--V -^•'Y'-"^* £.•>-.' 8& ■m \ Columbia Umbergitp intljeCttpofifretoiSorfe College of ^fjpstctan* ano burgeon* Reference lUbrarp NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland Gift of Edward B. Schlesinger, M.D. m*mmrmim***m •fW* HH^mwotspv > \ A PRACTICAL TREATISE ON THE DISEASES AND INJURIES OP THE URINARY BLADDER, THE PROSTATE GLAND, AND THE URETHRA. BY S. D. GROSS, M.D., PROFESSOR OF SURGERY IN THE UNIVERSITY OF LOUISVILLE; MEMBER OF THE AMERICAN MEDICAL ASSOCIATION; AUTHOR OF "ELEMENTS OF PATHOLOGICAL ANATOMY," ETC., ETC. WITH ONE HUNDRED AND SIX ILLUSTRATIONS. PHILADELPHIA: BLANCHARD AND LEA. 18 51. Entered, according to Act of Congress, in the year 1851, BY BLANCHARD AND LEA, In the Clerk's Office of the District Court for the Eastern District of Pennsylvania. 0. SHERMAN, PRINTER. PREFACE. The object of this work is to present, in a systematic and con- nected form, a full and comprehensive account of the diseases and injuries of the urinary bladder, the prostate gland, and the urethra. No apology can be necessary for such an undertaking. For many years I have myself felt the want of just such a book, or, at any rate, of one very much like it. No practitioner, who has been at all extensively engaged in the active duties of his profession, can have failed to perceive, as well as to lament, the defects which exist in the literature of this particular department of the healing art. While every other organ of the body has had its expounder and monographist, it is a singular fact that no systematic treatise has yet appeared, in the English language, on the maladies of the structures in question, especially those of the bladder, which are so common and so important, both in their pathological and practical relations. There has not yet been an attempt made on the part of any Ame- rican writer to supply this deficiency; and it is no disparagement to the foreign works which have been republished in this country to assert, that, valuable as in many respects they are, they are far in arrear of the existing state of the science to which they relate. The treatise of Sir Benjamin Collins Brodie, the very best in the English language, is a mere outline of the subject; and the same is true of the excellent volume of Mr. Coulson. The student seeks in vain in these productions for a full and comprehensive exposition of xii PREFACE. the nature, causes, symptoms, and treatment of the various lesions of the urinary apparatus, and of the operations which are required for their relief. He rises from their perusal unsatisfied and discon- tented, regretting that writers so able, intelligent, and experienced, should have limited themselves to so superficial a discussion of such an important and interesting class of affections. The monograph of the late Dr. Parrish, of Philadelphia, is a mere sketch of the more common diseases of the urinary bladder, and was never designed by its lamented author as a systematic treatise. Regarded as a record of the experience of an excellent observer and a skilful surgeon, it is exceedingly valuable, and cannot be too strongly recommended to the practitioner. It would, in fact, be difficult to find within the same compass, in the English language, a more truly useful contri- bution to the science of our profession. From the circumstance, however, that it has never been published in a separate form, it is doubtful whether it has received from the physicians of this country the consideration to which its intrinsic merits entitle it. Dr. Par- rish enjoyed for many years a most extensive practice, and there never has been a member of the American medical profession whose statements are more worthy of credit, or whose writings are charac- terized by a higher tone of moral feeling, or a greater share of genuine modesty. His remarks on retention of urine, and the use of the catheter, should be read and studied by every physician and surgeon. It will thus be perceived that I have written this work, not merely for the sake of composing a book, but for the purpose of filling, if possible, a void in medical literature. I have endeavoured to per- form for the bladder, the prostate gland, and the urethra, what has been so well done by Lawrence and Mackenzie for the eye, Hope for the heart, Budd for the liver, and Curling for the testis. How far I have succeeded in my design it is not for me to judge. Suffice it to say, that I have aimed honestly and faithfully to discharge the duties which I had thus voluntarily assumed, and that my sole ob- ject has been to furnish a monograph on the diseases and injuries of PREFACE. Xlll the urinary organs, that should be worthy of the favourable con- sideration of my professional brethren, and also, I trust, in some degree, of the present state of medical science in this country. The materials of which the work consists have been gradually ac- cumulating upon my hands for a long time; but it has been only within the last three years that the labour of arranging them, and of putting them in their present form, seriously occupied my atten- tion. The task, although not a light, has been an agreeable one. As the subject expanded under my eye, my feelings became more and more interested, and I almost regretted, when the last line was written, that my labour was ended. In looking over the printed sheets, as they have been sent to me by my publishers, I have found, here and there, an expression or a sentence that might have been improved, if I could have personally superintended the press; but the errors are, I believe, few and unimportant, and such as an indulgent reader, intent upon the acquisition of knowledge, rather than the discovery of faults, will readily excuse. My friend, Dr. Francis Gurney Smith, the talented editor of the Philadelphia Medical Examiner, is entitled to my warmest thanks, for the able manner in which he has corrected the proofs. The labour of superintending the press of a large scientific work may be imagined by the reader, but can only be appreciated by him -who has actually experienced it. The work is illustrated by upwards of one hundred engravings on wood, of which nearly one-half are from drawings prepared expressly for it, under my immediate supervision, by Mr. Henry A. Daniels, of New York, a young artist of great promise. Their fidelity may, therefore, be fully relied upon. The engravings were executed by Mr. W. B. Gihon of Philadelphia, whose skill in this particular depart- ment of art is well known. It was originally my intention to issue a separate volume of plates, of the full size of nature, as a companion to the text; but it was soon discovered that such a proceeding would so enhance the expense of the work as to place it beyond the reach of many of xiv PREFACE. those for whose benefit it is more particularly designed. The plan was, therefore, abandoned, though it is my intention to carry it out at some future period. It is proper to add, that a number of the drawings are from preparations in the pathological museum of the New York Hospital, to which, through the kindness of Dr. Post and Dr. Watson, free access was afforded me by Dr. Bowen, the polite and accomplished curator of that beautiful and valuable collection. My acknowledgments are also due, for similar favours, to Dr. Sabine, of New York, to Professors Parker and Watts, of the Col- lege of Physicians and Surgeons of that city, and to Professor Cox, of the New York Medical College. Louisville, June, 1851. TAELE OF CONTENTS. INTRODUCTION. CHAPTER I. PERINEUM. Boundaries, Skin of—Cellulo-adipose Tissue of—Superficial Fascia of—Ischio- rectal Fossa—Central Tendon of Perinseum—Transverse Muscle—Erector Muscle—Accelerator Muscle—Sub-pubic and Triangular Ligaments—Com- pressor Muscle of Urethra—Pubo-urethral Muscle—Glands of Cowper— Arteries of Perinseum—Internal Pudic—Accessory Pudic—Branches of In- ternal Pudic—Depth of Perinseum—Extent of Urethral Portion—External Surface of Perinseum—Ano-perinseal Compartment—Sphincter of Anus— Rectum—Recto-urethral Triangle, ----- 33-53 CHAPTER II. URINARY BLADDER. Description and Position—Relations of Bladder—Vesical Ligaments—Divi- sions of Bladder—Surfaces—Neck of the Bladder—Fascia and Ligaments of Bladder—Urachus—Mouth of the Urethra—Ureters, Orifices of—Vesical Trigone—Uvula of the Bladder—Bas-fond—Structure of the Bladder—Arte- ries of the Bladder—Development of the Bladder, - - - 54-66 CHAPTER III. ANATOMY OF THE PROSTATE. Description and Position—Relation of Prostate—Natural Dimensions of Pro- state—Colour—Consistence—Vascularity, ... - 67-75 CHAPTER IV. URETHRA. Extent, Diameter and Length—Direction—Divisions of Urethra into Prostatic, Membranous, Bulbous, and Spongy—Membranes of the Urethra—Mucous Follicles of Urethra, uses of, - - - - - - 76-83 XVI CONTENTS. CHAPTER V. URINE. Quantity Voided in Health—Colour—Specific Gravity—Reaction—Varieties of Urine, Potous, Chylous, and Sanguineous—Analysis of Urine—Changes of Urine in Disease—Albumen, Fibrine, Blood, Pus, and Kiesteine—Cystic and Xanthic Oxides—Oxalic Acid—Sugar—Oil—Bluish and Black Urine—Sedi- ments of Urine—Hairs in the Urine, - - - . . 84 DISEASES OF THE URINARY ORGANS. PART I. DISEASES AND INJURIES OF THE BLADDER. CHAPTER I. MALFORMATIONS AND IMPERFECTIONS. Section I. Absence of the Bladder—Terminations of Ureters in absence of Bladder, into the Rectum, the Vagina, or into the Urethra. Section II. Bilobed and Anomalous Bladder, examples of. Section III. Extrophy of the Bladder—Case and Description of—Description of Accessory Organs in Extrophy of Bladder in Male and Female, - - - 95-102 CHAPTER II. INJURIES OF THE BLADDER. Section I. Wounds of the Bladder—Varieties of—Incised—Symptoms—Gun- shot, Description of—Treatment of Wounds of the Bladder. Section II. Laceration of the Bladder—Causes—Age most Liable—Complications—Va- rieties of Lacerations—Symptoms—Diagnosis—Appearance' on Dissection— Sources of Danger in—Treatment, ----- 109-116 CHAPTER III. INFLAMMATION OF THE BLADDER. Section I. General Observations—Acute Inflammation—Extent—Causes— Anatomical Characters—Symptoms—Diversity of Symptoms according to CONTENTS. xvii Seat—Course—Prognosis—Treatment—Treatment when Dependent on a Cal- culus—a Foreign Body—Strangury—Gonorrhoea—Gout or Rheumatism— Repulsion of Cutaneous Disease—Stricture—Retention in Cystitis. Section II. Fibrinous Exudation of the Bladder—Causes—Cases Illustrative of— Coexistence—Physical Properties—Form—Effects—Symptoms—Treatment. Section III. Suppuration and Abscess of the Bladder—Situation and Point of Discharge—Symptoms—Diagnosis—Prognosis—Treatment. Section IV. Gangrene of the Bladder—Causes—Sometimes Epidemic—Anatomical Cha- racters—Rupture—Prognosis—Treatment. Section V. Ulceration of the Bladder—Size, Shape, and Depth—Sometimes Consecutive—Reparation— Causes—Symptoms—Diagnosis—Prognosis—Effects on neighbouring Organs —Morbid Alterations—Perforation and Adhesion—Treatment—Cases of Ul- ceration of the Bladder, ------ 117-162 CHAPTER IV. CHRONIC LESIONS OF THE BLADDER. Section I. Catarrh and Hypertrophy of the Bladder—Synonym—Varieties of —Age most Common—Symptoms—Diagnosis—Prognosis—Morbid Alterations —Treatment. Section II. Bar-like Ridge of the Neck of the Bladder—Shape —Description — Direction—Structure — Age most Subject — Symptoms— Diagnosis—Treatment. Section III. Sacculation of the Bladder—Synonyms —Development of a Pouch—Number, Size, and Form of Pouches—Contents —Part of Bladder Affected—Origin—Symptoms—Prognosis—Treatment, 163-191 CHAPTER V. NERVOUS AFFECTIONS OF THE BLADDER. Section I. Irritability of the Bladder—Characteristic Symptom—Age and Temperament — Symptoms — Diagnosis — Causes—Pathology—Prognosis— Treatment. Section II. Neuralgia of the Bladder—Synonym—Descrip- tion of Disease—Symptoms—Diagnostic signs—Causes—Period of Life most Liable—Treatment—Cases of Neuralgia. Section III. Paralysis of the Bladder—Causes—Varieties of—Symptoms—Prognosis—Treatment, 192-238 CHAPTER VI. HETEROLOGOUS FORMATIONS OF THE BLADDER. Section I. Scirrhus of the Bladder — Rarity — Coexists occasionally with Scirrhus in other Organs—Causes—Appearances on Dissection—Diagnostic Signs—Cases. Section II. Encephaloid—Seat—Number and Appearance of Tumours—Time of Duration—Influence of Age and Sex—Symptoms— Treatment—Cases of Encephaloid Disease. Section III. Colloid and Mela- nosis of the Bladder. Section IV. Tubercular Disease of the Bladder— Seat of Deposit, ------- 239-260 2 xviii CONTENTS. CHAPTER VII. FUNGOUS, ERECTILE, AND OTHER MORBID GROWTHS OF .THE BLADDER. Polypes, Description and Seat of—Age Liable to—Fatty and Steatomatous Growths of the Bladder—Rarity of Occurrence—Fungous Growths—Age and Sex most Liable—Form and Description of—Erectile and Vascular Tu- mours—Exciting Causes and Diagnostic Signs of these various Growths— Treatment,........261-267 CHAPTER VIII. WORMS IN THE BLADDER. Character and Variety of Worms—Spiroptera—Dactylius Aculeatus—Male and Female—Structure of—Causes—Symptoms—Treatment, - - 268-273 CHAPTER IX. SEROUS CYSTS AND HYDATIDS. Seat of Development of—Found in both Sexes—Size—Symptoms—Acephalocysts of Bladder,.........274 CHAPTER X. F(ETAL REMAINS IN THE BLADDER. Rarity—Sir B. Brodie's Case—Fragments usually Numerous, and Mixed with Calcareous Concretions—Place of Development of the Foetus—Symptoms— Dr. Josephi's Case, - - - - - - - 275-276 CHAPTER XI. HAIR IN THE BLADDER. Examples—More Common in Women—Most generally associated with Disease of the Uterus, Ovaries, or Fallopian Tube—State in which it Occurs—Mode of Excretion—Delpech's Case—Sometimes Mixed with Calcareous Matter, 277 CHAPTER XII. AIR IN THE BLADDER. Generally connected with Paralysis—Mode of Escape—Origin, - - 279 CONTENTS. XIX CHAPTER XIII. HEMORRHAGE OF THE BLADDER. Occurs in both Sexes—Men more Liable—Varieties, Idiopathic and Traumatic —Persons in whom Idiopathic Occur—Traumatic usually result of Wound of Bladder—Connexion with Stone—Sometimes Produced by Drastic Cathartics and Irritating Diuretics—Pathology—Quantity—Colour and Consistence- Symptoms—Diagnosis—Prognosis—Treatment, ... 280- CHAPTER XIV. RETENTION OF URINE. Section I. Symptoms, not always Recognised by Patient—Diagnosis—Diag- nostic Symptoms—Treatment — Causes Producing Retention — Mechanical Obstruction—Paralysis—Spasm—Inflammation — Presence of a Pelvic Tu- mour—Varieties and Seat of Mechanical Obstructions—Hypertrophy of Prostate—Coagulated Blood—Inspissated Mucus—Imperforate Prepuce— Priapism—Causes of Paralysis of Bladder—Hysterical Retention—Spasm, Treatment of Retention in—Treatment in Inflammatory Retention—Pelvic Tumours as a Cause—Serous Cysts—Prolapsus of Womb—Retroversion of Uterus—Parturition. Section II. Catheterism—Description of Catheters- Varieties of—Position of Patient—Mode of Introducing Catheters, Curved and Straight—Obstacles to the Introduction—Method of Retaining Catheters in the Bladder—Catheterism of Female—Female Catheter—Mode of Intro- duction. Section III. Puncture of the Bladder, when Necessary—Routes by which Bladder may be Approached—Rectum, Perinseum, and Supra-pubic Region—Mode of Procedure through Rectum—Through Impassable Stric- ture by Perinseum—Danger in Supra-pubic Puncture—Mode of Procedure, 287-315 CHAPTER XV. INCONTINENCE OF URINE. Definition—Consequences—Incontinence from External Injury, as in Litho- tomy—Treatment—Incontinence from Inflammation—Causes Producing In- flammation— Treatment — Incontinence from Paralysis of Bladder, or of Bladder and Urethra—Causes of—Persons most Liable—Treatment—Incon- tinence from Morbid Irritability of the Neck of the Bladder, or of entire Organ produced by Acid Urine—Sympathy with Kidney, Rectum, Anus, Vagina, or Uterus—Incontinence in Children, Pathology of—Treatment- Cases—Urinals—Varieties for both Sexes, - 316- XX CONTENTS. CHAPTER XVI. HERNIA OF THE BLADDER. Regions in which Protrusion may Occur—Complication—Occurs in both Sexes —Exciting Causes—Size of Tumour, Circumstances Affecting—Diagnosis —Vaginal Cystocele, Characteristics of—Treatment—Prolapsion of Female Bladder, ........ 324-327 CHAPTER XVII. UR'INARY DEPOSITS. Distinction between Sediment and Gravel—Number of Urinary, three, viz., Lithic, Oxalic, Phosphatic—Lithic most Common—Origin of Name—Some- times called Uric—Chemical Properties of—Amorphous Sediments, Varieties of—Yellow and Red—Physical and Chemical Properties of—Lateritious and Pink Sediment, Varieties of Red—Crystallized Sediments, Form, Colour, and Age at which most Frequent—Treatment of Lithic Diathesis—Hygienic and Therapeutic—Oxalic—Intermediate in Frequency between Lithic and Phosphatic—Form in which it Occurs-r-Physical Properties of Urine con- taining Oxalic Acid—Formation of Oxalic Acid—Symptoms—Treatment— Phosphatic Deposit, Colour and Solubility—Three Varieties of Form, Triple, Calcareous, Mixed—Triple consists of Phosphate of Ammonia and Magnesia —Form in which it Occurs—Often Alternate with Yellow Lithic, or Calcare- ous Deposit—Calcareous consists of Phosphate of Lime—Form—Colour— Condition of Urine in—Mixed Deposit, combination of Lithic and Calcareous —Character of Urine—Causes—Treatment, - - - - 328-340 CHAPTER XVIII. STONE IN THE BLADDER. Section I. Nature and Causes. Section II. Physical and Chemical Properties —Nucleus, Generally of Inspissated Mucus, Lymph, Clotted Blood, or some Saline Matter of the Urine—May be of any Foreign Substance introduced from without—Nucleus varies in Size, Colour, Form, and Consistence—Cal- culi vary in Number—Volume of Concretions—Weight—Consistence—Colour —Odour—Variety of Forms—Surface may be Smooth or Rough—Chemical Composition—Lithic Calculus, Description of—Uro-ammoniac, Description of —Oxalic or Mulberry, Description of—Hemp-seed—Phosphatic, or Bone- earth Calculus—Ammoniaco-magnesian—Fusible—Cystic—Xanthic—Fibri- nous—Urostealith. Section III. Situation—Generally lie Loose—May be- come Adherent—Modes of Adhesion. Section IV. Stone in the Inferior Animals. Section V. Symptoms—Rational and Physical—Pain—Feeling of Weight and Uneasiness in Pelvic Region—Frequent Micturition—Interrup- tion of Stream of Urine—Pain in Head of Penis—Enlargement of Penis and Prepuce—Priapism—Increased Secretion of Mucus—Bloody Urine—Inconti- » CONTENTS. xxi nence of Urine—Prolapsus of Anus—Sympathetic Suffering—Noise emitted by Calculus—Constitutional Effects. Section VI. Physical Signs—Sound- ing—Diagnosis—Form of Sounds—Preparation for Sounding—Operation— Danger of Sounding—Auscultation—Evidence Furnished by the Sound— Errors of Sounding—Stone may be Present, and not Detected by the Sound —Symptoms of Stone may be Simulated by Sympathetic Irritation—Latent Stone—State of Bladder as Ascertained by Sounding. Section VII. Patho- logical Effects. Section VIII. Treatment. Art. I. Medical Treatment. Art. II. Solution of the Stone. Art. III. Removal of entire Calculi through Urethra. Art. IV. Lithotripsy—History—Description and Mode of Ope- rating—Various Instruments Employed—Circumstances most Favourable— Preparation of Patient—Bad effects of this Operation. Art. V. Operation of Lithotomy—Age most Favourable—Preparatory Treatment—Lateral Opera- tion—Mode of Operating—Extent of Incision of Prostate—Extraction of the Stone—Difficulties of—Extraction of large Calculi—Cases—Accidents during and after Operation—Hemorrhage — Sinking—Retention of Urine—Undue Inflammation of Wound—Lesion of Prostate—Urinary Infiltration—Peritonitis —Wound of Rectum—Incontinence of Urine—Impotence—Perinseal Fistula —Time occupied in Performing Operation—After-treatment—Statistics— Relapse and Repetition of Operation—Cases relieved by Lateral Operation— Bilateral Operation—Origin and Description—Instrument employed, Double Lithotome Cache"— Quadrilateral Operation — Recto-vesical Operation — Supra-pubic—Lithectasy—Operation with Gorget—Operation with Beaked- knife—Operation at two Periods—Lithotomy in Female, - - 341-513 CHAPTER XIX. FOREIGN BODIES IN THE BLADDER. Preliminary Remark—Nature of the Foreign Bodies—Most Common Kinds— Modes of Introduction—Effects upon the Bladder—Spontaneous Expulsion- Extraction by the Forceps—Examples, - 514-516 PART II. DISEASES AND INJURIES OF THE PROSTATE GLAND. Liability of the Prostate to Various Diseases in Consequence of its Peculiar Re- lations—Old Age most Liable—Arrangement under different Heads: 1. Wounds; 2. Inflammation; 3. Suppuration and Abscess; 4. Ulceration; 5. Hypertrophy ; 6. Atrophy ; 7. Scirrhus; 8. Encephaloid; 9. Colloid and Me- lanosis; 10. Tubercle; 11. Cystic disease; 12. Hemorrhage; 13. Calculi; 14. Phlebolites, - - - -.....517 CHAPTER I. WOUNDS OF THE PROSTATE. Infrequent Occurrence—Comparative Importance—Result of Accident or De- sign—Varieties—Incised, Lacerated, Punctured, and Gun-shot—Example of xxii CONTENTS. an Incised Wound—Liable to be followed by Urinary Infiltration—Heals by the Granulating Process—Lacerated Wounds produced by forcible use of Instruments—Middle Lobe most Liable—False Passages sometimes made through the Gland—Case of Civiale—Dangers of Punctured Wounds of the Prostate—Sometimes followed by Inflammation and Death—Contusion of the Prostate in Extracting Urinary Calculi—Sloughing from severe Contusion and Laceration—Rarity of Gun-shot Wounds of the Prostate—Effects of Wounds of Prostate; 1. Hemorrhage; 2. Inflammation; 3. Infiltration of Urine and Sloughing; 4. Retention of Urine; 5. Urethro-vesical and Urethro- rectal Fistulse ; 6. Abscess—Diagnosis—Treatment, - - - 518- CHAPTER II. ACUTE PROSTATITIS. Section I. General Observations—Seldom exists as a Primary Inflammation —Generally Secondary—Most frequently occurs in Middle Life—Compara- tively rare in Childhood and Old Age—May be Idiopathic or Traumatic- Symptoms—Rectum generally Involved—Diagnosis—Causes—Progress and Termination—Pathological Changes—Treatment. Section II. Abscess of the Prostate—Infrequent in Occurrence—Seat—Number, Size, and Struc- ture—Open in Different Direction—a, into Urinary Bladder ; b, into Rectum ; c, Externally by Ulceration of the Structures of the Perinseum; d, into the Peritoneal Cavity—Age and Causes—Symptoms—Prognosis—Treatment— Two Indications, to limit the Suppurative Action, and to afford as speedy an Outlet as possible to the Effused Fluid—Mode of effecting each Detailed. Section III. Ulceration of the Prostate—Of infrequent Occurrence—Causes —Symptoms—Progress—Treatment—Case Detailed, - - 522-542 CHAPTER III. HYPERTROPHY OF THE PROSTATE. Definition—Senile most Common—Seat—Degree and Form—Consistence— Colour—Weight—Causes—Period of Life—Progress—Symptoms—Constitu- tional Symptoms—Diagnosis—Mercier's Exploring Bougie—Mode of con- ducting the Exploration—Effects of Hypertrophy of Prostate—Treatment— Hygienic—Therapeutic—Iodine—Cicuta—Mercury—Hydrochlorate of Am- monia—Counter-irritation—Cauterization—Scarification—Excision—Incision —Crushing—Perforation, ---... 543-576 CHAPTER IV. ATROPHY OF THE PROSTATE. Sometimes an effect of Senile Decay—More frequently the result of Compres- sion, or Structural Disease—Sometimes Congenital—Extent varies, - - 577 CONTENTS. xxiii CHAPTER V. HETEROLOGOUS FORMATIONS OF THE PROSTATE. Section I. Scirrhus—Extremely Rare—Seldom seen before Fifty-five or Sixty —Too little Known of it, to trace its History, or determine its Causes, Pro- gress, and Diagnosis—Description and Seat of Formation—Symptoms—Du- ration—Treatment. Section II. Encephaloid—More frequent than Scirrhus, nevertheless Rare—Most Common in Advanced Life—Origin—Symptoms— Cases. Section III. Colloid and Melanosis. Section IV. Tubercles—Rare —Mode of Occurrence—Volume of Gland commonly Diminished—No Charac- teristic Symptoms—Treatment, ----- 578-584 CHAPTER VI. CYSTIC DISEASE OF THE PROSTATE. Of Rare Occurrence—Vary in Number, Size, and Character of Contents—Ori- gin not Determined—Progress, Symptoms, Termination, and Treatment of this Affection not Known—Has been Observed at Different Periods of Life, but Old Persons most obnoxious to it, - - - - - 585 CHAPTER VII. FIBROUS TUMOURS OF THE PROSTATE. Size—Situation—Resemble Fibrous Tumours of Uterus—Usually Associated with Hypertrophy—Probably Developed under Influence of Chronic Irri- tation, --------- 586 CHAPTER VIII. HEMORRHAGE OF THE PROSTATE. Causes—Most common in Old People from Forcible use of Instruments—Some- times Spontaneous—Difficult of Recognition—Diagnosis—Prognosis—Treat- ment, --------- 587-589 CHAPTER IX. CALCULI OF THE PROSTATE. Differ from Vesical Concretions—Are apparently the Result of Disordered Fol- licular Secretion—Old Persons most Liable, though they may Occur at any Period—Number of Concretions—Volume—Figure—Colour—Consistence— Chemical Composition—Place of Origin—Progress of Development—Symp- toms—Diagnosis—Most commonly Associated with Disease of the Urinary Apparatus—Causes—Treatment, - 590-597 xxiv CONTENTS. CHAPTER X. PHLEBOLITES OF THE PROSTATE. Chiefly observed in Old Persons who have suffered from Disease or Irritation of Bladder, Prostate, Urethra, Rectum, or Anus—Size—Colour—Chemical Com- position—Mode of Origin, ------ 598-599 PART III. DISEASES AND INJURIES OF THE URETHRA. CHAPTER I. MALFORMATIONS AND IMPERFECTIONS OF THE URETHRA. Malformations of the Terminal Orifice—Absence, Contraction, or Obliteration of the Urethra—Duplicity of the Canal—Changes of Form—Deviations from the Normal Direction—Treatment—Hypospadias and Epispadias—Varieties of Hypospadias—Mode of Treatment—Epispadias, Treatment of, - 600-607 CHAPTER II. LACERATION OF THE URETHRA. Two Varieties of Causes, one Acting from Without and one from Within—Most commonly from Falls—Of Internal Causes, most common are Vesical Calculi, Bougies, and Catheters—Seat of Laceration—Extent of Injury—Symptoms__ Consequences—Diagnosis—Prognosis—Treatment, - - - 608-614 CHAPTER III. STRICTURE OF THE URETHRA. Definition and Varieties—Seat of Stricture—Opinions of Different Authors as regards Seat of Stricture—Number—Form—Consistence—Colour—Symptoms —Diagnosis—Physical Exploration—Mode of Conducting—Pathological Ef- fects— Causes—Prognosis—Treatment—Dilatation—Compression — Malaxa- tion—Cauterization—Incision—Scarification—External Division, - 615-651 CHAPTER IV. POLYPOID AND VASCULAR TUMOURS OF THE URETHRA. Vagueness of the Term Polype—Occurs in both Sexes—Site—Number-Mode of Formation—Mode of Removal—Vascular Tumours—Difference in Structure- Appearance of Tumours—Growth—Origin—Causes—Age most Liable—Cha- racteristic Features—Symptoms—Treatment, - - - 652-658 CONTENTS. XXV CHAPTER V. NEURALGIA OF THE URETHRA. Most common after Puberty—Occurs in both Sexes—Origin Obscure—Case of Neuralgia of Urethra—Prognosis—Treatment, ... 659-662 CHAPTER VI. HEMORRHAGE OF THE URETHRA. Varieties of Form—Spontaneous and Traumatic—Quantity Varies—Colour— Treatment,........663-666 CHAPTER VII. FOREIGN BODIES IN THE URETHRA. Foreign Bodies which Descend from the Bladder, or are Developed in the Urethra — Size of Concretion—Shape — Symptoms — Diagnosis—Case of Urethral Calculus—Treatment—Extraction—Lithotripsy—Excision—Foreign Bodies Introduced from Without—Cases—Effects—Difficulties and Mode of Extraction, -------- 667-681 CHAPTER VIII. INFILTRATION OF URINE. Definition, and Serious Effects of Accident—ATesical Extravasation—Diagnosis —Prognosis—Treatment—Urethral Form of Infiltration—Symptoms—Diag- nosis—Prognosis—Treatment. - 682-688 CHAPTER IX. URINARY ABSCESS. Nomenclature—Site—Exciting Causes — Size—Symptoms— Diagnosis—Treat- ment, --------- 689-693 xxvi CONTENTS. CHAPTER X. FISTULE OF THE URETHRA. Definition—Site—Extent—Number of Openings—Direction of Track—Character of Fluid furnished by New Passage—Immediate Cause—Efficient Cause— Diagnosis—Prognosis—Treatment—Suture—Excision — Urethroplasty—In- dian Method, ........ 694-704 CHAPTER XI. FALSE PASSAGES. Definition—Situation—Number of Channels—Length of Artificial Routes— Varieties of Form—Immediate Cause—Predisposing Causes—Natural Causes —Accidental Causes—Effects of False Passage—Symptoms—Treatment, 705-711 CHAPTER XII. LESIONS OF THE GALLINAGINOUS CREST. Liable to Inflammation and its Consequences—Causes—Symptoms—Liable to Hypertrophy—Degree of Enlargement—Effects—Treatment, - 712-714 CHAPTER XIII. INFLAMMATION AND ABSCESS OF COWPER'S GLANDS. Situation of Glands—Liable to Atrophy and Hypertrophy—Inflammation__ Symptoms—Diagnosis—Treatment, - 715-716 LIST OF ILLUSTRATIONS. FIGURE PAGE 1. Muscles and boundaries of the perinseum. Wilson's Anatomy, . . 37 2. Root of the penis and bulb of the urethra, with the triangular ligament. Morton's Surgical Anatomy, ...... 39 3. Triangular ligament of the urethra, glands of Cowper, and the arteries of the bulb. Morton's Surgical Anatomy, . . . .40 4. The arteries of the perinseum. Wilson's Anatomy, ... 44 5. The accessory pudic artery. From Dubrueil des Anomalies Art^rielles, 46 6. Side view of the pelvic viscera of the male, in their natural situation. Wilson, ........ 54 7. Longitudinal section of the bladder, prostate, and penis, exhibiting the urethra. Wilson, ....... 57 8. Bladder and prostate of a child of two years. Original. . . 65 9. Postero-lateral view of the prostate and bladder. Original. . . 67 10. Prostate at birth. Original. ...... 71 11. Prostate at four years. Original. . . . . .71 12. Prostate at twelve years. Original. ..... 71 13. Prostate at fourteen years. Original. . . . . .71 14. Prostate at twenty years. Original. ..... 72 15. Prostate at twenty-five years. Original. . . . . .72 16. Prostate at fifty-two years. Man tall and stout. Original. . . 72 17. Posterior view of bladder and prostate with third lobe. From Sir Eve- rard Home, ........ 74 18. Follicles of the prostate. From Mr. J. Quekett, ... 74 19. Internal view of the bladder and urethra. Smith and Horner's Atlas, . 77 20. Antero-posterior section of the pelvis of a male, exhibiting the viscera in their natural situation, and the curvatures of the urethra. Harri- son's Dublin Dissector, ...... 78 21. The bulbous, membranous, and prostatic portions of the urethra, with part of the bladder. Wilson, ..... 79 22. Extrophy of the bladder. From a drawing in possession of the subject, 99 XXV1U LIST OF ILLUSTRATIONS. FIGURE 23. Hypertrophy of the muscular fibres of the bladder. Original. 24. Bar-like ridge at the neck of the bladder. Original. 25. Sacculation of the bladder. Original. . 26. Fungous tumours of the bladder. From Civiale, 27. Erectile tumours of the bladder. Original. . 28, 29. Worms of the bladder. From Curling, .... 30, 31. Internal structure of the worms magnified. From Curling, . 32, 33. Different forms of male catheters. Original. 34. Double catheter. Original. ...... 35. Mode of introducing catheter. Morton's Surgical Anatomy, 36. Mode of securing catheter in the bladder. Sargent's Minor Surgery, . 37. Puncture of the bladder through the rectum. From Druitt, . 38. Male urinal for incontinence of urine. Original. 39. Female urinal for incontinence of urine. Original. . 40. Crystallized lithic acid. From Dr. Golding Bird, 41. Crystals of oxalic acid. Bird on Urinary Deposits, . 42. Triple phosphate. Bird on Urinary Deposits, . 43. Calculus with nucleus of cork. Original. .... 44. Uric calculus. Gross's Pathological Anatomy, . . . . 45. Internal concentric layers. Gross's Pathological Anatomy, . 46. Mulberry calculus. External appearance. Gross's Pathological Ana- tomy, ........ 47. Internal structure of same. Gross's Pathological Anatomy, 48. Hemp-seed calculus. Gross's Pathological Anatomy, 49. Phosphatic calculus. Gross's Pathological Anatomy, 50. Ammoniaco-magnesian calculus. Gross's Pathological Anatomy, 51. Fusible calculus. External appearance. Gross's Pathological Anatomy, 52. Internal structure of same. Gross's Pathological Anatomy, : 53. Cystic calculus. External appearance. Gross's Pathological Anatomy, 54. Internal structure of same. Gross's Pathological Anatomy, . 55. Calculi imbedded in the walls of the bladder. Original. . 56. Sound. Original. ....... 57. Sir Astley Cooper's forceps for extraction of stone. Fergusson's Practical Surgery, . . ..... 58. Weiss's Lithotriptor. From Druitt, . . 59. Handle of same. Druitt, ...... 60. Mode of using. Fergusson, ■•.... 61. Calculus in grasp of same. Druitt, ..... 62. Jacobson's stone-crusher, modified by Velpeau. Velpeau's Operative Surgery, ........ 63. Mode of securing patient in lithotomy. Fergusson, 64. Staff for operation of lithotomy. Fergusson, .... 65. Liston's knife. Fergusson, . 66. Method of incision. Fergusson, .... 67. Probe-pointed bistoury. Original, .... 68. Forceps for extraction of calculus. Velpeau, .... 69. Scoop for removing fragments of calculus. Fergusson, . 70. Section of prostate in lithotomy. Scarpa, .... LIST OF ILLUSTRATIONS. xxix 71. Forceps for crushing stone. Original, . 72. Physick's artery forceps. Original, .... 73. Tube to carry off urine after lithotomy. Fergusson, 74. Double lithotome cache". Velpeau, .... 75. Gorgets of Physick and Gibson. Original, 76. Female sound. Original, ..... 77. Straight staff. Original, ..... 78. Abscess of prostate. Original, .... 79. Hypertrophy of prostate. Original, 80. Lobulated hypertrophy of prostate. Original, 81,82. Hypertrophy of middle lobe. Original, 83. Irregular hypertrophy^of third lobe. Original, 84. Mercier's prostatic explorator. Original, 85. Obstruction of urethra in hypertrophy of prostate. Original, 86. Prostatic calculi. Marcet, .... 87. Epispadias. Liston, ...... 88, 89, 90. Stricture of urethra. Original, . 91. Graduated bougie. Velpeau, .... 92. Dilatation of urethra behind stricture. Original, 93. Effects of stricture upon urinary organs. Original, 94. Conical-pointed bougie. Original, 95. Olive-shaped bougie. Original, .... 96. Fusiform-shaped bougie. Original, 97. Cylindrical-shaped bougie. Original, 98. Porte-caustique. Original, .... 99. Lateral-bladed stylet. Original, .... 100. Urethral scarificator of Dupierris. Original, 101. Foreign body in the urethra. Original, 102. Articulated scoop of Bonnet. Velpeau, . 103. Hunter's forceps. Velpeau, ..... 104. Piece of knotted leather removed through urethra. Original, 105. Fistula of the urethra. Original, .... 106. False passage of the urethra. Original,! * INTRODUCTION. INTRODUCTION. CHAPTER I. PERINEUM. The term perinseum was formerly restricted to the triangular space comprised between the arch of the pubes and the upper margin of the anus, or an imaginary line extended from one tuberosity of the ischium to the other. At the present day, however, it is used in a wider sense, and is made to include also the region which intervenes be- tween the point here specified and the extremity of the coccyx. Considered in this manner, the perinseum is of a lozenge shape, the superior angle of which corresponds with the arch of the pubes; the inferior, with the tip of the coccyx; and the two lateral, with the ischiatic tuberosities. The most important objects embraced within these limits are the urethra and the anus, on which account the space is usually subdivided into two regions, having the form of two triangles, the bases of which are continuous with each other. To the upper part, which constitutes the perinseum, properly so called, the term urethro-perinseal is applied by modern anatomists, while the lower is denominated the ano-perinseal. The boundaries of the upper triangle are, superiorly, the pubic arch; inferiorly, an imaginary line extended from one ischiatic tube- rosity to the other; and laterally, the branches of the ischiatic and pubic bones. The sides of the triangle, which are nearly equal, rarely exceed three inches. The base is just above the verge of the anus, 3 34 INTRODUCTION. and consequently some distance below the level of the transverse perinseal muscles. In the centre of the space is a slight elevation, known as the raphe*, which divides it into two smaller triangles, of which the left is the one always selected for the lateral operation of lithotomy, because it affords the surgeon an opportunity of using his right hand. To obtain a connected view of the perinseum, it is ne- cessary that the various structures of which it is composed should be examined in detail. For this purpose a moderately lean subject should be selected; he should be placed upon an ordinary dissecting- table, with the breech close to its edge, and the hands and feet should be tied as in lithotomy. A silver catheter should be at hand, to distend the urethra; and to examine the deep structures of the perinseum, the pubic bone of one side should be sawn through about an inch from the symphysis. This will afford an opportunity of dis- secting Guthrie's and Wilson's muscles, Cowper's glands, the deep layer of the triangular ligament, and the membranous portion of the urethra. The skin of the perinseum is thin, delicate, and easily movable upon the subjacent structures, which renders it necessary to steady it with the finger before incising it in the operation of lithotomy. It is of a lighter colour than that of the scrotum, and is always co- vered, after the age of puberty, with more or less hair. Numerous sebaceous follicles are contained in it, and towards the anus it usually presents a few small wrinkles, especially in old subjects. The most interesting object connected with it is a slight, narrow ridge, ex- tended perpendicularly from the under surface of the penis, over the scrotum, as far back as the anus, where it terminates. This ridge is named the raphe. It forms the middle line of the perinseum, and indicates the place of union of its two sides. Surgically considered, the raphe* is of importance as a landmark to our incisions in the lateral operation of lithotomy, the introduction of the catheter, the opening of abscesses, and the division of impassable strictures. Immediately beneath the skin, and consequently intimately con- nected with it, is a layer of cellulo-adipous tissue, the thickness of which is very variable in different subjects. In children and corpu- lent persons it frequently exceeds an inch. It is continuous above with the subcutaneous lamina of the scrotum, and laterally with that of the thighs, having no intimate connexion anywhere with the pelvic bones. At the lower part of the perinseum, in front of the anus, it sensibly diminishes in thickness, and can hardly be said, in most PERINEUM. 35 cases, to exist between the skin and the sphincter muscle of that opening. A number of small vessels, branches of the internal pudic, ramify through this substance; but they rarely bleed so much, when divided, as to require any particular attention. The removal of the cellulo-adipous layer as above described brings into view the superficial fascia, properly so called. This is a thin, delicate, fibrous lamella, of a triangular shape, which is spread over the muscles of the perinseum, and is firmly attached on each side to the outer border of the branches of the pubic and ischiatic bones. In front, it is prolonged upwards into the scrotum, where it appears to become continuous with the dartos; behind, it winds round the posterior margin of the transverse muscle, and is finally inserted into the anterior layer of the triangular ligament of the urethra. This membrane consists of a single lamella, the fibres of which are for the most part disposed transversely; it is thin, transparent, and pierced at various points by the branches of the pudic vessels. From the manner in which the superficial fascia is arranged, it is evident that urine, poured out in consequence of a rupture of the urethra, can travel only in one direction, namely, forwards towards the scrotum, and upwards towards the groins. Its passage along the inside of the thighs and backwards round the anus is prevented by the attachment of the membrane to the pelvic bones and the trian- gular ligament. In some instances, however, the fluid breaks through this barrier, and extends down along the inside of the lower extre- mities. Morton refers to a case in which it reached nearly as far down as the knee. Such is a brief account of this fascia, as given by modern anato- mists. To this description important additions have been recently * made by Dr. Buck, one of the surgeons of the New York Hospital.1 He has demonstrated by careful dissections, one of which I had the satisfaction to witness, that the perinseal fascia forms distinct sheaths for the perinseal muscles, the spongy structure of the urethra, and the cavernous bodies of the penis. The portion which invests the muscles arises, as already stated, from the branches of the ischiatic and pubic bones, as far forward as the inferior edge of the pubic symphysis, where it is remarkably strong, and constitutes what is called the suspensory ligament. Posteriorly, it is continued over the transverse muscles, and prolonged upwards, on each side, into the ischio-rectal fossa. If a careful dissection be made of the penis, the 1 Transactions of the American Med. Assoc, vol. i. p. 367. 36 INTRODUCTION. skin and cellulo-fatty matter having been previously removed, it will be found that the fascia completely incloses the cavernous bodies as far as the head of the organ, which, with a little oaution, can be easily enucleated from the extremity of the two cylinders just mentioned, without disturbing its connexion with the spongy struc- ture of the urethra, which is itself invested by two layers of the fascia, one of them passing above, the other below it. The sheath is remarkably thick at the suspensory ligament, on the dorsal sur- face of the cavernous bodies, and at the crown of the penis, where its adhesions are also more distinctly marked. The cavity formed by the cavernous portion of the sheath is limited, posteriorly, by the triangular ligament. From the dissections of Dr. Buck, it appears sufficiently clear that the perinseal fascia answers the same purpose to the cavernous bodies of the penis, the spongy structure of the urethra, and perinseal mus- cles, that the fascia lata does to the muscles of the thigh. It forms a complete sheath to these parts, which serves to bind them down in their respective places, at the same time that it separates them from each other, and thus limits their diseases. The part which the mem- brane plays in urinous infiltration has been already adverted to, and must strike every one at first sight. Between the ischium and the rectum is a deep hollow, which, in the recent state, is occupied by a large quantity of cellulo-fatty matter. It has been described by Velpeau, in reference to its situation, under the name of the ischio-rectal fossa, and is deserving of notice here chiefly on account of the large abscesses which are liable to form in it. The knife likewise traverses it in the lateral operation of lithotomy. When this cavity is cleared of its fat, it is found to be of a triangular figure, the base of which corresponds to the skin and the apex to the angle formed by the union of the fibres of the elevator muscle and the obturator fascia. It is bounded posteriorly by the great gluteal muscle, anteriorly by the transverse muscle, internally by the elevator muscle and the pelvic aponeurosis, and externally by the tuberosity of the ischium. The fourth layer of the perinseum is formed by five muscles, Fig. 1, of which four occur in pairs, and are consequently perfectly sym- metrical in their shape, size, and situation. They are the trans- verse, the erector, and the accelerator, the latter being single. The anal sphincter projects slightly into this region, and unites in front with the accelerator and the two transverse muscles, by a common PERINEUM. 37 point, called the central tendon of the perinseum. This tendon has a whitisji appearance, and is continuous with the cellulo-fibrous raphe* Fig. 1. The muscles and boundaries of the perinseum, the skin, cellular tissue, and superficial fascia having been removed. 1. The accelerator muscle—the figure rests on the spongy body. 2. The caver- nous body on one side. 3. The erector muscle of the penis on one side. 4. The transverse muscle of the perinseum. 5. The triangular space through which the deep perinseal fascia is seen. 6. The sphincter muscle of the anus, of which the anterior extremity is cut off. 7. The elevator muscle of the anus of the left side. 8. The tuberosity of the ischium, between which and the anus is the ischio- rectal fossa. The same fossa is seen on the opposite side. 9. The spine of the ischium. 10. The left coccygeal muscle. of the accelerator muscle. It is situated between the bulb of the urethra and the anus, under cover of the superficial fascia and the common integuments. Posteriorly it is in contact with the trian- gular ligament. The transverse muscle is situated in front of the anus, at the boundary between this opening and the perinseum, properly so called. It is a thin, flat, irregular bundle, somewhat triangular in its shape, and arises from the inner surface of the tuberosity of the ischium, just above the erector muscle. From this point it is directed inwards and a little forwards, to be inserted into the central tendon of the perinseum, where it is sometimes con- tinuous with its fellow of the opposite side. It is covered by the superficial fascia, and rests upon the triangular ligament of the urethra. Its office is to support the perinseum, and to assist in de- fecation. The transverse muscle is sometimes absent; and, on the other hand, it is occasionally accompanied by a very small, delicate accessory muscle, running along its superior surface. It is always cut in the operation of lithotomy. The erector is a flat, narrow muscle, about three inches in length, 38 INTRODUCTION. stretched along the lateral boundary of the perinseum. It arises from the inner surface of the tuberosity of the ischium, immediately below the transverse muscle, passes forwards and upwards, and gradually degenerates into a strong, glistening aponeurosis, which is inserted into the sides of the cavernous body of the penis. The erector lies upon the branch of the ischium and the root of the virile member, under immediate cover of the superficial fascia. It is in relation on the inside with the accelerator muscle, from which, however, it is separated by a small quantity of cellular tissue and the superficial perinseal artery. No part of this muscle is endangered in the opera- tion for stone. The accelerator muscle, called more appropriately the bulbo-caver- nous muscle, is placed along the middle line of the perinseum, which it thus separates into two equal portions. It is of a cylindrical figure, and surrounds the bulb and posterior part of the body of the urethra like a sheath, which, however, is incomplete at each extremity. A white cellulo-fibrous raphe extends along the under surface of the muscle through its whole length, and serves as a point of origin to its fleshy fibres. From thence the fibres incline obliquely outwards and forwards to be inserted, the inferior into the triangular ligament of the urethra, the middle into each other, and the superior into the sides of the cavernous bodies of the penis. The lower part of the muscle is connected with the white tendinous line of the perinseum, and through it, with the transverse and sphincter muscles. From the manner in which the middle fibres of the accelerator encircle the urethra it is capable, under certain circumstances, of impeding, by its spasmodic action, the passage of the catheter along the posterior part of that tube. A few of the inferior fibres of this muscle are frequently divided in the operation of lithotomy. The anterior part of the outlet of the pelvis is closed up by two ligaments, which are joined together in such a manner as to form a continuous lamella from the symphysis of the pubes to the rectum. They lie under cover of the muscles above described, and cannot be examined until these structures are removed. When this has been done, it will be found that they differ from each other, not only in their situation, but likewise in their texture and arrangement. There is hardly any part of the anatomy of the perinseum which de- serves to be more carefully investigated than this in relation both to the operation of lithotomy, the introduction of the catheter, and the various injuries and diseases to which this interesting and important PERINEUM. 39 region is subject. The ligaments here referred to are named respec- tively, from their situation and shape, the sub-pubic and the trian- gular. Fig. 2. The root of the penis and the bulb of the urethra, with the triangular ligament: the muscles of the perinseum have been removed. 1. The coccyx. 2, 2. The tuberosities of the ischiatic bones. 3,3. The fascia lata of the thighs. 4, 4. The great sacro-sciatic ligament, a. The bulb of the urethra. 6. The spongy body, c, c. The limbs of the penis, d, d. The cavernous bodies, e, e. The external sphincter muscle of the anus. /, /. The elevators of the anus, covered by a prolongation of the triangular liga- ment, g, g. The great gluteal muscles, h, h. The triangular ligaments of the urethra. The artery of the bulb is seen on the left side as it runs between the leg of the penis and the bulb of the urethra. The sub-pubic, pubic, or inter-pubic ligament, as it has been vari- ously designated, occupies the upper part of the pubic arch, and is about half an inch in depth. It extends from the top of the arch to the superior margin of the triangular ligament, by the layers of which it is slightly overlapped, and is attached on each side to the inner border of the branch of the pubic bone. Its base, which is free, and a little concave, is directed downwards and backwards to the perinseal space. In its structure, the sub-pubic ligament is very dense, firm, and resisting, being composed of close, transverse fibres, of a pale yellowish colour. The triangular ligament has been a source of much confusion, in consequence of the numerous names under which it has been described by anatomists. Thus, it has been called the triangular ligament of the urethra, the deep perinseal fascia, the ligament of Cowper, the middle perinseal fascia, and the recto-urethral aponeurosis. The 40 INTRODUCTION. term ischio-pubic would be more appropriate than any of these, inas- much as it at once indicates both the situation and principal attach- ments of this lamella; but as I am not disposed to be an innovator, even in so trifling a matter as the naming of a ligament, I shall retain the appellation by which it is generally known in the books. The triangular ligament is a strong membranous lamella, which closes up the greater portion of the space beneath the symphysis of the pubes. As the name by which it is here designated im- Fig. 3. The triangular ligament of the urethra, the glands of Cowper, and the arteries of the bulb. The rectum has been removed, and the ligament, therefore, presents the appearance of terminating infe- riorly by a free border, which, in the natural condition of the parts, is not the case. The figures 1,1, mark Cowper's glands. 2. The posterior lamella of the triangular ligament, the anterior one having been cut away. 3, 3. The tuberosities of the ischiatic bones. 4. The pubic symphysis. A little below this figure is a strong semicircular band of fibres, which is the sub-pubic ligament. 5, 5. The dorsal arteries of the penis, the terminal branches of the internal pudic. 6, 6. The arteries of the bulb. 7. The opening in the triangular ligament through which the membranous portion of the urethra passes. plies, it is of a triangular shape, being narrower above than below. It is attached on each side to the inner border of the pubic and is- chial bones, and extends from the sub-pubic ligament, which it slightly overlaps, to the rectum, where it becomes continuous with the anal fascia. Its structure at this point is very delicate, and devoid of the ligamentous character which it presents higher up. It is pierced towards its superior margin by the dorsal veins of the penis, and somewhat lower down by the opening which serves to transmit the membranous portion of the urethra. This opening is situated about one inch below the pubic symphysis, directly opposite the raphe* of the perinseum, and consequently equidistant from the inner PERINEUM. 41 borders of the branches of the pubic bones. It is of a circular shape, and varies in diameter from three to four lines. The opening is not very well defined in the natural state, in consequence of its edges being prolonged for some distance upon the urethra; but if the penis be cut off immediately in front of the ligament it will be ren- dered very conspicuous. The triangular ligament is composed of two laminae, separated by a slight interval, in which are contained the glands of Cowper, the arteries of the bulb, a plexus of large veins, and the compressor mus- cles of the urethra, together with the base of the sub-pubic ligament. The anterior layer, which is much the stronger of the two, is pro- longed forwards round the urethra, and is ultimately connected be- hind the transverse muscle with the superficial fascia. The posterior layer sends a similar process backwards towards the fibrous invest- ment of the prostate gland, and is in close relation with the elevator muscle of the anus. The fibres of which this ligament is composed are arranged chiefly in a transverse direction, and are much more distinctly marked in front than behind, where they gradually dege- nerate into cellular tissue. Included between the layers of the deep fascia are, on each side of the median line, two small muscles, which have recently attracted much attention, not so much on account of any interest which they possess in relation to lithotomy and other operations upon the peri- nseal region, as on account of the influence which they are supposed to exert, under certain circumstances, upon the evacuation of the urine and the introduction of the catheter. Of these two strata, one is perpendicular in its direction, and descends from the pubes, the other is horizontal, and passes inwards from the ramus of the ischium, both being connected with the membranous portion of the urethra. The transverse muscle, which is usually more distinct than the other, and which is now generally known under the name of the compressor muscle of the urethra, although noticed by Santorini, was first accurately described, in 1834, by Mr. Guthrie, of London, in his excellent work on the Urinary Organs. From its situation and direction it might, with great propriety, be called the deep transverse perinseal muscle, in contradistinction to the superficial. It arises, by a narrow aponeurosis, from the posterior aspect of the ascending ramus of the ischium, a little below its junction with the descending ramus of the pubes. From this point its fibres, which soon become fleshy, pass transversely across the perinseum, with a slight inclina- 42 INTRODUCTION. tion upwards, as far as the membranous portion of the urethra, where they separate into two slips, one of which is expanded upon the upper, the other upon the lower surface of the tube, which they cover in its entire extent from the bulb to the prostate. The muscle, at its insertion, exhibits a fan-like arrangement, and is frequently connected, by a sort of tendinous raphe*, with its fellow of the oppo- site side. The inferior slip lies over Cowper's gland, Fig. 1. In the female, the compressor has a similar arrangement precisely as in the male. It is often very faintly developed in both sexes : I have found it wanting on one side. The perpendicular muscle, or, as it has been appropriately named from its attachments, the pubo-urethral, was particularly described in 1809 by the late Mr. James Wilson,1 an eminent anatomist of London. It is of a triangular shape, and arises, by a round, narrow tendon, from the posterior part of the pubic symphysis, about one- eighth of an inch from its fibro-cartilage, and nearly the same dis- tance below the attachment of the anterior vesical ligament. It descends vertically along the median line, gradually increases in breadth, and is connected, on the membranous portion of the urethra, with the upper slip of the compressor muscle. The probability is that this muscle is only a part of the anterior fibres of the elevator muscle of the anus. Wilson describes it as passing round the urethra, and as forming with its fellow a sling for supporting it. The two muscles now described are considered by some anatomists, not as separate and distinct, but merely as so many parts of a single structure. The account here given of them, however, seems to me, on the whole, to be more consonant with what obtains in other parts of the muscular system. The functions of these muscles are suffi- ciently evident. When both compressors act together, they can diminish the canal of the urethra, and perhaps, close it even entirely. If, on the other hand, only one acts, it ma^r compress the tube slightly, and at the same time draw it outwards towards the corre- sponding ischium. The contraction of the inferior fascicule doubt- less assists in expelling the secretion of Cowper's gland. The office of the pubo-urethral muscle is to draw the membranous portion of the urethra upwards towards the arch of the pubes. The pubo-urethral muscle is best seen in a dissection made from within the pelvis after the bladder has been turned down from its attachments to the pubes, and after the removal of the posterior • London Medico-Chir. Trans., vol. i. p. 176. PERINEUM. 43 layer of the deep perinseal fascia. The compressor, on the contrary, is more easily approached in front. For this purpose the anterior lamella is carefully raised, and the spongy body of the urethra, separated from its connexions for several inches, is drawn forwards to put the membranous portion, into which it is inserted, upon the stretch. A stout muscular subject should be selected for the dissec- tion. The glands of Cowper, which may be appropriately considered along with the muscles just described, are situated deeply in the perinseum, immediately beneath the membranous portion of the urethra, and just behind the anterior layer of the triangular liga- ment. They are two in number, are each about the size of a com- mon pea, and are of a light rose, grayish, or pale yellowish colour. In their shape they are generally rounded, but sometimes they are ovoidal, oblong, or nearly lenticular; their surface is rough and gra- nulated, and their consistence strongly resembles those of a salivary gland. They are inclosed, each in a thin fibrous investment, and are placed immediately under cover of the lower portion of the com- pressor muscle, the contraction of which greatly promotes the expul- sion of their secretion. Cowper's glands are compound bodies, composed of lobules which are connected together by dense cellular substance, and which consist essentially of minute cells, opening into corresponding delicate canals. These soon unite and form the proper excretory duct, which passes forwards beneath the mucous membrane of the urethra for about three quarters of an inch, and terminates by an oblique orifice upon the floor of the bulbous portion of the tube. These glands are often exceedingly small, and occasionally one or both are absent. They are sometimes divided in the operation of lithotomy, and they are liable to suffer from extension of gonorrhoeal inflammation. They secrete a viscid, transparent fluid, the use of which is unknown. A third gland occasionally lies between the other two. The structures of which the perinseum consists are pervaded and nourished by a number of arteries, which, from their size and rela- tions, claim the especial attention of the lithotomist. They are all derived from one common trunk, the internal pudic, which, therefore, requires to be considered first. The internal pudic artery arises from the anterior division of the internal iliac, either separately, or, as not unfrequently happens, by a trunk common to it and the ischiatic, which usually exceeds it a 44 INTRODUCTION. little in volume. Descending in front of the sciatic plexus of the pyriform muscle, it escapes from the pelvis at the inferior part of the great sciatic notch, but soon re-enters that cavity through the small sciatic foramen, turning round the spine of the ischium, and so apply- ing itself against the inner surface of the tuberosity of that bone. From this point it runs forwards and upwards along the branches of the ischium and pubes, nearly to the level of the sub-pubic ligament, where it divides into its two ultimate branches, namely, the dorsal artery of the penis and the artery of the cavernous body. Fig. 4. The arteries of the perinseum: on the right side the superficial arteries are seen, and on the left, the deep. 1. The penis, the left leg of which has been removed. 2. The accelerator muscles. 3. The erector muscle of the penis on the right side. 4. The anus, with its sphincter. 5. The branches of the ischiatic and pubic bones. 6. The tuberosity of the ischium. 7. The lesser sacro-sciatic ligament, attached by its apex to the spine of the ischium. 8. The coccyx. 9. The internal pubic artery, cross- ing the spine of the ischium and entering the perinseum. 10. The external hemorrhoidal branches. 11. The superficial perinseal artery, giving off the transverse perinseal upon the transverse muscle. 12. The same artery on the left side, cut off. 13. The artery of the bulb. 14. The two terminal branches of the internal pudic artery, one of which is seen entering the divided extremity of the leg of the penis, while the other ascends the dorsal surface of that organ. The internal pudic is usually described as consisting of three por- tions, but such an arrangement need not be adopted here, inasmuch as the vessel is of no special interest to the lithotomist until after it has re-entered the pelvis. The part which requires particular notice may be considered as extending from the inner margin of the small sciatic notch to the lower border of the sub-pubic ligament. The vessel included between these two points runs forwards and a little upwards in a gently curved direction, and is enclosed, with its nerve and vein, in a fibrous canal formed in the obturator fascia. It lies at first very deeply behind the tuberosity of the ischium, but as it proceeds towards its place of destination along the inner margin of PERINEUM. 45 the branch of this and the pubic bone, it gradually approaches the surface, and becomes comparatively superficial. The varieties in the origin and course of the internal pudic artery are very important in a surgical point of view. When it arises at the usual spot, and pursues the direction above indicated, it is in general, in no danger of being wounded in the lateral operation. Its deep position on the inside of the tuberosity and branch of the ischium is a sufficient protection against the knife, and indeed, in most cases, against the gorget and the lithotome. But when the artery inclines much towards the median line, or when its place is supplied by a supplemental vessel, running along the side of the bladder and the prostate gland, there will necessarily be considerable risk of hemorrhage. When the pudic artery is unusually small, or when it is altogether wanting, the defect is generally compensated by a small vessel which has been recently described by Professor Richard Quain,1 of London, under the name of the accessory pudic, though it had been previously noticed by other anatomists—as Burns, Meckel, Shaw, Monro, Velpeau, Spence, and Tiedemann, the latter of whom has beautifully delineated it in his magnificent plates. It is chiefly im- portant in relation to the neck of the bladder and prostate gland, and the consequent bearing it has upon the operation of lithotomy. The accessory artery varies considerably in regard to its origin. Generally it is given off from the internal pudic itself, just before this vessel escapes from the sacro-sciatic foramen, and passes along the lateral and inferior surface of the bladder, the side of the pro- state gland, Fig. 5, and the membranous portion of the urethra, to gain the dorsal surface of the penis. In some instances it lies upon the upper surface of the prostate gland; and occasionally, though rarely, it penetrates its substance. In the second place, the artery may arise from the internal iliac, and pursue the same course as when it is furnished by the pudic. Lastly, it may originate from the obturator or the epigastric. In either case it descends imme- diately behind the body of the pubes, and is consequently in no danger of being wounded in the lateral operation. An important variety in the course of the internal pudic has re- cently been described by Mr. Coote,2 of England. After re-enter- ing the pelvis through the lesser sacro-sciatic notch, the artery, 1 The Anatomy of the Arteries of the Human Body, p. 443, London, 1844. 3 London Medical Times, Nov. 17, 1849. 46 INTRODUCTION. instead of ascending, as usual, behind the ramus of the ischium and the pubes, passed on by the side of the rectum towards the triangular The accessory pudic artery, a. The prostate. 6. The penis, c. The bladder, d. Seminal vesicle. e. The pubic bone. /. The rectum, g. The accessory artery, coursing along the side of the prostate. ligament, and separated into its three terminal branches, one of .which was distributed to the bulb of the urethra, another to the root of the penis, and the third to the dorsal surface of the penis. Had lithotomy been performed upon this subject, the pudic artery would have been unavoidably divided. The anomaly existed on both sides. The internal pudic artery, in its passage from the pelvis across the perinseum, gives off a number of branches, most of which, if not all, are intimately concerned in the operation of lithotomy, and therefore require particular attention. They are named either from their direction, or from the parts to which they are distributed. 1. In examining these branches from below upwards, the first in order is the inferior hemorrhoidal. It is detached from the inter- nal pudic about twelve lines behind the transverse perinseal muscle, and consequently just before this vessel applies itself to the inner surface of the tuberosity of the ischium. Inclining inwards and slightly upwards, the hemorrhoidal artery runs across the ischio- rectal fossa, through the cellulo-adipous tissue in that situation, and PERINEUM. 47 is distributed to the inferior extremity of the rectum, the sphincter and elevator muscles, and the integuments about the anus. The hemorrhoidal artery is sometimes double *. and occasionally it is given off by the pudic just below the transverse perinseal muscle. It is generally of small size, and is in no danger of being wounded in the lateral operation. It is only when it originates much higher up than usual that it is liable to be divided. 2. The superficial perinseal artery is a long, slender vessel, lying in the fossa between the erector and accelerator muscles, on a line with the branches of the ischium and pubes. It arises from the pudic about six lines behind the transverse muscle, across which it runs as it ascends, and is finally spent upon the dartos, the scrotum, and the skin of the penis. In the early part of its course it is placed under cover of the superficial fascia, but as it proceeds upwards it gradually approaches the surface. The superficial perinseal artery is the most voluminous branch of the internal pudic; but it is fortunately seldom cut in the lateral operation. It is liable, however, to deviate from its natural direction, and to incline more than usually towards the raphe" of the perinseum. In this case, which is by no means an unfrequent one, the lithotomist would find it difficult to avoid it. It sometimes gives off the trans- verse perinseal artery. 3. The transverse perinseal artery generally arises from the pudic, from four to six lines in front of the superficial perinseal, of which it is sometimes an offset. Piercing the deep perinseal fascia near its base, it runs horizontally inwards along the posterior border of the transverse muscle, and terminates near the central tendinous point in several small twigs, which are distributed to the structures between the anus and the bulb of the urethra. It anastomoses with its fellow of the opposite side, and with the inferior hemorrhoidal arteries. This vessel is always cut in the operation of lithotomy; but owing to its small size it seldom bleeds so profusely as to require a ligature. It is sometimes double on one side; occasionally it is very small; and sometimes it originates much lower down than usual. In a case described by Belmas, it arose from the internal pudic just behind the lesser sciatic ligament, and extended forward over the bulb of the urethra across the lines of the lateral and bi-lateral operations. Its direction is generally transverse; but not unfrequently it inclines either obliquely upwards or downwards. 4. The artery of the bulb is a very short, thick, stunted branch, and 48 INTRODUCTION. is given off by the internal pudic opposite the inferior extremity of the crus of the penis. It passes horizontally inwards, between the layers of the triangular ligament, and ends near the margin of the opening which transmits the membranous portion of the urethra. Here it divides into two twigs, of which one descends a little, and is distributed to Cowper's glands, while the other, which is considerably larger, enters the bulb, and ramifies in the erectile tissue of the spongy body. This artery, surgically considered, is by far the most important branch of the pudic. When it is divided, as it not unfre- quently is in the operation of lithotomy, it is liable to bleed profusely, and is generally secured with much difficulty, owing to the depth at which it is situated, and the great extent to which it retracts. The artery of the bulb is liable to numerous variations both as it regards its origin and direction. From their connexion with the operation of lithotomy, these irregularities require a special notice. The vessel is sometimes unusually small, or defective in volume. A very few examples are recorded of its entire absence on both sides. Occasionally it is wanting on one side, but present on the other. On the other hand, it is sometimes double, or its place is supplied by two, three, or even four small twigs from the internal pudic. Instead of its usual origin and direction, the artery may take its rise far back near the tuberosity of the ischium, and proceed thence obliquely upwards and inwards towards the median line. When it pursues this course, it will scarcely fail to be wounded in the lateral operation. Instances have occurred in which it was furnished by the accessory pudic, much higher up than usual, where of course it would have been beyond the reach of the knife. Cruveilhier1 mentions a case where it arose from the obturator artery. It ran along the inner part of the obturator foramen, crossed perpendicularly the posterior surface of the branch of the pubes, and then passed on horizontally forwards over the internal pudic, above which it lay, to the bulb of the urethra. This arrangement was limited to the left side. On the right side the artery was normal. In a subject dissected by Mr. Spence2 of Edinburgh, the artery was given off by the pudic as usual; but in- stead of pursuing its accustomed route, it passed almost directly back- wards nearly to the anus, from which it again curved upwards to enter the bulb. Finally, in two cases recorded by Mr. Stanley, of 1 The Anatomy of the Human Body, edited by Dr. Pattison, p. 555. New York 1844. 3 Edinburgh Monthly Journal of Med. Science, No. 111. PERINEUM. 49 London, the vessel coming off from the pudic, posterior to the usual point, ran immediately above the inferior margin of the triangular ligament, and then proceeded upwards to the urethra as under ordi- nary circumstances. Such are the constituent elements of the perinseum. Let us now inquire into a few practical facts connected with this region, particu- larly its depth, the extent of its base, and the distance between the bulb of the urethra and the anus. The depth of this portion of the perinseum, or the distance from the surface of the skin to the neck of the bladder, is subject to con- siderable diversity, depending mainly upon the degree of obesity of the individual. Attempts have been made to determine this point by actual admeasurement with the pelvimeter. The subject is of great interest in relation to perinseal lithotomy. When the depth is unusually great, the operator may fail to divide to prostate to the requisite extent, or his knife may slip from the groove of the staff, and pass between the bladder and the rectum, wounding, perhaps, the latter before he completes his random incisions. Aware of the variations which the part presents in different individuals, he will not be likely, if he meets with any unexpected deviation, to be thrown off his guard, but to proceed as if nothing had happened. Dupuy- tren, whose examinations were conducted with much care, found the depth of the perinseum, in twenty-three well-formed adult subjects, to range between fourteen lines and four inches, the average being nearly two inches and a quarter. The least depth usually occurs in the leanest subjects, or in those who have suffered long and much from calculous irritation. In children from three to five years of age, I have repeatedly found the distance between the two points in question to be upwards of two inches. The extent of the urethral portion of the perinseum, or the distance between the tuberosities of the ischiatic bones, is also liable to indi- vidual disparity. In the recent subject, it rarely exceeds two inches and three-quarters, which is increased, in the dried skeleton, from one and a half to three lines. Dupuytren, in the twenty-three cases already alluded to, noticed that the distance ranged from two inches to three inches and a half. In certain varieties of pelvic deformity, the width is sometimes considerably diminished. Velpeau has occa- sionally found it as short as an inch and three-quarters. In a case published by Dr. Roberts of Paris, the space between the branches 4 50 INTRODUCTION. of the ischiatic and pubic bones did not exceed six lines. A narrow perinseum must necessarily form a great hindrance to the extraction of a stone, if not also to the performance of lithotomy. The external surface of the perinseum varies somewhat in its ap- pearance in different portions of its extent. Superiorly, it is convex from side to side, owing to the situation of the bulb of the urethra, which being often remarkably prominent, throws out the part in bold relief. Further down, as we approach the ischiatic tuberosities, it is more or less excavated or depressed, especially at the anus. The interval between the bulb and the anus, the recto-urethral triangle, as it is named, is liable to considerable variety, and has claims upon the attention of the surgeon, on account of the influence which it must exert upon the length of his incisions. Ordinarily it does not exceed eight or ten lines; but sometimes it is much diminished by the pro- jection forward of the gut. This occurrence will be more likely to happen in persons in whom the lower bowel has been for a long time habitually distended with fsecal matter. Under such circumstances, it occasionally becomes remarkably convex in front, and approaches the bulb much nearer than in the normal state. Furthermore, it is worthy of remark that the bulb itself may be inordinately prominent, and thus seriously encroach upon the space under consideration. In aged persons, especially in such as have suffered much from calculous irritation, some degree of swelling may be produced by the engorge- ment of the venous plexus of the part. When, from either cause, this space is materially diminished, both the bulb and the rectum will be in danger of being wounded in the operation of lithotomy. The inferior region of the perinseum, or the ano-perinceal com- partment, possesses but little interest to the lithotomist, and does not, therefore, require minute notice in a work of this nature. The most important objects included in it are the anus, the ischio-rectal fossa, and the inferior portion of the rectum. With the situation of the anus every one is familiar. It is a dilat- able opening, covered partly by skin and partly by mucous membrane, and encircled by two muscles, which, from their position and func- tions, are called the external and internal sphincters. These two muscles deserve brief notice here, from the fact that they are always divided in the recto-vesical operation of lithotomy. A few of the fibres of the external one are also sometimes cut across in the lateral section. When the anus is in a state of repose, the distance between it and the tuberosity of the ischium, on each side, is nearly one inch PERINEUM. 51 and a half, and hence it is generally sufficiently out of the way of the knife in the operation just mentioned. But during the straining which so frequently ensues while the patient is on the table, either just before or immediately after the incisions have been commenced, the bowel is exceedingly apt to protrude, and to press the edges of the orifice outwards towards the ischiatic bones, thereby materially les- sening the interval between them, and endangering the tube. The inconvenience resulting from this occurrence is sometimes so great as to compel the operator to push back the prolapsed parts with his fingers, and to wait a few minutes, until spasmodic action, on which it depends, has subsided. If he omits this precaution, or fails to lateralize the knife more than usually, he will be very likely to wound the bowel long before he reaches the bladder. The external sphincter lies immediately beneath the skin; it is of an elliptical figure, and completely encircles the anus, the two bun- dles of which it is composed being united with each other at the middle line. Anteriorly it is attached to the central tendinous raphe* of the perinseum, and posteriorly to the tip and back of the coccyx, by a narrow cellulo-fibrous band, about one inch in length. The fibres of the muscle, which are generally of a florid colour, extend about twelve lines beyond the lateral margin of the anus, a short dis- tance over into the ischio-rectal gutter, and are much more distinct and strong in some subjects than in others. Their deep surface is in relation with the internal sphincter muscle and a small quantity of cellular tissue. The internal sphincter muscle surrounds the lower part of the rectum, in the form of a belt. It is situated an inch above the anus, and is two lines thick, by a little more than six lines in height. Its fibres, which are paler than those of the external sphincter, are con- tinuous above with the circular fibres of the rectum, of which, in fact, they form a part, the only difference between them being that they are more closely and numerously aggregated together. Between the ischium and the rectum is a deep hollow, which, in the recent state, is occupied by a large quantity of cellulo-adipous substance. It has been described by Velpeau, in reference to its situation, under the name of the ischio-rectal fossa, and is deserving of notice here chiefly on account of the large abscesses which are liable to form in it. The knife likewise traverses it in the lateral operation of lithotomy. When this cavity is clear of its fat, it is found to be of a triangular figure, the base of which corresponds to 52 INTRODUCTION. the skin, and the apex to the angle formed by the union of the fibres of the elevator muscle of the anus and the obturator fascia. It is bounded, posteriorly, by the great gluteal muscle, anteriorly by the transverse muscle, internally by the elevator muscle and the pelvic aponeurosis, and externally by the tuberosity of the ischium. The surgical anatomy of the bladder, urethra, prostate gland, and perinseum, would be incomplete without a brief account of the rec- tum, which is so intimately related with them, especially in the lower portion of its extent. The division of the alimentary canal to which this name is applied, is about twelve inches in length, and reaches from the sigmoid flexure of the colon to the anus, in which it termi- nates. Anatomists usually describe it as consisting of three portions, a superior, a middle, and an inferior, of which only the last two are of any particular surgical interest. The middle portion of the reservoir is situated behind the bladder, in contact with the sacrum and coccyx; it is nearly horizontal in its direction, and is from three and a half to four inches in length. Its anterior surface, in the upper part of its extent, is covered by peri- tonaeum ; farther down, it lies in close relation with the seminal vesicles, the deferential tubes, and a small portion of the bas-fond of the bladder; and towards its termination it is in contact with the prostate gland and the commencement of the membranous portion of the urethra. " The remainder of this portion of the intestine lies imbedded in a quantity of cellular and adipous tissue, and receives an investment from the pelvic fascia, which maintains it fixed in its position upon the sacrum and coccyx." When the tube is unusually capacious, whether as a result of congenital formation, or of habitual distension, it occasionally projects considerably outwards, so as to overlap the sides of the bladder and the prostate gland, and be in danger of being injured during the division of the latter organ in the operation for stone. The inferior portion of the bowel extends from the extremity of the coccyx to the anus; it inclines obliquely downwards and back- wards, and is from an inch and a quarter to an inch and a half in length. More capacious above than below, it is surrounded by the fibres of the elevator muscles of the anus, and is strengthened, in front, by a prolongation of the deep perinseal ligament, which thus aids in keeping it in its place. Between this portion of the rectum and the bulb of the urethra is a deep, narrow recess, which, from its shape and connexions, is called the recto-urethral triangle, the base PERINEUM. 53 of which corresponds with the cutaneous surface of the perinseum, and the apex with the anterior extremity of the prostate gland. This space is occupied by cellulo-adipous tissue; and its chief sur- gical interest relates to the bilateral operation of lithotomy, the first incisions of which are carried across it. The middle portion of the rectum is connected to the base of the bladder and the prostate gland by a layer of cellular substance, which is quite lax in its texture, and liable to slight serous infiltration, when, from any cause, it becomes the seat of severe irritation. In protracted cases of stone, when the irritation is propagated from the bladder to this tissue, it is occasionally a good deal thickened, and so much condensed as to grate under the knife. The soft, lax character of this tissue explains the facility with which the gorget and the forceps are thrust between the bladder and the bowel, in operating for stone, detaching them extensively from each other, and so placing the parts in a condition favourable to the lodgment of the urine. The same circumstance enables us to account for the ease with which, in cases of tight, callous strictures, or false passes, a catheter or bougie may be forced on beyond the prostate gland and the neck of the bladder, much to the detriment of the patient and the embarrass- ment of the surgeon. No large arteries exist in the two portions of the bowel here de- scribed, and hence the occurrence of hemorrhage need seldom be dreaded in any of the recto-vesical operations. It is only when the parts are indurated from inflammatory deposits, and where, conse- quently, the vessels, when divided, are unable to retract, that any- thing like serious bleeding is to be apprehended; but even then it may generally be promptly arrested by compression and cold appli- cations. In old subjects, affected with piles, fistula, or stone, there is frequently an enlarged and varicose state of the hemorrhoidal veins, which, when divided, occasionally furnish a considerable flow of blood. CHAPTER II. URINARY BLADDER. The bladder is a musculo-membranous bag, which, serving as a reservoir for the urine, communicates, on the one hand, with the ure- ters, and on the other, with the urethra, the common outlet of this and the seminal fluid. It is situated in the anterior and middle part of the cavity of the pelvis, and varies in its position as well as in its shape, according as it is empty, partially filled, or thoroughly dis- Fig. 6. Side view of the pelvic viscera of the male, in their natural situation. 1. The divided surface of the pubic bone. 2. The divided surface of the sacrum. 3. The body of the bladder. 4. Its fundus, with the urachus at its apex. 5. The base of the bladder. 6. The ureter. 7. The neck of the bladder. 8,8. The pelvic fascia. The anterior vesical ligaments are seen just above figure 7. 9. The prostate gland. 10. The membranous portion of the urethra. 11. The triangular ligament, formed of two layers. 12. One of Cowper's glands. 13. The bulb of the spongy body. 14. The body of the spongy structure. 15. The right leg of the penis. 16. The upper part of the first portion of the rectum. 17. The recto-vesical fold of the peritonseum. 18. The second portion of the rectum. 19. The right seminal vesicle. 20. The deferent duct. 21. The rectum, covered by the descending layer of the pelvic fascia. 22. A part of the elevator muscle of the anus. 23. The external sphincter muscle. 24. The interval between the deep and superficial perinasal fascise: they are seen to be continuous beneath the number. URINARY BLADDER. 55 tended. When it is in a contracted condition, as it usually is after death, it is of a flattened, triangular form, the apex being directed towards the pubic symphysis, and the base towards the rec- tum. When it is distended, however, it mounts up into the hypo- gastric region, and assumes an elongated cylindrical figure, its sum- mit inclining upwards and forwards, the larger extremity downwards and backwards. Hence, the axis of the organ would coincide with a line drawn from the linea alba, midway between the pubes and umbilicus, to the inferior extremity of the coccyx. In order to obtain an accurate knowledge of the general configuration of the bladder, and of its relations to the surrounding structures, it should be moderately distended with air or water ; the penis should then be tied, and one side of the pelvis removed; the rectum, and the lower half of the anterior wall of the abdomen, should be left undisturbed. When this has been done, it will be found that the organ lies in con- tact, anteriorly, with the pubic bones and the straight muscles; superiorly, with the folds of the small intestines; posteriorly, with the rectum; and inferiorly, with the prostate gland and the seminal vesicles. In the very young subject, the bladder is contained almost wholly in the cavity of the abdomen, and is of a pyriform figure, with the base towards the umbilicus. As the pelvis enlarges, how- ever, it gradually sinks down into that cavity, and becomes moulded, as it were, into the shape which characterizes it in after-life, by the pressure of the superincumbent viscera. In the female, the organ corresponds below with the vagina and the uterus. It differs also considerably from that of the male, not only in being more capacious, but in being flattened in the antero-posterior direction, and expanded at the sides. These changes are not primitive but acquired, and de- pend, the first, upon the habit which women have of retaining their urine much longer than men, and, the second, upon the manner in which the bladder is wedged in between the uterus and the wall of the abdomen during pregnancy. The relations of the bladder are materially influenced, as was pre- viously stated, by its state of repletion or vacuity. When the organ is distended to its utmost with air, it projects outwards, in every direction, towards the walls of the pelvis, and ascends a considerable distance towards the umbilicus. To ascertain the changes which it experiences, under these circumstances, I made a careful examina- tion of the body of a well-formed male, twenty years of age, and 56 INTRODUCTION. about five feet ten inches in height. The organ was inflated through the urethra, to as great an extent as was practicable, with the mouth applied to a silver catheter, and, during the progress of the disten- tion, care was taken to remove the innominate bone of the left side, to enable me the better to determine the relations of its inferior parts. It should be added that the small and large bowels were nearly empty. The bladder mounted five inches above the top of the pubic sym- physis, and carried up the peritonaeum precisely two inches and a half from this point, or, what is the same thing, it left the organ un- covered by serous membrane to this extent in front. Its anterior surface was quite convex, and lay in close contact with the posterior surface of the straight and pyramidal muscles, which did not, how- ever, completely cover it. The width of this surface, at its middle and broadest part, was four inches and a half. The posterior surface, also quite convex, projected against the promontory of the sacrum, in such a manner as to allow nothing to intervene between them. Lower down it lay upon the rectum, which was entirely empty, and as it were, compressed by it. The com- mencement of the rectum was a little to the left side of the bladder, and was also in contact with it, but not much compressed by it. The sides of the organ were convex, and in contact with the parietes of the pelvis and the great vessels, the external iliac arteries and veins forming its superior boundary. On the right side, in a sort of pouch, or cul-de-sac, the bladder was in apposition with the coecum; and somewhat lower down and considerably farther back, was the vermiform appendage of the colon. The remainder of the lateral surface was in relation with the small bowel. On the left side, the organ was everywhere in contact with the folds of the ileum. On both sides, a little in front of the middle of the organ, was the epigastric artery, with its two veins, on its way towards the umbilicus. The distance, on each side, between the bladder and the antero-superior spinous process of the ilium, was two inches and a quarter. The top of the viscus, or the superior fundus, as it has been named, rounded and convex, was in contact with the folds of the small intestines, and reached to within two inches of the umbilicus. The finger, introduced into the rectum, received a distinct impulse on percussion of the hypogastrium, and, in turn, imparted, when URINARY BLADDER. 57 pressed against the bas-fond of the viscus, a distinct impulse to the hand upon the hypogastrium. The bladder is retained in its position by several folds of the peri- tonaeum, and by the reflection of the pelvic fascia, the former con- stituting what are called the false, the latter the true vesical liga- ments. In describing the exterior conformation of this organ, and its relation to the adjacent parts, it will be necessary, for the sake of accuracy of detail, to consider it as being divisible into a body, a neck, a base, and a summit; premising tha,t it is distended in the manner above stated. Fig. 7. Longitudinal section of the bladder, prostate, and penis, exhibiting the urethra. 1. The urachus. 2. The recto-vesical fold of the peritonaeum, at its point of reflection from the base of the bladder. 3. The orifice of the right ureter. 4. A slight ridge between the ureter and urethra, forming the lateral boundary of the vesical trigone. 5. The commencement of the urethra. 6. The prostatic portion. 7. The prostate. 8. The middle lobe. 9. The right seminal vesicle. 10. The membra- nous portion of the urethra. 11. Cowper's gland of the right side. 12. The bulbous portion of the urethra. 13. The navicular fossa. 14. The cavernous body. 15. The right leg of the penis. 16. The pectiniform septum. 17. The base of the gland. 18. The lower segment of the gland. 19. The uri- nary meatus. 20. The spongy body. 21. The bulb of the urethra. The summit of the bladder, called by some anatomists the superior base, or upper fundus, is of a rounded, convex form, and is directed obliquely upwards and forwards, being in contact, anteriorly, with the straight muscles of the abdomen, and, posteriorly, with the con- volutions of the small intestines. When the viscus is much distended, this part will be found occasionally to incline somewhat to the left side ; a fact already known to some of the earlier anatomists. It is fixed to the wall of the abdomen by the superior false ligament, by the urachus, and by the obliterated umbilical arteries; the portion in front of these structures being unprovided with a serous investment. 58 INTRODUCTION. The base of the bladder is the lowest and most dependent part of the sac. In the male, it corresponds with the rectum, the seminal vesicles, and the deferential ducts ; in the female, with the vagina and the inferior half of the neck of the uterus. It is bounded, poste- riorly, by the recto-vesical septum; anteriorly, by the prostate gland; and, on each side, by the lateral surface of the organ, with which it is insensibly confounded. Hence, its dimensions are nearly equal in every direction, the widest part, however, being behind. The seminal vesicles, as they extend from before backwards, divide this space into three surfaces, one being placed on each side, the other intermediately. Each lateral surface is convex, and somewhat broader in front than behind; the middle, on the contrary, is flattened, and much wider behind than before, being strictly triangular in its shape. This surface lies in close contact with the rectum, being separated from it merely by a small quantity of cellular substance, and a few small convoluted veins, and is particularly deserving of attention, as it is the spot which is always selected for the recto-vesical puncture in obstinate retention of urine. In its distended condition, the base of the bladder is destitute of a peritonseal investment, and may then be approached without fear of wounding this important structure. When, however, it is empty, or nearly so, the membrane descends some distance over the space be- tween the seminal vesicles and the deferential tubes, and thus sepa- rates the viscus from the rectum. The peritonseum, as it is reflected off from the bowel to the posterior surface of the bladder, forms a strong cul-de-sac, the edges of which are elevated into two sharp crescentic folds, known as the posterior vesical ligaments. The body of the organ is the part which intervenes between the base and the summit, and, in its shape, is not unlike a small flask. Although strictly cylindrical in its outline, it may be considered as presenting four surfaces, two lateral, an anterior, and a posterior. The anterior surface extends from the summit to the neck of the reservoir, and is consequently, in the healthy adult state, from four to six inches in length; ascending, however, not unfrequently, when the viscus is fully distended, nearly as high up as the umbilicus. It is placed immediately behind the pubic symphysis and the straight abdominal muscles, from which it is separated only by a small quantity of cellulo-adipous tissue. As this surface is always uncovered By the peritonseum, at least when the bladder is pretty well filled, it may be punctured with safety in the high operation for stone and for URINARY BLADDER. 59 the evacuation of the urine, in case of retention, complicated with great enlargement of the prostate gland, or serious disease of the lower bowel. The posterior surface is in contact with the rectum in the male, with the uterus in the female, and, in both sexes, occasionally with the folds of the small intestines; it is convex, smooth, and invested, in its whole extent, by the peritonseum. The lateral surfaces of the bladder, considerably wider below than above, are contiguous to the sides of the pelvis, and to the elevator muscles of the anus, to which they are connected by a large quantity of cellular substance. Along the back part of each of these surfaces are the deferential duct and the obliterated umbilical artery, the former of which is enclosed in a fold of peritonseum, denominated the lateral ligament of the bladder. This fold, extending outwards to- wards the side of the pelvis, may be considered as answering the same purpose to the urinary reservoir, that the broad ligament does to the uterus, both being apparently designed rather to permit these organs to distend themselves than to check their motions. The two lateral surfaces are not entirely covered by the peritonseum, but only so much of them as lies posterior to the deferential ducts; it being understood, of course, that the sac is not empty, but filled with air or fluid. The neck of the bladder is situated at the anterior and inferior part of the organ, and may be likened to the faucet of a cask stand- ing on its bottom. In its shape, it represents a truncated cone, the base of which looks backwards, while the apex terminates in the urethra. Its position, in the adult, is very nearly horizontal; but in the young subject it inclines obliquely downwards and forwards. The posterior part of it rests on the rectum, and the anterior is em- braced by the prostate gland. The neck of the bladder is cut in the operation of lithotomy by the perinseal method. To complete the account of the exterior of the bladder, it is neces- sary to describe its fascia and true ligaments. To do this, it is proper to premise that the pelvic aponeurosis, as it is termed, lines the inner surface of the elevator muscle of the anus, lying between it and the peritonseum, and extending as low down as on a level with an oblique line stretched from the inferior edge of the pubic symphy- sis to the spine of the ischium. At this point the membrane leaves the wall of the pelvis to be prolonged upon the side of the bladder and the prostate gland, with the structure of which it becomes in 60 INTRODUCTION. some degree identified. Posteriorly, it becomes attached to the lateral aspect of the rectum, and gradually "degenerates into a thm cellular lamella, which is lost on the vessels and nerves passing out at the pelvis. This structure, it may now be observed, forms what is called the vesical fascia ; and that portion of it which extends from the wall of the pelvis to the side of the bladder, is the true lateral ligament of this organ. This band is calculated not only to restrain the motions of the bladder, but, as it forms a kind of pouch on each side of it, it assists materially in closing up the pelvis, and in ward- ing off the pressure of the abdominal viscera. If the pelvic fascia be traced along the posterior part of the pubic symphysis, it will be found to be reflected from thence upon the neck of the bladder and the upper surface of the prostate gland, in the form of two dense, narrow, whitish bands, hardly an inch in length. These are the anterior vesical ligaments; they are stretched along each side of the middle line, and being of great strength, they assist materially, in sustaining the bladder in its proper position. A small depression, a sort of cul-de-sac, exists between these two bands, large enough to receive the point of the fore-finger; it is formed by the junction of the two fascise of the opposite sides, and serves to connect the middle and upper part of the bladder to the inferior margin of the pubic symphysis. It is occupied, in the natural state, by a small quantity of cellulo-adipous matter, and corresponds with the upper surface of the membranous portion of the urethra, the prostate gland, and the continuation of the dorsal veins of the penis. The urachus, to which allusion has already been made, is a thin, rounded cord, of a conical shape, extending from the centre of the summit of the bladder to the umbilical cord, where it terminates in a kind of cul-de-sac. As it proceeds upwards, it lies in close contact with the linea alba, being bounded on each side by the obliterated umbilical arteries, and enveloped partially by the peritonaeum. In early foetal life, the urachus contains a narrow central canal, hardly as large as a bristle, which communicates with the umbilical cord, and is generally effaced a short time before birth. It is evidently composed of the same structures as the bladder; but its use, in the human subject, is not very obvious. The urachus sometimes remains hollow for a long period after birth, if not, indeed, during the whole of life. When this is the case, it occasionally forms an outlet for the urine, which, instead of pass- ing off by the natural channel, is discharged at the umbilicus. This URINARY BLADDER. 61 circumstance, which has been noticed both in new-born children and in adults, is, of course, exceedingly rare, and is always associated with occlusion of the urethra. It has also been known, in this con- dition, to give lodgment to urinary concretions. Of this occurrence, quite a number of examples have been witnessed by observers; but the most interesting one is that related by Boyer of a young man of twenty-six. The cavity in the urachus was an inch and a half in length, and contained twelve concretions of the volume of a millet seed. One of them, larger than the rest, resembled a grain of barley. From the account of the French surgeon, it would seem that these calculi were actually lodged in the urachus, and not, as might at first be supposed, in a tubular prolongation of the bladder. In June, 1850, Thomas Paget, Esq., of England, communicated to the Royal Medical and Chirurgical Society, a case in which the urachus remained open, and a ring-shaped calculus, formed on a curved hair in the bladder, was extracted through the umbilicus.1 The patient, a man aged forty years, had suffered upwards of twelve months from frequent and painful micturition. The stone was readily detected by sounding; the urine frequently escaped at the navel, especially during violent efforts at work, and a catheter intro- duced into the bladder through the urethra, was easily made to appear at the abnormal opening. The man could retain a pint of urine at a time. The malformation, which existed from birth, was associated with an umbilical hernia of the size of a goose-egg. The calculus was seized with the finger carried at full length into the unnatural passage, dragged to the side of the bladder, and extracted at the umbilicus. Leaving the exterior of the bladder, and going into its interior, various objects present themselves, possessing a deep surgical, as well as no little physiological interest. Of these, the most important are the vesical trigone, the bas-fond, the orifices of the ureters, and the mouth of the urethra. The mouth of the urethra, or, what is the same thing, the orifice of the neck of the bladder, is of a circular figure, not unlike that of a Florence flask; its lower surface, however, presents occasionally a crescentic appearance, more especially if the middle lobe of the prostate gland is more than ordinarily prominent. The mucous membrane here is very smooth, vascular, and sensitive; and the cir- 1 American Jour. Med. Science, Oct., 1850, p. 490. 62 INTRODUCTION. cular fibres of the muscular tunic are so closely aggregated together that Sir Charles Bell has been induced to regard them as forming a distinct sphincter muscle. However this may be, it is certain that these fibres often exert a powerful influence in spasmodic retention of urine, the flow of which they greatly impede, if not entirely pre- vent, by their action. The cavity of the neck of the bladder, viewed from within, varies in its dimensions at different periods of life. Its diameters, mea- sured at its base and summit, in subjects of different ages, are thus stated by Belmas -1 Age. Base. Summit. From 3 to 8 years, 3 lines. 1£ lines. 8 to 16 " 4 » 2 " " 16 to 40 " 5 " 2 " " 40 to 60 " 6 " 3 " It will thus be perceived that, in the old, the capacity of the vesical neck at its summit does not augment in proportion to that of its base; whence it follows that the incision of the urethral extremity of the prostate in the lateral operation ought to be proportionally larger. The orifices of the ureters are situated at the posterior part of the vesical triangle, their direction being obliquely downwards and inwards. Lying about an inch and a half from each other, they are of a parabolical figure, and large enough to admit, without much difficulty, the end of an ordinary pocket director. Each opening is furnished with a small slip of fleshy fibres, extending obliquely down- wards and inwards, beneath the mucous membrane, as far as the uvula of the bladder, into which it is inserted, and where it unites with that of the opposite side. The office of these little muscles, if they deserve the name, is supposed, by Sir Charles, by whom they have been particularly described, to be that of dilating the orifice of the ureters, to enable these tubes to throw their contents more easily into the bladder. It is worthy of remark, in reference to the sub- ject of retention of urine, that if the muscular coat of the bladder be entirely removed, and the ureters dissected up, the organ, when inflated, will still retain its contents. When the distension, however, from urine, is very great and protracted, the orifices of these tubes are dilated, and regurgitation of the fluid is permitted. 1 Traite" de la Cystotomie Sus-pubienne, p. 72. URINARY BLADDER. 63 The vesical trigone is the smooth surface at the bottom of the bladder, between the mouth of the urethra and the orifices of the ureters. As its name implies, it is of a triangular form, the base being behind, and the apex in front. It is nearly horizontal in its direction, and is bounded by three imaginary lines, each of which is from an inch and a quarter to an inch and a half in length. The mucous membrane investing this portion of the bladder, is pale, highly sensitive, smooth, and so firmly adherent to the subjacent tunic as not to admit of corrugation. The trigone is somewhat larger in the female than in the male, in the latter of whom it cor- responds to the triangular interval between the seminal vesicles, the spot selected by the surgeon for the recto-vesical puncture. The uvula of the bladder may be considered as forming the anterior boundary of the trigone. It was first observed by Lieutaud, and is merely a slight elevation of the mucous membrane, caused by the projection of the middle lobe of the prostate. When this portion of the gland becomes much enlarged, as it often does in old people, the uvula may encroach so far upon the mouth of the urethra as to obstruct the flow of urine, as well as to oppose a serious impedi- ment to the introduction of the catheter. In the bladder of the young subject, no uvula exists; nor is it always present in old per- sons. The bas-fond is that portion of the floor of the bladder which lies behind the prostate gland. It is a very vascular, sensitive surface, and is particularly interesting in a surgical point of view, from the fact that in advanced life, and occasionally even at a comparatively early period, it is liable to be dilated into a sort of cup-like depres- sion, situated considerably beneath the level of the mouth of the urethra, and consequently well calculated to serve as a receptacle to the urine, when, from any cause, it is partially but permanently retained. Calculi are also liable to lodge in it, and so to elude the sound and the forceps. To remedy this difficulty, it is necessary, as will be stated elsewhere, to carry the finger into the rectum and ele- vate the sac. The structure of the bladder resembles that of the other hollow viscera. Like them, it is composed of three tunics, a serous, a mus- cular, and a mucous, which are united together by cellular tissue. The cellular substance between the middle and inner membranes presents itself in the form of a thin lamella, which the older anato- 64 INTRODUCTION. mists regarded as a distinct coat, but which is not usually so con- sidered at the present day. The serous coat, the outermost of the three, is merely a reflec- tion of the peritonseum, and forms, as has been already seen, only a partial investment for the organ, nearly the whole of its base and anterior surface, together with a part of its sides and summit, being uncovered. It has a smooth, polished aspect, and is so loosely con- nected to the muscular tunic as to be separated from it without diffi- culty. This arrangement is evidently intended to facilitate the free motion of the bladder underneath during the process of distension. The muscular tunic consists of strong, reddish fibres, arranged into two strata, closely connected by cellular tissue. The fibres of the external lamella are directed, for the most part, longitudinally, and appear to extend from the neck of the bladder to its summit; they are stronger in front and behind than at the sides of the viscus, where they usually pursue an oblique course, and are spread out in a very irregular manner. The fibres of the internal layer are nearly all arranged transversely; they are particularly well marked round the neck of the bladder, and, as they are so disposed here as to encircle the organ, they may be considered as forming a kind of sphincter muscle. The arrangement here mentioned can be most distinctly shown by everting the bladder, and dissecting off the mucous membrane immediately behind the orifice of the urethra. Some anatomists speak of a third stratum of fibres, situated inter- nally to the preceding, and presenting a reticulated appearance. It is doubtful, however, whether this disposition is not altogether the effect of disease ; it is certain, at any rate, that it is never so distinct as in hypertrophy of the muscular coat. Between the muscular and mucous tunics is a layer of dense, cel- lular tissue, serving to unite them intimately to one another. It possesses considerable strength and firmness, is highly elastic, and does not admit of serous infiltration, or deposits of fatty matter. It plays a very important part in certain diseases of the bladder, and is interesting, moreover, as constituting the so-called nervous tunic of the older anatomists. The mucous coat is of a pale reddish complexion, very extensible, and marked, in the collapsed state of the organ, by numerous wrin- kles, which are effaced during distension. Its mucous follicles, although very abundant, are so small that it is very difficult to de- tect them in the sound condition; in some diseases, however, their URINARY BLADDER. 65 presence is rendered very manifest. The internal coat is highly vascular and sensitive, and is intimately connected with the muscular one by the cellular lamella above described. It is continuous, on the one hand, with the mucous lining of the urethra, and on the other, with that of the ureters. The bladder receives its arteries from the umbilical, internal pudic, ischiatic, middle hemorrhoidal, obturator, and hypogastric: in the female, the spermatic also furnish a few small branches. These vessels are distributed to different parts of the organ, but the greater number terminate upon its base and neck; they all inosculate freely with each other, and thus form an elegant network placed imme- diately beneath the peritoneal investment. The veins of the viscus pursue very nearly the same course as the arteries; they open into the iliac veins, and are particularly abundant at the lower and lateral aspect of the organ, where they form an intricate interlacement, Fig. 8. Bladder and prostate of a child of two years, a. Bladder, b. Prostate, c. Membranous portion of the urethra, d. Urachus. which is often remarkably conspicuous in old persons, especially in such as have suffered a long time under stone, stricture, or prostatic disease. The lymphatic vessels, which are very numerous, terminate in the hypogastric ganglions. The nerves arise from the sacral 5 66 INTRODUCTION. plexus and the inferior extremity of the great sympathetic; the branches of the former presiding, in all probability, over the irrita- bility of the organ, the others over its sensibility. This peculiar nervous supply also accounts for the mixed character of the bladder, which is partly voluntary, partly involuntary. The bladder appears to be developed at an early period of utero- gestation. Originally of an elongated, cylindrical shape, not unlike a small intestine, it is prolonged as high up as the umbilicus, where it communicates, by means of the urachus, with the allantoid vesicle of the foetal cord. While it continues in this extra-pelvic situation, the organ has no bas-fond, properly so termed, nor is there any well-defined line of demarcation between it and the urethra. As soon, however, as the urachus becomes closed, which generally happens during the latter stages of pregnancy, the bladder begins slowly to descend, and, as the pelvic cavity enlarges, it gradually subsides into it; assuming, though not until some time after birth, the form and position belonging to it in adult life. CHAPTER III. ANATOMY OF THE PROSTATE. The prostate is a large, firm, follicular body, situated at the neck of the bladder and the commencement of the urethra, the latter of which either runs in a deep groove along its superior surface, or is entirely embedded in its substance. It lies behind and below the Fig. 9. Postero-lateral view of the prostate and bladder, a. Prostate gland, b. Membranous portion of the urethra, c. Rectum, drawn off from the prostate, d. Bladder, e. Seminal vesicle. /. Deferent tube. g. Triangular ligament of the urethra. pubic symphysis, between it and the rectum, being intimately at- tached to both of these structures by cellular and other substance. Its position is a little oblique, and its axis, therefore, is directed 68 INTRODUCTION. downwards and forwards. The distance of the gland from the pubic symphysis varies from three to six lines, according to the age of the subject and the dimensions of the pelvis. In the adult it does not, in general, exceed half an inch. In its shape, the prostate resembles a Spanish chestnut, or the ace of hearts on a playing card; it is narrow in front, where it is truncated, rounded at the sides, and broad behind, where it is slightly notched at the middle. In infancy and early childhood the situation of the gland is a good deal more oblique than it is in adults. The relations and connexions of this body are of great surgical interest, and should, therefore, be well understood by the practitioner. It is usual, for descriptive purposes, to consider it as consisting of two surfaces, two sides, a base, and an apex. Of the two surfaces, one is anterior and the other posterior. For the sake of greater clearness, however, it is better to call them pubic and rectal, more especially as the terms superior and inferior have also been applied to them, and thus have led to much confusion. The rectal surface is nearly flat, and is marked by a superficial groove, which extends vertically along the median plane, and serves to indicate the line of junction of the two lateral lobes. As its name implies, it corresponds with the rectum, to the anterior wall of which it is closely connected by dense cellular substance, in which there is never any fat or serum. If the finger be introduced into the gut, it will be found that the space between it and the prostate is very limited, and that the outline of the latter can, in general, be pretty distinctly defined, especially when the organ has attained its full development. It is for this reason that the surgeon usually avails himself of this mode of investigation when he is desirous of ascer- taining the real condition of the gland in case of disease. The pubic surface is directed towards the pubic arch, to which it is firmly attached by the anterior vesical ligaments. It is a little shorter than the rectal surface, and is regularly convex, except along the median plane, where it presents a slight furrow, corresponding with the one behind. Its distance from the pubic arch varies from six to eight lines. The sides of the gland are convex, and in relation with the ele- vator muscle of the anus, from which they are separated by a layer of the pelvic aponeurosis. The apex, directed downwards and for- wards, is truncated, and terminates at the membranous portion of the urethra; it is in contact with Wilson's muscles, and is less than half ANATOMY OF THE PROSTATE. 69 an inch from the deep perinseal fascia. The base, which is nearly horizontal, embraces the neck of the bladder, and is in contact with the seminal vesicles and the deferential tubes. Near its centre, on each side of the middle line, is the entrance of the ejaculatory ducts, the direction of which is obliquely forwards and inwards through the substance of the gland. A correct knowledge of the natural dimensions of the prostate, in the different periods of life, is of the greatest importance in relation to the operation of lithotomy and the proper appreciation of its own diseases. We find, accordingly, that the subject has received consi- derable attention from different observers. Among those who have contributed most to its elucidation, Deschamps occupies a pre-emi- nent rank. The proportions assigned by this celebrated lithotomist approach, perhaps, as near the truth as it is possible to arrive. From numerous measurements, the general results of which are recorded in his " Traite* Historique et Dogmatique de la Taille," he concludes that the size of the prostate varies not only in the different periods of life, but also in different individuals of the same age. He has ar- ranged his observations under the following heads. 1. In subjects from three to eight years of age, the thickness of the gland, measured anteriorly, is one line and three-quarters; pos- teriorly, two lines and a half; laterally, three lines and a half. When the prostate and neck of the bladder are laid open anteriorly, in their whole length, spread out, and left to themselves, without being stretched, the neck at the vesical uvula is from eight to ten lines in breadth, and consequently very nearly three lines in diameter. About a quarter of an inch above the lacuna of Morgagni, it is from six to eight lines ; on a level with the lacuna, from four to six lines ; and at the apex of the prostate, from three to four, four and a half, and even five lines. The length of the neck is from nine to ten lines. 2. In subjects from eight to sixteen years, the thickness of the ante- rior part is two lines; of the posterior, three lines; of the lateral, from four to five lines. When the prostate is laid open, its breadth at the vesical uvula is found to be from ten to thirteen lines, or very nearly four lines and a third in diameter. Three lines above the lacuna, the breadth is from eight to ten lines; on a level with the lacuna, from six to eight lines; and at the apex of the gland, from four to six, and sometimes even seven lines. The length of the neck is from eleven to twelve lines. 3. In subjects from sixteen to forty years of age, the thickness of the prostate, in front, is two lines and a half; behind, three lines; 70 INTRODUCTION. and at the sides, eight lines, frequently, indeed, nine, and sometimes even nine lines and a half. Laid open, the gland is fifteen lines broad at the vesical uvula, twelve lines at a quarter of an inch above the lacuna of Morgagni, and eight lines at the apex of the organ. The length of the neck of the bladder is from thirteen to fifteen lines. Finally, in advanced life, these dimensions augment two and even three lines, except the thickness of the anterior and posterior extre- mities of the gland, which Deschamps has never known greatly to exceed the above measurements. The following table is copied from Malgaigne's " Traite* Anatomie Chirurgicale,"1 and is founded upon upwards of forty cases in which this organ was measured by Mr. H. Bell. The subjects were from two to fifteen years, and the results are arranged under four cate- gories, according to their ages. Ages. Transverse diameter. Posterior oblique radius. Posterior direct radius. Anterior direct radius. 2 to 4 years. 5J to 6 lines. 2 to 2i lines. 1 line. £ line, 5 to 10 " 6 to 7£ " 2J to 3 " 2 to 2£ lines. i 10 to 12 " 7 to 8} " 2| to 3£ " 2 to 2£ " 1 to 1J " 12 to 15 » 8£ to 10 " H 2 to 2£ " 1J Dupuytren states3 the breadth of the prostate, measured at its base, in the adult, at from twenty to twenty-four lines, and its depth, which is a little greater at the sides than at the mesian plane, at from ten to twelve lines. Serm,3 on the contrary, found the gland, in the adult, only nineteen lines in width, at the centre of its transverse diameter, and only thirteen lines in its vertical direction along the middle line. Radii diverging from the urethra to the circumference of the organ, measure, towards its inferior and middle part, from seven to eight lines, directly outwards, nine lines, and towards the inferior and external part, from ten to eleven lines. In six examinations of the healthy adult gland, made some years ago, I found the average length to be twenty-one lines, the width eighteen lines, and the thickness nine lines. In a well-developed subject, about twenty years of age, and five feet seven and a half inches in height, whose genito-urinary apparatus I dissected with great care, the prostate presented the following dimensions: length of each lateral lobe, from one extremity to the other, one inch and three-quarters; breadth, at the widest part, which was about five lines in front of the seminal vesicles, one inch and five-eighths; 1 Brussels Edition, p. 372, 1838. 2 Memoire sur L'Operation de la Pierre, p. 21. Paris, 1836. 3 Malgaigne, op. cit., p. 365. ANATOMY OF THE PROSTATE. 71 breadth anteriorly, half an inch; and greatest thickness, namely, at the centre of the body, five-eighths of an inch. The dimensions assigned to this body by Dupuytren are, evidently, somewhat exaggerated; they differ, at all events, considerably from those obtained by the measurement of Deschamps, Serm, and myself. In the adult, I have found the medium weight of the healthy pro- state, in six subjects, to be about five drachms. In a case which I recently examined, and the dimensions of which are given above, the weight was only three drachms. Sharpey and Quain1 fix the weight at about six drachms, which is, I think, too high. I am not aware that any examinations have been made to ascertain the weight of the prostate in early life. The annexed engravings exhibit the size and form of the prostate gland in seven subjects of different ages. The drawings from which they are copied were executed by Mr. Daniels, under my immediate inspection, and their accuracy may therefore be fully relied upon.2 The colour of the prostate is influenced by age and other circum- stances. In infancy it is of a reddish tint, not unlike that of the thyroid gland; in childhood, it is of a lightish brown; in the adult, it is grayish, or nearly so; and in old subjects, it is generally of a dull drab-colour. Habitual engorgement has a tendency to heighten its complexion. A section of it, especially in advanced life, frequently exhibits a striated appearance. Fig. 10. Fig. 11. Fig. 12. Fig. 13. Fig. 10. Prostate at birth. Width, at base, 4 lines; a little above middle, 5 lines; at apex, 2 lines; length along the middle, 4 lines, and at the edge, 4J; thickness at base, 2 lines; at middle, Z\, and at apex, 1£. Weight, 13 grains. Fig. 11. Prostate at 4 years. Breadth at base, 6 lines; just above the middle, 7; and at the apex, 2|; length along the middle, 6 lines; and 7 lines at the margin; thickness at base, 2J lines; at the mid- dle, 4; and at apex, 2. Weight, 23 grains. Fig. 12. Prostate at 12 years. Width, 8£ lines, at base; 9£ above the middle, and 3 at apex; length along the middle, 8 lines, and S£ at the edge; thickness at base, 3; middle, 4£; and at apex, 2}. Weight, 43 grains. Fig. 13. Prostate at 14 years. Width at base, 11 lines; at middle, 9i; at apex, 4; length along the middle, 8 lines, and 10 at margin; thickness, 3i at base, 5 at middle, and 3 at apex. Weight, 58 grains. 1 Human Anatomy, ii. p. 526. Phila., 1849. 3 For opportunities of examining this gland in subjects of different ages, I am indebted, to some extent, to the kindness of different friends, particularly to Dr. Darling, the Demonstrator of Anatomy in the University of New York, Dr. Kelley and Dr. S. Rogers of Blackwell's Island, and Dr. Moore of the Bellevue Hospital. 72 INTRODUCTION. Fig. 15. Fig. 14. Prostate at 20 years. Breadth at base, 14 lines; at middle, 16; at apex, 5£; length along middle, 15 lines, and at edge, 16; thickness at base, 8 lines; middle, 10; and apex, 5£. Weight, 4 drachms and 1 scruple. Fig. 15. Prostate at 25 years. Width at base, 18 lines; middle, 20; and apex, 5; length along middle, 15 lines; and at edge, 18; thickness at base, 9 lines; middle, 10; at apex, 4. Weight, 4£ drachms. Fig. 16. Fig. 16. Prostate at 52, man tall and stout. Breadth at base, 12 lines; just above middle, 18; at apex, 5; length along middle, 15; and at edge, 18; thickness at base, 5 lines; middle, 8; and at apex, 4. Weight, Zi drachms. In its consistence the prostate bears a more close resemblance to the thyroid gland than to any other organ in the body. It is tough and fleshy in its feel, compressible, almost inelastic, and not easily torn, unless it has been previously incised, when it yields without difficulty to the finger. Of the truth of this I have had ample evi- dence both in the dead and in the living subject. In the operation of lithotomy my common practice is to dilate the wound of the pros- Fig. 14. ANATOMY OF THE PROSTATE. 73 tate with the finger; a proceeding which I have always found suffi- ciently easy. In old age, the consistence of the gland is much more firm than in early life, and nearly approaches that of the virgin uterus. The apex of the organ is, at all times, in health, the most resisting part. Two lobes, united behind by a small, delicate tubercle, compose this body; they are of an ovoidal shape, convex in front, slightly compressed behind, and narrower below than above, where they diverge from each other. These lobes are of equal dimensions in the healthy state, and their long axis is directed from before backwards. In the sulcus between them, exactly in the middle line, and conse- quently but a short distance from the mouth of the urethra, is a small body, now generally known as the middle or third lobe of the prostate. It is of a rounded form, and of variable dimensions; it rarely exceeds the volume of a pea, and is sometimes so small that it can hardly be said to exist. Indeed, the most careful dissection occasionally fails to detect it. Covered by the mucous and muscular coats of the bladder, it projects nearly on a level with the base of the lateral portions, which it closely resembles in its colour, struc- ture, and consistence. In order to see this body to the best advan- tage, it is necessary to raise the seminal vesicles and the deferential ducts from their connexions, and to draw them forwards over the posterior surface of the gland, Fig. 17. Although the name of Sir Everard Home is usually associated with the middle lobe, yet he can not be justly regarded as its discoverer; for both Morgagni and Hunter were aware of its existence in the natural state, and of its liability to chronic enlargement. Considering its diminutive size, the term lobule would be a more appropriate name for this body than that of lobe. Morgagni has described it under the name of caruncle; some have called it the tubercle of the prostate, and others the isthmus. The gland is invested by an appropriate capsule, of a grayish colour, which is continuous, on the one hand, with the vesical apo- neurosis, and, on the other, with the posterior lamella of the deep peri- nseal ligament. It is a dense, fibrous structure, and is evidently composed of two layers, enclosing between them the prostatic plexus of veins. The inner lamella, the more delicate of the two, is closely adherent to the outer surface of the organ, so that it is with great difficulty separated from it, and sends numerous processes into its parenchymatous substance, intersecting it in every possible direction. 74 INTRODUCTION. The whole investment is deserving of particular attention in relation to the operation of lithotomy, as much of the mischief resulting from its division is often attributable to infiltrations of urinary and other fluids between it and the contiguous surface of the gland. Fig. 17. Fig. 17. Posterior view of the bladder and prostate, with the third lobe, the seminal vesicles and ducts being drawn forwards, a. Ureter. 6. Bladder, c. Third lobe. d. Ejaculatory ducts, turned for- wards, e. Seminal vesicle. /. Deferent duct. Fig. 18. Follicles of the prostate, (magnified). When divested of its proper covering, the gland will be found to be of a soft fleshy consistence, and to be composed of an assemblage of mucous follicles, intimately united with each other, and filled with a thin, milky, and slightly viscid fluid. The size of the follicles varies; some are visible to the naked eye, and others are so minute as to require the aid of the microscope to detect them. According to Mr. Quekett, of London, who has recently examined them with much attention, their average diameter is about the one-hundredth part of an inch. They are connected together by an intermediate fibrous tissue, derived probably from the external investment of the gland, but they have no communication with each other, Fig. 18. Leading from these follicles are minute tubes, which unite together Fig. 18. ANATOMY OF THE PROSTATE. 75 to form the proper excretory ducts of the prostate. Of these, the diameter of which ranges from the sixth to the fourth of a line, there are usually from ten to fifteen, which pass forwards through the parenchymatous substance, and finally open upon the floor of the urethra around the gallinaginous crest, in the form of a horseshoe. These ducts and their terminal cells may be satisfactorily demon- strated by inflating them with air, or filling them with coloured size. Considering its size, the prostate is remarkably vascular. It is supplied by branches of the vesical, hemorrhoidal, and pudic arteries, which enter it in every direction, and form a delicate network upon the walls of its follicles and excretory ducts. Its veins, which are known under the name of prostatic plexus, lie between the lamellae of its fibrous capsule, and are liable, from the effects of age and disease, to great enlargement. Hence, when divided, as they always are in the lateral operation of lithotomy, they sometimes furnish a smart hemorrhage. They communicate in front with the dorsal vein of the penis, and behind with branches of the external iliac vein. The lym- phatics follow the same course as the veins. The nerves are derived from the hypogastric plexus. CHAPTER IV. URETHRA. The urethra extends from the neck of the bladder to the anterior extremity of the penis, and serves the twofold purpose of an outlet to the urine and the semen, Fig. 19. In its passage from behind forwards it perforates the triangular ligament of the perinseum, and then runs along the groove on the under surface of the penis, enve- loped by a layer of spongy, erectile tissue. The length of the tube has been variously estimated by different writers; but may be stated, on an average, to be about nine inches, the maximum being twelve, and minimum seven inches. Its diameter also varies in different regions of its extent, being about four lines and a half at the widest part, and from two and a half to three at the narrowest. Attempts have been made by anatomists to reduce the dimensions of the urethra to some general standard by actual measurement, the canal having been previously distended with wax or plaster of Paris, which served as a model. The proceeding, however, if not positively absurd, is practically of no benefit. Every surgeon knows that the length and diameter of the tube are not alike in any two individuals, any more than the feet or hands; and hence it would be just as ridiculous in him to expect to establish a standard in this respect as it would be for the boot or glove maker. Every case must be considered by itself; for an instrument that will suit one will not suit another. In a word, to the practical surgeon it does not matter whether the ure- thra is five inches or ten inches in length; whether it is two lines or five lines in width. Every case is peculiar, and requires a peculiar instrument. I have occasionally passed, with perfect ease, a catheter nearly five lines in diameter; and, on the other hand, I have expe- rienced great difficulty in introducing one of half that size. It may be stated, as a general rule, that the dimensions of the urethra are not influenced by the size of the penis. Thus, we not unfrequently see men with a large organ having a small urethra, and, conversely, with a small penis and a capacious excretory tube. URETHRA. 77 The narrowest part of the canal is at the external orifice, or a few lines behind it; this is also the most dense, and, consequently, the least extensible part; while every other portion may, without any Fig. 19. Internal view of the bladder and urethra. 1,1. The bladder, cut open by a crucial incision, and the four flaps separated. 2. The ureters. 3. Vesical orifices of the ureters. 4. Uvula of the bladder. 5. Superior fundus of the bladder. 6. Bas-fond of the bladder. 7. The smooth centre of the vesical triangle. 8. The gallinaginous crest. 9. Orifice of the ejaculatory duct. 10. Sinus near the urethral crest. 11. Ducts of the prostate. 12,13. Lateral lobes of the prostate. 14. Prostatic portion of the urethra; just above is the neck of the bladder. 15. Membranous portion. 16. One of Cowper's glands. 17. Orifices of the excretory ducts of Cowper's glands. 18. Section of the bulb of the urethra. 19. Cavernous bodies. 20. Gland of the penis. 21. Prepuce, dissected off. 22. Internal surface of the urethra, exhibiting its mucous lacunse. 23. Outer surface of the cavernous bodies. 24, 25. Accele- rator muscles. 26, 27. Erector muscles. detriment or danger of laceration, be stretched to nearly twice the natural size. Another narrow point exists at the commencement of the membranous portion, behind and in front of which, as far as the head of the penis, the tube has its greatest dimensions, and readily 78 INTRODUCTION. admits an instrument that will pass with difficulty along the other regions of the canal. The prostatic portion is, in the natural condi- tion, the widest part of the urethra. The direction of the urethra is materially influenced by the posi- tion of the penis, and the condition of the bladder and rectum. When both these viscera are distended, and the member hangs flac- cidly over the scrotum, the canal will be found to form three curva- tures, in their shape not unlike the Italian ^ ; if, on the contrary, the organ is raised towards the abdomen, the bladder and the rectum being at the same time empty, there will be only a single bend, and that but very slight, the concavity of which is directed upwards, Fig. 20. Now, by holding the penis at an angle of about sixty Fig. 20. Antero-posterior section of the pelvis of a male, exhibiting the viscera in their natural situation, and the curvatures of the urethra. 1. The bladder. 2. The prostate. 3,3. The urethra, laid open through its whole extent. 4. The seminal vesicle, laid open. 5. The bulb of the spongy body. 6. The spongy body, seen both above and below the urethra. 7. The cavernous body of the penis. 8. The right side of the scrotum. 9. The rectum. 10. The peritonseal lining of the abdominal muscles. 11. The peritonseal investment of the bladder. 12. The point where the peritonseum is reflected from the bladder upon the rectum. 13. The section of the pubic symphysis. 14. A line marking the situation of the triangular ligament. degrees with the trunk, and pressing it down from its pubic attach- ments towards the perinaeum, the three curvatures here spoken of will be almost completely effaced, and so the tube brought nearly into a straight line, with a slight inclination forwards and upwards. This fact, which is of great interest in reference to the introduction URETHRA. 79 of the straight catheter, appears to have been familiar to some of the ancient anatomists, but for a revival of it in the present day we are indebted mainly to some of the French investigators, particularly to Montagu, Amussat, and Leroy. The urethra may be divided, for practical purposes, into four por- tions, differing from each other in their extent, and in regard to the parts by which they are invested. These portions are, the prostatic, membranous, bulbous, and spongy. 1. The prostatic portion, Fig. 21, begins at the neck of the blad- Fig. 21. This cut exhibits the bulbous, membranous, and prostatic portions of the urethra, with part of the bladder. 1. Inner surface of the bladder. 2. Vesical trigone. 3. The orifices of the ureters. 4. Uvula of the bladder. 5. The gallinaginous crest. 6. The opening of the prostatic sinus. 7, 7. The orifices of the ejaculatory ducts. 8, 8. The apertures of the ducts of the prostate. The numbers 7, 7, and 8, 8, are placed on the cut surface of the supra-urethral portion of the prostate gland. 9, 9. The lateral lobes of the prostate, a. The membranous portion of the urethra, b, b. Cowper's glands, c, c. The apertures of the excretory ducts of Cowper's glands, d. The commencement of the bulbous portion of the urethra, e, e. The upper surface of the bulb. /, /. The legs of the penis, g, g. The cavernous bodies, h. The spongy portion of the urethra. der, and extends forwards a distance of from twelve to eighteen lines, according to the age and stature of the subject. It derives its name from the fact that it runs through the substance of the prostate gland. The relations of this portion of the canal with this body vary in different individuals, and deserve to be carefully considered on account of their surgical importance. In most of my examina- tions I have found the urethra situated towards the superior part of the prostate, in a sort of gutter, covered merely by a thin layer of 80 INTRODUCTION. parenchymatous substance. Sometimes the tube runs through the centre of the gland, which thus forms a kind of hollow cylinder for it. Occasionally, again, though very rarely, the urethra occupies the inferior part of this organ, the greater volume, by far, lying upon its upper surface. When this arrangement obtains, the canal and the rectum approach each other much nearer than usual, in con- sequence of which the latter is in danger of being wounded in the operation for stone. In its natural state, the prostatic portion is the widest part of the canal. In its shape, it is somewhat conical, the apex of the cone being directed forwards, and the base backwards. It is situated within the pelvic cavity, and is attached to the branches of the pubic bones by the anterior ligaments of the bladder; its direction, in the erect position of the body, being obliquely downwards and forwards. This is the case in the adult; but in the aged subject it is dragged down by the bas-fond of the bladder, and is, consequently, more horizontal. In childhood, when this viscus is, in great degree, lodged in the abdomen, the prostatic portion of the urethra is nearly verti- cal. These facts are important in relation to lithotomy. In the middle of the floor of the prostatic portion of the tube is a narrow, oblong, prominent ridge, which, from its fancied resemblance to the comb of the woodcock, has received the name of the gallina- ginous head; it is also called the verumontanum, and the urethral crest. It is formed by a duplicature of the lining membrane, enclos- ing a small quantity of dense cellular tissue, and varies in length from nine to twelve lines; it has a narrow rounded point in front, and a sort of bulbous expansion behind, near the neck of the blad- der, where it terminates. In the centre of the crest is a small cul- de-sac, formed by the orifice of a large mucous follicle ; and on each side in front is the mouth of the ejaculatory duct. Just behind the duct, in a longitudinal gutter, named the prostatic sinus, are the little openings of the excretory canals of the prostate gland, from eight to twelve in number, and so delicate as hardly to admit an ordinary-sized bristle. The sinus terminates posteriorly in a blind pouch, which merits special attention, as it is sometimes apt, especi- ally when it is enlarged, to arrest the beak of the catheter when an attempt is being made to pass it into the bladder. 2. The membranous portion extends from the apex of the prostate gland to the bulb, and obtains its name from a consideration of its structure. It is also sometimes called the muscular portion, from URETHRA. 81 the fact that it is surrounded by muscular fibres. It is the shortest and narrowest part of the canal, its length being usually not more than ten or twelve lines, and its diameter not more than three and a half or four. Its direction is nearly horizontal, though, in general, it is described as forming a slight curvature with the concavity look- ing upwards. Situated nearly one inch beneath the pubic symphysis, it passes through the opening in the deep perinaeal fascia, and unites with the bulb immediately behind the junction of the two cavernous bodies of the penis, its entrance being from above downwards, some- times several lines from the inferior extremity of the latter division of the canal. The membranous portion is composed entirely of the proper tunics of the urethra; it is supported, however, by a pair of small muscles, known as the muscles of Wilson, and is strengthened by a tubular prolongation of the deep perinseal fascia, one process of which extends forwards, and is insensibly lost upon the bulb, while the other passes backwards, and becomes continuous with the fibrous investment of the prostate gland. Additional muscular fibres are sometimes found in contact with this division of the canal, which they surround in the form of a sling, and which, by their contraction, may oppose a serious obstacle to the introduction of the catheter. From having been first noticed and described by Mr. Guthrie, of London, they are usually called by his name. 3. The bulbous portion is about an inch in length, and may be regarded as being intermediate in size between the spongy and pro- static divisions, though at first sight it would seem to be much more capacious than any other portion of the tube. Occupying the greater part of the space which exists beneath the legs of the penis, it is directed obliquely upwards and forwards, and is surrounded by the fibres of the accelerator muscle, the irregular, spasmodic action of which must often exert no little influence upon its calibre. It is continuous insensibly in front with the spongy portion, and is in- vested by a large quantity of erectile tissue, which abounds chiefly upon its inferior surface. Internally, it receives the orifices of the ducts of Cowper's glands, two small, reddish bodies, interposed be- tween the layers of the triangular ligament of the perinseum; and presents a remarkable dilatation, chiefly upon its inferior surface, called the sinus of the bulb. As this depression forms a considerable angle with the membranous portion of the canal, it constitutes one of the principal obstacles to the introduction of the catheter, and is therefore deserving of particular study. The manner of overcoming 6 82 INTRODUCTION. this impediment will be pointed out elsewhere. The bulb of the urethra receives a large branch from the internal pudic artery, and is liable to copious hemorrhage when there is a wound or rupture of the lining membrane. 4. The spongy portion is from four and a half to six inches in length, and is invested in the whole of its extent by a thin layer of spongy erectile tissue; whence its name. It is lodged in a groove on the under surface of the penis, at the anterior extremity of which it terminates in a narrow slit-like orifice. Its diameter, which is from three to four lines, continues nearly of the same uniform size from its commencement until it reaches the head of the penis, where it dilates into the navicular fossa, as it is named. This expansion is supposed by some of the French anatomists to be rather apparent than real; an opinion for which there is no just foundation; for I am satisfied, from repeated examinations, that it is always present in the normal state of the parts. The external orifice, technically called the urinary meatus, is the narrowest, as well as the least dilatable, part of the canal, and often opposes no little resistance to the introduction of a large sound or bougie. It derives its distinc- tive characters from the presence of a layer of firm cellulo-fibrous tissue, placed immediately beneath the mucous membrane. The urethra is composed of two membranes, the inner of which, being mucous in its character, is continuous, on the one hand, with the smooth covering of the head of the penis, and, on the other, with the mucous lining of the bladder. Two delicate, whitish, longitudi- nal ridges are observable upon the inner surface of this coat, corre- sponding with the middle line of the penis, and the inferior one of which terminates behind in the gallinaginous crest. Besides these, there are other folds, especially in the membranous and spongy por- tions, less distinctly marked than the preceding, and generally easily effaced by distension. Between the bulb and the external meatus a great number of small openings exist, giving the surface of the tube a sort of cribriform appearance; they are all directed forwards, and are merely the orifices of so many mucous follicles, placed exterior to the inner membrane, but lined each by a delicate process pro- longed from it into its interior. If bristles be introduced into these ducts, they may, in many cases, be carried backwards from three to six lines into the submucous tissue in which the crypts are lodged. They are most abundant upon the inferior surface of the tube, and are all quite small in the normal state, except one at the bottom of URETHRA. 83 the navicular fossa, which, from its large size, has received the name of the great sinus. These passages constantly discharge a thin, mucous fluid for lubricating the lining membrane, and in certain states of disease, as in gonorrhoea and stricture, they occasionally acquire such a bulk as to entangle the point of the bougie or catheter. The outer coat of the urethra is a thin lamella of cellular tissue, which serves to connect the tube to the subjacent textures. It is of an erectile spongy character, and is pervaded by a great number of minute vessels, which impart to it a singularly striated aspect, not unlike fleshy fibres. This reddish vascular appearance, added to the contractile power of the urethra, induced Mr. John Hunter, and afterwards Sir Everard Home, to believe that this tunic was essen- tially muscular in its nature. The opinion of the former of these writers rests wholly on assumptions, deduced from pathological facts and reasonings; that of the latter is founded upon minute microscopi- cal inspections. From these it would appear that the external mem- brane of the urethra is made up of short longitudinal fibres, variously interwoven with each other, and united together by a soft elastic substance. How far these results are worthy of confidence, is a point not easily determined. The question is still open, notwith- standing the numerous attempts that have been made to settle it. That the substance under consideration is really muscular is alto- gether improbable, though there are few practical surgeons who will deny its contractile power in certain states of the urethra. CHAPTER IV. URINE. There is no fluid, which, even within the limits of health, is liable to so many variations in its physical and chemical properties as the urine. Its quantity, also, is extremely uncertain, as it is influenced by numerous circumstances, especially by the state of the skin and the amount of liquids received into the stomach. On an average, however, a healthy person voids about forty ounces in the twenty- four hours. From this it may range from twenty ounces, as the minimum, to fifty ounces, as the maximum. When perfectly normal, the urine is of a pale amber colour, transparent, or nearly so, saline in its taste, and slightly aromatic in its odour. Its specific gravity varies greatly in health, and is always in an inverse ratio to its quantity. The average, throughout the twenty-four hours, is about 1*020. The fluid is always acid in health, and hence it readily im- parts a red tint to litmus paper. It deposits, on standing, a minute quantity of opaque mucus, in combination with a few epithelial scales. It does not, as was once supposed, contain any super-salts of lime. Its acid property is probably due to the presence of acid-salts.1 The quantity of solid matter that passes off by this excretion, daily, varies according to its specific gravity. It is, on an average, about two ounces, its minimum being half an ounce less, and the maximum half an ounce more. Three varieties of urine, differing materially in their physical and chemical properties, are recognised by modern observers. These are respectively denominated potous, chylous, and sanguineous. The first is that passed a short time after the free use of fluids, and is generally of a pale colour; and it is of low specific gravity, rarely 1 In the composition of this chapter I have availed myself freely of the article upon this subject in my Elements of Pathological Anatomy; I have also derived important aid from the works of Prout, Bird, Markwick, Rees, Griffith, and Willis. To those who wish to study this subject at length, the treatises of these authors are indispensable, especially the admirable and original one of Dr. Bird. URINE. 85 exceeding 1*009, and contains comparatively little solid matter. In chylous urine, the product of the digestion of a full meal, the specific gravity is generally considerably increased, and may be said to range between 1*020 and 1*030, the latter of which, however, it rarely at- tains. The sanguineous urine, the urine of the blood, or the morn- ing urine, is the most elaborate variety of the three. It is of the average density of 1*015 to 1*025, and exhibits in perfection all the essential properties of this important fluid. The most elaborate analysis of this fluid is by Berzelius. Accord- ing to this distinguished chemist, 1000 parts of urine are composed of Water - 933-00 Urea ---.._ 30-10 Uric acid - - - - - 1-00 Sulphate of potash - - - - - 3-71 Sulphate of soda ... - ^.\Q Phosphate of soda ----- 2-94 Phosphate of ammonia - - - - 1-65 Muriate of soda ----- 4.45 Muriate of ammonia - - - - 1-50 Phosphate of lime and magnesia - - - 1-00 Siliceous earth - -03 Vesical mucus - - - - - -32 Free lactic acid, lactate of ammonia, and animal matter not separable from them - - - 17-14 Besides these ingredients, the urine likewise contains a small amount of sulphur, phosphorus, and a peculiar yellow colouring matter, which has not yet been obtained in a separate state. In the urine of infants there is also generally some benzoic acid. Such, then, in a few words, are the characters of this excretion in the normal state of the system. But, as might be expected, this fluid undergoes great changes in various disorders of the body, which may be conveniently reduced, as has been suggested by Andral, to three classes. Under the first category are comprised those cases in which there is merely deficiency or excess of the natural constitu- ents of the urine ; in the second, there is an addition of new princi- ples, analogous to those that are contained in the blood; and under the third head are embraced such substances as are deposited with the urine, but are not found in the circulating fluid, either in the healthy or diseased state. Each of these classes affords interesting topics of inquiry, which demand brief consideration in this place, 86 INTRODUCTION. referring for more ample details to the excellent treatises of Berze- lius1 and Prout.2 1. Water and urea, being naturally present in greatest abundance, are more liable to variation than any of the other constituents of the urine. In nervous diseases, especially such as are of an hysterical nature, this secretion is generally copious, remarkably limpid, and of an aqueous character. In diabetes insipidus, the urine, which is discharged in immense quantities, is almost wholly composed of water; the urea is entirely absent; and the fluid, on evaporation, leaves a yellow-brownish syrup, in which there is no appearance of crystals, and which possesses a very feeble acid reaction. Urea is furnished sparingly in chronic inflammation of the liver, in the gra- nular disease of the kidney, in dyspepsia, pulmonary phthisis, gout, and intermittent fevers. This substance has been supposed, but erroneously, to be wanting in diabetes mellitus. Both Barruel and Henry have shown that it is generally present, and they suppose that the error into which other chemists have fallen, in respect to this matter, has arisen from the tendency which the sugar has to prevent the nitrate of urea from crystallizing. Urea sometimes exists in excess. This state is usually combined with preternatural activity of the renal function, and can be easily recognised by mix- ing with the urine an equal quantity of nitric acid. The lactic acid, which, according to Berzelius, naturally exists in the urine, is seldom or never altered either in quantity or quality. But this is not the case with the uric and phosphoric. The former of these, supposed by Dr. Prout never to be present in healthy urine, generally greatly predominates in arthritic affections, as is shown by the formation of the earthy concretions, which are so frequently seen in the joints of the extremities, and which seem to be composed prin- cipally of the urate of soda, with a small quantity of the urate of lime. Gravel commonly consists of uric acid, and it is well known that this substance forms the basis of one of the worst kinds of uri- nary calculi. In diabetes mellitus this acid is entirely absent, no trace of it whatever being discoverable by the most delicate tests. In some instances this acid occurs in a free state; but most gene- rally it appears in combination with an alkali; and, so long as this is the case, it does not yield a crystalline deposit. The undue secre- 1 Traits de Chimie, t. vii. Paris, 1833. 3 Inquiry into the Nature and Treatment of Gravel, &c. URINE. 87 tion of this substance is usually produced by errors in diet, and by whatever has a tendency to impair the digestive powers. Hence it is most commonly met with in dyspeptic persons, of a gouty, irritable habit, in whom it sometimes prevails to a most unhappy extent, con- stituting a sort of uric acid diathesis. A deficiency of phosphoric acid is not less injurious than an excess of uric. Prout supposes that, when this acid is not secreted in due proportion, the earthy materials of which it is the base are converted into neutral salts, and then precipitated, so as to afford an opportu- nity for the formation of a stone. The alkalies which enter into the composition of this fluid are sometimes secreted in excess, and, by combining with the acid ingre- dients, may form salts, which, on being deposited in the bladder, give rise to calculous concretions. This is especially the case with the lime and ammonia, the soda and potash producing little or no inconvenience. Urine always contains, even in the healthy state, a small quantity of mucus, which, however, as it is perfectly transparent, does not become visible until after the fluid has stood some time in a tall, narrow glass vessel. It then presents itself near the bottom of the receiver, as a light but distinct cloud, which contrasts very strikingly with the clear supernatant fluid. It is always more or less transpa- rent when moist, is not coagulable by boiling water, is soluble in caustic potash, and forms, on the addition of acetic acid, a thin, semi-opaque, corrugated, and characteristic pellicle. When dried, it has a peculiar shining aspect. Under the microscope, it is observed to have the same globular appearance as pus, but the particles are less numerous, and also less distinctly granular. They are suspended in a viscid, glairy fluid, combined with more or less albumen. The urine with which the mucus is united is generally alkaline, and re- markably prone to decomposition, which not unfrequently takes place even in the bladder, especially if it be long retained. How- ever this may be effected, whether in this organ, or subsequently to its expulsion, it always renders the fluid excessively offensive and disagreeable. The quantity of mucus is frequently much increased in disease. In cystorrhoea, for example, it is so abundant as to impart to the affection its distinctive character. An augmentation of quantity is usually associated with an augmentation of consistence. In chronic cystitis, attended with a copious secretion of mucus, the fluid is gene- 88 INTRODUCTION. rally exceedingly tough and viscid, adhering tenaciously to the bot- tom and sides of the receiver, and allowing itself to be drawn out in long, stringy threads. It is, also, under these circumstances, not unfrequently associated with phosphatic deposits. 2. The process of secretion, which is constantly going forward in the kidney, sometimes proceeds to a morbid extent, in consequence of which substances are generated which do not naturally occur in the urine. The most important of these, in reference to the patho- logy and treatment of diseases, are albumen, fibrin, and the colouring matter of the blood. Other substances are occasionally observed, which get into the urine accidentally, and impart to it their peculiar properties. Of this description are the yellow matter of the bile, asparagus, oil of turpentine, and most of the balsamic preparations. Cantu detected mercury in the urine of persons who had been sub- jected to frictions with that substance, in the form of ointment; and the ferro-cyanate of potash, tartaric acid, iodine, and a hundred other articles have been observed by different chemists in this fluid, after they had been used as medicines. In severe cases of jaundice, whether resulting from duodenitis, inflammation of the liver, or obstruction of the natural outlets of this organ, the bile passes from the blood into the kidneys, and communicates a yellow tint to the urine, at the same time that it renders it more acid. The most delicate test of its presence is mu- riatic acid, which causes either a green or brownish hue, according to the peculiar modification of the colouring principle of the foreign ingredient. Linen and paper will receive a very distinct yellow stain, which remains when dried. The muriate of iron and the ace- tate of lead produce a yellow precipitate, the sulphate of copper, a dirty green one. Albumen is said by some to be always contained in very minute quantity in healthy urine; but, however this may be, this substance is frequently present in certain diseases, in large proportion. In the granular affection of the kidney, so ably elucidated by Dr. Bright, albumen generally exists in considerable quantities, though it cannot be regarded as pathognomonic of that singular lesion, as it has been repeatedly observed in pneumonitis, dropsy of the abdomen, tubercles of the lungs, prurigo, and typhoid fever. Both Bouillaud and Piorry declare that they have frequently noticed this substance in diseases which had no connexion whatever with the urinary organs. Ac- cording to Dr. Blackall, it is characteristic of certain kinds of dropsy, URINE. 89 especially such as are accompanied with a phlogistic diathesis,—an opinion which has been amply confirmed by the researches of other pathologists. Albuminous urine is generally of low specific gravity, from defi- cient quantity of urea and salts, of a pale, opaline colour, and readily coagulable on exposure to heat. The ferro-cyanate of potassium, alum, and nitric acid will also curdle it. The urine may also contain fibrin; but this, I presume, is very rare; at all events, the subject is seldom alluded to by writers. Dr. Prout saw a remarkable instance of this deposit, in a middle-aged woman, who had a most voracious appetite, but was otherwise per- fectly healthy. Her urine, which was of a pale yellow tint, was ex- tremely thick, and contained a large quantity of matter, which bore the greatest resemblance to the fibrin of the blood. The appearance of this substance is occasionally associated with certain forms of dropsy ; but how it is produced it is impossible, in the present state of our knowledge, to determine, as nothing is yet certainly known respecting it. Perhaps it may depend upon some structural lesion of the kidney, that has hitherto escaped the attention of the anato- mist, or it may be that it is connected with a sort of inflammatory diathesis, either of the renal tissues, or of the system at large. The urine not unfrequently contains pure blood. This may be owing to various causes, the most common of which are external vio- lence, eventuating in a laceration of some of the vessels of the genito- urinary apparatus, the passage of a renal calculus, ulceration of the mucous surfaces, and the presence of encephaloid, fungous, or erec- tile tumours. Occasionally, though rarely, the fluid is the result of a process of exhalation. The quantity may be so small as to be hardly visible, or so large as to give the urine a dark-red, claret, or blackish aspect. In the former case, the fluid deposits a reddish sediment, and will either be of a light pink, or dirty, dingy hue, according to the period that has elapsed since the occurrence of the effusion. When the quantity is very abundant, a considerable portion of it usually presents itself in the form of black, half-dissolved clots, or in that of short, cylindrical pieces, nearly of the shape of leeches. When the blood exists in large quantity, its presence is, in general, easily detected by the peculiar colour which it imparts to the urine, by its tendency to subside to the bottom of the receiver, and by its alkaline properties. The readiest and most infallible mode, however, of discriminating between it and other substances is to examine it 90 INTRODUCTION. with the microscope. For this purpose, a minute portion of the suspected fluid is placed in a watch-glass under the field of the in- strument. If it be of a bloody character, it will be found to contain a great number of corpuscles, which, although usually somewhat altered in shape, are yet sufficiently characteristic. When the blood is very recent, or has not been acted upon much by the urine, it generally retains its normal appearance, and is consequently more easily distinguished. When blood exists in the urine in large quantity it is com- monly to be regarded as denotive of serious mischief in the genito- urinary apparatus. When it is mixed with pus, or mucus, or both, and voided with pain, it indicates ulceration of the bladder, kidney, or prostate gland. When it is passed along with particles of soft jelly-like matter, it denotes the existence of encephaloid disease, or of fungus hsematodes. Voided in a pure state, and in large quantity, without pain, it is probably merely an exudation from some portion of the mucous membrane of the genito-urinary apparatus. Pus is a very frequent ingredient of urine, and is generally deno- tive of organic lesion of the genito-urinary apparatus. Its admix- ture may, however, be purely accidental, as when it is caused by the bursting of an abscess into the bladder, or the pelvis of the kidney. It has also been supposed, though there is no positive evidence that such is the fact, to be occasionally vicarious of purulent deposits in remote parts, as the pleura and the lungs. The urine with which the pus is combined always contains albumen, is indisposed to putrefy, and is generally acid or neutral; when first voided, it is more or less turbid, but it soon assumes a pale appearance, though it never be- comes perfectly transparent. By repose, the pus falls to the bottom of the receiver, where it forms a dense homogeneous stratum, of variable thickness, and of a yellowish-white or greenish-yellow tint. Under the microscope it exhibits the appearance of spherical corpuscles, floating in an albu- minous fluid, opaque, white, rough on the surface, and more than one- third larger than the red particles of the blood. By agitation it readily mixes with the urine, to which it imparts its peculiar colour, but is not dissolved in it. If a portion of the pus be mixed with an equal quantity of a solution of potash, it will form a dense, trans- lucent, viscid compound, frequently so solid that the tube containing it may be inverted without any escaping. When putrefaction and alkalescence have commenced, the pus loses its distinctive characters; URINE. 91 the globules disappear, and the whole fluid is transformed into a ropy, glairy substance, of a dirty, turbid aspect. The best test for detecting pus in the urine is its coagulability by potash. Its fatty matter, which presents itself in the form of yellowish, butter-like globules, may be extracted by the addition of ether. The albumen, which purulent urine always contains, is easily detected by heat and nitric acid. A substance, termed kiesteine, was detected in the urine, a few years ago, by Nauche. He supposed it to be peculiar to pregnant women, but it has since been ascertained to be generally present also during the early months of lactation, and sometimes also in the virgin state. When first observed it usually presents itself in the form of little, isolated patches, which gradually coalesce, and form a pel- licle, from half a line to a line in thickness, of a whitish opaline tint, not unlike the greasy scum upon the surface of fat broth. Dr. Elisha K. Kane,1 who has carefully investigated the physical pro- perties of this substance, states that it occasionally makes its appear- ance in striated, irregular lines, somewhat similar to those of a spi- der's web, in rings, circles, trapeziums, and irregular figures of almost every shape, which become gradually obscured by the full develop- ment of the pellicle. It consists of a filamentous, flaky tissue, and is so coherent that it may occasionally be lifted off entire from the fluid which it covers. A portion of this substance commonly sub- sides, and forms a thin, bluish, or whitish layer at the bottom of the vessel. Its chemical nature has not been determined. Its smell sometimes resembles that of old cheese, but this is far from being constant. The time at which the pellicle appears varies. Dr. Kane has seen it well-marked at the end of thirty-six hours, and, on the other hand, he has known its appearance to be postponed until the eighth day. 3. In the third place, the urine may be altered by the ingress of principles which, so far as we know, are not naturally contained in the blood. Amongst these, the most common are the cystic and xanthic oxides, oxalic acid, and a peculiar saccharine substance, like the sugar of grapes. The cystic and xanthic oxides are never ob- served in healthy urine: they form the base of several varieties of vesical concretions, and the causes which predispose to their develop- ment are still unknown. Oxalic acid is more frequently seen, and 1 Amer. Jour. Med. Sciences, vol. iv., p. 13, N. Series. 92 INTRODUCTION. is often traceable to articles of diet which naturally possess a large quantity of this substance. An abundant secretion of sugar is a circumstance by no means uncommon. In diabetes mellitus, where it is generally present in large proportion, it forms the characteristic feature of the disease. The urine in this complaint is commonly of a pale straw-colour, of a faint, whey-like odour, and of a decidedly saccharine taste ; it has a greater specific gravity than in health, yields a syrup by evapora- tion, has little tendency to putrefy, and is susceptible of undergoing the vinous fermentation. Diabetic urine almost always contains the usual proportions of saline matters; but, in the majority of cases, there is a great deficiency of urea and lithic acid. In a specimen of this fluid, examined by Mr. Kane, of England, 1000 parts were found to be composed of 913 of water, 60 of sugar, 7 of urea, and 20 of salts. The quantity of urine discharged in diabetes is sometimes surpris- ing. Cases are on record, in which from two to four gallons have been voided every twenty-four hours for a number of weeks, and even months. The amount of saccharine matter is also very great. From some observations of Dr. Henry, of England, it appears that ten pints of diabetic urine, of the specific gravity of 1*040, contain upwards of a pound and a quarter of solid extract. The proximate cause of this disease is still unknown. From the facility with which the saccharine matter is furnished by the kidneys, it has been sup- posed to exist in the blood. No chemist, however, has hitherto suc- ceeded in detecting it in this fluid; and, until this be done, it would be idle to indulge in speculation. The kidneys are generally large and flabby, and there is almost always great disorder of the digestive apparatus. Though oil is not contained in healthy urine, it is found in certain diseases. In one instance, Prout observed a substance like butter; and, in some cases, the fluid has the aspect of milk. Of oily urine, Raciborski has pointed out three varieties. In the first, the fluid is of a reddish-yellow colour, and of a viscid, ropy consistence; in the second, it is of a mahogany brown. When this appearance is wit- nessed in acute diseases, it is always indicative, according to Landre*- Beauvais, of great danger. In the third, the fatty matter floats on the surface of the urine, forming a thin pellicle, not unlike a spider's web. URINE. 93 The urine is occasionally of a bluish tint, owing to the presence of a peculiar colouring matter, which it holds in suspension. This sub- stance, whatever may be its nature, is slightly soluble in boiling water and alcohol, has neither taste nor smell, and is entirely de- stroyed by nitric acid. Exposed to heat, it yields carbonate of am- monia and an empyreumatic oil. The urine may likewise be of a black colour, from the presence of melanic acid. When this substance is very abundant, the fluid has sometimes the appearance of black ink, or may be made such by the addition of an alkali. More frequently, a pink colour is observed, which is supposed by Dr. Prout, to be owing to the presence of pur- puric acid. Raciborski has often noticed this tint in rheumatic affec- tions of the joints, of which, however, it is far from being diagnostic ; and he has also witnessed it, though much less frequently, in catar- rhal complaints of the chest. The urine, under certain circumstances, deposits amorphous sedi- ments, which Dr. Prout has arranged into several classes, the diffe- rence of colour forming the basis of the division. They all consist essentially of the lithate of ammonia, tinged with the colouring prin- ciple of the urine, or the purpurates of ammonia and soda. The yel- low sediment is characteristic of health; the pink, of hectic; the lateritious, of inflammatory fever. To this statement, however, there are numerous exceptions. Lastly, the urine may contain hairs. Of this singular occurrence, highly interesting cases have been published by Magendie, Brodie, and some other writers. The hairs, which are occasionally quite numerous, are seldom more than five or six lines in length, and they generally appear in combination with an excessive secretion of earthy matters. Whence these hairs are derived, we have no means of ascertaining. The subjects of most of the cases that have been reported were old men of intemperate habits. n DISEASES OF THE URINARY ORGANS. PART I. DISEASES AND INJURIES OF THE BLADDER. CHAPTER I. MALFORMATIONS AND IMPERFECTIONS. SECTION I. ABSENCE OF THE BLADDER. The malformations of the bladder are rare, and in a practical point of view, not very important. They may be arranged under the following heads: 1. Absence of the bladder: 2. Bilobation, or multiplication of the organ: 3. Extrophy, or congenital eversion. Absence of the bladder has been observed only in a few instances, which is not surprising when we consider how essential its presence is to the comfort and well-being of the system. When the defect exists, the ureters may open at one of three places; either into the rectum, the vagina, or directly into the urethra. The order of fre- quency of these different modes of termination has not been ascer- tained ; but the probability is that it is as here enumerated. When the ureters terminate in the rectum, the part is converted into a true cloaca, as in birds and reptiles. Richardson has published, in the seventh volume of the Philosophical Society of London, the history of a youth who lived seventeen years without ever having urinated by the penis. He passed all his water by the anus, and the only inconvenience which he experienced was a slight but continued 96 DISEASES AND INJURIES OF THE BLADDER. diarrhoea. Haller1 cites examples of the insertion of the ureters into the vagina. A few instances are related in which the ureters were directly con- tinuous with the urethra. Of these, the best authenticated, perhaps, is that of Binninger,3 who observed it in the body of Abraham Clef, which he examined in the presence of several surgeons. The bladder was totally wanting. A probe introduced into the urethra could be readily passed alternately into the ureters, and from the ureters into the urethra; thus proving, beyond all doubt, that there was no inter- mediate sac. The kidneys were unusually large, and free from cal- culous concretions, although Clef had voided one some time before his death. The case loses much of its interest, from the fact that no account has been transmitted to us of the manner in which the subject of it voided his urine ; whether this fluid was discharged involuntarily in drops, or under the influence of the will, and consequently in the ordinary manner. As there was no special dilatation of the ureters, answering the purpose of a bladder, it is altogether probable that the evacuation was incessant, as in extrophy, or congenital eversion of this organ. Clef had evidently studiously concealed his infirmity from his friends and physician. SECTION II. BILOBED AND ANOMALOUS BLADDER. The bladder has been found divided into two or more compart- ments, either as a congenital defect, or as the result of disease. The internal septum upon which this arrangement depends is generally situated transversely, but occasionally it is directed obliquely, or even vertically. Of the latter variety an interesting example is recorded by Blasius. The bladder of a man who died of phthisis, was divided in the direction of its length into two equal portions, by a septum which extended from the superior part of the reservoir to its neck. Each compartment had a distinct ureter. Externally the organ ap- peared to be natural. (Observ. Med. Rarior. Cum. fig. ob. 19.) Bus- sie"re, a member of the Royal Society of London, has published, in the Philosophical Transactions for 1701, a case in which the bladder was triple, or divided into three distinct compartments. It was that 1 Element. Physiol., T. 7, p. 297. 3 Obs. Med., T. 2, c. 2. MALFORMATIONS AND IMPERFECTIONS. 97 of a man who died in consequence of a vesical affection, the principal symptom of which was great difficulty in passing water, which was discharged in small quantity. On dissection, the bladder was found to consist of three pouches or sacs of different capacities, the central one, which was regarded as the true organ, being intermediate in size between the other two, of which the right was the larger. The lateral pouches communicated with the main reservoir near its neck. A still more remarkable example of malformation is recorded by Molinetti. Here the individual, a female, had five bladders, five kidneys, and six ureters, of which two were inserted into the largest reservoir, while the remainder terminated each in one of the small sacs, which discharged their contents by special ducts into the main organs. This extraordinary number of bladders was the result alto- gether of an original vice of formation and not of disease. (Diss. Anat. Path., lib. 6, cap. 7.) A very singular case, in which the bladder was divided into two nearly equal parts, has been recorded by Bordenave. The patient had been subject to retention of urine, and the two sacs were situated the one behind the other, that which was regarded as the preterna- tural one having unusually thin walls. They communicated together by an opening of considerable size. Foubert examined the body of an old officer, who had been subject for several years to retention of urine, in the posterior and upper part of whose bladder there existed a depression of a conical form, the apex of which extended as far as the neck of the organ, and the interior of which lodged a portion of the ileum about six inches long. The bladder itself was large and relaxed. (Memoires de l'Acade'mie Chirurg., T. 2, 26. Paris, 1819.) A case of congenital malformation of the bladder, of a very sin- gular and unusual character, has been recently published by Dr. C. P. Johnson,1 Professor of Anatomy and Physiology in the Medical School at Richmond, Virginia. It occurred in a male child eight months of age, who had suffered for several weeks previously to its death from violent paroxysms of pain in the hypogastric and umbi- lical regions. The chief point of interest was an abnormal pouch, which, arising by a narrow pedicle from the lower and back part of the bladder, at the place naturally occupied by the right seminal vesicle, passed along the posterior wall of the bladder, about two 1 Medical Examiner and Record of Medical Science, July 1850, p. 381. 7 98 DISEASES AND INJURIES OF THE BLADDER. inches above its upper border. It was about ten lines in diameter, of an irregularly cylindrical shape, hollow, and of the same structure as the bladder, with which it communicated by a small aperture just within and below the orifice of the right ureter. The pouch, at the time of the dissection, was found to be filled with urine. The bladder was of the natural size and form; and the prostate gland, the left seminal vesicle, and the two ureters occupied their usual position. Most of the cases of supernumerary bladder, recorded by the older anatomists, are of a very doubtful character. That nature is occa- sionally guilty of a freak of this kind may be easily imagined; but the occurrence is extremely unfrequent, and, unless attested by com- petent testimony, should always be received with great distrust. I am not aware that Morgagni, Haller, or Meckel, among the older pathologists, or Lobstein, Cruveilhier, or Rokitansky, among the more recent, have met with a single example of such a malformation. SECTION III. EXTROPHY OF THE BLADDER. The most remarkable malformation of the bladder, amounting, in fact, to a hideous monstrosity, is extrophy, or congenital inversion, a condition which consists essentially in the absence of the anterior wall of this viscus, and the protrusion of its posterior wall across an opening in the inferior part of the linea alba. The affection is for- tunately rare, though it is said that Percy, in the course of his prac- tice, witnessed not less than twenty cases of it; a circumstance which can only be accounted for by the fact that individuals thus afflicted usually resort to large cities in pursuit of charity and professional aid. However this may be, the experience of the French surgeon, in this respect, is without a parallel. I have myself seen but one example of extrophy of this organ, of which the following are the most interesting points, as derived from a careful personal examina- tion, during a visit which the subject of it made to Louisville in 1847, to exhibit himself to the medical class of the university of that city. Joseph Head, nineteen years old, a native of Rhode Island, is five feet six inches high and well formed, but has never enjoyed robust health, having had ten different attacks of bilious fever. His intelli- gence is very ordinary, and he is a painter by trade, but has never MALFORMATIONS AND IMPERFECTIONS. 99 worked much at his business. He has a brother and a sister, who are both sound and well formed. Walking is painful to him, from the pressure and friction of his pantaloons upon the tumour ; he con- stantly keeps the part covered with a thick, soft compress, to imbibe the urine, changing it five or six times a day. His bowels are habi- tually constipated. His body and limbs are well proportioned and well developed, but he has no beard. Fig. 22. Extrophy of the bladder, a. Everted bladder. 6, b. Orifices of the ureters, c. Penis without urethra. d, d. Pubic symphysis, e. Scrotum and testis. /. Congenital inguinal hernia. The bladder is situated just above the pubic symphysis, in the median line, where it forms a rounded, convex tumour, four inches in breadth by three inches and a quarter in height. The tumour is soft and elastic, has a red, raw appearance, bleeds easily when touched, and is tender and even painful on pressure. Its size is increased when the patient stands up, and diminished when he lies down. The upper, central part of the tumour is covered with skin, a sort of imperfect copy of the original; everywhere else, it is red and raw. The skin, at its periphery, especially on the left side, is somewhat puckered, and has the aspect of a cicatrice. The orifices of the ureters, indicated by a frequent oozing, or occasional jet of urine, are quite small, and one inch and three-eighths of an inch apart: 100 DISEASES AND INJURIES OF THE BLADDER. the right is mammillated, and more prominent than the left. Between the tumour and the stunted penis a deep furrow exists, at the bottom of which are the mouths of the ejaculatory ducts, separated by an interval five-eighths of an inch in width. The interval between the pubic bones is four inches, and appears to be occupied by a dense, elastic structure, probably fibro-ligamen- tous in its character. The bodies and symphysis of these bones are evidently wanting. The penis is imperforate, and consists of two rudimentary caver- nous bodies. In its flaccid condition, it is upwards of two inches in its transverse diameter, and ten lines in the antero-posterior; it has a prepuce, and a tolerably distinct frsenum in the usual situation. The organ is flattened above, where it is in contact with the tumour. During erection, it increases to nearly double the ordinary size; the act, however, is unattended by any pleasurable sensation; on the contrary, it is always more or less painful, from the pressure which the distended organ exerts upon the tumour. A mucilaginous fluid, probably prostatic liquor, passes off involuntarily every day, and once or twice a week there are considerable seminal emissions, without any very agreeable feeling or 'emotion. The patient has at no time any amorous propensities. The scrotum is smaller than usual, and its surface is covered by a few straggling hairs. The spermatic vessels and ducts appear to be of the natural size and consistence. The testicles are well formed: the left hangs lower than the right. There is a hernia on the right side, but the bowel does not descend into the scrotum. No umbilicus is perceptible; one must, undoubtedly, have existed, but at what point cannot now be determined. Possibly, the umbili- cal vessels, which naturally run along the sides of the bladder, in their course towards the linea alba, may have issued at the place of union of the abdominal and vesical parietes, and thus prevented the formation of a navel, properly so called. The groins are pretty thickly covered with hair, which extends unusually far outwards towards the spine of the ilium; it is of the ordinary length, and of the same colour as that of the head. The above case is typical of all the examples of this variety of monstrosity that have been recorded by different observers as having occurred in the male. There are a few points, however, in the his- tory of this affection which require brief notice. The urinary tumour presents considerable diversity both as it MALFORMATIONS AND IMPERFECTIONS. 101 respects its form, size, ^and colour. In general, it is somewhat ovoidal, or globular; but occasionally, it is very irregular, or nearly flat. Its volume is greatly influenced by the age and position of the subject. In the child, it rarely exceeds that of a walnut, while in the adult, when it has attained its maximum development, it may be as big as a fist, or goose's egg. Very small when the subject is recumbent, it becomes quite prominent when he stands up, coughs, sneezes, or exerts himself much. The surface of the tumour is of a bright-red colour, and is constantly covered with a mucous secretion, which protects it, in some degree, from the injurious impression of the atmosphere. In elderly subjects, the part is sometimes partially invested with a cutaneous pellicle, in consequence of which it is much less sensitive, or irritable, than in infancy, childhood, and adolescence, in which it is generally very tender, and apt to bleed on the slightest touch. The orifices of the ureters, generally situated at the inferior part of the tumour, are usually marked each by a small tubercle, or conical eminence, from which the urine constantly drib- bles, rendering the person, unless very cleanly in his habits, uncom- fortable to himself and disgusting to those around him. The distance between the two apertures varies from one to two inches, according to the age of the subject. In all cases, there is a separation of the pubic bones, or, more properly speaking, an absence of their bodies. The interval between them varies, in different cases, from two and a half to five inches, according to the age of the subject and the width of the pelvis; and is occupied by a strong, dense, ligamentous substance, by which the gap is effectually closed. The cause of this condition is probably defective development, or an arrest of growth, similar in its nature to that in the soft parts. The penis, always preternaturally short and flattened, is generally bent backwards, and furnished with an imperfect prepuce. The cavernous bodies, attached below to the ischium, as in the natural state, are small and narrow, and are not always united along the middle line, except just behind the head of the penis. This organ is sometimes imperforate, and at other times it presents a gutter along its upper surface for the lodgment of the lower half of the urethra. When this is the case, the posterior part of the canal dis- plays the verumontanum, the mouths of the ejaculatory ducts, and the orifices of the prostatic canals. The prostate gland is generally present, but in a rudimentary state. The seminal vesicles, always very diminutive, are sometimes repre- 102 DISEASES AND INJURIES OF THE BLADDER. sented by two small tubercles. Whatever may be their volume, they are always situated behind the inferior part of the fungous tumour. The ejaculatory ducts pursue their natural route, but are unusually small. The scrotum is sometimes completely absent; at other times it exists merely in a rudimentary state. In the latter case, it may contain the testicles, while in the former, these organs are either lodged in the groin, or in a cutaneous bag at each side of the tumour. The testicles are sometimes normal; at other times they are dimi- nished in volume, or entirely absent; this, however, is rare. The rectum is commonly natural, both in its situation and dimen- sions ; sometimes it is considerably dilated, and sometimes, again, it is so much contracted as to give rise to great pain and difficulty in defecation. In the female, important changes are noticed in the genital organs. The clitoris may be absent, or it may deviate more or less from the normal standard. It is sometimes situated at one side of the median line, unusually small, or entirely absent. The attention of observers has not been specially directed to the condition of the urethra, and hence no precise intelligence has been elicited respecting it. The nymphse are disunited, and imperfectly developed; the pudendal lips are either absent, or they are moderately large, and covered with hair. In the latter case, they extend from the sides of the tumour towards the anus, without uniting, and without forming what is called the fourchette. The vagina usually exists in a rudimentary state; being preternaturally short, narrow, and flattened, with an uncom- monly small orifice, which has sometimes the appearance of a trans- verse slit or fissure. The uterus is sometimes absent, sometimes rudimentary, sometimes fully developed. In the latter case, the subject may menstruate, and conceive, as in the interesting case recorded by Thiebault.1 In the male, on the contrary, there must always be complete impotence, on account of the peculiar manner in which the ejaculatory ducts open upon the surface of the tumour. Extrophy of the bladder is utterly irremediable. All that can be done is to palliate the patient's suffering, by attention to cleanli- ness, and by the use of a closely-fitting bottle for receiving the urine. Where this cannot be obtained, the part must be kept constantly covered with a thick, soft compress, renewed as often as it becomes wet and disagreeable. The skin around may be protected, if neces- sary, with pomatum, simple cerate, or mutton suet. ' Journal General de Me'decine, T. 34, p. 178. CHAPTER II. INJURIES OF THE BLADDER. SECTION I. WOUNDS OF THE BLADDER. It is remarkable what little information is to be found, in syste- matic treatises on surgery, about wounds of the bladder. From their silence, one would suppose that their authors were either totally un- acquainted with the subject, or that they were afraid to discuss it. Their neglect to notice it cannot surely proceed from the infrequency of the occurrence of the accident, or any want of pathological and practical interest it may present. Wounds of the bladder may be incised, punctured, lacerated, or gunshot, according to the kind of weapon with which they are in- flicted. From the situation of the viscus, these injuries must always necessarily be complicated with lesion of the soft parts by which it is surrounded, and also not unfrequently with fracture of the pelvic bones. The bladder, when empty, is so small, and consequently so well protected by the pelvic bones, that there is but little chance of its being wounded in an ordinary accident or rencounter. It is only when it is full, and projects some distance above the pubes, that it is liable to be laid open by sharp cutting instruments, a sword, dirk, bayonet, spear, or splinter. A ball, however, may easily penetrate it when it is empty or entirely concealed in the cavity in which it is naturally contained. Lacerated wounds are usually inflicted by blows, falls, or kicks upon the hypogastric region, by the pressure of the child's head in parturition, or by the body being forcibly jammed between two hard and resisting objects, as a post and the wheel of a carriage. In the same manner, the organ may be severely bruised. Baron Larrey describes the case of a soldier whose bladder was badly contused by the horn of a bull. 104 DISEASES AND INJURIES OF THE BLADDER. A wound, no matter how produced, may transfix the bladder, or merely pierce one of its walls; in the former case, there will be two openings; in the latter, only one. Again, the lesion may involve the serous investment of the organ, or it may take place in front and below where it is destitute of peritoneum. These circumstances, as will be presently seen, have an important influence upon the prognosis and treatment of the accident. The best example of an incised wound of the bladder is the inci- sion made in supra-pubic and recto-vesical operations. In perinseal lithotomy, the knife divides the prostate gland rather than the blad- der. The best example of a punctured wound is that made by the trochar, for the purpose of drawing off the urine in cases of perma- nent retention from obstruction of the urethra. The following case of punctured wound of the urinary bladder is related by Dr. Schiitte,1 of Mullheim, in Germany. A healthy man, thirty-seven years of age, fell perpendicularly from a height of about eight feet on an upright wooden stake several feet long and fully an inch thick. Its end penetrated the inner surface of the left thigh, about three inches from the rectum, and opened the lower part of the urinary bladder above its sphincter muscle. The urine flowed continually and insensibly through the wound; but none passed by the urethra. A catheter was placed in the organ ; and leeches, cold lotions, and poultices were successively applied externally. The patient was kept on light food, and in about three weeks the wound had healed without any ill consequences. The symptoms of this lesion are, the existence of an opening in the lower part of the hypogastric region, the groin, or the perinseum; sudden and acute pain in the situation of the affected organ, extend- ing along the urethra, and often accompanied by slight priapism; an escape of urine, or urine and blood, at the external wound; fre- quent but ineffectual attempts at micturition; violent tenesmus; and a discharge of bloocLfrom the urethra. The system labours under all the effects of a violent shock. The countenance is pale and ghastly, the breathing is hurried and oppressed, the pulse is small and feeble, the stomach is nauseated, and the surface is covered with a cold, clammy perspiration. When the injury is complicated with perforation of the bowel, fsecal matter, mucus, bile, or gas, mixed with urine, or urine and blood, may issue both at the external open- 1 American Jour. Med. Sciences, N. S. 1, p. 517. INJURIES OF THE BLADDER. 105 ing and at the urethra. When the pelvic cavity is pierced, the state of collapse, the usual consequence of the accident, is speedily followed by symptoms of peritonitis, of which the patient almost always dies in two or three days. When the bladder is wounded through the perinseum or above the pubes, at a point where it is uncovered by serous membrane, urinous infiltration is liable to take place, and the probability of the occurrence will be so much the greater if the ex- ternal opening is disproportionably small, if the track of the wound is narrow and devious, and if the organ was much distended at the time of the accident. The discharge of urine at the external wound may be momentary, or it may last for a considerable period. It is sometimes continued; but for the most part it is intermittent, and exceedingly irregular in regard to its quantity. In some instances all the urine escapes by the external wound, especially if this be situated in the perinseum or in the rectum. Grunshot wounds of the bladder, although less fatal than punc- tured and incised wounds, are often extremely formidable, destroy- ing the patient immediately or remotely, producing extensive mis- chief among the soft parts, as well as in the pelvic bones, and leading to the formation of abscesses, sinuses, and fistules, which may last for months and years, and render life utterly miserable. When the ball is impelled with great velocity, it will be apt to enter the organ at one point, and pass out directly opposite at another, thus leaving two apertures, and either lodging in the neighbourhood, or issuing at the surface of the body. If, on the contrary, it move slowly, or be nearly spent, it will be likely to make only one opening, and to be arrested in the bladder, from which it may ultimately be dis- charged by the urethra, or by a fistulous passage; or, what is more probable, it will become incrusted with earthy matter, and thus form the nucleus of a calculus. The lesion is often complicated with fracture of the pelvic bones, injury of the large vessels, and per- foration of the rectum, the small intestines, the uterus, or the vagina. In the former case, serious mischief is sometimes done by the osseous splinters which the ball makes and detaches in its course towards the bladder, and which not unfrequently find their way into the interior of this organ, where they may give rise even to more disastrous con- sequences than the ball itself. Wadding, pieces of cloth, or portions of the patient's attire, may accompany the ball, and be temporarily or permanently retained in the bladder. 106 DISEASES AND INJURIES OF THE BLADDER. In a gunshot wound the danger of extravasation is not always in the first instance, but sometimes secondary. The ball may have penetrated the coats of the organ obliquely, or in a sort of valvular manner, or it may have been unusually small. In either of these cases, the urine may not escape at all, or the occurrence may be postponed until the separation of the sloughs. This will usually happen at some period from the seventh to the twelfth day, and during this time the patient should be closely watched, otherwise serious, if not fatal, mischief may be the result. Barzelloti1 relates the case of a medical student, shot through the bladder in a duel, who did not die from the peritonitis, consequent upon the extravasa- tion of urine, until the twentieth day from the accident. It is pro- bable that a piece of wadding or cloth may temporarily occlude the wound, and so prevent the effusion of the contents of the organ. It has been already stated that the ball, if lodged in the bladder, is variously disposed of. In the generality of cases, it soon becomes incrusted with earthy matter, which gradually increases in quantity until a considerable-sized calculus is the result, producing all the symptoms of a common concretion, and requiring, perhaps, the opera- tion of lithotomy for its removal. More rarely the ball causes ulcerative absorption, and is finally discharged through the peri- nseum, or the rectum; usually the latter, since it always has a ten- dency to fall into the bas-fond of the bladder. It is possible that the foreign body may become encysted, without producing any decided symptoms. When the ball is very small, it may escape externally through the urethra; but such an occurrence must neces- sarily be rare. The only instance in fact, of this kind of which I have any knowledge, is that related by Bonnetus. After the exter- nal wound had entirely cicatrized, and the patient was apparently well, he began to experience sharp pains, similar to those caused by a stone in the bladder. One day, in a violent effort at micturition, the ball, which was composed of lead, and of the size of a pea, was expelled through the urethra. Pieces of wadding, of cloth, and of bone, introduced into the blad- der, either alone or in union with the ball, are frequently discharged through the urethra. Sometimes, however, they are retained, and form the nucleus of a calculous concretion. Wounds of the bladder, however small, or insignificant, are ' Questioni di Med. Leg. T. iii. p. 174. INJURIES OF THE BLADDER. 107 amongst the most dangerous accidents to which a human being is exposed. It was formerly considered that all such lesions were necessarily fatal within a short period of their occurrence. Modern observation, however, has long since disproved the validity of this conclusion, and has shown that recoveries are by no means infre- quent, and that, too, under circumstances apparently the most des- perate. When the opening is small, and penetrates the cavity of the bladder obliquely, the viscus being at tl^g same time nearly or quite empty, effusion of urine may be prevented, and reparation effected by the adhesive process. A wound involving a part of the bladder that is uncovered by peritoneum is less dangerous than one in which this membrane is injured. The urine in the former case escapes into the subserous cellular tissue, where, although it may awaken severe inflammation, followed, perhaps, by abscess or gan- grene, it is less deleterious than when it finds its way into the general cavity of the abdomen, where its presence almost invariably causes death in a few days. A wound inflicted upon a distended bladder is in general more hazardous than one inflicted upon an empty bladder, because there is more risk of effusion of urine, and the consequent development of excessive inflammatory action. A wound of the inferior part of the bladder is less likely to prove serious than one affecting the body or fundus of the organ; and a gunshot wound than an incised or punctured one. Of the truth of the latter remark the statement of Dr. Thomson, in his " Report of Observations made in the Military Hospitals of Belgium," affords a striking and convincing illustration. "We saw," says he, " no fewer than fourteen cases recovering, in which the bladder had been pene- trated by musket-balls."1 Incised and punctured wounds, on the 1 "Gunshot wounds of the bladder," says Colles,a "are not always mortal. I saw a man who received a ball that went exactly through the sciatic notch, and penetrated the cavity of the bladder; it did not go through, but lodged in the blad- der. After some time the patient found that he could not make water, but after a deal of effort, a piece, or rather two pieces of cloth, which were rolled up into a ball and had lodged in his urethra, were shot out, and he then made water freely enough ; but the ball still remained in his bladder, and the only inconvenience he felt was that he could only make water while lying on his side. He could not make a drop in the erect position, and he afterwards submitted to the operation of hav- ing it cut out. The ball, although it had remained in the bladder twelve months, had not the slightest appearance of incrustation." » Lectures on the Theory and Practice of Surgery, edited by Simon M'Coy, Esq., p. 133, Philada. 1845. 108 DISEASES AND INJURIES OF THE BLADDER. contrary, nearly always prove fatal, and it was doubtless upon this circumstance that Hippocrates founded his famous aphorism, "eui perseeta vesica lethale." Finally, much of the success, in curable cases, depends upon our treatment, and the co-operation of the patient and his attendants. In the treatment of a wounded bladder two prominent indications are presented; first, to prevent extravasation of urine ; and secondly, the occurrence of undue inflammation. Unfortunately the first of these accidents often takes place at the moment of the injury, and consequently before the surgeon has an opportunity of interfering. When the bladder is distended, it mat- ters not where it is laid open, whether at a part invested by perito- neum or not, effusion of urine will be inevitable; the danger of the case will thus be increased, in an instant, an hundred fold. When the general cavity of the abdomen is penetrated, the contact of the fluid will in a few hours set up intense peritonitis, which no skill can possibly control. The disease proceeds in spite of the best di- rected efforts to combat it. This being the fact, the patient's only chance consists in preventing its occurrence. This is to be at- tempted by attention to position, and by the instant evacuation of the bladder. The patient should be placed almost semi-erect in bed, and the catheter, which should be of gum-elastic, should be left in the bladder, where it is to be secured in the usual manner, to enable the urine to pass off as fast as it comes down from the ureters. In a word, the organ should be kept constantly empty and contracted for the first fifteen or twenty days, or until there is reason to con- clude that the wound is closed, and all risk of infiltration over. The end of the instrument must not be permitted to become clogged, or to rise up in the bladder, otherwise the object for which it is em- ployed will not be attained. Care should also be taken that it do not press or rub against the mucous membrane, and thereby excite pain, spasm, or irritation, rendering its presence uncomfortable, if not intolerable. Should the latter result, however, follow, the cathe- ter must be withdrawn, and an attempt made to obviate the danger of distension by the frequent introduction of the instrument. The development of undue inflammation is to be prevented by the employment of antiphlogistic means. Foremost amongst these are general and local bleeding, calomel and opium, hot fomentations, and vesication of the abdomen. Anodynes must be given in full doses, both by the mouth and by the rectum, to allay pain and spasm of INJURIES OF THE BLADDER. 109 the bladder, induce sleep, and diminish the renal secretion. The drinks must be cooling and demulcent, the diet perfectly light and bland, and the bowels must be disturbed as little as possible during the first eight or ten days. No drastic purgatives are admissible. The best aperients are castor oil and sulphate of magnesia. Cathar- tic enemata must be avoided, on account of the pain and irritation which they produce by their pressure on the bladder. Abscesses, the result of urinous infiltration, are to be opened by early and free incisions. Nothing can be gained by an attempt to extract the foreign body, when the injury has been produced by fire-arms; for the very moment it is inflicted the urine escapes, and the bladder contracts upon itself so as to destroy the relations between the external and internal wounds. If the ball has fallen into the bladder, it may, if not too large, either pass off spontaneously, or be removed with the forceps ; should it be otherwise, and severe symptoms be caused by its presence, it must be cut out through the perinseum by an operation similar to that of lithotomy. This may be done immediately or within a short period after the accident, if the ball has entered beneath the pubes, for the reason that the organ will not only be freed thereby of a disagreeable intruder, but also because there will be less risk of urinous infiltra- tion. When the bladder has been transfixed, or wounded through the peritoneum, the accident, as all experience proves, inevitably termi- nates fatally. In view of this event, would it be proper to make an incision through the linea alba, and sponge out the extravasated fluid ? My opinion is that it would, and that it would be much more creditable to a surgeon to perform such an operation, provided it can be done immediately after the injury has been received, than to stand by, and see his patient perish from the effects of peritonitis. The only difficulty in the case might be the uncertainty of the abdominal effusion. SECTION II. LACERATION OF THE BLADDER. The urinary bladder, like the other hollow organs, as the heart, uterus, stomach, and intestines, is liable to laceration, from over-dis- 110 DISEASES AND INJURIES OF THE BLADDER. tension from its contents, or from external violence. The accident, although generally fatal, is of sufficient importance both in a patho- logical and practical point of view, to require brief notice in a work expressly devoted to the consideration of the injuries and diseases of the urinary passages. When the laceration takes place as a consequence of the inordinate accumulation of urine from paralysis of the muscular fibres of the bladder, hypertrophy of the prostate gland, or obstruction of the urethra, there is almost always some degree of softening of the diffe- rent coats of the organ, thus predisposing them to this occurrence. In such a case it is only necessary for the patient to use some unusual or sudden exertion, such as sneezing, vomiting, or straining at stool or micturition, to produce the effect in question. Indeed, the mere effort of turning about in bed might bring it on. The pressure of the diaphragm and the abdominal muscles under such circumstances upon the over-distended viscus, is equivalent to a tolerably severe blow, kick, or fall upon the hypogastric region, the most common cause of the accident when it results from external injury. A similar predisposition is sometimes established by the ulcerative process, and by excessive inflammatory action, eventuating in partial gangrene. The laceration when thus produced usually occurs at the fundus of the bladder, and is generally of small extent. But the most common cause of the accident is external violence, and it is worthy of remark, both in a surgical and a medico-legal point of view, that it may occur from the most trivial injury. Any force suddenly applied to the hypogastric region, as a smart blow, a kick, or a fall, will frequently suffice to produce it. For the force, how- ever, to be effective, it is necessary that the bladder should be dis- tended at the time of the accident. If it is empty, or only partially filled with urine, the blow, unless directed with great precision, will be inoperative. The laceration most commonly occurs in a scuffle, in which the individual receives the weight of the body of his antago- nist upon his abdomen, or in which this part is struck with the head, hand, elbow, foot, or knee. It may also be caused by a fall from a considerable height, by the pelvis being jammed between two hard and resisting objects, as a wall and the wheel of a carriage, or by striking the hypogastric region against a post, a stone, or the corner of a table. Mr. R. W. Smith, of Dublin, describes a case in which the laceration was produced by the person, a female, fifty years of age, falling, while in a state of intoxication, across the INJURIES OF THE BLADDER. Ill edge of a tub. The accident is liable to occur in females during parturition, in consequence of the pressure of the child's head, when the patient has neglected to empty the bladder. A case is mentioned by Mr. Hey,1 in which the fundus of the organ suddenly gave way on the fifth day after confinement, probably from injury sustained during labour. A large quantity of urine was found in the perito- neal cavity. The bladder is sometimes torn in the operation of lithotripsy, and also during the extraction of the calculus after the operation of lithotomy. The age of the patient does not appear to exert any marked influence upon laceration of the bladder from mechanical causes, whether these causes act through the abdominal parietes, through the uterus, or through the pelvic bones. Laceration depending upon over-distension of the bladder is most common in old subjects, in whom the powers of life have been enfeebled by protracted suffering, and is usually associated with softening, and attenuation of the diffe- rent tunics of the organ. King,3 Howship,3 and Malgaigne,4 have each published a case of the accident as occurring in the foetus. The lesion, from both causes, is, for obvious reasons, more common in males than in females. When caused by external violence, the lesion may be complicated with fracture of the pelvic bones, laceration of some of the paren- chymatous organs, as the spleen, liver, or kidney, and injury of the vessels, attended with internal hemorrhage. It is worthy of notice, especially in a medico-legal point of view, that it may occur without any mark of violence upon the surface. In many cases, however, if not in a majority, there is more or less contusion with ecchymosis of the skin, cellular tissue, and muscles of the hypogastric region, and sometimes also of the pubes and perinseum. The rent may be perpendicular, oblique, or transverse. Its edges are uneven, ragged, and everted. In some instances it is conside- rably diminished in size by a protrusion of the mucous membrane; and now and then it looks as if it had been made with a punch or sharp instrument. In extent it varies from a few lines to several inches, being at one time so small as hardly to admit a common-sized 1 Howship on the Urinary Organs, p. 253. a Guy's Hospital Reports, ii. p. 510. 8 Op. cit. 4 Vidal, Traite" de Pathol., Externe, 7 v. 218. Sec. Ed. 112 DISEASES AND INJURIES OF THE BLADDER. quill, and at another so large as to receive a small fist. Several lacerations occasionally exist, but usually there is only one. There is no regularity in regard to the seat of the lesion. It is most com- mon, however, upon the anterior and posterior surfaces of the bladder, next at the fundus, and lastly at the bas-fond. The neck also some- times suffers; and cases occur in which the viscus is literally torn from its attachments to the pelvic bones. The peritoneal coat alone may be torn, but this is rare; on the other hand, this coat may retain its integrity, and all the rest give way. This distinction is not imaginary, but real, and, as will be shown presently, has an important bearing upon the diagnosis and treatment of the injury. It leads, moreover, to a division of the lesion into partial and complete. In the former variety, the urine, instead of escaping into the abdominal cavity, is extensively infil- trated into the subserous cellular tissue of the bladder, of the pelvis, and of the abdominal muscles, and the peritoneum, at the seat of the lesion, bulges out in the form of a small translucent pouch. The accident usually reveals itself by well-marked symptoms, both general and local. Violent pain is instantly experienced in the hypogastric region, the face is pale and ghastly, the pulse is small, rapid, and fluttering, the respiration is hurried and difficult, the ex- tremities are cold, and the surface is covered with a clammy perspi- ration. The patient occasionally falls down in a state of insensibility, as if he had been struck on the head or stomach; but this is not always the case; for sometimes he is able to walk about, and per- haps go some distance before bad symptoms appear. Not unfre- quently he feels as if something had burst or given way in his abdo- men, attended, perhaps, with a crack, or audible noise. In nearly all cases there is a constant desire to urinate, and an inability to pass a single drop of water. A small quantity of blood often flows by the urethra. These symptoms are soon followed by nausea, and vomit- ing, intense thirst, excessive restlessness, and an expression of in- tensive suffering, with swelling and tenderness of the abdomen. The period of collapse may last from a few minutes to several hours or even days, and the patient may die from the shock of the system, or reaction may occur, and he may perish from the effects of peritonitis. The introduction of the catheter is generally followed by a flow of bloody or turbid urine, and not unfrequently by blood alone, either fluid, or partly fluid, and partly coagulated. The instrument enters • INJURIES OF THE BLADDER. 113 without difficulty, and the point sometimes passes through the rent in the bladder into the peritoneal cavity, where it may be made to move about in different directions, and even be felt by the finger across the walls of the abdomen. Of these symptoms the most worthy of reliance, in a diagnostic point of view, because the most constant, are .the sudden pain in the hypogastric region, a frequent but fruitless effort to urinate, an escape of blood by the urethra, the inability of the surgeon to relieve the bladder with the catheter, and the rapid collapse of the system. The sensation of tearing, or giving way, is often absent, and so is also the crack or audible noise. The character of the pain is not to be disregarded. It always comes on at the moment of the lacera- tion, and is generally so violent as to induce extreme faintness with all the other symptoms of prostration. It may be sharp or lancina- ting, hot or burning, colicky or cramp-like. The symptoms now enumerated, added to the history of the case, leave no doubt in regard to the nature of the lesion. In laceration of the bladder external to the peritoneum, or in the partial variety of the affection, the symptoms are equally severe in the first instance, but the reaction generally takes place sooner, and there is a longer interval between it and the occurrence of peritonitis. The pain during this period is less violent, the abdomen is not so tender under pressure, the pulse is not so much depressed, and there is less prostration of strength: More urine, too, flows by the catheter. The state of collapse having continued for some time, is at length followed by a certain amount of reaction, which is itself speedily suc- ceeded by symptoms of peritonitis. The countenance now becomes flushed, the skin is hot and dry, the pulse is small, quick, and wiry, the belly is tympanitic and exquisitely tender on pressure, the limbs are drawn up to relax the abdominal muscles, the respiration is quick and hurried, and the patient is often delirious at an early period of the attack. By and by, hiccup sets in with bilious vomiting, the pulse fails at the wrist, the surface is bathed with a cold clammy sweat of a urinous odour, the countenance becomes Hippocratic, and the patient falls into a state of coma, under which he gradually expires. On dissection, the ruptured organ is usually found to be very much contracted, and hardly ever contains more than a few drachms of urine. In some instances, especially in partial varieties of the 8 114 DISEASES AND INJURIES OF THE BLADDER. lesion, it is considerably dilated, from the presence of coagulated blood. The edges of the rent are generally ragged, sloughy, and of a deep red or purple colour; and the lining membrane of the organ exhibits evidence of high inflammatory action. All the tunics, in fact, are frequently softened, and altered in their appearance. The surface of the bladder is incrusted with lymph, and united to the neighbour- ing parts; the intestines adhere to each other ; the peritoneum is highly injected, and of a deep red colour; and the abdominal cavity contains more or less urine mixed with serum, lymph, and blood. In protracted cases, there is sometimes, in addition to these fluids, an effusion of pus. The quantity of urine that may be present may be very small, and, on the other hand, it may amount to several quarts. The same remark applies to the accumulated blood. When death occurs soon after the accident, neither the bladder nor the perito- neum exhibits any marked evidence of inflammation. In partial rupture, the subserous cellular tissue of the bladder, of the pelvic cavity, and of the abdominal muscles, is gangrenous, and infiltrated with urine; the peritoneum is highly inflamed; the bladder is softened and discoloured; and the abdominal cavity contains more or less serum and lymph. Sometimes the inflammation is limited to the neighbourhood of the bladder, and an effort is made by nature to repair the injury by an abundant effusion of lymph. In this manner a sort of adventitious sac may be formed, in which the urine, or the urine and blood may accumulate, and are prevented, either temporarily or permanently, from lighting up fatal peritonitis. Laceration of the bladder is nearly always fatal. Indeed, there are, so far as I know, only two cases of recovery from an injury of this kind upon record. One occurred in the practice of Mr. Rynd, of Dublin, and is described in his work on Strictures of the Urethra; the other was observed by Professor Syme, of Edin- burgh, and is recorded in his Contributions to the Pathology and Practice of Surgery. Death usually takes place in from three to six days from the acci- dent. It may, however, be postponed until a later period, and a case is mentioned by Dupuytren where the patient survived until the seventeenth day, although there were two openings, one of which was an inch and a half in length. INJURIES OF THE BLADDER. 