^' '"■MJ^ ^"%, CORNELL UNIVERSITY THE Jflotuer Hetcrmarti Sltbrary FOUNDED by" ROSWELL P. FLOWER for the use of the' N. Y. State Veterinary College 1897 CORNELL UNIVERSITY LIBRARY The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://archive.org/details/cu31924104225689 THE INTERNATIONAL ENCYCLOPEDIA OF SURGERY. VOL. YI. THE INTERNATIONAL ENCYCLOPAEDIA SUEG-EET A SYSTEMATIC TREATISE ON THE THEORY AND PRACTICE OF SURGERY BT « AUTHORS OF TAEIOUS ITATIOInTS EDITED BY JOHN ASHHURST, Je., M.D. PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA ILLUSTRATED WITH CHROMO-LITHOGRAPHS AND WOOD-CUTS IN SIX VOLUMES VOL. YI. # NEW YORK i. V, WILLIAM WOOD & COMPANY 1886 f/f?. nH-'V2, Copyright : WILLIAM WOOD & COMPANY, 1886. % I PREFACE The Sixth and Last Volume of the Encyclopedia concludes the consideration of the Injuries and Diseases of the Various Regions of the Body, and supplies certain articles which were necessarily omitted from previous volumes, owing to the inability of their authors to complete them in time for insertion in their appropriate places. The consideration of the Surgery of the Digestive Organs is com- pleted by Articles on the Injuries and Diseases of the CEsophagus, by Prof Solis-Cohen ; on Intestinal Obstruction, by the Editor ; and on Injuries and Diseases of the Rectum, by Mr. AUingham, of London. An exhaustive Article on Urinary Calculus is contributed by Prof. Keyes, of New York; and a short, special Article, based on personal ■experience of the Crushing Operation for Stone, by that veteran litho- tritist, Prof Kingston, of Montreal. The Surgery of the Bladder and Prostate is dealt with by Mr. Reginald Harrison, of Liverpool ; that of the Male Urethra by Prof Duplay, of Paris; and that of the Male Generative Organs by Mr. Royes Bell, of London. Three Articles are devoted to the Surgery of the Female Sexual Apparatus, con- tributed respectively by Prof Parvin, who writes on Injuries and Diseases of the Female Genitals ; by Dr. Robert P. Harris, who treats of the Csesarean Section and allied operations — a subject of which he is known to have long made a special study ; and by Dr. Charles C. Lee, of New York, who, when Dr. Muride found himself unable to (V) VI PREFACE. prepare the article on Ovarian and Uterine Tumors, most courteously acceded to the Editor's urgent request that he should undertake the task, and -who, in spite of the harassing interruptions of a laborious and exacting practice, has furnished an account of the subject, remark- able alike for its condensation and its eminently practical character. The material postponed from previous volumes embraces a series of three Articles on Diseases of the Bones, contributed by as many emi- nent surgeons of the Lyons School, Prof. Oilier, Prof Vincent, and Prof Poncet ; and a comprehensive Article on the Treatment of De- formities, by the vpell-known orthopaedic surgeon, Mr. F. R. Fisher, of London. In an Appendix are included three Articles on subjects which, though not usually considered in surgical treatises, are in themselves of the highest interest and importance : these are the Construction and Organization of Hospitals, here dealt vpith in a concise and practical manner by Dr. Cowles, of the McLean Asylum ; the Preparations to be made by Surgeons in time of War in entering upon Field Duty, vpith an Account of the Modern System of Ambulance Service, by Lieutenant-Colonel and Surgeon Clements, U. S. Army; and the History of Surgery, briefly but comprehensively reviewed by a writer justly famed for his erudition and profundity of antiquarian lore Dr. George J. Fisher, of Sing Sing, N. Y. The volume ends -with, an elaborate General Index, compiled by Dr H. R. Wharton, which will facilitate reference to all parts of the entire work. Two of the Editor's collaborators have died since the publication, of the last volume : Surgeon Bill of the U. S. Army, whose Article PKEFACE VU on Sabre, Bayonet, and Arrow Wounds will always be classical ; and, quite recently, the venerable Prof. Post, of New York, long a connect- ing link with a past generation of surgeons, but who despite his burden of years, which measurably exceeded the allotted three-score-and-ten, preserved full activity of mind and hand, and who, with the wisdom and long experience of age, was able to combine a boldjiess and operative skill which might well be envied by younger surgeons. The death- roll of Contributors to the Encyclopsedia, actual or promised, now numbers ten — all the Editor's countrymen — whose names are repro- duced here in honorem, a list of surgeons of whom America may well be proud : Gkoss and Van Buren ; Otis and Bill ; Lidell' and Hod- gen; Hodge and Hunter ; Post and Sims. In completing his task, which has occupied all his leisure moments for more than six years, and has involved an amount of anxiety and labor which few can appreciate who have not been engaged in similar undertakings, the Editor begs to renew the expression, given in the Preface to the First Volume, of his sincere thanks to the distinguished surgeons, both in Europe and in his own country, who have toiled with him in the preparation of the Encyclopsedia, and to whose cheerfully rendered collaboration is due the great success which the work has obtained. To the Publishers too, and to the numerous subscribers to the work, he owes thanks for the patient indulgence which they have extended to him in regard to the unavoidable delays which have attended the appearance of the several volumes. JOHN ASHHTJRST, Je. Philadelphia, 2000 West Dblancey Place, March, 1886. COMPLETE ALPHABETICAL LIST OF THE CONTRIBUTORS TO THE INTERNATIONAL ENCYCLOPAEDIA OF SURGERY. D. Hayes Agnbw, M.D., LL.D., Barton Professor of Surgery in the Uni- versity of Pennsylvania, Philadelphia. General Principles of Surgical Diagnosis. Vol. I. "William Allingham, F.R.C.S., Surgeon to ^t. Mark's Hospital, London. Injuries and Diseases of the Rectum. Vol. VI, Edmund Andrews, M.D., LL.D., Professor of Clinical Surgery in the Chicago Medical College, Surgeon to Mercy Hospital, Chicago. Injuries of the Joints. Vol. III. Thomas Annandalb, F.E.C.S.E., Regius Professor of Clinical Surgery in the University of Edinburgh, and Senior Surgeon to the Edinburgh Royal Infirmary. Diseases of the Breast. Vol. V. John Ashhukst, Jr., M.D., Professor of Clinical Sureery in the University of Pennsylvania, Philadelphia. Amputations. Vol. I. ; Excisions and Resections. Vol. IV. ; Intestinal Obstruction. Vol. VI. Richard Barwell, F.R.C.S., Surgeon to Charing Cross Hospital, London. Aneurism. Vol. III. ; Diseases of the Joints. Vol. IV. H. RoYES Bell, F.R.C.S., Surgeon to, and Demonstrator of Surgery at, King's College Hospital, London. Injuries and Diseases of the Male Genital Organs. Vol. VI. Edward Bellamy, F.R.C.S., Fellow of King's College, London ; Surgeon to the Charing Cross Hospital ; Member of the Board of Examiners, Royal College of Surgeons of England. Injuries and Surgical Diseases of the Lymphatics. Vol. III. Edward H. Bennett, M.D., F.R.C.S.I., President of the Royal College of Sur- geons in Ireland ; Professor of Surgery in Trinity College, Dublin, Surgeon to Sir Patrick Dun's Hospital, etc. Injuries of the Chest. Vol. V. *J. H. Bill, M.D., Surgeon and Brevet Lieutenant-Colonel, U. S. Army. Sahre and Bayonet Wounds ; Arrow Wounds. Vol. II. * Deceased. (ix) X COMPLETE ALPHABETICAL LIST OF THE CONTRIBUTORS John H. Brinton, M.D., Professor of the Practice of Surgery aud of Clinical Surgery in the Jefferson Medical College, Surgeon to St. Joseph's Hos- pital, Philadelphia. Operative Surgery in General. Vol. I. Thomas Bryant, F.E.C.S., Surgeon to, aud Lecturer on Surgery, at Guy's Hospital, London. Wounds. Vol. IL Albert H. Buck, M.D., of ISTew York. Injuries and Diseases of the Ear. Vol. V. Henry Trbntham Butlin, F.R.C.S., Assistant Surgeon to, and Demonstrator of Surgery at, St. Bartholomew's Hospital, London. Scrofula and Tu- bercle. Vol. I. ; Tvp^ors. Vol. IV W. Watson Chbynb, M.B., F.R.C.S., Assistant Surgeon to King's College Hospital, and Demonstrator of Surgery in King's College, London, The Antiseptic Method of Treating Wounds. Vol. II. Bennett A. Clements, M.D., Brevet Lieutenant-Colonel and Surgeon, IJ. S. Army. Preparation of Military Surgeon for Field Duties ; Apparatus Required ; Ambulances ; Duties in the Field. Vol. VI. J. Solis-Cohen, M.D., Professor of Diseases of the Throat and Chest in the Philadelphia Polyclinic, Honorary Professor of Laryngology in the Jef- ferson Medical College, Physician to the German Hospital, etc., Phila- delphia. Injuries and Diseases of the Air-passages. Vol. V. ; Injuries and Diseases of the (Esophagus. Vol. VI. P. S. Conner, M.D., Professor of Anatomy and Clinical Surgery in the Medical College of Ohio, Cincinnati ; Professor- of Surgery in the Dart- mouth Medical College, etc. Gunshot Wounds. Vol. II. ; Injuries and Diseases of the Muscles, Tendons, and Fascioe. Vol. HI. Edward Cowles, M.D., Superintendent of the McLean Asylum, Somerville, Massachusetts. Construction and Organization of Hospitals. Vol. VI. Francis Delaeield, M.D., Professor of Pathology and Practical Medicine in the College of Physicians and Surgeons, Medical Department of Columbia College, ISTew York. Pycemia and Allied Conditions. Vol. L Simon Duplay, M.D., Professor of Clinical Surgery in the Faculty of Medicine of Paris, Surgeon to the Lariboisi^re Hospital, etc., Paris. Injuries and Diseases of the Urethra. Vol. VI. George E. Fenwick, M.D., CM., Professor of Surgery in McGill University, Surgeon to the Montreal General Hospital, Montreal. Excision of the Knee-joint. Vol. IV. Frederic R. Fisher, F.R.C.S., Assistant Surgeon to the Victoria Hospital for Sick Children, London. Orthopcedic Surgery; The Treatment of Deformities. Vol. VI. George Jackson Fisher, A.M., M.D., of Sing Sing, J!^, Y. A History of Surgery. Vol. VI. William S. Forbes, M.D., Demonstrator of -Anatomy in the Jefferson Medi- cal College, Senior Surgeon to. the Episcopal Hospital, Philadelphia. Hydrophobia and Babies; Glanders, Malignant Pustule. Vol. I. J. A. Grant, M.D., M.R.C.P. Loud., F.R.C.S. Edin., Physician to the Gene- ral Protestant Hospital, Ottawa. The Effects of Cold. Vol. II. Robert P. Harris, A.M., M.D., of Philadelphia. The Ccesarean Section and its Substitutes ; Laparotomy for Ruptured Uterus and for Extra- Uterine Foetati,on. Vol. VI. TO THE INTERNATIONAL ENCYCLOPiEDIA OF SURGEKY. XI Reginald Harrison, F.R.C.S., Lecturer on Clinical Surgery in the Victoria University, Surgeon to the Royal Infirmary, Liverpool. Injuries cmd Diseases of the Bladder and Prostate. Vol. VI. Christopher Heath, F.R.C.S., Holme Professor of Clinical Surgery in Uni- versity College, London, and Surgeon to University College Hospital. Injuries and Diseases of the Mouth, Fauces, Tongue, Palate, and Jaws. Vol. V. William H. Kingston, M.D., D.C.L., L.R.C.S.E., etc., Professor of Clinical Surgery in the Montreal School of Medicine, Surgeon to the H6tel-Dieu Hospital, Montreal. Lithotrity. Vol. VI. *J0HN T. HoDGBN, M.D., LL.D., Professor of Surgical Anatomy in the St. Louis Medical College, St. Louis. Ulcers. Vol. II. Joseph W. Howe, M.D., Clinical Professor of Surgery in the Bellevue Hos- pital Medical College, New York. Diseases of the Cellular Tissue. Vol.- II. William Hunt, M.D., Senior Surgeon to the Pennsylvania Hospital, Phila- delphia. Traumatic Delirium and Delirium Tremens. Vol. I. *Charles T. Hunter, M.D., Demonstrator of Anatomy in the University of Pennsylvania, Surgeon to the Episcopal Hospital, Philadelphia. Minor Surgery. Vol. I. Christopher Johnston, M.D., Emeritus Professor of Surgery in the Univer- sity of Maryland, Baltimore. Plastic Surgery. Vol. I. E. L. Keyes, A.M., M.D., Professor of Genito-Urinary Surgery in the Bellevue Hospital Medical College of ISTew York, Consulting Surgeon to the Charity Hospital, Surgeon to Bellevue Hospital, to the Skin and Cancer Hospital, and to St. Elizabeth Hospital, NeMr York. Urinary Calculus. Vol. VI. ITorman W. Kingslby, M.D.S., D.D.S., Late Professor of Dental Art and Mechanism in the ISTevsr York College of Dentistry, !New York. Surgery of the Teeth and Adjacent Parts. Vol. V. Charles Carroll Lee, M.D., Surgeon to the Woman's Hospital, Consulting Surgeon to the Charity Hospital, ISTew York. Ovarian and Uterine Tumors. Vol. VI. George M. Lefperts, M.A., M.D., Clinical Professor of Laryngoscopy and Diseases of the Throat in the College of Physicians and Surgeons,. Medical Department of Columbia College, ]S"ew York, Consulting Laryngoscopic Surgeon to St. Luke's Hospital, etc. Diseases and Injuries of the Nose and its Accessory Sinuses. Vol. V. *John a. Lidbll, A.m., M.D., Late Surgeon to Bellevue Hospital, also Late Surgeon U. S. Volunteers in charge of Stanton U. S. Army General Hospital, Inspector of the Medical and Hospital Department of the Army of the Potomac, etc. Injuries of Bloodvessels. Vol. III. Injuries of the Back, including those of the Spinal Column, Spinal Membranes, and S-pinal Cord. Vol. IV. Henry M. Lyman, A.M., M.D., Professor of Physiology and of Diseases of the JSTervous System in the Rush Medical College, Chicago. Ancesthetics and Anaesthesia. Vol. I. Hunter McGuire, M.D., Formerly Professor of Surgery in the Medical College of Virgina, Richmond. Contusions. Vol. II. * Deceased. XU COMPLETE ALPHABETICAL LIST OF THE CONTKIBUTORS George H. B. Macleod, M.D., F.E.C.S. and F.R.S. Ediu., Senior Surgeon to, and Lecturer on Clinical Surgerj^ at, the Western Infirmary ; Eegius Professor of Surgery in the University of Glasgow; Surgeon in Ordinary to H. M. the Queen, in Scotland. Injuries and Diseases of the Neck. Vol. V. C. W. Mansell-Moullin, M.A., M.D. Oxon., F.R.C.S., Fellow of Pembroke College, Oxford ; Late Travelling Fellow, Univ. Oxon., Surgical Registrar to the London Hospital, London. Shock. Vol. I. Howard Marsh, F.R.C.S., Assistant Surgeon to St. Bartholomew's Hospital, London. Abscesses. Vol. II. E. M. Moore, M.D., Professor of the Principles and Practice of Surgery in the University of Buffalo. Gdngrene and Gangrenous Disease. Vol. II. Henry Morris, M.A. and M.B. Lond., F.R.C.S. Eng., Surgeon to, and Lecturer on Surgery at, the Middlesex Hospital, London. Injuries and Diseases of the Abdomen. Vol. V. Thomas George Morton, M.D., Surgeon to the Pennsylvania Hospital and to the Orthopaedic Hospital, Consulting Surgeon to the Jewish Hospital, etc., Philadelphia. The JEffects of Heat. Vol. II. Charles B. ]S"ancrede, M.D., Professor of General and Orthopaedic Surgery in the Philadelphia Polyclinic ; Surgeon to the Episcopal Hospital and to St. Christopher's Hospital, Philadelphia. Injuries and Diseases of the BurscR. Vol. II. ; Injuries of the Head. Vol. V. M. Nicaisb, M.D., Professor Agrege in the Faculty of Medicine of Paris ; Surgeon to the Hospitals, Paris. Injuries and Diseases of Nerves Vol. III. L. Ollier, M.D., Professor of Clinical Surgery in the Faculty of Lyons. Inflammatory Affections of the Boyies. Vol. VI. John H. Packard, M.D., Surgeon to the Pennsylvania Hospital and to St. Joseph's Hospital, Philadelphia. Poisoned Wounds. Vol. II. ; Injuries of Bones. Vol. IV. Theophilus Parvin, M.D., Professor of Obstetrics and Diseases of Women and Children in the Jefferson Medical College, Philadelphia. Injuries and Diseases of the Female Genitals. Vol. VI. A. PoNCET, Professor of Operative Surgery in the Faculty of Medicine of Lyons. Tumors of the Bones. Vol. VI. *Alfbed C. Post, M.D., LL.D., Emeritus Professor of Clinical Surgery in the University of the City of ISTew York ; Consulting Surgeon to the New York Hospital, St. Luke's Hospital, the Presbyterian Hospital, and the Woman's State Hospital, New York. Injuries and Diseases of the Face Cheeks., and Lips. Vol. V. J. Lewis Smith, M.D., Clinical Professor of Diseases of Children in the Belle- vue Hospital Medical College, New York. Rachitis. Vol. I. Alfred Stillb, M.D., LL.D., Emeritus Professor of the Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania Philadelphia. Erysipelas. Vol. I. ' S. Stricker, M.D., Professor of Experimental and General Pathology in the University of Vienna. Disturbances of Nutrition; The Pathology of In- flammation. Vol. I. * Deceased. TO THE INTERNATIONAL ENCYCLOPEDIA OP SURGERY. Xlll F. R. Sturqis, M.D., Professor of Venereal Diseases in the University of the City of l^ew York (Medical Department), Visiting Surgeon to the Third Venereal Division of Charity Hospital, Blackwell's Island, etc., New York. Venereal Diseases: The Simple Venereal Ulcer or Chancroid. Vol. II. Frederick Treves, F.E.C.S., Assistant Surgeon to, and Lecturer on Anatomy at, the London Hospital. Malformations and Diseases of the Spine. Vol. IV. ; Malformations and Diseases of the Head. Vol. V. *'W"illiam H. Van Buren, M.D., LL.D., Professor of the Principles and. Prac- tice of Surgery in the Bellevue Hospital Medical College, New York. Inflammation. Vol. I. Arthur Van Harlingen, M.D., Professor of Diseases of the Skin in the Philadelphia Polyclinic, Consulting Physician to the Dispensary for Skin Diseases, Philadelphia. Venereal Diseases: Syphilis. Vol. II. A. Verneuil, M.D., Professor of Clinical Surgery in the Faculty of Medi- cine, Paris. The .Reciprocal Effects of Constitutional Conditions and Injuries. Vol. I. Eugene Vincent, M.D., Professor Agrege, Surgeon-in-Chief of the Hospital of La Charite, Lyons. Scrofulo-tuberculous and other Structural Diseases of Bones. Vol. VI. Philip S. Wales, M.D., Surgeon-General of the .United States Navy. Scurvy. Vol. I. H. R. Wharton, M.D., Lecturer on Surgical Diseases of Children and Instructor in Clinical Surgery in the University of Pennsylvania, Assistant Surgeon to the University Hospital, Surgeon to the Children's . Hospital, Philadelphia. Ve^iereal Diseases: Bubon d'Dmblee, Venereal Warts or Vegetations, Pseudo-venereal Affections, Venereal Diseases in the Lower Animals. Vol. II. James C. White, M.D., Professor of Dermatology in Harvard University. Surgical Diseases of the Skin and its Appendages. Vol. II. J. William White, M.D., Lecturer on Venereal Diseases and Demonstrator of Surgery in the University of Pennsylvania, Assistant Surgeon to the University Hospital, Surgeon to the Philadelphia Hospital, Philadel- phia. Venerecd Diseases : Gonorrhoea. Vol. II. E. Williams, M.D., Professor of Ophthalmology in Miami Medical College, Cincinnati. Injuries and Diseases of the Eyes and their Appendages. Vol. V. John Wood, F.R.S., F.R.C.S., Professor of Surgery in King's College, and Senior Surgeon to King's College Hospital, London. Hernia. V ol. V. John A. Wyeth, M.D., Professor of Surgery in the New York Polyclinic, Surgeon to Mt. Sinai Hospital, New York. Surgical Diseases of the Vascular System. Vol. III. * Deceased, ALPHABETICAL LIST OF AUTHORS. (VOL. VI.) WILLIAM ALLINGHAM, JOHN ASHHURST, Jr., H. ROYES BELL,. BENNETT A. CLEMENTS, J. SOLIS-COHEN, EDWARD COWLES, SIMON DUPLAY, FREDERIC R. FISHER, GEORGE JACKSON FISHER, ROBERT P. HARRIS, REGINALD HARRISON, WILLIAM H. HINGSTON, EDWARD L. KEYES, CHARLES CARROLL LEE, LEOPOLD OLLIER, THEOPHILUS PARVIN, A. PONCET, EUGENE VINCENT. (xiv) THE INTERNATIONAL ENCYCLOPEDIA OF SURGERY, ARTICLES CONTAINED IN THE SIXTH VOLUME. Injuries and Diseases of the (Esophagus. By J. Solis-Cohen, M.D., Professor of Diseases of the Throat and Chest in the Philadelphia Polyclinic, Honorary Professor of Laryngology in the Jefterson Medical College, Physician to the German Hospital, etc. Page 1. Intestinal Obsteuction. By John Ashhurst, Jr., M.D., Professor of Clinical Surgery in the University of Pennsylvania. Page 45. Injuries and Diseases of the Rectum. By "William Allingham, P.R.C.S., Burgeon to St. Mark's Hospital, London. Page 93. Urinary Calculus. By E. L. Keyes, A.M., M.D., Professor of Genito- urinary Surgery in the Bellevue Hospital Medical College of ]!!^ew York; Consulting Surgeon to the Charity Hospital ; Surgeon to Bellevue Hos- pital, to the Skin and Cancer Hospital, and to St. Elizabeth Hospital. Page 145. Lithotrity. By Wm. H. Kingston, M.D., D.C.L., L.R.C.S.E., etc.. Pro- fessor of Clinical Surgery in the Montreal School of Medicine, Surgeon to the Hotel-Dieu Hospital, Montreal. Page 301. Injuries and Diseases of the Bladder and Prostate. By Reginald Harrison, F.R.C.S., Lecturer on Clinical Surgery in the Victoria Uni- versity, Surgeon to the Royal Infirmary, Liverpool. Page 323. Injuries and Diseases of the Urethra. By Simon Duplay, M.p., Pro- fessor of Clinical Surgery in the Faculty of Medicine of Pai'is, Surgeon to the Lariboisi^re Hospital, etc. Page 421. Injuries and Diseases of the Male Genital Organs. By H. Royes Bell, E.R.C.S., Surgeon to, and Demonstrator of Surgery at, King's College Hospital, London. Page 527. (XV) XVI THE INTERNATIONAL ENCYCLOPEDIA OF SUEGERY. Injuries and Diseases op the Female Genitals. By Theophilus Parvin, M.D., Professor of Obstetrics and Diseases of Women and Children in the Jefferson Medical College, Philadelphia. Page 663. The Cesarean Section and its Substitutes; Laparotomy for Ruptured Uterus and for Extra-Uterine Fcetation. By Eobebt P. Harris, A.M., M.D., of Philadelphia. Page 759. Ovarian and Uterine Tumors. By Charles Carroll Lee, M.D., Surgeon to the "Woman's Hospital, Consulting Surgeon to the Charity Hospital,. ^ew York. Page 789. Inflammatory Affections of the Bones. By L. Ollier, M.D., Professor of Clinical Surgery in the University of Lyons. Page 843. SCROFULO-TUBERCULOUS AND OTHER STRUCTURAL DISEASES OF BONES. By Eugene Vincent, M.D., Professor Agreg^, Surgeon-in-Chief of the Hos- pital of La Charite, Lyons. Page 901. Tumors of the Bones. By A. Poncet, Professor of Operative Surgery in the Faculty of Medicine of Lyons. • Page 973. Orthopedic Surgery : the Trbatmfnt of Deformities. By Frederic R, Fisher, F.R.C.S., Assistant Surgeon to the Victoria Hospital for Sick Children, London. Page 1001. APPENDIX. Construction and Organization of Hospitals. By Edward CowLes, M.D., Superintendent of the McLean Asylum, Somerville, Massachusetts,' Page 1089. Preparation of Military Surgeons for Field Duties; Apparatus Required; Ambulances ; Duties in the Field. By Bennett A. Clements, M.D.' Brevet Lieutenant-Colonel and Surgeon, U. S. Army. Page 1120.' A History of Surgery. By George Jackson Fishek, A.M., M D of Sing Sing, ^ew York. p^g^ l^^g^ CONTENTS. Preface . ...... CONTEIBUTOES TO THE INTERNATIONAL EnCTCLOPjEDIA OF SdRGERT Alphabetical List op Authors in Vol. VI. List op Articles in Vol. VI. ..... List of Illustrations ...... PAGE V ix xiv XV xli ;ge, INJURIES AND DISEASES OF THE (ESOPHAGUS. By J. SOLIS-COHEIT, M.D., PROFESSOK OF DISEASES OP THE THHOAT AND CHEST IN THE PHILADELPHIA POLYCLINIC, honorary professor of laryngology in the JEFFERSON MEDICAL COLLH PHYSICIAN to the GERMAN HOSPITAL, ETC. Wounds and ruptures of the oesophagus "Wounds of the oesophagus Wounds from without Wounds of internal origin Symptoms and diagnosis of oesophageal wounds Prognosis of oesophageal wounds Treatment of oesophageal wounds Ruptures of the oesophagus Foreign bodies in the oesophagus Points of lodgment Effects, immediate and consecutive Symptoms and diagnosis Prognosis Treatment . . Malformations of the oesophagus Morbid growths of the oesophagus Benign growths Malign growths Stricture of the oesophagus Coarctation stricture or extraneous stenosis Spasm and paralysis of the oesophagus Spasm of the oesophagus ot oesophagismus Paralysis of the oesophagus VOL. VI.— B (xvii) 1 1 2 2 3 4 5 6 7 9 9- 10 12 14 19 20 20 23 26 28 28 28 29 XVlll CONTENTS. Dilatation and sacculation of the oesophagus CEsophagocele Etiology and symptoms of dilated oesophag Diagnosis, prognosis, and treatment CEsophageal instruments Introduction of stomach-tube Bougies and dilators Operations on the oesophagus (Esophagotomy and (Esophagectomy External oesophagotomy Internal oesophagotomy Combined oesophagotomy Gastrotomic dilatation of the oesoph CEsophagectomy Gastrostomy and enterostomy . Gastrostomy Enterostomy PAGE 29 29 82 33 34 34 34 35 35 36 38 38 39 39 40 40 •43 INTESTINAL OBSTRUCTION. By JOHN" ASHHDRST, Jr., M.D., PROFESSOR OP CLINICAL SURGBEY IN THE UNIVERSITY OP PENNSYLVANIA, Intestinal obstruction .... Acute intestinal obstruction Congenital malformations . Impaction of foreign bodies, gall-stones, enterolites, etc. Intussusception or invagination Volvulus ..... Internal strangulation Enteritis and peritonitis Chronic intestinal obstruction . Fecal accumulations Stricture of the bowel Chronic invagination Traumatic changes Chronic peritonitis Pressure external to bowel Symptoms of intestinal obstruction Symptoms of acute obstruction Symptoms of chronic obstruction . Diagnosis of intestinal obstruction Differential diagnosis in acute obstruction Differential diagnosis in chronic obstruction Diagnosis as regards seat of obstruction 45 46 46 46 47 49 49 50 51 51 51 52 52 53 53 53 53 56 56 57 58 59 CONTENTS. XIX Prognosis of intestinal obstruction Prognosis of acute obstruction Prognosis of chronic obstruction Treatment of intestinal obstruction Treatment of acute obstruction Treatment of obstruction by foreign bodies, gall-stones Treatment of acute intussusception Treatment of volvulus Treatment of internal strangulation Treatment of chronic obstruction . Operative treatment of intestinal obstruction Paracentesis or puncture of the bowel Enterocentesis . _ . Laparotomy Mode of performing laparotomy Analysis of 346 cases of laparotomy for intestinal obstruction Tables of cases of laparotomy for intestinal obstruction Enterotomy Colotomy .... jCallisen's or Amussat's operation Littre's operation Tables of cases of colotomy Analysis of 351 cases of colotomy Enterectomy •• . Colectomy .... Table of cases of resection of the bowel 59 59 60 60 60 enterolites, etc 63 63 63 64 64 65 65 65 65 67 ruction 69 70 77 77 78 78 80 87 87 88 89 INJURIES AND DISEASES OF THE RECTUM. By WILLIAM ALLINGHAM, F.R.C.S., Anatomy and physiology of the rectum 'ii^xv o a. Jori.i.^\.±j 1jU1\ JJUi'S. 93 Muscular coat 93 Submucous connective tissue 94 Mucous membrane . 94 Muscles of rectum and anus 95 Vessels of rectum and anus 96 Nerves 96 Lymphatics 97 Eelations of rectum 97 Malformations of rectum and anus 97 Injuries of the rectum . 99 Wounds of the rectum 99 Foreign bodies in the rectum 100 XX CONTENTS. Fistula in ano .... Causes of fistula in ano Course of fistula in ano Treatment of fistula in ano Fistula in conjunction with phthisis Fissure and painful ulcer of rectum Proctitis .... Ulceration and stricture of the rectum . Cancer of the rectum Hemorrhoids .... External hemorrhoids Internal hemorrhoids Excision of hemorrhoids Clamp-and-cautery method Dilatation of anal sphincter Treatment by ligature Complications of internal hemorrhoids Treatment of hemorrhage after operations for hemorrhoids Procidentia and prolapsus of rectum Pruritus ani Polypus of rectum Impaction of feces Neuralgia of rectum Irritable rectum • Inflammation of the rectal pouches Recto-vesical and recto-urethral fistula 100 100 101 104 108 108 112 113 120 12& 126 128 131 132 133 133 135 136 137 13& 140 142 143 143 144 144- URINARY CALCULUS. By E. L. KEYES, A.M., M.D., PROFBSSOU OF GENITO-UEINARY SUEGF.RY IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE; OF NEW YORK ; CONSULTING SORGEON TO THE CHARITY HOSPITAL ; SURGEON TO BELLEVUE HOSPITAL, TO THE SKIN AND CANCER HOSPITAL, AND TO ST. ELIZABETH HOSPITAL. Urinary calculus Geographical distribution of stone Causes of stone formation Influence of colloids Richness of urine in solid ingredients Effect of age Water as influencing stone formation Sex, race,- and climate Social condition, habits, and occupation Exercise and fresh air, drink and food Constitution, acute maladies, heredity 145 147 149 149 151 152 163 154 154 155 155 CONTENTS. XXI Causes of stone formation — Chronic disease of urinary passages Foreign bodies Classification of urinary calculi . Structure of stones and nature of nuclei Bate of growth of urinary calculi Gross characters of urinary calculi Spontaneous fracture of calculi . Materials which enter into composition of urinary calculi Description of various types of urinary calculus Uric-acid calculus . Oxalate-of-lirae or mulberry calculus Mixed phosphatic or fusible calculus Urate-of-ammonium calculus Ammonio-magnesian phosphate Phosphate of lime . Carbonate-of-lime calculus Cystine or cystic-oxide calculus Xanthine, xanthic-oxide, or uric-oxide calculus Fibrinous and blood calculus Urostealith ; fatty or saponaceous calculus Indigo calculus Chemical analysis of stone Organic constituents Inorganic constituents Pathological results of urinary calculus Stone in the kidney Stone in the ureter Prostatic stone Urethral calculus Preputial calculi Umbilical calculi Urinary calculi outside of the urinary tract Stone in the bladder Position of stone in the bladder Syuiptoms of urinary calculus in the bladder Diagnosis of stone Sounding for stone Preventive treatment of stone . Electrolytric treatment of stone Solvent treatment of stone Palliative treatment of stone Selection of method of radical treatment Lithotomy statistics Lithotrity statistics Relapse after radical treatment Choice of operation Peculiarities of patient Peculiarities of stone 156 156 157 159 161 161 163 164 165 165 166 166 167 167 167 167 168 169 169 169 170 170 171 171 172 174 174 176 177 180 181 181 183 183 184 188 189 192 197 197 202 202 203 207 210 211 211 214 XXll CONTENTS. Causes of death after lithotomy and lithotrity Preparation of patient for radical treatment of stone Lithotrity . . ' . Mode of performing lithotrity Complications of lithotrity Search for last fragment Litholapaxy - . . . >- Mode of performing litholapaxy Search for last fragment After-treatment of litholapaxy Time consumed by operation Relapse after litholapaxy . Complications during operation Complications after operation Applicability of litholapaxy to women and children and for removal of sub stances other than urinary deposits Lithotomy ..... General considerations concerning lithotomy Selection of a method in lithotomy Operations through the perineum . Lateral lithotomy .... Obstacles encountered before operation Complications during perineal lithotomy Complications after perineal lithotomy Possible after-effects of perineal lithotomy Bilateral lithotomy Median lithotomy . Supra-pubic lithotomy Extra- vesical lithotomy Urinary calculus in the female Treatment of stone in the female Explanation of plate illustrating appearance of some forms of urinary calculus 215 216 218 225 228 232 232 244 245 24& 246. 247 247 250 251 251 257 257 261 263 275 275 280 283 285 285 287 293 293 296 300 LITHOTRITY. By WM. H. HmGSTON, M.D., D.C.L., L.RC.S.E., Etc., PKOFESSOR OF CLINICAL SURGERY IN THE MONTREAL SCHOOL OF MEDICINE, SURGEON TO THE HOTEL-DIEU HOSPITAL, MONTREAL. Introductory remarks ..... . 301 Instruments for exploration .... . 302 Exploration of the bladder .... . 303 Dangers and advantages of lithotrity . 308 Preliminaries to lithotrity .... . 312 Method of operating ..... . 314 CONTENTS. Rapid lithotrity Lithotrity in the female Lithotrity in children . XXlll 318 322 322 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. By EEGINALD HAEEISOJSr, F.R.C.S., LECTURER ON CLINICAL SURGERY IN THE VICTORIA UNIVERSITY, SURGEON TO THE ROYAL INFIRMARY, LIVERPOOL. Wounds of the bladder . 323 Incised wounds 323 Punctured wounds 324 Lacerated wounds . 324 Gunshot wounds 324 Rupture of the bladder . 326 Foreign bodies in the bladder . 331 Malformations and malpositions of the bladder 334 Complete absence of bladder 334 Two-cavity bladders 335 Exstrophy or extroversion of bladder 335 Patent urachus 339 Hernia of bladder . 339 Inversion of bladder 340 Cystitis ..... 341 Acute cystitis 341 Chronic cystitis 343 Ulceration of the bladder 350 Hypertrophy and atrophy of the bladder 351 Hypertrophy of the bladder 351 Atrophy of the bladder 352 Sacculated bladder 353 Tumors of the bladder . 355 Villous growths or papillomata 355 Mucous growths or myxomata 358 Fibrous growths or fibromata 359 Malignant growths , 361 Tubercle of the bladder 363 Bar at neck of bladder 365 Fissure of the bladder . . 366 Irritable bladder , 367 Injuries of the prostate . 370 Prostatitis and prostatic abscess . 372 Acute prostatitis . 372 Chronic prostatitis . 374 XXIV CONTENTS. . Prostatitis and prostatic abscess — Prostatorrhoea Prostatic irritation Hypertrophy of the prostate Atrophy of the prostate Tumors and cancer of the prostate Fibromas, prostatic tumors, or adenomas Malignant tumors . Tubercle of the prostate Cysts of the prostate Prostatic calculus Hsematuria .... Retention and incontinence of urine ; paralysis and atony ; spasm and neuralgia of the bladder " Retention of urine Incontinence of urine Paralysis of the bladder Atony of the bladder Spasm of the bladder Neuralgia of the bladder . Puncture of the bladder Tapping the bladder above the pubis Subpubic operation Puncture through symphysis pubis Tapping the bladder from the perineum Puncture from the rectum Appendix .... Prostatotomy Rupture of prostate and bladder 375 375 376 387 388 388 389 391 392 392 394 399 399 405 407 407 408 409 410 410 412 412 412 417 419 419 420 INJURIES AND DISEASES OF THE URETHEA. By SIMOl^ DdPLAY, M.D., PROFESSOR OF CLINICAL SURGERY IN THB FACULTY OF MEDICINE OF PARIS, SURGEON TO THE LARIBOISIBRE HOSPITAL, ETC. (Translated by CHARLES W. DULLE'S, M.D., Surgeon for Out-patients to the Hospital op the University of Pennsylvania, and to the Presbyterian Hospital in Philadelphia.) Exploration of the urethra and bladder Direct inspection, etc. Exploration of urethra Exploration of bladder Exploratory sounding Evacuatory catheterization Endoscopy 421 421 421 422 422 425 430 CONTENTS. XXV Traumatic lesions of urethra ..... Traumatic lesions of urethra produced from without inwards Wounds of urethra Contused wounds : ruptures and lacerations Traumatic lesions of urethra produced from within outwards (false passages) Foreign bodies in urethra Foreign bodies coming from bladder Foreign bodies formed in situ Foreign bodies introduced through meatus Vital and organic lesions of urethra Inflammation of urethra or urethritis Stricture of urethra Etiology and pathogenesis Pathological anatomy Symptomatology and diagnosis Complications Prognosis Treatment Cauterization Dilatation , Inflammatory dilatation Mechanical dilatation Urethrotomy Internal urethrotomy External urethrotomy General indications relative to treatment of strictures ; choice of method Spasm of urethra ; spasmodic stricture Idiopathic spasm and contracture Etiology Symptomatology Diagnosis Prognosis Treatment Symptomatic spasm and contracture Urinary pouches Urinary abscesses . Tumors and neoplasms of urethra . Vices of conformation of urethra Congenital strictures Occlusions of urethra Congenital urinary pouches Abnormal openings of urethra, etc. Hypospadia Etiology and pathogenesis Pathological anatomy Balanic or glandular hypospadia Penile hypospadia Scrotal and perineo-scrotal hypospadia PAGE 480 430 431 431 441 443 443 447 449 451 451 451 452 453 459 462 464 464 464 465 465 467 470 471 472 473 474 475 475 476 477 478 479 480 481 482 484 484 484 485 485 486 487 487 488 488 489 490 XXVI CONTENTS. Vices of conformation of urethra — Functional disturbances . . . • • .491 Diagnosis of liypospadia 491 Prognosis of hypospadia 492 Treatment of hypospadia 492 Epispadia .... . 496 Etiology and pathogenesis 496 Functional disturbances 498 Complications 499 Treatment .... 499 Conditions which may complicate diseases of urethra 502 Urinary infiltration 502 Urinary fistute .... 505 Urethro-rectal fistute 505 Urethro-perineo-scrotal fistulse 509 Urethro-penile Astute 513 Treatment by cauterization 515 Urethrorraphy 515 Urethroplasty 516 Urinary feyer .... 517 Acute form of urinary fever . 518 Chronic form of urinary fever 521 Etiology of urinary fever 521 Pathogenesis of urinary fever ^ 522 Treatment of urinary fever 524 INJURIES AND DISEASES OF THE MALE GENITAL ORGANS. By H. EOYES BELL, E.R.C.S., SURGEON TO, AND DEMONSTRATOR OF SURGERY AT, KING'S COLLEGE HOSPITAL, LONDON. Injuries and diseases of the penis 527 Wounds of the penis 527 Fracture and luxation of the penis 629 Foreign bodies in urethra . 531 Preputial calculi 531 Balanitis and posthitis 531 Inflammation of the penis . 532 Abscess of the penis . 532 Gangrene of the penis . 532 Erysipelas of the penis . 533 Herpes prseputialis 534 Congenital defects of penis 534 CONTENTS. XXVll Injuries and diseases of the penis — Phimosis and paraphimosis Tumors of the penis Amputation of the penis Affections of the scrotum Contusions and wounds of the scrotum Cutaneous eruptions CEdema of the scrotum Mortification of the scrotum Pneumatocele of the scrotum Syphilitic induration Elephantiasis of the scrotum Lymph-scrotum Tumors of the scrotum Malignant disease of the scrotum Cleft scrotum Hydrocele .... Common vaginal hydrocele Nature of fluid Symptoms Treatment Radical cure Inguinal hydrocele Congenital hydrocele Encysted hydrocele of the testicle Diffused hydrocele of the cord Encysted hydrocele of the cord Congenital hydrocele of the cord . General remarks on the diagnosis of hydrocele Complications of hydrocele Hydrocele of hernial sac . Haematocele .... Haematocele of the tunica vaginalis Encysted hematocele of testicle Heematocele of spermatic cord Intra-testicular haematocele Varicocele .... Anatomy of varicocele Diagnosis of varicocele Treatment of varicocele Radical cure of varicocele Anomalies of the testicle Anomalies in number of testicles . Imperfect transition of testicle Retracted testis Inversion and reversion of testis . Hypertrophy and atrophy of testicle Affections of vas deferens, vesiculoe seminales, and ejaculatory duct Affections of vas deferens ..... 536 640 544 547 547 647 547 648 649 549 549 551 552 654 557 658 558 559 562 664 565 569 569 570 572 573 574 674 575 576 677 577 680 580 681 581 682 584 584 586 691 691 592 697 597 698 600 600 XXVlll CONTENTS. Affections of vas deferens, vesicute seminales, and ejaculatory duct — Inflammation of vesiciilse seminales Affections of ejaculatory duct Spermatocele Neuroses of the testicle Injuries of the testicle . Orchitis Acute orchitis Spontaneous gangrene of testicle Encysted abscess of testis Inflammatory atrophy of testis Special varieties of orchitis Diagnosis and prognosis of orchitis Treatment of orchitis Chronic orchitis Syphilitic sarcocele or syphilitic orchitis Syphilitic epididymitis Benign fungus of the testicle Tuberculous and scrofulous disease of the testis Diagnosis . Prognosis and treatment . Cystic disease of testis Dermoid cysts in testicle and scrotum Solid tumor of the testis Enchondroma of the testis Fibrous tumors of the testis Fibro-plastic tumors of the testis Calcareous matter in epididymis Carcinoma of testis Sarcoma of testis . Lymphadenoma of testis Epithelioma of testis Excision of the testis . Entozoa in testicle and scrotum Functional disorders of male genital organs Spermatorrhoea : nocturnal and diurnal pollutions Etiology of spermatorrhcea Pathological anatomy * Symptoms Diagnosis Prognosis and treatment Impotence and sterility Impotence Prognosis Treatment Sterility Azoospermia Satyriasis . Priapism . 600 601 601 602 603 603 603 606 606 606 607 609 610 612 613 J15 616 618 623 624 625 627 628 628 630 631 631 631 634 636 636 636 638 638 638 642 645 645 646 647 652 652 655 656 656 657 658 660 CONTENTS. XXIX INJURIES AND DISEASES OF THE FEMALE GENITALS. By THEOPHILUS PARVIN", M.D., PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN IN THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA. Modes of exploration Touch and sight Table for examination ; general preparations ; position of Vaginal touch Rectal touch Vesical touch External touch or abdominal palpation Combined examination Mediate touch or examination with uterine sound or probe Visual examination Examination with speculum Mensuration, auscultation, and percussion Dilatation of cervical canal Curette and exploring needle Ruptures and wounds of the vagina Wounds of the pregnant uterus Lacerations of cervix uteri ; tracheloplasty Diagnosis of lacerated cervix Indications for tracheloplasty Preparatory treatment Operation .... After-treatment Accidents during and after operation Tears of the perineum . Varieties .... Treatment .... Perineorraphy Perineoplasty . Traumatism involving genital zone in pregnancy Foreign bodies in vagina Genital atresia .... Vulvar atresia Imperforate hymen Absence or rudimentary condition of vagina Complex atresia Accidental genital atresia . Double vagina .... Hydrocele muliebris patient PAGK 663 663 664 665 666 667 667 •668 669 671 671 673 674 675 675 676 678 680 680 681 681 684 684 685 686 686 686 688 695 695 698 698 698 699 701 701 702 702 XXX CONTENTS. PAGE Vulvar and vaginal fissures ....,,. 703 Noma pudendi . 703 Lupus .... 704 Elephantiasis of the vulva 705 Tumors of the vulva 707 Cysts of the vulva . 707 Lipomata of the vulva 708 Fibromata of the vulva 709 Warty tumors or vegetations of the vulva . 709 Hsematoma of the vulva 710 Cancer of the vulva 711 Vaginal tumors 712 Cystic tumors of vagina 712 Fibroids of vagina 714 Cancer of vagina . 714 Sarcoma of vagina 714 Mucous polypi of vagina . 715 Hsematoma of vagina 715 Uro-genital fistulse 715 Etiology of uro-genital fistulse 716 Symptoms and diagnosis . 717 Complications 718 Treatment 718 Special methods necessary in c lifFerent varietie s of fistulffi 723 Eecto-vaginal fistulse 723 Diseases of the cervix uteri 725 Ulceration of cervix 725 Hypertrophy of cervix 727 Fibroid tumors of cervix . 728 Polypi of cervix 729 Malignant disease of cervix 729 Sarcoma of cervix 729 Carcinoma of cervix . ' 730 Etiology and varieties 730 Symptoms and progress . 731 Diagnosis and treatment 733 Pregnancy in cases of cancer of cervix . 735 Amputation of cervix uteri .... 735 Amputation with bistoury or scissors 736 Amputation with ecraseur . 738 Amputation with galvano-cautery wire or knife 739 , Amputation with thermo-cautery knife 739 Vaginal extirpation of cancerous uterus 740 Elytrorrhaphy or colporrhaphy 740 Anterior colporrhaphy . , 741 Posterior colporrhaphy • 745 Median colporrhaphy 746 Colpo-perineorrhaphy . ■ 746 CONTENTS: • XXXI PAGE Episiorraphy Vaginismus 747 748 ■Coccygodynia . Sterility Impotentia concipiendi Impotentia gestandi Treatment 751 752 753 754 755 Artificial fecundation • 757 JNymphomania . 757 THE CESAREAN SECTION AND ITS SUBSTITUTES; LAPAROTOMY FOR RUPTURED UTERUS AND FOR EXTRA-UTERINE FCETATION. By ROBERT P. HARRIS, A.M. M.D., OF PHILADELPHIA. "The Caesarean section ; gastro-hysterotomy or laparo-hysterotoiny /History of Csesarean section Indications for operation . , . Risk in operating ..... Causes of fatality ..... Modes of operating .... Modern antiseptic operation Uterine sutures ..... New methods of performing gastro-hysterotomy Cohnstein's process .... Frank's process .... Kehrer's process .... Sanger's process .... The Porro-CEBsarean section ; laparo-hystero-obphorectomy History of Porro operation Mode of operating .... Miiller's modification .... Veit's modification .... Other minor changes . - . . Effect of Porro mutilation upon subjects of malacosteon •Gastro-elytrotomy or laparo-elytrotomy History ...... Jorg's, Eitgen's, and Baudelocque's methods . Physick's, Bell's, and Thomas's methods Method of operating .... Statistical record ..... 759 759 761 762 763 763 764 765 765 765 766 767 768 770 770 771 772 773 773 774 775 775 776 777 777 779 XXXll CONTENTS. Puerperal laparotomy or laparotomy after rupture of uterus Laparo-hystevectomy . Operation .... Puerperal laparo-cystotomy, laparo-cystectomy, and elytrotomy nancies Puerperal laparo-cystotomy Laparo-cystectomy Puerperal elytrotomy Secondary laparo-cystotomy in ectopic preg' PAGE 780 780 781 782 782 785 785 786 OVARIAN AND UTERINE TUMORS. By CHAELES CAREOLL LEE, M.D., SURGEON TO THE WOMAN'S HOSPITAL, CONSULTING SURGEON TO THE CHARITY HOSPITAL, NEW YORK. Ovarian tumors Ovarian cysts and cystomata Origin and causes Morbid anatomy Course and natural history Symptoms Diagnosis Prognosis Treatment Dermoid cysts of ovary Hydatids of ovary Solid tumors of ovary Fibroma . Sarcoma Carcinoma Uterine tumors Uterine fibroids Location and structure Degenerative changes Symptoms Diagnosis Prognosis Treatment Uterine fibro-cysts Sarcomata of uterus Pathology, etiology, and mode of occurrence Symptoms, diagnosis, prognosis, and treatment Carcinomata of uterus Pathology and mode of occurrence 789 789 789 790 792 793 798 803 804 804 805 805 805 806 806 807 807 807 808 809 810 811 812 814 815 815 816 816 816 CONTENTS. XXXlll Uterine tumors — Symptoms ........ 817 Diagnosis ..... . 818 Prognosis and treatment 819 Affections likely to be mistaken for ovarian or uterine tumors . 822 Cysts of the broad ligament . ^ 822 Pelvic haematocele .... 823 Ilio-pelvic abscess .... 826 Operations for ovarian and uterine tumors 828 Ovariotomy ..... 828 Vaginal ovariotomy .... 828 Abdominal ovariotomy 828 Mode of performing operation 830 After-treatment and complications 834 Contra-indications 834 Oophorectomy or Battey's operation 835 Vaginal method ..... 835 Abdominal section in laparotomy . 83ft Extirpation of uterine appendages, or Tait's operation . 837 Hysterectomy ...... 837 Vaginal hysterectomy .... 837 Extirpation of uterus by abdominal section 838 Freund's method .... 838 Ordinary operation ..... 840 Hegar's method . . . . , 841 INFLAMMATORY AFFECTIONS OF THE BONES. Bt L. OLLIEE, M.D., PHOFBSSOR OF CLINICAL SURGERY IN THE FACULTY OF LYONS. (Tkanslatbd by CHARLES W. DULLES, M.D., StrEHEOK foe Out-patients to the Hospital of THE University op Pennsylvania, and to the Peesbyteeian Hospital in Philadelphia.) Introductory remarks .••..... 843 Effects of irritation on constituents of bones ..... 844 Experimental study of inflammatory processes in bone . . , 845 Direct and indirect irritation of elements of bone . . . 849 Minute phenomena of osseous inflammation ; absorption of bone-substance by medullary cells ; action of osteoplasts .... 851 Inflammation of bone in relation to its constituent tissues ; periostitis, osteomye- litis, etc. ......... 852 General symptomatology of acute inflammations of bone . . . 857 Different clinical forms of spontaneous osteitis ..... 862 Inflammation of bone accompanying period of growth . . , 862 VOL. VI. — XXXIV CONTENTS. Different clinical forms of spontaneous osteitis^ Infectious inflammations of bone ...... Eheumatic and neuralgic in ammations of bone . . . . Abscesses of bone ........ Bone-inflammations from introduction of poisonous inorganic substances ; phosphorus osteitis ....... Bone-inflammation due to presence of parasitic elements in periosteum and osseous tissue ; actinomycosis .... Treatment of bone-inflammations ..... Influence of osseous inflammations on growth of bones . . Necrosis of bones ....... Sequestrotomy or necrotomy ..... 864 868 87a 872 875 876 881 892 899 SCROFULO-TITBERCULOUS AND OTHER STRUCTURAL DISEASES OF BONES. By EIJGENl] VmCENT, M.D., PEOFESSOR AGRtGt, StJRGEON-IN-CHIEP OF THE HOSPITAL OF LA CHARIT^, LYONS. (Translated bt CHARLES W. DULLES, M.D., Surgeok fob Out-patients to the Hospital op THE University of Pennsylvania, and to the Presbyterian Hospital in Philadelphia.) Scrofulo-tuberculous aflections of bones Classification and pathological anatomy of scrofulo-tuberculous osteopathies Undoubtedly tuberculous osteopathies Encysted tubercle Tuberculous infiltration of Nelaton ; confluent Ranvier Semi-transparent infiltration Puriform infiltration Disseminated tuberculosis Inoculability and parasitic nature of tuberculous Osteopathies which are probably tuberculous Caries Spina ventosa Seat of tuberculous osteopathies ; correlation with laws of Etiology of tuberculo-scrofulous osteopathies Symptoms and diagnosis of tuberculo-scrofulous osteopathies Symptoms of encysted tubercle Symptoms of tuberculous infiltration Symptoms of caries Symptoms of spina ventosa . Prognosis of tuberculo-scrofulous osteopathies Treatment of tuberculo-scrofulous osteopathies General treatment . 901 lous osteopathies 906 . 906 . 906 granulations o r . 909 • 910 ■ 910 ■ 914 osteopathies 914 • 914 ■ 914 ■ 916 growth 917 • 920 les 921 . 922 . 923 . 923 • • 924 . 926 • 927 • c 927 CONTENTS. XXXV Scrofulo-tuberculous affections of bones — Local treatment . . . , , Means to favor absorption of products Measures to hasten elimination of products, etc. Treatment of ossifluent abscesses Treatment of fistulous tracks Modifying injections Cauterization of diseased bone Scraping bone, trephining, gouging Resection or ablation of bone ; amputation Rachitis ...... Rachitis of adolescents ; late rachitis (Oilier) Local inflammatory rachitis Morbid conditions in which bone loses its normal consistence and resistance osteomalacia and fragilitas ossium Osteomalacia History and bibliography Pathological anatomy Physical properties External appearance and changes of power of resistance Deformities of skeleton Structure .... Chemical analysis of bones Symptomatology of osteomalacia Etiology and nature of osteomalacia . Predisposing causes Hygienic, pathological, and proximate causes Diagnosis of osteomalacia Prognosis and course of osteomalacia Treatment of osteomalacia Osteitis deformans of Paget ; benign hypertrophic osteomalacia Diagnosis and nature . Pseudo-malacia of inflamed bones . Atrophy of bones ; senile and fatty osteoporosis Eccentric atrophy Concentric atrophy Treatment Wasting of the bones Idiopathic fragility of the bones Syphilis of the bones 929 929 930 931 932 932 933 935 936 939 939 941 943 943 943 945 945 945 946 950 954 954 957 957 g'ig 960 961 961 963 965 966 967 968 969 970 971 971 972 XXXVl CONTENTS. TUMORS OF THE BONES. By A. PON"CET, PROFESSOR or OPERATIVE SURGERY IN THE FACUBTY OF MEDICINE OF LYONS. (Translated by CHARLES W. DULLES, M.D., Suegeoit for Odt-patients THE UiriVEKSITT OF PeNHSTLVANIA, AND TO THE PRESBYTERIAN HOSPITAL IN Tumors of the bones Exostoses . Osteogenic exostoses or exostoses of development Symptomatic exostoses Treatment of exostoses Fibromata of bones Myxomata of bones Lipomata of bones Chondromata of bones Pulsatile tumors of bone Cysts of bone Sarcomata of bone Myeloid tumors Fasciculated sarcomata Encephaloid sarcomata Condition of neighboring articulations in bone-sarcomata Spontaneous fractures . Generalization of bone-sarcomata Etiology and symptoms of bone-sarcomata Course of bone-sarcomata Diagnosis and treatment of bone-sarcomata Osteoid tumors .... Lymphadenomata of bone . Epitheliomata of bone Carcinomata of bone TO THE Hospital op Philadelphia.) PAGE 973 974 976 978 978 979 980 980 981 985 988 989 990 992 993 993 993 994 994 995 996 996 997 997 999 CONTENTS. xxxvn ORTHOPEDIC SURGERY: THE TREATMENT OF DEFORMITIES. By FREDERIC R. EISHER, F.R.O.S., ASSISTANT SURGEON TO THE VICTORIA HOSPITAL FOR SICK CHILDREN, LONDON. PAGE History of orthopaedic surgery ....... 1001 Club-foot ...... 1004 Talipes equinus ..... 1006 Paralytic equinus .... 1007 Spasmodic equinus .... 1008 Other forms of equinus 1069 Treatment of talipes equinus . 1009 Section of tendo Achillis . 1014 Treatment by manipulation 1015 Talipes arcuatus .... 1016 Talipes varus ..... 1018 Congenital varus .... 1019 Treatment of congenital varus 1022 Congenital varus in advanced life 1025 Relapsed varus .... 1028 Non-congenital varus .... 1028 Extension in treatment of club-foot . . 1030 Excision of tarsal bones in talipes varus 1032 Talipes valgus ..... 1034 Flat-foot ..... 1037 Talipes calcaneus ..... 1039 Hammer-toe and hallux valgus .... 1041 Curvature of bones ..... 1043 Osteotomy for curvature of bones .- 1045 Genu valgum ...... 1047 Treatment of genu valgum 1049 Operative treatment of genu valgum . 1050 Deformities of lower extremity from muscular contraction 1053 Deformities of upper extremity .... 1054 Dupuytren's contraction of the fingers 1055 Lateral curvature of the spine .... 1059 Nature and characteristics of deformity , 1060 Pathological anatomy of lateral curvature . 1060 Classification of cases ..... 1061 Progress of lateral curvature 1065 Diagnosis of lateral curvature 1067 Etiology of lateral curvature .... 1071 Treatment of lateral curvature .... 1077 Wry-neck or torticollis ...... 1083 Congenital dislocations ...... 1086 XXXVIU CONTENTS. APPENDIX. CONSTRUCTION AND ORGANIZATION OF HOSPITALS. Bt EDWARD COWLES, M.D., SUPERINTENDENT OF THE M°LEAN ASYLUM, SOMERVILLE, MASSACHUSETTS. FACE History of hospitals ........ 1089 Construction and organization of hospitals ..... 1091 General considerations as to hospitals ..... 1092 Location and site of hospitals ...... 1095 Materials and foundations of hospitals ..... 1095 Form and construction of hospital wards ..... 1096 Size of hospital and arrangement of wards and accessary buildings 1105 Ventilating, warming, and lighting . . . . .1110 Furnishing and fittings . . . . . . .1116 Organization and management . . . . . .1116 Nursing ......... 1117 Special hospitals . . . . . . . .1118 Cottage and convalescent hospitals . . . . .1119 PREPARATION OF MILITARY SURGEONS FOR FIELD DUTIES ; APPARATUS REQUIRED ; AMBULANCES ; DUTIES IN THE FIELD. By BENNETT A. CLEMENTS, M.D., BREVET LIEUTENANT-COLONEL AND SURGEON, U. 8. ARMY, Introductory remarks Importance of discipline Examination of men for enlistment Medical equipment for a regiment Hygiene of camps and sanitary, care of troops Directions for cooking in camp Ambulance corps Field hospitals . Mode of supply.of medicine and medical material Duties of medical officers in field 1120 1121 1122 1123 1125 1127 1128 1130 1132 1134 CONTENTS. SXXIX A HISTORY OF SUEGEEY. GEORGE JACKSON EISHER A.M., M.D., OP SING SING, N. Y. Surgery before the time of Hippocrates Surgery during the Hippocratio era Surgery during the Alexandrian era Surgery among the Romans Greek surgery from Galen to Paulus ^gineta Surgery during the Arabic period The School of Salernum Surgery among the Hindoos Surgery during the dark ages . . Early English surgery . Surgery in the sixteenth century Surgery in the seventeenth century Surgery in the eighteenth century Surgery in the nineteenth century Description op Plates in Vol. VI. GENERAL INDEX , . PAGE 1146 1148 1156 1156 1165 1171 1177 1179 1181 1183 1185 1196 1198 1200 1203 1205 LIST OF ILLUSTRATIONS. CHROMO-LITHOGRAPHS. PLATE PA8IS XXXIII. Various forms of urinary calculus . . . . .169 XXXIV. Tuberculosis of testis and elephantiasis of scrotum . . . 550 XXXV. Fibroma and carcinoma of testis ; retained testis ; epithelioma of scrotum; syphilitic testis ; diffuse orchitis . . . 555 WOODCUTS. (After Poulet.) five-franc piece. (After Poulet, (After Poulet, from Pilate, FIG. 1161. Fragments of bone lodged in oesophagus, 1162. Duplay's resonator . 1163. Perforation of oesophagus and aorta by a from Denonvilliers.) . 1164. Perforation of inferior thyroid artery by bone. (After Poulet, from Pilate.) 1165. Bond's forceps 1166. Surge's forceps . 1167. Cloquet's toothed forceps 1168. Cusco's forceps . 1169. Mathieu's jointed forceps 1170. Gama's forceps . 1171. Petit's hook 1172. Graefe's coin-catcher 1173. King coin-catcher 1174u Horse-hair parasol-snare . 1175. Traumatic stricture of oesophagus. (After Mackenzie.) 1176. General dilatation of (Esophagus. (After Luschka.) 1177. Traction diverticulum. (After Zenker and Ziemssen.) . 1178. Interior view of traction diverticulum. (After Zenker and Ziemssen.) 1179. Exploration of diverticulum with sound'. (After Zenker and Ziemssen.) 1180. Sectional outlines of Mackenzie's bougie 1181. CEsophageal dilators 1182. Graduated oesophageal dilator of Trousseau 1 1 83. Mackenzie's oesophagotome 1184. Method of feeding through gastric fistula. (Whitehead's patient.) 1186. Instrument for drawing India-rubber through fistula from within outwards (xli) 8 11 13 13 15 15 15 15 16 16 16 16 16 17 26 30 31 31 33 34 35 35 38 42 105 xlii LIST OF ILLUSTRATIONS. PIO. J-AGE 1186. Spring-scissors with probe-point in grooved director . . . 106 1187. Scissors for removing overlapping edges of skin in operation for fistula . 106 1188. Anal speculum ........ Ill 1189. Four-bladed anal speculum ...... Ill 1190. Eectal insufflator ... . . . . .117 1191. Instrument for applying ointments to rectum .... 117 1192. Instrument for detecting rectal stricture . . . . .119 1193. Rectal syringe ........ 119 1194. Clamp for hemorrhoids . . . . • . .132 1195. Screw-crushing instrument for hemorrhoids .... 134 1196. Forceps for grasping hemorrhoids . . . . .134 1197. Spring-scissors for hemorrhoids ...... 134 1198. Extraction of urethral calculus with Thompson's divulsor . . 179 1199. Thompson's searcher for vesical calculus .... 189 1200. Civiale's litholabe . . . . . . .219 1201. 1202. Jacobson's lithotrite .... . 220 1203. Heurteloup's percuteur ....... 220 1204, 1205. Thompson's fenestrated lithotrites . . . .221 1206, 1207. Thompson's non-fenestrated lithotrites .... 222 1208. Thompson's lithotrite, male blade ..... 222 1209. Thompson's lithotrite, female blade ..... 222 1210. Handle of Thompson's lithotrite ..... 222 1211. 1212. Jaws of Bigelow's lithotrite ..... 223 1213. Handle of Bigelow's lithotrite ...... 223 1214. Jaws of Keyes's lithotrite ...... 224 1215. Keyes's lithotrite ....... 224 1216. Urethral forceps ........ 230 1217,1218. Alligator forceps, straight and curved .... 230 1219. Leroy d'BtioUes's scoop ....... 230 1220. Urethral lithotrite •••.... 231 1221. Mathieu's instrument for perforating urethral calculi . . . 231 1222. Sir Philip Crampton's evacuating bottle .... 234 1223. Cornay's litheretie . . . . . . .235 1224. Mercier's washing bottle ...... 235 1225. Clover's first evacuator ....... 235 1226. Clover's improved evacuator . . . . ... 236 1227. Nekton's evacuating apparatus . . . . . . 236 1228. Bigelow's fii-st evacuator •••... 237 1229. Stand for evacuator ••••... 237 1230. Bigelow's second evacuator ••.... 237 1231. Bigelow's third evacuator •••... 238 1232. Bigelow's latest evacuator •••... 238 1233. Thompson's first evacuator •••... 239 1234. Thompson's second evacuator . . . .. , . 239 1235. Thompson's third evacuator . . . . . , . 239 1236. Thompson's fourth and latest evacuator ..... 240 1237. Reservoir of Thompson's evacuator ..... 240 1238. Otis's evacuator . . . . , , , . 241 LIST OF ILLUSTRATIONS. xliii PIS. 1239. Guyon's evacuator .... 1240, 1241. Evacuating tubes, curved and straight 1242. Eeyes's evacuating tube, straight 1243. Keyes's evacuating tube, curved 1244. Bar for separating limbs in lithotomy 1245. Anklet and wristlet for lithotomy 1246. Staff for lithotomy .... 1247. Rectangular staff for lithotomy . 1248. Lithotomy scalpel .... 1249. 1250. Blizard's probe-pointed lithotomy knife 1251. N. E. Smith's staff and knife for lithotomy 1252, 1253. Lithotomy forceps, straight 1264. Lithotomy forceps, curved 1255. Crested scoop ..... 1256. Blunt gorget ..... 1257. Crusher, or brise-pierre .... 1258. Maisonneuve's eclateur .... 1259. 1260. Tubes for washing out bladder after lithotomy 1261. Horner's awl ..... 1262. Thompson's tenaculum with detachable handle . 1263. Forcipressure forceps .... 1264. Gross's artery compressor 1265. Shirted canula for plugging wound after lithotomy 1266. Air-tampon for hemorrhage after lithotomy 1267. Dupuytren's double lithotome cache 1268. Wood's bisector ..... 1269. 1270. Staff for median lithotomy 1271. Little's lithotomy director 1272. Dolbeau's dilator for perineal lithotrity . 1273. Rectal colpeurynter .... 1274. Sound for exploring bladder 1275. Large oxalate-of-lime calculus with external phosphatic layer 1276. Rack-and-pinion lithotrite 1277. Lever-lithotrite ..... 1278. Civiale's lithotrite .... 1279. Gouley's lithotrite .... 1280. Mercier's instrument for removing elastic bougies from bladder 1281. Robert and Collin's instrument for removing foreign bodies from bladder 1282. Wood's operation for extroversion of bladder. (After Ashhurst.) 1283. Maury's operation for extroversion of bladder 1284. Urinal for extroversion of bladder .... 1285. Double-current catheter for washing out bladder 1286. Keyes's apparatus for irrigation of bladder 1287. Harrison's catheter for introducing pessaries into bladder 1288. Section of normal prostate ..... 1289. Enlargement of prostate towards rectum .... 1290. Considerable enlargement of prostate towards rectum with straightening of prostatic urethra .... PAGE 241 241 242 243 262 262 264 264 264 265 266 266 266 267 267 267 267 268 268 269 269 269 270 270 285 286 286 287 287 291 302 311 316 316 316 318 332 333 337 338 338 346 346 348 378 378 379 xliv LIST OF ILLUSTEATIONS. Fia, 1291,1292. Enlargement of third lobe of prostate . . . . 1293. J^nlargement of third lobe of prostate . . . . . 1294. Normal position of internal urinary meatus . . . . 1295. Internal meatus in ordinary form of enlargement of third lobe of prostate 1296. Pedunculated hypertrophy of third lobe of prostate; urethra opening on either side .... 1297. Bifid hypertrophy of third lobe of prostate 1298. Prostatic dilators 1299. Mercier's sonde coudee or elbowed catheter 1300. Poland's case of prostatic calculus 1301. Gouley's tunnelled catheter 1302. Trocar and canula for puncture of bladder through perineum 1303. Tapping bladder from perineum through enlarged prostate 1304. Instruments for tapping bladder through rectum 1305. Exploratory bougie 1306. Exploratory catheter 1307. Thompson's catheter-sound 1308. Exploratory sounding, first stage 1309. Exploratory sounding, second stage 1310. Ordinary catheter 1311. Metallic catheter in sections 1312. Gum catheters, straight and curved 1313. Elbowed catheters 1314. Gum catheters, straight and curved, with 1315. Evacuatory catheterization, first stage 1316. Evacuatory catheterization, third stage 1317. Stylet .... 1318. Calculus lodged in fossa navicularis. (After VoiUemier.) 1319. Urethral calculus composed of ten pieces. (After VoiUemier.) 1320. Urethro-vesical calculus. (After VoiUemier.) . 1321. Urethral calculus of phosphate of lime, natural size 1322. Jointed curette of Leroy d'BtioUes 1323. Hunter's forceps ...... 1324. Nelaton's urethral lithotrite .... 1325. Inflammatory stricture in lightest form . 1326. Inflammatory stricture in advanced stage 1327. Inflammatory stricture occupying almost whole length of urethra, VoUlemier.) ...... 1328. Cicatricial stricture. (After VoiUemier.) 1329. Cicatricial stricture following chancroid . 1330. Traumatic stricture. (After VoiUemier.) 1331. Otis's urethrometer ..... 1382. Elbowed and spirally twisted bougies 1333. Rigaud's dilator ...... 1334. Holt's divulsor ...... 1335. Voillemier's divulsor ..... 1336. Maisonneuve's urethrotome .... 1337. Congenital urinary pouch. (After Angers.) . . conical and olive-shaped ends (After FA6E 379 380 380 381 381 382 383 384 393 404 415 416 418 421 422 422 423 424 425 425 426 426 427 428 429 429 444 445 445 447 448 448 449 454 454 456 456 457 458 461 467 468 469 470 471 486 LIST OF ILLUSTRATIONS. xlv PIG. 1338, 1839. Peno-scrotal hypospadia ..... 1340. Perineo-scrotal hypospadia ..... 1341, 1342. Section of sub-penile band and straightening of penis 1343. Eestoration of urinary meatus ..... 1344. Formation of new canal ...... 1345. Modified quill-suture ...... 1346. Section showing arangement of deep and superficial sutures 1347. Definitive result of operation for hypospadia 1348. Complete epispadia ...... 1349. Formation of new canal ; shows raw surfaces and position of sutures 1350. Modified quill-suture ...... 1351. Section showing sutures applied ..... 1352. Definitive result of operation for epispadia 1353. TJrethrorraphy by Voillemier's method .... 1354. Nelaton's method of urethro-plasty .... 1355. Dislocation of penis. (From drawing in King's College Museum.) 1356. Dislocation of penis. (From patient of Sir W. Fergusson.) 1357. End of foreskin removed in phimosis, showing pin-hole-like orifice 1358. Old case of amputation of penis ..... 1359. Pedunculated fibrous tumor of scrotum . 1360. Chimney-sweep's cancer of scrotum .... 1361. Epithelial cancer of scrotum, early stage 1362. Cleft scrotum ....... 1363. Relation of parts in vaginal hydrocele .... 1364. Transverse section of vaginal hydrocele .... 1365. Vaginal hydrocele with disease of testis .... 1366. Encysted hydrocele of testicle, or spermatic hydrocele . 1367. Spontaneous hajmatocele from ruptured tunica vaginalis . 1368. Old hsematocele ....... 1369. Dissection showing right spermatic valve. (After Brinton.) 1370. Instrument for treatment of varicocele .... i371. Elastic ligature and leaden clamp for treatment of varicocele 1372. Misplaced testicle ...... 1373. Benign fungus testis ...... 1374. Tubercular disease of testis ..... 1375. Cystic sarcoma of testis . ... 1376. Section of enchondromatous testicle .... 1377. Spermatozoon of salamandra maculata .... 1378. Human spermatozoa ...... 1379. Introduction of ligature to secure lips of cervix uteri by Jackson's method 1380. Skene's hawk-bill scissors ..... 1381. Tracheloplasty. (After Emmet.) .... 1382. 1383, 1384. Tracheloplasty. (After Thorburn.) 1385. Perineoplasty. (After Thomas.) .... 1386. Perineoplasty; " butterfiy" denudation. (After Hildebrandt.) . 1387. 1388. Perineoplasty, flap method .... 1389. Perineoplasty, Hildebrandt's method .... 1390. Perineoplasty ; Hegar and Kaltenbach's mode of fastening sutures PAGE 489 490 493 494 494 495 495 496 498 500 500 501 501 516 517 530 530 536 546 553 554 555 557 559 560 561 571 578 579 582 587 588 596 616 623 625 629 639 640 682 682 683 683 689 689 690 690 691 xlvi LIST OF ILLUSTRATIONS. FIG. 1391. Perineoplasty; sutures fastened. (After Hegar and Kaltenbach.) 1392. Perineoplasty; denudation extending to vaginal cul-de-sac. (After Hegar and Kaltenbach.) .... 1393. 1394. Perineoplasty; Emmet's method . 1395. Perineoplasty by continued catgut suture 1396. Deep sutures drawn tightly and superficial sutures introduced 1397. Completed operation, surfaces in apposition, and ends of sutures tied 1398. Perineoplasty; catgut suture approximating walls of vagina 1399. Elephantiasis of vulva. (After Schroeder.) 1400. Qperation for elephantiasis of vulva. (After Munde.) . 1401. Fibroid of labium majus. (After Storer.) 1402. Removal of vaginal cyst by Schroeder's method 1403. Diagram showing various forms of uro-genital fistula 1404. Simon's operation for vesico- vaginal fistula 1405. Vesico-vaginal fistula, freshening edges . 1406. 1407, 1408. Vesico-vg,ginal fistula, introduction of sutures 1409. Vesico-vaginal fistula; twisting the sutures 1410. Sigmoid catheter ..... 1411. 1412. Amputation of cervix uteri by Sims's method 1413, 1414. Amputation of cervix uteri by Hegar's method 1415. Supra-vaginal amputation of cervix uteri by Schroeder's method 1416. Anterior colporraphy; Emmet's method 1417. Anterior colporraphy ; sutures adjusted . 1418. Anterior colporraphy; Hegar's method . 1419. Anterior colporraphy; Schroeder's method 1420. Posterior colporraphy ; Schroeder's method 1421. 1422. Posterior colporraphy ; Emmet's method 1423. Median colporraphy; LeFort's method . 1424. Colpo-perineorraphy ; Simon's method . 1425. Colpo-perineorraphy; Hegar's method . 1426. Eestoration of perineum by Schroeder's method 1427. Rarefying osteitis. (After Gerdy.) 1428. Condensing osteitis. (After Gerdy.) 1429. Transverse section of bone affected with rarefying osteitis. , (After Gerdy.) 1430. Transverse section of bone'afifected with condensing osteitis. (After Gerdy.) 1431. Fungus of actinomycosis. (After Ponfick.) 1432. Separation of diaphysis of tibia from corresponding epiphysis 1433. Double diaphyseal separation; left femul: and right tibia 1434. Juxta-epiphyseal osteitis with necrosis 1435. Forward flexion of diaphysis of tibia on upper epiphysis 1436. Arrest of development of ulna from juxta-epiphyseal osteitis. (After Poncet.) ...... 1437. Double spontaneous fracture of bones affected with osteitis 1438. 1439. Condensing osteitis and necrosis of femoral condyles 1440, 1441, 1442. Necrosis . . . 1443, 1444. Excised head of femur showing tuberculous infiltration 1445. Tuberculous nodule and latent sequestrum in head of femur 1446. Section of tuberculous bone. (After Ch. Nelaton.) PAGE 691 692 692 693 693 693 694 706 707 709 713 715 719 720 720 721 722 736 737 738 741 742 742 743 744 745 746 746 747 747 848 848 849 849 875 886 887 888 889 890 891 894 898 909 911 912 LIST OF ILLUSTKATIONS. xlvii via. 1447. Section througt periphery of patch of tuberculous infiltration. (After Ch. Nekton.) 144§. Diffuse infiltration ; acute tuberculous osteitis 1449. Lesions of caries. (After Ch. Nelaton.) 1450. Caries. (After Dubar.) 1451. Tuberculous adenitis following osteo-arthritis of same nature 1452. Local inflammatory rachitis of adolescents 1453. Longitudinal section of healthy femur 1454. Osteomalacic pelvis. (Stoltz's collection.) 1455. La femme Supiot. (After Morand.) 1456. Section of osteomalacic humerus. (After Mommsen.) 1457. Section of osteomalacic humerus, decalcified with nitric acid. (Czerny' case.) ....... 1458. Cranium of man with osteitis deformans. (After Paget.) 1459. 1460. Osteitis deformans. (After Paget.) 1461. Section of upper end of patient's right femur 1462. Histological preparation of one of the tibiae. (After Paget.) 1463. Section of femur curved from inflammatory softening. (Ollier's collection.) 1464. Cystic chondroma of sternum. (Poncet's case.) 1465. Paralytic equinus .... 1466. Paralytic equinus; partial recovery of anterior muscles 1467. Paralytic equinus ; severe stage of same deformity 1468. Spasmodic equinus. (After Adams.) 1469. Adams's shoe for treatment of talipes equinus . , 1470. Talipes arcuatus .... 1471. Diagram of foot in talipes arcuatus 1472. Diagram of normal foot .... 1 473. Congenital talipes varus with extreme equinus . 1474. Congenital talipes varus with extreme varus 1475. Congenital talipes varus with severe equinus and varus 1476. Adams's varus splint .... 1477. Advanced congenital varus 1478. Paralytic varus. (After Adams.) 1479. Spasmodic varus .... 1480. Extension-shoe for club-foot 1481. 1482. Severe equinus, before and after treatment 1483, 1484. Severe relapsed congenital varus . 1485. Result of treatment in subject of preceding illustration 1486. Relapsed varus after excision of tarsus 1487. Same case after orthopaedic treatment 1488. Congenital calcaneo-valgus 1489. Congenital equino-valgus 1490. Paralytic valgus .... 1491. Flat-foot ..... 1492. Congenital calcaneus • . 1493. Paralytic calcaneus. (After Adams.) . 1494. Hammer-toe ..... 1495. Genu valgum ..... 912 913 915 916 919 941 942 949 951 952 953 963 964 964 965 966 982 1007 1008 1008 1009 1012 1017 1018 1018 1019 1019 1019 1024 1025 1029 1029 1030 1030 1031 1032 1033 1034 1034 1035 1036 1038 1039 1040 1042 1048 xlviii LIST OF ILLUSTRATIONS. FIG. 1496. Trough-splint for genu valgum .... 1497. Genu valgum after treatment .... 1498. 1499. Dupuytren's finger-contraction 1500. Dissection of Dupuytren's finger-contraction. (After Adams.) 1501. Instrument for Dupuytren's finger-contraction. (After Adams.) 1502. Lateral curvature of spine ; long upper curve 1503. Diagram of thorax in lateral curvature. (After Shaw.) 1504. Lateral curvature of spine; long lower curve 1505. Lateral curvature of spine ; equal curves 1506. Lateral bending of spine 1507. Lateral deflection of spine in early stage of Pott's disease 1508. Combined lateral curvature a,nd bending 1509. Spinal support with levers and plates 1510. Spinal support with shields 1511. Spinal support with spring-plates 1512. Wry-neck 1513. Curvature of spine from wry-neck 1514. Ward in Johns Hopkins Hospital 1515. Pavilion of Johns Hopkins Hospital 1516. The Toilet system 1517. Square ward 1518. Antwerp Hospital 1519. Isolating ward 1520. London Fever Hospital 1521. Johns Hopkins Hospital 1522. Boston City Hospital 1523. 1524. Stoves for hospitals 1525, 1526. Barnes Hospital 1527. Medicine-pannier 1528. Upper tray of medicine-pannier 1529. Coolidge's medicine-case or field-companion 1530. Wheeling or Eosecrans ambulance-wagon 1531. Rucker ambulance-wagon 1532. New army ambulance-wagon 1533. Halstead's hand-litter 1534. Regulation hospital-tent . 1535. Autenreith medicine-wagon PAGE 1051 1051 1055 1056 1059 1062 1063 1064 1064 1068 1069 1070 1080 1802 1082 1084 1085 1098 1099 1100 1102 1103 1104 1105 1107 1108 1112 1114 1123 1124 1124 1129 1129 1130 1130 1130 1133 Note. — The thanks of the editor and puhlishers are due to the proprietors of "^The Sanitary- Engineer" for their courteous permission to use seyeral illustrations from " Billings on Ventila- tion." THE INTERNATIONAL ENCYCLOPAEDIA OF SURGERY. INJURIES AND DISEASES OF THE (ESOPHAGUS. BY J. SOLIS-COHEN, M.D., PKOPESSOK OF DISEASES OF THE THKOAT AND CHEST IN THE PHILADELPHIA POLYCLINIC, HONOEABT PEOFESSOK OF LAKYNGOLOGY IN THE JEFFERSON MEDICAL COLLEGE, PHYSICIAN TO THE GERMAN HOSPITAL, ETC. "Wounds and Euptuees of the (Esophagus. Wounds of the (Esophagus. — The whole of the oesophagus is so well pro- tected from ordinary injury that unintentional wounds of any portion of the healthy organ are quite rare. They occur in the usual varieties of contused, incised, punctured, lacerated, and gunshot wounds. They may be superficial or penetrating. They may interest the cervical or the thoracic portion of the (Esophagus. Wounds in the thoracic portion are almost exclusively punctured or lacerated in character, the depth of that portion of the organ greatly protecting it from contused and incised wounds. The lesion may be produced by an injury from without or by an injury from within. Wounds from without occur most frequently as the result of military encounters, duels, attempts at assassination, or attempts at suicide. Wounds from within are produced most frequently by pointed, sharp, or jagged foreign bodies impacted in the tube. In several cases severe wounds have been received by jugglers in the feat of sword-swallowing. Wounds from without are most frequently associated with wounds of the air-passages, lungs, or great cervical bloodvessels. For anatomical reasons they are much more frequent in the cervical than in the thoracic portion of the oesophagus. Wounds from within are more frequently isolated than associated with wounds of other structures. ^Nevertheless, the peculiarity of circumstance may produce an unusual com- plication, as in the cases of three sword-swallowers. The one violently pushed the blunt end of his sword past an obstacle felt in his oesophagus, and it penetrated the anterior wall of the gullet and passed into the pericardium. A second pierced the pericardium in an attempt to swallow a VOL. VI. — 1 ( 1 ) 2 INJURIES AND DISEASES OF THE (ESOPHAGUS. long, blunt, juggler's knife.* In the third case the weapon broke in the gullet, a portion remaining impacted. Attempts were made to push it into the Stomach and to dislodge it by emetics, the result being to cause lacera- tion of the stomach by the point, and of the oesophagus by the jagged end of the fragment.^ Wounds or other injuries of the aorta or other great vessels, of the pleura, lungs, trachea, or bronchi, sometimes occur as sequelae of internal wounds of the oesophagus, originally isolated. W^oundsfroyn without. — Apart from the operative, incised wounds of oesopha- gotomy and cesophagostomy, incised wounds of the oesophagus — transverse, longitudinal, triangular, and irregular — ^have been produced by suicidal and murderous cuts, by cuts from weapons in the hands of antagonists and assailants, and by cuts from the surgical knife in awkward attempts at tracheotomy, whether in one stroke or by dissection. Punctui'ed wounds have been due to the points of swords, bayonets, foils, and daggers, and to the horn of the ox.* Lacerated and gunshot wounds have been chiefly due to injuries by missiles discharged from fire-arms large or small. As illus- trating the rarity of wounds of the oesophagus from external injury without involvement of the air-passages, a special investigation by Horteloup* elicited but four recorded examples. ° Incised wounds of the oesophagus associated with wounds of the air-passages* are more common, especially in cases of cut-throat ; but many examples cited in that connection are in reality wounds of the pharynx, that cavity having been entered above the level of the anterior wall of the gullet. Incised wounds may be longitudinal, oblique, or transverse. Transverse or nearly transverse wounds sometimes implicate almost the entire circumference of the oesophagus, and occasionally sever the tube completely.' Punctured, lacerated, and gunshot wounds pre- sent the physical, features common to such injuries. Punctured wounds sometimes penetrate both walls of the oesophagus. Wounds of internal origin occur in the varieties of incised, punctured, and lacerated wounds. They may be intentional, as in the operations for internal oesophagotomy. They may be traumatic in origin, or the result of patho- logical processes, or they may be of combined origin. Accidental wounds are most frequently caused by sharp-pointed or irregular foreign bodies, such as nails, spicula of bone, dental plates, and the like ; but are sometimes the result of injury by weapons introduced accidentally or voluntarily. Punctured wounds may interest either the anterior or the posterior wall. The posterior wall has been penetrated by the point of a foiP which entered the mouth and lacerated the soft palate. The patient recovered.* The ante- rior wall has been penetrated by the point of the sword of a sword-swallower, the pericardium having been pierced as well.'" Lacerated wounds may be • Parkes, Trans. Path. Soo. Loud., 1848-9. A case of Dr. A. T. Thompson's, cited by Walshe (Diseases of the Lungs, Heart, and Aorta, 2d ed., p. 201. London, 1854). 2 Gussenbauer, Wien. med. Blatter, 20 uud 27 Deo. 1883 ; London Medical Record, April, 1884, p. 151. s Case cited by Knott (Pathology of CEsophagus, p. 151. Dublin, 1878) ; Dr. W. D. Hart- man, of West Chester, Pa., records a case of punctured wound of the oesophagus from the horn of a wild bullock. (Medical World, May, 1885, p. 171.) ^ Plaies du Larynx, de la TrachSe, et de I'CEsophage. Paris, 1869. 5 Larrey, Clinique Chirurgicale, t. ii. p. 158. Paris, 1829 (in this instance the lung was ■wounded) ; Payen, case narrated by Boyer (Traite des Maladies Chirurgicales, t. vii. p. 279. PaVis, 1831) ; Dupuytren, Blessures par Arraes de Guerre, t. ii. p. 334. 6 Par6, CEuvres Completes (Edition de Malgaigne), t. ii. p. 93. Paris, 1840. ' Parfi, op. cit. 8 Levillain, Journ. Univ. de M6d., p. 238, 1820; cited by Mondifere (Arch. G6n. de MSd., 2e Sfirie, t. ii.), and by Mackenzie (Manual of Diseases of the Throat and Nose, vol. ii. p. 183. London, 1884). 8 A nearly similar case, recorded by Wilmer (Cases and Remarks on Surgery, p. 86) and cited by Knott (op. cit., p. 149, Dublin, 1778), terminated fatally. 1" Parkes, loc. cit. ; Walshe, op. cit. (Dr. A. T. Thompson's case, already referred to.) WOUNDS AND RUPTURES OF THE (ESOPHAGUS. 6 produced by missiles from fire-arms, by jagged foreign bodies, by incautious use of instruments for exploration and for extraction, by articles inserted for juggling or for suicidal purposes, and by severe etibrts at vomiting in sub- jects with diseases of the oesophagus, or with impacted foreign bodies.' The pleural sac, the pericardium, and even denser tissues are sometimes lace- rated. Thus an instance of fracture of the fourth rib at the vertebral articu- lation is reported, in the case of an insane patient who introduced the handle of an explosive toy into the oesophagus.^ When the walls of the gullet are diseased, perforations or lacerated wounds are sometimes made with bougies and stomach tubes.^ Whether preceded or not by contused, punctured, or lacerated wounds, ulcerations of the walls of the oesophagus may result from inflammation set up by impacted or incarcerated foreign bodies. As a con- sequence, there may be penetration into the mediastinum, the trachea or bronchi, the pleura or lung, the aorta or other great bloodvessel, the peri- cardium, or even the heart.* Indeed, a case has been recorded in which a fish bone had passed through the intervertebral substance of an infant, and had wounded the spinal cord ;° and one in which caries of the cervical spine was produced by a nail which had penetrated the oesophagus.^ Symptoms of (Esophageal Wovnds. — In loenetrating wounds from without, the symptoms in their totality comprise pain in the region of the oesophagus or stomach, or in the direction of the wound through the neck and thorax, with nervousness, anxiety, dyspnoea, hiccough, thirst, and, if there be an ■ opening at all large, external escape of air, mucus, blood, food, and drink. There may, however, be no characteristic symptoms whatever, and the nature of the lesion may remain unrevealed until examination after death.' The special symptoms of contused wounds are said to be pain in swallowing, ■tumefaction pf the overlying tissues, sometimes to such a degi-ee as to impede deglutition and even respiration, with probably symptoms at a later period of suppurative inflammation and abscess. The symptoms of wounds from within comprise pain, cough, and dyspnoea, and the vomiting of mucus, blood, and food. Penetrating wounds produce additional symptoms. Thus, penetration into the mediastinum will occasion symptoms of collapse, and subsequently of suppurative inflammation of the connective tissue, and perhaps of pneu- monia ; penetration of the pleura will give rise to pleui'itis with probable empyema, to pneumothorax, or to pneumonia ; penetration of the peri- cardium, to pericarditis ; of the bloodvessels, to hemorrhage ; of the trachea or bronchi, to cough and expectoration of blood, mucus, saliva, and food. Diagnosis. — The history of the accident, the location and direction of the external wound, and the external escape of mucus, blood, saliva, food, or drink, will indicate the nature of the lesion in most instances of wound from without. It must be thoroughly ascertained, however, that such matters do not emerge from a wounded larynx or trachea. There may not be any escape of food passing along the oesophagus, and then the diagnosis cannot be made.* It is believed that minute punctured wounds often elude detection in this way.' Hsematemesis, however, following a penetrating wound of the neck or of the thorax, should be regarded as an indication of wound of the oesophagus. Superficial external wounds, giving rise to no characteristic symptoms, are difficult of diagnosis. Longitudinal penetrating wounds may ' Gusseiibauer, case cited by Carpenter (Medical News, July 7, 1883, p. 25). A broken blade dn the oesophagus of a sword-swallower. 2 Cruise, case cited by Horteloup (op. cit., p. 24'). ' Shaun, Brit. Med. Jour., Nov. 3, 1873. * Andrew, Lancet, 1860. " Mackenzie, op. cit., vol. ii. p. 192. « Steven, Brit. Med. Jour., Dec. 10, 1870. ' Dupuytren, case cited by Horteloup (op. cit.). 8 Dupuytreu's case already cited. s Horteloup, op. cit., p. 19. 4 INJURIES AND DISEASES OF THE (ESOPHAGUS. elude detection when their edges remain in contact. Gaping transverse- wounds speak for themselves. Violent thirst' and continuous hiccough^ are- said to be especially significant of wounds of the oesophagus. Contused wounds are difficult of diagnosis. Their existence is inferred from the evi- dence of serious injury of the overlying parts, coexisting with pain in the oesophagus, and with dysphagia and hiccough. In wounds from within, the diagnosis will depend on the history of a foreign body, the presence of blood in matters vomited or regurgitated, dysphagia, thirst, and localized pain. Prognosis. — The natural history of operative wounds of the oesophagus, in both external and internal cesophagotoray, indicates that but little danger is^ to be apprehended from a clean-cut longitudinal wound implicating no other important structure. Cicatrization may be expected in from five to eight days. Punctured wounds, and minute incised wounds, may be expected to unite in from three to four days. The arrangement of the muscular fibres of the oesophagus, in longitudinal and circular layers, favors muscular contraction in wounds of this character.^ Transverse wounds present a much graver prognosis on account of the greater liability that matters may escape from the oesophagus into the surrounding tissues, and thereby induce death by suftbcation or by inflammatory processes. The edges of a transverse wound may be so widely separated as to preclude the possibility of approximation,^ especially when the organ has been severed in its entire circumference. Even after recovery from such a complete severance, the edges of the result- ing fistula may remain so wide asunder as to necessitate permanent alimenta- tion by means of a tube passed through the opening.' The same result follows- lacerated bullet wounds,' or other wounds which have destroyed integral portions of the oesophageal walls. The prospect is much the best in wounds from without, when the wound is slight, longitudinal in direction, situated high up, and unassociated with wounds of the air-tubes or of the great blood- vessels. Suicidal wounds implicating the bloodvessels are usually fatal by hemorrhage. "When not immediately fatal, such wounds render the prognosis graver on account of the consequent debility produced by the hemorrhage. Wounds in the thoracic portion of the oesophagus are so inaccessible to sur- gical manipulation that the prognosis is rendered very grave indeed. In an undetailed mention by Mondiere of five personal observations' of wounds ia this region, recovery is reported in but one instance. Recovery from incised wounds of suicidal origin is not infrequent. Small punctured wounds are said to cicatrize spontaneously with great rapidity.* Recovery has ensued from a severe bayonet wound' in which the weapon had passed between the third and fourth ribs, wounding the lung, of course,, in its transit. The prognosis does not seem to be particularly grave in gunshot wounds,, even though the air-passage be implicated. In the tabular statement of a series of gunshot wounds of the neck occurring in the United States,'" it is to be noted that thei-e were eight cases of wound injuring the ossophagus without injury to the air passages, with four recoveries; two cases of wound injuring the trachea and oesophagus, both fatal ; one case of wound injuring the ' Larrey, Clinique Chirurgioale, t. ii. p. 156. Paris, 1829. » Mondifere, loc. cit. ' Larrey, op. cit,, t. ii. p. 157. * Parg, op. cit, 6 Trioii, case cited by Boujiu (Sur les Plaies de I'CEsophage, p. 15. Tlifese de Paris, 1828), and ■fay Knott (op, cit,, p, 150) ; Henschen, Upsala Lakareforenings Forhandlingar, 1874, and London Med. Record, August 16, 1875, 6 Mondifere, op, cit. ' Ibid. 8 Boulin, op, cit., p. 19. 8 Payen, case reported by Boyer (op. cit., t. vii. p. 279) ; cited by Boulin (op. cit,, p, 15) ; by N^laton (Elements de Pathologie Chirurgioale, t, iii, p, 477. Paris, 1854) ; by Horteloup (op. cit.) ; and by others. 1" Medical and Surgical History of the War of the Rebellion, Part III.; Surgical Volume, p.- 688. Washington, 1883. WOUNDS AND RUPTURES OF THE (ESOPHAGUS. <;ricoid cartilage and oesophagus, with I'ecovery ;' and one case of wound in- volving the pharynx and oesophagus, likewise with recovery. Internal hemor- rhage is given as the cause of death in one case of penetrating wound of the Langenbeck, Memorabilien, Heft 1, 1877; New York Med. Jourii., July, 1877 p 99 ^ Op. cit., vol. i. p. 71. . jt , !■■ • FOREIGN BODIES IN THE OESOPHAGUS. 9 In patients with stricture of the oesophagus, want of care in swallowing only proper morsels of food, or carelessness in putting improper things into the mouth, will give rise to the accident. Impaction is the more serious by reason of the stricture.' Points of Lodgment. — There being three anatomical regions at which the calibre of the oesophagus is normally smaller than elsewhere, there are that many points at which lodgment is the more likely to take place. These points are: (1) at the pharyngeal extremity of the tube: (2) at the point where the cesophagus is crossed by the left primitive bronchus ; and (3) at the point where it passes through the opening in the diaphragm, just above the expan- sion into the cardiac, extremity. Spiculated and irregularly shaped sub- stances are apt to become entangled or partially imbedded in the mucous membrane, and may become impacted at any portion of the cesophagus. Effects, Immediate and Consecutive. — Sudden death by suffocation may ensue hy compression of the trachea, by blocking the outlet of the air-passages when the foreign body is partly lodged iu the pharynx, or by spasm of the glottis, due to irritation. Death occurring in this manner has sometimes been mis- taken for death by cerebral apoplexy. Laceration by jagged objects may produce hsematemesis. Prolonged detention of a foreign body may some- times result in dilatation of the oesophagus, annular or sacculated. Sometimes the foreign body becomes permanently lodged in the diverticulum.^ Eoreign bodies sometimes remain for years in the cesophagus and cause comparatively little suffering. Sometimes, as with needles and pins, they work their way in safety through the different tissues to the surface of the body, even to the most unlikely regions.' In some instances, when unheard of, they probably become encysted. In others they occasion abscesses at various portions of the surface, with the contents of which they are discharged, or through the openings of which they are extracted. They may escape through an abscess of the neck.* Sometimes an oesophageal abscess, due to inflammation excited by a foreign body, communicates with the trachea, the bronchi, the pleura, the lung, the mediastinum, or the pericardium. ■ , Indigestible foreign bodies, propelled into the stomach, most frequently pass through the intestinal tract and are discharged by defecation. Some of them excite ulceration in the stomach, or in some portion of the intestine, and are discharged through an abscess bursting at the exterior of the body. They may thus escape at the epigastrium,* at the extremity of the rectum, or elsewhere. In the valuable memoir of Ildvin,* an instance is related in which three difl"erent substances, swallowed by the same individual, emerged through as many abscesses, at the right and left hypochondria, and at the lumbar region, respectively. Fish-bones are liable to produce serious multiple lesions. Thus, sudden death has been reported in a case of impaction in the oesophagus of a fish- bone which penetrated the stomach, the diaphragm, the pericardium, the posterior surface of the heart, the interventricular septum, and the left coro- nary vein;' and of a fish-bone which penetrated the oesophagus, diaphragm, and pericardium, and wounded the surface of the left ventricle.* Wound of ' Menzel, Arch. f. klin. Chir., Bd. xiii. S. 678. 1872; Jjrit. Med. Journ., Aug. 31, 1872, p. 243. 2 Monti, Jahrb. fur Kinderheilkunde, 20 Oct. 1875. 3 Cohen, Diseases of the Throat, etc., p. 319. New York, 1879. * Fortune, case cited by Poulet. ^ Cripps, Brit. Med. Journ., March 22, 1884, p. 561. 5 Mgmoire sur les corps etrangers de I'oesophage. Paris, 1743 ; M^moires de I'Academie Royale de Chirurgie, t. i. p. 561. Paris, 1761. ' Andrews, Lancet, Aug. 25, 1860, p. 186. 8 Eve, Brit. Med. Journ., April 3, 1880, p. 517. 10 INJURIES AND DISEASES OF THE (ESOPHAGUS. the spinal cord" has been discovered, after death, to have been due to penetra- tion by a fish-bone through the intervertebral substance. Symptoms. — The immediate symptoms, varying with the nature of the foreign substance, the position it occupies, and the condition of the oesopha- gus, are insignificant in ^ome instances, and markedly characteristic in others. Sometimes large coins, bones, and other bodies remain impacted in such a position as to give no evidence of their presence, until sudden death by hemorrhage leads to a post-mortem examination, which reveals erosion into the aorta^ or some other important vessel.^ The immediate symptoms comprise in their totality: dyspnoea, sometimes suftbcative ; dys- phagia or aphagia ; dysphonia or aphonia ; 'pain in the neck, thorax, or stomach ; nervousness, dread of death from the accident ; spasm of tlie oesophagus, of the air-passages, or even convulsive or tetanic spasm of the lower jaw and of the extremities ; retching, vomiting, expectoration, and hemorrhage. The functional symptoms usually cease upon spontaneous ex- pulsion of the foreign body, or upon its passage into the stomach, or upon its impaction in some portion of the gullet. Subsequent to the sensory and spasmodic symptoms, others are developed, in cases of long or permanent retention, indicative of inflammation, suppuration, ulceration, and perforation of the oesophagus. Finally, there may be insomnia, innutrition, pyrexia,, marasmus, hectic, and death by asthenia. Certain nervous symptoms some- times remain after expulsion of the foreign body, the result of its previous pressure, and torment the patient with fears that another foreign body is lodged in the cesophagus. A small, smooth substance may produce only a vague seijse of discomfort, indicative of its detention in some defined or undefined portion of the oesopha- gus. The sensations of patients are not reliable guides to the locations of foreign bodies. A large body provokes retching, and is often ejected thereby, especially when of some regijlar form. Spiculated bodies become sometimes nailed, as it were, to the mucous membrane by the act of vomiting. A pin, tack, knife-blade, or the like, will be apt to give rise to sensations of pricking,, and sometimes will occasion hemorrhage. Large bodies present a mechani- cal obstacle to the passage of solid food, and sharp ones produce pain in de- glutition. When respiration is mechanically impeded, the dyspnoea is usually greater in inspiration ; when disturbed by nervous influence, the dyspnoea is usually equally manifested in expiration also. Diagnosis. — The first element in the diagnosis is the history preceding- the immediate symptoms. This may be wanting in children, lunatics, and determined suicides. Inspection thro.ugh the mouth is rarely of service, even though an oesophagoscope be employed. With the aid of cesophagoscop3\ however, a small, flat piece of bone has been discovered two inches below the cricoid cartilage, on the anterior wall of the oesophagus.* External palpation sometimes detects an impacted body high up. Large bodies sometimes cause suflicient projection in the left cervical region to attract attention by the deformity which they produce. Stability of position is almost invariable. Li cases of fancied bodies in the cesophagus^ the alleged position of the obstacle is usually varied from time to time. Digital exploration through the mouth, if the finger be long enough, is some- times suflicient to detect a foreign body lodged high up. Care must be taken not to mistake the tense edge of the pharyngo-epiglottic ligament for the edge of a fish-bone, needle, pin, or other substance. Palpation with a ' Mackenzie, op. oit., vol. ii. p. 192. 2 B6gin, case cited by Poulet (op. cit., vol. i. p. 75). ' Eriohsen, Science and Art of Surgery, vol. i. p 189. " Mackenzie, op. cit., vol. ii. p. 193. FOREIGN BODIES IN THE (ESOPHAGUS. 11 sound, catheter, or bougie is usually requisite to detect the position of the- foreign body, and to determine its density, if unknown. This manipulation, however, is not always praeticable. One of the best appliances for this pur- pose is the sound of Langenbeck : a flexible, whalebone rod, tipped with a smooth, polished, metallic knob. The knob as it strikes a hard foreign body produces a click. The sounds most in use have ivory knobs. Knobs of vary- ing sizes should be supplied with each rod, firmly attachable by a screw. A special resonator has been devised by Duplay, and perfected by Collin, pro- vided with a sounding-box and an ear-tube (Fig. 1162) ; but such an. Fig. 1162. Dnplay's resonator. instrument of precision can rarely be required, although an instance has been recorded in which it permitted the recognition of a coin which could not be otherwise detected. Any instrument used in exploration should be marked in a graduated scale, so as to indicate the precise relations of a foreign body with the walls of the oesophagus. The sound, when possible, should be carried to the stomach. If no obstacle be encountered, it may be inferred, as a rule, that the foreign body has pdssed into the stomach, th9ugh the inference is not always reliable. The most careful sounding will some- times fail to detect the presence of a foreign body known to be in the (Eso- phagus.. Collections of mucus or of moist food around the foreign body, may cause the searcher to slip past it without detection. If the foreign body be of such a shape as to become closely applied to the wall of the oesophagus, the sound may slip by without encountering it.^ Fragments of bone niay escape detection in this manner.^ In a case in which the fragment of a sword, broken off in the oesophagus,- could not be detected in the gullet of a juggler, it was found, upon post- mortem examination after gastrotoray, that the fragment had become con- cealed behind a fold of iiljured membrane in which it had become caught^ probably during vomiting in attempts at expulsion by eniesis.^ Should ex- ploration of the oesophagus be impracticable without anaesthesia, the manipu- lations must be made with the patient recumbent. This is readily done by supporting the head a little below the level of the table or couch upon which the patient lies, thus bringing mouth, pharynx, and oesophagus into the same plane. Under other circumstances, the exploration is best made with the patient in the sitting posture, the head being well thrown back so as to ' Case of English half-penny applied against anterior wall. Marston, Brit. Med. Journ., Marcli- 4, 1882, p. 305. (Welch's case.) ' Legouest, case cited by Michel (Diet. Bncyclopgdique des Sciences Medicales, Art. CEsophage^ p. 515). ' Gussenbauer, Wien. med. Blatter, 20 und 27 Deo. 1883 ; London Med. Record, April, 1884, p, 151. 12 INJURIES AND DISEASES OF THE (ESOPHAGUS. bring the axis of the mouth and pharynx as nearly as practicable in a direct line with that of the oesophagus. The mistake is sometimes made of attribu- ting dyspnoea to the presence of a foreign body in the air-passage, under which circumstances a fruitless tracheotomy has been occasionally performed, when the foreign body has been, detected in the oesophagus on examination after ■death.' Careful exploration of the oesophagus during life should prevent such a mistake. It is possible, also, that late symptoms of sulibcation may be attributed wholly to prolonged disease of the air-passages, when really due to compression by a foreign body in the gullet.^ Prognosis. — It is only exceptionally that death by suffocation from pres- sure upon the air-passages ensues before surgical help can be procured. Death by laryngeal spasm^ sometimes occurs. The prognosis is favorable in the majority of cases in which prompt measures are taken to withdraw or displace the impacted foreign body. Any injury already sustained by the See Vol. IV. p. 632, supra; and Plate XX. Fig. 19. 52 ■ INTESTINAL OBSTRUCTION. the stricture a pouch is often formed, with thin walls, in which ulceration and perforation are apt to occur. Perforation is, of course, usually fatal through the development of peritonitis, but in some cases a fistulous commu- nication is formed with the bowel below the stricture {fistula bimucosa), thus giving at least temporary relief. Foreign bodies, such as fruit-stones, are often found in the dilated pouches above intestinal strictures, and, by one of these foreign bodies plugging the orifice of the constricted portion, symptoms of acute obstruction may ensue ; acute obstruction may also follow the forma- tion of a secondary volvulus, or the bending, or, as Mr. Treves calls it, " kink- ing," of the bowel at its constricted part. On the other hand, a patient may die from intestinal stricture, gradually sinking from exhaustion, without symptoms of obstruction having been at any time observed. Stricture of the bowel is more common in women than in men, and usually occurs in persons over forty years of age. Cicatricial stricture is met with at an earlier age than the malignant variety. Of 26 cases of stricture of the small intestine, collected by Mr. Treves, 10 followed ulceration (6 in malea and 4 in females) ; 2 were due to injury (both in males) ; 4 werB traceable to the changes occurring in strangulated hernia (2 in either sex) ; and 10 (5 in either sex) resulted from carcinoma. Of 8 cases of stricture at the ileo-ccecal valve, 3 were examples of simple and 5 of malignant stricture, , one in each category occurring in the male and the rest in the female sex.. Of 44 cases involving the colon, 13 were of simple stricture (2 in males and 11 in females);, 28 were of cancer (14 in either sex) ; and in 3 (2 in the male and 1 in the female sex) the nature of the constriction was unknown. The part of the. colon implicated in these 44 cases, and in 54 others collected by Dr. Hilton- Fagge and by Messrs. Coiipland and Morris, was the sigmoid fiexure in 58,, the descending colon in 11, the splenic flexure and transverse colon each in 7, the hepatic fiexure in 9, the ascending colon in 2, and the caecum in 4. Sarcomata occasionally occur in the intestine, as do various forms of non- malignant tumor, the latter usually in the form of polypi ; these do not, however, often produce obstruction, except by disposing to intussusception,^ in which case the occlusion is ordinarily of the acute variety. Chronic invaginations are occasionally met with, causing chronic and some- times only incomplete obstruction. They have been particularly studied by Eafinesque, who finds' that of 55 cases In which the locality of the intussuscep- tion was noted, no less than 33, or 60 per cent., were of the ileo-csecal variety,, and 6, or 10 per cent., of the ileo-colic, while 8, or 15 per cent., involved the large intestine alone, and as many the small intestine separately. An important peculiarity of chronic invagination is that it comparatively seldom ends in recovery by sloughing of the intussusceptum ; thus, of 124 cases of spon- taneous separation tabulated by Leichtenstern, in no less than 94, or 76 per cent., was the process accomplished during the first four weeks, and in only 18, or 15 per cent, after the second month. The proportion of cases in which spontaneous separation occurs in chronic cases, as given by Rafinesque, is only 11 per cent. Traumatic Changes. — The occurrence of intestinal stricture as a result of injury, causing partial rupture of the bowel, has already been alluded to, but a more common mode, probably, in which external injury causes obstructiou^ is by setting up a chronic peritonitis, which leads to thickening of the serous coat of the bowel and perhaps adhesion of contiguous coils, thus interfering 1 Op. oit., p. 62. SYMPTOMS OF INTESTINAL OBSTRUCTION. 53 with the peristaltic motion, or which causes a shrinking of the mesentery and secondary stenosis. Chronic Peritonitis. — Just as acute peritonitis gives rise to acute intes- tinal obstruction, which may sometimes be indistinguishable from that pro- duced by mechanical causes, so may chronic peritonitis give rise to chronic obstruction. In these cases the peritonitis is often of tuberculous origin. Pressure External to the Bowel. — Finally, chronic obstruction may be caused by sources of compression external to the intestine itself, among which may be mentioned various forms of abdominal abscess, tumors of the solid viscera, the pressure of a retroverted uterus, etc. It must not be forgotten that in any case of chronic obstruction, acute symptoms may be suddenly developed as the result of secondary volvulus, *' kinking," occlusion by gall-stones or fecal masses, or the development of •enteritis. Symptoms of Intestinal Obstruction. It may be said, in general terms, that in chronic obstruction, the symptoms are mainly due to the impeded passage of the intestinal contents, or, in other words, are symptoms of obstruction merely, and that in acute obstruction, "there are superadded the symptoms of strangulation. Symptoms of Acute Obstruction. — The most important of these are pain, abdominal tenderness, vital depression, vomiting, constipation, lessened flow ■of urine, tympanites, and, in cases of intussusception, the presence of a tumor. Pain. — The pain of acute intestinal obstruction {miserere mei) is extreme, and often agonizing. In strangulation by a band, or in internal hernia, it -commonly begins abruptly and continues without intermission, though often ■diminishing somewhat in severity as the case progresses ; in volvulus and in intussusception, on the other hand, the pain is usually at first paroxysmal, with intervals of comparative ease, but afterwards becomes constant, though ■even then presenting periods of exacerbation. The pain is often referred to a particular spot in the abdomen, and in a certain number of cases this is found after death to have corresponded with the locality of the lesion. In more cases, however, the sensations of the patient upon this point are decep- tive, and no direct connection can be traced between the seat of pain and the strangulated bowel. In the majority of cases, probably, the pain is referred to the neighborhood of the umbilicus {tormina), possibly owing, as suggested by Mr. Treves, to the fact that the solar plexus is situated a little above that posi- tion. The cause of the pain which accompanies acute intestinal obstruction is in the first place the direct injury to the bowel and mesentery produced by their strangulation ; afterwards the violent peristalsis which ensues, and which is abruptly checked at the seat of obstruction, causes exacerbations of suffering; and, finally, additional sources of pain are the extreme distension of the gut which sometimes follows, and the .development of inflammation in the bowel itself or in the peritoneum. In the early stage, the pain of acute obstruction may be somewhat relieved by pressure, but after the development of peri- tonitis it is aggravated by the slightest touch. A sudden cessation of pain ■(without the sti'angulation having been relieved) indicates the occurrence of •collapse or gangrene. Abdominal tenderness is usually absent in the earliest stage of acute obstruction, though in cases of simple enteritis it is jDresent from the begin- ning. In volvulus and intussusception it is soon developed — in connection 54 INTESTINAL OBSTRUCTION. with inflammation of the aftected part — but in strangulation bj a band it may be almost entirely wanting, and death may ensue without marked tenderness having been at any time observed. Tenderness limited to a particular spot — - unlike pain similarly localized — is an important symptom, as indicating th& seat of obstruction. Diffuse abdominal tenderness, if slight, may be due: simply to the violent peristaltic motion of the gut above the strangulated part, but if intense, it is indicative of peritonitis. Vital Depression. — In connection with the intense pain of acute obstruction,, there is commonly great prostration, commensurate with the tightness with which the bowel is strangulated. It is most marked in strangulation by a. band and in internal hernia, is somewhat less in volvulus and in the more- acute forms of invagination, and may be entirely absent in obstruction by gall-stones, etc., as it is, in the early stages, in chronic invagination, and in simple enteritis without mechanical occlusion. There is (says Mr. Treves, speaking of strangulation by bands) great muscular weak- ness, the face is drawn with pain, and has an aspect of horrible anxiety, the features become pinched, the eyes sunken and surrounded by bluish rings, and the voice weak and muffled. A cold sweat breaks out upon the surface, and in extreme cases the limbs- become cyanosed and the complexion livid. The patient at last sinks, retaining his- intelligence, as a rule, to the last. The pulse and breathing are both rapid in acute obstruction ; the former,, feeble and often thread-like, and the latter superficial and chiefly effected by the subsidiary muscles of respiration. The temperature is below the normal standard (except in enteritis), and may not even rise upon the development of" general peritoneal inflammation. There is great thirst, especially when there- is profuse vomiting, and, when this becomes stercoraceous, the patient has a, very offensive breath. Singultus is sometimes a distressing symptom. Vomiting. — This is an early and very prominent symptom in cases of strangulation by a band or diverticulum, but much less so in those of intus- susception and volvulus, until secondary enteritis is developed, when the- nausea and vomiting may be very distressing. The matters first ejected — -just as in cases of strangulated hernia — are the contents of the stomach, and then those of the upper bowel ; finally, the vomiting may become decidedly sterco- raceous in character. Occlusion of the small intestine is attended by earlier and more persistent vomiting than that of the larger bowel, but, on the other hand, the vomiting in the former case is less apt to be stercoraceous, though in some instances the contents of the lower ileum have an undoubtedly fecal character. The occurrence of stercoraceous vomiting was formerly attributed to a reversed peristaltic movement (anti-peristalsis) of the intestine, but though such reversed movements do undoubtedly sometimes occur, the ordinary, direct peristalsis is, when the bowel is occluded, quite sufficient for the pur- pose. This subject was particularly investigated by the late Dr. W. Brinton,. who conclusively showed that when obstruction was present, and the gut contained fluid, the effect of the peristaltic wave was to cause a reversed upward current in the centre of the intestine, just as a piston with a median perforation, driven forwards in the cylinder of a pump, forces water back- wards through its opening. Constipation \s, of course, a prominent symptom in all forms of intestinal obstruction, but it is by no means equally marked in all varieties. Absolute and persistent in cases of strangulation by a band, it is only partial in those of enteritis, and in some instances of chronic invagination has been at times entirely absent ; here, indeed, as in some cases of intestinal stricture,, the patient's chief complaint may be of diarrhoea. Even when complete strangulation has occurred — as in external hernia — the use^f enemata may SYMPTOMS OF INTESTINAL OBSTRUCTION. 55 cause one or two evacuations of fecal matter accumulated below the point of obstruction. In acute intussusception the patient experiences a constant desire to go to stool — which Mr. Pollock considers almost pathognomonic — and with the tenesmus there is not unfrequently a discharge of mucus from the rectum, mingled with fluid or clotted blood. Diminished Flow of Urine. — The amount of urine excreted is lessened in all cases of acute intestinal obstruction, and it has been maintained by Dr. Barlow and Dr. Golding Bird, as well as by Mr. Hilton, that the diminution is proportional to the proximity of the obstruction to the pylorus. Doubt has however been thrown upon this proposition by several writers, including Habershon, Leichtenstern, Sedgwick, Gay, and Treves, and it is probable that, as pointed out by the last-named surgeons, it is rather the completeness than the situation of the strangulation which determines the degree of anuria, and that the mistake has arisen from the fact that acute obstruction usually afleets the small, and chronic obstruction the large intestine. The flow is measurably restored when the patient is brought fully under the influence of opium, although the obstruction be unrelieved. This is partly due to the cessation of vomiting — which, by exhausting the .fluids of the system, itself tends to diminish the flow of urine — but mainly to the action of the drug on the nervous system. The symptom may be of some value, however, in cases of incomplete and chronic obstruction, the excretion being, as observed by Leichtenstern, constantly less in constrictions high up, as it is in those of the pylorus itself, but not in constrictions of the lower ileum and large intestine. TymjMnites. — This is an early and well-marked symptom in cases of vol- vulus, but is less prominent in other forms of intestinal obstruction, being indeed often absent unless general peritonitis is developed. The swelling in volvulus is usually at first limited to the left side (sigmoid flexure), though this rule is not without exceptions ; ultimately the whole belly becomes uni- formly distended. As a contrast to the tympanites of volvulus, I may refer to the so-called " signe de Dance,"^ which consists in the presence of a marked depression in the right iliac fossa, owing to the displacement of the Cfecum in cases of ilio-cseeal invagination. As pointed out by Rafinesque, this symp- tom may be artificially induced by inflating the rectum and lower bowel with air, and the position of an intussusception may thus sometimes be deter- mined. Visible movements of the coils of intestine, though common in cases of chronic obstruction, are rare when the occlusion is primarily acute ; hence, when observed with symptoms of acute obstruction, they indicate that the latter has been superadded to a previously existing chronic condition. The Abdominal Tumor. — This is one of the most important symptoms in cases of intussusception, and has been noted in more than one-half of the recorded cases. It must not be confounded with the localized, tympanitic distension of volvulus, nor with the tumor produced by impacted feces ; it would hardly seem necessary to say that no confusion should arise between this and the normal structures of the body, but that I have known the con- vexity of the lumbar vertebrae to be mistaken for an invaginated bowel. In the large majority of cases, the tumor of intussusception is found upon the left side, not attracting attention until the caecum and ascending colon are well advanced into the transverse and descending colon. In many cases, in chil- dren especially, the tumor can be distinctly felt from the rectum. It is much more prominent during an exacerbation of pain than when the bowel is qui- escent. The tumor of feccd accumulation is almost always found at the right side (caecum), and, which Treves and Sawyer consider a pathognomonic sign, may often be made to pit by flrm external pressui-e. ' Named after Dance, a French surgeon, who wrote in the early part of this century. 56 INTESTINAL OBSTRUCTION. Symptoms of Chkonio Obstruction. — These may be conveniently considered in contrast to the symptoms of acute obstruction as ah-eady described. The pain in chronic obstruction is not constant as in acute occlusion, but rather paroxysmal, of a distinctly colicky character, and, if the smaller bowel be the seat of obstruction, often coming on at a definite period after eating. If the obstruction suddenly becomes complete— as by a gall-stone becoming im- pacted in an intestinal stricture — the character of the pain instantly changes, being then continuous, though still subject to exacerbations. There is little or no abdominal tenderness, unless peritonitis supervene, and the vital de- pression of acute obstruction is replaced by gradual failure of the vital powers, with emaciation. The vomiting in chronic obstruction is less severe than in the acute variety, and not so apt to be stercoraceous, except before a fatal termination when the occlusion has become complete. Constipation is prob- ably the most important symptom in chronic obstruction, but it is by no means constant, and often alternates with, or is entirely replaced by, diarrhoea. I saw in consultation, some months since, a physician, whom I found to be suffering from cancer of the rectum, which ultimately proved fatal by per- foration followed by fecal extravasation and peritonitis; he was totally un- aware of his condition, and had for six months been treating himself for chronic diarrhoea. Even in cases of fecal impaction, there is often developed a catarrhal state of the bowel, causing a spurious diarrhoea which masks the patient's real condition. In chronic invagination, according to Eafinesque's statistics, diarrhoea is the rule and constipation the exception. Tenesmus is often well marked when the obstruction is in the lower bowel. The flow of urine is not commonly affected in chronic obstruction, unless the lesions be near the upper end of the small intestine, when, as already pointed out, it may be diminished. Tympanites is not an early symptom in chronic obstruc- tion, but may become quite prominent toward the termination of the case. When the obstruction affects the rectum or sigmoid flexure, the colon may perhaps be traced along the border of the abdomen, distended with fecal matter, while the tympanitic small intestines occupy the intermediate space. Coils of distended intestine may often be recognized both by touch and sight, especially during paroxysms of pain, and may be seen rolling over each other, as it were, with loud borborygmus and gurgling, the peristaltic motion being obviously arrested at the seat of occlusion. The tumor of intussusception appears to have been less often observed in chronic than in acute cases, but, as justly remarked by Rafinesque, it would no doubt have been noted more frequently if it had been oftener looked for. The tumor of fecal impaction has already been referred to. A distinct tumor can sometimes be observed in cases of obstruction from malignant neoplasm. Diagnosis of Intestinal Obstruction. There can hardly be any difiiculty in distinguishing between acute and chronic obstruction of the bowels, when it is remembered that in the former only are the symptoms those with which surgeons are familiar as accompany- ing strangulated hernia. But when chronic obstruction suddenly becomes acute, its diagnosis from that which is primarily acute is more difficult. Here the surgeon must be mainly guided by the history of the case, and perhaps by noting visible movements in the intestinal coils, a symptom, as already pointed out, almost entirely limited to cases of chronic obstruction. The differential diagnosis of the various forms of obstruction, and, espe- cially in chronic cases, of the part of the bowel involved, are matters of the highest importance, as bearing directly on the question of treatment. DIAGNOSIS OP INTESTINAL OBSTRUCTION. 57 Differential Diagnosis in Acute Obstruction. — The most important point to be determined here is whether the obstruction is due to enteritis, or whether there is positive mechanical occlusion. In the former case a cure may prob- ably be effected by the judicious employment of general and local remedies ; in the latter case the only hope of recovery will often lie in prompt operative interference. In enteritis there will be pain, mainly of a colicky character, with marked tenderness over the affected portion of bowel. There will probably be dorsal decubitus, and, if general peritonitis be setting in, the limbs will be drawn up as in that affection. There may be vomiting, but it is not a very marked symptom, and the ejecta will seldom be stercoraceous. There will be consti- pation, but enemata will usually bring away small quantities of fecal matter, showing that there is not absolute occlusion. There may be an obscure ful- ness and hardness over the affected portion of intestine, but there will be no well-defined tumor, as in intussusception, and the results of rectal exploi'ation will be negative. The patient will not be collapsed, as in internal strangula- tion, but, on the contrary, there will be some elevation of temperature, with other signs of fever. There will often be a history of exposure to cold, or of imprudence in diet, or of the administration of drastic purgatives. If the case appear to be one of mechanical occlusion, the surgeon must endeavor to decide whether the obstruction be due to intussusception ; to strangulation by a band, diverticulum, adhesions, or internal hernia; to acute volvulus; or to the lodgment of a gall-stone, enterolite, or foreign body. Intussusception is by far the most frequent form of mechanical obstruction met with in children and young persons. It occurs suddenly, usually with severe and increasing pain, which afterwards somewhat diminishes. The pain is either paroxysmal, or, if continuous, presents distinct exacerbations. When the characteristic tumor is found, it is usually tender on pressure. Vomiting occurs, but is only exceptionally stercoraceous. Diarrhoea is rather more common than constipation ; and in the large majority of cases there is a discharge of blood from the rectum. There is usually marked tenesmus, a symptom which Mr. Pollock considers pathognomonic. In about half of the cases a well-defined " sausage-shaped" tumor is observed, commonly on the left side of the abdomen, and it may often be felt by digital exploration of the rectum, or may even protrude through the anus. The patient is often collapsed, and the temperature is normal or subnormal unless general perito- nitis occurs, and is even then not materially elevated. Internal strayigulation by bands, etc., is most common in young adults, and slightly more frequent in the male than in the female sex. It begins sud- denly, with severe and continuous pain of a colicky character, often referred to the umbilicus. There is no tenderness, unless subsequent to the develop- ment of peritonitis. Vomiting is an early and most distressing symptom, and commonly becomes stercoraceous about the fifth day. There is complete constipation from the beginning. An enema may bring away the contents of the large intestine, but no fecal matter passes the seat of occlusion. Col- lapse is more marked in this than in any other form of intestinal obstruction. There -is great thirst, depending probably on the excessive vomiting, and the flow of urine is often notably diminished. There is, in the majority of cases, a history of one or more previous attacks of peritonitis. Volvulus is almost exclusively an affection of middle age and advanced life, and occurs in men about four times as often as in women. It occurs sud- denly, with severe pain, at first intermittent but afterwards continuous, often referred to the umbilical region, and afterward to the sigmoid flexure, where the twisting usually occurs. There is commonly tenderness over the distended bowel. Vomiting is a comparatively unimportant symptom, and, when it 58 INTESTINAL OBSTRUCTION. occurs, often relieves the patient's suffering temporarily. There is complete constipation, and in some cases tenesmus, but no discharge of blood. Tym- panites and meteorism occur early and increase rapidly, often causing dyspnoea by pressing on the diaphragm. The tympany is usually at first limited to the left side. There is less prostration than in internal strangulation. There is usually a history of previously existing constipation. Obstruction by gall-stones is most common in elderly women. It begins suddenly, with severe pain, free vomiting, which ultimately becomes sterco- raceous, and complete constipation. The patient is not prostrated as in other forms of acute obstruction. There have usually been previous attacks of a somewhat similar character. If a foreign body cause obstruction, a history of its having been swallowed can ordinarily be obtained. Enterolites often form such large masses that they can be detected by external palpation. It is hardly necessary to say, that, in every case of acute intestinal obstruc- tion, a careful examination should be made of all the localities in which external hernia may occur ; in obstruction in new-born children, also, the anus and rectum should be examined to ascertain if there is any congenital malformation. Differential Diagnosis in Chronic Obstruction. — In cases of chronic intestinal obstruction, it is important to distinguish between fecal accumula- tions, strictures of the bowel, and chronic invagination. The other forms of chronic obstruction are rare, and can usually be recognized by careful inquiry into the previous history and general condition of the patient ; thus, in the case of inflammatory changes from traumatism, there will be a history of injury ; in that of tuberculous peritonitis, there will be evidence of tubercle in other organs ; while if the obstruction be due to the pressure of an ovarian or uteri7ie tumor, the diagnosis may be made by noting the symptoms characteristic of those aftections. Fecal accuynulations, as a cause of intestinal obstruction, are most common in adult women, and especially among the subjects of hysteria or insanity. In a case of this kind there is a history of long-continued constipation, gradually increasing in obstinacy, with swelling of the abdomen, distended coils of intestine being sometimes plainly visible on external inspection. As the swelling increases, the abdomen may become painful, and at a late period vomiting may occur, seldom, however, becoming stercoraceous. The most important symptom is the appearance of a doughy tumor, often pitting on pressui-e, and usually occupying the position of the csecum. Intercurrent attacks of complete constipation are not infrequent, but readily yield to the use of enemata. Acute obstruction may follow as the result of paralysis of the gut (ileus paralyticus). Stricture of the small intestine may be suspected if in a middle-aged person there have been 'frequent attacks of painful indigestion, with nausea or vomiting, occurring at fixed intervals after the ingestion of food, and M'ith long intervals of entire freedom from suftering. The patient gradually becomes emaciated, and the intestinal movements can then often be traced through the abdominal wall. There is usually, but not invariably, constipa- tion. If the stricture be of a malignant charactfer, a tumor may be detected. Acute obstruction may occur as the result of sudden plugging of the con- stricted bowel with masses of undigested food, gall-stones, etc., or from the ■ formation of a secondary volvulus, or from " kinking." In stricture of the large intestine, no connection can be traced between the occurrence of painful paroxysms and the ingestion of food ; there is commonly tenesmus, and occa- sionally a discharge of blood from the rectum ; and there is often marked PROGNOSIS OF INTESTINAL OBSTRUCTION. 