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    CLINICAL  LECTURES



            ON




        DISEASES



           OP THE





URINARY  ORGANS. 
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Tc
 1869 
Re 9^o
/, CLINICAL  LECTURES
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DISEASES
0 Lf^jU,
ITRINAEY  ORGANS.
DELIVERED AT UNIVERSITY COLLEGE HOSPITAL.
            BY

     SIR HENRY THOMPSON,
SURGEON-EXTRAORDINARY TO H. M. THE KING OF THE BELGIANS ; PROFESSOR OJ>
  CLINICAL SURGERY, AND SURGEON TO UNIVERSITY COLLEGE HOSPITAL.
WITH ILLUSTRATIONS.

LIBRARY
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^^INGTOM^*.^
    PHILADELPHIA:
HEIRY 0. LEA.
       1869. 
Q^Sj)
       PHILADELPHIA :
COLLINS, PRINTER, 705 JATNE STREET. 
PREFACE.
  I think it right to say that these Lectures were never
committed to writing by me.  They were delivered in a
colloquial style, after the  arrangement of the subject had
been well considered, and were reported verbatim by one
of our best shorthand writers.  The copy furnished by him
was corrected, some  of those tautologies which seem to  be
necessary in teaching removed, and then sent to the Lancet.
But each Lecture still required more space than was avail
able in the columns of  a weekly journal,  and I further
reduced it, perhaps  one-fourth.   I now present, in one
small volume, at the suggestion of, I may truly say, nume-
rous correspondents, known and unknown to me, the cor-
rected  copy in full,  unchanged  in  form,  and therefore
unshorn of the familiarities which the conversational style
peculiar—and,  I believe, appropriate—to  the class-room
demands.  And I do this, also, because I prefer that these
Lectures, originally  short, should not suffer  any abbrevia-
tion, and because I desire to offer, not merely to the mem-
bers of my own clinical class, but to students at large, some
of the fruit of a long and careful study in that field of prac-
tical medicine,  in its widest sense, to which they relate.

  35, Wi.mi'olk Stkeet, London,
          Nov.  1868. 
 
            LIST  OF  LECTURES.



Lecture                                             Page
   I.—Introductory—Diagnosis......17

  II.—Stricture of the Urethra......36

  III.—Stricture of the Urethra (continued)    ...   56
  IV.—Hypertrophy of the Prostate and its Consequences   75

  V.—Retention of Urine    .        .....95
  VI.—Extravasation of Urine and Urinary Fistulas    .  107

 VII.—Stone in the Bladder.......119

VIII.—Lithotrity    /.......    .  134

  IX.—Lithotomy.......•      151
  X.—Cystitis and Prostatitis......166

  XL—Diseases of the Bladder ; Paralysis ; Atony ; Juve-
          nile Incontinence ; Tumors.....180
 XII.—Hematuria and Renal Calculus.....194 
 
              DISEASES
                        OF

THE  URINARY  ORGANS.
                   LECTUKE  I.

               Intkoductoky : Diagnosis.

   Gentlemen :—I propose to give a course of lectures on
the Surgical Diseases of the Urinary Organs, and my object
will be to afford you that information which  will be most
useful at the bedside.  I shall not consider their anatomy
or physiology, since that would make the course much too
long.  In the systematic lectures of the College it is impos-
sible to communicate all those practical  manoeuvres, those
little things which one  arrives at, either in the way of
diagnosis or treatment, which are so valuable in  practice
hereafter ; neither is it possible that you  should all acquire
them at the bedside,  since no hospital  can  furnish  patients
sufficient for the purpose; but you can  learn  a  great deal
by  the conversational  communications which are made
here.  It will be my aim to render available  the result of
experience which it  has  cost me years  to acquire, and I
shall do my  best to furnish to you what of it  is thus com-
municable in as many hours.
       2 
13     diseases op  the urinary organs.
  I have selected this  course  of clinical lectures on the
urinary organs for two reasons.   First, because my wards
always afford groups  of these cases;  you can always  find
there abundant material for consideration at the weekly
clinical lecture.  Secondly, because I do not know any set
of diseases that are so successfully dealt with if you under-
stand what you are about, or any in which you may make
silch dangerous mistakes if you  are not well  acquainted
with them.  Neither do I know any diseases in which you
can afford so  much  relief to  suffering, none in  which a
skilled  hand can do  so much for the patient, and none  in
which you can gain more credit for yourselves.  It is there-
fore exceedingly important that you  should be thoroughly
acquainted with them.
   I hope, in the course of  about  twelve  lectures, to carry
you through  the greater  portion of  the list  of subjects
named in Part I.

         I. Diseases of the Urinary Passages.
   a. Diseases essentially inflammatory.
         Urethritis,  ~\
         Prostatitis,   > acute and chronic.
         Cystitis,   J
   b. Diseases essentially obstructive.
         Stricture of the urethra.
         Hypertrophy of the prostate.
   c.  Calculous diseases.
         Of the urethra.
          Of the prostate.
          Of the bladder.
          Of the pelvis of the kidney. 
DIAGNOSIS.
  (I.  Tumors—malignant and non-malignant.
         Of the prostate.
         Of the bladder.

  II.  Diseases affecting the Secreting Organs.
  All organic changes in the kidney;  also those altered
    conditions of the urine which depend on constitutional
    disease, such as Bright's  disease and saccharine dia-
    betes.
But, before doing so,  I  shall ask you to consider  for a
moment the title I have affixed to this course—viz. " The
Surgical Diseases of the Urinary Organs."  Now, you may
inquire,  " What are the surgical diseases of  the urinary
organs, and what are not?  To my mind it is very easy
to tell you what are surgical diseases of those organs, but
not so easy to tell you  what are not.   Look at the list
before you, and see where the line should be drawn.  Cer-
tainly the  first division  belongs wholly to that class—all
diseases  of the  urinary passages, excluding the kidneys,
which we will assume to be secreting organs.  Undoubtedly
all that part belongs to the surgeon.  The physician, con-
ventionally, claims the second; but since it is impossible
to make  a  diagnosis  of any one of those  diseases without
well understanding the  whole, and as the physician does
not make a physical examination by means of an instru-
ment, I am compelled to regard all affections of the urinary
organs as naturally coming within the province of surgery.
This statement may not be universally received; but if we
consider  the matter, we shall see that  it is absolutely neces-
sary for the diagnosis of urinary diseases to be able to pass
a sound  or catheter.  I do not say that the physician  is 
20     DISEASES OF THE URINARY ORGANS.
incapable of doing this; but, conventionally, it is not prac-
tised by him.   And you can no more treat diseases of the
urinary organs without the ability to use these instruments
than you  can  treat diseases of the chest without under-
standing the use of the stethoscope.
  The first step in our course  is naturally that relating to
Diagnosis. I say almost nothing about the pathology and
treatment of any one of these diseases to-day.   The question
before us now is diagnosis, and you will understand this to
be a most important thing in all diseases—to know  accu-
rately what you are about to treat:  there is then little dif-
ficulty as to the management.  Many books  can  tell you
the one; no book can tell  you the  other.  Diagnosis can
only be  accomplished by the application of certain rules
after some practice.   It is  the first thing to  learn and  to
use; it is the last thing to be  perfectly acquired.   Indeed
no man, let him live as long as he may, will ever be a per-
fect  diagnostician.  He may approach  perfection; but if
he is a diligent student, as he ought always to  be, he will
improve his powers of diagnosis as long as he lives.  That
is  the  reason  why age or experience gives value to an
opinion.   It is long observation and extended  experience
that enable a  man to arrive at diagnosis with greater cer-
tainty than the younger practitioner can possibly do.
  Then we want to learn not merely diagnosis, but the art
of making a rapid diagnosis. When called to the bedside,
your action must often depend on  the first three or four
minutes  of your interview. It may be easy to go home
quietly, think over the case, pull down the authorities, and
say, "I think the patient has so and-so."  That  will not
always do; it may do in some cases, and it had better do 
DIAGNOSIS.
21
than that you  should attempt to treat the case without
having made up your mind  as to the diagnosis.  But that
which will make you successful, that which distinguishes
between the intelligent practitioner and him who is not so,
is the ability to make a rapid as well as an accurate diag-
nosis of the case before him.  Now, in  calling your atten-
tion to this subject, I am afraid I  cannot  guarantee  that
you shall leave this theatre an hour hence  first-rate  diag-
nosticians of these diseases; but I can give you the method
which, after a good deal of thought and experience, I have
found best to answer the end proposed,  and you can apply
it afterwards for yourselves.
  First, you should pursue  your diagnosis on a  uniform
plan—that is, you should adopt a uniform  mode of inter-
rogating  each case of urinary disease.  And what I say of
this disease is applicable to most others.  Your object is to
collect facts, and your diagnosis consists of the inference
which  you draw from those facts.   You will endeavor to
arrive at the facts  by the shortest possible route, and by
the most accurate  method.   You  should  ask questions,
make observations by the eye, by the hand, and by instru-
ments, and then examine the secretions.  Take them in
that order: first,  observation by  questions; second, ob-
servation by the eye, by  the hand, and  by the instrument,
which after all is  but a long finger. You  have no finger
which is  long enough to go down .these narrow passages,
and you  lengthen it  by means  of your instrument.   So
with regard to your  eyes:  your endoscope, whatever it
may be worth (as to which I shall have  something to say
presently),  is simply an increased ability to  see.
  First of  all with regard to questions.  You may make 
22     DISEASES OF THE URINARY ORGANS.
out most cases of urinary disease—say five out of six—by
four simple  questions, including the  minor  extensions
which arise out of them.   I always ask the  patient these
four questions,  and in the following order:—
  The first question is, " Have you any, and, if any, what
frequency in passing  water ?"   Then, as a branch of that
question, springing out of it, I ask whether the frequency
is more by day or by night, or influenced by any particular
circumstance.  How the question applies I will tell you
afterwards.
  Then, secondly, I ask whether  there is pain in passing
urine, and  whether before, or after, or during  micturition;
and whether at other  times also, and if produced or aggra-
vated by quick movements of the body.   The locality of
the pain is also to be  ascertained.
  Then I ask, as a third question, " Is the character of the
urine altered in appearance? Is  it turbid or  clear?"  Pos-
sibly the patient will  tell  you that it is turbid; but you
find, on  questioning  further, that it was  passed  perfectly
clear, and only became thick  after  cooling  or  standing.
Also, as arising out of this, you may often ask, " Does it
vary much in  quantity?" noting, of course, the specific
gravity.  The  healthy standard, however, must be allowed
very extensible limits; still quantity, I need not tell you,
is a very important element in regard of renal disease.
   The  fourth  and last  question is—whether blood has
passed in any  way, whether it- is florid or dark, whether
passed at the end or at the beginning of making water or
whether independently of micturition altogether • and such
like supplementary inquiries.
   These are the four  questions;  and let me  remark that 
                     DIAGNOSIS.                   23
the answers you get will depend very much upon the way
in which you put the questions.  The patient  is not al-
ways self-possessed, or he does not clearly understand the
nature of the question you put.  It is necessary to be very
precise and very distinct in your questions if you wish to
get accurate answers.   In fact, there is no such difficult
thing in all  experience, whether in our profession or out
of it, as to arrive at facts; and let me remind you  again,
that diagnosis consists in the acquisition of facts, and that
it is impossible without them.   Now you will say, how do
I apply this to the list of diseases before you ?
  First, as to the frequency of passing water.  There is no
serious affection of the urinary organs, except one or two
which  I will name, in which you  have not more or  less
frequency  of passing water.   Thus the  following  is an
exception:  A man may have  stricture to a considerable
extent; the stream may be very narrow,  and  he may not
for some  years  complain of frequency of passing  water.
Now observe, I  have classified these disease, so that we
may deal  with them more easily.   First  of all, there are
the  inflammatory diseases—inflammation  of the urethra,
of the  prostate, and of the bladder.  In all these you have
frequency in passing water.  Not  necessarily, however, in
urethritis,  until it reaches  the distant part of the  canal
near the bladder.  I do not propose to enter upon the sub-
ject of urethritis here, as you  have frequent opportunities
of studying it in the out-patients'  room.  1 am now only
referring to this symptom  of  frequency of passing water
as existing more or less in all these three diseases at some
time or another.  In hypertrophy of the prostate you have
it, and it is  remarkable  that it is more at night than in the 
24     DISEASES OF THE  URINARY  ORGANS.
day.  In chronic prostatitis it is usually present to a small
extent;  in cystitis it is, of course, a characteristic symp-
tom.  In  calculous diseases  it is  prominently met with,
and generally its degree is  in proportion to the amount of
movement permitted  to  the  patient.   Tumors, of course,
malignant  and non-malignant, are attended by the same
symptom.  In pyelitis, and in almost  all organic changes
of the kidney, in Bright's disease,  and in diabetes, there is
frequency of making water.  Whenever the natural cha-
racters of the urine are altered before it reaches the blad-
der, the  secretion  produces irritation.  This fact is worth
dwelling upon for  a  moment.  Diluted or  watery urine is
often  regarded as unirritating; on the contrary, it is not
generally well retained by the bladder.   The bladder is
never so  content as when  it contains  a urine of average,
or more  than  average,  specific gravity.  Some persons,
hysterical  patients for example, will pass urine which is
quite  pale, almost like natural water, and the bladder is
always more or less irritated by it. Of course, in diabetes,
you have not only the character of the urine altered, but
the quantity much increased.  And I  may remark that it
is chiefly in renal affections that alterations in quantity
take place; while, on the other hand, suppression of urine
is always a malady of the kidneys.
  The next question has reference to pain; and when you
get answers  as to the nature and seat of pain you will
begin to see your way towards a diagnosis.  In prostatitis
there  is  usually pain at the end of passing water—less
severe,  but resembling somewhat  that  of stone;  as  the
bladder contracts, when empty, on  the tender prostate.  In
cystitis the pain is usually before micturition, because the 
DIAGNOSIS.
25
inflamed  bladder is sensitive  on" being distended, and is
anxious to get rid of its contents.  The pain is just above
the pubes.  When cystitis is acute, pain may be felt in the
perineum also; but in  chronic or subacute cystitis  it is
supra-pubic, and not at the end  but at  the beginning of
making water, unless the prostate is  affected, and then the
tender  prostate gives  a little  pain at the  end, as I have
just said.
   In stricture of the urethra there is often pain about the
seat of  the  obstruction, an idea of which you  may obtain
by a simple experiment.  If, when  passing urine with a
full stream, you suddenly narrow the passage with  your
finger, so  as to diminish the  stream one-half or more, you
will experience an acute pain.
   There may be pain with  hypertrophy of the prostate,
inasmuch as this is frequently associated with chronic cys-
titis, when the pain is before making water, and  not after-
wards—differing in that respect from stone.  The bladder
wants to get rid of its contents, and can do so but  slowly,
on account  of the enlarged  prostate, which stands  as a
barrier  in the way.  During its first contractions, which
expel but little urine, there  is pain  above the  pubes and
deep in the  perineum;  but when  a third or a  half of the
contents has issued, the patient is relieved.
   I shall not dwell upon calculous disease of the urethra.
The calculus  is only a temporary lodger there,  and  as it
can often be felt externally by the hand, there is rarely any
difficulty  about the  diagnosis.    Calculous disease of the
prostate is also rare.  I shall not complicate what I wish
to be a  simple matter by dwelling upon  it, but call  your
attention  to the  commoner  condition  of calculus in the 
26     DISEASES OF THE URINARY ORGANS.
bladder.  Here the pain is quite distinct in its character :
it is felt at the end of passing water, because, the bladder
being emptied, the rough surface of the stone is left in con-
tact with the mucous membrane, doubtless that covering
the neck of  the bladder, which is unquestionably a sensi-
tive spot.  As soon as sufficient urine has trickled  down
into the bladder to separate the coats from the stone, relief
is obtained.   Then the pain is felt at the end of the  penis,
within an inch of it, about the base of the glans.   Further-
more, the pain is increased by movement: in other com-
plaints it is not necessarily so.  Put a patient in a rough-
going vehicle, or  make him jump from a step,' or perform
any rapid movement, and instantly he feels  severe pain,
probably at  the neck of the bladder, but also at the end of
the penis.   In prostatitis, inasmuch as the neck of  the
bladder is involved, there is  usually some  pain at the  end
of the penis, wrhich is a reason why chronic inflammation
of the prostate is sometimes mistaken for stone.
  With regard to calculus of the kidney,  I have little to
say about it here.  Of course you have pain referred to the
locality, right or  left, not  often to both kidneys; there is
tenderness also, and much increase of pain on movement.
It is usually on one side only, and perhaps more frequently
on the left than on the right side.
  One cannot, perhaps, say much about any characteristic
pain in connection with tumors.   They may be situated in
any part of the bladder; may obstruct the  urine more or
less; and accordingly as they produce cystitis, and obstruct
the flow of urine,  pain will be  experienced.
  The next  question  is as to the character of the  urine
itself.   Now, suppose your patient  has told you that he 
DIAGNOSIS.
27
has frequency in passing water, pain at the end of the penis
and at the neck of the bladder, and that the pain and  fre-
quency are aggravated by movement.  You may begin to
imagine, "Perhaps the man has stone in the bladder, and
I  shall have to sound  him."  Two questions  only have
already put this probability in your way, and you interro-
gate as to the character of the urine.  See how this carries
you a step further.  We recommence  our  list  as  to  this
inquiry. A preliminary remark, however, about examining
urine.  I do not  propose to  teach  you here a  systematic
mode of doing  this.  It is not in my department, and would
only be repeating that which it will be your duty to learn
elsewhere, and I hope  you will do so thoroughly.   But
there is this hint which I may give with respect to it.
g Whenever  you want a  specimen  from your  patient to
examine, do not tell him to send you a bottle of it passed
 in the usual way, or you will get a mixture of often doubt-
ful value.   What you require is the secretion  of the kid-
 neys, plus only anything there may be in the bladder; you
 do not want it complicated with anything which may come
 from the urethra.   Let  the man pass two  or three table-
 spoonfuls through the urethra first, so as to  sweep out
 whatever may be there,  which may be  put into a separate
 bottle, and then you will get a specimen—at any rate one
 of which you will know the source.  You will have the
 renal secretion plus anything in the bladder. Suppose the
 man has gleet  or chronic prostatitis: there will then  be a
 quantity of muco-purulent matter  in the urethra.  If all
 this Be carried into one vessel with the urine, how will you
 determine the different products, and decide by the micro-
 scope or by the eye what has come from the urethra, what 
28     DISEASES OF THE URINARY ORGANS.
from  the prostate, and  what  from the  kidneys?  You
cannot do it; but if you get rid of the source of error by
flushing  the urethra,  so to speak, and emptying  the con-
tents into a separate glass—say a wineglass—then taking
the bulk or remainder in a tumbler, you will generally
have  a sample of urine that .you can do something with.
If I felt disposed to indulge you  with gossip, I could tell
you stories of the gravest blunders committed by not attend-
ing to that simple point.   I can at all events tell you that
I have more than once known a learned practitioner treat
a patient for pyelitis who. had  nothing but a profuse  dis-
charge from the urethra; how the  urine  had been sent
twice a week in a bottle scrupulously made clean for the
purpose;  and  because a quantity of pus was found in it,
the patient, who had some symptoms corroborating that
view, was treated during some months for pyelitis; how a
surgeon at length found out that  the whole of the matter
came from the urethra, so that when the urethra was flushed
into the first glass all the matter was  there, and  that the
remaining  urine was  clear and healthy; and, finally, that
the " pyelitis" soon disappeared  under local treatment of
the urethra.  I do not know whether any one else may tell
you of that simple mode  of determining this matter;  and
I will assume that in the future you will none of you make
such a mistake as that I have mentioned.  I only know too
well how necessary it is to call attention to it  and how
seldom it is done.1
  Referring first to prostatitis, it is always associated more
or less with shreds in the Urine, which come from the "pros-

  1 See further remarks on this subject at the close of the last lecture. 
DIAGNOSIS.
<Ki
tatic part; and  if you  separate the urine as I have told
you, you will find that the whole of the thick matter will
be in the first glass, while that remaining  behind will  be
clear.  How  would it be with regard to calculus?   You
might have muco-pus in the first glass, but you would have
more in the second from the bladder.   Scarcely ever have
you calculus  in the bladder without having some muco-pus
from the bladder itself.  Occasionally, but very rarely,  do
I find a man with stone in the bladder having  perfectly
clear urine.  Not commonly do I sound a man for stone
who has  clear  urine,  unless  he has  marked symptoms,
because the presence of stone in the bladder almost alwaj-s
gives rise to a  certain amount of cystitis, and there  is
deposit  in consequence.  If the patient passes shreds  of
thick matter  in the first glass, and the urine left behind is
clear, and has symptoms like those of stone, rely upon it it
is a case of chronic prostatitis.
   The character of the urine in one of the forms of chronic
cystitis is well known.  There is at the bottom of the vessel
a  thick  mucilaginous  deposit, which does not issue in a
stream, but falls out in  a mass.  In acute cystitis the urine
is cloudy, and there is a considerable deposit of pus.   In
stricture of .the urethra, unless chronic cystitis has been  set
up, there is no deposit from the urine.   Here the character
of the stream is  important.  If, when the patient is passing
urine, you see a very  thin, small, spluttering stream,  or
urine issuing only in drops, you will know that there is
an obstruction, most likely stricture;  because, although in
hypertrophy of the prostate you may have the stream much
diminished, it will be a stream which falls downwards from
the organ. In stricture force may be brought to bear  on 
30     DISEASES OF  THE URINARY ORGANS.
the stream, so that, however small it  may be, it is often
fairly propelled;  but in hypertrophy, in which the expel-
ling apparatus  is involved, the muscles cannot  act, and,
therefore, however large or small  the stream, it generally
falls perpendicularly.   In calculous disease of the bladder
there is nothing to note  about  the nature of the stream,
except that it stops  suddenly sometimes—by no  means  a
constant symptom.  With  regard  to the debris of tumors
found in  the urine, the  microscope sometimes, not often,
throws light upon their  nature.   No doubt  you may see
cancer-cells in the urine, but it  is most difficult to identify
them.   I have seen such cells  declared to exist by good
observers in cases in which cancer was not present.   Young
pavement epithelium is easily mistaken for them.  Going
upwards from the bladder, we may note pyelitis, more or
less chronic—a disease in which the condition of the urine
is only one symptom among many others which must be
observed before arriving at a conclusion.
   The next question is, "Do you pass blood?"  and this
will bring you very near  indeed  to an opinion  on most
cases—not quite, because in any case you may first have
to sound.  In prostatitis there is often a little blood at the
end of micturition, as  in  stone;  in cystitis there is  not
necessarily blood, unless it is acute and far  advanced; in
stricture of the urethra there is not necessarily blood";  and
in hypertrophy of the prostate not necessarily. You may
have it or not, often only as the result of instruments.  It
tells most in the  question of stone.  Just as  in phthisis  a
large proportion of patients have haemoptysis at some time
or another; so in about the same proportion  of cases__say
four out of five—there is some blood with vesical calculus. 
DIAGNOSIS.                   31
  I want you to pay particular attention to these questions,
because I shall assume an acquaintance with them to under-
lie much of what I have to say hereafter.   What I wish to
add with regard to observation by the  eye, by the hand,
and by instruments will come under each particular subject
hereafter, and I will only briefly allude  to it to-day.  By
the eye you observe mainly whether the bladder is  dis-
tended or not, and you are assisted in ascertaining this by
palpation and percussion.  You examine the perineum and
scrotum also, with a view to extravasation of urine, peri-
neal ' abscess and fistula,  &c.  And  now we  come to the
question of instruments.   Suppose such  a case  as that to
which I have already referred, in which there are frequency
of passing urine, pain at the end of micturition, pain on any
considerable movement,  thickening of the  urine,  blood
passing occasionally, but  more on movement—you regard
it as highly probable that the man has stone.  You cannot
arrive at a certainty without instruments.   You may have
almost all these conditions in certain changes of the kidney
and in renal calculus, and you cannot distinguish them
unless  you skilfully explore the bladder with a sound.
When I claim great value for this instrument, quite under-
stand that  I am by no means desirous that in the case of
every patient who comes to you and complains of  some
frequency  in making w*ater, or pain in the act, you should
say, " Lie down, and let me pass an instrument."   Perhaps
the surgeon may be apt to abuse a little his power of pass-
ing instruments: it should never be done unless  it is abso-
lutely necessary.  I hold that an instrument, per se,  is an
evil—a very small one or a considerable  one, according to
the manner in which it is employed—and that it is never 
32     DISEASES OF THE URINARY ORGANS.
to be used unless  there is good  reason to  believe that a
greater evil is present which it may mitigate or cure.  But
when your patient has the  symptoms named, you will be
doing him an injury unless you  resort to it.  In cases of
stricture the instrument is also necessary; and so in ascer-
taining the condition of the bladder, whether it  is full or
empty.  A man may make water very frequently, strain
hard, and be very certain that he has emptied the bladder,
and  be quite deceived.  How can  you  tell ?  You find a
prominence above the pubes which you have no doubt is a
distended bladder; but it is just possible that  it may be a
solid tumor.   You cannot  know whether  the bladder is
emptied unless you pass an instrument.  Many a man has
had  an instrument  passed into the  bladder, and a quart of
urine has been found to be  left behind, when his own sen-
sations led  him to believe that he had expelled every drop.
We  shall see more of this when we come to the subjects of
retention and hypertrophy of the prostate.
  As we are now on the question of diagnosis, I take the
opportunity of showing you that the eye may be assisted
to a certain  extent  by  what  is  called the endoscope,
which is simply  an instrument that we have long been in
the habit of passing into all the cavities of  the body—the
ear, the vagina, the rectum—for the purpose of bringing
reflected light to bear upon the interior of those cavities.
For some years past this instrument has been employed for
the urethra. It is seventeen years ago since I first saw the
endoscope so applied.  This was in the hands of Mr. Avery,
of the Charing  Cross  Hospital.   As I was turning my
attention somewhat to this subject,  he asked me to see
some of his patients, and  a  new  instrument he was  then 
DIAGNOSIS.
33
making.  He showed me a long  tube, precisely similar to
this which I hold in my hand, with certain arrangements
enabling  one  to see deep portions of the urethra.   He
showed me cases of stricture, but I do not think he looked
into the bladder.  He paid a great deal of attention to the
subject, and the instrument was brought by him to a certain
state of perfection; unhappily, however, his death occurred
shortly afterwards, and the thing was  lost  sight  of here.
Various attempts  have been made with the same object,
long before and since, but I do not know that there is any-
thing on this table very superior to what Mr. Avery showed.
Within the last few years  M. Desormeaux, of Paris, has
paid great attention to the endoscope, and has perfected one
* f his own, consisting of a similar tube, but with different
appliances.  The various modes  in which light is applied
constitute the  differences between  the various kinds of
endoscope.  In all of them there is a tube of this descrip-
tion to pass into the cavity.  Six years  ago I had an endo-
scope of M. Desormeaux's, and exhibited it in tHe  hospital
—the instrument which you see here.   Dr. Cruise, of Dub-
lin, has brought it to greater perfection, and has produced
a better  instrument than we heretofore possessed.   This
also is here,  and you have often seen it  in  the wards,
applied by me both  to the urethra and to the rectum.  I
may tell you at once that if a man has a good  and a tole-
rably practised hand, with a fair share of intelligence, I do
not think he will gain a great deal by the endoscope ;  and
if he has  not, I think it will be of no use at all.   There are
some few cases  in which he may find it of value ; but do
not expect that the endoscope is going to work any marvels
in the diagnosis of surgical diseases of the urinary organs.
       3 
34     DISEASES  OF THE  URINARY ORGANS.
In nineteen cases out of twenty you ought to be able  to
arrive at the necessary information without it.  And it is
not the easiest thing in  the world  to apply.  As  already
remarked, a  man should not be put unnecessarily to the
pain and inconvenience of a sound or a catheter; but exami-
nation by  the endoscope is a somewhat more irritating and
tedious process.  In certain exceptional cases, in which you
are unable to arrive at  a conclusion without it, you may
employ it to some  advantage.  Now, here is a patient on
whom  I have never used it, and whose  case will offer a
certain test of its  power.  The man before you  had an
exceedingly bad stricture of the urethra, which I cut inter-
nally last  Tuesday week.  He is now perfectly well.  He
could not pass a drop of urine before  the operation, but
now he is able to pass it naturally;  and you will agree with
me that a great deal must have been done last Wednesday
week to make that change.  I cut through the strictures
deeply, and now we shall see whether we can find the cica-
trices.   I sliall use Desormeaux's endoscope, illuminated by
Dr. Cruise's lamp.—You see we have now made a careful
and prolonged examination.  The urethra is  of  a more
dusky red about  the part which has been affected, but that
is  all which  can be observed.  Changes in the color and
texture of the mucous membrane of the urethra and  bladder
are those which are most easily seen, and  which are of the
most importance to note.  The orifice of a stricture may be
sometimes seen, but the  result is without  practical utility.
A  stone in the bladder may  be easily seen, or rather the
small  portion  of it  upon which  the  end of the sound
impinges; but I have never gained anything by the sight.
A  calculus smaller  than a pea may be easily found by deli- 
DIAGNOSIS.
35
cate sounding, and an audible note elicited from it, more
easily than you can see it through the endoscopic  sound.
I may mention that no one has yet been able by its means
to identify the veru montanum, and  if you cannot see the
veru montanum, I think it is quite  possible that minute
pathological changes will often escape you.
   Mr. Baker has been good enough to send up another and
very simple  endoscope, designed by  Mr. Warwick, for
exhibition.  It may be used with  ordinary gaslight or
with sunlight.  It certainly seems, on comparison, to effect
nearly as much as the larger and more elaborate  instru-
ment. 
36     DISEASES OF THE URINARY ORGANS.
                  LECTURE  II.

              STRICTURE OF THE URETHRA.

