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UL0! THE CRANES  OF IBYCUS!"
        REVIEW OF THE EEPOET

COXCEEXIXG THE  LAST  ILLXESS-OF

      DR.  ALDEN  MARCH,
CRITICAL  COMMENTS  ON THE IMPROPER  MEDICAL
  TREATMENT OF THE CASE, AND STRICTURES ON
     PITIFUL DEVICES FOR CONCEALMENT
BY
y
    CHARLES A.  ROBERTSON, A.M., M. D.,
OPHTHALMIC AND AURAL SURGEON OF THE ALBANY HOSPITAL, AND SURGEON IN CHAHGE
     OF DISEASES OF THE EYE AT ST. PETER'S HOSPITAL, ALBANY, N. Y.
            CO '

{REPRINTED FROM THE N.'y^CEDICAL JOURNAL, JANUARY, 1870.]
            NEW YORK:
D. APPLE TON AND  COMPANY,
         90, 92 & 94 GRAND STREET.
               1870. 
>/z

 /M3I52-R
 |?70 
REVIEW OF  THE  REPORT OF  "LAST  ILLNESS
              OF DR.  ALDEN MARCH."
    In the October issue of the New York Medical Journal
appeared a statement* concerning the last illness of Dr. Alden
March, which purports to have been prepared " for the infor-
mation of the many friends  and  acquaintances" of the  de-
ceased.  A reprint of this article has been liberally distributed
among the students of the Albany Medical College, and else-
where.
    It is the purpose of the writer to examine the article criti-
cally, both in regard to the nature of the information it  im-
parts, and as to its value as a contribution to  medical  science.
It challenges  attention on account of numerous peculiar fea-
tures in the notions entertained respecting physiology, pathol-
ogy, therapeutics, and  facts.
    The medical attendants of the patient were three in num-
ber, of whom Dr. James  H. Armsbv, elsewhere said to have
been " nearly related " to  Dr. March, is named first, as having
chief charge of the case.  Dr. Armsby, the attending physician,
was seconded by Drs. James McNaughton and James P. Boyd
as physicians in counsel.   Dr. March, it is stated, " was occa-
sionally visited " by other physicians, but whether they concur-
red or  disagreed with the  physicians in charge, or only called
as friends, is not stated.   Incidentally, however, it is made to
appear that they did not concur.   But, dismissing these con-
siderations, let us endeavor to learn what ailed  Dr.  March,
   1 This statement is reprinted in full for the reader's information, as an
Appendix to this paper. 
4
REVIEW  OF THE REPORT OF
 what opinion was entertained by his medical  attendants, and
 what was done intelligently for his relief.
    Referring to this document, we learn that  Dr. March was
 in the " scventv-fourth year of his a^e."  He had been to New
 Orleans, returned, resumed " business with his usual alacrity; "
 had a " very fatiguing ride in the country, exposed to rain and
 cold."  "Went to  his bed quite  ill with fever, restlessness,
 pain over the region of the bladder, great thirst, and constant
 desire to  void  urine."  At night took cathartic. Next day
 " kept quiet, took diluents and  small  doses of opium  during
 the day."  " Next night had a warm bath, followed by Dover's
 powder."  " In  a few days " (how many not stated) ." he was out
 again, and attending to business."  " On the 6th  day of  June
 he was in his pew " at church, suffering great distress " from
 his old trouble."   His  old trouble  was an  affection  of the
 bladder and prostate gland, as we  are told, on the  second
 page, that Dr.  Tully, his former partner, died of disorder in
 this region, and Dr. March " remarked that he had the  same
 disease."  After the attack in church, he was conveyed to the
 residence of his son-in-law, and " there he remained until his
 sufferings were ended by death."  " He seemed possessed, from
 the first, with the idea that he had a great  accumulation of
 fasces in the  rectum, and that after very free evacuation  from
 the  bowels."   "His most troublesome  symptom was  pain
 about the neck of  the bladder, and an  irresistible desire to
 void urine every fifteen or twenty minutes." " Seldom passed
more than an ounce or two at a time," and " was passing daily
 from two to three quarts of apparently healthy urine."  It is
 said that  Dr. March had, for several  months, "  voided  from
three to six  quarts  daily," as he stated.  Its specific gravity,
 during part of his  illness, was 1005;  later it became 1010.
 " Attention was early called to a tumor occupying the lower
part of the abdomen, and distinctly traceable from the pubes
nearly to the umbilicus."  " The tumor was regarded as a dis-
tended and thickened bladder."  " There was not, at any time
much difference of  opinion  regarding  the nature of trie  case'
or the proper treatment to be pursued."  Exactly what the
diagnosis was is not stated, and the reader is left  to draw his
own inferences. 
         " LAST ILLNESS OF  DR. ALDEN  MARCH.'1       5

   Treatment.—At first,  five grains  of calomel and one of
opium, as a cathartic, the first night; next day rest, diluent
drinks, and small doses of opium.  Under a distinct heading,
we are told that " the treatment was  such as is usually pur-
sued in such case*, warm  baths, fomentations, diluent drinks,
anodyne injections, anodyne suppositories introduced into the
rectum, etc."  Every attention requisite was paid to regimen
and nursing, and every urgent symptom relieved as speedily
as possible.  The use of a catheter " was chiefly resorted to as
a means of exploration," and, therefore, does not properly come
under the head of treatment.  Still, it is convenient to note it
here.   The  catheter was  passed  on  two occasions:  the first
time, it is said, " the instrument passed, without difficulty, its
whole  length,  without  entering  the bladder,  but bringing
away clotted blood! "  The second time, " a few days  before
his death," the patient was chloroformed, and  a " longer in-
strument than usual was employed."  This " wras passed readily
the full length of an ordinary catheter," when it " met a firm,
resisting body, and seemed  to  fall into a cul-de-sac, in which
its point was fixed."   " The first attempt to introduce a cathe-
ter was made about a, fortnight before he died ; " he died eleven
days after confinement to  the house.
   " Uremic symptoms became more marked in the last two
days.   Hiccough, delirium, and drowsiness, became more de-
cided, his urine passed without effort, and, the last day, with-
out apparent consciousness."  The patient died on the morning
of June 17th,  the eleventh day after his distress in church.
   Such, in brief, is a summary of what is prepared, printed,
and published, for the information of the readers of this re-
markable paper.
   Under the  head of "Remarks" a very few words of infor-
mation as to post-mortem appearances are given,  and some ob-
servations and queries are made, that are suggestive, at least,
of another purpose than to enlighten those  who have sought
information regarding this  most interesting and instructive
case.
   Before proceeding to analyze and estimate this paper, the
reviewer will here introduce a report of the post-mortem ex-
amination of Dr. March, both because it has been inadequately 
6
REVIEW OF THE  REPORT  OF
presented by the medical  attendants themselves, and because
it will throw  light  on a  ju<t  analysis of the  narration of  the
nature and management of the  case.   This  report  was pre-
pared by Dr.  Edward R. Hun, at the request of Dr.  Armsby,
prior to  the  publication of the article  under review, and  re-
ceived his approbation.   Its correctness is also attested by  the
gentlemen whose names  are  signed to it, and by others who
were present  at the autopsy.