50 tympanites. If the stricture involve the rectum or even the sigmoid flexure, it can usually be detected by digital or manual exploration. Chronic invagination is most common in men, and in early adult life ; it begins abruptly, and afterwards assumes a chronic character — this is a very significant circumstance — and presents many of the symptoms of acute invagination, only that they are less severe, and that the vital depression of that condition is wanting. The most distinctive symptoms, beside the mode of invasion, are the appearance of the characteristic tumor, and the discharge of blood from the rectum. Diagnosis as Regards the Seat of Obstruction. — In acute obstruction the part affected is usually the small intestine, and in chronic obstruction the large bowel. When stercoraceous vomiting occurs as an early symptom, the seat of obstruction is probably in the lower part of the small intestine ; for, on the one hand, this symptom is not observed when the obstruction is in the upper part of the small bowel, and, on the other hand, in obstruction of the colon it occurs at a compai'atively late period. The amount of urine secreted is- probably not as important a diagnostic symptom as has been usually supposed^ a diminished flow being rather significant of the acuteness than of the high seat of the obstruction ; in chronic cases, however, anuria indicates obstruc- tion comparatively near the pylorus. The use of the long tube for diagnostic purposes is deceptive, the sigmoid flexure being often so movable that the end of the tube, while still in that segment of intestine, may reach the umbilicus, and may then be supposed to be in the transverse colon. A cer- tain amount of information may be gained by observing the quantity of ivater that can be injected into the lower bowel without escaping by the side of the injecting instrument ; but even this test is not certain, for, on the one hand, the capacity of the rectum alone varies very much in difterent individuals, and, on the other hand, it would appear that an occluded bowel may be sometimes permeable by fluids injected from below, while resisting any passage of fecal matter from above. Auscultation of the colon and ccecum^ while fluid is being injected into the rectum, is considered by Mr. Treves to be of great value ; if the fluid can be distinctly heard to enter the caecum, it gives evidence of course that the obstruction is not in the large intestine. Prognosis of Intestinal Obstruction. Prognosis of Acute Obstruction. — Acute obstruction of the bowel is always an affection replete with danger to the patient, and a cause of the gravest anxiety to the surgeon. By far the most favorable cases are those of enteritis, in which, indeed, under judicious treatment, a cure can usually be obtained. In acute intussusception there is at least a chance of spontaneous recovery, either by the bowel becoming disinvaginated under the influence of opium and enemata, or by sloughing and separation of the intussusceptum ; the latter occurrence offers the most hope, as may be seen from Leichtenstern's statistics, which show that 557 terminated cases gave in all 151 recoveriea (27 per cent.) and 406 deaths (73 per cent.), but that whereas 149 cases in which sloughing occurred gave 88 recoveries (59 per cent.) and only 61 deaths- (41 per cent.), 408 cases in which sloughing did not occur gave but 63- recoveries (15 per cent.) and no less than 345 deaths (85 per cent.). But in the other forms of acute obstruction — internal sti-angulation (which, next ta intussusception, is much the most common variety, constituting, according to Leichtenstern's figures, more than one-fourth of the whole), acute volvulus. 60 INTESTINAL OBSTKUCTION. etc. — the only hope of cure commonly lies in prompt operative interference, before the development of general peritonitis. Prognosis of Chronic Obstruction. — The least dangerous form of chi'onic obstruction is that caused by feeal accumulation, which can ordinarily , be removed without much difficulty. Even in cases of intestinal stricture, relief can often be aflbrded and the evil day warded oft" for a long while by the regulation o^ the diet and the judicious use of cathartics or enemata. The most unfavorable cases are those of chronic invagination, in which there is comparatively little chance of a cure by sloughing, and in which, therefore, if efforts at reduction by inflation, manipulation, etc., fail, operative measures become necessary. Treatment op Intestinal Obstruction. There is probably no class of cases so habitually mismanaged by otherwise intelligent practitioners, as that under consideration. This is partly owing to the fact that, these cases being comparatively rare, few physicians have the ojjportunity, or take the trouble, to make themselves familiar with their pathology, and hence, when forced to assume the responsibility of their treat- ment, administer remedies in the most empirical manner, and use their weapons, as it were, in the dark, and quite as often, therefore, to their patient's detriment as to their advantage. Thus, I have known frictions with ice to be persistently but, of course, fruitlessly employed in a case of intestinal stricture, and a patient with manifest intussusception to be tortured with repeated doses of calomel and jalap. Another reason for the unscientific way in which these cases are often treated, is that, since their prognosis is universally acknowl- edged to be very unfavorable, practitioners are tempted, on the " anceps remedium melius nullo" principle, to use heroic remedies which are certainly not harmless, and which are actually more likely to kill than to cure. In former times| metallic mercury, and afterwards ci'oton oil, were the battering- rams with which physicians tried to burst through the obstructions by which their patient's lives were threatened, and I very much fear that at the present day, the hasty resort to operative measures, encouraged by the much-vaunted modern triumphs of "abdominal surgery," is responsible for the loss of a good many lives which might perhaps be saved by more rational if less bril- liant treatment. I speak strongly upon this point, because I feel a certain degree of personal responsibility in the matter, an article published by myself some twelve years ago' having had a share in popularizing, the operation of abdominal section in these cases. I would strongly urge that the surgeon should not, in any case of intestinal obstruction, open the abdomen, unless he has been able to form some distinct notion of what he expects to find, or at least until he has been able to satisfy himself that there is positive mechanical occlusion, and that no less dangerous operation will suffice for its relief. Treatment of Acute Obstruction. — From my own experience, I am led to believe that a large proportion of the cases of acute intestinal obstruction met with in practice are really examples of enteritis, and that if they were recognized as such, and promptly treated, the number of recoveries would be much larger than it is at present. Eemembering that, as Sir Thomas "Watson ' On laparotomy, or abdominal section, as a remedy for intussusception ; with tables showing the results of the operation in cases of this affection, and in those of other forms of acute obstruc- tion of the bowels. (American Journal of the Medical Sciences, July, 1874, pp. 48 285.) TREATMENT OF INTESTINAL OBSTRUCTION. 61 expresses it, enteritis " is in most cases peritonitis, and something more," I have no hesitation in saying that the remedy of prime ipiportance is direct depletion by blood-letting. I have not employed general bleeding in these cases, but should not hesitate to do so if leeches could not be procured. I have, however, seen the whole aspect of the case changed by the application of leeches immediately o\'er the inflamed segment of bowel. If the patient be a vigorous adult, at least twelve ounces of blood should be taken in this way, and the leeching should be repeated if the symptoms recur. After the leeching, the whole abdomen should be covered with mercurial ointment, and a warm mush or hop poultice then applied over all. At the same time, the patient should be brought under the influence of opium, and occasional enemata of warm water, warm flaxseed tea, or warm olive oil may be employed. No purgative should be administered by the mouth. If any marked tenderness persist the next day, a moderate-sized blister may he applied with advantage. The patient should take only small quantities of concentrated food, and if there be vomiting, it is better to rely upon nutritive injections. I cannot illustrate this subject better than by quoting Sir Thomas Watson's graphic account of his own case: — " I well remember," he says, " though it is now many years ago, being myself badly treated for enteritis. Being ill, in a strange place, I sent for the nearest practitioner, who happened to be a very ignorant man. Finding that I was sick, and that my bowels did not act, he gave me, for two or three days in succession, strong drastic purges, with no other effect than that of increasing my sickness and adding to the abdominal pain I suffered. I was then se^n by a most intelligent physician (this was before I had paid any attention to physic myself), and the first thing he did was to have me copiously bled ; and the immediate eflPect of that bleeding was to send me to the night-chair." The course of treatment briefly sketched above is that which I would recom- mend in any case of obstruction recognized as depending upon enteritis ; and I will go further, and say that in any case of acute obstruction not obviously due to a mechanical cause, this mode of treatment should be given a fair trial before resorting to an operation. The special measures required by the different forms of acute obstruction, other than enteritis, will be considered presently, but I may refer first to cer- tain indications for treatment which ai'e common to all varieties. In the first place, bearing in mind that the most desperate cases sometimes end in spon- taneous recoverjr, the surgeon should aim to obviate the tendency to death by relieving pain, lessening excessive peristaltic action, avoiding abdominal distension, and maintaining the patient's strength. The most important single remedy in cases of acute intestinal obstruction is opium, which may be given either by the mouth, or hypodermically in the form of morphia. If by the mouth, the watery extract of opium is the best preparation, and may be given in half-grain or grain doses, every three or four hours, in com- bination with small doses of the extract of belladonna. The only objection to the use of opium is that by relieving the symptoms it may obscure the diagnosis, but when once the nature of the case has been determined, opium may be given with great freedom. It relieves the pain, checks the vomiting, arrests the violent peristaltic action, and under its use the tongue becomes moist, and the flow of urine is increased. The feeding of the patient is a very important matter in all cases of intestinal obstruction. Only such food, if any, should be given by the mouth, as will furnish the maximum of nutri- ment with the minimum of fecal residue ; indeed, in many cases it is better to abandon all efforts at feeding by the mouth, and to rely exclusively upon nutrient enemata. ■ To relieve the thirst, which is so often a distressing symp- €2 INTESTINAL OBSTRUCTION. torn in intestinal obstruction, the patient may be allowed to suck pieces of ice, and large enemata of water may be frequently administered. Kussmaul, Oahn, Senator, and Hasenclever, in Germany; Chantemesse, Kuhn, and Fauche, in Fi-ance ; and Whittaker, of Cincinnati, in America, recommend ■washing out the stomach, as a means of evacS^ting the fluid contents of the upper part of the small intestine, and thus relieving the distension and allaying the vomiting. The use of purgatives, whether by the mouth or by the rectum, should be absolutely forbidden; but simisle enemata of -warm icater, or, which Head pre- fers, of warm oil, administered through a long tube or nozzle, and preferably by the siphon or " gravity" method, are often of very great value, and may even be efficient in pushing back the invaginated bowel in the early stages of an intussusception. Libur and Jate have recorded cases in which cures were «iFected by the injection successively of solutions of bicarbonate of sodium and •of tartaric acid, and Ziemssen considers injections of this kind much more valuable than those of simple water ; enemata of ox-gall have been recom- mended by Murray, ofNewcastle-on-Tyne; and iced-waterinjections{\\h\ch.io\Tsx an important part'of what is known as Grissolle's method of treatment) have been successfully employed by Kormann, of Coburg. Tobacco enemata were formerly held in high repute, and were favored by the late Dr. Brinton. They are, however, dangerous in themselves, and their advantage over safer remedies is at least doubtful. Inflation of the intestijie with air, introduced through a long tube or with a long-nozzled bellows — a mode of treatment as old as Hippocrates — has occasionally succeeded in relieving the obstruction after the failure of other methods, and is certainly woi'thy of trial in a doubt- ful case, before resorting to an operation. An ingenious instrument for in- flating the bowel has been devised by Mr. Lund, of Manchester, its most important feature being the adaptation of a hollow elastic ring, which, being firmly pressed against the anus, prevents the escape of air by the side of the injecting tube. A few other remedies must be briefly mentioned- The administration of metallic mercury was in past times often resorted to in the treatment of intes- tinal obstruction, and this plan has of late years found an able advocate in a French writer, M. Matignon. There can be no doubt that in cases of obstruc- tion from fecal impaction, the use of mercury in this way has often been i?uccessful — not, as was formerly supposed, by the weight of the metal carry- ing everything befoi'e it, but, as pointed out by M. Matignon and Mr. Treves, by the drug becoming very finely divided in its onward passage, and by the resulting particles mechanically insinuating themselves around and amid the fecal mass, and thus causing its dislodgment and disintegration. In cases of intussusception or internal strangulation, however, mercury could certainly iil.i()n(, is thoroui^'hlyctliorized, placed iti tiio r(!ciniil)eiit poHtiire, and broui^'ht with IiIh hultockK to tho loot of the operating table or side of tho ImmI, ho that the surgeon can stand between the lower liiidiH, which slionld be Hupj)ort(;cde the sni'geon's mani|)ula(i()ns, one or more coils canula, introduced through the 1 wound, through the abdominal paricd.es. Mr. Treves advises, and I think judiciously, that the operator should first liass his hand to the position of the ciecum, by noting the condition of which ho can usually at onec! decide whelJier the obstruction is in the lai'ge or small intestine!. 1 f I lu) crhmiim is distended, tho lai'ge bowel is the seat oi' occlusion, and (lie siirgtHin then follows with liis hand Ihe course of tho colon until ho (ponies l:() the part allocated; if, on tlit! oilier hand, the cascum is empty, the obstruc^tion must be in the Uwser bowel, and sean^h is then made for undis- tended coils of small inti^stine, first in the ciccal region and about the upper edge of the jielvis, and then in the pelvic cavity where the empty loops are a]»t to hang when the obstruction is liigh up. In order to detcirmino the direction in which the surgecm should proceed in seeking for tho junction of the collapsed and disttiiidod portions of intestine, Mr. liand recalls tho ana- tomical tact that the root of tho mesentery is attached to the spinal column, ' Of ooui'se, tlid rootum slumW liavii Ixion oarofully and ropcatodly (ixiiiiiiiKid to make sure that it in nut itaolf tho seat "I' ol)sti-u 100 Polaillon, Recovered. Bull. Gen. de Th^rapeutique, 30 Aoftt, 1879. 101 Id. Died. Ihid. 102 Id. Recovered. Gazette Medicale, 25 Avril, 1885. 103 Pughe, ti Lancet, Dec. 6, 1884, p. 1019. 104 Eigaud, Died. Archives G^n de M^decine, Nov. 1876. 105 Eivington, (( Brit. Med. Journ., May 21, 1881. 106 Eoworth, Recovered. Ibid., Dec. 6, 1884. 107 [Sands], Died. Medical Record, April 22, 1882. 108 Savory, Recovered. Alder Smith, Brit. Med. Journ., May 26, 1883. 109 Smith, T. Died. Brit. Med. Journ., .Tan. 18, 1879. 110 Terrier, Recovered. Abeille Mfidicale, 4 Aout, 1879. 111 Tessier, Died. British American Journal, vol. i. p. 251, 1860. 112 Trelat, (c Gazette Medicale, 23 Aout, 1879. 113 Treves, (( Intestinal Obstruction, p. 108. London, 1884. 114 Id. Recovered. Ibid., p. 110. 115 Tripp, (( Louisville Med. News, Jan. 17, 1885. 116 Voigt, (e Prag. med. Wochenschrift, 1883. 117 Weinlechner, Id. ^ Died. Aertzl. Ber. der k.-k. allg. Krankenh. zu Wien, 1883. 118 (( Ibid. 119 Wells, Recovered. Lancet, July 14, 1877. Table VI. — Cases of Laparotomy for Obstruction from Tumors, Strictures, Ulcers, etc. No. Operator or Reporter. Result. Reference. 1 Avery, Died. Trans. Path. Soo. Lond., vol. ii. p. 62. 2 Barie et Duoastel, Undeterm'd. Progres Mgdioal, 1880. 3 Berger, Died. Bull. et. Mem. de la Soc. de Chlrurgie, 3 Nov. 1880. 4 Biesiadecki, It Brit. Med. Journ., Jan. 29, 1876. 5 Cameron, ti, Glasgow Med. Journ., April, 1879. 6 Davies-Colley, It Guy's Hosp. Reports, 3d S., vol. xix. 7 Duplay, ti Gazette Medicale, 26 .Tuillet, 1879. 8 Gussenbauer,! tt Hospital Gazette, Oct. 10, 1878. 9 Hamilton, ti Med. Times and Gazette, vol. i. p. 88, 1864. 10 Homans, Recovered. Bost. Med. and Surg. Journ., Feb. 14, 1884. 11 Id. Died. Ibid. 12 Lawson, • It Med. Times and Gaz., vol. i. p. 675, 1861. 13 Id. Recovered. Ibid., Jan. 18, 1879. 14 Le Fort, Died. Bull. G6n. de Thdrapeutique, 30 Aout, 1879. 15 Levis, It Personal communication. 16 Luke, tc Trans. Path. Soc. Lond., vol. ii. p. 218. Brit. Med. Joufn., Jan. 14, 1882! 17 MacCormao,' Recovered. IS Marsh,' (< Lancet, March 1, 1879. 19 Marshall,* Died. Ibid., April 22, 1882. 20 May, ti , Brit. Med. Journ., Feb. 24, 1883. 21 Mikulicz, tt Archiv f. klin. Chirurgie, Bd. xxx. 22 Monod, tt Archives G^n. de M^d., t. il. p. 455, 1838. 23 Mynter,' t( Buffalo Med. and Surg. Journ., vol. xix. p. 347. . Archiv f. klin. Chirurgie, Bd. ii. S. 318. 24 Pagenstecher, Recovered. . 25 Partsch, Died. Centralbl. f. Chir., Bd. x. S. 833. ' In ease 8, a portion of small intestine was exsected. ' In case 17, hysterectomy was also performed. ' In cases 18 and 23, the bowel was opened. * In case 19, a portion of large intestine was exsected. OPERATIVE TREATMENT OF INTESTINAL OBSTRUCTION. Table VI. — Concluded. 75 Ho. Operator or Reporter. Result. Reference. 26 Pitts,! Recovered. St. Thomas's Hosp. Reports, vol. xi. 27 Reybard, It Bull, de I'Aoad. de M6d., t. ix. p. 1031. 28 Riohter,' (C Med. News, Sept. 30, 1882. 29 Roser,' Died. Brit. Med. Journ., Sept. 27, 1879. 80 Tait, Undeterm'd. Med. Times and Gazette, Nov. 26, 1881. 31 Teale,' Recovered. Lancet, March 13, 1875. 32 Id. Died. Brit. Med. Journ., Jan. 11, 1879. 33 Id. (t Ibid. 34 Id. ti Ibid. 35 Id. (t Ibid. 36 Id. " Ibid. 37 Tillaux, Recovered. Gazette MSdicale, 21 Aoftt, 1880. Table VII. — Cases os Laparotomy for Obstruction due to Hernia of VARIOUS forms and TO " IlEUS." No. Operator or Reporter. Result. Reference. 1 Annandale,^ Died. Edinb. Med. Journal, Sept. 1873. 2 Bellamy,* Recovered. Trans. Clin. Society, vol. xii. 3 .Berger, Died. Bull, et Mem. de la Soo. de Chirurgie, 3 Nov. 1880. 4 [Blancard], Recovered. Mgm. de I'Aoad. Royale de Chirurgie, t. iv. p. 337. 5 Blum.s u Bull, et M^m. de la Soo. de Chirurgie, 10 Nov. 1880. 6 Bradley, Died. Lancet, April 6, 1878. 7 Briddon, (( Medical Record, May 15, 1880, and July 29, 1882. 8 Byrd, Recovered. Trans. Am. Med. Assoc, 1880, 1881. 9 CouIson,6 Died. Lancet, vol. ii. p. 303, 1863. 10 Dandridge,' • 0.0 Not stated 11 6 5 45.4 Aggregates 351 4 214 133 37.9 Enterectomy, or resection of a segment of the small intestine, has usually been performed in cases of gangrene of the bowel following strangulated hernia, or in those of fecal fistula ; but it may also be properly performed, subsequent to laparotomy (when it is called laparo-entereetomy), in cases of gangrene, certain eases of intestinal stricture and tumor, occlusion of the bowel by inseparable adhesions, volvulus, and irreducible, chronic intussus- ception. It is, of course, a more dangerous operation than laparo-enterotomy ; but, on the other hand, oft'ers, as that does not, a prospect of perfect and permanent cure. The operations of enterectomy and laparo-enterectomy may each be done in two ways : (1) the diseased portion of bowel may be simply cut away, and the ends attached to the external wound so as to form an arti- ficial anus ; (2) after resecting the diseased segment, the ends may be approx- imated with sutures and the gut returned into the abdominal cavity. The latter plan is the proper one in cases of fecal fistula, and in some cases of obstruction very high up in the small intestine, as in the duodenum, where the establishment of an artificial anus would very much interfere with the patient's nutrition ; but in all ordinary cases of intestinal obstruction, as in gangrene after strangulated hejrnia, it is safest at first to make an artificial anus, land on a subsequent occasion, if necessary, to attempt to restore the continuity of the intestine. In cases of hernia and fecal fistula, the operation is performed at the seat of disease ; in other cases it is better, as a rule, to make the incision in the course of the linea alba, and endeavor to bring the affected bowel to the median line, where, after resection, its ends can be most conveniently fastened ; but if this cannot be done, a second incision must be made directly over the obstructed part. It is often of the greatest importance, in this operation, to prevent the extravasation of blood and fecal matter into the abdomen ; hence, as soon as the diseased portion of bowel is exposed, it should be well drawn out, and the external wound either closed as far as possible, or filled with soft sponges 80 as to cut off all communication with the parts within. Several surgeons. 88 INTESTINAL OBSTRUCTION. including M. Rydygier, Mr. Treves, and Mr. Gibson, of Manchester, have devised ingenious clamps for temporarily compressing the gut, and thus pre- venting the escape of its contents. The section of the bowel is best made •with scissors, a portion of healthy bowel being left between the cut and the clamp, so as to allow space for the adjustment of the sutures. A triangular piece of the mesentery should also be excised, the base of the triangle cor- responding to the extent of the resected intestine, and the wound being closed with fine sutures. The clamps are then cautiously removed, first from the lower and afterwards from the upper end, and the parts are attached to the external wound by numerous stitches. When an attempt is made to restore the continuity of the gut, either as a primary or secondary procedure, the clamps, carefully adjusted, are fastened together so as to approximate the cut ends of bowel, and these, having been freshened, if necessary, are then secured to each other by two rows of sutures, one bringing together the edges of mucous membrane, and buried in the tissues of the gut, and the other applied through the serous and muscular coats, as in Lembert's method.' Mr. Treves justly condemns Grussenbauer's suture as needlessly complicated. In order to facilitate the introduction of the stitches, cylinders of dough, decalcified bone, etc., have been introduced into the bowel, but are objectionable as exposing to the risk of at lea^t tem- porary obstruction ; if any guide is needed, a bag of thin India-rubber may be used, as suggested by Treves, being inflated after its introduction, and Being allowed to collapse again, and withdrawn, before adjusting the last suture. The operation is completed by returning the sewed-up bowel into the abdomen, and closing the external wound. Colectomy, a resection of a portion of the large intestine, is less often practised than enterectomy; and indeed can seldom be recommended except in certain cases of malignant stricture of the colon, or of fecal fistula, or what Mr. Morris calls " false anus," of this part.^ In cases of this kind the place of incision is, of course, determined by that of the fistula, but under other circumstances colectomy is, as a rule, best effected through an incision in the lumbar region, as in lumbar colotomy, the bowel being drawn out and dealt with in the manner, and with the precautions, described in speakihg of enterectomy. Nicolaj'sen has reported a successful case of colectomy per- formed through the rectum. The statistics of these operations, enterectomy and colectomy, have been made a subject of special study by Madelung,* Rydygier,* lieichel," and Makins.* To the histories tabulated by these writers I have been able to add a num- ber of others, and the following table contains references to 186 cases, a larger series than has yet been collected : — ' See Fig. 1123. Vol. V. p. 989, supra. 2 See Vol. V. page 985, supra. 3 Archiv f. klin. Cliirurgie, Bd. xxvii. S. 277. •• Berliner klin. Woohenschrift, 18 Jahrgang, Nos. 41-43. 5 Deutsche Zeitschrift f. Chirurgie, Bd. xix. S. 230. ^ St. Thomas's Hosp. Reports, N. S., vol. xiii. p 181. OPERATIVE TREATMENT OF INTESTINAL OBSTRUCTION. Table XVII. — Cases of Resection with or without Suture op the Intestine. (Enterbctomy and Colectomy.) Operator. Besult. Albert, Recovered. Aman, Died. Ambrosi, (( Amitesarove, Recovered. Banks, (' Bardeleben, ied. Id. (t Id. t( Bardenheuer, Recovered. Id. Died. Barton, 1( Faudens, t( Baum, (( Id. Recovered. Id. Died, Beebe, Recovered. Berger, Bergmann, Died, Recovered. Billroth, (( Id. (C Id. (( Id. << Id. ** Id. Died. Id. tt Id. Recovered. Bouilly, Boyer, Bryant, Bryk, Id. Died. (( Recovered. Died. Byrd, Recovered. Id. it Calton, ti Cherni, Undeterm'd. Cooper, Id. Died. Cred6, Recovered. Id. (( Czerny, Id. Died. Id. Recovered. Dieffenbaoh, (( Dittel, ti DuTerger, Esmaroh, it Died. Feld, Recovered. Fischer, Died. Id. Recovered. Id. Died. Id. Recovered. Id. Died. Id. Recovered. Id. (( Id. c< Id. Died. Id. it Id. t( Id. Recovered. Id. ft Id. a Id. Died. Id. (C Folker, Recovered. Wien. med. Presse, 1881. Hygeia, Bd. xliii. Indipendente, tomo xxxiii. Union Med., t. i. CarS,oas, 1881. Clinical Notes on Two Years' Surgical Work, etc., p. 96. Deutsch. med. Wochensohrift, 1883. Ibid. Ibid. Die Drainirung der Peritoneal-hohle, 1881. Ibid. British Med. Journal, Jan. 31, 1885. Clinique des Plaies d'Armes ^ Feu, 1836. Centralblatt f. Chirurgie, 1879. Berlin, klin. Woohenschrift, 1881. Fortschr. d. Med., 1884. Ill, Medical Record, Sept. 22, 1883. Bull, et Mem. de la Sooi§tfi de Chirurgie, 1880. Deutsch. med. Wochensohrift, 1883. Wien. med. Woohenschrift, 1879. Ibid. Ibid., 1881. Archiv f. klin. Chirurgie, Bd. xxiv. Ibid., Bd. xxvii. Wien. med. Woohenschrift, 1881. Ibid. Am. Jonrn. Med. Sciences, April, 1883. Bull, de ia Society de Chirurgie, t. ix., 1883. Traits de Chirurgie. Lancet, May 13, 1882. Przeglad Lekarski,'l881. Ibid. Medical Record, Aug. 5, 1882. Ibid. Edinb. Med. and Surg. Journal, vol. xil. Index MediouB, Jan. 1881. Anat. and Surg. Treatment of Hernia. Ibid. Archiv f. klin. Chirurgie, Bd. xxvii. Ibid, rl. klin. Wochensohrift, 1880. Ibid. Ibid. Caspar's Woohenschrift, 1836. Wiener med. Wochensohrift, 1878. Mem. de I'Acad. Royale de Chirurgie, t. iii. Verhandl. d. Deutsch. Gesellsch. f. Chir., Bd. viii. Archiv f. klin. Chirurgie, Bd. xxx. Deutsche Zeitschrift f. Chirurgie, Bd. xix. Ibid. , Ibid. Ibid. Ibid. Ibid. Ibid. Ibid. Ibid. Ibid. Ibid. Ibid. Ibid. Ibid. Ibid. Ibid. British Med. Journal, Feb. 7 and Aug. 15, 1885. 90 INTESTINAL OBSTRUCTION. Table XVII. — Continued. No. Operator. Result. Reference. 65 Forbes, Died. Episcopal Hospital Records, 1885. 66 Fuller, Keoovered. Medical Record, vol. xxii. 67 Id. a Ibid. 68 Gaston, ti Med. and Surg. Hist. War of Rebellion, Second Surgi- cal Volume. 69 Gentilhomme, Undeterm'd. Index Medicus, April, 1883. 70 Grin don. Recovered. St. Louis Courier of Medicine, 1884. 71 Gussenbauer, It Archiv f. klin. Chirurgie, Bd. xxvii. 72 Id. 11 Ibid, 73 Id. Died. Ibid. 74 Guyon, (t Peyrot, De I'Intervention Chirurgicale dans I'Obstruc- tion Intestinale, p. 84. 75 Hagedorn, Recovered. Verhandl. d. Deutsch. Gesellscli. f. Chirurgie, A880. 76 Id. (( Ibid. 77 Hardie, (( Medical Chronicle, January, 1885. 78 Heusner, Died. Deutsch. med. Wochenschrift, 1880. 79 Hofinoker, li Wiener med. Presse. 80 Howse, 11 Med.-Chir. Trans., vol. lix. 81 Hueter, 11 Deutsch. Zeitschr. f. Chirurgie, Bd. ix. 82 in, Recovered. Medical Record, Sept. 22, 1883. 83 Id. Died. Ibid. 84 Jaffe, Recovered. Sammlung klinische Vortrage, No. 201. 85 Jessop, (( Brit. Med. Journal, May 2, 1885. 86 Id. (( Ibid. 87 Jobert, Died. Archives Gen. de MSdecine, 1824. 88 Id. *' M6m. de I'Acad. Royale de Med., t. xii. 89 Jones, n British Med. Journal, Feb. 7, 1885. 90 Julliard, Recovered. Revue M6d. de la Suisse Rom., 1881. 91 Id. (4 Centralbl. f. Chirurgie, 1882. 92 Id. It Ibid. 93 Kinloch, It Am. Journ. Med. Sciences, vol. liv. 94 Kocher, It Bull, de la See. Med. de la Suisse Rom., 1880. 95 Id. Died. Centralbl. f. Chirurgie, 1880. 96 Id. Recovered. Correspondenzbl. f. Schweizer Aerzte, 1878. 97 Koeberlg, It Gazette Hebdomadaire de M6d., 1881. 98 Korzenowski, Died. Berliner klin. Wochenschrift, 1881. 99 Kosinski, (t Ibid. 100 Kraussold, Recovered. Sammlung klinische Vortrage, No. 91. 101 Id. Died. Ibid. 102 Kuester, (( Verhandl. d. Deutsch. Gesellsch. f. Chirurgie, 1879. 103 Id. t( Ibid. 104 Id. It Ibid. 105 Id. ti Archiv f. klin. Chirurgie, Bd. xxvii. 106 Lartraiiman, ft Lancet, Aug. 4, 1883. 107 Langenbeok, ft Archiv f. klin. Chirurgie, Bd. xix. 108 Lavielle, Recovered. Journ. Gfin. de M6A., de Chir. et de Phar., t. xliii. 109 Leisrink, Died. Archiv f. klin. Chirurgie, Bd. xxviii. 110 Liicke, (( Deutsch. Zeitschr. f. Chirurgie, Bd. xii. 111 Ludvik, Recovered, Wiener med. Presse, 1880. 112 Luzenberg, (( Gross, Medical News, May 3, 1884. 113 MaoDonald, ti Lancet, Feb. 9, 1884. 114 Madelung, It Archiv f. klin. Chirurgie, Bd. xxvii. 115 Id. it Berliner klin. Wochenschrift, 1881. 116 Maisonneuve, Died. Gazette des Hopitaux, 1854. 117 Id. (( Ibid. 118 Maklns, Recovered. St. Thomas's Hosp. Reports, N. S., vol. xiii. 119 Marcy, Died. Ill, Medical Record, Sept. 22, 1883. 120 Marshall, (t Lancet, May 6, 1882. 121 Martini, Recovered. ■ Zeitsohrift f. Heilkunde, 1880. 122 Maydl, i( Wien. med. Presse, 1883. 123 Mensel, (C Deutsch. med. Wochenschrift, 1883 124 Id. tt Ibid. 125 Moldenkow und Minin, fi Centralbl. f. Chirurgie, 1881. 126 Morisani, Died. Rivista Internaz. di Med. et Chir., tomo i. pag Cooper, op. cit. . 146. 127 Nayler, Recovered. OPERATIVE TREATMENT OF INTESTINAL OBSTRUCTION. Table XVII. — Concluded. 91 No. Operator. Result. Reference. 128 Neuhauss, Recovered. Bull, et M6m. de la Soc. de Chirurgie, 1880. 129 Nicoladoni, (( Wiener med. Blatter, 1879. 130 Nioolayseu, " Nord. med. Arkiv, Bd. xiv. 131 Novaro, Died. Centralbl. f. Chirurgie, 1882. 132 Obalinski, ii Berliner klin. Woohenschrift, 1881. 133 Id. '* Ibid. 134 Id. (( Ibid. 135 Id. '* Ibid. 136 Perier, t( Gazette Mfidicale, 12 F6v. 1881. 137 Firogoff, Recovered. Grundzuge der allgem. Kriegschirurgie, S. 578, 1864. 138 Pitcher, (( Med. and Surg. Hist. War of Rebellion, Second Surg. Vol. 139 Pollard, Died. Lancet, March 17, 1883. 140 Porter, Recovered. Boston Med. and Surg. Journal, May 15, 1884. 141 Id. " Romans, ibid., July 30, 1885. 142 Prati, Died. Amer. Practitioner, Nov. 1883. 143 Kamdohr, Recovered. Hallerus, Disputat. Anatom., tom. vi. 144 Rehn, u Med. News, March 14, 1885. 145 Reybard, (C Memoire sur une Tumeur Cancfireuse, etc. 146 Riohter, u Medical News, Sept. 30, 1882. 147 Robsoii, Died. Medical Record, August 8 and 22, 1885. 148 Roohelt, n Wiener med. Presse, Bd. xxiii. 149 Roggenbaii, Recovered. Berliner klin. Wochensohr., 1881. 150 Roser, Died. Centralbl. f. Chirurgie, 1881. 151 Rydygier, Recovered. Deutschr. Zeitschr. f. Chirurgie, Bd. xv. 152 Id. Died. Berliner klin. Woohenschrift, 1881. 153 Salen, Uiideterm'd. Index Medicus, March, 1883. 154 Sohede, Recovered. Verhandl. d. Deutsch. Gesellsch. f. Chir., 18Y9. 155 Id. Died. Ibid. 156 Id. Recovered. Ibid. 157 Id. Died. Ibid., 1878. 158 Schinzinger, " Wiener med. Wochensohr., 1881. 159 Id. Recovered. Ibid. 160 Schmid, (< Hallerus, Bibliotheca CLirurgica, tom. ii. 161 Schonborn, Died. Deutsch. Zeitschrift f. Chirurgie, Bd. viii. 162 . Sooin, " Centralbl. f. Chirurgie, 1881. 163 Sutton, Recovered. Med. News, June 16, 1883. 164 Tandler, Died. Archiv f. klin. Chirurgie, Bd. xxvii. 165 Tauber, " Verhandl. d. Deutsch. Gesellsch. f. Chirurgie, Bd. ix. 166 Thiersch, Recovered. Berliner klin. Woohenschrift, 1881. 167 Id. Died. Verhandl. d. Deutsch, Gesellsch. f. Chirurgie, 1878. 168 Id. t( Beger, Berlin, klin. Wochensohr., 1882. 169 Trelat, (( Peyrot, op. cit. 170 Id. Undeterm'd. Gazette Medioale, 12 Fev. 1881. 171 Id. c( Ibid. 172 Treves, Died. Lancet, Dec. 16, 1882. 173 True, Recovered. Lyon Medicale, 1882. .174 Vermale, (( Obs. et Remarques de Chirurgie Pratique, 1767. 175 Viertel, it Deutsch. med. Woohenschrift, 1877. 176 Volkmann, u Kompe, Aertzliohes Intelligenzblatt, 1883. 177 Wahl, Died. St. Petersb. med. Woohenschrift, 1879. 178 Id. u British Med. Journal, May 26, 1883. 179 Weinlecbner, Recovered. Wiener med. Woohenschrift, 1881. 180 Id. Undeterm'd. Aertzl. Ber. der k.-k. allg. Krankenh. zu Wien., 1883. 181 Weiss, Died. Berliner klin. Woohenschrift, 1881. 182 Id. " Ibid. 183 Wells, Undeterm'd. British Medical Journal, Nov. 15, 1884. 184 Whitehead, Died. Ibid., Jan. 24, 1885. 185 Wolfler, £1 Wiener med. Woohenschrift, 1881. 186 Id. Recovered. Medical Record, May 19, 1883. Of the 186 cases embraced in the _ preceding table, 93 are reported as re- coveries and 86 as deaths, the result in 7 not having been ascertained ; the mortality of determined cases is therefore, according to these figures, 48 per cent. This corresponds very closely with the percentages given by Makins 92 INTESTINAL OBSTRUCTION. and Reichel, the former writer tabulating 94 cases with 44 deaths, or 46.8 per cent., and the latter 121 cases with 58 deaths, or 47.9 per cent. The mortality is least in cases of false anus (37.8 per cent., Reichel ; 38.4 per cent., Makins), and increases progressively to 40 per cent, in cases of injury to the bowel, 50 per cent, in cases of intestinal cancer, 52 per cent. (51.8 per cent., Reichel ; 52.7 per cent., Makins) in cases of gangrene following hernia, and 75 per cent, in cases of intestinal occlusion. Even, however, in the most favorable cases — those of false anus — the operation is a much graver one than that of Dupuytren' (use of the enterotome), 83 examples of which, collected" by Heiroann, gave 50 complete and 26 partial successes, and only 7 deaths (8.4 per cent.). ■ See Vol. v., page 983, supra. INJURIES AND DISEASES OF THE RECTUM. BY WILLIAM ALLINGHAM, F.R.C.S., SUKGEON TO ST. MAKK's HOSPITAL, LONDON. Anatomy and Physiology of the Rectum. The last portion of the intestinal canal, the rectum, measures from its commencement at the left sacro-iliac synchondrosis to its termination at the anus, from six to eight inches in the adult. The name rectum has but partial justification, and that only in comparison with the great bulk of the intes- tinal tract ; for this tube is anything but straight, having antero-posteriorly two well-marked curves, an upper, which follows precisely the curve of the sacrum and coccyx, and a lower, which commences at the tip of the coccyx, with its convexity forwards, and terminates about an inch from it at the small orifice known as the anus. Besides these antero-posterior curves, a lateral one, from left to right, is usually described, beginning at the left sacro-iliac synchondrosis, and termin- ating at the third sacral vertebra. But from observations iu the post-mortem room I am inclined to think that no hard and fast line can be drawn about this' lateral curve. The meso-rectum gives the first part of the rectum great play, and as often as not, on opening a body, what corresponds to the com- mencement of the rectum is found close to the right instead of the left synchondrosis. About an inch and a half from the orifice of the anus, which distance is occupied by the internal sphincter, a dilatation occurs in the lumen of the gut, and in those sufii'ering from chronic constipation this may assume enormous dimensions. I have myself found an impaction of feces lodged in this part, the size of a foetal head. The structure of the rectum diifers in some respects from that of the large intestine generally. Muscular Coat. — This is much thicker than in other parts of the bowel, for in defecation the expulsion of feces is greatly dependent on its action. As throughout the remainder of the intestinal tract, it consists of two layers — an external longitudinal, and an internal circular. The former of these, how- ever, is pretty evenly distributed around the gut, and is not collected into three bundles, as in the colon. On the anterior surface of the bowel the fibres are found lying thicker and closer than elsewhere. The termination of these lon- gitudinal fibres is interesting. Some of them, according to Dr. Garson, pass from the rectum to the bladder, immediately beneath the peritoneum. The remainder are continued to the lower margin of the internal sphincter, where some, according to Dr. Horner, who wrote in 1826, turn under this margin, between it and the external sphincter, and then extend upwards for an inch or two in contact with the mucous membrane, into which they are finally inserted. I must confess that I have not succeeded in proving to raj own (93) 94 INJURIES AND DISEASES OF THE RECTUM. satisfaction this terminal arrangement of fibres, although I have examined many rectums for that purpose. Other fib,res are said to pass between the bundles of the external sphincter, and to be inserted into the subcutaneous connective tissue around the anus ; while still a third set pass backwards towards the coccyx, into the anterior surface of which they are inserted by means of a very thin tendon. We now come to the circular fibres. Of these there is little to be said, except that, like the longitudinal, they are far better represented in the rectum than elsewhere throughout the intestinal tract. At the terminal inch and a half of the bowel they are collected iu great numerical force, and constitute the internal sphinctei'. I have often observed how this muscle varies in different individuals, both in extent and power, while dilating it previous to operating on internal hemorrhoids. In some it readily yields after a moment's efibri,, •while in others I have to use my whole strength for a considerable time. The explanation probablj' is, that, in the latter cases, the muscle has been subjected to frequent contractions in consequence of the pre- sence of a fissure or an ulcer of the anus, which has produced an increase iu its strength, and possibly in its bulk. A third sphincter has been described by O'Beirne, as situated high up, near the sigmoid flexure. Ifelaton, too, has •described a partial sphincter two and a half inches from the anal orifice. I must say that I myself do not believe in the existence of either the one or the •other of these additional sphincters, except as an occasional, and, in my expe- rience, an exceedingly rare, anatomical curiosity. The submucous connective tissue of the rectum is abundant, especially at its lower part, where it forms the nidus in which the rectal vessels ramify after having made their way through the muscular coat, as will be described hereafter. Strong septa pass between the bundles of muScular fibres, which form a kind of framework for them, to the fibrous stroma of the fat surround- ing the rectum. The mucous membrane lining the rectum does not materially dififer, as far as I am aware, from that found in the remainder of the large intestine ; like that it consists of closely packed Lieberkiihn's follicles, with here and there a solitary gland which is only a circumscribed nodule of lymphoid tissue. Immediately over the solitary glands, Lieberkiihn's follicles are absent. The muscularis mucosa — or unstriped muscular layer of the mucous membrane proper — is said to be well developed around the anus, and to counteract any tendency, should such exist, to prolapsus. Certain marks and folds of the mucous membrane are interesting, and will now be examined. First, there is the white line around the anus which marks the junction of mucous mem- brane and skin, as also the linear interval between the internal and external sphincters. N'ext, the columnae of the rectum, or the pillars of Glisson or of Morgagni. These, from six to eight in number, commence at the point of union of skin and mucous membrane, and extend about three-quarters of an inch or more up the bowel. They are permanent — that is, they are present •even when the anus and lower part of the rectum are distended and in each is found one of the parallel rectal arteries, branches of the superior hemor- rhoidal, described by Quain. Little arches, of mucous membrane, with their •concavities upwards, unite the anal extremities of these pillars, and have been called " anal valves." They are often so indistinct as not to be recog- nizable. Lastly, I must just mention the so-called valves of mucous mem- brane described by Houston, in the year 1830, although I may at once sav that I do not believe in their existence. He enumerates four, arranged in a spiral^ manner, the second, which is the largest, being on the anterior wall opposite the base of the bladder, and he ascribes to them the function of sus- -■^NATOMY AND PHYSIOLOGY OF THE RECTUM. 95 taining the fecal mass to avoid pressure on the sphinctier, until the rectum is fully distended. Having already stated my disbelief in their very existence, I need not waste space in refuting the physiological functions ascribed to them, but will pass at once to the consideration of the muscles of the rectum and anus. • Muscles op the E-ectum and Anus. — The external sphincter consists of voluntary fibres, which arise by a tendon from the tip of the coccyx, and are inserted into the central tendon of the perineum. It is elliptical in shape, and about half an inch in breadth. Its function is to close the aims under the influence of the will. Mr. Hilton, in his Lectures on Rest and Pain, has so admirably described what we occasionally owe this indomitable little sphincter, that I cannot refrain from quoting him : — The strength and endurance of the anal sphincters are well exemplified by their suc- cessful antagonism to the peristaltic action of the colon and rectum upon large quanti- ties of fluid or solid feculent matter, constantly gravitating towards the anal aperture, guarded by the watchful sphincters. Who is there that has not felt this kind of com- petitive struggle, this intestinal warfare going on within himself, fearing the issue, and has not been thankful for the result, and full of gratitude for the enduring strength of the little indomitable sphincter, which has averted a possible catastrophe. The nerve-supply of the external sphincter is derived from the hemor- rhoidal branch of the internal pudic nerve, and from the fourth sacral. The internal sphincter has already been described, in connection with the circular fibres of the rectum of which it is only an accentuation. Its nerve- supply is derived from Auerbach's plexus, and also from the hemorrhoidal branch of the internal pudic. The levator ani is an irregularly quadrilateral muscle, which, with its fellow of the opposite side, forms a kind of inverted cone with two openings in- feriorly for the transmission of the rectum and the urethra, in the male, the vagina of course in the female also passing through it. It arises from the posterior surface of the descending ramus of the pubis, sometimes from the articulat" cartilage, from the white line which marks the division of pelvic into obturator and recto-vesical fascia, from the internal surface of the spine of the ischium, and from the lesser sacro-ischiatic ligament. From this ex- tensive origin most of the fibres pass down towards the median line, and are inserted as follows : The anterior fibres course down along the side of the prostate, beneath which they meet their fellows at the central tendon of the perineum ; the middle fibres are inserted into the side of the rectum ; and the remaining fibres pass between the rectum and coccyx into a median raphe, the posterior of these being inserted into the sides of the coccyx. It should be mentioned that a set of fibres belonging to the levator ani have been described as almost horizontal in direction, arising from the pubis and being inserted into the coccyx. The action of the levator ani is likely enough to become a subject of dispute, as recently a new theory has been started, namely, that this muscle assists defecation by compressing the rectum at a point about two and a half inches from the anus — the point, in fact, at which the horizontal fibres are said to cross the rectum. I myself am not yet a convert to this novel view, and prefer to regard the levator ani, first, as an antagonist of the dia- phragm and abdominal muscles when compressing the abdominal contents ; secondly, as an antagonist of the sphincters in defecation by opening the anus. As this muscle when in action exerts pressure on the neck of the bladder through the fibres passing to the central tendon, thus preventing urine from entering the urethra, micturition and defecation cannot well occur 96 INJURIES AND DISEASES OF THE RECTUM. simultaneously. After an operation for internal hemorrhoids, it is usually necessary to pass a catheter the first night, in order to empty the bladder. I am not quite clear in my own mind how far the levator ani is directly re- sponsible for this, or whether the retention is due to nervous influences. The nerve supply of the levator ani is from the fourth sacral and from the internal pudic. The transversus perinei arises from the inner surface of the descending ramus of the pubis, close to the ischial tuberosity, and is inserted into the central tendon of the perineum. Its action has been described by Cruveilhier as assisting that of the external sphincter in compressing the anus. It has, however, always appeared to me to be mainly concerned in steadying the central tendon while the other muscles inserted into it are in action. Its nerve comes from the internal pudic through the perineal nerve. Vessels of the Eectum and Anus. — The blood supply of the rectum is derived from two sources, the infei'ior mesenteric and the internal iliac artery. The first terminates in the superior hemorrhoidal artery, which passes down behind the rectum between the two layers of meso-rectum, and soon divides into two branches, which in their turn break up into seven or eight — the parallel rectal arteries which are found in the pillars of Glisson already referred to. The internal iliac usually gives ofl:" the middle hemor- rohidal, through the inferior vesical, and the inferior hemorrhoidal through the internal pudic artery. Both these arteries are small, and are distributed to the lower part of the rectum and anus only. The veins correspond to the arteries, that is to say, there are three sets — superior, middle, and inferior — which, according to my observation, communicate freely in a plexlis around the lower part of the bowel, the hemorrhoidal plexus. The superior hemor- rhoidal vein is, like the artery, single. It is the commencement of the inferior mesenteric, and so joins the portal system ; like the other veins of this system, it is devoid of valves. Verneuil, who has devoted a great deal of time and labor to the elucidation of the anatomy of these veins,says that they commence at the upper border of the internal sphincter, and lie under the mucous membrane of the rectum. At a definite height of about four inches, they perforate abruptly the muscular coats of the bowel through " veritables boutonnieres musculaires," and unite to form five or six large veins found in the meso- rectum ; these then join the inferior mesenteric vein, as already explained. Verneuil is also of opinion that little or no anastomosis takes place between the superior and the other hemorrhoidal veins, and that, at least as far as this region is concerned, the portal and general systems are practically dis- tinct. I have already said that I by no means participate in this view. The middle hemorrhoidal veins, one on either side, join the internal iliac veins ; they arise from the hemorrhoidal plexus, and, according to Duret, are formed by two venous trunks, one in front of and the other behind the rectum. The inferior or external hemorrhoidal veins are also connected with the above- mentioned plexus, and empty themselves into the internal pudic veins. ITerves. — The sensory nerves which supply the skin around the anus are the inferior hemorrhoidal and the posterior swperficial perineal — branches of the internal pudic — and the posterior branches of the lower sacral nerves. The nerve supply of the muscles has already been referred to in the descrip- tion of these. The mesenteric and hypogastric plexuses supply many branches to the rectum, the muscular coat of which is provided with Auerbach's plexus, an oftshoot of that first mentioned. - The external sphincter is maintained in a state of tonic contraction by a centre in the lumbar portion of the MALFORMATIONS OF THE RECTUM AND ANUS. 97 spiual cord. During defecation this centre is inhibited by the action of the will, by emotions, or by other nervous events (Foster.) Lymphatics. — Those from the skin around the anus pass to the glands of the groin ; those from the rectum proper communicate with the glands in the hollow of the sacrum and the lumbar glands. So that in tissure or ulcer of the anus, the inguinal glands, and in cancer the pelvic and lumbar glands, will be affected. Relations of Rectum.- — The relation of the peritoneum to the rectum is by far the most important, and I will therefore begin with its consideration. The question is, how far down the rectum does the peritoneum extend ? how much of the rectum can be excised without running the risk of laying open the peritoneal cavity ? I have myself removed five inches of bowel from a male, without even seeing the p>eritoneum. In a female patient on whom I ope- rated, Douglas's pouch was only two inches from the anus. In another case, that of a male, three and a half inches of rectum were cut off, the peritoneal cavity was thereby opened, and a coil of intestine protruded. From these examples it will be seen that no hard and fast line can be drawn as to the distance down the rectum which the peritoneum extends. Still, bearing in mind the variations which have occurred in the practice of a single individ- ual, three inches may be taken as a fair average when the bladder is faii'ly distended with urine ; a little less if it be empty, a little more if it be fully distended. The upper portion of the rectum, which terminates at the third vertebra of the sacrum, is surrounded by peritoneum ; it has, in fact, a meso- rectum, which allows it considerable play. Thus Mr. Davy, by means of his lever in the rectum, easily compresses the, right common iliac artery. The other parts in relation with the rectum are, behind, the pyriformis muscle, sacral plexus of nerves, and branches of the internal iliac artery, and in front, in the male, the bladder and coils of small intestine ; in the female, the uterus takes the place of the bladder. The middle portion of the rectum begins at the third vertebra of the sacrum, and ends at the tip of the coccyx. It has behind it the sacrum and coccyx, and in front, at its upper limit, the peritoneal fold of Douglas, and then the base of the bladder, vesiculse seminales, and prostate gland. The lower portion has in front of it the membranous part of the urethra, separated by the triangular ligament on either side of the levator ani, and it is surrounded at its termination by the external sphincters. Malformations of the Rectum and Anus. As my personal experience of these errors in development has not been greater than that of any hospital surgeon not especially devoting himself to rectal surgery, I intend to treat this subject brieily, referring those among my readers who desire further information to Dr. Wm. Bodenhamer'e ex- haustive treatise on the " Etiology, Pathology, and Treatment of the Con- genital Malformations of the Rectum and Anus." The classification which I propose to adopt has, if no other merit, that ot simplicity. I shall divide all these cases into four divisions, as follows : — I. Those in which the anus is closed, the rectum being either partially or wholly deficient. II. Those in which the anus exists in its normal condition, but opens into a cul-de-sac, the rectum being partially or wholly deficient. III. Those in which a membranous septum, like a hymen, or a band of VOL. VI. — 7 98 INJURIES AND DISEASES OF THE RECTUM. skin derived from the scrotum and fixed to the coccyx, stretches across the orifice — in the first case preventing, and in the second obstructing the outflow of meconium. IV. Those in which the anus is absent, and in which the rectum opens into the bladder, urethra, or vagina, or in some other abnormal position. In regard to the treatment to be adopted in cases of the first three divisions, there can be room for no two opinions : an outlet must be effected ; obviously through the anus, if possible, but if not, through the sigmoid flexure in the left groin. In those cases in which a membranous septum, or a band of skin, stretches across the orifice, the treatment is easy and successful. A crucial incision through the first obstruction, the removal of the second by means of a snip at either extremity', is all that is required. Ifot so, however, in the class of cases in which the rectum itself is more or less deficient. Here the surgical procedure is diflicult, and, as a rule, not very successful. In the new-born infant, the pelvic measurements are naturally very small: the antero-posterior, from the tip of the coccyx to the symphysis pubis, and the lateral, from one tuber ischii to the other, are each but little over an inch. When therefore it is considered that a dissection of an inch and a half or more, up the pelvis, may have to be undertaken before the blind extremity of the rectum is found,. the advantages of adopting M. Verneuil's mode of procedure, namely, excising the coccyx, appear very great. Some surgeons recommend this step after a diligent search for the gut has been already made, but I am certain that this is a mistake. I think that in a case of this kind, in which life and death are in the scales, it is the operator's duty to give himself every chance from the beginning; and, always, of course, ex- cepting those cases in whiclj a bulging shows that the rectum is low down, removing the coccyx, although it be a mere nodule, increases the space in which to work in the right direction, that is, posteriorly. If the surgeon has succeeded in finding the rectum, should he bring it down and attach it by sutures to or as near to the skin as possible ? I am inclined to answer this question in the negative. If traction has to be put on the intestine to lower it, it is quite sure that the sutures will only tear or ulcerate through the wall of the gut, which will then cei'tainly recede and fix itself at some higher point; whereas, if the intestine comes down readily without traction, I do not know that much is gained by putting in sutures, though something may be lost by preventing matter from being evacuated from between the sides of the intestine and the wound. The great tendency to contraction which exists in these cases must be overcome by most diligent dilatation, at first with the little finger, and afterwards with the forefinger, three times a day ; after some months it may be- sufficient to pass the finger only once a day, and perhaps, when a year has passed, once a week may suffice. Still, the most rigid watch must be kept, and at the slightest sign of contrac- tion the times of dilatation must be redoubled. Supposing that, after a most careful and prolonged search for the rectum, the surgeon fails to find it, Avhat should be his next step ? Some writers recommend waiting half a day, in the hope that the bowel may come down during straining, but I am of opinion that this chance is exceedingly small, and that the delay will considerably lessen the probability of success attend- ing an operation in the groin. The incision should be parallel with Poupart's ligament, and shT)i!jld begin outside of its centre. It should be not less than an inch and a half in length, and about a third or half an inch from the ligament. After dividing the skin and muscles, the fascia transversalis is reached, with the peritoneum beneath it. I doubt if it v^yould be possible to insure dividing them sepa- INJURIES OF THE RECTUM. 99 rately ; at any rate, nothing ■would be gained by the attempt, so that they may be simply cut through together cleanly on a director. The lai'ge intestine can be recognized by the absence, or at all events shortness, of mesentery, which conveys a feeling of fixity to the hand, and by the mesen- tery being attached to the left side of the intestine, as well as by the saccu- lated appearance of the latter. The other distinctive signs of the large intestine — its longitudinal bands and appendices epiploicae — are generally too ill marked in the new-born child to be of diagnostic use. When the intestine has been found, it must be closely attached to the edges of the wound, peri- toneal surface to peritoneal surface, with fine sutures, and then a very small opening made into it. Nelaton recommended an opening of less than a third of an inch. When this operation of emergency has been successfully performed, should an attempt be made to establish a normal outlet by passing down a bougie through the wound in the intestine into the blind rectum, and directing it towards the perineal wound ? I think not, for the following reason : A very thorough search has already been made from below, which has proved fruit- less. Therefore there is strong reason to assume that the rectum terminates within the peritoneal cavity, and that its cul-de-sac is covered by peritoneum. At least so it has proved in several cases in which this procedure has been attempted, but has resulted in acute peritonitis and death. In those cases, in the female, in which the rectum communicates with the vagina, and has no other outlet, the treatment indicated is as follows : If the bowels can be properly relieved through the opening, the surgeon may wait until the child is six months old, when it will be better able to bear the ope- ration, which will also be rendered easier on account Of the parts being larger. If, however, it is a question of urgency, through the opening being too small for the passage of meconium, a bent probe should be passed through the fistula and directed towards the perineum, and then cut down upon. The prognosis in these cases is favorable. [If the rectum, in the male, open into the bladder or urethra, the best that can be done is to introduce a grooved director or small staff, and cut down upon this as in the operation of perineal section, thus forming a common cloaca for the escape of both fecal matter and urine. The opening must be kept patulous by subsequent dilatation. If the gut open on the surface of the bod}', at a distance from the normal position of the anus, it will usually be proper to decline an ojDeration, and merely dilate the opening so as to prevent fecal accumulation.] In conclusion, it must be mentioned that, although one would naturally suppose a speedy death to be the inevitable consequence of a rectum with no outlet, unrelieved by surgery, yet several cases are recorded in which periodic fecal vomiting has prevented such an issue. [Injuries of the Eectum. Wounds of the Eectum. — Incised, lacerated, contused, punctured, and gunshot wounds are all met with in the rectum, but, provided that they are uncomplicated, usually heal without difficulty, and present no points calling for special notice. If the lesion involve the vagina or bladder, recto-vaginal or recto-vesical fistula may follow, and a plastic operation may ultimately be required. If the peritoneum be opened, in a deep rectal wound, peritonitis is, of course, apt to ensue, though not inevitable, and death may result under these circumstances. Hemorrhage from a rectal wound should be controlled by the application of ligatures, if the bleeding points can be seen, but if not, 100 INJURIES AND DISEASES OF THE RECTUM. by pressure, which may be applied hy means of Bushe's apparatus, an instru- ment resembling the colpeurynter — an India-rubber bag which can be intro- duced in a -flaccid state, and afterwards distended with air or iced water— or, perhaps even more securely, by packing the gut around a tube or English catheter provided with an apron, as is done with the perineal wound after the operation of lithotomy. A remarkable case is recorded by Dr. Otis,' in which a distinguished officer, conducting a retreat under a heavy fire from the enemy, was killed by a ball entering his anus as he leaned forward over his horse's neck ; no external wound was perceptible, and the nature of the lesion wsas not recognized until, when the body was embalmed, the ball was found lodged in the patient's lung. Foreign Bodies in the Rectum. — These may have been directly introduced into the rectum through the anus, or through a wound, or may have de- scended from a higher point, having been swallowed, or, as in the case of gall-stones, having originated in another part of the patient's body. The variety of substances which have been found in patients' rectums, having been introduced either by themselves or by others, is very great,^ embracing such diverse substances as pebbles, slate-pencils, diamonds, bottles, beer-glasses,, forks, files, snails, and a pig's tail.' The sym-ptoms caused by foreign bodies in the rectum are those of local irritation, often attended by great pain, with con- stipation, sometimes ending in complete obstruction. Peritonitis may ensue. The treatment consists in extraction, by such means as may be suggested by the requirements of the particular case and the inventive faculty of the surgeon. Anaesthesia is usually required , and advantage may be derived from thorough dilatation of the sphincter. If necessary, V erneuil's operation of linear rec- totomy may be performed, as in cases recorded by Rafty and Turgis. Ano- dynes should be given afterwards in the form of suppository. Prompt treat- ment is essential in these cases, as the foreign body, if allowed to remain,, may perforate the rectum, causing fistula ; may ulcerate its way into the bladder, vagina, or peritoneum ; or may slip up into the sigmoid flexure or descending colon, from which it could only be removed by a more dangerous operation.] Fistula in Ano. Fistula is the most coromon rectal disease affecting the adult, certainly in hospital practice, and probably in private practice too. Men are more sub- ject to it than women. This disease is most frequently met with during middle age, but it is by no means restricted to that period of life. I have often operated upon infants in arms, and upon men from seventy to eighty years of age. Causes of Fistula in Ano. — The causes of fistula, or of abscess ending in fistula, are : Injui'ies to the anus ; injury to the mucous membrane of the bowel by very costive motions, by straining at stool, or by foreign bodies swallowed (fishbones and the bones of rabbits are occasionally found in rectal abscesses) ; exposure to wet and cold, and particularly sitting upon damp seats after exercise, when the parts are hot and perspiring. I have traced many cases of rectal abscess to sitting on the outside of an omnibus, shortly after active 1 Medical and Surgical History, etc., Second Surgical Volume, p. 319. 2 See Poulet's curious Treatise on Foreign Bodies in Surgical Practice, vol. i. pp. 217 et seq. New York. 1880. 3 See Marohettis's case. Vol. V., page 994, supra. MSTULA IN ANO. 101 "exertion. Predisposing causes are the scrofulous diathesis and certain de- praved conditions of the blood, such as frequently give rise to boils or carbuncles. Here I would observe that sudden and deep-seated suppuration is often found to occur after severe itching in the part, with only slight ery- thematous redness on the surface. Fistula in children almost always results from the presence of worms, or from injury to the anal region. Course of Fistula in Ano. — Fistula, in the majority of cases, commences by the formation of an abscess immediately beneath the skin, jnst outside of the anus ; it is generally said to commence in the ischio-rectal fossa, but I am certain that this is tlie rarer situation. It may also begin by ulceration of the mucous membrane of the rectum, as is seen in phthisical patients ; when it arises in this manner fecal matter collects in the connective tissue, and thus an abscess forms and opens on the outside. Lastly, an abscess may form in the submucous connective tissue of the rectum, and then burst into the bowel. This is its ordinary termination, but it may insidiously undermine the* rectum in any direction, and I am convinced that the more serious forms of •fistula not uncommonly originate in this manner. Rectal abscess may arise rapidly, when there will be redness, tenderness, and often very acute pain, with constitutional disturbance ; or it may be mouths in formation, and be perfectly painless even on manipulation, the only evidence of the abscess being a flat, boggy, crepitating enlargement which can be felt at the side of the anus. This form of abscess is the most danger- ous, as it is apt to be neglected ; it has little tendency to open spontaneously, and it results in a burrowing up by the side of the rectum to some distance, as well as under the skin towards the perineum, or buttock, or both. I think, •on the whole, by far the most usual course is for the abscess to form rapidly, with great pain, and if not interfered with to burst externally ; the patient then becomes suddenly easy, and fancies that his trouble is over. The cavity of the abscess seldom entirely closes, but sooner or later it contracts, leaving a weeping sinus with a pouting, papillary aperture, which may be situated near or far from the anus. It is not often that one sees a rectal abscess very ■early ; either the patient is not aware of the importance of attending to the early symptoms, or he temporizes, using fomentations or poultices ; or even when seen by the surgeon, the proper treatment is not always promptly adopted. I have seen large abscesses painted with iodine, in the hope of obtaining absorption. It is well to remember that, as soon a,s pus is formed, there is only one method of treatment to be for a moment considered, and that is ineisioji. It is certainly less damagi"ng to c-ut into an inflamed swelling near the anus ■without finding pus, than to let a day pass over after suppuration has com- menced ; the longer the abscess is left unopened, the greater is the danger of the formation of lateral sinuses. Before any pus exists, rest, warm fomenta- tions, and leeches may cut short the attack, but such a result is very rare. Very small abscesses can be well and easily opened in the following way : The patient being placed on the side in which the swelling exists, the surgeon , passes the forefinger of the left hand, well anointed, into the bowel, and then places the thumb of the same hand below the swelling, on the skin. 'Sow making outward pressure with the finger in the bowel, and thus rendering the swelling quite tense and defined, it being in fact taken between the finger and thumb, a curved bistoury is to be thrust well into the abscess, in a direction parallel to the long axis of the bowel, and made to cut its way out towards the anus ; it is well to make a thoroughly free incision, com- 102 INJURIES AND DISEASES OP THE RECTUM. mencing at the outermost part of the swelling. If the part be thoroughly- frozen by the ether-spray, this operation is rendered painless. The method of operating above described is, however, by no means suitable to a severe or deep-seated abscess ; but I can safely say that, if a patient suffering from this latter form will allow the surgeon to act in the proper way, it will be almost certain that no fistula will result. The following is the method which I adopt. The patient must take an anaesthetic, as the operation is very painful. I first lay open the abscess outside of the anus^ from end to end, and from behind forwards, that is, in the direction from the coccyx to the perineum. I then introduce my forefinger into the abscess- and break down any secondary cavities or loculi, carrying my finger up the side of the rectum as far as the abscess goes, probably under the sphincter muscles, so that only one large sac remains ; should there be burrowing outwards, I make an incision deeply into the buttock, at right angles to the first. I then syringe out the cavity, and . carefully fill it with wool soaked in carbolized oil, one part to twenty ; this I leave in for a day or two,, then take it out and examine the cavity, and dress the part again in the same^ manner, but in addition I now use, if I think it necessai-y, one or more drain- age-tubes. In a remarkably short time these patients recover; the sphincters- have not been divided, and the patient therefore escapes the risk of incon- tinence of feces or flatus, which sometimes occurs when both the sphincters are deeply incised. I could cite numbers of cases of very unfavorable aspect,, and in old persons, that have done quite well, when treated as I have de- scribed. To give the patient the best possible chance of recovery, he should, be kept on the sofa, if not in bed. I always think it advisable to clear out the bowels once, and then to confine them by an astringent dose of opium for three days ; entire rest is thus secured to the parts, and every opportunity is given for the cavity of the abscess to fill up. After a time the carbolized oil should be discarded, and lotions used containing sulphate of zinc or copper^ or friar's balsam, which last does great good. The surgeon should never stuff an abscess, but put wool in very lightly, and use drainage tubes, of which those of India-rubber are the best. The questions naturally arise, why do these abscesses usually fail to close up? Why do they form sinuses? There are doubtless several reasons, but the following may be sufficient : The constant motion of the parts, caused by action of the bowels and by movement of the sphincters, almost at every breath, and the presence of much loose areolar tissue and fat. The vessels also, near the rectum, are not well supported, and the veins have no valves ; there- is therefore a tendency to stasis, and this is inimical to rapid granulation. We know that abscesses are always apt to degenerate into sinuses when situated in any lax areolar tissue, as in the axilla, neck, or groin. After an abscess has long existed, the discharge loses its purulent charac- ter and becomes watery ; the cavity gradually contracts, and at last only a sinus, very often formed of dense tissue, remains. If now a probe be passed very tenderly into this sinus, allowing it to follow its own course, and after this is done, the finger be placed in thfe rectum, it will probably be found that the probe has traversed the sinus and passed thi'ough an internal opening,, and that it can be felt in the bowel. In this case there would be a typical, simple, complete fistula ; and this is by far the most common variety, very few fistulpe that have existed for more than three months being without an internal opening. Besides this common form there are two other descriptions of fistula, viz.,. the blind external fistula and the blind internal fistula. In the blind external fis- tula there is an external opening, and it is therefore called an external fistula,, but no internal opening, and hence a blind external fistula. In the other FISTULA IN AXO. 103 variety there is an internal opening, and consequently it is an internal fistula, but there is no external opening, wherefore it must be called a blind internal fistula. The blind internal form of fistula results usually from some injury to, or ulceration of, the lining membrane of the r§ctum, or abscess in the con- nective tissue beneath the mucous membrane, and it is most commonly found in consumptive patients. 'Sow, these terms " complete," " blind external," and " blind internal" are useful, but surgically they are of little moment; there is, however, an impor- tant division of fistulse as regards both patient and surgeon, and that is into anal fistulte and pelvic or rectal fistulre. An anal fistula is one which commences in the skin a fcAV lines from the margin of the anus, opens just inside the orifice, passes at most under a few fibres of the external sphincter, and is trivial and can be rapidly and safely cured, ^y pelvic or rectal fistula I mean a fistula which, commencing pro- bably by an abscess in the ischio-rectal fossa, passes underneath both sphincter muscles, and opens possibly high up in the bowel, indeed in the pelvis. This is the fistula which is dangerous to the patient, and it will call forth all the knowledge and experience of the surgeon to bring it to a successful issue. A patient with fistula should be examined in the following manner : He should be placed upon a hard couch, on the side upon which the disease is supposed to be situated, the buttocks being brought close to the edge of the couch, and the knees drawn up. The aims and surrounding parts should be carefully inspected to detect any visible malady. The orifice of a sinus may be seen, or some discoloration of the skin may show the site of the disease; then, feeling gently all around the anus with the forefinger, the surgeon will often, by the induration, detect the course and position of the sinus, which feels like a pipe or piece of wire beneath the skin. Having satisfied himself in these respects, he passes the pi'obe into the external aperture, holding it with a very light hand, and letting it almost find its own way. In many cases, as I have before said, it will pass right into the bowel ; when the probe has been passed as far as it will go without using any force, the surgeon in- troduces the forefinger of the left or right hand into the rectum, and feels for the internal opening of the fistula, if the probe has not passed through it; having found it, he can with the other hand guide the probe towards it. The internal opening is usually situated just within the anus, in the depres- sion which exists between the external and internal sphincters. I think that the reason that the internal opening is situated so often in this position, is because when the abscess forms, as in most cases it does, just outside of the anus, it does not burrow deeply, but passes close under the external sphincter ; it thus is prevented from ascending higher up the bowel by the thick band of the internal sphincter, and consequently is turned inwards, and makes its way through the lax areolar tissue, in the space between the two muscles. When the abscess really commences in the ischio-rectal fossa, it burrows deeply, and then most usuallj^ passes beneath the internal sphincter, and opens, if at all, high up in the rectum. Occasionally more than one internal opening exists, and I have many times seen what the late Mr. Syme declared could not occur — viz., two internal openings in the same isatient at the same time. It is all-important that this internal aperture be felt with the finger (so that in operating it may be included in the incision), for not infrequently, from the tortuous nature of the fistula, the probe cannot readily be got through it. This is markedly the case in the horse-shoe form of fistula, which is not uncommon. The sinus here runs around, generally dorsally, from one side of the anus to the other, so that the external and internal openings are placed on oj^posite sides of the bowel. This variety, if not properly diagnosed, is rarely cured by one 104 INJURIES AND DISEASES OF THE RECTUM. operation, the sinus being laid open on one side of the bowel, and left un- touched on the other. This mistake may generally be avoided by careful examination "with the finger externally, as a hardness can be felt on both sides of the anus ; the patient will also sometimes give assistance by sayine that he has felt something like a " piece of wire" on both sides of the bowet! When the surgeon passes his finger into the bowel to search for the internal opening, he should never forget to carry it higher up, to see if the rectum be otherwise healthy ; he may find stricture, ulceration, or malignant disease coexistent. Without this precaution these conditions may be overlooked. Fistula may exist for years without causing much pain or inconvenience to the patient. I have met with many persons who had had rectal sinuses foi ten years and upwards, and had never had anything done beyond the occasional passing of a probe when the external aperture had got blocked up, and when pain had been caused by the formation and retention of matter. When the tissues around the sinus become very dense, there may be for a long period an arrest of burrowing, but an attack of inflammation set up at any time will cause a fresh abscess. I am often anxiously asked by sufferers if a fistula can be cured without an operation. To this I reply, that I have seen fistulse of all kinds get well without treatment, but that these occurrences are quite excep- tions to the rule, and should not be depended upon ; still, if the fistula be sim- ple, and the patient be unwilling to submit to any opei'ation, certain methods may fairly be tried. For the last few years I have been successful on many occasions in curing blind external, and even complete, fistulse, by means oi carbolic acid and drainage-tubes. This mode of treatment offers, in my opinion, the best chance for the patient. I first dilate the outer opening oi the fistula for a few days with a small portion of sea-tangle or sponge-tent. When the opening is large enough, I clean out the sinus well, and then rapidly run down to the end of it a small piece of wool saturated in strong carbolic acid, with ten per cent, of water. I mount this wool upon a stiff' piece oi wire set in a handle, and just roughened at the free end ; I then withdraw the wire and put in a drainage-tube, just large enough to fill the sinus, and keep it in ; the interior of the sinus is, by the acid, induced to granulate, and, if successful, it will be found, almost day by day, that a shorter drainage- tube will be required until the whole sinus is filled up. It may be neces- sary to apply the acid moi'e than once, and to use other stimulants, such as friar's balsam, solutions of sulphate of copper or nitrate of silver, etc. ] have succeeded usually in some bad cases by scraping the walls of the sinus with a small curette of steel. I do not advise injecting the sinus ; wool on » probe is a much better mode of medicating. Care should always be taker to keep the external opening well dilated. A perforated ivory collar-stud answers admirably in effecting this, the small hole allowing pus to dribble through. One practical point I would mention. The further the externa' opening is from the sphincter, the more likelihood is there that a sinus maj heal. It is very important in these cases not to do any harm. The surgeor should always enjoin rest after a strong application, and watch that not toe much inflammation be set up. It must be remembered that most of the so-called spontaneous cures are illusory, and that the disease returns in time and the same may be said even of those in which treatment, short of division has seemed effectual. In my opinion there is nothing equal to the divisior of the fistula, and getting it to fill up soundly from the bottom. Whilst describing the treatment of fistula without cutting, I must refer tc the use of the elastic ligature, so valuable in cases in which the knife is contra-indicated. The advantages of the ligature are the following: There ii little or no jmin, during or after its use, and there is no bleeding — a manifes advantage in dealing with patients whose tissues bleed copiously on incision irSTPLA TN ABO. 105 In plithisical patients it is, in my opinion, the best means of dividing a sinus. In very deep, bad fistulse, the elastic ligature is most valuable as an auxiliary to the knife. In sinuses running high up the bowel, v^'here large vessels are inevitably met with, I use the ligature in preference to the knife, as I by this means often avoid dangerous hemorrhage. The objection to the general use of the ligature is that it is impossible, in many instances, to be absolutely sure that only one sinus exists. If there are lateral sinuses, or a sinus burrowing beneath or higher up the rectum than the main trunk through ■which the ligature is passed, the patient will not get well with one operation. In these complicated cases, the knife alone, or conjoined with the ligature, is the trustworthy remedy. I have for a long time now used only solid India-rubber, so strong that I cannot break it ; and I put it on as tightly as I can, and fasten it by means of a small pewter clip pressed together by strong forceps. The ligature cuts through in about six days. I have devised an instrument (Fig. 1185) for passing the India-rubber through a fistula, which renders this generally tedious process easy and expeditious. Fig. 1185. Instrument for drawing India-rubber through fistula from within outwards. And now we come to the consideration of cutting operations for fistula. First of all, the patient's bowels must have been well cleared out ; a purge three days before the operation, and again the night before, and an injection in the morning, will effect this. The patient should be placed on a hard mattress, on the side m which the fistula exists, the buttocks being brought quite to the edge, and the knees well drawn up to the abdomen. The surgeon now takes a Brodie's probe- director made of steel, with a small probe-point ; oils it and passes it into the external opening, through the sinus and the internal opening, if possible; then inserts his linger into the rectum, and on feeling the point of the director in the bowel, if the patient be not anfesthetized, tells him to strain down ; he will thus be able, without difficulty, to turn the point of the instrument out of the anus. This done, the tissues forming a bridge over the director are to be divided with a curved bistoury. If the fistula be deep, running beneath the sphincters, it will not be possible to get the point of the probe out at the anus, even if the patient be anaesthetized ; in such a case the surgeon must pass the director well through the sinus, then insert his left forefinger into the rectum, steady the director, and run a straight knife along the groove, cutting carefully towards the bowel until the parts are severed. To inex- pert surgeons I recommend my deeply-grooved director and scissors (Fig. 1186) ; I may add that gentle dilatation of the sphincters under these diffi- culties gives the surgeon an immense advantage of which I now constantly avail myself. If there be no internal opening, there will almost always be found some part where only mucous membrane intervenes between the point of the probe and the finger. At this spot, the director should be worked through, and the point brought down as before. When the fistula has been divided from the external to the internal opening, search is made higher with the probe 106 INJURIES AND DISEASES OF THE RECTUM. for aoy sinus running up beyond the internal opening ; if sneh exists, it must be laid open. Search is next made for lateral smuses extending from the outer opening ; also for any burrowing outwards beyond the same point. A fistulous orifice is often not at either end of the sinus, but somewhere in its. Fig. 1186. SpriDg-scissors with probe-point in grooved director. course. The part should be carefully examined to see if there is a secondary sinus running from and beneath the main track. Frequently, in fact nearly always, in old-standing cases, the deeper sinus does exist, and unless it be incised with the rest, the patient will not get well. When all the sinuses are slit up, the sui'geon with a pair of scissors (Fig. 1187) takes oft" a 'portion of the overlapping edges of skin ; they are often thin Fig. 1187. Scissors for removing overlapping edges of skin in operation for flstnla. and livid, having very little vitality. If not removed, they will fall down inta the wound and materially retard the healing process. I have frequently in- duced healingan a fistulous track which had'been only laid open, by paring ofl"^ the edges of the skin which were undermined. In old-standing cases, where there is much induration, it is very good practice to draw a straight knife- through the dense track of the fistula, and outwards beyond the external open- ing ; it is wonderful how rapidly quite cartilaginous hardness passes away after this has been done. This incision was pi'actised by the late Mr. Salmon, and is called his "back cut." Having completed the operation, the surgeon takes some absorbent cotton-wool, and with a probe packs it well into the bottom of the wound, packing it into every part, and being the more particular about this if the incisions have been extensive, or pass high up the bowel, or if the parts are very dense and gristly, and especially in cases operated on for the second time. Of course, if a large vessel is seen spirting, it is secured either by a ligature or by torsion before packing. The last step is to place a good firm pad between the buttocks, over the wounds, and a T bandage to exert, pressure on it. The most painful form_ of fistula, but at the same time fortunately the most uncommon, is the blind internal fistula. I have seen many cases where the aperture was one third of an inch in diameter. The feces, when liquid, pass into the sinus and create great suffering, a burning pain often lasting all day after the bowels have acted. In operating upon a blind internal fistula, if the surgeon can feel by the FISTULA IN ANO., 107 hardness externally the site of the abscess, he may plunge his knife into it, and thus make a complete fistula through which of course he passes his direc- tor. If he cannot feel any hardness or see any discoloration to guide him to the situation of the sac of the abscess, the best way of proceeding is to bend a silver probe-director into the form of a hook, and then hook this into the internal aperture, and bring the point down close under the skin ; he then cuts upon it, thrusts it through, and completes the operation. In operating upon women sufi'ering from fistula (especially when the sinus is near the perineum), I cut as little as possible, for anything like too free incisions are apt to end in incontinence of feces, or, at all events, in such par- tial loss of power, in the sphincter as to prevent the patient retaining flatus, a result which I need scarcely say is a most disagi-eeable one. Even in males, incontinence of wind and liquid feces almost always results from cutting the muscles, and principally the internal sphincter, in more than one place. It should be made a rule to divide the sphincters at right angles to the direc- tion of their fibres. If the muscles are divided at all obliquely, good union is never obtained, and even in comparatively slight cases incontinence may follow. The method which I have adopted in cases of incontinence of flatus and liquid feces, is the use of Paquelin's thermo-cautery. Its judicious employ- ment will stimulate the muscular fibres and cause them to contract, and by diminishing the circumference of the anus induce action of the fibres which are left. After an operation for fistula, the bowels should be confined for three days; a mild purge must then be administered, and full diet allowed. The wool usually comes out when the bowels act ; if not, I gently remove it. As a matter of fact I generally remove a portion of the wool the day after the operation, leaving only some at the bottom of the wound. If the whole plug is left in, the patient will probably be very uncomfortable, as he cannot easily get rid of wind, and the danger of primary hemorrhage being over in twenty-four hours, there is nothing gained by retaining a mass of wool in the bowel. Very little dressing is required in the after-treatment of fistula ; in fact, it is better to do too little than too ynuch. The wound should be gently cleansed every day by allowing some weak Condy's solution or carbolic lotion (1 in 60) to flow over it, then tenderly dried with cotton-wool, and lastly a little wool soaked in olive oil should very gently be laid in the wound. Only when the wound is sluggish do I prescribe lotions ; then, according to circumstances,- blackwash, carbolic acid, sulphate of zinc or copper, tartrate of iron, or friar's balsam, may be advantageous. Iodoform, finely powdered or in ointment, I have found to be an excellent application. Although the surgeon should not interfere with nature's work, he must be always on the watch during the healing process for any burrowing or formation of fresh sinuses. Whenever the discharge from a wound is more than its extent of surface seems to warrant, the surgeon may be sure that burrowing has commenced, and should search diligently for the sinus at once, for the longer it is left the larger and deeper it will get. Sometimes it is under the edges of the wound that it commences ; at other times, at the end of the wound internally or externally; and occasionally it seems to dive down from the base of the main fistula. Such a sinus should be laid open at once. The patient, too, should always be encouraged to report immediately any pain in or near the healing- fistula ; often he will be the first to discover, by the existence of some unpleasant sensation, the commencement of a small abscess or sinus, and will be able also to indicate its situation. It is important that the recumbent position should be kept for some time,, but not necessarily in bed. After the first week or ten days subsequent to th& 108 INJURIES AND DISEASES OF THE RECTUM. operation I usually allow ray patients to recline upon the sofa for the greater part of the day. Xever, if it can be avoided, should a fistula be operated upon that is from any cause acutely inflamed. While inflammation is going on, fresh sinuses are likely to form, the areolar tissue breaking down very readily ; if an ope- ration is performed under these conditions, failure is almost certain to ensue. All that should be done is to make a free dependent opening, and wait till the sac of the abscess contracts before laying open the resulting fistula with its offshofits. The subject oi fistula in conjunction with phthisis, which I have treated of very fully in my book on Diseases of the Rectum, I can only just advert to here, on account of want of space. From my cases I find that 16 per cent, of patients with anal fistulge have had well-marked phthisis either active or latent. Fistulse in persons of a phthisical tendency have the following pecu- liarities : They have a disposition to undermine the skin and mucous mem- brane with remarkable rapidity, but not to burrow deeply. The internal aperture is almost always large and open ; on passing the finger into the bowel the opening can be felt most distinctly, often a third of an inch in ■diameter. The external opening is also frequently large and ragged, not round ; it is irregular in form, and surrounded by livid flaps of skin ; when the probe is passed into this aperture, it can be swept around over- an area of more than an inch, and not infrequently the skin is so thin that the probe -can be seen beneath. The discharge is thin, watery, and curdy, very rarely really purulent. The sphincter muscles are almost always very weak. "When tjie surgeon introduces his finger into the bowel, he is hardly sensible of any resistance. being ottered. It is common to observe in these patients much longish, soft, silk^'-looking hair around the anus. When a case of this kind comes to me, I am never in a hurry to operate. 1 like to watch the patient for a little while, and observe whether the lung mischief is advancing, and also find out if the cough is constant. I wait, if 2 can, for genial weather when the patient need not be confined to a close room. As for the operation, it must be thorough, but as little interference as possible with the sphincter muscles, es2:iecially the internal, should be made. After the operation the patient should not be confined to bed, but should be allowed to lie for hours on a mattress in a bedroom facing south or west, well covered up on a couch, by the open window. He should not be purged after the operation, but his bowels should be opened by diet and mild laxatives. If his bowels act once in three days, it is usually quite sufficient. For my own part, I do not think that there are any clinical facts tending to show that the operation for fistula in phthisical ]iatients renders the lung. affection worse, or makes it more rapidly progressive. Except in the case of rapidly ■advancing phthisis, if the operation be performed discreetly, at the right time of year, and with favorable surroundings, the patient does well, and will be benefited, not damaged, by the cure of his rectal malady. Fissure and Painful Irritable Ulcer of the Rectum. These are found more frequently in women than in men, although not rare in the latter. I have seen fissure in a baby in arms, and in an old woman of eighty, who was also suftering from impaction of feces. By far the most usual seat of fissure is dorsal or nearly dorsal. It may be brought about by an injury or tearing of the delicate mucous membrane at the verge of the anus, such as may be caused by straining, or by the passage of very dry, hard motions; sometimes it follows severe diarrhosa; it is frequently FISSURE AND PAINFUL IRRITABLB ULCER OF THE RECTUM. 109 the sequel of a confinement, or the aecompaniment, and occasional result, of polypus. Syphilis is the origin of many fissures. In fissure, the pain during action of the bowels is more or less acute ; some describe it as like tearing open a wound, and doubtless it is of a very excruciat- ing character. I have known patients who for hours could not bear to stir from one position, the least movement causing an exacerbation of the pain. This agony induces the sufferer to postpone relieving the bowels as long as possible, the result being that the motion becomes desiccated and hardened, and inflicts more grievous pain when at last it has to be discharged. After an action of the bowels, the pain may in a short time entirely cease, and not return at all until another evacuation takes place ; but often it continues very severe, and of a burning character,^ or it is of a dull heavy kind and accom- panied by throbbing, lasting for hours, sometimes even all day, so that the patient is obliged to lie down, and is utterly incapable of attending to any business. In some instances the pain does not set in until a quarter or half an hour after the bowels have acted. In children and young persons, unless a polypus complicates the fissure, I think it is almost always curable without operation. In children suffering from hereditary syphilis, numerous small cracks around the anus are common, and they cause much pain. Mercurial applications and extreme cleanliness soon cure them, but they will return from time to time unless antisyphilitic medicines be taken for a lengthened period. Fissure, although really so simple a matter, and its cure generally so easy, wears out the patient's health and strength in a remarkable manner, the constant pain and irritation to the nervous system being more than most per- sons can bear. What under these circumstances is very extraordinai-y, is the length of time that people go on enduring the malady without having any- thing done for it. It is common for fissures to heal for a time, and then break out again, so that patients are apt to think that a perfect cure will presently result, and therefore defer proper treatment. The usual position on the right side is the best for making an examina- tion. The patient raises the upper buttock with the hand, and the surgeon then with forefinger and thumb gently opens the anus, telling the patient to strain down; at the same moment he will thus be able- to see just within the orifice an elongated ulcer, shaped like a split grain of barley ; its floor may be very red and inflamed, or, if the vilcer be of long standing, of a grayish color, with edges well defined and hard. Frequently the site of the fissure is marked externally by a small clavate papilla, or minute muco-cutaneous poly- poid growth ; this must not. be confounded with ordinary polypus, and is not the cause of the fissure, but the result of the local irritation and infiam- mation which have been going on. Sometimes the situation of the fissure is indicated by an inflamed and swollen piece of skin, and in this case ulcera- tion through this portion of integument not infrequently occurs, and a small but extremely painful fistula results. When operating for the fissure this club-shaped papilla ought to be snipped off", or the case may not do well, as it falls down into the wound and retards or quite prevents healing. Of course, too, if a fistula exists, it also must be laid open throughout its whole length, as otherwise no recovery will ensue. Fissure is very commonly associated with uterine displacement. The suc- cessful treatment of this may be sufiicient to cure the fissure (if no polypus exists), or at all events the ulcer will afterwards yield to local applications and general treatment. Even if the fissure be benefited by operation, as long as the uterine malady exists, there will be constant danger of a relapse taking place. If in combination with uterine displacement chronic cystitis and spasmodic pains in micturition are present, the surgeon may depend upon 110 INJURIES AND DISEASES OF THE RECTUM. it that the case will call for all his skill and patience to bring it to a success- fal issue. Gelatinous and fibrous polypi are not uncommon complications of fissure, and are generally situated at its upper or internal end. If the polypus is not removed at the time that the ulcer is divided, failure is certain to result. If the fissure is of recent origin, it may often be cured without operation, especially if it is situated anteriorly. In women this can almost certainly be accomplished. The syphilitic fissure is the most amenable to general treatment, and syphilitic fissures are often multiple. If an operation be re- quired for multiple fissures, one incision through the sphincters will be suffi- cient. In all cases of fissure, rest in the recumbent position should, as much as possible, be adopted. Mild laxatives should usually be given to keep the bowels open once daily, but diet will sometimes eft'ect this. The domestic remedy of figs soaked in oil, or onions and milk, at bedtime, may be sufficient. I often order a combination in equal parts of confection of sulphur and con- fection of senna ; small doses of sulphate of magnesium or of sulphate of potassium, half a tumbler of Pullna or Hunyadi-Janos water taken in the morning fasting, the cqmpound liquorice powder of the German Pharmaco- poeia, and the liquid extract of cascara sagrada, are great favorites of mine. It is necessary to alternate the medicines, as one or other seems to lose its eflfect. All drastic purges should be avoided, but I do not object to small doses of the aqueous extract of aloes combined with nux vomica and iron. The patient should manage to get the bowels to act the last thing at night, instead of in the morning, as the pain does not continue as long when lying down, and this habit may be brought about by a nightly injection of half a pint of cold water. After the action, "i xx to f 5ss of liq. opii sed. should be injected with f 3ij of cold starch. As an application, I know of nothing better than the following ointment: Hydrarg. subch]oridi,gr. iv; Morphise sulphatis, gr. j; Ext. belladonnse, gr. ij; Xing, sambuci, 5j, to be frequently applied. I have eflE'ected many cures with this ointment alone. A very light touch with the nitrate of silver, not to cauterize, but to sheathe the part with an albumi- nate of silver, is occasionally advisable. Should one little spot in the ulcer be particularly painful, it is probably clue to the exposure of a nerve filament, which may be destroyed by the application of the acid nitrate of mercury. If there be severe spasm of the sphincter, extract of belladonna should be thickly smeared around the anus over the muscle. If ointments disagree with the sore, finely powdered iodoform may be tried, mixed with white vase- , line, or lead-water in combination with opium. Painting over the part with liq. plumbi subaeetatis is a most successful remedy. But it must be acknowl- edged that the most carefully devised and carried out general treatment frequently fails. If the base of the ulcer be gray and hard, and if on passing the finger into the bowel, the sphincter is found hypertrophic and spasmodically contracted, feeling as it often does like a strong India-rubber band with its upper edge sharply and hardly defined, nothing but the adoption of operative measures to prevent all action of the muscle, for a greater or less length of time, is likely to efiect a cure of the fissure. The operation may be aided by intro- ducing a speculum ; this enables the surgeon to see exactly where his knife should go, and the parts are also rendered tense, so that their division is facilitated ; the incision should commence a little above the upper end of the fissure, and should terminate a little beyond its outer end, so that the whole sore may be cut through. As a general rule, the depth of incision should not be less than a quarter of an inch. If the outer end of the fissure be marked by a swollen and inflamed piece of FISSURE AND PAINFUL IllRITABLE ULCER OF THE RECTUM. Ill ekin, it is better to remove that with a pair of scissors, for by so doing the healing process is greatly expedited ; the small polypoid growth also, so often found in fissure, must be at the same time snipped oif, and a fistula, if such exist, laid open. If the fissure is quite dorsal, the fibres of the muscle should Fig. 1188. Fig. 1189. Anal speculum. Four-bladed anal speculum. he divided somewhat laterally. A small piece of cotton-wool should be placed in the wound, and allowed to remain for from twenty-four to forty- ■eight hours. The bowels must be kept confined for tw^o or three days after the operation. Usually there is no occasion to keep the patient in bed; a few days' rest on the sofa suflices. If, however, there be any uterine complication, the patient must be kept entirely at rest and lying down until the wound has soundly healed, as otherwise the wound will not close, or, what is worse, unhealthy ulceration will supervene. I come now to the consideration of the small circular ulcer usually situated higher up in the bowel than fissures are, and differing from them somewhat in symptoms, but not in treatment. The common situation of the small circu- lar ulcer is above, or about the lower edge of, the internal sphincter. There is less severe pain at the moment of defecation, but it comes on from five minutes to a quarter or half an hour after that act, and then is quite as in- tolerable as that resulting from fissure. These minute ulcers are more ditfi- cult to find than fissures, as they often cannot be seen without using a speculum, or getting the patients to strain violently, which they will not do for fear of exciting pain. An educated finger detects these ulcers directly ; they feel much like the internal aperture of a fistula, but their edges are harder, and therefore more defined, and there is no elevation above the surface of the surroundino- mucous membrane, as is frequently the case in fistula when a pouting opening exists. These ulcers often burrow, and then they become the" internal openings of blind internal fistulse. A great many apparently anomalous symptoms are produced by small painful ulcers of the rectum : retention of urine, pain in the back, and pain and numbness down the back of the legs, leading to unfounded fears of paralysis, may be mentioned as not uncommon. I cannot conclude my remarks on fissure and painful ulcer of the rectum without adverting to a mode of treatment which I have practised with success, especially in cases in which a cutting operation has been contra-indicated. I refer to dilatation. Originated by Recamier and much practised by Dolbeau, this manoeuvre, when properly carried out, cures fissures and ulcers on the same principle as dividing the sphincter with the knife, by paralyzing it until the ulcer has healed. 112 INJURIES AND DISEASES OF THE RECTUM. The patient should be thoroughly anaesthetized, and then the two thumbs should be introduced, one after the other, taking care to pi-ess the ball of one thumb over the fissure and the other directly opposite to it ; this prevents the fissure from being torn through, and the mucous membrane from being stripped oif. The thumbs are gradually separated, and the stretching is then repeated in the opposite direction, that is, at right angles, and then in other directions until everj' part of the anus has been dilated. Considerable pressure should then be applied to the sphincter muscles all around, pulling apart the anus with four fingers, two on each side, and kneading the muscles thoroughly ; by thus gently pressing and pulling, the sphincters completely give way, and the muscle, previously hard, feels like putty. This will occupj' at least five or six minutes to do thoroughly ; there is scarcely more than a drop or two of blood seen, but for a few days extravasation is -noticed about the anus. This operation appears, as far as I know, to be quite safe, and very little pain follows, much less indeed than one would expect. Many years ago I was in the habit of subcutaneously dividing the sphincters in cases of fis- sure, and just recently Mr. Pick, of St. George's Hospital, has spoken favor- ably of the method ; for my own part I gave it up, because there is great difficulty in knowing whether enough of the sphincter muscles has been divided ; also, when the patient is under ether, the muscle has no tension, and it is really impossible to cut with precision. I also found much pain after the operation, and very uncertain results. Abscess occurred in more than one instance. If the surgeon wants to avoid cutting, dilatation is on the whole very satisfactory, and I have very rarely failed to cure a simple fissure in this way. It is well to put half a grain of morphia into the rec- tum, and to apply cold water very freely, which soon does away with suffer- ing. It happens sometimes that the patient derives more relief from hot water than from cold. After the stretching, the bruising looks really alarm- ing, but it soon passes away, and I have only rarely seen an abscess follow. Proctitis. Inflammation of the rectum may occur in both a chronic and an acute form. The symptoms are a sensation of heat and fulness in the rectum, frequent desire to go to stool, and great tenesmus ; there may be a discharge of blood and mucus. With these symptoms impaction may be suspected, but a digital examination will settle that point. The acute form of the disease is very rare in this country, and is generally produced by some mechanical cause, such as the introduction of a foreign body. I call to mind a case of acute proctitis which resulted as a conse- quence of an unnatural oft'ence committed by a husband on his wife. Here there was no doubt of the rectum being acutely inflamed, as there was a well-marked blush around the anus and over the buttocks, as well as severe pain and tenderness in the rectum. But I saw no discharge. The most obstinate constipation was present, but was overcome by the use of O'Beirne's long tube as soon as it could be passed. Idiopathic acute inflammation of the rectum resembles dysentery in its symptoms, but is distinguished from it by the absence of abdominal pain or tenderness and of severe constitutional disturbance ; the pain is generally confined to the sacrum and perineum; the bladder is often sympathetically aff'ected, and there is not infrequently difficulty in passing water. The most effective treatment for this condition would be the use of leeches around the anus, hot baths, injections of water in small quantities as hot as could be borne, to which might be added a drachm of Battley's sedative. A ULCERATION AND STRICTUEE OF THE RECTUM. 113 hot bath, followed by a hypodermic injection of morphia, is likely to be of benefit. The patient should keep the recumbent position, and take very light, unstimulating nourishment ; no irritating purges should be given. If it be necessary to relieve the bowels of their contents, a flask of warm olive oil as an enema is the best that can be employed. I have seen very few such cases in this country, but they are not very uncommon in hot climates. The chronic variety of proctitis occurs in old people, and is best treated by injections of starch and opium, and by the internal use of such medicines as turpentine, aloes, confection of black pepper, and copaiba. I usually order frequent and small doses of Barbadoes aloes ; these act as a stimulant to the rectum, and induce healthy action, and very soon the disorder subsides. Hamamelis is another useful remedy ; it is in fact rapidlj^ curative in some cases. It may be used- as an injection, and may also be administered by the mouth. Ulceration and Stricture of the Eectum. Ulceration extending above the internal sphincter, and frequently situated entirely above that muscle, is not a very uncommon disease ; it inflicts great misery upon the patient, and, if neglected, leads to conditions quite incurable, and the patient dies of exhaustion unless extraordinary means are resorted to. In the earlier stages of the malady, careful, rational, and prolonged treatment is often successful, and the patient is restored to health ; but not so in severe and long-standing cases. Ulceration of the rectum can only be mistaken for malignant disease ; but with care and a well-educated finger an error in diagnosis should be a great rarity, though I must confess that I have made the mistake myself. As the earlier manifestations are fairly amenable to treatment, it is of the utmost importance that the disease should be recognized early. In the majority of these cases, the earliest symptom is morning diarrhoea, and that of a peculiar character ; the patient will tell you that the instant he gets out of bed he feels a most urgent desire to go to stool ; he does so, but^the result is not satisfactory. Wbat he passes is generally wind, a little loose fecal matter, and some discharge resembling cofl^ee grounds both in color and consistency ; occasionally the discharge is like the " white of an unboiled egg," or a "jelly fish ;" more rarely there is matter. The patient in all proba- bility has tenesmus, and does not feel relieved ; there is a somewhat burning and uncomfortable sensation, but not actual pain ; before he is dressed, he very likely has again to seek the closet ; this time he passes more feces, often lumpy, and occasionally smeared with blood. It may also happen that after breakfast, hot tea or coffee having been taken, the bowels will again act ; after this he feels all right, and goes about his business for the rest of the day, only, perhaps, being occasionally reminded by a disagreeable sensation that he has something wrong with his bowel. IsTot by any means always, but at times, the morning diarrhoea is attended with gripino- pain across the lower part of the abdomen, and great flatulent distension. All these symptoms are also met with in cases of malignant disease. When a medical man is consulted, the case is, in all probability and quite excusably, considered one of dikrrhcea of a dysenteric character, and is treated with some stomachic and opiate mixture, which aftbrds temporary relief. After this condition has lasted for some months, the length of this period of comparative quiescence being influenced by the seat of the ulceration and the rapidity of its exten- sion, the patient begins to have more burning pain after an evacuation ; there is also greater straining, and an increase in the quantity of discharge from VOL. vi.^ — 8 114 INJURIES AND DISEASES OF THE RECTUM. the bowel ; there is now not so much jelly-like matter, but more pus, more of the coffee-ground discharge, and more blood. The pain suffered is not very acute, but very wearying ; it is described as like a dull toothache, and is induced now by much standing about or walking. At this stage of the complaint the diarrhoea comes on in the evening as well as in the morning, and the patient's health begins to give way— only triflingly so perhaps, but he is dyspeptic, loses his appetite, and has paui in the rectum during the night, which disturbs his rest ; he also has wandering and apparently anomalous pains in the back, hips, down the leg, and sometimes in the penis. There is yet another symptom present in the later stages, marking the existence of some slight contraction of the bowel — alternating attacks of diarrhoea and -constipation ; and during the diarrhoea the patient passes a very large quantity of feces. These seizures are attended with severe colicky pains in the abdomen, faintness, and not unfrequently sickness. As the ulceration extends, attempts at healing take place ; these result in infiltration and thickening of the mucous and submucous tissues, and conse- quent diminution of the calibre of the bowel, so that real stricture of various forms supervenes. Coincident with all this there results a gradual loss of the contractile power of the rectum, and almost complete immobility, so that the lower part of the gut is converted into a passive tube through which the feces, if fluid, trickle; but, if solid, stick fast until pushed through by fresh formations above them. Invariably also there is loss of power in the sphinc- ters. "When diarrhoea is present, the patient has little or no control over his motions. Usually by this time abscesses have formed, or are in process of for- mation, and these breaking soon become fistulse. I have seen persons with eight external orifices, some situated three inches or more from the anus. On examining these cases of ulceration of the rectum, the surgeon may often feel, in the eai'lier stages, an ulcer situated dorsally about one and a half inches from the anus, oval in form, perhaps an inch long by half an inch wide, surrounded by a raised and sometimes hard edge ; there is acute pain caused on touching it, and it may be readily made to bleed. With a speculum he can distinctly see the ulcer, the edges well marked, the base grayish or very red and inflamed-looking, the surrounding mucous membrane being proba- bly healthy ; in the neighborhood of the ulcer may often be felt some lumps, which are either gummata or enlarged rectal glands. This is the stage in which the disease is often curable. At a later period of the malady, he will observe deep ulcers with great thickening of the mucous membrane, often also roughening to a considerable extent, as though the mucous mem- brane had been stripped off. At this stage there are generally, outside of the anus, swollen and tender flaps of skin, shiny, and covered with an ichorous discharge ; these flaps are commonly club-shaped, and are met with also in malignant disease ; but during the early development of the diseaseno ulceration is found near the anus, nor at the aperture. I must positively repeat that the large majority of these cases do not commence by any manifestation at the anus, such as gtowths or sores ; occasionally a fissure may be the first lesion, and the ulceration may extend from the wound made in attempting to cure it ; this is, however, the exception to the rule. So definite is this external appearance in long-standing disease, that one glance is suflBcient to enable an expert to predicate the existence of either cancer or severe ulceration ; these external enlai-gements are the result of the ulceration going on in the bowel, and the irritation caused by almost constant discharge. The ulceration may be confined to a part of the circumference of the bowel, or it may extend all around, and for some distance, but not usually more than four inches, up the rectum. ULCERATION AND STRICTURE OF THE RECTUM. 115 It also probably-will have travelled dovi^nvsrards close to the anus, and there the pain is sure to be very severe, because the part is more sensitive and more exposed to external influences and accidents. When the disease has reached this stage, of course stricture and most probably fistula will be present, as I have already mentioned ; and possibly, but not frequently, perforation into the bladder, the vagina, or the peritoneal cavity, may occur. The state of the patient is now most lamentable ; his or her aspect resembles that of a sufferer from malignant disease, and no remedy short of lumbar colotoray offers much chance of even prolonging life. You njay relieve these patients, but you can rarely do more ; a cure can scarcely be expected. I have seen ulceration utterly destroy both the anal sphincters, so that the anus was but a deeply ragged hole. A low form of peritonitis is a not uncommon complication of ulceration and stricture. It is attended with considerable pain in the abdomen, often intense for a short period. There are generally one or more tender spots, tympanites, and often vomiting, especially on first assuming the erect posi- tion in the morning ; generall}' the pain is brought on by standing or moving about. These attacks are sure to end in diarrhcea. When making a post-mortem examination in such cases, I have observed effusion into the peritoneal cavity and often numerous old and recent adhe- sions between the intestines ; the peritoneum is also thickened. In bad cases the whole of the rectum and even the sigmoid flexure may be involved in ulceration, and great thickening and contraction of the calibre of the bowel, caused by the attempts at repair, may be observed ; in various parts, large bridges of indurated muscle are exposed, and the mucous membrane is strangely roughened. I have seen more than one case in which necrosis of the sacrum had taken place. In the treatment of these attacks there should be perfect rest in bed, with spare diet ; opium may be given freelj^; fomentations relieve i:)ain, but I have not seen any benefit result from counter-irritation, except by an ordinary lin- seed or mustard poultice. I have often found that calomel and opium, given for some time, are advantageous in these cases. Erom the notes of my cases in St. Mark's Hospital, I find that out of 110 patients with ulceration and stricture, 92 were females and 18 males. Out •of the 110, 49 had undoubtedly suffered from constitutional syphilis, while 9 had some syphilitic symptoms, but not such as were decisive, so that I think that this number should be deducted from the whole number, 110, before considering the statistics of the remaining 101 ; we then find 49 who were most undoubtedly syphilitic, and 52 who as undoubtedly had never contracted syphilis, and many of whom had never had any venereal disease at all. These statistics differ from those published in my work on Diseases of the Rectum, showing a less proportion of syphilitic patients; but this may be merely acci- dental, and a further series may again reverse the results. Many of my patients 'have been subjected to colotomy in the lumbar region, and for the most part have done well, and I believe several (eight or nine) are now alive. Two of the women have married since the operation, and one has borne a child. For the relief of stri'cture and ulceration I have performed colotomy thirty-five times. , In sixteen cas^s I have performed Verneuil's operation of linear rectotomy, but always with the knife, never with the ecraseur or galvanic cautery, as he has recommended. This is the essence of Prof. Verneuil's operation : The whole stricture must be divided from its upper edge down to the coccyx, and through its entire depth. Thus a deep drain is made, from ^hich all discharges freely flow, •and as this heals up, the ulceration ceases, and the stricture is sometimes cured. 