With the Compliments of the Author. 
PAPERS UPOB 
GENITO-URINARY SURGERY. 
By A. T. CABOT, A.M., M.D., 
Surgeon at the Mass. General Hospital. 
XIV. Five Cases of Rupture of the Urethra Treated by Ex- 
ternal Urethrotomy and Suture. 
XV. A Case of Cyst of the Kidney, apparently Cured by a 
Single Aspiration. 
XVI. A Case of Cancer of the Urethra. 
XVII. A Case of Scirrhous Cancer of the Bladder in which 
Villi were not found in the Urine, and a Case of 
Cystitis with Ulceration, in which Villi were found 
in the Urine, although no Tumor existed. 
XVIII. A Case of Sacculated Bladder, with Autopsy. 
BOSTON: 
DAVID CLAPP & SON. 
1 89 6. PAPERS UPON 
GENITO-URINARY SURGERY. 
BY A. T. CABOT, A.M., M.D., 
Surgeon at the Mass. General Hospital. 
XIV. Five Cases of Rupture of the Urethra Treated by Ex- 
ternal Urethrotomy and Suture. 
XV. A Case of Cyst of the Kidney, apparently Cured by a 
Single Aspiration. 
XVI. A Case of Cancer of the Urethra. 
XVII. A Case of Scirrhous Cancer of the Bladder in which 
Villi were not found in the Urine, and a Case of 
Cystitis with Ulceration, in which Villi were found 
in the Urine, although no Tumor existed. 
XVIII. A Case of Sacculated Bladder, with Autopsy. 
BOSTON: 
DAVID CLAPP & SON. 
1 89 6. FIVE CASES OF RUPTURE OF THE URETHRA TREATED 
BY EXTERNAL URETHROTOMY AND SUTURE. 
Tiie intractable nature of traumatic stricture of the urethra is so 
well known that no apology is required for a report of some cases iu 
which an attempt was made, by immediate suture of the ruptured 
urethra, to furnish accurate coaptation of the divided ends of the canal 
and by promoting rapid and smooth healing of the mucous membrane, 
to avoid the formation of a stricture. 
French surgrous' have interested themselves much in this class of 
injuries. According to Salvait,1 their practice up to 1858 was to treat 
these cases by simple perineal incision. From that time till 1875 it 
became more and more the practice to search for the posterior part of 
the urethra by an early perineal section with the object of introducing 
and fastening in a catheter (sonde a demeure). 
Some difference of opinion still existed, however, among the best 
men during the decade commencing in 1880 as to whether it was well 
to introduce the catheter at once or whether it was better to simply 
establish perineal drainage by the early operation, and some days 
later, after the swelling had gone down, to search for the posterior 
urethra and place the sonde a demeure in position. 
The attempt to temporize led to the frequent resort to aspiration of 
the bladder for the purpose of relieving its tension until the urethra 
was able to resume its functions or until the formation of a perineal 
abscess or a urinary infiltration compelled a resort to more radical 
measures. 
During this decade the tendency towards an immediate suture of 
of the urethra began to show itself, and the very thorough and con- 
• Th£se, Paris, 1882, 1883. 4 
vincing experimental work of Dr. Kaufmann, of Zurich, showing that 
an immediate suture greatly lessened the extent of the cicatrix in the 
urethral wall, gave an impetus to a further trial of this method, even 
in the face of considerable opposition from some good authorities. 
Since that time a number of cases have been reported in which the 
immediate suture of the canal has been followed by the best results 
iu the way of quick and safe healing. 
The effect of urine leakage in favoring the formation of indurated, 
contracting fibrous tissue, and the part it consequently plays in stricture 
of the urethra, has been pointed out by Mr. Reginald Harrison and con- 
stantly urged by Dr. J. P. Bryson of St. Louis. A ruptured urethra 
offers the best possible conditions for the formation of tough fibrous 
tissue under the constant irritation of the urine. 
No one who has cut down upon a ruptured urethra and found the 
partially or completely separated ends of the canal lying in a ragged 
cavity filled with a blood-clot; and then, after the application of stitches, 
has seen the integrity of the urethra restored so that a catheter passes 
smoothly by the point of union into the bladder without a hitch, can 
doubt that by the operation the amount of cicatricial tissue will be 
greatly lessened and the chance of a troublesome stricture by so much 
reduced. 
If the urine can be kept from coming in contact with this closely 
joined wound for a few days, it will give time for such adhesion as to 
practically seal the tissues against subsequent urine leakage. When 
this can be successfully accomplished, it seems rational to hope that 
the cicatrix will be a thin and supple one and will not lead to trouble- 
some stricture formation. 
Hitherto, the formation of a stricture has been regarded as the in- 
evitable consequence of a urethral rupture; and while in the fortunate 
cases of moderate severity, the regular passage of a sound may keep 
the urethra permeable, a neglect of this precaution may be expected 
to result in a rapid closure of the stricture. In other cases of greater 
severity the stricture shows a constant tendency to contract in spite 
of every effort to keep it open, and repeated operations are required 
to avert the serious consequences of a complete closure. 