                    Autopsy or Alden March.
   Body  well nourished.  Palpation of the abdomen revealed the pres-
ence of a hard globular tumor occupying the hypogastrium.
   The abdomen was  laid open by  a crucial incision.  The  abdominal
Avails contained  a considerable layer of adipose tissue and the muscles  pre-
sented a healthy color.   Upon turning back the flaps, the bladder was found
to be distended,  and occupied the hypogastric region from the pubes to the
umbilicus, the fundus being a little  to the left of the median line.  There
were some old adhesions between the omental and vesical peritonceum.  A
trocar was introduced into the anterior portion of the bladder, and rather
more than a quart of slightly-turbid urine  was  drawn off.   A longitudinal
incision having been made along its anterior wall, the internal  surface of
the bladder was  brought into view, and was found to present the reticulated
appearance usually met with in cases where obstruction has been offered
to the free flow of urine, but there was no abnormal thickening of the walls
of the organ.  A deep depression existed  behind  the  prostate,  owing to
the enormous hypertrophy of  this gland.  A catheter was now  introduced
through the urethra into the bladder without difficulty.  The bladder, with
the  prostate and a  part of the membranous portion of the urethra, was re-
moved from the body in a mass, and the prostatic enlargement was now
well  shown, and appeared mainly due to hypertrophy  of the two lateral
lobes.
   A- catheter was passed from the bladder into the urethra until it emerged
externally, and then the incision already made along the anterior wall of
the bladder was prolonged downward through  the upper wall of the  ure-
thra, the catheter serving as a guide for the knife.   This having been done,
it was found that, although the prostatic portion of the urethra was  laid
open, yet the membranous portion  remained uncut. It was also observed
that  the connective  tissue lying anterior to the prostate gland and neck of
the bladder was stained and infiltrated with blood, although there was no
evidence of any  urinary infiltration.  The middle, lobe of the prostate  was
enlarged in such a manner as to form a cul-de-sac just below the vesical
orifice of  the urethra.   The kidneys were  rather larger than  usual  and
contained several cysts  filled with a straw-colored fluid, which  cvsts were
situated in the cortical  substance acd projected beyond the  surface of the 
  The words :  this paper [page 7th], in the  sentence following the
report of the  autopsy, have seemed equivocal  to some persons not
familiar with  medicine.  It is  hardly necessary to say that the re-
ference, as the context shows, is to the paper under review, and not
to the valuable report of the autopsy by Dr.  E. Ii.  Hun. 
 
LAST ILLNESS OF DR.  ALDEN  MARCH."        7
 organ.  The pelves of both kidneys were enlarged, but whatever fluid they
 may have contained, escaped unnoticed when the ureters  were divided.
 The renal tissue appeared somewhat congested, but was otherwise normal,
 and subsequent microscopic examination showed no alteration of the Mal-
 pighian bodies or uriniferous tubules.  The other abdominal viscera pre-
 sented nothing abnormal.
^   The head and thorax were not examined.
<.%    (Signed)                           Edward R. Hux,
 ■  iH                                     J. R. BOUI.WARE,
                                        Francis Burdick,
                                        Charles H. Porter.

     It  seems almost incredible that so many  errors  of judg-
 ment could be fallen into, so many mistakes in practice com-
 mitted, as appear in this paper.   It is unaccountable that  a
 paper, so lacking in clearness, so abundant in mistiness, should
 profess to issue for the  purpose of information.   The case was,
 professionally, an interesting one, and Dr. March was person-
 ally a man held in high consideration.  It is well known that,
 in this locality, great curiosity was felt to learn all the features
 of his illness, and it is no secret that, after his death, the ani-
 madversions respecting  his treatment were censorious and
 severe.   After waiting  patiently more than three  full months
 to ascertain the particulars and circumstances of the case, there
 appears this paper, in all important  matters not less vague and
 equivocal than the responses of the Delphic oracle.
     Considering well, however, what is unavoidably said, and
 fathoming carefully what is thereby inevitably implied, we
 ask, after studying  this paper, what was the matter with Dr.
 March ?  Interrogate the symptoms, examine his  medical his-
 tory, investigate his condition, as narrated, and it must seem
 that an error could scarcely be made by a physician of ordi-
 nary intelligence.  Here  is an  old man, subject to  retention or
 incontinence of urine for  more than ten years, so as to require
 a urinal for  his vade rnecum,  suddenly seized, after  exposure
 to cold and wet, with distress in the urinary organs and inabil-
 ity to evacuate his bladder naturally, and, being a surgeon, he
 tries to obtain relief by means of a  catheter.   He is unable to
 accomplish  the  introduction of the instrument, partly on ac-
 count of pain, and partly because of the inconvenience  of
 manipulating on one's own person.   The troublesome symp- 
8
REVIEW'  OF THE REPORT OF
toms multiply, the tumor detected in the hypogastrium aug-
ments, pain and desire to pass water persistently increase, a
sense of impaction in the rectum distresses him,  and from
time  to time, with forcible effort, a little water is expelled—
what explanation occurs to a mind medically  trained ?   What
other diagnosis than  retention of urine  can  be suggested  by
such symptoms in  a patient with such a history %
   The first prompting and effort for help, manifested by the
patient himself trying to introduce a catheter, proclaims that,
while his mind was clear, he  recognized the nature of his ail-
ment, and the proper  means of relief.   Why did not his med-
ical attendants also recognize it, and resort to the same means ?
They answer that they did, but " the parts were very tender,"
and use of  the catheter " wTas delayed  at his request," and also
that " there seemed no urgent necessity for it! "  Numerically
the reasons abound!  The first reason is  simply puerile.   Be-
cause a process is painful, is a physician to refrain from it, and
leave his patient to struggle on, and  die, even ?  The  second
reason has but little weight.  It was  natural and proper, un-
questionably, to respect the wish  of the  patient, especially as
he was a medical man, but here, as it  always  does, the respon-
sibility rested with the professional attendants,  and both duty
to the patient and manliness on their part required them to
assume the jurisdiction.  The third reason, if valid, was  suf-
ficient, and to adduce  the other reasons throws  a doubt in the
reader's mind  upon their conviction of its validity.   They tell
us that, while they were procrastinating,  " means wrere  being
resorted to, in the mean time, to allay irritation so as to facili-
tate the passage of an instrument, if necessary! " that is, if Dr.
March should  ever happen, in their estimation,  to have  reten-
tion of urine, they meant to  do something!  This, too, after
we are told on the previous page  that they had observed a
tumor in the abdomen, which they regarded  as a " distended
and  thickened bladder!"   Just why they  regarded  it  as
"thickened" (before the autopsy)  is not quite clear from any
data produced. We accept the word distended, however, and
ask what distended it  but urine ? How it  happened to become
so, we readily understand.   " Retention  of urine, dependent
upon  enlargement of the prostate  gland, is liable to be pro- 
         " LAST ILLNESS OF  DR. ALDEN  MARCH."       [)