116 INJURIES AND DISEASES OF THE RECTUM. The patient being in the lithotomy position, the surgeon passes his jSnger through the stricture as a guide, then introduces a long straight knife, and, when its point is fully above the stricture, cuts firmly down right through it in its whole depth, even to the sacrum if necessary, and brings the knife out at the tip of the coccyx. By keeping to the median line the bleeding is but trifling, and the whole of the diseased structure will have been cut through. So rapidly beneficial is this operation that in forty-eight hours I have seen night-sweats arrested, and a patient who seemed about to die rally, and eat and drink, and get well from that moment ; morbific discharges, instead of being absorbed, run out, and the patient is not poisoned. The wound should be well syringed, and the parts kept perfectly clean by injecting a very weak carbolic lotion (1 in 60). I always use dry absorbent cotton- wool as the dressing, sometimes carbolized, and I only want my patient washed at most twice in the day ; too frequent use of any fluid, carbolized or not, soddens and weakens the granulations ; dry dressings are those which I advise. Many of these patients have done well, and I have a record of at least fifteen permanent cures ; but in others the operation has failed, and I have seen a return of the disease after even three or four years. In the after- treatment I often place a tube in the wound, keeping it in at night, which tends to prevent contraction. Many of my eases have been treated by dilatation, assisted in some instances by small incisions ; stricture of the rectum, however, is a disease infinitely more uncertain, more prone to relapse, and more difficult to treat, than stric- ture of the urethra. In some few cases, immense good has resulted from the long-continued administration of iodide of potassium and perchloride of mer- cury ; but on the other hand, often when it has been expected to be of benefit^ no curative result has followed. On the whole, therefore, I place no great faith in specific remedies, although I always use them with tonics when I feel that the ulcerations are of syphilitic origin. ' On summing up my own cases, hospital as well as private, I can in brief state that in women rather more than 50 per cent, have suffered from un- doubted constitutional syphilis, and that in men about 40 per cent, have been in the same position. Among the causes of the ulceration, etc., in those who showed no evidence of syphilis, I may mention tuberculosis (not so uncommon as is generally supposed) ; dysentery and diarrhoea, usually following prolonged residence in tropical climates; obstinate, long-standing constipation; injuries to the uterus and vagina in parturition; and operations on the rectum in per- sons of bad constitution; but will these causes account for all the cases? I am obliged to say that I do not think so, and to confess that in many of these cases I do not know the cause. If we could answer the question why ulcera- tion and stricture are so much more frequent in the female than in the male, we should possibly have a clue; but for my part I cannot see that any satis- factory reply has been given to this question, more than it has to another, viz., Why is epithelioma comparatively seldom found in the rectums of women? In connection with this part of the subject, I may say that I am altogether at variance with some French authorities, such as M. Gosselin, and some eminent American surgeons, such as the late Dr. Erskine Mason, who hold that the vast majority of cases of stricture and ulceration, not cancerous, result from contamination by the discharges from "soft sores" or "chan- croids." I have gone very carefully and fully into the consideration of this matter, and I cannot too strongly and emphatically express my opinion that the ulceration which leads to stricture is the result of tertiary syphilis, and not of chancroid. My experience of soft sores neg,r the anus is that they speedily heal under proper treatment, and I have seen many cases cured in a few days by clean- ULCERATION AND STRUCTURE OF THE RECTUM. 117 liness and the use of a tartrate-of-iron lotion ; and though these patients have ibeen seen from time to time for other ailments, no ulceration or stricture of the rectum has been found to ensue. There are no maladies more baffling to the surgeon than ulcerations and strictures of the rectum, and, as I have before said, they are often quite in- curable, and nothing affords relief save colotomy. It is not quite impossible that, after this operation, the ulceration and stricture maj' get well, and that then the surgical opening in the loin may be closed ; this I have now in three cases successfully accomplished, but, on the other hand, I have frequently tried it and failed. In cases of circumscribed ulceration, I have great confidence in the efficacy of rest in the recumbent position, and of a wholly, or nearly, fluid diet, and I consider that milk should be the essential element of food in these cases. When the ulceration is deep and contraction has commenced, the disease is much more serious, and a very doubtful prognosis should be given. Still, if only the patient will submit to proper treatment for a lengthened period, a good deal may be done in all cases. In these, rest is even more important than it is in the earliest stage of the affection. Often the ulceration induces such an irritable condition of the rectum that nothing will be retained — neither any injection, suppository, nor ointment ; I have found that bismuth and char- coal, taken internally, will generally soon overcome this excessive irritability. Subcarbonate of bismuth may also be tried on the raucous membrane itself hy means of insufflation. Iodoform also is a very potent remedy. This, when Fig. 1190. Rectal insufflator. continuously used, may soothe the rectum, relieve pain, and promote healing. As a rule, I prefer ointments to suppositories or injections. The improved American instrument for the application of ointments obviates all difflculties of introduction, and I am sure that this irritates less than other methods of Fig. 1191. Instrument for application of ointments to rectum. medication ; all kinds of sedatives, opiates, and astringents may in turn be tried. I have seen the following formula most efficacious : Bismuthi subnitrat., 3ij ; Hydrarg. subchloridi, 9ij ; Morphife, gr. iij ; Grlycerinse, Jij ; Vaselini, ,lj ; this is a very sedative application, and sores seem to be benefited by it speedily. Subacetate of lead and milk (3j to f .?j), with belladonna and opium, will be found serviceable ; all sorts of astringents may be employed ; rhatany, friar's 118 INJURIES AND DISEASES OF THE RECTUM. balsam, zinc (the permanganate), copper, iron, nitrate of silver, etc. The last, carefully used in not too strong solution, is one of the most admirable appli- cations, often inducing in an ulcer a healthy appearance, and causing granu- lation ; so too, is the tartrate of iron in the proportion of ten grains to the ounce of water. Fuming nitric acid, and strong carbolic or chromic acid, applied under certain conditions, are potent remedies ; they often allay pain and start healing processes afresh, but they are double-edged tools, and must be used with great discretion, and with a distinct object in view. In ulceration, when the least stricture exists, soft bougies may be always employed, but it must be remembered that to do any good they must be used with the greatest gentleness. A bougie of too large a size should never be employed ; no greater mistake can.be made than to suppose that the larger the bougie that can be got in the better ; the surgeon should keep below the size that can be well boi-ne, rather than at all above it ; in the one case good may ensue, in the other, irritation and retrogression are seen to take place j a patient should never be given an ordinary bougie to use for himself, always an India-rubber one, and conical, if the stricture is more than two inches from the anus. But if the constriction is only about an inch or an inch and a half from the anus, the patient may be given a vulcanite conical tube furnished with a collar, to which tapes are fastened to keep it in the bowel, and also to prevent it from going up the rectum ; it may be passed and worn at night, if its intro- duction can be accomplished without any severe pain. When strictures are slight, and not very long, but annular in form, division in a few places with the knife, followed by judicious treatment with the tubes, may be very bene- ficial and even curative. The division I usually make at four points, and I take care just to cut through the induration, and reach the healthy tissues beneath, but not to go deeper ; the bowel should be filled with well-oiled lint or wool for twenty-four hours, and then the tube introduced and worn, only taking it out for the bowels to act, and to wash out the rectum with some antiseptic lotion. I prefer Condy's fluid or thymol, if the patient him- self applies it, as less dangerous than carbolic acid. I am of opinion that carbolic acid, if strong, is too irritant. In those cases in which the ulceration is extensive, and constriction so tight that a passage barely exists, or in which the lower part of the rectum is now merely a passive tube through which there is a perpetual leaking of semi-fluid feces, some relief may be aftbrded by dividing the fistulous pas- sages, which are nearly always present, with the elastic ligature. The knife is very likely to cause severe hemorrhage, as the divided vessels can neith'er retract nor contract in the hardened tissues. Constitutional treatment here is of no avail. Lumbar colotomy is the patient's only chance. Stricture of the rectum without ulceration is a somewhat uncommon aflfection. Its pathology corresponds to that of organic stricture of the urethra; that is to say, there is an inflammatory deposit in the submucous tissue, and an accompanying spasm of the muscular coat. I have seen stric- tures of the rectum so tight that I could not get the end of my little finger into them ; but when the patients had been brought well under the influence of an anaesthetic, I have been able to pass one or two fingers through easily. How inflammation and thickening are set up in the connective tissue of the bowel, it is difiicult to say. It may be that straining to evacuate the con- tents of the bowel forces down the upper part of the rectum into the lower, thus causing an intussusception, and bringing the part within the grasp of the sphincter muscles ; and I have often thought that this condition might be the starting point of the irritation. I have in some few cases had a suspicion ULCERATION AND STRICTURE OF THE RECTUM. lit) that long-continued pressure of the child's head in labor has been the exciting cause, bruising of the bowel having perhaps taken place. Possibly, also, in- flammation may be induced by the passage of very dry and hardened feces, though doubtless this condition may obtain for years, as it often does in old people, without producing stricture. I have seen one case in which the frequent and rather rough use of an enema-pipe produced a stricture. It is stated in some works that the stools in stricture are thin, long, and pipe-like. According to my experience, such stools occur far oftener in spasm of the sphincter, enlarged prostate gland, enlarged retro verted uterus, and tumors of the pelvis generally. In true stricture, on the other hand, the stool is in very small broken pieces, the feces having no actual form, and looseness often alternating with this lumpy condition. The discharge in simple stricture is like the white of an unboiled egg, or a jelly fish, and is passed when the bowels first act. There is no discharge looking like coffee-grounds, such as is constantly seen in ulceration, nor is there the morning diarrhcea which we find in that complaint. The pain ' is generally referred not to the bowel itself, but to distant parts, notably the penis, the perineum, the lower part of the back, the thighs, under the but- tocks, and occasionally the stomach. A stricture of the rectum, resulting entirel}' from muscular spasm, is a thing that I am very much disinclined to believe in. I am of opinion that these stric- tures exist only in the mind of the surgeon, who has been misled by the bougie catching in a fold of the gut, or against the promontory of the sacrum. If in doubt as to the existence of a stricture, the surgeon should use a long and very elastic enema-tube, and inject fluid as he passes it, so as to distend the gut and remove any intussusception of the upper part of the rectum. This condition, I think, has often been mistaken for stricture, as unless the bougie goes directly into the aperture of the invaginated portion of the gut, it gets into the sulcus at the side, which is a cul-de-sac, and which prevents the in- strument from passing. Ih exploring the rectum, I use vulcanite balls, olive-shaped bodies of different sizes, mounted on pewter stems, with flattened, roughened handles. Fig. 119 Instrnment for detecting rectal stricture. m . , " They bend easily to any form ; and by their use I can be certain of detecting a stricture. For when they pass, or on quietly withdrawing them, the ball is felt to come suddenly, and perhaps with some difiiculty, through the constriction. Fig. 1193. Kectal syringe. In cases of stricture where there is great spasm with a small amount of organic disease, much good may be done by the use of conical bougies. Opium or belladonna with oil should be injected previously, and the bougie should be smeared over with blue ointment, which is tenacious and lubi-icates 120 INJURIES AND DISEASES OF THE RECTUM. well. If the instrument cannot be quickly passed, it is better not to persever< as irritation will be set up and damage done. I strongly disapprove c forcible dilatation, such as that produced by Todd's dilator, as obstinat ulceration only too often results ; the amount of pressui'e made cannot b gauged. The only kind of stricture without ulceration which in my opinion shouL be divided, is that in which the constriction is semicircular or annular, am feels to the touch as though the bowel were encircled by a cord. Thes strictures are so resilient that, even if dilated to their fullest extent, they ■wil very soon return to their previous state of contraction. All other stricture without ulceration I treat by gentle dilatation with conical bougies, ver gradually increasing the size of the instrument. I pass a bougie twice o thrice a week, or daily, but not often the latter, being guided by the natur of the case ; that is, I never set up irritation if I can possibly avoid it. As all strictures of the rectum show a marked tendency towards return patients should be warned never to be long without having the bougie passed and, as soon as any of the old symptoms recur, at once to obtain treatment if this advice be acted upon, but little fear need be entertained of a dangerou; relapse, and I have now a very large number of patients who have been ii this way kept for ten years and upwards in perfect comfort. Stricture of the rectum cannot be quickly and permanently cured by anj means ; an experience of nearly twenty-five years has never shown me a singL case quickly cured, which has not as speedily relapsed. Cancer of the Rectum. Cancer of the rectum usually runs its course in about two years. In manj instances the duration of life is much less. I have watched a case o encephaloid which terminated fatally at the end of four months from th( appearance of its earliest symptoms. Colotomy was performed by me whei I first saw the patient, two months before death ; but I do not think that i delayed the progress of the disease one day, although it afibrded relief fron excruciating pain. On the other hand, I have seen many cases of scirrhui and epithelioma where the patient lived quite four years and a half (anc even longeritf^^ut any surgical interference. Cancer ^^^^vly a disease of middle life, but I have seen encephaloic rapidly fa^^^Hboy of seventeen ; and some years ago there was i^ St Mark's Ho^^lPlnder the care of my colleague, Mr. (xowlland, a boy, no thirteen, with cancer of the rectum. Scirrhus and epithelioma in old peopL usually run a very slow course, which may be accounted for by the fact tha in old people the vital forces are sluggish in disease as in health. It has been said that cancer is more frequent in women than in men. A; regards the rectum, this is directly the reverse of my experience. In mi statistics many more men are victims than women. From my experience too, there seems to be no ground to consider cancer of the rectum as a heredi tary malady. Some varieties of cancer may in their early stage be only and purely local But this stage is of very short duration, and the above statement is hardly certainly not practically, true of the more malignant forms. By this I meai that as soon as a growth exhibits itself, so as to be noticed by the patient the disease is commonly already constitutional, and the system is infected. As a rule, cancer of the rectum during some part of its course is mos horribly painful, the function of the part enhancing the suflering ; but ; have seen patients in whom there has not been excessive pain, particularly ii CANCER OF THE RECTUM. 121 the early stages. In the more advanced periods of the malady the- pain often becomes unremitting, from the fact that many nerves become involved, and are pressed upon or stretched, the neighboi-ing organs thus becoming seats of separate pain, even if they are not actually touched by the growth. I had a patient with cancer, which, commencing in the rectum, involved the whole cavity of the pelvis, and pain down the right sciatic nerve was one of his most distressing symptoms. The forms of malignant disease usually described as occurring in the rectum are epithelioma, scirrhus, encephaloid, colloid, and melanosis. I think that I have placed them in their order of frequency. I have never seen a mela- notic tumor of the rectum. I have seen many colloid tumors, but I am not sure that encephaloid may not be colloid, or pass into it. From my own clinical observation I should be inclined to say that in cancer of the rectum it is often very difficult, if even possible, to make any distinction between broken-down scirrhus and epithelioma. I have seen cancers of the rectum stony hard at one part and quite soft at another. Malignant growths are commonly found seated within three inches of. the anus, but often extend higher up, the most rapidly dangerous being about the upper part of the rectum and the lower portion of the sigmoid flexure. When cancer occurs near the anus, it may extend upwards ^beyond the reach of the finger, but more frequently it does not, and the whole extent of the disease can be ascertained. If epithelioma begins at the anus itself, it may extend upwards for a variable distance, usually, however, not so far as to put excision out of the question. There is in cancer of the rectum a peculiar odor, which one cannot describe, but which once recognized will rarely be forgotten. In my opinion the odor is pathognomonic. In scirrhus and encephaloid, the mucous membrane may for a time remain quite smooth and unaffected, though adherent to the growth below. In epithelioma, the mu- cous membi-ane seems to be implicated from the first throughout, and, even when the growth is considerable, will be found movable over structures beneath. Scirrhus is often found as a hard tumor seated in the rectum over the prostate gland, and, although it may not have arisen from the gland itself, nor invaded it;at all, yet it is remarkably adherent to it. The more malignant forms of cancer do not exist long in the rectum before secondary deposits occur in the lumbar glands, groin, Yw^m^^. The aspect of countenance which so often attends the cancerous cg^^^Bis very usual, and is seen earlier in cancer of the rectum, I think, tha^^^^H^ar disease of other parts. When the cancerous growth is high up, v^^BB[frequent and severe, is an early symptom, even when not much obstiTc^nOTi exists. The onset of cancer in the rectum is often- marked by very trivial symptoms. A patient may come into the surgeon's consulting room complaining of no more than a little diarrhoea in the morning, or even of only a little uneasi- ness in the bowel. He may look thoroughly healthy and strong, and may really think himself well in every respect save for the slight local trouble ; yet, on making an examination, it may be found that the disease is advanced beyond all possibility of doing any good. When cancer attacks the upper- most portion of the rectum, or the sigmoid flexure, it runs a hnore rapid course, and is much more dangerous ; indeed, sudden death is not uncommon, as total obstruction takes place quickly, and, unless colotomy be promptly performed, the intestine gives way above the obstruction, and death ensues. Cancerous stricture of the upper part of the sigmoid flexure, or of the de- scending colon, is not so immediatel}^ dangerous, although the obstruction may be total. I have seen cases of this kind in which life has lasted eight weeks or longer. 122 INJURIES AND DISEASES OF THE RECTUM. In regard to treatment, I have never seen any benefit result from the appli- cation of caustics to growths within the bowel, bat when a cancerous mass protrudes, which, however, is a somewhat rare occurrence, I have relieved pain and got rid of a good deal of the growth by using the arsenite of copper with mucilage as a paste ; it does not cause bleeding, and, as far as my experience goes, is free from danger. The treatment in the majority of cases of cancer resolves itself into an attempt to assuage the sufferings of the patient. Pain is mitigated by the recumbent position, and by sedatives, which should be used externally and internally, opium in its several forms being the most effective agent which we possess. It may be used as a suppository, in which case the best formula is morphia with glycerine and gelatine (three of glycerine to one of gelatine), as this melts very soon, and does not feel like a foreign body in the sensitive bowel. Injections of Battley's sedative, .nepenthe, or black drop, in starch, afford great relief Probably most patients obtain the greatest comfort from hypodermic injections of morphia, but no' opiate can be used long without inducing a state of mind almost as unendurable as the pain of the disease; therefore great care should be taken* to husband the remedy as much as pos- sible, never using a larger dose than is absolutely necessary, and bearing in mind that it may be necessary to rely upon it, more or less, even for months. I have tried the Chian turpentine, recommended by Mr. John Clay, of Bir- mingham, but have not been satisfied with its results, and have discontinued its use. When cancerous growths approach the anus, considerable relief may be obtained by dividing the sphincter muscles; defecation is thus rendered easier, and no possible compression can be exercised. When diminution of the calibre of the bowel is induced by cancer near the anus. Professor Verneuil has proposed free division of the gut in the dorsal median line; this operation I have frequently practised, thereby affording great temporary relief to my patients. In encephaloid of the rectum, much relief from pain and some advantage may be obtained by tearing out the growth by the fingers or the scoop. This must be done boldly, and the whole growth enucleated quickly and resolutely. If only the superficial portions are torn away, hemorrhage may occur to a considerable extent, which must exhaust the patient, and no real benefit will accrue. , In the cases in which I have adopted this plan of tr^jj^it, I have been surprised to observe that, after the removal of the cancerc^^H™rths, the facial appearance of the patients has improved immensely ; fflw^E'^y have all lost the malignant aspect, and not until the growths have^ KHg lly returned, and with it the poisoning of the blood and tissues, has thecountenance reassumed its worn, haggard look. So, also, in respect of health, strength, freedom from pain, appetite, and capacity for sleep, this change for the better has been remarkable. Two operations have been practised for the relief of rectal cancer : The one is extirpation of all the diseased portions of the rectum ; the other is colotomy, lumbar or inguinal, which only professes to relieve pain, and possibly to extend the term of the patient's life. Extirpation of the rectum may be undertaken in any form of cancer which does not necessitate the removal of more than four and three-quarters or five inches of the rectum in the male, and about one inch less in the female. If found closely adherent to the base of the bladder and prostate gland, or to the neck of the uterus in women, the operation is probably not admissible, and certainly not desirable. Again, if any enlarged glands exist in the inguinal or lumbar regions, the' operation cannot be recommended. Lastly, I should say that the patient ought not to be so exhausted as to render it doubtful whether the rather severe shock, consequent on the operation, may not greatly endanger life. CANCER OF THE RECTUM. ■ 123 The partial removal of the circumference of the bowel is in my opinion most unsatisfactory. In all the cases in which I have removed only part of the wall, there has been either a return of the disease in the rectum, or in the glands in the groin, or in some internal organ, mostly the liver. Up to the present time I have excised the rectum in its entire circum- ference in 36 patients. In my early cases my success was less than it has been since ; increased experience has taught me better ways of operating and more skill in arresting hemorrhage. I am not nearly as long in com- pleting the operation, and consequently my patients suffer less shock ; they rarely lose more than four or live ounces of blood, and are in the average not under ether more than thirty minutes^n many cases, indeed, much less time than that. I never stop to tie bleeding vessels as I go, but put on forceps and leave them hanging. I use an ecraseur with whipcord, not wire, for cutting through the bowel. I prefer it because it can be more easily applied, and more accurately adjusted. It might be expected that in my long career I should have excised the rectum in many more cases than I have, but the fact is that few really good cases for the operation present themselves. Cancer often commences high up in the bowel, and only comes into reach after existing for some months. I have seen so many patients with cancer of the rectum who had recently been examined by eminent surgeons, and no disease found, that I have come to the conclusion that the disease existed, but had only very recently come within reach of the finger. Moreover, I have myself examined patients who had very marked symptoms of malignant disease of the bowel, but in whom I could not detect any disease in the rectum, and in less than three months these patients have again presented themselves, and the growth has been felt two inches from the anus. The mode of operating which I prefer in all serious cases, that is, when more than three inches of the rectum has to be removed, is that which has found most favor with French writers. The surgeon commences the operation by making a deep dorsal incision, beginning just in front of the tip of the coccyx, and carried high up the bowel. I consider this the " key" to the operation ; it affords plenty of room and wonderfully facilitates the details, such as securing vessels quickly, and performing delicate dissections of the parts adherent to the prostate and base of the bladder, or to the vagina. Further, it forms a deep drain through which all morbific matters run away, and through which the whole wound can be easily washed out with weak Carbolic lotion, or some other antiseptic. In operating upon the male, a silver catheter should always be passed to steady the urethra and render the deep dissection safe and more rapid. I often keep a large tube in the rectum, after the operation, to favor the escape of flatus, which if retained sometimes causes the patient great pain. In women, an assistant's finger should be introduced into the vagina to afford the surgeon timely warning of his approach to the mucous mem- brane. If obliged to take out a portion of the recto-vaginal wall, I am not anxious about it, as in all my cases in which this has been done I have repaired the damage at the time of the operation, and in nearly all success- fully. In cases where the disease does not extend very high up the rectum, it is possible to leave the sphincter muscle, and bring down the bowel so as to suture it to the skin. I certainly have not had the success some surgeons claim in such cases. I have several times found the traction so great as to tear out the sutures, and at other times fecal matter has got into the wound, and the sutures have had to be taken out to clear away pus, etc. In two patients only have I had good results, the skin uniting with the mucous membrane very securely ; both patients were women, thin, and very good subjects for the operation. 124 INJURIES AND DISEASES OF THE EECTUM. When small portions of the rectum have to be removed, there are several ways in which this can be done, and the surgeon may avoid the dorsal in- cision and use a horse-shoe one around the dorsal circumference of the anus ; getting into the connective tissue, the flap may be turned forwards, the growth removed, and then the flap brought down and sutured to the bowel without sacriflcing the' sphincters. I have not myself met with a single case in which I could attempt this operation with any chance of success, and I much doubt if it is very practicable. Mr. James Adams, late of the London Hogpital, has suggested that colotomy should be performed prior to excising a cancer of the rectum. His arguments in favor of such a step are as follows : *' That in cases of any but the slightest degree the operation might prove incomplete, and the disease speedily return ; that after complete removal of the lower part of the rectum, the subsequent contraction is often very great, and even at times quite intractable ; and that in any case the healing of the wound would be much expedited and the local recurrence diminished by diverting the course of the fecal matter." I have not yet tried the combined operation of colotomy followed by excision, but I am disposed to think that there is much to commend it. I have found in all cases of excision of the rectum, in those of others as well as in my own, that by the third month after the operation very great contrac- tion will have taken place, unless certain precautions have been practised. The contractions once formed are most difiicult of cure, and in fact some are never thoroughly rectified. In all my cases, for years now, I have made my patients, after the expiration of ten or fourteen days from the operation, wear a vulcanite tube in the bowel. This is taken out daily while the bowels are acting, but at other times is constantly retained for some months ; the result is that no stricture or contraction of the anal orifice takes place, and that the patients are quite comfortable. In one of my cases a man has been compelled to wear a plug ever since the operation ; if he leaves it out for a couple of months, the parts re-contract. I use tubes of three or four inches in length, one end conical to render the introduction easy, and the other ending in a broadish flange to prevent its accidentally slipping into the rectum, and also to enable it to be stitched to a bandage which keeps it in place. Now what has been my success in the 36 cases in which I have operated since March 2, 1874 ? Unfortunately, with the very best intentions, accuracy in all particulars cannot be insured in answering this question. Patients, particularly those attended in hospital, go away, and are lost sight of, but I have done all that I could to follow up my cases, and have fairly succeeded, as I know the I'esult in 26. Of the 26 patients, 1 died about 4 years after the operation. 1 ' " 3 " 2 ' " 2 " 5 ' over 18 months " 7 ' about 1 year " 6 ' from the direct consequences of the operation 5 I know to be still alive. Of the 5 living patients, one was operated upon more than seven years ago ; the rest within two years. Of the 5 who died from the direct consequences of the operation (that is, within 14 days), 1 died by carbolic-acid poisoning — an assistant unwittingly injecting a strong solution to wash out the wound — the peritoneal cavity being open ; 1 from secondary hemorrhage on the 10th or 12th day ; 1 from peritonitis, a few days after the operation ; and 2 from erysipelas. There still remain the ten patients lost sight of; of these I can only say that they all went from my care after two months, when the early CANCER OF THE RECTUM. 125 dangers attending the operation had passed away ; two I saw after six months, and their cases bade fair to be very successful. I must contend that the operation in properly selected cases is one likely to afford excellent results, and I am sure that with increased experience the direct mortality may be decreased. Properly, my deaths from the operation per se may be reduced to 4, as the carbolic-acid -poisoning was absolutely an accident. As to the prolongation of life and the amount of comfort afforded, I think , it quite sufficient to justify my recommending the operation in all cases in which the growth can be fully removed. In two of my cases, which did well, I opened the peritoneum and removed a hard mass of glands, and in another case one gland ; and I am fully confident that if due precautions are taken, the opening the cavity of the abdomen does not greatly add to the danger. Since writing the above paragraphs I have performed three more excisions of the rectum, and all of the patients are, so far, doing well. I shall only quite briefly touch upon the question of colotomy, as the sub- ject has been fully considered elsewhere. Generally, I will say that colotomy is justifiable when an obstruction existing in the rectum, sigmoid flexure, or in the descending or transverse colon, places the patient's life in peril. Also, when an opening has taken place between the rectum and the bladder, or even the vagina high up, the distress in these cases being often exceedingly great. When cancer of the rectum is rapidly advancing, and all treatment fails to relieve pain, then also colotomy may be performed even if no ob- struction exists. I must, however, protest against colotomy being performed simply because a cancer exists in the rectum. Often neither pain nor obstruction will ensue for months, or they may never occur, and the patient may die of some other malady. Of course, if a surgeon at once persuades all his patients who have malignant growths of the rectum to submit to colotomy, under the promise that life will be much ' prolonged and suffering averted, he will have many cases to report and very good statistics, but I maintain that such statistics are really valueless. In one case, another surgeon performed colotomy three days after the patient had consulted me ; there w-as a growth, but no pain and no obstruction, and the patient was in fair health ; he died four months after the operation. In all probability, had he not been operated upon, he might have lived for years. I was once called to Eastbourne, to see a gentleman whom I found suffering from constant diarrho3a ; he was wasted to a shadow, and his skin was dry and furfuraceous. I found superficial ulceration in the rectum as far as I could reach, and the mucous membrane was studded with small elevated bodies. I said that the patient was suffering from tuber- culosis of the bowel, and that he would die in a few days. I was then asked if I did not think that colotomy was necessary, and was told that a surgeon was coming the next day to colotomize the patient. I fortunately succeeded in stopping the operation: the patient died in three days, and the post-mortem examination showed tuberculous deposits through the whole intestine. I saw a gentleman not long since who came to consult me about the trou- ble which he experienced from an opening that had been made in his right lumbar region for the relief of obstruction in the bowel. I found a con- siderable portion of the descending colon coming out of the wound.' He said that the operation had been done two years before, and that he had been said to have cancer. He said that he had never had any severe obstruction in the bowel, but that the surgeon thought that while his health was fair it Avas better to do the operation, so as to avoid difficulty that was sure to arise in the future. On carefully examining the patient's rectum, I found a very 126 INJURIES AND DISEASES OF THE- RECTUM. moderate syphilitic stricture, through which a bougie, as thick as my fore- finger, was easily passed. Hemorrhoids. External hemorrhoids may be divided into two varieties : the first includ- ing all hypertrophies or excrescences of skin around the anus ; the second, san- guineous venous tumors outside of the external sphincter. These are in fact either coagulations of blood in dilated veins, or coagulated extravasations into the connective tissue. The first variety of external hemorrhoids is often a sequel of the second, as, when a coagulum is absorbed, a small flap or tag of skin remains behind, marking its site and liable to give further trouble by accidentally becoming inflamed at a future period. Should this happen, the tag of skin becomes swollen, cedematous, and shiny, and exceedingly painful to the touch; sometimes it ulcerates, or suppuration may take place if the inflamma- tion runs high, and thus a small but painful little fistula may arise. At times the oedema is so considerable as to extend into the bowel, forming a large swollen ring of skin and everted mucous membrane all around the anus. With regard to the second variety, the sanguineous venous hemorrhoids, they are swollen, ovoid or globular, bluish tumors, very hard and exquisitely painful ; they can be pinched up between the finger and thumb from the tissues beneath, and they feel as if a foreign body were present there. Some- times, but rarely, they can by gentle pressure be emptied of their contents ; but this process is not followed by any beneflt to the patient, as in a few hours they become more painful and larger than before. By irritation they set up spasm of the sphincter and levatores ani muscles so that they are drawn up and pinched, thus adding much to the patient's suft'ering. Just as he is falling to sleep, a spasm takes place and wakes him up; in addition there is constant throbbing, and the sensation as if a foreign body were thrust into the anus ; this excites the desire every now and again to attempt to expel it by straining, which, if indulged in, of course aggravates the pain. Often the patient cannot sit down, save in a constrained attitude, nor can he walk; and when he coughs the succussion causes acute suft'ering. When the bowels act, and for some time afterwards, the distress is greatlj^ increased. Accompanying all this there are general feverishness, furred tongue, and usually constipation. Such then are the symptoms of an acute " attack" of external piles, and it must be remembered that one invasion predisposes to another. K"ow what are the causes of external hemorrhoids, remote and exciting? Amongst the former must be included, obstructions of the liver or portal system, fecal accumulations, and anything rendering the return of blood from the rectum diflBcult, Therefore, whatever induces constipation of a chronic type, may also be regarded as a predisposing cause of external hemorrhoids. Too good living — especially the consumption of large qijantities of meat — free indulgence in alcoholic drinks, excessive smoking, sedentary occupations, etc., are such causes. Among the exciting causes, exposure to wet or cold, friction from clothing, and the use of printed paper as a detergent (especially the cheap papers from which the ink comes oft" on the slightest friction), the neglect of proper ablutions, and straining, however induced, are in my experience the most common. Not unfrequently a little unusual eating and drinking, with- out any absolute excess, is the exciting cause ; an indulgence in effervescing wines or full-bodied ports or new spirits, being especially dangerous. The earliest symptom is a sensation of fulness or plugging up, and of slight pulsa- tion in the anus ; there is also a tendency to constipation, inducing a little HEMORRHOIDS. 127 straining ; this is frequently followed by itching of a very annoying character, coming on when the patient gets warm in bed, keeping him awake for some time, and inducing him to scratch the part. In the morning he finds his anus a little swollen and tender, and if he be an observant person with regard to himself, he will notice after a motion a slight stain of blood. The treatment in such a case should be abstinence from active exercise, with rather spare diet, embracing well-cooked vegetables and fish, but not much meat, and no beer or spirits ; even wine is not desirable. If a smoker, the patient must cut down his usual allowance ; smoking often causes a sympa- thetic irritation of the throat and rectum. He may take a'warm or a Turkish bath, and should wash the anus night and morning with warm water and Castile soap, after this applying some glj'cerine and tannic acid, or some calo- mel ointriient, or a lotion composed of one teaspoonful of the liq. plumbi diacetatis added to a wineglassful of fresh milk, which is very soothing. As to medicines, he may take a Plummer's pill, with a little taraxacum and belladonna, for two or three nights at bed-time ; and in the morning, fasting, some efl:ervescing citrate of magnesium, phosphate of sodium or sulphate of potassium and sodium, or this draught, which I have found very useful on many occasions : R. — Liq. magnes. carb. f^ss ; potassii bicarb. 9j ; syr. seu tinct. sennse fjij ; spt. sether. nit. f3ss; aquas purse ad f^ij. One third of a tumbler-full of Friedrichshall water, taken fasting with twice as much warm water, or Carlsbad salts, will also have a good effect. If the case be neglected, and advice be not sought until active inflammation has set in, and the symptoms I have described are in full force, the surgeon will save his patient much time, pain, and after-trouble, by snipping ofl:" the inflamed cutaneous excrescences, or, in the case of the sanguineous tumors, by laying them freely open by transfixion with a bistoury, and turning out the clot. The incision should be made in the direction of the radiating folds of the anus. A little absorbent cotton-wool should be laid into the wound, which will readily heal. It is always well in these cases to ascertain, by means of an injection, whether there be any internal piles associated with the external ; if so, they must be attended to, or the patient will probably be made worse by any operation on the external hemorrhoids. If the patient will not submit to operative treatment, the swollen parts should be well smeared with extract of belladonna and glycerine in equal parts, and a warm poultice applied. Sometimes cold is found by the patient to be more soothing ; ice should then be constantly applied, or, if this be unattainable, Goulard water with extract of belladonna. I have never seen much benefit derived from leeching, and often much ill. After having experienced one attack of hemorrhoids, a patient should guard himself against a repetition by simple living, plenty of exercise, abstin- ence from stimulants and excessive smoking, great cleanliness of the anus, and absolute regularity of the bowels. If medicinal aid be required to insure this, he will find equal parts of the confections of black pepper, sulphur, and senna, a capital remedy ; or the German licorice-powder, one teaspoonful of which, two or three times a week at bed-time, generally suf- fices to keep the bowels acting daily ; lastly, the mineral waters, such as Friedrichshall, Pullna, or Hunyadi-Janos, are often of great use. A steady perseverance in the line of treatment which I have suggested will in all pro- bability eradicate the hemorrhoidal tendency. A favorite prescription of mine to stave off attacks is the following : E,. — Magnes. sulph. Jss ; acid, nitric, dil. "l x ; succi taraxaci f3j ; infus. calumbse f gj. This should be taken twice in the day. This medicine acts gently on the liver and bowels, and at the same time is a tonic. After taking it for a week, the patient generally feels wonderfully better. His 128 INJURIES AND DISEASES OF THE RECTUM. appetite is good, his bowels are regular, and he is capable of bearing fatigue and enjoying exercise. Internal Hemorrhoids. — Although during pregnancy external venous hemorrhoids are frequent, and usually pass away after labor, the reverse is the case with regard to internal hemorrhoids ; these most frequently make their appearance after parturition, when all the parts are relaxed and uterine involution is going on. I will not attempt to give any reason for this pecu- liarity ; I only state a fact which I have repeatedly observed. As regards the other causes of internal hemorrhoids, they are practically those, which also produce external hemorrhoids. In addition, hereditary influence, and diseases of the genito-urinary system, must be included. I do not share M. Verneuil's view that the boutonnilres musculaires, de- scribed in the section on anatomy, play an important part in the etiology ^of the disease which we are now considering, mainly on two grounds: first, because the presence of arteries in hemorrhoidal growths is not thus accounted for ; and secondly, because it seems to me that the contraction of the circular and longitudinal muscular fibres of the bowel favors, and does not retard, the upward flow of the blood ; the button-hole apertures through the muscular walls of the rectum really play the part of valves to support the column of blood going to the liver, and in place of causing stasis pre- vent it, by opposing regurgitation in congested states of that organ. As regards the structure and appearance of internal hemorrhoids, three broadly-marked kinds may be observed : viz., the capillary hemorrhoid, the arterial hemorrhoid, and the venous hemorrhoid ; at times all perfectly dis- tinct, at other times united in the same patient. Hemorrhoids of the first variety I should describe as small, florid, raspberry- like looking tumors, having a granular, spongy surface, and bleeding on the slightest touch ; these piles are often situated rather high in the bowel. Al- though so small, the quantity of blood lost from them may be very consider- able. In structure they consist almost entirely of hypertrophic capillary vessels and spongy connective tissue, and therefore I think a good name for them is the capillary hemorrhoid. They resemble arterial nsevi very closely indeed in their microscopic structure, except that they are covered externally by a very much thinner membrane, and consequently are readily made to bleed. Ultimately, the main vessels feeding the growth increase in diameter, and the areolar tissue becomes thickened and more abundant. An exudation of lymph obliterates the capillaries, and so arrests bleeding from the surface. These changes I believe to be the result of slow processes of inflammation. In this way most commonly hemorrhoids of the second variety, arterial in- ternal hemorrhoids, are formed. They may be thus distinguished:. The tumors vary in size, attain sometimes very considerable dimensions, glisten on their surface, are slippery to the touch, hard, and vascular, and if scratched bleed freely, the blood being bright-red and issuing by jets. If the finger is passed into the bowel it will feel entering into the upper part of each hemor- rhoid an artery, pulsating with as much force as the radial, and in many cases of a calibre but little less. On dissecting one of these tumors, it will be found to consist of numerous arteries and veins, freely anastomosing, tor- tuous, and sometimes dilated into branches, and of a stroma of cell-growth and connective-tissue, the latter most abounding. The third variety is the venous internal hemorrhoid, and in this the venous system predominates. The tumors are often very large. I have seen them quite the size of a hen's egg. They are bluish or livid in color, and they are hardish; the surface maybe smooth and shiny, or pseudo-cutaneous; they prolapse very readily, and are often constantly down ; they do not usually HEMORRHOIDS. 129 bleed much, but, if pricked, the contained blood may be either venous or arterial. This form is commonly found in women who have borne children, and who have . enlargement or retroversion of the uterus; they often occur about the period of change of life. This form may be called the " passive" kind, and is frequent among spirit drinkers. I never hesitate to operate on these cases, but I observe certain precautions before doing so; if the liver is in fault, I prescribe careful living and a course of Carlsbad waters, together with shampooing and the cold douche. In women, any uterine complication should be attended to. In men, after the operation, extreme moderation of living should be enforced, the bowels should be kept acting regularly, daily, and stimulants should be interdicted. Some- times venous hemorrhage occurs a week or ten days after the operation, from the surface of the unhealed wounds ; if it be not extensive, it should not be interfered with. ■ The ordinary symptoms of internal hemorrhoids are bleeding at stool, which may continue for some little time afterwards ; constipation ; a feeling of discomfort and heaviness about the anus and lower part of the rectum ; and, lastly, protrusion of the hemorrhoids through the anus. The bleeding is usually the first symptom which attracts the patient's attention to the fact that there is something wrong with his rectum, and its amount and character vary considerably. At first usually slight, it may soon become so severe as to blanch the patic^nt, causing one to hesitate about operating, and making it desirable, if possible, to improve the patient's condition by the enforcement of rest, and by the use of tonics and astringent injections, iron and ergotine being especially useful. Should, however, the hemorrhage not cease very soon, the only thing to do is to operate at once, being most careful while operating to avoid any needless loss of blood. In these cases of great blanching the blood is quite watery, will not clot, and runs out freely from the slightest prick ; the operation must therefore be executed very rapidly. I often ligate four hemorrhoids in less than one minute ; and in such severe cases the ligature is, in my opinion, the only method that can be safely adopted. Some few months back I was present when, in one of these formidable cases, an operator, contrary to my advice, attempted to remove the piles by the clamp and, cautery. The result was that the patient nearly lost his life. I was able to temporarily stop the bleeding by pressure on the abdominal aorta, while ligatures were put on around all the diseased mass ; a moderate estimate of the amount of blood lost was three quarts. The character of the bleeding may be arterial, venous, or mixed. The older the hemorrhoids, as a rule, the more venous is the hemorrhage, but, on the other hand, when they have reached a very advanced stage hemorrhoids frequently do not bleed at all, but exude a sero-mucous fluid. Even from the first, a patient with internal hemorrhoids may never have lost a drop of blood, or, what is more probable, may not be conscious of ever having done so. The feeling of discomfort and heaviness in the rectum hardly ever amounts to pain. If there is pain, there is probably inflammation or an ulcer. "When the hemorrhoids come down, and are compressed by the sphincters, there will of course be pain, which is relieved by the patient's returning them into the bowel. This protrusion is what annoys the patient most, and urges him to undergo an operation. At first the piles come down during stool, but return spontaneously ; afterwards, the patient has to return them by pressure ; and lastly, although returned, they will not remain in place if the least exertion be made. Constipation, which usually precedes the advent of hemorrhoids, is nearly always rendered much more obstinate through the mechanical obstruction which they afford to the free evacuation of the bowels ; yet patients will tell VOL. VI. — 9 130 ' INJURIES AND DISEASES OF THE RECTUM. the surgeon that they go regularly to stool every morning, and only on cross- questioning them will he elicit the fact that, although the bowels may diur- nally respond to the call of nature, their action still leaves much to be desired, and at the best is very protracted and attended with violent straining and loss of blood. A useful question to ask these patients is, " You go to stool every morning, you say ; how long do you.remain there ?" In old-standing cases with protrusion, there is frequently a difficulty in retaining wind or loose motions; this is partly due to relaxation and weak- ness of the sphincter, partly to the loss of acute sensitiveness of the mucous membrane at the lower part of the rectum. This sensibility in the healthy subject gives timely warning to the sphincter ani to contract, when necessary. Before describing the modes of operating which I employ, I may say a few words as to the cases which in my opinion are not well suited for operative interference. The older I get the more convinced do I become that the only really reliable way of treating hemorrhoids is to remove them ; the only exception I would make, and that is a very partial one, is in those cases in which, together with hemorrhoids, there is found an ante-flexed or retro- flexed uterus. Here, I would say, the uterine displacement should be first corrected, and then the surgeon should use his judgment, being of course influenced by the urgency of the case and other considerations, as to whether he will operate or not. Even if the wounds heal satisfactorily, the distressing symptoms, bearing down, etc., may continue as before the removal of the piles. So, too, when there are vesical complications, the wounds heal slowly, and with a tendency to ulceration ; and when they have at last healed, the patient, as far as his symptoms are concerned, is not much, if at all, improved. A question often put by the patient to his surgeon is, "If I have my hemorrhoids removed now, will they return ?" This query is, in my opinion, best answered in the following way : " If after the operation you will follow the few simple rules of life which I shall give you, you may rely upon it that there will be no return of your hemorrhoids ; but if you give full play to the causes which produced them before, there may be such a return." But I am bound to say that, in my own practice, the cases in which I have operated a second • time for hemorrhoids have been so few that I could count them on my fingers. As the result of my experience I may safely say that the tendency to the fresh formation of hemorrhoids has been greatly overrated, and that if patients, after operation, will but attend to their bowels and live simply and rationally, with due regard to the necessity of taking exercise regularly, they need never fear a return of their old trouble. An exception may be made with regard to patients living in tropical climates. Unless great abstinence from alcohol be observed, piles will return. And now as regards the operation : The night before, and in some cases in which the liver is congested, for two or three nights before, I order a couple of pills, six grains of the pill of colocynth and hyoscyamus, and two of blue pill, to be taken ; and the next morning, an hour before the opei-ation, a copious soap-and-water enema should be administered, to make sure that the bowels are empty. I prefer operating early in the morning, as then the patient has the whole day before him in which to shake off the unpleasant effects of the ether and get rid of all pain, and as a consequence a quiet night will be insured, and refreshing sleep. The different modes of operating are briefly the following : I shall describe only those fully which I myself employ or think well of: — 1. Excision with knife or scissors. HEMORRHOIDS. 131 2. Mr. Whitehead's method of excision, combined with torsion and bring- ino" together the divided mucous surfaces. 3. Removal with the ecraseur of Chassaignac or the wire of Maisonueuve. 4. The application of various acids and caustic pastes. 5. The injection of carbolic acid or other caustic or astringent fluids into the body of the pile. 6. Punctuate cauterization of Demarquay, Reeves, and others. 7. Linear cauterization of Voillemier. 8. Removal by the galvanic-cautery wire. 9. Removal by the clamp and scissors, applying the actual cautery to arrest hemorrhage. 10. Dilatation of the sphincter muscles. 11. Ligature. 12. Removal by means of the screw-crusher. Excision is an operation which was much practised in the early part of this century. In cases in which the hemorrhoids are not very large or very numerous, it is in my opinion one of our best modes of procedure, as it is followed by very slight pain only, and rapid recovery ensues. I have had cases in which the wounds were soundly healed on the sixth day. In performing, excision I first gently but fully dilate the sphincter muscles, and employ a retractor to keep the anus well open ; I then seize the bowel deeply, above the pile, and cut the latter o3 at its base, not letting the bowel escape from the volsella until all bleeding has been arrested by torsion of the -arteries. Rarely more than two vessels spirt and require twisting. I wait for ■a little while to see that all hemorrhage has ceased, and then I treat the other piles in a similar manner. After all the arteries have ceased to bleed, I place a piece of cotton-wool, previously saturated in a solution of tannin and water (strength, one ounce of tannin to one ounce of water), within the anus as high as the scissors have cut. In no case has any recurrent hemorrhage taken place. This operation must be done slowly and carefully, and therefore occupies far more time than either ligature or crushing, which is a decided ■drawback to its employment, as I hold that prolonged anaesthesia is if pos- sible always to be avoided. About five years ago, Mr. Walter Whitehead, of Manchester, introduced a modification of this old method of excision, which he believes to be more in harmony with the principles of modern surgery. I will give his own description : — - After it had been decided to excise the hemorrhoids, a day in the following week ■was fixed for the operation, and in the mean time the patient was very carefully pre- pared by diet, aperients, and rest. The operation was conducted under chloroform, with the patient in the lithotomy position. As a preliminary measure, the function of the sphincter was suspended by forcible dilatation. Two thumbs were introduced into the rectum, and the circumference steadily kneaded in every direction until all resist- ance was overcome, and the sphincter rendered absolutely passive. The patulous con- dition of the rectum thus obtained, enabled the whole mass of piles to be extruded from the anus by introducing two fingers into the vagina and depressing the recto-vaginal wall. The hemorrhoids in size and appearance resembled an average ripe tomato, and ■were mapped on the surface into four irregular and unequal lobes. The lobes were next divided into four segments by longitudinal sections in the axis of the bowel and in the furrows marking the intervals between the several lobes. This was accomplished without the loss of any blood. Each portion was then secured in succession by Lund's ring forceps, and dissected with scissors; first transversely from the anal margin, and then upwards in the cellular plane to the highest limit of the he- morrhoidal growth, in this case about an inch and a half. Each segment was thus con- verted into a quadrilateral, wedge-shaped mass, the base below consisting of the hemorrhoid, and the apex above of the healthy mucous membrane of the bowel. 132 INJURIES AND DISEASES OF THE RECTUM. The mucous membrane at tlie highest point was next transversely divided, leaving the hemorrhoid simply attached by loose cellular tissue and by the vessels, proceeding from above and supplying the mass below. The forceps containing the hemorrhoid were then twisted until all connection was severed and the hemorrhoid removed. The divided surface of the mucous membrane was next drawn down, and attached by several fine silk sutures to the denuded border at the verge of the anus. The other portions having been treated in the same manner, the operation was com- pleted. The sections throughout were made by scissors. The loss of blood during the operation did not exceed a couple of ounces. The patient made a complete recovery, and regained the full capacity to discharge her domestic duties and social engagements. This operation Mr. Whitehead seems to have since modified, and he now outs out a ring of the howel commencing at the junction of the skin and mu- cous membrane ; he dissects the piles upward, and then by a circular incision removes the mass (and a portion of the bowel also, I suppose) ; the cut edges are then brought together. Primary union, Mr. Whitehead says, always takes place, and the patient gets speedily well ; he avers that in a large number of cases (200 and upwards), no contretemps has taken place, and by implication no death. Moreover, stricture has never resulted, nor ulceration. I fancy that in small excisions of the bowel for malignant disease, when the mucous membrane and skin have been brought together, such satisfactory results have not been obtained. The method of Mr. Whitehead deserves a full and fair trial, and it shall haye it at my hands very shortly; one objection I feel called upon to make, viz., that in inexpert hands much time must be occupied, and considerable loss of blood must take place. I atn quite sure that the frequent failures which are said to take place in other operations for piles, are the result of the very perfunctory and imperfect way in which they are conducted. I have constantly coming to me patients who have only been free from the surgeon for six months, and in whom the piles have returned ; this is clearly because real removal has never been per- formed ; a slight clamping, a little burning, removing only the mucous surface of the hemorrhoid, is all that has been done ; hemorrhage is only for a time arrested, and the disease continues to advance, having indeed been only very temporarily checked by the means used. The next seven in the list of operations which I have given, I will pass over, because they have little to recommend them ; when they are not uncer- tain methods they are dangerous, and occasionally they combine both danger and uncertainty' of result. Take, for instance, the " clamp and cautery" method. Mr. Henry Smith, who advocates this plan, lost four cases in 530 operations. Out of 195 patients Jig. 1194. Clamp for hemorrhoids. with whom I followed his recommendation, 2 died in consequence of the operation. On the other hand, in 1800 cases of ligation I have had but one HEMORRHOIDS. 133 doubtful death. In this case the patient, who was old and very bronchitic, succumbed in 36 hours after the application of the ligature, from acute pneu- monia. The " post hoc" here should not I think be considered the " propter hoc," but I record the case. In over 500 cases treated by crushing, I have not had one death from any cause whatever. I will pass on to dilatation of the anal sphincters, so strongly advocated by Messrs. Verneuil, Fontan, Panas, Gosselin, and Monod. The method is as follows: The patient being fully under the influence of an ansesthetic, the surgeon inserts both thumbs into the rectum and dilates gradually, first in the antero-posterior and afterwards in the opposite direction, using an amount of force sufficient to overcome spasm. He continues to manipulate the sphinc- ters until the muscles feel reduced to a thoroughly pulpy condition, so that he can easily insert his whole hand and even draw it out as a fist. The result is that paralysis of the sphincters is fully induced, and this condition will last certainly for four or five days, and possibly for even more. The patient jnust be kept recumbent for about a week. In all my operations for internal hemorrhoids I invariably make dilatation a prelude to whatever else I do. This I do for two reasons: first, the, rectum is thus rendered so patent that all disease can be seen and dealt with by knife, scissors, or crusher, without making any undue traction on the part; second, all spasm is done away with, and the great element in all such operations, viz., pain, is reduced to the minimum. The removal of piles by the screw-crusher is in my judgment a very valu- able operation. Very safe as regards hemorrhage, and almost painless, the recovery is more rapid than is eflected by most other methods. Mr. George Pollock was, as far as I know, the first to describe and practise the operation by means of a powerful crushing apparatus, and his success was very great ; but when I came to try this plan, I found that the instrument he used, which was one designed by Mr. Benham, like a large pair of pincers, was very defective ; it was too large, heavy, and clumsy, and did not after all, in severe cases, make enough pressure to insure the thorough destruction of the base of the hemorrhoid. My son, Mr. Herbert W. Allingham, then ■designed for me an instrument on a totally different principle ; it was small, light, and easy of adaptation to the pile, and its power was enormous, being worked by direct screw action and not by lever movement, as in Mr. Benham's pincers. After many trials, Messrs. Krohne & Sesemann, of Lon- don, made me a perfect instrument, which I use with much satisfaction and great success. The crusher is made of solid steel, forming an open square at one end, between the sides of which a second piece of steel slides up and down. The bar is connected with a powerful screw, which drives it firmly home against the distal end of the square, first by a sliding, and lastly by a screwing motion, and thus exerts a great crushing power from which the hemorrhoid cannot escape. By removing a pin, the screw and piston can be easily taken out for the purpose of cleaning. (Fig. 1195.) To aid in the adjustment of the crusher, the hemorrhoid is seized with volsella forceps (Fig. 1196) and drawn through the open square of the instrument. Treatment of Internal Piles hy Ligature. — Although I now almost invari- ably employ the crushing operation, there are still some cases for which I «lect ligature: those, for instance, in which the hemorrhoids form a continuous ring with no division into lobes. In these cases the crushing operation has drawbacks. At the sides of the crusher, hemorrhage may occur from laceration of the adjacent portion of the hemorrhoid ; the part crushed is not likely to bleed more than any other crushed hemorrhoid, 134 INJURIES AND DISEASES OF THE RECTUM. Fig. 1195. KROHNEZ< SESEMANN LONOON . A Screw-crnshing instrnment for hemorrhoids. Fig. 1196. Forceps for grasping hemorrhoids. but the hemorrhage proceeds from parts wounded in the application of the crusher. In these cases I always adopt ligation as being the best and safest procedure. The method of operating is as follows : The patient must lie on his right side^ on a hard couch, with his knees drawn well up to his abdomen. When he is fully anaesthetized, I gently but completely dilate the sphincter muscles. I then seize the hemorrhoids one by one with a volsella, and with a pair of strong, sharp, spring-scissors (Fig. 1197) separate the pile from its connection Fig. 1197. Spring-scissors for hemorrhoids. •with the muscular and submucous tissues upon which it rests ; the cut is to be made in the sulcus or white line which is seen where the skin meets the mucous membrane, and this incision is to be carried up the bowel, and parallel to it, to such a distance that the pile is left connected by an isthmus of vessels and mucous membrane only. There is no danger in making this incision, because all the larger vessels come from above, running parallel with the bowel, just beneath the mucous membrane, and thus enter the upper part of the pile. A well-waxed, strong, thin, silk ligature is now to be placed at the bottom of the deep groove which has been made, and, an assistant then drawing out the pile with some decision, the ligature is tied high up at the neck of the tumor as- tightly as possible. Great care must be taken to tie both knots of the liga- ture, BO that no slipping or giving way can take place. I myself always tie a third knot ; the secret of the well-doing of the patient depends greatly upon this tying — a part of the operation by no means easy. HEMORRHOIDS. 135 If the pile be very large, a small portion may now be cut off, taking care to leave sufiicient stump beyond the ligature to guard against its slipping. When all the hemorrhoids are thus tied, they should be returned within the sphincter ; after this is done, any superabundant skin which remains may be cutoff; but this should not be too freely excised, for fear of contraction when the wounds heal. I always place a pad of wool over the anus, and a tight T bandage, as it relieves pain most materially arid prevents any tendency to straining. It is advisable to commence by operating upon those piles that are situated inferiorly, as the patient lies, in order that the others may not be obscured by blood, but when the hemorrhoids are numerous, and there are small piles, either anterior or dorsal, it is better to tie the small ones first, as otherwise they may be overlooked. After the operation, the bowels should be confined for three or even four days. I find a solid one-grain opium pill, given as soon as the vomiting after the ether has ceased, and repeated twice, at inter- vals of two hours, the best article to begin with; afterwards a draught containing laudanum may be substituted. The diet, until the bowels have acted, should be light — spoon-diet in fact. After the bowels have operated, a more liberal allowance of food should be made ; I usually begin with fish, followed by meat the next day. I always advise entire abstinence from wine, beer, or spirits, unless there is some special condition indicating the necessity for their use. On the third or fourth night after the operation I order a mild aperient, such as the German licorice-powder, followed the next morning by a hot Seidlitz draught. The first action of the bowels is gene- rally rather painful, and sometimes exceedingly so. A hot linseed poultice applied to the anus immediately after the stool, mitigates the pain and comforts the patient. The ligatures separate about the sixth or seventh day. I generally give a gentle pull at them daily, commencing the day after the bowels are first relieved ; by this plan the ligatures always separate on the fifth or sixth day. The patient should be kept lying down during this period ; in fact, the more he observes the recumbent position until his wounds have healed, the better. This usually occurs a fortnight after the operation ; in veiy severe cases it may of course be longer before the wounds cicatrize. The dressing which I employ is of the simplest : a small piece of cotton-wool saturated with oil, or smeared with zinc-ointment, suffices — but it should be introduced with the greatest care and gentleness through the anal orifice. On the night of the ope- ration, the patient may be unable to pass urine, owing to reflex spasm in his urethra ; the urine must then be drawn off with a soft catheter, or he will pass a restless night. During the second week after operation, I always make a point of introducing my finger, well anointed, into the patient's bowel, to make sure that there is no tendency to contraction. Should there be such ten- dency I daily introduce the finger, and, if need be, tell the nurse in charge of the patient to repeat the act at night. Such contraction is of no serious moment, as it only affects mucous membrane, and in any case would pass away in time. But it is as well avoided, as it alarms the patient, who may think that he has got a stricture in place of his piles. The most common com.plication of internal hemorrhoids is fissure or small painful ulcer; pain, continuing long after the bowel is relieved, is its most certain sign. Fistula is a less common accompaniment of piles. When examining a case of hemorrhoids, the surgeon should never omit to pass the finger well into the bowel, to ascertain that no stricture, ulceration, or malig- nant disease is present. Impaction or accumulation of feces in the rectum or colon, is another complication worthy of mention. Lastly, polypus is some- times found in conjunction with hemorrhoids. 136 INJURIES AND DISEASES OF THE RECTUM. The preliminary dilatation usually suffices to cure a fissure or painful ulcer It is rarely necessary to divide the muscular fibres at the time of an opera tion by ligature, since dilatation has come into use. A fistula must of cours be laid open. An accumulation or impaction of feces must be broken dowi and got rid of before the day of operation, as otherwise the wounds will no heal kindly. A few words must be said as regards the treatment of hemorrhage afte operations in internal hemorrhoids. Primary hemorrhage, if the operation be carefully done, -is very rare ; occa sionally, when large and very vascular. hemorrhoids are ligatured, and then is also much superabundant skin cut away, a small vessel will bleed whei the patient recovers from shock. This is a trivial matter, and a ligature ii easily applied. Secondary hemorrhage is of more serious import, and occuri generally in elderly people of broken-down constitutions, or in those whc have been very free livers. As far as my experience goes, this hemorrhag( is usually more venouS than arterial, and occurs at or about the time of th( separation of the ligatures. I have found it utterly futile in cases of secondary hemorrhage to try anc place a ligature around the vessels ; it is usually the large veins or venoui sinuses which are opened by sloughing or ulceration, and when the surgeoi introduces a speculum and tries to find the source of bleeding, he can onlj see that the whole rectum is filled with blood, and on passing his finger M'il feel a quantity of clots. The best mode of arresting this form of hemorrhag< is as follows : — Pass a strong silk ligature through and near the apex of a cone-shapec sponge, and bring it back again, so that the apex of the sponge is held in i loop of the silk. Then wet the sponge, squeeze it dry, and powder it well filling up the lacunae with powdered subsulphate of iron. Pass the fore finger of the left hand into the bowel, and upon that as a guide push up the sjjonge — apex first — by means of a metal rod, bougie, or penholder, if nothinj better can be got. This sponge should be carried up the bowel at leas"^ five inches, the double thread hanging outside of the anus. When it is s( placed, fill up the whole of the rectum below the sponge, thoroughly anc ' carefully, with cotton-wool well powdered with the iron. When the bowe is thus completely stopped, take hold of the silk ligature attached to th( sponge, and while with one hand the sponge is pulled down, with the othe; push the wool u-p. This joint action will spread out the bell-shaped spongi like opening an umbrella, and will bring the m'ooI compactly together. Thii plug may remain in from a week to a fortnight or more. A male cathete: passed through the centre of the sponge, with the wool packed around it, ii a great improvement, as it enables the patient to pass flatus. Petention o urine will occur after this packing, but ma}^ be relieved with a catheter Stimulants are best withheld until reaction has set. in. Opium shoulc always be freely exhibited after the introduction of the plug, as otherwisi straining will be set up. As soon as it can be taken, nourishment is to bi given, and Liebig's cold soup, which can be quickly prepared, I have founc a wonderful restorative. Hot liquids, I need scarcely say, are to be avoided As soon as a patient can take solid food, he should have it, but it should b nourishing and easy of digestion. The drugs which I prefer are the tinctur; ferri perehloridi and the liquor ferri peracetatis, as these are not only ha3mo statics but also blood-repairers. o PROCIDENTIA AND PROLAPSUS OF THE RECTUM. 137 Procidentia and Prolapsus of the Rectum. True procidentia is the descent of the upper part of the rectum, in its whole thickness, or all its coats, through the anus. True prolapsus is a descent of the lowest part of the rectum, the mucous membrane and submucous tissue being turned out of the anus. A third variety consists of an intussusception, the upper part of the rectum descending through the lower part. It is easily diagnosed from ordinary procidentia by there being a 'more or less deep sulcus around the inner column of the intestine ; so that there are, as it were, two cylinders of rectum, one inside of the other. The expression prolapsus ani is often loosely applied to protruding in- ternal hemorrhoids, thus giving rise to unnecessary confusion. Internal hemorrhoids come down as distinct and separate tumors, with a smooth and shiny surface, and are hard to the touch. True prolapsus has no folds, except one towards the perineum (which indeed may be absent), and feels to the finger soft and velvety. But the most common cause of prolapsus is un- doubtedly the presence of internal hemorrhoids. I have seen it also as the result of straining, in fissure, and in conditions of the urinary tract accom- panied by difficulty of micturition, such as urethral stricture, the presence of a stone in the bladder, enlarged prostate, cystitis, etc. In children, diarrhoea, often the result of strumous inflammation of the bowels, worms, and phimosis, are responsible for a great many cases. Polypus may be the cause of either prolapsus, procidentia, or intussusception. It must be well under- stood that, as procidentia is only a more advanced degree of prolapsus, all the causes above mentioned will, if they act long enough, produce it also. When procidentia occurs conjointly with internal hemorrhoids, removing them by either crushing or ligature will almost certainly cure it. ' Procidentia of the rectum is more often seen in children than in adults, although it is by no means a rare affection in women — particularly those who have borne many children — and in men advanced in years. Procidentia in children is much favored by the formation of the pelvis, the sacrum being nearly straight. Moreover, all infants strain violently when their bowels act, even when their motions are quite soft; there appears to be some phy- siological necessity for this, which I do not pretend to explain or understand. But these facts are not quite sufiicient to account for the proneness of children to this malady ; there must be, in addition, some inherent weakness or ex- traneous source of irritation present, by which excessive straining is produced. There are many cases, however, in which we can assign no special cause, where the child is not manifestly unhealthy, and where no source of irritation can be detected. I am sure that the very bad custom of placing a child upon the chamber-utensil, and leaving it there for an indefinite period, as practised by many mothers and nurses, is a fertile cause of procidentia. In children the treatment is generally successful: it should first be addressed to the removal of any source of irritation ; this accomplished, a cure is speedily effected. Where no source of irritation can be discovered, the general health must he attended to. The child should never be allov^ed to sit and strain at stool ; the motions should be passed lying upon the side, at the edge of the bed, or in a standing position, and one buttock should be drawn to one side, so as to tighten the anal orifice while the feces are passing ; this device I have found to be very useful. When the bowels have acted, the protruded part ought to be well washed with cold water, and afterwards a solution of alum and oak-bark, or infusion of matico, should be thoroughly applied with a sponge ; the bowel must then be returned by gentle pressure, and the child should remain recumbeftt for some little while, lying upon its face on a 138 INJURIES AND DISEASES OF THE KECTUM. couch, before running about. < If there be any intestinal irritation, I order small doses of mercury with chalk, and rhubarb, at bedtime, and steel wine two or three times in the day. When the child is very ill-nourished, cod- liver oil does much good; the diet should be nutritious and digestible. If these mild measures do not succeed, I find the application of strong nitric acid the best remedy. The child should be anaesthetized, and the protruded gut well dried. The acid must be applied all over it, care being taken not to touch the verge of the anus or the skin. The part is then to be oiled and returned, and the rectum thoroughly stuffed with wool ; a pad must after this be applied outside of the anus, and kept firmly in position by straps of plaster, the buttocks being by the same means brought closely together; if this precaution be not adopted, when the child recovers from the anses- thetic, the straining being urgent, the whole plug will be forced out and the bowel will again protrude. When the pad is properly applied, the straining soon ceases, and the child suffers little or no pain. I always order a mixture of aromatic confection, with a drop or two of tincture of opium, so as to con- fine the bowels for four days. I then remove the strapping, and give a tea- spoonful of castor oil. When the bowels act the plug comes away, and there is no descent of the rectum. In procidentia in the adult the mass is sometimes very large ; I have seen it in a woman larger in circumference than a foetal head, and seven or eight inches in length. I have had, in my own practice, many cases of procidentia in which there was a hernial sac in the protrusion, and in all it was situated anteriorly, as from the anatomy of the part, of course, it must be ; the intes- tine could be returned from the sac, and it went back with a gurgling noise. As soon as the bowel protrudes, a hernia can be recognized by the fact that the opening of the gut is turned towards the sacrum ; when the hernia is reduced, the orifice is immediately restored to its normal position in the axis of the bowel. I have never found such a hernial protrusion in a child. In very old and bad cases of procidentia, more or less incontinence of feces always exists, owing to loss of tone in the sphincters and loss of sensitiveness in the, altered mucous membrane. Thus when fecal matter reaches the lower part of the rectum, the sphincters are not stimulated to action, nor is the patient aware of its presence. The most satisfactoi'y operation for proci- dentia in the adult with which I am acquainted is that recommended by Van Buren, which I perform as follows : — The patient is etherized, and the procidentia is drawn fully out of the anus by the volsella; I then make four or more longitudinal stripes, from the base to the apex of the protruded intestine, with the iron cautery at a dull red heat. I take care not to make the cauterization as deep towards the apex as at the base, because near the apex the peritoneum may be close beneath the intestine, while a deep burn near the base is not dangerous. I take care to avoid the large veins which can be seen on the' surface of the bowel. If the procidentia is very large, I make even six stripes. I then oil and return the intestine within the anus ; having done this, I partially divide the sjihincters on both sides of the anus with a sawing motion of the hot iron, and then insert a small portion of oiled wool. From the day of operation I never let the patient get out of bed for anything ; the motions are all passed lying down, and consequently the part never comes outside. If the wounds have not all thoroughly healed in a month, I continue the recumbent position for two weeks more, by which time it veiy rarely happens that cicatrization is not complete. The patient can then arise and get about, but still for some time I enjoin that evacuation of the motions should be accomplished lying down. The reason for the success of the treatment is simple enough. When the burns are all healed, the bowel by contraction of the longitudinal stripes is drawn PRURITUS ANI. 139 upwards, and circumferential diminution also takes place. In these cases, before operation, the sphincter muscles have quite lost power, and the anus is large and patulous ; by sawing through the anus with the iron, the muscles contract and regain their power, the patient having strength to cause the anus to close at will, and even to some extent to squeeze the finger when introduced. Sometimes when a large portion of the bowel comes down, there is much difficulty experienced in returning it. I have found that the passing up the bowel of a large flexible bougie, so as to carry before it the upper part of the descended gut, is of great service ; gentle taxis should at the same time b& practised. A tiresome diarrhoea is very commonly present, and there is often a dis- charge of mucus which keeps the linen damp and adds not a little to the general discomfort. One teaspoonful of powdered acorns in a tumblerful of milk, every morning, answers better than anything else that I know of, as a remedy for this. The frequent and bountiful application of cold water in these cases is to be most strongly recommended, as it fulfils the same purpose as astringent lotions, and quite as efliectually. Pruritus Ani. Pruritus ani, or painful itching of the anus, is frequently induced by habits; of too free eating and drinking ; it occurs thus in subjects of the lithic-acid diathesis. I am bound to say, however, that there are exceptious to this rule, as I have seen a most ascetic clergyman suflt'er dreadfully,' as well as a lady who had been all her life a total abstainer, and a remarkalily small eater. Hepatic afifeetions with constipation, disorders of the stomach, and uterine diseases, are prolific causes of pruritus ani; and gout, especially latent gout with its accompanying eczema, is responsible for a great deal of sufferings from this troublesome atFection. Amongst local causes, the presence of in- ternal hemori'hoids, vegetable parasites, pediculi, and ascarides, are the most frequent. Doubtless there are many cases of pruritus for which we are unable to assign any cause, and it may then be considered as a pure neurosis. On examining the part, a distinctly eczematous rash is often seen, which is moist from exudation ; or the anus may be dry and rugose, with bright redness consequent upon scratching ; occasionally there are numerous minute scales to be seen, forming irregular rings ; often there are cracks radiating from the anus and even extending up to the sacrum ; but what I consider the characteristic condition — which may always be noticed when the disease is severe and has lasted for any length of time — is the loss of the natural pig- ment of the part. To such an extent does this loss often occur, that patches around the anus, extending backwards as far as the sacrum and forwards to the scrotum, are of a dull-white, parchment-like character, and have lost all the normal elasticity of healthy skin. When considering a, case as to the question of treatment, it is always important to discover the cause of the irritation. I once had a patient who invariably got an attack of pruritus from eating lobster or crab, and another in whom salmon produced the same effect. There is but little doubt that excesses at table, combined with a want of active exercise, form not only a predisposing but also an exciting cause. Excessive smoking is another excitant of the disorder. When a tendency to the malady exists, over indul- gence in smoking may be immediately followed by an attack of pruritus. The surgeon should investigate closely the habits of his patient, and 140 INJURIES AND DISEASES OF THE RECTUM. should recommend a plain, sometimes even a low diet. He should interdict both beer and spirits, and should restrict the drinking to a little light sherry, or to claret and Vichy or Seltzer water. Coffee should be given up, and weak tea substituted. A walk of three or four miles, at such speed as to induce slight perspiration, should be taken daily, and every morning a sponge-bath is strongly advisable, with, once a week, a warm or, better still, a Turkish bath. The anus and parts around it should be washed every night when retiring to bed with warm water and tar or Castile soap. The bowels must be well opened daily ; the following prescription will be found beneficial : sulphate of magnesium, 9j ; powdered carbonate of magne- sium, gr. V ; wine of eolchicum, ni v ; syrup of senna, f5j ; compound tincture of cardamom, f3ss ; infusion of cinchona, fij, twice or thrice in the day ; and I also often order two grains of Plummer's pill with three grains of compound rhubarb pill, to be taken every other night for a week. I likewise frequently prescribe the mineral waters of Carlsbad, Friederichshall, Vichy, Hunyadi- Janos, etc. After washing the parts at night, let the patient apply this lotion on a piece of lint fixed with a T bandage : Sodse biboratis 5ij ; morphise hydrochlor. gr. xVj ; acidi hydrocyan. dil. fgss. The lint may be kept moist with this lotion by dabbing it through the bandage. Calomel ointment and chloroform locally (chloroform, f 3ij, glycerinse fiss, ung. sambuei §iss), sulphide of calcium inter- nally and externally, liquor carbonis detergens when there is much eczema, and carbolic glycerole, are all admirable remedies, and may well be tried in obstinate cases. When the surgeon has made up his mind that the disease is a nervous one, as I think it often is in spare and delicate, excitable people, he should give arsenic and quinine freely, and be prepared to push them to their physiolo- gical effect, at the same time of course using local means to allay irritation. In obstinate, old-standing cases, I usually commence treatment by rubbing the parts thoroughly with a solution of nitrate of silver, 9ij to f§j ; this softens the skin, and induces a more healthy action and secretion. The dis- order is much more common among men than among women ; it is not often met with in young persons. When an attack of pruritus comes on after mental overwork, bromide of potassium is very advantageous. Opium given internally increases the disorder. I have for' years past recommended the introduction into the anus, at bed- time, of a bone plug, shaped like the nipple of an infant's feeding-bottle, with a circular shield to prevent it from slipping into the bowel ; the nipple should be about an inch and a half in length, and as thick as the end of the fore- finger. I presume that it does good by exercising pressure upon the venous plexus and nerve-filaments close to the anus. At any rate, it stops the itch- ing and insures a good night's rest. I advise it to be worn every other night. Pruritus caused by a vegetable parasite is readily cured by a lotion of sul- phurous acid, one part in six. Polypus of the Rectum. By the word " polypus" I mean a pedunculated growth attached to the mucous membrane of th3 rectum, and genei-ally situated not less than an inch from the anus. Polypi may be attached two inches up the bowel, but only occasionally more than that distance. Polypi have been usually described as, of two kinds: the soft or follicular, and the hard or fibrous, the former being found in children and the latter in POLYPUS OF THE KECTCM. 141 grown-up persons. I am of opinion, however, that the soft polypus is not always the one found in young children, and consider the true fibrous variety rare even in the adult. In fact, this rough division is very far from express- ing the pathological truth, for the true fibrous polypus is in its anatomy an almost perfect counterpart of the fibroid tumor of the uterus, that is, a myoma. The few which I have myself seen have been nearly as large as wal- nuts ; they creak when cut, and the incised surface is of a pale color. The peduncle is about an inch and a half long, and is always attached- above the sphincters ; the tumoi's do not usually appear outside of the anus ; they do not bleed, but when they protrude they cause pain, irritation, and spasm, and often set up ulceration of the bowel. The discharge from them is of a very ichorous and ill-smelling character. The polypi usually found in the adult are smaller than the mucous polypi of children ; they are multiple. I have often found two growing from opposite sides of the rectum ; there may also be two stems with only one head. The pedicle may be an inch or a little more in length, and is not uncom- monly hollow ; the polypi are neither very hard nor soft, and are easily com- pressible; they are sometimes cystic; a large vessel runs up the stem, and in some cases can be felt to pulsate. In women rectal polypi are almost always soft, with remarkably long and rather slender stems. The polypi of children are small, vascular tumors, with peduncles often two inches long. They resemble small, half-ripe mulberries more than any- thing else. They bleed very freely at times, and occasion in the young great debility. They are said to be hypertrophies either of the glands of Lieber- kiihn, or of the mucous follicles of the rectum. They may be dangerous when high up, by occasioning intussusception of the bowel, with total obstruction and death. When the peduncle is more than an inch in length they usually protrude at stool, and require to be returned after the bowels are relieved. The general symptoms in children are: frequent desire to go to stool, accompanied by tenesmus ; occasional bleeding, with dischai'ge of mucus; and the protrusion from or appearance at the anus of a fleshy mass when the bowels are acting. In the adult, the history of polypus is curious. Without any previous discomfort of any kind, the patient suddenly finds a substance protruding from the anus after going to the closet. This is characteristic of the malady. Until the peduncle becomes long enough to allow the polypus to be extruded and grasi:)ed by the sphincter, no inconvenience is felt, and therefore the patient speaks of a sudden onset ; this is quite difiierent from the history of hemorrhoids. In examining a patient, an injection should be administered before intro- ducing the finger ; even if the polypus slips aAvay, the surgeon will always be able to feel the pedicle at its point of attachment. The only treatment to b6 recommended is the removal of the growth. This is best done by seizing the peduncle close to its base with the German catch-forceps, and gently twisting the polypus around until it comes away. There is no danger of hemorrhage, no pain, and scarcely any necessity for resting more than one day. If a ligature is used, the patient should rest until it separates, as otherwise abscesses may follow. The rarer kinds of polypi are the dermoid, the cystic, the sarcomatous, and the disseminated ; the latter are adenoid as a rule, and the mucous membrane of the rectum and of the colon may be closely studded with them. Another very rare tumor of the rectum is the villous. This consists of a lobulated, spongy mass, with long villus-like processes studding its surface ; it resembles exactty, though its villi are much larger, the growth of the same name found in the bladder. Usually it has a stem, broad rather than round, which I think is an 142 INJURIES AND DISEASES OF THE EECTUM. ■elongation of the mucous membrane rather than a new formation. These tumors may become malignant. I have seen two cases in which epithelioma replaced the villous growth. Impaction op Feces. By this expression is meant an accumulation in the pouch of the rectum, immediately above the internal sphincter. It occurs in females more com- monly than in males ; old women, and women shortly after their confine- ments, being especially liable t6 it. I have seen it in children, and call to mind a little boy, only three years of age, who had a veritable imjDaetion which gave a good deal of trouble ; but when it was removed the bowel re- gained its tone quickly, and regular action was afterwards easily kept up. The cause of the accumulation I believe to be nearl}' always, .primarily, a loss of power in the muscular coat of the rectum. Constipation is its inva- riable forerunner, and this may be due to spasm of the sphincter. In impac- tion, sphincter-spasm always exists, so that when the patient strains the anus protrudes like a nipple. The symptoms of impaction may be obscure, and I have known it mistaken for neuralgia of the rectum, gout of the rectum, and malignant disease of the t38ecum or sigmoid flexure. I once attended a gentleman w^ho had been be- lieved by his physician to have incipient disease of the brain, so much nervousness and hypochondriasis resulted from a very loaded colon and impacted rectum. In another case, phthisis had been diagnosed by several medical men on account of a constant cough, with hectic at night, and much emaciation. But the most common error is the mistaking of impaction for diarrhoea with tenesmus. In many of these cases the patient complains of a tendency to diarrhoea, liquid motions being frequently passed, especially after taking an aperient, but without any sense of relief; and on assuming the erect position, straining — severe, continuous, and irresistible — takes place. On lying down this generally passes away. In the history of these cases it is not rare to find that severe p^ins have been experienced in the right lumbar and left inguinal regions ; this symptom points to the fact that the csecum has been the seat of obstruction and dis- tension, and that when this has been removed, the feces have again lodged in the rectal pouch. Dyspepsia, irritability of temper, nervousness, and despon- dency — the patient supposing herself to be suffering from an incurable malady — a very muddy, yellow, skin suggestive of malignant disease, morning vomit- ing, loathing of all food, and excessive thirst, are among the common symptoms ■of this disorder. A peculiar, ringing cough, particularly in women, and also xiight-sweats, are not uncommon. In both men and women obstinate reten- tion of urine may be caused by impaction. When examining a patient, tumors may be felt in the caecum, the transverse colon, or the sigmoid flexui-e. The anus will be found nipple-shaped, and the sphincter muscle as hard as a piece of wood. On introducing the finger into the bowel (no easy matter), a ball of hardened, clayey feces will be found filling up the rectal pouch. This ball I have seen as large as a foetal head, and quite movable, so as to admit of liquid or thin fecal matter passing around by its sides, thus giving rise to the impression that diarrhoea rather than constipation existed. So deceptive is the feeling which this mass gives to the fingers, that I have more than once thought that I must be touching a tumor. In bad cases the sphincters must be dilated under an anaesthetic, and then the mass broken up with the finger or a lithotomy scoop, or the handle of a silver spoon. After having thoroughly disintegrated the impacted mass, NEURALGIA 01' THE RECTUM — IRRITABLE RECTUM. 143 injections of soap-suds and oil may be administered to get rid of the enor- mous quantities of feces that will come .down from the colon. It often takes time before the rectum can recover its power after its great distension, and therefore reaccumulation must be guarded against by injecting cold water, kneading the abdomen, and giving nux vomica with decoction of aloes. Exercise in the open air should be taken daily, and the diet should be moderate and simple. In the diagnosis between impaction and malignant disease, two points are of extreme importance. The first is, that in impaction the tumor differs in size and shape from time to time. The second, that the tumor in impaction has a decidedly doughy feel, and is irregularly soft. When the tumor is in the rectum, the introduction of the finger will at once clear up the doubt, if there be any. Concretions in the bowel ai'e rarer than impactions. They are usually formed around some foreign body. I have seen a quantity of human hair form the core of a concretion, the patient having swallowed the hair in a fit of mania. Biliary calculi are often found in the centre of these concretions. The strangest case that I have ever seen was one in which a sovereign, swal- lowed fifteen months before I removed the- concretion, was found to be its nucleus. It is curious that large bodies, such as a set of false teeth with gold mounting, may not be arrested anywhere in the intestines, while a small body, such as a sovereign or a date-stone, may fail to traverse the alimentary canal safely, and may indeed set up ulceration of the bowel and perforation. ITeuralgia of the Rectum. A pain in the rectum or sphincter muscles may be called neuralgia, when not the slightest lesion, sign of inflammation, or dischai'ge of any kind can be discovered, and when the pain is not aggravated by action of the bowels. This last is a most important point in diagnosis. I have more than once considered pains to be neuralgic which I afterwards discovered to originate from a structural lesion. Patients with rectal neuralgia are mostly delicate, irritable or nervous people, who have been subjected to neuralgic pains in other parts. I have noticed the attack to follow direct exposure to wet and cold, by sitting upon damp grass. One attack predisposes to another. Usually in these cases there is general debility with disorder of the digestive organs, mainly the liver. In treatment, the abdominal viscera must be first unloaded and put into condition, and then quinine, iron, strychnia, and hypodermic injections of morphia may at once cure the patient. In some instances, however, treat- ment only does temporary good, and nothing appears to be of permanent use. When the sphincter is the seat of pain, there is always spasmodic contrac- tion. Dilatation of the anus answers best here, followed 'by an injection of morphia. Irritable Rectum. This I believe io be really the result of a chronic inflammation of the mucous membrane, as it is accompanied by much heat in the bowel, and by tenesmus, as well as by a discharge of mucus. These cases are best treated by the administration of gentle laxatives and of alkalies with bitter infusions, and by insufflation of bismuth and charcoal into the rectum. When the irritability is allayed, injections of rhatany and starch, with small doses of the liquid extract of opium, will render the cure-permanent. 144 INJURIES AND DISEASES OF THE RECTUM. [Inflammation of the Rectal Pouches. Under the names of Encysted Rectum (Physick) and Sacciform Disease oj ike Anus (Gross), has been described an inflamed or ulcerated state of the rectal pouches or lacunse, which sometimes, particularly in old persons, become enlarged, and serve as receptacles for fecal matter. The symptoms of this afi'ection are intense itching and often severe pain, but without spasm of the sphincter. The diagnosis may be made by exploring the gut with a bent probe or blunt hook. The treatment consists in drawing down the affected pouches and excising with curved scissors the folds of mucous membrane at their base. Eecto-vesical Tistula. An abnormal opening between the rectum and bladder may be due to con- genital defect,' to ulceration, usually malignant in character, or to a wound, as occasionall}'^ happens in the operation of lithotomy. As a result, urine escapes into the bowel, and, if the opening be large, fecal matter may enter the bladder, causing great pain and irritation. In some cases, an attempt may be made to close the fistula by the application of caustics or the galvano- cautery, or by a plastic operation analogous to that employed in cases of vesico-vaginal fistula, but in cases of malignant ulceration palliative meas- ures are all that can ordinarily be recommended, though colotomy (preferably by Amussat's method^) may be occasionally justifiable. Recto-urethral fistula will be considered in the article on Injuries and Diseases of the Urethra.] * Sue page 99, supra, 2 See page 78, supra. URINARY CALCULUS. BY E. L. KEYES, A.M., M.D., PKOJ?ESSOE OF GK^rrrO-URINAKY SUEGERT IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE OF NEW YORK ; CONSULTING SURGEON TO THE CHARITY HOSPITAL ; SURGEON TO BELLEVUE HOSPITAL, TO THE SKIN AND CANCER HOSPITAL, AND TO ST, ELIZABETH HOSPITAL. " To make calculi of uric acid without colloids would be as hopeless a task as making ropes of sea sand." " The pebbles of the concrete would not hold together without the cement to bind them and act on their surface." The enunciation of this truth, by William M. Ord,^ marks the starting point of a new era in the scientific study of calculous formation. The expe- riments leading to these conclusions, begun by Eainey and improved upon by Ord, are the first serious efibrts toward a scientific appreciation of the subject of which we have any record. The beautiful micrographic illustrations of large thin sections of urinary calculi, recently published by Ultzmann,^ arid the accompanying lucid descrip- tions, seem to establish beyond question that there is a law governing the mas- sive crystallization of the various urinary salts, as uniform in its action as that which regulates the structure of the smallest crystal. Urinary calculus is not an accidental agglomeration of solids, crystalline and amorphous, in a cement of mucus. It is a massive crystallization of urinary ingredients in a colloid, and its formation occurs in obedience to a fixed law. Ultzmann recognizes that there is a law and demonstrates it ; but he fails to grasp the idea of the colloids, or to mention their influence. He recognizes only two causes of the crystallization — 1, an appropriate chemical condition of the urine ; 2, an abnormal condition of the urinary apparatus — notably inability on the part of the bladder to empty itself entirely. The first appearance of calculous disease cannot be determined, but in the nature of things it must have shown itself, or rather its symptoms must have appeared, soon after the earth was peopled, unless prostatic enlargement is a malady of modern times, which there is no reason to believe.^ Certain it is that an authentic record of stone exists in a medical treatise, called Sugruta, a Hindoo work, believed by some authorities to antedate the Hippocratic collection. In this work, which was published in Sanscrit, at Calcutta, in 1835, and afterwards translated into Latin l)y F. Hessler, a very fair description of cutting for stone " upon the gripe" is given, the method now commonly known as the method of Celsus. It seems doubtful whether the Hindoo method of extracting stone described in the Sugruta, was pi-ac- ' The Itffluenoe of Colloids upon Crystalline Form and Cohesion, p. 61. London, 1879. ' Die Harnconoretionen. 1882. ' Probably the most masterly treatise upon the history of stone which has been written, is BSgin's edition of the Traits historique et dogmatique de I'Operation de la Taille, by Deschamps, which appeared in Paris in 1796. VOL. VI.— 10 (145) 146 URINARY CALCULUS. tised by physicians, or only by certain travelling specialists, as was the case in Greece. The Chinese are believed to have been acquainted with stone long before the modern era, and Albucasis, among the Arabians, certainly performed lithotomy. Hippocrates was familiar with the existence of stone. He used sounds and catheters habitually, and described t'he use of instruments for the detec- tion of stone. But the mortality attending the operations of peripatetic lithotomists was so great that wounds of the bladder came to be looked upon as necessarily mortal, and Hippocrates could not countenance the practice of lithotomy. In spite of his conservative opposition the operation flourished, however, and Celsus tells how Ammonius of Alexandria, in the third century before our era, proposed that, after the soft parts had been divided, the stone should be cut by an instrument of his invention, if it should prove too large for extraction without injury to the neck of the bladder. From this circum- stance, lithotomy takes its name. Celsus wrote in the first century before our era, and the method of his day, cutting on the gripe, is now often spoken of as his. The chemical side of the study of stone includes many distinguished names — among them notably Van Swieten, Van Helmont, Scheele, who discovered uric acid in 1776, Bergman, who detected lime in calculi, Wol- laston, who discovered, or rather gave a fixed character to, the fusible, the mulberry, and the pure earthy-phosphatic calculus. All of these varieties were described accurately by him in 1797, and he afterwards added cj^stic oxide to the list. Fourcroy and Vauquelin announced soon after that they had detected urate of ammonium and silica in calculi, and a host of modern investigators in urinary physiology and pathology have helped to make our knowledge of the chemical and microscopical nature of calculous concre- tions very exact. Urinary calculus is a term applied to a concretion of more or less stony hardness found at any point along the urinary tract or in a fistula commu- nicating with that tract. The calculus may be formed of crystalline organic matter, of earthy phosphates, of fibrin, of indigo, or of other substance. It may form spontaneously, or upon a nucleus introduced from without. It may be microscopic in size, or as large as a child's head at term. A mi- nute rounded concretion, smaller than a millet-seed, may properly be called a stone if it shows a laminated structure under the microscope ; Mobile clus- ters of large size composed of a conglomeration of crystals, separate crystals, and sand, may, whatever their size, be properly termed gravel. This distinction has practical value in connection with the questions of prognosis and of the preventive treatment of stone. In these respects, if the careful scientific researches of Rainey, Ord, and Carter have any value, the distinction is important. For inasmuch as the salts of the urine' assume a solid state in the crystalloidal, or in the colloidal form, (submorphous of Car- ter), we have the element upon which to decide, in a given case, whether the tendency to stone formation is great or small. The crystalloidal forms may be somewhat disregarded ; the colloidal call for earnest consideration. Crystals under ordinary conditions in the urine do not unite to form a stone. Something more is necessary. Earthy phosphates also fail to form stone under ordinary conditions. Thompson has called special attention tc this, and it has long been a well-known fact that a patient with the so-called phosphatic diathesis may habitually urinate in such a way that the lattei part or the whole of his stream of urine is creamy-white with precipitated GEOGRAPHICAL DISTRIBUTION OF STONE. 147 earthy phosphates, and yet will never have a stone as long as the mucous membrane of the urinary tract remains free from infiammation. On this point Ultzmann^ does not agree with Thompson, but holds that extreme phosphaturia is a factor in phosphatic stone formation. While this may be true in those occasional cases of alkaline stone which contain no ammonia (the pure phosphate-of-lime and carbon ate-of-lime stones), it certainly doesrnot hold good for ordinary phosphatic stones — triple-phosphate and fusi- ble calculus — the onl}'^ true secondary stones. In the formation of these latter, inflammation of the mucous membrane of the urinary tract has always been an etiological factor ; and it makes no difference whether the urine has been customarily acid or alkaline, such an inflammation with obstruction to the free escape of urine is efficient to produce an ordinary phosphatic stone. Other individuals again, at intervals, pass red sand of crystallized uric acid with great freedom, but do not on that account alone necessarily get stone in the bladder. The element most essential for stone structure is the skeleton of the stone — • not so much the solid as the soft pai't — the colloids, the glue, by which the solid elements are collected and fixed. GrEOGRAPHICAL DISTRIBUTION OF StONE. It is well known that stone occurs much more frequently in certain dis- tricts than in others, but a S£ttisfactory explanation of this fact has not yet been given. The use of hard water for drinking does not explain the matter. Agnew^ says that in certain valleys in Lancaster County, Pennsylvania, of limestone formation, the water is very hard, being strongly impregnated with lime, and yet calculus is uncommon ; and he joins former writers in the very apposite reflection that it is difiicult to understand how calculi — most of which are composed of uric acid — could be formed out of lime. Civiale, whose statistical researches were very thorough, has written :^ — Dr. Warren, of Boston, has recently told me that stone is very rare in Massachusetts, and is almost unknown in those localities where granite rock abounds, while it is found occasionally at other points where the soil is calcareous ; but this alleged influence of the nature of the soil upon the production of the calculous disorder is an hypothesis only admitted in order to explain facts, the true cause of which is not evident. Several of the localities from which I have received statistical documents possess the granite formation, but in spite of this, calculus is far from being a rare disorder. Again, speaking of the stone cases reported from the department of Var, in France, he says: — The malady seems to be equally divided among all classes of society ; the nature of the soil, which is of flint and granite on the coast, and calcareous in the interior, does not appear to make any sensible difference in the distribution of cases. Cadge,* of !N^orwich, England, on the other hand, ascribes the great fre- quency of calculous (uric-acid) disorder in that district to the hardness of the water, and Prout shares his opinion. Reginald Harrison^ tries to establish a connection on the ground that hard waters interfere with digestion, and in this way modify the conditions of the solids and colloids in the urine. He mentions the frequency of stone in the young among the poor about JSTor- ' Op. oit., S. 30. 2 Principles and Practice of Surgery, vol. ii. p. 631. ' Traiti5 de I'Affection Calculeuse, p. 588. Paris, 1838. ' Brit. Med. Journal, vol. ii. pp. 207-212. 1874. ' Lectures on the Surgical Disorders of the Urinary Organs, 2d ed., p. 245. 1880. 148 URINAKY CALCULUS. wich, and the fact that milk is scarce and dear, and quotes Cadge's assertion that the frequency of stone in children will be found in strict accordance with the difficulty of procuring milk. Mastin' takes the other side, showing that in Kentucky and Tennessee — sandstone districts where the water is very soft — calculous disorders are com- mon, and are just as frequently encountered as in the limestone areas of the same region, where hard water is drunk. ISTo country is exempt from calculous' disorder, yet the areas of its prevalence are small. Thus in Eng- land, the eastern counties, Norfolk and Suffolk, appear to be most afflicted. It is noteworthy that as many cases occur each year in Norfolk, among its 438,656 inhabitants (Cadge), as in all Ireland with a population of 5,412,377. The northern counties of Ireland and of Scotland furnish more cases than the remaining portions of those countries. Calculous disease abounds in France, in Teneriffe, in Iceland, and in Egypt. Its frequency in Egypt is said by Roberts^ 'to be due to the presence of the minute urinary parasite, the Bilharzia heematobia. Stone is also very common in Russia, especially in the central parts of European Russia. Kleiu^ states that, cases of stone sometimes constitute a fifth of all those under treatment in the hospitals of Moscow. Estlander,* on the other hand, shows that primary calculus is almost unknown in Finland, the University Hos- pital case-books showing only one Finlander with uric-acid stone during a period of forty-four years. There were cases of phosphatie stone with paralyzed bladders, etc. Civiale' notices a similar immunity in Christiania, where out of 3211 patients in hospital during four years only one had stone, while in the hos- pital at Gothenburg, in Sweden, a hospital of sixty beds, there had been no stone case in fifty years. Fayrer^ says that stone is very common in the northwestern and central provinces of India, 554 cases having been cut for stone during a single six months in 1863. In Lower Bengal it is rare. Fayrer' says that lithotomy has been performed only about one hundred times in the Medical College Hospital of Calcutta. Harris confirms the fact, and ascribes the frequency of the malady in the Northwestern Provinces to the prevalence of cold winds from the Himalayas, and to the use of a heavy unferraented bread by the natives. Dr. Garden's* testimony from the Sarahunpore Dispensary is corro- borative of the frequency of stone in India. Mastin* refers to Curran for authority in stating that Hindostan is exceptionally rich in stone cases. Van- dyke Carter"" speaks for Bombay and the great prevalence of oxalate-of-lime calculi there. He thinks that stone is more common in "Western India than in the southern portion. Mr. Dudgeon," of Pekin, informs us that at Canton, in China, and at Takow, in Formosa, calculus is found, but apparently not elsewhere. At Pekin the water is full of lime, at Canton very soft. Kerr*'' also says that Canton fur- nishes the stone cases of China, and that not a single case was observed among the thousands of patients treated in the missionary hospitals at Hing-po, Shanghai, Pekin, and Hangkow. ' Causes and Geographical Distribution of Calculous Diseases. Trans. International Medical Congress, p. 609. Philadelphia, 1877. 2 Urinary and Renal Diseases. 2d American ed., p. 275. 1872. ' Ueber Steinkranheit uud ihre Behandlung. Archiv f. klin. Chir., Bd. vi. S. 78. * Trans. International Med. Congress, p. 663. Philadelphia, 1877. » Op. oit., p. 580. " Referred to by Coulson (Dis. of Bladder and Prostate, 6th ed., p. 378). ' Clinical and Pathological Observations in India, p. 385. 1873. ' Indian Annals of Med. Science, 1868, No. 23, p. 20. > Loo. clt. p. 618. "• Calculous Disease in Bombay. St. George's Hospital Reports, 1871-2, p. 85. " Calculus in China. Med. Times and Gazette, Sept. 2, 1876. p. 252. " New York Med. Journal, 1871. * CAUSES OF STONE FORMATION. 149 In Norway, Sweden, Denmark, Styria, and Spain, stone is not very common. In France and Holland it is abundant ; iia Austria, Germany, Italy, Syria, and Persia, it is reasonably' frequent. In Mexico, Central and South America, and Australia, as far as known, the disease is not common. Livingstone failed to find syphilis or stone among the natives of Central Africa. In ITorth America, in the United States, the greatest number of stone cases originate in the central districts — Tennessee, Kentucky, Ohio, Indiana, Mis- souri, Western Pennsylvania, and Virginia. In Utah it is said to be common. Authorities differ as to Georgia and North Carolina. In the ISTorthern, Eastern, the Gulf, Southern, and Western States calculus is uncommon, as it is also in the Canadas and British possessions. These peculiarities of dis- tribution are not satisfactorily accounted for by any peculiarities of water, food, or climate. Causes of Stone Formation. First among the causes of stone formation, according to the best modern investigation, must be placed the influence of the colloids. Doubtless such substances as disturb digestion and nerve-force, and furnish an excess of uric acid, of oxalate of lime, of phosphates, as the case may be, favor the forma- tion of stone, but alone they ^re not suflBlcient. Undoubtedly also without cystic oxide, urostealith, or indigo, in the urine, calculi formed of these ingredients could not occur. But the fact remains that urates and uric acid may be in excess in the urine for years, and phosphates for a life-time, and no concretions into stone take place, while at a given moment, presumably during a proper co-operation on the part of the colloids, primary (acid) stone starts into existence ; or the presence of a foreign body with inflamma- tion of the mucous membrane will speedily give rise to a secondary (alkaline phosphatic) stone in any individual, whether his diathesis be phosphatic or not. The colloid in the latter case is the alkaline muco-pus furnished by the inflamed mucous membrane. In 1857, George Rainey first showed at St. Thomas's Hospital that certain crystalline materials assumed globular forms •when precipitated in gummy solutions, and he announced his mature doctrine of " molecular coalescence and molecular disintegration" in a short treatise published in 1858, " on the mode of formation of shells of animals, etc." His researches led him to conclude that a law existed by which organized bodies assumed a rounded form on account of physical and not on account of vital agencies. The following was Mr. Rainey's process : a solution of gum arabic saturated with carbonate of potassium, sp. gi-. 