In the cases of sutured urethra that I have found reported up to 
this time, the patients have been kept under observation for too short 5 
a time to enable us to get any idea as to the final result in the matter of 
stricture formation. 
That I might contribute as far as possible towards supplying informa- 
tion on this point, I have followed my cases by every possible clue, 
and have succeeded in finding and examining three of them at periods 
from four and a half to two and a half years after the operation. I 
shall be greatly obliged for information as to either of the others that 
may have come under the observation of other practitioners. 
Case 1. J. C., aged eighteen, fell astride of a barrel twenty-six 
hours before entrance to the hospital, August 28, 1891. Urination 
was impossible, and an attempt to pass a catheter had failed. 
Under ether a perineal section was immediately done. The bulbous 
portion of the urethra was so crushed as to be divided across two-thirds 
of its extent, so that only a narrow strip of the roof of the canal 
remained intact. This rent in the urethra was closed by four catgut 
stitches so taken as to include the muscular and cavernous tissue sur- 
rounding the urethra but not encroaching upon the raucous membrane. 
When these were tied the canal was so restored that a catheter slipped 
in with perfect ease. It was fastened in place and the outer part of 
the wound was left open so that in case of any leakage the urine 
should not be shut up within the tissues. Recovery was uneventful. 
The catheter was removed upon the tenth day and the patient left the 
hospital well at the end of twenty days. 
For two years this patient had intermittent treatment with sounds 
and bougies, in accordance with advice given him at the hospital. A 
No. 27 French bougie was the largest size passed in this time. He 
was seen and examined on March 10, 1896, when he told me that he 
had not had an instrument passed for three years. The urine was 
clear and passed in a good stream. Sounds Nos. 26 and 28, French, 
passed without resistance and caused no bleeding. 
Case 2. P., aged twenty-three, entered the Massachusetts General 
Hospital, October 17, 1891. Twenty-four hours before entrance he 
had fallen astride a pail which caused a sharp hemorrhage from the 
urethra. He was unable to pass water, and his physician could not 
enter a catheter. 
Operation was done immediately. While being etherized there was 
a sharp hemorrhage from the urethra, which was restrained by 6 
pressure in the perineum. The perineum was occupied by a large clot 
of blood. Upon cutting into this and turning it out, the two ends of 
the urethra, completely separated, were found in the cavity. The 
ends of the canal were joined by six catgut stitches, and upon tying 
these the hemorrhage, which had been persistent and troublesome, 
w7as entirely stopped. A catheter was slipped in easily and was left 
in place. 
The patient proved unruly, and on several occasions removed the 
catheter. Presently a small abscess formed in the perineum which 
required opening. After this all went well; and he was discharged 
November 11th, thirty-one days after operation. 
Case 3. J. J. G., aged thirty-one, entered the hospital, July 2» 
1892. He had fallen astride a joist forty-three hours before entrance. 
This was followed by hemorrhage from the urethra and the formation 
of a large hematoma in the perineum, and the patient was unable to 
pass water nor could a catheter be introduced. 
At the time of entrance the bladder reached to the umbilicus. The 
distention of the bladder was relieved by aspiration, and as soon as 
arrangements could be made operation was done. Upon cutting into 
the perineum by the median line, a blood-clot about the size of an orange 
wTas found and turned out. In this case there was complete separation 
of the urethra and there was some difficulty in finding the proximal 
end, but when it was found the two portions of the urethra were easily 
united by catgut stitches and a catheter put in place. The patient 
made a good recovery, and went home twenty-three days after the 
operation. 
Case Jf. J. D. P., aged twenty-one, entered the hospital June 29, 
1893. In jumping off a bicycle he had struck the perineum on the 
rear wheel with so much force as to break the wheel. This caused 
ecchymosis in the perineum, hemorrhage from the urethra and inability 
to pass water. A large silver catheter was passed by his attendant 
under ether, and the bladder washed with boracic acid. 
The following day swelling and pain in the perineum had increased, 
and he had a chill. He was operated upon by an incision in the median 
line, and the clotted blood lying about the urethra was turned out. 
The rupture was found extending transversely across the bulb, com- 
pletely separating tie two parts. The ends of the urethra were united 7 
by catgut stitches; and these at once stopped the hemorrhage, which 
had been troublesome. The patient for a few days was pretty sick, 
with a tendency to a suppression of urine; but after this was over, he 
rapidly recovered. The catheter was out on the eleventh day, and he 
went home with the wound wholly healed on the nineteenth day. 
In answer to a letter, this patient reported in February, 1893. He 
had never had any trouble in urination and the water was perfectly 
clear. On examination by sounds the large sizes were arrested at the 
seat of the rnpture. After a No. 22 French sound had been passed 
through the stricture, it easily yielded up to a No. 25, French. One 
week later a No. 26, French, was readily passed without any exercise 
of force, and later still larger sizes were used. 
Case 5. C. F. M., aged twenty-two, entered the hospital October 
21, 1893. He had fallen astride a chair five days previous to entrance, 
since which time he had been constantly troubled with hemorrhage 
from the urethra, especially at the time of urination, with a tendency 
to swelling in the perineum. 
