URBAN TRANSPORTATION

urban transportation (see also traffic problems).— concurrently with the continuous growth of mechanically- operated industries, from their inception on a large scale following the application of steam as a source of power early in the roth century, there has been in all industrial, as distinguished from agricultural, countries an increasingly marked drift of population to the cities. of all the problems, whether old or new, created and intensified by this concentration of population in large cities, the most pressing is the furnishing of means of intra- urban transportation. this is especially the case in the large cities of great britain, germany and the united states. types of service —three types of transit services are now employed, the rapid transit railway, the strect railway and the omnibus. on the rapid transit railways, both beneath and above the surface of streets which, in the largest cities of europe and the united states, make possible long-distance high-speed intra-urban travel, the coal-burning steam locomotives have been replaced by electric motors (see railways, electrification of) attached to individual cars in the trains, which latter, on the interborough subways, new york, are composed of ro cars with a capacity of 44 seated passengers each and many more standing during the hours of maximum trafhc. urban transportation rapid transit railways.—railways of this character will be described as rapid transit railways regardless as to whether they are locally known as underground, subways, tubes or elevated, and in like manner surface railways or tramways will be termed street railways. ‘the greatest mileage of rapid transit rail- ways and the system carrying the heaviest traffic in one city is in new york, which in 1925 amounted to 224-71 m., composed of 100:26 m. of two tracks, 77°48 m. of three tracks and 46-97 m. of four tracks. the street railway is almost universally worked by the overhead electric trolley or the under- grouncl slot system, as in the london area. it is criticised on the grounds that it is nonflexible, occupies permanently a consider- able part of the roadway, and is liable to working troubles which occasionally suspend traffic over a wide area. intensity of the problem.—the intensity of the urban transpor- tation problem and particularly the demand for high-speed long- distance service is greater in american than in european cities due, in part at least, to the greater activity of the people, to the higher average scale of wages enabling the population to pay for transportation service and to the fact that the cities themselves are in large part the product of modern industrial development. the measure of the problem is given in the statistics of pas- sengers carried by the several means of travel and for com- parison london and new york, respectively the largest cities of europe and america, are taken for the years 1905, 1915 and 1925, the totals being stated in millions. type 1905 i915 1925 london rapid transit 272 459 575 street railways . 478 852 979 omnibuses . 291 689 1,658 total. ; 1,041 2,000 3,212 population : ; 6-858 7-341 7°65 rides, per head 152 272 420 rapid transit street railways . onminibuses . total population : rides, per head . while the total travel in the two cities has remained for 20 years substantially the same, the rides per capita in new york are greatly in excess of those in london, and the distribution among the several types is radically different. london and new york.—in londen all types of transportation show for each decade a substantial growth, but the greatest increase is in passengers carried by the omnibuses, whose traffic was more than doubled in the first 10 years and again doubled in the next 10. thus is short-distance travel cared for with the minimum of operating and capital cost since a free right-of-way is provided in the public streets and no construction other than the vehicles is involved. in new york the greatest demand is for a rapid transit service, the burden of which doubled and re- doubled during the past two periods of 10 years. the con- struction cost for the necessary long-distance high-speed facilities mount up to $10,000,000 per mile of four tracks exclusive of equipment. in both cities the rate of increase in the street rail- | ways is less in the second period than in the first, duc largely to the fact that there has been no increase in new facilities of this type, but in new york there is shown a very rapid growth in omnibus service in connection with which new routes have been established and additional vehicles put in commission particu- larly since 1915. the differences illustrate the greater intensity of the american problem. some american cittes.—to extend the comparison the fol- lowing figures give the corresponding data for three other american cities each typical of a distinct class: philadelphia, one of the oldest american cities with a steady growth in population, ol7 served by all forms of urban transportation; chicago, which in 100 years has risen from an insignificant hamlet to the second city in size in the united states and which has been equipped with rapid transit railways for some years; and detroit, an exhibit of phenomenal development in the past 20 years but which is still dependent for its local transportation on surface means. the figures are given in millions. rapid transit. : im a2 surface railways 382 474 585 omnibuses . io it total 382 516 685 population 1-4 1°7 2 rides, per head . 