1.4068, perfectly clear, was placed in a bottle, filling it one third, and two clean slips of glass were introduced into the liquid, touching above, separated below. The bottle was then filled carefully with a perfectly clear solution of gum, sp. gr. 1.0844, and set aside for a month. In this way Mr. Rainey succeeded in forming perfect spheres of carbonate of lime having all the hardness of pearls, and he demonstrated that they were built up oy the slow coalescence of minute molecules. The spheres showed radial and concentric markings, and a very distinct cross in polarized light. Where too spheres touched, they gradually coalesced into one perfect sphere, and where each sphere came into contact with the glass, a shallow pit formed in the latter, due to a new arrangement of its molecules. Mr. Rainey concluded that the " viscosity" of the gum destroyed the 150 URINARY CALCULUS. polarity of the crystal which would otherwise form, and that the molecules simply obeyed the law of mutual attraction. The gum was intermixed. with the lime in the spheres. When spheres so formed are placed in new solutions of gum of different specific gravity, they lose their laminated arrangement, split radially, and return to the molecular condition, a process termed by Mr. Eainey " mole- cular disintegration." This splitting of a concretion in a fluid of different specific gravity from that in which it was formed, is beautifully illustrative of what sometimes takes place in the human bladder in the spontaneous fracture of stone. Eainey obtained similar results by the use of the carbonates of barium and strontium. Professor Harting, of Utrecht, in 1872, published some original work in the same direction. William M. Ord has followed up Rainey's investiga- tions with some excellent independent researches directed mainly toward investigating the method of formation of urinary and other calculi, publish- ing the final results of his labors in 1879.' Professor F. Guthrie, and Drs. Montgomery, Jevons, Aseherson, and others, have labored in the same field. Dr. Ord's second proposition is the following : — " A crystalloid is deposited from solution in tbe presence of a colloid. This occurs in ... . uric acid and urates mixed with albumen and mucus,' in nitrate of urea crystallized from albuminous urine." The third proposition is — in part: — " Crystals are broken down and turned into spheres or spheroids, or molecules, by the action of colloids into which they are introduced," etc. Uric acid exists in three forms : — 1. Rectangular, oblong, colorless plates — pure uric acid. 2. Rhombohedra and its modifications — urinary uric acid. 3. Spherical form — calculous uric acid. Ord states that ISTo. 1 is the proper crystalline form of uric acid, and that the changes in form which the urinary crystals present (40-50 varieties) are assumed in obedience to Rainey's law of molecular coalescence, and vary with the quantity and quality of colloidal substances which the urine contains. The pure tendency to polarity in the crystals is modified, and mutual attrac- tion of the particles tends to produce curved lines in the crystalline form. Four substances in normal urine influence the form of crystals: mucus, urea, extractive coloring matter, and salts. To these must be added the ingredients ' of pathological urine capable of modifying crystalline form: albumen, sugar, blood, and pus. To mucus and purulent mucus seems largely due the rounded form which uric acid assumes, so that by proper experi- ments Ord was enabled to form small uric acid calculi under his very eye, as it were. Heat intensifies the action of a colloid, and a colloid in partial degeneration seems to be particularly active. Such a colloid is purulent mucus. "Therefore," says Ord,^ "if the causes of the varying prevalence of calculous disease in different communities and regions are to be fully and usefully examined, such sub- jects as constitutional proneness or indisposition to vesical catarrh, habits of life diet and regimen, or local conditions of soil, water, and climate, which can hinder or pro- mote the secretion of mucus or the occurrence of irritation in the urinary tract, must be carefully treated. And if such observations be applied to practice, we may hope to find ' The Influence of Colloids upon Crystalline Form and Cohesion. London, 1879 2 Op. oit., p. 61. . , . CAUSES OF SXONE FORMATION. 151 that the prevention of stone becomes partly possible through the prevention of the local conditions which constitute the soil in which it is sown and grows." Ord states that two-thirds of all calculi " are in bulk composed of, or start from, concretions of uric acid." His experiments with colloids and oxalate of lime lead him to believe that to mould oxalate of lime into calculi requires a denser colloid than usually exists in vesical urine. He therefore believes that the beginnings of oxalic calculi usually occur " in the recesses of the kidney among less diluted colloids." H. Yandyke Carter^ believes that it is during some febrile condition, or in connection with some irritation along the urinary tract, that calculi origin- ate; the colloid, mucus, pus, albumen, fibrin, and blood being present eoin- cidently with an excess of the saline ingredient out of which the nucleus is to be composed. He says : — " I have noticed in the interstices of a nucleus, composed of oxalate-of-lime spheroids and blood, isolated collections of rhomb-crystals, such as experiment shows will appear in a firm colloid in which oxalic acid and lime are caused to meet, and I venture to suppose that in this case a small mass of mucus served as the medium." In his micro- scopic researches Carter has found that " calculi are habitually surrounded by a thin layer of mucus in which goes on the process of molecular coalescence resulting in the addition of fresh layers."^ Richness of the Urine in Solid Ingredients. — Excess of solids alone in the urine does not necessarily give rise to stone. Ultzmann^ gives nearly the whole credit in calculous formation to the amount of solids in the urine, notably uric acid. In his investigations he found that about 94 per cent, of all stones had nuclei of uric acid. The element, he believes, which influences stone formation, is the shape of the uric acid crystals. This he found to be modified by the degree of acidity of the solution in. which the crystals were deposited, and consequently he assumes that the fan-shaped, sheaf-like masses of pointed, acicular crystals, are the obvious starting points of stone. This assumption is in direct opposition to the conclusions adopted by Ord after the demonstration of experiment. Ebstein* gives clinical strength to Ord's theories in quoting Ereriehs as finding in the tubules of the adult kidney, glomerules of urate of sodium, and in a case of Bright's disease amorphous fibrinous coagula with nodules of brown uric-acid crystals the size of a pin's head — evidently rounded by the colloid, and not sheaf-like. Rounded concretions of uric acid of varying size are not infrequently found in diseased kidneys, in cysts and dilated urinary tubules. That an excess of uric acid in the urine is the chief cause of stone in infan- tile life, is doubtless true. The uric-acid infarction of Virchow is a pheno- menon nearly constant in the kidneys of young infants. It has been found in infants who have never breathed, but is often absent in such cases, while it is most frequently met with in the kidneys of infants who have lived several days.' These long lines of reddish gritty substance in the kidney-tubules are believed by Ultzmann to be composed in part of urate of ammonium, and in part of urate of sodium. This statement of their exact nature is not uniformly accepted, but all agree that uric acid is a main ingre- dient in the infarctions, which occupy the straight urinary tubules, filling them up and giving the pyramids an appearance as if they had been injected. Ultzmann examined the brown dust passed out from these infarctions upon ' The Mioroscopio Structure and Mode of Formation of Urinary Calculi. London, 1873. ' Op. cit., page 40. ' Ueber Harnsteinbildung. Wiener Klinik, 1875. * Ziemssen's Handbnch d. spec. Pathologie nnd Therapie, Bd. ix. H. 2, S. 208. 5 Ebstein, loo. cit., S. 216. 152 URINARY CALCULUS. the infant's napkins with a l^fo. 10 Hartnack immersion lens, and found them to be composed of masses spherical and dumb-bell in shape. Concentrated urine (as that of intra-uterine life always is), and concentrated colloids (those found in the recesses of the kidney tubules), thus seem to give a rounded (colloidal) shape instead of crystalline forms. It is noteworthy that this brown dust is found more often on the napkins of puny infants than upon those of robust "babies. In examining specimens of kidney-substance after putrefaction had begun, large spherical globules were found in great abundance. Ultzmann does not mention colloids, but his testimony goes largely to sustain the assertions of Ord and Carter. His most recent conclusion is' that uric-acid infarctions in the kidneys of the newly born are composed of balls or concentrated groups of fine needles of urate of sodium, which would go to prove that in this sense he is correct in believing that the pointed crystal favors calculous formation. TJric acid is normally" present in all urine to the amount of about 10 grains daily. In the natural condition it is not free, but is in combination with alkaline bases which feebly hold it in solution. Any excess of acid of any other kind, such as the acid phosphate of sodium or (out of the body) lactic - acid, from acid fermentation of the urine, combines with the bases of urinary salts, and liberates uric acid. If now crystallization takes place in presence of the feeble and dilute col- loids of the bladder, the crystals assume acicular or rhomboid forms, and are passed as gravel. If, on the contrary, the acid crystallizes in the thicker mucous colloid of the kidney-tubules, it may take the laminated form, and is, from its very origin, a stone ready to gather about itself a film of fresh colloid from the mucous membrane of the urinary tract wherever it may lie, the colloid being furnished by the irritation which the presence of the stone occasions, and ever ready in this film of colloid to attract by molecular coa- lescence fresh particles of uric acid out of the urine. Finally, the stone may excite inflammation of the mucous membrane, cause an outpouring of stringy mucus, decomposition of urine, and precipitation of phosphates, and then its film of colloid becomes a nidus for the deposit of phosphatic accretions, and secondary or alkaline stone formation goes on. Oxalate of lime in the same way, when in excess, from the food, or from ner- vous or other causes, may crystallize in its customary octohedral form, or in the modifying presence of a colloid of mucus, blood, or pus, may assume the dangerous dumb-bell or the spherical shape, and may become at once a possible stone. And so of other substances. The phosphates notably do not precipitaite in a shape capable of forming stone, except in the presence of the colloid muco- pus coming from catarrhal inflammation. Even a foreign body, if unirritat^ ing, may remain in the bladder for a considerable period, and no phosphates will precipitate upon it unless catarrhal inflammation be present. If a small, smooth nucleus gets into a healthy bladder, it may at first ex- cite only enough irritation to surround itself with a film of mucus, in which acid stone formation goes on indefinitely, until the presence of the foreign body excites vesical catarrh, when peripheral deposits of phosphates will take place. Effect of Age in Causing Stone Formation. — l^o period of life is exempt from the liability to stone. I have removed, by lithotomy (successfully), from the bladder of a boy of nine, three calculi, weighing collectively very nearly two ounces, which, according to the statement of the mother, had been diag- nosticated at the birth of the child. Many operators have reported cases ' Op. cit., s. 25. CAUSES OF STONE FORMATION. 153 observed shortly after birth. J. W. Troizki^ extracted from the urethra of a male infant, one month old, a uric-acid stone weighing twenty-five centi- grammes, eight mm. long, and five mm. broad. This had formed during intra-uterine life, and had produced acute symptoms when the child was eight days old. Civiale never saw a case of congenital stone, but he quotes from Brendel that of a child dying two days after birth, in whose bladder a stone of some size was found, and he alludes to two male babies in whom urethral stone was found within twenty-four hours after birth. A. Jacobi^ says that he has detected "six cases of congenital renal calculi in forty autopsies," and believes so-called intestinal colic in children to be often renal colic. Langenbeck has settled the whole question of intra-uterine stone by discovering a calculus in the bladder of a male foetus of six months. This he reported orally to Mr. Coulson. Nearly all surgeons who have dealt with stone, report a greater number of operations upon children than upon adults, and it has been gene- rally admitted that calculus is more common in early than in advanced life. The conditions appropriate for prompt stone formation, as has been shown in connection with the question of the influence of colloids, are amply furnished by the infant, and but for the fact which Coulson has emphasized, that the relative number of young people in the world is so large when compared with the number of adults, it would be fair to conclude that stone was very com- mon in children. This, however, is not strictly true. Coulson^ has shown by calculations based upon the statistics of Civiale, that the liability to stone, at the different ages of life, when corrected by taking into consideration the number of people alive at different ages, is very different from the apparent liability computed by simply noting the number of cases occurripg at different ages. Thus, while out of a collection of 5376 cases, 2989 were found in persons under 20 years of age, the number of persons living and under 20 years, ih a given 100, is 46 ; so that while the actual liability appears to be 55 per cent., the real liability is below 25 per cent. In the same way, from 20 to 40, the liability is less than half what it is below 20 ; from 40 to 60, it nearly reaches the liability of youth ; while after 60 it is relatively nearly twice as great as it is below 20. Thus it will be seen that, according to reported statistics, stone is relatively more common after 60 than before 20, and that the period of early manhood is most exempt. This is undoubtedly due to the facts that all infants who have stone are operated upon or die before 20, and that, activity of life and freedom from debilitating agencies prevailing as a rule between 20 and 50, stone does not tend to form readily at this period. - The few who survive 60 are usually more or less feeble; prostatic disease exists in about one-third of the men, and the conditions favoring secondary phosphatic stone are active. If primary (acid) stones were alone computed, the percentage of young persons affected would easily surpass all others. Gross and Cadge have both called attention to the fact that in some dis- tricts stone seems to be more common in children ; in other sections in adults ; and Thompson is very positive in stating that while among the poor of London the children furnish many cases of acid stone, the old men of the same class of life do not have phosphatic stone. Water as Influencing Stone Formation. — The water question has been already discussed in connection with the geographical distribution of stone. ' Quoted in Centralblatt f. Chirurgie, No. 47, 1881, S. 751. « New York Med. Journal, July 21, 1883, p. 74. » Diseases of the Bladder and Prostate, 6tli ed., p. 369. 1881. 154 URINAKY CALCULUS. One curious means by which water may prove indirectly to be a source of stone formation, is suggested bya recent contribution on the formation of calculi, by Zauearol,^ surgeon to the Greek Hospital at Alexandria, Egypt. He says that the natives drink unfiltered Nile water, and imbibe the distoma hematobium, and that the animal and its ova can always be found in the urine and among the layers of stone in the case of the natives, who suffer frequently from calculous disorder. The foreigners, who only drink filtered ISTile water, do not often have stone, and their urine does not contain the dis- toma or its ova. Sex has undoubtedly an influence upon the frequency of vesical, but not of renal, calculus. Absence of the prostate, the large size and shortness of the female urethra, and the comparative freedom of women from urethral diseases and vesical catarrh, are sufficient almost to secure them immunity. Coulson estimates the relative frequency of stone in females as compared with males at 5 per cent. Prout makes it about the same. Klein, in Russia, puts it at a little over one-fifth of one per cent. Secondary phosphatic stones forming upon foreign bodies introduced from without, seem to be, relativelj' to the whole number of cases, more common in the female than in the male. E.ACE seems to influence stone formation. Gross,^ analyzing the lithotomies reported in some of our Southern States, found the proportion to be one in'%. negro to six in whites. Eayer says that the negro escapes in Egypt, while the Ai-ab suffers. Mastin' collected 3039 lithotomies -in America, and found only 102 put down to the negro, and 31 to the mulatto. Mastin says that gout is seldom if ever seen among the black people of the United States, and he quotes Winterbottom as vouching for the same fact in regard to the native Africans around Sierra Leone. Climate. — Statistics indicate that climate alone does not influence stone formation. Temperate zones seem to be most afflicted, yet the cold winds of the Himalayas, and the gales at !N"orwich, have been accused of contribut- ing to the calculous tendencies of those regions. The central districts of the United States, however, are not especially windy ; in France, Civiale found the proportion of cases in the Var district the same inland and on the coast. The ISTew England coast is subject to dampness and boisterous northeasterly gales, yet stone is infrequent there. Social Condition, PIabits, and Occupation. — These are not prominent etiological factors of stone. Civiale affirms this for France. Soldiers and sailors are reported by all who have given attention to their statistics to be remarkably free from stone, but most soldiers ' and sailors are between the ages of 20 and 40, and in good general health. Undoubtedly there are more stone cases among the poor than among the wealthy, but the latter class is comparatively small, and nearly all cases of the poor go to hospitals for operation, where they are sure to be recorded, while the wealthy escape tabulation to a certain extent. In ISTew York there is very little tendency to. stone formation. During ' fourteen years' active surgical work in two of the largest city hospitals (Charity and Bellevue), I have found in my service only two cases of stone. The cases which I have operated upon in hospital have been sent in by myself. Most of my operations have been done in private life. 1 Rev. de Chir., 10 Aodt, 1882, p. 645. s Op. oit., p. 168. " Loo. oit., p. 618. CAUSES OF STONE FORMATION. 155 Thompson' however " does does know any disease which marks more distinctly or more curiously, its relation with class than this. So common is stone in the children of the poor, comparatively speaking, that at Guy's Hospital, surrounded as it is by a very large neighborhood, densely populated by some of the worst-nourished classes of the community, quite one-half the cases admitted are children. Among the same classes, however, it is rare at the other end of life, very few elderly working men in London being afflicted with it. On the other hand, among the well-to-do and well-fed, while almost never found in childhood, it is comparatively common in advanced age." Exercise and fresh air militate against stone formation by thoroughly oxidizing the waste products of the body. Drink and Food. — Alcohol probably will not produce stone without the co-operation of other predisposing agencies. In large cities all over the world, alcohol is consumed freely, but no statistician has ever noted a special pre- valence of stone among dwellers in cities. Much liquor is consumed in Scotland and in Ireland, doubtless as much or more than in England, yet the latter locality is the favorite for stone. Some wines, like the Rhine wines (ScEmmering), being charged with bitartrate of potassium, rather check ten- dencies to stone, but sweet fermented wines and malt liquors, which increase the amount of uric acid, undoubtedly favor the formation of acid stone. Food alone cannot materially aifect stone formation by its quality. Where tlse tendency exists, it may be intensified by the nature of the food. Thus in India, Vandyke Carter found oxalate-of-lime nuclei most common in the calculi of the rice-eating natives. But it is not starch as food that causes stone, or the potato-eating Irishman would be prone to stone, which is not the case, l^or is it rice-starch, or the Chinaman would be as constant a stone-producer as the Indian — which again is not the case. In Europe and America, uric-acid stones are the rule, but if a meat diet caused stones, the latter would be much more common in cities, where much meat is consumed, than in the surrounding country where the fai-mers feed more sparingly on meat — but this again has not been noticed as a fact. Milk diet has been supposed to oppose the tendency to stone ; probably this is true, but it is a minor factor. Indigestion again has been accused of causing stone ; but if this were so, surely the disease ought to prevail in iN'ew England, where bad teeth and dyspepsia, due to hot bread, pie, and rapid eating, are the rule, and yet where stone is very rare. Constitution. — It is probable that gout and rheumatism increase any tendency which there may be to stone, because these diathetic conditions are usually accompanied by acidity of the urine, with excess of uric acid and urates. A gouty individual leading a sedentary life, drinking freely, and eating highly nitrogenized food, especially if he has a little dyspepsia, and is con- stantly kept anxious about his business or other matters, is in a fit condition to form stone easily. Such patients not uncommonly pass small uric-acid concretions. Acute Maladies. — Prout, Kletzinsky, and Beale have pointed out the tendency to a deposit of oxalate of lime in cholera patients. Any feverish condition furnishes in the accompanying concentration of the urine one of the factors of stone, and some authorities believe that all renal stones have their origin during a febrile state, perhaps of short duration. Heredity. — As gout is hereditary, so are the tendencies to stone. I have at present under observation a family in which three generations, all living, ' Clinical Lectures on Disease qf the Urinary Organs, 6th ed., p. 67. 1882. 156 URINARY CALCULUS. have strong and constantly out-cropping tendencies to the appearance of fine uric-acid gravel. The baby of three yeai-s and the grandfather of seventy manifest it about equall}-. The most celebrated recorded instance of inherited tendency to stone is that reported by Mr. Clubbe/ of Lowestoft, where six children all had stone, the father and mother passed quantities of uric acid, and the grandfather, grand- mother, .great uncle, six uncles, four aunts, and a cousin — all had had attacks of gravel, or had been cut for stone. Cadge* recently reported a case of stone in a female with sacculated bladder, who asserted that her father had died after lithotrity, and that her brother was then suiiering from stone. In several of nnj own calculous cases the patients, ^^■ithout prompting, have accounted for their stones on the ground that their fathers had had gravel. It seems to me more than probable that hereditary tendency to stone lies at the bottom of its regional distribution, and accounts for its geographical peculiarities. Generation after generation, gi'owing up in the same region, and intermarrying, would naturally reproduce and intensify any such physi- cal trait. In former years, when locomotion Avas slow, the few who emigrated married others with diflferent tendencies, and so failed to spread tlie habit, while those who married others with like tendencies established new areas of stone formation. Food, drink, and surroundings may have intensified or modified these natural physical peculiarities, but that the essence of the geographical distribution of stone (primary, acid stone) lies in intensified hereditary predis- position, seems to me at least plausible in lack of a better explanation. With modern facility and cheapness of locomotion, it seems at least possible that the centres of stone formation may finally be broken up, and that by more general and mixed marriages the disease may become more extended in geographical area, but less active. Chronic diskase of the urinary passages is unquestionably a factor in stone formation. iSti-icture of the urethra, although occasionally complicated by stone, is only so as an exception. Stricture provokes powerful contractions of the bladder to expel its contents. As a rule, the bladder empties itself, and there is generally no physical reason why stone should form. I have encountered stone as a complication of stricture in only three or four instances. Enlarged prostate, on the other hand, leads to eecentrio hypertrophy and atony. In tliis condition the patient has residual urine, often in a state of partial decomposi- tion from vesical catarrh, and thus all the conditions necessary for active, secondary, phosphatic stone are present. These conditions exist the world over, and sufficiently explaiu the great relative frequenc}- of stone in the aged. ISTo case of prostatic disease is fairly treated unless an exploration for stone is made, whether the patient presents any symptoms of stone or not. I)iseases of the spinal cord which cause paralysis or atony of the bladder lead to stone (phosphatic), unless the bladder is kept washed out. Foreign bodies play a chief part in the formation of secondary (phos- phatic) stones. Tlic irritation of the foreign body excites more or less catarrh ; the urine becomes alkaline, ammoniacal, and partly decomposed ; earthy and triple-phosphates are thrown down ; and in the colloid muco-pus about the foreign body the phosphatic material stiffens into stone. A foreign body never becomes encased with phosphatic material until after it has excited catarrhal inflammation of the mucous membrane upon which it rests. The same statement applies to any foreign body anywhere in the • Hereditariness of Stone, Lancet, Feb. 10, 1872, p. 204. s Lancet, January 5, 18S4, p. 6. CLASSIFICATION OF URINARY CALCDLI. 157 Tirinary tract, be it a blood-clot, the ovum of a parasite, a tooth, piece of bone, or bunch of hair from an ovarian cyst, a bullet from without, a piece of broken bougie, or any substance introduced by accident or design. Any calculous nucleus coming down from the kidney is as much a foreign body as if it had been introduced through the urethra, and is built upon by the same laws, by acid layers first, and then, after catarrh, by phosphatic layers. Classification of Urinary Calculi. Calculi as commonly encountered are made up of several ingredients, one of which is always animal matter, a sort of stroma that pervades the mass in which the other materials, crystalline and amorphous, are deposited. The cement-substance is constant and probably uniform in character. Different opinions are held concerning its exact nature. It contains mucus, fibrin, and albumen, but the final word has not been spoken as to its exact composition. Certain microscopic fungous spores and mycelium have also been found and described as part of the organic composition of a stone, but their presence seems purely accidental. The other ingredients which the cement substance holds together are not usually uniform in character — urates, uric acid, and oxalates occurring together in the same stone, and phosphates being perhaps added on the outside. The nucleus of a stone often differs in composition from the various super- imposed layers, but the name of the stone surgically depends upon that in- gredient which constitutes most of its bulk. The nucleus and the organic stroma are disregarded. An oxalate-of-lime nucleus in a large concretion of uric acid, surrounded by a thin layer of phosphates, in a surgical sense is a uric-acid stone. Scientifically this is not accurate, for a calculus owes its existence to its nucleus, and it would be more exact to name the stone according to that nu- cleus if its composition could be readily determined ; and in a certain practical sense also a stone might take its name from its nucleus, because only by determining the character of that nucleus can the special tendency of the patient toward calculus be decided, and possibly a more intelligent preventive treatment instituted. But a stone is often preserved whole for its beauty, and thus the character of its nucleus remains unknown. Moreover, the prac- tical surgical question of most importance when a stone is in the bladder is its hardness, as bearing upon the question of lithotomy or lithotrity. The substance composing the bulk of the stone decides this question, and therefore, properly, gives its name to the stone. Among the various classifications which have been proposed, that of Ultz- mann,i following Heller, is perhaps the most widely adopted and possessed of the greatest merit. It aims at scientific exactness, and deals with the pathological conditions which precede the formation of stone. In this classi- fication the nucleus names the stone, and although sometimes the surgical name of the stone differs from its scientific name as decided by this method, yet, purely for purposes of study, a classification by the nucleus can hardly be improved upon. Eut Ultzmanu^ in his latest utterances gives up his former classification on the ground that primary stones may form in the bladder, as well as in the kidney, and secondary stones in both regions. He ofiers no fitting substitute and I therefore prefer to modify his former classification so as to cover all 1 Ueber Harnsteinbildung, S. 156. 1875. " Die HamcoDoretionen, S. 15. 1882. 158 URINARY CALCULUS. cases, and to retain it thus modified. Ultzmann's classification was the fol- lowing : — 1. Primary stone formation. 2. Secondary stone formation. 3. Metamorphosed stones. 1. Primary stone formation of Ultzmann includes stones forming in acid urine, which is 'normal as far as any inflammatory exudation derived from the tissues is concerned. 2. Secondary stone formation includes stones forming in neutral urine — such as the crystalline phosphate and the carbonate of lime, and in urine rendered pathologically alkaline by the products of inflammation of the mucous mem- brane lining the urinary tract — the phosphatic stones. 3. Metamorphosed stones, according to Ultzmann, ai'e certain large kidney and bladder stones with uric-acid nucleus and phosphatic shell. It is claimed that an acid stone lying for years in purulent urine loses its acid crystals, in part or wholly, their place being supplied by alkaline phosphatic precipitates. This metamorphosis of stone is a pure assumption, and Ultzmann does not prove it, or seriously attempt to do so, in either his monograph on stone for- mation, his work on urinary analysis written with Hofiiiian, or his pamphlet on urinary concretions. In the last work he does not mention the subject. It is not uncommon to find a phosphatic stone with a nucleus of uric acid, and it is much- more reasonable to suppose that the nucleus, acting like any other foreign body, has produced catarrh of the mucous membrane, and has then become covered with phosphatic incrustation, than it is to believe that the stone has ever been composed entirely of uric acid, and has become partly metamorphosed into a phosphatic stone. This assumption holds as well for the pelvis of the kidney as for the bladder. Another fault of Ultzmann's classification is, that it places the phosphate- of-lime and carbonate-of-lime stone in the secondary class, and assigns no reasonable position to indigo, urostealith, or fibrin. I think that the division into primary and secondary stones is an excellent one, with this understanding, that primary stones are such as form primarily from altered urine and colloids, while secondary or symptomatic stones follow as a consequence of inflammatory lesions of the mucous membrane of the urinary tract, without regard to the condition of the urine in respect to its various salts. Only two stones give any trouble in the classification which I propose : uro- stealith and amorphous phosphate of lime. I rank them both with secondary stones, because amorphous phosphate of lime, when found at all as a separate stone not combined with the ammonio-magnesian phosphate, is a friable, mortar-like mass entangled in a magma of mucus, and although phosphate' of lime is found where there is no catarrh of the urinary passages, yet it is doubtful whether a stone ever forms from it except in the presence of such catarrh. Urostealith again has never been encountered except in association with mixed phosphates. It therefore seems probable that it only forms in the presence of catarrhal inflammation. The classification then which I propose is as follows : I. Primary stone — the mucous membranes of the urinary tract being sound when the stone forms— uric acid (urate of sodium, potassium, lime), oxalate of lime, cystine, xanthine, carbonate of lime, crystalline phosphate of lime, indigo. II. Secondary or symptomatic stone — the mucous membrane of the urinary passage being in a catarrhal state at the point where the stone forms urate STRUCTURE OF STONES AND NATURE OF NUCLEI. 159 of ammonium, triple phosphate, amorphous phosphate of lime, fusible calcu- lus, urostealith. Structure of Stones and Nature of Nuclei. All true calculi are composed of a nucleus, single or multiple, and layers more or leas concentric of the same or another material arranged around it. This is the case for large as well as for microscopic calculi, those requir- ing a magnifying power of 250 diameters (Beale)' — Iloft'man says. 200^ — to make out their lamination. This fact of lamination alone diflerentiates calculus from gravel, the latter being crystalline dust or concretions of crystals" more or less large, but not possessed of definite structural arrangement. The nucleus of a stone may consist of whatever, among the organized, crys- talline, or earthy constituents of normal or pathological urine, is capable of concreting into a more or less solid mass; or it may be a foreign substance coming from within the body, or introduced from without. Among the familiar examples of nuclei afe separate rhomb-crystals of uric acid and clusters of them; spheres of uric acid; dumb-bells of oxalate of lime, urates, etc.; a lump of inspissated pus, mucus, or blood, perhaps drying out and leaving a central cavity in its place ; lumps of tissue-debris (casts, epithelium, fibrin); eggs of entozoa; portions of bone, teeth, or hair, which have escaped from a neighboring dermoid cyst by ulceration into the bladder; bullets, shreds of clothing,' and other foreign matter shot into the bladder ; portions of bone from fractures of the pelvis ; foreign material from the rectum entering the bladder through fistulous communications ; portions of catheters, etc. ; and, finally, foreign bodies in endless variety which have been intro- duced through the urethra, usually under the impulse of depraved erotic fancies. Ultzmann's celebrated collection of 545 single vesical calculi gathered from various quarters, for the purpose of examining the nuclei, yielded 441, nearly 81 per cent., in which the nuclei were composed of uric acid, while from a further study of multiple calculi and those passed spontaneously he concluded that among primary stones the nucleus was composed of uric acid in 94 per cent.* Hoifman and Ultzmann declare, in their work on the analysis of urine,* that 90 per cent, of urinary calculi have nric-acid nuclei. Ord° states that two-thirds of all calculi (this estimate includes secondary stones) " are in bulk composed of, or start from, concretions of uric acid." From the specimens in the museum in Guy's Hospital, Golding-Bird finds the percentage of nuclei of uric acid and urates to be less than 50. In con- sidering the question of nuclei entirely apart from the nuclei of large stones, it must be remembered that a great number of acid nuclei are voided by the urethra; the patients passing them do not enter hospital, and their minute calculi do not find their way into museums. Roberts estimates that uric acid forms five-sixths of all primary calculi. Klein found that alternating calculi were most common in Russia, the nucleus being for the most part uric acid or urates, quite often covered with a layer of oxalate of lime. Beale states that two-thirds of all calculi in the different British museums are composed of uric acid,^ that dumb-bell crystals of oxa- late of lime are frequently found as the nucleus of uric-acid calculus, and ' Kidney Diseases, Urinary Deposits, etc., 3d ed., p. 405. 1869. 2 Hoffman und Ultzmann, Auleitung zur Untersuohung Harnes, Zweite Aufl. S. 109. 1878. ' Op. oit., p. 149. * American translation, p. 264. 1879. ' Op. cit., p. 60. * Kidney Diseases, Urinary Deposits, and Calculous Disorders, 3d ed., p. 409. London, 1869. 160 URINARY CALCULUS. sometimes a hollow space representing a former clot of mucus or of b^ood. This latter phenomenon has been recorded b}^ many observers. The well- known case of the Archbishop of Paris, referred to by Coulson and others, in which Fr^re Come predicted before operating that the stone inclosed a clot of blood, illustrates probably one stage of calculus with a hollow nucleus. The archbishop had formerly been a victim to hsematuria, and Frere Gome's guess was verified by the result. A remarkable instance of calculus containing a cavity was presented to the London Pathological Society by Mr. Shaw. The stone, composed of uric acid, was as large as a small walnut, but seemed very light. On section it was found to be a shell varying in thickness from a sixth to half an inch,, 'inclosing a large cavity, which latter [contained a stone as large as a pea. Doubtless the small stone had become surrounded with a clot of muco-pus upon which uric-acid crystals had precipitated, and after the shell had formed the soft centre had shrunk away.' Mr. George Lawson^ reports a calculus re- moved by lithotomy from a man of forty-eight. It was 2 J x 2 x 1 J inches in its various diameters. It weighed four ounces less sixty grains. Its surface was smooth, yellowish-white, and inodorous after being washed. Its composition was phosphatic. On making a section, a drachm of reddish-brown, stinking, ammoniacal fluid escaped. The true nucleus turned out to be a mulberry cal- culus, ragged in outline, seven-eighths of an inch in its two chief diameters. This nucleus lay in a free space which had been filled with the reddish-brown fluid. Mr. Lawson's explanation is the obvious one ; that the rough mul- berry calculus when free in the bladder had at last excited catarrh, that its interstices had become filled and surrounded by muco-pus mixed with ammo- niacal urine, that this smooth surface had then become encrusted by concen- tric phosphatic laminae, and that the inclosed contents had still further retro- graded into the brownish putrid liquid. Carter found oxalate of lime to be a more common ingredient in stone formation in India than in England.* This he ascribes to the vegetable character of the food. The nuclei he found to be composed of uric acid and urates in 50.30 per cent, at Grant College, Bombay, while in England from his sources of information he makes the percentage of stones having uric acid or urates as nuclei as high as 74.46.* Oxalate of lime, on the other hand, formed the nucleus in 38.65 per cent, at Grant College, while the English sources yield only 16.87 per cent. Carter, from his Indian researches, concludes^ that globular urates very often accumulate to form the nucleus of stone ; that oxalate of lime in sub- morphous form is very common ; but that crystals of uric acid " compara- tively seldom compose the nucleus of a calculus." Dumb-bell cr^-stals of oxalate of lime are conspicuous for their frequency among the spicular, granular, and globular urates when the latter occur as the nucleus of stone. As to structure. Carter's microscopic researches confirm the conclusions of Ord. The albuminous substance is the skeleton in which the solid material forms. Dissolving out the latter leaves the former quite perfect, in some cases, showing the fibrillated radial structure of the basis-substance. In this substance crystals and granules are deposited, the former assuming a peculiar crystalline arrangement (sub-morphous), while the latter undergo remodelling. This arrangement of the basis-substance in a fibrillated, radial manner is very similar, as Ord has pointed out, to the structure existing in the crab's shell as described by Mr. Eainey, and serves, according to Ord, to prove the sound- ' Trans. Path. Soc. Lond., vol. vi. p. 251. 2 Lancet, March 31, 1883, p. 545. 8 Calculous Diseases in Bombay and some other parts of India. St. George's Host) Eeuorts 1871-2, p. 85. " F- i- . * The original paper makes these figures 71.79. * Miorosoopic Structure, etc., of Urinary Calculi, p. 29. 1873. BATE OF GKOWTU OF URINARY CALCULI. 161 ness of the doctrine of molecular coalescence as applied to the formation of calculi. Eate of Growth of Urinary Calculi. Cornpact acid stones — uric-acid, and oxalate-of-lime — generally form slowly. Gross cut a man who had had symptoms of stone for twenty-six years, and the calculus was only as larsje as a hen's egg. I removed two ounces of acid stone from a boy of nine. No fixed rate can be named, the increase being doubt- leas mainly dependent, in acid stones, upon the proportion in the urine of the ingredient which is being deposited. The estimates of Meckel that primary fitoues gain from two to six lines in diameter yearly, and of Gross that the increase is from one to four drachms yearly, arc little better than guesses. Ultzmann attempted scientifically to establish the rate of growth for pri- mary stones by keeping them in acid urine which he renewed daily. He found that a number of small stones so treated in his own urine weighed on ^u average ten times as mut'h at the end of the year as they did at the be- ginning. He concludes that the rapid rate of increase can only hold good in the case of small stones.' Phosphatic stones grow more rapidly, as a rule, than acid stones, but they increase at a varying rate, the grade of the catarrhal process probably having more to do with it than anything else. I removed a hair pin from a young girl's bladder where it had remained unmolested for more than a year, yet it was encrusted with less than a drachm of phosphatic deposit. Poulet^ refers to a calculus, removed by lithotomy, which weighed two and a half ounces, and which had for its nucleus a soft catheter introduced by the patient ten months previously. This patient undoubtedly had had catarrhal cystitis, with atony and retention, for which he had introduced the catheter in the first place. Hence the rapidity of stone formation. Robert Abbe* re- moved by lithotrity, from a man of 70, an entire soft catheter and phosphatic material with which it had been encrusted. The phosphates only weighed forty grains, although" the catheter had been in this old man's bladder for seven months. These instances are sufficient to show the irregularity of the rate of growth of stones of either class. Gross Characters of Urinary Calculi. Calculi present peculiarities in shape, surface, color, size, weight, consist- ence, and number. Shape. — Calculi are ordinarily oval or rounded in form, and more or less fattened. Ultzmann argues* that the shape of any single stone forming in the bladder, the growth of which is not interfered with by accidental causes, is regulated by the system of crystallization to which belong the original crystals out of which the stone is composed. Thus uric-acid, phosphatic, and cystine stones are naturally of the flattened-oval t3'pe, having three main diameters, because their crystals tend to assume rhomboidal forms possessing three diameters. The oxalate-of-lime crystal belongs to the quadratic system, with two axes nearly equal ; hence these stones are globular. Calculi show facets, if a num- ' Op. oit., p. 162. ' Treatise on Foreign Bodies, etc., American translation, vol. ii. p. 155, 1880. ' Medical Record, December 24, 1881, p. 705. " Die Harnconcretionen, p. 9. 1882. VOL. VI. — 11 162 DRINARY CALCULUS. ber of them have been lying together, and if formed upon a foreign body they often approximate the shape of that body. They are found with hour- glass constrictions — notably where one part of the stone is encysted and another part free in the bladder, and very fantastic, branched shapes are often assumed by renal stones and by vesical phosphatic stones, which branch oft' sometimes into the ureter and sometimes into the urethra. Surface. — The surface of a calculus may be as smooth as glass, but it is generally rough. This is especially the case in oxalate-of-lime calculi. Phosphatic stones are sometimes quite smooth, sometimes worm-eaten on their surface. Color. — Calculi vary through nearly all shades, from white through yellow' to brown with tints of green, up to dark brown, nearly black. The color depends mainly upon urinary pigments, not upon admixture with blood. Size. — Calculi vary from microscopic size upwards. The largest I have seen is the kidney stone removed after death by MacGregor.' It measured 16f by 12J inches in its two circumferences. Several others, vesical stones^ of about the same circumference have been recorded. A stone one inch in diameter is considered surgically a medium-sized stone (Thompson), all below being small, and all above large. Weight. — This also varies from a fraction of a grain upwards. Gross refers to stones extracted by lithotomy, weighing as little as four, five, six, eight, or ten grains. Gross and Coulson have each removed a five-grain stone, and Ashhurst one of less than two grains, from a boy, by lithotomy. On the other hand, stones have been found weighing 50 ounces (MacGregor's weighed in the fresh state 51 ounces), while there is one stone on record, said by Coulson to have been in the possession of the French lithotomist Morand, which weighed 6 pounds and 3 ounces. The largest stone ever removed from the bladder successfully, of which I find any record, was a stone of over 20 ounces, removed after fragmentation by Dunlap, of Springfield, Ohio,^ from a man of 66. The patient lived nearly three years after the operation. Pulido'^ scrotal stone of 23J ounces occurred in a successful case, and Graefe's 26-ounce scrotal stone in another. The largest stone which was ever extracted from a living person, as far as I can ascertain, was a phosphatic concretion measuring ifinches around its largest circumference, and weighing 40-J ounces. This enormous mass was removed from a man of 39 by the supra-pubic operation. Uytterhoeven, of Brussels, was the operator. The patient died eight days afterwards. Leroy d'Etiolles records the case.' Among other cases of verj' large stone removed by the supra-pubic opera- tion — with a fatal result in each and every instance — are the' often-quoted historical examples of Vitellius, 22 ounces, and Deguise, 31 ounces, as well as the more recent ones — also fatal — of Mouod, 346 grammes (nearly a pound),, and of Despres, the elder, two pounds.^ A rather large stone of pure cystine, and notable on that account, with diameters 2J x If x 1 and a circumference of 7 inches, weighing a little more than 2J ounces, is recently reported" to have been successfully removed by John Treameane, in Australia, by the high operation. Consistence. — Oxalate of lime forms the hardest variety of stone. It is difficult to break, and fractures in angular fragments from the centre. The phosphatic calculi form in flakes and in a mortar-like mass. They are nearly ' Am. Journal of Med. Sci., Jan. 1877, p. 120. 2 Gross's System of Surgery, 6th ed., vol. ii. p. 752. ' Traits pratique de la gravelle, etc., 2e M., p. 95. Paris, 1869. * Bull, de la Soo. de Chir., 5 D6o. 1881, p. 758. 5 Australian Med. Journ., and Journal of Am. Med. Assoc, Deo. 8, 1883, p. 649. SPONTANEOUS FRACTURE OF CALCULI. 163 always rather soft, but are sometimes quite hard. Cystine calculi have a waxy consistence. Number. — Often single, calculi may be as numerous as in the case of Murat, alluded to by Ooulsofi, who vouches for 678 stones in the bladder and 10,000 in the kidneys of an old man. Physick extracted over 1000 stones' from the bladder of Chief Justice Marshall, of the Supreme Court of the United States. Xone of these stones was larger than a bean. Dr. Ellis Blake, of ISTew York, once showed me the bladder of a woman, distended to about the size of a small fist, absolutely full of stones about the size of duck shot. They were not counted. This patient, during life, had passed these minute stones freely. Sometimes they would drop from her as she moved about. Oxalate-of-lime calculus is rarely multiple. Spontaneous Fracture of Calculi. The spontaneous fracture of calculi within the bladder has been explained by Ord.^ Other observers had already written concerning it,^ but their theo- ries of its cause are less satisfactory than that given by this writer. Ord examined a number of specimens from various sources, and reported upon them to the London Pathological Society. He believes that the split- ting is due to the imbibition, by the mucous cement of a calculus, of urine of different reaction and specific gravity from that in which the stone was originally formed. He quotes the paper of Southam^ giving two cases observed by that surgeon, one by Luke, and one by Liston, and a drawing of a calculus from the Musee Dupuytren, in Paris. Southam thought that the rupture Was effected by the development of gas within the stone, but Ord believes that the internal force is the swelling of the colloid nucleus by the imbibition of fluid different from that in which the stone was formed. This swelling of the nu- cleus, Ord'' says, acts as a "bursting charge in a shell."' Coulson has recorded a case, where, according to his belief, two soft calculi crushed each other by mutual friction. Listen's calculus is supposed to have broken up under the. influence of violent bodily shock. Ord has collected a number of cases in which the swelling of the nucleus alone could account for the disintegration. He also, in another place," records an example of molecular disintegration of a calculus, as shown in a stone taken after death from the kidney. Ord concludes' that the spontaneous fracture of calculi may be due to the action of three causes : (1) Forces, arising within the calculus itself. (2) Molecular disintegration. (3) Weakness of some of the alternating layers within the outer shell of the calculus. When a calculus undergoes spontaneous rupture within the bladder, each fragment, unless expelled, becomes the nucleus of a new stone. Li this way, Ord believes, some examples of multiple calculi take their origin. His* most recent e&pression on this subject is a report upon Smith's case, in which he found spores and mycelium, and in w:hich he thinks that the fungus may have had something to do with the disintegration. ' Gibson, Institutes of Surgery, 5th ed., vol. ii. p. 220. " Trans. Path. See. Lond., vols, xxviii. p. 170, xxix. p. 161, xxx. pp. 314^320; and op. cit., p. 93. ' Otto Schmidt, Beitrage zur chirurgischeu Pathologie der Harnwerkzenge. Leipzig, 1865 ; quoted by Gross (Practical Treatise on the Diseases, Injuries, and Malformations of the Urinary Bladder, etc., p. 215). * Brit. Med. Journal, vol. i. p. 3. 1868. = Ibid., Sept. 7, 1878, p. 347. ^ Trans. Path. Soc. Loud., vol. xxxi. p. 185. ' Spontaneous Disintegration of Calculi. Brit. Med. Journal, May 10, 1879, p. 702. * Trans. Path. Soc. Lond., vol. xxxii. p. 304. 164 URINARY CALCULUS. Materials which Enter into the Composition of Urinary Calculi. The colloidal, albuminous, fatty, epithelial, purulent, extractive, and color- ing matters found in varying proportions in calculi, as well as foreign sub- stances introduced from without or coming from within the organism and forming nuclei, may be disregarded in considering the present question. Such substances as the urates of lime, magnesium, potassium, and sodium, and the carbonate of magnesium, which may occur in minute proportions mixed with other ingredients of a calculus, only call for casual mention, as well as the earthy matters found as a trace — silica (Berzelius, Vauquelin, Fourcroy, Vena- bles, and others), iron, myeline, haematoidin (Ultzmann), and cholesterine. "When a calculus is found to be formed largely of cholesterine, it is fair to sup- pose that a gall-stone has found its way into the urinary passages. An interest- ing article by Ludwig Giiterbock^ details a case of extraction by lithotrity from the bladder of a middle-aged woman, of a number of calculi weighing thirteen grammes, composed of cholesterine, with a little uric acid deposited in an outside layer about each calculus. This patient denied having had any previous malady, and the stones were too large to have been introduced from without through the urethra. No biliary constituents were found in solu- tion in the urine, and, as the patient recovered, it was not learned how the gall-stones had reached the bladder. Giiterbock refers to two cases previously reported, those of Faber and Pelletan (both in women). In the former, an autopsy demonstrated a communication between the gall-bladder and urinary bladder. Pelletan's patient had suffered pain in the right side for some time before the two hundred facetted gall-stones escaped by the urethra — which they did in a period of eight daj's — but in Giiterbock's case nothing pointed to previous biliary complications.'' The substances which form urinary calculus, constituting the bulk of the mass or well marked laminae, are the following : — • Gallensteinooucremente in der Harnblase, Archiv fiir path. Anat. u. Phys., Bd. Ixvi., Hft. 3, S. 273. * Prostatic concretions are not urinary calculi. Their consideration belongs to another article. Fecal calculus, so called, has been described, among others, by R. Williams (Lancet, Oct. 1, 1881). A small vesico-rectal fistula- existed in an old man with large prostate. Cancer of the bladder with perforation was diagnosticated. After death, ten drachms of hard, solid, fecal material was remoTed from the bladder, not coated with phosphates. No cancer was found. James Miller (Edinburgh Medical Journal, 1829, vol. xxxi. p. 61), in a letter to Liston, describes a curious fecal and urinary calculus as large as a turkey's egg, which he extracted from the rectum of a child who had been operated upon for imperforate anus, and in whom a communication existed between the rectum and bladder. The stone had to be bored into and crushed, and the anus and rectum freely incised, before the calculus could be removed. The stone consisted of a nucleus of primitive greenstone which the boy had swallowed, a coating of the fibrils of the pencil of oats, such as WoUaston found in the spongy portion of human alvine concretions in Scotland, and an outer coating, from half to three-fourths of an inch thick, of urinary mixed phosphates. Miller refers to a rectal concretion described by Marcet (Essay on Calculous Disorders, p. 126), as found in the rectum of an infant born with imperforate anus and having also a recto-vesical fistula. This stone was composed of mixed phosphates. Among the irregular substances found as calculi, stones introduced from without must not be lost sight of. Under the title " De la gravelle urinaire simul6e et de ses rapports chez la femme avec I'hysterie," Brongniart has collated twenty histories of cases full of curious interest in the Ann. des Org. Ggnito-Urinaires, Nov. 1883, p. 747. Urinary calculi in animals are occasionally reported. Ebsteln's recent scientific treatise on the Nature and Treatment of Urinary Calculus (Wiesbaden, 1884), discusses this subject quite fully. The Trans. Path. Soc. Lond., vol. xxxiv. p. 326, refers to a stone taken from the bladder of an ass and one from the bladder of a dog, both of carbonate of lime. I have a small box full of minute calculi of carbonate of lime, passed by a bull. Dr. D. G. Sutherland, of East Saginaw, Mich., presented me with a portion of a five-ounce urinary calculus of carbonate of lime cut from a mare on January 24, 1884. The animal survived. Mehu gives the analysis of four calculi of carbonate of lime from the bladder of a rabbit in Ann. des Organes Gfinito- Urinaires, t. i. No. 7, 1883, p. 454. DESCRIPTION OF THE VARIOUS TYPES OF URINARY CALCULUS. 165 OF VBKT COMMON OCOURKENCE. 1. Uric acid. 2. Oxalate of lime. 3. Mixed phosphates (lime, ammonium, magnesium). OF LESS COMMON OCCURRENCE. 4. Urate of ammonium. 5. Ammonio-magnesian phosphate. 6. Phosphate of lime. 7. Carbonate of lime. 8. Cystine. EXCESSIVELY RARE. 9. Xanthine. 10. Fibrin. H. Urostealith. 12. Indigo. Any of these substance may occur as the chief constituent, but one or more may also be deposited in the same calculus forming superimposed layers, the alternating calculus. Generally, for obvious reasons, the phosphates form the'outermost layer. The layers indicate the condition of the urine at the time each was being formed. According to Coulson,' alternating calculi con- stitute almost fifty per cent, of all specimens found in museums. Cystine, xanthine, urostealith, indigo, and fibrin, always stand alone, and do not form alternating layers in calculi — but any one of them may act as a nucleus and become coated with phosphates. Urostealith is only found in company with the phosphates, while indigo has been observed by Ultzmann in crys- talline form, included in or surrounding deposits of uric acid and oxalate of lime. Fibrin, as blood clot, is not very uncommon as a nucleus of a calculus — even a primary calculus. , Description of the Various Types op Urinary Calculus. Uric-acid calculus is the most common form encountered in the human subject. It was described in. 1776 by Scheele. The calculus of old men with enlarged prostates is an exception to the rule, being most often phosphatic. The uric-acid stone may be composed almost exclusively of uric acid, or may be mingled in its intimate structure, or in alternating layers, with more or less oxalate of lime and different urates. It is generally oval, rarely very large, and sometimes quite smooth, though more often granular or smoothly tuberculated. In color it varies fi-om a light fawn (Owen" Rees has seen a uric-acid calculus perfectly white) to a brownish or even a blackish-red. The so-called pisiform uric-acid calculus is a pea-like body, often possessed of many facets, occasionally single, generally multiple, and often of a pale yellowish-white color from a coating of urate of ammo- nium. Of this kind are commonly the stones passed at intervals by gouty patients during a series of years. Section discloses two forms of structure in uric-acid calculi, the laminated and the amorphous. A given stone may contain layers of both forms. The laminated unc-acid calculus, when cut through the centre and polished, resembles an agate. It displays a concentric arrangement of regularly curved lines of slightly varying color and thickness, looks crystalline when broken, and takes a high polish. Radiating lines are often observed upon it, extend- 1 Op. cit., p. 341. 166 URINARY CALCULUS. ing from the centre to the periphery. The stone is generally very hard. ] breaks with a loud noise, upon the application of sufficient force, into angula fragments along its laminae and radiating lines. The amorphous uric-acid calculus is generally of a dirty reddish-yellow coloi looking gritty, structureless on section or fracture, perhaps presenting rad; ating lines from the centre. Sometimes it is found with a radiating cract indicating a tendency to spontaneous fracture, which is said to be mor common in this than in the laminated variety. This form is sometimes quit soft, and breaks into irregular, angular fragments. OxALATE-OF-LiMB CALCULUS, OE MULBERRY CALCULUS, was described by Wo] laston in 1797, and occurs next in frequency to uric-acid stone among-primar; calculi. It is generally round, occurs singly in the bladder, and rarely exceed the size of a nut. It is usually covered with blunt asperities — whence th name — and varies in color from dark gray through brown to black. Some times the asperities are crystalline, small, sharply angular, and shining. Th oxalate-of-lime stone is commonly mixed with more or less uric acid, th different urates, and some carbonate of lime, with, often, a certain amount o blood. The blood comes from the mucous membrane of the bladder, irritate( by the asperities upon the stone, and, lodging in the depressions betweei these asperities, it becomes incorporated with the stone. The same rough nesa often sets up more or less catarrhal inflammation of the bladder, an( leads to a peripheral deposit of phosphates. Hemp-seed calculus is a sub-variety of the oxalate-of-lime stone. It occur in the kidney, and is a rounded, smooth, brown-colored body, somewha resembling a hemp-seed. It is generally of mixed composition, containinj oxalate and phosphate of lime in different proportions. Other varieties of oxalate-of-lime calculus have been noted. Dr. Yellol; describes one of a white or pale-brown color, and crystalline in structur* throughout. Mr. Poland' refers to this, and speaks of an oxalate-of-lim calculus which he extracted, pale-brown in color, which immediately crum bled, there being little or no animal matter in its composition ; and stil another variety has been described by Mr. Charles Williams, a milk-whit calculus of highly polished surface, generally encountered in the kidney, am having no crystals on its surface, but sometimes spinous projections. Oxalate-of-lime stone is excessively hard, and resists the lithotrite more thai any other calculus. It breaks with a sharp report into jagged, angular frag ments. On section it shows concentric laminfe, deposited in undulating line about the nucleus. The layers vary through shades of light yellow and browr to greenish or blackish-brown. Mixed Phosphatic or Pusible Calculus. — This is the variety of stone pre duced by catarrhal changes in the mucous membrane with which the urin lies in contact. It is this phosphatic material which encrusts ulcers, tumors and foreign bodies in the bladder. It forms the phosphatic layers about othe varieties of stone, and is the concretion commonly encountered in cases c enlarged prostate. In the total list, all stones considered, the fusible calci lus stands second, being estimated to form one-twelfth of the total numbei against one-seventeenth for oxalate-of-lime stones and five-sixths for those c uric acid. The fusible calculus was described by WoUaston in 1797. It is dull, dirtj white in color, varying in bulk from pin-head size up to that of enormoi masses, filling the bladder and weighing several pounds. These stones ai 1 Holmes's System of Surgery, vol. iv. p. 1024. DESCRIPTION OF THE VARIOUS TYPES OF URINARY CALCULUS. 167 for the most part multiple, showing facets from mutual contact. When single, their shape is not generally symmetrically round or oval, but irregular in some way. These are the stones that grow in a branching manner from the bladder into the prostatic sinus, into the ureters, and into sinuses and sacculi. Quite often, in fusible calculus, the nucleus is not central. This variety of ea,lculus is often light, soft, and mortar-like, crumbling readily under the lithotrite. It breaks into irregular pieces or in laminae, and is more or less hard, according as the triple-phosphate or the phosphate of lime prevails in its composition. So also its structure varies. Some speci- mens are white and structureless, others amorphous and crystalline, and others again laminated, and exhibiting triple-phosphate crystals between the slightly adherent laminae. * Urate-of-ammonium calculus, discovered by Fourcroy and Vauquelin in 1798, and described particularly by Prout in 1823, is yet a subject of some dis- cussion. Roberts thinks that it may be doubted " whether the calculi de- scribed by Prout as urate-of-ammonium, were really anything more than fawn- •colored ui'ic-aeid." Yet observers agree that the urate of ammonium does ■occasionally occur as a calculus, mainly in the kidneys and bladders of children. It does not reach a large size, and is flattened, oval, smooth, or granular, and :slate-gray or clay-colored. Its structure is close and finely laminated, but the laminae are so intimately united that the fracture often looks amorphous. The lamiuae, however, are easily separable. The stone is brittle and is suit- able for lithotrity. Ammonio-magnesian Phosphate. — This substance, also discovered by "Wol- laston,in 1797, and commonly called ti-iple phosphate, occurs occasionally as the main constituent of a calculus. It is rare to find it alone, but common as a layer in an alternating calculus, or combined with phosphate of lime in the fusible calculus. Sometimes alone it forms a secondai-y calculus upon a foreign body as a nucleus (Bryant). Calculi of triple-phosphate are white, unevenly round, rough, and crj'stalline ■on the surface, chalky and crystalline in texture, and not laminated. They become dulled in appearance when dry and old. Their bulk varies from a minute size up to that of very large concretions, weighing man}' ounces. Thompson speaks of one weighing nearly two pounds. They are very friable, and excellent objects for the lithotrite. The mass is made up of stellate, bibasic phosphate, and of neutral, ammonio-magnesian, phosphatie prisms (Wollaston). Phosphate op lime, quite common in combination (alternating and fusible oalculus) is very rare as the main ingredient of a stone. Wollaston described this substance in 1797. Two foi-ms are mentioned : (1) renal, (2) vesical. The renal phosphate-of-lime calculus is pale-brown, smooth, oval, and small, composed of neutral phosphate of lime, and made up of loosely united laminae, sometimes showing radial markings. The material' is soft and friable, and the laminae easily disconnected. These stones contain a large proportion of animal matter. The neutral phosphate fuses with the blowpipe. The vesical bone-earth phosphatie calculus is very rare. It is a mortar-like substance, semi-crystalline, entangled in a magma of mucus. The basic phosphate of lime is not fusible with the blowpipe. Carbonate-of-Lime Calculus. — This form, although common in herbaceous animals, is rare in man. Carbonate of lime not infrequently occurs as an ingredient in the oxalate-of-lime and in the phosphatie calculus. As the 168 URINAKY CALCULUS. main element of stone it is exceedingly rare, except in the case of prostatic concretions. The carbonate- of-lime calculus was first described by Brugnatelli, in 1819. It forms in the kidney as a rule, and is generally multiple. Among the most noted cases are those of Haldane, Hunstone, and "Waggstaffe, all carefully described by Roberts, who personally made a careful study of the specimens- passed from the patient under the care of Mr. Hunstone. In Hunstone's- case, says Roberts, " myriads of minute calculi of carbonate of lime were voided with the urine," " the largest of which were about the size of poppy- seeds, and the smallest only just visible to the naked eye as bright specks." Waggstaft'e's carbonate-of-lime calculus was a " large branching calculus"' taken from the kidney after death. Usually these calculi are small, rarely larger than a nut. They may he- white and friable (Prout), but are genei-all}' gray, yellowish, brownish, or even reddish, or bronzed, or amber-colored, and quite translucent (Roberts). They are exceedingly hard, and on section show a varying arrangement of curved lines about one or more nuclei, resembling in structure the mulberry calculus. Cystine ok Cystic-Oxide Calculus. — This form is almost sufficiently un- common to claim a place in the third group of stones, those I have desig- nated as " excessively rare." Arnaldo Cantani, in his essay on Cystinuria, etc.,' states that cases of cystine stone have only been reported 59 times in. medical literature up to the date of his jjaper. Wollaston discovered cystine in 1810, and believed it to be an especial and exclusive product of the walls of the bladder, but soon after Marcet found it in a kidney-stone, and Scherer in the liver. In 1824, Stromeyer and Prout found it in the urine where there was no calculus. Owen Rees thinks it more common in dogs than in men. Cleotta found it in the kidney of the ox. Beneke, in 1850, found only 3 cj'^stine calculi among the 649 of Hunter's- Museum. Leroy d'&iolles, among 1100 stones, found only 6 of cystine. Ivanchich encountered 1 in 300 cases of lithotrity, and Dumreicher 4 in lOS operations. Golding-Bird found 11 among the 374 calculi in Guy's Hospital Museum. Ultzmann has 8 in his table of 545 stones, 3 of which are in his special collection of 200 stones.^ Civiale, up to 1851, seems to have encoun- tered cystine only 8 times. Carter says that it forms less than 1 fier cent, of the stones in the ^Museum of Grant College, Bombay. It is exceptionally uncommon in the United States. Buck's collection in the Xew York Hos- ital contains one of large size removed by lithotrity. Cystine may form a calculus in the kidney or in the bladder, either consti- tuting the exclusive constituent of the calculus, or forming the nucleus. It is- encountered in connection with the mixed phosphates, uric acid, and oxalate and carbonate of lime. All observers report heredity as an active cause in its production. Cystine stones occur singly, but are often multiple. They are generally small, but have been found in the bladder weighing several ounces. They are rounded, smooth, or occasionally worm-eaten on the sur- face. Generally yellowish, they may be white or quite dark. On section they are smooth, pale-green, waxy-looking, not laminated. The fracture looks semi-transparent, satiny, and glistening. Golding-Bird says that the yel- lowish color changes to a blue-green when the stone is long kept exposed to- the light. 1 Cystinuria, FettsuchtundGallensteine. Berlin, 1881. The German translation, by Seigfrifid Hahn, forms part of the third volume of the Specielle Pathologie und Therapie der Stoffwechsel- krankheiten. 2 Die Harnconeretionen, S. 41. 1882- I a;- i// ■ W '- \ .•';'.o^ -ii*' 3. Alex. Dumas, Del, q URINARY CALCULUS, DESCRIPTION OF THE VARIOUS TYPES OF URINARY CALCULUS. 169 Cystine calculus is rather soft and friable, and is entirely suitable for lithotrity. Xanthine, Xanthic-Oxide, or Uric-Oxide Calculus. — Coulson^ gives a. bibliography and description of the seven cases of xanthine stone which were known to have existed at the date of his last edition, the first discovered by Marcet in 1815, weighing eight grains (Coulson by a misprint says ounces)^ and the last reported in 1873, by Gaillard, removed from a boy of 13, and weighing 350 grains. Dr. Porter, of Bridgeport, adds an eighth case, the only one recorded in^ America, the stone having been passed spontaneously from the kidney bj' a young lady. It weighed 48 grains. I have reproduced its appearance in sec- tion, in the plate which accompanies this article. (Plate XXXIII. , Fig. 4.) Dr. Porter's remarks upon the case are full of interest. They appeared in. the " ISTew England Medical Monthly," for May, 1882. Ultzmaim, among thousands of stones examined, never encountered xan- thine, and seems rather to doubt its existence. These stones are generally small, and resemble those of uric acid. They vary fi'om a light to a reddish- brown, are smooth and polished externally, laminated on section, hut without radiate structure, assume a waxy look when rubbed, and about equal uric- acid stones in hardness. They are generally single. They have been passed spontaneously and obtained by the aid of lithotomy — but no specimen, as far as reported, has been crushed with a lithotrite. They are suitable for re- moval by this method. Fibrinous and Blood Calculus. — Marcet was the first to describe this very- rare form of calculus. His specimens were quite small, and were passed spontaneously by a gentleman of 50. Roberts encountered a similar calculus- voided by a man of 35. Prout has seen and described several. Scott Alison (quoted by Beale) found several in the kidney, one as large as a horse-bean. They have been described as whitish-gray, amber-colored, dark reddish- brown, and black. They are usually small. Roberts has one as large as a walnut, taken from the bladder of a sheep. They are generally rough, and either hard, brittle, friable, with a fracture which has been described as rusty, dull, like baked clay, or of waxy consistence, or showing fibrous texture upoa fracture. They are more often multiple than single. Prout believes that they are composed of fibrin, and all agree that their occurrence is liable to be associated with previous renal hsematuria. In a neutral saline solution of one of these concretions Owen Rees found the remains of blood-corpuscles. Urostealith ; Fatty or Saponaceous Calculus. — This material is known to have formed calculous concretions in only four instances. Two vesical calculi, from the same individual, composed of a central saponaceous sub- stance surrounded by a thick coating of phosphates, are now in the Museum of the Royal College of Surgeons, London. They belong to Hunter's collection, and are described in the catalogue of 1842. The presence of the earthy soap forming the centre of the calculus is ascribed in the catalogue to the fact that soapsuds had been used to wash out the patient's bladder, and it is suggested that the fatty acids, combining with the earthy bases of the urine, had formed a nucleus of " earthy soap," which in its turn had become surrounded with, phosphates. Pleller^ described some similar masses in 1845, which, as small pisiform bodies, passed from a young man of 24. W. Moore,^ of Dublin, ia ' Op. cit., p. 328. 2 Harnooncretionen, S. 146. 3 Dab. Quart. Journ. of Med. Sci., vol. xvii. p. 473. 170 URINARY CALCULUS. 1853, observed two small calculi of saponaceous nature, and subsequently two large ones were taken after death from the same patient; and Vidau' has added another, in which the stone was as large as a bean, to the cases already known. Ultzmann,^ finding no urostealith among the thousands of stones which he has examined, concludes that this substance is a foreign matter which has been introduced from without, and therefore that it is not a true calculus. Thus it appears that urostealith has only been encountered in four patients. It consists of a yellowish or brownish material, which dries into a waxy-looking mass. It seems always to be associated with a deposit of earthy phosphates, both interstitially and often as a distinct, external layer. Indigo Calculus. — Ord* has described the specimen of indigo calculus which he showed to the London Pathological Society, March 5, 1878. Dr. Bloxam removed it after death from the right kidney of a patient, the other kidney being sarcomatous and containing an alkaline calculus. The indigo specimen was of a dai'k-brownish color in part, in part blue-black. It made a blue mark upon paper. It was about an inch in circumference, and weighed 40 grains. This is the only calculus of this sort thus far recorded. Ord expressed his belief to the Pathological Society that, as the ureter of the left kidney was occluded by a sarcomatous mass, some material produced by the disease in that kidney had been absorbed and excreted as indigo by the other. Ultzmann* has never encountered a calculus formed of indigo, but considers this substance not uncommon in connection with other deposits (uric acid and oxalate of lime). He possesses a uric-acid stone covered with a layer of iudigo as thick as paper, and gives a beatiful photograph (Plate 7) of a micro- scojiic section of stone, showing a number of blue crystals of indigo, shut in within a mass, of colorless oxalate of lime. Chemical Analysis of Stone. To examine a stone thoroughly it must be sawed through its nucleus, and the latter, with portions of the various concentric layers, separately tested. The best plan which I have found for conducting this examination methodi- cally, is that laid down by Loebisch,' and, with certain modifications, I have followed it. The dust collected from the sawing of the stone may be first roughly examined to obtain general information. In burning some of this in a Bunsen flame, further investigations may be largely directed by noticing whether the powder burns totally away or leaves a residue, whether the flame possesses color, or the smoke odor, and whether the powder crackles in burning (oxalate of lime). A minute fragment, to be tested, is pulverized and held at a red heat upon a bit of platinum-foil over a spirit lamp or Bunsen burner: — A. It is entirely consumed, except a trace : the fragment is composed of organic matter ; that is, uric acid, urate of ammonium, cystine, xanthine, ibrine, urostealith, or indigo. B. It is not very sensibly reduced in bulk by heat : the fragment is com- posed of inorganic matter — lime, potassium, sodium, or magnesium, in the form of urate, carbonate, oxalate, or phosphate. 1 Journ. de Pharm. et de Chim. ; and Loeljisch, Anleitung zur Ham-analyse, zweite Aufl. S. 418. 1881. 2 Op. cit., S. 5. 3 Op. oit., p. 144. ■' Op. oit. 6 Op. cit., S. 415. CHEMICAL ANALYSIS OF STONE. 171 A. Organic Constituents. — I. Dissolve a little of the powder with dilute nitric acid in a thin porcelain dish, dry it over a spirit lamp, and allow it to cool. Touch the yellowish-red sediment with a glass rod carrying a drop of liquor ammonise. A beautiful purple-red (murexid) reaction shows uric acid. This reaction is the same for uric acid and the urate of ammonium. To dis- tinguish between them, boil some of the powdered stone in water. The urate is dissolved, the uric acid very slightly. The clear hot water decanted, and allowed to cool, deposits the urate. Some of this dust is collected and boiled with liquor potassse. The fumes of ammonia are given oft", recognized by the peculiar odor ; yellow turmeric paper turns brown in the vapor ; a rod moist- ened in acetic acid becomes surrounded with white fumes. These positive tests indicate urate of ariimonium ; their fail ure shows uric acid alone. II. The murexid test fails. Dissolve a portion of the powder in dilute nitric acid and dry slowly with the spirit lamp ; a lemon-yellow deposit is left, which shows no change with ammonia, but becomes reddish-yellow on adding a drop of liquor potassse. This reaction shows xajithine. in. The burning powder on the platinum-foil gives off a disagreeable sul- phurous odor. The powder dissolves in a solution of ammonia. Acids re-precipitate it. The alkaline solution, allowed to evaporate, deposits the flat hexagonal crystals of cystine. IV. The burning powder smells like burning horn. "Water, alcohol^ and ether fail to dissolve the powder. Liquor ammonise or liquor potassse dis- solves it, and from such a solution acids re-precipitate it. It swells up in acetic acid, and promptly dissolves in boiling nitric acid. These tests indi- cate _^6rz«.e. V. The powder melts on the foil, then swells up and gives oft' a strong odor, recalling that of a mixture of shellac and benzoin. Ether dissolves it, and evaporating leaves an amorphous deposit, which, being heated, assumes a violet color. Vidau's urostealith calculus gave a negative result to this test. The powder dissolves into a soapy solution in warm, caustic alkalies. It dissolves with slight eftervescence in nitric acid, precipitates on evaporation without change of color, and the deposit becomes dark-yellow if touched with an alkali. These tests indicate urostealith. VI. The powder of Ord's indigo stone, on heating in a test-tube, developed purple-red fumes, which deposited dark-blue crystals on a cool surface. The crystals were characteristic, long hexagonal plates with pointed ends. The odor was sooty, like that of indigo. Strong sulphuric acid dissolved the powder first into a brownish, and then into a muddy-blue solution, which, after dilution with water and filtration, yielded a clear blue fluid. The spec- trum gave the indigo line in the yellow. Besides indigo, the stone contained phosphate of lime and a trace of blood. B. Inorganic Constituents. — "When a considerable residue is left after burning the powdered fragment upon a piece of platinum-foil, the stone is composed either almost entirely of inorganic ingredients, or of organic salts, the earthy inorganic bases of which are not consumed by fire : such as the urates of potassium, sodium, lime, or magnesium; the oxalate, carbonate, or phosphate of lime; the ammonio-magnesian. phosphate. I. The murexid test applied to the powder shows uric acid, but the resi- due left on heating proves the existence of an earthy base ; it is soda, potassa, lime, or magnesia. The urates generally exist in small quantity along with other ingredients ; they do not alone form stone. The powder is boiled in distilled water and filtered while hot. The filtrate is evaporated and the residue brought to a red-heat. If a portion of the ash held in a Bunsen flame burns yellow, sodium is present ; if violet, potassium. 172 UKINAKY CALCULUS. Magnesia and lime exist (if at all) in the precipitate of the boiling water, after moderate heating, as carbonates. A portion of the powder is dissolved in dilute hydrochloric acid, made neutral with ammonia, and the precipitate dissolved with acetic acid ; on adding oxalate of ammonium a white crystalline precipitate is thrown down (oxalate of lime). This test shows lime. After filtering out this precipitate the filtrate is treated with phosphate of sodium, and magnesium shows itself under the microscope as a precipitate of crystals of triple phosphate. II. The murexid test fails. The powder consists of oxalate of lime; of carbonate of lime or magnesium ; of triple phosphate, of secondary (neutral) phosphate of lime, or of tertiary (basic) phosphate of lime. Oxalate of Lime. — The powder of this substance crackles under the blow- pipe, red heat blackens it, further red heat whitens it, and it becomes car- bonate of lime, which now dissolves in dilate acids with effervescence. White heat reduces the powder to caustic lime, which no longer dissolves in dilute acids with effervescence, but turns moistened yellow-turmeric paper brown. Furthermore, powdered oxalate of lime, before being heated, is not influ- enced by acetic acid, but dissolves, without effervescence, in mineral acids, and is precipitated from such solutions by ammonia. To distinguish between the other substances mentioned above, put some of the powder into hydrochloric acid. It dissolves : (a) with effervescence, (b) without effervescence: — (a) Carbonate of Lime or Carbonate of Magnesium : — Carbonate of Lime. — The powder blackens under moderate heat ; whitens under intense heat into caustic lime, which, when moistened with water, turns yellow-turmeric paper brown. The powder, also, without previous heating, effervesces freely in dilute acids. Carbonate of Magnesium. — Dissolve the powder in dilute hydrochloric acid, neutralize the solution with ammonia, and dissolve the precipitate with acetic acid ; add phosphate of sodium and ammonium, and the magnesia will pre- cipitate as crystalline ammonio-magnesian phosphate in the shape of little stars or oblique crosses, the form of the crystals being due to the rapidity of the crystallization. (b) Oxalate of Lime or Phosphates: — Dissolves with- out efferves- cence. The pow- der is brought to a red heat and again tested with hydrochlo- ric „„4J It dissolves with effervescence S pecimen fuses. Some of the unheated dust is treated with liquor po- tassse. No efferves- cence follows, and the blow- pipe is used. oxalate of lime. Develops ) Triple ammonia. J pkate. phos- Develops ] Secondary no ammo- > (neutral) phos- nia. J phate of lime. Specimen will not fuse, and is tertiary (basic) phosphate of lime (bone earth). The Pathological Results of Urinary Calculus. A comprehensive view of the relation which urinary calculus bears to structural alterations in the urinary passages, is obtained by simply recognizing the distinction between the two great divisions of stone, the primary and the secondary'. The former are formed by the urine, often when the urinary organs are sound ; the latter demand as an essential factor in their formation that the mucous membrane lining that portion of the urinary passage in which they appear, shall be in a condition of chronic catarrhal inflammation ; consequently they only exist as a sequence of antecedent disease. THE PATHOLOGICAL RESULTS OF URINARY CALCULUS. 173 The primary stone, therefore, acting precisely lilce any other foreign body, may become the active agent of organic tissue-changes through the instru- mentality of the process of traumatic inflammation, while the secondary stone is essentially little more than an excretion solidified by accident. It is indeed rather a symptom or result of previous disease than a malady ; and although by its size and weight it may react upon the malady which caused it, and may become a traumatic factor increasing the intensity of that malady, yet it always continues to occupy a position second in importance to the original disease. A knowledge of this fact is of value in prognosis. When a primary stone is removed from the urinary passages spontaneously or surgicall}', provided that no other stone remains and that the surgical removal has caused no se- rious damage, the disease is entirely cured. K"ot so, however, when a secondary (phosphatic) stone is removed. The patient is not well ; one of his symptoms indeed has ceased, but the persistence of the cause which gave rise to that symptom (the secondary stone) may furnish the same symptoms (another stone) again. Consequently, the curative treatment of a patient practically begins after the extraction of his secondary stone, where in the case of extraction of a primary stone it virtually ends. The only exception to this rule is the case where a secondary phosphatic crust forms abOut a primary nucleus, the latter having alone served as the efficient cause for the catarrhal condition in the presence of which the phos- phatic deposit occurred. Plere, the foreign body being removed, the chronic inflammation which it occasioned may and often does spontaneously subside. In the kidney, a calculous infarction xaa,j lead to a cyst, but it rarely does 60. A stone retained in the pelvis of a kidney may block the ureter and occasion acute congestion, suppression, ursemia — if the other kidney be diseased — and death. It may occasion hydronephrosis. It may grow enor- mously, distend the pelvis of the kidney, and cause atrophy- of the secreting substance. It maj' give rise to pyelitis and catarrhal changes in the mucous membrane of the pelvis of the kidney, going on to calculous pyelitis, pyelo- nephritis, pyelo-nephrosis, or perinephric abscess. At any point along the ureter a stone may be arrested in its passage, and partly or wholly occlude the tube. In such a case, in addition to the results of occlusion at the renal orifice of the ureter, the tube itself becomes dilated above the point of obstruction, ulceration of the ureter at the point pressed upon may occur, granulations arise, and hsematuria ■^^•ith blood-casts of the ureter follow. In the bladder, at first subacute and then chronic cystitis is caused by pri- mary stone, leading ultimately to chronic vesical catarrh with secondary incrustation of the stone by phosphates. The chronic catarrh is marked by acute exacerbations, and may lead to extension of inflammation to the. kid- neys, and to all the sequences of a chronic cystitis. In the urethra, a stone may lodge in the prostatic sinus, or behind any point of physiological or pathological (stricture) narrowing of the canal. There it may grow to a large size and cause catarrhal changes in that portion of the mucous membrane upon which it presses, and in the distended urethra behind it. Therefore its accretions in the end are phosphatic, whatever its primary structure may have been. The foregoing remarks apply to calculi belonging to the primary group. All calculi forming outside of the urinary tract — sub-preputial, scrotal, peri- neal, in connection with abscesses and fistulse communicating with the urinary tract — are secondary, phosphatic, and symptomatic of urinary contact with the products of chronic inflammation. When such concretions, wherever situated, within or without the urinary 174 URINARY CALCULUS. channels, attain a certain size, they act locally as irritating foreign bodies, and increase the grade of the pre-existing inflammatory symptoms, together with the intensity of the subjective and functional phenomena to which these inflammatory symptoms give rise. Stone in the Kidney. All forms of urinary calculus are found in the kidney. The only indigo calculus on record was removed, after death, from the kidney. Urostealith has not yet been detected in the kidney after death, but of the four cases on record (Hunter's Museum, Heller, Moore, Vidau), in the second. Heller's, the patient complained of pain in the region of the right kidney, and passed all his small calculi by the urethra. This proof is circumstantial, but it is reasonably strong. Secondary stone deposits occur in the kidney, but only as a sequence of pre-existing stone formation, or as an epiphenomenon in pyelitis, pyelo- nephritis, tubercle, cancer, etc., of that organ. Renal nuclei usually pass on into the bladder. Those which do not escape from the kidney increase in size. They 'remain smooth and oval while small, and may continue in this condition while they grow, unless the pelvis of the kidney passes into a condition of chronic inflammation. In this case, alkaline deposit forms either spontaneously or upon the nucleus already at hand, and such secondary stones are liable to attain large size and to assume a branched form, extending into the calices and down into the mouth of the ureter. They often still remain oval, even after becoming phosphatic. A branching kidney stone, however, is not necessarily phos- phatic. Melchior Torres^ reports a large renal calculus, thoroughly branched, weighing over an ounce (37 grammes), and composed almost entirely of uric acid with a little urate of ammonium and oxalate of lime. This stone seemed to have formed as the direct result of an injury. A stone in the kidney, on the other hand, may reach enormous dimensions and retain its rounded form, not being in the least branched. Such was the large speci- men obtained after death by MacGregor, and already referred to. This stone has never been chemically examined, but, although apparently covered with a layer of phosphates, it is undoubtedly an acid (primary) stone. Its weight is 61 ounces. The symptoms of stone in the kidney (hsematuria, nephralgia, irritable blad- der, reflex pains), its spontaneous escape (nephritic colic), its results (calculous pyelitis, hydronephrosis), its surgical removal (litho-nephrotomy and nephrec- tomy), have been considered in a- previous article.^ It must not be forgotten that stone may remain for years in the kidney without producing any symp- tom, and may be accidentally discovered after death. Stone in the Ureter. There is no reason to believe that stone ever forms primarily in the ureter,and, as a rule, any calculus which fairly passes into the mouth of the ureter sooner or later works through and enters the bladder. The length of time required for this passage, in my experience, varies from a few minutes to many months. In one instance, a patient regularly had a paroxysm of nephritic colic on the ' Bull, de la Soo. Aiiat. de Paris, t. iii. p. 90. 1877. 2 See Vol. v., page 1075, supra. STONE IN THE URETER. 175 same day of the week for several successive weeks, being without pain on the other days, until iinally his stone passed. In another instance, a gentle- man was treated by a homoeopathic physician for what was called hernial colic (the patient wore a truss), during an entire winter. Under the use of alkaline diuretics, an acid stone which had been arrested during all this time at the vesical end of the ureter, was voided. Both ureters may be plugged simultaneously, sometimes with single, some- times with multiple calculi.' The distressing symptoms and high mortality recorded for cases of calculous anuria are well known. Reliquet'' quotes Merk- len's statement that out of fifty cases there were only nine cures. He proposes as a means of relief an increase of the blood pressure by a simultaneous elastic constriction of both lower extremities with elastic bands. Aided, seemingly, by this means, one. of the two cases in which it was tried ended in recovery. The suggestion is due to Prof. Bouchard. The constriction may be repeated daily, and the bandages may be left in place until difliculty of breathing and general physical distress make their removal imperative. If, instead of passing out or causing complete anuria, the calculus does not absolutely' occlude the ureter, then the urine trickles along side of it, and it ultimately sets up catarrhal inflammation in the ureter, and becomes a phos- phatic stone with acid nucleus. Or the calculus may form a pouch for itself, a sort of sacculation, as in a case shown by !N'orman Moore to the London Pathological Society.^ The specimen was removed after death. The pouch had become surrounded by a large deposit of fat, which Moore believed to be due to irritation. Total suppression due to calculus impacted in the ureter has caused a num- ber of deaths in persons from whom one kidney has been removed. So positively has this fact been observed that it has been brought forward as a reason why nephrectomy should not be performed. I have personal knowl- edge of one death from this cause. The symptoms of impacted stone in the ureter vary. There has generally been prolonged nephritic colic, without the passage of the stone. There is always, at first, partial anuria, complete if both ureters are plugged. More or less pain is felt about the region of the kidney on the affected side. There is often a dull pain in the groin, and more or less in the testicle of the same side. There may be considerable or very little irritability of the bladder, with some pus and blood in the urine. Localized tenderness, increased by manipulation, often marks the point in the ureter at which the stone lies. This point is usually near the upper or the lower outlet of the tube. Treatment. — -When a stone is stopped in a ureter, it is to be presumed that the methods employed for the relief of renal colic have failed — such as hot baths, diluents, opiates, diuretics, electricity, external manipulation, cups to the loins. Should there be complete calculous anuria, these methods should be persisted in with renewed energy, and Eeliquet's plan of simulta- neous elastic compression ot both lower extremities should be tried. Along with this, Reliquet recommends repeated rectal injection of small quantities of iced water. A little pilocarpin might be cautiously tried subcutaneously ifr^ E^^™)i to which might be added the copious use of Bethesda water or light beer. Modern surgery has further placed at our command more radical measures which should always be tried before it is too late, when a positive diagnosis can be made. ' Fatal case with autopsy. H. Haehner, Berlin, klin. Wochensohrift, 12 Sept. 1881, S. 531. ' Anuria calculeuse, etc., Note hie h, la Soo. de Med. de Paris, 11 Fev. 1882. (Extrait de L'Union MSdicale, 36me serie, 23 et 25 Mai, 1882.) 3 Lancet, March 25, 1882, p. 482. 176 URINARY CALCULUS. A brilliant innovation of modern surgery is nephrolithotomj' for calculous anuria. Dr. Thelen,' of Cologne, has described a succeissful case, Barden- Jieuer being the operator..,. Czerny first suggested the peribrmance of nephro- lithotomy. H. Morris^ first performed it, but not for obstruction ; his case was one of kidney stone without suppression.^ In Thelen's case the pati«nt had had left suppurative pyelitis and perinephric abscess. Through an in- cision made into this abscess the kidney was felt to be entirely atrophied. Suddenly, during convalescence, complete suppression came on. Bardenheuer thereupon exposed the other ureter in the fiank, found in it a calculus as large as a bean, firmly impacted, liberated the calculus bj' a longitudinal inci- sion, and sewed up the ureter. After temporary relief, a severe chill and high temperature caused Bardenheuer to reopen the wound, cut the ureter, and bring out its proximal end into the wound. A month afterwards the patient was doing well, urinating through the wound. Sometimes a stone, reaching the vesical orifice of a ureter but not entirely obstructing it, will grow by phosphatic accretion, and finally find its way into the bladder by ulceration, or it may prolong itself into the bladder, Sometimes a vesical stone grows into the ureter. Prostatic Stone. Two forms of concretion may be encountered in the prostate- and its sinus, the true prostatic concretion, and urinary calculus. The former will receive consideration in another article." Primary urinary calculus does not form in the prostate. An acid nucleus ■or fragment may lodge in the sinus, and for a time increase as aii acid stone. But sometimes nuclei detained in the prostate grow by the addition of layers mainly composed of phosphate of lime — in this way coming to resemble true prostatic concretions. There are five methods by which urinary calculus may form in the prostate. 1. A nucleus from the kidney may become arrested there and grow. • Ebel^ relates the case of a boy who, at the age of three, commenced to suffer from urinary discomfort and occasional attacks of retention. This persisted for six years, until a bean- sized stone was removed from the prostatic sinus by a cutting operation. 2. A fragment after lithotrity may behave in a similar manner. 3. A true prostatic concretion, reaching a certain size, may ulcerate its Tvay into the prostatic sinus and continue to grow, a pure phosphate-of-lime prostatic calculus, as in Mastin's^ case. Or it may receive accretions of uri- nary salts and grow backward into the bladder, reaching considerable dimen- sions — prostatico-vesical calculus. 4. A vesical calculus may send a prolongation forward into the prostate, Tesico-prostatic calculus. 5. An abscess in the prostate may leave a pouch in which urine accumulates, decomposes, and gives rise to a calculus. The same thing may happen in the fistulous tracts left by burrowing abscesses, and after lithotomy. Stones in this region attain great size, and may ulcerate their way out- wards into the scrotum, perineum, or rectum. A large phosphatic calculus ' Centralblatt f. Chir., 25 Marz, 1882, S. 185. 2 Lancet, Oct. 30, 1880, p. 698. ^ Up to May 23, 1884, eight cases of pure nephrolithotomy, all told, had been performed with- out one death. (Lancet, May 31, 1884, p. 983.) * See article on Injuries and Diseases of the Bladder and Prostate, infra. 5 Mag. f. d. ges. Heilk., Bd. xlviii. S. 271. 1837. « Medical News, August 16, 1884, p. 175. URETHRAL CALCULUS. 177 which presumably had been carried by the patient for fifty years, and had made a nest for itself in the perineum and prostate, was removed by Walton.' Its diameters were two and a half inches by one inch. Many other cases will be found included under the head of urethral calculus. /Symptoms.— Prostatic stones, even when very small, may give rise to much annoyance ; yet the parts sometimes acquire surprising tolerance of the foreign body, and the calculus may be first revealed during an autopsy. I find two cases in which large prostatic calculi were perforated by a natural channel for the escape of urine. One of these calculi, removed by Kushton Parker,^ weighed an ounce and a half. It seemed to replace the prostate, and had a central perforation. The other, observed by T. Sympson,^ had two channels widely separated from each other. It was a vesico-prostatic calculus. The actual symptoms of prostatic stone are a varying amount of pain, weight, heat, dragging, throbbing in the perineum and rectum — possibly abscess, irritability of the bladder, retention of urine, presence of more or less pus and blood in the urine, erotic desires and a tendency to priajaism — or there may be practically no symptoms at all. A searcher can generally be made to enter the bladder with ease, and diagnosis is established by the grating sound and confirmed by rectal touch. Treatment. — If the stone is small and has recently lodged in the prostatic sinus, an effort should be made to push it back into the bladder with a large, blunt, steel sound, or by passing a hollow tube up to the stone, and rapidly injecting a large amount of warm oil through it while the urethra is kept compressed about the tube. If these means fail, an attempt may be made to crush the stone with a small urethral lithotrite, or to extract it with the long urethral forceps or a Thompson's divulsor, as recommended for urethral calculus. Failing in this, and in all cases of large stone, a perineal incision is required — in the median line for stones of moderate dimensions ; lateral or bilateral incision for stones of very large size. Urethral Calculus. It is not probable that primary acid stone forms in the urethra. Secondary alkaline stones do originate there in ulcerated pouches, behind tight stric- ture, in cavities left by abscesses, and perhaps in dilated follicles with narrow mouths. Commonly, urethral stone forms upon a nucleus sent down from above, a kidney-stone, or a fragment left after lithotrity. In young chil- dren a kidney-stone on its passage is often arrested in the fossa navicularis, or at the meatus; in older persons, in the more sensitive membranous urethra. Here it remains grasped by the muscular urethral walls, and grows by the addition, first of uric acid, and afterwards of phosphates. Ulceration may ensue and the stone find its way out spontaneously (Civiale).* How long ure- thral stone may be carried is uncertain. In a case recorded by Block,* sucha stone was extracted after a sojourn of twenty-eight years. Urethral stone may be single or multiple to any extent ; particularly is urethral calculus multiple when the floor of the urethra communicates with a pouch beneath. I have encountered this condition once, extracting five phosphatic stones. The size which urethral calculus may reach, and other points connected with the subject, may be illustrated by briefly citing some curious cases. ZeissP has collected a number of these, among them Wattmann's case, that ' Trans. Path. Soo. Lond., vol. xiii. p. 143. 1862. 2 Brit. Med. Journ., vol. i. p. 85. 1878. , 3 Ibid., vol. 1. p. 413. 1878. i Op. cit., p. 607. ' Acta Acad. Nat. Curios., torn. viii. p. 441. Norimbergae, 1748. « Ueber die Steine in der Harnroehre des Mannes. Stuttgart, 1883. VOL. VI. — 12 178 URINAKY CALCULUS. of a man of 80, who passed in all 300 stones by the iirethra. Pulido's scrotal stone, weighing 23 J ounces, taken out by incision through the scrotum; the patient recovered with fistula. Rathelot's urethral stone of 60 grammes, re- moved by incision, fistu-la remaining. Grtefe's scrotal stone of 26 ounces, which escaped spontaneously while the patient was making a straining effort. Ulecia's case of an 80-gramrae stone removed by incision. Civiale's case of the old man whose bladder and urethra were so full of stones that no one had the patience to countthem. Voillemier's stone of 2 ounces 6 drachms, which filled the entire urethra from the meatus to the membranous portion, being com- posed of several segments. Camper's 5-ounce stone cut from the membranous urethra. Maigrot's stone of nearly 8 ounces, cut from the membranous and prostatic urethra by the bilateral operation, with fatal result. Da Luze's 20J-ounce scrotal stone. Heath's cystine stones, and many others of interest. Vanzetti^ tells of a Russian, who at the age of one year passed a kidney-stone which became arrested in the fossa navicularis, and ulcerated its way through the floor of the urethi'a. In its sac, which did not communicate with the preputial cavity, it grew for eighteen years, and when removed consisted of one large and many small calculi, weigh- ing collectively 224 grammes, more than seven ounces. Bellamy' removed two phosphatic calculi weighing one ounce, from a sac beneath the urethra just in front of the scrotum in a man of forty. The sac was incised and a small orifice of communication was found between it and the urethra. The patient re- covered without fistula. Walton' refers to another such sub-urethral sac connected with the spongy portion of the canal. It contained 146 calculi, and is now in the jyRjseum of St. Bartholomew's Hospital. Kerr* gives another case, where a similar sac was found to contain 291 calculi, four of which were as large as pigeon's eggs. This patient was 21 years old, and had carried the sap from birth. Symptoms. — The symptoms of urethral calculus vary with the position of the stone. A very small stone in the membranous urethra may cause partial or entire retention of urine by exciting permanent spasm of the "cut-off" muscles. I have recorded a case° where retention, over-distention, and over- flow ensued from this cause. Impacted calculus at the meatus may also (but rarely) cause retention, and calculus impacted in a tight stricture may do the same. Otherwise urethral stone causes irritation, gleet, irritability of the bladder, tendency to erection, pain on erection, general inflammatory phenomena, etc., more or less intense, according to the position and size of the stone and the general condition of the patient. In front of the peno- scrotal angle, or at any part of the canal, if the foreign body be large enough, it may be felt from the outside. Diagnosis, in doubtful casesj is made by touching the stone with a probe or sound introduced through the meatus. Treatment. — A urethral calculus, when small and round, may be washed out of the canal by causing the patient to drink freely of mild, diluted drinks, or even of gin or beer. The patient should be instructed to hold his urine as long as possible ; then he should receive a small, subcutaneous dose of morphinfe or a dose of chloral, take a very hot bath, pass his water freely in the bath, and, when the stream is under full headway, arrest it suddenly by compress- ing the urethra, without relaxing the eftbrt at urination, and" then immedi- ately allow the stream to continue its flow. This sudden distention of the urethra will often dislodge a small stone. If such a small stone lies behind 1 Bull, de la Soc. Anat. de Par., t. xix. p. 16. 1844. 2 Trans. Clin. Soo. Lond., vol. xi. p. 22. 1878. 3 Trans. Path. Soc. Lond., vol. xili. p. 43. 1862. * New York Med. Journal, vol. xv. p. 283. 1872. « Med. Record, March 6, 1875. URETHRAL CALCULUS. 179 the bulbo-membranous junction, it is better to push it back with a large, blunt, steel sound into the bladder, whence it may be afterwards washed out through a tube or crushed. Or it might be washed back into the bladder by injecting warm oil through an open tube passed down to it. If it can be felt in or anterior to the perineum, March's' expedient may be employed. This consists in passing a very large blunt steel sound up to the obstruction, and then, by external manipulations upon the calculus alone, to push out at the same time both it and the sound ; the latter, of course, maintaining an open urethra as it goes. This is very similar to the expedient first suggested by Averill, that a large eound should be carried down to the stone, and, while the patient made a continued eifort to urinate, the sound should be withdrawn that the stone might more easily escape through the distended urethra. When the stone is large, rough, angular, or lodged behind a constriction, these means do not suffice. It must then be extracted with forceps, or the urethra must be incised. I have not found the urethral lithotrite of service, but believe that it might be available in a case of prostatic stone. Leroy •d'Etiolles's scoop, the crocodile forceps, and the long urethral forceps, in my hands uniformly scrape, pinch, or tear the urethra, and I no longer use them. The best instrument in my experience for extracting foreign bodies from the urethra has been Thompson's divulsor, designed for splitting strictures. My first success^ was upon a physician in whose membranous urethra a rough oxalate-of-lime calculus had been lodged for two months, causing repeated retention of urine, vesical distention, and overflow. The accompanying figure shows the stone in position as it was caught and extracted. The diam- Fig. 1198. Extraction of urethral calculus with Thompson's divulsor. eters of this calculus were | and -f-^ inch. The whalebone guide slipped easily past it, and the tunnelled divulsor followed without difficulty. The blades were separated, and, on being approximated, caught the stone and extracted it with ease. I found afterwards that this expedient had been previously re- sorted to with success by Dr. Westmoreland,* of Georgia. Subsequently I removed^ a pin from the deep urethra of the male with the same instrument, and without any difficulty. A divulsor with one cross-bar is preferable to those which have two. • Trans. New York State Med. Soc, p. 71. 1867. « New Yoi-k Med. Record, March 6, 1875. 3 Atlanta Med. and Surg. Joiirn., Oct. 1874, p. 415. * New York Med. Record, May 1, 1875. 180 DRINAKY CALCULUS. In trying to remove an angular fragment with any instruroent, there would he great risk of tearing the urethra, and in any such case, or where the stone is quite large, a single, clean, free, longitudinal incision of the urethra at the site of the stone is probably better than other methods. Such incisions heal rapidly if kept clean, and never, in my experience, yield fistulse. All that it is necessary to do, even when the cut is extensive, is, if the urine be ammoniacal, to inject a little warm water through the urethra, letting it pass out by the fistula after each act of urination, when the healing pro- cess is approaching its termination. If the urine be normal, no such precaution is usually necessary. All encysted urethral stones require treatment by exter- nal incision, and the wound must be handled afterward according to general surgical principles. There is a liability for fistula to remain in these cases- when the urethra is much thickened and chronically inflamed at the position occupied by the stone. Preputial Calculi. Sub-preputial calculi are common in China. In Europe and America they are rare. Among 15,000 patients examined by Albers,' in 1835, only one case of preputial stone was found ; while Lewin,^ among 36,000 hospital patients examined during fifteen years, found only three cases. Kerr,^ on the other hand, declares that the affection is not uncommon in China, and gives a. table of 18 personal cases. This malady is encountered at all periods of life. Uncleanness and a tight prepuce are prime factors in its production. The efficient causes are three : (1) calcification of smegma ; (2) retention of a small renal or vesical stone passed from above; (3) ammoniacal degene- ration of urine retained within a tight prepuce. (1) Calcified Smegma. — Every one who has removed from a child a tight,, adherent prepuce, has noticed the little white rolls of smegma imprisoned behind the corona glandis. If these miasses are retained long enough they acquire considerable size, cause the prepuce to inflame, and, finally, calcify more or less completely. They may subsequently act as nuclei for the- precipitation of urinary salts out of urine retained in the preputial cavity. Salkowsky and Zahn have examined these concretions, and have found fat^ fatty acids, lime salts (but no uric or phosphoric acid), epithelium, choles- terine, and bacteria. (2) Retention of a Small Urinary Stone. — This occasionally happens, but is exceptionally rare, because any stone that can pass the meatus urinarius can,, as a rule, also escape at the preputial orifice. It may lodge, however, and then becomes a nucleus for further calculous deposit. (3) Most common among the causes of preputial stone is tightness of the preputial orifice and consequent retention within its cavity of a few drops of urine. This residuum decomposes, and deposits triple-phosphate crystals and earthy-phosphatic dust in a magma of mucous colloid, and deposits continue from new portions of urine until stones of considerable size may be formed. The composition of preputial calculi is ordinarily a little urate of ammonium and much triple and earthy phosphate, with a great deal of mucus, "they are generally multiple. The least number found in any of Kerr's cases was two ; the greatest number, 116. They are usually facetted and queerly fitted • Journ. der Chir. und Aus;enheilkunde, Bd. xxiv. S. 247. 1836. ' Ueter Prseputialsteine, Berl. klin. Wochensohr., Bd. xvi. S. 177 und 197. 1879. ' New York Med. Journal, xv. p. 283. URINARY CALCULI OUTSIDE OF THE URINARY TRACT. 181 into each other and about the glans penis, being often laminated and concavo- convex in shape, sometimes capping the glans penis, and perforated to allow the passage of urine. In size these calculi vary from a minute cluster of crystals up to concre- tions as large as an egg. In one of Kerr's cases they weighed one ounce two drachms and two scruples, and Bardeleben' refers to a stone reported by Dumeril, which weighed two hundred and iifty-five grammes — about eight •ounces. This sounds improbable. No reference is given, and I have been unable to find the original report. Civiale^ speaks of a young man of twenty, with phimosis, who, after practising coitus for the first time, experienced pain and a purulent discharge. Civiale removed five stones as large as prunes. These had been felt by the patient, but he had supposed that it was perfectly natural to have them. The results of subpreputial stone are disturbance in the function of the penis, .atrophy of the glans, and more or less ulceration and inflammation within the preputial cavity. The symptoms are hard lumps felt beneath the prepuce, more or less pain, purulent discharge, interference witli urination and coitus, involuntary pol- lutions — in some cases, finally, impotence. The treatment consists in ablation of the prepuce with the calculi. Umbilical Calculi. Scattered instances are encountered of cases in which a calculus has been ■extracted or spontaneously voided from the umbilical region, a calculus pre- sumably formed in a pervious urachus, or a kidney-stone that has found its way out through this sti'ange channel. Umbilical stones are generally phosphatic. Among the classical cases may be mentioned that of Boj'er, who took twelve calculi out of a patulous urachus in a man of twenty-six, and that of Thomas Paget,' of Leicester, who i-emoved, from the patulous urachus of a patient, a ring-like, phosphatic concretion with a hair for a nucleus. An- other case, in a man of forty, is reported by H. C. Stewart.^ The calculus is called phosphatic, and described as being as largo as a hazel-nut. H. T>. Vosburg' reports the case of a mechanic of fifty, from whose umbilical region a phosphatic stone as large as a hickory-nut was voided. A similar stone had been passed by the man in the same way twenty years previously. These records, and those of J. Dixon'and several others, generally make no mention of urinary symptoms. The complaint is of local discomfort, the inflamma- tory swelling is obvious, and the foreign body is palpable. The latter seems fully capable of discharging itself under poulticing) and recovery follows. Urinary Calculi outside of the Urinary Tract. Wherever urine may trickle through a fistulous track, secondary urinary calculus may form, composed of triple and earthy phosphates, mixed often with some urate of ammonium. Stones also, starting within the urethra, may by ulceration get into the scrotum, perineum, or elsewhere, and increase enormously as outside stones. Civiale' speaks of a stone taken from the > Lehrbuch der Cliirurgie, 7te Ausgabe, Bd. iv. S. 354. ' Op. cit., p. 560. ' Med.-Chir. Trans., vol. xxxiii. p. 294. (See J'ig. 1114, Vol. V., p. 970, supra.) » Lancet, vol. li. p. 294. 1849. ' Lond. Med. Repository, N. S., vol. i. p. 291. 1824. * Ibid. " ' Op. oit., p. 689. 182 URINARY CALCULUS. scrotum of a boy of eighteen, which was three inches long and one inch circumference centrally. Lippoman' records the case of a man of sixty-eigt who, fifteen years previously, had had a scrotal stone, weighing one hundn and twenty grammes, removed by incision. A fistula remained. New stoi formation occurred, and Lippoman took out four phosphatic calculi, weig ing forty grammes, as large collectively as a goose-egg. Louis^ ' refers to i enormous perineal stone, weighing ten and a half ounces, removed by M. c Graigneau from a patient of fifty-eight, who had been cut for a stone at tl age of eight, and was known to have carried his perineal stone more the twenty years. In the same article he quotes a most remarkable case from dissertation by Denys de Launay, printed in 1700. Five years after litho omy, a large stone escaped spontaneously from the perineum of the patien and was discovered in his bed. The surgeon who was summoned, it related, then and there, through the same opening, withdrew from the blai der a stone which weighed seventeen ounces. Amussat^ records another case of spontaneous exit of vesical calculi i front of the scrotum. The patient was thirty-three years old, and had sufter'c for twenty years previously from urinary symptoms; the stones had ulcerate their way through the skin, and were pressed out by the surgeon. Thei were two stones fitted together, collectively one by two inches in diamete It is narrated of this patient that, up to a short time before the spontaneoi exit of the stones, he had urinated and performed the sexual act naturally. B got well without a fistula. Alex. Patterson* reports a case of perineal stor following a traumatism. The patient removed an ounce with a chisel, an the rest of the stone, weighing 14| ounces, came away spontaneously. Vaginal calculus is a similar instance of outside stone formation. Herbe: Cole* describes two such calculi taken from the vagina of a child of eigh one of which had a button for a nucleus. The total weight of these mixe phosphatic stones was four ounces. The floor of the urethra had sloughe( J. G. Wilson, of Glasgow,^ speaks of a uterine calculus, discovered an removed during labor, and believed to have been due to vesico-uterine fistuli The secretary of the Edinburgh Obstetrical Society reports another precisel similar case in the same journal. In neither instance was the fistula seei Old medical writings contain numerous references to uterine calculi, most ( which are undoubtedly examples of calcareous tissue change.^ I ha\ removed, by lithotomy, a large phosphatic calculus which had collected i the vagina of a lady who had suffered from vesico-vaginal fistula, and wboi vulva had been nearly closed to create a reservoir for the urine. The cavities of abscesses in the pelvis, perineum, and thighs, which con municate with the bladder, often contain more or less phosphatic calculov material. Thus it will be seen that after lithotomy leaving a fistula, in cases ( abscess or wound communicating with the bladder, or in connection wit a stone ulcerating its way out, phosphatic calculous material is quite sure 1 precipitate in any situation outside of the bladder. The symptoms of such stones vary with their position and size. The treatment is removal and operative closure of the vesical end of tt fistula, when practicable. • Wratschebuyja Wedomosti, No. 454, 1881 ; and Oentralblatt f. Chir., 23 April, 1881. 2 M6m. de I'Acad. Roy. de Chir., t. iii. p. 332. ' Rev. de ThSrap. Med.-Chir., p. 372. Paris, 1869. * Glasgow Med. Journ., June, 1884, p. 409. 5 Lond. Med. Reposit., vol. viii. p. 109. 1817. 6 Edinb. Med. Journal, vol. viii. p. 92. 1826. ' An interesting article by Louis, with ample references to previously reported oases in tl line, is found in the Mem. de I'Acad. Roy. de Chir., t. ii. pp. 130-150. Paris, 1753. STONE IN THE BLADDER. 