m, >:.• :s T». rV-:' -V -^ ,:^ .'<> AS:" v^!'* !#*; Mi ■a;. V--i--.-H.-3r-'1 ■ J "■■,*,,-!•■ / LECTURES DISEASES OF THE URINARY ORGANS. SIR BENJAMIN C. BRODIE, Bart. F.R.S. SERJEANT SURGEON TO TUE QUEEN. jfvom t&c tfcfcDr SLonTion JT&ftfoTU ^ ; . Jj'lU 'ie: WITH ALTERATIONS AXD ADDITION*. PHILADELPHIA: LEA AN£> BLANCHARD. iS<13. .v.r.'.iL UERRTAM AJTD COOKE, TRIXTERS, WEST BKOOK.F1EI.D, MASS. ADVERTISEMENT. I have endeavored to make this edition of my Lectures on the Diseases of the Urinary Organs more worthy of being presented to the Public, by introducing into it the results of my later and more extended experience on the subjects to which they relate; and it has been the want of the leisure necessary for the accomplishment of this object that has caused the publication to be thus long delayed. The present volume is not very much increased in size as compared with its predecessors. Nevertheless.with the exception of the Lec- tures on Calculi of the Urinary Bladder and Lithotomy, there are few parts of it which remain such as they were formerly. Several errors are, I hope, corrected : some of the views which I had been led to entertain of disease are modified; and there is a considerable proportion of new matter. In the latter is included a Lecture on the Operation of Lithotrity, on which in the former editions of this work I did not feel myself competent to offer more than a (e\v general ob- servations. I have now ventured to discuss this new mode of treat- ment more at length, giving some practical instructions for the per- * IV ADVERTISEMENT. formance of the operation, which may probably be acceptable to the younger members of our Profession, and to those whose minds have not yet been directed to the subject; at the same time endeavoring to assign to it what I believe to be its proper place among the appliances of surgery, and what, if I am not greatly mistaken, will be conceded to it by others, when time and experience shall have dissipated alike the prejudices of those who under-rate its importance and usefulness, and of those who hold it to be raore useful than it really is. CONTENTS. LECTURE I. Paga On Diseases of the Male Urethra 9 Stricture of the Male Urethra 10 LECTURE II. Stricture of the Urethra—continued. 20 Diagnosis in Cases of Stricture of the Urethra 24 Treatment of a Retention of Urine from Stricture 2(3 LECTURE III. On the Cure of Stricture of the Male Urethra 31 LECTURE IV. Treatment of Stricture of the Male Urethra—continued. Uri- nary Abscesses and Fistulae 48 Obstructions of the Urethra arising from mechanical Injury, and their treatment 51 LECTURE V. On some other Diseases of the Male Urethra 56 Diseases of the Female Urethra 58 Irritable Bladder 59 Paralysis of the Bladder (50 Inflammation of the Bladder 63 Incontinence of Urin© 70 vi CONTENTS. LECTURE VI. Fungus Haematodes of the Bladder 73 Symptoms affecting the Bladder in consequence of Disease in the Kidney 76 Treatment of these Cases S3 LECTURE VII. Inflammation of the Prostate Gland 86 Chronic Enlargement of the Prostate Gland 90 Symptoms of the Chronic Enlargement of the Prostate Gland 92 LECTURE VIII. ^Treatment of the Chronic Enlargement of the Prostate Gland 102 Scirrhus of the Prostate Gland 112 LECTURE IX. Urinary Calculi 115 Sand in the Urine ib. LECTURE X. Renal Calculi ISO LECTURE XL History and Symptoms of Calculi of the Bladder 142 LECTURE XII. Calculi of the Bladder—continued 157 Treatment of Calculi of the Male Bladder 161 LECTURE XIII. Operation of Lithotomy 172 CONTENTS. vii LECTURE XIV. On the Causes of Death aficr Liihnlcrriy 1S3 On some oilier Methods of Lithotomy 196 Treatment of Calculus of the Female Bladder 193 Lithotrity LECTURE XV. 203 ON THE DISEASES OF THE URINARY ORGANS. LECTURE I. In this and the following lectures I propose to draw your atten- tion to the diseases affecting the urinary organs, as far as these come under the cognizance of the surgeon. Among all the important subjects which we are required to in- vestigate, I know of none more important than this. These dis- eases are always a source of great anxiety, in many instances of pain and misery, to the patient; and for the most part, if allowed to take their natural course, they terminate in his destruction. At the same time there is no class of diseases in which we are, on the whole, enabled to render those who suffer more essential service ; often by removing the disease altogether; at other times by reliev- ing the more distressing and dangerous symptoms. I shall call your attention first to the diseases of the urethra; afterwards to those of the bladder and prostate gland. My concluding observa- tions will relate to urinary and other calculi. On the Diseases of the Male Urethra. The urethra of the male being long and narrow, complicated in its structure and functions, you will not be surprised to learn that it is liable to more numerous as well as to more formidable diseases than the short, wide, and simple urethra.of the female. What I know of the diseases of the latter may be comprised in a few words ; while those of the former will require a more lengthened investigation. 2 10 STRICTURES OF THE Stricture of the Male Urethra. The canal of the urethra may be partially or completely ob- structed in various ways. Some of these causes of obstruction are to be looked for in the parts which are external to the urethra, and will be noticed in future lectures. At present I shall confine my observations to those obstructions which have their origin in the urethra itself, and to which the name of stricture of the urethra is commonly applied. The persons most liable to be affected with this disease are those who have passed the age of puberty, but have not yet passed the middle period of life. Occasionally, however, we meet with it in children ; and in a few instances it begins to exist in the latter part of life. It may sometimes be traced as the consequence of a severe or long continued attack of gonorrhoea : and it is not unusu- al to ascribe it to the use of irritating' injections administered on account of that disease. It would seem that whatever increases the stimulating qualities of the urine, so as to make it a cause of irritation to the parts with which it comes in contact, may lay the foundation of this disease. Thus we find it where the urine depos- its the lithic acid sand, where it is habitually overloaded with the lithate of ammonia, or where it is alkaline, and deposits crystals of the triple phosphate of ammonia and magnesia. In some rare in- stances it immediately follows mechanical injury : but this last va- riety of stricture presents some peculiarities, which make it worthy of being considered separately. We find a patient laboring under a difficulty in voiding his urine. It flows in a diminished stream, and the diminution gradually in- creases, until at last there is no stream at all, and it escapes only in drops. If the patient dies, and we have the opportunity of exam- ining the morbid appearances, we find some portion of the urethra contracted, and the mucous membrane, at the contracted part, thickened and deprived of its natural elasticity. The thickening seems at first to be of the simplest kind ; and we cannot explain it better than by ascribing it to an interstitial deposite of coagulated lymph (or albumen) which has become organized. If the disease has existed for many years, the contracted portion assumes a struc- ture approaching to that of cartilage, and the parts immediately in contact with it partake of this alteration to a greater or less extent We observe also another change as the disease advances. Instead of being confined, as it generally (though probably not always) is, in the first instance, to a small portion of the canal, the contraction extends in both directions, that is, towards the bladder and towards the external orifice, being however still more complete at the point MALE URETHRA. 11 at which it was originally established, and becoming gradually less as it recedes from it. If we carry our researches further, we find that in the majority of instances the disease began in the anterior portion of the mem- branous part of the urethra, immediately behind the bulb, and in the situation of the triangular ligament of the perineum ; that in some instances it had its origin in the urethra somewhere between the part just mentioned and the external orifice ; and that in a few cases it is confined to the external orifice and the canal immediately adjoining to it. Occasionally, where the original and principal stricture has been in the membranous portion of the urethra, there is another stricture anterior to it ; and in cases of very long stand- ing it is not unusual to find the greater part of the canal in a thick- ened and contracted state. But here, as on most other occasions, morbid anatomy affords us but an imperfect lesson in pathology ; and it is only from the ob- servation of what happens in the living body that we can learn one of the most important circumstances in the history of this disease. While in some cases there is from day to day but little variation in the size of the stream of urine, we find in others that it varies greatly, so that a patient who one day voids his urine with so much facility that he is scarcely conscious of the existence of any impedi- ment to his doing so, on the following day may void it only in drops, or even be unable to void it at all. This change, moreover, may take place in a very short space of time. The difficulty of micturition may almost immediately follow too copious libations of those liquors which cause the urine to be loaded with an excess of lithic acid, or lithate of ammonia : such for example as punch or champagne ; and, as I shall explain more fully hereafter, it may subside even more suddenly than it took place after the pressure of a full-sized bougie against the anterior part of the stricture, or the application to it of the nitrate of silver. The permanent alteration in the condition of the urethra, which is disclosed to us by dissec- tion, will not account for this phenomena ; and we are compelled to refer them to some power of contraction which exists in the living body, and is wanting in the dead. A multitude of facts which you will meet with in practice can be no otherwise explain- ed ; and no one much conversant with these cases will doubt that the distinction between spasmodic and permanent stricture is well founded. What I am about to mention seems to throw some light on this subject. Spasmodic stricture is always situated in the membranous portion of the urethra, where the canal is surrounded by a sort of sphincter muscle of no inconsiderable size, connected by a small double tendon to the arch of the pubes. A particular description of this muscle has been given by the late Mr. Wilson, in the first 12 STRICTURES OF THE volume of the Medico-Chirurgical Transactions; and it seems not unreasonable to suppose that it is the real seat of these spasmodic affections. We find nothing like spasmodic stricture in the ante- rior part of the canal, where there are no muscular fibres in imme- mediate contact with it. Instances are not wanting of persons who have been for a con- siderable time liable to occasional attacks of retention of urine from spasmodic stricture of the urethra, although in the intermediate periods there was no perceptible diminution of the stream of urine; and hence we are justified in the conclusion that a spasmodic stric- ture may exist independently of any actual organic disease. At the same time it must be acknowledged that the existence of a purely spasmodic stricture is of rare occurrence. Repeated attacks of spasmodic contraction, attended with violent efforts and straining to evacuate the contents of the bladder, cannot fail to lay the foui> dation of a permanent thickening of the mucous membrane; and at all events there can be no doubt that what was from the beginning a permanent stricture of the membranous portion of the urethra is a ways more or less liable to be affected with spasm. Even in the oldest cases of this description, we find the patient voiding his urine one day with tolerable facility, and another day only in drops or even suffering from a complete retention of urine in the bladder' A stricture which affects the external orifice and anterior ex- tremity of the urethra is, in many cases, connected with an adhe- sion of the inner surface of the prepuce to the glans. Such adhe- sion is usually the consequence of a congenital narrowness of the praepuce, combined with want of due attention on the part of the nurse to the child's cleanliness ; and hence it is that patients who labor under this kind of stricture frequently declare that they know not when the disease began, and that they cannot remember the time when the urine flowed in a full stream. The contraction thus established goes on increasing, but so gradually that it may not occasion a retention of urine, nor even any serious inconvenience until after the middle period of life. In other cases a strict ire ^ the anterior part o the urethra, whether situated near the orifice or two or three mches from it, seems to be the result of a chronfc inflammatory affection of the mucous membrane. There is a sli"ht degree of pam in making water, a gleety discharge, approaching in its character more nearly to mucus than to pus, a'nd a^imin bn of the stream of unne, which proceeds more'rapidly than wl e e the disease had begun in childhood, and by and bye a gristly indurat on may be felt through the substance of the corpus spLgiLZZT ing its exact situation, and extent of the disease. Tlfe oS'cau es' of stricture of the urethra, whether in the anterior nor ion of thf urethra, or near the bulb, have been already noticed A permanent stricture of the urethra cannot exist for any long MALE URETHRA. 13 period without the urethra becoming diseased otherwise. Small irregular prominences or tubercles are sometimes found on its inner surface, which seem to consist of minute deposits of coagulated lymph, which have become organized. Occasionally a narrow membranous band is seen extending from one side of the urethra to the other, as if there had been a partial adhesion of the opposite surfaces, which had afterwards become elongated. The orifices of the mucous glands and those of the prostatic ducts are often pre- ternaturally dilated, and indeed the whole canal of the urethra be- hind the stricture is widened, in consequence of the bladder forcibly impelling the urine into it, there being at the same time an insuf- ficient outlet for its escape. This dilatation of the urethra is most remarkable when the stric- ture is in the anterior part of the canal. I attended a gentleman, who for many years had labored under a stricture at the distance of three inches behind the external meatus. The posterior part of the urethra was so much dilated, that when he made water, a tumor, as large as a small orange, and offering a distinct fluctuation, pre- sented itself in the perineum. It might be compared to a second bladder. Once, when he sent to me, laboring under a complete retention of urine, I punctured the tumor in the perineum with a lancet. Immediately the urine gushed out in a full stream. From that time it flowed regularly through the artificial opening; all dif- ficulty in voiding it was at an end ; and thus 1 was enabled to direct my whole attention to the dilatation of the stricture, which was now speedily accomplished. In some cases of long standing, we find a gristly indurated mass at the lower portion of the penis, where it is covered by the scro- tum. This is probably, in some instances, the contracted portion of the urethra, thickened and converted into a substance approach- ing in its character to cartilage. But in other cases it depends on a different cause, as is plain from the following history :—A gentle- man who had passed many years in a hot climate, returned to Eng- land, laboring under a stricture of the urethra, and voiding his urine with great difficulty. A hard oblong tumor could be felt in the neighborhood of the stricture, though somewhat anterior to it, at the upper part of the scrotum. I dilated the stricture, so as to enable the patient to introduce a bougie for himself; but still the tumor remained unaltered. He died about a year afterwards of an accidental attack of disease in the brain; and I found, on dissec- tion, that the tumor had arisen from a deposition of lymph into the cells of the corpus spongiosum. Immediately behind the stricture there was an orifice, leading into a long and narrow sinus, extend- ing from the urethra into the gristly substance of the tumor. The direction of the sinus was from behind forwards, so that it was evi- dent that it could not have been produced by the improper use of 14 STRICTURES OP THE the bougie. I conclude that it was the result of the forcible and re- peated pressure of the urine against the urethra behind the stricture The same cause, of course, was sufficient to produce the gristly in- duration around it. In the foregoing observations, which have been intended chiefly to illustrate the pathology of stricture of the urethra, 1 have neces- sarily anticipated some of the observations that I have to offer re- specting the symptoms by which it is indicated in the living person, and the diagnosis of the disease. If a man under the middle period of life applies to you complain- ing of a difficulty of making water, the probability is that he labors under a stricture of the urethra. If an old man applies to you under the same circumstances, stating at the same time that his symptoms began several years ago, you may draw the same conclu- sion. But if he tells you that his symptoms are of later origin, you will have little reason to suspect the existence of stricture of the urethra, but great reason to believe that he labors under an enlarge- ment of the prostate gland. Stricture of the anterior part of the urethra, for the most part, proceeds very slowly; so that the pa- tient, in some instances, scarcely notices the diminution of the stream of urine, until he is actually compelled to strain in voiding it. A complete retention of urine does not occur until a very late period of the disease; and whenever it does occur, it is scarcely ever relieved spontaneously, that is, without the assistance of art. In these cases, there is generally a slight sense of scalding as the urine flows; and a mucous or muco-purulent discharge is a frequent, but not invariable, concomitant of the other symptoms. In cases of stricture affecting the membranous portion of the urethra, where the disease in its origin is purely spasmodic, it may be that the patient's attention is first drawn to his complaint in con- sequence of his being suddenly affected with a complete retention of urine, induced by some irregularity as to diet, exposure to cold, or perhaps by the application of a blister. But in another and much more common series of cases, the history is nearly as follows: —The patient voids his urine in a diminished stream. The dimi- nution gradually increases, being sometimes attended with a slight mucous or muco-purulent discharge. By and bye there is a com- plete retention of urine. This subsides spontaneously, or is relieved by art. After an interval (which may vary from weeks to months or even to years), he is overtaken by another attack of retention! During the whole of this time the stream of urine continues to be- come smaller; it is flattened, or otherwise altered in shape, or divided into two. At last the urine never flows in a stream larger MALE URETHRA. 15 than a thread, nor without great effort and straining. In some cases it dribbles away constantly and involuntarily, and the patient's clothes by day and his bed at night are absolutely sopped with urine, making him disgusting to himself and to all around him. This in- voluntary discharge of urine does not indicate an empty and con- tracted btadder. The bladder in fact is loaded with urine, and it is when it does not admit of further distention that the urine over- flows, and all beyond a certain quantity escapes without the patient being able to prevent it, the bladder being at the same time to be felt like an enormous tumor in the lower part of the abdomen. The exceptions to this rule are very rare ; and it applies not only to the involuntary flow of urine in cases of stricture, but also to that which takes places under other circumstances. The symptoms of retention of urine are sufficiently formidable, and not the less so as they generally attack the patient suddenly. He is perhaps sitting with his friends after dinner, and feels an in- clination to make water; in attempting to do so, however, he is disappointed. A second and third attempt are made after some time, and all without success. Now the case assumes a more se- rious aspect. An indescribable uneasiness is felt in .the region of the bladder. The efforts to void the urine are no longer voluntary. The patient is compelled to strain, and the whole of the abdominal muscles are in convulsive action, instinctively endeavoring to relieve the bladder of its contents, but all to no purpose. The bladder may be felt hard, and enlarged above the pubes. The heart sym- pathises with the local irritation, the pulse is hard and frequent, the face flushed, the skin hot, and the tongue is covered with a white fur. The violent efforts of the patient force out a few drops of urine, which give some relief; but the kidneys go on secreting, and the relief is only temporary. In the great majority of cases, the spasm is spontaneously or artifically relieved ; but there are, never- theless, numerous examples to the contrary, in which the retention terminates in death. The bladder itself may be ruptured at the fundus, the urine escaping into the cellular membrane, and into the cavity of the peritonaeum. Such an event occurred in St. George's Hospital many years ago. The patient exclaimed, after a violent paroxysm of straining, that the bladder had burst into the belly. He died; and, on examining the body, it was ascertained that the poor fellow's words were true. This case, and another similar one, have been published by Sir Everard Home. Fortunately such cases are rare. In most instances the rupture is not of the bladder, but of the urethra behind the stricture. Conceive a distended bladder, and the spasmodic action of the abdominal muscles and diaphragm of a powerful man acting like a syringe and forcing the urine through the lacerated urethra into the cellular membrane. In fact the scro- 16 STRICTURES OF THE turn, the penis, the perineum, sometimes even the groins, are enor- mously distended with urine. The first effect of this mischief is to relieve the patient's sufferings. There is no more straining, and the spasm of the stricture, no longer excited by the pressure behind, becomes relaxed, so as to allow some of the urine to flow by the na- tural channel. After this deceptive interval of ease, another order of symptoms shows itself. The urine, under any circumstances, would irritate the parts unaccustomed to its contact; but in a case of retention of urine, it has been long in the bladder ; much of its watery part has been absorbed ; and it is in consequence unusually impregnated with saline matter, so that its stimulating properties are much increased. Wherever this acrid fluid penetrates, it first excites inflammation, and then kills the parts with which it is in contact. The patient is seized with shivering; the skin of the scrotum, penis, and other parts becomes red and inflamed. If you make incisions into it, you find black offensive sloughs underneath. If the incision be not made, or be not sufficiently extensive, the skin becomes speckled with black spots, which increase in size, forming large sloughs. Sometimes a black spot is seen on the glans penis : an almost fatal symptom, indicating that the whole of the corpus spongiosum is infiltrated with urine. As this process of mortification goes on, the constitution becomes affected, as it would have been if the mortification had arisen from any other cause. At first the pulse is full, and the skin hot; but the depressing effects of an extensive destruction of living parts are soon manifest. The heart be;its feebly and frequently ; then the pulse becomes irregular, and afterwards intermittent. The skin is cold and clammy ; the patient is troubled with an incessant hiccough, which nothing re- lieves for more than a few minutes. By and bye a low delirium supervenes, which is followed by coma and death. But the danger from the effusion of urine is not the same in all cases. In the majority the effusion takes place in front of the tri- angular fascia of the perineum, or else the fascia gives way, and allows the urine to pass forward to the superficial parts, instead of penetrating to the deep-seated ; and under these circumstances, life may generally be preserved by the prompt interference of the sur- geon. In a very few cases, the effusion extends into the loose cellular membrane which surrounds the bladder, and the patient's case is hopeless. The time during which a retention of urine may continue before a rupture of the urethra or bladder takes place, is much longer than you would expect. Such a catastrophe as that which I have en- deavored to describe rarely occurs before the third or fourth day. It may indeed occur sooner; but often the period is even later than this. The retention may continue for a week, with occasional in- termissions, during which small quantities of urine are discharged ; Male urethra. 17 then it may become complete, and, the urethra giving way, the urine may be extravasated. The secretion of urine may be more or less abundant; the bladder may be more or less capable of dilatation ; and the period of the extravasation taking place must vary ac- cordingly. I am much mistaken if a stricture is not sometimes destroyed, at least in part, by ulceration. For example: I attended a gentleman who had labored under a stricture of the urethra for a great many years. He voided his urine with the greatest difficulty, the stric- ture being very rigid and unyielding; but I succeeded in intro- ducing a catgut bougie, and this enabled him to make water in a small stream. Under these circumstances he was seized with pain in the act of making water, which lasted for some minutes after- wards, being referred to the situation of the stricture in the poste- rior part of the urethra. The pain became more severe, and the patient described it to be intolerable, saying that he could compare it to nothing but the sensations which he supposed would be pro- duced, if melted lead had been poured into the canal. Every half hour he had a desire to make water, and his groans might be heard, not only through the whole house, but even in the street. In the course of a few days these symptoms began gradually to abate, and now it was discovered that the urine flowed in a much larger stream. When the attack had completely subsided, the condition of the pa- tient was much improved, and he made water more easily than he had done for many years. I know not how all these circumstances can be so well explained, as on the supposition of the stricture hav- ing been in a state of ulceration. Such a case is rare ; but what I am about to describe is common enough. The patient complains of more than usual difficulty in voiding his urine ; but the difficulty does not amount, at least in the first instance, to an absolute retention. Perhaps he has a shivering. There is a sense of fullness in the perineum, and some degree of deep-seated induration is perceptible in one part. This gradually increases, and a tumor presents itself under the skin of the peri- neum, surrounded with more or less of cedematous effusion, espe- cially into the scrotum. The skin becomes inflamed, and the fluc- tuation of fluid is perceptible underneath. An abscess bursts, or is opened with a lancet, and a considerable quantity of putrid pus is discharged. Here the oedema of the neighboring parts subsides, Pus continues to flow through the orifice of the abscess, and after some time it is observed that urine flows through it also. The dis- charge of pus diminishes, but the urine flows in larger quantity; and whenever the patient makes water, part escapes through the natural channel, and part by the new opening. The abscess has evidently a communication with the urethra behind the stricture. If you have an opportunity of dissecting the diseased parts white 3 18 STRICTURES OF THE the abscess is recent, you find it to open into the urethra by a ragged irregular orifice. If you examine them at a later period, the orifice in the urethra is found to be smooth, regular, and rounded at the margin ; the external orifice in the perineum is reduced to a narrow diameter, and is seen in the center of a button-like projection of the skin ; and the abscess itself is contracted, perhaps reduced to a narrow passage, with a smooth surface, which presents somewhat of the appearance of it being lined by a mucous membrane. We now say that the case is one of fistula in perineo. The whole of these phaenomena are easily explained. The urethra, constantly teazed by the pressure of the urine against it, ulcerates behind the stric- ture. If the stricture had been completely closed, as in a case of retention of urine, an extensive extravasation of urine would have immediately taken place ; but under the existing circumstances, this does not happen, and only a moderate quantity, perhaps not more than a few drops, dribbles into the cellular membrane, sufficient to induce inflammation and suppuration, and no further local mischief. A fistula in ano is formed in the same manner, by ulceration of the rectum, allowing the escape of a minute quantity of faeculent matter into the neighboring textures. The formation of the abscess in the perineum is always attended with some degree of fever. But sometimes the febrile symptoms are very urgent: the skin is hot, the pulse rapid, the tongue dry and brown, or covered with a black crust. If the abscess be left to burst of itself, it is more than probable that the patient will perish under these typhoid symptoms; if it be opened, a dark-color- ed offensive putrid pus is discharged, the bad qualities of which are manifestly owing to an admixture of urine. If the operation be not imprudently deferred, an immediate improvement follows the opening of the abscess; the pulse becomes less frequent, the skin less hot, the tongue clean and moist, and the patient, who appeared to be on the verge of death, is restored to life, and comparatively to health. I have described the simplest form of the urinary abscess. But it is often more complicated. It is not always confined to the perineum. Sometimes it makes its way forward through the upper part of the scrotum, and presents itself on the lower part of the penis, between the scrotum and the glans. At other times it bur- rows in the opposite direction, forming a large collection of matter in the nates, or it in iy burst in the groin or in the sr-rotum. In one case, in which I had the opportunity of examining the body after death, I found a large abscess in front of the pubes, extending half way towards the navel ; another among the adductor muscles of the left thigh ; and a third among the muscles at the upper part of the right thigh, as far outwards as the foramen ovale of the ischium ; the periosteum having been destroyed, and the bone it- MALE URETHRA. 19 self rendered carious to a considerable extent: and all these ab- scesses could be traced into an abscess in the perineum, communi- cating with the urethra behind a stricture by a small orifice. In another case which I attended with Mr. Samuel Cooper, there was a fistula in perineo, communicating with a large abscess of the pelvis on one side of the bladder. I have seen a few cases in which an abscess of this kind had made its way into the rectum, forming a fistulous communication between it and the urethra. If such communication be of a large size, it is a source of great distress, as faeculent matter occasionally passes through it from the rectum into the urethra. If it be small, how- ever, the absolute inconvenience is trifling, and the patient is ren- dered sensible of its existence only in consequence of a small quan- tity of air escaping occasionally by the urethra : and this may con- tinue, without any further symptoms supervening, for many years. There is one form of abscess of the perineum, which may be compared to what has been called a blind fistula of the rectum; the abscess having an opening into the urethra and none externally. Such an abscess may at one time be inflamed, swollen, and tender; then these symptoms may subside, but only to recur at a future period ; and this state of things may continue for many years. I conclude that in these cases the abscess is formed in the usual way, by ulceration of the urethra, and the infiltration of a small quantity of urine into the cellular texture ; but that, when a certain quantity of matter is collected in it, it bursts into the urethra, instead of finding its way to the surface, the communication being of sufficient size to prevent any considerable accumulation of matter afterwards. A fistula of this description is a source of inconvenience and mischief, and of nothing else. It is not so with a fistula which has an external opening. The latter answers, in some measure, the purpose of a safety-valve to the bladder, enabling the patient to void his urine even where the stricture is closed, and lessening the liability to retention. But even in this case the good is not un- mixed with evil. It occasionally happens that the external orifice of the fistula becomes inflamed and swollen, or that it actually heals, and that this is followed by an accumulation of matter with- in, attended with many, or with the whole of the symptoms which marked the first attack of the disease. And there may be even greater mischief ultimately. Mr. Vincent and myself attended a gentleman with a fistula in perineo, which he had neglected for many years. At last he observed that the callosity at the margin of the fistula had begun to increase ; and it went on increasing, so that it ultimately extended to the scrotum and penis. When we were called in, we found him with a malignant tumor, affecting the perineum, scrotum and penis, which had evidently had its origin in the fistula. He ultimately died in great distress and misery. 20 STIUCTURES OF THE LECTURE II. Stricture of the Urethra—continued. If you consider the relations which the urethra bears to the pros- tate gland and bladder, you will not wonder that these organs should suffer in old and inveterate cases of stricture. A chronic enlargement of the prostate gland is one of the most frequent changes with which the body is affected in old age; and it may take place in those who labor under stricture of the urethra as well as in other persons. There is, however, more than this merely accidental connection of the two diseases with each other; and those who have been long tormented with stricture are more liable to disease of the prostate, and are liable to it at an earlier period of life, than those in whom the urethra is free from obstruc- tion. In a great number of instances, where the patient is some- what advanced in years, when you have dilated the stricture, you find that the relief is incomplete, and remedies beyond those which the stricture itself demands are necessary to remove or palliate the symptoms produced by the disease of the prostate. I have already mentioned the dilatation of the ducts of the prostate, which is observed in some cases. Occasionally, where the urethra has been diseased for a long period, pus may be squeezed out of the dilated ducts. Circumscribed abscesses also form in the substance of the prostate, which, in some instances, burst and discharge their con- tents by the urethra, during the patient's lifetime ; while in others their existence is not ascertained until an incision is made into the diseased gland in the examination of the body after death. It is not my intention at present to enter into the history of the addi- tional symptoms which arise from this complication of disease of the prostate in old cases of stricture, since they do not materially differ from what we observe where the prostate is alone affected; to which subject I shall call your attention in a future lecture. The following observations, however, may be introduced now better than hereafter:— 1. Where a simple chronic enlargement of the prostate gland supervenes on stricture of the urethra, the latter usually becomes Jess liable to spasm, and is more easily dilated, and altogether more tractable than it was before: a change in its condition which is MALE URETHRA; 21 easily explained; as the pressure of the urine against the stricture when the patient strains in making water is a constant source of irritation, which is in a great measure removed as soon as a new impediment to the flow of the urine between the stricture and the bladder, is established by the tumor of the prostate. 2. But where the disease of the prostate goes beyond the mere enlargement, and suppuration has taken place in its substance, an opposite effect is produced on the stricture ; the abscess itself be- coming a source of irritation, rendering the stricture more sensitive, and more liable to spasm than it would have been otherwise. 3. Although the combination of stricture with enlarged prostate is common enough, it is not so common as it is by some surgeons sup- posed to be. An old man, who has a frequent desire to void his urine, and voids it slowly and with difficulty, applies to a surgeon whose hand is light and accustomed to the use of the catheter. The instrument is then introduced readily, or, at any rate, meets with no obstruction until it reaches the neck of the bladder, and the case is set down as one of enlarged prostate, which it really is. Anoth- er old man, under precisely similar circumstances, applies to a sur- geon who uses the catheter rudely and incautiously. The urethra resents this rough usage ; spasm is induced, and the point of the catheter cannot be passed further than the membranous part of the urethra. The case is then supposed to be one of stricture, and is treated as such : I need not tell you to how little purpose. I have already mentioned that the bladder is rendered irritable in many cases of stricture of the urethra. In consequence of this, it is never properly dilated, and it becomes small and contracted. If the stricture be dilated before any further disease in the bladder is established, the latter is relieved, and soon regains its natural ca- pacity. In many cases of old and neglected stricture, the mucous membrane of the bladder becomes affected with chronic inflamma- tion. It secretes a ropy adhesive mucus, which clings to the bot- tom of the vessel which receives it ; and sometimes this mucus is generated in such abundance as to obstruct the narrow orifice of the stricture, and add very much to the difficulty of making water. In such cases, if you examine the body after death, you find the vessels of the mucous membrane turgid with blood, and the whole membrane in consequence of a dark red color: and things may continue in this state, sometimes better and sometimes worse, for months, and even for some years. I have met with several cases of stricture of the urethra in which the mucous membrane of the bladder was found, after death, not only inflamed, but encrusted, even over a large portion of its surface, with coagulated lymph. Such an effusion of lymph is the result of acute inflammation, differing in its character from the chronic inflam- mation, which produces merely a secretion of the vesical mucus; 22 STRICTURES OF THE and it is observed chiefly (if not exclusively) when the patient has died after having been harrassed by repeated attacks of retention of urine. There are other cases in which the bladder, instead of being contracted, is rendered more capacious than natural; the patient never emptying it completely. I have already explained that this condition of the bladder is often indicated by an involuntary dis- charge, or incontinence of urine. Here, when you have dilated the stricture, the symptoms are only partially relieved ; and on in- troducing the catheter, you find a large accumulation of urine, which the patient was unable to void by his natural efforts. This particular symptom may occur where the stricture exists in combi- nation with enlargement of the prostate ; but it occurs also in old cases of stricture, independently of this complication. In most cases of stricture, the muscular coat of the bladder is thicker and stronger than natural. This circumstance is easily ex- plained. The bladder has been called on to make unusual exer- tions, and it is a law of the animal economy, that muscles which are unusually exercised shall become increased in bulk. In some instances, the mucous membrane is protruded through some of the interstices of the muscular fibres, forming numerous small cysts, communicating with the cavity of the bladder. These cysts appear to be produced in the following manner :—when the patient strains in making water, the mucous membrane, while it is pressed on by the muscular fibres externally, has to sustain an equivalent degree of pressure on its inner surface from the reaction of the urine. Wherever there happens to exist a small interstice between the muscular fibres, the latter force alone operates, and the bulging outwards of the mucous membrane is the necessary consequence. These cysts, however, are not peculiar to cases of stricture of the urethra, and they occur equally where the obstruc- tion to the flow of urine arises from an enlargement of the prostate gland, or from any other cause. A cyst being once estab- lished, continues to increase, and may ultimately attain a very large size. Many years ago I met with a case of long-neglected stricture of the urethra, in which, on examining the body after death, I found one of these cysts, interposed between the bladder and the rec- tum, at least equal in capacity to the bladder itself. Occasionally, as I shall explain to you more fully in a future lecture, a calculus finds its way into one of these cysts, increases in size, and be- comes impacted in it. For the most part the contents of the cysts are similar to those of the bladder itself; but I shall have occasion hereafter to mention a case in which a large cyst of this description contained pure pus, while in the bladder there was nothing but urine. In cases of stricture, where the disease has existed for many MALE URETHRA. 23 years, and nothing effectual has been done for its relief, abscesses form in the cellular membrane external to the bladder, but commu- nicating with it, similar to those which I have already described as connected with the urethra. A Considerable time elapses before such abscesses present themselves externally. They point at last in the groin, or above the pubes, discharging a putrid offensive pus in the first instance, and giving exit to urine afterwards. In I)r Hunter's Museum (which is now in Glasgow,) there is a preparation exhibit- ing an abscess of this kind communicating with the bladder at the fundus, extending upwards in the course of the urachus, and open- ing externally at the navel. I believe that the. formation of these abscesses is always preceded by chronic inflammation of the mucous membrane of the bladder, and their existence is marked by severe typhoid symptoms. For the most part they may be regarded as a sign of approaching dissolution. Stricture of the urethra, as it impedes the flow of urine from the bladder, so it cannot but interfere, to a certain extent, with the pas- sage of urine into it. One result of this is, that the ureters, pelves of the kidneys, and infundibula become dilated, the glandular struc- ture absorbed, and the whole organ converted into a membranous bag, divided by septa into different compartments, which, however, communicate with each other. The kidneys are also liable to be affected in other ways; but, to avoid a needless repetition, I may refer you for what I have to say on this subject to future lectures, especially to that on the diseases of the prostate gland. I have said that rigors sometimes occur during the formation of urinary abscesses. In this there is nothing remarkable, as rigors mark the existence of suppuration under a variety of other circum- stances. But rigors also occur in many cases of stricture indepen- dently of abscess. We meet with them most frequently in patients from hot climates. They usually recur at irregular periods, being in many instances brought on by the introduction of a bougie, or the application of caustic to a stricture. The paroxysm very nearly resembles that of an intermittent fever, and it is more severe when it follows the use of a bougie than when it occurs independently of it. In general, the cold fit having been followed by a hot fit, and that by a profuse perspiration, the patient is relieved. At other times, however, the constitution is disturbed for a great length of time afterwards ; and sometimes the rigor is followed by an attack of continued fever, which lasts for some days, or even for some weeks. I met with a case in which a rigor followed the application of caustic to a stricture, and this was followed by an attack of mania, which (if my recollection be accurate) did not subside for nearly a month. Another patient had labored under a stricture of the urethra for many years, during which no instrument had ever been made to enter the bladder. I succeeded in introducing a small gum cathe- 24 STRICTURES OF THE ter. Having emptied the bladder, I removed the catheter. In a few hours afterwards there was a severe rigor. An attack of fever ensued, attended with rheumatic inflammation of the muscles of the neck, from the effect of which the patient never entirely recovered, though he lived for many years afterwards. It has been said that stricture of the urethra lays the foundation of disease of the testicle. The introduction of a bougie will some- times induce acute inflammation of that organ, probably by irritating tha verumontanum and the orifice of the vas deferens ; and it is not improbable that chronic inflammation of the testicle may some- times arise in the same manner. It appears to me, however, that the effects of a stricture on the testicle have been, by some writers, very much exaggerated. An hospital surgeon, who is now no more, published a work in which he expressed himself as if he regarded almost all cases of chronic inflammation of the testicle as being de- pendent on disease of the urethra, and not curable, except under the use of the bougies. I need make no comment on such a fan- tastic hypothesis. Diagnosis in Cases of Stricture of the Urethra. I shall now suppose that a patient applies to you, believing that he has a stricture of the urethra. Perhaps you find on inquiry that the symptoms are equivocal ; and you require something more than a mere knowledge of them to enable you to determine whether a stricture does or does not exist: or it may be that the symptoms are so distinct and well marked that you can have no doubt as to the existence of a stricture, but you wish to know in what part of the urethra it is situated, and what is the degree of contraction. The knowledge that is required in either of these cases, is to be obtained by the examination of the urethra with a bougie, or some other in- strument corresponding to it. The best kind of bougie is that in common use, made of plaster spread on linen, and rolled up. It should be smooth on the sur- face, and neatly rounded at the extremity. The plaster bougie should be rubbed until it becomes warm, so that it may be moulded by the hand, and bent into the form of the urethra. Thus bent, it is much to be preferred to the elastic bougie, which is made of elastic gum on the outside and of catgut within. The latter may, it is true, be bent into any form; but it is elastic, and however you may bend it, it always regains its straight figure ; and hence it is not well constructed for being passed along the curved canal of the urethra. The bougie which is used for the purpose of examining the urethra should be of a full size, that is, large enough to fill the urethra without stretching it. A small bougie may deceive you in MALE URETHRA. 25 two ways: it may pass through a stricture, and thus lead you to believe that there is no stricture, when there really is one; or it may have its point entangled in the orifice of one of the mucous follicles of the urethra, or in some accidental irregularity of the canal, and lead you into the opposite mistake of supposing that there is a stricture where none exists. If you use a bougie of the size of the urethra, you are not at all liable to the first error, and you are much less liable to the second than you would be otherwise. The bougie should be cylindrical. There is no advantage in any bougie, except a very small one, being conical. "A conical bougie, becoming larger towards the point, which is held in the hand, is likely to extend forcibly the orifice of the urethra, and to excite in- flammation in it. The existence of stricture in the anterior part of the urethra, or at its orifice, is so easily ascertained, that it seems unnecessary to offer any observations on the subject. The following rules, then, are to be considered as relating especially to those cases in which it is a question whether there be, or be not, a stricture in the mem- branous part of the urethra, or in its immediate vicinity. I generally find it best to introduce the bougie with the patient in the erect posture, keeping the extremity of it, which I hold in my right hand, close to his groin, and passing it until it will go no further in that direction ; after which, by turning the instrument, I bring it horizontally forwards, and push it gently towards the blad- der. If the patient has well-marked symptoms of stricture, and the bougie meets with an obstruction in some part of the urethra, you may be justified in considering this as sufficient to indicate the existence and situation of the disease. If, however, the patient has no such well-marked symptoms, you should not advance at once to the conclusion that there is a stricture because the bougie does not immediately enter the bladder. The extremity even of a large bougie may hitch in some irregularity of the mucous membrane; or if you are at all rough in the use of it, a spasm may be induced in the membranous part of the urethra, or in the muscle which sur- rounds it, preventing the bougie from being passed, although no such cause of obstruction exists at other times. Under these cir- cumstances, you should introduce a silver catheter, or, what is bet- ter, a metallic sound, having a moderate curvature, and w7armed to the temperature of the body; and it is probable that, if there be no stricture, the metallic instrument will be easily introduced, al- though the plaster bougie could not be introduced at all. In short, where there are no decided symptoms of stricture you ought not to adopt the opinion that a stricture exists, without having made a very careful examination of the urethra. Inattention to this rule has led to many patients being subjected to a course of treatment for stricture who had never labored under the disease. 4 26 STRICTURES OF THE There is a fashion in diseases, or rather (to speak more properly) there is a fashion in the opinions entertained as to the prevalence of particular diseases, and when the attention of the medical profession and the public has been especially directed to a certain order of cases, such cases are almost invariably supposed to be much more common than they really are. A very few years ago it was so with respect to the disease which we have now under consideration. If a man had a troublesome gleet ; if he had an indurated testicle; if he had a priapism at night; if he had a frequent inclination to void his urine ; if he was impotent, or believed himself to be im- potent ; if the stream of urine was not perfectly cylindrical; or even if he was liable to an herpetic eruption on the prepuce; he was supposed by many surgeons to be laboring under stricture of the urethra, and was at once subjected to the unnecessary use of bougies. The number of persons who at this period were supposed to have a stricture of the urethra, and who really had no such disease, and many of whom had no disease at all, was not less than that of the young females who, at a still later period, have been the victims of another mischievous delusion, being laid up for years together on a sofa, under the supposition that' they labored under disease of the spine or hip, when in reality they suffered only from hyster- ical pains and spasms, which air and exercise would have cured, but which confinement and nursing, and the attendance of phy- sicians and surgeons, have only tended to aggravate. I dwell on this subject, because I am anxious that none of my pupils should fall into an errror so discreditable to themselves, and so mischievous to society. Treatment of a Retention of Urine from Stricture. It frequently happens that when you are first called to a patient with a stricture of the urethra it is on account of his laboring under a retention of urine in the bladder. At all events, this, when it does occur, demands your first attention. Here the patient is in a state of immediate danger; and you are to stand between him and de- struction. You have no time to pause, to deliberate, or to consult your friends or your books. Your patient is suffering torture; he and his friends are in a state of the greatest possible anxiety and alarm ; and it is important that you should have a perfect knowl- edge of all the remedies which are likely to be useful, so that you may be enabled to make an immediate application of them for his relief. You will observe that the causes of retention of urine are vari- ous. Stricture of the urethra is only one of them. The treat- ment which is applicable to a retention from one cause is not applica- MALE URETHRA. 27 ble to a retention from others. The observations which I am about to make relate exclusively to cases of retention from stricture: but even in these cases the immediate cause of the inability to void the urine is not always the same. I have explained how it is that abscess is formed in the perineum. Here, in the first instance, there has been no absolute retention of urine. If there had been, instead of an abscess, there would have been an extensive extravasation of urine into the cellular mem- brane. But when an abscess is once formed in the neighborhood of the urethra, and has attained a certain magnitude, it cannot fail to obstruct that canal, and, though not the consequence, may itself become a cause of retention of urine. This is especially liable to happen where the matter is pent up behind the deep-seated fascia of the perineum. To relieve the retention you must open the ab- scess. For what I have to say further on this subject, I may refer you to my next lecture. A stricture at the external orifice, or in the anterior part of the urethra, is a much less frequent cause of retention of urine than a stricture which is situated at the membranous part. Here the stric- ture is not liable to spasm, and you can look only to its mechanical dilatation. A small catgut bougie may generally be introduced into it. This may be followed by one of a larger size, and this again by a straight metallic instrument larger still. This will enable the pa- tient to void a portion, but not the whole, of his urine. The bougie or metallic sound must then be introduced again, and allow- ed to remain in the stricture until there is another impulse to make water, and this process must be repeated until the bladder is emp- tied. But in the very great majority of cases the immediate cause of a retention of urine is a spasmodic affection of a stricture at the membranous part of the urethra ; and it is to this class of cases that the observations which I have now to offer will especially relate. I have heard it recommended, even by some experienced sur- geons, that in these cases you should bleed your patient, that you should direct him to be put into a warm bath, and that certain other means should be employed, before you attempt to relieve him by the introduction of a bougie or catheter. But this recommen- dation does not correspond with what my own experience would suggest. The cause of the retention is local, and in the greater number of cases you will succeed in enabling the patient to empty the bladder by mechanical means. The plan which I would re- commend you to adopt is the following :— Begin by taking one of the smallest gum catheters, which has been kept for a considerable time on a curved iron wire, and which retains the curved form after the wire is withdrawn. Introduce it 28 STRICTURES OF THE without the wire ; and, as it approaches the stricture, turn the con- cavity of the catheter towards the pubes, elongating the penis at the same time by drawing it out as much as possible. It is not very improbable that it will pass through the stricture, and enter the bladder. The urine will then flow through it in a fine stream, and the patient will obtain immediate and complete relief. If you fail with the small gum catheter, try, not a plaster, but a small catgut bougie. Let this be well made; that is, firmly twist- ed, nicely rounded at the extremity, and every where well polished. Observe the same rule of elongating the urethra, and it will proba- bly enter the stricture. It is not necessary that the catgut bougie should pass on to the bladder ; it is sufficient if the stricture grasps, or holds it. Let it remain in the stricture until there is a violent impulse to make water. Then withdraw the bougie, and the urine will follow it in a small stream. If the patient empties the bladder, the object is attained; but, otherwise, re-introduce the catgut bougie, or rather introduce another of the same size (for a catgut bougie which has been once used is not fit to be employed a second time); and let the patient retain this second bougie as long as he can. If the straight catgut bougie cannot be passed, you will often succeed in effecting its introduction by bending the point of it thus :— This contrivance enables you to keep, the point sliding against the upper surface of the urethra, avoiding the lower part, in which the obstruction is always most perceptible, and in which the bougie is most likely to become, as it were, entangled. Even where you have failed to relieve the patient by means of the catgut bougie, you will often succeed in introducing a silver catheter, or an elastic gum catheter mounted on a firm iron stilet, into the bladder. The catheter employed on this occasion, if the stricture be of recent formation, should be nearly of the full size of the urethra; but if the stricture has been of long duration, it should be considerably smaller. The common silver catheter is not so well adapted for the purpose as that which I now show you. You will observe that it is shorter and less curved than usual; and that it is fixed in a wooden handle, which renders the instrument more manageable than it would be otherwise. If you use an elastic gum catheter, the iron stilet should have a flattened handle, re- sembling that of a common sound. You should pass it as far as the obstruction, and having ascertained where it is situated, withdraw the catheter a little, a quarter of an inch for example, and then, as MALE URETHRA. 29 you pass it on again towards the bladder, keep the point sliding against the upper part of the urethra, which is towards the pubes, avoiding the lower part, which is, of course, towards the perineum. Be careful to employ no violence. If you lacerate the urethra, so as to cause haemorrhage, you will be defeated in your object. Press the catheter firmly, but gently and steadily, against the stricture, keeping in your mind the anatomical position of the parts, and being careful to give the point of the instrument a right direction. When the pressure has been thus carefully continued for sometime, the stricture will begin to relax. It will allow the point of the catheter to enter, and, at last, to pass completely through it into the bladder. In some instances this will be accomplished in the space of one or two minutes ; while in others it may be necessary to per- severe for a quarter of an hour. As soon as the catheter has reached the bladder, the patient's sufferings are at an end, as the bladder becomes completely emptied. If you have used the elas- tic gum catheter, it may be prudent to allow it to remain in the urethra and bladder for one or two days, or even for a longer peri- od ; and this will go far towards accomplishing the cure of the stricture. If you are skilful and prudent in the management of the cathe- ter, you will generally succeed in introducing it into the bladder ; but if you fail in doing so, the attempt to introduce it may still be useful to the patient. The pressure of the catheter against the stricture, if kept up for a considerable time, exhausts the morbid irritability of this diseased portion of the urethra. The spasm be- comes in a considerable degree relaxed, and if you withdraw the in- strument when the patient has a violent impulse to make water, the urine will follow in a stream. Observe, that I am taking it for granted that you are careful to avoid all violence. If the mem- brane of the urethra be lacerated, the probability is, that that the spasm will not give way ; and if, under these circumstances, you persevere in the attempt to introduce the catheter, you will but aggravate the evil which it is your object to remove. The remedy on which you are most to rely, where these me- chanical means fail, is opium. From half a dram to a dram of laudanum may be given as a clyster in two or three ounces of thin starch. If this should not succeed, give opium by the mouth, and repeat the dose, if necessary, every hour until the patient can make water. According to my experience, the cases in which the stric- ture does not become relaxed under the use of opium, if adminis- tered freely, are very rare. The first effect of the opium is to diminish the distress which the patient experiences from the disten- tion of the bladder. Then the impulse to make water becomes less urgent; the paroxysms of straining are less severe and less fre- quent ; and after the patient has been in this state of comparative 30 STRICTURES OF THE ease for a short time, he begins to void his urine, at first in small, but afterwards in larger quantities. It is customary in these cases, to employ the warm bath. It is, indeed, sometimes useful, bat you can place no dependence on it as compared with opium. It is not sufficient that your patient should sit in a hip bath: the bath, to be at all efficient, must be complete ; his whole person ought, therefore, to be immersed, and he should remain in it for half an hour, or an hour, or longer, un- less he previously becomes faint. Bleeding from the arm is seldom required in cases of retention of urine from stricture ; but, in some instances, even where other means have failed, taking blood from the perineum by cupping gives immediate relief. Purgatives require some time to produce their effect, and, in most cases, at the period of your being called in, the symptoms are too urgent to admit of this delay. Where, however, a stricture is chief- ly spasmodic, and the retention follows the too great use of fer- mented liquor or spirits, I would advise you, if you are sent for on the commencement of the attack, to prescribe a draught of infusion of senna with the tartrate of potass and tincture of jalap. As soon as this has fully operated, and the bowels are emptied, give thirty or forty drops of tincture of opium by the mouth, or order an opiate clyster to be administered, and, in all probability, the attack will subside. After all, there is no absolute rule as to the treatment of reten- tion of urine from stricture. One person is relieved in one way, another in another ; and you will do well in each case to bear in mind the particular mode of treatment which has proved of service, in order that you may at once resort to it, if you are called a second time to the same patient, under the same circumstances. In one instance, you will be able to pass a catgut bougie, and not a cathe- ter ; in another, you will be able to pass a catheter, and not a catgut bougie. One individual is relieved by opium, another by the warm bath. A gentleman of my acquaintance, who was subject to at- tacks of this description for a considerable time, almost always began to make water after a pint of warm water had been thrown up as a clyster. To show what various treatment is necessary, I have been in the habit of mentioning the following case. A gentle- man, who had been long in hot climates, labored under an old stricture of the urethra. He was able to pass a bougie for himself; and he did this at regular periods, and for a long time experienced little or no inconvenience from his disorder. One night, however, he was seized with retention of urine, and called me out of my bed in consequence. I introduced a gum catheter, which entered the bladder with perfect ease, and drew off the urine. He called me up another night, and another, and another still; and one night he called me up twice. At last, it occurred to me that he always MALE URETHRA. 31 sent for me on the alternate nights; and on inquiry, I found that the attack of retention regularly came on about twelve o'clock, and even though the catheter had entered the bladder, the spasm did not relax, so as to enable him to make water by his own efforts, until five or six in the morning. I determined then to treat the case as we do many other intermitting and periodical diseases ; and I pre- scribed him the sulphate of quinine. The first night after he be- gan to take it he had an attack of retention; but he had no attack afterwards. Now let us suppose a case in which you have tried all the methods which I have described, to no purpose. The bladder be- comes more and more distended, the patient's sufferings go on from bad to worse. Are you to leave him to suffer and die ? By no means. You may puncture the bladder itself; or you may- make an opening into the urethra, behind the stricture, and thus prevent the catastrophe which would be otherwise inevitable. Four different operations have been proposed for the purpose of drawing off the urine, when it cannot be voided by the natural passage. The bladder may be punctured above the pubes, or from the rectum, or from the perineum ; or the urethra itself may be punctured between the stricture and the prostate. It is not my intention at present to enter into a detailed history of each of these operations ; but I shall nevertheless offer a few observations respecting them. You may prefer one operation to the other; but you will not be able in practice to resort to one ex- clusively. Your choice must be influenced by the particular cir- cumstances of each individual case. If the patient be thin, and the bladder be much distended, you may puncture it above the pubes ; but if the patient be corpulent, this operation will be diffi- cult ; and if the bladder be contracted, it will be impracticable. If the bladder be much distended, and the prostate gland be of its natural size, you may puncture it from the rectum ; but if the dis- tension be inconsiderable, or the prostate gland be enlarged, this operation will be at the same time difficult and dangerous. The puncture of the bladder from the perineum is so serious and severe an operation, and attended with so great a chance of mischief, from the effusion of urine into the loose cellular texture, that no surgeon of the present day, as far as I know, ventures to recommend it. The puncture of the urethra from the perineum in thin persons, where the parts to be divided are not altered from their natural structure, is a sufficiently simple and unobjectionable operation. The staff introduced into the urethra shows the situation of the stricture. The membranous portion of the urethra is situated be- hind the stricture, and below the symphysis of the pubes ; and the bulging of the urethra, as the urine is driven into it when the pa- tient strains, points out the exact spot at which it may be opened. 