  Last week, gentlemen, the subject of the  lecture was
rather general than special.  In commencing this course, I
shall  take to-day  the subject of stricture; and I do  so
because, if not really one of the most common of these dis-
orders, it  is often  supposed  to  be so.  Among the many
complaints of this class respecting which you may be con-
sulted, perhaps none will be more talked of than urethral
stricture.   It does not follow, however, that  stricture  is
really so common; in fact, it is much less so than many
suppose.   The word  happens to have been popularized,
and, therefore, when a person experiences a little trouble
in passing water, he is very apt to say that he has stricture.
Certainly, in three out of four  cases in which persons do
so, I find  there is nothing of the kind, but often merely
some temporary cause of irritation.  Then it must be con-
fessed that there is some confusion, even  amongst the pro-
fession, as to the mode in which the word " stricture" should
be employed.  It is said—and I have said it myself, because
I originally adopted the usual classification—that there are
three kinds of stricture—organic, inflammatory,  and spas-
modic strictures.  Now, it would save some confusion if we
employed this word  for only one kind—namely,  organic
stricture.  And what  is organic stricture ?  It is a deposit 
STRICTURE OF THE URETHRA.         37
of lymph round the  canal of the urethra at  some point,
which, not allowing  the canal to open to the stream, nar-
rows the current pro tanto.   There has usually been some
chronic inflammation, most commonly in the bulbous part
of the canal, and a deposit of lymph has  taken place in the
submucous and in the vascular  tissues surrounding the
urethra; and after this lymph has existed some time, it
contracts and forms fibrous  bands more or  less encircling
the canal.  We talk of the contraction  of the canal; but
this is due to a popular and not very correct notion of the
matter,  although it answers well  enough for  all practical
purposes.  You will do well to remember, in connection
with the pathology and treatment of urethral diseases, that
the urethra is not an open tube, like a gas-pipe,  for example,
into which you can pour  fluid.  On the contrary,  it is
always absolutely closed by muscular fibres, and it is only
when the tube  is habitually prevented  from fully dilating
to the stream of urine that it is strictured.
  And  this organic stricture  is  a  permanent  condition.
Once acquired, it cannot be dissipated by any known means.
It cannot be removed  by absorption.   You may dilate it,
you may cut through it, but there it will always be.  When
a man once has true organic stricture, he has it for ever.  If
any exceptions exist, the rarity is so extreme as practically
not to invalidate the axiom laid down.  Whatever treat-
ment you employ, there is always a tendency more or less
to contract afterwards.
  Now touching "inflammatory stricture" and "spasmodic
stricture." Inflammatory stricture is  merely a temporary
local inflammation of some part of the canal, which is then
narrowed for the time.  The patient is unable, as long as 
38     DISEASES OF  THE URINARY ORGANS.
that inflammation lasts, to pass water, or at best with diffi-
culty.  The inflammation usually affects the prostatic part
of the urethra,  which is not,  as you know, the seat  of
organic stricture.  If you call this condition stricture, you
may as well say  that the  throat is strictured when it is in-
flamed and the  tonsils  are swollen.   We only speak  of
stricture of the oesophagus or gullet in reference to a condi-
tion which is organic, when by some deposit the passage is
permanently narrowed,  and we never speak  of  stricture
there  under any other circumstances.  So  with regard  to
spasm.  The urethra may be narrowed to a certain extent
by spasm—that is to say, the water may be prevented from
passing outwards from the bladder, because there is some
irregular action  of the muscles around it.  But it is only
temporary;  it does not  necessarily imply  any  organic
change; although sometimes its occurrence depends on the
existence or organic change, yet this spasm is not stricture
of the canal.  I  will tell you what spasmodic stricture  is.
It is  exceedingly useful as an excuse for the failure  of
instruments. It is  a " refuge  for incompetence."   When
you cannot  pass a catheter, when you  find it exceedingly
difficult to get anything in, and in fact wish to desist, it is
a convenient thing,  and has always been so recognized, for
the doctor to say, " There is spasm."  Indeed, I believe  he
often  " lays  the flattering unction to his soul" that  it does
exist, although, in my opinion,  it does not,  or at least very
rarely.  " There is  spasm," says he, " now in the muscles,
and it will  be prudent  at present to  desist  from further
attempts to pass  an  instrument."  And no doubt when this
is said it is so.   Now, I do not  think that you ought ever
to fail in  passing an instrument because there  is  spasm. 
STRICTURE  OF THE  URETHRA.         39
Spams may prevent the  urine  from  going outwards; I
do not know  that it  ever prevents the instrument from
going in.  In most  cases it is  failure of  the  hand,  not
spasm of the urethra.  Still I cannot deny that it is a use-
ful excuse—that it has a sort  of foundation  in fact,  and
may thus be often a better explanation for the patient than
anything  else, when the  instrument does not pass.   But
when we speak  here  of stricture in future,  we shall refer
only to organic stricture, in the sense already  described.
All the mechanical treatment which I shall  have to speak
of will have reference only to" that kind  of stricture.   In
" inflammatory stricture," of course, you have no occasion
for instruments, unless retention of urine is  present.
   Now,  what are the symptoms  of stricture?   First, of
course, there is the smallness of the stream depending upon
the narrowed state of the canal.  Whatever the narrowing
of the canal is, in that proportion there must be a narrow-
ing of the stream. Next, there is often some straining to
pass  water, corresponding to obstruction of the passage;
and the stream itself is flattened, twisted, or  divided.   This
is accompanied by pain at the seat of stricture, and some-
times also over the pubes, if there is  any cystitis.  Asso-
ciated with this, it is common to have a little discharge
from the urethra; indeed a gleet is often  the  only thing
which the patient notices at first, and the surgeon, finding
that  this is not readily curved, uses an instrument and dis-
covers  stricture.  Frequency of making water, as I  told
you  last time, is not always present in stricture, although
it always is so when the case is severe and of long standing.
   Supposing a patient to apply to you with  all these symp-
toms, you endeavor to see him pass water.   He will prob- 
40     DISEASES OF  THE URINARY ORGANS.
ably lay some stress on the fact that it is twisted or divided.
Do not attribute  much  weight to  this circumstance  by
itself, for a  twisted stream often occurs when there is no
stricture.  It may be due  to an  alteration of the external
meatus; for as  the stream  issues from the  passage it is
modified by the shape or rigidity of the external meatus,
and after repeated inflammation there, the lips of the meatus
may be slightly thickened,  and permit  only the exit of
urine in a flattened and consequently twisted  stream; and
this is by no means an uncommon occurrence.
   We now come to the important point of diagnosis.   One
rule is to be invariably followed:  whenever  you examine
for stricture, take  a fair-sized instrument, say No. 8 or 9.
The patient may remonstrate, and will probably say, " That
won't pass;  it is useless to employ so large an instrument.'
Tell him that you do not  propose to pass it, but only to
discover where the obstruction is.   For if you use a small
instrument at first, it may pass through the stricture, if one
exists, without detecting it; but if the large instrument
goes on easily into the bladder,  you have the satisfaction
of telling your  patient that he has no stricture, and you
look  further for the cause of the difficulty.  Whatever,
then,  a man may tell you, and however  small the stream
may be, take an instrument not less than No. 8 or 9, pass
it gently down the canal, and if there is a stricture the in-
strument is arrested, and  you will find the exact position
of the obstruction.  Notice the point where it exists—four
inches, or five, as the case may be, because it will be useful
afterwards in dilating to know its exact locality.
   Now, in passing the instrument, you may meet with cir-
cumstances  which may  mislead you.  I  have  spoken to 
STRICTURE  OF THE  URETHRA.         41
you of error on the part of the patient, and I am bound to
say that the surgeon who is not much practised in  these
matters may also be deceived.  What  are the sources of
fallacy to  which he is  exposed?  How is it that he some-
times fancies there is stricture when there is not?  There
are some kinds of practice in which you may be hereafter
placed, that do not  afford the opportunity of often seeing
this disease, and in such it  is no great discredit to a man
to think  that he  has  found  stricture when none exists.
Not, of course, if he is  a professed surgeon; then it will be
a  great discredit to him.   But  if he has very little to do
with this kind of thing, he may encounter some difficulty
in the urethra, and he may suppose, but erroneously, that it
is due-to stricture.  Now, I want to guard you all against
this; for, though you  may not  all be operating surgeons,
I want you not to leave any course of lectures which  I
may give, without knowing precisely what are the sources
of fallacy, so that I may not hear of any of you  hereafter
making  such a mistake as that to which I have referred.
Let  me remind  you  again of  what was said about the
urethra being a closed canal.  I am not going to draw you
a diagram of  the  urethra  such  as you see in anatomical
books, in which it is  represented in sections  as an  open
passage;  for it is never in that  condition except in the act
of micturition.  First, close to  the meatus is  a  source of
fallacy—I mean the lacuna magna.   Then, here, five or six
 inches further on  [a diagram referred to], the bulb joins
 the membranous  portion, and the canal, from being wide
 or dilatable, becomes  less so.   Lastly, there is a source of
 difficulty at the neck of the bladder.  Those are the three
 points at  which persons may be mistaken  in passing an 
 42     DISEASES  OF  THE  URINARY ORGANS.
 instrument, and form erroneous notions in consequence re-
 specting the presence of stricture.
   Now, whenever you  pass an instrument, do not let your
 thoughts revert to those anatomical diagrams representing
 the urethra as an open tube;  bear in mind that it is simply
 a closed passage; so  that nothing is easier in passing an
 instrument, if you are  out of the line, than to find some
 obstruction in the folds or lacunae of the mucous membrane,
 t-ince it has more distensibility at  some points  than at
 others.  Of course, if it were simply an open  tube, there
 would be  less difficulty in going on; but, as it is not so,
 the point is liable to hitch against the soft parts on one side
 or the  other.   First,  as I have said, it is quite possible to
 get stopped at the very outset, which is embarrassing to a
 beginner, by engaging the point of the  instrument in the
 lacuna  magna.  Whenever, then, you begin to pass an in-
 strument,  let your first thought be to keep its point on the
 floor, so as to  avoid that obstacle.  You wish, of course, to
 pass it well for the patient.  Perhaps  he has  had instru-
 ments passed before, and you desire  to succeed at least as
 well  as the preceding  operator.  Now, there  is nothing
 which a patient appreciates so much  as the easy passing of
 an instrument.  It is  a  disagreeable operation, and if you
 pass it  more easily than other persons, you will probably
 retain your patient as long as he requires assistance of that
 kind.  If you stick and get  into the lacuna magna at the
 outset, he infers you to  be a bungler, and perhaps will not
 come to you again.
  Now, you see represented  in this diagram the bulb of
the urethra.  The canal is  more  distensible at this point,
and when you come to the  deep perineal  fascia the canal 
STRICTURE OF THE  URETHRA.         43
is much less distensible.   Practically, therefore, it is much
wider there than it is at  the orifice, and when you get  the
instrument at that point it is apt to hitch.   This is  the
place where  almost all  the fale passages  are  made:  the
  Fkj. i.—Diagram of urethra in natural condition, a, b, and c representing
      the prostatic, membranous, and spongy portions respectively.*
instrument  is  driven out  of  the canal  down below the
urethra, it being mainly at the floor that the canal is so
distensible.  The section of the corpus spongiosum is wider
below than above; the  texture is  soft and spongy.   The
urethra corresponds in  distensibility to the soft  structure
outside,  and although the  instrument gets smoothly down
to this point, it  may not  go  on into  the membranous
portion.  Now, take care, at first, to  get the  point of the
instrument so turned up as to avoid  this lower part.   No-
thing is so good as a well-curved instrument to avoid  that
obstacle.  I am in the  habit  of doing this in the case of
out-patients.   I like to  take  a  student who has never
passed an instrument before, and I say to him, " Pass this
bougie (a straight or slightly-curved  one) into the canal."
He passes it, and invariably,  when he arrives at  the mem-

  * The urethra should have heen shown  here as it really is, a closed
canal ; the line in the bulbous and prostatic portions having been made
by me merely a little thicker to mark (diagramatically) position and the
character of dilatability.  This line has been somewhat  exaggerated by
the artist. 
44     DISEASES OF THE URINARY ORGANS.
branous portion, stops.   I then take the same instrument,
give its point this form  (Fig. 2), and  then he passes it
Fig. 2.—Bougie, with point turned up.
immediately into the bladder.   As the instrument goes in,
it keeps close to the roof, instead of engaging itself in the
distensible part of the bulb.
  The last obstacle is at the neck of the bladder, and so
common is it, that you often hear of " stricture of the neck
of the bladder"—a thing which never exists.  There never
was a stricture  even in the prostatic portion.  "Stricture
at the neck of the bladder" was  a  household word some
years ago, and  even now you  sometimes hear of it; but
there is  no such thing.   It is  simply because there  is
sometimes difficulty in passing the neck  of the bladder
that it came to  be regarded as  a locality of stricture.  In
this case also a well-curved instrument is the best thing to
go in.  Let me recapitulate shortly the three sources  of
difficulty: First, the lacuna magna, which is avoided by
keeping on the floor of  the canal; then the narrow mem-
branous portion at the bulb, which  is avoided by keeping
the point  of the instrument well up;  and the same with
regard to  the neck of the bladder.
  I was going to read to you the notes of some cases  of
stricture  now in the ward  upstairs, but  I will not do so,
because you have  seen the cases, and  know pretty well 
            STRICTURE OF  THE URETHRA.         45
what they are, and I shall only refer to some of them as we
go on.  One has been treated by continuous dilatation, and
another by internal cutting.  Then we have several patients
treated by  common dilatation, and it is of common dilata-
tion that I have to speak to you to-day.  Suppose that you
have passed a full-sized instrument, and found that it stops
unmistakably, say, at  about five inches, the most usual
place; you will then, of course, have to pass smaller instru-
ments, to see what will go through it.  You have diagnosed
the fact of the stricture, and the situation; but you do not
know the calibre.  You ask the patient to make water.   If
he cannot  do so,  take a small gum-elastic' instrument, say
No. 1 or 2.  You pass No. 1, and that perhaps goes through
easily; then No. 2, which goes not quite so easily; then
No. 3, which goes in tightly.  No. 3, then,  is the calibre of
the stricture.  Now you have all the  main facts about the
stricture that you want to know.   The man's general condi-
tion, the frequency with which he makes water, the amount
of chronic cystitis—all these are questions to be considered;
but it is only with the mechanical part that I have to deal
to-day. Lastly, we will assume that he has only one stric-
ture ; for a patient may have two, but this is exceptional.
Now, what is the treatment ?  First and  foremost, Dilata-
tion—dilatation  always — dilatation  without  exception,
whenever it will succeed.  It is always to be tried first, be-
cause it is  the simplest and  easiest mode.  If you find a
man with a stricture ever so narrow or tight, by no means
think of operating till you have  tried whether dilatation
will succeed ?   What is dilatation?  A mechanical process
of stretching this organized lymph,  which  forms bands
round the canal at the strictured point.  It  is often said to 
46      DISEASES  OF  THE  URINARY  ORGANS.
produce absorption of this tissue, which I shall not deny,
but only say that there is not the smallest particle of proof
to support the notion.   Now, suppose  you have been able
to pass No. 3 bougie or catheter rather tightly through the
stricture and into the bladder, to be perfectly sure that all
has gone right, then you say to the patient, " That is enough
for to-day; come again in two or three days time for a
larger instrument."  Now, I  advise you, on such second or
third day, not to commence with the largest instrument pre-
viously passed.   Having passed Nos. 1, 2, and 3 on the first
occasion, you should now take Nos. 2, 3, and 4; and on the
third occasion 3, 4, and 5; and so on; always beginning
below the point you had attained on the previous occasion,
making the smaller instrument a sort of avant courier for
the larger one.   Further, never let the instrument remain
in the urethra ; withdraw it at  once ;  leaving it there sim-
ply increases irritation, and does not augment in the slightest
degree the dilating power. Thus you  find that the longer
you leave it the tighter it is held, and the more difficult and
painful it is to withdraw.  Not  until it has remained in the
stricture an hour or two does the stricture begin to relax,
as we see in "Continuous Dilatation."
  Now comes the question of the kind of instrument to be
employed.  The great principle which  underlies all me-
chanical treatment of  the  urinary organs, whether  for
stricture or for hypertrophied prostate, for retention of
the urine or for stone—the one great principle which must
decide for us the question of the kind  of instrument to be
employed is this: all instruments are to  be considered evils,
more or less,  never to  be resorted to unless a greater evil be
present.  The passage  of an  instrument of any kind into 
STRICTURE  OF THE  URETHRA.         47
the healthy urethra  must per se be a source of irritation.
Try it yourself;  and I advise you to do it, if you wish to
pass an instrument well;  for I hold that no man should
pass an instrument for another until he has passed one for
himself.   Of course  the amount  of irritation will depend
in great part on  the manner in which it  is passed, and on
the kind of instrument employed.  Let us consider, to use
a commercial simile, that in the case of your patient there
is " a debit and  credit side" in all treatment.  You intend,
beyond all doubt, to effect some  real good—that is, to the
"credit side'1 of  the account; but you cannot do it without
making some irritation in order to gain your end—that is
an entry on the  "debit side."  Be careful, then, that you
constantly bear  in mind the latter fact, and make  it your
business  to  diminish that  "debit"  as much as possible.
Do not  pass an instrument  unless there  is  some good
reason, unless there  is  some evil, for the sake of curing
which it is worth while to incur a little irritation.  Acting
upon this principle,  you will choose such an instrument as
you know by experience or otherwise to produce the least
possible irritation.   And this leads me to the question of
the difference  between solid  and flexible instruments.
Here I feel that I am treading on delicate ground; and
I will tell you why.   First of all, no one has been a greater
advocate than I was some  years ago of  solid instruments
as against soft  ones, influenced  by the  traditions of this
place, which are entirely in favor of the former.   I  can
give you the reason  for that.  The great  master-spirit of
this place, who  has been dead some twenty years or  more,
the man  who gave the tone to the place, and educated
almost all the elder  men here—I mean Liston—declared 
48     DISEASES OF  THE URINARY ORGANS.
his preference  for  the  solid  instrument in very strong
terms.  It is (1867) just twenty-one years ago since  I sat
in this room and  heard him deliver a lecture on that very
subject.  His powerful advocacy of the silver instrument,
and the contempt he had for others, were matters of  noto-
riety.   Starting,  then, with such  views,  and  regarding
him—as every  one does,  to a certain extent, the  man who
teaches them well and fairly what he learns—for a certain
time  as an oracle,  I was  strongly in favor of the  solid
instrument as against the inflexible.   But what is  much
more valuable  than any oracle, whoever he may be, is a
large personal  experience; and this has taught me that,
beyond all question, the flexible instrument is the best—if
only you  know how to use it—for the treatment of  stric-
ture,  and for all maladies  of the canal,  whenever it is
available.  I am so  certain of this that I have no  hesitation
in saying, that  a great  part of the success of any man who
has much to do' with this subject will depend upon his use
of flexible instruments as  against solid.  No  patient will
ever allow a surgeon to pass for him a solid instrument if
you have  passed  for him a flexible one as easily as you
are bound to do.   It  gives him so much  less  pain, and
produces  so  much  less irritation.   To continue my com-
mercial simile—it puts so much less on the "debit side" of
your  patient's case; you  get so much more of advantage,
and so much less of disadvantage.  I confess, then,  to a
considerable change of opinion even since I published my
first work on  the  subject;  and I do this without  the
slightest shame or the slightest repugnance.   I hold that the
end of life in this world is not achieved without  change in
our opinions.   You may rely upon it, with regard to any 
STRICTURE OF THE URETHRA.         49
subject whatever, whether politics, or religion, or our own
proper profession, if we hold the same opinions at forty years
of age as we did at twenty—and, perhaps, looking forward,
I may say if we hold the same opinions at sixty as we do at
forty—we live to very little  purpose.   It is an error to
look for a  life-long " consistency" in matters  of opinion
from men who  think for themselves, in whatever depart-
ment  their teaching may be.   You must expect them to
progress, or they will be bad teachers—just as I hope you
are all progressing now.  I have said this because I know
that so  much might be quoted from  what I held fifteen
years ago in contradiction to what I now am saying.  If I
did not  state this, you might  ask  me why, having said so
much in favor  of the silver  instrument, do I now say so
much in favor of the other.  You have my reason; it is
simply that I have learned better.
  There are two kinds of flexible instruments, the English
and the French.  Inasmuch as the French instrument pos-
sesses more flexibility than the English, I often prefer it.
Perhaps it is right that I should add  a word  or two to
what I  have said.  I believe the flexible instruments are
much better  now than they were  in Liston's time;  and I
think that, if we had had the  good fortune to retain him
so long (without taking credit for  making a shrewd guess),
he would have changed his opinion too.   This  is the kind
of flexible instrument much used in his  time.  It is called
a bougie; and  properly, since it is simply a kind of wax-
candle,  and is, in my opinion, a very imperfect instrument.
You  can bend  it into any form  by warming, but it  is a
very inferior instrument to  what is  generally used now.
The gum-elastic or  English flexible instrument is very
       4 
50     DISEASES OF THE  URINARY ORGANS.
valuable on account of one quality which it possesses, and
which does not  belong  to the French instrument—i. e., it
will preserve any curve, when cooled, which you  choose
to  apply to it under the influence of heat.  If I want a
small curve, I take  the instrument, put it in warm water,
give it the curve required, then put it in cold water, and
the curve is fixed or set.  The' French instrument is ex-
ceedingly flexible; you may wind it round your finger
without difficulty.  And it has another valuable character
namely, its peculiar tapering  point.  Now, a tapering point
per se is often undesirable in  the urethra, because it is very
liable to get into some lacuna.  It would  be an advantage
if you could  insure that it did not do this; but this lia-
          Fig. 3.—The bulbous-ended bougie and catheter.
bility is provided against now very ingeniously by means
of a little bulb at the end (see Fig. 3).   The  long  tapering
extremity guarded by the bulb insinuates  itself through
the healthy urethra, or through one not greatly contracted,
in a most certain and easy manner.  Such  an instrument
as that may be passed by the patient himself without diffi-
culty.  Indeed, it may almost be said to be " surgery made
too easy."  The merest tyro can pass it in nine cases out
of ten, although he  might not manage the tenth.  It  is
one of the most extraordinary instances  of English con-
servatism that these instruments are found in so few hands.
They are, however, at last being made here.  For years it
has been necessary to send to  Paris for  them; but a de- 
STRICTURE OF THE URETHRA.         51
mand is arising now, and they are at length manufactured
in this country.  If you will try the experiment on your-
selves, you  will find that  this instrument traverses the
urethra almost without your knowing it; and  it requires -
no knowledge of the canal in order to use it.  Now it may
appear to you very heterodox, but I advise you, in passing
an instrument,  to forget all about  jomt anatomy.  You
are taught it over the way, and it is most important that
you  should know it; but, in passing an instrument, forget
all about the different regions.  Think nothing about the
deep fascia,  the membranous portion,  or the  compressor
urethrse.  A solid instrument is  especially dangerous  in
the  hands of an  anatomist; he will push it the way  he
thinks right, as if all urethras were exactly of the same
form, and did not vary as much as noses do, or other fea-
tures.  This used to be the pretext for preferring the solid
instrument:  it was said, "You want to know exactly your
anatomy and pass the instrument accordingly."  I pity the
patient who has a solid instrument thrust into his body  by
a knowing man at anatomy. You want an instrument that
you can use most delicately, holding it lightly between the
finger and thumb, withdrawing it or changing its direction
as soon as you are  able to  perceive an obstruction.  Your
hand is to be educated for the power of delicately perceiv-
ing the characters of the passage by means of the instru-
ment within it; and rarely, if ever, are you to push a solid
instrument  in any given direction preconceived  to be the
right one.   If you wish to  combine the maximum amount
of dilatation with the minimum amount  of irritation, this
flexible instrument  is unquestionably the one for you  to
use. 
52     DISEASES OF  THE  URINARY  ORGANS.
  There is one other point to notice with reference to French
and English instruments—I mean the gauges.  Our num-
bers are from 1 to 12.  Here is No. 12 ; and you generally
consider, when you have reached that size, that you have
completed the dilatation.   In England, we cannot be  said
to have a uniform scale;  all our measurements are very
arbitrary.   One maker  has one scale, and another another;
and the Scotch scale differs  by one  and a  half from the
English;  so that the patient who takes No. 12 Scotch, takes
only 10|  English. Our more exact neighbors over the
Channel use the millimetre, and the number represents the
precise size, so that when I have named the size, I have
        20    zt     ttz   u    a*     ^y     26

       00000OO
       £/3    7    */3     2/3     8     y3     p
         *9    «    17   16   15  14  is   12  li
       OO  OOOOOOO
         '/3    6"    2/3  1/3   $   %  J/3   4  2/j
              1° 9  8   7   6  J 4 3  2 1
              OOOO  OO0000
              'A ^   2/3 7/3  2. 2/3 ll3 1  2/3 7/.3
                  Fig. 4.—French gauge.
named the exact calibre  of magnitude of the  urethra.
Instead of  1 to 12, the French have 1 to  30 (see Fig. 4).
They begin lower, and  go higher than we do, and  the steps
are more gradual. In  this way irritation may be lessened.
You may pass, for instance, a No. 4 English very easily, and
a No. 5 with great difficulty, or not at all, and an interme-
diate one might be the  proper size.  Their numbers 3 to 21
are about equal to our 1 to 12; showing you at once how1
much more gradual  the range is.  No. 1 is one millimetre
in circumference; No. 2 two millimetres, and so oa; so that 
STRICTURE OF THE  URETHRA.         53
the increase in size is uniform as well as gradual.  If I
have  a patient who will  take  No. 21, I know that his
urethra admits an  instrument  twenty-one millimetres in
circumference, and of course seven in diameter.  I advise
you in this, as in other matters, to be cosmopolitan in your
views, and to adopt improvements from all quarters.
   I have told you that simple dilatation consists in passing
every two or three days a  larger instrument, until  you
reach  the highest.   In many cases all goes on smoothly
from  the beginning to the end.  Then you teach the patient
to pass the  instrument for  himself, and he does so after-
wards once  a month, or once in  six weeks, to maintain a
sufficient calibre.
   I will touch but lightly on " continuous dilatation," or
the tying in of the  instrument.   There is a patient  upstairs
who is now undergoing it successfully.   You have tried,
we will suppose, the simple dilatation, and have not made
the amount of'progress desired;  or, perhaps, the  patient's
avocations may make it necessary to  have a more speedy
cure.   In either case you may say, " If you can give me ten
or fourteen days in your room, not necessarily in bed, but
 on the sofa quietly at home, I can almost certainly bring
you from the smallest number up to the highest,"—that is,
by " continuous dilatation."  In  " simple dilatation" the in-
strument is simply introduced,  and at  once withdrawn; in
 "continuous" you tie the instrument in, and allow it to re-
 main for several days.  You tie in a small catheter, which,
 if possible, is to be  gum-elastic, and so  that it only just
 enters the bladder.  And you should always take care that
 it is  small enough  to pass easily, so that  it lies loosely in
 the canal.   Those three conditions being granted, this is one 
54     DISEASES OF THE URINARY ORGANS.
of the safest and best modes of treating stricture.   There is
a patient upstairs who has finished the process, and to-day
the house surgeon tells me that he passed No. 11 with ease.
The man has not now the slightest  pain or frequency of
making water, and he has not been so well as he is now for
twenty years.   He says he is as well as ever he was in his
life;  he came here in an  exceedingly bad  condition.   He
had been treated as an out-patient, and making no progress,
I advised him to come in, and try continuous dilatation.  I
repeat, three conditions are necessary to success:  you must
have  a flexible  instrument; the point must not  be  far
in the bladder,  and  it must not fill the stricture, because,
remember, it is not a mere mechanical process ; you do not
want to distend the stricture as you would a lady's glove,
but you let the foreign body lie in  the  passage.  If you
leave a No.  1 in for a sufficient length of time, you will be
able, when you take it  out, to pass No.  10, without using
the intermediate numbers.   You do not  leave so small an
instrument  there, because the stream of urine would soon
wash it out, and it is necessary to put in a larger one to fill
the canal a  little more.  If, when you change the instru-
ment, you  put  in one quite as large as  the stricture will
admit, you  produce  pain  and irritation, and  infringe the
principle I have laid down, so that the progress is less satis-
factory.  In continuous dilatation, as well as in simple dila-
tation, you adopt the plan which gives the least amount of
pain and irritation to the patient, putting as little as possible
to the  debit side, and as  much  as possible to the credit.
Well, then,  having ceased to tie in any  longer, say at the
end of six,  eight, or ten days, according to the case,  you
Avill pass an instrument daily for two or three days.  Then 
STRICTURE OF THE URETHRA.         55
gradually increase the intervals  of time, maintaining as
much of the calibre gained as you fairly can.  Most com-
monly you lose a number or two from the  highest point
attained by tying in:  thus, if No. 12 was so reached, you
will probably maintain No. 9 or 10;  an excellent calibre
for a patient who commenced with No. 1, and that perhaps
not passed without much difficulty.   Of course there are
some few cases in which the contraction reappears rapidly,
and all that has been gained by the process is rapidly lost.
Clearly some other method than dilatation will be required
for such cases.  This subject, which embraces the operative
proceedings to be applied to the  treatment of stricture, I
shall speak of at our next meeting. 
56     DISEASES OF THE  URINARY  ORGANS.
                  LECTUKE  III.

              STRICTURE OF THE URETHRA.