183 Stone in the Bladder. The frequency of stone in the bladder, the serious discomfort which it occa- sions, and the brilliancy and success of the various operations for its removal, have made it a subject of great interest to surgeon?. The ingenuity of man has taxed itself to devise cunning instruments, monuments of mechanical skill, and to plan out bold operations for the relief of this painful disorder, aud probably no field in medicine or surgery has furnished a fairer harvest for the quack. Position of Stone in the Bladder. — A small calculus in a healthy blad- der lies at the neck of the organ when the latter is empty, and, during dis- tention, rests upon that portion of the bladder which is most dependent. The stone is freely movable, and consequently shifts its position with the varying posture of the patient. This change of position helps to explain the symptoms, relief during repose, aggravation by exercise when the foreign body is rubbed against the bladder's most sensitive portion, its neck. When the prostate is much enlarged, the stone habitually rests in the bas- fond behind it, and does not, in any ordinary position of the patient, ever touch the neck of the bladder except when the bladder is empty. In this way an old man may carry a small stone without suffering any of the cus- tomary symptoms. Such stones are frequently first detected by accident. When the bladder is sacculated, a stone may lodge in one of the pockets. Calculi, indeed, may form in these pockets and never leave them, thus becoming encysted stones, or the stone may lie partly within and partly without a pouch. A bilobed bladder may contain a stone' which may occupy the cavities alternately. A vesical tumor may fix the position of a stone. A calculus may form and remain in an abscess-cavity in the walls of the bladder. A stone may be adherent to an ulcerated surface, or to a tumor, or may be -fixed by partial impaction in the orifice of a ureter, or of the urethra. A stone may sometimes be retained by contraction of certain parts of the bladder-walls about it, thus being held behind the pubis ox at the fundus, there being no true adhesion. Encysted Calculus. — This variety generally commences as a sacculated stone, which, growing by concentric accretions, distends its pouch to its utmost capac- ity, the stone becoming larger than the mouth of the pouch. Such a stone may become hour-glass-shaped, for, after it has completely filled the pouch, it grows by deposit upon the exposed part presenting toward the bladder, and thus growing becomes in shape like a dumb-bell with a narrow neck. Such stones cause obscure symptoms and are often difficult to remove. When a stone in the bladder is very large, its position does not change. It becomes oval, and perhaps sends prolongations into the ureters and urethra ; the thickened and infiamed wall of the, bladder embraces it upon all sides and the urine trickles away, thei-e being perhaps true incontinence. Sjuch stones may be easily felt by the finger in the rectum. Adherent Calculus. — The possibility of the adhesion of a calculus to the vesical mucous membrane has been denied. It is certainly not as common as might be inferred from reading reports of cases of lithotomy, for it is not very exceptional to read that the stone adhered to the bladder and was ex- tracted with considerable difficulty. Undoubtedly this hypothesis is frequently suggested by difliculty in extract- ing a stone, especially if a rough side of the stone happens to come out cov- ' Case of Scarenzio, quoted by Gross (op. cit., p. 190). 184 URINARY CALCULUS. ered with a blood clot. But adhesion does occur in two ways: (1) ciystalli deposits form upon an eroded surface and are entangled in long gi^nulatioi and (2) the pressure of a rough stone may so irritate the mucous membra that granulations form and entangle themselves among the irregularities the stone. T. Gr. Morton' reports an operation for removal of a phosphatic calculus one hundred and sixty-five grains, which was firmly attached by a long pedii to the top of the bladder. All doubt about the adhesion of stones has be removed by evidence furnished at autopsies — such as the following : — A woman'' of 50 died at the Middlesex Hospital, England, of uterine and ovari cancer, having no symptoms of stone. A vesical calculus was found after death " flat scale or lamina about half an inch in diameter, situated at the base of the blad( about an inch from the opening of the uretiira." It reposed upon an ulcerated ar and minute shreds of tissue could be seen passing into the concretion which v composed mainly of phosphate of lime and crystals of oxalate of lime. Mr. Nui reports an example of adherent stone, as large as a nutmeg, composed exteriorly of u acid and phosphates, and found in a dead-house case. The stone was attached j behind the prostate. Finally, another post-mortem case is related by F. Powell.* occurred at the Necker Hospital, Paris, and Civiale exhibited the specimen to his cla The stone was phosphatic, projected three-quarters of an inch into the bladder, and h formed upon an ulcer at the base of the bladder, being firmly attached to the muscu coat. I have encountered adherent stone only once, and this was a thin laj mixed with granulations on the back wall of a bladder in a patient whon cut by the median operation, and from whom I extracted a small phospha stone. To remove the adherent laminated stone, I was obliged to use cons' erable force, and to scrape the mucous membrane bare, removing both grar lations and debris of stone. The patient made a good, recovery und injections acidulated with dilute nitric acid. When a stone is adherent, t symptoms it occasions are usually obscure and generally more like the syii toms of severe chronic cystitis than like the classical symptoms of stone. Symptoms ol Urinary Calculus in the Bladder. — There is no sympto; no set of symptoms, absolutely and invariably pathognomonic of the existen of stone in the bladd'er, except the physical sign furnished by touching directly or with an instrument. All so-called symptoms may be prese without stone. On the other hand, there is no ordinary symptom of calcul which may not be absent in a given case, and perhaps all of them may fa and the stone elude even a skilled searcher. A certain grouping of symptoms, however, is very suggestive of f presence of stone. These symptoms are : — 1. Frequency of urination, greater by day than by night, aggravated. 1 exercise, especially by jolting, and sometimes amounting to incontinence children, or even in an old patient with a large stone, or when a portion the stone grows into the urethral orifice. 2. Hsematuria, especially after exercise. 3. Sudden stoppage of the full stream of ul'ine, attended by pain and desire to strain. 4. Pain, sometimes referred to the rectum or perineum, more often to t' meatus urinarius, or, especially in the adult, to a point on the under surfa of the urethra, about three-quarters of an inch from the meatus. 1 Penna. Hosp. Reports, p. 49. 1869. 2 Van der Byl, Trans. Path. Soo. Lond., vol. Ix. p. 296. 18.')7-1858. 3 Med. Times and Gaz., vol. Ix. p. 579. 1854. ■' Ibid., vol. ixi p. 528. 1854. STONE IN THE BLADDER. 185 5. A tendency to pull at the end of the penis, especially in children and young adults, a habit which leads to permanent elongation of the prepuce in the former, and to masturbation in the latter. 6. Pus or stringy mucus in the urine. 7. Intense straining with severe pain during and after each act of urination, a pain often of agonizing intensity. These paroxysms exhaust the patient's strength, and during them he resembles a woman in the third stage of labor. In children, prolapse of the rectum is a common result of this straining, with fecal evacuations during the paroxysms, while adults complain of hemorrhoids, • pass blood by the rectum, and during the paroxysms suffer from unavoidable escape of intestinal flatus, and often of feces. The paroxysms vary in intensity and duration. 8. Reflex pains in the back, testicle, thigh, and not uncommonly in the sole of the foot (pododynia). 9. Priapism with, or moi'e often without, sexual desire. 10. All the symptoms of chronic catarrh of the bladder, especially in the case of secondary (phosphatic) calculi. Should several of these symptoms coincide in a given case, a suspicion of calculus is justified, but they may all occur when there is no stone, and stone may be in the bladder without furnishing any of these symptoms, while nothing is moi'e common in old men than for the presence of stone to be masked by the ordinary symptoms of catarrhal cystitis accompanying enlarged pi'ostate. Young people, as a rule, suffer more from stone than old ones. Their symptoms are generally more obvious, and an error of diagnosis from lack of symptoms is not likely to occur. With adults this is not always the case. I extracted by lithotrity a calculus larger than a pea from a gentleman who had passed it into his bladder during an attack of nephritic colic two months previously, and had not been inconvenienced by it in any way until a few days before applying to me. In many instances I have removed primary smooth stones of considerable size where the patients have been posi- tive that their symptoms only dated back a year or more, while a careful cross-questioning has been able to place the date of origin of the stone a number of years before, at some well-remembered attack of marked nephritic colic not followed by an escape of stone from the urethra. In one case a gentleman applied to rae for relief from slight irritability of the bladder, of recent occurrence. His urine was heavy, contained crystals of uric acid, and a few pus-cells. An alkaline diluent was ordered, and he was relieved and believed him- self well. After many months frequency of urination recurred, and then a search revealed the fact that the bladder was full of small calculi. I washed out six of these, as large as peas, through a Bigelow tube in my office, and felt many more larger ones rattling against it. This manoeuvre so relieved the patient that he pronounced himself well, and declined to submit to further instrumentation, and this in spite of my strono-est assertions that the bladder still contained stone. He simply declined to believe it, although I had felt them and made him hear the sound. A youth of about 18, with a congenitally long, tight prepuce, intensely nervous, and a masturbator, applied to me, complaining that he passed water too often, and was obliged to pull upon the penis and scratch the under surface of the urethra and the perineum during and after the act of urination, and to practise masturbation. He had no pain, no tenesmus, nor other symptom. The urine was not perfectly clear, but was no more purulent than might be expected in one who habitually urinated too often. As a first and necessary step in the case, I suggested circumcision. This was done, but no improvement followed. The patient was then searched, and a stone over an inch in diameter found and removed. 86 URINARY CALCULUS. ITo old man with prostatic hypertrophy and catarrhal disease of the bladder hould be allowed to go unsearched for stone, whether he has the so-called ymptoms of stone or not. In such cases there is very often no symptom iresent which could not be accounted for equally well by the catarrh of the iladder and the prostatic hypertrophy. But in these cases, when stone is- ound, its removal greatly comforts the patient, although it may not abso- utely cure him. But to return to a specific consideration of the separate ymptoms, any of which may be caused by stone, and the association of I'hich is nearly pathognomonic. 1. Frequency of Urination more marked hy Day. — This symptom is quite, onstant — except in the case of old men with prostatic enlargement. The atter almost uniformly causes nocturnal frequency of urination, and the n'esence of one or more small stones in the residual urine may not modify his symptom. Such a patient will urinate more often by night than by [ay, except during occasional exacerbations of the cystitis — "attacks of the tone" — when the'intervals by day will probably be shorter than they are by iia;ht. The stone in these patients never touches the neck of the bladder. "This rule does not hold good when in cases of enlarged prostate there is 10 residual urine, nor in any case where the stone is large. Here the diurnal requency of urination is more marked. A reason for this is not far to seek.. tVhen there is no bas-fond behind the prostate, the floor of the bladder is ibout on a level with its neck, and, when the patient is erect and moving ibout, the stone rolls against the neck of the bladder and irritates this sensi- ive part. During urination, also, the stone is driven against the vesical )rifice, and the tenesmus after urination — a blind efl:brt on the part of nature o get rid of the cause of annoyance — mercilessly grinds the stone against the nost tender part of the bladder. This is especially the case in young- ihildren. An irritation, even a cystitis, about the neck of the bladder, is in this way produced, and is mechanically aggravated bj' the movements of the stone hiring the day, while rest at night gives the tender vesical orifice a certain •espite. Considerable cystitis, even an ulcer,' may exist at the fundus of the bladder vith no frequency of urination to announce its presence ; but not so if the nflammation involves the neck of the bladder. In the latter case, urination s invariably too frequent, and especially so by day while the patient is con- scious of his sensations, and more particularly if he be moving about. With m enlarged prostate, residual urine, and a bas-fond behind the prostate in which the stone reposes, exercise does not rub the stone, if it be small, igainst the neck of the bladder, and urination does not raise it high enough to touch the neck of the bladder at all ; consequently^ the old man may continue, j,s is the wont of prostatic patients, to urinate too often by night, not being much annoyed by day except during the paroxysms of aggravation of the systitis, when the inflammation spreads to the vesical neck. Then the patient has " an attack of the stone." It is obvious why in irritability of the bladder 'neuralgia), ordinary cystitis complicating stricture of the urethra, acute prostatic disease, etc., urination should be more frequent by day than by night, although the patient has no stone; for in these cases the neck of the bladder is in a state of irritation, and the patient while awake is more con- scious of this irritation than during sleep. 2. Hcematima, as a symptom of" stone in the bladder, is traumatic in its origin. It arises from the direct mechanical injury done to the gorged vessels near the neck of the bladder by the stone, or, exceptionally, from the 1 See T. H. Banlett's case. Lancet, Feb. 5, 1876, p. 210. STONE IN THE BLADDER. 187 intensity of the cystitis alone. Hence it is valuable as an early diagnostic ^iixn of stone, and is generally noticed after exercise. It is rarely asbsent in children, frequently lacking in old men. In doubtful cases it may be recognized by the smoky tint of the urine, or even the microscope may be required. Hnematuria is so common that it has no value as a symptom, except when combined with others. 3. Sudden stoppage of the stream durivg urination is caused by the action of the stone as a ball-valve, the urine carrying it into the vesical orifice of the urethra. Children commonlj^ present this symptom, while old men frequently escape for the reasons given above. Conversely, the symptom occurs some- lime5 in cases of pedunculated prostatic tumor, and in cases of irritability and spasm of the cut-off muscles of the deep urethra, the cause of the spasm being generally reflex, and due to some disturbance of the prostate, bladder, or kidneys, or possibly sometimes to a stricture of the pendulous urethra. Occasionally the obstacle to urination is so great that the patient has to assume some unusual position in order to urinate at all. Eve, of JSTashville, lithoto- mized a patient who for two years before his operation had had to lie down when he wanted to urinate, and with a finger in the rectum push the stones in his bladder well up before the flow would start. One hundred and seven- teen calculi were removed from this patient by the cutting operation. 4. Pain in the bladder and penis is common with stone, especially in chil- dren ; old men may have little or none. When present, the pain is certainly aggravated by exercise. Encysted stones may cause but little pain. 5. The pain referred to the end of the penis is nearly as common in adults and old people with chronic cystitis without stone, as in those who have it. It is more intense with stone, and more often follows than precedes or attends urination. In young people, this pain, with tendency to pidl upon the penis, is nearly pathognomonic of stone. 6. Pus in the urine is more often due to other causes than to stone. 7. Vesical tenesmus, very intense in children, and in adults and old men during an " attack of the stone," is far from being confined to patients with calculous disease. It exists in many conditions of cystitis, from whatever cause, while its absence in the old maia with a small stone does not save him from the suspicion of having calculus, or excuse the surgeon for neglecting to search. 8. Distant reflex pains occur with stone, pains seemingly having no direct relation with the nerves supplying the bladder. Hunter's^ well-known case of the 'father of Lord Cavendish is in point, where a pain in the left arm existed as a reflex symptom of stone in the bladder. Pains in the back, loins, stomach, or thighs, may be due to vesical cal- culus and relieved by its extraction. Pododjaiia or podalgia, pain in the foot, is often a reflex symptom of irritation near the neck of the bladder or in the prostate, and may be associated with stone. It is very rare in young persons, quite common in old men, but more often absent than present in a ease of stone at any age. It is a pain in the foot, usually the sole, generally occupying one of the phalanges or the ball of the great toe. This pain may be a sharp sensation, a feeling of burning, or one of intense coldness. When due to stone it disappears with the extraction of the stone, but it may exist as a symptom of vesical, prostatic, or urethral disease, or may be due to gout or to alcoholic excess when the bladder is quite sound. T. B. Curtis^ has col- lected a number of interesting examples of this peculiar reflex pain, among them Pitha's own severe attack of cystalgia, which induced that distinguished. • Hunter's Works, Palmer's edition, vol. i. p. 321. ' Boston Med. and Surg. Journ., April 7, 1881, p. 316. 188 UaiNARY CALCULUS. urinary specialist to cause himself to be sounded for stone no less than fi timeswith negative result. Curtis also quotes Pitha's account of Dr. Reis< who, while suffering with stone, had a sensation as though his left foot^ w( placed upon a red-hot plate. The size of the hot spot diminished as the sto grew smaller at each sitting of lithotrity. Finally only a small point : mained. Pitha believed that he had removed every fragment. Search fou nothing, but the pododynia persisted and the patient declared that a smi fragment of stone certainly remained. Further search discovered this fn ment. It was removed, and the pain in the foot departed. Marshall Hall case of spasm of the sphincter ani is well known, and a very instructive cs is referred to by Gross,' as observed by John Duncan, of Scotland — that of five-year old boy with epilepsy of two years' duration, due to stone and ceasii permanently a fortnight after successful lithotomy. 9. Priapism. — This, like nearly all other symptoms of stone, is more coi mon in infants and young persons than in the adult or aged. It is n induced by or attended with sexual emotions in the adult, as a rule. A bi having the erection at first mechanically, may afterwards by association ha sexual inclinations with his erections, and may become confirmed in a habit masturbation. The erection is undoubtedly due to a turgescence of the vess( in the prostatic sious and about the neck of the bladder, and is irritative character. ' Yet occasionally erotic desires may occur as a symptom of stone late life. Such a case is recorded in a man of 85 by Bouvier.^ " 10. Symptoms of Chronic Vesical Catarrh.— The infant or j'oung pers( ■does not very often have this symptom of stone in the bladder, while in i old man it may be absolutel^'^ the only evidence of the existence of stone. Diagnosis of Stone. — The subjective "symptoms of stone are only sugg* live; no positive diagnosis can be made without the aid of physical mear 'The most common of these is sounding. Many devices have been resorted to to improve this manoeuvre, such as tl use of a peculiar polish upon the metal sound, that it may show a scratch, • the addition of a sounding,board to the searcher, or the attachment of a tul to connect the searcher with the surgeon's ear, or the adaptation of a micr phone to intensify the sound. These appliances are certainly not surgical. If the surgeon's hand is not de -cate enough to detect the contact of his searcher with a stone without the aid hearing, it will be wiser for him not to attempt to deal further with the'surge: -of the bladder. There is not generally any difliculty in hearing the sound oi ■Btone as it is struck, if the bladder contains some fluid, so that the end of t] searcher may be freely rotated and a little force be given to the stroke. Th sound aids the touch and helps the surgeon to differentiate between a ha and soft stone ; but the sound is very inferior to the sensation imparted the fingers through the searcher when it touches calculous material. The difficulty in finding stone is not to recognize it when it is touched, b to touch it at all, if the bladder is capacious ; for it may elude all search whi the bladder is full, and may be covered by the loose folds of the viscus ai out of reach when the bladder is empty. On one occasion, I was called to decide, in the case of an old man with a capacioi atonied bladder, whether stone was present or not. A prolonged search proved neg live, and the decision stood against the probability of calculus. As the bladder h ' According to my observation, the left foot is generally the one to suffer. ' Diseases of the Nervous System, p. 339. London, 1841. ■■" Urinary Organs, 3d edition, p. 197. 1876. 4 Bull, de I'Acad. de M^d., t. ii. p. 815. Paris, 1837-8. STONE IN THE BLADDER. 189 been injected with water, however, I asked the patient to stand up while I drew off the fluid throuo-h a soft catheter. This-he did, and as the last drops were coming away I recoo-nized the gritty feel of a small stone against the soft catheter, and verified the fact after" the bladder was empty by pushing tlie catheter back and forth several times. Lithotrity promptly relieved the patient. The Bigelow washing bottle and small tube would decide a case like this at once. Only two instruments are essential to discover a movable stone in the bladder — a searcher, and a washing bottle and metallic tube. In many instances, no especial form of instrument is necessary, and anything thrust into the bladder — a catheter, hard or soft, a common steel sound, or a lithoti'ite — strikes against the foreign body and reveals its presence even to the unskilled touch. Sometimes such instruments fail. A lithotrite is too heavy for deli- cate handling if the stone is small. A soft instrument cannot be directed over the various surfaces of the bladder. An instrument with a long curve has so wide a sweep that it cannot be manipulated at all except in a bladder full of water, and even then it is a physical impossibility to bring its tip into contact with the bas-f ond, jnst behind an enlarged prostate, the very seat of election for small stones in old -men. An instrument with a flat handle like that of the ordinary sound is not a good searcher, because it cannot be evenly and lightly rotated. A good searcher must be very light, composed of metal, and hollow, that urine may be withdrawn or water injected during the search without- removing the instrument ; it should have a slight bulb at its tip, and a cylindrical, corrugated handle, easy to grasp and to rotate. Probably the best instrument of this sort which has yet been devised, is Thompson's searcher. Fig. 1199. =jawt||J|WI-'Wl^i-t.»l'l Thompson's searcher for vesical calculus. This is usually made of white metal, graduated in inches, and furnished with a movable collar for roughly measuring the diameter of the stone. The common size for the adult is about 15 of the French scale, for the infant about 8. To sound for stone, the patient is placed upon a table or iirm couch, lying upon his back with the shoulders low, and the pelvis raised upon a hair cushion or otljer solid support so that it may be several inches higher than the shoulders. The thighs and legs are extended and lie flat. The bladder should, when possible, contain about three ounces of liquid. Special chairs and tables for sounding have been devised ; upon them the patient is strapped and the pelvis raised or lowered at will. Like the microphone and sounding board, these devices are more impressive than useful. The surgeon may prefer to have the thighs and legs flexed so as to relax the abdominal walls. This is a matter of indifference except when it is desired to explore the roof of the blad- der with the tip of the sound. In such case relaxed abdominal walls allow pressure over the bladder to bring all parts of the roof of the viscus within reach of the tip of the instrument. Most male adults can be searched as well without an anaesthetic as with it. With women and children anesthesia is always appropriate, in the former for reasons of delicacy, in the latter to restrain spasmodic ejection of the urine, and tc insure quiet manipulation, URINARY CALCULUS. lichis essential to all accurate searching.^ In any case when pain is great, B bladder vei'y irritable, or the patient nervous — and particularly for a ;ond search after one negative exploration — it is wiser to use ether than to ik failure without it. If the stone is movable and the bladder contains fluid, when the pelvis is Lsed higher than the shoulders, the stone will roll away from the tender ck of the bladder and rest at the fundus behind the trigone, where it is 3st easily found. The surgeon, standing at the patient's right side, introduces the searcher ntly, making its heel slide along the membranous urethra and the floor of e prostatic sinus, and aiding its passage through these segments of the ethra by pressing the skin over the pubes towai-ds the feet, with the left nd, so as to relax the suspensory ligament of the penis. In some cases the lole search is made less painful by keeping the ligament go relaxed through e entire sitting. When the heel of the searcher enters the bladder it should carried gently down the inclined plane formed by the base of the bladder itil it is arrested. Most often the stone will be struck at this point. If t, then the toe of the searcher should be gently rotated as far as it will go, st toward one and then toward the other side of the bladder, l^ext, the ircher is drawn forward, well inclined toward one side, and by I'otating the lindrical handle, gentle taps are given to the wall of the bladder, along the tire side as far forward as the instrument can be drawn. It is then slid ck to the fundus along the course it has just traversed. This double pass- e is repeated on the other side of the bladder. Ifext, the beak of the sound reversed, and the whole floor of the bladder is swept by to-and-fro lateral Dtions of its tip, as it is brought forward to the vesical neck and carried ck again to the fundus. If the result is negative, some water may be drawn ofi:' and the search re- ated, or, an expedient which I have found of great value, the patient may asked to stand erect with the searcher still in his bladder, and the urine a.y be drawn off through the searcher while he is standing, leaning forward ion a chair for support. As the urine flows away, the fceak of the sound ould be held quite near the neck of the bladder, and rotated from side to le until every drop of urine has passed. It is diflicult for even a minute 5ne to escape detection by this method. Should a stone be touched, the bulbous tip of the searcher passed over its rface will indicate ^^•hether it is rough or smooth. The character of the .ck produced by tapping the stone gives a clue to its composition, a dull, iv-pitched sound indicating a soft phosphatic stone, while a clear, high- tched click indicates uric acid or oxalate of lime. If, when the patient is quiet, the sound strikes a stone in being rotated first one side and then to the other, it is probable that two stoiies are present, itter evidence as to the composition of the stone is furnished by the condi- )n of the urine and the crystals it contains, than by the nature of the click. lus, if crystals of oxalate of lime, uric acid, cystine, or triple phosphates ound in the urine, it is fair to presume that at least the last coatings of e stone are composed of similar crystals. Another point in the diagnosis of stone is its size. This may be approxi- itely ascertauied as follows : The searcher is pushed to the back wall ot e bladder,- and then gently brought forward, tapping the vesical wall on eside upon which the stone lies until the latter is touched. ISTow the ding collar on the shaft of the instrument is pushed down to the meatus. The injection of a four-per-oent. solution of the hydrochlorate of cocaine In some cases makes i use of ether unnecessary. STONE IN THE BLADDER. 191 and the tappings on the surface of the stone are continued as the searcher is withdrawn, until a certain tap clears the stone and strikes the bladder in front of it. The graduations on the shaft of the searcher, between the sliding collar and the meatus, mark approximatively one diameter of the stone. The actual diameter is best ascertained with a small lithotrite, and multiple stones are best demonstrated by seizing one of them quite firmly in the jaws of the lithotrite, and using this as a searcher to strike one or more stones on either side. The size of a stone may often be estimated by passing one or two fingers into the rectum and feeling the stone between the finger and the searcher, or, in a thin person with a large stone and small prostate, by bi-manual pal- pation, one or two fingers in the rectum, while the other hand pushes down the abdominal wall over the bladder. With large prostate and deep bas-fond, a finger in the rectum will sometimes elevate a small stone within the reach of the searcher. . A stone may still escape detection by being encysted or situated in a hernial pouch, or behind an hour-glass contraction, or wrapped up in a blood-clot, or in a mass of mucus so as to yield no sound or sensation of hardness to the searcher. In cases of grave doubt, the bladder may be examined with straight and long curved sounds as well as with the searcher, and by lifting the floor and depressing the roof of the bladder so as to bring the point of an instrument into contact with every part of its wall. The lithotrite also would be of ser- vice in finding a stone enveloped in blood or mucus, as would extreme disten- tion of the bladder with warm water, and a change of position to throw a stone out of a large pouch or double bladder, if there should be any reason to believe this condition to exist. Furneaux Jordan,' in one case of tight stricture, sounded with an acupuncture needle through the perineum, and struck a stone. But all these means occasionally fail when a stone is very small. In such case no searcher approaches the accuracy of the washing bottle and small metallic evacuating tube, straight or curved — the Bigelow apparatus for wash- ing in litholapaxy. Such a tube being introduced, and the apparatus so man- aged that not a particle of air enters the bladder, the swash of the water will certainly bring any small stone into contact with the tube, and the sharp click can be plainly felt by the surgeon or heard by any one placing his ear over the bladder. This means in my hands has proved successful in more than one instance when all other efforts had failed. Notwithstanding the accurate means of investigation now possessed by the surgeon, it is still possible occasionally to overlook a stone, and in a doubtful case at least two examinations ought to be insisted upon before giving a final opinion ; and the second of these examinations should be practised with the patient under the influence of ether, and should be made with the searcher, washing bottle and tube, and lithotrite. Even then an error may be made: a small tumor, encrusted with crystals, may be declared to be a stone ; or a calculus may be overlooked, lying in a cyst, sacculus, or pouched ureter, or shrouded in a blood-clot or mass of viscid mucus. The fact, moreover, is of record that the very best surgeons (Cheselden, Morgagni, Abernethy, Dupuytren, Chopart) have failed to find large stones in the bladder, which an autopsy has revealed, while others, equally distin- guished, have cut for stone and found none. To say nothing of a host of piinor operators, the great Cheselden cut three times for stone and found nothing. Dupuytren, "Roux, and Crosse, too, committed like errors. ' Surgical Enquiries, 2d ed., p. 284. London. L92 URINARY CALCULUS. Chronic thickeiiiug of the bladder, with or without tumor, ulcef, or hete: jlogous deposit; feces in the rectum ; pelvic exostosis; a displaced uterus; th lard pelvic brim, with a thin bladder-wall lying against it; a prominent sacra mgle, and many other physical irregularities, have been mistaken for stont In one case with whicli I am familial', a small stone was felt in a child. The laters )peration was performed. The bladder was distended, and a gusli of urine followed th withdrawal of the knife. A search for stone was now instituted without result, whe inally it occurred to the operator to examine the clotted blood in the vessel containin ;he urine, and there a small stone was found, evidently having been expelled by the firs ;ush of urine. ITourse is quoted by Gross' as reporting a case wherein nine calculi wer odged in six sacculi ; and, although stone was once touched by the searcher lumerous subsequent examinations failed to detect it. He refers also ti Pott's case of calculus in a hernial pouch of the bladder situated in the groin md to Hartmann's, where a stone weighing three ounces was found in ; iiernial pouch of the bladder situated in one of the labia of a woman. When very large stones have escaped detection, it is supposed either that th sound entered between the stone and the wall of the bladder, and was ther 30 tightly held that it could not be rotated to strike the stone (but why th gritting sensation was not experienced, it is hard to understand)— or that th searcher failed to enter the bladder at all, being rotated in some dilated poi tion of the urethra mistaken for the bladder, as in two cases noted by Pelk tan.^ A pouched prostatic sinus may also be mistaken for the bladder in ai 3ld man, and thus a stone be overlooked. I have encountered an instance o t.his sort, and others are on record in which, the prostate being destroyed b; suppuration (MuUer, Civiale), the patient has been cut into this cavity anJ QOt into the bladder, and no stone has been detected until subsequentl; revealed by an autopsy. Hence it would seem that the masters of surgery in former daj's had goo( reason in formulating the cardinal rule in lithotomy, that even after the pre sence of a calculus had been recognized, and the patient was placed upon th table, if the stone could not be struck then and there, it was better to defe the operation. It is diiBcult to imagine sometimes what it has been whicl bas deceived the skilled touch, but grave errors have arisen, and their lessoi must not be disregarded. In many eases where a doubt suggests itself tha there may be no stone, although something is struck by the searcher whicl resembles stone, a small lithotrite, by grasping the foreign body and movinj it, will clear up all uncertainty. Finally, it must be remembered that sounding a patient for the first tim is an operation not devoid of risk. Fatal cystitis has been occasioned by i in inore than one instance (Prout, Fletcher, Civiale, Crosse, and others). W^ tmnecessarily prolonged, rough, or repeated manipulations should be pra( tised at a first sitting, or indeed at any time. The Preventive Treatment of Stone. Prevention, as a treatment for expected stone, is generally first thought c ifter a patient has passed a renal concretion. But the question may arise earhe than this, in connection with a possible inherited tendency to calculous diseas( jv in directing a course of life for a patient who persistently voids large quant ties of crystals. Of the two great classes of stone, one, the primary, is of const ' Op. clt., pp. 205-207. ' Segalas, Essai sur la Gravelle et la Pierre, 2me ^d., p. 155. 1839. PREVENTIVE TREATMENT OF STONE. 193 tutional or diathetic origin, and requires general measures to counteract the tendency to its production ; the other, secondary, is of local origin, and local preventive measures are here vastly more important. The latter are almost too obvious to require mention. They involve all the physical means employed for the relief of obstructive urethral and prostatic disease — removal of nuclei, the use of the catheter, vesical irrigation, medicated injections, and other means for controlling vesical catarrh — for without catarrh it is impossible for secondary stone to form. In the kidney and ureter it is often impossible to apply local measures, and here it is, therefore, that secondary stone once originated most often goes on, uninfluenced by any measure brought to bear against it. A somewhat brighter future for these conditions is promised by nephrotomy. There are certain general measures, however, which seem to oppose secon- dary stone formation even in the kidneys ; these are the use of — (1) A milk diet, when well borne by the stomach ; (2) An abundance of bland, diluent drinks ; (3) Tonics; (4) Mineral acids (sometimes) ; (5) Alkalies (sometimes) ; (6) Benzoic acid — occasionally ^or the salicjdates. (1) A milk diet, if well borne, sometimes I'educes catarrhal inflammation of the urinary mucous passages to a remarkable extent. Should a nucleus be present, however, no amount of milk diet can cure, although it may mod- erate, a local catarrh of that portion of the membrane upon which the foreign body lies. (2) Diluents act by lessening the irritation of the mucous surface through the greater blandness of the fluid which bathes it. In this way most of the mineral waters act which seem to have power in reducing chronic catarrhal urinary conditions. Such waters as the Bethesda, Poland, Clysmic, Glen Sum- mit, Mountain Valley (Arkansas), certainly do not act by virtue of any min- eral ingredients, and are not, as a rule, much more valuable than filtered rain water taken vei-y freely. They wash out the urinary passages and reduce irri- tation, but they do not dissolve stone, either alkaline or acid. The waters of Wildungen and Contrexville probably act in- a similar manner, although an especial claim is made for the latter that it dissolves mucus and tends to cause a diminution in the excretion of phosphates. I have no personal knowledge of the truth of these claims. (3) Tonics act by improving the digestion and the vitality of the tissues, and (4) mineral acids act in the same way, and not directl}^ through the urine. In a catarrhal condition of the urinary organs the administration of acid generally does not render the ammoniacal urine acid, but, by making the urine more dense, it may increase the grade of the catarrh, and conse- quently intensify the alkalinity of the urine. (6) Alkalies, on the other hand, sometimes agree very well, and by diminishing the acidity and acridity of the urine at the kidney, lessen the grade of the catarrh, and sometimes even gradually restore normal acidity to the'urine. (6) Benzoic acid in 10-grain or even larger doses, in caiDsules, will sometimes arrest ammoniacal changes and allay catarrh, but it is a substance not well borne by most stomach's. Salicine, salicylic acid, the salicylates, and even oil of wintergreen, chlorate of potassium, and naphthaline, have been found serviceable in some cases. Sometimes useful, they are generally powerless to do good, but where they do act their influence is antagonistic to secondary phosphatic stone formation. Concerning the formation of primary acid stone something more may be' VOL. VI. — 13 4 UKINAEY CALCULUS. id. It is difficult to speak definitely of this class of cases, with the excep- >n of those included in the uric-acid group. A primary acid nucleus most often composed of uric acid and the urates, and inherited tendencies stone usually manifest themselves by precipitation of the same salts. Here it is, fortunately, that preventive measures are of most avail ; indeed, this direction only has any serious advance been made. A tendency tolithiasis being recognized' by the constant or intermittent currence of urates and uric acid in the urine, and especially after one dney stone has been voided, the problem which arises is. How shall another cleus be prevented from forming ? The answer may be best given under z heads : — (1) Regulation of diet. (2) Attention to exercise. (3) Promotion of elimination by other channels. , (4) Dilution of the urine. (5) The use of solvents. (6) Attempts to avoid crystallization in colloidal forms. (1) Thompson has given this subject more study than any other surgeon, d with a greater measure of success. Uric-acid causation unquestionably s behind the kidney, in the state of the blood furnished to that organ ; and e blood again derives its qualities to a considerable extent from the quan- y and quality of the food, the state of the digestion, and the effect of air d exercise upon the blood. Physiology would naturally suggest that len the urates are in excess, the diet should be limited in its nitrogenous sments. In practice, however, as Thompson has taught and experience ily proves, the very opposite is the case, and it is the alcoholic, saccharine, d fatty elements of food, and not the meats, which have to be cut off when ) propose to reduce habitual tendencies to uric-acid formation. The reason for this seems to be that these elements tend to make the liver iorpid," as it is called, and in some way to interfere with the proper iboration of the blood. In practice, manifest advantage arises from giving up alcohol, especially all eet fermented and malt liquors, and the stronger wines, Madeira, port, and erry. Beer, champagne, and liqueurs are very harmful, unless an exception made for very dry champagne. If some alcoholic stimulant must be taken [• the stomach's sake, or on account of advanced age, or for other reason, choice should be made among the sound, light, red wines of France — the )rdeaux wines — and the thin Rhine wines ; or, if more alcohol be required, ittle very old brandy, whiskey, or gin, well diluted in water, may be used. Sugar in any form is harmful, and should be discarded as far as possible )m the dietary. Of the different kinds of fat, the same remai'k holds good, t to a less degree. Fried fats, rich gravy, and pastry are to be condemned ; en milk and pure butter are sometimes harmful, but not always so. These ;ter substances do not alter in anj' degree the solid constituents of the urine, if i may place confidence in the results of the experiments of Dr. Bocker, as oted by Garrod,* which show that "no influence whatever is exerted on the cretion of water, urea, uric acid, or any other constituent of the urine, by king from about a quarter of an ounce to three ounces of butter daily." A proper diet is one composed of meat, especially poultry and fish, bread, the cereals, green vegetables, salads, and fruits, with sometimes milk, tter, and eggs, if the latter substances agree with the patient's digestion. Certain kinds of food appear to possess special value. The experiments ide conjointly by Heller and a friend, also referred to by G-arrod,' are sugges- Urio Acid, its Physiology and its Relations to Renal Calculi and Gravel. Lancet, April 21, ;3, pp. 670-673. PREVENTIVE TREATMENT OF STONE. 195 tive. Heller first found out how much uric acid he and his friend excreted daily under a stated diet. Then Heller lived for a week on rye and wheaten bread, his friend on rye bread alone, water being their only drink. The uric acid was gradually replaced by hippuric acid, and finally only a trace of it remained in Heller's urine, none at all in the urine of his friend. During the next week, having returned to ordinary diet, the hippuric acid diminished and the uric acid reappeared. (2) Exercise in the open air is a prime factor in the reduction of uric-acid ■deposits. Any one subject to these deposits can bear testimony to the value of a summer in the woods, or of horse-back exercise persistently practised. (3) The elimination of uric acid and its compounds by other channels than the kidney, is an important element in the preventive treatment of primary stone. It is on a par with the treatment of gout as carried out at Carlsbad, and indeed the dietary regulations are founded on the same basis. The plan is to act upon the liver and intestinal glands by one of the natural mineral waters containing sulphate of sodium and sulphate of magnesium in solution. Thompson has proved that a dose of one of these waters will be amply ■cathartic, although the actual amount of sulphate of magnesium and sulphate ■of sodium in the draught be only one-fourth the amounf required, if the same ■drugs are bought of the apothecary. The waters which are most suitable are the Hunyadi Janos and the Fried- riehshall. The former is nearly three times as rich in the requisite ingredients as the latter, and may be used in a correspondingly smaller dose. Both should be taken warm, fasting in the morning, and in some instances the ■eftect is enhanced by diluting the draught, the Fried rich shall one-third, and the Hunyadi more than one-half, with hot water. The daily dose should be sufficient to cause one free and rather watery stool after breakfast, or even two at the beginning of a course. A small claret glass of Hunyadi, or a moderate tumblerful of Friederichshall, is the customary dose to begin with, but this may be reduced in most instances as the course goes on. At the beginning of such a course, and occasionally during its continuance, a blue pill may be administered with advantage, or a compound rhubarb pill (5 grains) with the addition of |— jV grain of blue pill (Thompson). Such a course should continue about two months, the mineral water being gradually reduced in amount each morning, and replaced by hot Carlsbad water, at a dose of about one tumblerful. The course may often be repeated with advantage after an interval of three or four mouths, and many patients will continue a light morning dose for years, with apparent advantage and no ■depleting effect. Where the patient is poor and cannot afford mineral waters, an efficient morning dose of Glauber's salt, with a slight addition of sulphate of magne- sium, may be substituted. This course freshens the patient, diminishes •dyspepsia, and increases the sense of comfort and well-being, while it unmis- takably reduces the amount of urates and uric acid in the urine. Another method of reducing the amount of uric acid is now undergoing investigation. Garrod has observed that the urine of a sucking calf contains uric acid, but that when the calf gets older and lives on grass, the uric acid •disappears and hippuric acid takes its place. Garrod also found that if the urine of a herbivorous animal was added to human urine and allowed to stand, no uric acid could be detected in the specimen, and that a solution of uric-acid calculus mixed with carbonate of lithium and added to the urine of a horse, failed to yield, when kept a few hours, any uric acid. The inference was plain, that the renal epithelia of the herbivoi'a were capable of excreting uric acid, but that the hippuric acid in solution subse- quently destroyed it. 196 URINAEY CALCULUS. Garrod also investigated the conversion of benzoic acid into hippxiric acid in the animal economy, and is now experimenting with hippurates and ben- zoates of sodium and potassium with results that he at present only indicates as having given him "great advantage" in the treatment of gout, of gravel,, and of calculus.' (4) Simple dilution of the urine is another useful means of counteract- ing tendencies to acid stone formation. If properly carried out, no harm, comes of it, and at least negatively it has value, for the greater the quantity of water with a given amount of solids to be eliminated, the less will be thfr tendency to precipitation. Many individuals with concentrated acid urine- have very little thirst, and are habitually light drinkers of water. A habit of drinking water freely may be encouraged. During meal times it is better to drink hot than cold water. The digestion is aided by such draughts. Between meals at any time a glass of water may be taken, and if it is not too- near a meal, iced water is as harmless as anything else. On retiring, also, a glass of water is particularly useful, since it serves to dilute the urine secreted during the night, which is more concentrated than that secreted at any other time. Filtered rain water is excellent for these purposes of dilu- tion, or any of the simple diluent spring waters — the Bethesda, Poland,. Mountain Valley, etc. (5) The use of solvents is a very prompt method by which urates and uric acid may be made to disappear, but it has less real value than those already mentioned for continuous use. By administering the citrate or the acetate of potassium, or the bicarbonate of sodium or potassium, or by the use of Vichy, Buftalo Lithia, or other natural alkaline mineral waters, the urates and crystals may usually be made to disappear from the urine, and the uric acid storms, as they have been called, may be calmed. These agents are of undoubted value, and in many conditions approaching an emergency can hardly be dispensed with. Their promptly effective action so long as the stomach is tolerant, is a valuable aid to the surgeon. For prolonged use, and when the patient's tendencies toward acid formation are very strong, the alkaline solvent treatment is not always available, since it may induce dyspepsia and lead to anaemia. When alkalies are used, they should be exhibited during the third hour after eating, at the time when the- acid in the chyme is neutralized, or has been reabsorbed. Then the alkali is promptly absorbed and exerts its maximum effect upon the urine.^ In my experience, if a course of alkalies is suitable and necessary for a very long period in the preventive treatment of stone, the boro-citrate of magnesium is a good preparation. This nearly tasteless powder may be taken dry upon the tongue in a dose of ten or more grains, and washed down with a swallow of water. It seems to tax the stomach less than the citrate of potassium, and some patients assert that it is of service. Like other alkalies, it should be given during the third hour after eating. The formation of oxalate-of-lime crystals, as is well known, may be modi- fied by the use of dilute nitro-muriatic acid, and the aid of this drug may be invoked in acute outbursts of uric-acid or oxalate-of-lime crystallization when digestion is at fault. To prevent cystine formation, Beale^ uses carbonate of ammonium freely. (6) An attempt to avoid crystallization in colloidal forms, is, perhaps, the most scientific direction that the preventive treatment of stone can take, but it is at the same time the most vague. The main colloid for acid stone is 1 Loc. oit., p. 673. ' Ralfe, Observations on Urinary- Pathology and Therapeutics. Lancet, Nov. 9 1879. 3 Lancet, August 30, 1884, p. 263. SOLVENT TREATMENT OS STONE. 197 probably mucus, and a little scratching of the mucous membrane bj' the sharp points of crystals, or irritation by concentrated urine, is sufficient to -call out enough mucus to act as a colloid and determine the character of the •crystals. Hence all efforts to make the urine bland and abundant are justified on purely scientific grounds. But the question is, Does any substance exist which militates directly against stone formation, either by reducing the colloids •or preventing their action? To this no answer can be given, but a substance has of late been brought before the notice of the profession, which pei'haps acts in this way. I refer to the fluid extract of hydrangea which has been mentioned during the past few j-ears a number of times in the American medical weeklies, as an agent calculated to arrest paroxysms of renal colic, ^nd even to relieve them when present. My experience with this drug is limited, but I think that I have seen some slight advantage follow its use in half-drachm or drachm doses after meals. Cider also, as an habitual drink, has given good results in my experience. The cider need not be absolutely sweet ; ordinary bottled cider answers all purposes, or even cider which is :slightly hard. Electrolytic Treatment of Stone. That the electric current influences crystallization has long been known. Ord states that magnetic currents cause oxalate of lime crystals to reach an unusually large size, and refers to Bridgman as asserting that submorphous forms of crystals (colloidal) appear sooner under a mild galvanic current than they would otherwise do in the same liquid. The construction of stone may thus be aided by electricity, and disintegration of calculi has been efi:ected by the same agency. Bouvier-Demortiers first thought of dissolving stones with the voltaic pile, and Gruithuisen, in 1813, found experimentally in the laboratory that with platinum points and a number of elements stones might be pierced by this means. In 1823, Dumas and Prevost' found that a fusible calculus of 92 grains, under the action of a pile of 120 couples, recharged hourly, lost 12 grains in 12 hours, and after 28 hours became a friable mass which ■crumbled on the slightest pressure. They experimented on a dog, and found that the process could be conducted without injuring the bladder. They then ■experimented in the. human bladder, but, with negative results, since uric-acid •calculi, being formed of one substance, were not suitable for voltaic dissolu- tion. Dumas and Prevost injected into the bladder a solution of nitrate of potassium, hoping to make by electrolytic action a soluble urate of potassium, but the experiment proved negative. Leroy d'Etiolles followed up these attempts, but came to negative con- ■clusions. Bence Jones did the same, in England, in 1852. Erckmann,^ under the auspices of Dr. Raymond, announces some successful experiments. Leroy d'Etiolles (fils),^ who saw the patients of Erckmann, does not con- sider the facts conclusive or the cases established, and to-day electrical litho- malaxy has no recognized place among the legitimate operations for stone. Solvent Treatment of Stone. , Pliny* speaks of the ashes of snail-shells as a proper solvent for stone. Hippocrates and Galen do not appear to have had confidence in any sub- ' Annales de Chiraie et de Physique, Juin et Jiiillet, 1823. 2 La lithomalakie electrique. Paris, 1863. ' Op. cit., p. 540. * Hist. Nat., lib. xxx. cap. viii. 198 URINARY CALCULUS. stance, but since Pliny many investigators have given time and attention to a study of the medical treatment of stone. The laity almost uniformly believe that stone may be dissolved by medicine, and tons of pills and pow- ders, rivers of supposed solvents, and oceans of mineral waters have been consumed by the victims either of stone or of their imaginations, in the delusive hope of cure. Aretseus, in the second century, introduced quick- lime as a stone-solvent, and Paulus ^gineta, in the seventh century, mentions- that some persons thought well of goat's blood. Avicehna (tenth century} was quite convinced of the efficacy of the impure carbonate of potassium, but his prescriptions were nauseating compounds containing a number of absurd ingredients in addition to the usual alkali, and his methods did not retain favor with the profession. Later authors, from Basilius in the fifteenth century to Mrs. Joanna Stephens in the eighteenth, used the same alkalies — potassa, lime, and soda — in simple combinations with vegetable diuretics, given by the mouth or injected into- the bladder. Many contented themselves with such remedies as the infu- sions and decoctions of various plants, roots, bulbs, or fruits, carbonic acid in water, distilled water, goat's blood, etc. The names of Blackrie, Chittick,. Darci, Morand, and Girardi become familiar in looking over the literature of this subject. In France the first sign of intelligent direction of the solvent treatment appeared when Fourcroy and Vauquelin did what they believed to be wise in using dilute acids in the treatment of alkaline stones, and alkalies in that of acid concretions. No remedy reputed to be a stone solvent has had such renown as that of Joanna Stephens. Physicians and patients in England became generally convinced of its value, and the English Parliament, after a long inquiry, under full conviction of its worth finally, in 1739, bought the secret of Mrs. Stephens at the modest figure of £5000. The medicines so purchased proved to be a powder of calcined egg-shells and snails ; a decoction of herbs with soap, ashes of swine's cresses, and honey ; and a pill of calcined snails, wild-carrot seeds, burdock seeds, ashen keys, hips and haws — all burnt to blackness — soap, and honey.' These com- pounds apparently effected wonders as long as they were secret remedies, but, their composition once disclosed, they soon lost their charm and fell into.- disuse. So celebrated did these remedies become that Morand was appointed by the French Academy to go to Loudon to look into the merits of the Cheselden cutting operation, and the cures by the Stephens I'emedies. On his return he reported^ that the remedy had been tried upon forty patients, in twenty- two of whom stone had been touched with a sound. Five of the latter were finally cut, and their stones showed no evidence of erosion. Morand found that some patients were soothed, and that some passed small calculi, worm- eaten in appearance, after taking the remedies ; therefore he thought favor- ably of the medicines, although none of the patients reported as cured would allow themselves to be sounded again. But the most pungent criticism upon the remedies of Mrs. Stephens, is that each of the four patients whose cures were vouched for by the trustees- appointed by the Government, and who had refused to allow themselves to be sounded, died with stone in the bladder, as proved by post-mortem examina- tion in each case.* ■ Gentleman's Magnzine, June, 1739, vol. ix. p. 291. ' M6m. de I'Acadfimie des Sciences, Annees 1740-41. ' Alston's Lectures on the Materia Medica, vol. i. p. 268. London, 1773. SOLVENT TREATMENT OP STONE. 199 This experience was repeated in other alleged instances of cure, as may be seen by looking into the rather extensive literature of the period.' Many patients, on the other hand, who took these remedies, had no stone at all, but being relieved by the alkali of certain symptoms, testified that they had been cured of stone. As soon as it began to be supposed that the lime in burnt egg and snail- shells effected the cure, Whytt, of Edinburgh, devised a cure by lime-water and soap, and published, among many others, the case of one David Miller, who took three pints of lime-water and an ounce and a half of Castile soap daily, and passed some broken fragments of stone, and in whose bladder, when he died eleven years subsequently, no stone was found. Mascagni, in Italy, published his own ease as an example of cure by drink- ing Seltzer water and a weak solution of bicarbonate of potassium. He had lumbar pains, and passed some acid gravel during the treatment. Heller^ reports the cure of a case of urostealith calculus, by administering two drachms of carbonate of sodium daily. The patient voided considerable masses of urostealith, and was pronounced cured in a fortnight. Chevalier and C. Petit, in France, stand at the head of the investigators into the value of natural mineral waters, notably Vichy, in dissolving stone ; but some of their conclusions have not been confirmed, as, for instance, that triple-phosphate calculi are acted upoii more efficiently by Vichy water than stones of uric acid (Petit) ; and Petit again made a famous mistake^ in assert- ing the cure of stone in a well-known gentleman, from whose bladder a stone as large as a hen's egg was removed after death. The committee appointed by the Academy of Medicine to examine the claims of Petit, decided against the probability that urinary concretions, " large enough to constitute actual stones," could be cured by the waters of Vichy ; yet even to this day patients with stone and gravel go to Vichy under the belief that their stones can be dissolved. The most serious scientific effort which has been made to establish the solvent treatment of stone, is that of Roberts,^ of Manchester. Basing his conclusions upon a large number of careful experiments, performed upon stones with various alkaline solutions out of the body, Roberts finds the car- bonate of potassium to be the best solvent for uric-acid concretions ; nauch better, he thinks, than the salts of lithium or sodium. If the solution be too strong, an alkaline bi-urate coats the stone, and further solution ceases, but such excess of alkalinity can hardly be maintained in the body. The citrates, acetates, and other alkaline salts given by the mouth, are all eliminated as carbonates in the urine, and the salt which in practice Roberts finds most effective, and least likely, by long-continued use, to upset the stomach, is the citrate of potassium. But the citrate of potassium may prove to be too diuretic, making the alka- line solution of urine too feeble to be effective. In such case he substitutes for it, in part or wholly, the bicarbonate of potassium or sodium, or the liquor potassse. The proper dose of the citrate, for an adult, is from forty to fifty grains in a gill of water every three or four hours, so that the daily dose shall be six drachms. The uriiie may become cloudy from precipitated phosphates, but this does not hinder solution, which continues unless the urine becomes ammoniacal, when all action ceases. Hence an essential condition is that ' James Parsons reports twelve such cases. (A description, etc., London, 1142.) Horace Wal- pole's case is in point. Thompson quotes it, and Le Roy d'EtioUes (fils) alludes to several very ' interesting cases. 2 Heller's Archiv, Bd. ii. S. 2. 1845. ' Leroy d'fitioUes (fils), Traits pratique de la gravelle, p. 531. Paris, 1869. < Urinary and Renal Diseases, Second American Edition, pp. 298-321. 1872. 200 URINARY CALCULUS. the urine shall be normally acid at the start, and shall not become ammonia- cal during the course of treatment. Roberts has continued these high daily doses of the citrate for many months without producing anaemia or gastric derangement. On account of the vigorous presentation of his method by Roberts, no opposition has been made to his conclusions, as a rule, and his faith in the .citrate of potassium has caused it to be generally accepted by the profession ; but quite recently Garrod' has repeated the experiments of Roberts, and claims that the latter was wrong in his conclusions as to the relative efficacy of the potassium and lithium salts. He shows, indeed, that " the results were, in each case, more than fifty per cent, in favor of the carbonate of lithium." Gai-rod explains Roberts's error on the ground of his having used an impure lithium salt, or having employed only very weak solutions. The irritating action of litbinra salts upon the stomach is also denied by Garrod, who appears to use the carbonate, but is not specific in his direc- tions. He says : — The only effect I have ever noticed has been that, when the quantity has been in- creased beyond a certain amount, a little tremor of the hands is produced, which passes off at once on the diminution or omission of the dose of the salt. I have known patients of their own accord continue the use of lithium salts for more than ten years, with the effect of entirely preventing the recurrence of the symptoms to remove which they had first been prescribed, and without the production of any injurious effects. For my-- self, I have not the least doubt as to the value of lithium salts as therapeutic agents, and am convinced that, by their employment, depositions of uric acid in the renal organs can, to a large extent, be prevented. Free dilution and administration upon a fasting sto- mach are points of much importance, which should be attended to in the administration of alkaline remedies. I have been much in the habit of using potassium with lithium in the form of the citrate or the carbonate ; the former to give neutralizing, the latter to increase the solvent power. This certainly sounds promising, coming from such a source. The citrate of lithium is more soluble and more easily borne by the stomach than the carbonate. It may be given in from ten to thirty grain doses. Injections of various substances into the bladder for the purpose of dissolving Btone have been used successfully ; Coulson alludes to a case in the practice of a Mr. Rutherford, but all these eflbrts have failed to favorably impress either the profession or the public, and Roberts demonstrates that the solution of acid stone by injection of alkalies is impracticable. Almond-oil and lemon-juice were injected by Baronius, the former as a calming agent, the latter as a sol- vent. Whytt used lime-water, as did also Butler, Campbell, and Rutherford. Hales tried, in animals, continuous irrigation through a double current cathe- ter. Gruithuisen made some experiments in 1813, and Cloquet followed in 1821. He preferred distilled water as the substance to be injected. Attempts have been made to surround the stone in a rubber bag, and then to throw acid into the bag. Leroy d'fitioUes^ made such attempts, and condemned not only them but all similar methods of treatment, and, following up the subject after- wards (1839-41),* decides absolutely against the practical utility of all forms of solvent treatment, whether used by the mouth or directly by injection. Hoskins's* nitro-saccharate and acetate-of-lead injections are of later date, their object being to disintegrate the calculus by double decomposition ; but this method lacks the confirmation of practical success, as does also the use of ■ Lancet, April 21, 1883, p. 669. 2 Expose des divers procfides pour gu6rir de la pierre. Paris, 1825. ' Lettres ^ l'Acad(5inie de M6decine sur la dissolution des oalculs. I ' Coulson, p. 593, quoting from Loudon Journal of Medicine, Oct. 1851. SOLVENT TREATMENT OF STONE. 201 acetate of lead (one grain to a fluidounce of water, with a few drops of acetic acid). Some reserve, perhaps, must be made in favor of the injection of dilute acids to dissolve phosphates precipitated in the muco-pus in catarrhal condi- tions of the bladder, and as a prophylactic against the tendency to phosphatic re-accumulation. Indeed, Brodie is quoted as having used a solution of two and a half minims of strong nitric acid to the fluidounce of water, injected through a double catheter for fifteen to thirty minutes two or three times a week, and j^ having succeeded in thus dissolving a phosphatic calculus. In face ooiistoric evidence, however, there can be but one deduction regard- ing the practical value of the solvent treatment of stone, namely, that it has no general applicability ; and yet in spite of all evidence, and of all history, the virtues of various pills and waters are proclaimed to day by the pro- prietors of these nostrums, and by some of their dupes, as boldly as if Mrs. Stephens and her calcined shells had never existed, and the advertisements of mineral springs abound in seemingly well-attested instances of cure of stone. A large stone cannot be dissolved, if for no other reason, on account of its animal matrix. For even allowing that the penetrating influence of the sol- vent could decalcify the outer layers to a considerable depth, yet the tenacious organic skeleton would remain adherent, arrest further solvent action, and form the best possible bed of colloid for new stone formation. ' ■ No pretence is now made in any scientific quarter that any stones can be dissolved by internal treatment, except those composed solely of uric acid, urates, or urostealith. BealeV recent announcement of the good effect of large doses of carbonate of ammonium in causing cystine to disappear from the urine, and the recurring passage of small cystine calculi to cease, must be borne in mind, and may make it possible to add cystine calculi to the list of those which we may hope to ■dissolve by the internal use of medicine. One of Scale's patients took 50 grains of ammonium carbonate three times a day, in a little water, for nearly three years. Oxalate of lime and the phosphates, not uncommon substances to form layers in alternating calculi, are an absolute bar to solvent action. Ammo- niacal urine is so likewise ; and indeed so many conditions militate against the solvent method, that it is only the fascination lent to it by the possibility of success which has induced so many honest and competent observers to approach it. Yet being a possibility, it is a legitimate resource in those cases in which more radical measures are contraindicated, notably in dealing with small stones in the kidney. The best method is undoubtedly the one proposed by Roberts, possibly substituting citrate of lithium for the citrate of potassium, as suggested by Garrod. Success can only be hoped for after a very long course, and when the stone is quite small and the urine normal, or at least not ammo- niaeal. The deposit of sediment (phosphates) from the urine which may take place during the course is no indication that the stone is being dissolved, for it is an amorphous phosphate due to alkalinity of the urine, and not a dissolved urate, and the stone may still be actually growing in size.^ JSTor must it be forgotten that there is a possible element of error inherent in all methods of treatment by internal medication, or by the free use of mineral water, namely, the occurrence of a very positive and prolonged change in the specific gravity and reaction of the urine in which the stone lies bathed, a circumstance which would favor spontaneous fracture and disintegration, and might lead to spon- taneous evacuation of the debris. This method of cure certainly sometimes occurs at mineral springs. > Lancet, Aug. 30, 1884, p. 363. 2 Thompson, Clinical Lectures on Diseases of Urinary Organs, 6th ed., p. 129. 1882. 202 I URINARY CALCULUS. It is not worth while to attack a stone in the bladder, however small, by the solvent method, whether through the mouth or by injection, for the former plan is far too imcertain, and the latter requires vastly more instrumentation, even if it could succeed at all, than the single sitting of lithotrity by which the foreign body can be removed. Acid injections are a valid and valuable- means of local medication against tendencies to recurrent phosphatic accumu- lations. The internal measures in vogue possess a symptomatic value apart from their alleged worth, in that the eiFect of the alkali is often soothing,, and they may be used in any case to comfort the patient, though he should, not be deceived into hoping too much from them. • Palliative Treatment of Stone. In some cases radical treatment is not justifiable. Such are cases of large- kidney-stones and phosphatic renal concretions where nephrotomy is not practicable, and all cases of vesical calculus in which, from the size or other peculiarity of the stone, or from the age, disease, or other condition of the patient, operation is contraindicated. In these cases, whether the stone- is renal or vesical, the general outline of palliative treatment is the same. Milk diet is often a valuable adjuvant to treatment, as is sometimes a de- cided course of alkalies, as proved by the many patients who believe them- selves bettered by taking the various advertised nostrums. The same remark applies to the use of the natural mineral waters. Both these remedies some- times fail on account of their diuretic quality, for the mechanical effect of too frequent urination, when there is a foreign body in the bladder, is irri- tating. The conduct of a case of this sort involves a judicious selection of anodynes and alkalies, rest, tonics, diet, and symptomatic local treatment. Much com- fort may often be afforded when cure is impossible. Selection of a Method of Radical Treatment. Certain general conclusions have been established by statistics, namely^ that the female tolerates lithotomj' better than the male ; the child better than the adult ; the patient with diseased kidneys less well than any other. It has been proved, also, that the size of the stone influences the rate of mor- tality, and thab an operation which may be best for one size of stone is less suitable for another. But statistics cannot demonstrate that one operation is better than another, simply because a given operator obtains brilliant results by a given method. There is no place in the literature of the present day for the heated discussions which flourished in France toward the middle of the present century as to the relative merits of lithotomy and lithotrity^ as a general operation for all cases. The present discussion is narrowed down to more exact limits, and deals with special indications furnished on the one hand by the patient, on the other hand by the calculus, for the use of one or the other operation .in any of the various modifications of each. Moreover, a new element has entered into the computation, which has not yet found its way generally into print as a factor in the problem of statistics and mortality ; that element is the new operation for stone — litholapaxy. Even Coulson, in his admirable chapter on statistics in his last edition, 1881, hardly mentions it. Enough material in this line has not yet been collected to seriously affect old statistics, but that it is an element which must modify them cannot be denied. SELECTION OF METHOD OF RADICAL TREATMENT. 203 Much reiteration of well-known facts and figures is unprofitable, and I shall content myself with as small a display of tables as possible, reserving- the practical consideration of the relative efficacy of the different methods for the section of this article which considers the choice of an operation as regards : (1) the peculiarities of the patient ; (2) the peculiarities of the stone.^ Lithotomy. — The phenomenal success of Martineau,^ 2 deaths in 84 cases,, and that of Pouteau,' 3 in 120, are apparently the best on record for litho- tomy among^the older records. It is a success to be aspired to, but rarely reached, although not quite as brilliant as it looks, since less than one-third of Martineau's patients had reached fifty years. Only eleven were over sixty, and both the deaths occurred among these eleven. Alan P. Smith* has recently reported still better figures, 52 consecutive cases of lithotomy without a death, 7 of the patients being between 40 and 71 years of age. Dudley, of Kentucky, is reported to have operated one hundred times con- secutively without a death ; but this evidence is not founded on personal,, written notes. Cheselden,^ the father of the lateral operation, cut 213 times,, averaging 1 death in 20 for all ages ; a superb result, and showing only 1 death in 35 under the age of 10. The late S. D. Gross, of Philadelphia, cut, all told, 165 patients, with 14 deaths: 72 of these were children, with 2. deaths, 1 in 36 ; 93 adults gave 12 deaths, 1 in 7f .« Gross,' out of 2303- American cases of lateral lithotomy at all ages, finds 156 deaths, 1 in 14|. A collection by the same writer of 2711 European operations gives a mortality of 278, 1 in 9f. Gross's general table* shows 18,570 operations at all ages, and by all cutting^ methods, with 1549 deaths, an average of 1 in 8.76. This would necessarily be a low average, since it includes all operators and all operations without selection, and pays no attention to the patient's age ; but it must not be for- gotten that many fatal cases fail to get recorded. It may be considered an excellent average if a general surgeon has a mortality no higher than 8 per cent, in his operations, 1 in 12| cases, without regard to age or selection.' Morton's tables, showing the mortality of lithotomy in the Pennsylvania Hospital at the hands of all operators, over a period of 122 years, give 1 death in 7 cases."* This method of reasoning by general statistics leads to a general conclu- sion, and has no value when applied to a special case or set of cases. Here the element of age comes in most prominently. Thompson's table, in this respect, as establishing a general average of mor- tality for the various ages, is full of value. It has never been practically con- tradicted by an array of figures from varying sources of equal weight and authenticity, and it is to-day a reasonably fair standard by which any one 1 See page 211, infra. ' Med.-Chirurg. Trans., vol. xi. p. 402. 1821... ' Quoted by Gross, op. cit., 3d ed., p. 276. 1876. * Trans, of Med. and Chir. Facility of Maryland, April, 1878. Reprint. » Cheseldeu's Anat., 5th ed., p. 322 et seq. 1740. 5 Am. Journ. Med. Sci., July, 1884, p. 305. ' Op. cit., p. 275. ^ System of Surgery, 6th ed., vol. ii. p. 736. 1882. ' A very recent table by Nishan Altonnian, of Turkey in Asia (Am. Journ. Med. Sci., .luly,^ 1883, p. 151), of 272 lithotomy operations, shows only 15 deaths, 1 in 18.13 : — Under 10 years 47 cases, 1 death. Between 10 and 20 years, 20 30 30 40 40 50 50 60 60 80 99 " 4 deaths. 66 " 2 " 38 " 2 " 23 " 4 " 6 " " 3 " 2 " '" Surgery in the Pennsylvania Hospital, p. 140. 1880. 204 URINARY CALCULUS. may measure the grade of his own success in cutting for stone. The table includes 1827 cases furnished by a great number of operators: — 1 died out of (about) every 14^ From 1-5 years 6-11 " " 12-16 " " 17-20 " " 21-29 " " 30-38 " " 39-48 " " 49-58 '• " 59-70 " " 71-81 " 23i H 7 8 6 4| 3| This shows that the safest time to cut for stone is after babyhood and Taefore pubei'ty. Next in order comes the infant age — below 5. Puberty has a depressing influence. Mature manhood gives better results, and after sixty, about one patient in every three and a half dies if cut. Coulson's' table (in decades) of 2972 cases furnished by Castara, Smith, Crosse, Cheselden, Dupuytren, and South, gives a somewhat similar result. I iave arranged it so that it may be compared with Thompson's: — Death rate. Age. Coulson. Thompson. Death rate. From 1-10 years . . . . 1 to 13.08 1 to about 18.91 » 11-20 1 " 10.28 1 " " 8.25 " 21-30 1 " 6.61 1 " " 4.00 " 31-40 1 " 5.83 1 " " 10.50 " 41-50 1 " 4.50 1 " " 6.00 " 51-60 1 " 3.65 1 " " 4.75 " 61-70 1 " 3.23 1 " " 3.75 " 71-80 1 " 2.71 1 " " 3.16 These figures are undoubtedly good standards to go by. Much better results with children have been achieved by individuals, and even in general hospitals. And much worse results are recorded of brilliant operators, but, in the main, the average of these figures has gone unchallenged. They relate to the lateral operation. The weight of the stone — other things being apparent!}^ equal — has a dis- tinct bearing on the mortality of lithotomy, as shown by the very interesting tables compiled by Gross'' from the 1327 cases of calculus tabulated by Crosse, •of Norwich, and by Garden, of the Saharunpore Dispensary. When the «toue weighed less than — 1 ounce there was . . . . .1 between 1 and 2 ounces there was . . 1 2 3 3 4 4 5 6 6 7 death in 11.01 » 6.55 2.72 ' 1.75 1.83 ' 3.50 ' 1. cases. Claims of superiority for one cutting opei:ation over another have been made on the ground of facility of execution (high operation), anatomical reasons (median), safety (perineal lithotrity), size of the stone (bilateral, vesi- •co-rectal). Statistics of these operations — other than the lateral — are of only ■secondary importance. The high operation is confessedly very fatal, although at present it is > Op. cit., p. 523. ' Practical Treatise on Diseases, Injuries, and Malformations of Urinary Bladder, etc., p. 278. SELECTION OF METHOD OF RADICAL TREATMEXT. 205 growing in favor in this country, through the advocacy of Dulles, of Phila- delphia, and iu Grermany and France under the influence of Petersen, Ultz- mann, Albert, Dittel, Langenbuch, Guyon, Perier, Bouley, Monod, and others. The general mortality seems to be about one in three and a half (Dulles^ gives 636 cases, 182 deaths, 1 in 3J). Frere Come had 100 cases and 19 deaths, 1 in 5.27, an excellent showing ; but of these 59 were in females, with 9 deaths,. 1 in 6.55, and 41 in males, of whom 10 died, 1 in 4.10. Souberbielle had 90 cases with 31 deaths, 1 in 2.90. Of his patients, 6 were under 20 years of age, and 2 died, 1 in 3. Therefore 30 per cent, of deaths is a fair average of mortality to accord to the operation as formerly practised, as far as statistics are a guide. It can be shown that modern statistics under the very best circumstances are but little better. Individual sets of small numbers of cases are not im- portant. My personal statistics are absolutely bad. At the date of ray ope- rating, several years ago, the total number of my operations by other methods had been thirty-eight, with one death. Then I operated three times in suc- cession by the suprapubic method, and all my patients died. Two were desperate cases and would have terminated fatally, I believe, under any cir- cumstances, but the other was an excellent case, and ought to have ended in recovery by any method. It was before the day of litholapaxy. The ope- ration was not at all complicated, but the patient died with suppression of urine, high temperature, and ursemia, in two days. ITo autopsy was allowed. There was no evidence of local mischief, and death undoubtedly came by the kidneys. As against these unfavorable statements T deem it just to array a set of cases communicated to me by letter, the results of which are unsur- passed. Mr. A. Grroves, of Fergus, Ontario, Canada, writes me that he has performed the high operation four times successfully. Cask I. — Man of sixty-three years, weighing three-hundred pounds, who had been a very hard drinker ; six stones removed. Five measured one and a quarter inch each in the longest diameter ; the sixth, quarter of an inch. Case II. — Man sixty-seven years old, much debilitated, stone one and a half inch in diameter. Case III Boy six years old, mulberry calculus one inch in diameter. Case IV Man sixty-four years old, twenty-five calculi removed. Truly a remarkable experience, and an excellent showing for the high operation. Dulles's^ statistical report, in April, 1878, gives a table of 20 cases as having occurred in the 10 years just preceding, with only two deaths, 1 in 10. But an analysis of the table shows that the average age of the patients was under 16 years, and that the two deaths were in infants of 4 and 2| years. Further, a foot-note says that two operations are left out of the computation because they were complicated by having had the lateral perineal operation done upon them at the same time with the high operation — yet another look at the table makes this reason hardly a good one, since it is observed that the table contains two successful cases in which this same double operation was done (Billroth's and Watson's), and a suspicion is excited that the two cases left out may perhaps have had a fatal issue, in which event the mortality would be 4 in 22 cases, 1 in 5|.^ ' Personal letter, and Gross's System of Surgery, 6th ed,, vol. ii. p. 759. ' Am. Joiirn. Med. Sci., April, 1878, p. 394. ' Replying to a letter, March 29, 1884, Dr. Dulles says that he has collected nearly 700 cases ; but he does not mention the death-rate, referring to the figures in Gross's Surgery, 1 in 3^, as his last utterance. He adds further, in explaining the construction to be put upon his table here referred to: "The two cases omitted were fatal. I omitted them because, while it is certainly right to credit the suprapubic method with success where it has been complicated with another 206 URINAKY CALCULUS. Finally, the very best operation scientifically, that now practised in France — the Petersen-Guyon-Perier operation, done antiseptically with drainage, etc. — shows according to Villeneuve,' in the 21 cases reported, a mortality of 30 per cent. — no better than that of the general table first constructed by Dulles, and including the figures of all operators. Guyon's'' 8 operations yielded 3 deaths, 1 in 2.66. As a final contribution to statistics, I may cite the thesis of A. Garcin,* of Strasbourg, 1884. He collates the published operations of suprapubic cystotomy during the years 1879-1883 — modern operations — referring for statistics up to 1851 to Giinther, and from 1851 to 1878 to Flury. Of the strictly modern operations, 94 were for the extraction of stone or foreign body from the bladder. Of these, 23 died, 24.40 per cent, as follows : — Age. 1-10 . 10-20 . 20-30 . * 30-50 . 50-70 . 70-90 . This is perhaps the best general showing ever made for the operation — but it surely is not very encouraging, and a later exhibit by Tuffier, Guyon's mouthpiece, is a shade worse. He uses Garcin's figures, and adds more recent ones, making 120 operations with a mortality of 27 per cent., and says that in the 22 cases, fell told, since 1879, in which suture of the vesical walls has been resorted to, the suture has failed 20 times.^ Since, however, this operation is often reserved for the most severe cases, its apparently bad showing does not possess all the significance it appears to have. This becomes more evident from a glance at the comparative results of the lateral and high operations when the weight of the stone is taken into consideration, as very clearly set forth in the following excellent table prepared by Gross.' Percentage No. of Cases. Ratio. of Mortality. . 22 1 : 4.40 22.72 . 26 1:26 3.84 . 8 1:4 25. . 7 1:7 14.28 . 16 1 : 2.28 43.75 . 11 1:2.75 36.36 Lateral operation. Suprapubic operation. Under §j 3j-ij • 3ij-iij • Siij-iv . §iv-v . 3v-vj . No. of cases. . 629 . 119 . 35 . 11 5 2 2 Rates of death. 1 in 11.25 1 1 1 1 1 1 6.61 2.18 1.57 1.66 2.00 1.00 No. of cases. 14 21 14 19 16 11 2 Rates of death. 1 in 4.66 1 " 1 " 1 " 1 " 1 « 1 " 5.25 3.50 3.16 2.28 2.75 2.00 hazardous procedure, it is, equally, unjust to deduct from its credit any case where such com- plication was followed by death. The former is undouhtedly a recovery from the operation, the latter cannot he charged to either method." 1 Rev. de Chirurgie., Sept., 1883, p. 665. 2 Ann. des Mai. des Org. Ggnito-Urinaires, D6c. 1882, et Janv. 1883. ' Contribution oliuique & IMtude de la cystotomie suspubienne, etc. Ann. des. Mai. des. Org. Genito-Urinaires, Juin, 1884, p. 360. < Certain foreign bodies are manifestly appropriate for removal by the high operation. Donnel Hughes (Phila. Med. Times, Dec. 15, 1883, p. 207) reports the successful removal of a steel bonnet- pin with a glass head. I find in the Philosophical Transactions (Abridged, 4th ed., 1731, Obs. 83 p. 162), the record of an amusing as well as instructive case. One Dorcas Blake, in 1694, was cut by Mr. Proby above the pubis to extract an ivory bodkin, four inches long. He cut outside the rectus muscle, and, as he very candidly confesses, " by God's great blessing, she was per- fectly cured." The interest in this case is increased by the fact that this " full-bodied, sanguine maid, about 20 years old" went before the Lord Mayor, June 10, 1695, and swore that she had swallowed the bodkin ; and her doctor believed her, although her vesical symptoms had appeared within a very suspiciously short time after the alleged swallowing. « Op. cit.,p. 296. SELECTION OF METHOD OF RADICAL TREATMENT. 207 This table clearly goes to show that the larger the stone, the safer relatively to the lateral section is the high operation. Eut it shows with still greater force and clearness that the high operation is not applicable to stones under one ounce in weight (and the majority of stones found in practice weigh less than one ounce), since the mortality of such stones is nearly three times greater for the suprapubic than for the lateral operation. This criticism is enforced by the unimpassioned eloquence of Billroth, a general surgeon, and therefore a most competent observer and critic, who in speaking of the operation remarks :' — This operation finds no great favor with me, although formerly when I was fortunate enough to be Von Langenbeok's clinical assistant, I was very much taken with it, and it appeared to me to be the ideal of an operation for stone. The cases of suprapubic operation in children performed by Von Langenbeck's masterly hand, did well eventually, but there was mucii sloughing of the cellular tissue in the neighborhood of the wound. After the slough separated the wound granulated up well and closed rapidly, but the •children always were very ill after the operation, and suffered far more than when subjected to median or lateral lithotomy. My conclusion from the evidence, therefore, is that the high operation is suitable for the management of very large stones, for encysted stones, for stones complicated by tumors of the bladder, and for certain foreign bodies, but that it is not appropriate for general application. The claims of the median operation have been advocated in this country by Markoe and others, and the operation has been rather more favored in some quarters than the lateral section. Its statistical showing has also beeh very good, particularly in this coun* try, but as the operation has been employed mainly with children, and in •cases of small stone, these results do not prove its value as a general procedure. The excellent analytical table of C. 'Williams,^ of 64 cases operated on at the Iforfolk and N"orwich Hospital, sets forth these facts quite clearly ; for of these operations, those done under the age of 40 showed a mortality of 1 in 14, .and of the remainder, done between 40 and 80, the deaths were 1 in S^j, while where the stone weighed over 3 drachms 2 scruples, only one recovery took place — a very large stone of 4J ounces — and in this instance a portion of the perineum and rectum sloughed, and a permanent perineo-recto-vesical fistula was established. Williams compares these 64 cases with the last 64 lateral lithotomies done in the same hospital — the mortality in the latter being 8, against 13 deaths in the same number of median sections. This showing, so favorable to lateral lithotomy, should be modified by saying that the average age in the patients submitted to lateral lithotomy was something under 38, while the age of those undergoing the median section averaged something under 45. The bilateral and recto-vesical manoeuvres are modifications of the lateral and median operations. The former is often appropriate, the latter never. Even in its best showing — Koenig's table — the mortality is 1 in 5.18 (ages not given), and fistula remained in those who got well in 1 case out of each 6. LiTHOTRiTY. — The statistics of lithotrity belong to two groups, one repre- senting the old, the other the modern operation. Statistics of the former are well known, of the latter not yet fully made up. A collection of lithotrity operations, 1470 in number, by various surgeons, has been made by Gross,^' with a mortality of 1 in 9.24. In children, out of 21 ' Clinical Surgery, New Sydenham Society's Translation, p. 276. London, 1881. " Holmes's System of Surgery, 2d ed., vol. iv. p. 1078. ' System of Surgery, 6th ed., voL ii. p. 736. 1882. 208 URINAKY CALCULUS. cases collected by Guersant, 6 terminated fatally, and 62 operations upon children in the Moscow Clinique furnished also 6 deaths — a very bad show- ing for calculus in the child. Gross's table relates to the old operation, and the ingures have at best a^ very vague significance, for all ages are included, and the cases were often selected. The fact of selection has greatly enhanced the apparent value of lithotrity. Thus Keith and Fergusson in 231 cases of lithotrity lost 21, a death-rate of 1 in 11.55, while out of 296 lithotomies, the same surgeons lost 75, or 1 in 3.94. Again, Gross has compared the results published at date of the lithotrities of Thompson, Brodie, Fergusson, and Keith — 637 cases in adult males, with 46 deaths, 1 in 13.84 — with the results of lateral lithotomy by various surgeons taken from Thompson's table and covering the same period of life, 723 cases with a death-rate of 1 in 4.82. "While selection of cases may here be accredited with a measure of the success, still the showing is admirable for the old operation of lithotrity iii adults. Coming down to special statistics, Fergusson lost 1 in 9.08 ; Brodie 1 in 12.77; Heurteloup claimed to have lost only 3 out 69 cases — 1 in 23 — and he operated at a single sitting ;' Keith^ 1 in 18.42. Civiale's well-known. statistics- claimed a mortality of only 1 in 41.50. But it is well known that he aban- doned the operation in ten patients who died, and these, being added, bring- his mortality WTp to 1 in 24, a result certainly good enough to be satisfied with. But the Necker Hospital statistics of Civiale, are those upon which most reliance can be placed, since they were kept by individuals unfriendly to the great lithotritist ; and these give^ for 78 cases 5 deaths, a rate of 1 in 15.60. Thompson's* latest figures are 422 lithotrities with a death-rate of 1 in 13 ; Cadge' reports 86 lithotrities with a death-rate of 1 in 10.75. Ivanchich,* in Germany, has done very well for the old operation. Out of 300 cases of short sittings, under ether when necessary, he lost in the first hundred 14, in the second hundred 5, in the third hundred 3 — in all 22, or about 7 per cent. — the last hundred giving the best showing ever made for old-fashioned lithotrity. The present showing of litholapaxy is better than this. The operation is in full course of experiment all over the world, and no figures now given will be accurate a few years hence. Some efl:brts have been made to collect material from which to general- ize: — Bigelow's announcement of the method appeared in January, 1878.' Up to Feb. 15, 1880, I had collected^ 120 cases at the hands of all operators, with 6 deaths, a mortality of 1 in 20. In November, 1880, the number had only reached 162.» Of these, 125 had been operated upon by surgeons who had recorded five or more operations, and might be presumed to be fairly skilful in vesical surgery. The mortality was 5 1 in 25. The remaining 37 operations had been done by surgeons having recorded less than five cases, and among these there were six deaths — 1 in 6.16. Gross,'" in 1882, reported for all operators 312, with 17 deaths — 1 in 18.35. Guyon's collection of 590 operations gives 36 deaths — 1 in 13.61. (Desnos.) Bigelow's personal statistics up ?arm borated irrigation, if retention or atony demands the use of the catheter. (4) Impaction of a Fragment in the Urethra. — This disagreeable accident ought never to occur. If the fragments left in the bladder are not small ■enough to pass easily, either the operation has been imperfectly done, or the case should have been treated by litholapaxy. But it is possible for a frag- ment to be left under any circumstances, and urethral impaction may ensue. If a fragment does become lodged in the urethra, the impaction is likely to take place at the bulbo-membranous narrowing of the canal, more rarely at the middle of the pendulous urethra, or near the meatus. In the first- mentioned situation it gives the most trouble, occasioning sometimes severe pain, and producing muscular spasm of the cut-off muscles even to the extent ■of causing retention. The removal of urethral calculi has already been considered (page 178), a,nd to that section the reader is referred for the different methods of remov- 230 URINARY CALCULUS. ing foreign bodies from the urethra. Among all the instruments employed, raj experience has led me to adopt the divulsor used as a forceps, for the reasons which I have already stated. But this instrument has not been commduly employed. Among those in ordinary use may be mentioned, as having re- ceived general sanction, the long urethral forceps (Fig. 1216), and the alligator 1216. Urethral forceps. forceps, straight and curved (Figs. 1217, 1218). My experience with all thes& instruments is, that they pinch, scratch, and tear the urethra, and that it ia Fig. 1217. Alligator forceps, straight. Fig. 1218. Alligator forceps, curved. difficult with them, often impossible, to seize a foreign body and extract it,, especially if the latter be angular and impacted. A very ingenious instrument, and one which may serve when the foreign body is impacted far forward, is the articulated scoop of Leroy d'S^tiolles. Fig. 1219 represents it — open and shut. The urethral lithotrite is an adap- Fig. 1219. leroy d'fitiolles's scoop. tation of a small male blade to a steel instrument, fashioned like the scoop of Leroy d'feiolles, and in which the female blade is worked by an analogous me- chanism (Fig. 1220). Mathieu, of Paris, has devised an ingenious instrument for reducing urethral stone to fragments. Fig. 1 221 shows? it, closed for intro- duction, and at work. The mechanism is in the handle. The stone is caught in the hollow of the closed female blade. Then, by rotation, half the female- LITHOTRITY. 231 blade goes around the foreign body and incloses it, after which the perforat- ing male blade is advanced. Fig. 1220. Urethral litliotrita. FiK. 1221. Mathieu's instrument for perforating urethral calculi. (6) Cystitis. — A moderate amount of superticial cystitis was not unusual after old-fashioned litliotrity, if the fragments left after the first crushing were large. It was indeed this well-known tendency which induced the English surgeons present at the meeting of the Royal Medical and Chirurgical Society of London, in 1878,' to lean toward the conclusion that lithotrity had been pushed too far ; that, except for small stones, lithotomy was a better operation; and that in the future more stones should be cut for, and fewer crushed. And it was partly by reasoning upon the same premises that Bigelow had at about the same date reached exactly the opposite conclusion, namely, that a stone, however large, was suitable for lithotrity, provided that it could all be re- moved from the bladder at one sitting. Bigelow's solution of the problem was the invention of litholapaxy. As matters stand to-day, therefore, the question of cystitis after lithotrity is not a serious one. Large stones are no longer dealt with by old-fashioned lithotrity, and much cystitis does not follow upon crushing a small stone. Litholapaxy, on the other hand, leaves the bladder empty, and the most im- portant causative factor of cystitis is removed. The treatment of cystitis following lithotrity is the same as that of cystitis from other causes — rest in bed, hot applications locally and hot baths, alka- lies and diluents by the stomach, anodynes as may be required — with use of the catheter and vesical injections in appropriate cases. If it so happen that fragments of any considerable size are left in the bladder, and that cystitis of a high grade supervenes, the surgeon's duty is plain. He must relieve the tender mucous membrane from the repeated injuries it is receiving from the sharp fragments, and a second thorough sitting of litholapaxy, under ether, and lithotomy, are his legitimate alternatives. In such serious cases as have sometimes been recorded, where the superficial cystitis is complicated with intei'stitial infiammation of the walls of the bladder, the formation of abscess, peri-cystitis and para-cystitis, the surgeon must be guided by general principles and meet the indications as the}^ arise. Occasionally, but very rarel}', chronic cystitis with a tendency to phosphatic re-accumulation follows lithotrity, even when the stone first removed has ' Lancet, March 16, 1878, p. 385. 232 URINARY CALCULUS. been formed of uric acid, and the bladder has been in fair condition at the time of operatinoj. (Thompson.) (6) Epididymitis occasionally occurs as a complication of lithotrity. It is due to the damage inflicted upon the deep urethra by the instruments e^i- ployed, or sometimes to the impaction of a fragment in the urethra. In the case of very old men it may possibly develop into a true orchitis, and the latter may culminate in abscess. I' have seen one instance of this complica- tion. Ordinarily, however, epididymitis is a very trifling matter, termi- nating in resolution in from two to ten days, and only notable on account of the annoyance which it occasions. Its treatment is by the use of hot anodyne applications and local support, the patient remaining in bed. No further sitting of lithotrity should be undertaken until the epididymis and cord are free from any tenderness on pressure. (7) Surgical kidney, fortunately a rare complication, will be considered in speaking of the complications of lithotomy. Search for the Last Fragment. — The reproach is constantly made against lithotrity that a fragment is often left behind, and that relapse becomes, therefore, inevitable. No patient should be deemed well after lithotrity until his flnal searching has proved him well, and modern methods of searching are nearly absolute in their conclusions. Phosphatic re-accumula- tion does occur, but this is not relapse, and does not depend upon the persist- ence of any nucleus left behind in the bladder. Such rough methods as making the patient ride a long distance in aA-ehicle without springs, over a rough road, before calling him well after treatment for stone, are no longer employed ; nor is the condition of the urine a trust- worthy test, for it may continue to show pus long after the last fragment has been removed. Nor can the searcher be relied upon with confldence, for if even a large stone may sometimes elude the searcher in skilled hands, how much more a minute fragment! The method of to-day, which ranks all others in accuracy, is the use of the washing-bottle, as employed in litho- lapaxy , with a small metallic tube. It is not much more painful than sound- ing with the searcher, if the bladder be not over-sensitive ; and if it is so used that not a bubble of air is allowed to enter the bladder, there is no test which approaches it in accuracy for detecting a final fragment. Every patient should be subjected to this test before he is pronounced well, and the test should be reapplied after several months. Litholapaxy. Bigelow has chosen this name (from ueos, a stone, and xdrtalt;, evacuation) to indicate his operation for the removal of stone. It is essentially lithotrity with the aim of reducing the entire stone to fragments and removing it through a tube by suction at one sitting, without regard to the amount of time consumed. More than three hours have been thus consumed without any resulting harm. Special apparatus for washing, and various tubes and lifAio- trites have been devised, in order to execute the manoeuvres of the operation more promptly and efi'ectively ; but the essence of the operation consists not in the instruments, but in its design — in the method — and litholapaxy might be eftected by any lithotrite, a soft catheter, and a piston syringe, if no better implements were at hand. That litholapaxy has established for itself a recognized position, is plain. In England it has been adopted by Thompson, Coulson, Harrison, and Teevan; in Germany by Billroth, Dittel, and Ultzmann. I have noticed no report LITHOLAPAXY. 233 from that sturdy old lithotritist of the old school, Ivanchich. In France, •Guyon is loud in its praises. In America, Van Buren, Caswell, and a host of others in the States and in Canada, have given it their warmest adhesion, while reports are beginning to come in from other sections of the globe. J. G. Kerr^ announces that the operation has taken root in his Missionary Hospital at Canton. P. J. Freyer^ praises it from India, reporting 111 cases. Zamcarol,^ from the hospital in Alexandria, Egypt, announces 14 eases with 2 deaths. H. Blanc* has made two reports from Bombay, one of six, a second of ten cases, .all successful. G. E. Post° has furnished a case from Syria. These have fallen under my notice, and doubtless many more have escaped me. It is rare that a word of serious discontent is heard, although minor criticisms on the operation are not infrequent. In France, I believe that the operation has not been warmly received except by Guyon. Eeliquet does not approve it. The history of litholapaxy is that of lithotrity. Indeed, the pioneers of old lithotrity set for themselves the task of freeing the bladder of the debris made by the lithotrite, and invented special spoon-shaped scoops, acting like lithotrites, to eft'ect this object. Civiale's sittings, very long at first, decreased in length as the operator gained ia experience, and had become reduced to the conventional two or three minutes when Thompson took up the banner in' England. Heurteloup* strove to clear the bladder at a single sitting, and publicly announced this to be his especial aim, but he had no ansesthetic, and his methods were rough and did not find favor. Heurteloup,' indeed, stated in so many words that it was not proper to crush a stone, and then leave the fragments in the bladder, but that the object of the operation ought to be to free the bladder of all debris and send the patient away cured. Kirmisson^ has forcibly brought out the fact that Heurteloup aimed at evacuation fully as much as at crushing, since he proposed a new name for the operation — " Lithocenose" (ueos, stone, and xivaat;, extraction). Leroy d'l^tiolles,' before the Acadeinie des Sciences, April 27, 1846, announced that he could extract from the bladder at a single sitting a stone thirty-five mil- limetres in diameter (something over 1^ inch), and at the same meeting boasted of success by the method of immediate extraction in over a hundred cases. Yet this method never gained favor. Antesthesia had not been dis- covered. The means employed to evacute the debris were crude and me- chanically imperfect. In the hands of the general operator, much damage must have been done which was never recorded, and even the prince of opera- tors, Civiale, gave up the method entirely, reducing his sittings to a very short limit. Heurteloup, before the end of his career, gave up the effort to relieve the bladder in one act, and short sittings repeated at intervals became the universal practice in lithotrity. Heurteloup went to England and introduced French lithotrity there, and in 1831 he published a book in London on the principles of the operation. But the champion of English lithotrity is alive to-day. Sir Henry Thomp- son has done more in his day and generation for the operation than any one except Bigelow, and, indeed, it looked at one time as if Thompson wei'e slowly working up to the method of rapid evacuation now in use, when the 1 Medical News, April 7, 1883, p. 382. 2 Lancet, Feb. 28, 1885, p. 378. » Soc. de Chirurgie, 7 Dec, 1881 ; Le Progrfes M^d., 10 D^c, 1881. ■■ Lancet, July 10, 1880, p. 49, and May 27, 1882, p. 857. = Ibid., July 9, 1881, p. 47. ' De la lithotripsle sans fragments au moyen des deux proc^d^s de I'extraction immediate ou de la pulverisation immediate des pierres v6sicales par les voies naturelles. Paris, 1847. ' Mfimoire lue h, rAcad^mie Imperiale de M^decine de Paris, pp. 301-9. 1857. * Des modifications raodernes de la litbotritie, p. 4. Paris, 1883. ^ Comptes rendus des Stances de I'Acad^mie des Sciences, t. i. p. 709. 1846 ; and Gfaz. M(5d. de Paris, 2 Mai, 1846, p. 354. 234 URINARY CALCULirS. unfortunate death of ISTapoleon III., under a secOTid sitting of lithotrity — which might indeed have been called litholapaxy, for chloroform and Clover's evacuating suction-apparatus were used — with other circumstances^ seemed suddenly to divert him from his progressive course. Up to this time Thompson had been teaching and practising longer sittings, more fre- quent use of ansesthesia, and more constant recourse to Clover's evacuating apparatus. He had also been urging as a proper course, in the event of active inflammation of the bladder following a iirst sitting, that the patient should be etherized without delay and his bladder at once cleared of debris- by the use of the washing bottle, as a proper treatment of the cystitis. Surely this was litholapaxy, but Thompson did not seem to appreciate it or to accept the spirit of the method, for we find him in March, 1878, three months after the appearance of Bigelow's first announcement of litholapaxy, reading a paper before the Royal Medical and Chirurgical Society' of London,, advocating shorter intervals between the sittings, it is true, but concluding that in future more stones must be cut for and fewer crushed; and that only small stones were suitable for lithotrity — such as could be dealt with in three or four sittings. Bigelow appears, from his own writings, to have arrived at his perfected operation partly by inductive reasoning and partly by experiment. The views of Otis as to the calibre of the urethra, and the patient tolerance of that canal under very wide distention, were being freely noised abroad. Bigelow had been in the habit of prolonging his sittings of ordinary litho- trity for from ten to fifteen minutes, and no harm had come from it, and the further lengthening of the sittings, the recognition of the value of prompt removal of the detritus, the adoption (practically) of the Otis standard of urethral calibre, and the construction of some large, thin-walled metal tubes with an ingenious suction apparatus at the distal end, made his operation,, which only needed to be modified by experience to become perfect. This operation is to-day accepted by Thompson, and is described in the last edition of his Lectures to the exclusion of old-fashioned lithotrity, which he apparently no longer performs. Indeed, the new operation promises in a few years to displace the old one entirely, and for the most part to do away also with lithotomy for males who have passed the age of puberty. Irish surgeons have seemed inclined to ascribe the origin of the idea of litholapaxy to Sir Philip Grampton,' who at the opening of the Meath Hos- pital, in Dublin, showed an evacuating bottle (Fig. 1222) which he had Fig. 1222. Sir Philip Crampton's evacuating bottle. devised for drawing away the urine from an atonied bladder in which litho- trity had been performed. The bottle was of glass. The air was exhausted from it and its stopcock turned. Then a Heurteloup's large-eyed steel cathe- ter was introduced into the atonied bladder full of water and crushed stone, 1 Dublin Quarterly Journ. of Med. Science, vol. i. p. 1. 1846. LITHOLAPAXY. 23& the bottle was attached, and the stopcock turned. The ease of a Mr. Rodger^ aged 70, is reported. His bladder was atonied. Heurteloup had previously operated upon him, but without entire success. Crampton relieved him by the aid of the evacuating bottle. Bigelow was fully aware of Crampton's device, and refers to it in his paper, but Crampton did not for a moment contemplate the idea of litholapaxy. He simply adopted an expedient to lend power to atonied muscles, and to expel the contents of a bladder the walls of which were incapable of per- forming that function for themselves. Heurteloup, too, used a large-eyed steel catheter with jointed stylet, and doubtless often washed out the bladder through it, but he did not conceive the idea of litholapaxy. Various other inventors from time to time devised evacuating tubes, to which syringes, rubber balls, or evacuating pumps were attached. Among the most prominent names are those of Leroy d'fitiolles, Cornay, Mercier,'Kelaton, Maisonneuve, Clover, and Coxeter. Cornay's lithiritie (Fig. 1223) was described in 1845, one year before Crampton's bottle, which it Fig. 1223. Cornay's litbSr6tie. resembled in many respects, differing in that it combined the possibility of injecting the bladder through a double-current catheter with the principle of pneumatic aspiration. Mercier, in 1872,' published a description of a wash- ing bottle (Fig. 1224) made of rubber, oval in shape, with a glass receiver for Fig. 1224. Fig. 1225. Mercier's waBhing bottle. Clover's first evacuator. fragments below. It very closely resembles in principle, and, indeed, in appearance, some of the first washers used by Thompson and Bigelow, and was worked without valves by alternate compression and relaxation of the rubber-bulb filled with water, while the fragments collected below in the glass receiver. But Mercier did not dream of litholapaxy. He states dis- tinctly^ that he had devised his washer for use " quand la retention devient 1 Traitement preservatif et curatif des sfidiments, etc. Paris, 1872. ! Op. oit., p. 370. 236 UKINAKY CALCULUS. complete"— in other words, to help the bladder out when it should prove inadequate to the task of expelling the urine and the debris. The English rubber suction-bottle, known as Clovers apparatus (J^igs. 1225 1226) having a glass receiver, and a metallic catheter with large eye, Fig. 1226. Clover's improved evacuator. ■or open at the end, is one of the best models of the old type of instrument. With it Thompson did good work before better washers we.re provided. The same tube, with a metallic pump above the receiver, was known in France as l^elaton's evacuating apparatus (Fig. 1227). Fig. 1227. N61aton'8 evacuating apparatus. Bigelow's first evacuator had the demerit of admitting air into the tube, which greatly interfered with the proper function of the instrument. Many modifications and devices have since appeared. I shall give illustrations showing the changes, but shall only describe the instrument as perfected. It is entirely possible that before these words appear in print, new and im- portant modifications may be made, though it is hard to imagine a washer that could work more perfectly than Bigelow's latest pattern. I have used all the varieties except Guyon's, and, thus far, prefer Bigelow's last model. Figs. 1228, 122G, 1230, and 1231, represent the Bigelow instruments. Fig. 1232 being the latest and best, the one he now advocates exclusively. Bigelow's last evacuator (Fig. 1232) is an elastic rubber bulb, with a glass receiver and two stopcocks of metal. Within the bulb is the tube-strainer — -a metallic tube, open at the end, and perforated with small holes crowded •closely together over its entire surface. The bulb is worked by alternate compression and relaxation of the hand which grasps it. The fluid in the glass receiver is out of the way of the currents started by compressing the bulb. This is filled from above, and any air in it accumulates there out of reach of the aperture of the tube. The air may be easily discharged through the upper stopcock, and its place may be supplied by directly pouring; water in or sucking it in through the coiled tube. The fragments of stone are drawn by suction through the evacuating catheter, the lower stopcock, and the open end of the tube. There are no valves, there is no stand, there is no rubber connecting-tube between the lower stopcock and the evacuating lilTHOLAPAXY. 23T catheter. The rubber walls of the bulb are thick, and their elasticity and suction power great. The apparatus when coupled may be entirely freed from air-bubbles.. The fragments are received at exactly the centre of the bulb and sink at once into the receiver. The return flow only moves the frag- Fig. 1228. Fig. 1229. Blgelow's first evacuator. Stand for the eracnator. Fig. 1230. Blgelow's second evacuator. 238 UKINARY CAIiCULUS. raents which have last escaped from the tube-strainer and does not carry them to the bladder. In the figure are certain accessaries of tho apparatus not essential to its use. The rubber tube fits at its angular metallic tip upon the upper stopcock of the evacuator, while the weighted extremity rests in a basin or pitcher of hot water ; during the use of the evacuator, by means of the combination, air is expelled from the bulb or water thrown out or sucked in at will, to vary Fig. 1231. Bigelow's third evacuator. Fig. 1232. Bigelow'8 latest evaonator. the amount of fluid in the bladder during the washing, the whole manoeuvre being promptly performed by turning -the upper stopcock and compressing LITHOLAPAXY. 239 and relaxing the bulb. The metallic funnel is to substitute the tube in fill- ing the evacuator through the upper stopcock. Operators who are familiar with the use of the tube seem to prefer it to Fig. 1233. Thompson's first eTacaator. Fig. 1234. Fig. 1235 Thompson's second evacnatoT. Thompson's third evacnator. 240 URINARY CALCULUS. the funnel. The extra stopcock below is for use upon the evacuating tube before coupling, that air may not enter it. Sir Henry Thompson's evacuator has also passed through four distinct stages. I represent them in the annexed figures, but only describe the latest. 1236. Thompson's fonrth and latest evacuator. It i-s a rubber bulb, the central axis of suction of which is nearly in the line of the axis of the evacuating tube, but not as much so as in the case of Bigelow's instrument. The glass reservoir is situated in. front of the rubber bulb, and a swinging, perforated valve hangs over the orifice of the tube, to prevent the return of fragments.into the bladder. Fig. 1237. Eeservoir of Thompson's evacuator. Other evacuators, such as those of Hill, and of Corradi of Florence, I dO' not think it necessary to reproduce. Otis's evacuator involves a new mechan- ism, and as it is the first of its pattern it should be allowed opportunity for modification before it is judged, because each of its chief rivals has received several modifications before being given to the world as perfect. The figure sufficiently describes it. The sphere through which the tubes show is of glass, as is also the receiving bottle. The tubes, stopcock, and couplings are of metal, the power a rubber ball. It works without valves and delivers efliectively. It is filled through a tube and stopcock at the tail of the rubber bulb, and may be worked with this bulb full either of air or of water. My objection to this instrument is that it is impossible to get the air all out of the glass sphere by any method of filling, so that although no air is thrown LITHOLAPAXY. 241 back and forth into the bladder, yet the noise it occasions in the glass sphere prevents an accurate appreciation of the size of the fragments as they strike against the tube within the bladder. I find the instrument also less con- venient in manipulation than the Bigelow bottle. It is a little cheaper than Fis. 1238. Otis'8 evacuator. other instruments, and further modifications may bring it to that degree of mechanical perfection for which Dr. Otis's instruments are so justly celebrated. Fig. 1239. Fig. 1240. Fig. 1241. Gruyon's evacuator. Curved evacuating tube. Straight evacuating tube. Q-uyon's evacuator (Fig. 1239) should be referred to, since it has done so much good work. It does not commend itself as a mechanical triumph, but Guyon has proved that it is effective. VOL. VI. — 16 242 UEINARY CALCULUS. The evacuating tubes used in litholapaxy are curved and straight. Thomp- son and Guyou prefer the former, Bigelow the latter, but all lithotritists use either, as occasion requires. The tubes are made of thin metal, the eye so shaped as to scrape the urethra as little as possible on the way in or out, and, theoretically, not to catch fragments which are too large to pass the tube. The former end is attained very satisfactorily, the latter not so. I have not yet seen a tube with an eye which does not catch and hold frag- ments too large to pass the tube, and I have tried them all. Fig. 1240 shows the curved tube in profile. The straight tube (Fig. 1241) is identical as to its eye and its general construction with the curved tube. These tubes are introduced as if they were curved or straight sounds, except that the straight tube may sometimes be twisted or rotated in through the fixed curve of the urethra where direct pushing will not succeed in making it pass. On account of the tendency of the eyes of all these tubes to catch fragments too large to pass through the tube itself, I have devised another form of straight tube, the eye of which cannot clog. When the eye of a tube does clog, if the fragment impacted in it is hard and angular, it may happen that water will not dislodge the fragment. 'No matter how forcibly the bulb is compressed, the fragment will stick in .its place, and will be withdrawn with the tube, unless the operator is willing to uncouple the evacuator and push a solid stylet of some sort down to the extremity of the tube, while the end of the latter is still in the bladder. This manoeuvre ex- poses the patient and his bed to a wetting, so that the surgeon is tempted to pull the tube out, charged as it is with a barb at its extremity. I have seen the roof of the urethra quite sharply scratched on more than one occasion in this way. Once I saw a stone, so caught in a tube, drawn forward until it caught at the point of physiological narrowing of the pen- dulous urethra, in the third inch from the meatus. Here it stuck, and it was impossible to move the tube either way, or to dislodge the stone even with a solid stylet. Finally, by the exercise of very considerable force, the tube, still holding the stone, was dragged out — a manoeuvre the reverse of surgical. W ith the aim of averting any possible impaction of a fragment in the eye of the tube, I have used a straight tube of thin metal open at both ends (Fig. 1242). A wooden obturator makes its introduction reasonably easy, and Fig. 1242. Keyes's evacuating tube, straight. a washer on the obturator allows the latter to be withdrawn without leakage beyond the stopcock, which, being turned, keeps the bed dry until the washing bottle has been fitted to the tube. Such a tube in some cases renders valuable service, particularly in evacuating a last fragment, or in washing out a small stone recently descended from the kidney. Anything which once enters cannot fail to pass, and anything which lodges in its vesi- cal opening will be immediately dislodged as the fibres of the vesical neck close over the tube during its withdrawal. It delivers very promptly to the washing bottle, but has tbis defect, that in order to make it functionate to its best advantage its vesical end must be drawn close- down to the neck of LITHOLAPAXY. 