32 STRICTURES OF THE But it may be that the patient is a fat person, with a deep perineum ; or that the parts in the vicinity of the stricture are in a state of gristly induration ; or that the perineum has been at a former period the seat of abscesses and sinuses ; or that such sinuses exist at the present moment: and any one of these circumstances will be suffi- cient to make the operation perplexing and difficult even to the best anatomist. On the whole, from what experience I have had on the subject, I am inclined to believe that the puncture of the bladder from the rectum is applicable to a greater number of cases than any other operation. In proper cases this operation is free from pain and danger, and it has the advantage of simplicity, being per- formed at once without difficulty. The trocar having been with- drawn, the canula should be allowed to remain in the rectum and bladder for one or two days. By the time that it is removed, the sides of the wound will have become agglutinated, and it may per- haps continue as a fistulous communication between the bladder and rectum until the stricture is cured. At least this happened in one instance ; and thus I was enabled to cure one of the most distres- sing cases of stricture which I ever had under my care. The pa- tient was a middle-aged gentleman, who had labored under the disease from his boyhood. The use of the bougie induced a secre- tion of ropy mucus in such quantity as to fill up the urethra, and to be in itself a material impediment to the passage of the urine, and not unfrequently it occasioned a complete obstruction of the urethra, and a retention of urine. In one of these attacks of re- tention, I punctured the bladder from the rectum, and the wound, as I have mentioned, became fistulous. Now, whenever the stric- ture was more closed than usual, the bladder was relieved through the fistulous passage, and the urine came away by the rectum. The secretion of the ropy mucus ceased: there was no recurrence of the retention of urine. Nothing now interfered with the neces- sary operations on the urethra, and the dilatation of the stricture was easily accomplished. It may be further observed respecting this operation of punctur- ing the bladder, that it is impossible to lay down any general rule as to the period beyond which it ought not to be delayed. You must exercise your own judgment, taking into consideration all the cir- cumstances of the particular case before you. Sometimes there will be no reason for resorting to it until after the lapse of three or four days ; and at other times it ought to be performed within thir- ty-six hours, or even sooner. After all, however necessary it may be to the safety of the patient in some instances, it is an operation that is very rarely required. Surgeons who see a great number of cases of retention of urine, may, in the course of their lives, be called on to perform it in a few instances. Those who perform it frequently, must often perform it MALE URETHRA. 33 unnecessarily; at least this is what I should say, judging from my own experience. Where the urethra has given way behind the stricture, and the urine has become effused into the cellular texture, very prompt and vigorous measures are necessary : delay is fatal. I remember the time when five out of six of those patients, in whom this mischief took place, perished ; but now, from the more active treament em- ployed, under the hands of a well-informed suigeon the great ma- jority recover. I have already mentioned, that the escape of the urine is followed by a relaxation of the stricture. You will, probably, now be able to introduce a catgut, or some other bougie (a catgut is to be pre- ferred), through the stricture into the bladder. If you can do so, it is so much the better. Introduce the bougie ; let the patient be held in the position in which you would place him for lithotomy ; make an incision in the perineum ; feel for the catgut bougie, make an incision on it, and, of course, you make an opening in the ure- thra. Through this opening, the catgut bougie serving you as a director, introduce a short gum catheter from the wound in the perineum into the bladder. You will generally find, although the effusion of urine has taken place, that there is still a large quantity of urine left in the bladder. Of course it is drawn off by the catheter, and the bladder is emptied. Allow the catheter, however, to remain in the wound and in the bladder. Then make extensive scarifications or incisions through the skin, wherever the urine has been effused underneath, and let these incisions extend to the sloughs of the cellular membrane. Apply a poultice : let the parts be fomented twice or three times daily. After one or two days, you may remove the short gum catheter, which, in the meantime, has kept the bladder empty. Your treatment of the patient, in other respects, must depend on his symptoms and general condition. At first, it is often right merely to give some saline medicine, with small doses of Dover's powder every six or eight hours: afterwards it will be proper to exhibit wine, ammonia, opium, and, perhaps, bark or the sulphate of quinine: in other cases opium, cordials, and tonics will be required in the beginning. As soon as the sloughs begin to separate, remove them with a pair of forceps, and dress the sores according to circumstances. In those cases of effusion of urine in which you are unable to pass an instrument into the bladder, you must be contented (as to the local treatment) with making a free incision in the perineum, and extensive scarifications in the neighborhood. Here the patient labors under a disadvantage, in consequence of the bladder re- maining loaded with urine; but nevertheless, if the scarifications are made at an early period, he usually recovers. 5 34 STRICTURES OF THE LECTURE III. On the Cure of Stricture of the Male Urethra. A stricture at the orifice may be dilated by means of a com- mon bougie, or a short metallic instrument; the size of the bougie being gradually increased, and the introduction being repeated daily or on the alternate days, according to circumstances. The process of dilatation is, however, in many instances, attended with much inconvenience to the patient. In those cases, especially, in which the contraction began in early life, every introduction of the bougie causes considerable pain ; at the same time that the disposition to contract is so great that the operation requires to be repeated almost daily. The consequence is, that the part is kept in a constant state of inflammation, and, between the disease and the remedy, is a source of constant annoyance to the patient. Under these cir- cumstances another mode of treatment may be had recourse to, as in the case which I am about to mention. A gentleman, thirty years of age, consulted me on account of a difficulty of making water, under which he had labored since he was a child. The difficulty had increased by slow and almost im- perceptible degrees, until at last, about fourteen months before he applied to me, he had a complete retention of urine. A surgeon, whom he then consulted, found the obstruction to be confined to the orifice, and that part of the urethra which is surrounded by the glans; and he relieved him without difficulty by means of a short and small bougie. This relief, however, was only temporary, and it was found necessary to have recourse to the use of the bougie almost daily ; and even then the patient was not able to void his urine without considerable difficulty. An attempt was therefore made to dilate the orifice further by means of larger bougies. But that treatment was productive of considerable inconvenience, and when the patient was under my care, the orifice of the urethra was tender and inflamed; the mucous membrane immediately within it seemed to be in a state of ulceration ; and not only the insertion of the bougie, but the contact of the urine always occasioned no trifling degree of pain. It was evident that something more must, if possible, be done for the patient's relief; and accordingly, I determined at once to divide MALE URETHRA. 35 the contracted part of the urethra. This was easily accomplished by means of a pair of knife-edged scissars, one blade with a blunt point being introduced into the urethra, and the division being made in the situation of the fraenum. No haemorrhage followed the operation. A piece of lint was kept between the cut surfaces to prevent their re-union, and in about ten days they were cicatrized, being covered by what had already assumed a good deal of the appearance of a mucous membrane. Strictures in the anterior part of the urethra, but behind the ori- fice, require to be mechanically dilated, by the introduction of bou- gies or metallic instruments. At all events, I know of no better method of treatment; and sometimes the patient obtains relief on very easy terms, the dilatation being readily accomplished, and the use of a bougie once in three or four days being sufficient to pre- vent a recurrence of the contraction. At other times, however, the disposition to contract is so great, that it becomes necessary to introduce the bougie once or twice daily ; and, indeed, I have known cases in which the patient was seldom able to expel his urine until the bougie had been employed. The simple rules which have been just laid down are not suffi- cient for the treatment of strictures at the bulb of the urethra. The circumstance of these being situated where the curvature of the urethra begins, at a distance of six or seven inches from the ex- ternal orifice, and their liability to spasm, distinguish them from strictures in the anterior part of the canal. The management of them requires greater skill, attention, and experience on the part of the surgeon ; but, at the same time, it must be acknowledged that it leads, on the whole, to more satisfactory results than that of strictures, which take place elsewhere. If you were to ask me, How then do you treat strictures at the bulb of the urethra? my answer would be, I have no particular method: sometimes I adopt one method, sometimes another, ac- cording to the peculiar circumstances of the case. I shall de- scribe the different plans of treatment to which you may have re- course, at the same time endeavoring to point out the particular class of cases to which each of them is applicable. I should premise that the disease is not to be cured by medicines; though medicine may sometimes be used with advantage in aid of the local treatment. Thus, where the liability to spasm is increased by a too abundant secretion of lithic acid by the kidneys, whether it shows itself in the form of red sand, or of small calculi, or of lithate of ammonia, attention to the diet and mode of life, and the exhibition of purgatives and alkalis, and such other remedies as may tend to restore the urine to a healthy condition, will be of es- sential service, and will enable you to accomplish, by means of the bougie, what you would in vain have attempted to accomplish 36 STRICTURES OF THE otherwise. In like manner, in cases of alkaline urine, a generous diet, and the exhibition of mineral acids, opiates, and tonics, will be productive of a similar advantage. In all cases attention should be paid to the state of the bowels, and the patient should be made to understand that a careful and regular mode of life in every re- spect is necessary to his recovery ; and that violent bodily exercise, especially riding on horseback, is always to be avoided. Tn long- standing cases of unusual difficulty and complication, I have some- times found it necessary to keep the patient confined to a sofa, or even to his bed, for some days before I began the peculiar treat- ment which his case required. Where, before the patient comes under your care, instruments have been much employed, without having penetrated through the stricture, it is always desirable that the urethra should be left for some time in a state of repose. At the end of a month or six weeks, the false passages (if any existed) may have healed ; the inflammation produced by previous operations may have subsided; and you will begin the treatment under much more advantageous circumstances than if you had entered upon it in the first instance. The methods which are chiefly useful in the case of stricture at the bulb of the urethra, are:—1st, the dilatation of it by means of the common plaster bougie ; 2dly, the dilatation of it by means of a metallic bougie, catheter, or sound ; 3dly, the retention of the elastic gum catheter in the urethra and bladder; 4thly, the applica- tion of the bougie armed with the nitrate of silver. I. The common plaster bougie, if of a small size, should be of a conical shape ; but if of a middle size, or of a full size, it should be cylindrical. Ascertain the size of the stream of urine, and in- troduce a bougie of this size, whatever it may be. If the bougie be very small, it may be used straight, otherwise it should be curved like a catheter, but in a less degree. Neither you nor your patient are to be disappointed because the bougie does not enter the stric- ture at the first trial. In many cases this will not happen until you have seen your patient three or four times ; and in very difficult cases the delay may be still greater than this. When a bougie has once entered the stricture and bladder, allow it to remain for a few minutes. In two or three days (not sooner) introduce either the same bougie, or one of the same size. Then withdraw it, and introduce one of a size larger. Allow this also to remain for a few minutes, and after two or three days more repeat the operation. Thus, by degrees, you dilate the stricture until it is of the same diameter with the rest of the urethra. This method of curing strictures is applicable to a great number of cases; and, wherever it will answer the purpose, I would advise you to resort to it in pre- ference to other methods. The common bougie gives the patient little or no pain ; it excites no irritation, unless it be introduced MALE URETHRA. 37 clumsily or rudely; and it can do no harm by penetrating or tear- ing the membrane of the urethra. II. The metallic instruments which I am in the habit of employing are not those which are sold under the name of the flexible metallic bougies. These are liable to lose the shape which you have given them during their introduction, and, in fact, are at the same time too flexible and too inflexible for any useful purpose. Those which I have, if of a small or middle size, are made of solid silver; the larger ones of silver or steel, or steel plated, or of a com- position similar to, but firmer than, that of the flexible metallic bougie. These sounds should be very slightly curved, and for ordinary cases not more than eight inches and a half or nine inches long, exclusive of the handle. You may use them as you would use the common bougie for the purpose of gradually dilating the stricture, beginning with one of a small size, and gradually proceed- ing to those which are larger. Sometimes you will find it best to introduce the sound without turning, that is, with the concavity towards the patient's abdomen ; at other times you will pass it more readily by keeping the handle, in the first instance, towards the pa- tient's left groin, turning the instrument afterwards as it approaches the stricture. In either case if you wish to avoid making a false passage, take care that the point is kept sliding, as it were, against the upper part of the urethra. Press the instrument firmly, but gently, against the stricture, in the expectation that it will gradually become dilated, and allow the point to enter ; then depress the handle and pass it into the bladder, provided that you can do so readily, and without the application of force ; but not otherwise. Two or three days afterwards (and the interval ought to be never less than this, and sometimes it ought to be greater), introduce the sound which has been passed before, withdraw it, and introduce another of a size larger, and thus go on dilating the stricture until that part of the urethra has regained its natural diameter. If in the course of these proceedings you are in doubt whether the sound has reached the bladder or not, you may easily determine the point in question by introducing a catheter. You might, indeed, use the catheter from the beginning, but that the openings near the point, and its comparative lightness, render the introduction of it less easy than that of the solid instrument. This method of treatment is applicable to a large proportion of the cases which you will meet with in practice : 1st, to those of old and indurated strictures, which the common bougie is incapable of dilating ; 2dly, to those in which, in consequence of some improper management, a false passage has been formed, into which the point of a common bougie will easily penetrate, but which an inflexible instrument may be made to avoid; 3dly, to those in which, from long-continued disease, and without any previous mismanagement, 38 STRICTURES OF THE the urethra has become distorted, and its surface irregular; and, 4thly, to several recent cases in which the smooth polished metahc surface gives less pain to the urethra, and is less likely to induce spasm, than the softer but less smooth surface of a common bougie. The temper of the urethra varies as much as the temper of the mind. Where circumstances seem to be nearly the same, you will find one method of treatment to suit one case, and another to suit another case ; and it will often happen that you cannot determine before- hand which method it will be best to adopt. But the treatment which 1 have just described is not applicable to the most difficult class of cases which you will meet with in practice. In using a small metallic instrument, there is always a great risk that it may penetrate the membrane of the urethra, and make a false passage, instead of entering and dilating the stricture; and, therefore, in a case in which a stricture has been long neglect- ed, and is reduced to a very narrow diameter, some other mode of proceeding is required. You may try a small plaster or catgut bougie first, and defer the use of the sound until the stricture is so far dilated as to justify theexpectation that one of a moderate size may be passed. If this cannot be accomplished, you may resort to another method, which will rarely fail. In speaking of the use of the silver catheter, where the patient labors under a total retention of urine, I said : " Press the catheter firmly and gently against the stricture, keeping in your mind the anatomical position of the parts, and being careful to give the point a right direction. When the pressure has been thus carefully continued for some time, the stric- ture will begin to relax, allowing the catheter to enter," &,c. &c. Now, in attempting the cure of old and inveterate cases of stricture, you will often find it convenient to act on the same principle, and in very many of them you will find this mode of treatment to be successful, where all others have failed. The sound should be rather above than below the middle size. Of course the same rule in this respect does not apply in every instance, but that which I generally find it most convenient to employ, has only a moderate curvature. It is made of silver, fixed in a flat wooden handle, being nine inches in length from the handle to the point; no part of it is more than one-fifth part of an inch in diameter, and at the point the diameter is reduced to one-sixth of an inch. In using the sound you should pass it carefully as far as the stric- ture, and then press the point firmly and steadily against it, taking care that it is directed in the line of the urethra towards the blad- der. The pressure is to be continued for five, ten, or fifteen min- utes, or even longer, according to circumstances ; and this process is to be repeated once in two or three days. If a false passage ex- ists, it is probably on the lower part of the urethra towards the perineum ; and it is in this situation that, by careless manage- MALE URETHRA. 39 ment, one may be easily made. To avoid this mischief, you must direct the point of the sound especially to the upper part of the stricture next the pubes. The pressure should be as much as can be made without the urethra being lacerated, and without inducing any considerable degree of pain. In some instances the stricture has little or no sensibility, in others it is exquisitely tender; and in the latter cases the pressure should be very trifling at first, but it may be gradually increased as the tenderness subsides (as it will do) under its influence. The result of this treatment is, that at each operation the anteri- or part of the stricture seems to become relaxed to a greater or less extent; and that at last the instrument penetrates entirely through it and enters the bladder. The period at which this happens, of course, varies in different cases. The permanent change of struc- ture may be trifling, the stricture being chiefly spasmodic, and one or two applications of the sound may be sufficient. There may be much gristly induration, occupying a considerable portion of the urethra, and many applications may be required. A patient was under my care, in whom the stricture was surrounded by a mass of hard substance, which could be distinctly felt in the perineum, ap- parently an inch or an inch and a half in length. The stream of urine was of the smallest size, and varied so little that it was evi- dent that there was little or no liability to spasms. For many years before I was consulted, no instrument had been made to enter the bladder; and the ordinary methods, after a long trial, failed in my hands, as they had done in those of others. At last I succeeded by the method which I have just described, but not till I had perse- vered in it for many months. III. In treating a stricture of the urethra with the gum catheter, you are to introduce it, and allow it to remain day and night in the urethra and bladder. If the patient can bear it to be retained for a sufficient length of lime, the stricture will become dilated not only to the size of the instrument employed, but to a size consider- ably larger. Perhaps you will be able to introduce the catheter without the wire or stilet. Do so, if possible. If not, you should employ one mounted in the way which I have already explained, on a strong, unyielding iron stilet, having a flattened iron handle like that of a common sound or staff. Being so mounted, it is more readily directed into the bladder than when mounted in the usual way, on a piece of thin flexible wire. When the gum catheter has entered the bladder, withdraw the stilet, and leave the catheter, with a wooden peg in its orifice, which the patient is to take out, whenever he has occasion to void his urine, it being at the same time secured by a suitable bandage. After three or four days you may withdraw the catheter for twelve hours ; or if much suppura- tion be induced in the urethra, you may withdraw it for a longer 40 STRICTURES OF THE period. Then introduce another catheter larger than the first; and thus you may, in the course of ten days or a fortnight, dilate a very contracted urethra to its full diameter. This is a very certain and expeditious method of curing a stricture. You may by these means sometimes accomplish as much in the course of ten days, as you would accomplish in three months by the occasional introduction of a bougie. This method is particularly applicable,— 1st, Where time is of much value, and it is of great consequence to the patient to obtain a cure as soon as possible. 2dly, Where a stricture is gristly and cartilaginous, and therefore not readily dilated by ordinary methods. 3dly, Where, from the long continuance of the disease, the urethra has become irregular in shape, or where a false passage has been made by previous mismanagement. Under these circumstan- ces, if you can succeed in introducing a gum catheter, and let it remain for a few days in the bladder, you will find your difficulties at an end ; the irregularities will disappear, and the false passages will heal. 4thly, There is still another class of cases, in which this method of treatment is particularly useful. I allude to those in which a severe rigor follows each introduction of the bougie. This disposi- tion to rigor is such, that it is sometimes impossible to proceed with the treatment in the ordinary way. Observe, in these cases, when the rigor takes place. It seldom follows the use of the bougie im- mediately. It almost always occurs soon after the patient has void- ed his urine, and seems to arise, not as the immediate effect of the operation, but in consequence of the urine flowing through the part which the bougie has dilated. Now, if, instead of a bougie, you use a gum catheter, and allow it to remain, the urine flowing through the catheter, the contact of it with the urethra is prevented, and the rigor is prevented also. I have no right to say that this plan will invariably succeed, but I do not remember that it failed in a single case among many in which I have resorted to it. IV. It remains for us to consider the treatment of a stricture by the application of caustic. This mode of treatment was first pro- posed by Mr. Hunter, who recommended it in particular cases. The more general application of the caustic to strictures was intro- duced by Sir Everard Home, with whose work on the subject of this disease you ought to be well acquainted. The caustic to be employed is the nitrate of silver. Let a cylindrical piece of it be inserted neatly into the extremity of a bougie. The round end of the bougie should be cut off, and the caustic should be as large as the bougie will carry ; and the bougie itself should be as large as the urethra will admit without being forcibly distended. First, pass a common bougie down to the stricture, and mark with your nail on the bougie the distance of the stricture from the external orifice of MALE URETHRA. 41 the urethra. Then measure off the same distance on the armed bougie ; pass it down to the stricture, and keep it pressed against it with a firm, heavy hand, during the space of a quarter of a minute, and sometimes for a longer time. Let this be repeated, if necessary, every third or fourth day; for every second day, as some have recommended, is, according to my experience, much too often. I have advised that you should press it firmly against the stricture, as otherwise the caustic is applied to the urethra anterior to the stric- ture, and not to the stricture itself. The first effect of the caustic is to cause the stricture to become dilated to a certain extent, prob- ably by relieving whatever disposition there is in it to spasm. It is a strong stimulus applied to a part which is morbidly irritable, and the morbid irritability becomes exhausted. The benefit which the patient derives immediately from the application of the caustic, is sometimes very remarkable. He may apply to you, making water in a stream like a thread, or only in drops; you apply the caustic, and in a few minutes afterwards he has a desire to discharge the contents of his bladder, and he finds that the urine flows in a very conside- rable stream. After this, any further benefit to be produced by the caustic must be the result of the destruction of the stricture, by the repeated formation of sloughs. But this is a tedious and diffi- cult process, especially in cases of old cartilaginous stricture. In fact, there are very few such cases, in which a cure can be effected by the caustic alone, however long you may persevere in its use; and whenever the caustic is frequently employed, you are in danger of creating a false passage, in consequence of the dissolved caustic flowing to the lower part of the urethra, and destroying the parts unequally. The cases to which this method of treatment is applicable, are, 1st, Those of spasmodic stricture, where two or three applications of the caustic may be sufficient to relieve all the urgent symptoms. 2dly, Some cases of old stricture, in which there still is a con- siderable disposition to spasm. In these last cases, apply the caustic two or three times, and no oftener. It will probably relieve the contraction as far as it is spasmodic, and thus enable you to proceed more advantageously with the use of the bougie or metallic sound. 3dly, The caustic may be used very properly in some cases of stricture which are endowed with peculiar irritability, in which every application of the common bougie induces severe pain, or brings on spasm, preventing it entering the stricture. Two or three applications of the caustic may be sufficient to deprive the stricture of that unnatural sensibility, which otherwise would have foiled your efforts to effect a cure. Notwithstanding what I have now stated, I very rarely use the armed bougie in my own practice, and I never resort to it in the first instance. My reasons for preferring the other methods of 6 42 STRICTURES OF THE treatment, in ordinary cases, are these: 1st, Although the caustic often removes spasm, it also very often induces it. It is true, that in many instances it enables a patient to make water with more facility ; but in many instances, also, it brings on a retention of urine. 2dly, Haemorrhage is a more frequent consequence of the use of the caustic than of the common bougie, and it sometimes takes place to a very great, and to an almost dangerous extent. 3dly, Where there is a disposition to rigors, the application of the caustic is almost certain to produce them ; and frequently the ap- plication of the caustic induces rigors, where there had been no manifest disposition to them previously. 4thly, Unless used with caution, the application of caustic may induce inflammation of the parts situated behind the stricture, terminating in the formation of abscess. I have known some cases of abscesses formed under these circumstances, which, from their peculiar situation, have prov- ed more troublesome and more difficult to manage than the original disease. In one case, which came under my observation many years ago, and in which, from the account given me, I was led to believe that a surgeon had been too liberal in his application of caustic to a stricture, a succession of abscesses took place, extend- ing in various directions, even to the nates, and attended with great disturbance of the constitution. The patient went into the coun- try, where, as I have been informed, he ultimately sunk under the combined effects of the stricture and abscesses. These are the principal evils which follow the use of the caustic ; but there are other arguments against it in particular cases. If the bougie has been improperly used, and a false passage has been produced, or if there be the beginning of a false passage, the dis- solved caustic will penetrate into this false passage, and aggravate the mischief, instead of destroying the stricture. In cases of old stricture, where there is much alteration in the structure of the parts, the caustic is absolutely inadequate to the cure ; and in many other cases, although the caustic may effect a cure at last, it does so by a very tedious process; and a cure would be effected in a much shorter space of time by the introduction of the metallic sound, or the retention of the gum catheter. There are still some other methods of treating stricture, but what I have to say concerning each of them may be comprised in a few words. Mr. Arnott has invented what he calls a dilator, made of a tube of varnished silk, which is to be introduced into the stricture, and then dilated by impelling air into it with a syringe. The con- trivance is ingenious; and I should think it very likely to be useful, where you wish to dilate the female urethra for the purpose of ex- tracting a calculus. It may be useful also, in dilating the orifice of an abscess or sinus, being used instead of a sponge tent. But it does not appear to me that either this, or a steel dilator, which I WALE URETHRA. 43 remember some one to have invented formerly, is likely to render us much assistance in the cure of a stricture. Such a dilator must be of a certain size. It cannot be supposed to be less than a mid- dle-sized bougie. Now, if you can manage to introduce a bougie or sound of a middle size into a stricture, the farther dilatation of it is easy enough, the cure may be said to be all but accomplished, and neither of the dilators is wanted. On the other hand, if the stricture be much contracted, the introduction of the dilator will be impossible. It is stated by Mr. Arnott, that the method proposed by him has this advantage, that it enables you to carry the process of dilatation farther than it can be carried by a bougie or sound, and that such farther dilatation removes the disposition in the ure- thra to contract, and thus produces a permanent cure of the stric- ture. I am by no means satisfied as to the correctness of the first of these assertions ; and as to the second, it is entirely contrary to my own experience of the effects of very large bougies. I have generally observed, that the dilatation of a stricture beyond the natural size of the canal is followed by pain and inflammation, and an aggravation instead of a diminution of the complaint. Mr. Stafford has invented an ingenious machine, which is intend- ed to divide a stricture by means of a cutting instrument. If any cases occur in which this method may be useful, they are undoubt- edly very few in number ; and great caution must be required, to avoid making false passages, which might be followed by effusion of urine and purulent deposits. There is, however, a modification of this practice which is free from these dangers, and which may be resorteoSto in certain cases, with great advantage, as I shall explain presently. It has been proposed, in cases of very old stricture, to make an incision in the perineum, so as to expose the whole of the con- tracted part of the urethra, and to divide the stricture with a knife, introducing a gum catheter afterwards through the urethra into the bladder, and allowing the wound to heal over it. I have performed this operation myself in one instance, and with success; and I have heard of it being performed several times by others. In the great- er number of cases (according to the reports which I have received), it has been performed with difficulty, and in some instances the patient has been sent to bed without it having been completed. Even under the most favorable circumstances, it cannot be other- wise than doubtful whether the stricture be properly divided, that is, whether the incision has passed through the narrow canal in the center, or through the solid substance on one side. I suppose that no surgeon would recommend such an operation except as a last resort, where no instrument could be made to pass through the stric- ture by other means. But such cases of impenetrable stricture are of very unfrequent occurrence; and where they do occur, I am 44 STRICTURES OF THE much mistaken if the modification of Mr. Stafford's operation, to which I have already alluded, will not effect a much easier and safer method of cure. In the following case (the only one in which I have had recourse to it) it succeeded perfectly :— A man, forty years of age, was admitted into St. George's Hos- pital, in the year 1835, laboring under a stricture, near the bulb of the urethra, complicated with a fistulous opening in the perineum. When he voided his urine, a very small quantity came away by the urethra, the greater part being discharged by the perineum. The disease had existed for more than twenty years, and the abscess in which the fistula had originated, had followed an injury received while riding on horseback thirteen years ago. For many years no instrument had been passed through the stricture. At last he be- came a patient under the late Mr. Earle, in St. Bartholomew's Hos- pital, where he remained under treatment for five months, but with no more success than formerly. Finding after repeated trials that no instrument could be made to penetrate through the stricture, with the concurrence of my col- leagues, I performed the following operation :— The patient having been placed in the same position as in lith- otomy, a full-sized plaster bougie was introduced, and held by an assistant with its extremity resting against the stricture. I then made an incision in the perineum, dilating the fistulous sinus, and laying open the membranous part of the urethra as far forward as the stricture, the exact situation of which was marked by the bou- gie. The bougie was then withdrawn, and an instrument was in- troduced in its place, consisting of a straight silver tube, ojosed at its extremity, except a narrow slit, through which a small lancet could be made to project by pressing on a stilet which projected the handle of the instrument. The round extremity of the tube being pressed against the anterior part of the stricture, I applied the fore- finger of the left hand, introduced through the wound in the peri- neum and urethra, to its posterior surface. The pressure of the instrument being distinctly communicated to the finger through the substance of the stricture, the lancet was protruded, and the stric- ture was divided. A silver catheter was then easily introduced through the urethra and the divided stricture into the bladder, and allowed to remain there. The urine of course flowed through the catheter. At the end of two days the silver catheter was removed, and replaced by one of elastic gum. The wound in the perineum gradually healed, and the patient ultimately recovered, making water in a full stream, and being able to introduce a sound of a full size into the bladder, so as to prevent a recurrence of the contrac- tion. The instrument used upon this occasion was ten inches in length, exclusive of the handle, and rather more than one quarter of an inch MALE URETHRA. 45 in diameter. The lancet measured three-sixteenths of an inch at its broadest part; it terminated in a sharp point, and could be made to project, by pressing a button on the other end of the stilet to which it was attached, to the length of half an inch, returning to its place within the silver tube, when the pressure was withdrawn, by the action of a spiral spring. In using it, one cutting edge of the lancet was directed towards the pubes, the other towards the perineum. The advantages of dividing the stricture by this method, as compared with other methods of operating, are, 1st, that the free opening made in the perineum prevents all danger from infil- tration of urine ; 2dly, that the fore-finger of one hand, being ap- plied to the posterior surface of the stricture, serves as a guide for the lancet, and enables you, with the exercise of a little skill and caution, to make an exact division of the stricture. In many cases of stricture, especially where the disease has exist- ed for several years, you find that, although a bougie may be passed through the contracted part of the urethra, it will not enter the bladder. You may possibly succeed in the introduction of a metal- lic sound or catheter, when you have failed to introduce a bougie; but not unfrequently the obstruction which has prevented you from passing the bougie, will prevent you from passing the metallic in- strument also. The obstruction in these cases arises from the irregularity of the surface of the urethra, where it is surrounded by the prostate gland, the immediate causes of which I have already described ; and sometimes from enlargement of the prostate gland itself. If you use violence, or employ any but the gentlest treat- ment, you lacerate the membrane of the urethra, and the substance of the prostate. You make a false passage leading into the space between the bladder and the rectum, which may prove a source of constant trouble and perplexity afterwards. When you meet with the difficulty which I have mentioned, do not be over-anxious im- mediately to overcome it. It is not the original disease, but the effect of the stricture. Remove the cause, and the effect will cease, not indeed at once, but by degrees. Be contented at first with the dilatation of the stricture. The urine will then flow in a full stream, and the pressure of it on the parts behind being removed, they will regain their healthy condition ; so that at last the catheter, or even the common bougie, will enter the bladder readily. I say that you are not, under the circumstances which I have de- scribed, to use violence. But I cannot too strongly impress it on your minds, that, in the treatment of stricture, you ought not to use violence under any circumstances. Your success in the cure of this disease will depend very much on your attending to this impor- tant rule. Whether you use a bougie, or a sound, or a catheter, let the instrument be held lightly, and, as it were, loosely, in your hand; it will then in some measure, find its own way in that direc- 46 STRICTURES OF THE lion in which there is the least resistance: whereas, if you grasp it with force, the point can pass only where you direct it, and is just as likely to take a wrong course as a right one. A stricture will in- variably resent rough usage: it will yield to patience and gentle treatment. In a few cases of incipient stricture, and in some of those in which a stricture is merely spasmodic, after a bougie has been used for a certain length of time, the use of it may be dispensed with, and there will be no recurrence of the stricture. But these cases are rare exceptions to the general rule, which is, that there is danger of a relapse, and that a patient who is desirous of continuing well, must submit to the occasional use of the bougie ever afterwards. I generally instruct the patient in the introduction of it for himself. At first he may introduce it once in three or four days. He may afterwards use it at longer intervals, and he must take some pains to determine what those intervals should be. One person will find it necessary never to omit the use of the bougie for a longer period than a week, and another will not have occasion to resort to it oftener than once in a month or six weeks. The management of a case of stricture in which the patient is liable to attacks like those of intermittent fever, is often very per- plexing. Occasionally, every introduction of a bougie is followed by a rigor, which is not only distressing to the patient at the time, but leaves him in a state of debility from which he may not recover for several days. And sometimes the rigor, as I have already ex- plained, is only the precursor of a still worse train of symptoms, as- suming the character of simple continued fever, of rheumatic fever, or even of mania. It is impossible to continue the use of the bougie under these circumstances. If you would cure the stricture, you must prevent the rigors. I have already mentioned one way of at- taining this object, namely, by leaving the gum catheter in the blad- der. You may also, in many instances where you expect the oc- currence of a rigor, anticipate the attack by giving your patient a dose of opium, eilher by the mouth or in the form of clyster, imme- diately after you have introduced the bougie. But you are not to be contented with meeting the present difficulty. You should look to the future, and endeavor to correct that state of the system on which the disposition to rigors depends. For example, I was sent for to see a gentleman who had long suffered from a stricture of the urethra, and who was at the time laboring under a severe attack of retention of urine. I drew off his urine with a small elastic gum catheter, which was passed with the greatest facility into the blad- der. In the course or two or three hours he experienced a desire to void his urine. It flowed readily in a stream, but immediately afterwards he was seized with a violent rigor. He remained fever- ish for a day or two, and then recovered. After a few days had MALE URETHRA. 47 elapsed, I began the dilatation of the stricture with a common bougie. The bougie was introduced without any difficulty, but it was followed by a rigor. The next time that the bougie was em- ployed, there was a third attack of the same kind ; and on the bougie being again resorted to, another and another rigor followed. I now omitted for a time the use of the bougie, and prescribed two grains of the s dphate of quinine to be taken every six hours. Under this treatment the patient's general health manifestly improv- ed ; and when, at the end of a week or ten days, we had re- course again to the bougie, there was no recurrence of the rigors. 48 STRICTURES OF THE LECTURE IV. Treatment of Stricture of the Male Urethra—continued. Uri- nary Abscesses and Fistula. You will meet with no cases in your practice of greater impor- tance than those of urinary abscess, connected with stricture of the urethra ; nor are there any in which the different results obtained from good and bad surgery are more conspicuous than in these. If an abscess, with distinct fluctuation of matter, presents itself in the perineum, no one would hesitate to make an opening for the pur- pose of enabling the matter to escape. But it will often happen that there are urgent constitutional symptoms, and that a patient is in a state of the greatest danger, while the abscess is still confined be- hind the deep-seated fascia, the only external manifestation of it being a slight degree of fulness, and deep-seated hardness of the perineum. These, however, will be your sufficient guides. Bear- ing in mind the anatomical position of the parts, introduce a sharp- pointed double-edged scalpel, so as to penetrate the fascia. Watch for the first drop of matter which escapes, and then dilate the open- ing which you have made downwards and outwards, that is, in the same direction as the incision in lithotomy. There is here no time for hesitation and delay. Many lives have been preserved under these circumstances, by the prompt interference of the surgeon, which would have been lost otherwise. A urinary abscess cannot be opened too soon whenever it appears, and the opening should be as free as it can be made with prudence. This last observation is especially applicable to those cases in which the abscess shows it- self in the lower part of the penis over the scrotum. If in such cases there be merely a small puncture, there is danger of some of the contents of the abscess being infiltrated into the loose cellular texture, producing an cedematous swelling first, and a succession of fresh abscesses afterwards. I have known some surgeons formerly, who supposed that a fistula connected with the urethra, required to be laid open like a fistula connected with the rectum. But I suppose that few are lia- MALE URETHRA. 49 ble to fall into such an error in the present day. The only cases of this description, in which the use of a bistoury or lancet may be re- quired, are those in which there is a lodgment of matter in some part of the perineum, and in which a more free external opening is neces- sary for its escape. The treatment of a fistula in perineo is, indeed, for the most part, as simple as possible. It is kept open by the urine flowing through it; and as soon as the urine finds a more ready outlet by the natural channel, the sides contract, and the sinus closes of itself. While the urethra remains contracted, no art can heal the fistula; nor ought you to wish to heal it, if it were possible for you to do so. But let the stricture be dilated, and in the great majority of cases the healing of it will be completed, even before the dilatation has gone so far as to restore the urethra to its original diameter. Sometimes, however, the healing of the fistula proceeds more slow- ly; and this especially happens where the opening is of a large size, in consequence of there having been some loss of substance from sloughing of the cellular membrane at the time of the abscess being formed. Even in these cases you will seldom find any other treat- ment necessary than that of dilating the stricture to the full diameter of the urethra, and then keeping it dilated by the daily introduction of a sound or catheter. The opening in the perineum may not close for a month, nor for six months, nor even for a year; still it will close at last. I formerly have advised the patient never to void his urine with- out the aid of the catheter; but I am now inclined to believe that the irritation thus kept up tends, on the whole, to delay rather than to ex- pedite the cure. At other times I have kept the patient in bed for some weeks, with an elastic gum catheter constantly in the urethra and bladder; but I cannot say that, with my present experience, I have much more faith in this mode of treatment than in that which I mentioned before. After a few days the urine generally begins to flow by the side of the catheter, which does not therefore answer the purpose for which it was introduced, of preventing its escape by the sinus. Then in many cases the catheter causes an abundant suppura- tion of the urethra; and the purulent discharge, finding its way into the sinus, prevents it from closing as much as it would be prevented by the contact of the urine. The following plan of treatment may, however, occasionally be used with some advantage, in aid of the daily introduction of the sound. Stimulate the bottom of the sinus once in three or four days by the application of the nitrate of silver, at the same time that you retard the healing of the external orifice by lightly touching it, once in a week or fortnight, with the caustic potash. The reason for applying the caustic potasli is as follows:—The ex- ternal opening is more inclined to heal than the opening into the ure- thra. If you stimulate the whole surface of the fistula with the nitrate of silver, the superficial parts may heal prematurely; the necessary 7 50 STRICTURES OF THE consequence of which will be another abscess and another discharge of matter. By applying the caustic potash to the external opening, you prevent this from healing, while the nitrate of silver promotes the contraction and cicatrization of the more deep-seated part of the fistula. An abscess or fistula, which has no opening except into the ure- thra, is to be treated in the same manner as the same kind of abscess in connection with the rectum. Watch for the opportunity when matter is collected in it, and then establish an external opening by dividing the integuments over it with a lancet, so as to convert it into a fistula of the ordinary kind. There are some of these cases, how- ever, the treatment of which requires a more particular explanation. A patient may apply to you who perhaps has had gonorrhoea former- ly, followed by a slight obstruction oTthe urethra, complaining at the same time of a discharge from the urethra, which he calls an obsti- nate gleet. You examine the perineum, and you find in it a small tumor, not larger than a horse-bean or filbert. It is at some distance from the surface, and the patient says that it has been coexistent with the gleet, and that it is sometimes inflamed and tender. Now this little tumor indicates the existence of a blind fistula. There is a small ori- fice in the urethra, and a narrow channel leading from it into the cen- tre of the tumor; and every time that the urine flows, a very small quan- tity finds its way into this channel, escaping from it immediately after- wards by regurgitation into the urethra. In consequence of the small- nessof the cavity, and the quantity of solid matter deposited on its outside, the fluctuation of fluid in it is not perceptible. I have known this state of things to continue, producing more or less occasional in- convenience, for many years. The first thing necessary to the cure is to make an opening in the perineum leading into the cavity in the centre of the tumor. But this may not be very easily accomplished, on account of the smallness of the cavity. You should introduce the lancet somewhat obliquely, so as to divide the tumor as nearly as pos- sible through its centre Then introduce some lint, so as to prevent the wound uniting by the first intention. After three or four days you may remove the lint, and then you will ascertain whether you have done what was required, by observing whether, when the patient voids his urine, any portion of it flows through the opening which you have made. If this be the case, nothing further is required than that the stricture should be dilated in the usual way. If, however, no urine flows through the opening, you may pioceed thus:—Introduce a piece of caustic potash through the wound into the center of the tumor, so as to make a considerable slough. A portion of the tumor being thus destroyed, the probability is that, when the slough has sepa- rated, it will be found that the central cavity is exposed, and that you have accomplished the object which you had in view. We occasionally meet with cases in which there is a fistulous open- MALE URETHRA. 51 ing into the urethra in some part of the space between the scrotum and the external orifice. Where the opening is of a small size, it may usually be made to contract and heal by touching the margin of it occasionally with the nitric acid or nitrate of silver. Where, how- ever, there has been a considerable loss of substance, either from ul- ceraiion or sloughing, it is impossible to close the opening without borrowing a portion of skin from the neighboring parts. Sir Astley Cooper and Mr. Earle have published an account of some cases in which this operation was attended with success. Since then, Mr. Dieffenbach has performed it in a great many instances. You will find an account of his practice in the " Dublin Journal of Medical Science," to which I may refer you for further information on the subject. Obstructions of the Urethra arising from Mechanical Injury. Treatment. The obstructions of the urethra which are occasionally met with as the result of mechanical injury necessarily produce many symptoms corresponding to those which occur in ordinary cases of stricture. They differ from them, however, in some essential circumstances, and therefore require a separate consideration. These obstructions may take place in any part of the canal, and may be produced in various ways. A foolish boy contrived to slip his penis into a small metallic ring. The swelling of the glans made its removal difficult, and, when this was at last accomplished, it had caused ulceration of the skin and corpus spongiosum, extending into the urethra. As the ulcer healed, the urethra became contracted; and when the patient was admitted into the hospital sometime after- wards, there was a small fistulous orifice in the middle of a hard cica- trix, through which the greater part of the urine was discharged, while a common probe was with difficulty passed from the external orifice through that portion of the urethra which was included in the cicatrix. But the more frequent seat of the obstruction is that part of the urethra which is immediately below the pubes, where the mucous membrane is especially liable to suffer from a blow, compressing it against the hard substance of the bone. In some cases these obstruc- tions are formed where there is no evident injury of the integuments or the other superficial parts of the perineum. For example, a man, twenty-two years of age, while riding a restive horse, was suddenly thrown forwards, so that his perineum received a severe blow from the pummel of the saddle. The accident caused at the time a severe pain, attended with a discharge of blood from the urethra. The bleeding continued during the night, but had ceased on the following morning. He then experienced a smarting pain in making water, 52 STRICTURES OF THE which however subsided in a few days. During the following month he suffered no inconvenience, but he now observed that his stream of urine was diminished in size, and that it was sometimes divided into two. The diminution of the stream continued, with a good deal of pain as the urine flowed. At last there was a complete retention of urine, which however subsided spontaneously in the course of a few hours. Seven months after the accident, when he was admitted into the hospital, the urine flowed in a stream not larger than a small wire. The catheter met with an obstruction behind the bulb of the urethra, and one of a very small size was with great difficulty introduced into the bladder, passing over what appeared to be a hard gristly and irre- gular surface. The dilatation of the contraction was not accomplished without a great deal of both local and constitutional disturbance, and it was not until after the lapse of five months that the patient was able to leave the hospital. At this time a catheter of a middle size could be introduced into the bladder, and the urine flowed in a stream, much below the natural size, but sufficiently large to enable the blad- der to be emptied without difficulty. In other cases a deep wound of the perineum may extend into the urethra. If the urethra be only partially divided, I conclude that no more mischief will ensue there after the operation of lithotomy; but if the division be complete, it is difficult to conceive that in the pro- gress of cicatrization a contraction of the urethra shall not ensue. I met with an example of this in a child, who had received a wound of the perineum some time before (if I recollect rightly) from a broken glass bottle. There was a hard cicatrix immediately below the pubes and behind the scrotum, and a fistulous sinus through which the urine flowed, while scarcely any was passed by the natural passage. But there are cases of more frequent occurence, in which a blow on the perineum has lacerated the urethra, contused the parts between it and the skin, caused an effusion of blood into the perineum and scro- tum, some portion of urine becoming infiltrated into the cellular mem- brane afterwards; the result of the whole being the formation of an abscess, and the destruction of the injured parts by sloughing to a greater or less extent. Here, as the sore heals, a hard gristly cica- trix is generated, adhering to the pubes, with an orifice in the centre, through which the whole or the greater part of the urine is discharged. The condition of a patient under the circumstances which have been described is much worse than that of one who labors under a perineal fistula connected with an ordinary stricture of the urethra. The difficulty of voiding the urine is more constant; it is liable to be increased, so as to become a complete retention, from attacks, not of spasm, but of inflammation, producing at the time much pain in the perineum, and followed by a fresh accumulation of matter beneath the cicatrix; and, in addition to all this, the treatment of these cases is not less troublesome to the surgeon than it is distressing to the patient, MALE URETHRA. 53 and for the most part does not lead to the same satisfactory results as that of ordinary stricture. In all cases in which there is reason to believe that the urethra has been divided or lacerated in consequence of an injury inflicted" on the perineum, it is the duty of the surgeon, not only to look at the great and immediate danger, but to guard against future ill consequences; and much may be done at this period towards preventing a most se- rious inconvenience, which would be relieved with difficulty after- wards. If there be a penetrating wound, in which the urethra is pro- bably implicated, an elastic gum catheter should be introduced with the least possible delay, and allowed to remain in the urethra and bladder until the healing of the wound is far advanced, or, at all events, until it is ascertained that the urethra has not suffered; the catheter being however occasionally removed for a limited time, if it seems to act as a source of irritation. In cases of contusion of the perineum, when the effusion of blood in the perineum and scrotum, and more especially the discharge of blood from the urethra, or any other circumstances, lead to the sus- picion that the urethra has been lacerated, the same treatment should be had recourse to: the gum catheter should be introduced as soon as possible, and allowed to remain for at least some days after the occurrence of the accident. The extravasation of blood does not in itself justify the making an incision in the perineum; and indeed, ac- cording to my experience, there can be no worse practice than that of making an incision in a case of simple ecchymosis, either in this or in any other situation. But where such extravasation exists, there is always reason to apprehend that there may be further mischief; the progress of the case, therefore, should be carefully watched, and on the first appearance of any symptoms which might be supposed to indicate that urine had escaped into the cellular membrane, or that suppuration had begun to take place, a staff should be introduced in- to the urethra instead of the gum catheter, and a free incision should be made from the perineum into it, the gum catheter being replaced afterwards. But it may be that these measures of precaution have not been adopted in the first instance, and that you are not consulted until af- ter the lapse of a considerable time, when the wound or laceration of the urethra is already healed, leaving the urethra contracted in the situation of the cicatrix. Here you may perhaps succeed in gra- dually dilating the urethra, as where there is an ordinary stricture. But, in a case which I have already mentioned, I have stated that " this was not accomplished without a great deal of local and con- s itutional disturbance;" and so it has been in all the cases of this kind which have fallen under rny observation. Nor will the occur- rence of such difficulties be a matter of surprise to any one who bears in mind that here the object is to dilate, not a genuine stricture, but 54 STRICTURES OF THK a cicatrix, of the urethra, and who has observed how the cicatrix of an old sore leg inflames and cracks when the subjacent muscles be- gin to increase in bulk from exercise, or how the endeavor to ex- tend forcibly the contraction after an extensive burn produces the same result. It may be that these difficulties are insuperable under the method of treatment by simple dilatation; and under these circum- stances, a small staff having been introduced into the bladder, the cicatrix of the urethra should be divided by an incision from the per- ineum, a gum catheter being introduced afterwards, and allowed lore- main until the wound is healed over it. But even then much remains to be accomplished. The cicatrix has still a greater disposition to contract than an ordinary stricture; the bougie or catheter must be had recourse to almost daily, and the patient must be contented if he can persevere in the use of instiuments of a moderate diameter, as the urethra will invariably resent the attempt to keep it dilated by those of large dimensions. Under the treatment which has been just described you will rarely fail to improve the condition of the patient in those cases in which the injury of the urethra has been of limited extent. But it is otherwise with respect to those other cases in which there has been an actual loss of substance of some portion of the canal from ulceration or sloughing. Here, either the patient must be left to the discomfort and misery of voiding the whole of his urine by the perineum for the remainder of his days, or he must submit to an operation, to perform which, in a satisfactory manner, requires the utmost exertion of skill on the part of the surgeon, and of which even then nothing better can be said than that it is the only thing which, under his peculiar circum- stances, affords him a reasonable prospect of relief. The object of the operation is to make an artificial communication between the an- terior and posterior portions of the urethra (so as to supply the place of that part of the canal which is deficient) through which the urine may flow instead of escaping by the fistulous opening in the perineum. I cannot explain what I have to say on this subject belter than by giving a brief history of a case which I have lately attended with Mr. Baker of Bulstrode Street. A young man, in making a leap on horseback, received a violent blow on the perineum from the pummel of the saddle. The imme- diate consequence of the injury was haemorrhage from the urethra, and this was followed by extravasation of urine and sloughing of the perineum to a considerable extent. A catheter was at first introduced into the bladder, but it was afterwards removed. The sloughs hav- ing separated, the sore in the perineum gradually closed, a small fistulous opening only being left immediately behind the scrotum, through which the whole of the urine was discharged. He was in this state seven months after the occurence of the accident, when he MALE URETHRA. 55 arrived in London, and Mr. Baker advised him to have my opinion on his case. On introducing an instrument into the urethra I found an obstruc- tion of the canal immediately below the pubes. Several ineffectual attempts having been made to penetrate the obstruction in the usual manner by bougies and sounds of various sizes, I had recourse to the following operation:—The patient having been placed in the same position as in lithotomy, a staff was introduced into the urethra, and held by Mr. Hilles, who, with Mr. Baker, assisted me in the operation, with the extremity of it resting against the obstruc- tion. I then made an incision in the perineum, extending backwards from the part in which the staff was to be felt, in the direction to- wards the prostrate gland. It was now evident that not less than three quarters of an inch of the urethra was deficient below the pubes; the place of it being occupied by a rigid cicatrix. This having been divided longitudinally by the point of the scalpal, I was enabled, though not without some difficulty, to pass the staff from the part at which the extremity of it rested, into the sound portion of the urethra towards the bladder, and then into the bladder itself. The staff was then withdrawn, and an elastic gum catheter having been substi- tuted for it, the latter was allowed to remain in the urethra and blad- der. On the ninth day after the operation, there being some degree of irritation at the neck of the bladder, the catheter was removed, being reintroduced, however, after two days more. From this time it was removed at intervals, which were sometimes longer, sometimes shorter, according to circumstances. The wound in the perineum gradually healed, and in less than ten weeks from the time of the op- eration was reduced to the diameter of a small pea. The patient was now able to introduce a silver catheter of the size of his urethra into the bladder without difficulty, and he repeated this operation so as to draw off his urine three or four times daily. When he voided his urine without the catheter, by placing the point of his finger on the opening in the perineum, he was enabled to discharge the whole in a sufficient stream by the ure:h:a.