A perineal section was done. Clots lying about the urethra were 
turned out, and it was found that the lower part of the urethra was 
torn across, the roof of the canal being the only part intact. The 
ends were joined by catgut stitcher, and a catheter was introduced and 
left in place. The catheter was removed on the tenth day, and the 
wound was entirely closed on the twentieth day. 
The patient returned for a time to the out-patient department for 
the passage of sounds. One month after his discharge from the hospital 
an instrument of No. 30 French calibre passed easily. This patient 
was seen again February 11, 1896. At this time a No. 30 French 
sound passed with ease through the whole canal, although he had had 
nothing passed since 1893. 
In all of these cases the immediate result was good. In three of 
them the opportunity was given for an examination some years after 
any dilating instruments had been used. In Gases 1 and 5 no stricture 
was found, and instruments as large or larger than any used after the 
operation slipped past the point of rupture with perfect ease. 
In Case 4, while no interference with urination was noticed, a nar- 
rowing of the urethra was found. This narrow point was, however, 
not a hard cicatricial stricture, but was so soft and yielding that without 
the least exercise of force it was rapidly dilated to a good size. 8 
These results would certainly encourage a continuation of attempts 
to promote immediate union of the urethra when divided by violence. 
The operation is not a difficult one. A median incision opens the 
blood cavity about the urethra. After the clots have been turned out, 
a sound passed down the urethra quickly shows us the anterior end. 
If the urethra is not fully divided across, the rent is then easily seen 
and readily repaired. When the division has been complete, the 
posterior end may not be so easily found, but in a fresh rupture the 
profuse bleeding which occurs from the bulb of the urethra, instead of 
obscuring our search, serves as a guide to that which we are seeking. 
If then, the bleeding point in the posterior part of the wound is seized 
with forceps and pulled forward, the collapsed and retracted end of the 
urethra will be brought to view. In a case of longer standing, when 
the bleeding has stopped the search may be more difficult, in which 
event firm pressure should be made above the pubes to force the escape 
of urine to serve as a guide. 
In all of these cases the suture was made with interrupted catgut 
stitches, which were all placed before any of them were tied. Care 
was taken to include only the cavernous and muscular tissue in the 
stitches and not to encroach on the mucous membrane. In every case, 
upon tying the stitches, the hemorrhage immediately stopped. 
CONCLUSIONS. 
(1) In cases of ruptured urethra, immediate perineal section with 
suture of the urethra should be practised. 
(2) By this procedure not only do we greatly lessen the danger of 
urinary infiltration and abscess, but we also, in a large proportion of 
cases, may hope to prevent the formation of close intractable strict- 
ures. 
(3) In an early operation the search for the posterior end of the 
urethra is much easier than it is later. The hemorrhage from the 
branches of the artery of the bulb serves as a guide to that end of the 
canal. A CASE OF CYST OF THE KIDNEY APPARENTLY 
CURED BY A SINGLE ASPIRATION.1 
On November 22, 1869, Mrs. A. A. L. was seen and the following 
history was obtained: Nine years ago, after a long cramped ride, she 
had an attack of pain in her bowels. This pain was spasmodic in 
character, and was accompanied by a lump in the right side of her 
abdomen. According to her present recollection, this lump was located 
about on the level of the umbilicus. In the next four years she had 
many such attacks, which were ascribed by some physicians to “ fuecal 
deposit,” and purgation was usually followed by relief. Seven years 
ago Dr. Rich, of Worcester, told her she had a floating kidney. 
For the past five years she has been free from these attacks, until 
the 28th of last August, when she was again seized with a pain in the 
abdomen similar to that previously experienced. This was again accom- 
panied by a lump in the right side and there was some vomiting. This 
time the lump did not disappear, as it had after the previous attacks, 
but steadily increased in size till it reached its present proportions, 
about eight weeks ago. 
Since then it has remained practically stationary, though she thinks 
it varies somewhat in size and hardness from time to time. There is 
no pain about it, though occasionally there is some sensitiveness to 
pressure at different points on its surface. 
Iler bowels are regular, and there is no noticeable irregularity about 
her catamenia. There has been no disturbance of micturition, and 
nothing abnormal has been noticed about the urine. 
Examination showed a tense, elastic tumor extending from just 
below the ribs on the right side down to the level of the anterior 
1 Road before the fourth annual meeting of the American Association of Genito- 
urinary Surgeons, Altoona, Pa., June 3, 1890. 10 
superior spine of the ilium. It reached a little across the middle line 
at the level of the umbilicus, and round into the lumbar region, where 
it could be easily felt when pressed back from in front. It was smooth- 
ly ovoid in outline and slightly movable. When the patient was on 
her back it moved up and down with respiration. It could not be 
reached through the vagina, and the pelvic organs seemed to be 
healthy in every way. 
The amount of urine passed in the twenty-four hours was about a 
quart, and the specific gravity was low—from 1-006 to 1-008. It did 
not contain albumin, nor did the microscope discover any casts or 
abnormal eells. 