243 the bladder and held there. If it is pushed too far in, it does not return the wash properly, and the back wallof the bladder flaps inconveniently, perhaps painfully, against its open end, being drawn upon it by the suction of the evacuating bottle. On the other hand, if it is held close to the vesical neck the orifice of the tube may slip out into the prostatic sinus during the work- ing of the bottle, and there bruise the membrane and fail to do its work. The tube therefore requires some care in its use, and for continuous work is not as valuable as those generally employed, but as an extra tube it has a function of its own, which I have found of value in shortening the operation. Furthermore, in introducing the tuba the operator must be quite certain that its tip has penetrated into the vesical cavity before he attaches the bottle, as otherwise, if he leaves the end of the tube in the prostatic sinus, he will wash in vain ; I have known this accident to happen in able hands, and to produce a low opinion of this tube's value in the mind of the operator. Finally, because a straight tube renders debris so, much more readily than a curved one, I have had a curved tube made (Fig. 1243), with a large eye Fig. 1243. Keyes's evacuating tube, curved. -on its straight part, and a stopcock for protecting the bed from wetting while entering and withdrawing the obturator, which should always be used when the eye is very large, for fear of drawing out an impacted fragment. This tube is curved as far as introduction goes, but straight for all purposes of delivery. It works very well in my hands. Joseph H. "Warren has devised a spiral revolving tip, for attachment to the end of curved and particularly of straight tubes, in order to facilitate their introduction. Experience at my hands does not justify the claims made for this addition to the instrument. As to size, Bigelow advocates the use of the very largest tube that will pass. Undoubtedly, the larger the tube the more satisfactorily does it render the debris to the washing bottle. But most operators rather shrink from distending the urethra to its utmost capacity, and use only as large a tube as the urethra will admit comfortably, perhaps after incising a bridled meatus. This is a sound rule to go by, and one generally followed. The meatus, if ■constricted, or with a pocket at its lower commissure, should be incised rather freely, and then as large a tube should be used as will go easily past the point of physiological narrowing in the third inch of the pendulous urethra, and nothing larger. This physiological point of narrowing almost invariably exists, and should not be cut or even over-stretched to accommo- date a tube. _ Perfectly effective work is constantly being done through tubes of moderate size. Thompson rarely goes above 16 English — 27 French — and has smaller tubes for those who require them. Guyon uses about the same size. I have performed the whole washing, in an old man whose urethra I M^as particularly desirous of sparing, with a 'No. 20 (French) curved tube. The tubes I employ run from 20 to 32 (French). 244 URINARY CALCULUS. Mode of Performing Litholapaxy. — The patient having been prepared as ah-eady directed (page 216), is etherized and placed upon a table covered with a rubber cloth. The table should be high, narrow, and long. The patient lies upon his back, with the hips elevated a few inches above the table, ' the shoulders being low. Two assistants are essential, one to administer the ausesthetic, the other to attend exclusively to emptying and refilling the washing bottle. It is well to have a third assistant to hand instruments, etc. The first manoeuvre is to introduce the curved tube selected for the opera- tion, incising the meatus if necessary. Through this tube all the urine is drained away. S"ow the washing bottle, charged with a saturated solution of borax at 100° F., is attached to the tube. But the urine having trickled away in its last drops through the tube leaves the latter full of air, an element fatal to nicety of washing. This air may be disposed of most simply. The tube is withdrawn until its eye is in the prostatic sinus, the washing bottle is attached and the stopcock turned, but no further motion made. In an instant, the air contained in the curved tube is felt and heard ascending' through the stopcock and mounting into the top of the rubber evacuator, where it does no harm, and whence it cannot possibly return into the bladder. As soon as the rising bubbles of air have announced that the tube is full of water, the bulb is compressed, water distends the prostatic sinus and neck of the bladder, and the tube passes on almost Unaided into the vesical cavity without damaging the neck of the organ. I have found this flushing manoeu- vre of great assistance in certain cases of enlargement of the prostatic third lobe. It is not necessary when a straight tube with obturator and stopcock is used, for in such a case the tube does not contain air. S^ow alternate contractions and relaxations of the rubber bulb are practised. This demon- strates the presence of the stone by the clicking noise made, while at the same time the wash disinfects the bladder. Two or three ounces of the fluid are left in the bladder, and the tube is withdrawn. The next step is the crushing. This is done according to the rules already laid down for ordinary lithotrity. All the seizures should be made deliber- ately, it being remembered that a cardinal rule of rapid lithotrity is to work, if not slowly, at least with deliberation. JSTo instrument should be used which can by any possibility clog. Seizures are made in prompt succession, no time being lost in clearing the blades. After a dozen or more successful seizures the lithotrite is withdrawn and the tube reinserted, with the precau- tions as regards the entrance of air already alluded to, and the washing commences. The curved tube is first held so that its curve presses backwards and downwards upon the bladder behind the trigone. Then it is moved from side to side, and partly drawn out, finally inverted and held a little way up by depressing its distal end — the washing being kept up constantly as these changes in position are being made. The straight tube is held with its aperture as nearly as possible in the centre of the bladder, and preferably turned downwards ; it also is rotated in different directions. The straight tube with an open end is so held that its opening lies just inside of the neck of the bladder. The washing is performed by an easy succession of synchronous movements- of the hand. When the fragments come into the receiver more slowly, and particularly to catch a last fragment, it is proper to compress the bulb rather violently, to maintain it compressed for an instant, and then suddenly to let up the pressure. When there is much angular debris the pieces rush together ' toward the eye of the evacuating tube, and, crowding into it, momentarily clog it, so that although they rattle most musically, there is very little show LITHOLAPAXY. 245 in the receiving bottle. In such a case much better rendering will be effected by a succession of sharp, jerky, partial contractions of the bottle, so as to dislodge the accumulating fragments about' the eye of the tube, only to stir up one or two, and to allow these to be sucked into the receiver. Occasionally an angular piece of stone will clog the eye of the tube, not large enough to prevent a reasonably free passage of fluid, but eflectually blocking the way to any fragments larger than dust. Now again, the frag- ments rattle about the tube, but the washing gives no return. An experi- enced operator always recognizes this accident at once ; an unobservant one may lose much time before he finds it out. When this accident occurs, a sharp gush of water sent suddenly through the tube will sometimes dislodge the fragment. Sometimes it will fail. Then the water should be drawn off, the tube uncoupled, and a solid stylet passed to drive out the fragment into the bladder. This is safer than to withdraw the tube with the stone impacted in it, although the latter course is the one usually adopted, and, as a rule, no harm comes of the slight scratch- ing of the urethra which it occasions. Often, as the tube is moved from side to side, and particularly when the curved tube is inverted, the bladder-wall flaps with a sharp click against the ■eye of the tube, and then flutters spasmodically with dull thuds against the ■ open end of the instrument. This suction of the bladder-wall into the eye ■of the instrument has never been known to do any harm, but it must bruise the organ somewhat, and its repetition should be avoided by shunning the particular manoeuvre which occasions it. When the bladder is empty, the sharp click given by the wall as it is sucked against the eye of the tube is often so hard in quality as to resemble the sound given by a fragment •of considerable size. An operator not accustomed to the sound may be •deceived in this way, and may go on indefinitely searching for a fragment which does not exist. Error may be avoided by noticing that the click may be produced at will by turning the tube in a given direction. A little experience teaches the operator all that can be known about this flut- tering of the bladder. Should air enter the bladder, it churns up the water needlessly, distends the bladder, and interferes with the efiiciency of the wash, while it so confuses the sounds that the click of small fragments against the tube can no longer be clearly distinguished. To dislodge the air, the bladder should be fully •distended, and then the handle of the tube strongly depressed between the thighs, so that its eye may be raised to the top of the bladder. While held in this position the rubber bulb is worked slowly, and the air escapes into the bottle, and remaining at its top can be discharged through the upper stopcock. After the fragments cease to collect in the receiver, the operator removes the tube, and hands the bottle and receiver to his assistant, who immediately pours out the water, more or less stained with blood, empties the fragments, and refills the bottle. While this is going on the operator has again intro- duced his lithotrite, made a dozen or more seizures, and by the time the bottle is ready there is usually enough debris to call for another wash. In this way, by alternate crushings and washings, the fragments are steadily reduced in size and extracted. Search for last Fragment. — A last fragment is sought for by ausculta- tion during the process of washing. Every bubble of air is scrupulously removed from the bladder, and with a small tube — the bladder containing a little surplus of water, so that when the exhausting bottle is full the oi'gan shall not be entirely empty — it is gently washed while the operator places 246 ■ URINARY CALCULUS. his ear directly over the lower part of the abdomen. The tube is turned ia various positions and the operator listens. The swash of. the water, as it rushes in and out, is heard with startling distinctness, and, if the manage- ment of the tube is skilful, any fragment of stone lying loose in the bladder is- sure in a short time to be driven against the metallic tube and to announce its presence by a characteristic click, quite distinct from that emitted by the flapping of the bladder-wall against the eye of the instrument. Fine sancl and thin scale of stones make no sharp click, and all such may be left fo pass by nature's efforts ; but any piece large enough to require the lithotrite can hardly escape detection by the educated ear. After-treatment of Litholapaxy. — This is practically the same as already laid down for cases of ordinary lithotrity. !N"o vesical M^ashings are required unless retention conies on, or atony exists, or the urine has been highly offensive before the operation. In such cases borated washings comfort and purify the bladder. The symptomatic treatment includes rest in bed, a hot-water rubber bottle for the hypogastrium — which is commonly the seat of pain — opium, quinine, sweet spirit of nitre, alkaline diluents, and mineral waters. The sense of relief experienced after litholapaxy is often immediate and delightful. The patient exclaims at his comfort. Reaction may be very moderate, but it is not well to be too promptly reassured, since after a period of several days' calm, similar to what is noticed sometimes when an old case of vesical atony is for the first time relieved by the catheter, cystitis may set in and considerable distress be experienced. There may be retention of urine for the fii'st twenty-four hours or more, or there may be none. There may be more or less urethral fever. Generally, the urine ceases to be bloody from the second to the fourth day,. and the patient may be up and about his room, or even out of doors, at the end of a week ; but in any case, no matter how well he may feel , it is expedient to avoid risks and to keep him upon his back for about that period. He may arise to urinate, or to take a hot-bath — but should not sit up for any length of time. One of my patients, however, a gentleman of nearly seventy, after quite a severe operation, got up and took his cold sponge bath every morning- without any evil result. Time consumed by the Operation. — Bigelow operated continuously during- upwards of three hours, removing seven hundred and fortj'-four grains, and his patient did perfectly well.' Thompson,^ starting with a much shorter limit of time, now says that none of his calculi have required more than seventy minutes, this time having been required to remove a hard uric-acid calculus- of which the debris weighed 1320 grains. The patient did well. Guyon's- longest operation lasted seventy-five minutes. Reginald Harrison removed a two-and-a-half ounce stone in two hours and ten minutes,' and Coulson, in an article* reporting eleven cases with two deaths, says that his largest stone weighed 2060 grains, and was removed in three hours and a quarter. My longest operation lasted ninety-five minutes. Therefore, it may be concluded that the element of time is not a very im- portant factor in the operation, and while it is obviously better to terminate the sitting with reasonable promptness, the signal for stopping is the com- plete evacuation of the stone. Of course, any general circumstance which ' Am. Journ. Med. Sei., January, 1878. ' Lectures on Diseases of the Urinary Organs, 6th ed., p. 82. 1882. s Brit. Med. Journ., Aug. 10, 1882. " Lancet, March 19, 1881, p- 453. LITHOLAPAXT. 247 would cause a surgeon to halt in the midst of any other operation, would weigh with equal, but with no greater force, here. The amount of debris which may be removed in a given time varies greatly with circumstances. The average now is much higher than formerly, since operators have learned their power. The best recorded yield in washing was three ounces (dry weight) of small stones in twenty minutes — 72 grains to the minute — a result obtained in Thomas Smith's celebrated case of multiple calculi. This result was obtained through a tube of size 'So. 27 (French). Bigelow's first set of cases yielded a little less than an average of three grains to the minute, while in a recent case^ he removed successfully 1388 grains in one hour and fifty-five minutes, exactly 12 grains to the minute. Thompson's^ first series yielded an average to the minute of 16 J grains when the stone was hard, 12| when it was soft, while one of his later cases, that of the large stone already alluded to, gave him nearly 19 grains to the minute. My own first average^ was only 4| grains to the minute, while a recent case of hard phosphatic stone, 765 grains in 45 minutes, furnished me an average of 17 grains to the minute, and the patient did admirably, being up and dressed in five days. How much better may be done, time must determine, but no operator who values the safety of his patient should rank speed in the operation as highly as care and skill. Relapse after Litholapaxy. — Relapse may occur after litholapaxy, as it does after lithotomy, a totally new stone formation taking place, but it can- not well occur otherwise if the precaution be taken to search the bladder carefully with a small tube and washing-bottle, after the patient has been up and about at his duties for a month or more. This manoeuvre is so necessaiy that it might almost be termed the last step in the operation. One thing only in the way of relapse cannot be guarded against bj' litho- lapaxy, or indeed by any operation, and that is phosphatic re-accumulation. In cases of chronic cystitis with atony, where the patient will not take intelli- gent care of his bladder, and in cases of encj^sted stone, or chronic pyelitis, and the like, phosphatic re-accumulation must and does occur. Intelligence on the part of the patient may be required in these cases, and acuteness on the part of the surgeon to detect the cause of the phosphatic re- accumulation, and to do away with that cause if possible. But even in those cases in which the cause cannot be removed, the comfort furnished to the patient by litholapaxy, without risk to life, is far greater than could be afforded either by simple lithotrity or by lithotomy. Often when the cause of the phosphatic re-accumulation is chronic vesical catarrh, kept up by enlarged prostate and muscular atony, relapse after litho- lapaxy may- be prevented by scrupulous attention to vesical irrigation, and by occasional injections of dilute nitric acid, of a strength varying from a few minims up to a fluidrachm, in a pint of warm water. Complications during the Operation. — These are injury to the urethra, injury to the bladder, hemorrhage, clogging of the lithotrite, breakage of a lithotrite, inability to introduce the tube, clogging of the tube. The urethra is not likely to be injured by a lithotrite unless the instrument is withdrawn with its jaws impacted, or still containing a hard, jagged frag- ment. The bladder may vei-y easily be injured to a varying extent by pinch- ing up a fold of mucous membrane, with more or less of the muscular coat of the bladder, or even tearing it away in the grasp of the instrument. The ' Boston Med. and Surg. .Tourn., Dec. 29, 1881, p.-612. ' Lancet, Jan. 10, 1880, p. 44. s lqo. cit., p. 14. 248 URINARY CALCULUS. resulting injuries are ecchymosis, contusions, excoriations, and lacerations of varying severity. It is possible with any lithotrite to pick up a fold of the bladder, pinch it slightly, and then let it go. I have done this on the cadaver and on the living subject with equal ease with the instruments of Bigelow, Thompson, and myself. With the old-fashioned fenestrated lithotrite, having_^a cutting edge upon the male blade, this accident was fraught with danger ; with modern instruments, managed with a little care, the accident is unimportant. In many cases it is impossible to perform litholapaxy without having the water, even of the first wash, distinctly tinged, sometimes positively darkened, with blood. This blood comes from the slight scratching injuries inflicted upon the mucous membrane of the bladder, and upon its neck, by the jaws of the litho- trite and the angular fragments of the stone. Such a moderate appearance of blood is a matter of course, and in no way compromises the success of the operation, or portends an outbreak of serious inflammation at its termination. Hutchison, of Brooklyn, using a lithotrite of one of my earlier and imper- fect models, reported that he pinched off shreds of mucous membrane from the bladder, but no reaction followed, and "the result was satisfactory." Wynkoop, of IS'ew York, using one of the earlier Bigelow instruments, found the jaws to clog, and had to use much force in extracting the blades. The clogging appears to have been due to some mechanical defect in the construc- tion of the instrument ; abscess ensued from laceration of the deep urethra, and the patient was subsequently cut for removal of the remains of the stone and for cure of the abscess, and recovered. In another case treated by the same operator, in which also Bigelow's lithotrite was used, the patient died twenty- nine hours afterwards, and at the autopsy a number of abrasions and minute lacerations of the mucous membrane of the bladder were found. Hence, it may be assumed that a certain amount of scratching damage to the bladder is commonly produced by all lithotrites,but that, as a rule, such moderate damage does no harm. It need hardly be added that the less damage done, the better, and that, other things being equal, the better the operator, and the more perfect the instrument, the less will be the physical injury inflicted upon the bladder. On two occasions in former years I have, while practising the old operation, pinched off small shreds of mucous membrane from the bladder — once, in fish- ing for a soft catheter in a paralyzed bladder, the patient denying any sensa- tion when the thin film of mucous membrane was seized, and once in working rapidly with an instrument which it was believed would not clog and could not catch the bladder. In neither of these cases did the least reactionary disturbance hinder the recovery of the patient, or indicate that any unusual damage had been done. In a case where a suit for malpractice was instituted in New Hampshire, one of the lawyers informed me that an irregular practitioner had passed the lithotrite but had found no stone. After considerable search, another sur- geon who was present introduced his finger into the rectum, and there found the jaws of the lithotrite which had passed through the membranous urethra. The wound healed, and the patient recovered. My personal experience' has led me to conclude that damage done to the urethra by a clogged instrument, or by the use of tubes too large for the canal, is more likely to be followed by disastrous results to the patient than similar or even greater damage inflicted upon the bladder. Much damage can be done to the urethra as well as to the bladder without serious conse- quences, as will be shown when speaking of the clogging in lithotrites and impaction in tubes. In any case, it is only just to the patient upon whom > Am. Journ. Med. Soi., April, 1880. LITHOLAPAXY. 249 litholapaxy is performed to use a lithotrite which will not clog, to operate, with all possible care, to employ tubes which do not stretch the canal too decidedly, and to dislodge impacted fragments before- withdrawing the tube. Hemorrhage during litholapaxy commonly occurs to a moderate degree, but the final wash, usually, is hardly, if at all, bloody. In some cases, on the other hand, the hemorrhage is profuse from the very first introduction of the lithotrite. I have had a case in which, on introducing the tube, pure blood flowed out, and only stopped after coagulation within the tube had made a plug large enough to occlude it. This plug was drawn out as a complete, long cast of the tube. The bleeding did not continue uniformly at this rate, and the washing was successfully followed up, but the amount of blood lost made it necessary to arrest the sitting before all the debris had been removed. Ten days subsequently the remaining two drachms of fragments were suc- cessfully removed, the I'emarkable fact being that on this occasion the amount of hemorrhage during the operation was exceptionally small. The patient was 75 years old ; the stone weighed 513 grains ; recovery was prompt and complete. In a case of hemorrhagic diathesis, or if the bladder happened to contain a villous growth along with the stone, very serious hemorrhage might occur. I am not aware that any case thus far has been reported in which a fatal result after litholapaxy has been ascribed to hemorrhage. Ultzmann, how- ever, has expressed the fear that serious, even fatal, hemorrhage may result from the operation.' Clogging and Breakage of the Lithotrite. — The lithotrites commonly in use at the date of introduction of litholapaxy were of two kinds, both dangerous. The fenestrated lithotrite had a cutting edge along both sides of the male blade, 'and the male blade fitted, snugly into the fenestra of the female blade. With this instrument, if the bladder was seized at all, a piece was quite cer- tain to be cut out. The bladder could not be pinched and dropped, and con- sequently the fenestrated instrument was used only on rare occasions and with special cai'e, when a very hard, large stone had to be fragmented into large segments preparatory to final pulverization. The danger of using the instrument freely was well known, and was ex- pressed by Thompson before the Royal Medical and Chirurgical Society of London, March 16, 1878, when he said that he had not used a fenestrated instrument in the bladder for ten years. The non-fen estrated, pulverizing lithotrite would not readily catch the bladder or harm it much, if it did pinch up a fold ; but it had its own espe- cial danger in th?t it was quite sure to clog with debris after a few seizures had been made, and that it was generally next to impossible to free the blades .when once the}' had become firmly impacted at the heel of the jaws. ' Conse- quently it was taught that, after from three to six successful seizures, the in- strument must be removed and its jaws disgorged, to avoid inflicting serious damage upon the urethra. In fact, at the meeting of the Royal Medical and Chirurgical Society, already alluded to, both Thompson and Coulsou laid great stress on this im- paction as sometimes " preventing the withdrawal of the instrument," and as having required, " in one case, incision in the perineum." With such instruments, manifestly, litholapaxy could not be properly performed. But since the introduction of the new operation a number of lithotrites have appeared whose claims consist in three elements: (1) strength; (2) blunted roughness and lateral bevelling of the male blade, so that the bladder, if caught, need not be seriously damaged ; (3) fenestration, with a ' Centralblatt f. Chirurgie, No. 24, S. 393. 1882. 250 URINARY CALCULUS. large spur at the heel of the male blade, and comparative breadth of th( female blade, to insure against impaction. I have already recorded the impaction of a Eeliquet instrument in my handf while performing old-fashioned lithotrity. In litholapaxy this accident haf not occurred to me, and with the instruments which I now use, it is impos sible. Coulson, at the meeting of the International Medical Congress, in London stated that on two occasions a lithotrite had broken in his hands. One o: these cases was reported in the Lancet.' The instrument was a Bigelow litho trite, defectively made. The collar holding on the male blade came off. Th( jaws had to be freed from debris by percussion, after which the lithotrite was withdrawn, no harm being done, and the operation was concluded with i fenestrated lithotrite. Several cases of slight clogging of some of the earlier Bigelow instruments due to defects in structure, have been reported (Wynkoop, Stein).^ One o; my lithotrites, of Tiemann's make, in the hands of Dr. Rockwell, of Brooklyn broke at the heel of the male blade upon a large oxalate-of-lime stone whicl was too hard to be crushed. The patient was cut at once successfully. I was present at an operation at the hands of Dr. Weir, when a Bigelow lithotrite broke at the collar under exactly similar circumstances. The patient was ther cut, and successfully relieved of a large oxalate-of-lime stone. Alan P. Smith' reports a case of serious clogging of a lithotrite in th( bladder of an old man. The instrument was of the Civiale model, made bj Robert and Collin. After it had clogged, no efforts made at the handle coulc free the jaws, and consequently the instrument was forcibly extracted, whei it was found that the jaws were separated to the extent of three-fourths o: an inch ; yet no evil result followed in this case. Agnew,* of Philadelphia, refers to one instance in his knowledge, where i lithotrite could not be closed on account of some defect in the button whid regulated the screw. As a consequence of withdrawing it with the bladei apart, injuries ensued which proved fatal. Should an instrument clog badly, it seems to me that it would be propei to cut the patient at once by the median section upon the lithotrite, dilat( the neck of the bladder, and bring out the jaws of the lithotrite in the wounc of the perineum, where they might be cleared. Such a course would bi devoid of any considerable danger. If the jaw of a lithotrite should breal within the bladder, it might be extracted by using a smaller lithotrite, o the knife might be resorted to with propriety. Complications occurring after Litholapaxy. — After litholapaxy, the sami complications may arise as have been already set down as possible after litho trity (urinary fever, retention, hemorrhage, cystitis, epididymitis — or evei surgical kidney, possibly pysemia, septicaemia, etc. — graver complication which will be considered under the head of complications of lithotomy). Theri is not, however, as much likelihood of complication after litholapaxy as afte lithotrity, because the former operation is devoid of one great source of danger namely, that arising from the repeated injuries inflicted upon the bladder b; the sharp fragments left behind between the sittings. The slighter complications are not uncommon (urinary fever, mild cystitis epididymitis) ; the others very rare. The complications most to be dreadei are pyelitis and surgical kidney, due to already diseased kidneys, and failini vitality in an old patient, when the risks of an operation have been assume^ • Lancet, Nov. 27, 1880, p. 853. « Keyes, Am. Journ. Med. Soi., April, 1880. * Maryland MedicalJourual, January 2, 1882. ^ Op cit., vol. ii. p. 661. LITHOTOMY. 251 rather than the prolonged endurance of the certain torture and slow death which would have followed had no operation been performed. I have not seen atony of the bladder follow litholapaxy, nor heard of it. Thompson' speaks also of chronic cystitis with phosphatic deposits as coming on in some cases as an atter-complieation of litholapaxy, when it did not exist before the operation. The same complication has arisen in in his hands after lithotomy. He says further, that "one of the most per- sistent examples of phosphatic cystitis" which he has seen of late years followed an operation of rapid lithotrity done two years before, in which he removed with great ease in six minutes a small uric-acid calculus weigh- ing 84 grains. He refers also to live other cases in which there was more or less chronic cystitis prolonged for a period of several months, in all of which " the calculus was uric acid, and cystitis was not present before the operation." When this complication occurs, it is to be met according to the general principles governing the conduct of a case of chronic cystitis with tendency to phosphatic accumulation. Applicability of Litholapaxy to Women and Children, and tor the Removal of Substances other than Urinary Deposits. — The applicability of litholapaxy to children has already been considered (page 211). Females of all ages are admirably suited for the operation. I have employed it at both extremes of life. Generally, the known existence of any substance in the bladder other than a urinary concretion, has been looked upon as a bar to the crushing operation, but with strong instruments and large tubes, certain exceptions must now be made. Pieces of bone, wood, wax, lead-pencil, slate-pencil, pipe- stem, or catheter, known to be acting as nuclei of stone, may be disregarded > crushed up, and washed away with the rest of the debris. I was present at an operation at the New York Hospital, in which Dr. Peters removed with some phosphatic debris quite a large piece of wax. Bigelow, in his first set of cases, removed a portion of catheter which was the nucleus of a stone. I have done the same. Holt C. Wilson^ has quite recently reported a case in which he removed successfully by litholapaxy, from a patient of 42, a phos- phatic stone and six inches of an English web-catheter, of size JSTo. 8 (ISTo. 1& French). Lithotomy. Lithotomy, like so many of the surgical terms which have been conse- crated by usage, is a misnomer. We no longer cut the stone, as history tells us was done b}' Ammonius, but we cut the soft parts, more or less, and extract the stone whole, or after it has been broken. The first known attempts at extracting stone from the bladder of the male seem to have been made long before the Christian era by the Hindoos. Doubtless, the idea first suggested itself to some one who witnessed the spon- taneous expulsion of a calculus through the perineum, or perhaps liberated a large stone from a perineal fistula by a stroke of the knife. Certain it is, that the operation known as "cutting on the gripe" — the apparatus minor, as it was afterwards called on account of the small number of instruments required for its execution ; also christened the method of Celsus, on account of the accurate description which that writer gave of the operation in the first century of our era — was the earliest ever performed, and that in spite of its rudeness and manifest imperfections, this, more or less modified, was • Op. cit., 6th ed., p. 94. ^ Med. Record, Deo. 23, 1882, p. 709. 252 TJRINAKY CALCULUS. the prevailing method of extracting stones from the bladder during twenty centuries. The description of the Indian method of cutting on the gripe is essentially the same as that of Celsus. The latter only advises the operation for child- ren between the ages of nine and fourteen ; afterwards it was used for patients of all ages, but it was recognized that the older the patient the more uncertain was the closure of the wound. Albucasis formulates this conclusion, and says that under fourteen years healing is easy. The rude manoeuvre of cutting on the gripe consisted essentially of three steps. First, some effort was made to cause the stone to fall toward the neck of the bladder by striking the shoulders, shaking the patient, and pressing upon or stroking the abdomen which had been- previously greased. The second step was to hook the stone down by putting one or two lingers into the anus, and assisting the descent by the pressure of the hand of an assistant upon the hypogastrium. Meantime, the patient was held firmly by the arms and legs upon the lap of a strong assistant (or two of them, sometimes with one more at each side to steady the group), leaning back upon his breast. An incision was now made, generally with a broad knife cutting at both edges near the point, upon the stone as it bulged in the perineum. This incision, as described by Celsus, was usually curved transversely above the anus, each horn of the incision looking outwards and backwards. But incisions of other shapes were also made transversely, curving upwards, and on either side, until finally it came to be the proper thing to make the incision upon the left of the raphe, curving outwards, the convexity of the incision looking towards the anus. Velpeau ascribes to Antyllus the left lateral incision. The third manoeuvre was the extraction of the stone. Sometimes it was foi'ced out by the pressure of the fingers behind it, but more often it had to be extracted with hooks, forceps, and the like, or cut with some special instrument to facilitate its removal — as practised by Ammonius. Various means of washing out the bladder and cleaning it of any remaining debris were afterwards introduced. This operation must have counted many successes, for it continued to thrive, passing through the hands of travelling specialists to find champions for its defence long after its more surgical rival, the Marian operation, had appeared upon the field. The neck of the bladder was probably not often cut into at all by most of the surgeons who cut upon the gripe, although it was the aim of the deep incision, as recommended by Celsus, to cut across the neck of the bladder transversely. The bladder-wall itself and the back part of the pros- tate were incised by most operators, and the seminal vesicle and ducts of the left side were very constantly cut through. There grew to be a prejudice against cutting into or across the middle line of the integument, or approaching the rectum — a prejudice which continued active after the introduction of the grooved staff by Marianus — on the ground that if the raphe were cut it would not heal, by reason of the callosity of the tissues there, and that fistula would be quite certain to follow ; and that if the hemorrhoidal vessels near the anus were opened, very dangerous or fatal bleeding would result. The apparatus major, the conception of which has been ascribed to the Italian surgeons Battista da Eapallo and Joannes de Romanis, was first pub- licly described by the pupil of the last-named surgeon, Marianus Sanctus, in 1524. Whereas almost no instruments had been required for the older opera- tion, this one was burdened down by machinery. The essential advance made by this operation, from a surgical standpoint, was the introduction of the itinerarium — the guide to the neck of th6 bladder — the grooved staff upon which the incision was to be made. LITHOTOMY. 253 Marianus did not, however, cut into the neck of the bladder. He coun- seled strongly against it, asserting that a division of the constricting muscles of the bladder would be unavoidably followed by incontinence of urine. The operation was essentially an incision in the left side of the perineum upon a grooved staff; by some operators it was made upon the extreme right. The urethra was opened to the breadth of the nail of the thumb, and the parts beyond were dilated and torn rudely with rough instruments. Some- times the stone was broken before extraction. Joannes de Romania advocated this modification, but Marianus objected to it. Extraction was effected by forceps and scoop. Ottavien da Villa, a pupilof Marianus, came to France and communicated his method to the surgeon Laurent Colot, and Henry II., in 1556, created for the latter the position of Court Lithotomist. The Colot family retained the secret, and practised lithotomy as specialists for more than a hundred years, and it is related that in the seventeenth century the secret was stolen from Jerome Colot (who died in 1684), by some ambitious surgeons who bored through the ceiling of the operating room at La Charite, in order to watch the great operator at his work. They were not a little surprised and disgusted to find that the operation so long kept secret, was only a slight modification of the apparatus major of Marianus, which was every-where known. Thus it appears that the apparatus major was essentially urethrotomy with dilatation of the neck of the bladder and extraction of the stone, often after it had been broken, an operation which in our own day has been slightly modified, but much improved, as the perineal lithotrity of Dolbeau. After the adoption in the apparatus major of the staflE", or itinerarium, all sorts of variations in the incision, external and internal, began to appear. Franco sustained the prejudices of his time, and feared to cut the raphe. His mind was actively occupied with devising better means for penetrating the bladder. He even suggested the use of a double cutting instrument re- sembling the double lithotome, which was then in use for enlarging wounds. With this he proposed to incise transversely the neck of the bladder, although there is no evidence to show that he ever actually did it. To Franco is ascribed remotely the origin of the lateral operation, somewhere near the middle of the sixteenth century, although to Frere Jacques undoubtedly the distinction more properly belongs. Franco, however, certainly did discover the siipra-pubic operation, and described it quite graphically in 1561. He was at that time cutting habitually in the perineum, when it happened to him to be called upon to extract a stone as large as a hen's egg from an infant two years old. He cut in the jjerineum and vainly tugged at the monster stone, but was unable to get it out, and then, actuated by the solici- tations of the parents and friends, who wished their child to die rather than suffer longer — and driven to it, as he himself confessed, by a false pride, lest he should be reproached with having been unable to get the stone away — he cut the child over the pubes, and the infant recovered. Attempts to fix the origin of the supra-pubic operation at a date earlier than this have failed, and historians now generally agree in giving Franco the credit of the origination of the operation in 1560. In 1581, Rosset first described a regular operative method of reaching the bladder by cutting above the pubis, but he never' practised it ; and although occasional cases are recorded, or alluded to (Pietre, Colot), and although there was considerable discussion about the operation, it M'as not until Fr^re Come, with his " sonde k dard" and other accessories (12 in all, which he considered essential to the proper performance of the task), had operated a number of times between 1758 and 1779, that the operation took veritable shape. Frfere Gome's operation has been the one commonly employed up to a late date. 254 URINARY CALCULUS. Much discusBlon relative to the high operation occurred among surgeons in the early part of the present century, and more favor came gradually to be accorded to it. Cheselden performed it, before finally adopting his per- fected lateral operation. Souberllielle became its champion in 1840. Vidal {de Cassis), in 1852, made a modification by doing the operation in two sittings, to avoid infiltration. Valette, in 1858, attempted to operate by cauterization; Chassaignac, and afterwards Tisseire, tried the ecraseur. Baudon made a special study of suturing the vesical walls. Petersen, in Germany, Poland, in England, Brit. Med. Jourii., Jan. 24, 1880. 262 URINARY CALCULUS. side, and behind the patient's Beck. By this contrivance the patient is held compactly together, and it is possible to operate with fewer assistants; but the bar is sometimes in the way, if an instrument has to be passed through the urethra during the operation, and if the patient takes ether badly, the freedom of his hands is an objection. Fig. 1244. Bar for separatiog limbs in lithotomj. Of anklets and wristlets there are several varieties. Prichard's anklets- and wristlets (Fig. 1245), are made of stout leather padded. The wristlet is- furnished with a strong hook, and on either side of each anklet is a rino- of metal. The pieces are put on separately and hooked up after anesthesia ia complete. Fig. 1245. Anklet and wristlet for lithotomy. Another variety hasa padded ring to slip over each foot, and, attached to the outer side of the ring, a leather strap which is to be buckled about thft wrist. Another has for the anklet a flat arrangement of padded leather, with the buckles in front and a hole for the heel behind, so as to allow greater ease LITHOTOMY, 263 of adjustment. Another, Reliquet's, has two iron bracelets, one for the wrist and^one for the ankle, the latter with a retentive piece which passes under the foot, "they are strapped on and hooked as usual. All preparations being made, the patient is etherized in bed, and then carried to the table. The anklets and wristlets are next put on separately. Then the grooved staff is inserted. Tillaux relates that in one case operated upon by Civiale and NMaton, these distinguished surgeons, having first bound their patient, had to release the bands before they could introduce the staff". The anklets are hooked to the wristlets, and the patient is drawn down to the foot of the table, the sacrum resting upon it, with, the back flat, and the nates very slightly projecting beyond its end. The assistants then steady the patient, holding the pelvis perfectly square, with the thighs equally flexed and abducted. The operator convinces himself that the end of the staff" is in contact with the stone, and requests the chief assistant to verify the fact. If the stone cannot be struck by the staff" in posi- tion, it is better to defer the operation. Except in cases of known encystment, the staff" can always be made to touch the stone, unless the latter be quite small and lying in a bas-fond behind the prostate. In such a case, a finger in the rectum will raise the stone and make it strilce the staff. The possibility of there being a false passage which the staff may enter, makes this precaution- ary verification of its contact with the stone imperative. The chief assistant holds the handle of the staff vertically upwards from the body, sometimes slightly inclined toward the patient's head, and bulging in the perineum if the operator so desires it. His thumb presses flatly against the rough side of the handle, three fingers embrace the penis in front, and the little finger passes behind the dorsum of the member. With his left hand he draws up the scrotum, maintaining the line of the raphe exactly in a central position. "With the hands so placed, the curve of the sound is to be held firmly hooked up under the sj'mphysis. The flat side of the handle of the staff" must be constantly held transversely to the long axis of the patient's body. The chief assistant must allow nothing to divert his atten- tion; no curiosity in leaning forward to watch the cut must disturb him, and at nothing less than the command of the operator may he alter this relation of affairs until the knife has entered the groove of the staff" and fairly incised the urethra. The operator now examines the rectum, and satisfies himself that it is empty, and that the curve of the sound passes the prostate. He touches the descend- ing pubic rami, and presses centrally through the perineum upon the sound, mapping out mentally the outlet of the pelvis and the anatomical relations of the soft parts in the perineum. Having calmly taken in the situation and thought over his plan, the operator is ready, and the patient is in position for any operation upon the perineum. I. Lateral Lithotomy. — The instruments required for lateral lithotomy are a steel staff of relatively large size — at least 21 (French) for an adult — and for a child in proportion. The handle should be coarsely roughened on the side that looks toward the beak, so that the thumb of the first assistant placed against it may run no risk of slipping or allowing the instrument to turn. The old-fashioned long curve is generally preferred (Fig. 1246), the curve starting backward from the shaft and bulging slightly behind its long axis. The groove should be rather broad and deep upon the right side of the staff, winding about it as a portion of a long spiral, and should end abruptly near the tip. A modified rectangular staff" (¥ig. 1247) is preferred by some operators on account of the ease with which the groove may be struck, starting as it does 264 URINARY CALCULUS. at the angle of the instrument. The operatioji known by the name of Buchanan, of Glasgow, and favorably thought of in England, is performed with a rectangular staff inserted well into the bladder until the angle of the staff' lies in the membranous urethra just in front of the apex of the prostate. Fig. 1246. Fig. 1247. Staff for lithotomy. Rectangular staff for lithotomy. The perineum is transfixed with a sharp-pointed bistoury, the groove of the staff' struck at the angle, and the knife carried directly onward into the bladder. The result is a cut like that of the lateral operation with both in- ternal and external incisions of moderate size. Fig. 1248. Lithotomy scalpel. It is well to have among the lithotomy instruments an ordinary searcher, with which to explore the bladder through the wound for fragments or multiple calculi. The scalpel generally used (Fig. 1248) is moderately bellied, LITHOTOMY. 265 seven or eight inches long, with a solid, straight back, a stout shank, and a blade about three inches long having a cutting edge of about an inch and a quarter. Some operators use the scalpel for the deep as well as for the super- iieial incision ; but a straight, probe-pointed bistoury with a stiff back is often preferred, or the Blizard knife (Fig. 1249). The English model (Fig. 1250) Fig. 1249. Fig. 1250. Blizard's probe-pointed lithotomy knife. of the same instrument has a more pronounced probe-point. Other forms of scalpel and bistoury, and cutting gorgets, are still, sometimes used. The Uthotome cache has few advocates in this country, but in France it is still popular. An American device, modelled after the well-known instrument of Sir James Earle,' is that of the late Professor JST. E. Smith, of Baltimore,^ and its claim has been championed by his son A. P. Smith, who has used it with brilliant success. l)r. A. P. Smith had operated 69 times at the latest report,^ with two deaths, 63 times with tlie instrument in question (Fig. 1251). It consists of a rectangular staff, with, a knife hinged upon the shaft in such a way that it cannot fail to strike the groove. The staff is introduced, and the hinged knife is made to penetrate the urethra. Upon a groove at the back of this knife the probe-end of a broad cutting gorget, shaped like a wide scalpel, is pushed along. It cannot fail to enter the groove of the staff, and on reaching the latter the end of the gorget drops into a cup- shaped cavity in the end of a watch spring Arhich is so arranged as to travel smoothly along the groove. The gorget, pushed steadily onwards until the end of the groove is reached, makes a cut of definite breadth in the direction of the incision of lateral lithotomy. Among the numerous varieties of forceps used to extract stone thei'e are two types, straight and curved. Forceps should have thin blades, slightly spoon-shaped, so as to embrace the stone and not add materially to its bulk. The extremities of the spoons should not touch when the instrument is closed, so as to avoid pinching the bladder. The inside of the sj)oons is rough, to pre- vent slipping. They are fairly broad, so that the rough stone may not project much beyond them, and their curve is rather long from before backwards, so as to throw as much of a wedge-shape as possible into the jaws when charged. The handles are usually crossed, to allow a maximum distention of the jaws with a minimum dilatation of the wound. One of the handles is always a ring for the thumb ; the other is sometimes left open to allow the hand to fit upon the instrument and exercise grasping power and traction more effectively. It is well to have at least two sizes of the straight shape. Curved forceps ^ Practical Observations on the Operation for Stone, 2d edit., with Appendix., London, 1803. ' Medical and Surgical Memoirs, hy Nathan Smith, M.D., edited with Addenda by Nathan R. Smith, M.D. Baltimore, 1831. A similar instrument has also been employed by Dr. Corbet, of Gla.sgow. (Med. Times and Gazette, Deo. 16, 1858.) ' Gross, System of Surgery, 6th ed., vol. ii. p. 754. 266 UKINAEY CALCULUS. Fig. 1252. Fig. 1253. Fig. 1251, IT. E. Smith's staff and knife for lithotomy. Lithotomy forceps, straight. are used for grasping a small stone behind a large prostate, or for getting a it if it is lodged above, behind the pubis. (Fig. 1254.) Fig. 1254. Lithotomy forceps, curved. The crested scoop (Fig. 1255) is of great value. The scoop end remove debris. The probe-pointed extremity, fitted into the groove of the staff o following the roof of the urethra, enters the bladder without fail, and the cres serves as a certain guide to the forceps, whose closed jaws are yet sufficient! separated to receive the crest between them. A blunt gorget having one straight and one curved margin (Fig. 1256 is recommended by Thompson, in case the perineum is so deep in a large fa LITHOTOMY. 26T man, and the prostate so long, that the finger cannot enter the neck of the bladder. The straight side of this gorget is entered along the staff, and upon it as a guide the forceps pass into the bladder. Fig. 1255. Crested scoop. Fig. 1256. Blunt gorget. Forceps to crush large stones have been devised in great variety. One- such instrument in common use has solid jaws, with a ridge of central teeth projecting backward in either jaw (Fig. 1257), and an adjustable hook and. Fig.. 1257. Crusher, or brise-pierr«. screw which are attached to the handles after the stone is caught, and which allow the screw-power to be brought to bear upon the stone. This forceps resembles Dolbeau's lithoclast. A number of other ingenious lithoclasts are used, most of which will readily break a phosphatic stone as large as they can grasp, but fail with an oxalate-of-lirae stone. Maisonneuve's instrument, the iclateur (Fig. 1258), for the fragmentation of very solid stone through a perineal. Fig. 1258. JifH" Maisonneuve's 6c]ateur. wound, is exceptionally powerful, but is clumsy and difficult of application. T have used it a number of times upon the dead body, but not upon the living. It is capable of fragmenting the hardest of urinary concretions. The curve of the female blade is insinuated carefully through the perineal wound, and by a- lateral movement made to pass around and beneath the large stone. Then the male blade or perforator, c b, with the inner drill e e withdrawn, is pushed. .268 URINARY CALCULUS. •down against the calculus and held firmly in place by turning the wheel d. rinally, the central drill at the end of the inner shaft e is by a rotation of the handle made to perforate the stone, and by further force exerted upon the wheel d, fragmentation is accomplished. ' A straight metallic tube (Fig. 1259), half an inch in diameter, with an obtu- rator, is useful in washing the bladder, and for the same purpose a metallic tube one-sixth inch in diameter, having a rounded head of hard rubber about balf an inch in diameter with numerous perforations looking backwards {Fig. 1260) ; a Davidson's or other syringe with a suitable nozzle, and a piece •of rubber pipe to form connections, complete the washing apparatus. Fig. 1259. Fig. 1260. Tubes for washing out bladder after lithotomy. The devices for arresting hemorrhage which have received approval over and above the common application of the ligature, and the use of heat, cold, and astringents, are seven. Of the seven, three are varieties of plugging, suitable for deep venous hemorrhage. They are th^rectal tampon, the s'hirted canula, and the air-tampon. The four appropriate for a deep arterial hemor- rhage are: (1) Horner's awl; (2) Thompson's tenaculum; (3) forcipressure forceps ; (4) Gross's artery compressor. Horner's awl (Fig. 1261), is a curved needle in a fixed handle. The thread is looped over the shoulder near the point, and the needle is passed along the Fig. 1261. Horner's awl. inner side of the ascending ramus of the ischium from behind the pudic artery, starting near the tuberosity and coming out toward the surface, so that the thread may be caught, the awl withdrawn, and the solid fieshy mass LITHOTOMY. 26^ containing the artery ligated. Thompson's tenaculum (Fig. 1262) unscrewa at 'the handle, a. The tenaculum including the vessel is tied in, separated Fig. 1262. Thompson's tenaculum with detacljable handle. from the handle, and left in the wound. The forcipressure forceps (Fig. 1263) is the best instrument for picking up any bleeding point that can be seen. Fig. 1263. Forcipressure forceps. The instrument may be locked, and left in the wound twenty-four hours or longer. Gross's artery compressor (Fig. 1264) is a similar contrivance, not as easy of application. Fig. 1264. Gross's artery compressor. The rectal tampon is highly spoken of by Kerr, of Canton. The ceiftre of a square piece of cloth, well oiled, is pressed into the anus, and a narrow roller bandage packed gradually into it until enough pressure has been made upon the deep parts of the wound to arrest all hemorrhage. Sometimes a little digital pressure is made upon the tampon for a few hours, the plug being pushed up against the symphysis. An anodyne may be required to allay tenesmus while the tampon is in i:)lace. Kerr says that from six to eighteen hours is long enough to allow the tampon to remain. The shirted canula (Fig. 1265) is a tampon consisting of a central tube of metal, around which near one end is gathered the small opening of a conical bag of coarse muslin. The bag is greased and inserted well into the wound, so that one end may lie in the vesical cavity. The conical sac is now stutfed on all sides with a thin roller bandage, until enough pressure has been brought to bear upon the sides of the wound to arrest all oozing, and then the tube is tied in. This is an excellent instrument, and even arterial hemorrhage may be arrested by its careful use'. It is allowed to remain twenty-four hours or longer, according to the extent and kind of hemorrhage for the arrest of which it has been employed. The urine escapes through the tube, and 270 URINARY CALCULUS. generally but little complaint is made of the pressure. It is unpacked by withdrawing the roller bandage before removal. A shirted canula may be improvised in a moment, in case of emergency, from a catheter and a square piece of muslin with a small hole in its centre. Fig. 1265. Bhirted canula for plugging the wound after lithotomy. Air-tampon for hemorrhage after lithotomy. A modern improvement upon the shirted canula is the air-tampon of Buckston Browne (Fig. 1266), the invention of which is ascribed by the French to Guyon. Both gentlemen undoubtedly devised the same instrument, each without the knowledge of the other. The figure shows Browne's tam- pon. It is a c^tral tube a, surrounded by a thin rubber bag B, which in its turn is inclosed in a bag of thin swan's-down calico, to prevent bursting of the rubber bag, and to insure against its slipping out of place wlTen once dis- tended in the wound. The dotted lines c, indicate the degree of distention which is possible. D is the tube, with stopcock F, by which the rubber bag is to be distended with air or water, and B the strings for tying in the entire , apparatus. , Gruyon's tampon is a simple oval rubber bag over a hollow tube. The English instrument-makers, Matthews Brothers,^ claim to have devised and introduced this instrument, and add that Bryant in his " Manual for the Practice of Surgery," 1872, described their tampon five years before the appearance of Mr. Browne's article in the Lancet. Their tampon was intended to be distended with cold water. This instrument is vastly the best single means of arresting hemorrhage after lithotomy which is at the surgeon's command. It is a perfected shirted canula. Its introduction, well greased, is very easy; it will arrest arterial as well as venous hemorrhage. Cold or heat may be applied to the wound with- out removing the tube from its place, simply by substituting hot or cold water for air. Its pressure is uniform and cannot harm the tissues. It causes less pain than any species of plugging. It insures free drainage for the urine, and allows the vesical cavity to be irrigated without removing the instrument. > Lancet, April 19, 1884, p. 738. LITHOTOMY. 271 It must be remembered that if the rubber is old it becomes brittle and bursts with distention. It is not ■well, therefore, to trust to this instrument alone. The surgeon should carry an ordinary shir ted canula as well as the tampon. The tampon is removed in not less than twenty-four hours. It has been left in. several days with no disadvantage. Anatomy of the Perineum. — It is immaterial whether we consider the peri- neum to be the whole of the inferior strait of the pelvis, as English authors do, or only the musculo-membranous plane which forms the anterior triangle, bounded by the rami of the ischium and pubis and by the ano-bi-ischiatic line, as is done by French writers. This triangle is really the important part in which all the work goes on in perineal lithotomy. A clear idea of the anat- omy of this anterior region is essential to an intelligent operation, and a mental picture of the parts within is a guide of no mean importance to the point of the surgeon's knife.' The object of the operator is to pass, in the young child below, in the old subject to the left side of, the bulb, by pushing the latter out of his way from the deeper parts of the wound before his knife enters the urethra. The ob- jective point in the urethra is the membranous portion of the canal, a little in front of the apex of the prostate. To reach it the posterior fibres of the accelerator urinse must be cut through, but the bulb and its artery should be spared, if possible. The structures which must of necessity be divided in lateral lithotomy, are the perineal integument and superficial fascia, some ■external hemorrhoidal vessels and nerves, the posterior fibres of the accelera- tor urinse muscle, some superficial perineal vessels and nerves, the transverse perineal muscle and artery, the deep perineal fascia, some anterior fibres of the levator ani, a portion of the compressor urethrse, the membranous and prostatic urethra, a part of the neck of the bladder, and a part of the prostate. The structures to be avoided are the bulb and its artery (by starting the incision to the left of the raphe and not too far forward), the rectum (by keeping away from the middle line), the pudic artery (by not cutting too far outwards), all but a small part of the vesical neck (by maintaining the knife at a proper angle, and by not carrying the incision too far backwards). It is well also to bear in mind that the pudic artery, ordinarily out of the way along the outer border of the perineal triangle, sometimes follows an anomalous course. Dubreuil has encountered it in the middle line, and Eichet has found it nearly in the position normally occupied by the trans- verse perineal. The artery of the bulb, also, sometimes starts from the pudic opposite the tuber ischii, and crosses the field of the incision in its passage toward the bulb. The accessory pudic may be divided at the upper ex- tremity of the prostate, if the incisiol^ there be too deep, and it must be re- membered that the veins about the prostate, particularly in old people', are very large and sometimes bleed alarmingly. Mode of performing the Lateral Operation.- — The veteran, skilful operator sometimes plunges his knife through the skin, into and along the groove of the staff', and into the neck of the bladder, at one thrust, cutting his way obliquely out and finishing the incision in a single movement. But such a brilliant mancsuvre is not desirable for general adoption. The incisions may ■ Such a mental picture can only be obtained as the result of numerous and careful dissec- tions. No anatomical plates can represent it in any fair way. The operator sliould have become familiar with the parts which he is about to cut by having frequently handled them, and he should be able to picture to himself each plane of the perineal tissues, with its muscles and vessels, as the patient lies before him on the table — at his mercy. If the surgeon cannot present this picture to his mind, he is not ready to operate. 272 URINARY CALCULUS. be best executed by dividing them into three steps ; the superficial incision^ opening the urethra, and the deep incision. For the su-perficial incision the operator places his left index finger upon the raphe of the perineum to steady the tissues centrally upon the groove of the staif, and enters the point of his scalpel boldly at a point about one inch and a quarter in front of the anus, and about one-third of an inch to the (patient's) left of the raphe. The incision is begun on the left of the raphe in order the more certainly in the second step of the operation ta escape the bnlb. The plane of the blade is directed so that the' superficial incision shall lie in the perineum midway between the anus and the tuber ischii. The point of the knife is made to penetrate directly inward toward the groove of the staff", more or less deeply according to the fatness of the individual, but sufficiently to cut well through the superficial tissues at the first stroke. From thence the incision is continued downwards and outwards about two and a half inches in a line midway between the anus and the tuber ischii, growing somewhat more superficial toward its termination. The left index finger now enters the wound, and pushes the bulb of the urethra towards the patient's right, while the pulp of the finger depresses the rectum and the nail is made to feel for the groove in the staff at a point as far back toward the membranous urethra as possible. A few light touches with the point of the knife, made always in the line of the first incision, facili- tate the approach of the finger to the depths of the perineum. The second step in the operation, opeyxing the urethra, commences when the finger-nail, deep in the perineum, recognizes the inner edge of the groove in the staff'. The point of the scalpel is now conducted along the nail, well backward, and made to enter the groove, when the operator and the holder of the staff at once recognize the rough feeling of contact between the two metallic surfaces. How the back of the point of the scalpel, pressed up firmly into the groove of the staff', is run directly inwards, the blade being held more horizontally as it advances, until the point has entered the neck of the bladder. Then the handle of the knife is slightly depressed, and its blade made to cut its way outward in the line of the original incision, enlarging it more or less according to the known dimensions of the stone to be extracted, thus terminating the deep incision, and completing the third step in the cutting operation. Exactly' what amount of pressure to place upon the blade of the knife in executing this third step, is a mattfer of judgment and of individual tact and experience, which cannot be written down in words. The old operator needs no caution upon this point. The young operator should remember that his caution is liable to make him incise the neck of the bladder too modestly, and that more injury will be caused by rude eft'orts at extracting a large stone through too small an incision, than would follow a reasonably free in- cision of the bladder's neck made at one stroke doAvnward and outward, and in a position to drain itself eff'ectively. Any sharp arterial spurt noticed during any of these incisions may be attended to by ligature at once, but ordinary bleeding may be disregarded. A gush of bloody urine, more or less copious according to the previous disten- tion of the bladder, follows the withdrawal of the knife on the last incision. The left index finger is at once inserted into the bladder aloiig the groove of the staff, and the latter is withdrawn. The finger, now witliin the bladder, generally touches the stone, arrests the further "outflow of urine, dilates the neck of the bladder, and appreciates the depth of the incision in the same. If this be considered insufficient, the Blizard knife is inserted along the finger, and, so guided, enlarges the original deep incision, cutting evenly out\\'ard and downward, so that the bottom of the wound may be one inclined plane. LITHOTOMY. 273 to such a depth as the operator may deem prudent. A further liberating inci- sion into the prostate and neck of the bladder may be made upon the patient's right side, if the operator thinks it necessary. Now the operator slides in the closed forceps upon his finger, dilating the neck of the bladder as he does so. Then taking one handle of the forceps in each hand, and gently but widely opening both blades toward the roof of the bladder, he elevates the haVidles, keeping the blades distended, and upon gently closing them laterally it is not improbable that he will seize the stone. If not, a second attempt is made in the same direction, or, failing again, one blade is depressed into the floor of the bladder by half rotating the instru- ment while the other is widely raised toward the roof. Now upon closing the blades the stone is pretty sure to be found within their grasp. If not, other efforts are made in various degrees of rotation of the instrument, per- haps aided by a finger in the rectum to raise the floor of the bladder, and finally the stone is seized. In a case of large prostate, with a bas-fond, the curved forceps should be used, and opened laterally upon the floor of the bladder. The same instrument may successfully seize a stone retained at the roof of the bladder, behind the pubis, in a position which would make it almost inaccessible to the straight forceps. The operator must now assure, himself, if the stone is large, that it has been caught in one of its smaller diameters. This he may do by feeling the presenting portion of the stone through the wound as well as through the rectal wall. Extraction is accomplished by traction from side to side and outwards, two- thirds lateral and one-third extractive, not directly outwards, but outwards and downwards in the axis of the inferior strait of the pelvis, easing the soft parts with a finger in the wound, and slipping them over any asperities in the presenting portion of the stone, carefully, slowly, but continuously, until the foreign body is removed. Sometimes the perineum is too deep for the finger. In such a case the crested scoop or blunt gorget may be used as a guide for the forceps. The finger or a searcher should lastly be introduced to explore for any further stone, then attention should be given to hemor- rhage, and finally the bladder should be washed out with warm water. In the child, the operation is much simpler. The urethra has no bulb to be feared before puberty, and for all practical purposes the prostate does not exist. The staff" can be plainly felt through the thin tissues of the perineum. The first incision generally touches the instrument, or even enters its groove. In the latter case it should be slid along the groove for a certain distance, so as to make a clean opening into the urethra, which may be immediately encountered by the finger as it enters the wound, as otherwise there would be danger of opening the urethra in two places. The Blizard knife completes the operation, the neck of the bladder and the whole of the prostate being cut . through at one incision, which should be relatively quite free, for if the neck of the bladder be not suificiently incised in the young subject, there is danger, upon introducing the finger for purposes of dilatation, of tearing the mem- branous urethra across, and of pushing the neck of the bladder, undilated, before the finger upwards into the pelvis, an accident greatly to be deplored both on account of the subsequent diflEiculty of entering the bladder, and particularly on account of the traumatic stricture in the membranous urethra to which the transverse rent gives rise. Small, sti'aight forceps easily extract the stone from a child, and the getting up is generally speedy. After-treatment- — When bleeding has been arrested and the bladder thoroughly washed — a thoroughtiess the more requisite if the stone has been at all broken or even clipped during extraction — the patient is put to bed, preferably upon a hard hair-mattress upon which has been placed a rubber cloth, and beneath the hips a folded sheet to absorb the urine as it flows VOL, VI. — 18 274 URINAHT CALCULUS. away. This sheet must be often changed as it becomes moistened with urine, and the buttocks and perineuto of the patient should be washed several times a day with warm water and alcohol, and afterwards lightly anointed with vaseline, to keep the skin in good order, particularly if the patient be fat and debilitated, and if the urine be ammoniacal. The patient may turn if he pleases, but he usually prefers to lie upon his back. Although surgeons differ as tp the advisability of tying in a catheter, the weight of authority is largely against it. It is difficult to see in what way it could be of any benefit in an ordinary case. It could not possibly prevent contact of urine with the cut surface, and it could hardly fail to prove a source of uneasiness, even if it did not set up local irritation. The urine at first flows away freely through the cut. Then, as inflam- matory swelling comes on upon the second or third day, most or all of it may pass through the urethra ; but when suppuration commences and the turgescence of the tissues subsides, the urine again escapes through the peri- neum, at first involuntarily, then, as the neck of the bladder recovers its retentive power, at the patient's will, finally resuming its natural channel as the wound in the perineum closes. This takes a varying period. Habitually more prompt in children (averag- ing perhaps ten days), and in persons in good health, it becomes longer with advancing age and in cases of debility. Three weeks is a fair time to count as a very moderate interval for repair to perfect itself in an ordinary case. Six weeks often pass before the wound is healed, and the time may extend itself to months in unfavorable cases. It is more surgical in principle to allow the wound to heal by granulation, and to favor drainage, thus opposing any tendency toward infiltration, than to. make any attempt to secure quick union. Yet primary union has been not only sought for but obtained. Professor Dudley,' of Kentucky, recorded primary union after perineal lithotomy 8 times in 135 cases. Mr. Crichton,^ of Scotland, made even a better record, claiming success 23 times in 200 operations, and Bouisson,* of Erance, collected some interesting examples, and advocated the attempt to secure quick union in certain cases, particularly when the stone was small, and when the median operation had been employed. Tolet, Boudou, and Ollivier have reported cases of quick union. It can hardly be called immediate, for although the urine escapes by the meatus from the first, yet the wound is not entirely healed for several — often as many as six — days. Crichton applied a simple wet compress to the wound and tied the legs together, using a warm sitz-bath in case of retention, and con- fining his attempts at quick union to patients in flourishing health and cases of small calculi. These attempts at quick union are of doubtful advantage, the few days that may be saved not making up for the increased risk of urinary infiltration. Even with the wound open, a child sometimes will get up and play about within a day or two, delighted to be rid of his former tormenting pain. An adult also often gets up after the bladder has resumed its retentive power, but before the perineal wound has healed. In cases of feeble persons, such hasty movements may entail subsequent perineal fistula, but in healthy individuals they usually do not. A little opium may be required for the first day or two, to ease pain, if it be great, and some quinine and an alkaline diuretic • Translvania Journal of Medicine and the Associated Sciences, vol. ix. p. 288. 1836. 2 British and Foreign Med.-Chir. Review, July, 1854. ' De la reunion immediate i, la suite de I'opfiration de la taille. Gaz. MSd. de Paris, 1867, pp. 704 et seq. LITHOTOMY. 275 are not out of place — although a milk diet generally answers for the latter. A chill and more or less fever before suppuration sets in are not infrequent, and a laxative upon the third day is often serviceable. After suppuration occurs, and granulations cover the wound, but little pain is experienced, and recovery is merely a matter of time. The. causes of death in fatal cases are much the same as those which have already been considered in speaking of lithotrity (p. 215), except that hemoi'- rhage and shock naturally play a larger part here than in the non-cutting operation. Rouxeau estimated that severe bleeding occurred in one-seventh of all cases operated on, and Begin charged 25 per cent, of the bad results that followed lithotomy to hemorrhage.^ Infiltration of urine is also more likely to occur than after the crushing operation, and therefore cellulitis, septicaemia, etc. Obstacles Encountered before the Operation. — Aside from the questions of renal or other organic disease, and of the condition of the heart and lungs as bear- ing upon antesthesia, three minor obstacles have been encountered by surgeons when considering the question of perineal lithotomy, viz., an impassable urethra, an obstacle to the left perineal incision, and a rickety pehys. (1) If the urethral obstacle be an anterior stricture, internal urethrotomy will over- come it; if a tight, deep stricture, it may be divided as the first step in litho- tomy, which should then be median. Furneaux Jordan, in such a case, made his diagnosis by acupuncture through the perineum, and cut his patient with- out a guide. If the obstacle be a prostatic lobe or tumor, perineal lithotomy may still be performed with the secondary object of removing the growth as one of its steps. (2) In some cases of anchylosed hip-joint the thigh is drawn across in such a way as to make section of the left half of the perineum im- possible. I have seen this, the section being made in the median line. Gross reports that Pope, of St. Louis, cut a patient toward the right side in such a case, and he refers also to Zeiss's dilemma, who found a congenitally displaced testicle in the left side of the perineum, and so cut to the right. {3) In rickets the pubic and ischial rami may leave a slit between them sO narrow as mechanically to oppose lithotomy. In slich a case the narrowness has only to be appreciated to immediately suggest supra-pubic lithotomy, for the bladder would necessarily be high up. Thompson notes the case of a boy of four years, whose antero-posterior pelvic diameter was only an inch, and yet whose stone was extracted through the perineum. Complications during Perineal Lithotomy. — Most of the complications likely to occur in perineal lithotomy are identical, whether the section has been lateral, bilateral, or median, and they may therefore conveniently be con- sidered here. ^ Such complications as shock, heart failure under an anaesthetic, etc., need not be referred to. The patient who died of fright, while Desault was tracing out with his finger the proposed line of incision upon the perineum, cannot properly be classed among the victims of lithotomy. Complications occur during the operation, after it, and as an ultimate result. « Villeneuve, Rev. de Chir., t. iii., Sept. 1883, p. 665. 276 URINARY CALCULUS. (1) Possible Complications during Perineal Lithotomy. 1. Failure to enter the bladder. 10. Abnormal position ofthe stone due to — 2. Incision of the body of the bladder. a. presence of a bas-fond. 3. Wounding the rectum. h. its being entrapped by mus- 4. Hemorrhage. cular contraction. 5. Rigidity of the neck of the bladder. c. " " adJierent. 6. Great depth of the perineum. d. " " encysted. 7. Enlargement of a prostatic lobe. 11. Wounding the bladder from within. 8. Tumor. 12. Foreign body as a nucleus. 9. Failure to find stone after lithotomy. 13. Faulty seizure of the calculus. 14. Multiple calculus. 15. Friable calculus. 16. Great size of calculus. 17. Aspiration of air by the rectum. (2) Possible Complications after Perineal Lithotomy. 1. Hemorrhage. 9. Sloughing of the rectum. 2. Filling up of the bladder by clot. 10. Cellulitis and infiltration. 3. Eetention of urine. 11. Phlebitis and pysemia. 4. Suppression of urine. 12. Cystitis. 5. Fragment left behind. 13. Surgical kidney. 6. Phosphatic incrustation of the wound. 14. Peritonitis. 7. Diphtheritic deposit upon the wound. 15. Tetanus. 8. Epididymitis. (3) Possible after-effects of Perineal Lithotomy. 1. Incontinence of urine. 3. Sterility. 2. Impotence. 4. Perineal fistula. (1) Possible Complications during Perineal Lithotomy. — 1. Failure to enter the Bladder. — This accident has occurred more than once, particularly in the case of children. It is due to the fact that the inci- sion into the urethra and prostate is not ample enough to admit the explor- ing finger, and that the latter either pushes off the bladder from the urethra^ or else, failing to enter the canal at all, wanders hopelessly in the cellular tissue of the recto-vesical space. The accident may be avoided in any case by passing a director along the groove of the staff before the latter is with- drawn from the bladder, and then using the director to guide the pulp of the finger into the bladder. The peculiar sensation imparted to the finger as it passes through the neck of the bladder, when once felt even upon the dead subject, is sufficient to allow the careful operator to recognize the parts and determine whether the neck of the bladder is entered by the finger or not. If the accident should occur, by carefully following along the roof of the urethra, the apex of the prostate must be sought, the bladder opened, the stone extracted, and free drainage established with a large rubber catheter passed through the wound, where it is to be retained until free suppuration sets in. The accident is a serious one, but not necessarily fatal. Cellulitis, and infiltration of urine are to be feared. A false passage made hy the staff" can always be guarded against, if the operator feels the stone with his staff before making his first incision. In children, a false passage may be made by failing to r.ecall the sharpness of the urethral curve; in adults, on account of a stricture or prostatic enlargement. The dreadful error of cutting upon a staff which has made a false route is only to be mentioned to be guarded against. Thompson has referred to two LITHOTOMY. 277 cases in which it was proved by autopsy that the point of the staff had pene- trated the roof of the bladder, thus leading to a fatal termination. He thinks that this perforation of the thin wall of an empty bladder may be the cause of certain rapidly fatal cases of peritonitis after lithotomy, and counsels the use of a staft" with short curve. 2. Incision of the Body of the Bladder. — This incision is habitually made in children. It is also often made where large stones are extracted from the adult. In some of the operations of the earlier lithotomists the body of the bladder was always incised. The result of this depth of incision in the adult is not necessarily fatal, and, while the careful operator avoids the mistake, he may make it unwittingly, and yet the case progress satisfactorily. 3. Wounding the Rectum. — The rectum has been wounded at the hands of nearly all the best operators — Thompson confesses to four such cases — either because the staff has been improperly held, or the finger not used to depress "the loose folds of the bowel during the deep incision, or because the gut has been very large (in old men) or much distended, or because the knife in the ■deep incision has not been sufficiently lateralized, or because in withdrawing a rough stone through a narrow external wound the rectum has been torn into. The lower down toward the sphincter that the opening occurs, and the smaller it is, the more readily does it heal, particularly if the subject be young and healthy; but the accident is always a disagreeable one, and it may •entail urethro-rectal fistula. The treatment is at first expectant, as most cases recover during the healing -of the wound. The rectum should be kept empty, and the wound should be frequently and freely irrigated. If fistula ensues and is well above the sphincter, after it has been allowed to contract during several months, it may be treated by cauterization with the electro-cautery or thermo-cautery, but ■only if the opening is not larger than a crow-quill. For larger openings a plastic operation should be attempted, by sliding the mucous membrane over the orifice, the margins of which have been pi'eviously made raw. Such an operation is exceedingly difficult, because the fistula usually lies at "the bottom of a sort of funnel, and stretching the sphincter makes the parts tense and deepens the funnel. If the fistula is low down, just above the sphincter, after due time it should be freely laid open through the sphincter and treated like an ordinary fistula in ano, or the edges may be freshened and brought together with silver wire. 4. Hemorrhage. — Moderate bleeding may be disregarded. An arterial spurt, however, should always receive attention at the time of its occurrence, unless it is made during the last incision, when the stone should be speedily ^-extracted, and then the hemorrhage attended to by ligature or by some of the 'means already detailed (p. 268). The forcijaressure forceps and the rubber tampon make hemorrhage much less to be dreaded than formerly. Very hot water injected into the wound is often efficient against oozing. 5. Rigidity of the Neck of the Bladder. — This is a complication encountered in old men, entirely apart from the size of the prostate. Thompson insists upon its importance. The neck of the bladder, even when incised, does not yield to dilatation, and it becomes necessary either to tear it in extracting the stone, or to cut it freely in one or more directions. The latter course is result of perforation of the bladder by the staff or the scalpel ; or by a lesion of the peritoneal cul-de-sac, when the latter extends very low down and the deep incision reaches too far at the base of the prostate. Urinary infiltration is the main cause of the mischief in these cases, which are nearly always fatal, although probably not always, for the free drainage may occasionally save the patient. As a secondary complication of inter- stitial cystitis, pelvic cellulitis, phlebitis, etc., the peritonitis forms part of the general process, aggravating and intensifying it, but not in itself materi- ally adding to the gravity of the more important surgical complications of which it forms a part. The indication in peritonitis is the free exhibition of morphine subcutaneously. 15. Tetanus has been recorded as a cause of death after lithotomy. (3) Possible after-effects of Perineal Lithotomy. — 1. Incontinence of Urine. — This sequence of lithotomy is happily rare. It is most common in young subjects, but in them may gradually disappear with lapse of time. When it occurs in an old man it is generally rebellious to all subsequent treatment. It is usually caused by violence (laceration, etc.), done to the neck of the bladder during rough efforts at extracting a large stone, where the internal incision is not sufliciently extensive. The treatment is to try cauterization of the vesical neck (Thompson records one success by this method), and, failing in this, to resort to a urinal. Generally at night, when the patient is recumbent, the incontinence is less marked than during the day. 2 and 3, Impotence and Sterility. — The latter of these two complications — • 284 UEINARY CALCULUS. both of whicti are happily very rare as after-effects of lithotomy — is more common than the former, for no matter what happens to the ejaculatory ducts, the power of erection usually remains if the testicles are preserved. But this is not invariable, as was shown by Civiale's* case of a man of 54, who became impotent after recto-vesical cystotomy, " ayant perdu la faculte d'entrer en erection." The older writers had this complication'in view in advising the lateral and para-rapheal operations rather than a deep median incision of the neck of the bladder, their object being to spare the seminal ducts. Injury was often done to these ducts, according to Ledran, in the old operation by the appa- ratus major, so that the semen was not ejaculated during sexual intercourse, but escaped afterwards, dribbling away or coming out upon .urination. A properly directed deep incision in the lateral operation, or in the bilateral deep cut, falls outside the course of the seminal duct as it tunnels the pros- tate, and the testimony of all observers is of accord upon this point, that when harm is done to the seminal canals during lithotomy, its cause is to be found rather in the bruising and tearing violence exercised in extracting a large rough stone through insufficient deep incisions, than in any irregularity or excess of those excisions. A demonstration that sterility may be induced by obliteration of the vas deferens has been given by Goodhart,^ who showed, at the Pathological Society in London, a specimen illustrating the oblitera- tion of one vas deferens after lithotomy in a dhild. Malgaigne^ saw two cases of impotence following perineal lithotomy, and Aston Key* one. Teevan gives also some testimony on this point,' recording four cases in which after lithotomy there was no emission during sexual intercourse. Treatment in cases of sterility following lithotomy is unavailing, unless it be in a case where a permanent fistula is left behind, and the semen escapes through it. In such a case the obvious remedy is closing the fistula. 4. Perineal Fistula. — This disagreeable after-effect of the perineal incision has been noted quite often. It may be caused by general debility of the patient, whose vital forces do not prove sufficient to effect the closure of his "wound; or by some accident, such as incrustation of the walls of the wound, detention of a fragment of stone, or some sloughing or ulceration of the wound which has followed the operation ; or by the existence of a stricture in the urethra anterior to the internal orifice of the fistula. A fistula cannot be said to exist until at least six months after the operation has been per- formed, for nature occasionally takes this much time to close the wound. The indications for treatment are to relieve stricture, if it exists, and by diluents and local treatment of the bladder to purify the urine, should the latter be ammoniacal. Then the expedients may be resorted to of passing the catheter for each act of urination, or making pressure upon the fistula during each natural urinary act. Palling in these measures, the fistula should have its external orifice enlarged, and its track scraped so that the pyogenic membrane may be removed and the healing process stimulated ; or the track of the fistula maj^ be freshened into activity by passing into it at inter- vals a probe dipped in nitric acid or with a bit of nitrate of silver fused upon its tip. Finally, other means failing, the fistula may be cut down upon and its sides dissected out, the freshened surfaces being kept together and the catheter passed to draw away the urine. In some cases all efforts fail, and a permanent fistula results. ' Op. cit., p. 579. Paris, 1838. « Trans. Path. Soo Lond., 1876. ' Journ. de M6d., Chir., et Pharm., t. xx. p. 548. 1855. * Guy's Hosp. Reports, 1st series, vol. ii. p. 26. 1837. « Traus. Clin. Soc. Lend., vol. vii. 1874, pp. 179, 180. LITHOTOMY. 285 II. Bilateral Lithotomy. — The bilateral operation of Dupuytren, suitable for the extraction of large stones by the perineum, is performed as follows: The patient is fixed in the ordinary lithotomy position, and the staii", having a median groove, is held centrally. A semi-lunar incision is made crossing the raphe, about one inch (from 22 to 24 millimetres) in front of the anus. The integument, cellular tissue, and anterior fibres of the sphincter are cut. The left index finger is now introduced into the wound and made to depress the rectum, while with short strokes of the knife the surgeon endeavors to free those muscular fibres, a part of the sphincter, which hold the bulb of the urethra attached to the anus. The bulb is now turned up and the finger seeks the membranous urethra far back in the wound. This is to be opened upon the nail, the knife being held transversely, to insure safety to the rectum. The operator now takes the double lithotome cach6 (Fig. 1267), enters its Fig. 1267. ^ Dupnytren's doable lithotome cach^. point in the groove of the staff, holding the instrument's convexity upwards. As soon as the lithotome is in the bladder the staff is removed, the blades of the lithotome are protruded, and the instrument is withdrawn, at first horizontally, and then with the handle slightly lowered so as to spare the rectum. As soon as the prostate has been cut through the blades are returned to their sheaths, and the lithotome is withdrawn. The operation of the late James R. Wood, of ISTew York, is essentially a pre-rectal, bilateral operation. After the incision is made across the perineum in front of the rectum, and the urethra opened, the cutting part of the opera- tion is terminated by placing the button of the bisector (Fig. 1268) in the cen- tral'groove of the staff. This button is so arranged that the bisector cannot escape after its button has once entered the groove. It is pushed directly onwards into the bladder, cutting the prostate and the vesical neck to a moderate extent transversely. Dilatation does the rest. The stone is extracted in the manner described when speaking of the lateral operation. m. Median Lithotomy. — The median operation is suitable only for small stones. The staff should have a broad, deep, median groove. The external incision is generally made from without inwards, although most American surgeons prefer the mauceuvre of Allarton,' who passes the left index finger into the rectum, and steadies the staff" with the point of his finger pressed against it at the apex of the prostate. A stiff^backed, straight bistoury, with doable cutting point, is then entered into the raphe half an inch in front of the anus and carried directly inwards, aiming for the groove in the staff at the point where it is steadied by the finger in the rectum. The groove is entered at this point, and the apex of the prostate slightly incised. The membranous urethra is cut through as the knife is being withdrawn, and the external wound is enlarged by the same motion, cutting upwards to an 1 A Treatise on Median Lithotomy. London, 1863. 286 URINARY CALCULUS. extent deemed sufficient for the extraction of the stone. _ An effort is usually made, by varying the direction of the handle during this manoeuvre of with- drawing the blade of the knife, to pass beneath and around the bulb, the Fig. 1268. Fig. 1269. Fig. 1270. Wood's bisector. Staff for median lithotomy. handle of the knife pointing nearly directly downwards while the membran- ous urethra is being incised, after which it is swept sharply around, looking nearly upwards as the incision in the raj^he is being completed. Many surgeons prefer to reach the membranous urethra in a different manner, as follows: "With the left index and thumb on either side of the raphe, stretching the skin, the surgeon commences his incision with a big- bellied scalpel upon the raphe at about one and one-half inches in front of the anus, and cuts directly downwards to within one-third of an inch of the latter. The skin, cellular tissue, and superficial perineal fascia are divided until the operator comes upon the raphe uniting the lateral halves of the accelerator urinse muscle. Following this backwards, the fibres of the sphinc- ter ani are encountered, and may be distinguished by the fact that they are not possessed of any median raphe. These are cut transversely, and the bulb, now exposed, is turned upwards out of harm's way. This method is particu- larly suitable to the case of old men, in whom the bulb, much enlarged, sags LITHOTOMY. 287 downwards almost upon the rectum, and is very liable to be cut if a puncture is resorted to as in AUarton's method. The left index is now passed into the wound behind the bulb, and made to search for the groove in the staff. The nail is there inserted, and upon this as a guide the membranous urethra is opened in the median line, and incised up to and into the apex of the prostate. The nail of the left index is main- tained in its position imtil the right index or a director has entered the urethra, as otherwise the opening in the latter may be hard to find. The right index finger is now gently inserted along the staff into the bladder, dilating its neck, or, in the case of children, a straight director such aS Little's (Fig. 1271) is passed into the bladder, the staff is withdi'awn, and Fig. 1271. G.TlEMAWN-CO. Little's lithotomy director. along the narrow director the finger and afterwards the forceps are carried into the organ. In this way the accident of lateral rupture of the urethra by the surgeon's finger may be avoided. After the neck of the bladder has been properly dilated by the finger, small straight forceps are introduced, and the stone is withdrawn. Recovery is rapid if the neck of the bladder has not been bruised in attempting to extract a large stone, one not suitable for the median method. The medio-lateral and medio-bilateral methods combine an external median opening with internal, liberating, prostatic incisions on one or both sides. Dolbeau's perineal lithotrity is an operation now practically obsolete even in France, the land of its birth. It may still be used successfully when the surgeon wishes to attempt to remove a large stone by the median method. The incisions up to the apex of the prostate are made from without inwards, as in the median operation. A special dilator (Fig. 1272) is then intro- Fig. 1272. Dolbeau's dilator for perineal lithotrity. duced along the staff into the neck of the bladder, and the latter is gradu- ally enlarged up to the maxim um point in the adult, which Dolbeau decided to be just short of one inch in diameter (24 millimetres). Up to this point the healthy neck of the adult bladder may be dilated without giving way. The crushing forceps (page 267) is now introduced, and, after fragmenta- tion into a number of large pieces, the debris is removed with forceps, scoop, and irrigation. Great care is necessary not to damage the vesical neck in attempting to remove large angular fragments. rV. Supra-pubic Lithotomy. — The best account of the modern high opera- tion as it is now practised in Europe— notably in France — that I can find, is 288 URINARY CALCULUS. the description by Villeneuve' of what he calls the Petersen-Guyoti-Perier operation. I shall borrow his description. The peculiarities of this method consist essentially in the employment of antiseptic precautious, distention of the bladder and rectum to protect the peritoneum, and vesical drainage to prevent infiltration, septicaemia, and other complications due to the faulty position of the wound ; for, say what one will, the position of the wound in the high operation is a faulty one, surgically speaking. It has been held that if the exact nature, relation, and position of the parts with the course of the bloodvessels, etc., were explained to an intelligent per- son who had never heard of stone in the bladder, and this person were asked what would be the best way to get the stone out, he certainly, directed by common sense, would choose -the shorter and more direct route, and would try to get at the stone by cutting above the pubis. This may be true in one sense, but the answer is equally logical. If the same nature, relation, and position of parts were explained to a modern sur- geon, well versed in sui'gical principles, and he were required to decide by induction by what route it would be most appropriate, surgically, to extract a stone from the bladder, he would certainly choose the perineal route, not- withstanding the thickness of the tissues, since natural drainage could be best accomplished by this means. ' The operation of Ferdinand Petersen is the one now generally imitated, since that surgeon's able article upon the scientific principles of the method first appeared.^ But none of these principles, as enunciated by Petersen, are original with him, strictly speaking, although to him belongs the credit of having grouped them into an effective whole. Asepsis in sui'gery had long been acknowledged as desirable wherever it could be applied. The vesical suture dates back to Rosset, in 1581, and Perier claims for France the introduction of rectal distention by a tampon as a step in the opei'ation, saying that Milliot announced the conception of the same method in 1875, five years before Petersen, in the Medical Con- gress at Lyons. Milliot' proposed to distend the rectal tampon with air. Perier first performed the Petersen operation (somewhat modified) in France, Gosselin* reporting his first two cases, one of which ended fatally. Perier" has advocated a special form of drainage which Guyon* has perfected. The vesical suture is not uniformly accepted in Germany, nor. generally in France. E. Bouley,' in his excellent monograph, collecting the cases of vesical suture from 1859 to 1881, has made a tabulated study of 23 such cases, among which failure occurred 10 times. He gives the following table: — Catgut ...... used 11 times, failed 7 times. Carbolized silk . . . . " 8 " " 3 " Ordinary thread . . , . " 2 " " " Metallic suture . . . . " 2 " « " Total .... 23 10 And in a general way he decides against the employment of sutures. That the bladder may be sutured successfully is certain. Such cases have been reported by Lister, Ultzman, and others, but the tissues are very friable. ' Rev. de Chirurgie, t. iii., Sept. 1883, p. 665. 2 Ueber Sectio Alta, Langenbeck's Aroliiv, S. 752. 1880. ' Methode operatoire par le baUonnement. Gaz. Mgd. de Paris, p. 422. 1875. " Bull, de I'Aoad. de Med., 2me s6r., t. x. p. 1128. 1881. 6 Bnll. et Mem. de la Soo. de Cliir., t. viii. p. 807. 5 Ann. dea Mai. des Organes Gfinlto-Urinaires, Dfic. 1882, et Janv. 1883. ' De la taille hypogastrique. Paris, 1883. LITHOTOMY, 289 It is a different thing, in laparotomy, to turn the two peritoneal surfaces covering the bladder in upon each other and suture them etiectively. This is constantly done. I know of a ease in which a distinguished surgeon, having opened the abdomen in a woman for another purpose, came upon something Ijdng in the pelvis. He was uncertain whether this something was the bladder or not, and, to decide the point, deliberately cut into the suspected tissue, and thus proved that it was the bladder. lie immediately turned in the serous surfaces, and sutured them nicely ; no evil result followed. T. (t. Thomas,' of New York, in one instance, having opened the female bladder in an exploratory way for diagnostic purposes, sewed the incision into the aMominal wound with silver sutures, leaving a catheter in the bladder through the urethra ; cure followed. The healthy bladder easily unites through its peritoneal coat, if this be wounded ; but not so easily the soft, friable, unhealthy bladder, not covered by peritoneum at the point incised. Trendelenburg says^ that there can hardly be cited a case of vesical suture where, after a short time, urine has not flowed in part or wholW through the wound. The recent thesis of Garcin* is instructive on this point. He deals with the 94 cases of supra-pubic operation published during the years 1879-83, and says that of 20 cases of vesical suture " there were only two cases in which union by first intention occurred." Again, out of the 94 cases, there were seven in which death occurred by urinary infiltration, and "five times this accident followed vesical suture." In one of Monod's cases, in a man^ of 63, suture was employed and a catheter left, a demeure, in the uretlira. A small sinus only remained unhealed in the abdominal incision. This was afterwards injected with tincture of iodine to secure its closure, but fatal erysipelas fol- lowed. Juillard* made an accidental rent five inches long in the bladder while attempting to separate adhesions in ovariotomy. He turned in the serous surfaces, not transfixing the mucous membrane with his sutures of catgut, fifteen in number, left a catheter in the urethra, and obtained union throughout the wound. Duchastelet, one of Giiyon's pupils, has proposed to go so far as to open the bladder always upon its peritoneal surface for the extraction of stone, in order to get a tougher texture and a serous surface to act upon by sutures in the effort toobtaiu union. Villeneuve rather inclines to join in this pi'oposition as a possible future advance for the high operation. tlpon the subject of preliminary vesical distention, as a step in the opera- tion, something must be said. The idea is a very old one. The bladder has been allowed to become distended by urine, the penis being ligated for a variable, sometimes a very long, time (even two days) before the operation. Air has been used as the distending agent, and water, pure or containing various substances — boracic acid, carbolic acid, etc. But the bladder has been ruptured by even moderate distention in some cases. Monod^ in one case fissured the bladder of a patient of 28 by inject- ing water — the quantity unknown — and the conclusion was reached in the discussion at the Paris Surgical Society that it was not safe to inject too much fluid, the limit being 350 grammes, a little more than eleven ounces. Petersen allows 600 grammes as the limit, 200 being the least amount. Monod's patient recovered in spite of the accident, but in a case in which Verneuil ruptured a man's bladder by injecting only 125 grammes of water, 1 stein, Med. Record, March 17, 1883, p. 286. 2 Berliner klinisohe Wochensclirift, 1881. ' Contribution clinique h. I'etude de la cystotomie sus-pubienne, aveo statistique comprenant les annees 1879-1883. Strasbourg, 1884. 4 Bull, de la Soc. de Chir., 5 Decembre, 1681, p. 758. 5 Centralblatt fiir Gynakologie, 7 Juli, 1883. 6 Rev. de Chirurgie, No. 4, 10 Mars, 1882, p. 296. VOL. VI. — 19 290 , URINAKY CALCULUS. the result was death, showing that prudence places the minimum amount to be injected at a safety point inside of Petersen's 200 grammes. Guyon's contribution to the Petersen-Guyon-Perier method is a special manoeuvre for rolling upwards the peritoneum out of harm's waj'. The high operation may be executed with the least possible apparatus: a sound, a knife, and the fingers may accomplish it. That the operation may be safely done with rude tools, is proved by the well-known case of John Doot, the smith of Amsterdam, who cut himself above the pubis in May, 1651, with a sharp shoemaker's knife, and delivered himself successfully of a large stone. It has alwaj's seemed to me probable that this operation must have been upon a stone encysted above the pubis, j)erhaps trying to ulcerate its own way out, or possibly upon a stone situated in a vesical hernia in the groin — but this is conjecture only. As to drainage of the bladder, many methods have been nsed. At one period in the operation it was one of the regular steps to open the urethra in its membranous portion, not purposely for drainage, but for the passage of instruments in the further continuance of the operation. Yet it is notable that in many cases of a severe character the perineum has been first opened by the lateral method in the hope of extracting the foreign body, and, when the operator has failed in this direction, the bladder has been opened above the pubis, and the oftending body removed, success crowning the operation. May it not have been in these serious cases that the perineal incision, instead of being a disagreeable complication, has been in reality the means of establishing eflicient surgical drainage which has saved the patient? Billroth 's well-known case of myomatous tumor in the bladder was one of this kind. Watson's ease, referred to by Dulles, was another, and a third was a striking case of extraction of a very large stone from a boy by Dr. Howe,' of 'Sew York, in which the peritoneum was opened and the intes- tines appeai-ed in the supra-pubic wound. There was, however, free drainage, the perineal opening was ample, and the boy recovered. Undoubtedly all cases cut both in the perineum and at the same time above the pubis do not recover, but it is doubtful if the perineal opening can be looked upon as a damaging complication. But there are other methods of draining the bladder more surgical than the perineal incision. The plan of leaving a soft catheter in the urethra is doubtless not a good one, because its presence in the sensitive neck of the bladder excites that organ to attempts at contraction, and the catheter may slip or be forced out, or may become occluded. As early as 1750, Palluci perforated the bas-fond of the bladder, and drained it in this manner through the perineum. Descharaps, in 1796, perforated through the bas-fond into the rectum, and brought the tube out through the anus. McBurney, of !N^ew York, did the same thing with the "convolvulus" catheter a few years ago, and I have used the same method for successfully draining the bladder. But I find in my cases that the tube, be it convolvulus or other, is apt to slip out. The actual cautery has been used as a means of opening the bladder, as has the ecraseur, and the operation has been divided between two sittings ; all these plans are designed to prevent infiltration, but all have been given up. The patient has been made to assume and maintain different positions after the operation, for purposes of drainage, but to no purpose. Thus even the abdominal decubitus has been insisted upon. It is said that Trendelenburg employs it. Monod declares that the greatest danger after this operation is from infil- * Reported to the New York Pathological and to the New York Surgical Societies in 1883. LITHOTOMY. 291 tration, and that it is most often due to tearing away the cellular attachments of the bladder from the pubis. Evidently a clean incision without tearing, and thorough drainage, are the proper means to employ to prevent infiltration. The following is a description of the Petersen-Guyon-Perier method as •described by Villeneuve: — Mode of Perform ing the High Operation.— AW hair is to be shaved from the pubis, the parts are to be washed in an antiseptic solution (carbolic acid 1 in 20, or bichloride of mercury 1 in 1000), and all the details of antiseptic surgery are to be carried out. Anaesthesia is pushed to complete relaxation. A silver •catheter with stopcock is introduced. The bladder is emptied and washed clean with a four-per-cent. solution of boracic acid. When the wash returns clean, the bladder is slowly distended with the same solution and the stopcocl^ turned ; meantime the penis has been tied over the silver catheter with a rubber tube, the tension of which is maintained by a forcipressure forceps. The amount of fluid varies with the receptivity and the degree of irrita- ibility and resistance of the bladder. If too much be thrown in, there is danger of rupturing the organ, an accident which has occurred in able hands (Monod, Cheselden, V erneuil). Two hundred grammes (between six and seven ounces) is considered a moderate amount, and six hundred grammes the limit. A piston syringe is used, and a guide to the amount to be thrown in is stated to be the resistance offered by the pressure within the bladder to the surgeon's hand as he depresses the piston — a degree of resistance to be learned by ex- perience. It is undoubtedly wiser here to err on the side of safety. Guyou believes that an irritable condition of the bladder, not tolerating distention, <;ontraindicates the operation. The ruliber ball (Fig. 1273) is next to be greased and inserted into the Fig. 1273. Rectal colpeurynter, onephalf natural size ; distended, and collapsed for introduction. rectum. It is an ordinaiy colpeurynter — Guyon insists that it should be made of stiff, thick rubber, so as to be hard and tense when distended — and through its tube from twelve to twenty ounces of warm .water are to be injected. Six hundred grammes is said to be about the proper amount, but undoubt- 292 URINARY CALCULUS. edly this quantity must vary in different cases. The distention of the rectum brings the bladder plainly into view above the pubis. An incision is now made exactly in the middle line, three or four inches- long, stopping at the pubic symphysis. The deep fascia is incised upon a director over the entire length of the superficial cut, and the sulcus between the recti muscles is sought. If the pyramidales are in the way, the muscular fibres are to be cut directly through in the middle line. ]^o tearing or pull- ing asunder is allowable, such separation of the elements of the muscle- favoring infiltration. The incision must be as clean as possible. After getting through the muscle, a yellow layer of fat is exposed, covered by the transveVsalis fascia. This thin fascia is seized with forceps in the- middle line, near the lower angle of the wound, a button-hole incision is made,, and the left forefinger is introduced, pulp upwards. The forefinger thus placed now pushes upwards the yellow layer of fat, carrying before it the peritoneal cul-de-sac. This is Guyon's manoeuvre. He says that by practising it the peritoneum is never seen. The cellulo-adipose layer, between the bladder and pubis, is not to be disturbed at all, and no efibrt is made to reach the neck of the bladder low down in front. Such unnecessary burrowing with the finger behind the bone invites infiltration. The finger which has pushed up the fat and the peritoneum is maintained in position in the upper angle, and serves as a guide to the point of the bistoury, which is made to puncture the bladder at this point, and to continue the incision downwards in the middle line from one and a quarter to one and three-quarters inches, according to the size of the calculus. A tenaculum, or the old-fashioned hooked gorget, or any suitable- blunt hook, might be used here to hold up the upper angle of the wound in the bladder. V illeneuve and Guyon make no mention of the need of any such contrivance, saying that the finger follows the bistoury into the bladder and at once finds the stone.' In making the incision into the distended bladder, no attention is to be paid to a plexus of prominent veins which are seen over the front wall of the- organ, and which may lie directly in the line of the proposed incision. It tears the tissues to attempt to ligate them. They are to be cleanly cut through. The hemorrhage, sometimes considerable at first, becomes arrested as the- bladder collapses. If no veins are seen, Petersen's manoeuvre may be adopted,, cutting slowly into the muscular layers of the bladder until the raucous mem- brane projects through the lips of the vesical wound, then seizing the latter and incising it. The liquid having run out, the next step is to untie the penis and remove the catheter. As this is being done the finger of the surgeon follows the bistourj' into the bladder, detects the stone and places it in a position favora- ble for removal. The forceps follow the finger, seize the stone, and extract it slowly, and with care not to bruise the sides of the vesical incision. If the latter be too small it should be enlarged toward the neck of the bladder with a probe-pointed bistoury, as the stone is held in the forceps. All the stones having been extracted, and any debris or clot removed, the bladder is to be carefully washed with the boracic-acid solution and the rectal tampon withdrawn. Two large parallel tubes of soft red rubber, fenestrated only at their ex- tremity, are now to be introduced upon the finger to the bottom of the bladder near the vesical neck. These tubes must be long enough to mount over the pubes and enter a urinal placed in the bed between the patient'^ ' Since this article has been in type, I learn that Guyon now has the lips of the vesical woun'l held apart by loops of silk ligature inserted on either side. (Annales de Dermatologie et de Syphi- ligraphie^ Nov. 1885.) URINARY CALCULUS IN THE FEMALE. 293 -thighs. The tubes are united together by silver wire, passed through their walls, but not into their cavity, and are attached superficially to the lips of the wound by a point of superficial suture on either side. The wound itself is closed in its upper third, the sutures being passed through the skin, superficial fascia, and borders of the recti muscles, with- out touching the bladder or the peritoneum. A few points of superficial «uture are required, and a Lister dressing, or a bichloride or iodoform anti- septic pad is applied, the dressing being perforated for the passage of the tubes. Guyon says that he has been able to wash the bladder through one of these tubes, the flow returning through the other without wetting the dressing. During the period of after-t];'eatment the dressing is removed two or three times and reapplied. The tubes are taken out at the end of a week, and in- iermittent catheterization by the urethra is then resorted to. Drainage by this method is said to be admirable, and the cure is said to be complete by the twentieth day. Complications. — The complications and accidents peculiar to supi'a-pubic lithotomy are three: Rupture of the bladder during preliminary distention, infiltration of the wound from bad drainage, and wounding the peritoneum. The first two of these complications have already been sufficiently con- sidered. Wounds of the peritoneum have been recorded at the hands of ■excellent operators (Douglas, Thornhill, Frere Come, Souberbielle, and •others). Among the 478 cases collated by Dulles it occurred as a complica- tion 13 times, but only once with a fatal result. In liowe's case, to which I iave alluded, the peritoneum was opened without any evil effect. Petersen, who, in 1878, made 14 expei-iments with his method upon the dead subject, never even saw the peritoneum during the operation, and in the 21 cases of the Petersen method published in France, this accident has not occurred. If the peritoneum should be wounded, and the bowel exposed, a flat sponge, wrung out of a warm antiseptic solution, should be placed over the upper angle of the wound until the operation is over, and then the peritoneal rent should be united by a very fine, continuous, catgut sutui'e, which in its turn should be buried in the healthy tissues united above it by deep sutures from without. Infiltration is usually fatal, but not necessarily so. It is to be treated on general surgical principles. Souberbielle only saw it once in 39 operations, a,nd Dulles only mentions it 7 times in his tables of 478. The cleaner the •cut, the less tearing of the tissues that occurs, and the better the drainage, the less is the chance of infiltration. ExTRA-VESiCAL LiTHOTOMY. — A calculus in a fistulous tract outside of the bladder, or in a cystocele in the groin or labium, yields symptoms depending on its size and position. Each case becomes a special study if removal is •called for, and must be met upon its merits. Cavities from which such cal- culi are removed should be scraped, and the vesical or urethral orifice of the tract should be closed, if possible. Extra-vesical liihotrity has been described ^is. a formal surgical pi'ocedure, but it surely does not deserve the dignity of iBuch designation. Urinary Calculus in the Female. The same causes which lead to stone formation in the bladder of the male are equally active in the female, but the physical conditions in the latter are less favorable to the retention and growth of the foreign body in the case of primary acid calculus, because the short, large urethra offers an easy exit for the nucleus, while the absence of a prostate, the rarity of sacculation, and 294 URINARY CALCULUS. fhe comparative infrequence of serious vesical catarrh, are sufficient to account for the relative rarity of secondary phosphatic stone in women. Cystocele, on the other hand — a condition quite analogous to sacculation — is- not uncommon in the female. Eoreign bodies as a nucleus for stone play a relatively more important part in vs^omen than in men, for obvious reasons. Gynaecologists have no- ticed that large stones are sometimes found in the female bladder shortly after the surgical closure of a vesico-vaginal fistula. Emmet says that he- has encountei'ed many such cases^ and that he sometimes has found a small portion of silver wire to be the nucleus of such a concretion. My collection contains one stoiie of this character, the inference being obvious that the operator, when closing the fistula, left a fragment of silver wire in the- bladder. As a rule, in such cases, Emmet' believes that the phosphatic nucleus of the stone forms upon some denuded portion of the cut surface which has been carelessly turned inward, and left thus when the surgeon has been adjusting the edges of the vesico-vaginal wound. Campbell,^ of Georgia, has taken the ground that stone may often exist within the bladder at th& moment of operation for fistula, and escape the notice of the surgeon, being held up and out of the way, concealed in the folds of the bladder, by partial vesical contraction, and coming down into the vesical cavity after the latter has been formed by an obliteration of the vaginal fistula. The relative frequency of stone in women is generally estimated at about 1 in 20 as compared with the male. In the Norwich collection (Crosse) 669- stones came from males, 35 from females, or 1 in 19. Civiale's' statistics from- the Hotel-Dieu show that, between 1808 and 1830, out of 284 operations for stone, 17 were upon females, a ratio of 1 in 16. Again, Civiale shows that in 1104 cases in Italy, the ratio of females to males was 1 in 18, and in Eranc& among 2834 operations 1 in 22. South,* in a table of operations at St. Thomas's Hospital from 1822 to 1845, gives only two as occurring in females among 144 cases, 1 in 72. Coulson* has shown that out of 2834 patients, 123 were females, 1 in 23. Prout gives the same number in his estimate. Kline is quoted by Coulson as making the proportion in the Moscow City Hospital,, from 1822 to 1860, much lower — 1792 cases, of which 4 were in females, 1 in 448. The sym.ptoms of stone in the bladder in the female are similar to those- observed in the male^namely, those of cj'stitis and vesical irritation ; fre- quent urination, often with blood; much tenesmus ; bearing-down, dragging- pains in the lower belly, groins, loins, and back, sometimes streaming down, the thighs ; and, not infrequently-, incontinence of urine. All these symp- toms are aggravated by exercise, and are subject to periods of exacerbation. The symptoms sometimes simulate those of uterine disease, but physical ex- ploration clears up the doubt. E-etention of urine in the female may be caused by impaction of stone in- the urethra. The diagnosis of stone in the female is easier than in the male. A finger in the vagina greatly facilitates the search, and a short, curved, or straight steel sound usually strikes the foreign body at once. In case of grave doubt, where a small stone is encysted or in an out-of-the-way position, it is en- tirely justifiable to administer ether, and, dilating the urethi'a, to explore the whole of the interior of the bladder with the finger. In one case, 1 Principles and Practice of Gynaecology, p. 741. 1879. ' Trans. Am. Gynaecol. Soc, vol. i., 1875 ; and Emmet, op. cit. 8 Traits de I'Affeotion Calculeuse, p. 594. Paris, 1838 < Chelius's Surgery, vol. ii. p. 635. s Lithotrity and Lithotomy, p. 247; and op cit., p. 370. URINAKY CALCULUS IN THE FEMALE. 