartilaginous, the
nervous, &c. are always exempt from it?
The essential fault of every medical doctrine is that of considering
diseases too abstractedly; they are so modified in each system, that
their aspect is wholly different. If I may be allowed the expression, it
is always the same individual, but in entering each system, it has a
different appearance there, so that often you cannot recognize it.
When will medicine be so far advanced that the treatment will
correspond with these varieties? There should certainly be a general
treatment of inflammation; but it should be modified differently,
according as we apply it to phlegmon, erysipelas, catarrh, &c.
This then is a very evident proof of that peculiar character which
inflammation takes in each part. We know with what ease and
rapidity the blood flows to any part of the skin in consequence of
irritation there; prick or rub briskly a part of this organ, it reddens in
a moment. This takes place also, though less sensibly, on the
mucous surfaces. This is not equally seen upon the serous; I have
frequently ascertained this on living animals, when I have laid bare
these surfaces and irritated them in different ways. The afflux of the
blood does not immediately follow the irritation: there is always an
interval between one and the other, never less than an hour.

VII. Structure, and Properties of the Capillaries.

What is the structure of the capillaries? So great is their tenuity

that we evidently cannot have upon this point, any kind of data
founded upon experiment and observation. Only it is very probable,
it is even certain, that this structure is modified differently in each
organ, that it is not the same in the tendons, the aponeuroses, the
muscles, &c. that it really partakes of the nature of the organ of
which it makes an integral part.
The membrane which lines the excretories, the arteries, the veins,
the exhalants, vessels which go into the system of the capillaries or
come out of it, is very like that of these capillaries; but it is not
certainly the same.
It is the diversity in the structure of the capillaries, according to
the organs in which they are found, which has an essential influence
upon the difference which the vital properties exhibit, particularly the
organic sensibility and the insensible organic contractility in each
system in which we examine them; hence peculiar modifications in
all those diseases over which these properties preside, and which
are seated especially in the capillaries, such as inflammations,
tumours, hemorrhages, &c. &c.
The difference in structure of the capillary system, sometimes
becomes manifest to the eye. Thus the spleen, the corpus
cavernosum, instead of presenting, like the serous surfaces, a
vascular net-work in which the blood oscillates in different directions,
according to the motion it receives, exhibit only spongy, cancellated
textures, whose nature is but little known, in which the blood
appears often to stagnate, instead of moving, &c.

VIII. Of the Circulation of the Capillaries.

The circulatory phenomena are of two kinds in the capillary

system: 1st, there is the motion of the fluids; 2d, the alterations
which they undergo.

Motion of the Fluids in the Capillary System.