For a week an accurate measure of the daily amount of urine was 
made, and at the same time the patient kept a close watch on the tumor, 
to see if there were any variations in size. No definite result was 
obtained, and afterward, when under constant observation for five days, 
no change in the tumor could be detected. 
The locality and character of the tumor led to a strong suspicion 
that it was a hydronephrotic kidney, and this feeling was strengthened 
by the history of previous attacks, accompanied by the presence of a 
tumor in the same region. 
On December 14, 1889, the tumor was aspirated through the lumbar 
region. Three pints of dark-brownish fluid were drawn off, completely 
emptying the sac and causing a disappearance of the tumor. The 
abdomen was then compressed by a swathe with a pad of cotton bat. 
ting over the former site of the tumor. 
The fluid removed was examined by Professor E. S. Wood, who 
reported as follows: Color, brown. Specific gravity, 1-011. Reaction, 
very slightly acid. Albumin, 0-27 per cent. 
There was much sediment, consisting chiefly of blood, normal and 
abnormal, and of small round cells, like renal cells, most of which were 
slightly fatty; also numerous brown granular cells of the same size as 
compound granule cells, but not flatty; two cylindrical bodies, some- 
what resembling casts, one of which was brown granular and the other 
contained small round, fatty cells. 
A quantitative analysis showed that 100 cubic centimetres contained 
0-034 gramme of urea, 0-590 gramme of NaCl, and 0-270 gramme of 
albumin. 11 
The small amount of urea in this fluid, and the character of the 
cells found in it, consisting of old and fresh blood and of compound 
granule cells, makes it seem probable that this was a cyst of the kidney 
rather than a hydronephrosis. 
The cyst showed no sign of refilling, and Mrs. L. slowly gained 
strength. On March 20th (three months after the aspiration) Mrs. L. 
was seen and thoroughly examined. No tumor could be discovered in 
the right side, though there was, perhaps, a little more resistance than 
on the other side. She was still not strong, though steadily gaining. 
There had been a very decided improvement in the character of her 
urine. On March 24th the amount in the twenty-four hours was 
forty-one ounces, and the specific gravity was 1/016. The reaction 
was acid and no abnormally formed elements were to be found in the 
sediment. 
There had been no reaccumulation of fluid in the cyst in three months, 
and in this time there had been so decided a gain in the quantity and 
character of the urine that it seemed probable that there had been 
a re-establishment of function in the remaining parts of the affected 
kidney. 
This case is reported as an unusually favorable instance of what a 
simple aspiration may accomplish in these cases. A CASE OF CANCER OF THE URETHRA.1 
Tiie rarity of a primary urethral carcinoma is my reason for put- 
ting the following case on record. 
C. W. T., an elderly man, entered the Massachusetts General Hospi- 
tal, March 29, 1895, and gave the following history: 
Thirty-five years ago he had gonorrhea, from which he entirely 
recovered. Niue years ago an abscess formed in the perineum through 
which, however, no urine passed. At that time the urine passed in a 
good stream, and he never noticed any trouble in urination until one 
year ago when he began to have some difficulty in passiug water. He 
did not, however, have complete retention, and his condition improved 
somewhat under medical treatment. Nine weeks before entrance, a 
swelling appeared in the perineum which was painful, and confined him 
to bed. At the end of a fortnight it was lanced, and pus was evacu- 
ated from it. A week later the urine began to come through the open- 
ing. For a time after this he improved in his comfort; but then the 
swelling began to spread, and less and less urine passed through the 
natural passage, until all of it came through the fistulaB. Examina- 
tion showed the perineum to he occupied by an indurated mass extending 
forward beneath the scrotum, with two fistulous openings over it. The 
urethra was impervious to instruments, even of the smallest size, all 
of which were arrested at about the peno-scrotal angle. 
On April 1st, the perineum was widely laid open, considerable pus 
being evacuated from various side pockets. The walls of the abscess 
were of such a sloughy character that nothing unusual was noticed at 
that time in the character of the case. A drainage-tube was carried 
through the cavity of the abscess and was brought out in front of the 
1 Read before tbe American Association of Genito-Urinary Surgeons, at Niagara 
Falls, May 30, 1895. Microscopical sections of tbe growth were shown to the Associa- 
tion. 14 
scrotum. The greater part of the induration cleared up in a few days, 
but there still remained a hard sloughing mass at the bottom of the 
cavity about the urethra. 
Ether was again administered on April 15, 1895, and a careful ex- 
amination showed this hard tissue to be distinctly of the character of a 
neoplasm. It extended forward to the peno-scrotal angle and back- 
ward to just anterior to the triangular ligament. The prostate was 
slightly enlarged, but not more than is usual in a man of his age. 
A piece of the new growth was cut out for examination. Dr. W. 
F. Whitney, who kindly examined it, reported as follows: “ The 
bulk of the fragment is composed of large solid masses of rather small, 
slightly cylindrical epithelial cells, separated by a relatively narrow 
stroma of vascularized connective tissue. The central parts of the 
epithelial masses, which have a more or less branching character, have 
undergone necrosis.” The tumor was thus shown to be a cancer, of 
which the cells were small and cylindrical in character. 