duced by the slightest exposure to cold."—(" Gross's Surgery,"
vol. ii., p. 741.)
   The opinion of the medical  attendants, if we may judge
from the  treatment, would, however, seem to have been that
inflammation existed, and  that upon allaying this by appro-
priate means the patient would be able naturally, or by art, to
empty the distended viscus.  They  felt no urgency to heed
the monition, obstaprincipils, "for he  was passing,"they say,
" daily from two to three quarts of apparently healthy urine,"
enough " to prevent, it was  supposed, ursemic poisoning from
its [urea] retention in the bladder."  If inflammation  existed,
where was the evidence %  Acute cystitis is a  very uncommon
disease, and generally  terminates within a week.   Its main
symptoms are a feeling of weight and pain in the hypogastric
region, augmented by  movement and  by  pressure.  Pain is
also  felt  in  the iliac and sacro-lumbar regions;  great deal of
febrile disturbance—not  " moderate  fever  in the daytime ! "
urine voided drop by drop—not " an ounce or two at a time ! "
At the neck of the bladder there is a scalding sensation, when
the urine is emitted guttatim by straining.  The  urine is of
increased specific gravity—not 1005 ! high colored, and con-
tains blood and pus—not the " color of pale sherry," not "  ap-
parently  healthy " urine.—(See Da Costa " On Medical Diag-
nosis."1)  This,  then, could not have been inflammation. The
symptoms did not indicate  it.
   We must,  then, return to  the diagnosis—retention  of
urine, owing to enlargement of the prostate gland.  Even then
he was deemed safe by his attendants, for he was passing, they
assert,  more than  the  standard quantity of urine, and was
emitting  a  small quantity  every fifteen or twenty minutes.
Still it was no criterion that retention, fatally-dangerous reten-
tion, did  not exist, because  he was passing water from time to
time.  An old  Frenchman was brought to the Middlesex Hos-
pital, supposed by his friends to have dropsy.   Being  interro-
gated, he said he formerly had some stoppage, but now " passed
plentv of water." His bladder, however, was  found distended,
a catheter was introduced  with some  difficulty, and  several
quarts of urine drawn off!  Too  late, though; an error of
diagnosis had  been committed  by his friends, a mistake in 
10
REVIEW  OF THE REPORT OF
treatment by  his physicians, and he  died.—(See " Watson's
Practice,11 p. 744.)  Said Dr. March, according to the paper
under review, " I pass quite water enough, why give  me un-
necessary pain ? "  The  pain was not inflicted,  although he
"was surrounded by sympathizing friends, tender nurses, and
experienced and attentive medical advisers," and, like the old
Frenchman, he died too.  The chief difference is, that one had
his water drawn off before death, the other after; but, in both
cases, too late to be of any other service than to establish a
fact in diagnosis, and add  one more regret to the list for what
" might have been ! "
   Perhaps Dr. March was passing more than a normal quan-
tity of water, yet we must not judge his case relatively to others,
but to himself.   He had been passing before  his illness the
enormous quantity, varying from three to six quarts !  at least,
as we are told, and now, while tormented by " excessive thirst,"
and drinking a " large amount [quantity] of ice-water," he had
fallen off to between two to three  quarts !   What had become
of the difference ?  The difference between two to three quarts
and three to six quarts is one to three quarts !   Was this dif-
ference (one to three  quarts) accumulating in the  distended
bladder ?  If any considerable portion of it was collecting there,
was not this an appalling consideration ?  Was this a  time to
delay and dally with sedatives and anodynes, to  pour diluent
fluids into  a patient, who was telling as plainly as figures can
speak, that he had in him  already more fluid than the urinary
organs could relieve him of?  Was this  an indication that a
catheter should be used " chiefly " for the purpose of  " explo-
ration "  in order to ascertain how long  the urethra was, and
how large and hard the prostate was ?   This was a novel use
of the instrument, surely, but a most unwarrantable thing to
do for such purpose f' chiefly," when the patient was supposed
to be suffering  from  inflammation—declared by " his most
troublesome symptom," " pain about the neck of the bladder."
   Perhaps the difference, above noted, of one to three quarts
was supposed to be suppressed, as we  see, under the  head of
Remarks, something  said of " ischuria renalis !" and so the
retention was still insignificant in the minds  of  Dr.  Armsbv
and the  others.   Ischuria renalis, when, instead of the normal 
         "LAST ILLNESS OF DR. ALDEN MARCH."      11

quantity of about one quart per diem, a patient is secreting
from two to three quarts of urine daily !  Ischuria renalis, sup-
pression of secretion by the  kidneys ;  are the gentlemen seri-
ous '.
   Dismissing this, however, let us revert again to the figures.
He was  passing as we  are told " an ounce  or  two of urine
every fifteen or twenty minutes."  This is sufficiently lax and
indefinite.   A difference of one hundred per cent, in measure-
ment, and twenty-five per cent, in time, when a patient's safety,
his life  even, depends on accuracy of observation, is serious.
But let us strike an average of quantity of urine voided and
of intervals of its emission, and we shall find that four quarts
was the quantity of urine necessarily evacuated in twenty-four
hours.  It follows then,  either that he was not passing so much
as " an ounce or two " at a time, or that he voided a good deal
more than  between two to three quarts a day.  The dilemma
is unfortunate, for it discovers a sad inappreciation of the vital
importance of precision.   The  whole statement is palpably
based on sheer conjecture, and  it is evident that no actual
measurement was  observed, either as to the  quantity passed
from  time  to  time, or  the aggregate quantity in twenty-four
hours.   It  seems  much more probable that  a drachm or two
at a time, as rumored, would  have been a closer  guess  than
an ounce or two, since it is what  is  more likely to occur in
cases of partial retention.
    The diagnosis of retention of urine, owing to enlargement
of the prostate gland, as a predisposing cause, and exposure to
cold,  as an exciting cause, being unmistakably established by
the data furnished in the account of the case, let us examine
the treatment.
    " The treatment was such as  is usually  pursued  in  such
cases,"  we  are gravely told.   It  consisted of "warm baths,
diluent drinks, anodyne  injections,  anodyne suppositories intro-
duced into the rectum,  etc." (whatever that may be).  " Small
doses of opium during the day " are also mentioned. By whom
such  treatment  is  " usually  pursued  in such cases" is not
stated.   Most assuredly it is not by the general profession.  If
it is usually done by the signers of the paper under considera-
tion, no one will presume to contest  their claim to originality, 
12
REVIEW OF  THE  REPORT OF
 at least.  Diluent  drinks, large quantities of ice-water, when
 a man is in agony because the organ, which is soon to be called
 on to receive these fluids, is already stretched to dreadful ten-
 sion with excess of water!  Anodynes, opiates solid and fluid,
per orem anumque !   Mature, with  agonizing voice, is crying
 piteously for relief—what is  to  be done, afford the relief, or
 stifle the cry ?  Stifle the cry ! says the logic of this usual treat-
 ment !  It was done; and the " spirit quietly departed."  Had
 this been  a  crying child, it would not have been  surprising,
 had a hireling, and not over-discerning nurse, administered a
 soothing anodyne,  instead of affording nourishment  to  the
 hungry infant, to allay the craving of its stomach and hush its
 cry; but we hardly expected  such treatment to  be practised
 and defended by medical men.
    It is very clear, from the  account, that the  patient was in
 danger of ursemic poisoning.   His bladder was distended from
 pubes to umbilicus.  However, he was passing urine " in suffi-
 cient quantity daily to prevent, it was supposed, ursemic poi-
soning from its retention in the bladder" Yet he was already
"occasionally delirious,  and  exhibited nervous symptoms;"
" but these were attributed to the free use of anodynes."  The
thoughtful reader is more likely  to regard them as  the escort
of that procession  of  " ursemic  symptoms" which " became
more marked in the last two days."
    We read in this paper: "It is not probable that ursemia is
often caused by mere retention of urine in the bladder, even
when a very small  quantity is voided  in twenty-four hours."
Why, uraemia not only "not often" but never occurs directly
from urine retained in the bladder!  The mucous  membrane
lining the bladder  is not an absorbing  surface.1  If the urine
is absolutely retained, it may become putrid, and the urea,
combining during the decomposition with twTo atoms of water^
is converted into carbonate of ammonia, and renders the urine
alkaline; but  the urea, of which the blood has once been  de-
purated by the kidneys  and in  solution, passed through the
ureters  into  the bladder as a  constituent of  the urine,°is not
   1 See article,  " Can  Medicinal Articles  be  absorbed by  the  Mucous
Membrane of the Bladder ? "—Medical Times and Gazette, April 10, 1869
Consult, also, on this point, an article in May (1869) number of this Journal' 
         "last  illxess  of dr.  alden march."       13