* *The last report which I had of this patient was six months after the operation, and to this effect: " that he had continued to improve, and expected in the course of a fort- night to be as well as ever." Since the manuscript of this Lecture was prepared for the press, a rase very similar to that described above has come under my care, in the person of a young man nine- teen years of age. He had received an injtrv of the perineum in leaping over a gate about a year age. Three quarters of an inch of the urethra below the pubes seemed to be deficient. I made an artificial canal, joining the anterior and posterior portions of the urethra t > each otht r. by perforating the cicatrix vvi;h the instrument Inning the crn- nealed lancet, described al page (;7, lea\ingan elastic gum catheter in the urethra and bladder afterwards. Al this lime about ten weeks after the operation, the patient voids his urine by >he urethra in a full siream. without pain or difficulty, no more than a few drops escaping by the opening in the perineum. A common plaster bougie may be in- troduced readily into the bladder. Mr. Guthrie saw this patient with me, and lent me his assistance at the operation 66 OTHER DISEASES OF THE LECTURE V. On some other Diseases cf the Male Urethra. There are some other diseases of the male urethra which, in a greater or less degree, obstruct the flow of urine, but which are to be distinguished from that disease to which our attention has been hither- to directed. In cases of ulcer of the glans including the whole circumference of the orifice of the urethra, as the ulcer heals, the orifice becomes con- tracted, so that when the healing process is completed the stream of urine is much reduced in size. But this is not all. The contraction, if left to itself, goes on increasing, until at last there is a complete re- tention of urine, and it is very probable that you are not called in un- til ibis last stage of the disease. The management of the case, in some instances, is rendered more complicated by the circumstance of the prepuce having contracted partial adhesio'ns to the surface of the glans, at the same time that there is a complete phimosis. Where this complication exists, you must begin with dividing or slitting up the prsepuce. You then find the exposed surface of the glans, in all probability, presenting (he ap- pearance of an irregular cicatrix, in which you at last discover, but not without a minute inspection, the contracted orifice of the urethra. Into this orifice introduce a small silver probe, such as is made to be inserted into the punctum lachrymale of the eyelid. Having with- drawn this, introduce another probe of a somewhat larger size; then one a little larger still; and afterwards insert a common silver director, passing it as far as one or two inches into the urethra. This will enable the patient to make water, the urine flowing along the groove of the director. After the bladder is emptied, introduce the point of a straight bistoury along the groove of the director, and divide the contracted orifice of the urethra. Let the patient retain a gum ca- theter in the urethra and bladder until the incision is nearly healed. He will then make water without the smallest difficulty or impedi- ment: but the cicatrix has the same disposition to contract as be- fore; and, in order to prevent the contraction again taking place, a bougie about two inches long should be introduced into the urethra every morning, and allowed to remain there for five or ten minutes. MALE URETHRA. 57 The urethra is, as you well know, surrounded by mucous folli- cles, which secrete a mucus by which the canal is lubricated. In some cases, one of these follicles becomes converted into a small in- durated tumor, varying from the size of a hernpseed to that of a horse- bean. Such a tumor is to be felt, imbedded, as it were, in the cor- pus spongiosum. The usual situation of it is about two or three inches from the external orifice, but it is sometimes perceptible close to the frsenum, and at other times within the scrotum. The disease undoubtedly originates in inflammation; but, being once established, the tumor may remain unaltered after all symptoms of active inflam- mation have subsided. If it be very small, it gives the patient little or no inconvenience; but otherwise, it torments him by producing chordee, and by keeping up a constant gleety discharge from the urethra. In many cases, in which what is called a gleet continues unabated for a great length of time, this depends on the irritation kept up in the urethra by one of these enlarged and indurated follicles. For the most part, it is better to allow the disease to take its own course. The tumor may disappear in the course of a few weeks or months. If it should not do so, you may then endeavor to reduce it by the external application of the unguentum hydragyri with cam- phor; or by keeping the patient in bed, with a gum catheter in the urethra and bladder. This plan may be pursued for a {'ew days each time, and repeated at intervals until the tumor is nearly dispersed. The gum catheter should be of a small size: a large one will produce an effect exactly contrary to what you wish, irritating the gland, and exciting a fresh attack of inflammation in it. I have known the at- tempt made to destroy one of these enlarged follicles by means of the bougie armed with the nitrate of silver; but in the cases to which I allude the treatment seemed to be injurious rather than beneficial. It has often occurred to me that the tumor, when not of a very large size, and not very closely attached to the surrounding parts, might be dissected out without injury to the corpus spongiosum or urethra; but I have never yet performed such an operation. In some instances suppuration takes place in one of these tumors, and an abscess bursts externally. The healing of the abscess is generally slow; and after it has healed, an induration remains, which, however, gradually dis- appears. In other cases it bursts internally, and the cavity of it is liable to become distended by a portion of the urine finding its way into it. Under these circumstances you may direct the patient to place his finger on the part when he makes water, so as to make a moderate pressure on it. Thus the urine will be prevented entering the abscess, which will at last, in all probability, heal. If, however, it should not heal, you may introduce a director into the urethra, and then make an incision in it so as to establish a free external opening, leading to the centre of the abscess, dressing the parts afterwards with S 58 DISEASES OF THE some stimulating ointment, and applying occasionally the nitrate of silver. I have seen one case, in which one of these enlarged glands pro- duced a complete obstruction of the urethra, and a retention of urine. The urethra became ulcerated behind the obstruction; the ulceration extended to the external parts, and the urine became extravasated in- to the cellular membrane of the scrotum and penis. The patient was admitted into the hospital with extensive mortification of these parts, and died. The examination of the body after death enabled me to ascertain the nature of the disease. Diseases of the Female Urethra. Passing over those affections of the male urethra which are connect- ed with syphilis and gonorrhoea, I shall draw your attention to the dis- eases of the female urethra. These are few and simple, and, as I have already had occasion to observe, all that is to be said respecting them may be comprised in a very few words. Stricture of the female urethra is very rare; nor have I ever seen it except at, or immediately within, the external meatus. I have a pre- paration which affords an example of stricture in this situation. It was taken from the body of a woman who died under the following circum- stances:—She was admitted into the hospital laboring under a very great difficulty of making water. The urine was voided almost in drops, with much effort and straining. On examination, I found the external orifice of the urethra so much contracted that it would scarcely admit a small probe. It was, however, dilated by means of bougies, and the patient voided her urine in a moderate stream. Some time afterwards she was seized with an attack of fever, which proved to be dependent on inflammation of the peritonaeum covering the liver, unconnected with the stricture, and of this she died. You will ob- serve in the preparation taken from this patient that the stricture is quite at the extremity of the urethra, occupying about half an inch of the canal. Sir Charles Clarke has described another disease of the female urethra, of which many examples have come under my own observa- tion. It consists of a tumor, or excrescence, having its origin from the urethra immediately within the external meatus. The tumor pro- jects externally; is of a soft texture; of a bright scarlet color; pos- sessed of exquisite sensibility; and it varies in size from that of large pin's head to the size of a horse-bean. It may be removed by the probe-pointed scissors, the basis of it being afterward destroyed with the caustic potass; or it may be removed by the application of a lig- ature. The first of these methods is that which I have myseif adopt- ed, and which my own experience in these cases would induce me to FEMALE URETHRA. 59 prefer. Cut off the tumor first as close to the base as possible; wait until the bleeding has ceased, and then apply the potassa fusa for a short time to the cut surface. I have contrived an instrument which you will find it very convenient to employ where you have recourse to this operation. It is a silver tube, incomplete in one part of its cir- cumference; so that, when introduced into the urethra, it allows the caustic to be applied to the tumor, while the sound part of the urethra is defended from it. On these, as on other occasions, where you em- ploy the caustic potass, you should take care that it is of the very best quality, and recently made; and after you have applied it, the parts in the neighborhood should be bathed with vinegar, which will neutralise the caustic alkali, and prevent it acting where the action of it is not required. In some of these cases, instead of the caustic potass, I have ap- plied the concentrated nitric acid, by means of a probe armed with lint and dipped in the acid; defending the neighboring parts by wash- ing them with a solution of the bicarbonate of potass; and I do not, indeed, know that either one of these caustics is preferable to the other. Irritable Bladder. In the greater number of cases of disease of the bladder, the most marked symptom under which the patient labors is a too frequent in- clination to void the urine. The bladder is irritable; and those who have not combined with the observation of symptoms the study of morbid anatomy are apt to confound with each other diseases which are essentially different, under the general appellation of irritable blad- der. In the observations which I am about to make, however, I shall apply the term irritable bladder to those cases only in which the irritability is not the consequence either of inflammation or of organic disease. If healthy urine escapes from the bladder, and comes in contact with other textures, the peritonaeum, for example, or the cellular mem- brane, it acts on these parts as a violent stimulus, inducing inflam- mation, gangrene, and death: while to the bladder it is no stimulus at all; the patient suffering no more inconvenience from it than he would have suffered if the bladder had been distended with the same quanti- tv of water. If, however, there be any derangement of the functions of the general system, or of the kidneys in consequence of which the chemical qualities of the urine are altered, it then becomes a stimulus to the bladder itself; and the patient, under these circumstances, suf- fers inconvenience, and feels the desire to expel the contents of the bladder, when there is only a small quantity of urine collected in it. In some of these cases the urine contains an unusual quantity of lithate 60 IRRITABLE BLADDER of ammonia, which is deposited, on cooling, mixed with other matter, in the form of a red or yellow uncrystalized sediment; or it may con- tain the pure lithic acid, showing itself in the form of a red sand. In other cases the urine is alkaline, having the odor of ammonia, and de- positing white crystals of the triple phosphate of ammonia and magne- sia. It is right that 1 should notice these cases at present, though it be only in a brief manner. For farther information respecting them, and the treatment which they require, I must refer you to some of my subsequent Lectures relating to calculous affections. Irritability of the bladder is occasionally a symptom of disease in, or of disease affecting, the nervous system. An elderly man, for example, complains of frequent attacks of giddiness. Sometimes, in walking, his head turns round, so that he is in danger of falling; and this symptom, probably, arises from an altered structure of the arteries of the brain, causing an imperfect state of the cerebral circu- lation. This state of things is sometimes attended with an irritable condition of the bladder; and although the urine is of a healthy quality, and the bladder itself is free from disease, the patient is tormented by a constant micturition, voiding his urine without pain, but at short in- tervals, and in small quantity at a lime You can do little for the patient's relief in such a case as this; but it is important that you should understand its real nature, so that, if you cannot effect a cure, you may avoid tormenting him with useless remedies. Irritability of the bladder is at other times the result of mere ner- vousness; of the same state of the nervous system, as, in some other individuals, occasions a constant winking of the eyes, or twitches of the muscles or other parts. The frequent expulsion of the urine, being once begun, is kept up by habit; the bladder becomes less ca- pacious than it ought to be; and it is not until after a lapse of time, nor without some effort on the part of the patient, that it is restored to its natural condition. There are others, who have a tendency to diabetes, and who, over- looking the two abundant secretion of urine, and observing only the too frequent inclination to expel it, consult you under the impression that they labor under a disease of the bladder, while the actual dis- ease is in the kidneys, or rather in the general system. Now, these things may appear too trivial, or to obvious, to be worthy of being mentioned; but I have known them to be a source of error; and I am anxious that, when you meet with such cases, you should not be perplexed in forming your diagnosis. Paralysis of the Bladder. Injuries and diseases of the brain and spinal marrow, which render 3 hmbs paralytic, may render the bladder paralytic also. The PARALYSIS OF THE BLADDER. 61 bladder is not unfrequently affected in the same manner in cases of typhus fever, or where there is a great general excitement in conse- quence of a compound fracture, or other severe local injury, espe- cially of the lower extremities. Retention of urine from paralysis of the bladder is attended with symptoms which are, in many respects, different from those which occur where the retention arises from mechanical obstruction. The same diminution of nervous influence, which renders the bladder in- capable of expelling the urine, renders it also insensible to its stimu- lus. Hence it is, that the accumulation of the urine in the bladder is productive of no actual suffering, and of comparatively little incon- venience. When a great degree of distension has taken place, the contents of the bladder begin to escape involuntarily; and this invol- tary flow of urine continues, so as to prevent further accumulation, but not so as to empty the bladder. Being made acquainted with the circumstances which I have just mentioned, you will understand how it is that this kind of retention of urine is not unfrequently overlooked, especially in the cases of corpulent individuals, in whom the bladder may be distended to a considerable size before it can be distinguish- ed by the hand above the pubes. In some instances, although the bladder has lost its contractile power, the patient is able, nevertheless, to get rid of a portion of its contents, in a stream, by his own natural efforts. This is accomplish- ed by means of the action of the abdominal muscles, but not until the bladder has become enormously distended. Here the urine is ex- pelled at short intervals, slowly, and in small quantity at a time. The patient believes the bladder to be empty, as he probably voids as many ounces of urine as are usually voided in twenty-four hours; and he is surprised to find, on the introduction of the catheter, that it draws off three or four pints, or even a larger quantity. Where this state of things has existed for a considerable time, if the patient dies, and you have the opportunity of instituting a post-mortem examination, you find the bladder very much dilated, the mucous membrane of a pale color, and the muscular tunic much attenuated. Where the bladder is affected with paralysis, the patient is to be relieved by means of the catheter: and this is easily accomplished; there being no mechanical impediment to the introduction of the in- strument. The operation must be repeated at stated intervals, at the same time that you attempt, by suitable remedies, to remove the cause of the paralysis, whatever it may be. But it may be reasonable to inquire what will happen if the cathe- ter be not employed. I have known such a retention of urine to ex- ist, some urine escaping, but the bladder remaining distended, without the real nature of the case having been understood, for a great length of time; that is, for many months, or even for one or two years. The same overloaded state of the bladder is a still more frequent con- 62 PARALYSIS OF THE BLADDER. sequence of the chronic enlargement of the prostate gland, to which elderly persons are liable, as I shall explain to you hereafter. From whichever of these causes it arises, it produces the same effects. The kidneys become diseased; they secrete at first albuminous, and afterwards purulent urine; and other changes are produced in these organs which I need not describe at present, as they will be fully ex- plained hereafter. Paralysis of the bladder is usually the result of some disease or in- jury, which affects other muscles as well as that of the bladder. Oc- casionally, however, it occurs without this complication; the bladder, and (as far as we can see) the bladder only, being deprived of its power of action. A gentleman, a lawyer by profession, of sedentary habits, and of what is commonly called a nervous temperament, ob- served that he had not the usual desire to void his urine, and that when he did void it, it was in a very slow stream, and in small quan- tity. On the following day he voided none at all, but he had, at the same time, no inclination to void it, and, therefore, did not suffer. Another day arrived, and, being still in the same condition, he thought it prudent to consult a surgeon; not because he experienced either pain or inconvenience, but because he knew, as he expressed it, that all could not be right. The surgeon introduced a catheter, which entered the bladder without the smallest difficulty, and drew off a large wash-hand-basinful of urine. The urine soon became again col- lected in the bladder, and the catheter was again had recourse to. The operation was repeated night and morning for a few days, at the end of which time the patient regained the power of making water, and was soon able to evacuate the contents of his bladder as usual. Some time afterwards he had another similar attack, from which he recovered more slowly than from the former one. The paralytic affection of the bladder, which occurs in hysterical females, is of a peculiar kind, and deserves a separate consideration. It appears to me that the symptoms are to be traced to a still higher source than in ordinary cases of paralysis; that, in the first instance, it is not that the nerves are rendered incapable of conveying the stim- ulus of volition, but that the effort of volition is itself wanting; and this corresponds with what is observed in cases of loss of voice, and in many other diseases connected with hysteria. As the distension of the bladder increases, the patient begins to be uneasy, and at last suffers actual pain; and as soon as this happens, the volition is exer- cised as usual, and the bladder begins to expel its contents. Thus, if the bladder be not relieved artificially, by the introduction of the catheter, the hysterical retention of urine is usually of short duration. If, however, the catheter be had recourse to, the natural cure is prevented, and the existence of the disease may be prolonged for an indefinite period of time—for weeks or even for months. The general rule to be observed in the treatment of these cases is to inter- INFLAMMATION OF THE BLADDER. 63 fere but little. You may administer an active aperient, or an assa- foetida enema, or you may give assafcelida by the mouth, but you should avoid using the catheter. This general rule, however, is not without its exceptions. In a few of these cases, where the bladder has been very much distended, the consequence of this over-disten- sion is, that it loses its power of contraction, and even though the pa- tient endeavors to make water, no urine flows. Under these circum- stances it is evident that artificial relief is necessary; and if it be not afforded, more than a simple inconvenience may be the result. A young woman was admitted into St. George's Hospital, in November, 1814, laboring under a train of symptoms which I believe to have been connected with the same condition of the nervous system as that which produces the phenomena of hysteria. I should be wandering from my subject, if I were to relate to you all the circumstances of this interesting and important case. It is sufficient for our present purpose that you should be informed that one of the symptoms was a retention of urine, which had been long neglected, and which existed to such an extent that forty ounces of urine were drawn off by the catheter; and that the patient ultimately died. In my notes I find the following account of the appearances which the bladder presented in the post-mortem examination:—" It was of a very large size, as if it had been for a long time unusually dilated. It was throughout of a dark color almost black. There were only some slight vestiges of its natural structure left; the muscular fibres being very much wasted, and the internal membrane presenting the appearance of a very thin film, which was readily separated from the parts below. The dark color of the bladder did not seem to arise from mortification, since there was neither foetor, nor any other mark of putrefaction." The state of the bladder was, indeed, very peculiar; not resembling any thing which has fallen under my observation either before or since. Inflammation of the Bladder. You will find in practice that acute inflammation of the bladder is of much less common occurrence than you would suppose it to be, from what is said on the subject by nosological writers. Cases of retention of urine, and cases of inflammation of the prostate gland, are not unfrequently mistaken for it by persons who are not very conversant with the diseases of the urinary organs. Acute inflammation of the bladder does, however, occur some- times. You have especially the opportunity of seeing it in cases of gonorrhoea. Where there is a sudden suppression of the discharge from the urethra, the metastasis takes place, sometimes to the testicle, sometimes to the prostate gland; at other times, but less frequently, to the mucous membrane of the bladder. The patient has a frequent 64 INFLAMMATION OF desire to void his urine, with a sensation as if there were urine in the bladder, when there is really no urine in it; and he strains to make water, with the bladder empty. There is pain referred to the region of the pubes and perineum. The urine deposits a sediment, which is of a different character in different cases, as I shall explain hereaf- ter. The pulse is frequent, the tongue furred, and there is a good deal of constitutional excitement. These symptoms may continue for several clays; and in cases of gonorrhoea they do not usually subside until the purulent discharge from the urethra is restored. The disease is to be combated by taking blood from (he arm, or from the loins by cupping, or from the lower part of the abdomen by leeches. The patient should be confined to bed and the horizontal posture. His bowels should be kept open by occasional doses of castor oil. Opium may be administered with advantage, especially in the form of clysters. Sometimes the urine retains its acid quality, turning the blue litmus paper red; and the sediment, which it deposits, is of a yellowish color, having no adhesive quality, and bearing some degree of resemblance to pus; and in these cases, if I am not much mistaken, the patient will derive benefit from the use of mercury,— two grains of calomel, and half a grain of opium, being administered twice or three times daily. In other cases the urine is alkaline, turn- ing the reddened litmus paper blue, and depositing a small quantity of adhesive mucus of a brownish color; and, under these circumstan- ces, T have known much good to arise from the use of the vinum col- chici, fifteen or twenty minims being given three times daily, for three or four successive days. Chronic inflammation of the bladder occurs very frequently as a secondary disease, depending on long-continued stricture of the ure- thra, disease of the prostate gland or kidneys, or stone in the blad- der. Women are also liable to it, in whom there exists an ulcerated communication between the bladder and vagina. As a primary affec- tion it is comparatively rare. However, it occurs as such sometimes; and I have seen a few patients in whom it had existed for a consider- able length of time, and could not be traced to any other disease. I shall describe to you, first, the appearance which the diseased parts exhibit on dissection; secondly, the symptoms which the dis- ease produces; and, lastly, the treatment which it requires. The mucous membrane is of a dark red color, in consequence of its numerous vessels ramnifying it on its surface, injected with their own blood. As the disease proceeds, the discoloration becomes greater, until, at last, the mucous membrane appears almost black from the turgid state of the vessels; at the same time that it is some- what thickened and pulpy to the touch. The inflammation extends up the membrane of the ureters; which, in their turn, assume much the same appearance with the bladder itself. The pelvis of each kidney, and the processes of the pelvis, or infundibula, become in- THE BLADDER. 65 flamed also: and these, as well as the ureters, are generally dilated, so as to be more capacious than natural. This dilatation is greatest where there has been a long continued difficulty in expelling the urine from the bladder; but it exists in other cases also, though in a less degree. In the advanced stage of the disease the inflammation is found to have extended to the glandular structure of the kidneys; and these organs become not only more vascular than natural, but enlarged in size, and of a soft consistence, even approaching in ap- pearance to that of a medullary tumor. Collections of muco-purulent fluid, tinged brown with grumous blood, and offensive to the smell, are sometimes found in the dilated infundibula; at other times there are distinct abscesses in the glandular structure. In cases where the disease is still farther advanced, before the patient dies, we find that the inflammation has extended to the muscular tunic of the bladder, and to the loose cellular membrane by which the bladder is surround- ed. Then coagulated albumen is deposited in the collular texture; not unfrequently small putrid abscesses are formed in it; and some- times it is found after death in a state of slough, or approaching to it. Occasionally, but rarely, ulceration takes place on the inner surface of the bladder, and sometimes to a very great extent. A patient, about fifty years of age, died in St. George's Hospital, laboring under the symptoms which 1 am about to describe. On examining the body, the mucous membrane was found destroyed every where, ex- cept a very small portion near the neck of the bladder. The muscu- lar fibres were as distinctly exposed as they could have been by the most careful dissection. The prostate gland in this case was slightly enlarged; the membrane of the ureters and pelves of the kidneys were much inflamed, and ihe ureters were dilated. I remember a preparation, exhibiting nearly the same appearances, in Dr. William Hunter's Museum, which was formerly in Windmill Street, but whicu is now in Glasgow. , . As chronic inflammation of the bladder is, in the majority ot cases, not a primary but a secondary affection, the symptoms of it are gen- erally blended with those of another disease, as of stone in the blad- der in one case; of stricture in the urethra, or enlargement of the prostate, in another case. I shall endeavor to describe the symptoms as nearly as I can, distinct from those of the diseases which it accom- panies, such as you find them to be in those cases, in which the in- flammation of the bladder is the only existing malady. The patient has frequent desire to void his urine, and the urine de- posits, as it cools, a thick adhesive mucus, which clings to the bot- tom of the vessel. This mucus is of a greyish colour, streaked with white, and sometimes tinged with blood. There is pain previously to making water, and also while the urine flows. These symptoms may continue for a great length of lime without becoming very urgent. However, they gradually increase, until the irritation ol the bladder 9 66 INFLAMMATION OF becomes excessive, and the quantity of mucus deposited is so great, as in some cases to be nearly equal to the urine itself. In this last respect, however, there is a great difference in different cases. The urine ultimately assumes a brownish hue, and is of a most offensive ammoniacal odor. The extension of the inflammation to the glan- dular structure of the kidneys is indicated by the access of a still more formidable train of symptoms. The patient has shiverings; is troubled with sickness and vomiting, with cold extremities and great pros- tration of strength; his pulse becomes irregular and intermitting; his tongue brown; he sinks, and dies. In the case which I mentioned, in which the bladder was extensively ulcerated, there was excruciat- ing pain referred to the perineum and urethra, especially after mak- ing water; and the introduction of a sound into the bladder occasion- ed excessive torment. The symptons which existed in the patient whose ulcerated bladder is preserved in Dr. William Hunter's Mu- seum, are thus described in Dr. Hunter's Catalogue:—" Great pain and scalding in voiding the urine, a discharge of pus, and occasional- ly of blood." The mucus, which is deposited by the urine in these cases, de- serves our especial notice. It is thick and viscid, clinging to the bot- tom of the vessel, and hanging down in the form of long ropes, when you attempt to pour it from one vessel to another. It is highly alka- line, turning the turmeric paper immediately brown. When small in quantity, although the mucus is alkaline, the urine often remains acid, as has been observed by Dr. Prout; but when the quantity of mu- cus is large, it imparts its alkaline quality to the whole of the urine, which, under these circumstances, is liable to deposit calculous mat- ter, composed of phosphate of lime, in small masses, of the consist- ence of recently made mortar. It is the formation of this peculiar mucus which led the old physicians and surgeons to apply to ibis dis- ease the name of catarrhus vesicas. It may appear remarkable that the mucous membrane of the bladder, when in a stale of inflammation, should secrete this peculiar mucus, while that of the urethra, under the same circumstances, secretes a fluid which cannot be distinguish- ed from true pu?. The very interesting r< searches of Dr. Babington, however, recorded in the second volume of the " Guy's HospitaT Re- ports," go far towards explaining ibis anomaly,-by showing that the pus from a common abscess assumes all the cliaracters of this kind of mucus on the addition of an alkali. In the treatment of chronic inflammation of the bladder, you are to consider whether it be a primary or secondary affection; and if the latter, the first thing to be done is, that you should remove or palliate the original complaint. If there be a stricture, you are to dilate it: if there be a stone in the bladder, you will in vain endeavor to remove the inflammation, without removing the stone, which has produced it: THE BLADDER. 67 if there be a disease in the prostate gland, you are to resort to the plan of treatment which I shall describe to you in a future Lecture. But even in these cases something may be done by other means towards relieving the affection of the bladder; and where this is the original disease, of course these other means are all on which you are to depend. Let the patient remain as much as possible in the horizontal pos- ture. When he sits or stands, there is the weight of the whole column of blood, from the head to the pelvis, pressing on the vessels of the bladder; and blood-vessels become distended, which are com- paratively empty when he lies down. The horizontal position is as important in diseases of the bladder as it is in diseases of the uterus; as important as an elevated posture and a high pillow are in cases of determination of blood to the head; and its importance rests on pre- cisely the same principle. Opium agrees remarkably well with patients who labor under chronic inflammation of the bladder. It may be administered by the mouth, or in the form of an enema at bedtime; and other sedatives, as the extract of hyoscvamus, or lettuce, or poppies, may be admin- istered besides, if necessary. The bowels should be kept in an open state, but no violent or drastic purgatives should be exhibited. Mer- curial remedies, whether given in the form of alteratives or in larger doses, so as to affect the constitution, are certainly not beneficial, and are often injurious. In a very few instances, where the digestion is impaired, small doses of alkalies combined with light bitters may be exhibited with advantage; but the extensive use of alkalies is prejudicial, causing the urine to become more alkaline, and the phosphatic salts to be de- posited in larger quantities than before. The uva ursi has the reputation of being useful as a remedy for chronic inflammation of the bladder. I must say, however, that this remedy has generally disappointed me in these cases, and that 1 have not seen those advantages produced by it, which the general reputa- tion of the medicine had led me to expect. 1 have seen much more good done by a very old medicine, which has been long ignomin- iously, but unjustly, expelled from the Pharmacopoeia of the Col- lege of Physicians, namely, the root of the pareira brava; and with regard to this, I am satisfied that it has a great influence over the disease, which is now under our consideration, lessening very material- ly the secretion of the ropy mucus, which is in itself a very great, evil, and, I believe, diminishing the inflammation of the bladder also.' It may be exhibited in the following manner:—Take half an ounce of the root of the pareira brava, add three pints of water, let it simmer gently, near the fire, until reduced to one pint.* The patient is to * The infusion of pareira brava, which has been introduced into the last Pharmaco- poeia of the College of Physicians, does not at all answer the purpose of the decoction, and is nearly useless. 68 INFLAMMATION OF drink from eight to twelve ounces of this decoction daily. If so large a quantity of liquid should be offensive to the patient's stomach, he may take the extract of pareira brava instead, twenty-five or thir- ty grains being equal to half a pint of the decoction. You may add to it moderate doses of the tincture of hyoscyamus; and in those cases in which there is a deposit of the phosphates, you may also add some of the muriatic or nitric acid. Very small doses of turpentine are sometimes beneficial in these cases. You may begin with one or two grains of Chios turpentine administered twice daily, giving a some- what larger quantity afterwards. I have often known the symptoms to be much alleviated under the use of the cubebs pepper; but it must be given only in small quantities. When given in large doses I believe it to be actually injurious. I was consulted by a gentleman who la- bored under chronic inflammation of the bladder, and 1 prescribed for him fifteen grains of the powdered cubebs to be taken every eight hours. He was very much relieved, so much so, that he began to look forward to his recovery. Being anxious to expedite his cure, of his own accord, and without my knowledge, he took the cubebs in larger (I believe in dram) doses. This was followed not by a diminution, but by an aggravation of all his symptoms. The irrita- tion of the bladder was much increased, the mucus was secreted in a much larger quantity than before, and ultimately the patient died; his death being, I will not say occasioned, but apparently very much hastened, by his imprudence in overdosing himself with the cubebs. The bladder is accessible to local applications, and the question will here arise, " Can nothing be done for the patient by means of remedies of this description?" The following are the results of my experience on this subject. In aggravated cases of the disease, where the symptoms are at their greatest height, the mildest injections, even those of tepid water, will do harm rather than good. They are especially to be avoided where the mucus deposited by the urine is highly tinged with blood. When however the symptoms have in some degree abated, the injec- tion of tepid water or decoction of poppies is in many instances pro- ductive of excellent effects. An elastic gum catheter may be introduced into tbe bladder, and the injection may be made by means of a small elastic gum syringe. The liquid should be al- lowed to remain in the bladder about thirty or forty seconds, and not more than an ounce and a half, or two ounces, should be injected at each time. If the bladder be distended, so as to occasion any con- siderable degree of pain, the effect is always injurious instead of be- ing beneficial. This operation may be repeated, according to cir- cumstances, once or twice in twenty-four hours. When there is a further abatement of the symptoms, the disease having assumed a still more chronic form, and the mucus being free (except on extraordinary occasions) from all admixture of blood, we THE BLADDER. 69 may venture to add to the injection a very small quantity of nitric acid. At first the proportion ought to be not more than that of one minim of the concentrated, or ten minims of the diluted nitric acid, to two ounces of distilled water; but afterwards this proportion may be doubled. I do not say that it should never be increased still fur- ther, but I have observed, that for the most part injections, which are stronger than this, are not only not useful but actually prejudicial. In having recourse to this mode of treatment, it is better to wash out the bladder first with a little tepid water; then to inject the acid solu- tion, allowing it to remain for not more than thirty seconds in the bladder. At first the operation should not be repeated oftener than once in every two days; afterwards it may be repeated once daily, but never more frequently than this. If the urine drawn off by the catheter be tinged with blood, the injection should be deferred to the following day; and if the injection be at any time followed by pain, and other symptoms indicating an increase of inflammation, it ought not to be had recourse to again until these have subsided. I was first led to adopt the use of the injections of nitric acid in the year 1826; and from the experience which I have now had of them, 1 do not hesitate to say, that, if the precautions which I have suggested, be properly observed, they will be found to form a valuable addition to our stock of remedies to be employed in these cases. They are useful not only where the chronic inflammation is the primary disease, but also where it occurs as a secondary affection, the result of a calculus in the bladder, or of a chronic enlargement of the pros- tate gland. It may be observed that, although treating of a chronic inflammation of a mucous membrane, I have not hitherto recommended the ab- straction of blood. I have, however, had recourse to it in many in- stances, generally by means of the application of cupping glasses to the loins. I will not say that it has never been beneficial, but ft is my duty to say also, that I have much more frequently found it to be in- jurious. However contrary it may seem to be to the principles on which the treatment of inflammatory diseases is generally to be con- ducted, I am satisfied that in those cases of inflammation of the blad- der in which the mucous membrane secretes a considerable quantity of thick, tenacious, ropy mucus, falling to the bottom of the urine, the rule of practice should be, not to take away blood; and that this admits of very few exceptions. In fact, this species of vesical inflam- mation is, in the great majority of cases, combined, in some way or another, with great debility of the general system, and the patient re- quires (for the most part) that his bodily powers should be supported, rather than that any demand should be made upon them. I may re- fer you to my Lectures on Calculous Disorders for some observations in further illustration of this subject. In speaking of inflammation of the bladder, I have considered it as 70 INCONTINENCE being either of the accute or chronic, kind; not only in compliance with general custom, but because 1 could not otherwise so convenient- ly express all that is required to be said on the subject. At the same time it is right for you to bear in mind, not only on this, but also on other occasions, that, however useful it may be to make it,,this dis- tinction is really artificial. The boundaries of accute and chronic in- flamation are not well defined. There are numerous cases in which we must hesitate to determine whether they may with most propriety be referred to one class or to the other; and there are other cases, which, while, at one period, they exhibit all the marks of acute in- flamation, exhibit, at another period, those of chronic inflammation with equal distinctness. Incontinence of Urine. By incontinence of urine, I intend to express an involuntary escape of urine from the bladder; a state of things entirely different from the constant discharges of urine which take place in cases of irritable blad- der, where each discharge is the result of a distinct act of volition, ex- cited by pain, or in some other way. Incontinence of urine may be the result of mechanical injury; thus it occasionally follows the operation of lithotomy in the male, and very frequently follows it in the female sex. In women also it not uncom- monly is the consequence of difficult parturition with a distended blad- der, where the pressure of the child has caused sloughing of the vagi- na, and thus laid the foundation of a communication between it and the neck of the bladder. The most frequent cause of incontinence of urine, however, in the male sex, is an over distended bladder. When the patient is unable to void his urine voluntarily, after a certain quantity is collected in it, the overplus is discharged involuntarily, and thus it is that this symp- tom occurs in cases of long-standing stricture of the urethra, of en- larged prostate gland, and of paralysis affecting the lower part of the body. The patient, and those about him, suppose the bladder to be empty, because the urine is always dribbling from him. But this very circumstance leads the surgeon to suspect the contrary; and ac- cordingly, on examining the abdomen, he discovers an enormous tu- mor, formed by the distended bladder, occupying the hypogastric re- gion, and extending upwards, perhaps as high as the navel. The remedy for this kind of incontinence is sufficiently obvious; nothing more being required than that the bladder should be emptied artificially at stated periods. In cases of stricture of the urethra, indeed, this can- not be always accomplished in the first instance; but the dilatation of the stricture, even to a very moderate extent, by the introduction of OF URINE. 71 a small bougie, will often be sufficient to give much, if not complete, relief. There are some cases of paralysis in which there is incontinence of urine although the bladder is empty, as if the same cause which ren- dered the lower limbs paralytic rendered the bladder incapable of distension. For example, a gentleman, sixty-three years of age, swallowed by mistake a bottle of liniment, of which the tincture of cantharides was a principal ingredient. In about three quarters of an hour an emetic was administered; nevertheless he was immediately afterwards affected with paralysis of the lower extremities, and ina- bility to void his urine. For the first fortnight he was under the ne- cessity of having his urine drawn off at stated periods. After this he regained the power of making water, but was tormented by an in- cessant desire to do so. When I was consulted, four years after the commencement of the attack, he was able to walk with the assist- ance of crutches. At times he had a sudden and irresistible impulse to void his urine, and expelled a small quantity by a voluntary effort; but at other times it flowed involuntarily without his being conscious of what happened, so that his clothes were as wet as possible. On introducing a catheter, I found that the bladder was empty. It may be supposed, that in this case something was to be attributed to the peculiar nature of the stimulus which had been swallowed. I have, however, observed the same thing in some cases of paralysis of the lower limbs, arising from other causes. I have occasionally seen what was called a case of incontinence of urine in young women having a disposition to hysteria: but from a close observation of such cases, I am led to believe, that the discharge of urine, although involuntary in appearance, is not involuntary in reality; and that this symptom, like many other hysterical symptoms, is to be referred to a rnis-direclion of the power of volition, and not to the actual want of it. The case which I am about to mention seems to confirm this view of the sub- ject. A lady, twenty years of age, for the last ten or eleven years had been troubled with a constant discharge of urine. It flowed (as she said) without her being able to prevent it while she sat in her chair, and while she was walking; so that she was quite unfit to live in society, or even in her own family. All the plans of treatment, recommended by myself and others, proved inefficacious. At last, on account of this infirmity, it was thought advisable that she should be separated from the rest of her family, and she was sent to reside at a distance from them. After some time she was seized with an urgent desire to return home, and immediately she regained the power of retaining her urine. She continued well when I heard of her some time afterwards. 1 have no doubt that the incontinence of urine during the night, which occurs so frequently in children, is, for the most part, in its origin, not altogether involuntary. But it soon becomes confirmed 72 INCONTINENCE OF L'RINE. by habit, and then the discharge is preceded by so slight an effort of volition, that the patient is scarcely conscious of it afterwards. It is reasonable to suppose, that those children whose urine is of a too stimulating quality, in consequence of an excess of lithic acid in it, may be more liable to this kind of incontinence than others; yet I must say, that my endeavors to relieve it by the exhibition of alkalies and purgatives, combined will a regulated diet, have been generally unsuccessful. A blister applied over the os sacrum, and repeated ac- cording to circumstances, is a more effectual remedy. Sir Charles Bell has observed, that children are more liable to this troublesome symptom when they lie on their back than when they lie on the face or side. This may explain, in part at least, the good arising from the blister. The same object may be attained by making the child wear, during the night, a machine, so contrived as to prevent him lying in the supine posture.* I do not know that you can absolutely rely on this method for the patient's cure, but it may often be employed advan- tageously, in combination with other methods of treatment. In some cases, the discharge of urine is periodical, returning at the same hour of the night and morning. You may then direct the nurse to take the child out of bed, so as to give him the opportunity of making water about an hour before; or if the patient be older, he may be provided with a clock, having a loud alarum, for the purpose of awakening him from his sleep at the proper moment. Under the same circumstances the sulphate of quinine may be administered with great advantage. But in no instance are any of these remedies likely to be successful, unless the patient himself feels a strong desire to be re- lieved; and unfortunately this desire is too often wanting, long habit gradually reconciling the mind to this, as it does to many other in- conveniences, until, at last, it seems to be a matter of indifference whether relief is obtained or not. I have heard of young persons being cured of this kind of incontinence of urine by applying caustic to the neck of the bladder, and by the introduction of bougies or ca- theters. If these methods of treatment produce any effect, I sus- pect that it is simply by annoying the patient, and by giving him that strong desire to be relieved, which I have just mentioned as the first step towards recovery. * A very convenient apparatus for this purpose is made by Mr. Sparkes, bandage maker, &c. of J\o. 28 Conduit Street. FUNGUS HASMATODKS OF THE BLADDER. 73 LECTURE VI. Fungus Hwmatodes of the Bladder. Morbid growths, having the same character, and running the same course with malignant diseases in other textures, are not uncommonly met with in the bladder. Those which I have had the opportunity of examining have belonged to the class of fungus hcemalodes. Some- times a portion of the tumor has resembled scirrhus; but I have nev- er met with one which was wholly of the last-mentioned structure. In one instance 1 found the tumor situated at the fundus, but the more ordinary situation of it is near the neck of the bladder. The disease appears to have its origin in the mucous membrane: sometimes occupying the whole of it, so that scarcely any of the na- tural structure remains at the time of the patient's death, but more frequently it arises from a limited portion of its surface, while the greater part of the membrane remains in a healthy state. As the dis- ease advances, it forms a large tumor projecting into the cavity of the bladder. In some instances it makes its way in other directions. In a case, in which the tumor was situated at its fundus, the bladder had contracted adhesions to the sigmoid flexure of the colon, and there was a large fungus projecting from it into the cavity of that portion of the intestine. In another case, some time before the patient died, a tumor presented itself in one groin, which rapidly increased to a con- siderable size. In examining the body after death, there were found scarcely any remains of the natural structure of the bladder. Nearly the whole of it was converted into a mass of fungous or medullary substance, occupying the cavity of the pelvis, and extending laterally so as to show itself in the groin. . In these cases the patient complains of a too frequent inclination to void his urine; of an uneasy sensation referred to the neck of the bladder, which sometimes amounts to severe pain extending to the perineum, and along the urethra to the glans, and in another direction to the pubes. This pain is generally aggravated after the urine is void- ed. I have known the patient to labor under a retention of urine, in consequence of the tumor pressing on the inner orifice of the ure- thra, so that it became necessary to puncture the bladder above the 10 74 FUNGUS HiEMATODES pubes. In another case there was a constant wearing pain in the loins, the cause of which was explained by the appearances observed in the post-mortem examination: the; tumor having obstructed the ori- fices of the ureters, which were in consequence dilated to the size of the small intestine, the pelvis and infundibula of the kidneys being dilated also, so as to form considerable sacs or pouches, distended with urine. The urine is usually turbid; sometimes depositing an adhesive mu- cus, the consequence of long-continued irritation kept by the tumor in the mucous membrane of the bladder. In the advanced stage of the disease the urine is of a dingy brown color, of an offensive cad- averous odor; and small fragments of medullary substance, which appear to have been separated from the surface of the tumor, may be detected in it. In all cases there is a disposition to haemorrhage; and in some, bloody urine is a constant, or nearly constant, symptom. The urine is not merely tinged with blood, but the blood comes away in large clots, of an irregular shape, in which small portions of me- dullary substance are not unfrequently enveloped. The haemorrhage is occasionally abundant, so that it materially7 contributes to the grad- ual exhaustion of the bodily powers, which the disease otherwise in- duces, and hastens the patient's death. These symptoms do not always occur in the same order; nor is the rapidity of their progress the same in all cases. I have known the disease to have run its course, so that the patient has fallen a vic- tim to it, in the short space of eight or ten months from the period of its commencement; and I have also known it to be protracted for seven or eight years. Usually, the first symptoms are a too frequent inclination to void the urine, and pain experienced after it has been voided; but, occasionally, the earliest warning which the patient has of the calamity under which he labors, is the appearance of blood in the urine. I have known the urine to be bloody for a short lime, then to become clear, and continue so for one or two years, when the blood has again shown itself, never wholly disappearing afterwards. In those cases in which fragments of organised medullary substance are to be detected in the urine, there can be no difficulty in the diag- nosis; but where this symptom is wanting, each case requires to be observed and studied, in order that it should be understood, as all the other symptoms are equivocal. In the very great majority of cases in which there is blood in the urine, the haemorrhage is the result of a calculus either in the kidney or bladder; but if there be no calculus, and the quantity of blood be considerable, it is more probable that it is derived from a medullary tumor, than from any other source. If the blood appears in the form of large masses of coagulum, of an ir- regular shape, we may be satisfied that it flows from the bladder, and not from the kidneys, and we may arrive at the same conclusion, if we find that a small quantity of pure blood is discharged from tbe OF THE BLADDER. 75 urethra after the effort made to expel the last drops of the urine. If under these circumstances the bladder be subjected to two or three careful examinations with the sound, and no calculus can be detected in it, there are strong grounds for suspecting the existence of a me- dullary tumor. These suspicions will be strengthened if the haemorr- hage be accompanied with a frequent inclination to make water, and a pain extending along the urethra, and to the perineum, after the urine has flowed; and if the tumor be of a large, or even of a mode- rate size, they may be completely confirmed in another way. Let about six ounces of tepid water be injected into the bladder; a sound, which is considerably curved, but not projecting at the point much beyond the curvature, being introduced into it afterwards. With such a sound as this every part of the bladder may be readily explored; and the extremity will be distinctly perceived striking against the tumor, at the same time that that side of the bladder in which it is situated is found to be of less capacity than the other. In using a silver cathe- ter in this manner, small portions of the substance of the tumor are sometimes found sticking in the eyes, or lateral openings, of the ca- theter, after it has been withdrawn. Fungus hmmatodes is not more under our control where it affects the bladder than where it occurs in other organs; and no method which art has hitherto devised affords us the means of even checking the progress of this horrible malady. Rest in the horizontal posture, and opium administered, according to circumstances, either by the mouth or in the form of enema, will do as much as can be done to- wards mitigating the patient's sufferings. If there be considerable haemorrhage, and the pulse be full and strong, blood may be taken from the arm, or from the loins by cupping. Otherwise the mineral acids, the acetate of lead, or other styptics, may be given internally. On the whole, it has appeared to me that the mineral acids have done more than any other medicine towards stopping the haemorrhage. Other morbid growths occasionally take place in the bladder. I have seen a case in which a fungus grew from a portion of the mu- cous membrane, having somewhat of a fibrous structure, and a good deal resembling in appearance the vessels of the placenta when un- ravelled. In Dr. William Hunter's Museum there is a preparation of a bladder, the inner membrane of which is, in several parts, elon- gated into laminae or processes, each about a quarter of an inch in length. I cannot undertake to point out to you in what manner such excrescences are to be distinguished from each other in the living body; and as all such cases are equally beyond the reach of remedies, such distinction, even if it could be made, would be of little practical importance. 76 SYMPTOMS AFFECTING Symptoms affecting the Bladder in consequence of Disease in the Kidney. Calculi of the kidney occasionally produce symptoms, which are referred to the bladder rather than to the kidney. I shall have occa- sion, in a future Lecture, to notice a well-marked example of this fact, which occurred in my own practice; and you will find others re- ferred to by Morgagni. " A patient," says this eminent pathologist, "complained of very little pain in the region of the kidney; while he was tormented with pain in the bladder so excruciating, that five or six physicians who attended him entertained no doubt that the seat of the disease was in that organ. On dissection, however, no morbid appearance whatever wTas discovered in the bladder, but there were large and ramifying calculi of the kidney." If calculi of the kidney produce symptoms which ma\r easily be mistaken for those of disease in the bladder, it may reasonably be ex- pected that some other diseases of the kidney should affect the^blad- der in the same manner. Several years have elapsed since I was first led to suspect this to be the case, and the result of all the expe- rience, which I have since had, has been to remove whatever doubts I might formerly have entertained on the subject. WThoever is much engaged in this branch of surgical practice will meet with a number of facts which cannot so well be explained on any other hypothesis, and which collectively form such a mass of circumstantial evidence, as is almost irresistible, in favor of the opinion " that the worst symp- toms of irritable bladder may occur as a consequence of disease of the kidney, the bladder itself, and the organs in immediate connection with it, having been free from disease in the first instance." The opportunities of obtaining direct or positive evidence, (that is, by means of post-mortem examination,) on a point like this, are of comparatively rare occurrence; for so intimate is the union of the different organs which constitute the urinary system with each other, that disease can scarcely exist for a great length of time in one of them, without extending in a greater or less degree to the rest. Such opportunities are, however, occasionally met with where the patient has died before the disease has reached its most advanced stage; and I am able to adduce the following histories in illustration of the fore- going observations. A gentleman consulted me in November, 1833, laboring under the following symptoms:—He voided his urine frequently, and in quan- tities varying from an ounce to an ounce and a half' Always after making water he had a severe pain lasting a few minutes, and extending along the course of the urethra. The urine was pale, semi-opaque, of an acid quality, and, when tested with heat and nitric acid, it was THE BLADDER, ETC. found to be highly albuminous. Occasionally, small masses of a sub- stance resembling coagulated albumen were seen floating in it. He made no complaint of pain in the loins; he was able to empty his bladder by his own efforts, and the urethra was free from stricture. There was no calculus in the bladder, nor had sand or gravel ever been observed in the urine. These symptoms had begun to exist in the preceding February, since which time they had gradually increas- ed. For a short time during the month of March, the urine had been tinged with blood. Ln addition to these local ailments, the general health was much impaired: the patient had lost flesh, was languid, dejected, and of a pallid countenance. Soon after 1 was consulted the urine became again tinged with blood. The bodily powers continued to fail, and the local symptoms became more urgent. There was a total loss of inclination for food, the extremities became cold, the pulse feeble, and he died at the end of February, 1834. On examining the body after death, the kidneys were found to be of a dark color from excessive vascularity, and of a soft and somewhat brittle consistence; the distinction between the cortical and tubular posi- tions being less marked than under ordinary circumstances. The in- vesting membrane of the kidney had a very slight adhesion to the kidney itself, but it adhered very closely to the adipose substance of the loins. On the surface of each kidney, and partly imbedded on its substance, were four or five membranous cysts, each of the size of a large pea; and in one of them there was a similar cyst, but as large as a nutmeg, completely imbedded in the cortical substance. The pelvis infundi- bula and ureters were not more capacious than under ordinary cir- cumstances; but, on their being slit open, their internal membranous surface presented the appearances of considerable inflammation. It could not be said that the bladder was found altogether free from disease, but the morbid appearances were so slight, compared with those observed in the kidney, that it seemed impossible to doubt that the last-mentioned organ had been the seat of the primary disease, and that the latter was affected only in a secondary manner. It was con- tracted, and the muscular tunic was somewhat thickened; but not more so than must have been the case in a person who from any cause had been teased for a considerable time by an incessant inclination to void his urine. The vessels of the mucous membrane were turgid with blood; but not in the same degree as those of the membranous struc- tures of the kidneys. A gentleman, fifty-five years of age, consulted me, with Mr. Bag- ster of Compton Street, Brunswick Square, in December, 1834, under the following circumstances:—He complained of an almost in- cessant inclination to void his urine; of an excruciating pain, referred to the region of the pubes and neck of the bladder, which occurred 78 SYMPTOMS AFFECTING as soon as the urine was expelled, and then subsided; and also of a most severe pain extending along the whole canal of the urethra. This last symptom was not especially connected with the expulsion of the urine. It was nearly constant, but not quite so, as it occasionally intermitted for twelve hours, or even for a longer period. The urine was acid, and when voided was slightly turbid, and of an opal color. When allowed to stand, it deposited some loose flakes, which bore a more near resemblance to coagulated lymph than to mucus. The clear urine, after this deposit had taken place, was tested by heat, and afterwards by the addition of nitric acid, and proved to be highly albuminous. There was no pain in the loins. On inquiring into the patient's history, I was informed that in child- hood he had voided a small calculus; that he had generally enjoyed good health until the year 1824, when he was affected by a succes- sion of slight febrile attacks, attended with sickness and vomiting, from which, however, he recovered, so as to be apparently quite well afterwards. In the year 1827 or 1828, and again in the year 1834, he had a similar attack. The last of these continued, with occasional remis- sions, from September to the beginning of November; and imme- diately after it had subsided the symptoms of irritation in the bladder and urethra first showed themselves, continuing unabated from this period up to that of my being consulted. After a careful investigation of the case, I gave it as my opinion, that the real seat of the disease was in the kidneys, and that the blad- der and urethra were only secondarily affected; and I proposed a plan of treatment accordingly. This was continued without any manifest improvement until the 5th of January, 1835, when the patient was suddenly seized with a pain in the neighborhood of the epigastrium, followed by urgent symptoms of peritoneal inflammation. In this illness he was attended by Dr. James Johnson and Mr. Bagster, but their efforts for his relief were unavailing; and he died in about four days after its commencement. On examining the body, the abdomen was found to contain a yellow fluid resembling a mixture of bile and serum. Coagulated lymph had been effused on different parts of the surface of the peritonaeum, but chiefly in the neighborhood of the duodenum and jejunum, and had produced adhesions, which, however, being recent, were easily sep- arated. The gall-bladder was attached in this manner to a fold of the jejunum; and on these adhesions being torn through, the bile was observed to escape from it in a small stream. On laying open the gall-bladder five or six biliary calculi, from the size of a pea to that of a horse-bean, were found in its cavity; and in one spot there was a distinct ulceration of the membrane lining it. This ulceration had extended completely through the peritonaeum, covering the gall-blad- der, so that it was evident that there must have been a communication THE BLADDER, ETC. 79 between the cavity of that viscus and the general cavity of the abdo- men, previous to the formation of the adhesions with the small intes- tine. The urethra and the urinary bladder presented no appearance of disease; but the tunics of the bladder were thinner than might have been expected, considering that the patient had for some time suffer- ed from a frequent inclination to make water. The mucous mem- brane was not more vascular than under ordinary circumstances. The prostate gland was not enlarged; but it might be supposed that its texture was a little firmer than usual. The right kidney was vascular, and of a somewhat soft and spongy texture; and its investing membrane adhered more closely to the fat of the loins than to the kidney itself. The ureter on this side was unusually small and attenuated. The left kidney was half as large again as usual. The fat of the loins, the investing membrane of the kidney, and the kidney itself, adhered so closely to each other, and were so consolidated that they could scarcely be separated from each other. In the upper part of this kidney there was a membranous cyst, containing about an ounce of a turbid fluid. This cyst appear- ed at first to have been formed by a dilated infundibulum; but on an accurate examination it was found to have no communication with the pelvis of the kidney. A good deal of earthy matter had been deposited in the membrane forming it, so that in one part it appeared like a shell of bone. In the lower part of the same kidney were two calculi (composed of the oxalate of lime), one as large as a horse-bean, the other smaller, but of a jagged and irregular figure. They lay in wo separate infundibula, projecting into the pelvis. This kidney, like the other, was soft and vascular. The ureter was in a natural state. What has been now stated seems to afford sufficient evidence as to the existence of symptoms referred to the bladder and urethra in some cases of disease in the kidney. But, with my present experience, I am led to this further conclusion, that a very large proportion of the cases, which have usually been confounded together, under the general appellation of irritable bladder, are really of this description; and that in many cases, in which the bladder is actually diseased, it was not so in the first instance, the disease in the bladder being altogether a secondary affection, which would never have existed if there had not been a previous disease in the kidneys. But nothing is more common than to meet with disease in the kid- ney in the examination of the body after death, where there had been no complaints as to the bladder and urethra during life; and in many living persons there are indubitable signs of the kidneys being diseas- ed, while the functions of the bladder and urethra are not in the slight- est degree disturbed. It cannot be supposed that it is merely from a caprice of nature that one organ should sometimes- sympathise, and 80 SYMPTOMS AFFECTING sometimes not, with the diseases of another; and the question there- fore arises, in what particular cases of renal disease is it that the sec- ondary affections of the bladder are liable to occur? I have already explained, that where the urine is overloaded with acid, showing itself in the form of lithate of ammonia, or brown or red sand, or where being alkaline it deposits crystals of the triple phosphate of ammonia and magnesia, it acts as a stimulus to the parts with which it comes in contact, and that an irritable state of the blad- der is the consequence. But there is no reason to doubt that other unhealthy secretions of urine may produce the same result; and 1 am much inclined to believe that such is the real explanation of the affection of the bladder in the cases which are now under our consid- eration. In such of them as have fallen under my observation the urine has been always altered from its healthy condition, and its sen- sible qualities may be described as follows:—There is usually a co- pious secretion, the specific gravity being below the ordinary standard. But there is some variety in this respect; and I have known the spe- cific gravity to be as high as 1.030. When tested with litmus paper it is generally found to be slightly acid; but occasionally it is alkaline; or it is sometimes alkaline, and sometimes acid; and, as I shall explain hereafter, the disposition in it to become alkaline increases as the dis- ease advances. When first voided the secretion is of a pale yellow color, opaque and turbid; sometimes having minute flakes of lymph floating in it. On the addition of nitric acid, or an exposure to heat, there is an abundant coagulation of albumen. When allowed to re- main at rest there is a deposit of opaque matter, and not unfrequently of pus. The urine is always albuminous, but quite different in appear- ance from that which is secreted in the cases which were first describ- ed by Dr. Bright, and to which the attention of physicians has been of late years so much directed. The albuminous matter seems to be me- chanically suspended, and not intimately blended and assimilated with it; as if the kidney were in a state of chronic inflammation, secreting urine from one set of vessels, and serum, or even pus, from others. Such, probably, is (he real nature of the disease when once establish- ed, whatever it may have been in its origin; and you will find this view of the case to be confirmed by some facts to which I shall draw your attention presently. The great majority of the patients who are thus affected are the male sex. Many of them seem to have been originally of a feeble, and what is commonly called a scrofulous, constitution. The disease, however, is by no means confined to persons of this description. It may be the result of a calculus long impacted in the kidney. Not un- frequently it follows an attack of gonorrhoea, though I suspect that it may, for the most part, be traced to the treatment employed, rather than to the gonorrhoea itself. I allude to the injudicious exhibition of large doses of copaivi and cubebs, especially of the latter. THE BLADDER, ETC. 81 The patient complains of a too frequent inclination to void his urine; the period during which he can retain it varying from a quarter of an hour to an hour. There is a cutting pain referred to the neck of the bladder and urethra as the urine flows, and remaining for some time af- terwards: there is a constant sense of uneasiness above the pubes. Sometimes there is a dull, but rarely a severe, pain in one or both loins; at other times there is no pain in the loins whatever, or so lit- tle, that the patient scarcely thinks of mentioning it until he is ques- tioned on the subject. In a few instances, masses of lymph, of the consistence and appearance of jelly, are found in the urine, which have evidently descended from the "kidney. In one case the patient, who for two or three years had had no other symptoms than a tco frequent desire to make water, and a deposit of pus in the urine, was suddenly seized with a most severe pain in the groin and testicle, so that I concluded that a renal calculus was making its way down the ureter. Instead of this, however, soon after the pain had suddenly terminated, there was found in the urine a mass of solid sub- stance, resembling fibrine, of a pale-brown color, of a conical- shape, smooth every where, except at the larger extremity, where it had an irregular and fringed appearance, as if it had been broken off from a larger mass. From this time he continued to suffer in the same manner, voiding similar masses of solid substance at various in- tervals, and in one of these attacks he died. His death took place in the country; and I believe that no examination of the body was made afterwards. From the account which I received, however, I was led to conclude that the immediate cause of death had been the retention of one of these masses of fibrine in the ureter. As the disease advances the patient becomes feeble and emaciat- ed; his complexion is sallow, and he is liable to attacks of nau- sea and even of vomiting, with a constant sense of languor and listlessness, and indisposition to both mental and bodily exertion. The desire to void the urine is incessant, and the sufferings caused by the accumulation of it in (he bladder are more severe. As the bodily health becomes impaired, the disposition to secrete alkaline urine is increased; and this change is the usual precursor of the more urgent svmptonis of affection of the bladder which mark the advanced stage of the disease. The urine deposits a large quantity of adhesive alkaline mucus: it is of an offensive ammoniacal odor, scalding the urethra as it flows, and producing a severe and constant pain in the hypogastnum. Even in the origin of the disease blood is sometimes disthargedwith the urine; but at this later period the disposition to haemorrhage is in- creased. In some cases the urine generally is tinged with blood, and at other times there is an evacuation of pure blood, adding greatly to the patient's misery, not only in consequence of the clots becoming lodged in the urethra, and obstructing the passage of the urine, but by increas- ing the debility of an already weakened frame. The pulse become! 