  You may remember, gentlemen, that at the last lecture
we commenced the subject of stricture, and considered the
treatment by " ordinary dilatation" and by  " continuous
dilatation."   You  will see at once that this  presupposed
that an instrument passed into the bladder.  It is, of course,
assumed  that in treating a case by means of  dilatation,
whether  continuous  or  simple, the instrument  has  fairly
passed through the stricture, otherwise the stricture is not
dilated.   But all cases of stricture are not so easily disposed
of.  It often happens that at the first, second, or  even third
trial you do not get the instrument into the obstructed part,
or only partially so ; or it leaves the canal altogether and
goes into a false passage.   At  all events, the instrument
does not  go through the stricture, and onwards, as it should
do, into the bladder.   Now that is a condition of difficulty
which opens a new subject  for us to-day.  We have now
to deal with more  difficult cases, those in  which all your
care and  experience,  if you have any, are needed.  It was
said by Liston, that of all operations in surgery,  there were
none so difficult, none which required so much  patience and
care, as the passing of a catheter through an obstinate and
very narrow stricture.  That statement is in his last edition 
STRICTURE OF THE  URETHRA.         57
of the " Practical Surgery" (p. 476), and  you can scarcely
have a higher authority for the fact there mentioned.
  Now there is one word which is often used to describe
stricture, to which I take a great objection, and I think the
sooner it is expunged from the vocabulary of surgery the
better.  Such a stricture as that of which I now speak  is
often  said to be  " impermeable."   What is  impermeable
stricture ?  Why, first, it does not denote a quality neces-
sarily inherent in the stricture at all, but rather the quality
of the surgeon.  For, you see, a stricture may be " imper-
meable" as regards A, but  not " impermeable" as regards
B, who  may pass  the  instrument easily enough.  But,
secondly, it is a contradiction in terms.  Stricture is a nar-
rowing of the canal; it is not  an obliteration of it.  There
must be an opening, and if there be an opening there must
be room for an instrument; it  cannot  be " impermeable."
It is only a question of the size of that instrument, and  of
skill or patience in the management of it.   The stricture
always  admits  urine, more or less in quantity, to  pass
through it, and I maintain the truth of the axiom  first
enunciated by Professor Syme, that whenever urine passes
outwards through a stricture, an  instrument ought with
care and perseverance to be got in.  I advise you to believe
in that doctrine, not that it  is true as regards yourselves  at
the present time, for I will assume that you have not suffi-
cient experience to  be able to pass an  instrument through
a stricture in all cases.  If you are able to do so, I can only
say that you are quite out of place here, and need not come
to learn.  It is exceedingly difficult to  pass an instrument
in some cases, but after a considerable amount  of experi-
ence you will find that there are very few in which it can- 
58     DISEASES OF THE URINARY ORGANS.
not be accomplished.   In the treatment of stricture, when
you have really a difficult case before you, it makes all the
difference  whether you act under a  belief that it is your
own fault if you do not succeed, or whether, on the other
hand, you hold the dogma that there  are a certain number
of cases which are " impermeable" to  all surgeons.   The
man who holds the  latter belief will be quite certain in
some  cases not to  succeed, whereas, probably, the man who
believes that in all cases an instrument may be  passed wjth
time and patience, will be very likely to succeed in all, or
at all  events will succeed better than the other.  " Imper-
meable" stricture  is not heard so much of now as it was
twenty years ago.  It was fully believed in then, and ope-
rations were frequently seen in the hospitals for it;  but I
will undertake to say that they are  very rare now.   The
operation consisted in passing a large  instrument down to
the stricture, and opening the  urethra upon  it  from the
perineum, and then getting through the obstruction, or by
it in  some way,  if the  operator could, into  the urethra
beyond.  It was  very seldom that the true  passage was
followed, but somehow, by dint of cutting, a way was made
for the instrument to go from the urethra before the stric-
ture, to the urethra behind the  stricture, and  it was not a
very successful proceeding.  That was acknowledged in all
books at that  time as an operation for impermeable stric-
ture, or as " perineal section."  I have  never had occasion
to perform it, and I  believe the necessity for it, if ever
existing, is excessively rare.   I have already given Pro-
fessor Syme credit for having first enunciated that doctrine,
and he has stoutly maintained it, to the great advantage of
patients who suffer from stricture. 
STRICTURE OF THE URETHRA.         59
  But you may have complete obliteration of the urethra,
which, as before said, is not stricture.  This is very rare;
but it occasionally happens, and chiefly after injury in the
perineum, as by the breaking of a vessel, or any wound
there cutting into  or  across the urethra.   If the opening
remains pervious, and gives exit to all the urine, a cicatrix
'occurs involving  the  anterior opening of the divided  ure-
thra, which is then closed altogether, and so the canal  is
obliterated in front of the fistula.
  Now, how are you to  deal with  a  really narrow  and
difficult structure?  I will assume that you have a case  in
which you have tried to pass an instrument three or  four
times, and have failed.   The first thing to do is to see the
patient make water.  Your failure to pass the instrument
may not have arisen from narrowing the urethra: there
may have been some  false passage made.   It may be  that
there is no stricture at all.  No greater failures are made
than with those patients who  have little  or no stricture,
either from the surgeon not knowing well how to pass the
instrument, or from there  being  a false passage into which
he gets, so that he  does not enter the bladder at all.  You
first of all see the stream of water, and judge by that what
size of instrument is to be used.  And always  let  the in-
strument correspond with  the size of the stream which you
see.  It should correspond in this way, however—it should
be a little smaller.  You know, of course, that when a  cur-
rent of  water passes into  a narrower passage than that  in
which it has been flowing, the stream is  more rapid than
before,  and  when  the passage  becomes  larger it flows
slowly again; so  that  the size of the stream as it flows
from the orifice is not to be taken as the  precise measure 
60     DISEASES OF  THE URINARY ORGANS.
of the  calibre of the narrowest part of the  canal.  You
should, therefore,  take  an instrument somewhat  smaller
than the stream.  There is a patient in No. 10 ward, whom
some of you have seen, who does not pass a stream at all:
the urine is only a succession of drops.   How small, then,
in such a case must be  the instrument that is  employed.
Then there is  one very important thing  to be  considered
in connection with  small  instruments—namely, that  no
more dangerous weapon can be  introduced  than a very
small  catheter, unless corresponding  care,  delicacy, and
gentleness are exercised; indeed, it is impossible to be too
careful in employing it.  You see how easy it is with such
an instrument as that which I hold in my hand  to get into
one of the lacunae, or into any  false  passage, or to drive it
through the soft walls of the urethra  into the tissues out-
side : therefore it should always be  used  with  the utmost
lightness of hand.   You must  not hold this slender cathe-
ter tightly, resolving to get it through any obstruction;
but it must be held  so lightly  that if  it meets  any undue
resistance it  will  slip through the fingers directly—any-
thing rather than wound the urethra.   I certainly cannot
advise you to try such an instrument until you have had
some fair amount  of practice with a larger one.   In cases
of difficulty, a small  gum instrument is often not of great
service.  I have been advocating gum elastic instruments
as the rule;  but if  you have  to deal with  a  very tight
stricture, and fail to pass the flexible catheter after one  or
two trials, you must use a small silver instrument.
   Now, one word upon the subject of using force.  Under no
circumstances whatever should force be used in the introduction
of an instrument through a stricture or into the bladder.  That 
           STRICTURE  OF THE  URETHRA.         61
is my dictum to-day.  Years ago it was matter of discus-
sion how much force should be employed; more years ago
still you heard of people  using instruments with great vio-
lence.   Now I am perfectly  satisfied, and  I believe  all
modern surgeons will tell you, that no forced is to be em-
ployed.  It is  very difficult to  say what one means  by
force;  but  what you are  to understand is, that no kind of
weight or pressure  is to  be put on the instrument which
can by any possibility carry it out of the canal;  and very
little force  will do  that.   The more difficult the  stricture
the less are you to dream of using force.   You will remem-
ber that the urethra is possibly of full size up to the point
of narrowing, and hence  it may be very difficult to find the
opening.   If you use force, you will perhaps perforate the
soft walls on either side,  and this done, you have increased
your difficulties; because, if you make a false passage, the
point of the instrument is much more likely to be caught
in  it than to pass through the  strictured part.
   Bemember, also,  that a stricture in the course of a canal
 does not necessarily follow the exact  direction of that canal.
 It  may be  a little tortuous;  may be on this side of the axis
 or on  that, not  necessarily in the middle.  You may see
 this sometimes in a dead body; and  you may infer it from
 experience on the living.  When  you have to deal with  a
 very narrow stricture, take a silver instrument which you
 intend to guide.  Do not rely upon mere groping to find the
 orifice.  First of all, it is exceedingly dull work to be con-
 stantly groping.  You should always adopt some method—
 any method you please,  provided that it shall seem to you
 exhaustive of the different modes of exploring the urethra.
 Some  of you saw the plan I adopted with a patient to-day; 
62     DISEASES OF  THE URINARY ORGANS.
and I believe that to be the best plan.  You should  go
systematically to work,  and slide your instrument from the
orifice of the urethra down the one side or the other.  This
diagram will show you what I mean.  If I go down on this
I shall probably not get into  the stricture ;  but if I slide
down gradually on the other, I shall probably get the  in-
strument in, because you see there is less obstruction on that
side.  Begin, then, by  the  roof.  The  roof is the firmest
part, and, by following it, will be most likely to carry the
point in.  The floor, on the contrary, is the softest, loosest,
and most spongy part;  and will be most likely to yield to
the instrument, and give way.   If your first effort does not
succeed, take the right side; if that does not do, take the
left; if that does not do, take the floor.  I know  no other
method so calculated to help you through a difficult stric-
ture.  If you are very  careful, you  may make the attempt
in this manner for twenty or thirty  minutes without doing
any damage; but if you find the patient suffering much, if
you are losing  patience, give it up,  or you will probably
make a false passage, and increase the difficulty tenfold.
   So much with regard to introducing an instrument into a
very narrow stricture.   Now suppose you have a false pas-
sage.  Of course I will assume that  you have not made one
—you will be much too careful for that; you are perhaps
not the first surgeon who has seen  the  patient; some one
else has seen him before you, and  made a false passage.
There is that case upstairs, in which the man has made a
false  passage himself, confessedly, notoriously,  because he
has taken a large instrument and pushed it completely into
the bowel.  He has used a No. 9 or  10 bougie, and treated
himself for stricture.  He is certainly an illustration of the 
STRICTURE OF THE  URETHRA.         63
old adage, that " he who treats himself has a fool for his
patient."  He has thrust the bougie out of the  urethra
through all the tissues between it and the rectum.  When
he was in the out-patient room he simply complained that
when he passed the catheter into the bladder he brought out
feces.  The truth is he never went into the bladder at all.
I suspected the cause, laid him on his back, and verified it,
and, as you know, he is now in my ward  upstairs.  I have
made two prolonged attempts, and  I carried a No. 1 silver
catheter into  the bladder to-day.  You can easily conceive
how difficult  that false passage must make it to  get the in-
strument in.  It is  only to be done by being very careful
in avoiding the side on which the false passage is.   A false
passage commences  usually on the floor, and, no doubt, for
the reason mentioned, the structures below being looser than
those above.  When  you examine a patient with a false
passage, you probably find the instrument passing up to its
very end, and no urine flows.   Hence the notion that there
is stricture at the neck of the bladder.  When  the instru-
ment is thus  passed, put your finger into the rectum, and
you will know instantly whether there is a false passage;
for, if so, there are  only the coats of the  bowel, which are
very thin, between your finger and the instrument, so that
you feel it very distinctly.  But if the instrument is in the
right passage, you feel the whole thickness of the prostate,
not always very considerable, between it  and  your finger,
still quite enough  to  show that you are in  the right
path.  It is almost  always in the  bulbous  portion that it
leaves the urethra and gets under the prostate.  What you
are to do, then, is to withdraw the catheter two inches or
so, then pass  it  on again, keeping as close along the upper 
64
DISEASES OF  THE URINARY ORGANS.
part of the  urethra as you can, ascertaining by means  of
the finger that the instrument is not passing in the old
route.  It will be very likely to do so, because it is much
more easy to get into a false passage than into the right one.
I have devoted as much time to this subject as I dare. I
have only given you these general hints; you will arrive
at the rest yourselves by  practice.  There is very often a
case of false passage upstairs, and I wish you sometimes to
verify the position of the catheter when it is in  the false
passage; to  observe, by introducing into the rectum your
finger, how very little tissue there is between it and the
instrument.   On the other hand, when  it is properly passed,
you feel  the thickness of the prostate intervening.  You
can only appreciate this by the touch, and will learn very
little more by talking of it.
  One word with regard to the injection of oil. When you
have a very narrow stricture to deal with, instead of oiling
the instrument, it is as well to throw  half an  ounce or an
ounce of olive oil into the urethra, holding the syringe well
round the meatus.  It is easy to insinuate half an ounce  or
an ounce of oil through a very narrow stricture.   It lubri-
cates  the parts,  and  sometimes the  urethra is  distended
with the oil, so that, if you can cleverly retain it with the
finger and thumb, you may introduce  the instrument when
you have been unable  in any other  way.  This is worth
noting.   It does not do well when there is much bleeding,
or the  tissues are torn,  but when it  is not  so the plan is
sometimes useful.
  Now suppose  that, following  these  hints, you have
carried the  instrument  through the  stricture; there is a
sort of grasp which is quite unmistakable.  That is a sen- 
STRICTURE  OF  THE URETHRA.         65
sation which you are always content to have, because, feel-
ing the catheter "held" by the stricture, you know you are
through it.  But that very " grasp" which you are so satis-
fied to have, makes it less easy to  manipulate the  point of
the catheter after it is through the  stricture, and you have
sources  of  danger to encounter  in the urethra  beyond.
Thus the mucous  membrane, being often reticulated with
dilated lacuna?, it  is easy to engage the point of the instru-
ment in one of those, and make a false passage. Be careful
never to use force in this stage, and, even after  you are
through, to get gently and quietly  into the bladder.  Here
is a drawing taken from a case which exactly illustrates
this condition.   (Fig.  5.)
   Let us pursue the case
one step further.  Suppose
you have got your catheter
in at last, after much diffi-
culty.   Do not pull it out.
You  will   say:  "I had
trouble enough to get  it
in; and now I will tie  it
in at once."  It  is gene-
rally  safe to  do that, al-
though it  is  a metal in-
strument;  and  you  may
keep   it  forty-eight  or
seventy-two hours before
removing it.  Do not then
                            Fig. 5.—Section of urethra, showing very
be in a hurry tO take it OUt,  narrow stricture, and dilated  and retiou-
if the  patient is tolerably lated "^rano™ and Prostatic P°rtions
comfortable.
       5
You will be 
66     DISEASES OF  THE URINARY ORGANS.
excessively disappointed to be obliged to repeat your task;
and it will be very disagreeable to the patient.  Keep it
in about three days, and then you will mostly be able to
change it for a  gum-elastic instrument. You then go on
with " continuous" dilatation, as already described, increas-
ing the size of the gum catheter from time to time.  You
get up, perhaps, to No. 10, and tell the patient, " This is a
great  point gained;"  but in ten  days or so, to your great
disappointment,  it may be that  the stricture will  admit
nothing larger than No. 2, or No. 3.  Now it  is clear that
you have to do with what is called a " resilient" or " con-
tractile" stricture.  It is not a question of  calibre so much
as a question of contractility.  The narrowing has gone
back almost to that condition in which it was at first. You
can now only get in,  say No. 2.  It  is useless  again to
attempt dilatation.  This is precisely that kind of excep-
tional case for which you reserve other means of treatment.
Understand that you may have stricture very  narrow, and
be able to dilate it, and the dilatation shall  be fairly per-
manent.  On the other hand, you may have stricture which
will admit even No. 5, or  No. 6, catheter easily, yet the
man will scarcely make  a  drop  of water, and you cannot
dilate the stricture more than a number  or two, do what
you will.   We had  an instance of  that in  the ward the
other day.  No.  6 instrument was  passed; but the man
could make  no  water  until I had operated.  These con-
tractile strictures have been  the plague of  surgeons from
time immemorial.  If you go back to  old records of surgery
—how far back ?—some hundreds  of years—you will find
that these cases have exhausted the wits of surgeons to the
present day.  All kinds of things have been used in  order 
           STRICTURE OF THE URETHRA.         67
to overcome the difficulty.  I cannot tell you one-half of
the matters of various kinds which have been put into the
human urethra,  for the purpose  of curing it.  I suppose
the human stomach has been made to receive more abomi-
nable things than any other receptacle in or out of the
human body.  But if you  consult t'he old surgical authors,
or even some modern books, you will see  that the urethra
has been used nearly as roughly, and that is saying a good
deal.   Verdigris,  savin,  the salts of all  sorts  of metals,
everything that  Could irritate, or that could be imagined
to be disagreeable, has been  employed to cure these  un-
fortunate strictures.  At  the  present moment I need  not
tell you that some surgeons have employed nitrate of silver
and caustic potash—not at all mild remedies, either of them.
Now the whole  question  of chemical  irritants, as applied
to stricture, I shall dismiss  with the  following words:  I
believe them to be unnecessary, undesirable,  and often in-
jurious.   Most modern surgeons, both in  this country and
abroad,  have  pronounced against the use of caustics and
chemical irritants in the treatment of stricture. I am bound
to tell you they  have still some advocates: what system
has not ?  I shall not pursue that question further.
   Then  what have we left ?  Several mechanical modes:
we may rupture, or over-distend, or cut these  unyielding
and contractile fibres, which constitute the stricture.  Ure-
throtomy, as it is  called—division of the strictured urethra
 by some form of knife—is, perhaps, all things considered,
 the most universally employed in such cases.  Now there
 are two  kinds of urethrotomy—external  urethrotomy and
 internal urethrotomy : the external applied from the peri-
 neum ;  the internal by means of the knife, or some other
 instrument applied within the urethra. 
68     DISEASES  OF  THE  URINARY ORGANS.
  I speak  first of internal urethrotomy.  There are two
modes of doing it.  You may cut the stricture from before
backwards, or from behind forwards, the latter  being the
method most commonly adopted.
  First, suppose you have a stricture at or near the orifice
—a very undilatable part.  You get in an instrument like
that which I hold in  my hand—a small bistourie  cached;
Fig. 6.—A small bistourie cachee.
project the blade and draw it outwards, dividing the ob-
struction.  Nothing can be more  simple.  By means of a
screw, you can raise the blade to a  small or to a  large
extent.   It should be used so  as to make a rather free inci-
sion, which is perfectly safe.  As a rule, the nearer the
stricture is situated to the orifice of the urethra, the more
necessary is it to cut, and  the safer is it  to  do so.  The
further the stricture is from the external meatus, as a rule,
the less necessary it is to cut, and there is rather more risk
in doing so.  All strictures at the meatus,  and within, say
about three inches  of it, which have resisted dilatafion—
and these generally do so—should be divided.  You can
dilate them, but the effect is temporary; and you can divide
them with ease and perfect safety.   This  drawing  shows
the condition in question.   The strictures are laid open after
examination, and present the appearance  of  much  larger
calibre than really existed  during  life.   (See Fig. 7.)
   Secondly, with regard to strictures at a distance of five 
           STRICTURE  OF  THE  URETHRA.         69
inches, the reason why it is somewhat less safe to cut them is
on account of the large amount of erectile tissue at that point.
In my own experience of sixteen or seventeen years of these
operations, I have never lost a case by either internal or ex-
ternal urethrotomy, either in the
hospital or out of it, and I have
had a great many cases; I cannot
say how many—perhaps a hun-
dred. Sometimes there may be a
dangerous amount of fever, and
rarely, cystitis;  much depends,
I need not say, on the way in
which the thing is  done.   Ex-
ternal  urethrotomy is  usually
known .as Syme's operation.  It
is necessary always, in that case,
to pass a small grooved staff or
                        .      Fig. 7.—Strictures near to the ori-
director  through  the stricture,      fice of the urethra.
to cut down upon the perineum,
as in median lithotomy, and divide the stricture completely
by cutting freely into the groove of the  staff. That is very
seldom  done  now.   It was much done twelve or  fifteen
years ago ; but other means have superseded it.   Occasion-
ally the operation  is still performed, chiefly  when there
are perineal fistulae which require to be laid open.   After
doing it, a catheter is tied in for forty-eight hours,  and an
instrument to  maintain a good calibre must be passed from
time to time afterwards.   Now, for internal urethrotomy in
these cases of  stricture in the bulbous urethra, this  instru-
ment of Civiale's which I hold in my hand is a very good
 
SES  OF THE  URINARY  ORGANS.
  one.   I  used it for a case here about  a
  month ago, and the result was simply per-
  fect.   It has a small bulb at the end, con-
  cealing a small sharp blade within, which
  you pass through the stricture.   You can
  then,  by means of the bulb, feel exactly
  the position of the stricture.  Having done
  this, you unsheath the blade about half an
  inch  beyond the  stricture, to  the  extent
  required, and draw it forward,  dividing
  the contracted part freely.   In that case,
  also, you should  tie in a catheter forty-
  eight hours, and after that pass an instru-
  ment  every third day, then every week,
  and so on.   Here are instruments for cut-
  ting from before backwards, and of various
  kinds; but I prefer the others as a rule.
  Here  is another which will act in both
  ways—a very complete instrument  of its
  kind,  which bears the name  of M. Trelat.
    We next come to the mode of  rupture;
  and here I will show you an instrument
  which bears the name of Mr. Holt, of the
  Westminster Hospital.  He has brought
  the instrument into notice, and the  mode
  of using it is his own.  It was invented by
  M. Perreve, of Paris, more than twenty
  years ago.   He used  it mainly, but  not
  altogether, for simple dilatation;  Mr. Holt
  uses it otherwise.   He carries  it through
  the stricture, and  then, instead of passing 
STRICTURE  OF THE  URETHRA.         71
at different times a succession of tubes of gradually increas-
ing calibre, he takes the largest tube at once, and forces it
down the urethra along the  central guide, so as at one
stroke to split everything that happens to  obstruct the
passage of the instrument.  Mr.  Holt does not tie  in an
instrument afterwards.  When the operation was first intro-
duced, I was strongly repelled by the violence of the pro-
ceeding; but I  examined some of Mr. Holt's cases with
him at the Westminster Hospital—now some ten years ago
—and was surprised to find  how few bad results followed.
Hence I tried the plan, and use it occasionally for a urethra
which has some two or three contracted points—a condition
rarely met with—so as to deal with them  all with certainty.
Rupture, however, is too rough a mode, in my opinion, for
most cases;  and I • prefer to  carry a fine blade  carefully
through the fibres of the stricture, and believe it to be the
best, and the most enduring in results.   But  the popular
sentiment about a knife cannot be ignored.   The British
public is not partial to a sharp edge, and is glad of almost
any substitute—a feeling one can quite understand.  So
that it is not always possible  to do the best thing, and we
have to select that which is next best.  You will then, pro-
bably, find the proceeding  by rupture a useful one when
dilatation has failed.  That operation suggested to me some
years ago  a  different method—namely, one which I have
called " over-distending" the  stricture.  It is simply this.
Here are two blades, as in the instrument used by Mr. Holt,
but these two blades  can be  separated for a  considerable
interval at one point,  and as slowly as you  please.   In
practice I do it very slowly,  so as to rupture as little as
possible, and to over-distend as much as possible,  the struc- 
72     DISEASES OF THE URINARY ORGANS.
tures which form the  obstruction.   There is this fact also
to be noted:  I wish you to remember that the bulbous
part of the urethra—the usual position of stricture—is also
the most distensible part in the natural condition  of the
canal.  Supposing the external meatus to be about  No. 12
(English scale) in calibre, the  bulbous  urethra  admits at
least No. 20 or 24.  Hence it follows that no  kind of dila-
tation or operation which is limited in  extent by the size
of the external meatus, more than half restores the urethra
which  has a  stricture  at the bulb.  It  is on this account
that I distend the contracted part to at least this, or even
to a larger size, or rupture it if I  please, by means of the
instrument in question.  I have now used it many times, and
it is certainly attended with good results.  It is to be used
only for strictures within the bulb.   I  have heard that it
has  been employed for those within three inches  of the
meatus;  it is a mistake to use it for such, which, as I said
before, ought to be cut.  This operation requires more care
than the other.  Mr. Holt's operation needs no care after
the instrument is once in place;  it is extremely easy to use
it.  If you once get the instrument in correctly, a single
impulse of the hand forces the tube through; and it is cer-
tainly tempting on that account.  And  for a considerable
time afterwards you have good  results  from these  opera-
tions.  I think, however, that internal  urethrotomy gives
results which are more enduring than any other; but it is
infinitely more difficult to perform properly, and, without
doubt, it requires a practised hand.
   One thing  is very necessary before you cut  a stricture,
namely, that  you have an exact idea of its situation and
extent.  Also, whether there is any other narrowed  spot in 
STRICTURE  OF  THE  URETHRA.          73
the canal besides the principal contraction.   If No.  11 or
12 pass easily along the urethra for 5 or 5 J- inches, rely on'
it you have only to do with a single stricture.  Not very
unfrequently you will find a  second near  to the external
meatus, or at a distance of  about  three  inches from it.
Supposing that your large bougie stops at either place, and
that a No. 7 or 8 only will pass through, you may, if you
please, take a bougie with a  bulb  at the extremity and a
narrow neck behind it; such  a bulb as will just go tightly
through the narrowed part; having  passed it, you feel it
free beyond, and, on withdrawing, it marks again the situa-
tion and  length of the stricture, the latter usually very
inconsiderably, and so renders it very evident.  With these
bulbous bougies, of various sizes, you  may determine the
existence of any narrowing in any part of the urethra with
great accuracy,  and for many years  I have never operated
without employing them carefully beforehand.
   Briefly let  me, at the close of this subject, remind you
that in all cases of impeded  micturition, attention  to the
general health often aids  in a considerable degree to miti-
gate the local troubles.  Do not overlook the  state of the
digestion. If this is unsatisfactory, if the bowels are unduly
constipated, the troubles  of the bladder and urethra will
be much increased ; and frequently  it happens that a mild
mercurial, followed by a dose  of Glauber's salts, or of Fried-
richshall water, in the  morning, gently unloads the liver
and bowels, and greatly relieves the most distressing symp-
toms.  Then take care  of what your patient eats, and more
especially let his alcoholic drinks be in moderate quantity,
and of the mildest kind.
   There is only one other word I have to say: do not be 
74     DISEASES OF  THE URINARY ORGANS.
partisans of any single method.  You hear one surgeon say,
" I always follow such and such a method : there is nothing
like it."  Or another, that he always adopts the proceeding
of M. Civiale;  and a third that of M. Maisonneuve, and so
on.   There has  been great fertility in inventions of this
description,  especially  in Paris, and  you  may  see  from
several of them very excellent  results.  Do not confine
your  selection  to any one method, whether I or any one
else  recommend it; but have every resource at  your dis-
posal.  If you have much to do with stricture, or with such
complaints, I can only tell you, you will want all  the  re-
sources within your reach.  Consider them carefully, and
select for each individual case that method which appears in
your judgment to be best adapted for it. 
HYPERTROPHY  OF THE  PROSTATE.      75
                 LECTURE  IV.

HYPERTROPHY OF THE PROSTATE AND ITS CONSEQUENCES.

  Gentlemen :—We may pass from the subject of stricture
to another very important complaint, and one of common
occurrence—viz., hypertrophy of the prostate.   It is one
which affects a large number of elderly people, and thus
the practitioner  is almost certain to  come in contact with
it pretty frequently.  Hence the necessity for our studying
these cases closely, and the more so because we do not see
them very often in  the beds  here,  most of them  being
treated as out-patients.
  It was  formerly  stated, on  the high authority of Sir
Benjamin Brodie, that  " when the hair  becomes gray and
scanty......the prostate gland  usually, I might per-
haps say invariably,  becomes increased  in size;" and that
is the impression which a large portion of the profession
have respecting it.  It was certainly  that which was gene-
rally received when  I first began to made some special re-
searches in reference  to this matter, now some ten or twelve
years ago.  I was then at the pains to examine after death
all the bodies of male  patients  over fifty-five years of age
who died in the Marylebone Infirmary ;  and afterwards, in
Greenwich Hospital,  the inquiry was pursued by Dr. Messer
and myself.  I took care to dissect each prostate very care-
fully, and discovered that, so far from the presence of pros-
tatic enlargement being the rule, this condition was quite 
76     DISEASES OF  THE URINARY  ORGANS.
exceptional.  I examined about two hundred cases—not
picked cases, but  all who died consecutively within a cer-
tain period, and I found that about one in three exhibited
after death some enlargement of the prostate.   But of those
do not suppose that anything like a large proportion mani-
fested symptoms; for only about one in seven, not more,
had symptoms of the complaint.  So that you see it is not
to more than one  in (let us say) ten men who live beyond
fifty-five years of age to whom you may expect to be called
to afford any relief for this affection.   That, no doubt, is
a large number.  If you suppose that one man in every
ten approaching sixty years of age has symptoms of en-
larged prostate, you will see at once how often, if you have
anything like a large practice, you may be called to attend
to these cases.
  We will  now  consider  one or two  anatomical  points
connected with enlarged  prostate.  This organ is, as you
know, composed of two lobes and a median portion. Now,
the part affected  with  hypertrophy very much influences
the results in relation to the function of micturition.  If is
not necessary that there  should be  much enlargement of
the prostate in order to produce very severe symptoms.
On the  other  hand, you may have a very large prostate,
and may have almost no symptoms.  Almost the largest I
ever saw, as big as a small cocoanut, produced very little
obstruction to the flow of the urine.  Thus, if  the median
portion  of  the prostate  is only slightly enlarged, there
may be retention.  Let this figure [diagram] represent the
two lobes, and this the median portion.  If there is a small
nipple-like  projection at the median portion,  just filling
the internal orifice of the urethra, that may be quite suffi- 
HYPERTROPHY OF  THE PROSTATE.       77
cient to prevent every drop of urine passing by the natural
efforts.   Sometimes there is a considerable enlargement
on one side, so that the passage is circuitous; and you will
sometimes find  the catheter carried to the  right or left,
according as the prostate may be large on one side or the
other.   I show  you several  examples: these are depicted
at Figs. 9, 10, 11.  You will remember, then, that if you
   FIG. 9.__Section of bladder and prostate, showing marked but not great
           enlargement of lateral lobes and median portion.

have  occasion  to  examine  a patient, and  you find a very
large prostate, it does not necessarily follow that he should
have  great difficulty  in  passing  his water; and, on the
other hand, although you may find inappreciable enlarge-
ment  by rectal examination or otherwise,  you may not
therefore conclude that all his troubles—and they may be
considerable—are not due to this complaint.
  I will now say a word  as to the age of  the patients.  I 
78     DISEASES  OF THE  URINARY ORGANS.
never saw an enlarged prostate (I mean, of course, hyper-
trophy,  not  enlargement  from  inflammation  and  other
causes) before the age of fifty-four; and if I have not seen
such a case, you may say that  it  never or  very rarely oc-
curs.  The usual time at which it begins  to show itself is
Fig. 10.—Section of bladder and prostate, the former hypertrophied, the latter
            forming prominent tumors within the bladder.

from fifty-seven to sixty.  If a man has it at all he will
have it generally by sixty.  If he gets over sixty-five "or
seventy, he  may have  it, but in a less degree;  that, how-
ever, does not commonly happen.  I have examined  the
bodies of men at ninety, without the slightest enlargement.
You see, then, that it is by no means necessarily connected
with age.  The man who escapes it at sixty-five will be
very likely  to escape it altogether, or nearly so.
  I speak next of the  symptoms.   An elderly man comes 
         HYPERTROPHY OF  THE PROSTATE.      79
to you and  says that  recently his water has not passed so
easily;  that it has issued in a dribbling stream, and he
cannot propel it; that he requires to  micturate a little
more frequently, especially in the morning—probably two
  Fig. 11.—Section of bladder and prostate, the latter forming an enormous
                   tumor.  A lateral view.

or three times while he is dressing, after which it becomes
less troublesome;  but at night it is rather more so than
during  the  day.  Then if he does  not  say much about
pain—which, of course, will excite  your suspicion of cal-
culus, or  some  other complaint—you will  say, " This is
probably a case of enlarged prostate."  You do not neces-
sarily proceed at  once to  pass the  catheter, but you will
ask the  four questions already referred to.   You will ask
how frequently  he makes  water, and then, in connection
with frequency, whether the water ever passes without his
being aware of it, or  without his willing it.  In many ad- 
80     DISEASES OF THE URINARY  ORGANS.
vanced cases, you will find that some urine passes during a
violent effort, such as coughing, or  at night, during sleep.
If so, it is probably a case of rather long standing.  But if
the patient only speaks of the frequency of making water
—not inordinate, but moderate frequency—then you ask
for  pain, and if any, whether before, during, or after the
passing of water.  If before, and the patient is relieved by
making water, it is  probably  hypertrophied prostate.  If
it is after, you may expect calculus, which comes into con-
tact with the mucous membrane of the bladder when the
water is gone;  whereas, if he has  a distended bladder, as
he is likely to have, with enlarged prostate, it is painful as
distension occurs, and becomes less so as the urine passes
off.  Then you  inquire  about the  character of the  secre-
tion, whether it is  clear or cloudy.  In most cases,  at the
commencement, it is clear.  In a great number of cases of
prostatic enlargement, although the bladder has not been
emptied for months or a  year,  the water is still clear.  On
the  other hand, if it is  an  advanced case,  the water will
certainly be cloudy.  And while you are talking of that,
you will also ask-about  the stream.  You  will generally
find that it is a dribbling stream, different from the stream
in cases of stricture.  In stricture, the stream is often pro-
pelled exceedingly well, although  it is no larger  than a
thread; and  so long as there is a  stream, the patient can
act upon it by will, so as to  make it stronger; whereas,
strain as he may, in  prostatic enlargement, he often cannot
influence the stream, except for the worse.  It may happen,
from the median portion  being forced by the straining into
the passage, that the patient voids urine less well the more
he  strains.  Generally speaking, the expelling apparatus 
         HYPERTROPHY  OF THE  PROSTATE.      81
at the neck  of  the  bladder  is involved in  the enlarged
prostate, and ceases  to  act; so that with all  his straining
he cannot  make much  difference, and  the stream is  not
propelled with any force.   Then you ask the fourth ques-
tion:  "Do  you pass blood?"   Usually, in the early stages,
the reply will be in the  negative, although a  little may
appear after much exercise, so far suggesting stone.   You
ask the patient to let you see him  pass water, if he can, for
that will help you materially.  If the stream is such as I
have  described,  you  will infer that it is a case of prostatic
enlargement.
   Then you complete your diagnosis by mechanical means,
and  for this purpose you will first  use a  catheter.  You
should invariably make the patient  pass water before you
begin, because  your object  is not  merely to  ascertain
whether enlarged prostate exists, but, what is much more
important, what  the effect of  it is, how far it is a  barrier
to the exit of urine from the bladder.  The great point to
him and to  you is  not merely the  size, or condition, or
shape of the prostate, but to what extent is it a barrier to
the exit of urine. It is the quantity of urine left  behind
which will determine future  treatment. I should advise
you to  use a gum catheter, well curved, and certainly not
a small one.   As in stricture, always  begin with a catheter
of not less than 8 or 9,  and of course without a stylet.   In
passing it, keep the  shaft well back  in the grain, so as to
maintain the curve.  As soon as  you have arrived at the
bladder, carefully empty it, and  note the quantity with-
drawn.   It may vary greatly, from an ounce up to almost
anything you please.  I have drawn  off six pints, but that
       6 
S2     DISEASES OF THE URINARY ORGANS.
is  a  very large amount.  You may find commonly from
six to twenty ounces.
  Now, with regard to the employment of the instrument
for patients with  the symptoms described, do not forget
that frequency of passing water, and still more the passing
of it involuntarily, indicate the necessity for the catheter.
It  is remarkable  how common are the errors, not merely
of patients, but of practitioners on this point.  They  are
apt to be misled by the fact that  the patient insists,  " I do
not make too little water; I  am  making water too  fre-
quently, and too  much  of it, and  I am sure my bladder
must be empty.  Tell me how to  retain  my water,  and  I
shall be much obliged to  you.  Don't think of drawing it
off."   It  is surprising how that sometimes influences  the
practitioner.   Nevertheless, these  are the very circum-
stances in which you should pass the catheter and ascertain
the fact.  Always bear  this in mind (and I  wish, figura-
tively  speaking,  to render that sentence in  the largest
capitals), that involuntary  micturition indicates  re-
tention, and not incontinence.  There are a- few excep-
tions to the rule, but very few.  Most of the mistakes that
are made on this point arise  from the use, or,  as I shall
show you,  the abuse, of the word " incontinence," which
means, of course,  that the  bladder is empty; and  certainly,
when the bladder cannot hold  its contents, its condition is
rightly  described by the  word incontinence.  Now, that
happens  only in very uncommon but well-defined circum-
stances, such as in some cases of cerebral  or cerebro-spinal
paralysis, and in rare  injuries to the neck of the bladder;
and in these the urine runs off as fast as it comes from the
ureters, the bladder  having ceased to act as  a  reservoir. 
         HYPERTROPHY OF THE  PROSTATE.       83
You see this  one external  physical sign is the  same  in
these cases and in those in which the bladder is distended
with urine; that is, there is urine dribbling  off by the
urethra.   But mark how totally different are the two con-
ditions in question : in one the bladder is full, in the other
the bladder is empty.  Whenever,  then, you meet with
this -involuntary flow of urine  miscalled " incontinence,"
do not confound it with the condition in which  the bladder
is empty.  Rely upon it the bladder is full, and the only
way of relieving the patient is  by the use of the catheter.
I lay  great stress upon this, because  I  have seen lives
sacrificed to a  forgetfulness of  this point.   I  have made
post-mortem examinations of persons who have died from
the effects of retention undiscovered during life, misunder-
stood  because  the urine constantly passed off, as it was
supposed, " so freely."
   Now we know that our views of things, and our conse-
 quent acts, are very much determined by  the manner in
 which we use and apply words respecting them, and it is
 impossible to be too clear  and defined in all our  language,
 especially in that which relates to pathological conditions
 and surgical practice.   I cannot express to you how strong
 my sense is of the importance of this matter; hence I have
 made it  my constant business to point  out the common
 misuse of terms in connection with this subject.
   First,  then,  the term incontinence, which means  the
 bladder  is empty, or "cannot  contain," should never be
 employed by  you to denote the  phenomenon  that  the
  patient's urine flows involuntarily; for, as we have seen,
  in that condition the bladder is generally full. It is better
  to speak of it as " involuntary  micturition," without refer- 
84      DISEASES  OF  THE  URINARY  ORGANS.
ence to the cause, and when  this is found to be distended
bladder, to use the  term " overflow."   Then, remembering
always my maxim,  that " involuntary micturition indicates
mostly retention, not incontinence," you will never make
the fatal blunder I have spoken of, and which I assert to
be  so  common.  This,  too,  assimilates  our usage  very
nearly to that of French surgeons. The French, with-their
more logical  use of language, speak of the bladder as " en-
gorged" and  " overflowing," but never as " incontinent"
except to denote that rare condition in which the bladder
is always perfectly empty. I have, therefore, long been in
the habit of  denoting a bladder which  is full, but allows
surplus urine to  run off  little  by little against the will of
the patient as an " engorged"  bladder, and the phenomenon
thus described as " overflow;"  and I hope you will do so
too.  This brings us, by the way, to another misapplication
of terms.   In this country, the  condition of the organ just
alluded to  is  often  called " paralysis" of the bladder, and
the unfortunate word leads to mistakes in practice.  The
bladder is rarely paralyzed.   I  know nothing of it except
as an effect of spinal or cerebral changes.  The bladder is
never by itself the subject of paralysis, meaning, of course,
an affection of the nerves, either central or peripheral.  It
may be unable to expel  its contents, because there is me-
chanical obstruction, as  enlarged prostate, stricture, or
impacted stone, or  because  the  muscles have  lost their
power  of contracting from long over-distension; but this
latter is " atony."  This  inability is in neither case due to
impaired nervous supply—a subject  to  be considered at
some subsequent meeting. [ Vide Lecture XL]
  After this digression, which its importance must excuse, 
         HYPERTROPHY OF THE PROSTATE.       85
we will go on to complete the diagnosis.  While the pa-
tient lies on his back, you place your finger in the rectum,
and examine the size  of the prostate, whether it is very
tender, and whether  the  enlargement is more on the right
or the left side.  Of course you do this as gently as you
can.   The finger should be well oiled and very slowly
introduced.   The best position for  the patient is lying on
the back, because you can press the other hand above the
pubes, and gentle pressure there brings the bladder and
prostate  near the finger, and you can  ascertain  whether
the bladder is distended  or  not.  These are the points of
diagnosis which it  is desirable to  ascertain, and beyond
these it is not usual or desirable to carry your inquiry.
  We shall now come  to  the treatment.  The medicinal
treatment of enlarged prostate may be dismissed in a few
words.  There is nothing to be done for it—that is, you
cannot diminish the hypertrophy.  There  is often tem-
porary enlargement from congestion;  and that you can do
something for.   But hypertrophy cannot be diminished  by
any known means.  All  sorts of things  have heen  tried:
iodine in all its forms.   And there is scarcely anything in
the Pharmacopoeia that presented a chance of doing good
that has not been tried.   We must simply say that, for the
present, we know no means of combating the enlargement
itself.  But much may be done by way of palliative  to the
results of the complaint; and  much  of this treatment is
mechanical.  This will  consist first in relieving the partial
retention, which has become habitual, by the catheter.   I
have reserved for this place what I have to  say about the
instrument itself.   The  reason  for preferring,  as a rule,
the gum catheter for this purpose is as follows: Different 
S6     DISEASES OF THE  URINARY ORGANS.
curves are required for different patients, and the English
gum catheter I will  back against any other instrument,
English or foreign, for  general use.  Unlike the French
catheter, which is admirable for softness and elasticity, you
have the power of making it  assume any form you like—
a quality, perhaps, not  so often rendered  available as it
might  be, but which  to my  mind is of immense service.
The instrument-maker generally curves the catheter pretty
much in this  way (see  Fig. 12): the point straight, and not
                        Fig. 12.