again taken  into the circulation, to poison the blood by its
presence.  If the bladder be surcharged,  the conduits  from
the kidneys,  that is, the  ureters,  are  necessarily overfilled,
and the pelves of the kidneys charged to repletion with urine
that cannot be transmitted.  Of course, their functions  must
be  seriously  disturbed, and, if  the impediment—that is, the
urine in the  bladder—be not removed, all action of the kid-
neys  will be suspended,  the effete azotized  product called
urea will not be eliminated from the blood, but  will accumu-
late :  disorder of the nervous centres occurs, " nervous symp-
toms," analogous to  those produced by many narcotic poisons
(" anodynes "), soon  exhibit themselves, and, if the secretion is
not restored,  the patient dies comatose.   The spirit quietly de-
parts, in a stupor deep and painless enough, without need of
" small  doses of opium during the  day," or " anodyne injec-
tions " and " anodyne suppositories," to increase and intensify
that stupor.
    Will it  be urged, in  vindication of the unaccountable
method displayed in managing this  case, that an  attempt was
made to evacuate the bladder, but it was found  impossible to
introduce a catheter ? It is strange that the attempt was made
at all, if it was not necessary to  draw off the urine; if it was
necessary, it is more  than  strange—it is  wicked, if not crimi-
nal—that all  further  attempts were  finally abandoned, and the
patient  left to his fate.  Oh, but, we are told, " ursemic symp-
toms were not so urgent as to warrant puncturing the bladder."
Indeed! Ursemia is not such a gentle, tractable affair, that it
may be trusted or slighted until it  becomes urgent.   The pa-
tient  is like a vessel drifting in a  storm toward a lee-shore.
Far away the sailor faintly discerns  the scarcely-perceptible
land, which a glimmer, through  a rift in the clouds, shows for
a moment.   " Land  on the lee-bow! " cries the lookout.  The
captain, in fancied security, has been " laying-to" his craft,
with only sail enough to keep her steady, while the gale sends
blast after blast howling among spars and shrouds.  The bil-
lows sweep the decks from stem  to quarter, and to attempt to
carry  sail in such a storm would seem madness to one not un-
derstanding the perils which that  kindly beam of light had
disclosed.  Drifting  passively must inevitably insure the de- 
14            review  of the report of
struction of all on the lee-shore.  To spread sail  may seem like
a challenge to the mad elements, and may result in  carrying
away the masts, which already bend like whip-sticks before the
tempest, or the vessel may be driven beneath the inexorable
waters.  Both alternatives are dangerous, but the skilful mari-
ner speedily makes a choice.  Quickly the necessary close-reefed
sails are spread, and, keeping her course close to the wind, the
imperilled ship reaches the  broad, open main,  safe from  one
danger, at least.   The first symptoms of ursemia are as urgent
as the first sight of a lee-shore, and demand as  much  decision
and promptitude.  If the catheter cannot be introduced, punc-
ture of the bladder becomes  an imperative necessity.   The ob-
jection urged is  that puncture through the rectum, or above
the pubes, might jeopardize life by  urinary infiltration.  If
these considerations obtained so  weightily as to preponderate
against interference in these regions, then interpubic puncture
could have been made, against which the objection raised does
not lie.   But there was no more danger of urinary infiltration
in this case than in any other case of retention.  The argument
made is not  against the applicability of puncture in this case,
but  against  the operation of puncture altogether.   It either
was or was not a proper thing to do.  If the former, no timidity
should have stood in the way of its performance; if the latter,
then all talk about danger of urinary infiltration is irrelevant
and trifling.
   We are  perfectly astounded  at the self-stultification and
the disregard of physiology  and pathology exhibited by the
remarks and queries in the last three sentences of this lumi-
nous paper.  We read: " In the examination that was made of
the urine, the proportion of urea contained in it was below the
average; * but was that caused by the absorption of that con-
stituent after it got into the bladder ?  Is it not more probable
that it was retained in the blood  by  the diseased action of the
kidney, as in ischuria renalis ?   Such, at all events, was the
view taken by those in charge of this case, and made them dis-
inclined to an operation (puncture) of such ^doubtful utility."
The fact in physiology, that the lining of the bladder is not an
absorbing surface, has already been  considered.  Let us look
for the  stultification.  Turning back three pages to Professor 
          " LAST ILLNESS OF  DR. ALDEX MARCH."      15