Its origin from the urethral mucous membrane, or from some of the 
glands associated with it, was made clear by the anatomical relations 
found at the operation. The tumor was separated by a wide interval 
from the skin and did not extend in either direction beyond the perineal 
portion of the urethra. 
As regards treatment, the case came under observation too late to 
admit of any possibility of eradicating the tumor by operation and the 
escape of urine was perfectly free and painless after the perineum had 
been freely laid open. The only further treatment was directed to 
keeping the urine in a bland and unirritating state by the use of benzo- 
ate of soda and to diminish the discomforts of the sloughing mass in 
the perineum by the use of antiseptic applications. 
Dr. F. Tilden Brown, in the preparation of his article upon urethral 
diseases, in “ A System of Genito-Urinary Diseases,” etc., was able to 
find but five recorded cases of urethral carcinoma:1 those of Schustler, 
Thiersch, Guy on, Trzebicky and Guiard. In four of these, exact 
post-mortem and microscopic examinations were made, and in all four 
cases the urethral cancer was found situated in the perineal portion of 
the canal. In Schustler’s and in Guiard’s cases the perineal swelling 
1 At the time that this paper was read Dr. R. W. Taylor cited a recently reported 
case of Oberlander’s in the International Centralblatt. 15 
simulated an abscess and led to incision. These two cases were very 
like the one just reported. 
In these cases, also, the carcinoma had undergone colloid degenera- 
tion and softening. In the case that I have reported, a marked feature 
was the tendency to necrosis of the cells in the centre of the masses 
of epithelium. This was easily explained by the scanty supply of 
nourishment supplied by the sparse connective-tissue network. 
Brown says: “ The origin of urethral cancer is from the urethral 
mucous membrane, and Thiersch has drawn attention to the possibility 
of its originating in the region of a stricture. Poncet and Paget 
record cases in which the carcinoma seems to have originated from 
the margin of an old fistula.” 
Although in my case there had once been an abscess, this had not 
resulted in a fistula and there had been no evidence of a stricture, 
although one of large calibre may have existed. The cylindrical charac- 
ter of the epithelial cells suggests the possibility of the disease having 
started in one of the mucous glands (of Littrd); but the fact that the 
epithelium that covers the urethral mucous membrane in the bulbous 
portion of the canal is rather cylindrical in shape, leaves us unable to 
argue anything from the character of the cells. 
While undoubtedly a cancer of the deep urethra is a great rarity, I 
can remember one case of cancer of the penis in which the disease 
seemed to have started in the region of the fossa navicularis. In this 
connection, too, it may be interesting to put on record a case in which 
a cancer of the prostate extended forward into the urethra. 
D. A. P., an old gentleman of seventy, had been troubled for ten 
years with some difficulty of urination. In September, 1894, this 
difficulty became much aggravated, and the straining to pass water 
became extreme. In November he began to suffer pain through the 
penis and rectum, and considerable burning as the water passed. 
I first saw him February 4, 1895. He was then a thin, frail-looking 
man. The bladder at this time formed a distinct elastic ball above the 
pubes. The prostate was found to be very large and nodular. A 
diagnosis of probable malignant disease of the prostate was made, and 
the use of a catheter advised. He returned to the care of his regular 
physician, Dr. Frank Blaisdell, of Goffstown, N. H., and was for a 
time somewhat more comfortable. 16 
1 saw him again in consultation with Dr. Blaisdell, May 16, 1895. 
He was using the catheter twice in the twenty-four hours, and getting 
five or six hours of ease after its use. The examination now showed 
the prostate to be still larger and more nodular than at the previous 
examination. The point of especial interest was that, at this second ex- 
amination, I found a nodular hard mass, from three-fourths of an inch to 
an inch in diameter, extending forward along the urethra through the 
perineum and to the perineo-scrotal junction. 
This is the only case in which I have observed the extension of 
malignant disease forward from the prostate along the urethra. The 
tendency in other cases that I have seen was to extension backward 
into the bladder. A CASE OF SCIRRHOUS CANCER OF THE BLADDER IN 
WHICH VILLI WERE NOT FOUND IN THE URINE, 
AND A CASE OF CYSTITIS WITH ULCERATION, 
IN WHICH VILLI WERE FOUND IN THE 
URINE, ALTHOUGH NO TUMOR EXISTED.1 
TriE first patient was a man of fifty-five. The duration of his ill- 
ness from the appearance of the first symptoms to death was about two 
and a half years. 
The history was briefly as follows: 
Two years and a half ago, after a long ride on horseback, he had 
quite a sharp haematuria, of short duration. Soon after this he began 
to notice frequency of micturition, which was presently associated with 
pain. His pain was of two kinds; One, a dull, persistent pain, felt 
just above the pubes and sometimes to the left, sometimes to the right 
of the median line. The other pain was sharper in character, was felt 
along the uretha and through the penis, and was aggravated by mictu- 
rition. 