These fluids are, 1st, the blood; 2d, others differing from it in their
composition, though we only know their differences of appearance.
Let us examine the laws of the motion of each kind.
The blood, after it has entered the capillary system, is evidently
beyond the influence of the heart, and only circulates by that of the
tonic forces, or the insensible contractility of the part. If we examine
the phenomena of this capillary system but little, we shall be easily
convinced of this truth, which Bordeu first taught. The capillary
system is really the boundary, beyond which the influence of the
heart does not extend. Hence why all the vessels that go out of this
system, exhibit in the fluid they contain a motion that does not
correspond with that of the arteries that go to it. 1st. After what we
have said, there is no doubt of this, as it regards the veins. 2d. It is
also true as it respects the excretories. The increase of secretions
does not correspond with the increase of the action of the heart, nor
does their diminution with the diminution of the pulsations. Who
does not know, on the contrary, that often in a violent paroxysm of
fever, in which the agitation of the arterial blood is very great, all the
glands seem to shut up their ducts and not to pour out any fluid?
3d. It is the same with all the exhalations; it is not when a fever is
the greatest, that we sweat the most, but when it is somewhat
diminished. Hemorrhages are evidently but an exhalation; now who
does not know, that the pulse is often very weak, when the blood
flows abundantly from the mucous surfaces of the womb, the
nostrils, the bronchia, &c.? Who does not know on the contrary that
in extreme agitations of the heart, most often the blood does not
flow by the exhalants? Is the quickness of the pulse increased during
menstruation? It is the redness of the capillary system, the
abundance of the blood of this system, which is often, as I have
said, the forerunner of active hemorrhages; but it is never the
increase of the action of the heart. Oftentimes fungous tumours, soft
flesh that shoots up in wounds of a bad nature, polypi, &c. pour out
blood; the heart has nothing to do with these hemorrhages, they
come evidently from the capillary system. Who does not know, that
frequently when the exhalants pour out copiously serous fluids upon
the membrane of that name, in the production of dropsies, the heart
is, like all the other parts, in a state of real inertia?
Since then all the vessels going from the capillary system exhibit
in their motions no sort of harmony with those of the heart, it is
evident that the influence of this organ is interrupted, is terminated
at the capillary system.
 Observe nutrition; it is clearly the capillary system that distributes
everywhere the materials that it has received by the impulse of the
heart; now the influence of this does not extend to the place where
the nutritive matter is deposited. In fact, its impulse everywhere
equal and uniform, pushes the blood with nearly an equal force to all
parts, with some exceptions in the fœtus. Now nutrition is on the
contrary extremely unequal; at one age, it is one part that takes
more increase, consequently receives more nutritive matter; at
another age, it is another organ. This inequality, is the first and
principal phenomenon of growth.
How can we reconcile with the sole and uniform impulse of the
heart in all parts, inflammation, the production of herpes, of
different eruptions, &c. which appear in some places? Would
inflammation exhibit so many aspects, according to the system it
seizes, if the heart alone presided over its development? All the
difference between catarrh, erysipelas, phlegmon, &c. would
disappear; and there would be only what arose from being nearer, or
further from the heart.
Let us cease then to consider this organ as the sole agent which
presides over the motion of the great vessels and the small, which,
in these last, driving the blood abundantly to a part, produces there
inflammation, which by its impulse causes the different cutaneous
eruptions, secretions, exhalations, &c. The whole doctrine of the
mechanicians rested, as we know, upon the great extent which they
gave to the movements of the heart.
There are evidently two kinds of diseases in relation to the
circulation; 1st, those that affect the general; 2d, those that affect
the capillary circulation. Different fevers form especially the first
kind. Different eruptions, tumours, inflammations, &c. produce the
second; now, though many relations connect the second with the
first, it is not essentially dependant upon it; the following is the
proof of this; fevers can evidently only exist in animals with great
vessels, in those in which the fluids move in a mass; they cannot
take place in zoophytes and plants, which have only a capillary
circulation; yet these last classes of animals and all vegetables are
subject to all the affections that disturb the capillary circulation.
Thus we see upon plants many tumours; their wounds unite; two
portions even contract adhesions, as a graft proves. The diseases of
their capillary system are no doubt different from those of animals in
their progress and their nature; but they exhibit always the same
general character, because they are derived from the same
properties, organic sensibility and insensible contractility.
Since the diseases of the capillary system are not essentially
connected with those of the general vascular system, they are not
then dependant on it; the circulation of the first is but indirectly
subordinate to that of the second. Hence why the two circulations
can be separate; why more than half of the organized beings have
only the capillary. This is the most important, since it immediately
pours out the materials of nutrition, of exhalations, of absorption:
thus it exists in all organized beings. We cannot conceive of any one
without it, because we cannot conceive of any one that is not
continually composed and decomposed by nutrition.
From what we have thus far said, it is evident, that the blood after
it has arrived in the capillary system, is moved there only by the
tonic influence of the solids; now, as the least cause alters and
changes their properties, it is subject there to an infinity of irregular
motions. The least irritation makes it recede, advance, deviate to the
right, or the left, &c. In the ordinary state, it moves generally in an
uniform manner from the arteries towards the veins; but at every
instant it may find causes of irregular oscillations in its innumerable
anastomoses; hence, as we have seen, the necessity of these
anastomoses. These irregular oscillations in the motion of the blood
in the capillary system, can be seen with a microscope. Haller,
Spallanzani and others, whose experiments are too well known for
me to relate them here, saw them a hundred times. They saw the
globules advance, recede, move in many different directions in
animals with red and cold blood, when they irritated the mesentery
or any other transparent part. In animals with red and warm blood,
in those even whose mesentery is almost as transparent as that of
the frog, as in the guinea-pig, it has appeared to me infinitely more