well curved—the  worst form  in  which  you can  put a
catheter for use.   For prostatic enlargement you require
a catheter well curved to its very point.   You should keep
the instrument on an over-curved stylet for a month or so
before employing it: and you will  then find  it  easily
assume the proper form, when you will pass it, as I need
not say, without a stylet.  If you  require  a stiff instru-
ment, a silver catheter should  be selected;  not a gum ca-
theter with a stylet in it.  To return : you want the point,
of course, to be carried  over the obstruction formed by
the enlarged prostate; and as the heat of the urethra al-
ways relaxes the curve, whatever it may be, by the time
it  arrives at the  neck of the  bladder, the ordinary gum 
         HYPERTROPHY OF THE PROSTATE.       87
catheter, as you have it from the maker, becomes nearly
straight, and  will not pass over the  enlargement.  [Dia-
gram.]  Now, when you have a catheter which has been
well over-curved for a month or  two, you remove  the
stylet and  turn back the  shaft, so as  tovundo the extreme
curve and  produce an ordinary one.  And what happens
when you  pass it?  In spite of the heat of the  urethra,
the catheter has a tendency to curve more, instead of less,
as it passes down the passage.  And  this  is precisely the
difference between  success and non-success.  That little
manoeuvre I regard as of extreme value.  It is a very
simple  thing:  keep  the  catheter  over-curved — not for
stricture, but for enlarged prostate;  then  turn back the
shaft immediately before using.  The curve gradually in-
creases as it goes onwards, and it passes over the  enlarge-
ment into the bladder.   This is so simple  that  it  seems
scarcely worth making so much of; but I can only tell you
that I know nothing of its kind that exceeds it in value.
   Then there is  another  thing: you may  want a special
curve for a particular case. We have silver catheters with
various curves (see  Fig. 13).  Here are several which are
very useful.   But the English gum  catheter  possesses a
quality  which, as I have before told  you, is not  found in
any other:  put it into warm water and bend  it  into any
form you like; then dip it immediately into  cold  water,
and it will maintain the required form. But the best form
so produced may easily be spoiled by your  mode  of using
it.   Of  course the curve must not be  altered while the in-
strument is passing through the anterior part of the canal,
for it is at  the posterior part that  this form is required;
the shaft of the catheter must be kept closely back in  the 
88      DISEASES OF THE  URINARY ORGANS.
groin, and the penis brought  round the curve, so as to pre-
serve the latter  until  it reaches the deep urethra, when,
  Fig. 13.—a, Gum catheter mounted on a stylet of the proper curve for use ;
          b, c, d, silver prostatic catheters of different curves.

by well depressing the  shaft, the  point will rise over any
obstruction into the bladder.
  The general treatment is not to be disregarded; and here
I shall defer  a good deal  of what I might otherwise say
until I come to speak of chronic cystitis, which will occupy
a subsequent lecture.  Cystitis  is associated with  so many 
         HYPERTROPHY  OF THE  PROSTATE.      89
diseases of the urinary organs that I may as well refer to
the treatment under that head, instead of taking it sepa-
rately, and recapitulating it in  connection with each dis-
ease.   But,  as far as the general treatment of  prostatic
enlargement goes, the main  thing is to prevent local  con-
gestion.  You must tell the patient above all  things to
avoid anything like chills affecting the pelvic region, sitting
on  cold  seats, exposure to  cold; too  much  excitement,
sexual or otherwise; long journeys, riding in  jolting car-
riages—all of which tend to produce pelvic congestion, and
to interfere  materially with the  condition of the  prostate;
since it very readily becomes temporarily enlarged from
these causes, and most of the troubles which the  patient
experiences depend upon them.
   One other point has relation to the action of the bowels.
You  may make a man with enlarged prostate very com-
fortable if you keep the bowels in  gentle action.  If he
has  constipation, and  scybala lodge in the rectum, their
presence is often the source of great discomfort.  Some-
times a simple enema of warm water gives instant relief;
but, if necessary, the action of the bowels must be provided        \
for by means of gentle laxatives, such as senna,  manna,
bitartrate of potash, sulphur, or by sulphate of soda;  any-
thing  which will act mildly, quickly, and without irrita-
tion, will keep him in a very different condition from that
which is associated with habitual constipation.
   I will devote the few minutes that remain to those cases
of prostatic enlargement in which the difficulty of passing
the catheter is considerable, and there is retention of urine.
You  may have a patient in whom  prostatic enlargement
has made itself manifested  rather suddenly ; he may have 
90     DISEASES OF THE URINARY ORGANS.
had  symptoms which he "has  not  noticed, but  he is sud-
denly attacked with congestion, he  cannot make water, and
he is in great distress in consequence.  It is not a question
how long a time is to elapse before the catheter is to be
passed; you  should  relieve him at once.  You find there
is a distended bladder, evidenced by dulness of  percussion
above the pubes.  Possibly, before you, others may have
tried, and you may be called  to pass the catheter in cir-
cumstances of some danger to life.  Now, in the first place,
you  should be careful with regard to position. I advise
you  to pass the instrument with the patient in the lying
position first, if the bladder is  very large; if it is not very
large, perhaps it is as well, or better, to pass it standing.
You can empty the bladder better in the standing posi-
tion ; but if you find  that the  bladder is very large, make
the patient lie down before  you  draw off  the water.  I
have known great mischief arise from drawing  off a large
quantity of water from a patient when in  a  standing posi-
tion.  I have even known death occur suddenly from this
cause.  If I had time, I could  tell  you of a case in which
a charge of manslaughter was brought against a surgeon
in a court of justice in relation  to  such an  occurrence.
The  circumstances were all well known to  me, for I was
there to defend  a brother practitioner, who was unjustly
charged.  In  that case a catheter had been  passed in the
upright position, and the patient fell dead from syncope,
when six pints of urine had passed; just as a patient with
ascites might do  if you tapped  the abdomen in that same
position.   No doubt  it was an error, but nothing could be
more monstrous  than to make it the ground of  a criminal
action.  It is a very instructive case, and I mention it to 
         HYPERTROPHY OF THE PROSTATE.       91
show that in cases where  the bladder is large, especially
in old men, you may have fatal syncope, arising in the
way I  have described.  I always take  care, if I find the
bladder is  large, to pass the catheter when the  patient is
lying down.   Take care also, in these circumstances, to
draw off only part of  the urine; and after a quart or so
has passed, wait a little before you empty the bladder.  If
you fail to pass a gum-elastic instrument, by all means use
a silver one, especially if false passages have been made.
The silver prostatic catheter is  sometimes essential; that
is, one which is much  longer and has a larger curve than
the ordinary instrument.  They are generally made longer
than most  cases require.    Indeed,  the common silver
catheter, about No. 10, or, at most, one which is only two
inches longer, suffices for the majority of cases.  Very
rarely is the fourteen-inch catheter necessary.  Sometimes,
when these fail, a cathether with a short  beak, like the
sound, or lithotrite, will pass easily.  And always remem-
ber  that anything like obstruction at the end  can only
denote that you are out of your path.  No  force  should be
employed.   It is not a narrow passage; it may be a little
close, perhaps, when you reach the prostate; but if you
find any obstruction,  you  should  withdraw  and  find
another route, to the right or to the left.  Here, also, let
me repeat, never use force under any circumstances what-
ever.
  It may be  said,  "Why have you not  mentioned hot
baths and opium?"   In cases of retention from prostatic
enlargement, there is a serious objection to the expectant
method; you  must take into account the future condition
of the bladder.'  If you permit the bladder to remain over- 
92     DISEASES OF THE  URINARY  ORGANS.
distended, say for a day or two, the fear  is that it will not
readily contract again. In the case of an old man's bladder,
thoroughly distended by  long retention, it is very likely
not to recover its powers.   Although the patient has made
water fairly up to the time of retention,  if you leave him
too long with opium, hot baths, and treatment of that kind,
the bladder is getting  bigger all the time, and you will
very likely have more  trouble with it afterwards than if
you had relieved him with the instrument at once.
   Again, if you have had  a great deal of trouble in passing
the catheter, I suppose  you must  leave the instrument in;
but it is not  good practice in these cases.  Rather with-
draw it,  and use it again;  because the prostate will  be
injured by an inlying catheter.   Unlike  stricture,  which is
often well treated by an  inlying  catheter, the prostate  is
always more or less  irritated by it;  but  less harm accrues
from a flexible than  from a silver  instrument.  Better still
if you can pass a vulcanized India-rubber catheter, which
is the only one which lies harmlessly in the urethra in a
case of prostatic enlargement.  It may sometimes be  in-
sinuated by a series of short quick  pushes, thus  [illustrating
the method] ; or, failing in that manner,  by mounting it on
a  stylet of any  curve which may be desired, and subse-
quently withdrawing the  stylet.  Nothing is easier than to
keep it in its place, and it has the  merit of rarely  becoming
incrusted with phosphates; while it does not necessarily
prevent the patient moving about his room. In  short, the
vulcanized catheter is sometimes of the  greatest service.
   Subsequently,  as the canal recovers, should the bladder
not regain its tone, and it is therefore  necessary to use the
catheter two or three times in the twenty-four hours, you 
HYPERTROPHY OF  THE PROSTATE.       93
will  probably in  the course of time teach the patient to
relieve  himself;  and he will often, with a  little tuition,
succeed remarkably well.   With respect to the frequency
with which he should be advised to do this, it will depend
mainly  upon the amount of urine left in the bladder after
a natural effort of micturition.   The patient's own feelings
will aid in answering the question;  but if you find him,
after having  passed water, retaining  say  six ounces, a
catheter passed every night and morning will probably be
sufficient.  The bladder must be emptied, or the urine will
in time decompose, become irritating, and chronic cystitis
will result.  If a pint is left behind after making  water,
the bladder should be relieved, as a rule, three times a day.
If the patient makes no water by his own effort, he should
be relieved four or five times, or even more—certainly not
less, as a rule, than three or four times  in the twenty-four
hours.
   You often find (and this  is a matter  of considerable im-
 portance) that although up to the time  of the attack, or of
 the necessity for the use of the catheter, the water has been
 perfectly clear, yet, after  you begin to use the catheter
 habitually, the patient  gets more or less cystitis,  and is
 feverish and unwell.   That stage has very  often  to be
 passed  by those persons  who  suddenly change from  a
 natural mode of micturition to an artificial one.  It requires
 some judgment to say when that change should be made;
 but as soon as you find it necessary to pass the catheter
 regularly, the patient will often show some  change  in his
 general condition;  and  you should be aware of this  and
 watch  the results.   Sir Benjamin  Brodie was the first to
 point out, in his valuable lectures  on the Urinary Organs, 
94     DISEASES OF THE URINARY ORGANS.
that sometimes  patients gradually succumb to a low or
feverish  condition after beginning to use the instrument.
The remedy, or rather the  preventive method, is this: Do
not empty  the  bladder on each  occasion  of using the
catheter  at  first.  If the patient has  been in the habit,
perhaps,  of retaining at least a pint of urine after he has
made water, it is a great change for him to have the bladder
quite  empty two or three times a day; and it is thus that
the organ becomes irritable, the  urine  charged with pus,
and then he loses his appetite, becomes feverish, and is
sometimes in danger of losing his life.  The rule under
such circumstances  is to proceed  cautiously.   Instead of
drawing off a pint, draw off half a pint; leave some behind,
and so make a  compromise between the condition of the
bladder and the general condition of the patient.  Draw
off half or only a third of a pint; you will thus relieve
him a little, and so  gradually, in the course of a month,
you may accomplish the entire emptying of the bladder,
and all will  go on smoothly and well.  Notwithstanding
all  your care, now and then you will find a case in which
during this  process  the tongue  grows  slowly  more red,
dry, and contracted; the powers of life gradually fail; the
senses become impaired, and the patient sinks.  You will
always find in such cases, by autopsy, old-standing pyelitis,
with dilatation  and injury  to the renal structure, and you
will know that in no circumstances could the patient have
long survived. 
RETENTION OF  URINE.
95
                  LECTURE V.

                 RETENTION OF URINE.

  Gentlemen:—Retention of urine is the principal subject
for to-day ; and if we at all realize what is the condition of
a patient who suffers from retention, with the acute  and
constant pain which it involves, we shall feel how import-
ant it is to relieve him, not  only as easily, but as early as
possible.   And there are very few cases in which you  will
meet with more gratitude if your treatment is skilful and
prompt.  For not merely are his physical sufferings extreme
—and I suppose every man who has been so situated as to
be unable to relieve a distended bladder, even for  a short
time, has had some glimpse, though only a faint one, of the
distress occasioned  by inability to pass water  for  several
hours, or even days—not  only, I say, is the pain intense,
but there is extreme anxiety of mind also.  He fears  that
the bladder may burst (a circumstance, however, of exceed-
ing rarity), and he always looks forward with gloomy pros-
pects to the consequence of not obtaining relief.
  Now while  retention  of urine is very common in the
hospital, it is not so in private practice.  The circumstances
of exposure, the more hazardous callings which men have
who form hospital patients, determine this difference; there-
fore, when met with among the higher classes,  it is always
a very grave  matter, and in all circumstances, wherever
encountered, will demand  all your care and skill. 
96     DISEASES OF THE URINARY ORGANS.
  Then, again, if you are successful, the relief which you
afford  is instantaneous.  It is  not like the questionable
result of a dose of medicine, which a sceptical patient may
persist in attributing solely to our great ally—the curative
power of nature.  There can be no  uncertainty as  to the
result of your treatment if, after twenty-four hours of agony,
relief follows your dexterous use of the catheter, and the
two  or three pints which the patient was unable to void
are withdrawn by your hand.  He tells  you that he is " in
heaven"—a common expression with such patients—and he
never will doubt for a moment that you were the author of
his "translation."
  Retention  comes before us in three typical forms, each
requiring a different  species of treatment.  There may be
some instances which cannot be absolutely so classed, and
some the characters of which belong equally to two forms;
still, for convenience, it is well  to adopt this classification.
First of all, you may have retention occurring in a young
and healthy man who has no stricture;  next, it may occur
in an older man who is the subject of confirmed organic
stricture; and, lastly, it may occur in a man who is neither
young nor hale, and who  has  no stricture, but  has an
enlarged prostate.  Of the last  I have nothing to say; we
have already discussed that subject, and  the mode of reliev-
ing retention in connection with enlarged  prostate.   But I
shall  ask  your attention to the  two other conditions—
namely, retention from inflammatory swelling, and reten-
tion arising from organic stricture.
  With regard to the first kind, you will probably learn a
history something like the following:—within a month or
six weeks the patient, who is generally a young man, has 
               RETENTION OF  URINE.             97
had gonorrhoea.   He has obtained considerable relief from
treatment, and has in consequence allowed himself some
relaxation of the regimen to which he has been lately sub-
mitting.  Thus, perhaps, he has indulged a little in the use
of alcoholic stimulants, has taken some unusual amount of
exercise, a  game  of cricket or the like,  and, after  being
over-heated, has been  sitting on a cold stone or damp grass;
or, lastly, he may have indulged in some  strong emotional
excitement.  Under  those  circumstances what  is  called
" inflammatory stricture" may be produced.  Now let me
say, repeating myself slightly, that that condition has no
right to the name of stricture.  First of all, the inflamma-
tion is probably at the neck of the bladder or in the pros-
tate.   It is difficult to ascertain that, except by inference,
confirmed, however, by a rectal examination ; for, happily,
we very rarely make post-mortems under  such circum-
stances, as  the patient does  not succumb  to the complaint.
But what almost to a certainty takes place is a degree of
inflammation and swelling of the prostate, not in the least
resembling stricture—that is, it is not a circumscribed nar-
rowing at a particular part of the passage, but a tumefac-
tion of the prostate gland, which  prevents the expulsive
apparatus of the  bladder acting and discharging its con-
tents.  That is usually the real condition in what is called
inflammatory or spasmodic retention.
   This condition of  the  prostate resembles that  which
affects the  tonsils, and which we  call inflammatory sore
throat.  Both complaints consist  in the enlargement of
glands which more or less surround narrow passages, and
so interferes with the functions of  those passages; both
occur rapidly, and may be produced by external cold.
       7 
  98     DISEASES OF  THE URINARY ORGANS.
    Now, what are the early signs of inflammatory  reten-
  tion ?  First, there is usually some cessation of the gonor-
  rhoeal discharge.   Just as in the case of orchitis, where
  the  urethral inflammation is supposed to subside and to
  attack one of the testes, the inflammation of  the prostate
  is similarly associated  with diminished discharge, and if
  you examine by the rectum, a tender  and swollen condi-
  tion of the  prostate will be discovered.   Then the stream
  of urine grows smaller and smaller, and in a very  short
  time the patient  loses the  power to relieve himself alto-
 gether.  He is feverish, very restless, and suffers severe
 pain about the  lower part of the abdomen  and in the
 perineum.  Those who are the subjects of stricture may
 have become in some measure accustomed  to the difficulty,
 but when an  active young  fellow is thus attacked for the
 first time, he is in a state of extreme distress.
   Now as  to  the treatment of such  a  case.  The patient
 desires ardently to be relieved immediately, and declares
 he cannot endure his sufferings.   You see him bent nearly
 double in order to relieve the pressure  of the abdominal
 muscles  of the bladder, and he is even breathing shortly
 and quickly to avoid their action  there.  The old treat-
 ment in such cases—the  classical treatment  of twenty
 years  ago—was  bleeding  from the  arm or  perineum,
 repeated hot baths, and large doses of opium, so as to
 enable the patient to bear the pain and dispense with the
 catheter.  The reason assigned was,  that in an inflamed
state  of the canal, you might do more  harm than good
with a catheter, and  that it  was therefore better to miti-
gate pain by the means described.  I  have  told you that I
dissent from that treatment altogether, although  it  is  still 
RETENTION OF  URINE.
99
employed to some extent.  For, first, you must look at
the after-consequences;  and if you allow a young man to
remain thirty-six or forty-eight  hours with an unrelieved
bladder, because you fear to use  an instrument, permanent
mischief may be done.   I have seen patients who for years
have been unable to empty the bladder  after  treatment of
this kind.   Extreme and  continued distension of that
organ sometimes destroys  or permanently diminishes its
contractile power, and produces  a condition which is pro-
perly termed  " atony of the bladder."  Therefore, if you
pass the catheter, even at the risk of doing a little mischief
to the urethra, I am disposed to think' you would be wise
in incurring that little risk  rather than expose the patient
to the other danger.  But then it ought to be done without
such risk.   For my own part, I always take a  moderate-
sized gum catheter—one not larger  than No. 6,  as a large
one gives in these circumstances unnecessary pain—which
has been tolerably well curved in the way I have before
 described, since it has  to  enter over a swollen prostate.
In this manner there is generally no difficulty in relieving
the patient, who is exceedingly grateful for what you have
 done; whereas if you put him  through that long process,
 and he relieves himself ultimately, he thanks  you for little,
 comparatively speaking, and he runs the risk to which I
 have referred.  But in the  event of the gum catheter not
 passing, you should try a silver catheter of the  same size.
 I believe one of the first persons to denounce the old plan
 of bleeding and hot bathing was Mr. Guthrie.  If you turn
 to the racy writings of  that experienced and practical sur-
 geon, you will find an anecdote in connection  with this
 subject. He relates the account of a visit which  he paid to 
100    DISEASES OF THE URINARY ORGANS.
a patient in the circumstances of retention I have described,
and the reason, in strong  and graphic language, why he
then gave up for ever the bath and bleeding practice, and
passed the catheter at once for such cases in future.
  So much for the inflammatory condition of the prostate,
producing obstruction to micturition.   I need not refer at
any length to spasmodic retention, which rarely happens.
At the same  time  it may be as well to say that  no doubt
where an inflamed condition of the urethra exists, spasm
of the muscles may coexist; but the precise share which
each  takes in contributing to the result will not  influence
the treatment.
  Now I come to  the  second  form of  retention—viz. that
depending upon  organic  stricture.  Here we generally
have to do with an older man, because it is rare to find a
young one suffering from confirmed organic stricture.  As
a rule, to  which they are exceptions, such a patient mostly
has stricture  ten or twelve  years before he  gets complete
retention. # First  of all  you have to  ascertain that  it is
stricture.   You will probably  find  that he  suffers less
acutely than  in the previous instance, but  still a great deal;
the progress of the  case has  been more  gradual, and the
derangement  has  not  necessarily been brought on by any
great or sudden imprudence.  He has  been passing water
with  difficulty for weeks or months, and at length some
slight thing has produced a condition of absolute retention;
the last ounce has broken the camel's back.  Or it may
not be absolute retention as before;  there may be some
dribbling, indeed the patient may have been relieving him-
self in that  inefficient way  for  days,  but  the bladder is
greatly distended, and to all  intents  and purposes it  is a 
RETENTION OF  URINE.
101
case of urgent retention.   You find probably also that the
patient  is  accustomed to instruments.   Now,  what you
have to do is to take an instrument of middle size, and
pass it down to the seat of obstruction, to see where it  is.
You will probably find it four or five inches from the ex-
ternal  meatus.  You  should then take  the  finest  gum
catheter and endeavor to insinuate it into the bladder, and
if you are sufficiently fortunate to do that, you should tie
it in at once, so that you may have no further trouble with
it.  But that is not a very difficult case of retention.  Sup-
posing you do not get the gum catheter in, I should then
recommend a  small  silver  one, either No.  1,  or  even
smaller, and use it in the manner I described to you in the
lecture  before  last.   Notwithstanding all  your care and
skill, and those, perhaps, of your friends whom you may
have called in, the instrument is still not  passed.  There
may have been false passages (they are easy to make), and
there may be such difficulty that it is almost  impossible
for any one to pass a catheter after your failure.  We then
come to the question: what  is to  be done next?   Well
then, first, much may be effected for these cases by opium
and hot baths.  Suppose the water is dribbling off, and
you shrink from the dernier ressort—that is, puncturing the
bladder, or other operation to relieve the retention of the
urine—a  safe middle  course  may still exist for some  of
these cases.  The patient  up to this time  may have been
exposed to cold;  let him have the benefit of a warm bed
and hot baths, with  large doses of  opium—and you  must
be very liberal with opium if  you use it at  all—so  as
materially to mitigate the involuntary straining, which  he
can no more help than he can help breathing, and which 
102    DISEASES OF  THE URINARY ORGANS.
is  utterly unsuccessful as regards the  contents  of the
bladder, often making  matters rather worse than  better.
The result may be that the water will dribble off more
freely than before, and you may find,  after two or three
days, that it will come in  a larger stream, and that then
you can pass the instrument without much difficulty.  The
patient may often be saved an operation thus, if there are
grounds for declining to  perform it.  On the whole, how-
ever, I do not advise waiting very long; still it is better
that the patient should be temporized with in that way
than that he should be damaged by an unsafe hand, either
with knife or catheter.  Most  men, indeed, are quite suffi-
ciently confident in  their powers to rely on instrumental
methods when they find that a patient  cannot make water.
Still, if you are convinced that you are not doing any good
with the catheter—still more that you are doing mischief,
you can in most of these cases have recourse to opium or
to an inhalation of chloroform, with hot baths  and fomen-
tations, with success, as regards the immediate and urgent
condition.
   But we will assume  that you have done all that you can
do in this way, and that  the question of relief by some
other means must be  met. The bladder is increasing in
size, notwithstanding  your treatment.  You examine the
supra-pubic region carefully, and find  a tense and perhaps
 large tumor there, reaching to the umbilicus, or nearly so,
 more like a uterus  than  a bladder.  In some  old cases of
 stricture there is not necessarily large supra-pubic dulness,
 for the bladder is thickened and contracted.  Introducing
 the finger into the rectum, you find there also  a swelling,
 produced by the distended bladder, and you then seek to 
RETENTION OF  URINE.
103
obtain the sensation of fluctuation.  If, placing my hand
above  the pubes, I feel a distinct wave communicated to
my other index finger  in the bowel, I know that to be a
point at which  the trocar  can be inserted  with safety.
Also, if I  find a well-marked rotfnded tumor over  the
pubes  which is dull on percussion, the bowel around it
clear and distinct, I have reason to  believe that an opera-
tion over the pubes would be successful.  Again, the ques-
tion arises: Why not attempt to relieve the bladder by an
operation on the urethra itself from  the perineum, so as, if
possible, to cure the stricture, and at the same time relieve
the bladder ?   Might it not  be  wise in this manner, as it
were, to kill two birds with  one stone, and not be content
with merely puncturing the bladder by the rectum or above
the pubes ?
  At this  point let  me revert to the different  practice and
different experience of surgeons in relation to this matter.
Let  me give you the experience of Mr. Liston.  He once
said, from this chair, that during the whole of his connec-
tion with  the Royal Infirmary of Edinburgh, and subse-
quently with this hospital  up  to the time at which  he
spake—namely, three or four years before his death—he
had never punctured a bladder for retention of urine.   On
the other  hand,  there  are men living in this town who
have punctured a bladder fifty times or more.   Mr. Liston
meant  to imply that a good  surgeon ought rarely to find
it necessary to resort to any  other means than the catheter
in circumstances of retention.  But  do not supppse for a
moment that the gentleman I spoke  of who has punctured
a bladder fifty times, does so because  he fails to pass  the
catheter under those circumstances, but because he thinks 
104    DISEASES OF THE URINARY ORGANS.
it wiser to puncture the bladder than to persevere too much
with the catheter.  Then, again, both Liston and Guthrie
occasionally performed the perineal operation just spoken
of.  From the perineum the urethra may be reached behind
the stricture. Now, without entering into a long discussion
on the subject, I may say that this mode has lost favor of
late years.   It is no easy thing to find the urethra behind
the stricture; and a man may make an awkward wound in
the perineum, and never hit  the  urethra at all.  Then  it
does not follow that  it should be desirable  to  divide the
obstruction at all, so far as its cure is concerned; for the
stricture, when the time comes to  treat it, may be amenable
to dilatation.   The reason why  puncturing through the
rectum has been done so often by Mr. Cock,  of Guy's Hos-
pital, is because he conceived  it to be an excellent kind of
treatment.  He  says:  "Let us withdraw the urine from
the urethra altogether for a few days, and the urethra will
recover itself, so that we may be able to cure the stricture
with  ease."  And that is  often  true.  He  punctures the
bladder by the rectum  under the circumstances I have
mentioned; and  this  is his instrument for doing it.  In
this way, the water not passing by the urethra  at all, the
urethra is lying fallow, so to speak; and in a short time the
instrument can  be passed—say No. 2, or 3, or  4 catheter,
although before you could not pass No. 1.   This, then, is
a  species of treatment of stricture which  Mr. Cock has
introduced; and, at all events, he has proved  how easily
and safely  this  operation may be performed:  he has,  in
fact, familiarized us with a proceeding which  before was
often thought a very  grave and serious affair.
   If, then, you have  failed to pass the catheter, and the 
RETENTION OF  URINE.
105
symptoms are urgent,  you have two proceedings before
you: puncturing  by the rectum, or above the  pubes (see
Fig. 14).  By carrying into the bowel your finger—a rea-
sonably long finger—you arrive at a point just behind the
prostate.  The other hand is placed above the pubes, that
the wave of fluid, by its pressure, may be distinctly felt by
the finger in the rectum.  You are then quite certain of
what you are going to  do.  Along this finger, kept firmly
in place, your trocar is slipped, and then boldly, but care-
fully, pushed into the bladder.  This is always an anxious
moment, because, if you have not hit the bladder, it is a
serious matter to  have  thrust this long instrument into the
centre of the body, and find no urine escaping.  The best
position for  the  patient is sitting on the edge of a bed,
resting his back on pillows behind, the legs apart, each on
a  chair; an assistant by him placing one hand on either
side above the pubes, so as to steady the bladder, and press
it down towards the rectum.  It is well  to remember, sub-
sequently, that if the canula slips out, you will not be able
to get it into the  same opening again.  The muscular fibre
of the bladder instantly closes,  and you have to make
another puncture—not a matter of much consequence, but
better avoided.
   For the supra-pubic operation you divide the structures
in the middle line  until you reach the linea alba.   Then
carefully making your way deeper, you will soon discover
fluctuation;  and, having the bladder steadied as before,
you will thrust  the trocar  slightly downwards.  In this
case you retain the silver canula for two or three days;
but you may  soon substitute a gum instrument.  Now,
supposing there is a probability that your patient may re- 
106    DISEASES OF THE  URINARY  ORGANS.

quire this artificial relief by tube for some time, you will,
of course, prefer the situation above the pubes, because it
      Fig. 14.—A section of the pelvis showing bladder and rectum.

is much more easy to wear the  tube there than it is in the
rectum, where it interferes with the functions of the bowel,
and is otherwise much in the way.  I have known patients
who have passed all the  urine through a tube above the
pubes from ten to fifteen  years, and who lead  active and
comfortable lives in  consequence, the natural passage be-
ing completely obstructed. One of them, who had suffered
greatly before, and was now in perfect comfort, told  me
that " he did not know whether this mode of passing water
was not preferable to the original one!"  That,  however, I
conceive, is quite a matter of taste.
  Our next subject will be Extravasation and Fistulae. 
EXTRAVASATION OF  URINE.         107
                  LECTURE  VI.

    EXTRAVASATION OF URINE AND URINARY FISTULA.