27% 303 346 chicago rapid transit 124 165 217 surface railways 350 623 842 omnibuses . ay 53 total at4 788 i-117 population . . ", rides, per head . 2: detroit surface railways 88 240 358 omnibuses . ws 43 total 88 240 401 population ; 0-3 0-6 1-2 rides, per head . 323 the striking features of these statistics, which are fairly representative of ‘american cities, are that the growth in rides is greater than the growth in population except in detroit where population is advancing by great strides and faster than new transportation facilities have been provided, and that the relative increase in rides is greater according as the cities are greater—in short there isa cumulative result that produces the serious aspect of the new problem. taking the four cities in question, while the combined popula- tion in 1925 was 150% of what it was in ro0s, the rides were 250%. if the ratio of growth be squared it will be seen that the increase in rides in 20 years was 1°11 times that of the square of the growth in population. in other words, if a city be doubled in number of inhabitants the burden of urban transportation will be increased fourfold. taking the individual cases it will be seen that the ratio of rides to population increases with the size of the city. thus the ratio between the increase of rides and the square of the increase of population is for detroit 0-44; philadel- phia o-9; chicago 1:0; new york 1-4. another complication in urban transportation is the use of the motor-car, the expansion of which still further congests the streets and tends to prevent increasing surface transportation facilities by surface railways or omnibuses. this is particularly in evidence in america where on account of the low cost of certain cars they are freely used by all classes. the local reg- istration in the two largest citics for 10 years was as follows:— 1915 | type | 1920 | 1925 new york passenger . .. | 59,850 152,036 365,894 commercial . nt 12,148 83,746 114,022 chicago passenger 36,419 86,709 290,956 commercial 7.384 22,900 48,262 these figures, without parallel in other countries, are repeated proportionally in other american cities. in the united states there is one car for every six persons, while in great britain there is (1926) 1 for 57, in france 1 for 69 and in germany 1 for 272. (see moror vehicles.) (w.b.p.) 918 urology (see 27.797)—recent progress in urology has been due largely to improvements in the cystoscope, advances in ra- diology, use of diathermy and close co-operation between urolo- gists, bacteriologists, and bio-chemists. endo-vesical instruments are now available from the simplest cystoscope, consisting of a telescope within an irrigating sheath, to complicated instruments with which lesions can be treated surgically under direct vision instead of by an open operation. similarly, advances in radiology have led to the detection of calculi hitherto regarded as transparent to the rays, and to stereoscopic radiograms indispensable for locating a suspicious shadow in the neighbourhood of the kidney or uretcr. pyelog- raphy also gives information concerning the size and shape of the renal pelvis and calices. a skiagram is taken after a fluid opaque to the x-rays (c.g., sodium iodide or lipiodol) has been introduced into the renal pelvis by means of a ureteric catheter. it is of great value in diagnosing early dilation of the kidney, silent hydronephrosis, polycystic kidney, malformation of the pelvis and renal tumours encroaching on the pelvis;in localising shadows in the renal area such as calcified mesenteric glands and gall stones, and in differentiating between abdominal and renal tumours. by similar means, silhouettes of the bladder or male urethra can be obtained, though in the latter instance they are not indispensable, for the canal can be examined easily and thoroughly with a urethroscope. perirenal inflation with co. was introduced by carelli of buenos aires and in radiographs shows clearly alterations in shape, size and density, therefore being useful in such conditions as early hydronephrosis, polycystic kidneys, tuberculosis, tumours and stones not dense enough to show by ordinary radiography; but its greatest value lies in giving a clear and distinct radiogram of the suprarenal capsule. ~ diathermy —diathermy (see elecrro-therapy )acts by virtue of the heat generated in the tissues by the resistance they offer to the passage of an electric current. for this purpose a very strong current must be used, deprived of its stimulating and electrolytic properties by alternations of not less than 500,000 per second. ae the only sensation produced by a current of such high fre- quency is one of heat ranging, according to the strength of the current, from a pleasing warmth to a temperature high enough to char the tissues for a distance of about 1 cm. from the electrode. all degrees of diathermy are used for diseases of the genito- urinary system, the lower temperatures for testicular neuralgia and epididymo-orchitis, chronic urethritis and prostatitis, and benign enlargement of the prostate when a radical operation is inadvisable. destructive diathermy is now the method of choice in the treatment of certain forms of papilloma of the bladder and urethra, and in the median bar type of prostatic obstruction. it has also been employed with moderate success for carcinoma of the prostate. use of radinm.