 Mosher's test of the urine, we find mention made of the low
 specific gravity, the absence of diabetic sugar, of albumen, of
 the slightly acid reaction, and of the fact that there was " urea
 in  a given  quantity less than  the average, but, as he passed
 more urine than the average daily, the whole quantity of urea
 voided might  be equal to the average " (and we  may add,
 might exceed  the  average).  Forgetting all this, in their pre-
 cipitate zeal to vindicate  themselves, Dr. Armsby and his as-
 sociates in the  case go on to assert that they did not resort to
 a trocar to puncture the bladder and relieve  the patient from
 his distress and peril, because, according to  their view, the
 apparent deficiency of urea, where no actual deficiency existed,
 was owring to the urea being retained (the italics are their own)
 as in ischuria renalis; that is, on one page we are told that  in
 twenty-four hours a normal quantity  of urea  was secreted, and
 on  the other we are told that the reason why no instrumental
 aid was attempted  wras, because in twenty-four hours a normal
 quantity of urea was not  secreted !  This is very much like
 the logic of the person who returned the cracked vessel to the
 lender, and  defended himself by saying that it was  cracked
 when he  got it, that he never borrowed the vessel, and that it
 was whole when he returned it!  Then, too, it is made to ap-
 pear that the reason why the urine was not drawn off by art,
 was not owing to  the difficulty in introducing a catheter, not
 to the fact that he was passing plenty of water and there was
 no need of it, not to  the  danger of urinary  infiltration from
 puncture, but because of " diseased action of the kidney as  in
 ischuria renalis."   So it seems it was disease of the  kidneys,
 after  all, that  was under  treatment, and very bad treatment,
 too, for that!   It  seems a little tardy, to be sure, to speak  of
 it, and it is very singular that entire absence  of evidence  of
 renal trouble should have existed.
    According  to Professor Mosher's tests, the urine was per-
fectly healthy.   A low specific gravity and excess of water
existed, but where  diluent drinks were freely given  this was
natural, and to  be expected, unless there were  " diseased action
of the kidney,  as in ischuria  renalis."   It  is an occasional
individual peculiarity of certain persons to void an excessive 
16
REVIEW  OF THE REPORT OF
 quantity  of water, and  some habitually pass very  dilute
 urine.1
    Again, he was  drinking  diluents freely, and the observa-
 tion is made by Bischoff that the ingestion of a large quantity
 of  water  diminishes the excretion of urea.  Then, too, the
 patient was an old man,  and interstitial changes were lessened
 in  activity, and in a corresponding degree the elimination of
 urea was less rapid.2  Therefore, it were no evidence that this
 patient had disease of the kidneys, even if it were shown that
 the quantity of urea was absolutely instead of relatively dimin-
 ished.
    We come now to the report  of the autopsy prepared by
 Dr. Hun.  He speaks  of the kidneys as presenting a healthy
 appearance on inspection, with exception of being somewhat
 congested and  having on  the surface several cysts projecting
 from the cortical substance.  The existence of cysts on the sur-
 face of  the kidneys is unimportant in this connection, for they
 are not supposed to exert any influence to pervert  the action
 of the organ.  The paper says " the kidneys exhibited evidence
 of disease and former inflammation ; "  but what evidence and
 what kind of disease, is left in the mist and unstated—except
 that adhesions and cysts are mentioned.  It would satisfy scien-
tific curiosity to know to what the kidneys could be adherent
 except to the fat in which they were embedded !  (Dr. March
 weighed over one hundred and ninety pounds.)  Dr. Hun says
 that the pelves of both kidneys were distended, as  is usual in
 cases of retention.   The Malpighian  bodies and uriniferous
 tubules he declares to have been found healthy on subsequent
 examination with the microscope.   The other statement is that
 " in the tubular part there was some evidence of disease," but,
 with the same indefiniteness that characterizes all essential parts
of this remarkable  paper, no information is vouchsafed as to
the  nature of the evidence, or of the disease.  This is hardly
what we should expect in a printed paper claiming the atten-
tion and respect of scientific men.   However, the fact that the
kidneys secreted abundantly, and that no morbid product what-
ever existed in  the urine, is conclusive that any pathological
      1 Beale, "On Urinary Diseases,"  p. 80.
      2 Analyses, by Leoanu, Journal de Pharmacie, tomexxv. 
         "LAST ILLNESS OF DR. ALDEN MARCH."      17

change discovered in the kidneys must have been exceedingly
trivia], and had nothing whatever to do with the death of the
patient.
   " The bladder was found enlarged and much changed in
its structure," is the loose generality of one statement.   Dr.
Hun says that it contained more than a quart of turbid urine;
the precise quantity over, he  informs the writer, was not
measured.  The internal  surface presented the usual  appear-
ance found when obstruction has long prevented the free flow
of urine.  As the bladder has been preserved, it may be ex-
amined, it is presumed, by any  one curious to see it, although
changed by the preservative fluid.   The observer will find the
middle coat,  perhaps,  slightly  thickened, and the muscular
fibres as  distinct as the fleshy columns of the heart.   The
prostate gland, as both Dr. Hun and Dr. Armsby  state, is
largely hypertrophied, measuring fully twice the normal diam-
eter in every direction.   The middle lobe, isthmus, or trans-
verse process, as it is variously  termed, does not appear to be
developed like the lateral lobes, however, but it is carried up-
ward, and put on stretch, as a thick membrane by the enlarge-
ment of the lateral lobes.  Query : Was this the  obstacle to
the introduction of the  catheter encountered by the medical
attendants ?
   At the autopsy a catheter was introduced into the  bladder
by the gentleman who  performed the sectio cadaveris.  He
used an ordinary catheter, which he found of sufficient length
to penetrate the bladder ; as he  stated to the reviewer.  He
said that, upon well depressing  the handle of the instrument,
its beak passed over the obstacle and entered the cavity of the
viscus.   In his paper, Dr. Armsby says: " The instrument
passed readily the whole length of an ordinary catheter, until
it met a firm, resisting body and seemed to fall into a cul-de-sac,
in which  its  point was fixed.  It was repeatedly withdrawn,
and  its point carried along the anterior wall of the prostatic
urethra, but  the handle of the  catheter  could not  be  de-
pressed," etc.  Now, the cul-de-sac is on the posterior wall of
the urethra, and not the anterior at all, so that it is impossible
that this was the cul-de-sac in which its point engaged.  Where,
then, was  it ?   Dr. Hun tells us, in his report.   In removal of
         2 
18
REVIEW OF THE REPORT OF
the bladder, the prostate gland and a part of the membranous
urethra were also  removed.  After removal  of the bladder,
which had been laid open by anterior section, a  catheter was
passed from the anterior of the organ into the urethra, until it
emerged externally, and the  incision  in the  anterior wall of
the bladder was prolonged downward  on the catheter  as a
director through the upper wall of the urethra.  It was  then
found that, although the prostatic portion of the urethra was
laid open, yet the membranous portion beyond the point of the
catheter remained uncut!  This appearance is well shown in
the photographs first taken.  It was also observed that the
connective tissue, lying  anterior to the prostate  gland  and
neck of the bladder, was stained and infiltrated with blood!
Here, then, was the cul-de-sac!  Here was where "the blood
coagulated in the catheter"  was drawn !  This extravasated
blood was not a post-mortem stain.  It was not on a cut sur-
face, but infiltrated into the connective tissue.  How does this
strike the professional reader ?  There is but one explanation.
A false passage  had been made during life by thrusting the
point of the catheter through the  anterior wTall of the mem-
branous urethra.  The point had perhaps found a " cid-de-sac "
somewhere after passing under the pubic arch, the full length
of an ordinary catheter, but where the reviewer will not ven-
ture to guess, for there has been  already too much guessing
exhibited in this case.  Dr. Hun informs us of the particulars
of  this post-mortem  catheterization.    This  paper does not
allude to it!   Far be it from the reviewer to question the
veracity of any one ; but it is miraculous that a catheter which
was long enough to traverse the urethra and enter the bladder
of Dr. March after death, was not long enough to do this, as
the learned professor and counsel say, before death!  Perhaps
this notable silence as to the post-mortem use  of the catheter
was not observed  for  concealment; the fact may have  been
forgotten, or regarded as insignificant—perhaps so!  Let us
examine still further into facts before pronouncing a verdict.
    On  the 18th of June, the day after  the  decease of the
patient, a stereograph of the interior of  the bladder and  pros-
tate gland was taken by Haines, of Albany.   After this, the
specimen was kept in some antiseptic fluid until the 25th of 
          "LAST ILLNESS  OF DR.  ALDEN  MARCH."      19