115 The immediate source of danger from laceration of the bladder is the poisonous effect which the urine exerts upon the nervous system, and which, together with the excruciating pain, appears to be the cause of the collapse into which the patient so frequently falls almost at the moment of the accident. The depression and suffering may be so great as to occasion death in a few minutes, or, at furthest, in a few hours. Another source of danger is the consequent hemorrhage, which is profuse in proportion to the extent of the laceration, and the size of the injured vessels. When the accident is complicated with frac- ture of the pelvic bones, a large artery or vein may be implicated, and the individual may speedily sink from exhaustion. The amount of hemorrhage cannot be estimated by the quantity of blood which escapes by the urethra; the bleeding goes on internally, and the fluid collects in the bladder or pelvic cavity. When the blood exists in large quantity, and in a solid state, it may form a hard tumour, which can be easily felt by the hand upon the abdomen or the finger in the rectum. Not much need be said upon the treatment of this lesion. It is obvious, from what has been already stated, that no measures, how- ever well directed, will, in general, be of any avail in saving life. Immediate quietude in the recumbent posture must be enjoined, and reaction must be promoted by a recourse to the usual remedies. The moment this is established, blood should be taken freely from the arm, and the belly should be covered with leeches, followed by hot fomentations. The application of a large blister will often be serviceable in moderating and circumscribing the resulting inflamma- tion, the chief object in the treatment after the occurrence of re- action : the warm bath sometimes affords great relief. The further effusion of urine is prevented by the frequent introduction of the catheter; or, when the patient can bear it, by the permanent reten- tion of the instrument in the bladder. In general, however, all the mischief that can be done, is done in the first instance by the escape of the urine into the peritoneal cavity, from which it will not be in the power of the surgeon to remove it, or to prevent its pernicious effects. Keeping the patient constantly in the semi-erect posture may be of use where the rent is situated at the fundus or posterior surface of the bladder. When the laceration is partial, or when the peritoneal coat retains its integrity, benefit might be derived from free incisions, 116 DISEASES AND INJURIES OF THE BLADDER. practised above the pubes or in the perinseum. In such a case, the urine is generally extensively infiltrated in the cellular tissue of these parts, and its progress is often indicated by an erysipelatous flush, which thus serves as a guide to the knife. Constitutional remedies will be of no avail beyond their power of correcting the secretions and sustaining the sinking energies of life. For these purposes the usual means are resorted to. In all cases, anodynes are indicated, and they should be administered early and liberally, both to allay pain, and to encourage reaction. If the patient survives the first effects of peritonitis, -abscesses may form and require opening, just as in infiltration of urine from rupture of the urethra. CHAPTER III. INFLAMMATION OF THE BLADDER. SECTION I. GENERAL OBSERVATIONS. Inflammation of the bladder, technically termed cystitis, gene- rally begins in the mucous membrane, and presents itself under two varieties of form, the acute and the chronic. Of these, the first is exceedingly infrequent; a circumstance the more surprising when we consider the heterogeneous nature of the urine, and the great variety of changes to which this fluid is subject from food, drink, medicine, and disease. In the course of an extensive practice during the last twenty years, comparatively few cases of this complaint have fallen under my observation; nor has this organ, in the numerous dissec- tions which I have made within that period, exhibited, except in a few instances, evidences of this affection. Dr. Louis, of Paris, examined the mucous membrane of the bladder in five hundred sub- jects, dead of various diseases, without discovering any serious lesion in any of them. In six there was simple redness or injection of the vessels, but no change of structure; in a few only, was there any softening and organic derangement. Similar testimony in regard to the infrequency of acute inflammation of the bladder, is borne by Brodie, Hope, Begin, Coulson, and other writers on the diseases of the urinary apparatus. The chronic form of the malady, on the contrary, is sufficiently common, and often entails a vast amount of suffering, which, continuing for months, and perhaps years, finally saps the foundations of life, and brings the patient to a premature grave. Acute inflammation rarely occupies the whole of the mucous sur- face of the bladder; on the contrary, it usually occurs in irregular, circumscribed spots, from the size of a twenty-five cent piece to that of the palm of the hand. Any portion of the organ is liable to 118 DISEASES AND INJURIES OF THE BLADDER. suffer, but the parts most frequently affected are the neck and bas- fond, for the reason, probably, that they are naturally very sensitive, and that they are more exposed from their situation to the exciting causes of the disease. During its progress, the inflammation often spreads from the mucous membrane to the submucous cellular tissue, and from thence to the muscular tunic. The peritoneal investment is rarely implicated, in any considerable degree, however serious the attack. The disease, in this respect, bears the closest resemblance to enteritis, which, commencing in the villous lining of the bowel, gradually extends from one coat to another, until, in many cases, the whole of them are involved in the morbid action. It is difficult to say whether acute inflammation of the bladder ever begins in the muscular tunic, or whether, when it exists, it is not always a secon- dary lesion. My own observations, as well as analogical reasoning, incline me to adopt the latter view. There are, of course, excep- tions, but these, I suppose, are few. One thing is certain, namely, that in no case of severe cystitis can either of these coats be seri- ously affected for any length of time without the other becoming also involved. The causes of acute cystitis are many and various. It has some- times occurred as a consequence of the imprudent use of cantha- rides, oil of turpentine, nitrate of potassa, and other stimulating articles, from the direct influence, probably, which they exert upon the mucous lining of the bladder. Contusions of the perinseum and hypogastrium, from blows, kicks, or falls, may give rise to it: it also originates, and that not infrequently, from the extension of gonor- rhoea, from the injection of irritating fluids, from the introduction of catheters, bougies, and sounds, and from the application of blisters. Occasionally it is traceable to the effects of excessive venery, and to inordinate distension of the bladder from neglect to void the urine. Sudden transition from heat to cold, and the repulsion of cutaneous eruptions, also produce acute cystitis, especially in persons of a gouty and rheumatic habit. But the most frequent causes are, without doubt, wounds of the bladder, the presence of calculous concretions, rough horseback or carriage exercise, the intemperate use of stimulating drinks, enlargement of the prostate gland, stricture of the urethra, and injury sustained during parturition, whether from the pressure of the child's head, or the injudicious use of instru- ments. Finally, we must not omit, in this list of exciting causes, to mention protracted retention of urinej which, it is well known, INFLAMMATION OF THE BLADDER. 119 often awakens violent and even fatal cystitis. The fluid in ques- tion becomes, under such circumstances, a twofold source of mis- chief, first by its mechanical pressure, and secondly, by its chemical action. Acute cystitis is more common in adults than in children and old people, in the strong and robust than the weak and sickly, and in men than in women. It also occurs more frequently in autumn and winter than in spring or summer, and in cold than in warm climates. Various circumstances, such as an arthritic diathesis, intemperance in eating and drinking, and permanent obstacles to micturition, pre- dispose to its development. The more important anatomical characters of acute cystitis, are, increased vascularity, loss of transparency, softening, and deposits of lymph, with alteration of the natural secretion. The discoloration varies, according to the extent and degree of the morbid action, from the lightest rose to the deepest purple. It usually displays itself in small and tolerably well-defined patches, which are always most distinct at the centre of the inflamed part, from which they gradually diminish in intensity until they are insen- sibly lost in the surrounding healthy structures. In some cases, especially in such as run their course with great rapidity, blood is effused in the submucous cellular tissue, and the part exhibits a truly ecchymotic aspect, similar to that which is seen in a bloodshot eye. This appearance existed, in a remarkable degree, in the bladder of a young man of about twenty, whose body I examined a few years ago in our University. Nothing was known of his previous history, but it was evident from the condition of his bowels, that he had died of co- litis. The bladder contained about four ounces of dirty, turbid-looking urine; and the mucous membrane, at the bas-fond, over a space of about three inches in diameter, was of a deep cherry colour, from the presence of extravasated blood in the submucous cellular tissue. A portion of the affected surface was incrusted with coagulating lymph, which had to be removed before the extent of the ecchymosis could be fully traced. There can be little doubt that this man had a violent attack of cystitis a short time before his death. The bloodvessels, in this disease, have either an arborescent or a capilliform arrangement, according to the severity of the morbid action. More or less opacity almost always accompanies the discoloration; and when the disease is unusually violent, there is not only some degree of softening, but also considerable tumefaction of the mucous 120 DISEASES AND INJURIES OF THE BLADDER. membrane. These changes are generally most conspicuous in those cases in which the inflammation has been somewhat protracted. A deposit of lymph is rather a rare phenomenon, and appears to occur chiefly, as will be shown elsewhere, as the result of external violence, in consequence of the inordinate use of cantharides, or from the irri- tation of a calculous concretion. The veins about the neck and bas- fond of the bladder are engorged with black blood, and the muscular tunic is preternaturally red, softened, and in some places, almost gangrenous. When the inflammation has involved the peritoneal investment, this part will be found abnormally vascular, incrusted with lymph, and perhaps, more or less adherent to the surrounding viscera. In some instances minute abscesses are seen in the sub- mucous cellular tissue, or in the substance of the muscular coat, and purulent matter in the veins of the neck of the bladder and of the prostate gland. These phenomena are most apt to occur in traumatic cystitis. At the commencement of the disease, the secretion of mucus is somewhat augmented in quantity, but thinner and less viscid than in the natural state. When at its height, it is almost entirely suppressed, and the membrane, consequently, is somewhat dry, as happens in acute inflammation of the Schneiderian membrane ; but as this period is always of short duration, the secretion is soon re- established, and often discharged in great abundance, being of a thick, ropy consistence, and of a pale straw, grayish, drab, or greenish colour. In high grades of the disease, the secretion, instead of being mucous, is puriform, or muco-purulent, and tinged with blood, which seems to be poured out, under these circumstances, in the form of exhalation, though occasionally it is no doubt caused by a laceration of some of the capillary vessels. In violent attacks, the inflammation is no longer limited to the mucous and other tunics of the bladder, but it extends to and in- volves the surrounding and associated organs. The parts which are more particularly liable to suffer are the ureters and the prostate gland. Along the former the morbid action is propagated to the kidneys, the functions of which are often much deranged, as is evinced by the secretion of urine being either entirely suspended, or very much diminished in quantity, as well as altered in quality. The mucous lining of the ureters, from one extremity to the other, is abnormally red and turgid, and their inferior outlet is sometimes almost obliterated, or choked up with lymph, or lymph and mucus, and pus. The prostate gland may be considerably swollen, especially INFLAMMATION OF THE BLADDER. 121 when the disease affects the neck of the bladder, and thus seriously complicate the primary disorder, by increasing the local distress, and serving as a mechanical obstacle to the excretion of the urine. Having thus noticed the seat, causes, and anatomical characters of acute cystitis, we proceed next to point out its symptoms. These vary, of course, according to the period that has elapsed since the attack, the nature of the exciting causes, the age of the patient, and numerous other circumstances, which will readily suggest themselves to the mind of the reader. Generally speaking, the malady is ushered in by bold and well-marked phenomena, so as to afford at once a pretty satisfactory clue to the mischief that is going on in the part affected. The first symptom which usually attracts attention is a dull, obscure, deep-seated pain, or, rather, a sort of gnawing uneasi- ness in the region of the bladder, which, rapidly increasing in in- tensity, soon extends to the neighbouring organs. At this early stage, there is little or no constitutional disturbance; or if there be any disorder of this kind, it is manifested by slight chills alternating with flushes of heat, some thirst, and a little excitement of the pulse, which is, perhaps, a little more hard and frequent than usual. The patient now begins to experience frequent calls to void his urine, which is expelled in small quantities, or, it may be, drop by drop, accompanied with violent straining, distressing spasm, and a peculiar burning, or scalding, at the neck of the bladder and along the course of the urethra, not unlike what results from the contact of boiling water, melted lead, or hot iron. The hypogastrium is distended, painful, and so exquisitely tender as to render even the weight of the bed-clothes intolerable. The limbs are drawn up, and the body bent forward, to relax the abdominal muscles, and relieve the tension of the bladder. As the disease progresses, the desire to pass water becomes more frequent and urgent, the pain in the bladder assumes a lancinating, tearing, or throbbing character, and the small quantity of urine which dribbles off is thick, ropy, and turbid, reddish, or tinged with blood. The pain shoots along the testicles, groins, upper part of the thighs, and spermatic cords, to the sacro-lumbar region, where it is often almost insupportable. It is augmented by the slightest movement of the body, by pressure and percussion, by the passage of the contents of the bowels, by the insertion of the finger into the rectum, and by the introduction of the catheter. The peri- nseum feels sore to the touch, and there is incessant vesical tenesmus, accompanied by a degree of straining, or bearing down, equal to what 122 DISEASES AND INJURIES OF THE BLADDER. occurs in childbirth. Notwithstanding these efforts at micturition, which are sometimes almost without intermission, the urine, never being entirely expelled, gradually accumulates, and the bladder at length ascends above the pubes into, the hypogastric region, forming a globular and elastic tumour, exquisitely sensitive under the slightest touch. In some cases there is, almost from the very com- mencement, a constant stillicidium of urine, and in others complete retention of this fluid. When the disease is fully developed, there is always more or less constitutional derangement. The pulse is quick, hard, small, and frequent, or frequent and wiry; the skin is hot and dry; the tongue is incrusted with a whitish fur; the appetite is impaired; the thirst is urgent; the bowels are constipated; the countenance is anxious and dejected; and the patient is in a state of constant restlessness and agitation, moaning and sighing, and unable to find relief in any position in which he can place himself. The limbs are drawn up as in acute enteritis, and there is generally great distress in the anus and rectum, from an extension of the inflammation. Nausea and vomiting, with severe precordial oppression, are rarely absent in this stage of the complaint. When the kidneys are implicated, there is more or less uneasiness in the loins, attended occasionally with com- plete suppression of the urinary secretion. In many cases, the dis- tress in the sacro-lumbar region is excessive; the back feels as if it would break in two, or as if it were sawed in pieces. Towards the close of the disease, the surface is bathed with a cold, clammy perspiration, and exhales a peculiar urinous odour; the mind wanders; hiccup supervenes ; the strength rapidly declines ; the countenance assumes a Hippocratic expression; the extremities become cold; and the patient finally sinks into a state of coma, from which he is destined never to awake. Some diversity occurs in the symptoms of cystitis, dependent upon the particular seat of the morbid action. When the neck of the bladder is mainly affected, excessive pain and a sense of weight or fulness are experienced in the anus and perinaeum ; there is obstinate retention of urine, with an incessant desire to micturate; and severe scalding or burning is felt along the urethra, from one extremity of it to the other. In some instances, the patient is tormented with frequent erections and itching of the head of the penis. The passage of a catheter causes extreme suffering, and similar effects follow the introduction of the finger into the rectum, and even the process of INFLAMMATION OF THE BLADDER. 123 defecation, especially when the bowels are distended with hardened faeces. When the anterior wall of the bladder is inflamed, there is great tenderness on pressure and percussion, with a sense of constriction in the hypogastric region ; the patient lies on his side, and the knees are partially flexed, to prevent tension of the abdominal muscles. There is likewise, under these circumstances, less pain about the neck of the bladder, the desire to micturate is not so frequent, and the water can be retained longer and better. When the inflammation occupies the bas-fond, or inferior part of the bladder, the rectum is more apt to suffer, and the patient is harassed with constant strain- ing and tenesmus. Sometimes the disease is seated round the outlets * of the ureters, which thus become involved in the affection, followed occasionally by suppression of urine with its whole train of concomi- tant evils. Although very little urine is discharged at any one time during the progress of this complaint, yet the quantity expelled in the twenty- four hours is nearly the same as in the healthy state. To the taste it is generally acid, while in its appearance it varies from a dirty drab to a deep red: occasionally it is of a pale lemon colour, lactes- cent, or whey-like. On inspecting it in a transparent vessel, with the aid of a good light, numerous shreds of mucus, or of mucus and lymph, are seen floating in it, which, if the fluid be permitted to remain at rest, gradually subside to the bottom of the receiver, form- ing a large, ropy, gelatinous-looking mass, equal to one-fifth, one- fourth, or even one-third of the entire excretion. At the commence- ment of the disorder, the urine is not albuminous, but it seldom fails to become so during its progress. When there is renal complication, the secretion is either entirely arrested, or it is performed very sparingly; notwithstanding which the patient is incessantly tor- mented with dysury, or a feeling of strangury. Acute cystitis usually runs its course with considerable rapidity. It seldom continues beyond the sixth or eighth day without termi- nating in resolution, tending to suppuration, passing into gangrene, or assuming a chronic type. When the malady is about to decline, there is a gradual abatement of the pain; the desire to micturate is less frequent; the urine, although still turbid, is more copious; the scalding sensation along the urethra diminishes; and the patient is able to bear pressure on the hypogastrium and perinseum. With this abatement of the local suffering there is a corresponding amelio- 124 DISEASES AND INJURIES OF THE BLADDER. ration in the condition of the general system. The thirst and fever decline; the pulse becomes softer and slower; the skin is rendered uniformly moist and cool; the gastric irritability disappears; and the general restlessness ceases. In short, from being an object of the most distressing torments, the poor patient feels as if he were translated into elysium, so great is the change. A sensation of numbness, weight, or uneasiness usually remains in the affected part for several days after the violence of the symptoms has subsided. The prognosis of cystitis depends upon the various circumstances enumerated among the exciting causes. When the inflammation is limited, the constitution sound, and the fever moderate, the disease generally yields very readily to treatment, and may even disappear of its own accord. When, however, the system is enfeebled by pre- vious suffering, debauch, or intemperance, the complaint is to be dreaded, not only on account of the want of power in the constitution to resist its influence, but its tendency to spread, and to terminate in gangrene. Cystitis from protracted over-distension of the bladder usually proves fatal from the fourth to the sixth day, being preceded by coma, urinous smell of the perspiration, and suppression of the renal secretion. When the disease is associated with stone, stricture of the urethra, enlargement of the prostate gland, or organic lesion of the kidneys, the prognosis is unfavourable, as the worst conse- quences are to be apprehended. Cystitis from a lacerated wound is more dangerous than cystitis from an incised wound; and the trau- matic form of the disease than the idiopathic. The seat of the disease exerts some influence over its progress and termination. Thus, inflammation of the neck of the viscus may prove dangerous by impeding micturition; and, of the back part of the bas-fond, by obstructing the flow of urine from the ureters. When the disease is situated at the summit, or posterior wall of the bladder, the morbid action may extend to the serous investment, and induce fatal peritonitis. When the inflammation depends upon retrocedent gout, or rheumatism, it may prove dangerous by resisting the means employed to reinvite it to its original seat. Idiopathic cystitis is more dangerous in men than in women, and in childhood and old age than in youth and middle life. Treatment. — A due consideration of the nature, causes, and symptoms of this affection cannot fail to lead to the adoption of correct principles of treatment. Inflammatory in its character, the means employed to combat it must be strictly antiphlogistic, or the INFLAMMATION OF THE BLADDER. 125 same precisely as in the phlegmasise of other parts of the mucous system. The leading indications, in every case of acute cystitis, are, first, to subdue symptomatic excitement; and, second, to quiet local irritation. For accomplishing the first of these ends, the remedies mainly relied upon, in the earlier stages of the complaint, are general and topical bleeding, cathartics, and diaphoretics, aided by an anti- phlogistic regimen. Promptly and vigorously employed, there are few cases of acute cystitis which resist these means beyond the second or third day, and such as do are always more easily managed afterwards by mild treatment. I have repeatedly cut short, by the lancet alone, attacks of this disease so severe as to leave the patient no rest, and so threatening as to induce the worst apprehensions for his ultimate recovery. The same treatment has often promptly succeeded in my hands after other and less efficient means had been employed for days with little or no benefit. A remedy so potent should, therefore, never be neglected, except under circumstances of the most positive contra-indication. It is, of course, not to be in- ferred from this remark, that it is to be resorted to indiscriminately, or without due regard to the activity of the symptoms, the constitu- tion of the patient, and the period of the complaint. If the person be old and feeble, or the attack of considerable duration, the lancet must be used very cautiously, or be altogether superseded by leeches and other measures. Where the remedy is applicable, it should be employed not only early in the disease, but to as great an extent as the system will bear. In a word, we bleed here, as in other violent inflammatory affections, for effect, and not for ounces. As soon as the patient feels faint, the arm is tied up, to be reopened, in urgent cases, as soon as any tendency is perceived to a renewal of the original symptoms. But I would not restrict the employment of the lancet to the more severe forms of cystitis, or to such cases only as are accompanied by symptomatic excitement. To do so would be to deprive the patient, in many instances, of a most powerful agent in combating what may be considered as the milder cases of this complaint. There is a variety of cystitis, properly denominated acute, as it respects the local distress, in which there is an entire absence of constitutional disturbance, and yet the suffering is exceedingly severe. In these cases there is no remedy, according to my experience, which is fol- lowed by such prompt and permanent relief as copious bleeding at 126 DISEASES AND INJURIES OF THE BLADDER. the arm. The operation rarely requires to be repeated, and is gene- rally sufficient, with the aid of a gentle laxative and a dose of Dover's powder, to effect a cure in thirty-six or forty-eight hours ; sometimes, indeed, much sooner. The bowels demand early attention, especially if they are over- loaded with fsecal matter, the pressure of which would prove inju- rious to the inflamed and suffering organ. Where there is no marked derangement of the biliary secretion, the best purgative is castor-oil, or sulphate of magnesia, aided by an enema of cool water, thin gruel, or soap-suds. If an opposite condition exist, a dose of calomel should be given, either alone, or, in urgent cases, in union with rhubarb and jalap. Under no circumstances is it proper to administer medicines calculated to irritate the lower bowel, and, through it, the urinary bladder. When the secretions have been restored, or corrected, the intestinal canal must be kept open by saline aperients, or slightly stimulating injections. In the use of the latter, care is to be taken that they are not too large, and that the urine be previously evacuated, otherwise their good effects will be more than counterbalanced by their pressure on the affected viscus. As soon as proper depletion has been practised, and the alimen- tary canal well cleared out, diaphoretics are indicated, and rarely fail to prove beneficial. Various articles may be exhibited for this purpose; but the one which I have found most useful, and which, therefore, I usually employ, is the tartrate of antimony and potassa, in the form of the antimonial mixture, of which the dose is a table- spoonful every three or four hours.1 This seldom fails to produce copious diaphoresis, to allay vascular excitement, to calm the affected organ, and to keep the bowels in a soluble condition. The dose must always be strictly graduated by the tolerance of the stomach; for the medicine should never be carried so far as to induce vomiting, retching, or griping. Where the skin is already soft, or where a diaphoretic and opiate are required, nothing is so beneficial as Do- ver's powder, in doses from ten to fifteen grains, three or four times in the twenty-four hours. This combination is especially valuable in that variety of cystitis which depends upon cold, gout, rheuma- 1 The combination which I am in the habit of using, in this and other forms of inflammation, consists of three grains of tartrate of antimony, forty to sixty drops of laudanum, one ounce and a half of epsom salts, and eight ounces of water, with a sufficient quantity of loaf sugar to disguise the taste of the ingredients. INFLAMMATION OF THE BLADDER. 127 tism, or irritation of the bowels. Should the stomach be irritable, the effervescing draught would be preferable to the other diaphore- tics, both on account of its anti-emetic properties and its action upon the skin. The action of the above medicines may be favoured by tepid drinks, the warm bath, and hot fomentations. The best drinks are such as are somewhat demulcent, as gum arabic water, slippery-elm water, rice water, or flaxseed tea, rendered palatable by the addition of a little lemon juice, citrate of potassa, or the neutral mixture. In the use of these and similar articles care must be taken not to allow the pa- tient to indulge so freely as to run the risk of producing too great a flow of urine; the object should be merely to allay the acrimony of this fluid, and to render it more acceptable, so to speak, to the suffer- ing organ. The fact is, this is a point which cannot be too strongly insisted upon, inasmuch as it materially conduces to the comfort of the patient, by diminishing the necessity for constantly passing his water. For the same reason, his drinks should always be tepid, that they may promote perspiration instead of the renal secretion, as they would if they were cold. Diuretics, strictly so called, are improper in this affection, and should therefore be avoided. It is only in case the urine is acrid, high- coloured, or very scanty, that they are to be thought of, and then none but the mildest articles are admissible. A small quantity of nitrate of potassa, or sweet spirits of nitre, mixed with some demulcent fluid, may, under such circumstances, be given to modify the renal secre- tion, and allay vesical irritation. All the more stimulating articles, such as turpentine and cantharides, are, as has been just intimated, to be discarded. In the gouty and rheumatic forms of the malady, colchicum is sometimes beneficial, and may be given night and morn- ing, after the force of the disease has been broken, in the dose of one drachm, in combination with a third or fourth of a grain of sulphate of morphia. In the latter stages of the disease, a tea, composed of uva ursi and hops, in the proportion of one ounce of the former and half an ounce of the latter to the quart of water, proves sometimes highly advantageous. An ordinary sized wine-glassful of this should be given five or six times a day, either alone, or, where there are acid eructations, in combination Avith fifteen or twenty grains of the bicar- bonate of soda. The hop forms a valuable ingredient in this prepa- ration, on account of its soothing effects upon the urinary organs, as 128 DISEASES AND INJURIES OF THE BLADDER. well as upon the general system. The medicine should be as fresh as possible, or, in default of this, a certain amount of lupuline should be added to it. In the lighter grades of cystitis, this tea often acts like a charm, promptly allaying the pain and spasm at the neck of the bladder, and powerfully promoting resolution. Among the more important local remedies for arresting cystitis, and tranquillizing the affected organ, are, leeching and cupping, anodyne enemata, fomentations, and the hip-bath. The use of these means is often indicated at an early period of the disease, and can seldom be entirely dispensed with in any except the mildest cases. Much benefit is often derived from free local bleeding, which is generally best accomplished, in this disease, by leeches, applied either to the perinseum and the verge of the anus, to the upper and inner parts of the thigh, or, when the summit of the bladder is affected, to the hypogastric region. The number of leeches to be used must be proportioned to the activity of the local distress, the age and consti- tution of the patient, and the actual condition of the system. For an adult, in ordinary cases, not less than fifteen or twenty are re- quired, and, in severe cases, a still greater number. After they have dropped off, it is important that the flow of blood should be encouraged for several hours with cloths wrung out of warm water, and frequently renewed. Leeching here, as elsewhere, should never take the place of the lancet; it is only after general depletion has been practised, or, where this is contra-indicated by the state of the pulse and other circumstances, that it should be resorted to. Used with this precaution, it is a most valuable remedial agent, and one which rarely disappoints expectation. In the repetition of it, much judgment is necessary, for the regulation of which experience alone can furnish a safe and satisfactory guide. The pain and distress in the back, which often constitute a souroe of so much suffering in acute cystitis, are often promptly relieved by the application of cups, either dry or wet, to the sacro-lumbar region. Mustard plasters and anodyne embrocations are also highly efficacious under such circumstances, and must not be neglected, especially if the patient is unwilling or unable to submit to cupping. In severe cases, the best application is a large blister, followed by an emol- lient poultice over the vesicated surface. Of all the local remedies none hold a higher rank in the treat- ment of this affection than anodynes, administered by the rectum, INFLAMMATION OF THE BLADDER. 129 either in the form of injections, or in that of suppositories. They not only allay pain and spasm, but they quiet the bladder, and ren- der it more able to bear the presence of the urine, a desire to pass which is a principal cause of the patient's suffering. The best form of injection is from half a drachm to a drachm and a half of lauda- num to two ounces of tepid water, thrown up with a good pewter syringe, with a long nozzle, which is far preferable to all the patent contrivances of the kind of which I have any knowledge. The bowel should be previously cleared out with a purgative, or an enema, and care should be taken not to force the fluid against the anterior wall of the rectum. The quantity of laudanum here speci- fied is a dose for an adult; for a younger subject, or a person enfeebled by age and disease, a smaller quantity will suffice. The repetition of the medicine must be regulated by circumstances ; if it pass off soon after it is administered, it should be immediately re- newed, and the same rule should be enforced, if it is retained, if it does not answer the desired end in two or three hours. Where laudanum is inadmissible, on account of some idiosyncrasy, black drop, or morphia, may be employed as a substitute. Anodyne suppositories are frequently beneficial in acute cystitis, and may often be advantageously used in place of injections, especi- ally when, in consequence of tenderness or disease of the anus, the latter are difficult of administration. They may be composed of various articles, but the best is powdered opium, thoroughly mixed with conserve of roses, and introduced upon the end of the fore- finger, well oiled. The quantity of opium, thus inserted, should vary from two to four grains, according to the urgency of the local and general distress. Morphia, lactucarium, and cicuta, may be used as a substitute, but are not equal to this substance. As auxiliary remedies, in the treatment of this disease, mention may be here made of fomentations with cloths wrung out of hot water, either simple, or medicated with laudanum, laudanum and camphor, poppies, or hops. The cloths should consist of flannel, arranged in six or eight thicknesses, and should be sufficiently large to invest the whole abdomen, from the pubes to the epigastrium. To prevent evaporation, and confine the heat, the surface of the flannel should be covered with a piece of oiled silk. In cold weather, two sets of cloths ought to be used, in order that no unpleasant reaction may take place while they are being changed. When thus employed, fomentations are often exceedingly grateful to the affected part, as 9 130 DISEASES AND INJURIES OF THE BLADDER. well as to the general system, from the tendency they have to relieve pain and spasm, and to promote perspiration. The warm hip-bath, or immersion of the entire body in warm water, is sometimes eminently serviceable in relieving the local suffering, and exciting the emunctories of the cutaneous surface. Generally speak- ing, the latter is to be preferred to the former, on account of the greater convenience and less fatigue which attend its administration, as well as the more thorough relaxation of the system. The tem- perature of the water should range from 85° to 92°, and the immer- sion should be continued from twenty minutes to an hour, according to the effects of the remedy, which should always be carefully noted. Transient bathing is commonly worse than useless, inasmuch as it only serves to harass and excite the patient, without being followed by any compensating benefit. The hip-bath is objectionable, chiefly because its employment is attended with great bodily constraint, and consequent inconvenience and fatigue. The exciting causes of this disease lead to certain modifications of the treatment, which should be well understood by the practitioner. The principal circumstances which require to be considered in this relation are urinary concretions and other foreign bodies, the use of cantharides, the extension of gonorrhoeal inflammation, the repulsion of gout, rheumatism, and cutaneous eruptions, stricture, and enlarge- ment of the prostate gland. A few remarks under each of these heads will be sufficient for my purpose. The treatment of cystitis, dependent upon the presence of a calcu- lus, is to be conducted upon general principles; no effort should be made to extract the foreign body, much less to break it up. The organ, perhaps accustomed for a long time to its contact, may be temporarily annoyed, if not overpowered, by the intruder, but with the assistance of antiphlogistic means, early and efficiently employed, it will soon be able to shake off the disease thus awakened, and return to its pristine condition. To cut out the stone, under such circumstances, might prove fatal; to crush it, would be certain to be so. When the inflammation is subdued, the foreign body is removed, and recurrence of the disease prevented. The case is different when the cystitis has been induced by a foreign substance having penetrated the bladder from without, as a splinter, or piece of bone. Here the first object should be to remove the extraneous substance as early as possible, on the well-known prin- INFLAMMATION OF THE BLADDER. 131 ciple that the disease induced by its presence cannot be cured as long as it remains in contact with the affected viscus. Cystitis, caused by the absorption, or internal use of cantharides, requires a treatment somewhat peculiar. This variety of inflamma- tion, technically called strangury, is induced by the specific action of cantharidin, the proximate principle of the fly, upon the neck of the bladder, terminating in a constant desire to pass water, accom- panied with excessive pain and spasm at the neck of the organ, and horrible scalding along the urethra. The symptoms are generally urgent, and require prompt and vigorous interference. A large emollient poultice is applied to the vesicated surface, hot cloths are laid upon the abdomen, the perinseum, and the genitals, and a drachm of laudanum, mixed with two ounces of tepid water, is injected into the lower bowel. Demulcent drinks with sweet spirits of nitre are freely taken; and, in severe cases, a full anodyne is exhibited by the mouth. A popular remedy, of great value in this affection, espe- cially in its milder forms, is a decoction of parsley root and water- melon seeds. It should be used as freely as the stomach will bear, either alone, or in combination with spirits of nitre and paregoric. There are few cases of strangury which resist these means, or which require more active treatment, as bleeding, purging, diaphoretics, and the warm bath. Dr. Mulock,1 of Dublin, has recently found great benefit in stran- gury from blistering with cantharides from the solution of potassa— the liquor potassce of the United States Pharmacopoeia—in doses of thirty drops every hour. In three cases treated in this way speedy relief was obtained. He was led to the use of this preparation from its known efficacy in allaying irritation of the bladder from other causes. It should be exhibited largely diluted with some demulcent fluid. Cystitis, occasioned by an extension of gonorrhoea, is characterized by severe tenesmus, a frequent desire to micturate, and great pain in passing the last drops of urine, which is sometimes tinged with blood. The inflammation, which may occur at any period of the specific disease, is, in great measure, confined to the neck of the bladder, and rarely assumes a violent character. The treatment is strictly antiphlogistic, aided by the internal exhibition of copaiba, and the use of anodyne enemata. ' Dublin Quarterly Journal of Medicine, Aug., 1848. 132 DISEASES AND INJURIES OF THE BLADDER. When cystitis depends upon a gouty or rheumatic state of the constitution, or upon a retrocession of these diseases, colchicum is indicated, and ought to be conjoined with other antiphlogistic means. The dose of the medicine, and its mode of administration, must be regulated by the circumstances of each individual case, and hardly admit of precise detail. My own experience has led me to conclude that one full dose, given at bedtime, is preferable to small ones, frequently repeated. Another valuable remedy in this variety of cystitis is calomel, administered with a view to its constitutional effect. In obstinate cases of this kind, it is, in fact, almost indispensable. It may be given, three or four times a day, in doses of two grains, combined with half a grain of opium, to prevent it from acting too freely upon the bowels, and aid in procuring sleep. As soon as the gums be- come tender, the mercury is discontinued, or administered in smaller quantity or at longer intervals. When the attack depends upon retrocedent gout or rheumatism, it will be necessary, in addition to the means already specified, to're- sort to vesication, either with ammonia, hot water, or cantharides. Where the symptoms are so urgent as to require prompt interference, the object in question is best effected with one of the former of these agents; but in ordinary cases preference should generally be given to the fly. The blister should be applied to the seat of the original malady, to reinvite it to the tissues which it has left. Where the local distress is very severe, no harm, but, on the contrary, much benefit, will accrue from placing it over the hypogastric or sacral region, or as near as possible to the organ involved by the translation of the disease. We have the authority of Desbois de Rochefort and others in favour of this practice, of the propriety of which, under the cir- cumstances adverted to, there can be no doubts, notwithstanding the fact that the irritation produced by cantharidin occasionally causes an effusion of lymph upon the inner surface of the bladder. When the cystitis has been induced by the sudden repulsion of some cutaneous disease, as tetter, urticaria, or erysipelas, the indi- cation is to reinvite the disease to its former situation, by the appli- cation of blisters, and the exhibition of such means as the state of the system may seem to require. Finally, when the cystitis is complicated with, or dependent upon, stricture, or enlargement of the prostate gland, the treatment must be of a mixed character; an attempt being made, while we en- FIBRINOUS EXUDATION OF THE BLADDER. 133 deavour to cure the vesical symptoms, to relieve the pre-existent affection. I have said nothing, in the preceding pages, of direct medication as a means of curing cystitis; because such a mode of treatment is more likely, in my judgment, to do harm than good. It is only in the latter stage of the disease, when the acute symptoms have dis- appeared, that such a course would be at all admissible, and then it could hardly be required. Finally, should retention of urine occur, no time is to be lost in having recourse to the catheter. This accident often ensues at an early stage of the disease, and always requires the closest vigilance on the part of the surgeon; for the accumulated fluid not only acts injuriously by distending the coats of the bladder, already crippled and enfeebled in consequence of the inflamed condition of its mus- cular fibres, but by undergoing speedy decomposition, whereby it becomes a source of direct mischief to the lining membrane. To prevent these evils, the catheter should be used every six or eight hours, or whenever there is the slightest tendency to distension, taking care to withdraw it as soon as the urine has been evacuated. It has been proposed, under these circumstances, to retain the in- strument permanently in the organ for two or three days at a time; but to do this would be to subject the patient to great pain, and the bladder to increased irritation, if not to the danger of gangrene, or perforation of its walls. SECTION II. FIBRINOUS EXUDATION OF THE BLADDER. The mucous membrane of the bladder, like that of the alimentary and aerial canals, is liable to deposits of lymph, which, from the cha- racter they play in certain states of this organ, require some notice in this place. Various appellations have been employed to designate this form of inflammation, as fibrinous, plastic, exudative, diphtheritic, and pseudo-membranous, according to the peculiar fancy or notion of different writers. Rokitansky uses the term croupous, evidently from the similarity which the disease, in his opinion, bears to croup- ous inflammation of the air-passages. The word fibrinous, invented by modern pathologists, is now generally considered as less objec- 134 DISEASES AND INJURIES OF THE BLADDER. tionable than any other, and is, therefore, retained on the present occasion. Causes.—This variety of inflammation is exceedingly rare as an idiopathic affection; but as a result of external violence, or direct irritation of the mucous membrane, it is more common than is gene- rally supposed. In calculous disorders, especially when the stone is very rough and bulky, lymph is not unfrequently poured out, not abundantly, it is true, but yet in sufficient quantity to imbed the concretion, either partially or completely, and thus render its extrac- tion very difficult, if not impracticable. Pieces of bougies, bullets, needles, and other extraneous substances are occasionally retained by it, either by becoming encysted, or by being buried in it. It ap- pears, from the observations of Dr. Morel-Lavale'e, that a true diphtheritic inflammation of the bladder is sometimes developed under the influence of cantharides, when used as a remedial agent. Since this fact was first enunciated, a few years ago, by this physician, the occurrence has been noticed by different practitioners, amongst others, by Dr. Ame'de'e Latour, who has recorded a very interesting example of it. Whether, however, it is to be viewed merely as a co- incidence, or in the light of cause and effect, is a point which remains unsettled. If we adopt the latter conclusion, which I am not inclined to do, it certainly behooves us to be very cautious in the use of this article. The effect has been most frequently witnessed after the endermic application of cantharides; but it also sometimes takes place in consequence of its internal exhibition. This form of inflammation, or, more properly speaking, the deposit to which it gives rise, is most common at the neck and bas-fond of the bladder, though no part is entirely exempt from it. It has been noticed in both sexes, and at almost every period of life. The following cases beautifully illustrate this form of vesical in- flammation ; in two, the disease was brought on by external violence, and in one the exciting cause is not mentioned. Case I.1—An old pensioner, in falling from a scaffolding, experi- enced a severe contusion of the back, followed by retention of urine. The fluid was drawn off regularly for some weeks, when violent pelvic symptoms supervened, and at last nothing but a small quantity of thick pus flowed through the catheter. The suffering becoming more urgent, the bladder, which was very much distended, and had 1 Liston's Elements of Surgery, p. 489; Phil. 1846. FIBRINOUS EXUDATION OF THE BLADDER. 135 ascended to the umbilicus, was opened above the pubes. Much pu- rulent matter, mixed with foetid urine, escaped from the wound, as also a false membrane, which lined the mucous coat of the viscus. The membrane had a flocculent appearance; in some places it was distinctly fibrous, and, in others, thin and transparent: its inner sur- face was rough, and raised into minute granules, the result, appa- rently, of a recent deposit of lymph. The patient died, exhausted, about three weeks after the injury, having, during this period, voided his urine partly by the urethra, and partly by the wound. No dis- section seems to have been made after death. Case II.1—A man, aged seventy-seven years, was admitted into the Charity Hospital in Paris, under the care of Dr. Louis, on the 23d of March, 1827, in a desperate condition. It was ascertained that he had lately been obliged to make water very frequently, but without any pain. Two or three times he voided blood in consider- able quantity, and the same occurrence was occasionally noticed for a fortnight before he entered the institution. He died the following night, with marks of gangrene of the lower extremities. The blad- der, contracted to about the size of a man's fist, projected slightly above the pubes, and was adherent to the arch of the colon by a membranous band two inches long. It contained between three and four ounces of dark, purulent fluid. The inner surface of the viscus was red, and invested by an adventitious membrane, more than a line thick, and of a filamentous texture, but quite soft and lacerable. The urethra was perfectly sound. The immediate cause of death was a rupture of the left auricle of the heart, within the peri- cardium. Case III.—A highly interesting and instructive case of the mem- braniform variety of cystitis was communicated to me, several years ago, by Dr. R. B. Harper, of Tipton County, in the state of Tennes- see. A boy, three years of age, received, late in the autumn of 1840, an injury from the fall of a rail upon his abdomen, from which, how- ever, he complained very little at the time. Early in January, there was a considerable discharge of blood from the urethra along with the urine, followed, in a few days, by purulent matter and shreds of lymph. There was at first no uneasiness or difficulty in evacuating the bladder, but micturition, by degrees, became painful, and the urine was expelled drop by drop. In the latter part of March, when 1 Johnson's Medico-Chir. Rev., vol. 8, p. 492. New Series. 136 diseases and injuries of the bladder. the little patient fell in the hands of Dr. Harper, there was great distension of the bladder, inflammation of the orifice of the urethra, and an urgent desire to pass water every twenty or thirty minutes, attended with a most distressing, scalding sensation. The catheter was repeatedly introduced, without the slightest relief; the organ retained its abnormal dimensions, and little or no urine followed the effort. Death occurred on the 20th of April, preceded by inflamma- tion of the brain. On dissection, the bladder was found to be nearly filled with half a pint of lymph, which was firmly attached to its ■ posterior wall, between the openings of the ureters, from which a small portion, of a singularly fasciculated appearance, hung forward into the neck of the organ. The whole mass was of a whitish aspect, fibrous in its texture, and evidently organized, numerous vessels being visible in its interior. Coexistence.—Pseudo-membranous inflammation of the bladder occasionally occurs in association with the same disease in other parts of the body. In the following instance, recorded in the 68th volume of the "Journal Ge'ne'rale de Me'decine," by Dr. Destre*es, a French physician, it coexisted with fibrinous exudation of the ali- mentary canal. A man, presenting all the symptoms of enteritis and cystitis, expelled, while at stool, so large a piece of false mem- brane that, in his fright, he supposed he was parting with his bowels. He discharged, at the same time, with great pain, from his bladder, a quantity of thick mucus, mixed with portions of lymph. Physical Properties.—These deposits vary much in their colour, consistence, quantity, and mode of arrangement. Generally speak- ing, they are of a grayish or drab colour, but now and then dark brown, greenish, or even reddish, from an admixture of the colouring matter of the blood, a small quantity of which is occasionally poured out along with the fibrinous matter, and thus imparts to it more or less of its characteristic hue. In its consistence, it varies from that of a thin solution of arrow-root to that of the buffy coat of the blood, according to its age and the presence or absence of organization. When the effusion is considerable, different portions often exhibit different degrees of consistence; thus, one part may be perfectly soft, another moderately firm, and a third, perhaps, as tough as a fibrous membrane. The quantity of the deposit is generally small; though sometimes, as in the case reported to me by Dr. Harper, it is very large, and nearly fills the whole bladder. Form.—The exudation occurs under several varieties of form. It FIBRINOUS EXUDATION OF THE BLADDER. 137 rarely presents itself as a distinct membrane, spread over the inner Burface of the bladder; at all events, it hardly ever covers it in its whole extent. In most cases, it occurs in small patches, from the size of a dime to that of an American dollar, from a fourth of a line to a line in thickness, soft, filamentous, and of a grayish or drab colour. Now and then, again, the deposit presents itself in the form of small dots, not larger, perhaps, than a millet-seed, or a pin's head, isolated, or grouped together, and, in their appearance, not unlike little ulcers, for which a superficial observer might, in fact, easily mistake them. A band-like arrangement is sometimes observed, but this is rare, and occurs chiefly in connexion with calculous concre- tions. Finally, this substance most frequently presents itself as an amorphous mass, attached to the bas-fond of the bladder, of variable size, more or less firm in its consistence, and of a dirty grayish or brownish colour. Cases occur in which it is prolonged into the ure- thra and one or both ureters. It rarely happens that this substance, in whatever form it pre- sents itself, is organized. Such an occurrence is, as a general rule, incompatible with the irritating character of the urine, which, the moment it comes in contact with the deposit, deprives it of vitality, and renders it effete. It is only in rare cases that it retains its plastic nature, that it is vascularized, and that it becomes, so to speak, "part and parcel" of the membrane upon which it is developed. Effects.—When this substance is deposited in large quantities, it must necessarily considerably diminish the capacity of the bladder, and seriously embarrass its functions. I have already alluded to the fact that it occasionally invests urinary concretions, and renders their extraction difficult, if not impossible. When it extends into the urethra, it may choke up that passage, and thus impede the flow of urine. I have se- veral times seen complete retention ensue from this cause. Prolonged upwards into the ureters, it interferes with the descent of the urine from the kidneys into the bladder, an occurrence which has occasion- ally led to fatal results. Fortunately, however, in most cases, this substance is discharged almost as fast as it is secreted, and thus the evil consequences alluded to are prevented. There are no symptoms by which this form of inflammation is dis- tinguishable from ordinary cystitis. The only circumstance upon which the slightest reliance can be placed is the presence in the urine, or at the orifice of the urethra, of some of the exuded matter; but 138 DISEASES AND INJURIES OF THE BLADDER. as this may be derived from other sources, as the ureters, the renal calyces, or the urethra itself, it cannot serve as a diagnostic sign. The treatment of fibrinous inflammation must be conducted upon antiphlogistic principles, which, as they do not present anything peculiar, need not be dwelt upon here. If retention of urine exists, the catheter must be employed, and when there is reason to believe, from the nature of the symptoms, that the bladder is nearly filled with lymph, the proper proceeding is to open it above the pubes, and turn out its contents. Re-accumulation may possibly be prevented by injections of a solution of nitrate of silver, in the proportion of from four to ten grains of the salt to the ounce of water. No internal remedies, so far as our knowledge at present extends, promise to be of any avail in arresting the secretion. SECTION III. SUPPURATION AND ABSCESS OF THE BLADDER. A discharge of pus, or muco-purulent fluid, from the lining mem- brane of the bladder, although sufficiently common in connexion with chronic cystitis, is infrequent as a consequence of the acute form of the disease. The organ, in this respect, bears a striking resemblance to certain portions of the alimentary canal, which perform this act apparently with much reluctance when labouring under high morbid excitement. The discharge, moreover, is usually of brief continu- ance, and small in quantity, while in chronic cystitis it often lasts for a long time, and is occasionally astonishingly profuse. The pus in suppurative cystitis varies considerably in its proper- ties. In general it is of a pale straw-colour, moderately thick, ropy, and free from odour; sometimes it is greenish or reddish, thin and excessively foetid. These qualities are usually more conspicuous in the chronic than in the acute form of the disease, and are denotive of serious disorder of the lining membrane. The discharge, espe- cially in chronic cystitis, is accompanied with a copious secretion of ropy mucus, with which the matter is intermixed, and which gra- dually subsides to the bottom of the receiver, often adhering to it with great tenacity. When the quantity of pus is large, or dispropor- tioned to the quantity of mucus, the urine is apt to exhibit a whitish, yellowish, or lactescent aspect, which, however, it soon loses, in con- ABSCESS OF THE BLADDER. 139 sequence of the tendency which these fluids have to separate from each other. The presence of the purulent matter in the urine can always be detected by the sight, aided, in cases of doubt, by the microscope and the ordinary tests. The matter, instead of being secreted by the free surface of the mucous membrane, occasionally presents itself in the form of an abscess, situated in the submucous cellular tissue, or between the muscular and serous tunics. The occurrence, although infrequent, requires to be understood by the practitioner. Abscesses forming between the coats of the bladder, cannot, from the nature of their situation, attain much volume, and we accordingly find that they are seldom larger than a pea, filbert, or a pigeon's egg. The exceptions in which they acquire the magnitude of a walnut, a billiard-ball, or an orange, are exceedingly rare. They may occur in any part of the viscus, but are most frequently observed at its neck; and it is seldom that there is more than one, though occasionally as many as five or six have been observed in the same individual. These abscesses are sometimes of a scrofulous character, in which case the matter is of a curdy or cheesy appearance, similar to that of a tubercular cavity of the lung, or a suppurating lymphatic gland. Under ordinary circumstances, however, it is of a thick cream- like consistence, and of a light yellowish colour, as in common phlegmon. After having existed for an indefinite period, the abscess makes an attempt to evacuate its contents, by exciting ulcerative absorption of the parts by which it is covered. This occurs in different directions, according to the situation of the matter, and the nature of the super- incumbent tissues. a. In the great majority of cases, the matter points inwards towards the cavity of the bladder, into which it finally escapes, and passes off along with the urine. Such a termination is necessarily attended by a sloughy, ragged condition of the mucous membrane, the effect of which, both upon the part and the system, is often most disastrous. The discharge of the matter may be caused simply by ulceration, or it may be produced by the catheter in attempting to draw off the urine, or ascertain the state of the bladder. b. In the second place, the abscess may open into the rectum, the sigmoid flexure, or the ileum. Of these different communications, the first is the most frequent, as well as the most unfortunate, as it admits of a constant interchange of the contents of the two pas- sages. 140 DISEASES AND INJURIES OF THE BLADDER. c. A third mode in which the purulent matter may escape is into the uterus or vagina. Examples of this, although exceedingly rare, are mentioned by different authors. d. In the fourth place, a communication may be established be- tween the bladder and the abdominal cavity, and the matter find an outlet in that way. Such an occurrence is necessarily fatal, as it induces violent inflammation of the peritoneum, causing death in thirty-six or forty-eight hours. e. A fifth mode of evacuation is through the parietes of the abdo- men, above the pubes. This termination is not unlikely to occur when the abscess is developed in the anterior wall of the viscus, in the cellular tissue between the muscular and peritoneal coats. The irritation excited by its presence might lead to an effusion of lymph, followed by adhesion of the contiguous surfaces, and subsequently by ulcerative perforation of the wall of the abdomen. In the female, an abscess of the bladder has sometimes opened into the pudendal lip, and in the male, in the loose cellular tissue of the scrotum. /. Lastly, it is not impossible that a vesical abscess might, under peculiar circumstances, open into an enlarged ovary, ureter, or Fal- lopian tube. I am not aware that any cases of the kind have been recorded by authors, and I allude to the circumstance as one rather of possibility than of probability. Finally, the matter, instead of being collected into an abscess, is sometimes diffused through the cellular tissue of the coats of the bladder, which, in consequence, exhibit a soft, oedematous aspect, and pit under pressure. Upon puncturing the affected part, at different points, the pent-up fluid escapes as from an anasarcous limb, espe- cially if it be intermixed with serum, and the swelling proportion- ably subsides. This form of suppuration, of which interesting examples are recorded by Bonnetus,1 Ruysch,3 and other observers, may take place under the influence of calculous irritation, or as a consequence of external violence, which, in fact, is its most frequent cause. The occurrence is, of course, very rare. Suppuration of the bladder may be the result of idiopathic inflam- mation, either acute or chronic; or it may be caused by external violence, or by the presence of some foreign body, as a calculus, a bougie, or a catheter. Abscesses are generally produced in the latter way, under the influence of protracted irritation, operating directly upon the tunics of the organ. Occasionally there is reason 1 Sepulch. Anat. T. 11, lib. 3, p. 590. 2 Obs. Anat.-Chirurg., ob. 89, p. 82. SUPPURATION OF THE BLADDER. 141 to believe that they are developed in consequence of the irritation of some neighbouring or associated viscus, as the ureter, kidney, pro- state gland, or uterus. The purulent collections which are some- times found between the coats of the bladder, after the operation of lithotomy, probably have their origin in phlebitis. Scrofulous ab- scesses of the bladder are very rare, and are observed chiefly, if not exclusively, in persons of a scrofulous predisposition. The occurrence of suppuration is denoted by frequent chills or rigors, alternating with flushes of heat; by an increase of thirst, anxiety, and restlessness; by the character of the pain, which is dull, aching, and throbbing; and by a feeling of weight in the peri- nseum and anus. The mind generally wanders, and, in many cases, there is confirmed delirium. As the fever declines, the urine is secreted more abundantly, and exhibits a peculiar whitish appear- ance, indicative of the presence of pus. In abscess, before the rupture of the enclosing cyst, no such evidence is discernible. The diagnosis of suppurative cystitis is obscure; indeed, it is seldom that the true character of the complaint is revealed until an opportunity is afforded for examining the parts after death. It has been supposed that the gradual subsidence of the inflammatory symp- toms, and the appearance of pus in the urine are positive evidences of the occurrence of this event. Nothing, however, can be more erroneous. The symptoms of cystitis may be simulated by other diseases, both of the bladder and of the neighbouring organs, and the pus contained in the urine may be derived from an inflamed and dis- organized prostate, kidney, or ureter. It is important, therefore, in trying to decide the question of the real character of the disorder, to take into consideration, not merely the actual condition of the patient, but to connect with it, as far as this can be done, its pre- vious history. In abscess, the diagnosis is sometimes determined by the sudden appearance in the urine of a large quantity of pus, after a violent effort at micturition, or an attempt to draw off the urine. Even here, however, it should not be forgotten that the matter may be derived from an abscess of the prostate gland, of the kidney, bowel, or uterus. Infiltration of pus into the coats of the bladder cannot be distinguished during life. The prognosis of suppuration of the mucous membrane of the bladder is usually favourable, especially when it is a termination of the acute form of the disease. Under these circumstances, a judicious recourse to antiphlogistic measures seldom fails to arrest it, and put a stop to the local disorder by which it has been induced. Suppura- 142 DISEASES AND INJURIES OF THE BLADDER. tion, dependent upon chronic inflammation, often persists for a long time, obstinately resisting every method of treatment that can be brought to bear against it. When produced by external violence, the discharge may be so copious as to bring on hectic fever, with all its train of evils. In calculous disease, the suppuration usually disappears promptly after the removal of the exciting cause. In abscess the prognosis is, in general, not favourable. Reco- very is more likely to take place when the disorder is the result of external violence than when it is the effect of some internal cause. Much, however, must necessarily, under such circumstances, depend upon the nature and extent of the injury. In calculous patients, the prognosis is unfavourable, because abscess after abscess is liable to form, until the patient's strength is undermined by local and con- stitutional suffering, or his life destroyed by total suppression of urine. The treatment of suppurative inflammation of the bladder is to be conducted upon general antiphlogistic principles, in its early stages, and, subsequently, upon the tonic and invigorating plan. When hectic irritation is present, the best remedies are quinine and elixir of vitriol, in doses proportioned to the age and condition of the patient. The diet must be bland and nourishing; demulcent drinks must be freely used, to obtund the acrimony of the urine ; and the bowels must be maintained in a soluble state, by blue mass and rhubarb, Epsom salts, or calcined magnesia. All local sources of irritation must be removed as early as possible ; the catheter is used, if necessary, for the relief of retention; spasm of the bladder is allayed by anodyne suppositories or opiate injections; and sleep is procured by the internal exhibition of opium, the salts of morphia, or black drop. If abscesses point, they must be opened with the knife. SECTION IV. GANGRENE OF THE BLADDER. Acute inflammation of the bladder sometimes ends in gangrene, or a loss of vitality of the affected part. This mode of termination is fortunately infrequent, as the morbid action which gives rise to it is, in general, easily arrested by the early and vigorous employment of GANGRENE OF THE BLADDER. 143 antiphlogistic remedies. It is particularly to be apprehended when the cystitis is marked by great violence, when it has been induced by external injury, and when it occurs in old, infirm, broken-down subjects, or in persons whose health has been much impaired by pre- vious suffering. Sometimes it succeeds to an attack of acute inflam- mation, engrafted upon a chronic one. Gangrene of the bladder, although it may occur as a consequence of idiopathic inflammation, is almost always a result of external vio- lence, or over-distension from urine. One of the most common causes of this mode of termination is compression of the' organ during the passage of the child's head in parturition. The accident is most liable to happen when there is an undue disproportion be- tween the size of the infant and the capacity of the pelvis, coupled with a neglect to void the urine. The distended bladder being thus compressed not only by the uterus from behind forwards, but in every direction by its own contents, either bursts, or, what is more likely, suffers severe contusion, which cannot fail to be followed by violent inflammation, and even gangrene. The maladroit application of the forceps or crotchet has occasionally led to similar results. A circumscribed form of gangrene is sometimes produced by the pres- sure upon a particular portion of the mucous membrane, of the end of a catheter permanently retained in the bladder, for drawing off the urine, as in paralysis of this organ, or in enlargement of the pro- state gland. Excessive distension of the bladder, if long continued, is often followed by extensive gangrene, and is an occurrence, therefore, against which all judicious practitioners carefully guard. All the component structures of the organ are violently stretched, as well as compressed; the vessels and nerves are flattened; the circulation is embarrassed, and finally arrested; and the nervous fluid either ceases to be transmitted, or is no longer capable of exerting its specific influence. The gangrene, in these cases, is frequently preceded by inflammation, but there is reason to believe that it sometimes occurs independently of this process. When the distension is both exces- sive and protracted, the whole organ may be deprived of its vitality; but, in general, the mortification occurs in small circumscribed spots, from the dimensions of a dime to those of a dollar. Gangrene of the bladder occasionally follows the operation of lithotomy, and laceration of the mucous membrane consequent upon the employment of instruments. From this cause many patients 144 DISEASES AND INJURIES OF THE BLADDER. have perished since the introduction of lithotripsy. In performing this operation there is no little danger, especially in the hands of a young and inexperienced surgeon, of pinching and tearing the coats of the bladder ; an effect almost sure to be followed by violent cys- titis and gangrene. Infiltration of urine into the tissues around this organ may be mentioned as another cause of this mode of termina- tion. Gangrene of the bladder is occasionally epidemic. Mons. Cossy, a French writer, has described, in the "Archives of Medicine," of Paris, for September, 1843, a well-marked form of this affection in persons labouring under typhoid fever. He observed it very often in the same season, and in the same locality, and was thence led to regard it as of an epidemic character. A similar tendency has been noticed, but less frequently, by other authors. I am not aware that any American writer has met with it. The period which intervenes between the development of cystitis and the occurrence of gangrene, varies in different cases and under different circumstances. In general, it does not exceed six or eight days; but it may be considerably shorter, and, on the other hand, it is sometimes delayed to the end of the second or the middle of the third week. In traumatic cases, gangrene often occurs at an early stage of the disease, and speedily destroys the patient. Gangrene may occur in any region of the bladder, and it is im- possible to say, in the present state of the science, whether one part is more liable to suffer than another. As in other hollow viscera, it may be general or partial, that is, it may pervade the entire organ, or be limited to particular spots; and, again, it may affect the whole thickness of the organ, or be confined to one or two of its tunics. The occurrence of mortification of the bladder is announced by great prostration of strength; sudden cessation of pain; coldness of the extremities ; small, weak, and frequent pulse ; profuse, clammy, and offensive perspiration; cadaverous expression of the countenance; mental confusion, delirium, and coma; hiccup ; twitching of the ten- dons ; and towards the close, colliquative diarrhoea, and involuntary discharge of the fseces. The urine is of a brownish or blackish colour, emits a peculiarly foetid or cadaverous odour, and is effec- tually retained by the dead, crippled, or paralysed organ. On dissection, the mucous membrane is found to be of a dark red, livid, or purple complexion, very soft, easily torn, and bathed with GANGRENE OF THE BLADDER. 145 a thin, sanious fluid, of an excessively foetid odour. In some in- stances, the eschars are of a greenish, grayish, or drab colour, and have a sort of depressed appearance, as if they were sunk beneath the natural level. The parts immediately around the seat of the gangrene are generally remarkably tumid and spongy, from the dis- tension of the capillary vessels and the presence of effused fluids. The submucous cellular substance at the affected part, as well as for some distance beyond, is infiltrated with bloody matter, and yields under the slightest pressure; the muscular fibres are preternaturally dark and lacerable; and the peritoneal investment exhibits all the evidences of high inflammatory action, being more or less discoloured, incrusted with lymph, and adherent to the neighbouring parts. In cases where the disease does not speedily terminate life, the muscular coat is sometimes denuded over a large space, and the sloughs lie loose in the urinary reservoir, small fragments of them having per- haps been voided during life. Gangrene of the bladder is sometimes followed by a rupture of the coats of this organ, and the escape of its contents. This event is most likely to happen when there has been protracted retention of urine with inordinate distension, and may take place very suddenly, while the patient, perhaps, is turning about in bed, or during a fit of coughing or vomiting; or it may occur slowly and gradually, as a result of ulceration. In the latter case, the opening is generally small, and is often accompanied by an effusion of lymph upon the outer surface of the organ, or, what is the same thing, by an imper- fect agglutination of the bladder to the neighbouring parts. When the rupture occurs spontaneously, or under the influence of muscular exertion, it is always followed by an escape of urine, either into the cavity of the abdomen, or into the cellular tissue of the pelvis. In either case, the ultimate consequences are the same. In the former, that is, when the fluid passes into the cavity of the abdomen, violent peritonitis soon arises, attended by the most intense suffering, and terminating fatally in a very few days. The pulse is hard, small, and wiry; the countenance expressive of great anxiety; the skin hot and dry ; the breathing hurried and laborious; the belly tense, tender, and tympanitic; the thirst urgent; the bowels torpid; and the bladder tormented with a constant pain and spasm, unable to expel a drop of urine. Symptoms of exhaustion soon set in, and death is seldom delayed later than the end of the second or the be- ginning of the fourth day. The patient is sometimes rendered con- 10 146 DISEASES AND INJURIES OF THE BLADDER. scious of the rupture by a peculiar noise, or by a feeling of something having suddenly given way. Be this as it may, he is instantly seized with the most agonizing pain, with an inability to move or turn about, and a sense of profound depression; symptoms which are always sufficiently characteristic of the true nature of the accident. On dis- section, the abdominal cavity is found to be filled with a mixture of serum and urine, highly foetid, and of a dark, dirty appearance; the peritoneum is injected and covered with lymph; the bowels and pelvic viscera are glued together, and the bladder is empty or nearly so, is softened, discoloured, and torn at one or more points. When the urine is extravasated into the cellular tissue of the pelvis, the case, as already stated, is equally dangerous, though not gene- rally quite so soon fatal. The symptoms are the same as in urinous infiltration from other causes, and need not, therefore, be described in this place, as they will be pointed out in another part of the work. ,The prognosis of this disease is always unfavourable. Recovery, it is true, sometimes occurs even when the gangrene is apparently extensive, but such an event must always be regarded as an excep- tional one. In general, the inflammation which precedes and accom- panies the mortification, even when the latter is slight, is so severe, and causes such an amount of local and constitutional suffering, that few systems, however strong and robust, can withstand its deleterious effects. Aware of these facts, the practitioner cannot be too cautious in delivering his opinion as to the probable issue of any particular case. The treatment of gangrene of the bladder is easily told. The object is to prevent the lesion rather than to cure it after it has been established. With this view, the practitioner must redouble his efforts the moment he sees that this event is threatened, and en- deavour, by a judicious and well-directed course of treatment, to arrest the inflammatory action. Should gangrene be inevitable, the indication is to support the system, and by means of quinine, ammo- nia, brandy, opiates, and nutritious food, assist the patient in throw- ing off the effects of the local disorder. The distension of the bladder is obviated by the catheter. ULCERATION OF THE BLADDER. 147 SECTION V. ULCERATION OF THE BLADDER. Ulceration of the bladder, as an occasional occurrence, has been observed from the earliest periods of the profession, and has been described, with various degrees of accuracy and minuteness, by dif- ferent modern pathologists. That this process should now and then present itself is not surprising when we reflect upon the extensive surface of the bladder, the delicacy and great susceptibility of its lining membrane, and %h.e important sympathetic relations which sub- sist between it and the rest of the organism. That it is much less frequent, however, than it was formerly supposed to be, the concur- rent experience of the profession amply attests. Judging from the results of my own observations, both at the bed-side and in the dis- secting-room, I am disposed to rank it amongst the rarest accidents to which this organ is obnoxious. Of the cause of this immunity we are entirely ignorant. That it depends upon some peculiarity of organization is highly probable; but what this peculiarity is, or wherein it consists, it is impossible, in the actual state of our know- ledge, to determine. How far the mucous follicles influence, pro- mote, or prevent the production of ulcerative action, has not been ascertained; all that is positively known is, that certain regions in which these little bodies abound are more prone to suffer from it than others, and with this fact we must, for the present, be satisfied. Ulcers of the mucous membrane of the bladder are usually neither numerous nor large. In fact, it is rare, in any case, to find more than two or three, and these may be so small as to elude superficial inspection. This is especially true of the follicular form of the dis- ease, in which the morbid process begins in, and is confined to these little bodies. Sometimes, however, the number is much greater, and the size more considerable, the lining membrane exhibiting, in con- sequence, a ragged, riddled appearance. At other times, again, though this is rare, there is one single ulcer, so large as to occupy the greater portion of the organ, and denude the muscular fibres as thoroughly as if they had been dissected by the most skilful anatomist. Much diversity obtains in regard to the shape and depth of these ulcers. Their most common appearance here,.as in the bowels, is that of depressed breaches of continuity of the mucous corion, of a 148 DISEASES AND INJURIES OF THE BLADDER. circular or oval form, with the edges slightly elevated above the sur- rounding level. Not unfrequently, however, they are exceedingly irre- gular in their figure, and their edges are hard and thick, fissured, puck- ered, or jagged. Appearances like these are most common in old, chronic cases, but are very rare in such as are recent. In another series of cases, the ulcers are of an irregular form, with undermined, shreddy, ragged edges, the mucous membrane being raised for some distance from the muscular layer, and almost deprived of its vitality. This variety of the disease is most frequently noticed in follicular ulceration, caused by scrofulous action, and may be shown to great advantage by floating the affected surface in water. The bottom of the ulcer is originally formed by the submucous cellular substance; but as the disease progresses it may erode the muscular fibres, and even the serous investment. In the latter case, which, however, is comparatively rare, it is not uncommon for per- forations to occur, followed by an escape of urine into the abdominal cavity, and the development of fatal peritonitis; or by adhesion of the organ to the neighbouring viscera, and the reciprocal passage of their contents. Most generally a communication is established with the sigmoid flexure of the colon or with one of the coils of the small intestine, the parietes of which are firmly glued to those of the bladder by plastic lymph, poured out during the progress of the ulcerative action. In the female, the ulcer sometimes opens into the uterus or the vagina; and, in both sexes, not unfrequently into the rectum. The ulceration is sometimes consecutive, that is, matter is deposited in the submucous cellular tissue, by which the lining membrane is elevated into little abscesses, from the size of a millet seed to that of a small pea. After a while, the covering breaks or sloughs, from the pressure of the pus, and thus an ulcer is formed, exhibiting a foul, ragged aspect, and pursuing the same course pretty much as when the morbid action begins in the mucous corion, or in one of the mucous follicles. When several of these purulent depots exist in close proximity, they may communicate by fistulous tracts, as ab- scesses occasionally do beneath the skin and the lining membrane of the bowel. This variety of ulcer sometimes owes its origin to a de- posit of tubercular matter, of which I have seen several cases in my own practice, and of which a good example has been recorded by Baillie,1 in his work on Morbid Anatomy. 1 Works, by Wardrop, vol. ii. p. 262. ULCERATION OF THE BLADDER. 149 The question may now be asked, Do ulcers of the bladder ever undergo a process of reparation ? Concerning this point, which is one of deep interest in whatever light it can be contemplated, various opinions have been entertained by pathologists. That the occur- rence is possible, no one can doubt; but that it is infrequent is a fact which is fully established by daily observation. Indeed, it could hardly be expected to be otherwise, when we reflect for a single moment upon the situation, structure, and functions of the bladder, and the heterogeneous nature of the urine. Liable, from its position, to be constantly compressed by the pelvic viscera, subjected to inces- sant distension, and obliged to undergo frequent contractions, in order to expel its contents, no organ could possibly be placed under more unfavourable circumstances as it respects the healing of an ulcer of its lining membrane. In addition to all this, it should be remembered that the urine itself, from being loaded with acrid matter, or in a state of partial decomposition, becomes a source of irritation, highly prejudicial to the process under consideration. Still, notwith- standing all these disadvantageous circumstances, it cannot be denied, as already hinted, that ulcers of this organ do occasionally heal. In support of this view, it may be stated, first, that these ulcers have been repeatedly found incrusted with plastic lymph, as if nature had been occupied in repairing them ; and secondly, that the mucous mem- brane occasionally exhibits a puckered and contracted appearance, strongly indicative of complete cicatrization. The possibility of this occurrence is, moreover, rendered highly probable, if not proved, by analogy, or by what is known to happen in other parts of the mucous system. In the alimentary canal, for example, such an event is by no means infrequent, as the dissections of pathologists have clearly established; in the tonsils, mouth, vagina, and uterus, the same thing is constantly witnessed; why, then, should ulcers of the mucous coat of the bladder be regarded as beyond the reach and influence of the same law ? Ulcers of the bladder heal in the same manner as ulcers of the bowels and other mucous canals. Two modes of reparation are gene- rally recognised by pathologists. In one, which is the more frequent of the two, the breach is gradually filled up with granulations, by a process in every respect similar to that which presides over the repa- ration of an ulcer of the skin. In the other, the surface of the breach is covered with a thin layer or film of plastic lymph, which, pressing down the edges of the ulcer, soon becomes vascularized, and is ulti- 150 DISEASES AND INJURIES OF THE BLADDER. mately transformed into an analogous fibrous tissue. An ulcer that heals in this manner always leaves a sort of scar, or a whitish, puck- ered, or corrugated appearance, the nature of which is unmistakeable. Having considered the mechanism of ulceration, we may next ad- vert to its causes, and the circumstances under which it occurs. In relation to these points, all the cases which are met with may be referred to two general heads, according as they make their impres- sion upon the mucous membrane in the first instance, or secondarily through the neighbouring organs. Uncomplicated cystitis rarely passes into ulceration, while the reverse obtains in that variety of the disorder which depends upon stricture of the urethra, enlarge- ment of the prostate gland, or organic disease of the kidney. Nor is acute inflammation very prone to terminate in this way; on the contrary, in the great majority of instances the ulceration can be distinctly traced to the chronic form of the complaint, and the more protracted this is the more liable does it appear to be to produce this result. Paralysis of the bladder, injury of the spinal cord, and orga- nic lesion of the kidney, are very apt to induce ulceration, from the changes which they create in the composition of the urine, and which seem to act deleteriously upon the sensibility of the lining membrane. But there are other causes which operate, in great measure, if not exclusively, by the mechanical impulse which they communicate to particular parts of the bladder, or even the whole organ. Thus, calculous concretions, or sandy deposits, often in- duce ulceration, solely by the pressure which they exert upon the mucous membrane. The same thing occasionally happens, though much less frequently than might be supposed, from the introduction and lodgment of foreign bodies, as a piece of bougie, a pin, or a bullet. A cause very different from any of the preceding is tubercular disease. This implies a peculiar morbid action, not only of the part itself, but of the whole system, and is exceedingly prone to produce ulceration. The tubercular matter is generally deposited in the submucous cellular tissue, where after having remained in a crude state for an indefinite period, it gradually softens, and is ultimately eliminated by the process under consideration. The resulting ulcer, as was previously stated, is generally very small, and rough at the bottom, with thin, ragged, and irregular margins, which are at the same time frequently undermined. What influence, if any, age, sex, temperament, occupation, and ULCERATION OF THE BLADDER. 151 other circumstances exert upon the production and maintenance of this disease, are points respecting which we have no positive or reli- able information. It would appear, from the cases of it upon record, that it is much more frequent in women than in men, and in old, de- crepit, than in young, vigorous subjects. Ulceration may occur in any part of the bladder; but is most commonly met with in the bas-fond and cervical region. Symptoms.—The symptoms of ulcerated bladder do not differ essentially, in the early stage of the disease, from those of subacute or chronic inflammation. Even at a later period, they are not always distinct, or well-marked. The most prominent local pheno- mena are, pain and uneasiness in the pelvic cavity, with spasm, frequent micturition, and an offensive state of the urine. The pain is of an acute, burning, or scalding character, and is aggravated by exercise, an overloaded state of the bowels, by pressure on the hypo- gastric region, the perinseum, and the anus, by the finger in the rec- tum, and by the introduction of the catheter. It often darts along the course of the ureters to the loins, and is always most severe during the passage of the urine and for a few minutes after, when it goes off, but returns again as the secretion accumulates. In many cases there is severe pain in the loins and kidneys; it is generally intermittent, or liable to temporary exacerbations, and is of a dull, heavy, aching character, though sometimes it is quite acute; occasionally it is distinctly neuralgic. Not unfrequently there is also pain in the groins and the upper part of the thighs. Great tenderness is experienced when the finger, passed into the rectum or vagina, is pressed against the bas-fond of the bladder. In the female there is often a burning sensation at the orifice of the urethra, and severe pain in the pudendal lips, and even in the pubic bones. The testicles, in the male, are sometimes exquisitely tender, and there is great distress, with more or less itching in the prepuce and the head of the penis. In fatal cases, the pain, after having been all along agonizing, sometimes disappears nearly entirely a few days before the patient expires. The same is occasionally true of the de- sire to make water. The inclination to urinate is not incessant, but comes on in pa- roxysms, which gradually increase in frequency, and are attended with intense suffering. Indeed, every effort of the kind, in the more aggravated forms of the complaint, gives rise to the most violent spasm and straining, during which the patient grasps the 152 DISEASES AND INJURIES OF THE BLADDER. penis and squeezes it with the utmost firmness; frequently he rolls about in bed or upon the floor, doubles himself up, screams at the top of his voice, turns ghastly pale in the face, and looks as if he were deprived of his reason. During all this time the urine is expelled with much difficulty, or voided in drops, accompanied with an almost insupportable scalding of the urethra. Gradually, per- haps suddenly, the pain and distress subside, and the patient, exhausted by his exertions, sinks into a somnolent state, from which he is roused in fifteen or twenty minutes to pass through a similar attack. The urine, in this disease, is seldom permitted to accumulate to any extent, and hence it is generally voided in small quantities at a time. The reason of this is sufficiently evident. The urine is not only more irritating than it is in the normal state, but the moment it begins to distend the bladder, the ulcerated surface is put on the stretch, and the organ becomes intolerant of its contents. The patient experiences an immediate and urgent desire to relieve him- self, and usually loses no time in obeying his feelings. The fluid, which is generally acid and slightly albuminous, deposits, on cooling, a considerable amount of thick, ropy mucus; sometimes it contains fine shreds of lymph, or the debris of the affected membrane. In the advanced stages of the complaint, it is excessively offensive, of a dark colour, occasionally like coffee in appearance, and often mixed with pus, or tinged with blood. An ammoniacal state of this fluid is not uncommon at this period. Where there is extensive destruc- tion of the lining membrane, little or no mucus is seen in the urine. As the disease progresses, the sympathies and functions of the urinary organs are completely subverted, and the patient's health is materially impaired by the local derangement. His countenance is anxious and sallow, the nervous system is excited and unstrung, he is irritable and feverish, the appetite is disordered, the pulse is small and quick, and there are well-marked febrile exacerbations in the evening, sometimes, indeed, twice a day, preceded by chills or rigors, and followed by copious sweats. In protracted cases, or where the destruction of the mucous membrane is extensive, pains are felt in the perinseum and the rectum, only a few drops of urine can be retained at a time, the body is excessively emaciated, and the patient dies gradually exhausted by his suffering. Sometimes, however, on.the other hand, the symptoms are comparatively mild, and but little distress is experienced in the urinary apparatus, from ULCERATION OF THE BLADDER. 153 the commencement to the termination of the case. This is particu- larly liable to happen when the disease is of a tubercular character. The truth of this statement is forcibly illustrated by the subjoined case, which fell under my notice during my residence at Cincinnati. The patient was a tall, slender man, thirty years of age, for the last four of which he had laboured under lumbar abscess, of which he finally died. On dissection, I found upon the mucous membrane of the bladder five distinct ulcers, in close proximity with each other, the largest of which was twelve lines in length by six in width; the smallest was about the size of a split pea. They had a rough, un- even appearance, and were evidently of a tubercular character. The bladder was very much contracted, and contained about two ounces of thick, purulent fluid, resembling that which was found in the right kidney, which was nearly destroyed by tubercular disease. Strumous matter was also abundantly contained in the lymphatic ganglions of the pelvis, the seminal vesicles, and the prostate gland. Not a tubercle could, upon the closest scrutiny, be detected in the lungs, which, together with the heart, brain, and most of the abdo- minal viscera, were perfectly sound. Notwithstanding this amount of disease of the urinary bladder and the right kidney, the patient never complained of the slightest difficulty in voiding his urine, or of any pain or uneasiness that could be referred to these organs. Whether the urinary lesion was masked, in this case, by the lumbar abscess, or whether this exemption from suffering is peculiar to this form of ulceration, I am unable to state. The subject is worthy of further inquiry. Diagnosis.—The diagnosis of this disease is difficult, and cannot always be determined during life. The affections for which it is most liable to be mistaken are simple cystitis, catarrh, and stone. From the former it can generally be distinguished by its obstinate persis- tence, by the greater extent and violence of the local distress, by the incessant desire to void the urine, which is never suffered to accumu- late, by the more frequent recurrence of spasms, by the more severe burning or scalding along the urethra, and, lastly, by the presence of pus in the urine, and in the more aggravated forms of the com- plaint, the absence of mucus. The latter occurrence is readily explained, under these circumstances, by the destruction of the lining membrane, which, as was previously stated, sometimes pervades the entire organ, denuding the muscular fibres as thoroughly as if they had been displayed by the most careful dissection. 154 DISEASES AND INJURIES OF THE BLADDER. In catarrh, the characteristic symptom is a copious secretion of thick, tough, ropy mucus, with a turbid appearance and an ammo- niacal smell of the urine. The local and constitutional distress is less severe than in ulceration, the desire to micturate is not so fre- quent, there is less sensibility in the urethra, and there is often com- plete intermission of the vesical disturbance, the patient remaining comparatively comfortable for days and weeks. In ulceration, the symptoms are persistent, and the disease steadily proceeds from bad to worse. In stone, the pain is most severe immediately after passing the urine, and is generally much aggravated by rough exercise, the urine is also more frequently bloody, there is less irritability of the ure- thra, and the intervals between the paroxysms are longer than in ulceration. If doubt exist, the sound is used cautiously and gently, lest, if the case be one of ulceration, it increase the local inflamma- tion, and endanger life. In ulceration, there is sometimes a discharge of the debris of the mucous membrane, which never happens in simple cystitis, catarrh, and calculous disorder. It should be carefully distinguished from the shreds of lymph which are occasionally voided in pseudo-mem- branous inflammation. When perforations exist, a discharge of gas, fsecal matter, ingesta, and other substances, along with the urine, leaves no doubt respect- ing the nature of the disease. The gas occasionally escapes by the urethra with an explosive noise, or in little bubbles mixed with urine. A discharge of urine by the anus or vulva indicates that the ulcer has taken the direction of the rectum or vagina. The prognosis of this disease is most unfavourable. That cures are occasionally effected, and that too, without the aid of much treat- ment, is unquestionably true; but such a result must be regarded as extremely rare. Generally speaking, the ulcerative process pro- ceeds in spite of the best-directed efforts of the practitioner, gradually undermining the health, and exhausting the vital powers. The period at which death occurs varies from five or six months to several years. In a case of most extensive ulceration of this organ, described by Dr. Budd,1 of London, the disease proved fatal at the end of the ninth month from the first appearance of vesical symptoms. The patient was a female fifty-seven years of age. The bladder was entirely denuded of mucous membrane, except at a spot as large as 1 London Medical Gazette, Nov. 26th, 1841. ULCERATION OF THE BLADDER. 155 a shilling on the posterior surface of the viscus, just behind the urethra, and at another immediately round the orifice of the right ureter. The muscular fibres were nearly natural in their appear- ance, and the peritoneal investment was free from inflammation. The left ureter was thickened and ulcerated. Both kidneys were rather small, and the left contained a number of miliary tubercles. Pregnancy is said occasionally to mitigate the suffering from this disease, and to retard its progress. In 1827, Mr. Coulson,1 inspected the body of a French woman, who, immediately after her delivery, was attacked with all the symptoms of ulceration of this organ, and died within a week after. " On examination," he says, "the whole inner membrane of the bladder was found completely destroyed. I could not obtain any accurate account of the case, but I learnt that the patient, for the few days she was in the hospital prior to her delivery, did not complain of the affection of her bladder. One case, however, I watched from the commencement of the disease, which occurred a month after marriage, to the death of the patient, which took place a month after delivery, and during the latter half of her pregnancy, her symptoms were much milder than before, but soon after the child was born, they returned with their accustomed severity, and destroyed the person." A pathologist cannot fail to recognise here a well-known law, by which one affection often masks another. Pulmonary phthisis, as was long ago observed by practitioners, is sometimes entirely suspended by pregnancy; and every physician has noticed the fact that two severe diseases of any kind can seldom go on at the same time without modifying or counteracting each other. Effects on Neighbouring Organs.—In ulceration of the bladder there is nearly always more or less disease of the urethra, prostate gland, seminal vesicles, the ureters, and kidneys. All these organs are not necessarily involved at the same time, but not unfrequently this is the case, and there are few instances in which several of them do not participate in the vesical affection. The most common lesion of the urethra is inflammation of its lining membrane, which is usually most conspicuous near the neck of the bladder, and is some- times marked by high vascularity. The prostate gland is usually enlarged, softened in its texture, and engorged with blood; occasion- ally its ducts are expanded, and its substance is pervaded by pus or 1 Diseases of the Bladder, Philadelphia, 1841. 156 DISEASES AND INJURIES OF THE BLADDER. sanious fluid. It is rare that this body suffers from an encroachment of the ulceration. The seminal vesicles seldom entirely escape the ravages of the malady. The most frequent morbid appearance of these reservoirs is high discoloration of their lining membrane, with softening of their texture, and an infiltrated and injected condition of the cellular tissue by which they are connected to the bladder. Their contents usually exhibit the character of spoiled semen, which is sometimes of a very foetid odour. The ureters are variously affected; inflamed, ulcerated, dilated, contracted, thickened, or at- tenuated. The left is said to be more frequently diseased than the right, but in what proportion is unknown. One of the kidneys is sometimes natural, but in general, both are implicated, though not in an equal degree. The lesion most commonly met with in these organs is inflammation, with ulceration of their substance, and a pretty copious secretion of pus. Another not infrequent effect is atrophy, and cases occur in which one of these glands is converted into a membranous pouch, totally devoid of parenchymatous tissue, and filled with sero-purulent fluid. In the scrofulous variety of ulceration, tubercular deposits are sometimes present in the renal substance. In a case which I shall mention presently, matter of this kind existed in great abundance, especially in the right kidney. Morbid Alterations.—The bladder, in this disease, presents no uni- formity in regard to its pathological appearances. Its capacity is normal, diminished, or increased; the muscular fibres are preter- naturally distinct, and of a deep red colour; the mucous membrane, when not completely destroyed, is sometimes covered with patches of lymph, and is nearly always remarkably thick, spongy, and vascular, immediately round the ulcers. Purulent matter, mixed with shreds of fibrin and the debris of the lining membrane, is generally found in the bottom of the bladder, and is derived either from this organ itself or from the ureters and the kidneys. The peritoneal invest- ment, although usually healthy, is sometimes partially covered with lymph, and pretty firmly adherent to the neighbouring parts. Occa- sionally the coats of the viscus are exceedingly soft, and incapable of resisting the slightest traction. In other cases, again, they are re- markably tough and indurated, owing, doubtless, to interstitial fibri- nous deposits. If perforations and adhesions form, in consequence of this disease, it is remarkable how long the patient may live with this loathsome infirmity. Mr. Wilson, of London, in his Lectures on the Urinary ULCERATION OF THE BLADDER. 157 Organs, alludes to a case in which the bladder and ileum had been united for fifteen years, and yet the patient during all this time en- joyed tolerable health. Ulceration, to a large extent, had taken place through the adherent parts, allowing of a free and constant passage of faecal matter from the bowel to the urinary reservoir. The patient died at the age of sixty-eight. Being a female, the shortness of the urethra prevented the retention of the extraneous substance, and no calculus formed. I am acquainted with a clergy- man of the German Reformed Church, now eighty-five years old, from whose bladder faecal matter has been discharged for upwards of a quarter of a century. His health, with the exception of an occa- sional attack of colic, has been excellent. The passage of faeces along this route occurred, at first, at long intervals, and rarely con- tinued longer than three or four days at a time; of late, it has been much more frequent, and, within the last twelve months, almost con- stant. When perforation takes place without adhesion, death gene- rally supervenes, in from twenty-four to forty-eight hours, from inflammation of the peritoneum. Treatment.—From what has been said under the head of cystitis, the practitioner will have no difficulty in deducing the principles which ought to guide him in the management of ulceration of the bladder. His conduct here, as in similar affections elsewhere, must be regulated by the age and constitution of the patient, the duration and progress of the disease, the effects of previous treatment, and various other circumstances which will readily suggest themselves to his mind, and which we cannot stop to detail here. At the com- mencement of the complaint, the means employed to arrest it must be strictly antiphlogistic, and subsequently they must be modified to meet individual contingencies, as they are developed under the eye of the practitioner. Active depletion by the lancet will seldom be called for after the expiration of the first week or ten days ; while the local abstraction of blood by leeches is proper in every stage of the disorder, and constitutes one of our most valuable therapeutic resources. The best regions for applying them are the perinseum, the parts around the anus, the upper and inner surface of the thighs, and the inferior portion of the abdomen, the number being propor- tioned to the exigencies of each particular case. The bowels should be constantly kept in a soluble condition; but active purgation is injurious, and must be abstained from. The best aperients are Epsom salts, castor oil, or a pill composed of equal 158 DISEASES AND INJURIES OF THE BLADDER. parts of blue mass and rhubarb. Mercury, with a view to its sali- vant effects, is of no use, except in the early stage of the complaint, and must, therefore, be avoided. The greatest attention should be paid to the secretions throughout the whole progress of the disease. Any disorder, or irregularity of this kind, is sure to aggravate the local distress, and therefore requires the most vigilant care. The diet should be light but nutritious, and consist chiefly of stale bread, toast, mealy potatoes, rice, hominy, and mush, with weak tea or milk at breakfast and supper. Animal food, the coarser kinds of vegetables, condiments, coffee, wine, spirits, acids, and malt liquors, should be interdicted. The drinks, which should be taken in great moderation, so as not to increase unduly the renal secretion, should consist of plain water, linseed-tea, or gum-arabic water. The patient should constantly wear flannel next the skin, and carefully guard against all sudden vicissitudes of temperature. In the winter, during the cold season, he should reside in a warm cli- mate, where the atmosphere is all the time perfectly dry, or he should confine himself to a warm room, the atmosphere of which may be frequently renewed by ventilation. He should, moreover, keep himself as much as possible in the recumbent posture. Sexual intercourse, and rough exercise of every description, must be care- fully avoided. Of the internal remedies calculated to act directly upon the urinary apparatus, the most important are the pareira brava, buchu, uva ursi, hops, and carrot-seeds, which may be administered either in the form of infusion, decoction, or extract, alone, or variously combined with each other, or with copaiba, cubebs, hyoscyamus, cicuta, the alkalies, the mineral acids, or the muriated tincture of iron. These articles are all beneficial in ulceration of the bladder, but experience has shown that none of them retain their good effects beyond a few days. It is important, therefore, that they should be frequently changed or varied, and not be continued too long at a time. Whatever mode of treatment be employed, opium, laudanum, or morphia is indispensable for quieting the bladder and procuring sleep. In fact, without this remedy life would be utterly insupport- able in this disease. Its exhibition is demanded not only by the sound principles of practice, but it is loudly called for by the patient himself, who, aware of its happy effects, often takes it of his own accord, without waiting for the advice of his physician. The most ULCERATION OF THE BLADDER. 159 eligible, or least objectionable form of administration is that of an enema, or a suppository; but it may also be given by the mouth, though in this case it is more apt to produce constipation and de- rangement of the digestive function. In whatever manner it be exhibited, it should be employed in full doses, repeated at longer or shorter intervals, according to the exigencies of each individual case. Small doses, frequently repeated, only serve to render the system irritable without relieving the local suffering. Remedies addressed directly to the affected surface are sometimes highly serviceable. Of these the number is very considerable, for there is hardly an article of the Materia Medica that has not occa- sionally been employed; but the best undoubtedly are such as are of an anodyne character, as infusion of poppy, opium, hop, aconite, and cicuta; the salts of morphia have also been recommended; and benefit has sometimes followed the use of tepid water, either simple, or medicated with tar, tannin, sulphate of zinc, creasote, nitrate of silver, and other substances. Lime-water, black wash, and a weak solution of iodine have occasionally proved advantageous. The amount of reliance to he placed upon these remedies may be readily inferred from their number and variety. Like the internal means, above alluded to, they soon lose their beneficial effects, and are some- times positively injurious. Great caution, in fact, is always necessary in their employment. The best mode of introducing them is by means of a gum-elastic bag, or patent syringe, carefully adapted to the end of a moderate-sized silver catheter. The quantity of any injection of this kind should not, at first, exceed an ounce, or an ounce and a half; afterwards it may be gradually increased to three or even four ounces. An anodyne injection should be retained as long as possi- ble ; an astringent one not more than a few minutes. Counter-irritation in the form of issue, seton, or pustulation with tartar emetic, is often advantageous in this affection, and should always be resorted to as early as practicable. The points for esta- blishing it are the perinseum and the supra-pubic region. The dis- charge should be maintained for a long time, and should be promoted, if necessary, by stimulating lotions or unguents. The urine seldom requires to be drawn off in this disease; a cir- cumstance which is so much the more fortunate, because the use of the catheter is always attended with an increase of pain, and often with positive injury to the affected surface. At no time should the instrument be retained in the organ beyond a few minutes. 160 DISEASES AND INJURIES OF THE BLADDER. CASES OF ULCERATION OF THE BLADDER. Case I.1—Margaret Marshall, aged fifty-seven years, a native of London, and married thirty-four years, but has had no children, became affected on Christmas, 1840, with pain in the region of the bladder, attended with frequent and painful micturition. When she was admitted into King's College Hospital, on the 30th of June, under the care of Dr. Budd, she was considerably emaciated, and complained, in addition to the above symptoms, of a burning pain at the orifice of the urethra, in the left labium, and in the ramus of the pubes. The urine, which was voided in small quantity at a time, was acid, slightly albuminous, and mixed with pus. An examination with the catheter caused severe pain; and she complained of great tenderness when the finger, passed into the vagina, was pressed against the bladder. She had no sleep or appetite; her thirst was great, and there was considerable irritative fever. The emaciation gradually increased, and she died, completely worn out by pain and suffering, on the 8th of October. Towards the last, the urine fre- quently contained, in addition to the pus, a small quantity of blood. She complained throughout of agonizing pain in the left labium and in the left side of the bladder; and always lay on her right side, for the sake, as she said, of easing it. She had no pain in the right labium or in the loins. During the whole of her stay in the hospital, she had occasional vomiting, and constipated bowels; the effect, no doubt, of the large doses of morphia which she was constantly obliged to take to mitigate her distress. The bladder, on dissection, was found to be quite denuded of mu- cous membrane, except in a space about the size of a shilling on the posterior surface, immediately within the urethra, and in a very small spot around the orifice of the right ureter. The muscular fibres, which were thus exposed, exhibited no trace of ulceration, and were nearly of their natural appearance. The left half of the bladder was not more diseased than the right, except that the mu- cous membrane was entirely destroyed about the orifice of the left ureter. A few very small, whitish points, not unlike tubercles, were seen upon the mucous membrane at the back part of the urethra, the whole surface of which was quite vascular. The left kidney 1 London Medical Gazette, for 1841-42, p. 358. ULCERATION OF THE BLADDER. 161 contained a number of tubercles in its cortical substance, some in a softened and others in a concrete state ; and the mucous membrane of the corresponding ureter was very much thickened, rough, and ulcerated. The right kidney and ureter were healthy. All the other viscera, pelvic, abdominal, and thoracic, were in a natural condition. Case II.—A woman, aged thirty-six, and supposed to be labouring under stone, was seen by Mr. Coulson,1 on the 17th of May, 1834. She had frequent desire to make water, attended with darting, shoot- ing pains in the region of the bladder, which were much increased by walking, or exercise of any kind. The urine was acid, and con- tained some shreds of lymph or mucus. Sounding caused intense suffering, and failed to detect a stone. The pulse was small and quick, the skin dry and rough, the tongue white, and the counte- nance anxious and expressive of deep distress. She had been in this state for two months. The urine became gradually more loaded with mucus ; at times it was tinged with blood ; and at length matter was voided with it. These symptoms were succeeded by nausea, com- plete loss of strength, emaciation, and hectic flushes. On the 24th of November, death put an end to her sufferings. A few days prior to this, the pus ceased to appear in the urine, and the pain and fre- quent desire to make water, for the only time during her long ill- ness, almost left her. The bladder was not thickened or contracted, but so completely divested of its mucous membrane that not a single vestige could be seen. No dissection could represent the arrangement of the mus- cular structure so well as it existed in this case. One spot, of the size of a shilling, towards the fundus, was black, and almost gan- grenous. The ulceration had not extended to the urethra, but its lining membrane was highly inflamed. The right kidney was natural, but there was ulceration of the left, and its interior was filled with pus. The renal extremity of the left ureter was blocked up by a detached portion of the substance of the kidney. Case III.—A fistulous communication occasionally exists between the bladder and the ileum, producing symptoms similar to those of stone. Of this an instructive example is recorded by Mr. Worth- ington, of England, in the London Lancet for July, 1844. The patient, a female, sixty-five years of age, previously enjoying good 1 Diseases of the Bladder, p. 115, Amer. edit. 11 162 DISEASES AND INJURIES OF THE BLADDER. health, began, four years ago, to suffer from pain in the right iliac region, the cause of which could not be satisfactorily traced. In November, 1842, symptoms indicating disturbance of the urinary organs commenced. Her suffering was much aggravated; she had frequent and painful micturition; and the urine, bloody, ropy, and highly offensive, often deposited fragments of extraneous matter. The sound was introduced, but no calculus was found, although a distinct grating was felt. The treatment consisted chiefly of anodynes. The patient survived about four months, and died from an attack of diarrhoea. Adhesions were observed between the intestines and the pelvic viscera; and a communication, large enough to admit the end of the index-finger, and evidently caused by ulceration, existed be- tween the ileum and the fundus of the bladder, which were closely united together. The cavity of the bladder was occupied with fecu- lent matter and undigested food, such as currants, seeds, and other vegetable matters. CHAPTER IV. CHRONIC LESIONS OF THE BLADDER. SECTION I. CATARRH AND HYPERTROPHY OF THE BLADDER. Catarrh of the bladder, technically denominated cystorrhoea, signifies an inordinate secretion of white, glairy mucus, attended with chronic inflammation of the lining membrane. It is analogous in its character to gleet, leucorrhoea, and other kindred affections, and is generally a symptom merely of a more serious disease. Of the various names that have been employed to designate it, the most appropriate and expressive is cystorrhoea. This disease has usually been described by authors as consisting of two varieties, the acute and the chronic; an arrangement for which, I conceive, there is no necessity, since the former affection does not differ in any respect from ordinary acute cystitis, described in a preceding chapter. This distinction is of practical importance, and should not be lost sight of in the further consideration of the subject. Catarrh of the bladder is most common in advanced age. Indeed, it may be said to be almost peculiar to this period. I have never met with it before puberty, except as an attendant upon stone, and but very rarely, under any circumstances, before the forty-fifth or fiftieth year. Persons of a gouty or rheumatic habit are supposed to be particularly obnoxious to it; of this I have witnessed no corrobora- tive facts in my own practice.1 When the disease has been once 1 " Most frequently," says Dr. Prout, " it attacks the gouty; and the worst case I ever witnessed occurred in a gentleman, who, for many years, had been a martyr to gout, and in whom it succeeded to an acute seizure in the bladder, that took place during an attack of that affection."—Treatise on Urinary Diseases, p. 223. Philadelphia, 1826. 164 DISEASES AND INJURIES OF THE BLADDER. developed, it is no doubt capable of being influenced by this diathesis; but in what degree, or under what particular circumstances, is not known. The disease is also said to be more common in winter than in summer, and in cold than in warm climates. Gunther1 and Cho- part3 both say that it prevails epidemically. Finally, males are more liable to it than females, for the obvious reason that they are more subject to obstruction of the urinary passages, and to all kinds of exposure. Cystorrhoea is always dependent, directly or indirectly, upon some obstacle to the evacuation of the urine, or upon a diseased condition of the bladder itself. Hence the most common exciting causes are stricture of the urethra, the presence of a calculus, hypertrophy, and enlargement of the prostate gland. In fact, there are few protracted cases of this kind in which this affection is not witnessed to a greater or less extent, or of which it does not constitute in the end a promi- nent symptom. Nearly ail\ the very worst forms of vesical catarrh I have ever seen have been of this description. Paralysis of the bladder, whether produced by over-distension of the organ by urine, or injury or disease of the spine, frequently gives rise to this state. The muscular fibres having lost their expulsive power, the water is never completely evacuated at any one time, even when the catheter is used, but a portion remains in the bottom of the bladder, where it is speedily decomposed, and thus acts as an irritant to the lining membrane, followed by an inordinate secretion of mucus. Cystor- rhoea is a constant attendant upon sacculation, ulceration, hyper- trophy, and carcinoma of the bladder. When the affection is once established, it may be easily aggravated or re-induced by exposure to cold, exercise on horseback, sounding, venereal excesses, drastic purgatives, indulgence in ardent spirits, stimulating food, irritating injections, diuretics, and other remedies, as turpentine and cantha- rides, over-distension of the bladder, neuralgia, retrocession of gout, repulsion of cutaneous eruptions, local injury, and disease of the adjoining parts, as the anus, rectum, vagina, and uterus. Cystorrhoea generally comes on in a slow, gradual, and insidious manner; and hence there is frequently serious structural lesion be- fore the true character of the malady is revealed, or even suspected. The obstruction to the evacuation of the urine upon which it com- monly depends, absorbs for a time the patient's entire attention, and 1 Dencker, Diss, de Catarrho Vesicae ; Duisb. 1789. 2 Traite des Maladies des Voies Urinaires, T. i. p. 412. Paris, 1830. CATARRH OF THE BLADDER. 165 it is only by accident that he is at length apprised of the real condi- tion of the bladder. The inflammation which accompanies the affec- tion, and which is always the immediate cause of the cystorrhoea, is of a chronic character, and usually, in the first instance, of a very mild grade. It is for this reason that the term subacute has been sometimes applied to it. The characteristic symptom of the disease, as was before stated, is an inordinate secretion of mucus. This is associated, in nearly all cases, with an altered condition of the urine, frequent and difficult micturition, pain in the region of the affected organ, as well as in the adjoining parts, and more or less constitutional derangement. The quantity of mucus secreted varies remarkably in different cases and under different circumstances. In the incipient stages, and in the milder forms of the affection, it is generally small, not exceeding perhaps a few drachms in the twenty-four hours. At a more advanced period, the quantity is often considerable; and in some in- stances the discharge is truly enormous. Barthez mentions a case of a patient who voided not less than fifteen pounds in thirty-six hours. This, however, is a rare exception. Very frequently the mucus amounts to one-third, and even one-half of the entire dis- charge. It is liable to be increased by the state of the bladder, as well as by that of the system, and generally corresponds with the degree of inflammation of the lining membrane by which it is fur- nished. The colour of the mucus exhibits almost every variety of shade, from the natural hue to red, brown, or black. The most common tints, especially in the milder forms of catarrh, are white, grayish, or pale drab. A yellowish colour is not uncommon, and usually depends upon the presence of a small quantity of pus. When the attendant inflammation is high, the mucus may be of a reddish, brownish, or blackish aspect, from the admixture of blood, either freshly effused, or variously altered by its sojourn in the bladder. A creamy, greenish, striated, or streaked appearance is sometimes observed. The mucus in the early period of the disease, is so internately blended with the urine that it does not become perceptible until the latter begins to cool. It then presents itself in the form of an opaque, grayish, or whitish cloud, fleecy in its appearance, and at first suspended in the fluid, but gradually subsiding to the bottom. Its con- sistence gradually augments as the urine cools. Not unfrequently it 166 DISEASES AND INJURIES OF THE BLADDER. occurs in flakes, strings, or small lumps. In the confirmed stage of the affection, it is always thick, ropy, and tenacious, and separates from the urine during micturition, or immediately after. It always in such cases adheres with great firmness to the bottom of the re- ceiver, and is often so glutinous that in pouring it from one vessel into another it draws itself out upwards of a foot in length without breaking. The mucus in its odour usually partakes of that of the urine. In the more aggravated forms of the affection it is generally offensive, and soon decomposed. In its character it is nearly always alkaline. The urine, in the early stage of the complaint, is nearly natural, both in its colour, odour, consistence, and chemical properties. By degrees, however, it assumes a turbid, muddy aspect, becomes more or less offensive, is thick, acrid, and surcharged with earthy ingre- dients. It is most commonly of an alkaline character; but some- times it is acid, and in rare instances neutral. When intermixed with blood, pus, or albumen, it may be of a reddish colour, brownish, yellowish, grayish, or lactescent, and of the consistence of a thin solution of starch, isinglass, or arrow-root. The quantity secreted varies: sometimes it is small; at other times considerable; and occasionally it hardly amounts to four or five ounces in the twenty- four hours. During the progress of the disease, the urine always becomes highly acrid, so that the bladder can hardly tolerate it even for a few minutes. It generally emits a peculiar ammoniacal odour, is rapidly decomposed, both in the bladder and out of it, and is nearly always mixed with purulent and phosphatic matter. If a silver catheter is used late in the disease, it usually comes out of the blad- der of a bronze, brownish, or black colour, in consequence of the presence of a minute quantity of sulphuretted hydrogen. The pus that is present in this disease is derived from various sources; sometimes from the bladder, sometimes from the ureters, or the prostate gland, but in general from the kidneys, one or both of which are often seriously involved in the mischief. By rest and cooling, it separates from the urine, and settles at the bottom of the receiver, or, rather, upon the surface or in the substance of the mucus, to which it frequently imparts a striated or punctiform ap- pearance. Its quantity in the twenty-four hours varies from a few drops to several drachms; it is usually of a pale yellowish, ash, or CATARRH OF THE BLADDER. 167 grayish colour, and is readily distinguishable by its specific gravity, and globular character. Its presence is always to be regarded with great attention, as it is generally indicative of serious disease of the organs from which it is derived. It usually possesses an alkaline character. The matter is often puriform instead of purulent. This appear- ance is denotive of a milder grade of disease, and often comes and goes as the catarrh, from some accidental or intercurrent circumstance, increases or declines in intensity. The fluid is commonly more inti- mately blended with the mucus, with which it forms a whitish, gray- ish, or milky, and tremulous deposit, which becomes quite tough and viscid upon cooling, and always adheres with considerable firmness to the bottom of the receiver. It differs, moreover, from pus, in having an acid instead of an alkaline reaction. The urine is voided frequently, in small quantity, and with more or less difficulty. Generally, it passes off in interrupted jets, in a small, feeble stream, or in drops, accompanied by violent spasm and straining. Great effort is often required to start it, and it rarely happens that the whole of it is evacuated at any one time. When the urine is loaded with thick, ropy mucus, the difficulty of voiding it is much increased, and the patient is frequently obliged to have recourse to the catheter. The number of times micturition is per- formed is variable. I have recently had under my care a gentleman from Mississippi, for catarrh of the bladder, caused by a long, nar- row, and callous stricture of the urethra, who was obliged to urinate, on an average, every fifteen or twenty minutes. Such examples are, of course, rare; but it is by no means uncommon to see a patient, affected with this disease, make water from thirty to forty times in the twenty-four hours. The pain attending this affection is liable to much diversity. In general, it is of an obtuse, or a dull, heavy, aching character, and is situated low down in the pelvis, from which it radiates along the urethra, the perinseum, the anus, and the inside of the thighs. In the more aggravated forms of the disease, it is scalding, burning, pricking or spasmodic, and accompanied with the most violent strain- ing and tenesmus. It is usually most severe during the passage of the last drops of urine, subsides entirely, or in great measure, soon after the micturition is completed, and gradually reappears as the bladder is refilled. In some instances, indeed not unfrequently, a good deal of pain is experienced in the hypogastrium, the testicles, 168 DISEASES AND INJURIES OF THE BLADDER. the loins, and the sacrum; in rare cases, it extends down the limbs as far as the legs, and even the feet. It is liable to be aggra- vated by exposure to cold, venereal indulgence, rough exercise, the erect posture, pressure on the abdomen, drastic purgatives, and whatever has a tendency to augment the secretion of mucus. Patients affected with cystorrhoea are sometimes impotent, even if they are comparatively young. I have met with several instances of this kind. In one remarkable case, the gentleman, forty-four years of age, had experienced no sexual desire for upwards of six years, though he was naturally of an amorous disposition. His penis had become soft and flabby, and had not been in a state of complete erection for a long time. He had occasional emissions, but they were always unaccompanied with the proper feeling. Owing to the frequent micturition which forms so striking a feature of this disease, and the severe straining which generally attends it, catarrh of the bladder is often complicated with hemorrhoids, prolapsion of the bowel, swelling of the testes, and even with hernia. The diagnosis of this disease is always easy. Its characteristic symptom, as before stated, is an inordinate discharge of mucus, de- pendent upon chronic or subacute inflammation of the lining mem- brane, and accompanied with frequent, painful, and difficult micturi- tion. Almost the only affection with which it is liable to be con- founded is seminal emission; but this can only happen when the seminal fluid flows into the bladder, and mixes with the urine, in consequence of a stricture of the urethra, or enlargement of the prostate gland. The distinction is, that in catarrh the discharge is always greater, more constant, and also more ropy, tenacious, and offensive; the local suffering is always more severe, and there is a more frequent desire to urinate. In seminal disease, the matter is voided in small quantity, and at remote intervals; it has a peculiar odour, is of a light colour, and is insoluble in the water, in which it floats about in shreds. When there is any doubt, the best way is to submit a few drops of the suspected fluid to microscopical ex- amination. If it be semen, it will be found to consist of small oblong bodies, with delicate tapering tails. From gonorrhoea it is readily distinguished by the character of the discharge, the absence of urethritis, and the history of the case. Its connexion with stone can only be determined by sounding. In suppuration of the bladder, the discharge is of a yellowish colour, globular in its character, and specifically heavier than in catarrh. CATARRH OF THE BLADDER. 169 The prognosis in cystorrhoea varies with many circumstances which hardly admit of precise detail. Much will necessarily depend upon the age and constitution of the patient, the duration of the disease, and the condition of the bladder and of the associated organs. In its incipient stage, it is sometimes not difficult to cure ; but when, com- mencing gradually, it has at length come to disorder the whole system, it rarely terminates favourably. It not unfrequently remains station- ary for a time, or even almost entirely disappears, and then recurs perhaps with increased violence, merely from the slightest irregula- rity in diet, drinking a glass of wine, exposure to cold, fatigue, or venereal indulgence. The prognosis is always more unfavourable in old than in young subjects, in protracted than in recent cases, and in the simple than in the complicated forms of the disease. When the kidneys, ureters, prostate gland, or urethra are much involved, the complaint generally proves fatal under the best management, the patient being gradually worn by local suffering and constitutional irritation. Fig. 23. The morbid alterations observed in those who die of this disease are various. In the early stage, and in the milder forms, the mucous membrane usually presents slight marks of inflammation, with little or no lesion of the other tunics. After some time, however, the muscular fibres become hypertrophied, and exhibit the peculiar reti- 170 DISEASES AND INJURIES OF THE BLADDER. form arrangement delineated in Fig. 23. The cellulo-fibrous lamella is also much thickened, as well as increased in density, and the mucous membrane, particularly the portion which corresponds with the bas-fond of the organ, is often thrown into large, heavy ridges. In some instances the lining membrane is ulcerated, covered with patches of lymph, or protruded across the muscular fibres, in the form of one or more pouches. The walls of the bladder are fre- quently five or six times the natural thickness. The kidneys, ureters, and prostate gland are generally implicated in the mischief; some- times to a fatal extent. In entering upon the treatment of this affection, it is of great im- portance to ascertain the nature of the exciting cause; for the patient may otherwise be put upon a course of remedies calculated to prove useless, if not positively injurious. If there be stricture of the ure- thra, stone, or hypertrophy of the prostate gland, or disease of the neighbouring and associated organs, it will be imperative upon the practitioner to pursue the respective modes of treatment usually adopted for these several complaints; since otherwise no topical or constitutional means can be of the least avail. In truth, the only chance of cure, in nearly all cases, depends upon the early removal of the exciting cause, particularly when this cause interferes with the ready discharge of the urine. A thorough preliminary exami- nation should always be made of the urethra, the prostate gland, the interior of the bladder, and the rectum. It would be useless to repeat here what has been already said, in other portions of this treatise, respecting the employment of anti- phlogistics. The propriety of these measures is self-evident. They are imperatively demanded in all cases attended with violent pain and frequent micturition, even when there is no marked constitu- tional disturbance. The abstraction, under such circumstances, of fifteen or twenty ounces of blood from the arm will often do more good in breaking up the disease than any other remedies that we possess. Where the lancet is inadmissible, twenty or thirty leeches may be applied to the perinseum and inside of the thighs, or to the lower part of the hypogastric region. The topical bleeding should be followed by the warm bath, warm fomentations,-and warm ene- mata. The bowels must be opened with saline cathartics; or, where the secretions are much deranged, with calomel and jalap. All articles tending to irritate the rectum should be carefully avoided. The most perfect quietude, both of mind and body, must be enjoined; CATARRH OF THE BLADDER. 171 the diet should be as light and unirritant as possible ; and the patient should be requested to make free use of demulcent drinks, as gum- arabic water, flaxseed tea, or slippery elm water. When, by these means, the violence of the disease has been sub- dued, I know of no remedy so well calculated, in ordinary cases, to ameliorate the morbid condition of the bladder as the balsam of copaiba. This remedy is not new in the treatment of vesical catarrh. On the contrary, mention of it is made by various authors both of the last and the early part of the present century. In this country it does not seem to have met with much favour until about fifteen years ago, when the attention of the profession was prominently directed to the subject by my friend, Dr. Rene* La Roche, of Phila- delphia, in an excellent paper in the fourteenth volume of the Ame- rican Journal of the Medical Sciences. Since that period, I have employed the copaiba in numerous instances of vesical catarrh, and have rarely been disappointed in my expectations. To be effectual, it should be given in doses not exceeding ten, fifteen, or twenty drops, three or four times in the twenty-four hours. The best form is that of emulsion, prepared with gum-arabic and loaf-sugar. Its nauseating, griping, and purging tendencies should be counteracted by combining with each dose a few drops of laudanum, or a small quantity of morphia. Where it does not disagree with the stomach, or produce other mischief, its employment may often be advanta- geously persisted in for several successive weeks. Small doses are always preferable to large, which are apt not only to cause gastric and intestinal disorder, but also irritation of the urinary apparatus. When the patient is troubled with pyrosis, or acid eructations, the medicine may be advantageously conjoined with bicarbonate of soda. The terebinthinate preparations are sometimes highly beneficial in this affection. They should be used in small doses, largely diluted with gum-water. They may be given by themselves, or in associa- tion with copaiba, cubebs, and other articles. The Chian turpentine is, on the whole, the best of this class of remedies, exhibited in the form of pills, with extract of henbane, cicuta, or colchicum. The pareira brava, which has been so much vaunted in the treat- ment of this affection by Brodie and others, has never accomplished much good in my hands, in any stage of the disease, whether em- ployed alone or in combination with other articles. I have generally found it to create nausea and other disagreeable effects, rendering its continuance improper, at the same time that it did not seem to 172 DISEASES AND INJURIES OF THE BLADDER. exert any special influence upon the urinary apparatus. It is usually administered in the form of infusion, prepared in the proportion of half an ounce of the root to a pint of water, of which the dose is from one to two ounces three times a day. I commonly, however, prefer the aqueous extract combined with opium, morphia, or lupuline, and given in doses of from five to fifteen grains every seven or eight hours. From buchu, another article much extolled in the treatment of catarrh of the bladder, I have never derived much advantage. It is less irritating to the stomach than the pareira brava, but can never be relied upon for correcting the discharge, and removing the morbid condition of the mucous membrane upon which it depends. In com- bination, however, with uva ursi and other remedies, presently to be mentioned, it may occasionally be employed with benefit. It is best given in an infusion, in doses of from one to two ounces three or four times a day. Another article which has a specific tendency to the urinary organs is uva ursi. I have used it a good deal in the treatment of cystorrhoea, and have occasionally experienced the best effects from it. I have found it particularly serviceable in cases attended with excessive morbid sensibility of the neck of the bladder. It may be advantageously combined with buchu; and, in the class of cases just mentioned, with carbonate of soda or potash. The extract has seemed to me to be less active than the infusion, of which the dose is the same as of buchu. The epigaia repens, commonly called the trailing arbutus, ground- laurel, or May-flower, may occasionally prove useful in this malady. It possesses moderately diuretic, as well as slightly astringent, pro- perties, and is closely allied, in its effects upon the urinary organs, to the uva ursi and buchu. The best form of exhibition is a strong decoction, prepared with one ounce of the dried leaves to a pint of water, of which a large wine-glassful may be taken every two or three hours. In a case of chronic inflammation of the pelvic viscera, accompanied with suppuration and severe pain of the bladder and urethra, Dr. E. Ives, of New Haven, derived signal advantage from the free use of this medicine after other kindred remedies had failed to afford relief. Dr. Knight, of the same city, has also em- ployed it with marked benefit in a similar instance. The patient had deep-seated inflammation of the perinseum, tending to suppura- tion, and requiring the use of the catheter; it extended to the CATARRH OF THE BLADDER. 173 kidneys, bladder, urethra, and prostate gland, and was attended with morbid secretions, and a highly albuminous state of the urine. A decoction of the epigsea, of the strength of two drachms to half a pint of water, was given every two hours, in doses of a wine-glassful. In twenty-four hours the urine was free from albumen. The medi- cine was now omitted, and in twenty-four hours the albumen reap- peared. The epigsea was again administered, and continued without any return of this substance. " It is proper to state," observes Dr. Ives,1 the reporter of the case, " that the inflammation had been subdued by appropriate treatment before the employment of the epigsea, and that the albuminuria appeared as a sequel to the dis- ease." A combination of some of the articles above mentioned may often be advantageously employed. Indeed, the effect is usually much more conspicuous, when they are given in this manner, than when they are used separately. I have long been in the habit of admi- nistering, with the happiest effect, a combination of buchu, uva ursi, and cubebs, sometimes in the form of an infusion, but more generally in that of a tincture, given several times a day in conjunction with a small quantity of bicarbonate of soda. Occasionally a few drops of the balsam of copaiba, the muriated tincture of iron, or dilute nitric acid, may be advantageously added to each dose of these medicines. When thus combined, it is of course impossible to deter- mine what merit is due to §ach respective article. The muriated tincture of iron, given by itself, sometimes answers an excellent purpose. It is a valuable tonic, and evidently exerts a direct influence upon the urinary organs. The use of it is particu- larly indicated in cases attended with a want of appetite, loss of strength, and great pallor of the countenance. The ordinary dose is from ten to fifteen drops three times a day. Cubebs are also sometimes used; and Mr. Brodie speaks favourably of Chian tur- pentine, given in doses of from one to two grains twice daily. When the disease is associated with a gouty or rheumatic state of the system, colchicum should be employed, and the best form of ex- hibiting it is in combination with an anodyne. My usual practice is to give one drachm or one drachm and a half of the vinous tincture with fifty drops of laudanum, or half a grain of morphia, every night at bedtime, followed every other morning by a small quantity 1 Transactions of the Amer. Med. Assoc, vol. iii. p. 314. 174 DISEASES AND INJURIES OF THE BLADDER. of Epsom salts and calcined magnesia, to clear out the bowels gently. In some instances the acetic extract, in the dose of two grains, forms a valuable substitute. The benzoic acid is sometimes used in this disease, and answers when everything else has failed. I have repeatedly employed it with excellent effects, and can speak positively as to its value in the treatment of cystorrhoea. It may be given by itself; or, what I prefer, in union with the balsam of copaiba. It occasionally acts like a charm. The dose is from five to fifteen grains three or four times a day, suspended in mucilage of gum arabic. It may some- times be beneficially combined with a few drops of Harlem oil. In all cases of vesical catarrh, the urine should be subjected to the usual tests. If it be found to be acid, the carbonated alkalies should be exhibited, of which the best is soda, given three or four times a day, either alone or in union with some of the articles above mentioned, in doses of from eight to twelve grains. Weak ley is sometimes serviceable. I have found it of advantage when the usual alkaline remedies have failed. It is prepared by pouring half a gallon of boiling water upon a pint of hickory ashes, and frequently shaking the ingredients. At the end of twenty-four hours the liquor is decanted. The dose is a wine-glassful several times a day. If, on the other hand, the urine is alkaline, the employment of the nitric, muriatic, or sulphuric acid is indicated. The use of these different agents is beneficial in neutralizing the irritating proper- ties of the urine, and rendering the bladder more tolerant of its presence. To allay pain and induce sleep, anodynes are indispensable in almost every stage of this disease. They may be given either by the mouth, or by the rectum in the form of enemata or supposito- ries. Whenever a necessity for the remedy exists, it should be ad- ministered in full doses, repeated at remote intervals. Two grains of opium, half a grain of morphia, or fifty drops of laudanum, are an average quantity in such cases; but sometimes double and triple this quantity is required before the object is attained. An injection, composed of from one to two drachms of tincture of opium and two ounces of starch water, often powerfully contributes to allay the pain and spasm of the bladder. An anodyne suppository not unfre- quently answers the purpose much better than an enema. It exerts the same calming influence, and possesses the additional advantage that it does not stimulate the rectum to throw off its contents. An CATARRH OF THE BLADDER. 175 excellent suppository consists of two grains of opium, five grains of camphor, two of extract of belladonna, and five of soap, carefully mixed together, and introduced into the rectum upon the end of the forefinger, or, what is better, a suppository syringe, well oiled for the purpose; the remedy should be repeated two or three times a day; and, in violent cases, much oftener. The addition of the belladonna is particularly valuable in allaying the morbid sensibility of the bladder and rectum, which is sometimes excessive. When a diapho- retic effect is desired along with the anodyne, the most efficient remedies that can be employed are Dover's powder, opium and ipe- cacuanha, or opium and antimony. Counter-irritation, in the form of a seton, an issue, or tartar- emetic pustulation, is often highly beneficial in this disease, and should never be neglected in obstinate cases. The best situations for applying it are the perinseum and the supra-pubic region. When there is much pain in the back, or when there is reason to suspect the existence of renal disease, the counter-irritation may be established upon the sacrum, or in the loins. The best form is the seton: the issue is inconvenient; and tartar-emetic pustulation is not only painful, but it occasionally induces all the bad effects that result from an overdose of the medicine when taken by the mouth. However produced, it is very important that the discharge should be free, and maintained persistently for a long time. Some of the continental surgeons of Europe are partial, in the more rebellious forms of this affection, to the counter-irritation arising from the application of the moxa or hot iron; but I am not aware that it possesses any superiority over the ordinary issue or seton. Mercu- rial frictions, and stimulating embrocations, as the volatile liniment, spirits of camphor, and Granville's lotion, have also been recom- mended ; but are seldom productive of much benefit. Blisters, except at the commencement of the disease, or when there is a sudden aggravation of the discharge, seldom afford much relief. In truth, it is doubtful whether their beneficial effects are not fully counterbalanced by the injurious impression which they sometimes make upon the neck of the bladder, leading to an increase of the local suffering. The parts usually selected for their appli- cation are the hypogastrium and the sacrum. Chopart, Dessault and others, prefer the inside of the thigh, especially when the attack is dependent upon an arthritic state of the system. In employing these agents, care should be taken to avoid strangury, by sprinkling 176 DISEASES AND INJURIES OF THE BLADDER. the surface of the blister with morphia and powdered camphor. Their application should always be succeeded by a large emollient poultice. The remedies addressed directly to the suffering organ itself, are irrigations, astringent and other injections, and cauterization. Irrigation of the bladder has been much employed of late in the treatment of this affection, and there can be no doubt that it is, in many cases, a valuable auxiliary to the other means already pointed out. The practice originated, I believe, with Mr. Foot, of London, and is highly recommended by Cloquet. It is particularly valuable when there is an abundant discharge of thick, tenacious mucus, attended with atony of the muscular fibres of the bladder, and a consequent difficulty of micturition. In these cases more or less urine is permanently retained in the bladder, and thus becomes a source of mischief. The operation is performed with tepid water, injected with a pint syringe through a double catheter, so that the fluid, mixed with the mucous and other matters, may pass off by one tube as fast as it enters by the other. The instrument should be fur- nished with spacious eyelets, to prevent obstruction, and should be as large as is consistent with its easy introduction. The operation, which may be repeated once or twice a day, is inadmissible when the urine is bloody, or when there are symptoms of cystitis. Fluids of various kinds, astringent, anodyne, and alterant, are sometimes introduced into the bladder, for the purpose of making a direct impression upon the inflamed surface. The articles most commonly resorted to are alum, zinc, lead, copper, iodine, nitrate of silver, creasote, opium, morphia, laudanum, cicuta, bichloride of mercury, and nitric acid. In using any of these preparations the rule is to begin with a very weak solution, and to introduce only an ounce or two at a time. The fluid is thrown in through a common catheter, and is retained from one to five or even ten minutes, according to the tolerance of the suffering organ. The injection is repeated not oftener than once a day, and in some cases only every third or fourth day. Cauterization with the solid nitrate of silver has been lately re- commended by Civiale and other writers. I have made trial of the remedy in a few instances ; but do not think it made any decided impression upon the disease. It is chiefly applicable to those cases in which the catarrh is dependent upon inflammation of the neck of the bladder, accompanied with an unusual degree of morbid CATARRH OF THE BLADDER. 177 sensibility. The operation is best performed with a common porte- caustique, the cup of which is rapidly passed over the affected sur- face, and then withdrawn. The bladder is previously emptied, other- wise the salt will be neutralized by the urine. The cauterization is repeated once every fifth or sixth day. Oftener than this would prove injurious. In obstinate and intractable cases of cystorrhoea, where all other remedies have failed to afford relief, it has been proposed to pene- trate the neck of the bladder by means of an incision, similar to that made in the lateral operation of lithotomy. The object is to afford a free outlet to the mucous secretion as fast as it takes place, and to put the organ thereby into a state of comparative repose. In a word, the principle is the same as in the operation for anal fissure and fistule. The wound is not permitted to close too soon, and yet care is taken lest it become fistulous. The operation here mentioned was originally suggested, I believe, by Mr. Guthrie, of London, in his work on the Urinary Organs; but I am not aware that he ever exe- cuted it. The credit of doing this belongs, there is reason to believe, to my friend, Dr. Parker, the distinguished professor of surgery in the College of Physicians and Surgeons of New York. His patient, whom I had an opportunity of seeing several times after the opera- tion, was John Peiffer, a married man, aged fifty, a native of Ger- many, and a cutler by occupation, who was admitted into the Bel- levue Hospital, April 10th, 1850. Five years ago he contracted gonorrhoea, which lasted five weeks, and was attended with swelling of the testicles. Chronic enlargement of the right deferent duct followed ; and about two years ago he began to suffer from pain along the urethra, which soon became constant and severe. While in bed he can retain his water half an hour; but when walking about he has a desire to pass it every five minutes. A large sound was readily introduced without pain, and without detecting any calculus. He voids in the twenty-four hours about thirty-two ounces of urine, con- taining some mucus and phosphate of lime, but no pus or albumen. The prostate gland seems to be slightly enlarged, but there is no evidence of disease of the kidneys. The bowels are in a soluble con- dition. The patient was ordered, soon after his admission, suppositories of opium twice in the twenty-four hours, with an injection into the bladder of Magendie's solution of morphia. The suppositories were continued for four weeks, with but temporary relief. A seton was 12 178 DISEASES AND INJURIES OF THE BLADDER. subsequently introduced into the perinseum, and the morphia injection was replaced by a solution of nitrate of silver, in the proportion of ten grains to the ounce of water. No material benefit accrued; on the contrary, the general health continued to decline; he had fre- quent attacks of vomiting, the pain in the urethra was very severe, and he had a constant desire to pass his water, which always depo- sited a large quantity of mucus. Under these circumstances, Dr. Parker was induced to perform the lateral operation, on the 23d of November. The incision was quite free, and was followed by the loss of about sixteen ounces of blood. For the first twelve hours the patient experienced severe pain in the bladder, urethra, and left thigh, but this gradually yielded to the liberal use of anodynes. A very decided improvement of the former symptoms soon became apparent; the pulse diminished in frequency; the urine passed off freely by the wound; the patient slept better; and for a time he seemed to be in a fair way of re- covery. About the end of the third week, however, he became worse; his strength now rapidly declined; the vesical distress increased; and he began to exhibit all the evidences of a poisoned state of the system from the retention or absorption of urea. He continued in this manner until the 24th of December, when he expired, death having been preceded by delirium and coma. On dissection, the bladder was found to be greatly contracted; the muscular coat was considerably hypertrophied; and the mucous surface was studded with numerous miliary tubercles. The wound was much reduced in size, and incrusted with earthy matter. The left kidney was slightly enlarged and congested, but otherwise healthy. The right kidney was under the natural size, and was filled with softened tubercular matter. The stomach, heart, and liver were healthy. Both lungs contained tubercles at their sum- mits, and in the left there was a small cavity. Although this case terminated fatally, yet from the relief expe- rienced by the patient, it holds out sufficient encouragement to us to repeat the operation in similar instances. From the amount of disease in the kidney, the case was evidently a bad one for the knife. Had the man laboured under stone, and been cut for it, he must necessarily have perished at no distant day, probably sooner than he did. Without, therefore, laying down the case of Dr. Parker as the basis of a rule of practice in this distressing and frequently un- manageable affection, I think the treatment adopted by him is CATARRH OF THE BLADDER. 179 worthy of imitation. I shall certainly not hesitate to resort to it the first favourable opportunity that may present itself to my notice. The operation, it seems to me, is particularly applicable to that form of cystorrhoea in which there is marked hypertrophy of the prostate gland and the muscular coat of the bladder. Finally, in the management of this affection the utmost attention must be paid to the diet, which should be of a farinaceous character, perfectly simple and unirritant. During the existence of a paroxysm of the disease, nothing but arrow-root, tapioca, sago, rice, or gruel, should be allowed, and that only in small quantity. As the symp- toms disappear, or when convalescence is fairly established, animal broths and a little of the lighter kinds of meat may be used. But neither at this nor at any previous period are condiments, as mustard and pepper, admissible. Even salt should be employed most sparingly. The slightest indiscretion in eating will be almost certain to be fol- lowed by an aggravation of the complaint, or a return of all the former symptoms. Vegetable acids, subacid fruits, wine, spirits, and fermented liquors are prejudicial, and must be abstained from. The best drink is cold water, either simple or rendered mucilaginous with gum Arabic, slippery-elm, or flaxseed. When there is decided de- bility, the mineral acids, quinine, iron, and the bitter infusions are indicated. Exposure to cold must be carefully guarded against. Flannel must be worn next the skin, both summer and winter; riding on horseback is to be interdicted; sexual intercourse is to be abstained from; and the bladder must be daily emptied for a long time at stated intervals. A residence in a warm climate sometimes exerts a happy influence. Several of my patients have derived signal benefit from spending their winters in New Orleans, Cuba, and Texas. When the kidneys, ureters, or prostate gland are seriously affected, no remedy, external or internal, local or constitutional, seems to have the power of checking this distressing malady. Life gradually ebbs away, and the patient dies completely exhausted. All we can advise under such circumstances, is perfect tranquillity, a light but generous diet, anodynes by the mouth and the rectum, the warm bath, and attention to the bowels. Occasionally an accidental hemorrhage occurs, and procures a temporary suspension of the suffering. 180 DISEASES AND INJURIES OF THE BLADDER. SECTION II. BAR-LIKE RIDGE OF THE NECK OF THE BLADDER. A peculiar form of hypertrophy, chiefly affecting the neck of the bladder, is sometimes met with, particularly in old subjects. The disease is probably not infrequent in its occurrence, but from the fact that it has hitherto been generally confounded with chronic enlarge- ment of the middle lobe of the prostate gland, it is only recently that it has begun to excite professional attention. Although incidentally noticed by others, the first clear and accurate account of the lesion was presented by Mr. Guthrie, of London, in his excellent work on the " Anatomy and Diseases of the Bladder and the Urethra," pub- lished in 1834. He has applied to it the appropriate and expressive name of the bar of the neck of the bladder. The affection, of which the annexed wood-cut, Fig. 24, from a Fig. 24. Bar-like ridge at the neck of the bladder, a. Transverse bar. b, b. Orifices of the ureters. The bladder was hypertrophied, and the prostate was enormously increased in volume. The third lobe formed a rounded, prominent mass which projected into the interior of the bladder, and overhung the bar. specimen in Dr. Sabine's cabinet, affords a beautiful illustration, essen- tially consists in an hypertrophied condition of the cellulo-fibrous la- mella at the lower part of the neck of the bladder, which is elevated in the form of a ridge, of variable shape and size. In the preparation from which the marginal drawing was taken, the ridge is fully two inches in length by four lines in height; it lies immediately behind the third lobe of the prostate, which is itself singularly enlarged and disfigured, and is considerably larger on the right side than on the left, where BAR-LIKE RIDGE OF THE NECK OF THE BLADDER. 181 it is comparatively sharp and thin. Its extremities are free; it is directed obliquely backwards, and it is attached by a tolerably thick base to the lower wall of the bladder, of which, in fact, it is a part. Immediately posterior to this ridge is another but smaller one, of the same shape. Beyond this, the surface of the bladder exhibits a remarkably reticulated appearance from the hypertrophied condition of its muscular tunic, the fibres of which are immensely enlarged, and arranged in bundles similar to the fleshy columns of the heart. The parietes of the organ are upwards of half an inch in thickness, and the prostate gland is more than thrice the natural volume. The middle lobe of this organ is greatly hypertrophied, and consists, of three distinct masses, separated by deep grooves; they are rounded off behind, where they are in contact with the main ridge of the bladder already described, and they are quite slender and narrow in front. The patient from whom the preparation was obtained was nearly seventy years of age, and had laboured for many years under cystorrhoea, accompanied with excessive suffering and frequent mic- turition. The direction of this bar or ridge is horizontal, with now and then a slight degree of obliquity. Its ordinary length is from an inch and a quarter to two inches; in height it is from three to five or six lines, and in thickness from two to four. Its free edge is generally blunt and rounded off; but occasionally it is quite thin and sharp. Its extremities are sometimes free, sometimes adherent, or insensibly continuous with the wall of the bladder ; or one is free, and the other attached. The base of the bar is usually rather broad, and is firmly attached to the inferior surface of the organ; or, more properly speaking, it is a prolongation of this surface. In some instances it is double, foliated, or bifurcated. It is of a firm, tough consistence, feeling very much like the uterine tissue, which, after maceration, and immersion in alcohol, it also resembles a good deal in its colour. Its complexion, in the recent state, varies according to circumstances, from the slightest change of the natural hue to the deepest purple. The abnormal ridge is usually very simple in its structure. If a careful dissection be made, it will be found, in most cases, to consist merely of a prolongation of the submucous cellular tissue, enclosed by the lining membrane. Occasionally, however, it also contains a few muscular fibres, in a state of thickening and induration. When com- posed of cellular tissue alone, it is of a pale, grayish, or whitish aspect internally, and so tough and firm in its consistence as almost to 182 DISEASES AND INJURIES OF THE BLADDER. grate under the knife that is used for dividing it. When the bar consists partly of cellular tissue, and partly of muscular fibres, a section of it usually displays a striated, reddish appearance. Viewed, then, in reference to its structure, the abnormal ridge is in reality nothing more than an unusual degree of hypertrophy of the sub- mucous cellular tissue, or of this substance and the muscular tunic, local and circumscribed in its character. The enveloping mucous membrane is generally more or less thickened, studded with villosities, and pervaded by enlarged capillary vessels. This variety of hypertrophy is occasionally observed in compara- tively early life; but in the great majority of instances it occurs in old men who have laboured for a long time under vesical irritation. The causes under the influence of which it is developed are such as lead to obstruction to the evacuation of the urine, and the habitual retention of this fluid in the bladder. Hence, the most common exciting circumstances are strictures of the urethra, hypertrophy of the prostate gland, vesical calculi, and the existence of fungous, fibrous, and other growths, either in the bladder, or in its excretory canal. When any cause of this description is permitted to continue in operation for several years, hypertrophy of the tunics of the bladder, either general or partial, is an inevitable result, in confor- mity with a law of the economy that muscular fibres and other tissues increase in size in proportion to the manner in which they are exer- cised and irritated. In partial hypertrophy, seated principally in the submucous cellular substance, there is doubtless not merely an increase from a deposit of nutritive matter, but also, and, perhaps chiefly, from inflammatory plasma. From the nature of its exciting causes, it might be inferred, a priori, that this affection is generally, if not always, co-existent with hypertrophy of the prostate gland, or of the bladder, or, in fact, of both these organs simultaneously. What a process of reasoning, founded upon our knowledge of what occurs under similar circum- stances in other parts of the body, might thus assume as a legitimate conclusion, dissection has amply verified. In all the specimens which I have seen of this affection, the coincidence in question was so strik- ing as to leave no doubt upon the subject. The disease, like chronic disorder of the bladder and prostate gland generally, is exceedingly insidious in its character, and hence a considerable period commonly elapses before the patient and prac- titioner are made aware of what is going on. The symptoms deno- BAR-LIKE RIDGE OF THE NECK OF THE BLADDER. 183 tive of its presence are, in all respects, similar to those which indicate the existence of hypertrophy of the adjoining structures, with mechanical obstruction to the flow of urine. "This disease," observes Mr. Guthrie,1 " may commence at an early period of life, and can then be kept at bay by the periodical introduction of the catheter, but as long as this source of disease remains, the patient is never safe. It slumbers on like a smothered fire, ready at some future time, when the patient is more advanced in life, or on the application of an additional exciting cause, to burst forth with renewed vigour, and to lead to his destruction by the production of disease in the neighbouring parts. Fortunately it is, like the chronic enlargement of the prostate, more commonly the disease of an ad- vanced period of life, and is usually as insidious in its commence- ment and progress. The patient is aware of there being something the matter with him, but he knows not what; he finds he has a more frequent desire to make water than formerly, particularly at night; that it does not flow so readily nor so freely as it had usually done; and that he is more free from irritation whilst his mind is particu- larly occupied, and especially after dinner, when he can often refrain from attempting to make water for four or five hours. On this account the complaint is frequently attributed to nervousness, or to derangement of the stomach, giving rise to vitiated or faulty secre- tion of urine." The malady, thus begun, gradually but steadily proceeds from bad to worse. The obstruction to micturition increases; the incli- nation to make water recurs from fifteen to thirty times in the twenty-four hours ; an unusually long time is occupied in passing it; and, with all the efforts the poor patient can command, he is never able to empty his bladder completely. In consequence of this de- fect, more or less of the fluid remains constantly in the most depen- dent portion of the organ, where it soon spoils, and thus becomes a source of additional irritation. At this stage of the affection, the patient is harassed with pain in the bladder, particularly severe at the neck of the viscus, and excessive straining and tenesmus, accom- panied by scalding or burning of the urethra, at every attempt at micturition. The urine is loaded with a large quantity .of thick, ropy mucus, and emits a foetid ammoniacal odour, which is greatly increased after the fluid has stood a few hours in the chamber. The water is generally acid, but sometimes it is alkaline, and at other 1 Op. cit., page 255. 184 DISEASES AND INJURIES OF THE BLADDER. times it is alternately acid and alkaline in pretty rapid succession. Occasionally, again, the supernatant fluid is acid, while the thick, viscid mucus beneath is alkaline. The quantity voided in the twenty-four hours is nearly the same as in the natural state,— though, in this respect, much diversity occurs in different cases and stages of the complaint. The fluid is commonly surcharged with the earthy salts, has a dirty, turbid, high-coloured appearance. Albumen and pus are also frequent ingredients, especially when there is serious involvement of the kidneys, or disorganization of the mucous coat of the bladder. The health, in due time, begins to suffer. The system becomes feverish and irritable, the countenance has a wan, sallow appearance, the expression is anxious and fretful, the appetite and sleep are im- paired, the stomach is weak, acid, and flatulent, the bowels are irre- gular, the general secretions are disordered, the muscles waste, and the body, once plump and full, is gradually reduced to a skeleton. Thus life slowly ebbs away, the patient literally dying by inches, unless he should be so fortunate as to be seized with acute cystitis, which, under these circumstances, sometimes terminates his suffering in a few days. There are, unfortunately, no diagnostic symptoms of this lesion. The signs are rather of a negative than a positive character. The prominent phenomena are those of cystorrhoea, which always exist in chronic enlargement of the prostate gland, general hypertrophy of the bladder, stricture of the urethra, and urinary calculi. The embarrassment is not a little increased by the fact that the disease generally, if not invariably, co-exists with these affections, either as cause or effect. In all cases a careful exploration with the finger and catheter should be instituted as most likely to clear up the diffi- culty environing the diagnosis. If there be stricture, especially of long standing, the probability is, that the symptoms are dependent upon it, and that they will gradually disappear after its removal. Stone in the bladder is, in general, easily detected by the sound; en- largement of the prostate, by the catheter in the urethra and the finger in the rectum. A similar mode of exploration must be adopted when the cystorrhoea, or vesical affection, does not depend upon any of the preceding lesions. The instrument, in this case, will readily pass as low down as the orifice of the bladder, where, meeting the bar, ridge, or artificial dam, it will be either completely arrested, or advance with difficulty. If the finger be now introduced into the rectum, and carried up as high as possible, the point may, if the prostate is nearly BAR-LIKE RIDGE OF THE NECK OF THE BLADDER. 185 of the natural bulk, be hooked round its posterior extremity, and be thus brought directly opposite the bar, and consequently between it and the beak of the instrument. By careful manipulation, we may in this manner not only obtain a knowledge of the existence of the ridge, but also a tolerably correct idea of its form and dimensions. There is no likelihood of such a body being confounded with an en- cephaloid tumour, inasmuch as the latter is generally very rapid in its growth, soon acquires a large bulk, and is almost always attended with a discharge of blood, which is never witnessed in the bar-like ridge. In encephaloid, moreover, the tumour is commonly situated farther back, and does not, consequently, offer so much impediment to the passage of the urine. The treatment of an affection of which the diagnosis is so obscure and difficult of determination, must necessarily be uncertain, if not wholly empirical. The symptoms, in fact, must be prescribed for rather than the lesion which gives rise to them. It is unnecessary here to repeat what has been said, in a previous chapter, upon the treatment of cystorrhoea, which forms so striking and prominent a feature of the complaint we are now considering. It will be sufficient to state in general terms, that the remedies which are applicable to that affection are also applicable to this, with the addition of several others presently to be mentioned. Uva ursi, buchu, balsam of copaiba, Chian turpentine, bicarbonate of soda and potass, nitric acid, muriated tincture of iron, benzoic acid, and hyoscyamus, are all brought in play, either singly or variously combined, and aided by gentle purgatives, with an occasional dose of calomel, a farinaceous diet, rest of the genital organs, and avoidance of all excitement, both bodily and mental. If much local distress exists, leeches to the perinseum and the inside of the thighs, the hot bath, and anodyne enemata must be prescribed. If there is much debility, a little meat may be allowed, with a glass of porter or ale. In general, however, fermented liquors, wine and spirits, are inadmissible. Gin, from its specific tendency to the urinary apparatus, appears occasionally to exert a beneficial effect, and may be used in moderate quantities, in union with gum arabic water, especially if the patient is of intempe- rate habits. The bladder must be relieved with the catheter, used at regular intervals, not too remote nor yet too short, or it must be retained in the organ permanently, being removed occasionally for the purpose of cleanliness. The instrument by its pressure exerts a sorbefacient effect upon the bar-like ridge, and thus aids in reducing its volume, 186 DISEASES AND INJURIES OF THE BLADDER. at the same time that it prevents undue accumulation, and the evil con- sequences resulting from the constant presence of vitiated and offen- sive urine, mucus, and earthy salts. But the pressure must be gentle and not too persistent, otherwise harm will result instead of benefit. Washing out the bladder with tepid water, slightly impregnated with opium and astringent medicines, is likely to prove useful, and is, therefore, worthy of trial. Cauterization of the part with Lalle- mand's porte-caustique will generally allay the heat and burning pain, and exert a direct and controlling influence over the concomi- tant morbid action of the mucous membrane in the immediate vicinity of the bar. The operation is performed with great gentleness, yet efficiently, and in such a manner as to bring the nitrate of silver in con- tact with a surface at least from one to two inches in diameter. The local irritation and distress are temporarily increased, but they subside in a few hours, and never fail to be followed by marked relief, though frequently, not until the patient has taken a full anodyne. The cauterization is repeated every sixth or eighth day, and in the interval the patient is subjected to the treatment already indicated. Scarification of the bar has been proposed as a remedy in this complaint by Mr. Guthrie, and he speaks of an instrument which he has invented for the purpose. An ordinary Stafford's tube, with a moderate curve, however, will enable any one, skilled in the use of the catheter, to perform the operation with facility. The remedy affords relief by disgorgement of the capillary vessels, and stimu- lation of the absorbents. A repetition of it is called for every fourth or fifth day. Such are the means at our command in the milder and more com- mon forms of this disorder; it cannot be disguised that they are rather palliative than curative. When they fail, and there is no other prospect of relief, Mr. Guthrie thinks we should afford the patient the benefit of an operation, similar to that which is practised for the removal of the stone. To such a procedure I can see no pos- sible objection; the parts must be relieved, or death will be inevi- table. The operation itself does not involve any special danger, the bleeding which attends it will remove vascular engorgement, and the muscular fibres of the bladder will be placed in a quiescent condition, highly favourable to the subsidence of chronic irritation. The urine and mucus will flow off involuntarily, and unless the wound be permitted to heal too soon, a new and more healthy action will be almost sure to follow. SACCULATION OF THE BLADDER. 187 SECTION III. SACCULATION OF THE BLADDER. This is a very singular affection, which is usually described under the name of hernia of the mucous membrane of the bladder. Cho- part has proposed to call it internal cystocele, in contra-distinction to external cystocele, that form of the affection in which the organ issues from the pelvic cavity, either alone, or in union with a portion of the bowel. It has also been denominated the sacculated, the encysted, the herniary, and the diverticulated bladder. Broke has described the pouches, of which the disease essentially consists, under the name of vesical appendages. Sacculation of the bladder is a protrusion of the mucous mem- brane through an abnormal opening in the muscular tunic, and the Section of the bladder and prostate, a. Mucous surface of the bladder, b, b. Lateral lobes of the prostate, c. Middle lobe. d. Large cyst or pouch, partially laid open, and communicating with the bladder by a small orifice. consequent development of a pouch, bag, or sac. An adventitious cavity is thus formed which communicates with the interior of the 188 DISEASES AND INJURIES OF THE BLADDER. bladder, and which is very different from the serous cysts which are found in rare instances in the coats of this reservoir. The affection is much more frequent than is generally supposed. I have repeated- ly met with it in my own dissections, and there is hardly a practi- tioner of much experience who does not occasionally see a case of it. These pouches vary very much both in number, size, and form, as well as in their structure, and the character of their contents. Some- times there is only one; and, should this be of large size, it may give the organ the appearance of being double. The greatest num- ber I have seen was six. Generally there are not more than two, three, or four. In a case described by Houstel in the " Mdmoires de 1'Academic de Chirurgie,"1 there were not less than thirty-eight, all of them very small, and situated chiefly at the lower and back part of the bladder. In their volume they range between a pea and an ordi- nary fist. Usually, however, they do not exceed that of a pigeon's egg, or a small marble. In their shape they are globular, ovoidal, pyriform, or conical. At an early period they generally have thin, transparent walls, formed exclusively by the mucous and peritoneal tunics; but as they increase in age, they are liable to become thick- ened, dense, and opaque, from interstitial or adventitious deposits. It is seldom that any muscular fibres enter info their structure. Their internal surface is commonly smooth and polished; but in some in- stances it is rough, spongy, or studded with excrescences. They are covered by the peritoneal coat of the bladder, and not unfrequently adherent to the neighbouring parts, in consequence of effusions of lymph. Sometimes, though rarely, they are double, or divided into several compartments by imperfect septa. When the pouches are distended with air, they give the bladder, especially when numerous, a singularly hilly, knobby, or bossalated appearance, at the same time that it sets them off in bold relief. The opening of communication between the cyst and the bladder is usually round, smooth, polished, and not larger than a goose-quill. Occasionally, however, it is extremely irregular, and so capacious as to admit a finger, or a pullet's egg. These cysts are usually occupied by urine, which, from its pro- tracted sojourn in them, is liable to become decomposed, and to give rise to inflammation, followed by deposits of mucus, and even puru- lent matter. When they are very large, it is rarely that they are 1 T. 1, p. 195. Paris, 1819. SACCULATION OF THE BLADDER. 189 completely emptied at any one time, and hence the same evil conse- quences that result from partial retention of urine from paralysis of the bladder or obstruction of the urethra. It is well known that calcu- lous concretions not unfrequently find their way into these abnormal pouches; and in some instances it is not improbable that they are developed in them. Much diversity obtains in these cases in regard to the number, size, and disposition of the foreign bodies. Thus, they may be solitary or multiple, small or large, loose or adherent, smooth or rough; just precisely as in the bladder itself. There is no part of the bladder that is entirely exempt from this morbid change. Most frequently, however, it is observed at its sides and summit; for the reason apparently that there is less pres- sure here than in front and behind, and consequently more room for the protrusion of the lining membrane. When the cysts are nume- rous, they occupy different portions of the organ, though sometimes they are limited to a particular situation. Sacculation of the bladder is always associated with, and, in fact, directly dependent upon, some mechanical obstruction to the ready egress of the urine. The most common causes are stricture of the urethra, enlargement of the prostate gland, and calculous concre- tions. Hence the affection is much more frequent in men than in women, in whom there is rarely much permanent impediment of any kind to the emission of the urine. Old age is the period of life most prone to it. I have never seen an instance of it in a young subject, though it may doubtless occur at an early period, espe- cially when it is produced by the presence of a calculous concretion. ' The mode of origin of these cysts is sufficiently well understood. The first step in their formation is the existence of a mechanical ob- struction at the neck of the bladder, or in the urethra, attended with more or less difficulty in voiding the urine. As the obstacle ad- vances, the desire to make water becomes more frequent, and the exertion required to empty the bladder also increases. To surmount the impediment, the muscular coat of the organ is obliged, every few hours, to use the most powerful contraction, in consequence of which its fibres, naturally more closely grouped together at some points than at others, gradually separate from each other, forming a sort of network, the meshes of which vary, in the first instance, from the size of a millet-seed to that of a pea. The resistance of the muscular tunic being thus removed in certain situations, the mucous membrane, pressed upon on every side by the distended bladder, readily 190 DISEASES AND INJURIES OF THE BLADDER. enters the crevices just alluded to, and, by a continuance of the exciting cause, gradually bulges out beyond the level of the peritoneal sur- face. The process by which these changes are accomplished is slow, and the probability is that many years elapse before the resulting pouches acquire their ultimate limits. Once formed, their ten- dency is to augment with every increase of the local obstacle upon the presence of which their development depends. The symptoms of this affection are, in general, exceedingly ob- scure, and it often happens that we are not apprised of its existence until we come to inspect the parts after death. When the abnor- mal pouch is unusually large and occupies the summit or anterior surface of the bladder, it may sometimes be felt above the pubes, or between this part and the umbilicus, like a distinct, circumscribed tumour, more or less movable, soft, elastic, fluctuating, and tender on pressure. The instances, however, in which this can be done are rare. No satisfactory idea of the nature of the affection can be derived from an examination with the finger in the rectum. The patient has frequent desire to urinate, and can pass only a small quantity of water at a time; every effort of the kind being attended with severe straining and tenesmus, during which the body is bent forward, and the hypogastric region is compressed with the hands, to promote the evacuation of the bladder and its appendages. The urine is scanty, surcharged with thick, ropy mucus, and readily de- composed ; exhaling, after it has stood a short time, an ammoniacal odour. In the mean time, the general health declines ; the patient becomes feverish, the appetite fails, the body is gradually emaciated, and the sleep is much disturbed by the frequent calls to micturition. In a word, all the symptoms, both local and general, of hypertrophy of the bladder are present. It is obvious that the symptoms here enumerated cannot be re- garded as diagnostic of encysted bladder. The only one upon which the slightest reliance can be placed in this respect, is the existence of a tumour in the hypogastric region. When this is circumscribed, movable, elastic, and fluctuating, and especially when it is only par- tially emptied at each effort at micturition, and again acquires its former volume as the urine accumulates in the bladder, the presump- tion is strong that there is a sacculated condition of the mucous membrane. The suspicion is increased, if not converted into cer- tainty, when the swelling disappears under the use of the catheter, which may sometimes, by a happy hit, be passed into the abnormal SACCULATION OF THE BLADDER. 191 pouch, and when the patient is labouring under some or all of the rational symptoms above specified. Additional evidence will be afforded if the sac contains a calculus, which never varies its position, but is always perceived at the same point. Sacculation of the bladder is always connected with hypertrophy of the muscular tunic, the fibres of which, as already stated, exhibit a plexiform arrangement, and are often three or four times the natural thickness. The mucous membrane and submucous cellular tissue are also more or less altered, the former being frequently thrown into large folds, especially in the bas-fond of the organ, and the latter converted into a tough, grayish substance, very different from the healthy texture. The peritoneal covering is generally sound. More or less disease commonly exists in the ureters and kidneys, similar to what occurs in hypertrophy of the bladder apart from any protrusion of the lining membrane. The prognosis of this disease is eminently unfavourable, not so much on its own account as on that]of the morbid changes with which it is generally associated, and which are commonly of an incurable nature. Owing to the peculiar arrangement of the cysts, and the absence in them of muscular fibres, their contents are rarely, if ever, entirely expelled; the consequence is that they soon become a source of irritation to their lining membrane, followed often by inflamma- tion and its different products, particularly an inordinate secretion of mucus, or of mucus and of pus. Sometimes they become the seat of a large abscess. Gangrene occasionally seizes upon them, and in a few rare instances they have given way at one or more points, followed by an escape of their contents into the pelvic cavity, where they have speedily induced fatal peritonitis. No kind of treatment, either local or general, is of any avail in this affection, the morbid changes of which are entirely beyond the influence of remedies. The only method that can be adopted is to remove the exciting cause, and thus prevent any further increase of the difficulty. Any impediment, therefore, to the flow of urine should be sought for, and promptly attended to. The water should be passed at regular intervals, or drawn off with the catheter, to protect the bladder from over-distension and undue exertion. Any inflam- matory complications that may manifest themselves must be met by the lancet, antimonials, the warm bath, leeches, fomentations, and anodynes. CHAPTER V. NERVOUS AFFECTIONS OF THE BLADDER. SECTION I. IRRITABILITY OF THE BLADDER. The characteristic symptom of this disease is frequent micturition. In the natural state, the urine is excreted from four to six times in the twenty-four hours; the quantity varying from thirty to forty-five ounces, according to the season of the year, the state of the weather, and the habits of the individual. The act is generally more fre- quently performed by the male than the female, owing to various circumstances, but chiefly to the smaller size of his bladder, and the fact that he consumes a larger amount of stimulating food and drink. In irritability of the bladder, the urine is voided every hour or two, perhaps, indeed, every few minutes, and the process is commonly attended with more or less pain, spasm, and burning at the neck of the bladder and along the urethra. The fluid may be perfectly natural, both in its physical and chemical properties; or it may be increased or diminished in quantity, and variously altered in quality. Age and Temperament.—The disease is not peculiar to either sex, to any period of life, or to any particular temperament, habit, or occupation. I have, however, most frequently met with it in chil- dren and in persons about the age of puberty, and in individuals who are naturally of a nervous, irritable disposition, or prone to attacks of gout and rheumatism. A very unpleasant and intractable form of vesical irritation occasionally occurs in weakly and scrofulous subjects. There is a variety of this affection peculiar to young boys and girls, in which the intolerance of the bladder occurs chiefly at night, during sleep. Particular mention will be made of it when I come to speak of incontinence of urine. The malady may affect the whole bladder, IRRITABILITY OF THE BLADDER. 193 or only a part of it; in most cases it is limited to the neck of the organ, and to the prostatic portion of the urethra; regions remark- able for their sensibility both in health and in disease. Symptoms.—When the disease is fully established, the patient is obliged to urinate every few minutes, and is hardly ever entirely free from suffering. The process, which is generally more frequent in the day than at night, and in the erect than in the recumbent pos- ture, is accompanied with tenesmus, more or less straining, pain at the neck of the bladder, and a sense of scalding in the urethra. The stream of water may be natural, or variously altered in its form and force. Thus, it may be forked, twisted, or spiral, strong and full, small and feeble. In many cases it is ejected in jets, or voided in drops. The fluid again may be normal as to its quantity and quality, or it may deviate more or less from the healthy standard. In ge- neral, it is acid, high-coloured, and surcharged with mucus of a whitish or grayish complexion, which gradually subsides to the bottom of the vessel during the process of cooling. In consequence of the straining, the patient often suffers from irritation of the rectum, hemorrhoids, partial prolapsus of the mucous membrane, and pru- ritus of the anus, or the parts around. The urethra and the prostate gland are generally unnaturally sensitive to the touch, and hence much difficulty is frequently experienced in attempting to introduce a catheter or bougie, which, from the spasm which it excites, is some- times grasped with extraordinary firmness. A very common accom- paniment of this affection, especially in young men, is a tendency to erections and seminal emissions. Indeed, there are few cases be- tween the ages of twenty and thirty, in which this symptom is entirely absent. Neuralgic pains of the bladder, the penis, testicles, and spermatic cord, are also frequently present, and greatly aggra- vate the local distress. As the disease wears on, the general health, perhaps originally good, gradually suffers. The digestive organs lose their tone; the appetite is impaired; the bowels are constipated; and the patient is harassed with flatulence, colicky pains, and acid eructations. The extremities are cold, the sleep is disturbed, the flesh wastes, and the mind is gloomy and despondent. Such is a faint picture of the miserable condition which attends irritability of the bladder in its confirmed stages, and in its more aggravated forms. Diagnosis.—This disease is sometimes mistaken for stone. In the chapter on urinary calculi several instances are mentioned in 13 194 DISEASES AND INJURIES OF THE BLADDER. which this error was committed, and where the patients, in conse- quence, came very near being subjected to the operation of litho- tomy. In the autumn of 1847, a boy four years of age, with a pale, sickly look, was brought to me from the state of Indiana, with what was supposed to be stone in the bladder. He had an almost inces- sant desire to micturate, complained of severe pain in the urethra and neck of the bladder, pulled constantly at the prepuce, and strained violently whenever he voided his urine, which was occa- sionally tinged with blood. Suspecting he had stone, I sounded him repeatedly, but found nothing in the bladder. Upon inquiry, I ascer- tained that he had had several attacks of intermittent fever during the last eighteen months, and that he had been frequently affected with diarrhoea, alternating with constipation. His urine was acid and rather high-coloured. I requested his father to give him, every other night, a dose of calomel and rhubarb, with bicarbonate of soda, and in the interval quinine and Fowler's solution; and under this treatment he rapidly recovered. Whenever doubt exists in regard to the diagnosis of the complaint, recourse should be had to the sound. Irritability of the bladder may be arranged under different heads, according to the causes by which it is induced, or the circumstances under which it is developed. 1. Disease of the urinary apparatus. 2. Altered state of the urine. 3. Diuretic medicines. 4. Disorder of the genital organs. 5. Disease of the alimentary canal. 6. Lesion of the brain and spinal cord. 7. General debility. 8. Ex- posure to cold and heat. 9. Disease of the pelvic viscera. 1. Disease of the urinary apparatus, no matter what may be its character or situation, is a frequent cause of vesical irritability. As a familiar instance, we may mention stricture of the urethra. In the confirmed stage of this affection, one of the most constant symptoms is a frequent desire to void the urine ; and in the female the presence of warty excrescences, at the orifice of this canal, generally pro- duces similar effects. Persons affected with stone, vesical catarrh, hypertrophy of the muscular coat of the bladder, ulceration of the mucous membrane of this organ, enlargement of the prostate gland, and disease of the ureters or kidneys, are seldom free for any length of time from this kind of irritability, which, in some of the maladies here mentioned, is often a source of the most frightful suffering. The presence of a fungous tumour, a clot of blood, inspissated mucus, coagulating lymph, or purulent matter; in short, of any foreign or adventitious substance, invariably leads to the same result. How- IRRITABILITY OF THE BLADDER. 195 ship1 refers to a case in which the disease was caused by a growth of hair within the bladder. A considerable degree of irritability of this organ sometimes succeeds to the operation of lithotomy, external injury of the bladder, and perinseal fistule. (gonorrhoea is a fruitful source of vesical irritability. The inflam- mation which characterizes this disease is often suddenly transferred from the urethra to the neck of the bladder, giving rise to frequent micturition, tenesmus, and severe pain in passing the last drops of urine, which are occasionally mixed with blood or pus. Irritability occasionally results from congestion of the neck of the bladder, the prostate gland, and the seminal vesicles. These organs, like other parts of the body, are liable to impeded circulation, or stagnation of blood, causing simply turgescence of the vessels, and morbid sensibility of the mucous membrane. The condition is similar to that of the retina in certain forms of amaurosis, and most commonly occurs in robust, plethoric subjects, between twenty and forty years of age. It is characterized by a feeling of fulness in the perinseum, almost uninterrupted micturition, and smarting of the neck of the bladder, with a scalding sensation of the urethra. Some- times the patient is conscious of a strong throbbing in the parts. These symptoms, which are always aggravated by exercise, and even by the erect posture, are liable to be renewed by the slightest expo- sure to cold, by a full meal and a few glasses of wine, by drastic purgatives, and by venereal excesses. 2. Irritability of the bladder is frequently induced by an altered state of the urine, which produces nearly the same effect upon the bladder as a foreign body. The fluid is generally more or less acid, dark-coloured, and strongly disposed to become ammoniacal. It often deposits a copious sediment of mucus, is unusually scanty, and is speedily decomposed after being voided. This form of irritability is most common in elderly subjects, particularly such as are predis- posed to gout, rheumatism, and gravel. Males are more liable to it than females. The disease is usually associated with disorder of the general health, which is, doubtless, the immediate cause of the altered state of the urine upon which it depends. The most promi- nent symptoms are dyspepsia, constipation, capricious appetite, sour eructations, coldness of the extremities, dryness of the skin, soreness in the lumbar region, neuralgic pains in various parts of the body, 1 A Practical Treatise on Urinary Diseases, p. 166. London, 1823. 196 DISEASES AND INJURIES OF THE BLADDER. and a sense of burning in the urethra. In protracted cases, the altered secretion is sometimes directly dependent upon a morbid condition of the kidney. 3. An irritable state of the bladder sometimes results from the use of diuretics. The article most liable to produce this effect is cantharides. When taken internally, in an excessive dose, it acts promptly upon the urinary organs, causing great distress at the neck of the bladder, with burning of the urethra, and the most urgent desire to void the urine, which comes off drop by drop, usually tinged with blood, and accompanied by severe spasm and straining. These symptoms are generally attended by the most violent erections. Ex- hibited in smaller quantities, the effects are more mild, but hardly less persistent, and, in the aggregate, less distressing. Nitrate of potash sometimes acts with extraordinary power upon the urinary apparatus. I have known an over-dose produce effects upon the bladder very similar to those of cantharides, and scarcely less severe. When administered for a long time as a diuretic, it seldom fails to irritate the neck of the bladder, and occasion fre- quent micturition. Vesical irritability is often induced by the use of stimulating drinks, fruits, and vegetables, causing an excess of acid in the urine, with a morbid sensibility of the mucous mem- brane. 4. Venereal excesses, whether in the form of frequent coition, masturbation, or involuntary losses, are exciting causes of this affec- tion. There is not a practitioner of any experience who has not met with cases of this kind. I have myself witnessed many. In the following case, which I give on account of the well-marked character of the symptoms, the disease was the result of onanism. It occurred in my private practice, in a youth of seventeen years of age, from Monroe County, in the state of Indiana. In the autumn of 1847, he was seized with irritability of the bladder, attended with frequent inclination to pass water, soreness of the urethra, and itch- ing of the prepuce. The affection gradually increased, and when he visited me in October, 1849, he was obliged to urinate from ten to twenty times daily, while at night, after going to bed, he was perfectly free from suffering. He had, on an average, a seminal emission every forty-eight hours, which he often excited by arti- ficial means. Suspecting he might be labouring under stone, I sounded him twice, but was unable to detect any foreign body. The instrument, as it passed along the urethra and the neck of the IRRITABILITY OF THE BLADDER. 197 bladder, caused exquisite pain, and a violent erection of the penis. His general health was much impaired; he was very thin; the pulse was languid; the extremities were cold; the tongue was heavily furred; the appetite was bad; and the bowels were habitually constipated. In short, he had the aspect of an onanist, and all the symptoms of a dyspeptic. A few brisk cathartics, two cauteriza- tions, and the use of sulphate of quinine and iron, soon relieved this poor fellow both of his vesical and seminal troubles. In boys a degree of irritation about the bladder is sometimes pro- duced by an extremely long and narrow prepuce. The existence of this malformation usually prevents the ready escape of the urine, in consequence of which the edges of the foreskin become inflamed and sore, causing frequent desire to pass water, accompanied with severe pain and even spasm. 5. Disorder of the digestive apparatus is capable of producing this disease. The sympathy which exists between the stomach and urinary bladder is familiar to every physiologist and pathologist. There are few confirmed dyspeptics who are entirely free from this disease. The digestive powers of such persons are habitually en- feebled ; the stomach is sour and flatulent; the bowels are costive ; and the urine is scanty, high-coloured, and surcharged with lithic acid, or lithate of ammonia. We have already alluded, under an- other head, to the changes which this fluid undergoes in consequence of the use of stimulating drinks, high-seasoned food, fruits, and vegetables, and it is, therefore, unnecessary to discuss the subject on the present occasion. An irritable state of this organ is sometimes produced by the pre- sence of ascarides, hemorrhoidal tumours, carcinomatous disease, ulce- ration of the mucous membrane of the rectum, organic stricture, anal fistule, and prolapsion of the bowel. Pruritus of the anus, nates, and perinseum, may also give rise to it. The irritation in these cases is often excessive, and closely resembles that produced by stone in the bladder. A very interesting and instructive case, in which the irritability of the bladder was occasioned by the presence of a tape-worm, has been recently related by Mr. Tuffnel, in the Dublin Medical Press for February, 1848. * The patient, a man of temperate habits, had en- joyed good health until three months ago, when he began to suffer 1 Ranking's Half-Yearly Abstract, January to June, 1848, p. 77. 198 DISEASES AND INJURIES OF THE BLADDER. from dyspepsia with hemorrhoids and uneasiness in the rectum. The symptoms gradually increased, and were followed by tenesmus and frequent calls to make water, which was voided in a twisted jet, and accompanied by severe straining, but no pain. Opiates afforded temporary relief, but he became emaciated, and his health suffered severely. A tight stricture, probably the result of a previous gonor- rhoea, occupied the membranous portion of the urethra, and the urine was highly acid, and loaded with lithate of ammonia. The prostate was of the natural size, but very sensitive to the touch. Mr. Tuffnell prescribed rest in the recumbent position, purgation with castor oil, warm water enemata night and morning, and the internal use of infu- sion of calumba with tincture of hyoscyamus. Under this treatment the improvement was so rapid that the man resumed his usual habits at the end of a week. His symptoms, however, immediately recurred, and were as immediately relieved by the former treatment. A second speedy recovery was effected, but he returned in a few days, suffering as severely as ever. The irritation about the anus had now greatly increased, and he was observed at the same time frequently rubbing his nose, which suggested the idea of the possible presence of worms in the intestines. A purgative of turpentine and castor oil was accordingly administered, and the following morning a tape-worm, measuring thirty feet, was evacuated. All the former symptoms immediately subsided, the urine became clear and natural, and the general health was soon permanently restored. 6. An irritable state of the bladder is occasionally dependent upon lesion of the nervous system. Many years ago I attended the late Mr. Wright Smith, of Cincinnati, on account of concussion of the spinal cord, produced by a fall upon his lumbar region from a wine cask. The most prominent symptoms during the first three days, were disorder of the intellectual faculties, and an almost inces- sant inclination to void the urine, which was remarkably copious and limpid. As the concussion subsided, the desire became less frequent, and the fluid gradually assumed its normal characters. Similar effects are often noticed in injuries of the vertebral column and organic dis- ease of the spinal cord, attended with partial paralysis of the bladder. The urine, in such cases, is always exceedingly acrid, high-coloured, offensive, surcharged with glairy mucus and gritty matter, and passed with preternatural frequency. A considerable degree of morbid sensibility of the bladder is some- times produced by congestion of the brain, or nervous exhaustion, IRRITABILITY OF THE BLADDER. 199 brought on by mental fatigue, or inordinate excitement. Cases of this description, which are not by any means infrequent, are most common in elderly men, of sedentary habits, and of a nervous, exci- table temperament. Mere mental emotion will occasionally induce the affection, as a violent paroxysm of fear, grief, or anger. Again, an irritation seated in a remote part of the body, has been known to give rise to it. Pinel saw an instance of it, caused by disease of the thyroid gland. Irritability of the bladder has sometimes been caused by the habit of too frequent micturition. The urine is the natural stimulus of the organ, and if this is too often withdrawn a certain degree of intole- rance is apt to be engendered. The organ, under the influence of this habit, gradually diminishes in size, the muscular fibres are thickened, and the mucous membrane becomes so sensitive as to be unable to bear the slightest distension. Literary men often suffer in this way, especially if they are dyspeptic, or predisposed to gout and rheumatism. There is a form of vesical irritability, very common in young girls, soon after the age of puberty, which may be appropriately included under the present head, though it is probably of a mixed character, as it respects its origin. The affection is generally associated with spinal irritation, and dysmenorrhoea, or imperfect menstruation. The extremities are cold, the bowels constipated, the tongue coated, the appetite impaired, and the digestion languid and difficult. The patient, moreover, is flatulent, nervous, and troubled with palpitation of the heart, the action of which is hurried by the slightest agitation and exertion. The disease frequently lasts for years, and sometimes during the greater part of life. 7. Among the causes of this disease, may be mentioned any con- siderable and long-continued debility, such as occurs from immoderate venery, spermatorrhoea, onanism, hemorrhage, and Chronic diarrhoea. It is occasionally a sequela of typhus, typhoid, and other fevers, espe- cially when the disease has been very protracted, or treated too energetically. Grief, anxiety, and other depressing passions, termi- nating in derangement of the secretions and loss of tone of the sto- mach, not unfrequently, as was before remarked, produce irritability of the bladder. 8. Exposure to cold, or sudden suppression of the cutaneous perspiration, is sometimes followed by this affection. This is occa- sionally noticed in persons who, after having been immersed for 200 DISEASES AND INJURIES OF THE BLADDER. a long time in a hot atmosphere, suddenly go out in the open air in a cold winter day. The first effect of such a transition is a chilly state of the surface, and an arrest of the perspiration, which are often succeeded in a few moments by a desire to void the urine, so urgent as to admit of hardly any delay. Exposure to the rays of the hot sun is capable of rendering the bladder temporarily irritable. I have seen several instances in which the disease appeared to have been thus induced. The patients were all field labourers, and had been engaged at hard work in intensely hot weather; the affection was characterized by an incessant inclination to micturate, and by excessive scalding at the neck of the bladder, with a sense of general prostration, lasting for several hours before it could be relieved. 9. Finally, an enlarged ovary, a displaced, gravid, or diseased uterus, or a morbid growth of the pelvis, may occasion symptoms of vesical irritability. The effect may be purely sympathetic, or it may be caused by pressure on the bladder. Accoucheurs are well aware of this occurrence, of which I have seen several well-marked exam- ples. The affection is most common in old and middle-aged females, though it may take place at any period of life. It is singular that the local suffering is, in many cases, confined wholly to the blad- der, while the organ originally and mainly affected is free from irritation. The disease, in this respect, strongly resembles coxalgia, in which most of the pain is felt in the knee, and not in the hip, the seat of the morbid action ; and it clearly points out the importance of carefully ascertaining, in all obscure cases, the condition of the pel- vic viscera, particularly of the uterus. Pathology.—From what has been said respecting the causes of this affection, it is not surprising that so little should be known about its pathology. As the disease, in its idiopathic form, never of itself proves fatal, opportunities of ascertaining, by dissection, the exact condition of the parts, are exceedingly infrequent; and in the few cases in which they have been afforded, no satisfactory results have been observed. The most plausible conclusion, perhaps, in the absence of positive facts, is that the complaint consists in an exaltation of the nervous sensibility of the mucous membrane, similar to what is occasionally witnessed in the retina, the fauces, urethra, and other mucous canals. What strengthens this opinion is the fact that it is frequently connected with a weak, scrofulous state of the constitution; and that, when this is the case, it generally resists every mode of treatment that has yet been devised for its IRRITABILITY OF THE BLADDER. 201 relief; affording thus an analogy, and that a very striking one, to cer- tain forms of strumous ophthalmia, alike distressing to the patient, and troublesome to the surgeon. The bladder, in the more confirmed stages of the affection, is much contracted, but its coats, instead of being thickened, are generally preternaturally thin, and remarka- ble for their pallor. When the complaint depends upon local causes, as stone in the bladder, stricture of the urethra, or enlargement of the prostate gland, the anatomical changes are more distinct, and afford a more satisfactory solution of the real nature of the case. Under such circumstances, there are always, or nearly always, evidences of in- flammation or congestion of the lining membrane and hypertrophy of the muscular fibres, with alteration of the secretions, and, in some instances, slight deposits of lymph. Very frequently, as was previously remarked, the irritability is purely sympathetic, depending upon lesion of some neighbouring organ, as the kidney, seminal vesicle, anus, uterus, stomach, or bowel. I have already alluded to an instance in which it seemed to have been produced by a diseased condition of the thyroid gland; and the fact that it is occasionally excited by congestion or organic lesion of the brain, independently of any appreciable structural change of the bladder, is familiar to every pathologist. Prognosis.—The prognosis of this affection is influenced by so many contingent and concomitant circumstances that any remarks that may be made respecting it must of necessity be vague and in- definite. This will not appear strange when we take into considera- tion the great number and variety of causes by which it is induced and maintained. The idiopathic form of the complaint, although frequently very obstinate, generally, after a time, yields to a well- directed course of treatment. When the disease occurs in weak, scrofulous subjects, it is always remarkably intractable, frequently lasting for years, or ending, perhaps, only with life. The irritation of the bladder of young children, attended with nocturnal incontinence of urine, sometimes disappears spontaneously towards the approach of puberty, while at other times it is exceedingly rebellious, and suc- cessfully resists the most judiciously devised means of the physician to overcome it. Hysterical irritability seldom continues long, though it is not always readily amenable to treatment. When dependent upon local causes, of a curable nature, prompt relief may generally be obtained. All, in fact, that is necessary, in 202 DISEASES AND INJURIES OF THE BLADDER. sueh cases, is to remove the source of the irritation, and the disease will subside of its own accord. Under opposite circumstances, how- ever, the complaint is commonly irremediable, however judicious and well-directed our efforts to combat it. Thus, nothing can be done, with any reasonable hope of success, for a case of irritability of the bladder, caused by carcinoma of the rectum, an enlarged ovary, or a tubercular kidney, and so of many other forms of the disorder. Treatment.—In entering upon the treatment of this complaint, so protean in its character, a strict inquiry should, in every instance, be instituted into its origin, which, as has been already seen, may be either sympathetic, nervous, congestive, or inflammatory; and the practice regulated accordingly; otherwise the physician will only be likely to harass his patient, and employ means which can lead to no beneficial result. Indeed, it may be confidently affirmed that there is no class of diseases which demand a more thorough investigation to enable him to form a correct judgment upon the parts primarily affected than this. The truth of this remark is fully borne out by the long catalogue of causes under the influence of which this dis- order is developed, and which no one can read without being im- pressed with the importance of a most profound knowledge of the physiology and pathology of the urinary apparatus. The exciting cause of the complaint having been ascertained, the first thing to be attempted is, if possible, to remove it. Strictures must be relieved by the bougie or knife, calculi extracted from the bladder, hypertrophy of the prostate reduced, and all sources of local irritation dried up. When the irritability depends upon congestion or inflammation, the application of leeches to the perinaeum, the hip- bath, and, in plethoric subjects, venesection, are indicated. Purga- tives, rest in the recumbent posture, low diet, the internal use of balsam of copaiba, anodyne injections, and demulcent drinks, should not be neglected. In that form of the complaint which arises from organic disease of the kidney, ureter, or bladder, no mode of treat- ment yet devised does much good. The affection here is strictly symptomatic, and usually lasts, in spite of all that can be done for its relief, until the malady upon which it depends is cured, or the patient dies. If the disorder depend upon an altered state of the urine, the practice must be regulated accordingly. In all cases of an obscure nature, or where there is reason to believe that this fluid exerts such an agency, a careful inquiry must be made into its character, by IRRITABILITY OF THE BLADDER. 