—radium (q.v.) has been used extensively for carcinoma of the prostate and bladder. it is applied in the form of needles and emanation tubes or seeds implanted directly into the growth, but has not yet emerged from the experimental stage. caution is required in its use, for large doses produce great irritation and may be followed by excessive infiltrations of the bladder neck. again, emanation tubes placed too close to the pouch of douglas have caused peritonitis and death. in view of these disadvantages and the discouraging results they have encountered many urologists are now averse to using it at all. | urinary antiseptics— both mercurochrome and hexyl-resor- cinol are powerful antiseptics, and though not “ideal” are valuable additions to the comparatively few powerful bacte- ricides which can be administered with safety. mercurochrome can be used either locally or intravenously. in cases of chronic cystitis, usually due to ihe colon bacillus, instillation of a watery solution (o:2-1-0%) sometimes has a remarkable eclfect. in pyogenic coccal infections the results are not so striking. in pyelitis, irrigation with mercurochrome is not so irritating as with silver nitrate. instillations appear to be particularly urology valuable for chronic posterior urethritis, especially when com- plicated by prostatitis and vesiculitis. when given intrave- nously in doses of from 1to5mg. per kg. of body weight results have been most encouraging, especially in acute coccal and bacil- lary infections of the genito-urinary tract associated with pyrexia. chronic afebrile colon bacilluria, on the other hand, does not always respond so readily to this treatment. in rare cases, pronounced febrile and gastro-intestinal reactions follow the injection but these usually subside in 24 hours. the danger to the kidneys of such a powerful mercurial compound must never be overlooked, but young (baltimore) considers it may be used intravenously without fear of injury. hexyl-resorcinol [csli3(oh)2cekli3] is a synthetic compound first described by leonard. possessing forty-five times the germicidal power of phenol, it conforms experimentally to the qualifications necessary for an ideal urinary antiseptic in that it is chemically stable, non-toxic, non-irritating to the urinary tract, has an antiseptic and bactericidal action in high dilution in urine of any reaction, and is eliminated in high percentage by the kidneys. on the other hand, it can only exert its germicidal properties on tissues with which the urine comes in contact, and therefore infections of the renal parenchyma and submucous tissues of the urinary tract are not affected by it. if taken on an empty stomach the drug may cause griping or catharsis. in- fections due to pyogenic cocci appear to yield to the drug with remarkable rapidity. b.coli infections of the urinary mucosa with a low bacterial count can be cured with hexyl-resorcinol, but when the count is high and the sub-mucous tissues are in- fected, prolonged treatment combined with appropriate local treatment is necessary. when administered prophylactically two days before, and daily after operations on the bladder, the wounds remain healthy and healing is accelerated. tests of renal function.—tests for estimating the function of one or both kidneys are now employed regularly. though not conclusive, they are capable of giving a warning which should be heeded, particularly in operations on the urinary tract. ‘thus in prostatectomy they serve to determine a one- or two-stage opera- tion, and since they have been adopted asa routine the mortality from uraemia has become almost negligible. the chief tests in use in englandarce: (1) the urea concentration test (maclean and de wesselow); (2) estimation of blood urea; (3) colour tests. the technique of applying these tests can be found in appro- priate text-books. the range of normality of the blood urea is so great that this test alone is of little value unless the urea retention is above 50 mg. per 100 cu.cm. of blood, but when combined with the urea concentration test it gives an excellent indication of the renal efficiency. in some clinics on the continent great reliance is placed on the elimination of creatinin and chlorides as tests of renal efficiency. the dyes chiefly employed for colour tests are indigo-carmine and phenolsulphonephthalein. indigo-carmine can be employed during a cystoscopy and gives a good in- dication of the function of one kidney without the use of a ureteric catheter (chromocystoscopy). a o-4% solution in- jected either intravenously (5 c.c.) or intramuscularly (20 c.c.) should tinge the urine of a healthy kidney in five minutes. phenolsulphonephthalein is excreted