  Before  commencing the subject of urinary fistulae,  I
shall  briefly allude to a condition  closely related to reten-
tion, just considered, viz: extravasation of urine.   And it
is related in this way:  Suppose that from bad treatment,
neglect, or  otherwise,  the patient has had  no relief, and
when you  are called in  you find there is  no question of
puncturing  the  bladder,  for the  urethra  has punctured
itself, so to speak; that is, Nature  (as in the case of all
maladies) has done something; often she acts in a clumsy
way, but sometimes not more  clumsily than the surgeon.
There is no question that many who  are the subjects of
stricture or retention, and receive no  surgical aid at  all,
will  lose their lives in consequence;  but they are some-
times saved by extravasation of urine taking place.  What
then happens is, that behind the stricture a portion of  the
urethra gives way, perhaps during some  violent act of
straining, and through the rent so made, a quantity of urine
is driven  with  great force into the cellular  interspaces.
Well, we know where  that  must go, from the anatomical
disposition of the fascia, viz : into the scrotum, up into  the
groin above Poupart's  ligament,  and  towards the belly.
Occurring,  as it usually does, in the bulbous part of  the
urethra, where the walls of the canal  are weak, the urine 
108    DISEASES OF THE  URINARY ORGAN'S.
cannot pass backwards behind the scrotum, or the back
part of the perineum; neither  can it get into the thighs,
because it is checked by Poupart's ligament.  I have seen
it  rise as high as the chest, and I  have made incisions  to
evacuate it, in a bad case of extravasation, as high as this
point.  Once taken place, it follows that at every action of
the bladder more fluid is driven in with force, so that the
cellular interspaces  are  separated, and the  fluid usually
finds its way upwards.  Generally, you ought to know at
once, by the appearance of  the  patient,  what has taken
place, although  it is possible sometimes  to  confound the
condition I speak of with  ordinary inflammatory oedema
of the scrotum, for  it may commence very gradually and
insidiously.  In  ordinary cases, you see a hard perineum,
a  large red tense scrotum, the penis  swollen, and a red
blush perhaps rising over the pubes.  In order to ascertain
the true  state of things, you  must ask for the antecedents,
and you will probably learn that there was great difficulty
in passing urine, followed by rather sudden relief.  When
a man has had retention for some days, and  extravasation
suddenly takes  place,  instant relief is  experienced—the
frightful want to make water disappears as soon as the
fluid finds its way into the  scrotum; but he soon feels new
pains, not necessarily very severe, and, what is worse, con-
stitutional symptoms rapidly set in.  The poisonons fluid
quickly destroys the cellular tissue, so that sloughing soon
begins.  After  forty-eight hours or so,  gangrenous  dis-
colorations appear, and the urine .may find its way into the
corpus cavernosum, when a dark spot appears on the glans,
showing that the structure of the penis itself is infiltrated.
Without describing further this condition, which you must 
EXTRAVASATION OF  URINE.         109
   have seen for yourselves, and which may be seen now to
   some extent in a patient in the ward up stairs, let me say,
   do not in such a case be afraid of the knife.  You have no
   occasion for a catheter; the urine has found its way into
   the cellular tissue,  and you must let it out as freely as
   possible.   On each  side of the perineum make a deep in-
   cision.   You  need not  limit the incision to two or even
   three inches; because you are really  cutting into urine,
   not into flesh.  The structure  is so enormously distended,
   that there  is but little flesh to divide; and although the
•   incision may appear very deep and  long, when  the water
   has run out, it will be comparatively small.  The incisions
   generally bleed  rather freely.   One  may soon lose  a pint
   of blood from three to four incisions.  The urine runs out
   also, and as the distension goes off, the vessels are enabled
   to contract better; but if you see any little vessel spouting,
   tie it at once.  An incision  should be made on each side
   of the penis,  because if it is made in  the middle line, there
   is not sufficient communication for the incisions on the one
   side to relieve the other.  Do  not be extravagant in these
   incisions;  still it is better to err on  the side of freedom
   than to be  too niggardly in the use of the knife.   The next
   day, if the case has  done well, you will find the scrotum
   much reduced in size, and the parts altogether much less
   swollen and inflamed.  You have now a direct  communi-
   cation  through  the cellular tissue from  the bladder, and,
   with that rent behind the stricture, as a rule, you  will be
   safer in letting the catheter alone, and permitting the water
   to drain off.  What happens ?  Why, just  what happens
   after puncturing the bladder.  When the water flows off
   by another passage, "the urethra begins to improve,  and  in 
110    DISEASES OF THE URINARY ORGANS.
three or four days you will probably have no difficulty in
passing No. 3 or 4 catheter.  With these  patients, bad as
they are, prostrated as they are when you see them, if the
case has not gone too far, and  too much gangrene has not
taken place, very striking and rapid recoveries often follow.
The whole scrotum  may slough away, and  the testicles
may be seen uncovered in the wound, and yet  all may heal
up soundly and well.
  This leads us to the next subject.  After the exit of the
urine by these artificial channels, some of them fail to heal
and  remain patent, and thus form what we term urinary  ,
fistulas. Now this day week there were in my ward three
cases illustrating  this condition, and rather exceptionally
obstinate ones.  One was caused by extravasation of urine,
and the other two by the more usual and common cause—
stricture of the urethra.
  We  have spoken  of extravasation;  how does stricture
give rise to a fistula?  Thus: in some patients, when  a
stricture has existed  some time, and has had no treatment,
or bad treatment, it is not uncommon for  chronic  abscess
to form, say in the perineum, between the urethra and the
surface.  In time this opens  externally, and a few days
afterwards a little urine finds its way through it,  and passes
at each time of making water.   If no relief is afforded to
the  patient, another  forms; and  so  several  sinuses may
arise, and other openings in various and surrounding parts,
all giving exit to the urine.  These fistulas may take place
in a  great number of situations, such  as in  the penis, in the
scrotum, in the perineum, in the groin, and in the rectum;
but the last are very rare.  We will consider  the first four
by themselves, because fistulas  which bpen into the rectum 
            EXTRAVASATION OF URINE.          Ill
require a different treatment altogether.   Then, respecting
their specific characters, I shall  make three classes, exam-
ples of which may be found in any of the localities named.
First, fistulas may consist of simple openings  or channels
between the urethra and the external surface; or, secondly,
they  may  be surrounded  with inflammatory  induration,
which makes them more difficult to heal; and,  lastly, they
may be complicated with loss  of substance from sloughing,
so that even a portion of the -urethra itself may have been
destroyed; and  these are  the most difficult cases to deal
with.  Hence these fistulas classify themselves naturally as
simple, indurated, and fistulas  with loss of substance.
   I will deal briefly with the " simple urinary fistula."
Whatever  part of the canal it is connected with, it almost
always heals if  the stricture with which it  is associated is
dilated.  Dilate the stricture, and in nine cases out of ten
the fistula will heal.   Patients, especially in private prac-
tice, are  often extremely anxious  about the result  of an
opening in the perineum or elsewhere through which the
urine passes;  and it  is right  that  you should assure them
for the most part, if the stricture is thoroughly dilated, the
unnatural  passage will  heal of itself. But there is another
point to be considered in connection with this—viz. the
quantity of urine passed by the fistula, compared with the
quantity passed  by the natural passage.   Of course the
gravity of the thing depends very much on the relative
proportions passed by the two ways.  Usually about three-
fourths of the water will pass by the right way,  and one-
fourth or one-fifth by the wrong passage.  If a large quan-
tity—say three-fourths—passes by the unnatural  opening,
then probably a considerable  amount of stricture is present. 
112    DISEASES  OF THE  URINARY  ORGANS.
Nevertheless, as the stricture is dilated,  you will see that
the proportion  passing through the fistula will  gradually
decrease  until it ceases altogether, and  the part soundly
heals;  but this latter result is achieved only on the condi-
tion that you maintain the stricture in a dilated  condition.
  Now we come to fistulas which are associated with much
inflammation and induration in the perineum.  These may
be multiple; in which case you may find five or six open-
ings.  I have known a man with a dozen, so that  instead of
the urine being discharged by one stream, it flows as from
a watering-pot.  Even this condition, however, very much
improves as the stricture is dilated, and may get quite well;
but this is not always the case.  Then there are some in-
stances looking much less formidable, like those upstairs,
with perhaps only two or three openings, through which the
greater part of the water has passed for a long while.  You
recollect  that we fully dilated the stricture in each case;
but  still no improvement as regards the flow of urine
through  the  fistulas took place.  A No. 12  catheter was
passed ; but the patients did not get well.  The condition
of the  perineum improved very much; but still more than
one-half the urine obstinately held its erratic course through
the perineal openings.   Now, what is commonly done in
such circumstances?   Usually  operative proceedings of
some kind are resorted to;  or, if these have been postponed
or rejected, a  rather tedious process has been employed.
The principle laid down—and I have myself applied it suc-
cessfully—is, that it is necessary to  take care that  the ex-
ternal  openings should be very free, insuring this either
by means of the knife, or by potassa fusa, or by some other
means; so that the urine may not be detained in  its way 
EXTRAVASATION  OF  URINE.         113
from the urethra to the external surface, causing fresh indu-
ration or thickening.  Next, you may go on to excite adhe-
sive inflammation in the track of the fistula by a hot wire,
or by touching it with cantharides or a strong solution of
nitrate of silver.   No doubt this treatment sometimes suc-
ceeds ; but it is at best a tedious process.   Then  it was
sometimes attempted to cure such fistulas by tying in a gum
catheter for weeks, or even for months.  But this generally
fails; and for this reason: that urine always finds its way
from  the bladder by the side of the catheter, along  the
urethra, and  so into the fistulas by the force of capillary
attraction; and thus the object supposed to  be attainable
never was and never could be so accomplished. The prac-
tical surgeon soon discovers that tying in an instrument
never insures the transit of the urine through  it; some will
always  pass by the side and defeat your purpose.   I have,
therefore adopted  the plan of teaching the patient to pass
the catheter himself; and that is by far the most rapid and
the most certain method.  With regard to  the two cases
upstairs, ten  or fifteen years ago I  should  have applied
potassa fusa or the galvanic cautery,  or something  of that
kind; but the fistulas have  soundly healed through insur-
ing, by means of the catheter, not, as by the other process,
that the urine  should percolate rapidly through the peri-
neum, but that it should not pass through at all—in fact,
turning the current another way.   You first teach the man
to pass  a No.  7 or 8  gum catheter himself—an easy matter
enough.  He then agrees to pass  it every time he requires
micturition, night and day.  On no occasion is he to permit
the urine to  flow spontaneously—say during  five or six
weeks—not even when he goes to  stool; and this is avoided
      8 
114    DISEASES OF THE URINARY ORGANS.
by always  using  the catheter immediately before.   That
plan has been followed in each one of the three cases in
question, without difficulty, and with perfect success; for
each man has a sound perineum, and has now relinquished
the use of the instrument.
  Now I come to the third form of fistula, that in which
there is loss of substance.   This class must be  dismissed
rather briefly, because its full consideration would involve
a tedious  detail  of many different surgical  procedures.
Where you have this loss of substance, a plastic operation
of some kind is generally required, to fill up the gap which
exists.  When  the  opening is  small, you may contract it
very materially by the heated wire or galvanic cautery, or
by any mode which  tends to produce a contradiction of the
tissues.  You know that cicatrices which result from burns
contract considerably, and you avail yourself of that action
in this instance.  Most commonly,  however, if the  soft
parts have been  largely destroyed, some plastic operation
is required for the cure.  Thus,  on passing a silver cathe-
ter, when a portion of the urethra has sloughed away, you
may see perhaps a quarter, or a third, or even half an inch
of  the catheter exposed  in the wound.  The  successful
treatment of such cases demands much care and  nice ma-
nagement.   They do not often come under our notice, and
less often do they get completely cured. I have had in the
hospital but three or four such cases, in which, by means  of
plastic operations, the patients  have been entirely cured.
Some of you saw  one  last winter—a  man who had just
between the angle of the penis and the scrotum an opening,
showing at least a third of an  inch  of the catheter, the
whole of the floor of the urethra having sloughed away. 
EXTRAVASATION  OF  URINE.
115
The operation in that case was one of the most successful
I ever saw.  The first  operation completed it, with the
exception of an opening  not larger than a pin-hole.  What
was done was to pare the edges all  round, then to get a
flap of skin from the scrotum below, which was brought
up to cover in completely the wound, the margins being
carefully attached by a number of little  sutures.   That
fistula healed  perfectly.  And why did  it heal ?  Here  is
the important point: there was one condition necessary,
without which it would have failed.  A week or two before
this operation, I made the patient learn to pass the catheter
habitually, so  as to  draw  off every drop of  urine;  and
finding  him thoroughly expert at  it, I performed the ope-
ration ;  and for a month he never allowed a single drop of
water to pass otherwise than by the catheter.  Had I tied the
catheter in, it would  not have been sufficient, because the
water, as I have told you, always finds its way by the side
sooner  or  later.  Luckily, he performed his  part  of the
compact to the letter for the stated term, so there was no
reason  why the wound  should not heal there as  well as
anywhere  else.   The little tiny opening which remained
was perfectly closed with the heated wire, and the urethra
can  now perform all its functions perfectly  well.  You
know there  is  another very  important  function con-
nected with this canal,  besides that of micturition.  I do
not know what  you may think  that function worth, but it
is one which may involve very important considerations in
cases where transmission of a great family name or title or
estates  depends on it.  Whether this be so or no, there is
no doubt that every man conceives that  to be an important
function for himself,  whatever others think of it for him; 
116    DISEASES OF THE  URINARY ORGANS.
and it could not in this case have  been performed unless
that opening had been closed.
  Now, in order to  go into the whole subject, I should
want  a lecture or two to tell you of the different kinds of
operations wThich are performed in different spots.  I have
taken the case described as a typical one.  It is one of the
most difficult to close.  The penis is liable to differences in   *
form: the patient may be troubled with  erections, which
may damage any operation, and there is very little flesh to
deal with.  In the perineum you have two or three inches
of depth,  so that you can cut flaps of any size and thick-
ness.
  A word or two about the rectum.  You remember that
I made an exception in reference to  fistula coming from the
urethra into the rectum.  There is a case upstairs in which
it occurred  from the patient himself thrusting a bougie
from  his  urethra into the  rectum.   More  commonly it
occurs from prostatic abscess.  In  these cases, at each act
of micturition, urine passes into the rectum—often a very
troublesome, even distressing circumstance.  The rectum
becomes excoriated, and  the  patient is obliged  very fre-
quently to go to stool.  I shall say very few words about
it, because each  case must be treated on its own merits.  I
will give you the result of my own  experience,  and that is
all I can do.  I  do not know that there are any published
records  respecting these   cases.  They are very few  in
number, but they are very important when they do occur
I cured one case by position. It was the case of a young
officer whom I saw in private practice (I have not met  with
a precisely similar one in the hospital, and therefore refer
to it), who passed three or four tablespoonfuls of urine into
\ 
EXTRAVASATION  OF  URINE.         117
the bowels  at each  act of micturition, after having had
some abscesses there which I did  not see.   It occurred to
me,  after some wholly  inadequate treatment by  other
means, to tell him to lie down on  his face, and make water
in that position, never allowing a drop of  urine to pass in
any other way.  In a few weeks he was quite cured—very
luckily for him, and for me  too.   If you ever meet with
such a case, the plan is worth trying. I have had two  other
such cases  since, but the plan has not succeeded.  In the
instance  to which I refer, it occurred to me that the  force
of gravity would carry all the proper way, and it did so.
None passed into the rectum, and at the end of six weeks
the patient was well.  I  saw him some years afterwards,
and  he was soundly cured.  I take it that I should now
have made that man pass the catheter into his bladder, and
draw off every drop of water; and  I have no doubt it would
have been successful.  Unless there is a loss of substance,
that  usually does cure the patient; but if there  is a loss
of substance, and worse still, if  the opening is from the
bladder into the rectum direct, then nothing is  left but to
examine the place  thoroughly in the first instance.   Put
the patient on his back, as for lithotomy, and introduce a
duck-bill vaginal speculum, as you have seen me  do,  so as
to get a good  light thrown  upon it.  If it is sufficiently
large to do a plastic operation, I should not hesitate to per-
form the same operation that is done for openings between
the bladder and  vagina—that is, to  pare the  edges, and
stitch them together with silver  sutures,—only it is  more
difficult, as there is less room in  the rectum for  manipu-
lating than in the vagina.  In the vagina there is plenty
of space for the work? but I  have done it  also in  the male 
 118    DISEASES OF  THE URINARY ORGANS.
in one case.  I found it possible to do, though difficult •
and I believe that is the best plan when these cases occur
with  loss of substance.  If the opening, however, is very
small, it may be  greatly diminished in size, if not closed,
by applications of the galvanic cautery. 
STONE  IN THE BLADDER.
119
                LECTURE  VII.

               STONE IN THE BLADDER.

  Gentlemen:—I wish to give you to-day  a  sketch  in
outline, embracing all the  principal points, if I can, of a
very large and important subject—viz., stone in the bladder
of the adult male.  I shall say little about stone in children,
and nothing, at the present  time, about stone in women.
  First of all, in what classes of cases is stone most com-
mon?   Contrary to what is stated in books on the subject,
it is most common in individuals from fifty to seventy.  In
books you will find it stated to be most common in chil-
dren.  Perhaps it is  so if you take the number of cases in
children as compared with  the number of cases in elderly
adults, although this is by no means certain, but not  if you
take the individuals of either class relatively to the num-
bers of that class living at  the time.
  I think it may be  said that the most favorite period for
calculus is from about fifty-five to seventy-five;  the next
in order is that below puberty, and the most rare  period
is that of middle age.  Looking at the cases numerically,
you may put it down as a general rule that half the total
number of hospital cases occur below thirteen years  of age.
I cannot refer you to any more exact researches than those
which  were made with great labor some years ago  by
myself.  Out of 1827 such cases, each one of which was 
120    DISEASES OF THE  URINARY  ORGANS.
reported to me in writing, and of which I  knew all  the
principal particulars, one-half occurred before the age of
thirteen.  You will remember that this is in hospital prac-
tice, which gives a somewhat  different  set of cases from
those seen in private.
  Now, with regard to the varieties of stone, I do not give
you here all the chemical  distinctions; that  is not neces-
sary ;  but I  will mention  three chief classes which it is
important to consider in relation to the  practical manage-
ment  and the removal of stone.   That which is most  fre-
quently met with is  uric  acid and  its combinations;  the
second  is that in which phosphoric acid is combined with
volatile alkali and the alkaline earths; and, lastly, there
is oxalate  of lime.  For all  practical purposes those  are
the three great divisions.  Among these, uric acid and the
urates form  about three-fifths in  number, the rest  being
phosphates, with the exception of about three or four per
cent, of oxalate of lime calculus.
   Next, what is the ordinary history of stone? We know
well, of course, that the appearance of a stone of some size
in the bladder is not the  first stage of the malady.  The
stone begins always—I am now speaking of uric acid—as
fine sand or gravel, to use popular terms: that is to say,
there is an excess of urates, which, perhaps, steadily per-
sist; then, possibly, of uric acid, in characteristic cayenne-
pepper-like masses of crystals; then there are small rounded
bodies of this  latter aggregated within the kidney, about
the size of a shot, or somewhat larger, of which you have
very  good  specimens here.   An  acid  calculus,  then, is
always formed  within the kidney; and it  is a  fortunate
thing if it descends into the  bladder, because sometimes it 
STONE  IN THE BLADDER.
121
is retained in the kidney, and, as renal calculus, becomes
the source of great misery, for which surgery can do little,
although medicine may be of some  small  service.  But if
it comes down into the bladder,  it is usually passed—say
in nine cases out of ten—without any operation whatever.
The patient has an attack of severe pain in the back, over
the hip, in the groin and testicle, lasting for some hours,
and it probably ends in  the descent of the  calculus  from
the kidney to the bladder.  When it gets there, after a day
or two, or before, it is generally expelled by the urine,
and there is an end of the matter;  only the patient  must
be  told, or  ought to know, that this occurrence shows a
strong proclivity towards the formation of stone,  and he
should immediately do all he can to prevent its continuing,
as in the nature of things it will do.  But if the bladder
is unable to expel the calculus, it soon increases in  size by
deposit on its surface  of acid from the urine, and a very
hard but  rather brittle stone  is formed in  the course of
time.  All the stones which you see in this box have been
passed through the urethra by the natural efforts; and it
is worth knowing how large a stone may  be so passed in
some cases.   Usually, when they get as large  as some of
these, they fail to pass, and then some operation must be
performed for their removal.
  The phosphatic calculus is not necessarily formed in the
kidney; it is so sometimes, but usually it  is formed in the
bladder.   In the mucus of a diseased bladder a good deal
of phosphate of  lime  is formed, and  this,  meeting  with
ammonia  from the decomposed  urine, produces the am-
moniaco-magnesian phosphate.  This, with the phosphate
of lime, makes "fusible calculus," the commonest form met 
122     DISEASES  OF  THE  URINARY ORGANS.
with.  Its structure is not dense, and  it is easily crushed.
The oxalate of lime, or mulberry calculus, I need not tell
you,  is not originally formed in  the  bladder, but in the
kidney, and it is the hardest in structure and the roughest
in external surface  of all.
   Now, what are the symptoms of stone?   These we will
seek, if you please, by means of the four questions always
to be used.   A  patient tells  you,  perhaps, that  he has
passed some  gravel for a year or two, and may show you
some small stones  which he has passed.  For the last few
months, perhaps, he has not seen any; but, during that
. period, has had increasing difficulty in passing his water, a
circumstance  which will strongly excite  your suspicion.
First, as to frequency of micturition.  The patient has for
some time had more or less frequency, but it is  increased
during the day when moving about, and decreased at  night
when he is at rest.   This is contrary to what usually  takes
place in prostatic enlargement, and hence it is a good  diag-
nostic point.
   You next  ask for pain.   The patient with calculus of
the bladder has  almost always pain, and this is referred to
a particular  spot, the lowrer part  of the glans penis,  about
an inch or less from the external meatus.  Remember, you
may  have that pain when there is no  stone in the bladder,
as in chronic  prostatitis  and in some affections of the blad-
der;  but in  stone  it is almost always  present.  Further,
with regard to pain, the question should be asked, whether
the  patient feels  it before, during, or  after making water.
He will tell  you that it is during  and  after; whereas you
know, in hypertrophied prostate, and  in all cases in which
water is  retained,  the pain is  before  passing water, and it 
STONE  IN THE BLADDER.
123
is relieved  by the act.  A man with stone feels  pain  after
making water, because the foreign body is then left in con-
tact with the lining of the bladder, and being driven to its
neck, severe  pain and  a  sense of desire to micturate are
felt,  perhaps for four  or five minutes, until fresh urine
entering, the coats of the bladder are separated from the
stone.
  Then you ask him the condition of the urine.  In nine
cases out of ten you find that there is muco-pus, and also
perhaps streaks of  blood.  There is almost always more
or less clouded or muco-purulent urine with calculus.
  Then, lastly, you  ask him with regard to blood.  Almost
invariably  at some time blood  has passed, and it  is ■ in-
creased by movement.   A  patient with  calculus suffers
more pain,  and has  more  bleeding, and the urine becomes
more thick, if he takes much  exercise.  He cannot ride on
horseback,  nor in a jolting  vehicle, without considerable
pain; in fact, all quick movements of the body intensify
the symptoms. Certainly a patient presenting such condi-
tions ought not to be allowed to go without sounding.
  Then,  how do you  sound?  You should  employ an
instrument like this, with a small short curved beak, be-
cause it can be turned in any direction.   If you take an
instrument with a  large curve,  like  a catheter,  you are
unable to rotate it in  the bladder, and hence it does not
explore sufficiently.
  When I entered this room, you heard  me ask for the
hospital  sounds, for I  knew  I should find among them a
good example of what a sound ought not to be.  Here is
one, for example, which no one could rotate, or ever find
a small stone behind an enlarged prostate with, except by 
124    DISEASES OF THE URINARY ORGANS.
sheer accident.  It has precisely the form of a common ca-
theter.  You will  say, naturally enough, " Why are such
sounds here, and who has used them?"  They were used
formerly, and found a good many stones, too, in the hands
of our illustrious predecessors.  But I will answer for  it,
they have missed  a  good many stones, also;  and this is
precisely what I want you not  to do.   I have no hesitation
whatever in saying that more stones are missed in sound-
ing than are found by the ordinary methods  adopted  in
this country; and that must be the case if a sound of the
form of the common  catheter  is relied on for the purpose.
But with an  instrument which has this small  beak at the
end of it, you can search in every direction (see Fig. 15).  If







                        Fig. 15.

there is a large stone, of course you  can find it with any-
thing; but our great  object is to find the small  stones. As
a rule, anybody can find a big stone; the  art consists  in
finding a small one.  It is most important to find a small
stone, because it will  grow large, and may be very formida-
ble to deal with; whereas when it is small, it is a far less
formidable matter.   You  may promise the patient, in the
case of a small stone, that it may be removed without risk-
ing his life; whereas in the case of a large stone, there is
always some risk, often considerable danger. 
STONE  IN THE  BLADDER.
125
a ,s
a "a
  In the next place, how are you to use this instrument ?
  First of all, it is not  to be introduced in the same way
as the ordinary catheter.   With the ordi-
nary catheter you stand at the left side of
the patient, and make a gentle sweep thus
into the bladder.   With  the sound  you
stand at  the  right side, and use a different
manipulation, which  I  shall show you on
the living patient, at my next  lecture, post-
poning, therefore,  my remarks on the sub-
ject until then.
  But you have something else to do  be-
sides  merely discovering the  presence of
stone.  It is necessary to  have other  par-
ticulars respecting it, because  the nature of
the operation to be performed will depend
on  them.  First of all, it is essential to
know what the size of the stone is  before
you decide  on what  you will do with it.
From the note elicited  by merely striking
it, you can get  some  indication of its size.
It is often sufficient for practical purposes
to use a sound (which I have long used
myself, and  have recently introduced) pro-
vided with a  little slide on the shaft, which,
by  proper manipulation, enables  you  to
ascertain very nearly the size of a stone,
as you have  frequently seen in the wards.
  Then  there is another way.  You may
introduce a  lithotrite (which  gives, how-
ever,  a little  more disturbance to the patient) and seize the
s a
<J <o 
126    DISEASES OF THE URINARY ORGANS.
stone in two or three directions, so as to ascertain its dia-
meters.
  At the same time you ascertain its nature.  A phospha-
tic  stone gives a  very different sound  from  the others.
The specimen before me is dry, and therefore will not give
the sound to which I refer.   When wet, it is  spongy and
soft, with  a rough surface, and  always gives a dull note
when struck;  whereas the uric-acid stone gives a hard
ring.  Then you will judge partly by the condition of the
urine.   If the urine is acid, and if, also, uric acid is thrown
down, you may conclude  that the  patient  has  a uric-acid
stone.   If so, it is  likely he has passed small calculi before.
If  the urine is very alkaline, and there is a great deal of
phosphatic matter, you may  conclude  that it  is  a phos-
phatic stone, or, at all events, it is covered with phosphates.
  The number of  stones is the next thing.   Usually there
is only  one stone,  but occasionally there are more.  There
is a patient here on whom I shall  perform lithotrity to-
morrow, who has  two rather large uric-acid stones in the
bladder. The way to determine that point  is this: Having
seized one in the  lithotrite, you move it  gently in every
direction as a sound for others. If then you encounter one
on  one side and  one  on  the other, you know that there
must be at least three stones.
  I have spoken  of  uric acid and of  phosphatic  calculi.
But it may happen that you have an oxalate-of-lime stone—
a very important thing to ascertain. You examine the urine,
and see if there is much oxalate of lime thrown down.  The
patient may have  passed  a small  mass of  oxalate of lime
before, and you may infer that an oxalate-of-lime calculus
exists now; but  then it may be covered up with phos- 
              STONE IN  THE  BLADDER.           127
phates, and so deceive  you.  I will  give you a case in
point.  I had to deal with a very large stone in the bladder
of a  private  patient.   I crushed the  stone four  times,
bringing away large quantities of phosphatic material.  I
always noticed that  my lithotrite never went through .the
stone; it always went a certain way, and  then there was a
hard  mass.  After four sittings I could not crush  any
more.  It  was clear that  there  was a very  hard central
stone, from which I had taken away a large crust of phos-
phates.   My strongest  lithotrite made no impression upon
the stone.   I  know, from  experience,  the recoil of the
lithotrite from an oxalate-of-lime stone so well, that I had
no hesitation in saying this was an example of that kind.
Accordingly I cut him, and a large  oxalate-of-lime stone
was  removed.  In a case like that, you would not have
oxalate of  lime in the urine, but phosphates.  In the case
of a uric-acid  stone, you may make an impression upon it
with the lithotrite—its teeth will  bite into it; but in the
case of a large oxalate-of-lime stone, it is like laying hold
of a  piece of iron—you make no impression whatever
upon it.
  Having  got  all these data, the next important question
is, what are you to do ?  Are you to cut or to crush ?  You
know there are only two  modes of removing the  stone.
You must  either make an opening sufficiently large to
admit of its withdrawal, or you must crush the stone into
very small fragments, so that they may be expelled by the
natural passage.  It was less important to make a diagnosis
of all these points, when  we  had but  one operation—
namely, that of cutting.  Formerly, whether the stone was
large or small, the patient was always cut.  There was no 
128     DISEASES  OF  THE  URINARY  ORGANS.
other way of removing it.  Now that we have two opera-
tions, it is very important that we should choose the right
one; because, let me  tell you, if  you do  not  determine
pretty accurately the  characters of the  stone, and select
the right operation, you may do more harm than if you
cut every patient.   If  you crush the very large  stone, and
cut for the very small one, you will have greater mortality
than if you simply resorted to the one operation  of cutting
in all cases.  When lithotrity was first introduced, it was
rather a clumsy operation ; and when the cases were not
judiciously selected, when surgeons crushed without mak-
ing a diagnosis of all these points—crushed stones  that
ought really to have been cut, and left for  cutting stones
which might  have been  crushed — the entire  mortality
resulting  from  operations for stone was greater than
previously, when every case was cut.  I cannot give  you
a stronger argument for the necessity of apportioning the
operation judiciously.
  Now, without taking up your time too much, I will lay
down what you will understand to be the  axioms which
should direct you, in a general way, in making your selec-
tion.   First  of all,  I will  say  that  all  stones, under
puberty, with very  few exceptions, are to be cut.  Under
fourteen or fifteen  years  of  age, stones  occurring in the
male are to be cut,  unless  they are very small, and can be
crushed, say, in one operation; because lithotrity is not a
very easy or successful operation in children, the urethra
being small and the bladder  very irritable; whereas, as is
well known,  lithotomy is  a very  successful operation in
these cases.   We do not want a better operation, compara-
tively speaking, and one may be content to let well alone. 
              STONE IN THE BLADDER.          129
Not more than one death in fifteen or sixteen cases occurs
from  lithotomy in children.  I do not think, therefore, we
can do  better than to cut in these cases, as  a rule.  If,
however, you  have in a child of, say three or four years
old or upwards, a stone no bigger than an orange-pip, you
may very probably succeed in crushing it, under chloro-
form, in one, or at most two sittings;  and this it is usually
advisable to do.
  That  leaves us all the cases above puberty.  Then I will
say, in general terms, that all the cases above  puberty are
to be crushed, with certain rare exceptions.  The first ex-
ception is in a case of an oxalate-of-lime calculus, which is
let us say, an inch in diameter.   Under an inch in diame-
ter you may crush an  oxalate-of-lime calculus.  I have
crushed four or five in my time.   The cases are very rare.
Two  of them were in this hospital.  An oxalate-of-lime
stone, from the size of a bean up to an inch in diameter,
can usually be crushed;  above that size no instrument can
deal with it,  and the fragments will be  so hard that  the
operation might be of doubtful value, even if we succeeded
in crushing.  That, then, is the first exception  to the gen-
eral law that all cases in adults are to be crushed.
  Secondly, a  large stone of uric acid, or a  phosphatic
stone of very large size,' had generally better be cut than
crushed.  Mechanically  speaking, it is possible to crush
any  stone, whether uric or phosphatic; but,  considering
the number of sittings required,  and the amount of irrita-
tion produced, the single operation of cutting will  be  the
better of the two when the stone is—shall I say—full two
inches in diameter.  A stone which is two inches in diame-
ter, either phosphatic or uric acid, had perhaps better  be
       9 
130    DISEASES  OF THE  URINARY  ORGANS.
cut.   No doubt  a rather  larger phosphatie stone may be
crushed.   Here is a very large  one, two ounces and a half
in weight.   The phosphatic stone is very friable, and you
may deal with rather larger  phosphatic  stones than uric-
acid stones  by lithotrity.   So much for the exceptions to
cutting, regarding the characters of the stone itself.
  Now what are the conditions on the  part of the organs
which will  make it necessary for  you to cut instead of
crush ?  If you have a bad stricture of the urethra you can-
not crush ; if you have a very highly diseased condition of
the bladder, probably you cannot crush;  but such excep-
tions  are  very few indeed.  First  of all, I will tell you
what  are  not  exceptions,  but which are  stated  to be so in
books, and are generally considered as exceptions; because
lithotrity has  advanced since the time of most books.  I
have recently crushed a uric-acid stone in a case of organic
stricture with small instruments made for the purpose; but
the stricture was not a very narrow one.   Hypertrophy of
the prostate was  said to be an exception:  it was said that
you could not crush under those circumstances.  I make
no difference whatever in respect of that  matter; I would
as soon crush in the case of hypertrophied prostate  as in
any other.   It is only a question of delicate manipulation.
If the hypertrophied prostate occurs in a  man who has had
instruments passed,  he will have  become habituated to
them, and is therefore a better  subject than a healthy one
who has not been so  accustomed.   Next, it was said that
when the bladder could not empty its contents  by its own
power, and the urine had  to be drawn off' by means of a
catheter, lithotrity  was contraindicated,  inasmuch as the
fragments could not be passed.  On the contrary, I rather 
              STOVE IN  THE BLADDER.          131
prefer such a case, for the reason just assigned—that is, the
bladder and the urethra are habituated to instruments; and
as to not removing the fragments, there is  no  difficulty at
all in removing the very last fragment, thanks to the im-
proved  methods  now employed.  It was  said  also  that
great irritability of the bladder was a reason why we could
not crush.   It was said that if the bladder  could not hold
above three or four or five ounces of urine, there would  be
no room for the lithotrite to work, and therefore the sur-
geon must cut.   I  make no objection on that ground,
because the irritation of the bladder is due to the presence
of stone; and as soon as you begin  to get  away the stone,
the irritation often diminishes.  Besides, it  is not necessary
to have four ounces of water in the bladder: one ounce is
ample.   There is no occasion to have four or five  ounces
 in order to perform  the operation of lithotrity.   It might
 have been so with  the  old clumsy instrument, but  with
 modern instruments  there  is no  necessity to protect the
 bladder from contact with them.   When instruments were
 used that were apt to catch the coats of the bladder, it was
 no doubt  desirable  to have a quantity  of water in the
 bladder;  but with modern instruments, which will  not lay
 hold of the coats of the bladder, there is no difficulty what-
 ever in crushing  with a  single ounce of water.  I do not
 care whether the bladder  is empty or contains a large
 quantity  of water, provided only that it  is not too full.
 Nothing is worse than too much water, because the stone
 rolls about, and  you must, figuratively speaking, play a
 game of hide-and-seek to catch  it.  It is better to have an
 empty  bladder than a bladder with half a pint of water in it.
   You see, then, that the exceptions are very few; indeed 
132    DISEASES  OF THE  URINARY  ORGANS.
there are very few adult  cases which cannot  be crushed,
provided you give proper care and attention.  If surgeons
of the present generation now growing  progress, as they
must, and become more intelligent and more careful than
those who have gone before—if they are  better acquainted
with the subject, as in the nature of things they must  be,
as our sons will be wiser than ourselves, and our  grandsons
wiser than they, there will be fewer and fewer exceptions;
because, if the stone is discovered when sufficiently small, it
can always be crushed  with an almost certain chance of
success; so that lithotomy for adults must at some day dis-
appear, except for cases which have been neglected by the
patients themselves, or have been overlooked by  the medi-
cal attendant.
  A rather large uric-acid stone is the growth of several
years; a large phosphatic stone  is perhaps  the growth of
two  or three years;,  an oxalate-of-lime  of full size, say
from seven to ten years; and it is very hard if, long before
the expiration of such  periods, the stone cannot be found
and disposed of by lithotrity.  It is certain that if there be
proper intelligence and proper supervision of the patient, a
stone would be always discovered, when it can be crushed
with almost a certainty of success; so that  the only cases
in which lithotomy will have to be performed will be those
in which the  patient has neglected himself, and, although
suffering from severe pain for years, has never gone to any
surgeon to tell him about  it.  But those cases must be very
few indeed.  I  hope you will live  to see  the  day when
lithotomy for adults will  disappear.  I do not suppose I
shall; but I do expect to  live to see one thing, and that is,
lithotomy becoming very much rarer than it now is.  You 
STONE  IN THE  BLADDER.
133
certainly will live to see it one of the rarest operations.  I
do not say that I look forward to that with any particular
pleasure; for  it is  a grand operation, demanding  all the
skill, self-command, and  force of a man.   It is one of the
best practical tests of a  good surgeon, and, looking at  it
from that point of  view,  one  cannot desire its discontinu-
ance ; but it will disappear, most assuredly ; and as it will
be  for the benefit  of humanity that  it should, we  must
acquiesce in the result.
  Next week I shall place two stone patients on this table,
and demonstrate the operation of lithotrity for you  here in
my lecture on that subject. 
134    DISEASES  OF THE  URINARY  ORGANS.
                 LECTURE VIII.

                      LITHOTRITY.