After the first haemorrhage there were several similar attacks of 
bleeding occurring at considerable intervals, and the severity of the 
pain and the frequency of the micturition, though somewhat intermit- 
tent, increased pretty steadily in spite of all measures for their relief. 
In March, 1888, Dr. John Homans, who saw the patient in consul- 
tation with his medical attendant, touched a stone and gave ether, 
intending to remove it by litholapaxy; but he was unable to grasp any- 
thing with the lithotrite, and the washing brought away only a little 
calcareous matter. 
This operation was followed for a few days by some relief of the 
pain. 
1 Read at the annual meeting of the American Association of Genito-urinary Sur- 
geons, May 22, 1889. 18 
Examination of the urine at this time showed nothing beyond a little 
mucus in the sediment, with many oxalate-of-lime crystals. 
In July, 1888, I saw the patient for the first time. The symptoms 
had continued about the same since March, although he had during the 
interval steadily lost flesh and strength. 
Careful examination of the urine detected nothing beyond a moder- 
ate amount of pus in the sediment. 
With the sound a stone could be felt which seemed to lie or be held 
in the upper part of the bladder, and was most easily found when the 
viscus was empty. 
Abdominal palpation revealed nothing in the bladder or kidney, and 
by the rectum only a moderate symmetrical enlargement of the pros- 
tate was felt. 
It was decided to again etherize the patient, and, if the stone still 
eluded the lithotrite, to do lithotomy. 
Ether was given early in August, 1888, and with the lithotrite the 
stone was again felt in the top of the bladder, but could not be grasped. 
The sensation imparted through the instrument was as if a calculus 
lay in a sac in the vesical wall, where it could not be reached with the 
blade of the lithotrite. 
Owing to its position, it was thought that it could probably be dealt 
with by suprapubic cystotomy, and the high incision was made after 
filling the bladder and distending the rectum with a rubber bag after 
the Garson-Petersen method. 
Upon coming down upon the bladder, a hard mass about an inch and 
a half in tranverse diameter was felt behind the pubes. It was at first 
thought that this was the encapsulated stone, but the knife thrust into 
it did not encounter a stone, nor did it open the bladder. 
This thrust did open the peritonaeum, although it was made close 
upon the upper edge of the pubes. 
By separating the tissues laterally and further investigating the con- 
dition, it was found that the central tumor extended down behind the 
pubes as far as could be felt, and was surrounded by several smaller 
nodules, which, when punctured with a needle, gave no calcareous re- 
sistance. Further, it was found that the tissues about were adherent 
to and puckered into the tumor, which was evidently a malignant new 
growth. 19 
The contracting character of this tumor, shown by the puckering of 
the tissues about it, made the diagnosis of scirrhous cancer probable, 
and its extension deeply behind the pubes toward the prostate made it 
evident that the growth could not be removed with any reasonable 
hope of present safety to the patient. In view of this and of the 
practical certainty of its return, it was decided to desist from further 
interference. The peritoneal rent was closed with a fine, continuous 
silk suture, and the outer wound was brought together with interrupted 
sutures. 
The patient made a good recovery from this operation. In the 
washings which were obtained from the bladder at this time, one bit 
was found which Dr. W. W. Gannett thought to be a piece of a new 
growth. 
From this time the disease steadily progressed, with a good deal of 
pain and a gradually increasing frequency of micturition, which seemed 
to be due largely to a progressive diminution in the size of the bladder. 
The patient finally died, April 17, 1889, with evidence of disease of 
the kidneys, which came on rapidly toward the end of life. 
At the autopsy, pyelonephritis was found, together with the local 
condition which is shown in the specimen. 
The bladder is reduced to a small size, and is attached to the pubes 
by a new growth which involves the whole anterior bladder wall and 
projects into the vesical cavity as an irregular papillomatous nodule, 
one portion of which is covered by a thick calcareous incrustation. 
The tumor outside of the bladder forms one nodule about two inches 
in diameter, which has grown into the lower end of the rectus and 
pyramidalis muscle and encroaches somewhat upon the upper edge of 
the pubes. 
Microscopical examinations by Dr. W. F. Whitney has shown this 
to be a carcinoma with much contracting intercellular tissue. The an- 
terior commissure of the prostate shows a similar carcinomatous 
change. 
The specimen does not enable one to say whether the tumor had its 
origin in the bladder wall or whether it started in the prostate. 
Klebs and some other observers think that cancer of the male blad- 
der always starts in the prostate, and, although many exceptions to 
this rule have been reported, it is doubtless true that a large proportion 20 
of the cancers situated near the neck of the bladder are prostatic in 
their origin. 
In this case clinical observation never showed any marked change 
in the prostate beyond a slight, even enlargement. The character of 
the growth was unusual among bladder tumors, and the difficulty of 
diagnosis, owing to the absence of villi in the urine, was of interest. 