203 the employment of the usual tests. If it be found to be red, scanty, and acid, alkalies will be indicated, and the one which I usually prefer is the bicarbonate of soda, either alone, or in union with the bicarbonate of potassa. From fifteen to thirty grains, dissolved in two ounces of plain water, and taken an hour after meals, is a pro- per average dose for an adult. Occasionally the alkali is advan- tageously combined with a strong infusion of uva ursi and hops. Hickory ley, calcined magnesia, and oxide of bismuth, are sometimes useful, though rarely to be depended on. If, on the contrary, the urine manifests an alkaline reaction, acids will be required, such as the nitric, muriatic, and sulphuric, of which the first deserves the pre- ference. I have seen the disease sometimes promptly disappear under the use of the muriated tincture of iron. I have found the article most useful in irritability of the bladder, attended with a weak and languid state of the digestive organs, coldness of the ex- tremities, and great pallor of the countenance. If the patient be of a rheumatic or gouty habit, colchicum will be useful, and may be exhibited alone, or in combination with morphia and nitric ether. The best form of exhibition is the acetous extract, of which two grains may be given every twelve hours. The urine in these cases is generally red, and charged with lithic acid, on which account it is often necessary to interpose alkaline remedies. Active cathartics, a restricted diet, the warm bath, and topical bleeding will also be proper in persons of this description. In ob- stinate cases, the exhibition of mercury, carried to slight ptyalism, will be advantageous, and promptly arrest the irritability of the bladder. When the disease has been induced by the improper employment of diuretics, a discontinuance of the remedy, demulcent drinks, the hip-bath, hot fomentations, and a full anodyne by the mouth or rectum, will, in general, put a speedy stop to it. All venereal excesses must be abandoned, and means taken to improve the disastrous effects produced by them. Of these, the most important are quinine and the chalybeate tonics, blue mass and rhubarb, as a purgative, a light but nutritious diet, cold ablu- tions, the cold shower-bath, and exercise in the open air. If sperma- torrhoea be present, nothing short of cauterization will be likely to answer, and should be practised with the least possible delay. By the use of this remedy we cure both the seminal discharges and the irritability of the bladder. 204 DISEASES AND INJURIES OF THE BLADDER. When the irritation has arisen from disorder of the digestive organs, particular attention should be given to the correction of the secretions: the diet should be carefully regulated, and the bowels should from time to time be duly evacuated. If dyspeptic symp- toms, with acid eructations, are present, tonics, such as quinine and the milder preparations of iron, alkalies, change of air, and sea- bathing, are indicated. Attention to the diet is of paramount im- portance in all cases of this kind, and is sometimes of itself almost sufficient to effect a cure. Subacid fruits, the coarser varieties of vegetables, coffee, strong tea, pastry, fresh bread and biscuit should be studiously avoided, on account of their tendency to produce in- digestion, flatulence, and pain in the bowels, with alteration of the urinary secretion. For the same reason, porter, ale, cider, sherry, and Madeira, are usually hurtful. Sometimes an almost purely milk diet does better than any other; and occasionally I have known a patient to be much benefited by the use of a little good French brandy or Holland gin two or three times a day. If symptoms of worms be present, anthelmintics are indicated, of which calomel, spirits of turpentine, and chenopodium are the most valuable. In those forms of the complaint which are dependent upon the presence of piles, ulcers, fistule, or other organic changes of the rectum, anus, or circumjacent parts, there can, of course, be no hope of relief without striking at the root of the evil. Tumours must be removed, ulcers cauterized or incised, and sinuses laid open, and then the vesical irritation will usually be short-lived. Lesion of the brain and spinal cord, leading to irritability of the bladder, must be treated upon general principles. The great indi- cation here, as in other forms of the disorder, is to ascertain the nature of the exciting cause, and then to regulate our practice accordingly. It is impossible, where the causes of a disease are so numerous, to speak, under separate heads, of the treatment adapted to its different forms. In that variety of vesical irritability which is so common in young girls at or soon after the age of puberty, and which, as was before stated, is probably of a mixed character, depending, perhaps, partly upon spinal irritation, and partly upon disorder of the uterine functions, much benefit will be derived from a proper regulation of the bowels, chalybeate tonics, particularly Griffith's compound iron mixture, Plummer's pill, the shower-bath, and daily exercise in the open air. In protracted and obstinate cases, the uterus must be IRRITABILITY OF THE BLADDER. 205 explored with the speculum, and any disease that may be found must be treated according to the principles laid down by writers on female complaints. The slightest congestion, the most trifling dis- placement, or the smallest possible ulcer of this organ, has been known to maintain the bladder in an irritable condition for months and even years, the general health being in the mean time perfectly wretched, and life hardly worth possessing. When the disease depends upon general debility, the patient must be put upon an invigorating diet, nutritious drinks, tonics, and other appropriate means for improving and confirming the general health. The principles of treatment, under such circumstances, are self-evi- dent, and need not be enlarged upon in this place. In weak, scrofu- lous subjects, trial should be made of iodine and its different prepa- rations, especially iodide of iron and iodide of potassium ; the disease, however, is generally exceedingly obstinate, and all efforts to arrest it prove unavailing. If the disease has been induced by cold, and the patient is robust and plethoric, venesection, carried to syncope, will generally afford prompt relief, especially if it be aided by a brisk cathartic, anodyne injections, hot fomentations, and a diaphoretic draught, as, for ex- ample, a combination of antimony and morphia, or a full dose of Dover's powder. There are few cases of this kind of vesical irrita- tion which resist this treatment beyond a few hours. Irritability of the bladder, dependent upon an enlarged ovary, the existence of a pelvic tumour, or a gravid uterus, seldom, if ever, admits of relief. All that the practitioner can do in any case of this kind, is to palliate the suffering by the use of anodynes, by a proper regulation of the diet and bowels, and by strict attention to the general health. When the disease is symptomatic of malposition of the uterus, a radical cure may frequently be hoped for, even when the displacement is considerable and of long standing. There are certain remedies that have sometimes been advan- tageously used in the treatment of this affection, which, as they do not admit of special classification, may be briefly mentioned here. Among these is the extract of belladonna, administered internally, or applied in the form of a plaster, an ointment, or a solution. In my own practice I have found this substance most useful in that variety of the complaint which is attended with neuralgic symptoms, or sharp, darting or shooting pains in the region of the bladder and pelvis. It may be given in doses from the fourth to the sixth of a 206 DISEASES AND INJURIES OF THE BLADDER. grain three times a day, alone, or in union with other articles, its effects being carefully watched lest it prove injurious. A belladonna plaster is an excellent adjuvant in this class of cases; it should be made of the pure extract, spread upon soft leather, and applied moist. The most eligible regions are the sacrum and the hypogastrium. Sometimes I employ a strong ointment of belladonna, composed of two drachms of the extract to six drachms of lard, with the addition of fifteen grains of strychnine. This is rubbed thoroughly twice a day upon the perinseum, sacrum, and lower part of the abdomen. An opiate plaster often answers an excellent purpose. I have already incidentally spoken of the balsam of copaiba in the treatment of this affection. The remedy is particularly applicable to irritability dependent upon extension of gonorrhoeal inflammation, vesical catarrh, and organic disease of the kidney. It should be administered in small doses, three or four times daily, suspended in mucilage of gum Arabic. Tincture of cantharides has often been beneficially employed in this disorder. I have exhibited it with marked advantage in several cases during the last few years, and equally flattering results have been obtained from it by other practitioners. I have found it most reliable in the irritation of the bladder in young children and hyste- rical girls, when carried to the extent of slight strangury. As soon as this effect passes off, there is generally a very decided improve- ment, which, under the subsequent continuance of the remedy, in smaller doses, finally eventuates in a complete cure. Where a tonic is at the same time indicated, the cantharides maybe exhibited along with the muriated tincture of iron, or Griffith's compound iron mixture. Brodie, Coulson, and others, speak in very flattering terms of the buchu and pareira brava in the treatment of vesical irritability. Although I have frequently employed these articles, both alone and variously combined, either with each other or with other remedies, I cannot recall a solitary instance in which they seemed to afford any permanent benefit. Nor can I make any better report of cubebs. Haerlem oil has occasionally been employed with happy effects when everything else has failed. The dose is from ten to twenty drops two or three times a day, in mucilage of gum Arabic, or sugar and water. Dr. Physick was in the habit of prescribing, with decided success, in this affection, the saturated tincture of poke-berries— NEURALGIA OF THE BLADDER. 207 Phytolacca decandra. He gave it in two-drachm doses every seven or eight hours. Dr. Gibrin, a French physician, has detailed, in the " Bulletin de l'Academie," for March, 1837, several cases of irritable bladder, evidently dependent upon chronic inflammation, in which he suc- ceeded in effecting a cure with a decoction of soot. The symptoms were occasional retention of urine, pain in the hypogastrium, and a frequent desire to make water, which was turbid, foetid, and mixed with mucus, and sometimes even with blood. Having tried various modes of treatment without benefit, he had recourse to the above article, prepared with two ounces to the pound of water. It was filtered through paper, and injected into the bladder twice a day. Good effects almost immediately followed the administration of the remedy. The pain ceased, the patient's sleep returned, the urine gradually resumed its normal appearance, and the bladder regained its accustomed tolerance. Washing out the bladder with tepid water is an old remedy in this affection, which has occasionally, though rarely, afforded relief. The same may be said of anodyne and astringent injections. SECTION II. NEURALGIA OF THE BLADDER. One of the most singular maladies of the uriiftiry bladder is neu- ralgia, or, as it is usually denominated, tic douloureux. As the name imports, it is a nervous affection, characterized by severe suffering, which is generally referred to the neck of the organ, and is distinctly paroxysmal in its attacks, recurring daily, or every other day, about the same period. Formerly neuralgia was supposed to be peculiar to the branches of the fifth pair of nerves, or, in other words, to have a purely facial locality. More recent investigation has shown that it may exist in other parts of the body, and there are few prac- titioners, especially in the Western States, who have not witnessed examples of it in the principal viscera. I have noticed it in the eye, stomach, bowels, uterus, spinal cord, testicle, urethra, and urinary bladder. As occurring in the latter organ, a full digest of the exist- ing state of the science is still a desideratum. In the early stage of this disease the symptoms are frequently 208 DISEASES AND INJURIES OF THE BLADDER. vague and ill-defined. At first, there is merely a sense of uneasiness in the perinseal region, accompanied with a sharp, darting, or tin- gling pain, recurring only at long intervals. Sometimes, in addition to the shooting pain, there is an unpleasant aching, with a feeling of numbness. In this manner three or four days may elapse before the disease attracts any particular attention. By degrees the attacks become more frequent, as well as more severe, and assume a de- cidedly periodical character, returning about the same hour every day, generally early in the evening or towards morning. The paroxysms vary in their duration from two to six hours, and while they continue, the suffering is often of the most racking and agonizing nature. The pain, which is commonly of a sharp, stabbing, darting description, is distinctly referred to the neck or inferior part of the bladder, and bears a very exact resemblance to that produced by a fit of the stone. In most cases it extends to the neighbouring organs, as the rectum and anus, the urethra, and the inside of the thighs. In the female it is occasionally reflected upon the uterus, and in the male along the course of the spermatic cord. In both sexes it is generally very severe in the sacral and lumbar regions. Coincident with this is a sensation of heat and burning in the urethra, with a frequent desire to make water, which is always attended with diffi- culty. The burning or smarting is particularly distressing at the extremity of the penis, from which it frequently extends to other parts, as the pubes, groin, anus, or sacrum. The urine is thrown out in jets, or the stream is suddenly arrested, and the smaller the quantity in the bladder the greater is the suffering in voiding it. The paroxysm generally goes off gradually, leaving no other in- convenience than a sense of soreness or aching in the neck of the bladder, perinseum, and posterior part of the urethra. During the intermissions the urine is voided without difficulty, and the patient feels comparatively comfortable, almost as well, indeed, as if he had not suffered any pain. When the attacks assume the quotidian type, they usually occur, as was before intimated, in the evening, during the night, or early in the morning. Occasionally they make their appearance soon after eating, and in a few instances they have been known to recur twice in the twenty-four hours; thus leaving the poor sufferer scarcely a moment free from pain. Fever rarely accompanies this affection, however obstinate or pro- tracted. The appetite is variable and capricious, the stomach is teased with flatulence, digestion is bad, and the patient feels uncom- NEURALGIA OF THE BLADDER. 209 fortable after eating. The bowels are disposed to be torpid, and require to be regulated by medicine. The sleep is interrupted and unrefreshing; the pulse, which at first is not perceptibly altered, becomes quick and irritable ; the feet and hands are habitually cold; the general health gradually declines; and the countenance wears an anxious, haggard look. In obstinate cases, there is a discharge of a thin gleety matter from the bladder, with great soreness in the perinseum and hypogastric region. Another symptom which is occa- sionally present is a sense of coldness in these parts, which frequently extends to the groin and inner parts of the thighs, and is almost constantly accompanied with some degree of numbness. The urine is almost always natural, both in regard to quality and quantity, ex- cept in gouty and rheumatic subjects, in whom it is generally acid, scanty, and intermixed with red sand. The diagnostic signs of this disease are not always very distinct. We have already remarked that the attacks, especially when very severe, bear the closest resemblance to the paroxysms produced by calculous concretions, and it will be presently seen that they are fre- quently associated with, if not dependent upon, other affections. Hence it is not always easy by any means to form a correct opinion respecting the true nature of the case. In doubtful circumstances, sounding of the bladder is advisable, and should never be omitted; but even this does not always answer the purpose. In the case of a young female, mentioned by the late Dr. Parrish of Philadelphia,1 the symptoms of vesical calculus were so strongly marked that she was repeatedly sounded by the different surgeons of the Pennsylvania Hospital, and that excellent practitioner even proposed dilating the urethra with sponge-tents, in order to introduce the finger into the bladder the more satisfactorily to ascertain its real condition. Various expedients were resorted to without relief, and she finally sank under an attack of dysentery. On inspection, no trace of disease was anywhere discoverable, excepting in the bowels. The bladder contained no stone, and the whole urinary apparatus ex- hibited a perfectly normal appearance. Mr. Rowland observes, that the operation of lithotomy has sometimes been performed in neuralgic affections of the bladder, under an erroneous opinion as to the nature of the case.3 On the whole, the most important signs, perhaps, are the paroxysmal character of the disease, the sharp and darting pains, 1 Practical Observations on Strangulated Hernia, p. 312. Philadelphia, 1836. 2 Treatise on Neuralgia ; Dunglison's Medical Library, p. 265. 1839. 14 210 DISEASES AND INJURIES OF THE BLADDER. the uncomfortable itching and scalding in making water, the attempts at which are very frequent, urgent, and difficult, and the numbness of the perinseum, scrotum, groins, and thighs. Of the causes of vesical neuralgia very little is known. In general, indeed, they are wholly inappreciable. It is often, as was previously stated, associated with disease of the neighbouring organs, but how far it is influenced by, or dependent upon it, it is impossible, in the present state of our knowledge, to determine. In the case of Dr. Parrish just alluded to, it was complicated with obstinate amenor- rhoea and occasional vomiting of blood, but no cause could be assigned for the neuralgic affection of the bladder, which was excessively severe, and of several years' standing. In some instances it has been known to supervene upon parturition, to continue for several months, and then totally disappear. It is observed for the most part in persons of a nervous temperament, and in those who are subject to the same malady in other regions of the body. Venereal indulgences, mastur- bation, stricture of the urethra, stone in the bladder, organic disease of the uterus, and hemorrhoidal affections, are all capable of exciting it. Habitual constipation of the bowels, dyspepsia, mental emotions, and depraved condition of the urinary secretion, are also circumstances which favour its production. What influence miasm exerts upon its development is not ascertained. Judging from what we know of this malady as it occurs in other parts of the body, it is without doubt, often a very considerable, if not the only cause. An elderly gentle- man whom I attended several years ago, was subject to neuralgic attacks of the bladder and right knee, which generally lasted eight or ten days at a time, then disappeared and recurred about once every three months. In early life he had been severely affected with rheumatism, and a short time before the vesical neuralgia came on he had laboured under intermittent fever, which left him with an enlarged and indurated state of the spleen. Neuralgia of the bladder is not confined to any particular period of life, though the old and middle-aged are without doubt most sub- ject to it. Nor is it peculiar to the male sex. Women not unfre- quently suffer from it, but in what proportion is a point concerning which we are still ignorant. Nor are we any wiser in regard to the influence of occupation or mode of life. In respect to both these subjects our data are too imperfect to enable us to arrive at any satisfactory conclusions. What the nature of this malady is, is a point respecting which we NEURALGIA OF THE BLADDER. 211 are still entirely ignorant. As the name imports, it would appear to be a nervous disorder; but whether it is really seated in the nerves, in the mucous coat, or in the muscular fibres of the bladder, has not been determined. Dissection has thrown no light on this interesting and intricate subject, and the question as to its real seat must therefore, for the present, remain unsettled. Vesical neuralgia, although an exceedingly painful and distressing disease, seldom terminates fatally. In many cases, perhaps the majority of them, it is remarkably obstinate, and persists for weeks or even months, in spite of the best-directed treatment; on the other hand, instances occasionally occtrr which disappear almost as suddenly as they come on. This is especially the case when the disease has a miasmatic origin, or when it supervenes upon inter- mittent fever. Occasionally it continues with but little intermission for several years, undermining thus the general health, and laying the foundation of serious and irreparable mischief. It is obvious, from what has been already stated, that the treat- ment of this affection must be regulated by the causes by which it is induced. As these are generally obscure, or entirely inappreciable, the practitioner is frequently obliged to grope about in the dark, and employ various measures before he finally succeeds in hitting upon one that is attended with any benefit. When the disease is connected with an inflammatory state of the system, as it is occa- sionally found to be, prompt and efficient bloodletting is the remedy upon which, in the commencement, our hopes of success must be mainly placed. The first bleeding should be carried to the extent of producing a decisive impression on the system, and the operation should be repeated every day or two until the violence of the parox- ysm has abated. When the disease assumes a chronic character the abstraction of blood from the arm will not be required oftener than once a fortnight, or three weeks. In many cases nothing is found to answer so well as the plan we are now considering, both in neu- ralgia of the bladder and of other parts of the body. With regard to local bleeding by leeches, not much can be said in favour of its utility. Where there is tenderness in the perinseum, the course of the urethra, the sacrum or loins, it may do good by relieving vascular fulness, and sustaining the antiphlogistic impression made by the previous venesection, which in this, as in most other maladies, should be premised before the other is employed. The leeches should be applied directly to the seat of the pain, and the bleeding be after- 212 DISEASES AND INJURIES DF THE BLADDER. wards encouraged by cloths wrung out of hot water. The same remarks may be made in reference to cupping. Purgatives are decidedly useful in this affection, especially in that variety of it dependent upon a miasmatic origin, constipation of the bowels, or deranged menstrual action. They are particularly valuable in the early stage of the attack, and should be administered in doses adequate to procure free evacuations. The more drastic articles of this kind, however, should be avoided, as they generally produce serous stools, and frequently do mischief by exciting nausea, vomiting, and tormina. Mercurial purgatives are, on the whole, those from which most advantage ma/ be expected, whatever may be the cause of the disease. In no instance, however, should they be carried so far as to induce salivation, as this has a tendency usually to aggra- vate the disease, and render it more intractable, although it will occasionally shorten, or even perhaps entirely prevent the paroxysms for a few days. From ten to twenty grains of calomel, with one of opium and two of ipecacuanha, should be given at bedtime, followed in the morning with an ounce of castor oil, or a cupful of a strong infusion of senna. After the bowels have thus been thoroughly evacuated, they should be kept in a soluble condition by the milder kinds of laxatives, with an occasional dose of blue pill, say five or six grains every third or fourth night. From abundant experience in the treatment of neuralgic affections, as occurring in different parts of the body, I am convinced that a systematic course of purga- tion is not only unequivocally beneficial, but absolutely indispensable to a speedy and permanent cure. When the disease is complicated with amenorrhoea, the cathartic medicines should be combined with aloetic and emmenagogue preparations, with a view to their specific effects on the uterus. Much has been said, within the last fifteen or twenty years, of the beneficial effects of the carbonate of iron in the treatment of neu- ralgic maladies, and there can be no doubt that, under judicious management, it is among our most valuable curative means. Dr. Elliotson, of London, in an able paper on this article, in the thir- teenth volume of the Medico-Chirurgical Transactions, speaks of it in the highest terms of commendation. It should be given in doses of from one to four drachms every four hours, in twice its weight of molasses, strict attention being paid to keep the bowels open during its employment. It need scarcely be added, that iron is only ad- missible in those cases which are unaccompanied with inflammation NEURALGIA OF THE BLADDER. 213 or organic disease of the stomach or bowels. On the whole, I am disposed to believe that this medicine is far inferior in the treatment of this affection, whether seated in the urinary bladder or in other parts of the body, to quinine and arsenic. These articles, at all events, are much more frequently employed in this country than the iron, and are by many considered almost as specifics. When neu- ralgia arises from malaria, they are generally sufficient to break up the paroxysms in two or three days, or so to modify their character as to bring them more readily within our control. After adequate alvine evacuations have been produced by the method already ad- verted to, with or without general bleeding, the quinine should be administered in doses of about four grains every three hours, until fifteen or twenty grains have been taken. It should then be discon- tinued until the next day, when it should be resumed, and persevered in until the same quantity has been used. By this time the parox- ysms will usually have abated very much in violence, or perhaps altogether subsided. Some practitioners administer the article in larger but less frequently repeated doses, a method which, although sometimes highly beneficial, is frequently objectionable on account of the distress which the medicine is apt to produce in the head. When the disease has been thus moderated or subdued, the best medicines to eradicate it are arsenic, strychnine, and aconite, in union with opium. The formula which I have been in the habit of using for many years past, both in vesical and other forms of neural- gia, is the following: R. Acid, arseniosi gr. ij. Strychninse gr. j. Ext. aconite gr. viij. Pulv. opii gr. v.—M. These ingredients should be incorporated with each other with the greatest care, and be divided into sixteen pills of equal size, of which one is to be administered every six hours, or four in the twenty-four hours. In some instances, the opium may be advantageously increased, or, where it disagrees with the patient, it maybe replaced by lupuline or hyoscyamus. When nausea ensues, the pills are to be used less frequent- ly, or instead of giving one pill at a dose, only one-half or two-thirds of one should be employed at a time. Attention to this point is a matter of paramount importance, as it respects the benefit to be derived from this combination. Another rule is, not to continue the exhibition of the 214 DISEASES AND INJURIES OF THE BLADDER. pills longer than a week or ten days at a time, to allow the stomach a short recess, when they are to be resumed, and taken as before. When administered with these precautions, arsenic, strychnine, and aconite seldom fail to produce a most favourable impression, and are often, of themselves, sufficient to effect a cure. Where this is not the case, they should be employed along with other remedies, of which purgatives, and the warm bath are amongst the most efficacious. With Fowler's solution of arsenic, so much vaunted in the treatment of this affection, I have but little experience; but I have given it sufficiently often to satisfy me that it is far inferior, in every respect, to arsenic in substance. It is more liable to nauseate, and does not exert the same controlling influence in arresting the disease. To moderate the violence of the paroxysm, large doses of narco- tics are frequently indispensable. Of these the best are the salts of morphia, either alone or in combination with nauseants, according to the state of the vascular system. In some instances, where other means have failed to afford relief, I have derived the greatest benefit from the steady, persistent use of narcotics. I might, indeed, cite several cases in which the protracted exhibition of this class of reme- dies resulted in a radical cure. My rule is to give narcotics in full and sustained doses, taking care always previously to clear out the bowels, and restore the secretions. Where one article, or mode of exhibition, is found to disagree, another should be substituted. When the pain is very violent, or when narcotics cannot be taken by the mouth, opiate injections or suppositories should be used. An emetic of ipecacuanha or tartrate of antimony, at the approach of the paroxysm, will sometimes have the effect of cutting it short, or materially abridging it. The remedy is particularly indicated when the disease is associated, as it often is in malarious districts, with gastric and biliary disorder. Much benefit may also accrue, in many cases, from the warm bath, or the application of steam to the affected part. This can be readily effected by connecting one end of a gum-elastic tube with the spout of a tea kettle, filled with hot water, and placing the other under the bed-clothes. Fomentations with hops, opium, or laudanum will also be highly serviceable. In persons of a gouty, rheumatic habit, who are predisposed to cold, and in whom the urine is habitually loaded with uric acid, no remedy will be so likely to be successful as colchicum. The best form of exhibition is the vinous tincture, in the dose of one drachm NEURALGIA OF THE BLADDER. 215 at bedtime, in union with half a grain to a grain of morphia. Under the influence of this medicine, aided by an occasional purgative of calomel and rhubarb, the secretions are speedily restored, the urine changes its character, and the gastric functions are improved. When the stomach is oppressed with acidity and flatulence, alkaline diuretics should be tried, in the intervals of the colchicum; and a good form for their exhibition is a combination of bicarbonate of soda and potash. An occasional dose of calcined magnesia, to clear out the bowels, and neutralize the acid contents of the alimentary canal, will also, under these circumstances, prove highly beneficial. Mons. Civiale, in an able article on vesical neuralgia in the " Ga- zette Me'dicale" for July, 1836, states, that he has cured many cases of this disease by the repeated introduction of bougies into the bladder, on the well-known principle that the contact of a foreign body has a tendency to allay the disordered sensibility of the affected part. The instrument, which must be soft and of moderate size, should be retained for five or ten minutes, and then withdrawn, the operation being repeated daily until it passes without pain. A larger bougie should then be substituted, and in this manner the treatment is to be continued until the morbid sensibility of the mucous mem- brane of the urethra and the neck of the bladder is completely destroyed. In most cases, observes Civiale, the success of this me- thod is prompt and decisive, though occasionally it fails, or the good effects of it manifest themselves only after a long time. Under these circumstances, he seeks to make a stronger impression with a large-sized catheter, the friction of which will sometimes alone produce a cure. I must confess my distrust in the remedy of the distinguished French surgeon. In nearly all my trials, and they have been quite numerous, little benefit has resulted, no matter how the operation was performed, whether with a small or large instrument, whether at long or short intervals. Such, in truth, has been the want of my success with this mode of treatment, that I have for some years past entirely abandoned it. The operation, even when performed with the greatest possible gentleness, is sometimes productive of exquisite suffering, and is occasionally followed by an aggravation of all the symptoms. Injections of acetate of lead and opium, or of a watery solution of opium and hyoscyamus, are, I think, in every respect, to be preferred. They are much more soothing to the bladder and urethra, and their administration is almost exempt from pain and 216 DISEASES AND INJURIES OF THE BLADDER. inconvenience. They should be employed tepid, cool, or cold, as may be most agreeable to the part and system. In the more aggravated and intractable forms of the malady, re- course must be had to counter-irritation to the perinseum, the supra- pubic region, the sacrum, or upper and inner part of the thighs. The best forms are the moxa and the caustic-paste issue. Tartar emetic pustulation is exceedingly painful, and well calculated to aggravate the local mischief. On one occasion I made trial of the actual cautery, but without any apparent benefit. The case will be mentioned elsewhere. When the neuralgia depends upon stricture of the urethra, foreign bodies in the bladder, hemorrhoids or other disease of the anus, none but the most transient amelioration can be expected from any mode of treatment until these causes have been removed. The great object of inquiry, therefore, at the very commencement, should be to ascertain, if possible, the source of the irritation, by a careful examination of the whole genito-urinary apparatus, as well as the perinseum and inferior outlet of the alimentary canal. The strictest attention should be paid to diet. Fermented liquors, wine, spirits, fruits and vegetables should be avoided ; also strong coffee, fresh bread, everything, in short, calculated to disorder the digestive apparatus, and induce acidity and flatulence. Flannel should be worn next the skin, especially in the variable and uncer- tain climate of our western and southern regions, and exposure of all kinds should be sedulously guarded against. Throughout the whole course of the treatment, the frequent use of the warm bath will be found a most important auxiliary, not only in moderating the violence of the paroxysms, but in breaking up the disease. When indigestion prevails, the carbonate of potass or soda may be re- sorted to, either alone, or, what is better, combined with some of the simple tonics, such as columba, gentian, hop, or cascarilla, in infusion. CASES OF NEURALGIA. Case I.—One of the most interesting cases of neuralgia of the bladder of which I have any knowledge, occurred in my private practice in 1844. The patient was a coloured man about twenty- eight years of age, the property of Mr. McGruder, of the Pond NEURALGIA OF THE BLADDER. 217 Settlement, in the neighbourhood of Louisville. He had generally enjoyed good health until about two years prior to my visit to him. The prominent symptoms were, a frequent desire to pass his urine, and severe pain in the bladder, darting about in different directions, frequently paroxysmal in its character, and aggravated by exercise, the erect posture, and exposure to cold. His sufferings became at length so severe that he was obliged to abandon all out-of-door exer- cise, and confine himself strictly to the house. When I first saw him in the spring of 1844, he was compelled to void his urine every twenty or thirty minutes; the neuralgic pains were exceedingly violent, especially in the evening; his appetite was bad; the tongue was coated; the bowels were constipated; and his nights were usually spent without sleep. Although his sufferings were almost constant, he retained a good deal of flesh, and his countenance did not exhibit much trace of the local distress. The urine was generally somewhat acid, and of a light pale colour, with a slight increase of mucus. There was usually more or less scalding during micturition, and the discharge of the last drops of urine was always attended with spasm and tenesmus. The pains extended frequently along the spermatic cord, as far as the sacro-lumbar region, down the thighs, the perinseum, and even the testes, which were usually retracted, and exquisitely tender on pressure. The patient had never had gonorrhoea, syphilis, gout, or rheumatism ; and his habits had always been regular. He had been brought up in a malarious district, but had never suffered much from intermittent fever, nor has he ever had neuralgia in any other part of the body. Supposing the patient might have stone, I deemed it my duty, before putting him upon the use of anti-neuralgic remedies, to sound him ; but, after the most careful search, found nothing. The opera- tion was subsequently repeated several times with the same result. Giving him a dose of calomel, rhubarb, and jalap, to open his bowels freely, I enjoined a light diet, and ordered him to use, three times daily, a pill composed of the eighth of a grain of arsenious acid, one half that quantity of strychnine, and half a grain of extract of aconite, with three grains of quinine. The prescription was con- tinued for a week, when it was temporarily omitted, on account of the disordered condition of the stomach. Meanwhile little impres- sion was made upon the disease. As soon as the nausea had sub- sided, the use of the medicine was resumed, but in smaller quantity. In this way another week elapsed, and still the disease went on. 218 DISEASES AND INJURIES OF THE BLADDER. Colchicum and morphia were now substituted, and under this combi- nation, aided by the daily use of the hot bath and bicarbonate of soda and hop tea, the symptoms improved, the patient began to have some appetite and sleep, and the micturition diminished con- siderably in frequency. The amelioration, however, was of short dura- tion. In eight or ten days the symptoms were as violent as ever. The copaiba mixture was now directed with the addition to each dose of three to five grains of benzoic acid. Under this prescrip- tion, which was continued for several weeks, no amendment was produced. Morphia, in large doses, both by the mouth and the rectum, was next tried, but with no other than transient relief. The original prescription was now resumed, and again used for several weeks with an occasional intermission. A large issue was also established in the sacro-lumbar region with the actual cautery, and the effect of the bougie, as recommended by Civiale, was tried. No relief followed. Finally, anodyne injections were thrown, at first, once, and afterwards twice a day, into the bladder ; suppositories were also employed morning and evening; and, as a tonic, the patient was directed to take, three times a day, fifteen drops of the muriated tincture of iron in combination with a drachm of elixir of paregoric. In short, the treatment was varied in every possible form for five or six months, without the slightest permanent, or, in fact, even any decided temporary benefit. Becoming discouraged, the pa- tient finally went home, where, after lingering for six or eight months longer, he sank under the effects of his ailments. No examination of the body was permitted. Case II.—A married woman, twenty-nine years of age, the mother of three children, visited me in 1846, for neuralgia of the bladder, under which she had laboured upwards of four years. She was tall and slender, with a pale, sallow complexion, and was of a nervous, excitable disposition. Soon after her second confinement, she ob- served a small swelling on the left nympha, a short distance from the orifice of the urethra, which, in time, became exquisitely tender, and gradually acquired the bulk of a pigeon's egg; it was of a red, florid colour, and of great firmness. About five months after it was first noticed, it began to pain her, especially late in the evening, so that she was unable to rest well at night; her appetite also declined, the bowels were costive, and she was obliged to void her urine six or eight times in the twenty-four hours. Micturition was attended with a scalding sensation in the urethra and the neck of the bladder, fol- NEURALGIA OF THE BLADDER. 219 lowed, in a few months, by dull, heavy, aching pains, which, at inter- vals, darted through these parts in different directions, as well as through the thighs, the groins, and perinseum. She also suf- fered severely in her back as well as in the thighs and legs ; and the little tumour was a source of incessant annoyance. During her last pregnancy, which was terminated about six months previously to her visit to me, her neuralgic pains were greatly augmented, both in frequency and violence ; nor did her confinement bring with it any decided or permanent relief. She had formerly suffered from neu- ralgia of the facial nerves. Believing, from the history of the case, that the vesical affection was owing to the tumour above described, I at once excised it, and then placed the patient upon a course of constitutional treatment, under which she rapidly recovered. Indeed, she had hardly any severe neuralgic pains after the operation. The remedies directed for her consisted chiefly of the compound calomel pill, and of the internal use, three times daily, of quinine and the aromatic wine of the citrate of iron, in the proportion of three grains of the former to a drachm and a half of the latter. Her strength and colour rapidly improved, the circulation of the extremities was restored, her spirits, which had been previously much depressed, became remark- ably buoyant, and, when she left Louisville, after a sojourn of three weeks, she seemed to be the most happy and delighted being in the world. Case III.—A gentleman, sixty-seven years of age, a judge of a county court, contracted, while a youth, a severe gonorrhoea, from the effects of which he did not recover for several months. When twenty-three years old, he noticed that the stream of urine was much smaller than formerly, and that micturition was attended with a scalding sensation in the urethra and neck of the bladder. Under the use of a bougie, the canal was gradually restored to its former calibre, and the urinary symptoms disappeared. At the age of fifty- nine he again contracted gonorrhoea, which continued, off and on, for nearly eighteen months, and finally left him with a considerable stricture, attended with a frequent desire to void his water, and neu- ralgic pains in the bladder and pelvic region. He had taken various nostrums until July, 1844, when he came to town, and put himself under my care. His condition at this period was as follows: the pulse was soft, full, and sixty in the minute; the tongue was clean ; the bowels were regular, and the passages of a healthy character; 220 DISEASES AND INJURIES OF THE BLADDER. the urine was much increased in quantity and rather pale, but of the natural smell and taste; and micturition was always attended with great pain, especially at the neck of the bladder, in the urethra, and at the head of the penis. The calls to urinate were very fre- quent, particularly at night, and he rarely passed more than a table- spoonful of water at a time. His sleep was disturbed by getting up every half hour. Whenever the bladder was more than ordi- narily distended, the pain extended up the loins, along the spermatic cords, and down the thighs, the perinseum, and the testicles, the latter of which were exquisitely tender and sensitive. Latterly, he experienced burning sensations in the hands and feet, especially in the evening and early part of the night. His constitution now also began to suffer; he became peevish and fretful, had little or no appetite, and was habitually constipated. A middle-sized catheter passed with great difficulty into the bladder, and created the most intense pain, leading almost to syncope. The morbid sensibility of the urethra was excessive. An organic stricture evidently existed in the membranous portion of the urethra; the prostate gland seemed to be little, if any, enlarged. The instrument failed to detect any foreign body, and its introduction was followed by a dis- charge of upwards of a pint of pure blood. At least a week elapsed before he recovered from the effects of the operation. As the general health was greatly deranged, it was evident that no impression could be made upon the local affection until this was improved. The patient was accordingly put upon the use of purga- tives, consisting, at first, of calomel and rhubarb, and, afterwards, of blue mass, rhubarb, and Castile soap, with a small quantity of ipeca- cuanha ; the diet was carefully regulated; a hot bath was directed twice a day; and strict attention was paid to recumbency. Leeches were applied to the perinseum; and, as the urine was turbid, and alkaline, a liberal use of bicarbonate of soda and potash was en- joined. Under this management, in less than a fortnight, the im- provement was most striking; appetite and sleep returned, the coun- tenance lost its anxious expression, and the patient was able to retain his water from two to three hours at a time. An attempt was now made to relieve the stricture, upon which, it was evident, nearly all the local suffering depended. The instrument met with less resist- ance than formerly, and produced comparatively little pain either in the urethra or at the neck of the bladder. In forty-eight hours, a larger catheter was passed, and in this manner the treatment was NEURALGIA OF THE BLADDER. 221 continued for the next four weeks, at the end of which time the parts were nearly entirely well. It should have been observed, that free use was made, during the greater portion of this time, of uva ursi and hop tea, with soda and potash, the warm bath, porter, and a light but nourishing diet. In a fortnight more, the judge returned to his residence, to resume his official duties. He wrote me several months afterwards, stating that, under the occasional use of the bougie, and the remedies just mentioned, his general health remained good; that he rarely, and then only for a few minutes, suffered from his neural- gic pains. Case IV.—J. W., of Kentucky, aged twenty-six, a clerk in a dry goods store, of a nervous, melancholy temperament, always enjoyed good health until June, 1849, when he began to suffer from dyspep- sia and constipation, attended with neuralgic pain in the right shoulder, which occasionally shifted to the other side, and was always aggravated by exercise, defecation, and exposure to the weather. Soon after this he had sexual intercourse, which was followed, in a short time, by excessive pain in the lower part of the back, and, in about a fortnight, by scalding of the urethra, itching in the head of the penis, and a high-coloured state of the urine. These symptoms were speedily succeeded by pain and burning at the neck of the bladder, and a peculiar tingling sensation along the whole of the urethra; darting pain and burning were also perceived in the rec- tum and the upper and inner parts of the thighs. The urine was flocculent and slightly acid, and there was a thin, glairy discharge from the urethra. Occasionally severe strangury supervened, though it rarely continued beyond ten or fifteen minutes at a time. The patient never had any disease of the genito-urinary organs before. In June, 1850, the patient writes as follows : " I do not suffer as much now as I did some months ago from strangury, or distress at the neck of the bladder; but the disease of the rectum has greatly increased. I am now unable to walk any distance, or sit on a chair any length of time, without an aggravation of my distress. I am at present troubled with an aching pain in the perinseum, anus, and neck of the bladder; and, for the last two weeks, there has been a thin, ropy, mucous discharge from the urethra. I am occasionally annoyed with nocturnal emissions ; there is no regularity in their occurrence; sometimes they take place twice a week, and sometimes only once a fortnight; sometimes I escape three or four weeks, and then have two or three in rapid succession. Exercise on foot will 222 DISEASES AND INJURIES OF THE BLADDER. produce them in the daytime." I sounded the bladder in this case, but found no stone, stricture of the urethra, or disease of the pro- state gland. The operation was productive of severe pain and dis- tress, which did not entirely disappear for five or six days. It is not necessary to enter into the particulars respecting the treatment of this case. It is sufficient to state that an immense number of articles were used, singly and combinedly, without any marked or decided benefit from any of them. Leeches were applied to the perinseum, in small and in large numbers; the neck of the bladder, urethra, prostate gland, and rectum were repeatedly caute- rized ; steady purgation was maintained; the food and drink were carefully regulated; the hip bath and opiate suppositories were con- stantly used; anti-neuralgic remedies were exhibited for a long time; and counter-irritation by blisters and tartar emetic ointment re- ceived a fair trial. In short, everything was done, but nothing did any good. After a trial of nearly six months, the poor fellow left town in despair of obtaining relief from a disease so distressing and unrelenting. Ten or twelve weeks after he got home, he wrote me that his general health had somewhat improved, but that the local disorder was much as before. SECTION III. PARALYSIS OF THE BLADDER. The bladder is destined, in the natural state, to retain the urine for an indefinite period, and then to expel it by the contraction of its muscular fibres, aided by the action of the diaphragm and of the abdominal muscles. When the organ is deprived of this power it is said to be in a state of paralysis, and the paralysis is either partial or complete, according to the extent of the loss. It is important also, to know that the affection may be either essential or sympto- matic, or, in other words, that it may be dependent upon causes inhe- rent in the bladder itself, or upon a diseased condition of other parts of the system. Another distinction, long ago recognised by Zuber1 and other German authors, is into paralysis of the neck of the organ, and paralysis of its body. This arrangement is of no little practical 1 Diss, de Morbis Vesicae.—Soemmering, Traite" des Maladies de la Vessie et de 1'UreHre, p. 69. Paris, 1824. PARALYSIS OF THE BLADDER. 223 importance, inasmuch as the first variety of the affection is gene- rally attended with incontinence, and the other with retention of urine. Paralysis of the bladder may result from a great many different causes, a knowledge of which will materially contribute to a right comprehension of the pathology of the disease, and put the surgeon on his guard against a variety of errors. The following arrange- ment will be sufficiently minute for practical purposes : 1, Paralysis from external injury; 2, from inflammation; 3, from over-distension of the muscular fibres ; 4, from disease or injury of the cerebro-spinal axis; 5, from loss of tone of the general system; and 6, from the effects of old age. To each of these varieties it will be necessary to devote separate consideration. I. Palsy of the bladder sometimes arises from external violence. My attention was first prominently directed to this subject nearly twenty years ago, in consequence of being called to a patient, who, in a scuffle with a fellow-labourer, had received a kick upon the hypogastric region, his bladder being at the time full of urine. He was seized soon after with severe pain in the pelvis, accompanied with a stinging sensation along the course of the urethra, and an utter inability to pass a drop of urine. The catheter was introduced, and repeated twice a day for nearly a week before the organ fully re- gained its functions. The muscular fibres had evidently experienced a violent contusion, in consequence of which they had lost their power of contraction. The occurrence is generally caused by the passage of the wheel of a carriage, by blows or falls, or by the body being jammed in between two firm and resisting objects, as a post and a wagon. It is sometimes complicated with fracture of the pelvic bones, and occasionally supervenes upon injury of the peri- nseum. Obstetricians have long been familiar with this form of paralysis, which often follows severe and protracted labour, in con- sequence of the pressure which the child's head, as it descends into the lower strait, exerts upon the bladder, especially if the urine has not been previously evacuated. A similar effect is sometimes pro- duced by the mal-adroit use of the forceps. II. Paralysis sometimes accompanies, or rather follows, inflam- mation of the bladder. In mild cases of this description, and in the early stages, the organ is generally extremely irritable, and there- fore contracts with increased vigour and frequency, the patient being compelled to void his urine every few minutes. The bladder, in fact, 224 DISEASES AND INJURIES OF THE BLADDER. is in the same condition, as it respects its middle tunic, that the rectum is in dysentery; the muscular fibres are in a state of irritation, and hence there is, in both cases, incessant and painful contraction. In violent cystitis, on the contrary, the muscular coat is overwhelmed by the morbid action, and is consequently no longer capable of per- forming its office. It is paralysed just as the small intestine is in acute peritonitis, or the orbicular muscle of the eye in certain forms of conjunctivitis. In this variety of palsy, the patient generally suffers severe pain, and has a constant inclination to void his urine, which is often very turbid, high-coloured, or even bloody, and more or less offensive. III. In the third place, paralysis of the bladder may arise from over-distension of its muscular fibres. This variety of the affection is most common in advanced life, but may occur at any period, even in the most tender infancy. It is usually produced by a neglect to empty the bladder when a desire is felt to urinate, the patient, per- haps, not finding it convenient at the moment, or for some time after, to obey the promptings of nature. When at length he makes the effort, he is unable to succeed, the muscular fibres have been over- stretched, and are deprived of their contractile power. In short, they are in a state of paralysis, and the most violent straining is incapable of exciting them; the catheter alone can afford relief. Old men who are in the habit of taking a great deal of exercise on horseback, are very liable to this form of palsy. Instead of dis- mounting when they experience a desire to urinate, they continue their ride, and when they reach their place of destination, they are frequently unable to pass a drop of water. I have seen quite a number of cases of this kind, some of which have done well, while others have terminated fatally, generally within the first five or six days. IV. The paralysis dependent upon lesion of the spinal marrow, the brain, and the nerves which are detached from them, is nearly always associated with paralysis of the inferior extremities. The causes which commonly give rise to this affection, are serous effu- sions, apoplexy, the presence of tumours, sprains, concussion, frac- tures, and dislocations. In short, whatever is capable of producing compression of the cerebro-spinal axis, or of the nerves which supply the lower half of the body, may induce the lesion. The paralysis of the bladder, in these cases, may exist in various degrees, from a slight want of muscular power to complete inability. When the PARALYSIS OF THE BLADDER. 225 affection is confined exclusively to the neck of the organ, while the rest retains its faculty of contracting, the consequence will be incon- tinence of urine. It may disappear in a few hours or a few days, or continue for months or years, or to a greater or less extent during life. The paraplegia may pass off, and the paralysis of the bladder alone remain, though in general the reverse is the case, the power of urinating being restored before that of locomotion. I have met with repeated instances illustrative of the truth of this remark. When the paralysis is associated with paraplegia, the sensibility of the bladder is generally so much impaired that the patient is uncon- scious of his situation. He suffers no pain or inconvenience, and does not complain of any derangement of the urinary apparatus. The bladder, in truth, is a mere passive reservoir, which often becomes enormously distended before any one is apprised of its con- dition. It is a matter of paramount importance, therefore, in all cases of injury of the spine and brain, that the practitioner should ascertain, at every visit, whether the patient can void his urine, or whether it is retained in the bladder. He should be careful, more- over, not to mistake the dribbling, which almost always exists in these cases after the first three or four days, for incontinence. When a certain degree of sensibility remains, the pelvic pains, the constant desire to urinate, and the sense of weight and distension in the hypogastric region, usually sufficiently indicate the nature of the complaint. In nearly all instances the palsy comes on immediately after the accident that produces the paraplegia, and in fatal cases obstinately persists to the last. When the paralysis of the bladder is produced by injury of the spinal cord, the urine is usually highly alkaline, turbid, of an ammo- niacal odour, and surcharged with thick, ropy mucus. Phosphatic matter soon makes its appearance; inflammation is speedily set up in the lining membrane; and, if the patient survive any time, ulcera- tion frequently takes place, followed by a discharge of blood, and even pus. Persons thus affected are very prone to calculous disease; in some instances the whole of the inner surface of the bladder is incrusted with calcareous matter. V. In the fifth division of the subject are comprised those cases in which the paralysis arises apparently from a want of tone or power in the general system, and not from any defect, in the first instance, in the bladder itself. To this class belongs the paralysis which is so frequently witnessed during the progress of encephalitis, apoplexy, 15 226 DISEASES AND INJURIES OF THE BLADDER. and fever, especially typhoid. The affection, indeed, is much more common than is usually supposed, and is unfortunately often over- looked by the professional attendant. From ignorance of the sub- ject, or, what is equally culpable, inattention, much suffering is thus sometimes produced ; the primary disease is greatly aggravated, and life is brought into imminent danger. The paralysis may occur at any period of the febrile complaint; but is most apt to show itself in the advanced stages, when there is considerable depression of the nervous system. The first link in the morbid chain seems to be a want of sensibility of the bladder, in consequence of which the urine ceases to make its accustomed impression, and continues to accumu- late without awakening any desire to evacuate it. When at length the proper inclination is felt, the muscular fibres will be found to have been so much stretched that they are incapable of fulfilling their office. The patient, lying in a state of stupor, drowsiness, or delirium, is unable to indicate his wants, and thus the distension goes on increasing until the bladder is in danger of bursting. When some degree of sensibility remains, he makes known his suffering by his moans and restlessness, and by placing the hand upon the hypogastric region, by grasping the penis, or by making ineffectual efforts to void his urine. In complete insensibility, he is unconscious of any incon- venience. Analogous to the paralysis of the bladder now described, is that form of the affection which occasionally supervenes upon compound fractures and dislocations, severe injuries of the lower extremities, wounds of the bowels, strangulated hernia, and contusions of the ab- dominal muscles. Every surgeon is aware that the bladder some- times loses its power of contraction after amputation of the thigh and leg, the removal of large tumours, and other important operations. The tying of a hemorrhoidal tumour is occasionally followed by this result. Twelve years ago I performed an operation of this kind upon a gentleman in Cincinnati; the bladder was completely para- lysed the next morning, and nearly a week elapsed before he was able to pass his water without the aid of the catheter. Finally, to this class may be referred the palsy which results from inordinate sexual indulgence, and long-continued self-abuse. These causes, by weakening the tone of the system, may induce a corre- sponding debility of the bladder, and thus render it incapable of con- tracting with sufficient force to expel its contents. The defect, which PARALYSIS OF THE BLADDER. 227 is most common in old men, occasionally occurs in young subjects, and rarely exists in a complete degree. Great torpor of the bladder, amounting to actual paralysis, is sometimes caused by mere local exhaustion, or temporary arrestation of the nervous influence. Thus an opiate enema or suppository, will occasionally deprive the organ, for several hours and even days, of its muscular irritability. The paralysis, which is generally slight at first, may ultimately, by a continuance of the remedy, become so complete as to require the use of the catheter for the evacuation of the urine. VI. There is a variety of palsy of the bladder to which the term senile may be appropriately applied, as it is almost peculiar to old age. As the body loses its elasticity, the cornea grows dim, and the power of locomotion diminishes, the bladder, participating in the general decay, becomes less sensible to the presence of the urine, and less capable of expelling it. The complaint is most common in elderly men who have led a life of indolence and inactivity, who have indulged freely in the pleasures of the table, and who have habitually neglected the calls of nature. Persons of a gouty and rheumatic diathesis are said to be peculiarly liable to its attacks. There is no mechanical obstruction to the flow of urine, but simply a want of power in the muscular fibres of the bladder, in consequence of which it contracts feebly and imperfectly upon its contents. The paralysis is seldom complete, and usually comes on in a slow, stealthy manner, having already, in most cases, made considerable progress before there is any suspicion of its real character. One of the first symp- toms which attracts attention is a slight difficulty in starting the urine; the patient is conscious that he is obliged to make a greater effort; and a longer period is required to complete the evacuation. At the close of the discharge, the water comes away in drops, and a portion often remains in the urethra, from which it issues after the micturition is completed, thus soiling the linen, and causing more or less discomfort. The bladder is never, at any time, entirely emptied, but a small quantity of urine is retained in the inferior part of the viscus, where it becomes a source of irritation, not only to the mucous membrane but also to the muscular fibres. As the disease advances,' the muscular contractility is still further impaired; and the water, instead of being ejected in a bold, full stream, falls between the patient's legs; or, to use a vulgar expression, he pisses upon his shoes. 228 DISEASES AND INJURIES OF THE BLADDER. Whatever may be the cause of the paralysis, or the circumstances under which it takes place, the symptoms which attend it, are, in general, sufficiently well-marked. As soon as the bladder has lost its power of contraction, its contents accumulate and distend its walls. The organ, thus pressed upon in every direction, gradually rises above the pubes into the hypogastric region, forming a tumour which ascends sometimes as high as the umbilicus, and as far out- wards on each side as the brim of the pelvis. The swelling is of an ovoidal shape, fluctuating, indolent at first, but painful afterwards, and attended with complete retention, which constitutes the charac- teristic symptom of the affection. After the paralysis has continued for several days, the water generally dribbles off in drops, and thus incontinence is added to the retention. In the milder forms of the malady, the power of contraction is only diminished, not entirely lost, and a portion of the urine is still voided, under the influence of the will, either at regular or remote intervals. The duration of the paralysis varies from a few hours or days to several weeks, months, or even years. Occasionally it ceases only with life. It is unnecessary to give a detailed account of the changes observed in this disease after death. As in other vesical affections, signs of con- gestion or of inflammation are generally discovered in various parts of the lining membrane ; the muscular fibres are pale and indistinct, and the parietes of the organ are remarkably thin, flabby, and attenuated. In some instances blackish, dark-coloured, or grayish spots are visible, and are evidently the effect of incipient gangrene. In neglected cases, or in those which run their course very rapidly, the different coats are very much softened, and hence they sometimes give way at one or more points, followed by an escape of the urine into the general peritoneal cavity. When the paralysis is of long standing, it is not unusual to meet with ulcers and phosphatic incrus- tations of the mucous membrane. Disease of the associated organs is by no means uncommon, but does not form a necessary concomi- tant or consequence. The prognosis of vesical paralysis can be correctly estimated only by an attentive consideration of its causes. Much will also neces- sarily depend upon the treatment, the age of the patient, the state of the system, and the duration of the disease. When the retention of urine, which constitutes, as has been already stated, the charac- teristic symptom of the affection, is not early relieved, a long time must necessarily elapse before the elongated and over-stretched fibres PARALYSIS OF THE BLADDER. 229 will regain their former vigour. When the distension continues in full force for four or five days, the tone of the organ is liable to be destroyed for life; indeed, such cases often speedily terminate in death, even when the most urgent symptom has been relieved by the catheter. An instance in point occurred to me in 1845, in an old gentleman of sixty, at Rock Haven, thirty miles below this city (Louisville). He had laboured under paralysis of the bladder, with complete retention, from Monday at twelve o'clock until nearly the same hour on Thurs- day night. I had no difficulty in passing the catheter; upwards of a quart of water was drawn off, and the patient felt himself immensely relieved in a few minutes. Notwithstanding he rested well during the remainder of the night, and had a good pulse when I took my leave of him in the morning after a late breakfast, he died early the following Saturday evening, in a state of complete exhaustion. No examination was made ; but the probability was, as I learned from the attending physician, that there was partial gangrene of the suffering organ. When the paralysis depends upon organic lesion of the brain or spinal cord, or upon permanent compression of the bladder or of the nerves which supply its tunics, it may generally be regarded as incurable. Recovery will be more probable in young than in old subjects, and in recent than in old cases. It must be obvious, that an affection depending upon so many and such opposite causes, must require, for its removal, a variety of modes of treatment. The first inquiry, in all cases, should, there- fore, be, how has the malady been induced ? or, in other words, what are the influences by which it has been developed and sustained ? Upon the proper solution of this question must necessarily hinge the success of our curative agents. Two important indications are presented in every case of this disease; first, to draw off the urine, and secondly, to restore the tone of the muscular fibres of the affected organ. To fulfil the first, all that is necessary is to use the catheter. This should be done at stated intervals, to prevent undue accumulation, and to compel the viscus to return, as it were, to its original habits. Carefully perse- vered in, this practice is frequently of itself sufficient, in a short time, to cure the malady. In confirmed cases, the instrument should be employed once about every four hours, especially if there be much renal secretion; in opposite states, on the contrary, three or four times a day will be often enough. I generally prefer introduc- ing the catheter every time it is necessary to draw off the urine to 230 DISEASES AND INJURIES OF THE BLADDER. letting it remain in the bladder permanently; and as there is seldom any difficulty in doing this, the patient usually soon learns to perform the operation himself. Sometimes, however, the improvement is more rapid and decided when the catheter is constantly retained, and the water permitted to flow off every hour or two. I have found this practice particularly useful in cases of paralysis, attended with pain and spasm of the neck of the bladder, and a frequent desire to urinate. When the accumulation is very great, and has continued for several days, it is a good rule not to evacuate all the water at once, for fear of inducing severe depression from the sudden removal of the stimulus of distension. I have seen several cases in which I am satisfied the patients lost their lives from inattention to this pre- caution. My own practice, under such circumstances, is not only to allow a small quantity of urine to remain, but to support the weak- ened organ by swathing the abdomen, precisely as after parturition, and tapping in ascites. When the catheter is permanently left in the bladder, it should be confined in the usual manner, and cleaned every other day; otherwise it will be certain to become encrusted with inspissated mucus, if not with earthy matter, and thus produce an injurious impression upon the affected organ. Much harm is often done in this disease by the protracted employ- ment of the catheter. The proper plan is always to discontinue it as soon as it is discovered that the organ has regained its expulsive power. The patient should be requested from time to time to try to evacuate the bladder by his own efforts, and if he is not able to effect the object completely he should be assisted with the catheter; for the rule is, in all cases, to draw off every particle of water at least twice in the twenty-four hours. By employing the instru- ment too long, the organ becomes habituated to its use, and a much longer time will necessarily elapse before a cure takes place. The second indication, which is to impart tone to the bladder, or reanimate its exhausted energies, may be fulfilled in various ways. It has been already seen that the regular evacuation of the urine is sometimes of itself sufficient to answer this purpose; in general, however, it has to be aided by other means, both of a constitutional and a local character, and it is not always easy to determine which of these is entitled to the greater share of the credit. Among the remedies which ought to be mentioned first are cathar- tics, which constitute a most valuable class of agents in nearly all cases of this disease, no matter what may be its exciting cause. Of PARALYSIS OF THE BLADDER. 231 the truth of this statement no one can entertain a reasonable doubt if he reflects, for a single moment, that paralysis of the bladder is frequently associated with paraplegia and excessive torpor of the bowels. A brisk cathartic, consisting of calomel and jalap, or calo- mel, rhubarb, and aloes, will, under such circumstances, often pro- duce the most prompt and happy effect, not only ridding the alimen- tary canal, perhaps, of much vitiated and offensive matter, but improving the secretions, and rousing the energies of the whole system. The first thing, therefore, that should be done, after the bladder has been relieved of its burden, is to clear out the bowels; and, as a general rule, the best article for the purpose is calomel, in union with some of the substances before mentioned. In some instances I give the mercurial alone, in fifteen or twenty grain doses, followed in eight or ten hours by an ounce of castor oil and a drachm of spirits of turpentine; or by an active enema, of which the turpentine forms a principal ingredient. The cathartic may be repeated, at first once a day, and afterwards every other day, until a decided amendment takes place, when it should be administered at longer intervals, and with a more sparing hand. Emetics are sometimes of signal benefit in this disease. They are particularly valuable where the paralysis is coincident with disorder of the digestive organs and torpor of the general system. They are contra-indicated in the traumatic form of the disease, whether de- pendent upon direct injury, or indirectly upon injury of the brain and spinal cord. The best form of exhibition is a combination of tartrate of antimony and ipecacuanha, in the proportion of one grain of the former to twenty or thirty of the latter, repeated every half hour until full emesis is induced. The stomach should be washed out thoroughly with valerian tea or warm mustard-water. After the bowels have been well evacuated, and the secretions restored, recourse may be had to remedies calculated to make a more direct impression upon the nervous system, if not upon the suffering organ itself. At the head of this class of agents may be placed strychnine, cantharides, and arnica. With the exception of the inflammatory form of the affection, there is hardly a case of vesical paralysis in which these remedies may not be employed with a fair prospect of benefiting the patient. They may be used either separately, or, as I generally prefer, in combination with each other. Given in this manner, their effect is usually more prompt and de- cided than Avhen they are administered alone. An excellent formula 232 DISEASES AND INJURIES OF THE BLADDER. is one-sixteenth of a grain of strychnine, an eighth of a grain of cantharides, and from three to five grains of the extract of arnica, three times in the twenty-four hours; care being taken to watch their effect, and to diminish or augment the quantity of the respec- tive articles, as circumstances may seem to indicate. If spasmodic twitchings ensue, the patient suffer from strangury, or the stomach become irritable, they are to be regarded as an evidence that they have been carried far enough, that the dose should be modified, or that the offending substance should be temporarily suspended; to be resumed, if necessary, at another period. Instead of the strychnine, the extract of nux vomica may sometimes be advantageously used; it occasionally agrees better with the system, and seems to exert a more happy influence in arousing the enfeebled organ to the per- formance of its functions. In paralysis of the bladder, consequent upon typhoid and other fevers, masturbation, and general exhaustion, few remedies are so serviceable as the arnica. It is a powerful stimulant, and acts with peculiar energy upon the nervous system. It is, therefore, well adapted to all cases of the malady dependent upon general debility. It may be administered in substance, infusion, extract, or tincture. I usually prefer the latter, as more elegant and agreeable, in doses from forty to sixty drops three times a day. Its effects should be carefully watched; otherwise it may cause vomiting and purging, headache, vertigo, and spasmodic twitchings. Where a tonic is at the same time indicated, it may be usefully combined with some of the vegetable bitters, acids, or ferruginous preparations. Strong testimony has recently been published in favour of the ergot of rye in the treatment of this affection. The attention of the profession was first directed to the remedy by Dr. Allier, in the "Journal des Connaissances Mddico-Chirurgicales," for November, 1838, in consequence of having witnessed its stimulating effects upon the urinary organs in females to whom it had been adminis- tered to promote uterine contractions. He relates four cases of the disease, which were apparently cured by it, although in one it had existed nearly three months before its employment. They all oc- curred in elderly men, from over-distension of the bladder. The dose usually given, in the twenty-four hours, was from one to two scruples of the recent powder. Since the publication of the paper of Dr. Allier, other cases in which the secale cornutum was successfully employed have been PARALYSIS OF THE BLADDER. 233 reported by various writers, and the remedy may therefore be re- garded as one of no ordinary promise. Dr. Day, of London, in his interesting " Treatise on the Diseases of Advanced Age," re- cently republished in Philadelphia, declares that he has often used the ergot of rye with the best results in the paralysis of the bladder of old people, and he gives it a decided preference over cantharides and arnica. He usually administers it in the form of a very strong tincture, prepared with six ounces of the substance to a pint of spirit; the dose being a drachm three times a day in an effervescing draught of citrate of ammonia. In whatever form the article be used, it is generally best to begin with eight or ten grains every five or six hours, and increase the dose gradually as the treatment pro- gresses. It should never be pulverized, when given in substance, until it is about to be used, as exposure has a tendency rapidly to deteriorate it, and render it inert. My experience with the ergot is limited; I have employed it in a "few instances, but without realizing any special benefit. The ergot commonly excites an abundant secretion of urine, slight tenesmus of the bladder, and pain, or a sense of uneasiness, in the hypogastric region. When given in large doses, or for any length of time, it is liable to produce stupor, general heaviness, dilatation of the pupils, slight convulsive tremors, and a sense of pricking, or formication. In enfeebled states of the system, it sometimes manifests a septic tendency, which is best counteracted by a nourishing animal diet. In the inflammatory form of the disease, characterized by pain and spasm of the neck of the bladder, with a constant desire to urinate, and more or less febrile commotion, the treatment should be conducted strictly upon antiphlogistic principles. Blood is taken from the arm, or from the neighbourhood of the affected part by leeching or cupping; the bowels are properly evacuated; and recourse is had to the warm bath, hot fomentations, and anodyne enemata. The distended and enfeebled organ is relieved by the catheter, which is continued until the urgent symptoms have disap- peared, when the emission of the urine is entrusted as much as possible to the efforts of nature. When the disease is associated with general debility, tonics are indicated, and often exert an excellent effect, both upon the system at large, and upon the urinary bladder. Much judgment is fre- quently necessary to enable us to determine the proper period of 234 DISEASES AND INJURIES OF THE BLADDER. their employment, the time of their continuance, and the article that is best adapted to the particular case in hand. In general, a preference is conceded to the chalybeate preparations, of which the best are the muriated tincture, the sulphate, and the citrate, in the form of the aromatic wine. The first of these is supposed to have a specific tendency to the urinary organs, and may be administered, in a small quantity of mucilage, three times a day, in doses of from ten to twenty drops. The sulphate is usually advantageously com- bined with quinine, or some of the vegetable extracts; the common dose is about two grains. The aromatic wine, which is one of the best preparations of the kind Ave possess, usually agrees better with the stomach than either of the two others, and is particularly adapted to vesical paralysis associated with anaemia, a pale tongue, a pallid complexion, and cold extremities. The dose is from one to two drachms thrice a day. It need hardly be remarked that any tonic that may be selected may be combined, if it be thought neces- sary, with strychnine, cantharides, arnica, and other articles. In hysterical paralysis the mind is affected rather than the blad- der. The muscular fibres of this organ retain their contractility, but the patient is unable, or pretends to be unable, to excite them to action. The want of power is no doubt sometimes real, but oftener it is feigned. Such cases are always promptly relieved by assafoetida, valerian, and morphia, aided by the catheter, which is frequently obliged to be used three or four times a day; these remedies, how- ever, are merely palliative, not radical; and, with regard to the instrument, it may be remarked that the patient usually gets worse the oftener it is employed. To effect a permanent cure, the treat- ment should be directed to the improvement rather of the mind and of the general health than of the condition of the bladder. As the subject will be brought up again for consideration, it may be dismissed, for the present, with the remark, that there is no disease more difficult of management, none which requires nicer judgment for its detection, and none which is so annoying to the practitioner. Counter-irritation is a useful auxiliary after the bowels have been evacuated and the secretions corrected, and may be excited by the application of a blister, tartar emetic ointment, the moxa, or the actual cautery. A succession of blisters over the dorso-lumbar region often proves highly beneficial, by stimulating the spinal cord, and the nerves which it sends to the lower half of the body. The vesicating agent should PARALYSIS OF THE BLADDER. 235 be retained long enough to elevate the epidermis, and to cause con- siderable excitement in the surrounding parts. The best dressing is an emollient poultice, renewed every six or eight hours for a day and a half, when the dead cuticle should be removed over a space about the size of an American dollar, and the raw surface sprinkled with the fourth of a grain of strychnine. The application may be re- peated every twelve hours, either in the same, in smaller, or in larger quantity, according to the impression which it makes upon the system. The remedy, thus used, is sometimes much more strik- ing in its effects than when it is exhibited internally. It deserves to be noticed, with respect to this powerful article, that if the vesi- cated surface is covered with lymph, it will produce little or no im- pression. It should, therefore, be carefully inspected at each dress- ing;, and divested of adherent matter. Where this can not be done, without inflicting unnecessary pain, the quantity of the strychnine should be proportionably increased. As soon as the vesicated sur- face begins to heal, another blister is to be applied, either at the same point, or in its immediate vicinity. There is hardly any form of vesical paralysis, excepting, perhaps, the inflammatory, in which this mode of counter-irritation will not prove more or less advantageous. In the milder varieties, it some- times acts like a charm. I recently had under my charge a gentle- man from Bowling Green, fifty-nine years of age, a blacksmith by trade, who was relieved in this way in a few days. He had slight weakness of the bladder for a number of years, and also of the lower extremities, especially the left. His general health has not been good, he is dyspeptic, hears badly, and is constantly annoyed with dizziness. He has voided his urine with considerable difficulty for fifteen months, and for the last three weeks he has not been able to pass a drop without the aid of the catheter. I purged this man well with calomel, colocynth, and jalap, gave him, three times a day, a pill composed of quinine, sulphate of iron, extract of quassia, and strychnine, regulated his diet, had his spine thoroughly rubbed morning and evening with strong veratria ointment, and applied a pitch plaster with Spanish flies, to the lumbar region. Under this treatment, he so far recovered, in a few days, as to be able to lay aside his catheter, his general health is much improved, and the vesical paralysis has entirely disappeared. I am not partial to pustulation with tartar emetic ointment, but this mode of counter-irritation is occasionally advantageous, and may 236 DISEASES AND INJURIES OF THE BLADDER. be employed either upon the sacrum, the loins, the hypogastrium, or the perinseum. The strength of the ointment may be increased by the addition of croton oil, and its effects require to be carefully watched, otherwise the patient may experience all the unpleasant consequences of an over-dose by the mouth. The remedy should, I think, be but seldom employed. With the moxa I have no experience in the treatment of this affection. It may possibly occasionally answer in mild cases, but I should hardly be disposed to temporize with such an inefficient agent in the more severe grades of the complaint. Larrey speaks of it in high terms in this and other analogous diseases, but I am unac- quainted with any writer in this country or in Great Britain who advocates it. The best points for its application are the upper part of the sacrum, the perinseum, and the supra-pubic region. The actual cautery is a much more energetic agent-than the moxa, and in the more rebellious forms of vesical paralysis, is not only a justifiable, but a highly proper remedy. The best place for applying it is about the junction of the last lumbar vertebra with the sacrum; in traumatic cases, however, when the disease depends upon injury of the spine, it ought, sometimes, to be used much higher up. The great advantage of the hot iron is, that it establishes not only an excellent issue, furnishing, for weeks and even months an abundant secretion of pus, but that it makes a much stronger and more abiding impression upon the nervous system. The eschar usually separates in six or eight days, leaving a fine, raw surface, which may after- wards be used, if deemed proper, as an avenue for the introduction of strychnine and other kindred articles. The cautery which I com- monly employ for this object is fully one inch in diameter. By put- ting the patient under the influence of chloroform, the application may be made without the slightest pain. This mode of counter-irri- tation is particularly valuable in vesical paralysis associated with paraplegia, or loss of power in the lower half of the body, whether the result of traumatic injury, over-distension, or senile decay. Counter-irritation by seton is hardly to be recommended in any case. It is a dirty, filthy, painful method, which can scarcely be too pointedly condemned. If it be at all justifiable, under any circum- stances, it is where the palsy is associated with an irritable condition of the neck of the bladder, with a frequent desire to urinate. In such a case, a seton, worn in the perinaeum, might, I conceive, be advan- tageous, and, perhaps, even preferable to some of the other forms of counter-irritation, already described. PARALYSIS OF THE BLADDER. 237 Frictions over the perinseum and hypogastrium with stimulating embrocations, such as turpentine and ammonia, are sometimes ser- viceable. In several instances, I have derived material benefit from the use of mustard plasters to these parts, and to the sacro-lumbar region. They should be applied at least once a day, and be retained for twenty-five or thirty minutes each time, or until the surface of the skin is completely reddened. An irritating plaster, worn upon the loins or the sacrum, is occasionally attended with the happiest effects. In the case already mentioned, prompt relief was afforded in this way. The best articles of this description are the ammoniac and mercurial plaster, the compound pitch plaster, and the plaster of pitch with Spanish flies. Another remedy of great potency in many cases of this disease, is the cold douche. It is a most powerful stimulant, and sometimes rouses the dormant energies of the bladder when almost everything else has failed. The water should be poured from a pitcher at a height of three or four feet alternately upon the hypogastric region and the inferior portion of the spine, for two or three minutes at a time, and the application should be followed immediately with fric- tions with a coarse dry towel until there is a perfect glow upon the surface. Sponging the loins, hips, and pubic region morning and evening with cold salt water, and rubbing them afterwards with a tolerably hard flesh-brush, has sometimes a happy effect. The same is true of injections of cold water into the rectum. Finally, galvanism, as a local stimulant, should not be neglected. It is often beneficial in other forms of paralysis, and has occasionally been of service in that of the bladder. It is particularly indicated in senile palsy, attended with a partial failure of the muscles of the lower half of the body. In the use of this agent, care is to be taken not to continue its application too long at each sitting. From eight to fifteen minutes twice a day, is much better than twenty or thirty minutes once a day. It should be applied at different points, as the sacro-lumbar region, the middle of the spine, the perinaeum, and the hypogastrium, either at the same time, or in succession. No very satisfactory observations have yet been made in regard to direct medication in the treatment of vesical paralysis. Paul of JEgina, and some modern practitioners, have advised astringent in- jections ; and Deschamps states that he cured several cases with injections of cold water. These means are especially called for when the disease is accompanied with inordinate secretion of mucus, or of 238 DISEASES AND INJURIES OF THE BLADDER. mucus and phosphatic matter, which, if permitted to remain in the bladder for any length of time, always become a source of irritation. It is not improbable that weak solutions of strychnine, veratria, and other kindred articles, introduced in this way, and retained in the bladder for a few minutes at a time, might prove beneficial. At all events, the practice is well worthy of trial, and affords an interesting field of inquiry. I have occasionally injected strychnine, in obsti- nate cases of this complaint, into the rectum, with excellent results. In a very obstinate case of paralysis of the bladder, which resisted every known method of treatment, both general and local, for ten weeks, a cure was speedily effected by injections of strychnine. The patient was a man aged sixty-eight, who, after a drinking bout and exposure to cold, found himself unable to void his urine. At the end of the above period, Dr. Lecluyse dissolved six grains of strych- nine, with a little alcohol, in a pint of water, and of this solution he injected into the bladder, previously emptied, two ounces four times a day. No effect was perceptible until about the end of the fifth day, when some urine appeared between the catheter, which had been retained in the bladder, and the urethra. The instrument being removed, the patient found that he had regained complete voluntary command over the bladder; and from this time on he experienced no further inconvenience.1 The direct application to the surface of the bladder of the tincture of cantharides was proposed some years ago by Mons. Lisfranc3 of Paris. One drop of the fluid was introduced through a catheter, and followed by an injection of simple lukewarm water. Next day double that quantity was instilled, and the operation was after- wards repeated night and morning; an additional drop of the tinc- ture being used on each successive occasion. No perceptible local irritation ensued, and a cure was soon effected; all the ordinary methods of treatment having previously failed. It is hardly possible to conceive that such feeble medication would do much good, and not to conclude, that, in the case before us, the patient would not have recovered without it just as promptly as with it. 1 Annales de la Soci6t6 d'Emulation de la Flandre Occidentale, 1850. a Amer. Jour. Med. Sciences, New Series, No. 12, p. 473. CHAPTER VI. HETEROLOGOUS FORMATIONS OF THE BLADDER. SECTION I. SCIRRHUS OF THE BLADDER. Scirrhus of the bladder, properly so called, is of such infrequent occurrence that many pathologists have been induced to deny its existence. Mr. Travers, in a valuable paper on malignant diseases, in the seventeenth volume of the Medico-Chirurgical Transactions of London, remarks, that he has never met with true scirrho-cancerous ulceration of this viscus. Mr. Howship, Sir Benjamin C. Brodie, and Mr. Coulson, in their works on the urinary organs, hardly allude to the subject; Mr. Mayo, in his " Outlines of Pathology," is equally silent; and so is Mons. Begin, the author of an elaborate article on cancer, in the " Dictionnaire de Me'decine et Chirurgie Pratiques." Similar testimony is borne by Dr. Walshe in his excellent and learned paper upon this subject, in the Cyclopaedia of Practical Surgery, published under the supervision of Dr. Costello, of London. From all this it may be inferred that the disease in question is exceedingly rare. I have myself witnessed only one case of it in a practice of nearly twenty-five years. Dr. G. L. Bayle, of Paris, in his Posthu- mous Treatise on Cancerous Maladies, speaks, it is true, of this affec- tion at considerable length, describing its symptoms, diagnostic cha- racters, causes, and pathological effects; but, as he has given no cases of it, we are left in doubt as to whether it is really scirrhus or some other disease. That the lesion is occasionally propagated to this organ from the neighbouring structures, as the rectum and pro- state gland in the male, and the uterus and vagina in the female, is familiar to every physician. My own practice has furnished me with a number of instances of it in both sexes. 240 DISEASES AND INJURIES OF THE BLADDER. The disease, which has been observed more frequently in men than in women, is most common between the ages of forty-five and sixty, agreeing, in this respect, with scirrhus as it occurs in other organs and tissues of the body. The parts of the viscus most liable to it are the neck and bas-fond; it is seldom seen at the summit or body. The extent of the morbid deposit may be very slight, or so great as to involve nearly the whole of the organ. In a case which I shall describe fully at the close of this chapter, the disease formed a broad thick belt round the entire circumference of the bladder, from its neck as far as the openings of the ureters. In an instance mentioned by Lallemand, the tumour was two inches thick, and from two to three inches in diameter; it commenced just behind the prostate gland, and was of a dense, gristly consistence. All the tunics of the bladder were transformed into a lardaceous, scirrhous substance. Scirrhus of the bladder occasionally co-exists with scirrhus in other organs. The parts most liable to suffer in this way are the liver, the uterus, the breast, and the prostate gland. Professor Samuel Cooper, of London, has described a well-marked example of scirrhous tumour of this organ, in a subject whose thigh bone of one side and a rib were infiltrated with the same morbid matter. Occasionally the disease co-exists with stone, or polypous growths. Of the causes of this disease, as it occurs in the bladder, we are totally ignorant. Its mode of invasion is generally insidious; its progress slow; and its termination fatal. No plan of treatment, of which Ave have any knowledge, exerts the slightest influence over it, beyond that of a palliative. The bladder, on dissection, is generally found to be contracted, and to contain a small quantity of dark-coloured, foetid urine, mixed with pus or sanguinolent matter. Its coats are hypertrophied, or irregularly thickened, and so firm and dense as to grate under the knife. The muscular fibres are unnaturally red and distinct, and sometimes they exhibit the peculiar fasciculated arrangement so con- spicuous in chronic inflammation or vesical catarrh. The outer sur- face is occasionally covered with lymph, or adherent to the surround- ing parts; and cases occur in which the viscus communicates with the ileum, the rectum, vagina, or uterus. Laid open, so as to ex- hibit its interior, the inner surface is found to be studded with scirrhous tubercles, closely aggregated together, firm and dense in their texture, and of a white, grayish, or lardaceous appearance. Occasionally there is only a single mass, which is then, perhaps, of SCIRRHUS OF THE BLADDER. 241 considerable volume, and of unequal density, structure, and colour. In cases of long standing, the morbid deposit is usually in a state of advanced ulceration, and presents a foul, ragged surface, with thick, abrupt, and everted edges. In some instances, again, the part is studded with small excrescences, like the top of a cauliflower. The submucous cellular tissue is generally the nidus of the heteroclite matter. The lining membrane immediately around the disease is commonly somewhat thickened, preternaturally dense, injected, and of a dark purple colour. During the progress of this disease the associated organs are apt to become implicated. When the scirrhus is situated at the neck of the viscus, it may extend to the prostate gland, and completely sub- vert its structure. In its progress backwards, it sometimes en- croaches upon the outlets of the ureters, and thus prevents the descent of the urine. The kidneys are usually more or less affected, and the ureters are liable to be variously altered, being either dilated or contracted, inflamed, or lined with lymph. Persons affected with scirrhus of the bladder are troubled with a frequent inclination to void their urine, which generally passes off in a small, imperfect stream, or drop by drop; with a sense of scalding or burning at the neck of the organ and along the course of the urethra; with violent spasm, and straining; and with deep-seated pain in the pelvic region, extending to the perinseum, anus, thighs, groins, back, and hypogastrium. The pain is either of a dull, heavy, aching or gnawing character, or it is sharp, and lancinating, shooting about in different directions, and keeping steady pace with the morbid action. The general health, at first unimpaired, gradu- ally suffers; the countenance assumes a peculiar sallow appearance; the appetite fails; the secretions become deranged ; the bowels are torpid; emaciation sets in; and the patient is finally, after months of torture, worn out by hectic irritation. In the only case of this disease that has fallen under my notice, I witnessed, during a period of several months, an amount of suffering such as I never saw before, and hope I may never be called upon to behold again. There are no signs by which scirrhus can be distinguished from other diseases of the bladder. The most reliable evidences are, the peculiar character of the pain, the progressive emaciation, the wan and sallow state of the countenance, the age of the patient, the excessive burning at the neck of the organ and in the urethra imme- diately after micturition, and the occasional discharge of small frag- 16 242 DISEASES AND INJURIES OF THE BLADDER. ments of the heterologous matter. Negative testimony is afforded by the operation of sounding. No positive conclusions can be drawn from the frequent micturition, the condition of the urine, and the presence of mucus, pus, or puriform fluid. The following case, already more than once alluded to, strikingly illustrates the symptoms, pathological appearances, and hopeless character of this disease, as well as the futile nature of any mode of treatment that may be instituted for its relief. The patient, Mr. G., a married gentleman, was forty-four years of age, and a lawyer by profession. He Avas a man of sanguine temperament, very active in his habits, stout, well-built, and gene- rally in good health. When twenty years old, he contracted gonor- rhoea, which terminated in stricture of the urethra, which lasted until within a short period of his death, and which was greatly aggra- vated by a new attack of urethritis in the winter of 1841. The narrowing extended from within about three inches of the meatus down to the bulb, and was often accompanied, especially of late years, by a thick and rather profuse discharge, not unlike that of the affection just mentioned. Micturition was difficult, as well as painful, and had to be often assisted by compression and pulling of the penis. Latterly the urine was voided in a small, feeble stream, and much force was required to expel the last drops. For the last two years and a half, the water was occasionally passed involuntarily, on which account the patient was constantly obliged to wear a cloth in his pantaloons, and not unfrequently to change the pantaloons themselves once or twice a day, in order to keep himself clean and comfortable. About seven years and a half ago, soon after the second attack of urethritis, he began to experience pain in the region of the bladder, accompanied with frequent micturition, and great uneasiness at the head of the penis. The urine, which was rather above the natural quantity, contained an unusual amount of mucus, and emit- ted a strong ammoniacal odour. Occasional attacks of acute cystitis supervened, but they were generally slight, and always promptly yielded to the copaiba mixture. During all this time the general health was excellent; the complexion was fine; and the patient was quite fleshy. It may be remarked here, that his habits were strictly temperate, and that he led a most active and exciting life, especially during the presidential campaigns of 1840 and '44. In this condition he continued until February, 1848, when, after prolonged SCIRRHUS OF THE BLADDER. 243 exposure to the night air, great bodily fatigue, and the excessive excitement consequent upon the gubernatorial nomination at Frank- fort, on the 22d of that month, he was seized with retention of urine. Dr. Sneed, an eminent practitioner of that city, being sent for, at- tempted to afford relief with the catheter, aided by venesection and the hot-bath. After great difficulty, the instrument was passed, and the bladder evacuated. Mr. G. described to me his sufferings, on that occasion, as having been of the most intense and agonizing nature. After having been partially relieved, he arrived at his residence in this city on the 28th, and I was immediately requested to see him. His symptoms, at this time, were those of acute cys- titis ; he was compelled to urinate every thirty or forty minutes, and felt excessive pain deep in the pelvic region, scalding along the urethra, and great uneasiness in the head of the penis, which he constantly compressed with his hand. The pain was of a hot, burning character, and was always most severe for a few minutes after micturition. The urine was highly offensive, of an ammoniacal odour, and loaded with white, glairy mucus, which, after having stood a few hours, became remarkably ropy, and adhered firmly to the bottom of the receiver. He voided, on different occasions, lumps of what seemed to be organized lymph and portions of the mucous coat of the bladder; some of these were upwards of an inch long and nearly the same in width, and they all had a ragged and de- cayed appearance. Great pain was always experienced in passing them, and now and then the patient was obliged to assist their expul- sion with the bougie. Perfect rest in the horizontal posture, rigid abstinence, the use of the copaiba mixture, anodyne suppositories, and leeches to the perinseum and hypogastrium, along with the inter- nal exhibition of bicarbonate of soda in hop and uva ursi tea, restored him to tolerable comfort in the space of about three weeks. The liver was repeatedly torpid, and calomel and blue mass had to be resorted to several times to counteract this tendency. Such Avas the condition of the patient about the middle of March. I pointed out to him the importance of steady attention to his case; he was considerably emaciated, but his appetite was good, and, de- spite my remonstrance, he soon went about his business. The mic- turition continued to be preternaturally frequent—say from fifteen to twenty times in the twenty-four hours—and the urine exhibited nearly the same appearance as during the attack from which he had just recovered. Early in June, being one of the state electors of 244 DISEASES AND INJURIES OF THE BLADDER. Kentucky, he went to Philadelphia, to the convention for nominating a candidate for the presidency, and while there, as well as on his way hither, he suffered severely with his bladder and urethra. He reached home on the 21st of the month, and immediately took to his bed. His symptoms were again those of acute cystitis, that is, a perfect repetition of those in March. The urethra was exquisitely irritable in the greater part of its course ; there Avas excessive pain in the head of the penis during and immediately after micturition, which was performed from twenty-five to forty times in the twenty- four hours; and the urine, of a foetid, ammoniacal odour, deposited, upon standing, a large quantity of thick, ropy mucus, often streaked or intermixed with pus. There was considerable tenderness on pressure of the perinseum and the supra-pubic region, especially the latter, when it was usually followed by a desire to pass water, and by severe distress in the head of the penis. Whenever the patient attempted to empty his bladder, he was obliged to turn over on his right side, every effort to accomplish his object in any other posture proving abortive. The liver was habitually torpid, and, in conse- quence of the anodynes necessary to relieve his suffering, the bowels ■ were seldom moved without the aid of purgatives. Notwithstanding this, the skin was soft, the pulse natural, and the appetite good. Under a course of treatment essentially similar to that pursued in March, the symptoms were somewhat ameliorated. In a few days, however, he became worse, and Professor Miller joined me in con- sultation. It was agreed that we should inject the bladder with a solution of nitrate of silver, in the proportion of two grains to the ounce of water, and to continue the use of the copaiba mixture, with laudanum and Hoffman's anodyne, to allay the violent spasm during and immediately after micturition. Such was the exquisite sensi- bility of the urethra that I was obliged, before introducing the catheter, to put the patient under the full influence of chloroform. The instrument, a middle-sized one, passed without difficulty, and the injection was followed by but little pain. It was repeated in four days, but it caused so much distress that we were induced to abandon it, and substitute, successively, a weak solution of sulphate of copper, nitric acid, and creosote, and, finally, an infusion of poppy-heads, opium, and extract of cicuta. These preparations were used, respectively, once a day, every other day, or every fourth day, according to circumstances, in the quantity of from two to three ounces, and retained, according to the tolerance of the bladder, SCIRRHUS OF THE BLADDER. 245 from fifteen minutes to an hour at a time. No marked improvement followed their use. On one or two occasions the patient seemed to be better for a few days, but then, all at once, and without any assignable cause, the symptoms recurred, if possible, with increased violence. The copaiba, on the whole, seemed to afford more relief than any other single article, or in fact, than all other remedies put together. It was taken, at first, alone, and afterwards, as it lost its effect, in combination successively with benzoic acid, the muriated tincture of iron, soda, potash, nitric acid, in short, everything that could be thought of; and all without any obvious advantage. The warm bath, used for an hour at a time, seemed for a while to exert a composing influence, but it was soon obliged to be discontinued on account of the fatigue and inconvenience attending its adminis- tration. Early in September, Dr. Samuel R. Richardson was added to the consultation. The patient, at this time, was considerably ema- ciated, and had little or no appetite; the tongue and mucous mem- brane of the mouth had a red, fiery appearance; the liver and bowels Avere torpid; there was a sense of excessive heat in the anus and rectum ; much difficulty was experienced in retaining the injec- tions ; and the urine, which was decidedly alkaline, was voided, on an average, every hour and ten minutes. From two to five minutes were required to complete the act, which was always accompanied with excessive pain, violent straining, severe spasm of the muscles of the thighs and buttocks, and a feeling at the head of the penis and anterior part of the urethra, as if molten lead had been poured upon them. There was also, at this period, severe pain in the sacro- lumbar region, which, however, was promptly relieved by the appli- cation of a gum ammoniac and mercurial plaster. It is worthy of remark, that there was, at no time, during the whole attack, any fever beyond a day or two, and then it was always very slight. The pulse was generally about seventy in a minute, soft and regular. During the last few weeks, the emaciation, which had been all along progressive, became very great, and at the time of his death it was extreme. The stomach was occasionally irritable, but rather as an effect of the medicines than of the disease; and the sleep was, of course, greatly disturbed by the constant inclination to void the urine. The mind remained unimpaired up to the last week, when, for the first time, it began to wander. Finally, the urine became very scanty, and highly alkaline, and such was the excessive pain 246 DISEASES AND INJURIES OF THE BLADDER. attending its passage, that the patient was obliged, for the last five days of his existence, to be kept pretty constantly under the influ- ence of chloroform. This, however, had the effect of only partially relieving his suffering. He expired at 8 o'clock, A. M., on Wednes- day, September 27, 1848. The body was examined eight hours after death, in the presence of Professor Miller, Dr. Richardson, Dr. Proctor, and Dr. Bozeman. The bladder, separated from the surrounding parts, was unusually large and firm. In detaching it at its neck, I accidentally ruptured its anterior wall, and let out a small quantity of thick, whitish, and offensive mucus. Laid open longitudinally in front, the interior was found to be in a scirrhous condition, from the cervix to the insertion of the ureters, in the entire circumference of the organ. The heteroclite matter was of a whitish colour, dense and firm, and, at one point, nearly an inch in thickness. At its upper boundary it formed a sort of belt, which was so closely contracted as hardly to admit the end of the middle finger, and which thus served to divide the cavity of the reservoir into two compartments. Of these the lower was quite rough on the surface, slightly ulcerated at two points, and studded with vegetations, or shreds of lymph and mucous membrane. The muscular and internal tunics were in a state of complete disorganization. The upper portion of the reservoir was comparatively healthy, and alone capable of retaining any urine dur- ing life. It presented at its inferior and posterior part the orifices of the ureters. The mucous membrane was of a dark slate-colour, and studded with small reddish granulations. The muscular coat was somewhat thickened, but perfectly free from scirrhus; the peritoneal investment was healthy. The prostate was not enlarged, but had evidently participated in the scirrhous degeneration. It was of a whitish colour, unal- tered in shape, and of preternatural density. The urethra was not examined. Both kidneys were affected with Bright's disease. They were con- siderably smaller than natural, of a pale reddish complexion, and somewhat wrinkled or fissured; their cortical substance contained a considerable number of yellowish granulations, from the size of a pin-head to that of a millet-seed, and of a dense, firm consistence. The mucous membrane of the pelves and calyces was inflamed, and the fibrous tunic, though free from disease, was easily peeled off in its entire extent. The right kidney presented, at its upper ex- SCIRRHUS OF THE BLADDER. 247 tremity, a serous cyst, as large as a walnut without its shell. The supra-renal capsules were healthy. Both ureters, especially the left, were somewhat dilated near their entrance into the bladder, and their lining membrane was inflamed throughout. The seminal vesicles were of a light brownish tint, and in a state of complete atrophy. The right one was situated nearly horizon- tally. The deferential ducts were pervious, and contained each a drop of thin, dirty, reddish fluid. It may be added here, as an interesting physiological circumstance, that the patient had experi- enced no sexual desires for nearly six years, though the testes were both perfectly sound all the time. The stomach, bowels, peritoneum, and spleen, were perfectly healthy. The liver, which was about the ordinary volume, was in a state of cirrhosis throughout. The gall-bladder contained about half an ounce of moderately thick, black bile. In the subjoined case, for the particulars of which I am indebted to Dr. W. H. Church, resident surgeon of the New York Hospital, the disease was associated with scirrhus of the liver. The patient, Robert Shippen, a mulatto, a servant by occupation, forty years of age, was admitted into the above institution on the 2d of January, 1851, under Dr. Watson, the attending surgeon, to whose kindness I am indebted for an opportunity of inspecting the urinary apparatus after death. His first sickness occurred twenty years ago, when he con- tracted a gonorrhoea, which was treated with injections, and imme- diately after the cure of which the stream of water became smaller than natural, and so continued to the present time. Independently of the above trouble, he was never seriously ill until a year ago, when he had intermittent fever, which lasted one month. Two months after this, he began to feel severe darting pains in the regions of the liver and spleen, aggravated during defecation, which was effected Avith a good deal of difficulty, and attended with much straining. Very soon his urine became dark-coloured; and in voiding it he felt a burning pain through the whole extent of the urethra ; frequently during its passage the water was suddenly stopped for a moment, when it escaped drop by drop for several minutes. These symptoms continued to increase in severity until six weeks ago, when, in attempt- ing to relieve his bowels, he found it almost impossible to do so; a discharge of foetid purulent matter being often the only result of such 248 DISEASES AND INJURIES OF THE BLADDER. efforts. There were also at various times discharges of a similar character from the urethra. About a month before his admission, he noticed, for the first time, a swelling and hardness at the upper part of the abdomen, Avhich have gradually increased to the present period, causing difficulty of breathing and a feeling of weight in that region. Two weeks ago his legs and feet began to swell, and he states that he has also some- times noticed slight oedema of his face. At the time of his admission, the patient was unable to lie upon his left side or back without pain, and he was obliged to pass his urine very frequently both day and night. The stream was very small and twisted ; sometimes double ; and the urine was of a dark colour mixed with blood. Micturition was always attended with a simultaneous passage from his bowels. The patient referred his greatest distress to the perinseum ; and upon examining this part, a tumour was found projecting from, and filling the space between the urethra and the rectum. An attempt was made to pass a bougie into the bladder, but it was arrested at the bulbous portion of the urethra; the finger was then introduced into the rectum, but the instrument could not be felt, owing to a large firm tumour occupying the place of the prostate gland, and extending further back than the finger could reach; it was tender on pressure, and unyielding. The attempt to pass the bougie caused so much hemorrhage that it was immediately desisted from. When sitting up a tumour was perceived in the hypo- gastrium, which, on handling, had the feel and fluctuation of water; but partially disappeared on the resumption of the recumbent posi- tion. He complained of continual pain in the abdomen, particularly in the liver, which filled the right hypochondriac and epigastric regions, extending far over towards the left side, as well as several inches below the umbilicus. The organ was not tender on pressure. The quantity of urine was less than natural, and on being tested was found to be alkaline, with slight traces of albumen, but no other evi- dence of derangement. His legs and feet were somewhat cedematous. The pulse was weaker than natural and more frequent; he had but little appetite; the tongue was covered with a brown fur, and he complained of great thirst; the bowels were constipated. He was ordered ten grains of calomel, to be followed by rhubarb and mag- nesia, to drink freely of flaxseed tea, and at bed-time to take one drachm of tincture of hyoscyamus. January 3d.—The medicine has operated freely; the patient slept SCIRRHUS OF THE BLADDER. 249 better than usual, and felt more comfortable this morning. He can void his urine in small quantities without a simultaneous discharge from the rectum, and the secretion is slightly increased. He was directed to take, three times daily, a pill composed of three grains each of blue mass and extract of taraxacum, with the free use of de- mulcent drinks, and a nourishing diet. January \2th.—There is not much change since the last report. The patient complains of severe pain in the abdomen, and his pulse is more feeble. The former treatment was continued with a bottle of porter daily, and anodyne to relieve the pain. This morning he had a severe attack of epistaxis, which ceased spontaneously. January 14£A.—The patient has continued gradually to sink, and this morning the pulse is hardly perceptible at the wrists. The sur- face is cold, and he has severe pain in the abdomen. He lingered until twelve o'clock at noon, when he died. The body was examined twenty-four hours after death. Upon cutting into the cavity of the abdomen an effusion of serum was found amounting to one gallon. The liver was enormously enlarged and filled with cancerous deposits, which were distributed through the whole of its substance. On the surface they appeared in round patches, slightly elevated and varying in size from that of a sixpence to that of a dollar. A section of one of these tubercles exhibited the characteristic aspect of soft cancer. The organ weighed, immediately after its removal, eleven pounds and a quarter. The intestines were healthy. The whole urinary apparatus was removed and carefully examined. The kidneys were somewhat enlarged, as were also their pelves; and the calibre of the right ureter was increased to at least three times its normal size. Between the bladder and the rectum was a large scirrhous tumour, the size of a goose's egg, involving the inferior wall of the bladder and separating it from the bowel. The urethra was easily traced as far as the bulbous portion, but here it was almost obliterated, and could not be distinctly followed into the bladder. The prostate gland was about the natural size, but unusually firm, and exhibited well-marked appearances of scir- rhous disease in the upper portion of its extent. The posterior wall of the bladder was covered with bright red granulations, very much resembling the papillas of the tongue in scarlatina, and occupying the place of the mucous membrane upon the anterior face of the tumour. Similar granulations also existed in the urethra for two-fifths of its 250 DISEASES AND INJURIES OF THE BLADDER. length, but they were of a darker colour and firmer consistence. The tumour in its whole extent presented the scirrhous character. The cavity of the bladder was diminished in size. The rectum Avas slightly congested, but in other respects healthy. The liver contained a great number of tumours, of a white appearance, and apparently of the mixed scirrhous and encephaloid character so common in that organ. A hard tumour, of the size of a Madeira nut, was firmly attached to the internal femoral vein. It was probably an enlarged lymphatic ganglion. All the other organs of the body were in a healthy con- dition. A few atheromatous deposits were found in the beginning of the aorta. The nares were examined, but nothing could be dis- covered there to account for the epistaxis. SECTION II. ENCEPHALOID. The bladder is sometimes the seat of encephaloid. This disease, which is likewise known by the name of fungus hsematodes, soft can- cer, or medullary sarcoma, is of a malignant character, and usually runs its course with great rapidity, destroying life occasionally in a few months. Any portion of the bladder may be affected with it, but its most common situation, by far, is just behind the neck of the organ, between the mouth of the urethra and the outlets of the ureters. The tumours vary much in number and appearance. Sometimes there is only a single one, which projects into the bladder and almost obliterates its cavity. In other instances as many, perhaps, as six, ten, or a dozen, are found, from the volume of a pea up to that of a walnut. In their shape no uniformity is observable. Nevertheless, they are, for the most part, somewhat rounded or pyriform, their attachment being effected by a narrow, elongated pedicle. The larger tumours often grow from a broad, flattened base, and occasion- ally from two or even three distinct footstalks. Externally they are of a grayish, or marbled appearance, while in their interior they are of a dull white or ash-colour. Their consistence is also variable, though in most instances it may be said to bear a very close resem- blance to the cerebral substance of a child under two years of age. Occasionally they exhibit a compound structure, one part being en- ENCEPHALOID. 251 cephaloid, another melanotic, a third hematoid or scirrhous. Sir Benjamin C. Brodie supposes that these tumours have their origin in the mucous membrane, an opinion which, I am convinced, is errone- ous. From repeated examinations I can unhesitatingly affirm that they take their rise in the submucous cellular substance, from which they project into the cavity of the bladder, carrying the lining mem- brane of that viscus along with them, so as to receive from it a com- plete investment. Tumours of this kind are often associated with calculous concre- tions, which are either partially embedded in their substance, or else lie loose in the bladder. When the patient labours, as he is apt to do, under the calculous diathesis, the surface of the morbid growth may become encrusted with sabulous matter, and hence, when the sound is employed, the sensation, and even the noise, may be of such a character as to deceive the most experienced surgeon. When of large size, these tumours encroach so much upon the bladder as to fill, in great measure, its cavity. Under such circum- stances, it often occurs that the coats of the organ are destroyed by ulcerative absorption, and that the morbid growths project through the perforation which is thus formed into the surrounding parts, as the colon, rectum, or small bowel. Again, it may happen that the disease, commencing in the vagina or uterus, may affect the bladder secondarily. In a patient who died in the Middlesex Hospital with medullary sarcoma of the organs just mentioned, Mr. Mayo1 found the bladder studded with small, white tubercles, about the size of peas, which had formed behind the mucous coat, but projected inwards. They appeared in all three of these situations of the same medullary texture. In most cases of encephaloid the intermediate substance of the bladder is perfectly healthy. In others it is diseased, and hyper- trophy is its most common alteration. Sometimes the organ is con- tracted, even to twice, thrice, or four times, the natural volume; occasionally, on the contrary, though rarely, it is enlarged, either partially or generally. The reduction has been known to amount to upward of five-sixths of the natural volume, the viscus being unable to hold more than an ounce or two of fluid at a time. In cases of long standing, accompanied with great difficulty of passing water, the muscular coat becomes immensely thickened, and of a deep red- 1 Outlines of Pathology, p. 541. London, 1836. 252 DISEASES AND INJURIES OF THE BLADDER. dish colour. The ureters are also sometimes affected, most commonly dilated, from the morbid growth plugging up their orifices, and thus causing the urine to accumulate in their interior. In the latter stages of the malady, the surface of the tumour opens at one or more points, from which there is a discharge of foul sanious matter, with encephaloid substance and clots of blood, and the lymphatic gan- glions of the pelvis become enlarged or even affected with fungus haematodes. I have already intimated that vesical fungus usually runs its course with great rapidity. The average period at which death occurs may be stated at about twelve months. Occasionally, however, life is prolonged to eighteen or twenty months, and in a few instances, even to the fourth or fifth year. Brodie1 states that he has known the disease to be protracted for seven or eight years. What influence age, sex, occupation, mode of life, and other cir- cumstances, exert upon the production of this disease, has not been satisfactorily ascertained, owing, not so much to its infrequency, as to a want of proper details of the cases of it upon record. Thus far it has been observed principally in men after the forty-fifth year. In women, it is generally associated with fungus of the uterus, vagina, or rectum. Concerning the exciting causes of it we are also in com- plete ignorance. In a few instances it has been traced to the effects of external violence, as a blow or kick on the perinseum, groin, or pubic region; but, in the great majority of cases, no reason what- ever can be assigned for its occurrence. The most prominent symptoms of this malady are local distress, frequent micturition, bloody urine, and a peculiar cachectic condition of the countenance. Let us examine these phenomena, somewhat in detail. The local suffering is always referred to the neck of the bladder, and consists originally merely in a sense of uneasiness; in the pro- gress of the disease it assumes a sharp, darting, or lancinating cha- racter, and extends to the neighbouring parts, such as the urethra, the perinseum, and groin. Sometimes it is felt even in the head of the penis, the sacrum, or loins; and in both sexes it is often accom- panied with a sense of weight, warmth, throbbing, or bearing down. It is generally worse immediately after voiding the urine, and is aggravated by pressure on the hypogastric region, by distension of 1 On the Urinary Organs, p. 107. Second Edition. London, 1835. ENCEPHALOID. 253 the bowels by flatus or fsecal matter, and by rough carriage or horse- back exercise. It is worthy of note, that, while in most cases the pain is of the most frightful character, in others it is entirely absent, excepting during the last few days of the patient's existence. The urine, which is at first of a dirty turbid appearance, or per- haps even entirely natural, is, in the advanced stage of the disorder, of a dingy brown colour, more or less slimy, of an offensive, cadave- rous odour, and mixed with fragments of encephaloid matter and clots of blood. Hemorrhage, indeed, is one of the most constant symptoms, and when associated with a discharge of cerebral sub- stance, may be considered as pathognomonic of the nature of the malady. The blood not only tinges the urine, but generally comes away in large clots or pellets of a dark modena or brownish colour. Until ulceration sets in the hemorrhage is usually very slight; after this occurrence it is always more profuse, and frequently so constant as to lead to great or even fatal exhaustion. In addition to these symptoms there is sometimes retention of urine, from the tumour plugging up the mouth of the urethra. Clots of blood or pellets of encephaloid matter may also become arrested in the passage, and so produce similar effects. In the latter stages of the disease, there is an aggravation of all the symptoms. The pain is more constant and severe, the micturi- tion more frequent and distressing, the hemorrhage is more copious, the urine, more turbid and offensive, is generally mixed with purulent matter and tenacious mucus, the digestive powers are sensibly im- paired, the sleep is disturbed and unrefreshing, the strength rapidly declines, the countenance assumes a sallow, cadaverous appearance, and the patient at length dies hectic and exhausted. In this enumeration of the symptoms of vesical fungus, reference has been made to several signs which are generally regarded as suf- ficiently characteristic of its existence. These are, first, uneasiness about the neck of the bladder; secondly, frequent desire to micturate; thirdly, a bloody state of the urine ; fourthly, a discharge of cere- bral matter ; and, fifthly, a peculiar hue of the countenance, in- dicating what is termed a cancerous cachexy. When all these symptoms are present, no reasonable doubt can be entertained respecting the nature of the case. Still, as he is constantly liable to err, the practitioner should never rest satisfied until the bladder has been thoroughly explored by the sound. Should no calculus be detected, it will afford additional proof of the existence of fungus. 254 DISEASES AND INJURIES OF THE BLADDER. The operation, it may also be stated, is generally attended, in the latter case, with considerable hemorrhage. The tumour can often be perceived by the finger introduced into the rectum, and the local distress is always aggravated by this kind of exploration. From the history Of this affection, as occurring in this and other organs, it may justly be regarded as one of the most malignant which the practitioner is called upon to treat. In no instance, so far as my information extends, has the patient derived any but the most transient benefit from the various curative measures that have been suggested for its relief. Nor is it likely, judging from the peculiar organization of encephaloid, that it will ever become amena- ble to the resources of surgery. To mitigate the suffering is all that can be done. With this view the strictest attention should be paid to the patient's diet, the bowels should be kept in a soluble state, the secretions of the skin, kidneys, liver, and mucous membranes should be duly regulated, rest in the recumbent posture should be enjoined, and the pain should be assuaged by morphia, cicuta, and other seda- tives. Where the local uneasiness is very great the frequent use of the hip-bath and opiate suppositories will be found eminently ser- viceable, and ought never to be neglected. Laudanum and starch enemata are less beneficial, because, from the constant straining which accompanies micturition, they are rarely retained long enough to answer the purpose for Avhich they are exhibited. To check the hemorrhage, Avhich is almost always considerable, especially after ulceration has set in, the acetate of lead, nut-gall, the muriated tincture of iron, the sulphate of quinine, and the mineral acids are our best medicines. With the same view the following formula, re- commended by Mr. Coulson, may be used. K. Infus. Rosse comp. 3vj. Pulv. Aluminis 3ss. Pulv. Gallarum 3iss. Acid. Sulph. dil. 3j.—M. Of this mixture two tablespoonfuls are to be administered every four hours. In addition to these measures, advantage may be de- rived, in obstinate cases of hemorrhage, from injections of the acetate of lead, or sulphate of alumina, and some bland mucilaginous fluid, in a tepid state. ENCEPHALOID. 255 CASES OF ENCEPHALOID DISEASE. Case I.1—A pauper, sixty-eight years of age, had laboured under an affection of the bladder upwards of five years, and d.uring the last six months he had suffered the most excruciating pain in the pelvic and lumbar regions, attended with almost constant inclina- tion to void his urine, which Avas effected with the greatest difficulty, either by drops, or in a very small stream, and generally coloured with blood. There was also great pain in the rectum, which was much aggravated by costiveness, and the prostate gland was en- larged and tender on pressure. A catheter of the smallest size entered the bladder with the greatest difficulty. A few days before he expired, the patient passed scarcely anything but blood, and the efforts of the bladder were of the most violent and distressing cha- racter. On dissection, the bladder was found to contain a tumour as big as a large orange, composed principally of loose coagula, mixed with a white pulpy substance. Its origin was derived mainly from the prostate gland, especially its middle lobe; but a portion of it, which was dense and hard, projected backwards over the lower surface of the bladder, and plugged up completely both ureters. The orifice of the urethra was also nearly closed. The excretory tube of the right kidney, which was large and very pale, was dilated in its whole ex- tent, and had given way about the middle of its course. The left kidney was natural; but its pelvis and ureter were greatly distended with turbid, foetid urine. The peritoneum was inflamed, and con- tained three pints of offensive-smelling fluid, mixed with blood. A number of small tumours, similar in their texture and colour to that of the bladder, existed in the liver and lungs. Case II.2—C. Askey, coachman, sixty-three years old, had been afflicted for several months with severe pain in the left hip, pelvis, and loins; continual uneasiness in the head of the penis, and fre- quent desire to make water, which came away with difficulty, and sometimes blended with a considerable quantity of blood. Long suffering and frequent returns of profuse hemorrhage had already reduced the patient to extreme emaciation and debility. No calcu- 1 Langstaff, Cases of Fungus Haematodes, London Medico-Chir. Trans., vol. viii. p. 279. 2 Samuel Cooper, London Medico-Chir. Trans., vol. xvii. p. 51. 256 diseases and INJURIES of the bladder. lus could be detected with the sound, and the suffering was never increased by exercise. Death occurred on the 20th of November, from copious hemorrhage of the bladder; but a few days before, while turning himself in bed, the patient broke his left thigh. The bladder contained about six ounces of turbid brown urine, and nearly as much coagulated blood. On the inner surface of the fundus of the organ, directly behind the pubes, was a hard, firm tumour, exceeding a crown piece in diameter, from which the copious bleedings had evidently taken place from time to time during the last five months of the patient's life. The kidneys were healthy; but the ureters were very much dilated, thin, transparent, and greatly distended with urine. All the lymphatic ganglions, in the vicinity of the abdominal aorta, were enlarged, and converted into a hard scirrhous substance. A similar substance surrounded the ends of the fragments of the broken femur, and also those of the fifth rib on the right side, which was accidentally found to have been fractured. Case III.1—A woman, aged fifty-seven, had a smarting uneasiness in making water, which in six months excited severe straining, accom- panied, when the bearing down was at all violent, with a discharge of blood. There were pains about the loins and hips, especially on the left side; the inclination to urinate was renewed every ten minutes, the local distress daily increased, the pulse was small, feeble, and 120 in a minute, and a tumour within the abdomen was manifest to the hand and eye. Fever and watchfulness now ensued, and the patient died gradually exhausted. On laying open the abdomen, the lymphatic ganglions of the pelvis and lumbar region were found in a state of carcinomatous enlargement, many of them being of the size of a hen's egg, and adherent, at various points, to the small intestines. The bladder was occupied by a congeries of tumours, seated in the submucous cellular tissue, which was very dense and firm, as well as much thickened. The quantity of disease varied at different points. Posteriorly and at the sides it was from two to three inches in thickness, while in front it was not more than twelve lines. It was made up principally of a soft, white, pulpy matter, interspersed with a cream-like substance. Many of the smaller tumours contained coagulated blood. Case IV.—Mr. Howship2 was requested to visit a female, aged 1 Howship, A Practical Treatise on the Urinary Organs, p. 198. 2 Op. cit. p. 194. ENCEPHALOID. 257 seventy-nine, who had long felt uneasiness about the bladder, and now complained of constant desire to pass water, which was of a turbid, purulent nature, voided in the smallest quantity, and some- times streaked with blood. The complaint had for the last two months advanced imperceptibly, but now allowed neither sleep nor comfort. Sometimes there was difficulty in micturition, accompanied with darting and cutting pains in the part. The bowels were habitu- ally regular. Pressure against the bladder, by the finger in the rectum, caused great suffering, and a sensation similar to that ex- perienced in passing water. She expired the day after Mr. Howship first saw her. The bladder contained a little thick bloody urine, and irregular masses of sabulous deposit, with a considerable quantity of pulpy, brain-like matter, decomposed and putrid at some points, and of a cream colour, firm consistence, and vascular texture at others. Several of the' tumours exactly resembled fungus hsematodes in their appearance. One, which lay on the left side, towards the posterior part of the bladder, was of the diameter of a five-shilling piece, and in a state of ulceration, with a ragged, pulpy cavity. The mucous lining towards the origin of the urethra was unnaturally red, and incrusted with sabulous matter. Case V.—Dr. E. Bissell,1 of Norwalk, Connecticut, has described an extraordinary instance of this disease in a man sixty-seven years of age, who had enjoyed uninterrupted health until April, 1842. About this period he was seized with irritation in the bladder and constant inclination to urinate, attended with frequent discharges of blood, and agonizing pains, which finally produced exhaustion and death. The tumour, which could be felt through the rectum and the abdominal walls, was of an ovoidal shape, nine inches in the vertical direction by four and a half in the transverse. It originated near the neck of the bladder, and was of the real encephaloid cha- racter. Its texture was soft, pliable, and easily torn with the finger. The organ Avas so completely filled with it that it was unable to hold the smallest quantity of urine. The kidneys and other viscera were sound. Case VI.—A man who had been repeatedly sounded for stone entered the Hotel-Dieu of Paris, under the care of the celebrated Dessault.3 He had felt for some time past fixed and lancinating pains in the region of the bladder, which gradually augmented in violence, 1 American Jour. Med. Sciences, New Series, vol. vii. p. 122. 1844. 2 Surgical Works, by Smith, vol. ii. p. 153. Phila., 1814. 17 258 DISEASES AND INJURIES OF THE BLADDER. and were accompanied by bloody micturition, troublesome itching at the end of the penis, and an occasional discharge of pellets of putri- fied flesh from the urethra. The flow of urine became more and more difficult, a catheter could hardly be passed into the bladder, and the patient at length died worn out with marasmus and horrible suffering. The tumour, originating from the neck of the bladder, was larger than two fists, and filled the whole cavity of the viscus. Case VII.1—An old man was admitted into the surgical ward of the Bicetre of Paris, in 1834, for retention of urine. There was almost a constant discharge of nearly pure blood from the urethra. The patient was much emaciated, and a circumscribed tumour could be plainly felt in the hypogastric region. Various attempts were made to draw off the urine with the catheter, but without success. After death the cavity of the bladder was found to be almost entirely effaced; its posterior wall was occupied by a cancerous tumour larger than a fist, and composed of encephaloid tissue. The free surface of the morbid mass was fungous, and of a blackish colour. The mus- cular fibres were red and hypertrophied; and near the summit of the bladder the peritoneum was raised into several prominences which had been distinguished during life across the attenuated parietes of the abdomen. Cancerous matter was found in the neighbouring veins. All the other viscera were sound. Case VIII.—Fungus hsematodes is occasionally developed between the peritoneal and muscular coats of the bladder. The following case of this occurrence is related by Mr. Bulley, in the London Med. Gazette for October, 1845. The tumour was as large as a middle- sized cocoanut, and extended from the fundus of the organ along its posterior surface to within three-quarters of an inch of the prostate gland. The upper portion of the mass was in a state of softening, easily broken down, and intermixed with pus; in the middle it closely resembled healthy brain, and at the lower part it was of a firm, fibrous, almost scirrhous consistence. The patient was a man forty years old. The urine had passed latterly in small quantity, and was invariably mixed with blood. The tumour pressed upon the rectum to a great extent, and was thus probably the cause of the anasarcous condition of the parts about the anus. Encephaloid deposits were found in the lungs, liver, and the interior of the heart. 1 Mercier, Recherches sur les Maladies des Organes Urinaires et G^nitaux, p. 134. Paris, 1841. TUBERCULAR DISEASE OF THE BLADDER. 259 SECTION III. COLLOID AND MELANOSIS OF THE BLADDER. Colloid and melanosis have never been observed, so far as I know, in the urinary bladder. That they do, however, occur here appears not improbable, especially when it is recollected that both these varie- ties of cancer are occasionally developed in some of the other mucous cavities. Be this as it may, they must be exceedingly rare; and, as we are entirely ignorant of their history, in relation to the organ in question, no further notice need be taken of them in this place. SECTION IV. TUBERCULAR DISEASE OF THE BLADDER. The bladder is sometimes the seat of tubercular disease. The deposit is commonly met with in the form of minute granulations, similar to those which occur in the bowels and the air-tubes. They are of a pale yellowish colour, rounded or spherical in their shape, of a semi-concrete consistence, and of the size of a radish-seed or a small shot. Their number is generally small. It is probable that they may occur in any part of the bladder; but they are by far most common in the neck and bas-fond of the organ. The seat of this deposit is in the mucous follicles, in the substance of the mucous membrane, and in the submucous cellular tissue. In some instances, especially when the granulations are numerous, the heterologous matter can be shown to exist simultaneously in all these situations. Each tubercle, while in a crude state, is surrounded by a delicate vascular network, which contrasts so much the more strikingly with the neighbouring parts, inasmuch as these are almost always perfectly healthy. After these bodies have existed for an indefinite period, they begin to soften, and are finally entirely broken down and expelled, leaving in their stead so many small, roundish ulcers, with thin, ragged, and undermined edges, precisely as in the larynx, trachea, and alimentary canal. Tubercular disease of the bladder is generally, if not invariably, associated with the same deposit in other parts of the body, espe- 260 DISEASES AND INJURIES OF THE BLADDER. cially the kidney and the prostate gland. Its co-existence with tubercular disease of the lungs is uncommon. Dr. Lombard of Geneva noticed it only once in one hundred autopsies. Louis does not record a solitary instance of it in connexion with his three hun- dred and fifty-eight cases of pulmonary phthisis. Rilliet and Bar- thez make no mention of the coincidence in their dissections, which amounted to three hundred and fourteen. In my own examinations I have never observed it. In fact, in the only instance in which I have ever found this disease, death was produced by a psoas abscess, the lungs being perfectly sound. A considerable quantity of tuber- cular deposit, however, existed in the kidneys, the prostate gland, and the seminal vesicles. It is not known what influence, if any, age, sex, temperament, habit, climate, and occupation exert upon the production and pro- gress of this disease. The probability, however, is that the same laws are in operation here as in tubercular deposits in other parts of the body. There are, unfortunately, no symptoms by which we can, with any certainty, determine the existence of tubercular disease of the blad- der. As long as the deposit remains in a state of crudity, there is, in general, merely a slight degree of irritability of the mucous mem- brane, with increased frequency of micturition; but these effects do not differ in any respect from those produced by ordinary causes. In a case described by Dupuytren, the symptoms resembled those of stone, and this eminent surgeon actually cut his little patient, a boy two years and a half old. When the softening process has com- menced, the peculiar matter of tubercle is discharged along with the urine, in which it can often be detected with the naked eye. Where any doubt exists concerning the true nature of the purulent fluid, a small quantity of it should be placed under the field of a microscope. If it be tubercular, it will be distinguished by the peculiar character of its corpuscles, which are much larger than those of ordinary pus, of a whitish-yellow colour, and of a lenticular, round, or oval form, with jagged edges, and concentric rings. These circumstances, added to the history of the case, and the fact that the patient gene- rally experiences, at this stage of the affection, severe pain and spasm at every attempt at micturition, will go far in clearing up the diagnosis. CHAPTER VII. POLYPOUS, FUNGOUS, ERECTILE, AND OTHER MORBID GROWTHS OF THE BLADDER. Various morbid growths, not strictly malignant in their character, occasionally occur in the urinary bladder, such, for example, as polypes; but even these are exceedingly rare, and thus far I have not had an opportunity of observing an instance. Dr. Baillie, with- out particularly describing this heteroclite product, observes, that he has seen only one example of it. It filled the greater part of the cavity of the organ, was of a pretty firm texture, and presented a very irregular appearance, being made up of various projecting masses.1 Numerous cases of this disease are recorded by the older authors. Zacutus Lusitanus found a polype in the bladder of a man who died of retention of urine, of the size of a goose's egg, the inte- rior of which was occupied by a tough, glutinous substance. It was situated at the neck of the viscus,,and caused great difficulty in mic- turition. Another but harder and more fleshy mass existed in the body of the bladder.2 In a man sixty years of age, for the last two of which he had experienced constant pain in voiding his urine, Kirch- ner,3 a German physician, found the neck of the bladder very much thickened, and occupied by a small fibrinous body, not more than a few lines in length, which projected forwards into the urethra, and thus obstructed the flow of urine. Similar cases are mentioned by Sylvius, Rollin, and other authors. Warner4 removed a polype from 1 Works, by Wardrop, vol. ii. p. 264. London, 1825. *■ Prax. Medic. Admirab., Lib. ii. Obs. lxxi. p. 58. 3 Medic. National. Zeitung for 1799, p. 138. 4 London Philos. Transact., No. 495, p. 414,1749; also Warner's Cases in Surgery. In this case the tumour proj ected into the urethra, causing retention of urine, for which the catheter was obliged to be constantly used. This was frequently attended 262 DISEASES AND INJURIES OF THE BLADDER. a young woman which grew from the neck of the bladder into the urethra, so as to cause serious embarrassment in voiding the urine; and an instance of the same kind precisely, fell under the notice of Walter,1 in a girl who died of spasmodic disease. This disease occasionally exists at a very early period. An exceed- ingly instructive case illustrative of this fact is recorded by the late Mr. Crosse, in his excellent work on Urinary Calculus, published in Lon- don in 1835. When this distinguished lithotomist was first consulted, the boy was only a year and a half old, and the vesical disorder, namely, frequent desire to pass his water, had already been present upwards of a month. He was continually wet with urine, which was voided in drops at intervals varying from a few minutes to half an hour, and every effort of the kind was attended with the most violent straining and rubbing of the head of the penis. The rest was con- stantly disturbed, the body became greatly emaciated, the general health rapidly declined, and the countenance was expressive of the deepest suffering. Under the belief that the little patient was affected with calculus, the bladder was repeatedly sounded by Mr. Crosse and another surgeon, a practitioner of great experience; and finally, when two years old, it was determined that an operation should be attempted for his relief. In opening the membranous part of the urethra, a semi-transparent substance appeared in the wound, re- sembling the mucus which had passed from the bowel when the child was placed on the table; and for a moment the operator feared he had cut into the rectum. On carrying the knife forward fairly to the neck of the bladder, the incision became instantly filled with a mass resembling, at first sight, the vermiform process and several folds of small intestine, but which, upon further examination, was found to be composed of a cluster of soft polypes, connected to each other and the inner surface of the organ by a loose, pendulous mem- with great pain as well as considerable hemorrhage, by which the patient was at length much reduced. The tumour was attached to the lower part of the bladder, near its neck, and could be felt, though not without difficulty, with the finger. The bladder being full of water, and the patient made to strain, the tumour was thus forced down, when it was seized with a crooked needle, and a ligature passed through its substance. An incision was next made into the urethra, when the morbid mass was pulled down, and tied firmly round its base. Some pain of the abdomen followed the operation, but the retention of urine immediately subsided. The tumour, which resembled a turkey's egg in shape and size, dropped off on the sixth day, and the woman soon entirely recovered. 1 Krankh. der Nieren und Harnblase, p. 30. MORBID GROWTHS OF THE BLADDER. 263 brane. They varied in their size from that of a pea up to that of a big grape, the attachment of some being by a narrow neck, of others by a broad base. All that were within sight were cut off with the scissors; many, however, remained, and no material benefit resulted from the operation. Death occurred in forty-four hours, preceded by perpetual straining efforts. On inspection, the peritoneum was found to be entirely free from inflammation, and the rectum was also uninjured. The cavity of the bladder was still occupied by several tumours, which adhered to the lining membrane at the inferior part of the organ, towards its neck. One large mass with a broad base, firmer than the rest, and situated near the orifice of the left ureter, must have been the resisting body, which, according to Mr. Crosse, was so generally felt on sounding. A few smaller ones, from the volume of a pea to that of a bean, were loose in the bladder. Towards the neck of the viscus the tumours had a different structure, presenting a wart-like or tuberculated sur- face. They were all covered by a reflexion of the mucous mem- brane, none of which was in a healthy condition, being loose, gelati- nous, and thickened, in all parts where there were no polypes, from the orifices of the ureters to the fundus. The neck of the organ and the prostatic portion of the urethra were much dilated, and the nar- row base by which the tumours in this situation were attached was so flabby as to allow them to project into the excretory canal, causing the obstruction to the flow of urine, and the unnatural fulness of the perinseum before adverted to. The muscular coat was also conside- rably hypertrophied, the ureters were enlarged and contorted, and at the fundus of the organ, in the subserous cellular substance, was a small abscess filled with pus. M. A. Petit, of Lyons, once performed the operation of cystotomy on a young woman, in the belief that there was a stone, both he and his friend supposing they had felt one. It turned out, however, to be a tumour, and they agreed that nothing could be done; the patient lived a year after, and on dissection, the bladder was found to be occupied by a large pyriform polype with an extremely narrow pedicle.1 I have already alluded to the case of Warner, in which a tumour of this kind was successfully extirpated from the inside of the bladder. Various anomalous growths, known by the terms fatty and steato- 1 Crosse on Urinary Calculus, p. 49. 264 DISEASES AND INJURIES OF THE BLADDER. matous, are sometimes observed in the bladder, but their occurrence is so rare that it is scarcely necessary here to allude to, much less to describe them. They seldom attain a large bulk, are generally situated in the bas-fond of the organ, and always exhibit the same structure as in other parts of the body. Interesting cases of this morbid product are recorded by Schaffer,1 Ludwig,2 and Schwertner.3 In the instance mentioned by the second of these writers, the subject was a man sixty years of age, who died from retention of urine. On laying open the bladder, two tumours were discovered, one of which, movable, and about the size of a filbert, was situated at the right side of the neck of the organ; the other, fixed, and of the volume of an English nut, a little further out. They were both traversed by varicose veins, and of a fatty nature. In the case recorded by Schaffer, the morbid product was of a steatomatous character; it was of the size of a hen's egg, and lay immediately between the outlets of the ureters, where it could be felt by the finger introduced into the rectum. The lining membrane of the bladder was considerably hypertrophied, especially at the posterior part of the organ, and its inner surface covered with a thick tenacious mucus. The patient, an old man, had laboured for several years under great difficulty of micturition, accompanied with violent straining efforts, uneasiness in the loins, and a sense of weight in the pelvis and perinseum. In Schwertner's case the tumour was-also of the steatomatous kind, in- terspersed with small scirrhous masses; it weighed nearly one pound, and was so voluminous as to encroach very much upon the pelvic cavity, its surface being in a state of ulceration. Frequent micturi- tion, A-iolent pains in the bladder and hip, and bloody urine, were the most prominent symptoms. The patient was a middle-aged man. The bladder is sometimes the seat of a peculiar fungous growth, a species of vegetation of the mucous membrane. The disease is occa- sionally noticed in early life, but is most common in middle-aged and elderly subjects. Males are most liable to it. It is generally in- sidious in its origin, and nothing is known respecting the nature of its exciting causes. The growth varies in its size from that of a pea to that of a pullet's egg, and is of a soft, spongy consistence, with a rough, fimbriated, or villous surface. In some instances, as in the specimen from which the annexed drawing was taken, it oc- 1 Medicin. National Zeitung fur Mai, 1798. 2 Prolusio, de Ischuria ex tumoribus Vesicae. Lips. 1767. 3 Richter's Chirurg. Biblioth. Band V. S. 554. MORBID GROWTHS OF THE BLADDER. 265 curs in considerable numbers, so as to stud the greater part of the surface of the bladder. Its form is generally globular, ovoidal, or pediculated, and its colour is commonly a few shades redder than that of the mucous membrane upon which it rests, and from which it arises. Examined with the knife, the tumour is found to consist of Fig. 26. Fungous tumours of the bladder, copied from Civiale. The walls of the bladder are much thickened; and the inner surface of the viscus is studded with numerous excrescences, the surface of which has a singularly fimbriated appearance. The prostate is much increased in volume, and the middle lobe forms a nipple-like process which projects backwards into the bladder. The urethral crest is much enlarged. a grayish, cellulo-fibrous tissue, covered by a prolongation of the lining membrane. Small vessels enter it in different directions, and are liable, when ruptured, to pour out a considerable quantity of blood. The surface of the morbid growth is often incrusted with calculous matter, and, in the few instances in which I have met with it, it was associated with stone in the bladder. The only evidence of the existence of this disease is the presence in the urine of a por- tion of the abnormal substance. All other symptoms are fallacious. Tumours of an erectile, vascular character, similar to that of an anastomotic aneurism, or a maternal nsevus, sometimes occur in this organ. The annexed drawing, Fig. 27, taken from a preparation in the pathological collection of the New York Hospital, represents a growth of this description. The specimen was deposited by Dr. 266 DISEASES AND INJURIES OF THE BLADDER. Cheeseman, one of the surgeons of that institution, to whose polite- ness I am indebted for the following history of the case. The patient was a widow, seventy-two years of age, of a spare habit of body, and the mother of five or six children. Though naturally feeble, her general health was always good until about three years before her death, Avhen she began to complain of uneasiness in her bladder, attended with a frequent inclination to void her urine, which was always mixed with blood. Her symptoms gradually increased in Fig. 27. violence ; she became pale and ansemic, and finally died completely exhausted. For some time before her death, she suffered severely from pain in the bladder during micturition, especially immediately after the passage of the last drops of water. She never experienced any retention of urine, and the blood always came away in a dis- solved condition. Upon examining the bladder, after death, a tumour was found upon its floor, of a soft, spongy character, of a florid colour, circular in its form, and about two inches in diameter. It seemed to spring from the mucous membrane, and had a rough, irregular sur- face, not unlike that of a cauliflower. The parts around were free from inflammation and other disease ; but the muscular tunic was somewhat thickened and reticulated. All the other organs were healthy. MORBID GROWTHS OF THE BLADDER. 267 Of the exciting causes and diagnostic characters of polypous, fun- gous, steatomatous, and other tumours of the bladder, nothing, unfor- tunately, is known. From the constant pains in the pelvic region, with the straining efforts, and frequent inclination to void the urine, which are almost constantly present, the existence of stone is apt to be suspected ; an apprehension which is not always relieved by sound- ing, which, however, should never be omitted in cases of a doubtful nature. Whenever, in any manner, their real character can be ascer- tained, the bladder should be laid open, as in the common operation of cystotomy, and the morbid growth removed with a pair of probe- pointed scissors curved on the flat. From their want of vascularity it is not probable that much hemorrhage would attend this procedure, and if the subsequent inflammation, which would no doubt generally be considerable, could be combatted, the patient would be perfectly safe, the more especially as the disease is rarely, if ever, of a malig- nant character, and consequently not liable to reproduction. In 1834, Mons. Civiale, the distinguished lithotomist, communi- cated to the Academy of Sciences, of Paris, the particulars of several cases of fungous tumours of the bladder, in which he appears to have succeeded in effecting a complete cure by means of torsion and crush- ing. The apparatus employed for this purpose was of peculiar con- struction, and the operation consisted in separating the morbid growth from its attachments, and then breaking it into small fragments, Avhich were afterwards discharged along with the urine. In one of the patients thus treated, considerable blood was lost, and in another the operation was followed by high inflammation. They both, how- ever, completely recovered. Where the diagnosis can be clearly de- termined, such a mode of procedure might not be improper; but in all doubtful cases, and especially when the tumour is of a vascular character, I should be very loath to resort to it. Le Cat, long ago, recommended cutting forceps for removing fungous tumours of the bladder.1 No internal remedies, so far as is known to us, exert the slightest influence in arresting these tumours, or in modifying their growth and development. Hence, all that the practitioner can do, where the disease cannot be reached by operation, is to endeavour to pal- liate the patient's suffering, by anodynes, and such other means as his actual condition may, from time to time, seem to require. 1 Philos. Transact, of London, vol. xlvii. p. 29. CHAPTER VIII. WORMS IN TIHE BLADDER. It seems almost incredible, when we reflect upon the irritative nature of the urine, that the bladder should ever be the residence of worms. Such, nevertheless, is the fact, and the probability is that the occurrence is much more frequent than is generally supposed. Many instances of the kind, bearing all the intrinsic evidence of authenticity, are recorded by the older writers, as Rhodius, Bonnetus, Bartholin, Tulpius, Barry, Henkel, and Acrel, and by Lawrence, Curling, Brigham, Campbell, and others, among the moderns. The worms are either of a distinct and specific character, such as are found in no other situation, or they creep into the bladder from the rectum, the colon, or the small intestine. In nearly all the recorded instances of the latter, the animal was of the lumbricoid or ascaric variety, which left its accustomed habitation, and migrated into the urinary reservoir, either by perforating the coats of the alimentary canal, or, as more frequently happened, through an ulcer produced by the irritation of an abscess, a piece of bone, or some other extraneous body. Of the worms which naturally inhabit the urinary bladder, only two species have hitherto been discovered ; the one by Mr. William Lawrence, the other by Mr. T. B. Curling, of London. The animal described1 by the first of these distinguished surgeons, is the spiroptera, of which, in the space of about two years, a young, unmarried woman, twenty-four years of age, voided not less than from eight hundred to a thousand. They varied in length from four to six inches, and were remarkably slender at the middle, from which they gradually in- creased towards the extremities, which were small and tapering. One of the surfaces of the body exhibited the appearance of a double 1 Medico-Chir. Transactions of London, vol. ii. p. 385. WORMS IN THE BLADDER. 269 row of small protuberances, while the other was marked by a groove with two rising edges. They were soft when first voided, and of a yellowish colour. The body seemed homogeneous throughout, and careful microscopical observation failed to throw any light upon its organization. The smaller worms, which were seen only on one occasion, were semi-transparent, and of a rounded form, with pointed extremities. I am not acquainted with any instances in which this worm has been noticed in the human subject by other observers. The worm discovered by Mr. Curling1 has been named by him dactylius aculeatus, from its peculiar ring-like appearance. It was voided with the urine, for a number of days, by a little girl, five years of age, who was affected with subacute pneumonitis, and who was also occasionally troubled with ascarides. The worm is of a light colour, cylindrical in its form, annulated, and slightly tapering towards the extremities, particularly the anterior, which is the smaller. The female is four-fifths of an inch long Fig. 28, the male two-fifths, Fig. 29. The head is Fig. 28. Fig. 29. truncated ; the mouth orbicular; the neck distinctly annulated; and the tail, also annulated, is obtuse. The tegument, of a delicate transparent structure, and containing two layers of muscular fibres, one circular, and the other longitudinal, is armed with a number of sharp-pointed spines, arranged in equi- distant rows, in clusters of three, four, or even five. They cover nearly the whole surface, and seemed to be perfectly under the con- trol of the animal, which has the power of protruding and retracting them at pleasure. The alimentary canal commences at the mouth by three small convoluted tubes, which soon unite into a single one, which proceeds for some distance in a tortuous direction, when it becomes sacculated, and, enlarging as it descends, it terminates at the extremity of the tail in a trilobular anus. The structure of the female is much more complicated than that of the male. The vulva is situated near the anterior extremity, about one-fifth of an inch from the head, and has the appearance of an opaque, mammillated process. The animal swells at this part, the tegument is thicker, there are no spines, and, for a short dis- tance above and below the vulva, the body is encircled by a series of regular, dark-coloured fibres. About midway between the head 1 Medico-Chir. Transactions of London, vol. ii. p. 274. 270 DISEASES AND INJURIES OF THE BLADDER. Fig. 30. Kg. 31. Fig. 30.—a. The head. b. The caudal extre- mity, c. Sacculated alimentary canal, d. Dark lines at the junction of the anterior and middle third of the animal. Fig. 31.—a. Head, with the orbicular mouth. 6. Caudal extremity, with the labiated anus. c. Vulva, d. The three tubes by which the alimentary canal commences, e. Alimentary canal. /. Pulsating tube in the alimen- tary canal, g. Lobulated bodies round the commencement of the alimentary canal, h. Glandular bodies on the sides of the canal, t. movable fimbriated bodies near the vulva, k. Convoluted oviducts. WORMS IN THE BLADDER. 271 and vulva, and on opposite sides of the alimentary canal, are two granular bodies, of an oval form, and just below these, two slightly convoluted tubular processes. No genital apparatus was discernible in the male. Both sexes have a distinct vascular, and, doubtless also, a nervous system. The wood-cuts on the opposite page, repre- sent the internal structure of the worm. Fig. 30 is the male, Fig. 31 the female, both magnified ten times. In the interesting case related by Dr. Campbell,1 of Connecticut, a man, sixty-five years of age, passed, in the space of three weeks, thirty small, red-headed worms, not more than half an inch long. Their bodies were made up of a great many minute cartilaginous rings, and were furnished with a number of legs, arranged in two distinct rows, extending from one extremity to the other. They were hard, very active, strong, and remarkably tenacious of life. Two of them, inclosed in a quill, and carried in the pocket, were, at the end of four weeks, as lively and vigorous as at the moment when they left the bladder. It is to be regretted that Dr. Campbell could not determine the species to which these worms belonged. Of the causes of vesical worms nothing whatever is known. The number of recorded cases are too few, and the facts connected with them have been too imperfectly noted, to justify us in drawing any conclusions from them, in regard to the etiology of these singular beings. The symptoms of worms in the bladder are exceedingly equivocal. In general, they are such as'attend stone. The patient is harassed with pain, frequent and difficult micturition, spasm and sudden stop- page of the flow of urine, followed ultimately by fever, derangement of the digestive organs, and gradual emaciation. Sometimes there is paralysis of the bladder, the contents of which are obliged to be evacuated from time to time with the catheter. If the sound be used, and it comes in contact with the foreign body, the sensation is imparted to the hand of a soft mass or tumour, which fails to emit the sharp noise, or click, peculiar to calculus. The urine, espe- cially in protracted cases, is frequently loaded with mucus, and sometimes tinged Avith blood. The only diagnostic sign is the appearance of the worm itself. In the case described by Mr. Lawrence, the patient, a female twenty-four years of age, was seized, in the winter of 1806, with 1 Amer. Journ. Med. Sciences, vol. xxi. p. 130. 272 DISEASES AND INJURIES OF THE BLADDER. retention of urine, requiring the daily use of the catheter. She complained of great weight in the bladder, pain about the loins, and numbness of the thighs. She seldom passed any water, and then only a few drops, much tinged with blood. By 1809, she was much emaciated; her tongue had often a typhoid appearance ; she had no appetite; there was pain in the lumbar and vesical regions ; and for six months she had voided no urine, except with the aid of the instrument. About this time she was seized with violent fits when- ever the water was retained longer than usual, or whenever the pain and burning heat in the bladder were particularly great. Sounding increased the local distress, and produced in the patient a sensation as if the instrument had struck against a ball at the top of the organ. From this period the feeling of weight gradually augmented, and she experienced an internal fluttering, as if something was moving. The quantity of urine gradually diminished, the fluttering became more violent, and so strong as to be perceptible to the hand; and the bladder, which was much enlarged, even when entirely empty, was so tender that the weight of the bed-clothes could not be borne. Worms now began to pass, affording, for the first time, a clue to the nature of the disease. No symptoms of derangement of the urinary organs existed in the case of Mr. Curling. The discovery of the worms was altogether accidental. In the case reported by Dr. Campbell, the patient had been affected for several years with occasional interruptions of the flow of urine, which went on gradually increasing until it amounted to complete retention. There was, moreover, irritation at the neck of the bladder, accompanied with pain, and a frequent desire to make water. In the case mentioned by Dr. Brigham,1 of Connecti- cut, in which a married woman, thirty-five years old, passed a white round worm, about six inches long, the symptoms so closely resem- bled those of stone that the sound was repeatedly used, and he was sent for to perform the operation of lithotomy. From the situation of the bladder, it is evident that any worms infesting it must be beyond the reach of medicines, administered by the mouth. It does not appear, that, in the cases observed by Mr. Lawrence, Curling, and others, any benefit whatever resulted from the use of anthelmintics ; such, for example, as the oil of turpentine, and the balsam of copaiba, which, it is well known, has a specific 1 Amer. Journ. Med. Sciences, vol. xx. p. 59. WORMS IN THE BLADDER. 273 tendency to the urinary organs. The best mode of proceeding is to employ stimulating injections, three or four times a day, for the pur- pose of making a direct impression upon the worms. Of the various articles that suggest themselves the most likely to effect the object are a solution of vinegar, creosote, aloes, chenopodium, spirits of tur- pentine, and garlic. These, if properly diluted, may be thrown into the bladder without injury to its lining membrane, and with a reason- able prospect of proving destructive to its inmates. To derive full benefit from their administration, the urine should, in all cases, be previously evacuated, that the fluid may be brought in more imme- diate contact with the entozoa. The frequent introduction of the catheter has, in repeated instances, been attended with good results. By pressing the point of the instrument against an animal of this kind, it might be squeezed to death, and even be entangled in its eyelets. Dr. Artaud, a French surgeon, succeeded, in one instance, in removing a number of worms and fleshy substances from the blad- der of an unmarried woman of twenty-six, by means of Hunter's forceps. 18 CHAPTER IX. SEROUS CYSTS AND HYDATIDS. Serous cysts have sometimes been discharged from the urethra, and found after death floating loose in the bladder. The probability is that they are seldom, if ever, developed in this organ, but that they pass into it from the kidney, along the ureter, or from the pelvic cavity through an artificial opening. They have been observed in both sexes, and at different periods of life. Varying in size between a millet-seed and a pigeon's egg, they are of a globular figure, white and transparent, and filled with a thin, watery fluid. Their presence is productive of pain and spasm of the bladder, with frequent mictu- rition and sudden stoppage of the flow of urine, followed sometimes by total obstruction. The occasional existence of acephalocysts in the bladder is well known. Though generally very small, they sometimes attain the volume of a pullet's egg; they are of a globular or ovoidal shape, and exhibit the same structure as in other parts of the body. Like the serous cysts just described, they produce no characteristic symp- toms, and are probably always developed originally in the kidneys, or in the cavity of the pelvis. CHAPTER X. FCETAL REMAINS IN THE BLADDER. The remains of a foetus have sometimes been found in the bladder; but the occurrence is extremely rare, and is hardly of any practical interest. Occasionally only a single bone is met with, as in the in- stance mentioned by Sir Benjamin C. Brodie, where there was merely a jaw, with full-grown teeth. Most commonly, the osseous fragments exist in considerable numbers, and are intermixed with soft substance and calcareous concretions. In all cases of this kind, the foetus is originally developed in the abdominal cavity, the ovary, or the Fal- lopian tube, from which it gradually makes its way into the urinary reservoir, in consequence of ulcerative action produced by its own presence. The resulting symptoms resemble those of stone in the bladder; but the diagnosis must necessarily be obscure, unless there is a discharge of bony fragments, teeth, hair, or other debris of the included foetus. When the quantity of retained matter is conside- rable, it may form a tumour, which will be hard to the touch, and readily distinguishable through the walls of the abdomen, the vagina, and the rectum. The most remarkable example, perhaps, of this occurrence upon record, is that mentioned by Dr. Josephi,1 of Rostock. I subjoin the following abstract of it in illustration of its symptoms and progress. A woman, in the thirty-seventh week of her second pregnancy, was seized Avith violent pains in the abdomen, which were followed by paralysis of the right leg, on recovering from which, a few weeks after, she no longer perceived the movements of her child. Her breasts, however, were filled with milk. Towards the fifteenth month a discharge of putrid blood took place from the vagina. A month after this her menses returned, and she enjoyed pretty good health, except that she had frequent pains in the bowels and a sense of pres- 1 London Medical and Physical Journal, vol. xiv. p. 519. 276 DISEASES AND INJURIES OF THE BLADDER. sure in the bladder. At the end of nine years she began to suffer from ischury, attended with violent spasms in the pelvis, and a con- stant inclination to pass water, which was very scanty, of a whitish, purulent character, and often mixed with thick, jelly-like lumps. Three years after this, she observed a hard body in the urethra, fol- lowed by degrees by a discharge of ninety-four calculi, a number of cranial bones, some vertebrae, six teeth, a tibia, and a part of a fibula, and twenty-one flat pieces. Twenty months subsequently, and when the woman was forty-seven years of age, Dr. Josephi found her bladder much distended, and easily distinguishable by the touch. The supra-pubic operation was now performed, and the whole organ was discovered to be filled with a hard mass, intermixed with soft substance. One hundred and twenty pieces of bone, partly entire and partly eroded, were extracted; besides twenty calcareous con- cretions, some cartilages, a portion of the skull and face, and the bowels, which were of a dark blue colour. The operation ended fatally in three days. The bladder was of a thin, spongy texture, and at many parts cartilaginous. Its inner surface was studded with a great many soft excrescences. At the upper part of the organ was a hole about the size of a sixpence, with hard, callous edges. Towards the right side was a considerable bag, adhering to the bladder, and containing a portion of the bowel. Opposite to this, on the left side, was another opening, about two inches and a half in diameter. Through this opening the bowel protruded into the bladder, along with a fold of the peritoneum, which formed a separate sac, the surface of which was smooth, and covered with purulent matter. The right ovary and part of the right Fallopian tube were destroyed. The uterus and other viscera were sound. CHAPTER XI. HAIR IN THE BLADDER. A number of examples in which this phenomenon was observed, are recorded by authors. The publications, however, which, so far as I know, contain the most ample information on the subject, are Voigtel's " Handbuch der Pathologischen Anatomie," and Delpech's " Chirurgie Clinique." In the first of these productions are refe- rences to nearly all the cases of the kind which had been recorded up to the time of its appearance early in the present century. The affection is more common in women than in men, in the former of whom it is frequently associated with disease of the uterus, ovary, or Fallopian tube, and is probably nearly always the product of a false conception. What corroborates this view is, that in many cases, the bladder and uterus are closely adherent, and communicate together by a distinct opening; moreover, the foreign substance is occasionally found in company with foetal remains, as a bone, carti- lage, or tooth. The hair may be loose in the bladder, or it may be encysted or enclosed in a membranous sac. When it exists in con- siderable quantity, it gives rise to severe pain, irritability of the bladder, and all the ordinary symptoms of stone. A discharge of hair has been known to continue, with various interruptions, for several years. Tulpius relates an instance in which it was voided regularly every fortnight. It generally passes off in small pellets, surrounded by mucous and earthy matter. In the male, it usually occurs in connexion with stone, to the surface of which it sometimes firmly adheres. The hair is occasionally closely matted, and of great length. In the very interesting and instructive case recorded by Delpech,1 large quantities of hair, mixed with calculous matter, were from time to time extracted from the bladder through the urethra. The dis- 1 Chirurgie Clinique, T. xi. p. 521. 278 DISEASES AND INJURIES OF THE BLADDER. ease caused severe pain in making water, and other symptoms of stone. Having obtained all the information he could respecting the nature of the complaint, by repeated soundings and manual explora- tions, he divided the meatus with the lithotome cache" towards the pubic symphysis, and extracted a small calculus, together with a large mass of hair and earthy matter, which had been contained in a cyst in the back part of the bladder, where this organ was united to the uterus. A portion of the cyst itself was subsequently removed, partly by ligature, and partly by injections, passed through a pipe into its cavity from a height of six feet. The woman finally reco- vered, after the discharge of an additional quantity of hair and cal- culous matter, and a substance as large as a hen's egg, which was covered by scalp, and contained a molar tooth. CHAPTER XII. AIR IN THE BLADDER. Cases are occasionally observed in which the bladder contains air, although in every respect organically sound. The phenomenon has been chiefly witnessed in connexion with paralysis of the bladder, consequent upon over-distension, injury of the spine, or disease of the brain. The urine is generally natural, both as it respects its colour, quantity, specific gravity, and chemical reaction. The air, the precise character of which is unknown, either issues in the form of bubbles, or passes off with a gurgling noise; the latter is especially apt to occur when a catheter is used. In some instances the organ has been found nearly filled with gas. It is not easy to determine how the air is formed in these cases, whether it is a secretion by the mucous coat of the bladder, or whether it is the result of decom- position of the urine. It is not unlikely that the former is the more correct explanation of the two;—at all events, the conjecture, for it amounts to nothing more, derives support from the fact that the viscus is generally in a state of paralysis, and therefore incapable of performing its functions in a healthy or satisfactory manner. In great torpor of the bowels, gaseous distension is of frequent occur- rence, and probably arises from this cause. CHAPTER XIII. HEMORRHAGE OF THE BLADDER. A discharge of blood from the bladder, technically denominated haematuria, although not of frequent occurrence, is generally a source Of disquietude to the patient, from a belief, not altogether unfound- ed, that it is a symptom of evil portent. The subject is one, how- ever, apart from any consideration of this kind, of sufficient im- portance to merit attention in a monograph on the diseases of the urinary passages. This is the more necessary, because of the re- serve, if not actual silence, with which it is treated in most of our systematic works on surgery. Hemorrhage of the bladder occurs in both sexes, and at all periods of life. Men, however, are more prone to it than women ; and it is likewise more common in old and middle-aged subjects than in children and adolescents. A sort of endemic tendency to this form of hemorrhage has sometimes been noticed, but the circum- stance is extremely rare, and I have never witnessed it. What in- fluence, if any, climate, and season, and habit exert upon the pro- duction of this affection, we have no facts to determine. The hemorrhage is of such infrequency, comparatively speaking, that it would be a difficult matter to clear up this subject. Vesical hemorrhage presents itself under two varieties of form, the idiopathic and the traumatic. The idiopathic variety is infre- quent, and is met with chiefly in elderly persons, of a weak, lax habit of body, or in such as are affected with scurvy or an anaemic condition of the system. It sometimes occurs in association with, or as a consequence of, rubeola, small-pox, plague, and typhoid fever. The traumatic form of hemorrhage is usually the result of a wound of the bladder, such, for instance, as is made in the operation of lithotomy; or of the rude or forcible use of instruments, as the lithontriptor, the bougie, sound, or catheter. The bleeding, under such circumstances, may proceed either from one tolerably large HEMORRHAGE OF THE BLADDER. 281 vessel, or from a considerable number of small ones, and in either case, it may be small and insignificant, or so profuse as to endanger life. Persons affected with stone are very liable to suffer from hemor- rhage of the bladder, especially after rough exercise, whether con- ducted on foot, in a carriage, or on horseback. Some years ago I had a calculous patient, twenty-three years of age, who experienced frequent attacks of this kind from the most trivial exertions, in many of which he lost from two to three ounces of blood. Worms, accidentally lodged in the bladder, or developed there, have been known to cause a profuse and even a fatal hemorrhage. Violent concussion of the body, as from a fall or counter-blow, severe exer- cise on 'horseback, and venereal excesses, may be enumerated as among the more common causes of this affection. A considerable hemorrhage of the bladder occasionally results from the use of drastic cathartics and irritating diuretics, especially cantha- rides and spirits of turpentine. Ulceration of the mucous and sub- mucous cellular tissues of the organ is nearly always accompanied by bleeding, and one of the most characteristic signs of fungous, ence- phaloid, and erectile tumours, is a considerable discharge of blood. In a case of the latter growth, to which allusion will be made in its proper place, the hemorrhage was so constant and profuse as to end fatally. Finally, vesical hemorrhage is sometimes vicarious of the menstrual flux and suppressed hemorrhoidal discharges. It has also, though rarely, marked the crisis of other diseases. The pathology of this affection is thus perceived to vary according to the nature of the exciting cause. In the traumatic form, for in- stance, the bleeding is produced by direct injury of the vessels, and the same is probably true when it accompanies ulceration and the presence of a stone. In the latter case, the friction of the concre- tion, especially when it is rough, against the surface of the bladder, is sufficient to lacerate the delicate vessels of the mucous membrane, and to produce frequently a smart discharge of blood. In the idio- pathic form, the probability is that the bleeding is the result of a process of exhalation, or more philosophically speaking, of secretion. The hemorrhage which accompanies the presence of erectile, fun- gous, and other tumours, is caused, in most cases, by rupture of the bloodvessels, from over-distension of their coats, which are generally, in these formations, in a weakened and fragile condition, and there- fore prone to give Avay under the slightest causes. 282 DISEASES AND INJURIES OF THE BLADDER. The quantity of blood varies in different cases, and under different circumstances, from a few drachms to several pounds. In the trau- matic variety the flow may be so copious as to prove fatal in a few hours, if not, indeed, much sooner. Persons who are cut for stone, or whose bladders are wounded accidentally, not unfrequently lose their lives in this manner. A copious hemorrhage may also result, as was previously intimated, from ulceration of the bladder, and from the presence of morbid growths. In these cases, however, life is usually destroyed gradually, not suddenly, as it sometimes is when the bleeding is of a traumatic nature. A violent hemorrhage occa- sionally follows upon severe bodily exertion, as in the instance re- corded by Van Swieten,1 of a riding-master, who, soon after an at- tempt to break a stubborn horse, discharged not less than eight pounds of blood in a few hours. After recovering from the attack, he remained well for several years, when he had a return of the bleeding, more copious and protracted than the first, from the effects of which he never recovered. Great debility ensued, and he finally died dropsical. The blood varies likewise in its colour and consistence. When recently effused into the empty bladder, it is of the natural appear- ance ; but if it has been retained for some time, or been mixed with the urine, it assumes a dark-brownish, turbid, or muddy hue, not unlike port wine, or the water used for washing flesh, or bleeding in the foot. In some instances, especially when it is pent up for a long time, it is of the colour of tar or molasses. In its consistence, the blood may be liquid, semi-fluid, or completely coagulated. The former condition generally obtains when the effusion is recent, and the second, when it is of several hours standing. Full coagulation seldom takes place, except in the traumatic form of the affection, in connexion with an empty, or partially empty bladder. These changes in the colour and consistence of the effused blood are owing to the chemical action of the urine, and hence they will generally be slight or well marked, according to the quantity and quality of the fluid present. The most important, because the most characteristic symptom of vesical hemorrhage, is a discharge of blood from the urethra, either alone or in combination with the urine, and accompanied, if the quantity be at all considerable, by a frequent desire to micturate, ' Comment, in Aph. Pat., 1422, p. 251. HEMORRHAGE OF THE BLADDER. 283 spasm at the neck of the bladder, and a burning sensation along the course of the urethra. When the blood coagulates nearly as fast as it is poured out by the bladder, it may lead to retention of urine, either partial or complete, temporary or permanent. Copious effu- sions of this kind may be followed, sooner or later, by all the symp- toms of exhaustion, such as nausea, faintness, pallor of the counte- nance, feebleness of the pulse, sighing, restlessness, coldness of the extremities, and clammy perspiration, excessive thirst, and death. Hemorrhage of the bladder is liable to be mistaken for hemorrhage of the kidneys, the ureters, prostate gland, and urethra; and it need hardly be added that the diagnosis is sometimes difficult, if not impracticable. In case of direct injury of the bladder by wound, calculus, or instrument, there need be no room for doubt. The nature of the lesion is sufficiently obvious. In the idiopathic form of the hemorrhage, however, great uncertainty must frequently exist. Under such circumstances, the history of the case, and the absence of disease or injury of the associated organs, may assist in clearing up the difficulty, and leading to a correct diagnosis. In renal hemorrhage, the disruption is usually dependent upon injury or organic disease of the kidneys, and is, therefore, apt to be pre- ceded and accompanied by symptoms referable to these organs, such as aching, heat and pain in the loins, retraction of the testes, and an altered state of the urinary secretion, with, perhaps, some de- rangement of the general health. The blood is commonly of a pale pink or claret complexion, and either entirely fluid, or partly fluid and partly coagulated; it is never voided in a pure state, as it often is when it proceeds from the urethra or the neck of the bladder. When the blood proceeds from the ureters, it is generally pro- duced by the presence of a calculus, the passage of which lacerates some of the vessels of the mucous membrane, and gives rise to sudden and violent pain, extending to the back and groins, intermitting in its character, and attended with retraction of the testes, distressing nausea, vomiting, cold sweats, and a sense of excessive prostration, and even faintness. Hemorrhage of the urethra is generally produced by external vio- lence, the passage of a calculous concretion, or the venereal orgasm, and the blood commonly passes off in small cylindrical or vermiform pieces, without any material change of colour, or any desire to void the urine. In many cases the blood is discharged in drops, or in a small stream. It is worthy of remark, that the same appearances 284 DISEASES AND INJURIES OF THE BLADDER. may be present when the blood proceeds from the prostate gland, or the neck of the bladder, or, in fact, from any other portion of this organ, without mixing with the urine. It should also be borne in mind, that, in hemorrhage of the urethra, the blood may regurgitate into the bladder, where, uniting with the contents of that viscus, it may assume the aspect and consistence which belong to the blood in vesical hemorrhage. In such a case, it may be exceedingly difficult to establish the diagnosis as to the source of the bleeding. Hemorrhage of the bladder is serious or otherwise, according to the circumstances under the influence of which it is produced. In the traumatic form, as already stated, it may terminate life in a few minutes, or, at all events, be so copious as to induce great exhaus- tion of the vital powers. As an accompaniment of fungous and other tumours, it always portends danger, not, however, perhaps so much on its own account, as on account of the disease which gives rise to it, which is seldom amenable to treatment of any kind. The idiopathic form is in general easily managed, and therefore rarely fatal. The signs which indicate danger, in an attack of this descrip- tion, are pallor of the face, nausea, vomiting, sighing, restlessness, small and feeble pulse, cold sweats, and general prostration with prsecordial oppression. Hemorrhage may prove serious in another way; not by inducing fatal exhaustion, but by causing intractable retention of urine from the retention of coagulated blood. In the treatment of vesical hemorrhage, attention must be paid to the nature of the exciting cause, which must necessarily, in all cases, exert a controlling influence in regard to our therapeutic agents. In the traumatic variety, the ordinary haemostatics are, of course, indicated, and should be employed without delay. Accessible arte- ries are exposed and tied, and, where this is impracticable, compres- sion and cold applications are used. When the hemorrhage depends upon the presence of a foreign body, such as a calculus or worm, the offending cause is sought for and removed. When it proceeds from an encephaloid, fungous, or erectile tumour, palliation alone is at- tempted ; for the morbid growth by which the bleeding is induced will be sure to progress, and at no distant day destroy life. In such cases, our main reliance is upon opium and lead, gallic acid, and alum, with acidulated drinks, rest in the recumbent posture, and cold applications to the perinaeum and hypogastrium. The catheter is carefully avoided, for its introduction could scarcely fail to re-excite the hemorrhage, by disturbing the morbid growth or the mucous HEMORRHAGE OF THE BLADDER. 285 surface in its immediate vicinity. In a case of vesical hemorrhage, dependent upon the presence of fungous excrescences of the bladder, and in which the loss of blood was frequent and sometimes conside- rable, I generally succeeded in affording prompt relief by a good dose of calomel and rhubarb, followed by alum and opium, with sulphuric acid and infusion of roses as a common drink. In idiopathic hemorrhage of the bladder, great attention must be paid to the system; vascular action is reduced, the bowels are regu- lated, the secretions are corrected or improved, the diet must be light and unstimulant, and the drinks should be cooling and acidu- lated. Absolute rest in the recumbent posture is of primary impor- tance. The internal remedies upon which reliance is mainly to be placed, are gallic acid, in doses of from three to five grains, acetate of lead, and sulphate of alum. These articles ought usually to be combined with opium, and be repeated every two, three, or four hours, according to the exigencies of each particular case. Tannic acid, matico, and sulphuric acid, also prove highly efficacious, and occasionally succeed where other remedies fail. When the hemor- rhage is caused by an anaemic state of the system, chalybeate tonics are indicated, and the best forms are the muriated tincture, the sul- phate, and the aromatic wine of iron, in doses proportioned to the age of the patient and the tolerance of the stomach. In bleeding of the bladder, vicarious of the menstrual flux, emmenagogues and aloetic purgatives are required, to aid in restoring the function upon the suppression of which the discharge of blood depends. In all cases, the action of the internal remedies is promoted by refrigerant appli- cations to the perinseum, the inside of the thighs, and the hypo- gastric region. Cold enemata are also beneficial, and a lump of ice introduced into the rectum sometimes acts like a charm. When the hemorrhage is accompanied by pain and spasm, leeching and cupping over the sacrum may be useful. Direct medication, in the form of astringent injections, such as solutions of alum, acetate of lead, and gallic acid, have occasionally proved serviceable, and should not be neglected in obstinate cases. Great precaution, however, is neces- sary in their administration, lest the catheter injure the mucous membrane, and thus increase the flow of blood. In general, the blood which is poured out in vesical hemorrhage is dissolved by the urine, and thrown off by the natural channel. In some instances, however, especially when the secretion of urine is deficient, or the quantity of blood disproportionably large, the accu- 286 DISEASES AND INJURIES OF THE BLADDER. mulated fluid coagulates and distends the bladder, which forms a hard, firm tumour above the pubes, and leads to complete retention of urine, attended by the most urgent and distressing symptoms. To free the organ of its contents, under such circumstances, is often no easy task. The more simple means are of course resorted to first. With a silver catheter, introduced along the urethra, an attempt is made to break up the coagulated mass, and then to dis- solve the pieces by the injection of tepid water and acetic acid, in the proportion of one ounce of the latter to five ounces of the former. Vinegar is a powerful solvent of blood, and is far better than water alone. The injections should be conducted with great care, and should be repeated two or three times in the twenty-four hours. Some of the smaller coagula may sometimes be removed by a syringe applied to the catheter, though such a procedure is, in general, quite ineffectual. When all other means fail, and the symptoms are so urgent as not to admit of further delay, the only thing to be done is to open the bladder. The operation may be performed either at the perinseum, or above the pubes, and is conducted in the same manner as for the removal of stone. When practicable, the lateral method should always be preferred, both on account of the facility of its execution, and the more dependent situation of the aperture. CHAPTER XIV. RETENTION OF URINE. SECTION I. GENERAL OBSERVATIONS. The symptoms of retention of urine are generally well-marked, even at an early stage of the complaint. In this respect, however, there is, as might be supposed, considerable diversity in different cases, depending mainly upon the natural tolerance of the bladder, and the character of the exciting cause of the disease. In paralysis of the muscular fibres of the organ, attended with loss of sensation, the accumulation may make great progress, and yet the individual not be aware of his real condition. A slight discharge of urine, perhaps, occasionally takes place; or if, as often happens, inconti- nence is soon superadded to the original disorder, the fluid dribbles off incessantly, and thus both patient and physician are lulled into a false security. When, on the contrary, the retention is inflamma- tory, more or less pain, and frequent inclination to void the urine, with inability to do so, attend the complaint, and at once expose its true character. In all cases, where suspicion points to the disease, a careful examination of the hypogastric region should be instituted, aided, if there be any obscurity, by the finger in the rectum or the vagina. The tumour in the hypogastrium, formed by the distended bladder, fluctuates distinctly, especially when the retention is caused by paralysis; it is tender on pressure and percussion, and is fixed in its situation, or indisposed to obey the motions of the body. Pain frequently exists at a very early stage, and steadily increases until, in many instances, it becomes agonizing. In protracted cases, more especially in the inflammatory form of the affection, it is often 288 DISEASES AND INJURIES OF THE BLADDER. accompanied with forcing, straining, or bearing down sensations, similar to those in dysentery and parturition; with rigors alterna- ting with flushes of heat, thirst, and excessive restlessness; the patient tossing about in the wildest and most frightful manner. The urine, in the mean time, is discharged in gushes, jets, or drops, not in a full stream, or in any considerable quantity at a time. This symptom often sets in at an early stage of the complaint, and is apt to lead the unwary into error, by inducing the belief that the case is one of mere incontinence instead of retention. Such a mistake, unfortunately not uncommon, is often fatal to the poor sufferer; the proper means of relief are neglected, the accumulation pro- gresses, and the bladder, distended to its utmost power of endurance, either mortifies, or bursts; or, more or less of the fluid is absorbed, and the patient dies under all the symptoms which denote the suppression of the renal secretion. The fatal event, however, in- deed, is generally preceded by a typhoid state of the system; a small, shattered pulse; cold, clammy sweats; pale and shrunken features; hiccup and twitching of the tendons ; nausea, extreme restlessness, urinous perspiration, and profound coma. During the progress of the retention, the distended bladder, by pressing on the rectum, impedes the exit of the fseces, and leads to pain and fulness of the bowels. From the same cause, there is sometimes partial prolapsion of the vagina, and, in both sexes, even of the rectum. When the tumour has reached its maximum development, it pushes up the diaphragm, and sensibly embarrasses the respiratory function. The coats of the bladder, in the more severe forms of the affection, are attenuated, and, owing to the constant pressure which they experience, ultimately inflame, and are ready to give way under the accumulated suffering. In those who die, softened, ulcerated, or gangrenous patches are often observed; the valves of the ureters are forced apart, and the urine, highly vitiated and offensive, ceases to descend from the kidneys, or is, as was before stated, entirely suppressed. The period at which death occurs in this affection varies in different cases and under different circumstances. Most patients, if not relieved, perish in five or six days; a few before this time, and a few not until later. The immediate cause of death may be rupture of the bladder, with effusion of urine into the peritoneal cavity; exhaustion from mortification of the coats of the organ; or empoisoning of the system from suppression of the renal secretion. RETENTION OF URINE. 289 Diagnosis.—One would suppose that retention of urine could seldom, if ever, be mistaken, when we consider its mode of origin, progress, and symptoms, which are usually sufficiently characteristic. Yet, strange as it may appear, some very singular, as well as very unfortunate blunders have occasionally been committed, in this respect, and that too by men who, from their skill and experience, ought to have known better. The affection with which it is most liable to be confounded is ascites, or dropsy of the peritoneal cavity. I subjoin the following cases in illustration of the subject, hoping they may serve as a beacon-light to prevent similar mistakes in future. The first case is mentioned by Boyer,1 upon the authority of Frank, an eminent German physician. A young man having re- ceived a fall upon his loins, became paralytic, and affected with incontinence of urine. Notwithstanding this, the abdomen enlarged prodigiously, and the surgeon was about to tap the patient, when an exploration of the bladder through the rectum, made at the sug- gestion of Frank, caused a discharge of urine by the urethra. A catheter was introduced, and at two operations twenty-four pounds of water were withdrawn. The instrument, which was retained at first in the bladder, was removed a few days before the death of the patient, on account of the excessive pain and distress in the lumbar region. Upon dissection, eighty pounds of urine were found in the bladder, which had pushed the diaphragm up into the chest, and greatly embarrassed the respiratory movements. Wandcehren, a Dutch surgeon, had the candour to avow that he attended a woman whom he believed to be labouring under dropsy, but who died of retention of urine, not, however, before he had accidentally punctured the bladder.2 A similar case is mentioned by Sir Everard Home. A delicate female perceived that her abdomen was enlarging with- out any appreciable cause or special inconvenience; the distension was gradual, and was soon followed by anasarca, first, of the lower extremities, and then of the upper. The disease was pronounced ascites, and tapping was advised for its relief. The fluctuation of the tumour was quite evident. Before the operation was performed some diuretics were prescribed; and it was ascertained, in the mean time, that there had been a total suppression of urine for three days. 1 Maladies Chir., T. ix. p. 181. 2 Chopart, Maladies des Voies Urinaires, T. i. 340. 19 290 DISEASES AND INJURIES OF THE BLADDER. The catheter being introduced, eighteen pounds of urine were re- moved, followed by the subsidence of the abdominal tumour, and the disappearance of the anasarca.1 On the other hand, dropsy has sometimes been mistaken for re- tention of urine. The elder Berard relates a case of the kind. The patient was supposed to be labouring under distension of the blad- der ; the catheter, as was conjectured, came in contact with a stricture, and was pushed on with so much violence as to pierce the bladder, followed by an escape of the ascitic fluid. The patient died, and the fact here stated was verified by the dissection of the body.2 In the above cases, the list of which might be considerably ex- tended, the error in the diagnosis evidently arose from a superficial examination, and from a hasty conclusion in regard to the nature of the disease. Had the facts, as they existed, been carefully inquired into, there is no probability that any mistake could have taken place, much less such a serious one as happened in several of the cases. It is only in paralysis of the bladder followed by a gradual accu- mulation of urine, without any particular local distress, that difficulty of the kind will be liable to occur; but even here no man in his senses would be likely to tap a patient without a careful circumstan- tial examination of the case, more especially if there happened to be incontinence of urine. Such examples teach us the value of care, and the importance of taking nothing for granted. A careless practitioner might mistake a distended bladder for a supra-pubic abscess. A man, says Colot, had not relieved his blad- der for eight days, when all of a sudden he voided a large quantity of urine. Notwithstanding this emission, the tumour, which existed above the pubes, did not diminish; the part, moreover, became hot and tense. The surgeon in attendance, believing there was an abscess, decided to puncture the swelling, when Colot, convinced of the contrary, introduced a catheter into the bladder ; a large amount of urine came away, and the supposed abscess at once disappeared. The same lithotomist states that, on another occasion, he was instru- mental in preventing a similar mistake.3 The diagnostic symptoms are, the existence of a hard, pyriform, circumscribed tumour, corresponding with the middle line, more or 1 Boyer, op. cit., T. ix. p. 179. 2 A. Berard, Diagnostic Chirurgicale, p. 122. Paris, 1836. 3 Belmas, Traite de la Cystotomie Suspubienne, p. 63. RETENTION OF URINE. 291 less tender on pressure, fluctuating, not affected by change of pos- ture, and gradually increasing in volume; a frequent desire to void the urine, which, if passed at all, is discharged in drops, or small jets, never in a full stream or in any considerable quantity; uneasi- ness, and a sense of weight in the pelvic region, soon followed by pain and spasm; straining, forcing, or tenesmus at every attempt at micturition; at first, absence of fever, and then rigors, alternating with flushes of heat; and, in the latter stages of the affection, exces- sive restlessness, an indescribable sense of oppression, urinous breath and perspiration, typhomania, and a hippocratic condition of the countenance. In addition to these signs, which none but a heedless practitioner can mistake, there is also generally, after the first few days, a constant dribbling of urine, and the distended bladder can be easily felt by the finger in the rectum and the vagina. In ascites, with which this affection is most liable to be confounded, the abdominal tumour is diffused, not circumscribed, and changes its form and situation with the position of the body ; there is little or no tenderness on pressure or percussion ; the sense of fluctuation is more distinct; the progress of the disease is more tardy; the urine, although more scanty than in health, is voided several times in the twenty-four hours, generally without pain or difficulty ; there is com- monly anasarca of the lower extremities ; the skin is remarkably dry and harsh; and there is usually an absence of febrile disturbance, and ahvays of typhomania and urinous perspiration. The treatment of retention of urine is by the catheter ; no time is wasted in the hope of overcoming the difficulty by other means ; the indication is to relieve the distended organ with the least possi- ble delay, and the instrument is therefore resorted to at once, before the part and the system have sustained serious mischief. Immediate relief folloAvs the use of the instrument; the pains and other symp- toms disappear; and the patient passes from a state of torment into one of entire happiness, similar to that of the poor female, who, after having been racked for several days with the most violent labour-pains, finds herself at length safely delivered of her burden, and is ready to sink into a profound slumber. When there is great distension, amounting to several quarts, it is best and safest, as a general rule, not to empty the bladder at a single operation, but gradually, drawing off a portion of its contents now, and another by and by. The catheter is introduced, and half the fluid is evacuated, to afford the over-stretched fibres an oppor- 292 DISEASES AND INJURIES OF THE BLADDER. tunity of contracting and regaining their power. Some hours after- wards the instrument is again used, and the remainder of the urine is withdrawn. Under this practice there is less risk of inflammation of the bladder and of general exhaustion. Where this precaution is neglected, the abdomen should be supported with a compress and a broad roller, as after tapping and parturition. A large opiate should also be exhibited just before, or immediately after, the operation, premising, of course, that there is no contra-indication on account of cerebral oppression. Retention of urine may be produced, first, by mechanical obstruc- tion ; secondly, by paralysis; thirdly, by spasm; fourthly, by inflam- mation ; and fifthly by the presence of a pelvic tumour. Hence, in order to understand the treatment of this affection, it is necessary to devote separate consideration to each class of causes. I. The first class of causes may affect either the urethra, the bladder, or the head of the penis. a. The urethra may be obstructed by an organic stricture, a cal- culus, clotted blood, coagulating lymph, inspissated mucus, or an enlarged mucous follicle. A catheter, bougie, or other foreign body may break off in the canal, and thus become an impediment to the egress of the urine. In 1848, I attended a gentleman, forty-four years of age, in whom retention was repeatedly caused by the arrest in the urethra of large pieces of solid and apparently organized lymph, some of them upwards of two inches in length. He had long laboured under disease of the bladder, from the effects of which he finally died. A considerable quantity of this substance is some- times deposited in this canal, as a consequence of inflammation, where, gluing together its walls, it produces the same effect as an organic stricture. The obstruction is occasionally produced by a small tumour, caused by enlargement of a mucous follicle. The tumour varies in size from an apple seed to a pea, is quite hard and firm, and feels as if it were embedded in the spongy body of the canal. Its situation is commonly in the anterior part of the urethra, but sometimes it is far back, or just in front of the neck of the bladder. When it acquires a considerable bulk, it may at length lead to complete retention, fol- lowed by ulceration of the tube behind the seat of the obstruction, extravasation of urine, and even death. The treatment is regulated by the size of the tumour. The moment it begins to act obstructingly, the catheter, lubricated with some RETENTION OF URINE. 293 gently stimulating ointment, is introduced once a day, and kept in contact Avith the part for several minutes. Simultaneously with this, an attempt is made to promote its absorption by external applica- tions, as the camphorated mercurial ointment, or some preparation of iodine. If these means fail, and the obstruction steadily increases, an incision is made through the spongy body, down upon the tumour, which is then removed with the knife or scissors. Retention in the female, is occasionally caused by maldirection of the urethra, or by the manner in which this tube mounts up in front of the pubes. The jet of urine, in consequence of this arrangement, passes upAvards and forwards, and the catheter, to reach the bladder, must be inclined, at first, from above downwards, and then. upwards and backwards. Secondly, the obstacle may lie exterior to the urethra, and the consequences be the same as when it exists internally. Thus an abscess in the perinseum, if not timeously evacuated, may, by its pres- sure, force the sides of the tube so firmly together as to offer an effectual barrier to the Aoav of urine. Similar effects may result from a deep-seated collection of blood, an effusion of lymph, or the presence of a boil, a phlegmon, or a malignant tumour. Cancer of the penis, in its progress towards the bladder, and contusions of the perinseum, with or without rupture of the urethra, are frequently followed by the worst forms of retention of urine. It is obvious, from what precedes, that the treatment of retention of urine, caused by mechanical obstruction of the urethra, must vary according to circumstances. In organic stricture, the ordinary means are resorted to, and when these fail, our only resource is puncture of the bladder. Fortunately, however, this is rarely, if ever, necessary, for even in apparently the most desperate cases, we may usually succeed, with patience and proper management, in entering the bladder. A silver catheter, of suitable size, is carried down to the seat of the obstruction, and, by steady but firm pressure, urged on towards the distended reservoir. Occasionally the imme- diate cause of the retention is spasm, excited by the irritable state of the stricture. In such circumstances I have repeatedly succeeded in obtaining prompt relief by pressing the instrument for a few minutes against the anterior surface of the obstacle. Where the passage of even the smallest-sized catheter is impracticable, the stricture may be divided Avith the lancetted stylet, as described in a preceding section. I confess I have great repugnance to puncturing 294 DISEASES AND INJURIES OF THE BLADDER. the bladder, and should never think of resorting to it until all other means are exhausted. It is difficult to imagine a case Avhere it would be really necessary. An impacted calculus may, in general, be pushed back into the bladder or extracted with the urethra-forceps. Where these means fail, it is removed by incision, the patient being placed, if the offend- ing body be lodged low down, as in the operation of lithotomy. Pieces of bougie or catheter, broken off and retained in the tube, are managed upon the same principles. Clotted blood, coagulated lymph, and inspissated mucus are easily displaced by the catheter, or forced out by the urine. When the sides of the urethra are glued together by adhesive matter, as occasionally happens in contusions of the perinaeum, the obstacle can only be overcome by the gentle use of the instrument. In such cases false passages might be easily made. When the obstacle is seated externally, and bulges inwards so as to occlude the canal, the knife supersedes the catheter, the use of which would be productive of much pain, especially in a perinseal abscess. The parts are freely divided from without; the distension is instantly removed, and the urine is enabled to flow along the natural channel. When the obstruction is produced by extravasated blood, in consequence of a fall or kick, its absorption is promoted by the application of acetate of lead, muriate of ammonia, or spirituous embrocations. In retention from malignant disease of the penis, the bladder is relieved by puncture above the pubes. In contusions of the perinaeum without rupture of the urethra, the catheter is used; but when the accident is attended by laceration, a large incision is made, to save the tissues from urinous infiltration. b. In the second place, the obstruction may be seated in the bladder. Of this class of causes the most frequent are, hypertrophy of the prostate gland, coagulated blood, inspissated mucus, coagu- lated lymph, and urinary concretions. The gravid uterus, or any other pelvic tumour, may, by compressing the neck of the bladder, give rise to the same effect. The most common form of obstruction of the bladder, productive of retention of urine, is hypertrophy of the prostate gland. This affection, which is almost peculiar to old age, and which is generally the result of chronic inflammation, is liable to exist in various degrees, from the slightest change of volume to eight or ten times the natural bulk. The hypertrophy may involve the entire organ, RETENTION OF URINE. 