11 82 SYMPTOMS AFFECTING small and frequent, the tongue is dry and brown, or red and glossy, with a disposition to aphthae; there is coldness of the extremities; and these symptoms usually precede the patient's dissolution. But it is other- wise in some instances", the patient dying almost suddenly even in a less advanced stage of his complaint. It would appear that not only in these, but in many other cases of disease of the kidney, the powers of the con- stitution become so impaired, that an accidental circumstance, which, if the patient were in health, would be productive of no more than a tem- porary derangement of his system, may he sufficient to extinguish life. 1 have even known a case in which the introduction of a bougie hav- ing been followed by a severe rigor, the usual re-action never took place, and the patient died in consequence. I have had several opportunities of examining the morbid appear- ances after death, where the patient had died in this last stage of the disease, and where the history of the case seemed clearly to prove that the kidney had been the only part affected in the first instance. One or both kidneys are found enlarged in size; unusually vascular; of a dark red color: soft and readily lorn; the disiinction between the cortical and tubular portions being less distinct than under ordinary circumstances. Interspersed throughout ibis diseased mass there are sometimes small deposits of a yellow substance, apparently unorganiz- ed lymph. The membranous capsule adheres more close y to the surrounding parts than to the kidney itself. Sometimes the kidney and ureter are imbedded in a mass of firm organized lymph, which in- volves all the neighboring structures. Frequently there are thin membranous bags of various sizes in the cortical substance containing, not urine, but a serous fluid. Abscesses are found in the kidney of various sizes, some of which may have made their way into the pelvis and infundibula. In one case one kidney was of double its natural size, and full of deposits of cheesy matter, resembling that which is found in scrofulous lymphatic glands, varying in quanliiy from the bulk of a pea to that of a horse-bean. The other was diseased in the same manner, but to a less extent. Sometimes an offensive mixture of pus and urine is found in the pelvis and ureter. Occasionally, but rarely, there are deposits of phosphate of lime adhering to the ma- millary processes; more frequently there are similar deposits on the inner surface of the membranous cysts and abscesses. The mucous membrane of the bladder and ureters, in most instances, is every where of a dark-red color, from excessive vascularity, and exh.bits the other appearances which have been already described in the his- tory of inflammation of the mucous membrane. In a few cases, how- ever, the appearance of inflammation is only in patches, and where it exists the mucous membrane is ulcerated. These ulcers occur more especially about the orifice of the ureter, the outer extremity of which is seen making a small nipple-like projection in the centre. If the pa- tient survives this stage of the disease, the ulceration of the mucous THE BLADDER, ETC 83 membrane extends until it occupies a large portion of the internal sur- face of the bladder. Nor are these secondary diseases confined to the bladder. 1 have seen cases in which abscesses and ulcers of the prostate gland were apparently to be referred to the same source. I shall call your attention to this last-mentioned subject again in the next Lecture. Treatment of these Cases. You will easily believe that, in the advanced stage of the compli- cated disease which 1 have just described, little is to be done byr art for the patient's relief. The exhibition of the decoction of the root of the pareira brava, with mineral or vegetable acids, may render the urine less alkaline, and somewhat restrain the secretion of the adhe- sive mucus from the inflamed mucous membrane. Large doses of opium may, in some degree, mitigate the patient's sufferings, and the prudent exhibition of wine may for a lime uphold his failing powers. But this is all; and the disease will pursue its course to a fatal termi- nation in defiance of all your efforts to arrest its progress. Even when you are consulted at an earlier period, you will find, in many cases, that the best exertions of your skill end in disappointment. It seems as if when ihe kidney has been for a considerable time the seat of disease, even though no actual organic change of structure has taken place in it, it were almost incapable of recovery, and, at all events, if one drop of matter be deposited in its substance, this must be re- garded as the rudiment of a large abscess, and as leading, almost in- evitably, to the worst ultimate result. There are, however, cases in which much may be accomplished under a judicious treatment; and I have notes of several in which pa- tients who had been great sufferers for one or two, or even a greater number of years, were apparently restored to health. The remedies which I have found useful have been few in number, and the history of them may be comprised in a few words. If the urine be more than usually loaded with lithic acid, some ad- vantage may be derived from the exhibition of moderate doses of the liquor potassoz, or the bicarbonate of potass. But this is seldom ne- cessary, and alkalies ought to be administered with great caution where there is danger of the urine becoming alkaline, and where this change in the quality of the secretion is likely to be followed by such serious consequences as those which I have described. Whenever the urine is already alkaline, or has a tendency to be alkaline, of course the opposite treatment is indicated, and the mineral acids should be given in larger or smaller doses according to circumstances. In robust persons, where the disease is but 1'ntle advanced, and there is much pain in the loins, a moderate quantity of blood may be 84 BYMPTOMS AFFECTING taken from the loins by cupping. But there can be no greater prac- tical error than to suppose that because a disease partakes of th? in- flammatory character, it is therefore to be relieved by blood-letting. Many f,uch diseases are liable to occur in persons of debilitated con- stitution, and huve a tendency to increase the debility in which they have originated, being at the same time aggravated instead of being relieved, not only by the loss of blood, but by active depletion in othor ways. In some instances I have known much good to arise, apparently, from blisters applied near the affected loin, or from issues made with caustic, or setons in the same situation. Uut even these should not be had recourse to without due consideration; and in per- sons of a delicate habit lam inclined to restrict their use to those cases in which the pain in the loins is considerable, or in which there is a discharge of pus, or of masses of unorganized lymph from the kidney. For the same reason that depleting remedies are to be used with caution, it is never desirable that the patient should be placed on a very low or abstemious system of diet. He should have animal food daily, with the addition of a moderate quantity of ale or wine. He should, if possible, reside on a dry gravelly soil rather than in a low and damp situation; or he may derive benefit from a residence at the sea-side. The uvaursi has a doubtful reputation as a remedy in cases of dis- ease of the bladder, some believing it to be of great efficacy, and oth- ers attributing to it no efficacy whatever. My own experience would lead me to suspect that its influence is confined to the cases of which I am now treating, but that in these it may in some inslances be em- ployed with much advantage. It must be administered, however, in larger doses than those which I find to be in common use. Thus from 5j. to 5ij. of the extract may be given in pills daily, or from Sviii. to §xvi. of the following infusion, which has appeared tome to be more efficient than the extract. 1^; Folio) urn uva ursi § j Jlquce. distillate ferveutis §xviij. Macera per horas ij, dein decoque ad § xvj et cola. But neither the exstract nor the infusion produce an immediate im- provement; and if the experiment of taking this medicine be begun the patient must make up his mind to persevere in it for a very con- siderable time, before he can form an opinion as to the result. There is, however, another remedy, which, if my observation? be cor- rect, is much more to be relied on than the uva ursi, namely, the diosma crenala, or buchu. Of this, also, I am led to believe that its efficacy as a medicine is limited to this particular class of cases, and in these I cannot doubt that I have seen it productive of the most beneficial effects. From giss. to gij. of the infusion of the diosma THE BLADDER, ETC. S5 (of the Pharmacopoeia) may be given twice or three times daily. The operation of it is slow, like that of the uva ursi. Many weeks must elapse before there is any sensible amendment, so that it is needless for the patient to take it unless he fully intends to continue to do so for a very long period. I have known persons who, with some brief occasional intermissions, have persevered in its use, slowly but uni- formly mending, even for two or three years. Where there is a su- perabundance of lithic acid in the urine, small doses of the bicarbon- ate of potass, or liquor potassce, may be added to the infusion; and where the urine is alkaline, or has a tendency to be so, it may be given in combination wiih the mineral acids. Another remedy, which 1 have administered with great apparent advantage in these cases, is the linclura ferri murialis. It may be given in doses of q viij. to \\\ xv. tw ice daily, either in any simple vehicle, or in combination with the infusion of the diosma. In the latter case, the tincture may be given for a month or six weeks at a time; and this course may be repeated occasienally, the infusion be- ing still administered in the intervals. Before I conclude the present Lecture, I feel it to be my duty to caution you against the unnecessary introduction of instruments into the bladder in these cases. It may be right, probably it is so in most cases, in the first instance, to introduce a sound or catheter, so as to ascertain whether there be an obstruction in the urethra, or a calculus in the bladder, or whether the patient retains the power of emptying I he bladder by his own efforts. But if these questions be determined in the negative, it is better that you should abstain from the further use of instruments. Every examination gives the patient a good deal of pain at the time, and it often happens that much dis- tress, boih local and constitutional, follows, which may not subside for two or three days. Rigors also are more likely to occur after such examinations, than in ordinary cases of urinary disease; and I have already observed, that these are attended with actual danger in all cases in which the powers of the system are exhausted by long continued disease of the kidney. Where it is thought advisable to examine the urethra and bladder by the introduction of instruments, twenty or thirty minims of tincture of opium may be administered im- mediately afterwards. This will rarely fail to prevent the occurrence of a rigor, and no inconvenience, which the laudanum may occasion, can be put in competition with the great advantage arising from its use. 66 INFLAMMATION OF LECTURE VII. Inflammation of the Prostate Gland. Affections of the prostate gland are met with chiefly in those who are advanced in years. This organ, however, is not altogether exempt from disease in earlier life. In cases of gonorrhoea it not un- frequently happens that the discharge from the urethra suddenly ceases, and that the inflammation, leaving the part originally affected, attacks the prostate. The peculiar symptoms which occur in the cases to which I allude cannot be well explained in any other way, and it may be observed that ihey never occur except in the male sex. The patient observes that the gonorrhoeal discharge stains his linen much less than it did before, or that it ceases altogether; and he ex- periences at the same time a frequent inclination to void his urine, and a difficulty in voiding it. Pie complains of uneasiness and pain, re- ferred to the neck of the bladder, and extending forward in the course of the perineum and urethra, and aggravated on each attempt to make water. In some cases there is a complete retention of urine. The impulse to make water is then violent and irresistible; and it is attend- ed with more suffering than in ordinary cases of retention, on account of the contents of the bladder being pressed with force against the inflamed and tender prostate. There is a sense of fulness in the pe- rineum and rectum; and the prostate is manifestly tender when exam- ined from the rectum with the finger. Not uncommonly suppuration takes place, and an abscess forms, of which the symptoms, in the first instance, are generally obscure. As the abscess advances, the perineum becomes tender, and there is a perceptible though slight tumefaction and hardness in some one part of it. The abscess, if left to take its own course, sometimes bursts internally—that is, into the urethra; more frequenily it makes its way through the fascia, cellular membrane, and muscles of the perineum, and bursts through the external skin. These local changes are attended with no small degree of disturb- ance of the general system. The pulse is frequent, the skin hot, the tongue furred, and the formation of matter is often indicated by rigors. The first objcet of the surgeon should be to prevent suppuration. THE PROSTATE. 87 The patient should remain in bed, in the horizontal posture. Blood is to be taken from the loins, or perineum, by cupping; and the cupping should be repeated, or not, according to circumstan- ces. Cupping on the perineum, however, can be performed only by a dexterous cupper; and where such an one cannot be pro- cured, leeches must be applied instead. An active aperient should bo exhibited, followed by an opiate in the form of an enema or suppository; and the patient will often derive the greatest benefit from ihe use of calomel taken in pills in sufficient quantity to subject him to the mercurial influence. If there be a retention of urine, the gum catheter, without a wire or stilet, may, in almost eve- ry case, be readily passed into the bladder. It is better to use a ve- ry small catheter, and to introduce it again, whenever it is necessary to do so, than to leave it constantly in the urethra and bladder. If there be reason to believe that abscess is formed, you should endeavor to procure an external discharge for the matter, in order to prevent it bursting into the urethra. If such symptoms as I have described exist, and go on for some time increasing, and you discover a fulness and tenderness of the perineum, do not wait for any more certain in- dication of the abscess; but introduce a lancet, in the direction indi- cated by the tenderness and swelling. It will often be necessary to pass it quite up to the shoulders, or even to the handle, before you reach the abscess. But you may do this fearlessly. There is no dan- ger of any ill consequences from such a puncture. If there be abscess, you will by this proceeding immediately relieve the distress which the patient suffers, at the same time that you prevent further mischief. If, on the oilier hand, there be no abscess, the puncture does not make the condition of the patient worse than it was before. Indeed, partly from the loss of blood, partly by removing the tension of the soft parts of the perineum, it is generally useful to the patient, even when it does not answer the purpose of allowing the escape of matter. But abscess of the prostate gland may take place in young men un- der other circumstances, besides those which I have just mentioned. A man about thirty years of age was received into the hospital, voiding his urine every twenty or thirty minutes, and complaining of an aching pain in the loins; but of no pain any where else. The urine deposited a small quantity of yellow puriform sediment. He said that the symptoms had begun two years ago, and thai in the commencement of ihe disease the urine had been tinged with blood. 1 prescribed the use of an opiate clyster every tii_:bt; and under this treatment the in- clination to make water became less frequent. About a month after his admission into the hospital, the patient was suddenly seized with symptoms of apoplexy, and he died in the course of a few hours. In the examination of the body, we discovered an abscess of the size of a large walnut, occupying the posterior part of the prostate gland, and extending into the space between the bladder 68 INFLAMMATION op and vasa deferentia behind the neck of the bladder. On slitting open that portion of the urethra which passes through the prostate, a large irregular ulcerated orifice was discovered behind the verumontanum, through which the probe passed at once into the cavity of ihe ab- scess. 1 had the opportunity of observing the same morbid appearances in the pcst-morlem examination of a patient who died under ihe caie of Dr. Prout and myself, and who had long labored under symptoms of disease at the neck of ihe bladder. 1 conclude that in ihe following case, also, the seat of the abscels was in the prostate gland. A gentleman, about thirty years of age, consulted me, complaining that the urine flowed slowly, and with difficulty. I introduced a gum catheter, and found a considerable quantity of urine left in the blad- der, after he had voided what he could by his own efforts. There was no stricture of the urethra, and the use of the instrument did not relieve the difficulty of making water, so that it was necessary to in- troduce it two or three limes daily. When this plan had been per- severed in for three or four days, there took place one evening a se- vere attack of shivering. The next day it was discovered that ihe urine deposited a considerable quantity of pus. The patient could now make water and empty his bladder without the assistance of the catheter: however, he was directed not to do so, but to use the ca- theter for himself every six or eight hours. The urine continued to deposit the same purulent sediment, but the quantity of it gradually diminished, and in the course of two or three we.ics it disappeared entirely; and no symptoms being left, the further use of the catheter was not considered necessary. I have seen this gentleman several times since, on other occasions, and, as far as I know, he has never had any return of ihe complaint. In the case which 1 have mentioned as having been attended by Dr. Prout and myself, in addition to the abscess at the neck of the bladder, there were abscesses and extensive disorganization of the kidneys. I may here refer you to what 1 observed as to the co-ex- istence of disease in the kidney and bladder in the last Lecture. We cannot well doubt ihe existence of this combination in the following case, although the fact was not absolutely proved by dissection. A young man had symptoms which led me to suspect the existence of abscess of the profile. Under these circumstances, he was spized with a rigor, with pain in the loins, extending downwards in the course of the ureter; in short, with symptoms like those produced by the passage of a caculus from ihe kidney into the bladder. These symptoms suddenly ceased, and he voided not a calculus, but a mass ol lymph and pus, and some blood, which came away with the urine. I now was led to believe that I had been mistaken in my notion as to the original seat of the disease, and to suspect that the neck of the bladder bad been affected only from sympathy with the kidney; but OF THE PROSTATE. 89 soon afterwards another abscess presented itself in the perineum, which I opened with a lancet, proving that my original opinion had not been incorrect. This gentleman went into the country, and soon af- terwards died laboring under a severe diarrhoea. Unfortunately, the body was not examined after death. When a patient labors under such symptoms as would lead you to believe that an abscess has formed in the prostate, communicating with the neck of the bladder, you should direct him not only to be as quiet as possible, but to remain altogether in the horizontal posture. You should instruct him in the use of the gum catheter; and he should in- troduce it for himself whenever he has the desire to void his urine, so that he may always make water by means of the catheter, and not by his own efforts. In some instances I have caused the gum cathe- ter to be constantly retained in the urethra and bladder, until the ab- scess has healed: but this plan not unfrequently irritates the neck of the bladder; and the occasional introduction of the catheter is, for the most part, to be preferred. In some instances, even this excites ir- ritation, and the catheter must be omitted altogether. Besides this, you must attend to the state of the patient's general health. There is usually in these cases a weak state of the constitu- tion; the patient is probably of a scrofulous habit; and the healing of the abscess may be promoted by the exhibition of the sulphate of quinine, or steel, or other tonics. I have been led to believe, in some cases, that good has been derived from the internal use of the cubebs pepper, twenty grains of which may be administered three times daily. It seems to act as a gentle stimulus to these parts, pro- bably operating on the disease much in the same way as Ward's paste operates on abscesses, and fistulae, and ulcers of the rectum. I have mentioned formerly that an enlargement of the prostate gland sometimes occurs as a consequence of stricture of the urethra, subsiding spontaneously after the stricture is cured. The same thing may happen after gonorrhoea, especially where the patient^ has neg- lected his complaint; hunting and using other violent exercise before the discharge has ceased. In one case of this kind the prostate was enlarged (apparently) to four or five times its natural size, producing much uneasiness from pressure on the rectum, but not in any de- gree interfering with the functions ofthe bladder. The disease sub- side d; but very gradually; and in the course of three or four years no perceptible enlargement remained. I shall mention the particulars of another case, in which the patient attributed the disease to an attack of gonorrhoea at a former period, 12 90 CHRONIC ENLARGEMENT and which is also of some interest on account of its having immediate- ly yielded to the treatment employed. A gentleman, thirty-one years of age, consulted me, with Mr. Turner, of King Street, Holborn, under the following circumstances. He complained of pain, referred to the perineum hypogastrium and back part of the pelvis, extending down the thighs. The pains, how- ever, were not very severe. He had a sense of obstruction in the rectum on the passage of the faeces. He was tormented by the de- sire to void his urine more frequently than is usual; but he had no difficulty in voiding it: he could empty his bladder by his own efforts, and the urine was transparent and healthy. The urethra was free from disease; but the prostate gland, when examined from the rectum, was found to be enlarged to two or three times its ordinary size. The patient said the disease had existed in its present form for three or four years; but that he could nevertheless trace its origin to a severe gonorrhoea under which he had labored ten years ago. He had no other complaints. We prescribed for him two grains of the iodide of potassium to be taken three times daily. This plan was pursued under Mr. Turner's direction for about seven weeks, when I was again consulted. He was now nearly free from pain; voided his urine not more frequently than other persons, and as much as S x. at once. The prostate gland was reduced to its natural size. As a matter of precaution l advised that the iodide of potassium should be taken for another fortnight. Chronic Enlargement of the Prostate Gland. I have said that the prostate gland is more frequently the seat of disease in old age than it is in youth. At different periods of human life different changes take place in the condition of the organs of which the system is composed; and none of these are more remarkable than those which show that the individual has entered on that downward course, which is to end in his dissolution. When the hair becomes grey and scanty, when specks of earthy matter begin to be deposited in the tunics of the arteries, and when a white zone is formed at the margin of the cornea, at this same period the prostate gland usually, I might perhaps say invariably, becomes increased in size. This change in the condition of the prostate lakes place slowly, and at first imperceptibly, and the term chronic en- largement is not improperly employed to distinguish it from the in- flammatory attacks to which the prostate is liable in earlier life. In the post-mortem examination of persons, who die laboring under this disease, we find the prostate sometimes enlarged only in a slight degree; but frequently it is two or three times, and occasionally even OF THE PROSTATE. 91 ten or fifteen times, its natural size. We also find more or less alte- ration in its texture. For the most part it is harder than natural; but, in a few instances, it is the reverse. In some instances, the enlarged prostate retains nearly its natural form; and, under these circumstan- ces, if you lay open the cavity of the bladder, you find the existence of the disease marked only by the appearance of an uniform circular projection surrounding the internal orifice of the urethra. More fre- quently, however, the form of the prostate is altered, and it no lon- ger presents the appearance of a chestnut placed at the neck of the bladder, and perforated by the urethra. Posteriorly the lateral por- tions of the prostate are found extending on the outside of the vesi- cular seminales, between the bladder and the rectum. That part of the prostate, also, which is situated between the vasa deferentia and the neck of the bladder, and to which Sir Everard Home has given the name of the third lobe, becomes enlarged also, forming a tumor projecting forward into the cavity of the bladder, behind the inner orifice of the urethra. This tumor varies in size from that of a horse- bean to that of an orange. When small, it is of a conical form, with the apex of the cone projecting into the bladder, and the basis being continued into the rest of the prostate. When large, the basis is often the narrowest part, and it swells out so as to have a pyriform figure towards the bladder. In some instances, by the side of that wliich I have just mentioned, there is another tumor, formed by one of the lateral portions, also projecting into the bladder. The canal of the urethra, where it passes through the enlarged prostate, is generally flattened; and when the latter is divided trans- versely, the urethra appears like a slit, rather than like a cylindrical canal. Not unfrequently the enlargement of the prostate so alters the form of the urethra, that instead of pursuing a straight course through the gland, it is inclined first to one side and then to the other. You would expect the urethra to be rendered narrow in consequence of the increased bulk of the parts by which it is surrounded; and so it is in many instances: in others, however, it is actually wider, being di- lated into a kind of sinus, where it lies in the centre of the prostate. 1 have known such a sinus to exist, of a sufficient size to contain two or three ounces of fluid. In addition to these changes, the natural curve of the urethra, as it approaches the bladder, is increased. It forms a portion of a smaller circle. It also becomes elongated, so tint the distance between the orifice on the glans penis and the cavity of the bladder is greater than natural. This is the necessary conse- quence of the increased size of the prostate; and in this manner as much as an inch or an inch and a half is sometimes added to the length of the urethra. Malignant diseases of the prostate are of very rare occurrence, and it is certainly a great mistake to apply the term scirrhus to the cases which are now under our consideration. The chronic enlargement 92 CHRONIC ENLARGEMENT of the prostate may be said to be a disease of a peculiar kind, having no exact resemblance to what we meet with in any other organ. It may, however, in some respects, be compared to the chronic en- largement of the thyroid gland, known by the name of bronchocele. Like the latter, it is generally slow in its progress; and frequently, after having reached a certain point, if proper treatment be employ- ed, it remains almost stationary for many years. It is on the whole a rare occurrence for it to terminate in ulceration or abscess; and the symptoms, to which it gives rise, are, with a fewT exceptions, to be referred to the influence which the disease exercises over the func- tions of the parts in the neighborhood. Symptoms of the Chronic Enlargement of the Prostate Gland. There are but few individuals who, in the latter period of life, do not suffer some degree of inconvenience in consequence of the en- larged state of the prostate. The bladder becomes irritable, and there is a more frequent inclination to void the urine than under or- dinary circumstances: at the same time the urine is ejected in a slow- er stream. These symptoms come on very gradually, and for a con- siderable lime attract but little of the patient's attention. A sudden and violent aggravation of them may, however, take place at any period. In consequence of exposure to damp and cold, or some ir- regularity as to diet, and, very frequently, as a result of venereal ex- citement at a time when the sexual powers are beginning to decline, there is an increased determination of blood to the prostate, which was before enlarged, causing it to become still further increased in size. The expulsion of the urine then becomes more difficult than it was before, and soon is prevented altogether. There is, in short, a complete retention of urine. The symptoms of retention of urine, from enlargement of the pros- tate, are not very different from those which occur where the reten- tion is the consequence of stricture, but the termination is different. I never saw a case in which, under these circumstances, the bladder had given way, as sometimes happens where there is a retention from stricture; but I am informed that such a case has occurred, and that the bladder, ruptured at its fundus, is preserved in the Museum of St. Bartholomew's Hospital. It is evident that the urethra itself can- not be ruptured, as the urine does not even enter it, the obstruction being altogether posterior to it. But the patient cannot survive a re- tention of urine from this cause, any more than he can survive a re- tention of urine from other causes, beyond a certain period of time. The powers of his nervous system become exhausted: there is a cessation of local suffering; the tongue becomes dry and black, coma supervenes, and the symptoms terminate in death. Mr. Travers has OF THE PROSTATE. 93 informed me of two cases of long-continued retention in consequence of enlargement of the prostate, which fell under his observation, in each of which the mucous membrane was converted into a slough, and was found, after death, lying loose in the cavity of the bladder. The prostate being once enlarged, it is evident that a very small addition to its bulk may be sufficient, under certain circumstances, to prevent the expulsion of urine bom the bladder. Hence it is, that no individual who labors under this disease can be regarded as being at any time free from the danger of a complete retention of urine. This, however, where surgical assistance can be procured, and proper treatment is employed, is for the most part only a passing evil. The patient is relieved by the judicious administration of art, and a con- siderable time may elapse before he experiences another similar at- tack. But he is liable to other evils, which, although less formidable in appearance, and more insidious and gradual in their progress, lead, if neglected, to a no less fatal result. As the disease advances, the urine is ejected in so slow a stream that it drops perpendicularly downwards from the orifice of the urethra. It is voided at short in- tervals—every hour, or half hour, or every twenty minutes; or, per- haps, it dribbles away involuntarily. This latter symptom occurs es- pecially when the patient is in bed, and is a source of great anxiety and distress. At the same time, a slight degree of pain is experienced in the course of ihe urethra, and in the glans penis. At first the urine is clear, in no way different from that of a healthy person; then a few small threads or flocculi are seen floating in it; and after- wards it becomes slightly turbid and opaque. If, under these circum- stances, you introduce the catheter into the bladder, you find a simple explanation of all these symptoms. Although the patient is continual- ly voiding his urine, and gets rid of the usual quantity in the twenty- four hours, his bladder is never empty. A certain portion of urine is always stagnant in it, the quantity of the residum varying, in different cases, from one or two ounces to one or two pints, or even more. Now, I do not mean to assert that all persons, in whom the prostate is enlarged, lose the power of emptying the bladder, but I certainly believe that this happens in the greater number of instances; and you will soon learn how important is the knowledge of this fact, whether it be viewed in connection with pathological science or practical sur- sery- . , . . When the prostate gland is much enlarged, the tumor, projecting into the bladder, irritates the mucous membrane, which becomes in consequence affected with chronic inflammation. The same effect is produced, and to a still greater extent, by the constantly distended state of the bladder. The inflamed surface secretes a thick, tena- cious mucus, having an offensive ammoniacal odor, which is in itself a source of irritation, aggravating the inflammation in which it had its 94 CHRONIC ENLARGEMENT origin. T have already explained to you what are the symptoms and the consequences of chronic inflammation of the mucous membrane of the bladder, and you will easily understand how much this compli- cation must add to the patient's sufferings and danger. Chronic in- flammation of the mucous membrane of the bladder is, indeed, one of the most frequent causes of death in neglected cases of enlarge- ment of the prostate; and where it does not operate directly, it fre- quently operates indirectly, so as to produce a fatal result. Small earthy deposits are formed in the alkaline mucus; many of which, in- stead of being expelled by the urethra, fall to the bottom of the resi- duary urine: these, increasing in size, and ultimately becoming ce- mented together, lay the certain foundation of a calculus in the blad- der. I shall give you a more particular history of vesical calculi, pro- duced under these peculiar circumstances, in a future Lecture. In all cases of enlarged prostate, in which the disease is allowed to take its own course, the muscular tunic of the bladder becomes in- creased in thickness and strength. The reason of this is obvious. The bladder has been called on to make unusual efforts; and all mus- cles, under these circumstances, acquire an increase of size. The mucous membrane frequently becomes protruded through the triangu- lar spaces between the muscular fibres, forming pouches, or cysts, similar to those which I have already mentioned as occurring in neg- lected cases of stricture of the urethra. These cysts are generally small, but occasionally they attain a large size: and it is remarkable that they sometimes contain what appears to be pure pus, while the bladder, with which they communicate, contains only urine. An old gentleman consulted me, laboring under disease of the prostate gland. He had a frequent inclination to void his urine; and on introducing the catheter, immediately after he had voided it, about three or four ounces of urine were found to have been left in the bladder. But what he chiefly complained of was an uneasy sensation in the rectum. He gave it the name of a worming sensation, and said it was as if a worm were crawling between the bowel and the bladder. One day, after drawing off the usual quantity of nearly clear urine, on introduc- ing the catheter a little further, to my surprise, half a pint of pus came away. The same thing occurred two or three times afterwards. At first I was led to believe that the catheter had entered the cavity of a common abscess. But it was not long before I had the opportu- nity of ascertaining the real nature of the case. The patient died; and on examining the body, the prostate gland was found a good deal enlarged: there were three cysts, of various sizes, communicating with the bladder, and formed in the manner which I have just described. The largest of these was situated between the bladder and the rectum, and contained half a pint of pus. There was no ulcerated surface: and the pus was evidently secreted by the mucous membrane of which the cyst was composed. OF THE PROSTATE. • 9.') It is not uncommon, on making a section of an enlarged prosiate gland, to find in its substance several small collections of a muco-pu- rulent fluid, having the appearance of pus mixed with the natural se- cretion of the gland. Sometimes there is a distinct abscess, which attains a very considerable size, presenting itself, at last, in one or another situation, according to circumstances. A gentleman who had labored under enlargement of the prostate for many years com- plained of uneasy sensations about ihe hips, extending down the thighs. At the same' time his pulse was somewhat accelerated, and he was subject to attacks of chilliness, not amounting to rigors. He was in the habit of introducing the catheter; and he observed that it entered the neck of the bladder with some degree of difficulty, as if the urethra, where it passes through the prostate, was contracted in its diameter. These symptoms had existed for many months, when at last, while he was in the act of using the catheter, an abscess burst, and several ounces of pure pus were discharged by the urethra. I lfad another patient who complained of similar sensations, and also of an increased difficulty in introducing the catheter, so that I was led lo believe that an abscess had formed in the prostate. When he had continued in this state for many weeks, an abscess burst into the rec- tum, discharging a considerable quantity of pus, and this was followed by the relief of all the symptoms. In a third case, the patient, not content with leading the quiet life which I had recommended, return- ed to his favorite pursuit of hunting. The formation of an abscess in the prostate was the consequence. When I was again consulted, the abscess had presented itself in the perineum. I opened it with a lancet, and some ounces of pus escaped. However, the whole of its contents were not freely discharged through the artificial opening, and the abscess afterwards burst into the urethra. For a long time matter continued to flow in large quantity by the orifice in the pe- rineum, and by the urethra also. At last the quantity of discharge underwent a sensible but gradual diminution. It had not, however, entirely subsided when I last saw the patient, which was more than two years from the period of the abscess having been opened. I have said that it is not uncommon to find or dissection that sup- puration had begun to take place in the substance of the prostate, probably in its excreting ducts; and I conclude that such is the origin of the abscess in the greater number of cases in which an abscess is formed. It is, however, not improbable that in some instances sup- puration may take place in the cellular membrane external to an en- larged prosiate, as an abscess connected with a diseased lymphatic gland is often situated, not in the substance of the gland, but on its surface, in the cellular membrane between it and the skin. Ulceration of the surface of that portion of the prostate which pro- jects into the bladder occurs occasionally in the very advanced stage of the disease. An elderly gentleman, who labored under disease of 96 CHRONIC ENLARGEMENT the prostate gland, and was in consequence unable to empty his blad- der by his own efforts, was in the habit of relieving himself by the introduction of the catheter twice or three times daily. He had gone on in this way for a year and a half, when he began to experience great uneasiness as soon as a very few ounces of urine were collected in the bladder, and was, in consequence, under the necessity of intro- ducing the catheter four or five limes in the twenty-four hours; at the same time that the urine became dark-colored, as if from a small ad- mixture of blood. These symptoms gradually increased, until at last the accumulation of even two or three ounces of urine produced vio- lent spasms of the bladder and abdominal muscles, attended with such agonizing pain that he could not forbear screaming. The introduc- tion of the catheter relieved him for a time; but in the course of one or two hours the pain and spasms returned as severe as before, and continued until the catheter was again had recourse to. He remain- ed in this state nearly three weeks, and at the end of that period died^ as if exhausted by excessive suffering. On examining the body after death, the prostate gland was found much enlarged. The posterior mid- dle portion of the prostate projected into the bladder, forming a tumor as large as a walnut, and one of the lateral portions projected in the same manner of a still larger size. The surface of each of these tu- mors was in a state of ulceration. The mucous membrane of the bladder was almost of a black color, in consequence of its vessels be- ing very much loaded with blood. In another patient, in whom symptoms of the same kind, but less in degree, had existed for more than a year before the disease terminated in death, the prostate was found to be ten or twelve times its natural size, making a large circu- lar projection into the bladder, round the internal orifice of the ure- thra. Nearly the whole of this portion was superficially ulcerated, and in some places the ulcerated surface was incrusted with a thin layer of coagulated lymph. A prostate gland which is extensively ulcerated is liable to bleed; but this may be the case also with a prostate which is not ulcerated, or which is ulcerated only to a small extent. Haemorrhage may, in fact, take place from an enlarged prostate as from any other tumor. Generally, the haemorrhage is small in quantity; but sometimes it is abundant and alarming. A gentleman labored under disease of the prostate. He was in the habit of introducing the gum catheter him- self. One evening he observed that blood flowed with the urine. In the course of the night he called me up, and I found him with the bladder enormously distended, prominent in the abdomen as high as the navel, and blood still flowing from the urethra. 1 introduced a large catheter, but no urine escaped. The bladder was distended, not with urine, but with blood. I directed the patient to lose blood by cupping in the loins, and to remain quiet; and, under this treat- ment, the haemorrhage ceased; not, however, until a very large quan- OF THE PROSTATE. 97 tity of blood had been lost. The catheter was afterw ards introdticed three or four times daily. The blood by degrees became dissolved in the urine, and, after two or three weeks, the latter was as clear as it had been before the attack of haemorrhage took place. But the pulse was frequent, the skin hot, the tongue dry and brown, and the patient survived the haemorrhage only a month. In the post-mortem examinaiion, 1 found the mucous membrane of the bladder exten- sively inflamed; a large tumor of the prostate projected into the blad- der; and it appeared to me that I could discern the exact spot in which the vessels of the tumor had given way, and from which the haemorrhage had proceeded. I have seen many other cases of hae- morrhage from the prostate. I had one patient, in particular, who had two attacks of haemorrhage even to a greater extent than in the case which I have just related, from both of which, however, he re- covered, under the treatment which I shall describe hereafter. I have already explained in what manner the bladder suffers in consequence of enlargement of the prostate gland. The kidneys suf- fer also, and it is this which principally baffles our skill, and renders vain all our efforts for the patient's relief, in neglected cases of this description. In a former Lecture I have stated, that disease of the kidney is a frequent consequence of a negleoted stricture of the urethra. The renal affections which arise from this cause are very similar to those which arise from disease of the prostate. The same description will apply to both orders of cases; and it is for this reason that I only briefly alluded to the subject as connected with disease of the ure- thra, referring you to the present Lecture for further information on it. These secondary renal affections are various. 1. In many cases the secretion of urine is considerably augmented. There is a very larg*e flow of urine of a pale straw color, and this may take place without any considerable alteration in the structure of the kidneys that we can discover on dissection. In one instance, in which the urine had been such as I have described for some years before the patient died, both kidneys were found of a pale color, and the glan- dular structure of one of them was much diminished in bulk, the pel- vis being at the same time considerably dilated. In other respects, the appearance of these organs was the same as under ordinary cir- cumstances. 2. There are other cases, in which the secretion of urine is much diminished in quantity or wholly suppressed. My attention was first called to this fact by the following case, which came under my ob- servation many years ago. A man, who was not much past the mid- dle period of fife, but who was old in constitution, had symptoms of enlargement of the prostate gland for two years or more before I saw him. At this time he was harassed by an incessant desire to void his 13 98 CHRONIC ENLARGEMENT urine. But the quantity which he voided at one time was very small, so that the whole amount of what was discharged in twenty-four hours did not exceed half a pint. He complained also of pain in ihe loins, extending across the abdomen. He was subject to occasional at- tacks of chilliness, but his skin was usually hot and dry, and he had a frequent pulse. On introducing a catheter into the bladder, I drew off half a pint of urine, although the patient had made water immedi- ately before the operation. The introduction of the catheter was re- peated twice daily; and under this treatment the quantity of urine drawn off gradually diminished; so that, at the end of a fortnight, he was enabled to empty his bladder by his own efforts. As the quan- tity of urine retained in the bladder became smaller, so the secretion became more abundant, until it amounted to two pints or more in the course of the day and night. Under these circumstances the patient returned to his home in the country, and I have had no opportunity of learning in what manner the case terminated. I attended a gentleman, about seventy years of age, with disease in the prostate. I had instructed him in using the catheter for him- self, and he drew oft' his urine regularly. Some months after I first saw him, he observed that he drew off'less urine than usual; and that the whole quantity of urine secreted in the day and night was much diminished. There was no distention of the bladder. The catheter entered the bladder readily, but drew off only a very small quantity of urine. At last the secretion of urine was reduced to three or four ounces daily, and I believe to less. Now another order of symptoms began to show themselves. The legs became oedematous: this was followed by difficulty of breathing; the patient was almost suffocated, except when his shoulders were very much raised by a number of pillows under them. Then he became drowsy; afterwards comatose, with dilated pupils. There were all the symptoms of effusion of fluid into the chest and ventricles of the brain; and with these symptoms he died. I have no written notes of the case: but if my recollection be accurate, not above ten days or a fortnight elapsed from the time when tbe diminution of the secretion of urine w%as first observed to the day of the patient's death. Unfortunately, the relations would not permit the body to be examined. I was consulted concerning another case, which may throw some light on the one which I have just related, in conjunction with my friend Mr. Stanley. We had some difficulty at first in determin- ing whether there was actually a suppression of the secretion of urine in the kidneys, or a retention of it in the bladder; and this difficulty was increased by the circumstance of the patient being unusually cor, pulent; so that, even if the bladder had been a good deal distended, we should have been scarcely able to perceive the usual prominence above the pubes. At last, however, we satisfied ourselves that the catheter drew off no urine, because there was none in the bladder. OF THE PROSTATE. 99 The patient died, and Mr. Stanley examined the body. He found a growth of medullary fungus immediately behind the internal orifice of the urethra, projecting into the bladder, and extending to the orifices of the ureters. It seemed that this disease, at the termination of the ureters, had impeded the flow of urine into the bladder from the kid- neys, both ureters being much enlarged, and distended with urine through their whole extent. The kidneys were very soft and vascu- lar, but contained no large accumulation of urine. As such cases are not generally noticed by surgical writers, I shall not think that I occupy your time unnecessarily in mentioning the par- ticulars of another, which, allowance being made for the difference of the original disease, is similar to those which I have just described, and will serve to illustrate further the influence which an obstruction of the ureters exercises over the functions of the kidneys. 1 was desired to visit a gentleman between forty and fifty years of age, who was represented to me as having been long troubled with a stricture of the urethra, and as laboring at this time under a retention of urine in the bladder. On introducing a small catheter, I discovered an ob- struction of the membranous portion of the urethra, but with some difficulty I made the instrument enter the bladder. The patient had voided no urine for "the two or three previous days, nevertheless not more than a few drops were drawn off by the catheter. The operation was repeated two or three times afterwards, and with the same result. At this time the patient was perfectly sensible, and gave Sir Henry Halford, Dr. Somerville, and myself a distinct history of his com- plaints. In the course of the next twenty-four hours, however, his mind began to wander, and at the end of three days more he died comatose. On examining the body, we discovered a very narrow gristly con- traction of the urethra, which was evidently a disease of long stand- ing. The urethra behind the contraction was much dilated. The whole of the soft parts behind the stricture, surrounding the urethra, prostate gland, and bladder as far back as the ureters, were much thickened, agglutimated, and indurated, apparently from the effusion of lymph at some former period, which had become organized. This change from the natural condition was greatest where the right ureter enters the bladder, and the orifice of this canal was in consequence so much contracted that scarcely the smallest probe could be intro- duced into it. The whole of the right ureter, above the contraction, was dilated to the size of the small intestine, the mucous membrane being thicker than under ordinary circumstances, and the inner sur- face bearing marks of slight inflammation. The orifice of the left ureter was also contracted; but in a less degree than that of the right; and the ureter itself dilated to two or three times its ordinary size. Both kidneys were unusually vascular, and of a soft consistence. In the right kidney there were two cysts containing serum, not commu- 100 CHRONIC ENLARGEMENT nicating with the infundibula. A small quantity of discolored fluid was found in the pelves; but there were not races of urine either in the kidneys or ureters, or bladder. The vesicular seminales were involv- ed in the mass of organized lymph which surrounded the neck of the bladder, and converted into a gristly mass, with scarcely any remains of their natural structure. The ventricles of the brain contained an ounce and a half of serous fluid; and about four ounces of fluid were found in the cavity of each pleura. 3. In cases of diseased prostate gland, as in all other cases in which there has been for a long time a considerable impediment to the flow of urine from the bladder, the ureters are liable to become dilated, the pelvis of the kidneys and infundibula being dilated afterwards. I shall describe this peculiar change in the structure of the kidney more at length when I call your attention to the subject of renal calculi. 4. In other cases, both of stricture of the urethra and of enlarge- ment of the prostate gland, the kidneys become diseased in conse- quence of inflammation which had begun in the mucous membrane of the bladder, extending upwards to those organs along the ureters. The morbid appearances, wdiich the kidneys present under these cir- cumstances, have been already described in the Lecture on diseases of the bladder. 5. But it is not uncommon in cases of stricture of the urethra for the kidneys to exhibit on dissection appearances of disease, although the membrane of the bladder and ureters is but little altered from its tnatural condition. These appearances are such as chronic inflamma- ion might be expected to produce, where it had not been preceded by inflammation extending up the mucous membrane; and they do not in any material degree differ from those which 1 described in the fifth Lecture, when I drew your attention to that peculiar class of cases in which there are symptoms of irritable bladder arising from disease in the kidneys. In all the cases which have been just enumerated the ureters are affected in the same manner, being in a greater or less degree dilated, but one generally more than ihe other; while the effects produced on the kidneys vary according to circumstances. Thus where the ob- struction to the flow of urine is of such a nature as to operate direct- ly on both ureters, the result is a complete suppression of the urinary secretion; but where the cause of obstruction is more remote from the kidneys, the-bladder, which is a dilatable organ, being interposed be- tween them, the result is the gradual production of a disease of the kidneys, which, if not inflammatory in the beginning, very soon as- assumes that character, running the ordinary course of chronic inflam- mation afterwards. Where the disease of the kidneys has been preceded by inflamma- tion of the mucous membrane of the bladder and ureters, the adhesive alkaline mucus which it contains forms the predominant character of OF THE PROSTATE. 101 the urine. But in the other class of cases, the urine is voided turbid, with small flakes of lymph floating in it. It exhibits abundant indica- tions of the presence of albumen on being tested with nitric acid, or heat, and it sometimes deposits pus. In all cases, as the disease in the kidneys makes progress, it gives origin to an order of symptoms quite different from those which mark the early stage of the disease of the prostate gland, and which I need only briefly enumerate, as they very nearly correspond to those which I have already described in the concluding part of ihe last Lecture. The patient complains of an uneasy sensation in the loins, which at last amounts to considera- ble pain. He feels as if the back required support, and places a cushion behind him for that purpose- Then there is pain extending across the anterior part of the abdomen near the hypogastrium, and sometimes pain, and even chronic inflammation and enlargement, of one of the testicles. By degrees the local disease affects the general system. The patient is observed to be languid and listless; he dis- likes exertion, and scarcely pays any attention to things which he would formerly have regarded as objects of the greatest interest. The pulse becomes feeble; the hands and feet are cold; the stomach re- fuses food; there is an incessant nausea and sickness: one or two rigors probably occur, which are followed by still more marked symp- toms of debility, which gradually become aggravated, until they ter- minate in death. Besides the more manifest and important consequences of the chronic enlargement of the prostate gland, which I have already de- scribed, and which are to be "attributed to the connection of the part diseased with the urinary organs, there are others less dangerous, but sufficiently distressing, which arise from the contiguity of the prostate to the rectum. When this gland is only slightly enlarged, it produces no inconvenient pressure on that bowel; but when the enlargement is considerable, there is a constant sense of weight and bearing down, and the patient has a feeling which leads him to think that he has oc- casion to evacuate his faeces, although the rectum is empty. I attend- ed an old gentleman who suffered from this kind of tenesmus for some years before he died, and to such an extent as to he rendered quite unfit for living in society. Slighter cases of the kind are not of un- frequent occurrence. The patient usually attributes the sensations which he experiences to internal piles; and, indeed, this last-mention- ed disease is often met with in those who labor under enlargement of the prostate, being probably produced by the pressure of the tumor on ihe larger hemorrhoidal veins. 