solely by the kidneys and so differs from indigo-carmine, which is only partly excreted by the kidneys. in america it is used almost exclusively, but in england it has not been popular owing to the somewhat elaborate tech- nique required and to the difficulty, since the war, of obtaining a reliable preparation of the dye. the test is very reliable pro- vided the pure compound is used. ‘the capacity or otherwise of a patient to resist the spread of sepsis to the upper urinary tract after an operation, such as prostatectomy, is a factor which may upset the calculations of both surgeon and bio-chemist. macadam and shiskin have found that the cholesterol content of the blood gives a fair in- dication of the power of resistance. the average in a series of healthy adults under so years of age was found to be o-16%. above 50 years it ranges between 0-13 % and o-19%. practical expericnce led these workers to conclude that in prostatic urology obstruction a blood-cholesterol below 0-13°> indicates such a lowered resistance to the spread of sepsis as to constitute a bad operative risk. cases with a high blood-urea and a normal blood-cholesterol all recovered from a two-stage prostatectomy, but out of eight cases with a high blood-urea and a low blood- cholesterol all died save one. the kidney— dudgeon and others have pointed out that the combination of pus cells and a pure culture of staphylococcus albus in the urine of one kidney is almost pathognomonic of a stone in that kidney. with certain reservations all cases of renal calculus are now subjected to operation, for the stone, whether causing symptoms or not, slowly but surely injures the kidney and often determines a scrious bacterial infection. small stones are more dangerous than large ones, for they may lodge in the ureter and cause hydronephrosis, anuria and so on. the problem of bilateral lithiasis is a difficult one, but on the whole urologists advocate operation on the healthiest kidney first, as there is always the possibility that nephrectomy may be necessary on the side which is more grossly affected. pyclolithoto- my is now performed in preference to nephrolithotomy whenever possible. decapsulation of the kidney for nephritis has been per- formed on many occasions with varying success, but is viewed with increasing favour. the benefit obtained is probably due to the mechanical relief of renal tension, and this certainly explains the immediate improvement following unilateral decapsulation in eclamptic uraemia. the indications for this operation are uraemia, anuria, oedema, excessive albuminuria and obstinate haematuria. contra-indications are age, heart diseases and extensive cardiovascular changes. renal tuberculosis. —investigations by braasch in the mayo clinic have disproved the common opinion that renal tuber- culosis is usually primarily unilateral. in seven out of 22 apparently unilateral cases, the urine from the supposed healthy kidney was proved to contain tubercle bacilli by animal in- oculation, a fact which goes far to explain the comparatively heavy mortality in the first few years after nephrectomy. continental writers estimate that in life the infection is bilateral in about 15° of cases, whereas in the post-mortem room it is as high as 65%. this fully bears out the experience that spon- taneous cure is extremely rare and that the only rational treat- ment of unilateral tuberculosis is early nephrectomy. in bilateral infections, ekehorn advocates and practises removal of that kidney which is found by inspection to be the most dis- eased, or which is thought to be the cause of pyrexia and dis- tressing bladder symptoms. in 20 cases reported by him the results were good enough to justify the operation. the treat- ment of the tuberculous ureter is still under discussion, most workers considering that it heals naturally after the diseased kidney has been removed, while others advocate a primary nephro-ureterectomy to prevent infection of the lower urinary tract by the diseased ureter. all are now in favour of a post- operative course of tuberculin. movable kidney—operations for nephroptosis are de- creasing in number year by year, for surgeons have now re- alised that the condition is commonly associated with glenard’s disease and with such general symptoms as headache, gastric discomfort, neurasthenia and ptoses of various kinds, for which fixation of the kidney gives no relief whatever. nephropexy is now reserved chielly for cases of intermittent hydronephrosis, haematuria, casts and albuminurias, and for uncomplicated renal pain relieved absolutely by rest in the horizontal position. uretcral calculus —lin the case of small stones impacted in the ureter most urologists favour removal by manipulative and other methods rather than by ureterolithotomy. the chief methods employed are: (i.) dilation of the ureter combined with instillation of sterile liquid paraffin, subcutancous injection of atropine, and forced diuresis with contrexeville water; (i1.) intra- ureteral instillation of 5 cu.cm. of a 2% solution of papaverine sulphate, selected for its analgesic and antispasmodic properties; (iii.) dilation of the ureter by diathermy, and (iv.) division of the ureteric meatus with scissors through a cystoscope. 