295 or it may be limited to one of its lateral lobes, or even to its mam- millary process. In most cases all these parts are affected simulta- neously, though not to the same extent. A very distressing and intractable form of retention of urine is occasionally produced by the mammillary process, or, as it is more commonly called, the third lobe of the prostate, which is often many times larger than in the healthy state, constituting a thick, triangular body, which closes the mouth of the bladder like a valve. When the hypertrophy is seated in one of the lateral lobes, the commencement of the urethra may be forced to one side, and in this Avay it may cause not only retention of urine, but offer great difficulty to the introduction of the catheter. Retention of urine, dependent upon enlargement of the prostate gland, is usually of a temporary character, but is liable to be pro- duced by the slightest exposure to cold, by irregularity of diet, by horseback exercise, sexual indulgence, or neglect to empty the bladder. During the attack, as well as for some time after, the urine is loaded with thick, tenacious mucus, and exhales an offensive ammoniacal odour, the calls to micturition are frequent and urgent, there is scalding in the urethra, with a sense of weight or throbbing in the perinaeum, and the patient often suffers indescribable torments. As the disease progresses, the bladder diminishes in capacity, so that it can scarcely hold an ounce of urine at a time, and its muscular fibres, thickened and hypertrophied, assume a retiform appearance, not unlike that of the fleshy columns of the heart. The kidneys are frequently diseased, and the urethra is almost always conside- rably elongated. In protracted cases, the retention is apt to be attended Avith incontinence, and the organ is rarely entirely emptied without instrumental aid. The treatment is by the catheter; and one of silver is far prefer- able to one of gum elastic. It must be large in the curve, and at least two inches longer than in ordinary cases, otherwise it will fail to reach the distended reservoir. The instrument passes on without difficulty until it comes in contact with the enlarged gland, when its progress is arrested. Instead of forcing it onward, the surgeon in- troduces the left index finger, well oiled, into the rectum, and placing it against the instrument, he guides its beak into the bladder, by pushing it gently tOAvards one side or upwards towards the pubes, at the same time that he urges the handle on with the right hand. By this manoeuvre the obstacle is usually overcome without much trouble, 296 DISEASES AND INJURIES OF THE BLADDER. however great the enlargement of the prostate. To empty the bladder completely it is necessary, as the point of the catheter can- not reach the cavity behind the gland, to raise the patient's hips, so as to force the urine out of its hiding-place. I am well aware that many highly respectable practitioners give a preference, in these cases, to the gum elastic catheter; but, what- ever may be said in its favour, I feel satisfied, from personal expe- rience, that it is altogether inferior to the silver instrument. The former is soft, flexible, and easily bent upon itself when it meets with the slightest resistance; the latter, on the contrary, is firm, un- yielding, and therefore well calculated, with proper care, to sur- mount every obstacle that may oppose its progress. Much time is frequently wasted, and much mischief done, in retention of urine from enlarged prostate, from the fruitless attempts which the prac- titioner makes to insert the gum elastic catheter. Unless he has more tact in the use of the instrument, and more knowledge of the anatomy of the parts, than fall to the lot of most men, he will be almost sure to be baffled in nine cases out of ten; comparatively little skill, on the other hand, will enable him to pass a silver in- strument. When the enlargement of the prostate is associated with inflam- matory symptoms, as it occasionally is when it is dependent upon engorgement rather than upon hypertrophy, properly so called, the treatment is by antiphlogistics, such as venesection, leeching, anti- monials, the hip-bath, and anodyne enemata. The catheter is with- held, if possible, for fear of adding to the excitement. Undue distension is of course avoided. Retention of urine, from coagulated blood in the bladder, is a very serious affair. The fluid may be poured out by the bladder itself, descend from the kidneys, or regurgitate from the urethra, either as a consequence of injury or disease. However furnished, it soon coagulates, and thus affords a barrier to the flow of urine. When the quantity of blood is very large, which, however, cannot always be satisfactorily determined beforehand, relief must be sought by an opening in the perinseum, similar to that in lithotomy. Under ordi- nary circumstances, however, evacuation is attempted by a full-sized silver catheter, with large eyelets, aided by injections of warm water, and an exhausting syringe. The water dissolves the blood, and renders its removal more easy. The usual hsemostatic means are also employed. When the blood has been recently effused, in con- RETENTION OF URINE. 297 sequence of injury inflicted by the catheter, it is best to wait a few hours, sometimes as many as six or eight, until the fluid has sub- sided to the bottom of the bladder, or been dissolved by the urine. In such a case, the introduction of the instrument can do no good, since the blood plugs up the openings in its extremity, and thus pre- vents the passage of the water. Retention, caused by inspissated mucus, coagulating lymph, worms, or calculous concretions, is, in general, easily relieved by the catheter, and does not, therefore, require special consideration. When it de- pends upon the pressure of the gravid uterus, the position of the latter should be rectified by the finger introduced into the vagina, aided by complete relaxation of the abdominal muscles. Retention of urine is sometimes occasioned by pressure of the rectum upon the neck of the bladder. Anything having a tendency to cause inordinate distension of the bowel may induce such a condi- tion, as an earthy concretion, or an encephaloid growth. In hemor- rhoidal disease, especially the bleeding variety, retention of urine is by no means infrequent, and the same result now and then follows an abscess of the anus. Here relief must be attempted by a removal of the exciting cause. c. Retention of urine may be occasioned by an imperforate pre- puce. Many years ago I met with an instance of this kind, in an infant two days old, in which the foreskin was distended into a pel- lucid, fluctuating tumour, nearly as large as a pullet's egg. The little patient was in great pain, but was instantly relieved by a free incision, which was followed by at least four ounces of urine. Re- tention from an imperforate state of the urethra requires similar treatment. In the female, the flow of urine is sometimes obstructed by fleshy excrescences in the orifice of the tube. Excision is, of course, the proper remedy. d. Retention of urine may be caused by priapism. This condition of the penis may be the effect either of inflammation, as in gonor- rhoea, of direct injury, or of lesion of the cerebellum or spinal cord. Of the former variety, in which, however, the priapism seemed to depend upon an effusion of lymph in the cavernous bodies of the penis, an interesting case came under my observation, many years ago, in a stout, athletic, young carpenter, who after having been drenched in a heavy rain, had connexion with his wife on the fol- lowing night. In the morning, when he awoke, the penis was in a state of painful erection, with complete retention of urine. The 298 DISEASES AND INJURIES OF THE BLADDER. priapism continued nearly two weeks, and required the most rigorous antiphlogistic treatment, Avith the occasional use of the catheter. When the retention depends upon lesion of the brain or spinal cord, attention must be directed to the removal of the exciting cause. II. Retention of urine from paralysis is of frequent occurrence. The most common causes of this condition of the bladder are, apo- plexy, injury of the spine, over-distension of the organ, the effects of fever, contusions, lacerated wounds, and capital operations. In compression of the brain, whether produced by depression of the cranial bones, or effusion of blood, retention of urine is a prominent symptom, and a long time often elapses before Ave can dispense with the catheter. Injury of the spine is liable to lead to the same re- sult, and in this case the circumstances are peculiarly distressing; for, in addition to the loss of power, the urine is apt to be surcharged with phosphatic matter, followed by ulceration of the lining membrane. The effect of over-distension, in causing paralysis, is well exemplified in tedious labours, in which the head of the child presses long on the urethra, and the woman neglects or is unable to empty the bladder. When the child is born, she cannot void a drop of water. Old men are very prone to suffer from over-distension, in consequence of cold, external violence, the effects of disease, enlargement of the prostate gland, and neglect to obey the calls to urinate. If the catheter is not promptly employed, incontinence comes on, for which, unfortunately, the disease is frequently mistaken both by the patient and the surgeon. In low fevers, especially when delirium is present, in compound fractures and dislocations, in lacerated wounds, and in contusions of the abdomen, frequent inquiry should be made into the condition of the bladder, in order to guard against retention, or to relieve it speedily, if it be found to be unavoidable. From want of attention to this subject, many lives are lost. I always make it a rule, after performing a capital operation, to ascertain, at my first visit, Avhether my patient has voided his urine. Retention from paralysis is relieved by the catheter, employed early, and steadily until the bladder regains its contractility, the instrument passes without difficulty, and the urine is drawn off at regular intervals, at least three times in the twenty-four hours. Any considerable accumulation is prevented, and it is better to reintroduce the catheter frequently than to permit it to remain. ' Indeed, it is only under peculiar circumstances, as when the physician is at an inconvenient distance from his patient, or where the passage of the RETENTION OF URINE. 299 instrument is attended with unusual difficulty, that it should be retained in the bladder. In the latter case, the catheter is stopped up, and the urine evacuated at stated periods, otherwise, as the natural stimulus of the organ is absent, a longer time must necessarily elapse before the muscular coat recovers its wonted functions. When the return of contractility is slow and imperfect, gentle but steady purgation, the internal use of strychnine, or of cantharides and the muriated tincture of iron, the cold bath, vesication of the sacro- lumbar region, and irritating frictions to the spine, will be of advan- tage. In retention from traumatic paralysis, the treatment is conducted upon general principles. The catheter is used from time to time, the secretions are properly attended to, and the usual means are employed to improve the tone of the muscular system. Under this head may be noticed a variety of retention of urine, which is occasionally met with in hysterical females, and which seems to be dependent rather upon a deficiency of volition than upon paralysis of the muscular fibres of the bladder. The patient cannot, or thinks she cannot, urinate, and therefore does not try to relieve herself* The affection is, in general, only temporary, but may last for several days or even weeks. Purgatives, assafoetida clysters, and the internal use of antispasmodics, are the remedies mainly to be relied upon. Cold water, poured upon the sacro-lumbar region, in a continuous stream, from a height of three or four feet, often affords speedy relief. The catheter must, if possible, be avoided, and in all cases, especially when there is reason to believe that the complaint is feigned, it is of great importance not to encourage the patient by an appearance of commiseration. The folloAving observations of Dr. Watson, of London,1 on this sub- ject, are so just and pertinent, that I am induced to transcribe them in full. Speaking of hysteria, he says : " Some of the shapes assumed by this pathological Proteus are hideous and disgusting. Paralysis of the muscular fibres of the bladder, or spasm of its sphincter, sometimes really occurs, sometimes is only aped, in hysteria. It is a common trick Avith these patients to pretend that they are labouring under retention of urine; and that, although the bladder is full, they can- not make water. The daily introduction of the catheter by a dresser or an apprentice appears to gratify their morbid and prurient feel- ings. Sometimes, no doubt, the difficulty is real; but it is oftener feigned or exaggerated. I have again and again known it disap- 1 Lectures on the Practice of Physic, by Condie, p. 430. Philad. 1845. 300 DISEASES AND INJURIES OF THE BLADDER. pear upon the patient's being left without pity to her own resources. But girls have been known to drink their urine, in order to conceal the fact of their having been obliged and able to void it. The state of mind evinced by many of these hysterical young persons is such as to entitle them to our deepest commiseration. The deceptive ap- pearances displayed in the bodily functions and feelings find their counterpart in the mental. The patients are deceitful, perverse, and obstinate: practising, or attempting to practise, the most aimless and unnatural impositions. They will produce fragments of common gravel, and assert that these were voided with the urine; or they will secrete cinders and stones in the vagina, and pretend to be suffering under some calculous disease. A young woman contrived, in one of our hospitals, to make the surgeons believe that she had stone in the bladder, and she actually submitted to be placed upon the operating table, and to be tied up in the posture for lithotomy, before a theatre- full of students ; and then the imposture was detected. Sometimes they simulate suppression of urine, and after swallowing what they have passed, vomit it up again, to induce the belief that the secretion has taken place through the new and unnatural channel." III. Retention of urine from spasm of the neck of the bladder or of the urethra, is commonly produced by cold, by suppression of the cutaneous perspiration, by the irritation of ascarides, hemorrhoidal tumours, or stone in the bladder, by disorder of the digestive appa- ratus, by the use of fermented, vinous, or alcoholic drinks, high- seasoned food, and the effects of cantharides. The remitting pains, the violent straining, and the frequent desire to urinate, clearly indi- cate the nature of the complaint. The warm bath, hot fomenta- tions, either simple or medicated, and the inhalation of chloroform, followed by the free use of camphor and opium, or of laudanum and sulphuric ether, either by the mouth or rectum, generally afford prompt relief. When the symptoms are urgent, recourse is had to the catheter, which often overcomes the spasm in an instant, long before it has reached the bladder. When the introduction is difficult, the instrument should be gently pressed against the obstruction, and then suddenly withdrawn; a manoeuvre which rarely fails to be followed by a free discharge of water. IV. Retention of urine may be produced by inflammation of the ure- thra and the neck of the bladder. The most common exciting causes of this form of the disease are gonorrhoea, horseback exercise, the long- continued use of cantharides, hard drinking, and venereal excesses. RETENTION OF URINE. 301 The symptoms are, a frequent desire to urinate, with an inability to pass more than a few drops of water at a time ; a sense of smarting, burning, or scalding in the urethra and the head of the penis; vio- lent straining; a feeling of weight about the anus, and throbbing in the perinseum. Occasionally the urine is mixed with blood or pus. If relief is not soon procured, the distended bladder ascends above the pubes, and becomes extremely painful to the touch; the patient is feverish, thirsty, and restless ; the pulse is hard and quick ; the skin is hot and dry; nausea and vomiting succeed, and not unfre- quently there is considerable delirium. The treatment is of course antiphlogistic. Perfect recumbency is enjoined ; blood is freely taken from the arm, or by leeches from the perinseum; the stomach is kept under the full influence of nau- seants; and cloths, wrung out of hot water and laudanum, are applied to the hypogastric region. Spasm is allayed by anodyne enemata, and mucilaginous drinks are not neglected. The warm bath is often eminently useful, especially after thorough venesection. The bowels are moved by mild laxatives, as Epsom salts, or calcined magnesia; but all drastic cathartics are carefully avoided, since, by irritating the large intestine, their tendency is to fret the bladder and induce spasm. When the symptoms are urgent, and the means here indicated are inefficacious, the catheter must be used, but not without the greatest care and gentleness. As the instrument, if retained in the inflamed bladder and urethra, would only be calcu- lated to create mischief, the rule is to withdraw it as soon as the urine has been evacuated. In inflammatory retention of urine, accompanied by spasm of the bladder and urethra, prompt and decided relief has occasionally been obtained from the exhibition of a tobacco enema, in the form of smoke or infusion. The employment of this medicine in the treatment of this affection was, I believe, originally proposed by the late Mr. Henry Earle, of London, in a paper in the sixth volume of the Medico-Chirurgical Transactions. The powerful effects of the article in strangulated hernia, first led him to administer it in obsti- nate retention of urine; and in the work adverted to he has detailed the particulars of three cases in Avhich its exhibition was attended with the happiest result. The enema was prepared with one drachm of tobacco to eight ounces of water, the whole of which was thrown into the bowel at one operation. This was speedily succeeded by great muscular relaxation, copious perspiration, and a disposition to 302 DISEASES AND INJURIES OF THE BLADDER. syncope, followed by a free discharge of urine, and complete relief of the disagreeable symptoms. I have, I confess, in common Avith many members of the profes- sion, almost an invincible repugnance to the employment of a remedy so violent in its action and so difficult to control as tobacco. Now that the surgeon has chloroform and sulphuric ether at his command, hardly any case can arise demanding its exhibition. Nevertheless, a contingency might occur, as when it is impossible to unburthen the bladder in consequence of excessive narrowing of the urethra, with violent spasm and straining, in which, after all other means have failed, it might be proper to resort to it; not, however, in the large dose recommended by Earle, but in small quantity, the effects of the remedy being sedulously watched, that the patient may not be brought to death's door. For, it should ever be borne in mind, that the action of tobacco varies greatly in different individuals, and that it has occasionally produced the most alarming prostration; nay, even death. It ought not, therefore, to be adopted indiscrimi- nately, but be reserved for those cases in which the ordinary means, aided by anaesthetic agents, have failed. Under such circumstances only can its administration be justifiable. V. Finally, retention of urine may depend upon the presence of a pelvic tumour. Of this class of causes, several varieties may be enumerated. a. The difficulty may arise from the presence of a serous cyst, or hydatid, between the bladder and the rectum. Of this, an instruc- tive example has been furnished by Lesauvage,1 which may, with much propriety, be reproduced in this place. A man, sixty years old, having several tumours in the abdomen, was seized repeatedly with retention of urine, for the relief of which catheterism was always performed with difficulty. Finally, the introduction of the instrument was rendered impossible, arrested as it was at the neck of the bladder. The abdominal tumour offering an insurmountable obstacle to the hypogastric operation, the bladder was punctured through the rectum, with so much the more confidence, as the finger, introduced into the anus, felt a soft, fluctuating swelling. The trocar had hardly pierced the organ when there was an abundant floAv, both by the canula and the urethra, of a fluid of very different qualities; one was evidently urine, the other the contents of a cyst, 1 Bulletin de la Faculte" de MeU, 1813, p. 439. CATHETERISM. 303 which, situated between the rectum and the bladder, opposed the flow of urine by compressing the neck of the latter organ. b. Retention sometimes arises from prolapsus of the womb. The most effectual means of relief is to replace the dislocated organ, by pushing it upwards and backwards while the patient is recumbent. The introduction of the catheter is rarely required. c. The affection may depend upon retroversion of the uterus. In this affection the dislocated organ drags the posterior part of the bladder downwards and backwards, at the same time that it raises the neck of this reservoir, and places it, as it were, behind the pubic symphysis. The necessary consequence of this mal-position is an increase in the length and curvature of the urethra, the concavity of which is directed forwards. The remedy consists, of course, in replacing the uterus. When the reduction is not immediately prac- ticable, or when it fails to afford relief, the catheter must be em- ployed, taking care to give it the proper curvature, and to keep it in close contact with the posterior surface of the pubic bones. d. Distension of the bladder sometimes occurs during parturition. The bladder mounts up into the abdominal cavity, and drags the urethra up behind the pubic symphysis, against which it is some- times so closely applied, as to render it difficult to introduce a catheter. Distension of the organ, under such circumstances, is particularly to be dreaded, as it has occasionally been followed by laceration of its coats, and the escape of the urine into the peri- toneal cavity. SECTION II. CATHETERISM. The introduction of the catheter, although apparently very simple, is one of the nicest and most delicate processes in surgery. It requires skill of the highest order, as well as the most intimate knoAvledge of the anatomy of the urinary organs. If I were called upon to state what I considered as the most important operation that a practitioner is obliged to perform, I should unhesitatingly say the introduction of the catheter. It is true, the most untutored and aAvkAvard surgeon may occasionally, nay, perhaps not unfrequently, reach the bladder without difficulty; but let such an individual 304 DISEASES AND INJURIES OF THE BLADDER. attempt the passage of the instrument when there is some mechanical obstacle, as a stricture or an enlarged prostate, and he will be sure to be foiled. The moment the catheter is arrested, he becomes bewildered; his hand trembles, dismay is depicted in every feature large drops of sweat stand upon his brow, and his whole frame is paralysed. If, under these circumstances, he proceed, he will inflict severe suffering upon his patient, if not actually endanger his life. To avoid such an occurrence, as disgraceful as it is unfortunate, the operation should be constantly practised upon the dead subject; the anatomy of the urinary apparatus should be thoroughly studied; and the eye, hand, and instrument should be trained to move in concert with each other. Catheters are cylindrical tubes, varying in their composition, size, and shape. The best are made of silver, Fig. 32, and are, for an adult, about nine inches and a half long, by two lines and a half in diameter; they are perfectly smooth, light, and bent for one-third of their length, to accommodate them to the natural curvature of the urethra. The vesical extremity, Avhich is rounded off, but closed at the point, and of the same thickness as the rest of the instrument, has an oval hole on each side, a quarter of an inch long and about a line and a half in width, for the entrance of the urine. Instead of this arrangement, this part of the tube is sometimes pierced with numerous little apertures, Fig. 33, but these are objectionable, because of their greater liability to become clogged with blood and mucus. The other extremity, usually called the handle of the instrument, is open, and is provided on each side with a small ring, for securing it in its place when it is necessary to retain it in the bladder. The French have a convenient silver catheter which they carry about with them in their pocket cases ; it consists of two pieces, united by a screw, and is therefore well adapted for either sex. The gum-elastic instrument, so much lauded by some practitioners, I seldom resort to. It is very liable to bend whenever it meets, with the slightest resistance, and is, moreover, easily injured by the urine. Nevertheless, it may occasionally be employed with advantage, especially if it be rendered firm by the stylet. Every practitioner should have an assortment of catheters, of different dimensions, that he may be prepared for emergencies. For a child, from a few months to several years old, a tube, five inches long, and about the size of a crow-quill, will be sufficiently large. The straight catheter, although easily introduced, is not much in vogue. For washing out CATHETERISM. 305 Fig. 32. Fig. 34. Fig. 33. the bladder for the removal of blood and mucus, or for introducing medicated fluids, a double catheter is necessary, Fig. 34. When used for the first of these purposes, it may be constructed of gum elastic; but when the object is to throw up some medicated fluid, such as nitric acid and water, a gold or silver instrument is required. When the urethra is entirely sound, a tolerably large catheter, one that will gently distend the parietes of the tube, is selected. An instrument of this size will, in general, glide along much more easily than a smaller one, since it is not so liable to be arrested by the folds and follicles of the mucous membrane, or to impinge against the margins of the opening in the triangular ligament. Before introducing it, it should always be well oiled, and carefully warmed by rubbing it between the thumb and fingers, or by plunging it into hot water. The catheter may be introduced while the patient is standing, sitting, or lying; but, whatever posture may be selected, it is important that the thighs should be mode- rately separated from each other, and flexed upon the pelvis, to relax the abdo- minal muscles. In the first case, the patient leans with his back against the wall, and inclines his chest slightly forwards, so that he may not change his position during the ope- ration. The sur- geon may take his place either at the front or side. If he sit, the breech should project over the chair, and the body be directed backwards. The position of 20 306 DISEASES AND INJURIES OF THE BLADDER. the operator is the same as before. The most convenient posture, how- ever, is the recumbent. The patient lies on his back, near the edge of the bed, the head supported by a pillow, and the knees, slightly sepa- rated from each other, somewhat raised. The surgeon, standing by the left side of the bed, takes the penis in the left hand, and lifts it to a right angle with the body, to efface the curve which it forms at the pubes. The catheter, held in the right hand, between the thumb and first two fingers, is inserted into the orifice of the urethra, its Fig. 35. Section of the pelvis, showing when the handle of the catheter ought to be depressed to disengage its point from the sinus of the bulb. 1. Is the bladder. 2, 2. The prostate gland; the seminal vesicle is seen behind the gland. 3. The rectum. 4. The cut surface of the pubic symphysis. A. The catheter is introduced into the urethra as far as the bulb. B. The dotted line which indicates the direction in which the handle of the instrument is to be lowered to lift the beak out of the sinus of the bulb. C. The inferior margin of the opening in the triangular ligament of the urethra, and against which the point of the catheter frequently hitches. D. Is another point at which the beak is sometimes arrested. concavity being directed towards the pubes, and the handle being nearly in contact with the median line of the abdomen. The instru- ment is now passed onward, until its beak reaches the sinus of the bulb, which lies upon the anterior surface of the triangular ligament, CATHETERISM. 307 rather deep in the perinseum. To disengage it from this depression, the handle is changed from the horizontal direction, in which it has hitherto been held, into the vertical, at the same time that the point is slightly retracted. By this manoeuvre, the curved portion is brought under the arch of the pubes, and immediately opposite the opening in the triangular ligament. By now depressing the handle of the instrument on a level with the thighs, or rather a little between them, its point glides readily over the prostatic part of the urethra into the bladder. In performing this operation, no force is employed; on the con- trary, the whole proceeding is conducted with the utmost gentleness. The catheter, held as tightly as possible, is made to glide along, as it were, by its own weight and that of the hand. The penis should be drawn slightly forward, over the instrument, just sufficiently to ren- der the urethra a little tense. Everything like stretching and pull- ing must be avoided. In introducing the straight catheter, the patient lies on his back, and the surgeon stands on the right side of the bed, instead of on the left, as in the other case. The penis is held in the left hand, at a right angle with the body, and the instrument is carried down perpendicularly as far as the sinus of the bulb. To free it from this depression, the point is retracted two or three lines, and then, while the penis is lowered between the thighs, it is at once pushed onward into the bladder. The natural obstacles to the passage of the catheter are the mucous follicles, the sinus of the bulb, and the margins of the open- ing in the triangular ligament. The first is easily avoided by using a large instrument with a rounded instead of a conical point; the second, by withdrawing it two or three lines before it is pushed on ; and the last, by carrying it parallel with the raphe* of the perinseum, and not more than an inch below the arch of the pubes. The orifices of the prostate gland, the outlets of the seminal ducts, the sinus pocularis, and the gallinaginous crest, can hardly be considered as offering any opposition to the progress of the instrument. When the prostate gland is enlarged, the finger, introduced into the rectum, will enable the surgeon to push the catheter forwards towards the pubes, or towards either side, as circumstances may require. Various contrivances are used for retaining the catheter in the 308 DISEASES AND INJURIES OF THE BLADDER. bladder. The one which I usually prefer, consists of a broad waist- F.g 36 band, with two thigh pieces fastened in front and behind, so as not to interfere with the anus or the scrotum. The instrument having been introduced, is secured by two strips of linen, tape, or oiled silk, by tying the middle of each to the ring of the catheter, and the ends to the circular and vertical bands. Another very good plan is to surround the penis with an ivory, elastic, or linen yoke, and to secure this against the pubes by means of four pieces of tape, carried round the thighs and pelvis. The catheter is then fas- tened to the ring or yoke in the usual man- ner. In the annexed drawing, Fig. 36, the instrument is secured to a piece of linen, passed round the penis, just behind the glans. The contrivance, however, is objectionable, on account of its liability to injure the penis, in case of the erection of the organ. Catheterism of the female is easy enough, unless the urethra hap- pens to be displaced by the weight of the uterus or the pressure of some morbid growth, in which event it is occasionally attended with great difficulty. It should always be performed under cover of the clothes, while the patient lies upon her back, near the edge of the bed. Ocular inspection can be justifiable only when the parts are in a state of great disease, or when the tube has undergone much change in its relative position. The best mode of proceeding is to apply the index finger of the left hand to the upper margin of the orifice of the vagina, which thus serves as a guide to the instrument, which is placed upon its palmar surface, and then moved upwards along the middle line, until its point arrives at the dimple-shaped depression, marking the situation of the mouth of the urethra. The catheter is then passed on with its concavity upwards until it reaches the cavity of the bladder ; a circumstance which will be indicated by the want of resistance and the flow of the urine. Or, instead of this, the finger may be placed upon the clitoris, just below the commis- sure of the nymphse, and the instrument carried from thence down- wards along the central line of the vestibule, until its point slips into the tube. When there is much difficulty in performing the opera- tion, in consequence of a change in the direction of the urethra, the PUNCTURE OF THE BLADDER. 309 ordinary instrument may be conveniently replaced by a gum-elastic one. The female catheter is made of silver, and is not more than five inches in length. Its vesical extremity is somewhat bent, to adapt it to the shape of the urethra, and is perforated with numerous fora- mina, instead of having eyelets, as in the male instrument. The other end is provided with two rings, in order to fasten the instru- ment, when it is necessary to retain it in the bladder, by means of tapes, to a T bandage. SECTION III. PUNCTURE OF THE BLADDER. When the bougie, catheter, and other means have failed to pro- duce relief, the only thing that remains is to puncture the bladder. Fortunately this operation is seldom necessary; thus far, I have not been obliged to perform it, though on two occasions, and two only, I did not know whether I should not be compelled to resort to it. The first case was that of an old gentleman, upwards of seventy years of age, who had been subject to retention of urine from paralysis of the bladder. In one of these attacks, his physician, who was not very expert in the use of the catheter, made numerous, but fruit- less, attempts to draw off the urine with a gum-elastic instrument. Called in soon after, I experienced no difficulty in reaching the organ with a silver catheter, but as its eyelets became immediately closed with blood, not a drop of fluid followed, though the instru- ment was several times cleaned and reintroduced. As the symptoms were not particularly urgent, it was agreed not to renew the efforts until next morning, when, if necessary, puncture of the bladder might be had recourse to. On revisiting the patient, catheterism was again performed, and, greatly to my delight, with entire success, nearly a quart of clear urine passing off. It is obvious, in this case, that the blood which had choked up the instrument the previous evening, had ceased to flow, and that what had entered the bladder had subsided to the bottom of the organ, Avhere it could no longer act obstructingly. In the other case, the symptoms were more urgent; the patient was a painter, thirty-five years of age, and the retention was occa- 310 DISEASES AND INJURIES OF THE BLADDER. sioned by a tight stricture of the urethra of long standing. For months past his bladder was never entirely empty at any one time. Early one evening last September he came into my office, racked with pain from complete retention, under which he had laboured upwards of twenty-four hours; his physiognomy was expressive of deep distress, and he was seized, every few minutes, with violent tenesmus. The bladder was much distended, forming a hard, promi- nent, and tender tumour, extending nearly as high as the umbilicus. Another practitioner had in vain attempted to pass a gum-elastic catheter ; the parts were very sore from the operation, which was persisted in for a long time, and a good deal of blood had escaped by the urethra. To assure myself of the condition of this canal, I tried to introduce a silver instrument, but failed. Satisfied that the urethra was too irritable to justify any protracted trial of this kind, I requested the patient to go home, and to take at once a grain of morphia, to use tepid drinks, and to bathe his feet in hot mustard water. I also requested him to repeat the anodyne, if necessary, every three hours in half grain doses. Upon visiting him early next morning, I learned that he had spent a tolerably comfortable night, and that, although he had not voided a drop of urine, he was free from pain or spasm. He had altogether taken two grains of morphia. Putting him now under the influence of chloroform, I tried to overcome the obstacle by different sized catheters, but without success, owing to its great length and firmness. Finally, I introduced a urethratome to divide the stricture, but with hardly any better luck; the instrument advanced only a short distance, and then became permanently arrested. Desisting, for fear of doing harm instead of good, I told the patient I should visit him early in the afternoon, prepared, if he was not relieved, to puncture his bladder. On my return, I was gratified to learn that he had voided, with comparative facility, upwards of a quart of urine, with entire relief of his symptoms. In a week afterwards, I passed a tolerably large-sized catheter into the bladder, much to the surprise and happiness of my patient. His general health, previously not a little impaired, rapidly improved, and for the first time, in several years, he was able to empty his bladder. The above cases are eminently instructive; they show what may be accomplished by delay, and by the employment of soothing measures. Had I been impatient in the one case, or withheld anodynes in the other, the probability is that the local distress would PUNCTURE OF THE BLADDER. 311 have been greatly increased, and that it might have become necessary to puncture the bladder. From what I have seen of retention of urine, I am satisfied that puncture of the bladder is rarely, if ever, necessary. It is only in cases of excessive enlargement of the prostate gland, attended with great tenderness and swelling of the surrounding parts; in lacera- tion of the urethra and infiltration of urine into the scrotum; and in deep-seated, impassable stricture, that the operation should ever be seriously thought of. All other forms of retention will, there is reason to believe, yield to the catheter, aided by time and by sooth- ing measures. The celebrated Dessault, indeed, used to maintain that puncture of the bladder was never necessary, on the ground that there was no case in which a skilful practitioner could not reach this organ with a catheter. During the eight years in which he held the rank of chief surgeon to the H<5tel-Dieu in Paris, he performed the operation only once, and that was soon after he took charge of the institution. It is true, some of his cotemporaries have declared that he trusted too implicitly in his dexterity, and that he occasionally made a false passage; but this may have been a mere imputation, raised, without any just foundation, by his detrac- tors. Be this as it may, no one, who has any experience on the subject, can doubt that the operation has often been performed unnecessarily, and that those who have most frequently executed it have been young men, little versed in the use of the catheter and bougie. The late Mr. Liston, whose experience in the treatment of urinary affections must have been very extensive, states that he never punctured the bladder but once.1 There are three routes by which the bladder may be approached when this operation becomes necessary, namely,—the rectum, the perinseum, and the supra-pubic region. Of these, the first is the one usually preferred, on account of the facility of performing the operation, and its supposed freedom of danger from urinous infiltra- tion. It is, of course, contra-indicated when there is great enlarge- ment of the prostate gland, or serious disease of the anus, rectum, or bas-fond of the bladder. Under such circumstances, the supra- pubic region is selected. The puncture by the rectum is executed with a curved trocar, about four inches in length, and provided with a canula. The breech of the patient is brought over the edge of 1 Elements of Surgery, p. 507. Philadelphia, 1846. 312 DISEASES AND INJURIES OF THE BLADDER. the bed, and his legs are supported by two assistants, as in the operation for stone. The surgeon, oiling the index and middle fingers of the left hand, introduces them into the bowel, in con- tact with its anterior wall; he now takes the instrument in the right hand, retracts the point of the trocar within its sheath, and then Fig. 37. places it in the groove formed by the junction of the two fingers in the anus. The only thing that remains to be done is to carry the instrument on until it has fully passed the posterior margin of the prostate, when, by depressing its handle, the point is urged on through the superimposed structures into the interior of the bladder. The want of resistance, and a slight escape of urine will indicate that the instrument has reached its destination. By a sort of double movement, the trocar is now withdrawn and the canula pushed farther on into the distended viscus. The urine being evacuated, the canula is either at once removed, or, if there be any serious obstacle along the natural passage, it is retained until this is surmounted. In the latter case, the instrument is secured by a T bandage. In performing this operation, care is taken not to wound the prostate gland, the deferential ducts, or the seminal vesicles. The first of these organs lies in the middle line, and can usually be easily recognised by the finger; the others are situated higher up, and a little further out, diverging from each other as they proceed up- wards, leaving thus a triangular space, the apex of which is below, and the base above. It is this spot which is selected for the opera- tion. Sometimes, especially in very aged persons, the puncture is followed by slight hemorrhage, from wounding the enlarged veins PUNCTURE OF THE BLADDER. 313 in this situation. It need hardly be added, what is self-evident, that the rectum should always be well cleared out, just before the operation, with an enema. The operation by the rectum is simple enough; it requires little skill, and is performed in a few seconds. The chief objection to it is, that it is apt to leave a fistulous communication between the bladder and the bowels, permitting a reciprocal discharge of their contents, which, in the case of the former organ, occasionally leads to serious distress, and even to the formation of stone. When the retention is caused by impassable stricture, or by in- jury of the urethra, the perinseum, or the neck of the bladder, followed by infiltration of urine, puncture by the perinseum is to be preferred, in every respect, to either of the other procedures. The operation, however, it must be confessed, is not easy, especially if the relations of the parts are changed by extravasated blood, urine, or inflammatory deposits. On the other hand, it has the advantage of making the opening more in the natural direction of the urine, and affording an opportunity to remove, at the same time, the obstruction upon which the retention may immediately depend; in other words, it enables us to accomplish by one operation what we are obliged, if we puncture through the rectum, or the hypogastrium, to do by two. The patient is placed in the position of lithotomy, with the breech projecting slightly over the edge of the table. A moderate-sized catheter is carried down to the seat of the obstruction, where it is firmly held by an assistant, and its point exposed by direct incision, in the central raphe* of the perinseum. The knife is next conveyed backAvards through the constricted part, and thence by successive touches on through the posterior portion of the urethra as far* as the neck of the bladder. The latter stage of the operation is frequently materially facilitated by the bulging dilatation on the vesical aspect of the stricture. As soon as the bladder is reached, the urine gushes out in a full stream, and the patient is instantly relieved. The ope- ration being completed, the catheter is passed on and retained in the usual manner, care being taken to withdraAv it occasionally for the purposes of cleanliness. The bladder being relieved by the removal of the obstructing cause, the wound soon heals, and a permanent cure is the result. In performing this operation, the surgeon must be on his guard, otherwise he may puncture the rectum, or divide the artery of the bulb ; in the former case a troublesome fistula might be the conse- 314 DISEASES AND INJURIES OF THE BLADDER. quence ; in the latter, a serious hemorrhage. He should, in fact, employ the same precautions as in perinseal lithotomy. Puncture of the bladder above the pubes has generally been re- garded as more objectionable than by any other route, not because of any particular difficulty in the operation, but because of its greater liability, as has been conjectured, to be followed by an escape of urine into the peritoneal cavity and the surrounding cellular sub- stance. Both events are to be dreaded, especially the former, which is almost certainly fatal in thirty-six or forty-eight hours from its occurrence. The operation is performed in the same manner as supra-pubic lithotomy, only that the opening is much smaller. The patient being placed on his back, and the skin divested of hair, an incision is made from below upwards, along the median line, from an inch to an inch and a half in length, according to the leanness or obesity of the part, first through the common integuments, and then through the fibrous structure between the pyramidal muscles, down to the cellular tissue which overlays the distended organ. Through this opening the bladder is punctured at its lowest part, by means of a trocar, such as is used in tapping the abdomen, the point of the instrument being inclined obliquely downwards and backwards in the direction of the promontory of the sacrum. Transfixion being com- pleted, the trocar is withdrawn, and the canula gently passed into the bladder, where it is retained by an appropriate bandage, until the obstructing cause necessitating the operation has been removed. The patient in the mean time lies on his side, to promote the escape of the urine. Mr. Abernethy, who gave a decided preference to this mode of puncturing the bladder, often performed the operation with no other apparatus than a pocket scalpel and a lancet; he did not even always, it seems, leave a canula in the organ, the collapse of this sac sometimes preventing him from finding the opening he had made into it. Notwithstanding this, he never witnessed any ill effects from the procedure, such as effusion of urine into the cellular sub- stance, or the peritoneal cavity.1 No hemorrhage attends the ope- ration. Mons. Mondiere has given, in the Revue Medicale for April, 1841, the following interesting statistics of ninety-two cases of puncture of the bladder. 1 Willis on Urinary Diseases, p. 210. Philadelphia, 1839. PUNCTURE OF THE BLADDER. 315 Puncture. No. Cases. Success. Fistula. Infiltration. Abscess. Hemorrhage. Death. Perinseal, 9 6 10 0 1 1 Recto-vesical, 28 19 3 3 1 0 2 Supra-pubic, 65 49 0 0 0 0 6 Total, 92 74 4 3 1 19' From this table it would seem that the recto-vesical operation is less fatal than either of the others, but that it is more liable to be followed by fistula, infiltration, and abscess. As respects its mor- tality, the perinseal and supra-pubic punctures are about on a par. The proportion of fatal cases to the number of recoveries, is remark- ably small. I recollect a singular instance of supra-pubic paracentesis of the bladder, in which the puncture, after having been perfectly healed, reopened after a lapse of fourteen years. The patient, Mr. Levan Lawrence, of the vicinity of Louisville, Kentucky, was a farmer by occupation, and was upwards of seventy-two years of age at the time of his death. In the autumn of 1831, while on a visit to the interior of Indiana, he was seized with retention of urine, for which a physi- cian of Terre Haute performed the operation in question, though it was doubtless unnecessary. For several months he wore a tube in the wound; upon laying aside which the parts speedily cicatrized, and so continued until about four weeks before he died, when, all at once, it reopened, the skin having been the seat, for several days, of erysipelatous inflammation. Urine afterwards continued to dis- charge through the abnormal passage up to the time of the patient's dissolution, the immediate cause of which was constitutional ex- haustion. 1 Amer. Jour. Med. Sciences, vol. iii. 495. CHAPTER XV. INCONTINENCE OF URINE. Incontinence of urine, the reverse of retention, with which it is often associated, may occur at any period of life, and may be partial or complete, temporary or permanent. It is in general a very dis- tressing affection, for the constant discharge not only keeps the clothes wet, but it excoriates the thighs and genital organs, and thus leads to much suffering. The smell is also extremely offensive. It may be excited by a great variety of circumstances, the most prominent of which, however, are referable to external injury, or to inflamma- tion, spasm, paralysis, or morbid sensibility of the bladder, or of this organ and the urethra. The water may pass off as fast as it is secreted, or it may be retained for a time, and then either dribble away, or be discharged in a full stream. I. The best example of incontinence from external injury is afforded in lithotomy. Of the frequency of this occurrence after this operation in the male, no estimate can be formed, as we have no correct data. There is reason, however, to believe that it is rare. In this form of the affection, the incontinence is generally most distress- ing in the day, while the person is in the erect posture. In the only instance of the kind that has come under my notice, the patient, a boy nine years of age, has the most perfect control over his water at night, or during recumbency; but as soon as he rises or walks about, it begins to dribble off, even when there is no distension of the blad- der, and so continues until he lies down. In this variety of incon- tinence, there is evidently a partial loss of power of the muscular fibres at the neck of the bladder, united with excessive morbid irri- tability of the mucous membrane. A kick, blow, or fall upon the perinseum is occasionally followed by the same result. In the female the operation of lithotomy is extremely liable to be succeeded by in- continence. Incontinence from external injury, often disappears spontaneously; INCONTINENCE OF URINE. 317 and, on the other hand, it is occasionally incurable. The treatment must be conducted on general principles. In the early stages, much benefit will frequently be derived from leeches to the perinseum, rest in the horizontal posture, light diet, and gentle purgatives, along with the liberal use of bicarbonate of soda and decoction of uva ursi. Where there is much morbid irritability of the bladder, direct medi- cation may be resorted to, by cauterization, or astringent and ano- dyne injections. Compression of the perinseum with a spring truss will also be worthy of a trial. II. Incontinence from inflammation may depend upon various causes, as external violence, the extension of gonorrhoea, stone in the bladder, and stricture of the urethra. The escape is usually partial, and is almost constantly associated with spasm. The treat- ment consists in removing the exciting cause, which is frequently of itself sufficient to effect a cure, and in the employment of the lancet, the hip-bath, antispasmodics, and anodyne injections. The catheter often affords instant relief. III. Paralysis of the bladder, or of this viscus and the urethra, however induced, is a frequent cause of incontinence. The loss of power may be the result of direct injury, as a severe contusion of the abdomen, pelvis, or perinseum, or it may be the consequence of some disorder of the sacro-lumbar nerves. In the latter months of pregnancy, as well as during protracted parturition, the neck of the bladder is sometimes paralysed by the pressure of the child's head, and the incontinence thus produced may last a long time. This affection is occasionally met with in fever, in concussion of the brain, in injury of the spinal marrow, in hysteria, epilepsy, and other ner- vous diseases. Old men who have led irregular and dissolute lives, and who have laboured long under disease of the urinary passages, are very prone to suffer from incontinence of urine. In the treatment of incontinence from paralysis, our remedies must be addressed chiefly to the invigoration of the nervous system. For this purpose, after having cleared out the bowels and corrected the secretions, the patient is put on the use of strychnine, either alone or in union with some mild tonic medicine, such as the extract of gentian and sulphate of iron. The dose of strychnine should not exceed at first the sixteenth of a grain, three times a day, but it may be gradually increased to the twelfth, or even the tenth of a grain. Advantage will be derived from combining with it a small quantity of powdered cantharides, especially if the latter article be carried to 318 DISEASES AND INJURIES OF THE BLADDER. the extent of slight strangury. The muriated tincture of iron is often a valuable remedy. The diet must be light but nutritious, and the patient should make frequent use of the cold shower-bath, fol- lowed by dry frictions. Exercise in the open air is also attended to. Counter-irritation is kept up in the sacro-lumbar region, either by a succession of blisters, tartar emetic ointment, the moxa, or in obsti- nate cases even by the actual cautery. When the loss of tone has been induced by long-continued pressure on the bladder, as, for instance, in severe labour, little benefit is to be expected from any mode of treatment. Such cases usually either get well of their own accord, or they persist in spite of our best-directed efforts to relieve them. IV. Incontinence may arise from a morbid irritability of the neck of the bladder, or of the entire organ, excited by the acid character of the urine, or by sympathy with the kidney, rectum, anus, vagina, or uterus. In the early months of pregnancy, the patient is often tormented Avith a constant desire to urinate, and if the inclination be not instantly gratified, the water flows off involuntarily. Worms in the lower bowel, hemorrhoidal tumours, and fissure of the anus are often attended with incontinence. Masturbation, or inordinate sexual indulgence, by establishing a morbid sensibility of the mucous membrane of the neck of the bladder, or commencement of the ure- thra, may be followed by the same result. In most of these in- stances, the incontinence is incomplete. To this form of incontinence obviously belongs that variety of the disease which occurs in young subjects. It is most common in chil- dren before the period of puberty, and often begins at a very early age. The discharge, which may take place twice or even thrice during the night, is sometimes effected under the influence of the will or of a dream, but in general it is strictly involuntary. When it becomes habitual, as, in fact, it usually does, it may last for years, and be even prolonged into advanced life, though in most cases it gradually disappears on the approach of adolescence. It is pro- moted by the use of fluids, by exposure to cold, and by sleeping on the back, a posture which is favourable to the accumulation of urine in the morbidly sensitive portion of the bladder. The pathology of this affection consists, as has been already stated, in an exaltation of the natural sensibility of the mucous membrane of the neck of the bladder, unaccompanied, in many cases, by any appreciable change of structure. Sometimes there is INCONTINENCE OF URINE. 319 slight thickening of the part, and occasionally the affected surface is somewhat inflamed. In protracted cases, there may be hypertro- phy of the prostate gland, though never to any considerable extent. The sphincter of the bladder is easily relaxed, and yields to the most trifling impulse: hence the urine often flows off even when there is no fulness or distension of the organ. In the treatment of this form of incontinence, particular inquiry should be made into the nature of the exciting cause, the removal of which is of paramount importance. The condition of the urine is examined, disease of the neighbouring structures is corrected, and the patient's habits are attended to. Where there is no tangible cause, the case must be managed on general principles. In that variety of the affection which is met with in boys and girls, the cure may be greatly expedited by proper attention to the diet, which should always be bland and unirritant. Late suppers are avoided, and the patient must abstain entirely from drinks for several hours before going to bed. During the night he is to be waked two or three times for the purpose of emptying his bladder, and this prac- tice is to be persisted in for weeks and even months, until the dis- agreeable habit is broken up. During all this time, as well as, in- deed, for a long period afterwards, the child should lie upon his side, to prevent the urine from coming in contact with, and irritating the neck of the bladder. The internal remedies from which I have derived most benefit in the treatment of this affection, are strychnine and cantharides, given three times a day, in the proportion of the tAvelfth or sixteenth of a grain of the former to the eighth or tenth of a grain of the latter, according to the age of the subject. A minute portion of opium forms a valuable addition : and, in atonic cases, I often combine with these articles some of the preparations of iron. When the strychnine disagrees, or fails to answer the pur- pose, we may substitute the extract of nux vomica. In either case, it is important to watch the effects of the remedy. I have great confidence in the use of cantharides in this affection, and have known it to afford relief when everything else seemed to prove unavailing. I prefer the powder to the tincture, and occasionally continue the exhibition of it until slight strangury is induced. Very recently benzoic acid has been highly recommended as possessing a control- ling influence in cases of this kind; but the few trials which I have made of it have disappointed my expectations. When the morbid sensibility of the bladder is connected with inflammation, the balsam 320 DISEASES AND INJURIES OF THE BLADDER. of copaiba, in doses of from ten to fifteen drops every six or eight hours, is sometimes highly beneficial. In large doses it is sure to irritate the stomach, and to disagree with the urinary organs. In this variety of the affection, a full anodyne at night, especially in the form of Dover's powder, often exerts a happy effect in controlling the discharge. As auxiliary measures, the cold shower-bath should be used once or twice a day, or cold water poured from a considerable height upon the lower portion of the spine, and blisters applied to the sacro-lumbar region, the perinseum, or the inside of the thighs. In obstinate cases, the neck of the bladder is cauterized as in spermatorrhoea, but much more mildly, on account of the more tender age of the patient. In the female, the application is made to the orifice of the urethra.1 Very recently belladonna has been recommended in the treatment of this variety of incontinence of urine by Dr. Trousseau and Dr. Blanche, of Paris.2 The latter, who is physician to the H<3pital des Enfans, has published two very obstinate cases, one fifteen and the other eighteen years of age, in which a great variety of remedies, as sulphurous baths, cold and astringent applications, tonics, tannin, spurred rye, and nux vomica, had all failed, and in which ultimately belladonna was exhibited with complete success. The best mode of administering the medicine is in the form of extract, in doses varying from the sixteenth to the eighth of a grain, according to the age of the patient, every night at bedtime. A steady persistence of the treatment for several months is necessary to insure a cure. The application of pressure to the urethra, gentle but steady, and gradually increased, has sometimes been found beneficial in removing this complaint. Many years ago, the attention of the profession was called to the subject by Mr. Hyslop, of England, in a short paper in the sixth volume of the Medico-Chirurgical Society of London. He illustrates the good effects of the treatment by the details of a case, which was promptly relieved in this manner. The patient was a youth, thirteen years of age, for the last nine of which he had never passed a single day or night without several involuntary 1 Mons. Petrequin states (Johnson's Medico-Chirurgical Review, vol. xxxi., p. 218), that he has treated successfully many cases of nocturnal incontinence of urine in children, with the tincture of nux vomica, as an embrocation to the loins and peri- naeum. Another method, to which he has sometimes recourse, consists in the intro- duction into the rectum of a seton, or skein of thread, well covered with a cerate of this substance. 2 Amer. Jour. Med. Scien., N. S., vol. xvii., 187. INCONTINENCE OF URINE. 321 discharges of his urine. Tonics, cold bathing, opiates and blisters, had all been tried to no purpose. When Mr. Hyslop first saw him, he was in wretched health, with great depression of spirits, and severe excoriation of the genital organs and neighbouring parts. The pressure was made with a bougie, cut off several inches from its extremity, and large enough to distend the urethra. The instru- ment was then placed along the under surface of the penis, on the outside of and parallel with the excretory canal, with the point pro- jecting a short distance beyond the glans, and confined with adhesive strips, extending as far back as the scrotum. In this manner the sides of the urethra Avere so completely approximated that no space Avas left by which the urine could escape. Whenever the patient Avas obliged to pass his water, which was, at first, every four or five hours, the pressure was removed, and immediately after reapplied. In this way the treatment was continued, without any unpleasant symptoms, for three days, at the expiration of which the affection had entirely disappeared. When the incontinence depends upon morbid sensibility of the urethra and neck of the bladder, such a proceeding is worthy of trial, especially Avhere the more ordinary means have failed. When the tender surface is situated behind the scrotum, the probability is that the pressure of a truss, resting upon the perinseum, might be serviceable. The pad should be placed directly over the middle line, and should bear so firmly upon the part as to occlude the urethra. In all cases of nocturnal incontinence, the practitioner must endea- vour to secure the co-operation of the patient. The unhappy effects arising from a persistence of the habit must be fully pointed out; the child must be reasoned with, and even threatened with chastise- ment ; the fear of punishment puts him on the alert, and induces him to keep a constant Avatch over the bladder. The patient, of course, is not beaten; nor does any sensible man ever think, at the present day, of tying up the penis : such a proceeding would be not less cruel than absurd. Of the folly and danger of the employment of artificial means for restraining nocturnal incontinence of urine, the following cases serve as interesting and valuable examples. Case I.—A child, nine years of age, had been long troubled with this complaint, and never passed a night without wetting the bed. His chagrin Avas excessive, and as everything had been tried in vain for his relief, he Avas advised to tie a piece of packthread round the 21 322 DISEASES AND INJURIES OF THE BLADDER. penis. During the night the pain awoke him, but ashamed to com- plain, he permitted the ligature to remain on until morning, by which time it had become intolerable. J. L. Petit, the illustrious secretary of the Academy of Surgery, being called to his aid, found that the skin of one half of the member, below the seat of the con- striction, had fallen into gangrene. Upon the removal of the thread, the urine flowed with some difficulty, but by degrees three half pints were discharged; the bladder, however, had lost so much of its contractile power that it was unable to expel the whole of its contents. After making two deep and parallel incisions, he divided the prepuce, which was affected with congenital phimosis, and ap- plied the dressings in such a manner as to leave an opening for the escape of the urine. Suppuration was soon established, a few flaps of skin separated, the sore assumed a healthy aspect, and in tAventy days the cure was completed. The most remarkable circumstance of this case was, that the patient ceased from the moment of the accident to wet his bed, and so continued ever afterwards. Case II.1—A lad, aged eight years, passed a brass curtain-ring over his penis, to prevent incontinence of urine during the night, and thereby escape chastisement, to which he had been frequently subjected. Great swelling soon occurred round the foreign body, which he was unable to remove, and he experienced much pain and difficulty in voiding his urine. The integuments under the ring gra- dually ulcerated, and when the swelling subsided the ring seemed to be concealed in the substance of the penis. Cicatrization took place, and all uneasiness soon ceased. The penis performed well all that was required of it; the urine passed easily, and after a while the boy, now a man, became the father of a family. When between fifty and sixty years of age, he applied to Mr. Liston, the narrator of the case. For some years previously difficulty in making water had been coming on, and frequent desire to pass it in the night-time rendered him very uncomfortable. He was obliged to have a vessel constantly in bed, and was generally disturbed every half hour. The penis had become very unserviceable, and he was now anxious to have the ring removed. A broad, hard substance was felt sur- rounding the penis, close to the pubic symphysis; an incision Avas made into the urethra at that part, and a calculus easily extracted. The uneasy symptoms quickly disappeared, and the patient recovered with a small fistula, for Avhich he refused to be treated. The cal- 1 Liston's Elements of Surgery, p. 509. Phil. 1846. INCONTINENCE OF URINE. 323 cuius was of the size of a prune, crescentic in shape, and composed of uric acid, with a crust of ammoniaco-magnesian phosphate. A section of it disclosed about two-thirds of the brass curtain-ring, firmly impacted in the centre, and partially decomposed. Finally, when the incontinence is irremediable, the patient should wear a urinal, to prevent the fluid from soiling his clothes, and thus rendering him not only disagreeable to himself but offensive to his neighbours. The best contrivance for this purpose is a gum elastic bottle, shaped somewhat like a Florence flask, and capable of holding about twelve ounces. This should be closely adapted to the parts, and changed as often as circumstances may require. A larger bottle might be used at night, to obviate the necessity of rising; and such an expedient would also enable the sufferer to observe a greater amount of cleanliness. The subjoined cuts will convey a better idea of the apparatus than any description, however elaborate. Fig. 38 Fig. 38. Fig. 39. represents the male, and Fig. 39 the female urinal. The articles are of French manufacture, but they are for sale by Mr. Tieman, cutler, Chatham Street, New York. Each instrument is furnished at its inferior extremity with a screw, for the purpose of evacuating the urine after it has accumulated to some extent in the artificial reservoir. The interior should be frequently washed for the sake of cleanliness, and every patient should be provided with an extra vessel, so that he may not suffer any inconvenience in case of accident. CHAPTER XVI. HERNIA OF THE BLADDER. The bladder, like the other abdominal viscera, is liable to protrude from the pelvic cavity, constituting what is denominated a cystocele. The accident, although uncommon, is of great practical interest, and therefore requires some notice in this place. It is said to have been first described by T. D. Sala, since whose time it has been por- trayed with so much accuracy by different pathologists and surgeons as to render it impossible to add anything new to its history. The protrusion may take place in different regions, the principal of which are the inguinal, the femoral, and the vaginal, the latter of which is its most common seat. Pipelet le Jeune relates an instance in which it occurred in the perinseum; and, in the fourth volume of the Edinburgh Medical and Surgical Journal, mention is made of a cystic hernia which projected between the elevator muscle of the anus and the internal obturator muscle into the pudendum. Zerdier saw a case where the bladder with the urachus and umbilical artery was drawn down into the scro- tum. An instance of protrusion of this organ through a wound, caused by a bullock's horn, is recorded by Larrey. A distended bladder has occasionally been protruded before the head of the child in labour; and an instance is recorded by Merriman where a tumour thus formed was actually opened under the supposition that it was a hydrocephalus. A hernia of this description is sometimes complicated with a bu- bonocele, or hernia of the groin, which it may either precede, or follow. In those enormous abdominal ruptures, in Avhich a large mass of the intestinal tube is protruded, the bladder occasionally forms a constituent part of the tumour. On the other hand, the bladder sometimes descends first, and thus paves the way, as it were, for the escape of the bowel. A very interesting fact, in relation to the HERNIA OF THE BLADDER. 325 subject of the present treatise, is the occasional coexistence of stone in the protruded organ. Of this occurrence quite a number of examples are mentioned by authors. One of the most interesting, in a practical point of view, is that recorded by Sala, in which the patient had all the symptoms of stone, though none could be felt by the sound. After death the foreign body was found in the blad- der, which was contained in the groin. In a case given by Petit, the calculi, which were several in number, were discharged by the urethra. Hartmann has recorded an instance in which a pudendal cystocele contained a stone weighing three ounces. Hernia of the bladder occurs in both sexes, and at different periods of life. A case is given by Pott of a boy of thirteen. The occurrence, however, is most common in elderly male subjects who have been repeatedly afflicted with retention of urine. Of the exciting causes nothing special is known; but the probability is that they do not differ from those of hernia in general. In women, the affection has been noticed from the effects of dropsy and pregnancy, particularly that form of it known as vaginal cysto- cele. In children, it has sometimes been caused by the irritation of stone. The cystic hernia is destitute of a proper peritoneal sac. As the bladder, in the natural state, is covered only partially by serous membrane, it is evident, that, as it passes out of the abdomen, it must lie exterior to this investment. The only exception to this rule is where the rupture is of long standing, or the tumour is of great bulk, in which case the fundus of the bladder may drag the peritoneum down into the scrotum, so as to form a hernial sac, into which a portion of bowel or omentum may afterwards protrude. The sAvelling is always formed, in great measure, by the superior portion of the viscus, and is generally of small size, though occa- sionally it has been known to attain the magnitude of a fist or of a goose's egg. When the disease is complicated with bubonocele, the intestinal hernia invariably lies in front of the cystic. A cystocele is a soft, elastic, and fluctuating tumour, which varies in its size according to the amount of urine contained in the pro- truded part. When the bladder is full, the tumour is large and tense, but very small, or almost effaced, when the viscus is empty. It is free from pain, increases from above downwards, and attains its volume in a slow and gradual manner. When examined in a dark room, with the aid of a candle, it appears translucent, very 326 DISEASES AND INJURIES OF THE BLADDER. much like a hydrocele. If the tumour be compressed, it diminishes in size, and the patient experiences an inclination to void his urine. If reducible, it returns during recumbency, but reappears soon after the resumption of the erect posture. If, on the contrary, the parts are adherent, or if the muscular coat of the bladder is paralysed, the patient cannot expel his urine from the tumour unless he resorts to compression. The diagnosis of cystocele is a matter of importance, as a tumour of this kind has occasionally been cut into by mistake. This accident occurred to the celebrated Pott, of England. The most decisive symptom is the change which the swelling undergoes in its volume during micturition. As the water flows off, the tumour decreases, or entirely disappears, to recur again, however, as soon as the urine has reaccumulated to some extent in the protruded part. A cysto- cele has not the doughy, inelastic feel of an omental hernia, nor the soft gaseous feel of an intestinal one, nor does it return with that peculiar gurgling noise which accompanies the ascent of the latter. When the bladder is contained in the scrotum, the disease might be mistaken for a hydrocele, though such a mistake could hardly be committed except by a careless, superficial observer. In vaginal cystocele, of which I have seen several examples, the swelling is of a globular shape, free from pain, and of a soft, elastic feel, imparting, on handling, the sensation of its fluid contents. Situated at the anterior portion of the vagina, the tumour varies in volume from that of a pigeon's egg up to that of a fist, and is either contained within the tube, or protrudes beyond the vulva. In the more aggravated forms of the complaint, the entire cylinder of the tube is involved. For the production of this affection a certain degree of relaxation of the walls of the vagina is necessary, and hence it is most common in females who have borne many chil- dren, or who have suffered a long time under leucorrhoea. When the tumour protrudes beyond the vulva, it forms a translucent sac, not unlike a serous cyst, or the amniotic bag. The diagnosis is de- termined, first, by the facility with which the tumour is reduced; secondly, by the absence of any opening in its walls ; thirdly, by the want of displacement of the uterus ; and fourthly, by the fact that the volume of the swelling is greatly diminished by catheterism. The treatment of cystocele, seated in the groin or scrotum, does not differ from that of intestinal hernia. When the tumour is re- ducible, it should be kept up by means of an appropriate truss; but HERNIA OF THE BLADDER. 327 when the viscus has contracted adhesions, and no longer admits of reposition, the patient must be contented with a suspensory bag. The urine that accumulates in the lower part of the sac must be discharged by raising and compressing the tumour during micturition. If retention should take place, and relief cannot be afforded by the catheter, the part should be punctured. If calculi collect, and become a source of great suffering, they may be extracted by incision of the sac.1 Such an operation was successfully performed by Pott. For the relief of vaginal cystocele, the principal remedies are, the frequent withdrawal of the urine, injections of cold astringent lotions into the vagina, the use of a well-constructed pessary, and rest in the recumbent posture. The general health must be improved by laxatives, light but nourishing diet, and the use of chalybeate tonics. Although not strictly relevant to the present subject, mention may be made here of an affection, which is of the deepest interest in its diagnostic relations. I allude to prolapsion of the female bladder at the urethra, forming a tumour at the external orifice of the tube, between the pudendal lips. The occurrence is exceedingly rare ; but as it is liable to be confounded with the vascular, polypoid, and other growths found in this situation, it requires to be briefly considered in this place. The most interesting case of the kind ever published is by the late Mr. Crosse, of Norwich, England. It happened in a child between two and three years of age; and the tumour, which projected visibly at the external lips, was about the size and shape of a walnut. It was of a red, scarlet colour, and had a rough, granular surface, not unlike that of a large strawberry. The pro- fessional attendant supposed the tumour to be of a vascular nature, and accordingly proposed to remove it with the ligature, which he was on the point of applying, when, fortunately, the true character of the affection was detected. Had the operation been performed, the child would have been killed. Mr. Crosse pushed the tumour back into the vulva, and from thence into the urethra, which was so much dilated as readily to admit the little finger. The tumour had existed for "a considerable time," and did not return after it was reduced. Mr. Murphy, of Dublin, has seen a similar case, which was cured by reposition. 1 S. Cooper's First Lines of Surgery, by Dr. Parker, vol. ii. p. 213. CHAPTER XVII. URINARY DEPOSITS. It has been already seen elsewhere that the urine, under particu- lar diseased conditions of the system, or of the urinary apparatus, may contain pus, mucus, and other materials, which are either entirely foreign to it, or which enter it only very sparingly in the natural state. It only remains, therefore, in connexion with the present subject, that we should consider those substances which are liable to separate from this fluid, either after it has been evacuated and permitted to cool, or Avhile it is still lodged in the bladder, and retains its normal temperature. In the one case, the deposit is amorphous, and termed a sediment; in the other it presents itself either as a crystalline matter, and constituting what is denominated gravel; or it is converted into a hard solid body, called a calculus, stone, or concretion. The number of substances most liable to be thus precipitated from the urine, are three, namely, the lithic, the oxalic, and the phosphatic. These deposits are accompanied by peculiar diatheses, or states of the constitution, under the influence of which they are produced. I. The lithic deposit, as being the most common of all, may be con- sidered first. It derives its name from the circumstance that it enters largely into the composition of several varieties of urinary calculi. It is often called the uric deposit. Lithic acid is a peculiar animal substance, which contains a considerable quantity of nitro- gen, and is easily soluble in a solution of caustic potassa, but inso- luble in water. It is dissolved by nitric acid with effervescence; and before the blowpipe it emits a disagreeable foetid smell, similar to that of burnt horn, with a combination of hydrocyanic acid. This is owing to the fact that it is always united in the urine with ammo- nia, with which it forms a salt, the superlithate of ammonia, the acid being in excess. In the natural state of the urine, the acid is held in perfect solution, but in certain morbid conditions of this fluid, or URINARY DEPOSITS. 329 when the acid is secreted in excess, it is thrown down in the form of amorphous sediments, or crystalline salts. The urine depositing lithic acid always reddens litmus paper, and its specific gravity is generally over 1*020. According to Dr. Bird, it frequently con- tains an excess of urea, and when this is the case it crystallizes slowly Avhen mixed with nitric acid in a watch-glass. Of the amorphous sediments, there are two, the yellow and the red, their names being derived from the peculiarity of their colour. They consist of lithic acid in combination with ammonia, are readily dissipated by heat, and never appear in the urine until after it has cooled. The yellow sediment consists almost wholly of the lithate of ammo- nia, tinged Avith the colouring matter of the urine. In its complexion, it runs through almost every intermediate shade between a pale fawn and a deep orange. In some instances it is nearly entirely white. It is of very frequent occurrence, and often disappears with great rapidity, to reappear, perhaps, almost immediately from the slightest causes. Heat readily dissolves it; and the addition of a drop of nitric acid causes a deposit of numerous crystals. An excess of yellow sediment may generally be regarded as denotive of disturbance of the digestive functions, or disorder of the cutaneous transpiration. The urine depositing this substance is of a pale amber tint, more or less acid, and clear when voided. Its quantity is commonly con- fined within the natural limits, and its specific gravity ranges from 1*015 to 1*025. The yellow deposit is very common in children, and frequently alternates with the crystalline sediment. The red sediment is composed of lithate of ammonia, in union with a peculiar colouring pigment, to which Dr. Bird has applied the term purpurine. This colouring matter is of a highly carbonaceous cha- racter, and is always present in those states of the system which are attended with imperfect assimilation, or a Avant of proper aeration of the blood. Hence, it is very common in fat, indolent persons, who take little exercise, and are fond of the pleasures of the table, and in those Avho are labouring under disease of the lungs, or chylopoietic viscera. This, form of sediment varies in its tint from a pale pink to a deep purple, according to the amount of purpurine present in the urine. A very frequent species is the lateritious, or brick-dust sedi- ment, so common in fever, rheumatism, and gout. The pink sedi- ment, described by Prout, is merely a variety of this; it is exceed- ingly rare, and is generally expressive of organic disease of the lungs, 330 DISEASES AND INJURIES OF THE BLADDER. liver, or spleen. It is occasionally an accompaniment of hectic irritation, and of dropsical effusions. When there is an excess of purpurine, the deposit is sometimes of a deep purple colour, not unlike that of the blood. The urine depositing this sediment is of a red, or brownish colour, preternaturally acid, and of high specific gravity, ranging from 1-025 to 1*035. Its quantity is ordinarily considerably below the normal standard. By adding to it a drop of nitric acid, it gene- rally becomes turbid, from the precipitation of lithic acid. The crystallized sediments, red sand, or gravel, consist of lithic acid, nearly in a pure state. They appear in the form of minute particles, resembling very much, in shape, size, and colour, the par- ticles of Cayenne pepper. Heat does not dissolve them, as it does lithate of ammonia. Under the microscope, they are found to consist of exceedingly delicate crystals, most of which have the appearance of rhombic prisms, which may, therefore, be assumed as their normal form. The most perfect specimens are generally contained in the deposits of yellow sand in the urine of young infants. The crystals are sometimes nearly square ; or they are very thin, and longer than broad, so as to represent square tables ; or finally, they are so thin as to appear merely like pale lozenge-shaped lamellse. Occasionally they lie across each other, and are firmly coherent. These varieties have been particularly described by Dr. Bird, and are well shown in the adjoining cut. The colour of this crystallized substance is subject to considerable diversity. When the deposit is unaccompanied by fever, it is usually more or less yellow ; but when the reverse is the case, it is pale red, lateritious, brick red, or brownish. A pink tint is exceedingly rare. The urine from which the matter is precipitated, is generally scanty, deep-coloured, acid, and of high specific gravity. The quantity of this deposit is sometimes astonishingly great. I have seen cases in which it was discharged to the extent of four or five drachms a day for many weeks. The crystallized lithic deposits may occur at any period, but are most common in young children and aged persons. They are generally produced under the influence of a luxurious, indolent life, attended with dyspepsia, flatulence, acidity, and constipation of the bowels, with disorder of the cutaneous secretion. Frequently they URINARY DEPOSITS. 331 arc connected with gout, rheumatism, and chronic disease of the skin. The symptoms which attend them are pain in the loins, urethra, and neck of the bladder ; aching and retraction of the testes ; frequent and difficult micturition; impairment of the digestive functions; a dry, harsh, husky state of the skin, and more or less feverishness. The disease often exists at an early period, and is sometimes appa- rently hereditary. In the treatment of this affection, the first and most important point is to ascertain, if possible, the causes by which it has been induced, in order that we may employ the knowledge thus obtained as the basis of our therapeutic measures. From what has been already stated upon this subject, under the heads of the different lithic deposits, it may be assumed that they are all dependent, either directly or indirectly, upon the retention in the system of an inordi- nate quantity of albumen, fibrine, and other nitrogenous principles, which, in consequence of derangement of the cutaneous and other emunctories, are obliged to pass off by the kidneys. Of the various causes which may conduce to this result, the most important are, first, debility of the digestive organs, with consequent imperfect assimilative action; secondly, the use of unwholesome food and drink; thirdly, defective oxygenation of the blood, from disorder of the lungs and skin ; and fourthly, congestion, irritation, or inflam- mation of the urinary apparatus. What the immediate circumstances are which tend to influence the different forms of lithic deposits, have not been satisfactorily determined; though chemical science will probably ere long succeed in solving the problem, which, at present, ia everyAvhere surrounded by conjecture. Much will doubtless de- pend, in every case, upon the amount of lithic acid formed, and the presence or absence of a stronger acid, such, for example, as the hydrochloric or butyric, a very minute quantity of which is sufficient to precipitate all the lithic acid contained in a large quantity of urine.1 Looking at the causes, then, which lead to the production of lithic deposits, the first indication is to. improve and invigorate the state of the digestive organs. This is to be fulfilled, first, by attention to the patient's diet; and secondly, by a proper regulation of his bowels. As a general rule, no articles of food should be permitted that are known to disagree with the stomach. If the sufferer is of 1 Druitt's Surgery, by Sargent, p. 477. Phila. 1848. 332 DISEASES AND INJURIES OF THE BLADDER. suitable age, his own experience will frequently teach him what is wholesome and what is not, in this respect. With children, the matter is different. All kinds of pastry, fresh bread, and oily, fatty and saccharine substances, should be interdicted. Boiled fish raw oysters, and the white meats usually agree well with the stomach and may be used in moderation once a day. For breakfast and supper, the latter of which should always be very light, brown bread, dry toast, and soda biscuit, with a small quantity of butter and a cup of black tea, will generally be sufficient. At dinner green vegetables and ripe fruits may be indulged in, provided they do not impede the digestive process, or create flatulence and acidity. When the stomach can bear and digest them, they are often of great benefit, by the tendency they have to promote the peristaltic action of the bowels, and to furnish the urine with alkaline matter, thereby preventing the deposit of gravel, or lithic acid. Beef, pork, and mutton, if used at all, should be taken very sparingly. Whatever food be employed, the great and important rule is to masticate it as thoroughly as possible, to eat sloAvly, and not to overload the sto- mach, or overtask the powers of this organ. Coffee, beer, and alco- hol should be avoided; the first two seldom fail to produce flatulence and indigestion, and the latter is objectionable on account of its tendency to load the blood with carbonaceous matter. If the patient has been accustomed to the use of wine, he should either be obliged to discontinue it entirely, or limit himself to a glass or two of dry sherry or Madeira at dinner. My own observation, however, has abundantly satisfied me that, both in this and the other urinary deposits, brandy and gin are far preferable to Avine. Hard water must be avoided. To regulate the bowels, which are often much deranged in this affection, the patient should occasionally take some mild aperient, such as blue mass and rhubarb, or the compound calomel pill, espe- cially if there is evidence of defective or disordered hepatic secre- tion. Active purgation is rarely required, or proper. While there is much acid in the stomach and bowels, Castile soap may be advan- tageously united with the cathartic medicines. To aid in properly oxygenating the blood, exercise is of paramount importance. This should be taken daily at stated periods, in the open air, on foot, on horseback, or in a carriage, according to the state of the weather and the convenience of the patient. The former mode, when nothing interferes to prevent it, is perhaps the URINARY DEPOSITS. 333 best, from its tendency to excite the action of the skin, which the others have not. A golden rule is, whatever mode be adopted, never to carry the exercise to fatigue, or to take it immediately after a meal. In both cases, mischief would result; in the one, by caus- ing the oxydation of a large quantity of the muscular tissue, and in the other, by diverting the blood from the stomach, and thereby weakening the digestive powers. From the intimate relation subsisting between the skin and the urinary organs, it need hardly be said that whatever deranges the cutaneous functions has a tendency to lead to the formation of lithic sediments. Hence, in the treatment of this affection, it is a matter of primary importance to maintain the skin habitually in as clean and pure a condition as possible, by frequent ablutions and a change of linen. In warm weather, the surface of the body should be sponged at least twice a day with cold water, either simple, or im- pregnated with salt, mustard, or red pepper, followed by frictions with a coarse napkin, a hair-glove, or flesh-brush. The same plan may be pursued in winter, provided there is no contra-indication to its employment; for there can be no doubt at all that cold ablutions are very decidedly preferable, in this state of the urinary organs, to warm or tepid, inasmuch as they exert a much more invigorating influence, not only upon the skin, but upon the system at large. They are, in fact, to the external surface, what cold air is to the lungs. Nevertheless, a warm bath is occasionally highly beneficial, especially during a fit of the gravel. It has been said that a warm bath, strongly impregnated with carbonate of soda and potassa, is a useful means of conveying alkalies into the blood, particularly if taken when the stomach is empty; but it is questionable whether it has any other effect than that of purifying the skin and soothing the nervous system. Too much attention cannot be paid in the treatment of this affec- tion to the body and bedclothes ; both should be frequently changed and aired; flannel should be worn next the skin both summer and winter ; the patient should avoid exposure to cold, and his sleeping apartment should be frequently ventilated, and, if possible, it should be without fire. When the lithic deposit is connected with a gouty or rheumatic diathesis, recourse must be had to colchicum, preceded and accom- panied by mercurial cathartics. In nearly all cases of this kind there is marked derangement of the chylopoietic viscera, which it 334 DISEASES AND INJURIES OF THE BLADDER. is important to correct, at least to a considerable extent, before we resort to the exhibition of colchicum, with a view of directly im- proving the condition of the blood and the urinary secretion. Not unfrequently it is necessary to administer mercury in alterative doses, in combination with opium, until slight ptyalism is produced. Every physician knows the value of this remedy in gout and rheu- matism. When tonics are required, the best articles are quinine, iron, and the mineral acids, particularly the nitric and the nitro-muriatic. The vegetable acids, however, are also beneficial, and occasionally afford relief where the mineral fail. Both kinds may be given either alone or in combination with some of the vegetable bitters, two or three times in the twenty-four hours. In the lithic deposits atten- dant upon the exhausting night sweats of pulmonary phthisis, the best acid is the aromatic sulphuric. Quinine and iron, in the form of sulphate, iodide, or citrate, are particularly indicated in the dys- peptic forms of the affection. To neutralize any acid that may be generated in the stomach, to prevent flatulence, to preserve the lithic acid in solution, and to tranquillize the bladder, which is often extremely irritable in this disease, alkalies must be used. The best, according to my own ex- perience, are the bicarbonate of soda and of potassa, either alone or in conjunction with each other. They should be given twice or thrice a day, in doses of from fifteen to thirty grains, largely diluted with water. The best time of exhibition is about an hour after meals, when the digestive process is in full play. Dr. Bird1 is in the habit of prescribing what he terms the artificial Vichy water, prepared by stirring half a drachm of bicarbonate of potassa with five grains of citric acid in a tumblerful of lukewarm water. The mixture evolves enough carbonic acid to sparkle, and is not dis- agreeable. The biborate of soda exerts great influence upon uric acid, and may occasionally be administered beneficially; but it should be used with great caution in females, from its stimulant action upon the uterus. Phosphate of soda, liquor potassa?, and benzoic acid, are also valuable remedies, and may be tried where the more ordinary means fail, or are productive of little good. Irritation of the urinary apparatus, especially if inflammatory in its nature, may, in general, be relieved by the means already men- tioned, or by the application of leeches, cups, and blisters to the 1 On Urinary Deposits, p. 85. Phila. 1845. URINARY DEPOSITS. 335 lumbar region, the sacrum, or the perinseum. The warm bath will also be useful, and anodyne injections rarely fail to afford prompt relief. Finally, I ought to mention the good effects that may be derived, in the treatment of lithic deposits, from the use of anodynes. Of all the remedies which are prescribed for these affections, there are few, if any, which exert a more happy or controlling influence upon the excretions in question. In the milder forms they often alone effect a cure, while in the more severe they never fail to mitigate the local distress and improve the general health. The best articles of this class are the salts of morphia, lupuline, and hyoscyamus, which may be given either by themselves, or variously combined with some of the internal remedies above mentioned. When there is marked disorder of the skin, the anodyne may be administered in the form of Dover's poAvder, which, Avhile it allays pain, acts specifi- cally both upon the cutaneous and urinary secretions. II. The oxalic deposit holds, in point of frequency, an interme- diate rank between the lithic and phosphatic. It occurs in the form of a white, glistening powder, which is suspended in the urine, and manifests no disposition to precipitate itself, unless it can attach itself to some substance capable of constituting a nucleus. Examined with the microscope, this powder is found to consist of beautiful, transparent crystals, of an octohedral figure, with sharp and well- defined edges and angles. Occasionally, though rarely, they are shaped like dumb-bells, or like two kidneys united at their concavities, and so closely approximated as to Fig-41 appear almost circular,1 Fig. 41. They vary much in ^<^2 their size, but in general they are exceedingly minute. If they are subjected to ignition on platinum foil, the ^ ^ oxalic acid is decomposed, and a small quantity of car- a rx ^ bonate of lime is left, which is readily dissolved with ^ effervescence on the addition of dilute nitric acid. Oxa- HI *~| lie acid sometimes occurs as a distinct deposit, in the 3 " form of a small concretion, resembling a hemp-seed, ^~J which may be retained in the bladder, and go on gradu- ally increasing until it constitutes a mulberry calculus. Urine containing oxalic acid is generally of a distinct amber colour; but occasionally it is preternaturally dark or pale. Its spe- 1 Bird, on Urinary Deposits, p. 105. 336 DISEASES AND INJURIES OF THE BLADDER. cific gravity, which is extremely variable, ranges from 1*015 to 1*025, and is usually greatest in night specimens. The fluid is always decidedly acid, and very frequently contains slight traces of lithic sediment, urate of ammonia, or triple phosphate. In all cases there is a greater proportion of urea than in natural and healthy urine of the same density; and a very constant phenomenon also is the occur- rence of epithelial cells, which generally exist in large quantity, and in a nucleated form. To detect the presence of oxalic acid, the sus- pected fluid should be permitted to stand for a few hours in a glass vessel. At the end of this time, the upper six-sevenths should be poured off, after which the remainder should be put in a watch-glass, and gently warmed over a lamp. If oxalic acid be present, it will manifest itself in a few seconds by falling to the bottom of the cap- sule, in the form of a white, glistening powder. The artificial deposit always has the effect of rendering the urine specifically lighter.1 The formation of oxalic acid is favoured by whatever has a ten- dency to impair the assimilative powers, and to exhaust the vital energies. Hence it is most commonly induced by errors of diet, or the use of unwholesome food and drink, excessive mental exertion, inordinate venery, exposure to cold, long-continued suppression of the cutaneous perspiration, and injury of the spinal cord, brain, or sacro-lumbar nerves. What the immediate agency is under the influence of which it is developed, is still a mystery. Liebig and Wohler have shown that oxalic acid is readily formed during the oxydation of lithic acid, and it is probable, therefore, that the pro- cess is purely chemical. It has been supposed that the acid may be introduced from without, directly through the circulation; a view which derives confirmation from the fact that certain articles of food, such as rhubarb, sorrel, and tomato, which naturally contain this substance in considerable quantity, sensibly promote its formation. It has been ascertained that there is no connexion between the oxalic diathesis and diabetes; nor is there any, according to Dr. Bird, between it and saccharine matter. The symptoms of this affection are such as indicate the presence of derangement of the digestive and nervous functions. Dyspepsia exists in a marked degree; the appetite is capricious ; the stomach is harassed with flatulence and acidity; the bowels are costive, and frequently tender on pressure, or the seat of colicky pains; the 1 Bird, op. cit. URINARY DEPOSITS. 337 mind is gloomy and despondent; the temper is fretful; the surface is exceedingly susceptible to external impressions; the extremities are almost constantly cold; the sleep is disturbed by disagreeable dreams; and the patient continually broods over his disease, having a thousand misgivings and the most horrible forebodings. Pain in the loins is rarely, if ever, altogether absent, the sexual power is usually much impaired; and the urine is often voided with uncommon frequency, as well as with more or less heat and smarting. As the disorder advances, the patient becomes excessively emaciated, and ultimately falls into a confirmed state of hypochondriasis. Consump- tive symptoms are sometimes present in this affection, and in many cases the skin is covered with boils and scaly eruptions. In the treatment of this disorder, the first thing to be done is to improve the general health. Errors of diet, if any exist, must be corrected; all unwholesome and indigestible articles are to be avoided ; the food must be thoroughly masticated, and it must be light, bland, and nourishing. A fish diet is occasionally of the greatest benefit. Sugar, malt liquors, and wine are injurious. A small quantity of good French brandy may be taken at dinner; or, in fact, three or four times a day, if there exist marked debility. It will give tone to the stomaoh, and prevent the formation of acid. The bowels must be maintained in a soluble condition; but active depletion of every description is inadmissible. The body should be well pro- tected with clothing, and the utmost attention should be paid to the skin, Avhich should be washed daily, with tepid salt water, or some other stimulating fluid, and thoroughly rubbed with a coarse dry towel, or a flesh-brush. Warm bathing is often of immense benefit. In the milder forms of the affection, especially in summer, nothing makes a more rapid and decided impression than cool ablutions and regular exercise in the open air. When there is a tendency to gout or rheumatism, colchicum and hydriodate of potash will be of service, and should be exhibited in the usual manner. Tonics are demanded where there is much debility, with indigestion and emaciation, and the best articles, under such circumstances, are quinine and sulphate of iron, in combination with capsicum and hyoscyamus. Sulphate of zinc in the dose of one grain, two or three times a day, is said to ansAver an excellent purpose in cases of this kind, but I have no experience with the remedy. The mineral acids, as the dilute nitric and nitro-muriatic, also possess valuable tonic properties, and often exert a direct influence upon the renal secretion. When calculi 00 338 DISEASES AND INJURIES OF THE BLADDER. form, and the urine loses its acid reaction, recourse must be had to some of the alkalies, as the bicarbonate of soda and the solution of potash. III. The phosphatic deposit is characterized by its Avhitish colour, by its pulverulent arrangement, by its solubility in dilute hydro- chloric acid, and by its insolubility in ammonia and solution of potash. It presents itself under three distinct varieties of form, the triple, the calcareous, and the mixed, each of which demands succinct notice in this place. 1. The triple phosphate consists of phosphate of ammonia and magnesia, on which account it is generally called the ammoniaco- magnesian phosphate. It commonly occurs in minute white crystals, of a beautifully brilliant aspect, transparent, or opaque, and remarkable for their sharp angles and edges. In their form, these crystals exhibit great diversity; but in most cases they %z3 are prismatic. Occasionally they have a stellar, penni- %form, or foliaceous arrangement,1 Fig. 42. They often float on the surface of the urine, especially if it is partially decomposed, and look like an iridescent film of grease. The urine Avhich accompanies this deposit is preternaturally copious, pale, or whitish, and of low specific gravity, ranging from 1*005 to 1*014. It has a faint, sickening smell, which soon becomes ammonia- cal and offensive, is very feebly acid, and scarcely, if at all, reddens litmus paper. In some instances of the affection, the fluid is unna- turally dark, brownish, or greenish-brown, decidedly alkaline, and loaded with dense ropy mucus. The triple phosphatic deposit very often alternates with the yellow lithic or calcareous deposit. Old persons are more subject to it than children and adolescents, and it is always associated with great dis- order of the digestive organs. The patient is weak, irritable, and bloodless; the slightest exercise fatigues him, and he complains con- stantly of a dull, heavy, aching pain in the lumbar region. Over- exertion, errors of diet, dyspepsia, severe courses of mercury, and excessive venery, are the most common exciting causes. 2. The calcareous deposit is composed of phosphate of lime, and occurs in the form of an impalpable powder, of a whitish, grayish, or drab colour. Occasionally it is more or less dark, from the admix- 1 Bird, op. cit., p. 134. URINARY DEPOSITS. 339 ture of the colouring matter of the urine. The urine, as in the triple variety, is pale, copious, and of low specific gravity, and readily decomposed by exposure to the atmosphere. The deposit is often accompanied by an inordinate secretion of mucus, and from the fact that it frequently occurs in chronic cystitis, it has been supposed that it is sometimes furnished by the lining membrane of the uri- nary passages instead of by the urine. Whether this is really the fact, or whether the two phenomena are merely coincident, is unknown. Without altogether denying the power of the mucous membrane of the bladder and kidney to secrete phosphatic matter, I am disposed to regard the occurrence as one of great rarity. If we adopt this view, it follows, as a necessary corollary, that the deposit under consideration is derived in a great degree, if not exclusively, from the urine. 3. The mixed deposit, consisting of a combination of the two pre- ceding, is very common, and is supposed to be the result of the joint agency of the kidney, and the lining membrane of the urinary passages. The earthy matter is of a whitish colour, partly amor- phous, and partly crystallized, and usually intermixed with mucus, which is often secreted in large quantity, and of a ropy, viscid cha- racter. The urine is foetid, pale, and abundant, and deposits a thick mortar-like sediment upon standing. The most common causes of this condition are, injury of the lower part of the spine, organic dis- ease of the kidney and bladder, dyspepsia, long-continued bodily fatigue, mental anxiety, night-watching, unwholesome food, and debilitating medicines. Patients thus affected are weak and dyspep- tic, irritable, nervous, easily affected by cold, thin and emaciated, and of a gloomy, desponding disposition. The urine is voided more frequently than in health, and with more or less pain and scalding along the urethra. Pain in the loins is seldom entirely absent. In the treatment of this affection, the principal indications are, first, to improve the condition of the digestive organs; secondly, to acidify the urine; and thirdly, to strengthen the system. To accom- plish the first of these objects, it-is necessary to regulate the diet, and administer mild aperients. Stale bread, soda biscuit, rice, hominy, mealy potatoes, boiled fish, mutton chops, beef-steak, and poultry, are the articles that are best borne under such circum- stances ; the food should be well masticated, and care taken never to overload the stomach. Ripe malt liquor, or good port, sherry, or Madeira wine, may be used in moderation, and are often of use in 340 DISEASES AND INJURIES OF THE BLADDER. supporting the strength. Most commonly, hoAvever, where a stimu- lus of this kind is required, brandy will be found preferable to every- thing else. Hard water should be avoided. Exercise should be taken daily in the open air, but it must never be carried so far as to induce fatigue; the patient's sleeping apartment should be frequently ventilated, and the whole body should be sponged morning and even- ing with cool, tepid, or warm water, as may be most agreeable to the feelings. The bowels must be kept open, but not actively purged, with some mild aperient, as blue mass and rhubarb, Epsom salts, or some alkaline mineral water. To fulfil the second indication, acids are required, of which the dilute nitric is the best. It may be administered by itself, in a large quantity of water, or what is generally preferable, in union with hyoscyamus, black drop, paregoric, or infusion of opium. Anodynes can rarely be wholly dispensed with, and are often of immense bene- fit, from the manner in which they allay pain and nervous irritation. In some instances the muriated tincture of iron proves useful. When the urine is rendered preternaturally acid, or when there is marked pyrosis, recourse must be had to soda, or soda and potash, along with uva ursi and hop tea. All diuretics, properly so called, are injurious. The third indication is fulfilled by the use of tonics, such as qui- nine, bark, and steel; a plain but generous diet; exercise in the open air, and change of residence. A sea voyage is sometimes of immense benefit in this affection. Exposure to cold, irregularities of diet, and indiscretions of every sort, should be avoided, both during the actual existence of this diathesis, as well as for a long time afterwards, on account of the great tendency to relapse. When the deposit depends upon lesion of the spinal cord, the internal use of strychnine, and counter-irritation, in the form of blisters, issues, or the hot iron, will be of benefit. If inflammation of the bladder or kidney exists, it must be combated by the ordi- nary means. CHAPTER XVIII. STONE IN THE BLADDER. SECTION I. NATURE AND CAUSES. Most urinary calculi originate in the kidneys, from which they descend into the bladder, where, if they are retained for any length of time, they gradually increase in size, and ultimately produce more or less obstruction. Their progress along the ureter is some- times slow and painful; at other times rapid and almost free from suffering. The amount of the local distress is greatly influenced by the nature of the concretion, and by the degree of resistance afforded by the tube through which the foreign body is obliged to pass. A small, smooth calculus usually causes little inconvenience; while a large, or rough one, often occasions the most exquisite tor- ture. The process of descent, which generally occupies from twelve to forty-eight hours, is characterized by excessive nausea, and vomit- ing, great restlessness and jactitation, pain in the back, groin, and thigh, retraction of the testicles, numbness along the spermatic cord, a sense of constriction at the umbilicus, and tenderness of the hypogastrium, with coldness of the extremities, rigors, and a feeling of excessive prostration. The urine gradually accumulating behind the calculus, the ureter is slowly dilated, and the concretion at length reaches the bladder, from which it is either ejected, or in which it remains, until it is finally disposed of by operation. As soon as the passage is completed, the pain and sympathetic irritation subside, the patient frequently falling into a tranquil and refreshing sleep. The descent of the calculus from the kidney may be greatly expe- dited, as Avell as rendered less painful, by the abstraction of blood from the arm, or the loins and hypogastric region, by large doses of 342 DISEASES AND INJURIES OF THE BLADDER. morphia along with castor-oil and turpentine, the hot bath, fomenta- tions, and anodyne injections. The free use of chloroform or sulphuric ether will also prove highly beneficial. Stone occurs at all periods of life, from the most tender infancy to the most decrepit old age. Indeed, there is reason to believe that it occasionally exists as an intra-uterine affection. Geyer1 relates the case of a boy who suffered from calculus of the bladder from birth. He was cut in his twelfth year, when the stone had acquired so large a bulk that it had to be broken before it could be extracted. The whole mass weighed ten ounces. Stahl2 found a calculus of the size of a peach-kernel, in an infant of three weeks, that had suffered great distress from its birth in passing its water. Similar examples are mentioned by Nicolai,3 Armstrong,4 Richel,5 Greding,6 Nosaus,7 and others. Of 5376 cases mentioned by Civiale, in his Treatise on Calculous Affections, 2416 were children, 2167 adults, and 793 old persons: 1946 occurred before the age of ten, 943 from ten to twenty, 460 from twenty to thirty, 330 from thirty to forty, 391 from forty to fifty, 513 from fifty to sixty, 577 from sixty to seventy, 199 from seventy to eighty, and 17 after eighty.8 Children are more subject to this disease in certain districts than in others, and the same is true in regard to adults. The greater proportion of calculous cases in Wirtemberg, in the mountains of Switzerland, the Neapolitan States, and in some of the counties of England, especially Norfolk, occurs in young persons, from causes hitherto unexplained. In the United States, a larger number of children are affected with this disorder, in Kentucky, Ohio, Tennes- see, and Alabama, than in any other regions. Pennsylvania, Vir- ginia, Maryland, the two Carolinas, Georgia, Florida, Louisiana, and Arkansas, also furnish a considerable number of cases. The inhabi- tants of Missouri, IoAva, Wisconsin, Michigan, Indiana, New York, and New Jersey are comparatively exempt; and in the New England 1 Miscel. Nat. Curios., Dec. 11, An. V. p. 456. 2 Diss. De Morb. Fcetuum in Utero Materno, S 6. 3 Von. Erzeugung der Kinds im Mutter Leibe, Halle, 1746, p. 223. 4 Ueber die Gewohulichen Krankheiten Regensb. 1788. 5 Voigtel's Handbuch der Path. Anatomie, 3 B. p. 289. 6 In Ludwigii Advers. Med. Pract. vol. iii. P. iv. p. 742. 7 Jour, de Medecine, T. lxxii. p. 369. 8 See the Author's edition of Liston's Surgery, p. 531. Philad. 1846. STONE IN THE BLADDER. 343 States generally a case of calculus of the bladder is so rare as to excite the surprise of the observer. In Canada and the other British Provinces of North America the disorder is also very infrequent; at all events, none of the surgeons of these regions have acquired much reputation as lithotomists, and but few cases of stone are brought from thence into this country. We are justified, therefore, in be- lieving that the malady is uncommon there. The same remarks are applicable to Texas, Mexico, and California, as I have assured my- self by repeated inquiries from respectable and intelligent practi- tioners in those territories. The causes of these differences have not been ascertained ; attempts have been made to trace them to the effects of climate, and to the influence of the water, food, and habits of the people, but without success. It is not satisfactorily ascertained whether this affection is heredi- tary. Facts certainly warrant the inference that it is. Thus, Civiale relates the case of a man on whom he practised lithotrity whose mother had had stone, and one of whose children died of it. He also performed the operation on two brothers, whose grandfather and two uncles had laboured under the disorder. Prout speaks of a family in which the father, son, and grandson were all affected with uric acid calculi. I have not met with any cases illustrative of the present topic. Coloured persons appear to be remarkably exempt from calculous complaints. Whether this is the case in all countries where the negro resides I am not informed, but it is certain that the circum- stance obtains, in an eminent degree, in the black population of the Southwest. During a residence of ten years in Kentucky, I do not recollect to have met Avith a solitary example of gravel or stone in a coloured person. My impression is that Dr. Dudley in his large calculous practice has never cut more than two or three individuals of this description. To what this immunity is due, our knowledge does not enable us to determine. The circumstance is so much the more surprising when it is remembered that the coloured people of that region are constantly exposed to hard labour, and that their fare is often of the coarsest character. Urinary calculi are much more frequent in men than women, be- cause they are more constantly exposed to the exciting causes of the complaint; and secondly, because of the more complicated structure of the urinary apparatus, Avhich prevents the ready discharge of sabulous matter, and thus favours the formation of stone. But for 344 DISEASES AND INJURIES OF THE BLADDER. the latter circumstance, the probability is that young girls would suffer nearly as often as boys. What influence, if any, occupation exerts upon the production of this disorder, we have no statistical facts to determine. In the south- western states, especially in Ohio, Kentucky, and Tennessee, the great majority of calculous subjects are farmers and mechanics, or the sons of persons of this description ; and the same is true, I suppose, of the calculous cases in the other states. Persons who are habitually ex- posed to cold and wet are said to be particularly prone to this com- plaint ; the fact, however, if it be one, requires confirmation before it can be received as true. It has been already shown, as it regards sailors, who were formerly supposed to be very liable to stone of the bladder, that they are extremely exempt from it. Climate, doubtless, exercises no little influence in the formation of urinary concretions. It has been already stated that, in the United States, this disease is most common in Ohio, Kentucky, Tennessee, and Alabama; a circumstance which, so far as is known, does not depend upon any peculiarity of living, and which may therefore be supposed to be owing to some mysterious operation of the climate. In Holland calculous disorders are very common, and the 'circum- stance is the more remarkable, because of the great use that is made of gin, which is a powerful diuretic. That this liquor is not the cause of this occurrence is proved by the fact that the Dutch colo- nists of Batavia, in the island of Java, whose habits are not at all dissimilar from those of the people of the mother-country, are almost entirely exempt from this affection. Soemmering informs us that the disease is altogether unknown in some situations bordering on the Rhine.1 Calculous affections are, as was stated before, much more common in Norfolk than in any other part of England, and yet the habits of the residents there are the same as in the other counties. In the East Indies, stone is comparatively unusual, though not so much so as was formerly imagined. We have already seen that it is proverbially uncommon in New England. It is hardly safe, how- ever, to indulge in any remarks concerning a subject Avhich is in- volved in so much obscurity as the one under consideration. Much of what has been advanced is wholly conjectural, and, therefore, scarcely Avorthy of serious attention. Patient and multiplied obser- vations in different parts of the world are alone competent to furnish 1 Coulson on the Bladder, p. 166. London, 1842. STONE IN THE BLADDER. 345 us Avith any real and substantial light; for these we must wait before we are justified in coming to any positive conclusion. Certain kinds of food predispose to the formation of calculous disease. All articles which have a tendency to create acidity and flatulence, must exert a deleterious influence upon the renal secretion, changing its properties, and promoting the deposition of earthy matter. How far the constant use of hot bread, biscuit, and pastry, Avhich are consumed in such enormous quantities in this country, especially in the southwestern states, conduces to bring about calcu- lous disorders, we have no means of deciding. That the daily em- ployment of these articles is prejudicial no one can doubt. Their influence in producing dyspepsia, so prevalent in every part of the Union, is familiar to every observer, and need not, therefore, be dis- cussed in this place. Hot bread, in its various forms, frequently only half-baked, and generally but half-masticated before it is swal- lowed, is sufficient, if used for any length of time, to wear out the strongest stomach, and to break down the most vigorous frame. What the effects of such a state of the system must be upon the urinary secretion, every pathologist knows. A weakened digestion, with a sour and flatulent state of .the stomach, constipation of the boAvels, and an irritable condition of the brain, cannot by any possi- bility produce a healthy blood, any more than a morbid state of the blood can produce a healthy urine. It has been supposed that the use of corn bread and bacon predis- poses to the development of calculous disorders. That such may be the case is possible, but the fact, if it be one, remains to be esta- blished. The negro of the Southwest, who employs hardly any other kind of bread, and whose principal meat is salt bacon, is proverbially exempt from this class of diseases; and it is also well known, at least to the practitioners of that region of country, that a great many of the Calculous patients there are under five years of age. Now, young children are seldom sufficiently fond of corn bread to make it their principal food; they generally prefer wheat bread, potatoes, and meat, the latter of Avhich is often consumed in large quantities before the completion of dentition. Moreover, in many cases of calculous disease of children, well-marked symptoms of the affection are observed before the infant is weaned, and consequently before it has had an opportunity of tasting the kind of bread in question. In Ohio, where stone is perhaps nearly as frequent as in Kentucky, but little corn bread is used, while in the latter state it forms, in many families, 346 DISEASES AND INJURIES OF THE BLADDER. the principal table diet. In Norfolk, England, Avhere calculous com- plaints are probably more frequent than in any other portion of the world, corn bread, as an article of food, is unknown. What influence, if any, the inordinate use of coffee and tea exert upon the production of this disease, is not ascertained. That they may predispose to the occurrence, especially when they are habitually taken hot, by weakening the digestive powers, and changing the renal secretion, is, I think, highly probable. No facts of a satisfactory nature have yet been published in regard to the agency of wine, cider, malt liquors, and spirits, in producing stone of the bladder. Many respectable writers and practitioners are of opinion that the production of calculous diseases is promoted by the use of hard, impure water, in consequence of the changes which it is supposed to induce in the renal secretion. The opinion is plausible, and may be true, but how far, or to what extent, nobody has attempted to decide. If it be true that in Kentucky, Alabama, Tennessee, and Ohio, most calculous cases occur in limestone regions, it is equally true that many are found in the freestone districts of those states. The formation of stone in the bladder is often remarkably favoured by stricture of the urethra, enlargement of the prostate gland, and organic disease of the bladder, ureters, and kidneys. Whatever, in fact, has a tendency, for any length of time, to obstruct the flow of urine, or change the character of this fluid, whether during its secre- tion or after its arrival in the bladder, may be looked upon as a pre- disposing cause of this disorder. If the urine happen under these circumstances to be at all surcharged with earthy salts, or even where it contains merely its normal proportions, more or less of these sub- stances is liable to be retained in the bottom of the viscus, where it serves afterwards, in many instances, as the nucleus of a calculous concretion. This liability is greatly increased when there is habi- tually, along with the mechanical obstruction, an inordinate secre- tion of mucus. Injury of the brain, spinal cord, or the nerves which supply the urinary organs, especially the kidneys and the bladder, is highly conducive to the development of stone. The properties of the urine are generally more or less altered in this affection, and the fluid com- monly contains an unusual amount of saline material. Paraplegia and paralysis of the bladder, if existing for any length of time, are always sure to be followed by the deposition of the earthy phosphates, and, in many cases also, by the formation of stone. Whether these STONE IN THE BLADDER. 347 substances are derived, under these circumstances, directly from the urine, or whether they are furnished by the mucous membrane of the bladder, is a point of which pathologists are ignorant. Finally, the formation of vesical calculus is favoured by gout and rheumatism. Such at least is the declaration of many writers, both medical and surgical. How true it may be no one knows, for we have no statistical facts upon the subject, and all our other information amounts to nothing but conjecture. SECTION II. PHYSICAL AND CHEMICAL PROPERTIES. 1. Most calculi have a central nucleus, upon which the earthy matter accumulates or crystallizes. This nucleus may be formed by any solid, or semi-solid substance, whether generated in the urinary organs, or introduced from without. The earthy matter, contained •in the urine, gradually collects around this substance, which thus serves as its basis, and assists in moulding its shape. That this is the case, especially with the bladder, is undeniably proved by the well-known experiment of Boerhaave. This celebrated physician introduced a small round pebble into the bladder of a dog. The wound healed perfectly in a very short time. A few months after- wards the animal was killed, and there was found a calculus of con- siderable volume, of which the pebble was the nucleus. Similar results have been witnessed a thousand times in the human subject, from the accidental or intentional introduction of foreign bodies into the bladder. Generally speaking, the nucleus consists of inspissated mucus, lymph, clotted blood, or some saline matter of the urine. In many instances, however, the concretion is formed round a foreign body, introduced either by the patient himself through design or accident, or in the same manner by a second party. A person shot in battle has been known, at a subsequent period, to suffer from stone in the bladder, in consequence of the ball having lodged in that organ, and thus invited, as it were, a deposit of calcareous matter. A surgeon may become the innocent cause of a similar occurrence. In treating a diseased urethra, or in exploring this canal, the bladder, or the prostate gland, the catheter, bougie, or sound which he uses may 1 348 DISEASES AND INJURIES OF THE BLADDER. break off, and afterwards lead to the development of a stone. Many such cases are upon record. A great variety of substances, as nails, tacks, bullets, needle-cases, fruit-stones, peas, beans, pebbles, tents, hairs, small keys, pipe-stems, glass tubes, grass stalks, pieces of straw, pins, and needles, have been accidentally lodged in the bladder, by patients endeavouring to relieve stricture, to procure evacuations of urine, to excite onanism, or create public sympathy. Examples of this kind are, for obvious reasons, more common in the female than in the male. O'Brien relates1 an instance in which the nucleus consisted of a human tooth; Liston,3 one in which it was formed by a brass ring; and Malago,3 one in which it was composed of a globule of mercury. In my private collection is a portion of calculus, presented to me by Dr. Jetton, of Tennessee, which con- tains three of the caudal bones of a squirrel. The man from whom it was removed was thirty-five years of age, and the probability is that he was in the habit of exciting onanism with the tail of this animal, a piece of which broke off, and slipped into the bladder in an attempt of this kind. In the annexed drawing, taken from a preparation in the cabinet of Dr. Sabine of New York, the nucleus consists of a piece of cork. Dr. Van Buren, son-in-law of Fig. 43. Dr. Mott, and one of the surgeons of the Bellevue Hospital, informs me that he has a stone, the nucleus of which is formed by the head of a stalk of wheat. It was removed from a man nearly seventy years of age. He had introduced the straw for an improper purpose, and the barbs no doubt prevented its retraction; the consequence was that it passed beyond his reach, and ultimately into the bladder. The nucleus varies much in its size, colour, form, and consistence 1 Dublin Journal of Medical Science for March, 1834. a Edinb. Med. & Surg. Jour., vol. xix. p. 57. 8 Filiatre Sebezio, 1845. STONE IN THE BLADDER. 349 Although generally single, it is sometimes double, triple, and even quadruple : its situation is not always strictly central. The instances in which the concretion is hollow, or the nucleus loose, are rare. 2. Calculi vary much in their number. In general, there is only one; now and then there are two or three; and sometimes, though rarely, there are several dozens, or even several hundred. The largest number I have ever found was fifty-four, which I removed from the bladder of an old gentleman, upwards of seventy-six years of age, from Oldham County, Kentucky. They were of a dull whitish colour, smooth, irregular in their shape, and from the size of the kernel of a filbert to that of a common marble. Fifty-five were found in the bladder of the celebrated Buffon. Examples are men- tioned of sixty, seventy, eighty, ninety-six, and one hundred. The greatest number ever extracted by Sir Astley Cooper was one hun- dred and forty-two. Dessault took upAvards of two hundred from the bladder of a priest. Similar instances are mentioned by Kriiger, Dupuytren, and others. Dr. John Kelly,1 of the State of New York, has published a case of two hundred and twenty-eight. Tulpius, Boerhaave, Beauchene, and Ribes each record a case of three hun- dred or upwards. In the instance mentioned by the latter, this number was found after death in a man who had previously under- gone the operation of lithotomy three times. Murat met with six hundred and seventy-eight. Schurig, in his "Lithology," refers to a case of seven hundred. The most extraordinary example, however, upon record, occurred in the practice of the late Dr. Physick, who extracted from Judge Marshall, of the Supreme Court of the United States, upwards of one thousand calculi, from the size of a partridge shot to that of a bean. They were all of an oval shape, and marked each by a small black spot.2 The mulberry calculus is almost ahvays solitary; and the same is true, but not to the same extent, of the uric calculus. The phos- phatic calculus, on the contrary, is not unfrequently multiple. When the concretions are numerous, they are always proportionably small, and more or less smooth on the surface, from the constant friction Avhich they exert upon each other in the bladder. On the other hand, solitary stones are generally rough, and comparatively large. 3. The volume of urinary concretions ranges between a hemp-seed and a cocoa-nut. In the great majority of instances it does not 1 Amer. Jour. Med. Sciences, Jany., 1847, p. 246. a Gibson's Institutes of Surgery, xi. p. 220. Fifth edition. 350 DISEASES AND INJURIES OF THE BLADDER. exceed that of an almond, a pullet's egg, or a walnut, the latter of Avhich indeed it seldom reaches. In young subjects, and in recent cases generally, the size is usually inconsiderable. I have a number of calculi, extracted from children from three to five years of a^e, which, in their volume, hardly equal a common marble. The size of a urinary concretion, however, does not necessarily depend upon the period of its sojourn in the bladder, or the age of the patient. Occa- sionally it increases very rapidly, so as to attain a considerable bulk in a very feAV months; and, on the other hand, it may remain small for many years. In 1844, I operated upon a man twenty-six years old, who had laboured under well-marked calculous symptoms from his earliest infancy, and yet the stone was hardly as big as a hen's egg* The chemical constitution appears to exert no inconsiderable in- fluence upon the volume of urinary concretions; thus, the ammo- niaco-magnesian and the fusible calculi are capable of attaining a very large size, while the uric, oxalic, cystic, xanthic, and fibrinous, are almost always comparatively small, no matter what may be their own age or the age of the patient. This fact is interesting in a practical point of view; because, by ascertaining the calculous dia- thesis of the sufferer, we shall be able to form a tolerably correct idea as to the volume of the stone under which he is labouring. It has been already seen, that when urinary calculi co-exist in great numbers, they are always proportionably small. In the most remarkable case of this kind upon record,—that of Judge Marshall, previously referred to,—the size of none of the concretions, which amounted to upwards of one thousand, exceeded that of a bean, while many of them were not larger than a partridge shot. It is worthy of remark also, that under these circumstances, the individual calculi are generally of unequal dimensions. 4. The consideration of the weight of urinary concretions is necessarily connected with that of their volume. In general this does not exceed a few drachms or ounces. Out of every one hundred calculi, as they occur in the cabinets of different institutions, or private indiAdduals, few will be found to weigh more than five or six drachms. The smallest probably ever removed by operation was one of ten grains, extracted by Mr. Martineau, of Norwich, England, from a boy thirteen years old. Many examples, however, are re- corded of four, six, eight, ten, twelve, fifteen, and even sixteen ounces. Instances of eighteen, nineteen, and twenty ounces, are STONE IN THE BLADDER. 351 related by Borellus, Lusitanus, Cheselden, Pauw, Foschini, Wris- berg, and Sandifort. Fabricius Hildanus describes a calculus which weighed twenty-two ounces, and was four inches and a half in length, by three and a half in breadth. Examples of from twenty-four to thirty ounces are recorded by Deschamps, Pauw, Paget, Tolet, King, and other authors. In the case mentioned by the latter,1 the patient, who was forty-six years of age, had suffered from his in- fancy, and the stone Avas seven inches and a half long, by fifteen inches in circumference. Several' instances exist in which the con- cretion weighed thirty-five, forty, forty-five, and even fifty ounces. Mr. Henry Earle,2 of London, has published the particulars of a calculus which weighed forty-four ounces, and was sixteen inches in circumference. It was impossible to break it, and the operator was compelled to leave his task unfinished. Deschamps gives a case of fifty-one ounces; Verduc, one of three pounds three ounces; and, as if to cap the climax, Kesselring3 one of upwards of six pounds. 5. Not a little diversity obtains in respect to the consistence of vesical concretions. As a general rule, it may be said to vary from that of semi-concrete mortar, chalk, or wax, to that of stone or marble. The hardest calculi are the oxalic and uric, which gene- rally emit a clear sound when struck with steel, and cannot be frac- tured without a considerable degree of force. Calculi, on the other hand, composed of ammoniaco-magnesian phosphate and phosphate of lime, are friable, and easily reduced to powder. In extracting such concretions from the bladder, they not unfrequently break under the pressure of the forceps. The cystic and fibrinous calculi are quite soft, the latter scarcely equalling that of yellow wax. It often happens that one part of a stone is hard and compact, while another is soft, friable, or even pulverulent. This diversity of con- sistence is strikingly exhibited in what are denominated the alterna- ting calculi, and seems to depend, in great measure, if not entirely, upon the component elements of the different layers of which such concretions consist. It is not improbable that the age of a stone may exert some influence upon its consistence, though it is impos- sible to estimate the amount or degree of it. Stones are occasionally composed of a mixture of sabulous matter and hair, more or less intimately matted together. Their consis- 1 London Medical and Physical Journal for 1828. 2 London Medico-Chir. Trans., vol. xi. p. 82. 3 Commer. Liter. Norimb. 1739, hebd. 9. 352 DISEASES AND INJURIES OF THE BLADDER. tence resembles that of old lath-plaster; they are easily crushed, or pulverized, and they are of a Avhitish, grayish, or pale drab colour. Their formation is of rare occurrence, and they appear to consist principally of phosphate of lime and magnesia. Where the hair comes from is not ascertained. 6. The colour of these bodies is not less variable than their other physical properties. The most common shades are white, grayish, drab, fawn, reddish, rose, and brown. Concretions of a bluish, greenish, black, or slate colour are rare. In the alternating cal- culi, a combination of tints is generally observable, and even one part of the surface of a stone may differ essentially, in this respect, from another. The cystic and fibrinous calculi are of a yellow colour, not unlike that of yellow wax; the phosphatic are whitish or grayish; the oxalic, dark or blackish; the uric, rose, reddish, or brown. 7. Most calculi, at the moment of their extraction from the bladder, and for a short time afterwards, emit a strong urinous odour, which they gradually lose by exposure to the atmosphere. It may also be completely destroyed by ablution in warm water, and rapid desiccation before the fire. More or less, however, of the animal matter is usually retained, so that maceration at any future time, if not too remote, is apt to be followed by a slight reproduction of the original odour. When sawed, rasped, or rubbed, urinary concretions give out a smell similar to that of bone, horn, or ivory. Fourcroy considered the spermaceti odour furnished by mulberry calculi, thus treated, as characteristic of the species; this, however, is a mistake. 8. Vesical calculi are capable of assuming a great variety of forms. The circumstances which are chiefly concerned in producing this result are the action of the bladder, the friction which the con- cretions, when multiple, exert upon one another, and the nature of the nucleus. One of the most constant symptoms of vesical calcu- lus is a frequent micturition, at the close of which the bladder always contracts violently upon the foreign body. When this con- traction is uniform, the concretion will be likely to be of a regular figure; but the reverse when this power is exerted unequally. The attrition which vesical calculi, when multiple, experience from the friction to which they are incessantly exposed, seldom fails to effect a change in their configuration. Such concretions are nearly always smooth, angular, and more or less polished, while, on the STONE IN THE BLADDER. 353 contrary, the solitary are generally rough, and comparatively regular in their shape. The influence exerted by the nucleus in moulding the form of the concretion is well illustrated by those cases in which the deposit takes place round a foreign body, as a bullet, pin, needle, or bit of bougie, accidentally introduced into the bladder. The configuration of the stone, under such circumstances, almost always partakes of that of the extraneous substance. Finally, it is not unlikely that the chemical constitution exerts more or less influence upon the form of the concretion. Vesical calculi are commonly of an oval form, but occasionally they are round, spherical, or even cylindrical. Other varieties of form are sometimes seen, as the conical, pyriform, cubic, triangular, pyramidal, gourd-like, polygonal, and the tetrahedral. Sometimes the concretion is thin and flat, like a coin, lenticular, semilunar, or in the shape of a mushroom, a kidney, a mulberry, a bean, or a heart. Again, it may be large and bulbous at the extremities, and narrow at the middle, like a dumb-bell. Dr. Mussey, Professor of Surgery in the Medical College of Ohio, has a most singular-shaped calculus, which he removed, many years ago, from the bladder of a man after death. It has a very delicate nucleus, from which a number of slender prongs project, of an irregularly cylindrical shape, and some of them upwards of an inch in length. A large concre- tion Avill occasionally assume the form of the bladder, and have even prolongations or projections, representing the shape of the urethra, the ducts of the prostate gland, or the ureters. In fact, there is no end to the grotesque appearance of these foreign bodies. Mor- gagni speaks of a perforated stone, voided by a female. The shape of a calculus is sometimes materially influenced by that of its nucleus. If this is very long, as when it consists of a piece of catheter, bougie, straw, or flower-stalk, the concretion will also be apt to be long and slender, the reverse being the case when the nucleus is rounded, or OAroidal. The fact is interesting in regard to the manner in which the foreign body should be seized with the for- ceps, Avith a view to its removal from the bladder, whether this be attempted by incision, or the natural channel. 9. The surface of these concretions may be smooth or rough. The former is generally the case when several exist together, from the friction which they exert upon each other ; Avhen there is only one, however, it is almost always rough. From the cause just mentioned, multiple calculi may not only be smooth but even highly polished, 23 354 DISEASES AND INJURIES OF THE BLADDER. and rendered angular, polygonal, rhomboidal, or tetrahedral. The oxalic concretion derives its common name from the roughness of its surface, which resembles that of fruit of the mulberry. The uric acid calculus is usually finely tuberculated. In some of these foreign bodies the surface is scabrous, mammillated, knotty, convoluted, or covered with spines, prongs, or stalactites. 10. The chemical composition of urinary calculi has attracted much attention during the last fifty years, and the individuals who ha\re par- ticularly distinguished themselves for their researches in this respect are Scheele, Bergmann, Wollaston, Brande, Marcet, Fourcroy, Prout, Berzelius, Henry, Scharling, Taylor, and Bird. In this country, the most valuable contribution that has been made to this branch of chemical science is from the pen of Professor Peter, of Kentucky. His paper, which was originally published in the fifth volume of the Western Lancet, is founded upon an analysis of eighty-one calculi in the museum of the medical department of Transylvania Univer- sity, and is one of deep interest in reference especially to the relative frequency of stone in Lexington, and the probable causes by which it is induced. To this paper, which has since appeared in a separate form, I beg leave to refer the attention of the reader for a large amount of valuable information, having a direct bearing upon the nature and composition of urinary concretions in a region of country where calculous affections are more common than in any other parts of America. It is to be hoped that the labours of Dr. Peter will have the effect of stimulating others to similar investigations; for it is only by the combined researches of chemical philosophers in different portions of the country that the subject can be placed in its true light. The subjoined account, which is transferred, with little alteration, from my work on Pathological Anatomy, includes the most impor- tant species of urinary concretions that have hitherto been described. The uric calculus, called also the lithic calculus, the most common species of all, was first noticed by Scheele, in 1776. In its colour it is brownish, inclining to that of mahogany, of a flattened oval shape, occa- sionally finely tuberculated on the surface, but most generally smooth, though not polished, unless there are several concretions at the same time, and from the size of a currant to that of a hen's egg. If the uric calculus be divided with the saw, it will be found to consist of several layers arranged concentrically around a common nucleus, the laminae being frequently distinguishable from each other by a slight diffe- STONE IN THE BLADDER. 355 rence in colour, and sometimes by the interposition of other ingre- dients. Water has but little action upon it; it is perfectly dissolved by caustic potash; and disappears with effervescence in hot nitric acid, the solution affording, on evaporation to dryness, a bright carmine-coloured residue ; before the blow-pipe, it becomes black, emits a peculiar animal odour, and is gradually consumed, leaving a minute quantity of white, alkaline ashes. Fig. 44 shows the oval shape and finely tuberculated surface of the calculus; Fig. 45 the internal concentric layers. Fig. 44. Fig. 45. As a variety of the preceding the uro-ammoniac calculus may be here mentioned. It is principally observed in children, and is so extremely rare that several distinguished chemists have been induced to deny its existence. It is generally of small size, with a smooth surface, of a clay colour, and composed of concentric rings, which present a very fine earthy appearance when fractured. Much more soluble in water than the uric calculus, it gives out a strong ammo- niacal smell when heated with caustic potash, and deflagrates re- markably below the blow-pipe. This variety of calculous concretion was first described by Fourcroy. Next to the uric calculus, in point of frequency, is the oxalic, which is generally of a dark brown colour, rough and tuberculated on the surface, very hard, compact, and imperfectly laminated, seldom larger than a walnut, spherical, and always single. Under 356 DISEASES AND INJURIES OF THE BLADDER. the bloAV-pipe, it expands and effloresces into a white powder; it dissolves slowly in muriatic and nitric acid, provided it be previously well broken up. In the alkalies, it is perfectly insoluble. This species of urinary concretion, called by many the mulberry calculus from its resemblance to the fruit of the mulberry, was first correctly analyzed, in 1797, by Dr. Wollaston, who proved it to consist essen- tially of oxalate of lime. Figs. 46 and 47 show the external appear- ance and internal structure of this concretion. Fig. 46. Fig. 47. Fig. 48. Fig. 49. A variety of this species of calculus has been described by the term hemp-seed, from some resemblance which it bears in colour and lustre to that substance. Fig. 48. It is always of small size, remarkably smooth, and generally exists in considerable numbers, being rarely if ever found alone. The phosphatic calculus, Fig. 49, described by Wollaston in 1797, is of a pale brownish colour, and of a loosely lami- nated structure, with a smooth, polished surface, like porcelain. The shape is mostly oval, and the size, though generally small, is sometimes very considerable. It whitens when exposed to the blow-pipe, but does not fuse ; and readily dissolves in muriatic acid, without effervescence. This calculus, composed essentially of phos- phate of lime, is extremely rare, as forming entire concretions, but frequently constitutes alternate layers with other matters. It is sometimes called the bone-earth calculus, and occasionally contains small quantities of carbonate of lime. STONE IN THE BLADDER. 357 Fig. 50. The next species is the ammoniaco-magnesian, so called from its being composed of the phosphate of ammonia and magnesia. Fig. 50. This mixed calculus is of a white colour, friable, crystallized on the surface, and looks a good deal like a mass of chalk : its texture being never lami- nated, it easily dissolves in dilute acids, but is insoluble in caustic potash; before the blow- pipe, it exhales an ammoniacal odour, and at length melts into a vitreous substance. This species of concretion, first noticed by Wollaston in 1797, sometimes attains an immense size. In a case mentioned by Dr. Thompson, the circumference was fourteen inches, and the weight nearly two pounds. The fusible calculus, the nature of which was first determined by Wollaston, consists of a combination of the last two. It is of a white colour, extremely brittle, leaves a soft dust on the fingers, and is easily separated into layers: when broken, it presents a ragged, uneven surface. It is insoluble in caustic potash, but gives off ammonia; and, under the blow-pipe, it is readily converted into a Fig. 51. Fig. 52. transparent, pearly-looking glass. This concretion is very common, and sometimes attains a very large size. It is frequently met with as an incrustation of foreign bodies. Figs. 51 and 52 exhibit the outer appearance and internal structure of this concretion. 358 DISEASES AND INJURIES OF THE BLADDER. A very rare species of urinary concretion is the cystic, so called from an erroneous supposition that it was peculiar to the bladder. It consists of a confused, crystallized mass, of a white yelloAvish colour with a smooth surface. The structure is compact, and the fracture exhibits a peculiar glistening lustre, like that of a body having a high refractive density. It exhales a strong characteristic odour under the blow-pipe, and is very abundantly dissolved in acids and alkalies, with both of which it crystallizes. This species is commonly of an irregular, spherical shape, and seldom attains a large volume. Wollaston termed it an oxide, and gave it the name of cystic, from a belief that it occurred exclusively in the urinary bladder. It has since been detected, however, in the kidney. The external and internal appearances of the cystic calculus are shown in Figs. 53 and 54. Fig. 53. Fig. 54. The xanthic calculus was first pointed out by Dr. Marcet, whose account of it is the best that is extant. It is extremely rare. Its texture is compact, hard, and laminated: its colour is of a cinnamon brown, its surface smooth, and its volume small. It dissolves very readily in acids and alkalies, and is gradually consumed before the blow-pipe, leaving a minute quantity of white ashes. There is what is called the fibrinous calculus. Like the preceding species, this is also extremely rare, and appears to be composed principally of the fibrin of the blood, a property to which it owes its name, and by which it is characterized. Sir Benjamin Brodie1 has described a concretion of this kind, which was about the size of a horse-bean, of an oval shape, and of a yellow transparent appear- ance, not unlike amber, but less hard. When dried, it shrunk to a small size, and became considerably shrivelled. 1 Lectures on the Urinary Organs, p. 214, second edition. London, 1835. STONE IN THE BLADDER. 359 Finally, there is a concretion recently described by Heller, under the name of urostealith. It is exceedingly rare, and I do not know that anybody else has noticed it. The specimen, analyzed by the German chemist, was obtained from a man of tolerably good consti- tution, twenty-four years of age, whose chief complaint was pain in the region of the right kidney, with difficulty in micturition. The concretions were of a rounded form, soft, elastic, and from the volume of a hemp-seed to that of a hazel-nut, most of them being as large as a pea. They become brittle on being dried, when they present the appearance of wax, of a greenish-yellow hue when viewed by transmitted light. When heated, they melt, and emit a peculiar, pungent odour, similar to that of benzoin. Urostealith is readily dissolved by ether and by solutions of caustic potash, but it is insoluble in boiling water, and nearly so in alcohol. It seems to be composed of a particular kind of fatty matter.1 SECTION III. SITUATION. Calculi generally lie loose within the cavity of the bladder, and are, consequently, liable to shift their position, not only with that of the viscus in which they are contained, but also with that of the body. Hence, at one moment they may be at the bas-fond of the organ, at another at its neck, another at its superior portion or base, at another at its sides, and at another, perhaps, at its anterior part, just above or behind the pubes. A knowledge of this variation, in the position of these foreign substances, is of no little importance in regard to the operation of sounding. Their most common situation is, undoubtedly, the bas-fond of the bladder, from the fact that this is the most dependent portion of the reservoir. In old subjects, affected Avith enlargement of the prostate, the concretion generally lies just behind this body, in a sort of pouch, hollow, or cul-de-sac. When this is the case, and the calculus is of large size, it may often be easily felt by the finger in the rectum. When the bladder is per- fectly sound, the concretion, especially when the patient is in the 1 Simon's Animal Chemistry, p. 635, Phila. 1840; also Markwick on Urine, p. 93, Phila. 1848. 360 DISEASES AND INJURIES OF THE BLADDER. erect position, and the urine evacuated, rests against the neck of the organ, and sometimes even projects into the orifice of the urethra. Cases occur in Avhich the concretion is alternately loose and fixed. This may be owing to several circumstances, of which the most con- stant, perhaps, is the existence of an abnormal pouch. The foreign body may also be arrested in the folds of the mucous membrane in the depression behind the prostate, in the substance of this gland, in the orifice of the ureter, or in the mouth of the urethra. Vesical calculi may become permanently adherent, attached, or fixed. This may take place in different ways, and in a variety of circumstances. The following may be mentioned as the most im- portant: 1. An effusion of coagulating lymph: 2. The formation of an abnormal pouch : 3. The existence of a fungous tumour or excres- cence : 4. A bilobed state of the bladder: 5. The projection of the concretion into the ureter, or some other passage: 6. Its lodgment in the Avail of the bladder. 1. The continued irritation caused by the presence of a calculus may lead to an effusion of coagulating lymph, the quantity of which, however, is rarely considerable. When this substance possesses a good deal of plastic power, it may become organized, notwithstanding the heterogeneous character of the urine with which it is incessantly in contact. Abnormal bands may thus be formed, by which the foreign body is tied to the inner surface of the bladder, and perma- nently retafned in its place. Or the quantity of lymph poured out may be so great as to surround and almost bury the concretion. In either case, its extraction may be attended Avith much difficulty. 2. Sometimes the calculi are contained in distinct cysts, sacs, or pouches, formed, as has been already seen, by a protrusion of the mucous membrane across the muscular fibres of the bladder. Whether they are originally developed in these abnormal receptacles, or whe- ther they are formed in the bladder, and find their way accidentally into them afterwards, is not clearly known. The probability is, that both modes occasionally obtain. The volume of the incarcerated concretion is seldom large, nor is it often that more than one is con- tained in one pouch. Every sac, however, even if there be a consi- derable number, may be occupied by a stone. 3. A stone may become fixed by a fungous tumour or excrescence of the bladder. This occurrence, although rare, has been noticed by different observers. The most common situation of this morbid groAvth is the bas-fond of the organ, Avhere it may acquire a volume r STONE IN THE BLADDER. 361 ranging between that of a marble and that of a pullet's egg. When the stone is unusually rough, knobby, or spinous, an attachment may easily be formed between it and the tumour, by the processes which the latter sends into the openings, or round the projections of the former. The adhesion thus established may be very firm, especially if there be at the same time a considerable effusion of lymph. 4. A bilobed state of the bladder is sometimes observed, the organ consisting, as the name implies, of two compartments, of which the smaller one is usually above the other. A calculus, developed in the lesser pouch, may not be able to pass into the larger, in consequence of the small size of the opening of communication, and may, there- fore, be regarded as extra-vesicular. 5. A stone may become permanently impacted by projecting into the urethra, the canals of the prostate, the orifice of the ejaculatory ducts, or the outlet of the ureter. The latter accident may happen in consequence of the imperfect descent of the concretion, or the calculus may be developed in the bladder, and be gradually prolonged into the tube. In a few rare instances the stone has been known to project into both ureters as well as into the urethra. 6. The concretion is occasionally imbedded in the wall of the bladder. The sabulous matter, in this case, is probably deposited originally into a mucous follicle, lacuna, or fossa, where it gradually augments in quantity, and effects a secure lodgment by raising the mucous membrane over its surface, and contracting firm adhesions to the muscular fibres beneath. Several such calculi are represented Fig. 55. in the annexed drawing. In general, the concretions are small, though they have been known occasionally to acquire a considerable bulk. In their number, they may vary from one to half a dozen or 362 DISEASES AND INJURIES OF THE BLADDER. even more. An example has been recorded in Avhich a calculus was lodged between the coats of the bladder. 7. Finally, the calculous matter, instead of being collected into a distinct concretion, is sometimes spread out in the form of a layer upon the bas-fond of the bladder. The crust thus formed is of va- riable extent, and ranges from the merest lamella to a mass several lines thick. In the latter case, it generally exhibits a concentric, lamellated arrangement. Its adhesion to the bladder is sometimes so firm as to render it difficult for the surgeon to break it. A layer of this kind, of considerable thickness, now and then forms round a spongy, erectile, or fibrous tumour of the bladder. When the cal- culous matter presents this peculiar arrangement, it grates under the instrument, and can be distinctly felt through the rectum. When struck with the sound, it emits a peculiar noise, not unlike that of a cracked pot. I have seen several specimens in which this lamella- form arrangement coexisted with separate calculi. SECTION IV. STONE IN THE INFERIOR ANIMALS. It is curious, as well as instructive, to find that stone, which is so frequent in the human subject, also occurs in the inferior animals. A knowledge of this fact affords an additional illustration of the nature and origin of the disease in man. Stone has been found in many orders of the mammalia, herbivo- rous and carnivorous, in birds, fishes, and reptiles. The probability is that it is much more common in all these classes than is generally supposed. Short-lived as many of them are, and simple as are the habits of most of them, it is well known that many of them, espe- cially among the domestic quadrupeds, are liable to the heterologous formations, and to various kinds of calcareous deposits. In the horse, ass, ox, sheep, dog, and hog, urinary concretions have been noticed from time immemorial. In my private cabinet is a beautiful specimen from the bladder of the latter animal. It is of a whitish colour, of a rounded oblong shape, very rough on the surface, and weighs eight ounces. It was presented to me by Dr. Ector, of Georgia, a graduate of the University of Louisville. Professor Cobb has a magnificent calculus from the bladder of a dog. STONE IN THE BLADDER. 363 Rats and mice are said to be particularly subject to urinary cal- culi, and the disease is also met with in the cat and rabbit. Among birds, the domestic fowl is the only one, so far as my information extends, in which stone has been observed. Several varieties of fishes, especially the sturgeon, are liable to it. Among reptiles it has been found in the tortoise and the boa constrictor. The younger Professor Silliman has a beautiful specimen from a whale. It is per- fectly white, and of a triangular shape, and forms one of at least half a bushel of similar concretions obtained from the same animal. In the higher orders of animals, the constitution, symptoms, and morbid appearances are very similar to those observed in the human subject. Generally speaking, the calculi of the herbivora consist of earthy phosphates and carbonates, while those of the carnivora con- tain, in addition to these and other ingredients, a considerable pro- portion of uric acid. In reptiles the chemical composition of these concretions is much the same as in the latter class of animals. In a urinary calculus from a boa constrictor, Wurzer obtained forty parts of uric acid, nineteen of phosphate of lime, eighteen of urate of am- monia, nine of urate of soda, ten of albumen, and three of organic matter, with a minute quantity of iron and manganese. Vauquelin analyzed a urinary calculus found in a tortoise, and ascertained that it was composed of chloride of sodium, phosphate of lime, uric acid, and animal matter. A stone, removed by Lesueur,1 the naturalist, from the Trionix spinosus, a species of ray found in the Wabash River, in Indiana, afforded, on analysis, the following results: Phosphate of lime, .... 56-19 Carbonate of lime, 3-09 Carbonate of magnesia, 1-10 Silica, ....... 4-76 Salts and soluble organic matter, . 1-91 Animal matter, insoluble in water, 13-00 Water, ....... 20-00 100-00 The calculus was of a roundish, flattened form, of a pale yellowish colour externally, and white within. It was composed of concentric layers, weighed upwards of half an ounce, and had a specific gravity of 1*875. Another calculus, much smaller than the preceding, had a delicate nucleus, evidently composed of a fragment of a shell. 1 London Lancet, Oct. 1844. 364 DISEASES AND INJURIES OF THE BLADDER. SECTION V. SYMPTOMS. The symptoms of stone in the bladder may be conveniently divided into the rational and physical; or into those which are furnished by the suffering organ, and the parts in its immediate vicinity, and those which are derived by the surgeon from a careful manual exploration. They may be divided, moreover, into local and general, as they affect the urinary apparatus, or the system at large. The rational symptoms, Avhich may be considered first, are not only numerous but considerably diversified in their character. They maybe thus enumerated: 1. Pain in making water, especially when the last drops are expelled, felt both in the bladder and the adjacent parts. 2. A sense of weight and uneasiness in the pelvis, anus, and perinseum. 3. Frequent micturition. 4. An occasional interruption of the stream of urine. 5. Pain and itching in the head of the penis, with smarting or pricking sensations in the urethra, particularly at its orifice. 6. Enlargement of the penis and elongation of the pre- puce. 7. Occasional priapism, Avith or without sexual desire. 8. An increased secretion of mucus from the lining membrane of the bladder. 9. A bloody state of the urine. 10. Incontinence of urine. 11. Prolapsus of the anus. 12. Sympathetic suffering. 13. Noise furnished by the calculi knocking against each other in the bladder. The above symptoms usually come on gradually, and a considerable period often elapses before the patient is led to suspect the real nature of his condition. This is especially the case when the general health is good, and the bladder perfectly sound. Indeed, under such circumstances, the organ may, for a long time, take no cognisance of the presence of the foreign body. Gradually, however, marks of the disease are developed, and assume such a character as hardly to admit of being misinterpreted. Pain is felt at the neck of the bladder, reflected along the course of the urethra, and particularly keen during the emission of the last drops of water ; the desire to urinate is more frequent than natural, and the effort to resist it more unavailing; there is a sense of weight or uneasiness in the perinseum and anus; the stream of urine is often suddenly interrupted ; more or less dis- tress is experienced in the head of the penis; and, finally, every STONE IN THE BLADDER. 365 attempt at micturition is attended with straining and tenesmus. To these symptoms are gradually superadded most, if not all, of those above indicated. No regularity or uniformity, however, is witnessed, as a general rule, in the manner of their appearance. We may next proceed to examinate these symptoms in detail. 1. Pain.—This is usually one of the earliest symptoms of stone in the bladder. Although nearly always present, yet it varies very much in different cases, both as to its character, intensity, extent, and duration. It is commonly of a sharp, darting, pricking, or burning nature, and is felt most keenly at the neck of the bladder, just before, during, and for a few moments after micturition. Not unfrequently it is dull, heavy, or aching. Sometimes it is periodical, and apparently of a neuralgic nature, recurring regularly once*or twice every twenty-four or forty-eight hours, precisely like the paroxysm of an intermittent fever. Of this variety of pain several well-marked examples have fallen under my observation. The patients were all under six years of age, and had not been exposed, so far as could be ascertained, to any miasmatic influence. When the pain is neuralgic, and distinctly periodical, the suffering in the interval is generally mild. A case, that of an individual who had laboured under stone for a long time, is mentioned by Deschamps,1 in which the pain, of a sharp, cutting character, came on regularly for upwards of eight months, at every return of the new moon. It increased as she became full, and decreased as she declined. The patient was perfectly comfortable in the interval. The pain, no matter what may be its character, is generally aggra- vated by rough exercise, as leaping, running, or riding on horse- back ; by pressure on the hypogastric region; by distension of the rectum ; and even by a mere change of the position of the body. It is always exceedingly severe when the last drops of urine are ex- pelled, because the bladder is then tightly contracted, and brought fully in contact with every portion of the stone. The suffering, in this affection, is considerably influenced by the form and volume of the concretion, the condition of the mucous membrane of the bladder, the temperament of the patient, and the state of the general health. A voluminous stone causes more pain than a small one, because it impinges against a larger surface; and a rough stone more than a smooth one. This, hoAvever, is not always true. When the stone is 1 Traite de la Taille, T. ii. p. 183. 366 DISEASES AND INJURIES OF THE BLADDER. spiculated, or studded with long spines, the suffering is sometimes very slight, probably because they admit of the more ready passage of the urine, in the same manner that a very rough body lodged in the bronchial tube will occasionally cause less distress than a smooth body, because it produces less obstruction to the entrance of the air. Even the nature of the concretion appears to be capable of pro- ducing a difference in the amount of suffering. Thus, the phosphatic and uric calculi almost always create more constant and severe pain than the oxalic, cystic, and fibrinous. An inflamed, ulcerated, or hypertrophied bladder is less patient of its contents than a compara- tively healthy one. The pain is also greater when the calculous affec- tion is complicated with disease of the kidney, ureter, prostate gland, urethra, testis, anus, or rectum. A nervous temperament and an irritable state of the system materially influence the local suffering. Gouty and rheumatic subjects, labouring under stone of the bladder, often experience severe fits of pain during cold and damp states of the weather. Irregularity of diet or intemperance of any kind will produce the same effect. An adherent, fixed, or encysted calculus creates less local irrita- tion than one that is loose, or free; and one that is situated in the side of the bladder than one that is habitually in contact with the trigone or neck of this organ, for the reason that these parts are naturally more sensible and intolerant. Sometimes temporary alle- viation is experienced from the surface of the concretion becoming coated with lymph, blood, or mucus, which thus destroys its irritating character. Old men who never completely empty the bladder, and persons affected with paralysis of this organ, suffer little pain from this disease. Finally, the pain in this disease may be slight or severe, transient or constant. Confined at first to the bladder, it generally soon ex- tends to the neighbouring parts, as the urethra, penis, testicles, peri- nseum, anus, thighs, groins, and even the lumbar region. One or both testicles often become painful, and are commonly retracted whenever there is a severe fit of suffering. Numbness of the thighs is complained of by many patients. 2. Feeling of Weight and Uneasiness in the Pelvic Region.—Most patients affected Avith vesical calculus, experience a sense of weight, aching, soreness, uneasiness, or fatigue in the lower part of the pelvis, perinseum, and anus, with numbness and darting pains in the thighs and pubic region. It is often present at an early stage of the complaint, STONE IN THE BLADDER. 367 and is seldom entirely absent in any instance. Rough exercise, sexual intercourse, and pressure on the hypogastric region, always increase it; and it is generally more constant and severe when the stone is voluminous than when it is diminutive. 3. Frequent Micturition.—A very prominent, early and constant symptom of this disease is a frequent desire to urinate. Instead of pass- ing his water four or five times in the twenty-four hours, the patient is perhaps obliged to pass it every hour and a half or two hours. In some instances, indeed, the calls to make water are almost incessant, and what aggravates the distress in such cases, is the inability to resist them. This symptom, which is liable to be greatly aggravated by certain states of the urinary apparatus, as, for example, an ulcerated condition of the lining membrane of the bladder, hypertrophy of the prostate gland, or stricture of the urethra, generally exists at a very early period of the disease, when the stone, perhaps, has not yet ac- quired the bulk of a hazel-nut or even a cherry. It evidently de- pends upon a morbid sensibility of the neck of the bladder, caused by the frequent contact of the foreign body, and is always increased, or temporarily aggravated, by rough exercise, by the operation of sounding, the use of drastic purgatives, and various other causes. 4. Interruption of the Stream of Urine.—Another very valuable, because a very constant symptom of stone in the bladder, is a sudden stoppage of the flow of water. This is so common an occurrence that it may be regarded almost as pathognomonic. It is caused by the sudden falling of the concretion against the neck of the bladder, and so producing a partial or complete occlusion of the orifice of the urethra. It generally makes its appearance early in the disease, and is often one of the first symptoms that attracts attention. As it may occasionally be absent during urination, so it may sometimes come on repeatedly during the same excretion. The interruption thus caused, although generally momentary, may endure several minutes, or even much longer. A change of posture, gentle pressure on the hypogastric region, anus, or perinseum, or rest for a few minutes on the back, usually suffice to dislodge the stone, and to free the orifice of the urethra. Occasionally, hoAvever, it happens that the concre- tion is firmly impacted in this tube, and then the stoppage amounts to a real retention, requiring the use of the catheter to push the in- truder out of the Avay. A stooping posture is usually adopted during micturition ; but not 368 DISEASES AND INJURIES OF THE BLADDER. unfrequently the patient is obliged to place himself in a particular atti- tude. Thus he sometimes crosses or separates his legs, inclines his body to one side, lies down, bends forwards, or supports himself upon his knees and elbows ; sometimes he leans over and rests on his head. One of my patients, a lad five years old, was constantly in the habit, when passing his water, of lying on his back and throwing his but- tocks up in the air. The object of all such manoeuvres, of course, is to avert pain by preventing the stone from interrupting the stream of urine, or by reinviting the flow when it has been arrested. 5. Pain in the Head of the Penis.—After the disease has continued some time, and occasionally even in its earliest stages, the patient ex- periences pain in the head of the penis, accompanied with a sense of smarting, scalding, itching, or pricking in the canal and orifice of the urethra. This symptom is often extremely unpleasant, and consti- tutes a source of real suffering. It exists in varying degrees, from the slightest uneasiness to the most excruciating torture. From per- sonal observation I am satisfied that it is much more frequent and severe in the young and middle-aged than in the old, in whom it is sometimes very slight. It is seldom wholly absent in any case. To mitigate this distress, which is generally very much aggravated during micturition, the patient soon acquires the habit of forcibly grasping the penis, and not only compressing but stretching it. How this pain is produced we do not know, unless we account for it on the principle of continuous sympathy. An analogous instance is afforded in the hip-joint disease of children, in which the earliest and often the most prominent symptom complained of is pain in the correspond- ing knee. 6. Enlargement of the Penis and Prepuce.—In consequence of the suffering just adverted to, the patient, as already intimated, frequently grasps the penis, pulling and compressing it to obtund its sensibilities. What his instincts prompted him to do in the first instance, to miti- gate his pain, habit rapidly confirms, and hence it is not uncommon with this class of patients to have the hand constantly in the breeches. Disgusting as the practice certainly is, it is, nevertheless, entirely pardonable when Ave remember the object of it. Indeed, there would seem to be, in many cases, a positive necessity for it. From the con- stant employment of it, the head of the penis is rendered not only unnaturally large, but the whole organ is increased in volume and the prepuce more or less thickened and elongated. STONE IN THE BLADDER. 369 7. Priapism.—From the constant irritation of the neck of the bladder, the urethra, and other parts, and the habitual traction and compression of the penis, frequent priapism takes place, with or with- out sexual desire. This symptom is often present at an early stage of the disease, and is sometimes witnessed in the most tender infants. The erections vary much in their frequency and duration. Their obstinacy is sometimes remarkable. After puberty, they are occa- sionally attended by emissions, from the irritability being communi- cated to the seminal vesicles. 8. Increased Secretion of Mucus.—A very common attendant upon stone is an inordinate secretion of mucus from the inner surface of the bladder. This, like some of the other symptoms already de- scribed, sIioavs itself at a variable interval during the progress of the malady, being sometimes present early, and sometimes not until late. The quantity of the discharge is commonly less in the young than in the aged, in recent cases than in old, and in a healthy than a dis- eased bladder. Rough exercise, exposure to cold, and indiscretions of diet, have a tendency materially to increase it. Appearing occa- sionally in small flakes immediately after micturition, it is generally so intimately blended Avith the urine as not to show itself until this fluid is cooled, or has stood some time in the chamber. It may be clear and thin, like a solution of gum Arabic; or of a grayish, drab, or yel- lowish colour; and of a thick, ropy consistence, similar to the white of an egg. In the latter case, it is usually more or less foetid, be- comes rapidly decomposed after it is emitted, forms a thick, tough layer at the bottom of the receiver, and constitutes not unfrequently one-fourth, or even one-third of the entire excretion. The urine is then also variously altered, not only in quantity but likewise in quality, and frequently contains, in addition to the mucus, more or less sabu- lous matter. 9. Bloody Urine.—A sanguinolent state of the urine is sometimes observed, but not as frequently as we might, at first sight, be led to suppose. It is more common in the old and middle-aged than in the young, and is often directly traceable to the effects of exercise, as walking, jumping, or riding. The immediate cause of this symptom is the friction Avhich the stone, under these circumstances, exerts upon the mucous membrane, thereby rupturing some of its minute vessels. The sanguinolent appearance may last several days; but, in general, it promptly subsides under the influence of the recum- bent position and demulcent drinks. The quantity of blood effused 24 370 DISEASES AND INJURIES OF THE BLADDER. varies from a few drops to as many drachms or ounces. In ulcera- tion of the bladder, or when there is a fungous tumour, or a vascular excrescence in this organ, the extravasation may amount to a real hemorrhage. It is not unlikely, that in some of these cases, the blood is derived from the kidney. 10. Incontinence of Urine.—Incontinence of urine, not constant, or even frequent, but occasional, is another symptom of this disease. It may be produced by several causes, of Avhich the principal are first, the presence of an unusually large stone, filling nearly the whole of the bladder; secondly, a loss of power of the sphincter muscle; and, thirdly, the partial obstruction of the orifice of the urethra, by the intromission of the foreign body. The urine, in all these cases, may dribble away incessantly, or it may be detained for some time, and then pass off involuntarily. 11. Prolapsus of the Anus.—A very common symptom of stone in the bladder, is a protrusion of the bowel, occasioned by the severe straining to which the patient is subjected whenever he passes his urine. It is most frequent in young children and old men, but is also often witnessed in the adolescent and middle-aged. Persons of a weak, relaxed habit of body are most apt to suffer from it. I have noticed it, however, repeatedly, in robust, fleshy subjects, in children as well as adults. It makes its appearance at various periods after the development of the disease, and exists in different degrees, from the slightest eversion of the mucous mem- brane, to the protrusion of a large portion of the gut. In confirmed cases, the prolapsion is liable to be attended, at every attempt at micturition, with a discharge of flatus, mucus, and even fseces. 12. Sympathetic suffering.—Observation has shown, that pain and other disagreeable sensations, caused by irritation of the ure- thra, or neck of the bladder, are sometimes perceived at parts very remote from the seat of the disease. Thus, a patient has repeatedly been known to complain of severe pain at the extremity of the coccygeal bone, during the passage of a bougie. Like effects have sometimes been experienced in the knee, heel, and foot. The pre- sence of a stone in the bladder has occasionally produced similar phenomena. An English nobleman, who had a vesical calculus, suf- fered from pain in his arm, for which his professional attendants were for a long time unable to account. Upon introducing a sound, the true nature of the case was detected, the stone was removed, and the symptoms disappeared. STONE IN THE BLADDER. 371 13. Noise emitted by the Calculus.—The patient occasionally hears the calculi knock against each other in the bladder. Covillard1 refers to the case of a man who could feel the concretions, of which there were nine, shake in his bladder. Fabricius ab Aquapendente alludes to similar examples.2 When the calculi are numerous, and of considerable size, the bladder capacious, and the movement of the body, sudden and violent, such an occurrence is not impossible. Persons affected with hydro-thorax often feel and even hear the water splash about in the chest. With regard to the bladder, these phenomena appear the less surprising, when we reflect that urinary calculi have been known, under some violent movement of the body, to strike each other so hard as to break into small fragments. 14. Constitutional effects.—Finally, the constitutional effects of stone vary considerably in different cases, and under different cir- cumstances. At the commencement of the disease,' the general health, in the great majority of instances, is but little, if at all, im- paired ; this is particularly true of children, who, although suffering severe local distress, often retain their flesh and good looks in a remarkable degree, showing that their assimilative powers are in excellent condition. In some cases, however, the system feels the effects of the local mischief at an early period, and, in the more advanced stages, it rarely entirely escapes. Young men and old subjects usually suffer more than children. When the affection is simple, the constitutional symptoms are generally slight, compared with what they often are, Avhen it is complicated with serious lesion of the urinary organs, especially of the bladder and the kidney. Under such circumstances, the general health is commonly severely deranged; the patient is thin and wan ; his countenance is expres- sive of deep distress; the pulse is small, frequent, and irritable; the skin is dry and husky, and exhales a peculiar urinous odour; the surface is remarkably susceptible to external impressions; the sleep is disturbed at night; the appetite is impaired; the stomach is harassed with sour eructations; the bowels are irregular; the uri- nary secretion is vitiated; and the extremities are constantly cold. When the disease exists in its worst form, the symptoms here enume- rated become greatly aggravated; and the patient is gradually worn out by hectic irritation, accompanied by night sweats and colliqua- 1 Obs. Iatrochir. p. 44. 2 Opera Chirurgica, p. 541. 372 DISEASES AND INJURIES OF THE BLADDER. tive diarrhoea. The duration of the disease, from its commencement to its final termination in death, varies, in different cases, and under different circumstances, from eighteen or twenty montbs, to ten, fif- teen, twenty, and even thirty years. The symptoms of this disease, after having, perhaps, existed for a long time in an aggravated form, are occasionally completely ar- rested, or so much mitigated as to induce the patient to believe that he is well. The pain diminishes, micturition is rendered more easy, and the general health decidedly improved. In this way the case progresses for weeks, perhaps, indeed, for months, Avhen all of a sudden, in consequence, it may be, of exposure to cold, or some irregularity of the diet, the disease returns with its wonted violence; the urine assumes a turbid, purulent, or lactescent aspect; fever sets in ; the tongue is covered with a whitish fur ; the digestive function is disturbed; the face becomes pale and Wan; rapid emaciation takes place; and death at length relieves the poor patient of all his troubles. In other cases, the symptoms recur in a very mild form, and the patient lives for years in comparative comfort. The causes of these changes are seldom appreciable. SECTION VI. PHYSICAL SIGNS—SOUNDING—DIAGNOSIS. When the symptoms above described are all present, or even when several of them are absent, there is a strong probability that the patient is labouring under stone of the bladder, and this proba- bility is converted into certainty, when the surgeon is able to feel and hear the foreign body. Nevertheless, as will be subsequently seen, cases occasionally occur, in which, notwithstanding the exist- ence of both the rational and physical signs, no concretion is to be discovered. On the other hand, a stone may apparently have been detected, and yet when the patient comes to be cut, no stone is found. Instances of both these occurrences have been repeatedly met with, and that, too, in the hands of the most experienced and accomplished lithotomists. It will be my duty, therefore, to point out in the present chapter, in as clear and summary a manner as possible, the principal sources of these errors. From what has been just stated, it is evident that no conscientious STONE IN THE BLADDER. 373 or enlightened surgeon would ever think of performing the operation of lithotomy unless he is fully convinced of the existence of a calculus. To remove, therefore, all doubt upon the subject, no matter how clearly marked may be the rational symptoms, it is always necessary, as a preliminary step, to resort to sounding. This consists in intro- ducing into the bladder an instrument shaped like a catheter, and either solid or hollow, with which the cavity of the organ is explored in every possible direction, and in the most patient, thorough manner. The instrument itself is called a sound. Sounds vary in their construction, in their size, and in the materials of which they are composed. The best are solid, well polished, and made of steel, with varying degrees of curvature. For an adult, the length, from one extremity to the other, should be about twelve inches, of which two inches and a half should be allowed for the handle, Fig. 56. Children, of course, re- quire a shorter instrument. Generally speaking, a sound of moderate diameter is preferable to one of large size, as it does not distend the parietes of the urethra, and is consequently much more easily moved about in the bladder. The vesical extremi- ty, or beak, should be rounded off, not conical, or pointed, otherwise it will be liable to be arrested by the irregularities of the urethra, by the orifices of the prostatic and ejaculatory ducts, and by the folds of the bladder. The curved portion ought not, as a general rule, exceed three inches, and should form an angle of about 45° with the straight por- tion. If the curved part is too long, too acute, or too obtuse, it will be more difficult to bring the point of the instrument in contact with the foreign body, especially Avhen this happens to lie in the bas-fond of the bladder, and to move it about with that degree of freedom which is so necessary when Ave Avish to make a thorough exploration of the entire reservoir. For the same reason, it is hardly ever advisable to use a straight sound. The handle of an adult sound should not be less than two inches in length, by one inch and an eighth in width; it should taper some- Avhat toAvards the stem of the instrument, be about one line in thick- ness, rounded off at the corners, and Avell polished. Every lithoto- V. 374 DISEASES AND INJURIES OF THE BLADDER. mist should be provided with several sounds, of various sizes and curvatures. Some lithotomists prefer the ordinary silver catheter, to the instru- ment now described, on the ground that it is more convenient Avhen it is necessary to inject the bladder, or draw off the urine. This is undoubtedly an advantage, which is not compensated, however, by the disadvantages of the more obscure noise and sensation, which such an instrument yields from its collision with the calculus. The gum- elastic catheter is unworthy of reliance, and should never be used by any one who has a proper respect for his own credit, or for the welfare of his patient. Previously to sounding, the bowels should always be well cleared out with castor oil, or a purgative enema. A full rectum, by press- ing upon the bladder, must necessarily tend to impede the movements of the instrument, and may, especially when it contains hardened lumps, even impart deceptive sensations to the hand of the surgeon. Such a condition will also interfere, more or less, with the introduction of the finger into the anus, and its play in the distended gut. A patient is never sounded when the bladder is empty. In this condition the organ is apt to contract upon its contents, and may so prevent the instrument from moving about with that freedom which is so necessary for detecting the stone. The quantity of water which the bladder should contain, must vary according to circumstances, as the capacity of the organ, and the size of the concretion; but, in general, it need not exceed three or four ounces. If the urine is too abundant, there is danger that the stone, especially if it be small, will be lost in the fluid, and thus elude the sound. I have repeatedly met with cases, where the bladder Avas so irritable as to be hardly able to retain any urine, even for a few minutes. Under such cir- cumstances, and also where the patient has urinated inadvertently, the requisite distension should be produced by the injection of tepid water, through a silver catheter, which may then be used as a sound, care being taken to stop its orifice, to prevent the regurgitation of the fluid. a. Operation.—During sounding, the patient should lie upon his back, on a sofa, near the edge of the bed, or upon the floor, with his head and shoulders somewhat elevated, and the lower extre- mities slightly flexed and separated, to relax the abdominal mus- cles. Adults are sometimes sounded in the erect posture; chil- dren never, except under particular circumstances. The surgeon STONE IN THE BLADDER. 375 comports himself precisely as in catheterism. He takes his position at the left side of the patient, either sitting, kneeling, or standing, as the case may be, warms and oils the instrument, and introduces it in the same manner, and with the same precautions as when he per- forins the operation just adverted to. Frequently the sound encounters the stone the moment it enters the neck of the bladder; but should this not happen, it must be passed further in, and moved about in different directions until the object is accomplished. To explore the lateral parts of the bladder, the instrument must be rotated upon its axis, first on one side, and then on the other. The bas-fond of the organ is best examined by holding the sound at a right angle with the body, and the superior portion or fundus, by depressing it between the thighs. The anterior or pubic surface of the bladder can be reached only by an instru- ment with a very long curve, not unlike that of an English S. Very frequently the stone cannot be felt, in consequence of its lying in a pouch in the bas-fond of the organ, just behind the prostate gland. When this is the case, the index finger of the left hand, properly oiled, is introduced into the rectum, and the foreign body pushed forward from its lurking-place against the sound. Sometimes it is necessary to change the position of the patient, making him lie on his side, sit or stand, bend forward, or raise his buttocks. Dr. Physick occasionally placed his patients nearly on their head, so as to render the fundus of the bladder the most dependent portion of the viscus. Indeed, every variety of expediency is sometimes re- quired to enable us to accomplish the object of this preliminary operation. Children often greatly embarrass us by their cries, as Avell as their struggles. These sources of annoyance, may be, how- ever, pretty effectually counteracted at the present, by the use of chloroform, which I am in the habit of employing in nearly all cases of the kind, both for the purpose of preventing pain, and calming the patient's mind. The noise and sensation communicated by sounding are peculiar. The noise is a sort of click, or a clear metallic resonance, if it may be so called, which is caused by the collision of the stone and the instrument, and Avhich the contact of no other bodies in the bladder can produce. It is, therefore, peculiar, and hence, in the highest degree valuable as a diagnostic sign. It may often be perceived at a distance of several yards from the patient, and is generally more distinct Avhen the stone is hard and of moderate size, than Avhen it is 376 DISEASES AND INJURIES OF THE BLADDER. very small or unusually large. The sensation communicated to the hand, is likewise liable to considerable diversity. When the calculus is diminutive, it is generally proportionably faint, and indicative of a want of resistance on the part of the body touched; if, on the other hand, the concretion is large or of medium bulk, the instrument, in encountering it, receives a sort of shock which is rapidly and for- cibly communicated to the hand, and is so characteristic, that it can never, where it has been once perceived, be mistaken. A grating, rubbing, or friction sensation is sometimes distinguished ; but this is rather indicative of a fasciculated state of the bladder, of the exis- tence of a morbid growth, or an incrusted condition of the mucous membrane, than of the presence of a calculus. b. Danger of Sounding.—Patients are often brought to the sur- geon from a distance to be lithotomized. When this is the case they should not be sounded until they have recovered from their fatigue. Nor should the operation be performed during or immediately after a "fit of the stone." Indeed, simple as the operation is, it should never be resorted to without due consideration. If it is important, as it is universally acknowledged to be, to prepare the system for the operation of lithotomy, it is hardly less so, in my judgment, to prepare it for that of sounding. From neglect of this precaution, patients are often subjected to much suffering, and even to great risk. Indeed, there is reason to believe that life has been repeatedly sacrificed in this way. Bad consequences occasionally follow, even when the utmost care is taken. In 1844, I sounded a young man who had been tortured for twenty-four years Avith stone in the blad- der, attended with chronic cystitis, and great disorder of the general health. The operation was performed with all possible gentleness, and yet three weeks elapsed before he was sufficiently recovered to justify the performance of lithotomy. Severe cystitis ensued, accom- panied with violent spasm of the bladder, and the bowels became tympanitic and exceedingly tender on pressure, evincing the exist- ence of peritonitis. These symptoms gradually yielded to the ordi- nary antiphlogistic remedies, but not without inducing the belief, at one period, that the patient would perish. The sounding should always be conducted with the utmost gentle- ness, and should never be continued beyond a feAV minutes at a time. A protracted operation of this kind is generally productive of mis- chief, and cannot be too pointedly condemned. Should severe pain ensue, it must be allayed by a full anodyne ; and any inflammatory STONE IN THE BLADDER. 377 symptoms that may arise, are to be combated by the usual remedies. In all cases, the patient should be directed to make free use of demulcent drinks. Mr. Fletcher1 relates the following interesting case, in which this operation proved fatal. A healthy boy, six years old, was brought to a hospital Avith symptoms of stone, for which he was twice sounded by the surgeon, who satisfied himself, on both occasions, of the existence of the disease. On the day, however, appointed for the operation, he could not detect it, and several of his friends tried successively, with no better success. The surgeon at length put a stop to these proceedings, but his interference was too late. The boy was put to bed, complaining that his belly ached. Active peri- toneal inflammation followed; and, notwithstanding the most ener- getic means to control it, death took place on the fourth day after the sounding. The inner membrane of the bladder was spotted deep-red everywhere, and its peritoneal coat was glued to that of the intestines, which were on all sides inflamed and covered with lymph. Mr. Crosse2 says, " In consequence of persevering and unsuccess ful attempts to discover a stone with the sound, in a little boy, in- flammation of the bladder came on, attended by vomiting, and ex- tending to the peritoneum; the most active antiphlogistic treatment failed to arrest it, and death ensued in four days." Sanson, Civiale, and other doctors allude to similar instances, in some of which death appears to have been produced by injury inflicted, in sounding, upon the urethra, prostate gland, or neck of the bladder. Professor Horner3 mentions the case of a man, fifty years of age, Avho died of violent inflammation of the bladder, accompanied by peritonitis, in less than three days after he was sounded. c. Auscultation.—When the stone is uncommonly small, or the feel and noise elicited by the contact of the sound are very feeble, recourse may be had to auscultation, as was long ago proposed, in cases of this kind, by Laennec. This may be done by applying the stethoscope either to the pubic region, to the sacrum, or to the perineum, or to all these points successively; at the same time that the sound is moved about in the bladder in different directions, as in the ordinary method. By adopting this procedure, it will hardly be 1 Medico-Chirurgical Notes and Illustrations, p. 89. 2 Essay on Urinary Calculus, p. 43. 3 A Treatise on Pathological Anatomy, p. 193. 378 DISEASES AND INJURIES OF THE BLADDER. possible, if the instrument happen to touch the stone, not to dis- tinguish some noise. As air is a better conductor of sound than liquids, Dr. Ashmead, of Philadelphia, proposed, many years ago as a preliminary step, to draw off the urine, and substitute this fluid ; a sufficient quantity to distend the bladder being thrown in by means of a syringe. The suggestion, although ingenious, has not been carried out by lithotomists, chiefly, perhaps, because it is troublesome of execution, and because feAV operators would be will- ing to cut a patient, in whom the existence of the calculus is so equivocal. It has been lately proposed to perform vesical ausculta- tion by attaching the stethoscope to a silver catheter. From the experiments of Velpeau, Ludgere, and others, it would seem that the noise, produced by the collision of the instrument against the stone, is most distinct when the exploration is conducted in this manner. My OAvn observations have satisfied me of the correctness of the result obtained by these gentlemen. Nevertheless, I must confess, I should be indisposed, under any circumstances, to place much con- fidence in this mode of diagnosis. I should hardly feel at liberty to cut into my patient's bladder, if I had no better or more satisfac- tory evidence of the existence of the stone than what Avas derived from auscultation, whether executed in the ordinary way, or as suggested by Ashmead, or as practised by Velpeau and other sur- geons. It is important for the surgeon to be aware, in practising vesical auscultation, that, when the bladder is perfectly empty, the instru- ment, as it is moved backwards and forwards over the mucous mem- brane, occasions a friction sound, like that of the working of a pump. If, on the contrary, the organ contains a small quantity of urine, " a gurgling sound results, similar to that which is produced by chewing the saliva between the teeth when the mouth is closed."1 Lisfranc ascertained, many years ago, that pieces of flesh introduced into the bladder, and struck with the sound, do not yield any noise. This fact is of no little value in regard to the discrimination between a fungous growth of the bladder and a calculus of this organ. d. Evidence furnished by the Sound, in regard to the Volume, Situation, and Number of Calculi.—Sounding enables us not only to detect the presence of a calculus in the bladder, but it frequently furnishes important data in regard to its bulk, situation, and consis- 1 Laennec's Treatise on the Diseases of the Chest, p. 719. New York, 1830. STONE IN THE BLADDER. 379 tence, and as to whether it is single or multiple, rough or smooth, loose or attached. It is usually not very difficult to form a tolerably correct idea of the volume of a stone. If it is easily pushed about by the instru- ment, and lost, as it were, in the midst of the water, it may be in- ferred that it is small; on the contrary, it may be concluded that it is quite bulky, if it maintains its position under the action of the sound, or if it can be touched simultaneously at a number of points, or, what is the same thing, if it presents a large surface. The noise furnished by the shock of the instrument will also afford valu- able information. Small concretions emit a fainter sound than large ones, and the harder varieties, as the oxalic and uric, than the phos- phatic and ammoniaco-magnesian, which are comparatively soft. A big calculus is always easily felt by the finger in the rectum; while a small one is either not perceived at all, or only in a very imperfect manner. In trying to ascertain the situation of a stone in the bladder, im- portant aid may be derived from the introduction of the finger into the rectum, or vagina. Indeed, this can, in many instances, be done in no other way. My invariable plan is, when I sound a patient, to resort to this expedient. In old subjects, in which the calculus fre- quently lodges in a cul-de-sac just behind the prostate gland, its presence can hardly be detected without it. In children, too, it is a most valuable auxiliary. The pelvis, at this age, is usually so short and narrow that nothing is more easy than to trace the whole out- line of the inferior posterior portion of the bladder, enabling us frequently at once to determine not only the situation of the concre- tion, but also Avhether it is loose or fixed, small or large, single or multiple. When there is reason to suspect that the stone is situated in the fundus of the bladder, or just behind the pubes, it might, especially if it be large, and the bowels are perfectly empty, be pos- sible to detect it Avith the hand, applied to the lower part of the hypogastric region. The noise furnished by the instrument enables us sometimes to determine pretty accurately the consistence, structure, or chemical qualities of the foreign body. The uric and oxalic calculi, as pre- viously stated, emit a clear sound or click; the phosphatic, a flat sound; and the ammoniaco-magnesian, a sound intermediate between the tAvo. By carrying the sound into different parts of the bladder, we may 380 DISEASES AND INJURIES OF THE BLADDER. ascertain whether there is but one stone or whether there are several and even form a tolerably correct idea of their actual number. When several coexist they are usually small, and the sound, upon striking them, produces a sort of clashing sensation, attended with a rattling noise. The stone may be supposed to be smooth, when the sound, brought in contact with its surface, glides easily over it, without being im- peded in its progress. If, on the contrary, it is rough, spinous, or tuberculated, the point of the sound is liable to become arrested, and may thus impart a grating sensation to the fingers. It has been already stated that the multiple calculi are nearly always smooth, and the single more or less rough. We judge that the stone lies loosely within the bladder, when it changes from time to time its position, or migrates, as it were, from one part of the organ to another. An encysted or adherent stone is always found in the same situation, due allowance being made for the alterations of form, Avhich the bladder undergoes from the pre- sence or absence of urine. e. Errors of Sounding.—Although sounding is the only certain method of detecting a stone in the bladder, it is occasionally liable to error. Numerous cases are upon record where a foreign body was supposed to be present, and where the poor patients were sub- jected to all the pains and perils of lithotomy, and yet no calculus was found, either at the time of the operation, or after death. Sur- geons of the most consummate skill and the most extensive experience have fallen into this error. It is for the purpose of avoiding a repe- tition of such mistakes, so discreditable to those who commit them, that I shall endeavour briefly to point out their sources. Great men may sometimes commit an error with impunity which would bring ruin and disgrace upon a more humble member of the profession. Chesel- den,1 the most celebrated lithotomist of his age and country, cut three patients without finding any stone. Blanc,2 Dupuytren,3 Roux,4 and Crosse,5 all operated, expecting to find a stone, where there proved to be none. The late Dr. Physick6 came very near com- 1 Benjamin Bell's System of Surgery, ii. p. 40. Edinburgh, 1784. 2 Dessault's Chirurgical Journal, translated by Gosling, i. p. 125. London, 1794. 3 Lecons Orales, T. ii. p. 334. 4 Johnson's Medico-Chir. Rev., April, 1827, p. 549. 5 Essay on Urinary Calculus, p. 50. 6 Liston's Practical Surgery, by Norris, p. 310. Philad., 1838. STONE IN THE BLADDER. 381 mitting the same mistake. He sounded a patient, and had no doubt there was a stone. His health, however, was bad, and the operation was postponed. He died some time after, and upon examination no stone was found. Mr. Crosse,1 who, as we have just seen, was himself unfortunate in one instance, states that he has notes of not less than eight cases in which the operation was needlessly performed, and to several of which he was an eye-witness. The late Mr. Samuel Cooper,2 of London, was acquainted with the particulars of at least seven such cases, at tAVO of which he was present. Velpeau3 says he has a knowledge of four instances, where the patients were subjected to the operation without there being any calculi in the bladder. South4 mentions the case of a child, two years and a half old, who was cut for stone, but in whom no stone was found, although he had suffered very severely, and a calculus was supposed to have been felt. I am acquainted with two instances in Avhich the patients were lithotomized without there being any stone. One of these was a child, under four years of age, whose parents resided in Indiana. He was sounded several times, and a stone was supposed to be present, but none was found at the time of the operation. He recovered quickly, and is still living. The other case occurred in Kentucky, in an old man, upwards of sixty years of age, who was cut by the same sur- geon, under the supposition that he had. calculus. He died a few days after the operation, and, upon examination, the bladder was found to contain nothing but a fungous tumour, portions of Avhich had repeatedly come away by the urethra during life. Many similar examples are recorded in the " Mdmoires de 1'Academic de Chirurgie " of Paris. It is worthy of remark, that quite a number of the patients in whom no stone was found were promptly and entirely relieved of the symptoms which had been attributed to its presence. On the other hand, it is equally certain that some of them perished from the effects of the operation, while others who survived it received no benefit from it. The circumstances which may lead to the commission of the error above mentioned differ very much in their character, and are depen- 1 Essay on Urinary Calculus, p. 50. 2 Dictionary of Surgery, vol. ii. p. 134. New York, 1842. 3 Velpeau, Operative Medicine, vol. iii. p. 891. 4 Chelius's Surgery, South's Edition, vol. iii. p. 277. 382 DISEASES AND INJURIES OF THE BLADDER. dent for their origin either upon the bladder itself, or upon the sur- rounding parts. The following are the most important. I. In the first class are included an indurated and contracted state of the bladder, the development of an osseous cyst, and the formation of a fibrous, encephaloid, or polypous tumour, and a deposit of tubercular matter. a. A bladder in a state of induration, whether produced by a mere hypertrophy of its muscular coat, or a cancerous degeneration of its mucous and sub-mucous cellular tissues, may communicate such a sensation through the sound as to induce the belief that there is a calculus. We have already, in a previous part of this work, considered these lesions in sufficient detail, and it is not necessary, therefore, to do more than refer to them here. Cheselden was betrayed not less than three times by this condition of the bladder in the course of his practice, which was very extensive. Two of his patients were young subjects. Blanc,1 a French surgeon, met with a similar occurrence in a child five years old, who had all the rational signs of a urinary calculus. The operation was performed, and death took place at the end of twenty-four hours. The bladder, which was free from stone, was very much contracted, and of a firm cartilaginous consistence, almost like horn, imparting, when touched with the sound, the sensation of a hard body. A fasciculated or sacculated bladder might be equally productive of deception. b. Secondly, the deception may be produced by an osseous cyst, situated in the bas-fond or some other portion of the bladder. An instance of this kind fell under the observation of Mr. Middleton,2 of St. George's Hospital, London, in 1739. The patient was a negro fifteen years of age, in whom the symptoms of calculus were so well marked that no doubt was entertained respecting the nature of the disease. The stone was felt through the sound by a number of operators, among Avhom Avas Cheselden. The boy was lithoto- mized, but no calculus Avas found. Death occurred the next day; upon examining the body, it was discovered that the symptoms had been produced by a round, bony cyst, as large as a chestnut, situ- ated at the posterior and lateral part of the bladder, and occupied by a hard, calcareous substance. c. Another source of error may arise from the presence of a fibrous, fungous, or polypous tumour. Many cases of this kind are 1 Dessault's Parisian Chirurgical Journal, translated by Gosling, vol. ii. p. 1^5. 2 Deschamps, de la Taille, T. i. p. 281. STONE IN THE BLADDER. 383 upon record, and it is incumbent upon the lithotomist to be aware of the fact. One, in which a bleeding fungus was mistaken for a calculus, is mentioned by Mr. Key, of London, in the second volume of Guy's Hospital Reports. The patient was sounded repeatedly by an experienced surgeon, and pronounced to have stone. Being placed under the care of a lithotritist, a day was appointed for the operation; but before this arrived, the man became ill, and died. No stone was discovered in the bladder, but, instead of this, a bleed- ing fungus of considerable size was seen, growing from the mucous membrane. In the case of a child eighteen months old, recorded by Mr. Crosse, in his excellent Essay on Urinary Calculus, the error arose from the presence of a number of polypous tumours, which sprung from the inner surface of the bladder, and had been mistaken by the sound for a urinary concretion. Mention has been made of this singular case in another part of this work. The sensation communicated by such growths through the instru- ment is, in general, remarkably faint, and strongly resembles that produced by striking a heart or liver. It is dull, flat, obtuse. No sound is emitted by the percussion, much less that peculiar click, or sharp, ringing, metallic noise, so characteristic of the presence of a calculus. There is, moreover, no change discoverable in the situation of the morbid product; on the contrary, it is always felt at the same spot, and the sensation which it imparts to the fingers of the ex- aminer is the same, Avhether the bladder contains much or little fluid. I recollect, some years ago, repeatedly sounding an old gentleman for what he and his friends supposed to be a stone. The instrument always promptly encountered the foreign body, but it never produced any noise or hard feel, such as we are accustomed to perceive when there is a calculus. The consequence was that I declined to operate; a course in the propriety of which I was confirmed by the circum- stance that the patient had, on various occasions, discharged small pieces of fungous matter, as well as blood, by the urethra. Becom- ing at length dissatisfied with me, because I Avould not cut him, he placed himself under the care of another physician, who operated but found no stone. Death happening a few days after, it was ascer- tained that the symptoms which had so long distressed him, and which had so strongly resembled those of calculus, had resulted from a fungous tumour in the bas-fond of the bladder. Fungous, encephaloid, or vascular tumours of the bladder may be further distinguished from calculus by their liability to bleed from 384 DISEASES AND INJURIES OF THE BLADDER. sounding or rough exercise, and by the occasional discharge of pieces, shreds, or fragments of the morbid groAvth along with the urine. These appearances will, for obvious reasons, be more liable to occur in the advanced than in the early stages of the disease. d. Tubercular deposits have, in at least one instance, led to a wrong diagnosis. Baron Dupuytren1 cut a child tAvo years and a half old, Avho had for a considerable time laboured under violent pains of the bladder. The foreign body was repeatedly touched with the sound, but occasionally the instrument failed to detect it. The operation was performed, but no stone was discovered. Death took place some time after, when the bas-fond of the bladder, near the orifice of the right ureter, was found to be studded with softened tubercles. Similar deposits existed in the lungs. e. A singular cause of deception is mentioned by Joubert, a French surgeon.2 In sounding a man, who Avas labouring under some uri- nary disease, he was unable to traverse the bas-fond of the bladder, in consequence of the instrument being arrested by a hard, resisting body. He naturally inferred that he had struck a calculus, pro- bably one of large size. The patient, however, died before he was operated upon, and, on dissection, it was found that the foreign substance, which seemed to adhere to the bas-fond of the bladder, was nothing else than the summit of this organ, which had become invaginated, and thus formed a cavity on its outside, in which a portion of the Small bowel was lodged. II. In the second division of the subject may be comprised certain affections Avhich involve the parts in the immediate vicinity of the bladder, as the prostate gland, rectum, uterus, vagina, and pelvic bones. a. The prostate gland, as is well known, is very liable to enlarge- . ment, especially in old age, giving rise to symptoms which not un- frequently simulate those produced by stone in the bladder. When the middle lobe is hypertrophied, it forms a hard prominence just behind the neck of the bladder, which materially obstructs the flow of urine, and may readily communicate a deceptive sensation through the sound. In general, however, the impression is more faint than in stone, and the hypertrophied part is completely stationary, while in the latter disease the foreign substance is almost always movable. Another mark of distinction is that the enlarged organ may be felt 1 Lecons Orales, T. ii. p. 334. 2 Balmas, Traite" de la Cystotomie Sus-pubienne, p. 63. STONE IN THE BLADDER. 385 distinctly through the rectum, just behind the neck of the bladder, as a hard, firm, and resisting body, the position of which it is impos- sible to change by any effort of the finger. A small calculus embedded in the substance of the prostate, has occasionally led to an erroneous diagnosis. Indeed, in several cases of this kind which have fallen under my own observation, the greatest circumspection was necessary to avoid mistake. The marks of dis- tinction are, that the concretion is fixed in its situation, that it is uncommonly small, and that it is always encountered the moment the extremity of the sound enters the bladder. The noise, moreover, emitted by the concretion is very faint, and a grating or rubbing sensation may be perceived by the finger in the rectum, very different from the noise and feel when there is a vesical calculus. When a number of prostatic calculi exist in a pouch or cyst, a distinct clash- ing may sometimes be produced by pressing them against each other, or between the finger and the sound. b. A scirrhous, polypous, or fibrous tumour of the rectum, or an earthy concretion lodged there, might be mistaken for a stone in the bladder. One would hardly suppose that hardened and impacted fseces would ever be a source of deception, and yet several well- authenticated examples of this description are upon record. Rutti 1 mentions an instance in which, although the sound seemed to confirm the existence of a stone in the bladder, no trace of anything of the kind was found after death. A mass of hardened excrements in the rectum had given rise to the mistake. c. Error may arise from mal-position of the uterus. Lassus2 records the following case. A female, supposed to have an encysted calculus in the bladder, underwent the operation of lithotomy. Death took place soon after; and, upon examination, the uterus was found to be situated across the pelvis, the mouth lying upon the middle of the rectum, and the highest portion of the body of the organ upon the bas-fond of the bladder, which it had thus thrust forwards so as to form a tumour, which had been mistaken for an encysted calculus. The patient had experienced all the rational symptoms of the disease. Two similar cases are mentioned by Levret. A foreign body as a pessary in the vagina, or a scir- rhous tumour of the inferior extremity of the uterus, might lead to mistake. 