 July.   It  was then  taken to the same artist, and another
 negative  was photographed.  Dr. Armsby  desired possession
 of  the  first negative, but was unable to purchase it from the
 artist.  He then requested that no copies, or prints, from the
 original negative should be sold, but copies from the second
 negative only.   The first photograph shows the real appear-
 ance of the bladder when fresh ; the second exhibits very well
 the effect of Goadby's solution, or other antiseptic, in altering
 its  appearance, especially when supplemented by the tactile
 ingenuity  of  dexterous  manipulators.   Had not the writer
 seen " a whistle  made of  a pig's  tail," he would hardly have
 supposed the bladder from which the  first pictures were pho-
 tographed to be so plastic and tractile that the second, by any
 cunning, could  claim to represent it.  The two plates which
 are reliable are  numbered 37, 38;  the other two, 37*, 38*.
 The \\l-starred  photographs represent behind the vesical tri-
 angle {trigone vesicate) " a deep circular depression  or  sac."
 This is, simply, the pouch, called  the lower fundus, or bas
fond of the bladder (the well-known receptacle of urinary cal-
 culi), which, by means of hooks and pins and guys, is tortured
 into something  quite "deep" and abnormal in appearance.
 The muscles of the ureters (a structure " very distinctly devel-
 oped in the hypertrophied  condition that usually attends dis-
 eases of the bladder "—see " Morton's Anatomy," p. 340) are
 moulded  until  they are transformed into what  is called a
 " bar-like  ridge."  In front of this is the third lobe of the
 prostate, in the original photographs represented as a rather
 thick membrane stretched across the  neck of the bladder; in
 the photographs, inspired by an after-thought, it is tricked into
 " a firm, elevated " transverse ridge, " half  an inch  in thick-
 ness !"   (See backs  of photographs.)  Reference is  made  on
 the backs of the photographs to  Gross; but, in his " Patho-
 logical Anatomy," he speaks of transverse ridges of " mucous
 membrane" sometimes "three or four lines  in thickness," and
 not of fabrications, " half an inch in thickness and an inch in
 depth!"   By the photographs,  the walls of the bladder are
 also made to look thicker.   The ingenuity of  the  writer is
 severely taxed to explain this transaction with the photographs
 so  as to save the professor from humiliation;  and, not feeling 
20            REVIEW OF THE REPORT OF
himself competent to do  so, he leaves the facts to speak for
themselves.
    Under the head of "Remarks," it is said :  " It was reported
that he " (Dr. March) " had malignant tumor or cancer in the
bowels, and could not recover.  The only foundation for such
a report was that some  gentlemen, of high character and ex-
perience, were inclined to  believe that the tumor, which  was
distinctly felt, was not simply a diseased and enlarged bladder,
but had connected with it, and external to it, another growth,
probably of a  malignant  character.  This  opinion was not
shared by the attending physicians.  Nothing in the post mor-
tem was found to confirm its correctness."  This statement has
been severely censured as disingenuous, and as inspired neither
by a nice sense of honor,  nor of justice in  the author.  The
real truth is that, on or about the 9th day of June, Dr. March
felt himself  to be in extreme danger, and wished to see, per-
haps for the  last time, and talk with some of his medical friends
and colleagues.  Drs. Thomas Hun, J. Y. P. Quackenbush, S.
O. Yanderpoel, and J.  S.  Mosher, visited him.  Before  they
saw him, Dr. Armsby stated that a catheter  had been passed
twice, but that  the bladder contained no urine.  Dr. Hun re-
marked that the tumor, which was said to have  developed so
rapidly, must then be cancerous.  When come into the  pres-
ence of the sufferer, at his request, Dr. Hun placed his hand
on  " the tumor." He saw no reason to alter his opinion, pre-
viously formed,  for, like all present, he believed the bladder to
be empty, as Dr. Armsby  had stated.  These  gentlemen vis-
ited Dr. March, at his request, only as friends, and in no sense
as physicians.   They assumed no responsibility in the  case,
and it is most  unfair and unworthy conduct  to fling an in-
sinuation  against their  perspicacity and discernment  for  a
mere conjecture, based on incorrect information and insuffi-
cient data.   One of these gentlemen states to the writer that
Dr. Armsby adopted the  opinion that  "the tumor" was  a
malignant growth, and acknowledged so to  him a day or two
before the patient's death.  A prominent surgeon from another
towm, who was  by chance  with  Dr.  March  at his dissolution,
assures the writer that, at breakfast, Dr. Armsby spoke of the
case as one of cancerous disease.  Far be it from the writer to 
          "LAST  ILLNESS  OF DR.  ALDEN MARCH."      21

 accuse Dr. Armsby of falsehood when he, as one of the signers
 of the paper, says, " this opinion was not shared by the attend-
 ing physicians ! "  But these discrepancies belong to the his-
 tory of this remarkable case, and, having accepted  the  chal-
 lenge to criticise, which publication always implies, the writer
 cannot well repress them, and  treat the subject according to
 its deserts.
    Had the opinion, casually expressed by one of  the friends
 of Dr. March, as stated  above, been formed  after deliberate
 examination, it would not have been so unexampled  as to jus-
 tify the pettiness of allusion to it in order to slur it, for, in the
 Bibliotheque Medicate, it  is  reported that two leaders of sci-
 ence in France mistook distention of the bladder for malignant
 disease.  Curiously enough, too, this diagnosis is the only one
 that would seem to vindicate the treatment pursued in this
 case, since,  if the diagnosis  was  "distended and thickened
 bladder," the medical attendants followed a course  which was
 not merely erroneous, but abominable.
    This paper has been termed remarkable, and, with the light
 now let in upon it, there would seem to be but one judgment
 of it possible.  To allow it to pass unchallenged and uncon-
 tradicted seemed wrong to the writer, and to savor of conces-
 sion and concurrence.  Both from  its own internal evidence,
 and from evidence elsewhere obtained, it  appeared to be little
 better than a scientific fraud.  Its fabrication is artful, specious,
 and sophistical, and, as a contribution to history, it appeared
 questionable, for it purports  to contain  facts  that are differ-
 ently stated by other and truthful  men, both prior and subse-
 quent to its appearance,  and, in  important matters, it  sup-
 presses  facts altogether.  If the examiner is  wrong, the good
 metal will  be all the brighter for its rubbing; if right, the
 counterfeit  ought to be nailed to the counter.  Two of the
 signers of this paper are Professors in the Albany Medical Col-
 lege—one is now in the great  vacancy left by Alden March—
 and every student has been provided with a copy of the docu-
ment.   The position of a professor has been degraded by this
attempt to  give consideration  and  authority to such fallacious
theories and detestable methods.   Had the paper  originated
with a beginner in practice, its essence and its  manner should 
22    REVIEW  OF REPORT  OF "LAST  ILLNESS," ETC.

have caused regret, perhaps  derision, but it would, doubtless,
not have received the equivocal compliment of formal repre-
hension ; but of teachers wTe demand teachings characterized
by  proficiency, clearness, and honesty  of purpose.  These
young men, the medical students, read that this most singular
treatment is "  usual in  such cases ! "  Instead of  acknowl-
edging  the  terrible  mistake  with manliness  and humilitv,
whose discovery,  at  the post-mortem investigation,  caused a
shudder of mortification and grief in the breasts of lookers-on,
an attempt is made to justify it, and the scorn of the  profes-
sion is provoked by crafty efforts to confuse and obscure the
sad affair amid irrelevancies, obliquities, non-sequiturs, and
artful perversions.  The  intelligence, sagacity, and skill of
the whole profession are impugned by calling  this treatment
" usual," in order to seek protection in  the subterfuge  from
the condemnation which  the paper shows is already  keenly
felt.
    " Usual  in such cases ! "  Never !   It is  negative and in-
efficient for good, positive and potent for harm.  An ailment,
simple and tractable at first, if properly managed, is, through
inaptness, unskilfulness, or timidity, allowed to become  uncon-
trollable.   This " usual"  treatment ? Is this the teaching in
the Albany  Medical College ?   Are the young men there in-
structed to leave a bladder distended with urine to the impo-
tent efforts of unaided Nature, and to treat ursemic poisoning
with opium ?  Does Dr. Armsby, who has now obtained Dr.
March's  place,  so teach ?  Fortunately, there  are professors
there wTho scout such practice.  Everywhere the profession  is
heard repelling and repudiating the allegation that this " is
usual treatment in such cases," and from the grave of the old
surgeon  who has fallen  arises a  solemn warning against  its
repetition. 
APPENDIX.
             LAST ILLNESS OF DR. ALDEN MARCH.