difficult to trace the motion of the blood in the capillaries.
It is easy to see that all the phenomena of inflammation, of
different eruptions, of tumours, &c. are especially founded upon this
susceptibility of the blood, in the capillary system, to move in an
infinite variety of directions, wherever irritation calls it.
From what has been said, it is evident that there are times when
the blood passes with less rapidity through the capillary system, and
there are others, when it moves more quickly. How then is the
relation always preserved the same, between the arterial and the
venous blood? It is in this way; the irregular oscillations hardly ever
take place except in one part of the capillary system; in no case is
the whole of it affected; thus if the blood moves more slowly in the
cutaneous capillary system, its velocity is increased in the cellular,
the muscular, &c.
This is in fact an invariable law in the vital forces, that if on the
one hand they increase in energy, on the other, they diminish; we
might say, that there was only a certain quantity in the animal
economy, that this might be divided in different proportions, but it
cannot be increased or diminished. This principle results so evidently
from all the phenomena of the economy, that I think it unnecessary
to support it by numerous proofs; now, taking this as
incontrovertible, it is evident that one portion of the capillary system
increasing its action, only at the expense of the others, the sum total
of blood transmitted from the arteries to the veins remains always
nearly the same. All the systems are then, in this respect, supporters
of each other; if nothing passes by the capillaries of one, it is the
same thing, provided the capillaries of another transmit double the
amount of fluid that they do in an ordinary state.
Observe the blood in the cutaneous capillaries before the
paroxysm of intermittent fevers; it recedes from these capillaries; all
the surfaces that it reddened, become pale; the capillaries of the
other systems supply the momentary defect of the action of these.
Who knows if, in many cases where the skin becomes very red,
when much blood enters it, there is not in the other systems a
paleness analogous to that of the skin during the cold fit of fever? I
not only think this very probable, but I have no doubt of it. The
external capillaries certainly contain more blood in summer, whilst
those of the internal systems receive more in winter. There is then
continual varieties in the mode of the passage of this fluid through
the general capillary system; each system transmits by turns, more
or less, according as it is affected.
When we see the glands, frequently in a short time pour out an
enormous quantity of fluid, the serous, cutaneous, mucous
exhalants, &c. furnish also much greater proportions than in a
natural state, we are astonished that the circulation can at the same
time continue with the same regularity; we are not less so
undoubtedly, when we see on the contrary all the evacuations
suppressed, and nothing goes out from the animal solids; now in all
these cases, it is the capillary system, whose forces differently
modified in the different parts, re-establishes the general equilibrium
which would inevitably be lost, if the heart was the agent of impulse
which pushed to the extremities the secreted and exhaled fluids, and
transmitted the black blood to the veins.
Sometimes however a derangement almost universal takes place
in the capillary system, especially on the exterior; this takes place in
sudden changes of the air. Though the vital laws preside essentially
over the capillary circulation, yet the degree of pressure of the
surrounding air can modify it to a certain point; we have a proof of
this in cupping glasses, or in any other means that produce suddenly
a vacuum upon a part of the body; then the fluids pressed in the
neighbourhood by the external air, and not compressed on the
contrary at the place of the cupping glass, raise up and distend
considerably the skin. The sudden changes of the atmosphere
produce upon the whole body, though in a less degree, the effect of
a cupping glass. If the air is rarefied, the whole external capillary
system is more full; even the sub-cutaneous veins swell; a very
considerable part of the blood experiences then a derangement in its
motion, between the two systems with red and black blood. The
harmony, the correspondence of these two systems is disturbed;
hence the uneasiness, the sense of weight, &c. of which we are
instantly relieved by a sudden change of the atmosphere.
The evacuation of the blood also establishes differences, though
less, in the capillary system. Bleeding is of two kinds; one lessens
the blood of the circulation of the great trunks; and then it is
sometimes red, as in arteriotomy; but most often it is the black, that
is drawn off; the other takes blood from the capillary circulation; this
is done by leeches, cupping, &c. Each produces a different change in
the course of the blood. Physicians formerly were desirous of
knowing from which vein they ought to bleed. I think it is much
more important to know when we should by bleeding, act upon the
general circulation, and when upon the capillary. In many local
congestions, I do not think that you can diminish the quantity of
blood in a part of the capillary system, by diminishing the mass of
this fluid in the great trunks; you might take a quarter at least of the
blood that there then was in the economy, if the part is irritated, the
blood will still flow as much to this part. On the contrary, you may
double by transfusion, the mass of this fluid in an animal, local
inflammations will not arise, because there must be a preliminary
irritation before the blood flows towards, and enters a particular part
of the capillary system.
The fluids differing from the blood which circulate in the capillary
system, 1st. are evidently like it beyond the influence of the heart.
2d. The influence of the tonic powers presides over their motions.
3d. They are consequently subject to irregular oscillations, according
as the capillaries are differently affected.
We know not the nature of most of these fluids, because they
cannot be subjected to our experiments. They are those that enter
the ligaments, the tendons, the aponeuroses, the hair, the cartilages,
the fibro-cartilages, a part of the cutaneous, mucous, serous
surfaces, &c. They communicate with the blood from which they
arise, by the capillary systems, they afterwards move in their own
systems. In most of the organs in which they exist alone, as in those
called white, they are very slow in their motion, because the
sensibility of these organs is obscure and dull. Thus different
tumours, to the formation of which they contribute, have, as we
shall see, almost always a chronic progress.
There are often in the animal economy those tumours, that are
commonly called lymphatic, though we are wholly ignorant of the
fluids that form them. They are found especially in the
neighbourhood of the articulations; but sometimes only the
cartilages, the cellular texture, the bones, &c. are the seat of these
white tumours; it is important to ascertain the characters that
distinguish them from the tumours in which the blood especially
enters.