1 Traits des Voies Urinaires, p. 25. 2 M6d. Oper. T. i. p. 315. 25 \ 386 DISEASES AND INJURIES OF THE BLADDER. d. An exostosis of the pelvic bones may be another source of mistake. All these bones are more or less liable to this kind of morbid growth, which sometimes acquires such a magnitude as to encroach very seriously upon the pelvic viscera, impeding the flow of urine, and the descent of the child's head during parturition. When the exostosis is situated on the sacrum, the inner surface of the ilium, or behind the pubes, and the patient is at the same time affected with an irritable state of the bladder, Avith frequent and painful micturition, the case might be easily enough mistaken for one of stone. The rational symptoms of the malady being present, it is only necessary that the sound should strike against the tumour, to convince a young or an inexperienced lithotomist, anxious for the eclat of an operation, that his patient has a vesical calculus. e. Finally, the mistake under consideration may be occasioned by an unusually projecting sacrum, in a very narrow pelvis, affording resistance to the sound, and inducing the belief that there is a vesi- cal calculus. Such a case is mentioned by Mr. Crosse,1 and I am satisfied that the error has occurred much more frequently than is generally supposed. This condition of the sacrum and pelvis is most common in male children, under five years of age. Distortion of the bones of the pelvis, by which the cavity of this name is greatly diminished in size, might lead to an error of diagnosis, in the same manner as when there is an exostosis. /. A Stone may be present, and yet not be detected by the Sound. —It is well known that there may be a stone in the bladder, and yet the surgeon be unable to detect it by sounding, aided, per- haps, by all the auxiliary means he can command. This failure has frequently occurred, even where the concretion has been uncom- monly large, and where the operation has been repeatedly performed with the greatest care and skill, and varied in every possible manner. Want of success has sometimes attended, even where the calculi were multiple, or where a considerable number coexisted. Again, it has happened that a stone has been promptly detected in a first sounding, and perhaps not at all, or only after much trouble, in a sub- sequent one. Or the reverse of this may occur, that is, the concre- tion may elude the instrument in a first and second sounding, but be always readily detected afterwards. It is with sounding as with everything else. To perform it well requires great tact in the use 1 Essay on Urinary Calculus, p. 50. STONE IN THE BLADDER. 387 of instruments, a perfect knowledge of the anatomy of the urinary apparatus, and a degree of experience which multiplied observation alone can supply. But the want of success, in this operation, is not confined exclusively to the young, the ignorant, or the unskilful. Men of the most consummate dexterity have occasionally failed in detecting a stone, when a stone really existed. I recollect a case, illustrative of the present subject, which occurred many years ago, and Avhich made a strong impression upon me at the time. Mr. Harding, an elderly gentleman, of Philadelphia, and a captain in the merchants' service, had laboured for several years under all the rational symptoms of stone in the bladder. As he made frequent voyages to Liverpool, he determined, on one of these occasions, to visit London, for the purpose of submitting his case to Mr., now Sir Benjamin, Brodic. A most thorough exploration of the bladder was made by this gentleman, so distinguished for his knoAvledge of urinary diseases, but no stone was found. Upon his return to America, Captain Harding lost no time in consulting the late Dr. Physick, who lived within less than one hundred yards of his OAvn residence. A calculus, of considerable size, was promptly detected by the sound, and in a few days removed by the lateral operation. These facts were communicated to me, upwards of twenty years ago, by Captain Harding himself, who was a very respectable and intelli- gent man. Numerous circumstances may interfere with, or entirely prevent, the detection of a vesical calculus. Some of these relate to the stone itself, some to the bladder, and some to the neighbouring and associate organs. The subjoined arrangement comprises the most important of these causes. I. Obstacles dependent upon the calculus itself. 1. The stone may be unusually small, in which case it will not only be more difficult to detect it, but when found it will be more liable, if such an expression may be used, to jump aAvay from the instrument, and so elude its contact. The sound emitted by it will also be proportionably faint and indistinct. 2. The concretion may not only be diminutive, but it may be coated over Avith a layer of lymph or inspissated mucus, so that the instrument shall glide over it Avithout receiving from it the customary impression. 3. A very bulky stone, without exhibiting anything peculiar 388 DISEASES AND INJURIES OF THE BLADDER. in other respects, has sometimes eluded the sound. The principal reason of this is, the situation of the foreign body in a dependent or unusual part of the bladder, the size and form of the instrument, or the manner of conducting the exploration. II. Obstacles connected with the bladder. 1. The calculus may be encysted, or contained in a particular pouch, formed by the protrusion of the mucous membrane across the muscular fibres of the bladder. In this case the foreign body lies virtually on the outside of the urinary reservoir, within the pelvic cavity, and may be so protected by the thickened parietes of the organ as to render its detection utterly impracticable by the most careful sounding. In an instance mentioned by Mr. Nourse, in the forty-third volume of the London Philosophical Transactions, the calculi, nine in number, and contained in six separate cysts, were detected in the first sounding but never afterwards. Ellerus relates a case in which a stone existed between the coats of the bladder.1 2. In many cases, especially in aged subjects, a pouch or cul-de- sac exists in the bas-fond of the bladder, immediately behind the prostate gland, in which the calculus may lie secure from the sound. The proper method for dislodging the concretion, when thus hid, has been already pointed out. 3. The stone sometimes lodges in front of the bladder, just behind the pubes, either in a cyst or sort of cul-de-sac. When this happens, it will be difficult, if not impossible, to reach it, unless the instru- ment is unusually long, its curve uncommonly great, and its handle inordinately depressed between the patient's thighs. 4. The urinary bladder may be bilobed, or divided by a sort of diaphragm into tAvo compartments, the upper of Avhich may contain a calculus, Avhich no sound, however shaped or managed, may be able to reach or detect. 5. When the urinary bladder escapes into the groin, as it does in certain forms of hernia, it may contain a stone which no sounding, however skilfully conducted, can discover. In a case of this descrip- tion, recorded by T. D. Sala, the patient had all the symptoms of stone, but no stone could be felt during life. After death, it was found in the bladder, which had passed into the groin. Pott2 gives a similar instance. The patient was a boy thirteen years of age, and 1 Morgagni, Seat and Causes of Diseases, vol. ii. p. 354. 2 Chirurgical Works, vol. ii. p. 397. Phila., 1819. STONE IN THE BLADDER. 389 the stone was removed by incision from the groin, where it had been confined in a firm, strong, white cyst, connected with the bladder. Urine passed by the wound for several weeks, and the cure was com- plete in a month. In the female, the bladder sometimes passes into one of the great lips. Hartmann1 met with a case of this kind in which the protruded part contained a stone weighing three ounces. 6. A stone, especially when small, may be temporarily lost in the folds of the bladder, and so elude the sound. When this organ is fasciculated, the foreign body might be arrested permanently in one of the depressions or cavities which are so frequently met with under such circumstances. A stone so imbedded would be likely to remain small, and burying itself, as it were, beneath the hypertrophied mus- cular fibres of the bladder, would impart through the sound a very faint and imperfect sensation to the hand. 7. The bladder may contain too much or too little water. In the former case, unless the stone is of considerable size, it will be diffi- cult to touch it, or, if struck, to obtain the characteristic feel and click. It will fly before the instrument, and be lost in the midst of the fluid. If, on the other hand, the quantity of urine is very small, the bladder, by contracting forcibly upon the concretion, may hold it firmly in its grasp, and so prevent it from being satisfactorily felt and heard. In such a case, moreover, the stone, especially if it be small, may be concealed in the folds of the mucous membrane. 8. Finally, the surgeon may fail in his attempt to feel the stone, in consequence of an immense accumulation of blood or inspissated mucus in the bladder. From the same cause, especially the latter, the pain arising from the presence of the concretion may become materially mitigated, particularly if the adherent mucus is very thick, or intermingled Avith coagulating lymph. III. Obstacles arising from the neighbouring organs, as the ureter, prostate gland, and urethra. a. The stone may elude detection in consequence of an enormous dilatation of the ureter. The sound may move about in the abnormal pouch with the same freedom nearly as in the bladder, in which the calculus is contained, but which the instrument fails to enter. Such a contingency, although very infrequent, has been several times en- countered in practice. b. The prostate gland, excavated by disease, as an ulcer or an 1 Eph. Nat. Cur. Ann., v. obs. 71. 390 DISEASES AND INJURIES OF THE BLADDER. abscess, may occasionally conceal a small calculus so as to prevent it from being touched by the sound, or felt by the finger, in the rectum. When there is reason to suspect such a condition, the proper mode of proceeding would be to use a sound with the slightest possible curve, and to push the calculus out of its bed by inserting the finger into the boAvel. The prostate gland is sometimes converted into an immense pouch, in which the end of the sound may be arrested, without detecting any stone, instead of passing into the bladder, where the foreign body is actually situated. Miiller,1 a German writer, mentions the case of a boy, eight years of age, in whom such a lesion led to this mistake. He was sounded twice without any stone being discovered. The third time, however, it was detected, and the operation was ac- cordingly performed; a large quantity of pus escaped, but no calcu- lus was found. The patient died, and on dissection it Avas perceived that the bladder had been converted into a fleshy mass, contracted tightly round a concretion of the size of a small lemon. The pro- state was partly destroyed by suppuration, and presented an enor- mous cavity into Avhich the instrument had wandered during sounding, and which had been mistaken for the bladder. A similar case is mentioned by CiAriale.2 c. Another source of error is the introduction of the sound into an abnormal pouch of the urethra. This affection, although infrequent, occasionally exists, and may lead to deception. Pelletan3, an eminent French surgeon, saw two cases which were mistaken in this manner; in one, the stone was of the size of a pullet's egg; and in the other, a child seven years of age, it nearly filled the bladder. g. The Symptoms of Stone may be simulated by sympathetic irrita- tion.—The irritation which gives rise to this embarrassment may be situated in the urinary organs themselves, or in the neighbouring viscera. The following remarks and observations will place this subject in a proper light. The symptoms may depend upon an irritable bladder.—Of this occurrence, every surgeon at all extensively engaged in practice, must have witnessed examples. I have seen quite a number, and have often experienced no little embarrassment in making out the diagnosis. I subjoin the following case as a type of a thousand 1 Diss. Raram de Calc. Vesic. Observat. Continens, p. 17. 2 Traite de 1'Affection Calculeuse, p. 485. Paris, 1838. 3 Segalas, Essai Sur la Gravelle et la Pierre, p. 155, sec. edit. Paris, 1839. STONE IN THE BLADDER. 391 others, and because it produced, at the time, no inconsiderable share of notoriety in the neighbourhood in which it took place. Oliver B----, a tall, well-grown boy, three years and a half old, a resident of Tennessee, had been labouring, for upwards of eighteen months, under what were supposed to be symptoms of vesical calculus. He had a frequent desire to pass his water, accompanied with spas- modic pain at the neck of the bladder, and occasional interruption of the stream of urine. His sufferings, though liable to occur at any period, were usually most severe towards evening, and often lasted two or three hours at a time. He had been sounded repeatedly by an intelligent physician of the neighbourhood, who was convinced he both felt and heard the calculus. At the request of the father of the child, backed by the assurance of the family physician that there was no doubt about the nature of the case, I Avas induced, early in April, 1844, to visit the little patient at a distance of upwards of two hundred miles from my resi- dence. On my arrival, I found the boy quite fleshy and in fine health, with a good appetite and ruddy complexion, able to exercise about the premises, and enjoying sound sleep at night. He had had but one paroxysm, and that a very slight one, of difficulty in urinat- ing for the last six weeks. This was about a fortnight before my visit, and instant relief was afforded by passing a catheter doAvn to the bulbous portion of the urethra. It is proper to observe, that, during the above period, the boy had, at my suggestion, made free use of uva ursi and hop tea, with bicarbonate of soda, that his diet consisted chiefly of bread and milk, and that he took occasionally a hip-bath. The bowels having been thoroughly evacuated, I sounded the little patient the morning after my arrival, but found no s^tone, although the operation Avas unduly protracted, and the instrument moved about in the bladder in every possible direction. All that could be detected was a roughness in the prostatic portion of the urethra, apparently at the right side of the gallinaginous crest. When this part was touched by the instrument, it emitted a faint, dull sound, and imparted a slight grating sensation, easily recognised by the finger in the rec- tum. The operation was repeated the next day, but with no better success. The roughness, however, Avas again felt and even heard. During both these examinations, I took care to vary the posture of the patient; I had also my finger several times in the rectum, moving it about from side to side, and carrying it as high up as the promon- 392 DISEASES AND INJURIES OF THE BLADDER. tory of the sacrum, which I could feel distinctly; I Avas assisted, on both occasions, by several physicians of the neighbourhood. Of course I declined to operate. The boy was subsequently sounded by Dr. Buchanan and Dr. Jennings, two eminent practitioners of Nash- ville, but no stone was detected. His symptoms never returned, with any severity, after my visit, and I am informed that he has been perfectly well for several years. No one can doubt, for a moment, that this was a case merely of morbid sensibility of the mucous membrane of the bladder attended with neuralgic pain. The roughness alluded to was probably caused by a slight incrustation of lymph. I would not have cut this patient for the whole State in which he lives. Ulceration of the bladder, chronic enlargement of the prostate gland, stricture of the urethra, and disease of the ureter or kidney, may all give rise to errors of diagnosis. In suppuration of the latter organ, the matter often collects in the bladder, and by its acrimony irritates the mucous membrane, much in the same manner as a stone. A calculus impacted in the lower extremity of the ureter may occa- sion all the symptoms of a vesical concretion; they are usually, however, attended by more pain in the lumbar region, by a greater amount of constitutional disturbance, and by less distress in voiding the urine. In some instances the foreign body may be felt by the finger carried high up into the rectum. Chronic enlargement of the prostate gland often induces a train of symptoms very similar to those of a vesical calculus. The patient, in the advanced stage of the disease, is troubled with frequent and difficult micturition, pain, and burning in the bladder, irritation of the urethra and head of the penis, a feeling of weight in the pelvis, and a turbid, offensive state of the urine. The marks of distinction are, that the suffering is less liable to be aggravated by exercise, that the intervals of ease are longer, and that the enlarged organ can be readily felt through the rectum. Incredible as it would seem, calculus of the bladder is sometimes simulated by aneurism of the abdominal aorta, as in the interesting case related by Mr. Fenwick, of England.1 The subject of the case was a man thirty-two years of age, for the last two of which he had laboured under distress of mind and was otherwise indisposed. For some time past he complained of violent pain in the head of the 1 London Lancet, Jan. 24, 1846; also Amer. Journ. Med. Sciences, vol. ii. p. 492. New Series. STONE IN THE BLADDER. 393 penis and pubic region, during and after micturition, also of pain in the kidneys and epigastrium; the urine was red, and deposited a thick sediment; the tongue was white, and the appetite bad. The symptoms appearing to indicate the presence of stone in the bladder, a sound was introduced, but no calculus could be detected. There was nothing which created a suspicion that the disease was aneurism. The patient, soon after he was admitted into the Infirmary at New- castle-upon-Tyne, died under symptoms of great exhaustion, pre- ceded by sudden fainting. The abdomen was found filled with blood, which had proceeded from the rupture of an aneurism of the aorta, about the size of an orange; it had produced caries of the bodies of the vertebrse on which it rested, and was accompanied by hypertro- phy of the left ventricle of the heart and thickening of the tricuspid valve. There was no calculus in the bladder, and no disease in any portion of the urinary organs. "This case," as Mr. Fenwick remarks, "presents an instance of a fact frequently observed in the practice of medicine, that an irri- tation applied to a nerve is often only indicated by pain in a distant part. Here the pressure upon the aortic plexus produced the usual symptoms of calculus in the bladder, by means, we may suppose, of the communications of the aortic with the hypogastric plexus of nerves." h. Latent Stone.—The presence of a stone in the bladder generally gives rise to well-marked symptoms, which, if they are not charac- teristic, always strongly point to the affected organ, and ultimately lead to the detection of the foreign body by the sound. There are, however, instances in which this morbid product may exist in the bladder for a long time, and even acquire a large bulk, without occasioning any local suffering indicative of its formation, such as spasmodic pain, frequent micturition, and sudden interruption of the stream of urine.1 To cases of this kind the term latent may very properly be applied. Latent stone is most common in advanced life, though it occasion- ally occurs at an earlier period. I am not aware that it has ever been noticed in children or young adults. 1 Henricus ab Heer (Observationes Medicse rariores, ob. 26, 1685), mentions an instance in which the stone attained the magnitude of a goose's egg, without pro- ducing any symptoms. Mr. Howship (A Practical Treatise on the Urinary Organs, p. Vlb, London, 1823), states that he examined the body of a man whose bladder contained at least a dozen calculi, several of them as large as a chestnut, and yet he never had any symptoms of the disease. 394 DISEASES AND INJURIES OF THE BLADDER. It is not easy to account for the absence of suffering in such cases. Various circumstances have been adduced for the purpose of explain- ing it, but very few of them are, it must be confessed, either philo- sophical or satisfactory. The generally received opinion is that it is owing to the smoothness and immobility of the morbid product, and to the want of sensibility of the mucous membrane. This view appears to be confirmed by the interesting cases mentioned by Frere Cosme,1 and Van Hclmont. In the former, that of a watchmaker, forty-five years old, the patient never experienced any suffering in the bladder, except that he could not retain his water long. This continued for many years, Avhen one day in lifting a heavy clock, he Avas suddenly seized with a severe pain in the hypogastric region. This becoming gradually more and more insupportable, he Avas in- duced to enter one of the public hospitals of Paris, where the sound detected a large calculus, which was removed by the high operation, and which weighed twenty-four ounces. In the case related by Van Helmont, the patient, a priest, without any previous suffering, sud- denly experienced symptoms of stone from lifting a book. The concretion was easily detected by the sound, and was afterwards removed by an operation. In each of these instances the calculus evidently changed its situation, in consequence of the exertion made by the patient in lifting a heavy weight; it might have been encyst- ed, enclosed in a pouch, or attached by a band of false membrane, which gave way at the moment, and thus led to the usual symptoms, as well as to the necessity for an operation. When the concretion lies loose in the bladder, the absence of symptoms may be accounted for by supposing that there is great and permanent insensibility of the mucous membrane of the bladder, such as might be supposed to exist in partial or complete paralysis of that organ. A case, re- corded by Deschamps,2 appears to have been of this description. The patient, an octogenarian tailor, had frequent retention of urine from palsy of the bladder; and, although a stone was distinctly felt by the sound, he never experienced any of the ordinary phenomena of the malady. We are not sufficiently familiar Avith this form of vesical calculus to enable us to judge what influence affections of other parts of the body may have in disguising it, or preventing the development of local symptoms. Further and more faithfully con- ducted observations than any that have yet been made can alone 1 Deschamps, Traite de la Taille, T. i. p. 166. 2 Op. cit. T. i. p. 165. STONE IN THE BLADDER. 395 settle this question. For the present, it is enough to know that such a form of disease occasionally exists. i. State of the Bladder as ascertained by Sounding.—One great object in sounding, is to determine, if possible, the existence or non- existence of stone. Another object, hardly less important, especially in reference to the ultimate dislodgment of the foreign body, by an operation, is to ascertain the condition of the urinary apparatus. This can frequently be accomplished in no other manner. By moving the instrument about the bladder in different directions, touching, first one part, and then another, and duly weighing the impressions which it conveys to the hand, we become apprised of the capacity of the organ, and the amount of its sensibility or tolerance. Moreover, we can generally determine, with considerable accuracy, by such a mode of exploration, whether the inner surface of the bladder is smooth or rough, ulcerated, or fasciculated, incrusted with lymph or sabulous matter, or studded with fungous, fibrous, or other morbid growths. The passage of the sound along the urethra ena- bles us to judge whether this tube is healthy or diseased, contracted, changed in its direction, or obstructed by the presence of a foreign body or an adventitious formation. The condition of the prostate gland is best determined by inserting the finger into the rectum, at the same time that the sound is pressed against it from before backwards. We may thus often pretty accurately measure its dimensions, its degree of consistence, and the amount of obstruction which it pro- duces at the neck of the bladder, both as it respects the emission of the urine and the passage of our instruments. The anus and rectum should also be carefully examined, either by the finger alone, or by means of the speculum, with a view to ascertain whether they are healthy or diseased. The light which Ave derive from these explora- tions frequently enables us to form a tolerably correct idea of the probable issue of the case, or the propriety and result of surgical in- terference. SECTION VII. PATHOLOGICAL EFFECTS. Although the formation of vesical calculus is the immediate result of a morbid condition of the urinary secretion, the bladder and its 396 DISEASES AND INJURIES OF THE BLADDER. associate organs are generally diseased to a greater or less extent in the progress of the affection. The primary impression is probably always made upon the viscus in which the concretion is confined * but the irritation which its protracted presence there induces is gra- dually reflected upon the other portions of the apparatus, awakening in them, in the first instance, important sympathetic actions, and ultimately serious structural lesions. The secondary effects thus set up are sometimes sufficient to mask the original disease, and often lay the foundation for the patient's destruction, long before it would otherwise take place. The morbid anatomy of vesical calculus, considered in reference to its different stages, is still imperfectly understood, owing to the fact that comparatively few opportunities are afforded for investigating it. It would be interesting and important, in a practical point of view, to determine the relative fre- quency of the secondary effects of this disease, the period of life at which they are most liable to occur, and the degree of influence which is exerted upon them by the age, volume, and nature of the calculus. The bladder, accustomed as it is to the constant contact of the urine, a fluid of so heterogeneous a character, can rarely, for any length of time, bear the presence of a calculus without suffering more or less injury. One of the first, and indeed almost necessary effects, to which the foreign body gives rise, is inflammation of the mucous coat. This occurs for the most part, early in the complaint, and varies in its degree, in different cases, and under different circum- stances. The symptoms are spasmodic pains in the lower part of the pelvis, frequent desire to make water, and an increased secretion of vesical mucus. The inflammation is most severe at the neck and bas-fond of the bladder, and is generally much increased by rough exercise, and by whatever has a tendency to stimulate the contrac- tion of the bladder, or change the position of the foreign body. Another effect, and that not an infrequent one, is a thickening of the lining membrane, accompanied with an increased vascularity, and the development of granulations. These bodies vary in their size from that of the smallest pin-head, to that of a split pea; they are of a reddish colour, and frequently exist in great numbers. When they are unusually large and prominent, they give the mem- brane a mammillated appearance, not unlike that which is occasionally observed in the mucous coat of the stomach of a phthisical subject. They occur most frequently in the bas-fond of the organ, in old STONE IN THE BLADDER. 397 persons, who have been long affected with calculus. In some in- stances the inner coat is thrown into large permanent bars, folds, or ridges. The irritation, at first limited to the mucous membrane, gradually extends to the other tunics of the bladder, especially the cellulo- fibrous and muscular, both of which, in turn, become hypertrophied, reddened, and indurated; these changes, which are generally most conspicuous in old subjects, in the advanced stages of the disease, are often accompanied by a fasciculated state of the bladder, or an arrangement similar to that of the inner surface of the ventricles of the heart. When all the tunics are hypertrophied, their thickness may amount to a third of an inch, half an inch, or, in very bad cases, even to an inch. Sometimes the mucous lining projects across the muscular fibres in such a manner as to form one or more pouches, in which the foreign body occasionally becomes arrested, either tem- porarily or permanently. A copious secretion of thick, tough mucus usually attends these morbid changes, and not unfrequently, even a considerable discharge of pus, lymph, or blood, or of all these substances together. Coagulating lymph is occasionally poured out in the progress of this affection. It is usually small in quantity, and, owing to its ad- mixture AYith the urine, is generally discharged along with that fluid. Sometimes, however, it becomes organized, and may thus render a stone, originally loose, more or less adherent. A diminution in size of the bladder is not infrequent, even in young subjects, but is much more common in old persons who have laboured for many years under the continued irritation of a calculus. It is almost always a concomitant of the hypertrophied and fascicu- lated bladder, and may go on until the organ is unable to contain more than an ounce or two of urine. The opposite of this state, or an increase of size, is occasionally met with. It occurs chiefly in very old subjects, and in persons Avho have long suffered under para- lysis of the bladder. It varies in extent from the slightest increase to double and even triple the natural volume. Ulceration of the mucous coat is another effect of stone of the bladder. It is most frequently observed at the neck and bas-fond of the organ, in the advanced stages of the complaint, but it occasion- ally exists at an'-early period, and before the concretion attains much volume. In the latter case, the probability is that the disease is of a scrofulous character. The ulcers vary in extent, in number, and ^1 398 DISEASES AND INJURIES OF THE BLADDER. situation, and are productive of the most violent suffering, though the symptoms to which they give rise are not characteristic. One of the most distressing accidents which take place, during the progress of this disease, is perforation of the bladder, followed by a partial or complete escape of the stone, and the formation of a fistula. It is denoted by severe local suffering, along with much constitutional disturbance, and for the most part occurs in the ad- vanced stages of the malady, when the patient's strength is much reduced by protracted irritation, and generally proves incurable. When it is accompanied by an extravasation of urine into the sur- rounding cellular tissue, it may terminate fatally in a few days, or lead to violent inflammation and suppuration, inducing death at a more distant period. The part of the bladder most prone to perfo- ration is the bas-fond, because, being the most dependent portion of the organ, it is more constantly in contact with the foreign body; but the opening may take place at any point. Thus a calculus has been known to escape at the groin, above the pubes, and at the perinseum. In the female, it may be discharged through the vagina, and thus occasion a vesico-vaginal fistula. The urethra rarely suffers, except in its prostatic portion, which may be unnaturally red, inflamed, hypertrophied, or attenuated. When the calculus is small, and is often forcibly impelled into the tube by the stream of urine, it may become greatly dilated, or transformed into a sort of pouch. A calculus seldom remains long in the bladder without exciting disease in the prostate gland. This frequently happens, even in very young subjects, and while the malady is still in its incipiency; but is much more common in the aged and in the more advanced periods. The organ, from the continued irritation which it suffers, receives an unnatural amount of blood, in consequence of Avhich it gradually increases in volume and density, and thereby immensely aggravates the primary affection. It sometimes enlarges in every direction, impeding the flow of urine, augmenting the pain and spasm of the bladder, and even producing serious pressure upon the rectum. Ulceration, abscess, and sloughing may folloAV from the constant and excessive irritation. In some instances the prostate is converted into a cavity, nearly equal to that of the contracted bladder itself, and capable of lodging a calculus ♦of considerable size. The ureters are frequently reddened and thickened, and some- STONE IN THE BLADDER. 399 times even ulcerated. One or both are occasionally enormously enlarged, or one is enlarged and the other contracted. These changes are most common in old subjects, and in protracted cases. The kidneys rarely entirely escape in this disease. There are feAV cases, of long standing, in which they are not abnormally red, inflamed, increased in size, or altered in structure. In the worst forms of the malady, it is not unusual to see one of them converted into a large pouch, filled with purulent matter, or turbid urine. Abscesses and fistulse occasionally form in the perinseum; and, from the frequent straining to which the patient is subjected in mic- turition, prolapsus of the anus takes place, attended with relaxation of the sphincter muscle, inflammation and thickening of the mucous membrane, and hemorrhoidal tumours. The orifices of the seminal ducts are, in many cases, dilated, or otherAvise affected, and the ducts themselves may be variously altered. The seminal vesicles are sometimes atrophied, or diminished in volume and changed in structure. When the neck or bas-fond of the blad- der suffers much, one or both of these reservoirs may become acutely inflamed, and sometimes even gangrenous. It may be mentioned, in this connexion, that a calculus of the bladder has sometimes obstructed parturition, and required extrac- tion before the labour could be completed. Such a case recently occurred in the practice of a French physician, Dr. Monod, in a woman of forty, pregnant for the first time. The membranes had been ruptured, and the pains were frequent; but the labour did not advance by reason of a large tumour on the anterior wall of the vagina: it was hard to the touch, and completely filled the entrance of the canal. From its form and position it was readily recognised as a vesical calculus, and the diagnosis was confirmed by the sound. An incision was made into the walls of the tumour with a curved bistoury, and the stone, weighing nearly three ounces, was removed Avith the fingers.1 Finally, another effect which occasionally occurs is the sponta- neous fracture of the calculus, succeeded by violent irritation of the bladder, and sometimes even the death of the patient. The organ, unaccustomed to the presence of more than one such body, resents the encroachment of the fragments, which are occasionally very numerous, in the same manner it does the invasion of a foreign 1 New York Jour, of Med. and Surg., p. 274, Sept. 1850. 400 DISEASES AND INJURIES OF THE BLADDER. body, accidentally introduced from without. The sharp, angular, and rugged points of the fragments fret and irritate the mucous mem- brane, which is thus induced to take on inflammation, Avhich is some- times so intense and so unmanageable as to destroy life in a few days. Besides, some of the pieces may lodge in the urethra, and produce partial or complete retention of urine. The immediate cause of fracture of urinary calculi within the bladder is no doubt the inordinate contraction of the muscular fibres of this organ. It may also be produced, I should think, by the stones, especially if they be numerous, striking violently against each other during severe bodily exercise, as in leaping and running. The accident, which has been observed both in man and in the infe- rior animals, will be more likely to happen when the bladder is con- siderably hypertrophied, and the concretion comparatively soft or fragile. In one remarkable instance, a calculus was broken into forty fragments. The dangers of this accident are strikingly illustrated by the cir- cumstances of a case which happened in the practice of the late Mr. Liston.1 A physician, who had laboured under symptoms of stone for a long time, and who had ascertained the existence of the foreign body by sounding himself ten years previously, met Mr. Liston one morning in consultation. Three days after he was called to the gentleman, whom he found nearly moribund from inflammation of the whole urinary apparatus, his urethra being at the same time blocked up by large fragments of stone. It appeared that on part- ing with him, immediately after their consultation, he had been sud- denly summoned to an urgent case of midwifery. He ran quickly down a steep street, at the bottom of which he was seized with an irresistible desire to make water, which he did in small quantity, mixed with much blood. He passed some pieces of stone with very sharp angles. His symptoms grew worse; he had retention, from obstruction of the urethra; suppression followed, and death termi- nated his sufferings in a very feAV days. Many portions of the cal- culus were voided, and many others, with the nucleus, occupied the bladder and urinary passage. The kidneys were dark-coloured, and one appeared to be nearly gangrenous. The practice in this case, as soon as its nature was fully ascertained, should have been, as Mr. Liston justly observes, to cut into the bladder, and clear it of its contents. 1 Elements of Surgery, p. 533. Phila. 1846. STONE IN THE BLADDER. 401 SECTION VIII. TREATMENT. Art. I. Medical Treatment.—Persons affected with stone in the bladder do not always find it convenient to submit to the operation of lithotomy, and it becomes a matter, therefore, of great importance to render them as comfortable as their circumstances may admit of. By attention to the general health, as regulated by food, drink, and exer- cise, much may be done to allay local suffering, and make the patient almost forget his disease. A concretion, which may have been a source of great distress for years, may, by appropriate and well-directed treatment, become a comparatively harmless tenant of the bladder, and thus convert a state of torture into one of elysium. Many cases are on record, in which, from the improvement of their symp- toms, calculous subjects have imagined themselves cured of their ailments, when, in fact, the change they experienced was solely owing to the increased tolerance of the organ, in consequence of the effects of remedies. The improvement thus produced has sometimes lasted many years, though, in general, it is comparatively short. A consideration of this circumstance has led to a belief, not altogether unfounded, that urinary concretions are sometimes dissolved in the bladder, and voided along with the urine. Hence, certain remedies supposed to be endowed with this property, had received the name of lithontriptics, or solvents ami disintegrators of stone. Much of what might be said under this head has been anticipated in the article on the different calculous deposits. A brief statement of the more prominent facts must, therefore, suffice in this place. It is hardly necessary to remark that a due regulation of the diet is of paramount importance in the treatment of stone in the bladder. Most patients, in fact, know from painful experience, the kind of food and drink that agree best with the stomach. In adults, there- fore, little caution in this respect is necessary; but in children, who are unable to judge for themselves, the proper injunctions should always be given to the parents and nurses. Without entering into minuti;o, which the limits of this treatise forbid, it may be observed, in general terms, that the diet should be plain and simple, easy of digestion, and yet sufficiently nutritious. Plainly roasted meats, 26 ^ 402 DISEASES AND INJURIES OF THE BLADDER. boiled fish, mealy Irish and dry sweet potatoes, Avell-boiled rice and hominy, soda biscuit, and stale Avheat bread, Avith Aveak tea, or milk and water, are, in general, the most suitable articles. Coffee, Avine and fermented liquors, cider, and subacid fruits, with pastry, and the coarser kinds of vegetables, are to be eschewed. If the patient be feeble, or has been in the habit of using liquor, a little French brandy, or what is better, Holland gin, may be alloAved at dinner and after exercise. Gin, as is well known, has a sort of specific tendency to the urinary organs, and its exhibition is occasionally attended with good effects. Some persons are greatly benefited by hop-tea, beer, or malt liquors. Generally speaking, however, these articles produce more harm than good. All kinds of water impreg- nated Avith lime, must be abstained from, from their tendency to favour the increase of calculous deposits. The patient should be well clad, avoid exposure to wet and cold, and refrain from rough exercise of every description. In the winter, he should keep him- self Avell housed, or reside, if possible, in a warm and genial climate. Sexual excitement must be carefully guarded against, for any indul- gence of the kind is always sure to be followed by an aggravation of the complaint. The urine must, in all cases, be kept in as neutral a condition as possible. If it be acid, alkalines are indicated, and contrariwise, if it be alkaline, acids are required. Frequent examinations of this fluid, are, therefore, necessary, in order that the remedies may be varied as the circumstances of each particular case may render it proper. These examinations may commonly be made by the patient himself, or by his nurse, who should always be instructed by the attendant in the use of the usual tests. It should be remarked here that some patients are most benefited by alkalies, others by acids, even when the urine and the stone are both apparently of the same character. No satisfactory reason can be offered for this seeming discrepancy, with which every physician of experience is familiar. In my own practice, I have generally derived most benefit from the use of alkaline remedies, no matter Avhat may have been the nature of the diathesis or concretion. The best alkalies in the treatment of vesical calculi are, beyond all question, the bicarbonates of soda and potassa, either alone, or variously combined with each other. In my own practice I have generally given a preference to the soda, for the reason that it has seemed to me to exert a more obtunding effect upon the mucous sur- STONE IN THE BLADDER. 403 faces of the urinary passages. The best form of exhibition is in so- lution in strong hop and uva ursi tea, in the proportion of thirty grains to the ounce, three or four times a day. Some practitioners are in the habit of administering it in large quantities of rain water. Whatever vehicle be adopted, the best period for using the medicine is about one hour after meals, and at bedtime, just before the patient retires. Exhibited in this way, it readily mixes with the ingesta, prevents the evolution of acidity and flatulence, and exerts a more controlling influence over the urinary secretion. The quantity of the salt may be gradually increased to forty, fifty, and even sixty grains, according to the tolerance of the stomach ; and a good plan is to pretermit the use of it occasionally for a few days. Carbonate of potassa is sometimes employed alone, but its beneficial influence is always greatly enhanced by giving it in union with soda. The liquor potassa*, as it is called, sometimes answers an excellent purpose in these cases, particularly in persons of a dyspeptic habit. It should be administered largely diluted with water, in doses varying from twenty to forty drops, three times daily, or, what is better under such circum- stances, in combination with some of the simple bitters, as tincture of gentian, quassia, or cinchona. Some patients derive much benefit from the free use of lime Avater, Castile soap, magnesia, and lye. The celebrated remedy of Mrs. Stephens, purchased more than a century ago, at an enormous expense, by the English government, consisted of Castile soap and egg-shells. During the height of its renown, and before its composition was disclosed, it was the fashionable medicine Avith calculous patients, of every condition and rank in Great Britain ; it was swallowed in large quantities, and there is reason to believe that it often produced the most salutary effects. It not only generally allayed the vesical symptoms, but occasionally dissolved the stone, as is proved by a number of well-authenticated cases. In one, lime-water Avas substituted for egg-shells, and the results Avere equally remarkable and striking. As illustrative of the influence of this remedy, and the extraordinary quantity in Avhich it Avas sometimes taken, is, among many others, the remarkable instance of David Miller, as related by Dr. Whytt, of Edinburgh.1 This man had long been a victim to stone of the bladder; his suffer- ings were of the most excruciating character, and he had tried, but in 1 Essay on the Virtues of Lime-water and Soap in the Cure of Stone. Edinb. 1752. Willis on Urinary Diseases, p. 184. Phila. 1839. 404 DISEASES AND INJURIES OF THE BLADDER. vain, a great variety of means for his relief. He finally had recourse to Castile soap to the extent of an ounce and a half daily, washed down with three pints of lime-water, and soon experienced decided benefit; his condition gradually improved, and at length, after pass- ing, at different times, several fragments of calculus, he Avas com- pletely freed from his misery. He remained well for eleven years, and when he died no stone was discovered. Marked benefit, sometimes of a permanent character, springs from the long-continued use of certain mineral waters. Many cases are related in which local suffering disappeared, and particles of stone were voided under their influence. Their efficacy, in the treatment of this disease, doubtless, depends upon the property which they possess of depriving the urine of its acids, and thereby neutralizing it, or rendering it alkaline. Their virtues, in this respect, have been known from remote antiquity, and have been fully attested by modern experience. Of the various Avaters celebrated for their virtues of solving calculi and soothing the bladder, those of Vichy, in France, are the most remarkable, on account of the nume- rous cases that have been relieved by their use. Their reputation extends back several centuries, and their efficacy has been corroborated by the testimony of some of the most respectable physicians of modern times. Space will not permit me to enter into any particu- lars on this subject, but those who wish to enlarge their knowledge respecting it will find ample references in the admirable treatise of Dr. Willis on Urinary Diseases, and in an able and interesting article on stone in the bladder, in the twelfth volume of the British and Foreign Medical RevieAV. The Vichy waters contain a large quantity of free carbonic acid, and very nearly a drachm and a half of bicarbonate of soda in every thousand drachms of the menstruum, upon the presence of which their good effects no doubt depend. The probability is that these and similar waters act not as mere diluents, but that they also exert some chemical influence upon the urine. Whe- ther any of the mineral waters found in such immense numbers and varieties in this country, possess virtues similar to those of the Vichy waters as stone-sohTents, experience has not determined. It is cer- tain, however, that many calculous patients have derived much benefit from their use. When the urine is decidedly alkaline in its character, acids are indicated, and it is remarkable how soon, in many cases, under these circumstances, their good effects become manifest. How these fluids STONE IN THE BLADDER. 405 act in producing their beneficial results, is still a mooted point. It has been supposed by some that they enter the circulation and exert a direct impression upon the blood, thereby counteracting its ten- dency to the formation of alkalies. Others, on the contrary, believe that their beneficial effects take place in the kidney, by the chemical change which they produce in the secretion of this organ. The probability is that both explanations are correct. Be this as it may, it is certain that most persons affected in this manner deri\Te signal advantage from the use of these remedies, for they seldom fail to improve the condition of the digestive apparatus, to allay flatulence, and to promote the appetite, and, just in proportion as they do this, do they improve the state of the urinary organs. The length of time during which they should be continued must depend upon cir- cumstances. I have found in my own practice that the alternate use of acids and alkalies is generally productive of more benefit in the treatment of calculous complaints than the protracted use of one or the other of these substances alone. The acids which are usually employed to produce these changes are the nitric and muriatic, of which the former is the preferable. The best form of exhibition is the dilute nitric acid of the shops, in doses of from twenty to thirty drops, three times daily, in nearly half a tumblerful of cold water, sweetened with a little sugar, to render it palatable. The sulphuric acid is also sometimes used, but its good effects are less apparent, and occasionally it seems to be rather prejudicial than beneficial. Much improvement sometimes results from the exhibition of phosphoric acid; and cases occur in which marked relief follows from the use of certain vegetable acids, as the citric and tartaric. Art. II. Solution of the Stone.—The idea of dissolving stone in the bladder, by means of injections is not neAv. The cele- brated Dr. Hales, of England, busied himself with this subject early in the last century, by experiments, both upon man and dogs, and he even invented a double-current catheter, which he used for washing out this sac, and directing his fluids Avith greater certainty against the foreign body. About the same time, a French surgeon, of the name of P. Dessault, published an account of dissoh'ing stone, in which he recommended the use of the Bareges water, not only by the mouth, but by Avay of injections into the bladder. In 1752, Dr. William Butler, of Edinburgh, instituted experiments with lime- water, and a case soon after occurred in the practice of Dr. Ruther- 406 DISEASES AND INJURIES OF THE BLADDER. ford, of that city, in which this mode of treatment was followed by complete success. Subsequently the same plan was recommended by Fourcroy, Berzelius, and other chemists, through Avhose influence the subject has been prominently brought before the profession of the present day. Magendie, Amussat, Leroy, Brodie, and Willis, have done much to attract attention to it in France and Eno-land and to establish its claims upon the confidence of the practitioner. The injections employed for dissolving stone in the bladder have varied in the hands of different surgeons. Some, as Dr. Jurino, of Geneva, and J. Cloquet, of Paris, use simple Avater; others prefer lime-water. P. Dessault, as has been already seen, recommended injections of the Bareges water; Petit, Chevallier, and D'Arcet, on the contrary, speak favourably of injections of the Vichy water. Dr. Ritter, of Cassel, succeeded in removing a stone from the bladder of a gentleman of forty, by injections of weak solutions of the caustic alkalies, assisted by the same medicines taken by the mouth.1 Dr. Dorsey, of Philadelphia, made numerous experiments on the solution of calculi with the gastric juice of the inferior animals ; the same fluid was previously recommended by a pupil of Spallanzani, and favourable mention has been made of it, within the last feAV years, by Millot, a French surgeon, who proposes to use it, diluted with equal parts of tepid water. Pelouze and Gay-Lussac recom- mended borate of soda, which they think possesses more energetic solvent powers than the bicarbonates of soda and potassa. In Eng- land, trials have been made with malic acid and nitro-saccharate of lead, but with no satisfactory results. Mr. Brodie has, in several instances, successfully employed injections of nitric acid, in the pro- portion of about two drops to the ounce of water. Muriatic acid has also been used. Whatever substance be used, care must be taken not to inject too much at first, and also that the solution is not so strong as to irritate the mucous surfaces. As the bladder becomes accustomed to the medicine, it may be employed more freely, and of greater strength. One daily injection is generally sufficient; some patients, however, bear two and even three. The bladder should always be emptied just before its administration, and the fluid should be retained as long as it can be conveniently borne. When much mucus is pre- sent, the bladder should be previously washed out with tepid water, 1 Brit, and Foreign Med. Rev. vol. xii. p. 399. STONE IN THE BLADDER. 407 thrown up through a double catheter. The treatment generally requires to be continued for several months before any decided im- pression is made upon the concretion, and should always be aided by the free internal use of lithontriptic remedies. The kinds of calculi which are most amenable to medicated injec- tions are the phosphatic, which are comparatively soft and friable, and are therefore easily disintegrated, or so reduced in size that they may readily escape through the urethra. The best solvent for them Avould seem to be nitric acid, as used by Mr. Brodie, that is, of the strength of two drops to the ounce of water, passed in a slow and steady current over the concretion by means of a double catheter. Solutions of alkalies, borax, and other alkaline salts have been used in cases of lithic calculi, in combination with their internal adminis- tration, and have often afforded great relief; either effecting their disintegration, or so modifying the action of the bladder as to ren- der them comparatively harmless. No attempts that have yet been made to solve mulberry calculi have succeeded. Modern chemistry may possibly discover some remedy which may have this effect. I have no experience Avith this mode of treating stone, and I sup- pose feAV surgeons in this country have. Most of our calculous cases are from a distance, and are anxious, when they reach us, to be relieved as speedily as possible of their burden. Few have the time, or means, or patience, to submit to a process, which, while it must always be tedious and inconvenient, is generally uncertain, sometimes painful, and not always devoid of danger. The subject, hoAvever, is Avorthy of further attention, and it is to be hoped it will be investigated in a manner commensurate with its importance. Galvanic Electricity, has been applied to the solution of urinary calculi. This agent was first suggested, for purposes of this kind, by a French physician, of the name of Bouvier Desmortiers, who actually performed some experiments with it, though the effects he obtained were very tardy and unsatisfactory. The subject was afterwards taken up by Gruithuisen Prevost, and Dumas, Bonnet, Willis, and other physicians, with hardly any better luck. One great obstacle to the employment of this remedy is the difficulty of transmitting the galvanic fluid to the concretion, the disintegration of Avhich it is intended to effect. Gruithuisen, Avho Avas fully sensible of this diffi- culty, proposed to remedy it by the construction of a canula, capable of containing two isolated wires, the ends of Avhich were placed in immediate contact Avith the foreign body. By this arrangement, set 408 DISEASES AND INJURIES OF THE BLADDER. in play by a battery of three hundred pairs of plates, he supposed it possible to destroy almost any stone, however large or firm. He has left, however, no evidence that he succeeded in accomplishing his object. Indeed, it Avould be hard to find a single well-authenticated case of disintegration of a calculus by the application of this agent. Modern science has supplied us Avith much better means for trans- mitting this fluid into the affected organ, but it is a question, Avhether, with all the knowledge we possess, the treatment is really worthy of serious consideration. My own opinion is that little is to be expected from it, and that it would be a mere waste of time to resort to it. There are few calculous patients that would not be rather cut than galvanized. Art. III. Removal of Entire Calculi through the Urethra.—The fact that small calculi sometimes escape during micturition Avas long ago noticed by practitioners, and has been turned to good practical account by modern surgeons. When it is known, for example, that a concretion has recently descended from the kidney, its expulsion from the bladder may occasionally be effected by making the patient grasp the head of his penis, while he distends the urethra with urine; then, letting go his hold, he empties his bladder with all the force he can direct upon it by the action of the diaphragm and abdominal muscles. The water should be previously accumulated to the greatest possible extent, and during its evacuation the patient should lie upon his belly, or bend his body forward, to place the stone in the most favourable position for reaching the urethra. These attempts at ex- trusion are generally much facilitated by the prior dilatation of the tube by means of the bougie or catheter. The canal being thus ex- panded to a greater or less extent will more readily admit the passage of the foreign body by the pressure of the advancing stream of Avater. When the concretion is quite small, a single introduction of the in- strument will sometimes suffice; but, in general, systematic dilatation will be necessary, and, it need hardly be added, that this should always be conducted with the greatest care and gentleness. I sub- join the following case in illustration of this mode of treatment. A gentleman, Mr. William Pippin, sixty-seven years of age, of Livingston County, Kentucky, was brought to me last summer at Louisville by my friend Dr. Bass, his family physician. The sound readily detected a calculus, which was so small that I proposed to crush it AA'ith Jacobson's instrument. Accordingly, the next morn- ing, I introduced a large silver catheter, to dilate the urethra. The STONE IN THE BLADDER. 409 instrument was retained thirty minutes, when it was withdrawn, but Avas reinserted in a few hours to let off the urine, which refused to pass voluntarily. Soon after the water begun to flow, the stone en- tered the urethra, and presently appeared at the external meatus, where it became impacted. Dr. Bass tried to remove it with a pair of forceps, but he only succeeded in getting away a small fragment. I saw the patient at 4 o'clock in the afternoon, and found the con- cretion slightly protruded at the external orifice, where it was for- cibly held by the margins of the meatus, which were quite tight, and indisposed to recede. Seizing hold of it with the thumb and fingers, I extracted it, though not without some difficulty, pain, and hemor- rhage. In less than twenty minutes, the patient had a severe rigor, for which he took at once half a grain of morphia. A copious per- spiration soon followed; he slept well all night, and in the morning he felt so comfortable that he was induced to return home. The concretion was upwards of three-quarters of an inch in length and one inch and nearly a quarter in circumference at its widest part; it was rough on the surface, rounded off at the ends, and arched at its middle. It was slightly conical in its shape, and presented by its smaller extremity. Its curved condition must have considerably impeded its passage. Mr. Pippin had Aroided several calculi previ- ously, but none of them were as large as the one which I removed. The ancient Egyptian practitioners, who were well acquainted with this operation, occasionally extracted by it calculi as large as an olive, or even a small nut. They were in the habit of effecting the dilatation of the urethra by the insufflation of air and the introduc- tion of extensible cartilaginous tubes. When the process was carried sufficiently far to admit of the passage of the foreign body, the latter was pushed forward into the prostatic portion of the canal by means of the finger introduced into the rectum. A wooden canula being noAV inserted into the urethra, in contact with the stone, the mouth was applied to its projecting extremity, when, strong suction being made, the instrument Avas sloAvly withdraAvn, the concretion following it as a plug. This ingenious procedure of the Egyptians, as has been justly observed by an eminent writer,1 in the British and Foreign Medical ReA'ieAv, is as applicable now as it was in ancient times, and 1 The article here alluded to is from the pen of Dr. AVillis, of London, a gentleman who is justly distinguished for his valuable contributions to the pathology and treat- ment of urinary diseases. -^ 410 DISEASES AND INJURIES OF THE BLADDER. might occasionally be employed Avith advantage in the hands of a skilful operator. An exhausting syringe should be used instead of the mouth. Attempts have been made, especially in recent times, to remove calculi entire from the bladder through the urethra by means of for- ceps. It was observed, long ago, that during catheterism small con- cretions became occasionally impacted in the eyelets of the instru- ment, which they followed upon its withdrawal. A circumstance, so interesting and important, was Avell calculated to arrest the attention of surgeons, and Ave accordingly find that they have taken full advan- tage of it. Instruments have been constructed for the special pur- pose of seizing the stone, and removing it entire. Sanctorius, if not the first, was one of the earlier surgeons Avho busied themselves in this manner. He has described the operation with some minute- ness, and has figured a pair of forceps, Avhich he contrived for per- forming it. Hales, Hunter, and others also invented instruments, which have been greatly improved in modern times by Sir Astley Cooper and some of the French lithotomists. The forceps of the English surgeon, which are here represented, Fig. 57, consist of two movable blades, shaped, Avhen closed, like a curved catheter. They are introduced in the ordi- nary manner, and are used, at first, as a searcher. When the stone is found, the blades are gently separated, and expanded over it, when, being again shut, the instrument is carefully withdraAvn. An index upon the surface of the instrument serves to show the size of the calculus, or, what is the same thing, the possibility of removing it entire. When the concretion cannot be extracted in this manner, it may, if not too hard or large, be crushed, and be disposed of piecemeal. In performing this operation, it is important that the bladder should be perfectly free from irri- tation, that the urethra be previously dilated by the catheter or bougie, and that the forceps do not pinch the mucous membrane. If these precautions are neglected, serious mischief may folloAV. At least one instance is on record where death ensued, although the operation was performed by a competent surgeon, and the forceps were introduced only twice.1 1 Brit, and Foreign Med. Review, vol. xii. p. 404. STONE IN THE BLADDER. 411 Art. IV. Lithotripsy.—It is not my intention, in this place, to enter into the history of lithotripsy, or an account of the different steps by Avhich, from humble and unsatisfactory beginnings, it has attained its present extraordinary degree of perfection. To such of my readers as are desirous of being enlightened upon the subject, the recent work of Dr. Civiale, of Paris, entitled " Traite" Pratique et Historique de la Lithotritie," published in 1847, will afford ample information, derived as it is from his large personal experience and his abundant reading. The most that I shall aim to do is to point out the manner of performing the operation, the class of cases to which it is particularly applicable, and the consequences to which, even in the hands of the most skilful, it is liable to give rise. To Civiale mankind are, beyond doubt, indebted for the invention of an operation, which threatened at one time to supersede lithotomy, and struck terror into the minds of the knives-men. Although it is certain that he obtained some hints respecting it from previous and cotemporary authors, yet it must be evident enough to every impar- tial inquirer that the invention was the result mainly of his own labours and ingenuity. The attempts that have been made by envious and designing men to defraud him of his claims by ran- sacking the writings of the ancient physicians, and ascribing to them a discovery Avhich justly belongs to modern times, are as absurd as they are malicious and disreputable. They remind one forcibly of the days of Pare-, when that illustrious man, reviled and persecuted by his cotemporaries, Avas compelled, by the force of circumstances, to renounce his claims to the discovery of the ligature, and to discard an honour to which he alone was entitled. But mankind are seldom long, at least in modern times, in detecting and rewarding merit; Civiale has already outlived the persecutions of his enemies, and he now enjoys the enviable reputation of being the first lithotriptist in the Avorld. The first successful operation of this kind was performed by Civiale in 1824, at tAVO sittings, as they are technically named; the stone was small, and every vestige was removed. Previously to this, name- ly, in lb 13, Gruithuisen, a Bavarian physician, proposed to seize, and perforate the stone by drilling; and in 1819, Elderton, an Eno-lish surgeon, formally recommended for the same purpose, a curved lithotrite. A few years later, Dr. James Arnott, of London, suggested the idea of using a small circular saw, introduced through a canula, for rasping calculous concretions; merely with a view, 412 DISEASES AND INJURIES OF THE BLADDER. however, of obtaining specimens for chemical examination. Amussat and Leroy also busied themselves about this period in studying the subject, and rendered valuable service by the invention of several in- struments. None of these gentlemen, however, made any practical application of their operations to the living subject; a circumstance which is so much the more surprising when we recollect the memora- ble case of General Martin. This officer, more famous for his surgical than his military exploits, in 1775, while a resident in India, invented an instrument, provided with a sort of rasp, which he passed through his urethra into the bladder, and with which he detached, from time to time, small fragments of his calculus. It was com- monly believed, from the relief Avhich he received from his operations, that he had succeeded in effecting a complete cure. When he died, however, the bladder was found to contain a large portion of stone; the probability is that the relief Avhich he experienced was OAving to the reduced volume of the concretion, to its greater smoothness, or to the manner in which it lay behind the prostate gland, in the bas- fond of the urinary sac. A full history of this remarkable case is to be found in the second volume of Sir Everard Home's work on the Diseases of the Prostate Gland. The operation originally executed by Civiale has been denominated lithotrity, as it consisted in seizing, boring, perforating, or piercing the calculus. The name is still retained by this distinguished writer, and likewise by some of the English, as Brodie, and Fergus- son, although the operation itself has been essentially modified. As performed, at the present day, at least by most surgeons, it consists in breaking, crushing, or grinding the foreign body, and is, therefore, more appropriately termed lithotripsy. The instrument employed by Civiale, in his earlier operations, was a silver canula, about eleven inches in length by two and a half to four lines in diameter, and containing a steel tube, furnished with three branches, claws, or pincers, so arranged as to be separated at pleasure, and therefore well calculated to seize and hold the foreign body. The upper extremity of the tube was marked by a scale, to enable the surgeon to judge of the degree of expansion of the claws, after the instrument had reached the urinary sac. Within the steel tube, again, and about six inches longer than it, was a cylindrical rod, called the perforator, one end of which was fashioned into a sort of crown with sharp teeth, to bore the stone, and break it into frag- ments ; while the other, upon which there was a graduated scale STONE IN THE BLADDER. 413 for measuring the size of the calculus, was rounded off, slightly serrated, and adapted to the jaws of a grooved pulley. Finally, the apparatus was completed by a steel drill bow, twenty-five inches in length, jointed in the centre, but firm and elastic, and intended to move the perforator during the operation. Although great improvements have been effected in this instru- ment within the last quarter of a century, there are comparatively few surgeons who do not now altogether prefer the operation of litho- tripsy, not only because it is equally efficient, but because it is much more simple, and also more easy of execution. The merit of the discovery of this operation is usually, at least in this country, ascribed to Baron Heurteloup of Paris ; but there is no doubt that much credit is also due to Mr. Weiss, the celebrated London cutler. As early as 1824, this gentleman contrived an instrument for this purpose; which, after having been variously modified by different lithotriptists, among others by Heurteloup himself, was subsequently remodelled and greatly improved by the inventor. The instrument, Fig. 58. JJ as now constructed, is remarkable for its simplicity, its strength, and its adaptation to the end proposed. It is composed of two blades, Fig. 58, curved at the extremity at an angle of about 55 degrees, twelve inches in length, and about the size of an ordinary catheter; Fig. 59. the one sliding within the other, and propelled by means of a screw. Near the upper end of the male rod is a graduated scale, intended to indicate the size of the stone. The extremities of the beak, on 414 DISEASES AND INJURIES OF THE BLADDER. their inside, are serrated, or notched, the better to seize, retain, and crush the concretion. The curved portion of the fixed blade is hol- low, to prevent impaction of the fragments. Fig. 59 represents the Fig. 60. screw or handle, by turning which, in the manner indicated by the accompanying drawing, Fig. 60, the male blade is propelled on- wards, slowly and'gently, or, as observed by Mr. Fergusson, by short, Fig. 61. sudden jerks, so as to imitate slight percussions, until the concretion is shattered. Fig. 61 exhibits the calculus in the jaws of the instru- ment. Another instrument, the merits of which are certainly equal, if not superior, to those of the one just described, is that of Dr. Jacob- son, an eminent surgeon of Copenhagen. For simplicity and facility of use, it Avould be difficult to conceive of anything more perfect or convenient. It consists of a silver canula, about ten inches long by three lines in diameter, the upper extremity of which is furnished with a circular steel rim, an inch in Avidth, while the lower is slightly STONE IN THE BLADDER. 415 curved for about two inches, and terminates in a blunt point. Within this tube is a steel rod, calculated to move backwards and forwards at pleasure, and connected, inferiorly, with the one just described by means of an articulated chain consisting of three links. The supe- rior extremity projects beyond the horizontal rim of the canula, and is furnished with a stout screw, which is intended to work the chain backwards and forwards, during the seizure and comminution of the stone. A graduated scale exists upon the instrument for measuring the volume of the stone. It has been alleged that the lithotriptor of Jacobson is inferior, in several respects, to that of Heurteloup and Weiss; but, mainly, on account of its greater liability to pinch the coats of the bladder, and its Fis-62- inability to grasp so large a calculus. It is also said to be more difficult to seize the concretion so readily Avhen it lies behind the prostate in a cul-de-sac of the bladder. These objections, how- ever, are rather imaginary than real. In the first place, it is not an easy matter for a skilful surgeon, in any case, to in- clude the coats of the bladder in the jaws of his instrument; the contingency, at all events, is a remote one, and can scarcely happen if care be taken to round off the margins of this part of the instrument; secondly, no calculus larger than what can be embraced by Jacobson's litho- triptor should ever be attempted to be crushed by this operation ; and, lastly, if the stone lies low in the bas-fond of the bladder, and cannot be readily seized, the difficulty is easily remedied by the introduction of the finger in the rectum. These objections, therefore, fall to the ground. Fig. 62 represents Jacobson's stone-crusher, as modified by Velpeau. With either of the above instruments the operation may, in general, be safely and expeditiously performed. The percussor of Heurteloup, is, I believe, but rarely used anywhere at the present day; it is an awkward and clumsy affair, and ought, in my judgment, to be discarded from our armamentarium. 416 DISEASES AND INJURIES OF THE BLADDER. It is not every case of stone that admits of being crushed. There are certain circumstances which imperatively forbid it; and hence much judgment is frequently required to enable the surgeon to make a proper selection. When the operation was in its infancy, there is reason to believe that it was too often employed indiscriminately both to the detriment of patient and surgeon; and, on the other hand, many persons were doubtless subjected to lithotomy who Avould have made excellent subjects for lithotripsy. Fortunately, a better state of things prevails at the present day; the jealousy which existed between the stone-breaker, and the knife-man, has ceased ; and the consequence is, that more judgment is displayed in the selection of cases for the two operations. In this country, however, lithotripsy is still in its infancy; in fact, it can hardly be said to have received fair play from the hands of the lithotomists. Dr. Dudley, who has ope- rated more frequently for stone than any surgeon in America, has never, I believe, employed lithotripsy; and the same is true of some of our other practitioners. Those who have busied themselves most with this operation, in this country, are Dr. Randolph, Dr. Gibson, and Dr. Pancoast of Philadelphia, and Dr. N. R. Smith, of Baltimore; the first of whom unfortunately died too soon for the cause of surgery, which he was so nobly engaged in cultivating. Many other surgeons have occasionally resorted to it, but comparatively few have made it the subject of their special study and practice. The operation was first performed in the United States, by Dr. Depeyre of New York.1 The circumstances which are favourable to the operation, are, chiefly, a sound condition of the genito-urinary organs, the existence of a small and comparatively soft calculus, and a good state of the general health. As it respects the parts which are immediately concerned in the operation, it is important that they should be as free from organic disease as possible, otherwise the play of the instrument will be liable not only to be impeded, but almost sure to prove injurious. There must be no stricture of the urethra; en- largement of the prostate; sacculation, ulceration, hypertrophy, or permanent contraction of the bladder ; and no disease of the ureters and kidneys. Even an excess of morbid sensibility of the urinary passages is incompatible with the operation. The stone should be small, soft, and loose. A large concretion can not be easily grasped 1 New York Med. Jour., for February, 1831. STONE IN THE BLADDER. 417 and retained by the instrument; a very hard one would Avith diffi- culty be crushed, and an adherent or encysted one could not be seized. The mulberry calculus is generally so firm and dense as to resist any amount of pressure that may be safely employed against it; and the uric acid concretion is frequently so large as to render it impossible to seize it. In the latter case, too, even supposing that fracture could be easily accomplished, it would hardly be proper to operate, on account of the great number of fragments which would result from the crushing, and which would thus necessitate the fre- quent re-introduction of the instruments; besides, they would be very apt to become a source of new irritation, and thus give rise to violent cystitis. For the same reason, the operation is inadmissible when there are a number of calculi. Finally, care should be taken, also, that the bladder does not contain much viscid mucus, lest some of the debris of the concretion be entangled in it, and so be retained, thereby endangering relapse. Serious disease of the neighbouring parts, as the perinseum, anus, rectum, vagina, and uterus, also contra- indicates the propriety of the operation. The general health should be good. If the patient is broken down and is dyspeptic, or harassed with flatulence, acidity, and consti- pation ; emaciated, nervous, and irritable; or worn out by hectic; the operation is not to be thought of. If performed under these circumstances, it would be almost certain to be followed by some local and constitutional symptoms; perhaps, by fatal results. Age constitutes no valid objection to the operation. If the gene- ral health is good; if there is no organic disease of the urinary apparatus ; and if the manipulative processes are conducted with the requisite care and skill, it does not matter how old or how young the patient may be, he will have a reasonable chance of recovery. Leroy, Civiale, and others, long ago demonstrated the practicability, and safety, of the operation upon children of three and four years of age ; and Dr. Smith, of Baltimore, has in several instances, resorted to it successfully, at a much earlier period. Supposing the operation has been determined upon, it should never be resorted to, until the system, and the parts which are more immediately concerned in it, have been subjected to a course of pre- liminary treatment. If the general health is good, and the bladder is labouring merely under the mechanical inconvenience produced by the stone, little, if anything, will be required beyond a few doses of aperient medicine, rest in the recumbent posture, for five or six days, 27 418 DISEASES AND INJURIES OF THE BLADDER. light diet, and the free use of diluent drinks. Should the reverse be the case, a more thorough preparation must be instituted. As long as the general health is at all deranged, the operation will be sure to be succeeded by untoward symptoms, and the likelihood of the recur- rence will be materially increased, if, conjoined with this, there is an unusual degree of morbid sensibility of the urinary passages. Under such circumstances, in addition to the ordinary means adverted to it may be necessary to take blood from the arm, or by leeches from the perinseum and the hypogastric region, especially if the patient is young and robust, and to employ the warm bath, bicarbonate of soda with hop and uva ursi tea, and anodynes by the rectum. In this manner, the part and the system being quieted, the operation may be under- gone with comparative impunity. The general health having been thus amended, and the urinary organs placed in as quiet a condition as possible, the surgeon pro- ceeds to dilate the urethra, to permit the more ready introduction and play of the lithotriptor. This usually requires but a few days, and is best accomplished with a series of silver catheters, used two or three times in the twenty-four hours. Besides the benefits just referred to, the dilatation of the canal has the advantage of accustoming the parts to the presence of instruments, and favouring the escape of calculous fragments after the operation. I can perceive no reason for administering chloroform in this ope- ration, except in the case of children. On the contrary, I think it ought generally to be avoided, For, independently of the fact that it is usually unattended with much pain, it is a matter, I conceive, of no little importance, that the patient's mind should be perfectly clear, in order that he may promptly inform the surgeon of his suf- fering, should any arise, whether from too rough a manipulation, too great a size of the stone, or the seizure and inclusion of the mucous membrane of the bladder. Such contingencies may, it is true, be remote; but it is avcII enough to be aware of them, and to guard against their occurrence. In children, on the contrary, who are unable to give any satisfactory intimation of their real feelings, ansesthesia is of great advantage. They are saved from suffering; and, being rendered perfectly quiet and tractable, the surgeon may deliberately proceed with his manipulations, satisfying himself by a thorough examination of the condition of every part of the bladder. During the operation, the patient may lie upon his back, near the edge of the bed, or he may sit in an easy-chair, with a movable STONE IN THE BLADDER. 419 back, as may be most convenient. Heurteloup, and some others, use what is called a rectangular bed, but such a contrivance may well be dispensed with, especially in private practice. If the patient is re- cumbent, the head and shoulders should be moderately elevated, the breech should be raised by a pillow, and the thighs should be separated and upheld by assistants. If the urine has not been permitted to accumulate previously, to the amount of six or eight ounces, this quantity of tepid water should now be gently injected through a silver catheter. Care must be taken, on the one hand, that the viscus is not too empty, otherwise it will not admit of the requisite play of the lithotriptor, and on the other, that it is not too much crowded Avith fluid, lest it drown the stone, as it Avere. The litho- triptor, Avarmed and Avell oiled, is now carried into the bladder, in the same manner as a common catheter. Upon reaching the organ it will probably at once come in contact with the foreign body; but should it not do so it must be used as a searcher until this object is attained. The instrument is next planted against the inferior wall of the bladder, the sliding blade is carefully retracted, and then, by a Avriggling movement of the wrist, or a sort of sleight-of-hand, the concretion is engaged in the jaws of the forceps, Avhich are at once closed upon it. Satisfying himself now that the lithotriptor does not embrace the mucous membrane of the bladder, by moving its point from side to side, or turning it round, he holds it as firmly and stea- dily as possible with his left hand, while with the other he propels the screw at the handle of the instrument, and thus slowly crushes the calculus. If the concretion is small and friable, one effort of this kind will probably be sufficient; but, in general, several will be ne- cessary before this object is fully attained; for, even supposing that the foreign body has been pretty thoroughly broken in the first instance, there are almost always some coarse fragments left which require separate seizure and grinding before they can be expelled. The stone being broken, and a portion of it, if possible, commi- nuted, the instrument is closed and withdrawn, care being taken that no large fragments remain impacted in its jaws, lest serious injury be thereby inflicted upon the urinary passages. The patient should now be desired to void his urine, to afford an opportunity to the smaller fragments to escape; the passage of any that remain behind being favoured immediately after by injecting the bladder, freely and re- peatedly Avith tepid water, through a short, large-eyed catheter. The operation, however, should be performed with all possible gentleness, 420 DISEASES AND INJURIES OF THE BLADDER. and should be desisted from, the moment it becomes a source of much uneasiness or pain. The patient is now put to bed, kept upon light diet, and requested to drink large quantities of diluents, such as gum- arabic water, or linseed tea. If much pain or spasm ensue, with a frequent desire to empty the bladder, a large anodyne is given by the mouth or rectum, and recourse is had to the warm bath, with medicated fomentations to the abdomen and perinseum. Retention of urine, so apt to follow the operation, is relieved with the catheter. If peritonitis is threatened, as indicated by a small, hard, and fre- quent pulse, and excessive tenderness of the belly, blood must be taken freely by the lancet, and by means of leeches; opium and calomel must be administered internally ; and the hypogastric region must be covered with a large blister, followed by emollient poultices. In short, the antiphlogistic treatment must be carried to its fullest extent. If no untoward symptoms arise, the operation may be repeated in five or six days ; otherwise it must be delayed a longer time. Too much caution cannot be used in this respect. " Slow haste" should be the motto of every judicious lithotriptist. At the end of this period, or in a week at furthest, the bladder generally becomes suffi- ciently quiet to admit of further manipulation, which is now borne without pain, inconvenience, or danger. Thus, the treatment is proceeded with until the bladder is thoroughly freed of foreign mat- ter ; and in order to make sure of this, frequent recourse must be had to the sound, that the organ may be explored in every possible direction; for, should the smallest particle of calculus remain be- hind, it will be certain, at no distant day, to become the nucleus of a new concretion. The length of each sitting must depend upon circumstances. In general, it should not exceed eight or ten minutes; and, where the operation is painful, or followed by fainty sensations, it should be much shorter; for, if persisted in under such circumstances, great mischief may be the consequence. In all cases, it is a safe rule to be governed by the feelings of the patient. The bad effects of this operation are: 1. Hemorrhage; 2. Rigors and fever; 3. Retention of urine ; 4. Contusion and laceration of the prostate and urethra; 5. Cystitis ; 6. Perforation of the bladder; 7. Impaction of the fragments of the stone in the urethra; 8. Peri- tonitis ; 9. Bending and fracture of the lithotriptor. 1. A discharge of blood is not an infrequent attendant upon this STONE IN THE BLADDER. 421 operation. It may be very small, or so profuse as to create feelings of alarm for the patient's safety. The blood may proceed from the urethra, the bladder, or the prostate gland, or from all these parts simultaneously; and it may be caused simply by the friction of the instruments, or by actual laceration of the mucous membrane. Re- cumbency, cold applications to the perinseum, the pubes, and the hypogastrium, and the internal use of acetate of lead and opium, or opium and gallic acid, are generally sufficient to put a stop to it. 2. There are few patients who do not suffer from rigors after this operation. In some instances they come on almost immediately, and in others not for several hours. They are sometimes exceedingly severe and protracted, and are always followed, in that case, by high fever and even delirium, which pass off after a while, in copious per- spiration. Occasionally the patient falls into a sort of collapse, from which it is exceedingly difficult to rouse him. The best reme- dies are, a full dose of morphia, hot drinks, especially brandy toddy, and sinapisms to the spine, extremities, and prsecordial region. 3. Another frequent consequence of lithotripsy is a difficulty of passing Avater, amounting sometimes to complete retention. This may be owing to several causes, of which the most common are, the shock received by the bladder during the crushing of the stone, or a certain amount of contusion of the mucous and muscular tunics, the presence of a considerable quantity of coagulated blood, or, finally, the lodgment of a fragment of the concretion in the urethra. The symptom is not in itself of dangerous import; but it should never pass unheeded, lest the accumulation proceed too far, and thereby seriously jeopard life. Fomentations, the warm bath, and a full opiate, are the proper remedies, followed, if necessary, by the catheter. 4. Contusion and even laceration of the urinary passages occa- sionally occur. This accident will be most likely to take place when there is a disproportion between the diameter of the urethra and the size of the instruments, especially if the surgeon has little experience in operating; Avhen the patient is restless and unmanageable; when the stone is unusually large or firm; or when the lithotriptor bends or breaks, so that it is Avithdrawn with great difficulty. Occasion- ally, the mucous coat is included in the jaws of the instrument, and is either severely bruised, or torn off in the form of a patch. Such an accident, although not necessarily followed by serious conse- quences, may generally be easily avoided by observing the precautions 422 DISEASES AND INJURIES OF THE BLADDER. adverted to in a previous paragraph. The case must be treated antiphlogistically, and by the free use of diluents. 5. One of the worst effects of this operation is cystitis, which generally sets in within the first twenty-four or thirty-six hours, and occasionally proceeds rapidly to a fatal termination in spite of the best-directed efforts of the surgeon. The most prominent symp- toms are, a constant desire to pass water, accompanied with great pain, and a sense of scalding along the urethra; spasm at the neck of the bladder; a feeling of weight and tension low down in the pelvis; a viscid, turbid state of the urine; tenderness on pressure of the hypogastrium; and high constitutional excitement. The treatment is conducted according to the ordinary rules of surgery; by venesection, leeches, purgatives, antimonials, diaphoretics, as Dover's powder, the warm bath, fomentations, blisters, and opiate injections. These remedies are employed early, with a bold, vigor- ous hand. 6. Perforation of the bladder is an accident fortunately of rare occurrence. It has sometimes happened in the hands of the most skilful operators, as Breschet, Tanchon, and Bancal. It is by no means peculiar to this operation, and cannot, therefore, be, with propriety, alleged as an objection against it. The same thing has happened repeatedly in the operation of lithotomy. The accident is necessarily a most serious one, and should, therefore, always be carefully guarded against. Sometimes it is caused by the instru- ment itself; sometimes, by a fragment of the calculus, a sharp corner of which is pressed into the coats of the bladder, as the litho- triptor is withdrawn. However induced, the lesion is generally followed by infiltration of urine and death. Little can be done to prevent this event. The belly soon becomes tense, tympani- tic, and exquisitely tender under pressure; great distress and pain are experienced in the bladder and urethra; the patient has frequent chills, alternating with flushes of heat; and the system soon sinks into a typhoid condition. Fomentations, opiates by the mouth and rectum, and internal stimulants, constitute our chief remedial re- sources. Depletion of every description is inadmissible. 7. A fragment of the broken calculus is sometimes arrested in the urethra, where it either simply produces retention of urine, or, in addition, more or less irritation of the mucous membrane. If the piece is sharp or angular, serious mischief may ensue before it is finally dislodged. The treatment varies. If the concretion is STONE IN THE BLADDER. 423 situated far Jback, an attempt should be made to thrust it into the bladder; but if it has advanced considerably forward, it may be removed with the forceps. 8. Lithotripsy is sometimes followed by peritonitis. The occur- rence, however, is rare, and is generally the result of an extension of morbid action from the bladder. It is most liable to arise in persons of a nervous, irritable temperament, from the protracted and injudicious use of the lithotriptor. It is characterized by a small, frequent, and wiry state of the pulse, a tender and tympa- nitic condition of the belly, difficult micturition, and inflammatory fever, followed, in a short time, by typhoid symptoms and death. The disease must be combatted by antiphlogistic measures, early and vigorously plied. The pulse, being small and feeble, is liable to betray the practitioner into a state of fatal inactivity. 9. Great embarrassment and mischief sometimes result from the bending or fracture of the stone-crusher. Cases are recorded, in which, in consequence of these accidents, the instrument was obliged to be sawed off on a level with the head of the penis, and then ex- tracted either by an opening through the perinseum or above the pubes. A feAV of the patients thus treated have recovered, but the majority have perished from the effects of their injuries. An ounce of pre- vention in such a case is worth a pound of cure. No instrument should ever be employed for so important an operation that is liable to such a contingency. Both the surgeon and his cutler should be held personally responsible for it. Art. V. Operation of Lithotomy.—It would be an endless task to give an account of the various operations of lithotomy, as they have been practised by different surgeons in different ages and in various parts of the world. Such an undertaking might prove an agreeable literary pastime, but as a practical effort it would be un- productive of any useful results. The elaborate and learned work of Deschamps, moreover, renders such a labour unnecessary, inasmuch as it supplies everything of interest, or value, in relation to these operations, from the earliest time to the present; and all, or nearly all, that modern science has contributed to the subject, has been fully embodied by his commentator and continuator, Dr. L. J. Be'gin. Referring the reader, therefore, to the treatise of the celebrated Frenchman, justly regarded as an immense storehouse of erudition and research, I shall content myself here with an account of a feAV of the more important operations, as they are performed by the most 424 DISEASES AND INJURIES OF THE BLADDER. eminent surgeons of the present day. These are the lateral, bilateral quadrilateral, supra-pubic, and recto-vesical. Lithotomy may be performed at any period of life. Experience however, has established the interesting and important fact that the greatest number of recoveries take place in children and old subjects. Persons of middle age, or between twenty-five and fifty, are more liable to suffer from inflammation of the urinary apparatus, and, perhaps also, from erysipelas of the wound, and phlebitis of the neck of the bladder and prostate gland. Upon this circumstance surgeons are, I believe, generally agreed, though they are unable to assign any reason for its occurrence. It would be desirable to present a subject of so much interest in a perfectly satisfactory light, divested of all doubt and uncertainty; but for this we have unfortunately no statistics, which can alone settle the point. Lithotomy has sometimes been performed at a very early age. Civiale refers to a child that was cut at ten weeks; Mr. Keate, of St. George's Hospital, London, operated in two cases at tAvelve months ; Mr. Key,1 of the same city, in one at sixteen months; John Hunter, in one at eighteen months; and Mr. South,3 of London, in one at twenty months. The youngest child I have cut was a little over three years. Infancy and childhood are peculiarly propitious for the operation. The disease, at this period, is usually free from complication, both local and constitutional; the wound made by the knife readily heals; traumatic fever seldom runs high; and there is little or no danger of urinary infiltration, erysipelas, phlebitis, or peritoneal inflammation. Another advantage is the absence of mental anxiety, and anticipation of an unfavourable issue,—a circum- stance which often exerts an unhappy influence upon lithotomy in adults. Old age is no bar to an operation, provided the patient is other- wise in a good condition. In 1843, I cut a gentleman aged seventy- seven years, a resident of one of the border counties of Kentucky, and extracted from his bladder not less than fifty-four calculi, from the size of a large pea to that of an ordinary marble. He recovered promptly from the effects of the operation, but died suddenly, six weeks afterwards, from an attack of apoplexy. Mr. Attenburrow, 1 "I have cut a child for stone at the early age of sixteen months; and have assisted at an operation where the patient had only completed its thirteenth month." Guy's Hospital Reports, vol. ii. p. 17, 1837. * Chelius's Surgery, vol. iii. p. 297, Amer. ed. STONE IN THE BLADDER. 425 of Nottingham, England, operated successfully, in one instance, upon a man of eighty-five; and, in another, upon a man of eighty-seven. Mr. Cline, of London, cut a patient at eighty-two; Sir Astley Cooper, one at seventy-six. Chief Justice Marshall, of the Supreme Court of the United States, was lithotomized at a very advanced age, by the late Dr. Physick of Philadelphia, who extracted upwards of a thou- sand concretions, from the volume of a partridge shot to that of a bean. The recovery was rapid and complete, and the patient lived a number of years afterwards in the enjoyment of excellent health. It need hardly be said that every patient, about to undergo litho- tomy, should be subjected to a certain degree of preparatory treat- ment, in order to place him in the best possible condition to bear the shock and other ill effects of the operation. There is no doubt that much of our success depends upon the manner in which this is done. The amount of this preliminary treatment must necessarily vary in different cases, and does not, therefore, admit of precise specification. When the patient is in good general health, as is evinced by the state of iis complexion, appetite, sleep, and digestion, he will seldom re- quire anything more than a dose or two of aperient medicine, and abstinence from animal food, with rest in his room. Four or five days will, in fact, generally suffice to put him in a proper condition for the operation. But it is very different when he is in bad health. Here a more thorough course of preparatory measures is necessary. The secretions must be rectified, the bowels must be opened by mer- curial and other cathartics, the diet must be regulated, and, in a word, all sources of excitement, local and constitutional, must be re- moved. When these objects have been attained, then, and not until then, will it be proper to subject the patient to the knife. Too much preparation, however, should be avoided ; for it is as bad as too little; indeed, if anything, worse. To starve and purge a patient to death before an operation is as bad as to kill him after it. No surgeon having a proper regard for his own character and the dignity of his profession, would be likely to operate in case the patient is affected with organic disease of the lungs, or of any other important viscera. Serious lesion of the kidneys, ureters, bladder, and prostate gland also forbids interference. In short, whenever the health is much impaired by previous suffering, not solely dependent upon the presence of the urinary concretion, the judicious surgeon will hesitate not*a little before he will resort to the knife. 426 DISEASES AND INJURIES OF THE BLADDER. 1. Lateral Operation.—Of the different operations for stone the lateral, perinseal, or infrapubic, as it has been variously termed is by far the most important, not only on account of its greater fre- quency, but also on account of the remarkable success which has hitherto attended it. In the description which I am about to give I shall speak of it as I am myself in the habit of executing it, premising that this does not differ, in any essential particular, from the method devised and so happily practised by Cheselden and his disciples. The design of the lateral operation is to make an opening on the left side of the perinseum, extending from the surface of the skin through the neck of the bladder and the prostate gland, and large enough to admit of the easy extraction of the foreign body. It is usually described as consisting of three steps, or stages. In the first, the surgeon divides the skin, the cellulo-adipous tissue, and the superficial fascia; in the second, the transverse muscle, the trian- gular ligament, and the membranous portion of the urethra; and in the third and last, the prostate gland, and the neck of the bladder. The wound made in the operation may be said to represent a trun- cated cone, the apex of which corresponds with the neck of the blad- der, and the base with the surface of the perinseum. In the adult, its extent externally varies from three inches to three inches and a half, while internally it does not, as a general rule, exceed eighteen or twenty lines. Its superior angle is an inch and a quarter above the verge of the anus, and immediately on the left side of the raphe" of the perinseum; the inferior, on the contrary, is usually about three quarters of an inch to an inch below the anus, and a little nearer to the tuberosity of the ischium than to the outlet in question. The inner wall of the wound corresponds with the middle line of the peri- nseum ; the external, with the ramus of the ischium and the erector muscle of the penis. a. Mode of Operating.—The evening before the operation, a brisk purgative is administered, to clear out the alimentary canal. The article which I usually select for this purpose is castor oil; but if there be disorder of the secretions, as indicated by the state of the tongue and stomach, a combination of calomel and rhubarb with a few grains of jalap is to be preferred. If it appears probable that the rectum has not been thoroughly evacuated, a stimulating enema, consisting of tepid salt water, or strong soapsuds, is used, a few hours before the operation. I consider it of paramount importance, both as it respects the safety STONE IN THE BLADDER. 427 of the lower bowel, and the comfort of the surgeon, that this pre- cept should be faithfully attended to in all cases. Moreover, by opening the bowels freely immediately before the operation, there will be no necessity, as a general rule, for any purgative medicine for two or three days after. The operation should always be per- formed late in the morning, in order that the surgeon may have a good light, not only at the time, but subsequently, if any untoward occurrence should arise, such as hemorrhage. The patient's break- fast on the day of the operation should be as light as possible, espe- cially if it be designed to give him chloroform. The patient is requested to retain his urine for three or four hours before the operation; for a certain degree of distension of the blad- der is necessary to prevent injury of its walls, and facilitate the extraction of the foreign body. If he be a child, and cannot hold his water without great difficulty, a piece of tape should be tied loosely round the penis; otherwise he will be sure to disobey an injunction which every lithotomist must regard as of no little conse- quence. In old subjects, affected with excessive irritability of the bladder, with a constant desire to micturate, it is necessary to inject the organ with a few ounces of tepid water just before commencing the operation. During the operation the patient lies upon his back on a narrow breakfast table, about four feet in length, and provided with stout, firm legs, to prevent it from shaking. It is covered with a folded blanket or comfort, over which are spread, first, a piece of soft oil- cloth, and next, a folded sheet. Several pillows are required for the head and shoulders, which, however, should be but slightly raised, otherwise the abdomen will be doubled up, and unduly compress the bladder. Much elevation of the head is also improper in case chlo- roform is administered. The breech is fully exposed to the operator, and is therefore brought Iqw down, a little over the edge of the table. His head and trunk are held by assistants, one of whom administers chloroform. Tavo stout Avorsted bands, from six to eight feet in length by two inches and a half in width, are required to bind the patient's limbs. They should each have a hole in the middle, to afford greater security against their slipping; or they may be arranged as in Fig. 63. To apply them, the patient, stripped to his shirt, and placed upon the table, is desired to grasp his feet, in such a manner as to apply his fingers to the sole and the thumb to the instep; in which position 428 DISEASES AND INJURIES OF THE BLADDER. they are confined by means of the worsted fillets, passed round them in the form of the figure 8, the ends being tied in a double knot or fastened with stout pins. The duty of binding the patient is generally confided to the assistants, for which reason it is often done so badly as to be fol- lowed by much delay and annoyance; the patient, perhaps, becoming untied during the operation. A careful supervision should, therefore, always be exer- cised in this respect by the surgeon. The limbs, bound as here directed, are given in charge of two assistants, who, standing one on each side of the patient, place one hand upon the top of the knee, and the other beneath the sole of the foot. When the operation is about to be commenced, the thighs are moderately separated from each other, and held nearly at a right angle with the trunk. It can be easily perceived how important it must be in reference to the speedy and successful execution of the operation, that the patient's limbs should be thoroughly controlled, and out of the surgeon's way. It is usually recommended that the staff be introduced previously to the ligation of the patient; but to such a procedure I am alto- gether averse, because it is productive of serious annoyance to the patient, and is almost sure to be followed by a premature escape of the urine. Besides, it is a source of inconvenience to the persons who have charge of the limbs. My rule, therefore, always is to tie the patient first, and immediately after to introduce the staff; taking care to confide it to a good, intelligent assistant, one who is thoroughly acquainted Avith the anatomy of the pelvis, and the different steps of the operation. A poor staff-holder is a great curse; for he often excessively embarrasses the surgeon, and makes him commit blunders he might otherwise avoid. During the operation, the instrument is to be held perpendicularly, with the handle nearly at a right angle with the trunk, and inclined slightly towards the right side. The curved portion, securely lodged in the bladder, is hooked up closely against the pubic symphysis. The object of this advice is to pre- vent the instrument from pressing upon the rectum, which would thus be in danger of being wounded. By inclining the handle of the staff a little towards the right groin, the curved portion is made to bear against the left side of the perinseum, with the effect of ren- STONE IN THE BLADDER. 429 dering it somewhat prominent, and thereby facilitating the division of the membranous portion of the urethra. The assistant having charge of the instrument, stands on the left side of the patient, in order that he may use his right hand, and also holds the scrotum out of the way. The staff, Fig. 64, made of steel, and shaped like an ordinary silver catheter, is about ten inches in length, exclusive of the handle, which should be at least two inches long by two lines and a half in thickness and fifteen lines in width, and perfectly rough on the surface, that it may be the more securely held in the hand.1 The groove, placed a little towards the left side, and extending from near the middle of the instrument to within a short dis- tance of its beak, should be perfectly smooth, and as deep and wide as possible. It is warmed and oiled, previously to its introduction, like an ordinary catheter, and should be large enough to distend the urethra to as great a degree as is compati- ble with the patient's comfort. By adopt- ing this advice, the surgeon will find it comparatively easy to find the staff, and effect, in a safe and proper manner, the division of the neck of the bladder and the prostate gland. The surgeon, during the operation, sits upon a low, firm chair, or stool, as he may find it most convenient. Or he may put himself, as I am wont to do, in the half-kneeling posture, resting upon the right knee. I generally prefer this posture, because it affords greater freedom to my hands and elbows, by placing them, as it were, in a more depending situation. To protect his person and clothes from blood, urine, and faeces, he should wear a long India-rubber apron. A piece of old carpet, or a sheet, is laid upon the floor, under the patient's breech, to receive the fluids. < 1 The late Mr. Key, of London, was in the habit of using a straight staff, but I do not know that any one, at least in this country, has imitated him in this respect. It is said that he always cut on the instrument, in a way peculiar to himself, with great ease and dexterity. 430 DISEASES AND INJURIES OF THE BLADDER. Everything being thus prepared—the rectum cleared out, the in- struments arranged on a tray, the limbs tied and held out of the way, the staff in the bladder and in the hand of the assistant, the breech projecting over the table, and the patient fully under the chloro- form—the operator is ready to begin. Introducing the index-finger, well oiled, into the rectum, to induce it to contract, and ascertain the position of the staff, and marking with his eye the situation of the tuberosity of the ischium, he stretches the integuments of the peri- nseum with the thumb and fingers of the left hand, and commences Fig. 65. Fig. 66. his incisions. The knife, Fig. 65,—usually called a Liston-knife, with a cutting edge not exceeding two inches in length, and a long, stout handle,—is entered just by the side of the raphe", on the left half of the perinseum, an inch and a quarter above the margin of the anus, and is carried obliquely downwards and outwards, a short dis- tance below the tuberosity of the ischium, and a little nearer to this point than to the anus, Fig. 66. If the part is unusually full, the instrument is plunged in at the first stroke, to the depth of at least one inch; otherwise it must be used more cautiously. As the knife descends, it is gradually withdrawn from its deep position, so as to give the wound a sloping appearance. The length of the incision must be regulated by the size of the perinseum and the age of the STONE IN THE BLADDER. 431 patient; but, in the adult, it should not, in general, be less than three to three inches and a half. In the young subject it must be proportionately smaller. Placing the point of the left index-finger in the upper angle of the wound, the knife is re-entered just by the side of it and is made to divide, by repeated touches with its edge, the deep cellular substance of the perinseum, the transverse muscle, and a portion of the triangular ligament, with a few of the fibres of the elevator muscle. The membranous portion of the urethra being thus ex- posed a little in front of the prostate gland, the surgeon feels for the groove of the staff, at the bottom of the wound, and having found it, he cuts into it through the denuded tube, the finger-nail serving as a guide to the point of the knife. The length of the open- ing in the urethra need not exceed the third of an inch. The knife, inserted into the groove of the staff, through the open- ing in the urethra, is now carried on into the bladder, dividing as it passes along, the neck of the organ and the left lobe of the prostate, in a direction obliquely downwards and outwards, which is in that of its long axis. In executing this step of the operation, the rectum is to be held out of the way, by pressing it over towards the right side with the left index-finger, which should be steadily kept in the bottom of the wound, from the moment of the first incision. Great care should also be taken not to prolong the incision in the prostate gland too far back, for fear of penetrating the reflection of the pelvic fascia and the adjacent venous plexus. As soon as the bladder has been opened, the urine escapes, gene- rally in a gush; the knife is now removed, and the finger, lying in the bottom of the wound, is placed in contact with the staff, which is immediately withdrawn. The urine, as it passes off, frequently forces the calculus down against the artificial opening, so as to afford the surgeon an opportunity of ascertaining its form and bulk. When this does not happen, the finger is carried into the bladder to its full length, and used as a searcher. If the stone is found to be dispro- portionably large, the wound must be immediately dilated, either with the finger or the bistoury, according as the resistance may seem to depend upon the prostate or the muscular structures. In elderly subjects, the instrument will generally be necessary, as the gland is not sufficiently lacerable to yield to pressure. The knife which I usually employ for this purpose is a probe-pointed bistoury, closely resembling that of Blizard, Fig. 67. 432 DISEASES AND INJURIES OF THE BLADDER. The incisions being completed, the next step of the operation is to extract the calculus. This is to be done with the forceps, Fig. 68, which are conveyed into the bladder along the upper surface of the Fig. 67. Fig. 68. index-finger, lying in the bottom of the wound in contact with the foreign body. The forceps are introduced with the blades closed, and are used at first as a searcher. As soon as they are brought in contact with the concretion, the blades are expanded over it, in the direction of its long axis, and with a firm grasp, to prevent the risk ol slipping. Taking care that the instrument does not embrace any of the folds of the mucous membrane, the operator endeavours to extract the foreign substance by gently moving the forceps from side to side, or upwards and downwards, on the same principle as in the delivery of the child's head. The facility with which the stone may be seized STONE IN THE BLADDER. 433 depends upon circumstances. In general, it lies in contact with the inner extremity of the wound, and may be readily caught in the em- brace of the blades of the instrument. Sometimes, however, as when it is lodged in the bas-fond of the organ, it refuses to come down, and may thus embarrass the young operator. The difficulty, as will be particularly mentioned hereafter, is easily remedied by inserting the finger in the rectum, and pushing the concretion forwards against the forceps. When the stone is situated in the superior fundus of the bladder, the forceps must be carried high up, in the direction of the long axis of the pelvis, where they are to be moved about as a searcher. Occasionally it lies behind the pubic symphysis, and can- not be seized until it has. been dislodged by pressure upon the infe- rior part of the hypogastric region, aided by the finger in the bladder. If the calculus is very small, it is sometimes more easily extracted with the scoop, Fig. 69, than with the forceps. The same instrument Fig. 69. /& .-—JHKHftg - ^^ should also be used when the concretion has been broken, whether accidentally, or designedly, into fragments, which must then be re- moved piecemeal. The scoop is about ten inches in length, and is shaped, as its name indicates, at each extremity, like a spoon. An instrument like this may be made very serviceable in extracting an adherent, encysted, or impacted concretion. As soon as the foreign body has been extracted, the bladder is washed out Avith tepid water, thrown up in a full stream from a large syringe. Any pieces, or fragments, that may have escaped the for- ceps or scoop are thus removed; otherwise there will almost certainly be a return of the calculous affection, the smallest particle frequently serving as a nucleus for a nevs* concretion. The bladder having been washed out in the manner here mentioned, a female sound is next introduced through the wound into the interior of the viscus, and used as a searcher with a view of ascertaining whether any stones or fragments have been left behind. Should this be the case, the forceps, scoop, and syringe are again used till complete clearance is effected. In general, when the stone is rough, it is an evidence that it is solitary; but to this rule, there are, as will be seen by and by, exceptions, and of these the surgeon should be aware. The opera- 28 434 DISEASES AND INJURIES OF THE BLADDER. tion being finished, the patient is unbound, and conveyed to his bed an oil-cloth and a folded sheet being placed under his breech, to pro- tect the clothing, and absorb the urine. b. Extent of the Incision of the Prostate.—There is probably no subject connected with the lateral operation of lithotomy respecting which more diversity of opinion has been entertained than that which relates to the extent to which the incision in the prostate gland should be carried. This contrariety of opinion, however, exists in a much less degree now than it did formerly. Modern lithotomists seem to be pretty well agreed that the division should always be as limited as it can be consistently with the safe and easy extraction of the foreign body. In my own operations I have strictly adhered to this rule, and have never had any occasion to regret it, but quite the reverse. The wound should in no instance, however bulky the stone may be, extend entirely through the lateral lobe of the prostate, on account of the danger of urinary infiltration, which seldom fails to be followed by the worst consequences, whatever may be the cause that gives rise to it. When the concretion is very voluminous, Fig. 70. This engraving, copied from Scarpa, represents the left lobe of the prostate, as it is divided in the lateral operation, a. Marks the incision of the membranous portion of the urethra and the side of the gland. 6. The left lobe of the prostate, b*. The right lobe of the organ, c. The bulb of the ure- thra. Close behind are observed Cowper's glands, d, d. The legs of the penis, e,«. The seminal vesicles, f.f. The deferent ducts, g. The ureter of the left side. it should either be broken, and extracted piecemeal, or what is better, the opening should be enlarged by incising the opposite STONE IN THE BLADDER. * 435 half of the gland, as recommended and practised by Liston and other lithotomists. If this do not afford sufficient room, the only resource is to crush the calculus, or to remove it by the supra-pubic section. In ordinary cases, where the foreign body is of moderate dimensions, I incise the gland to a very limited extent, and immediately after enlarge the opening with the finger, the pressure of which is gene- rally sufficient for the purpose. Where it is not, the probe-pointed bistoury is used as a substitute. It is remarkable how lacerable the organ is in children and adolescents, and to what extent it may be torn, without endangering the parts by infiltration. In old subjects, especially such as have laboured for a long time under induration and enlargement of the gland, the division is generally obliged to be effected with the bistoury. From the influence which attention to this subject has a tendency to exert upon recovery after this operation, it is impossible to lay too much stress upon it. It is a subject, in fact, of paramount impor- tance, and no operator does his duty who neglects it. Apart, too, from the consideration here stated, it is evident that the operation, if thus executed, will be less likely to be attended with injury to the rectum and the pudic artery. Quite different is it with regard to the outer wound. While the internal should always be small, the external can scarcely be too large, or too free and dependent. The extent of the outer wound should never be less, in the adult, than three inches to three inches and a half; in very young subjects it must, of course, be proportion- ably limited, but even in them it should rarely be less than two inches and a quarter. There is no little risk of urinary infiltration where the external wound is small and elevated; for it serves to retain the water, as in a sort of reservoir, and enables it to fret and irritate the deep portions of the wound before they have received a glazing of plastic matter. The rule, then, in regard to this subject is briefly and simply this, a small internal incision, and a free exter- nal one. To Scarpa is due the merit of having first directed the attention of the profession to the importance of making, in all cases of this operation, a small section of the prostate gland. Until the publi- cation of his celebrated Memoir on Lithotomy, operators were gene- rally in the habit of dividing this organ very freely, or even in its whole extent. The consequence was that many of the patients thus treated perished from infiltration of urine; an occurrence which is 436 DISEASES AND INJURIES OF THE BLADDER. fortunately rarely witnessed at the present day, owing to the smaller size of the internal wound. The real anatomical cause of infiltration of urine, after this operation, was first explained by Dr. Granville Sharp Pattison, the present distinguished professor of anatomy in the University of New York. He ascertained by careful dissections of the prostate gland and the neck of the bladder, that the danger does not arise from a division of the former organ, but from injury of the vesical reflection of the pelvic fascia, thereby allowing the fluid in question to insinuate itself into the surrounding cellular tissue and even into the peritoneal cavity. This fact he zealously taught in his lectures nearly thirty-five years ago, and he subsequently pub- lished an account of his investigations in one of the early volumes of the American Medical Recorder. e. Extraction of the Stone.—It has been already intimated that the forceps should be used, during the extraction of the calculus, with great gentleness, that they should be moved about as carefully as possible, and that they should not, on any account, be permitted to grasp the bladder, or tear its lining membrane. Provided these precautions are duly observed, they may be introduced and with- drawn a great number of times without any serious detriment. In the case of Mount, previously alluded to, from whom I removed fifty- four concretions, the forceps and scoop were introduced at least thirty times, and yet old as he was, and long as he had suffered from vesical irritation, he experienced no particular inconvenience from this cause. In a case mentioned by Sir Astley Cooper, this distinguished surgeon introduced the forceps about seventy times, without any injury to the patient, who made a very good recovery. The cruelties practised in former times in extracting stones from the bladder are seldom perpetrated at the present day. It makes one's blood almost turn cold as he reads the record of this kind of misdeeds. Men, it would seem, actually prided themselves upon the amount of pain and suffering they inflicted upon their victims, whose stifled groans sometimes only ceased with their last breath. We read of cases in which such violence was used, in the extraction of the stone, that the operator fell, exhausted, into the arms of his assis- tants ; in which large portions of the prostate gland were wrenched away ; in which the bladder was frightfully mangled and lacerated; in which one pair of forceps after another was bent, twisted, and broken; in fine, where everything was done to torture the poor pa- tient, and bring discredit upon the operation. The result of such STONE IN THE BLADDER. 437 practice it is not difficult to guess. If the victim survive the imme- diate effects of the mal-treatment, he is sure to perish in a few days from peritonitis, inflammation of the neck of the bladder, or infil- tration of urine. The following case, mentioned by Mr. Fletcher, of England, in his Medico-Chirurgical Notes and Illustrations, published at London in 1831, shows the danger to which a patient may be subjected by long, painful, and repeated attempts at extracting urinary calculi. A healthy, middle-aged man, of unusual moral energy, and excellent spirits, underwent the lateral section Avith firmness and alacrity. Although the bladder was opened without difficulty by a free incision, the stone would not pass. After exerting himself to no purpose, the operator rested, and then recommenced his labours with redoubled vigour, placing his right foot against a chair, which was supported by a pupil. The straining and creaking of the forceps, as he occa- sionally lifted the suffering wretch from the table, lasted nearly two hours. His efforts were at length successful, but the man was so much exhausted that he expired in a few minutes after being carried to bed. The calculus exceeded five ounces in weight. The body was not examined. 1. Difficulties of Extraction.—Difficulty frequently occurs in the extraction of the stone. This may depend, first, upon the stone itself; secondly, upon the bladder; and thirdly upon the pelvis. First, the difficulty may be caused by the lodgment of the stone in the bas-fond of the bladder, which is naturally the most depen- dent portion of the organ, and which, in old subjects, affected with enlargement of the prostate gland, is often converted into a sort of cul-de-sac. A concretion, especially when of inconsiderable volume, may be so deeply buried here as to elude every attempt, on the part of the surgeon, to seize it. The remedy is to raise the stone up, and place it within reach of the instrument, by the left index-finger inserted into the rectum. The stone is sometimes lodged above the pubes, from which it may refuse to descend to the inferior part of the organ. When this is the case, an attempt should be made to displace it by compressing the hypogastrium, after thorough relaxation of the abdominal mus- cles. Should this fail, a strong probe, bent into a hook, may be used. Sometimes the stone may be drawn down with the point of the index-finger. Secondly, the stone may be entangled in the folds of the mucous 438 DISEASES AND INJURIES OF THE BLADDER. membrane; or it may be spasmodically grasped by the bladder, which may thus prevent the blades of the forceps from bem" ex- panded over it. In the former case, the scoop replaces the forceps, as being better calculated to disengage the foreign substance; or, if this fail, dislodgment may be attempted by throwing cold Avater into the bladder, in a full stream from a large syringe. In the latter case, the surgeon desists for a few minutes, until the organ relaxes its convulsive grasp, Avhen the foreign body is seized, and extracted. Should the spasm be severe and refuse to yield, which, however, it will seldom do, it might be well to administer a full anodyne, and defer extraction until the part and system are brought under the entire influence of the remedy. Thirdly, it sometimes happens that the stone is encysted, or partly encysted, and partly free. When there is reason to believe that this state exists, it is advisable to introduce the finger into the bladder and to rupture the cyst with the nail; or, where this is impracti- cable, on account of its great strength and thickness, to divide it with a probe-pointed bistoury,—or a knife, fashioned like a gum- lancet, and furnished with a long handle. A similar procedure may be employed Avhen the calculus has been rendered adherent by a mass of organized lymph; or is embedded in the wall of the blad- der ; impacted in the orifice of the ureter; or lodged in the body of the prostate gland. Fourthly, it may be difficult to seize the stone on account of the great depth of the perinseum, attended, perhaps, with an extra- ordinary length of the bladder. In 1843, I cut an old man in whom these obstacles existed irf a most embarrassing degree. The perinseum was at least three inches and a half in depth, and the bladder so enormously elongated, that, although it contained fifty- four calculi, a considerable time elapsed before I could reach them, notwithstanding my forceps, which were quite long, were buried up to their handle. The concretions were evidently lodged in the superior fundus of the organ, entirely beyond the reach of my finger, and almost beyond that of the instrument. Such an occurrence is rare in children, but not infrequent in old subjects. The remedy con- sists in making firm pressure upon the bladder just above the pubes, by which the stone is forced down into the lower part of the viscus. Fifthly, the stone, under the grasp of the forceps, may break into numerous fragments, be reduced to a soft pulpy mass, or be crushed into small sandy particles. Sometimes, indeed, it is fractured spon- STONE IN THE BLADDER. 439 taneously in the bladder before the patient is cut. The occurrence necessarily renders the operation tedious, if not actually more diffi- cult, and there is always danger, however carefully it may be con- ducted, that some of the foreign substance will remain behind, and become the nucleus of a new formation. If the fragments are large, they may be extracted with the forceps ; if small, with the scoop and syringe, with which the cavity of the bladder should be thoroughly washed out by throwing into it copious and repeated streams of tepid water. Sixthly, delay and inconvenience may arise from the presence of a considerable number of calculi. It is a generally received opinion among surgeons, that, when a stone, removed from the bladder, is rough on the surface, it is to be considered as a proof that there are no others. To this rule, however, many exceptions occur, as was shown, long ago, by Warner1 and other practitioners. I have my- self seen several examples of it, and all modern writers allude to the fact; which, as it is fully established, should put lithotomists upon their guard, and induce them never to neglect, on any occasion, the exploration of the bladder before the patient is untied and re- placed in bed. As many as ten rough calculi have been removed from the same person at one operation. When the stones are multiple, they should be extracted one after another, either with the forceps, or with the forceps and scoop. The repeated introduction of these instruments, if properly conducted, is rarely productive of much inconvenience; on the contrary, it is astonishing how well, in general, the operation is borne. It is only when the bladder or the neighbouring parts are severely irritated, bruised, or lacerated that serious mischief is to be apprehended. Seventhly, extraction may be rendered difficult by the fracture of the asperities of the calculus. Of this I had a remarkable instance in a gentleman of the name of Lentz, whom I cut early last fall. The stone was covered with long spines, a number of which broke off under the pressure of the forceps, which, in consequence, I was obliged to re-introduce at least six or eight times, before I was able to maintain my hold with sufficient force to effect extraction. Eighthly, embarrassment and delay may proceed from the manner in which the stone is grasped. It is hardly necessary to state, that the concretion should always, if possible, be seized by the forceps 1 Cases in Surgery, p. 217. London, 1760. 440 DISEASES AND INJURIES OF THE BLADDER. by its smallest diameter; but the reverse may happen, and then the extraction will, of course, be rendered proportionably difficult. When the surgeon has reason to believe that the calculus has been seized by its longest diameter, the finger should be at once introduced into the wound to ascertain the fact, and be prepared, if need be, to assist in changing the position of the foreign body. Before this can be done, however, the forceps must relax their hold upon the calculus, but it is not necessary to withdraw them from the bladder. For want of attention to this point, great injury is sometimes done to the neck of the bladder, as well as great delay experienced in removing the concretion. Ninthly: embarrassment occasionally results from an inability to find the concretion, after the bladder has been opened. This may depend upon some of the causes already detailed; or it may be owing to the expulsion of the stone, especially if it be of small volume, at the moment of completing the section of the neck of the bladder and the prostate gland. The urine, in such a case, may drive the calculus before it, which may thus escape without the knowledge of the operator, and be lost in the pool of blood and water, in the folds of the blanket, or upon the floor. Such an acci- dent might not only subject the patient to needless suffering, from long-continued and fruitless attempts to find the concretion ; but also seriously compromise the character of the surgeon. Tenthly: but the greatest embarrassment which the lithotomist has to encounter in the extraction of the stone, arises from its bulk. It may be stated, as a general rule, that when the concretion weighs three or four ounces it will pass the wound with considerable diffi- culty, and the impediment will be much augmented if it weighs six or eight ounces. It is true, a much larger calculus has sometimes been removed successfully; but in most cases of this description the patient has had a very narrow escape, and suffered a long time,— perhaps permanently,—from the injury sustained by the bladder, or the bladder and perinseum, in the extraction of the foreign body. Cases illustrative of this fact will be hereafter mentioned. When the calculus is of unusual magnitude, the extraction is to be accomplished either by simply enlarging the wound, if this had not been already done, to the utmost permissible limits; or by incis- ing the right lobe of the prostate gland to the same extent as the left; or, finally, by breaking the concretion, and removing it piece- meal. Dilatation of the wound is effected with the probe-pointed STONE IN THE BLADDER. 441 bistoury, carried downwards and outwards in the direction of the original incisions, while the stone is held firmly by the forceps. The perinseum being thus rendered protuberant, the resisting parts are put upon the stretch, and consequently yield more readily before the knife. The right lobe of the prostate is divided in the same manner and in the same direction as the left. These two methods, it may now be observed, may almost always be resorted to with a reasonable prospect of success, when the weight of the stone does not exceed three or four ounces. When the concretion is very bulky, crushing will generally be necessary. Sometimes a combina- tion of these expedients may be advantageously employed. Eleventhly: embarrassment of a serious, if not an insurmountable character, may arise from unusual narrowness of the outlet of the pelvis. In rickety subjects, the opening is sometimes reduced to a mere vertical slit. Some years ago, a soldier, affected with vesical calculus, died in one of the hospitals of Paris, in whom the distance between the branches of the ischiatic and pubic bones did not exceed six lines.1 In such a case, the perinseal operation of lithotomy, would, of course, be inadmissible. For breaking stones in the bladder, various instruments have been contrived, some of which are simple and convenient enough, while others are very clumsy and awkward. A goodly sized volume might be written upon this subject alone, and that too, without exhausting it. The forceps represented in the annexed cut, Fig. 71, are well Fig. 71. calculated for this operation, and maybe safely employed in all cases where such a procedure is likely to be required. Dr. Jameson, a distinguished surgeon, of Baltimore, recommended, many years ago, an instrument constructed upon the principles of the obstetric forceps, with a central drill. The blades, which are movable, fenestrated at 1 Robert, Journ. des Progr6s. T. 8, p. 200. 442 DISEASES AND INJURIES OF THE BLADDER. their vesical extremity, are closed by a slide, and are admirably adapted for grasping a large calculus. The forceps being applied in the usual manner, the drill is set in motion, and the foreign body bro- ken into fragments, which are afterwards extracted piecemeal. 2. Extraction of Large Calculi.—The subjoined observations re- specting the extraction of large calculi, by different operators, with the results of their success, are condensed principally from a valu- able and interesting paper on the subject, by Mr. H. Earle, in the eleventh volume of the Medico-Chirurgical Transactions of London. The facts which they disclose are of the highest practical importance. Ambrose Pare' relates the case of a confectioner, who was cut in 1570, by John Collot, when the stone weighed nine ounces, and was three inches and a half in diameter (Des Monstres. Lib. 25, ch. 15). In an instance described by Tolet, a calculus weighing ten ounces, and measuring nearly four inches in diameter, Avas happily extracted, and the patient had recovered from the immediate effects of his wound, when an abscess formed in the kidney from the presence of a con- cretion, and terminated fatally on the ninth day from the operation. Gooch (Surgical Observations, p. 54), relates a case in which Mr. Hamer, of Norwich, removed, by the lateral section, a stone of the weight of fifteen ounces, its diameter being four inches and three- quarters in one direction, by three and a half in the other. The man, who was forty-eight years of age, survived, though the wound never entirely healed. Cheselden, withdrew a concretion of twelve ounces, and succeeded in curing his patient. Klein (Chir. Bemerk- ungen, Stuttgard, 1801), successfully extracted a stone of thirteen ounces; it was somewhat conical in its form, and was nearly nine inches in circumference at its largest extremity, by three inches and three-quarters in length. The same eminent surgeon refers to a case (Mursinna's Journal fur die Chirurgie, vol. iv. p. 94) in which a con- cretion weighing twelve ounces and two drachms, was successfully removed. In 1818, Charles Mayo, Esq., of Winchester (London Medico-Chirurg. Trans., xi. p. 54), operated upon a man aged twenty- eight, and extracted a stone of fourteen ounces and two drachms, avoirdupois; it measured eight inches and a half- in its smallest cir- cumference by rather more than ten in the largest, and broke into several big pieces in the attempts to extract it. Mr. W. B. Dickson, of England (ib. p. 61), successfully removed from a man of sixty-two, a calculus of a globular shape, and composed chiefly of phosphate of lime, which weighed eleven ounces. It broke into several fragments, STONE IN THE BLADDER. 443 which were taken away piecemeal. The operation was followed by sloughing of the rectum, and when the case was reported, several months aftenvards, a small fistulous opening still existed between this cavity and the bladder. Although the above cases clearly show that a stone, even of large size, may occasionally be successfully extracted, yet it is equally cer- tain that they must be regarded as so many exceptions to the rule, rather than as the rule itself. Most generally, indeed, the patient dies either from exhaustion during the operation, or from the effects of inflammation a short time afterwards. The following examples will place this subject in a more satisfactory light. Fabricius Hildanus records (De Lithotomi4 Vesica, liber 1, cap. 8, p. 720, et cent. 4, obser. 51), a case operated on by Vitelius, in which the stone weighed twenty-two ounces; it was four and a half inches in length, and three inches and a half in width. The man, who was twenty-one years of age, died under the operation, which was very difficult, painful, and protracted. Geyer (Miscell. Nat. Cur. Dec. 11, an. v. obs. ccxxxi. p. 456) witnessed an operation on a boy, where the calculus was of the volume of a turkey's egg, and so adhe- rent to the bladder, that it had to be broken and extracted piece- meal. The fragments weighed ten ounces, and the patient died three days after the operation. Palucci (Nouvelles Remarques sur la Lithotomie, p. 72); La Mott (Chirurg. Observationes, p. 320); Vidal (Traite sur la Production des Pierres dans le Corps Humain, p. 262); and Eller (Histoire de l'Academie de Berlin, 1757, p. 30), all mention examples of twelve ounces, which were extracted by opera- tions, but in no one instance with a successful result. Charles Preston (Philosoph. Trans. London, xix. p. 310) states that he saw at Paris, a stone which weighed fifty-one ounces, which was taken from a religious brother in 1690, who died before the operation was concluded. A calculus of the weight of eighteen ounces is described by Borrellus (Histor. et Observ. Med. Phys. Centur. 2, obs. 22, 12mo. Leip. 1676) as haA'ing been extracted by Quesnotus, but the patient did not survive. Marteau de Grandvilliers removed one of fourteen, and another of twelve ounces, with fatal results (Journal de Medecine, T. xii. p. 54). Mr. Birche extracted a stone of sixteen ounces from a man in St. Thomas's Hospital, London, (Medico-Ch. Trans, xi. p. 76). Deguise (Recueil Periodique, T. vii. p. 423, et T. xiv. p. 424), removed one of thirty-one ounces, from a patient, aged sixty-five, by the high operation, having previously opened the blad- 444 DISEASES AND INJURIES OF THE BLADDER. der through the perinseum. Death ensued on the sixth day. Sir Astley Cooper (op. cit. xi. 73) cut a man, forty-three years of age, and found a stone which weighed sixteen ounces. The diameter in the long axis was four and a half inches; in the short axis, three and a quarter inches. It could not be broken, such was its firmness, and the wound in the perinseum was, therefore, obliged to be ex- tended as far back as the sacro-sciatic ligament. The patient sur- vived the operation only four hours. In the case of a man forty- three years old, cut by Mr. Dalrymple, in the Norwich Hospital, in June, 1818, the weight of the calculus was upwards of twelve ounces, and death occurred at the expiration of about three hours. The stone could not be broken, and after the lapse of about an hour, all hopes of extracting it were abandoned. (London Medico-Ch. Trans, xi. p. 71.) Dr. Mott, of New York, has in his possession a triple-phosphate calculus, weighing seventeen ounces and two drachms, which he removed by the ordinary operation, from an elderly gentleman, who died on the fifth day.1 It is fortunately rare, at the present day, that a lithotomist meets with a very large calculus. The operation has become so common that most of the cases, occurring in particular regions of country, are sure to be found out, and submitted to the knife, at an early period after the appearance of the characteristic symptoms. It is only occasionally that an example of the kind is witnessed, and then, only in old men, living in a state of isolation, away from surgical aid. I have never heard of a case of stone of fifteen ounces in any part of the United States, except the one above-mentioned. The following case illustrates some of the difficulties which some- times occur in lithotomy, when the stone is of great size. I may mention that the operator was young and inexperienced, and that the calculus might possibly have been extracted through the peri- nseum, without recourse to the supra-pubic incision. The case was doubtless well calculated to perplex an older surgeon; it was a first one, and may be compared in its effects upon the mind, to a first case of labour, with a breech, arm, or shoulder presentation. The young gentleman, in announcing his troubles, writes, "I am in a 'bad box,' the worst kind of a 'bad box;' I have operated recently for stone, through the perinseum, passed the scalpel into the bladder, with little difficulty. The knife, on entering the viscus, struck against the cal- 1 Dr. Van Buren's MS. Letter to the author. STONE IN THE BLADDER. 445 cuius. I now introduced my finger, and touched the stone, which I found to be of enormous size, filling up the whole cavity of the bladder, which was firmly and spasmodically contracted upon the foreign body. Finding the incision in the neck of the bladder, too small, I enlarged it to nearly two inches. I then introduced the forceps, but could not carry them into the bladder, much less ex- pand them over the stone. I made many attempts to move the stone and change its position, but it was so large, and so exceedingly rough, that this could not be done. I now enlarged the wound in all directions to the greatest possible extent, and then renewed my efforts at extraction, but was again completely foiled. Whenever I touched the stone, it produced the most severe vesical spasm and bearing down pains, similar to those of parturition. Finding all attempts to remove the stone of no avail, I was indeed greatly at a loss. The case was now just this. I had cut down to the stone, but found it impossible to extract it. The awful condition of the wretched man Avas before me with all its horrors. I would have given half my existence for a consultation." In this quandary, the operator, rather than abandon his patient to his fate, proceeded to open the bladder above the pubes. Having reached the organ, he placed his finger upon it, and found it hard, and firmly contracted upon the stone. An incision, upwards of two inches in length, was then made into it, when, introducing a finger, he suc- ceeded, though not without difficulty, in raising the small end of the stone into the Avound. "I now," says he, "seized it with the for- ceps, and attempted to extract it, but failed. I then tried to break it, but in this also I failed. Finally, I tried again with my finger, and after some difficulty succeeded in removing a calculus of a pyri- form figure, Aveighing eight ounces, and measuring nine inches and a quarter in its greater, and seven inches and a half in its lesser cir- cumference, by three inches and a half in diameter." Notwithstanding two such large wounds, and the violence used in extracting the stone, the patient did remarkably well, and finally recovered. On the eighteenth day after the operation, he was able to Avalk about his room, and Avas gaining flesh and strength, both Avounds healing kindly and even rapidly. The only inconvenience which he experienced was from a communication between the bladder and the rectum, caused by carrying the knife too far back in the attempt to enlarge the incision in the neck of the bladder. My correspondent closes his letter in the following expressive words:. 446 DISEASES AND INJURIES OF THE BLADDER. « Mr. W----, is a very stout, tough kind of a man; I do not believe that thunder and lightning could kill him." The experience thus bought, has not been without benefit; instead of intimidating my friend, he has resolutely pursued his course, and has acquired no little reputation in his neighbourhood, as a lithotomist. The only error, perhaps, which he committed, was that he did not attempt to break the calculus, and extract it piecemeal. Such an attempt, how- ever, might have proved fruitless, when we reflect upon the fact, previously adverted to, that he found it impossible, in consequence of the large size of the foreign body, to carry the forceps into the bladder, and to expand the blades over the calculus. Many years ago, Dr. John D. Godman, cut a patient at Cincin- nati, for a stone which was found to be so large as not to admit of crushing or extraction. After numerous attempts to free the bladder the case was abandoned, as hopeless. The wound healed up, and the man subsequently walked to Carlisle, Pennsylvania, a distance of nearly seven hundred miles. Here he was operated upon a second time, with the like result, by Dr. Given. After recovering, he pro- ceeded to Philadelphia, where he was finally relieved by Dr. Gibson and Dr. Physick. The bladder being opened, the stone was found almost to fill the organ, and was, therefore, obliged to be broken before it could be extracted. The patient recovered in a fortnight, and again walked home, as Dr. Chapman facetiously remarked, "a stone lighter than when he came."1 It is said that Marjolin once met with an instance in which the stone was so large, that it Avas necessary, before extraction could be effected, to saw through the bones of the pubes. McGill, an English surgeon of the last century, once performed the high operation, without being able to remove the stone. The patient died on the fourteenth day, when the attempt to extract the calculus was re- neAved, the straight muscles being previously cut away at their infe- rior attachments. This method also failing, he sawed off one of the pubic bones, and then succeeded. d. Accidents during and after the Operation. 1. Hemorrhage.— One of the most serious accidents attending perinseal lithotomy is hemorrhage. This, which may be either arterial or venous, may take place at the time of the operation, before the completion, perhaps, of the incisions, or after the incisions -have been made, but before the 1 Gibson's Surgery, vol. ii. STONE IN THE BLADDER. 447 stone is extracted ; or it may not happen until after the foreign body has been removed, and the patient put to bed; in fact, not until after the expiration of several hours or even days. In the former case, the hemorrhage is said to be primitive; in the latter, secondary. The quantity of blood lost may be small, or so copious as to induce severe and even fatal exhaustion. It is impossible, in the present state of the science, to form any accurate idea of the mortality from hemorrhage, or even the fre- quency of its occurrence, after perinseal lithotomy. Various esti- mates have been made by different writers, but the data upon which they are based are too imperfect to justify us in placing any reliance upon them. Mons. L. J. Bdgin, of the Val-de-Grace Hospital of Paris, thinks that one out of every twenty or twenty-four who sub- mit to the lateral operation perishes from the loss of blood; while the mortality from the bilateral method, as practised by Dupuytren and other surgeons, is only one in forty-two. My own conviction is that this estimate is much too high. It is seldom, indeed, that we hear of a patient dying from the loss of blood from the common operation, especially when it is executed with the knife. The most distinguished lithotomists hardly allude to the subject, and writers on surgery are almost equally silent. Rau, Tolet, Colot, Cheselden, Deschamps, Klein, and Dessault, rarely lost a patient from this cause. The most celebrated modern operators, as Martinau, Roux, Liston, Crosse, Langenbeck, and Dudley, appear to have not been less fortunate in this respect. In operating with the gorget, the danger of hemorrhage is probably greater than in operating with the knife, especially with the young and inexperienced surgeon. An unusually wide gorget must always endanger the pudic artery, and the same is true of the knife Avhen the incision is made too far out towards the ischium. The artery of the bulb is rarely divided, ex- cept Avhen the incision is extended too high up; and the hemorrhoidal artery is usually avoided by taking care not to carry the instrument too deeply into the ischio-rectal fossa. In short, when proper caution is observed in performing the operation; when the pelvis is of the ordinary width; and Avhen the vessels of the perinseum are perfectly regular, both as it respects their distribution and volume, little danger, I presume, is to be apprehended from hemorrhage. Under ordinary circumstances, the loss of blood need not exceed four or five ounces. In many of my operations it has not, I am sure, equalled half that quantity. A moderate flow of blood, espe- 448 DISEASES AND INJURIES OF THE BLADDER. cially in young, plethoric subjects, is rather desirable than other- wise, since it is a great security against subsequent vascular excite- ment. Where the patient is thin and feeble, too much care cannot be observed in regard to the loss of blood; the smallest quantity, in such a case, may prove a serious matter. The principal sources of the hemorrhage in this operation are the artery of the bulb and the superficial artery of the perinseum. In old subjects a copious flow of blood occasionally proceeds from the veins of the neck of the bladder and the prostate gland. The pudic artery, in its normal course, can hardly be wounded posteriorly, from the manner in which it is protected by the ramus of the ischium; as it extends forwards, however, into the anterior part of the perinseum, it becomes more exposed, especially when it lies between the layers of the triangular ligament, and is, therefore, in danger of. being injured. This accident, which has occurred to Physick, Charles Bell, Everard Home, Crosse, and many other distinguished operators, is most liable to happen when the prostate is divided with the gorget, the lithotome cache*, or the beaked-knife of Blizard. When the pudic artery arises directly from the internal iliac, and passes forwards over the side of the prostate, on its way towards the penis, it is hardly possible for it to escape, no matter how the operation is performed. An anomaly of this kind was the cause of a fatal hemorrhage in the celebrated case of Mr. Shaw, of London. The artery of the bulb is one of the largest branches of the pudic, and is apt, when divided, to bleed profusely. From its deep position, and the readiness with which it retracts, it is always secured with difficulty. The late Mr. Key, of London, was of opinion that this vessel is almost always divided in the lateral operation; a view in which I am not disposed to concur, for the reason, that, if this were the case, the mortality from this operation would be much greater than it is. It is best avoided by making the incision Ioav in the perinseum ; but when this is done there is danger of cutting into the groove of the staff through the prostate gland instead of the mem- branous portion of the urethra; a circumstance which would lead to much difficulty in extracting the stone. When the artery arises lower down than natural, its division is almost inevitable. In a case of fatal hemorrhage, which occurred to Mr. Kerr, of Aberdeen,1 on the fifth day after the operation, the bulbar and transverse arteries 1 Banking's Half-Yearly Abstract, July to December, 1847, p. 208. STONE IN THE BLADDER. 449 came off by a common trunk, which soon separated into two branches, of which the one that corresponded Avith the former vessel ran much farther back than usual, so as to be in the line of the incision, and was, of course, divided along with the latter. A tremendous gush of blood sometimes proceeds from the trans- verse perinseal artery, which is occasionally enormously enlarged, even in very young subjects, probably in consequence of the long- continued irritation kept up by the stone in the bladder. The bleeding, in this case, generally follows the first incision, and should be imme- diately arrested by the ligature. In one of my patients, a young man about twenty-one years of age, the blood flowed from the divided vessel with a loud hissing noise and in a full stream, to the amount of three or four ounces before my assistant succeeded in tying it. The superficial perinseal artery rarely escapes the knife ; but the bleeding is generally so trifling as not to require any particular notice on the part of the operator. It is only when the vessel is uncommonly large, or when it retracts within the opening of the fascia through which it emerges, that it is likely to become a source of trouble. In either case, the hemorrhage may be so profuse as to induce the belief that it proceeds from a wound of the pudic artery. The inferior hemorrhoidal artery, the posterior branch of the pudic, is generally of small size, and is in no danger of being injured, except when it is given off unusually high up, and passes almost across the ischio-rectal space without dividing. Should such an anomaly exist, the hemorrhage might be quite free, though it would be easily enough arrested, unless the vessel is cut so close to its origin as to retract within the surrounding tissues, or its coats are so diseased as to be incapable of supporting a ligature. A considerable hemorrhage occasionally proceeds from the vesical veins, or the arteries and veins of the prostate gland. In old per- sons, especially in such as have laboured long under stone in the bladder, stricture of the urethra, perinseal fistula, irritation of the rectum, or disease of the prostate, these vessels are exceedingly prone to varicose enlargement, forming a close plexus, which is habitually distended with black blood. The cellulo-fibrous tissue in which this plexus is included, is, under such circumstances, also much changed in its character, being not only increased in quantity but likewise considerably indurated. Hence, when these vessels are divided they are unable to retract, or bury themselves among the 29 450 DISEASES AND INJURIES OF THE BLADDER. surrounding parts, and the hemorrhage, which is often very profuse, the blood welling out simultaneously from a great number of points can only be arrested by protracted compression, aided by cold appli- cations. On the whole, it is exceedingly probable, that, in very many cases, if not in a majority, in which the hemorrhage is at all copious, it proceeds from an anomalous arrangement of the perinseal arteries. Boyer, who was a believer in the frequent occurrence of this acci- dent after the lateral operation, makes the following just remarks. " The blame of the hemorrhage is often thrown upon the operator, or on the method which he may have selected; but in most cases improperly; for the perinseal arteries present such a multitude of varieties, both in their situation and course, that the most skilful surgeon cannot be certain of avoiding them, no matter what proce- dure he may adopt." Much difficulty is often experienced in ascertaining whence the blood proceeds. When the transverse perineal artery is divided, its source is usually sufficiently obvious, from the superficial situation of the vessel; but when the pudic artery, or the artery of the bulb, is cut, it is no easy matter frequently to decide this important question. Nothing, in such a case, short of the most thorough examination can enable us to detect the bleeding orifice. This examination should be conducted with the fingers, assisted by a sponge mop, and a small pair of lithotomy forceps, for separating the deep portion of the wound. It has occurred to me that a small wire speculum might be made available to such an exploration, and I have accordingly requested Mr. Tiemann, my cutler, to add such an instrument to my case. A stream of tepid water, directed upon the wound, from a syringe, would be of service in Avashing off the blood, and pointing out the spot whence it issues. The seat of the hemorrhage will often enable us to determine its source. Thus, when it proceeds from the artery of the bulb, the blood issues from the upper angle of the wound; from the lower angle, when it is furnished by the hemorrhoidal; and from the ex- ternal part of the wound, when it comes from the pudic, or superficial perinseal. When the hemorrhage is seated very deeply, the proba- bility is that it proceeds from the vesical plexus, from some of the vessels of the prostate gland, or from an irregular distribution of the pudic, as in the case, already adverted to, of the late Mr. Shaw. When the hemorrhage arises from the injury, division, or lacera- STONE IN THE BLADDER. 451 tion of a fungous tumour of the bladder, its source will usually be sufficiently indicated by the difficulty or peculiarity attending the operation, and by the absence of hemorrhage from the perinseal vessels. HoAvever the hemorrhage may be induced, or from whatever source it may originate, it is to be borne in mind that the blood may escape only partially, or perhaps not at all, at the wound, but that it passes inwards into the bladder, where it is either retained, or expelled from time to time in thick clots. The organ, under these circumstances, will form a hard, solid tumour, Avhich is more or less tender on pressure, and which may mount as high as the umbilicus. The expulsion of the clots, or rather the efforts made by the bladder to rid itself of its contents, are attended with violent suffering, and bear a close resem- blance to labour-pains. The means for arresting the hemorrhage are:—1. The ligature; 2. Torsion; 3. Compression; 4. Cauterization and styptics; 5. Cold applications. 1. In all cases where the artery is within reach, the ligature should be employed in preference to any other expedient. The reasons for this are obvious, and need not be here discussed. The vessel should be seized with the forceps, tenaculum, or needle, and secured in the usual manner, one of the ends of the ligature being left hanging out of the wound, for fear of its escaping into the bladder, and thereby laying the foundation of a future calculus. When the artery of the bulb is cut, it may be drawn forwards by means of a pair of very slender polypus-forceps, which answer the purpose much better than the common instrument, or the tenaculum, which permits the blood to escape by its sides, so as to obscure the bleeding orifice, and in- terfere Avith the application of the ligature. The pudic artery, OAving to its deep situation, is best secured with Physick's for- ceps, represented in the annexed drawing. It is an admirable instrument, and should find a place in every lithotomy-case. It is far superior to Deschamp's needle, and the clumsy contrivance of Verdier. It is not necessary, at the present day, to consider the proposal of the latter writer, to surround the pudic artery and the ramus of the ischium with a ligature carried across the thyroid foramen. Such a suggestion is not to be seriously entertained. 2. Torsion, as a means of arresting hemorrhage of the perinseum, is to be thought of only when a small artery is divided, or when 452 DISEASES AND INJURIES OF THE BLADDER. the vessel from which the blood proceeds is situated so deeply as to render it difficult to tie it. It is here, as else- where, under ordinary circumstances, far inferior to the ligature. 3. Compression, Avhich may be resorted to in all cases where it is impossible to use the ligature or torsion, may be made with the finger, a tampon, a canula, or a pair of forceps. The former of these methods was much employed by Pouteau, who some- times maintained the pressure for hours together, by a relay of assistants. The practice might be useful in some cases, as when the other means fail, but it is too inconvenient and fatiguing, both to the patient and the surgeon, to be resorted to on slight occasions. A more eligible mode of making compression is by means of a canula, surrounded by charpie, sponge, or cotton. The canula may consist of a piece of silver, or gum elastic, three inches and a half long, by four lines in diameter, and provided at the perinseal extremity with two holes or rings for securing it, by means of threads or ribbons, to a T bandage. The instrument is introduced into the bladder, and firmly surrounded by charpie, or some other substance, for the twofold purpose of conducting off the urine, and compressing the bleed- ing vessel. It should be retained in its place for four or five days, or until there is reason to believe that all danger of hemorrhage is over. When no canula is at hand, and the case is urgent, a female catheter, a piece of reed, or the spout of a tin coffee- pot, may be used as a substitute. The compression may be effected, in the third place, with a com- mon tent, or a tampon of sponge, charpie, or soft linen; but in this case it is necessary to keep a catheter in the urethra for carrying off the urine. This mode of compression is particularly applicable to deep-seated hemorrhage, or to cases where the blood proceeds from the vesical veins, or the arteries and veins of the prostate. This kind of hemorrhage, as has been already seen, is most common in aged calculous patients, and can hardly be arrested in any other STONE IN THE BLADDER. 453 manner. In this variety of compression, as well as in the preceding, the deep portion of the wound must be plugged first, dossil being piled upon dossil until the whole is filled up. A soft compress is then applied to the perinseum, and the whole confined by a T ban- dage. Lastly, in obstinate cases, where neither the ligature, torsion, nor the more ordinary modes of compression are available, the hemor- rhage may be arrested by pressure, made with a pair of long slender forceps, provided with moderately sharp teeth, and a ring for closing the handles. The instrument must of course be light, and so applied as to embrace along with the artery some of the surrounding tissues. Although I have spoken here of compression, and pointed out the manner in which it may be made, and the circumstances in which it is applicable, I must confess I have no partiality for it. On the contrary, I should ahvays resort to it with reluctance, inasmuch as it is not only attended with more or less pain, but is liable to lead to undue inflammation both of the perinseum and the bladder, and may even be productive of serious consequences. There are cases, however, in which it is unavoidable, and in which no judicious prac- titioner Avould hesitate to employ it. In a case in which I had occasion, last autumn, to employ com- pression on account of a hemorrhage which threatened to become serious, and in which the blood issued from a large number of points, the wound did not entirely close for nearly three months. The patient did Avell in every other respect, and no cause, except the one here mentioned, could be assigned for this untoward occurrence. The compression was effected by means of a piece of sponge, which Avas retained for four days, when every particle of it Avas removed. 4. I can hardly imagine a case of hemorrhage, consequent upon the operation of lithotomy, in which it Avould be proper to use the actual cautery or what are called styptics. All such measures must be fraught with danger, and can be justifiable only as a dernier resort. High inflammation, if not sloughing, would be almost cer- tain to follow their employment. 5. Cold applications, in the form of irrigations, may be used, in many cases, with benefit. Made directly to the wound, or the peri- neum, they have a tendency to promote the contraction of the bleeding vessels, to allay pain, and prevent inflammatory action. The Avater, which must not be too cold, should be directed upon the part, in a continuous but gentle stream, from a patent syringe, and 454 DISEASES AND INJURIES OF THE BLADDER. the pelvis should be so situated as to enable it to run into a tub at the side of the bed. A piece of oil cloth, placed under the nates, will more effectually secure this object. The operation may, if necessary, be kept up several hours without risk of injury. Mons. L. J. Begin, who has written a paper on this subject in the "Mr- moires de V Academic Roy ale de Medecine,"1 asserts that he has employed this method with the most complete success in two patients, although they were reduced to an almost hopeless state prior to its institution. It may be aided by cold applications to the hypogastric region, groins, and inside of the thighs ; by strict recumbency; by cooling, acidulated drinks; and by full doses of opium, which should never be omitted, as they constitute an important part in the treat- ment of all traumatic hemorrhages. The period, after the operation, at which secondary hemorrhage sets in varies from a few minutes to several hours or days. If it does not come on within the first ten or twelve hours, the probability will be strong that it will not show itself at all. In general, it will make its appearance as soon as reaction is established, or the patient has recovered from the shock of the operation. An artery that may have ceased to bleed, in consequence of the enfeebled state of the heart, may now furnish an abundant jet, alarming the bystanders, and rapidly exhausting the patient. Such a case admits of no delay. Prompt and vigorous action is required, or all will be lost. Hesi- tation would be fatal. The means already pointed out, must be put in force ; the coagulated blood must be removed Avith the fingers, scoop, or syringe ; the bleeding vessel must be exposed and tied ; or, if the ligature is inadmissible, compression or irrigation must be resorted to, and steadily maintained until all danger is past. The older lithotomists speak of secondary hemorrhage taking place several days, and even weeks, after the operation. When it is recollected what violence they employed in extracting the stone, we need not be surprised at the occurrence, which is fortunately ex- tremely rare in the present improved mode of proceeding. 2. Sinking.—FeAV patients at the present day, perish from the shock of the operation of lithotomy. Indeed, great depression, or death, can hardly occur, in the hands of a skilful surgeon, unless the patient is labouring under some idiosyncrasy, under disease of the heart or large vessels, or under excessive debility from previous 1 T. 10, p. 120. Paris, 1843. STONE IN THE BLADDER. 455 suffering. It is, however, easy to conceive that very alarming, if not fatal, results may ensue when the operation is unusually protracted, when great violence is used in extracting the stone, accompanied with severe contusion or laceration of the bladder or perinseum, or when there has been a considerable loss of blood. Under such cir- cumstances the shock may be so great that the patient may die upon the table, soon after he is put to bed, or, at all events, during the first tAventy-four hours, without, perhaps, any attempt at reaction. In former times, death was occasionally produced by excessive pain, operating upon a nervous and debilitated constitution; but since the introduction of chloroform and other ansesthetic agents no such accident has occurred. When a patient is labouring under " shock," the circumstance is denoted by the excessive pallor of the counte- nance, by the small, rapid, fluttering, and indistinct pulse, the cold- ness of the extremities, the disturbed breathing, the rolled-up eye- ball, the intense thirst and constant restlessness, the incoherent state of the mind, and the deadly prostration of the system. The treatment must be stimulating. The head is laid low, to favour the action of the heart and the return of the blood to the brain ; a free access of air is provided; a smelling-bottle is held to the nose; and, if the patient can swallow, he must take large quan- tities of brandy, either alone or in union with ammonia. These remedies are aided, if necessary, by the application of heat, friction, and sinapisms. When the danger is imminent, mustard should be applied to the spine, as well as to the prsecordial region, and recourse should be had to injections of spirits of turpentine, alcohol, or am- monia. When reaction begins, the patient must be carefully watched, lest over stimulation take place, followed by excessive nervous and sanguineous excitement. 3. Retention of Urine.—This accident is indicated by a total ces- sation of the flow of urine, by sharp, burning, or scalding pains in the lower part of the pelvis, attended with tenesmus and a constant desire to pass water, and by a gradual distension of the bladder, which can be felt as a firm, tender, and ovoidal tumour in the hypo- gastric region. It may be caused by inordinate tumefaction of the wound and spasm of the urethra ; or, as more frequently happens, by the closure of the two passages by coagulated blood. In the former case, relief is afforded by the catheter; in the latter, by clearing away the blood with the finger or scoop, and inserting, if necessary on account of the persistence of the hemorrhage, a canula, for the 456 DISEASES AND INJURIES OF THE BLADDER. twofold object of compressing the bleeding vessels, and conducting off the urine. 4. Undue Inflammation of the Wound.—The wound made in the operation of lithotomy may take on undue inflammation, in conse- quence of the injury done to the soft parts in extracting the stone, slight urinous infiltration, or some defect of the constitution. It usually supervenes within the first forty-eight hours. The action is sometimes erysipelatous, and is then apt to spread from the wound to the nates and the thighs, as well as to the groin and the abdomen. Unless the disease, in whatever form it presents itself, is promptly arrested, copious* suppuration may ensue, lasting, it may be, for a number of days, and seriously jeoparding the patient, perhaps already much exhausted by previous suffering. The inflammation sometimes runs into gangrene, producing a dark, foul appearance of the wound, and involving, as it extends, the neck of the bladder, the cellular tissue between this organ and the rectum, and even the rectum itself. This accident happened to me in a patient on whom I operated in the winter of 1844, and to whose case I have already several times alluded. He was twenty-six years of age, of a deli- cate constitution, and had been affected with the disease from his infancy. I cut him on a Friday, extracting a rough, heavy calculus, about the size of a hen's egg. He bore the operation, which was performed in good time, exceedingly Avell, and nothing untoward occurred until the following Monday, when the wound, without much previous swelling, began to assume an unhealthy erysipelatous aspect. The next day it looked still worse, and the man was seized with a thin, watery diarrhoea, having, in rapid succession, not less than eleven motions. Late in the afternoon, fsecal matter was seen issuing through the wound, and thus continued for several weeks, the quantity gradually diminishing, and the wound steadily contracting. The cicatrization was completed in less than a month; but when the man left town, a little urine still flowed by the rectum. I have since learned that he speedily recovered after he reached home. A peculiar form of inflammation, named phlebitis, occasionally occurs after this operation. It is most frequently met with in elderly subjects, affected with an unusual development of the veins of the neck of the bladder, and the prostate gland. The disease usually arises within the first four or five days, and soon spreads through the neighbouring cellular tissue, assuming a diffused erysi. STONE IN THE BLADDER. 457 pelatous character, and terminating, if the patient survive sufficiently long, in purulent infiltration. The French surgeons consider phle- bitis as a very common cause of death after this operation; a view which has not, I believe, been confirmed by English and American observers. The treatment is antiphlogistic, conducted cautiously, and with due regard to the constitution. Cold or warm applications are used as may be most grateful to the part and the system ; iodine is applied to the surface around the wound, especially in the erysipelatous form of the inflammation, and the utmost attention is paid to cleanliness. If gangrene supervene, the wound must be syringed with Aveak solutions of nitric acid, tincture of myrrh, or the fluid chloride of soda, for the purpose both of correcting foetor, and instituting a more healthful action. The constitutional treatment must be directed upon general principles. 5. Lesion of the Prostate G-land.—This gland may be seriously injured in this operation, either by the knife, the finger, the forceps, or the calculus. When the perinseum is of unusual depth, it may be difficult, especially for an inexperienced operator, to make a smooth section of the organ ; perhaps the knife slips out of the groove of the staff, and, in attempting to reinsert it, it may be thrust in at a dif- ferent point. Thus, the part may be nicked, as it were, and the consequence will be that the Avound will be multiple instead of being simple, as it always ought to be. Again, harm may be done with the finger, in attempting to enlarge the wound of the prostate after slight incision has been practised. In general, however, there is little danger from this course. The most serious mischief is usually inflicted by the forceps, the blades of which, instead of being ex- panded over the stone, embrace a portion of the gland, and either bruise it severely, or tear it away from the body. The part of the organ most liable to suffer in this way is the enlarged middle lobe, as it lies behind the neck of the bladder in the form of a narrow ridge, or nipple-shaped prominence. The error can generally be readily detected by the peculiar feel of the tumour, which is soft and compressible, while the calculus is hard and unyielding. Where doubt exists, the instrument should be carried up into the cavity of the bladder after seizure has been effected, or the finger may be placed in contact with the body as it lies within the grasp of the forceps. In the former case, the instrument Avill refuse to ascend if it has hold of the prostate gland, and in the latter the discrimination 458 DISEASES AND INJURIES OF THE BLADDER. is easily determined by the sense of touch. The accident, however must be extremely rare, and ought never to happen in the hands of a skilful operator. When the third lobe is in the way of the stone, it should be do- pressed with the finger; or, what is better, the bas-fond of the blad- der should be elevated through the rectum ; an expedient which will bring the stone on a level with the jaws of the instrument, and enable the operator to seize it with great facility. When the prostate has been much contused, or lacerated, whether unavoidably, or through inadvertence, the best practice is to cut away the injured part with a pair of long, curved, blunt-pointed scissors, such as surgeons are in the habit of using for excising the uvula. The wound is thus converted into a simple one, which does not slough but heals by the granulating process. Where the stone is very large, the prostate may suffer excessive contusion during its extraction, followed by violent inflammation and even sloughing. In such a case, which is fortunately of rare occurrence, our chief reliance must obviously be upon the employ- ment of antiphlogistic remedies, particularly leeches and ice to the perinseum, in the early stage of the treatment, and, afterwards, upon fomentations and poultices. 6. Urinary Infiltration.—One of the most frequent, as well as dangerous effects of lithotomy, is an escape of urine into the cellular tissue of the perinseum, or of the perinseum and the parts imme- diately around the neck of the bladder. Its occurrence is favoured by too free a division of the prostate gland; by the small size of the wound, or by its being too conical or sloping; by the early and in- ordinate tumefaction of the cut surfaces; and, above all, by the per- foration of the reflected portion of the pelvic fascia. The attack usually comes on within a short time after the operation, and is apt to run its course with frightful rapidity. A sense of weight, heat, and smarting at the neck of the bladder, and pain in the hypogastric region behind the pubes, attended with symptoms of excessive con- stitutional irritation, denote the commencement of the disease. The skin is hot and dry, the pulse weak and frequent, the tongue parched and brown, the wound glazed and foetid, urine scanty and high- coloured. The prostration rapidly increases, the surface becomes covered with a cold, clammy sweat, hiccup sets in, the abdomen grows tympanitic, and the patient dies completely exhausted, usually in three or four days from the invasion of the malady. On dissection, STONE IN THE BLADDER. 459 the surfaces of the wound, the infiltrated parts, the neck of the blad- der, and even the prostate gland are all found in a highly inflamed, offensive, and sloughy condition. The pelvic portion of the peri- toneum is frequently red, injected, and incrusted with lymph. Little can be done to arrest the progress of this affection when once esta- blished. Depletion by the lancet, and by purgatives is wholly inad- missible. The system, poisoned by the effects of the acrid urine, must be sustained, not further depressed. The internal remedies that promise most assistance are carbonate of ammonia, quinine, camphor, and capsicum, in combination with the liberal use of brandy and opium. Anodynes are indispensable from the very beginning. The best topical means are saturnine and opium fomentations, medicated cataplasms, injections of a weak solution of nitric acid or chloride of soda, and touching the whole track of the wound as early as possible, with nitrate of silver or the tincture of iodine. When the infiltration is caused by the small size, ill shape, or improper direction of the wound, the defect must be remedied by the knife. An outlet should be made for the "urine, either by means of the catheter in the urethra, or a tube passed through the artificial route. Leeches, hot fomen- tations, and blisters may be applied to the hypogastric region. 7. Peritonitis.—Peritonitis seldom follows the operation of litho- tomy, whether performed at the perinseum or above the pubes. It is, hoAvever, more frequent in the latter than in the former, because the peritoneum is more liable to be wounded, and because there is also more danger of urinous infiltration. In the perinseal operation, it is ex- ceedingly rare that the serous membrane of the pelvis is injured by the knife, but great mischief is occasionally done to the bladder and the surrounding parts by rude and long-continued attempts at extracting the foreign body. From these and other causes the dis- ease in question is sometimes lighted up, more particularly in old persons Avhose constitution has been broken down by protracted suffering. It usually appears within the first thirty-six or forty- eight hours, and is ushered in by severe rigors alternating with flushes of heat, aching of the back and limbs, restlessness and intense thirst. The distinctive signs are a burning pain of the abdomen with tenderness on pressure, tympanitis, a small, wiry, and frequent pulse, speedily followed by excessive prostration, cold, clammy SAveats, hiccough, nausea, or vomiting, and a cadaverous state of the features. The attack rarely lasts beyond the third day, and often terminates fatally in a much shorter period. The appearances 460 DISEASES AND INJURIES OF THE BLADDER. after death are generally well-marked, even when the disease has run its course very rapidly. The peritoneal surface is red and in- jected ; the bladder and intestines are coated with lymph; and the pelvic cavity almost always contains a little turbid or bloody serum. Evidences of inflammation are also observed in the mucous membrane of the bladder. The treatment must be prompt and vigorous. The practitioner must not be deceived by the state of the pulse, but the very fact that it is wiry and contracted must put him on his guard, and induce him to resort to depletion, both general and local, if the patient is in any condition to bear it. The quantity of blood to be taken must, of course, be regulated by the exigency of each particular case. Where the lancet is inadmissible, a goodly number of leeches may be applied to the hypogastrium, followed by fomentations, frequently renewed, and consisting simply of hot water, or of water in which hops, opium, or poppy-heads have been infused. When prompt relief does not follow this treatment, the Avhole abdomen should be covered Avith a blister. At the commencement of the attack the warm-bath occasionally proves highly serviceable, but later in the disease its beneficial effects are more than counter- balanced by the fatigue and exhaustion induced by its employment. The best internal remedies are calomel and opium, in the proportion of from three to five grains of the former to one or two of the latter, repeated every three or four hours. 8. Wound of the Rectum.—This accident may happen in any of the three stages of lithotomy; but it is not likely to occur, if the operation be performed in the manner advised in a previous chap- ter.1 By gently depressing the bowel over towards the right side with the left index-finger, as the knife divides the deeper seated structures of the perinseum and the membranous portion of the urethra, 1 Deschamps thinks that this accident is not so rare as is generally imagined, and adds that it occurred not less than four times in his own practice. (Traite de la Tailler, T. iii. 327.) Cheselden acknowledged to Moraud that he had twice, in operating, wounded the rectum. (John Bell's Surgery, iv. 242.) The accident also occasionally occurred to Frere Cosme. Deschamps says that the rectum is some- times so large as to cover nearly the sides of the prostate gland, and that it will then be almost impossible to avoid wounding it. (Op. cit. T. iii. p. 332.) I have recently heard a distinguished surgeon say, in conversing on this subject, that he had opened the rectum at least three or four times in about twenty operations, and without any serious consequences. He seemed to regard the accident as a mere bagatelle! STONE IN THE BLADDER. 461 all danger of this kind is avoided. It is only by neglecting this precaution, or omitting to lateralize the knife sufficiently, in this stage of the proceeding, that the rectum is likely to suffer. If the accident do occur, the opening will commonly be found to be small, and to be situated immediately in front of the neck of the bladder. There will be an interchange between the parts of urine and fseces, the quantity of which varies in different cases, and the discharge of which may continue for an indefinite period. In general, however, it soon begins to diminish, and ceases altogether in fifteen or twenty days, or, at farthest, in a month. In children, the opening some- times closes completely in less than a week ; sometimes, indeed, by the first intention. An accident of this kind is in general more disagreeable than dan- gerous. Unless the wound is very large, and the patient in dilapidated health, nature, assisted by art, is almost always competent to effect a cure. The proper plan of proceeding is to prevent the bowels from acting, except every third or fourth day, by means of anodynes, to wash out the rectum once every twenty-four hours with cold water, to permit none but the most bland and simple food, and to enjoin a strict observance of the recumbent posture. The suggestion of Poutcau, Dessault, and others, to divide the parts that lie between the external orifice of the wound and the opening into the gut, cannot, I think, be too much deprecated. If the practice be at all justifiable, under any circumstances, it is only when the track has become fistulous or remained in this state sufficiently long to induce the conviction that it cannot be cured, either by the efforts of nature, or the means just pointed out. When the operation is un- avoidable, it should be conducted upon the same principle as in anal fistula. 9. Incontinence of Urine. — Incontinence of urine, consequent upon perinseal lithotomy, is happily infrequent. It is not always easy to determine how this accident is produced. Occasionally there is reason to believe that it depends upon the irregular union of the edges of the wound, no matter how well the operation may have been executed. Most commonly, however, it arises from injury inflicted upon the neck of the bladder during the extraction of a large or very rough calculus, by which the parts are over- stretched, bruised, or lacerated. The loss of power of the sphincter muscle may be partial or complete. In the one case, the urine is retained for some time, and then passed involuntarily; in the « 462 DISEASES AND INJURIES OF THE BLADDER. other, it flows off drop by drop as fast as it reaches the bladder, and thus keeps the patient in a constant state of discomfort. In most instances the power of retaining the fluid is greater in the recumbent than in the erect or semi-erect posture, because less pressure is exerted by it upon the neck of the bladder in the former case than in the latter. The affection is usually accompanied by a sense of uneasiness, soreness, or burning at the lower part of the pelvis, or at the commencement of the urethra. WThen there is a probability that incontinence of urine will take place, every effort should be made to prevent it. The patient should be strictly confined to his bed, a warm bath should be administered once a day, for twenty-five or thirty minutes at a time, tepid Avater should be frequently thrown into the rectum, and the urine should be deprived of its acrimony by the free use of demulcent fluids. When the affection is fully established, it will be necessary, in ad- dition to these means, to leech the perinseum occasionally, and to apply gentle but steady pressure upon that part with the pad of a T truss, or an instrument constructed upon the same principles as that which is sometimes worn for compressing the anus in prolapsus of the rectum. In obstinate cases, cauterization of the neck of the bladder and the commencement of the urethra may be tried with some pros- pect of success. Internally the patient may use the muriated tinc- ture of iron, strychnine, and cantharides. 10. Impotence.—This, like incontinence of urine, is very rare after perinseal lithotomy. As the operation is usually performed, the prostate gland is divided externally to the seminal ducts, which con- sequently remain intact. But even when they are accidentally wounded, it is doubtful whether any ill effects will result. When impotence follows the operation, it is almost always caused by vio- lence done to the seminal ducts or their orifices during the extraction of the stone, terminating in inflammation and, perhaps, in slight gangrene. There is no remedy for its relief. Sometimes the patient is rendered impotent in consequence of the semen being nearly all discharged through a urethro-rectal fistula instead of the natural passage. Berard cites1 a case of this kind in a young man of nine- teen, who laboured under this infirmity from having been cut for stone eleven years previously. Nearly all the semen flowed off by the rectum, and thus disqualified the individual for marrying. 1 Diet, de Me"decine des Sciences M6dicales, T. xxx. p. 124, 1846. STONE IN THE BLADDER. 463 11. Pen'nceal Fistula. — The wound made in lithotomy gene- rally heals in from three to four weeks; but sometimes it remains open much longer, and occasionally it does not close at all, but de- generates into a fistula. This may be owing to injury done to the bladder at the time of the operation; or it may be caused more remotely by ulceration or sloughing. In some instances it is depen- dent upon the lodgment of sabulous matter, the impaction of a fragment of stone, or the constant intromission of thick, ropy mucus. Most of the water flows through the natural channel; only a small quantity escapes by the fistula. Sometimes the perinseal opening is reduced doAvn to the size of a thin bristle, and so continues for many years, now and then shedding a few drops of urine. The abnormal track, as all similar passages in other parts of the body, becomes gradually lined by an adventitious mucous membrane. The existence of the fistula is determined by the appearance of the urine at the external opening, and by an examination with a probe. The treatment consists in retaining a silver catheter constantly in the urethra, and in cauterizing, every sixth or eighth day, the neck of the bladder with nitrate of silver. The patient should be con- fined to his back, with the nates resting continually higher than the other parts of the body, in order that the urine may be prevented from coming in contact with the inner orifice of the fistula. When the track is unusually small, and the perinseum uncommonly thin, relief may sometimes be afforded by the occasional introduction of a heated probe or wire. In obstinate cases, when the ordinary reme- dies have proved unavailing, the parts should be divided with the knife, as in the first instance, though much less extensively. It has been found that a fistula of this kind, produced by a first operation, has been radically cured by a second. All foreign substances, ob- structing the artificial route, must of course be removed as early as possible. e. Time occupied in Performing the Operation.—A few remarks will not be amiss here respecting the time occupied in performing this operation. This must necessarily vary according to many cir- cumstances, of which the principal are, the dexterity of the surgeon, the character of the assistants, the size of the wound, and the volume of the calculus, together with its freedom from adhesion, and the facility Avith which it may be seized with the forceps. Manual skill can be acquired only by experience, and is often ob- tained at great expense to the patient, and no little anxiety and 464 DISEASES AND INJURIES OF THE BLADDER. distress to the operator. Hence, however well prepared by education and habit, his first attempt will not probably be the most brilliant, or the most gratifying to his vanity. The patient will be likely to be kept unusually long upon the table; the wound will be too small, or the calculus will be attached, misplaced, or too large. In fact every reason is assigned for the delay but the right one. I recollect in my first case a number of minutes elapsed before clearance of the bladder was effected, and the patient untied. The delay arose from the difficulty I experienced in Avithdrawing the stone, which seemed to me, at the time, to be attached to the bas-fond of the bladder, but which, in reality, as I now believe, was only disproportionably large to my incision in the neck of the bladder and the prostate gland. Had this been a little longer, the extraction would probably have been effected in one-fourth the time. As it was, I was obliged to dilate it with the bistoury before I attained my object. The patient, however, had a speedy recovery; a circumstance which atoned, in some degree, for my dilatory movements. Of late years, a minute or two have sufficed to do the business; and, on one occasion, not long ago, I made my incision and extracted a calculus in thirty seconds. I have heard of a young surgeon consuming an hour and twenty-six minutes in the operation, although there was nothing un- usual in the case; and yet his patient recovered. In one of my own cases, I was nearly a quarter of an hour at work; but then there was an immensely deep perinseum, and an excessively elon- gated bladder, with fifty-four calculi. It is not always the most rapid and brilliant operation that is the most successful. Le Cat cut half a dozen individuals in nearly twice as many minutes, and lost nearly every one. Rapidity is certainly highly commendable; but it should never be at the expense of the patient's safety. No lithotomist should cut against time. His motto should be "festina lente," slow haste. He should feel his way in every step of the operation; and never, for a moment, lose his self-possession. A great deal depends upon one's assistants in this operation. If these are experienced, or well-trained, everything moves in concert; the patient is thoroughly held upon the table, the limbs are properly secured, the staff is in its right place, and the instruments are handed in the order in which they are needed. If an artery spring, a finger is ready to compress it; in short, all the surgeon's wants are anticipated. Thus, everything like confusion is prevented; the operation, once commenced, is proceeded with until it is completed. STONE IN THE BLADDER. 465 Much delay, of an unavoidable kind, may arise from the size of the stone, or from its situation in the bladder. For this the operator is not responsible. Vexatious delay is also sometimes occasioned by the protrusion of the rectum, at the moment the surgeon begins his incisions, or immediately after. For this, too, he is not blameable. The size of the wound, especially the deep portion, cannot always be regulated beforehand. It may require to be enlarged ; but this never seriously protracts the operation. In several of my cases, slight embarrassment arose from inordinate straining and bulging of the perinseum, the patient being at the time under the full influence of chloroform. /. After-Treatment.—As soon as the stone is extracted, and it has been ascertained that there are no bleeding vessels requiring a liga- ture, the patient is untied, sponged, and carefully carried to bed by one or two assistants. As he is obliged to remain in the recumbent posture from ten to twenty days, it is very important that he should be rendered as comfortable, in every respect, as possible. The bed upon Avhich he is to lie, and which should always be properly arranged' before the operation, should be provided with slats and a cotton, moss, or hair mattress. Feathers are never to be used, as they permit the nates to sink into them, and keep both part and system too warm. The mattress is covered with a sheet, over which is spread a large piece of soft oil-cloth, to protect the bedding from urine and blood. Another sheet, folded several times, and arranged so as to make the middle of it correspond with the buttocks, is placed upon the top of the oil-cloth, and serves to ward off pressure, and receive the secre- tions as they flow from the wound. The head and shoulders should be slightly elevated by a pillow. My experience has taught me that it matters little, if any, what posture the patient assumes after he has been put to bed. I usually, however, request him to lie on his right side for the first five or six hours, to afford the lips of the wound an opportunity of becoming glazed Avith lymph before he is obliged to urinate. At the end of this period, and, indeed, often much earlier, I permit him to rest upon his back, or upon either side, as may be most agreeable to him. Young subjects, unless they are incessantly watched, will seldom remain in the same posture beyond a few minutes, and I must con- fess I have yet to see a case in which any detriment resulted from this source. It is equally unnecessary, in my judgment, to tie the patient's 30 466 DISEASES AND INJURIES OF THE BLADDER. knees together after the operation is over, and he has been put to bed; or to introduce a tube into the bladder by the wound, for the purpose of conducting off the urine, and thus preventing infiltration of the surrounding cellular tissue. This expe- dient, which was already insisted upon by Col- lot, early in the last century, and which has been advocated, as a rule of practice, by some highly respectable surgeons of the present day, can neither be necessary nor proper, except in those cases in which the incisions have been made, either through inadvertence or design, unusually extensive. When the operation has been properly performed, or when the parts have been divided with the requisite care and atten- tion, such a contingency must be exceedingly rare. Indeed, I consider the practice not only as useless in reference to the object proposed, but as eminently cal- ' culated to prove mischievous. The contact of the tube with the sur- face of the bladder must necessarily tend to excite inflammation of the mucous membrane, to create pain and spasm at the neck of the organ, to fret and irritate the wound, and to produce a constant desire to pass water. No surgeon at the present day thinks of interposing a tent between the lips of the wound, or of applying cataplasms, cold lotions, or warm fomentations for promoting its cure. Such practice has been long since exploded, and is not likely to be ever revived. The rule here is, as in all similar cases, to keep the parts cool and unencum- bered. The urine sometimes begins to flow by the wound in a few minutes after the operation; but in general little or none passes for the first four or five hours. It then usually comes away in a gush, attended frequently with severe pain and spasm of the neck of the bladder. The first discharges are commonly sanguinolent, and therefore leave a characteristic stain upon the sheet. By the end of the first day the edges of the wound are generally so much swollen that the urine ceases to flow through the perinseum, and takes the course of the urethra. This, however, rarely continues beyond twenty-four or thirty-six hours, when the tumefaction alluded to has usually so far subsided as to allow the fluid to flow in its original direction, not in gushes, but in an occasional stream, or drop by drop. The period STONE IN THE BLADDER. 467 at which the urine begins to pass off permanently by the urethra varies from ten to fourteen days. Occasionally, however, I have known it to happen as early as the eighth day, and as late as the twentieth. The change in the direction of the fluid is generally attended with more or less pain at the neck of the bladder, and a scalding, smarting, or burning sensation in the urethra and head of the penis. The treatment after the operation must be strictly antiphlogistic. The patient is kept quietly upon his back, and all excitement, both bodily and mental, is sedulously guarded against. The pain conse- quent upon the operation is often extremely severe, and is generally referred to the neck of the bladder. It is of a cutting, darting, or burning character, and is either continued, or it comes on in frequent paroxysms. It generally makes its appearance immediately after the operation, and is sometimes so severe as to cause the patient to scream out at the top of his voice. To arrest this suffering as speedily as possible, as well as to allay the general agitation which is so frequent a concomitant of lithotomy, a full anodyne should be ' administered, generally within a few minutes after the patient has been removed to his bed. If he be an adult, he should take not less than one grain of morphia or its equivalent of solid opium or lauda- num. To administer a smaller dose than this would only be tempo- rizing. The pain must be allayed promptly and effectually, otherwise it may be productive of serious mischief, such as exhaustion, con- vulsions, or inflammation. Demulcent drinks should be used freely throughout the treatment, especially during the first few days. They not only allay thirst, but what is of great importance, they dilute the urine, and diminish its acrid qualities, thus rendering it more acceptable both to the bladder and the wound. They may consist of elm-bark water, flaxseed tea, or gum arabic water, and they may be simple, or combined with nitrate of potassa, bicarbonate of soda, or dilute nitric acid, according to the particular indication of each case. The diet must be light, unirritant, and of the most simple kind. For the first few days, the patient should take little else than water- panada, thin gruel, or weak chicken broth. After that he may use a little rice, toast and tea, a few crackers, or a small quantity of mush and milk. No meat or vegetables should be permitted under twelve days or a fortnight. It should be remembered that the slightest indiscretion in diet may greatly retard recovery, or even 468 DISEASES AND INJURIES OF THE BLADDER. jeopard life. The patient should consider himself as an invalid, and govern his appetite accordingly. Of course, there are excep- tions to all rules. Thus, a patient may be in such infirm health as to require a nourishing diet, tonics, and stimulants, from the very commencement of the after-treatment. Much judgment is doubtless required to enable the practitioner to decide when such a plan is proper, and it is obvious that no specific rules can be laid down for his government. In all cases I make it a rule to prevent any action of the bowels for the first three days. I have always pursued this practice under a conviction that the less the rectum is disturbed the better it will be for the bladder. For this purpose I invariably give a full anodyne immediately after the operation, even where it may not be necessary on account of the pain and general agitation. Where care is taken to clear out the alimentary canal thoroughly before the operation, the patient cannot suffer any possible inconvenience from the want of an evacuation during the period here specified. At the end of this time I generally order a dose of castor oil, or Epsom salts, assisted, if the purgative is tardy in its action, by an enema of tepid soap-suds. The same, or other means, may be resorted to afterwards to keep the bowels in a soluble condition. If, during the progress of the case, the patient's tongue becomes coated, and his appetite impaired; or if his general health suffers; or he does not improve as well and as rapidly as he ought; or, finally, if the urinary secretion is loaded with mucous and earthy matter; the best remedy he can use is a dose of calomel, which often, in these circumstances, acts like a charm in promoting recovery. The sheet under the buttocks is frequently renewed, and every possible attention paid to cleanliness. Sometimes the patient's com- fort is greatly promoted by a soft sponge, or an old napkin placed beneath the perinseum, and arranged so as not to compress or ob- struct the wound. The urine is thus imbibed as fast as it flows off, and the consequence is a less frequent necessity for a change of bed and body clothes. Excoriations of the nates and neighbouring parts must be prevented by frequent ablutions ; and the scrotum must be kept out of the Avay of the Avound by a suspensory bandage. During the progress of the treatment, it sometimes happens that the edges of the wound become incrusted with earthy matter, forming a thin, whitish sheet, which adheres quite firmly to their surface. The occurrence is not productive of pain; but, as it prevents the STONE IN THE BLADDER. 469 formation of healthy granulations, it serves to retard the reunion of the parts, and should, therefore, be promptly attended to. The de- posit is of a phosphatic character, and hence the best remedy is the nitric acid lotion, in the proportion of about four drops to the ounce of water, applied by means of a folded cloth. Where the incrustation extends far back, the fluid may be injected once or twice daily into the bladder. In most cases, the local application should be aided by the internal exhibition of the remedy.. When the wound is tardy in healing, or has contracted to a mere orifice, a catheter ought to be permanently retained in the bladder, to conduct off the urine through the natural channel. The walls of the urethra being then equally distended, and the sides of the wound compressed, a cure sometimes follows in a few days. g. Statistics.—We might next give statistics of the results of the lateral operation; but I am not certain that such a course would, in the present state of the science, be of any real value to the reader, imperfect and unsatisfactory as it would necessarily be obliged to be. To form anything even like a correct average estimate, it would be necessary for the compiler of such an account to have at his com- mand the data furnished by the operations, not only of the principal hospitals, but also of the principal private lithotomists in different parts of the world. With such means and facilities it might be pos- sible to arrive at an approximative estimate, but this would be all. Those who have looked into the statistical tables and facts that have been supplied from time to time, must have been struck with the re- markable discrepancies of the successes and failures of different operators, and the utter impossibility of deducing from them any useful practical precepts. That this should so be, is not surprising, when Ave reflect upon the circumstances which tend to influence the results of the operation. These circumstances are numerous and diversified in their character; but the most important are referable, first, to the skill of the surgeon; secondly, to the manner of pre- paring the patient's system; thirdly, to the age and health of the patient; fourthly, to the nature and volume of the concretion, and its situation in the bladder; and, lastly, to the selection of our cases. Children and elderly persons are, all other things being equal, better subjects for the operation than adolescents, or adults, between the ao-es of tAventy-five and fifty; a large or an encysted calculus will be more likely to produce mischief, during its extraction, than one that is small, or free; and a sickly individual, or one whose constitution 470 DISEASES AND INJURIES OF THE BLADDER. has been impaired by protracted disease, will run more risk than a healthy one. Then, again, a great deal apparently depends upon sheer luck. Thus, an operator will occasionally have the good for- tune to cut twenty or thirty cases in succession, without, perhaps, losing a single one, and he is disposed to congratulate himself upon his infallibility; all at once, however, the tables are turned against him, and the next two or three patients slip through his hands, and that, too, perhaps, withou^ any appreciable cause. His good luck has forsaken him, and by the time he reaches his fiftieth case he has the mortification to see that his victories, like those of a skilful gene- ral, have not been achieved without a certain number of victims. It has been calculated that about one patient out of every five that are cut for stone by the lateral method perishes ; and this esti- mate, taking the general average result, is, perhaps, pretty near the truth. Considered, however, with reference to individual operators, it is incorrect. Thus, taking the results furnished by some of our own lithotomists, it will be found that they afford a much more grati- fying picture. Dr. Dudley, for instance, is said to have lost only 5 cases out of 180 cut up to the beginning of 1846 ; Dr. Mettauer, of Virginia, 2 out of 73; Dr. John C. Warren, of Boston, 2 out of 30, of which three, however, were by the bilateral method; and Dr. Gibson, of Philadelphia, 6 out of upwards of 50. My own cases, amounting to 24, have all been successful. I invariably use the knife ; while Dudley and Gibson employ the gorget. In the Penn- sylvania Hospital, at Philadelphia, between 1752 and 1848, 83 cases of stone were cut by the lateral method, and, except in a few instances of very young children, by means of the gorget. Of this number, 72 were cured, and 10 died; 1 being set down as re- lieved.1 h. Relapse and Repetition of the Operation.—When it is con- sidered that most vesical concretions have their origin in the kid- neys, or, at all events, that these organs are often cotemporaneously affected, it is not surprising that the disease should occasionally return after operation. What number of cases relapse after being lithoto- mized, is a point for the determination of which we have no positive or reliable data. Nor is our information any more certain as it respects the period at which the malady reappears. In two of my cases, the time was very short; in one, it did not exceed four weeks. 1 Dr. Norris's Report on Surgery, Trans. Amer. Med. Assoc, vol. i. p. 163. STONE IN THE BLADDER. 471 When this happens, the vesical affection is always, as a general rule, complicated with renal disorder, resulting in the formation of con- cretions, which gradually descend into the bladder, where their pre- sence is speedily followed by a reproduction of the previous symp- toms. This circumstance Avas strikingly evinced in the instance of Alexander, from whom I extracted two calculi, with only very tem- porary relief, and whose kidneys, in less than a year after the operation, Avere literally filled with calculous matter; at the same time that the bladder contained eleven distinct concretions, from the volume of a millet seed to that of a small filbert. In such a case, there evidently exists a calculous diathesis, which no treatment, whatever be its character, can correct or arrest. It is worthy of notice that the new stone, especially when rapidly formed, is usually very soft and fragile, breaking under the gentlest pressure of the forceps. The case is quite different when the relapse is occasioned by an imperfect clearance of the bladder. The accident, fortunately infre- quent, has happened to good operators, and is not always avoidable, especially Avhen there are several concretions, of which one is ex- tremely small; or when there is only one, and a spiculum, or frag- ment breaks off, and hides itself, as it were, between the folds of the bladder, or in the bas-fond of the viscus. Injection of the viscus Avith a large syringe and a full stream of water is the best guarantee against this contingency. Should recurrence of the symptoms take place, no time must be lost in ascertaining the real condition of the bladder. If the concretion is small, extrusion is promoted by dilatation of the urethra; if this fail, lithotomy is again employed, and now, if possible, with greater care, to insure future immunity. A case occurred to Dupuytren in which he cut twice in three days. Sir Astley Cooper operated three times in one case, and his nephew, Mr. Bransby Cooper, also, upon another individual, within the space of four years. Dr. Van Buren informs me that Dr. Mott has, on three occasions, operated a second time on the same patient, and that one of the cases had a fatal issue. But the most remarkable instance of this kind upon record is that reported by Mons. Clever de Maldigny, a military surgeon, at a meeting of the French Institute, in May, 1827.l In a paper on 1 Revue Me"dicale, June, 1827 ; London Lancet, vol. xii. p. 556. 472 DISEASES AND INJURIES OF THE BLADDER. lithotomy, read before this learned body, he stated that he had been the subject of stone not less than seven times, and that he had six times undergone the lateral operation, namely, at the age of six eight, eighteen, twenty, twenty-two, and twenty-four years. The sixth time, the stone was situated at the neck of the bladder, and the patient cut himself, a glass being placed between his legs, to enable him to direct the bistoury in the course of the cicatrice of the previous incisions. The calculus was extracted Avith the fingers. In his seventh attack, he had recourse to lithotrity, which Avas suc- cessfully performed at four sittings, by Dr. Civiale. Subsequently, Clever was operated upon for stone the eighth time.1 When the perinseum has been repeatedly cut for the removal of stone from the bladder, the resulting cicatrice is apt to become preternaturally dense, and to offer more resistance to the knife than the healthy tissues. The part occasionally remains tender for a long time, and in some instances it has been known to be the seat of neuralgic pain. A second operation has often permanently cured a small but intractable fistula left by the first. i. Cases of Stone relieved by the Lateral Operation.—As a sort of appendix to this article, I am induced to subjoin a brief history of twenty-four cases of urinary calculi successfully relieved by the lateral method. They may prove interesting, not only to young lithotomists, but perhaps also, to those of riper experience. Every example of this kind is a real contribution to surgical science. I regret it is not in my power to present an account of the chemical analysis of the different concretions removed in these operations. At some future period, perhaps not remote, I hope to be able to do this. Case I.—William Mountjoy, tAvelve years of age, a resident of Hickman County, Kentucky, had symptoms of stone from his earliest childhood. He was always puny and fretful, and frequently com- plained of chilly sensations in the lumbar region, for the relief of which he was in the habit of sitting with his back towards the fire. Upon sounding him, in the presence of his uncle, Professor Miller, I at once detected a calculus, apparently of large size. His system being properly prepared, by a short course of diet, and the use of mild purgatives, I cut him early in February, 1841, in presence of the medical class of the University of Louisville. The stone proved 1 Lond. Med. and Surg. Jour., New Series, vol. v. p. 264. STONE IN THE BLADDER. 473 to be of large volume, considering the age of the patient, and some minutes elapsed before I could effect extraction; I thought at the time that it was attached to the bas-fond of the bladder, and this belief was strengthened by the fact that its surface was partially incrusted with fibrin. Still, I could not be certain that it did ad- here, and, in reflecting upon the case afterwards, it occurred to me that the difficulty might have been occasioned by two small an open- ing in the neck of the bladder and the prostate gland. No blood was lost in the operation; a large quantity of sabulous matter was discharged through the incision for some time after, but in other respects everything went on favourably; the urine began to pass by the urethra on the thirteenth day, and by the eighteenth it ceased to flow altogether through the wound, which was completely cicatrized in less than four weeks. Mountjoy has had no symptoms of stone since the operation, a period now of ten years. His health is excellent in every respect, and he is able to endure much fatigue and exposure on the farm, on which he labours. Case II.