919 severe reactions after cystoscopic manipulations, and_ ir- regular stones greater than 1 cm. in diameter are indications for uretero-lithotomy. ‘the pelvic portion of the ureter is now always exposed extraperitoneally, either through a paramedian subumbilical incision or by kidd’s inguinal operation. transplantation of the ureter —the ureter may be implanted into another part of the bladder, either for stricture of its extra- mural portion or after partial cystectomy for growths involving the ureteric orifice. for inoperable bladder growths and for extrophy of the bladder, coffey has devised a method of simul- taneous transplantation of both ureters into the pelvic colon, which does not obstruct the ureters or disturb kidney function. bladder.—the bacteriology of cystitis and pyelocystitis has reccived much attention from bacteriologists. the most im- portant recent communications on this subject are by dudgeon, wordley and bawtree. these workers have isolated from different cases:— (1) a special group of haemolytic bacilli, strongly resembling but not identical with the paratyphoid bacillus; (2) the colon bacillus; (3) proteus. vestcal diverticula.—improvements in the cystoscope have led to earlier recognition of diverticula. swift joly reviews the whole subject and discusses the relative value of the different operations. he also points out that accompanying prostatic or urethral obstruction should be treated at the same time whenever possible. puapilloma.—these tumours are now treated by fulguration through a cystoscope whenever possible, and in many instances can be destroyed completely at one sitting and under local anaesthesia. when the papilloma is sessile and diathermy can only be applied to the surface nearest the cystoscope, several treatments at intervals of a week or ten days may be required, a portion of the growth being destroyed at each sitting. sub- sequently a cystoscopic examination should be made at inter- vals of three to six months for at least three years, so that fresh growths can be kept in check. open operation by the suprapubic route is reserved for large growths, especially if sessile and for those involving the urcteric orifice. in some cases the tumour can be destroyed by diathermy with a large electrode, in others a partial cystectomy, with or without transplantation of the urcter, is necessary. attention has been called to the danger of “‘ graft-recurrences ” in the abdominal wall after removal of papillomata by the suprapubic route, and maybury and dyke have reported a case in which three successive im- plants grew in the abdominal wall. the primary vesical growth was benign but the recurrent implants became progressively malignant. carcinoma should be excised whenever possible, for as yet the results of treatment with imbedded radium is dis- appointing and uncertain. in the flat ulcerating form of car- cinoma, peculiar to the aged, a fair measure of comfort and rclief can be obtained from deep x-ray therapy. the prostute—yor chronic inflammatory lesions of the prostate and seminal vesicles diathermy is valuable and acts, not only on the gland itself, but also on the arthritic and other complications so frequently associated with gonorrheal prostatitis and vesiculitis. in cases of enlarged prostate where operation is impossible owing to age, cardiovascular changes, advanced renal (lisease, etc., a fair measure of relief can be obtained by medical diathermy or by deep x-ray therapy. in all other cases pros- tatectomy is undoubtedly the correct procedure. the type of enlargement most suitable for operation is that due to chronic lobular prostatitis with pronounced adenomata; the second type, chronic interstitial prostatitis or fibrous prostate, presents many difficulties to the operator but should be removed whenever possible, as it causes a severer degree of obstruction and con- sequent impairment of the renal function than the adenomatous variety. before deciding on an operation the chemical tests of renal efficiency should be carried out, for the type of operation selected will depend almost entirely on these tests. careful pre- liminary treatment, often lasting several weeks, is nearly as important as the operation itself. 920 after much discussion, the majority of urologists have decided in favour of the suprapubic operation in one or two stages. the two-stage operation has reduced the mortality from uraemia to a negligible quantity and is indicated in all cases with renal deficiency, severe cystitis, retention, or four or more ounces of residual urine. the thomson-walker operation is un- doubtedly an improvement on the somewhat crude but re- markably effective operation practised by freyer. it takes longer but eliminates the risk of post-operative stricture. the perineal operation, performed almost exclusively by young of baltimore, is in england reserved for carcinoma and for the fibrous type of prostate. here the advantages of control of haem- orrhage and perfect drainage are outweighed by the dangers of pelvic cellulitis, perineal fistula and incontinence of urine. prostatic bars.