Phenomena of the Alteration of the Fluids in the Capillary System.

We have just treated of the phenomena of the motion of the fluids

in the general capillary system; let us now speak of the changes
which they undergo there in their nature.
The blood exhibits a remarkable phenomenon in the general
capillary system; from red, which it was in the arteries, it becomes
black. How does this take place? It evidently can happen only in two
ways, viz. either by the addition or subtraction of some principles. Is
it charged with carbon and hydrogen? Does it deposit only oxygen in
the organs? Are these two causes united to give it its blackness? I
think that it will always be difficult to decide upon these questions,
which do not appear to me to be capable of any positive experiment.
However, when we see the arterial blood furnish all the organs with
the materials of their secretion, nutrition and exhalation, it is to be
presumed that it leaves in these organs, rather than takes from
them, the principle of its colour.
 Sometimes the red blood passes through the capillary system,
without losing its colour; for example, when the blood has flowed for
a long time black from a vein, we sometimes see it come out red, or
nearly so, just before it ceases to flow. In opening the renal vein, I
have two or three times made this observation, which has, I think,
been noticed by some authors.
The blood becomes more or less black in the general capillary
system. If you have observed bleedings, you have undoubtedly seen
in diseases innumerable varieties in the colour of the blood that
comes from the vein. Has this fluid a different blackness in each part
of the capillary system? It has appeared to me that the difference is
not very great in this respect. I have frequently had occasion to
open the renal, saphena, jugular veins, &c. the blood has appeared
to me to be everywhere of nearly the same colour. I wished to see if
the blood returning from an inflamed part was more or less black; I
made then in the hind leg of a dog a number of wounds near each
other, and left them open to the air. At the end of three days, when
the inflammation appeared to be greatest, I opened high up on the
diseased and the sound limb, the saphena and the crural veins, in
order to examine their blood comparatively; I could discover no
sensible difference. I bled a man who had a whitlow with an
inflammatory swelling of the whole hand, and the inferior part of the
fore arm; the blood appeared of the same colour as usual. Yet, as
the veins bring also the blood of parts not inflamed, more minute
researches must be made.
An object which deserves to be determined with precision, is this,
viz. the cases in which, in general diseases, there is an alteration in
the deep colour of the blood, and the symptoms which correspond
with these alterations. At present we only know that it is more deep
coloured in some cases and less so in others.

IX. Of the Capillaries considered as the seat of the

production of Heat.
 Every one knows the innumerable hypotheses that were made
upon the production of animal heat by the mechanical physicians.
Modern chemists, in showing the insufficiency of these theories,
have substituted one that has not less difficulties. The lungs are
considered by them as the place in which the caloric is extricated,
and the arteries, a kind of tubes, that carry the heat to all parts of
the body. The production of this great phenomenon belongs then
wholly, according to them, to the pulmonary capillary system. I
believe, on the contrary, and I have taught in my courses on
physiology, that it is in the general capillary system that it has its
seat.
I shall not stop to refute the hypothesis of the chemists. When we
place on one side, all the phenomena of animal heat, and on the
other, this hypothesis, it appears so inadequate to their explanation,
that I think every methodical mind can do it without my assistance.
These phenomena are the following:
1st. Every living and organized being, both animal and vegetable,
has a temperature of its own. 2d. This temperature is nearly the
same in all ages in animals. 3d. It is entirely independent of that of
the atmosphere; it remains the same in a warm as in a colder
medium. 4th. Caloric is often disengaged in health more abundantly
in some parts than in others. 5th. In inflammation there is evidently
a more considerable extrication of it. 6th. The vital forces, especially
the tonic power, have a very decided influence upon the extrication
of caloric. 7th. Each organ has its own temperature, and it is from all
these partial temperatures, that the general one arises. 8th. There is
oftentimes an immediate connexion between the respiratory and
circulatory phenomena, and those of the production of heat; the first
increasing, the second increase also in proportion. At other times
this relation does not exist.
If, below these phenomena, you place the theory of Lavoisier,
Crawford, &c. I do not believe you can make it accord with them,
and conceive how caloric, disengaged in the pulmonary capillary
system can be spread, as they say, through the whole animal
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