—George R. Fellice, aged four years, born of healthy parents, in Trimble County, Kentucky, came under my care in December, 1841. The part of the country in which he lives abounds in limestone. His health was good until ten months ago, when he began to complain of uneasiness in the pubic region, and of pain during micturition, accompanied with violent itching in the foreskin, tenesmus, and sudden stoppage of the flow of urine. About eight weeks after this, prolapsion of the bowel occurred, and added greatly to the local distress. The urine was loaded with mucus, and usually mixed with a little blood; it was generally voided in small quanti- ties at a time, and often passed off involuntarily; the skin of the scrotum and perinseum was excoriated, and the little patient was thin, irritable, and slightly feverish, especially at night. At my first visit to him, on the 18th of the month, I directed him to take eight grains of calomel with a third of a grain of opium and half a grain of ipecacuanha, together with a hot foot-bath, and an enema of twenty-five drops of laudanum at bedtime. In the morning, this was followed by half an ounce of castor oil, to clear out the bowels; and, afterAvards, by a strong infusion of uva ursi and hops, of which he took an ordinary-sized wineglassful, with eight grains of bicar- bonate of soda, every six hours. The diet Avas also carefully regu- lated. Upon sounding him, a few days after, the instrument readily 474 DISEASES AND INJURIES OF THE BLADDER. came in contact with a calculus. Under the above treatment, the local distress gradually abated; the appetite improved, there was less fever, and the sleep was more tranquil. On the 23d, while labouring under the effects of a dose of oil, the patient passed several large lumbricoid worms. The operation was performed the next day at 12 o'clock, before the medical class of the University of Louisville, Dr. Doune holding the staff. Nothing unusual occurred during its performance except violent prolapsion of the bowel and a free discharge of fsecal matter ; the stone, which was easily enough extracted, was of a flattened oval form, rough on the surface, of a light colour, and about the size of an ordinary marble. Severe pain was complained of immediately after the patient was put to bed, for which he took forty drops of laudanum. At 9 o'clock in the even- ing, he had some fever, a dry, hot skin, and a full, frequent pulse, but no pain. The next morning the patient was thirsty and some- what restless, and complained of slight pain in his bowels, for which fomentations of hops were applied to the abdomen, and half an ounce of oil administered. In the evening, the medicine produced several free alvine discharges, together with a lumbricoid worm, and the griping entirely disappeared. A fourth of a grain of morphia was given at bedtime in a tablespoonful of the spirit of Mindererus, with the effect of inducing sleep and perspiration. From this time on nothing of peculiar interest in the case occurred, except that the pulse continued to be preternaturally frequent, that there was occa- sionally slight febrile excitement, and that the little patient was sometimes annoyed with flatulence and colicky pains. On the 31st of December two more worms were discharged. The wound all along looked well; the urine passed off freely by the urethra on the 7th of January; and on the 11th of the month it ceased to flow by the wound, which was healed entirely in a few days more. Case III.—William Davis, aged three years and two months, a native of Louisville, Kentucky, the son of a hack driver, always en- joyed good health until four months ago, when his parents noticed that he experienced pain in urinating. His suffering increased in violence, and the urine passed off involuntarily in drops. He had, at the same time, severe itching in the prepuce, pain in the peri- nseum, and excessive tenesmus, with prolapsion of the bowel. The parts in the neighbourhood of the penis were excoriated, from the acridity of the urine. I sounded this boy, for the first time, on the 14th of January, 1842, and afterAvards repeated the operation six STONE IN THE BLADDER. 475 times before the existence of a calculus was satisfactorily ascertained. Lithotomy was performed on the 1st of February, in the presence of the medical class, and of Doctors Drake, T. L. Caldwell, S. R. Richardson, Colescott, and Doune, Avho held the staff. The bladder was easily reached, though some delay arose in consequence of the great protrusion of the rectum, and the violent action of the anus. The stone, hardly as big as a common filbert, was of an irregular shape, and of a grayish colour. Owing to his struggles during the operation, the little patient was considerably exhausted, and some time elapsed before reaction was fully established. He took twenty- five drops of laudanum immediately after being put to bed, which soon composed him. No unpleasant symptoms occurred after the operation; the bowels were opened at the end of the third day with castor oil; on the tenth, the urine began to pass off by the urethra, and on the twenty-fourth the wound Avas completely cicatrized. For some time after the operation the little patient remained well; but by degrees he became thin and puny, and began to suffer from irritability of the bladder, with frequent pains in the lumbar region. The symptoms gradually increased in violence, and he died in eighteen months from the time he was cut, in a state of excessive emaciation. On dissection, I found the bladder entirely sound and free from cal- culous deposit; the ureters also were healthy, and so was the right kidney. The left kidney was nearly twice the natural size, and con- tained a concretion as large as an ordinary hazel-nut; the organ ad- hered firmly to the outer surface of the descending colon, which was perforated by a small opening, the edges of which had a dark, gan- grenous appearance. Case IV.—Reuben Dowler, aged 17 years, came to Louisville in March, 1842, from Muhlenberg County, Kentucky, of which he is a native, to request my advice for what his physician supposed to be stone in the bladder. He had laboured under well-marked symptoms of this affection nearly half his life; and latterly his sufferings had been of the most constant and cruel nature. Notwithstanding this, how- ever, his general health seemed to be but little impaired, and in the intervals of his pains, Avhich had much of a neuralgic character, he was quite cheerful. He had been obliged, for some months past, to void his urine from tAventy to thirty times in the tAventy-four hours, and the efforts were always attended with severe spasm at the neck of the bladder, and scalding along the urethra. The prepuce, from the constant traction exerted upon it, was unusually elongated, and 476 DISEASES AND INJURIES OF THE BLADDER. the lower bowel was almost habitually prolapsed. He had been brought up on a farm, but had never been able to work hard, and for the last two years he had been much confined to the house, from an inability to walk and ride. He had an attack of intermittent fever at the age of eleven. A stone having been detected, and the system being properly prepared, I performed the lateral operation on the 14th of March, removing a calculus of a rounded shape, about the volume of an ordinary marble, and weighing nearly five drachms. A portion of the concretion broke off in the bladder during the attempt at extrac- tion, and had to be removed with the scoop. The only annoyance that occurred during the operation was the violent protrusion of the rectum, which compelled me several times to replace it, before I could make my deep incisions. The patient suffered for several days from his former pains, but under the use of opiates and carbonate of soda, they gradually abated in severity, and at length entirely dis- appeared. The urine passed off by the natural channel on the nine- teenth day, and the wound was entirely healed in a little less than four weeks. Case V.—May 20th, 1843. James Doran, six years of age, was brought to me to-day by his father, a farmer of Washington County, Indiana, on account of excessive and frequently recurring pains in the region of his bladder, accompanied latterly with an almost con- stant desire to urinate. The boy was considerably emaciated, had but little appetite, and had suffered, during the last few weeks, from diarrhoea. The vesical symptoms had existed for nearly two years. He had been rather puny from his birth, though he had never expe- rienced any severe illness. I sounded him forty-eight hours after his arrival in town, and, after some difficulty, detected a calculus, situated apparently a considerable distance from the neck of the bladder. He bore the operation badly, but contrary to my expecta- tions, he Avas quite comfortable the following morning, having passed a good night under the influence of the anodyne he took at bed- time. Six days having been spent in preparing the system, I opened the bladder by the lateral method, and extracted a calculus of an ovoidal form, the weight of which was a little under three drachms. Every- thing passed off well during the operation, and nothing worthy of note occurred afterwards ; the water began to flow off by the penis on the eighth day, and by the end of the fourteenth it had ceased to STONE IN THE BLADDER. 477 pass off by the Avound, which was firmly closed at the beginning of the fourth week. The lad rapidly regained his general health, and has had no return of his complaint since. He was born and reared in a limestone region. Case VI.—Mr. Mount, of La Grange, Kentucky, seventy-seven years of age, short and stout, of a strong, healthy constitution, and a farmer by occupation, applied to me in December, 1843, for an affection of the bladder, for which he had been treated by Dr. Drane, a distinguished practitioner of New Castle. Symptoms of vesical disease were first noticed ten months ago. He was sounded several times by Dr. Drane, who detected the presence of a calculus in the first examination, but in none of the others. At the request of this gentleman, the patient came to Louisville, to obtain my opinion upon his case. Being in excellent general health, I sounded him soon after his arrival in town, and at once came in contact Avith a stone, which seemed to be quite small, and which emitted, when struck, a singularly clear, metallic noise. When the patient stood up, the calculus descended to the neck of the bladder, and could be distinctly felt through the rectum. For some months he had laboured under excessive irritability of the bladder, with frequent desire to urinate. Ten days before his arrival in Louisville, he set out in a carriage to visit me, but after travelling five miles he Avas obliged to return home on horseback, sitting sidewise on his saddle, on account of the great aggravation of his local suffering. At my suggestion, he was put on the free use of uva ursi and hop tea, with bicarbonate of soda and potash, under which the irritability of his bladder rapidly subsided, and in a week he Avas able to ride from La Grange to Westport, a distance of twelve miles, without suffering or inconvenience. The frequency and difficulty of micturition had also much diminished. After keeping Mr. Mount on low diet, and purging him gently for a Aveek, I cut him on Saturday, December 17th, in presence of Pro- fessors Drake and Miller, and of Drs. Colescott, of Louisville, Sim- mons, of St. Louis, Duncan, of NeAV Orleans, and Borland, of Mem- phis, extracting fifty-four calculi, varying in size from that of a pea to that of a partridge egg. All, excepting one, seemed to be en- cysted at the superior fundus of the bladder, which was immensely elongated, extending nearly to a level with the umbilicus. The forceps and scoop were introduced at least thirty times, and not a little difficulty Avas experienced in rupturing the cyst and detaching the calculi. The perinseum was fully four inches and a half thick 478 DISEASES AND INJURIES OF THE BLADDER. and it was scarcely possible for me to touch the neck of the bladder with the point of my forefinger. The operation, which lasted twenty-five minutes, was well borne by the patient, and was unat- tended with any accident. Immediately after the operation, the patient complained of severe pain at the extremity of the penis, for which he took half a grain of morphia every two hours until relief was afforded, which happened after the third dose. He slept well during the night, and the urine passed off freely by the wound; there was some thirst, and a little tenderness in the hypogastric region. On Sunday night, the patient had a slight chill, but in the morning his skin was moist and cool, and he expressed himself as quite comfortable. As he was weak and hungry, I ordered chicken-broth for him, of which he partook freely, with manifest advantage. In the evening, the urine, which had hitherto passed entirely through the wound, was observed to floAv, partly through it, and partly through the natural route. From this period on, the patient rapidly improved, and in less than ten days, despite my utmost remonstrance, he dressed himself and started for home. Fortunately, he suffered no inconvenience from his pre- mature exposure; he reached his residence in safety, and rapidly improved in flesh and vigour. Six weeks after the operation, while apparently in excellent health, Mr. Mount was suddenly seized with apoplexy, which terminated his existence in a few minutes. No examination being permitted, the condition of the urinary organs could not, of course, be ascertained. Dr. Hugh Rodman, who saw him occasionally after he left Louisville, informed me that he was free from all his former suffering, and that the wound was entirely healed, except at its upper part, where there was a little opening, scarcely big enough to admit the finest probe. Case VII.—John Stinson, aged five years, a native and resident of Gallatin County, Illinois, has had symptoms of stone for the last twenty months. He Avas sounded six weeks ago by a physician of the neighbourhood, but no stone was discovered. When he arrived in Louisville, in April, 1844, he had the appearance of being in good health, and but for his urinary difficulty no one would have suspected he Avas sick. He was stout and robust, well-grown for his age, and enjoyed good appetite and sleep. His father was a carpenter, and lived in a limestone region. I sounded this boy three times before I was fully satisfied he had a stone. As his general health seemed to be good, there was no STONE IN THE BLADDER. 479 reason for delaying the operation, and I accordingly cut him four days after his arrival in town. The calculus was of an irregularly oval figure, and hardly as large as a common hazel-nut. No unplea- sant symptoms succeeded, and he was well in less than three weeks; the urine passing entirely by the natural channel by the end of the twelfth day. Case VIII.—May 19th, 1844. Elias Elam, ten years and a half old, the son of a blacksmith of Crittenden County, Arkansas,—a limestone region—has complained, for the last three years, of a fre- quent inclination to void his urine, accompanied with spasm at the neck of the bladder, and great distress in the prepuce. On several occasions, the urine has been bloody, especially after rough exercise. The general health is little affected, the countenance being full and ruddy. Ho has never had fever of any kind, though he has always lived in a malarious district. His father has never been seriously ill; his mother died a few years ago of pulmonary phthisis. Having assured myself of the presence of a calculus, I cut Elias on the sixth day after his arrival in town. Two circumstances served to annoy me during the operation: one was the prolapsion of the bowel, and the other the fracture of the stone under the pressure of the forceps. Little delay, however, was occasioned by either of these accidents, and the operation was completed in good time. Hardly two ounces of blood were lost. The lad experienced severe pain shortly after the operation, for which I gave him fifty drops of lau- danum, under which he became gradually easy and tranquil. The next day he was somewhat feverish, and complained of slight tender- ness in the hypogastric region. To relieve these symptoms eight grains of Dover's powder were administered, and warm fomentations applied to the abdomen. On the third day, he took a dose of castor oil, and from thence on he had no further use for medicine of any kind. The water passed off wholly by the urethra by the fifteenth day, and in three Aveeks and a half the wound was completely cica- trized. Case IX.—J. Peters, aged 27, a resident of Hardin County, Ken- tucky, a thin, slender man, of middle stature, came to Louisville in October, 1845, with symptoms of stone, under which he had suffered, more or less severely, ever since his second year. His general health Avas much impaired, and he had never been able to attend to any regular business. For years past, he was obliged to void his urine, on an average, from fifteen to twenty times in the twenty-four hours. 480 DISEASES AND INJURIES OF THE BLADDER. Latterly, micturition had become much more frequent. On his arrival in town, the urine deposited, upon standing for a short time, a con- siderable quantity of mucus, and was always expelled with a good deal of pain and difficulty. The body exhaled a peculiar urinous odour. As Peters had come to town on foot, a distance of about sixty-five miles from his residence, I deferred sounding him until he had recovered entirely from the fatigue of his journey. Upon intro- ducing the sound, I easily detected what I supposed to be a tolerably large stone. The operation, although performed with the greatest gentleness, was followed, in a short time, by violent pain in the blad- der, and great tenderness in the hypogastric region, with rigors and high fever. Nearly three weeks elapsed before he fully recovered from its effects, which I was apprehensive, at one period, might prove fatal to him, and which yielded only to the most careful treatment, such as vesication of the abdomen and the internal exhibition of calomel and opium, folloAved by tonics and a nourishing diet. As soon as the effects of the sounding had fairly passed off, I per- formed the lateral operation of lithotomy, in presence of the medical class of the University of Louisville, and extracted a calculus of a round form, and nearly four inches in circumference. No untoward symptoms arose until the end of the third day, when a troublesome diarrhoea supervened, and the wound assumed an erysipelatous aspect; in twenty-four hours after it gave vent to fsecal matter, thus showing the existence of an opening between it and the bowel. That this communication was the result wholly of the sloughing process, and not from any improper interference of the knife, is evinced by the fact that Peters had not less than eleven passages previously Avithout anything issuing at the Avound. The patient, whose pulse had become weak and faltering, was promptly put on calomel and opium, with quinine and milk punch, under the use of which he gradually regained his strength; the erysipelas slowly disappeared, and in less than four weeks the wound was entirely healed. When he left town, his gene- ral health was greatly improved, and the only inconvenience he expe- rienced was a discharge, at long intervals, of a small quantity of urine by the rectum. I learned, several months after his return home, that the fistula had entirely closed, and that he was enjoying excellent health. He has suffered no relapse. Peters was from a limestone region. Case X.—Edwin Marshall, aged nine years, a native of Critten- den County, Kentucky, was affected from his earliest infancy until STONE IN THE BLADDER. 481 lie was two years old, with diarrhoea and scald-head. He lived in a limestone region. In 1840 he was seized with symptoms of stone, soon after an attack of scarlet fever, from which he suffered severely. The local distress became gradually more and more aggravated, though his appetite and general health continued to be good. At intervals, at first, of several weeks, and afterwards, of several months, he experienced violent neuralgic pains, coming on in pretty regular paroxysms every day, and usually lasting about a fortnight before they disappeared. His suffering, which was excruciating as long as the paroxysms continued, was referred chiefly to the head of the penis and the neck of the bladder, and was attended with a con- stant desire to pass water, which came away either in drops, or in very small quantity at a time. In the intervals of the paroxysms, he urinated less frequently, but still oftener than naturally; at night, he always wet the bed. After subjecting him, for a week, to a course of preliminary treat- ment, I operated upon this lad on the 22d of November, 1845, in presence of the medical class, and extracted a small oxalic acid cal- culus, of a black colour, and with a remarkably rough surface. Soon after being put to bed, he was attacked with violent pain, seated chiefly in the wound and the head of the penis. A few days subse- quently, his neuralgic symptoms returned, the paroxysms coming on every evening, and continuing from one to two hours, being attended with the most severe distress at the neck of the bladder, as well as in the external wound, which, however, looked perfectly healthy all the time. Under the use of quinine and Fowler's solution of arsenic, the neuralgic paroxysms speedily subsided, and did not afterwards recur. The water began to flow through the urethra on the eleventh day, and by the sixteenth it passed off entirely in that direction. At the end of the third week, the wound being nearly cicatrized, the patient was taken home. He has had no symptoms of urinary disease since. Case XI.—Patrick Phalan, six years of age, of a sanguine tem- perament, short stature, son of a drayman, and a native of Ireland, from Avhich he emigrated to this country when ten months old, was brought to me by his father in the summer of 1846, with symp- toms of stone. After he reached America, he lived one year at Quebec, and afterAvards, for twice that period, at Pottsville, Penn- sylvania ; since then he has resided at Louisville. He was always very healthy till he was two years of age, Avhen he began to suffer 31 482 DISEASES AND INJURIES OF THE BLADDER. from difficulty in voiding his urine, which gradually increased in severity up to the time of the operation. I sounded him in June and readily detected a calculus. His general health was perfectly good at this time, but a year ago he had an attack of intermittent fever, which continued three months, when it disappeared, and he regained his accustomed strength. He has used lime water ever since he has been in Louisville. There is no calculous disease in any other member of the family. I cut Patrick, June 7th, 1846, in presence of Drs. Cochran, Richardson, Summers, Bozeman, Edgar, and Colescott, the latter holding the staff. The stone was hardly as large as a common gar- den bean, and its weight was only five grains.1 No accident occurred during the operation, and the wound was completely healed by the seventeenth day. The urine began to pass through the urethra on the fifth day, and on the ninth it ceased to flow by the wound. Although Patrick had a very rapid recovery, he has laboured under incontinence of urine ever since the operation. At night, or when recumbent, he holds his water perfectly and without difficulty, but when he stands up or walks about, it dribbles off constantly, and wets his clothes. He has no pain or soreness in the urinary organs, and his general health is excellent. I visited this lad last summer, four years after the operation, and found him as here described. I have proposed a regular course of treatment for his relief, but to this his parents will not consent. Case XII.—John Orrand, thirty years of age, married, a stage- driver by occupation, of Russellville, Kentucky, a limestone region, had a severe attack of fever about two years ago, attended with loss of consciousness and frequent involuntary discharges of large quan- tities of urine. During his convalescence, these symptoms abated somewhat in violence, but the urine now became bloody, and there was always more or less tenesmus in micturition. Particles of gritty matter, and an unusual amount of inspissated mucus were also fre- quently observed about this time in the chamber. In a word, all the symptoms of stone existed. When the patient arrived at Louis- ville in December, 1846, he was very much reduced in flesh and 1 An instance is mentioned, in a preceding section, in which the calculus, sup- posed to be the smallest ever extracted by operation, weighed ten grains. If I could have ascertained beforehand, in the above case, that the concretion was not larger than it proved to be after removal, I should certainly have performed lithotripsy instead of lithotomy. STONE IN THE BLADDER. 483 strength ; he had almost a constant desire to pass water ; the bowel Avas frequently prolapsed ; and there was excessive pain in the region of the bladder, darting along the perinseum, thighs, and groins, and accompanied by violent tenesmus at every effort at micturition. He had also a most distressing itching in the head of the penis, and latterly he was troubled with involuntary emissions of semen. The urine, on standing a short time, deposited a large quantity of thick, tough mucus, which, in a few hours, emitted a foetid ammoniacal odour. From the commencement of his illness until the time of the operation, he discharged altogether upwards of a pint of white cal- careous -matter, with an occasional concretion, from the size of a large pin's head to that of a pea. I cut Orrand on the 16th of December, and extracted a phospha- tic calculus, about the size of a pullet's egg. No accident occurred during the operation; for some days the patient remained weak, and required porter and a nourishing diet, but his flesh and strength gradually increased, and in three weeks the wound was nearly healed, all the urine being voided by the urethra. He went home early in January; for some time after he was much improved, but early in April, 1848, that is, fifteen months from the operation, his calculous symptoms returned, and his sufferings became nearly as great as ever. He now complained of great pain and weakness in his back, and constantly passed calcareous matter. When I last heard from him, his health Avas very bad, and no doubt existed as to the character of his disease. Case XIII.—William Stamper, aged seven years and a half, the son of a farmer in Jackson County, Tennessee, came under my care on the 15th of September, 1847, for an affection of the urinary bladder, under Avhich he had laboured for the last twenty-two months. The principal symptoms were, a frequent desire to make water, with great pain and burning in voiding it, occasional prolapsus of the rectum, and an inveterate itching at the head of the penis. These symptoms Avere ahvays most severe when the patient was in the erect posture, when the urine often dribbled away, so as to wet the clothes. The general health Avas not materially impaired; the appetite and sleep were good; and the countenance betrayed no signs of the local distress. A calculus, apparently small in size, was discovered on the first introduction of the sound. As the tongue Avas somewhat coated, I deemed it my duty to administer a dose of aperient medi- cine. On the morning of the sixth day, everything appearing 484 DISEASES AND INJURIES OF THE BLADDER. favourable, I performed the operation, and extracted a small calculus. A fourth of a grain of morphia speedily allayed the pain which followed the use of the knife, and the little fellow soon went off into tranquil sleep. The next morning there was a little excitement, but not enough to render it proper to give any medicine. In short, everything progressed most auspiciously ; the wound gradually con- tracted ; the urine passed off altogether by the urethra by the four- teenth day; and at the end of the third week the external opening was completely cicatrized, except at a single point, Avhich was still granulating. Case XIV.—May 9th, 1848. I was consulted to-day respecting Sidney West, a lad twelve years of age, a resident of Christian County, Kentucky, a limestone region. I learn, that, when quite an infant, he suffered for a long time from diarrhoea, and afterAvards, for nearly eighteen months, from constipation. At four years of age, he became affected with prolapsion of the anus, and difficulty in passing his urine, which was voided much more frequently than previously. Neuralgia of the bladder afterwards ensued, and greatly aggravated the local distress, which was particularly violent at night and in damp weather. As the disease advanced, incontinence of urine took place, the penis, from being habitually pressed and pulled, increased enormously in size, and the patient often used his fingers to prolapse the bowel, as this afforded him great relief in passing his water. During part of the time, the patient had severe neuralgic pain in his eyes, usually paroxysmal in its character, and always attended with vomiting. His general health remained good. Having ascertained the presence of a calculus by the sound, and spent six days in preparing the system, I performed the operation of lithotomy on the 15th of May. Some little difficulty was experienced in extracting the stone, in consequence of the contraction of the bladder, which took place in a degree which I never witnessed be- fore in any of my cases, and materially interfered with the expansion of the blades of the forceps. This was the more remarkable, inas- much as the patient had been under the full influence of chloroform. The urine, for the first three days, passed nearly all through the urethra, it then issued at the wound until the end of the second week, when it resumed its natural channel. The patient now began to sit up, and on the sixteenth day he left Louisville for home. The only medicine Avhich he took after the operation was an occasional dose of castor oil, to relieve his bowels. STONE IN THE BLADDER. 485 The calculus weighed one ounce and three quarters, and was nearly two inches in length by three-fourths of an inch in diameter ; it Avas hard, compact, of a brownish colour, slightly tuberculated on the surface, and of a flattened, cylindrical shape. Cask XV.—Talbot Hamilton, aged four years and four months, a native of Spencer County, Indiana, was brought to me by his father, in June, 1848, with stone in the bladder. He lives in a lime- stone region, and has been labouring under urinary symptoms since February, 1846. His suffering gradually increased in severity, and at length became almost intolerable; he often sought relief by lying upon his abdomen with a pillow under his chest, and at night he generally wet the bed ; the scrotum Avas red and inflamed ; the pre- puce slightly ulcerated ; the penis was unusually large, and the body exhaled a peculiar urinous odour. The calculus was readily detected by the sound, and was removed by the lateral operation on the 8th of June, the patient being under the influence of chloroform. Soon after being put to bed he took fifty drops of laudanum, to allay pain, and calm the system. About the eleventh day, the wound began to look pale and flabby, a little blood occasionally passed off with the urine, and the little fellow had a thin, sickly appearance. Brandy, quinine, a nourishing diet, and exercise in the open air were directed, and soon had the effect of improving his condition. On the six- teenth day after the operation the urine had ceased to flow through the Avound, and the patient left Louisville for his home in Indiana. From a letter received, on the 8th of July, from Dr. De Bruler, Avho had the kindness to send me the case, I learned that Talbot had very much improved in health, that he experienced but little pain in passing his urine, and that the wound was nearly entirely healed. Subsequently, late in October, the Doctor wrote me that the boy had been constantly getting worse for the last two months, and that he suffered quite as badly as before the operation, at the same time ex- pressing his apprehension that there was a return of the disease. Whether this Avas really the case, I am unable to say, as I have since received no further intelligence respecting him. Case XVI.—June 24, 1848. Claiborne Wadlington, twenty years old, a farmer by occupation, from Caldwell County, Kentucky, has had symptoms of urinary disease since his childhood, frequently attended Avith discharge of blood from the urethra. Last fall his suffering greatly increased in severity, and prevented him from Avorking, although his general health continued good. He voided 486 DISEASES and injuries of the bladder. occasionally small quantities of purulent matter, and had an almost constant inclination to pass his urine. Along with these symptoms he had excessive pain and itching in the prepuce and head of the penis. When he arrived in town, his general health Avas sensibly impaired, his hands and feet were habitually cold and clammy, his countenance was expressive of anxiety, and his body exhaled a peculiar urinous odour. The operation was performed on the 29th of June, in presence of Dr. Stone, of New Orleans, Dr. LeAvis, of Mobile, and a number of physicians of Louisville. In incising the skin and subcutaneous cellular tissue, I cut an artery, apparently the superficial perinseal, which bled so copiously as to require imme- diate ligation; the blood issued with astonishing impetuosity, and with a peculiar whizzing noise. No other impediment occurred to arrest my progress, and the stone, one of considerable volume, was readily seized and extracted. Everything went on well until the fourteenth day, when the pa- tient had a chill, succeeded by high fever; he had a similar attack the next day, only more violent, and of longer duration. Under the exhibition of quinine, the fever was speedily arrested, and the patient had no return afterwards. The urine passed entirely by the urethra on the twentieth day after the operation, and he soon after went home, in fine health and spirits. Wadlington was from a lime- stone district. Case XVII.—Albert Andrews, aged eight years and two months, of Henderson County, Tennessee,—a freestone district,—was always healthy until he was two years old, when he began to show symp- toms of urinary calculus, mild at first, but gradually increasing in violence. The urine Avas occasionally bloody, and the desire to void it became more and more frequent, especially during the last eighteen months. He has pain in the region of the prostate gland, itching at the head of the penis, occasional diarrhoea, and prolapsion of the bowel. His general health has, nevertheless, been quite good. I cut him, while under the influence of chloroform, on the 19th of March, 1849, extracting a calculus the size of a small marble, of a dark colour, and very rough on the surface. Thirty hours after- wards, he had some pain and tenderness on pressure in the hypo- gastric region, which were promptly relieved by a dose of oil, assisted by an enema. On the 31st of March, the urine had commenced flowing through the natural channel, and, in a few days after, it STONE IN THE BLADDER. 487 passed off entirely in that direction. He has remained well since the operation. Case XVIII.—Robert Rainey, twenty-two years old, tall, slender, and dark complexion, a resident of Barren County, Kentucky,—a limestone region,—a young man of temperate habits, first experi- enced difficulty in the bladder eight years ago. While engaged in quarrying stone, he was suddenly seized with a frequent desire to urinate, with sudden cessation of the stream of urine, and itching of the head of the penis. These symptoms continued, in a mild form, until he went to Mexico with our troops, in 1847, when, after a severe march for several days, they were so much aggravated that he was compelled to remain in bed for several months. After this period, until January, 1849, he was comparatively comfortable. His suffer- ing now increased, and early in May following he voided a small calculus. He arrived at Louisville on the 15th of June, 1849, and on the 18th I removed from him a rough, oval calculus, an inch and a half in length, by nearly one inch in thickness. Before put- ting the patient to bed, I was obliged to tie a small deep-seated artery, which continued to bleed for some minutes. It was easily seized with a pair of dissecting forceps. A few small clots of blood came away through the wound on the second day after the operation, and the urine flowed almost entirely by the urethra until the end of the third day. After that it passed again through the wound, till the ninth day, when it was discharged, partly in that direction, and partly along the natural channel. Two days after the operation, Rainey had a slight attack of cholera, which left him in a weak con- dition for some time. He left Louisville on the 11th of July, in the stage for Glasgow, in the neighbourhood of which he lived, the wound being nearly entirely cicatrized. The urine ceased to flow through the wound on the fifteenth day after the operation. Case XIX.—July 19th, 1849. To-day I was requested by my friend, Dr. Patrick Cochran, to visit with him, in the lower part of Louisville, George Schnetz, a stout, fat, healthy-looking child, three years and a half old, the son of a German foundry-man. The in- strument readily detected a calculus, symptoms of which had existed for the last eleven months. I performed the lateral operation on the 11th of August, extracting a concretion of a yellowish colour, ovoidal in shape, tuberculated on the surface, and weighing only sixteen grains. Nothing of any interest occurred, either at the time of the operation, or subsequently. The only medicine he took was a dose 488 DISEASES AND INJURIES OF THE BLADDER. of castor oil at the end of the third day. The wound healed rapidly, and by the fourteenth day all the urine was voided through the natural channel. The lad has enjoyed excellent health up to the present period, February, 1851. Case XX.—The subject of this case was M. L. Shelby, aged 22, a resident of Livingston County, Kentucky, a limestone region. TAvelve years ago he was attacked with scrofulous inflammation of the joints of the right, upper, and lower extremities, attended with protracted confinement and severe suffering. Since then he has had two attacks of congestive fever, but has never had " fever and ague." When about twelve years old, he first noticed that his bladder was affected, being the seat of occasional pain and hemorrhage, occurring at intervals of several months, for a number of successive years. These symptoms were at length succeeded by a discharge of muco- purulent matter from the bladder, and an inordinate secretion of urine, attended with great pain in the lumbar region. About a year ago, the urine became less abundant, but was observed to present a white, lactescent appearance. The perinseum and left buttock were the seat each, at a former period, of a fistula, the result probably of disease of the ischium. The former, at the time of my examination, was hard and firm, from interstitial deposit. His maternal grand- mother was troubled with a calculous affection of the bladder, but no other members of his family. Shelby came to Louisville in October, 1849, much shattered in health, and depressed in spirits; he was excessively emaciated, peevish, and fretful. He passed his urine, on an average, every half hour, and the bladder was so irritable that he was obliged to be sounded while under the influence of chloroform. Owing to these circumstances, I was compelled to postpone the operation for nearly a month, endeavouring, in the meanwhile, to prepare him for it by regulating his diet, attending to his bowels, and exhibiting soda along with hop and uva ursi tea. Finding that but little im- pression could be made upon his system, by these and other means, in consequence of the excessive distress in the bladder, which de- stroyed his appetite and sleep, I determined to cut him without fur- ther delay. Accordingly, on the 20th of October, assisted by Drs. Richardson, Colescott, Thomson, and Henry, I performed the lateral operation, removing a uric acid calculus, of the volume of a small walnut without its shell, the patient being under the influence of chloroform. No bad symptoms folloAved the operation; on the con- STONE IN THE BLADDER. 489 trary, the patient rapidly improved in health and spirits, and, under the use of milk punch and a nourishing diet, he soon gained flesh and strength. The wound contracted slowly but steadily; the urine gra- dually resumed its natural route, and, in less than three weeks, nearly the whole of it passed by the urethra. Three days after the operation Shelby was attacked with swelling of the body of the penis, accompanied with great hardness of the urethra, circumscribed, pain- ful, and exquisitely tender to the touch. This continued several weeks, but was gradually subsiding when he left Louisville, on Satur- day, December 15th. After his return home, his improvement was rapid, and, in less than three months, his restoration was complete. On visiting me last summer,—1850—I found him so fleshy that I did not, at first, recognise him. Case XXI.—Thomas Alexander, fourteen years of age, came to me on the 21st of November, 1849, from Henry County, Tennessee, Avith symptoms of stone in the bladder. With the exception of two or three mild attacks of intermittent fever, which is common in his neighbourhood, his general health was always good until several months ago. He lives in a freestone region, and is not aAvare that any of his immediate relatives have ever suffered from calculous dis- ease. He has always, from early infancy, had difficulty in voiding his urine, which he has, for some time past, been obliged to discharge every fifteen or twenty minutes, often mixed with blood. Within the last six months, he has passed several small concretions, and has suffered much from pain in the sacro-lumbar region. Being in good health upon his arrival in Louisville, I cut Thomas two days after, removing two stones, one of which, shaped somewhat like a squirrel's head, and as large as an ordinary apricot, projected into the neck of the bladder, and Avas extracted in thirty seconds from the moment the knife touched the integuments. The other was a little smaller, and Avas also promptly dislodged. No untoward symptoms occurred after the operation. On the 2d of December, the urine passed almost entirely through the natural channel, the wound was nearly closed, and the general health was gradually improving. On the 8th, he left for his home in Tennessee, in excellent condition, the opening being almost cicatrized, and permitting only a few drops of urine to escape through at a time. He Avas directed to live light, to pay attention to his bowels, and use an infusion, three or four times daily, of uva ursi and hops with bicarbonate of soda. Soon after reaching home, Thomas Avas taken worse; there was a 490 DISEASES AND INJURIES OF THE BLADDER. return of pain in the bladder, and he had great, and almost incessant distress in the region of the kidneys; with violent tenesmus, and a frequent desire to micturate; in short, he had again all the symptoms of urinary calculus. The general health gradually declined, and the wound never entirely healed, owing to the constant passage of sabu- lous matter, and the adhesion of more or less of this to the sides of the opening. Everything was done to mitigate his suffering, but to little purpose. Nothing but the most liberal use of anodynes afforded the slightest relief. In this condition, his father determined to put him on board a steamer, and revisit Louisville; he arrived in town on the 3d of October, 1850. Soon after leaving home, Thomas was seized with vomiting and purging, followed, in forty-eight hours, by symptoms of dysentery. He was unable to retain anything on his stomach; his thirst was excessive; and he had frequent discharges of blood and mucus. He had improved somewhat in flesh during the last two months; but since this attack he had become greatly emaciated. The case resisted all treatment, and he expired early in the morning of the 5th. A careful examination revealed the following facts. The fistula in the perinseum was of the diameter of a common probe, and was incrusted, nearly in its entire extent, by sabulous matter, a small quantity of which was visible at its external orifice, situated at the upper part of the cicatrice. The skin for some distance around the opening was red and excoriated, from the acrid nature of the discharges. The bladder was much contracted, and hardly capable of holding a pullet's egg; it contained no urine, but some purulent matter, and fifteen calculi, from the size of a mustard seed to that of a pea, irre- gular in their shape, of a white colour, and rough on the surface. The mucous coat was considerably thickened, mammillated, and throughout of a slate colour. Sabulous matter existed in abundance at the bottom of the vesical orifice of the fistula, and readily accounted for the want of union of the wound. The coats of the bladder were pale, firm, and nearly half an inch thick in the posterior half of the organ; but in front of this they were free from hypertrophy and of the natural consistence. The urethra was healthy. The prostate gland was remarkably small, but of normal colour and consistence. The ureters were of a pale drab colour externally, unusually firm and large, and remarkably thickened in their coats; they contained each a small quantity of muco-purulent matter, intermixed with gritty substance. Their lining membrane was longitudinally corrugated, STONE IN THE BLADDER. 491 of a pale straw colour, and considerably thickened. The renal extre- mities of both tubes were someAvhat contracted. Both kidneys adhered with great firmness to the surrounding parts, and were imbedded in a small quantity of fat. The right was some- what hypertrophied, hard, and of a dusky hue externally; internally it was more pale; the calyces were enlarged, and filled with purulent matter and grains of sand, with several small concretions similar to those found in the bladder. The left kidney was a little larger than the right; when pressed upon it grated, and felt like a bag of mortar; it was remarkably firm, and of a dusky colour, and contained a large quantity of sabulous and stony matter. The mucous membrane of the pelvis and calyces was chronically inflamed. The right renal capsule was natural; the left had disappeared. The abdominal vis- cera were sound. The rest of the body was not examined. Case XXII.—Richard Webster, aged seven years, a resident of Carroll County, Kentucky, a limestone region, has suffered all his life from calculous disease, but has not been ill in any other way, except that he had a severe attack of cholera when two years old. The inclination to urinate was very frequent, and the Avater was often discharged with so much difficulty that it was necessary to resort to the catheter: occasionally it contained blood and muco- purulent matter. Two of his maternal uncles voided small calculi on different occasions, but none of the other branches of his family suffered from the disease. The little patient was brought to me by Dr. Taylor, of Carrollton, on the 26th of November, and the next day I performed upon him the lateral operation. The stone was oval, rough, and about an inch and a quarter in diameter. On the 6th of December the urine began to pass off by the penis, and the wound was rapidly advancing towards cicatrization. When the boy left, two days subsequently, it was nearly closed. Case XXIII.—Thomas Cardwell, sixty-five years of age, mar- ried, a native of Charlotte County, Virginia, but for many years a resident of Kentucky, of temperate habits, of no particular occupa- tion, and of a stout, robust frame, has suffered from early infancy from excessive pain of the stomach and bowels, which resisted, for many years, every mode of treatment that could be devised for its relief. It usually came on periodically, and was evidently of a neu- ralgic character. In spite of his suffering, which was almost con- stant, his appetite remained good, and his general health was but little affected. At the age of thirty-seven, while pursuing the occu- 492 DISEASES AND INJURIES OF THE BLADDER. pation of a farmer, and several years after he was relieved of his neuralgic complaint, he was suddenly seized with violent pain in the bladder, with retention of urine. Nearly a week elapsed before he recovered from the attack. The vesical pain Avas intermittent, and of a neuralgic nature. In October, 1822, he was sounded by Dr. Dudley, of Lexington, Avho readily detected a foreign body, but five days afterAvards, when about to operate, it could no longer be found, and surgical interference was, therefore, postponed. The introduc- tion of the instrument Avas followed by retention, which lasted forty- eight hours, when the water was discharged with great force, proba- bly carrying the concretion before it. For fifteen years after this, he was free from calculous complaints, though he had occasionally slight pain in the region of the bladder. At the end of that period, the symptoms of stone returned, and gradually increased, until the autumn of 1849, when they became exceedingly urgent and dis- tressing, the patient being obliged to refrain from exercise, and to use the catheter at least once a day to clear the bladder of urine, mucus, and blood. It is proper to observe that Mr. Cardwell has used lime-water as a constant drink, for the last fifteen years, and that his principal diet, all his life, has been corn bread and bacon, with coffee at breakfast and supper. I cut Mr. Cardwell on the 20th of May, 1850, in the presence of Drs. Colescott, T. G. Richardson, Thomson, Trabue, and Clark, removing a calculus of a flattened, ovoidal shape, an inch and five- eighths in its long diameter, and an inch and a quarter in the short. He was under the influence of chloroform, and the only thing of interest noticed during the operation was the manner in which he retracted his perinseum. The urine began to flow by the urethra on the eighth day, and ceased to pass by the wound altogether on the four- teenth. On the second day, he had a little fever, but it lasted only a few hours, and did not recur afterAvards. The only medicine he took was castor oil, to regulate his bowels. He left Louisville on the 12th of June, the wound being nearly cicatrized, and his general health excellent. Case XXIV.—August 24, 1850. John B. Lentz, aged twenty- eight years, married, a native of Pennsylvania, but a resident for eleven years of Kentucky, slender, of middle height, weight one hundred and forty, temperate habits, and an engineer by occupation, has had symptoms of stone for five years. His general health has always been good, though he has been much exposed to wet and STONE IN THE BLADDER. 493 cold, in consequence of his business. His father and a paternal uncle both had stone. During his residence in the West, he has generally used the water of the Ohio and Mississippi rivers. His symptoms were slight until a few months ago, when they were sud- denly aggravated, probably from exposure to wet while at Paducah, where he had several severe paroxysms of difficult micturition, at- tended with excessive burning at the neck of the bladder, violent itching behind the testes, and a discharge of bloody urine. He arrived at Louisville, August 24; and, upon sounding him the next day, I at once detected the presence of a calculus. A week was spent in preparing him for the operation, which was performed on Saturday, August 31, in the presence of Drs. Richardson, Raphael, Thomson, Clark, Washington, and Dr. Colescott, the latter holding the staff. In making the external incision, I divided what appeared to be the superficial perinseal artery, which was immediately compressed by an assistant, and the rest of the operation proceeded with. The bladder Avas reached in less than twenty seconds, and the staff withdrawn. On attempting to seize the stone, it repeatedly slipped out of the grasp of the forceps, which rendered the proceeding rather tedious. When finally extracted, it was found that the difficulty depended upon the spiculated surface of the calculus, the projections breaking off under the slightest pressure of the instrument. The stone measured nearly five inches in circumference, and weighed one ounce and one drachm and a half. The operation completed, I tied the divided artery, above men- tioned, but found, to my surprise, that the flow of blood, instead of being arrested, appeared at innumerable points on the surface of the Avound. It was of a venous colour, and led to the idea that it might proceed chiefly from the neck of the bladder. On cleaning the wound, however, it was found to ooze out, as above stated, at diffe- rent points. The patient was put to bed in the hope that the hemor- rhage would cease ; but in this I was disappointed. He was now brought to the edge of the bed, and the wound carefully cleaned, to ascertain, if possible, the source of the bleeding. Seeing no vessel from Avhich it could proceed, I determined to introduce a large, soft piece of sponge, sufficiently long to reach to the neck of the bladder, and then apply ice to the perinseum and hypogastrium. This had the effect of arresting the bleeding at once. The operation was performed at 10 o'clock in the forenoon; and the next morning at 494 DISEASES AND INJURIES OF THE BLADDER. 8, upon removing the plug, the bleeding returned, the blood oozing out as before, and compelling me to reintroduce the sponge. This had again the desired effect; the plug was retained till the following Wednesday, when it was withdrawn, without a recurrence of hemor- rhage. In all other respects, things progressed favourably; there was a little fever for the first two days, and some tenderness in the wound, but nothing serious. It should be observed that the urine flowed freely through the wound by the side of the sponge, for the first twenty-four hours; afterwards most of it flowed along the urethra until the sponge was removed. Nearly three weeks elapsed before it passed through the urethra, and three months before the wound was entirely closed. Both these effects probably depended upon the use of the plug; for his general health was all the time excellent, and could hardly, in my judgment, have had any agency in retarding the healing process. 2. Bilateral Operation.—The merit of devising this operation is usually ascribed to Celsus, though it more probably belongs to Le Dran. Its advantages have been prominently set forth in modern times by Chaussier, Beclard, and Dupuytren, the latter of whom performed it successfully in 1824, and who may be said to have regularized and perfected it. In this operation, the perinseum and the prostate gland are divided on both sides, with less risk, it is asserted, than in the ordinary method, of wounding the pelvic fascia and the surrounding plexus of veins. It is contended, moreover, by the advocates of this plan, first, that it is better adapted to the removals of large calculi; secondly, that it is applicable to all ages and to both sexes; thirdly, that it is singularly easy of execution; and, fourthly, that it secures the rectum, the perinseal arteries, and the seminal ducts, from liability to injury. That some of these advantages are exaggerated is sufficiently evident. Thus, as it respects hemorrhage, it is perfectly certain that several patients have perished from it. It is also certain that it is not easier of execution than the lateral secthpn, which is often performed in an almost incredibly short time ; nor is it any better adapted to persons of different ages. If it possess any advantages at all over the ordinary method, it must be on the ground that it affords a larger opening for the passage of the foreign body, and that it is attended with less danger to the rectum and the seminal ducts. But even of these the former is, in great degree, counterbalanced by the modern method of dividing the right lobe of the prostate, if the wound in STONE IN THE BLADDER. 495 the left be found insufficient for the extraction of the calculus. In reality, then, the bilateral section has but one advantage over the lateral, namely, the greater immunity which it affords to the bowel and the seminal tubes. The bilateral operation has sometimes been performed instead of the lateral, on account of difficulty occasioned by malposition of the thigh, which has been known to project so far across the perinseum as to diminish the width of this region, and to be seriously in the way of the operator. The deformity may be owing to a congenital vice of the hip-joint, or to anchylosis from disease or accident. In such a case, it may be necessary to approach the bladder through the rectum or the hypogastrium. My distinguished friend and former pupil, Dr. Pope, Professor of Surgery in the University of St. Louis, in one instance, not long ago, surmounted the difficulty thus occasioned by the bilateral operation. One hip was anchylosed, and the thigh hung directly in the way of the operator. The stone, which had formed round a piece of necrosed bone, was unusually large, and required to be broken before it could be extracted.1 The bilateral operation of lithotomy has never had any distin- guished advocates in Great Britain, where the ordinary method seems to be universally preferred to all others. Nor has it, so far as I am informed, received much countenance in Germany, Russia, and Italy. It was first performed in this country in 1832, by Dr. Ashmead, of Philadelphia. It was repeated soon after by Dr. Ogier, of Charleston; and within the last ten years has been practised by Stevens, Warren, Mussey, Eve, Parker, Watson, Hoffman, Post, May, Pancoast, and other surgeons. It was also, as I am informed, the favourite method of the late Dr. Bushe, of New York. I have myself been so much wedded to the lateral method that I have never felt inclined to employ any other. Most of the surgeons above named use the knife, both for dividing the perinseum and the prostate gland. My distinguished friend, Professor Eve, of Georgia, avIio is one of the most able and strenuous advocates of the bilateral method, informs me that he always employs the lithotome cache" of Dupuytren. Of fourteen patients cut with this instrument, only one died, but from no cause connected with the operation. Dr. Stevens, of New York, has devised an instru- ment, named the prostatic bisector, which he uses for cutting the 1 Trans. Amer. Med. Association, vol. iii. p. 377. 496 DISEASES AND INJURIES OF THE BLADDER. prostate gland and neck of the bladder. An instrument very much on the same plan had been previously contrived by Dr. Pattison and Dr. Bushe. Dr. Mussey, of Cincinnati, formerly employed the lithotome cache', but of late years, as he has recently informed me, he has given a decided preference to the knife. The last twenty- three operations which he has performed were done in this manner. No statistics on an extended scale have been furnished of the results of this operation, so as to enable us to form anything like a correct estimate of its absolute or relative value. It has been stated that Dupuytren operated in this manner twenty-six times in succession, at the Hotel-Dieu at Paris, without losing a single case, and that, out of seventy patients whom he cut after he adopted this procedure, only six died. The probability, however, is that this is a mistake; for it is declared by Sanson and Begin, the editors of Dupuytren's posthumous work on the bilateral operation, that the mortality in the hands of this illustrious surgeon was as high as one in four and a half.1 The bilateral operation requires the same preliminary measures as the other method. The patient is placed in the same position, the limbs and the staff are held in the same manner, and the surgeon occupies the same situation. The incisions through the perinseum, as far as the groove of the staff, are executed with an ordinary scalpel, and the prostate is divided with a double lithotome cache', a Liston knife, or a probe-pointed bistoury, according to the whim, fancy, or caprice of the lithotomist. The French generally operate with the lithotSme, which is also the favourite instrument of some of the surgeons of this country. Dr. Warren also uses this instru- ment. The double lithotome was greatly improved by Dupuytren, and is accurately represented in the annexed drawing. "It consists of two long, narrow blades, folding upon each other, and con- cealed in a case, which is slightly curved, and adapted, by its size and shape, to be passed along the groove of the staff into the bladder. Thus, the instrument is introduced through the urethra without injury to the parts, while a mechanical contrivance attached to the handle allows the blades to be expanded after it has been lodged in the bladder. They quit the sheath on each side, and, when separated, 1 Operation de la Pierre, d'apres une mgthode nouvelle par le Baron Dupuytren; par Sanson et Begin, p. 12. Paris, 1836. Also, Morton on the Perintcum, p. 77. STONE IN THE BLADDER. 497 resemble the blades of a pair of scissors with the cutting edges re- versed. In this state the instrument is withdrawn, and cuts its way out. The size of the opening produced of course depends upon the extent to which the blades have been expanded, their degree of separation being indi- cated by an index."1 The operation consists in making a semilunar incision across the perinseum, beginning on the right side midAvay between the tuberosity of the ischium and the margin of the anus, but a little nearer the former than the latter, and terminating at the corre- sponding point of the opposite side. The concavity of the cut is directed doAvnwards, and its centre, situated at the raphe" of the perinseum, is about nine lines above the anus. In this direction are divided successively the skin, the cellulo-adipous tissue, and the superficial fascia, together with a feAV of the anterior fibres of the external sphincter muscle. The end of the left fore-finger is now placed in the bottom of the wound, just as in the ordinary proce- dure, the staff sought, and the membranous portion of the urethra laid open. The incision in this canal need not exceed four lines. The nail of the finger is then applied to the staff, to serve as a guide to the lithotome, the beak of which is next inserted into the groove of the instrument, with its concavity looking upwards. Taking care, by moving the litho- tome several times forwards and backwards, that it is securely lodged in the grooA7e, the surgeon seizes the handle of the staff, and depresses it nearly to a level Avith the abdomen, at the same time that he loAvers the lithotome, and pushes it onward into the bladder. As soon as the instrument has reached the bladder, its point is disengaged from the staff, which is imme- diately removed. The lithotOme is then turned round with its con- cavity towards the rectum, and while it is in this position it is Avith- drawn, its blades being expanded by pressing on their springs. In this manner, it cuts its way out, slowly and steadily, dividing in its 1 Brit, and Foreign Med. Rev., vol. ii. p. 101. 32 498 DISEASES AND INJURIES OF THE BLADDER. retrograde course the sides of the prostate, in a direction obliquely downwards and outwards, as in the ordinary section. The finger now takes the place of the instrument, the situation of the stone is ascertained, the forceps are introduced, and extraction is effected in the usual manner. 3. Quadrilateral Operation.—Nothing need be said here of the quadrilateral operation of lithotomy, devised by Mons. Vidal, of Paris,1 beyond the fact that it is one of those singular novelties of which there seems to be so much fondness in French surgeons. It was first formally announced by this distinguished gentleman in his inaugural dissertation in 1828, although he had performed it upon the dead subject several years previously. The first essays with it upon the living subject were made by Velpeau and the younger Guersant, of Paris. It has since been performed by Goyrand of Aix, Rolland of Toulouse, and Roux of Toulon, with several success- ful results. The operation consists in dividing the prostate at four different points; and the advantage which has been urged in its favour is that the wounds thus made admit of the more easy extrac- tion of large calculi; to which the procedure is restricted. Whether this advantage is not more than counterbalanced by the ill effects which must result from such extensive hacking of the gland, is a point concerning which every lithotomist is as competent to judge as I am myself. There is no probability that the operation will attract serious attention anywhere, much less that it will be frequently per- formed. 4. Recto- Vesical Operation.—The recto-vesical operation, devised in 1816, by Sanson, of Paris, is already obsolete.2 When first in- troduced to the notice of surgeons, it was invested with a sort of eclat, on account of its supposed advantages, of Avhich not the least striking is its apparent simplicity, and the facility Avith which it may be executed. It was also imagined that it Avas entirely free from the risk of hemorrhage, and that, from the dependent character of the wound, it admitted of the more easy extraction of the foreign body. Like all professional novelties, it was embraced by some, and denounced by others. Time progressed; the operation was tried, and found wanting. Experience showed that it was often succeeded by extensive suppuration of the cellular tissue within the pelvis, thus endangering both part and system; that the ejaculatory ducts, 1 Traits de Pathol. Extern., T. v. p. 271. Paris, 1846. 2 Sabatier, Medecine Ope>atoire, T. 4, p. 332. Paris, 1832. STONE IN THE BLADDER. 499 and even the seminal vesicles, were occasionally wounded; and lastly, though not least, that it was liable to leave a fistulous com- munication between the bladder and the rectum. These disadvan- tages are more than counterbalanced by any benefits which it was supposed to possess by Sanson and his followers. It is not surpris- ing, therefore, that it should soon have fallen into disuse. Two modes of operating were at one time in vogue, differing from one another chiefly in the relative extent of the incisions. In one, known as Vacca's method, the membranous portion of the urethra is opened in front of the anus, directly in the middle line, with an ordinary scalpel. As soon as the staff, held as in the lateral opera- tion, is fairly exposed, a probe-pointed bistoury is inserted into it, and carried into the bladder, dividing in its progress the inferior part of the body of the prostate, with a small portion of the anterior wall of the rectum. In Sanson's operation, the only difference is, that the incision is carried somewhat higher up. In the original operation by this sur- geon, the rectum Avas divided to the extent only of an inch and a half, Avhereas, in this, it is at least from six to eight lines longer. When prolonged beyond the posterior margin of the prostate, as it is in Sanson's operation, the incision is liable to penetrate the peritoneum; an accident Avhich has several times occurred in prac- tice. Although the recto-vesical operation has been discarded, as one of the regular operations of lithotomy, circumstances may arise which may render it not only justifiable but highly proper. Thus, the stone may be lodged in the bas-fond of the bladder, or impacted in one of the ureters, and bulge into the rectum, forming a tumour from two to three inches aboAre the verge of the anus. In such a case, the foreign body would be more accessible by the recto-vesical than the perinseal incision. 5. Supra-Pubic Operation.—In the supra-pubic, or high opera- tion, as it is commonly called, the bladder is opened above the pubes, in the direction of the linea alba. The proceeding, although objec- tionable as a general rule, may occasionally be resorted to with advantage, and, therefore, requires brief consideration in this place. The operation has not been often performed in this country. Pro- fessor Gibson, of Philadelphia, was the first to employ it, in the case of an old gentleman of Alrginia, who was affected with great en- largement of the prostate gland, and who died soon after from the 500 DISEASES AND INJURIES OP THE BLADDER. effects of peritonitis, consequent upon urinary effusion. Dr. Car- penter, of Lancaster, Pennsylvania, repeated the operation soon after with a more fortunate result. A short time before I entered upon my professional studies with the late Dr. George McClellan, of Philadelphia, that gentleman performed the operation; but his patient, whose constitution had been much shattered by previous suffering, died in a short time after. Subsequently he repeated the operation, not less than six or eight times, with Avhat success I have not learnt. Within the last twenty years, supra-pubic cystotomy has been employed, Avith various degrees of success, by different American practitioners; none of whom, so far as my knowledge extends, are disposed to give it a preference over the lateral method. In Europe, the great modern champion of this operation is Dr. Souberbielle, of Paris, whose experience Avith it is much greater, and, therefore, entitled to more confidence, than that of any other modern surgeon. From a paper, inserted in the eighth volume of the " Memoires de 1'Academic Royale de Mddecine," it appears that he performed the operation thirty-nine times, between the years 1828 and 1834, and that with an amount of success so flattering that he is inclined to prefer it to every other procedure. In Eng- land, the operation excited a good deal of attention, first, in the time of Douglass, Cheselden, Pye, and Thornhill, all of whom re- peatedly performed it; and, more recently, in consequence chiefly of the writings of Mr. Carpue,1 Avho witnessed a number of Dr. Souber- bielle's cases, and was at much pains, after his return from France, to attract to it the notice of the British profession. The originator of the operation was Franco. The chief advantages of the high operation are, that it is free from hemorrhage; that it does not expose the patient to injury of the rectum and the ejaculatory ducts; that there is no risk from inflammation of the neck of the bladder; that it may be performed where the lateral section is impracticable, on account of impassable stricture of the urethra, excessive depth of the perinseum, deformity of the pelvis, or great enlargement of the prostate gland; and, lastly, that it admits of the more easy removal of a large, attached, or encysted calculus. As an offset to these advantages, it is to be remarked, that the procedure is liable to be followed by injury of the peritoneum and urinary infiltration, not to say anything of the 1 A History of the High Operation for the Stone. London, 1819. STONE IN THE BLADDER. 501 difficulty of executing it when the abdomen is loaded with fat, or the bladder does not ascend any distance above the pubes. The latter of these dangers may, however, in general, be avoided by premising a perinseal puncture, to serve as an outlet to the urine, which thus drains off as fast as it reaches the neck of the bladder. The former, too, may usually be guarded against, if the precaution be used, first, to distend the bladder thoroughly before the operation, and, secondly, to push the peritoneum gently before the knife after cutting through the inferior part of the linea alba. In performing the operation, the patient is placed recumbent, upon a narrow table, Avith the legs hanging loosely over its lower edge, and the feet resting upon a chair. The head and shoulders are somewhat elevated by pillows, to relax the abdominal muscles. Any hair that may cover the supra-pubic region is to be removed with the razor or scalpel. The bladder, if not previously distended by the retention of its own contents, is now filled with tepid water until it rises a considerable distance above the pubes. Trifling as this part of the operation apparently is, it cannot be performed with too much care, to prevent the rupture of the organ ; an accident which happened occasionally in the hands of the older lithotomists. These preliminaries being duly attended to, the surgeon, standing on the left side of the patient, makes an incision from three and a half to four inches in length, commencing at the pubic symphysis, and extending upwards toAvards the umbilicus, in the direction of the linea alba. It should pass through the skin and cellulo-adipous sub- stance, doAvn to the aponeuroses of the abdominal muscles. These structures, being thus exposed, are next cautiously divided to the same extent. Any vessels that may bleed are now secured; or, what will usually ansAver equally well, compressed by the finger of an assistant. The bladder will now be found at the bottom of the Avound, forming a tolerably large, fluctuating tumour, and invested merely by a thin layer of cellular tissue. To divide this a few gentle touches of the knife are sufficient; or, what is better and more safe, the dissection may be effected with the rounded steel end of the handle of the instrument. Conducted in this manner, there is hardly any possibility of wounding the peritoneum, the great dan- ger in this stage of the operation. If the bladder is quite promi- nent, it should now be transfixed by a delicate tenaculum; othenvise it should be rendered sufficiently so by the introduction of a sound through the urethra. In either case, it is, I conceive, a matter of 502 DISEASES AND INJURIES OF THE BLADDER. paramount importance to secure the bladder before it is incised, in order to prevent it from collapsing, and sinking doAvn behind the pubic bones; an occurrence which cannot fail greatly to embarrass the subsequent steps of the operation. A puncture is next made into the anterior surface of the viscus, on a level witli the pubic symphysis, large enough to admit the index-finger of the left hand, which is at once introduced, and used as a searcher to ascertain the situation and volume of the stone. The opening is afterwards en- larged, with a probe-pointed bistoury, to any extent that may be required; the forceps are introduced; and the stone is seized and removed. A short silver tube, carefully rounded at the end, and pierced with numerous apertures at the sides, is now introduced into the bladder, at the lower part of the wound, and secured in by two pieces of tape, fastened to a broad roller; the edges of the remainder of the wound being previously approximated by several points of the twisted suture, aided by adhesive strips. Instead of a tube, a slip of linen may be inserted into the bladder, for conducting away the urine. This it does on the principle of a syphon. Such is the ordinary mode of proceeding. For the sake of greater safety, as it respects infiltration, it has been recently proposed to cut into the membranous portion of the urethra, on the left side of the perinseum, making an opening barely large enough to admit of the ready introduction and lodgment of a common lithotomy tube, to afford the urine an opportunity of passing off as soon as it reaches the bladder. In this case, the whole of the supra-pubic wound is accurately closed immediately after the extraction of the calculus, to insure union by the first intention. Souberbielle introduces a syphon-catheter into the urethra as soon as the operation is over, and retains it there until the wound is healed, Avhich it generally is in from fifteen to tAventy days. When the instrument becomes a source of irritation to the bladder, it is removed, and the water is permitted to escape, either partially or wholly, by the wound. He also opens the bladder by a sonde-a- dard, introduced by the urethra, and brought out through the linea alba, above the pubes. Although the high operation is generally exempt from hemor- rhage, yet a case is mentioned in which Pye, an English lithotomist, is said to have lost his patient from this cause. The probability is that the blood, in this instance, came from an anomalous artery or STONE IN THE BLADDER. 503 an irregular distribution of the circumflex iliac.1 In a case operated upon by Thornhill there was also considerable, though not fatal, bleeding.2 When such an occurrence takes place, the bleeding vessel should be searched for, and secured with the ligature. If the blood issues at numerous points, as it may when there is a hemorrhagic diathesis, the tampon should be employed; and the same treatment will be likely to prove beneficial when the fluid proceeds from a vessel of the bladder. It has been seen that the chief danger of this operation is injury of the peritoneum. When this is followed by the admission of urine, even in the smallest possible quantity, into the general cavity of the abdomen, violent inflammation is sure to ensue, and to destroy the patient in a few days. Mere lesion of the membrane, without ex- travasation, is, on the contrary, comparatively harmless. That this is the fact is amply proved by the results of the operations of Frere Cosme, Thornhill, Douglass, Crozat, Le"onardon, and others, who all committed this error without any serious detriment to their patients. When abscesses form in consequence of an escape of the urine into the connecting cellular tissue round the wound, early and free incisions are made, followed by the warm water dressings. If the matter be allowed to remain pent up, serious mischief must result from its tendency to burrow, and irritate the peritoneum. 6. Lithectasy.—The operation of lithectasy consists in making an opening into the urethra through the perinseum, smaller than in ordinary lithotomy, and in slowly dilating the neck of the bladder until the aperture is sufficiently capacious to admit of the passage of the foreign body. The expedient is a modern invention, having been first employed by Sir Astley Cooper in 1819, at the suggestion of Dr. Arnott, of London. The recent revival of it is due to Dr. Willis, an English surgeon. I am not aware that it has been adopted by any American lithotomists. The position of the patient and of the staff is the same as in the ordinary method. The incision, about an inch and a half in length, extends along the raphe" of the perinseum to within about six lines of 1 "In th£ old method of performing this operation, hemorrhage," says Carpue, "must be common, as I have been sent for to examine three persons who died shortly after the operation, and who, on inspection, I found had died from hemor- rhage, from the puncture of a branch of the circumflexus ilii, which anastomosed with the epigastric.'' History of the High Operation, p. 151. 2 Traite" de la Cystotomie Sus-pubienne; par Denis Belmas, p. 267. Paris, 1827. 504 DISEASES AND INJURIES OF THE BLADDER. the margin of the anus. As soon as the staff is felt at the bottom of the wound, the membranous portion of the urethra is freely divided over it, after which the operation is completed with an Arnott's dilator. This consists of a cylindrical bag of oiled silk, which is carefully insinuated into the bladder along the groove of the instrument, and is injected with tepid water until the patient begins to complain of uneasiness. The distension is increased at short intervals, not forcibly and suddenly, lest it produce pain and other mischief, but gently and slowly, without fretting or irritating the parts. The dilatation is generally sufficiently advanced, in thirty or forty hours, to enable the surgeon to introduce the forceps and extract the calculus. It is difficult to conceive what advantage such a proceeding pos- sesses over the ordinary operation. I must confess it does not impress me at all favourably. Even supposing that the dilatation is not productive of much pain, it is not difficult to imagine that it might be followed by erysipelas of the perinseum, and severe inflam- mation of the neck of the bladder. Of the few cases in which lithec- tasy has been practised, the results are by no means flattering. Besides, an operation attended with so much delay must necessarily create a good deal of apprehension in the patient, especially if he is nervous or timid in regard to his ultimate safety; and, in the last place, the foreign body, unless exceedingly diminutive, is not likely to pass through so small a wound without great difficulty, and with- out inflicting undue violence upon the surrounding parts. If I were myself affected with calculus, and were compelled to choose between lithectasy and the ordinary procedure, I should certainly give my decision in favour of the latter, both on account of its greater expe- dition, its greater freedom from pain and mental anxiety, and, as I believe, also its greater safety. 7. Operation with the Gorget.—The gorget is fast falling into desuetude. Whether this is owing to any intrinsic defect in the instrument itself, or merely to the manner of using it, cannot be easily determined. However this may be, very few operators, either in this country or in England, continue to employ it. Dr. Dudley, of Lexington, has performed all his operations, upward of two hundred in number, Avith it; and I am told that he still uses the same instrument with which he commenced his brilliant career as a lithotomist, forty years ago. Dr. Gibson, of Philadelphia, also adheres to the gorget, and so do likewise a few of the other surgeons of that STONE IN THE BLADDER. 505 city. Most American operators prefer the knife, which is also the case in England, France, and other portions of continental Europe. The gorget has undoubtedly committed many blunders, the recital of which would form one of the most sickening chapters in the history of surgical wrongs. Nevertheless, it has done, and still continues to do, good service in the hands of some of our most eminent men, and ought not, therefore, perhaps, to be spoken of too lightly or severely, for its faults are, perhaps, after all, rather attributable to the surgeon than to the dumb instrument with which he does his bungling work. The gorget has sometimes slipped into the cellular tissue betAveen the bladder and the rectum, or between this organ and the pubes ; thereby bruising and otherwise injuring the parts, and favouring the occurrence of urinary infiltration. Cases are mentioned, where, by a blind and heroic thrust, the instrument completely severed the bladder from its connexions, pierced the rectum, or penetrated the peritoneal cavity, and passed high up among the boAvels. Mr. John Bell, in his History of Lithotomy, says, " I have seen the gorget driven twice, not into the bladder, but deep among the boAvels; for although there was a stone, the surgeon never reached the bladder. Not one drop of urine followed; the stone was not extracted ; and the boy died the second day from the operation." Sir James Earle observes that he has more than once known this instrument, though passed in the right direction, pushed on so far, and with such violence, as to go through the opposite side of the bladder. Mr. Benjamin Bell found in two instances, on dissection, that this organ was wounded in three different parts, at its neck, in its side, and towards its superior fundus. The late Mr. Crosse states that he has repeatedly seen the gorget slip between the bladder and the rectum; in one instance he declares that the instrument, after entering the bladder, pierced its coats from within outAvards, so as to stop against the pubic bone. Brom- field, in passing the gorget, perforated the opposite side of the blad- der, and found, to his horror, on withdrawing the instrument, that the intestine had descended through the opening. The bowel had to be held out of the way while he extracted two calculi, though it was forced out again by the child's screaming before he attained his object. " As soon as he was convinced, by his finger, that the bladder AA'as totally free from any pieces of stone, he again returned the intestine into the pelvis, and brought the child's thighs close together; a piece of dry lint was applied to the wound, and a pledget over it; he was then sent to bed with no hopes of his sur- 506 DISEASES AND INJURIES OF THE BLADDER. viving till the next day ; but, contrary to expectation, the child had a very good night, and was perfectly well in little more than a fort- night." It is said that the celebrated Scarpa thrust the gorget, which was looked upon as the palladium of his fame, between the bladder and the rectum. The operation with the gorget differs, in no wise, in its early stages, from the operation with the knife. The period for using the instrument is immediately after the incision of the membranous portion of the urethra. The surgeon then exchanges the scalpel for the gorget, the beak of which he places in the groove of the staff, guided by the point of the left index-finger. After assuring himself, by drawing the instrument slightly backwards and forwards, that it is in no danger of slipping, he takes hold of the handle of the staff, and by a simultaneous movement of his hands, he lowers the instrument and the gorget nearly to a level with the abdomen; pushing at the same time the latter onward into the bladder. In executing this part of the operation, care should be taken not only that the gorget do not slip out of its place, and thus pass betAveen the rectum and the bladder, but that it is properly lateralized, other- wise there will be great risk of injury to the rectum and the pudic artery. The annexed engraving, represents the gorget, as modified and improved by Physick and Gibson. Fig. 75. 8. Operation with the Beaked-knife.—Instead of the gorget, some lithotomists employ a beaked-knife, or a probe-pointed bistoury, for dividing the neck of the bladder and the prostate gland. The beaked- knife was invented, I believe, by Sir William Blizard, in his day one of the most skilful lithotomists of London. The instrument, which STONE IN THE BLADDER. 507 may be either straight, or somewhat concave on its cutting edge, has since been variously modified, but does not differ essentially from the ordinary blunt-pointed bistoury, except that it is a good deal longer in the blade and handle. Many excellent operators, among whom may be enumerated Sir Benjamin B. Brodie, of London, and Dr. Mott, of New York, still employ this instrument, which I have also used in some of my cases, though of late years I have generally contented myself with the scalpel. The beaked-knife is a capital instrument for enlarging the incision, and for dividing the rigbt lobe of the prostate gland, to facilitate the extraction of large calculi. 9. Operation at Two Periods.—It occasionally happens, during the extraction of a stone, that the patient becomes greatly exhausted before the operator is able to accomplish his object, and when, per- haps, a continuance of his efforts might seriously jeopard his life. This event may depend upon several circumstances; the principal of Avhich are referable to the stone itself, as its extraordinary bulk, its attachment to the bladder, its lodgment in a distinct cyst, or its situation above the pubes. It may also be caused, at least in part, by hemorrhage, copious, it may be, and difficult of management, so that before extraction can be effected, the patient may be faint, and unable to endure further interference. To meet this contingency, it has been proposed to suspend all proceedings, and to defer the ex- traction of the stone till some future occasion, not too remote from the first. This operation, it may now be observed, constitutes what the French surgeons call the operation "en deux temps;" that is, literally an operation performed at two different periods. The names of many of the older and more respectable lithotomists might be adduced in favour of this method; which, however, thanks to modern science and skill, is rarely adopted at the present day. The earliest mention of it is by Celsus, who deprecates all rough and protracted attempts at extracting calculi, on account of their ten- dency to excite A'iolent, if not fatal, inflammation. He observes that patients Avho have been cut have occasionally perished from long-con- tinued and fruitless efforts in searching for a concretion, which, when small, has been known to be forced down by the urine, and to escape by the Avound. The same practice was afterwards particularly re- commended by Franco and Fabricius Hildanus. Albucasis likewise expresses himself in favour of it, but only in cases of hemorrhage, Avhich at that period of the profession were very common, and proved a source of considerable mortality. Callot, SaA'iard, Tolet, and other 508 DISEASES AND INJURIES OF THE BLADDER. French lithotomists, occasionally performed the operation. In 1710, Professor Thompson, of Edinburgh, had recourse to it, in an instance where, by "his prudence and forbearance," he is supposed to have saved his patient. The practice has never been in favour in Great Britain; and in the United States I am not aware that it has ever been adopted. Franco, it would seem, was the first who gave a full and connected account of this method.1 His experience taught him that there are cases Avhere the patient suffers much from the violence of the opera- tion, and where, consequently, it would be extremely hazardous to proceed, inasmuch as fatal exhaustion might ensue, and death occur on the table. Under such circumstances he directs the lithotomist to desist, and to put the patient to bed, the treatment being con- ducted upon general principles. After a few days, when the fever has abated, the stone will often be found so situated as to admit of extraction by the usual means. If it do not present itself at the mouth of the wound, he advises that the finger be introduced into the rectum, and the abdomen compressed above the pubes, to force the concretion to the neck of the bladder, where it may be more easily seized. If the stone be of extraordinary bulk, it should be broken with strong forceps, and removed piecemeal. There is no probability that the operation " en deux temps" will ever again become fashionable. Modern lithotomists are too expert in the use of the knife and forceps to render it necessary to employ an expedient which must be regarded as the resource only of dulness and stupidity. A thorough knowledge of the anatomy of the peri- naeum, a rapid performance of the operation, and the use of chloro- form, render the whole proceeding comparatively easy, both for the surgeon and the patient. Where the stone is unusually bulky, which, however, rarely happens at present, the incision of the prostate must be proportionably enlarged, or, where this has already been carried to a proper and safe extent, the foreign body must be crushed, and extracted piecemeal; and this, too, is generally, in the hands of a skilful operator, the matter of a few minutes. Where the concre- tion is encysted, or adherent, it is detached with the finger, scoop, or bistoury. In short, it is only where the stone, besides being very voluminous, is excessively hard, and cannot be broken without the greatest difficulty; or where it is so small that it cannot be found 1 See the excellent paper of Mr. H. Earle on Extraction of Large Calculi, in the eleventh volume of the Medico-Chirurgical Transactions of London. STONE IN THE BLADDER. 509 without the most protracted search; where the patient has lost a large quantity of blood; or, finally, Avhere there is excessive shock; it is only, I repeat it, under such circumstances, that the operation will ever be likely to be required. 10. Lithotomy in the Female.—Women are much less liable to urinary calculi than men, though the reverse has been asserted by some very respectable authorities. In a practice of upwards of twenty years, I have met with but few instances of this affection in the other sex. As most of this time was spent in Ohio and Ken- tucky, where calculous disorders are quite common, I am led to infer that the statement here made is strictly correct. The reason of this difference, as mentioned elsewhere, is owing, in part at least, to the shortness, Avidth, and dilatability of the female urethra, which thus permits the concretion, in most cases, to pass off immediately after it descends from the kidneys, or after it is formed in the bladder. In the male, on the contrary, the smallest particle of earthy matter is liable to be retained, and to become the nucleus of a stone. I am satisfied, also, from personal observation, that women suffer much less than men from urinary deposits; a circumstance which is easily understood when we reflect upon the fact that they are much more regular in their habits, that their mode of life is more simple, and that they are much less exposed to the various exciting causes of the disease. The period of life at which they are most subject to stone in the bladder is from the age of twenty to that of fifty. The symptoms Avhich attend this affection in the female are similar to those which characterize it in the other sex. Frequent micturi- tion, pain in the region of the bladder, and the presence of an un- usual quantity of mucus in the urine, Avhich is also occasionally tinged Avith blood, especially after rough motion or exercise, and the coexistence of renal and constitutional disorder, are the most com- mon signs. In sounding, the patient is placed upon her back, on the floor or upon the edge of the bed ; and the instrument, a short steel rod, slightly curved at the extremity, is carried about through the interior of the bladder, so as to explore, if necessary, every recess 510 DISEASES AND INJURIES OF THE BLADDER. of this organ. In young children, the finger may, if deemed advi- sable, be inserted into the rectum; but in grown subjects it is best always to introduce it into the vagina. The operation of sounding should always be conducted with as much delicacy as possible, the patient being covered with a sheet. Exposure of the person must be studiously avoided. Stones occurring in the female bladder occasionally acquire an enormous volume. In general, however, they are comparatively small, and do not weigh more than six or eight drachms. In their physical and chemical properties they do not differ, so far as we know, from calculi in the other sex. Quite a number of cases are upon record in Avhich calculi of large size have been expelled spontaneously from the female bladder. The urethra, under such circumstances, is gradually dilated, and probably also much shortened, from the pressure exerted upon it by the foreign body, which thus paves the way for its own evacuation. The expul- sion is sometimes effected suddenly, perhaps under the influence of a violent attempt at micturition, or an effort at coughing, sneezing, or vomiting; but, in general, it is accomplished slowly, and with more or less pain, and difficulty in voiding the urine. Instances of the spontaneous discharge of stones, weighing two, three, four, five, and even six ounces, are mentioned by different authors. Klauder1 met with a case in which a stone, of the volume of a goose's egg, and weighing 12 ounces, was discharged in this manner. It was of a rounded figure, yellow, very compact, and remarkably smooth. In some of these cases, there was afterwards incontinence of urine; but usually the difficulty was transient, and the patients ultimately com- pletely recovered. Occasionally the calculus is evacuated through the vagina, in consequence of ulceration of the anterior wall of this tube. Such an occurrence is fortunately rare, for it is generally, if not always, followed by a permanent fistula of the part. Various plans have been proposed and practised for the extraction of calculi from the female bladder. Of these a few only need be considered, as the rest are either obsolete, or are seldom required in the class of cases falling under the observation of the modern litho- tomist. The operations to which I allude are dilatation of the ure- thra, crushing, and incision, as practised by Dubois and other surgeons. 1 Miscel. Natur. Curios., Dec. 11, Art. 5, p. 395. STONE IN THE BLADDER. 511 The method of dilatation has been practised from an early period of the profession, and has been received with various degrees of favour by different lithotomists. The principal objection to it is, its liability to be followed by incontinence of urine, in consequence of which it has of late years fallen very much into disrepute. It is more particularly adapted to small concretions, unaccompanied with any serious disease of the urethra and the neck of the bladder. The dilatation may be effected slowly, or rapidly, by means of instruments specially contrived for the purpose, or by sponge tents, bougies, or catheters. I ahvays use the latter, and one of gum is preferable to one of silver. When the stone is small, or not more than about three quarters of an inch in diameter, the necessary dilatation may be pro- cured in a few hours, or, at all events, in a few days; but, under opposite circumstances, it must be effected more slowly and cau- tiously, not only because it will be attended with less suffering, but also because there will be less risk of subsequent incontinence. It is impossible to say how far, in any given case, the procedure may with safety be carried. I should be very loth to trust to it exclu- sively where the stone is of great size ; in such a case, I should dilate to a certain extent, and then resort to crushing, or, if the case was unfavourable for such a procedure, to incision of the urethra and the neck of the bladder. The dilatation having been carried sufficiently far, the forceps are introduced, and the stone being seized, is extracted. In doing this, care should be taken not to grasp any of the folds of the bladder, or to lacerate the urethra. If the foreign body lies in a dependent situation, advantage may be derived from the finger in the vagina or the rectum. Crushing may be employed Avhen the stone is comparatively soft, yet so large as to render it impossible to extract it without undue dilatation of the urethra. The object may be effected either with a small pair of lithotomy forceps, rather narrower than common in the blades, or with Heurteloup's, Weiss', or Jacobson's lithotriptor. The operation is repeated from time to time until the foreign body is sufficiently reduced, and the fragments are washed out at each sitting in the usual manner. Incision, according to the method of Dubois, which I prefer to any other, is easy of execution, perfectly free from the danger of hemorrhage, and not liable to be followed by incontinence of urine. The only instruments which are required for its performance are a 512 DISEASES AND INJURIES OF THE BLADDER. straight staff, five inches in length, and a straight probe-pointed bistoury. The staff being introduced into the urinary sac, an inci- sion is made directly upwards toAvards the pubic symphysis, extend- ing through the urethra and the neck of the bladder, in their entire Fig. 77. length. The opening may afterwards, if necessary, be dilated with the finger to almost any extent that may be required for the safe and easy extraction of the calculus. When the concretion, however, is of unusual magnitude, and cannot be thus removed, the incision may be extended doAvnwards and outwards towards the tube- rosity of the ischium. From the direction of the wound in this operation there is much greater probability of an early reunion of its edges than when the incision is carried downwards, as in the more common methods, and consequently much less risk of incontinence of urine. Mr. Fergusson, of London, in order to lessen the chances of in- continence, has recently proposed an operation for extracting calculi from the female bladder, which seems to me to be admirably adapted to the object in ordinary cases. It consists in slowly dilating the urethra, by means of a metallic instrument, till it is capable of ad- mitting the forefinger, and in dividing the anterior half of the tube with a probe-pointed bistoury. The posterior portion of the urethra and the neck of the bladder are not touched by the knife, inasmuch as they are readily expanded under the pressure of the finger. In this manner, Mr. Fergusson extracted, some years ago, a stone three inches in circumference, and had the satisfaction to find that his patient had the power of retaining her urine immediately after- wards.1 It is possible that the ill effects of the lateral operation of lithoto- my in the female may have been somewhat exaggerated. However this may be, it is certain that it is not ahvays followed by inconti- nence of urine, even when the stone is of great size. The truth of this assertion is fully sustained by the interesting case of Dr. J. ; Practical Surgery, p. 135, second London edition; Druitt, op. cit. p. 497. STONE IN THE BLADDER. 513 Kearney Rogers, of New York, the particulars of which he had the kindness to communicate to me a few months ago. The patient was a Avidow, thirty-six years of age, during the last seven of which she had laboured under symptoms of stone, and passed more or less white earthy-looking matter. The operation was performed with a long, broad, straight bistoury, the incision being carried downwards and outwards towards the tuberosity of the ischium. The stone was so large that, although the wound was considerably dilated, it could not be extracted until after it was seized with two pairs of forceps, expanded crucially over its long axis. No incontinence of urine followed. The day after the operation, she retained half a pint, and the capa- city of the bladder gradually increased as the cure progressed. Twenty years have elapsed since the operation, and the woman has never been troubled with calculous symptoms since. The stone, which Dr. Rogers had the kindness to show me, and which I mea- sured, Aveighed nine ounces and five drachms immediately after its removal. A portion of it was broken off during extraction. It is of an ovoidal shape; its surface is rough; and it appears to consist principally of uric acid. It is nine inches and a half in its long circumference, and seven inches and three-quarters in the short, at the widest part. Whatever procedure be adopted, I conceive it to be a matter of primary importance that the patient should be kept perfectly at rest, in the recumbent posture, until the parts have regained their original tone. This should be done not merely where the incision has been practised, though here it is of the greatest moment, but even where the operation is limited to dilatation. To a want of this precaution much of the bad effects attendant upon these various procedures is doubtless justly ascribable. 33 CHAPTER XIX. FOREIGN BODIES IN THE BLADDER. It is necessary that I should make some remarks here respecting foreign bodies of the bladder introduced from without, and not de- veloped in the organ. The subject may be appropriately considered immediately after that of urinary calculi, with the operations for the relief of which it is intimately associated. The foreign bodies that may thus find their way into the bladder are too diversified in their character to admit of any very precise enumeration. The most common, however, as well as the most im- portant, are balls, pins, needles, fragments of bone, pieces of straw, or other vegetable substances, and bits of catheters and bougies. Such bodies may be introduced into the bladder either accidentally, as in the case of balls and splinters of bone; or they may be thrust up designedly, but with no intention of leaving them in this unfor- tunate situation. Many a poor fellow, while in the act of exciting onanism, has unwittingly introduced a piece of straw, wood, or iron wire into the urethra, from which it soon after slipped into the bladder. Surgeons have often broken off the catheter in the blad- der, and a bougie has occasionally met with a similar mishap. The slippery-elm bougie, at one time used a good deal in the Southwest, has several times, within my knowledge, broken off in the bladder, from which it was obliged to be subsequently removed by an opera- tion. I recollect a case of this kind which occurred many years ago in Ohio, where a man, while under treatment for stricture, met with this accident. A piece of the bougie broke off far back in the ure- thra, from which it soon after passed into the bladder, and so served as the nucleus of a tolerably large calculus. In cauterizing the neck of the bladder for the cure of seminal weakness and other affec- tions, the cup of Lallemand's "porte-caustique" has been repeatedly left in the interior of this organ, much to the annoyance and chagrin of the surgeon. Accidents of a similar character occasionally hap- FOREIGN BODIES IN THE BLADDER. 515 pen in the operation of lithotripsy; and in 1841 Mons. Leroy addressed a paper to the Royal Academy of Sciences of Paris, in which he gives an account of an instrument invented by him for seizing and extracting pieces of the stone-crusher in the event of its breaking off in the bladder. Balls sometimes enter the pelvic cavity, and from thence gradually find their way into the bladder by ulcera- tive absorption. In the same manner a fragment of bone, detached by external violence, or the effects of disease, has repeatedly been known to pass into this organ. However introduced, the effects upon the foreign substance and the bladder are generally similar, or at any rate, if they differ at all, they differ only in a very slight degree. The extraneous body usually becomes incrusted in a very short time with earthy matter, the deposit of which often proceeds with extraordinary rapidity, and sometimes attains a large bulk in a few months. The deposit is generally of a lithic or phosphatic nature ; in rare cases, it is oxalic. The symptoms awakened by the presence of the intruder, whatever it may be, are similar to those which characterize stone in the blad- der. The diagnosis is commonly easily established by the history of each particular case, aided, where any doubt remains, by a careful exploration with the sound. The extraneous body, if small, may be expelled spontaneously; but, generally speaking, it must be extracted by operation. A bullet, of ordinary size, might be removed simply by dilating the urethra; or, this failing, by Cooper's forceps. ■ In one instance, the ball was sufficiently small to pass off with the urine. Where the foreign body refuses to come away of its own accord, or the forceps are unavail- ing, relief must be attempted by the lateral operation, executed in the usual manner. In a case mentioned by Baudens, that dis- tinguished surgeon was induced to have recourse to the high opera- tion, on account of the ball having entered at the bottom of the linea alba, so that it was only necessary to enlarge the wound to reach the cavity of the bladder. Many cases are upon record where bits of gum-elastic catheters and bougies have been extracted from the bladder, by means of the forceps. The operation is of course much more difficult in the male than in the female, on account of the greater length and narrowness of the urethra. It is well enough, in all cases of this kind, to dilate the tube for several days previously, to facilitate the movements of the instrument, as well as to afford more room for the foreign body 516 DISEASES AND INJURIES OF THE BLADDER. as it is drawn along. By a dexterous twist of the hand, the forceps are made to seize the extremity of the intruder, which may then be withdrawn without difficulty; Avhereas if it be grasped at its middle or even but a short distance from its extremity, it will bend upon itself, and thus offer an insuperable barrier to extraction. The late Mr. Tyrrell, of London, had the good fortune, on one occasion, to clear in this way the bladder of a man of forty of a piece of silver catheter, three inches in length, and of the size of a No. 10. The foreign body being situated horizontally at the fundus of the viscus, was first dislodged with the end of a sound, and brought doAvn be- hind the prostate gland. After several ineffectual attempts, he succeeded in seizing the end of the tube, and drawing it into the urethra, Avhere the forceps lost their hold. Inserting his finger im- mediately into the rectum, he compressed the urethra so as to prevent the foreign body from receding, and then reintroducing the forceps, he at once caught and removed it. I have been induced to give an abstract of this interesting case, because it shows the manner in which the operation of extraction should be conducted in similar cases. When the foreign body is a pin or a needle, it may sometimes be entrapped by the eye of a catheter, as in the memorable case of Lamotte. This distinguished surgeon being called to a young woman, into whose bladder a large pin, attached to her napkin, accidentally dropped headforemost, he sounded her thrice with all possible patience, each time feeling the foreign body without being able to entangle it. Upon making a fourth trial, however, he was more successful. Moving the instrument carefully and gently about in the bladder, the pin fell across the eyes of the tube, with which it was withdrawn, not, however, without producing considerable lace- ration of the urethra. PAET II. DISEASES AND INJURIES OF THE PROSTATE GLAND. TnE prostate gland, from the peculiarity of its situation, and its intimate connexion with the bladder, the urethra, and the seminal vesicles, is constantly exposed to inconvenience and hardship, and hence, like all other parts of the body, it is liable to various diseases; not so much, however, from any proneness of its own, as from its unfortunate relations. Until the age of puberty, it has merely a rudimentary existence, and is, therefore, seldom affected in any way. After its functional activity, however, is awakened, it becomes more liable to disorder, and this tendency may be said steadily to increase as we advance in life. With the exception of acute inflammation and suppuration, tubercle, and encephaloid, all the lesions of the prostate are more common in old age than in infancy and adoles- cence. The affections of the prostate may be conveniently arranged under the following heads : 1. Wounds ; 2. Inflammation ; 3. Suppu- ration and Abscess ; 4. Ulceration; 5. Hypertrophy ; 6. Atrophy; 7. Scirrhus ; 8. Encephaloid ; 9. Colloid and Melanosis ; 10. Tubercle; 11. Cystic disease; 12. Hemorrhage; 13. Calculi; 14. Phlebolites. These affections will be considered in the order here enumerated. CHAPTER I. WOUNDS OF THE PROSTATE. Wounds of the prostate are of such unfrequent occurrence as hardly to merit attention in a practical point of view. The subject has been considered somewhat in detail by M. Vidal, in his Treatise on Surgery, and with a degree of importance to which, in my judg- ment, it is not entitled. All that is really valuable respecting it, lias been already pointed out in connexion with retention of urine, catheterism, and lithotomy. Nevertheless, as the subject has found its way into at least one system of surgery, and that the most able now extant, it would not be proper to omit the consideration of it wholly in a work of this nature. It is for this reason mainly that I shall endeavour to exhibit, in as concise a manner as possible, the leading facts of the case. Wounds of the prostate are the result either of accident or design. In the latter case, they are made by the surgeon with a vieAV to the accomplishment of some useful purpose, as the extraction of a stone or the evacuation of the urine. However induced, they vary in ex- tent and importance, from a mere scratch, as it were, to the complete division of the organ. In respect to their character, they are of different kinds, as incised, lacerated, punctured, and gun-shot, as in other parts of the body. The best example of an incised wound of this gland is that which occurs in the lateral operation of lithotomy, in which the organ is always divided on one side, generally the left. The extent of the wound varies in the hands of different surgeons, some being in favour of a small, others of a free division. The subject, which is of great practical importance, has been discussed elsewhere, and need not, therefore, detain us here. A wound of this nature derives its chief interest from its extent, which, if too great, or carried beyond certain limits, is extremely liable to be followed by urinary infiltration, ab- scess, or gangrene of the neighbouring parts rather than of the gland WOUNDS OF THE PROSTATE. 519 itself. When confined Avithin proper bounds it rarely inflames much, and would no doubt often, if not generally, unite by the first inten- tion, if it were not for the contact of the urine, which has a tendency not only to wash off any lymph that may be effused upon its surface, but also to deprive this substance of its vitality. It is for this reason that the opening made for the extraction of stone seldom, if ever, heals in any other manner than by the granulating process. Some swelling usually occurs in the parts soon after the operation, in con- sequence of which the urine passes in great measure along the ure- thra, but begins to flow again by the abnormal route as the tumefac- tion subsides. Granulations gradually spring up, the edges of the wound approach each other, and in eighteen or twenty days, the re- union is generally completed. Although this is the ordinary course pursued by nature in a wound of this description, yet a case occa- sionally occurs in which the closure is effected almost immediately, apparently by the adhesive process. Beclard once performed the bilateral operation upon a patient Avho passed all his urine in less than three hours afterwards through the urethra, in consequence, as was supposed, of the speedy reunion of the edges of the wound in the prostate gland. Such an occurrence is, of course, exceedingly rare, and nothing smacks of greater ignorance than to hear men speak of it as a common event. Lacerated wounds of the prostate are generally produced by the forcible use of instruments in attempting to draw off the urine. Any portion of the gland may suffer in this Avay, but the one which is most liable to be injured is the middle lobe, which, from its size and situa- tion, often forms a serious obstacle to the evacuation of the bladder, and therefore is most commonly perforated by the catheter. The whole gland is sometimes accidentally bored, if such an expression is allow- able, in this manner, without being followed by any serious mischief, much less by loss of life. Civiale relates1 a remarkable example, Avhich may be briefly mentioned here, as it strikingly illustrates the comparative harmlessness of this form of injury. A false passage, commencing at the right side and anterior part of the gallinaginous crest, traversed the gland from before backwards, and from above dowmvards, and led to a purulent depot between this body and the rectum. Another, which began at the middle line, behind the crest pierced the prostate in the same direction as the preceding, and ter- 1 Trait6 Pratique des Maladies des Organes Genito-Urinaires. Deuxieme partie 1841. 520 DISEASES AND INJURIES OF THE PROSTATE GLAND. minated at the same point. A third commenced at the right side of the second, and immediately began to bifurcate; one process being directed outwards, opened into the bladder behind the right lobe of the gland, while the other, which inclined obliquely outwards and backwards, also communicated with the bladder by forming, in front of the orifice of the urethra, on the same side, a subdivision separated only by a thin, narrow septum. All the passages were of long standing. Punctured wounds of the prostate, as these perforations may be appropriately denominated, are sometimes dangerous from the manner in which they interfere with the neighbouring parts. The gland itself, as has just been seen in the remarkable instance cited from Civiale, suffers, in general, comparatively little. The passages soon become lined by false membrane, and assist after- wards in conducting the urine to the urethra. It is only when they penetrate the pelvic fascia, that they are at all liable to be followed by violent inflammation and death. A perforation of this kind sometimes extends into the rectum, and leads to the forma- tion of a fistula. The prostate is occasionally severely lacerated and contused in extracting urinary calculi, either by the forceps, or the foreign body, which may be disproportionably large, or unusually rough on the surface. Not a few cases have occurred in which the greater portion of the gland has been rudely severed, or so violently bruised as to die and slough. Many an inexperienced operator has seized an enlarged middle lobe, and torn it off, under a belief that his forceps had hold of a stone. Such errors, which, however, nowadays, are fortunately rare, can seldom fail to be followed by the most disas- trous consequences. A severe wound of the prostate is sometimes made by a splinter of bone, in fracture of the pelvis. The accident is an important one, inasmuch as it is apt to give rise to suppuration, and even sloughing, both of the parenchymatous substance of the organ and of the surrounding parts. Gun-shot wounds of the prostate are exceedingly rare, and so little is known about them that it is unnecessary to enter into any details respecting their symptoms and treatment. The most prominent effects of wounds of the prostate are: 1. Hemorrhage, which, however, is seldom considerable; 2. Inflamma- tion ; 3. Infiltration of urine and sloughing; 4. Retention of urine WOUNDS OF THE PROSTATE. 521 from tumefaction of the affected parts, and the pressure which they exert upon the calibre of the prostatic portion of the urethra; 5. Urethro-vesical and urethro-rectal fistulse; 6. Abscess, situated either in the substance of the organ, or between the gland and the rectum. Wounds of the prostate, especially when unattended by lesion of the skin, must necessarily be more or less obscure in their character, if not wholly beyond our power of diagnosis. This being the case, little need be said on the subject of treatment, beyond the fact that this should be conducted upon general principles. From the great liberty which we may take with this gland, the slight pain which attends its injuries, and the little sympathy which it enjoys with the rest of the system, even the parts Avith which it is more immediately associated, it is obvious that ordinary wounds, whether simple, lacerated, contused, or punctured, are generally amenable to the common antiphlogistic means, and that there is much less reason to dread them, in relation to inflammation and its effects, than the sur- rounding structures. Wounds of the prostate are sometimes attended by troublesome hemorrhage, especially in elderly persons. As there are no large arterial trunks from which the bleeding can proceed, it is not impro- bable that it emanates, under such circumstances, from the prostatic plexus of veins, which are often varicose and much increased in volume, particularly in calculous subjects, or in such as are affected with excessive enlargement of the prostate. A severe, and even fatal hemorrhage, however, might be caused by the division of an anomalous artery, which occasionally passes along the side of this gland, on its way to the penis, and which has been cut, in one instance, at least, in the lateral operation for stone. From what- ever source the hemorrhage arises, it is obvious that our chief reli- apce, for arresting it, must be placed upon compression, since it would be folly to attempt ligation. The manner of applying com- pression has been pointed out in connexion with the operation of lithotomy, and need not, therefore, be restated here. CHAPTER II. ACUTE PROSTATITIS. SECTION I. GENERAL OBSERVATIONS. Acute inflammation of the prostate seldom exists as a primary affection, except when it is produced by direct injury. In general, it is altogether of a secondary character, or the result of an exten- sion of disease from the adjacent and associated organs. Its own structure disqualifies it, in a great degree, for originating morbid action; a circumstance in which it may be said to bear a close resemblance to the pancreas, the salivary glands, and the thyroid body. Acute inflammation is most frequently met with in middle life, when the genital organs are in their full vigour; on the con- trary, it is comparatively rare in childhood and old age, when these organs are either in a state of latency, or ill-fitted for the discharge of their functions. The disease, as in other parts of the body, may be idiopathic or traumatic. Symptoms.—The attacks of acute prostatitis are sometimes sud- den and unexpected; at other times gradual, and preceded by symp- toms of general indisposition. From whatever cause it may proceed, whether from cold, external injury, retained urine, metastasis from gout and rheumatism, or extension of gonorrhoeal inflammation, the first intimation, in general, of its occurrence is pain, burning, and sense of weight at the neck of the bladder, soon followed by a fre- quent and almost irrepressible desire to void the urine. The pain at first is slight, and of a dull, heavy, aching character; but, as the malady progresses, it rapidly augments in severity, and becomes sharp, darting, pungent, or stinging; it is deep-seated, more or less constant, and is increased by the erect posture, by any sudden con- ACUTE PROSTATITIS. 523 cussive movements of the body, by pressure upon the perinseum and hypogastrium, by defecation and micturition, and by pressure of the finger in the rectum. The pain often shoots along the pubes, thighs, ureters, and spermatic cords; and is sometimes exceedingly distress- ing in the sacro-lumbar region. In the more violent forms of the com- plaint, and especially when suppuration is threatened, it is throbbing or pulsatile. The testicles are retracted towards the abdominal rings, and a feeling of numbness is experienced in the surrounding parts. The difficulty of micturition, which is usually a prominent feature, even in the early stage of the disease, keeps steady pace with the swelling of the prostate, and is often succeeded by complete retention. The urine is generally scanty, high-coloured, dirty, or turbid, and so acrid as to occasion severe scalding or burning as it passes along the urethra. So agonizing, indeed, is this sensation, that it is frequently compared by the patient to the effects produced by the contact of molten lead. The urine commonly contains a considerable quantity of mucus; the product both of the affected gland and of the urinary bladder, the inner membrane of which always participates, at an early period, in the morbid action. In some instances, especially in the more violent forms of the disease, the fluid is tinged with blood. The rectum generally becomes involved, from extension of the original disease, at an early stage of the inflammation. The patient experiences a frequent inclination to go to stool; the parts are ex- quisitely tender and painful; the fseces are voided with much diffi- culty, and, not unfrequently, in a flattened or compressed form; and there is a constant feeling of tenesmus, as in dysentery and cystitis. In many cases, Avhen the disease has existed several days, the bowel feels as if it Avere stuffed or filled with a foreign body; and if the finger be introduced into it the inflamed gland will be found to be exquisitely tender, and to form a tumour so large, in some instances, as almost to obliterate the cavity of the tube. If an attempt be made, at this stage of the complaint, to pass the catheter, the instru- ment will be likely to become arrested by the enlarged organ, and to cause severe pain and spasm. Priapism sometimes attends, and occasionally there is involuntary discharges of semen, generally tinged with blood. These local symptoms are generally accompanied by well-marked constitutional disturbance. The countenance is flushed; the skin hot and dry; the pulse full, hard, and frequent; the tongue furred, 524 DISEASES AND INJURIES OF THE PROSTATE GLAND. and the appetite impaired. The thirst is commonly urgent; there is excessive restlessness; the bowels are constipated; and not unfre- quently there is nausea and even vomiting. Delirium occasionally exists, and generally, especially when attended by rigors, denotes the approach of suppuration. Diagnosis.—Acute prostatitis is liable to be mistaken for other affections. Cystitis and stone in the bladder are the diseases with which ft is most apt to be confounded. In general, however, the diagnosis is sufficiently easy. The characteristic symptoms are the deep-seated, burning, and throbbing pain, the gradually increasing difficulty in micturition, the excessive scalding of the urethra as the urine flows over its mucous surface, the feeling of weight and stuffing in the rectum, the constant tenesmus and desire to go to stool, and the flattened form of the fasces. When all these phenomena are present, hardly a reasonable doubt can exist in respect to the true nature of the malady, especially if it have supervened suddenly upon external violence or a suppression of a gonorrhoeal discharge. For- tunately, hoAvever, the surgeon need not rely upon these or any other symptoms to determine the diagnosis. In all cases he has it in his power to examine the gland directly with the finger and the catheter. With the former of these in the rectum, the prostate, as before stated, can be distinctly felt as a solid, painful tumour, some- times almost sufficiently large to close the tube and seriously impede the passage of the fseces; whilst, if he attempt to introduce the latter into the bladder, he will find it exceedingly difficult, if not impracticable, to succeed, unless he possesses more than ordinary skill in the management of this instrument. The enlargement upon which these obstacles depend is, of course, always more conspicuous after the inflammation has made some progress; in its early stages it is frequently very slight. In cystitis the prostate is little, if at all, enlarged; there is less pain and tenderness on pressure of the perinseum and the rectum; the urine is retained with more difficulty, and is generally voided every few minutes; the lower bowel suffers less, and the patient does not experience the feeling of fulness and stuffing about the anus that he does in inflammation of the prostate. In stone of the bladder, the symptoms are usually less urgent than in either of the other affections, and all doubt about the case generally vanishes under the operation of sounding. Causes.—The causes of acute prostatitis are both numerous and ACUTE PROSTATITIS. 525 diversified, and, as they have an important practical bearing, a rapid survey of them cannot be uninteresting or useless to the surgeon. One of the most common exciting causes of this affection is irrita- tion of the mucous membrane of the urethra, especially that form of it which attends gonorrhoea. Anatomy furnishes a ready and satis- factory reason of this occurrence. The lining membrane of the urethra, the seat of the inflammation, is prolonged backwards over the neck of the bladder, and from thence into the excretory ducts of the prostate, and it is very easy, therefore, to see how morbid action, going on in one of these parts, may extend to the other. In short, the disease, in such a case, takes place, not from sympathy, but in consequence of the continuity of structure, just as disease sometimes spreads from the nose to the lachrymal passages, or from the duodenum to the excretory canal of the liver, and even to the liver itself. This mode of propagating morbid action is not un- common, and has been long known to pathologists. It is only when the prostatitis is developed soon after the contraction of a gonorrhoea and while the irritation is limited to the anterior extremity of the urethra, that it can be said to be truly sympathetic; in all other circumstances, it is directly dependent upon an extension of the morbid action along the mucous surfaces. A gonorrhoea, in such cases, inflicts the same injury upon the prostate that it occasionally inflicts upon the testicle, shaking off, at least for a time, its own burden, and fastening it upon its neighbour. Another occasional cause of acute inflammation of this gland is stricture of the urethra; more particularly when it is seated low doAvn in the tube, and is accompanied with difficult micturition. The violent and continued straining Avhich is required to surmount the mechanical obstacle, keeps up an incessant irritation in the prostate, leading to engorgement of its vessels, and finally, in many instances, to inflammation of its substance. I am satisfied, from ample observation, that whatever has a tendency permanently to diminish the stream of urine and impede its flow, whether it depends upon disease of the urethra, the bladder, or the prostate, is calcu- lated, in no inconsiderable degree, to awaken this affection. In old subjects, indeed, I do not hesitate to regard it as the most common exciting cause of all. It will be perceived, therefore, if this conclu- sion be correct, how important it is, in a practical point of view, to be acquainted Avith this circumstance. Venereal excesses, onanism, frequent and prolonged erections, and 526 DISEASES AND INJURIES OF THE PROSTATE GLAND. constant exercise upon horseback, will also occasionally induce this disease, by maintaining habitual engorgement of the prostate. Hemorrhoidal tumours, ulcers, carcinoma, ascarides, and other affec- tions of the rectum and the anus, probably act in the same manner. Drastic and heating purgatives, particularly such as manifest a direct tendency to the lower bowel, sometimes cause the disease, though less frequently, I think, than is generally imagined. Vel- peau asserts that stimulating diuretics, as copaiba and cubebs, employed in the treatment of gonorrhoea, are apt to produce it. My own opinion is that such a result rarely, if ever, follows the exhibition of these medicines; I have constantly used them for the last tAventy years, in large as well as in small doses, and in every stage of the malady, and yet I cannot recaH to my recollection a solitary instance in which they appeared to exert any pernicious effect upon the prostate. I am not aware, moreover, that the state- ment of the French surgeon has been verified by the experience of others equally entitled to credence. That the internal use of can- tharides, which act specifically upon the neck of the bladder, stimu- lating injections, and caustic applications, may occasionally produce imflammation of this gland, is indisputable. Another cause of this complaint is injury applied to the perinseum, or directly to the organ itself, as in the rude introduction of the catheter, or the protracted retention of this instrument in the bladder. The operation of lithotomy, in which the prostate is always involved, is rarely followed by severe inflammation of this body. Finally, acute prostatitis may be induced by the sudden suppres- sion of the cutaneous perspiration, by cold applications to the peri- nseum, especially when the body is overheated and there is a gonorrhoeal discharge, and by the inordinate use of high-seasoned food, wine, and alcoholic liquors. Progress and Termination.—Acute prostatitis is generally rapid in its course. It seldom continues longer than eight or ten days Avithout tending to resolution or suppuration. When the attack is moderate, or even Avhen it is violent, provided it is combatted by prompt and efficient means, it usually ends favourably. When resolution is about to take place, the local distress gradually diminishes, micturition is performed with more facility, the urine becomes more abundant and assumes a lighter colour, the fever subsides, and the skin is rendered uniformly soft and moist. The formation of matter is denoted by an ACUTE PROSTATITIS. 527 obstinate persistence of the inflammatory symptoms, both local and general, by rigors, chills or shiverings, by violent flushes, by a heavy, throbbing pain in the affected part, by delirium, and, not unfre- quently, retention of urine. Idiopathic prostatitis never terminates in gangrene; but this effect occasionally, though rarely, follows the traumatic form of the affection. Pathological Changes.—The swelling of the prostate, in simple cases of inflammation, depends mainly upon an effusion of serum into the meshes of its cellular tissue, and upon a dilated condition of its capillary vessels. In the more severe forms, there is, in addition, a deposition of coagulating lymph, of blood, and even of pus. The latter fluid generally occurs in minute, disseminated points, not larger than a pin's head, and of a pale straw colour. They are most con- spicuous in the cellular substance of the organ, a section of which, when thus affected, bears a tolerably close resemblance to the pul- monary tissues in a state of grayish hepatization. The gland is red, and infiltrated, but still retains its cohesive pro- perties ; it is only in the advanced stages of the disease that it be- comes soft and friable. The mucous follicles are enlarged, injected, and distended with a thick, ropy secretion; the excretory ducts, on the contrary, are generally diminished in size, and sometimes even obliterated by the adhesion of their sides. Occasionally they yield, upon pressure, a thin, bloody, and slightly viscid fluid. The fibrous capsule is unnaturally red and vascular, tense, and covered, here and there, with plastic deposits. The size of the gland varies, in different cases, from the slightest increase of the natural bulk to the volume of a Avalnut, a hen's egg, or an orange. The swelling generally in- volves both the lateral lobes, though not in an equal degree. The body and middle lobe are also frequently much enlarged. The parts adjacent to the prostate usually participate in the morbid changes. Treatment.—Acute prostatitis, being a rapid and highly dangerous disease, must be met Avith the most energetic antiphlogistic measures. Free depletion by the lancet, by leeches, and by cups is almost always indicated, and should be practised with the least possible delay. The object, of course, in all cases is to promote resolution, and pre- vent suppuration. The amount of blood abstracted from the arm must vary, as in other phlegmasial affections, according to the age and habits of the patient, the state of his pulse, the duration and intensity of the morbid action, and the effects of previous treatment. It should be taken from a large orifice, while the patient is in the 528 DISEASES AND INJURIES OF THE PROSTATE GLAND. semi-erect posture, and should be permitted to flow until there is an approach to syncope, or, in bad cases, until this has actually taken place. One such bleeding will effect more good in subduing the malady than half a dozen small ones. If the bowels are over- loaded, the venesection is immediately followed by an active purga- tive, consisting of an ounce of sulphate of magnesia with the eighth of a grain of tartar emetic ; or, if there be decided evidence of bilious derangement, of twenty grains of calomel and the same quantity of jalap. The object should be to render the fsecal matter as liquid as possible, in order that, as it descends along the rectum, it may not injuriously compress the affected gland. All griping and heating cathartics must be carefully avoided; and it is prefera- ble, as a general rule, to avoid this class of remedies altogether, and to rely principally, at least for the first few days, upon laxative enemata. If much fever be present, accompanied with heat and dryness of the skin, thirst, restlessness, and high arterial action, the venesection may be repeated, or the patient may at once be put upon the use of tartrate of antimony. The dose should not at first exceed the sixth or eighth of a grain, repeated every tAVO or three hours, and the effects of the remedy should be carefully watched, lest it produce vomiting and griping, which would necessarily do harm. Or, instead of this medicine, if the activity of the pulse has been moderated by the previous treatment, Dover's powder, or the solution of acetate of ammonia, may be given, aided by tepid demulcent drinks, and the warm bath. The kind of bath is an object of no little importance in the management of this disease. The hip-bath is the one usually recommended; but I am satisfied that its beneficial effects are fre- quently more than counterbalanced by the inconvenience which attends its administration. To be at all efficacious in relaxing the cutaneous exhalents, it is necessary that the immersion should be continued at least from tAventy-five to forty-five minutes; a period which must inevitably lead to great fatigue, to say nothing of the afflux of blood that is likely to take place to the inflamed organ from the peculiar position of the trunk. It is for these reasons that I seldom resort to this agent in the treatment of acute disease either of the prostate or the urinary bladder. All the good effects that can be desired in such cases may be readily obtained from the steam- bath, prepared either by conducting the vapour of hot Avater to the body of the patient from a tea-kettle, or by placing near him, under ACUTE PROSTATITIS. 529 the bed-clothes, a few hot bricks, wrapped up in flannels previously moistened with vinegar and water. By either contrivance, free dia- phoresis may generally be induced in a few minutes. When the violence of the local inflammatory action has been some- what subdued by the foregoing measures, and sometimes, indeed, even before, one of the most powerful means for promoting resolu- tion is leeching. The best points for performing the operation are the perinseum, the parts around the anus, the inner and upper sur- face of the thighs, the pubes, and the hypogastric region. The number of leeches to be applied must vary from eight or a dozen to thirty, forty, or fifty, according to the exigencies of each particular case; and the repetition of the bleeding must be governed by the state of the pulse and the continuance or subsidence of the local action. Occasionally blood may be advantageously taken by leeches from the anterior wall of the rectum, previously dilated with the speculum ; in general, however, the parts are too tender and painful to admit of the requisite distension. Should the operation be deter- mined upon, a bivalve speculum should be selected, the upper ex- tremity and posterior cleft of which are to be closed with cotton, to prevent the leeches, on the one hand, from ascending the intestine, and, on the other, from seizing hold of parts where the abstraction of blood would prove of little or no avail. When the leeching is over, and the flow of blood has ceased, the perinseum, anus, pubes, and hypogastrium should be kept constantly covered with flannel cloths, wrung out of a strong infusion of hops or opium. These applications are much preferable, in every respect, to emollient poultices, which not only frequently oppress by their weight, but soon become dry and disagreeable. Indeed, they may be considered both here and in cystitis as among our most valuable adjuvants; they relax the parts, promote perspiration, and relieve pain and spasm. The pain and straining, which so commonly attend this malady, are often promptly relieved by the use of an anodyne enema. The same rules should be observed here, in respect to the administration of this remedy, as in cystitis and spasmodic retention of urine. When the irritation of the bowel is too great to enable the rectum to retain the injection, an opiate suppository will form a valuable if not an indispensable, substitute. The internal use of opium will also be found highly valuable especially after the inflammatory symptoms have been moderated bv 34 J 530 DISEASES AND INJURIES OF THE PROSTATE GLAND. bleeding, antimonials, and laxatives. It should be exhibited in full doses, every six or eight hours, either alone or in combination with four or five grains of calomel. The latter article I consider particu- larly important, in the subacute form of the malady, to assist in promoting the absorption of effused fluids, and modifying the action of the capillary vessels. It should never be carried to the extent of ptyalism, and its effects, therefore, should be sedulously Avatched. When a diaphoretic and anodyne impression is indicated, Dover's powder may be usefully exhibited, but the dose should be considera- bly larger than under ordinary circumstances. The condition of the bladder is early attended to, and retention of urine, so liable to occur during the progress of the complaint, is promptly relieved with the catheter. The instrument is handled with the greatest gentleness, and coaxed onward, if necessary, with the finger in the rectum. As the operation is always painful, and productive of spasmodic contraction of the parts about the neck of the bladder, it is a good plan always to exhibit, a few hours before it is attempted, a full anodyne enema. Finally, absolute rest in the recumbent posture is indispensable throughout the whole treatment; the diet must be of the most bland and simple character; and the drinks must consist of gum-water, linseed-tea, slippery elm water, and other mucilaginous fluids. Ni- trate of potassa and other stimulating diuretics are inadmissible, on account of their tendency to excite the renal secretion, and thereby increase the quantity of urine in the bladder. SECTION II. ABSCESS OF THE PROSTATE. Acute inflammation of the prostate, if unsubdued, occasionally terminates in abscess. The event, however, is unfrequent, though the reverse, I am well aware, has been asserted by many writers. There may be a greater proclivity to this occurrence in the in- habitants of some countries than in those of others, growing out of their habits of life, the nature of their pursuits, and the in- fluence of climate; and hence when I assert that it is uncommon, I wish to be understood as having special reference to the peo- ple among whom I practise. A careful examination of the structure ABSCESS OF THE PROSTATE. 531 of the prostate is sufficient to convince any one that it is ill-adapted, if such an expression is allowable, to become the seat of abscess. In this respect, this organ may be said to bear a close resemblance to the uterus, liver, spleen, and pancreas. Sfat.—Any part of the prostate may become the seat of abscess, and I am not aware that the occurrence is more frequent in one situation than it is in another. The middle lobe, however, is less liable to suffer than the rest of the organ, and often escapes entirely even when the latter is nearly destroyed by it. The matter may be seated upon the surface of the gland, immediately beneath its fibrous capsule, in its proper parenchymatous structure, or in its excretory ducts. Occasionally it exists simultaneously at all these points. In the annexed cut, the abscess was seated in the lateral lobe. Fig. 78. Number, Size, and Structure.—Abscesses of the prostate vary much both in their number and size. Sometimes, and this is what happens most frequently, there is only one, while at other times there are as many as six or eight, a dozen, fifteen, or even twenty, scattered through the substance of the organ, and giving it, when their contents are removed, a riddled, sieve-like appearance, not un- like that of the cribriform lamella of the ethmoid bone. Under such circumstances it is not unusual for several of them to communicate together. When numerous, their dimensions are generally propor- tionably small, not exceeding, perhaps, the volume of a millet-seed or a pea. A solitary abscess of large size is sometimes seen. Sir Benjamin Brodie relates the history of one which contained at least half a pint of pus; the patient was an old man, and the matter escaped through the catheter after the urine had been drawn off. A similar case is mentioned by J. L. Petit ;* and doubtless many others have occurred in practice. 1 (Euvres Chirurgicales, T. iii. 532 DISEASES AND INJURIES OF THE PROSTATE GLAND. When the abscess is of long standing, or slow in finding an outlet, it is generally, no matter what may be it's size, surrounded by a cyst, of a pale yellowish colour, smooth internally, rough and flocculent on the outside, dense in texture, and from the fourth of a line to a line in thickness. The contents of such a depfit do not differ essen- tially from those of a common phlegmonous abscess in other parts of the body. In general, they are of a light straw colour, and of a thick, cream-like consistence, free from odour, and possessed of all the properties of laudable pus. Sometimes, however, they are more or less bloody, or sero-sanguinolent, and intermixed with lymph, mucus, and the debris of the affected gland. Occasionally, espe- cially when it is long retained, the matter is excessively foetid. The structures around the abscess are infiltrated with serous and other fluids, more or less softened, and of a brownish or reddish ap- pearance, from the injected condition of their capillaries. When the purulent depots are numerous, they are sometimes entirely dis- organized, and converted into a substance closely resembling wet tow. A common and almost a necessary effect of an abscess of the prostate is the formation of a cavity, which is often more serious in its consequences than the abscess itself. Abscesses of the prostate open in different directions, as the urethra and the bladder, the rectum, the perinseum, and the perito- neal cavity. A knowledge of these circumstances is of no little importance in a practical point of view, and it is proper, therefore, that the subject should be considered somewhat in detail. a. The most natural, though at the same time the most unfortunate direction, as it respects the affected structures, in which the abscess opens, is into the urinary bladder, or the orifice of the urethra, from which the matter is subsequently discharged along with the urine. Sometimes the abscess points and breaks almost simultaneously at both these situations. When it is bulky, a large quantity of pus may thus be evacuated at once; or it may drain off slowly and almost imperceptibly. In the former case, the matter may be dis- charged in a pure state, or it may be mixed with the urine, which will then be of a lactescent, whitish, or grayish appearance, and perhaps more or less offensive; in the latter, the urine will exhibit little, if any, change, and deposit merely a thin, whitish sediment, visible at the bottom of the receiver. b. The matter may be evacuated into the rectum, and be dis- charged either alone or in union with the fseces. This mode of ABSCESS OF THE PROSTATE. 533 communication is by no means uncommon, and is almost certain to occur when the abscess is developed in the posterior part of the gland. The abnormal opening, situated at a variable height from the anal outlet, is generally within reach of the finger, and often continues fistulous a long time, permitting a ready interchange of the contents of the two reservoirs. The disease, in this case, is frequently complicated with inflammation and suppuration of the seminal vesicles and the adjacent structures. c. In the third place, the pus may escape externally by inducing ulceration of the structures of the perinseum. The progress of the fluid is indicated by excessive pain in the part, and by a hard, red, circumscribed swelling, which finally points, and breaks. In some instances the matter escapes into the surrounding cellular tissue, and extends upwards to the scrotum and even the penis, following the same course that the urine does when it is infiltrated into the peri- nseum. d. Finally, the abscess may burst into the peritoneal cavity, at the side or posterior part of the prostate, and so cause fatal inflam- mation. The occurrence, which is fortunately very rare, is an- nounced by severe pain in the pelvic region, a small, quick, and contracted pulse, violent rigors, and rapid prostration of the vital powers. Death usually occurs in from thirty-six to forty-eight hours. Such are the various points at which the matter of a prostatic abscess may ultimately find an outlet. Of these the first is, as pre- viously stated, the most natural as well as the most frequent, but also at the same time the most undesirable one, as it involves a greater amount of risk to the patient, from the contact of the urine with the cavity of the purulent dep6t after the escape of its contents. In this way an additional cause of inflammation is produced, which often operates to the destruction both of the part and the system. The passage of the matter across the perinseum is uncommon, though the contrary has been asserted by Sir Benjamin Brodie,1 and is always 1 " The abscess, if left to take its own course, sometimes bursts internally, that is, into the urethra; more frequently it makes its way through the fascia, cellular membrane, and muscles of the perinaeum, and bursts through the external skin." Lectures on the Diseases of the Urinary Organs, p. 112, second edition. London, 1835. Amussat asserts that abscesses of the prostate scarcely ever open spontane- ously on the outside, or require the employment of the bistoury. The pus, he adds, most frequently enters the urethra, either in consequence of the efforts of the patient in urinating, or the introduction of the catheter. Lectures on Retention of Urine and the Diseases of the Prostate, translated by Dr. Jervey, p. 86. Phila. 1840. 534 DISEASES AND INJURIES OF THE PROSTATE GLAND. attended with great delay and immense suffering, on account of the resistance offered by the fascia and muscles in this region. The escape of the pus through the rectum is unfortunate, as it frequently entails obstinate fistula; but the most disastrous route of all is that in which the contents of the abscess pass into the peritoneal cavity, and excite fatal inflammation. Age and Causes.—This disease occurs at all periods of life, though not with equal frequency. Young men and adults are most prone to it; on the contrary, it is very rare in childhood and old age. Mr. Mayo1 records an interesting case of it in an infant of two years. The abscess was of large size, and communicated by a considerable orifice with the urethra. The exciting causes are the same as those of inflammation of the prostate, and need not, therefore, be repeated in this place. It is not known what influence, if any, is exerted upon the production of this complaint by occupation, season, climate, and other circumstances. It is supposed by many, and not without reason, that chronic enlargement of the prostate, and an arthritic diathesis powerfully predispose to its occurrence. Abscesses of the prostate are sometimes of a scrofulous nature. Very recently I observed an instance of this kind, in a lad about fourteen years of age, a subject in the dissecting-room. He was very tall and slender for his age, and the abscess, which Avas less than a grain of coffee, occupied the posterior extremity of the left lateral lobe, and was filled with softened tubercular matter. The gland was, in other respects, perfectly healthy. No history of the case could be obtained. Scrofulous abscesses are necessarily chronic, and insidious in their character. Symptoms. — The formation of abscess of the prostate is not always announced by characteristic phenomena, and hence it not unfrequently happens that the first intimation which the patient and his attendant have of the real nature of the case is a sudden dis- charge of pus along the urethra, consequent upon the introduction of the catheter, or a violent effort at micturition. In general, how- ever, when this event is about to take place, there is an increase of all the previous symptoms, both local and constitutional. The pain becomes exceedingly violent, and assumes an aching, throbbing character; there is a sense of weight and pressure at the neck of the bladder; the patient has almost a constant desire to void his 1 Outlines of Human Pathology, p. 547. London, 1836. ABSCESS OF THE PROSTATE. 535 urine, which is discharged with much difficulty, and either in drops, or in a small and feeble stream ; the urethra is the seat of a scalding or burning sensation ; the rectum feels as if it were distended by a foreign body; and more or less uneasiness is experienced in all the associated organs. In some instances the local suffering is of the most agonizing description, depriving the patient of appetite and sleep, and rapidly undermining the vital powers. Complete reten- tion of urine occasionally supervenes. Along with these symptoms there are generally severe rigors, alternating with flushes of heat, intense thirst, excessive restlessness, high fever, and even delirium. When this combination of phenomena exists there can hardly be any doubt about the nature of the case, especially if the individual has previously laboured under acute or chronic prostatitis. An examina- tion by the rectum will afford additional light, and will often detect fluctuation, more particularly if the matter occupies the posterior part of the gland. At an advanced stage of the complaint, the abscess may point in the bowel, or in the perinseum, and thus remove all doubt respecting the diagnosis. Prognosis.—Abscess of the prostate is generally to be regarded as a dangerous affection. The local suffering, if not promptly sub- dued by a natural or artificial outlet for the pent-up fluid, is of itself sufficient, in may cases, to bring on serious, if not fatal exhaustion. It behooves us, therefore, to be ahvays guarded in our prognosis. Even under the most favourable circumstances, and where there is apparently little danger from the immediate ravages of the malady, the patient may fall a victim to its secondary effects. One of the worst consequences of this affection is a fistulous communication with the rectum, the urethra, the perinseum, or urinary bladder, which it is sometimes impossible to heal, and which renders the individual alike uncomfortable to himself and disagreeable to those around him. A large abscess is, of course, all other circumstances being equal, more dangerous than a small one, and a number of small ones than a solitary small one. The prognosis, moreover, will be materially influenced by the patient's habits, his age, and his pre- vious health. Treatment.—In the treatment of this malady two important in- dications are presented; first, to limit the suppurative action, and secondly, to afford as speedy an outlet as possible to the effused fluid. To fulfil the first of these objects, prompt recourse must be had to depletion, provided this has not been already carried suffi- 536 DISEASES AND INJURIES OF THE PROSTATE GLAND. ciently far, to antimonials, diaphoretics, anodynes, and emollient applications. Leeches to the perinseum and the loAver part of the hypogastrium will often prove eminently serviceable, and can seldom be dispensed with. They should be applied in numbers varying with the age of the patient, the progress and intensity of the disease, and the nature of the previous treatment. For an adult, not less than twenty or twenty-five will be likely to ansAver the purpose; after they have dropped off, the flow of blood should be encouraged with cloths wrung out of warm Avater, and renewed every eight or ten minutes for several hours, unless signs of exhaustion appear, when it must be at once arrested. By these means, promptly and faithfully employed, the suppurative process is limited, the suffering subdued, and the abscess brought to a state of maturity. The second indication to be fulfilled is the opening of the abscess; and the question therefore arises, are we justifiable in doing this ? Not a few practitioners are of opinion that such collections should always be permitted to pursue their own course, on account of the uncertainty of distinguishing them and the difficulty of reaching them with the knife. I cannot agree in the propriety of this advice. As long as the matter is pent up the part is unrelieved, and the ab- scess has a tendency to increase and produce further mischief; nay, its contents may burrow extensively among the adjacent structures, doing great injury not only to them but also to the prostate, and finally, perhaps, escaping into the pelvic cavity; an event certain to be followed by fatal peritonitis. It is absurd to look upon an ab- scess of the prostate as a peculiar affection, for it does not differ from a phlegmonous abscess in any other part of the body, except by its situation, and there is nothing in this, I conceive, that should exempt it from ordinary treatment. The rule, therefore, which should be adopted in all cases of this disease, is to anticipate nature by an artificial opening, instead of allowing her to pursue her own wayward course; a course which is frequently tedious, ill-directed, and inadequate. It has been already stated that the most favourable route for the escape of the matter is through the perinseum, and hence, whenever it points in this direction, no time should be lost in furnishing it an outlet. For this purpose a long, straight, narrow-pointed bistoury is much preferable to an abscess lancet, Avhich is not only unsteady in the handle but too short in the blade; even if it be pushed up as far as its shoulders. The incision should be made in the most promi- ABSCESS OF THE PROSTATE. 537 nent part of the swelling, and care should be taken, on the one hand, to avoid the rectum, and, on the other, the urethra and urinary bladder. It must be quite free, and made as dependent as possible. A small tent may be retained in the track for a few days to prevent premature closure. When the abscess points in the rectum, as will be indicated by the large size and fluctuating character of the swelling, it may be readily reached with a curved trocar, four or five inches long. The patient is placed as in the operation of lithotomy, and the left index and middle fingers, well oiled, are carried up the bowel until they come in contact with the most prominent part of the abscess. The trocar, concealed within its canula, is then placed in the groove formed by the junction of the two fingers, and as soon as it has reached its destination, it is thrust into the swelling, and immediately withdrawn, at the same time that the canula is pushed farther in. When the matter is discharged, the instrument is removed, and the case is treated upon general principles. For some days after the opera- tion the lower bowel should be kept as quiescent as possible. When the abscess bulges inwards towards the urethra and the neck of the bladder, it may be punctured with a common silver catheter, carried down in the usual way, and moved about in different direc- tions, as in searching for a urinary calculus. Or, instead of this, a sound with a conical beak and a small curve, may be used, and this, on the whole, is preferable, inasmuch as it can be made to pierce the abscess with more facility. The slightest pressure frequently suffices to effect our object. When the abscess is not yet completely matured, and the local suffering is such as to render delay improper, the operation may be executed with the lancetted stylet used for dividing strictures of the urethra. When, by any of these proce- dures, the matter has been evacuated, the urine should be frequently drawn off with the catheter, to prevent its entrance and sojourn in the interior of the sac ; an occurrence not only productive of exquisite pain and spasm, but liable to be followed by the worst consequences as it respects the recovery of the affected gland. When the parts are tolerant of the presence of the instrument, it may be permanently retained in the urinary passages, until all danger from the above cause is past. When the abscess is of a scrofulous character, as indicated by the nature of the pus, the system should be subjected to the influence of iodine and tonics. 538 DISEASES AND INJURIES OF THE PROSTATE GLAND. SECTION III. ULCERATION OF THE PROSTATE. Ulceration of the prostate is of such infrequent occurrence, and of such difficult recognition, that if it were not for my desire to pre- sent a full and connected view of the maladies of this organ, I should hardly deem it necessary to allude to it here. The lesion Avas first described by Sir Everard Home, in his monograph on the Diseases of the Prostate Gland, published at London in 1811; but, with the exception of Vidal, no writer on surgery has considered it of suffi- cient importance to incorporate an account of it in his work. Ci- viale has devoted a short chapter to it in his Treatise on the Urinary Organs, consisting chiefly of a repetition of the observations of the English surgeon. The disease is induced by various causes, of which the principal are, the presence of calculous concretions in the substance of the organ, wounds, or lacerations, whether by accident or the forcible employment of instruments, and the formation and evacuation of abscesses. Of these, the first and third are doubtless the most common. Wounds of the prostate, whether incised or lacerated, generally heal in a short time, either by the first intention, or by the granulating process. It is only in rare instances that they are fol- lowed by ulceration, or sloughing. When stones exist in the gland in considerable numbers, they gradually produce absorption of the adjacent parenchymatous textures, and thus lead to the formation of corresponding ulcers. If the irritation continues, the intervening septa are gradually broken down, and a large cavity is the result. A single concretion, especially if of large size, occasionally causes similar effects, and may even lead to perforation of the rectum or perinseum. The evacuation of an abscess is necessarily followed by an ulcer, which, serving as a receptacle for the urine, remains open for a great length of time, if, indeed, it ever heals. In the tubercular form of the affection, a considerable number of ulcers occasionally ensue from the bursting of the purulent depots, which are frequently quite numerous. The lesion may occupy the entire gland, or be confined to a particular part. The middle lobe, when in a state of enlargement, suffers perhaps quite as frequently as any other portion. Sometimes the ulcerative process begins simultaneously at several ULCERATION OF THE PROSTATE. 539 points, which, gradually increasing, finally coalesce, and thus form one large cavity. When the result of abscess, a prostatic calculus, or a slough, the ulcer is generally ragged and irregular, and becomes lined in time by an organized false membrane. The symptoms which accompany ulceration of the prostate are such as indicate the existence of chronic disease of this organ and of the neck of the bladder. The patient has a frequent desire to make water, the passage of which is attended with a scalding sensa- tion along the urethra, and more or less spasm and tenesmus; there is severe pain in the region of the affected part, of a sharp, burning, or lancinating character, and darting through the neighbouring parts ; constant itching and uneasiness are experienced in the head of the penis; and the urine, which is voided perhaps every half hour, is more or less turbid, and loaded Avith a thick, glairy, ropy mucus. Occasionally there is a discharge of blood, variable in quantity, as well as in regard to the frequency of its recurrence. The local symp- toms, in fact, generally strongly simulate those of vesical calculi. In the progress of the disease, the constitution necessarily suffers; the digestive organs become deranged; the flesh wastes; the coun- tenance is wan, thin, and haggard; the pulse is small and irritable ; and the patient, worn out by the loss of sleep, and physical suffer- ing, gradually falls into a state of marasmus, from which he is des- tined never to recover. " The best distinguishing mark," says Sir Everard Home,1 " which I have learned, from experience, of a diseased state of the prostate gland, is the viscid mucus mixed with the urine. This mucus, I am convinced, is produced entirely from that gland, and is met with whenever its functions are much disturbed. The occasional appearance of this mucus is a consequence of every attack of inflammation from whatever cause; but when it continues without abatement, whatever mode of life the patient follows, and whatever medical treatment is adopted, and lasts for months, there is no doubt of a permanent disease having taken place in the gland; either an ulcerated state of the surface of the middle lobe, of one of the lateral lobes, or an ulcer in the substance of the gland." The introduction of the ca- theter is always attended Avith excessive pain, and an aggravation of the local distress; pressure.on the perinseum, and insertion of the linger into the rectum, produce similar effects. In the more violent forms of the affection, the patient finds it impossible to remain long 1 Op. cit., p. 234. 540 DISEASES AND INJURIES OF THE PROSTATE GLAND. in the erect posture, or even to sit on a chair; all active exercise, in fact, is impracticable. Perhaps the most reliable circumstances, in a diagnostic point of view, are, the absence of vesical calculi, long- continued suffering in the region of the neck of the bladder, a con- stant secretion of thick, glairy mucus, a frequent desire to void the urine, and an occasional discharge of blood. During the progress of this affection, disease is apt to be awakened in the other parts of the urinary passages. The bladder and urethra become inflamed, tender, and exquisitely irritable, and occasionally even the seat of ulcerative action. The ureters and kidneys are also sometimes liable to suffer; the urine is changed in its proper- ties ; and calculi occasionally form in the bladder; thus greatly com- plicating the case. The testicles often become tender, hemorrhoids form round the anus, and the bowel descends during micturition. It need hardly be said that the affection under consideration is one of an exceedingly grave character. The chief danger arises from the function of the parts, and the constant presence of the urine, which, fretting and irritating the affected surfaces, prevents them from cicatrizing. Hence, the disease is always intractable, and seldom fails to prove fatal. The period at which this event occurs varies from a few months to several years. The treatment of ulceration is altogether unsatisfactory and empi- rical. Attention must be paid to the general health, by regulating the diet, the bowels, and the secretions ; the warm bath should be used from time to time ;.the patient should avoid exercise and the erect posture; pain should be allayed by opiates ; the bladder occasionally washed out with tepid water, either simple or medicated; and the affected surfaces should be lightly touched once every five or six days with a weak solution—ten grains to the ounce—of nitrate of silver, applied with a piece of soft sponge, projected from a silver canula. If the pain, scalding, and spasm are great, leeches and counter-irritation will be beneficial. The best internal remedies are balsam of copaiba, cubebs, and spirits of turpentine largely diluted with demulcent fluids. The following case, for the particulars of which I am indebted to the politeness of Dr. Bowen, curator of the Pathological Museum of the New York Hospital, affords a well-marked example of ulcera- tion of the prostate, but whether the disease began in this organ, or in the urethra or bladder, it is impossible to determine. The pre- paration marked 660 is described as one of chronic cystitis and pyeletis. ULCERATION OF THE PROSTATE. 541 John Johnson, aged 35, seaman, was admitted January 24, 1850, for supposed stone in the bladder. None, however, was found upon sounding. He had the aspect of a person suffering from serious organic disease; he was emaciated and very feeble, and had a small, weak pulse, without any acceleration, and a cool skin. There Avas no hectic. He had a frequent desire to pass his water, attended with pain and scalding, especially in the posterior part of the urethra. The flow of urine Avas sometimes free, sometimes obstructed ; the region of the bladder felt tender on pressure; and there was occa- sionally a sharp, lancinating pain in the testicles, which were often very much retracted. The left one was slightly enlarged, and some tenderness extended along the corresponding cord. There was no pain or suffering in the region of the kidneys. The urine was of a deep red colour, slightly acid, and of the specific gravity of 1*020, but of normal quantity. After standing a short time, it deposited a copious sediment of pus and blood. The patient stated that about a year before his admission he first experienced a scalding sensation in passing his water, with a diminution of the stream; that he never had gonorrhoea or other venereal disease; and that the introduction of a bougie was followed by a discharge of bloody urine, which con- tinued for two or three weeks. The stream of urine Avas sometimes natural, sometimes lessened, and sometimes obstructed by stringy mucus. The patient had a tendency to diarrhoea, and gradual ex- haustion of the vital powers. There Avas no evidence of renal disease. Under the influence of carbonate of potash, the suffering decreased, until the urine became alkaline, when the pus was replaced by a stringy mucus, which sometimes obstructed the urethra. The urine gradually lost its bloody appearance, and its specific gravity fell to 1*012. After the alkalies were discontinued, it gradually regained its acid properties. The diarrhoea was checked for a time, but soon returned; the dejections being of a peculiar orange colour, without mucus or blood. Suppression of urine came on two days before death, AA'hich happened on the 15th of March. An examination of the body revealed the following facts. The intestines were united to the bladder, the left ureter, kidney, and spleen, by old and firm adhesions, and all, except the latter, were imbedded in a thick, dense layer of organized lymph. The convex surface of the liver was glued to the diaphragm by recent effusion. The urethra, laid open along its dorsal surface, presented nothing unusual, except a slight slaty discoloration, and an unnatural degree of vascularity. At the posterior extremity of the membranous por- 542 DISEASES AND INJURIES OF THE PROSTATE GLAND. tion, the walls suddenly ceased by a well-defined ulcerated edge, the tube terminating in a large cavity, capable of containing an ounce of fluid, and lined by an organized false membrane. The cavity occupied precisely the situation of the prostate gland, of which not a vestige could be perceived. About an inch in front of the cavity, and extending some distance along the urethra, is a dense, firm tex- ture, which is evidently the remains of a stricture. Beyond the cavity, the neck of the bladder Avas distinguishable, but greatly deformed by irregular ulceration ; its muscular fibres being hyper- trophied and ragged. The cavity of the bladder contained at least half a pint of pus ; it was preternaturally small, and had lost its proper shape. It exhibited a dark red appearance, and Avas com- pletely deprived of mucous membrane. The muscular fibres were hypertrophied, dark red, brittle, and everywhere exposed as if they had been dissected. Here and there they were destroyed by ulcera- tion. The peritoneal coat was inseparably united by a thick, false membrane with the surrounding parts. Immediately upon the fundus of the bladder, and limited by firm adhesions, was an abscess, of about the diameter of the large intestine. From this point it ex- tended upwards and over towards the left side, following the course of the ureter, and terminating behind the left kidney, about its mid- dle. It was evidently of ancient origin, had organized walls, and was capable of containing fully a pint of matter. While examining the cavity of the abscess, the left ureter, enlarged and thickened, could be plainly seen, just above its middle portion, and on its ante- rior surface, to communicate with the abscess by an irregular opening, half an inch in length. The canal was perfectly free in its entire extent. The left kidney, invested by a thick, firm, false membrane, was of the natural volume. On incising the organ, a quantity of thick pus gushed out, and its tubular structure was found to be nearly destroyed. The cortical structure was healthy. The right kidney was sound. The lungs contained some miliary tubercles. All the other organs were in a natural state. It is impossible, as already stated, to determine, from the history of this interesting case, where the disease commenced. The proba- bility is, as Dr. Bowen has suggested in his comments respecting it, that the patient, although he denied it, had gonorrhoea, terminating in stricture, and this, in its turn, in inflammation, which gradually extended to the prostate gland, and from thence to the bladder, the peritoneum, the left ureter, and kidney, producing the ravages which were revealed by the dissection. CHAPTER III. HYPERTROPHY OF THE PROSTATE. Hypertrophy is an augmentation of the volume of the prostate, produced by increased nutrition of its constitutional elements. There are several forms of it, but the most common by far is that to which the term senile has been applied, from its being a frequent accom- paniment of old age. Until the latter part of the last century, this affection was very imperfectly understood. Muralt, Bartholin, Bon- netus, Morgagni, Sandifort, Herhold, and others, indeed, had each seen and described cases of it; but it had not particularly arrested their attention, nor led to any valuable practical inferences. It was reserved for John Hunter to throw new light on this subject. In his " Treatise on the Venereal Disease," issued in 1786, he gave a succinct but graphic account of it, pointed out its principal effects upon the urinary apparatus, and spoke of the means best adapted for relieving it. The picture thus drawn by this illustrious master was subsequently most ably filled up by his nephew, Sir Everard Home, Avhose monograph on the "Treatment of the Diseases of the Prostate Gland" appeared in London in 1811, and comprises the most elaborate body of facts that has ever been published on the subject. Since that period the malady has attracted general profes- sional attention, and has been described, though seldom with any minuteness, in most systematic treatises on surgery. Very recently, valuable contributions to this department of pathology and practice have been made by Mercier and Civiale, of Paris, in their works on the genito-urinary organs. Sir Benjamin C. Brodie has also pub- lished some excellent observations upon the subject. Seat.—Hypertrophy may occur in any part of the prostate, and exist in various degrees. Most commonly it affects the entire gland, though not uniformly. It has been very generally believed, in con- sequence, probably, of a statement of Sir Everard Home, that the 544 DISEASES AND INJURIES OF THE PROSTATE GLAND. left lobe is more frequently involved than the right. The opinion, however, is not borne out by the results of dissection; and no reason, anatomical, physiological, or pathological, can be assigned for the occurrence, supposing it to exist. My own experience does not enable me to settle the question; a circumstance which I regret so much the less, because, practically considered, it is really of no importance one way or another. In nearly all cases, when the hypertrophy has made considerable progress, both the lateral masses are implicated; not necessarily, however, in the same degree. Occasionally the lesion is almost exclusively confined to the third lobe, and that too, perhaps, Avhen the enlargement is so great as to cause retention of urine, and, ultimately, the patient's death. Degree and Form.—The hypertrophy exists in various degrees, from the slightest augmentation of the natural volume of the pros- tate to the dimensions of a pullet's egg, a walnut, or a medium-sized orange. In rare cases, indeed, it may even considerably exceed the latter dimensions. Bartholin records an instance in which the gland is said to have equalled the size of a man's head; but this is evi- dently an exaggeration, as is proved by the fact that the pelvic cavity is incapable of containing a body of this magnitude. The greatest increase of volume usually occurs in the long axis of the organ, in consequence, no doubt, of the want of resistance in this direction. Under these circumstances, the lateral lobes are of an elongated, oval shape, generally larger in the middle than at the extremities, convex in front, and rather compressed behind. When, on the contrary, the hypertrophy advances equally in all directions, these bodies will be apt to be somewhat obround, or like the half of an orange. Enlargement of the gland in front and below is opposed by the elevator muscles of the anus, the deep perinseal fascia, and the pubic bones. Occasionally the organ increases more in the transverse than in the vertical diameter, extending outwards towards the sides of the pelvis, and thus overlapping and compressing the rectum. The adjoining engraving, Fig. 79, from a specimen in the collection of Dr. Sabine, of New York, represents the prostate greatly enlarged in every direction, and of a flattened, cylindrical shape. The size is reduced one half. When the lateral masses are equally enlarged, they frequently project inwards towards the median line, so as almost to touch each other. This occurrence, however, is rare, and is met with only in the more aggravated forms of the malady. More commonly there HYPERTROPHY OF THE PROSTATE. 545 is a small interval between them, representing the appearance, when the gland is laid open longitudinally along its pubic surface, of a median groove or gutter. When one lateral lobe is more enlarged than the other, the more bulky one frequently encroaches more or Fig. 79. less upon the smaller one, and thus produces a lateral curvature, or a change in * the direction of the neck of the bladder and the com- mencement of the urethra. Again, it occasionally happens that one lobe projects over on one side, and the other lobe on the opposite, giving rise thereby to two curvatures instead of one, as in the former case. Fig. 80. Whatever may be the shape of the enlarged masses, or the direc- tion in Avhich the hypertrophy occurs, their surfaces, both external 35 546 DISEASES AND INJURIES OF THE PROSTATE GLAND. and internal, may be perfectly smooth, or they may be more or lesa irregular, knotty, and even lobulated. Sometimes small prominences exist upon them, attached by a broad base, and evidently prolonged from their proper substance, which they resemble in colour and structure. Fig. 80, from a specimen in my collection, exhibits this form of the enlargement. Several such bodies are occasionally found close together, thus producing a lobulated appearance. Cysts sometimes form in the enlarged masses, from the size of a pea up to that of a large marble, filled with serous fluid, and lined by a sort of false membrane. Finally, the surface of these bodies has been found excoriated, fissured, and even ulcerated. When the middle lobe is hypertrophied, it generally forms a sort of mammillary process, which is more or less vertical in its position, and varies in size from that of the female nipple to that of a pullet's egg, Fig. 811 and Fig. 82. The apex of the tumour is free and Fig. 81. Fig. 82. rounded, while the base is immovably fixed, and rests as it were upon the posterior extremity of each lateral mass. Its position is usually 1 From a specimen in the private collection of Professor Mott, in the College of Physicians and Surgeons of New York. It may be stated here that all the figures, illustrative of enlargement of the prostate, are original. HYPERTROPHY OF THE PROSTATE. 547 median; but sometimes I have found it to project more to one side than the other, and thus create an additional impediment to the introduction of the catheter. Although the form of the third lobe, when hypertrophied, is generally as here represented, cases occasion- ally occur in which it is exceedingly irregular, setting everything like accuracy of description at defiance. Next to the mammillated variety, is, according to my own observation, the triangular, in which the tumour is large behind and narrow in front, terminating in a tolerably sharp crest. More rarely it is of a rounded shape, or broad and convex on its free surface, and adherent by a small pedicle. I have seen specimens in which the swelling consisted of three ob- long bodies, placed side by side; as in Fig. 83, from a specimen in Fig. 83. my private cabinet; and examples are recorded in which there were as many as four and even five such lobes. Whatever be the form and volume of the tumour, it ahvays projects towards the bladder, drawing up the prostatic portion of the urethra, and elongating the verumontanum. Consistence. — The consistence of a hypertrophied prostate is liable to considerable diversity, and occurs under two very opposite forms, the hard and the soft. In the first, the more frequent of the two, the induration varies from the slightest increase of the natural consistence to the firmness of the fibrous tissue. It was OAvinff no doubt to this circumstance that the older pathologists were so con- 548 DISEASES AND INJURIES OF THE PROSTATE GLAND. stantly in the habit of considering this affection as being of a scir- rhous character; an error, perhaps, not entirely exploded at the present day. When the induration exists in a high degree, the affected part tears with difficulty, and offers considerable resistance to the scalpel, but does not yield a crepitating sound. Interspersed through its substance are numerous granulations, of a grayish colour, rounded or oval in their shape, and hardly as large as a millet-seed. They are inclosed each in a cellulo-fibrous Capsule, to which they adhere by a delicate pedicle, and from Avhich they may be easily enucleated. A section of the gland exhibits a rough, irregular sur- face, caused by the manner in Avhich the granulations project from the cells or lodges in which they are naturally embedded. By pressure, a thin, milky fluid is obtained from it, which is probably merely the prostatic fluid, somewhat altered in its properties and slightly increased in quantity. In the soft variety, the enlargement proceeds in a more uniform manner, and attains, as a general rule, a greater magnitude than in the hard. The affected tissues are more or less elastic, and yield readily under the pressure of the finger. The granulations are larger and more conspicuous than in the first variety, are of a soft, spongy texture, and of a whitish or grayish aspect. By a little care they can be easily separated from their cellulo-fibrous capsules, Avhen it will be found that their principal bond of union is a delicate pedi- cle, through which they receive their blood-vessels, nerves, and lym- phatics. Their shape is the same as in the hard variety, and the fluid which exudes from them on pressure is a little more abundant, and of an opaque, milky, yellowish, or brownish hue. The nature of the granulations above described is not well-ascer- tained. It is highly probable, however, that they are nothing but the terminal follicles of the prostate, in a state of enlargement and partial occlusion. The capsules in which they are inclosed are of a dense, fibrous structure, and are evidently formed out of the natural fibrous element, very much hypertrophied. The lesion bears the greatest analogy to cirrhosis of the liver, so ably described by Laennec, Carswell, and other pathologists. Colour.—From the remarks made on the structure of the prostate in a previous section, it would appear that its colour varies in the different periods of life, from circumstances directly dependent upon its nutritive functions. In senile hypertrophy, which generally takes place under the influence of causes operating in a slow and gradual HYPERTROPHY OF THE PROSTATE. 549 manner, there is usually a diminution of colour, in consequence, ap- parently, of the concomitant compression of the capillary vessels which ramify through the substance of the organ. Hence, if a section be made of the parenchymatous structure, the surface will be seen to be of a dull grayish, light ash, or pale drab tint, and to emit hardly any blood on pressure. When the hypertrophy is pro- duced and kept up by irritation, there is sometimes an increase of colour, and an augmented capillary circulation. Under such cir- cumstances, the parenchymatous substance may exhibit various shades of red and broAvn, and afford a considerable quantity of blood under pressure and maceration. Weight.—The Aveight of a hypertrophied prostate is necessarily augmented in all cases. In the adult, as was before stated, the average weight is from three to five drachms. In the affection under consideration the increase of Aveight ranges from a few grains to several drachms. In the more aggravated forms, it sometimes amounts to several ounces. Ford1 relates an instance in which the organ weighed nine ounces. Causes.—Hypertrophy is always produced under the influence of causes which act in a slow and permanent manner. When the ope- ration of the exciting agent is brief and transitory, the result is merely a temporary enlargement, from which the organ gradually recovers by its oavii energies as soon as the irritation which awakened it is removed. Habitual engorgement acts in the former manner, and may, therefore, be regarded, in all cases, as the immediate cause of the affection. Augmented action necessarily occasions an aug- mented afflux of blood, and a corresponding increase of nutrition. Diminished action has a reverse effect. A great variety of causes, some of them real, and others imaginary, have been assigned as being capable of producing this disease. Amongst the former have been generally enumerated excessive ve- nery, stricture of the urethra, disease of the bladder, horseback exercise, gonorrhoea, and the employment of stimulating diuretics. That protracted and frequently-repeated sexual intercourse is capable of inducing hypertrophy of the prostate is unquestionable; but that the lesion is often excited in this Avay is a point which re- mains to be established. Men with enlarged prostates are, it is well knoAvn, frequently exceedingly lecherous, from an extension, pro- 1 London Med. and Phys. Jour., March, 1802. 550 DISEASES AND INJURIES OF THE PROSTATE GLAND. bably, of irritation to the ejaculatory ducts and the seminal vesicles; and hence what has so commonly been regarded as a cause may, in reality, be merely an effect of this disease. Be this as it may, hyper- trophy occasionally exists, and that in a high grade, in persons who have led a life of the most perfect chastity. The case of the late Dr. Fothergill of London is one in point here. This celebrated physi- cian, who had laboured for many years under this distressing malady, declared on his death-bed that he had never in his life had sexual intercourse. Stricture of the urethra has been very commonly accused as an exciting cause of this disease, but with what justice is still a mooted question. Sir Everard Home1 is of the opinion that the lesion is frequently induced in this manner, but unfortunately his assertion does not seem to be supported by positive facts. In the cases which came under his observation, in all six or seven in number, the pro- minent symptom was difficulty of micturition; and he has afforded us no means of judging, except in a solitary instance, that this did not depend exclusively upon the stricture. In the latter case, the patient, who was seventy-six years old, died, and the prostate was found en- larged in its whole extent. No post mortem examination was made in any of his other cases. Civiale2 declares that the prostate is usually healthy in persons affected with permanent stricture; and he adds that the same thing frequently happens from other disorders giving rise to retention of urine. Mercier3 thinks that stricture of the urethra, so far from being a cause of hypertrophy of this body, is generally cal- culated to produce the converse of this effect. The pressure which the accumulated urine constantly exerts upon the gland, under such circumstances, impedes its capillary circulation, and opposes its nutri- tion. My own experience fully corroborates the conclusion of the French surgeons, and I am therefore inclined to believe, that, when the two affections occur together, they should be viewed in the light, not of cause and effect, but merely as coincident disorders. I have seen quite a number of cases of stricture in old men in whom the prostate was little, if at all, enlarged. A considerable hypertrophy of the prostate is occasionally deve- loped under the influence of the irritation resulting from the presence of a vesical calculus. That cases of this kind are not uncommon is 1 Practical Observations on the Treatment of the Diseases of the Prostate Gland. 2 Traite" des Maladies de l'Urethre, p. 116. 3 Op. cit. p. 205. HYPERTROPHY OF THE PROSTATE. 551 a matter of daily observation. The affection thus produced is some- times noticed at a very tender age, and is sufficiently frequent in old subjects. The irritation upon which the hypertrophy in such cases depends may originate either in the gland itself, or it may be propa- gated to it from the urinary bladder. In either event, it is followed by an increased capillary circulation, and a corresponding augmen- tation of the nutritive function. Another very common cause, as is supposed, is horseback exercise. This is always attended with a rapid succession of shocks of the pelvis and pressure of the perinseum, and is liable to be followed by venous congestion of the prostate. This idea is certainly plausible, but it labours under the disadvantage of not being sustained by a solitary proof. I am acquainted with a great many country physicians, clergymen, sheriffs, constables, and collectors, who are in the daily habit of riding on horseback, and yet are wholly free from this affection. I am not aware that cavalry men and dragoons are more obnoxious to it than other persons. Velpeau, Acton, and several other writers lay much stress upon gonorrhoea as an exciting cause of this lesion, and there is no doubt that it often leads to this result. The specific disease frequently extends to the posterior part of the urethra and even to the neck of the bladder, where, if it is permitted to remain for any length of time, it is very apt to produce permanent engorgement of the pro- state, followed by hypertrophy of its parenchymatous structure. The gland appears in this case to suffer from an extension of the dis- ease in the same manner as the testicle sometimes does. This form of the lesion occasionally exists at a comparatively early age, and that, too, in a high degree. It has not been ascertained to what extent, if any, the prostate is liable to be influenced by constitutional syphilis. It may be sup- posed, however, that, like the testicle and spermatic cord, it may suffer in the secondary and tertiary forms of this malady ; a conjec- ture Avhich derives countenance from the fact that this organ is tra- versed by the ejaculatory ducts, in their passage towards the urethra. At all events, it is well enough always, in chronic enlargement of the prostate, to inquire particularly into the patient's habits, and if the two diseases are found to coexist, to treat the case accordingly. Finally, the protracted or frequent use of stimulating diuretics, of wine, and alcoholic drinks ; exposure to cold ; the repulsion of cuta- neous diseases; gout and rheumatism; external violence; the frequent 552 DISEASES AND INJURIES OF THE PROSTATE GLAND. introduction of the catheter; and habitual straining at stool, as in chronic diarrhoea and other affections of the bowels ; may all be enu- merated as so many exciting or predisposing causes of this affection. Period of Life.—Hypertrophy of the prostate is emphatically a disease of old age. While all the other organs of the body, almost without exception, experience a diminution of Aveight and bulk as man approaches the period of decrepitude, the gland in question alone manifests a tendency to transcend the limits assigned to it by nature. No observations that have yet been made afford a clue to this singular circumstance. The senile form of the lesion rarely takes place, at least, in any considerable degree, before the age of fifty, fifty-five, or sixty; slight cases of it are occasionally met with at forty-five, nay, even at forty; but this is exceedingly rare, and constitutes an exception to an important general laAV. The affection is not unfrequently witnessed in old men of seventy, seventy-five, and even eighty ; but when this is the case the probability is that it commenced much earlier, and now shows itself, for the first time, by appropriate symptoms. "When the hair," observes Sir Benjamin Brodie,1 " becomes gray and scanty, Avhen specks of earthy matter begin to be deposited in the tunics of the arteries, and when a white zone is formed at the margin of the cornea, at this same period the prostate gland usually, I might perhaps say invariably, becomes in- creased in size." This view, I am inclined to think, is more poetical than real. The belief, I know, is very general, even in the profes- sion, that there is hardly a man of, fifty who has not an enlarged prostate. My experience has supplied me with no facts in support of this opinion. The conclusion is too SAveeping. The Avord "old" is a relative one, and should be used in no other sense in reference to the present subject. Thus, one man is old at forty, another at fifty, another at sixty, and another, perhaps, not until he is seventy. Gray hair, earthy specks in the coats of the arteries, and a zone around the cornea, are no signs of old age, physiologically and phi- losophically considered. Hypertrophy, not the result of old age, may occur at any period of life, under the influence of inflammatory excitement and vascular engorgement. I have observed cases of it from this cause in subjects under five years of age, and others have met with it still earlier. It is most common, however, in middle life, from an extension of gonorrhoeal inflammation and other sources of permanent irritation. 1 Lectures on the Urinary Organs, p. 118, second edit., 1835. HYPERTROPHY OF THE PROSTATE. 553 Progress.—Senile hypertrophy generally advances very tardily, and hence a long time often elapses before the gland attains such a bulk as to lead to serious inconvenience. In many cases, indeed, after having acquired a certain magnitude, its progress is arrested, and the organ remains stationary for several years, if not during the rest of life. The inflammatory form, on the contrary, is usually more rapid in its march, and may attain a considerable height in a feAV months. It is also less persistent than senile hypertrophy, and is more amenable to treatment. Symptoms.—This change in the condition of the prostate is usually very insidious in its mode of invasion and the circumstances attend- ing its progress. No symptoms, indicative of its seat or peculiar character, show themselves until long after the mischief has com- menced. Its march is not only slow but eminently stealthy and deceptive. The affection, in a word, is chronic from its inception, and cannot, without great difficulty and circumspection, be distin- guished, in its earlier stages, from chronic disease of the bladder and the urethra. Irritation at the neck of the bladder and a frequent desire to pass the urine are the symptoms which generally first attract the atten- tion of the patient. From the mildness, however, of their character, they rarely create any unpleasant apprehensions, and the real nature of the disease, therefore, is often overlooked at a time when a know- ledge of it is of paramount importance. By degrees other troubles are added, and it is in this manner that he is finally brought to a full sense of his situation. The distress at the neck of the bladder becomes more constant, as well as more severe, and there is not only a frequent desire to void the urine, but great difficulty in starting it. The stream also is unnaturally feeble; and, instead of being pro- jected in the form of an arch, as it is in the healthy state of the genito-urinary organs, it falls perpendicularly from the urinary orifice betAvcen the patient's feet, or upon his shoes. Slight pain is felt along the urethra, accompanied by a burning or scalding sensation in the head of the penis, and a free discharge of prostatic fluid. In consequence of the frequent and violent straining which attends the process of micturition, hemorrhoids, hernia, and prolapsion of the bowel are apt to occur; and for the same reason the fseces are liable to be voided simultaneously with the urine. The mucous membrane is sometimes habitually everted at the verge of the anus, and ex- hibits itself in the form of a red, tender fold, which is constantly 554 DISEASES AND INJURIES OF THE PROSTATE GLAND. irritated from exposure to the atmosphere, the contact of acrid secre- tions, and the pressure of the adjacent parts. The rectum never feels entirely empty, even after the most thorough purgation, but as if it contained a lump or ball, and the fseces are often passed in a flattened form, especially if they happen to be of a solid consistence. At night the patient is disturbed by an involuntary discharge of seminal fluid, or he is perhaps harassed with erections Avithout emis- sions. This phenomenon occasionally exists in very old men, and adds greatly to the local distress. The testicles sometimes sympa- thize with the affected gland, and become very tender and even enlarged. In two cases I have found the disease associated with hydrocele on the left side. Hernia may also be produced by the straining which attends the disease. Such are the symptoms which denote the existence of this disease in its earlier stages and in its milder forms. As it advances they become more and more aggravated, though they are still essentially the same in character. The desire to urinate increases in frequency; the bladder is less patient of its contents; the pain is more severe and constant, as well as more extensively diffused; micturition is attended with greater difficulty; and the prostate is the seat of a constant soreness. The general health, which until now was, per- haps, tolerably good, gradually declines, the appetite fails, emacia- tion ensues, and the sufferer, obliged almost incessantly to make water, obtains hardly any sleep. The constitution, assailed by an enemy that gives it no rest, is at length exhausted; the pulse is small and feeble; the surface is dry and hot, or bedewed with a cold, clammy sweat; the feet are cedematous ; the teeth are incrusted with sordes ; the tongue is dry and black ; and the patient falls into a state of coma from which he is destined never to awake. Such is the course of a disease, which, in the amount of distress it entails, is one of the most frightful in the whole catalogue of nosology. Truly the pitcher is broken at the fountain and the wheel at the cistern. The pain which accompanies this affection varies in different indi- viduals and in the same person under different circumstances. It is not in proportion to the size of the organ, but to the difficulty in expelling the urine. It is generally felt most keenly at the neck of the bladder, in the urethra, and at the head of the penis. It is increased by exercise, the erect posture, the pressure of the urine, and by sexual intercourse. In most cases it extends to the sur- HYPERTROPHY OF THE PROSTATE. 555 rounding parts, as the perinseum and the anus, the testes and sper- matic cords, the sacrum, loins, thighs, and groins. It may be dull, heavy, or aching; throbbing or pulsatile; hot, scalding, or burning ; or sharp and darting, as in neuralgia. Very often it is of a spas- modic nature, and is accompanied by the most violent tenesmus. The patient sometimes complains of a "bruised feeling," or of a sense of soreness, at first in the perinseum, and afterwards about the anus, in the thighs and groins. A very unpleasant symptom of this affection is a sense of weight or fulness in the pelvis, and a feeling as if the bladder were never entirely empty. This evidently arises from two circumstances: first, from the pressure of the enlarged gland itself, and, secondly, from the presence of a certain quantity of urine, which is never wholly expelled, no matter how violent may be the efforts made for that purpose. The fluid which is thus retained is soon decomposed, and thus becomes a source of irritation both to the bladder and the af- fected gland. The urine, at first perfectly clear, and, to all appearance, natural, becomes gradually changed in its properties and sometimes even in its quantity. It is generally thick, foetid, acrid, and highly alkaline ; depositing, upon standing, a great abundance of thick, ropy mucus, often streaked with phosphatic matter, and always firmly adhering to the bottom of the receiver. The fluid is soon decomposed,— indeed it is frequently so before it is voided,—and there always exhales a strong ammoniacal odour. Its colour, in cases of long continuance, is commonly more or less dark. When hypertrophy is accompanied by ulceration of the prostate it is sometimes tinged with blood. The quantity of urine may be natural, increased, or dimi- nished. In general, I have found it to be somewhat increased, but this was probably owing to the quantity of the patient's drink, rather than to the direct influence of the local disease upon the kidneys. The urine, Avhich is at first discharged only six or eight times a day, is at length voided every hour, every half hour, or even every fifteen or tAventy minutes. During the act of micturition, the patient is obliged to straddle his legs, to bend his body forwards, and to make the most violent muscular efforts in order to accomplish his purpose. He strains and presses, in fact, with all his might, as if he Avere determined to expel not only his urine, but his bladder along with it. During these exertions his fseces frequently escape 556 DISEASES AND INJURIES OF TnE PROSTATE GLAND. into his pantaloons, and the bowel descends several inches below the anus ; his face is flushed, and his eyes look as if they were ready to jump from their sockets. At last, after months and years, perhaps, of the most horrible suffering, the urine is either retained, or has to be draAvn off constantly with the catheter, or it dribbles aAvay inces- santly, the sphincter being no longer able to perform its office. In general, the incontinence of urine is conjoined with retention; for, as was before stated, the bladder is rarely, if ever, wholly emptied, on account of the increased size of the prostate and the cul-de-sac which the former organ presents behind the latter. The constitutional symptoms of this disease, like the local, are dependent rather upon the amount of sympathy manifested by the surrounding parts than upon the degree of enlargement of the prostate. In the earlier stages there is little or no fever, and per- haps, in truth, little or no disorder of any kind. As the disease progresses, hoAvever, the health manifestly suffers; the tongue is coated, the pulse is irritable, the sleep is disturbed by unpleasant dreams, the skin is inclined to be dry, the feet are cold in the day and hot at night, the appetite is deranged, the bowels are irregular, and the urine is acrid and high-coloured, at times scanty, and at other times preternaturally abundant. These symptoms, as well as the local, are liable to temporary aggravation from exposure to cold, exercise on horseback, venereal indulgence, stimulating drinks, and high-seasoned food. Diagnosis.—The diagnosis of hypertrophy of this gland is to be determined by the age of the patient, and by a careful physical exploration of the parts, rather than by a study of the rational symptoms, Avhich are often simulated, to a painful extent, by some of the diseases of the adjacent and associated organs. The affections with which it is most liable to be confounded are stricture of the urethra, urinary calculi, catarrh of the bladder, and stricture of the rectum. Hypertrophy of the prostate is a disease almost peculiar to ad- vanced life; and hence, when an individual who has attained the age of fifty, fifty-five, or sixty, is affected with the train of symptoms above enumerated, the presumption is strong that the case is one of chronic enlargement of this body, and nothing else. Stricture of the urethra occurs most frequently in middle life, and its existence may always be readily ascertained by a careful examination of the canal in which it is located. When the two affections are combined, HYPERTROPHY OF THE PROSTATE. 557 —a circumstance, however, which is not very common,—all that is necessary, in addition to the passage.of the bougie, is to introduce the finger into the rectum, which will at once decide the diagnosis. The symptoms which accompany stone of the bladder are very similar to those of hypertrophy of the prostate, and hence a careless observer might easily mistake the one of these affections for the other. A little attention, however, will always enable him to make out a correct diagnosis. If a stone be suspected, the introduction of the sound will not be slow in detecting its presence. Moreover, cal- culous disease occurs at all periods of life, while hypertrophy of the prostate, as was before stated, is most common in old age. In the former affection, one of the most important rational symptoms is a sudden stoppage of the urine from the falling of the concretion against the mouth of the urethra; in the latter, on the contrary, the water, Avhen once started, usually flows until it is all discharged. Catarrh of the bladder, the result of chronic or subacute inflam- mation of the lining membrane of this viscus, is induced by various causes, and is characterized by a copious discharge of thick, viscid, f(ctid mucus,—a symptom which is also present in chronic enlarge- ment of the prostate. The only way to distinguish between the two affections is by passing a bougie and by exploring the rectum with the finger. Chronic enlargement of the prostate, especially when it exists in a high degree, is occasionally attended with difficulty of defecation, and a flattened appearance of the fseces. Similar phenomena are generally present in contraction of the rectum from organic disease of its tunics, whether it be of a simple or malignant character; and the diagnosis is further obscured if, as often happens, the disease extend from the boAvel to the bladder and the prostate, giving rise to a frequent desire to pass the urine, and an abundant discharge of thick, ropy, and offensive mucus. In such a case, a careful digital examination of the gut is indispensable to a correct appreciation of the situation and character of the lesion. After all, it Avas hardly necessary to say even this much in regard to the diagnosis of this disease, for no educated surgeon would ever think of treating a case involving the slightest doubt, without a thorough exploration of the anus, the urethra, and the neck of the bladder. To examine the parts through the rectum, the best plan is to place the patient upon his back, with his nates close to the edge of the 558 DISEASES AND INJURIES OF THE PROSTATE GLAND. bed, and the thighs widely separated from each other and raised towards the abdomen. Or, instead of this, he may support himself upon his knees and elbows, as is occasionally done in the operation for anal fistula. The surgeon then oils the right index-finger, and introduces it gently into the gut, previously emptied by an enema, as high up as possible, the palmar surface being directed fonvards towards the pubic symphysis. Closing the hand, and pressing it firmly into the gutter between the nates, he moves the fore-finger about in different directions, first upwards along the median line, and then successively towards each side, noting, as he does so, the impression made upon it by the enlarged organ. If the finger be long, it can, by this procedure, be readily carried to a height of three inches, while its point may be made to describe the segment of a circle nearly two inches and a half in extent,—a space rarely tran- scended by the prostate, however much it may be hypertrophied. The extent to which the gland encroaches upon the rectum is variable; it may be very slight, or it may be so great as to produce partial occlusion of the tube, and consequently more or less difficulty in defecation. The tumour is usually easily felt by the finger, and rarely exceeds the volume of a pullet's egg; it may be as big, hoAV- ever, as a middle-sized orange, or even as a small fist. It is com- monly larger on one side than on the other, and feels like a hard, solid substance, the surface of which is either smooth and uniform, or knobby and irregular. In the earlier stages of the disease, the gland may generally be pushed a little upwards and to either side; but when it is much enlarged, it is immovably fixed behind and below the arch of the pubes, and imparts to the finger which touches it the sensation of a hard, firm, and inelastic body. The lateral lobes are always more easily distinguished than the middle, Avhich, when much augmented in volume, is frequently dragged up so high as to be entirely beyond the reach even of the longest finger. Valuable information, in regard to the size and shape of the tumour, may generally be obtained by an exploration of the com- mencement of the urethra and the neck of the bladder, or, in other words, of the prostate itself. If properly conducted, indeed, it throws more light upon the subject than any other mode of proceed- ing. The instrument employed for this purpose may be a common sound or a silver catheter, about eleven inches in length, and a little above the ordinary diameter, with a short, abrupt curve. One of the best contrivances of the kind of which I have any knowledge is HYPERTROPHY OF THE PROSTATE. 559 that devised by Mercier, and delineated in his work on the genito- urinary organs. It consists simply of a straight metallic rod Fig. 84. the vesical extremity of which, bent at an angle of from 100 to 110 degrees, does not exceed eight or ten lines in length. The beak is rounded off, and slightly bulbous. The handle is furnished with a polygonal plate, which is arranged perpendicularly to the curved portion, and has a mark on the face corresponding with the beak. The rod is graduated, like an exploring bougie, and is a little larger than a common catheter. Thus constructed, the instru- ment is decidedly preferable to the ordinary one; it penetrates the parts more readily, and, owing to the brevity of its curve, is more easily turned about in the bladder;—circumstances of great impor- tance in such an investigation. In conducting the exploration, the patient lies upon his back, as in ordinary catheterism, and the rectum is previously cleared by an enema. The bladder should contain a moderate quantity of urine, lest its contraction interfere with the success of the operation. The instrument, Avarmed and well oiled, is introduced in the usual manner until it reaches the neck of the bladder. Here, if there be any con- siderable enlargement, it will be almost sure to be arrested, and to convey to the finger the sensation as if it were pressing against a solid and resisting body. To surmount this obstacle, which may be either directly in the middle line, or towards either side, according as it is produced by the middle lobe, or by one or both of the lateral masses, it is generally necessary to insert the left index-finger into the rectum, and to use it to guide the instrument on into the bladder. The conduct, if I may use the expression, of the instrument, as it passes along the neck of the bladder, will be influenced by the character and extent of the hypertrophy, and is deserving of par- ticular attention. If the middle lobe alone is affected, the obstruc- tion will be found at the middle line, and the handle will have to be 560 DISEASES AND INJURIES OF THE PROSTATE GLAND. considerably depressed to enable the beak to glide over it into the bladder. In addition to this it may be necessary, as above stated, to insert the finger into the rectum, in order to push the curved por- tion of the instrument close against the pubic arch. To ascertain the size of the tumour, the vesical extremity of the explorator is hooked over its posterior surface, and passed successively round its sides, the finger being still in the bowel, and placed against the beak of the explorator. When both the lateral masses are enlarged equally at their inner margins, unaccompanied by hypertrophy of the rest of the organ, the passage will retain its normal course, and the instrument will advance in a straight line, just as it does in the healthy state of the parts. If, on the contrary, the growth be un- equal, the canal will incline to one side, and the deformity will be indicated by a corresponding change in the direction of the explora- tor. Sometimes a double curve exists, one being formed, for in- stance by the right lobe, and the other by the left; or, there may be two projections on one side with two corresponding depressions on the opposite. Effects.—Hypertrophy of the prostate, especially when it exists in any considerable degree, is rarely unaccompanied by more or less suffering of the adjacent parts. The affections which thus complicate it are frequently of a most serious and distressing character, and call more loudly for medical and surgical interference than the primary malady upon which they depend. The organ which is most liable to suffer in this disease is the bladder, which frequently becomes affected at an early period, in consequence of the mechanical obstruction afforded by the prostate to the flow of urine. The most common lesion is hypertrophy of the muscular tunic, varying in degree from the slightest change to ten or fifteen times the natural thickness. The muscular fibres are of a deep florid complexion; and, when the obstruction is of long stand- ing, they are generally collected into large fasciculi, not unlike the fleshy columns of the heart. The laAvs under the influence of which these alterations are effected, have been pointed out in a previous chapter, and need not, therefore, detain us here. Some of the very worst cases of hypertrophy of the urinary bladder that I have ever witnessed were produced by chronic enlargement of the prostate. The disease is generally accompanied with irritability of the organ, and diminution of its capacity; sometimes, however, it is insensible, and more or less dilated. HYPERTROPHY OF THE PROSTATE. 561 Another consequence of obstruction from enlargement of the prostate is a sacculated condition of the bladder. This is caused by an outward protrusion of the mucous membrane across the inter- stices of the hypertrophied fibres, and is a direct result of the exces- sive contraction of these fibres upon the contents of the organ during micturition. The mucous membrane is sometimes mammillated, or elevated into ridges just behind the mouth of the urethra; at other times it is ulce- rated, of a dark, mottled colour, engorged with blood, and studded with enlarged follicles. Fungous excrescences are sometimes found. The bas-fond is frequently entirely effaced, or converted into a nar- row, deep cul-de-sac, forming a receptacle for the accumulation of mucus, the stagnation of urine, and the lodgment of calculous con- cretions. In the former case, the orifices of the ureters lie just behind the neck of the bladder, separated by a small interval, and directed obliquely inwards and forwards. This change is generally most prominent when the hypertrophy exists with the bar-like ridge of the bladder, described in a previous part of this treatise. Enlargement of the prostate is not unfrequently followed by the formation of calculous concretions. The reason of this is that the earthy salts, naturally contained in the urine, are more apt to be retained in the bas-fond of the bladder, in consequence of the ob- struction to micturition. When this event occurs, two circumstances, worthy of notice, are liable to take place; one is, that the stone is productive of less suffering from its inability to fall against the orifice of the urethra and thus impede the discharge of the urine; and the other, that it is more difficult, from its concealed situation behind the prostate, to extract it. Hemorrhage is occasionally observed as an effect of this change in the volume of the prostate. The blood, which is usually small in quantity, may proceed from any portion of the bladder; but in general it is furnished by that part of the mucous membrane which covers the neck and bas-fond of the organ. Sometimes it proceeds from the gallinaginous crest, or even from the gland itself. It may be the effect either of exhalation, ulceration, or rupture. The blood is either discharged along with the urine, or it is retained and re- quires to be removed by artificial means. The urethra, during the progress of this disease, often undergoes important alterations, Avhich are liable to be followed by serious diffi- culty as it respects the evacuation of the urine and the introduction 36 562 DISEASES AND INJURIES OF THE PROSTATE GLAND. of the catheter and other instruments. These changes, which are deserving of attentive consideration, are limited exclusively to the posterior part of the canal, or that portion of it which is surrounded and embraced by the prostate, and are referable mainly to the dimen- sions, direction, and form of the tube. Elongation of the prostatic portion of the urethra exists nearly always in the more aggravated forms of hypertrophy of this gland. It varies in degree from a feAV lines to two inches, which, however, it rarely attains. With this addition from disease, the prostatic por- tion of the canal may require a length of tAvo inches, two inches and a half, and, in extraordinary cases, even three inches. Mr. Guthrie1 mentions an instance in which the elongation was nearly four inches, requiring a proportionably long catheter to draw off the urine. With such an example, which is of course an extreme one, I have never met. The increase of length may be produced by hypertrophy of the lateral masses alone, by the middle lobe alone, or, as more commonly happens, by the joint agency of all these parts. In en- largement of the middle lobe, the urethra is dragged up behind the pubic arch, and is thus proportionably augmented in length, at the same time that it generally presents a sickle-like curve, the convexity of which looks towards the rectum. Hence, in drawing off the urine, the catheter should not only be unusually long but unusually curved, and unusually depressed, otherwise it will fail to reach its destination. When the lateral masses are alone affected, in an equal degree, the intervening canal may retain its natural size and cylindrical shape, or it may change its form, and become either diminished or increased in its dimensions. In a specimen in my cabinet, in which there is no appearance whatever of a middle lobe, but in which both the late- ral portions are considerably augmented in volume, the prostatic part of the urethra is merely increased in length, while its form and size are apparently perfectly normal. From all absence of hyper- trophy of the muscular coat of the bladder, it is evident that there was no obstruction during life to the evacuation of the urine. It is only, indeed, in cases where the increase of development takes place at the inner margins of the lateral lobes that the sides of the canal, embraced by them, will approach, and ultimately be brought into apposition with each other; a condition always accompanied by par- tial or complete retention. 