In connection with this observation the writer would like to briefly 
report another case of difficult diagnosis in which villi were present in 
the urine, although no tumor existed in the bladder: 
The patient was an old man with an enlarged prostate and quite a 
severe cystitis. He was seen in consultation with Dr. Reed, of Dor- 
chester, and was suffering much from the obstruction to micturition 
caused by the prostatic enlargement. A catheter was tied into the 
bladder to relieve the constant tenesmus which made rest impossible, 
and a specimen of the urine was examined by Dr. W. W. Gannett. It 
was a foul urine, containing blood and pus, with what appeared to be 
well-marked villi from a papillomatous growth. 
The age of the patient made it seem probable that a cancerous 
growth existed in the bladder, and drainage through a perineal opening 
was advised. The family could not at first make up their minds to 
this, and when they finally sent for me the patient was moribund and 
no operation was deemed advisable. He died a few hours later. 
A partial autopsy was made, and the following is Dr. Gannett’s re- 
port on the condition of the bladder and prostate: 
“ The cavity of the bladder was enlarged and the wall was about 
three times the usual thickness. The trabeculae were fairly promi- 
nent. The mucous membrane in general was of a slatey color and quite 
opaque. Here and there in the trigonum were small areas covered 
with a fibrinous false membrane, which was firmly adherent. 
“ Each lateral lobe of the prostate was enlarged to the size of a big 
horse-chestnut, and the so-called middle lobe formed a pear-shaped 
body about the diameter and rather longer than a big olive. It meas- 
ured from the colliculus seminalis to the posterior tip seven centi- 
metres. 
“ There was a loss of mucous membrane upon portions of its upper 
surface, and also a few diphtheritic patches. 
“The whole specimen was hardened, and vertical sections were 
made through various parts. In the middle lobe of the prostate the 21 
erosian had bared the gland structure and there was a proliferation of 
the glands in the form of long acini, lined by a single layer of epithe- 
leum. These, projecting into the ulcerated surface and separated from 
each other by a thin layer of fibrous tissue, gave the appearance of 
villi, and it was probably these that were found in the urine. 
“ No evidence of cancer was found in the prostate.” 
We had here a severe cystitis with erosion of the bladder surface of 
the prostate laying bare the proliferating gland acini, and, some of 
these becoming separated and being found in the urine, presented the 
appearance of villi from a papillomatous growth. 
I do not remember to have seen this source of error in such cases 
mentioned, and it therefore seems to me important to put this report 
upon record. A CASE OF SACCULATED BLADDER, WITH AUTOPSY. 
Tiie following case of sacculated bladder presented certain points of 
practical interest. I will first report the clinical part of the case, and 
then will describe the pathological condition. 
William H. consulted me first in November, 1889. He was then 
fifty-seven years of age, and had suffered with symptoms of stone for 
three or four years. As far as could be determined, this stone origin- 
ated in the bladder, as he had never suffered from renal colic. In the 
middle of November I removed, by litholapaxy, a stone weighing 116 
grains, and composed of uric acid and urates. He made a good recov-r 
ery from this operation. The bladder was washed out with a lithola- 
paxy pump on two subsequent occasions, the first time a small quantity 
of sand and gravel coming away, and the last time the washing being 
perfectly clear. He was not seen again until March, 1891. 
At that time he again applied to me, and reported that, though very 
much more comfortable after the last operation, he was not entirely re* 
lieved of his symptoms, some frequency of passing water and slight 
pain, referred to the penis, continuing. He had used a catheter dur- 
ing this time every night, drawing each time from two to three ounces 
of residual urine. He had occasionally passed a little gravel. I 
sounded him without detecting a stone, and advised an ether examina- 
tion. 
This was made on the 18th of March, 1891. The bladder felt 
roughened to the sound, but no stone could be touched. For further 
exploration, I made a perineal incision, and the finger, introduced into 
the bladder, touched a little rough surface of stone rather high up on 
the posterior wall, where it could be barely reached with the aid of the 
hand above the pubes, pressing the bladder downward. It was made 
out that this bit of stone was a projecting portion of a calculus which 24 
Was enclosed In a pocket, and it being impossible to dislodge it from 
this pocket by any manipulation of the finger, a suprapubic incision 
was made over the point of a sound, introduced through the perineal 
wound. Through this opening above, the atone could readily be 
reached. It was found to be about the size of an English walnut, and 
to be contained in a pocket, the neck of which was not larger than a 
small pencil, and attached to this was a little, roughened bit of bone, 
projecting into the bladder cavity. The neck of the sac was gradually 
enlarged so as to admit a pair of forceps, and after many attempts to 
withdraw the stone, it was finally broken by the forceps and removed 
piecemeal. It was difficult to remove the last fragments, but with a 
scoop and irrigation this was apparently accomplished. The bladder 
cavity now seemed to be free. 
He had a slight chill the following day, with a temperature up to 
102°. From this time on he did pretty well until the 6th of April; 
but at that time the urine still contained an abundance of pus, and it 
being necessary to readjust the tubes, an examination was made under 
ether, and the bladder was searched without anything being found. 