  Gentlemen :—I  shall  place  on our lecture-table two
patients with stone in the bladder,  one of sixty-two, the
other of sixty-five  years of age.  One man  has  a stone
about an inch in diameter; the other has  two stones, each
about three-quarters of an inch in diameter;  and in both
the composition is uric acid.
  Now, if a patient  has never had any instrument passed
into the bladder before, and if the urethra  is not capacious,
it is desirable to pass a bougie two  or three times before
commencing.  In the present cases the urethra is not very
sensitive; it is large in size, and there is no occasion to do
this.  Next, it is  desirable that the patient should not be
below his ordinary standard of health.  You will not begin
to operate when there is an attack of fever, nor unless the
digestion  is  in fair  order,  and  the bowels  are acting
tolerably well.  Take care that you  have  the local organs,
and the whole system, in as favorable a state  as  possible
at the outset.
  Having decided to  crush, there arises the  question of
instruments.  Now, I  shall simply show  you the kind of
instrument which I  have used,  and  also, to a certain ex-
tent, what has been  used in the  past.   I may  say that
lithotrity,  as  an  operation,  owes  its existence to  the 
LITHOTRITY.
135
French  surgeons, mainly to Civiale, but  not  forgetting
Leroy d'Etiolles and others.  My old friend Civiale, who
only last year died  at a  good old age, and full of honors,
was the first  surgeon to  crush  a stone  successfully; that
was in the  year 1822.  It had been  done occasionally by
patients themselves.  In one case a  man  had managed to
grind down with a small  file a  little stone in the bladder,
and  that has been called  lithotrity. But the first man
who systematically  performed the operation on  the  living
patient  was  Civiale, and he  operated  on  his  first two
patients before the Academy of Medicine, with this instru-
ment that I hold in my hand.   You  see how different it is
from anything we now employ. It is a straight instrument,
with a central axis and. three  claws, which were made to
project after its introduction into the bladder.  [The man-
ner of using  it is shown.]   You see what a very different
mode of proceeding that  is from the method now adopted.
Yet that was, to a  certain  extent,  a successful  operation.
I cannot now carry you through all the stages by which
the various improvements  originated, but  the next great
change was the curved instrument.   This was a great step
in advance, and the curved form, with slight modification,
is still the  prevailing form with all  operators.   But here
is an old pattern, worked  with a  simple thumb-screw in
the handle, which still holds its ground,  I regret to say, in
this  country.  It  has   long  been  exploded  elsewhere,
although still  used in London.  Nevertheless,  it  is the
instrument with which Sir B. Brodie earned his success,
and is used thus.   [Explanation.]   You see how  long a
time it takes, and how much movement  is  necessary with
it in the bladder.  You cannot  do any respectable amount 
136    DISEASES  OF THE  URINARY  ORGANS.
of crushing in less than five minutes in this way.  A great
improvement upon that  instrument was made by Civiale
and Charriere, of Paris.  The object was to avoid the loss
of time and the jar occasioned by screwing and unscrewing,
and in this new instrument the sliding movement is instan-
taneously changed into a screw movement, and vice versa,
by the turning of a disk  in the handle.   [Instrument and
method exhibited.]   Meantime  Sir William Fergusson de-
vised and adopted  the rack-and-pinion  method,  which is
an improvement on the old instruments before described.
Lastly, I show  you a lithotrite, due in part to  my own
design, and in part to Messrs. Weiss, which is now so widely
used that I must notice it also, especially as it is that which
  Fig. 17.—The handle of this lithotrite is shown ; as it is this which affords
              the power to operate with great facility.
you always see me use here.  In what respect does it differ
from others?  In  this,  that it  enables  you to operate in
less time, and with less movement or shock to the bladder,
than any other  instrument; and time, you  know,  is a
matter of importance.   It makes a good deal of difference
to a patient, whether you retain in  his bladder an instru-
ment for three minutes or for one  minute.   If  you  pass a
bougie into your own bladder at once and withdraw it, you
may experience very little  discomfort;  but leave it  there
for three or four minutes, and see how you  like it.  Every
half minute after  the  first the pain increases.   The mere
sojourn of the instrument in the bladder is  a source of
irritation precisely  corresponding  to  the time, within 
LITHOTRITY.
137
certain  limits,  it continues there.   Anything,  therefore,
that will diminish  the time of the  operation, and  the
amount of movement and concussion, will necessarily give
a greater prospect of success.
  Now for the proceeding itself.  There is  no operation
that I know which demands attention  to so  many minute
details, all of them being very important.  For its success-
ful performance, it is essential that the surgeon should not
only attend to the operation pure  and  simple,  but  to all
the details connected with the  case.  Lithotrity neglected
had better not be done at all. Either let it be done accord-
ing to  certain principles, and with great attention to detail,
or  let  lithotomy  be performed instead.  One naturally
recoils from many details; it is therefore essential to find
out what principles regulate them.  And, happily, these
are very simple.   What is the problem to be solved?  It
is the  removal of a stone without  injury to the bladder
either  in employing the instruments, or by  the action of
the fragments themselves.  That is  what we have to aim
at, and if accomplished success is certain.
   Now, I need not say that by any  cutting operation that
is impossible.  There is at the outset a severe injury to
the patient in the shape of a large and deep wound,  and it
is this which, in any form, is always a  risk.  Let us see
how far wre can hope to solve the  problem  by lithotrity.
All the chances of injury possible arise from these two
sources:  the stone itself, and the instruments used to ex-
tract it.
   First, the stone.   In its natural condition, as we know,
it occasions no dangerous injury to  the  bladder, although
it causes  much pain, and ultimately chronic  disease.  But 
138    DISEASES OF THE URINARY ORGANS.
when it  is broken up into large  angular fragments with
sharp edges, it  becomes  a source of injury, and  severe
cystitis  may be  thus  readily induced.  It is in accordance
with my principle that I advise that these should be pul-
verized one at a time; you do  not  attack them all at once,
and  break them  up  indiscriminately into  sharp  pieces.
Then you will take care that this de'bris is  not hurried
away when first made, and while it is sharp;  if it can  re-
main in the bladder two or three  days before it passes, it
will  become somewhat  water-worn,  and will pass more
easily; at the  same time the urethra will be less sore, and
in better condition for its transit.  It  is as well also some-
times to promote the flow of urine by giving diluents  and
diuretics.
   Secondly, the instrument used, and  the method of mani-
pulating it, may be productive of much injury, both to the
bladder and to the urethra.   It has therefore been  an ob-
ject with me to lessen, as much as possible, the number of
instruments employed, the amount of manipulation applied
to them, and  the time devoted to the process.  I have
shown you how, in conformity with this  principle, I have
endeavored  to produce an instrument which  should give
the least possible irritation.   And I will only add,  that if
we can get an  instrument which will do its work with less
disturbance still, it will  be, pro tanto, a valuable step in
advance.
   Now as to diminishing the number  of instruments used.
Formerly it was laid down as an  axiom that you  should
never use a lithotrite in a patient's bladder, unless  it con-
tained a  known quantity of urine or other fluid.  Hence
the urine was  always withdrawn  before introducing the 
LITHOTRITY.
139
lithotrite, and four or five ounces of water were injected.
I have shown that these preliminary injections are wholly
unnecessary, and I never use them—never even asking a
patient to hold his water beforehand, nor when he mictu-
rated last.  It is said, " If there  is only a small quantity
of water, how can you be sure that you will not injure the
coats of the bladder  in endeavoring to  seize the stone ?"
There is no difficulty in that  respect, because these instru-
ments are so constructed, that you could scarcely lay hold
of the bladder with them  if you tried to do so.  When
you had instruments in which the blades closed upon each
other accurately it was different.  But these blades never
do so; hence the safety of the instrument.
   Then there is  another species of mechanical irritation
which may be met with.  It was common—and it is now
with some surgeons—to withdraw large fragments of stone
from the bladder through the urethra.  The surgeon would
lay hold of them with the forceps, or with some other con-
trivance, and would  really seem to think he had accom-
plished something to be proud of if he drew from the blad-
der a calculus as large as a bean.  Now, in order to draw
out such a calculus,  you must first catch it.  Well, if you
have once caught it, why not give it one turn of the screw
and reduce it to powder ?   Why subject the neck of  the
bladder and the  urethra to  pain and injury by dragging
through a distance of six or seven inches, through a deli-
cate and sensitive canal, a sharp angular fragment of stone ?
So far from looking upon it as an achievement in surgery,
I look upon it as a thing especially to be avoided.  Never,
then on any pretence, withdraw an instrument containing
a fragment or debris too large  to pass easily through the 
140    DISEASES  OF THE  URINARY ORGANS.
urethra.   Our object is mainly to crush  the stone into small
broken material, which will then pass harmlessly and easily
enough.   Again, it was the custom, after crushing, to inject
repeatedly and forcibly several ounces of water  into the
bladder, the patient being placed upright, in order to remove
the fragments just made.  Now, this is an irritating  pro-
cess, more so often than the use of the lithotrite, and for the
reason just named I regard it as a useless and meddlesome
proceeding.  You see, then, that we get rid of the prelimi-
nary injections, the after injections, and also the withdraw-
ing of the fragments.  As  a rule, everything is to be done
with the lithotrite.  One good flat-bladed lithotrite will do
seven-eighths of all the work.   Other means, Clover's appa-
ratus for example, which is the best of all, may be employed
in exceptional  cases.
   Having enumerated what I  believe to be the simple prin-
ciples  of lithotrity, I will further illustrate the practice.
Usually,  when  you have  a large  stone to deal  with, it is
necessary to begin with the fenestrated  instrument—that is,
one in which the female blade is entirely perforated, allow-
ing the male to pass through  it.  This  is always a more or
Fig. 18.—The fenestrated lithotrite.
less dangerous instrument; hence it is used as little as pos-
sible. (Fig. 18.)  I never use it unless the stone is actually 
LITHOTRITY.
141
so large that it cannot be crushed by the flat-bladed instru-
ment.  The edges of the instrument exactly meet, and are
sharp, and the fragments made by it are always rough and
irritating.  Always, when it is possible, I use the lithotrite
with flat blades—blades which reduce the stone to powder
(Figs. 19 and 20).   The blades do not meet each other, and
cannot catch or  hurt the bladder, and the movement alto-
Figs. 19 and 20.—Lithotrites with flat blades.
  gether is easier than that of the other instrument.  [A pa-
  tient is brought in.]
    I have told you that there is a difference in the mode of
  introducing the lithotrite  and the catheter.  You know
  that in passing a catheter, we, in this country, stand on the
  left side of the patient; in France, the surgeon  stands on
* the right side.  In passing  the catheter  for a recumbent
  patient, you hold it somewhat horizontally, draw the penis
  gently over it, and give a  gentle sweep, in  this way, into
  the bladder.  In passing the lithotrite a different movement 
142    DISEASES OF THE  URINARY ORGANS.
is required.   You may stand  on either side, but it is better
to be on the right side, because that is the convenient side
for operating, and it is awkward to go round the patient to
operate after passing  the lithotrite.   Well, then, standing
at his right side, and partially turning your back to his face,
you let the lithotrite slowly and easily find  its way until
the shaft reaches nearly the vertical direction.  Arrived
at this point, you retain it in that position for a few seconds,
allowing it to go  on, still  so  placed, by its own weight, in
order that it may slip under the pubic arch.  This done,
you gently depress the handle, and it slides readily into the
bladder.  There is no more easy instrument  to pass than
the lithotrite with proper management.  I have now intro-
duced the lithotrite, and have to find the stone and seize it.
In order to do this I simply open the blades and close;  the
stone is  between them.  I  touch the little  button here,
which changes the sliding movement into a screwing one,
turn the handle and crush.  I then disengage the button,
again open  and close, and now  I have a  large  fragment
between  them, and, repeating the action, again crush.   A
good quantity of ddbris results; less than a minute  has
been  occupied, and I withdraw the  lithotrite  slowly  and
gently, and here is some of the debris,  which you see is uric
acid, between the blades.   There is no trace of blood,  and
the patient has made no complaint of pain.  If you ask him
he will, I dare say, tell you it was not agreeable; but it is
nothing to take chloroform for—nothing like extracting a
tooth,  for  example.  Now we will have  another patient  ,
[who is placed on the table, the other walking away] ; he
has had two  sittings before, and knows all about it.   I in-
troduce the instrument in the same way as  before.  I open 
                    LITHOTRITY.                  143
and close the blades, and find nothing.  Turning them to
the right I feel nothing.  Turning to the left, I feel nothing.
I then depress the shaft, and turn the instrument over, so
that the blades are reversed and point downwards;  I open
and close, and seize a small fragment deep behind the pros-
tate.  Having crushed that piece, I  open and close in the
same  position, and find  one  a little larger, and  having
crushed  it  I  withdraw the  instrument.  This  is  always
rather more painful for the patient than when the stone is
found in the usual situation, and it occupies more time, per-
haps two minutes instead of one.  It is not usual to have a
case of so much difficulty, if you call it difficulty, as that.
   Now let me give you a hint about crushing,  which is a
very  useful  one.  Whenever you have found a  stone, or a
good-sized fragment, and have crushed  it, keep the litho-
trite exactly in that place, and although you may have had
some  trouble in finding it, you will now continue to find it
several times running.  It reminds me of fishing for perch ;
when you have caught one, you may catch, perhaps, twenty
or thirty more out of the same hole, if you will but  stop
there, and not go fishing  about among the shallows.   It is
the same in  lithotrity.  You will go on seizing  and crush-
ing if you contrive to keep the lithotrite precisely in the
same  place.   In fact, there is what may  be called a certain
favorite " area" in  every bladder in which to  operate—a
certain spot which is a favorite haunt, so to speak, for frag-
ments of stone.  If you find that out in  each bladder you
will always  be able to crush; if you do not, you may  often
have  some difficulty in discovering your stone.   The  area
will,  of course,  vary somewhat with the position of the
patient.  If the patient was standing, for instance, the area 
 144    DISEASES OF  THE URINARY ORGANS.
 would not be the same as in a lying posture.  It is best to
 raise the pelvis two or three inches; then you get an area
 for operating which is  not too close  to the neck of the
 bladder.  The neck of the bladder is a very sensitive part,
 and you should always avoid it, because in pulling out the
 male blade you may impinge against the neck of the blad-
 der if you are not careful.  One of your maxims in litho-
 trity  should be never to pull out forcibly the male blade.
 You should pull it out carefully and delicately, so  as to
feel the neck, and  it  is a bad  lithotrite, remember, if the
 male blade does not slide with perfect ease.   This diagram
 will show  you what I mean by the area for operating.  If
 the patient is lying without a cushion, it will be nearer the
 neck of the bladder than if the pelvis is well raised.   In
 the last case  you saw just now, the man had an enlarged
 prostate, and when the lithotrite was introduced the stone
 was not found, as you saw, until the lithotrite was reversed.
 It is more essential in the case of an enlarged prostate to
 put a high cushion under the pelvis, in order to throw back
 the fragments to the posterior part of the bladder, so that
 the area may be as far from the neck as possible.
   There may be  some  advantage in  operating on dead
 bodies.  But there is a great difference between the feel of
 the thing in  the living  and in the dead body.  The con-
 ditions encountered in the mere flaccid bag which consti-
 tutes the bladder in a dead  body is very different to that
 in the living. If you have  a master to  give you lessons, it
 may serve your purpose, but not nearly so well as in the
 living body.
   So much for the sittings.  But it is of great importance
 to watch well the patient afterwards.  You heard me say in 
                     LITHOTRITY.                 145
the theatre the other day, and I may shortly advert to it
here, that you should not encourage the early passing of the
fragments.   They rest at the bottom of the bladder ; and I
usually keep the  patient in bed, and pretty much on his
back, for thirty-six hours or so  afterwards: he should,  at
all events for that period of time, pass urine in  that posi-
tion, so that the sharp angular fragments are left at the
bottom of the bladder, and are not forced into the urethra.
This used to be, and still is, much neglected, and the con-
sequence is, that if a man has an urgent want to pass water,
he will get up and strain.  The sharp fragments are driven
into the neck of the bladder by the  effort, and  bleeding,
pain,  sometimes inflammation of the prostate or of the tes-
ticle follow.   But by adopting  the  position  named, the
sharp fragments get waterworn, and the urethra, which has
been irritated and is perhaps a little swollen from the contact
of the instrument, recovers itself, and the passages and frag-
ments are better  adapted to each other  than before.  I
believe this is not taught anywhere but by myself; it is a
very simple matter but an important one.   Never  allow a
man who has been subjected to lithotrity to micturate  in
the standing position between the first and the second sit-
ting, when the fragments are all  large and sharp.  When
you have crushed two or three times, perhaps, he may get
up  and make water occasionally; but  after each  sitting,
for twenty-four or thirty-six  hours,  he  should not pass
water  in the erect posture.
  Immediately after a sitting, a  hot  linseed poultiec may
be placed above the pubes, and is a comfort to the  patient.
The bowels should act the day before  or on the morning  of
       10 
146    DISEASES OF THE URINARY ORGANS.
the sitting, so that the patient may not have to rise soon
after and strain.
  Now, suppose  that we have—at five, or six, or eight
sittings, according to the size  of the stone—almost if not
quite removed it, a very important duty remains.  It has
been  objected to lithotrity—and  there was some  truth,
perhaps,  in the  allegation formerly, but not  now, if the
operation is done well—that you never made sure  of get-
ting rid of  the last fragment; that you might leave a por-
tion to become the nucleus of a future stone.   But there
is very little more difficulty in getting  away the last frag-
ment  than  any other, provided  you go the right  way to
work.  Generally speaking, in four cases out of five, the
last fragment passes as the others—that is, by the patient's
natural efforts.  But suppose there remains  a  bit too big
to pass—suppose you have reason to believe this from the
continuance of the pain, &c.—you then take an instrument
with short  wide rounded blades, with which you can ex-
plore  easily in the reversed position.  With  such a one
you may thus search the whole  floor of the bladder with
perfect safety.  Now, supposing you have  done this and
have found a bit of stone, and do not know whether there
is another—some little symptons are left, but you do  not
find any more—what is to be  done ?  You do not know
whether these symptons are due to a fragment of stone
which escapes you,  or whether to the irritation  arising
from the  long residence of the stone in  the bladder, and
also, to a certain extent,  to your instrumental efforts to
find it.  This is what I  advise: wait for a week and see
whether the patient is better, and if there is any doubt at
all  about it, make him take some severe exercise.  I do 
LITHOTRITY.
147
not know anything  here in  London  better than  a  long
omnibus drive.  Tell him to expend  a shilling  in omni-
buses—say between  Mile End  and  Kensington—and if
that does not find out the fragment in a, man's bladder, I
scarcely  know what will.  If he can stand that, especially
if the roads are mending—if he is not worse for such a
journey—rely upon it,  he has not any fragment left: the
irritation is due to the state of the bladder, and not to a
fragment.  If the latter exists, the patient will  to a  cer-
tainty be the worse for his drive, and perhaps there may
be some  bleeding.  I admit that it is difficult to tell some-
times what the irritation is due to ; and it is only by wait-
ing and testing in some way that you  can find out.
   Then there is another very good mode of getting rid of
the last fragment, and  also of removing fragments at any
time when they are not well  expelled by the natural efforts.
I mean the apparatus  of Mr. Clover,  who, well known by
his  chloroform instrument,  has  also  given  us 'a valuable
addition to the instruments  for  lithotrity.   It is a  very
fascinating apparatus, and looks  so well that there is some
risk in its being used when  not  required.  There are cer-
tain conditions in which the fragments never come away
well.  For  example,  a patient  has no power of  making
water, except by a catheter ;  then few fragments, probably,
will be  passed  in that  way, and you will require other
means.   For him the apparatus in question is the very
thing.   After crushing, this  large catheter is indroduced,
 and the fragments  are sucked out by the  action of this
powerful India-rubber bottle which is attached to it.   The
process  is rather trying, however, for the bladder; and it 
148    DISEASES OF  THE URINARY ORGANS.
costs rather  more pain and  time  than  an ordinary sitting
for lithotrity.
  One troublesome  thing that very rarely happens is the
impaction of  a  fragment.   If you adopt  the  system of
lithotrity which I have shown you, it is  remarkable how
seldom that happens.  I have never had to open the urethra
to remove a fragment in my life.  I have occasionally had
to remove one by the forceps, but that is very rare; and
among all  the complicated  inventions for  the  purpose, I
know nothing so good as the common  long forceps which
I show you here.  During the last year,  certainly, I have
not even had occasion to use them.  The  more thoroughly
you crush the stone, the less use there  will  be for forceps.
Here  is a bottle  containing what I call well-broken stone.
You see it is almost powder: a very different  sort of thing
from that  in the other bottle, where you  see a large num-
ber of big fragments that were probably  passed with diffi-
culty.  It is an old saying: " a carpenter may  be known
by his chips:" certaintly the skill of the lithotritist may
be known by the ddbris he  makes.
  One other point I have to mention—namely, should you
employ chloroform?  Some operators prefer it.  Now, first
of all, I think the operation ought not  to be sufficiently
painful  to make chloroform necessary.  If  it  was like ex-
tracting a tooth,  I should give chloroform.  But there is a
better reason than that for not giving chloroform : without
it you can better judge of the susceptibilities of the patient
at the time.  On some occasions the bladder  is more irri-
table  than on others; and if the patient suffers  much, you
do not have so long a sitting.  If he scarcely suffers at all,
you go on "making hay while  the sun shines," and crush 
LITHOTRITY.
149
three or  four times.   On  ordinary occasions, two separate
introductions of the lithotrite suffice.  Too much lithotrity,
when the bladder is irritable and  painful, is usually an
equivalent to doing  the patient some mischief.  This is a
point as  to which you cannot judge, if chloroform is ad-
ministered.  It has been said that  chloroform should not
be given, because if the patient  is  not under its influence,
he will call out  if you seize the coats of the bladder in
mistake for the stone.  That  is altogether an error.  The
coats of the bladder  should never be injured, and with pro-
per instruments it can scarcely happen.
  I had intended to  speak to you of certain contingencies
that may happen, but it is now too late to dwell upon them.
I will  simply name  them ; they will  come into  considera-
tion in their  appropriate places in subsequent lectures.
The first contingency is fever ; secondly, bleeding; thirdly,
cystitis; fourthly, orchitis;  fifthly, retention of  the urine;
and lastly, exhaustion, which is sometimes fatal.  A pecu-
liar kind of feverish attack is, as you know, common after
all  instrumental  operations on  the  urethra.   The  pheno-
mena  of cold  chill, dry burning heat, and sweating, pro-
ceeding in this order more or  less severely.  Do not "meet
these  symptoms" by a too active treatment; I know none
of much  service; when  the  patient is thirsty, give him
drink, and don't  press food on him until  he is  somewhat
disposed  for it.  Rely on it, what we  call fever here,  is
nature's  struggle against some  poison in the course  of
elimination; only take care that the hygienic  conditions
are good.  After the attack he is weak, and requires good
and nourishing food.  Bleeding is rarely troublesome, and
does not require  much treatment.   Cystitis  gives  a  little 
 150    DISEASES OF  THE URINARY ORGANS.
 trouble occasionally, and is to be treated in the ordinary
 way described in our course.  Inflammation of the testicle
 requires you to desist for a time from operating.   Chronic
 retention  of urine is  apt to  occur very insidiously—not
 absolute, but  partial retention.   Always look out  for it,
 if frequency of micturition increases, and the urine becomes
 increasingly  thick, and if  the  bladder is not emptying
 itself, you must  pass  the  catheter  once or twice a day.
 Sometimes exhaustion occurs; after a number of sittings
 the patient's strength  gives way.   That, however, is very
 rare.
  In my next lecture I shall take the subject of lithotomy,
and give you a general sketch of the different modes which
have been practised, and which are being used at the pre-
sent day. 
LITHOTOMY.
151
                 LECTURE  IX.

                      LITHOTOMY.

  Gentlemen :—It was understood, as the result of our dis-
cussion in the first lecture on Stone in the Bladder, that all
cases below the age of puberty, with very few exceptions,
should be cut; those only in which the stone is quite small
being reserved for lithotrity. Then there were certain adult
cases, where the stone is large, or other difficulties exist, in
which the operation of cutting must be performed.  Hence
we have next to study the operation of lithotomy, and this
advantageously follows the consideration of lithotrity.
  The proceeding of " cutting for the stone" has always
been a subject of extreme  interest; indeed, you will  find
no operation that has exercised a greater fascination for the
veteran  operator, while there  is none which  more excites
the ambition of young surgeons.   There is none respecting
which an  old  student comes to his  teacher  here with so
much just pride and happy sense of newly acquired power,
as when he tells him,  " I have just cut  successfully my
first stone case down in the country."  On the other hand,
the true surgeon who  loves  his art, is  always at home when
the theme of discussion embraces the history and practice
of lithotomy ;  and I  verily believe that some  acquaintance
with the former is one of the  best ways of commencing a
study of the latter.   I will therefore give you a sketch, 
lo2    DISEASES OF  THE URINARY  ORGANS.
although it must be very slight and meagre, of the different
stages by which lithotomy has arrived through early periods
at its present condition.
  The first record we have of lithotomy is in the Augustan
age.   I shall speak  first of lithotomy under  the Classic
period, then under the Mediasval period, and  then  under
our  own period—the period in which, without regard to
what has gone before, and with the  utmost indifference to
authority or antiquity, we sift anew everything to the bot-
tom, in what we call  " the spirit of the nineteenth century."
I dare say there was  an earlier period  still, even before the
time of Celsus, the author of the first account (who, by the
way, was a physician, and never operated); and if some
enterprising Lyell in surgery would make the inquiry, he
might find traces of a pre-historic period;  because wherever
there are human remains, calculi must  exist. I do not
know that uric-acid stones would endure long.   We know
that  the  excreta of fishes are preserved  for thousands and
thousands of years, and  I doubt not that some of these
human excreta might be  found also,  and that oxalate-of-
lime  calculi, at  least, must  exist, among  other human
remains.   As so many  observers are seeking the early
records of the human race, I throw out the hint; and cer-
tainly, if I were  so searching, I should not forget to seek,
among other things, the matters in question.  Whether we
shall thus ever find any instruments which could be iden-
tified as the means by which those stones  were removed is
doubtful.   We will,  however, not occupy our time with
speculation, but will be satisfied to begin with such facts as
we can find, say about 2500 years ago.   More than 2000
years  have  passed since Celsus wrote, and hence I have 
LITHOTOMY.
153
named that date, as the operation was evidently an  estab-
lished  practice at that  time.  Hippocrates  speaks  of it,
although he made his pupils take an oath that they  would
never practise lithotomy.  For then lithotomy was an occu-
pation by itself, and not a very exalted one in popular esti-
mation, being only practised by certain itinerant performers.
What they did was described by Celsus in his seventh book,
and it was called  " cutting on the gripe."  The method was
simple, and so were the instruments, on which account they
were afterwards termed the  " apparatus minor," to  distin-
guish them from the " apparatus major," which came  into
vogue in the Mediasval period.  The operator  commenced
by placing his patient, usually a boy, upon the  knees of a
man who was seated.   If it  was an adult patient (but such
were rarely cut), two  men sat side by side (their legs form-
ing the operating table),  so that their arms might clasp the
patient and control his  struggles.   The operator  used no
staff whatever, but inserted two or three fingers into the
rectum, and endeavored so to feel the stone, which he could
only do if it was  large.  If he succeeded  in this,  he fixed
it firmly, or " griped" it with the ends of his fingers—hence
the term "cutting on the gripe;"  and pressing  it down
towards  the  perineum,  he made a semilunar  cut with a
broad scalpel until he reached it.   Then, if unable to press
it out with his fingers, he drew it out with a hook.  Now,
this rough-and-ready mode was extant until about the six-
teenth century ;  indeed, up  to  the  seventeenth century it
was largely practised in Europe.  Even in the latter  part
of the seventeenth century,  when Frere Jacques appeared,
the ancient mode of cutting on the  gripe was chiefly prac-
tised. 
154    DISEASES OF THE URINARY ORGANS.
  We now come to the Mediasval period, when at  least
three different operations appeared.  Appropriately enough,
too, a monk figures now as the most famous operator.
  First, we will consider the " Marian method," or "appa-
ratus major"—a median operation, originated by Johannes
de Romanis, but receiving its name from his pupil, Maria-
nus Sanctus.  It is called the "apparatus major" because,
while " cutting on the gripe" required  only a knife and a
hook, this table  would be scarcely large enough  for the
instruments employed for the Marian operation.   They are
not here, but you may see them at the College of Surgeons.
By this  method a vertical incision was made by the side of
the raphe', and the urethra was opened  on a staff at about
the membranous portion.  A dilator was then thrust into
the wound, and another upon that (male and female dilators
they were called), and the  canal and the neck of the bladder
were torn asunder with  great rudeness.  Its only resem-
blance to the present median operation  is, that the incision
is in nearly the same place.  But anything more barbarous
than the practice you can hardly conceive.  The stones
were larger then  than they are now, and the incision was
small;  and in order to dilate and extract, various machines
were employed, the result of much  mechanical ingenuity,
and forming the  origin of half the surgical instruments
now in  use.  It was a very unsuccessful  operation, and
was gradually  lost sight of in consequence.  Still, it held
its ground  in places, and  for certain cases, as late as to a
part of the eighteenth century.
  Next  I shall name the  high or suprapubic  operation,
which appeared about the end of the sixteenth century, and
this has maintained a position of greater  or less import- 
LITHOTOMY.
155
ance to the present day.  More  than this I shall not say
on  the present occasion, as we  concern ourselves mainly
with perineal lithotomy.
  I now come to a new proceeding, which rudely shadowed
forth our  present  lateral operation.   It was performed on
a staff1, which wras  not grooved as now, but yet it roughly
served as a guide into the bladder.  The operator com-
menced by  thrusting a long  knife  into the ischio-rectal
fossa, and so on into the bladder behind the prostate, and,
cutting forward, he made the entire wound at one incision.
Invented, as it was  believed, by Pierre Franco  (sixteenth
century), its apostle and promulgator was the celebrated
Frere Jacques, who flourished in the seventeenth century,
and is  said to have cut 5000 times for stone.   Probably he
did not cut 500; but a cipher more or less was a  trifle for
the inexact and credulous mind of the  period.   Like
others  of his craft, he was an itinerant operator, not em-
barrassed with too much anatomy, and France was mainly
the scene of his labors.  After him,  Rau, in Holland, pur-
sued the same practice.
  It will be interesting to you to know what was going on
meantime in our own country.   Most patients, up to the
end of the seventeenth century, who were cut, submitted
either  to  the old  operation  "on the  gripe," or to the
"Marian."   In the beginning of the eighteenth century,
the high operation was first practised here.  At this period
there came to London a Leicestershire lad, subsequently
known  as  Cheselden,  the  celebrated surgeon  of St.
Thomas's  Hospital; and he at  first did the high opera-
tion.  But  he had heard of the recent successes of Frere
Jacques' method, and tried it, modifying it as his experi- 
156    DISEASES OF THE URINARY ORGANS.
ence suggested, until he performed almost exactly what we
now call the  lateral operation, and  with the best  results.
His  success was so great, that  in 1729, when he had per-
formed  the operation  several years, and cut  about one
hundred patients, Morand, the  French  surgeon, was  sent
from Paris to see him  operate, and report upon the subject.
He remained  here for some time,  Cheselden getting to-
gether a number of cases and  operating on them before
him.  Morand then returned and  reported to the  French
Academy so  favorably on the  subject, that  Cheselden's
operation became generally accepted as the best.   In it
the deep incision was made, if  possible, within the limits
of the prostate gland, and involving its left side only, by
means of a scalpel  of moderate size, cutting its way in-
wards along  the groove  of the staff.   A few years after-
wards  Cheselden retired,  having cut 213 patients of all
ages, with ten deaths.   Those are the first figures that we
can depend upon in connection with the operation, for, as
I have told you before, the figures of the Mediasval period
are monstrous and incredible; for not only was the famous
monk said to have cut 5000, but  to have lost  " scarcely
any."  Cheselden, who improved the mode, and cut at all
ages, including very many children (who are, as you know,
extremely safe to cut), had barely five per cent, of deaths,
which was an enormous result, and no doubt the greatest
that had been yet made.
   At this point the operation  continued for  some years
until the end of  the century, and then " the gorget" came
into fashion.   A few  years ago a patient was rarely cut
without  it; now, I  suppose, few of you know what it is.
Originally, one  of the directors used in the " apparatus 
                     LITHOTOMY.                  157
major," its edges were sharpened for  the purpose of mak-
ing the deep incision through the prostate.   This was the
idea of Sir Cassar Hawkins, whose name was affixed to it;
but subsequently almost every surgeon had his own gorget,
making it wider or narrower, or altering it in some fashion
or another.   A great deal of mystery has been made of
this instrument, but it is simply a wide knife with a beak
at the end, which is  kept  in the  groove of the staff.   In
using  the ordinary knife,  if you  require a deep incision,
the blade must leave the staff a little.  The object of the
gorget is to  make  an incision sufficiently  deep  without
leaving the staff.  Here is one which formerly belonged
to Scarpa, the  celebrated  anatomist, and here are others
which, having been used by many  celebrated operators,
have fallen into my  hands, and they are leading types of
the instrument.
   In 1816, Dupuytren, of Paris, not being content with the
lateral, introduced his bilateral operation.   His object was
to make  the deep incision by a  cut on  each  side of the
prostate, instead of one large one  on one side only.  And
he, with  the same view of limiting accurately the extent of
the wound, designed a special instrument for the purpose.
This, the "two-bladed lithotome," is also a member of the
ancient surgical armamentarium, made more elegant and
manageable by modern skill.  Instead of making the in-
ternal incision by pushing a cutting blade inwards, as writh
the knife or gorget, you carry this instrument [showing it]
into the  bladder along the  staff, there open its two con-
cealed blades, and drawing it towards you, cut your way
outwards.  You can arrange the blades so as to  have the
incision as wide or as narrow as you  please. 
153    DISEASES OF THE URINARY ORGANS.
  In 1825 or 1830, the " median operation," often loosely
spoken of as a revived Marian operation, came  into some
note in this country, and with it  Mr. Allarton's name is
chiefly associated.   In  the mean  time Civiale, in Paris,
combined the median and  bilateral  operations, and you
have  seen  me frequently perform  both  of  them  here.
Then Nelaton has recently performed the pre-rectal opera-
tion, which is, after all, only a carefully dissected bilateral
operation.
  I now  come to the mode of performing the lateral and
the medio-bilateral operations, and will give a few general
hints which will apply equally to either.  As I  have said
before, when we have to do with many details, let us try
to revert to first  principles, and define clearly the object
we aim at.  I  told you that the object of lithotrity is to
remove the stone without  injury to  the patient, either
from the stone or  the instrument.  In lithotomy you must
have a wound, and the object is to  make it in such parts
as shall  least  endanger the bloodvessels, the viscera, or
the neck of'the bladder, and to remove the stone through
the lower outlet of  the  pelvis with  as little  mischief as
possible to any of those parts.   When that problem is best
solved, we shall  have the best form of lithotomy.  It is
quite open  to discussion whether  we  have yet found  out
the best  way, although we have been  2500 years—to say
nothing of the pre-historic period—in coming to our pre-
sent position.  Only  the other day, Sir William Fergusson
was proposing to revert  in some fashion to the ancient
classic form which bears the name of Celsus.  Then  Mr.
Erichsen last year performed Dupuytren's bilateral method,
which has become obsolete in Paris.  And in  that great 
                     LITHOTOMY.                  159
school of surgery two or three kinds of operation are in
vogue, and there is by no means an agreement as to which
is the best.
  Now, in order to aid you to solve the problem for your-
selves, I have placed before you a diagram drawn accurately
from the preparation, showing the bones and ligaments of
the pelvis, in the position for lithotomy.  The lower outlet
is opposite to us; it is in the patient  filled by soft parts,
and it is the opening into which you have to cut, and through
which you must remove the stone, and in all that you do,
you must be limited  by its boundaries of bone.  I like to
have that in my mind's eye when the patient is tied up and
I take my seat to operate.  Here also are diagrams, show-
ing two stages of the dissection of the perineum.   But I
take it for granted that you know your anatomy too well to
require any detailed  account here of the important parts
involved  in the operation.  I shall  simply  name those
which concern us.   First, there is the  pudic artery, safely
sheltered under the pubic ramus; but  it gives a branch to
the bulb, a vessel to be avoided at the upper part of the
space.  Then  in the same part  is the bulb of the urethra,
which is  not to be  thought too lightly of; indeed, it is
the source of some of the chief dangers ; it is a vascular ex-
pansion from the vessel named, and cutting into it deeply is
as bad as cutting into the vessel itself, if not worse.  Next,
there is the rectum in the middle and lower part, which it
is also important to  avoid.  The other diagram shows the
position of the prostate, which must be divided in the deep
incision.
   I will now very briefly touch on the principal steps of
the operation.  The patient's bowels are  to be thoroughly 
160
DISEASES OF THE
URINARY ORGANS.
emptied by an enema a few hours before.  Do not trouble
yourself about the quantity of urine in the bladder.   Some
think it very important that it should be full.  Cheselden,
on the other hand, preferred it to be empty, saying that in
this condition the stone was easily found close to the neck
of the bladder.   I have seen great pains taken to inject the
bladder before operating; but the unconscious patient has
usually succeeded in emptying it, in spite of tying the penis,
and such-like precautions.
  The first thing the operator does is to pass the staff into
the bladder and find the stone.   Never think of cutting a
man if you are  not fully satisfied that the staff is in contact
with it.  Frightful blunders have been made through indif-
ference to this rule.   Suppose, for example, the staff is in a
false passage,and is not in the bladder at all; one shudders
at the idea of an operation performed  on a staff so placed—
an exhibition distressing to all concerned—never to be for-
gotten either by the operator or by the bystander, and pro-
bably  fatal to the patient.  The " click," then, is to be dis-
tinctly audible  to yourself and to a  witness, and  the staff is
to be put into the hand of your best friend, who is to  attend
implicitly to your instructions, and to no others, whatever
they may be.  The patient is then  to be  tied up firmly;
better still if secured by these  leather anklets and wrist-
bands, devised by Mr. Prichard, of  Bristol, because they
truly realize the proverb, " fast  bind, safe find," which our
old friends the garters often did not.
  Now, what are the instructions to  your friend, the staff-
holder ?  You want it held firmly, and, of all things, not to
leave the bladder.   I  don't think you will gain much by
cultivating a fancy for any particular spot, such as right or 
LITHOTOMY.
161
left, or projecting in the perineum.  If it is to be steady
and in one spot, which is  the main thing, there must be a
point  of support for it to rest against, and there is but one
such spot in the whole region.  Rely upon it, then, you
had better tell him to keep it close to the arch of the pubes,
well hooked up, with  the handle pretty nearly vertical.
Your fingers now traverse the region and find the lines of
the rami, also the condition of the bowel, whether empty
and contracted, or the reverse.
  Now, relative to  the first incision, different  authorities
advise different  places at  which  to  enter the scalpel and
commence.   Without discussing  these, let me say that, as
a rule, the usual spot should be, for an adult, an inch  or
an inch and a quarter in front of the anus,  a  little on the
left side of the raphe\  Go in boldly, slightly pointing up-
wards, near to or into the  staff,  and then  gradually less
deeply till you  come out  about  three inches lower down
towards the inner side of the tuber ischii.  It is very plea-
sant to feel that  you touch the staff in that first incision,
and it saves trouble and uncertainty to have gone close to
it, which you always ought to do ; never let it be a timid
shallow cut, merely dividing the skin.  The end of your
index finger follows, and should feel the staff easily through
the tissues.   Fixing  the finger-nail  upon it, the  point  of
the knife is  placed firmly in the groove, and  is run steadily
on in contact with the staff.  Keep the point up, and you
will be safe; let it down, and  you may slip out and get
into the rectum, or nobody knows where.   Simply go on,
letting the blade be a little more  horizontal  as it proceeds.
Go on till you  are well into  the bladder, not  letting the
point leave the staff.  The depth of the incision will depend
       11 
162    DISEASES OF  THE URINARY ORGANS.
upon  the angle which the knife makes with  the  staff: if
you withdraw with the knife close to the staff, of course you
will only make a wound the width of the knife ; and if the
edge is directed outwards  and downwards  against the soft
parts, with a light hand,  as you come out, you will make
a freer and cleaner opening.  It is  better to be rather free
in cutting than otherwise [the presence of a large stone is
assumed], but you must not make the incision too wide.
There has been a great deal of good advice expended upon
this subject—the depth of the incision, but it  is manifestly
impossible for one man to make another understand what
he means or what he  does by any amount  of talk.   My
belief is, however, that the result of our anxious care about
this matter is, practically, that we are apt to cut rather too
niggardly than too freely, and that the neck of the bladder,
in consequence, receives severer injury from the stone and
forceps than it otherwise would receive from the knife.
This relates, of course, to adults;  for in children you can
scarcely find the prostate—it weighs but a few grains, and
does not come in for a moment's  consideration, and your
knife goes far beyond its limits; yet these  little patients
are the safest to cut.   Of course there is a very great differ-
ence in the two  ages, due to the different  conditions of
puberty and childhood.   To return.   The incision being
completed, your left  index finger immediately follows close
along the staff into the bladder, where you will probably
just touch  the stone.   The finger  goes firmly and deeply
in, stopping the urine perhaps to some extent in its outflow,
and accomplishes some dilatation of the parts. Then you
slide the forceps closely along the palmar surface of the
finger, and  insinuate them into the bladder,  which makes 
LITHOTOMY.
163
dilatation number two.   Then, generally  speaking, you
have but to open the instrument earefully, yet widely, one
blade flat at the bottom of the bladder, the other towards
the top,  and closing  the blades, the stone is  probably
between them.   If it  seems that  you have a  good hold,
draw gradually outwards and downwards, easing or  adjust-
ing, if you can, with the left  index ; and  so you make the
third and last dilatation.   Remember not  to pull out hori-
zontally and bruise the parts against the pubic arch, but
downwards into the widest part of the lower  pelvic aper-
ture.  And don't be hurried for the sake  of anybody else.
You and your patient are to be, for you,  at this moment,
the only  persons present, and your responsibility to  him
must never be forgotten for an  instant through the influ-
ence of bystanders and lookers-on.
  I must now briefly add that you will search for a  second
stone, tie any vessel spouting within  sight,  insert the tube
into the bladder, perhaps inject  a syringeful or two of cold
water, and stuff the wound round it if the  hemorrhage is
free.  The patient is  placed  in bed on his  back, with one
or two pillows  under each ham, and the  parts involved
exposed  to air and light, so that you  see  how the urine
flows.  The less meddling afterwards generally the better.
  I have only time  to say a word or two about the median
and medio-bilateral operations.  For the median, an inci-
sion is made in the  line of the raphe from  about two inches
and a half above the anus, downwards as near its margin
as is safe, for you want all the space you can get. Dissect-
ing down to the staff, with a finger in the rectum, and open-
ing the urethra in the membranous portion  or  thereabout,
you  carry a director on into  the  bladder;  your finger
follows, and dilates, and then the forceps on that.  I may 
 164    DISEASES OF THE URINARY ORGANS.
 tell you that  it  is generally performed  by thrusting a
 straight bistoury, back downwards, in front of the anus, into
 the staff, and cutting  upwards and outwards at one inci-
 sion.  I prefer the other mode.  Manifestly this operation
 will not do for large stones, which mainly, thanks to litho-
 trity, are what we have to deal with now.  Hence the
 applicability of the " median" is extended by  making it
 " medio-bilateral," and in this manner:  Having  performed
 the median, as just described, up to  the point of opening
 the urethra, instead of introducing a director, you introduce
 the two-bladed  lithotome, and when  it is in the bladder
 you open the blades, and two moderate incisions are made,
 one right, the other left, as you draw the  opened instru-
 ment outwards in the grove of the staff.  These two opera-
 tions I have now performed  about  thirty times, and I do
 not know, after all, that  there  is much to choose  between
 them and the old " lateral." To make an accurate estimate,
 one requires at least 100  cases of each operation by the
 same hand.  Nevertheless, I may say a word, "finally, on
 the principle which essentially distinguishes these opera-
 tions.  They are the result of opposite convictions respect-
 ing  the  hazard of the knife.  There is a  set of men to
 whom anatomy is a bugbear, and who are afraid of cutting
 as much as is  absolutely necessary;  and there  are other
 men less timid—mind, I don't say less cautious—who re-
 gard the larger freer style of operation as better than the
 small or fearful style.  All surgeons,  of course, tend more
 or less to fall into  one  of these two classes.  The anatomi-
 cal school have devised a variety of  median operations in
 order to  avoid certain bloodvessels, &c, and they sacrifice
 space in doing so.   They answer excellently well for small
and  medium-sized  stones;  but these are, or should  be, 
LITHOTOMY.
165
crushed now, and we do not want any operation for  such
stones.   The  perineal  operation which  offers the  most
room, the recto-vesical  excepted, is  the lateral operation.
All the  others named are essentially median  operations.
Now, I am  bound to say that formerly, judging theoreti-
cally, and  performing less lithotrity  than  now, I had  a
leaning to median methods, being disposed  to  think that
they would be  attended with less  hemorrhage than the
others.   But I do not find  this so in practice,  and I  have
arrived at the conclusion that there is quite as much bleed-
ing as in the lateral operation.   I  attribute  this  to the
bulb.  I regard the bulb  as  a large artery to all  intents
and purposes.  You  cut into that spongy tissue—not in all
cases, but in some—and there is as much  bleeding  as if
you cut the artery of the bulb, and more difficulty  in con-
trolling  it.  The bulb must be cut more or  less  in the
median operation.  The problem  is how to get into the
bladder without wounding the bulb,  its  artery, and the
rectum;  and I believe that a well-performed lateral opera-
tion  accomplishes this,  where a free opening for a large
stone is required, better than any other.
  I cannot tell you  which of  these two operations is the
easier; if anything, perhaps, the lateral.  But  here is the
important fact, which is  but  beginning to be realized by
the profession, viz.:  that only exceptional  cases of large
stone in the adult require any cutting  operation, since all
the small and middle-sized  ones can  be much more safely
removed by the  crushing process; and it is this fact which
is bringing these various forms of lithotomy under the full
and serious consideration of surgeons at the  present day.
  The next lecture  will relate to diseases affecting the
bladder itself. 
166    DISEASES OF THE URINARY  ORGANS.
                   LECTURE  X.