    TnE following account of the case of the late Dr. March has been pre-
 pared under the direction of the physicians who  had the principal charge
 of the patient, for the information of the many friends and acquaintances
 of that distinguished surgeon and professor.   The information contained
 in the preliminary  remarks was derived from a gentleman nearly related
 to the patient, and for many years his most intimate associate.
   Dr. March had suffered  for many years from irritation of the  bladder,
 which fact was known to his intimate friends.  Any unusual mental ex-
 citement, such as the performance  of a hazardous surgical operation, was
 sure to increase this irritation.  It sometimes occasioned  him considerable
 annoyance.
   More than fifteen years ago, while travelling with his family in Switzer-
 land, he met with an accident, while descending Mont Righi; slipping  on
 the rock and striking the lower part of the abdomen on a projecting point.
 The  injury was severe, and confined him to his room in Lucerne several
 days with local symptoms.  During the rest of his journey, and long after
 his return, he used to refer  to this accident as an injury of the bladder, and
 complained of soreness in the lower part of the abdomen.  More than ten
 years ago, when speaking of the case of Dr. Tully, his former partner, who
 died of disease of the bladder and prostate, he remarked  that he  had  the
 same disease, and that it was increasing every year.
   Before this time he provided himself with a urinal; and, when travel-
 ling, he kept it  at  hand night and day.   Some time later, he met with
 another accident in running up the  steps of a railroad depot.  Tripping  on
 a step, he struck heavily  on the edge of the platform.  He suffered very
much at the time, and was exceedingly alarmed.  Speaking of the accident,
he said,  " I thought that I had killed myself, that I had ruptured my blad-
der." He never recovered entirely  from this injury.   He was in the habit 
24
APPENDIX.
for a long time of placing his hand over the lower part of the abdomen, as
if in the act of examining or percussing.
    This habit has been noticed by his  friends, and been spoken of by his
pupils since his death, as having been noticed also in  the lecture-room.   A
few weeks before his death he made the journey to New Orleans to attend
the meeting of the American Medical Association.  On his way he suffered
from the extreme heat and fatigue, but rested only a  few hours at Charles-
ton and Atlanta.  He wrote from  Charleston, " I  am almost  overcome
with the heat."  From New Orleans he wrote, " I have enjoyed the meet-
ing very much, and seeing so many of my old  friends, perhaps for the last
time."   Alas!  so it turned out.  It is  not a little remarkable that no fewer
than four ex-presidents of the American Medical Association died within a
few weeks of each other—Moultry, Eve, A. H. Stevens, and Alden March.
    On his way home, Dr. March travelled night and  day continually, with-
out appearing to suffer from  the journey.   He resumed  his professional
business with  his usual alacrity, attended  to distant calls, and continued
his  weekly  cliuique  at the hospital.  After a very  fatiguing ride  in the
country, exposed to rain and cold, he went to his bed quite ill with fever,
restlessness, pain over the region of the bladder, great thirst, and  constant
desire to void urine.   He passed a restless night.  On going to bed he took
a pill of five grains of calomel and one  of opium, which acted freely  on the
bowels in  the morning, and seemed  to afford  relief.   He kept quiet, took
diluents and small doses of opium during the day.  Next night, at the sug-
gestion of one  of his colleagues, he had a warm bath, followed by Dover's
powder, which afforded great  relief, and  procured  him a tolerably com-
fortable night's rest.  In a few days he was out again and  attending  to
business, but his countenance continued somewhat sallow, and the expres-
sion anxious.  A few days after, he  gave his last clinique  at the hospital,
and performed a tedious operation.   It was the removal of a tumor which
lay  over and involved the carotid  artery and internal jugular vein.   He
was greatly fatigued, and went home  quite unwell.   From this time  his
health was broken down, and his declining strength quite  apparent.  But
his  strong will would not allow him to  take  rest.   He kept going about,
but could not attend  much to out-door patients.
    He made it a practice, never, if it  could be avoided, to be absent from
his  place in church on the Sabbath.  On the 6th of June he was, as usual,
in his pew, and remained during the service, but in great distress from I113
old trouble. At the  close he rushed from his seat to the closet of the lec-
ture-room and relieved himself by partially emptying the bladder, after a
painful effort.  He remarked to a friend, " I never suffered so much pain
in my life; I could not have borne  it another  minute."  After this it was
thought best, in order to  insure greater quietude, and to avoid the annoy-
ance of professional consultations, to have him  removed to the residence
of his son-in-law, David I. Boyd, Esq.,  in Park Place.  There he remained
until his sufferings were ended by his death.  There he was surrounded by
sympathizing friends, tender nurses, and experienced and  attentive medi- 
APPENDIX.
25
 cal advisers.  His regular medical attendants were his colleagues, Profes-
 sors James H. Armsby and McNaughton, and Dr. James P. Boyd ; but he
 was occasionally visited by the leading physicians and surgeons of Albany,
 and some from the surrounding districts.
     There was not  at any time  much difference of opinion regarding the
 nature of the case or the proper treatment to be pursued.  It is true that
 some erroneous statements appeared  in  the newspapers  in regard to the
 nature of the disease, but these were not authorized by those who had
 charge of the case.  After Dr. March became confined to his room, he had
 moderate fever in the daytime,  but more at night.  There was  excessive
 thirst, and he drank a large quantity of ice-water.  His nights were rest-
 less and his sleep unrefreshing.  His appetite was  better for the first week
 than could have been expected, and he was ready to take as much food as
 his medical attendants were willing to allow him.   His most troublesome
 symptom was pain about the neck of the bladder,  and an irresistible desire
 to void urine every fifteen or twenty minutes.
    He seldom passed more than an  ounce or two at a time, but passing it
 so often, the quantity voided daily, for the first week or ten days, amounted
 to between two and three quarts.   Attention was early called to a tumor
 occupying the lower part of  the abdomen, and distinctly traceable from
 the pubes nearly to the umbilicus, but much better defined on the left side
 of the mesial line than on the right side.  On the left of the linea alba it
 was a soft, solid mass, fixed in its position.  On the right of that line, the
 tumor was not as well defined,  or  traceable to the pubes, but yielded a
 faint sound  on percussion.  The tumor was regarded as a distended and
 thickened bladder, bound to the left side by adhesions to the omentum and
 abdominal parietes.
    The injuries received in that region rendered such adhesions more than
 probable.  The patient did not seem to recollect how long the tumor had
 been felt by him, but he seemed to feel certain that his bladder was some-
 how displaced, and that he had for years been afflicted with disease of the
 prostate gland.
    The introduction of the catheter was early suggested, but  as the parts
 were very tender, and he had  himself repeatedly tried to introduce it with-
 out success, it was delayed at  his own request.  There seemed no urgent
 necessity for it, as he was passing daily from two to three quarts of appar-
 ently healthy urine, and means were being resorted to in the mean time to
 allay irritation, so as to facilitate the passage of an instrument, if necessary.
 The first attempt to introduce a catheter was made about a fortnight before