1 have already mentioned a case in which an abscess of the prostate burst into the rectum. In this in- stance the abscess formed a second time, and again made its way in- to the bowel; after which it soon healed, and the patient had never any further inconvenience from it. 102 CHRONIC ENLARGEMENT LECTURE VIII. Treatment of the Chronic Enlargement of the Prostate Gland. If you bear in%mind that the chronic enlargement of the prostate gland to which I called your attention in the last lecture, is not an ac- cidental disease, but one of a series of natural changes which the sys- tem undergoes after the middle period of life, you will not be surpris- ed to find that it is but little under the dominion of art. When from any cause the vessels of the prostate are more than usually turgid with blood, the quantity of blood which they contain may be dimin- ished, and thus a reduction of size, to a certain extent, may be effect- ed. It is with this view that we recommend topical blood-letting, the exhibition of gentle purgatives, a moderate diet, and, above all, perfect rest in the horizontal posture. But we are not acquainted with any method of treatment which is capable of restoring the gland to its original condition. I need not'occupy your time with a de- scription of all the experiments which I have known to be made with a view to this result, as it would be only to give you a history of their failure. As, however, I have already referred to a case of enlarge- ment of the prostate occurring in early life, in which great advantage seemed to arise from the exhibition of the iodide of potassium, it is right that I should mention that no experience which I have had would lead me to believe that this medicine is useful in cases of the chronic enlargement of that gland in older persons. Nevertheless, in these cases, much may be done by means of proper surgical treatment. The prostate of a man advanced in life cannot be rendered like that of a young man, any more than his grey hairs can be converted into black: but the train of evils which the enlarged prostate produces by its influence on the urinary organs may be, in some instances, altogether prevented, and in others very much diminished, so as to remove the patient from a state of extreme, and even immediate danger, to one of comparative security. In considering the treatment by means of which this object is to be attained, we will suppose, first, that you are called to a patient laboring under a complete retention of urine in the bladder. The treatment of retention of urine from diseased prostate is one OF THE PROSTATA. 103 of the most imost important subjects in surgery. The patient suffers miserably; his life is at stake; he lives or dies according to the skill which you are able to exercise in his favor. The case is altogether different from one of retention of urine from stricture. Bougies are of no service: even if you pass one into the bladder, no urine follows; the parts collapse and close as the bougie is withdrawn. Neither is laudanum useful in these cases. Here is no spasm-for laudanum to relieve. If it produces any sensible effect, it is that it makes the patient less sensible of pain: it makes him think himself belter than he really is. It deceives him and his friends for a time, but it does nothing towards curing the retention. When the retention of urine has taken place suddenly, in conse- quence of a sudden addition to the bulk of the prostate, the patient may derive advantage from losing blood. He may be bled in the arm, or cupped in the loins; and I have known this in a few cases to be of itself sufficient to enable him to make water. But in the very great majority of cases the retention can he relieved only by the use of the catheter. I rarely use any but a gum catheter. It gives you rather more trouble to learn the use of the gum catheter, and to become dexter- ous in the management of it, than it does to learn the use of the sil- ver catheter. When, however, you have once become familiar with the gum catheter, you will generally prefer it to the other; and there is always this advantage in it, that, when you have succeeded in in- troducing it into the bladder, it may, if necessary, be allowed to re- main there. A gum catheter may be retained in the urethra and bladder with very little inconvenience to the patient, which is not the case with a silver catheter. As Sir Everard Home has observed, the gum catheter may be used in two ways; without a wire or stilet, when it is a flexible in- strument; or mounted on an iron stilet, in which case it is inflexible. You should be provided with a number of gum catheters, mounted not on small flexible straight wires, like those usually sold by the in- strument makers, but on strong iron slilets, having the curve of a sil- ver catheter. The stilets which belong to the larger gum catheters should have flattened iron handles, resembling that of a common sound. Let your gum catheters be kept thus prepared for a considerable time before they are wanted for use. They will then become fixed in the proper curvature. With the stilet such a catheter is as inflexible as if it were made of silver: without it, it is capable of retaining its shape to a certain extent; yet it is flexible. I always begin with passing such an instrument as this first. If the gum catheter without the stilet will enter the bladder, it is so much the better. It gives the patient no pain: it is incapable of lacerating the urethra, or producing haemorrhage: it may do all that is required; and it can do no harm, even in a rough hand. If you fail in intro- 104 CHRONIC ENLARGEMENT ducing it, the failure will not make it more difficult to pass another instrument afterwards. In difficult cases, indeed, the gum catheter without the stilet will not succeed. You must then use your gum ca- theter mounted in the way which I have already explained. You ought not to use a catheter so large as to give pain; but for the most part you will find one which is large enough to fill the ure- thra, without stretching it, to be more easy of introduction than a smaller one. A very small catheter approaches to a pointed instru- ment, and the extremity of it is liable to become entangled in the tu- mor of the prostate. The stilet ought to he considerably curved. The reason of this is obvious. The tumor which projects into the bladder, and which affords the principal obstruction to ihe catheter, is situated at the posterior part of the inner orifice of the urethra. A catheter which is slightly curved comes directly in contact with this tumor. In a caiheter which is much curved, the point is directed forward towards the pubes, and it avoids the obstruciion behind. Al- ways bear in mind, in introducing the caiheter, that it is to be used with a light hand. It should be held as it were loosely in the fingers. It will then, in great measure, find its own way, in that direction in which there is the least resistance. If you grasp it firmly, it can go only where you direct it, and it is likely to puncture and lacerate the membrane of the urethra, and the substance of the prosiate, and to make a false passage, instead of entering the bladder. I generally find that 1 introduce the catheter best by keeping the handle of it at first close to the left groin of the patient. I pass it as far as possible in this position; then I bring the handle forwards, nearby at a right angle to the pubes, and not elevating it towards the patient's navel. The next thing is to depress the handle, which is to be done gently and slowly, by placing a single finger on it, and press- ing it downwards towards the space between the thighs. In depressing the handle, you generally find the point of the cathe- ter slide into the bladder. Sometimes, however, this does not hap- pen until you withdraw the stilet; and, in the act of doing this, the in- troduction of the catheter is completed. Oilier artifices are necessary, in difficult cases, to enable the cathe- ter to reach the bladder. It may be useful to bend the point forward as it approaches the prostate, either by means of the finger in the rec- tum, or by pressure made on the perineum. * In many instances, the introduction of the catheter will be best accomplished by taking care, while you depress the handle, to keep the concave surface closely pressed against the arch of the pubes, so that it may turn round it a3 a centre. But it is impossible to explain to you in words all the minute cir- cumstances which practice and experience will teach you, and on which your success in this manual operation will very much depend. In some cases of diseased prostate, the urethra becomes very irri- OF THE PROSTATE. 105 table, and liable to spasm at the membranous part. This is observed especially where several rude attempts to introduce the catheter have been made before you have been called to ihe patient. Here the gum catheter on an iron stilet is certain to bring on spasm, unless it be handled with the greatest dexterity and gentleness; and sometimes it will induce spasm in spite of all your care; so that you cannot make it pass even to the neck of the bladder. But a gum catheter without a wire, being a softer instrument, is not very likely to produce the same effect; and I have frequently found the following method to be successful:—1 have passed the gum catheter as far as it could be made to pass without the stilet: it has probably slopped at the neck of the bladder, that is, at the tumor of the prostate: I have then introduced the stilet into the catheter, without withdrawing the latter from the urethra; and thus having made the catheter, without the stilet, pass through the part which is the seal of the spasm, I have been enabled afterwards, by employing the stilet, to direct the point over the tumor of the prostate into the bladder. I cannot loo strongly impress on your minds the necessity of gen- tle manipulation in all these operations. To attempt to force the catheter into the bladder is an almost certain method of causing it to penetrate into parts which it ought not to enter, and adds greatly to the difficulty of introducing it into the bladder afterwards. Besides, such rude treatment lays the foundation of much subsequent mischief, in the shape of abscesses in deep-seated parts, from whence the mat- ter collected cannot find a ready exit. Such abscesses are not con- fined to the substance of the prostate gland, or its immediate neighbor- hood. I was consulted by a gentleman who had suffered fiom reten- tion of urine from an enlargement of the prostate some months pre- viously; the catheter having been, as I understood, introduced with considerable difficulty. From that time, whenever a few ounces of urine were collected in the bladder, he had complained of a most se- vere pain, referred nearly to the situation of the entrance of the left ureter. The patient ultimately died; and on examining the body af- ter death I found a false passage extending from the urethra behind the prostate gland into an abscess between the bladder and rectum, and at the spot to which the pain had been referred. When the catheter has entered the bladder, and the urine is evac- uated, you must pursue one of two courses: either allowing it to re- main in the urethra and bladder, secured by a proper bandage, and with a peg in the orifice, so that the patient may relieve himself when- ever he has a desire to void his urine; or withdrawing it, and reintro- ducing it as soon as the bladder becomes again distended. Now, I do not' mean to lay it down absolutely as a rule, that, you should al- low the catheter to remain, but I am certain that it is prudent to do so in the great majority of cases. If you remove it, so abundant is the flow of urine which immediately takes place from the kidneys, 14 106 CHRONIC ENLARGEMENT that you will find the bladder again loaded, and requiring the re-intro- duction of the catheter, within five or six, perhaps even within three or four, hours. It will be necessary to use the catheter again after another short interval; and it will often happen, when there has been no difficulty in the first introduction of it, that there is considerable difficulty afterwards. You avoid all this by leaving the catheter in the bladder; and there is another advantage in this mode of proceeding. The prostate gland is kept in a state of more complete repose, and in one much more favorable to recovery, so far as recovery can take place, than it would be in, if irritated by repeated introductions of the instrument. After the catheter has remained in the urethra for some days, you may withdraw it; and if the patient is now able to empiy bis bladder by his own efforts, it may be laid aside altogedier; otherwise, it must be regularly introduced once or twice in a day, or oftener, according to circumstances. Where the enlargement of the prostate and reten- tion of urine have come on suddenly, the patient generally regains the power of emptying the bladder in the course of three or four weeks, and sometimes much sooner; but where the disease has come on gradually, he never regains it completely. In the former case, he may be liable to a recurrence of the retention of urine, at longer or shorter intervals; but in the latter, he is more or less of an invalid ever afterwards. Before we quit this subject of retention of urine from an enlarge- ment of the prostate, there is, however, another point to be consider- ed. You will very rarely fail, by dexterous management, to intro- duce the catheter; but you may fail, nevertheless, in some instances. What is to be done under these circumstances? Are you lo punc- ture the bladder? and if so, in what situation? It will be of no ser- vice here to do what some recommend in cases of retention of urine from stricture; namely, to make an opening into the urethra, beneath the pubes. The size of the prostate renders the case unfavorable for the puncture from the perineum, or the rectum. You may puncture the bladder above the pubes; or you may proceed thus:—When all your efforts to introduce the catheter have been unavailing; when you fell the point pressing against the tumor of the prostate, and unable to pass over it; apply some force to the instrument at the same time that you depress the handle. It will generally penetrate through the pros- tate, enter the bladder by an artificial opening, and relieve ihe patient; and of course will continue to relieve him, if you allow it to remain in the bladder, This mode of proceeding has been strongly recommended by some very good surgeons, and I am not aware that it is attended with dan- ger, although it may not be without its disadvantages. There is reason to believe, that in some cases in which this has been done, the natur- al orifice of the urethra has become so closed that the patient never OF THE PROSTATE. 107 could void a drop of urine by his own efforts, being compelled to rely wholly on the use of the catheter ever after. Sir Everard Home has published the history of a case of this kind which was attended by Mr. Hunter and himself. You may see the bladder of this pa- tient, with the perforation of the prostate through which the catheter used to be introduced, preserved in the museum of the College of Surgeons. The inconvenience which I have now described does not, however, exist in every instance. An old gentleman, the only patient indeed in whom I ever purposely perforated the prostate when labor- ing under a retention urine, ultimately legained the power of making water, so as to be able to dispense entirely with the use of the ca- theter. Let us now suppose a case in which a patient consults you laboring under symptoms that indicate a partial retention of urine in the bladder. He is unable to empty the bladder by his own efforts. You then are to introduce the catheter, and empty it artificially. The remedy seems to be very obvious: yet it had not occurred to surgeons generally, until it was suggested by Sir Everard Home, within the last thirty years; and to him we are indebted for this great improvement in practical surgery. The immediate effect of drawing oft" the water is to give the patient the greatest comfort. He loses the irritation which tormented him before; he is free from pain; and is no longer harassed by the incessant desire to make water. But the relief is only temporary. In a few hours the bladder is again loaded, and the symptoms return. The catheter is then to be in- troduced again; and you must continue to introduce it at regular in- tervals. These intervals will vary in different cases. One patient is quite comfortable if the urine be drawn off twice in the twenty-four hours, while another requires it to be done every six or eight hours. 1 rarely recommend the catheter to be used oftener than this. If employed six or eight times in the day and night, it is likely to irri- tate the prostate, and to do harm instead of good. This plan is to be pursued, probably, to the end of the patient's life. It may be dis- tressing to him to be thus dependent on the use of the catheter, but it is the least of two evils. The repeated introduction of it is an incon- venience, but it prevents misery and destruction. Without it, slow inflammation of the mucous membrane of the bladder, extending along the ureters to ihe kidneys, will supervene; abscess will form in the prostate; and probably stone in the bladder. But where the ca- theter is used regularly, these evils are at any rale delayed for a con- siderable time, and in by far the greater number of cases are prevent- ed altogether. But is ihe patient to be subject to the daily attendance of a sur- geon for the remainder of his life? This cannot be necessary. Let him learn to introduce the catheter for himself. If possible, let him use the gum catheter without the wire or stilet. It is less likely to 103 CHRONIC ENLARGEMENT occasion irritation than a harder instrument, and he can never with this do himself any material injury. Now, it is this continued use of the catheter, in those cases in which the patient is unable completely to empty the bladder by his own ef- forts, which constitutes the principal part of the treatment to be em- ployed in ordinary cases of disease of the prostate gland. In some cases nothing more is required; and the patient who is dexterous in the use of the catheter, and who is careful never to neglect the regu- lar introduction of it, passes through the remainder of his life, an in- valid indeed, but with 1 iitie or no actual suffering; and dies at last of some other disease, entirely independent of that which exists at the neck of the bladder. But there are many cases in which this is not in itself sufficient, and in which other treatment is necessary to remove or palliate the distressing and even dangerous symptoms which arise in the progress of the complaint. When the mucous membrane of the bladder is affected by slow in- flammation, the patient complaining of augmented irritation and pain, and the urine depositing ropy, adhesive, alkaline mucus, you are to employ those remedies which I recommended formerly under these circumstances, when speaking of diseases of the bladder; such as small doses of the cubebs pepper; the decoction of the pareria brava, combined with tincture of hyoscyamus, and mineral acids; opiate clysters or suppositories; and rest in the horizontal posture. By prop- er attention, you may generally relieve the symptoms of chronic in- flammation of the mucous membrane which occur in consequence of a diseased prostate, when they exist in a moderate degree. When, however, the case has been long neglected, and the inflammation has extended from the bladder to ihe ureters and kidneys, neither these nor any other remedies will be of real service, and the patient will sink, in defiance of all your skill, under his complicated maladies. If the patient labors under such symptoms as lead you to believe that there is inflammation of the prostate, which, if it proceeds, may terminate in the formation of abscess, take blood from the perineum by leeches or cupping, administer gentle aperient medicines, and ad- vise the patient to avoid all but the most moderate bodily exertions. By these means you will often succeed in preventing suppuration from tak- ing place. If abscess, however, be already formed, and has burst in the perineum or into the rectum, nothing is required, or ai least nothing can be done, beyond maintaining as much as possible the general health, so that the power of the patient's constitution may be under the most favorable circumstances for repairing the mischief which has taken place. If the abscess has burst into the urethra, or at the neck of the bladder, it is very desirable to avoid, for a time, the fre- quent introduction of the catheter, the point of which is liable to be- come entangled in the abscess, producing a fresh attack of inflamma- OF THE PROSTATE. 109 lion, and perhaps sloughing, of its inner surface, with a train cf dan- gerous constitutional symptoms. Under these circumstances, 1 gen- erally allow the gum catheter to be constantly retained in the ureihra and bladder, until there is reason to believe that the abscess is heaied. '1 he catheter used on these occasions should be rather less than the middle size. A catheter, which completely fills ihe canal of the ure- thra, may press on the orifice of the abscess so as to interfere with the free dischaige of its contents, and thus may incrtaseihe evil which it is intended to remove. In seme ca.^es, however, alter the forma- tion of abscess, the neck of the bladder becomes so tender, tiiat the constant retention of the catheter cannot be endured. We have then no alternative; the catheier must be used at slated periods, great care being taken that its points should not penetrate into the cavity, nor even into the orifice of the abscess. An abscess which has an external opening is likely to discharge its contents more freely, and therefore heals more readily, than one which has burst into the bladder, or urethra, or rectum. Whenever, there- fore, the j-ymptoms lead us to suspect that suppuration is taking place, we should from time to time examine the perineum and scrotum, and not hesilate, where any tumor can be discovered, to make a puncture with a lancet, without wailing for it to present itself at the sur- face. In those cases in which there is reason to believe that the diseased prostate is in a state of ulceration, the distressing symptoms which arise are to be ten bated chiefly Ly tie free use ol opium, adminis- tered in the form of clysters or suppositories. In some instances, the patient enjoys on the whole more cemfort if the catheter be al- lowed to remain constantly in the urethra and bladder: in other in- stances it is the reverse, and the catheter must be intry a thick cushion, so that it may be higher than his shoulders. The first step of the operation is to introduce a silver catheter, and thus empty the bladder of its contents. From five to six ounces of tepid water are then to be injected into the bladder, so as lo distend it moderately. If any considerable portion of the water should escape, the injection should be repeated, it being absolutely necessary Ikat the operation should never be attempted on an empty bladder. The forceps is next to be introduced, and of course wilh the blades closed. It is first to be used as a sound, so as to ascertain the exact situation of the calculus. If this be not readily detected, the patient may be directed to turn on one side, placing himself on his back as;ain afterwards; by which change of position the calculus may probably be made to roll into some more convenient place, within reach of the forceps. The blades of the forceps are then to be cau- tiously opened over the calculus, and afterwards closed upon it. By this simple management wilh a light hand, the calculus is seized with facility in manv cases; otherwise you may adopt the following me- thod, which rarely fails:—Let the "forceps be opened with the con- vexity of its blades pressed against that part of the bladder which is towards the rectum, so as to make it the lowest or most depending situ- ation. Then, by a slight motion given to the handle of the instru- ment', the calculus is made to roll into its grasp; and thus I have of- ten been enabled to remove several small stones at once. The advantages arising from the elevation of the pelvis is, that the calculus is then less liable lo be lodged near the neck of the bladder, where the seizing it is aKvays more difficult than when it lies near the fundus. Attention to this point'is especially of importance in cases of enlarged prostate. Sometimes, however, when the calculus is very hrge, notwithstanding this precaution, it will remain in the hoi- 164 CALCULI OP low behind the prostate. You should make no attempt to seize it when it lie3 in this situation, but endeavor, by varying the position of the patient to make it roll into some other part of the bladder, or else defer the operation to some future opportunity. When the calculus is grasped, you may know exactly its diameter by means of a scale fixed to the handle of ihe forceps. If it be of a very small size, you have only to withdraw the forceps from the bladder in the usual manner, and the stone wilh it. If it be of a very large size, so that it is evident that it cannot be made to enter the urethra, you need only to open the forceps again to set it at liberty; and you may then determine, at your leisure what other method should be adopted for the patient's relief. But the forceps may seize a calculus of an intermediate size; one which may be made to enter the urethra to a certain distance, being then stopped by some narrow portion of the canal. The neck of the bladder is very easily dilat- ed, and a calculus of considerable size may be drawn into that por- tion of the canal which lies in the perineum. It may then be very distinctly felt through the integuments behind the scrotum; and if a s*mall incision be made on it in ibis situation it is easily extracted, 'ho forceps, after the removal of the stone, being closed, and withdrawn in the usual manner. I have performed this operation several times, and have extracted calculi of more than an inch in one, and of nearly an inch in another, diameter. It is so simple, ihat, in two instances in which I had recourse to it, although 1 had no pair of hands lo as- sist me but my own, it was not attended with ihe smallest difficulty. The patient should be directed to remain in bed afterwards, and an elastic gum catheter should be allowed to remain in the urethra and bladder, for the purpose of drawing off the urine, and preventing it dribbling through the wound. With this precaution, ihe wound will, in some instances, be enabled to heal in less than a fortnight. But it will sometimes happen, that a calculus which is easily drawn through that part of the urethra which lies in the perineum meeis with an impediment in ihe anterior part of the canal; ihat is, eilher at the external orifice, or exactly at ihe anterior part of ihe scrotum, or somewhere in the intermediate space. If ihe impediment he close 10 the orifice, that part is easily dilated by means ol a probe-pointed bis- toury; and if it be in another part of the canal, you may remove ii by means of an incision made through ihe skin, corpus spongiosum, and membrane of ihe urethra. Let me caution you, however, never to make such an incision into the urethra immediately in front of the scrotum. It is difficult, when you do so, even by the constant retention of an elastic gum catheter, to prevent a small quantity of urine finding its way into the loose cellular texture of the scrotum; and tins may be productive of a succession of troublesome abscesses, or even of dan- gerous consequences. If a calculus seized by the forceps can be drawn so far forwards in the urethra, if may be always drawn some- THE BLADDER. 165 what further; or if the forceps be so constructed that the blades may be closed and compressed by means of a screw, it may be crushed while in the urethra, and llv.is removed in fragments. On the last mentioned subject, however, I must refer you to a future Lecture, in which I shall neat of the operation of lhhotrhy. 1 have been thus particular in describing the use of the urethra for- ceps, because I am satisfied that there is nothing in surgery more de- serving than this is of the attention of ihe student. If ever ihe period should arrive, at which surgeons generally have made themselves ex- pert in the performance of ibis operation, and the public are made fully aware of the great importance of their making an early applica- tion for relief, the disease of stone in the bladder, now so terrible, will ba regarded as a comparatively trifling ailment; and wilh a few excep- tions, patients who labor under it will no longer feel that they have to choose between a miserable death from the disease, and the employ- ment of a dangerous remedy. Before I quit the subjeci, I ought lo mention, that I have found this method of Irealment applicable lo cases which I was formerly accustomed lo consider as being nearly hopeless. I have already ex- plained to vou in what manner, where ihe mucous membrane of ihe bladder is affected wilh a chronic inflammation, a multitude of small ir- regululy shaped calculi become collected in it, composed chiefly of phosphate of lime deposiled by the adhesive mucus, which is secreted under these circumstances. Such cases are altogether unfit for any serious operation; and the patients usually die afier some months, or even one or two years, of lingering misery. In the summer cf 1833, however, an elderly gentleman, laboring under ibis complication of disease, with the addition of an enlargement of the prostate gland, placed himself under rny care. The urine was ammoniacal, filling the chamber wilh an offensive odor, and depositing a large quantity of adhesive mucus. The desire to make water was incessant, and the act of making it was attended with the greatest suffering. On the in- troduction of a sound, a large quantity of calculous matter was de- tecied in the bladdei-. The patient was unable to empty the bladder by his own efforts; there being always a residuum of two or three ounces of urine left in it. In the treatment of the case, 1 began with drawing off'ihe urine once daily, by means of an elastic gum catheter, washing out the bladder by an injection of tepid water afterwards. I then added a single minim ol the concentrated nitric acid to each ounce of ihe water used for the injection. This local application was attended with excellent results. The mucous secretion became very much diminished in quantiiy; and the bladder at the same time so much less irritable, that four or five ounces, either of urine or warm water, could be retained in it without much inconvenience. I now proceeded to extract the calculi which it contained, by means of the urethra forceps. None of these were of a large size, but they were 166 CALCULI OF very numerous, so that several operations were required, occupying, with the necessary intervals, not less than four or five weeks. At last the whole of them were extracted. The chronic inflammation of the mucous membrane now completely subsided; but as the patient still was unable to empty his bladder, I recommended that he should use the catheter at regular intervals, always injecting seme tepid water after he had drawn off his urine. The patient lived in a state of comfort for nearly a year, when, being, as I have already slated, an old man, he died of another complaint. However useful the method of treatment whi^h T have just describ- ed may be while ihe stone is still of small dimensions, it is evident that it can be of no avail in oilier cases. We must resort to other expedients, whenever the stone is of loo large a size 10 be drawn easily through the neck of the bladder. It has been observed by chemists, ihat lithic acid admits of being dissolved by a strong solution of pure or caustic alkali. It has been also observed ihat calculi composed of the phosphates are acted on by the mineral acids; and it may not unreasonably be entertained as a question, how far those changes, which take place out of the body, may be produced while ihe calculus is still in the bladder of a living person. This problem, of the solution of calculi by chemical agents, has occupied ihe minds of many individuals boih in past and present times. It has been proposed by some to administer the menstruum by ihe mouth, so that it might be conveyed into the urine by ihe usual channels; and by others to inject it into ihe bladder, by means of a catheter. This subject is one of great interest, and well deserves our serious and unprejudiced consideration. I fear that those who have expected by these methods to relieve pa- tients of lithic-acid calculi, have much over-rated the effects of alkaline lixivia on them. The fact is, that although alkalies certainly are capa- ble of acting on this kind of calculus, their action, except when employ- ed in a very concentrated form, is so inconsiderable, as to amount 10 almost nothing. Neither the stomach nor the bladder is capable of bearing the quantity of alkali which is necessaiy lo ihe production of the desired effect; and even if they were, it would be impossible 10 .maintain so constant a supply of the alkali as would be necessary to the destruction of a calculus of even moderate dimensions. Mr. lirande, moreover, has observed that the carbonates of potass and soda have no action on lithic acid; that they are incapable of dissolv- ing it; and that, if the pure alkali be taken by the mouth, it never reaches the bladder in this state, but only in that of a carbonate: and 3 THE BLADDER. 167 here, then, is an insuperable objection to all attempts to dissolve liihic- acid calculi by means of alkalies taken into the stomach. When there is a lithic-acid calculus in the bladder, and the lithic-acid dia- thesis prevails in the system, the first effect of alkalies laken into the stomach is to render ihe urine neutral; thus preventing ihe further in- crease of ihe calculus. So far, then, alkalies are useful. But if they are administered in slill larger quantity, so as to render the urine alkaline, the phosphates begin to be deposited. The calculus then continues to grow even more rapidly than before; but its composi- tion is altered, and layers of ihe triple phosphate are deposited on the lithic-acid nucleus. Such is the view of the subject taken by Mr. Brande; and if you read what he has said on the subject in his pa- pers on calculi, you will, if I am not much mistaken, be satisfied that it is well founded. But you will, not improbably, hear of cases in which it has been supposed that, under the use of alkaline medicines, calculi have come away by ihe urethra, broken down into fragments; and you will hear of others in which, under the same mode of treatment, the symptoms dependent on the calculus have vanished; and this circumstance has in itself been regarded as a sufficient proof of the calculus having been dissolved, although no calculous matter had ever been discover- ed in the urine. But none of these cases will stand the test of criti- cal inquiry. I have in a former Lecture referred to some remarkable cases, in which calculi seemed lo have been actually broken into pieces in the bladder. Bui however it was that this happened, it is evident that it was to be attributed to the operation of mechanical causes, and not of chemical solution. In other cases the supposed fragments, instead of being parts of an old stone dissolved, have been actually a new formation—the mischievous result of the indiscreet and unscientific exhibition of alkaline medicines. Such cases, in- stead of adding to the laurels of surgery, only show how this im- portant and useful art may become a source of evil instead of good, when it falls into the hands of the inconsiderate or ignorant. Wilh respect to the cases of ihe second order, you will obseive, that, when you come to investigate them, you never find that the symptoms have altogether and completely subsided. There has been some diminution of I hem, but that is all; and various cir- cumstances will explain whatever amendment has taken place. Thus a sione may become encysted, which was not so originally. So it was, probably, in a case, the histoiy of which I related in a former Lecture. Another remarkable example of ibis occurrence presented ilself to Sir Astley Cooper and myself. A genlleman, about sixty- s x years of age, consulted us concerning a frequent desire lo make water, attended with pain and other symptoms, such as a stone in the bladder might occasion. XV§ had a suspicion that there was a stone in the bladder, and had purposed to examine the bladder with a 163 CALCULI OF sound. Previously to ibis beirg dene, however, the symptoms be- gan lo subside, so ihat ihe patient suffered ccnparaiively hide incon- venience from them. About a year and a half afterwards he died of another, and wholly different, disease. On examining the body af- ter death, we found, at ihe fundus cf the bladder, a c\st formed by the protrusion of the mucous membrane between ihe muscular fibres; and in this cyst was lodged a calculus of the size of a haztl-nut, of which it seemed impossible lo doubt that it had been the cause of all the distress which the patient had suffered formerly. Now let us suppose that, in such a case as this, the existence of the calculus hav- ing been ascertained, the patient had gone through a course of alka- line medicines; would it nol have been supposed by himself and his friends ihat ihe alkalies had produced a cure?—and if the real cir- cumstances had not been disc loscd by a post-mortem examinaion, would not the case have been I aided down, as affordirg an example of the great influence of alkalies over calculous disorders? Another eireumslance may occasion a considerable abatement of the sympirms of s'one in the bladder; namely, an enhiigcmeni of ihe prosiate gland. The more urgent symptoms produced by a calcu- lus arise firm its reining in contact with ihe internal orifice of ihe urethra. But where ihe prostate is enlarged, so as 10 form a tumor projecting into the bladder, this is in great measure prevented. The calculus beecmes lodged, as it were, in the hollow behind ihe tumor, and is thus pievented falling down on ihe neck of the bladder; and if the enlargement of the prostate supervenes on a stone in ihe bladder, the symptoms of the latter disease are likely to be, in no inconsidera- ble degree, relieved. Sir Eveiard Home has published an account of two cases, ihe circumstances of which are, as it would seem, lo he explained in ibis manner. These cases are especially interesting on this account,—ihat both of ihem had been published while the pa- tients were yet alive, in proof of the efficacy of solvents. In e.-ch of them, the stones, which were supposed to have been dissolved, were found in ihe bladder, after death, apparently unaltered. I may mention as a matter of curiosity, that one of these patients was Sir Everard's own father. The mineral acids undoubtedly exercise a much greater chemical action on calculi composed of the phosphates, than alkalies do on those which are composed of lithic acid. It is not, indeed, possible to exhibit them by the mouth in such quantity as to render the urine sufficiently acid for the purposes of a solvent; but we have no right lo conclude from thence that they may not produce this effect if in- jected into the bladder by the urethra. I have already explained the use of injections of a weak solut:on of ni'ric acid, in relieving chronic inflammation of the mucous mem- brane of the bladder. In making furthar experiments on the subject, I found that where the mucous membrane was not inflamed at all, or THE BLADDER. 169 inflamed only in a slight degree, the proportion of the nitric, acid might be increased lo two minims or two minims and a half of the concen- trated acid lo an ounce of distilled water, without any ill consequences, or even iuconv ei.ience, aiising from it. I next endeavored lo ascer- tain lo whiit extent a solution of this stre. gib was capable of a- ling on a calculus of the mxed phosphates. The change produced was Suf- ficiently ob\ ious, especially when ihe soliuicn was made to pass over the calculus in a si ream for a considerable lime. It gradual! • dimin- ished in size, and al last began to be broken down into minute frag- ments. Aboul this lime, an elderh gentleman consulted me under the lollouing circumsiances:—He had labored under stricture ol ihe urethra for a great number of > ears. The stricture had been much neglected; and, at last, had produced ihe usud • onsequences—dis- ease of the bladder— lint is, i bronic inflammation ol its mucous mem- brane, and, piobably, disease of the kidney also. The patient bad an alums', incessant desire to void his urine; every attempt to do so was attended wilh ihe most excruciating pain; the urine, at ihe s;.me lime, being highly alkaline, offensive lo the smell, deposing a laige quantity of viscid mucus, wilh which were blended small panic!, s of phosplwle of lime, resembling ineriar. He was chinking lime-water, which some one had advised him lo take, with great perseverance, and, the more he drank, the more be suffered, and ihe more moitar came uu;y. This, he thought, was all as it ought lo he; and he ex- pressed himself as palients olten do under ihe same circumstances, saying dial, no doubi, it was better that he should get rid of the gravel, and thai the lime-water must be doing him good. However, nol being so well satisfied on the- point as my palient seemed to be, 1 advised him to leave off me lime-waier. The symptoms were immediately al- lered for ihe betler; but slill they were bad enough. The next step was to introduce a catheter, and afterwards a sound, into the bladder. When this was accomplished, which, on account of the contracted stale of the urethra, was al first not without some difficulty, I at once detecicd a calculus. Here, ihen, was a case of calculus manifestly composed of ihe phosphates, arising out of a diseased slate of the bl.idder, and a case in which the danger of any kind of operation would have been so greal, that no prudent-surgeon would t; ink him- self justified in recommending it to the patient. Dr. Prout was con- sulted ai my request, and he agreed with me in thinking, tha*, under ihe peculiar circumsiances of the case, it was one well fined for ihe experiment which 1 had proposed with ihe nitric acid injection. For ibis purpose I procured ihe catheter which 1 now show vou. I: is made of ihe purest gold which can he worked. It has two chan- nels, which are separated from each oilier by a longitudinal septum running the w hole lengih of ihe instrument. Each channel termin- ates by a distinct tube at ihe handle, and has a separate eye, or open- ing, at the other end of the catheter. By means of this instrument, t70 CALCULI OF you will observe that a liquid may be injected into the bladder, enter- ing it by one passage, and flowing out of it by the other, so that there may be a current through ihe bladder, without that organ being incon- veniently distended. 1 h d contrived a complicated apparatus for the purpose of making the injection; but I was afterwards led to prefer the simpler connivance of an elastic gum bolile, having a stopcock, and an elastic gum tube attached to it. At first 1 washed out the bladder with some distilled water, to get rid of the mucus which was lodged in it. '1 hen 1 injected the solution of nitric, acid very slowly, using the same liquid over and over again several times. Afier the operation was performed, the liquid which had been employed as an injection was tested by the addition of a highly concentrated solution of pure ammonia; and it was always found, ihat, if the ammonia was added in a sufficient, but not loo large a quantity, the phosphates were precipitated in abundance. The patient suffered no material in- convenience from this operation. It was continued sometimes for fifteen minutes, sometimes for half an hour, and repeated, accord- ing to circumstances, once in two, or three, or four days. At last, in making waier, the patient voided these two small calculi, compos- ed of the phosphate of lime, with a small proportion of the triple phcsphaie. It was impossible to doubt that they had been acted on, and partly dissolved, by the acid injection, and that they had at last, come away by the urethra, in consequence of their having been thus reduced in size. For some time after this occurred, the patient was in a state of comparative ease. He had still symptoms of stricture of ihe ureihra and diseased bl.idder, but he was free from the more urgent symptoms under which he had labored formerly. By degrees, however, these symptoms began to recur; and I have no doubt that there was a fresh formation of calculi, produced chiefly, as was the case with the former ones, by the diseased state of the bladder. If he had remained in London, I should probably have been able to have given him some further relief, by repeating and continuing ihe use of (be injection. But he went into the country, where, having been for a long time in a very bad state of general health, he at last died, as I was informed, of some disease not immediately connected with that on account of which I had been consulted. Since the occurrence of this case, I have, from time to time, as opportunities presented themselves, endeavored to follow up the in- vestigation; and T have connived a more complete apparatus for the purpose of making ihe injection. From ihe experiments which I have made, 1 feel jtstified in drawing the following conclusions:— 1. That a calculus, composed externally of the phosphates, may be acted on by this injection so as to become gradually reduced in size, while it \s still in the bladder of a living person. 2. That there is reason to believe ihat small calculi, composed throughout of the mixed phosphates, such as are met with in some THE BLADDER. 171 cases of diseased prostate gland and bladder, are capable of being en- tirely dissolved under this mode of treatment, and that it is probable that it may therefore be applied with advantage to some of these cases, in which, from the contracted state of the bladder, or from other cir- cumstances, the extraction of such calculi by means of the urethra- forceps cannot be accomplished. 173 L1TII0T0MI LECTURE XIII. Operation of Lithotomy. I procefd to describe the method of extracting a calculus by means of an incision of the bladder. This is what is commonly call- ed the operation of lithotomy. 1 shall draw your attention to ihe operation on the male sex first, and afterwards to that on the female. You mav make an opening into the bladder al ils fundus; and this is what is meant when we speak of the hisih operation. You may al- so make the opening at ihe neck of the bladder. The experience of ihe great majority of surgeons, from the time of lithotomy having been first practised lo the present day, is in favor of ihe lailer method of operating; but as to the exact mode of making the inci>ion at the neck of ibe bladder, there has been, and still is, a consideralde variety of opinion. I shall explain lo you what I am led to believe to be ihe most eligible method of performing the operation; endeavoring to establish, at ihe same time, the principles on which ii is to be con- ducted; ihe observance of which will enable yon to do all ihat human menus can do towards the sale y of your patient. In order that the object of the operation nay be clearly understood bv those, who have not yet studied the subject, I am accustomed to explain it in the following manner:— A small calculus mav he voided by the urethra, without an opera- tion of anv kind. A larger calculus is prevented coining away, be- cause the urethra is too smal to receive; it. The obvious remedy for this is to dilate the urethra, lo make it wider; and if it cannot be sufficiently dilated by the bougie, it must be dilated by the knife. But it is unnecessary to divide ihe urethra for this purpose through its whole extent. It is much easier to cut down on the urethra where it lies in ihe perineum, and dilate ihe posterior portion of it (which includes what is called ihe membranous part, and also that which lies imbedded in the prostate gland). The stone may iben be extracted through ihe wound in ihe perineum, the greater part of the urethra remaining untouched and unhurt. In performing this operation there are some things to be especially kept in view. IN THE MALE. 173 1st, The external incisions are to be made in such a manner as that there may be a sufficient space for the easy extraction of the calculus. Such a space does not exist between the two rami of the pubes, in the upper part of the perineum. Neither will it be obtained by an incision made in a vertical direction, in the line of the raphe of the perineum, unless, indeed, it be carried so low down as to divide ihe anus and a portion of. the rectum. But if the incision be made obliquely, beginning at the raphe of the perineum, and extending laterally between the anus and the tuberosity of ischium, there will be room, as far as the external parts are concerned, for the extraction of a very large calculus. Such an incision vvill manifestly answer the intended purpose, at the same time thai it is not liable to the objec- tions which may be urged against the incision made in ihe course of the raphe, and extending inio the rectum. 2dly, The incisions are to be made so as to avoid any considerable and dangerous bajinorrhage. It is idle lo say that the occurrence of such a hemorrhage is a hypothetical evil. Even in a young person, with a small mass of substance in ihe perineum, there are vessels which may bleed much if divided. But ihe operation is frequenily performed on persons advanced in life who have a deep perineum, ihat is, in whom a large quantity of soft parts must be divided before the knife can reach the bladder. The vessels of the perineum are in them large in proportion; and an incision made with the utmost care will sometimes divide vessels which will bleed profusely. On this account, ihe incisions should noi be more extensive than is really ne- cessary; especially in the deep parts of the perineum, where the bleeding vessels are not so readily lo be discovered, nor so easily commanded, as ihey are near the surface. Willi ihe same view the incisions should be low down in the perineum, so that there may be as little rU< as possible of wounding the artery of the bulb of the urethra; at the same lime that care is taken not to carry them close to ihe ischium, where the trunk of the internal pudic arteiy is situated, and where its branches are, of course, of a larger size than at a greater distance from their origin. Sdly, It is, on other accounts, of great consequence that there should be no large incision of ihe neck of the bladder. The prosiate gland is of a firm, dense structure; and when it is divided, the mine passes over the cut surface, without there being any danger of it pen- etrating inio its substance, or into the neighboring textures. Hut on the outside of the prostate, and neck of ihe bladder, is a loose cellu- lar membrane, which, if the urine has access to ii, may become iufil- H-aied wiih it 10 a very great extent; and which, thus infiltrated, is likily to be rendered the seat of extensive inflammation, sloughing, and abscesses. It is important, therefore, that we should avoid car- rying ihe incision beyond the boundaries of the prostate into this loose cellular membrane. It is true, that, if the stone, which is to be ex« 174 LITHOTOMY ti acted, be beyond a certain magnitude, this cannot be avoided; but it may be avoided otherwise. Not only a small stone, but one con- siderably above the average size, may be taken out of the bladder, through a wound which does not extend beyond the limits which I have mentioned; and in many instances where, from the size of the stone, this cannot be accomplished by means of an incision confined to one side of the prostate, the object may be attained by making a double section, and dividing the prostate on both sides. The dangers attendant on an extensive wound of the neck of the bladder, penetrating beyond the margin of the prostate, are not mere- ly theoretical. As long ago as the year 1810, the case which I am about to mention first opened my eyes to the ill consequences arising from a communication being made between the cavity of the bladder and the loose cellular membrane in which it is enveloped. I was present at the operation of lithotomy, performed by a very experienc- ed and skilful surgeon. There seemed to be no difficulty in its per- formance, and the forceps was introduced only once into the bladder; but the bladder (as I suppose) was in a contracted state, and the surgeon, in opening the forceps, observed a resist- ance, which suddenly gave way, as if a ligature had been broken. In the evening the patient was apparently well; but during the night he had no sleep, and he complained exceedingly of hunger. On the fol- lowing day, towards the afternoon, his abdomen became a good deal distended, and the pulse rose to 150 in a minute. He was low and desponding; his hands were cold, and his respiration frequent. Du- ring the following night, (the second from ihe operation) these symp- toms became aggravated. He had still no sleep; the pulse was more rapid and feeble; and on the following morning he died. It fell to my lot to examine the body after death. In doing so I found that the mucous membrane and muscular tunic of the bladder had been ruptured for about the extent of three quarters of an inch. The rupture was situated on the left side, just anteriorly to the rectum, and it, of course, extended into the cellular membrane on the outside of the bladder. The cellular membrane in the neighborhood of the rupture, and for some distance upwards in the course ol the ureter, had the appearance of being infiltrated with urine; it was inflamed and sloughy; and at the lower part, close to the bladder, its cells were occupied by a small quantity of pus. In the year 1816 1 met with the following case, which confirmed the suspicions which the preceding case had excited in my mind:— A little boy, about a year old, was admitted in o the hospital, labor- ing under stone in the bladder. I performed the operation for its extraction, making the incision of the prostate with a common scal- pel. Having introduced my finger into the bladder, I ft It a very large stone, and at the same time found that I had made a very small incision. On this I introduced a probe-pointed bistoury, and dilated IN THE MALE. 175 the wound, as I thought, sufficiently for the easy extraction of the stone. On ihe following day the pulse was rapid: the patient w?as low and depressed; and from this time he continued to sink, until he died on the third day after the operation. On dissection, I found thai the wound at the neck of the bladder had extended beyond the boundaries of the prostate gland. The cellular membrane in the neighborhood had all the appearance of having been infiltrated wilh urine. It was in part inflamed, and in part in a state of slough, be- ing converted into a substance resem! ling wet tow. There was nothing else to account for the patient's death. Some time after ihe occurrence of this last case, I had the oppor- tunity of perusing Scarpa's Memoir on the Cutting Gorget, and was gratified to find that the views which I had been led to form corres- ponded to those of this distinguished surgeon. That these views are correct, I cannot at this moment entertain the smallest doubt. They are supported by other cases which have fallen under my observa- tion, in which the patient manifestly died from inflammation and sloughing of the loose cellular membrane surrounding the prostate and neck of the bladder. If any one who has had much experience in lithotomy will look back at the cases which he has met with, in which patients have died after the operation, he will, if I am not much mistaken, find that what I have just mentioned will explain many things whch would be otherwise inexplicable; in particular, he will find an easy solution of the great danger which attends the ex- traction of very large calculi. He will also be enabled to compre- hend wherefore it is that patients, on whom the operation is perform- ed wi'h the greatest apparent dexterity and ease, and in the shortest possible space of time, sometimes die in the course of two orjhree days after the operation; while others, in whom ihe stone appears to have been extracted with difficulty, recover without any unfavorable symptoms. I proceed next to explain to you in detail the various steps of the operation. The first, as I have already stated, is the making an incision into the urethra, where it lies in the perineum; the second is the dilating, or dividing that canal where it is surrounded by the prostate. To facilitate the accomplishment of these objects, it is convenient to begin with introducing into the urethra this solid steel instrument, which we call a staff. It is of the figure of a sound; from which, however, it differs: first, in the handle, which, instead of being smooth and polished, is made rough, in order that it may be more firmly and steadily held; secondly, in having a groove, like that of a director, on its convex side. It is, in fact, a director, and in- tended to answer precisely the same purpose. The staffs sold by the instrument-makers are generally of too small a size. They should be as large as the urethra will easily admit without being pain- fully stretched. A large staff is more easily felt in the perineum than 176 LITHOTOMY a small one, and it admits, of course, of a deeper and wider groove. The groove ought to become gradually shallower just before il ter- minates at the extremity of the instrument, in order that ihe point may be neally rounded off'. The edges of the groove ougiil 10 be carefu.ly rounded off also. Attention to these circumstances in the construction of the staff', renders its inlroduciion more easy. J gen- erally begin the operation wilh introducing the staff into the bladder, merely because it is, on ihe whole, more readily managed when the patient is standing erect, than alier he is placed on ihe table. The next thing is to secure ihe patient in a proper posture, with the perineum exposed. About two feet six inches is a convenient height for the table. The patient should be placed on it, lying on his back, supported by pillows, with his shoulders somewhat elevat- ed. He should be directed to grasp ihe outside of ea» h foot wish the hand of the same side; and iheu ihe hand and foot are to be bound together by several turns of these bandages, which we call li- thotomy garters. If the patient be corpulent, he probably will not be able to grasp his feel, and he must in that case grasp his ankles instead. Besides the lithotomy garters, it is convenient lo apply another bandage—the neck strap,—which is thrown over the back of the neck, and passed under each ham. These bandages are not em- ployed with a view to prevent ihe patient snuggling, as persons out of the profession generally suppose, but solely for ihe pur; ose ahea- dy mentioned, namely, to keep him in a convenient posture, wi h the perineum properly exposed. Thus prepared, ihe patient is drawn towards the end of the table, with ihe bullocks rather pnjeding over it. Several assistants are required, one to support the patient on each side, holding his feet, hands, and knees, and keeping the lower limbs well asunder; a third to give you the instruments, in the order in which you want them; and a fourth to hold the handle of the slaff. It is also convenient, though by no means necessaiy, lo have another assistant, to support ihe . patient's shoulders. Your assistant, who holds the staff", may stand on either side; but it is usual for him to stand on ihe patient's left side, in order that he may lake the handle of ihe staff'in his right hand. The surgeon himself should be seated on a stool before the patient. He is first to attend to ihe position of the staff", taking care that it is held nearly perpendicularly; the handle of it being, however, a liule inclined towards the patient's right groin. '1 his causes ihe convexi- ty of ihe instrument to project sligluly on the left side of the peri- neum. In ihe first part of the operation your attention is to be directed to ihe staff". You are 10 feel it wilh your lefi hand, and the knife, held iu your right hand is to be directed towards it. It is a sure £uide> following which you can never err, even in the deepest pc- IK THE MALE. 177 rinetim. On the other hand, if you lose sight of it, you are cutting in the perineum as it were at random; you divide parts which you ought not to divide; especially you are in danger of carrying your incisions too near to the ramus of the ischium, where the arterial branches of the internal pudic artery are of a larger size than in the centre cf the perineum, and therefore more liable to bleed. I have seen some surgeons endeavor to introduce the point of the double- edged scalpel into the groove of tie staff at the first incision. But I caution you against this, as a great error in the operation; except, indeed, it be in the case of a young and very lean subject. Where there is any quantity of fat in ihe perineum, or any thing even dis- tantly approaching to what wre call a deep perineum, if you attempt to cut at once into the groove of the staff", the result is, that you open the urethra too far forwards; you divide the corpus spongiosum of the penis, which need not in reality be divided at all: and you are then certain of wounding the artery of the bulb of the urethra, which otherwise is, in most instances, avoided. Another inconvenience which attends on this method of proceeding is, that the wound being loo near to the scrotum, the cellular membrane of it is in danger of being infiltrated with blood: and another still is, that a greater mass of substance is left to be divided, when you continue the incision into the bladder, than there would have been if you had cut into the urethra farther back in the first instance. I say, then, let the opening in the urethra be made deep in the perineum, behind the bulb, and as near as can be to the prostate. Place the thumb of your left hand on the skin over the staff; and, in a man of ordinary size, about an inch and a quarter before the anus. Begin your incision immediately below this, on the left side of ihe raphe, and continue it backwards and towards the left side, into the space between the anus and the tuberosity of the left ischium. Here you may cut freely; you can injure nothing of consequence. Then ("eel for the staff' in the wound; direct the point of your knife towards it, and carefully cut into the groove, where it lies in the membranous part of the urethra. All these incisions are, you vvill observe, made low down the perineum, that is, near to the rectum. I have already given you what I conceive to be sufficient reasons for avoiding incis- ions in the upper part of the perineum. I may add another, namely, that if the external part of ihe wound be in the lower part of the perineum, there is a depending orifice for the free discharge of the urine after the operation, which there would not be otherwise. There is also a great authority in favor of this mode of proceeding. Ches- elden made his incisions in the way which I have mentioned, as is proved by the anxiety which be evinced to avoid injuring the rectum. Had he done otherwise, it would never have entered into his con- templation that the rectum was in danger. The next step of the operation is the continuance of the incision 23 178 LITHOTOMT along the posterior part of the urethra, and the dilatation of the neck of the bladder. Some recommend this to be acccmplished by means of the common scalpel, with which you have made ihe external incisions, the point being steadily introduced along ihe groove of ihe siafl", with the edge turned outwards, so as to divide the left side of ihe prostate. This was Cheselden's method of operating. 1 draw this conclusion from Cheselden's own account of bis operation, not from ihe absurd statement published by his contemporary, Dr. Douglas, who evident- ly understood nothing of the matter, and, indeed, describes an r>pi-ra- tion which it is next to impossible to perform. But after having in- cised the prostate and neck of the bladder, Cheselden introduced ihe instrument which I now show you, the blunt gorget, so as to dilate the wound still further, answering at the same time ihe purpose of a conductor for the forceps; and, as far as I can learn, ibis method was followed generally by the English surgeons up to the lime of SirCaa- sar Hawkins. This celebrated operator, who exercised his skill, and acquired his reputation, within ihe walls of our hosi ital, caused one side of the gorget to be ground to a sharp edge, and thus convened the blunt into a cutting gorget. The cutting gorgei of Sir Caesar Hawkins (and all those that have been since invented are but modifi- cations of it) was intended to supersede the use of the knife in open- ing ihe neck of the bladder, at ihe same time ihat it answered the pur- pose of a blunt gorget in other respects. It would be presumptuous in me to say that the culling gorget is not a good instrument, when it has been employed, not only by many of cur more disiinguishpd, but by some of our most successful liihotomists. Nevertheless, I cannot but think that there are some considerable objections 10 it. The in- cision is made as it is being thrust into the bladder. In consequence of the thick wedge-like form of the insirument, ihe prosiate, and es- pecially a hard and enlarged prosiate, offers to it considerable resist- ance. A certain quantity of force is necessary for its introduction; and if that force be not well applied, ihe beak may slip out of the groove of the staff into the space between the bladder and rectum,— an accident which is loo surely followed by the death of ihe patient. Now I know that such an accident ought not to happen; but I also know that I have seen it happen to a very experienced and dexteicus lithotomist. There is, of course, a still greater chance of its happen- ing to an inexperienced liihoicmist (and all are inexperienced in ihe first instance). These considerations lead me to recommend you not to begin with the cutting gorget: you may adopt it, if you | lease, af- terwards. For my own part, although 1 have very frequenily used the cutting gorget, I generally make ihe incision ol the prosiate with the knife which I now show you. You will observe that ihe blade is broad enough to divide a considerable portion of the prostaie, as it en- ters the bladder, without its being necessaiy to increase the size of the incision by culling laterally afterwards; and that, instead of a sharp IN THE MALE. 170 point, it terminates in a beak, fitted to the groove of the staff. In or- dinary cases, a knife of this kind, with a single cutting edge, is suffi- cient; but in cases of very large calculi, there are good reasons for dividing both sides of the prostate. There is no objection to this be- ing done, that I can discover; and for such cases I have been for so ue time in the habit of uiing this double-edged knife, with a beak projecting Irom its centre. Hiving made the opening into the membranous part of the urethra, you are to insert the beak of the beaked knife into the groove of the staff. You then take the handle of the staff inio the left hand, de* pressing it at ihe same time. You depress your right hand also, so that ihe handle of the knife, which you hold in it, lies in the lower part of the external wound You are now to push the knife along the groove of the staff'into the bladder, with its cutting edge inclined out- wards and a litile downwards, towards the ramus of the ischium, if you use a single-edged knife; but holding it horizontally, if you use one with a double edge. Let ibis be done slowly, cautiously, taking care that you do not lose the feeling of the beaksliding over the smooth surface of the staff for a single instant. Generally, as the knife en- ters the bladder, a few drops of urine escape, but never any large quantity. This being accomplished, you are to withdraw the knife along ihe groove of the staff'in the same line in which you introduced it. Never cut with it laterally, except you find it afterwards abso- lutely necessary to do so, on account of ihe large size of the stone; for in culling laterally, you will find it difficult to measure exactly the extern of ycur incision; and you may endanger your patient's life in consequence of your dividing the parts beyond the boundaries of the prostate. The next step of the operation is to introduce your finger, directed by the staff', into the bladder, so that you may feel the parts which are divided, and determine whether ihe incision is properly made. If you operate ou a child, or on a young and thin person, you may then at once introduce the forceps into the bladder. But if you ope- rate on a full-grown person, and especially on one having a deep pe- rineum, it will be prudent for you first to introduce this instrument, which we call a blunt gorget, previously to the use of the forceps. The blunt gorget is, as you perceive, an oblong plate of steel, turn- ed up at the edges, so as to present a concave surface above, and a convex surface be'ovv. The handle is inclined downwards; and that extremity, which is opposite to the handle, gradually becomes nar- rower, and terminates in a beak similar to that of the lithotomy knife. The surgeon lakes the blunt gorget in his right hand, and inserts the beak in the groove of ihe staff'; then, holding the handle of the staff in bis L'fl hand, and depressing it at the same lime, he carefully intro- duces the gorget into the bladder. Having done so, he withdraw* the staff, and leaves the gorget in the wound. 