                CYSTITIS AND PROSTATITIS.

   Gentlemen:—It is  quite  possible that  you may see
 little or nothing, even during a considerable experience of
 general practice,  of  those  diseases which  have occupied
 our last three lectures.   Some men never meet with a case
 of stone in the bladder  during a lifetime, and of those who
 do,  very few undertake themselves to treat it.  But the
 very reverse  of this is the case  with the  subject which
 comes before us to-day.  Fraught with much less of what
 one calls "interest" for an operator, its  attractiveness to
 the  student must  be found  in  the fact that  cystitis, or in-
 flammation of the bladder,  is  the commonest  affection of
 that organ, that it is certain to occur in his practice, and
 probably not unfrequently.   For, whatever else you may
 have in  connection  with  the urinary  organs, you are
 certain  to have cystitis.  If a man has stricture severely,
 or stone, or disease of  the  kidney, or disease of the pros-
 tate, sooner or later he has cystitis, either acute or chronic,
 the  symptoms of which are  often  the  most prominent
 features in all these diseases.
  Then I beg you to  remember that cystitis  has  almost
 always  some ascertainable  cause,  and that  it very rarely
 indeed appears in  what  is called an idiopathic form.  You
will find that there is, or has been, gonorrhoea, or stricture, 
CYSTITIS  AND PROSTATITIS.         167
or disease of the prostate, or retained urine, or urine altered
in character, or some other such  cause;  and if you have
readily come to the conclusion that any case before you is
idiopathic, suspect that you have not discovered the cause,
and the probability is that you have not searched deeply
or carefully enough.  Here and there the true pathology
will elude our  best efforts.  Possibly you  may be forced
to attribute it to a gouty diathesis.  A very refuge in time
of trouble for practitioners of feeble diagnostic power is
gout, particularly " suppressed gout;"  therefore beware of
it.  And while, I think, it must be admitted that inflamma-
tions, both of the urethra and of the bladder, may be some-
times mere local developments of the ubiquitous influence
so named, I am sure that this cause is of exceedingly rare
occurrence.  Certain irritant poisons also—amongst  which
cantharides is the most prominent and likely to be met
with—occasion cystitis, which I  have seen severe in cha-
racter, and lasting from ten to twenty hours, as the effect
of an ordinary blister.
   First,  then,  I shall  call your attention to  acute, and
and secondly, and chiefly,  to chronic cystitis.
   Acute  cystitis appears  in two  very distinct forms: one
 which is severe and dangerous, the other  which is much
 less so.
   The dangerous form is that which accompanies the most
 severe lesions to which the bladder is exposed.  The first
 breaking up of a large and hard stone into large fragments,
 either spontaneously or by the  lithotrite, has sometimes
 caused it; violence  to the bladder in lithotomy and the
 like are causes.  Rigors, bloody urine, extreme pain and
 irritability of the organ, announce the fact, and the patient 
168    DISEASES OF THE URINARY ORGANS.
succumbs in a few days.  At the autopsy you will see the
lining membrane of a dark crimson hue throughout, or
nearly so, and often spots where it appears to be sloughing
and exposing the muscular  fibres.
  The less  severe form of acute cystitis is common enough.
There is reason to believe that  the neck of the bladder is
the part mainly affected in  these cases; and the reason for
this is that, what we call cystitis is often really inflamma-
tion of  the  prostate  mainly,  or of  the  urethra passing
through  it, entirely so perhaps at  first, and that  the mu-
cous membrane of the bladder is  affected by extension.
And as, anatomically, I don't know how we can  make an
accurate separation between these  two organs, it is often
legitimate  to speak of this affection as " inflammation of
the neck of the bladder."  After gonorrhoea, or from ex-
ternal cold and damp, and in  connection with many cir
cumstances of no apparent  importance, a man becomes the
subject of frequent and painful micturition, and has a sense
of aching  or gnawing pain above the pubes; while the
urine is cloudy from an  increase of the natural  mucus of
the bladder  (not the tenacious viscid  secretion, mind,
which I shall speak of under the head of Chronic Cystitis);
and there  is  usually some constitutional sympathy with
the local disturbance, evinced by loss of appetite and gene-
ral feverishness.
   The treatment consists in mild laxatives and diuretics,
demulcents, hot hip-baths,  local poultices, and anodynes, if
necessary.   Besides these,  the use of certain infusions, and
decoctions, of which I shall speak hereafter.
   But that which most requires our attention is the chronic
form of the  disease.   It is that which requires  the most 
CYSTITIS AND  PROSTATITIS.        169
care and judgment, and for which we have most to do in
the shape of treatment.  Chronic cystitis also  appears in
two distinct forms.  In the simpler, there is little else than
some  increase of  the natural mucus from the bladder
mixed with the urine.  Just as when you have  a common
cold, there is inflammation of the mucous membrane of the
nose and towards the  frontal sinuses, with increase of its
secretion, so the mucous  membrane of the bladder adds
mucus to the urine; and the inflamed mucous membrane,
being more sensitive,  will not permit itself to be much
extended by accumulating urine, but forces the bladder to
expel it as soon as possible : hence the frequency of making
water.  But, besides this, there  is  another form, in which
the mucus  has a distinct character.  It is  often  spoken of,
and not very wisely, as " catarrh of the bladder"—another
example of an unfortunate term leading to error in practice.
The mucus is very tenacious, and when you empty a vessel
containing the urine of such a patient, it runs off first, and
then a quantity of  ropy mucus follows in a mass.  You
may see a  pint or more of this material passed in the
course of the day, and it  acquires the viscid character on
standing.   Some patients pass it for  months together, and
such are said, especially abroad, to  have " catarrh of the
bladder," which, and there especially, is said to be a very
dangerous and a very incurable  disease.   Indeed, to tell a
foreigner that he has "catarrh of the bladder," is to alarm
the poor man exceedingly.   Now,  this  is  because it is
regarded as an essential disease, instead of a mere symptom;
for of course it is no more a disease than dropsy is.  For-
merly, you  know we talked of dropsy as a very formid-
able malady, and it still  is so to the popular mind;  but 
170    DISEASES OF THE URINARY ORGANS.
no intelligent student would now, I suppose, be satisfied to
think of  it except as a symptom.  He would say: "Is it
due to cardiac, to renal, or  to hepatic disease ?   What is
the cause of it ?"  Precisely so is it with this " catarrh of the
bladder."  You inquire what is  the cause of it, and you
find in nine cases out ten there is a very distinct cause, and
mostly a removable one.   You are not to be stopped by
this name,  and ask  me what  is good for catarrh; but
you must carry further the diagnosis, and ascertain  the
precise condition which has occasioned it.  And the most
common  cause is one too often overlooked, as I shall re-
peat—viz. inability of the bladder, either from atony of its
coats or prostatic obstruction, to  empty its coats; yet this
peculiar  muco-purulent secretion  does by no means neces-
sarily occur in these  circumstances, and I  cannot tell you
at present how it happens that in some cases of retained
urine it contains only some light flocculent  mucus, and that
in others there shall be a very large quantity of this tena-
cious matter.
   With regard to the treatment,  the first thing  is  to take
care that the bladder is emptied  by a catheter once, twice,
or three  times a day, in the easiest manner possible, of
which I treated in the fourth lecture.  And this is necessary
because decomposing urine is a   great source of irritation
to the mucous membrane.  The urea contained  in  the
secretion which enters by the ureters in a  healthy  state is
soon  decomposed into carbonate  of ammonia, and  the
ammoniacal salt is an acrid and irritating substance.  You
explain to  your patient that his bladder, not having been
emptied  for many months perhaps, has acquired somewhat
the condition which  a badly washed  utensil would  have 
CYSTITIS AND PROSTATITIS.
171
done in like circumstances—a useful and sufficiently accu-
rate  illustration for the lay understanding, and he will
appreciate  it when he finds, as  he probably will, that the
mucus diminishes considerably after a few days of this
treatment.  But suppose it does not do so, or does  so but
slightly, what  then?   I  will  tell you  what  sometimes
happens, and I am not sure that the fact I am about  to ask
your  attention to has  been observed or recorded.  It is
this: you cannot completely empty every bladder with the cathe-
ter.  When the prostate is irregular in shape, and throws
out protuberances into the bladder, there are sinuses or
spaces between them, which retain one, two, or even more
drachms of urine.  Again, there  are not unfrequently nu-
merous sacculi in the  coats of the bladder which  act in
the same way.  When obstruction at  the neck has existed
some time, the daily straining—although not considerable
—necessary to  expel the  urine, produces hypertrophy of
the muscular bands which  form that coat of the bladder.
Now, you know hydraulic pressure is equal in every direc-
tion, and in course of time the expulsive act, more power-
ful than in health, gradually forces  the  mucous  lining
between the interlacing muscular bands, and little pouches
result.  In these  it is not uncommon for calculi to secrete
themselves, and thus in time encysted calculus is formed.
In any case, however, those pouches become  receptacles
for urine, which  becomes  stale,  and irritating, in  conse-
quence, and not at all unfrequently they attain a large size;
such a one is depicted at Fig. 21.  Now, the  mere with-
drawal of the urine  by catheter by no means empties the
reservoir in these  circumstances, and enough  of noxious
fluid is left in these pouches or sacculi to maintain the un- 
1<2    DISEASES OF  THE URINARY  ORGANS.
healthy condition  of  the lining membrane.  What  you
bave to do is, to wash out the bladder at least once a day
with a little warm water  before  you remove the catheter.
I am very particular indeed as to the manner of doing this.
Washing out  the bladder may be a very valuable mode of
treatment,  or a  mere contrivance for seriously  irritating
that organ, according to the mode in which it is performed.
  Fig. 21.—Section of bladder and prostate.  A large sac of the former, marked
b, produced by long-standing unrelieved retention of urine; a bougie lies in the
small opening by which it communicated with the bladder.
A common mode—indeed that which I  always  saw em-
ployed  some  years ago—was  to attach  to the  catheter
(which was often of silver, and it is unnecessary to repeat
my views about that) a  large metal syringe, and to throw
in with considerable force six or eight ounces of water.  I
wish you to cherish a wholesome horror of that proceed-
ing, and in no case can it be necessary.  A healthy bladder, 
CYSTITIS AND  PROSTATITIS.         173
and  much  more, a tender one, can only be disturbed  and
pained by such  a process.  This sensitive organ is  only
accustomed to be distended gradually by the continued
percolation  into it of urine from the kidneys.  Let  your
washing-out at least conform in some respect to that pro-
cess. Never, under any circumstances, throw in more than
two ounces; and even this quantity, for efficient washing,
is better avoided.  Proceed, then, as follows:   You  have
a flexible catheter in the bladder; have ready a four-ounce
India-rubber bottle with a brass nozzle and stopcock, the
nozzle  long and  tapering, so as to fit a catheter of any
size between  Nos. 5 and  10, filled with warm water—say
at 100° Fahr.   Attach the nozzle gently to the catheter,
and throw in slowly a fourth of the contents;  let that run
out, and it will be thick  and dirty,  no doubt;  then inject
another fourth,  which will be  less  so;  again  another,
which  will return clearer than the preceding;  and the
fourth  portion  will  probably  come  away nearly  clear.
Now, these four separate washings of an ounce each will
have been really more efficient than two washings of four
 ounces each;  and you will, in obedience to my never-
 failing injunction, have reduced the amount of instrumental
 irritation to a minimum.   Ten to one but the patient will
 regard  your  performance  as  soothing  to his feelings.
 There are other methods of effecting the object, but this
 is the principle I want  you to understand;  and the  mode
 of  carrying it  out wbich I have described is one of the
 simplest.
   What if this washing-out has not  accomplished all we
 wish ?   We may then,  and often with great advantage, try
 medicated  injections.  Perhaps  the  best mild astringent, 
174    DISEASES OF THE URINARY ORGANS.
when the urine is alkaline and depositing phosphates, is
the acetate of lead, in the proportion of one grain to four
ounces of warm water, not stronger; to be used once a
day.  After this comes the dilute nitric acid;  one or two
minims to the ounce of water.   Then you may try nitrate
of silver in small quantity—certainly not more than one
grain to four ounces to begin with, going up to about half
a grain, or one grain at most, to the ounce.  You may also
use, especially where  the urine is offensive, carbolic acid;
one or two minims to four  ounces is quite strong enough.
Then there is a soothing injection well worth your remem-
bering—viz., biborate of soda and glycerine.   It may be
used where there is no great occasion for an astringent, or
it may be combined with one.   The value of this for sore
mouth suggested to me its use  for an irritable bladder, and
experience has confirmed  my expectation.   Here  is my
formula:  Two  ounces of glycerine will  hold  in solution
one ounce of biborate of soda; to this add two  ounces of
water.  Let this be the solution, of which you add two or
three teaspoonfuls to  four  ounces of warm  water.   I  ar-
range all these solutions for four ounces, because the four-
ounce India-rubber  injecting bottle already described is a
convenient and portable instrument.
  In circumstances of great pain, you may inject anodynes
into the bladder if you please; but they are of little value-
And you need not be afraid of the quantity; for the mu-
cous membrane of the bladder appears to have no absorb-
ing power, unlike the neighboring tissue which lines the
rectum.  And there,  indeed,  is your place for action, if
spasm and pain greatly disturb the patient;  a  suppository
of cocoanut butter, containing  from half a grain to a grain 
            CYSTITIS  AND PROSTATITIS.         175
of morphia,  is  often  of the greatest  service.   Counter-
irritants play a  small part among our remedies; perhaps
the best and safest is a hot linseed poultice, well sprinkled
with strong flour of mustard, above the pubes.   I  cannot
say much for croton oil, nitrate of silver, &c, there.  Hot
fomentations, in the  form of bran-bags, hot flannels, &c,
alleviate pain materially; so also hot hip-baths and  the
hot bidet.
   Then there is a host of infusions and decoctions reputed
to exercise a beneficial influence in cystitis.   I will name
some of them in what  I think to  be about the order of
their value for the cases one commonly meets with: Buchu,
Triticum repens, Alchimella arvensis, Pareira brava, and
Uva ursi.  Now, for the doses of these, your conventional
tablespoonful is a  miserably inefficient  measure.  Of the
first, fourth, and fifth, give half a pint daily ; of the second
and third,  a pint, that is of their infusions or decoctions, as
the case may be.
   The  underground  stem of the  Triticum repens, or the
common couch  grass, was introduced some years  ago by
myself.  Of this I will  only say that it maintains its credit,
and is  undoubtedly very useful in many cases.  For  use,
boil  two ounces in one pint of water for a quarter of an
hour; the strained liquor to  be  taken by the  patient in
four doses in the  twenty-four hours.   It was  a favorite
remedy in the old  herbals; and it formed the staple medi-
cine  against what  was called "strangury,"  which, a  few
centuries  ago, meant everything like pain or difficulty in
making water, no matter  what the cause; for  the art of
diagnosis  then was  in  its earliest infancy.   The " Parsley
piert" (derived from " percer  la pierre," and not  a  parsley 
 176    DISEASES  OF THE  URINARY  ORGANS.
 or  umbelliferous plant at all), or Alchimella arvensis, has
 proved in my experience an  admirable remedy in obscure
 cases.   Use it as an infusion :  one  ounce to the pint.   Be-
 sides these there are the resins, which have  a certain
 amount of influence  upon the mucous membrane of the
 bladder; such, for instance, as copaiba, Venice turpentine,
 &c.  You should not, however, give the dose which you
 would give in gonorrhoea.  Five minims of copaiba, three
 or  four times  a day, in  mucilage, often answers well.  I
 may say the same of  the oil of cubebs.
  One word about alkalies.  As a rule, no  doubt, alkalies,
 in neutralizing highly acid urine, help to  control chronic
 cystitis; and I like the liquor potassas, as well as the bi-
 carbonates, tartrates,  and citrates, which appear to have
 more diuretic action, and to increase the quantity of urine,
 when you would rather avoid this action  and lessen the
 frequency of micturition.  The old combination of liquor
 potassas and henbane, affirmed to be a union of incompati-
 bles, nevertheless seems to me  about the most  valuable
 form in practice.  I have no doubt that it is sufficiently
 correct that both henbane and belladonna are deprived of
 their specific  activities when  mixed with liquor potassas.
 Chemically, I  dare say that is  so.   But I  am perfectly
 satisfied that this combination materially controls painful
 and frequent micturition in the complaint we are consider-
ing.  Hence I  have of late gone  back to  it, and for the
reason stated.
  Now as to acids.  Remember that these are by no means
the compliment of alkalies in relation to the urine.  Beware
of the popular notion  that it is possible to produce an acid
reaction on urine by  giving mineral acids  by the mouth. 
            CYSTITIS AND PROSTATITIS.         177
By giving alkalies, you can make the urine neutral or alka-
line to any extent you please, but you cannot do the con-
verse with these acids.  Yet I constantly hear it said, " The
patient's urine is very alkaline: had we not better order
acids?"  My reply is, "By all means; give an ounce  or
two daily if you like, but it will not change the reaction of
the urine."  I have given these quantities, greatly diluted,
of course, without the slightest effect on alkaline urine. No
doubt mineral acids  are useful in giving tone, and so do
good; but don't prescribe them with the view of directly
acting on the urine.   The acids  that do act on the urine
are benzoic acid and citric acid, but you have to give  so
much of these that I do not know whether the  remedy is
not mostly worse than the disease. The benzoic acid,  having
some balsamic  character, may be useful in some cases  of
chronic cystitis.  The best way to give it is in pills, as it
is not soluble  in water.   Three or four grains, with one
drop of glycerine, is a good form ;  and you must give  as
many as ten or  twelve pills a  day if you wish to do any
good.  At all events, it is useless to give less than  six;
that would be twenty-four grains in the day.  Lemon-juice
has also an acid influence on the urine, and if it agrees with
the stomach may be taken in large quantity.   But  here is
the important fact for you to remember : Surplus of  acid
in the urine is a constitutional error, and it enters the uri-
nary  passages  at the kidney.   It requires constitutional
treatment, of the  digestive rather  than  of the excretory
organs, and mere alkaline  treatment  does but mask the
acid, does not cure it.  You have to remodel the patient's
habits control  his diet, and take care that his liver and
bowels act healthily and freely.  On the other  hand, per-
       12 
173    DISEASES  OF THE  URINARY  ORGANS.
sistent alkali in the urine is, in nineteen cases out of twenty,
a local formation in the bladder.   It  requires  local treat-
ment, as  by catheter and injecting-bottle, and  not physic.
Now  and then you have alkaline urine, milky-looking,
with amorphous phosphates, as a constitutional condition ;
but this is rare as  compared with the cases I  am  now de-
scribing.
  I shall close this lecture  with some brief  remarks on
acute and chronic prostatitis:
  Acute  prostatitis occurs in different degrees of severity,
and often comes first before the practitioner's notice, when
it causes  retention  of urine by obstructing the neck of the
bladder.   How this emergency is to be met I have described
at some length in the fifth lecture.   The organ is often con-
siderably swollen and  very tender, and  the inflammation
may give rise to abscess in the substance of the gland, or
adjacent  to  it; and the matter may burst, either into  the
urethra, its most common course, or into the rectum.
  Chronic inflammation of the urethra passing through the
prostate,  and more or less affecting the prostate itself, is  a
condition less generally known or recognized. Nevertheless,
it is  a common and important affection.  AVe  see it fre-
quently, not always, as the result of obstinate gonorrhoea.
I have already referred to it as  the  cause of symptoms
resembling, more than any other malady, those of  calculus
in  the bladder when mild in degree.  Thus a patient of
twenty or thirty years of age tells you that the following
symptoms have rather  gradually  appeared :  Undue fre-
quency of micturition; pain following the act, and felt in
the end of the penis; occasionally a little blood seen with
the last few  drops  of urine, which may be a little  cloudy
with  muco-purulent deposit;  a  sense of heat  and weight 
CYSTITIS AND PROSTATITIS.         179
in the perineum and rectum; there is, perhaps, also  some
gleety discharge in the urethra.  All these conditions are
aggravated by exercise.  You see he gives you a complete
sketch of the symptoms of calculus;  and how are you to
distinguish them ? By the history and by sounding.  Thus,
there is  no history of the descent of calculus from  the
kidney, nor of gravel previously passed.  But there  is the
fact of a chronic gonorrhoea resisting, perhaps, months of
treatment.  And if the patient shows no improvement, you
must not decline  to sound him.   You do  so, and find
nothing,  but that the prostatic urethra was very sensitive,
and you  make  him worse, perhaps, for a day or two.
  What  is to be done ?  First and  foremost, as a rule, ab-
jure all  instruments, which, in  most cases, can only do
mischief.  Treat it as you would a chronic inflammation of
the ear  or  eye—i. e. blister an adjacent surface; make  a
small blister every four or five days on  either  side of the
raphe of the perineum, by applying with a bru*sh the Lin.
epispast. of the Pharmacopoeia, not so freely as to distress
him or prevent locomotion, and keep it up for four or six
weeks.   I have found the best  results from this method,
combined with a tonic medicine and regimen, and you will
find the  patient himself gladly exchanging the dull weary
aching in the perineum  for the  smart of the blister,  and
cheerfully noticing  how the  former gradually subsides
under the influence of the latter.  In exceptional  cases,
where chronic gleet is a prominent symptom, the applica-
tion of a solution of nitrate of silver, not more than five or
ten grains to the ounce of water, to  the prostatic urethra,
may be very serviceable.
   I shall in my next lecture, proceed with diseases of the
bladder. 
180    DISEASES  OF THE  URINARY ORGANS.
                 LECTURE  XI.

  DISEASES  OF THE BLADDER ;  PARALYSIS ;  ATONY ;
          JUVENILE INCONTINENCE;  TUMORS.