1 Op. cit, p. 235. HYPERTROPHY OF THE PROSTATE. 563 In hypertrophy of all the constituent parts of the prostate, the in- cluded portion of the urethra generally presents itself in the form of a vertical slit, Avhich in some of my examinations I have found to be fully three-quarters of an inch in depth, that is, in the recto-pubic direction—while its sides Avere occasionally almost, indeed, quite, in contact with each other: Fig. 85, from a specimen in my collection. Fig. 85. In such a case as this the obstruction must necessarily be attended Avith more or less impediment to the discharge of the urine, and hypertrophy of the muscular fibres of the bladder. In a second series of cases of universal hypertrophy, the prostatic portion of the canal is materially increased in its diameter, evidently by the projection of the middle lobe between the two lateral, the edges of'which are thus kept permanently asunder. This state, which occasionally exists to a great and deplorable extent, is often accompanied Avith incontinence of urine, which, under such circum- stances, is liable to be ascribed to paralysis of the bladder. Lateral curvature of the canal is occasionally met Avith, being generally dependent upon an unequal enlargement of the inner edges of the lateral lobes. An unusual projection on one side will neces- sarily encroach in a corresponding degree upon the other side, fol- lowed by a proportionable deviation from the median line. The cur- 564 DISEASES AND INJURIES OF THE PROSTATE GLAND. vature, which seldom exists in a high degree, is sometimes double; occasionally it is accompanied by a sort of contorted or tAvisted state of the urethra. The form and dimensions of the vesico-urethral orifice, or mouth of the urethra, are considerably influenced by the nature of the hy- pertrophy. When both lobes are equally and alone enlarged, it is generally circular, and but little, if any, diminished in size. Fre- quently it presents itself as a narrow, vertical slit, not unlike the chink of the glottis. This condition generally accompanies hyper- trophy of the inner edges of the lateral lobes, and antero-posterior enlargement of the prostatic part of the urethra. In a third series of cases, it has the shape and appearance very much of the mouth of a pitcher closed by its lid; that is, it is a transverse fissure, bounded in front and at the sides by the lateral lobes, and behind by the en- larged central mass. Lateral deviation of the urethra is sometimes produced by an irre- gular development of the middle lobe, the remainder of the gland being unaffected. In this manner one of the lateral masses is pushed to one side, followed by a corresponding bend in the tube, which is always most conspicuous at its posterior extremity. Finally, Avhen the middle lobe is of unusual volume, the canal, as it extends back- wards, becomes sometimes bifid, or separated into two grooves, bounded each by the contiguous surfaces of the middle and lateral masses. The ureters are seldom entirely sound. Sometimes only one suffers; at other times both are involved, though not in an equal degree. The most common lesion is dilatation of their calibre with irregular thickening or attenuation of their tunics. Occasionally one of these tubes is partially obstructed, either as a consequence of con- traction or of a deposition of lymph. The kidneys often sympathize in the disorganization of the pro- state, or, rather, in the changes which it induces in the bladder and the ureters. One of the most common lesions is chronic inflamma- tion of their parenchymatous tissues, which are of a dark complexion, engorged with blood, increased in size, and preternaturally firm in their consistence. In some instances one or even both organs are partially destroyed, or converted into cysts or pouches. Ulceration of the mucous membrane is occasionally witnessed; noAv and then an abscess exists; and not unfrequently the parenchymatous tissues ex- hibit the peculiar degeneration known as Bright's disease. HYPERTROPHY OF THE PROSTATE. 565 The seminal vesicles are liable to suffer during the progress of this disease. The irritation is readily reflected from the prostate to these reservoirs along their excretory tubes, inducing in them, at first, subacute, and finally chronic inflammation, followed by structural lesion of their walls, alteration of their capacity, and modification of their secretions, which are sometimes of a muco-purulent character. The testicles, in hypertrophy of the prostate, are seldom much affected, unless it coexists with stricture of the urethra. Sometimes one of these organs is SAvollen, or both are morbidly sensitive, 6*r there is an accumulation of water in the vaginal tunic; a complication of which I have seen several well-marked examples. The spermatic cords are generally natural. It rarely happens that this disease exists in a marked degree or for any length of time without extending to and implicating the rectum. In consequence of the frequent and violent efforts which the patient is compelled to make to overcome the obstruction to the discharge of the urine, the hemorrhoidal vessels gradually become enlarged and varicose, and often give Avay under the pressure of their contents, leading thus to at least one variety of hemorrhoidal tumours. For the same reason prolapsion of the bowel is not uncommon. The lining membrane is habitually congested and irritated ; an inordinate secretion of glairy mucus is going on ; and every effort at defecation is attended with severe suffering. In fact, the bowel never feels com- fortable or empty. Treatment.—In entering upon the treatment of this affection, we have to lament the impotency of our art and the limited nature of our therapeutic resources. Notwithstanding the numerous attempts that have been made from time to time to place it upon a scientific basis, it must be confessed, hoAvever humiliating the acknowledgment may be, that it is eminently empirical, tentative, and unsatisfactory. These remarks are particularly true of the senile form of the com- plaint, Avhich hardly ever yields to any mode of treatment, however judiciously devised or perseveringly employed. The disorder, in this respect, bears a close resemblance to certain kinds of morbid growths, which, Avhen once developed, are utterly beyond the reach of medi- cine ; no remedies exert the slightest influence upon their progress; nothing can change their character, modify their action, or suspend their nutrition. The malady progresses in spite of the best-directed efforts of the surgeon, and only ceases with life. For this result so mortifying to his pride, and so unfortunate for the patient, the 566 DISEASES AND INJURIES OF THE PROSTATE GLAND. practitioner is not responsible; it is inherent in the very nature of the disease, and does not, therefore, depend upon any Avant of skill in the selection and application of our remedial agents. General depletion is very rarely indicated in this variety of pros- tatic disease. If, however, the patient be plethoric, the enlargement considerable, and the sympathetic reaction great, no remedy will be so likely to afford prompt and decided relief as a full bleeding at the arm. This is true, whatever may be the character of the hypertro- phy. The propriety of a repetition of the venesection must depend upon the circumstances of each individual case, and often requires great judgment upon the part of the practitioner. The detraction of blood should ahvays, in the more aggravated varieties of the com- plaint, be speedily followed by the use of the antimonial mixture, in the hope of subduing the action of the heart, unlocking the secre- tions, and clearing out the bowels. All irritating, heating, or griping cathartics must here, as in most of the other affections of the pro- state, be entirely proscribed. Aloetic and other preparations having a particular tendency to the rectum, are to be avoided. At the same time, it must be borne in mind that an overloaded state of the bowels is never permissible; on the contrary, it is to be carefully guarded against, for it can never exist for any length of time with- out producing an increase of irritation, if not positive mischief. Sul- phate of magnesia, or jalap and supertartrate of potassa, by rendering the fseces soft and Avatery, are particularly well adapted to cases of such a nature. Where manifest disorder of the biliary secretion exists, a few grains of calomel will generally prove serviceable. Sometimes a laxative enema answers a good purpose, and obviates the necessity of giving this kind of medicine by the mouth. The food should be perfectly plain, and easily digestible, and un- irritant. It should be well masticated, and be free from all heating or stimulating admixtures. Condiments of every description, wine, brandy, and fermented drinks, are carefully avoided. Unless strict attention be paid to these rules, no reasonable hope, even of tempo- rary amendment, can be indulged. All the exciting causes of the disease are to be carefully avoided. Above all, it is necessary that the patient should abstain from horse- back exercise and from sexual intercourse. From the tendency Avhich these pursuits have to produce engorgement of the prostate and the rectum, I am satisfied that too much stress cannot be laid upon their prohibition. I would go so far, in all cases, as to make HYPERTROPHY OF THE PROSTATE. 567 the injunction absolute. Where the passions are unusually strong, and the desire for sexual intercourse is very frequent, and almost unconquerable, as it often is in persons labouring under this com- plaint, it may even be necessary for a time to interdict female society, until, by proper treatment, the feeling in question is sub- dued. Repose in the horizontal posture is hardly less necessary here than it is in the more acute affections of the prostate. By this re- mark I do not, of course, mean that the patient shall confine himself constantly to his bed, and avoid all exercise ;—by no means ; on the contrary, he should not neglect, whenever the weather is pleasant, to stir about for a few hours every day in the open air, either on foot, or in a gentle carriage. When he is in the house, let him lie upon a lounge, or recline upon an easy chair with a movable back. For the purpose of acting directly, as it were, upon the gland, and thereby lessening its volume, various remedies have been pro- posed. Among the more important of these are, iodine and its different combinations, cicuta, mercury, hydrochlorate of ammonia, local depletion, and counter-irritation by issues, setons, blisters, and tartar-emetic pustulation. Of these remedies it may be observed, in general terms, that their efficacy has been fully tested by different observers, and that they are all to be regarded in the light merely of palliatives. Iodine is indicated more especially in those cases in which the hypertrophy depends upon a syphilitic taint of the system, or an effusion of lymph, and Avhich are characterized by a rapid progress. The best form of exhibition is Lugol's solution, or the iodide of potassium, either alone or in union with iodide of iron. The latter combination is particularly indicated where it is desirable to obtain both an alterative and a tonic effect. In whatever form it be admi- nistered, a long continuance of the article is imperiously demanded ; care being taken to intermit its use for a few days every two or three Aveeks, as its good effects will be more likely to be elicited in this Avay than if it be employed persistently. Cicuta has been with many a favourite remedy in the treatment of this affection; but it would be difficult to determine Avhether it really possesses any virtues in lessening the volume of the enlarged gland. The probability is, that the attention of practitioners was first directed to its employment in hypertrophy of this body, from the beneficial effects which have occasionally been witnessed from 568 DISEASES AND INJURIES OF THE PROSTATE GLAND. its exhibition in cases of bronchocele. My own experience in its use in this affection is very limited; but judging from this and the little reliance which is placed in it by some recent a\titers, I should feel inclined to doubt its efficacy, especially Avhen given by itself. Administered in combination with other articles, it may occa- sionally prove beneficial. I have not found that mercury, exhibited with a view to its con- stitutional effects, is capable of exciting any particular influence over this affection in any of its forms or stages, nor are the accounts of this remedy published by others, of a more flattering or encouraging nature. While mercury possesses an astonishing power in removing chronic enlargement of the liver, spleen, and testicle, it has little, if any, virtue in hypertrophy of the prostate and thyroid gland. Nevertheless, in obstinate cases, where other means have failed to afford relief, I should not hesitate to resort to it. In employing it, great care is to be taken not to produce ptyalism, which cannot do any good, and may do much harm. A moderate mercurial influence, sustained for four or five weeks, will be likely to secure all the advantages that this remedy is capable of affording. From three to five grains of blue mass with one grain of extract of cicuta, should be given three times daily, until the gums are slightly touched. The medicine is then to be discontinued until the primary impression begins to subside, when it may be again resumed, and exhibited as before. Administered in this manner, proper attention being at the same time paid to the bowels, the diet, and exercise, a partial re- duction of the affected organ may occasionally take place. When an alterant plan of treatment is required, as, for example, when the enlargement has been induced by a syphilitic cause, the mercury may be advantageously exhibited in union with iodide of potassium. Under such circumstances, the bichloride, cyanuret, or deuto-ioduret of mercury is preferable to calomel and blue mass. Donovan's solu- tion would also be worthy of trial. Hydrochlorate of Ammonia has been long familiar to the profes- sion as a valuable remedy for the removal of visceral induration and enlargement. I am not aware that it has ever been employed in the treatment of hypertrophy of the prostate, and I merely call attention to the article here as well Avorthy of trial in this obstinate and in- tractable disease. It might be exhibited either alone or in combi- nation with a minute portion of tartrate of antimony, in the dose of fifteen or twenty grains three or four times a day. HYPERTROPHY OF THE PROSTATE. 569 There are few remedies Avhich afford greater relief in this affection, whether the result of inflammatory action ■ or of senile decay, than leeching. The blood may be taken either from the anterior wall of the rectum, and consequently almost directly from the prostate itself, or from the perinseum and the. inside of the thighs. The quantity abstracted must be regulated by the circumstances of each individual case; but in general it is best that it should be small, and that the operation should be frequently repeated. When the leeches are ap- plied to the interior of the rectum, Amussat's anal speculum should be used. The plan which I usually adopt is to apply from four to six leeches to the perinseum every fourth or fifth day. Sometimes blood may be advantageously taken by means of cups from the hypo- gastric region ; but in general this is a more painful and less elegant mode than leeching. Counter-irritation by issues, setons, blisters, and pustulation with tartar emetic ointment are valuable adjuvants in the treatment of chronic enlargement of the prostate, and should ahvays be employed concurrently Avith other means. The choice of the remedy and the place to Avhich it is applied must be regulated by circumstances. My favourite practice is to insert a seton into the perinseum. In some instances, however, I have derived marked benefit from a caustic issue just above the pubes. Blistering and pustulation I rarely use. John Hunter recommends that vesicants should be repeatedly applied to the perinseum, and that a constant discharge should be maintained from their surface by irritating unguents. About ten years ago Mr. Stafford1 of London published an account of six cases of chronic enlargement of the prostate, most of them occurring in elderly persons, in which marked success followed the use of iodide of potassium exhibited by the rectum. The form in which it Avas given was that of a suppository, consisting of from three to five grains of the salt with five grains of the extract of cicuta and the same quantity of extract of hyoscyamus, introduced into the boAvel night and morning. The strength of the remedies was gra- dually increased to ten grains. The treatment was continued from one to two or three months, and was aided by the daily use of a bougie anointed with iodine ointment, composed of five grains of the salt and one drachm of simple cerate. The urine was drawn off every twelve hours Avith the catheter. Under this management the 1 London Medical Gazette, Oct. 29, 1841, p. 181. 570 DISEASES AND INJURIES OF THE PROSTATE GLAND. gland became gradually reduced in size, the pain subsided, the irrita- tion at the neck of the bladder disappeared, and micturition was performed nearly with its accustomed facility. These cases unfor- tunately prove too much; though it is but justice to Mr. Stafford to state that his mode of treatment has occasionally succeeded in the hands of other practitioners. Sir Everard Home was in the habit of using suppositories of opium and hemlock; which not only, as he informs us, relieved the irrita- tion, but also lessened the volume of the gland. Mercier states that he has derived great benefit from suppositories of Vigo's compound mercurial plaster. To allay the irritation of the bladder which so frequently attends this disease, the warm bath, fomentations, opiate suppositories, and anodyne injections are necessary. The circumstances regulating the use of these remedies have been already pointed out, and need there- fore not be dwelt upon in this place. Finally, the patient must pay particular attention to the time and manner in which he voids his urine. He should be taught, on the one hand, the importance of not evacuating the bladder too fre- quently, and, on the other, of not permitting too great an accumu- lation. Micturition should not, on an average, be performed oftener than once every four hours. If the bladder be emptied every few hours, the mischief is much increased, and the organ is at length rendered so irritable and fretful as to be unable to contain more than a few ounces of water at a time. Moreover, he must not strain in passing his urine, but endeavour to do this in as calm and composed a manner as possible. The object should be to maintain the prostate and bladder constantly in a quiescent condition; and hence it is fre- quently necessary to draw off the water at stated periods with the catheter. Any considerable accumulation is likely to prove a source of irritation, if not of actual disease, to the affected parts. For the same reason, injection of the bladder, as advised under the head of " catarrh" of that organ, often produces great relief by dislodging the thick, ropy, and offensive mucus which so often collects in the bas-fond of the bladder. To relieve the prostate from the pressure of irritating urine, and deprive the urethra temporarily of its office, it has been proposed to puncture the bladder above the pubes, and make the patient wear a silver tube. An opportunity is thus afforded to the water to drain off nearly as fast as it is deposited in the bladder, which is thereby HYPERTROPHY OF THE PROSTATE. 571 placed in an easy, quiet condition, and prevented from constantly contracting upon its contents. As a dernier resort, such an opera- tion may perhaps be justifiable, on the ground that it might prolong life; but under no other circumstances, I conceive, should it ever be performed. Independently of the inconvenience and discomfort to which it must necessarily subject the patient, rendering him disagree- able to himself and to all around him, it is by no means free from the danger of urinary infiltration ; nor is it at all certain that it will, in any case, effect a cure. As means calculated to produce a direct impression upon this organ, mention may be made here of cauterization, excision, incision, and crushing. It is not easy to comprehend how cauterization acts in bringing about a diminution of the volume of a hypertrophied prostate, and yet the operation has not only been proposed but received high en- comiums. If the application could be made directly to the affected structures, it would be easy to perceive that it might prove beneficial, but this is not so apparent when it is remembered that it can only be made to the mucous membrane of the urethra, which, in the situation under consideration, is of very limited extent. Moreover, the ope- ration is frequently productive of severe pain and of an aggravation of all the symptoms, both local and constitutional. It is for these reasons that I have always had a disinclination, almost amounting to aversion, to employ it, except in the very mildest forms of the dis- ease. The cauterization, if deemed advisable, is performed with Lallemand's instrument, which is carried into the prostatic portion of the urethra, with the lining membrane of which it is gently but fully brought in contact. It should not be oftener repeated than once a fortnight, and any irritation following it should be combated by demulcent drinks, anodynes, recumbency, and the warm bath. An attempt has been recently made to treat hypertrophy of the prostate, especially of its middle lobe, by the direct application of different ointments, as those of iodine and iodide of potassium. The proposal originated Avith Mr. Stafford,1 who has long been favourably knoAvn for his skill in devising means for overcoming some of the mechanical obstructions of the urinary organs. His plan consists in charging the point of a bougie with the substance intended to be 1 An Essay on the Treatment of some Affections of the Prostate Gland, p. 19. London, 1840. 572 DISEASES AND INJURIES OF THE PROSTATE GLAND. used, and then dipping it into melted talloAV so as to give it a thin coating. The instrument, thus prepared, is passed doAvn to the affected part, where the tallow is soon removed by the heat of the mucous membrane, followed by the escape and diffusion of the oint- ment. By drawing it gently backAvards and forwards a certain amount of friction is produced, greatly facilitating the inunction. Much caution is required in regard to the strength of the ointment, on account of the prostate being frequently in an irritable and in- flamed condition, and consequently unable to bear any strong appli- cation. The parts must occasionally eA^en be soothed by a sort of preliminary treatment with anodynes, such as belladonna, opium, or hyoscyamus. The safest plan, therefore, always is to begin with a very weak ointment, as one, for example, composed of one grain of iodide of potassium to the drachm of simple cerate, and gradually increase its strength as the patient is found able to bear it. " I have then gone on," says Mr. Stafford, "Avith two, three, four, five, and even as far as ten grains, or a scruple to the drachm, according as the case required it. After this I have added iodine to it; half a grain, one, two, three, four, or even more grains in the same manner. The surgeon who applies it can alone judge of its effects." Where the potash cannot be applied directly to the gland, in the manner above indicated, it may be administered by the rectum in the form of injection. From thirty to forty grains of this article, dis- solved in a suitable quantity of rain-water, may be thus introduced twice a day, at the same time that other remedies, such as those already pointed out, are employed to aid its action. Scarification of the affected gland has occasionally been practised, and sometimes apparently with advantage. The operation Avas first suggested by Mr. Costello,1 of London, in 1837. From the good effects which this operation frequently exerts over chronic enlarge- ment of the tonsils, the uvula, and the testicle, it is not surprising that it should have been applied to the treatment of hypertrophy of the prostate. It not only diminishes the vascular turgidity, which is generally so prominent a pathological condition in this lesion, but it has a tendency to stimulate the absorbent vessels, and thus to bring about a reduction of the volume of the diseased organ. The quantity of blood procured in this way sometimes amounts to several ounces. The operation, which gives rise to little or no pain, is per- 1 British Annals of Medicine for February and March, 1837. HYPERTROPHY OF THE PROSTATE. 573 formed with a curved lancetted stylet, similar to that used for dividing strictures of the urethra, and is quite safe in the hands of an experienced surgeon, one Avell acquainted with the anatomy of the parts. It may be repeated every third or fourth day, and is particularly worthy of trial where there is an unusual degree of irritability of the prostate. Excision of the prostate has been recommended. The operation is spoken of by some of the older surgeons, but has not, so far as I know, received the sanction of any of the moderns. It does not appear that any one has really ever had the hardihood or folly to perform it, and this is no doubt the best thing that can be said in commendation of it. The idea of extirpating the entire gland is, indeed, too absurd to be seriously entertained. Such an operation, even supposing it Avere practicable, and that the patient could sur- vive it, would be far worse than the disease; for it would inevitably lead to the formation of an incurable fistula, rendering life utterly miserable. Excision of the middle lobe would be less objectionable, and might, in fact, be resorted to with a fair prospect of success, in all cases in Avhich this body forms a permanent obstacle to the pas- sage of the urine. When it is attached by a narrow footstalk, the operation could hardly fail, and might afford the only chance of relief. I should certainly myself prefer it, under such circumstances, to the operation of " crushing," recommended by some of the French surgeons, and to the puncture of the bladder above the pubes. I should not even expect much difficulty in the execution of it. The position of the patient and the incisions in the perinseum would have to be the same as in the lateral operation of lithotomy. The en- larged lobe might be easily cut off at its base with a pair of stout, probe-pointed scissors, curved on the flat; or, it might be twisted off with a polypus-forceps. Another operation for the relief of chronic enlargement of the prostate is incision. One of the principal advocates of this method of treatment is Mr. Guthrie,1 of London. It is founded upon the 1 Op. cit. p. 251. "A question has arisen in my mind," says Mr. Guthrie, " whether any operation could be done on the prostate from the perinseum; and I was led to entertain it from finding that in a patient, on whom I had operated for stone, whose prostate gland was much enlarged, I had rendered him a further ser- vice in the diminution of the prostate; so that instead of making his water with difficulty, he afterwards made it easily, and the catheter passed with facility, in- stead of meeting with a considerable obstacle at the neck of the bladder. In fact I was satisfied I had cured, or nearly so, the disease of the left lobe of the prostate! 574 DISEASES AND INJURIES OF THE PROSTATE GLAND. fact that the operation of lithotomy, performed upon persons af- fected with this complaint, has occasionally relieved them of it. Of the propriety and utility of this process I am unable to speak from personal observation, but judging from the results recorded by others I am disposed to place little confidence in it. If it is calculated to do any good at all, it must be in those cases of hypertrophy of the gland in which there is extraordinary vascularity of the parenchy- matous substance, and a varicose condition of the venous plexus. Where the disease is complicated with urinary calculus, no one, of course, would hesitate to have recourse to the knife. The operation is conducted upon the same principles as the operation of lithotomy; the lateral or bilateral method being adopted according as one or both lobes are affected. The operation of crushing, devised, I believe, by some French surgeon, is applicable only to the middle lobe of the prostate. It was evidently originally suggested by the operation of lithotripsy, of which, in fact, it is merely a modification. It consists in seizing hold of the enlarged body with Jacobson's lithotrite, and grinding, squeezing, pressing, or mashing it into a soft, pulpy sub- stance, which is detached partly by the instrument, and partly by the sloughing process, and afterwards discharged with the urine. The instrument is used at first as a sound, to ascertain the site of the tumour, which is then caught between its branches and crushed or broken off. The proceeding is best adapted to those cases in which the middle lobe adheres by a small pedicle, and rises up be- hind the mouth of the bladder in the form of a narrow, elongated valve. The operation is not attended with much pain, for the affected part admits of being freely dealt with; but it is liable to be followed by hemorrhage, severe inflammation, and even death, on which I found to be much enlarged during the operation." In commenting upon this operation, the late Dr. Parrish,1 of Philadelphia, adduces the case of Chief Justice Marshall, from whom a large number of urinary calculi were removed by Dr. Physick. The prostate was considerably enlarged at the time of the operation, and the third lobe was distinctly felt in the bladder. The illustrious patient hap- pily recovered, and enjoyed tolerable health for several years. He finally died of disease unconnected with the urinary organs. A post-mortem examination was made, and it was ascertained, by Dr. Physick, that the volume of the gland had not been diminished by the operation. Mercier has advanced the same opinion as Mr. Guthrie. 1 Practical Observations on Strangulated Hernia, and some of the Diseases of the Urinary Organs, p. 256. Phila., 1836. HYPERTROPHY OF THE PROSTATE. 575 which account it ought, I think, to be discarded from practice. Besides, its performance involves an amount of skill possessed by few surgeons. Perforation of the middle lobe of the prostate has been proposed where this body forms an insuperable barrier to the evacuation of the urine, whether by the natural efforts or by artificial means. The expedient, under such circumstances, is decidedly preferable, I con- ceive, to puncture of the bladder; an operation which I have never had occasion to perform on account of enlargement of the prostate, and which I hope for the honour of modern surgery will soon be wholly abandoned. I have a specimen in my private collection in Avhich this method was adopted with admirable effect. The case occurred during my residence at Cincinnati in a German labourer, named Langhoff, sixty-seven years of age, who had been afflicted for a long time with difficulty in voiding his urine, in consequence of hypertrophy of the middle lobe of the prostate, which no plan of treatment that could be devised had the least tendency to diminish. At length, complete retention, irremediable by the ordinary means, occurred, when the operation in question was agreed upon, and at once performed with a silver, conical-pointed catheter. Immediate relief followed, and the patient lived in comparative comfort for several years. He ultimately died of acute pneumonitis. I found the prostate enlarged in all directions; the middle lobe formed a broad mammillated tumour, pierced at its base by a rounded canal fully equal in diameter to the membranous portion of the urethra; and the bladder was universally hypertrophied and greatly reduced in size. When this operation is deemed expedient, it may be performed either with a silver catheter, rather conical at the point, or with a small trocar inclosed in a silver canula. The instrument which I would recommend, does not differ materially from that devised by Mr. Stafford, of London. It consists simply of a silver tube, curved like a common catheter, and containing a movable trocar, which may be re- tracted or thrust forward at pleasure. The instrument is introduced in the usual manner as far as the seat of the obstruction, where it is firmly held until the trocar is pushed across the base of the swelling into the bladder. The want of resistance will indicate that the trans- fixion has been completed. The trocar is then withdrawn, and the canula left in the bladder. In a few days this is also removed, and a large catheter substituted. In this manner the treatment is con- 576 DISEASES AND INJURIES OF THE PROSTATE GLAND. ducted until the new canal has become lined by a mucous membrane, when the occasional passage of the catheter will suffice to prevent occlusion. In performing this operation, great care must be taken to keep the instrument in the middle line, and at a proper distance, on the one hand, from the arch of the pubes, and, on the other, from the rectum. It need hardly be added that a thorough knowledge of the anatomy of the parts and great delicacy of touch are indispen- sable prerequisites to its successful execution. CHAPTER IV. ATROPHY OF THE PROSTATE. The prostate, like other organs, is liable to atrophy. The affec- tion sometimes exists as an effect of senile decay, but more frequently it is the result of mechanical compression, or structural disease. Thus, a calculous concretion, either developed in the gland itself, or habitually lying at the neck of the bladder, may, by the pressure which it exerts upon the prostate, lead to gradual absorption of its substance, and great diminution of its volume. A similar change is sometimes brought about by an abscess, or a tubercular deposit. In fact, most cases of atrophy of the prostate are produced in this manner. The senile form of the lesion is extremely rare, and seldom exists as a pure, uncomplicated affection. The few instances of it which have fallen under my own observation occurred in old persons who had long suffered under disease of the bladder, or of the bladder and the urethra. Atrophy of the prostate occasionally exists as a congenital de- fect. Baillie1 has described a case in which the gland was so extremely small that it could hardly be considered as being fit for its office. It is proper to observe, however, that the deficiency in this instance was associated with ectropium of the urinary bladder, and malformation of the genital organs: the prostatic utricle was larger than natural. The extent of the atrophy varies ; thus it may involve the entire gland, one of its lobes, or only a part of a lobe. In extreme cases the proper structure is almost entirely effaced, and hardly anything remains but its fibrous capsule. In the more ordinary forms, how- ever, the gland is only somewhat reduced in bulk, preternaturally firm, and of a paler colour than in the normal state. The cel- lular element is wanting, and has been superseded by the fibrous* 1 London Medical and Chirurgical Trans., vol. i. p. 194. 37 CHAPTER V. HETEROLOGOUS FORMATIONS OF THE PROSTATE. SECTION I. SCIRRHUS. The occurrence of scirrhus in the prostate is extremely rare. It is hardly ever met with before the age of fifty-five or sixty, and is most common in persons who have long laboured under stricture of the urethra, urinary calculi, or organic disease of the bladder. For- merly every species of induration of this body was regarded as car- cinomatous, and it is highly probable that many, even at the present day, notwithstanding the recent advances of pathological anatomy, still confound these lesions with each other. I have myself never observed a well-marked example of pure, uncomplicated scirrhus of the prostate. Professor Walshe1 states that true scirrhus is of sin- gularly rare occurrence in this body, and he does not seem to have met with it in his own dissections. Dr. Mercier,2 of Paris, expresses himself to the same effect. "Nothing," says he, "is more rare than a scirrhous degeneration of this gland;" and he adds that, notwith- standing his long and laborious researches, he has never seen a case of cancer primitively developed in this organ. On the other hand, Chopart, Dessault, Soemmering, Boyer, Howship, and others speak of it as being extremely common. Too little is known of this affection to enable us to trace its history, or to determine its causes, progress, and diagnosis. The gland is of a gristly hardness, knotty and irregular in its shape, and of a whitish, grayish, or drab colour, with delicate fibrinous intersections. 1 On Cancer, by Warren, p. 308. Boston, 1844. 2 Recherches but les Maladies des Organes Urinaires et Genitaux, p. 167. Paris, 1841. HETEROLOGOUS FORMATIONS OF THE PROSTATE. 579 Its volume is usually somewhat augmented, but it may be quite na- tural, and occasionally it is even considerably diminished. The new deposit may occupy the whole gland, or it may be limited to a parti- cular portion of it; in general, it involves both lobes, though not in an equal degree. In other respects the disease follows the same course as in other parts of the body. Micturition is frequent and difficult; a sharp, lancinating pain is felt at the neck of the bladder, in the rectum, and along the inside of the thighs; the urine is high- coloured, foetid, and surcharged with viscid mucus; the general health is impaired; the countenance exhibits a peculiarly cadaverous aspect; and the patient, harassed by suffering, and deprived of appe- tite and sleep, finally dies from hectic irritation. The duration of this affection varies from twelve months to two or three years. Scirrhus of the prostate is no more amenable to treatment than scirrhus in other parts of the body. Rest in the recumbent posture, strict attention to the diet, the occasional application of a few leeches to the perinseum, the warm hip-bath, and the exhibition of anodynes by the mouth and the rectum, comprise the whole of our therapeutic resources. If retention of urine is present, the catheter is used to prevent undue distension and rupture of the bladder. SECTION II. ENCEPHALOID. Encephaloid, medullary sarcoma, or fungus hsematodes sometimes occurs in the prostate. Although more frequent than scirrhus, or hard cancer, it is, nevertheless, exceedingly rare, and hence, a good history of it is still a desideratum. The records of a few isolated cases constitute all our available information. The disease is most common in advanced life, though no period seems to be exempt from it. Nearly all the cases, the history of which I have had an opportunity of examining, occurred after the age of fifty. In one instance, recorded below, the patient was sc\renty years old. On the other hand, in a case reported by Mr. Stafford of England, the age was only five years. The origin of this affection is sometimes attributed to the irritation of a urinary calculus, to the presence of a stricture, or protractedx 580 DISEASES AND INJURIES OF THE PROSTATE GLAND. inflammation of the urethra; but, in general, it commences here, as in other parts of the body, without any apparent cause. A sense of weight and uneasiness at the neck of the bladder, with a slight impediment to the flow of urine, is usually the first sign of this disease. This is soon succeeded by a discharge of blood, which is at first so small as hardly to tinge the urine, but gradually in- creases in quantity, and at length becomes a source of great debility, if not actual exhaustion. In some instances it is voided in large clots, and constitutes the major part of the excretion. There is ordinarily but little pain until ulceration sets in, when it is frequently exceedingly severe, as well as persistent. Sometimes it is dull, heavy, and aching; sometimes sharp and lancinating, as in scirrhus; sometimes burning, scalding, or pulsatile. In all cases there is a constant desire to pass urine, and sympathetic irritation of the rec- tum with inclination to stool. As the malady progresses, the urine becomes turbid, foetid, ammoniacal, and loaded Avith thick, ropy mucus ; the countenance exhibits a peculiar cadaverous aspect; hectic irritation arises; and, finally, death, so long and so anxiously ex- pected, closes the scene. The duration of the disease seldom exceeds twelve months. There are no signs by which encephaloid can be distinguished, with any clearness, from some of the other affections to which this body is liable. The most reliable evidences are, a discharge of blood Avith the urine, the occasional expulsion of cerebriform substance or orga- nized clots, the frequent desire to pass water, and the ability to feel the enlarged gland through the rectum. The heterologous deposit may affect the entire organ, or be limited to one of its lobes, which, howrever, is exceedingly rare. The resulting tumour varies in its volume from that of a pullet's egg to that of a middle-sized orange. A dissection of the tumour shows it to be composed of all the ele- ments of the encephaloid tissue, as it occurs in other organs of the body. In one part it exhibits a fibrous arrangement, in another, perhaps, a structure similar to that of the cerebral substance, and in a third the appearance of an apoplectic depot. Sometimes the proper glandular texture is completely annihilated, while at other times portions of it remain, either perfectly distinct, or, as more frequently happens, in- termixed with the morbid growth. The commencement of the ure- thra, the neck and bas-fond of the bladder, the ureters, and even the kidneys are often involved in the mischief. No kind of treatment, either local or general, is of any service in HETEROLOGOUS FORMATIONS OF THE PROSTATE. 581 this affection, which is entirely beyond the influence of remedies, even in its earliest stages. All that can be done is to draw off the urine, as occasion may require, with the catheter, to allay pain by anodynes and opiate suppositories, and to support the strength by nourishing diet, stimulants, and tonics. The subjoined cases are well-marked examples of encephaloid in early life and old age. Case I.—A boy, five years of age, whose case is described by Mr. Stafford,1 had suffered for several months under irritable bladder, and was at length seized with retention of urine. The countenance was anxious and distressed, there was considerable fever, and the tongue was furred. A small gum-elastic catheter was passed without diffi- culty, and twenty-five ounces of urine of natural colour drawn off. As the bladder had completely lost its power, the instrument was used at first twice a day, and afterwards it was retained con- tinually. There was no pain or any other symptom denotive of dis- ease of any particular organ. The boy gradually sunk, and died in eight days from the time Mr. Stafford first saw him. The prostate was found to be somewhat globular in its shape, and equal in size to the largest walnut. Immediately behind the orifice of the urethra the middle lobe projected upwards in the form of a rounded nipple- like process, nearly of the volume of a small hazel-nut. A section of the gland exhibited a decidedly encephaloid character, both in colour, consistence, and texture, apparently intermixed at one part with melanotic matter. The bladder was contracted to the iize of a turkey's egg; it contained about an ounce of urine mingled with purulent matter, and its mucous membrane was somewhat thickened. The kidneys, brain, and viscera of the chest and abdomen were healthy. Case II.—In a patient, aged 68, Mr. Langstaff2 found an ence- phaloid tumour of the prostate as large as an orange; it was connected chiefly with its third lobe, and had occasioned absorption of the mu- cous membrane of the bladder, into the cavity of which it projected so as to plug up the orifices of both ureters and also nearly that of the urethra. The patient had suffered under vesical symptoms for upwards of five years ; and, for the last six months, he had had most excruciating pains in the Avhole urinary apparatus. He voided his urine in drops, or in a very small stream, had constant uneasiness in 1 London Medico-Chir. Trans, xxii. 218. 2 Walshe on Cancer, p. 309. Boston, 1844. 582 DISEASES AND INJURIES OF THE PROSTATE GLAND. the rectum, and was costive. One of the smallest sized bougies passed with great difficulty. The existence of the tumour was ascer- tained by examination with the finger in the rectum. Towards the last there was continual hsematuria, and death was finally caused by rupture of the right ureter, followed by an effusion of three pints of urine and blood behind the peritoneum. Encephaloid tumours were also contained in the liver and lung. Case III.—Mons. Mercier describes1 an encephaloid prostate in an old man of seventy. He was excessively emaciated, and had ex- perienced difficulty of micturition for eighteen months. He had never had any disease of the urinary organs. Death occurred on the thir- tieth day after his admission into the H6tel-Dieu. The prostate was found to be of the volume of an ostrich's egg, and exhibited, in the highest degree, all the characters of softened encephaloid tissue. Each lobe contained a sanguineous dep6t, similar to what is seen in the brain in apoplexy, of a black colour, and feeble consistence. The posterior part of the urethra was destroyed, or converted into a soft, pulpy substance. The bladder was moderately distended with black urine, its walls were thickened, and its mucous membrane was of a slate colour, and elevated, at two points, by little abscesses. The small curvature of the stomach also contained softened encephaloid matter. A few tubercles existed in the lungs. Case IV.—A man, fifty-five years of age, naturally of a robust constitution, but worn out by long suffering, came under the care of Mons. Civiale in 1837.3 He had laboured for the last thirty years under symptoms of gravel; his urine, which was frequently bloody, was generally turbid and foetid, and deposited a large quantity of mucus ; the kidneys had been long deranged; and micturition was difficult and painful. During the last five months his condition had been so much aggravated that he was obliged almost constantly to keep his bed. He had been repeatedly sounded, but no foreign body was detected until he came under the care of Mons. Civiale. He grew gradually worse, and death soon relieved him from his suffer- ings. The bladder contained a mulberry calculus of the size of a pigeon's egg. The middle lobe of the prostate was as big as a pul- let's egg, and formed a considerable projection at the anterior angle 1 Recherches sur les Maladies des Organes Urinaires et Genitaux, p. 169. 2 Traits Pratique sur les Maladies des Organes Genito-Urinaires, Deuxieme partie, p. 446. HETEROLOGOUS FORMATIONS OF THE PROSTATE. 583 of the vesical trigone. In front, the tumour extended to the mem- branous portion of the urethra, and presented a large excavation, which was prolonged backwards from one and a half to two inches. The prostate at this point was disorganized and softened, yielding, upon pressure, a cerebriform substance. SECTION III. COLLOID AND MELANOSIS. Of these two affections I have never met with any examples in the prostate, nor am I aware that any instances of it have been recorded in our scientific treatises and medical journals. The nearest ap- proach to melanosis of this organ of which I have any knowledge, occurred in the case mentioned by Mr. Stafford, previously referred to, in which a peculiar black substance was interspersed through an encephaloid tumour in a boy five years of age. SECTION IV. TUBERCLES. The prostate gland is occasionally the seat of tubercles. The affection, however, is extremely rare, and is usually associated with similar deposits in the seminal vesicles, urinary bladder, kidneys, testicles, and other organs. In a case which came under my ob- servation in 1838, during my residence in Cincinnati, it coexisted with psoas abscess. The patient was a tall, slender man, tAventy- seven years of age, for the last four of Avhich he had laboured under spinal disease, from the immediate effects of which he finally died. The tubercles, which Avere eight in number, and about {.he size of a pea, were of a pale yellowish colour, of a soft, curdy consistence, and scattered through different parts of the gland, which was at the same time considerably reduced in bulk. Strumous matter was also contained, and that in great abundance, in the seminal vesicles, in the right kidney and ureter, and in the lymphatic ganglions of the pelvis. The lungs were entirely free from it. The deposit occurs either in one tolerably large mass, or in the 584 DISEASES AND INJURIES OF THE PROSTATE GLAND. form of miliary bodies, from the size of a pin's head to that of a small pea. Occasionally the whole organ is transformed by the heterologous substance. I am not aware that the deposit ever exists here, as it does in some of the other structures, as an infiltration. The probability is, that the component elements of the gland are too compactly arranged to admit of such an occurrence. The morbid product, whatever may be the form in which it appears, is of a pale yellowish, grayish, or whitish aspect, and of a soft, cheesy, or curdy consistence. It manifests the same disposition to disintegration and the formation of abscesses as in other situations. Lallemand men- tions an instance in which not less than thirty small abscesses of this kind were found in the prostate gland ; they coexisted with numerous crude tubercles in the same organ and also in the kidneys. The volume of the prostate in this affection may be natural, in- creased, or diminished. Most commonly it is in the latter condition. In the case previously referred to it was remarkably small. The deposit seldom occurs in early life, at least so far as we can judge from the few instances of it upon record, and it always manifests a preference for the mucous follicles, in which it seems to be originally developed. Tubercles of the prostate gland produce no characteristic symp- toms. In the case which fell under my observation at Cincinnati, the only evidence of disease of the urinary apparatus was an irrita- ble condition of the bladder, accompanied Avith a frequent desire to make water. When ulceration or abscess occurs, the progress and termination are the same as in similar affections resulting from ordi- nary causes. Since the diagnosis of this malady can never be satisfactorily determined, every attempt to treat it upon scientific principles must prove unavailing. When its character is suspected, recourse may be had to the internal exhibition of iodine in some of its more valuable forms, and to counter-irritation in the perinseum by an issue or a seton. CHAPTER VI. CYSTIC DISEASE OF THE PROSTATE. Cysts occasionally exist in the prostate, but their occurrence is extremely rare, and is of interest in a pathological rather than a practical point of view. They vary very much, both in number and size, as well as in the character of their contents. In general, there are not more than six or eight, from the volume of a millet-seed to that of a currant, a pea, or a hazel-nut. In some instances, however, their number is much greater; and, on the other hand, examples occasionally occur in which there is only one, which is then propor- tionably large, occupying, perhaps, one-fourth, one-third, or even one-half of the entire gland. Their contents are transparent, fluid, and of a serous character. Particular cells sometimes contain a thick, viscid, and albuminous substance, either perfectly clear, or of a white, opaline appearance. The prostate, in this affection, is usually hypertrophied, and consolidated in its texture. When the cysts are large and numerous, which, however, rarely happens, the proper structure is, in great measure, absorbed, and its remains con- verted into a dense, fibrous substance. The mode of origin of these cysts has not been determined. They are in all probability dilated and closed follicles, or expanded and closed excretory ducts, and are therefore similar to the encysted tumours, which occur upon the inner surface of the lips, round the mouth of the uterus, and in the interior of the kidneys, from ob- struction of the uriniferous tubes. Nothing is known respecting the progress, symptoms, termination, and treatment of this affection. It has been observed at different periods of life, but old persons are most obnoxious to it. CHAPTER VII. FIBROUS TUMOURS OF THE PROSTATE. Rokitansky, in his Pathological Anatomy, states that he has fre- quently met with fibrous tumours of the prostate. In my oAvn dis- sections I have several times seen the same affection, and a well- marked specimen of the kind is contained in the private collection of my friend Dr. Sabine, of New York, to whom I am indebted for several drawings illustrative of the morbid condition of this organ. Fibrous tumours of the prostate vary in their volume from that of a pea to that of a small almond; they are of a rounded, spheri- cal, or ovoidal form, of a firm, dense consistence, and of a dull, gray- ish colour. They are usually situated on the outer surface of the gland, but occasionally they project inwards, so as to encroach upon the urethra and the neck of the bladder. In the few cases in which I have observed these tumours they were solitary; sometimes, how- ever, there are as many as three or four. When they are seated upon the periphery of the organ they give it a rough, knobby, or nodulated appearance. They usually grow from a broad base, which seems to be insensibly lost in the proper glandular substance. A section of these tumours displays a grayish or drab-coloured tis- sue, of a tough, inelastic character, having little moisture, and but few vessels. Fibrous tumours of the prostate bear a strong resemblance to fibrous tumours of the uterus, both in their situation and structure. They are always associated with hypertrophy of the gland, and are rarely found, except in old subjects, who have long laboured under organic disease of the urinary apparatus. They are probably deve- loped under the influence of chronic irritation, leading to irregular-, local, or circumscribed supernutrition of the parenchymatous structure of the part. There are no symptoms which, so far as has been ascertained, are peculiar to this species of formation, and hence nothing is known respecting their treatment. CHAPTER VIII. HEMORRHAGE OF THE PROSTATE GLAND. The prostate gland, like other parts of the body, is liable to hemor- rhage, varying in degree from a few drops to several ounces. The occurrence, however, is extremely rare, and is chiefly met with in aged subjects, in consequence of the forcible use of instruments, leading to a laceration of the substance of the organ, or to a rupture of some of its vessels, which, at this period of life, are frequently in a state of enlargement and varicosity. Catheterism, under such cir- cumstances, even when performed with extreme delicacy and gentle- ness, is liable to be followed by a copious flow of blood. In old persons affected with hypertrophy of the gland, riding on horseback, venereal indulgence, a fall on the buttock, or a blow upon the peri- nseum, will occasionally give rise to this form of hemorrhage, which, although generally slight, may be so abundant as to create no little uneasiness for the patient's safety. A smart bleeding of the prostate is sometimes produced by the irritation of a calculus, either of the bladder, or lodged in its own substance. The hemorrhage is occa- sionally spontaneous, and then probably depends upon ulceration of the organ, a granular condition of its surface, or the presence of a fungous, erectile, or encephaloid tumour. Hemorrhage of this organ is generally difficult of recognition, owing to its liability to be confounded with hemorrhage of the blad- der and the urethra. When the blood proceeds from the prostate, a portion generally escapes in a pure state, free from urine, both pre- vious to and after the evacuation of the bladder, while that Avhich passes into the bladder is of a dark muddy appearance, and is voided during micturition. These phenomena, howeA'er, are not character- istic, and it is only by coupling with them the history of the case that they assume a diagnostic value. Thus, if along with an escape 588 DISEASES AND INJURIES OF THE PROSTATE GLAND. of blood from the urethra or bladder, the patient is conscious of having received an injury either by a blow on the perinseum, or by the introduction of an instrument in the region of the prostate, the probability is that it proceeds from this gland, and not from the uri- nary passages, properly so termed. When the hemorrhage is caused by an ulcer of the prostate, or the presence of a hsematoid tumour, the circumstance is, in general, easily determined by the sound or catheter. The prognosis of this variety of hemorrhage is favourable or other- wise according as it is simple or traumatic, or dependent upon ulce- ration of the gland, or the presence of malignant disease. In the former case, it is generally readily amenable to treatment, and, there- fore, free from danger; in the latter, it is commonly obstinate, and irremediable. The treatment of hemorrhage of the prostate is to be conducted upon the same principles as that of hemorrhage of the urinary pas- sages generally. In many cases, it ceases spontaneously, or readily yields to rest in the recumbent posture, cold applications to the peri- nseum, and cold, acidulated drinks. Where these means fail, or where the hemorrhage is at all copious, recourse is to be had to the exhibition of gallic acid, in union with opium, every two or three hours, in the proportion of two or three grains of the former to half a grain of the latter. Few cases resist this combination beyond ten or twelve hours, and in many instances it arrests the discharge much sooner. When gallic acid fails to afford relief, acetate of lead, tannin, alum, sulphuric acid, spirits of turpentine, and the muriated tincture of iron, may be used as substitutes, with a reasonable hope of success. As adjuvants, cold applications to the anus, perinseum, and the hypo- gastric region, should not be neglected. Sometimes marked relief has followed the exhibition of Ruspini's styptic, as it is termed. In a case treated by Mr. Brodie, in which a frightful hemorrhage was connected with a very diseased prostate, it promptly arrested the discharge after all other remedies had failed. The skin had become pale, the pulse was feeble, and the patient was exhausted; yet the bleeding continued. " Large quantities of blood were drawn off with the catheter ; nevertheless the bladder continued to become more and more distended with blood, and was felt promi- nent in the belly as high as the navel. All other remedies having failed, I gave the patient a dose of the nostrum known by the name of HEMORRHAGE OF THE PROSTATE GLAND. 589 Ruspini's styptic, and repeated the dose two or three times in the course of the next twelve hours. In about half an hour after the first dose was taken, the hemorrhage ceased, and it never recurred."1 I have no experience with this remedy, and I mention it here solely on the authority of Mr. Brodie, which, in all matters pertaining to the urinary organs, is of the highest character. The dose is not mentioned by the London surgeon. 1 Brodie's Select Works, p. 100. Phila., 1847. CHAPTER IX. CALCULI OF THE PROSTATE. The prostate, like the bladder and the kidney, is liable to the for- mation of calculi, which generally become a source of severe suffering, imperiously demanding surgical and other interference. They are entirely different, both in their structure and composition, from vesi- cal concretions, and appear to be the result, at least in most instances, of disordered follicular secretion, dependent, in all probability, upon subacute or chronic irritation. The annexed engraving, from Mar- cet, conveys a good idea of the situation, size, and form of these little bodies. Fig. 86. Old persons are most prone to the formation of these concretions; they may, however, occur at almost any period of life. A few years ago I met with an instance in a young man of twenty; and others have seen the affection at a still earlier age. In their number, the concretions vary in different cases from a solitary one to several dozens. Marcet1 gives an instance of up- wards of one hundred; and Cruveilhier2 met with one in which there 1 Essay on Calculous Disorders, pi. ix. London, 1817. 2 Anatomic Pathologique du Corps Humain, livraison xvii. &c. CALCULI OF THE PROSTATE. 591 were so many that they could not be counted. A similar example is recorded by Sir Benjamin Brodie, in his work on the urinary organs. In general, however, the number of these bodies is small, not exceeding, perhaps, six, eight, ten, or a dozen. The volume of these bodies, like their number, is liable to consi- derable diversity. In general, they are diminutive. The smallest are commonly not bigger than an ordinary pin's head, and the largest rarely exceed the size of a pea. In some instances they have been found of the volume of a hazel-nut, a horse-bean, a chestnut, and even a pullet's egg. Their size is generally in an inverse ratio to their number; being very small when they are many, and comparatively bulky when they are single. The figure of these concretions is usually more or less rounded, especially if they are solitary; if, however, they are numerous, they are apt to be polyhedral, or facetted; in some instances they are flat- tened on the sides like a grain of corn; now and then they are elon- gated, pear-shaped, conical, cuboidal, ramiform, or narrow and con- stricted at the middle, like an hour-glass. In the case of a young man of twenty, I found them of a regularly pyramidal figure. When there is only one concretion, the surface is generally rough, or finely tuberculated; if, on the contrary, they are numerous, it is always smooth and polished; an appearance evidently produced by their mutual friction. In some instances these calculi are, as it were, articulated together, the rounded extremity of one being received into a corresponding concavity of another. Prostatic calculi exhibit no uniformity in respect to their colour. The most common tints are brownish, yellowish, grayish, and reddish- brown. Sometimes they are of a blackish, greenish, marbled, or mottled complexion. Their interior is usually a few shades lighter than the surface. During their development, they become covered with a brownish film from the natural secretion of the gland. Their consistence is firm, almost or quite equal to that of a urinary calculus. In rare instances, they are friable, and pulverulent. In regard to their structure, some are compact, others radiated and laminated. When struck with a steel instrument, they emit a click- ing noise, similar to that of a vesical concretion, but more faint. Marcet and other chemists long ago ascertained that these concre- tions consist nearly entirely of phosphate of lime; a substance which is sometimes secreted by the prostate in immense quantities, suffi- ciently, indeed, to give the urine a milky aspect. Lassaigne, who 592 DISEASES AND INJURIES OF THE PROSTATE GLAND. has recently made a quantitative analysis, states that there are con- tained in 100 parts 85J of phosphate of lime, J of carbonate of lime, and 15 of animal matter. From a careful examination of these concretions, in the different stages of their development, I am led to conclude that they are ori- ginally formed in the follicles and ducts of the prostate, from which they either escape, in whole or in part, as they increase in volume, or they remain, and gradually destroy its substance. I have no reason to believe that they ever arise in the proper parenchyma of the gland. When their number is considerable, at the same time that they are rather bulky, they are apt to break down the interven- ing structures, and to become aggregated together. In this way a large sac is sometimes formed, in which the concretions lie like shot in a bag, and the walls of which are of a whitish appearance, and of a fibro-cellular texture. A single cyst of this description occa- sionally contains as many as twenty, forty, and even sixty calculi, from the dimensions of a mustard-seed to those of a pea, and inter- mixed with thin, glairy mucus. The changes which accompany the formation of the cyst are always attended by the obliteration of the orifices of the excretory ducts, produced by inflammatory irritation and an effusion of plastic lymph. The mode of development, in fact, is similar to that which presides over the formation of ranula, lacteal tumours, and serous cysts in other organs. The bag may be solitary, or there may be several, and they vary in their size from that of a currant to that of a pullet's egg. During the progress of their development, these bodies are liable to produce absorption of the surrounding parts, and to change their situation. Thus, some of them may escape entirely from the gland, and either fall into the bladder to become the nuclei, perhaps, of a corresponding number of urinary concretions, or they may be ex- creted along with the urine. Some, again, may become impacted in the orifices of the excretory ducts, or in some abnormal aperture, and project upon the free surface of the urethra, either at its pros- tatic or membranous portion. Lastly, it is not improbable, that, when they are situated towards the back part of the gland, they may, by continued ulcerative absorption, finally escape into the cellular substance between it and the rectum. Such an event, however, must be extremely rare. Calculi, resembling those now described, are occasionally found in the ejaculatory ducts, which traverse the prostate from behind V CALCULI OF THE PROSTATE. 593 forwards. It is not probable, hoAvever, that they are of the same character; on the contrary, it is more reasonable to conclude that they are derived from the seminal vesicles, which, as is well known, are sometimes, though rarely, the seat of a peculiar form of concre- tion. I have myself seen one well-marked example of this, in a young man of twenty. Symptoms.—There is no uniformity in the effects produced by these bodies, either upon the urinary passages, or upon the system at large. When small, they seldom cause much uneasiness, some- times, indeed, not the slightest, and it is, therefore, not surprising that their presence should often be overlooked during life. This may be the case, even Avhen they exist in considerable numbers. At times, however, they are productive of great inconvenience, if not of excessive suffering. One of the most common symptoms is a dull, aching, wandering pain, with a sense of uneasiness in the perinseum and neck of the bladder; this is frequently attended with difficult micturition, and is liable to be aggravated whenever there is the most trifling derangement of the general health. During the progress of the disease the bladder becomes highly irritable; there is a constant desire to urinate, and the water is loaded with thick, glairy mucus, very much as in catarrh. Occasionally the concre- tions encroach so much upon the prostatic portion of the urethra as to give rise to partial, and sometimes even complete retention of urine. In a case mentioned by Sir Astley Cooper,1 the calculi, of which there was an immense number, produced not only painful feelings in the perinseum, but a degree of irritation which kept the patient in a state of continued mental excitement, bordering on insanity. The suffering occasioned by these bodies is usually not constant; on the contrary, after having persisted for some time, it may cease altogether, or recur only at long intervals. From the preceding remarks it will be perceived that the diagnosis of prostatic calculi is by no means always easy. The rational symp- toms are, in truth, of little account in the determination of the question; for, like those of vesical calculi, they may be simulated by other affections, in so embarrassing a degree, as to render them utterly Avorthless. We have already seen that the detection of these bodies, even when they exist in considerable numbers, is often en- tirely fortuitous. They are particularly liable to be overlooked when * Lectures on Surgery, by Tyrrell, p. 321. Phila. 1835. 38 594 DISEASES AND INJURIES OF THE PROSTATE GLAND. they occur in union with urinary calculi, stricture of the urethra, or hypertrophy of the prostate. When bulky or numerous, or when many of them are aggregated together, and lodged in a large cyst, or finally, when they project, as they now and then do, upon the free surface of the urethra, or into the bladder, they may be detected by a digital examination of the rectum, and the intro- duction of a sound, bougie, or catheter. As the instrument glides along it rubs against the foreign body, and imparts to the fingers a distinct grating sensation. If it consist of steel, the concretion may not only be felt, but it will be apt, if struck, to yield a sharp, metal- lic click, similar to that elicited by the contact of the sound in uri- nary calculi. If a smooth wax bougie be used, its surface will some- times be rendered rough by its collision with the extraneous body. When the finger is introduced into the rectum, the prostate being at the same time pressed backwards with a sound or silver catheter, the concretions may often be felt as so many hard, irregular projec- tions, the position of which remains unchanged by any force that can be applied to them. They move neither laterally, forwards, nor backwards, as generally happens in vesical calculi. When a con- siderable number are collected together in a nest, they give the finger the feel of a bag of marbles, of a mass of clotted blood, or of a bag of air ; and if struck with a sound, they produce a sort of dull, jar- ring, crepitating noise. Sometimes a concretion of this kind is discharged along with the urine, when a careful examination of its character promptly reveals its true nature and origin. In all cases of doubt, chemical tests should be employed. Another sign upon Avhich great reliance is to be placed is the cir- cumstance that the concretion can be felt only in one particular spot, and that it is generally immovably fixed, or nearly so. Let the patient assume what posture he pleases, the situation of the foreign body remains unaltered; it is always there, and nowhere else. In this respect, a prostatic calculus differs remarkably from a vesical calculus, which is liable to change its situation not only with every variation of posture, but also according to the state of reple- tion and vacuity of the bladder. I do not deem it necessary to say anything in particular respecting the general symptoms of prostatic calculi, inasmuch as they do not, usually, differ materially from those which accompany stone in the bladder. The health frequently continues good for many years, with the exception, perhaps, of an occasional paroxysm of fever, loss CALCULI OF THE PROSTATE. 595 of appetite, and disorder of the bowels. By and by, however, it begins to decline, and at length, after years of suffering, it is com- pletely shattered. A young man of the name of Roberts, from East Tennessee, whom I attended seven years ago, suffered as severely as any human being possibly could from this disease, under which he had laboured from early infancy. He was literally reduced to a skeleton, and had not strength enough to walk across his room. He had an incessant desire to void his water, and had excessive Bcalding and burning of the urethra, and was constantly pulling at his prepuce, Avhich Avas the seat of a most distressing pain and itch- ing. I sounded him .repeatedly without detecting any stone in the bladder, the coats of which Avere evidently much thickened, and the capacity greatly diminished. In the prostatic portion of the urethra the instrument always encountered a mass of hard substance, emitting a distinct noise, and easily felt by a digital exploration of the rectum. On one occasion I detached several calculi, which Avere afterwards excreted with the urine, and were found to be of a regular pyramidal shape, smooth and polished on the surface, of a dark brownish colour, and of the size of a very small grain of corn. The patient was too much exhausted to justify an operation, and I, therefore, sent him home, where he soon after died. His body Avas not examined. The calculi under consideration are usually associated with disease of the urinary apparatus. The most common affections are, 1. Stric- ture of the urethra. 2. Enlargement of the prostate. 3. Stone in the bladder. 4. Hypertrophy of the muscular coat of the bladder. 5. Organic lesion of the ureters and kidneys. The gland in Avhich they are situated is not always hypertrophied; on the contrary, it is sometimes considerably wasted, and even entirely changed in its sub- stance, being converted into a thin, fibrous shell, destitute, in great degree, of the normal structure. Its consistence, in this affection, may be natural, diminished, or augmented. The concretions may occur in any part of the gland, and sometimes they are scattered through its entire substance. Occasionally, though rarely, they are found almost exclusively in the middle lobe, which is then in a state of hypertrophy. A single calculus sometimes extends from the pro- state forward into the membranous portion of the urethra, which is thus often dilated many times beyond its natural calibre. The late Mr. James Wilson,1 of London, alludes to a case in which several 1 Lectures on the Urinary and Genital Organs, p. 355. London, 1821. 596 DISEASES AND INJURIES OF THE PROSTATE GLAND. concretions of this kind were discharged through an abscess in the perinseum ; and examples are recorded in which they found their way into the rectum. Of the remote causes of calculous formations of the prostate nothing certain is knoAvn, and in the absence of facts it would be idle to in- dulge in speculation. They are probably of the same nature as those which regulate the development of stone in the bladder. The imme- diate cause is a deposit of phosphate of lime, in consequence of an excess of this substance in the secretion of the gland. The urine has no agency whatever in their production; and it is important to remember, as Avas previously intimated, that they are entirely dissi- milar, in every essential particular, to vesical calculi. It is proper here to allude to a variety of concretion of the pro- state, which has usually been regarded, though, as I conceive, erro- neously, as altogether distinct from the preceding. Mr. Quekett, of England, Avho has recently examined it with much care, states that it frequently exists in such immense numbers as to seem almost to be a part of the natural secretion of the gland, in the minute follicles of which it is developed. It is of a white, brownish, red, or deep yellow colour; and its consistence varies from that of suet or wax to the firmness of fibro-cartilage, sand, or stone. The volume of these bodies is so minute that it generally requires the aid of a microscope to detect them; it is for this reason that they often elude the eye of the observer. Their chemical constitution, Avhich probably varies in the different stages of their evolution, has not been determined. I cannot suppose that these concretions possess anything peculiar; on the contrary, I think it must be admitted that they are merely rudimentary calculi, Avhich, during the progress of their development, acquire all the characteristic features Avhich have been here ascribed to them. Treatment.—In the treatment of prostatic calculi not much is to be expected from the employment of internal remedies, beyond the good effects which they may exert upon the general health, which must of course ahvays receive due attention. So far as our present knowledge is concerned, there are no medicines, in whatever form or mode they may be exhibited, capable of dissolving bodies of this kind. Any complications that may exist must be met upon general principles; strictures of the urethra must be removed, vesical calculi extracted, morbid sensibility of the bladder corrected, the bowels opened, and the diet regulated. To counteract the tendency to CALCULI OF THE PROSTATE. 597 phosphatic deposits, the different acids, especially the nitric, must be put in requisition, either singly or jointly with infusion of uva ursi and hops, buchu, or pareira brava. Alkalies are indicated Avhere there is marked acidity of the stomach, a sour state of the urine, and excessive irritability of the mucous membrane of the bladder, with a constant desire to pass water. The radical treatment, which is of course purely mechanical, must be regulated by circumstances. When the calculus projects into the urethra, it sometimes admits of being detached with the sound or catheter, and pushed back into the bladder, from which, if it be not too bulky, it is afterwards discharged along with the urine. To faci- litate the separation it will be found useful to introduce the finger into the rectum, so as to steady the gland, and bring it thus more fully within reach of the instrument. When the concretion projects from the gland, but is firmly fixed in its substance, an attempt may be made to seize and extract it with Weiss' forceps, employed upon the same principle as in calculus of the urethra. Civiale and others have repeatedly succeeded in dislodging phosphatic concretions with the litholabe, first detaching them, and then removing them either whole or piecemeal, as in the operation of lithotripsy. When the calculi are encysted, or contained in a bag in the paren- chymatous substance, the only Avay in which they can be approached is to cut down to the organ upon the staff, as in the ordinary opera- tion of lithotomy. The operation is not difficult; nor is it attended or followed by any ill effects. When there are several bags, situated in different parts of the prostate, a corresponding number of inci- sions may be required, and these may be made either at the same or at different periods. Before resorting to an operation of such mag- nitude and importance, the surgeon should always determine, if pos- sible, the precise locality of the foreign bodies; otherwise, after he has made the necessary incisions, he may experience much difficulty in finding the object of his search, or be greatly embarrassed, if not completely foiled, in his attempts at extraction. Occasionally the calculi lie in the cellular substance between the prostate and the rectum, having passed thither by ulcerative absorption. In such a case, instead of cutting through the perinseum, as under ordinary circumstances, I should prefer making an incision through the boAvel • a proceeding which Avould be considerably facilitated by dilating the tube freely with the speculum. CHAPTER X. PHLEBOLITES OF THE PROSTATE. The veins in different regions of the body are liable to the forma- tion of earthy concretions, which are hence denominated phlebolites, that is, vein-stones. In the female they are not unfrequently met with in the vessels of the vagina and the uterus, and in the male in the venous plexus of the prostate. As they occur in the latter, they are chiefly observed in elderly persons, who have long suffered under disease or irritation of the bladder, the prostate, the urethra, or the rectum and anus. The concretions, which are seldom nume- rous, and which are either free or adherent, vary in their size from that of a radish-seed to that of a pea; they are of an irregularly globular shape, smooth on the surface, of a pale, grayish colour, and of the consistence of chalk or lime. When fractured, they are found to be composed of concentric layers, of the same colour as their exterior. Of the chemical composition of these bodies no accurate information has been published; the probability, however, is that they consist of phosphate and carbonate of lime,—princi- pally the former,—cemented together by a small quantity of animal matter. A difference of opinion still exists respecting the mode of origin of these bodies. Some imagine that they are developed in the coats of the veins, from which they finally escape into their interior by a partial destruction of the lining membrane; others, on the contrary, believe that they are formed directly from the fibrous matter of the blood itself,—a conclusion confirmed by my own dissections. It is certain that they can often be detected almost in the very act of their development; some parts being red and soft like half-coagu- lated blood, others firm and fibrous, others hard and earthy. The deposition of inorganic matter may begin either at the centre or at the periphery, or simultaneously at both. PHLEBOLITES OF THE PROSTATE. 599 The veins in which these stones are found are generally more or less dilated, tortuous, and hypertrophied. In some instances they are obliterated both above and below the seat of the concretion, which is thus included as it were in a sort of cyst. There are no symptoms by which the existence of these vein- Btones can be recognised; nor have we any knowledge of the causes which predispose or lead to their formation. PAKT III. DISEASES AND INJURIES OF THE URETHRA. CHAPTER I. MALFORMATIONS AND IMPERFECTIONS OF THE URETHKA. The urethra is liable to a variety of malformations, which, although exceedingly rare, ought, nevertheless, to be known, on account of their practical relations. The subject is, unfortunately, involved in no inconsiderable degree of mystery, from a disposition in the profession, so remarkable in former times, to exaggerate the most trifling deviations from the natural standard, and to invest them with an importance that does not legitimately belong to them. Another reason, perhaps, is, that no individual experience, however large, can be of any material use in elucidating the true character of these defects, and that he who interests himself in their investi- gation must content himself in playing the part of a compiler. It does not fall within the scope or design of this treatise to present a full and detailed account of this subject; all I shall aim at is an outline of the more important facts in their relation to the surgical pathology of this tube. The most common vices of this canal may be arranged under the following heads: 1. Malformations of the terminal orifice; 2. Ab- sence, contraction, or obliteration of the urethra; 3. Duplicity of the canal; 4. Changes of form; 5. Deviations from the normal direction. 1. The urinary meatus, the anterior orifice of the urethra, is situated at the summit of the penis, Avhere, in the natural state, it forms a vertical slit, the edges of which are slightly rounded off, and of a cherry-red colour. This aperture, like the rest of the canal, is MALFORMATIONS OF THE URETHRA. 601 subject to certain vices, of which the principal relate to its position, size, form, and number. The aperture is occasionally situated con- siderably higher up or lower down than in the normal state; and in some instances, and these are by no means infrequent, it is placed upon the upper or under surface of the penis; in the former case, the malformation constitutes what is called epispadias, in the latter, hypospadias. I have seen no example in which the orifice was situated at the side of the median line of the gland. The urethra sometimes terminates at the inferior portion of the abdomen. Hal- ler refers to an instance in which it opened in the inguinal region; and Geoffroy Saint-Hilaire mentions one where the meatus was situated in the right groin. The meatus, instead of presenting itself in the form of a vertical slit, is sometimes of a rounded, circular, or ovoidal configuration. Its size may also be unnatural. Thus, it is sometimes remarkably large, or so small as hardly to admit the extremity of an ordinary silver probe. In the former case, which is rather rare, it constitutes a predisposition to gonorrhoea and chancre, from the fact that it offers an unusually wide surface for the contact and lodgment of the specific virus. The meatus is sometimes double, and even triple; a circumstance which has led to a belief, at one time common enough among anato- mists, of the existence of a double urethra. In the celebrated case of Fabricius Hildanus, so often cited in support of this opinion, there were two openings on the head of the penis, but only one canal. Vidal relates an instance in which there were three orifices, two of Avhich pierced the gland, while the other was situated at the lowermost part of the naA'icular fossa, nearly at the base of the frsenum. The latter was quite capacious, and afforded vent both to the urine and the semen; the rest were very small and contracted, and permitted the urine to pass only when this fluid was ejected Avith unusual force. The orifice is occasionally occluded, either partially or completely. In the former case, the narrowing may be effected by an unusually small opening with inverted edges; in the latter, by an extension of the mucous membrane, or of the mucous membrane and a small quantity of the proper structure of the gland. 2. The urethra may be absent. Of this occurrence the best marked example is seen in that variety of extrophy of the bladder in which the urine and semen are discharged above the pubes. This species 602 DISEASES AND INJURIES OF THE URETHRA. of malformation is exceedingly rare, and is necessarily accompanied with impotence. The tube in question is sometimes preternaturally narrow, or completely occluded. The defect may involve the entire canal, or it may be limited to a particular portion. Julius Cloquct met with an instance in a new-born child, in which the contraction existed at the middle of the urethra, and was upwards of an inch in length. The passage is occasionally closed by a prolongation of the mucous covering of the head of the penis; or by an internal septum, formed by a duplicature of the lining membrane; or, finally, by a sort of cellulo-fibrous substance. These varieties of occlusion of the urethra bear the greatest possible analogy to those of the rectum, and require the same modes of treatment for their relief. 3. Many, authors speak of what they regard as a double urethra. Vesalius mentions the case of a young nobleman, who had two canals of this kind, one for the transmission of the urine, the other for the passage of the semen. Other instances are narrated in which one of the tubes, after extending some distance back, terminated in a cul- de-sac. Such an anomaly, of which practitioners have recorded numerous examples, may be congenital, or acquired, more commonly the latter, in consequence of the maladroit use of instruments, even- tuating in the formation of a false passage. Vidal,1 who has care- fully studied this subject, by an analysis of the more important pub- lished cases, has arrived at the following conclusions respecting it: first, that the actual state of the science warrants the belief that the head of the penis may have several orifices instead of one; and secondly, that certain facts authorize us to admit the occasional existence of two canals; but that there is no instance, of a well- authenticated character, which tends to show that there has ever been a double urethra, properly so termed; or, in other words, two separate and distinct channels for the transmission of the urine and semen. 4. The tube is liable to changes of form. These seldom pervade the entire canal, but are limited to particular portions of its extent. Of these, the navicular fossa is, perhaps, most frequently affected. This part, which is naturally very wide, is sometimes absent, so that the spongy portion of the urethra is throughout of the same uniform dimensions. At other times, though very rarely, the fossa is remark- ably dilated, or expanded into an elongated pouch, Avhich may thus 1 Pathol. Externe, T. v. p. 11. MALFORMATIONS OF THE URETHRA. 603 serve as a temporary reservoir for the urine, the seminal fluid, and even calculous concretions, especially when it happens to be conjoined with an unusually narrow meatus. If, on the contrary, the meatus is very capacious, as when it extends as far as the base of the gland, constituting the first degree of hypospadias, it may form a serious inconvenience, inasmuch as it predisposes the part to the venereal infection by affording lodgment to gonorrhoeal and chan- crous matter. The bulbous part of the canal is occasionally unnaturally dilated, forming a species of cul-de-sac, well calculated to arrest the point of the catheter, and impede its progress towards the bladder. In some cases, very few, however, in number, this part presents an un- usually projecting septum, equally calculated to embarrass the ope- rator. The sinus in front of the verumontanum is sometimes so much enlarged as to be capable of receiving the end of a very large cathe- ter ; and a similar expansion is occasionally seen at each side of this crest. In some instances, the verumontanum is prolonged much further back than usual, giving rise, by a species of expansion, to two lateral folds, which are continuous in front, and resemble two little valves. An analogous arrangement sometimes exists towards the membranous portion of the urethra, but in this case the concave margin of the valve- like process looks toAvards the bladder instead of forwards. This variety of malformation, which is probably sometimes the result of disease, was first delineated by Langenbeck in his memoir on litho- tomy, and has been particularly noticed by Velpeau, in his Surgical Anatomy. Lisfranc states that he has several times seen a depres- sion between the two lateral lobes of the prostate. In one of his cases, the abnormal cavity was two lines in length, a line in width, and a line and a half in depth : the gallinaginous crest was deformed, and directed towards the right side.1 5. The tube sometimes deviates from the normal direction. In the infant, in whom the bladder is elongated, and situated, in great measure, in the abdominal cavity, the tube is a good deal more curved than in the adult. It is also influenced, in some instances, by the height and shape of the pubes. In the foetus, according to Chaus- sier, its curvature is often augmented by the distension of the rectum by the meconium. > Vidal, Pathol. Externe, T. v. p. 7. 604 DISEASES AND INJURIES OF THE URETHRA. Cases occur in which the tube terminates in the bladder a little lower down than usual; a circumstance which materially diminishes the bas-fond of the bladder, and predisposes to incontinence of urine. The prostatic portion of the urethra occasionally runs through the gland of that name in such a manner that nearly the Avhole of that body lies above it. In such a case, the tube is in close contact with the rectum, which must thus be endangered in the operation for stone. In some instances the reverse of this is the case, the tube being lodged in a mere gutter in the upper surface of the gland. I am not aAvarc that any lateral deviations have been observed; if any occur, they must be exceedingly infrequent. Treatment.—Many of these defects now described are, of course, irremediable, and are, on this account, more interesting to the phy- siologist and pathologist than to the surgeon. There are some of them, however, which admit of relief, and which, therefore, require further notice in this place. Occlusion of the external meatus of the urethra must be speedily remedied by an operation, otherwise the urine may accumulate to so great an extent as to lead to a rupture of the tube, with an infil- tration of the fluid in the connecting cellular tissue. Unfortunately the existence of this malformation cannot always be at once deter- mined, on account of the narrow and elongated condition of the pre- puce, which prevents the inspection of the affected part. It is only, in general, in consequence of the absence of micturition, and the presence of a small, elastic, and translucent swelling behind the head of the penis, that attention is directed to the seat of the malforma- tion, and the proper means of overcoming it. When the occlusion is caused simply by a septum or duplicature of the lining membrane, forming a sort of hymen or diaphragm, a vertical incision in the direction of the natural outlet will generally suffice to afford relief; the precaution being observed to keep the edges of the wound apart with a tent of slippery-elm, or a silver tube, so arranged as to pre- vent it, on the one hand, from slipping out, and, on the other, from passing backAvard into the bladder. When, on the contrary, the im- perforation depends upon the presence of a fibrous tissue, and reaches a considerable distance back, the operation will be more serious, and will require to be performed with a trocar, the canula of which, or a proper substitute, may be employed aftenvards to keep the canal pervious. The malformations known under the names of hypospadias and MALFORMATIONS OF THE URETHRA. 605 epispadias are defects of a serious character, as they entail not un- frequently great suffering and inconvenience upon their unhappy subjects. From the manner in which the urine is discharged, the neighbouring parts are kept continually in a tender, irritable, and excoriated state ; at the same time that they exhale so unpleasant an odour as to render the patient disagreeable both to himself and to those around him. But, Avhat is worse than all, they often render the individual impotent, and thus disqualify him for matrimony. This must necessarily be the case whenever the defect exists far back, and is so great as to allow the whole of the semen to escape at the preternatural aperture; or where the fissure extends all the way from the pubic symphysis, or perinseum, to the head of the penis. Examples of this description are, therefore, of the deepest interest in a medico-legal point of view; for, although the subjects of them may be able to copulate, yet from their inability to project the semen into the uterus, the intercourse cannot prove fruitful. When the mal- formation is associated with shortening and incurvation of the penis, or excessive length of the member with great redundancy of the pre- puce, even copulation may be impracticable. Hypospadias and epi- spadias occasionally, though rarely, coexist. Hypospadias presents itself under three varieties of form, of which the most common, as Avell as the most simple, is the one in which the urethra opens just behind the frsenum; it is generally accompanied by a fissure of the gland, which is destitute of a natural orifice, and has a broad, flattened, and unseemly appearance. In the second form, the tube opens at some point intermediate between the first and the scrotum ; and in the third, the urethra terminates at the latter organ, which is cleft at the middle line, so as to form two lobes, closely re- sembling the pudendal lips. In the second variety of the malformation, the urethra extends occasionally as far fonvards as the crown of the penis, where it ends in a sort of cul-de-sac. In the more simple variety of hypospadias, a cure may be attempted by paring the edges of the fissure, and uniting them by means of in- terrupted sutures over a catheter introduced into the bladder. The sutures should be placed near each other, and the intervals between them should be carefully closed with strips of isinglass plaster, or what is better, collodion, or the article sold in the shops under the name of Comstock's liquid cuticle. They should not be removed before the end of the fourth day, by which time the greater portion of the wound will have pretty firmly united. Any part that may remain unclosed may be touched Avith nitrate of silver, to induce the 606 DISEASES AND INJURIES OF THE URETHRA. formation of healthy granulations. The same mode of proceeding is adopted when the fissure exists farther back, only that it will be necessary, in addition, to establish an artificial urethra by means of a trocar, pushed in the direction of the natural channel. The canal thus made is kept pervious by the catheter, until it has received the mucous lining, after which the instrument should be worn a few hours every day for a number of months, to prevent undue contraction, which is so apt to follow all operations of this sort. When there is much deficiency of the parts, autoplasty may be necessary; the gap being filled up by borrowing a piece of integument from the scrotum or perinseum. When hypospadias is complicated with great shortening of the spongy substance of the urethra, accompanied Avith incurvation of the penis, the defect may sometimes be remedied by cutting out a V-shaped piece of the cavernous bodies, at their dorsal surface. Such an operation was performed successfully, many years ago, by the late Dr. Physick, and also, in 1844, by Professor Pancoast, of Philadelphia. It may be divided into three stages. In the first, the skin of the dorsal surface of the penis is pinched up longitudi- nally, and then divided transversely by transfixing its base. Se- condly, the cavernous bodies being thus exposed, a wedge-shaped piece, from half an inch to an inch in length, according to the extent of the incurvation, and embracing about two-thirds of the thickness of the two cylinders, is excised with the bistoury, by carrying the instrument in a sloping direction, first from behind fonvards toAvards the gland, and then backwards toAvards the pubes. The hemorrhage is usually slight, and ceases of its own accord. Lastly, the edges of the triangular wound are tacked together by several points of the interrupted suture; after which the penis is placed in a hollow, well-padded splint, to which it is secured by an appropriate roller. The parts are kept cool with cold Avater, to prevent undue inflam- mation, and the stitches are removed at the end of the fifth day. In a case of hypospadias, accompanied with considerable incurva- tion, which was under my charge last summer, I dissected off the integuments at the seat of the bend, and then made four horizontal incisions, at intervals of several lines, into the fibrous sheath of the cavernous bodies, in order to restore them to their normal length. The operation had the effect intended, but, in consequence of the difficulty of keeping the organ extended, there was a reproduction of the curve within a very short period after the cicatrization of the parts. MALFORMATIONS OF THE URETHRA. 607 In epispadias, which is much more rare than hypospadias, the malformation affects the dorsal surface of the penis, and likewise presents itself under several varieties of form. In the subjoined Fig. 87. sketch, copied from Liston, the fissure extends from the pubic symphysis to the extremity of the penis, which has a singularly flattened and distorted appearance. The mucous membrane, under such circumstances, is generally abnormally pale, and its lacunse are beautifully distinct. In the more simple forms of epispa- dias, the urethra terminates a short distance behind the gland of the penis, which is usually more or less disfigured. The treatment for the rectification of these defects is to be conducted upon the same principles as that for the different varieties of hypospadias, already described. In Mr. Liston's case, in which nearly four inches of the urethra were exposed, a complete cure was effected in a few days. The operation consisted in paring the edges of the cleft thoroughly, and putting them together over a catheter, by means of many points of the twisted suture. Union by the first intention took place in the entire track, except near the pubes, where a very minute fistulous opening remained, through which not more than a drop of urine oozed during micturition. This was afterwards closed with a heated needle. The organ was in all respects, and for all purposes, as perfect as could be desired.1 1 Practical Surgery, p. 573. London, 1840. I take much pleasure in referring here to a valuable paper on hypospadias and epispadias by Dr. Mettauer, an emi- nent surgeon of Virginia, in the American Journal of the Medical Sciences for July, 1842. The operation performed by this gentleman upon one of his patients was both novel and ingenious, and is worthy of imitation in similar cases. CHAPTER II. LACERATION OF THE URETHRA. The urethra, like other mucous canals, is liable to laceration; and the lesion, although not common, is of sufficient importance to merit attention in a work specially devoted to the injuries and diseases of the urinary organs. The subject is the more deserving of conside- ration here, because it has either been entirely overlooked in most of our systematic treatises on surgery, or noticed so cursorily as to afford no satisfactory information. The omission can be explained only by the fact that few writers have any practical knowledge of the lesion, and that no analysis has yet been made of the cases which are scattered through our periodical literature. The best work on the subject, so far as my information extends, is a little monograph of Dr. I. Franc, published at Montpellier, in 1840, under the title of " Observations sur les Re'tre'cissements de l'Ure'tre par Cause Traumatique." There is also a short but valuable paper on laceration of the urethra, by Dr. Isaac Hays, of Philadelphia, in the nineteenth volume of the American Journal of the Medical Sciences, of which he is the able and distinguished editor. Rupture of the urethra is produced by two varieties of causes, the one acting from without, the other from within. Under the first may be comprised falls, Woavs, and kicks upon the perinseum, or the perinseum and the penis; under the second, injury done by the lodgment of a calculus, and the rude, forcible, or injudicious use of catheters, bougies, and sounds. In the majority of instances, the laceration is caused by falls from a considerable height, in which the perinseum strikes against some sharp, angular, or projecting body, while the thighs are more or less separated from each other. From the peculiar character of their occupation, sailors, masons, carpenters, painters, house-cleaners, coachmen, and teamsters are more prone to this kind of injury than any other classes of individuals. Sometimes the laceration is occa- LACERATION of the urethra. 609 sioned by a blow or kick upon the perinseum, from the foot of a man or a horse; and a case is mentioned, in the London Medical and Physical Journal for May, 1809, in which it was produced by the person being throAvn forcibly forward on the pommel of his saddle. It need hardly be added, that balls and other missiles are capable of causing the injury in its most aggravated form. Of the internal causes of laceration of the urethra, the most common are vesical calculi, bougies, and catheters. After litho- tripsy, serious injury is often inflicted by sharp, angular frag- ments of stone impinging against, and rupturing the mucous mem- brane ; and the same circumstance occasionally occurs when a small but rough calculus, in its attempt at extrusion, becomes im- pacted in the posterior portion of the tube. The mischief which is sometimes done to the urethra in the rude introduction of the cathe- ter, bougie, and sound, is familiar to every one. Laceration of this canal has occasionally taken place under a violent erection, especially if the penis, while in this condition, happened to be struck acciden- tally against a hard and resisting body. The laceration varies, as to its seat, according to the nature of the vulnerating body, or the character of the exciting cause. When it results from a blow, fall, or kick upon the perinseum, it occurs usually immediately in front of the triangular ligament, betAveen it and the bulb; occasionally it is situated behind this point; and sometimes, though rarely, it is met with in the spongy portion of the tube. When the rupture is caused by the passage of a calculus, or of an instrument, it may be seated in any region of the urethra, from the neck of the bladder to the external orifice. There is no uniformity in regard to the extent of this injury. While in some instances it is extremely slight, presenting itself per- haps merely in the form of a minute fissure, slit, or crevice, in others it is so great as to embrace one-half, two-thirds, or even the entire circumference of the tube. In the latter case, the ends of the di- vided canal frequently lose their apposition, and thus oppose a serious, if not an insurmountable barrier to the introduction of the catheter. The laceration may be limited to the mucous membrane, or it may involve all the tissues which intervene between the canal and the ex- ternal surface along Avith it, according to its seat, and the nature of the vulnerating body. Finally, it may be solitary or multiple, longi- tudinal, transverse, or oblique. The symptoms of this affection are generally sufficiently charac- 39 610 DISEASES AND INJURIES OF THE URETHRA. teristic. The most prominent arc, pain in the affected part, hemor- rhage from the urethra, inability to void the urine, or the discharge of this fluid in a small and imperfect manner, discoloration and swelling of the perinseum, or of the perinseum, scrotum, and penis, and great difficulty, if not utter impossibility, of introducing the ca- theter. The patient is weak and faint, perhaps sick at the stomach, and labours under all the effects of a severe shock. The pain is usually in direct proportion to the extent and violence of the accident. It is of an acute, sharp, cutting character, as if caused by a pen-knife, razor, or lancet, is generally circumscribed or limited to the seat of the injury, and is greatly aggravated by the passage of the urine, by motion, and by pressure upon the perinseum. It is not intermittent but constant, and is sometimes compared by the patient to the sensation produced by the contact of molten lead. Although originally circumscribed, it soon extends to the circumja- cent parts, as the testicles, groins, thighs, anus, and the bladder, and becomes so severe as not to allow the poor sufferer a moment's comfort. The hemorrhage varies in quantity from a few drops to a number of ounces, according to the extent of the injury suffered by the urethra and the circumjacent textures. The loss of a pint of blood soon after the accident is no unusual occurrence. The discharge, which is ge- nerally transient, sometimes continues for a number of days, and is always aggravated or reproduced at every attempt to introduce the catheter. Occasionally the blood, instead of issuing at the external orifice of the urethra, escapes at the abnormal opening, lodges in the surrounding cellular tissue, or passes back into the bladder, Avhere it is either retained, or dissolved, and excreted along with the urine. Few patients affected with rupture of the urethra, are able to void their urine with anything like their accustomed facility. On the contrary, there is usually a great deal of difficulty, accompanied with excessive pain and straining, and a constant desire to relieve the bladder. In many cases, indeed, there is complete retention from the very beginning, caused either by the loss of apposition of the divided ends of the tube, by the presence of coagulated blood, or by the disabled condition of the bladder itself. Sometimes, again, though rarely, there is total suppression of urine. The discoloration of the affected part may occur instantly, or not under a few hours. It varies from light red to deep purple or black, and involves not only the perinseum, but frequently also the scrotum LACERATION OF THE URETHRA. 611 and the penis. The immediate cause of this symptom is an extrava- sation of blood into the subcutaneous cellular tissue, the quantity of which varies, in different cases, from a few drachms to several ounces. When considerable, it must necessarily lead to proportional disten- sion of the affected region, which is still further increased, in a short time, by the ordinary products of inflammation. Although there are few cases of laceration of the urethra by external violence in which there is not some degree of discoloration of the integuments, it is worthy of remark that the parts occasionally present an entirely na- tural appearance. If an attempt be made in this affection to draw off the urine, the catheter will either not enter the bladder at all, or it will meet with more or less resistance at the seat of the injury. Its arrival at this point will be indicated by a peculiar grating sensation, which no ex- perienced hand can possibly mistake. When the laceration is con- siderable, the extremity of the instrument will be apt to take a wrong direction, or to become entangled by the edges of the wound. If the tube be completely severed, and the divided ends have lost their pa- rallelism, the greatest difficulty will be experienced in performing the operation ; and, in many instances, no surgeon, however skilful, will be able to succeed. Should the instrument fortunately reach the bladder, its withdraAval will generally be followed by a renewal of the hemorrhage. Another bad consequence of laceration of the urethra, especially when produced by external causes, is extravasation of urine into the surrounding cellular tissue. When the accident occurs in the posterior part of the tube, in front of the triangular ligament, the fluid generally distends the perinseum, and thence proceeds for- wards, underneath the dartos, into the scrotum and spongy body of the penis. In such a case, violent inflammation, often followed by sloughing, and even death, is an inevitable result. Diagnosis.—When a man has received a fall, bloAV, or kick upon the peringeum, or the genitals, and is almost immediately after seized with a sharp, cutting, or burning pain in the region of the injury, and a discharge of blood from the urethra, it may be pretty positively affirmed that he is labouring under the effects of a laceration of this canal. The diagnosis is fully confirmed, when, superadded to these symptoms, there is a frequent desire to empty the bladder, Avith an inability to pass a drop of water. The peculiar grating sensation, previously alluded to, as being communicated to the hand on attempt- 612 DISEASES AND INJURIES OF THE URETHRA. ing to introduce a catheter, is another valuable sign, almost of itself characteristic of the nature of the accident. A mere contusion of the urethra, unaccompanied by any rupture, is easily distinguished from the latter affection by the absence of hemorrhage, and of the severe burning pain which results from the contact of the urine. In neither case can any positive conclusions be drawn from the character of the constitutional symptoms, which are often as severe in one of these lesions as in the other. Prognosis.—The danger of this lesion is usually in direct propor- tion to its extent, and the state of the bladder at the time it is in- flicted. If the laceration is considerable, and the patient has not made water for some time, urinous infiltration will be almost certain to occur, and to be followed by all the mischief which it is capable of producing whenever it comes in contact with tissues which are not accustomed to its presence. The usual consequences of such an acci- dent are, severe pain and swelling of the affected parts, retention of urine, violent rigors, great depression of the pulse, delirium, exces- sive thirst, and constant restlessness. If the parts be not relieved by early and free incisions, they soon fall into gangrene; hiccup and subsultus ensue; and the patient dies in great agony, generally be- fore the eighth day, and sometimes as early as the fourth or fifth. In slight cases, the prognosis is always more favourable; but even here the patient can scarcely be considered as out of danger as long as there is any possibility of urinous infiltration. Apart from this contingency, a wound or rent of the urethra is attended with no more hazard than a similar injury in any other region of the body; it heals quite as readily, and does not give rise to any more suffering. The injury, even when comparatively slight, is sometimes followed by great contraction of the corresponding portion of the tube. Treatment.—The treatment of this accident must be prompt and decisive, otherAvise great, if not irreparable mischief must inevitably befall both part and system. As the chief danger consists in the escape of the urine by the breach of the urethra into the cellular tissue of the perinseum and scrotum, every means, calculated to obviate such a calamity, should be instantly put in requisition. If the rent be small, the first thing to be done is to endeavour to pass a catheter into the bladder; an operation which is to be conducted in as gentle and cautious a manner as possible, lest the point of the instrument be intercepted by the wound, and thus take a wrong direction. The catheter should rather be over than under the ordi- LACERATION OF THE URETHRA. 613 nary size, so that, Avhen introduced, and fixed in its place, it may slightly distend the parietes of the tube, and thereby prevent the urine from flowing between the contiguous surfaces. The object of this proceeding is to carry off the Avater from the bladder as fast as it arrives there, without permitting it to come in contact with the lacerated surface. Unless this be attained, the treatment must not be thought of, much less employed. It does not matter whether the instrument used is one of silver or of gum, though I always myself prefer the former on account of the greater facility of intro- ducing it, and the less necessity for changing it after it has been some time in the bladder. If, on the contrary, the rent be very extensive, as is indicated by the hemorrhage and other symptoms, the only rational treatment is to make a large incision into the part, to afford a free exit to the urine, which will otherwise be sure to insinuate itself rapidly into the cellular tissue of the perinseum and scrotum. The operation is conducted upon the same principles as that of lithotomy. The patient being placed and secured in the usual manner, a staff or grooved director is introduced into the urethra, and carried down to the seat of the rupture, where it is carefully held by an assistant. Taking the point of the instrument for his guide, the surgeon cuts along the raphe" of the perinseum, directly over the affected part, until the urethra is completely laid open to any extent that may be necessary. The same precautions, in regard to the wounding of the rectum and the vessels of the perinseum, are to be observed here as in puncture of the bladder. When the operation is completed, a catheter is introduced into the bladder through the natural opening of the urethra, arid fixed in its situation by a T-bandage. The instrument must be worn until the external wound is healed, else it will be difficult, if not impossible, to restore the canal to its natural condition. The operation here described is easy of execution, and indispen- sable to the safety of the patient; it places him at once in a state of comparative security, by preventing urinous infiltration, and af- fording nature an opportunity of repairing the breach at the least possible expense of time and suffering. No danger whatever is to be apprehended from its performance; and the Avound usually heals in a very short time, Avithout the aid of any dressings. When the laceration of the tube is very extensive, but unaccompanied by any external opening, it is often difficult, as has been justly remarked by 614 DISEASES AND INJURIES OF THE URETHRA. Mr. Earle,1 of London, to persuade the patient or his friends of the necessity of an operation; and, in such a case, " much decision and firmness are required on the part of the surgeon, who should act at once, or he may be too late to prevent extensive or even fatal effu- sion of urine." If some hours have elapsed since the occurrence of the injury, as not unfrequently happens when the patient, from ignorance or other causes, neglects to send for surgical aid, and it be apparent, from the nature of the symptoms, that there is urinous infiltration, no time is to be lost in making numerous and deep incisions into the affected parts. A free outlet must be afforded to the pent up fluid, and to the inflammatory products which so soon succeed to it, other- wise extensive sloughing and even death may be the consequence. Hesitancy, in a case of this kind, must yield to decision; tardiness to promptness; timidity to boldness. The patient is saved or lost in a moment. The treatment above mentioned, as applicable to the various con- tingencies connected with this lesion, may often be advantageously aided by general and topical bleeding, purgatives, demulcent drinks, the Avarm bath, anodynes, fomentations, and poultices. Much judg- ment is generally required in the adaptation of particular remedies to particular cases. When infiltration is present, depletion is usually badly borne, and should be practised with the greatest circumspec- tion. It has been proposed in laceration of the urethra, followed by obstinate retention of urine, to puncture the bladder through the rectum or the abdomen. To such a proceeding, which has unfortu- nately been too often carried into effect, there is great objection; for, even supposing that it relieves the distended organ, it does not strike at the main evil, the urinous infiltration of the surrounding parts. It is better, therefore, always to incise the affected tissues as freely as possible, cutting down to the urethra, and laying it open so as to afford full vent to the urine. The contraction of the tube which sometimes succeeds to this injury is to be managed upon the same principles as an ordinary stricture. The subject Avill be adverted to in its proper place. 1 London Medical and Physical Journal, April, 1828, p. 317; Amer. Jour. Med. Sciences, xix. p. 393. CHAPTER III. STRICTURE OF THE URETHRA. By the term stricture is understood a diminution of the calibre of the urethra, either of a transient or permanent character. The affection, in the former case, commonly depends upon a spasmodic contraction of the tube, and is hence known by the name of spas- modic stricture; it lasts only for a short time, is paroxysmal in its nature, and often disappears as suddenly and unexpectedly as it comes on. In the latter, on the contrary, it is always caused by an effusion of plastic lymph into the lining membrane and the subjacent cellular tissue of the urethra, Avhere a portion of this substance re- mains, and is ultimately organized, being thus incorporated as a con- stituent element Avith the pre-existing structures. To this form of coarctation, to which the succeeding remarks will be limited, the term organic is usually applied, • and, as signifying the same thing, the word permanent is occasionally employed. Organic strictures are divided into simple and complicated, com- mon and traumatic, partial and complete, soft and callous, dilatable and undilatable, permeable and impermeable, recent and old. These terms, Avhich are constantly employed by writers, are sufficiently significant, and do not, therefore, require any special explanation. Seat.—Much diversity prevails in relation to the seat, number, form, consistence, and extent of organic strictures. A careful exa- mination of these circumstances must, therefore, constitute the next subject of inquiry, for it is self-evident, that, without a well-grounded knowledge of them, our treatment must generally be conducted in a random and hap-hazard manner. No part of the urethra, except, perhaps, the prostatic, is entirely exempt from organic stricture. The disease, however, as might be expected, does not occur with equal frequency at all points of the tube. It would be exceedingly difficult, if not impossible, looking merely at the statements of authors, to determine where it is most 616 DISEASES AND INJURIES OF THE URETHRA. commonly found, for upon no subject, connected Avith the urinary organs, does there exist a greater contrariety of opinion. This is not surprising Avhen it is considered that every man forms his judg- ment according to his experience or his means of observation. The results of my practice lead me to infer that the affection is most com- mon, first, in that portion of the urethra which is comprised betAveen the scrotum and the head of the penis; secondly, at the membranous part of the tube, or at the junction of this and the bulbous part, and lastly, at the anterior extremity, within a few lines of the meatus. I have never seen a stricture in the prostatic portion of the canal, and therefore conclude that it must be exceedingly rare here, if in- deed it ever exists. I have repeatedly met with the disease near the external meatus. "Every part of the urethra," says John Hunter (Complete Works, by Palmer, ii. p. 102), "is not equally subject to strictures, for there appears to be one part which is much more liable to them than the whole of the urethra besides, that is, about the bulbous part. We find them, however, sometimes on this side of the bulb, but very seldom beyond it. I never saAv a stricture in that part of the ure- thra which passes through the prostate gland." "I have not," remarks John Shaw, of London (Medico-Chir. Trans, xii. p. 461), " in more than a hundred dissections which I have made of diseases of the urethra, seen a stricture or narrowing of the canal, posterior to the ligament of the bulb ; nor have I been able to find one example of stricture beyond this part among those preserved in the College museum." Soemmering also declares (Traite* des Maladies de la Vessie et de l'Uretre, par Hollard, p. 165, Paris, 1824), that the lesion never occurs in that part of the canal which is surrounded by the prostate. Ricord, hoAvever, has seen this portion of the urethra narrowed, independently of the prostate; and a similar case is cited by Mr. Crosse, of England. (Acton on Venereal Diseases, p. 101. New York, 1846.) Ducamp (Treatise on Retention of Urine, translated by Dr. Her- bert, p. 12, New York, 1827) states that five times out of six the obstruction is situated at a distance of from four and a half to five inches and a half from the external orifice of the urethra. If, he adds, greater precision be required, it may be affirmed that in four cases out of five it is to be found at four inches and three-quarters to five inches and three lines. He has sometimes discovered a stric- ture at the distance of four inches; in two cases it occurred at about STRICTURE OF THE URETHRA. 617 two inches; and in two others it was situated at the very orifice of the canal. Lallemand asserts that the statement of Ducamp is incorrect, and that the greater number of strictures occur at the pubic arch, that is, about six inches from the external orifice. " The ordinary situa- tion of a permanent stricture," says Sir B. C. Brodie (Lectures on the Diseases of the Urinary Organs, p. 6, third edition, Loncl., 1835), " is at the membranous part of the urethra, just behind the bulb of the corpus spongiosum." According to Amussat (Lectures on Reten- tion of Urine, translated by Dr. Jervey, p. 15, Phila., 1840), the most common site is the point of union between the bulbous and mus- cular portions of the canal. The obstruction, he says, is also very frequently met with at the commencement of the navicular fossa, near the external opening. He has never seen it in the prostatic part of the tube. " It is at the junction," says Vidal (Pathologie Externe, T. v. p. 52, deux, edit, Paris, 1846), " of the membranous and bulbous portions, rather towards the first, that true coarctations are most frequent." Civiale (Traite* Pratique sur les Maladies des Organes Genito-Urinaires, T. i. p. 124) affirms that the only regions in Avhich true organic strictures are found, are first, the external orifice; secondly, the two extremities of the navicular fossa; thirdly, the an- terior part of the spongy portion; and fourthly, the sub-pubic curve, at the union of the membranous and bulbous divisions. Number.—Strictures vary much as to their number. In a majo- rity of the cases that have fallen under my observation, there was not more than one; frequently, however, I have seen two, and occa- sionally I have met Avith three and even four. The latter number is rare; nevertheless, it is sometimes exceeded. Thus, John Hunter saw an instance of six; Lallemand, of seven; and Colot, of eight. When the strictures are multiple, they may be in close proximity with each other, or separated by a considerable interval. A French writer, Ducamp, states that when there are several coarctations, the most extensive one will commonly be found at the curve of the ure- thra, and the others between this point and the head of the penis. My practice has not furnished me with any such coincidence. Form.—The most common form of stricture is that in Avhich the urethra exhibits the appearance as if a thread or piece of twine had been tied around it. It is not, hoAvever, as might be inferred from this remark, ahvays circular; on the contrary, it is often oblique, and sometimes even bifurcated. It may embrace the entire circum- 618 DISEASES AND INJURIES OF THE URETHRA. ference of the tube, or only a part of it; and varies in its antero- posterior extent from half a line, or even less, to several inches. In a remarkable instance which I witnessed, many years ago, in the practice of a physician of Pennsylvania, the contraction involved nearly the Avhole length of the canal from one extremity to the other. The degree of coarctation ranges between the slightest diminution of the natural size to almost complete obliteration. When the disease Fig. 88. Fig. 89. Fig. 90. has reached this point, the urine is discharged in drops, and the blad- der is seldom, if ever, entirely empty. No stricture, however firm or narrow, can be said to be impermeable, in the true acceptation of that term. A very rare form of the disease, called the bridle-stricture, is occa- sionally met with. In this variety, which has been particularly de- STRICTURE OF THE URETHRA. 619 scribed by Sir Charles Bell, although it had been previously noticed by others, the urethra is obstructed by a small narrow band, which is stretched across the tube from one side to the other. It is com- posed of plastic lymph, and is usually of a tough, fibrinous consis- tence, being of a pale straw colour, and of variable form and dimen- sions. Occasionally it is a narrow, thread-like band, arranged so as to divide the passage into two parts ; sometimes it has the appearance of a valve, similar to that of a vein; and now and then it presents itself in the form of a fleshy excrescence, vegetation, or caruncle. Few surgeons have been so fortunate as to see this stricture, and not a few have denied its existence altogether. For my own part, I am not certain that I have ever met with a solitary instance of the bridle- stricture, properly so termed, while I have several times seen fleshy groAvths in the urethra. Consistence.— The contracted part may be soft and elastic, or hard and firm, according to the duration of the disease, and the degree of transformation of the effused lymph, upon the presence of Avhich the obstacle depends. Recent strictures are generally soft and yielding, on Avhich account they are frequently described as dilatable strictures; old strictures, on the contrary, are usually cal- lous, tight, and resisting. Exceptions to this rule are, of course, not uncommon. Thus, I have known a stricture acquire such a de- gree of firmness, in a few months, as to render it impossible to pass even the smallest sized bougie until after it had been divided with the lancetted stylet. On the contrary, I have occasionally met with an ancient stricture which readily and permanently yielded to the process of dilatation in a very few days. It is worthy of remark, that the consistence of a stricture, especially if it be large, is seldom uniform, but that it varies in different parts of the coarctation, being, perhaps, quite soft at one point, hard at another, and fibro-cartila- ginous at a third. Colour.—Organic strictures vary in their colour. This is some- times perfectly normal; but, in general, the affected part is of a grayish, light straw, or whitish aspect, forming thus a striking con- trast with the rosy tint of the surrounding surface. Si/mptoms.—The symptoms of stricture, considered generally, are, diminution of the stream of urine, which is usually spiral, forked, or dribblino-; frequent, sIoav, and difficult micturition, often preceded, accompanied, or followed by a sense of scalding; a discharge of thin, gleety matter from the urethra; uneasiness about the loins, 620 DISEASES AND INJURIES OF THE URETHRA. perinseum, and anus ; pain in coition; nocturnal emissions ; elonga- tion and thickening of the penis; and hardness at the seat of the obstruction, detectable by the finger. During the progress of the disease, the patient is liable to be troubled Avith swelling of the tes- ticle, chordee, hemorrhoids, hernia, and retention or incontinence of urine. The general health is variously affected; sometimes slightly, at other times severely. In the more aggravated forms of the malady, there is almost always derangement of the digestive organs; the system is more or less irritable ; and the slightest exposure, fatigue, intemperance, or irregularity in eating, is apt to be followed by an exacerbation of the local suffering. Let us examine these symptoms a little in detail. One of the first circumstances which generally attract the atten- tion of the patient, and lead him to suspect that something wrong is going on in his urinary organs, is a slight diminution of the stream of urine, accompanied by a sense of scalding in the urethra, a feel- ing of weight at the neck of the bladder, and an increased frequency of micturition. He is, perhaps, obliged to use the chamber several times during the night; and, if he is exposed to cold, takes much exercise, or indulges a little more than usual in the pleasures of the table, he finds that he is unable to retain his water as Avell as for- merly, or that it passes only drop by drop, and with considerable pain and spasm. By and by, the local symptoms assume a more decisive character. The stream of urine is much smaller than it was at first, and has a Aviry, tAvisted, spiral, or corkscrew shape. Sometimes it is double, forked, or bifurcated. Its force also is sen- sibly lessened; instead of being projected in an arched form, as it is in the natural state, to a distance, perhaps, of several yards, it falls perpendicularly between the patient's feet, or upon his troAvsers, although he is conscious that the bladder at the time is making un- usual efforts to expel its contents. In the worst forms of the disease, the urine is discharged in drops, or it dribbles away from the penis, and flows noiselessly into the receiver. This mode of micturition may be constant or intermittent; and is often, from the most trifling cause, followed by complete retention. A prominent symptom of stricture is frequent, slow, and difficult micturition. In the healthy state, the moment the bladder con- tracts, its contents begin to Aoav, nor do they cease until they are completely evacuated. In stricture, on the contrary, great difficulty is often experienced in starting the urine, and an unusual length of STRICTURE OF THE URETHRA. 621 time is required to effect its discharge, accompanied by much strain- ing, and pulling of the penis. In fact, the affected part is obliged to undergo a sort of preliminary dilatation, which, as well as the subsequent steps of the process, demands the full play and co-opera- tion of the diaphragm and the abdominal muscles. Straining, some- times violent and long-continued, is seldom entirely absent in this disease. To promote the flow of urine, the patient throws his body forwards, and squeezes Avith all his might, as if he were about to force out both his bladder and his bowels. In nearly all cases there is morbid sensibility of the urethra, or of the urethra and the neck of the bladder. The affection is evidently seated in the mucous lining of the part, and often constitutes a source of real suffering. Considerable diversity obtains in regard to the nature and amount of this morbid sensibility. Most commonly it is a scalding or burning; but sometimes it is merely a feeling of sore- ness, uneasiness, or tickling. It may be circumscribed or diffused; slight or severe; intermittent or persistent. The most trifling cir- cumstance, such as an acrid state of the urine, an attack of rheuma- tism, exposure to cold, or the use of stimulating food or drink, is liable to increase it. Another effect of stricture is a discharge from the urethra, de- nominated gleet, or, as it is called by the French, a sweating of the penis. This symptom is of frequent occurrence, and is, in fact, sometimes the only one present; still it is not characteristic. The matter, which is mucous, serous, or muco-purulent, is more or less opaque, thin, and viscid, and varies in quantity from a few drops to half a drachm or more in the twenty-four hours. It is usually most abundant in the morning, before micturition, stains the patient's linen and agglutinates the lips of the orifice of the urethra. The discharge has sometimes a thready appearance, like vermicelli; and not unfrequently it occurs in the form of little flakes, of a whitish or yellowish colour, similar to particles of soft-boiled rice. The secretion, in whatever aspect it exhibits itself, proceeds from the mucous mem- brane of the urethra, which, in most cases of stricture, is in a state of inflammation, both behind and in front of the site of the obstruc- tion. It is sometimes absent for days together, and then, in conse- quence of increased local irritation, returns as copiously as ever. Trifling as this symptom apparently is, it ahvays proves a source of great annoyance to the patient, who looks for it fifty times a day, 622 DISEASES AND INJURIES OF THE URETHRA. and is sure, when he finds it, to post off to consult his physician about it. Patients affected Avith stricture suffer much with pain and tender- ness in the perinosum, anus, and penis. Very frequently, the irrita- tion, which is always purely sympathetic, extends to the groin, the sacro-lumbar region, and the testes, the latter of which are occasion- ally so exquisitely sensitive as to be unable to bear the slightest pressure or even the touch of the finger. The bladder also is often the seat of considerable pain, of a scalding or burning character, and chiefly referable to the neck of the organ, though sometimes it is diffused over the entire viscus, and is much increased by pressure upon the hypogastrium, rough exercise, sexual intercourse, and other causes. A most distressing symptom, occasionally witnessed in this complaint, is a constant irritation in the superior part of the rectum. It is most apt to manifest itself when the disease extends its ravages to the prostate gland and the cellular substance betAveen the bladder and the bowel. Nocturnal emissions are very prone to occur in stricture, especially in that variety which is attended with an unusual amount of morbid sensibility of the urethra and the neck of the bladder. They gene- rally take place under the influence of a lascivious dream, and are almost ahvays accompanied by imperfect erections and considerable pain. The semen, at such times, as Avell as in the act of coition, instead of being ejaculated, passes backAvards into the bladder, or is retained in the urethra, behind the obstruction, from which it after- wards oozes out by degrees, or is discharged along with the urine, in a state of solution. It is for this reason that a man, affected Avith a tight, callous stricture, is sometimes impotent; for, although he may be able to copulate, he cannot procreate, because none of the secre- tion reaches its destination, except, perhaps, Avhere the act is unduly protracted. The penis, in stricture, undergoes a sort of hypertrophy; it is longer and thicker than usual, more or less deformed, and deprived, at least, in some degree, of its natural sensibility. The prepuce, which generally participates in the enlargement, is sometimes so much infiltrated Avith serosity as to require to be punctured, in order to prevent gangrene. These appearances are caused by the constant pressure and pulling which the patient is obliged to exert to facilitate the process of micturition. There is often a good deal of hardness of the urethra, not in its STRICTURE OF THE URETHRA. 623 entire extent, but at some particular point. The parts most com- monly implicated, according to my observation, are the bulbous and membranous, where the deposit of lymph, the immediate cause of this symptom, is sometimes so considerable as to compress the tube, or throAV it out of its natural course, thus greatly increasing the difficulty of introducing a catheter or bougie. The induration, which is always produced by an extension of the inflammation of the mu- cous membrane of the urethra to the subjacent tissues, is generally easily detected by the application of the finger, and should not be confounded with that which is caused by the stricture itself. Chordee is frequently a troublesome symptom in this disease. Although most common at night, it sometimes comes on in the day, and always proves a source of much annoyance, if not of actual suffering. When the cells of the spongy structure of the urethra are distended with lymph, the penis in erection may be drawn down- wards, upwards, or laterally, according to the situation of the effusion, upon the presence of which the incurvation depends. Another symptom, which is occasionally noticed in this affection, is hematuria, or a discharge of blood from the urethra. The he- morrhage is usually slight, and seems to be most common in old, callous strictures, attended with dilatation of the canal, and varico- sity of the lining membrane. The occurrence is most frequent dur- ing erections, and probably always depends upon a laceration of some of the larger vessels of the affected part, which are unduly stretched Avhen the penis is in this condition. A considerable he- morrhage is also sometimes excited during the passage of a bougie or catheter, no matter hoAV gently this may be effected. During the progress of the disease, the patient, in consequence of the constant straining to which he is subjected whenever he attempts to void his urine, is liable to suffer from hemorrhoids, prolapsion of the bowel, and even hernia. These complications, which are suffi- ciently common, especially in elderly persons, greatly increase the local distress, and assist materially in undermining the general health. The urine is variously altered in stricture, according to the degree of irritation of the urinary bladder, the prostate gland, the ureters, and the kidneys. When these organs participate in the mischief, as they are apt to do sooner or later, they throw off an unusual amount of mucus, which, mingling Avith the urine, imparts to it a remarka- bly viscid, ropy character, changes its colour, and induces new 624 DISEASES AND INJURIES OF THE URETHRA. chemical affinities. The fluid is generally loaded with saline matter, is speedily decomposed on exposure to the atmosphere, and, in fact, often even in the bladder emits an ammoniacal odour, is of a whitish, lactescent, dark, or blackish complexion. Finally; as two other effects of stricture, I may here mention retention and incontinence of urine. As these affections, hoAvever, will be particularly described hereafter, I will merely add that the former is most common in the milder forms of the malady, and the latter in the more severe. It should not, however, be forgotten that the constant dribbling, witnessed under such circumstances, is usually an evidence of retention rather than of incontinence; the distinction is of great practical consequence, and a correct diagnosis is therefore of paramount importance. Where the urine passes off incessantly, the attendant may rest assured, as a general rule, that the bladder is never entirely empty, but that a certain quantity of water remains in its more dependent portion, where it soon becomes a source of irritation and suffering. Diagnosis—Physical Exploration.—Although the symptoms which have now been considered are, in general, sufficiently denotive of the real nature of the disease which produces them, they can, neverthe- less, not be regarded as pathognomonic. They may be the result of other causes, and are, therefore, rather of negative than positive value. To establish, in an unequivocal manner, the diagnosis in any given case, it is indispensably necessary to explore the urethra with some instrument. The one Avhich I usually select for this purpose, is a common silver catheter, of moderate size, and a little conical at the extremity, which is passed down the tube, first, to the obstruc- tion, then into it, and lastly, if possible, beyond it. In this manner we may easily obtain an idea of the seat and extent of the stricture, as Avell as of its consistence. Where greater accuracy is required, I use a Avax bougie, which is carried sloAvly down to the obstruction, upon reaching which the penis is pulled slightly forward, over it, and a mark made upon it with the thumb-nail immediately in front of the head of the organ. This will indicate the precise distance of the Fig. 91. [.) I. I '., -I \ -jI I I l„| 1 ) l»j I I .^i I I lw| I I l>.| -^^^^"^P**) stricture from the external orifice of the urethra. Instead of this instrument, a graduated bougie, the end of which is tipped with cob- STRICTURE OF THE URETHRA. 625 bier's wax, may be used. To ascertain the extent and consistence of the obstruction all that is necessary is to insinuate the point of the bougie into the affected part, and to retain it there for a few minutes, until it has become moulded to its place. Thus, an exact impression of the stricture is obtained, which may afterwards, as has been alleged by some of the French surgeons, as Ducamp and Civiale, be turned to great account in the treatment. For my own part, I must confess I think such an examination of little consequence, in any way, and hence I seldom resort to it. For all practical pur- poses, the ordinary mode, above described, answers every object for which such a procedure is instituted. When there is a plurality of strictures, the fact cannot ahvays be determined until the most ante- rior one has been removed. All examinations of this kind should be conducted with the utmost gentleness and deliberation. All rough and hasty proceedings are calculated to do harm by exciting spasm and irritation, and should, therefore, be carefully avoided. By slow and cautious manipulations the point of an instrument may often be insinuated into the tightest stricture, or into one so tender and irritable as to resent every attempt of an opposite description. A tolerably correct idea of the nature, seat, and extent of a stric- ture may sometimes be acquired by the application of the thumb and finger along the under surface of the penis. The part corresponding to the obstruction is not only indurated but contracted, and in such a case it is almost as easy to determine the character of the affection by an external examination as by the use of the catheter or bougie. These remarks are chiefly applicable, of course, to strictures of the spongy portion of the canal; for, when the disease is situated far back, a more accurate and thorough exploration alone will suffice. Dr. Henry J. BigeloAv,1 Professor of Surgery in Harvard Univer- sity, has recently called the attention of the profession of this country to the use of gutta percha for taking impressions of stricture. He has performed numerous experiments Avith it, and thinks it far supe- rior for this purpose to Avax, so commonly trusted to. His method of employing it is to take a medium-sized bougie of this kind, well oiled, and to pass the tip rapidly to and fro in the edge of the flame of a candle until it is so warm as to be indented by the nail; the mass will remain plastic after the surface has ceased to be hot, and 1 Bost. Med. and Surg. Jour., Feb. 7, 1849. 40 626 DISEASES AND INJURIES OF THE URETHRA. may be quickly carried down to the stricture, being very smooth and pliable. If it be pressed against the obstruction for a minute with a force equivalent to the weight of one or two ounces, and then left in the part triple this space of time to cool, it will present, when slowly and carefully disengaged from the stricture, a firm, unyield- ing, and most accurate impression of the inequalities of the callous surface. "The tip," observes Dr. Bigelow, "maybe cut off, and preserved, furnishing, with others, a complete history of the confor- mation of the stricture under treatment." The gutta percha used, for this purpose, should be perfectly pure ; and no warm water should be employed in preparing it, as the steam given off by it has a ten- dency to soften the bougie for several inches, and render it liable to curl up against the stricture, like a small elastic bougie. I have little experience with this mode of taking impressions of strictures ; but from the fact that it comes so highly recommended for this purpose, by so clever a surgeon as Dr. BigeloAv, I should think it deserving of the favourable consideration of the profession. It seems to me to be particularly valuable in bifurcated strictures, or strictures attended with formation of false routes, inasmuch as the smallest point can be easily insinuated into the narrowest passage, and thus indicate which is the natural and which the abnormal one. Pathological Effects of Stricture.—Stricture seldom exists long Fig. 92. without giving rise to disease in the adjoining and associated parts. The organs, besides the urethra, which are most liable to suffer are STRICTURE OF THE URETHRA. 627 the prostate gland, the bladder, the ureters, and the kidneys. The testes, penis, seminal vesicles, perinseum, anus, and rectum, also not unfrequently participate in the evils consequent upon the malady. The affections which thus spring up during the progress of the me- chanical obstacle of the urethra are often of a most serious character, and add greatly to the distress and danger of the case. One of the most frequent, as well as most serious lesions conse- quent upon stricture, is a dilatation of the urethra behind the seat of the obstruction, Fig. 92. This is evidently owing to the manner in which the urine is impelled against the stricture whenever an attempt is made to evacuate it; and varies in degree from the slightest increase of the natural calibre of the tube to that of a pouch, capable of hold- ing an almond or a pullet's egg. In the more aggravated forms of the affection, the abnormal reservoir presents the appearance, and subserves the purpose, of an accessory bladder, which is habitually distended with urine. The parietes of the dilated part are generally attenuated, and therefore liable to give way under the pressure of its contents. The enlargement is most common at the membranous and prostatic portions of the urethra, but may take place at any point of its extent. Sometimes it involves nearly the whole length of the canal, and is so great as to admit a middle-sized finger. The urethra in front of the obstruction is either normal, diminished, or dilated. The latter occurrence, of which Sir Charles Bell has re- lated and figured a most extraordinary example, is exceedingly rare, and cannot be satisfactorily accounted for upon any known patholo- gical principles. In cases of long standing, and especially in those which are accompanied by fistula of the perinseum, allowing most of the urine to escape in that direction, this portion of the canal is sometimes considerably diminished, but never entirely obliterated. In the milder forms of the malady, the tube in front of the stricture is generally natural. There are few cases of organic stricture in which there is not more or less inflammation of the mucous membrane at, and for some distance beyond, the seat of the obstruction. The greatest amount usually exists behind the stricture, but there is not unfrequently a sood deal within it, as well as in front of it. The disease is indi- cated by increased vascularity, and sometimes, also, by a deposition of lymph. Occasionally the mucous membrane is ulcerated, or budded with soft warty excrescences. Another consequence of stricture is the development of a fistula in 628 DISEASES AND INJURIES OF THE URETHRA. the perinaeum, caused by ulceration or rupture of the mucous mem- brane behind the seat of the obstruction, and the escape of a small quantity of urine into the subjacent tissues; or by the existence of irritation exterior to the canal, and its gradual extension to its inte- rior. In either case, an abscess, or, whatvis worse, a slough, is formed, followed by a fistula, through Avhich more or less of the urine continues to be discharged until the stricture upon which it depends is removed. A peculiar cellulated appearance of the urethra is sometimes ob- served as a result of this disease. It consists of a number of little cavities, pouches, or depressions, of an oval form, and confined chiefly to the lower surface and sides of the tube. They are covered by a smooth, glossy membrane, and are always most common in the posterior portion of the urethra. It has been supposed that these cells are formed by a rupture of the mucous lining; but it is more probable that they are caused merely by its excessive attenuation, and a partial separation of the subjacent tissues. It was formerly supposed that enlargement of the prostate was a very common effect of organic stricture of the urethra. Recent and more accurate observation, however, has fully disproved the truth of this opinion, and shown that when these two affections coexist, the circumstance is generally to be regarded as purely accidental. Al- though enlargement is infrequent, this gland unfortunately often suffers in other respects. The most common lesion, in tight, callous, and protracted stricture, is inflammation of the substance of the organ, eventuating occasionally in suppuration, the development of an abscess, the formation of calculous concretions, complete atrophy, or the degeneration of the gland into a membranous pouch. From extension of the irritation, an abscess sometimes forms between the bladder and the rectum, causing excessive suffering, and ultimately, perhaps, a fistulous communication. Another effect, and that by no means an infrequent one, especially in tight and long-continued stricture, is a dilatation of the excretory ducts of the prostate. These canals are, as is well known, exceed- ingly diminutive in the natural state, but under the influence of the protracted irritation of the disease under consideration, they some- times become so much enlarged as readily to intercept the point of a full-sized bougie. When such a lesion is suspected, care should be taken to raise the beak of the instrument as it glides over the pro- STRICTURE OF THE URETHRA. 629 static portion of the urethra, otherwise the accident in question might very easily occur, and a false passage be the result. The bladder, in confirmed cases, soon becomes hypertrophied, and finally sacculated. So common, indeed, is this coincidence, that it must always be viewed in the light of cause and effect. The nature of these two affections has been fully described elsewhere, and I shall, therefore, merely add here that they are generally the cause of the mucous discharges, which, in many cases, form so striking a feature of urethral stricture. Another occurrence, worthy of passing notice in this place, is the proneness, in patients affected with this malady, to the development of urinary calculi. This subject, like that of hypertrophy of the bladder, will be fully discussed in its ap- propriate place. The ureters frequently participate in the disorders which arise in the progress of organic stricture. The most common lesion is inflam- mation of their lining membrane, with suppuration and deposits of lymph, and irregular dilatation of their calibre. Their parietes are sometimes considerably thickened, or thickened at some points, and attenuated at others; and occasionally they exhibit a strictured, nodose, or puckered appearance. Cases occur in which one of these tubes is sometimes very much contracted, or nearly obliterated. The kidneys are variously affected in this disease. Inflammation frequently occurs at an early period, and gradually progresses until it ends in serious mischief, if not in total ruin of the affected organ. The malady seldom exists in the same degree in both viscera. Some- times one is entirely healthy, or nearly so, while the other is con- verted into a large abscess, filled Avith serous cysts, inflamed, hyper- trophied, granulated, or changed into a membranous pouch, devoid of renal tissue. The subjoined sketch, strikingly illustrates the effects of stric- ture of the urethra upon the rest of the urinary organs. The prostate gland is completely destroyed, the mucous membrane of the bladder is removed by ulceration, the ureter is immensely enlarged, and the kidney is converted into a mere shell, which was filled at the time of the dissection with purulent matter. The drawing is from a specimen in the pathological collection of the New York Hospital. The testes are prone to suffer in stricture, apparently from conti- nuous sympathy, or, more properly speaking, direct irritation. In many cases they become morbidly sensitive; and it is not uncommon for one or both to be swollen and indurated. The irritation occa- 630 DISEASES AND INJURIES OF THE URETHRA. sionally extends to the vaginal tunic, and produces hydrocele. The spermatic cords are sometimes remarkably tender, or enlarged and unnaturally hard. Fig. 93. The seminal vesicles are also liable to suffer; their lining membrane becomes inflamed, and, in cases of long standing, their volume is occasionally remarkably diminished, at the same time that their coats are very firm, dense, and contracted. One of the most singular occurrences in old and severe strictures of the urethra is an inordinate development of the penis. The whole organ is not only elongated but remarkably thick, hard, and rigid; a circumstance" which appears to be owing, not so much to the irri- tation of the neck of the bladder, which often exists in a high degree STRICTURE OF THE URETHRA. 631 in this disease, as to the milking efforts, if I may so express myself, which the patient is constantly obliged to make in order to promote the flow of urine through the obstructed urethra. For the same reason, the prepuce is often remarkably swollen and oedematous. Causes of Stricture.—The causes of stricture may be conveniently arranged under two great heads, the traumatic and the inflamma- tory. Of these the latter are by far the more common. Tumours and fleshy excrescences of the urethra, and a varicose state of the mucous membrane of this canal, cannot give rise to stricture, properly so termed, and should, therefore, be excluded from the list of exciting causes. Violence inflicted upon the urethra, whether from without or within, may excite irritation, and develope a stricture. A wound, penetrating the tube, may fail to unite evenly, and so induce the disease. Some of the very worst and most unmanageable cases that I have ever seen were thus produced. The particular kind of injury is generally a blow, fall, or kick upon the perinseum, eventuating in a laceration of the lining membrane, or of this membrane and the subjacent tissues. Sailors not unfrequently suffer in this way, by being precipitated from the rigging of a vessel; and I have seen several instances in which the accident was produced by persons falling from a considerable height upon the post of a chair. A bad stricture occasionally results from violence inflicted by a catheter or bougie. The cicatrice left after lithotomy, especially when the operation has been followed by severe inflammation, and a calculus permanently lodged in the membranous portion of the urethra, has sometimes been succeeded by obstinate contraction. Of the inflammatory causes of stricture, the most frequent, un- questionably, is gonorrhoea, though it is not, as has been asserted by some, the only one. Whenever this disease is obstinate and pro- tracted, or attended with much irritation, it is almost certain to be followed by a considerable effusion of lymph, and more or less con- traction of the urethra. It has been supposed that stimulating injections, employed too early in this disease, are capable of pro- ducing the affection ; this is undoubtedly true, but I am satisfied that the occurrence is much less frequent than is generally imagined. The point is one of practical, and not of mere theoretical importance, inasmuch as it establishes the fact that the disease is much more at fault than the remedies employed for its cure. In a word, it shows 632 DISEASES AND INJURIES OF THE URETHRA. how mischievous a gonorrhoea may be, and Iioav diligent the physician should be in his endeavours to remove it. Protracted erections, or frequent and prolonged intercourse, have also been regarded as a cause of stricture, Avith what truth remains to be proved. I will not deny that the disease may be produced in this Avay; but there is certainly no evidence whatever that it is a common effect. Finally; stricture is occasionally produced by chancre of the urethra. Of this I have witnessed several very obstinate cases; and of the fact mention is made by every writer upon the two diseases. The obstruction, Avhen thus induced, is generally situated at the anterior extremity of the urethra, just behind the external orifice. Prognosis.—Stricture, if taken in hand before it has become hard and firm, or while it is still recent, and before it has given rise to any serious lesion of the urinary apparatus, is, in general, neither dangerous, nor difficult to cure. It is, in fact, under such circum- stances, rather an inconvenience than a disease. When, however, it has made considerable progress, offers much resistance to the passage of the urine, and has excited inflammation in the neighbouring organs, it may be considered as a very serious affection, liable, if permitted to proceed, to be followed by the worst consequences, as may be gathered from the account of its pathological effects in another section. As a general rule, it may be stated that a recent stricture is much more easy of cure than an old one; a small than a large one ; a soft than a callous one; an inflammatory than a trau- matic one., Furthermore, a stricture of the membranous portion of the urethra is usually harder to manage than one of the spongy, chiefly because the former, in consequence of its depth and the parts by which it is embraced, is less under our control than the latter, which is comparatively accessible. An obstruction in this situation is also more liable, as a general principle, to awaken serious disease of the prostate gland, the urinary bladder, the ureters, and the kidneys. When a stricture is obstinate and protracted, it may gradually so far undermine the general health as to cause death ; or life may be assailed by the supervention of retention of urine, or by the extra- vasation of this fluid into the perinseum or scrotum, in consequence of a laceration of the urethra. The immediate cause of death is sometimes a small calculus plugging up the canal behind the stric- ture, and so preventing the discharge of the urine. When the STRICTURE OF THE URETHRA. 633 health is much impaired from protracted vesical or renal complica- tions, the brain sometimes sympathizes in the general disorder; a slow, subacute inflammation, attended by coma, is set up in this organ and in the arachnoid membrane; and the patient at length dies from serous effusion. Treatment.—Various methods have been employed for effecting the permanent cure of stricture. Of these the most important, and consequently the most Avorthy of notice, are dilatation, compression, cauterization, incision, and external division,—each of which has been more or less modified, according to the wants, whims, or caprice of different practitioners. It must be obvious, at a glance, that these methods, so opposite in their character and design, are not equally adapted to all forms of the disease which they are intended to remedy. Hence it will be perceived that there is a necessity, not only for describing these procedures, considered as so many distinct operations, but also for pointing out the cases to which each in par- ticular is applicable. Before resorting to any of these expedients, it is of paramount importance, I conceive, to attend to the general health, and to sub- due local inflammation. Unless this be done, the practitioner will run great risk of doing harm instead of good. To effect this object, the patient should be kept in the recumbent posture for six or eight days previously to the intended operation; the bowels should be freely moved every forty-eight hours with some mild purgative; the secretions should be duly regulated; the diet should be light and unirritant; and recourse should be had occasionally to the warm bath. If there be any inflammation, irritation, or spasm of the urethra and the bladder, leeches must be applied to the perinseum, followed by fomentations and anodyne enemata. Demulcent drinks should also be used; and there are few cases which will not be bene- fited by the exhibition of bicarbonate of soda and balsam of copaiba. Too much stress cannot be placed upon this preliminary treatment; indeed, I should consider it highly culpable to neglect it under any circumstances. When the way has been thus paved, the particular kind of treatment is to be determined by a careful consideration of the nature of the obstruction. There are few points in surgery which require more judgment and experience than this. Some practitioners are in the habit of relying mainly, in their attempts to cure organic stricture, upon constitutional means, espe- cially rigid abstinence, carried almost to starvation, and the daily 634 DISEASES AND INJURIES OF THE URETHRA. use of nauseating doses of tartarized antimony, or the frequent exhi- bition of emetics; conjoined with rest in the recumbent posture, and the avoidance of all sources of bodily excitement. That such a mode of treatment is well calculated to allay vascular action, and promote the absorption of the effused lymph Avhich gives rise to the obstruction, may be readily imagined; but any advantages thus accruing are generally more than counterbalanced by the hardships which attend it. In the callous form of the disease, such a proceed- ing must be perfectly futile; for there are few cases which can receive any permanent benefit from it, and in which it will not be more likely to wear out the patient than his stricture. Of a con- siderable number of persons whom I have known to be treated upon this principle, I do not recollect a single one that experienced any decisive or permanent relief, or that was willing again to submit to its exorbitant, unscientific, and injurious exactions. 1. Dilatation.—This process was applied to the cure of stricture at an early period of the profession, and was for a long time the only one in use. Notwithstanding the various attempts that have been made to supersede it, and the reproaches that have been cast upon it by different writers, it still maintains its place in the estima- tion of enlightened practitioners, and there can be no doubt that it is more frequently applicable than any other plan that has yet been devised. Various instruments have been recommended for this operation. The most common are bougies, made of different materials, shapes, and sizes. The earliest instruments of this kind of which we have any knowledge were composed of lead, or some other metal, which was succeeded in the sixteenth century by wax, and subsequently by gum-elastic, so much in vogue at the present day. In recent times, bougies constructed of whalebone, cat-gut, and flexible ivory, have been recommended, and frequently employed with advantage. My friend, Dr. William A. McDowell, formerly of Louisville, published, some years ago, a paper on strictures, in which he speaks very fa- vourably of the slippery-elm bougie, having employed it successfully, as he informs us, in quite a number of instances. The fact is, almost any substance, provided it is not too brittle, and admits of a good polish, may be used for the purpose. Some surgeons, amongst others, Arnott, of London, and Perreve, of Paris, have invented special dilators for the treatment of this affection. Bougies are straight or curved, solid or hollow, cylindrical or STRICTURE OF THE URETHRA. 635 Fig. Fig. Fig. Fig. 94. 95. 96. 97. E ^ conical, flexible or inflexible, according to the choice of the operator, or the exigencies of each particular case of stricture. When the ob- struction is situated very deeply, a curved instrument is generally preferred, because it corresponds more accurately with the form of the canal along which it has to pass, whereas a straight one usually answers very well when the obstacle occurs in the spongy portion of the urethra. A firm, solid bougie is usually more easy of introduc- tion than a soft, hollow one; but the latter possesses the important advantage, when it is desired to retain an instrument permanently in the tube, of conducting the urine off, and thus obviating the neces- sity of a frequent change. The vesical ex- tremity of a bougie may be cylindrical, coni- cal, olive-shaped, or fusiform. Much impor- tance has been ascribed to this circumstance, and yet, strange to say, nothing definite has been agreed upon. If there be any prepon- derance of weight, it is, perhaps, in favour of the conical shape, as this is generally most in accordance with the form of the stricture which the instrument has to pene- trate. The length of a bougie varies from a few inches to that of the ordinary catheter. When the obstruction is situated at the ante- rior part of the tube, a short instrument is commonly more convenient and manageable than a long one. My conviction, founded upon ample expe- rience, is, that the very best instrument for dilating a stricture is the common silver ca- theter, with a slightly conical point. I have employed this instrument now in the treatment of this affection for upwards of twenty years, and nothing could induce me to abandon it. It possesses all the requisites that such an instru- ment ought to have, namely, lightness, firm- ness, and durability, and is incomparably su- perior, in every respect, to all the metallic, wax, gum-elastic, ivory, and other bougies that have ever been invented. In making this statement, I do not wish to be understood as saying that bougies are entirely worthless, or that they ought never to be used. If I were to do this, 636 DISEASES AND INJURIES OF THE URETHRA. I should certainly do injustice to my judgment, and assert what is contrary to the experience of some of the ablest and most enlight- ened surgeons of the age, both in this country and in Europe. My desire is merely to recommend, in strong and decided terms, an instrument which is capable, as a general rule, of fulfilling every indication presented in this disease, even in its worst forms, and which, I am satisfied, is much less appreciated than it deserves to be. Independently of other considerations, a very strong reason for preferring a silver catheter to every other contrivance for dilating strictures, is the fact that it is often necessary to retain the instru- ment in the bladder, both for the purpose of facilitating the cure and drawing off the urine. In this respect, it is far superior to the gum-elastic catheter, which is not only, in many cases, exceedingly difficult of introduction, but is soon injured, if not entirely spoiled, by the contact of the acrid water. The silver instrument, on the contrary, can be retained without detriment a number of days, and possesses the additional advantage of not incommoding by its weight. In performing the operation, the same rules are to be observed, as it respects the position of the patient, the situation of the surgeon, and the warming and oiling of the instrument, as in ordinary catheterism. In my own practice, I generally find it most conve- nient to make the patient lie upon his back, near the edge of the bed, and to stand at his right side. His lower extremities should be perfectly unincumbered by the bed-clothes, drawn up, and well sepa- rated ; the head and shoulders are to be elevated by a large pillow; and the hands should be entirely out of the way, that no interrup- tion may occur from any inadvertent or intentional movement on their part. The instrument, a small or middle-sized catheter, slightly conical at the extremity, well oiled and properly warmed, is now taken in the right hand, with the handle on a level with the median line of the abdomen, while the penis is held in the left hand perpendicularly with the trunk. The point of the catheter is now inserted into the meatus, and passed on as gently as possible to the seat of the obstruction. Waiting a few moments, to enable the parts to accommodate themselves as it were to the presence of the foreign body, the latter is gradually insinuated into the stricture, either by a steady backward pressure, or by a sort of rotatory movement, and af- terwards passed on into the canal beyond it. When this object has STRICTURE OF THE URETHRA. 637 been accomplished, the instrument is either almost immediately with- drawn, or it is conveyed into the bladder, and retained there for twenty-four or forty-eight hours. The latter course is the one which I usually adopt, and which, as a general rule, I have rarely found objectionable. By this method I have frequently succeeded in restoring the urethra to its natural size in a few days, and that, too, when the disease was of quite an obstinate character. When the dilatation is conducted upon this principle, it will sometimes be ad- vantageous to use several catheters in succession, beginning with one that will readily enter and pass the stricture, and immediately after substituting one of larger diameter. When the operation is thus forcibly performed, it is liable to be followed by inflammation of the urethra and sometimes even of the neck of the bladder and the prostate gland. I have never, how- ever, known it to assume a serious character from this cause in any case. Still, such an event might happen, and it is important that the young practitioner should be aware of the fact. The slight ure- thritis which generally ensues is speedily followed by the suppura- tive process, and the discharge of a small quantity of muco-purulent matter, similar to what is witnessed in the milder forms of gonorrhoea. The flow is usually of short duration, though I have known it occa- sionally to continue rather profusely for several weeks. A conside- rable bleeding sometimes attends the operation; and in a few instances I have seen it followed by severe pain, rigors, and high fever. But dilatation is not always performed in this rapid and forcible manner. There is another mode of conducting it, more slow and gradual, if not more safe and free from suffering. The rule in this case is, to proceed as cautiously and gently as possible, to avoid all risk of irritation, commencing with an instrument that will readily pass the obstruction, and using afterwards a series of steadily in- creasing sizes until the cure is perfected. The introduction is re- peated, at first, every second or third day, and subsequently, when the canal has become tolerant of the operation, once every twenty- four hours. When the dilatation has advanced considerably, it is a good plan occasionally to pass a small catheter, followed immediately by a larger one, which may be carried into the bladder, and then almost instantly withdraAvn. Thus the treatment is conducted, gently and not forcibly, slowly and not rapidly, until the obstacle is surmounted, which will usually happen in from one to two months, 638 DISEASES AND INJURIES OF THE URETHRA. according to the nature of the case, the skill of the surgeon, the co- operation of the patient, and the absence or presence of complica- tions. In whatever manner the dilatation be conducted, whether forcibly or slowly, it is of paramount importance, after the cure is apparently completed, to introduce occasionally a large-sized catheter as far as the bladder. This may be done, at first, every third or fourth day, then once a week, then every fortnight, and at length once a month. Where this precaution is neglected, little hope can be entertained of a permanent cure, and the practitioner has sometimes the mortifica- tion to find a relapse in a few weeks. Before the patient is finally dismissed, he should be taught the introduction of the catheter. Dilatation, when performed in a slow and gradual manner, acts upon the principle of compression, stimulating the affected part, and causing absorption of the effused lymph upon which the coarctation depends. The effect, in fact, appears to be similar to that produced by a bandage, the only difference being, that, in the one case the pressure is made from within outwards, and, in the others, from without inwards. The idea formerly entertained was, that it always produced ulceration of the affected part; but if this were the case it would be more likely to cause the disease than to cure it. Even in forcible dilatation, such a result rarely, if ever, happens; for the little rents which are sometimes made by it are speedily closed with plas- tic lymph, which ultimately becomes organized and transformed into mucous tissue. Where the object is to dilate the parts very gradually, or where the process is obliged to be steadily maintained for a long period, benefit may be derived from the employment of the slippery-elm bougie. This is made of the inner bark of the tree of this name, of cylindrical form, with a slightly conical extremity, and of suitable size. The surface is rendered as smooth as possible, first with a sharp knife, and afterwards with a wet woollen cloth. Prepared in this manner, it is sufficiently firm and even to admit of easy intro- duction, without the risk of breaking in the urethra, and slipping into the bladder,—an accident which has several times happened to sur- geons, and led to the necessity of an operation similar to that of lithotomy. The great merit of the slippery-elm bougie is twofold: first, its soothing character, by which it tends to diminish the morbid sensibility of the urethra; and, secondly, its faculty of expanding under the natural moisture of the part, which it thus dilates and STRICTURE OF THE URETHRA. 639 stimulates. Another advantage, of no inconsiderable importance, is, that the portion of the instrument corresponding with the stricture, swells during its sojourn in the tube, and thereby affords us, when it is withdrawn, an opportunity of judging of the extent and degree of the contraction. 2. Compression.—When the stricture is so hard and tight that it cannot be penetrated in the usual manner, an attempt may be made to remove it by pressing the end of the instrument against its ante- rior extremity. The operation is conducted upon the same principle as in gradual dilatation; and in general, six or eight weeks elapse before the obstruction is so far overcome as to admit of the passage of a full-sized catheter. Ulceration and suppuration occasionally follow this treatment; effects which should be carefully avoided, since they have a tendency to aggravate the complaint. I have not much experience with this mode of treatment, and I candidly confess that I have a feeling against it, amounting almost to aversion. The only case to which it seems to me to be at all ap- plicable is, where the stricture is situated in the membranous por- tion of the urethra, and is so tough and narrow as to resist the ordi- nary method. Here I might, perhaps, occasionally resort to it, but even then not with much hope of ultimate or permanent success. In the few instances in which I have had recourse to it, the benefit, if there was any, was extremely slight and transient. Sir Benjamin Brodie and some other distinguished authorities, however, declare that they have occasionally employed it with marked success. The French surgeons occasionally resort to external compression; a mode of treatment which they have described under the imposing name of malaxation, a term synonymous with that of softening. It simply consists in carrying a bougie beyond the stricture, and in re- taining it there as long as the patient can hold his water; and in maintaining a firm compression during this period by means of the fingers, or a compress and bandage, upon the affected part. The object is to stimulate the absorbent vessels, and to promote the soft- ening of the organized and indurated lymph, upon the presence of which the contraction mainly depends. Dr. Dupierris, who has given a short account of this mode of treatment, seems to think well of it • for my own part, I am inclined to consider it as a futile and unsurgical proceeding, not likely to be employed by a man who has hands to act, and judgment to guide them. The process of dilatation, or as it might, with great propriety, be 640 DISEASES AND INJURIES OF THE URETHRA. termed, the treatment by compression, is mainly applicable to soft and recent stricture. To those of an opposite character it is utterly unsuited, and should always gh7e place to incision, either from within or without. I have no patience with dilatation for the removal of a hard, tough, narrow, and almost impermeable obstruction; such a disease cannot be managed successfully by such a procedure; the most prolonged use of the instrument can do no good, and is only calculated to deceive the patient and bring surgery into discredit. 3. Cauterization.—Cauterization, as a means of curing stricture, has been in use from time immemorial. Many of the older surgeons, in conformity with their peculiar, and, as they have since proved, erroneous, notions, that the disease generally depends upon the deve- lopment of carnosities, excrescences, or fleshy growths, gave it a decided preference over every other method. Philippe, Alphonso Ferri, Aldereto, and Amatus Lusitanus, employed it with much suc- cess upwards of four centuries ago, and have given a particular de- scription of the manner of performing the operation. Pare and Wiseman, the two most illustrious surgeons of their respective times, also warmly recommend it; and in the latter part of the last century it came almost into universal vogue, chiefly through the example and influence of John Hunter and Sir Everard Home. Its most distin- guished advocates at the present day, are Whately, Sir Charles Bell, Ducamp, Lallemand, and Amussat. The practice of cauterization, once so prevalent, seems to be on the decline. In England, where, in consequence of the sanction of John Hunter, it Avas so long enthusiastically followed, it is now less frequently employed than in any other country.1 In the United States, where it has never had any very strong hold upon the pro- fessional mind, it is rarely resorted to by our best physicians. In France it appears to be in higher repute than in any other part of the world, mainly, perhaps, on account of the encomiums passed upon it by several of the most distinguished surgeons of that country. Amid the great contrariety of opinion that has been expressed upon the subject, it is extremely difficult, if not impossible, to form a cor- rect judgment of the value of the practice under consideration. Nor is the difficulty at all diminished when we reflect that caustic is fre- quently applied with different views; by some, simply as a sorbe- facient, by others, as an escharotic; that some use it very sparingly, 1 Johnson's Medico-Chir. Rev., July, 1842, p. 125. STRICTURE OF THE URETHRA. 641 and others very freely; that some restrict it to particular cases or stages of the disease, and others employ it indiscriminately in all, no matter what may be the character, situation, or duration of the obstruction. For the solution of such a question, an amount of expe- rience much greater than falls to the lot of any single individual, is necessary. In considering the subject it should not be forgotten that there is frequently a fashion in surgery as there is in medicine, and that particular modes of treatment are, on the one hand, often unjustly extolled, and, on the other, unjustly condemned. Caute- rization, properly used, is a valuable curative agent; but, if indiscri- minately employed, it is capable of doing serious, if not irreparable mischief. The circumstances to which it appears to be more parti- cularly adapted, and to Avhich, in my judgment, it ought to be re- stricted, are those in which the stricture, without being very tight or extensive, is of a firm, gristly, and resilient character, and in which there is an undue amount of morbid sensibility of the mucous mem- brane of the urethra. I never resort to it where the obstruction is either very slight or very great; for in the former case I have rarely failed to effect a cure by dilatation, and in the latter I have almost always been obliged to have recourse to division. It may be further observed that cauterization should seldom be relied upon alone, but that its action should always be aided by the bougie or catheter; a mode of proceeding Avhich greatly expedites the cure, and affords an additional guarantee against relapse, Avhich is so apt to occur when this precaution is omitted. Cauterization, as practised at the present day, is generally effected with the nitrate of silver, originally suggested for this purpose by Wiseman, and subsequently so highly lauded by John Hunter. Whately recommends the caustic potash, for which he claims the most extravagant pretensions. Ambrose Pare* used a composition of poAvdered savin, ochre, antimony, and prepared tutty. Alphonso Ferri and his cotemporaries employed equal parts of verdigris, orpi- ment, vitriol, and rock alum. For applying the nitrate of silver, the best instrument of which I have any knowledge is the one represented in the adjoining cut. It is fashioned like a common silver catheter, and is either straight or curved, according to the situation of the stricture. At the pos- terior surface of its vesical extremity is an eyelet, about three-quar- ters of an inch in length by two lines in width, which corresponds 41 642 DISEASES AND INJURIES OF THE URETHRA. with the caustic in the cup, attached to the rod in the interior of the tube. The cup is partially filled with tallow, soap, or extract of hyoscyamus, which is next sprinkled with a thin layer of the powdered salt, when it is fit for use. This method is much better than that of melting || the caustic into the cup, as is generally done, over the flame of a lamp. Lallemand's porte-caustique, which is commonly employed for cauterizing stric- tures, is objectionable, on account of the manner in which the cup, attached to the inner rod, is pro- jected during the operation, thus rendering it liable to break off in the urethra. This occurrence is not imaginary, but real; for it has repeatedly been witnessed in practice, and cannot, therefore, be too carefully guarded against.1 The instrument above figured is free from all danger of this sort. Instead of solid nitrate I use occasionally a strong solution of this substance, in the proportion of from forty to sixty grains to the ounce of water, applied by means of a piece of sponge, attached to the end of the stylet of the porte-caustique. The patient, during the operation, observes the same posture as in ordinary catheterism. The in- strument being conveyed down to the stricture, or, rather into it, the stylet, which was previously retracted, is now unscrewed, and pushed on until the cup is opposite the eyelet pre- viously described. Then, by a sort of rotatory movement of the tube, the caustic is brought fairly in contact with the whole of the affected surface. No haste or violence is used in executing this step of the operation, but the entire proceeding is conducted with the ut- most care and deliberation. The application is not continued longer than twenty, twenty-five, or thirty seconds, lest the caustic be too widely diffused over the surrounding surface, and is renewed once every fifth or sixth day. It is usually attended with some pain, and is 1 Several cases are upon record in which the end of the stylet broke off in the urethra, to the great horror both of the patient and his attendant. In one instance, that of a physician of Buffalo, who cauterized himself, the occurrence proved fatal. Such accidents should render practitioners extremely cautious in the use of this and similar instruments. STRICTURE OF THE URETHRA. 643 followed by a frequent desire to urinate, by a sense of scalding in the urethra, and by a thin, sero-sanguinolent discharge, which in a short time assumes a muco-purulent character, and generally disappears altogether, along with the other symptoms, in four or five days. The application of the nitrate of silver, as conducted at the present period by enlightened and scientific surgeons, is seldom productive of much suffering or inconvenience. We no longer hear of the severe pain, the violent swoonings, the profuse hemorrhages, the distressing stran- gury, and the excessive constitutional reaction which followed the use of the remedy in the time of Hunter and of his immediate suc- cessors. Only a small quantity of the article is required at each application, and, if this be judiciously made, no possible harm can result in any case. Of the truth of this remark every practitioner, familiar with this substance, must be perfectly aware. Nitrate of silver has been supposed to act as an escharotic. If this were the case it would be more likely to occasion than to cure stric- ture ; for it would lead to ulceration, and the reparative process which would follow could hardly fail to cause a narrowing of the canal. The fact is, the only effect which it produces is a detachment of the epithelium of the lining membrane, and a softening of the matter which gives rise to the obstruction; in other words, it acts mainly as a sorbefacient, rousing the absorbent vessels of the part, and inciting them to the removal of the adventitious deposit. The action of this substance is well shown upon an exposed mucous sur- face. If, for example, it be put in contact with the tongue, lip, or palate, it instantly causes coagulation of the natural secretion, slight, almost imperceptible shrivelling of the epithelial investment, and in- creased discharge from the mucous follicles. There is never any slough, or destruction of the vitality of the part, hoAvever large the quantity of caustic employed* Mr. Whately, of London, strongly recommends, as was before stated, caustic potash, the kali purum of the old pharmacopoeia, on the ground, as he alleges, that it possesses decided advantages over the nitrate of silver. Since the publication of his work on stric- tures, early in the present century, in which he first directed the attention of the profession to the subject, the usefulness of this article in the treatment of this disease has been attested by nu- merous practitioners, and can, therefore, be no longer a matter of doubt or dispute. I have myself employed it with the most happy 644 DISEASES AND INJURIES OP THE URETHRA. effects, in cases in Avhich the lunar caustic had failed to afford relief. Much prejudice has existed against this substance in the minds of surgeons, because they seem to think that its application must neces- sarily be followed by a slough. Nothing can be more erroneous than this opinion. Mr. Whately himself took great pains, in the work referred to, to explain its mode of action, and to describe the manner in Avhich it should be used. He distinctly affirms, that if properly applied, it merely abrades without destroying the mucous membrane of the stricture; and in this view every one acquainted with the subject fully coincides. Without conceding to the caustic potash all the advantages that have been claimed for it by its ad- vocates, and without yielding to it any superiority over the nitrate of silver, I am constrained to believe, both from my own experience and from the testimony of others, more competent, perhaps, to form a correct judgment upon the subject than I am, that it may often be turned to good account in the management of this disease, and that it is worthy of further trial. It cannot be supposed that an article which has been so frequently tested, and which has so long enjoyed the confidence of some of the most distinguished surgeons of the present century, can be wholly useless. The advocates of the nitrate of silver and the caustic potash, in attempting to ascertain the rela- tive merits of these two articles, have not done each other justice; they have become exclusivists instead of eclectics ; in the ardour of their controversy, they have permitted their zeal to outrun their judgment. ' In applying the caustic potash, the same general rules should be observed as in the use of the nitrate of silver. Even the same in- strument may be employed; a small quantity of the caustic, gene- rally not more than the tenth of a grain, is mixed with a little lard, and introduced into the cup of the stylet. If the urethra be at all irritable, means should be taken to calm it, before the operation, otherwise serious injury will be almost sure to follow. It is well, also, as a general practice, to take an impression of the stricture, and to measure its precise distance from the external orifice of the urethra. Having observed these precautions, which are of no little consequence as it respects a successful issue, the instrument is passed to the seat of the obstruction, where it is permitted to remain for a few moments with the stylet advanced, to give the caustic time to dis- solve and diffuse itself over the surrounding surface. It is then STRICTURE OF THE URETHRA. 645 moved slowly backwards and forwards over the contracted portion until a feeling of heat is experienced, when it is instantly withdrawn. The rule is never to retain it long enough to produce a sense of burning, except in firm, gristly strictures, in which the caustic may be used with much greater freedom. The after-treatment does not differ from that of ordinary cauterization. When the pain is very severe, which, however, rarely happens, the urethra should be freely syringed with a solution of vinegar and water, to neutralize the alkali. The application, which is usually followed by the same train of phenomena as when the lunar caustic is employed, may be re- peated every sixth or seventh day, according to its effects, and the circumstances of each particular case. 4. Incision.—When the stricture is very old, gristly, tight, and intractable, or indisposed to yield to dilatation, or dilatation and cauterization, incision must be practised. This operation is not of recent inArention, for it appears to have been employed three hun- dred years ago by De Vega and Diaz. It was also performed at the beginning of the seventeenth century by Mayerne, in France. Soon after this period it fell into disuse, and so continued until it was re- vived by Doerner of Germany. In the latter part of the last cen- tury, Dr. Physick employed an instrument, of a peculiar construc- tion, for dividing strictures, a description and figure of which are to be found in the second volume of Dorsey's Surgery, published at Philadelphia in 1813. About the same time, or shortly after, simi- lar attempts were made by Sir Charles Blicke, Mr. Grindel, Mr. Nayler and others, of England. To Mr. Stafford, of London, how- ever, is due the credit of having first brought this operation fully under the notice of the profession. In his work on Strictures, the first edition of which appeared nearly thirty years ago, he has given an elaborate description of the procedure, accompanied by drawings of ingenious and excellent instruments, which have since been va- riously modified and improved, either by himself or by others. The method by incision, as recommended and practised by Mr. Stafford and other surgeons has met with much opposition, and has even been denounced as barbarous and disgraceful. In such an opinion I can- not concur. I have performed the operation too frequently not to be convinced of its efficacy, if not of its superiority over all other plans. When a stricture is very old, firm, and unyielding, or almost car- 646 DISEASES AND INJURIES OF THE URETHRA. tilaginous in its consistence, no mode of dilatation, hoAvever judi- ciously and perseveringly employed can succeed, either alone or in combination with cauterization, and in such a case I never hesitate to resort at once to incision, satisfied that nothing else will answer. I have repeatedly had under my charge patients who had been sub- jected to the treatment by dilatation for months and months, Avith- out the slightest benefit, and who were almost instantly relieved by the operation under consideration. This fact has been witnessed again and again by my private pupils and by the public classes of the University of Louisville. And why should there be any hesita- tion or doubt concerning this operation ? Where are its dangers, or the difficulties of its execution? I confess I cannot see any; and in making this remark let no one regard me as a visionary enthu- siast. What I say is not speculation, but the result of personal observation; not prejudice, but actual experience at the bedside. It is only when the stricture is situated far back, in the membranous portion of the urethra, that the method is obnoxious to objection. Under such circumstances, especially when the obstruction is nearly impermeable, or where it is accompanied by a tortuous condition of the urethra, there may, I admit, not only be danger in attempting division, but the operation requires an amount of skill and anatomi- cal knowledge which few men possess. But even here the well- directed efforts of the patient and persevering surgeon will generally be crowned with success. To the unskilful alone is the operation a stumbling-block ; to the ignorant, foolishness. The instruments required for this operation vary according to the seat and nature of the stricture. For a coarctation of the orifice of the urethra, or for one just behind it, a narrow-bladed, probe-pointed bistoury will answer every purpose; but for the remainder of the tube the best instrument is that of Stafford, composed of a grooved canula, containing a stylet, armed with a little blade, which is made to project at will. The extremity of the canula, which is intended to lie within the stricture during its division, is of a conical shape, quite thin, and about three-quarters of an inch long. The instru- ment which I have been in the habit, for many years, of employing in permeable strictures, is represented in Fig. 99 : a, is the blade, and b, the instrument with the stylet and blade retracted. It is called the lateral-bladed stylet, and could not, I think, be im- proved. It is a perfect thing of its kind. For the impassable stric- ture, a urethral perforator is required. This consists of a round, STRICTURE OF THE URETHRA. 647 graduated, silver tube, furnished with a stylet, at one end of which there is a lancet, while at the other there is a handle. Both these Fig. 99. I aa= instruments, it may now be added, may be either straight or curved, according to the site of the stricture. With any of the instruments here mentioned the division of a stricture may, in general, be easily and safely effected. When the disease is seated just behind the opening of the urethra, I always employ a very narrow, blunt-pointed bistoury, with which the con- tracted part is freely cut in its entire length, either laterally, above and below, or at all these situations, according to the nature and extent of the obstruction. Another instrument which answers very well for performing this operation, is the small knife used by ocu- lists for enlarging the incision in the cornea in extracting cataract. For cutting a stricture situated between the head of the penis and the bulbous portion of the tube, a straight, lateral-bladed stylet is the most convenient. The conical extremity of the instrument being securely engaged in the contracted part, the penis is drawn forward, and the lancet pressed steadily against the resisting surface until it is completely divided at two, three, or more points of its circumference. For a stricture of the membranous portion of the urethra, the most suitable instrument is a curved perforator, used upon the same prin- ciple as the lateral-bladed stylet, but with a degree of caution the greater, as this part of the canal is more intricate in its relations and direction. In whatever manner the operation is performed, the moment it is over a metallic catheter is passed into the bladder, and retained there, either permanently or a few hours every day, until the urethra has regained its natural diameter. When the stricture is very long, or hard and tortuous, more than one operation may be necessary to effect its division. In such a case, the surgeon, having accomplished a part of his object, desists, and finishes the remainder at another sitting. In general, however, I prefer to do all that is necessary at one time. Dividing one part to-day, and another part to-morrow, is trifling with the patient's feeling; besides, we give him more pain, and induce greater inflam- 648 DISEASES AND INJURIES OF THE URETHRA. mation than when the procedure is completed at one sitting. The usual effects of the operation are, first, a certain amount of pain, which, however, is rarely severe; secondly, hemorrhage, generally slight, but sometimes copious; thirdly, scalding in voiding the urine, with a frequent desire so to do; and, fourthly, rigors, followed by high fever and free perspiration. A false passage is sometimes made; but the occurrence is much more likely to happen in the hands of an ignorant than in those of a skilful surgeon. 5. Scarification.—As a modification of the operation of incision, allusion may be here made to scarification, which has attracted some attention within the last ten years, particularly in France and this country, in consequence chiefly of the high commendations of my friend Dr. Dupierris, formerly of New Orleans, now of Havana. In his " Me'moire sur les Retre"cissements Organiques du Canal de l'Ur^tre," of which a second edition was issued at Paris in 1847, this gentleman has given a full account of the method of performing the operation, and pointed out what he conceives to be its pecu- liar advantages. The instrument which he uses, and of which he is the inventor, is constructed upon the same principle as that of Staf- ford, and is either straight or curved, according to the seat of the stricture. The annexed cut will afford a better idea of it than any description, however elaborate. Its distinguishing feature is a little Fig. 100. lancet-shaped blade, which is secured to the lower extremity of the stylet, and admits of being moved backwards and forwards through a lateral slit in the beak of the canula. The instrument, called the coarctome, is introduced in the same manner as a common catheter, sound, or bougie. If there be any difficulty in engaging its beak in the stricture, it may be easily surmounted by rotating it upon its axis, and pulling forward the penis. The resistance offered to the instrument, and to the finger applied to the seat of the obstruction, will indicate whether the part referred to is in its proper situation. When this has been ascertained, the surgeon moves the stylet of the coarctome forwards and backwards, and thus notches the stricture on one side. When the disease involves the greater portion of the STRICTURE OF THE URETHRA. 649 canal, or its entire circumference, and it is deemed advisable to scarify it at several points, all that is necessary is to turn the instru- ment round, which can be easily done without the trouble or incon- venience of withdrawing and reintroducing it. The operation being completed, a catheter is carried into the bladder, and the case treated upon general principles. The operation is seldom attended with much pain, or any hemor- rhage. When the stricture is not very large or firm, one or two scarifications are generally sufficient; but where the case is different, it may be necessary to repeat them as often as six or eight times, at intervals of so many days. Some inequality or roughness now and then remains at the incised part, especially when the healing process has been unusually tardy or imperfect; this is best remedied by cauterization. Scarification, as a remedy for the cure of stricture, acts in the same manner as incision, of which, as was before intimated, it is merely a modification. The process is best adapted to the milder varieties of firm, gristly contractions, seated in the spongy portion of the canal. I should certainly not resort to it either in the very simple or very aggravated forms of the malady; in the first it would be un- necessary, in the second, inadequate. 6. External Division.—This plan of treating stricture, originally practised in the last century, has recently met with a strenuous ad- vocate in Mr. Syme, Professor of Clinical Surgery in the University of Edinburgh. In a short monograph on this disease, published in 1849, he has taken great pains to point out the advantages of this method, and has detailed a number of interesting cases in which it was followed by prompt and permanent cures. Successful results, by the same procedure, had been previously obtained by I. L. Petit, Lavanier, Eckstrom, Arnott, Jameson, and other surgeons. Nearly ten years ago, I performed, with the kind assistance of Professor Cobb, an operation of this kind upon a young man of twenty-one, a shoemaker by occupation, from the State of Illinois. He had rup- tured his urethra several years previously, in consequence of a fall astride the post of a chair. The parts gradually healed, leaving a narrow fistulous opening far back in the perinseum, through Avhich, with great difficulty, he voided his urine, none passing by the natural channel. No catheter of the smallest size could be introduced into the bladder. The operation, presently to be described, was performed with hardly any trouble, and the patient remained perfectly well for 650 DISEASES AND INJURIES OF THE URETHRA. five or six months, when, in consequence of neglect to use the cathe- ter, a relapse gradually occurred, and his symptoms became as bad as they had been before. The operation is by no means free from danger, and requires the most consummate skill for its successful execution. None but a mad- man or a fool would attempt it, unless he had a profound knowledge of the anatomy of the parts, and a thorough acquaintance with the use of instruments. Of all the operations of surgery this is the least to be coveted. I Avell recollect the impression which it made upon me, many years ago, during my residence in a neighbouring city. The patient, the subject of it, was an old coloured man, who had been afflicted for a long time with a tight, gristly stricture of the membranous portion of the urethra, attended with frequent micturi- tion, vesical catarrh, and excessive irritability of the urethra. Vari- ous but fruitless attempts had been made to pass a catheter. The urine constantly trickled away, the bladder was never entirely empty, and the general health was completely wrecked. Life was fast ebbing away, and it was evident that something must be done, and that speedily, to relieve the patient. An operation was decided on, and a long time was occupied in its performance, during which big drops of sweat rolled in profusion from the young surgeon's forehead. Chloroform was not then in use, and the poor man suf- fered the torments of the damned. The tale is soon told. After several hours had been spent in idle efforts to reach the bladder, the operation was abandoned in despair; the patient was unbound and put to bed, and, in two days after, he was carried to his grave. Such a case needs no comment; it speaks for itself. I am sure I shall never forget it. In another case, which I witnessed when I was a student, the whole urethra, from the meatus to the scrotum, a distance of upwards of five inches, was laid open by the operator. The patient was a young man, hardly twenty years of age, and the stricture was ex- ceedingly close and firm. A catheter was introduced into the blad- der, and the edges of the wound in the skin Avere approximated by numerous points of the interrupted suture. Violent rigors, with severe inflammation of the parts, ensued, and for a few days the patient was in a critical condition. But little of the wound united by the adhesive process, and several fistulous openings existed when I last saw the case, more than a year after the operation. Fortunately such an operation can seldom, if ever, be required. It STRICTURE OF THE URETHRA. 651 was certainly not necessary in the case above mentioned. It is only when the stricture is situated in the membranous portion of the tube, and is impermeable to the bougie, catheter, or lancetted stylet, that it can ever be proper. Under such circumstances, it would be far preferable to puncture of the bladder, the only resort, according to some, when the disease is attended with retention. In performing this operation, the patient is placed in the same position as in lithotomy; the hands and feet are bound together; and two persons take charge of the limbs. A staff or grooved director, either straight or slightly curved, is conveyed to the seat of the obstruction, and confided to another assistant, who also holds up the scrotum. The surgeon, sitting on a low chair, or resting upon one knee, takes a narrow-bladed scalpel, and makes an incision into the raphe* of the perinseum, about an inch and a quarter in length, taking care, on the one hand, not to interfere with the rec- tum, and, on the other, not to extend it too high up towards the bulb of the urethra. The knife is plunged in, at the first stroke, to a considerable depth, and is then used to divide, by successive touches, the parts overlaying the stricture. Feeling now for the end of the staff, the point of the instrument is inserted into the contracted part, which is next freely divided in a direction from before back- wards. A catheter is now introduced into the bladder, and the case is treated, to all intents and purposes, as one of lithotomy. There is usually little bleeding, and the wound seldom remains open beyond the fifteenth or eighteenth day. After the first forty-eight hours, the catheter need not be used oftener than once a day, but this practice should be persisted in for a long time, otherwise relapse will be in- evitable, such is the tendency in these cases to contraction. When the operation has been well executed, the cure is generally perma- nent. CHAPTER IV. POLYPOID AND VASCULAR TUMOURS OF THE URETHRA. Much confusion has hitherto existed in the minds of pathologists respecting certain morbid growths of the urethra, known by the name of polypous tumours, fleshy vegetations, and warty excres- cences. This confusion will not be likely to be removed as long as writers and teachers continue to attach different meanings, expres- sions, or ideas, to the same disease. The term polype is often used in a very vague sense, and may, therefore, denote little, much, or nothing at all, according to the peculiar views of each particular author. Whether genuine polypes, such as are found in the nose, vagina, and uterus, ever form in the urethra, is a point which has not been clearly established by observation, either during life or after death. For my own part, I can perceive no reason why they should not, seeing that this canal is lined by the same kind of struc- ture as the parts just mentioned; which, it is well known, are not unfrequently the seat of this variety of abnormal growth. Be this as it may, there is no doubt that excrescences occasionally form in the urethra, which, from their texture and organization, closely resemble polypous tumours, and to which, consequently, we may, to say the least, with great propriety, apply the term polypoid. Polypoid tumours occur in both sexes, and in different portions of the urethra. In the male, the most common site is the anterior part of the tube, just behind the urinary meatus; sometimes they are situ- ated farther back; and, in a case mentioned by Amussat, they existed in the membranous division of the canal. In women, they are also generally situated superficially, so that during their progress they not unfrequently project beyond the external orifice of the urethra. In rare instances, they occupy the posterior part of the tube, and may then pass into the bladder, just as a polype of the nose some- times hangs into the throat. TUMOURS OF THE URETHRA. 653 In the male, to whom the succeeding account is intended chiefly to apply, the number of these tumours varies from one to three or four ; frequently, they are solitary. In their volume, they range between the smallest pin's head and an ordinary pea. Their shape is irregu- lar ; pyriform, conical, or spheroidal. They are of a reddish com- plexion, soft and spongy in their consistence, and of a mucous structure. Their surface is sometimes perfectly smooth; at other times slightly granulated, rough, or studded with villosities. When minutely examined they are found to consist of a cellular, or cellulo- vascular substance, invested by a prolongation of the lining membrane of the urethra. How these little bodies are formed, is still a disputed point. The probability is that they are the result merely of a species of hyper- trophy of the mucous villi of the urethra, produced by an exaltation of the common process of nutrition. In what respect, if any, their development is influenced by inflammatory irritation, we have no means of determining. In one instance, that of a young man of twenty-four, who was under my charge last summer, the tumour, which was situated just behind the urinary meatus, and of the size of a hemp-seed, was evidently of a gonorrhoeal origin. These polypoid tumours are generally free from pain, in which respect they differ, and that remarkably, from the vascular growths described below. They rarely advance beyond the size above men- tioned, are usually unattended by mucous, gleety, or purulent dis- charge, and seldom materially obstruct micturition. Their develop- ment is tardy and insidious, and they generally manifest no disposition to reappear after extirpation. When deep-seated, they may exist for many years, Avithout the possibility of detection. The removal of these excrescences is best effected by excision with the knife or scissors. When situated in front of the canal, just behind the external orifice, a small iris-knife may be used. In what- ever manner the excision is accomplished, the surface should always be touched immediately after with nitrate of silver or sulphate of copper, to destroy every ramification of the abnormal structure. When such a tumour is deeply seated, and acquires an unusually large bulk, it may be pinched off Avith a pair of urethra-forceps; or, where this is impracticable, an incision may be made down upon it through the spongy body of the penis. The second variety of morbid growth of the urethra is generally denominated the "vascular tumour," or "fleshy excrescence." It is 654 DISEASES AND INJURIES OF THE URETHRA. very different in its structure from the preceding, and is in great measure, if not entirely, peculiar to the female, being usually situated just within the margin of the urinary meatus, or in the anterior por- tion of the excretory tube. In some instances, however, it lies far- ther back, and may then project slightly into the bladder. Cases also occur in which it occupies the parts immediately round the uri- nary meatus. In some instances, though rarely, the excrescences are found simultaneously in all these situations. Although incidentally noticed by Morgagni and other pathologists of the last century, this variety of tumour was first accurately de- scribed by Sir C. M. Clark, in his work on the Diseases of Females. Good accounts of it have also been published by Boyer, Wardrop, Kaldebrand, Rosenmiiller, Dubois, Prochaska, Lever, and Bavoux. In this country the attention of the profession was first prominently directed to the subject by Dr. Alexander E. Hosack, of New York, in an able article in the American Journal of the Medical Sciences for February, 1840. The fleshy excrescence of the urethra is of a bright florid colour, exquisitely sensitive, and of a conical, ovoidal, or rounded form. In its volume it varies from that of a large pin's head to that of a cur- rant, a pea, or a cherry, which latter it rarely exceeds. Its attach- ment is generally by a tolerably broad base, but in many cases, espe- cially when it is pyriform, it adheres by a narrow pedicle. In number, it varies from one to ten or fifteen, though, in general, it does not exceed three or four. Frequently, in fact, it is solitary. When several exist, they are either isolated, or grouped together. In its structure, this variety of tumour is essentially vascular, and hence it frequently bleeds upon the slightest touch. Minutely exa- mined, it is found to consist of a congeries of minute vessels, arterial and venous, which are connected together by delicate cellular tissue, and invested by a prolongation of the mucous membrane. From the exquisite pain of which it is the seat, it is evident that it must also be well supplied with nerves, though it is not easy to demonstrate their existence. Thus constituted, it is of a soft, spongy consistence, and of an erectile character, with a smooth and florid surface. Considerable diversity obtains in regard to the appearance of these tumours, depending, probably, not so much upon any peculiarity in their organization, as upon their age and the degree of irritation to which they are subjected. Thus, instead of being of a red, scarlet colour, they are sometimes quite pale, grayish, spotted, or purple. TUMOURS OF THE URETHRA. 655 Their surface is occasionally fissured, lobulated, or rough and granu- lated, like a strawberry, studded with small villosities, or covered with minute prominences, similar to those upon a suppurating wound. Their sensibility, although generally exquisite, is sometimes very Blight, or almost null. The growth of these excrescences is usually tardy. After they have attained a certain volume, they frequently advance in an imper- ceptible manner, or remain stationary altogether. Their origin is commonly insidious, and hence a considerable period often elapses before the patient is rendered aware of their existence, or before their true nature is suspected by the practitioner. Of their causes nothing whatever is known. They seem to be developed in the sub- mucous cellular tissue, and, as already stated, they never attain a larger bulk than a cherry or a small horse-bean, whatever may be their age, or situation. They are not confined to any particular period of life, but are most common after the age of thirty-five or forty. They rarely, if ever, occur before the time of. puberty. I have met with them, in one instance, in a girl of seventeen, and, in another, in a married woman of sixty-three. The characteristic features of these tumours are, their florid com- plexion, their exquisite sensibility, their insidious origin, their slow development, and their small size. The suffering which attends them is often so great as to render the patient utterly miserable, and unfit for the ordinary duties of life. It is much increased by walking, the erect posture, sexual intercourse, and even the contact of the dress. The slightest touch, indeed, is commonly intolerable. The pain, which is frequently of a sharp, shooting character, extends, in many cases, into the pelvis, up the back, and down the thighs. From the situation of the morbid growths, micturition is mechanically ob- structed ; the stream of urine is sometimes reduced to the size of the smallest thread, and the evacuation of the fluid is accompanied with a hot scalding sensation, severe pain, and great straining. The blad- der is excessively irritable, and there is almost a constant inclination to void its contents. Occasionally, the symptoms closely simulate those of stone, or cancer of the vagina. In the more aggravated forms of the affection, the general health is apt to suffer; symptoms of dyspepsia gradually show themselves ; the stomach is weak and flatulent; the bowels are constipated; the urine is high-coloured, scanty, and acid; the spirits are depressed; the patient is unable to move about, or take the slightest exercise, and the system is finally worn out by 656 DISEASES AND INJURIES OF THE URETHRA. feverish excitement and loss of sleep. Little discharge attends these tumours, except Avhen they are chafed or irritated by exercise, Avhen they are liable to become inflamed, and to pour out a thin muco- purulent fluid. From the account here given of these excrescences, there is little probability that they will be confounded with other morbid growths of the female urethra and its external orifice. The tumours for Avhich they are most liable to be mistaken are the verrucous, from which, however, they may, in general, be easily distinguished by their his- tory, the peculiarity of their situation, their florid appearance, their great sensibility, and the obscure nature of their origin. The verru- cous excrescence is placed exterior to the urethra, upon the vestibule, is insensible, does not bleed when touched, and is of the same colour as the surface from Avhich it grows. It is always accompanied, more- over, by a mucous discharge, and is generally multiple. In malig- nant disease of the urethra, the tumour is rough, fissured, or lobulated; hard and firm ; comparatively free from pain and of large size. Its growth is more rapid than the fleshy tumour of the urethra; and as it progresses it is liable to involve the lymphatic glands of the groin. The countenance also, in the latter stage of the affection, assumes the aspect peculiar to the cancerous cachexy. The polypoid tumour, although occupying the same situation, is easily distinguished from the vascular tumour by its larger size, its want of sensibility, its pale colour, and its indisposition to bleed even when rudely touched. Like the vascular excrescence, it may obstruct the flow of urine, but it is never attended with the local and general distress that characterize the other growth. It need hardly be added that no opinion should ever be given concerning any tumour in this part of the body with- out a thorough examination, both tactile and visual. A case is mentioned, under the head of cystocele, where a tumour, formed by a prolapsion of the bladder, came very near being mis- taken for a vascular excrescence. It happened in a child between two and three years of age ; the swelling was about the size and shape of a walnut, with a rough, granular surface, not unlike that of a large strawberry. The professional attendant proposed to remove it with a ligature, which he was about to apply, Avhen another surgeon, Avho was called into consultation, fortunately detected the true "character of the disease, and thus saved the child's life. Although these tumours are, in general, not dangerous, yet they may, by the protracted irritation to which they give rise, occasion- TUMOURS OF THE URETHRA. 