295 Thompson found a stone so thoroughly encysted as to he practically imbedded in the vesical walls, which had to be cut through in order to liberate the oifending body. Emmet' also describes a remarkable case. He detected a stone, found it always in the same place, and made out that it was detained in the ureter. By making backward pressure with a large sound in the bladder, the stone could always be felt by the finger, introduced either into the vagina or the rectum. Therefore, with the stone so held in place by a sound, a speculum was introduced into the vagina, and the stone was cut down upon with scis- sors, the wound being enlarged toward the neck of the bladder. In this way the calculus was removed without opening either the peritoneum or the vesical cavity. I have this stone in my collection now. It is about as large as the httle finger, 1 J inch long, J inch in diameter, 4| inches in the long and 1| inch in the short circumference. Interrupted sutures were applied, and the patient did well. From motives of delicacy, women often conceal the fact of being afflicted with vesical maladies, and this may perhaps explain why so many cases are on record where enormous stones have been passed spontaneously by the urethra, or have ulcerated their way through the vesico-vaginal septum. Coulson quotes Bouque as saying that out of 204 collected cases of vesico-vaginal fistula, 6 were due to this cause. Agnew^ records a personal case in which a calculus as large as a goose-egg ulcerated its way into the vagina, and in which the opening closed spontaneously without leaving a fistula behind. Gross^ refers to CoUot, Beards, Baker Brown, Aliddleton, Botti, Klauder, Garden, and "Wilks, as having recorded cases of the spontaneous discharge of stones, the calculi varying in weight from two to twelve ounces. Tho. Molineux* records the case of one Mrs. Margaret Plunkett, who expelled through the " urinary passage," without medical or surgical aid, a stone weighing §ij S'j 9j gr. vj, Troy, and having circumferences 7^',^ X 5| inches. Incontinence followed, Anotlier case in the Transactions is that of a "Gentlewoman of Wallingford," 6.3 years old, who had taken from her by her husband, without instruments and without blood, a stone having a length of 4| inches, and a compass of 5^ ; weight |iij, avoirdu- pois. She recovered with incontinence. Garden's case* is that in which four stones were passed by a woman, one of them 5X4 inches in circumference. Coulson* quotes from Tulpius, that a lady of 89 passed spontaneously by the urethra a stone weighing three ounces and two drachms. Guerin' records the case of a woman who passed in the same manner a stone as large as a pullet's egg, weighing nearly an ounce. This she did without any surgical aid, four days be- fore confinement. Incontinence of urine, generally permanent, has been found to follow the expulsion of the stone in these cases. Yelloly* records the case of a woman from whose urethra there was extracted without operation a stone weighing 3 ounces 3|- drachms, Troy ; 3|- inches long, 2 broad, 1^ thick ; 7| X 5-| inches in circumference. Incontinence followed. I have found the record of another case, in a woman of 80, who passed a stone weighing 40 grammes, 5 inches in circumference. Incontinence followed at first, but after twenty days this venerable dame could hold her urine for more than an hour. She had passed 453 stones previously. These instances go to show that this malady does not necessarily shorten life in the female. Finally, as showing how large a stone may be extracted ' Op. oit., p. 754. 2 Op. cit., vol. 11. p. 693. » Urinary Organs, p. 300. 1876. ♦ Philosophical Transactions, abridged, etc., 4th ed,, 1731. Obs. 66, p. 151. « Ibid., Obs. 61, p. 150. « Op. clt., p. 370. ' Journal de Med., Chlr., Pharm., etc., t. xxxi. p. 162. Paris, 1769. . « Med.-Chir. Trans., vol. vi. p. 574. London, 1819. 296 URINARY CALCULUS. surgically without causing incontinence, may be instanced a case recorded b' W. F. Atlee.' The patient was an old woman of 73 ; the urethi-a was rapidly dilated, and a har( stone weighing 220 grains, 3^^ X 2/^^ inches in circumference, was extracted ; no in cotitinence of urine followed. Stone in the female bladder may prove an obstacle to parturition. Life two lives at once, have been sacrificed from this cause. ThrelfalP records a case where (he existence of stone was not suspected before labo commenced, nor diagnosticated until after death, when the calculus was removed an( found to weigh 6 ounces 5 drachms 34 grains, and to be 3f inches long, 2^ broad, 2- thick. A more fortunate case, quoted by Poland^ from Velpeau, is one in which a ston< weighing 9^ ounces was extracted from a woman in the iourth month of pregnancy witl a successful result, the woman going on afterwards to a happy deliverance at term. Hugenberger's* collection of twenty-three cases of calculus occurring during pregnancy is very instructive. In four of these the stone was removed during the early months of pregnancy. In seven the patient passed the stone spon taneously, often with serious after-effect. Coulson* records a personal case ii which the stone had a hair-pin for a nucleus. The stone was raised above thi pubis, and the labor continued favorably. Two months afterwards the ston was removed by lithotrity and the hair-pin extracted. In Monod's* cas€ vaginal lithotomy was performed after labor had commenced, and the womai was then delivered with forceps. Eriehsen' cites a case in which a larg stone prevented parturition and necessitated craniotomy. Craniotomy wa also resorted to in Threlfall's case, already alluded to. The obvious course to pursue when stone complicates pregnancy, is to remov the calculus at the earliest possible period. If its existence is not made ou until labor sets in, the stone should, if possible, be pushed above the brim c the pelvis, out of the way of the foetal head ; such a course has the sanctioi of high authority (Smellie, Dubois, and others). If this cannot be done, th offending body must be removed, preferably by vaginal cystotomy. Treatment of Stone in the Female. — Cutting on the stone, the latte being seized by a finger passed above it through the vagina or (in a virgir through the rectum, was the method first advised by Celsus, Rhazes, Albi; casis, and sometimes by Pare, practised with disastrous results by Frfer Jacques, and soon abandoned as an unsurgical and deadly method. Mar: anus Sanctus, Collot, and others advocated urethral cystotomy. After thi may be mentioned the French vestibular operation devised by Lisfranc, whic' was very rarely practised, and which has been uniformly condemned ; an< then the various operations of incising the urethra, dilating the urethrs lithotrity, vesico-vaginal lithotomy, and the supra-pubic section. At the present day but three methods retain a position of general approva namely, (1) dilatation of the urethra for small stones, (2) litholapaxy fo larger ones, unless it is desired to drain. the bladder subsequently in the cae of phosphatic calculi, when (3) vesico-vaginal lithotomy is the favorite. A few words will suflace to dispose of the other methods, before taking u these three operations of choice. , Urethral Lithotomy. ^-The urethra has been cut below, above, laterally 1 Trans. Coll. Phys. Phila,, N. S., vol. iv. p. 368. ' Edinburgh Med. and Surg. Journ., vol. xxxi. p. 56. 1829. ' Art. Urinary Calculi and Lithotomy. Holmes's System of Surgery, 2d edit., vol. iv. p. 109' * Volkmann's Sammlung klinisoher Vortrage, No. 88, S. 660. 5 Op. cit., p. 517. « Med. TimesaudGaz.,voL i. p. 356. 1858. ' Referred to by Coulson (op. cit., p. 617J. URINARY CALCULUS IN THE FEMALE. 297 lailaterally, through a part or through its entire length, and sometimes into "the neck of the bladder. Generally this method is combined with dilatation •of the neck of the bladder, and the wound is sutured afterwards, a soft or sometimes a Sims's hard catheter being left in the bladder for several days. The objection to this method is that it is wholly unnecessary. Any stone that can be taken out by slightly cutting the urethra, may be more easily i-emoved by litholapaxy with less dilatation of the urethra. If the calculus is so large that the urethral incision must extend into the neck of the bladder, there is great danger of permanent incontinence, and an incision through the vesico- vaginal septum is preferable and less likely to be followed by a failure •of the wound to heal, while if vesico-vagiiial fistula does unexpectedly result, its subsequent closure is a comparatively simple matter. The supra-pubic operation in the female is also not often called for. Its mortality, statistically, is less than in the male subject, a little more than 12 per cent, as compared with about 30 per cent. In the case of very large stones and of certain foreign bodies, perhaps in some cases of encysted stone, and jtossibly in very young children with small vaginae, the high operation might be chosen with advantage. In such cases the Petersen-Guyon-Perier opera- tion already described (page 291) would be applicable, substituting a thin rubber bag inserted into the bladder through the urethra (Milliot's method), and there inflated, in place of the vesical injection, and draining afterwards ■by a tube passed through the floor of the bladder and out by the vagina, instead of by two tubes through the abdominal incision, irrigation being practised through a catheter passed at stated intervals through the urethra. There remain to be considered urethral dilatation, litholapaxy, and vesico- vaginal lithotomy. Urethral Dilatation. — Franco proposed the use of a dilator, but found that when the muscular fibres of the urethra were torn, permanent incontinence waslikely to ensue. The introduction of anaesthesia has made safe dilatation more possible, and this method, as applied to the extraction of small stones less than half an inch in their smallest diameter, is entirely suitable for use at the present day. Bryant places the limit of size at which a stone may be safely exti'acted by dilatation, at a circumference of two inches. Various instruments and methods have been devised for the purpose of dilating the urethral canal, some acting rapidly, some slowly. Sponge-tents, water-pressure, and all means of slow dilatatiou have fallen into disuse. At present it is customary to employ a two-bladed or three-bladed forceps and the fingers, commencing with the little finger. I have found the most conve- nient instrument to be the dilator of Dolbeau (page 287). By introducing the different sizes of this dilator, it becomes presently very possible to intro- duce the finger without force, and then with a narrow-bladed forceps to •extract the stone. I have n^ver dilated the female urethra to a size larger than three-fourths of an inch in diameter. This I have done a number of times for the extraction of stone and for other purposes, and I have not yet met with any case of incontinence of urine as a result either temporary or permanent. The method seems an excellent one when the stone is quite small. No after-treatment other than rest for a few days, and the administration of a urinary diluent, is called for. Either litholapaxy, or ordinary lithotrity, may be employed in the female with great ease and safety. The former is applicable to all cases in which the stone <;an be grasped and fractured by the crushmg instrument. ISTo stone is too small for it, and it might perhaps be adopted with ad-^antage even in cases where the stone was so small that it could be safely extracted through the dilated urethra. The only cases unsuited for this operation are, where the £tone is encysted, where the nucleus is some foreign body which cannot be 298 URINARY CALCULUS. safely removed by crushing and washing out the fragments, where the stone is-- so large that it cannot be seized, or so hard that it cannot be crushed after having been caught, and, finally, where the bladder is very irritable, much in- flamed or ulcerated, or contains a tumor as well as a stone, and where it is deemed wiser to leave the organ totally at rest after the operation. In such cases vaginal cystotomy is preferable to litholapaxy. Sometimes in connec- tion witli stone there is incontinence of urine, and water thrown into the bladder immediately returns through the urethra. In such a case, if the blad- der does not become more passive under profound ansesthesia, the operation may still be safely performed with a small smooth lithotrite and a straight tube for washing. I have operated successfully upon female subjects at both extremes of life, in a child of four years and in an old lady past sixty. The operative manoeuvres are the same as in the male, but much simpler. A finger in the vagina may greatly aid the operator. The straight tube gives the most eft'ective return to the washing bottle, but a curved tube may be used. The female urethra is so easily dilatable that a very large tube will pass. The after-care involves rest, and perhaps vesical irrigation, with the administration of a little anodyne for a few days. Vaginal Lithotomy. — This operation is at present a favorite one for the extraction of stone from the female bladder, in those eases which cannot be dealt with by litholapaxy. The dependent opening can be made amply large, the bladder is drained through it eft'ectively, tj&e operation is safe and successful. The mortality, according to Aveling's' statistics collected in 1864,^ isabout 3 per cent. — 1 out of 35 cases. Vidal had 30 eases without a death,, but he complained that fistula often followed. Agnew^ credits 48 operations to American surgeons with two deaths. In both these cases the stone was very large. Rousset appears to have been the first to devise and perform the operation near the end of the sixteenth century. Fabricius Hildanus fol- lowed in the seventeenth. Bussiere, in 1699, took out by this method a stone weighing five ounces and a half. Mery, in 1700, described the opera- tion, and many others followed, but th'e fear of permanent vesico-vaginal; fistula caused it to be received with caution, and to be absolutely rejected by many surgeons. According to Velpeau, permanent fistula remains in one case out of every four operated upon. In order to overcome this tendency to persistent fistula, attempts have been made to effect immediate closure of the wound, and a number of successes have been recorded, so that this method has with many come to be looked upon as a good one. This position is, however, not accepted by American gynaecologists of the present day. Emmet says that the vesical wound heals promptly after incision, if the bladder be irrigated and if incrustation of the cut edges with ammonio-magnesian deposits be prevented. He takes the ground that the wound is liable to close too promptly for the good of the bladder, that is, before the chronic inflammation has subsided, and he has recently devised a means of retaining the incision permanently open until it is the will of the surgeon to close it. This means' is the attachment of the mucous membrane of the bladder to that of the vagina, along the entire length of the incision on both sides, by points of fine suture. In this way healing becomes impossible, and the vesico-vaginal fistula remains until the bladder has recovered, after which it is closed by the usual method. In speaking of this operation, Emmet^ gives to Sims the credit of suggest- ing the propriety of opening the floor of the bladder in the female for the ' Obstetrical Transactions, vol. v. 1864. ' Op cit., vol. ii. p. 695. ' Oral communication. * Principles and Practice of Gynsecology, p. 728. 1879. URINARY CALCULUS IN THE FEMALE. 299 relief of chronic cystitis. The operation is performed with the patient lying- in the Sims position on the left side, with the shoulders low, the hips ele- vated, the thighs and legs flexed. The vagina is held open by a speculum in the hands of an assistant. A sound with a short curve is introduced into- the urethra and turned backwards, so that its tip sharply depresses the floor, of the bladder near its neck. A tenaculum is used to steady the parts, and this tip is cut down upon boldly, so that the wound may penetrate the vaginal and the vesical wall at the same site. Scissors are introduced into this button-hole, and an incision is made directly upwards, an inch if necessary, or a little more. Through such an incision a large stone may be removed. If it prove too large, it may be crushed with some of the powerful instruments employed for the male, and the fragments removed separately. The patient is next placed upon her back with a bed-pan beneath her. The small nozzle of a Davidson's syringe is passed into the urethra, the vagina held open with two fingers, and copious irrigation practised until all fragments, blood-clot, etc., have been removed. If the bladder is found healthy, the wound is brought together at once with silver sutures, and the case is treated exactly like one of operation for vesico- vaginal fistula. If the bladder is not healthy, it is irrigated twice daily, and the wound is kept open by the daily introduction of a sound separating its edges, or, as Emmet now advises and practises, by attaching the vesical to the vaginal mucous membrane along the entire length of the wound on both sides. A silver suture, properly applied and twisted, will arrest any hemorrhage. In order to keep the wound from closing too rapidly. Fallen advises that the incision should be made with the Paquelin thermo-cautery, but Emmet does not sanction this modification. Emmet narrates a case in which, by opening the floor of the bladder, he was on one occasion enabled to detect a stone fixed in the mouth of one of the- ureters, and to remove it easily by means of a narrow pair of curette forceps^ EXPLANATION OP PLATE ILLUSTRATING THE APPEARANCI OF SOME OF THE FORMS OF URINARY CALCULUS. Fig. 1. Alternating calculus; showing on section multiple nucleus of oxalate of lime, waving lines of oxalate-of-lime formation surrounding the nuclei, ther alternating layers of uric acid, urate of ammonium, oxalate of lime, and phosphates, succeeding each other. Natural size. From the collection of Van Buren and Keyes. Fig. 2. Uric-acid calculus, natural size, showing on section concentric lamination about the nucleus of uric acid, waving lines of oxalate of lime, and radiate structure of uric acid beyond. From the collection of Van Buren and Keyes. Pig. 3. Mulberry calculus, natural size. Oxalate of lime. From the collection of Van Buren and Keyes. Tig. 4. Kidney-stone of xanthic oxide now in Army Medical Museum, "Washington. Described by Dr. G. L. Porter, Bridgeport, Conn., in the New England Medical Monthly, May, 1882. Fig. 5. Kidney-stone of cystine, in the possession of Dr. Eobt. F. Weir, of New York. 3*168. 6, 7. Mixed phosphatic calculi, showing formation on foreign body (bit of althea root> and excentric position of nucleus. Both stones natural From the collection of Van Baren and Keyes. (300) LITHOTRITY. BY WM. H. KINGSTON, M.D., D.C.L., L.E.C.S.E., Etc. PEOFESSOE OP CLINICAL SURGERY IN THE MONTEEAL SCHOOL OP MEDICIKE ; SCKGEON TO THE HOTEL-DIEU HOSPITAL, MOHTEEAL. The operation for the removal of stone in the hladder has always heen considered one of the most dangerous of surgical procedures, as it is at the same time one of the most ancient. ITo surgical disease has given rise to more discussion, none to more controversy ; and not alone in modern times, for Hippocrates dwells lengthily upon the disease and the means of its remedy ;. and so hazardous was any attempt at the removal of stone considered, that those who practised it were of that migratory class which deemed it inadvisable to remain long in one place, while the Father of Medicine him- self considered the operation so critical, or so unworthy, or both, that he made his pupils solemnly affirm that they would never attempt it. If history is to be believed, there was a seeming necessity for this affirmation in the fact that Tryphon, the usurper, induced a lithotomist of the time to operate, with fatal result, upon Antiochus the Sixth, for a stone which did not exist. At a later period, Celsus and the Alexandrian school taught that stone was irremediable in persons over fifteen years of age. Then, as men grew bolder, age was less considered, but the season of the year became important, and operations for stone were performed only in spring time. At that season the subjects of vesical calculus were gathered into certain localities, where the peripatetic lithotomist would visit them ; and, as a certain proportion of them would die, the operator found it convenient to be soon at a. safe dis- tance from the scene of his triumphs and of his disasters, well knowing that no amount or degree of the former could render his presence safe near the scene of the latter. And thus the operation continued to fluctuate in favor till near our own day, when the operation for stone was admitted to be one of the most brilliant and useful in surgery. During all these centuries but three principal methods were practised to open the bladder, and to reach and remove the stone: 1, by the hypogas- trium ; 2, by the perineum ; and 3, by the rectum. And one alone, the second, while it was the oldest, continued to be that which received the most general approval. These various methods, however, are here only mentioned, as a consideration of them does not enter into the purpose of this article. The circumstances under which vesical calculi are formed, and the symp- toms which they produce, have been fully considered in the preceding article,' and I shall therefore proceed at once to consider the mode of exploring a bladder which is suspected to contain stone, in order to determine whether 1 See pages 149, 184, supra. (301) 302 LITHOTRITT. or not a calculus is really present, and, if so, whether the case is one fitted for the operation of lithotrity. Instruments foe Explokation. — Considerable advances have of late years been made in the construction of instruments for exploration. It may be said: 1, That the instruments must be metallic — either silver, platinum, steel, or copper; I much prefer steel.. It is of small moment whether they are solid or hollow — some prefer one, some the other — but it is of much moment tbey should not be perforated with eyelets, nor furnished with stylets. If catheters alone are available, they should be deprived of their stylets as soon as they enter the bladder, when the urine must be retained by the thumb or index finger placed over the end. 2. Of still greater moment is the shape of the instrument. It should have a short, abrupt curve. One of the shape delineated in Fig. 1274 is the best suited for Fig. 1274. Sound for exploriog bladder. general purposes. It diflfers from Van Buren's in being of uniform size throughout, and from Benique's in not being bellied backwards at the curve — both these instruments appearing to me objectionable. The surgeon should also be provided with similar instruments of a longer curve — like that of the ordinary catheter — and corresponding to the usual curve of the urethra. Although this is different in different persons, the curve long since adopted by Pare, afterwards by Heurteloup, and more recently still by Thompson, is that which would seem to be most generally approved in America, namely, a curve equal to one-fourth the circumference of a circle three and a third inches in diameter. Usually', the stone is most easily detected with the sharp-curved instrument, but in some situations the longer curve is serviceable. 3. The size of the sound should be much under the calibre of the urethra to be examined — not so small as to permit the urine to flow away too rapidly, yet not so large as to interfere in any degree with the easy manipulation of the instrument when in the bladder.' Endoscope. — In cases of suspected stone. Cruise's endoscope has been repeatedly used, but with what advantage I have yet to learn. I have, after a fair trial commenced in 1867, discontinued its use, and I can conceive of no case in which more reliable information cannot be obtained with other means of diagnosis. In my hands it has signally failed to fulfil the expectations which I had formed regai'ding it. Whatever value it possesses in detecting inflamed • I have liitherto failed to recognize that relationship between the size of the urethra and the circumference of the flaccid penis which is described by Dr. Otis, and have not infrequently resorted to what Mr. Berkeley Hill claims as "the only exact mode of learning the size of a given urethra," the use of the urethrometer ; I have, on the other hand, often had occasion to notice the frequent absence of the relationship referred to, and especially since the adoption of Bigelow's method has led me to use catheters of the largest size. It will, I think, be found that Dr. Otls's rule will not be feund applicable in Canada, especially among, French Canadians. This was well marked in two oases in which, a few years since, I operated in presence of Mr. Reginald Harrison, then in Montreal, when a small urethra was met with in a youth of large proportions, and a large urethra in another of very moderate proportions. Much more readily "do I admit another statement of Dr. Otis, germane to this question, to wit, that we must recognize and respect a distinct individuality in each case, as regards the size of the normal urethra, irrespective of standards, or even of physical dimensions. EXPLOKATION OF THE BLADDER. 303 or ulcerated spots on the lining membrane of the urethra or bladder, it has none in searching for stone ; and no practical surgeon should waste his time in using it for the latter purpose when he can more readily touch than see the calculus. As much and as little may be said of the electric lamp, which, however, may some day aid materially in throwing light where much is sometimes needed ; and the interior of the abdomen being rendered diapha- nous, an opaque body, such as a calculus, may yet be found to cast or receive a shadow. This was suggested to my mind at the meeting of the Interna- tional Medical Congress in Paris, seventeen years ago, but thus far no advan- tage has resulted as regards the detection of stone. Exploration of the Bladder. — It is advisable that this should be done, if convenient, when the bladder is more or less full. But this is a precaution of less moment than is often believed by those who labor under the erroneous impression that the bladder is always in a state of contraction upon its con- tents. It is true that an exploration of all parts of the organ is not as easily made when the bladder is empty ; yet, as a stone is usually met with soon after •entering the bladder, its presence can generally be at once made evident. If, however, a stone be not at once detected, a more thorough examination should be deferred till the bladder is partly filled. I say imrtly filled ad- visedly, for examination of a fall bladder is often more painful than is that of one but partially filled. The injection of tepid water, or of any other fluid into the bladder, as a preliminary to sounding, is an objection- able procedure, and for reasons which will be stated hereafter. If the sur- geon is right-handed, let him hold the sound in his right hand ; if left- handed, he should use his left hand; if ambidextrous, one or the other hand ; but let him not change hands during the introduction of the instru- ment. This cannot be done without more or less losing of ground, and with- out more or less disturbance of the instrument. The left hand should merely steady the penis till the point of the instrument has entered the urethra, after- which there is no use for it till the prostate is reached, and not even then in children or young adults. The practice of pushing the instrument with one hand, and drawing the penis with the other, is not to be recommended. It is no doubt very desirable that one should possess a thorough knowledge of the anatomy of the urethra and of the curves which it makes in diflerent parts of the canal, but the best knowledge is that acquired gradually by the practice of introducing the catheter into urethrse of various dimensions and of different curves. By one possessing such experience, any arbitrary rules founded upon observation in the dissecting-room are often found to be faulty. The tour de maitre is veiy brilliant, but whether the instrument is introduced with handle downwards or upwards is really of small moment. What is of great mbment, however, is the sloio introduction of the instrument — even where no difficulty would be experienced in introducing it rapidly. The instrument should also be removed slowly — a matter very strongly and very wisely in- sisted upon by Dr. Gouley — yet not generally attended to. When the sound is within the bladder, its convex portion — the handle being elevated — may at once be felt to strike against the stone as it lies behind the prostate and near the neck of the bladder. If not, the point should be turned to right and left, then forwards and upwards ; and if not in this situation the stone will not uncommonly be felt as the instrument is being drawn back towards its first position. If still not found, the sound may be turned with its -point back- wards in the median line, and then to the right and left. If felt immediately after entering the bladder, and if felt in whatever direction the sound is turned, it is reasonable to conclude that the stone is a large one. If felt sometimes on one side, sometimes on the other, and if easily 304 LITHOTKITY. displaced, its small volume may be conjectured. Its free or encysted condi- tion may be inferred from the ease or difficulty with which, when once touched, it can be touched again. If soft and friable, the sound elicited by striking against the .stone may be dull and muffled ; if the " click" be a sharp one, it is usual to conjecture that the stone is hard. If, on touching it, the instrument can be sent in every other direction without feeling others^ it is likely that the stone is single. It is often found that a change in the position of the patient will facilitate the detection of stone. By some an examination in the erect posture is sub- mitted to more readily than if lying down. It looks less formidable. It is the one I usually begin with, and, if unsatisfactory, the patient can be easily induced to assume a reclining position, or, if necessary, both in succession. On one occasion when I suspected stone, an examination in either posture was fruitless, and it was only when the patient bent forward in a kneeling position that the calculus could be felt. When a patient is examined in the standing posture a running conversation should be kept up to divert his attention, and also to give early intimation of dizziness, faintness, or sickness. But no patient should be allowed to pass an instrument for himself when in the erect position.' Sometimes, when all these methods fail with a full blad- der, they may be successful with an empty or partially empty one. As the urine escapes, the instrument being just within the bladder, the calculus is drawn in against it when washed towards the urethra. When ordinary sounding fails to detect stone, it has been recommended to apply the stetho- scope above the pubes while the bladder is being explored, when calculi of small size may be heard when they are too small to be felt. Another plan is to apply a sounding-board at the end of the instrument itself. In explor- ing for stone, however, the finger is more delicate than the ear, and the appre- ciation it makes of a calculus is more reliable. Some years ago Professor Andrews, of Chicago, exhibited to the Illinois ■ State Medical Society a stone-searcher, which utilized both the sense of hearing and that of touch. The instrument which he used consisted of a tube, hollow or solid, which was attached to an ordinary Thompson's searcher,, and the free end, mounted with an ear-piece, was placed in the surgeon's ear. The suggestion is an ingenious one, but I doubt if the educated and sensitive sense of touch is much aided by this contrivance. Sand or grit which can be heard, may also be felt. But these methods, although usually successful, are sufficiently often unsuccessful to make it our duty not to pronounce too emphatically against the existence of stone after one or two, or even several examinations, when the symptoms point in that direction. Sometimes the calculus is small and eludes detection ; sometimes it lies securely imbedded in a pcJuch ; some- times the bladder is so dilated as to present the appearance of a second viscus ;. sometimes the stone lies in a kind of cul-de-sac of its own ; sometimes, and especially in old men, the stone lies below an enlarged prostate ; and some- times it eludes detection for a time, and, when found, can be touched again at pleasure. Desire Bayard, aged 22, and presenting all the signs of calculus, was admitted to the Hotel-Dieu Hospital. On introducing a sound the calculus was at once felt. Next day the patient was placed upon the operating table, and chloroform was admin- istered preparatory to operating. The sound was again introduced, but a long and careful examination failed to establish the presence of stone. The patient was after- ' The members of the profession in Montreal will remember the sad result to one of the most distinguished of their body, in the prime of life, of an attempt of tlie kind. Before the metaUic instrument had reached the bladder, he fainted and fell forwards upon it. Severe injury of the urethra was caused, with extravasation of urine, gangrene, and death. ' EXPLORATION OF THE BLADDER. 305 ■wards brought into the operating theatre several times, and examined by myself, and also by the late Dr. Munro, the senior surgeon, whose surgical experience was perhaps not exceeded on this continent. We examined the patient when sitting, standing, and lying, and when prone and supine, with instruments of every degree of curvature, but the desired " click" was neither heard nor felt. Three weeks elapsed in this way when, examining him in bed, 1 caused him to kneel and bend forward upon his hands, when the characteristic click was elicited. The stone was lying below, and in front of the prostate. I turned it back with the short curved sound, and with Civiale's lithotrite seized it, and in six sittings reduced it to fragments. The stone was of uric acid, and the debris weighed more than an ounce and a half. Sometimes an interposed membrane efFectnally prevents the recognition of stone. Scattered through the literature of the subject the details of numer- ous such cases are met with. When, however, many pouches are said to have existed in the same patient, each one hiding a stone and no part of the surface of the calculus being uncovered, I am inclined to think that possibly the instrument used may not have possessed the proper curve. If, on the one hand, calculi may sometimes exist in the bladder and yet defy detection, there are, on the other hand, certain conditions of the urinary apparatus which give rise to the belief that calculi are present when they are not. There is scarcely a surgeon who has not felt the instrument striking against what he has erroneously considered to be a stone ; and numerous have been the operations for the removal of stone where no stone existed. I shall mention these sources of error in the order of their frequence: (1) an uneven, irregular condition of the lining membrane of the bladder ; (2) the folding of that membrane ; (3) its roughened condition, as if sanded ; (4) without any morbid condition of the bladder, the sudden jolting movement often experienced in turning the point of the sound quickly from the middle line to either right or left ; (5) polypoid, fibrous, or scirrhous masses, attached or free in any part of the bladder ; (6) bony or other tumors of the pubis, sac- rum, or ischium ; (7) the striking of the handle of the instrument against a button on the patient's or surgeon's clothing ; (8) indurated feces in the rectum ; and (9) in females, a misplaced uterus or ovary. These, and other sources of error, are sufficiently numerous to make it desirable not to be satisfied with once striking the calculus. A second and a third touch are advisable. A distinguished Canadian surgeon, now dead, once fancied that he detected stone in the bladder of a young child who presented the usual signs of calculus. Lithotomy was decided upon. Of those present at the operation a select few /eft tlie click ; the others politely heard it ; but when the bladder was cut into no stone was found. Fortunately for the surgeon, the child's condition was improved by the operation, and nothino- dis- agreeable grew out of it. Brodie, Cloquet, Houstel, Velpeau, and many others in Europe have related somewhat similar experiences. Not only must the presence of a calculus be clearly made out, but its size form, density, position, etc., must also be determined, and whether it is free or encysted. These are matters of interest to the lithotomist, who cuts for all calculi, hard and soft, large and small, encysted and free; but to the litho- tritist, who selects his cases, they are of much greater moment. If the stone is not easily found, and if it is not easily refound ; if, moreover, it moves on the slightest contact with the instrument, it is reasonable to infer that it is a small one, and that it is free. But if we meet it in all directions, and if the sound strikes it in some way in all positions as we enter the blad- der, we have reason to conclude that the stone is large. Its approximate size may be determined by the sound alone, made to travel in all directions VOL. VI.— 20 806 LITHOTRITY. over its surface ; but its exact volume can only be made out by measuremen' and the lithotrite is perhaps the most convenient instrument for the purpos< The density of a stone may be approximately established by the sense c touch, and by the sound elicited when it is struck — the soft, friable stone usi ally giving out a comparatively dull sound, and the hard stone a sharp sounc But operators would fall into frequent error were they guided solely bj^ the sens of touch or of hearing in deciding upon the density or hardness of a calculus I have more than once elicited a very sharp, ringing sound from a soft stone and a dull sound from a hard one. The clearness of sound not unfrequentl. depends upon the slight extent of contact of the calculus with the surface of th mucous membrane of the bladder ; and the dulness upon the more extensiv contact whereby the bladder partially envelojjs it and muffles the sounc Clearness or dulness often depends upon the ease and quickness with whia the stone can be struck. With an instrument which completely fills the un thra, and which has its movements somewhat impeded in consequence, th sound will not be as clear as when the stone is struck quickly, sharply lightly, and with freedom, by an instrument not so held. Moreover, the not elicited may be dull or clear according to the part of the instrument wit which the stone is struck : when with the point, the sound is clearer whe struck laterally than when directly ; and laterally or directly, the sound i clearer than when struck by the instrument at a distance from the point. In word, it must be borne in mind that the sound produced by striking the ston is not solely dependent upon its size, hardness, or density, but is much mod fied b}'' the condition of the containing viscus and the canal which leads to i the instrument which impinges on it, and the hand by which this is helc Indeed, the sound elicited is as different in the hands of difterent persons a would be the sound elicited from the same thorax, with the same hamme and pleximeter, in the hands of a Piorry and of an untrained student. The question of number may be approximately settled by the same instri ment which establishes the question of size or density. If the instrumer strike a calculus on one side, and can then dip down and move about in a directions without striking another, it is reasonable to conclude that the stori is single. If, however, the instrument can be made to strike in several dire( tions, first on one side and then on another, and can then dip down, and, a it were, elicit a separate click, first on one side and then on another, it 1 reasonable to conclude that the stone is not single. But this is not alwaj's reliable, and I am now in the habit of trusting t the lithotrite alone to elucidate the question of one or more. With a calcuk firmly within the jaws of the instrument, the lithotrite is made to grope fc other calculi, and to elicit sounds that could not be caused by the imprisone stone. In this way the presence of at least a second calculus can be estal lished ; but more numerous ones are not so unmistakably made out. W may conjecture their presence, however, if the instrument seems to met with numerous bodies in all directions, displace them easily, and dip down i all directions and still displace. But it is not safe to conjecture the numbe by using either the sound or the lithotrite. Twelve years ago I examined a old man with the sound and made out the existence of separate calculi, but ho^ many I could not tell, though I suspected only three or four. I urged the us of the lithotrite, but he elected the knife. I did not regret his choice, as ■ enabled me to remove and save twenty-five stones of almost uniform siz and shape, each about the size of a hazel-nut. The number of calculi in tbi instance could not be approximately conjectured before the operation. But a circumstance of greater moment than the number of calculi, as it ofte decides the choice of operation, is their free or encysted position within tti bladder. It would seem a priori easy to say when a, calculus is free, au( EXPLOKATION OF THE BLADDER. 307 -when encysted, to determine the extent to which it is encircled. But in practice this is often found to be difficult. The sound may appear to move the calculus in all directions, but it may be the bladder which moves ; or the calculus may appear immovable when it is entirely free, but within a contracted organ. The sound may be made to move around the calculus with great difficulty, yet the calculus may be free, for a large stone in a dis- eased and thickened bladder is not easily defined; and, on the other hand, the sound may be made to move around the calculus with much freedom though it be adherent. In 1872 I operated by lithotomy upon a boy from St. Ours. The stone was at once detected, and the sound moved around it freely, but more than half the calculus was deeply imbedded in the left ui'eter, from which, however, it was easily withdrawn. Sometimes the stone is more or less hidden in a pouch of the bladder from which it cannot be removed. P. Derome, aged 72, had been for many years the subject of the usual symptoms of stone in the bladder. On examination, I found a calculus of about 1^ inclies in diameter lying at the back part of the organ, behind the prostate. I used, the lithotrite, and had no difficulty in reducing a considerable portion of the stone to powder. Short sittings, and not too frequent, were then in order. Ten days afterwards I again used the lithotrite, but was able to remove but a trifling quantity. I then suggested lithot- omy, but to this tlie patient was reluctant to submit. He died, and a post-mortem examination, at which Mr. (now Dr.) Roddick assisted, showed a calculus, its free convexity broken away by the lithotrite, and reduced apparently to about two-thirds of its original volume, deeply imbedded in the posterior wall of the bladder. It is not always easy, when sounding for stone, to distinguish between the surface of the mucous membrane of the bladder and the surface of the pouch in which the stone is imbedded, and especially when the stone is large, and the bladder rugous or diminished in capacity. But these sacs or pouches in the bladder, containing calculi, are fortunately of rare occurrence. When the presence of a calculus is clearly made out, and its size, form, •quality, and situation determined, means for its removal are to be considered, for the number of persons reported as cured without operation — either spon- taneously, or by galvanism, electricity, or injections, even when conducted in that ingenious manner styled litholysis,' when the stone is large, or by the use of mineral waters by the mouth, bladder, rectum, or skin, in cases •of smaller calculi^ — is too small to justify the postponement of operative measures. Some persons, it is true, have been cured without operation. The calculi, when small, have passed by the urethra ; but generally this spontaneous passage occurs soon after they have reached the bladder, and before they have attained the size of a grain of wheat or maize. Calculi have been known to find their exit by ulceration through the perineum and the •rectum; but the faint hope of such a termination should induce no sane ■ Proposed, biit, as far as I know, never practically adopted, by the late Dr. John Duncan, and published in the Edinburgh Medical Journal : the calculus was to be encased, while in the bladder, "in a thin pouch of highly vulcanized India-rubber, introduced by a suitable contrivance ; and with the interior of this pouch, containing the stone, free communication was to be had through the urethra by means of two small rubber-tubes, through one of which the operator could, at will, inject any stated quantity or kind of solvent which he might require for dealing with any par- ticular formation, the remaining tube being for the exit of the disintegrated stone in solution. ' The curious in this matter are referred to the works of Ambroise Par6 for a number of pre- scriptions in vogue at the time, and which received that writer's approbation, for the cure of stone without operation. They are, if nothing more, illustrations of the polypharmacy of the period, and comprise: "Syrop;" "Bouillon;" " Poudre singulifere ;" "Clystfere;" "Autre clystfere pour appaiser la douleur;" " Breuvage fort commendable;" "Apozeme;" "Poudre fort propre h. dissiper la matifere du caloul;" "Clystere facile;" "Frictions;" "Vomisse- anents ;" "Bains;" " D^coctum pour faire un demy bain;" "Decoction k faire olystfere ;" "Poudre propre k comminuer le sable," etc. 308 LITHOTRITY. person to await patiently an event so unlikely to occur, and, if occurring^ far more painful and hazardous than a well-conducted surgical operation. The methods of relief are practically but two : that by cutting and that- by crushing. The first, notwithstanding the simplification of the operation^ is still pregnant with danger, while advocates of the latter think it so little hazardous, and so well suited to calculi of every description, as to render the cutting operation under any circumstance uncalled for. But this is an error into which none but enthusiasts are likely to fall. To the first operation there must ever remain the dangers of shock, hemorrhage, inflammation, uri- nary infiltration, deep-seated abscess, gangrene, peritonitis, phlebitis, puru- lent infiltration, sympathetic afl'ections of distant organs, as of the brain or pleurse, or of the bladder, extending to the ureters, kidneys, or intestines,, and the less grave risks of urinary fistula, incontinence of urine, injury to the rectum, etc. Each method of operating has its peculiar perils, though some perils are common to both. Lithotrity has its own dangers ; but whatever its dangers, whatever its disadvantages, the field for its employment is steadily widening, and litho- trity is, now-a-days, preferred to lithotomy in cases where, twenty years ago,, the crushing operation would have been considered inapplicable. Even the conditions which were then considered essential to its successful perform- ance — relating to the size and texture of the stone, the state of the viscus in which it is found, or of the channel along which the debris is to travel — are- modified so as to admit a very much larger number of cases to this operation than was at one time thought to be possible. Lithotrity has its own dangers- as well as its advantages, and to these and to those I shall now give attention. Dangers and Advantages of Lithotrity. — The term lithotrity, in its most extended sense, may include the seizing of a small calculus in the bladder and its extraction by the urethra ; it also includes the breaking up, compression in some way, crushing, squeezing, condensation, or perforation, of large calculi,, and the removal of their debris, allowing this to pass by the urethra or to be- washed out of the bladder. Manoeuvres so various have received various names, and the lover of Greek may find terms to his fancy or his astonish- ment: lithocenosis, lithodialysis, litholaby, lithomyly, lithontripsy, litho- tripsy, lithophag}', lithopriny, and lithotrity. The first eight have become almost obsolete ; the last is now commonly used. In no department of sur- gery, perhaps, have advances been more steady and more signal than in this- modern operation ; modern as concerns most of its essential features. Eor nothing could be so unlike the present procedure as the use of the three-pronged forceps which seized and endeavored to penetrate or pierce the calculus, the maschabarabilia of the Arabs, or the four-pronged instrument of France. But there is no satisfactory evidence that before the beginning of the present century a calculus of any size had ever been removed from the bladder with- out cutting — the testimony of Colonel Martine to the contrary notwithstand- ing. The calculi said to have been removed were from the urethra, and not from the bladder. There is nationality sometimes even in science, and, if we put aside the claims of G-ruithuisen, who first taught that sounds of large calibre could b& passed with ease through the urethra, the credit of having created lithotrity unquestionably belongs to France. To Leroy d'j&tiolles is probably due the invention of the greater number of instruments designed for crushing stone, and to Oiviale their more exten- sive' employment. It is a singular fact that the introduction of the lithotrite was coeval with, and in a measui'e resulted from, the use of the straight catheter. Until the beginning of this century, a curve to a catheter was con- DAKGBKS AND ADVANTAGES OF LITHOTRITY. 309 isidered a necessity. But the use of a straight instrument led to the invention -of the lithotrite, which was again, in its turn, brouglit to a curve as the form -of greatest adaptability. The fii'st lithotrites were curved ; but they were soon afterwards made ^straight, to be again curved as they are now, and are ever likely to remain. It is useless to trace the gradations from the rough, complicated, and unsafe instruments of fifty years ago, to the elegant, light, yet strong lithotrites of to-day. The circumstance that a bloodless operation for the removal of stone was found to be possible, was sufficient to stimulate the ingenuity alike of isurgeon and instrument-maker in many countries in Europe ; and America, in the person of Ashmead, evinced a like interest. It stimulated, at the same time, an interest in the subject of lithotomy, and reopened a considera- tion of the various procedures for i-emoving the stone whole. But the two Frenchmen already named, to whom must now be joined Amussat, Charriere, Heurteloup, Mercier, Eecamier, and Tonchu, of France, more recently Sir Henry Thompson, of England, and still more recently Prof Bigelow, of Boston, have given in their beautiful closed and fenestrated instruments the best means of quickly i-educing a stone to powder and of removing it from the bladder. Various have been the methods advocated during these fifty years, but they may be all reduced to (1) perforation ; (2) perforation and divulsion, or ■excentric rupture ; (3) concentric or surface grinding ; (4) crushing. There is nothing brilliant in any of these methods, and no opportunity is .afforded for dash or boldness, or even of sang-froid ; near assistants may hear .an occasional crushing sound ; but neither they nor the operator can see any- thing. The latter could operate equally well were he blind, for, from the beginning to the end of the operation, it is carried on in the dark. And not alone in the dark, but the peccant body, lying hidden within the bladder, is not touched save by a metallic instrument, many inches in advance of the -operator's fingers. From the first discovery of the stone till its final removal from the body, there is, there can be, no contact except mediatel}^ through .a metallic instrument. Of no operation in surgery can this more truly be .said: "We see not what we attack, and touch not what we remove." On several occasions I have published in the medical press some practical observations on lithotomy and lithotrity, and on the selection of the cases suit- :able to each operation. But every succeeding year has taken fi'om the former .and added to the latter. Age, at one time considered an essential element in the choice, is so no longer. Even children in whom the shallowness of the perineum and the xmirritating nature of the urine seemed fairly to indicate lithotomy, are now subjected to the lithotrite. Nor does old age, with its accompanying -enlarged prostate, any longer forbid or render less satisfactory the operation -of crushing, and since Mr. Henry Smith, of King's College Hospital, London, lithotritized with success, more than twenty years ago, a man of more than -eighty-one years, persons of the most advanced age have been similarly treated. The state of the urethra has much to do with the choice and also with the -•success of the operation; that tolerance or intolerance of the urethra — "the temper of the urethra," as Sir Benjamin Brodie styled it — which " varies as ^much as the temper of the mind." This tolerance or intolerance of the "urethra for instruments may be easily understood by those who have noticed Ihe great tolerance of some urethrse, and the equally great intolerance of others, for injections. There are some urethrfe so tolerant of strong caustic and astrin- gent solutions as to appear unafi:ected hy them ; while there are others so sen- sitive that even the most trifling addition to tepid water causes urethritis •or cystitis of alarming severity. Injections of tepid water alone often 310 LITHOTRITY. arouse inflammatory action. Before the practice of rapid lithotrity becarr general, when several sittings were necessary for even moderate-sized and friab! calculi, this was a question of moment. But it is so no longer, and the urethi that can tolerate the grooved staff" for cutting purposes, can alike bear the uf of the lithotrite. The irritation sometimes set up in the urinary apjiaratus b the too-prolonged and too-frequent introduction of the lithotrite, is not usuall irritation of the bladder, as is commonly supposed, but of the urethra ; and th severe constitutional disturbance which often follows, results from the passag to and from the bladder, and not from any trouble lit up within that viscui The bladder is not easily irritated ; but the urethra is relatively sensitive an prone to disturbance. A large calculus, when broken up, as long as it remain within the bladder gives but little discomfort; but the passage of the smalles fragment causes both pain and disturbance of the circulation. It was th recognition of this greater sensibility of the urethra, probably, which lei to the use of the external canula, or " chemise," as it was termed, which wa placed within the urethra to protect its walls, but which is now no longer t be met with save as a curiosity in the surgical cabinet, though the sensibilit of the organ which it was intended to protect has continued the same. ISTor is stricture^ whatever may be its character or situation, even if it hav become cicatricial, to be regarded as an obstacle to the performance of lithe trity. If the crushing operation would be selected without stricture, it shouL be the more readily selected where stricture exists. Some of the most sue cessful operations of which I have knowledge have been performed after th patients had undergone treatment for stricture. !N^or are those heteroplasti growths which grow in and around, and press upon, the urinary canal, to oft'e insuperable obstacles to lithotrity, unless they are themselves not amenabl to treatment. The treatment necessary for the cure of stricture, whether single or multiple and whether situated in the membranous, bulbous, or penile portion of th urethra, as a preliminary to lithotrity, familiarizes the ofttimes capricious coy, and uncertain canal to the presence of instruments, and renders the sul: sequent use of the lithotrite comparatively free from irritation. When dila tation alone is practised, the bougie brings the calibre of the urethra up to au( beyond that required for the lithotrite, and when incision with elilatation, o internal or external urethotomj', is practised, the same result is obtained. But other circumstances have a controlling influence on the selection o rejection of lithotrity : to wit, the size and hardness of the stone. The siz of the calculus is less regarded than formerly, and, provided that the ston is not too hard, size alone should not pi'event the performance of lithotritji The comparativeh' earlj' detection of stone, while it is yet small, has rendere( the operation of lithotomy less needful. Large stones are met with less fre quently than formerly. Now and then our hospitals furnish cases of ston of large size in individuals who have lived far from the aid of surgery, til forceel by long suffering to find their way to the larger cities ; but since th practice of lithotrity has become more general, and the detection of ston more early, calculi have been steadily decreasing in size, and promise to di so still more in the future. The hardness of a stone may generally be recognized by the resistance i off'ers to the lithotrite, and by the manner in which the jaws of the latte grasp it. But the seemingly unmistakable evidence of hardness or of soft ' By the term stricture I mean that organic stricture, that ohang^e in tlie wall of the urethra either in the mucous or submucous tissue, by which is ofifered a greater or less impediment to th easy flow of urine. "Spasm" and "inflammation," as Mr. Reginald Harrison well observes " may be superadded, but they do not constitute stricture in the acceptation of the term which i now generally adopted." DANGERS AND ADVANTAGES OF LITHOTEITY. . 311 ness thus elicited, is liable to error : the stone may not be the same through- out ; — • D , aged 21, on the 17th of July, 1873, came tome from Syracuse, in the State of New York. He had been a suiFerer from infancy. On his admission to the hospital I at once struck an enormous stone. It seemed to be soft however, arid I decided to employ the lithotrite. Atthefirst sitting a large quantity of very soft phosphatic matter was broken off and reduced to fragments, which came away during thefollowing week, when the second sitting was begun ; but the jaws of Civiale's strong-toothed instrument closed upon a cal- culus seemingly unlike that previously felt. The screw was applied, and as much force used as was consistent with the integrity of the lithotrite, but no impression whatever was made upon the calculus. I at once resorted to the knife, and by the lateral method safely removed a stone measuring nine and a half inches in its greatest circumference, and weighing five ounces and five drachms — the largest stone I have ever seen removed from a living body. An inspection of the specimen showed that no instrument hitherto devised could have crushed it, and that no operation, however prolonged — not even the two thousand strokes which Leroy is said to have given a calculus ineffectually — could have caused its disintegration. Its shape was a somewhat flattened ovoid. One end was partially covered with nearly a half-inch coating of soft phosphatic de- posit ; the other end, which rested upon and was partially encysted in the bladder, was a rough uric-acid stone ; but the greater bulk of the calculus, and the part upon which the lithotrite could make no impression whatever, was of oxalate of lime. The varied structure — so adapted to mislead — and the enormous size of this stone, led me to present it the same year at a meeting of the Canada Medical Association, in St. John, New Bruns- wick, and I introduce here an engraving from a full-sized photograph. The patient, I may add, made a rapid recovery. In this case an examination of the urine, and even of the debris of the stone itself, would have been misleading, as the outer coating alone was soft, while the interior was of the hardest character. Fig 1275. 4 \ \ t / ^^ r Large oxalatVof-lime calculus, with external phosphatic layer. State of Bladder and Kidneys. — What condition of the bladder contra-indi- cates the operation of lithotrity ? I know of no condition of the bladder which alone should influence a decision in favor of lithotomy, which could not with equal reason be deemed favorable to lithotrity. ISTor yet the' state of the kidneys : although, as in other o]3erations, it is desirable to have these organs in a healthy condition for removal of stone from the bladder, I know of no condition which forbids the operation, though it may have much to do with the choice of the method to be adopted. 312 LITHOTRITY, Preliminaries to Lithotrity. — Surgical writers, generally, have recom- mended (1) that the irritable bladder should be deprived of its irritability by emollient injections before the operation ; (2) that the urethra should be habituated to the passage and presence of metallic instruments before using the lithotrite; (3) that the bladder should be partially filled with tepid water or other fluid ; and (4) that, when the bladder cannot retain urine for two or more hours, recourse should not be had to this procedure. (1) In the first place, the readiest way to diminish the irritability of the bladder is to remove therefrom the calculus which has given rise to it. Emollient injections are useless, and are sometimes a source of mischief. (2) If the urethra can be accustomed to, and become tolerant of, the sound or metallic bougie, it can as readily become accustomed to and tolerant of the lithotrite at the time of the operation. But it must be borne in mind that there are, on the part of the urethra, periods of tolerance and times of intoler- ance of the presence of instruments, independent altogether of the duration of their employment. At one time the urethra will bear the presence of an instrument, and at another it will not, and this without regard to the size of the instrument. It is difficult to account for this varying tolerance of instru- ments. It is a fact, however, known to all surgeons, and alluded to by many. Gouleysays: "The instrument may have been passed at regular intervals for weeks or months without any very great amount of pain, and without giving rise to any discomfort ; or it may have been followed on one or two occasions by a mild attack of fever ; but finally the same careful catheteriza- tion is practised — but on the wroytg day perhaps, when the patient's functions are temporarily disordered — and in a few hours he is suddenly and unexpect- edly seized with a severe rigor from the effects of which he may never rally." A surgeon of distinction in this city had completed very successfully the operation of lithotrity, and the patient, relieved of his sufferings, had left the hospital and had returned to his home in the country. Some months afterwards tlie surgeon, being near the residence of his patient, called to see him and suggested an exploration of the blad- der. A metallic sound was carefully introduced, but ere it had reached the bladder the patient was dead. On August 20, 1881, A. B., aged 13 years, was admitted to the Hotel-Dieu suffering from symptoms of calculus. Chloroform was used, and a metallic No. 6 sound was introduced ; the bladder was explored, but no stone could be detected. No inconvenience whatever resulted from the examination, and the little fellow continued to run about the ward as if nothing unusual had occurred. Three days afterwards he was subjected to an examination of about the same duration. No difficulty was experienced in entering the bladder, no difficulty was experienced in the easy movement of the sound when within it, and no hemorrhage followed. Later in the day I was summoned to the patient's bedside, and found his condition to be alarming. He had had a rigor which had lasted a couple of hours ; he had now a pale and anxious countenance, and a weak, thread-like pulse (140), and cold extremities. From this condition he did not rally, and he died in the afternoon of the following day, twenty-eight hours after the second exploration. The anaesthetic (chloroform) and instruments (No. 6 long, curved, silver sound, and Sir H. Thompson's explorer) were the same in both in- stances, and employed by the same persons ; and the duration of the examination on both occasions (about six minutes) was about the same, and on both occasions in pre- sence of the same class, in the same surgical theatre. The body was so quickly claimed by the relatives that no post-mortem examination was obtainable. (3) The suggestion to fill the bladder with tepid water, or at least to intro- duce eight or ten ounces, is made under the impression that the movements of the instrument will thus be freer, and that the detection and seizure of the stone will be easier. But this impression arises from a misconception of the true state of the bladder. That viscus is but sparingly supplied with mus- PRELIMINARIES TO LITHOTRITY. 313 cular tissue, and it is not contracted upon its contents, as is the uterus. The walls of the bladder lie in easy apposition, and the lithotrite can move about as readily in an empty bladder as in a full one. This experiment may be easily performed on the dead subject. Indeed, of the two, I prefer the «mpty or nearly empty bladdier to a full one. I do not request the patient to void his urine, but I do not ask him to retain it too long. It is a matter of indifl'erence. (4) It follows as a corollary, from what has been said, that the circum- stance that the bladder cannot retain urine for some hours, is not a reason for rejecting lithotrity for lithotomy. It often happens that the subjects of stone -cannot retain their urine for more than a few minutes, and some, not for a moment : — In 1872, Mr. W. S. came to me from Quebec, for the removal of stone. For seve- ral years lie had been unable to retain his urine. Incontinence was complete. A ■caoutchouc bag was attached to the penis, and a tube led from it to a larger one which he carried in the leg of his boot. The parts were so excoriated and his sufferino-s so great that I advised him to submit to the knife. To this he would not consent, and <;ontrary to my judgment, I was constrained to use the lithotrite. At the first sitting I crushed two large-sized uric-acid calculi, and repeated the operation three days afterwards. After the first operation, and before any of the debris had passed away, the patient could retain his urine two hours ; after the second sitting he retained his ■urine a. much longer period ; and after the third and last sitting, he was able to retain his urine as long as ever in his life, and, as far as I know, his condition has continued •comfortable ever since. Injections. — There was, in the early years of lithotrity, remarkable unanim- ity of opinion in favor of drawing off the urine and injecting into the bladder a certain quantity of warm water, as a preliminary to the use of the litho- trite. There was also remarkable unanimity of opinion as to the quantity and not less than four ounces, and usually not more than six ounces was regarded as the cj^cloid within which it was deemed safe and wise to oscillate. It was also considered necessary to know what quantity of water the blad- der would tolerate within it, and, this quantity being a known quantity the bladder's capacitj^, ascertained in this way, became its known capacity. It was also imagined and taught that, tepid water being less irritating than urine, the bladder would be tolerant of the presence of a greater amount of the former than of the latter fluid. But urine is proper to'^the viscus which ■contains it, and is less irritating to its coats than any foreign fluid however bland, just as the secretion of the lachrymal gland, more irritating than water is more grateful to the eye which it bathes ; moreover, as Pollock says' ■" other things being equal, there is no beneflt in tepid water over urine as a medium in which to crush a calculus." In later years the orthodox four or six ounces was reduced to two ounces, and still more recently' some distin- guished operators have discontinued the use of injections altogether. I have never practised filling the bladder with warm water: it seems to me but a mischievous and unnecessary meddling, and the reasons for the use of injec- tions have never appeared to me cogent. On the contrary, I have always observed that when practised by others the procedure is a painful and distress- ing one, not free from danger, and of a nature to arouse patients from appa- rently deep sleep. Indeed, I have generally noticed that the injection causes more pain than the sound or lithotrite, and that even when chloroform is used, there is rarely an occasion on which the sleep is so sound as not to be easily disturbed by the injection. Some surgeons, however, run into the ex- treme of operating only when the bladder is full, and when the patient is expe- riencing a strong desire to micturate. It is preferable to operate when the 314 LITHOTKITY. bladder contains some fluid, and a practical method is to suggest to the- patient not to make water immediately before submitting to the employ-^ ment of the lithotrite. Sir Henry Thompson's plan is a good one — to ask the patient " to retain his urine for a little less than his accustomed period before the sitting ; that is, if naturally he is able to retain his urine for about an hour, he is requested to pass it forty minutes before the time of the visit." In this way the inconvenience of an empty bladder, and the still greater inconvenience of a too full bladder, are both avoided. But even this moderate desire for a small quantity of urine in the bladder cannot always be gratified, as in the case of the gentleman frorn Quebec to which I have already referred. I reluctantly employed the lithotrite in this case, yet I never had a more favorable recovery. Since then I have never regarded with an\' apprehension the opening and closing of a lithotrite in a bladder which was intolerant of the presence of even the smallest quantity of urine, nor has it occurred to me to supplement the vesical contents' witk warm water. Injections have been recommended in the erroneous belief that without them the play of the instrument would be restricted, or that the walls of the bladder would be caught between the blades of the lithotrite and injured. But it should be borne in mind that, as already pointed out,, the walls of a healthy bladder are not closed and contracted upon its contents, but that they lie loosely and lightly in contact, receiving \\ ithin them the water which trickles along the ureters without any vis a tergo or pumping- power in kidney or ureter. The degree of fulness of the bladder admit- tedly influences the search for stone. Acting on this assumption, Civiale had constructed a lithoclast — a small, short instrument with a groove along- the centre of the male blade — which permitted the urine or the injected fluid to escape slowly ; and, while it was escaping, the instrument was turned in every direction to search for the stone. Size of Lithotrite. — It was formerly the custom, sustained by the approval of the late Sir W. Fergusson, to commence the operation with a large-sized lithotrite ; to break the stone into pieces, and then to take a smaller instrument to reduce the fragments to less proportions, so that they might more readily pass through the urethra. But if the lithotrite used in the first instance be not too large, not more than 11 or 12 of the English scale — one not too large to be easily manii3ulated,yet not so small as to be in danger of being bent or broken — it is better to keep to the same instrument throughout. The length of the instrument must be proportionate to the length of the canal. In children the canal is short, and a short, small-sized instrument sufiices ; but in cases of enlarged prostate in elderly persons, M'here the canal, especially at its prostatic end, may be elongated several inches, the necessity for a long lithotrite is obvious. A lithotrite of about twelve inches is sufficient for ordinary purposes ; but, in some cases, anything under fourteen and a half inches would be inadequate. Method of Operating. — The patient's body should be so elevated that the surgeon's right arm, while operating, may be nearly horizontal. If the patient is in bed, the surgeon should be seated at his side; if the patient is on the operating table, the surgeon should stand. The operator boing upon the right side of the patient, who lies upon his back, with his head and shoulders elevated and his thighs flexed, the closed lithotrite, well oiled and in the right hand, is slowly introduced within the meatus in the same maimer as an ordinary catheter, the penis being sup- ported merely — not seized — by the index and middle fingers of the left hand. It is of small moment on which side the operator chooses to place himself; but it is of importance that, having elected one side, he should keep to it. METHOD OF OPERATING. 315 At the beginning of my hospital career the right side of the patient seemed to me preferable, and I adopted it, and now, from habit perhaps, consider it the easier and more natural one. I therefore recommend it. It was the position which I generally saw selected by Civiale and by Sir Philip Cramp- ton. The introduction of the lithotrite is practised by some indiiferently,. either sitting or standing, and on the right or left side of the patient. If, with an instrument of such inconsiderable weight as a catheter, it is not allowable to add nmeh additional weight, still less is it allowable with an instrument already many times heavier. The increased weight of the lithotrite is alone more than sufficient, when once it has passed the mea- tus, to insure its passage along the urethra and into the bladder. The calibre of the canal is nowhere less than at the meatus, and here alone a slight amount of pressure, with a somewhat rotatory movement, may be allowable. The meatus is rarely as wide as the rest of the urethra, even in the healthiest persons and in those who have never had balanitis. My experience in this respect corresponds with that of Mr. Berkeley Hill, who thinks that the meatus is " normally narrower than the rest of the canal, or that its morbid contraction is exceedingly common." The meatus once passed, no difficulty is generally experienced till the instrument is beneath the pubic symphysis, when its handle must be depressed. This carries it. beyond the membranous portion, where delay sometimes occurs, and to the prostatic, where difficulty is sometimes experienced, especially in old men, in whom prostatic enlargement is usually accompanied by elongation of th& corresponding portion of the urethra, to such a degree as sometimes to lead the inexperienced surgeon to believe that his lithotrite is already in the bladder, when its point may be impinging against the superior wall of the- urethral canal. When within the bladder, it is advisable to advance the instrument well along the floor of the organ, to make sure of its being com- pletely within the cavity, before commencing the search for the calculus. Not infrequently the instrument as it advances strikes against the stone. If not, it is to be again slowly withdrawn to just within the neck, when the insttument is made to dip gently from right to left and from left to right of the median line, then from front to back and from back to front. Sometimes- the point of the instrument requires to be elevated, sometimes to be dipped backwards, but always with the greatest gentleness ; and sometimes, also, the difficulties experienced when searching with the sound are again renewed with the lithotrite, difficulties arising in great measure from concealment of the stone in a saccular depression behind an enlarged prostate, from the floating about of a small calculus in a capacious bladder, or from the- diminished space in an irritable one. Sometimes it is considered necessary to turn the patient on either side, and various contrivances have been sug- gested and used for the purpose, the most complete perhaps being that of Reliquet, which elevates the pelvis at will or turns it in either direction. But without any special apparatus an air pillow will be found convenient. I have never had occasion to turn patients upon the side, and prefer having them always upon the back. One is less apt to forget the relations of th& lithotrite to the body when the patient is in that position. When the calculus is touched with the still closed lithotrite, it is well to determine on which side it lies, so that the instrument, when opened, may the more readily grasp it. But though desirable this is not essential, and the investigation should not be pursued at the expense of any sutt'ering^ from manipulation that can be avoided. When the stone is again feU,. the male blade is gradually withdrawn and again pressed home, while- the female blade rests against the back of the bladder, the penis in th& mean time being gently held in position. In this way the stone will gener- S16 LITHOTKITY. ally be at once seized within the blades. If not, the instrument is agair .and again opened and closed, while gently turning it to the right and left and backwards and forwards. When seized, the stone is to be dealt with according to the particular method which has been decided upon. If it is contained within a litholabe. the stone is broken with blows i'rom a hammer, of sufficient force and quick- ness to crush it without injuring the instrument.' If with the rack and pinion lithotrite, the penis is held in the same manner, and the handle, which is sometimes on the right side, sometimes on the left, is worked by the right ■or left hand, the penis and contained instrument being held by the other. As the rack-and-piniou instrument cannot be worked without more or less Rack-and-pinion lithotrite. same movement of its point within the bladder, it is objectionable. The -objection applies with equal force to the lever instrument (Fig. 1277), which requires too much movement of the right hand. I have discarded both for Fig. 1277. r/f/MHM &. CO. Lever-lithotrite, the, to my mind, more satisfactory lithotrite of Civiale, which may be easily worked, with or without the screw, this being released or attached by turn- Civiale's lithotrite. ing what instrument-makers call the revolving cap. Weiss's lithotrite has a.11 the advantages of Civiale's, and also an additional merit. The screw power is in connection with the male blade, and is more readily released, this being accomplished bj' placing the thumb of either hand upon a button or the handle, the movement being effected in a line with the shaft of th( instrument. But the cylindrical form of the handle, added by Thompson though admitting of greater force in the hands of the operator, does not per mit the same delicacy in manipulation as does Civiale's round-headed instru ' I mention this method, though now obsolete. METHOD OF OPERATING. 31 T ment. That instrument is, however, the better to which the operator is th& more accustomed. Sir Henry Thompson's lithotrite^ has considerable advantages for stones- that are neither too large nor too hard. The instruments hitherto described are fenestrated. Thompson's has a small opening, yet for all practical purposes is closed, and the depression in the female blade permits it to- receive and retain a considerable quantity of the fragments, which may generally be removed without injury to the canal. The means of releasing- and of attaching the screw are placed on the handle of the female portion of the instrument. But to Thompson's, as to all flat lithotrites insuffici- ently fenestrated, there are these objections : they become quickly filled with fragments, large and small, and the female blade, no matter how full, still permits additional matter to be pressed into it by the male blade, when perhaps the blades, separated by calculous matter, cannot be accurately closed,, and have to be withdrawn in this way through the urethra. I have more than once seen difficulty in removing this instrument, and especially through- the narrower portions of the urethra, where lacerations have apparently taken place. It is not always easy to prevent the overloading of the female blade,, for the first turn of the screw or the first pressure of the unaided wrist may impact it with more than it can contain. The most dexterous must be prepared for this occurrence. Before the time of rapid lithotrity, before the time of washing out the bladder after the operation for crushing, Sir Henry Thompson's instrument was deservedly a favorite one. It enabled the operator,, with a fair-sized urethra, and one tolerant of manipulation and of the presence of instruments, to introduce any number of times an empty lithotrite, and remove a full one. And many times have I completed the operation of litho- trity in this way in two or three sittings. But, as already stated, repeated introductions and withdrawals are not advisable, however carefull;^ performed, and a prolonged sitting means correspondingly numerous passages of the in- strument through a sensitive canal. There are many cases, however, in which Thompson's lithotrite is still the best — cases in which friable and moderate- sized calculi are met with, and in which the urethra is capacious and pos- sessed of a minimum degree of sensibility. Bigelow'a lithotrite^ has few advantages over Sir H. Thompson's and Civiale's flat instruments, save that it has a longer and larger female blade,, turned down at the end to facilitate its introduction, and fenestrated at the heel for the reception of a projecting shoulder on the male blade. It is a flat instrument, and may be choked in the same way as Thompson's or Civiale's. When closed, the male is completely hidden within the female blade. The instrument breaks the stone effectually, but does not reduce it to fragments. To do this the broken pieces must be seized again and again. Its crushing- power is not by any means equal to that of the open, fenestrated instrument;, and it works by continuous pressure rather than by sharp, distinct, and inter- rupted crushings. The absence of lateral guides on the handle, to tell when the screw is on or off, is confusing; but the instrument-maker can easily remedy this defect. Dr. Gouley's lithotrite (Fig. 1279) has some advantages not possessed by^ other instruments, but has disadvantages also. The edges are sharply cut- ting, but the bulk of the stone must be reduced by pressure, and pressure of a continuous kind. The dread of cutting the walls of the bladder by an instru- ment apparently equal to that work, is ill-founded. In this respect its construc- tion offers nothing more hazardous than that of the instruments longer in use^ » See Figs. 1204-1210, pages 221, 222, supra. s See Figs. 1211-1213, page 223, supra. 318 LITHOTRITY. Fig. 1279. Gouley's lithotrite. France, unwilling that other countries should outstrip her in the perfectioi of instruments for crushing stone, in which, for so many years she excelled has not been idle. Civiale's, Heurteloup's, and Leroy d'Etiolles's instruments have been variously modified in handle, shaft, and blade. But more i-ecentlj Eeliquet has furnished a lithotrite which has certain advantages over othei instruments, especially in reducing calculi to fragments sufficiently small tc enable them to pass through the evacuating eanula. The advantages of Reliquet's instrument are chiefly these: (1) the obliqut ■disposition of the teeth on the margin of. the female blade prevents the calculus from slipping towards the point when the teeth of the male blade cut anc €rush it. (2) The teeth of the male blade act singly upon the imprisoned calculus, and drive it against the transverse teeth in the female blade, betweer which it is reduced to the desired size, the fragments falling behind and oui of the way of the male blade. Hence (3) the disadvantages of over-filling the female blade, and of necessitating the frequent withdrawal of the litho- trite to clean it, as in flat instruments, are avoided. But there is also e drawback to the general use of the instrument. When it is closed, the teeth of the male blade project beyond the female, below, and the serratec margins of the female blade, above, are free. In its closed condition the instrument can neither be introduced nor withdrawn ; the blades must be partially open, and by a piece of mechanism this action is limited. Operators familiar with other lithotrites, which are always firmly closed prior to intro duction or withdrawal, are apt to be unprepared for tliis novelty. A smal' blade, less deep, and one which would occupy less space when closed, woulc answer every purpose. In spite of this defect, however, much of what its enthusiastic inventor claims for it must be admitted, and especially the advantages of a flat instrument without the inconveniences of clogging enabling the lithotrite to be manipulated for any length of time within the bladder without the risk of difficulty in its removal. It can be used with the pressure of the palm of the hand, or with the screw as in ordinary instruments or, in cases of hard stones, with percussion by a hammer. Duration of Operation. — This also has been greatly modified. Frencli surgeons place the utmost limit of duration, beyond which it is imprndeni to go, at twelve minutes. " Apres cinq, huit, dix, ou tout au plus douze minutes, il convient de terminer la seance," says Velpeau. Other operators since then have greatly increased the duration of the operation. I have man^' times manipulated the lithotrite for an hour, anei Bigelow in this country, and many operators in Europe, have advocated much more pro longed sittings, but, as I shall have occasion to point out, the risk to the patient is not diminished thereby. Eapid Litiiotrity. — It was, as it were, but a swing of the pendulum be tween permitting, in all cases, the fragments of a calculus to find their waj EAPID LITHOTRITY. 319 out of the bladder, without injection and without aspiration, and allowing no portion of a calculus to remain after fragmentation without being washed out through the urethra, or drawn out through a canula. If error there were in the former practice, the error was in its universal adoption. And the error into which many have recently fallen, of washing awa}' the fragments in every instance, is an error fraught with no less mis- chief. It is but a few years since the greatest surgeons were content with ^' crushing the stone, and waiting for the gradual and spontaneous egress of the fragments." Some,^like Eergusson, had tried single and double injections and currents of water, but with so little satisfaction that " forcible disintegra- tion and chance were finally trusted to," chance generally bringing away in due season the fragments which had beeu broken off, after they had lodged perhaps for a time in the prostatic or membranous portion of the urethra, or at the meatus. It is less than twenty-five years since it was generally con- sidered unwise to touch fragments of stone in the bladder, or to attempt to bring them away. In speaking of injection as a preliminary to crushing, I gave among the reasons for its non-employment, the irritation set up in the bladder which it was not in the power of an antesthetic completely to mask ; the same objection would obtain, in a considerable proportion of cases, to the use of injection as a sequel to crushing. Professor Andrews uses "warm carbolized ■water during the whole operation of litholapaxy, both to distend the bladder during the crushing, and to wash out the fragments afterwards ;" but, grant- ing that " carbolized water acts as a decided local ansesthetic, benumbing the nervous activity of the bladder and lessening the shock of prolonged opera- tions ;" granting that " it checks bleeding, and leaves the viscus in a thoroughly antiseptic condition, preventing the formation and putrefaction of pus, and acting as a very powerful local antiphlogistic"^ — granting all this, and it is granting much — the wisdom of its use in mechanically distending the bladder as a preliminary to, or during the operation of, crushing, may fairly be doubted. The addition of carbolic acid to water cannot diminish — and it is not pretended that it increases — the undesirable mechanical action of warm water forced into the bladder through the urethra, though in the cystitis which accompanies the presence of stone, and which may continue after its withdrawal, the injection of a warm one-pcr-cent. solution of carbolic acid may be, as Mr. Batterham says, "most efficacious in allaying pain." The aim of every operator, from the time of Civiale to the present has been, however, to diminish the inconveniences arising from the passage of these fragments. The fragments produced by the earlier instruments were not as large, indeed, nor as angular, as those produced by later instruments. The earlier lithotrites did not break the stone into pieces, but scraped its surfaces and gradually reduced it to powder or to small gravel, and the quantity broken down at each sitting was not as large as that obtained now. Yet fragments of considerable size could sometimes be detached. Acci- dents which occurred from time to time from their being lodged in some part of the urethral canal, led Leroy d'Etiolles to recommend an evacuating canula, and Heurteloup to introduce an instrument which has since, in the modification of Sir Henry Thompson, nearly reached perfection as a means of retaining the fragments within the female blade and permitting their extrac- tion in this way. But this latter instrument is used on the assumption that the urethra is less susceptible of mischief from the introduction and with- drawal of a metallic instrument, than is the bladder from the presence of frag- ments. Civiale desired the detention of the latter within the bladder till their angles were rounded oft", and Heurteloup advised the maintenance of 320 LITHOTRITY. the recumbent posture to retard their departure. This practice has since, till comparatively recently, been very generally observed. For washing out the bladder, it is necessary that tepid water should reacli the organ in sufficient volume to bring back with it in its refluence the debris- of the calculus. It is necessary, therefore, that it should reach the bladder with a certain degree of rapidity, and with a certain amount of force. And here- precisely is where the difficulty appears to occur : an elastic bag in the grasp of an assistant's hand at one end of an unyielding tube ; and a bladder more- or less diseased — with ureters perhaps unhealthy,, and kidneys more or less changed in structure — at the other. Every pressure of the hand on the rubber bag is felt at every portion of the bladder, and through the constricted orifices of the ureter, the pelvis of the kidney, and even through its tubuli uriuifepi at the cortical walls. I confess that in the performance of rapid litho- trity, my chief anxiety formerly began with the injections ; not that the- integrity of the passive, good-natured bladder was to be feared, but rather that of the delicate structures beyond, whose office it was to separate from the circulating fluid the peccant urea which it contained. For, however correctly we may estimate the propelling force at one end, we cannot so easily estimate- the resisting power at the other. Sometimes the bladder commences its- expulsive efforts at the first entrance of the fluid, and it is not easy to distin- guish between the normal resistance offered by a healthy bladder when full^ and the spasmodic efforts of an irritable one to prevent its becoming full. The bladder may, without much disturbance of its functions, suffer a certain degree of gradual distention from within ; but distention fi'om without by a fluid which, however bland, is foreign to it, is not equally free from mischief. I have always observed, when patients have been under the influence of chloro- form, and have generally been assured by those who were not under the influ- ence of an anaesthetic, that their sufferings began with the injection of water, and not when the lithotrite was doing its work of disintegration and before any effort was made to urinate. Still, as the advantages of getting rid of a. calculus are so great, and as there are but two methods of effecting this rapid delivery, that by washing out the bladder will continue to be the favorite in the greater number of cases. But great gentleness in manipulation and light- ness in pressure, with due recognition of the resistance which the bladder offers to the distending liquid, must be cultivated. As the accoucheur can perceive uterine contractions before the patient herself, so likewise can the surgeon recognize the efforts of the bladder to expel its contents before the patient is aware of them. But rapid lithotrity, in the days when it was first recommended, was not what is meant by that term to-day. Rapid lithotrity meant operating as- long and as often as it was believed that the bladder would tolerate the pre- sence of a solid instrument within it, without in any manner jeopardizing- its integrity. Rapid lithotrity meant crushing a stone, waiting for the blad- der to recover itself (a period usually thought to be not less than three or four days), and then searching for the fragments and dealing with them as in the first instance ; and that lithotrity was most rapid in which the shortest interval existed between the sittings. Cautious men allowed intervals of ten or fifteen days, and limited each sitting to four or five minutes. Rapid lithotrity to-day, however, means something far more rapid and far-reaching in its operation, and far more satisfactory in its results. Rapid litho- trity often means the removal of a calculus at a single sitting ; a most desirable result, certainly, but one which must sometimes be purchased at the expense of much unnecessary inconvenience and suffering. Rapid litho- trity, conducted with care and prudence, and with due regard to the patient's general and local condition, is a most satisfactory procedure ; but rapid litho- RAPID LITHOTRITY. 321 trity, when it means the invariable completion of the operation at a single sitting, may mean suffering, disaster, and death. Long sittings are not invariably vs^ell borne, and are, therefore, not invariably wise. It must not be imagined that, because the patient is anaesthetized, no inconvenience will result from prolonged manipulation. The same intolerance of instruments may exist when the patient is asleep as when he is awake, though he may be unable to give any outward manifestation of that intolerance. To generalize the application of long sittings, thei-efore, is a grave error, and success is more likely to attend the practice of those who correctly appreciate the degree of irritability proper to the individual bladder, and proportion the length and duration, and the force, of their manipulations, with due regard to the balance of all the parts entering into the formation of the urinary apparatus, than of those who regard only the size and hardness of a calculus, and t^e cubic capacity of the viscus which contains it. ISTot alone has the bladder to be considered : to my mind the condition of the urethra is of still greater moment; not alone its calibre, but its individuality, so to speak; and more than these, the kidneys — those organs which are so often at fault in calculous subjects, and which, unluckily for the operator and for the patient also, may be diseased without giving rise to any appreciable abnormal condition of the urine. The first break in my last series of thirty-five successful cases of lithotrity occurred in this way. One of the most marked modifications of this operation, which more than any other, perhaps, has undergone important changes since the days of Civiale, who, less than sixty years ago, first introduced it to notice, is the getting rid, without cutting, of a stone even of considerable size at a single sitting. This important modification is due in principal measure toDr. Bigelow, of Boston, who advocates crushing the stone, and washing out all the debris, at a single ~ sitting. It will not take from the great credit due to Professor Bigelow, for it to be said that the recommendation to wash out the bladder did not originate with him. More than twelve years ago. Dr. L. Aug. Mercier, in a little book entitled " Traitement preservatif et curatif des sediments, de la gravelle, de la pierre urinaire, et de di verses maladies dependant de la diathese urique," recommended washing out the bladder, and gave a cut of an instru- ment made for him for the purpose some years before by Charriere, of Paris, and which was not unlike the first India-rubber bag employed in this country. Mercier's method was not generally adopted, however, and it was usual till quite recently to trust to chance for the passage of the friiigments. It was only when chance did not suffice that return was again had to the lithotrite, and to large-sized, large-eyed catheters, or to the use of a small scoop. But the instrument now used by Bigelow so far surpasses Mercier's, that it may be said to be a new one ; and the knowledge acquired, chiefiy through the observations of American surgeons, of the greater calibre of the male urethra and of its greater tolerance of large-sized metallic instruments than was formally believed, has changed the views of lithotritists as to the best means of .dealing with the fragments of a calculus. Judging from the im- provements which are constantly being made in it, Bigelow's instrument may not yet have reached its highest point of perfection ; but in its latest form^ it closely approaches it. There remain to be said a few words on the method of using it ; the work of crushing being ended, a canula of the full size of the urethra is introduced, when, warm water bein^ in readiness and the canula being attached to the pumping apparatus, the slightest pressure of the fingers and thumb on the rubber ball — a force not more than sufiicient to dimple its walls — sufiices to 1 See Fig. 1232, page 238, supra. VOL. VI. — 21 322 LITHOTRITY. agitate the fragments of the calculus and bring them within the large eye of the tube. The appreciation by Dr. Bigelow of the very gentle pressure which suffices to put in motion fragments differing but little in specific gravity from the fluid in which they were originally formed, entitles him to the gratitude of every suiferer from vesical calculus who desires to be rid of it with the least possible delay, and with the least possible pain. LiTHOTKiTY IN THE Female. — We are not often called upon to operate for stone in the bladder in the female. The anatomy of the female urinary appa- ratus favors the early escape of calculi through the urethra, and before they have attained a size to require the surgeon's assistance. But in those exceptional cases in which the calculus remains within the bladder, it must be extremely rare for any other operation than crushing to be called for. If neither stricture nor enlarged prostate is an insuperable obstacle to crushing in the male, how much more favorable is the female urethra for the manipulation of crushing instruments ? Its shortness and its large normal calibre, suscep- tible of considerable inci-ease b}^ the use of the lithotrite, render extraction of stone by incision into the bladder, either through its neck or through the vesico-vaginal septum, rarely necessary ; and still more rarely is the more formidable supra-pubic operation called for, except in cases of immensely large and hard calculi. ■ LiTHOTMTY IN CHILDREN. — Eor a long time it was felt that in children, at least, lithotomy would continue to hold its place, the operation on them being usually considered an easy and a safe one. I3ut, however safe the opera- tion may usually be considered, and however easy of performance, we some- times meet with unexpected difficulty and delay in its performance, and with disappointment in its results. The most accomplished surgeons have failed to reach the bladder, the left index finger going deeply into the perineum and pushing the prostate and neck of the bladder before it, and have well nigh abandoned the operation under the impression there was no stone, when in reality the bladder had not been opened. Two cases of this kind have come under my notice: in both long gropings occurred, and in one the prostate and neck of the bladder were pushed before the finger, leading to a suspicion of faulty diagnosis. Fortunately the operators did not trust too implicitly to the finger. This risk is mentioned merely incidentally, to show that lithotomy in children is not always completely free from difficulty. In the mean time tlie sphere of lithotrity has within the past few years been greatly extended, and it is possible that hereafter it may be found preferable in selected cases even in children. INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. BY REGINALD HARRISON, F.R.C.S., LECTUREU ON CLINICAL SUEGEEY IN THE VICTORIA CNIVERSITT, SURGEON TO THE ROYAL INFIRMAET, LIVERPOOL. Wounds of the Bladder. The bladder may be rendered physically incapable of retaining urine, by reason of penetrating wounds from without, or laceration of its walls from within the pelvis by fractured bones, or by rupture resulting from sudden compression exercised over it when in a state of distension. These are the more usual causes of this lesion ; instances, however, are on record in which it seems to have followed the use of catheters and such like instruments in the male, and of midwifery forceps in the female. Wounds of the bladder are ■classified as incised, punctured, lacerated, and gunshot wounds. Incised Wounds. — Owing to the manner in which it is protected by the pelvis, incised wounds of the bladder are of rare occurrence; the late American war failed to furnish an illustration of either this or the following variety. These wounds are generally the result of stabbing ; occasionally they are inflicted suicidally ; and cases are recorded in which they were made by the patient himself for the purpose of relieving urgent retention.^ Sometimes these wounds take very remarkable directions. A case of Mr. Couper's is recorded, in which a sailor's knife, entering at the left buttock, was found to have opened the bladder. Post-mortem examination showed that the weapon, penetrating the gluteal muscles, had cut through a part of the great sacro- sciatic ligament, completely divided the pudic artery and nerve, and one vein, and, opening the bladder at its lower part close to the trigone, had made a wound large ■enough to admit the tip of the forefinger. The case further illustrates a frequent result of this injury, viz., diffuse inflammation of the cellular tissue of the pelvis, with acute peritonitis.^ Where wounds of the bladder have also penetrated the peritoneal, cavity, a fatal result has almost invariably followed. The bladder has been uninten- tionally opened by the knife of the surgeon in the removal of tumors involv- ing the pelvic cavity. The late Dr. Marion Sims recently referred to this accident and its treatment in the following passage : — ^ The bladder has beek wounded in ovariotomy and in extirpation of uterine fibroids. This accident happened once in the hands of the great ovariotomist, Washington Atlee ; also in the practice of an eminent surgeon in New York ; and it occurred to me in the ' Lancet, Sept. 4, 1880. " Medical Times and Gazette, June 14, 1879. » British Medical Journal, Deo. 17, 1881. ( 323 ) 324 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. removal of an enormous uterine fibroma. The bladder was cut across for several inches, as it was extensively spread out over the anterior face of the tumor. The wound of th& viscus was closed with fine silver wire. The patient died a few hours afterwards of shock and hemorrhage. Dr. Thomas reports a case where he found the bladder closely- attached to the anterior face of an ovarian tumor. There was some doubt about it, and he cut into the bladder, passed his finger in to clear up the diagnosis, and then closed the incision by suture ; the patient quickly recovered. Punctured wounds are by no means common. They are generally caused by falls from a height, the patient being impaled on stakes, spikes, or other sharp projections. These injuries are usually accompanied by a considerable amount of laceration, which frequently involves the rectum and neighboring structures. "When recovery follows, a fistulous opening is often left. Punc- tured wounds of the bladder are sometimes made by the surgeon with an aspirator-needle or a trocar, for the relief of retention of urine, advantage- being taken of the anatomical disposition of the parts to open the viscus- without wounding the peritoneum. Consequently this operation is almost invariably practised with impunity, its results thus contrasting with those- which usually follow accidental wounds of the organ. Lacbrateu wounds, like those of the last variety, are very fatal. When the peritoneum is involved, they are always most serious; other parts in thfr neighborhood are often injured: and, if recovery takes place, some permanent inconvenience, such as a fistula, is almost unavoidable. The possibility of a wound of the bladder being complicated with fracture must not be lost sight of; and in making explorations with the finger, care should be taken to remove any fragment of bone which may be separated, or is at all likely to- become neci'osed. Instances are on record where pieces of bone have made their way into the bladder, either by penetration at the time of injury, or subsequently by exfoliation and ulceration, and have formed the nuclei of vesical calculi. Dr. Banister' has recentlj'^ published an account of a patient in whom two vesical calculi, formed on nuclei of bone, resulted from a gun- shot wound of the pelvis. The possibility of the bladder being wounded must always be remembered where fracture of the pelvis exists ; for in this way it has been both punctured and lacerated with fatal results. Hence, it has become a rule in all cases of injury to the pelvis, when the violence has been considerable, for the surgeon to make a careful examination of the bladder with the catheter, for the purpose of ascertaining this point. Gunshot wounds are, for the most part, met with in military practice, although examples of them are not wanting in civil life. The damage that is thus occasioned, not only to the bladder but to adjacent parts, is often very extensive, and it seems remarkable that recovery should be as frequent as statistics show it to be. In 131 cases of gunshot wound of the bladder, complicated with fracture of one or other of the adjacent bones, collected by Dr. i?artels^ and quoted by Coulson,^ there were only 38 deaths ; from which we may infer, that these wounds by their extent aftbrd a facility for the escape of Urine and pus, which is favorable to recovery, a deduction rendered still more pi'obable b}'^ the figures showing double wounds of the bladder to be somewhat less dangei'ous than single ones. Military experience furnishes many examples in Avhich the bladder and rectum having been shot through, recovery has followed — a result which has been generally attributed ' American Journal of the Medical Sciences, January, 1882. * Archiv- fur klin. Chir., Bd. xxii. ^ On Diseases of the Bladder and Prostate, 6tli ed., p. 86. WOUNDS OF TUB BLADDER. 325 by the various observers to the thorough drainage which has thus become a necessary part of the management of these cases. All recorded observations indicate that there is, in this class of injuries, considerable danger of extra- vasation of urine occurring about the third or fourth day, when the sloughs are beginning to separate. Immediately following upon this w-e may have peritonitis, cellulitis, or septicaemia, which are frequent causes of death. Bullets and missiles lodged in the neighborhood of the bladder, have been known to make their way into it by ulceration, and military practice aflbrds numerous examples in which urinary calculi have formed on such nuclei as bullets, pieces of shells, arrowheads, and other miscellaneous objects which entered in this manner. A wound of the bladder is generally indicated bj' the escape of urine, more or less bloody, through the laceration, or by the urethra. The position ^nd direction of the opening may assist in the diagnosis. Pain along the course of the urethra, ineffectual attempts to urinate, vesical tenesmus, imperfect priapism, and shock, are other symptoms which are more or less prominent. In the treatment of wounds of the bladder, regard must be had mainly to those circumstances which usually bring about a fatal termination : these -are urinary extravasation and peritonitis, j^o method of treating a wound of the bladder can be regarded as efficient which does not provide for the free escape of the urine, as fast as it is secreted. Where the wound opens into the peritoneal cavity, acute inflammation rapidly supervenes, and it ■often happens that peritonitis is far advanced before the practitioner has the ■opportunity of doing anything to avert it. Where there is reason to believe that urine is thus finding its way into the abdominal cavity, the position of the patient is one fraught with the greatest danger. Under the circum- stances it becomes a grave consideration whether we should content ourselves with such drainage from the bladder as a catheter would aftbrd, or whether, by a perineal incision, we should not provide an escape for the urine, at least as free as that by which it is finding its way into the jaeritoneal cavity. The •cases recorded by Dr. Walker^ and Dr. Erskine Mason^ favor the adoption of the latter proceeding. In both instances there was rupture of the bladder, Tvith peritonitis. In both lateral cystotomy was performed, and both ended in perfect recovery. This is a practice worthy of imitation. I shall presently refer to the circumstances under which it might be deemed desirable to attempt to close an opening in the walls of the bladder, to prevent urine finding its way into the peritoneum. Extravasation of urine msiy occur either immediately after the injury, or secondarily, as we have noticed in gunshot injuries, about the time that the sloughs separate. In either instance, but more particularly in the latter, it is to be regarded as a most dangerous complication requiring bold and de- cisive action. In all cases of wound of the bladder, as long as urine escapes freely, either by the urethra or through the external wound, no anxiety need be entertained on this point. Should, however, the patient have a feel- ing of chilliness, or a rigor, with sudden diminution or cessation of the flow of urine, and perhaps redness and brawniness of some part of the skin adja- cent to the wound, there will be much ground for apprehension. A catheter should be at once introduced, either through the wound or along the urethra, by whichever means a flow of urine may be best secured and maintained. Should there be any external indication of extravasated urine, free incisions ' Med. Commnnications of the Mass. Med. Society, vol. vii. ' New York Med. Journal, vol. xvi. 1872. 326 INJURIES AND DISEASES OP THE BLADDER AND PROSTATE. must be made wherever there is tension, in accordance with the rules of surgery relating to this point. When the extravasation is secondary, it is unfortunately most frequently found taking place where it cannot be seen,, into the cellular tissue around the neck of the bladder, giving rise to a very fatal form of pelvic cellulitis. In any case of wound or contusion in the- neighborhood of the bladder, should there arise grounds for believing that urinary extravasation into the deeper tissues of the pelvis is going on, a most careful exploration by the finger, not only of the wound but also of the- rectum, should be made, and if any indication, such as tension or fluctuation, be discovered, the surgeon should not hesitate to make an incision. Even in the absence of evidence as to the direction urine may be taking, when signs- of its extravasation are present at or about the usual time of separation of the sloughs — when it is not infrequent — I do not think that the question of performing perineal cystotomy for the purpose of providing drainage should be set aside. In Dr. Erskine Mason's case, this measure was not adopted till sixty -two hours after the bladder had been ruptured. If no exit for urine is fur- nished, if it be allowed to collect within the pelvis or become diifused among- the tissues, a fatal result is unavoidable. Such a consideration, therefore, determines the expediency of opening the bladder when there are no other means of reaching the point from which the extravasation is proceeding- Pelvic cellulitis occurring under these circumstances, is much more likely on anatomical grounds to extend rapidlj' backward than to come forward. Hence it is important to recognize its earliest possible manifestations, and to- meet them without delay. In gunshot or other wounds in the neighborhood of the bladder, resulting- from explosions, careful exploration of the wound must be made with th& view of detecting, and if practicable removing, any foreign body which may be lodged within the viscus. The examination of the bladder with the- catheter is a proceeding which should not be omitted under such circumstances.. In many of the cases in which missiles, incrusted with phosphates, have been extracted by lithotomy, it is probable that in the first instance these were lodged in the vicinity of the bladder, into which they subsequently made; their way by ulceration. Rupture of the Bladder. This injury is most frequently caused by the application of violence over the region of the bladder when the latter is in a more or less distended condition. iN^umerous instances are recorded in which the damage has been done in drunken quarrels by blows or kicks, or when in wrestling one man tumbles heavily, falling with his knee on the abdomen of his yielding or perhaps prostrate antagonist. The extreme frequency with which this acci- dent is associated with drunkenness has led to alcoholic influence being included amongst its predisposing causes. Mr. Rivington, in a recent article on this subject,' speaks of intra-peritoneal rupture as one of the penalties of drink, and adds to his own testimony that of M. Houel,^ in the following quotation: "Alcohol has a double influence in predisposing to this injury, for it causes an increased and rapid secretion of urine, and quick distension of the bladder ; it also deadens the sensitiveness of its mucous membrane, and the call to micturate is so feeble that it is disregarded by the drunkard, and the distension is allowed to increase." The bladder has been ruptured, when distended, by violent muscular action, • Lancet, June 3, 1882. ' Des Plaies et des Raptures de la Vessie. Paris, 1S57. RUPTURE OF THE BLADDER. 327 9 the explanation being suggested, that in these instances the coats of the bladder have undergone some change by which their power of resistance has been sensibly diminished. I have recorded a case' in which there were good grounds for believing that the injury was caused in this way : — The patient, a young man, had been suffering from retention of urine for some days. When admitted into the Liverpool Infirmary, he was in a state of collapse from which he never rallied. A catheter was introduced into his bladder immediately after his admission, but only a few drops of blood-stained fluid escaped. At the post- mortem examination, a rupture was found in the posterior wall of the bladder, com- municating with the peritoneal cavity. The edges of the opening were covered by lymph, and the rent measured, when not stretched, an inch and a half in length. There were also signs of peritonitis. Though from the history of the patient there was no doubt that he had suffered from prolonged retention, no sensible diminution of the dimensions of the urethra could be discovered. Dr. Gouley^ records a case in which rupture of the fundus of the bladder occurred during etherization in a patient suffering from extreme retention of urine, consequent on a complete rupture of the urethra at the bulbo-meni- branous junction. He says that whilst the anaesthetic was being given the patient became greatly excited, and that during one of his struggling fits the abdominal tumor suddenly disappeared, and the former area of dulness became tympanitic. Dr. T. K. Cruse^ also furnishes particulars of six cases illustrative of muscular action as effecting this lesion. It must be remembered that this injury may be occasioned by external violence' without its being indicated by any corresponding mark or abrasion, and further, that it may be complicated as well as caused by fracture of the protecting bone. I have known it happen where the pelvis had been broken by a horse falling on his jockey, whilst steeplechasiog. These points are not unimportant to recollect, especially under circumstances involving medico- legal inquiries. Men are far more liable to this injury than women. The comparative immunity of the female is explained by Dr. Harrison* as being mainly due to certain anatomical peculiarities, having regard to the greater size of the female pelvis and the direction of the bladder. Possibly the shortness and distensibilitj' of the urethra in the female, by permitting a rapid emptying of the bladder on the sudden application of compression — a sort of safety-valve action — has more to do in explaining the rarity of the injury in women than has hitherto been conceded. A reference to any large number of collected cases of rupture of the bladder, seems to indicate that> the lesion oftenest occurs in that part of the vesical wall which is least able, by reason of its structural relations, to adapt itself by yielding on the appli- cation of any sudden compressing force. Hence the frequency with which the tear is found at the junction of the posterior wall and the fundus. It is important to notice the kind of wound which is usually met with when a more or less distended bladder gives way under the effect of violence suddenly applied to it. When an examination has been made in cases proving almost immediately fatal, it has been found that the wound has been of the nature of a fissure, varying in extent and direction. In one case which I examined, the opening, though complete, looked like a crack half an inch in length, whilst others have been found nearly two inches long. In the character of these w.ounds I have never seen anything which would lead me to believe that repair would not be probable on accurate coaptation of their ' Lectures on the Surgical Disorders of the Urinary Organs, 2d ed., p. 39. " Diseases of the Urinary Organs, p. 245. ' Medical Record, Aug. 1, 1871. ' Dublin Journal of Medical Soienpe, vol. ix. 328 INJUEIES AND DISEASES OF THE BLADDER AND PROSTATE. *des with sutures, provided that other circumstances were favorable. "When examined after the lapse of some hours from the infliction of the injury, these wounds present varying indications of the acute inflammatory mischief in which they so soon become involved. This was well illustrated by the case to which I have already referred. The symptoms of rupture of the bladder are, in addition to the local signs, those which usually indicate laceration of any other important internal organ. Cases however are occasionally met with in which urgent symptoms remain in abeyance for some time. Mr. Holmes' records one terminating fatally, where a man walked to St. George's Hospital complaining of a blow received in the hypogastric region thirty-six hours previously, but exhibit- ing no distress of any kind ; post-mortem examination showed the existence of an extensive laceration of the bladder. Somewhat similar instances will be found elsewhere narrated.^ The following passage, from Gross,^ referring to seven t}- -eight case? analyzed by Dr. Stephen Smith, bears upon the point now under notice : — The primaiy symptoms are stated to have been severe in fifty-nine of the cases, and it is worthy of note that in forty-three of these the rupture extended into the peritoneal cavity. In nine cases, in seven of which the peritoneum was affected, the symptoms were slight, and in three they were entirely absent. In twenty-eight instances there was from the beginning inability to urinate ; in three, on the contrary, the bladder retained its expulsive power. Bloody urine was drawn off in twenty-five cases and clear urine in four. In seven of the cases the patients were able to walk after the occurrence of the injury. Seven of the patients felt a sensation at the moment of the accident as of the bladder bursting. In nearly all there was an absence of evidence of external violence. The indications of ruptured bladder may be generally stated as pain over the region of the organ, inability to urinate, and more or less collapse followed by signs, local and general, of inflammation. Symptoms such as these, taken in conjunction with the history of the patient, would naturally lead to an examination of the bladder with the catheter. On the intro- duction of the instrument the bladder may be found absolutely empty, the viscus being felt so firndy contracted on the point of the catheter, as almost to suggest that it had failed to reach it ; or a few drachms of blood-stained urine may escape. In some instances the catheter has found its way through the wound, and has thus entered the cavity of the abdomen, from which urine more or less blood-stained has been removed. These injuries are exceedingly fatal ; out of the seventy-eight eases ana- lyzed by Dr. Stephen Smith,^ in 1851, there were only five recoveries. The consideration of figures such as these indicates that in this particular direc- tion abdominal surgery, which during recent years has made such rapid strides, has yet much to accomplish. The treatment of ruptured bladder riiust have special reference to the two va- rieties of this lesion — (1) where the cavity of the peritoneum is opened, and (2) the extra-peritoneal form, where the rupture is in that part of the blad- der which is outside the line of reflection of its peritoneal investment. The difference is essentially this: in the former case, the urine and blood pass directl}- into the abdominal cavity, whilst in the latter they infiltrate the tis- sues around the bladder, and produce consequences in every respect similar to those observed in urinary infiltration of parts which are more superficial, and * Principles and Practice of Surgery, p. 223, note. « Med. Times and Gazette, Sept. 28, 1872. 3 Practical Treatise on the Diseases, Injuries, and Malformations of the Urinarv Bladder, etc., p. 322. ^ * New York Journal of Medicine, N. S., vol. vi. RUPTURE OF THE BLADDER. 