130 LITH0T0MT The gorget is intended to answer the purpose of a director for the forceps. But it answers another purpose also; it is a dilator of the wound. The knife divides only a portion of the prostate. The gorget splits the remainder as far as its breadlh allows it to do so. Do not for an instant suppose that this isany rude or violent proceed- ing. It is far otherwise. The incision of ihe prostate having been begun by ihe knife, ihe extension cf it by means of the blunt gorget is accomplished with the greatest ease. If you perform the operation on the dead body in the way which I have described, and dissect the parts afterwards, you will distinguish very readily ihe clean smooth surface made by the cut of the knife, from the fibrous or striated" sur- face, made by the splitting of the gorget. You will ask, Why not make such a division of the parts by cutting laterally with the knife? Why prefer the dilatation of the wound by the blunt gorget? My answer is, that the separation of the parts with the latter instrument causes no haemorrhage; and that it ceases as soon as it reaches ihe margin of the prostate; that is, as soon as it reaches the condensed cellular membrane, which forms what may be called its capsule. Before explaining the use of the lithotomy-forceps, I must show you its construction. One of the handles terminates in a ring, ihe other in a loop. The blades become broader towards the extremity; and their opposite surfaces are concave, and armed with small point- ed projections, or teeth. When closed as far as they can be closed, the ends do not exactly come in contact. Thus they are well fined to hold the stone, which they have seized, at the same time thai, if the stone be not seized, it is impossible for them to pinch the mucous membrane of the bladder. This particular forceps is made accord- ing to the patiern of that which Cheselden employed on most occa- sions, as described by Douglas, and you will find it very generally useful. You must not, however, rely on this alone: you must have forceps which are longer and larger: others much smaller, especially for operations on children. You should be provided, also, with curv- ed forceps, to be used where ihe stone lies in the hollow behind an enlarged prostate gland. The surgeon, then, holding the handle of the blunt gorget with the left hand, introduces the forceps wilh his right, along the concave sur- face of the gorget, into the bladder. This is to be done cautiously, and without violence. But it is to be observed, nevertheless, that the forceps will always experience a certain degree of resistance, and that some force is necessary to make them enter the bladder. You know when they have entered by ihe resistance ceasing, and, in many cases, by a gush of urine taking place at the time. In a deep pe- rineum the forceps will have to penetrate to a great depth before reach- ing the bladder. This is one of the sources of difficulty and doubt to a young surgeon, who is apt to think that the forceps must brve ac- tually entered the bladder, when it has, in reality, penetrated no far* IN THE MALE. 181 tber than the prostate. The forceps having been introduced, the gor- get is to be withdrawn. The surgeon is not to open and close the forceps at random. He is to use it at first as a sound, exploring the different parts of the bladder, until he has ascertained where the stone lies. 'J he discove- ry of the stone will be very much facilitated by the introduction of the finger along the groove of the staff, previously to ihe introduction of ihe blunt gorget; at least in most instances. In a case of enlarg- ed prostate and deep perineum, where ihe finger will not reach ihe bladder, this mode of examination is, of course, of no avail. The stone being touched by the forceps, the blades are to be opened upon it, and the slone is, in general, readily grasped. 1 have already mentioned a case in which the muscular coat of the bladder was rup- tured, in consequence of the surgeon too forcibly and hastily opening ihe forceps; and this will be a lesson to you as to your conduct in this part of the operation. But I conceive that ihe danger of such an accident as this is not the same in all cases. In some instances, when you begin the operation, ihe bladder is distended wilh urine; then, when the instruments enter it, the urine rushes out, not impell- ed by muscular action, but by its own gravity, and ihe pressure of ihe viscera. Under these circumstances, when you introduce your finger into the bladder, you find the muscular tunic relaxed, with the mucous membrane hanging in folds; and, in consequence, they are not likely to be ruptured. In other instances, ihe patient voids his urine immediately before ihe operation, or, perhaps, during ihe intro- duction of ihe staff'. Here, the urine, having been made 10 flow by ihe patient's own efforts, the muscular tunic is contracted: it offers a considerable resistance to the opening of ihe forceps, and is liable to be ruptured, if ihe blades are opened rudely and incautiously. It sometimes happens ihat a small stone lies, as it were, concealed in some part of the bladder, perhaps beneath a fold of ihe mucous membrane, so that you cannot easily bring the forceps in coniact wilh it. You will then frequenily succeed in seizing it in the follow- ing manner:—Expand the forceps gently and carefully, until the blades are widely separated from each oilier, holding them at the same time in such a position as that ihe blades open horizontally. This dislodges the slone, and causes it to fall to the lower surface of the bladder; and then, as you close the forceps, you find ihat you have seized it. In other cases, where there is a tumor at the neck of ihe bladder, caused by an enlargement of ihe prostate gland, the stone is liable to be lodged behind ihe projection. You feel the stone; but the forceps slides over its surface, and does not grasp it. It is in such a case as this that the curved forceps is useful, being capable of dipping into the hollow behind the prostate. Under these circumstances, you may also find it useful to introduce the finger into the rectum, and raise the bladder, by means of it, towards the pubes. 182 LITHOTOMI It is evident, however, that this expedient can be of no use, except where ihe bladder is within reach of the finger, which it rarely is in a case of enlarged prostate. The next ihing to be done is ihe extraction of the stone with the forceps; and, simple as it may appear to be, ihere are several ihings to be attended lo n ibis part of ihe operation. The forceps is to be withdrawn from ihe bbid.ler in the direction of ihe external wound. For the most part, it is belter that lie con- vexity of one blade of ihe forceps should be turned upwards, and that of the other blade downwards. Attention lo this point is especially of consequence, in cases where there is an enlarged prosiate gland, forming a tumor projecting into ihe bladder. The smooth convex surface of the blade of the forceps is not interfered wilh by the pro- jection; whereas, if the forceps be turned in the oilier direction, ihe slone, coming in contact wilh the tumor, becomes as it were entan- gled by it, and the extraciion of it is rendered difficult. The slone must be grasped wilh a certain degree of force, otherwise it may es- cape from ihe forceps. Bui, on the other hand, it is important that you should not, in ordinary cases, apply so much force as to crush it, for ibis will make the operation not only more difficult, and tedious, and painful, but also more dangerous. You should always endeavor lo determine, before you proceed to ihe operation, whai is ihe probable nature of ihe stone, in order ihat you may judge how far it is, or is not, likely to be easily broken. The lithic acid calculus is of a very hard texture, and is broken with difficulty. The oxalate of lime cal- culus is also hard, but it is more brittle than Hie lithic acid calculus. If ihe urine be alkaline, without containing the adhesive mucus secret- ed by the bladder, you know ihat ihe external layer is composed of (he triple phosphate, and a calculus of this kind is much more easily broken Uian either of ihose which have been before mentioned. But ihe most brittle of all, and thai which requires the greatest degree of caution iirits extraciion, is the fusible calculus, formed partly by ihe triple phosphate of the urine, and partly by the phosphate of lime generated by the adhesive mucus secreted by the membrane of ihe bladder; and ihe greater ihe quantity of ihe adhesive mucus, and the larger the proportion of the phosphate of lime, the more liable is the calculus to be crushed beneath ihe pressure of ihe forceps. If, having seized the stone, you find that it cannot be readily drawn through the neck of the bladder, you are to bear in mind, that this may be because you have hold of its long diameter. Let it then drop out of ihe forceps, and endeavor to seize it in a more convenient man- ner. In some cases you will find it expedient to dilate the wound of the prostate by a second incision. This, however, is never proper, except where you have divided only one side on ihe prostate in the first instance. You may then introduce a straight probe-pointed bis- toury, and make an incision in the opposite or undivided side of the IN THE MALE. 183 prostate. But this is to be done with ihe greatest caution. A care- less incision may occasion a fiightful haemorrhage, or it may extend beyond the boundaries of the prosiate into ihe cellular texture exter- nal to it; and 1 have already explained to you how much ibis may en- danger the life of ihe patient. It is scarcely possible for me lo say too much as lo ihe cau- tion necessary in ihe extraciion of a large calculus. Yon must com- mand not 01 ly all your skill, but all jour patience; indeed, patience is here the gn atest indication of skili. You are to draw ii out gradu- ally, endeavoring to dilate the parts through which it is lo pass, in- stead of tearing ihem; and it is astonishing to what an extent ibis gradual dilatation may be accomplished, in the hands of a prudent surgeon. 1 have told you how important it is that you should avoid crushing the stone. But even this rule has its excepiious. A slone may be so large ihat no degree of gentleness and cauticn will enable you lo extract it entire without extensive laceration of ihe nee k of the bladder, extending into the surrounding cellular membrane; and, under these circumsiances, it is ihe smallest of the two evils thai it should be broken into pieces. The fragments are lo be extracted one alter anothei, larger or smaller forceps being used, according to circumsiances. Some of the smaller fragments m;.y be removed by means of this instrument, a kind of steel spoon, to which we gave the name of scoop; and the very smallest of all may be washed out of the bladder by introducing the pipe of a syringe into it, and ii jeciing inio it a sufficient quantity of lepid water. You are lo as- cerlain, at l.isl, whether ihe win le of the fragments are extracted, by exploring the cavity of the bladder carefully, by means of ihissiraight sound iniioduced by the wound, and, in most cases, also, by exam- ining it wilh the finger. When a fusible calculus, containing a large proportion of the phos- phate of lime, is broken, it often happens that some of the fragments are of so small a size ihat ihey remain like panicles of rifar&e sand in ihe bladder, even in spile of all the precautions which you can lake at the time of the operation, and further attentions are required. Lei the patient recover of the first effecisof the operation: ihenonce or iwice daily introduce a caiheter by the urethra into ihe blad- der, and inject half a pint of tepid water, or of a weak infusion of linseed, through it, by means of an elastic gum botile. The liquid flowing in by the catheter will flow out by ihe wound, carrying the panicles of sand wilh it; and ihus, at last, the bladder will be emp- tied of them. In a case of enlarged prostate, indeed, this plan may not answer; as frequenily the paiienl is not more able after the ope- ration to empty the bladder by the wound, ihan he was before to empty il by the natural passage. For these cases you must be provided with'a large catheter, having an apeiture three or four times the size ol ihat commonly made, cluse to ihe point, on ihe upper or concave 07 184 LITHOTOMT side. The liquid being injected by the catheter, will be discharged by ii also, carrying every lime some of ihe small fragments of cal- culi with i;, until none are left in the bladder. It very rarely happens ihat you meet with an encysted calculus where you perform the operation of lithotomy. In fact, in ihe great majority of cases of encysted calculi, the bladder is diseased; so that they are quiie unfit for an operation. However, such an event cc- curs occasionally. A boy, about sixteen years of age, was admit- ted into the hospital in ihe year 1816. He had suffered a long time from stone in the bladder. There were these remarkable cir- cumstances in his case; namely, that the stone could sometimes be felt distinctly with the sound, appearing to be of a large size, while at other times it could not be felt at all; and that, sometimes, when the bladder was empty of urine, it could be perceived distinctly wilh the finger from the rectum, while at other limes, when there was urine in the bladder, it could not be detected ::t all by ibis mode of exami- nation. In peiforming the operation, when Iliad introduced my fin- ger into the bladder, 1 could, at first, discover no stone. At last I fell it on the anterior part of the bladder, behind the pubes. It was not lying loose in the cavity of the bladder, but evidently contained in a cyst, communicating with the bladder by a round opening. By means of a probe pointed bistoury, I carefully dilated the orifice of the cyst, and ihen, introducing my finger, separated the membrane of it from ihe calculus, until I was enabled to lake hold of the stone with ihe forceps. The calculus is preserved among those in our museum. Ii was not only encysted, but adhering also, for it was brought away with a portion of the membranous lining of the cyst closely attached to it. The boy recovered. After ihe operation your patient is lo return to his bed, where he *is to be hid on hi> back, wilh his shoulders and loins as much elevat- ed as they can be without inconvenience, so as to make the wound in the p^ineum as depending as possible. The thighs are lo be somewhat elevated by a bolster placed under the hams, and the knees are to be a litile assunder. The urine flows, not through the urethra, but through the wound; and the first and two or three succeeding gushes of it usually give the patient a good deal of smarting pain. In many cases, where there has been a deep perineum, and especially where the calculus has proved lo be of a large size, I have introduced an elastic gum canula through the wound into the bladder, ami allow- ed it to remain for the first two or three days; that is, until there was time for the surrounding pans lo become consolidated by inflammation. Such a canula makes an excellent conductor for the urine. It keeps the bladder always empty, and prevents the pain which otherwise is experienced on the first passage of the urine. It prevents also that obstruction to the flow of the urine which sometimes occurs after the operation, in consequence of the wound having become plugged by a IN THE MALE. 185 coagtilum of blood. In cases in which the calculus has been of so large a size as to make it probable that, in the extraciion of it, the solt parts have been lacerated beyond the boundaries of the prostate, the canula will answer.another good purpose by lessening the danger of the urine becoming effused into ihe cellular membrane. In ordinary cases the after-treatment is very simple. The wound requires little mere than atteniion to cleanliness; for of what service can applications be to a wound, over which the urine constantly flows? It gradually contracts and granulates; and as it does so, the urine be- gins to flow by the urethra. As the wound becomes more contract- ed, more urine flows by the natural passage; and usually, in less than a month from the time of the operation, the function of the urethra is completely restored, and the wound is healed. In a few cases there may be reason for applying leeches to the low- er part of the abdomen, and in still fewer it may be right to take blood from the arm. Fomentations applied lo the abdomen are sometimes proper also; and to this we may add the precautions necessary after most other operations with respect to the functions of the intestines, and the diet. There are cases, however, in which still further attentions are re- quired. Where the bladder is in a state of chronic inflammation he- fore the operation, secreting adhesive mucus, that inflammation is al- ways aggravated by the necessary introduction of instruments at the time of the operation, and there is always an increased secretion of the adhesive mucus afterwards. Again, in some cases, where those symptoms did not exist previously, they* are induced by the operation. Now, under these circumstances, ihe mucus being liable to deposit the phosphate of lime, and the whole of the urine being rendered al- kaline, there is a great liability to a calculous formation, and it will often require much care to prevent this calamity coming a second time upon the.patient. Opium, mineral or vegetable acids, and es- pecially the decoction of the pariera brava, may be here resorted to with advantage. But 1 need not occupy your time by a detail of the treatment which is proper under these circumstances; it is sufficient for me to refer you to what I said on this subject in the first of my Lectures on Calculous Disorders. In some of these cases, the whole of the wound becomes encrusted wilh a white calculous deposit. Stimulaim°- applications to the surface of it are then likely to be use- ful; such as a lotion of a decoction of bark and tincture of myrrh, solution of the nitrate of silver, or of nitric acid. As by other means the urine is brought into a more healthy condition, these lmions pro- mote the separation of the concretion from the surface of the wound, which then gets into a state to granulate and heal. 24 136 CAUSES OF DEATH LECTURE XIV. On the Causes of Death after Lithotomy. It is much more agreeable to contemplate the cases in which our art is successful, than those in which it fails: but the study of the latter is not less instructive than that of the former; and 1 should be guilty of a serious omission if I were to dismiss the subject of lithoto- my without endeavoring to explain the circumstances which render the operation hazardous; under which it is likely to shorten the pa- tient's life, instead of leading to his cure. 1 have already pointed out what I conceive to be the bad conse- quences of a too free division of the prostate gland. All that I have been able to observe for many years past has confirmed me in the opinion, that an incision of the prostate, extending into the loose cel- lular texture surrounding the neck of the bladder, is replete with dan- ger to the patient. Such a dtvision of parts is never necessary where the calculus is of moderate dimensions; but it cannot be avoided where it is of a very large size; and hence the extraction of stones of this description can never be accomplished without a great proba- bility of the patient not surviving the operation. The symptoms which arise in these cases are not well marked in the first instance. There is some heat of skin, and generally an ab- sence of perspiration; there is usually an abundant flow of urine through the wound; the pulse, as to frequency, is somewhat above the natural standard; and the patient, although free from suffering, has no disposition to sleep. This state of things continues for twen- ty-four, or even for forty-eight, hours after the operation; then the more characteristic and alarming symptoms show themselves. The pulse becomes more frequent, rising to 90, 100, and at last to 140, in a minute; the heat of skin becomes still greater; the tongue dry; the countenance anxious. Afterwards, as you count the pulse, you find every now and then a beat weaker than the rest; and then there are complete intermissions. At first the intermissions are not more than one or two in a minute; by degrees they become more frequent, until they occur every third or fourth beat. There is an occasional hiccough; the patient complains of some degree of tenderness in the AFTER LITHOTOMY. 187 lower part of the abdomen, especially in the left groin; the belly be- comes tympanitic, that is, the stomach and intestines are filled with air; the distention of the belly increases; the hiccoughs are more fre- quent; the pulse, continuing to intermit, becomes weak and fluttering. In some instances, the patient retains his understanding even to the last; while in others he falls into a state of low delirium previous to death. Occasionally, in the progress of such a case, ihe patient has a severe rigor, and sometimes he complains of a pain in the loins. Where these symptoms begin at an early period, he may die within forty- eight hours from the time of the operation; but in other cases, death may not take place for four or five days, or even for a week. On dissection, you find the cellular membrane round the neck of the blad- der, and between the prostate and the rectum, bearing marks of in- flammation, infiltrated with lymph and serum; and, to a greater or less extent, converted into a slough. If death has taken place at an early period, the intestines are found distended wilh air, and there is a very slight effusion of serum in that part of the peritonaeum which descends into the pelvis. But if the patient has labored under these symptoms for many days before he dies, the peritonaeum, where it is reflected from the bladder to the rectum, is seen of a darker color than natural, and encrusted with lymph; and at a still later period there is the appearance of inflammation, to a greater or less extent, throughout the peritonaeum generally. But the peritoneal inflamma- tion is evidently not the primary disease: it is the inflammation and sloughing of the cellular membrane of the pelvis which has induced inflammation of the adjoining portion of that membrane. Something also is to be attributed to the tympanitic distension of the intestines, which, if continued for a considerable time, is always liable to be at- tended with tenderness of the abdomen, and some degree of pento- neeal inflammation. It is important that you should not fall into the error of regarding such cases as I have just described as cases of simple peritonaeal in- flammation; for the remedies which would be useful in the latter case are injurious here. The abstraction of blood, or even the operation of an active purgative, will cause the patient to sink more rapidly, tending only to hasten his death. The proper system to be pursued is the opposite to that of depletion. The patient should take such nutriment as his stomach is capable of digesting. The bowels may be keot open by injections, or by the exhibition of some very gentle pur- gative; and ammonia, wine, and brandy are to be adm.nin.stered, when the state of the general system indicates that stimulants are necessary. Under this kind of treatment I have certainly known two children to recover, who were affected in the manner which I have described. In one of the'cases to which I allude, an abscess formed in the neigh- borhood of the neck of the bladder, which burst into the wound, and then the symptoms subsided. In the other a slough separated into 1S3 CAUSES OF DEATH the rectum, and a fistulous communication remained afterwards be- tween that bowrel and the neck of the bladder; but it was of a small size, and productive of no serious inconvenience. In adults the chance of recovery is, at any rate, much smaller than in children. Can any thing be done for their assistance in the way of local treat- ment? Let us consider how it is that the dangerous symptoms arise. There is suppuration and sloughing of the cellular membrane round the neck of ihe bladder, and the constitution is disturbed, as it is in a case of carbuncle; or, what is still more analogous, as it is in those cases in which there is sloughing of the cellular membrane of ihe scro- tum, in consequence of the effusion of urine arising from the rupture of the urethra behind a stricture. And, in these cases, what is the practice recommended? Do we not divide the soft parts freely over the sloughing cellular membrane; and is not this operation productive of the most signal benefit? Is it possible to resort to any practice corresponding to this, in the cases now under our consideration? There is only one way in which this can be accomplished, namely, by laying the sloughing abscess open into the rectum. I made this ex- periment in one instance, and I will tell you the result. In Septem- ber, 1825, I operated on a patient, a man between fifty and sixty years of age, laboring under stone in the bladder, in St. George's Hospital. The calculus was extracted without the smallest difficul- ty. Bat I performed the operation with what is called Mr. Blizard's lithotomy knife. This is a long, narrow, straight, probe-pointed bis- toury, and you must cut with it laterally, in order that you may divide the prosiate, so that it is difficult to determine the exact extent of the Incisipn. Immediately afier the operation, I had some, misgivings and was led lo fear that I had made the incision to such an extent as to penetrate beyond the boundaries of the prosiate. At first, indeed the patient seemed to be going on as well as possible; but, in about forty-eight hours from the time of the operation, some unfavorable symptoms began to show themselves. On the third day the counte- nance had become anxious, the skin was hot, and the pulse occasion- ally intermitted. On the following day (the fourth) the pulse inter- mitted once in fifteen beats; the skin was hot and dry, and the abdo- men began to be tense and swollen. I could not doubt that those symptoms existed which I had known to be the precursors of deaih in some other cases. Under these circumstances, with the concur- rence of my colleagues, I performed the operation which I am about to describe. I introduced the forefinger of the left hand into the rec tum. I then passed a probe-pointed curved bistoury into the wound and quite to its farthest extremity on the left side of the neck of the bladder. The probe point having been felt through the lunics of the rectum, I pushed it carefully through them, and," drawing it down- wards, divided the lower part of the rectum, sphincter and dl. Thus the wound and the rectum were laid into each other. Little or no has AFTER LITH0T0MT. 189 morrhage followed. The relief was immediate. In five minutes af- ter the operation the intermissions of flhe pulse had diminished from one in fifteen to one in fifty beats. In an hour it did not intermit at all. Dining the two following days the patient appeared quite well; the pulse was regular, between 70 and 80 in a minute. On ihe next day there was a slight occurrence of the intermissions of the pulse, but it subsided on ihe exhibition of some brandy and ammonia. Af- ter ibis there was a progressive amendment; the pulse, however, con- tinuing to beat between 80 and 90 in a minute for the two or three following weeks. After about a month, the wound in the rectum be- gan to contract, and the urine to flow by the natural passage; and in another fortnight the patient went into the country, nearly the whole of the urine at this time flowing by the urethra. I have already informed you that my experience does not justify me in stating, that, after the operation of lithotomy, there is no danger ol death from haemorrhage; and 1 have mentioned that I had myself the misfortune of losing one patient from ibis cause. This case, w Inch occurred many years ago, was that of an old man, with an enlarged prostate and an unusually deep perineum. The blood seemed to pro- ceed from the neighborhood of the neck of the bladder, and, what was remarkable, it was venous. I was foiled in all my attempts to restrain the haemorrhage, and the patient survived the operation only a few hours. I have known some other cases of death from haemorrhage, occur- ring in the practice of other surgeons. It must be acknowledged, how- ever, that such cases are but a very few out of a great number; and that the chance of a patient's bleeding to death, where the incisions are made low down, and are not more extensive than is really neces- sary, and where proper attention is paid, and proper precautions are used, after the operation, is so small, that it need not enter into your calculations. I speak of attention and precautions after the operation; for, without these, I suspect a dangerous haemorrhage would occur more frequently than it does. I performed the operation on an old gentleman, and extracted a large calculus. But a still larger stone re- mained in the bladder, which could not be extracted through the inci- sion which I had made, without the application of what I conceived to be a dangerous degree of force. 1 therefore made another incision in the right-side of the prostate, with a straight probe-pointed bistou- ry, and the calculus was then easily extracted. A frightful haemorr- hage followed the last incision; so that I have no doubt that the pa- tient would have died from loss of blood, if an assistant had not pres- sed the internal pudic artery against the bone with his finger for sev- eral hours. Some years before this, soon after I had been elected assistant surgeon to the hospital, Sir Everard, ihen Mr. Home, ope- rated on an elderly man for calculus in the bladder. There was a considerable bleeding at the time of the operation, but it was not much 190 CAUSES OF DEATH regarded, and the patient was taken to his bed. About half an hour afterwards, the nurse came to me in great alarm, saying that the stone- patient was bleeding to death. When I reached his bedside, I found him pale and yawning, the bed drenched with blood, and a complete puddle of blood on the floor under the bed also. I drew him to the end of the bed; and, having placed him in the position in which he had been placed for the operation, found the blood still flowing from the wound. On pressing the internal pudic artery of the left side against the bone, by means of the finger, the haemorrhage was im- mediately suspended. Fortunately the patient was a thin person, and, without any great difficulty, with the assistance of a small flexible sil- ver needle, I was enabled to pass a ligature round the trunk of the pudic artery. This fully answered the intended purpose. The pa- tient was saved; but, if assistance had been delayed even a few min- utes longer, it must have been unavailing. I have sometimes heard it observed by by-standers, when a patient has lost a good deal of blood at the time of the operation, " that he has lost no more than it will do him good to lose." I have, however, great doubts whether, even in the case of the strongest man, the los- ing much blood adds to his chance of recovery; and it is evident that, in the case of a person of originally weak constitution, or of one whose bodily powers are exhausted by his previous sufferings, or who labors under disease of the kidneys or other organs, the loss of a con- siderable quantity of blood in the operation is likely to make all the difference between its success and failure. I may lake this opportunity of observing, that secondary haemorr- hage sometimes occurs after lithotomy: I suppose, in consequence of the separation of the slough. A little boy, on whom I had operated, lost, what was, for him, a large quantity of blood; and (if I recollect right, for I have no notes of the case) some time in the second week after the operation. He was excessively lowered by the haemorr- hage, but ultimately recovered. Mr. Earle related to me a case of haemorrhage seven or eight days after lithotomy, which occurred to him in St. Bartholomew's Hospital. The bleeding was sufficient to be alarming; but he succeeded in stopping it by introducing through the wound into the bladder a tent, composed of a quantity of lint, wrapped round an elastic gum catheter. Patient's may, and continually do, recover, in whom circumstan- ces have occurred causing the operation to be protracted for a con- siderable time. Nevertheless, other things being the same, there can be no doubt that, as the operation occupies a longer time, so it is more dangerous. When I was a student at the hospital, a large fat man, with a very large calculus, submitted to the operation. He was in good health otherwise; but the stone broke into a number of frag- ments. There was a deep perineum; and these circumstances com- bined made the operation very difficult, although performed by a very AFTER LITHOTOMY. 191 skilful surgeon. The patient was more than an hour on the table. He died very soon after being taken back to bed, manifestly from ex- haustion. The causes of failure which I have already enumerated are con- nected with circumstances which occur during the operation, and which may be supposed to be, to a certain extent at least, under the control of the surgeon. But there are other cases, in which death takes place as a consequence of the operation, although nothing has happened in the performance of it which the most anxious surgeon could wish to have been otherwise. Some individuals are good sub- jects for the operation, and recover, perhaps without a bad symptom, although the operation may have been very indifferently performed. Others may be truly said to be bad subjects, and die, even though the operation be performed in the most perfect manner. What is it that constitutes this essential difference between these two classes of cases? It is, according lo my experience, the presence or abscence of organic disease. A patient with organic disease of other organs has a smaller chance of recovery than he would have had if such dis- ease did not exist; but it is organic disease of the urinary organs, the kidneys, or bladder, or parts connected with them, that is to be es- pecially apprehended, as increasing, ten-fold, the hazard of the oper- ation. Of persons in whom the calculus is not of large size, on whom the operation is performed, I will not say very well, but not very un- skilfully, and who are free from all organic disease, there are very few who do not recover; while, of those, in whom organic disease exists, there are few who do not die. It becomes, then, the duty of the surgeon to consider what are the organic diseases most likely to occur in combination with stone in the bladder, and how they are to to be recognised in the living person, in order that he may be enabled to judge, before he proposes an operation, or before he accedes to the patient's wishes that he should undertake it, how far it is, or is not, probable that it may prove successful. The common enlargement of the gland, such as occurs in old men, and existing in a moderate degree, does not, as far as my observation extends, add to the danger of the operation. In fact, it succeeds, on the whole, better in old men between seventy and eighty years of age, than in those who are ten or twenty years younger, although the former are likely to have the prostate of a larger size than the latter. An excessive enlargement of the prostate, however, is to be regarded as an unfavorable circumstance, inasmuch as, by adding to the dis- tance between the bladder and skin of the perineum, and placing the bladder beyond the reach of the finger, it increases the difficulties of the operation to an extent which cannot be well estimated by one who has not had personal experience of what those difficulties are. I may take this opportunity of mentioning, that I have performed the operation on two individuals, who for some years previous, in conse- 192 CAUSES OF DEATH quence of the enlargement of the prostate, had been unable to void a drop of urine without the aid of the catheter. The first of them remained in this respect after the operation, exactly as he was before, and required -the use of the catheter, even while the wound in the perineum was still open. The other has not only regained the power of making water, but at this time, two years after the operation, is still able completely to empty his bladder by his own efforts. It sometimes happens that the prostate gland, where it projects into the bladder, is ulcerated. I have formerly explained to you what are the symptoms produced by this combination of ulcerated prostate and calculus in the bladder. It remains for me to tell you the result of the operation of lithotomy, performed under these circumstances. When I was a very young member of our profession, 1 was present at two such operations. In ihe first of these cases the operation was recommended by two of the most eminent surgeons who were then in practice. It was performed, to all appearance, dexterously, oc- cupying scarcely three minutes. The patient died within ten minutes after he had ceen replaced in bed. In the second case the bladder contained eighteen or twenty calculi (I believe more), which, of course, made the operation more tedious. As soon as it was over, the patient fell into a state of stupor, from which he never recovered. He died in about twelve hours. Chronic, inflammation of the mucous membrane of ihe bladder is not very uncommon in cases of slone in the bladder; and although by no means a favorable circumstance, is not to be regarded as so unfavor- able as lo justify you in declining to perform ihe operation on this ac- count; indeed, if you were to do so, all your patients wilh fusible cal- culus would be left to die, for it is on this chronic inflammation that the deposition of the mixed phosphates, which constitute the fusible calculus, usually depends. But chronic inflammation of the mucous membrane is sometimes aggravated, so much so, indeed, as to assume the characters of acute inflammation. The inclination to void the urine is then incessant, night and day, preventing sleep, and attended with horrible suffering. The urine deposits a large quantity of offen- sive, ropy, adhesive mucus, of a red color, in consequence of blood being blended wilh it. Such cases as these are unfavorable for the operation. It may hasten the patient's death; or more frequently the patient will die in spite of it, and the operation will have the credit of having occasioned his dissolution. I have twice performed the operation under the circumstances w hich I just mentioned. In neither case did 1 recommende it, but the contrary. The patients, however, re- quired it of ine, being driven to it by excessive suffering; and I per- formed it in compliance with their wishes, as a matter of duty. I will tell you the result. The first patient experienced great and im- mediate relief. The wound granulated, and was completely healed in less than three weeks; but, nevertheless it was evident that there AFTER LITHOTOMY. 193 was something wrong. The patient was languid and listless, incapable of exei ion, and not even desiring to make it. At the end of a fort- night, or rather more, he began to complain of pains, like those of rheumatism, but more severe, in the shoulder, arm, and other parts of the body. He had rigors, gradually became weaker and weaker, and died about a month after the operation. On examining the body, the mucous membrane of the bladder was found still hearing the marks of much inflammation. The inflammation had extended to the cellu- lar membrane external to the bladder, which was, in some parts, in- filtrated with lymph and serum; and a small quantity of pus had been effused in the neighborhood of one ureter. One of the kidneys was almost completely wasted; but this was manifestly the result of dis- ease at some former period, and, in all probability, had no immediate connection with the patient's death. In the second case there was also great immediate relief: so that for some days there were no bad symptoms of any description, and I told the patient's friends that all danger from the operation was at an end. But at the end of about a wcJk from the time of the calculus having been extracted, he began to sink. It was difficult to say what he ailed, but it was evident that his physical powers were on the decline; and in the course of four or five days more he died. On examining the body, the mucous mem- brane of the bladder was found to be of a dark color, in consequence of ils vessels being very much loaded wilh blood. The same ap- pearance was traced along the membrane of the ureters to the pelves and infundibula of the kidneys, and these last-mentioned parts were distended with what appeared to be an admixture of pus and adhesive mucus From what I have seen in some other cases, I am led to believe that these patients would have died nearly as soon, P«haPs J«,l« aJ soon, if the operation had not been performed. They died, as I Inve already said, in spile of the operation, and not in consequence o H BuY these areffistinctions which the public, and even some members of our own profession, do not comprehend. It is desirable, on dl accounts, to avoid, if possible, performing an operation under tnese peculia circumstances. Such cases only tend to bring it into di'epute and prevent some other persons submitting to it, in whom there mioht be scarcely a doubt as to its success. , .., a tht> In t e ast-mentioned case there was disease in the kidneys the con eo ence of inflammation extending upwards along the ureters, ,om de mueous membrane of the bladder. But disease ongina- • L 1 Hnev where the bladder itself is in a healthy state, equal- ed to lie J n^ of ihe operation. The patient is unable to bear 194 CAUSE9 OF DEATH have died sooner or later if the operation had not been performed; but the operation hastens bis death, and is therefore to be avoided. A boy, sixteen years of age, a midshipman in the navy, had for many years labored under severe pain in the loins, and latterly ha*d suffered from the usual symptoms of calculus in the bladder. The poor fellow, however, went on doing his duty on board ship, until he could do it no longer. He was then placed under my care. His sufferings from the calculus were excessive; and, in addition to these, he had severe pains in the loins, and occasional rigors. The urine was turbid, and when exposed to heat, or on the addition of nitric acid, exhibited a large deposit of albumen; and Dr. Prout, who was consulted with me, detected some other circumstances connected with its chemical composition, which he had never before noticed, except in combination with organic disease of the kidney. Besides all this, the patient was depressed and languid, and losing flesh. Under these circumstances, Dr. Prout and myself strongly advised that he should not undergo the operation. Some time afterwards, however, his sufferings from the disease became so severe, that he declared he would rather die than submit to them any longer; and, at the earnest request of himself and his friends, I removed the stone from the bladder. It was of a middle size, and composed of the oxalate of lime. Every thing in the operation and immediately after it was as favorable as possible. For the first week, the patient seemed to go on well; he was free from pain, and happy, and his health improved. The only remarkable circumstance was an enormous secretion of urine, amounting to diabetes. At the end of a few days this ceased, but it was followed by a profuse diarrhoea. There was a succession of watery evacuations from the bowels, which nothing could check. He became weaker and weaker, had a shivering, and died before the usual re-action took place, about a fortnight after the operation. On examining the body an enormous abscess was found in one kidney, and connected with it, five or six calculi of the oxalate of lime, of various sizes and of irregular shapes. The following remarkable case occurred in this hospital in the year 1808. Sir Everard (then Mr.) Home performed the operation for stone in the bladder on a boy seventeen years of age. The patient was in a state of depression previous to the operation; but with such knowledge as existed at that time on these subjects, it was not sup- posed that there were any sufficient reasons why he should not under- go it. In the course of the following night, however, he died. On dissection, the bladder was found inflamed, and the mucous mem- brane ulcerated. The ureters, pelves, and infundibula of the kidneys were dilated. The kidneys themselves were of a pale color, and in the upper part of each of them was a large abscess. The abscess connected with the right kidney had burst into the abdomen (proba AFTER LITHOTOMY. 195 bly at the time of the operation), and not less than half a pint of pus had become effused into it immediately below the liver. Before determining on lithotomy, you have no more important du- ty to perform than that of inquiring into the state of the kidneys. I have already'explained lo you what symptoms mark the existence of disease in the kidneys, connected with calculi. One thing to be es- pecially attended to, with a view to a correct diagnosis, is the state of the urine. The urine may be alkaline, and thus in an unnatural state, and yet the kidneys may be free from organic disease,rand the patient a proper subject for the operation. It is purulent and turbid urine, loaded with albumen, by which your apprehensions as to the result of an operation will be chiefly excited. Albuminous urine, however, where all other circumstances are quite favorable, is not a sufficient reason for your declining the operation. I had a patient with stone in the bladder, a gentleman sixty years of age, whose urine was constantly turbid when first voided, depositing albuminous or fibrinous matter afterwards. At first, I hesitated to recommend the operation; but finding that he had no other bad symptoms, my opinion altered. I performed the operation; the [patient recovered without the smallest untoward circumstance occurring, and lived lor several years, dying at last of another complaint. Success in lithotomy must undoubtedly depend in a great degree on the manual skill of the surgeon, and on the mode in which the operation is performed; but it depends still more on the condition, of Zi patient with respect to his general health, especially on the exist- ence^ or non-existence of organic disease. Not a little may be at- tributed to accident,which may at one time throw in your way a suc- cession of cases which are favorable, and at another timeasacces- sfon of cases which are unfavorable, to the operation; and hencei it has often happened, that a surgeon who has been fortunate in the re- su lii of h s-practice as a lithotomist at one period, has been unfortu- nate at another. An experienced surgeon has general y had an ad- vintaEe over others, in consequence of his greater skill in diagnosis, vantage ovei uuicio, tl__ „,uotu01. *UP ronstitution is, or IS U./Tet me cive you one caution more: never hastily occasions. B"1 lel .™e 6lve 3 calculus has existed in the bladder P^2ZVtt£Z' K a^d advice of h. 196 LITHOTOMY IN THE MALE. friends, has missed the period at which an operation would have been almost free from danger; has dragged on an anxious and uncomforta- ble existence, month after month, and even year after year; trying, at one time, medicines prescribed by regular physicians, and, at another time, medicines prescribed by quacks—all to* no purpose; and at last has been driven by his sufferings to make up his mind to undergo the operation, when his condition has become so altered, that a prudent strgeon would either altogether decline to undertake it, or would perform it wiih great unwillingness, and solely as an act of duty, or, if you please, of humanity, towards a suffering fellow- creature. On some other Methods of Lithotomy. Whatever advances may have made in the other parts of surgery it may be confidently asserted, that there has been no real improve- ment in the lateral operation of lithotomy since it was practised by Cheselden, more than a century ago. The method which I have de- scribed to you is, indeed, that of Cheselden, fromVhom it has been adopted generally, not only by the operators of this country, but by those of the continent of Europe. There have not been wanting, however, ingenious persons, who have endeavoured to extract calculi from the bladder in other ways, in the expectation of discovering an operation simpler, or safer, than that of Lmeselden. Of late years, an attempt has been made in Paris to revive the high operation, in which the incision of the bladder i4 made at its fundus, where it lies behind the pubes, and immediately belowthe part at which the peritoneum is reflected over it. The high operation was indeed, recommended by Cheselden himself, in the early part of his career; but he soon abandoned it for the lateral operation, from which ast method he never deviated afterwards. The late advocates for the high operation, however, suppose that they have made in it an essen- tial improvement, inasmuch as they adopt means for keepin- the blid der empty of urine afterwards, so as to allow the wound i,fits fimdus to heal, without the danger of an effusion taking place into the sur- rounding cellular membrane. For this purpose some make an incision into the urethra from the perineum, from which they introduce an elastic gum canula into the bladder: while others employ the simple expedient of a gum catheter introduced, by ,he urethra in the usua manner. I have been present on three or four occasions, wlien he high operation was performed; but nothing that I have wines ed would lead me to recommend it to you; nor, indeed, does i appear LTase of^th'^1' ^ ^f "* " ^ f^rmance'cr it, excT t ' 1 H» case of a thin person, wuh a stone ol so large a size, that the ex- PROSTATIC CALCULI. 197 traction of it by the usual method would be either impracticable, or attended with the greatest risk to the patient's life. But even for cases such as these, it may be a question, whether there is not a bet- ter method of proceeding, in the recto-vesical operation; in which the incision of the perineum is made to extend through the tunics of the rectum and the sphincter ani muscle. Here the parts which afford the chief resistance to the extraciion of a large stone are divided; and, although the incision of the neck of the bladder extends beyond the boundaries of the prostate, the. ill consequences arising from the escape of urine into the cellular membrane are likely to be in great measure obviated, in consequence of the free opening which has been made into the rectum. If you refer to a case which I have already relat- ed, in which, some days after the removal of a calculus by the usual method, I was induced to lay the wound of the perineum, as far as the neck of the bladder, completely into the rectum, you will find in it much in favor of the recto-vesical operation in those cases, in which ihe great bulk of the stone makes an extensive incision of the pros- tate and bladder necessary. Further than this, I have little to offer, from my own experience, on this subject. In ihe only instance in which I performed the recto vesical operation, the patient, who had suffered from a stone in the b'adder for more than twenty years, died in about three weeks, wiih abscesses in fhe kidneys, and a large ab- scess on one side of ihe pelvis, having no communication wiih the wound, and which I believe to have existed long before he came un- der my care. The stone in this case had been supposed to be of an unusual magnitude. It proved to be much smaller than was expect- ed; but I felt convinced at the lime, that if it had been many times larger than it was, it would, nevertheless, have been extracted with the greatest facility. Calculi of the Prostate Gland. Calculi occasionally form in the ducts of ihe prostate gland. In the museum of this hospital there is a preparation of an enlarged pros- tate, in every part of which are found minute calculi, none of ihem bigger than a pin's head, *and too numerous to be counted. In gene- ral," however, they are fewer in number, and larger in size; I have seen them as large as a pea, or even as a horse-bean. They are composed of ihe phosphate of lime, of a light brown co'or, and not unfrequently are smooth and somewhat glossy on the surface. I be- lieve that they frequently exist for a considerable time, without the pa- tient being aware that he labors under any kind of disease. In oth- er cases they cause a sense of irritation, referred to the perineum and neck of the bladder, and sometimes a difficulty of making water; so that patients have applied to me, supposing themselves to labor un- 198 TREATMENT OF der a stricture of the urethra, whose real complaint was the formation of prostatic calculi. We know of no medicine that is capable of preventing the forma- tion of this kind of calculus; and in ordinary cases there seems to be nothing for us to do, beyond the occasional introduction of a full-sized bougie, to keep the urethra dilated, and thus favor the escape of the calculi, as fast as they become disentangled from the ducts of the pros- tate, in which they have been generated. There are some cases in which a number of these calculi are col- lected in a cyst in the prostate gland, plainly perceptible by means of a metalic sound introduced into the urethra, and just before it enters the bladder; to be felt also from the rectum, sliding on each other un- der the pressure of the finger. In a case of this kind you may intro- duce a staff into the urethra: and with this for your guide, make an incision in the perineum extending to the prostate, but not into the bladder, and thus extract the calculi. Several years ago in a case of this kind I succeeded in removing a large number of prostatic calculi with the assistance of Weiss's urethra forceps. There is always dan- ger of some of these calculi finding their way into the bladder, and thus laying the foundation of calculi of that organ. This happened in the case to which I have just referred; so that, after I had com- pletely emptied the cyst of the prostate, I had to remove a consider- able number of calculi, of a still larger size, but of the same chemical composition, from the cavity of the bladder. Treatment of Calculus of the Female Bladder. In women, calculi of a small size are expelled, as they are in the male sex, without ulceration, or other injury to the urethra, and with- out the patient suffering any inconvenience afterwards. Calculi of a very considerable size occasionally escape from the fe- male bladder; but the natural cure in these cases is effected by a less simple process. A woman was admitted into our hospital, under the care of the physicians. On inquiring into her case, the apothecary of the hospital found a large calculus lying in the vagina, and he extract- ed it with his fingers. The urethra and vagina had ulcerated, and the calculus had passed through the ulcerated opening. The patient was thus relieved of the disease under which she had for a long time labor- ed; but it left another and very distressing disease behind it, namely, an incontinence of urine. Many cases similar to this have been re- corded by writers; and you will find a paper on the subject, which is well worthy of your attention, by Dr. Yelloly, in one of the volumes of the Medico-Chirurgical Transactions. There is reason to believe that incontinence of urine always follows the natural cure, where the calculus has made its way out of the bladder by ulceration. CALCULUS IN THE FEMALE. 199 The peculiar structure of the female urethra renders it much more capable of dilatation than the urethra of the other sex; and stones of considerable size may be removed in this manner, without the aid of any cutting instrument. If you look over the early volumes of the Philosophical Transactions, you will find that this is no new invention; but the operation had fallen into disuse, and, indeed, I may say that it had been forgotten, when it was revived by Mr. Thomas. Mr. Thomas was called to a lady, who, I know not for what pnrpose, had deposited an ivory toothpick, three inches long, in her bladder. He introduced a piece of sponge tent into the urethra; as the sponge swelled, the urethra became dilated, and the toothpick was then easily extracted. Since then the same operation has been performed by Sir Astley Cooper, and various other surgeons. I have myself em- ployed this method in several instances. In the first, I accomplished the dilatation by means of a piece of sponge tent; in the others, I made use of the dilator which Mr. Weiss has invented for this pur- pose, and which is undoubtedly to be preferred to the sponge tent, as it enables you to dilate the parts very gradually, and does not inter- fere with the free escape of the urine. None of these suffered from actual incontinence of urine, but one of them in whom the calculus was of a large size could not retain more than two or three ounces of urine in the bladder afterwards. When you attempt the dilatation of the female urethra, I would advise you to proceed gradually. The process, however, may in most instances be completed, and the stone extracted, in less than twenty-four hours. If you use the sponge tent, it should be of that kind which is made by compressing a piece of wet sponge between two pieces of board in a vice, or under a very heavy weight, and not that prepared with wax; and the tent should be once or twice remov- ed and renewed, in order that it may be increased in size, and also that the patient may not suffer from retention of urine. But the method of dilatation is not to be recommended except in cases of calculi of moderate size. Where the stone is large, an incision of the urethra is necessary for its extraction; and this may be accomplished in the following manner:—Introduce a director or straight staff into the urethra and bladder, and then, by means of a cutting gorget, a common straight bistoury, or the bislouri cache divide one side of the urethra, dilating that canal to a sufficient size for the introduction of the forceps. It has been most usual to make the in cision of the urethra obliquely downwards and outwards, so as to in- clude a small portion of the vagina. The bladder is completely with- in reach of the finger, and nothing can be more easy or expeditious than the method which I have just described. But the patient is gene rally subject to the great inconvenience of an incontinence of urine afterwards, I need not tell you how important it is that such a result should be avoided. The late Mr. Hey of Leeds, in one instance, 200 TREATMENT OF after the operation, introduced a tent, formed of a roll of linen, into the vagina: I conclude that this was done wiih a view to keep the cut surfaces in a state of apposition, and cause them to unite by the first intention: at any rate the experiment succeeded, and the patient was able to retain her mine afterwards. I repeated Mr. Hey's ex- periment in a case in St. George's Hospital, but not with the same success. The patient, however, was a young and restless child: it was difficult to retain the tent in the vagina, and I do not think that, in this instance, the method was fairly tried. I have not repealed the experiment, as I have been informed that it has failed in other hands. I was led to believe that the whole of the female urethra could be dilated easily, and to a great extent, with the exception of the exter- nal orifice, and, under ibis impression, in the next case which came under my care, I tried another modification of the operation. Hav- ing introduced a straight staff into the urethra, I made a small incis- ion extending through the peculiar structure which surrounds the ori- fice of ihat canal, but no further. The wound did not extend more than one third of an inch in any direction. 1 was then enabled gra- dually, and with very little force, to introduce a pair of forceps, and extract the calculus. The patient after the operation was not troub- led wiih actual incontinence of urine. She could retain it for one or two hours, but not so long as an ordinary person. The calculus, however, in this case, was not of above an average size; and f do not suppose that the same method of operating would be found applicable to a case in which it was of large dimensions. Soon after this I had an opportunity of trying another method of operating, which, as I was informed, had been adopted by an eminent provincial surgeon, and which had not been followed by ihe usual in- continence of mine. I introduced a bislouri cache into the urethra, having previou>ly fixed ihe screw in-ihe handle of the instrument, so that the cutting edge could not be made to project more than to a very small extent; perhaps lo about one sixth of an inch. Then draw- ing out the bislouri, wiih the cutting edge turned directly upwards, I endeavored to divide the membrane of the urethra immediately be- low the symphysis of the pubes, without allowing the incision lo ex- tend inio the contiguous cellular structure, 'i he next step of the ope- ration was to introduce Weiss's dilator, and dilate the urethra, so as to allow of the introduction of ihe finger, and afterwards of the for- ceps, into the bladder. As the urethra now offered no resistance, this dilatation was readily effected in the course of a few minutes; and thus the stone was extracted. The patient, like the preceding one, did not suffer from actual incontinence of urine after the opera- tion; she could not, however, retain it for so long a time as before the disease exis.ed; I believe not longer than two hours. But I have performed the same operation since in several other cases with a still more favorable result. In two of them I ascer- » CALCULUS IN THE FEMALE. 201 tained that the urine was perfectly retained afterwards. The stones, however, in these cases were of moderate size. Where the stone is large, 1 suspect that there is no method of removing it entire from the female bladder without an incontinence of urine, to a greater or less extent, being a consequence of the operation. 26 202 LITHOTRITY. LECTURE XV. LITHOTRITY. Until within the last few years, lithotomy was the only method practised by surgeons for the purpose of extracting calculi from the bladder. In the year 1S21, Sir Astley Cooper first succeeded in the removal of small calculi by means of the urethra forceps. Since then a still more important addition has been made to our means of relieving patients afflicted with this malady, by the invention of an operation which has for its object to crush the calculus, and thus en- able it to escape, or be withdrawn from the bladder and urethra in fragments. Various individuals have claimed some share of the credit of in= troducing this operation to the world. As long ago as the year 1775, General Martin, then a resident in India, contrived to pass an instrur ment through his urethra into the bladder, which he employed as a rasp, by means of which he was enabled to detach small fragments of a calculus. It was generally believed that he had succeeded in ef- fecting a cure of his complaint. But the report was exaggerated, as is proved by the singular history of his case, published by Sir Eve- rard Home at the end of the second volume of his Observations on Diseases of the Prostate Gland. In the year 1817, Mr. Elderton, formerly a student in attendance on my lectures, sent for my inspection the plan of an instrument which he proposed to make with a view to ibis kind of operation; but, as far as I know, no such instrument was ever employed on the living person. But whatever may have been thought, or said, or planned by others, there seems to be no doubt that the individual who first ac- tually practised this method of treating calculous disorders was M. Civiale of Paris, and to him therefore the world is mainly indebted for this great improvement in surgery. It scarcely ever happens, however, that an invention is perfect in the first instance; and ihe operation which I am about to describe is not that which was introduced by M. Civiale formerly, npr which that distinguished surgeon himself practises at the present lime. Many years ago Mr. Weiss made an instrument on the principle LlTHOTRIT?. 