 he died.   The instrument passed without difficulty its whole length, with-
 out entering the bladder; blood coagulated in the catheter, and  no urine
 passed through it, but some passed external to  it  and followed its with-
drawal.  As the operation caused distress and exhaustion, it was  not per-
sisted in.   It  was chiefly  resorted to  as a means of  exploration,  and
revealed the great eiongation  of the prostatic portion of the  uretlira, as
well as the great enlargement and induration of the prostate  gland.  No 
26
APPENDIX.
other attempt was made until a few days before his death.  Whenever it
was  proposed, he would say,  "I pass quite water enough, why give  me
unnecessary pain ?"
   At the second attempt, he was put under the influence of  chloroform,
and a longer instrument than  usual was employed.  It was passed readily
the whole length of an ordinary catheter until it met a firm, resisting body,
and seemed to fall into a cul-de-sac in which its point was fixed.  It was
repeatedly withdrawn, and its point carried along the anterior wall of  the
prostatic urethra; but the handle of the  catheter could not be depressed,
on account of the great enlargement and  induration of the prostate gland.
   Several instruments, metallic and flexible, were tried, but with no better
success.  As the operation was exhaustive,  and  not likely to succeed at
last,  it was deemed best not to persevere.
   Up to this time he passed his urine voluntarily and  in sufficient quan-
tity daily to prevent,  it was supposed, ursemic poisoning from its retention
in the  bladder.  He was occasionally  delirious,  and  exhibited nervous
symptoms and disturbance of the stomach and bowels; but these were
attributed to the free use of anodynes, necessarily administered  to relieve
his distress.  There was no involuntary  dribbling of urine at any time, or
other evidence  of over-distention of the  bladder.  He seemed possessed
from the first with the  idea that he had a great accumulation of faeces in
the rectum, and that after very free evacuations  from the bowels, from
repeated doses of castor-oil.
   The sensation, doubtless, was caused by the enlargement and induration
of the prostate,  and the pressure of the bladder on the rectum.  Ursemic
symptoms became more marked in the last two days.  Hiccough, delirium,
and drowsiness, became more decided, his urine passed without effort,  and
the last day, without apparent consciousness, into a urinal, but in  less
quantity than before.  Almost to the last hour he could be roused to con-
sciousness.  His spirit quietly departed on the  morning of June 17th, in
the seventy-fourth year of his age.
   State of the Urine.—As Dr. March had so long suffered from disturb-
ance of the urinary organs, attention was at once drawn to the quantity
and  quality of  his urine.  He informed his  medical attendants that, for
several months, he had voided from three to  six quarts daily.   The urine
was  clear and free from any sediment, and of the color of pale sherry.
   There  were some suspicions of diabetes,  but,  when tested by  Prof.
Mosher, it was found to contain no sugar, and its specific gravity was only
1.005; it  contained  no albumen.  Later in the disease  the  gravity  was
1.010, and urea in a given quantity less than the average, but, as he passed
more urine than the  average daily, the whole quantity of urea voided might
be equal to the average.  The urine had a slightly acid  reaction.
   Treatment.—The treatment  was such  as is usually pursued in such
cases—warm baths, fomentations, diluent drinks, anodyne injections ano-
dyne suppositories introduced into the rectum, etc.  Every attention requi- 
APPENDIX.
27
site was paid to regimen and nursing, and every urgent symptom relieved
as speedily as possible.
   Remarks.—It is usual when a citizen, occupying a distinguished  posi-
tion  in society, is known to be dangerously ill, that various reports about
the case get into circulation.  Dr.  March's case  was no  exception.  It
was reported that he had a malignant tumor or cancer in the bowels, and
could not recover.   The only foundation for such  a report  was, that some
gentlemen of high character and experience were  inclined  to believe that
the tumor, which was distinctly felt, was  not simply a diseased and en-
larged bladder, but had connected  with it, and  external  to it, another
growth, probably of a malignant character.  This opinion  was not shared
by the attending physicians.  Nothing in the post-mortem examination
was found to confirm its correctness.
   The bladder was found enlarged, and much changed in  its structure.
   The prostate gland was very much enlarged in  every direction, and in-
durated, but nothing indicated  that it was affected by a cancerous disease.
There was no appearance of recent inflammation in the interior of the
bladder, but the outside exhibited evidence of former inflammations, more
especially on the left side of  the linea alba, in the shape  of  adhesions
to the pubes,  the  omentum, and abdominal parietes,  accounting for the
position and character of the tumor felt in that region during life.   Even
after the bladder was partly exposed to sight, by the division of the ad-
dominal parietes, the  distended  bladder, with its  adhesions, conveyed to
the hand of the examiner the feeling as if a sponge or some such  substance
occupied the interior of the bladder instead of urine.  When the  urine was
drawn off, the coats of the bladder, especially on the right  side of the
mesial line, were found less thickened than might have  been expected ; but
the bladder, owing to its  adhesions, did  not  collapse.  The  kidneys also
exhibited evidence of disease and former inflammation.   Besides adhesions,
both kidneys had serous cysts on their  outer surface; the cysts on the left
side  were of larger size than those on the right.
   In the tubular part there was some evidence of disease; the ureters
were not enlarged or distended with urine.   The bladder has  been pre-
served, and  photographs of it  have been  taken, and a minute description
of the morbid appearances given by Drs. Armsby and Haskins,  by whom
the examination was made in the presence of many physicians.   The ques-
tion  may be asked, indeed has  been already asked, "Why, as the catheter
could not be introduced, was not the bladder tapped ?  Might not such an
operation have prevented uraemia, or have prolonged life, if it did not save
it ? "  These questions would probably be differently answered by different
persons.
   Ursemic  symptoms were not so  urgent as to  warrant  puncturing the
bladder,  even if the  patient would consent.  The  physicians  in charge
thought such  an  operation would not only be useless, but injurious,   A
perforation tlirough the rectum would be likely to be followed by urinary 
28                        APPENDIX.

infiltration, and above the pubes the same result would be probable.  It is
not probable that uraemia  is often caused by mere  retention of urine  in
the bladder, even when a very small quantity of urine is voided in twenty-
four hours.  It is very probable that Dr. March had not for months en-
tirely emptied the bladder at any time, yet his general health seemed good,
and his body well nourished.  It is true that, in the examination that was
made of the urine, the proportion of urea contained in it was below the
average;  but was that caused by the absorption of that constituent after it
got into the bladder?  Is it not more probable that it was retained in the
blood by the diseased action of the kidney, as in ischuria renalis?   Such,
at all events, was the view  taken by those in charge of this case, and made
them disinclined to resort to an operation of such doubtful utility.
                                             James McNaughton,
                                             James P. Boyd,
                                             James II.  Armsby. 
WITH COMPLIMENTS OF THE AUTHOR.
LAST ILLNESS OF DR. ALDEN MARCH.
A  CRITICISM
ON THE
MAKAGEMEJNT  OF HIS CASE.
      NEW YORK:
D. APPLETON AND COMPANY,
    90, 92 & 94 Grand Street.
         1870. 
 
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