—in about 25% of patients with syniptoms of prostatic obstruction but without palpable enlargement of the prostate, a careful cystoscopic examination reveals the presence of a ridge of hypertrophied tissue, either on the posterior lip of the prostate overhanging the internal meatus, or projecting up- wards from the floor of the prostatic urethra and constituting the so-called median bar. for the relief of this type of obstruction h. young invented his well-known punch, later improved by kenneth walker, by adapting it for diathermy. (see electro- therapy.) carcinoma.—hitherto, treatment of prostatic carcinoma by radium has been so unsatisfactory that many surgeons have ceased to use it. diathermy has been more or less successful in conferring relief, but the results can hardly be described as brilliant. whenever possible, young’s perineal resection ap- pears to be the most satisfactory procedure; failing this, ex- cellent results have been sometimes obtained from deep x-ray therapy. the testis —steinach of vienna performed vasoligation in senile rats with a view to increasing the internal secretion of their testes and thereby stimulating their failing energics. for two to four weeks after bilateral division of the vas between ligatures no appreciable change was noticeable. the rats then began to show a return of sexual excitement and vigour, in some instances equalling that of young males. this was followed in rapid succession by a return of pugnacity, increase in muscular energy and a copious growth of fur. the change lasted for about six months, when the animal gradually lost his youthful appearance and powers and became senile again, eventually dying within a few weeks of the onset of the change. steinach found that the operation induced degeneration of the seminal epithelium (later followed by regeneration) and an increase in the interstitial tissue. in man the operation has been attended by very variable results. the greatest successes appear to have occurred in cases of premature old age; when performed for impotence alone it is not so satisfactory, and is quite useless if the testis be already atrophied. some cases of arteriosclerosis have been greatly benefited by it. testicular grafts (see rejuvenation).—grafts from lower ani- mals have been employed for many years with more or less similar results, viz., improvement shortly after implantation, followed by atrophy and absorption of the graft, and a return on the part of the patient to the original condition. voronoff in rg20 used testes of anthropoid apes and found that they survived for three years or longer, and that the initial improvement in the patient’s condition was maintained. kenneth walker has on several occasions employed a healthy human ectopic testis. he concludes that the life of a hetero-graft is not longer than two years, that absorption of the graft does not necessarily imply a return of the patient to his former condition, and that permanent improvement 1s probably due to increased growth in other endocrine tissues stimujated into activity by the grait. tuberculous epididymitis—when this disease is advanced castration is indicated, but when it is localised to the globus major or minor epididymectomy is now regarded as the correct procedure. the full extent cf the disease must always be de- termined with care. uruguay the urethra.—the great improvement in urethroscopes has simplified the diagnosis and treatment of urethral conditions. with the joly type of posterior urethroscope, diathermy can be applied where formerly a scrious cutting operation was neces- siry. there is now an increasing tendency to revert to former methods and to treat stricture of the urethra by gradual dilata- tion with metal sounds or gum elastic bougies, urethrotomy being reserved for resilient and cartilaginous strictures and those complicated by fistulae. if contraction recurs after in- ternal urethrotomy many surgeons advocate excision of the stricture and axial anastomosis. when a large amount of cicatricial tissue has been excised, the gap has been successfully bridged in one case by implantation of the patient’s appendix, and in another by a child’s prepuce fashioned into a canal around a catheter. bipliograpiy.—f. leguen and fe. papin, prects d’urologie (1921); georges marion, traite d'urologie (1921); l. s. dudgeon, e. wordley and f. bawtree, “ bacteriology of cystitis,’ jour. of hygiene, vol, 20, no. 2 (1921) and vol. 21, no. 2 (1922); j. s. joly, “ diverticula,” lancet (sept. 1 1923); hugh cabot, ed., afedern urology, in original contributions by american authors, 2nd ed., 2 vol. (1924); l. l. fulkerson, gynecologic urology (1925); r. c. coffey, ‘' transplantation of ureters,”’ northwest medicine, vol. 24 (may 1925); e. p. cumberbatch and c. a. robinson, “ treatment of gonococcal infection by diathermy,” proc. roy. soc. med., vol. 18 (1925); l. s. dudgeon, “ bacteriology of cystitis,’ 7bid., (april 1925); w. macadam and c. shiskin, ‘‘ cholesterol and resistance,” british jour. surgery, vol. 12 (1925); b. c. maybury and s. c., dyke, “ graft recurrence,” tbid., (oct. 1925); h. h. young and dd. m. davis, young’s practice of urology, with collaboration of f. p. johnson, 2 vol. (1926). (c, a, r. n.)