203 of what I have called the sliding forceps, having a screw attached to it for the purpose of dividing calculi, while still in the bladder, into fragments; but it was of rude construction, and such as it then wras, was certainly not fitted for use on the living person. Some time after M. Civiale had begun to practise the mechanical destruction of calculi in Paris, Baron Heurteloup engaged in the same undertaking in this country. At first he pursued M. Civiale's meth- od of operating; but finding it liable to some very serious objections, he adopted the principle of the sliding forceps invented by Mr. Weiss, at the same time modifying its shape so as to render it more conve- nient for being passed into the bladder, and for seizing and retaining the stone afterwnrds. Besides this he made another change in the instru- ment, rejecting the screw, and substituting for it a peculiar apparatus which enabled him to crush the calculus by the stroke of a hammer. Now the first of these alterations made by Baron Heurteloup I believe to have been of essential importance; in fact, without it the instru- ment would have remained wholly inapplicable to any useful purpose. But as to the second alteration I cannot say that any thing that I have seen, either in my own practice or in that of others, would lead me to regard it as being any improvement whatever. On the contrary, all the experience which I have had would lead me to believe that in those cases, to which this operatian can be properly applied, there is no- thing that can be done by the hammer which may not be done quite as effectually by the screw, while the latter method is not liable to many- serious objections which may be urged against the former. It is not, however, my intention to enter into any critical discus- sion of the comparative merits of these two methods of proceeding. My principal object in these lectures is to give you the results of my own experience, to put youas nearly as I can do so in my own place; and T shall, therefore, without further comment, proceed to explain the steps of the operation which 1 have myself adopted, and which I would recommend you to practise. The instrument made by Mr. Weiss, and which seems to me to be not capable of much improvement, consists of a very strong sliding forceps, having adapted to it a'handle, in which is a screw, by means of which the forceps may be closed with sufficient force to break the calculus, which is seized between the blades. The average length of Mr. Weiss's instrument is about eleven inches exclusive of the han- dle. It is quite straight for about the first nine inches, while the re- maining two inches, or two inches and a half, at ihe extremity remote from the handle, are bent with a more sudden turn than is usual in a catheter. You will require to be provided with several instruments of this kind of various sizes, and with some variety of shapes. For calculi of a small size the construction (except as to the addition of the screw) need scarcely differ from that of ihe common urethra-forceps which I described formerly: but for larger ones the opposite blades 204 LITHOTRITY. of the forceps should be furnished with projections or teeth; and for those of a still larger size you will find it convenient to be provided with a forceps, in the fixed blade of which there is a longitudinal slit, while there is a corresponding wedge-like projection, fitted lo enter the slit, in the opposite surface of the movable blade. In using this instrument you will extract no fragments of the calculus at ihe lime; theyr will drop into the bladder through the longitudinal aperture; but there is this advantage in it, that it will enable you to crush a calculus which might not be easily crushed otherwise, and, in fact, one of any magnitude. On some occasions you will require an instrument of greater length than those which I have mentioned. I have one thirteen inches long, which I had made for a patient with an enormous irreducible inguinal hernia, and in whom the common forceps would scarcely reach the neck of the bladder. The diameter of the lithotrity-forceps mayr vary according to the size of the calculus and that of the urethra. As a general rule, and as a measure of security, it should be as large as the urethra will readi- ly admit. With the same view care should be taken that the steel is properly tempered, sufficiently so to prevent it being liable to bend, and not so much as to make it brittle. For obvious reasons the lithotrity-forceps should be of a cylindri- cal form in every part, except, of course, in the handle. -You will, however, find it convenient to be provided with one, the blades of which beyond the curvature are somewhat flattened, and in propor- tion broader than elsewhere. I saw such an instrument in the hands of M. Civiale, and have found it very useful for the purpose for which he recommends it; namely, the seizing and crushing the smaller frag- ments after all the larger ones have been disposed of. I shall point out to you hereafter the class of cases lo which, as it appears to me, this operation is especially applicable. But it being admitted that a particular case is of this description, still it is neces- sary that ihe patient should be placed in the most favorable condition for the performance of the operation, and some preparatory measures are usually required for this purpose. As I have observed on a former occasion, the forceps should never be used in an empty bladder, nor in one which cannot retain at least six ounces of water without inconvenience. Often when you are first consulted the bladder is so irritable that the patient strains to emply it even when there is not more than two ounces of urine in it. Under these circumstances he ought to remain, not only in a state of repose, but absolutely in the recumbent posture, and once daily, or in some LITHOTRITY. 205 ins tances on the alternate days, a catheter having been introduced, some ounces of tepid water should be injected into the bladder by means of a syringe. In this manner the bladder will be gradually ren- dered more capacious, so that in a course of a wTeek or ten days you will be enabled to proceed to the operation. It may be that the bladder is not only irritable, so that it will not con- tain more than a very small quantity of liquid, but that its lining mem- brane is affected with a chronic inflammation, causing a large deposit of adhesive mucus in the urine. Here, also, it is advisable to defer the operation, and in addition to the recumbent posture, and the injection of tepid waler, you may prescribe narcotics, the decoction of the pa- reira brava, and such other remedies as are useful in cases of chronic inflammation of the bladder under other circumstances. An abun- dant formation of adhesive mucus always forms a great objection to any attempt being made to crush a calculus; first, because it indicates such a condition of the bladder as would render it but ill capable of bearing the disturbance which the operation must in a greater or less degree occasion; and, secondly, because the circumstance of the frag- ments of the calculus being liable to become entangled in the viscid secretion forms a considerable impediment to their being seized by the forceps, as well as no their escape afterwards. It is otherwise where the mucus exists only in small quantity. This forms no objection to the performance of the operation; and indeed it vvill often happen that the bladder is sensibly relieved, and that the mucus altogether disappears after the first crushing of the calculus, and even before there has been time for any of the fragments to come away. _ It is necessary that the urethra should be capable of admitting an instrument of sufficient size and strength for crushing the calculus. A small urethra may be required lo be dilated by the occasional intro- duction of a bougie. In some instances there is a natural contraction of the urethra immediately behind, or even within the glans, which cannot easily be dilated by common means, and which it is best to di- vide with a bistoury. I shall explain hereafter that there are certain states of enlarged prostate gland which are very unfavorable to the operation, making it either very difficult or wholly impracticable. There are other ca- ses in which there seems to be a tumid condition of the prostate gland, forming no small impediment to the introduction of the instrument, and rendering the part liable to bleed on the attempt being made, but which being the result of accidental causes will subside after a few days of constant repose in the recumbent posture. I have observed this state of things lo exist especially after traveling in a carriage; and it forms one of many reasons, where the patient has come from a distance, for not recommending the operation to be had recourse to until he has had ample time to recover from the fatigues of his journey. It being supposed that the necessary precautions have been taken, 206 LITHOTRITY. and that there is no reason for further delay as to the performance of the operation, we have to consider the steps of the operation itself. The patient should be placed in the recumbent posture, lying on his back, either on a sofa, or on the edge of a bed, with his feet sup- ported by two chairs. In the former case the surgeon will be on one side, and in the latter he will be immediately in front of the patient. A bolster or thick cushion should be placed under the pelvis so as to keep the neck of the bladder somewhat elevated. A silver catheter is then to be introduced into the bladder, through which, by means of a syringe, such a quantity of tepid water should be injected as can be easily borne. The catheter used for this purpose should be pro- vided with a stopcock, and the extremity7 of it should not be prolong- ed a great deal beyond the curvature. It may then be used, not on- ly as a catheter, but also as a sound, for the purpose of exploring the bladder, and ascertaining in what part of the bladder the calculus is, at that time, lodged. This knowledge is always useful, but it is by no means indispensable; and I have often been able to seize a small stone with the forceps which I had not been able to detect by other methods previously. The injection of the bladder having been com- pleted the catheter is to be withdrawn, and the lithotrity-forceps is to be introduced in its place. In consequence of the peculiar shape of the latter this is less easily accomplished than the introduction of the catheter. The mere depression of the handle is not always sufficient to make it enter the bladder; and it is often necessary at the same time to apply a moderate but steady force during the time that the curved part of the instrument is passing through the neck of the bladder. This is especially the case where the prostate gland is in any degree enlarged. You will know when the instrument has fairly entered the bladder by the facility with which you can move it in any direction, and by your being able to open the bladder to any extent without giving the patient pain. You may then explore the bladder with the forceps, and endeavor to ascertain the exact situation of the calculus in it. If it be lying on one side, by opening the blades, and then gently and cautiously turning them towards it, you will probably be enabled to seize it. If you do not succeed by this method, by the following you will rarely fail. Raise the handle of the forceps so as to bring the convexiiy of the fixed blade in contact wilh the posterior part of the bladder; then open the movable blade, at the same time making a moderate pres- sure downwards in such a manner as to depress the bladder towards the rectum. The instrument being then gently shaken by a lateral motion of the hand, ihe calculus, in whatever part of the bladder it may be situated, will roll between the blades and will be seized by closing them. Having been thus carefully secured, by turning the screw it is broken into fragments. The whole of ibis is a very sim- ple process, requiring but little practice to make you a perfect master LITHOTRITY. 207 of it. When the calculus has been once broken, the fragments are to be seized and crushed in the same manner. They will fall one after another into the grasp of the forceps; and there is no limit to the number that may be crushed at one time, except what is afforded by the diameter of the urethra. Every fragment that is crushed adds to the accumulation of calculous matter; and if the accumulation be very large, it becomes difficult, or impossible, to withdraw the instru- ment without injury to the membrane of that canal. The marks on the handle of the instrument inform you of the exact extent to which the blades are separated; and you must use your own discretion, founded on your knowledge of the size of the urethra, as to the point at which you should stop. The forceps first used being then withdrawn, you may use a second, and even a third, in the same manner; and thus you may not only crush a great number of frag- ments at one operation, but you may remove from the bladder a great deal of what has been crushed. I have said that, lest the urethra should be injured in this part of the operation, you are to be careful to withdraw the forceps before the blades are too much separated from each other by the calculous matter collected between them. Wilh the !,ame view you should withdraw it slowly and gently, as it is better that the urethra should be gradually dilated than that it should be forcibly stretched, or bruised, or lacerated. The directions which 1 have just given will apply to all cases in which the calculus is of moderate dimensions. But when you have reason to believe that it is of larger size it will be more prudent to use, in the first instance, the lithotrity-forceps which I have already described as having a longitudinal slit in the fixed blade, and a cor- responding wedge-like projection in the movable blade. I believe that there is scarcely any calculus, however large, which will not yield to the pressure of this instrument. It is true that it will simply break it into fragments, and that none of the latter will be brought away between the blades. But it is required only in the first instance, and the common forceps, which answer both purposes, may be used afterwards. When as much has been done as you think can be done with pru- dence at one operation, the catheter should be again introduced, and the bladder emptied of the water which it contains. Another syringe. full of water may then be injected, which the patient may be left to void by his own efforts, or which may be drawn off by means of a lar-e catheter, with two appertu.es near the extremity of sufficient sizl to allow some of the smaller fragments to escape through them. I have heard of a patient being allowed to walk about as usual im- mediately after the operation. But I am satisfied that this a most un- safe and imprudent practice, and that it is much wiser to insist on his remaining quiet on a sofa or in bed. It is often prudent to administer 208 LITHOTRITY. a dose of opium afterwards; and at any rate this should always be done when the forceps has had a good deal of calculous matter ac- cumulated in it, so that the urethra must have been forcibly dilated during their extraction. Such forcible dilatation or stretching of the urethra is in the greater number of instances followed by a rigor; and a dose gS opium administered after the operation will seldom fail to prevent this ill consequence. An aperient pill composed of the com- pound extract of colocynth, combined with the pilula hydrargyria may be administered in the evening, with a view to counteract the in- fluence of the opium in stopping the action of the bowels and the se- cretion of the liver. It is necessary that you should watch the patient afterwards, lest he should suffer from retention of urine, produced by the lodgment of some of the remains of the calculus in the urethra, and which might render the introduction of a small catheter necessary. But this is an inconvenience which very rarely occurs, where the patient remains in a state of repose after the operation; and, indeed, it is remarkable, that the fragments left in the bladder often do not seem to find their way into the urethra for the first day or two after the calculus has been crushed. From this period they begin lo pass away with the urine; and the patient should be desired to collect and preserve them, in order that you may be enabled to form some kind of opinion as to the bulk of the calculus which has been broken down. For the most part the escape of the fragments takes place without difficulty, and with little inconvenience lo the patient. I never met with but two instances in my own practice, in which the lodgment of them in the urethra was productive of any real harm, and of these I shall give you an account hereafter. When a calculus is of small size, and there is no unusual irritabili- ty of the bladder, a single operation is often sufficient for the patient's cure. In less favorable cases it may be necessary to repeat it sever- al times. The intervals between the respective operations must vary according to circumstances; the only rule that can be laid down be- ing, that the operation should never be repeated until the patient has recovered from the effects of what had been done previously, and that it should not be delayed long afterwards. It is, of course, of essential importance that every portion of the calculus should find its way out of the bladder; and a principal ob- jection made to this operation has been, that the smallest fragment if it so happens that it has been left behind, will occasion a recurrence of the disease. To prevent so great an evil it is necessary that you should explore the bladder carefully, not only with the sound, bu" with the forceps, at least twice after you have had reason to be ieve that the cure was complete; and with this precaution, according to SLr^T"'m TeS in, which the Patie°t is able to empty the bladder by his own efforts, the chance of a fragment remaining oVrm LITHOTRITY. 209 the nucleus of a future calculus is so small that it need not enter into your calculations. But it is quite otherwise in those cases in which the patient, in consequence of an enlargement of the prostate gland, is unable to empty the bladder by his own efforts. Hence only a small portion of the crushed calculus will come away in the stream of urine, and you must be satisfied with washing out the remainder of it through the catheter by repeated injections of tepid water. Mr. Weiss has invented a forceps which, when the blades are opened in the bladder, answers at the same time the purpose of a catheter, and this is often very useful; still on ordinary occasions you will find no- thing to answer the purpose better than a silver catheter of as large a size as the urethra, with two very large apertures near the closed ex- tremity, not placed laterally, as in ordinary catheters, but one on the anterior or concave, and the other on the posterior or convex sur- face. It may indeed be said, that, in the cases now referred to, this kind of operation ought not to be recommended. But it will some- times happen, that although the patient may have had no difficulty of emptying the bladder before the operation, the prostate may be ren- dered tumid in consequence of its being irritated by the repeated in- troduction of instruments, so that he is unable to empty the bladder afterwards. Besides, although this state of things adds to the diffi- culty of the operation, it is not in itself sufficient to prevent it being brought to a successful termination; and in cases in which there is good reason to believe that the calculus is of a small size, it forms no objection to it. The effects of a surgical operation are seldom merely negative; and a prudent surgeon before he undertakes it vvill feel that it is his duty to look, not merely at the favorable, but also at the unfavorable results, by which it may be followed. We can by no other means form a just estimate of what the operation is really worth, and in this, as in all other cases, the first step towards avoiding a threatened evil, is to know what the evil really is, and what are the peculiar circum- stances to which its existence may be traced. It may be said, that haemorrhage is one of the inconveniences at- tendant on the operation of lithotrity. It may arise from the forcible introduction of the lithotrity-forceps through the neck of the bladder, where the prostate gland is somewhat enlarged; or, from the dilata- tion of the prostate and urethra in the act of withdrawing the forceps, when the blades are charged with a considerable accumulation of the crushed calculus matter. The loss of blood, for the most part, does not amount to more than a few drops; but in some instances I have known it to be sufficient to discolor the urine for one or two days af- terwards. In a former Lecture I have referred to certain cases of enlarged prostate, in which the vessels of that gland are so turgid with blood as to be liable to bleed profusely, even on the introduction of a catheter, and I conclude that, in such cases, considerable haemorrhage 210 LITHOTRITY. would also follow the use of the lithotrity-forceps. They must, bow- ever, be of rare occurrence, as I have met with no instances in which haemorrhage has taken place to such an extent as to interfere with the complete performance of the operation. The occurrence of rigors is another ill consequence of lithotriiy in some instances. 1 have already mentioned that a rigor is usually produced by the stretching of the urethra at the time of the forceps being withdrawn from the bladder, and that, in most instances, it may be prevented by the exhibition of a dose of opium immediate- ly after the operation. This symptom may, however, arise from oth- er causes; as, for example, from a fragment of calculus finding its way into the urethra, which is too large to be expelled by the pres- sure of the stream of urine; and it sometimes happens that the effect of a dose of opium is, not to prevent the rigor altogether, but to cause it to be deferred until the following day. The liability to rigors, however, where due precautions are used, is seldom such as to in- terfere in any great degree wilh the process necessary for the patient's cure, and his ultimate recovery; and 1 never met with a case in which it could be said to have done so, unless, indeed, we suppose it to have exercised an unfavorable influence, by hastening the pro- gress of disease of a kidney, in a case, the particulars of which I shall have occasion to mention before this Lecture is concluded. I have already referred to two cases in which there is reason to be- lieve that a fragment of a calculus impacted in the membrane of the urethra had been concerned in producing an urinous abscess of the perineum. In each of these there was a good deal of pain, and con- stitutional disturbance, until the abscess was opened, and this being done, the symptoms were immediately relieved. The first of these patients labored under symptoms of renal disease, under which he gradually sunk, and died at the end of about two months after the ab- scess was opened; a tumor having some time before his death present- ed itself in the abdomen, which 1 believe to have had its seat in one of the kidneys, though I had not the opportunity of ascertaining the fact by a post-mortem examination. In the oiher case, the opening in the perineum healed, under very simple treatment, and the patient was soon restored to health. The rule of practice which applies to other abscesses in the perineum applies to these also. They cannot be opened at a loo early period, and they become dangerous when this operation is delayed. In some instances the patient complains of pain referred to the whole canal of the urethra, in consequence of a considerable num- ber of fragments escaping at the same time. In others, he expe- riences much irritation of the bladder, and an incessant desire lo void bis urine, apparently produced by a fragment remaining for some time lodged in the urethra, close to the neck of the bladder. It is evi- dent that the lodgment of a large portion of a calculus, or an ac- LITHOTRITY. 211 cumulation of small ones in any part of the urethra, may occasion an absolute retention of urine. This is, however, a rare occurrence, as I have not met wilh it, except where it lastedjonly for a limited pe- riod of time, in tny own practice. Of course, a diminution, and of- ten a great diminution, of the stream of urine is always to be looked for, while the fragments are coming away, and the involuntary strain- ing to make water, which this occasions, is a principal agent in the final expulsion of them from the urethra. With a view to promote ihe escape of the fragments, by increas- ing the flow of the urine, the patient may be directed to drink plen- tifully of barley water and other diluting liquors. Where any kind of inconvenience arises from the retention of the fragments in the urethra, a catheter, of a middle size, may be introduced carefully into the bladder. In some cases it will, by making even a slight al- teration in their position, enable them to come away easily, though they seemed to be almost immovable before. In other cases it may push them back into the bladder, to be more minutely crushed at the next operation. 1 have sometimes gven the patient relief by extract- ing portions of a calculus which lay in the anterior part of the ure- thra, wiih a long slender forceps, and I suppose that cases may oc- cur, in which a fragment may be so completely impacted in the ure- thra, as to make it necessary lo make an incision in the perineum or penis for its removal. I have not, however, ever had occasion to resort to this expedient in my own practice. But in all cases prevention is better than cure, and the means of preventing the evils which have been just described are very much in our own power, and in that of our patients. A state of perfect repose, in the recumbent posture, except when it is necessary to re- move from one room to another, should be considered as indispensa- ble after the operation, and I venture to say, that where this rule is observed, it will very seldom happen that the passage of the frag- ments along the urethra is productive of any serious inconvenience. Inflammation of ihe mucous membrane of the bladder, indicated by a deposit of adhesive mucus from the urine, and a too frequent micturition, with more or less of a febrile excitement, of the system, is sometimes an immediate result of the operation, subsiding spontane- ously in the course of two or three days. Occasionally it seems to be connected wiih the lodgment of some fragments of the calculus in the neck of the bladder, and continues until they are removed from that situation, either by passing forwards along the urethra, or by being pushed backwards into the bladder by the catheter. Sev- eral years ago I was called to see a case in consultation, in which, after the breaking of a calculus, severe inflammation of the bladder followed, continuing, in spite of all remedies employed, until, at the end of three or four weeks, it terminated in the patient's death. The calculus, in this case, had been of a very large size, and the nume- 212 LITHOTRITY. rous fragments into which it had been divided might reasonably be supposed to have been an abundant source of irritation. But, in ad- dition to this, I have good reason to believe, that the patient had not remained in that slate of complete repose, which, for other reasons, I have already recommended, and which seems to be, on every ac- count, necessary to his security after the operation. It is due to you, that you should be made acquainted with the un- favorable circumstances which may attend on this mode of treatment; but you are not to suppose that it often happens that these exist to any considerable extent, or that the probability of their occurrence is sufficient to counterbalance the great advantages which the new opera- tion often presents over that of lithotomy. It would be a great error to represent it as preferable on all occasions; but it is so in a great many instances; and I shall next endeavor, as a guide for your future practice, to explainjby what signs you may distinguish from each other the cases to which it is applicable, and those to which it is not. In boys under the age of puberty lithotomy is so simple, and so • generally successful, that we ought to hesitate before we abandon it for any other kind of operation. There is also a manifest objection to lithotrity in these cases, on account of the small size the urethra, which is such that it would not admit of the introduction of instruments of sufficient strength to crush a calculus of more than moderate dimensions. In the female sex the extraction of a calculus from the bladder by the ordinary methods is attended with little danger; while the opera- tion of crushing it is rendered difficult, in consequence of the short and wide urethra allowing the water which has been injected into the bladder to escape by the side of the lithotrity-forceps before the ope- ration is completed. In cases in which the calculus has attained a very large size, it is often difficult to seize it with the lithotrity-forceps; the operation of crushing requires to be repeated a great number of times so that many weeks may elapse before the cure is accomplished* a larger quantity of fragments is left in the bladder, of which the ne- cessary consequence is a great liability to inflammation of the mucous membrane; and of course the inconvenience produced by the passage of the fragments along the urethra is multiplied, as compared wuh what happens when the calculus is smaller. These circumstances form a sufficient objection to the operation of lithotrity in these cases. It is true, that they are unfavorable cases for lithotomy also; but I have little doubt that the latter method is the safer of the two. It admits of a question, whether, in such cases, the two modes of ope- rating may not be advantageously combined, the calculus being crush- ed into three or four pieces first, and extracted by the usual incision afterwards. The operation of lithotrity, as I have already observed, is not well adapted to those cases of enlargement of the prostate LITHOTRITY. 213 gland, in which the patient is enabled to empty the bladder by his own efforts, unless the calculus be of a small size, so that there may- be no great difficulty in washing the minute fragments, into which it has been crushed, out of the bladder through a large catheter. There is also another objection to the operation in some cases of enlargement of the prostate, namely, that the tumor which projects from it into the cavity of the bladder, makes it difficult to elevate the handle of the forceps sufficiently to seize the stone easily in the usual manner. I have described the dangers which attend on lithotomy in those cases in which a calculus of the bladder is complicaied with disease of the kidney. One of the principal of these is connected with the loss of blood, which that operation must always occasion to some extent, and not unfrequently to a great extent, in spite of the best exertions of the surgeons to prevent it. I have no doubt that, in such cases, the operation of crushing is the safest method of proceeding; but a small shock to the system will sometimes destroy the life of a patient who labors under renal disease, and it vvill be of- ten more prudent to trust to the means which we possess of palliating his sufferings, than to run the risk of shortening his life in the endeav- or to obtain a cure. The case which I am about to describe is, in many respects, interesting, and especially so as it serves to illustrate the ill consequences which may follow even a trifling operation, where there is a considerable disease of the kidney. A gentleman consulted me in the year 1836 on account of calculi in the bladder. Six months previously he had been placed under cir- cumstances which compelled him to retain his urine for an unusual length of time, and he experienced great distress in consequence. From that period he had suffered more or less from pain in the loins, to which the usual symptoms of calculi of the bladder were superadded afterwards. He presented no appearance of ill health otherwise . Having injected the bladder with tepid water in the usual manner, I seiz- ed two very small stones with the lithotrity-forceps, and crushed them, extracting nearly the whole of the fragments between the blades of the instrument. All this was accomplished without the smallest delay or difficulty; but the patient was seized with a rigor afterwards. At the end of about forty-eight hours he was suddenly attacked by a most severe and agonising pain referred to the loins, which could only be mit- igated by a large dose of opium. In the course of a few hours ihe pain had subsided, and the pulse, which had been very frequent while the pain lasted, was reduced to the ordinary standard. After two days more he had another similar attack, which subsided like the for- mer one, leaving him apparently perfectly recovered. Subsequent- ly he had many other attacks of the same kind, lasting for a longer time, and recurring at shorter intervals, one of them being preceded by a severe rigor. The pulse now remained always increased in fre- 214 LITHOTRITY. quency, the skin was hot, delirium alternated with drowsiness, and the patient gradually sunk, and died on the tenth day after the operation. On examining the body, the bladder was found in a perfectly healthy state, except that it contained four small calculi, not larger than horse- beans, which, if the patient had survived, wouhl have been easily crushed by another operation. The right kidney was very little al- tered from its natural condition. The left kidney was of double the ordinary size. The investing membrane adhered more closely to the surrounding adeps than to the kidney itself, and when it was removed the surface of the kidney presented a mottled appearance, in conse- quence of a great number of depositions of straw-colored lymph in its substance. The membrane of the infundibula and pelvis was in- flamed, and these cavities contained a considerable quantity of dark- colored muco-purulent fluid. With the exception of such cases as those which have been enu- merated, there are few to which this method of treatment may not be advantageously applied. It may be said that the exceptions are nu- merous: but they are the result chiefly of delay. If a patient seeks the assistance of a competent surgeon within six or even twelve months after a calculus has descended from the kidney into the bladder, the urine having remained acid, it will rarely happen that he may not ob- tain a cure by a single operation, and with so small an amount of dan- ger that it need scarcely enter into his calculations. As time advan- ces, the facility with which he can be relieved diminishes, and after the lapse of two or three years, especially if the urine has become alkaline, it is probable that the calculus will have attained such a size as to render the old operation preferable, and that the ac- cess of disease in the bladder or kidneys may render any operation hazardous. It would be absurd to say, and it would be unreasonable of human-kind to expect, that an operation which has for its object to relieve them of a disease so terrible as that of a stone in the bladder, can be always free from inconvenience, and difficulty and danger. Nevertheless, from what experience I have had, I am satisfied that the operation of lithotrity, if had recourse to only in proper cases, is not only much more successful than that of lithotomy, but that it is lia- ble to fewer objections than almost any other of the principal opera- tions of surgery. THE END. I i : TO THE MEDICAL PROFESSION. LEA AND BLANCHARD present a condensed list of Books published and preparing for publication by (hem, and would refer to the other pages of their catalogue for a more detailed account. The prices, and all other information in relation to them, will be given on application, free of postage. Being extensively engaged jn the publication of Medical and Scientific works, it will be their effort to furnish them at prices lower than I formerly, and as low asjhey can be afforded consistent with correct and well-eixeeuted editions. The latest ^editions will always be furnished; and, to their present extensive list, they -will add, from time to time, such other good works as the wants of the profession may call for. Their publications may be found at all the prin- cipal Bookstores throughout the Union. Anatomical Atlas, by Smith and Horner, imperial 8vo., nearly 650 figures. Arnott's Elements of Physics, new edition, in 1 vol. 8vo., 484 closely printed pages. American Medical Journal, published quarterly at $5 a year. Abercrombie on the Stomach, 1 vol. Svo., 320 pag«s. AbeTcrombie on the Brain, a new edition, 1 vol. 8vo., 824 pages. Alison's Outlines of Pathology, in 1 vol. 8vo., 420 pages. Ashwell on the Diseases of Females, complete in one large vol. 8vo. * Andral on the Blood, 120 pages, 8vo. Bird's Natural Philosophy, 1 vol. 8vo., preparing. Budd on the Liver, 1 vol. 8vo., preparing. Bell on the Teeth, with plates, 1 vol. 8vo., 351 pages. Buckland's Geology and Mineralogy, 2 vols. 8vo., with numerous plates and maps. Berzelius on the Kidneys and Urine, 1 vol. small 8vo., 179 pages. Bridgewater Treatises, with numerous illustrations, 7 vols. 8vo., 32S7 pages. Bartletton Fevers, &c, 1 vol. 8vo., 393 pages. Bartlett on the Philosophy of Medicine, 1 vol. 8vo., 312 pages. Brigham on Mental Excitement and Cultivation, 1 vol. 12mo., 204 pages. Billing's Principles of Medicine, 1 vol. 8vo., 304 pages. Brodie on Urinary Organs, 1 vol. 8vo., 214 pages. Brodie on the Joints, 1 vol. 8vo., 216 pages. Brodie's Surgical Lectures, 1 vol. 8vo., at press. Chapman on Thoracic and Abdominal Viscera, 1 vol. Svo., 384 pages. Chapman on Fevers, Dropsy, Gout, &c, 1vol. 8vo.,450 pages. Chitty's Medical Jurisprudence, 1 vol. Svo., 509 large pages. Carpenter's Human Physiology, 1 vol. Svo., 618 pages. with cuts. Carpenter's General and Comparative Physiology, 1 vol. 8vo., preparing. Carpenter's Vegetable Physiology, 1 vol. 12mo., with cuts, 300 pages. Carpenter's Animal Physiology, to be published here- after. Cogper, Sir Astley, his work on Hernia, imperial 8vo., with plates, 428 pages. Cooper on Dislocations and Fractures, 1 vol. 8vo., with Cuts, 499 pages. Cooper on the Testis and Thymus Gland, 1 vol. impe- rial 8vo., many plates. Cooper on the,Anatomy and Diseases of the Breast, 1 vol. 8vo., plates, at press. Obndie on Diseases of Children, 1 vol. 8vo., 651 pages. Costello's Cyclopaedia of Practical Surgery, to be pub- lished hereafter. Chojchill oh Females, 3d American edition, 1 vol. 8vo., 572 large pages, Churchill's Theory and Practice of Midwifery, 1 vol. 8vd., 519,pages, with cuts. Cyclopaedia of Practical Medicine, by Forbes. &c. Edited by Dunglison, in 4 large super-royal vols. Carson's Medical Formulary, in preparation. Dewees's System of Midwifery, with plates, 10th edit., 600 pages. Dewees on Children, 8th edition, 548 pages. Dewees on Females, with plates, 8th edition,532 pages. Dunglison's Physiology, 5th edition, 2 vols. 8vo., 1304 pages, with 300 cuts. Dnnglisoil's Therapeutics and Materia Medica, a new i work, 2 vols. 8vo.. 1004 pages. Dunglison's Medical Dictionary, 4th edition, lvol. 8vo., 771 very large pages. Dunglison's New Remedies, 5th edition, 1843,615 pages. Dunglison on Human Health, in 1 vol. Svo., 464 pages. Dunglison's Practice of Medicine, 2d edition, 2 vols. esvo., 1322 pages Dunglison's Medical Student, a new edition, 1 vol. 12mo., 312 pages. j Drain's Modern Surgery, 1 vol. 8vo., 534 pages, 2d edition, many cuts/ "Ellis's Medical Formulary, 7th edition, 1 vol. Svo., 262 pages. Elliotson's Mesmeric Cases. 8vo., 56 pages. Esquirol's Great Work on Insanity, translated by Hunt, 1 vol. 8vo., nearly ready. f Fownes's Elementary Chemistry, preparing. Fergusson's Practical Surgery, 1 vol. 8vo., 629 pages. Graham's Chemistry, with cuts, 1 vol. 8vo., 750 pages. Goddard's Dissector's Companion, in preparation. Gregory's Chemistry, 1 vol.8vo., preparing. Guthrie on the Bladder and Urethra, 1 vol. 8vo., at press. Hoblyn's Dictionary of Medical Terms, by Hays, I vol. 12mo., at press. Harris on the Maxillary Sinus, 1 vol. small 8vo., 165 pages. Horner's Special Anatomy, 2 vols. 8vo., 6th edition. 1114 pages. Hodge on the Mechanism of Parturition, in 1 vol. 4to., with many plates, (preparing.) Hope on the Heart, 1 vol. 8vo., 572 pages. Harrison on the Nervous System, 1 vol. Svo., 292 pages. Jones and Todd on the Ear, 1 vol., preparing. Kirby on Animals, many plates, 1 vol. 8vo., 519 pages. Lawrence on the Eye, 1 vol. 8vo., 77S pages. Lawrence on Ruptures, 1 vol. Svo., 430 pages. Miller's Principles of Surgery, 1 vol. Svo. Medical Botany, with numerous cuts, preparing. Maury's Dental Surgery, with plates, a new work, 1 vol. 8vo., 285 pages, Mutter's Surgery, 2 vols. 8vo.,now in preparation, with cuts. Mullet's Physiology, 1 vol. 8vo., 886 pages. Manual of Ophthalmic Medicine and Surgery, to be published hereafter. Medical News and Library, published monthly. Meigs's Translation of Colombat De L'Isere on the Dis- eases of Females, 1 vol. 8vo. Prout on the Stomach aud Renal Diseases. 1 vol. 8vc, with coloured plates, 465 pages. Popular Medicine, by Coates, 1 vol. 8vo., 614 pages. Philip on Protracted Indigestion, 1 vol., 240 pages. Pereira's Materia Medica, 2 vols. Svo., 1566 very targe and closely printed pages. Roget's Animal and Vegetable Physiology, with many cuts, 2 vols. 8vo., 871 pages. Roget's Outlines of Physiology, 1 vol. 8vo., 516 pages. Rigby's System of Midwifery, 1 vol. 8vo., 491 pages. Ricord on Venereal, new edition, 1 vol. 8vo., 256 page's. Ramsbotham on Parturition, with numerous plates, 1 vol. imperial 8vo., 458 pages. Robertson on the Teeth, 1 vol. 8vo., 229 pages. Stanley on the Bones, 1 vol. 8vo., preparing. Squarey's Agricultural Chemistry, 12mo., 150 pages. Select Medical Essays by Chapman and others, 2 vors. 8vo.. 1149 pages, double columns. Taylor's New Work on Medical Jurisprudence, by Griffith, 1 Vol. Svo., 540 pages. Tweedie's Library of Practical Medicine, 3 vols. 8vo., 2d edition, revised, 2016 large pages. Traill's Medical Jurisprudence, 1 vol. 8vo., 234 pages. Trimmer's Geology and Mineralogy, with many cuts. 1 vol. Svo., 527 pages. Todd's Cyclopaedia of Anatomy and Physiology, to*e published hereafter. Walshe's Diagnosis of the Diseases of the Lungs, 1 vol. 12mo., 310 pages. Watson's Principles and Praetice of Physic, 1 vol. 8vo., 920 very large pages. Wilson's Human Anatomy, with cuts, 1 vol. 8vo., a new and improved edition, 608 pages. -y Wilson's Dissector, or Practical and Surgical Anato- my, by Goddard, with cuts, 1 vol. 12mo., 444 pages. Wilson on the Skin, 1 vol. Svo.. 370 pages. Youatt on the Horse, by Skinner, with cuts, 443 pages, 1 vol. Svo. Youatt and Clater's Cattle Doctor, 1 vol. 12mo., with, cuts. 2i-2 pages. Williams's Pathology, or Principles of Medicine, 1 vo 8vo.. 3^3 pages. Williams'* Lectures on Stomach, Brain, &c, 1 vo Pvo.. preparing. Williams on Respiratory Organs, by Clymer, 1 vo 8vo., 500 pages. They have other works in preparation, not included in this list. JUST ISSUED BY LEA & BLANCHARD. WILLIAMS AND CLYMER ON THE RESPIRATORY ORGANS, ETC. A TREATISE ON THE 'DISEASES OF THE RESPIRATORY ORGANS, INCLUDING THE TRACHEA, LARYNX, LUNGS, AND PLEURA. Br 'CHARLES J. B. WILLIAMS, M. D., Consulting Physician to the Hospital for Consumption and diseases of the Chest; Author of " Principles of Medicine," &c. &c. WITH NUMEROUS ADDITIONS AND NOTES. By MEREDITH CLYMER, M. D., Physician to the Philadelphia Hospital. In One neat 8vo. Volume, with Cuts. NOW READY, ANOTHER VOLUME OF THE SERIES OF SIR ASTLEY COOPER'S WORKS. ON THE STRUCTURE AND DISEASES OF THE TESTIS, ILLUSTRATED BY 120 FIGURES. From the Second London Edition. By BRANSBY B. COOPER, Esq. "The republication of this splendid volume supplies a want that has been very severely felt from the ex- haustion of the first edition of it . . . The extraordinary merits of this treatise have been so long and so univer- sally acknowledged, that it would be a work of supererogation to represent them in our pages. The practical surgeon who is not master of its contents, cannot be fully aware of the imperfection of his own knowledge oa tbe subject of diseases of the testicle."—British and Foreign Medical Review. AND ON THE ANATOMY OF THE THYMUS GLAm ILLUSTRATED BY 57 FIGURES. The two works together in one beautiful imperial octavo volume, illus- trated in the best style of lithography, and printed and bound to match the author's great work on Hernia, lately published. BRIGHAM ON MENTAL EXCITEMENT. REMARKS ON THE INFLUENCE OF MENTAL CULTIVATION AND MENTAL EXCITEMENT UPON HEALTH. . Third Edition. By A. BRIGHAM, M.D., Superintendent and Physician of the Stale Lunatic Asylum, Utica, N. Y. In One Vol. 12mo. This popular lfctle work has been reprinted in London, Edinburgh and Glasgow. In this third American Edition the author has included all the improvements of the three British editors, and has also added new matter which brings it up to the day, and rendera it still more worth/ of the favour it has so long enjpyed, 4 NOW READY, MEIGS'S TRANSLATION COLOMBAT DE L'ISERE OH THE DISEASES OF FEMALES, A TREATISE ON THE DISEASES'OF FEMALES, AND ON THE SPECIAL HYGIENK OF THEIR SEX. WITH NUMEROUS WOOD-CUTS. BY COLOMBAT DE L'ISERE, M. D., Chevalier of the Legion of Honour; late Surgeon to the Hospital of the Rue de Valois, devotc£tQ,the Diseases of Females. Sfc <$-c. A TRANSLATED, WITH MANY NOTES AND ADDITIONS, Bi C. D. MEIGS, M.D., Professor of Obstetrics and Diseases of Women and Children in the Jefferson Medical College,,cfe. 4'e- In One Volume, 8vo. The'notes and addenda of Professor Meigs are very extensive and valuable, bringing the whole upto the.day of publication, and' giving whatever may be necessary with regard to American practice. It forms a large octavo volume of near 700 pages, »vith numerous wood-cuts. LATELY ^PUBLISHER A NEW EDITION O? WILSON'S HTJMAN ANATOMY. MUCH IMPROVED. A SYSTEM OF HUMAN ANATOMY, GENERAL AND SPECIAL. By ERASMUS WILSON, M.D., SECOND AMERICAN EDITION. EDITED BY ,PAUL B. GODDARD, A.M., M.D., Lecturer on Anatomy, and Demonstrator in the University of Pennsylvania, <$-c. WITH OYER TWO HUNDRED ILLUSTRATION'S, ( Beautifully Printed from the Second London Edition. From the Preface to the Second American Edition. * The very rapid sale of the first edition of this work, is evidence of its appreciation by the profession, and 1.1 most gratifying to the author and American editor. In preparing the present edition no pains have been spared to render it as complete a manual of Anatomy for the medical student as possible. A chapter on. Histology has therefore been prefixed, and a considerable number of new cuts added. Among the latter, are. some veryfrnr ones of the nerves which were almost wholly omitted from the original work. Great care has also been taken to have this edition correct, and the cuts carefully and beautifully worked, and it is confidently believed that it will give satisfaction, offering a farther inducement to its general use as a Text Book in the various. College*."v LATELY PUBLISHED, A NEW AND MUCH LMPR.OVED EDITION OF DRUITT'SJUR &HE7. THE PRINCIPLES AND PRACTICE' OF MOURN S0R8ERY, By ROBERT DRUITT, Surgeon-. FROM THE THIRD LONDON EDITION. ILLUSTRATED BY ONE HUNDRED AND FIFTY-THREE WOOD ENGRAVINGS. WITH NOTES AND COMMENTS By JOSHUA B. FLINT, M.M. S. S. In One Volume, 8vo. '■An unsurpassable compendium not only of surgical but of medical practice."—London Medical Gazette. "•It may be said with truth that the work of Mr. Druitt affords a complete, through brief and condensed view, of the entire field of modern surgery. We know of no work on the same subject, having the appearaner or a manual, which includes so many topics of interest,\q the surgeon; and the terse manner in which each has been treated evinces a most enviable quality of nuhd -on the part of the author, w)io seems to have an innate power of searching out and gTasping the leading facts and features of the most elaborate productions of the peu Notwithstanding various weedings and alterations, we find that there are nearly fifty pages of additional mai- ler in the present volume, and evidently ranch has been done by both author and publishers to sustain the leputation already acquired. The wood-cuts havd been greatly increased in number, and the pencil and graver of William Bagg have added brilliancy to this portion of the book. * * * It is a useful handbook ibr the practitioner, and we should deem a teacher of surgery unpardonable who did not recommend it to his pupils. In our own opinion, it is admirably adapted to the wants of the student; and with congratulations to dhe author and publisher—for the latter deserve much credit for the handsome appearance of the volume—on the success of their undertaking, we leave the present edition as a piquant proportion of the ample store of knowledge which it is the good fortune of the rising youth in the profession to be so cheaply provided with in th« preeent day."—Provincial Had. Journal. NOW AT PRESS, ESQUIROL'S GREAT WORK ON INSANITY. MENTAL MALADIES, CONSIDERED IN RELATION TO MEDICINE, HYGIENE, AND MEDICAL JURISPRUDENCE. By E. ESQUIROL, Principal Physician of the '■ Maison Royals des Alienes de Charenton," &c. &c. TRANSLATED, WITH ADDITIONS, By E. K. HUNT, M. D.,. In One Volume, Svo. • This great work has long been considered as the highest authority on the important points of which it treats. The^otes and additions of the Translator, Dr. Hunt, will be numerous and valuable, bringing the scientific and medical parts of the treatise up to the day of publication, and embodying the results of the milder and improved American practice in the treatment of the insane. ' NOW READY, * ASHWELL ON THE JISEASES OF FEMALES, A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN, ILLUSTRATED BY CASES DERIVED FROM HOSPITAL AND PRIVATE PRACTICE. By SAMUEL ASHWELL, M. D., Member of the Royal College of Physicians; Obstetric Physician and Lecturer to Guy's Hospital, &c. WITH ADDITIONS, By PAUL BECK GODDARD, M. D. , In One Vol. Svo. CONTENTS—Part I.—Functional Diseases. Introductory Remarks on the Functional Affections of the Female System.—Chlorosis, and Illustrative Cases. —Amenorrhoea, and Illustrative Cases.—F.mmenagogues.—Dysmenorrhea, and Illustrative Cases.—For- mulae of Remedies.—Profuse Menstruation—Menorrhagia, and Illustrative Casesf— Leucorrhoea, and Illustrative Cases.—Inflammation of the Cervix Uteri, and Illustrative Cases.—Formulae of Remedies.— Affections attendant on the decline of the Catamenial Function.—Hysteria.—Irritable Uterus or Hystera4- gia, and Illustrative Cases. » Part II.—Organic Diseases. Of the Organic Diseases of the Internal and External Female Genitals.—General Remarks on the History . and Symptoms, Diagnosis, Pathology and Prognosis of the Organic Diseases of the Uterine System.—OX the Tumours of the Walls of the Uterus, characterized by Induration.—On Premature Labour in Preg- nancy complicated with Organic Diseases, and Illustrative Cases.—Organic Diseases of the Os and Ceryix Uteri.—Congestion of the Uterus.—Acute Metritis.—Chronic Metritis.—Cancer of the Uterus, and Illus- trative Cases.—Simple Ulceration of the Cervix and Os Uteri.—Corroding Ulcer of the Uterus.—Cauli- flower Excrescence of the Uterus.—Occlusion and Rigidity of the Cervix Uteri, and Illustrative Cases. Part III. Organic Diseases of the Mucous Membrane of the Cavity of the Uterus.—Poly pus of the Uterus, and illustrative Cases.—Displacements of the Uterus.—Diseases of the Ovaries.—Of the Diseases of the External Organs of Generation in the Female. Appendix. On the Morbid consequences of undue Lactation, with Illustrative Cases.—Case of Pregnancy complicated with Abdominal Tumours.—Induction of Premature Labour, &c. &c.' A NEW EDITION OF CHURCHILL ON FEMALES. THE DISEASES OF FEMALES; INCLUDING THOSE OE PREGNANCY AND CHILDBED, By FLEETWOOD CHURCHILL. M.D., Author of "Theory and Practice of Midwifery,1' &c. &c. THIRD AMERICAN, FROM THE SECOND LONDON EDITION. With Illustrations. Edited, with Notes, Br ROBERT M. HUSTON, M.D., &c. &c. In One Volume, Svo. "In complying with the demand of the profession in this eountry for a third edition, the Editor has much plea- sure in the opportunity thus afforded of presenting the work in its more perfect form. All the additional relb- Vmwe and illustrations contained in the English copy, are retained in this." 6 A IKAGSnTXCEJVT AND CHEAP WORE. SMITH & HORNER'S ANATOMICAL ATLAS. 4 Just Published, Price Five Dollars in Parts. AN ANATOMICAL ATLAS ILLUSTRATIVE OF THE STRUCTURE OF THE HUMAN BODY. BY HENRY H. SMITH, M.D., Fellow of the College of Physicians, <$-e. UNDER THE SUPERVISION OF WILLIAM E. HORNER, M.D., Professor of Anatomy in the University of Pennsylvania. In One large Volume, Imperial Octavo. This work is but just completed, having been delayed over the time intended by the great difficulty in giving ~to the illustrations the desired finish and perfection.. It consists of five parts, whose contents are as follows: Part I. The Bones and Ligaments, with one hundred and thirty engravings. Part II. The Muscular and Dermoid Systems, with ninety-one engravings. Part III. The Organs of Digestion and Generation, with one hundred and ninety-one engravings. Part IV. The Organs of Respiration and Circulation, with ninety-eight engravings. Part V. The Nervous System and the Senses, with one hundred and twenty-six engravings. Forming altogether a complete System of Anatomical Plates, of nearly SIX HUNDRED AND FIFTY FIGURES, executed in the best style of art, and making one large imperial octavo volume. Those who do not want it in parts can have the work bound in extra cloth or sheep at an extra cost. This work possesses novelty both in the design and the execution. It is the first attempt to apply engraving on wood, on a large scale, to the illustration of human anatomy, and the beauty of the parts issued induces the publishers to flatter themselves with the hope of the perfect success of their undertaking. The plan of tse work is at once novel and convenient. Each page is perfect in itself, the references being immediately under Ihe figures, so that the eye takes in the whole at a glance, and obviates the necessity of continual reference backwards and forwards. The cuts are selected from the best and most accurate sources; and, where neces- sary, original drawings have been made from the admirable Anatomical Collection of the University of Penn- sylvania. It embraces all the late beautiful discoveries arising from the use of the microscope in the investi- gation of the minute structure of the tissues. In the getting up of this very complete work, the publishers have spared neither pains nor expense, and they now present it to the profession, with the full confidence that it will be deemed all that is wanted in a scientific and artistical point of view, while, at the same time, its-very, low price places it within the reach of all. It is particularly adapted to supply the place of skeletons or subjects, as the profession will see by examining the Ksi of plates now annexed. " These figures are well selected, and present a complete and accurate representation of that wonderfu} fabrw, (he human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and ils superb artistical execution, have been already pointed out. We must congratulate the student upon the aompletion of this atlas, as it is the most convenient work of the kind that has yet appeared; and, we must arid, the very beautiful manner in which it is ' got up' is so creditable to the country as to be flattering to our national pride."—American Medical Journal. "This is an exquisite volume, and a beautiful specimen of art. We have numerous Anatomieal Atlases, but we will venture to say that none equal h in cheapness, and none surpass it in faithfulness and spirit. We strongly recommend to our friends, both urban and suburban, the purchase of this excellent work, for which ,.both editor and publisher deserve the thanks of the profession."—Medical Examiner. " We would strongly recommend it, not only to the student, but also to the working practitioner, who, f although grown rusty in the toils of his narness, still has the desire, and often the necessity, of refreshing his '" knowledge in this fundamental part of the science'of medicine."—New York Journal of Medicine and Surg. " The plan of this Atlas is admirable, and its execution superior to any thing of the kind before published m this country. It is a real labour-saving affair, and we regard its publication as the greatest boon that could be conferred on the student of anatomy. It will be equally valuable to the practitioner, by affording him an easy ^means of recalling the details learned in the dissecting room, and which are soon forgotten."—American Medi- cal Journal. " It is a beautiful as well as particularly useful design, which should be extensively patronized by physicians, feurgeons and medical students."—Boston Med. and Surg. Journal. "It has been the aim of the author of the Atlas to comprise in it the valuable points of all previous works, to embrace the latest microscopical observations on the anatomy of the tissues, and by placing it at a moderate 1 irice to enable all to acquire it who may need its assistance in the dissecting or operaung room, or other field t if practice."—Western Journal of Med. and Surgery. ''These numbers complete the series of this beautiful work, which fully merits the praise bestowed upon the e srlier numbers. We regard all the engravings as possessing an accuracy only equalled by their beauty, a. ad cordially recommend the work to SU engaged in the study of anatomy."—New York Journal of Medidtte at id Surgery. 1A more elegant work than the one before us conld no! eas^ be Placed by a Physiclan uPon me teble <* liis; student."—-Western Journal of Medicine and Surgery. . . , .. u\We were much pleased with Part I, but the Second Part gratifies us still mort, both as regards the attract- ive nature of the subject, (The Dermoid and Muscular Systems,) and the beautiful artistical execution of the illu strations. We have here delineated the most accurate microscopic views of some of the tissues, as, for m« snce,the cellular and adipose tissues, ihfe epidermis}-cVWosum and cutis vera, the sebaceoni>aad perspiratory organs of the skin, the perspiratory gland* and hair*Of the skin, and the hair and nails. The. Mo ws the general anatomy of the muscles, an5, lastly, their Separate delineations. We_ would recommend this Anatomical Atlas tooir readers in the ver^ strong te S&"--*"0 York Journal of Medxctne and S^- LIST OF THE ILLUSTRATIONS EMBRACING SIX HUNDRED AND THIRTY-SIX FIGURES IN SMITH AND HORNER'S ATLAS. A HlGHLY-ITNISHED VlEW OF THE BONES OF THE H~EAD, TlEW OF CUVIER'S AiykTOMICAL THEATRE, ... facing the title-page. . . . . vignette PART I.—BONES Fig. 1 Front view of adult skeleton. 2 Hack view of adult skeleton. 3 Foetal skeleton. 4 Cellular structure of femur. 5 Cellular and compound structure of tibia. 6 Fibres of compact matter of bone. 7 Concentric lamella? of bone. 8 Compact matter under the microscope. 9 Haversian canals and lacunae of bone. 10 Vessels of compact matter. 11 Minute structure of bones. 12 Ossification in cartilage. IS Ossification in the scapula. 14 Puncta ossifiuationis in femur. 15 Side view of the spinal column. 16 Epiphyses and diaphysis of bone. If External periosteum. 18 Puuctum osyificationis in the head. 19 A cervical vertebra. 20 The atlas. '21 The dentata. '22 Side view'of the cervical vertebra. '2.3 Side view of the dorsal vertebra. ■24 A dorsal vertebra. '25 Side view of the lumbar vertebrae. '26 Side view of one of the lumbar vertebra. •27 Perpendicular view of the lumbar verlebrse. 28 Anterior view of sacrum. •29 Posterior view of sacrum. 30 The bones of the coccyx. ,51 Outside view of the innominatum. 32 Inside view of the innominatum. 33 Anterior view of the male pelvis. 34 Anterior view of the female pelvis. 55 Front of the thorax. 36 The first rib. .57 General characters of a rib. 38 Front view of the sternum. .59 Head of a Peruvian Indian. 40 Head of a Choctaw Indian. 4.1 Front view of the os fronlis. 42 Under surface of the os frontis. 43 Internal surface of the os front is. 44 External surface of the parietal bone.s 45 Internal surface of the parietal bone. 46 External surface of the osnecipitis. 47 Internal surface of the os ociipitis. 48 External surface of the temporal bone. 49 Internal surface of the temporal bone. 50 Internal surface of the sphenoid bor.e. 51 Anterior surface of the sphenoid bone. 52 Posterior surface of the ethmoid bone. 53 Front view of the bones of the face. 54 Outside of the upper maxilla. 55 Inside of the upper maxilla. 56 Posterior surface of the palate bone. 57 The nasal bones. 58 The os unguis. 59 Inferior spongy bone. 60 Right malar bone. 61 The vomer. 62 Inferior maxillary bone. 63 Sutures of the vault of the cranium. AND LIGAMEN.TS. Fig. 64 Sutures of the posterior of the cranium. 65 DLploe of the cranium. 66 Inside of the base of the cranium. 67 Outside of the base of the cranium. 68 The facial angle. 69 The fontanels. 70 The os hyoides. 71 Posterior of the scapula. 72 Axillary margin of the scapula. 73 The clavicle. 74 The humerus^ 75 The ulna. 76 The radius. 77 The bones of the carpus. 78 The bones of the hand. 79 Articulation of the carpal bones. 80 Anterior view of the femur. 81 Posterior view of the femur. 82 The tibia. 83 The fibula. 84 Anterior view of the patella. 8S Posterior view of the patella. 86 The os calcis. 87 The astragalus. 88 The navtculare.' 89 The cuboid bone; 90 The three cuneiform bones. 91 Top of the foot. 92 The sole of the foot. 93 Cells in cartilage, 94 Articular cartilage under the microscope. 95 Costal cartilage uiwler the microscope. 96 Magnified section of cartilage. 97 Magnified view of ftbro-cartilage. 98 White fibrous tissue. 99 Yellow fibrous tissue. 100 Ligaments of the jaw. lUl Internal view of the same. 102 Vert'n:;l section of the same. 103 Anterior vertebral ligaments. 104 Posterior vertebral ligaments. 105 Yellow ligaments. 106 Costo-vertebral ligaments. 107 Oceipito-altoidien ligaments. 108 Posterior view of the same. 109 Upper part of the same. 110 Moderator ligaments. Ill Anterinr pelvic ligaments. 112 Posterior pelvic ligaments. 113 Sterno-clavieular ligaments. 114 Scapulo-humeral articulation. 115 External view of elbow joint. 116 Internal view of elbow joint. 117 Ligaments of the wrist. 118 liiagram of the carpal synovial membrane 119 Ligaments of the hip joint. I'20 Anterior view of the knee joint. l'2l Posterior view of the knee joint. 122 Section of the ri^ht knee joint. 123 Section of the kit knee joint. 1'24 Internal side of the ankle joint. 125 External side of the ankle joint. 125 Posterior view of the ankle joint 127 Ligaments of the sole of the foot. 128 Vertical section of the foot PART II.—DERMOID AND MUSCULAR SYSTEMS. 129 Muscle's on the front of the body ,full length. 131 'Muscles on the back of the hoAy.fnH length. 180 The cellular tissue. 132 Fat »e'siclet. 133 Blood-vessels of fat. 134 Cell membrane of fat vesicles. IS5 Magnified view of the epidermic. Illustrations to Smith and Horner's tfttlas, continued. Fig. 136 Cellular tissue of the skin. 137 Rete mucosum, ore, of foot. 138 Epidermis and rete mucosum. 139 Cutis vera, magnified. 140 Cutaneous papilla. 141 Internal face of cutis vera. 142 Integuments of foot under ihe microscope. 143 Cutaneous glands. 144 Sudoriferous organs. 145 Sebaceous glands and hairs. 146 Perspiratory gland magnified. ' 147 A hair under the microscope. 148 A hair from the face under the microscope. 149 Follicle of a hair. 150 Arteries of a hair. 151 Skin of the beard magnified. 152 External surface of the thumb nail. 153 Internal surface of the thumb nail. 154 Section of nail of fore linger. 155 Same highly magnified. 156 Development of muscular fibre. lf>7 Another view of the same. 158 Arrangement of fibres of muscle. 159 Discs ormuscular fibre. 160 Muscular fibre broken transversely. 161 Striped elementary fibres magnified. 162 Stria of fibres from the heart of an ox. 163 Transverse section of biceps muscle. , 164 Fibres of the pectoral is major. 165 Attachment of tendon to muscle. 166 Nerve terminating in muscle. 167 Superficial muscles of face and neck. 168 Deep-seated muscles of face and neck. 169 Lateral view of the same. 170 Lateral view of superficial muscles of face. 171 Lateral view of deep-seated muscles of face. 172 Tensor tarsi or muscle of Horner. 173 Pterygoid muscles. 174 Muscles of neck. 175 Muscles of tongue. 176 Fascia profunda colli. 177 Superficial muscles of thorax. 178 Deep-seated muscles of thorax. 179 Front view of abdominal muscles. PART III.—ORGANS OF DIGESTION AND GENERATION. Fig. 180 Side view of abdominal muscles. 181 External parts concerned in hernia. 182 Internal parts concerned in hernia. 183 Deep-seated muscles of trunk. 184 Inguinal and femoral rings. 185 Deep-seated muscles of neck. 186 Superficial muscjes of back. 187 Posterior parities of chest and abdomen. 188 Under side of diaphragm. 189 Second layer of muscles of back. 190 Muscles of vertebral gutter. 191 Fourth layer of muscles of back. 192 Muscles behind cervical vertebra. 193 Deltoid muscle. 194 Anterior view of muscles of shoulder. 195 Posterior view of muscles of shoulder. 196 Another view of the same. 197 Fascia brachialis. 198 Fascia of the fore-arm. 199 Muscles on the back of the hand. 200 Muscles on the front of the arm. 201 Muscles on the baik of the arm. 202 Pronators of the fore-arm. £03 Flexor muscles of fore-arm. 204 Muscles in palm of hand. 205 Deep flexors of the finger's. 206 Superficial extensors. 207 Deep-seated extensors. 208 Rotator muscles of the thigh- 209 Muscles on the back of the hip. 210 Deep muscles on the front of thigh. 211 Superficial muscles on the front of thigh. 212 Muscles on the back of the thigh. 213 Muscles on front of leg. 214 Muscles on back of leg. 215 Deep-seated muscles on back of leg. 216 Muscles on the sole of the foot 217 Another view of the same. 218 Deep muscles on front of arm. 219 Deep muscles on back of arm. 220 Digestive organs in their whole length. 221 Cavity of the mouth. 222 Labial and buccal glands. 223 Teeth in the upper and lower jaws. 224 Upper jaw, with sockets for teeth. 225 Lower jaw, with sockets for teeth. 226 Under side of the teeth in the upper jaw. 227 Upper side of the teeth in the lower jaw. 228 to 235. Eight teeth, from the upper jaw, 236 to 243. Eight teeth from the lower jaw. 244 to 251. Side view of eight upper jaw teeth. 252 to 259. Side view of eight lower jaw teeth. 260 to 265. Sections of eight teeth. 266 to 267. Enamel and structure of two of the teeth. 268 Bicuspis tooth under the microscope. 269 Position of enamel fibres. 270 Hexagonal enamel fibres. 271 Enamel fibres very highly magnified. 272 A very highly magnified view of fig. 268. 273 Internal portion of the dental tubes. 274 External portion of the dental tubes. 275 Section of the crown of a tooth. 276 Tubes at the root of a bicuspis. 277 Upper surface of the tongue. 278 Under surface of the tongue. 279 Periglottis turned off the tongue. 280 Muscles of the tongue. 281 Another view of the same. 282 Section of the tongue. £83 Styloid muscles, cic. 284 Section of a gustatory papilla. 285 View of another papilla. 286 Root of the mouth and soft palate. 287 Front view of the pharynx and muscles. 288 Back view of the pharynx and muscles. 289 Under side of the soft palate. 290 A lobule of the parotid gland. 291 Salivary glands. 292 Internal surface of the pharynx. 293 External surface of the pharynx. 294 Vertical section of the pharynx. 295 Muscular coat of the oesophagus. , 296 Longitudinal section of the oesophagus. 297 Parietes of the abdomen. 298 Reflexions of the peritoneum. 299 Viscera of the chest and abdomen. 300 Another view of the same. 301 The intestines in situ. 302 Stomach and oesophagus. 303 Front view of the stomach. 304 Interior of the 6tomach. 305 The stomach and duodenum. S06 Interior of the duodenum. S07 Gastric glands. 508 Mucous coat of the stomach. 309 An intestinal villus. 310 Its vessels. 311 Glands of the 6tomach magnified. 312 Villus and lacteal. 313 Muscular coat of the ileum. 314 Jejunum distended and dried. 315 Follicles of Lieberkuhn 316 Glands of Brunner. 317 Intestinal glands. 318 Valvula conniventes. 319 lleo-colic valve. 320 Villi and intestinal follicles. S21 Veins of the ileum. 322 Villi filled wilh chyle. S23 Peyer's glands S24 Villi of the jejunum under the microscope. 325 The cacum. S26 The mesocolon and colon, 327 Muscular coat of the colon. Illustrations to Smith and Horner's Atlas continued. Fig 328 329 350 331 332 333 384 335 336 338 339 340 341 343 344 346 347 348 349 350 351 352 353 354. 356 357 358 359 361 382 363 364 365 366 368 370 371 372 Fg. Muscular fibres of the rectum. 373 Curvatures of the large intestine. 374 Mucous follicles of the rectum. 375 Rectal pouches. 376 Follicles of the colon, highly magnified. 377 Folds and follicles of the stomach. 378 Follicles, &c. of the jejunum. S79 Villi and follicles of the ileum. 380 Muciparous glands of the stomach. 381 Ileum inverted, &c. S82 Glands of Peyer magnified. 383 Peritoneum of the liver injected. S84 Liver in situ. S85 Under surface of the liver. 342 Hepatic vein. 386 Parenchyma of the liver. 