  Gentlemen:—On two occasions recently a patient has
been sent to my ward affirmed to have "paralysis of the
bladder;" such, at least, is the statement that accompanied
them here.  On examining one of  them we found a not
unhealthy-looking elderly laboring  man, from whom, by
much questioning, we elicited the following facts: That he
was nearly sixty years of age;  that he has passed his water
much too frequently for four  or five years;  that he was
much disturbed at night to do it,  although lately it has
come away without his knowledge during sleep; that when
he makes an effort at work the same thing often happens;
that  the  stream is weak, falling almost perpendicularly;
that he has " no particular pains," but is not so strong as
formerly, having  become much weaker of late; and that
for the last few months the urine has been  cloudy and has
had a disagreeable smell.  With all  this his ordinary func-
tions had been fairly performed, and he had followed  his
daily labor until three weeks ago.
  The man was desired to unfasten his dress;  as he did so
you remarked a urinous odor, and that certain cloths, which
did duty  for an India-rubber receptacle—a luxury beyond
the means of  our patient—were wet  with the  secretion. 
            DISEASES OF  THE BLADDER.         131
Two conditions only could cause  this unhappy state of
things :  either the bladder was incapable of doing its duty
as a reservoir, and permitted the urine to  escape as fast as
it entered from the ureters, or it was unable to expel its
contents, so that it was over-distended by them, the surplus
oozing out, or being forced out, in the manner described.
  Now a glance of the eye might  have nearly sufficed to
settle this question.  I pointed out  a marked protuberance
above the pubic symphysis ; and after placing the patient
on his back, the dulness by percussion corresponding with
that spot, and the clear bowel-note all  round, diminished
the doubt that this was a collection  of fluid, if any such
doubt yet existed.  Still this was not quite all that it was
necessarv to know; it was just possible that the swelling
might be a solid tumor of the bladder, occupying its proper
space and much more,  and so destroying its function as a
reservoir.   To the hand, however, the protuberance was
clearlv made up of fluid ;  but even  this is short of absolute
demonstration, for the  most practised hand has been known
sometimes to " lose its cunning," or  to have found a too
deceptive quality in the object handled.  Finally, you saw
that a well-curved gum catheter glided into  the bladder,
and upwards of 40 ozs. of somewhat stale urine flowed off.
I then examined the prostate,  and found no  very  obvious
enlargement.
   Now.  was this a case  of "paralysis of the bladder?"
Certainly not.  His history showed  that he had had no
seizure of any kind, and I beg you to  understand that
without some change in a nervous centre there is no paraly-
sis of the bladder.  Recall, if you please, what I said in
my fourth lecture on this subject.   This  term is  applied, 
182    DISEASES OF THE  URINARY  ORGANS.
or rather misapplied, every day to  such  cases as the one
before us, and with the result not merely of masking the
true pathological state, which ought always, if possible,  to
be indicated by a nosological term, but of misleading the
inquirer, since it indicates a condition which by no  means
exists.
  What, then, is the defect or disease occasioning the symp-
toms in this case ?  Probably, atony of the bladder.  I will
speak presently with more precision.  The bladder fails  to
expel its contents in the two following conditions: either a
growth from the prostate, by no means  necessarily large,
obstructs the neck, so that the natural power of a healthy
bladder—which may, moreover, have been reinforced for
the difficulty, by hypertrophy of its fibres rendering  it
stronger—cannot propel the urine by or  over the obstruc-
tion into the urethra; or these muscular fibres of the blad-
der are so enfeebled, or even atrophied, that their propel-
ling power is lost or greatly diminished, and the organ be-
comes a thin flaccid bag, and can exert no expulsive force
upon its contents.
  The two conditions sometimes coincide.   We may have
hypertrophy  of the  bladder  following  obstruction from
stricture  of the urethra.  On the other hand, with obstruc-
tion from the prostate, the vesical coats sometimes extend
and become thin.  But atony may be produced without any
disease of the prostate, and then mainly from the subject  of
it having been placed in circumstances which obliged him
to retain his urine for a too considerable period, so that the
bladder became over-distended, and has failed subsequently
to regain its tone.  Unfortunately, a single error of this kind
will sometimes produce an irremediable atony. 
            DISEASES OF THE BLADDER.        183
  Now on further questioning our patient, we did not find
that he could recall any such instance, nor  that he  ever
formed  the  habit of  permitting   such  over-distension.
Neither did the affection occur suddenly;  on the contrary,
the symptoms  appeared gradually.  What  is still more
significant is, that they occurred just at  that time of life
when prostatic hypertrophy commences, if it appears at all.
Still, the prostate was not obviously large on examination
by the bowel.  We arrive, then, at the following conclu-
sions : That this man has some enlargement of the prostate,
which though not obvious in the rectum, consists in a small
nipple-like projection of the median portion,  occluding the
neck of the bladder, and that, from  the size of the bladder,
as just now demonstrated by percussion and by its contents,
its walls are thin, and have lost their contractile power;  in
other words,  are in a condition of atony.
  I think there is no escape from these conclusions, and I
beg that you will not only never permit yourselves to allude
to this condition as " paralysis," but that  you will protest
against so loose and improper a use of the term when you
hear it thus misapplied  by others.  Now, true paralysis of
the bladder occurs from injury to the spine, and also as one
of that large  group of symptoms which result from disease
in the cerebral or  cerebro-spinal centres.   You find it asso-
ciated with slightly unsteady gait, with impaired articula-
tion, or with some of  the slighter signs of such central
mischief, as wrell  as with those  which are most  obvious;
and I have even  found it  persisting after all other signs
have nearly—I cannot say  quite—disappeared.
  In all cases, as  in that of this patient  in the ward, it is
essential to empty the bladder by means of the gum catheter 
1S-A    DISEASES OF THE  URINARY  ORGANS.
three or four times daily, to remove the  urine completely,
and at least to offer the possibility of re-acquiring power to
the muscular coat, which does not exist so long as that coat
remains constantly distended by the retained urine.
  Next, for pure atony and for slight paralysis, uncompli-
cated with prostatic enlargement, a little  aid may be some-
times afforded to the patient through  the  agency of elec-
tricity, by cold douches and injections, and by tonics ;  but
less advantage is  to be derived  from these means, in  my
opinion, than some have appeared to  believe, although I by
no means  say they are not sometimes serviceable.   I have
seen an increase of expulsive power attained rapidly during
the daily application of an electro-magnetic current  to the
bladder, and in the following manner:  To one pole  the
ordinary handle and  moist sponge are attached, which is
placed over the lumbar vertebras; an  elastic bougie, con-
taining a conducting wire, and tipped with metal, is  attached
to the other pole, and is introduced into the bladder.   A
weak current is set going, and its effects  watched.   Thus a
slight sensation only is to be produced.  Move the bougie
about gently in contact with the walls of the bladder, the
urine having been just withdrawn; and,  finally, let  it  rest
a little in  the neck of the bladder, where  greater discomfort
is felt; in all, allowing the current to pass for eight or ten
minutes before withdrawing.
  A very different condition to that just described some-
times results after severe lesion, and also after local injury
—viz. inability on the part of the bladder to  act in  any
way as a reservoir. In this unfortunate situation the urine
leaves the organ by the urethra as fast as it enters by the
ureters.   This is  complete incontinence, in the true sense 
            DISEASES OF THE BLADDER.         185
of the term.  Little else than mechanical contrivances are
of any  avail.   And these  consist in  making  a reservoir
outside  instead of inside  the body;  one which  can be
emptied at  the patient's will.  Happily, such  cases are
very rare.
  But there is a partial incontinence which is very com-
mon, and which is, moreover, amenable to treatment.  You
will be  consulted by an anxious mother who, bringing her
boy or  a girl, of any age below puberty, and occasionally
above that period, tells you that every night, or nearly so,
this young  person wets  the bed.  Examples of this are
frequently seen in my out-patient room.  You know that,
in a child with a busy  excitable brain, muscular move-
ments occur during sleep of a much more active character
than those which usually occur in the adult, or in children
of a more placid temperament.  Anything up to somnam-
bulism  may take  place  during  sleep  in  a child whose
physique is  weak, and the slave of a restless, ceaseless
activity of mind; and micturition during sleep often occurs
in connection with this state.   Clearly, however, not only
in such cases; for  in some very dull  and  stupid children,
in whom intelligence appears to be below the average, the
same  thing  may happen.   And it  may also be admitted
that there are  cases which do not fall  into either of these
classes.   For such unfortunate patients all sorts of reme-
dtes and all kinds of management  are adopted,  including
even a  periodical employment of the birch—a species of
" cytisus" which I trust  you will never admit into your
own therapeutic scheme.   Depend upon it that  " punish-
ment" for this form of youthful frailty will not answer;
and whatever of strength to the moral faculty may be com- 
 186    DISEASES OF THE URINARY ORGANS.
 municated in obedience to the ancient injunction not to
 spare the rod—a question beyond our province to discuss—
 do not regard it as binding on us who practise the healing
 art.  The child's attendants often lose patience at the per-
 petual recurrence of the disagreeable infirmity, and believe
 it to be the result of wilfulness or of carelessness. I  have
 seen much cruelty practised, even by the nearest relatives
 of these unhappy offenders.   Give it no countenance what-
 ever.
   Now for treatment, briefly, and  as much  as I can on
 general  principles.  For class  the first, you will cultivate
 the physical side of life; remove as much as possible the
 sources of over-mental stimulation;  strengthen  the consti-
 tution through the agency of diet, country air, or sea-bath-
 ing, if possible, and give steel wine and cod-liver oil.   For
 class the second—those of torpid and deficient intelligence
 —you must  show the importance  of developing mind.
 Endeavor to call the will  into  play as much as possible,
 and enlist it to aid you in  preventing the act.  These are
 the children who are usually ill-treated;  instead of which
 they must be made sensible of the degradation of the habit,
 so as to get a stimulus for volition in relation to it.  Here
 remedies which  act specifically on  the organs are  most
 appropriate.  First and chiefest is belladonna;  which ap-
 parently paralyzes the expulsive muscles of the bladder
 and the sensitiveness of the organ at  the same  time.  Thus
 in elderly  people, who have feeble power to  expel the
 urine, a dose often produces complete retention, and  that
for some time, unaccompanied by consciousness of incon-
venience from it.  You give small doses, say of the tincture,
in the afternoon  and evening, increasing gradually when 
            DISEASES OF  THE BLADDER.         187
it may be necessary, and if the bladder is thus made to re-
tain  the  urine  all night for a few weeks, on relaxing the
dose gradually, the habit of retaining is found to be formed
and  to persist.  This  remedy is so excellent a one, that it
has almost  superseded blisters to  the  sacrum and  such
counter-irritants.   After it, nux vomica may be tried.
Then, for confirmed cases, after the failure of  other treat-
ment, especially for those who have arrived at puberty, or
thereabouts, a mild caustic solution to the prostatic urethra
—say ten grains to the ounce of water—has  answered in
my hands;  to  be repeated with  a stronger  solution  if
necessary.
  In all  cases inquire carefully for derangements  of diges-
tion, in all its stages, from primary stomach symptoms to
worms in the lower bowel—not unfruitful in their adverse
influence.   Of course you will take care that the  child has
not too much fluid, nor takes too much of  solid food con-
taining much water  in its  composition, during the latter
third of  the day; and that it is taken up to pass water late
in the evening, when its attendants go to bed.
   A short  sketch  of Tumors proper to the  bladder will
finish this part of our subject.  Of course you are to under-
stand that all those outgrowths from the prostatewhich come
under the head of hypertrophy, since they are  more or less
composed of structure identical  with, or very similar to,
that composing this organ, however much they may project
into the  cavity of the bladder, are not to be included in
the present class.
   Tumors proper to the bladder are of rare occurrence.  I
wish you to know what they are—what it is possible you
may meet with, so that you may have the chance  of recog- 
188    DISEASES OF  THE URINARY ORGANS.
nizing an example if it falls in your way.  As with those
in other parts of the body, they are classified according to
the amount of force which they manifest to invade  sur-
rounding structures, or to reproduce themselves elsewhere.
Thus, first, we have simple fibrous growths, chiefly in the
form of polypi, springing from the walls of the bladder,
and  wholly unassociated with the prostate; the  rarest of
all forms—in  short, exceedingly rare, known to me  per-
sonally only in museums.
   Secondly, there is the " villous or vascular tumor" of the
bladder, miscalled " villous cancer;"  for it has no invading
or reproductive power beyond the organ in which it arises.
   Thirdly, there is epithelioma—the lowest type of malig-
nant formation, and slowest of development.
   Fourthly, true scirrhus  occurs  in the walls of the blad-
der ;  and, much less commonly, encephaloid.
   Now, putting the first form out of the question, it  may
be said in general terms of all the rest, that the single and
most certain characteristic of the presence  of a tumor is
persistent vesical hematuria, no calculous or other obvious
cause existing.
   But never arrive hastily at the conclusion in  your  own
mind, nor even too readily admit the suspicion that tumor
is present: for you will remember, in the first place, that
it is exceedingly  rare, compared  with other  causes  of
similar symptoms; and, secondly, that there are no posi-
tive signs, or almost none which  can be so regarded, of its
existence.   It is only by a long process, and after much
careful watching of any case, and consequently when the
disease is  in a somewhat advanced stage of development,
that  you  can, per viam  exclusionis,  conclude with some 
DISEASES OF THE BLADDER.        189
reason that a tumor is present.   The symptoms are almost
identical with those of calculus, and the patient is  certain
to be  sounded more  than once or twice before tumor is
even suspected.  Suppose, then, that you have verified the
absence of stricture, of prostatic enlargement, of calculus,
of primary  renal disease, and  you are at  a loss to know
why your patient passes  water with great  frequency and
pain,  the secretion containing more or less  muco-pus, and
having blood in it often  or continuously, the quantity of
which is increased by exercise—you direct  your inquiries
to the existence of vesical tumour.  And you will proceed
thus:  First, you will introduce  into the bladder the short-
beaked sound, and with a finger  in the rectum you  will
carefully explore the thickness of the structures inter-
vening between the finger and the sound. Next, the sound
being still in the bladder, you will not find much difficulty,
provided the  patient is thin, in gaining some information
of a  like kind  by palpation above and behind the pubic
symphysis.   Further, by movements of the sound itself,
you may detect a hard mass of scirrhus on either side of
the vesical walls, the sound not turning over readily to the
 left or right, as the case may be.  You will not discover a
 villous tumor thus, for it is much too  soft, and will elude
 the  most delicate traversing of the  cavity which can be
 achieved.   Even an epithelial growth, which  is  usually
 wide  in its base, of flocculent surface, and sprouting into
 the  cavity, although not very luxuriantly, is so  deficient
 in induration as not to be readily discoverable. It scarcely
 destroys  the  flexibility of  the  vesical coats, which is the
 fact you have to ascertain.
   Next, you  may search for enlarged glands in  the iliac 
190    DISEASES  OF THE  URINARY  ORGANS.
regions, but they  are palpable only in advanced cases of
scirrhus, and you will obtain such  light on the subject as
a search for cancerous growths in other parts of the body
may afford you.  Thus, not long ago, I had my diagnosis
of cancer of the bladder in the case of an elderly patient
made certain by the appearance of a secondary growth,
springing from the cranium.
  Again,  you will repeatedly and  carefully examine the
deposits  in  the urine for the appearance of organic ma-
terials cast off from the growth, which may serve to indi-
cate its nature.  Thus I have detected under the microscope
the peculiar structure which the processes  of  the villous
tumor present  to the eye.  But  what of the  cells of epi-
thelioma,  and what of " cancer-cells ?"  I am compelled to
resign to others—and I am well aware that several writers
on this subject  have proclaimed  the value of microscopic
examination  of the  urine  in  vesical cancer—the  good
fortune of identifying malignant disease by  this means.
First, suppose  you have  caught your " cancer-cell,"  are
you prepared to swear to its identity ?  As students, I will
assume you have  examined, say  a few hundred specimens
of urine,  not many, but enough, at all events, for my  pur-
pose,  and that you have, therefore, not a little perplexed
yourselves, if you are of an inquiring turn, with all that
fruitful progeny of cells, epithelium of different parts and
in all stages of growth, &c, which  are desquamated  in
health, but especially under  the  influence of any morbid
action in those passages, and which appear therefore in the
urine. Some of the best " cancer cells" I ever saw in my
life were collected from a patient's urine, and placed under
the microscope by an eminent microscopic observer, for 
DISEASES OF THE BLADDER.         191
the purposes of a very important  consultation, at which I
assisted.   After a careful examination of the  patient,  I
admitted  the  beauty  and perfection  of  the microscopic
observation, but on larger grounds denied the existence of
cancer in the bladder ;  and the ultimate result, happily for
the patient, confirmed that view,  and disproved the cell.
Most valuable as is the  microscope in this  great class of
maladies,  ranking next, and very near to, the sound itself,
never  let it obscure for you those broad features of the
case which are to be determined by the unassisted eye and
touch, as applied to the  body, and to the urinary  secre-
tion itself through  the  means of  reagents.  But when
you find, as sometimes happens,  distinct masses of soft,
almost  semitranslucent  structure  of  considerable  size,
passed by the  urethra at micturition, and discover on ex-
amination that these evidently  consist of rapidly formed
cell-growth, the cells of large dimensions, and containing
two or three nuclei, the observation will go far to confirm
your suspicions of cancer aroused by pre-existing  symp-
toms.
   Lastly, you will, in  endeavoring to determine the par-
ticular kind of growth, observe the nature of the hemor-
rhage and the character of the pain.  In malignant disease,
the  hemorrhage is irregular  in  its occurrence, long inter-
vals being sometimes observed in which no bleeding ap-
pears; and when it does take place it is often in considera-
ble quantity, and it may persist for  some time;  moreover,
the blood is usually  of a florid color.  In villous growths
the  urine is generally more persistently  colored, and pre-
sents a reddish tint, resembling the juice of raw meat—
not dark or smoky in hue;  occasionally, however, rapid 
192    DISEASES OF THE URINARY ORGANS.
and  considerable hemorrhage  takes  place.  The  pain  of
cancer is more  constant and  severe  than that of villous
growth, the latter not being necessarily accompanied with
great pain, unless obstruction  to the outflow of urine  is
produced by the tumor.
   What shall I say here respecting the treatment of vesi-
cal tumor ?   That it must be  shaped  according to the ex-
istence  or predominance of certain symptoms, which may
be regarded as three in number: hemorrhage; painful and
frequent micturition; retention of urine.
   For the treatment of hemorrhage, I  have little to say for
the internal astringents; I mean those administered by the
mouth, as gallic and tannic acids, lead, alum, matico, &c.;
the last named being perhaps the best. I know nothing so
valuable as injections into the bladder of nitrate of silver,
commencing with a very weak solution.  But for the local
treatment of vesical hemorrhage, never forget how essen-
tial are delicacy and gentleness in all  your manipulations,
otherwise you will provoke hemorrhage  rather than re-
strain it.
   For alleviation of pain or frequency of micturition do
not spare opiates—trying any form, or all forms in turn,
until  you find that which most assuages it and  least dis-
turbs the digestive organs.  Give them by mouth, subcu-
taneously, or by suppository.   Never mind how much, in
order to  act effectually.  It is not a question of saving life,
but a question of mitigating that  most frightful of human
miseries—prolonged, continuous, severe bodily suffering;
and this for  a patient whose doom is certain, and to whom
life has  come to be for the most  part a dire  calamity.
While you are bound, therefore, on the one hand, jealously 
            DISEASES OF THE BLADDER.        193
to guard life, I hold that  you are equally responsible, on
the other,  that  it shall be rendered fairly endurable.   I
confess that I have felt sometimes almost indignant at the
sight  of a  poor fellow-creature, worn out with anguish,
praying for death, who, thanks to a well-meaning but weak
timidity, is permitted only such small comfort as fifteen  or
twenty  minims of liquor opii, or of a solution of morphia,
once or  twice in the twenty-four hours can afford.
   For the  relief of retention,  such catheterism  must be
applied  as the case requires, whether periodically or con-
tinuously, as the comfort and the exigencies of the patient
render desirable.
   I shall close this course with a lecture  on " Hematuria,"
which will permit me to glance at most of those subjects
which have not yet come under our consideration.
13 
194    DISEASES  OF  THE  URINARY  ORGANS.
                 LECTURE  XII.

          HEMATURIA AND RENAL CALCULUS.

  •Gentlemen:—I propose  to-day to  complete the pro-
gramme I originally designed for this course by consider-
ing a phenomenon of common occurrence known as Hasma-
turia.
  Let us  define the  term.   What is Hasmaturia?   The
outflow  of urine containing blood in admixture.  Thus
bleeding  from the penis at other times than at that  of
micturition is, of course, not hasmaturia.  Bleeding coin-
cident with micturition from chordee, or operation, or from
any known injury in the course of the urethra, is  also not
to be included.   The blood then usually issues by the side
of the stream of urine, and  is only partially mixed at its
line  of contact, or it  may follow rather than accompany
the urine.
  Hasmaturia, then, is a symptom.  Its presence is, in all
cases of urinary disease, to be sought.   Hence the inquiry
forms one question—the third—of the necessary four which
I instructed  you always to ask in forming  a diagnosis.
Here is a glass of urine, evidently containing an admixture
of blood.  What is the source of it ?   Now, it is often not
an easy thing to state at once what point of that long and
complicated organic  apparatus, which  commences in the
Malpighian corpuscles and ends at the external  meatus, is 
       HEMATURIA  AND RENAL CALCULUS.    195
the source of the blood in question.  Sometimes  it is ex-
ceedingly difficult to define its  source.   Thus  it is that in
medicine you will often find some symptom, the pathologi-
cal cause of which is not very  obvious, getting a specific
name, which comes at length to denote a distinct  disease ;
and just as you will be asked, as I told you the other day,
what is good for dropsy, you may also be asked what is
good for hasmaturia.
   Now, the consideration of this question, besides affording
us new material for inquiry, will bring us over some of the
ground we have already travelled together.  I  don't regret
that—for your sakes, I mean.  It will  stand  in  the same
relation to the past as the arithmetical " proof" does to the
already worked sum.   It is in some respects a synthetical
operation following an analytical one.   When, therefore,
you see a specimen of urine containing  blood,  you will, as
a matter of course, make a rough mental note of the pro-
portion of blood present,  and  you will mark the color.
And as you can count on your fingers the ordinary sources
of blood, these will pass rapidly in review at the same time.
Let us name them as follows:—
   1. The kidneys, where it may be  from diseased action,
more or less temporary, as inflammation ; or from disease
more or less persisting, as degeneration  of structure; or
from  mechanical injury, as from calculus there,  or by  a
strain, or a blow on the back.  If the hasmaturia  is the re-
sult of inflammation, there will be general fever  denoting
its presence;  if produced by  slow organic change, there
will be the history of  failing  health, and probably urine
changed in quality otherwise than by the mere admixture
of blood.  Where blood is in very small quantity,  as it will
naturally be at times, note the character  of the urine proper 
196    DISEASES OF  THE URINARY ORGANS.
—whether of low specific gravity, pale, with albumen in
greater proportion than blood or pus will account for ; per-
haps renal casts may be found;  and look out for dropsies
in any degree.  In both the preceding forms, if blood is
present, it will give the smoke tint to the secretion.  Per-
haps it  may be affirmed that such  urine, associated with
very little if any local pain, is more likely to come from
the kidney than  elsewhere.  In  malignant  renal  tumor,
blood may be large in quantity at times; the rapidity of
growth and the size attained, are the marked characteristics
of the disease.   If mechanical  injury be the  origin  of
hasmaturia, there will  be the history of a blow  or  strain;
or there may be the signs and symptoms of renal calculus,
of which more detail presently.
  2. Then, putting aside the ureters, you will  remember
the bladder as the second source of hemorrhage; and here
it  may be due to severe cystitis, calculus, or  tumor.  The
first is obvious enough from muco-pus in the  urine, and
through other signs; while  the second may well be sus-
pected by the symptoms, and its  presence realized by the
sound.  Here the hemorrhage is usually florid, and in pro-
portion to the patient's movements.  But the third condi-
tion—namely, that the hemorrhage arises  from tumor—is
not always so readily to be affirmed.   As a rule, however,
blood from such  a source is larger in quantity  than from
stone, and may be associated with  less of muco-pus.   If the
tumor is malignant, it may be felt  by examination, and the
pain is often severe;  if villous, it gives an even pale-red
tint for  days together to the urine; and in both cases the
blood is  florid, unless it is long  retained in the bladder,
when dark sanies, like coffee grounds, results.
  3. In hemorrhage from the prostate, the third principal 
       HEMATURIA  AND RENAL CALCULUS.    197
locality or source, the same thing  occurs, if the organ is
hypertrophied and the blood is retained; but here the age
of the patient, and the ascertained  condition of the organ
from the bowel, aid the diagnosis.   A slight appearance of
blood mixed with the  last few drops of urine is not a rare
occurrence in chronic prostatitis.
  4. When bleeding arises from stricture of the urethra,
the patient's history and the cause of the bleeding, almost
always instrumental, leave no room for doubt.   From the
use of instruments also in the bladder, hemorrhage some-
times  arises.  Then it is not to be forgotten  that  occa-
sionally blood is found in the urine as the result of violent
diuretics, from purpura, in  fevers,  and  in a hemorrhagic
diathesis.
  Now for the treatment of hemorrhage.   When you have
determined that its source is above  the bladder—that is, in
the kidney or in its  pelvis, probably the first and  most
 influential remedial agent is rest in the recumbent position.
Whether from a lesion affecting the intimate structure, or
from the mechanical irritation of a calculus in  any part of
the organ, rest is the first and the essential condition.  The
patient is, moreover, to be  maintained  in as cool and tran-
quil a state as possible.
  It is in renal more than in any other form of hasmatiuria,
perhaps, that direct  or internal astringents or  styptics are
useful. I shall do no more than name those which are most
commonly used—namely, gallic and tannic acids; lead and
turpentine; equal  to them is, I  think,  the  infusion of
matico, say in doses of two ounces every two or three hours.
The tincture of iron, and also sulphuric acid, may  some-
times  be  taken with advantage.
                          13* 
 198    DISEASES  OF THE  URINARY  ORGANS.
   It is, however, in cases of severe hemorrhage from  the
 bladder, or more commonly from an enlarged prostate, that
 active and judicious treatment is necessary.   You will be
 called sometimes to a patient wrhose  bladder  is distended
 with coagulated blood, or who is passing frequently a quan-
 tity of fluid in which blood is the predominating element.
 Usually this has arisen from some injury inflicted by  the
 instrument,  although it may also be from tumor of  the
 vesical walls.  Here you will keep the patient on his back,
 and forbid the upright position, or any straining, so far as
 you can prevent it, in passing water.  To this end give
 opium liberally, to subdue the painful  and continued action
 of the bladder.   Apply cold by means of bags of ice to  the
 perineum  and  above  the pubes.   Better still,  introduce
 small pieces of ice into the rectum.  Do not use an instru-
 ment if it is possible to do without it.   There is a great
 dread  in some  people's minds about the existence  of a
 large  coagulum in the bladder.   I have even  known a
 bladder to be opened above the pubes by the surgeon,  for
 the mere  purpose of evacuating a mass of clotted blood.
 Leave  it alone:  it will gradually be dissolved and got  rid
 of by the  continued action of the urine; while if you are
 in haste to interfere, and are  very successful in removing
 it, you will succeed also most probably in setting up fresh
 hemorrhage.  The bleeding vessels have a far better chance
 of closing  effectually if they are not subjected to mechani-
 cal interference.   Meanwhile, support  the patient's powers
by good broths, &c.
   But it sometimes happens that  hemorrhage occurs in a
patient who has long lost all power of passing urine except
by catheter.   This is a very different  position.  Here the
coagulated mass which fills the bladder must sometimes be 
       HEMATURIA AND RENAL CALCULUS.    199
removed, or no  urine can be brought  away.  Thus, you
introduce a catheter, and none appears,  for the end of the
instrument passes into  a mass of coagulum, and nothing
can issue.   Sometimes sufficient may be removed by attach-
ing to a large silver  catheter a six-ounce syringe or a
stomach-pump.  Clover's lithotrity apparatus has answered
remarkably well with me in two or three instances.  Let
me caution you, as a rule, never to inject styptics into the
bladder in these circumstances; the irritation does more
harm than good.  The only  exception I have  ever found
serviceable has been in injecting a little iced water, or iced
solution of matico, immediately after removing the clots
from the bladder.
  In passing to another subject, I beg  to call your atten-
tion to a glass before you containing some urine of a dark
and somewhat unnatural tint.  Let us interrogate the case
of  the  patient from whom  it came.   In obtaining this
specimen  I took  care  that he should first pass about an
ounce into a  separate vessel, to clear his urethra—a pre-
caution  always absolutely necessary to avoid  error,  as I
have before warned you—and the remainder into this.  It
is less translucent than  average healthy urine is, and has a
deeper color.  The hue is not red, but slightly orange, with
a dirty brownish tint, commonly and .very well distinguished
by the word " smoky."   That tint denotes blood to an ordi-
narily practised  eye.  Why is it not red ?   Because blood,
after a  certain term of contact with urine, loses  its red
color and becomes brown ; and you see it in that condition,
or according to the quantity, producing any depth of hue
from this up to that of  London porter.  Put  it under the
microscope, and you will find plenty of blood-corpuscles.
We get this broad principle,  then-, to start with :  bleeding 
200    DISEASES OF THE URINARY ORGANS.
from the more distant parts of the urinary system, unless
in very  large quantity, will  almost certainly make the
urine brown, while  urine  which contains  red blood has
almost certainly issued recently from some source in the
bladder, probably at  or near its neck, these being the more
common sites of vesical hasmaturia.
  In the case before us, then, we proceed easily and rapidly
to eliminate many of the sources of bleeding by physical
exploration, and by the account which the patient gives of
his sensations.  He makes a good stream when a fair amount
of urine has accumulated in his bladder, but this  does not
often happen, for he passes  it every two  hours, or  less, in
the day, not so frequently at night:  no straining  is neces-
sary.   Pain in the course of the urethra is experienced
during and after  micturition; not severe.   He is uneasy
about the pelvis and loins  on  taking exercise, and  more
blood passes afterwards.  He is somewhat emaciated, and
so presents a good condition for examination by the hand.
He is subject to variation in the intensity of the symptoms,
having now  and then attacks of a few  days'   duration
in which they are aggravated, and he dates their commence-
ment in an attack which occurred seven years ago.  His
age is forty five years.  He  has never passed gravel.  He
is much  less robust  than formerly ; his digestion  is not
good.  A full sized bougie  passes easily into the  bladder;
no stricture ; hypertrophy of prostate at his age not possi-
ble.  On sounding, he is manifestly more tender than usual;
nothing is felt, nor any deviation from the natural condition,
by simultaneous examination  by the rectum.  Palpation
of lower part of  abdomen shows nothing.   Arriving close
under the last ribs of left  side with one hand, the other
pressing firmly on left renal region, he flinches unmistaka- 
        HEMATURIA AND RENAL  CALCULUS.    201
bly; that is the spot,  he says, where he feels pain at times
and on movement;  right side, nothing.  We examine his
urine: sp. gr. 1018, acid, small brownish deposit on stand-
ing; under  microscope, blood-corpuscles,  some pus-cor-
puscles, epithelium, no crystals, no casts ; albumen, a little ;
corresponding with organic matters present.
   What is the seat of the lesion in his case?  You say,
perhaps the bladder:  we found it tender to the sound, and
it acts with undue frequency.  Yet remember this is by no
means evidence of any primary morbid change there, such
conditions constantly  accompanying diseases affecting pri-
marily the kidneys or the upper part of the ureter.  Much
more probably the kidney.   The manifest local tenderness,
the repeated attacks, the impaired health, the history, the
absence of all the more common  causes of cystitis in any
form, point to the left kidney as the seat of mischief.   The
absence of albumen and renal  casts—a fact of not much
weight, although their presence is of the utmost importance
—lead us to believe him free from organic changes affecting
the renal organs.  I conclude  that  his left kidney is the
seat of calculus, although he  has never passed one, and
has at present no crystalline deposit in his urine—a fact by
no means essential to  the diagnosis; and that this calculus
is the source of the blood and pus found in his urine.
  It is  sometimes not easy to say what kind of calculus
exists in these cases,  of which this is  a fair type.  When
any calculous matters have been  passed which  can be
examined, or when  the crystalline  deposit in the urine is
constant, the inference is pretty clear.  Add to this that
the probability in any case is strong in favor of uric acid,
from its known  frequency of occurrence — taking large 
202    DISEASES OF THE URINARY ORGANS.
numbers, say at least fifteen to one as compared with oxa-
late of lime.
  For treatment:  Alkaline diuretics and diuretic vegetable
infusions, before named, for a period of time;  attention to
the digestive  functions and to that of the skin, for  the
kidneys are probably working too much vicariously  for
some other function acting lazily;  moderation in highly
nitrogenized food; mild alcoholic drinks, perhaps in most
cases permitting only a light and  mild Bordeaux.  Of all
medicinal remedies,  perhaps  none are  so valuable  as
mineral waters, especially those  which have  sulphate of
soda, largely diluted,  as the main  ingredient.  Take Carls-
bad, Friedrichshalle, and Marienbad as examples.  For two
well-known  remedial agents, which  are very popular, each
among its class, I am bound to tell you, I have very small
esteem.  Here, in town, it seems to  me  that every man
advises his neighbor, and on every pretext, to drink Vichy
water—advice which  is cheap, and  of which the  value in
most  instances by no means exceeds the  cost.   In  the
country,  where perhaps the fairer  sex more  usually  dis-
pense similar aid  to their suffering neighbors, the  prescrip-
tion is mostly gin-and-water.  Of the first, or natural
product, which is a strong solution of  carbonate of soda, I
must say that, if not absolutely injurious, it is  at least greatly
inferior to potash; and of the second, or artificial  one, that
it is about as serviceable to the kidneys as a pair of spurs to
a jaded horse—makes him travel for a time, but takes it out
of him in the long run. For the paroxysms of severe pain
which denote the passage  of a renal calculus, you will  find
hot hip-baths, prolonged or often repeated,  of the greatest
service; the temperature may  be increased to anything the
patient can  bear.  Large doses of  opiate, also, to assuage 
       HEMATURIA  AND RENAL CALCULUS.    ZV6
severe pain;  and abundance of barley-water, potash-water,
or the like, for drink.
  I shall here, by way of episode, refer to a mode of deter-
mining the true characters of  a patient's urine, which is of
extreme value  in some doubtful cases—a mode which has
never  to my knowledge been recommended or practised,
and which I have systematized for myself.  I have already
told you how essential it is to  avoid admixture of urethral
products with urine, if you desire to have a pure specimen.
It is sometimes quite as essential to  avoid its admixture
with products of the bladder.  And I defy you to achieve
an absolute diagnosis—by which I mean a demonstration,
and  never be  satisfied with  less, if it be practicable—in
some few cases, without following the method in question.
When, therefore, it is essential to my purpose to obtain an
absolutely pure specimen of the renal secretion, I pass a soft
gum catheter, of medium size, into the bladder, the patient
standing, draw off  all the urine, carefully wash out the
viscus by repeated small injections of warm water (before
shown to be rather  soothing  than irritating in their influ-
ence), and then  permit  the urine  to pass, as it will  do,
guttatim, into a test-tube,  or  other small glass vessel, for
purposes of examination.  The bladder ceases for a time to
be a  reservoir; it does not expand, but is contracted round
the catheter, and  the urine  percolates from  the ureters
direct.  You have, indeed, virtually just lengthened  the
ureters as far as to. your glass. And now you have a speci-
 men  which,  for appreciating  albumen, for determining
 reaction, and for  freedom  from  vesical pus,  and even
 blood, and from cell-growths of vesical origin, is of the
 greatest value, and has often furnished me with the only
 data previously wanting to accomplish an exact diagnosis 
 204    DISEASES  OF  THE  URINARY  ORGANS.
 Mind never  to be  satisfied to guess at  anything;  make,
 very cautiously,  if you  will, your  provisional theories
 about a doubtful case—indeed, the intellectual faculty will
 do this  constantly,  and without  reference to the will—but
 arrive at no conclusion, take no action, except so far  as
 you are warranted by facts.
   I have  reserved these few words to the  last, as the
 most important.  The first words I uttered in this course
 were designed to convey to you my strong  sense of the
 importance of acquiring the  habit of making an accurate
 diagnosis, and a rapid one, if possible.  My last shall be to
 express once more the same conviction.  Not because I
 undervalue the subject of treatment, but precisely with the
 opposite view; being anxious, above all things, that you
 and I should afford some essential  service to  those who
 have confided to us the care  of their maladies. I adjure
 you to spare no pains to obtain the most  complete know-
 ledge of  the complaint  itself, since it is the only mode  of
 arriving at a knowledge of what will  be sound and efficient
 treatment.
   I beg to  thank you for  the  extreme attention and assi-
 duity with  which you have followed me during this course,
 and to assure you that such a  manifestation on your part
 has rendered our meetings for these  colloquial discourses
 some of the most agreeable relaxations which have fallen
to my lot, to vary the routine of an anxious and very active
professional life.
THE  END. 
• 
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