The opening into the sac had, at this time, contracted so that it could 
with difficulty be found. The temperature again arose to 102° after 
the operation, but two days later came back to the normal point. The 
urine, which had hitherto been abundant, began soon after this to di- 
minish in quantity. It contained a little albumen, but no more than 
the pus would account for. No casts were ever detected. 
From this time on, in spite of all efforts to assist and supplement the 
action of the kidneys, he gradually failed, with a progressively dimin- 
ishing amount of urine; and about six weeks after the last exami- 
nation he died. 
At the autopsy nothing of especial importance was found, except in 
the urinary organs. The bladder was much thickened and inflamed, 
the mucous membrane being highly congested and eroded in places. 
The wall of the bladder was not much trabeculated. The ureters on 
both sides were somewhat dilated, and were slit up with the scissors 
directly through to the bladder. These incisions passed directly through 
two pockets arranged symmetrically, one associated with each ureter, 
lying a little above and outside of it. One of these pockets was the 
one from which the stone had been previously removed. It still con- 25 
tained a little fragment of stone. On the other side the pocket was 
very much more narrow, opening into the bladder by a very small 
opening, and this contained in the upper part a little calculus about the 
size of a kidney bean. This smaller pocket lay rather closer to the 
ureter with which it was associated, than did the pocket on the other 
side. A careful search of the posterior walls of the bladder revealed 
the existence of a number more pockets similar to the last one found, 
— that is, having very small communications with the bladder. A 
careful search among these failed to show any other containing a stone. 
The right ureter, which was that one associated with the smaller 
pocket, which lay closer to it than was the case on the other side, was 
considerably distended with thick, purulent material, and the pelvis of 
the kidney on that side was slightly dilated and fdled with the same 
sort of grumous material. The right kidney was somewhat shrunken, 
in a state of interstitial nephritis, with which was associated a pyelo- 
nephritis. On the other side the nreter was more nearly normal, 
though somewhat dilated. That kidney, the left, was in a state of 
moderate pyelo-nephritis. 
The condition, then, which led to the fatal result, was an interstitial 
nephritis, with a pyelo-nephritis superadded to it. The pyelitis was 
no doubt secondary, and was unquestionably aggravated by the obstruc- 
tion to the ureters due to the pressure upon them of the sacculated 
stones. 
The symmetrical disposition of the sacculi, and the thickness of their 
walls led me to think that there might be some congenital cause for 
them. I therefore had the walls of these pockets carefully examined 
under the microscope, and found that the muscular coat of the bladder 
ran a considerable way up on the pockets and ceased towards the apex, 
— the outermost part of the pockets being simply composed of the 
mucous membrane surrounded by fibrous tissue. 
In regard to vesical diverticula, Orth says they are situated prefera- 
bly on the sides and base of the bladder, and also on the posterior wall. 
They are either congenital or acquired. In the congenital cases,—also 
in the acquired cases which are brought about by the pressure of 
stones,—we find all the coats of the bladder in their walls, even the 
muscular layer. On the contrary, in the greater number of the ac- 
quired diverticula, the condition is a hernia of the mucous membrane 26 
between enlarged bands of muscular tissue. Only when they are small 
can a part of the muscular coat still be shown in their wall. 
These hernias of the mucosa are often very numerous in hypertro- 
phied bladders, and may be symmetrically arranged in accordance with 
the arrangement of the muscular bundles. They are at first quite 
small and flat, but become more rounded and larger, until they reach 
the size of a walnut, an egg, or a child’s head. The opening between 
the muscular fibres, at first angular, becomes more rounded with the in- 
crease of size, but may be very small, even when the diverticulum is large. 
In my case the way in which the muscular coat ran part of the way 
up on the walls of the diverticula, seemed to show that in part, at least, 
they depended upon a congenital condition for their production. The 
openings in all of them were round and very small, instead of irregu- 
lar, as you would expect if the mucous membrane had simply pushed 
out between the muscular bundles. The muscular tissue surrounding 
their necks was more abundant and ran much further up on their walls, 
than would be the case if it simply represented the muscular bundles 
which had been pushed aside as the mucous membrane forced out be- 
tween them. So that I am inclined to regard this as a case of con- 
genitally diverticulated bladder, in which perhaps the mechanical 
effects of the pressure of urine had some influence in enlarging the 
pouches. The fact that there were stones in but two of them, and that 
in one case the stone was very small, shows that they were not pockets 
formed by the pressure of stones. 
This case illustrated very well the importance of making a digital 
exploration of the bladder in cases of uncertain diagnosis, where per- 
sistent symptoms continue, and also showed how much more easily such 
conditions can be reached and treated by supra-pubic incision than 
through the perineum. 
I think there can be but little doubt that it is better practice to 
crush a stone in situ, when it is so thoroughly encapsulated as in this 
case, rather than to try to free it by incision. For a considerable in- 
cision in the neck of the sac would have exposed the patient to the 
danger of urine infiltration and perivesical abscess. 
Finally, the possibility of the symmetrical arrangement of pockets 
should be borne in mind when operating on these cases, and a knowl- 
edge of this point may lead to the discovery of pouches that would oth- 
erwise be overlooked.