387 Hepatic blood-vessels. 345 Biliary ducts. 388 Angular lobules of the liver. S89 Rounded hepatic lobules. 390 Coats of the gall bladder. 591 Gall bladder injected. 392 Veua portarum. 393 External face of the spleen. 594 Internal face of the spleen. 395 Splenic vein. 396 Pancreas &c, injected. 355 Urinary organs. 397 Right kidney and capsule. 398 Left kidney and capsule. 399 Kidney under the microscope. 400 The ureter. S60 Section of right kidney. 401 Section of the left kidney. 402 Pyramids of Malpighi. 403 Lobes of the kidney.. 404 Renal arteries, &c, injected. 405 Section of the kidney highly magnified. 406 Copora Malpighiana. 367 Same magnified. 407 Tubuli uriniferi. 369 Corpora Wolffiana. 408 The bladder and urethra, full length. 409 Muscular coat of the bladder. 410 Another view of the same. Sphincter apparatus of the bladder. Prostate and vesicula seminales. Side view of the pelvic viscera. The glans penis injected. The penis distended and dried. Section of the same. Vertical section of the male pelvis, &c Septum pectiniforme. Arteries of the penis. Vertical section of the urethra. Vesicula seminales injected. Muscles of the male perineum. Interior of ihe pelvis, seen from above. Testis in the foetus. Diagram of the descent of the testis. Tunica vaginalis testis. Transverse section of the testis. Relative position of the prostate. Vas deferens. Vertical section of the bladder. The testicle injected with mercury. Another view. # Minute structure of the testis. Female generative organs. Another view of the same. External orgaus in the foetus. Muscles of the female perineum. Side view of the female pelvis, &c. Relative position of the female organs.' Section of the uterus, 8tc. Fallopian tubes, ovaries^ &C Front view of the mammary gland. The same after removal of the skin. Side view of the breast Origin of lactiferous ducts. Lactiferous tubes during lactation. Minute termination of a tube. Ducts injected ; after Sir Astley Cooper. PART IV—ORGANS OF RESPIRATION AND CIRCULATION. 411 Front view of the thyroid cartilage. 450 412 Side view of the thyroid cartilage. 451 413 Posterior of the arytenoid cartilage. 452 414 Anterior of the arytenoid cartilage. 453 415 Epiglottis cartilage. 416 Cricoid cartilage. 454 417 Ligaments of the larynx. 455 418 Side view of the same. 456 419 The thyroid gland. 457 420 Internal surface of the larynx. 458 421 Crieo-thyroid muscles. 459 422 Crico-arytenoid muscles. 460 423 Articulations of the larynx. 461 424 Vertical section of the larynx. 462 425 The vocal ligaments. 426 Thymus gland. 463 427 Front view of the lungs. 464 428 Back view of the lungs. 465 429 The trachea and bronchia. 466 4.30 Lungs, heart, &c. 467 431 First appearance of the blood-vessels. 468 432 Capillary vessels magnified. 469 433 Another view of the same. 471 434 Blood globules. 472 435 Another view of the same. 473 436 The mediastina. 474 437 Parenchyma of the lung. 475 438 The heart and pericardium. 476 439 Anterior view of the heart. 477 440 Posterior view of the heart. 478 441 Anterior view of its muscular structure, 479 442 Posterior view of the same. 480 443 Interior of the right ventricle. 481 444 Interior of the left ventricle. 482 445 Mitral valve, the size of life. 48.5 446 The auriculo-ventricular valves. 484 447 Section of the ventricles. 485 448 The arteries from the arch of the aorta. 486 449 The arteries of the neck, the size of life. 487 The external carotid artery. A front view of arteries of head and neck. The internal maxillary artery. Vertebral and carotid arteries with the aorta. Axillary and brachial arteries. The brachial artery. Its division at the elbow. One of the anomalies of the brachial artery. Radial and ulnar arteries. Another view of the same. The arcus sublimis and profundus. The aorta in its entire length. Arteries of the stomach and liver. Superior mesenteric arteiy. Inferior mesenteric artery. Abdominal aorta. Primitive iliac and femoral arteries. Perineal arteries of the male. Position of the arteries in the inguinal canal. Internal iliac artery. 470 Femoral artery. Gluteal and ischiatic arteries. Branches of the ischiatic artery. Popliteal artery. Anterior tibial artery. Posterior tibial artery. Superficial arteries on the top of the foot. Deep-seated arteries on the top of the foot. Posterior tibial artery at the ankle. The plantar arteries. Arteries and veins of the face and seek. Great vessels from the heart. External jugular vein. Lateral view of the vertebral sinuses. Posterior view of the vertebral sinuses. Anterior view of the vertebral sinuses. Superficial veins of the arm. The same at the elbow. Illustrations to Smith and Horner's Atlas continued. Pig. 488 The veins ofthe hand. 489 The great veins of the trunk. 490 Positions of the arteries and veins ofthe trunk. 491 The vena cava. 492 The vena portarum. 493 Deep veins ofthe back of the leg. 494 Positions of the veins to the arteries in the arm. 495 Superficial veins of the thigh. 496 Saphena vein. 497 Superficial veins of the leg. 408 Lymphatics of the upper extremity. Fig. 499 The lymphatics and glands ofthe axilla. 500. The femoral and aortic lymphatics. 501 The lymphatics of the small intestines. 502 The thoracic duct. 503 The lymphatics of the groin. 504 Superficial lymphatics of the Oiigh. 505 Lymphatics of the jejunum. 506 Deep lymphatics of the thigh. 507 Superficial lymphatics of the leg. 508 Deep lymphatics of the leg. PART V.—THE NERVOUS SYSTEM AND SENSES. 509 Dura mater cerebri and spinalis. 510 Anterior view of brain and spinal marrow. 511 Anterior view ofthe spinal marrow, &c. 512 Lateral view ofthe spinal marrow, &c. & 513 Posterior view ofthe spinal marrow, &c 514 Decussation of Mitischelli. 515'Origins ofthe spinal nerves. 516 Anterior view of spinal marrow and nerves. 517 Posterior view of spinal marrow and nerves. 518 Anterior spinal commissure- s' Posterior spinal commissure. 520 Transverse section of the spinal marrow^ 521 Dura mater and sinuses. 522 Sinuses laid open. 523 Sinuses at the base of the cranium. 524 Pons Varolii, cerebellum, etc 525 Superior face of |he cerebellum. ■ 526 Inferior face ofthe cerebellum. 527 Another view of the cerebellum. 528 View ofthe arbor vita, &c 529 Posterior view ofthe medulla oblongata. 530 A vertical section ofthe cerebellum. 531 Another section of the cerebellum, 532 Convolutions ofthe cerebrum, 533 The cerebrum entire. 534 A section of its base. 535 The corpus callosurn entire, 536 Diverging fibres of tire cerebrum, &c 537 Vertical section of the head, 538 Section of the corpus callosurn. 559 Longitudinal section ofthe brain. 540 View of a dissection by Gall. 541 The commissures ofthe brain. 542 Lateral ventricles. 543 Corpora striata-fornix, &c 544 Fifth ventricle and lyra. 545 Anotherjview of the lateral ventricles. 546 Another'view of the ventricles. 547 Origins of the 4th and 5th pairs of nerves. 548 The circle of Willis. 549 A side view of the nose. 550 The nasal cartilages. 551 Bones and cartilages ofthe nose, 552 Oval cartilages, etc. 553 Schneiderian membrane. 554 External parietes of the left nostril. 555 Arteries of the nose. 556 Pituitary membrane injected. 557 Posterior nares. 558 Front view of the eye. 559 Side view ofthe eye. 560 Posterior view of the eyelids, &c. 561 Glandula palpebrarum. 562 Lachrymal canals. 563 Muscles ofthe eyeball. 564 Side view ofthe eyeball. 565 Longitudinal section ofthe eyeball. 566 Horizontal section of ihe eyeball. 567 Anterior view of a transverse section. 568 Posterior view of a transverse section. 569 Choroid coat injected. 570 Veins of the choroid coat 571 The iris, 572 Thejretina and lens. 573 External view ofthe same. 574 Vessels in the conjunctiva. 575 Retina, injected and magnified. 576 Iris,highly magnified. '577 Vitreous humour and lens. 578 Crystalline adult lens. 579 Lens of the foetus, magnified. 580 Side view of the lens. 581 Membrana pupillaris. 582 Another view ofthe same. 583 Posterior view of the same. 584 A view of-the left ear. 585 Its sebaceous follicles. 586 Cartilages ofthe ear. 587 The same with its muscles. 588 The cranial side of the ear. 589 Meatus auditorius externus, &c. 590 Labyrinth and bones of the ear. 591 Full view of the malleus. 592 The incus. 593 Another view of the malleus. 594 A front view of the stapes. 595 Magnified view of the stapes. 596 Magnified view ofthe incus. 597 Cellular structure of the malleus. * 598 Magnified view of the labyrinth. 599 Natural size of the labyrinth. 600 Labyrinth laid open and magnified. 601 Labyrinth, natural size. 602 Labyrinth of a foetus. 603 Another view ofthe same. 604 Nerves ofthe labyrinth. 005 A view of the vestibule, See. 606 Its soft parts, &c. 607 An ampulla and nerve. 608 Plan of the cochlea. 609 Lamina spiralis, ccc. 610 The auditory nerve. 611 Nerve on the lamina spiralis. 612 Arrangement of the cochlea. 613 Veins of the cochlea, highly magnified. 614 Opening ofthe Eustachian tube in the throat 615 Portio mollis of the seventh-pair of nerves. 616 The olfactory nerves. 617 The optic and seven other pairs of nerves. 618 Third, fourth and sixth pairs of nerves. 619 Distribution ofthe fifth pair. 620 The facial nerve. 621 The hypo-glossal nerves. 622 A plan of the eighth pair of nerves. 623 The distribution of the eighth, pair. 624 The great sympathetic nerve. 625 The brachial plexus, 626 Nerves of the front ofthe arm. 627 Nerves of the back of the arm. 628 Lumbar and ischiatic nerves. 629 Posterior branches to the hip, &c. 630 Anterior crural nerve. 631 Anterior tibial nerve. 632 Branches of the popliteal nerve, 633 Posterior tibial nerve on the leg. 654 Posterior tibial nerve on the foot. NOW READY. TAYLOR'S MEDICAL JURISPRUDENCE. MEDICAL JURISPRUDENCE, By ALFRED S. TAYLOR, Lecturer on Medical Jurisprudence and Chemistry at Guy's Hospital, &c. With numerous Notes and Additions, and references to American practice and law. By R. E. GRIFFITH, M. D. In One Volume, 8vo. " Contents.—poisoning—wounds—infanticide—drowning—hanging—stran- gulation— SUFFOCATION-LIGHTNING-COLD-STARVATION--RAPE--PREGNANCY -DELIVERY--BIRTH--INHERITANCE-LEGITIMACY—INSANITY, &C. &C. "The promise ofthe first parts was so'full, and the ability displayed was so unquestionable, that all who felt jealous ofthe honour of our national medical literature hailed with delight the appearance of a comprehensiva arid original work of English growth, on one of the most important and difficult departments of our science. Everywhere, indeed, we find evidences of extensive reading and laborious research; the copious literature, both of France and Germany, on the subject of Medical Jurisprudence, is laid under frequent contribution, and we have the pleasure of meeting with the accumulated stores of science and experience on this branch \ of knowledge, it may be said of the whole world, condensed and made accessible in this admirable volume. It is. in fact, not only the fullest and mosvt satisfactory book we have ever consulted on the subject of Which it treats, but it is also one ofthe most masterly books we have ever perused. |!o much precise individual know- ledge, under guidance of judgment and entical powers of so high an order, as meet us in every" page of Mr. t Taylor's work, we have iarely encountered."—London Med. Gazette. "We recommend Mr. Taylor's work as the ablest, most comprehensive, and, above all, the most practrcally useful book wh'ch exists on the subject of legal medicine. .Any man of sound judgment, who has mastered the contents of Taylor's 'Medical Jurisprudence,' may go into a court of law with the most perfect confidence al" being able to acquit himself creditably."—Medico-Chirurgical Review. " The work of Mr. Taylor may be regarded as a full systematic treatise on the subject of Medical Jurispru- dence. It certainly presents a Very excellent view, which may be named both full and condensed, of the present state of knowledge on Medical Jurisprudence. The author has illustrated many of the doubtful points of the science by good and interesting cases. He has, in general, shown much judgment in the examination of the difficult and ambiguous cases; but the whole treatise is so ably prepared that we have no hesitation in recommending it as a very useful guide to the student."—Edinburgh Med. awl Surg. Journal. '•The most elaborate and complete work that has yet appeared. It contains an immense quantity of cases, lately tried, which entitles it to be considered now what Beck was in its day."—Dublin Medical Journal. •'Medical Jurisprudence ought to be a prominent branch ofthe studies of every lawyer: but what books shall they read? We have seen none so calculated to serve the purpose of a text-book as this manual. Mr. Taylor possesses the happy arV of expressing himself on a scientific topic in intelligible language. lis size. fits'it to be a circuit companion.."—Law Times. ALSO, NOW READY, MILLER'S PRINCIPLES OF SURGERY. THE PRINCIPLES OF SURGERY. By JAMES MILLER, F. R. S. E , F. R. C. S. E., Professor of Surgery in the University of Edinburgh, &c. In One neat Svo. Volume, To match in size with Fergnsson's Operative Surgery. " No one can peruse diis work without the conviction that he has been addressed by an accomplished sur- geon, endowed with no mean literary skill or doubtful good sense, and who knows how to grace or illumine nis subjects with the later lights of our rapidly advancing physiology. The book deserves a strong recom- mendation, and must secure itself a general perusal.'"—Mtdical Times. BARTLETTT"PHILOSOPHY~OF MEDICINE. AN ESSAY ON THE PHILOSOPHY OF MEDICAL SCIENCE. IN TWO PARTS. " I trust that I have got hold of my pitcher by the right handle."—John Joachim Beecher. By ELIS11A BARTLETT, M D , Professor of the Theory and Practice of Medicine in the University of Maryland. In One neat Octavo Volume. "We have not room m the present number of our journal, for such a notice of this philosophical and elegant ■yrork. as its merits justly demand. It is «vidently destined to create quite a sensation in the medical world; ;ind we shall therefore give an extended analysis of its contents, accompanied by some comments in our Jan- uary number. In the mean time, we advise allour readers to purchase and carefully read it."—N. Y. Journal of Medicine. , / ^J° Gentlemen who receive this Catalogue would mfich oblige the Publishers, if, after reading it, they would hand it, or the following eight pages, to their friends. 12 THE EXPLORING EXPEDITION. LEA AND BLANCHARD, PHILADELPHIA, ARE PREPARING TOR PTJBLICATIOK^Ain) Will SH0RT1T ISSUE, THE NARRATIVE OF THE - UNITED STATES EXPLORING EXPEDITION during the years 1838, 1839, 1840, 1841, and 1842. By CHARLES WILKES, U. S. N., COMMANDER OP THE EXPEDITION, ETC., ETC. In Five Octavo Volumes, of about 2500 Pages; with over 300 Cuts, and Maps. As the history ofthe only Expedition yet commissioned by our Government to explore foreign countries, this work must present features of unusual interest to every American. Much curiosity has been excited respecting this enterprise, from the length of time during which it was in preparation, and from the various conflicting re- ports which were circulated during its protracted absence. The Squadron—six vessels—sailed from Norfolk in August, 1838, and after making important observations on the voyage, via. Madeira, arrived at Rio, when their investigations were successfully prosecuted. Sailing thence for Cape Horn, they examined the commercial capabilities of Rio Negro. Arriving at Cape Horn, two ofthe vessels were dispatched to investigate Palmer's Land, and other Antarctic Regions; whence, after encoun- tering great danger, they returned safely, and sailed with the whole Squadron for Valparaiso and Callao. After making important observations on the West Coast of South America, regarding the commerce, political history, &c, of that portion of America, they sailed for Sydney, cruising among the numerous groups of islands of the Pacific Archipelago, where the results were peculiarly important, as connected with the commerce and Whale Fishery of our country, as well as the aid they were able to bring to the various missionary establishments en- gaged in the introduction of Christianity and civilization. After remaining some time at Sydney, pursuing im- portant investigations, Ihey sailed for the Antarctic Regions, leaving behind them the corps of Naturalists to explore that singular country, the observations on which will be found of great interest. The Squadron then proceeding South, made the brilliant discovery of the Antarctic Continent, on the 19th January, 1S40, in 1600 east longitude, along which they coasted, in a westerly direction, to 95° east, a distance of 1500 miles. On the return of the vessels, theytouehed at New Zealand, when the Naturalists were again taken on board. They ne*t proceeded to the Friendly Islands of Cook, the Feejee Group, and reached the Sandwich Islands late in the fell, which precluded them from going to the North-West Coast that season. The Paumotu, Samoan, and King's Mills group of islands were visited, and a particular examination made of the Island of Hawaii, its interesting waters and volcanic eruptions. In the spring, the Squadron proceeded to the Oregon Territory, now exciting so much interest in a political point of view; it wa£ thoroughly examined vn regard to its commercial and agricul- tural prospects, &c. Here the Peacock was lost on the dangerous bar of the Columbia river. After the Oregon, Upper California was examined. The Expedition now returned to the Sandwich Islands, and thence sailed for Manilla and Singapore, touching at the Philippine Islands, and passing through the Sooloo Sla, the channels of which being correctly ascertained, will greatly benefit the important navigation to China. Touching at the Cape of Good Hope and Rio, this important and successful Exploring Expedition finally, on the Kith of June, 1842, arrived at New York, after an absence of three years and ten months. During the whole Voyage, every opportunity was taken to procure information, investigate unknown or little frequented parts of those seas now reached by our commerce, and thoroughly to institute scientific investigations of all kinds. To illustrate these, a vast number of drawings and maps have been executed; but the chief objects in view were of a practical nature. Numerous regulations have been made with the rulers of various islands, to secure the safety of our commerce, now daily increasing in those seas. In short, every thing has been done which lay in the power of officers or men to make the Expedition redound to the interest and honour of the Coiratry; and in the volumes to be issued will be found its history and embodiment EAST'S REPORTS. LEA AND BLANCHARD, PHILADELPHIA, HAVE IN PRESS, AND WILL SHORTLY PUBLISH, REPORTS OF CASES ADJUDGED AND DETERMINED IN THE COURT OF KING'S BENCH; WITH TABLES OF THE NAMES OF THE CASES, AND PRINCIPAL MATTERS. By EDWARD HYDE EAST, Esq., OF THE INNER TEMPLE, BARRISTER AT LAW, EDITED, WITH NOTES AND REFERENCES. By G. M. WHARTON, ESQ., OP THE PHILADELPHIA BAR. In this new and ^improved Edition, the sixteen original will be com- prised in eight large Royal Octavo volumes, printed with beautiful Long Primer type, on paper manufactured expressly for the purpose, and every care will be takeL, in their passage through the press, to insure perfect accuracy. 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These considerations have induced the publishers to prepare a new edi- tion, in which nothing should be omitted. The editor, G. M. Wharton, Esq., proposes to add a brief annotation of the leading cases in the Reports, with references to the more important decisions upon similar points in the principal commercial States ofthe Union, while the Notes of Mr. Day will be retained, and, though the whole work will be compressed into eight volumes, the original Cases, as reported, will be preserved entire. At the head of each Report, a reference will be had to the paging of the English Edition, directly under the name ofthe case, and the original indexes will be incorporated together at the end of each volume of this Edition. Subscriptions received by the publishers, Lea & Blanchard, Philadel- phia, and the principal Booksellers throughout the Union. 14 LIBRARY OF STANDARD LITERATURE, Lea & Blanchard are publishing, under the general title of The Library of Standard Literature, a number of valuable works on History, Biography, &c. &c, which merit a permanent place in every library. Among them are contained the following: NIEBUHR'S HISTORY OF ROME. * Complete in Two large 8vo. Volumes, or Five Parts, Paper, at $1 each. THE HISTORY OF ROME, BY B. G. NIEBUHR. TRANSLATED BY JULIUS CHARLES HARE. M.A. | WILLIAM SMITH, Ph. D. and CONNOP THIRLWALL, M.A. LEONARD SCHM1TZ, Ph. P. WITH A MAP. The last three parts of this valuable work have never before been published in this country, having only lately been printed in Germany, and translated in England. They complete the history, bringing it down to the time of Constantine. ' *• Here we cjose our remarks upon this memorable work; a work which, of all mat have appeared in our age, is ihe best fitted to excite men of learning to intellectual activity ; from which the most accomplished scholar mav gather fresh stores of knowledge, to which the most experienced politician may resort for theoretical and practical iiistruction, afld which no person can read as it ought to be read, without feeling the better and more generous sen- timents of his common human nature enlivened and strengthened."—Edinburgh Review, Jan., 1833. "The world has now in Niebuhr an imperishable model."—Edinburgh Review, fan., 1844. "At length the American reader can have easy access to the unrivaled History of Rome, by Niebuhr, a work which combines deep critical research with full political disquisition and comparison."— Colonization Herald. 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Together with a General History ofthe Horse; a disser- tation on the American Trotting Horse, how trained and jockeyed, an account of his remarkable performances, and an Essay on the Ass and the Mule, BY J. S. SKINNER, Assistant Post-Master General and Editor ofthe Turf Register. In One Volume, octavo. YOUATT AND GLATER'S CATTLE AND SHEEP-DOCTOR. NOW READY, EVERY MAN HIS OWN CATTLE AND SHEEP-DOCTOR: CONTAINING THE CAUSES, SYMPTOMS, AND TREATMENT OF ALL THE DISEASES INCIDENT TO OXEN, SHEEP, A3JO) SWIXfE. By FRANCIS CLATER. EDITED, REVISED, AND ALMOST REWRITTEN, By WILLIAk YOUATT, Author of "The Horse," &c. Together vnth numerous Additions, by the American Editor, J. S. Skinner. AMONG WHICH ARE AN ESSAY ON THE USE OF OXEN, WITH MODES OF BREAKING, FEEDING, GRAZING, ETC. AND A.TREATISE ON THE GROWTH, IMPROVEMENT AND BREEDING OF SHEEP, AND THE SOILS ADAPTED TO THEIR RAISING. With numerous Cuts and Illustrations. In one volume, 12mo. Price Fifty Cents, in Cloth. JUST PUBLISHED, OR, M ARSTON; THE MEMOIRS OF A STATESMAN, In two parts, at 25 Cents each. DICKENS' THE CHIMES, NEW WORK. A GOBLIN ST OF SOME BELLS THAT RUNG AN OLD YEAR OUT AND A NEW-YEAR IN. A CHEAP EDITION, IN PAPER COVERS, AND A FINE EDITION WITH PLATES. q^j" See the List for a new edition of Campbell's Poetical Works, by Wash. Irving and Lord Jeffreys. 19 WATSON'S PRACTICE OF MEDICINE. L. & B. HAVE LATELY PUBLISHED LECTURES ON THE PRINCIPLES AND PRACTICE OE PHYSIC. DELIVERED AT KING'S COLLEGE, LONDON. Br THOMAS WATSON, M. D., Fellow ofthe Royal College of Physicians, Physician to the Middlesex Hospital, %c. l We know not. indeed, of any work of the same a work adapted to the wants of young practitioners, size that contains a greater amount of useful and m- combining, as it does, sound principles and substantial tere3ting matter. We are satisfied, indeed, that nophy- practice. It is not too much to say, that it is a represent- sician; well read and observing as he may be, can rise ativeof the actual state of medicine as taught and prac- from its perusal without having added largely to his tised by the most eminent physicians of the present day, stock of valuable information."— Medical Examiner. and as such we would advi3e every one about embark- " We regard these lectures as the best exposition of ing in the practice of physic to provide himself with a their subjects ef any we remember to have read. The copyofit."—Western Journal of Med. and Surgery. author is assuredly master of his art. His has been a " The medical literature of this country has been en- life of observation and study, and in this work he has richedby a work of standard excellence, which we can given us the matured results of these mental efforts."— proudly hold up to our brethren of other countries as a New Orleans Medical Journal. representative of the. natural state of British medicine, "Open this huge, well-furnished volume where we as professed and practised by our most enlightened phy- may, the eye immediately rests on something that car- sicians. And, for our own parts, we are not only wiV- ries value on its front. We are impressed al once with ling that our characters as scientific physicians and the strength and depth ofthe lecturer's views, ilegains skilful practitioners may.be deduced from the doctrines an our admiration in proportion to Ihe extent of our ac- Contained in this book, but we hesitate not to declare qnaintance with his profound researches. Whoever our belief, that for sound, trustworthy principles, and rrwns this book,, will have an acknowledged treasure if substantial, good practice, it cannot be paralleled by any the combined wisdom of the highest authorities is appre- similar production in any other country. * * * * We ciated."—Boston'Mtd. and Surg. Journal. would advise no one to set himself down in practice, un- " One of the most practically useful books that ever provided with a copy."—British and Foreign Medical was presented to the 3tudent— indeed, a more admirable Review. summary of general and special pathology, and of the 20 7T0HZS BY PJtOFESSOU DTJNGLIS01T. Lea & Blanchard publish and have for sale the following valuable Medical Works by Professor Robley Dunglison. lit U&IJ1 ST IPSt'XOltCDlbQXEt'Xe WITH UPWARDS OE THREE HUNDRED ILLUSTRATIONS, By ROBLEY DUNGLISON, M. D., PROFESSOR OP THE INSTITUTES OP MEDICINE, &C. IN JEFFERSON MEDICAL COLLEGE, PHILADA.J ATTENDING PHYSICIAN AND LECTURER ON CLINICAL MEDICINE AT THE PHILADA. MEDICAL HOSPITAL; * SECRETARY TO THE AMERICAN PHILOSOPHICAL SOCIETY, &C. &C. FIFTH EDITION, GREATLY MODIFIES AND IMPROVED. TN TWO VOLUMES, OF 1304 LAS.GE OCTAVO PAGES. In presenting this new and much improved edition of Professor Dunglison's standard work on Physiology, the Publishers beg to state, that "although only a short time has elapsed since the publication of the fourth edition of this work, the labours of Physiologists have been so numerous, diversified, and important, as to demand ma- terial modifications and additions in the present edition, and that no little time and industry have been bestowed by the author to introduce these, and to digest the various materials contained in the ex'professo treatises, as well as ihe variousjournals of this country and of Europe. '•To this edition nearly, ninety wood-cuts have been added to elucidate either topics that had been already treat- ed.of in the previous editions, or such as are new in this; most of the old cuts have been retouched, and many replaced by others that are superior. Altogether, the author has endeavoured to make the work a ju3t and im- partial record of Physiological science, and to render it worthy a continuance of that favour which has been so liberally extended to it." The size of the volumes has been materially increased, by the addition of over eighty pages, and the illustrations are far superior to those of any former edition. THE PRACTICE OF MEDICINE, OR A TREATISE ON SPECIAL PATHOLOGY AND THERAPEUTICS. BY ROBLEY DUNGLISON, M. D., CONTAINING THE DISEASES OF THE ALIMENTARY CANAL, THE DISEASES OF THE CIRCULATORY APPARATUS, DISEASES OF THE GLANDULAR ORGANS, DISEASES OF THE ORGANS OF THE SENSES, DISEASES OF THE RESPIRATORY ORGANS, DISEASES OF THE GLANDIFORM GANGLIONS, DISEASES OF THE NERVOUS SYSTEM, DISEASES OF THE ORGANS OF REPRODUCTION, DISEASES INVOLVING VARIOUS ORGANS, &c. &c. In Two Volumes, Octavo. This work has been introduced as a text-book in many of the Medical colleges, and the general favour with which it has been received, is a guarantee of its value to the practitioner and student. " In the volumes before ns. Dr. Dunglison has proved that his acquaintance with the present facts and doc-< trines, wheresoever originating, is most extensive and intimate, and the judgment, skill, and impartiality with which the materials of the work have been collected, weighed, arranged, and exposed, are strikingly manifested in every chapter. Great care is everywhere taken to indicate the source of information, and'under the head of treatment, formulae of the most appropriate remedies are everywhere introduced. In conclusion, we congratu- late the students and junior practitioners of America, on possessing in ihe present volumes, a work of standard merit, to which they may confidently refer in their doubts and difficulties."—British and Foreign Medical Review for July, 1842. ' "Since the foregoing observations were written, we have received a second edition of Dunglison's work, a sufficient indication ol the high character it has already attained in America, and justly attained."—British and Foreign Medical Review for October, 1844. a We hail the appearance of this work, which has just been issued from the prolific press of*Messrs. Lea & Blanchard, of Philadelphia, with no ordinary degree of pleasure. Comprised in two large and closely printed volumes, it exhibits a'more full, accurate, and comprehensive digest of the existing state of medicine than any Other treatise with which we are acquainted in the English language. It discusses many topics—some of them of great practical importance, which are entirely omitted in the writings of Eberle, Dewees, Hosack. Graves, Stokes. Mcintosh, and Gregory; and it cannot fail, therefore, to be of great value, not only to the student, but to the practitioner, ns it affords himready access to information of which he stands in daily need in the exercise of his profession. It has been the desire ofthe author, well known as one of the most abundant writers ofthe age, to render his work strictly practical; and to this end he has been induced, whenever opportunity offered, to incorporate the results of his own experience with that of his scientific brethren in America and Europe. To the former, ample justice seems to have been done throughout. We believe this constitutes the seventh work which Professor Dunglison has published within the last ten years; and, when we reflect upon the large amount of labour and reflection which must have been necessary in their preparation, it is amazing how he could have accomplished so much in so short a time."—Louisville Journal. NEW REMEDIES, PHARMACEUTICALLY AND THERAPEUTICALLY CONSIDERED, Br ROBLEY DUNGLISON, M.D., In One Volume, Octavo—over 600 pages, the Fourth Edition. 21 Contents of Cyclopsedia of Practical Medicine. Contagion, Dr. Brown. ' . Convalescence, Dr. Tweedie. Convulsions, Dr. Adair Crawford. " Infantile, Dr. Locock. " Puerperal, Dr.Locock. Coryza. Dr. Williams. Counter Irritation, Dr. Williams. Croup, Dr. Cheyne. CONTENTS OF PART V. Ciowp,(conlinued,) Dr. Cheyne. Cyanosis, Dr. Crampton. Cystitis, Dr. Cumin. Dead; Persons found, Dr. Beatty. Delirium. Dr. Pritchard. ' " Tremens, Drs. Carter and Dunglison. Dengue, Dr. Dunglison, Dentition, Disorders of, Dr. Joy. Derivation. Dr. Stokes. Diabetes. Dr. Bardsley. Diagnosis, Dr. Marshall Hall. Diaphoretics. Dr. A. T. Thomson. Diarrhoea, Drs. Crampton and Forbes. " Adipous, Dr. Dunglison. Dietetics, Dr. Paris. CONTENTS OF PART VI. Dietetics, (continued,)Dr. Paris. Disease, Dr. Conolly. Disinfectants, Dr. Dunglison. Disinfection, Dr. Brown. Diuretics, Dr. A. T. Thomson. . Dropsy, Dr. Darwatl. Dysentery, Dr. Brown. , Dysmenorrhoea. Dr. Locock. Dysphagia, Dr. Stokes. Dyspnoea, Dr. Williams. - Dysuria, Dr. Cumin. Ecthyma. Dr. Todd. Eczema. Dr. Joy. Education. Physical, Dr. Barlow. Electricity, Dr. Apjohn. Elephantiasis, Dr. Joy. Emetics. Dr. A. T. Thomson. Emmenagogues, Dr. A. T. Thomson. CONTENTS OF PART VIL Hmphysema, Dr. R. Townsend. " of the Lungs, Dr. R. Townsend. Empyema, Dr. R. Townsend. Endemic diseases, Dr. Hancock. Enteritis. Drs. Stokes and Dunglison. Ephelis, Dr. Todd. Epidemics, Dr. Hancock. Epilepsy, Dr. Cheyne. Epistaxis, Dr. Kerr. Ereihismus Mercurial is, Dr. Burder. Erysipelas. Dr. Tweedie. Erythema, Dr. Joy. Eulrophic, Dr. Dunglison. Exanthemata, Dr. Tweedie. Expectorants, Dr. A. T. Thomson. Expectoration. Dr. Williams. Favus, Dr. A. T. Thomson. Feigned diseases, Drs. Scott, Forbes and Marshall. CONTENTS OF PART VIII. Feigned diseases, [continued,) Drs. Scott, Forbes and Marshall. Fever, general doctrine of, Dr. Tweedie. " Continued, and its modifications, Dr. Tweedie. " Typhus, Dr. Tweedie. " Epidemfc Gastric, Dr. Cheyne. " Intermittent. Dr. Brown. " Remittent, Dr. Brown. " Malignant Remitent, Dr. Dunglison. " Infantile, Dr. Joy. " Hectic, Dr. Brown. " Puerperal, Dr. Lee. " Yellow, Dr. Gillkrest. CONTENTS OF PART IX. Fever, Yellow, [continued,) Dr. Gillkrest. ' Fungus Haematodes, Dr. Kerr. Galvanism, Drs. Apjohn and Dunglison. Gastritis, Dr. Stokes. Gastrodynia, Dr. Barlow. Gasrro-Enterius. Dr. Stokes. Glanders, Dr. Dunglison. Glossitis, Dr. Kerr. £4 OlottiS, Spasm of the, Dr. Joy. Gout, Dr. Barlow. Htmatemesis. Dr. Goldie. Haemoptysis, Dr. Law. Headache, Dr. Burder. Heart, Diseases ofthe. Dr. Hope. '' Dilatation ofthe. Dr. Hope. u Displacement ofthe, Dr. Townsend. " Fatty and greasy degeneration ofthe, Dr. Hope. " Hypertrophy of the, Dr. Hope. CONTENTS OF PART X. Heart, Hypertrophy of \i\a.(continued.) Dr. Hope. " Malformations ofthe. Dr. Williams. " Polypus of.the, Dr. Dunglison. " Rupture of the, Dr. Townsend. " Diseases ofthe Valves ofthe, Dr. Hope. Haemorrhage, Dr. Watson. Haemorrhoids, Dr. Bufne. Hereditary transmission of disease, Dr. Brown. Herpes. Dr. A. T. Thomson. Hiccup, Dr. Ash. Hooping Cough, Dr. Johnson. Hydatids. Dr. Kerr. Hydrocephalus, Dr. Joy. Hydropericardium, Dr. Darwall. Hydrophobia, Dr. Bardsley. CONTENTS OF PART XI. Hydrophobia, (continued,) Dr. Bardsley. Hydrothorax, Dr. Darwall. Hyperaesthesi'a. Dr. Dunglison. Hypertrophy, Dr. Townsend. Hypochondriasis, Dr. Pritchard. Hysteria, Dr. Conolly, Ichthyosis. Dr. Thomson. Identity, Dr. Montgomery. Impetigo, Dr. A. T. Thomson. Impotence, Dr. Beatty. Incubus, Dr. Williams. Luliagstion, Dr. Todd, CONTENTS OF PART XII. Indigestion, (continued.) Dr. Todd. Induration, Dr. Carswell. Infanticide, Dr. Arrowsmith. Infection, Dr. Brown. Inflammation, Drs. Adair Crawford and Tweedie. CONTENTS OF PART XIII. Influenza, Dr. Hancock. Insanity, Dr. Pritchard. Intussusception, Dr. Dunglison. IrCitation, Dr. Williams. Jaundice, Dr. Burder. ' " of the Infant, Dr. Dunglison. Kidneys, diseases of, Dr. Carter. Lactation, Dr. Locock.. Laryngitis, Dr. Cheyne. " Chronic, Dr. Dunglison. Latent diseases, Dr. Christison. , Lepra, Dr. Houghton. Leucorrhoea, Dr. Locock. ■ Lichen, Dr. Houghton. Liver; Diseases ofthe, Dr. Stokes. CONTENTS OF PART XIV. Liver, Diseases ofthe, (continued.) Dr. Venables. " Inflammation ofthe. Dr. Stokes. Malaria and Miasma, Dr. Brown. Medicine, History of, Dr. Bostock. " American, before the Revolution, Dr. J. B. Beck. ' " State of in the 19th century, Dr. Alison. " Practical, Principles of, Dr. Conolly. CONTENTS OF PART XV. Medicine, Practical, Principles of, Dr. Conolly. Melama, Dr. Goldie. ' Melanosis, Dr. Carswell. Menorrhagia, Dr. Locock. Menstruation, Pathology of, Dr. Locock. Miliaria, Dr. Tweedie. Milk Sickness, Dr. Dunglison. Mind, Soundness and Unsoundness of, Drs. Pritchard and Dunglison. Molluscum, Dr. Dunglison. Mortification, Dr. Carswell. Narcotics, Dr. A. T. Thomson. Contents of'Cyclopaedia of Practical Medicine. Nanseants, Dr. Dunglison. Nephralgia and Nephritis, Dr. Carter. Neuralgia. Dr. Elliotson. Noli-.\ln-Tangere or Lupus, Dr. Houghton. Nyctalopia, Dr. Grant. CONTENTS OF PART XVI. Nyctalopia, (continued.) Dr. Grant Obesity, Dr. Williams. (Edema, Dr. Darwall. Ophthalmia, Dr- Jacobs and Dunglison. Otalgia and Otitis, Dr. Burne. Gsraria, Diseases of the, Dr. Lee. Palpitation, Drs. Hope and Dunglison. Pancreas, diseases ofthe, Dr. Cartet. Paralysis, Dr. Todd. Parotitis; Dr. Kerr. Parturients, Dr. Dunglison. Pellagra, Dr. Kerr. Pemphigus, Dr. Corrigan. Perforation ofthe Hollow Viscera. Dr. Carswell. Pericarditis, Dr. Hope. . Peritonitis, Drs. McAdam and Stokes. CONTENTS OF PART XVH. Peritonitis, (continued.) Dr. Stokes. Phlegmasia Dolens, Dr, Lee. Pityriasis. Dr. Cumin. Hague, Dr. Brown. Plethora, Dr. Barlow. Pleurisy, Dr. Law. Plica Polonica, Dr. Corrigan. Pneumonia, Dr. Williams. Pneumothorax, Dr. Houghton. Porrigo, Dr. A. T. Thomson. CONTENTS OF PART XVIII. Porrigo, (continued.) Dr. A. T. Thomson. Pregnancy and Delivery, signs of, Dr. Montgomery. Prognosis, Dr. Ash. Prurigo, Dr. A. T. Thomson. Pseudo-Morbid Appearances, Dr. Todd. Psoriasis, Dr. Cumin. Ptyalism, Dr! Dunglison. Puerperal Diseases, Dr. Marshall HalL. Pulse, I}r. Bostock. Purpura, Dr. Goldie. Pus, Dr. Tweedie. Pyrosis, Dr Kerr. Rape, Dr. Beatty. i CONTENTS OF PART XIX. Refrigerants, Dr, A. T. Thomson. Rheumatism, Drs. Barbw and Dunglison. j Rickets, Dr. Cumin. Roseola, Dr. Tweedie. Rubeola, Dr. Montgomery. Rupia, Dr. Corrigan. Scabies, Dr. Houghton. Scarlatina, Dr. Tweedie. Scirrhus, Dr. Carswell. Scorbutus, Dr. Kerr. Scrofula, Dr. Cumin. CONTENTS OF PART XX. Scrofula, (continued,) Dr. Cumin. Sedatives, Drs. A. T. Thomson and Dunglison. Sex, Doubtful, Dr. Beatty. Small Pox, Dr. Gregory. Softening of Organs, Dr. Carswell. Somnambulism and Animal Magnetism, Dr. PritchartU Spermatorrhoea, Dr. Dunglison. Spinal Marrow, Diseases ofthe, Dr. Todd. Spleen, Diseases ofthe, Drs. Bigsby anrl Dunglison. .Statistics, Medical, Drs. Hawkins and Dunglison. Stethoscope^Dr. Williams. Stimulants. Dr. A. T. Thomson. Stomach, Organic Diseases of, Dr. Houghton. CONTENTS OF PART XXI. Stomach, Organic Diseases of, (continued,) Dr. Hough- ton and Dunglison. Stomatitis, Dr. Dunglison. Strophulus, Dr. Dunglison. Succession of Inheritance, Legitimacy, Dr. Montgomery. Suppuration, Dr. Todd. * Survivorship, Dr. Beatty. Sycosis, Dr. Cumin. Sym tomato logy, Dr. Marshall Hall. Syncope, Dr. Ash. Tabes Mesenterica, Dr. Joy. Temperament. Dr. Pritchard. Tetanies, Dr. Dunglison. Tetanus, Dr. Symonds. Throat. Diseases ofthe, Dr. Tweedie. Tissue Adventitious, Tonics, Dr. A. T. Thomson. CONTENTS OF PART XXII. Tonics, (continued,) Dr. A. T. Thomson. Toothache, Dr. Dunglison. Toxicology, Drs. Apjohn and Dunglison. Transformations, Dt. Duesbury. Transfusion. Dr. Kay. Tubercle, Dr. Carswell. Tubercular Phthisis, Dr. Clark. M We rejoice that this work is to be placed within the reach ofthe profession in this country, it being unques- tionably one of very great value to the practitioner. This estimate of it has not been formed from a hasty exami- nation, but after an intimate acquaintance derived from frequent consultation of it during the past nine or ten years. The editors are practitioners of established reputation, and the list of contributors embraces many ofthe most eminent professors and teachers of London, Edinburgh. Dublin and Glasgow. It is, indeed, the great merit of this work that the principal articles have been furnished by practitioners who have not only devoted especial attention to the diseases about which they have written, but have also enjoyed opportunities for an extensive practical acquaintance wilh them,—and whose reputation carries the assurance of their competency justly to appreciate the opinions of others, while it stamps their own doctrines with high and just authority."—American Medical Journal. " Do young physicians generally know what a treasure is offered to them in Dr. Dunglison's revised edition? Without wishing to be thought importunate, we cannot very well refrain from urging upon them the claims of this highly meritorious undertaking."—Boston Medical and Surgical Journal. "It has been to us, both as learner and teacher, a work for ready and frequent reference, one in which modern English Medicine is exhibited in the most advantageous light, and with adaptations to various tastes and expecta- tions. The PuUlishers can be safely relied on as both able and willing to carry thi3 undertaking through with all possible expedition."—Medical Examiner. " Such a work as this has long been wanting in this country. British medicine ought to have set itself forth in this way much sooner. We have often wondered that the medical profession and the enterprising publishers of Great Britain did not, long ere this, enter upon such an undertaking as a Cyclopaedia of Practical Medicine."— Lonrio n Medical Gazette. " The Cyclopaedia of Practical Medicine, a work which does honour to our country, and to which one is proud lo see the "names of so many provincial physicians attached."—Dr. Hastings' Address lo Provincial Medical atul ' Surgical Association. '' Of the medical publications ofthe past year, one may be more particularly noticed, as partaking, from its ex- tent and the number of contributors, somewhat of the nature of a national undertaking, namely, the "Cyclopaedia of Practical Medicine.' It accomplishes what has been noticed as most desirable, by presenting, on several impor- tant topics of medical inquiry, full, comprehensive, and well-digested expositions, showing the present state of our knowledge on each. In this country, a work of this kind was much wanted: and that now supplied cannot but be deemed an important acquisition. The difficulties of the undertaking were not slight, and it required great energies to surmount them. These energies, however, were possessed by the able and distinguished editors, who, witb/dilio-ence aitil labour such as few can know or appreciate, have succeeded in concentrating in a worku>f moderate size, a body of practical knowledge of great extent and usefulness."—Dr. Barlow's Address to the Med. and Sur. Association. 25 Cyclopaedia of Practical Medicine continued. "This Cyclopaedia is pronounced on all hands to be one of the most valuable medical publications of the day. It is meant to be a library of Practical Medicine. As a work of reference it is invaluable. Among the contribu- tors to its pages it numbers many of the most experienced and learned physicians of the age. ami as a whole it forms a compendium of medical science and practice from which practitioners and students may draw the rioh*s»t instruction."— Western Journ. of Med. and Surgery. l; In our last number we noticed the publication of this splendid work by Lea and Blanchard. We have since received three additional parts, an examination of which lias confinned us in our rirsi impress:on, that as a work of reference for the practitioner—as a cyclopaedia of practical medicine—it is admirably adapted to the wants of the American profession. In fact, it might advantageously find a place in the library of any gentleman, wlio has leisure and taste for looking somewhat into the nature, causes, and cure of diseases."—Western Journal of Mat. and Surgery. hThe favourable opinion which we expressed on former occasions from the specimens then before us, is m no degree lessened by a further acquaintance with its scope and execution."—Medical Examiner. *• In conversation with practising physicians, we have been gratified to find that this work comes fully up » the high expectations formed of it from the complimentary notices of the Journals, and that as a work of reference it is regarded as superior to any thing hitherto published on Practical Medicine."—Western Journal of Med. and Surgery. *#* In reply to the numerous inquiries made to them respect- ing Tweedie's Library of Practical'Medicine, the Publishers beg leave to state that its place is supplied, in a great measure, by the Cyclopaedia of Practical Medicine, a work much more extended in its plan and execution. The works are entirely distinct and by different authors. The "Library" consists of essays on dis-" eases, systematically arranged. The " Cyclopaedia" embraces these subjects treated in a more extended manner, together with numerous interesting essays on all important points of Medical Jurisprudence, Materia Medica and Therapeutics, Obstetrics, History of Medicine, &c, &c. by the first physicians of England, the whole arranged alphabetically for easier reference. JUST PUBLISHED, CHAPMAN ON FEVERS, &c. LECTURES ON THF MORE IMPORTANT ERUPTIVE FEVERS, HEMORRHAGES AND DROPSIES, AND ON GOUT AND RHEUMATISM, DELIVERED IN THE UNIVERSITY OF PENNSYLVANIA. By N. CHAPMAN, M. D., Professor ofthe Theory and Practice of Medicine, Sec. &c. In one neat octavo volume. This volume contains Lectures on the following subjects: EXANTHEMATOUS FEVERS. Variola, or Small Pox; Inoculated Small Pox; Varicella, or Chicken Pox; Variolas Vaccinias, or Vaccinia, or Cow-pock; Varioloid Disease; Rubeola, Morbilli. or Measles: Scarlatina vel Febris Rubra—Scarlet Fever HjEMORKHAUKS. Haemoptysis, Spitting of Blood: Haemorrhagia Narium, or Haemorrhage'from the Nose: Ha;matemesis. or Vornitr ing of Blood: Haematuria, or Voiding of Bloody-Urine: Hasmorrhagia Uterina, or Uter.ne Hseinorrluv'e'- Hainor- Aois or Haemorrhoids; Cutaneous Haemorrhage; Purpura Hemorrhagica. DK0PS1ES. Ascites; Encysted Dropsy: Hydrothorax; Hydrops Pericardii; Hydrocephalus Internus, acute subacute and chronic: Anasarca; with a Disquisition on the Management ofthe whole. GOUT, RHKUMATISM, &c &c. THEY HAVE ALSO FUR S,ALE LECTURES ON THE MORE IMPORTANT DISEASES OFTHE t THORACIC AND ABDOMINAL VISCERA, DELIV.ERED IN THE UNIVERSITY OF PENNSYLVANIA. By N. CHAPMAN, M.D. Professor ofthe Theory and*Practice of Medicine, &c. In one Volume, octavo. 26 LEA & BLANCHARD PUBLISH AND HAVE FOR SALE, HORNER S ANATOMY. SPECIAL ANATOMY AND HISTOLOGY. BY WILLIAM E. HORNER, M. D., Professor of Anatomy in the University of Pennsylvania. Member ofthe Imperial Medico-Chirurgical Academy of St. Petersburg, of the Am. Philosophical Society, ice. &c. Sixth edition, in two volumes, 8vo. " Another edition of this standard work of Professor Horner has made its appearance to which many additions have lu-cn made, and upon which much labo,ur has been bestowed by the author. The additions are chiefly in the department of Histology, or Elementary Anatomy, and so important are they that the Professor has added the lerm to the title of his work. P'.vry part of this edition seems to have undergone the most careful revision, and its readers may rest assured of having the science of Anatomy fully brought up to the present day."'—Am. Med. Journal. GRAHAM'S CHEMISTRY, THE ELEMENTS OF CHEMISTRY, Including the application of the Science to the Arte. WITH NUMEROUS ILLUSTRATIONS. BY THOMAS GRAHAM, F. R. «., L. andE.D. Professor of Chemistry in University College, London, &c. &c. WITH NOTES AND ADDITIONS BY ROBERT BRIDGES, M. D., &c. &c. In One Vol. Octavo. The great advancement recently made in all branchesof chemical investigation renders necessary anew text book which shall clearly elucidate the numerous discoveries, especially in the department connected with organic Chemistry and Physiology, in which such gigantic strides have been made during the last few years. The pre- sent treatise is considered by eminent judges to fulfil all these indications, and to be peculiarly adapted to the wants ofthe medical student and practitioner. }u adapting it to the wants ofthe American profession, the editor has endeavoured to render his portion of the work worthy the exalted reputation ofthe first chemist of England. It is already introduced as a text book rn many ofthe Colleges, and has universal approbation. "Professor Graham"s work is one ofthe best, if not the best, of all English text books, andisof such Tecent date as to embrace all the latest discoveries. The appearance of a correct and amended American Edition, under the care of "Dr. Bridges, will prove an acceptable thing to both teachers and students of Chemistry in this country." —Silliman's Journal.__________ F£Ri:iRA7S~BZATEKIA MEDICA. WITH NEAR THREE HUNDRED ENGRAVINGS ON WOOD. THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. COMPREHENDING THE NATUB AL HISTORY, PREPARATION, PROPERTIES, COMPOSITION, EFFECTS, AND USES OF MEDICINES. BY JONATHAN PEREIRA, M.D., F.R. 8. and L.S. From the Second London Edition, enlarged and improved. WITH NOTES AND ADDITIONS Br JOSEPH CARSON, M- D. f In Two Vols. Octavo., The object of the author has been to supply the Medical Student with a Class Book on Materia Medica, containing a faithful outline of this Department of Medicine which should embrace a concise account ot the most important discoveries in Natural History, Chemistry, Physiology and Therapeutics, in so far as they pertain to Pharmaco- logy, and treat the subjects in the order of their natural historical relations. TThis great Library or Cyclopaedia of Materia Medica has been fully revised by DR. JOSEPH CARSON, profes- sor of Materia Medica and Pharmacy in the "College of Pharmacy," and forms Two Volumes, octavo, of near 1C00 large and closely-printed pages. It may be fully relied upon as a permanent and standard work for the country,—embodying, as it does, full references to the U. S. Pharmacopoeia and an account of the Medical Plants indigenous to the United States._______________________________________ FERGUSSON'S PRACTICAL SURGERY. A SYSTEM OF PRACTICAL SURGERY, BY WILLIAM FERGUSSON, F.R.S E., Professor of Surgery in King's College, London; Surgeon to King's College Hospitrf, &c. tec. WITH TWO HUNDRED AND FORTY-SIX ILLUSTRATIONS. Engraved by Gilbert, after drawings by Bagg. WITH NOTES AND ADDITIONAL ILLUSTRATIONS BY GEORGE W. NORRIS, M. D., In one yolume octavo. The prrMishers commend this work to the attention ofthe Profession as combining cheapness and elegance w«a aflear'sound, and practical treatment of every subject in surgical science. \o pains or expense have beea .nnred'io present it in a stvle equal, if not superior to the London edition, and to match the editions of " Wilson* Anatomy » '• Churchill's System of Midwifery," and " Carpenter's Human Physiology." It is now exteaeivery usCfl a* a text book. LEA AND BLANCHARD ARE PREPARING FOR PUBLICATION A MANUAL' OF ELEMENTARY CHEMISTRY, THEORETICAL AND PRACTICAL. By GEORGE FOWNES, PH. D. WITH NUMEROUS WOOD ENGRAVINGS, And Notes and Additions by ROBERT BRIDGES, M.D., Professor of Chemistry in the "Philadelphia Medical Association," &c. fcc. In one vol. royal 12mo. HOBLYNS DICTIONARY. , .A DICTIONARY OF TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES, * FOR THE USE OF STUDENTS. BY RICHARD D. HOBLYN, M. D., &c • From the Second London Edition, with numerous additions. BY ISAAC HAYS, M.D., &c. In One Volume, royal 12mo. GUTHRIE ON THE ANATOMY OF THE BLADDER AND THE URETHRA, AND THE TREATMENT OF THE OBSTRUCTIONS TO WHICH THOSE PASSAGES ARE LIABLE. From the Third London Edition, In one volume, 8vo. .—.------------------*—.—-—. ALSO, * ANOTHER VOLUME OF THE SPLENDID SERIES OF THE WORKS OF SIR ASTLEY COOPER. COOPER ON THE ANATOMY AND DISEASES OF THE BREAST. The whole to form one large and beautiful imperial octavo volume, with numerous plates in the best style of Lithography, and printed and bound to match the volumes on Hernia and the Testis already issued. L. & B. HAVE LATELY PUBLISHED CARPENTERS PHYSIOLOGY. PRINCIPLES OF HUMAN PHYSIOLOGY. With their chief applications to Pathology, Hygiene, and Forensic Medicine. Especially designed for the use of Students. ' With over One Hundred beautiful Illustrations on Wood. BY WILLIAM B. CARPENTER, M. D., Lecturer on Physiolosy in the Bristol Medical School. FIRST AMERICAN EDITION, WITH NOTES BY THE AUTHOR, AND NOTES AND ADDITIONS ,BY MEREDITH CLYMER, M. D., In one volume, octavo. Id" This edition of Carpenter's Physiology has been most carefully prepared by Dr. Cly- mer, at the request of Professor Jackson, for his lectures at the University of Pennsylvania. ALISONS PATHOLOGY. A NEW WORK. OUTLINES OF PATHOLOGY AND PRACTICE OF MEDICINE. BY WILLIAM PULTENEY ALISON, M.D., Professor of the Practice of Medicine in the University of Edinburgh, Sec. kc. In three Parts—Part I.—Preliminary Observations-Part II.-Inflammatory and Febrile Diseases and Part III., Chronic or Non-Febrile Diseases. In one volume'octavo. For nninerous other works not detailed, see the Two following . Pages. 38 j IN THE WORKS VARIOUS DEPARTMENTS MEDICINE AND SUKGEEY: j PUBLISHED ( BY ' ■ ( ( LEA & BLANCHARD, ANATOMY. ANATOMICAL ATLAS, illustrative of the Structure of the Human Body; with over Six Hundred Illustrations; the most complete work of the kind ever issued,— beautafrlly executed, in One Volume Im- periaTOctavo; by H. H. Smith, M.D., un- der the supervision of Professor W. E. Hor- ner. HORNER'S Special Anatomy and His- I tology; 6th edition, much improved. 2 vols. | 8vo., 1114 pages. WILSON'S Human Anatomy; anew edition (the second) revised, with additions ; by Dr. Goddard : 207 beautiful cuts. 8vo., ! 608 pages. WILSON'S Dissector, or Practical and Surgical Anatomy; with additions by God- . dard—106 cuts. Royal 12mo., 444 pages. PHYSIOLOGY. CARPENTER'S Human Physiology; with notes and additions by Meredith Cly- mer, and over 100 cuts—in 8vo., 618 pages. 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CYCLOPEDIA OF PRACTICAL MEDICINE ; comprising Treatises on the nature and treatment of Diseases, includ- ing those of Women and Children, Materia Medica, Therapeutics. Medical Jurispru- \ dence, &.c, &c. Edited by Forbes, Twee-; die, Conolly and Dunglison. 4 large Su- per-Royal Octavo Volumes. About 3000 pages in double columns. DUNGLISON'S Medical Dictionary ; 4th edition, containing over 40,000 words and synonymes ; large 8vo., of 772 pages, double columns. MEDICAL NEWS AND LIBRARY Published Monthly at One Dollar a Year. SELECT MEDICAL ESSAYS; by Drs. Dunglison, Chapman and others.—2 vols. 8vo., 1150 pages. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. LEA St BLANCHARD are the Publishers ofthe American Journal ofthe Medical Sciences. Edited by ISAAC HAYS. M. D., Surgeon to Wills' Hospital, Physician to the Philadelphia Orphan Asylum,Member of the Am. Philos. Soc, Sec. ic. Sec, assisted by numerous collaborators in every section of the Union. This Journal was commenced TWENTY-FIVE YEARS AGO. and it is therefore the oldest Medical Journal now existing in the United States, and its permanency may be considered as established. It was originally edited by Dr. Chapman, who has been a constant contributor to its pages j and, for the last eighteen years, it has been under the editorial direction of Dv. Isaac Hays. The pages of this Journal contain the recordb of the experience of the most distinguished members of the Profession in every part of the Union. CONTENTS OF THE NO. FOR JANUARY, 1S45. Memoirs and Cases.—Art. I. Cases of Strangulated Hernia, with some remarks principally intended to show the necessity of an early resort to the operation. By John C. Warren, M. D. II. On the Pathology of Remittent Fever. By John A. Swett, M. D. III. On the treatment of Yellow Fever. By F. Wurdemann, IVI.D. IV. On the Pulse of the Insane, by Pliny Earle. M. D. V. Temporary Protrus.on of the Eyeball, with loss of Vision, from rheumatic inflammation. By Isaac G. Porter, M. D. VI. On Obstetrical Auscultation. By L. S. Joy nes. Al. D. VII. Tumour of the Neck, of extraordinary size, successfully removed. By P. C. Spen- cer, Al. D. [With two wood cuts] VIII. Surgical Cases. By Edwin Hall, M. D. IX. Cases of Strangulated Htj-nia. By A. B. Shipman, M. D. Reviews.—X. Pouchet on the Fecundation of the Mammiferae. Raciborski on Puberty and the Critical Age in Women, and of the Periodical Discharge of Ova, &c. Bischoff on the Proof of the Periodical Ripening and Sttiaration ofthe Ovaof Mammalia and Man, independent of Coitus. XI. Chadwickon Interment in Towns. Bibliographical Notices.—XII. I. The Twentieth Annual Report ofthe Officers of the Retreat for the Insane at Hartford. 2. Eighth Annual Report of the Physician and Superintendent of the Vermont Asylum for the Insane. 3. Report of the Superintendent of the Boston Lunatic hospital, and PhysiciaTi of the Public Institutions of South Boston.—XIII. 1. Reports of the state of the Kent County Lunatic Asylum. 2. State- ments of the Visiting Committee of the County Lunatic Asylum, near Gloucester. 3. The Report of the Committee of Visitors of the Lunatic Asylum for the County of Leicester. 4. Thirty-third Annual Report of the General Lunatic Asylum, near Nottingham. 5. Reixjrtf of the Medical Officers of the Lunatic Asylum for th,e"County of Lancaster. 6. Fifty-ninth, Sixty-fourth and Sixty-Eighth Reports of the Visiting Justices of the County Lunatic Asylum at Hanwell. XIV. Zeis on the Plastic Surgery of Celsus: on Organic Adhesions: arid on Inverted Toe-Nail. XV. Wattman on Means of Preventing the Rapid Occurrence of Fatal Symp- i lonrs in the Accidental Introduction of Air into the Veins. XVI. Hennemann on a New Series of Subcuta- neous Operations. XVII. Huftland's Enchiridion Medicum. XVIII. Summary of the Transactions of the College of Physicians of Philadelphia. March to October, JS44. XIX. Chairman on the more important Eruptive Fevers, Haemorrhages and Dropsies, and on Gout and Rheumatism. SUMMARY OF THE IMPROVEMENTS AND DISCOVERIES IN THE MEDICAL SCIENCES. Aisatomy and Physiology.—1. Scherer on the Coloration of the Blood. 2. Jobert de Lamballe on the Struc- ture of the Uterus. 3. Mulder on the products of the oxidation of Protein in the Animal Organism. 4. Moreau on the causes which determine the Sex yi feneration. 5. Magtndie on the Influence of Heat and of Stoves on Animal Life. 6. Bernard and Barreswil on Alimentary Substances. 7. Schvan on the importance of Bile in the Living Animal Organism. 8. Blaquiere on Gunshot Wound of the Anterior Cerebral Lobes. 9. Boudet on the Chemical Composition of the Pulmonary Parenchyma and of Tubercles. Matekia Medica and Pharmacy.—10. Seidlilz on Cotton as a Dressing to Blisters. 11. Devay on the mode of preparing the Valerianate of Zinc. 12. Bouchardat on Croton Oil Plaster. 13. Millot on the Lithontriptic action of the Gastric Juice. 14. Gumprechl on Cortex Franguhc. 15. Scheidemandel on the mode of preparing some Narcotic Extracts in small quantities. 16. Burton on a new method of making Medicated Tinctures. 17. Hoffman on Caroub of Judea in Asthmatic Affections. Medical Pathology and Thbrapeutics and Practical Medicine.—IS. Lossttu on Small-pox in persons vrtio had been Vaccinated. 19. Berlini and BeUingiere on Nitrate of S.lver in Chronic Diarrhoea. 20. Bellin- gtere on Balsam of Copaiba in Chronic Bronchitis. 21. Druill on the uses of Pure Tannin. 22. Fourcault on the causes of Albuminuria. 23. Meyer's Researches on Albuminuria. 24. Rees on the Pathology and Treat- ment of the Morbus Brightii, and various forms of Anaemia. 25. Gregory on Deaths from Small-pox after Vaccination, in London. 26. Devay on Valerianate of Zinc in Nervous Affections. 27. Perini on a singular , case of Encephalitis. 28. Salvagnoli on Analysis of the Blood of Persons Exposed to Malaria. 29. (Esterlen on the Passflfe of Metallic Mercury into the Blood and Solid Tissues. 30. Lamolhe on Epilepsy caused by a Foreign Body in the Ear, and cured by its removal. 31. Symptoms of Acute Pleurisy, caused by Intestinal Worms. 32. J. and J. H. Smith on Sulphate of Iron combined with an Alkaline Carbonate, an Antidote for Prussic Acid. 33. Mac Donnel On the Diagnosis of Empyema. 34. Mondiere on a Taenia evacuated through au opening in the Abdominal Parietes. 35. Trousseau on the Signs of Auscultation in Young Children. SJurgical Pathology and Thekapeutics and Operative Surgery.—36. Syme on treatment of Obstinate Stricture of the Urethra. 37. Reybard on Suture of the Intestine. 39. Bodinier on the Nature and Source ofthe Liquid which flows from the Ear producing C3dema of the Scalp. 39. Danville on Gunshot Wound, where the eiiarge passed from the Navel to the Back without fatal consequences. 40. Sandham on mode of Reducing Partial Displacement of the Semi-lunar Cartilages of the Knee-joint. 41. Porter on Operation for the Radical Cure of Hydrocele. 42. Two cases of Luxation of the Iliac Bone upon the Sacrum. 43. Singular cause of Error in Diagnosis of Affections ofthe Knee. 44. Daniell on Warty Excrescences near the Verge of the Anus. 43. Daniell on Enormous Steatoma removed from the Shoulder. 46. Jeaffreson on Operations tor Removal of Oyarian Tumours. 47. Bird on Removal of a Diseased Ovary. 48. Wiesel on Ununited Fracture Successfully Treated by Acupuncture. 49. Monin on Lirxation of the Forearm forwards without fracture of the Olecranon. 50. Segalas on Influence of Traumatic Lesions of the Spinal Cord on Diseases of the Urinary Passages. 51. Wildebrand on the Treatment of Syphilis by Tartar-emetic. 52. Barbiere's case of Recovery from Wound with Hernia of the Lung. 53. Syme on Popliteal Aneurism in a Child. 54. Rognetta on Epidemic Erysipelas. 55. Inman on Mortality attending the,operation of Tying the Large Arteries. 56. Vanzetti on Fibrous Tumour of the Parotid. 57. Vidal on New Operation for Varicocele. 58. Inman onMortality attending the Operation for Hernia. 59. Laugier on Immovable Bandages of Starched Paper for the Treatment of Fractures of the Limbs. 60. Cox on Gunshot Wound of the Chest—evacuation of the ball per anum. 61. Wilde on Discharges from the Ears. 62. Syme on Bursal Swelling of the Wrist and Palm of the Hann. Ophthalmology.—63. Morant on Epidemic Ophthalmia. 64. Bernard's Method of Curing Lachrymal Fistulas and Chronic Lachrymations reputed incurable. 65. Dalrymple on Cy si attached to the Anterior Surface of the Iris. Midwifery.—66. Prael on Caesarian operation performed with success both for the mother and child; rupture of (tie uterus and of the abdominal parietes thirteen months subsequently, during a second pregnancy; delivery of the foetus through this spontaneous opening; complete recovery of the mother. 67. Fischer's case of Gravid Uterus passing into the Sac of an old Inguinal Hernia.—Caesarian Section. 6b. Aubinais on Polypus ofthe Uterus adherent to the Placenta Successfully Removed. 69. Ginestet on the Juice of the Urtica Urens in Uterine Hemorrhage. 70. Darbey on Prolapsed Uterus— Pregnancy. 71. Lee on Dropsy of the Amnion 72. Lee on the Causes and Treatment of Uterine Hemorrhasre, in the latter months of pregnancy. 73. Lee on Retained Pla- centa. 74. Lisfranc on Diagnosis of Inverted Uterus and Polypus. 75. Mvrj>hy's Statistics of Obstetric Practice. Medical JuRisPRUDtNi e and Toxicology.—76. Olivier on Arsenic in the Earth of Cemeteries. 77. Ramsay on Aconitum Napellus. 7- Jacob on Poisoning by Euphorbia Lathyris. 79. Rupture of the Omentum. 80. Lis- franc's opinion on some Disputed Points rp Obstetrical Medical Jurisprudence. 81. Hereditary Insanity, how far, in cases of alleged Unsoundness of mind, it may be pleaded. 82. Simpson on Relative Weight and Size of the .Male and Female at Birth. 83. Copper Tanks at St. Helena. 84. Trial for Murder. 85. Case of Suicide. Mi. Recent English Law Cases. 87. Obituary of Dr. Abercrombie. American Intelligence.—Original Communications.—Horner on the Preservation of the Human Body for Anatomical Purposes. Proceedings ofthe Association of Medical Superintendents of American Institutions for the Insane. Perkins's Cases of Congestive Fever. Domestic Summary.—Fourgeaud on Mortality among Children in St. Louis. Le Conte on Extraordinary Effects of a Stroke of Lightning. Bowles on Removal of a Diseased Ovarium. Herrick on Rupture of the Spleen. Marthens on Fracture during Pregnancy. Buck and Watson on Opium a Hazardous Remedy in Stran- gulated Henna. Yellow Fever at WoodviUe, Miss. Daois on Colon Strangulated by the Meso-colon. Clark on Discharge of a Lumbricus from the Male Urethra. M'Dowell's cases of Extirpation of Diseased Ovaria. New Work* Death of Dr. Forry. 31 AMERICAN MEDICAL JOURNAL PUBLISHERS' NOTICE. In presenting the first number for the year of The American Journal of the Medical Sciences, the Publishers must offer their thanks to the profession for the increased favour extended to this long-established periodical, now the oldest Medi- cal Journal in the Union. As an evidence of this patronage it may be stated, that notwithstanding an enlarged edition was printed for last year, at the present time not a single copy of the January or October numbers can be supplied. It is intended to continue the work as heretofore, with about 261 large pages, quarterly, with such cuts and plates as are essential to illustrate the different papers; and particular attention is invited to that portion embracing THE""RETROSPECT FOR THE QUARTER, Presenting, as it does, the most copious Summary ofthe Improvements and Dis- coveries, in Medicine and Surgery, from all the various Journals published abroad and at home. With-a view of extending the circulation ofthe Journal, the publishers are now ■ furnishing, with it— A MONTHLY PERIODICAL, FREE OF CHARGE, to such subscribers as remit Five Dollars in advance. Attention is solicited to the following terms:— Those persons who remit Five Dollars by the first of March, will receive not only The Medic 1 Journal for 1845, but the Medical News and Library for 1845, free from any further charge. For Ten Dollars they will furnish the Journal for 1845 and 1846, and the News for 1844, 1845 and 1846 free from any further charge. Subscribers who have not yet paid for the year'1844, are particularly requested to remit at once, and are informed that if Ten Dollars are remitted at once it will bs placed to their credit for the Journal for 1844 and 1845, and the News for the same years sent free of charge. No such terms can be made except to subscribers who remit in advance,free of postage, and direct to the Publishers. ^ Agents can furnish the News gratis to be sent by mail, only in cases where the subscription, Five Dollars, for the Journal, is paid in advance; under no other cir- cumstances will they send The News gratis. Early orders are solicited, as very few more copies of the Journal will be printed than are actually subscribed for, and subscribers may be disappointed in obtaining the early Numbers of the year, as was the case in the last volume. The Medical News and Library for 1845 will contain, in addition to the News ofthe month, THE SURGICAL LECTURES OF SIR BENJAMIN RRODIE; Thus following Watson's Practice of Physic, (which occupied the Library portion ofthe News for 1843 and 1844,) with a work on Surgery of great practical value, and by one ofthe first and most authoritative surgeons of the day. The pages ofthe Lectures will be so arranged that, when complete, they can be bound in a volume. The News and Library will be issued monthly, and contain 32 pages, and go by mail as a newspaper. Pric% One Dollar a year, payable in advance, and in current funds, free of postage. Postmasters are at liberty to frank remittances in payment for subscriptions. The Publishers beg to present the Contents of the Journal for January 1845, which will be found on the preceding page. W^" This paper may be delivered to any physician if declined by the person to whom it is addressed or if they have removed—and Postmasters and Others will particularly oblige the publishers by furnishing a list of the Physicians and Law- yers of their county or neighbourhood. In addition to the business it may bring to the office, a copy of " The Complete Florist,'" or such other volume, will be sent by m.til gratis for any ten or more names furnished free of cost. Philadelphia^ January, 1845. 32 —„. **"•» :.r.f Cf.r' £@ Sufe'%^',.*1* :-^:':-.:^, ,~J$ i*ft s. -^ **, ■*-; £*& ■fc I r$ U;T ■*.-•* N^>'1ft1**: '^ •*•• -S-fe**"^ s.i*a ^Sfewa :„.,;.':