657 ally destroy life, or reduce the patient to the very verge of the grave. When extirpated, or removed by caustic or ligature, they are apt to return, and to acquire, in a short time, their original volume. Occa- sionally they assume a malignant tendency, and gradually degenerate into open sores, which manifest no disposition to heal, and which dis- charge a thin, foul, irritating ichor. The treatment of this variety of tumour is strictly of a local cha- racter. Constitutional remedies, beyond their effect of improving the secretions and imparting tone to the system, are of no benefit. Attempts have been made from time to time to repress this morbid growth by astringent and sorbefacient applications, such as acetate of lead, Goulard's extract, tincture of iodine, and nitrate of silver; but without success. Instead, therefore, of wasting his time in this way, the surgeon should proceed at once to the employment of the only remedy known to be capable of affording permanent relief, namely, excision. This may be accomplished either with the knife or the scissors, according to the situation of the tumour. Seizure is effected with a small double hook, or a pair of broad-bladed forceps; the morbid growth is put gently on the stretch, or, if situated far back, carefully drawn forward, and then pared or snipped off with one stroke of the instrument, close to the mucous surface, or, if pos- sible, so as to include a portion of this. Where this cannot be done, the surgeon waits till the bleeding has ceased, and then touches the cut surface with a stick of Vienna paste. The caustic is held in con- tact with the part for about a minute, which is immediately washed with a piece of soft sponge dipped in diluted vinegar, to prevent mis- chief to the surrounding textures. The object of this procedure is to destroy the deep-seated portion of the excrescence, and, by modi- fying the capillary action of the part, to guard against its reproduc- tion, which is otherwise almost certain to take place. Some surgeons employ the caustic potash for this purpose, but as this substance is liable to diffuse itself over the neighbouring surface, it is better ahvays to resort to the Vienna paste, which has little tendency of this sort. The same remark is applicable to the different acids, as the nitric and muriatic, as Avell as to the acid nitrate of mercury, so much vaunted, of late, in the treatment of excrescences of the genito- urinary organs. When the excrescence is situated some distance within the urethra, it may become necessary, as a preliminary measure, to dilate the tube, in the same manner as when the surgeon Avishes to extract a 42 658 DISEASES AND INJURIES OF THE URETHRA. urinary calculus. Such a proceeding, however, can seldom be called for, and should ahvays, if possible, be avoided, on account of the danger of incontinence of urine. When the excrescences are situated round the external meatus, or just within the urethra, and are so numerous as to form a kind of belt or zone around its circumference, the safest plan is to excise the affected portion of the tube, including the mucous membrane and submucous cellular tissue. The bleeding which follows the opera- tion, and which is occasionally quite profuse, is readily staunched by pressure with a tent and compress wet with a strong solution of alum or gallic acid. Retention of urine sometimes ensues, and has to be met with the catheter. The removal of these tumours is sometimes effected by ligature. The operation is both awkward and painful, and worse than all, is seldom effectual, a portion of the excrescence being usually left be- hind, thus favouring repullulation. Should it be preferred, great care should be taken to apply the ligature as closely as possible to the base of the morbid growth, and to draw it with sufficient firmness to insure its speedy strangulation. Detachment usually takes place in three or four days. A practical precaution, of some consequence in using the ligature, is that it should not be too fine or delicate, nor drawn too tightly, otherwise it will cut through the tumour prema- turely. Any reproductive tendency that may manifest itself after these operations, should be counteracted by the nitrate of silver, or by a solution of this substance in nitric acid, by the muriated tincture of iron, or, what I prefer, by the tincture of iodine. CHAPTER V. NEURALGIA OF THE URETHRA. It is not surprising that the excretory canal of the urine should be liable to neuralgia, especially when we consider its structure and functions, and the various sources of irritation to which it is sub- ject. The disease occasionally exists at an early period of life, but is most common after the age of puberty, in young persons of a nervous, excitable temperament. Although it occurs in both sexes, it is much more frequent in males than in females, both because of the greater length and more complicated structure of the urethra in the former than in the latter, and because of their greater liability to all kinds of exposure. The origin of this disease is generally obscure; sometimes it is traceable to external injury, as a bruise, or to the lodgment of a calculus ; sometimes it manifestly depends upon the practice of onan- ism, or frequent sexual intercourse ; noAv and then it follows an attack of gonorrhoea, orchitis, or disorder of the bladder, prostate gland, ureter, or kidney. In the Southwest, where this affection is not infrequent, it is often dependent upon miasmatic impregna- tion of the system, and may, therefore, be said, under such circum- stances, to have the same origin as intermittent fever. In the female, I have knoAvn neuralgia of the urethra to be connected with hysteria and dysmenorrhoea. In many cases, the disease is asso- ciated Avith neuralgia of other parts of the body, especially of the head, chest, and back. The manner in which this disease makes its appearance is va- riable ; being sometimes sudden and unexpected, at other times gradual, and preceded by a sense of fatigue, soreness, or uneasi- ness in the affected part. The pain is of a sharp, pricking cha- racter, darting about in different directions with the rapidity of lightning; it frequently remits or even intermits for a few seconds and then recurs with its former violence ; it is generally attended ' 660 DISEASES AND INJURIES OF THE URETHRA. with considerable soreness of the urethra and the penis, a fre- quent desire to micturate, and more or less scalding in voiding the urine. Occasionally the disease is strictly periodical in its attacks, coming on at a particular time once every day, lasting an hour or two, and then gradually declining, to reappear about the same time the next day. In some cases, it assumes the ter- tian or quartan type. Distinct chilly sensations occasionally mark its access, especially when it is of miasmatic origin. The follow- ing case, one of many that have occurred in my practice, affords a good idea of the nature of this affection. T. C. H., a student of medicine, twenty-six years of age, of temperate habits, and good constitution, was seized, on Saturday, the 12th of January, 1843, with a frequent and urgent desire to micturate, attended with a scalding sensation of the urethra, which was at the time entirely free from disease. Indeed, the patient had never had an attack of gonorrhoea, nor was he conscious that the parts had ever been injured in any way whatever. Although he had no difficulty in emptying his bladder, he found that void- ing his urine neither relieved the desire to void this fluid, nor to put a stop to the pain, which was of a darting, pricking charac- ter. Being in good health in other respects, he supposed that the symptoms would soon disappear, and therefore contented himself with a large dose of paregoric, under the influence of which he passed the night comfortably enough. In the morning the pain was gone; but, to his surprise, it returned late in the afternoon, and from that time on it assumed a periodical type, recurring regularly about the same hour every day. Thus it continued for a week. The general health, in the meanwhile, appeared to be excellent; the appetite was good, the urine retained its normal character, and all the functions seemed to be well executed. Sa- tisfied, from a careful examination of the case, that the disease was neuralgia, I put the patient at once upon the use of quinine and arsenic, giving him four grains of the former with the tenth of a grain of the latter, every five hours. At bedtime he took blue mass and rhubarb in sufficient quantity to move his bowels. Under the influence of this treatment, aided by proper diet, the disease promptly lost its periodical character, and became, in every re- spect, mitigated. In ten days, the patient was so much relieved as to be able to go to the lecture-room, having still, however, a slight burning sensation in the urethra. Supposing that this would disap- NEURALGIA OF THE URETHRA. 661 pear spontaneously, he discontinued his medicine, and resumed his accustomed mode of living. On the 6th of February, the pain re- turned with some severity, but not as before, in regular paroxysms. The same prescription, with the addition of the sixteenth of a grain of strychnine, was ordered, and steadily persisted in until the 13th of the month, when all the symptoms had disappeared. To guard against relapse, the use of the medicine was resumed in five days, and continued for forty-eight hours, when it was finally laid aside : the cure being apparently complete. Neuralgia of the urethra is often a troublesome and obstinate, though never a fatal, disease. I have known it to continue for years, not steadily but intermittingly, and finally to disappear quite suddenly, without any evident cause, or without any particular treat- ment. The disease is most apt to prove obstinate when it coexists with neuralgia of other parts of the body, when it occurs in persons of a nervous, irritable temperament, or when it is associated with organic lesion of the genito-urinary apparatus. The treatment of this affection is to be conducted upon the same principles as that of neuralgia in other parts of the body. The cause is, of course, first of all, to be inquired into, and, if possible, removed; then a searching cathartic is administered, containing a few grains of calomel, to clear out the bowels, and restore the secre- tions of the liver and the mucous follicles of the alimentary canal; and after this, recourse is had to the ordinary anti-neuralgic reme- dies, such as quinine, arsenic, strychnine, and aconite, variously com- bined, and persistently exhibited, their effects being duly watched, both by the patient and his attendant, for fear of over-dosing. When the affection is of a purely miasmatic origin, no other treatment is generally required; a few days suffice to mitigate the morbid action, and a few more to dispel it. In rare cases, long continuance of treatment is necessary, and, in all, care should be taken to guard against relapse. This object is best attained by making the patient take his anti-neuralgic remedies for two or three successive days every week; the bowels should not be neglected; the diet should be properly regulated; and the patient must avoid exposure to cold and wet. In the milder forms of the disease, quinine alone will often speedily effect a cure; but, in general, I combine with this substance some or all of the articles above mentioned. In obstinate cases, carbonate of iron sometimes succeeds when all other remedies fail; this medicine should be given in doses from one to three drachms, three or four 662 DISEASES AND INJURIES OF THE URETHRA. times a day, and should be aided in its operation by the use of cathartics and alterants. Frequently patients affected Avith this disease are greatly benefited, and even entirely relieved, by a change of air. Little is necessary in the way of local treatment. During the paroxysm, the penis may be immersed in warm water, or fomented with hot cloths, impregnated with laudanum; or, better still, the patient may use a hot bath, and an anodyne enema. These measures are particularly indicated when the pain extends to the neck of the bladder, or when the attack is attended Avith a frequent desire to micturate, a sense of scalding along the urethra, and great uneasi- ness in the head of the penis. The application of veratria and bel- ladonna ointment is sometimes of service, in mitigating the local distress and re-establishing healthy action. In some cases I have witnessed good effects, especially in cold weather, from making the patient constantly carry his penis in a thick flannel stall, to protect it from atmospheric vicissitudes, which, as is well known, exert a most powerful influence over neuralgic diseases, in whatever part of the body occurring. The organ should be habitually ele- vated, and care be taken that the pantaloons do not exert any undue pressure upon it. It need scarcely be said that all sexual intercourse should be avoided. CHAPTER VI. HEMORRHAGE OF THE URETHRA. Hemorrhage of the urethra, although not very common, is al- ways alarming to the patient, and often a source of much embarrass- ment to the practitioner. It may present itself under two varieties of form, the spontaneous and the traumatic, of which the latter is by far the more frequent. When the mucous membrane is in a varicose condition, or abnormally soft and vascular, as it sometimes is in con- sequence of protracted congestion, the slightest cause is frequently sufficient to bring on a discharge of blood. Under such circum- stances, it is hardly possible to introduce a catheter, a bougie, or a sound without inducing some degree of bleeding. Spontaneous hemorrhage of the urethra is most common in old and middle-aged persons, who have led a life of irregularity and de- bauch, and labour under habitual relaxation of the lining membrane of this tube. In such individuals, the slightest erection, straining at stool, or horseback exercise, is sufficient to bring on an attack. Fre- quently, indeed, it makes its appearance without any assignable cause whatever, perhaps while the patient is lying in bed, or walking about. I am occasionally in attendance upon a gentleman, about thirty-six years of age, who has had repeated eruptions of this kind, without having been able, in a solitary instance, to trace them to any par- ticular agency. The discharge, in him, is usually of a dark modena colour, small in quantity, and of short duration. Spontaneous hemorrhage here, as elsewhere, is generally the result of a process of exhalation. Occasionally it may depend upon the rupture of a capillary vessel. Traumatic hemorrhage of the urethra arises from various causes. Most frequently it depends upon violence inflicted upon the tube by the passage or lodgment of a urinary concretion, the introduction of an instrument, as a catheter or bougie, or an attempt to force a 664 diseases and injuries of the urethra. stricture. It is a very common consequence of injury of the peri- nseum; and often follows the operation of cauterization. Hemor- rhage of the urethra occasionally complicates the acute stage of gonorrhoea, as the result of a rupture of some of the vessels of the lining membrane from chordee, or the act of coition. A frightful and even fatal hemorrhage has occasionally been produced by mas- turbation. It may also be caused by ulceration, or the presence of a chancre. A very interesting case of urethral hemorrhage, occur- ring immediately after sexual intercourse in a middle-aged gentle- man, has been recently reported by Dr. Russell, of Boston.1 The excitement was not greater than usual, and he had never before experienced such an effect. The quantity of blood lost was about a pint, and the patient remained quite feeble for several days, but without any signs of local irritation. The quantity of the effused blood varies from a few drops to several ounces. Although it is generally greatest in cases of lacera- tion and ulcerative perforation of the tube, it is sometimes not less abundant when it has its source in a slight abrasion of the lining membrane. The most abundant hemorrhages usually proceed from the posterior part of the urethra, probably on account of the greater vascularity there, both of the mucous tissue and of the surrounding structures. It is not often that the bleeding, under any circum- stances, is very copious, or that the blood issues rapidly, or in a full, round stream. I have, however, seen several cases in which the hemorrhage was so great as to produce serious exhaustion, and where, if it had not been promptly arrested, it might have terminated fatally. The colour of the effused fluid varies from bright scarlet to black or modena. In spontaneous hemorrhage, it is generally, at least according to my own experience, of a venous complexion, whereas in the traumatic form it is commonly of an arterial hue. Contact with the urine always renders it preternaturally dark. When the hemorrhage is caused by violence, and has its source high up in the urethra, the blood may regurgitate into the bladder, where, from its contact with- the urine, it soon coagulates, and often leads to retention. When, on the contrary, it has its rise in the anterior portion of the tube, the fluid generally escapes externally, either in a slow, trickling manner, or in a tolerably full stream. 1 Amer. Jour. Med. Scien., Oct. 1850, p. 323. ■ hemorrhage of the urethra. 665 Sometimes the blood coagulates in the urethra, forming a long, cylindrical plug, accurately representing the size and shape of the canal, and of sufficient firmness to be pulled away without breaking. Bleeding of the urethra seldom requires surgical interference; in most cases it ceases spontaneously, or is easily arrested by repose in the horizontal posture upon a hair mattrass, iced drinks, and pressure, for a few minutes, upon the perinseum, directly opposite to the part from Avhich the blood proceeds. This may be made either, with the finger, or by means of a tAvisted towel, rolled up, and applied firmly against the canal. In employing pressure, it is a matter of great moment that it be made properly, otherwise it will not only be use- less, but decidedly injurious. It is not always easy to hit the pre- cise spot from which the blood issues; hence the finger must be moved about from one point to another until the object is attained. If the pressure be applied in front of the seat of the hemorrhage, there is great probability that it will continue, and that the blood Avill pass back into the bladder, constituting thus a case of concealed hemorrhage, similar to that which is occasionally met with in the uterus. Such an occurrence might not only prove dangerous, but fatal. On the other hand, the pressure must not be made behind the affected part, for this proceeding, although not attended with the same risk, would be equally futile. The course which I generally pur- sue is, to place the finger upon the part from which the blood is sup- posed to proceed; holding it there for a few seconds, I ascertain whether it arrests the bleeding; if it do, I remove it, and apply it a little farther back ; if the finger was upon the proper spot in the first instance, there will immediately be a recurrence of the hemorrhage, and the seat of the pressure is instantly changed accordingly. A cold enema sometimes puts a sudden stop to this variety of hemorrhage; and another excellent expedient is the application of pounded ice to the perinseum, or the perinseum and the hypogastrium. Care, hoAvever, must be taken, in the use of the latter agent, that it be not continued too long, lest it produce chilliness, followed by vio- lent reaction. Benefit may also be expected, in some cases, from injecting the urethra with cold water, or some astringent lotion, such as a solution of subacetate of lead, alum, gallic acid or creasote. The fluid should be thrown up as high as possible, in a full stream, and the operation should be continued for a considerable length of time, or until there is reason to believe that the relaxed or ruptured vessels are completely constringed. Q66 diseases and injuries of the urethra. When the case is obstinate, and the more ordinary remedies have failed, recourse must be had to compression from within outwards. This is always easily accomplished, except in cases of severe lacera- tion, by means of a full-sized silver catheter, introduced into the bladder. The mere contact of the instrument frequently suffices to arrest the flow of blood; but, should this not answer, counter-pressure is made with the finger, a bandage, adhesive strips, or, when the hemorrhage is deep-seated, with a compress and roller. The best internal remedy in hemorrhage of the urethra, is gallic acid, in doses from three to five grains every two or three hours. Where the case is urgent, it may be given more liberally, in combi- nation with opium. Exhibited by itself, in large doses, it is apt to create nausea and vomiting, and to fail in producing the desired effect. In the spontaneous variety of this affection, gallic acid gene- rally acts like a charm, completely arresting the flow of blood in a few hours. In the traumatic form, although not equally efficacious, it rarely fails to be of signal benefit. Another excellent remedy in this affection is the subacetate of lead in combination with opium; three grains of the former with one of the latter should be given every three hours, and continued until the necessity for its exhibition ceases. Alum is another valuable agent in this affection. It should be administered in doses from thirty to sixty grains every two or three hours. Employed in smaller quan- tity, little benefit is to be looked for. In very obstinate cases, there are perhaps no articles that hold out greater prospects of success than spirits of turpentine and the muriated tincture of iron, in doses of ten drops each, repeated every hour. Both these medicines act specifically upon the urinary organs, and are particularly indicated in urethral hemorrhage occurring in weak, sickly individuals. CHAPTER VII. FOREIGN BODIES IN THE URETHRA. The urethra, like the rectum, oesophagus, and other mucous canals, is liable to the introduction and lodgment of foreign bodies, which differ very much in their character according to the source from which they are derived. Considered with reference to this point, they may be appropriately arranged under two heads: 1. Foreign bodies which descend from the urinary bladder, or which are deve- loped in the canal itself. 2. Substances forced into the urethra through its external orifice. 1. Foreign Bodies which Descend from the Bladder, or are Deve- loped in the Urethra.—Most of the foreign bodies which descend into the urethra from the bladder are simply earthy concretions, which are developed either in the latter organ, in the prostate gland, or in the kidneys. Sometimes, however, they consist of articles which were originally admitted through the urethra, and which have after- wards, in consequence of the force impressed upon them by the blad- der or the stream of urine, taken a retrograde course. A bean, a bit of catheter, the end of a bougie, a needle, or a piece of wood, has sometimes met with such a fate. A ball, a pebble, a portion of wadding, or a fragment of bone, accidentally introduced into the bladder, may likeAvise pass from this organ into the urethra, and be- come impacted in it. The concretions which descend from the bladder and lodge in the urethra, vary much in regard to their volume, their shape, the cha- racter of their surface, and their chemical composition. It would require more time than can be allotted to the subject if I were to enter into the consideration of these different points; a circumstance which I regret the less, because it is really of little, if any, practical interest. The urethra being itself small, it rarely happens that the concretion is more than three or four lines in its short diameter although it may be twice, thrice, or even four times as large in the 668 diseases and injuries of the urethra. opposite direction. I extracted, not long ago, from the urethra of an old gentleman of sixty-seven, a calculus which was nearly one inch in length, while it was hardly three lines in thickness. When the passage is morbidly dilated, as it sometimes is behind a tight, callous stricture, it may admit a concretion of much greater volume. In its shape, the foreign body may be rounded, ovoidal, oblong, co- nical, angular, or curved. When it is perfectly straight, it will be more likely to enter the canal than when it is crooked; and its intro- duction will also be facilitated when the presenting extremity is comparatively small. Finally, the concretion may be perfectly smooth, partly smooth and partly rough, or rough and tuberculated in its entire extent. A smooth body will, all other circumstances being equal, enter and pass the urethra with greater ease and less pain than a rough one. The foreign substance may be prevented from escaping by a stricture. Fig. 101. Secondly, the concretion may be developed in the urethra itself. The occurrence is rare; but that it is possible is shown by the fact that a foreign body, such as a piece of straw or a bit of bougie, lodged in this tube, has sometimes become speedily incrusted with sabulous matter, and that calculi have occasionally formed in a peri- foreign bodies in the urethra. 669 neal fistule, the scrotum, and the prepuce. The development is favoured by the existence of an abnormal pouch of the urethra, or by an organic stricture attended with dilatation and ulceration of the canal behind the obstruction. The concretions do not seem to differ, in any essential particular, as it respects their physical and chemical properties, from those which form in the bladder and kidneys. They are usually diminutive; and they vary in their number from one to five or six. A very extraordinary example of calculus of the urethra is men- tioned by my distinguished friend, Professor Mutter, of Philadelphia, in his notes to Liston's " Operations of Surgery." The patient was a young man of twenty, of very feeble health, and with evidence of chronic inflammation of the bladder. The concretion, which was immovably fixed in its situation, hard, smooth, and about the dia- meter of an ordinary pipe-stem, was accurately moulded to the urethra, and reached from within an inch of the external orifice of the tube to the neck of the bladder. A urinary concretion, or any other foreign body forced from the bladder into the urethra, may lodge in any portion of this tube, from its commencement to its termination, and the symptoms awa- kened by its presence will not essentially vary whatever may be the part affected. When the substance is permanently fixed, it gene- rally attains a greater magnitude in the membranous division of the canal than in any other, simply because this portion of the tube is naturally very dilatable. Sometimes, however, large concretions form at the prostatic portion, the sinus of the bulb, and the navi- cular fossa. The passage of a calculus from the bladder along the urethra is frequently productive of great inconvenience and distress. The in- tromission is generally sudden and unexpected, taking place while the patient is engaged in micturition. It is instantly folloAved by an interruption of the stream of urine, an urgent desire to empty the bladder, severe straining, more or less pain, and a sense of burning or tearing in the urethra. If the substance is small, it may be expelled in a few minutes, perhaps during a new effort at micturition, fol- lowed by immediate and permanent relief. If, on the contrary, it is disproportionably bulky, it may be arrested for several hours or even days, and give rise to severe suffering, accompanied by partial or complete retention of urine, painful erections, and probably also by slight hemorrhage from laceration of the mucous membrane. When 670 DISEASES AND INJURIES OF THE URETHRA. the calculus is of extraordinary size, it can hardly fail to lodge per- manently, and to lead to all the distress, both local and constitutional, which is always sure to result from the protracted obstruction of an important excretory tube. The symptoms which attend the passage of a calculus along the urethra may be simulated by those produced by other causes, and are, therefore, of no positive value in determining the nature of the accident. To establish the diagnosis, it is necessary to institute a careful examination with the finger and the catheter. When the foreign body occupies the spongy portion of the urethra, the finger, applied to the loAver surface of the penis, will generally readily detect it, and give the surgeon a correct idea both of its volume and con- figuration. The same means will enable him to ascertain whether it is fixed or movable. When the substance is situated farther back, as in the membranous or prostatic portion, the exploration must be conducted with the finger in the rectum, otherwise, especially if it be very small, it will be impossible to feel it, on account of the great thickness of the soft parts. When the foreign body cannot be detected with the finger, or where any doubt remains respecting the real nature of the obstruc- tion, recourse must be had to the catheter. The best instrument, for this purpose, is a silver one, well rounded at the vesical extremity, and of medium size. This is introduced in the usual manner, and carried on towards the bladder as slowly and as gently as possible. If the obstruction has been caused by the presence'of a calculus, the contact of the catheter with the foreign body will produce a pe- culiar sound and a rubbing or grating sensation which no one, prac- tised in such examinations, can mistake. The diagnosis is established. Some idea may be obtained concerning the volume of the concretion by observing whether the instrument is completely arrested by it, or Avhether it slips between it and the walls of the urethra. In making this exploration, care should be taken, by inserting the finger in the rectum, that the foreign substance be not pushed back into the bladder; an occurrence always to be deprecated, unless it is rendered absolutely necessary in consequence of retention of urine, or the Avant of proper instruments for performing extraction. It is Avorthy of remark, that, when the calculus has escaped from the urethra and lodged in the subjacent structures, the instrument may fail to detect it, even when it is of large size. When a calculous concretion has been developed in the urethra, FOREIGN BODIES IN THE URETHRA. 671 or has been forced into it from the bladder and retained there for a long time, its tendency is to increase, by the addition of new deposits from the earthy salts of the urine. The extent to which this augmentation may reach is variable, as are also the effects to which it may lead, as it respects the surrounding tissues. A con- cretion, weighing five or six ounces, has occasionally been developed in this situation, and given rise to all the symptoms of vesical cal- culus. Long before it attains such a bulk, the foreign substance, producing ulcerative absorption, leaves the canal of the urethra, and forms a sort of cul-de-sac by the expansion, thickening, and conden- sation of the circumjacent structures. It has been supposed that this secondary receptacle is produced simply by a dilatation of the canal, in consequence of the continued pressure of the foreign substance; but if this be the case, it can only be true of the disease in its ear- lier stages, for it is impossible to imagine that a tube, so small as the urethra, could, under any circumstances, increase so much in size as to accommodate a stone of the weight above mentioned. During a visit which I recently made to Philadelphia, Dr. Peace, a distinguished surgeon of that city, had the kindness to give me the particulars of the following very interesting case of urethral calculus, which he relieved by operation. The patient, Daniel McMenony, aged twelve years, was admitted into the Pennsylvania Hospital, on the 10th of August, 1842, for a swelling of the scro- tum produced by the kick of a cow. In the course of a week all the symptoms of inflammation had disappeared, and a large tumour was felt under the scrotum. A sound was introduced, and a stone was immediately detected. The boy stated that he had been cut, two years ago, for stone, by Dr. Randolph, and that he had remained well for three months, when he began to observe some difficulty in urinating, attended with a swelling within the scrotum, and some degree of pain, especially at the close of micturition. An incision was made immediately behind the scrotum, and a calculus, weighing four ounces, was exposed, broken, and removed with the scoop and forceps. No bad effects followed the operation. In a few days a small stone was detected in the bladder, from which it was removed subsequently, at three sittings, by means of Heurteloup's instrument. The opening made in the urethra became fistulous, and a catheter was passed with some difficulty into the bladder, but could not be retained on account of exciting erysipelas. The patient was after- 672 DISEASES AND INJURIES OF TnE URETHRA. wards sent into the country to recruit his health, and did not again apply for admission. A calculus, permanently impacted in the neck of the bladder, has been known to cause complete absorption of the prostate gland, and great dilatation of the corresponding portion of the urethra. The foreign body, in this case, being situated partly in the bladder, and partly in the urethra, sometimes attains an extraordinary volume, and presents a most fantastic appearance, especially Avhen it extends several inches into the latter tube. The symptoms are those of ordi- nary vesical calculus, except that there is not so much interruption to the stream of urine, because of the immovable condition of the concretion, and also that there is, for the same reason, more fre- quently incontinence, in conseqnence of the loss of power of the sphincter muscle. Finally, a calculus, after having remained in the urethra for an indefinite period, sometimes effects its own expulsion. This it does by exciting absorption of the surrounding parts, Avhich gradually progresses until all the tissues give way, save, perhaps, the cutaneous, which at length yields under a violent effort at micturition. Or, in- stead of this, the skin ulcerates at the most prominent portion of the tumour, and exposes the foreign body to such an extent as that it may be easily extracted. Treatment.—The treatment of urethral calculi must necessarily be influenced by a variety of circumstances, some of which hardly admit * of precise detail. When the foreign body is lodged in the posterior portion of the tube, and is so large as to obstruct the flow of urine, the safest plan is to push it back into the bladder, whence it came. For this purpose a full-sized silver catheter, with a blunt extremity and a small curve, is used; this is introduced in the usual manner, and then gently but firmly pressed against the concretion^ at the same time that the finger is applied upon the perinseum, to prevent the formation of a false passage. A small instrument is unsuitable, inasmuch as its point might pass between the calculus and the wall of the urethra. Any spasmodic action that may exist, whether in the tube itself, or in the muscles by which it is surrounded, should be combated by venesection, tartar emetic, the hot bath, and anodyne enemata; or, what is better than all, by the exhibition of chloroform. Unless the concretion is very bulky, rough, or curved, this plan will seldom fail, and should always, I conceive, be preferred to the more uncertain method of extraction. If, on the contrary, the extraneous body is comparatively small, FOREIGN BODIES IN THE URETHRA. 673 or so irregular on the surface as to enable the patient to void his urine, it should not be pushed back, but removed. Delay here is of little consequence, as the accident is rarely attended with much suf- fering, and the surgeon has ample time to prepare for the operation. Before resorting to extraction, an attempt should be made to favour the expulsion of the concretion, by dilating the portion of the ure- thra which is in front of it, by means of the catheter or bougie. This process has been successful in more instances than one. Occa- sionally extrusion may be effected by injections of sweet oil, or by closing the prepuce, and holding it tightly while the patient is making a powerful effort to expel his urine, at the same time that pressure is applied along the under surface of the urethra, to urge on the foreign body. When the calculus occupies the spongy portion of the tube, it is clear enough that it ought to be extracted, whatever may be its size or form. To push it back into the bladder would be difficult and hazardous, on account of the distance at which it is situated, and the curved direction of the canal, to say nothing of the violent spasm which such an attempt is calculated to awaken in the perinseal muscles. Extraction.—When the foreign body, whatever be its situation, is so firmly impacted that it can neither be expelled by the powers of the patient, nor pushed back into the bladder, extraction is neces- sary. This may generally be effected when the concretion is near the orifice of the urethra, or in that portion of it which corresponds with the head of the penis, by very simple means, as a pair of nar- row-bladed dissecting forceps, or even the fingers; but the reverse is often the case when it is lodged far back in the canal. One of the most simple contrivances for effecting our object, under such circumstances, is the wire-loop, originally suggested by Marini. This consists, as the name implies, of a piece of smooth, thin, flexible wire, of silver or copper, bent like a hair-pin, the convex extremity of which is passed down the urethra, and insinuated behind the foreign body, which is then caught and drawn out. A modification of this instrument, if so it deserves to be styled, was made by Julius Cloquet, by adapting to it a silver canula with a side-screw, in order the more effectually to secure the calculus after it has been seized by the Ayire. The objection to this instru- ment, in both its forms, is the difficulty of passing it behind the 43 674 DISEASES AND INJURIES OF THE URETHRA. concretion, which, when large enough to lodge, usually fills up the entire passage. When these simple means fail, and also in the more difficult forms of the accident, recourse must be had to the urethral forceps, of which a great variety have been devised by surgeons. Of these the most useful and important are those of Sir Astley Cooper, Civiale, Amussat, Leroy d'Etiolles, and Bonnet, which are all constructed upon the same principles, though they differ from each other in their form and mode of arrangement. Several of these instruments are represented in the annexed drawings, which preclude the necessity of any laboured description. The one to which I give the prefe- rence, both on account of its simplicity and its happy adaptation to the end proposed, is the articulated scoop of Bonnet, of Lyons; it is Fig. 102. armed with a stylet, and is furnished with a head for seizing and fixing the foreign body. The instrument, well oiled, is introduced shut, until it comes in contact with the concretion, when its blades are expanded over it; the extraction being effected in the most slow and gentle manner, to prevent injury of the mucous membrane. Fig. 103. Fig. 103 represents Hunter's forceps, as improved by modern sur- geons. Lithotripsy.—Breaking or crushing is applicable only when the calculus is soft or friable; but as this can hardly ever be known beforehand, it is seldom available. The operation, moreover, is seldom safe, however carefully performed, being liable to be fol- lowed by laceration of the mucous membrane, infiltration of urine, and severe inflammation. It may be done with a straight sound or silver catheter, well rounded at the point, care being taken to steady the concretion with the thumb and finger, to prevent it from receding. The fragments are afterwards washed out by the stream of urine, which should always be retained for several hours previous to the operation. Leroy uses an instrument, called the spoon-shaped stone- FOREIGN BODIES IN THE URETHRA. 675 crusher. It is very similar to Civiale's instrument for breaking vesical calculi. Urethral lithotripsy ought seldom to be resorted to, except when the concretion is situated in the spongy portion of the tube, and is of the consistence above mentioned. When it is lodged far back, the operation is difficult and hazardous. In the remarkable case of Dr. Mutter, previously referred to, that gentleman succeeded in freeing the urethra by cutting off daily a piece of the stone, with a pair of small, strong, slightly curved, sharp-cutting forceps, expressly constructed for the purpose. As the urethra was very irritable, the operation was attended with some pain, but nothing serious ensued, and in a short time the entire cylinder was removed. Excision.—This operation, which becomes necessary when extrac- tion fails, varies according to the situation of the foreign body. When the concretion is lodged deeply, as in the prostatic or membranous parts of the tube, it is performed very much after the manner of Celsus, in cutting on the gripe, as it was called. The rectum having been thoroughly emptied by an enema, and the patient placed as in the operation of lithotomy, the surgeon introduces the fore and middle fingers of the left hand, well oiled, into the anus, and uses them to push the stone forward, to make it protrude and form a tumour in the perinseum. An incision is then made, either of a lunated shape, as in the bilateral method, or, which is better, be- cause more easy and simple, obliquely downwards and outwards, as in the ordinary operation; first through the skin and cellular sub- stance, then through the muscles, and finally through the urethra. A small opening will generally suffice. When the concretion is fully exposed, it may either be pressed out with the fingers, or ex- tracted with a blunt hook or pair of forceps. In performing this operation care must be taken to guard the rectum. When the calculus is impacted in the navicular fossa, its removal is easily effected by incising the lower part of the urethra where this tube corresponds with the head of the penis. The operation may be performed Avith a narrow, probe-pointed bistoury, or a cataract- knife. The operation is also very simple when the concretion is lodged in the membranous portion of the tube. The skin being carefully tightened by an assistant, the surgeon, armed with a scalpel or bis- toury, divides the parts with one stroke of his instrument along the 676 DISEASES AND INJURIES OF THE URETHRA. median line at the inferior surface of the penis. The calculus being removed, a silver catheter is introduced into the bladder, and the edges of the wound are brought together by several points of the interrupted suture. When the foreign body lies in that portion of the urethra Avhich corresponds with the scrotum, incision should be practised with great caution, from the fact that it is liable to be folloAved by infiltration of urine and all the bad consequences of this accident. In such a case, I would advise immediate cauterization of the wound with nitrate of silver, to favour the deposit of lymph, and an avoidance of micturition for ten or twelve hours, or until the parts have become fully consolidated; or, what Avould be preferable, an incision might be made through the skin and cellular tissue over the tumour, and the wound stuffed with lint. The requisite amount of inflammation having been excited, the operation is completed by dividing the parietes of the urethra in the usual manner. In this manner the bad effects in question might be effectually avoided. 2. Foreign Bodies Introduced from Without.—Of foreign bodies introduced into the urethra from without, the number and variety are quite considerable. Indeed, a volume might be written upon the subject without exhausting it. The occurrence is sometimes for- tuitous, or the result of accident; but more frequently it takes place through design, either of the patient himself, or of mischievous and wicked persons, who take advantage of the helpless state of their in- tended victim. Bits of catheters, bougies, quills, pipe-stems, wood, straw, and other substances have been accidentally lodged in the urethra, by individuals endeavouring to draw off their urine, relieve a stricture, or provoke onanism. Females, apparently from mere wantonness, or a desire to excite sympathy and commiseration, often introduce pebbles, cherry-stones, chicken-bones, pins, needles, and other articles into the urethra. Moraud cites the case of a girl of twenty, who had inserted a tooth-pick into this passage, from Avhich it soon slipped into the bladder, from which it was finally extracted by an operation. Pamard mentions an instance in which the foreign substance was an ivory whistle, three inches and a half long, and five lines in diameter at its centre. Rigal was obliged to remove from the bladder of a young female a wooden needle-case, which had passed into the urethra in masturbating. Morgagni asserts that it was by no means uncommon, in his day, in Italy, for lascivious girls to introduce into this canal the golden pins worn in their hair. In the pathological museum of the New York Hospital is a glass FOREIGN BODIES IN THE URETHRA. 677 jar marked 92, which is nearly filled with pieces of burnt brick, which were removed, at different times, by Dr. Stevens and other surgeons, from the bladder'of a woman, who was in the habit of in- troducing them, apparently for the purpose of rendering herself an object of interest and commiseration. Dr. Lente, one of the resi- dent surgeons of the institution, has done me the favour to examine these pieces, and to communicate to me the result of his observations. Some of them are tolerably smooth, having evidently been made so by scraping, while others are quite rough and irregular. Only sixty- seven pieces, or about one-third of the entire number, are preserved. In their shape, some are cylindrical, others fusiform; the ends of the latter, however, taper but little, and are round and abrupt. Many of them are slightly curved, the patient having probably discovered, by constant practice, that this was the most convenient form for their easy introduction. The longest concretion is two inches and a third in length, and two inches and a third in circumference at its widest part; the smallest, on the contrary, is only fifteen lines in length, and eight lines in circumference. In their weight, they vary from one drachm to half an ounce. Bodies similar to the above are sometimes forced up the urethra of the male. Soule* has recently published the case of a young man of twenty-three, from whose urethra he removed a hair-pin; Fardeau saw an individual from whom he extracted an iron wire, upwards of seven inches long, one end of which had pierced the tube, and be- come fixed in the inner edge of the tuberosity of the ischium; and Lallemand operated upon a patient, aged fifty years, who had a sail- maker's needle, four inches long, in his urethra. Civiale extracted from the bladder of a man, by means of lithotrity, a bean, which had been introduced through the urethra eleven months previously, and which gave rise to all the symptoms of stone.1 I shall have occasion presently to revert to some of these cases. Dr. James R. Wood, an excellent surgeon of New York, has recently shown me a pewter spoon-handle, five inches in length, which he removed from the ure- thra of an old man of seventy-two, who had been in the habit of using it for producing artificial excitement. One evening it slipped out of his fingers, and passed beyond his reach. Dr. Wood intro- duced a catheter, but found he could get it no further than the junc- tion of the bulbous and membranous portions of the tube. To prevent 1 Deslandes on Manhood, p. 131. Boston, 1845. 678 DISEASES AND INJURIES OF THE URETHRA. the foreign body from passing completely into the bladder, he fixed it with his finger in the rectum, and then extracted it with the urethra forceps. In another case, for the particulars of which I am indebted to the same gentleman, the foreign body was a piece of leather, eighteen inches long, and about the size of a No. 7 cathether. The patient was a man forty-five years of age, who, while practising onanism, by means of this substance, found himself unable to withdraw it, although he used great exertion so to do. When Dr. Wood saw him, soon after the accident, four inches of the string were seen to protrude at the external orifice; while the other end, rolled up into a large and firm knot, by the patient's manipulations, was discovered in the bladder by the finger in the rectum. By great and steady traction upon the free extremity of the foreign body, maintained for fifteen minutes, aided by division of the meatus, to allow the knot to pass, he finally succeeded in extracting it. The annexed drawing, Fig. 104, is an accurate representation of the vesical extremity of the string with its knot. Fig. 104. Foreign bodies, introduced from without, produce various effects, according to the manner in which they are inserted, their nature, the distance which they have travelled, and the period of their so- journ. There is one feature which they all possess in common, namely, a remarkable propensity to migrate to the bladder, no matter what may be their form, size, or composition. The bladder manifests, so to speak, in all cases of this kind, a disposition to swal- low the foreign body, or to suck it in. In what manner this is effected has not been satisfactorily explained. It is probable that it is produced by one of three circumstances, either by a sort of peristaltic action of the tube, by suction of the bladder, or, what is more plausible, by capillary attraction. Be this as it may, the man- ner in which it happens does not affect the fact, a knowledge of which is quite sufficient for all practical purposes. FOREIGN BODIES IN THE URETHRA. 679 In some cases the extraneous substance becomes impacted, and remains in the tube for an indefinite period, perhaps for many years, attended, it may be, with little inconvenience or functional distur- bance. Occasionally it forms the nucleus of a urinary concretion, or its surface becomes incrusted with earthy matter. When bulky, it gives rise to retention of urine, with inflammation of the urethra, severe pain, morbid erections, frequent micturition, rigors, and high constitutional disorder. Hemorrhage is liable to attend when the foreign substance has an unusually rough surface, or when it has been rudely inserted. Finally, it occasionally happens, as was previously stated, that the escape of a concretion is prevented by an organic stricture. When the case is urgent, or admits of no delay, in consequence of retention of the urine, relief must be afforded either by dividing the stricture with the lancetted stylet, and then extracting the calculus in the usual manner, or, when this is impracticable, by making an incision into the tube, embracing both the stricture and the foreign body. Much tact and ingenuity are often required to extract a foreign body introduced from without. This is especially the case when it has broken off low down in the passage, or when it has pierced its walls. Much difficulty may also result from the peculiar nature or shape of the article. Thus, a hair-pin, inserted head foremost, and pushed out of sight, might greatly perplex, and completely baffle, a man unaccustomed to think for himself, or rely upon his own resources. Boinet, a French surgeon, being called to a case of this kind, had recourse to the following ingenious expedient. Taking hold of the penis, he bent this organ strongly upwards, at the same time that he made firm pressure upon the head of the pin, to pre- vent it from receding. By this manoeuvre the points of the instru- ment were forced through the lower wall of the urethra; the two branches were then separated transversely, when one of them was cut off, and the other pulled out. The operation lasted only a few minutes, and was not followed by any unpleasant effects. This ex- pedient was recently employed with complete success by Soule* of France. A young man, twenty-three years of age, had introduced a hair-pin, head foremost, into his urethra, the ends of the branches being about one inch from the meatus, and consequently entirely out of sight. Every attempt was made to extract the foreign body through that aperture, but in vain. He then had recourse to Boinet's process, and accomplished his object in a few minutes. 680 DISEASES AND INJURIES OF THE URETHRA. I have already alluded to the case reported by Fardeau of a young man who introduced into his urethra, for the purpose of titillating it, an iron wire upwards of seven inches in length. The end of the wire was bent into a hook, probably to excite more vivid sensations. One day, while indulging in this strange operation, he suddenly felt a severe pain, which proved to have been caused by a laceration of the membranous portion of the canal. In his attempts to withdraw the wire, the unfortunate man only forced the hook further into the soft parts. He then rounded the projecting part of the iron into a ring, hoping thus to be able to extract it the more easily. Finding all his efforts fruitless, and expecting every moment to die, he sent for Dr. Fardeau. The penis and scrotum were enormously swollen, hot, and painful; the bladder was unable to expel its contents ; and the patient had high fever with incipient delirium. Grasping the loose portion of the wire, Dr. Fardeau soon found, to his astonish- ment, that the end was immovably fixed in the inner edge of the tuberosity of the ischium. An oblong incision being made over this part, the hook was seized, and the wire was withdrawn through the perinseum. The patient was completely restored.1 When the foreign substance is of a simple character, as the stalk of a plant, a tooth-pick, or a pin, it may, if it have not slipped too far back, be extracted with a pair of delicate forceps. To render the success more certain, the penis should be held horizontally, and slightly on the stretch, otherwise it may be difficult to expand the blades of the instrument over the extremity of the intruder. Care should also be taken that the forceps do not pass between the sub- stance and the wall of the urethra. Another precaution, not to be overlooked, is to apply pressure just behind the foreign body, to prevent it from receding during the attempts at extraction. When the operation fails, it will be proper, as a dernier resort, to cut down upon it through the walls of the tube, and remove it with the for- ceps. A small opening, barely large enough to expose the anterior extremity of the impacted body, will suffice. A common needle might be extracted after the method of Boinet, described above; a pebble, bean, or seed-stone, with the forceps employed for removing urethral calculi. Mons. VidaF had the good luck, some years ago, to extract a pin 1 Deslandes on Manhood, p. 129. Bost. 1845. 2 Pathologie Externe, T. v. p. 109. Deux. edit. FOREIGN BODIES IN THE URETHRA. 681 from the urethra of a child six years of age, by means of a curved catheter. The foreign body had been lodged in the posterior part of the tube for twelve days, and had occasioned severe suffering. The instrument was introduced with the convexity towards the pubic symphysis, as far as the bulb, when, instead of being pushed on into the bladder, he turned it round, as in the operation of the tour de maitre, and suddenly withdrew it from the passage. To his sur- prise, he found the pin lying in the eye of the catheter. This was certainly a lucky operation; an operation which might be repeated a hundred times, even by Mons. Vidal himself, without success. CHAPTER VIII. INFILTRATION OF URINE. By the term "infiltration," as applied to the urine, surgeons un- derstand an escape of this fluid from the urinary passages, and its diffusion through the surrounding cellular tissue. It is usually re- stricted, at the present day, though, as it seems to me, without much propriety, to the extravasations which occur at the neck of the blad- der and along the posterior parts of the urethra. There are two forms of the affection, the vesical and the urethral, each of which requires brief consideration. The accident, in whatever form it may present itself, is always a most unfortunate one, on account of the serious effects to which it is sure to give rise. The urine, naturally acrid in its character, and rendered, perhaps, still more so by disease, or by its protracted re- tention in the bladder, no sooner comes in contact with the tissues into which it has escaped than it lights up violent inflammatory ac- tion, which rarely ceases but with their destruction. The fluid, in fact, instead of being an unirritant and harmless substance, as it is when it is confined within its proper reservoirs, now that it has be- come unpent, plays the character of a virulent poison, both to the part and to the system. In a few hours after the infiltration has taken place, excessive action is set up ; the pain is of a sharp, burn- ing, stinging nature ; the skin, which presents an erysipelatous blush, is hot, dry, and exquisitely tender to the touch ; the swelling is great and rapid; micturition soon becomes impracticable, if it was not already so at the beginning; and there is high constitutional excite- ment, with a rapid pulse, dryness of the surface, intense thirst, excessive restlessness, headache, and delirium. As the case proceeds, the affected parts assume a black, livid appearance, crepitate on pres- sure, and are deprived of their vitality; a urinous odour exhales from the infiltrated structures, and sometimes even from the whole body ; and the patient sinks into a low, typhoid condition, which is INFILTRATION OF URINE. 683 speedily followed by hiccough, twitching of the tendons, cold clammy sweats, the hippocratic countenance, deep coma, and death. The period at which the latter event occurs varies from four to six or eight days, according to the extent of the infiltration, the acridity of the urine, the resulting inflammation, and the state of the system at the time of the accident. In some instances the smallest quantity of urine, not, perhaps, exceeding a few drops, is sufficient to pro- duce the most violent symptoms in four or five hours, followed by mortification and death in a few days; while in others, the effusion may be much more extensive and yet the effects much more mild. Generally, however, the inflammation is of the most severe cha- racter, and is followed by the worst consequences. 1. The vesical form of the lesion may be produced by a rupture of the bladder from external violence, from over-distension from urine, or from perforative ulceration of the coats of the organ. After the operation of lithotomy, infiltration is unfortunately but too common, and is one of the chief sources of danger. This may depend upon two circumstances, that is, either upon too extensive a division of the prostate gland, or upon the small size of the external wound; in the former case, the urine will be apt to insinuate itself into the subse- rous cellular tissue of the pelvic cavity, in the latter, into the cellular substance round the neck of the bladder and in the perinseum. Severe and even fatal infiltration of urine sometimes follows the operation of lithotripsy, either from violence done at the time of crushing the stone, or from the impaction of sharp fragments at the neck of the organ, during the withdrawal of the instruments. I recollect a case of this kind where death was caused in a few days. Puncture of the bladder above the pubes, and the high operation of lithotomy, are both liable to be followed by infiltration of urine; and the same is true, only perhaps to a greater extent, of the recto-vesical operation. One of the worst and most extensive cases of extravasation I have ever witnessed was produced by a wound of the neck of the bladder from a spiculum of bone. When this organ is ruptured, as a con- sequence of external violence, the aperture is usually situated in that portion of its surface which is invested by the peritoneum, and death is almost certain to happen in two or three days from inflammation of this membrane. Vesical extravasation is not always easily recognised in its early stages. The diagnosis will, of course, be greatly assisted by a con- sideration of the history of the case. If the bladder has been long 684 DISEASES AND INJURIES OF THE URETHRA. distended, its rupture, the immediate cause of the extravasation, may have been perceived by the patient at the moment of its occurrence; he is conscious that something has given Avay ; he perhaps expe- riences the most delightful relief, and flatters himself that he will soon be Avell. A feAV hours, however, suffice to undeceive him; his sufferings recur with increased violence; he is unable to void a drop of urine ; low muttering delirium sets in; excessive distress is felt in the pelvic cavity, and death usually ensues in thirty-six or forty- eight hours. In such a case the diagnosis is easy enough. The same is true when the symptoms previously pointed out exist after an operation, or an external injury. The prognosis in vesical extravasation is generally most unfa- vourable. Whenever the urine gains admission into the peritoneal cavity, it is exceedingly rare, no matter how small may be the quan- tity of the effused fluid, that the patient recovers. Death, under these circumstances, is seldom postponed beyond the end of the second or third day. When the fluid is infiltrated into the subserous cellular tissue round the neck of the bladder, or at the base of the viscus, extensive gangrene is apt to occur, and to place life in im- minent jeopardy, either proximately or remotely. Recovery, how- ever, although extremely rare, under such circumstances, is not altogether impossible. The fluid may advance outwardly towards the perinseum, and be discharged, along wTith more or less pus and shreddy cellular substance, by the surgeon's knife, or by ulcerative action. The case will be tedious ; the cure probably imperfect. The treatment of this variety of urinary extravasation is, in the highest degree, unsatisfactory. Several forms of it, in fact, are entirely beyond the reach both of the surgeon and the physician. What, for example, is to be hoped from any measures, however well planned or energetic, when urine has been extravasated into the peritoneal cavity, or at all extensively into the subserous cellular tissue, on the sides or at the base of the bladder ? Surely nothing. Death will occur in spite of all we can do. There is, in truth, but one case in which vesical infiltration is in the least amenable to treatment, and that is where the urine has a tendency to advance towards the perinseum. Here the treatment obviously consists in making early, free, and dependent incisions, to give vent to effused fluids, urinary, sanious, and purulent; and in sustaining the system by the timely use of tonics and stimulants, particularly brandy and quinine, with a light but generous diet. " No case in which an INFILTRATION OF URINE. 685 outward and efficient opening has been afforded, is to be considered too desperate. Nourishment and stimuli must be steadily adminis- tered. Unexpected and wonderful recoveries have rewarded perse- verance."1 2. The urethral form of infiltratipn is more common than the vesical, and, fortunately also, in general, more manageable. The cause under which it usually takes place is a laceration of the urethra, either in consequence of external violence, severe straining during micturition, as in stricture, the passage of a urinary calcu- lus, or the maladroit use of instruments, as the catheter or bougie. When the canal is ruptured far back by a fall astride a chair, a blow, or a kick, infiltration of urine is almost inevitable. The accident is sometimes produced by violent straining in attempts to void the urine, on account of the obstacle afforded by a tight, cal- lous stricture. In this affection, the portion of the urethra behind the obstruction is often remarkably dilated and attenuated, and therefore liable to give way under any unusual effort at micturition; the more so, because the muscular fibres of the bladder are generally at the same time very considerably hypertrophied. When the rup- ture follows upon such a cause, the urine is sent abroad into the connecting cellular tissue with great force, as if it had been dis- charged from a syringe, and gives rise to the most disastrous conse- quences. If the rupture takes place in the commencement of the mem- branous portion of the urethra, behind the triangular ligament, the case may remain obscure for several hours or even days; there is little or no prominence in the perinseum from swelling, the scrotum is uninvolved, and the patient may not have been conscious of a sense of yielding, as he is when the bladder gives aAvay. The urine is deep-seated, and may burrow extensively before it declares itself externally. The most reliable symptoms of the mischief that is going on, are, pain and throbbing deep in the perinseum; difficulty, or utter impossibility of voiding the urine, with, perhaps, a frequent desire to do so; a sense of fulness in the anus and rectum ; tender- ness in the hypogastrium; and extraordinary constitutional distur- bance. By and by, the urine makes an effort to approach the surface, its progress being preceded and accompanied by heat, pain, redness, and SAvelling, and by a rapidly increasing typhoid state of 1 Miller's Practical Surgery, p. 356. Phila. 1849. 686 DISEASES AND INJURIES OF THE URETHRA. the system. In some instances, the first evidence of such an attempt, on the part of the fluid, is the appearance of a certain amount of tumefaction and discoloration, at first red, and then purple, of the gland of the penis; showing that the urine has obtained admission into the spongy structure of -this organ, and that it is sloAvly but surely extending its ravages. If the rupture occurs in that portion of the urethra which lies in front of the triangular ligament, between it and the bulb, the urine escapes into the cellular tissue of the perinseum, and proceeds forwards and upwards underneath the dartos into the scrotum, which it often pervades through its entire extent. In its progress it may travel along the subcutaneous cellular substance of the penis and the groins, over to the pubes, and sometimes even as high up as the um- bilicus. The passage of the fluid is commonly indicated by a reddish, erysipelatous blush, which, on the approach of mortification, is gene- rally replaced by a dark, livid, or black appearance of the skin. The swelling of the perinseum, scrotum, and penis, in fact, of all the parts here mentioned, is sometimes excessive. The reason why the urine does not, in this variety of rupture, extend backwards towards the neck of the bladder, round the anus, or downwards along the thighs, is the manner in which the triangular ligament and superfi- cial fascia are attached to each other and to the edges of the branches of the pubic and ischiatic bones. There are, however, notwithstand- ing this arrangement, cases in which it breaks through these barriers, and spreads backwards upon the nates and the ischio-rectal fossse ; and downwards along the inner surface of the thighs, perhaps to a distance of many inches. In the worst forms of this affection, not only the scrotum, but the skin of the penis, the groins, and the upper parts of the thighs fall into gangrene, and the testicles, thus completely denuded, are suspended merely by the spermatic cords and vessels. Urinary infiltration of the scrotum is liable to be confounded with ecchymosis of this organ, the more so, because both affections are frequently produced by the same accident, namely, a fall or blow upon the perinseum. A careful examination of the part, however, and an attentive consideration of the history of the case, will gene- rally enable us to distinguish between the two affections. In ecchy- mosis, the swelling and discoloration come on within a few minutes, or, at furthest, a few hours, after the occurrence of the injury, and are caused by an extravasation of blood from a rupture of some of INFILTRATION OF URINE. 687 the scrotal vessels. The patient is in great pain, and cannot void his urine, though he is compelled to make frequent efforts to do so; the parts are more or less distended by the effused fluid, and the skin is of a dark, livid, or purple colour. The pain in ecchymosis is usually milder than in urinary infiltration, the constitutional excite- ment is also less, and there is an absence of the peculiar erysipela- tous blush which generally precedes and accompanies the march of extravasated urine. The diagnosis is important to be clearly esta- blished, because the treatment of the two lesions is diametrically different. The prognosis of urethral infiltration is seldom flattering, though apparently the most desperate cases occasionally recover. Much will necessarily depend upon the nature and extent of the lesion which gives rise to it, the state of the system at the time of the in- jury, and the promptness and judgment with which the accident is managed in its earlier stages. If the urethra is extensively lacerated, so that little or no urine can pass off in that direction; if the patient is old or dilapidated at the time the mischief is inflicted, and if the extravasated fluid has become extensively diffused, little hope is to be entertained of a favourable issue. Death will be likely to happen in spite of all that can be done. The case is generally regarded as desperate when the urine is extravasated into the spongy body of the penis; an occurrence which is commonly preceded by severe pain and tenderness of the part, and a livid discoloration of the head of the organ. The treatment of this variety of infiltration must be prompt and energetic, otherwise serious mischief, if not loss of life, will be the result. The first thing, and in fact almost the only thing, to be done, in the early stage of the affection, is to make large and depen- dent incisions, to afford vent to the pent-up and irritating fluids. The parts must be cut freely, not sparingly, at different points, and to as great a depth as is consistent with the safety of the large vessels of the perinseum. The incisions should, of course, be made vertically, not obliquely, much less transversely. It is surprising to what an extent the affected parts may frequently be divided. Incisions that would shock an inexperienced or timid practitioner are borne with perfect impunity, and often heal with little deformity. In violent cases, mere scarification is worse than useless. The door must be freely opened, and the intruder must be forced out with a bold hand. As soon as the distended parts have been freely and thoroughly 688 DISEASES AND INJURIES OF THE URETHRA. divided, a gum-elastic catheter should be introduced into the bladder, and be alloAved to remain there during the cure. The urine is thus enabled to pass off as fast as it reaches the bladder, and is thereby prevented from doing further mischief. The gum-elastic catheter is preferable, in these cases, to a silver one, on account of its greater softness and pliancy, which enable it to accommodate itself more readily to the urethra, altered and distorted as it frequently is by the accompanying tumefaction. The introduction of an instrument of any kind is often attended with immense difficulty, and is some- times utterly impracticable. The best local applications, after the parts have been properly in- cised, are warm fomentations of acetate of lead and opium, hops, or poppy-heads. They should be frequently renewed, and their heat and moisture should be maintained by oiled silk and dry flannel. When the sloughing process has fairly begun, the fomentations may be advantageously superseded by emollient poultices, with the addi- tion of yeast, port wine, nitric acid, or chloride of soda, properly tem- pered with water. When the eschars are detached, the sore is to be managed upon general principles. Throughout the treatment, the scrotum and penis are to be supported with a suspensory ban- dage. Should the parts remain fistulous, an operation may be required for their relief, but not until they have become thoroughly cicatrized in the neighbourhood of the abnormal apertures. It is surprising, when there has been the most extensive sloughing, how rapidly, in some instances, nature succeeds in repairing the injury. The testicles, as was before stated, are sometimes entirely denuded, or, perhaps, merely suspended by the spermatic cords, and yet, con- trary to what might be supposed to happen in such cases, the breach is frequently closed in a very brief space with comparatively little deformity. CHAPTER IX. URINARY ABSCESS. Abscesses, to which the term urinary is usually applied, are liable to form in the cellular tissue round the urethra, leading, if impro- perly managed, to fistula and other mischief. The expression is a generic one, and is employed to designate any collection of pus, the exciting cause of which is an escape of urine from the urinary pas- sages into a part which is unaccustomed to its presence, and which, therefore, never fails to resent the intrusion. Thus, a urinary ab- scess sometimes forms deep in the pelvis, in the perinseum, or above the pubes, after puncture of the bladder, the operation of lithotomy, or injury of the bladder from a ball, a sabre, or a splinter of bone. As applied to the urethra, the term " urinary" is not sufficiently definite ; for it denotes merely one circumstance in the history of this lesion, namely, the nature of the exciting cause. The nomenclature might be improved by a substitution of the word "urethral," or, still better, by the term " sub-urethral," inasmuch as it would serve to point out at once, not only the character of the affection, but like- wise its situation. The ordinary site of urinary abscess is the perinseum, between the bulb of the urethra and the anus. A very common situation also is the upper part of the perinseum, just behind the junction of the caver- nous bodies of the penis, and, consequently, at the inferior portion of the scrotum. The next most frequent point is the scrotum itself, and, lastly, the under surface of the penis. Instances are observed, though they are rare, in which the abscess forms at the side of the anus, at the nates, near the tip of the coccyx, and at the upper and inner part of the thigh. It seldom happens that more than one such swellino- occurs at a time. There may, however, be as many as two or even three. The exciting causes of the lesion are various. The most common, 44 690 DISEASES AND INJURIES OF THE URETHRA. perhaps, is the existence of a tight organic stricture of the urethra, attended with attenuation and dilatation of the tube immediately posterior to it. A sort of pouch is thus formed, in Avhich the urine habitually lodges, and fretting and teasing the mucous membrane until it produces perforative ulceration. However minute the open- ing may be, a small quantity of fluid is sure to insinuate itself into the subjacent cellular substance, and to give rise to the lesion under consideration. Or, instead of this, the weakened and dilated part behind the seat of the obstruction may yield at one or more points during a violent effort at micturition, while the poor patient is, per- haps, straining with all his might to relieve the bladder of its accu- mulated load. A little crack or fissure, not larger, it may be, than a pin's head, may thus become a source of immense mischief and trouble. Or a rough, angular calculus may lodge in the urethra, and tear the mucous membrane, either as it is forced along by the pres- sure of the urine, or during an attempt at manual extrusion. Or a false route may be made with a bougie, sound, or catheter; or the urethra may be perforated by a sharp, narrow-pointed instrument, or it may be lacerated by a fall astride a chair, the bough of a tree, or an iron railing. The reason why false passages are not more fre- quently followed by infiltration and abscess, is doubtless because the urine does not find an easy entrance, on account of their direction from before backwards, which is the reverse of that of the natural channel. It is worthy of remark, that when the urethra is opened, to any considerable extent, by external violence, no matter how in- flicted, infiltration will be much more likely to result than abscess. It is only, in fact, when the aperture is exceedingly small, or where, if the reverse is the case, it is speedily glazed with lymph, that the one will be apt to be prevented and the other to form. An abscess of this description is sometimes produced in another way. Tetter, for example, is formed in the cellular tissue exteriorly to the urethra, and gradually extends inwards until it ultimately causes ulcerative absorption of the lining membrane, followed by an escape of the pus into the tube, and the ingress of a small quantity of urine into the cavity of the abscess. Thus an abscess that is ori- ginally simple may be converted into a urinary abscess. A boil, a carbuncle, or an erysipelas, commencing in the skin and subjacent cellular texture, may lead to the same effect. Abscesses exterior to the urethra are liable to form under a variety of circumstances, of URINARY ABSCESS. 691 which the most important are gonorrhoeal inflammation, stricture, and external injury. There are cases in which this variety of abscess forms without any obvious causes, or without apparently any previous or coexistent lesion of the urethra. This affection is very tardy in its progress, and seems to be occasionally connected with a scrofulous state of the constitution. In this respect it bears a striking resemblance to those abscesses which are sometimes developed around the anus, in phthi- sical subjects. Urethral abscesses are generally small and circumscribed, not dif- fused, as in urinary infiltration, properly so called; for in the one case the irritating fluid, under the influence of which they are de- veloped, is bounded, or walled in, by a deposit of plastic lymph, while in the other it is sent abroad into the connecting cellular tissue, and often spreads over an almost incredible extent of surface: de- priving lymph, skin, and other structures rapidly of their vitality. In this respect, a urinary abscess may be said to hold the same re- lation to urinary infiltration that a common boil does to a carbuncle. In the one, the swelling is small, and circumscribed, in the other, it is diffused, and the attendant deposit is cacoplastic, and, consequently, incapable of setting limits to the extravasated fluid. The first evidence of an abscess of this kind is usually a small, deep-seated tubercle, tender on pressure, hard, distinctly circum- scribed, and more or less movable. This gradually increases in bulk, and manifests a disposition to approach the surface, though, in gene- ral, six or eight days will elapse before it attains this point. The integument, previously free from discoloration, now assumes an ery- sipelatous blush, and often pits slightly on pressure; the pain and tension steadily augment; the structures around feel stiff and un- comfortable ; throbbing takes place; the urine is passed with un- usual difficulty, from mechanical compression of the urethra; and the patient is seized with shivering, alternating with flushes of heat. In this stage of the affection, the skin is hot and dry, the tongue is broAvn, the pulse is faltering, the thirst is intense, and there is ex- cessive restlessness with a tendency to delirium. In the worst form of the lesion, the scrotum is oedematous, the perinseum bulges out in the form of a large tumour, the parts round the anus are swollen and tender, defecation is painful, micturition is difficult, if not im- practicable, and the patient is unable to walk about, or even to sit, or stand. The contents of a urinary abscess are generally thin, 692 DISEASES AND INJURIES OF THE URETHRA. dark-coloured, acrid, and more or less foetid. The pus, which con- tains comparatively few globules, is usually intermixed with lymph, urine, and the de*bris of the affected part. There is a form of this affection, in which the symptoms are of a milder character, and which is almost entitled to the appellation of chronic. I have seen it more commonly in persons of a debilitated frame, with a tendency to tubercular disease of the lungs or other parts of the body. The swelling, in such cases, is remarkably tardy, and is seldom larger than a pigeon's egg, or a common marble. It is rarely attended, at least for the first week or ten days, by any pain, and there is but little discoloration of the skin. If left to itself, from twelve to eighteen days will elapse before it will break, and discharge its thick, and ill-elaborated contents. The diagnosis of this disease is not always so easy as might, at first sight, be supposed. Its character may be suspected when a tumour, small, hard, circumscribed, and almost indolent, forms deeply in the perinseum, or along the middle of the scrotum, in connexion with stricture of the urethra, chronic gonorrhoea, or disease of the neck of the bladder; when its progress is unusually tardy, when it gradually approaches the surface, and when the skin, previously to giving way, is of a red, erysipelatous aspect. In the acute variety of the lesion, in which the symptoms are of a bolder character, the local affection is generally accompanied, especially after the first five or six days, by excessive constitutional disturbance, a feeble, falter- ing pulse, rigors, restlessness, and typhomania. In the traumatic form, a strict inquiry into the history of the case, particularly as to the manner of its occurrence, with a careful examination of the part, will usually enable us to arrive at a correct conclusion. After all, however, the matter is not one of much moment, in a practical sense, for in all doubtful cases, attended with local swelling and difficulty of micturition, the treatment is the same. Whatever may be the size, situation, progress, or real character of an abscess of the urethra, it is always necessarily followed by a fis- tula, through which the urine is afterwards discharged, either partly, or wholly, much to the discomfort and inconvenience of the poor pa- tient. The disease, therefore, although seldom dangerous to life, is always to be dreaded on account of this circumstance, which is so much the more unfortunate, because it does not always admit of relief by treatment. The treatment of urinary abscess is sufficiently simple. The anti- URINARY ABSCESS. 693 phlogistic regimen, rest, recumbency, leeching, and fomentation, will limit the morbid action; and an early external incision will prevent the diffusion of the matter and the urine. If stricture be present, it is removed in the ordinary manner. When the sac has been emp- tied, and the accompanying inflammation has, in a great measure, disappeared, a catheter should be retained in the bladder, to prevent the escape of its contents by the abnormal orifices, the edges of which are to be touched, from time to time, with nitrate of silver, to promote cicatrization. If the parts around the aperture remain hard and callous, they should be pencilled, once a day, with tincture of iodine, or well rubbed Avith camphorated mercurial ointment, to stimulate the absorbents, and hasten the removal of effused fluids. CHAPTER X. FISTULE OF THE URETHRA. A fistule is an accidental track, narrow, straight, or tortuous, lined by an adventitious membrane, and communicating, on the one hand, with the urethra, and, on the other, with the cutaneous sur- face. To such a channel the term complete is usually applied, while the term incomplete is employed to designate that form of the affec- Fig. 105. tion in which there is only one orifice, whether internal or external. The latter distinction is absurd, and should be abandoned; for there fistule of the urethra. 695 is really no such disease as an incomplete fistule of the urethra, however true it may be of a fistule of the anus. The most common site of fistule is that portion of the tube which corresponds with the perinseum, and the scrotum; the disease some- times occurs further back, and occasionally it exists near the ante- rior orifice. A rare form of fistule sometimes supervenes upon the operation of lithotomy, the abnormal channel extending from the urethra to the rectum. The abnormal tracks vary much in extent. Those which occur in the spongy portion of the urethra are always very short, while those which implicate the membranous and bulbous parts are sometimes remarkably long and sinuous. Cases have been witnessed in which they have passed down the thigh backwards towards the anus, out- wards towards the nates, inwards towards the pelvis, or upwards into the groin and the hypogastric region. In its diameter, the acciden- tal passage may be so narrow as hardly to admit the finest bristle, or so capacious as to receive a large probe or a goose-quill. Every fistule of this kind has two openings, of which the internal one is usually single, however numerous may be the branches of the abnormal track, or however riddled the cutaneous surface. In some cases, two, three, and even four orifices exist in the urethra; but this is very rare, and always constitutes a serious impediment to a permanent cure. The internal opening is generally of an irregular shape, and varies in size between the smallest pin's head and the end of the little finger. The number of external openings varies in different cases. Gene- rally speaking, there is but one, or, at most, two or three. I have never seen more than five. Ledran1 met Avith an instance of thirty; and Civiale2 refers to one of fifty-two. When the number is con- siderable, the affected surface presents a riddled, sieve-like aspect. No regularity prevails in regard to the form and size of the external apertures. They may be circular, triangular, or ovoidal, or they may have the appearance of a slit, rent, or fissure; and in their dimensions they may be so small, on the one hand, as to be hardly visible, and so large, on the other, as to admit the end of a probe, a grooved director, or a goose-quill. The situation of the external orifice is usually indicated by the presence of a red, fleshy papilla, 1 Traite des Operations de Chirurgie, p. 368. 2 Traite sur les Maladies des Organes Genito-Urinaires, Premier partie, p. 393. 696 diseases and injuries of the urethra. which projects slightly beyond the level of the surrounding surface, and is constantly bathed Avith purulent matter, or pus and urine. Occasionally the opening has a sort of valve-like arrangement. The abnormal track may be straight or sinuous, single or multi- ple. If a probe be introduced into the external orifice, it may pass on towards the urethra in a direct line, and this is generally the case when the disease occupies the spongy portion of the urethra; on the other hand, the passage is frequently remarkably tortuous, especially if it be long, or situated in the perinseum or scrotum. In most cases, there is at first only one track, but as this is liable to obstruc- tion, fresh inflammation is excited, a new abscess forms, and in this way another channel is added to the previous one. Thus, the origi- nal track possesses a sort of multiplying power, which is often em- ployed to the great detriment both of the part and of the system. This abnormal channel is originally nothing but a sinus, or tubular ulcer, which becomes soon covered by granulations, and ultimately by an adventitious membrane. This membrane, formed from the plastic lymph of the blood, bears, when fully developed, a very close resemblance to the mucous tissue, but differs from it in not having any follicles. Its free surface is smooth and polished, or rough and slightly granulated; the other is firmly attached by short cellular substance to the parts which it serves to line. This new membrane is usually very thin, firm in its consistence, and of a white, drab, or gray colour; it is liberally supplied with vessels, nerves, and absorbents, is the seat of a constant secretion of muco- purulent matter, and is liable, like all new textures, to inflammation and its effects. In cases of long standing, it occasionally acquires a dense, fibrous character. The fluid furnished by the new passage is generally thin and gleety, as in chronic gonorrhoea, and mingled with the natural secretions or excretions of the urethra. When the lining membrane is inflamed, or irritated, it is sometimes entirely suspended, or of a bloody, sanious, purulent, or muco-purulent character. The quan- tity of urine flowing along it varies from a few drops to several ounces in the twenty-four hours; and cases are not wanting, espe- cially when the fistule is a consequence of impermeable stricture, in which all the water is discharged through it. The abnormal passage occasionally contains one or more calculous concretions, from the volume of a mustard-seed to that of a cherry or a hazel-nut. They are developed in the passage, or they are conveyed into it acciden- FISTULE OF THE URETHRA. 697 tally from the bladder or the prostate gland. The parts in the im- mediate vicinity of the fistule are variously affected. Sometimes they are almost natural, or the changes which they have undergone are so slight that it is difficult to detect them; most generally, how- ever, they are considerably swollen, very much indurated, chafed, excoriated, and exquisitely sensitive. If cut, they offer more or less resistance to the knife, and emit a peculiar grating noise. When the irritation has been very protracted, and the patient's health long deranged, they sometimes become the seat of carcinomatous degene- ration. It is not often that the periosteum and the bones suffer in this disease, since their deep situation is generally an effectual pro- tection against the contact of the urine. The immediate cause of this affection is a solution of continuity of the mucous membrane, produced by ulceration, abscess, gangrene, or laceration, and followed by an escape of urine into the connecting cellular tissue. Here, acting as a powerful irritant, the fluid speedily excites inflammation, which soon terminates in suppuration, or, it may be, in the death of the affected parts. When the matter is evacuated, or the slough detached, the urine, being no longer pent up, issues at the accidental opening, •which now constitutes, in the legitimate sense of the term, a fistule. It is an error to suppose that the solution of continuity, leading to the establishment of this lesion, always begins in ulceration of the lining membrane; I am aware that this opinion is held by Sir Benjamin Brodie, an autho- rity of the highest respectability; but I am sure that it is not borne out by the facts of the case, while it is equally certain that it is con- trary to the experience of some of the most able pathologists of the present day. If the process which precedes the formation of the fistule be carefully watched, it will be found, in many cases, that it begins in the cellular tissue exterior to the urethra, in the form of a hard, circumscribed swelling, seated, perhaps, deeply in the peri- nseum, and gradually tending to suppuration, or the formation of an abscess. If the case be promptly met by a free incision, the proper treatment under such circumstances, the mucous membrane escapes unharmed, and the cavity of the abscess is gradually filled up by the joint agency of the granulating process and the contraction and approximation of its sides. In a word, no fistule takes place. If, on the other hand, the abscess is neglected, or, what is the same thing, suffered to proceed, its contents, bound down by the perinseal aponeurosis, and consequently unable to find an external outlet, will 698 DISEASES AND INJURIES OF THE URETHRA. gradually but surely extend towards the urethra, the lining mem- brane of which it ultimately perforates. As soon as the matter has passed off, the urine is admitted into the cavity of the abscess, where it excites additional irritation, leading, perhaps, to the formation of a new abscess, and ulceration of the skin. The efficient causes of urethral fistule are various. The most fre- quent, undoubtedly, is stricture, attended with dilatation of the tube behind the seat of the obstruction; but it may also originate from ill-managed attempts to pass instruments, or from the protracted sojourn of catheters and bougies, from gonorrhoea, retention of urine, external violence, and from the operation of lithotomy. I have several times seen the urethra become fistulous in consequence of chancre, situated either within the tube, and extending outwards, or commencing on the surface of the penis, and proceeding inwardly. Occasionally the disease originates in obstruction of the tube by a urinary calculus. The mucous membrane behind the obstacle is gradually dilated and attenuated, and finally takes on ulceration, which, advancing to the deeper structures, leads to an escape of urine, and the formation of an abscess. The opening left by the evacuation of the matter remains fistulous, and affords vent to the urine. The same train of phenomena takes place in stricture. The mucous membrane posterior to the obstruction, being constantly fretted and irritated by the presence of the urine, ultimately gives way, and the disease in question is the speedy consequence. A person affected with urethral fistule is to be regarded as an object of the deepest sympathy and commiseration. Although he may be able to retain his urine for a considerable interval, or, per- haps, even the usual period, yet whenever he attempts to void it a certain quantity always escapes at the abnormal channel, wetting his clothes, and irritating the skin of the perinseum, the scrotum, and the thighs. When the opening is situated far back, there may be an incessant dribbling, and, in such a case, no care can secure his comfort, or protect him from the offensive smell which exhales from him wherever he goes. The parts in the immediate vicinity of the fistule are constantly sore, swollen, excoriated, and subject to new attacks of inflammation, which are often followed by new abscesses and new tracks. In the more severe forms of the complaint, the patient finds it difficult, if not impossible, to move about, or take his accustomed exercise; the bladder becomes irritable, and intolerant of its contents ; the calls to micturition increase in frequency ; the FISTULE OF THE URETHRA. 699 urine is loaded with mucus, and exhales a disagreeable, ammoniacal odour; the general health declines; the appetite fails; the body wastes; and the poor sufferer, abandoned to despair and wretched- ness, hails death as a welcome messenger. The diagnosis of this disease is usually easy. An opening exists in some portion or other of the urethra, and this opening transmits a urinous fluid, either in drops, in jets, or in a continuous stream, synchronous with the act of micturition. The quantity of fluid evacuated by the natural route varies with the character and degree of the obstruction upon which the fistule usually depends. In some instances nearly the whole passes off by the accidental passage; in others, only a few drops or teaspoonfuls. When the track is situated in the membranous or prostatic portion of the tube, the urine may dribble away constantly; but this is rare. A probe, of small size, introduced into the external orifice, readily enters the urethra, pro- vided the abnormal passage is not very narrow, oblique, angular, or sinuous. When this is the case, it may be difficult, if not impos- sible, to effect the object, however adroitly or perseveringly we may conduct the operation. Where there is any doubt upon the subject, the surgeon should recall the history of the case, or the circum- stances which preceded and accompanied the formation of the fistule, explore carefully the course of the urethra, both internally and ex- ternally, and observe whether the discharge of urine at the outer opening is synchronous with that of the natural channel. In regard to their prognosis, it may be observed that urethral fis- tules are, in general, a source of inconvenience rather than of danger. When the disease is of an aggravated character, and is complicated with an intractable stricture, life may gradually be destroyed by constitutional irritation, or by local suffering from disease of the bladder, the prostate gland, or the kidneys. In simple fistule no such result is to be apprehended. The case, if well managed, is productive of little trouble, and is readily relieved by treatment. When the affection is accompanied by great loss of substance, or when it involves the posterior and more deeply seated portions of the tube, it may be incurable, and render the patient miserable for life. A fistule of the urethra has sometimes been followed by impotence, not from a want of erection or ability to copulate, but on account of the escape of the greater part of the spermatic fluid by the accidental route. Treatment.—The treatment of this affection, although obvious 700 DISEASES AND INJURIES OF THE URETHRA. enough, is not always easy. The first thing that is to be done is to seek for, and, if possible, to remove, the exciting cause. In most cases this will be found to be a stricture, probably of long standing, more or less tight, and semicartilaginous, attended with inflammation, perhaps even ulceration, of the mucous membrane, and dilatation of the tube behind the seat of the obstruction. Having already, in a previous chapter, spoken at length of the character and treatment of this affection, it is not necessary to refer to the subject here any farther than to observe, that, when the disease upon which the fistule depends is removed, the abnormal track ordinarily closes of its own accord, and the urine gradually resumes its accustomed route. In all cases, it is a matter of great moment, as I conceive, as soon as circumstances will admit of it, to retain a catheter permanently in the bladder, in order that the urine may flow off, from time to time, without coming in contact with the internal opening of the fistule. Although this is the more necessary when the fistule is deep-seated, and affords a constant drainage, I prefer it, as a general rule, to the frequent introduction and withdrawal of the instrument, which are always attended with the risk of injuring the affected part, and in- volve an amount of attendance which few practitioners can bestow. It is to be understood, of course, that the permanent retention of the catheter is not to be persisted in when it becomes a source of decided suffering, either as it respects the urethra, the bladder, or the pro- state gland; nor is the treatment to be thought of when it does not fulfil the intention for which it is employed. If the urine flow by the side of the instrument, betAveen it and the urethra, no benefit can result from its presence, and the sooner it is removed the better. The instrument, to answer the purpose, should be rather over than under the usual size; it should distend the urethra gently, not forci- bly, and it should be provided with large eyelets, to prevent it from becoming clogged with mucus. It should, moreover, be composed of silver, a substance far preferable to gum-elastic, which is easily soft- ened and roughened by the urine, and requires to be frequently replaced in consequence. If the catheter is too large, it will be apt to dilate the internal orifice of the fistule, and prevent the approxi- mation and reunion of its edges. If, on the contrary, it is too small, it will not only not answer the object for which it is employed, but become a source of irritation both to the urethra and the abnormal track, from its constant contact with the urine. Conducted upon the principles now mentioned, this mode of treat- FISTULE OF THE URETHRA. 701 ment rarely fails in the more mild and uncomplicated forms of the malady. When the natural route for the urine is re-established, the fistule gradually contracts, the indurated parts regain their normal consistence, and the external orifice is ultimately obliterated. The cure may often be greatly expedited by a strict observance of the antiphlogistic regimen, and by the application of leeches, blisters, and astringent lotions to the affected parts. When there is much induration, the most appropriate topical remedies are tincture of iodine, and camphorated mercurial ointment. Obstinate sinuses must be laid open with the knife. It sometimes happens, after all obstruction in the urethra has been removed, that the fistule manifests no disposition to heal, but remains pervious to the urine. Several causes may give rise to this occur- rence. In the first place, it may be owing to the presence of a cal- careous concretion, which, as was previously stated, sometimes forms in a passage of this kind, and prevents it from closing up. The proper remedy, of course, in such a case, is to remove the foreign body, for as long as it remains no progress towards a cure can be expected. The extraction may be effected either with the forceps alone, as Avhere the passage is very spacious; or with the forceps and knife where it is narrow, or small and sinuous. Secondly, the indisposition to unite may depend upon the presence of an abnormal pouch, or upon an unusually large internal orifice. In either case, the proper remedy is a free incision, so as to enable the parts to heal from the bottom. Thirdly, the occurrence may be owing to the peculiar nature of the lining membrane of the accidental track, which may be of a firm, almost semicartilaginous consistence, and be constantly bathed, on its free surface, with a thin, glairy mucus, preventing the opposite sides from adhering. When this is the case, the object should be to destroy the secreting surface, and to promote the granulating process, by means of stimulants or escharotics. One of the best remedies for accomplishing this end is the nitrate of silver, which may be used either in substance, as when the fistule is very shallow, or in the form of a tolerably strong solution, carefully introduced with a small ivory syringe, or a common probe. Forty grains of the salt to the ounce of water is the proportion which I usually employ, and I seldom repeat the application oftener than once every forty- eight hours. Sometimes I have used with advantage a piece of sul- phate of copper, cut to a delicate point, and retained for ten or twelve seconds in the abnormal passage. In obstinate cases, recourse may 702 DISEASES AND INJURIES OF THE URETHRA. be had to the occasional introduction of a heated wire, or to a probe dipped in nitric acid, a concentrated solution of lunar caustic, or the acid nitrate of mercury. Too much caution, however, cannot be observed in the use of these and similar remedies, which are well calculated, if applied too freely, to cause severe inflammation and even sloughing. The object, in all cases, should simply be to destroy the lining membrane, without involving any of the surrounding tissues. Any tendency to premature closure of the external orifice is prevented by touching its margins, every feAV days, with caustic potash, or some other escharotic substance. When the fistule is obstinate and protracted; when its internal orifice is uncommonly large, or where there are several openings of this kind; or, finally, when it depends upon an old stricture, so firm, narrow, and extensive that it cannot be destroyed in the ordinary manner, the only course left is to lay the parts open by an external incision,—a procedure which often remarkably expedites the cure of both affections. The patient is placed as in the operation of litho- tomy. A grooved director is carried down to the stricture, and held there by an assistant, while the surgeon introduces a probe into the fistulous track, just behind the obstruction, and then divides the in- tervening structure with a knife. A silver catheter, of suitable size, is next conveyed into the bladder, and retained there until the wound is nearly healed; care being taken to withdraw it occasionally for the purpose of cleanliness. When the cicatrization is completed, the usual means are employed to prevent a recurrence of the con- traction. When the fistule involves the spongy portion of the urethra, and has been caused by chancre, or external injury, attended Avith loss of substance, it may be necessary to have recourse to suture, as the more ordinary means not unfrequently fail, in consequence of the difficulty with which the accidental opening cicatrizes in this situa- tion. The suture usually employed is the twisted, made with very short, slender needles, placed not more than a line and a half apart. A middle-sized catheter having been previously introduced into the bladder, the edges of the opening are carefully pared, as in hare- lip, and then nicely approximated, the ends of the ligatures being passed from one needle to the other, the points of which are next broken off with the forceps. Instead of this suture, some sur- geons recommend the interrupted, which, however, does not possess any advantages. Dieffenbach suggested the plan of running the FISTULE OF THE URETHRA. 703 suture round the fistulous orifice, after the fashion of a purse-string. When the thread is tightened it draws the skin into puckers, and approximates the edges of the aperture so completely as to enable them occasionally to unite by the first intention. Several cases in which this treatment has been successfully employed have been published by Dieffenbach and other surgeons. The principal objection against the employment of the suture, in any form, for the relief of this affection, is its liability to tear itself out before the completion of the adhesive process, in consequence of the morbid erections which are so apt to take place after the opera- tion. It is this occurrence which so frequently mars the result of our efforts, and renders it necessary to repeat them. To guard against these erections, which often become troublesome within the first few hours after the operation, recourse should be had to ano- dyne enemata, or suppositories of opium and camphor, and to the application of pounded ice to the perinseum and hypogastrium. It has been proposed, as a kind of dernier resort, in obstinate and intractable fistule, in which the ordinary methods have failed, to divert the urine from the accidental channel into an artificial one, so that none may come in contact with the raw edges before they are firmly united. The operation has been sanctioned by high authority, and has been employed successfully in several instances. In a case treated by Ricord, with whom the suggestion originated, the opening was situated anterior to the scrotum, in the spongy portion of the urethra; in which, from the great thinness and mobility of the tissues, the disease is often extremely difficult to heal. He made an incision into the membranous portion of the tube, and kept it open for the passage of the whole of the urine until the accidental track was completely united, when it was permitted to close. The patient had been previously subjected to various methods without the slightest benefit. Excision has sometimes been practised with advantage. When the parts in which the stricture is situated are unusually callous and circumscribed, an elliptical portion, embracing the external orifice, is cut out, and the raw surfaces are approximated by suture over a silver catheter, previously introduced into the bladder. When the abnormal track is attended with considerable loss of substance, urethroplasty may become necessary. This term is em- ployed to designate a process which has for its object the restoration, by the transplantation of a piece of healthy integument, of a part 704 DISEASES AND INJURIES OF THE URETHRA. of the urethra that has been lost, either partially or wholly, by acci- dent or disease. The operation, which requires no little skill for its successful issue, is chiefly applicable to fistules opening into the spongy portion of the tube. Different modes of urethroplasty have been devised, each of which possesses, perhaps, certain advantages in particular cases; none of them, however, are very certain in their results, and hence it is a good rule never to resort to them as long as there is any prospect of affording relief by other means. One of the most simple of these processes is that of Dieffenbach, which consists in paring the raw edges of the opening over a cathe- ter, previously introduced into the bladder, so as to form a crescentic cleft, the long diameter of which corresponds with that of the penis. A longitudinal incision is then made on each side of the cleft, when the intervening integuments are raised in two bridge-like flaps, and united closely at the middle line by numerous points of the inter- rupted suture. The catheter remains in the parts until the adhe- sion is completed, which will be about the fourth or fifth day. When the fistule is situated on that part of the urethra which cor- responds with the head of the penis, a closure may sometimes be effected by inverting a piece of the prepuce, and fastening it by means of the twisted suture. A case in which the operation was entirely successful is mentioned by Mr. Costello, of London, in the Cyclopaedia of Practical Surgery. Alliot, a French surgeon, anxious to avoid the inconveniences which frequently result from the passage of the urine between the catheter and the parietes of the urethra, has proposed to convert the orifice of the fistule into a simple ulcer, by elevating the integument on one side of the accidental channel, drawing it across the aperture, and fastening it securely by the twisted suture to the corresponding edge, previously rendered raw. This ingenious process seems to have been completely successful in the hands of its inventor. The Indian method, as it is called, is performed by closing the gap by borrowing the integuments from the neighbouring parts, as the scrotum, the perinseum, or the thigh. The callous edges of the opening are previously pared so as to produce a new surface, when a portion of sound skin is dissected off, except at one point, and in- serted into the wound, to which it is accurately fitted, and then secured by suture; the whole being supported by a compress and bandage. CHAPTER XI. FALSE PASSAGES. A false passage is an artificial canal, communicating with the urethra, and generally produced by the injudicious use of a bougie or a catheter. All portions of the tube are subject to it, but it is most frequent in the membranous and prostatic, owing to the in- equality of their surface, and their fixed position beneath the pubic symphysis. A false passage sometimes occurs at the sinus of the bulb from the point of a catheter being arrested in it; and for the same reason it occasionally commences in one of the numerous folli- cles of the lining membrane. The accident, however, is generally produced in consequence of the existence of a stricture, in attempt- ing to force which the instrument leaves the natural channel, in front of the obstruction, and makes a new one. In cases of chronic enlargement of the prostate, the substance of this gland is occa- sionally perforated, to afford an exit to the urine. False passages are much more easily made than is generally be- lieved, and it is only surprising, when we reflect upon the want of anatomical knowledge and dexterity in the use of instruments, that they are so seldom met with. When the mucous membrane is soft- ened, or chronically inflamed, as it frequently is in firm, semi-car- tilaginous strictures, it often yields under the slightest pressure, and hence it is not unlikely that the accident occasionally occurs when it is not in the least suspected. The artificial route is commonly situated at the inferior surface of the tube, chiefly because when an instrument is attempted to be intro- duced into the bladder, its point is almost always pressed in this direction, Avhich also presents the greatest number of natural obsta- cles to its easy passage. Sometimes the perforation occurs at the sides of the urethra, and occasionally also, but rarely, at its supe- rior surface. 45 706 diseases and injuries of the urethra. It is rare to find more than one such channel. Tavo, however, are occasionally met with; and Civiale mentions an instance in Avhich there were three, one above, another below, and the third on the right side. In Fig. 106, taken from a specimen in the Pathological Fig. 106. Museum of the New York Hospital, the number was still greater. When several such passages coexist, they sometimes communicate with each other. The length of the artificial route varies from a few lines to several inches. Sir Charles Bell relates an instance where it was four inches ; it ran parallel with the natural channel, between it and the rectum, and had been made by a catheter, which had pierced the mucous membrane in front of a hard, gristly stricture. A similar case fell under my own observation in 1847, in a coloured man, between thirty and forty years of age, a servant of Mr. Thornton Thompson, in the neighbourhood of Louisville. He had been affected with stricture for many years, and finally died of abscess of the left kidney. Upon dissection, in which I was assisted by my former pupils, Dr. Boze- FALSE PASSAGES. 707 man of Alabama, and Dr. Summers of Virginia, I found a tight, semi-cartilaginous stricture, just behind the head of the penis, from the anterior part of Avhich a false passage ran along the inferior sur- face of the tube nearly three inches and a half in length. The pre- paration is in my private collection. Generally speaking, however, these false routes are comparatively short, not exceeding, perhaps, ten, fifteen, or twenty lines. False passages occur under different varieties of form, of which the folloAving are the principal. 1. The most simple, and generally also the least dangerous form, is where it presents itself as a cul-de- sac, or blind pouch, running parallel with the urethra, from which it is often separated merely by the mucous membrane; it varies in length from a feAV lines to several inches, and may occur in any por- tion of the tube, though it is most frequent at its posterior part. 2. In a second variety, the false route, after having travelled a cer- tain distance, communicates again with the urethra, which is thus perforated at two distinct points. The abnormal channel, in time, becomes lined by an adventitious membrane, and often performs the functions of the original one. 3. The passage communicates with the bladder. This variety, Avhich is by no means infrequent, is usually the result of an attempt to force a stricture of the mem- branous portion of the urethra ; in Avhich the point of the instrument passes out of the natural channel into the cellular tissue between the rectum and the bladder, and thence on into the latter organ. In some instances, the catheter perforates the substance of the prostate, runs round its side, or proceeds along its upper surface. Whatever course the instrument may take to reach the bladder, the occurrence is always one of great danger, from its liability to be followed by infiltration of urine, and the whole train of evils which such an acci- dent is capable of inducing. 4. In a fourth variety, the passage communicates with the rectum. That such an occurrence should occasionally happen, in the hands of an ignorant or unskilful prac- titioner, is not difficult to imagine when we reflect upon the little force it requires to lacerate the urethra, the yielding nature of the cellular tissue between the bowel and the bladder, and the close prox- imity of these two reserA'oirs to each other. Much as the accident is to be deprecated, it is a remarkable fact that it is rarely followed by any- thing serious ; the track neither admits urine nur foecal matter, and, in fact, usually closes in a feAV hours. 5. Authors mention a fifth case, in which the abnormal route opens both into the rectum and 708 DISEASES AND INJURIES OF THE URETHRA. the bladder. To produce this result it is necessary that the vulne- rating body should, in its onward passage, pierce the boAvel twice, entering it at one point, and emerging at another to reach the latter viscus. An occurrence like this, of which a remarkable example is related by Deschamps, might be folloAved by severe inflammation, and, possibly, also, by a recto-vesical fistula. 6. And finally, an in- stance is upon record Avhere the false route extended from the urethra to the ischium. A false passage, in its recent state, is merely a laceration of the mucous membrane and the neighbouring tissues, which either heals within a short time after it has been made, or it continues open, and becomes lined by an adventitious membrane, differing in no material respect, except in the absence of mucous follicles, from the natural structure. In time, the new channel sometimes usurps the place of the original, Avhich, as it has no longer any functions to perform, gradually diminishes in size, and is occasionally, especially in pro- tracted cases, nearly obliterated. The immediate cause of this lesion, as was previously intimated, is undue force, or misdirected pressure, exerted in the act of dilating a stricture, cauterizing the urethra, drawing off the urine, or sound- ing the bladder. An instrument of some kind or other is indispen- sable to its production ; and hence it is almost needless to add how important it is for the surgeon to be upon his guard whenever he attempts any operation, however simple, upon the canal under con- sideration. To avoid the formation of a false passage, he should not only be acquainted Avith the urethra in its healthy and diseased states, but he should have a most thorough knowledge of the nature and uses of the various instruments which are designed to traverse it, whether for its own benefit or for the relief of the prostate gland, the bladder, and the seminal vesicles. The predisposing causes of this lesion may be arranged under two heads, the natural and the accidental. A brief enumeration of these circumstances will not be without its benefit, for it will serve as a beacon to warn us of the danger of the heedless and injudicious use of instruments in the treatment of urinary affections. The natural causes are the mucous lacunae, the sinus of the bulb, the margins of the triangular ligament, the sinus pocularis, and the anterior border of the prostate gland; and, it is worthy of remark, that these obstacles to the easy introduction of the catheter nearly all exist along the inferior surface of the canal. Hence, to avoid them, FALSE PASSAGES. 709 the instrument should be gently pressed against the upper part of the urethra, by which its beak will be made to glide past these obstacles without any danger of being intercepted by them. Care should be taken also that the extremity of the instrument be not too pointed, as this will render it more liable to become entangled in the folds of the lining membrane or in the mouths of the mucous follicles. The accidental causes, predisposing to the formation of false pas- sages, are, first, an inflamed, softened, or ulcerated state of the mucous membrane; secondly, a preternatural development of the lacunse or mucous follicles; thirdly, the existence of a tight, narrow, semi-car- tilaginous stricture; fourthly, a deviation of the urethra from its natural direction ; and fifthly, the nature and form of the instrument used in our operations. It does not require much foresight to perceive that the mucous tissue of the urethra, when in a state of disease, will be much more likely to give way, under the pressure of a bougie or catheter, than when it is perfectly healthy. The existence, therefore, of ulceration or softening of the lining membrane of this canal may be justly re- garded as a predisposing cause to the formation of a false passage. The same is true of an unnaturally large follicle, and of a firm stric- ture. The situation of a stricture also exerts an important influence upon the production of this lesion. The deeper it is situated the less manageable is it generally found to be, and the more likely, there- fore, will be the instrument, employed to dilate or cure it, to tear the urethra. A deviation of this tube from its natural direction is by no means rare; I have seen several remarkable examples of it, and ha\re never knoAvn one Avhich did not seriously embarrass me in my efforts to introduce an instrument into the bladder. Much also depends upon the form and character of the instrument used in our operations. A flexible catheter or bougie is less likely to produce mischief than a metallic one ; a blunt, than a conical one ; a curved, than a straight one. Finally, a great deal depends upon the character of the surgeon; whether he is skilful or ignorant, pa- tient or hasty, gentle or rough. The effects of a false passage vary according to circumstances. AVhen it consists of a mere cul-de-sac, little or no harm generally results. The slight inflammation which succeeds its formation usually subsides in a feAV days, and is just sufficient, in most cases, to cause adhesion of the opposite sides of the artificial channel. The reason Avhy the accident so frequently occurs, even far back in the tube, 710 DISEASES AND INJURIES OF THE URETHRA. without being followed by extravasation of urine, is that the fluid does not find an easy entrance, on account of the valve-like opening in the mucous membrane, and the oblique direction of the passage from before backwards, Avhich is the reverse of the natural stream. When the route exists in the vicinity of the bladder, or when it com- municates with this reservoir, the danger may be very great, for it may then give rise to infiltration, abscess, and even gangrene. When it extends into the rectum, or the rectum and bladder, a fistule may follow. The formation of false passages is seldom indicated by any reliable symptoms, and the consequence is that it often occurs Avithout being suspected either by the patient or the surgeon. This is the less to be regretted, because, in a great majority of cases, the lesion neither requires nor admits of any remedy. The most constant evidences are, hemorrhage, pain, and a feeling of laceration; but, if these be examined in detail, it will be found, as has been just intimated, that they are of no value whatever as diagnostics. More or less bleeding, for example, may folloAV any operation upon the urethra, however gently or skilfully conducted. This is true of this tube both in its healthy and diseased states. Every surgeon of experience has seen cases in which the slightest touch with a bougie or catheter has been followed by a tolerably smart hemorrhage. No just inference can be deduced from the nature and amount of the pain consequent upon such an injury, for the greatest possible diversity prevails, in this respect, in different individuals, depending upon the natural or mor- bid sensibility of the tube, the state of the system, and the extent of the laceration. It has been said, that, in a false passage, it is'of a stinging, pricking character; but this is not ahvays true, on the one hand, and on the other, it is equally certain that the same kind of suffering frequently attends the dilatation of a stricture. Finally, the tearing sensation, complained of by the patient, is altogether deceptive; for it is often experienced when no laceration has taken place. On the whole, then, no confidence whatever can be placed in any of the symptoms furnished by the patient. Hoav, then, is the existence of the lesion to be determined ? Is any reliance to be put in the observation of the surgeon ? The only circumstances Avorthy of notice, as far as he is concerned, are, first, a peculiar grating sen- sation communicated to his hand, while engaged in operating upon the urethra; secondly, a sudden slipping of the instrument from its position, or a feeling as if something had given Avay; and thirdly, a FALSE PASSAGES. 711 deviation of the instrument from the normal direction of the canal. Although these accidents do not positively indicate the formation of the lesion in question, yet Avhen they occur the surgeon should at once desist, and finish his operation at some future period. The treatment of false passages must be conducted upon general principles. Hemorrhage must be arrested, pain allayed, and further irritation, by the use of instruments, prevented. Rest in the recum- bent posture, light diet, purgatives, antimonials, leeches, fomenta- tions, and the warm hip-bath will, in general, put a speedy stop to the local inflammation. The false route, if complete, and consequent upon the presence of an impermeable stricture, will become gradually lined by an adventitious membrane, and in a short time take the place, and perform the office, of the obliterated part of the urethra. Should retention of urine occur, and resist the ordinary remedies, relief must be attempted, either by breaking down the original obstacle, if this be deemed advisable or practicable, or by puncturing the bladder. If the symptoms indicate the existence of urinous infiltration, early and free incisions must be made, followed by anodyne fomentations, and the usual internal means. CHAPTER XII. LESIONS OF THE GALLINAGINOUS CREST. The gallinaginous crest, or, as it is often denominated, the veru- montanum, is liable, from its situation at the floor of the prostatic portion of the urethra, and from its intimate relation to the orifices of the ejaculatory and prostatic ducts, to inflammation and its con- sequences. The lesions of this body were first described, though in a brief and unsatisfactory manner, by Sir Everard Home, in his Treatise on the Diseases of the Prostate Gland. Since that period they have been noticed by other observers, and they have recently been made the subject of a short chapter in the excellent work on the urinary organs by Dr. Civiale, of Paris. Whether the lesions of the gallinaginous crest ever exist as independent affections, or whether they always occur in association with disease of the neighbouring structures, is not clearly ascertained. The question is one of difficult solution, and can be determined only by dissection, which, unfortunately, the practitioner seldom has an opportunity of performing. Acute inflammation of the gallinaginous crest is most commonly induced by an extension of gonorrhoeal inflammation, by stricture of the urethra, by disease of the ejaculatory ducts, and by the presence of prostatic calculi. It may also be excited, there is reason to believe, by rough horseback exercise, by inordinate sexual indul- gence, and by the injudicious employment of instruments. Stimulat- ing diuretics, such as cantharides and spirits of turpentine, may also give rise to it. The crest, when thus affected, is of a florid appear- ance, of a soft, spongy consistence, and slightly increased in volume, in consequence of interstitial deposits. Lymph is sometimes effused upon its surface, either in the form of minute points, or as a distinct layer. There are no signs by which, in the present stage of the science, it is possible to distinguish this affection from disease of the adjacent LESIONS OF THE GALLINAGINOUS CREST. 713 parts. The spasm, pain, and frequent desire to urinate, together with the increased secretion of mucus which accompany it, also attend inflammation of the prostate gland and the neck of the blad- der, and are, therefore, valueless as diagnostics. The circumstance is, fortunately, of little moment in a practical point of view, inas- much as the treatment is essentially the same, in whichever of these structures the malady is located. Under the influence of antiphlo- gistics, vigorously plied, the lesion rapidly subsides, and the part gradually recovers its original character. Neither ulceration nor gangrene is likely to occur, unless the inflammation has been in- duced by external violence, attended with extensive laceration of its tissues. The gallinaginous crest is liable to hypertrophy, or chronic en- largement ; the result, doubtless, of inflammation and interstitial deposits. In stricture of the urethra and hypertrophy of the pro- state, I have repeatedly seen it from three to four times the normal volume, at the same time that it was considerably indurated, and changed in its configuration. Occasionally it deviates a good deal to one side. The size which this body sometimes attains is almost incredible. Thus, in an instance recorded by De Ble*gny, it formed a projection as big as a small walnut. The seminal fluid was of a thick, vitiated quality, and the ejaculatory canals were choked up with small, hard, spherical concretions, as large as peas. The pa- tient, a Avidower, sixty years of age, and the father of several chil- dren, contracted a second marriage, but he never could produce an emission, although he had perfect erections. In an old man who died of retention of urine at the Hotel Dieu in Paris, the verumon- tanum was as large as a big walnut. The hypertrophy was asso- ciated with profound disease of some of the other portions of the urinary passages, and it Avas, therefore, impossible to ascertain the amount of influence it exercised during the patient's life.1 When the verumontanum is much enlarged, it is generally of a pale, mottled complexion, more or less deformed, and considerably augmented in its consistence. Its mucous membrane is thickened, villous, and traversed by large vessels; Avhile its proper substance is of a Avhitish, or grayish aspect, intersected by fibrinous bands, and so firm as almost to grate under the knife. Hypertrophy of this body, existing in any considerable degree, 1 Civiale, Traite" Pratique des Maladies des Organes Genito-Urinaires, deux. ed. partie 2de, p. 234. 714 DISEASES AND INJURIES OF THE URETHRA. must necessarily obstruct the flow of urine, and interfere with the introduction of the catheter. In this respect, in fact, its effects must be similar to those produced by hypertrophy of the prostate, especially of its middle lobe. From its intimate relations with the ejaculatory ducts, it must also impede, if not wholly prevent, the discharge of semen, and may thus become a cause of impotence. This was evidently the case in the individual whose history has been narrated by De Blegny, and Avhich is alluded to in a previous para- graph. Sir Everard Home met with an instance in which the orifices of the ejaculatory ducts were covered over by a false mem- brane. Hypertrophy of the urethral crest has no symptoms of its own, and hence the utmost uncertainty must always exist with regard to its diagnosis. The phenomena which attend it must be such, in the great majority of instances, as indicate obstruction to the flow of urine, and the passage of instruments, accompanied, in all proba- bility, by an increased discharge of glairy, viscid mucus. A careful exploration Avith the metallic catheter, aided by the finger in the rectum, may throw some light upon the case, by pointing out the precise seat of the enlarged body; but, in general, even this fails, and the practitioner is, therefore, obliged to abandon himself wholly to conjecture. This being the case, it is obvious that the treatment of the affection must be conducted according to the common rules of surgery ; or, more properly speaking, upon the same principles as chronic disease of the prostate gland, the neck of the bladder, and the posterior portion of the urethra. CHAPTER XIII. INFLAMMATION AND ABSCESS OF COWPER'S GLANDS. In connexion with the lesions of the gallinaginous crest, we may here briefly notice the diseases of Cowper's glands, so far at least as they are at present known. These two bodies, which are situated between the two lamellse of the triangular ligament, and Avhich, in their normal state, are hardly as large as a common pea, are subject to inflammation and its consequences. They are also liable to atro- phy and hypertrophy: and instances occur in which one of them is absent, or where one is unusually small, while the other is of the natural size, or disproportionably large. Their consistence is some- times so much increased as to lead to a belief, probably not very well founded, that they are subject to the scirrhous degeneration. When they are much indurated, the glands are of a Avhitish colour, rough on the surface, and remarkably granulated in their texture. I am not aAvare that these little bodies are ever the seat of tubercular deposits, and yet there is no reason why they should be exempt from it. It is probable, judging from their structure and their proxi- mity to the urethra, that the diseases of these glands are not only more frequent, but also more complicated in their character, than is generally supposed; but as they are seldom, from their isolated posi- tion, the subject of examination, their affections are generally over- looked. Inflammation of these glands is most apt to arise during the pro- gress of gonorrhoea, from an extension of the irritation of the urethra along their excretory ducts. It may, however, be produced by other causes, as a bloAv or fall upon the perinseum, urinous infiltration, or disease of the prostate gland and neck of the bladder. The proba- bility also is that they sometimes suffer in stricture of the urethra. Be this as it may, the disease either comes on insidiously, or it is characterized by bold and open symptoms, such as pain and tender- 716 DISEASES AND INJURIES OF THE URETHRA. ness in the perinseum, heat or scalding in the urethra, and a frequent desire to urinate, with more or less fever. The distress, both local and general, is aggravated if matter forms; the swelling increases ; there is difficult micturition, on account of the distension of the sur- rounding parts; the skin of the perinseum becomes discoloured ; fluctuation is perceived; and, finally, the abscess breaks and dis- charges its contents. In general, however, a number of days must elapse before this can happen, owing to the deep situation of the matter and the manner in which it is bound down by the perinseal fascia and the anterior lamella of the triangular ligament. Nor does it always, if, indeed, generally, manifest a tendency to eva- cuate itself externally; on the contrary, there is reason to believe, from what has been just stated in relation to its situation, that it is more frequently discharged into the urethra. The diagnosis of this disease must necessarily be unsatisfactory; for there is hardly any surgeon whose sense of discrimination is so acute as to enable him to distinguish between it and abscess of the surrounding structures. The treatment must, therefore, be con- ducted upon general principles, being directed, in the first instance, to the mitigation of the inflammatory symptoms, and afterwards, if suppuration occur, to the evacuation of the matter. When there is great local distress, accompanied by a sense of tension and throb- bing, with a livid state of the skin, no time should be lost in making a free incision; otherwise the abscess may burst into the urethra, and thus lead to urinary infiltration. After the matter has been evacuated by the knife, the inflammation will gradually disappear, and the parts will regain their natural condition. Any induration that may remain may be readily discussed by the application of iodine, camphorated mercurial ointment, leeches, and blisters. INDEX. Abnormal pouch of the urethra, 390 Abscess of bladder, 138 causes of, 140 diagnosis of, 141 discharging into rectum, 139 ileum, 139 sig. flexure, 139 uterus, 140 vagina, 140 abdom. cavity, 140 through abdom. parietes, 140 prognosis of, 141 symptoms of, 140 treatment of, 142 Abscess of prostate gland, 530 age most liable, 534 causes of, 534 number, size, and structure, 531 prognosis of, 535 seat of, 531 symptoms, 534 directions in which, may dis- charge, 532 a. into the bladder, 532 6. into the rectum, 532 c. into peritoneal cavity, 533 d. externally through the perinaeum, 533 treatment of, 535 Abscess, urinary, 689 site of, 689 exciting cause of, 689 symptoms, 696 diagnosis, 692 treatment, 692 Abscess, urethral and sub-urethral, 589 Absence of the bladder, 95 urethra, 601 Accelerator muscle, 38 Accessory pudic artery, 45 Accidents during lithotomy, 446-463 Acephalocysts, 274 Acids in treatment of stone, 404 Acid reaction of urine, 84 uric, 86 Aconite in neuralgic bladder, 212 Action of Wilson and Guthrie's muscles, 42 Actual cautery in paralysis of the bladder, 236 Acute prostatitis, 522 causes of, 524 diagnosis of, 524 pathological changes, 527 progress and termination, 526 symptoms of, 522 treatment of, 527 Acute cystitis, 117 anodyne suppositories in, 129 character of urine in, 123 causes of, 118 duration of, 123 pathology of, 119 prognosis of, 124 symptoms of, 121 treatment of, 124 from gonorrhoea, 131 rheumatism, 132 gout, 132 repulsion of cutaneous disease, 132 stricture, 132 suppurative, 141 Age most liable to stone, 342 Age proper for lithotomy, 424 Air in the bladder, 279 Albuminous urine, 88 Ammoniaco-magnesian calculus, 357 Anal sphincter, 57 Analysis, chemical, of prostatic calculi, 591 cystic calculi, 363 urine, 85 Anatomy of the perinaeum, 34 prostate, 73 Anatomical characteristics of ulcerated blad- der, 156 Anodyne injections in inflammation of the bladder, 129 Anomalous bladder, 96 Ano-perinaeal region, 50 Anus, 50 prolapsion of, 370 sphincter of, 51 Aneurism of abdom. aorta simulating stone in bladder, 392 Appearance of prostate in cystic disease, 584 718 INDEX. Arnica, use of, in paralysis of bladder, 232 Artery, bulbous, 47 internal pudic, 43 Arteries of bladder, 65 perinaeum, 43 Arsenic in neuralgic bladder, 212 Atrophy of prostrate, 577 Ausculting for stone, 377 Average quantity of urine, 84 Bar-like ridge of neck of bladder, 180 structure and di- rection of, 181 symptoms of, 183 diagnosis of, 184 treatment of, 185 Bath, hip, 130 Beaked knife, 506 Belladonna in incontinence of urine, 320 Belladonna in irritability of bladder, 205 Berzelius' analysis of urine, 85 Bilateral operation for stone, 490 Bilobated bladder, 96 Black, rarity of stone in, 343 Bladder, urinary, 54 arteries of, 65 relations of, 55 situation of, 54 ligaments of, 57-9 superior fundus of, 57 structure of, 63,4 base of, 58 body and surfaces of, 59 development of, 66 neck of, 59 uvula of, 63 abscess of, 138 causes of, 140 diagnosis of, 141 discharge of, into rec- tum, 139 sigmoid flexure, 139 ileum, 139 uterus, 140 vagina, 140 abdom. cavity, 140 through abdominal pa- rietes, 140 prognosis of, 141 symptoms of, 140 treatment of, 142 absence of, 95 air in, 279 anomalous, 96 catarrh of, 163 chronic lesions of, 163 colloid of, 259 congenital inversion of, 98 disease of, 95 dactylus aculeatus in, 269 encephaloid of, 250 cases of, 255 causes of, 252 origin of, 251 symptoms of, 252 treatment of, 254 urine in, 253 erectile growths of, 261 Bladder, extrophy of, 98 treatment of, 102 fatty growths of, 264 female, prolapsion of, 327 fibrinous exudation of, 133 causes of, 134 cases of, 135 effects of, 137 form of, 136 symptoms of, 137 treatment of, 138 physical proper- ties of, 136 foetal remains in, 275 cases of, 276 foreign bodies in, 514 effects of, 515 extraction of, 515 fungous growths of, 264 gangrene of, 142 causes of, 143 effects of, 145 epidemic of, 144 treatment of, 146 hair in, 277 hemorrhage of, 280 causes of, 281 diagnosis of, 283 idiopathic, 280 pathology of, 281 symptoms of, 282 traumatic, 280 treatment of, 284 hernia of, 324. coverings of, 325 persons most liable, 325 heterologous formations of, 239 hypertrophy of, 163 imperfections of, 95 incision in neck of, 178 inflammation of, 117 causes of, 118 character of urine in, 123 duration of, 123 pathology of, 119 prognosis of, 124 symptoms of, 121 treatment of, 124 from gonorrhoea, 131 rheumatism, 132 gout, 132 repulsion of cutane- ous disease, 132 stricture, 132 suppurative, 141 injuries of, 103 irrigation of, 176 irritability of, 192 belladonna in, 205 causes of, 194 diagnosis of, 193 diet in, 204 pathology, 200 prognosis, 201 symptoms of, 193 treatment of, 202 laceration of, 109 diagnosis of, 113 INDEX. 719 Bladder, laceration of, mortality of, 114 symptoms of, 112 treatment of, 115 malformations of, 95 melanosis of, 259 morbid growths of, 261 causes of, 267 diagnosis of, 267 treatment of. 267 nervous affections of, 192 neuralgia of, 207 carb. of iron in, 212 arsenic in, 212 aconite in, 212 cases of, 216 causes of, 210 diagnosis, 209 diet in, 216 strychnia in, 212 symptoms of, 207 treatment of, 211 paralysis of, 222 actual cautery in, 236 arnica in, 231 cantharides in, 231 causes of, 223 ergot of rye in, 232 inflammatory, 233 hysterical, 234 moxa in, 236 pathology of, 228 prognosis of, 228 senile, 227 seton, 236 strychnia in, 231 symptoms of, 228 treatment of, 229 polypous growths of, 261 cases of, 262 causes of, 267 diagnosis of, 267 treatment of, 267 puncture of, 309 through rectum, 311 perinaeum, 313 supra-pubic mode, 314 necessity of, 311 statistics of, 315 sacculation of, 187 number and shape of pouch- es in, 188 origin of, 189 prognosis of, 191 symptoms of, 190 treatment of, 191 scirrhus of, 239 anat. characters of, 240 cases of, 242 causes of, 240 progress of, 241 symptoms of, 241 spiroptera in, 268 steatomatous growths of, 264 stone in, 341 age most liable, 342 causes of, 341 hereditary nature of, 343 rarity in the black, 343 sex most liable, 343 Bladder, stone in, physical properties of, 347 colour, 352 consistence, 351 weight, 350 volume, 349 odour, 352 shape, 352 pathological effects of, 395 spontaneous fracture of, 399 medical treatment of, 401 dietetic regulations for, 401 use of alkalies in, 402 acids in, 404 solution of, 405 removal of, through urethra, 408 operation for, by crushing, 410 lateral operation for, 426 bilateral operation for, 494 quadrilateral do. do. 498 recto-vesical do. do. 498 supra-pubic, do. do. 499 situation of, 359 symptoms of, 364 operation for, with the gorget, 504 operation for, with the beaked knife, 506 operation at two periods, 507 extraction of, by dilatation, 511 crushing, 511 incision, 511 lithectasy in, 503 Fergusson's operation for, 512 suppuration of, 187 symptoms of, 141 ulceration of, 147 causes of, 150 diagnosis of, 153 healing of, 149 effects on neighbour- ing organs, 155 prognosis of, 154 symptoms of, 151 treatment of, 157 worms in, 268 cases of, 272 causes of, 271 symptoms, 271 wounds of, 103 varieties of, 103 gun-shot, 105 incised, 104 punctured, 104 treatment, 109 Black-coloured urine, 93 Blue, " " 93 Bloody urine, 89 Blisters in cystorrhoea, 175 Boundaries of perinseum, 33 Bright's disease of kidney, 88 urine in, 88 Buchu in cystorrhoea, 172 Bulbous artery, 47 Bulbous portion of urethra, 81 Calcareous deposits from urine, 338 720 INDEX. Calculi of the prostate gland, 590 age most liable, 590 colour of, 591 consistence of, 591 chem. analysis of, 591 complications of, 595 1, stricture of urethra, 595 2, enlarged prostate, 595 3, stone in bladder, 595 4, hypertrophy of mus- cular coat of bladder, 595 5, organic lesions of blad- der, 595 causes of, 596 diagnosis of, 593 mode of origin of, 592 number of, 591 size of, 591 symptoms, 593 treatment, 596 Calculi, urethral, 667 cases of, 671 diagnosis of, 670 extraction of, 673 symptoms of, 670 treatment of, 672 Cantharides, in irritable bladder, 206 paralysis of bladder, 231 Carbonate of iron, in neuralgic bladder, 212 Case of irritable bladder simulating stone, 391 Cases of worms in bladder, 272 Castile soap in treatment of stone, 403 Catarrh of the bladder, 163 Cats, stone in bladder of, 363 Catheterism, 303 importance of, 303 in the female, 308 modes of performing, 308 Catheters, 304 description of, 304 introduction of, 305 methods for retaining, in the bladder, 307 Cause of death from retention of urine, 288 Causes of stricture, 631 Cause of urinary infiltration after lithotomy, 436 Cauterization in cystorrhoea, 176 in stricture, 640 paralysis of bladder, 236 Central tendon of the perinaeum, 37 Character of the wound made in lithotomy, 426 Changes in the form of the urethra, 602 direction of the urethra, 603 Characteristics of phosphatic urine, 338 Chemical analysis of prostatic calculi, 571 composition of stone, 354 a. uric acid calculus, 354 6. uro-ammoniacal calculus, 355 c. oxalic acid, 355 d. hemp seed, 356 e. phosphatic, 356 /. ammoniaco-magnesian, 357 g. fusible, 357 Chemical analysis of prostatic calculi. k. cystic, 358 i. xanthic calculus, 358 j. fibrinous, 358 Chloroform in lithotomy, 418 Chronic lesions of the bladder, 163 Chylous urine, 84 Circumstances favourable to lithotrity, 416 lithotomy, 425 Civiale's invention, 411 Climate influencing formation of stone in bladder, 344 Colloid of bladder, 259 prostate, 583 Colour of cystic stone, 352 urethral stricture, 619 Coloured urine, 93 Compressor urethrae muscle, 41 Compression in hypertrophied prostate, 639 Congenital inversion of bladder, 98 Consistence of urethral stricture, 619 cystic stone, 351 Contused wounds of the prostate, 520 Coverings of the prostate, 73 Cowper's glands, 43 infl. and abscess of, 715 diagnosis of, 716 origin of, 715 symptoms of, 716 treatment of, 716 Crest, gallinaginous, 80 lesions of, 712 inflammation of, 712 symptoms of, 712 treatment of, 713 hypertrophy of, 713 symptoms of, 714 treatment of, 714 Crushing stone in bladder, 410—511 hypertrophied prostate, 574 Cysts, serous, 274 Cystocele, internal, 187 vaginal, 326 Cystic calculi, 358, 363 chem. analysis of, 363 neuralgia, 212 causes of, 210 diagnosis of, 209 diet in, 216 symptoms of, 207 treatment of, 211 hernia, 325 coverings of, 325 diagnosis of, 326 symptoms of, 325 treatment of, 326 disease of prostate, 584 appearance of, 584 origin of, 584 Cystitis, acute, 117 anodyne suppositories in, 129 character of urine in, 123 causes of, 118 duration of, 123 pathology of, 119 prognosis of, 124 symptoms of, 121 treatment of, 121 from gonorrhoea, 131 INDEX. 721 Cystitis, from gout, 132 rheumatism, 132 repulsion of cutaneous dis- ease, 132 stricture, 132 suppurative, 141 Cystorrhoea, 163 anodynes in, 174 buchu in, 172 cauterization of bladder in, 176 character of mucus in, 166 urine in, 166 causes of, 164 Chian turpentine in, 171 counter-irritation in, 175 diagnosis of, 168 diet in, 179 epigasa repens in, 172 muriated tinct. of iron in, 173 pathology of, 170 prognosis of, 169 treatment of, 170 Dactylus aculeatus in bladder, 269 description of, 269 Decoction of soot in irritable bladder, 207 Description of rectum, 52 Development of urinary bladder, 66 Diabetes mellitus, urine in, 92 Diagnosis of stricture, 624 Diet in urinary deposits, 216 Dietetic regulations for stone in the bladder, 401 Dieffenbach's urethroplastic operation, 704 Dilatation of urethral stricture, 634 Dimensions of prostate gland, 69 urethra, 76 Direction of the urethra, 78 in which abscess of prostate may discharge, 532 a. into the bladder, 532 6. into the rectum, 532 c. through the perinaeum, 533 d. into the peritoneal cavity, 533 Disease of bladder, 95 urinary organs, 95 Diseases of the prostate gland, 517 Disease of the urethra, 600 kidney, Bright's, 88 Double lithotome, 496 urethra, 602 Effects of wounds of the prostate, 520 hypertrophy of the prostate, 560 foreign bodies in bladder, 515 stricture of the urethra, 626 Egg-shells in the treatment of stone, 403 Elderly males, liability of, to cystic hernia, 325 Employment of chloroform in the operation for stone, 418 Encephaloid of bladder, 250 cases of, 255 causes of, 252 origin of, 251 symptoms of, 252 treatment of, 254 urine in, 253 4G Encephaloid disease of prostate, 579 age most liable, 579 cases of, 581 causes of, 579 diagnosis of, 580 symptoms of, 580 pathology of, 580 treatment of, 581 Encysted calculus, 360, 389 Epidemic gangrene of bladder, 144 Epigaea repens in cystorrhoea, 172 Epispadias, 607 treatment of, 607 Erector muscle, 37 Erectile growths of bladder, 261 Errors of sounding, 380 Escape of bladder into groin, 389 Excavated prostate, 389 Exostosis of pelvic bones, 386 Extraction of foreign bodies from the blad- der, 515 urethral calculi, 673 stone by crushing, 511 dilatation, 511 incision, 511 through urethra, 408 with the scoop, 433 Extrophy of bladder, 98 treatment of, 102 Exudation of the bladder, fibrinous, 133 cases of, 135 causes of, 134 effects of, 137 form of, 136, phys. properties of, 136 symptoms of, 137 treatment of, 138 False passages, 705 parts of the urethra most liable to, 705 general situation of, 705 number of, 706 length of, 706 varieties in form of, 707 causes of, 708 effects of, 709 symptoms of, 710 diagnosis of, 710 treatment of, 711 Fatty»growths of the bladder, 264 Female bladder, prolapsion of, 327 lithotomy in, 508 Fergusson's method of operating for stone in the female, 512 Fibrinous calculus, 358 urine, 89 exudation of bladder, 133 cases of, 135 causes of, 134 effects of, 137 form of, 136 phys. properties of, 136 symptoms of, 137 treatment of, 138 Fibrous tumours of the prostate gland. 586 nature and origin of, 586 722 INDEX. Fistule of the urethra, 694 causes of, 698 diagnosis of, 699 number of openings, 695 prognosis of, 699 site of, 695 treatment of, 699 escharotics in, 701 external incision in, 702 use of suture in, 702 excision in, 703 urethroplasty in, 703 Fomentations, 129 Foetal remains in bladder, 275 cases of, 276 Foreign bodies in the bladder, 514 effects of, 515 extraction of, ,515 Foreign bodies in the urethra, 667 1. Calculi descending from bladder, 667 case of, 671 diagnosis of, 670 extraction of, 673 excision for, 675 lithotripsy in, 674 symptoms of, 670 treatment of, 672 2. Foreign bodies introduced from with- out, 676 cases of, 677 Form of hypertrophied prostate, 544 Frequency of prostatic scirrhus, 578 Frequent micturition in stone, 367 Fungous growths of the bladder, 264 Fusible calculus, 357 Gallinaginous crest, 80 lesions of, 712 inflam. and abscess of, 712 signs of, 712 treatment of, 713 hypertrophy of, 713 signs of, 714 diagnosis of, 714 treatment of, 714 Gangrene of bladder, 142 causes of, 143 effects of, 145 epidemic, 144 treatment of, 146 Glands of Cowper, 43 inflam. and abscess of, 715 causes of, 715 diagnosis of, 716 treatment of, 716 Gonorrhoeal cystitis, 131 Gorget, operation with, 504 Gouty cystitis, 132 Gravel, 354 Growths of bladder, steatomatous, 264 fungous, 264 fatty, 264 polypous, 261 cases of, 262 causes of, 267 diagnosis of. 267 treatment of, 267 Gun-shot wounds of bladder, 105 prostate, 520 Guthrie's muscle, 41 Hair in the bladder, 277 in urine, 93 Hemorrhage of the bladder, 280 idiopathic, 280 traumatic, 280 causes of, 281 pathology of, 281 symptoms of, 282 diagnosis of, 283 treatment of, 284 urethra, 663 spontaneous, 663 traumatic, 663 treatment of, 665 urethral crest, 283 prostate, 587 cause of, 587 diagnosis of, 587 prognosis of, 588 treatment of, 588 Hemp-seed calculus, 356 Herbivora, stone in the, 363 Hernia of the bladder, 324 coverings of, 325 persons most liable to, 325 Heurteloup's discovery of lithotripsy, 413 Heterologous formations of the bladder, 239 prostate, 578 Hip-bath, 130 Hydatids, 274 Hypertrophy of the bladder, 163 prostate, 543 seat of, 543 degree and form of, 544 consistence of, 547 colour of, 548 weight of, 549 causes of, 549 progress of, 553 symptoms of, 553 diagnosis of, 556 effects of, 560 complications of, 565 treatment of, 565 iodine in, 567 mercury in, 568 cauterization in, 571 scarification, 572 Hypospadias, 605 varieties of, 605 treatment of, 605 Hysterical paralysis of bladder, 234 Imperfections of bladder, 95 urethra, 600 Incision in neck of bladder, 178 Incontinence of urine, 316 from external injury, 316 from inflammation, 317 from paralysis of bladder, 317 from morbid irritability, 318 pathology of, 318 treatment of, 319 INDEX. 723 Incontinence of urine, belladonna in, 320 cases of, 322 Inferior hemorrhoidal artery, 46 Infiltration of urine, 682 1. from vesical lesion, 684 symptoms of, 684 diagnosis of, 684 prognosis of, 684 treatment of, 684 2. from urethral lesion, 686 symptoms of, 686 diagnosis of, 686 prognosis of, 687 treatment of, 687 Inflammation of the bladder, 117 causes of, 118 pathology of, 119 symptoms of, 121 duration of, 123 prognosis of, 124 treatment of, 124 Injuries of the bladder, 103 prostate, 517 urethra, 600 Internal pudic artery, 43 cystocele, 187 Irrigation of the bladder, 176 Irritability of the bladder, 192 symptoms of, 193 diagnosis of, 193 causes of, 194 pathology of, 200 prognosis of, 201 treatment of, 202 diet in, 204 belladonna in, 205 Ischio-rectal fossa, 36 Jacobson's instrument for crushing stone,414 Kidney, Bright's disease of, 88 Kiesteine in urine, 91 Laceration of the bladder, 109 symptoms of, 112 diagnosis of, 113 mortality of, 114 treatment of, 115 urethra, 608 causes of, 608 diagnosis of, 611 prognosis of, 612 symptoms of, 609 treatment ot, 612 Latent stone, 393 Lateral operation for stone, 426 Lithic acid calculus, 354 deposits, 328 Ligaments of the bladder, 57-59 Lithectasy, 503 Lithotomy, 423 Lithotrity, 411 Lithotripsy, 674 Malformations of the bladder, 95 urethra, 600 urachus, 61 Meatus, urinary, 82 Melanosis of blndder, 259 Melanosis of prostate, 583 Medical treatment of stone, 401 Mercury in hypertrophied prostate, 568 Mixed deposits from urine, 339 Morbid secretion of urine, 88 growths of the bladder, 261 causes of, 267 diagnosis of, 267 treatment of, 267 Mortification of bladder, 144 Moxa in paralysis of bladder, 236 Mucus in urine, 87 Mucous follicles of urethra, 82 Muscles of the perinaeum, 36 Muscle of Guthrie, 41 Wilson, 43 Neck of the bladder, 59 Nervous affections of the bladder, 192 Neuralgia of bladder, 207 symptoms of, 207 diagnosis of, 209 causes of, 210 treatment of, 211 carbonate of iron in, 212 arsenic in, 212 strychnia in, 212 aconite in, 212 injections in, 216 diet in, 216 cases of, 216 urethra, 659 cases of, 661 causes of, 659 symptoms of, 659 treatment of, 661 Oily urine, 92 Oxalic acid calculus, 355 deposits, 335 Paralysis of the bladder, 222 causes of, 223 symptoms of, 228 pathology of, 228 prognosis of, 228 treatment of, 229 Pathological effects of stone, 395 Perinasum, 33 shape and boundaries of, 33 anatomy of, 34 superficial fascia of, 35 muscles of, 36 central tendon of, 37 arteries of, 43 Phlebolites of the prostate, 598 cause of, 598 Phosphatic calculus, 356 deposits, 338 Physical properties of stone, 347 Pink-coloured urine, 93 Polypoid tumours of the urethra, 652 situation, 652 number, 653 size, 653 iVi'ypous growths of bladder, 261 cases of, 262 cause and diagnosis of, 267 724 INDEX. Polypous growths of bladder, treatment of, 267 Potous urine, 84 Prostate gland, 67 situation of, 67 relations of, 68 connexions of, 68 dimensions of, 69 colour of, 71 anatomy of, 73 coverings of, 73 veins of 75 disease of, 398 encephaloid of, 578 causes of, 579 diagnosis of, 580 symptoms of, 580 pathology of, 580 treatment, 581 hypertrophy of, 543 causes of, 549 diagnosis of, 556 effects of, 560 treatment of, 565 wounds of, 518 incised, 518 lacerated, 519 punctured, 520 contused, 520 gun-shot, 520 diagnosis of, 520 treatment of, 521 injuries of, 517 tubercle of, 583 symptoms of, 584 diagnosis of, 584 melanosis of, 583 Prostatic portion of urethra, 79 plexus, 75 Prolapsion of female bladder, 327 Pubo-urethral muscle, 42 Puncture of bladder, 309 necessity of, 311 by rectum, 311 by perinaeum, 313 supra-pubic method, 314 statistics of, 315 Punctured wounds of bladder, 104 Pus in the urine, 90 Quadrilateral operation for stone, 424. Rarity of stone in the black, 343 Rats, stone in, 363 Recto-vesical operation for stone, 498 Recto-urethral triangle, 52 Rectum, 52 description of, 52 Reptiles, stone in, 363 Retention of urine, 133, 287 . symptoms of, 287 cause of death in, 288 diagnosis of, 289 treatment of, 291 causes of, 292 I. mechanical obstruc- tion, 292 II. paralysis, 298 Retention of urine, III. spasm, 300 IV. inflammation, 300 V. pelvic tumours, 302 VI. coagulated blood, 296 VII. inspissated mu- cus, 297 VIII. hypertrophy of prostate, 294 IX. imperforate pre- puce, 294 X. priapism, 294 XI. prolapsus uteri, 303 Rheumatic cystitis, 132 Sacculation of the bladder, 187 cause of, 189 prognosis of, 191 symptoms of, 190 treatment of, 191 Sanguineous urine, 85 Scirrhus of the bladder, 229 causes of, 240 cases of, 242 anatomical characters of. 240 progress of, 241 symptoms of, 241 prostate, 578 frequency of, 578 Senile paralysis of bladder, 327 Serous cysts, 274 Sex most liable to stone, 343 Sinus of the urethral bulb, 81 Situation of stone in the bladder, 359 Solution of stone in the bladder, 405 Sounds, 373 Sounding, mode of operation, 374 danger of, 376 errors of, 380 Specific gravity of urine, 84 Spiroptera in the bladder, 268 Sphincter ani, 57 Spontaneous fracture of stone in the bladder, 399 State of bladder as ascertained by sounding. 395 Steatomatous growths of the bladder, 264 Stone in the bladder, 341 nature and causes of, 341 age most liable to, 342 hereditary nature of, 343 rarity of, in the black, 343 sex most liable to, 343 influence of occupation on, 344 climate on, 344 physical properties of, 347 number of, 348 volume of, 349 colour of, 352 weight of, 350 consistence of, 351 odour of, 352 shape of, 352 chemical composition of, 354 a. uric acid, 354 b. uro-ammoniac, 355 INDEX. in evt-ry way superior to its predecessors, additions and alterations having been made whenever the advance of science has rendered them desirable. The typographical execution of the work will al-o be found to have undergone a similar improvement and the work is now confidently presented as in every way worthy the position it has acquired as the standard American text-book on the Diseases of Females. It contains a vast amount of practical knowledge, by one who has accurately observed and retained the experience of many years, and who tells the re- Bult in a free, familiar, and pleasant manner.—Dub- lin Quarterly Journal. There is an off-hand fervor, a glow, and a warm- heartedness infecting the effort of Dr. Meigs, which is entirely captivating, and which absolutely hur- ries the reader through from beginning to end. Be- sides, the book teems with solid instruction, and it shows the very highest evidence of ability, viz., the clearness with which the information is pre- sented. We know of no better test of one's under- standing a subject than the evidence of the power of lucidly explaining it. The most elementary, as well as the obscurest subjects, under the pencil of Prof. Meigsi are isolated and made to stand out in such bold relief, as to produce distinct impressions upon the mind and memory of the reader. — The Charleston Med. Journal. BY THE SAME AUTHOR. OBSTETRICS: THE SCIENCE AND THE ART. Second edition, revised and improved. With one hundred and thirty-one illustrations. In one beautifully printed octavo volume, of seven hundred and fifty-two large pages. (Lately Published.) The rapid demand for a second edition of this work is a sufficient evidence that it has supplied a desideratum of the profession, notwithstanding the numerous treatises on the same subject which have appeared within the last few years. Adopting a system of his own, the author has combined the leading principles of his interesting and difficult subject, with a thorough exposition of its rules of practice, presenting the results of long and extensive experience and of familiar acquaintance with all the modern writers on this department of medicine. As an American Treatise on Mid- wifery, which has at once assumed the position of a classic, it possesses peculiar claims to ihe at- tention and study of the practitioner and student, while the numerous alterations and revisions which it has undergone in the present edition are shown by the great enlargement of the work, which is not only increased as to the size of the page, but also in the number. Among other addi* tions may be mentioned A NEW AND IMPORTANT CHAPTER ON "CHILDBED FEVER." BY THE SAME author. (Now Ready.) A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK OF THE UTERUS. With numerous plates, drawn and colored from nature in the highest style of art. In one handsome octavo volume, extra cloth. The object of the author in this work has been to present in a small compass the practical results of his long experience in this important and distressing class of diseases. The great changes intro- duced into practice, and the accessions to our knowledge on the subject, within the last few years, resulting from the use of the metroscope, brings within the ordinary practice of every physician numerous cases which were formerly regarded as incurable, and renders of great value a work like the present combining practical directions for diagnosis and treatment with an ample series of illus- trations, copied accurately from colored drawings made by the author, after nature. No such accu- rate delineations of the pathology of the neck of the uterus have heretofore been given, requiring, as they do the rare combination of physician and artist, and their paramount importance to llie physician in whose practice such cases are frequent, is too evident to be dwelt upon, while in artistic execution they are far in advance of anything of the kind as yet produced in this country. BY THE SAME AUTHOR. OBSERVATIONS ON CERTAIN OF THE DISEASES OF YOUNG CHILDREN. In one handsome octavo volume, of 214 pages. BY THE same author. (In Press.) ON THE NATURE, SIGNS, AND TREATMENT OF PUERPERAL FEVER. In one handsome octavo volume. Professor Meigs has enlarged and amended this great work, for such it unquestionably is, having passed the ordeal of criticism at home and abroad, but been improved thereby ; for in this new edition the author has introduced real improvements, and increased the value and utility of the h>ok im- measurably. It presents so many novel, bright, and sparkling thoughts; such an exuberance of new ideas on almost every page, that we confess our- selves to have become enamored with the book and its author; and cannot withhold our congratu- lations from our Philadelphia confreres, that such a teacher is in their service. We regret that our limits will not allow of a more extended notice of this work, but must content ourselves with thus commending it as worthy of diligent perusal by physicians as well as students, who are st-eking to be thoroughly instructed in the important practical subjects of which it treats.—N. Y. Med. Cazette. AND SCIENTIFIC PUBLICATIONS. 21 MILLER (JAMES), F. R. S. E., Professor of Surgery in the University of Edinburgh, &c. P5J.NuniPI'ES OF SURGERY. Third American, from the second and revised Edinburgh edition. Revised, with Additions, by F. W. Sargent, M. D., author of " Minor Sur- gery, &c In one large and very beautiful volume, of seven hundred and fifty-two pages, with two hundred and forty exquisite illustrations on wood. The publishers have endeavored to render the present edition of this work, in every point of me- ehanical execution, worthy of its very high reputation, and they confidently present "it to the pro- fession as one of the handsomest volumes as yet issued in this country. This edition is far superior, both in the abundance and quality of its material? to any of the preceding. We hope it will be extensively read, and the sound principles which are herein taught treasured up for future application. The work takes rank with Watson's Practice of Physic; it certainly does not fall behind that great work in soundness of princi guage. This opinion, deliberately formed after a careful study of the first edition, we have had no cause to change on examining the second. This edition has undergone thorough revision by the au- thor; many expressions have been modified, and a mass of new matter introduced. The book is got up in the finest style, and is an evidence of the progress of typography in our country.—Charleston Medical Journal and Review. We recommend it to both student and practitioner, feeling assured that as it now comes to us, it pre- sents the most satisfactory exposition of the modern doctrines of the principles of surgery to be found in any volume in any language.—N. Y. Journal of Medicine. pie or depth of reasoning and research. No physi- cian who values his reputation, or seeks the interests of his clients, can acquit himself before his God and tfie world without making himself familiar with the Bound and philosophical views developed in the fore- going book.—New Orleans Medical and Surgical Journal. Without doubt the ablest exposition of the prin- ciples of that branch of the healing art in any lan- BY the same author. (Now Ready.) THE PRACTICE OF SURGERY. Third American from the second Edin- burgh edition. Edited, with Additions, by F. W. Sargent, M. D , one of the Surgeons to Will's Hospital, &c Illustrated by three hundred and nineteen engravings on wood. In one large octavo volume, of over seven hundred pages. This new edition will be found greatly improved and enlarged, as well by the addition of much new matter as by the introduction of a large and complete series of handsome illustrations. An equal improvement exists in the mechanical execution of the work, rendering it in every respect a companion volume to the "Principles." No encomium of ours could add to the popularity of Miller's Surgery. Its reputation in this country is unsurpassed by that of any other work, and, when taken in connection with the author's Principles of Surgery, constitues a whole, without reference to which no conscientious surgeon would be willing to practice his art The additions, by Dr. Sargent, have materially enhanced the value of the work.— Southern Medical and Surgical Journal. It is seldom that two volumes have ever made so profound an impression in so short a time as the " Principles" and the " Practice" of Surgery by Mr. Miller—or so richly nperited the reputation they have acquired. Th'e author is an eminently sensi- ble, practical, and well-informed man, who knows exactly what lie is talking about and exactly how to talk it.—Kentucky Medical Recorder. The two volumes together form a complete expose of the present state of Surgery, and they ought to be on the shelves of every surgeon.—JV. J. Med. Re- porter. By the almost unanimous voice of the profession, his works, both on the principles and practice of surgery have been assigned the highest rank. If we were limited to but one work on surgery, that one should be Miller's, as we regard it superior to aH others.—St. Louis Med. and Surg. Journal. The author distinguished alike as a practitioner and writer, has in this and his " Principles,'' pre- sented to the profession one of the most complete and reliable systems of Surgery extant. His style of writing is original, impressive, and engaging, ener- getic, concise, and lucid. Few have the faculty of condensing so much in small space, and at the same time so persistently holding the attention; indeed, he appears to make the very process of condensation a means of eliminating attractions. Whether as a text-book for students or a book of reference for practitioners, it cannot be too strongly recommend- ed.—Southern Journal of the Medical and Physical Sciences. MALGAIGNE (J. F.). OPERATIVE SURGERY, based on Normal and Pathological Anatomy. Trans- lated from the French, by Frederick Brittan, A. B., M. D. With numerous illustrations on wood. In one handsome octavo volume, of nearly six hundred pages. We have long been accustomed to refer to it as one of the most valuable text-books in our library.— Buffalo Med. and Surg. Journal. Certainly one of the best books published on ope- rative surgery.—Edinburgh Medical Journal. To express in a few words our opinion of MaU gaigne's work, we unhesitatingly pronounce it the very best guide in surgical operations that has come before the profession in any language.—Charleston Med. and Surg. Journal. MOHR (FRANCIS), PH. D., AND REDWOOD (TH EOPH I LUS). PRACTICAL PHARMACY. Comprising the Arrangements, Apparatus, and Manipulations of the Pharmaceutical Shop and Laboratory. Edited, with extensive Additions, by Prof. William Procter, of the Philadelphia College of Pharmacy. In one handsomely printed octavo volume, of 570 pages, with over 500 engravings on wood. It is a book, however, which will be in the hands of almost every one who is much interested in phar- maceutical operations, as we know of no other pub- lication so well calculated to fill a void long felt.— Medical Examiner. The book is strictly practical, and describes only manipulations or methods of performing the nume- rous processes the pharmaceutist has to go through, jto the preparation and manufacture of medicines, together with all the apparatus and fixtures neces- sary thereto. On these matters, this work is very full and complete, and details, in a style uncom- monly clear and lucid, not only the more compli- cated and difficult processes, but those not less im- portant ones, the most simple and common.—Buffalo Medical Journal. The country practitioner who is obliged to dis- pense his own medicines, will find it a most valuable assistant.—Monthly Journal and Retrospect. 22 BLANCHARD & LEA'S MEDICAL MACLISE (JOSEPH), SURGEON. SURGICAL ANATOMY. Forming one volume, very large imperial quarto. With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored. Con- taining one hundred and ninety Figures, many of them the size of life. Together with copious and explanatory letter-press. Strongly and handsomely bound in extra cloth, being one of the cheapest and best executed Surgical works as yet issued in this country. Copies can be sent by mail, in five parts, done up in stout covers. This great work being now concluded, the publishers confidently present it to the attention of the profession as worthy in every respect of their approbation and patronage. No complete work of the kind has yet been published in the English language, and it therefore will supply a want long felt in this country of an accurate and comprehensive Atlas of Surgical Anatomy to which the student and practitioner can at all times refer, to ascertain the exact relative position of the various portions of the human frame towards each other and to the surface, as well as their abnormal de- viations. The importance of such a work to the student in the absence of anatomical material, and to the practitioner when about attempting an operation, is evident, while the price of the book, not- withstanding the large size, beauty, and finish of the very numerous illustrations, is so low as to place it within the reach of every member of the profession. The publishers therefore confidently anticipate a very extended circulation for this magnificent work. One of the greatest artistic triumphs of the age in Surgical Anatomy.—British American Medical Journal. Too much cannot be said in its praise; indeed, we have not language to do it justice.—Ohio Medi- cal and Surgical Journal. The most admirable surgical atlas we have seen. To the practitioner deprived of demonstrative dis- sections upon the human subject, it is an invaluable companion.—N. J. Medical Reporter. The most accurately engraved and beautifully colored plates we have ever seen in an American book—one of the best and cheapest surgical works ever published.—Buffalo Medical Journal. It is very rare that so elegantly printed, so well illustrated, and so useful a work, is offered at so moderate a price.—Charleston Medical Journal. Its plates can boast a superiority which places them almost beyond the reach of competition.—Medi- oal Examiner. Every practitioner, we think, should have a work of this kind within reach.—Southern Medical and Surgical Journal. No such lithographic illustrations of surgical re- gions have hitherto, we think, been given.—Boston Medical and Surgical Journal. As a surgical anatomist, Mr. Maclise has proba- bly no superior.—British and Foreign Medico-Chi- rurgical Review. Of great value to the student engaged in dissect- ing, and to the surgeon at a distance from the means of keeping up his anatomical knowledge.—Medical Times. The mechanical execution cannot be excelled.— Transylvania Medical Journal. A work which has no parallel in point of accu- racy and cheapness in the English language.—-N. Y. Journal of Medicine. To all engaged in the study or practice of their profession, such a work is almost indispensable.— Dublin Quarterly Medical Journal. No practitioner whose means will admit should fail to possess it.—Ranking's Abstract. Country practitioners will find these plates of im- mense value.—N. Y. Medical Gazette. We are extremely gratified to announce to the profession the completion of this truly magnificent work, which, as a whole, certainly stands unri- valled, both for accuracy of drawing, beauty of coloring, and all the requisite explanations of the subject in hand.—The New Orleans Medical and Surgical Journal. This is by far the ablest work on Surgical Ana- tomy that has come under our observation. We know of no other work that would justify a stu- dent, in any degree, for neglect of actual dissec- tion. In those sudden emergencies that so often urise, and which require'the instantaneous command of minute anatomical knowledge, a work of this kind keeps the details of the dissecting-room perpetually fresh in the memory.—The Western Journal of Medi- cine and Surgery. figgf The very low price at which this work is furnished, and the beauty of its execution, require an extended sale to compensate the publishers for the heavy expenses incurred. MULLER (PROFESSOR J.), M.D. PRINCIPLES OF PHYSICS AND METEOROLOGY. Edited, with Addi- tions, by R. Eglesfeld Griffith, M. D. In one large and handsome octavo volume, extra cloth, with 550 wood-cuts, and two colored plates. The Physics of Mflller is a work superb, complete. I tion to the scientific records of this country may b« unique: the greatest want known to English Science | duly estimated by the fact that the cost of the origi- eould not have been better supplied. The work is I nal drawings and engravings alone has exceeded the of surpassing interest. The value of this contribu- sum of £2,000.—Lancet. MAYNE (JOHN), M. D., M. R. C. S., A DISPENSATORY AND THERAPEUTICAL REMEMBRANCER. Com- prising the entire lists of Materia Medica, with every Practical Formula contained in the three British Pharmacopoeias. With relative Tables subjoined, illustrating, by upwards of six hundred and sixty examples, the Extemporaneous Forms and Combinations suitable for the different Medicines. Edited, with the addition of the Formulae of the United States Pharmacopoeia, by R. Eglesfeld Griffith, M. D. In one 12mo. volume, extra cloth, of over 300 large pages. MATTEUCCI (CARLO). LECTURES ON THE PHYSICAL PHENOMENA OF LIVING BEINGS. Edited by J. Pereira, M. D. In one neat royal 12mo. volume, extra cloth, with cuts, 388 pages. AND SCIENTIF C PUBLICATIONS. 23 NEILL (JOHN), M. D., Surgeon to the Pennsylvania Hospital, &c; and FRANCIS GURNEY SMITH, M.D., Professor of Institutes of Medicine in the Pennsylvania Medical College. AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE; for the Use and Examination of Students. Second edition, revised and improved. In one very large and handsomely printed royal 12mo. volume, of over one thousand pages, with three hundred and fifty illustrations on wood. Strongly bound in leather, with raised bands. The speedy sale of a large impression of this work has afforded to the authors gratifying evidence of the correctness of the views which actuated them in its preparation. In meeting the demand for a second edition, they have therefore been desirous to render it more worthy of the favor with which it has been received. To accomplish this, they have spared neither time nor labor in embo- dying in it such discoveries and improvements as have been made since its first appearance, and such alterations as have been suggested by its practical use in the class and examination-room. Considerable modifications have thus been introduced throughout all the departments treated of in the volume, hut more especially in the portion devoted to the " Practice of Medicine," which has been entirely rearranged and rewritten. The authors therefore again submit their work to the profession, with the hope that their efforts may tend, however humbly, to advance the great cause •f medical education. Notwithstanding the enlarged size and improved execution of this work, the price has not been increased, and it is confidently presented as one of the cheapest volumes now before the profession. In the rapid course of lectures, where work for Having made free use of this volume in our ex the students is heavy, and review necessary for an examination, a compend is not only valuable, but it is almost n sine qua non. The one before us is, in most of the divisions, the most unexceptionable of all books of the kind that we know of. The newest and soundest doctrines and the latest im- provements and discoveries are explicitly, though concisely, laid before the student. Of course it is useless for us to recommend it to all last course students, but there is a class to whom we verv sincerely commend this cheap book as worth its weight in silver — that class is the graduates in medicine of more than ten years' standing, who have not studied medicine since. They will perhaps find out from it that the science is not exactly now what it was when they left it off.—The Stethoscope aminations of pupils, we can speak from experi- ence in recommending it as an admirable compend for students, and as especially useful to preceptors who examine their pupils. It will save the teacher much labor by enabling him readily to recall all of the points upon which his pupils should be ex- amined. A work of this sort should be in the hands of every one who takes pupils into his office with a view of examining them; and this is unquestionably the best of its class. Let every practitioner who has pupils provide himself with it, and he will find the labor of refreshing his knowledge so much facilitated that he will be able to do justice to his pupilsat very little cost of time or trouble to himself.—Transyl- vania Med. Journal. NELIGAN (J. MOORE), M. D., M. R. I.A., &c. A PRACTICAL TREATISE ON DISEASES OF THE SKIN. In one neat royal 12mo. volume, of 334 pages. OWEN (PROF. R). ON THE DIFFERENT FORMS OF THE SKELETON. One vol. royal 12mo., with numerous illustrations. (Preparing.) POPULAR PHYSIOLOGY. THE PHYSIOLOGY OF ANIMAL AND VEGETABLE LIFE. In one neat royal 12mo. volume, of about 200 pages, with 100 wood-cuts. (Just Ready.) The latest information on physiological subjects will be found in this work, popularly arid clearly explained, rendering it suitable for schools and school libraries, as well as for private readers. PHILLIPS (BENJAMIN), F. R. S., &c. SCROFULA; its Nature, its Prevalence, its Causes, and the Principles of its Treatment. In one volume, octavo, with a plate. PANCOAST (J.), M. D., Professor of Anatomy in the Jefferson Medical College, Philadelphia, &c. OPERATIVE SURGERY; or, A Description and Demonstration of the various Processes of the Art; including all the New Operations, and exhibiting the State of Surgical Science in its present advanced condition. Complete in one roval 4to. volume, of 380 pages of letter-press description and eighty large 4to. plales, comprising 486 illustrations. Second edition, improved. Blanchard cV Lea having become the publishers of this important book, have much pleasure in offering it to the profession. This excellent work is constructed on the model of the French Surgical Works by Velpeau and Mal- o-aigne; and, so far as the English language is con- cerned, we are proud as an American to say that, of its kind it has no superior.—N. Y. Journal of Medicine. PARKER (LANGSTON)., Sur«eon to the Queen's Hospital, Birmingham. THE MODERN TREATMENT OF SYPHILITIC DISEASES, BOTH PRI- MARY AND SECONDARY; comprising the Treatment of Constitutional and Confirmed Syphi- lis bv a safe and successful method. With numerous Cases, Formulae, and Clinical Observa- tions. From the Third and entirely rewritten London edition. In one neat octavo volume. (Now Ready.) 24 BLANCHARD & LEA'S MEDICAL (Now Complete.) PEREIRA (JONATHAN), M. D., F. R. S., AND L. S. THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. Third American edition, enlarged and improved by the author; including Notices of most of the Medicinal Substances in use in ihe civilized world, and forming an Encyclopaedia of Materia Medica. Edited, with Additions, by Joseph Carson, M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. In two very large octavo volumes of 2100 pages, on small type, with over four hundred and fifty illustrations. Volume I.—Lately issued, containing the Inorganic Materia Medica, over 800 pages, with 145 illustrations. Volume II.—Now ready, embraces the Organic Materia Medica, and forms a very large octavo volume of 1250 pages, with two plates and three hundred handsome wood-cuts. The present edition of this valuable and standard work will enhance in every respect its well- deserved reputation. The care bestowed upon its revision by the author may be estimated by the fact that its size has been increased by about five hundred pages. These additions have extended to every portion of the work, and embrace not only the materials afforded by the recent editions of the pharmacopoeias, but also all the important information accessible to the care and industry of the author in treatises, essays, memoirs, monographs, and from correspondents in various parts of the globe. In this manner the work comprises the most recent and reliable information respecting all the articles of the Materia Medica, their natural and commercial history, chemical and thera- peutical properties, preparation, uses, doses, and modes of administration, brought up to the present time, with a completeness not to be met with elsewhere. A considerable portion of the work which preceded the remainder in London, has also enjoyed the advantage of a further revision by the author expressly for this country, and in addition to this the editor, Professor Carson, has made whatever additions appeared desirable to adapt it thoroughly to the U. S. Pharmacopoeia, and to the wants of the American profession. An equal improvement will likewise be observable in every department of its mechanical execution. It is printed from new type, on good white paper, with a greatly extended and improved series of illustrations. Gentlemen who have the first volume are recommended to complete their copies without delay. The first volume will no longer be sold separate. When we remember that Philology, Natural His- tory, Botany, Chemistry, Physics, and the Micro- scope, are all brought forward to elucidate the sub- ject, one cannot fail to see that the reader has here a work worthy of the name of an encyclopedia of Materia Medica. Our own opinion of its merits is that of its editors, and also that of the whole profes- sion, both of this and foreign countries—namely, " that in copiousness of details, in extent, variety, and accuracy of information, and in lucid explana- tion of difficult and recondite subjects, it surpasses all other works on Materia Medica hitherto pub- lished." We cannot close this notice without allud- ing to the special additions of the American editor, which pertain to the prominent vegetable produc- tions of this country, and to the directions of the United States Pharmacopoeia, in connection with all the articles contained in the volume which are re- ferred to by it. The illustrations have been increased, and this edition by Dr. Carson cannot well be re- garded in any other light than that of a treasure which should be found in the library of every physi- cian.—Neto York Journal of Medical and Collateral Science, March, 1854. The third edition of his " Elements of Materia Medica, although completed under the supervision of others, is by far the most elaborate treatise in the English language, and will, while medical literature' is cherished, continue a monument alike honorable to his genius, as to his learning and industry.— American Journal of Pharmacy, March, 1854. The work, in its present shape, and so far as can be judged from the portion,before the public, forms the most comprehensive and complete treatise on materia medica extant in the English language.— Dr. Pereira has been nt great pains to introduce into his work, not only ail the information on the natural, chemical, and commercial history of medi- cines, which might be serviceable to the physician and surgeon, but whatever might enable his read- ers to understand thoroughly the mode of prepar- ing and manufacturing various articles employed either for preparing medicines, o> for certain pur- poses in the arts connected with materia medica and the practice of medicine. The accounts of the physiological and therapeutic effects of remedies are given with great clearness and accuracy, and in a manner calculated to interest as well as instruct the reader.—The Edinburgh Medical and Surgical Journal. PEASELEE (E. R.), M. D. Professor of Anatomy and Physiology in Dartmouth College, ice. HUMAN HISTOLOGY, in its applications to Physiology and General Pathology, designed as a Text-Book for Medical Students. With numerous illustrations. In one handsome royal 12mo. volume. (Preparing.) The subject of this work is one, the growing importance of which, as the basis of Anatomy and Physiology, demands for it a separate volume. The book will therefore supply an acknowledged deficiency in medical text-books, while the name of the author, and his experience as a teacher for the last thirteen years, is a guarantee that it will be thoroughly adapted to the use of the student. PIRRIE (WILLIAM), F. R. S. E., Professor of Surgery in the University of Aberdeen. THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M. D., Demonstrator of Anatomy in the University of Pennsylvania, Surgeon to the Pennsylvania Hospital, &c. In one very handsome octavo volume, of 780 pages, with 316 illus- (Just Isszied.) trations We know of no other surgical work of a reason- able size, wherein there is so much theory and prac- tice, or where subjects are more soundly or clearly taught—The Stethoscope. There is scarcely a disease of the bone or soft parts, fracture, or dislocation, that is not illustrated by accurate wood-engravings. Then, again, every instrument employed by the surgeon is thus repre- sented. These engravings are not only correct, but really beautiful, showing the astonishing degree of perfection to which the art of wood-engraving has arrived. Prof. Pirrie, in the work before us, has elaborately discussed the principles of surgery, and a safe and effectual practice predicated upon them. Perhaps no work upon this subject heretofore issued is so full upon the science of the nrt of surgery.— Nashville Journal of Medicine and Surgery. One of the best treatises on surgery in the English language.—Canada Med. Journal. Our impression is, that, as a manual for students, Pirrie's is the best work extant.—Western Med. ana Surg. Journal. AND SCIENTIFIC PUBLICATIONS. 23 RAMSBOTHAM (FRANCIS H.), M.D. TgE> PRTNCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY, in reference to the Process of Parturition. Sixth American, from the last London edition. Illustrated with one hundred and forty-eight Figures, on fifty-five Lithographic Plates. In one large and handsomely printed volume, imperial octavo, with 520 pages. In this edition, the plates have all been redrawn, and the text carefully read and corrected. It is therefore presented as in every way worthy the favor with which it has so long been received. From Prof. Hodge, of the University of Pa. To the American public, it is most valuable, from its intrinsic undoubted excellence, and as beine Hie best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive throughout OUT COlintTV. ' iv ■uiuueiiuui oar country We recommend the student who desires to mas- ter this difficult subject with the least possible trouble, to possess himself at once of a copy of this work.—American Journal of the Med. Sciences. It stands at the head of the long list of excellent obstetric works published in the last few years in Great Britain, Ireland, and the Continent of Eu- rope. We consider this book indispensable to the library of every physician engaged in the practice of midwifery.—Southern Med. and Surg. Journal. When the whole profession is thus unanimous in placing such a work in the very first rank as regards the extent and correctness of all the details of the theory and practice of so important a branch of learning, our commendation or condemnation would be of little consequence; but regarding it as the most useful of all works of the kind,°we think it but an act of justice to urge its claims upon the profession.—N. O. Med. Journal. RICORD (P.), M. D,, Surgeon to the Hopital du Midi, Paris, &c. ILLUSTRATIONS OF SYPHILITIC DISEASE. Translated from the French, by Thomas F. Betton, M. D. With the addition of a History of Syphilis, and a complete Bib- liography and Formulary of Remedies, collated and arranged, by Paul B. Goddard, M.D. With fifty large quarto plates, comprising one hundred and seventeen beautifully colored illustrations. In one large and handsome quarto volume. Blanchard & Lea having purchased the remainder of this valuable work, which was originally sold as a subscription book, are now prepared to offer it to the profession. It is universally known as one of the handsomest volumes as yet presented in this country, and as containing the only ex- tended and thorough series of illustrations on the subject. by the same author. (Now Ready.) A TREATISE ON THE VENEREAL DISEASE. By John Hunter, F. R. S. With copious Additions, by Ph. Ricord, M. D. Edited, with Notes, by Freeman J. Bumstead, M. D. In one handsome octavo volume, with plates. From the Translator's Preface. " M. Ricord's annotations to Hunter's Treatise on the Venereal Disease were first published at Paris, in 1S40, in connection with Dr. G. Richelot's translation of the work, including the contri- butions of Sir Everard Home and Mr. Babington. In a second edition, which has recently ap- peared, M. Ricord has thoroughly revised his part of the work, bringing it up to the knowledge of the present day, and so materially increasing it that it noyv constitutes full one-third of the volume. " This publication has been received with great favor by the French, both because it has placed within their reach an important work of Hunter, and also because it is the only recent practical work which M. Ricord has published, no edition of his Traite des Maladies Veniriennes having appeared for the last fifteen years." Every one will recognize the attractiveness and value which this work derives from thus preseming the opinions of these two masters side by side. But, it must be admitted, what has made the fortune of the book, is the fact that it contains the "most com- plete embodiment of the veritable doctrines of the H&pilal du Midi," which has ever been msde public. The doctrinal ideas of M. Ricord, ideas which, if not universally adopted, are incontestably dominant, have heretofore only been interpreted by more or less skilful secretaries, sometimes accredited and sometimes not. In the notes to Hunter, the master substitutes him- self for his interpreters, and gives his original thoughts to the world, in a summary form it is irue, but in a lucid and perfectly intelligible manner. In conclu- sion we can say that this is incontesiably the best treatise on syphilis with which we are acquainted, and. as we do not ofien employ the phrase, we may be excused for expressing the hope that it may find a place in the library of every physician—Virginia Med. and Surg Journal. BY THE SAME AUTHOR. LETTERS ON SYPHILIS, addressed to the Chief Editor of the Union Medicale. With an Introduction, by Amedee Latour. Translated by W. P. Lattimore, M. D. In one neat octavo volume. Blanchard & Lea are now the publishers of this valuable work. From the Translator's Preface. To those who have listened to the able and interesting lectures of our author at the Hopital du Midi this volume will need no commendation; while to those who have not had the pleasure to which we allude, the book will commend itself by the truths it contains, told as they are in the same inimitable style in which M. Ricord delivers hia clinical lectures. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON VENEREAL DISEASES. With a Therar peutical Summary and Special Formulary. Translated by Sidney Doane, M. D/ Fourth edition. One volume, octavo, 340 pages. 26 BLANCHARD & LEA'S MEDICAL RIGBY (EDWARD , M. D., Physician to the General Lying-in Hospital, &o. A SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. Second American Edition. One volume octavo, 422 pages. ROYLE (J. FORBES), M.D. MATERIA MEDICA AND THERAPEUTICS; including the Proparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States. With many new medicines. Edited by Joseph Carson, M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. With ninety-eight illustrations. In one large octavo volume. of about seven hundred pages. This work is, indeed, a most valuable one, and will fill up an important vacancy that existed be- tween Dr. Pereira's -most learned and complete system of Materia Medica, and the class of pro- ductions on the other extreme, which are neces- sarily imperfect from their small extent.—British and Foreign Medical Review. SKEY (FREDERICK C), F. R. S., &.C. OPERATIVE SURGERY. In one very handsome octavo volume of over 650 pages, with about one hundred wood-cuts. Its literary execution is superior to most surgical treatises. It abounds in excellent moral hints, and is replete with original surgical expedients and sug- gestions.—Buffalo Med. and Surg. Journal. With high talents, extensive practice, and a long experience, Mr. Skey is perhaps competent to the task of writing a complete work on operative sur- gery.—Charleston Med. Journal. We cannot withhold from this work our high com- mendation St.udentsand practitioners will find it a* invaluable teacher and guide upon every topic con- nected with this department.—JV. Y. Medical Ga- zette. A work of the very highest, importance—a work by itself.—London Med. Gazette. SHARPEY (WILLIAM), M.D., JONES QUAIN, M.D., AND RICHARD QUAIN, F. R. S., &c. HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidy, M.D. Complete in two large octavo volumes, of about thirteen hundred pages. Beautifully illustrated with over five hundred engravings on wood. We have no hesitation in recommending this trea- tise on anatomy as the most complete ku that sub- ject in the English language; and the only one, perhaps, in any language, which brings the stale of knowledge forward to the most recent. disco- It is indeed a work calculated to make an era in anatomical study, by placing before the student every department of his science, with a view to the relative importance of each ; and so skilfully have the different parts been interwoven, that no one who makes this work the basis of his studies, will hereafter have any excuse for neglecting or undervaluing any important particulars connected with the structure of the human frame; and whether the bias of his mind lead him in a more especial manner to surgery, physic, or physiology, he will find here a work at once so comprehensive and practical as to defend him from exclusiveness on the one hand, and pedantry on the other.— Monthly Journal and Retrospect of the Medical Sciences. veries.—The Edinburgh Med. and Surg. Journal. Admirably calculated to fulfil the object for which it is intended.—Provincial Medical Journal. The most complete Treatise on Anatomy in the English language.—Edinburgh Medical Journal. There is no work in the.English language to be preferred to Dr. Quain's Elements of Anatomy.— London Journal of Medicine. SMITH (HENRY H.), M. D., AND HORNER (WILLIAM E.), M.D. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, with about six hundred and fifty beautiful figures. These figures are well selected, and present a complete and accurate representation of that won- derful fabric, the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its superb artistical execution, have been already pointed out. We must congratu- late the student upon the completion of this Atlas, as it is the most convenient work of the kind that has yet appeared ; and we must add, the very beau- tiful manner in which it is ,l got up" is so creditable to the country as to be flattering to our national pride.—American Medical Journal. SARGENT (F. W.), M. D. ON BANDAGING AND OTHER POINTS OF MINOR SURGERY. In one handsome royal 12mo. volume of nearly 400 pages, with 128 wood-cuts. The very best manual of Minor Surgery we have We have carefully examined this work, and find it seen; an American volume, with nearly four hundred welt executed and admirably adapted to the use of pages of good practical lessons, illustrated by about the student. Besides the subjects usually embraced one hundred and thirty wood-cuts. In these days in works on Minor Surgery, there is a short chapter of "trial," when a doctor's reputation hangs upon on bathing, another on anaesthetic agents, and an a clove hitch, or the roll of a bandage, it would be appendix of formulae. The author hasgiven an ex- cellent work on this subject,and his publishers have illustrated and printed it in most beautiful style— '1 he Charleston Medical Journal. nge well, perhaps, to carry such a volume as Mr. Sar- gent's always in our coat-pocket, or, at all events, to listen attentively to his instructions at home.— Buffalo Med. Journal. STANLEY (EDWARD). A TREATISE ON DISEASES OF THE BONES. extra cloth, 286 pages. In one volume, octavo, AND SCIENTIFIC PUBLICATIONS. 27 ddtxt™^ STILLE (ALFRED), M. D. FKINCIPLES OF THERAPEUTICS. In one handsome volume. (Preparing.) SIMON (JOHN), F. R. S. GENERAL PATHOLOGY, as conducive to the Establishment of Rational Principles for the Prevention and Cure of Disease. A Course of Lectures delivered at St. 1 homas s Hospital during the summer Session of 1850. In one neat octavo volume. (Lately SMITH (TYLER W.), M. D., Lecturer on Obstetrics in the Hunterian School of Medicine. ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OF OBSTETRICS. In one large duodecimo volume, of 400 pages. SIBSON (FRANCIS), M. D., Physician to St. Mary's Hospital. MEDICAL ANATOMY. Illustrating the Form, Structure, and Position of the Internal Organs in Health and Disease. In large imperial quarto, with splendid colored plates. To match "Machse's Surgical Anatomy." (Preparing.) SOLLY (SAMUEL), F. R. S. THE HUMAN BRAIN; its Structure, Physiology, and Diseases. With a Description of Ihe Typical Forms of the Brain in the Animal Kingdom. From the Second and much enlarged London edition. In one octavo volume, with 120 wood-cuts. SCHOEDLER (FRIEDRICH), PH.D., Professor of the Natural Sciences at Worms, &c. THE BOOK OF NATURE; an Elementary Introduction to the Sciences of Physics, Astronomy, Chemistry, Mineralogy, Geology, Botany, Zoology, and Physiology. First American edition, with a Glossary and other Additions and Improvements; from the second English edition. Translated from the sixth German edition, by Henry Medlock, F. C. S., &c. In one thick volume, small octavo, of about seven hundred pages, with 679 illustrations on wood. Suitable for the higher Schools and private students. (Now Ready.) This volume, as its title shows, covers nearly all I seen presents the reader with so wide a ran<*e of ele- tte sciences, and embodies a vast amount of informa- mentary knowledge, with so full illustrations, at so tion for instruction. No other work that we have | cheap a rate.—Silliman's Journal, Nov. 1853. TAYLOR (ALFRED S.), M. D., F. R. S., Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital. MEDICAL JURISPRUDENCE. Third American, from the fourth and improved English Edition. With Notes and References to American Decisions, by Edward Hartshorne M. D. In one large octavo volume, of about seven hundred pages. (Just Issued.) We know of no work on Medical Jurisprudence which contains in the same space anything like the same amount of valuable matter—N. Y. Journal of Medicine The American editor has appended several im- portant facts, the whole constituting by far the best, most reliable, and interesting treatise on Medical Jurisprudence, and one that we cannot too strongly recommend to all who desire to become acquainted with the true and correct exposition of this depart- ment of medical literature.—Northern Lancet. No work upon the subject can be put into the hands of students either of law or medicine which will engage them more closely or profitably ; and none could be offered to the busy practitioner of either culling, for the purpose of casual or hasty reference, that would be more likely to afford the aid desired. We therefore recommend it as the best and safest manual for daily use.—American Journal of Medical Sciences. We have heretofore had reason to refer to it in terms of commendation, and need now only state that, in the edition before us, the author has com- pletely revised the whole work, making many addi- tions and alterations, and brought it fully up to the present state of knowledge. The task of the A meri- can editor has been to present all the important facts and cases that have recently occurred in our own country, bearing on the subjects treated of. No better work can be placed in the hands of the physician or jurist.—St. Louis Medical and Surgical Journal. BY THE SAME AUTHOR. ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Edited, with Notes and Additions, by R. E. Griffith, M. D. In one large octavo volume, of 688 pages. The most elaborate work on the subject that our literature possesses.—British and Foreign Medico- Chirurgical Review. It contains a vast body of facts, which embrace all that is important in toxicology, all that is necessary to the guidance of the medical jurist, and all that can be desired by the lawyer. — Medico- Chirurgical Review. One of the most practical and trustworthy works on Poisons in our language.—Western Journal oj Medicine. It is, so far as our knowledge extends, incompa- rably the best upon the subject; in the highest de- gree creditable to the author, entirely trustworthy, and indispensable to the student and practitioner.— N. Y. Annalist THOMSON (A. T.), M. D., F. R. S., &c. DOMESTIC MANAGEMENT OF THE . SICK ROOM, necessary in aid of Medical Treatment for the Cure of Diseases. Edited by R. E. Griffith, M. D. In one large royal 12mo. volume, with wood-cuts, 360 pages. 28 BLANCHARD & LEA'S MEDICAL TOMES (JOHN), A MANUAL OF DENTAL PRACTICE. on wood. In one handsome volume. (Preparing.) F. R. S. Illustrated by numerous engravings TODD (R. B.), M. D., AND BOWMAN (WILLIAM', F. R. S. PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With numerous handsome wood-cuts. Parts I, II, and III, in one octavo volume, 552 pages. Part IV will complete the work. The distinguishing peculiarity of this work is, that the authors investigate for themselves every fact averted; and it is the immense labor consequent upon the vast number of observations re- quisite to carry out this plan, which has so long delayed the appearance o^ its completion. The first portion ot Part IV, with numerous original illustrations, was published in the Medical News and Library for 1853, and the completion will be issued immediately on its appearance in London. Those who have subscribed since the appearance of the preceding portion of the work can have the three parts by mail, on.remittance of $2 50 to the publishers. TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. VOLUME VI, for 1853, large 8vo., of 870 pages, with numerous colored plates and wood-cuts. Also to be had, a few sets of the Transactions from 1848 to 18o3, in six large octavo volumes, price $25. These volumes are all published by and sold on account of the Association. WATSON (THOMAS), M. D., &c. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Third American, from the last London edition. Revved, with Additions, by D. Francis Condie, M. D , author of a "Treatise on the Diseases of Children," &c. In one octavo volume, of nearly eleven hundred large pages, strongly bound with raised bands. Confessedly one of the very best works on the principles and practice of physic in the English or any other language.—Med. Examiner. Asa text-book it has no equal; as a compendium of pathology and practice no superior.—New York Annalist. To suv that it is the very best work on the sub- ject now extant, is but to echo the sentiment of the medical press throughout the country. — N. O. Medical Journal. Of the text-books recently republished Watson is very justly the principal favorite.—Holmes's Rep. to Nat. Med. Assoc. By universal consent the work ranks among the very best text-books in our language.—Illinois and Indiana. Med. Journal. Regarded on all hands as one of the very best, if not the very best, systematic treatise on practical medicine extant.—St. Louis Med. Journal. We know of no work better calculated for being placed in the hands of the student, and for a text- book ; on every important point the author seems to have posted up his knowledge to the day.— Amer. Med. Journal. One of the most practically useful books that ever was presented to the student. — N. Y. Med. Journal. WALSHE (W. H.), M. D., Professor of the Principles and Practice of Medicine in University College, London. DISEASES OF THE HEART, LUNGS, AND APPENDAGES; their Symptoms and Treatment. In one handsome volume, large royal 12mo., 512 pages. We consider this as the ablest work in the En- I the author being the first stethoscopist of the day.— giish language, on the subject of which it treats; | Charleston Medical journal. WHAT TO OBSERVE AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. Publi.-hed under the authority of the London Society for Medical Observation. In one very handsome volume, royal 12mo , extra cloth (Just Issued.) We hail the appearance of this book as the grand desideratum.—Charleston Medical Journal. This is truly a very capital book. The whole medical world will reap advantages from its publi- cation. The medical journals will soon show its influence on the character of the •'Reports of Cases" which they publish. Drs. Ballard and Walshe have given to the world, through a small but useful medical organization, a cheap but invaluable book. We do advise every reader of this notice to buy it and use it. Unless he is so vain as to imagine him- self superior to theordinary human capacity, he will in six months see its inestimable advantages.— Stethoscope. WILDE (W. R.), Surgeon to St. Mark's Ophthalmic and aural Hospital, Dublin. AURAL SURGERY, AND THE NATURE AND TREATMENT OF DIS- EASES OF THE EAR. In one handsome octavo volume, with illustrations. (Now Ready.) So little is generally known in this country concerning the causes, symptoms, and treatment of aural aliections, that a practical and scientific work on that subject, from a practitioner of Mr. WiideV great experience, cannot fail to be productive of much benefit, by attracting attention to thi> ob.-cure class of disea^es, which too frequently escape attention until past relief. The im- mense n.unlier of cases which have come under Mr Wilde's observation for many years, have afforded him opportunities rarely enjoyed lor investigating this branch of medical science, and hi* work may therefore be regarded as of the highest authority. laws, and amenable to the same general methods of Ueaimem as other morbid processes The work is uoi written to supply the cravings ot popular patro This *ork certainly contains more iiiformupon on the subject lo which it is devoted than any other with which we are acquainted. We feel graieful o the autlioi for his rnanlul effort to rescue this depart ment of the experience of the last three or four years has suggested, and has made such alterations a> the progress of scientific investigation has rendered expedient. The illustrations have ertso been materially augmented, the number of plates being increased from eight to sixteen. The " Diseases of the Skin," by Mr. Erasmus Wilson, m;iy now be regarded as the standard work in thai department of medical literature. The plates by which this edition is accompanied leave nothing to be desired, so far as excellence of delinea- tion ami perfect accuracy of illustration are con- «orned.—Medico-Chirurgical Review. Of these plates it is impossible to speak too highly. The representations of the various forms of cuta- neous disease are singularly accurate, and the color- ing exceeds almost anything we have met wilh m point of delicacy and finish.—British and Foreign Medical Review. BY THE SAME AUTHOR. ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON SYPHILITIC ERUPTIONS. In one small octavo volume, beautifully printed, with four exqui- site colored plates, presenting more than thirty varieties of syphilitic eruptions. connection with its transmissibility, pathology and sequelae. His facts and references will, we are satis- fied, be received as decisive, in regard to many questiones vexatoe. They appear to u's entitled t« notice at some, length.—Medical Examiner. Dr. Wilson's views on the general subject of Syphilis appear to us in the main sound and judi- cious, and we commend the book as an excellent monograph on the subject. Dr. Wilson has pre- sented us a very faithful and lucid description of Syphilis and has cleared up many obscure points in BY THE same author. (Now Ready.) HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preserva- tion and Management. Second American, from the fourth London edition. One neat volume, royal 12mo., with numerous illustrations. Copies can be had done up in paper covers for mailing, price 75 cents. WHITEHEAD (JAMES), F. R. C. S., &c. THE CAUSES AND TREATMENT OF ABORTION AND STERILITY; bein°- the Result of an Extended Practical Inquiry into the Physiological and Morbid Conditions of the Uterus. Second American Edition. In one volume, octavo, 368 pages. (Now Ready.) this department of our profession, that the practi- tioner who does not consult the recent works on the complaints of females, will soon find himself in the rear of his more studious brethr»n. This is one of the works which must be studied by those who would know what the present stn te of our knowledge is respecting the causes and treatment of abortion and sterility.—The Western Journal of Medicine and Surgery. The simple title of this work gives a very imper feet idea of its contents. The subject of sterility occupies a mere fraction of space, and upwards of one-half of the whole volume is taken up with an elaborate account, of menstruation as a physiological process, and of the disorders which Us deviations tVotn health are apt to produce.—Medical Chirurg. Review. guoh are the advances made from year to year in 30 BLANCHARD & LEA'S MEDICAL WEST (CHARLES), M. D., Physician to the Hospital for Sick Children, Ac. LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. Second American, from the Second and Enlarged London edition. In one volume, octavo, of nearly five hundred pages. (Now Ready:) From the Preface to the Second Edition. In the preparation of the second edition of these Lectures, the whole work has been carefully revised. A few formulae have been introduced and a minute alphabetical index has been appended while additions amounting altogether to fifty pages, have been made, wherever I felt that more extended observation, or more careful reflection had enabled me to supply some of those deficiencies which I am well aware, are still far too numerous. The work now contains the result of 640 observations, and 199 post-mortem examinations, chiefly made among 16,276 children who came under my notice during the ten years of my connection with the Children's Infirmary in Lambeth. We take leave of Dr. West with great respect for his attainments, a due appreciation of his acute powers of observation, and a deep sense of obliga- tion for this valuable contribution to our profes- sional literature. His book is undoubtedly in many respects the best we possess on diseases of children The extracts we have given will, we hope, satisfy our readers of its value; and yet in all candor we must say that they are even inferior to some other parts, the length of which prohibited our entering upon them. That the book will shortly be in the hands of most of our readers we do not doubt, and it will give us much pleasure if our strong recommend- ation of it may contribute towards the result.—The Dublin Quarterly Journal of Medical Science. Dr. West has placed the profession under deep ob- ligation by this able, thorough, and finished work upon a subject which almost daily taxes to the ut- most the skill of the general practitioner. He has with singular felicity threaded his way through all the tortuous labyrinths of the difficult subject ho has undertaken to elucidate, and has in many of the darkest corners left a light, for the benefit of suc- ceeding travellers, which will never be extinguished. Not the least captivating feature in this admirable performance is its easy, conversational style, which acquires force from its very simplicity, and leaves an impression upon the memory, of the truths it conveys, as clear and refreshing as its own purity. The author's position secured him extraordinary fa- cilities for the investigation of children's diseases, and his powers of observation and discrimination have enabled him to make the most of these great advantages.—Nashville Medical Journal. BY THE SAME AUTHOR. (hi Press.) AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCE- RATION OF THE OS UTERI. Being the Croonian Lectures for the year 1854. In one neat octavo volume, extra cloth. This work will appear in the " Medical News and Library" during the latter portion of 1854, and will be published in a separate forni about December. WILLIAMS (C. J. B.), M. D., F. R. S., Professor of Clinical Medicine in University College, London, &c. PRINCIPLES OF MEDICINE; comprising General Pathology and Therapeu- tics, and a brief general view of Etiology, Nosology, Semeiology, Diagnosis, Prognosis, and Hygienics. Edited, with Additions, by Meredith Clymer, M. D. Fourth American, from the last and enlarged London edition. In one octavo volume, of 476 pages. (Now Ready.) This new edition has been materially enlarged and brought up by the editor. It possesses the strongest claims to the attention of the medical student and practitioner, from the admirable manner in which the various inquiries in the different branches of pathology are investigated, combined, and generalized by an experienced practical physician, and directly applied to the investigation and treatment of disease.—Editor's Preface. The best exposition in our language, or, we be- lieve, in any language, of rational medicine, in its present improved and rapidly improving state.— British and Foreign Medico-Chirurg. Review. Few books have proved moTe useful, or met with a more ready sale than this, and no practitioner should regard his library as complete without it, —Ohio Med. and Surg. Journal. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON DISEASES OF THE RESPIRATORY ORGANS; including Diseases of the Larynx, Trachea, Lungs, and Pleurae. With numerous Additions and Notes, by M. Clymer, M. D. With wood-cuts. In one octavo volume, pp. 508. YOUATT (WILLIAM), V. S. THE HORSE. A new edition, with numerous illustrations; together with a general history of the Horse; a Dissertation on the American Trotting Horse; how Trained and Jockeyed; an Account of his Remarkable Performances; and an Essay on the Ass and the Mule. By J. S. Skinner, formerly Assistant Postmaster-General, and Editor of the Turf Register. One large octavo volume. BY THE SAME AUTHOR. THE DOG. Edited by E. J. Lewis, M. D. With numerous and beautiful illustrations. In one very handsome volume, crown 8vo., crimson cloth, gilt. AND SCIENTIFIC PUBLICATIONS. 31 B. & L. subjoin a condensed list of their publications in general and educational Literature, of which more detailed catalogues will be furnished on application. HISTORY AND BIOGRAPHY. BROWNINGS HISTORY OF THE HUG UK NOTS. 1 vol.8vo. CAMPBELLS (LORD) LIVES OF THE LORD CHAN* ELLORS OF ENGLAND, from the earl- iest limes 10 the Reign of George IV. 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