329 Avhere its effects can be seen. With the view of narrowing the principles of treatment, it is important carefully to analyze these two conditions. (1) Where the rupture has extended into the peritoneal cavity, I cannot find -any evidence to warrant the belief that life has ever been saved without the intervention of surgery. In the few instances in which recovery has taken place, it has been directly traceable to the aid which nature has received from the surgeon's hand. It will be desirable to ascertain under what circumstances a favorable issue has thus been brought about. There is sufficient evidence to conclude that ■catheterization alone has in some instances been effectual. The cases recorded by Mr. Chaldicott' and Di\ Thorp^ illustrate this. For in these there can be no doubt that large quantities of urine were drawn off from the peritoneal •cavity, which, if allowed to remain, would, it is reasonable to suppose, have induced fatal consequences. Dr. Macdougall^also records two cases of recov- ery after rupture of the bladder where catheterization afforded important aid in bringing about recovery. The view taken that the use of the catheter has, in these and other instances, determined the satisfactory result, is strength- ■ened by what has been observed in cases which have terminated fatally. There are reasons for believing that the peritoneum is more tolerant of the presence of healthy urine than we might at first sight be inclined to suppose. In fact we may go further, and say that in these cases the fatal peritonitis set up, is due, not as much to the entrance of healthy urine within the cavity of an uninjured peritoneum, as to the decomposition of the urine which follows its •confinement by, or even contact with, tissues more or less disintegrated by violence. jVIenzel's^ experiments are confirmatory of this view, as they de- Tnonstrate that healthy urine does not, of itself, necessarily cause destruction, and that its eftects on the tissues are harmless as long as an escape is pro- vided for it. Subcutaneous injections of fresh healthy urine, made experi- mentally by Keyes,' in man, were followed by no irritation whatever. It is when urine becomes retained, and decomposes, that it manifests its destruc- tive powers upon the tissues with which it is in contact. If no extensive •damage be done to the abdominal parietes, if the urine which finds its way into the cavity of the peritoneum be not largely contaminated with blood or other readily putrefiable matter.and if escape, as by catheterization, be [irovided for urine so effused, peritonitis need not necessarily be provoked. In Dr. Thorp's case, to which reference has been made, in addition to catheteriza- tion, washing out of the peritoneum with tepid water, through the catheter, was employed. In the majority of cases of intra-peritoneal rupture of the bladder, one or other or all of these conditions necessary to recovery are usu- ally absent. The effused urine, often largely mixed with blood, comes in contact with bruised and lacerated tissues, and, unprovided with any way of ■escape, decomposes and gives rise to that rapid and destructive inflammation, probably septicsemic in its nature, which, in spite of all treatment, brings about a fatal termination in the course of a few daj-s. Again, as already mentioned, cases of rupture of the bladder have been suc- cessfully treated by cystotomy, and, since these injuries are obviously hopeless if left to themselves, it has been further proposed to perform abdominal section for the purpose of allowing the opening in the bladder to be closed with sutures. Mr. Heath* and Mr. Willett' record cases in which this was done,' and though the results were in neither instance successful, this might have ' Provincial Med. and Surg. Journal, 1846. ^ Dublin Quarterly Jour, of Med. Sci., 1868. ^ Edinburgh Medical Journal, Jan. 1877. ' Wiener med. Wochensohrift, Nos. 81-85, 1869. * Van Buren and Keyes, Diseases of the Genito-Urinary Organs, p. 144. New York, 1874. ' Med.-Chir. Transactions, vol. Ixii. ' St. Bartholomew's Hospital Reports, vol. xii. 330 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. been due to the giving way of the sutures which at the post-mortem examina- tion was found to have taken place. In no class of cases have more brilliant results been obtained than in those involving the opening and exploration of the abdominal cavitj-, and the manipulation of the organs contained in it ; and it is reasonable to infer that ruptures of the bladder, now almost always fatal, will some day be brought within the range of this procedure. Fischer, of Buda-Pesth,' from a series of experiments on dogs, draws the conclusion that, in wounds of the bladder, success depends almost entirely on the accuracy with which the sutures are jDlaced. He used for this purpose catgut and antiseptic silk, and anticipates a greater success in man by reason of the possibility of retaining a catheter in the bladder. Dr. E. Vincent/ of Lyons, in a paper on laparotomy and intra-peritoneal cystorraj)hy in dogs and rabbits, draws equally hopeful conclusions with regard to wounds of the human bladder. Ilis method of procedure consisted in opening the abdomen and the blad- der ; sometimes portions of the wall of the latter were removed. By then temporarily closing the parietal wound, only urine was allowed to remain in contact with the viscera. Subsequently the abdomen was reopened and cleansed, after which the wound in the bladder was carefully closed and the parietal opening again adjusted with sutures. Recover^' took place, in rab- bits, in cases where the peritoneum had been exposed to the action of the urine- for as long as forty-eight hours. (2) In the second variety of cases the bladder is ruptured outside the line of its peritoneal investmeyit. Recovery may occur in spite of the severe nature of the lesion, provided that free vent be given to any urine which is extravasated. The following case may be regarded as tyjaical of this kind of rupture, and illustrates the main principle in treatment upon which it is necessary to lay stress : — ■ A middle-aged man came under my care, in 1866, for injuries about the pelvis caused' by a fall of earth in some dock excavations. There was a fracture of the right ilium^ with considerable bruising of the adjacent parts. On passing a catheter, the bladder appeared to be contracted on the end of the instrument, and only a few drachms of blood- stained fluid escaped. The patient remained in a state of collapse all the day of hi& admission into hospital, and in the evening I found that no urine had escaped by the catheter, which had been retained. The perineum externally was somewhat tumid, but not discolored. On passing a finger into the rectum, a fulness could be felt in front of the bowel, which rendered the line of the prostate quite undistinguishable. Under these circumstances it was thought best to make a perineal incision in the median line, in the direction of the neck of the bladder. This was done, and resulted in the dis- charge of blood-clots mixed with urine. On examining the wound with the fingers, the prostate was found separated from the underlying structures, and on its under surface could be felt a depression, which proved to be the end ofga laceration. Through this extensive incision blood-stained urine continued to flow during the six days that the patient lived. His other injuries added to this one proved too much for him, and he sank from exhaustion on the seventh day. At the post-mortem examination the pros- tate and neck of the bladder were found completely separated from the parts beneath, and there was a rent in the bladder, commencing an inch behind the prostate and ex- tending forwards through it. The wound did not communicate with the peritoneum, and there were no signs of peritonitis. In addition, there was a comminuted fracture of the right ilium, passing downwards within the brim of the pelvis. The practice adopted in this case would have probably saved the patient's life had there been no injuries beyond those of the bladder and prostate, as the incision provided a free and direct escape for urine. The reasons for concluding that the bladder was ruptured within reach of the finger, in addi- ' Trans. International Med.. Congress. London, 1881. 2 itid. FOREIGN BODIES IN THE BLADDER. 331 tion to the evidence aflbrded by the catheter and the nature of the injury,, were, the tumefaction of the perineum and fulness felt in front of the howel on introducing the finger into the rectum. This, taken in conjunction with the fact that no urine could be obtained by the catheter, justified the conclu- sion arrived at and the practice adopted. As already stated, this case brings into prominence that principle in treatment which is paramount in the general management of injuries of this kind. There is another part of the viscus which is also uncovered by peritoneum,, where we are in the habit of tapping it with impunity. I allude to that portion of it which is situated immediately above the pubis and below the anterior reflection of the serous membrane. Here also it may give way with- out permitting urine to escape into the abdominal cavity. A typical exam- ple of this class (the only one published to my knowledge) was recorded b_y the late Professor Syme.^ The course taken by the urine, and the treatment by incision which was successfully ad-opted, were in correspondence with th& analogous features in the case quoted from my own practice. It has been stated that laceration of the bladder may occur without extrava- sation of urine ensuing as a consequence. I do not see what positive evi- dence we can have of this : the nature of the injury, and possibly hsematuria, might suggest it. Should it be suspected in any case that a partial rupture had taken place, which, by some means or other, such, for instance, as the- presence of a clot in the wound, or the exudation of inflammatory material, had become occluded, I should not feel disposed either to pass a catheter, provided that there was no retention, or to retain one. Reliance might under these circumstances be placed on nature completing safely what sh& had begun so well, aiding her perhaps in keeping the parts quiet, as in the case of wounded intestine, by the administration of opium. Should it be necessary to use a catheter, a soft rubber one should be selected, as answering- every purpose, without exposing the patient to the risk of opening up a wound which might be healing by adhesion, or occluded by clot. In addition to those measures which have been urged as likely to avert peritoneal inflammation by directly dealing with the causes most frequently provoking it, prompt means must, on any signs of its occurrence, be taken to- limit its extent and diminish its severity. These consist in the use of sooth- ing applications to'the abdomen and the free administration of opium. I have found nothing to give greater relief to the feeling of tension about the parts which these patients generally complain of, than local depletion with leeches, followed by the application of a hot flaxseed poultice. These meas- ures must, however, be regarded as subsidiary to those having for their object the prevention of urine making its way into the peritoneal cavity, or becom- ing extravasated and retiined amid the cellular tissue in relation with the bladder. Foreign Bodies in the Bladder. A very miscellaneous collection might be made of various articles which by accident or design have found their way into the bladder. The records of surgery furnish instances of pins, needles, catheters, pencil-cases, tobacco- pipe stems, wires, feathers, shoe-strings, and grass-heads, being so located. "When a foreign body becomes lodged in the bladder, one of three things will most likely happen to it : if small, it may be spontaneously expelled during^ the act of micturition; if it remain, it may possibly form the nucleus of a stone, which will generally be phosphatic ; or by exercising pressure on the ' Contributions to the Pathology and Practice of Surgery, p. 332. Edinburgh, 1848. S32 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. wall of the bladder, it may cause ulceration, and finally escape into the cavity of the peritoneum, thus permitting urine to become extravasated and causing •death by the production of peritonitis in its most intense and fatal form. Any of these three events may happen, the probability of one or another iieing chiefly determined by the shape and bulk of the article. Symptoms.- — The presence of a foreign body in the bladder will be indicated hj symptoms similar to those met with in stone: these will be, vesical irrita- bility in varying degree ; pain, for the most part after micturition ; and pro- "bably alkalinity and ofFeusiveness of the urine. Exploration of the bladder with the sound will aflibrd indications of the presence of a foreign body, or of the calculous incrustation in which it is imbedded. Sections of stone removed by lithotomy not unfrequently show the original nucleus to have been some small extraneous body, such as a piece of bone, the head of a pin, or a portion of slate-pencil. "When a patient acquaints the practitioner with the precise nature of the accident which has happened to him, the former is j)repared to remove the foreign body by means of a suitable instrument; but it not unfre- ■quently happens, especially \\\t\i females, that deception is practised, and that no explanation of certain bladder symptoms is afforded until a thorough exam- ination is made with the sound. Even then, sometimes, the practitioner has to act on the presumption that the foreign body is a calculus. A ease is Tecorded by Dr. Robert Abbe' where he was proceeding to remove what he supposed to be a large calculus, after Bigelow's method, when the discovery "was made that the bladder contained a gum-elastic catheter encrusted with j)hosphates, which had slipped in six months previously. This was success- fully removed in two portions, by the lithotrite, and the patient made a good recovery. Treatment. — In the case of flexible bougies or portions thereof which have thus entered the bladder, their extraction may be effected with a smooth- bladed lithotrite. If not seized by their ends, gum elastic instruments are dso yielding that, excepting the larger sizes, they may be generally brought Fig. 1280. Meroier's instrument for removing elastic bougies from the bladder. away doubled up, by the exercise of a moderate amount of traction. This lias been frequently done with success. Or Mercier's instrument (Fig. 1280), -w-hich will permit of the removal of a larger-sized flexible catheter or bougie Ihan can be extracted by the lithotrite, may be used. 1 Medical Record, Deo. 24, 1881. FOREIGN BODIES IN THE BLADDER. 333- - In attempting the removal of inflexible cylindrical bodies from the bladder with the lithotrite, the ditHculty is due mainly to the fact that they are generally seized transversely to their long axis, so rendering extraction by this method impossible. To provide against this, MM. Robert and Collin have devised an extractor (Fig. 1281) having the blades so arranged that when a solid body of this Fig. 1281. Robert and Collin's instrument for removing foreign bodies from the bladder. kind is seized, its direction is made to correspond with that of the instru- ment as shown in the figure. In the absence of such an instrument, it must not be forgotten that much may be done to favor the possibility of extracting- an inelastic cylindrical body with the ordinary lithotrite, provided that this be systematically used with the object of arriving at one or other extremity. In this way I succeeded in withdrawing a pencil-case three and a half inches long, from the bladder of a patient who alleged that it had been passed down the urethra on the previous night, whilst he was in a state of intoxica- tion, by a woman of the town. He recovered without a bad symptom.' Lithotrity has been employed for the removal of foreign bodies together with the incrustations which have formed upon them. In selecting this method, regard must be had to the probability of the foreign body being of such a nature as to be removable in this way. I know of this procedure having to be abdandoned for lithotomy, in a case where the nucleus turned out to be a hair-pin, in which the blades of the lithoti'ite had become entangled. When there is no other alternative, lithotomy will be resorted to ; this operation has on many occasions, under these circumstances, been suc- cessfully practised. A case is recorded by Mr. J. W. Baker, of Derby, in which a piece of bougie remained in the bladder for five years, and was then removed, encrusted with phosphates, by lithotomy .^ The female bladder is also occasionally found to contain various foreign bodies ; of these the ortlinary hair-pin is perhaps the most common. On account of its two prongs and shape it is not always easy of extraction. In a case of this kind which I have recorded,^ there was some tumefaction to the left of the symphysis pubis as if an abscess was impending. It i& probable that the pin might have been expelled in this way had not its. removal been effected by surgical interfei'ence. As in cases of stone, ope?'a,- tions on the female bladder, where the urethra is incised, are apt to be fol- lowed by permanent incontinence of urine ; rapid dilatation of the canal should be employed in jjveference whenever it is practicable. In regard to the nature of the concretion found on foreign bodies in the bladder, it may be said that any substance other than the earthy phosphates^, is extremely rare. ' Op. cit, p. 185. 2 British Medical Journal, Deo. 5, 1874. 3 Op oit. p. 189. 334 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. It will be proper to mention here that a few cases are on record where most exceptional substances have found their way into the bladder. Ovarian and dermoid cysts have been known to empty themselves into it. A case is recorded by Sir Henry Thompson' in which some foetal remains were removed from this organ. Then again instances are occasionally met with where fecal matters and flatus have been discharged into the bladder, often occasioning much distress. For the most part these cases have been due to cancerous ulceration between the bladder and intestines, and can only be temporarily remedied by colotomy. For these symptoms alone, resort has frequently been had to this operation with the greatest relief to the patient. It is alleged that in addition to the modes mentioned, foreign bodies may find their way into the bladder from the intestines by ulceration. The following case is recorded by Mr. A. Eoberts, of the Sydney Hospital, New South Wales.^ The patient, aged 47, had swallowed a piece of slate-pencil two and a quarter inches long, which was subsequently successfully removed by lithotomy. ■Commenting on this case, the author says : " I have left no stone unturned to elucidate the truth in this very interesting case, and can only state that, after much hesitation, I have arrived at the conclusion that the pencil was swallowed by the mouth, and made its way by inflammation and ulceration into the bladder." As exemplifying a more probable mode by which a foreign body may enter the bladder, and form the nucleus of a stone, a case recorded by Mr. A. J. Gumming^ may be mentioned, in which the patient had been treated for vesical diseasQ. At the autopsy, the bladder was found to contain a large stone, the nucleus of which was a pin. The pin had evidently made its way from the appendix vermiformis into the bladder, and had left a fistulous commu- nication through which also worms had been enabled to crawl into the viscus. [A precisely similar case was recorded by Dr. Kingdon.'] Malformations and Malpositions of the Bladder. Of the various deformities which come under the notice of the surgeon, it will be generally admitted that, in the production of discomfort- and in the denial of the gratification of natural desires, none can compare with those which will now be brought under consideration. These malformations, for the most part, occur in male subjects, often well developed in other respects. Complete absence of a bladder, or of an independent receptacle for urine, is occasionally, though very rarely, met with. Under these circumstances the ureters open by the umbilicus, in the urethra or vagina, or into the rectuin. It is possible that this last-mentioned condition first suggested the expediency, in extroversion of the bladder, of endeavoring by operation to make the ureters discharge into the gut, and thus carry the urine into the rectum. "Where the bladder has been completely absent, I am not aware of attempts having been made, with any degree of success, to construct one ; nor can I, after a careful examination of the literature relating to the subject, suggest any surgical procedure which would be at all likely to ameliorate so unfor- tunate a condition. Dr. Oliver* records a case of absence of the bladder in a woman who died at the age of fifty-three. Throughout the whole of the illness which proved fatal to her, frequent micturition is reported as being one of her symptoms. At the post-mortem examina- tion, the ureters, only one of which was pervious, were found to open into the urethra, ' Lancet, Nov. 22, 1863. " Med. Times and Gazette, July 30, 1859. ' British Medical Journal, Oct. 22, 1881. * Trans. Provinc. Med. and Surg. Association, vol. x. p. 198. 6 Lancet, Deo. 6, 1879 MALFORMATIONS AND MALPOSITIONS OF THE BLADDER. 335 at about 1|- inches from the meatus. The pervious ureter was largely dilated, being described as like a coil of child's small intestine, contracted above at its connection with the kidney, and constricted below before joining the urethra. Dr. Oliver remarks, " a certain amount of natural or spasmodic contraction at this point would prevent a con- tinual dribbling away of urine, and thus allow more comfort to the patient." 1 refer to this case, and take it in conjunction with what is sometimes ob- served as a consequence of stricture or prostatic obstruction of long standing, where the ureters may almost be said to have become subsidiary bladders, as suggesting another direction in which something might be done to render less intolerable the condition of persons laboring under this deformity. Two-CAVITY BLADDERS, Or, morc corrcctly speaking, bladders with a septum, have been described. Other instances, in which a bladder has had subsidiary bladders connected with it, have also been referred to as varieties of malfor- mation. These, however, are for the most part the result of disease, and will receive consideration hereafter, when sacculation of the bladder is discussed. Under this heading I may mention a remarkable case of double bladder, which is recorded by Dr. A. P. Smith, of Baltimore.' The patient complained ■of irritation, in connection with micturition. On examining him it was discovered that he had a double penis, with bladders to correspond, and his symptoms were explained by the presence of a stone in one of the bladders, whilst the other was healthy. Lithotomy was successfully performed. Van Buren^ describes a similar deformity. Exstrophy or Extroversion of the Bladder. — I will now proceed to notice the commonest form of abnormalitj', extroversion of the bladder. Here not only does the bladder protrude, in appearance like a fungating mass, through the abdominal parietes, but its anterior wall, as well as the pubic symphysis, are both wanting. Below the bladder, in the male, a short penis usually projects, on the dorsum of which is a shallow gutter representing the uninclosed urethra. Erom the orifices of the ureters, which can be plainly seen at the lower part of the mucous surface, the urine constantly drips over the scrotum and adjacent parts, excoriating the skin, saturating the clothes of the unfortunate victim, and giving rise to a most unpleasant urinous smell. There are greater and lesser degrees of the deformity. The remaining parts of the generative apparatus — viz., the prostate, vesiculae seminales, and tes- ticles — ar'e usually present, but in a somewhat rudimentary condition. In such persons an inguinal hernia on one or both sides is commonly met with. Sexual desire is more or less present, with, of course, incapacity for its natural gratification. In some recorded cases this has greatly added to the misery of the patient, and has suggested the propriety of emasculation by removal of the testicles. In the female the nature of the deformity is analo- gous, but instances of it are much less frequently met with than in the male.' Treatment. — The operations which have been devised for the purpose of remedying this distressing condition may be divided into two classes : one, having for its object the diversion of the stream of urine into the lower bowel, so as to utilize the rectum as a common cloaca ; the other, or plastic method, in which the scrotal and abdominal integuments are used not only ' Transactions of the Medical and Chirurgical Faculty of the State of Maryland, April, 1878. 2 Op. cit. p. 5. ' In an Interesting account of the dissection of a specimen of this malformation, McWhinnie has referred to some Important physiological experiments which the nature of the deformity per- mitted ; amongst these may be mentioned, as appropriate to the subject-matter of this article, that asparagus was found to affect the odor of the urine in eight and a half minutes, and tur- pentine in four and a half minutes. (London Medical Gazette, March 1, 1850.) 3S6 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. for the purpose of covering in the protruding bladder, but further with the- view of providing some sort of receptacle for the urine. From a careful study of the results which have accrued from the practice of both these- methods, it seems probable that most relief will eventually be obtained by their combination. One or other can only be regarded as a partial proceed- ing, for in the former no provision is made for the covering and protection of the mucous membrane, whilst in the latter, however perfectly integument from neighboring parts may be arranged so as to complete a receptacje for the urine, still in the absence of any valvular or muscular arrangement by means of which the contents may be retained or expelled at will, a state of incontinence must remain, which is only imperfectly provided for by artificial contrivances. It will be proper now to consider more in detail what may be regarded aa the typical procedures in each of the two classes, which represent the opera- tive means at present at our disposal for remedying the various degrees of extroversion. The only instance I know of in which the attempt to divert the urine into the rectum was to any extent sutcessful, is one recorded by Mr. Simon,^ who, in this case, by means of threads passed from the uretei's into the bowel,, succeeded in establishing a free communication between them. Although a considerable quantity of urine made its way by the new, route into the rectum, a portion of it escaped as before ; nor does it appear to have been possible to prevent this. Hence the operation can only be regarded as hav- ing been partially successful. For a similar object a seton was used by Mr. Lloyd,^ but with a fatal result,, from injury to the recto-vesical pouch of peritoneum. With the view of avoiding as far as possible, the last-mentioned risk, Mr. Holmes^ has pro- posed establishing the communication by means of a pair of screw-forceps,, by which pressure can be exercised on the bladder and rectum. By screw- ins up the instrument, these two points are brought together, through the compression of the intervening tissues, and in this ingenious way an opening is established by the formation of a slough. In the case, however, in which Mr. Holmes adopted this method, there seems to have been a difiiculty in keeping the new route open, and urine continued to flow over the pubes in considerable quantities. More recently, Mr. Thomas Smith, of St. Bartholomew's Hospital, has recorded a case^ in which he attempted to establish a permanent connection between the ureters and the posterior surface of the colon. Though with considerable difiiculty, he succeeded in efl'ecting the communication on one side, but when making a similar attempt on the other, a fatal result ensued. The following passage from Mr. Smith's communication, having a general bearing upon this class of operations, may be quoted : — The kidneys seem to have been the organs to suffer by the operation, the secreting structure on one side, the left, being entirely removed by suppuration, while the func- tion of the right kidney was so quickly and seriously afifected as to put an end to. life within three days. The more rapid implication of the kidney in my own case was- probably due to the more direct communication between the cavity of the bowel and the pelvis of that organ. The whole length of the ureter intervened in Mr. Simon's- case between the bowel and the kidney, whereas in my patient there were but twa inches of ureter. In connection with this subject, it may be worth considering how far the function of the kidney might be influenced by the introduction of intestinal gas ' Lancet, vol. ii. 1852. 2 Ibid., voL ii. 1851. ' Surgical Treatment of Children's Diseases, p. 148. ' St, Bartholomew's Hospital Reports, vol. xv. MALFORMATIONS AND MALPOSITIONS OF THE BLADDER, 337 to its pelvis. In my own case, when the colon was distended by flatus, one could feel certain that gas would find its way into the ureter, and so into the pelvis of the kidney. Assuming that it is possible to establish the most complete and satisfactory communication between the rudimentary bladder, or the ureters, and the bowel, the degree of comfort which this arrangement would confer on the patient still remains undetermined. Whether the rectum is capable, in the human subject, of adapting itself to the twofold office of bladder and bowel is, to say the least, problematical. In a case where the ureters opened into the rectum, the patient suffered from constant diarrhoea and irritation induced by the passage of the urine into the bowel.' We may now proceed to consider the second class of operations which have been practised, namely, those of a distinctly plastic character. The first successful operation of this kind was performed in 1858, by the late Professor Joseph Pancoast, of Philadelphia,^ who used two reversed skin flaps, taken from the groins, and turned with their epidermal surfaces towards the vesical mucous membrane. In England, Mr. Timothy Holmes^ soon followed in the same direction, and subsequently Mr. John Wood,* of King's College, further added importantly to our resources in the devising and adjusting of flaps for both sexes. Referring to these operations, Professor Gross considers that Wood's plan is best ■ adapted for the female, and that employed by the late Dr. Maury^ (which was essentially that recommended by Roux, of Brignoles) for the male. Fig. 1282. Wood's operation for extroyerBion of the bladder. (After Ashlmrst,) For the performance of Wood's operation (Fig. 1282), an umbilical flap, A, is turned down over the bladder, the groin flaps, J3 and C being superim- posed and joined together by their free Jborders, a b, a' b', so as to meet in the middle line. The details of this operation may be best studied by referring ' Philosophical Transactions, vol. vli. ' Op. cit., p. 149. ' American Journal of the Medical Sciences, VOL. VI. — 22 2 North American Med.-Chir. Review, 1859. < Med.-Chir. Trans., vol. lii. July, 1871. I 338 INJURIES ANf) DISEASES OF THE BLADDEK AND PROSTATE. Maury's operation for extroversion of tlie bladSer. to Mr. Wood's original communication on the subject. Maury's operation is thus described by Gross } — A flap is taken from the perineum and scrotum by carrying a curvilinear incision from the outer third of Poupart's ligament, across the middle of the perineum, to a cor- responding point on the opposite side ; the flap is dissected up carefully, to avoid vfounding the testicles, or hernia should the latter be present, until the root of the penis is reached, when that organ is slipped through a small open- ing made for it in the centre of the flap, by which means the urine issues without coming in contact with the wound. A curvilinear incision is then carried across the abdomen, and a short flap dissected up for about an inch; un- der this, the scrotal flap, its cutaneous surface having been vivified, is slid, and attached by several points of a modifi- cation of the tongue and groove suture of Professor Pancoast. (Fig. 1283.) In a recent communication on the subject, Mr. Rushton Parker, of Liverpool,^ whilst advocating in principle Wood's method of operating, lays stress upon certain improvements suggested by Dr. Greig Smith, of Bristol,^ which he considers contributed much to the success of the operation in the cases which he records. These are as follows : (1) The adoption of a pear-shaped or bellows-shaped flap as an anterior lining, not only to the bladder, but also to the simultane- ously completed dorsal aspect of the urethra, and the covering of the latter or urethral portion of the flap with a strip of skin obtained by bring- ing out the penis and prepuce through a hole in the scrotum. (2) The better-planned, and more thoroughly completed attachment of the cover- ing flaps without gaps, and the substitution of " relaxation-sutures" and interrupted " edge-su- tures" for hare-lip pins and twisted sutures. (3) The adoption of boracic-acid dressings, whereby decomposition is prevented, and the inevitable urinary infiltration rendered innocuous ; conse- quently, primary union being extensively ob- tained, the duration of the treatment is limited to the shortest possible period. In Mr. Parker's cases, where union by first intention occurred almost completely, the boracic dressings were kept constantly wet and fresh by the use of a bath in which the patient lay throughout the treatment, the bath being so constructed that the hips were kept immersed in warm boracic lotion Urinal for extroversion of the bladder, whilst the limbs and trunk remained dry. ' Op. cit., p. 365. ' Liverpool Med.-Chlr. Journal, January, 1882. » British Med, Journal, February 7 and 28, 1880. Fig. 1284. MALFORMATIONS AND MALPOSITIONS OF THE BLADDER. 339 The patients all slept as well in the bath as they had previously done in bed. After the operation, a properly constructed urinal will be required, at all €vents during the daytime. Something similar to that represented in the accompanying illustration (Fig. 1284) will be found convenient. At night, however, a simple appliance such as a sponge, secured to the perineum, may be substituted, and thus the skin may be relieved from the constant pressure of the apparatus. Though a plastic operation may not be successful in furnishing a reservoir for the urine, capable of being acted upon at will, yet the providing of a pro- tection for the exposed mucous membrane, as well as a means whereby the urine may be more readily collected, are results which can be promised, and which warrant the performance of an operation based upon the principles to which reference has been made. [Though, upon the whole, satisfactoiy in their results, these plastic opera- tions for extroverted bladder are not free from risk, 100 cases to which the •editor has references having given at least 20 deaths.] Patent Urachus. — In the early foetus, the sac of the allantois consists of an extra-abdominal and an intra-abdominal portion, which communicate with •each other through the umbilicus. Soon the extra-abdominal part disap- pears, the lower half of the intra-abdominal segment becomes the urinary bladder, and, ordinarily about the thirtieth week of intra-uterine life, the upper half becomes obliterated and forms a fibrous cord, the urachus, passing from the apex of the bladder to the umbilicus. Occasionally, however, it remains open, and in such a case the patient is liable to the discharge of urine from the navel, and to the formation of a urinary fistula which may suppurate and lodge urinary concretions. Patency of the urachus is most frequently observed in connection with some obstacle to micturition. treatment. — To remedy this defect, various means similar to those employed in the treatment of other fistulfe have been recommended, including the application of the cautery and plastic operations. Care must in the first place be taken to remove any hindrance to micturition which may exist, such for instance as that occasioned by a contracted meatus, a phimosis, or a urethral calculus. A case is recorded by Dr. Cadell,' in which, in a female child, a cure was attempted by temporarily establishing a state of vesical incontinence by dilating the urethra. Mr. Paget, of Leicester,' records a case in which he extracted through the urachus a vesical ■calculus which had formed on a hair ; he subsequently succeeded in closing the opening by paring the edges and approximating them with sutures. Hernia op the Bladder. — Amongst the rarer varieties of hernial protru- sion is that in which the bladder forms the whole or a part of the tumor : in ^ome instances it is accompanied by intestine, behind which it usually lies. In the male, cystocele most frequently occurs in the inguinal canal ; it may be either complete or incomplete, or may even extend like an intestinal hernia into the scrotum. In the female the displacement is most commonly vaginal. As the bladder is only partially covered by peritoneum, it can be readily understood that when it becomes thus displaced, the protrusion is, for the most part, destitute of a sac. Fortunately, however, cystocele differs from other hernise in seldom rendering necessary any surgical operation, and then only for the purpose of meeting some complication to which the normally located viscus is also exposed. I am not aware of an instance of strangula- ' Edinburgh Medical Journal, 1878. ' Med.-Chlr. Transactions, vol. xxxiii. 340 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. tion of the bladder having taken place, such as to require a surgical opera- tion for its relief. Some remarkable examples of cystocele are recorded: in one, narrated by Mr> Clements,^ the whole bladder had passed out through the abdominal ring into the scrotum, where it formed a tumor of large dimensions capable of holding two quarts of urine. Cases are reported in which a cystocele occasioned retention of urine and cys- titis, as well as others in which calculi were found. The comparative rarity of this aflfection has led to some errors being com- mitted both in diagnosis and treatment, vs^hich have resulted in serious con- sequences. The possibility of its being mistaken for a hydrocele must not be overlooked. Pott^ records a case in which he cut into a cystocele on the- supposition that he was dealing with a diseased testicle, and there are. other instances in which the tumor has been mistaken for abscess or inflamma- tory enlargement about the groin. The diagnosis of a cystocele is not attended with much difliculty under ordinary circumstances. It is a soft, elastic, fluctuating tumor, varying in size in accordance with the amount of urine contained, and capable of being- emptied by pressure, on the application of which a desire to micturate is- experienced. In Mr. Clements's case the patient could not pass water with- out flrst raising the rupture towards the belly and then rolling it about^ when urine would pass freely, though in small quantities at a time. In the female, the protrusion, as already mentioned, is usually vaginal, occupyiiig^ the anterior wall of the canal, and being commonly spoken of as a prolapse- of the bladder. It occurs in females of a lax habit, who have sufi"ered from prolonged leucorrhceal discharge, but oftener it is one of the results of the child-bearing period, being probably occasioned by some over-stretching of the parts in labor, or by subsequent subinvolution of the vaginal walls. Instances are recorded in which it has produced considerable embarrassment during delivery ; when it has been occasionally punctured, under the belief that it was a cyst of the ovum or a hydrocephalic head. The treatment of this displacement is in principle similar to that applicable- to other form's of hernia ; it is either palliative or radical : the former division includes the use of supports or trusses adapted to the position and nature of the protrusion ; the latter, the prevention or limitation of the displace- ment by some plastic operation. In the female, the use of astringent lotions and the wearing of a suitable pessary are generally sufiicient to prevent the occurrence of any considerable inconvenience. For the relief of the more un- manageable cases of vaginal cystocele, various expedients have been adopted. These consist for the most part in the removal of portions of the vaginal wall, and the drawing together by sutures of the edges of the wound, with the view of securing a narrowing of the canal. Dr. Marion Sims and Mr. Baker Brown both described operations of this kind, termed elytrorraphy,. which have been followed by good results. In the last place, it must be mentioned that cases are on record in which the prolapse has been so unman- ageable, that almost complete occlusion of the vaginal orifice by paring the labia and uniting them with sutures has been found necessary for success. Inversion oi' the Bladder. — This term is used to describe a condition — exceedingly rare — in which the viscus is turned inside out and protrudes through the urethra. It is only met with in females, and is generally partial, seldom complete. Dr. Gross' refers to only -seven cases of the latter ' Observations in Surgery and Pathology. London, 1832. 2 Philosophical Transactions. London, 1764. ' Op. cit., p. 349. CYSTITIS. 341 variety, indicating the exceptional character of the displacement. [An eighth <;ase, complicated with prolapsus of the rectum, in a child sixteen months old, ■came under the editor's observation in the spring of 1884.] In a paper on this subject, Mr. John Croft^ briefly describes the appearances and symptoms of the affection, as follows : " A small, pyriform, red, vascular, elastic tumor, situated between the labia, below the clitoris, and in front of the vaginal orifice ; the urethra not distinguishable ; the ureters exposed, and perhaps distilling urine ; a history of more or less incontinence previous to the ap- pearance of the tumor ; these symptoms should lead one to recognize an inversio vesicae, and to distinguish such ah affection from a solid polypoid growth." In the case recorded by Mr. Croft, rupture of the inverted bladder, and escape of peritoneal fluid took place owing to the violent expulsive eiForts set up by the protru- sion. In spite of this serious complication, after return of the bladder had been ■eifected by manipulation under chloroform, the patient made a good recovery, which, from a subsequent report, appears to have been permanent. In a similar case recorded by Dr. Lowe,^ it is stated that treatment by actual cautery was employed, and occupied eleven months ; there was no relapse, but some degree of incontinence remained. Sufferers from this displacement have, on account of its rarity and resem- blance to a polypoid growth, been exposed to some risks connected with :& false diagnosis. Mr. Crosse,^ under the impression that the inverted viscus was a vascular tumor, was contemplating its removal by ligature before he discovered its true nature. The affection appears to be due, not to :any malformation of the parts, but to a condition of relaxation as a predis- posing cause, and to some violent expulsive effort, attendant on micturition ■or the discharge of feces, as the exciting cause. Treatment. — The individual cases to which reference has been made indi- cate what may be done towards remedying this extremely rare displacement. Cystitis. Cystitis, or inflammation of the bladder, is met with in varying degrees of ■severity, being usually described as acute or chronic ; but between these ex- tremes all shades of the affection are to be seen, and hence this classification must only be accepted as representing typical examples. Acute cystitis may be provoked in any of the following ways, which are selected as examples of causation, rather than as including all the circum- stances under which the disease may arise : by extension of inflammation from some adjacent part, as in gonorrhcea ; by changes in the urine resulting from its decomposition, as in retention from stricture ; by injuries of various kinds, not excepting surgical operations ; by the irritation caused by frag- rnents of calculi ; and by the presence in the urine of certain elements foreign to its composition, of which those derived from cantharides, oil of turpentine, and other stimulating drugs, furnish illustrations. In reference to the causation of cystitis, it has been well remarked by Dr. "Owen Rees,* that " it may indeed be regarded quite as an open question "whether we have a right to believe in inflammation occurring in the bladder, ' St. Thomas's Hospital Reports, Ne-w Series, vol. ii. 2 Lancet, March 8, 1862. ' Transactions of the Provincial Medical and Surgical Association, New Series, 1846. ■* Croonian Lectures on Calculous Disease, p. 47. 342 INJUKIES AND DISEASES Or THE BLADDER AND PROSTATE. irrespective of mechanical cause or the presence of some chemical irritant^ and otherwise than as the effect of long-continued sympathetic irritation." The most acute form of cystitis is that occasionally seen in connection with surgical procedures having for their object the removal of stone from the bladder ; it may even follow the preliminary examination known as- sounding, by which the presence of a calculus is determined. The produc- tion of cystitis after lithotrity has been attributed by Professor Bigelow, not as much to damage inflicted by the presence of the lithotrite within the bladder, as to the retention, afe foreign bodies, of fragments of the stone. With the view of removing so fruitful a cause of inflammation, in connection with these operations. Professor Eigelow' has demonstrated the feasibility of withdrawing at one sitting the whole of the fragments by sufficient tritura- tion and suitable aspiration; with the result of considerably diminishing- the risk of cystitis. Not only has be- thus, to a large extent, succeeded in ridding the operation of its chief source of danger and failure, but he has^ proved the safety with which lithotrity, in suitable cases, can, like litho- tolny, be completed at one sitting. Incidental allusion is made to this subject here, only as bearing on the causation of cystitis. Additional interest has recently been attached to the production of cysti- tis and ammoniacal urine, by the discovery of bacteria in fresh urine, under apparently inexplicable circumstances, as illustrated by Dr. W. Roberts.^ Clinically, it is important to remember that very active cystitis has been pro- voked by the use of unclean instruments, such as catheters ; and, further,, that certain drugs capable of controlling it, as for example the salicylates and quinine, probably owe this power to their action as bactericides.- Symptoms. — Acute cystitis, however provoked (and it can never be regarded as spontaneous in origin, or idiopathic), usually presents the following symp- toms, of which the local are the first to appear. There is deep pain, increased on pressure, immediately above the pubes ; micturition becomes frequent, and is most distressing, a few drops of urine being the only result of prolonged and spasmodic efforts. The limited area of the tenderness is sufficient, in conjunction with the vesical irritability, to indicate the organ implicated. The urine is high-colored, and sometimes tinged with blood. In proportion to the severity of the inflammation, so do the neighboring parts sympathize. There is rectal tenesmus, and a distressing feeling of fulness about the peri- neum, as if there were something which ought to be expelled. Subsequently the urine is found to be loaded with lithates and mucus, and ultimately it becomes ammoniacal. The constitutional symptoms are those indicating in- flammation of a vital organ. The attack is usually ushered in by rigors, or a feeling of chilliness, and the symptoms of an acute febrile attack soon super- vene, unless the cause of the inflammation is speedily removed ; as, for in- stance, fragments of stone left behind in the bladder after the operation of lithotrity. These symptoms rapidly assume a fatal character; the tongue becomes brown, the pulse thready, and the skin clammy, and death occurs within a week from the commencement of the attack. In the acuter forms of cystitis, the mucous membrane is the part chiefly in- volved ; after death this is found deeply injected, with here and there patches of a still deeper hue, as if from submucous hemorrhages. Occasionally the mucous membrane of the bladder, when inflamed, throws out an exudative material, which has suggested the name of diphtheritic or croupous cystitis. Casts of the vesical cavity may in this way be formed, and ' Litholapaxy, or Rapid Lithotrity with Evacuation. 2 Brit. Med. Journal, October 15, 1881. ' CYSTITIS. 343 cause retention, necessitating the operation of tapping. Diphtheritic inflam- mation of the bladder has been noted as occurring in association with the presence of diphtheria elsewhere. Billroth' says that he has only met with this condition as a secondary affection, consequent on fracture of the spine, rupture or stricture of the urethra, or hypertrophy of the prostate. Both sloughing and abscess are sometimes, though rarely, met with as results of cystitis. Such destructive lesions as these are, as Charcot suggests, due, not as much to the intensity of the inflammation, as to the presence of causative or at least of coexistent changes in the spinal cord, particularly in the gray matter. Treatment. — The treatment of the various degrees of cystitis designated as acute, may be briefly summed up as follows. The exciting cause must, if possible, be removed. Fragments of stone, pent-up gonorrhoeal matter in the urethra or in its lacunsB, and urine made ofliensive by retention, or by the irritating foreign elements present in the excretion and derived from certain drugs in excessive doses, are all' excitants of cystitis, which either may be removed, or the effects of which may be mitigated. The retention of a catheter under these circumstances can do no good, unless, from paralysis or otherwise, the bladder is incapable of voiding its contents. I have sometimes found the injection and withdrawal of small quantities of tepid water not only soothing, but eflicacious in removing possible sources of irritation. As a rule, local depletion by leeches, above the pubes or over the perineum, speedily relieves the feeling of tension of which patients complain at the onset of the disorder. Hot applications in the form of fomentations and hip baths, are also indicated. Among topical remedies which give the greatest relief, I believe that nothing can compare with hot bran poultices, well satu- rated with laudanum and laid over the abdomen. These are extremely light, and are very soothing and relaxing to parts invariably complained of as feeling tense. Opium in the form of suppositories will also be required. It is important that the patient should partake freely of diluent drinks and pleasantly flavored alkaline medicines, which quench thirst and are grateful to the palate. Hyoscyamus in full doses has long been regarded as probably the most useful, single remedy in inflammatory affections of the bladder. Chronic Cystitis. — Inflammation commencing in an acute or subacute form, not unfrequently merges into the chronic variety of this disorder, which is extremely common. Causes. — Vesical catarrh is a constant complication of various disorders of the genito-urinary organs. The kidney, or rather the digestive apparatus, is frequently responsible for its origin : we see this illustrated in certain gouty afiections, in which the urine is rendered intensely irritating by the crystals it contains; and again we have cystitis provoked by the passage into the bladder of urine largely charged with pus derived from a suppurating kidney. Passing to the bladder itself, we find instances of inflammation produced by the presence of stone, by the formation of pouches or sacculi, in which urine lodges and decomposes, by paralysis from spinal disease, and by the irritation occasioned by intravesical growths. The enlarged prostate is probably the most frequent cause of chronic cystitis, as it leads to either partial or complete retention and urinary decomposition. In this way cystitis may be maintained almost indefinitely. Coming to the urethra, the gonorrhoeal poison is a frequent excitant of inflammation in the viscus behind it ; whilst stricture, in the double capacity of a local irritant and a source of retention, is largely and ver}^ evidently I'e- • Clinical Surgery, New Sydenham Society's Translation. 1881. 344 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. sponsible for the production of this affection. To these and lilce causes of irri- tation of the urinary reservoir, we must add some of the means which are used for their relief, where certain ill effects unfortunately result from well- intentioned efforts. I refer to the production of cystitis by . operative measures, such as the passage of catheters, bougies, sounds, and lithotrites into the bladder ; and to the use or abuse of injections in potent forms for the treatment of disorders of the urethra. Here then we have such a multiplicity of causes of chronic cystitis, that we shall do well never to commence its systematic treatment without feeling that there is a cause to be determined, if success in treatment is to be attained. The mischief produced by this affection is by no means limited to the mucous membrane of the bladder, though this is chiefly involved. The urine becomes loaded with the excessive secretion of the membrane, a condition of alkalinity of the urine is produced, ammonia is generated and evolved, and more remote changes, not only in the bladder but in other organs, follow. These changes have reference principally to the kidney, and to the formation of vesical calculus. Chronic pyelitis is a by no means uncommon accompani- ment of long-standing cystitis, and there is nothing remarkable in the fact that these two conditions should so frequently coexist. When the intensely irritating nature of the compounds into which urine is converted is considered, as well as the constant evolution of volatile ammonia which is going on in the central reservoir of the urinary apparatus, there can be no diflaculty in understanding the connection between the two. These secondary changes in the kidney are undoubtedly the most serious of the local results following protracted inflammation of the bladder. The effects of what has been spoken of as the ammoniacal fermentation of urine are, however, in some cases by no means limited to the kidneys. General symptoms, which include pains about the head, dryness of the tongue, nausea, hsematuria, and diarrhoea, are directly traceable (a point on which Billroth lays stress) to a condition of ammonsemia which often attends chronic cystitis. The relation of cystitis to the formation of vesical calculus cannot be passed by without notice. That a certain degree of irritation, if not of inflammation, is a constant factor in stone production there can be but little doubt. Let us observe what follows the excitation of inflammation of a moderate amount in the bladder, by the introduction into it of an extraneous substance. A piece of bougie may thus become accidentally lodged : cystilAs is produced, the urine is rendered alkaline, and phosphates are thrown down in abundance, and aggregated around the foreign body. As long as this remains in the bladder, the cystitis continues, and the concretion increases in size ; until even- tually the portion of bougie, being completely covered in, ceases itself to play any part in the process of stone formation which is in progress. And what is true of phosphatic calculi, is equally true, though in a somewhat different sense, of calculous concretions of other chemical composition. The latter do not necessarily arise out of the products of urinary decomposition which cystitis provokes, but when certain constituents of the urine are present in excess, such as uric acid and urates in the gouty, or oxalates in the dyspeptic, the mechanical irritation which these salts may create leads to the pouring out of mucus from the vesical membrane in greater abundance than is natural. Thus a colloid is provided, which plays an important part in the process of stone formation. In corroboration of this view I will quote the following passage from Dr. Vandyke Carter's work: — ' 1 The Microscopic Structure and Mode of Formation of Urinary Calculi, p. 39. CYSTITIS. 345 An excess of mucus, perhaps altered in character, in the urinary passages, or the effusion of albumen, fibrine, or blood, and the like, say from congestion of the kidneys or from irritation of the urinary tract, would furnish a colloid medium with which uric acid, the urates, or oxalates — themselves, perhaps, in excess — could combine in the manner before described ; should there happen, also, an undue concentration or special loading of the urine, the probabilities would be strengthened that to some illness — fevers of various kinds, ague, or an attack of cholera, renal congestion or inflammation — would be correctly dated the commencement of a calculus. It must also be assumed that the continued growth of a stone is dependent upon the presence of organic matter, and this at every stage. Sufficient importance has not been attached to chronic cystitis, in its rela- tion to structural kidney disease — surgical kidney — as well as to the part it plays in the formation of stone, l^o description of it can have any claim to completeness, unless reference is made to these as amongst its most common results. Symptoms. — The symptoms of chronic cystitis vary both in kind and degree ; in the slighter cases there is irritability of the bladder, with an in- creased deposit of flocculent mucus, in which pus-corpuscles are entangled. This condition is frequently seen as a complication of gonorrhoea. The other and more severe variety is attended with a large secretion of mucus, which clings tenaciously to the bottom of the vessel into which the urine has been passed. To this the term catarrh has been applied, a name which is justified by the amount of muco-purulent secretion thrown off by the vesical mucous membrane, and by the resemblance which it bears to the expectoration met with in certain cases of bronchitis. The treatment of chronic cystitis necessarily resolves itself into a considera- tion of the causes producing the disease, which should be carefully gone over. Many of these — as, for instance, the presence in excess of certain of the inorganic constituents of the urine, stone, and stricture — are capable of cor- rection ; whilst others — such as tumors and the enlarged prostate — may only admit of a palliation of the symptoms to which they give rise. Still, the removal of the cause must be the first object in treatment, and is never to be lost sight of throughout. In the slighter forms of cystitis, removal of the cause, combined, perhaps, with the internal administration of buchu, or of an alkali with hyoscyamus, is sufficient to efifect a cure. Further, the following indications will require ful- filling: (1) The complete emptying of the bladder ; (2) its thorough cleansing and astringing ; (3) the promoting of a healthy tone in the mucous membrane, by the use, for the most part, of internal medicines having some specific action. (1) As residual urine by its decomposition is a frequent cause of vesical catarrh, provision must be made for the complete emptying of the viscus as often as may be necessary. This is best accomplished by the use of a catheter which the patient may be taught to pass for himself. Among catheters of various kinds, preference will generally be given to those made of soft rubber, which are admirably adapted for the purpose ; they wear well, and are not apt to crack about the eye, as is olten the case with the ordinary elastic, olive- pointed instruments, which are favorably known by reason of their easy intro- duction. The frequency with which the catheter is to be used varies in different cases. In some, it is sufficient to draw off the residual urine once or twice in the twenty-four hours; whilst in others, until the cystitis has to some extent subsided, the catheter may be required more frequently. (2) The bladder must not only be kept thoroughly cleansed, but the use of astringent injections is, moreover, often highly beneficial. To commence with, tepid water in small quantities may be employed, by attaching a glass 346 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE, funnel, with about two feet of rubber tubing, to the end of a catheter, "When the funnel is held up and water poured into it, the current passes into the bladder ; by lowering the funnel, the water escapes. In this way the viscus can be thoroughly cleansed ; or the same can be effected by means of a. rubber Fig. 1285. Fig. 1286. Double-current catheter for washii^g oat the bladder. bottle r or syringe, fitted to the end of an ordinary catheter, or, which some surgeons prefer, a double-current catheter. Where it is necessary to continue the operation for a' length of time, Keyes's apparatus will be found exceed- ingly useful. From the accompanying sketch (Fig. 1286) this is seen to consist of a vulcanized-rubber bottle, which is capable of hplding a pint of fluid, and which, by means of a ring, can be suspended to any convenient hook ; and a piece of tubing, five feet in length, terminating in a stopcock, which per- mits fluid to flow either through the catheter-end or the outlet-pipe, accord- ing to the direction in which the tap is turned. A conical, metallic, catheter mouth-piece completes the connection with the catheter. A soft-rubber ca- theter is generally preferred. The in- strument is used in the following way : The bag, being filled with the fluid to be injected, is hung up about six feet from the floor ; the stopcock is then turned until some of the fluid escapes, so that no air is allowed to enter the blad- der. The patient being in the erect , position, then introduces the catheter, and connects it with the tubing. By the alternate action of the tap, the fluid is made either to enter the bladder, or to escape ; if the latter, it passes into the receptacle. The instrument can be readily adapted to the recumbent posi- tion. Beyond other advantages which the apparatus possesses, it enables patients to perform this operation without assistance. Care should be taken to prevent the forcing of air into the bladder along with the fluid injected. When the urine is bloody, the presence of air in the bladder speedily leads to putrefactive changes and to the evolution of gas in considerable quantities, which not only is offensive, but is capable of producing retention of a very painful character. There is a source of annoyance that patients occasionally complain of, which it is easy to avoid. As the bladder is expelling the last portion of the injec- Eeyes's apparatus for Irrigation of the bladder. CYSTITIS. 34T tion, if the surgeon is holding the catheter he sometimes feels a slight clicks or shock, which the patient with a sensitive bladder is conscious of, and which, though it is very momentary, he rather dreads on the next occasion that the operation has to be repeated. Guthrie refers to these sensations as " the fluttering blows of the bladder." He speaks of them as simulating stone and indicating the presence of saeculi. The click seems to be caused by the mucous membrane being sucked into the eye of the catheter as the bladder is emptied of the last few drops, for I have never noticed it when using a solid instrument, such as a bougie. It is to be avoided by carefully watching the flow, and, as it is terminating, by withdrawing the catheter till the end is well within the prostatic urethra. It is better to do this than to obviate the inconvenience by having a catheter with sevei'al small openings, as such an instrument is liable to break. A catheter for washing out the bladder should have the eyes of moderate size, with their edges bevelled like those of the American instrument, so as not to scratch the urethra ; the openings should be as near to the end as possible to avoid the introduction of an unneces- sary length of tubing. To cleanse the bladder, injections of tepid water with about ten grains of borax to the ounce are generally employed : when the urine remains in an unhealthy condition for some time afterwards, one drop of nitric acid or five of the tincture of perchloride of iron in half a pint of warm water may be substituted with advantage. When the urine is maco-purulent, after cystitis consequent on stricture or stone, injections of quinine are often beneficial. Attention was first called to- the value of this drug in these cases by Mr. N"unn,^ who speaks of its acting- as a bactericide in the chronic form of cystitis known as catarrh ; when the urine is purulent and offensive, it has been found exceedingly efficacious. The neutral sulphate of quinine, dissolved in distilled water, in the propor- tion of two grains to the ounce, will be most suitable. If the solution is not quite clear, a drop of dilute nitro-muriatic acid is to be added, and then it should be strained. A quantity not exceeding two ounces may be injected by a catheter and rubber bottle, the patient being instructed to retain the injection, if possible, for a time, provided that doing so be not distressing. The internal administration of quinine, in ten-grain doses, has not only been found to act as a sedative to the bladder, but is useful in arresting putrefactive changes in the urine. Its efficacy for this purpose has been urged by Dr. Simmons, who, in explaining the natui-e of this action, refers to an observa- tion by Dr. Kerner, that seventy per cent, of the drug is eliminated by the kidneys in from three to twenty-four hours after it has been taken.^ To alleviate the extreme irritability of the bladder which often remains after the more active symptoms of inflammation have passed away, a solution of morphia, injected into the organ by means of a gum-elastic catheter ta which a ball-syringe has been attached, often gives the patient a good night ■after rectal suppositories in various forms have been tried without success. For a similar object, I sometimes employ in these cases vesical pessaries, containing either morphia or belladonna, or other soothing agents. These are passed into the bladder by means of a specially adapted catheter in which the pessary is placed. With this instrument the whole of the urine is first drawn oflF, after which, by pressing the stylet, the pessary is projected into the bladder. The pessaries are made with oleum theobromse, and are so shaped as to fill in the open end of the catheter, thus giving it the appear- ance of an ordinary instrument. The shape of the pessaries is shown in the figure (Fig. 1287, A). A grain of morphia introduced into the bladder in ' Lancet, Feb. 23, 1878. ^ American Journal of the Medical Sciences, April, 1879. S48 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. this way, and repeated when necessary, often completely relieves the distress- ing symptoms of iri'itation. The use of these vesical pessaries has been -extended to other eases where astringent applications to the bladder are indi- cated, and extended experience has shown the advantage, under certain cir- cumstances, of this mode of medicating the bladder. Fig. 1287. e.TIEMANN diCO Harrison's catheter for introdncingr pessaries into the bladder. There is a variety of opinion with reference to the power of the bladder to absorb drugs introduced into it, as well as the constituents of the urine, in certain cases. That some special provision does exist to prevent the normal mucous membrane from absorbing readily, there can be no doubt, When, however, the lining membrane of the bladder becomes altered by dis- eased action going on in its interior, it then seems capable of absorbing nol only drugs, but also certain products into which urine is resolved when i1 undergoes decomposition. In this way are explained cases of ammonsemia Tvhich have been recorded. It often happens that though the inflammation has been removed and the liladder cleansed, this long remains preternaturally sensitive and irritable, Where other means have tailed to give relief under these circumstances, the application of hot water to the interior of the organ has been found of much service.' Commencing at a temperature of 100° F., measured by the thermo- meter, increasing quantities of water are injected daily, and the temperature gradually raised, until, in some instances, 120° F. has been reached. Dr. R F. Weir^ refers to the value of the hot douche in cases of this nature, and Mr. Guthrie' also appears to have derived considerable advantage from its -employment. It will be proper here to draw attention to a mode of treating cystitis which has been recently advocated by Mr. John Chiene,* under the name ol l)laclder-drainage. Its object is to keep the viscus unemployed as a reservoir, and so to give it complete rest for as long a period as may seem desirable This is-eft'ected through siphon action by means of a catheter and piece ol rubber tubing, which convey the urine, as it drops from the ureters, into £ vessel beside the patient's bed. Some excellent results have in this way beer ■obtained, not only in chronic cystitis, but also in other urinary afl:'ections in which it is necessary to keep the bladder empty and the patient dry. I1 is another illustration of what John Hilton wrote of as the value of physio logical rest. (3) The third indication is to promote, by internal remedies, a healthy ton* of the vesical mucous membrane. Amongst these remedies are two specially worthy of mention, namely, uva ursi and buchu, which are often of greai value in this stage of the complaint. A formula of Dr. Gross's will be founc exceedingly useful. It consists of one ounce and a half of the leaves of th( ' Harrison, The Prevention of Stricture and of Prostatic Obstruction. London, 18S1. 2 American Clinical Lectures (Seguin), vol, iii No. 8, " On the Anatomy and Diseases of the Bladder, -1 Edinburgh Medical Journal, December, 1880. CYSTITIS. 349 ■uva ursi, and half an ounce of hops, or one drachm of lupuline, infused for two hours in a quart of boiling water, in a covered vessel. To the strained liquor are added two drachms of bicarbonate of sodium, and two grains of morphia if there be much pain. Of this mixture, a wineglassful is to be taken five or six times a day. It is of importance that only the recently made infusion should be used, as much of the volatile essential principle of the drug is lost in the preparation of the concentrated essences which, on account of their convenience, are now so extensively used. Amongst demul- cents, ordinary barley water, and a decoction of the ulmus fulva or slippery elm, and of the triticum repens or couch grass, extolled by Sir Henry Thompson, will be found of service in allaying irritation. In the treatment of cystitis, reference is often made to the reaction of the urine, as indicating the necessity for administering either acids or alka- lies. Our object should be to obtain that condition of the excretion which is the least likely to provoke irritation. We sometimes find that alkalies are being poured in'with a vigorous hand, quite regardless of the fact that healthy urine has an acid reaction. When, however, the acid is much in excess, or the mucous membrane infiamed, relief generally follows the administration of 5,n alkali. In some of these cases, when other means have failed, it is remarkable, with what rapidity pus disappears from the urine under the influence of chlorate of potassium. It is best prescribed in the proportion of half an ounce of the salt to a pint of flavored water, a tablespoonful to be taken every three or four hours. In reference to the precise manner in which chlorate of potassium acts in cystitis, it is conjectured, from an analysis by Ludwig, that the salt may be decomposed in the kidneys by the acid urine, and that chloric acid, being consequently set free, brings about a change in the reaction' of the urine in the bladder.' In regard to diet. Dr. George Johnson^ has shown the value of milk, in both acute and chronic cystitis, its eflFect being to render the urine less irri- tating. In the treatment of cystitis as it occurs in the female, there are no better instructions than those contained in a practical paper on this subject by Dr. J. Braxton Hicks.^ The author points out how little is to be expected from internal remedies, beyond correcting the functions generally, and how much may be done by local treatment. Reliance is placed chiefly in washing out the bladder with slightly acidulated warm water, until it is clear of phos- phates and mucus, and afterwards injecting, with a view to its retention, a. solution of morphia. Subsequently the permanganate or chlorate of potassium is employed in a similar manner. On the subsidence of the acute symptoms^ injections of tannin or of perchloride of iron, folio ViJ'ed by morphia, are substi- tuted, and are again changed as the bladder becomes less sensitive for more potent astringents, such as the nitrate of silver. Lastly, it must not be forgotten that there are cases of chronic • cystitis which appear to be quite irremediable by any methods such as those referred to. In these the bladder is little else than a chronic abscess-cavity, into which urine finds access. Under these circumstances, cystotomy, in the male, becomes a justifiable proceeding ; whilst, in the female, the establish- ment of a condition of temporary incontinence by dilatation of the urethra, is frequently followed by permanent relief. The advantages of cystotomy as a means of permanently relieving this condition in the male, have been • Lancet, Feb. 25, 1882. 2 Ibid., Deo. 16, 1876. 3 British Med. Jour., July 11, 1874. 350 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE, urged by Dr. E.. F. Weir,' who in a brief history of the operation furnishes a table of forty-seven cases, with the following results : By median perineal section, there were ten cases, six patients being cured, three relieved, and one dying. By the lateral section there were thirty-two cases, thirteen patients being cured, four relieved, and eleven dying, while in four cases the operation failed. By the bilateral section there were five cases, four ending in cure, and one in death. In the selection of the precise mode of proceeding, the median incision will be found to have an advantage by reason of its greater immunity from hemorrhage. Care, however, must be taken, when it is adopted, to secure urinary incontinence for some days at least, either by in- serting through the wound a lithotomy tube by which urine can constantly escape, or by over-distending the prostatic urethra with the finger, or with a dilator. Where the lateral incision is practised, incontinence naturally fol- lows, as after the removal of a stone from the bladder in this way. Dr. Hayes Agnew^ has suggested that, in hopeless cases of chronic cystitis, the patient might be made comfortable by separating the connection of the ureters with the bladder, and bringing them out through the abdominal walls, estab- lishing fistulse either in the iliac or in the lumbar region, and thereby divert- ing the urine entirely from the bladder. Dr. Agnew supports this \iery formidable suggestion by a reference to the experience of persons suffering from certain urinary fistulas occasioned by accident. Though the feasibility of such a proceeding has been tested on the dead subject, it has not hitherto been illustrated clinically. Ulceration op the Bladder. This is an occasional result of inflammation. I have known it occur as a consequence of the retention in the bladder for some days of a catheter ill adapted for the purpose. Most frequently it happens in bladders which have become inflamed whilst in a paralytic condition, when it is probably associated with some changes in the spinal cord. Where catheterization is employed under these circumstances, extreme care is necessary in consequence of the insensitive condition of the patient, not to occasion any damage to the mucous membrane of the bladder which may be followed by ulceration. Hilton^ re- fers to a case of this kind, in which, after death, three ulcerated patches were found at points corresponding with those which the catheter touched daily. The same author also relates a case in which a patient was in the habit of daily catheterizing himself. One day, on being sent for, Mr. Hilton found him dying of peritonitis brought on by perforation of the bladder. After death a perforated ulcer was found corresponding with the \ery spot upon which the end of the catheter must have pressed. Similar care is required to avoid any- thing like continuous pressure on the vesical wall when a catheter has to be retained. The possibility of ulceration of the bladder, when associated with stricture of the urethra, being followed by rupture and extravasation of urine into the surrounding tissues, should not be lo'st sight of. Though such an occurrence is extremely rare, there are instances in which it is most likely that this took place. This was probably the nature of the case recorded by Dr. T. K. Cruse.^ Exfoliation of the mucous membrane of the bladder has occurred in association with ulceration. Cases^ are recorded in which the entire lining has 1 On Cystotomy for Cystitis in the Male, New York Med. Journ., June 12, 1880. ' Pliiladelphia Medical Times, Feb. 12, 1881. 3 Guy's Hospital Reports, 3d series, vol. xi. •* Rupture of the Bladder dependent on Stricture of the Urethra. Medical Record, Aug. 1, 1871. 6 Tj'n.Ti«_ Vaih. Snp.. TinTi(^-_ vnl . w. HYPEETROPHy AND ATROPHY OF THE BLADDER. 351 been thrown ofi' and has caused retention, or, in the female, has been extruded thrpugh the urethra. In some instances of this nature the mucous membrane appears to have been dissected ofl' by ulceration from its subjacent coat ; whilst in others this effect has been the result, not of molecular death, but of the conversion of the entire membrane into a slough, by reason of the vio- lence of the preceding inflammation. Perforating Ulcers. — ^Some remarkable instances of perforating ulcer of the bladder have been recorded, where, apparently, there were no indications of the presence of the affection previous to the setting in of fatal symptoms. To this category belongs the interesting case recorded by Mr. Bartleet, of Birmingham,^ where the ulceration made its way into the ileum, and caused death, as it were accidentally, by setting up peritonitis. The ulcer, whilst confined to the bladder, as Mr. Bartleet remarks, appears to have gone through all its stages without presenting any symptoms, the patient con- tinuing to follow his accustomed occupation. A sudden lifting movement, which occasioned acute pain, probably broke down a recent adhesion between the bladder and the bowel, leading to extravasation of urine into the perito- neal cavity, and thus ultimately causing death. The possibility of rupture of the bladder from muscular contraction being preceded by ulceration, the symptoms of which have been in abeyance, must not be forgotten. Dr. Pad- ley^ has recorded a case in which extravasation of urine into the abdominal areolar tissue, followed by cellulitis and sloughing, was probably preceded by ulceration of the bladder. This patient had previously been under treatment for a perforating ulcer of the soft palate. Communications between the blad- der and intestines appear, in some cases, to have existed for considerable peri- ods of time, and to have led to formation of stone within the former. In the early days of lithotrity, Mr. Charles Hawkins^ recorded a successful case of this kind. As the intestines are more prone to ulceration than the bladder, it is probable that, as a rule, the latter becomes only secondarily involved. Symptoms. — The symptoms of ulcerated bladder do not differ essentially from those of cystitis. The urine is frequently tinged with blood, and con- tains fragments of disorganized mucous membrane. Such patients are often sounded, on the suspicion that a stone may be present, with the result of con- siderably aggravating all their symptoms. Treatment. — The simpler forms of ulceration hardly require any special treatment. Where there is reason to believe that this condition exists, every care should be taken to prevent over-distension, and to avoid the unnecessary introduction of instruments into the bladder. Hypertrophy and Atrophy of the Bladder. Hypertrophy op the bladder may be regarded as a natural consequence of obstructed micturition. As in the circulatory system, the heart, by an increase of its bulk, adapts itself to meet any obstacle which may be placed in front of it, so in the urinary apparatus does the bladder, by proportionate development, make provision for any additional resistance which it has to overcome. With reference to uniform hypertrophy of the bladder, there is comparative- ly little to be said. There are, however, extreme variations in the relations existing between the amount of hypertrophy and the capacity of the viscus, a circumstance which has caused some authors to speak of concentric and excen- tric hypertrophy, as indicating that in the one the increased development of ' Lancet, February 5, 1876. 2 Lancet, March 4, 1882. ' Medico-Chirurgical Transactions, vol. xli. 352 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. the -muscular coat is at the expense of the cavity, whilst in the other the con- dition is reversed. Both conditions, in variable degrees, are commonly mel v^ith, and are explicable by individual diflerenees of vesical irritability. Ont person with a strioture will make water ou every available occasion, whilsl another, similarly situated, rather shirks the straining which the act requires and consequent^ is disposed to err in an opposite direction. This is a reason- able explanation of the varying degrees of bladder-capacity observed in other- wise similar cases of uniform hypertrophy. As a rule, hypertrophy exists as long as there is a cause for it. When the stricture, or other obstacle, is re- moved, the hypertrophy, in most cases, gradually disappears. This condition u sometimes, however, a cause for the continuance of irritability and frequenl urination, long after the stricture has been, to all intents and purposes, suffi- ciently relieved. Under these circumstances, cystotomy has been resorted tc with good results. It may be asked. What is the rationale of this ? How is an hypertrophied bladder, with a small capacity, to be made capacious and tolerant by not allowing urine to collect in it for an interval of two or thre€ weeks or more ? The explanation is to be found in the fact, that, for the time being, the bladder is prevented from acting as a muscular organ, and that atrophy, or loss of muscularity, therefore, follows. Possibly it is only undei circumstances such as these, that anything need be said with regard to the treatment of uniform vesical hypertrophy. When, however, the hypertrophy is partial — when the increase is confined to one set of fibres, or to one part oJ the bladder— symptoms are produced, and changes are brought about, which will require further remark. There is a condition which has been described as a columniform state oi the bladder, in which the interior presents an appearance similar to that ol the cavities of the heart, the muscular fibres not being spread out uniformly, but being collected in bundles, like the columnce. earnece. Hence the name, Between these elevations are corresponding depressions, against which the urine is forced when the expulsive power of the bladder is exercised. In this way sacculi are formed, as will be presently noticed. This is a condition fre- quently observed in connection with prostatic hypertrophy. It is usuallj associated with dilatation of the bladder, and with fatty degeneration of its muscular coat. There is a tolerably frequent example of limited hypertrophj; which was pointed out by Mr. Guthrie,' where, in connection with enlarge- ment of the prostate, a bar is formed at the neck of the bladder by the exces- sive development of the muscular fibres in that locality. As an illustratior of limited hypertrophy it is referred to here, but it will require fuller consid- eration in a separate section. Amongst hypertrophies limited to certain por- tions of the bladder, must be included those in which an excessive develop- ment of muscular fibres has taken place between the orifices of the ureters In this way, in a case recorded by Mr. Bickersteth,^ a bladder was practically divided into two compartments by a muscular barrier thrown across betweer those openings, and considerable difficulty was experienced in the removal ol a stone with the forceps, after the bladder had been opened, the stone being lodged in the upper depression. Atrophy of the Bladder. — In this condition, which is only rarely met with the bladder, either by accident or otherwise, is rendered incapable of acting as a reservoir by reason of the urine escaping immediately after entering it In some reported cases of malformation and of extensive vesical fistula, this change appears to have taken place, the bladder being little else than a rudi mentary organ. ' Op. oit., p. 271. » Liverpool Med. and Surg. Reports, vol. i. 1867. SACCULATED BLADDER. 353 Sacculated Bladder. The formation of sacculi, or pouches, in connection with the bladder, is observed in cases of enlargement of the prostate aiid other disorders in which freedom of micturition' is interfered with. It most frequently exists, as already stated, where hypertrophy of the muscular coat has taken place, the explanation being that the mucous membrane protrudes between the meshes of muscular fibres. In these depressions urine lodges. Uiader the pressure exercised by the bladder during micturition, these pouches deepen, until, perhaps, they are capable of containing several ounces of urine. They may form at any part of the bladder where the mucous lining is unsup- ported by muscular fibre. The presence of these sacs often occasions serious inconvenience ; they are spaces in which urine collects and decomposes ; not unfrequently calculi have been found in them ; and in some recorded instances, by concealing sharp fragments of stone after lithotrity, they have contributed to' the production of a fatal cystitis. Hence they are considerable sources of embarrassment to the surgeon in his treatment of many vesical aftections — an embarrassment which is by no means lessened by the fact that their exist- ence is difiicult to determine. The following case, recorded by Dr. Warren,* illustrates some of the features of sacculated bladder : — The patient, fifty-two years of age, had had symptoms of vesical disease for twelve years. The urine was alkaline, contained pus, and was passed frequently and with pain. An examination with a sound detected a stone. Some vesical pain followed the passage of the instrument, and the urine became strongly ammoniacal ; an attempt was therefore made to wash out the bladder with warm water injections, but the expulsive efforts were so great as to force out not only the water as fast as injected, but also the soft- rubber catheter employed. Finally, a small quantity was introduced at a time, but, however often this was repeated, the injected water came away dark, and foul in odor. All the symptoms grew worse ; the urine was passed in a putrid state ; and the patient died on the ninth day after the examination. At the autopsy, the bladder was found _ to consist of four compartments, three of which contained calculi. In the central one was a large phosphatic stone, nearly spherical, and five centimetres in diameter. The other stones were about two centi- metres in their longest diameters, and were somewhat flattened. They were dense, and probably consisted of urates. The walls of the bladder were much thickened, and there was a diphtheritic inflammation of its mucous membrane. The kidneys were large, soft, and contained small abscesses ; the ureters were dilated. When the existence of sacculi is suspected, it is not a bad plan, after cathe- terizing the patient while recumbent, and thus emptying his bladder, to alter his position by making him stand, and then to see if more urine escapes on moving the catheter gently about ; or the order in position may be reversed. Guthrie" mentions the case of a gentleman in whom the existence of one or more pouches was determined by injecting the bladder with warm water ; on withdrawing it only a portion would be obtained, and rarely the whole of it, even by any change of position. I saw a gentleman who had irritability of the bladder, and who was suspected to be suffering from stone. I had searched his bladder with a sound, and also with a catheter, for a cause, but in vain. One day, on examining him with a prostatic catheter, after having apparently emptied the bladder, in moving the instrument about I felt it suddenly pass over something with a jerk, and then, on gently pressing it, it went a couple of inches further in. This was followed by the discharge of about two ounces of milky- looking urine. There was no bleeding. My patient went home, pondering over the ' Boston Medical and Surgical Journal, March 21, 1878. ^ Op. cit., p. 30. VOL. VI. — 23 354 INJURIES AND DISEASES Off THE BLADDEK AND PROSTATE. suggestion made to him — that his vesical irritability was due to a sacculation in which urine lodged, and which we had accidentally discovered. He was immediately relieved, and remained so for forty-eight hours, when the feeling of irritability returned. Hav- ing had some experience in catheterizing himself, he again passed the same instrument, and, having drawn off some water, he began cautiously to feel about his bladder, with the same result as before. The patient came to the same conclusion that I had, namely, that he had a sacculated bladder, and, being an ingenious man, he devised a stylet by which he could readily pass his catheter into the secondary receptable. When I saw him last, he informed me that, by in this way passing an instrument for himself, from time to time, he had been completely cured of his irritable bladder ; and he believed that the sacculation had almost, if not entirely, disappeared. As bearing upon the difficulty of recognizing sacculi, I will quote the following remarks from an eminent authority: — It will naturally be asked, How can this state of sacculation of the bladder, with or without stone, be diagnosed during life? It must, I fear, be admitted that the indica- tions are few and unreliable. By noting that a man, having an enlarged prostate, makes water slowly and with considerable exertion ; that when a catheter is used, and after the bladder has been apparently emptied, there is a still further flow ; and particularly if the appearance of the urine during the double flow vary consicjerably, we may infer that cysts or sacculi do exist, although we cannot surely know it.' Careful examination of the region of the bladder may sometimes tend to the detection of sacculation. Examination of the supra-pubic region with the hand should also not be omitted. I was reminded of the importance of this on looking through the specimens in the Museum of the l^ew York Hospital. Appended to one (784), where there was a sac larger than a hen's egg, opening into the bladder near the fundus, and in which there were several calculi, was the note, "These calculi could not be detected by the sound during life, but the pouch containing them could be felt through the abdominal parietes." As an illustration of the enormous dimensions to which a sacculus may attain, reference may be made to the case reported by Dr. Murchison,* in which a large abdominal tumor was thus produced. The nature of the tumor was determined by puncture. Tn another case, recorded by Dr. Warren,^ such a sacculus had assumed many of the characteristics of a con- siderable ascites. Amongst the consequences which may arise from sacculation of the bladder involving its posterior wall, suppuration of the sacculus must not be overlooked. This probably results from its containing decomposed urine, which, owing to some sudden change in position of the parts, cannot find exit into the general cavity of the viscus, and consequently sets up suppu- ration. An abscess has been thus formed which opened into the rectum, and in this way a communication between the bladder and rectum has been established. It is probable that this was the course of events in a ease of recto-vesical fistula with fecal calculus, in a man, reported by Dr. W. R. Williams.* Pelvic cellulitis has also been similarly provoked. Treatment. — Beyond the removal of any cause, such as a stone or other impediment to micturition, which may have favored the production of saccu- lation, there is but little that can be done in the way of treatment for this affection. Care must be taken that the bladder is kept regularly emptied, as far as it is possible to do so, ancj its cavity must be cleansed by injection if necessary. • W. Cadge, Sacculation and Stone in the Bladder. Brit. Med. Journal, October 2, 1875. 2 Trans. Path. Soo. Lond., vol. xiv. " American Medical Times, N. S. vol. iv. * Lancet, Oct. 1, 1881. TUMORS OF THE BLADDER. 355 Tumors of the Bladder. In undertaking to treat of the various tumors affecting any organ of the body, the first difficulty which arises is the selection of a classification which will alike meet clinical and histological requirements. To ettect anything like harmony is, in the present state of pathology, well nigh impossible. A strictly histological arrangement would not be found to suffice for clinical study. Hence, in view of the principal object of this article, the subject will be approached with reference to clinical rather than other purposes. Tumors of the bladder may be classified as follows : (1) Villous growths, ov papillomata. (2) Mucous growths, or myxomata. (3) Fibrous growths, or fibromata. (4) Malignant or cancerous tumors. Villous growths, or papillomata, form the commonest variety of new growth met with in the bladder, and are most frequent after puberty. Tumors of this kind used to be described under the name of villous cancer, but there are no substantial reasons for regarding them as cancerous, or as even malignant : they show no tendency to ulcerate or to become open sores, to invotve structures other than the mucous membrane, to implicate glands, or to become generalized. When they prove fatal, it is by hemorrhage and con- sequent exhaustion, such as might take place from a, nsevus. There are good reasons for believing that they may exist for long periods of time without giving any indication of their presence. Cases have been recorded in which there were considerable intervals between attacks of hemorrhage probably due to growths of this kind, and in which, during periods of quiescence, the patients remained comparatively free from inconvenience. In the museum ■of St. George's Hospital thei-e is a specimen of such a growth, attached to the neck of the bladder of a gentleman aged eighty-one. His first attack of hemorrhage had occurred twenty years before death, and had lasted for eight months ; following this had been an interval of four years ; and then a re- currence of hemorrhage, which ultimately proved fatal. Bi'odie also refers to the disease as occasionally extendmg over a period of seven or eight years. This is altogether unlike the ordinary history of cancerous maladies. Symptoms. — Until they occasion hemorrhage, more or less persistent or recurrent, there are usually no symptoms from which the existence of these growths may be suspected. The hemorrhage to which they almost necessarily give rise, leads to an exploration of the bladder, in the course of which a portion of the growth becomes detached ; examination of clots and debris ■discharged under these circumstances has frequently led to the detection of the growth, by the evidence which the microscope has thus afforded. In a case of this kind in which I employed a double-current catheter for douching the bladder with hot water, a considerable piece of the growth was found blocking the return-tube. Mr. Davies CoUey' has suggested that in cases of suspected villous growth, a wash-bottle and catheter, as adapted for the removal of fragments of calculus from the bladder, might be advantageously utilized to bring away portions of the tumor for verification of the diagnosis. A smooth-bladed lithotrite has also been used for the same purpose. Per- sistent and recurrent hemorrhage, unexplained by other causes, and the detection of portions of the growth in the urine, are the points in diagnosis upon which stress is laid. On examining these growths, it may sometimes be observed that the delicate fringes which mainly compose them are en- crusted with phosphates sufficient to produce a gritty sensation when a metal » Trans. Clin. Soo. Lond., 1880. 356 INJURIES AND DISEASES OF THE BLADDEK AND PROSTATE. sound is moved over them. As instrumental examination of the bladder, w^hen a villous growth is present, is invariably followed by a large increase in the quantity of blood discharged with the urine, all unnecessary inter- ference must be avoided. These tumoi's are occasionally multiple, a favorite site being near the open- ings of the ureters, around both of which clusters of the growth may be seen hanging. They are usually attached to an otherwise apparently healthy- looking mucous membrane, by a pedicle. There is no thickening of the walls of the bladder, and its lining membrane is the only part connected with the growth. In size they vary much, and some of the smallest have proved equally as fatal as the larger ones, from the continuous hemorrhage to which they have given rise. Occasionally they have caused retention of urine by occluding the internal opening of the urethra. Microscopically, these growths consist of a number of villi, each of which is composed of a basement membrane continuous with that of the mucous or submucous connective, covered with a thick layer of columnar or spheroidal epithelium. Each villus incloses one or more capillary vessels, arranged in loops which often present a varicose appearance. Treatment. — With regard to the treatment of these growths, it must be remembered that there is nothing either in their structure or in their clinical history to lead to the belief that they would be incurable, provided that we had means of directly dealing with them either by destroying or removing them. On the contrary, there are reasons for believing that in a few instances they have disappeared, or at all events have ceased to produce symptoms; possibly, as Dr. Habershon has suggested, they may have been effectually disposed of by a process of sloughing, such as sometimes occurs with other vascular bodies. In considering their treatment, reference must be had, first, to the possibility of cure, and secondly, to the palliation of the symptoms to which they give rise. In dealing with some of the methods of treatment which have been successfully adopted, we are met by the objection that indisputable evidence of the presence of these growths has not in these cases been furnished ; that is, though suspected, it has never been absolutely demonstrated ; and this objection applies to a case of my own, hitherto unpublished, in which I had good reasons for believing that I was dealing with a papilloma : — Early in 1877, a gentleman aged 34 consulted me for persistent hEematuria : he begged that I would not sound him as others had done, assuring me that the absence of stone was proved beyond a doubt, and that each operation was invariably followed by a serious aggravation of his symptoms. He was very much blanched, and I was not sorry to acquiesce in his wish. He had been ill in this way for nearly three years, having from time to time varying periods during which the urine was free from blood. There was no cause that I could discover ; no history of renal colic, nor anything to furnish a clue. A jolt in a carriage was invariably followed by a recurrence of the hemorrhage. He told me that he had taken almost every styptic and astringent that the pharmacopoeia contained. I examined his urine, which contained blood and clots in considerable quantities, but could discover no organized shreds, though I looked for them on several occasions. At this time I was engaged in making some experiments on the arresting of hemorrhage with hot water. As I had come to the conclusion that the hemorrhage in this case was from the bladder, probably from a villous growth, I determined to try it here. Accordingly, a double-current catheter was arranged, with which the patient injected into his bladder, twice a day, small quantities of hot water in gradually in- creasing amounts. We commenced with water at 96° Fahr. and gradually increased the temperature until 116° Fahr. was reached, which point was maintained for nearly a month. In a week the blood had entirely disappeared. 1 saw this patient several years afterwards ; he was perfectly well, and had suffered no recurrence of hsematuria from the time that he had first used the hot douche. TUMORS OF THE BLADDER. 357 I give this case for what it is worth, merely remarking that I believed it to be one of papilloma. The remarkable eit'ect of hot water in blanching tissues and removing congestion from mucous membranes is now so well recognized, that I may be excused for referring to it in connection with its application to the treatment of these growths. The use of astringents and styptics,, by the mouth, or locally by injection, has not given any very reliable results. Gallic and sulphuric acids, acetate of lead, iron, turpentine, ergot, matico, and hamamelis, have all been tried with some degree of success. Of the various means for arresting hemor- rhage and soothing the local irritation which is aroused, I have found the ap- plication of a bag of ice above the pubes, and the use of opium suppositories, of most service. The influence of cold and rest in controlling hemorrhage is well understood, and they are applicable here. My experience of heat, as already detailed, would lead me to try it again, provided that I could bring it in actual contact with the spot from which the hemorrhage proceeded. The injection into the bladder of a weak solution of nitrate of silver (gr. ^-f 3j), has sometimes proved efficacious. The operative measures which have been resorted to will now be con- sidered. As already pointed out, these growths are not necessarily of a malignant nature, and there is good reason for believing that occasionally they disappear spontaneously, either as a consequence of their accidental selt- strangulation, or by sloughing, coincident with an attack of cystitis. Hence, with more perfect means for making a diagnosis, there is no reason why they should not be included with others which are curable by operation. Civiale appears to have attempted their removal by evulsion with the lithotrite, but the results of this somewhat hazardous and indiscriminate mode of pro- •cedure do not seem to have encouraged its adoption by other operators. The precision and freedom necessary for the complete removal of these tumors ■can obviously only be obtained by cystotomy and direct exploration of the bladder. To remove a portion of a villous growth is worse than useless. The first complete operation of this kind appears to have been performed by Mr. Crosse, of JSTorwieh, who, like other operators, performed cystotomy under the belief that the bladder might contain a calculus. A mass of poly- poid excrescences was found and removed, but the child died in forty-eight hours. ' From this date (1835) up to the present a somewhat similar procedure has heen adopted in at least ninety-eight cases, as will be seen from the table on page 360. Dr. Gross points out that, on account of the multiplicity of the tumors; the operation holds out little prospect of relief in children unless it be by supra-pubic incision. In a case recorded by Mr. Howard Marsh,^ both the bladder and vagina of a child of two years were completely filled with polypoid excrescences. We may now proceed to consider in detail the various operations which have been adopted in these cases. The bladder has been opened in the following ways : (1) by median cyst- otomy, (2) by perineal urethrotomy and dilation of the vesical neck, (3) by lateral cystotomy, (4) by median cystotomy, followed by supra-pubic incision, (5) by supra-pubic cystotomy alone, (6) — in the female — by rapid dilatation of the urethra, and (7) by section of the urethra and extension of the incision into the base of the bladder. Lateral cystotomy, as for stone, was the operation practised in Professor Humphry's case. There is much to be said in favor of the lateral over any median operation. By means of the former, a far more thorough exploration of the bladder can be made with the finger, and, if necessary, additional ' Trans. Path. Soo. Lond., vol. xxf. 858 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. room can be readily obtained by bilateral section of the prostate, as is done for the removal of large stones. Possibly a median cystotomy may commend itself to some by reason of the diminished risk of wounding any vessel large- enough to give'rise to troublesome, if not dangerous, hemorrhage. It must be remembered, howrever, that complete ablation of the growth is the object of the proceeding, and that on the thoroughness with which this is done depends, its success. From a tolerably large experience of lithotomy and cystotomy, I have no hesitation in saying which mode of opening the bladder gives the- greater facilities for conducting manipulations within its interior. If a lateral cystotomy were found not to provide sufficient room to permit of the- removal of the growth, supra-pubic incision might supplement it after the- plan adopted by Billroth.* In his case, the tumor having been removed, a. drainage-tube was passed through the bladder and allowed to hang out from the lower opening.^ In the female, dilatation of the urethra is the first pro- ceeding to be adopted, and in some instances this alone has given ample room. Where more space has been required, a 7nedian incision through the urethra and vesico-vaginal septum ha^ been practised. Having obtained access to the tumor or tumors, we may now proceed to- consider the various means by which they may be separated from the vesical walls. In some cases, avulsion with the finger, aided, as in Humphry's case,, by the forceps, has been sufficient. In Crosse's case scissors were employed. In the female, ligature of the growth has been more frequently resorted to than any other proceeding. A convenient mode of applying the ligature is- by a double canula ; in this way the loop can be slipped down to the attach- ment of the tumor and strangulation readily effected. From none of the- reports of the operation does it appear that any serious or uncontrollable hemorrhage has resulted. Dr. Gross suggests that before resorting to any cutting operation irrigation of the bladder might be tried. I have already alluded to a case in which a- considerable portion of a villous growth was found impacted in the return- tube of a double-current catheter. Mucous GROWTHS OR MYXOMATA, identical in every respect with the mucous polypi of the nose, are occasionally met with in the bladder. The extent of their surface-connection with tlie vesical lining membrane is variable, the- attachments of the growths being slight and fragile in some cases, while in others they involve a considerable area. They are entirely confined to the mucous membrane, being unconnected with the other coats of the organ. ISTot unfrequently they are associated with more or loss hypertrophy of the- muscular tunic, a circumstance which is readily explicable. The symptoms to which these growths give rise simulate those of stone in- the bladder. It has, however, been generally noticed that in striking con- trast to what happens with villous growths, myxomata are seldom accom- panied by hemori'hage. The bladder is irritable, and there is much paia and straining ; the urine usually contains mucus and an abundance of epithe- lium. Examination of the bladder by the sound, in conjunction with the finger in the rectum, determines the absence of a stone, and the probable pre- sence of a growth, which, in some instances, has been so large as almost to- fill the interior of the viscus. In the female, dilatation of the urethra and. direct exploration of the bladder with the finger can, generally, be practised.. 1 Arohiv f. klin. Chir., Bd. xviii. S. 411. ^ Dr. A. Patterson (Glasgo-w- Medical Journal, April, 1882) has recently recorded a case ot lithotomy, in -which, after making the lateral incision into the bladder, it -was found impossible to extract the stone by this way. A supra-pubic opening was made in addition, and through thia a large calculus was withdrawn. The patient made a good recovery. TUMOKS OF THE BLADDER. 359 Amongst the most characteristic instances of these growths are those recorded by Mr. Crosse and by Mr. Savory.^ In the former, the bladder, on being opened, was found filled with polypi, in every way resembling those of the nose. Their removal could only be eifected by the finger and a pair of scissors, and death occurred after violent fits of tenesmus within forty-eight hours. In Mr. Savory's case, the patient, a female child aged thirteen months, had sufi:'ered from symptoms resembling those of stone. This case was further complicated by the existence of a patent and suppurating urachus, a condition probably attributable to the passage of urine by the urethra having been obstructed by the tumor within the bladder. Post-mortem examination showed this to consist of a pendulous growth, identical in structure with nasal polypi, attached to the inner surface of the bladder behind the orifices of the ureters, which were much dilated. The specimen will be found in the Museum of St. Bartholomew's Hospital. It has been said that a growth of this kind may be mistaken for eversion of the bladder, or for a vascular tumor of the urethra. Careful examination with the finger or the probe, for the purpose of tracing the relations and connections of the protrusion, will insure a correct diagnosis. Fibrous growths or fibromata are, as the name implies, firmer and more fibrous in their structure than the tumors already considered. These growths appear to take origin in the submucous tissue of the bladder, being circum- scribed in their attachment, or even pedunculated. One of the best exam- ples of this kind of growth, to which reference has been made in connection with cystotomy for intra-vesical tumors, is recorded by Professor Humphry.' It is as follows : — W. N , aged 21, light-complexioned, healthy-looking, was admitted into Adden- brooke's Hospital, Cambridge, on September 17, 1877. Six weeks previously he had begun to feel pain at the root of the penis after micturition, and the desire to pass water had become frequent. At the time of his admission he had, in addition, blood in the urine after any exertion ; but this subsided completely, or nearly so, when he remained in bed. He several times made the attempt to get up ; on his doing so, however, the blood invariably reappeared, and the other symptoms were aggravated. Occasionally the flow of water suddenly stopped during micturition. There were pus and blood- corpuscles in the urine, also crystals of oxalate of lime and epithelial scales, but no casts from the kidneys. I sounded him on two or three occasions, but could not discover a calculus, nor obtain any other information as to the nature of the disease. The sounding was always fol- lowed by bleeding. Under treatment, the oxalate crystals disappeared, but no improve- ment in the other symptoms took place. On the contrary, they became more severe, especially the pain and straining, which were relieved only by opium. A flexible cath- eter was left in the bladder, but it could not be borne. A firmish mass could be felt above and behind the pubis, and from the rectum ; it appeared to occupy the position of, and to be connected with, the bladder. The patient wasted, and his sufferings were so great that I determined to make an incision into the bladder, for the purpose of ascer- taining the precise nature and situation of the disease, and of taking any further steps which might offer a prospect of relief. If the disease were merely inflammatory and ulcerative, a free exit for the contents of the bladder might prove beneficial. If, as there was much reason to believe, a growth had taken place into the bladder, the opera- tion would do no harm, and there might be a possibility of removing the growth. Accordingly, on October 17, I cut into the bladder on a staff introduced through the urethra, making the usual incision for the lateral operation of lithotomy, and, intro- ducing my finger, found the bladder occupied by a firm mass, about the size of an orange, with a ragged surface. It was attached by a pedicle as thick as my finger, to the inte- rior of the bladder, near the orifice of the right ureter. Partly with the finger, and ' Med. Times and Gazette, vol. ii. 1852. 2 Medico-Chirurgical Transactions, vol. Ixii. 360 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. partly with forceps, I contrived to tear through this pedicle, and then extracted the detached mass with lithotomy forceps. I next, with my finger-nail, scratched out what I judged to be the root of the polypus, taking care not to perforate the coats of the blad- der, for fear of admitting the urine into the cellplar tissue of the pelvis. The growth was of moderately firm structure, of the kind called fibroma or fibro-sareoma. During four and twenty hours after the operation, great pain was experienced about the region of the bladder ; the urine flowed through the wound. For two days subse- quently there was comparative ease. Then the pain returned with even greater sever- ity than before the operation. It was relieved only by subcutaneous injections of mor- phia, the quantity of which we were obliged to increase till it amounted to three grains in the twenty-four hours. In the intervals, when the influence of the morphia was pass- ing off, the patient's cries were loud and incessant. The wound became coated with phosphates, and the bowels were very constipated, evacuations being obtained with much diflRculty through the agency of medicines and enemata. This state of things went on for about two months. We supposed that the disease had returned or had been incom- pletely removed, and we had little hope of the patient's recovery. After that time, however, to our surprise, he began to mend ; the pain diminished, and the quantity of morphia was lessened ; the wound assumed a healthy appearance and healed up ; the urine was passed by the natural passage, without pain and at longer intervals. In the early part of January, 1878, he was well enough to return home, and was quite well and at work in January, 1879. "With reference to the treatment of the last two forms of vesical tumor which have been described, the remarks made iu connection with the subject of papilloma are equally applicable. The removal of these growths has been safely effected by cystotomy, which is, as a rule, to be recommended. Before proceeding to consider the remaining group of tumors affecting the bladder, I would take the opportunity of urging the more general employ- ment of cystotomy as an exploratory operation in cases of doubtful nature, where there are good reasons for believing that the disease is situated within the limits of the bladder, and where other treatment has failed to give relief. Where tumors have in this way been discovered, and have been found to be bej'ond removal, the patient's condition has not, as a rule, been seriously aggravated by a properly performed cystotomy. On the contrary, there are many instances where, though the operation may have failed to cure, it has relieved by freeing the patient from the distress which is invariably associated with impeded micturition and pent-up discharges, derived both from the urine and from the growths. [Dr. Stein,! of New York, has collected 98 cases in which tumors have been removed from the bladder, 53 in male and 45 in female patients. The nature of the operation, and the result, in these cases, may be seen from the following table : — Nature of operation. Cases. Recov- ered. Died. Undeter- miued. Mortality per cent. (Males). External perineal urethrotomy Perineal cystotomy Supra-pubio cystotomy Perineal and supra-pubic incisions combined . (Females). Urethral dilatation Vaginal incision 31 10 10 2 37 8 17 6 1 24 5 14 3 8 1 10 3 i" 2 3 43.9 33.3 88.9 50.0 29.4 37.5 Aggregates 98 53 39 6 39.8 Medical Record, March 14, 1885. TUMORS OF THE BLADDER. 361 It should be mentioned also that Civiale succeeded in removing a small tumor from the male bladder by grasping it with a lithotrite, and that Sonnenburg has removed a iibro-sarcoma from the female bladder by resect- ing its anterior wall. The patient died some weeks after the operation. Listen removed a cyst of false membrane, or, more probably, a cast of ex- foliated mucous membrane, from the bladder by the supra-pubic incision, and successful perineal operations, not included in Dr. Stein's list, have been recorded by Duplay, Pitts, and Anderson.] Malignant Growths of the Bladder. — Among malignant and cancerous tumors affecting the bladder, we must include some which involve it by con- tiguity. The kinds of carcinoma affecting the bladder are, scirrhous, encepha- loid, and epithelial. Authors appear to differ considerably in their estimates of the relative frequency of these. Scirrhus, as far as my own observation goes, when it affects the bladder does so only secondarily, that is to say, as an extension from some other organ, such as the uterus or vagina in the female, or the rectum or prostate in the male. Gross' observes that — The usual variety of carcinoma, met with in the bladder, as shown by modern histological research, is the epithelial. What was formerly known as scirrhus, is nothing more than the firm, infiltrating form of epithelioma, characterized by a dense stroma of fibrous tissue, pervaded by small and infrequent alveoli, which contain heaps of loose epithelial cells and epidermic pearls. The soft, juicy, medullary, or fungoid form of the affection, generally denominated encephaloid, is of the same nature, but its stroma is more delicate and more vascular, and the loculi larger, while the cells are the seat of granular and fatty metamorphosis and disintegration. In many specimens the latter assume a cylindrical shape, when the mass presents the minute appearances afforded by cylindrical epithelioma of the gastro-intestinal mucous track. Other varieties of carcinoma are almost unknown. Though malignant growths of the bladder usuallj^ proceed very rapidly, .epitheliomata of slow progress are met with. Sir Henry Thompson records the following instance : — ^ A preparation which I exhibited at the Pathological Society was from the body of a patient who certainly had been the subject of it for eight or ten years. In his case the symptoms resembled those of stone, only that the slightest degree of movement produced bleeding in the later stages. Injections of nitrate of silver, from half a grain to a grain to the ounce, controlled this tendency remarkably, and enabled him to walk a mile or two without hemorrhage. After death the same deposit was found in one kidney. Sarcoma is one of the rarest diseases of the bladder. Heath^ records the case of a woman, aged 39, whose bladder w^as found largely occupied by a villous growth situated on a hardened base which proved to be a round- celled sarcoma. Like carcinoma, sarcoma of the bladder may be primary or secondary ; it may be round-celled or sjsindle-celled, and may assume, in the course of its growth, an appearance not unlike that of a papilloma. Com- menting on the asserted infrequency of these tumors. Dr. Stein^ remarks, " seeing the resemblance between round-celled sarcoma and encephaloid cancer in regard both to their clinical and physical characters, and in the absence of microscopical data, we are with Gross in the belief, that probably many tumors formerly described as encephaloid cancer, belonged to the variety of soft sarcomata." When undergoing ulceration, malignant tumors of the bladder, by throwing out excrescences, sometimes assume an appearance not unlike that of ordi- ' Opi olt., p. 143. ^ Holmes's System of Surgery, vol. iv. p. 900. ' Medical Times and Gazette, vol. ii. 1879. * Study of Tumors of the Bladder, p. 35. New York, 1881. 362 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. nary villous growths, wlaence*the term villous cancer has been wrongly applied to them. Cancer of the bladder is seldom seen involving the front or summit of the organ, but usually appears about the neck or trigone, or at the opening of the ureters, and as a rule proceeds with much rapidity. Com- mencing as a general infiltration of the coats of the bladder, it soon passes on to ulceration. Surrounding organs not unfrequently become infiltrated, and death ensues from perforation and urinary infiltration, or from exhaus- tion. The disease in its early stages is often obscure, sudden and consider- able discharges of blood being the only symptom. Then cystitis comes on, and, with other signs of ulceration, cells 8.nd even fragments of the tumor have sometimes been found in the urine. Microscopical examination of these has thrown light on the case, but this evidence is perhaps hardly trustworthy further than as showing that structural disintegration is going on. Exploration of the bladder with the sound, although it often aggravates the symptoms, generally adds some evidence as to the presence of the disease. Lymphatic glandular enlargement may be detected in thin subjects. Pain is generally referred to the loins, and there is more or less interference with micturitioh. The cancerous cachexia is often well marked. Where cancer involves the bladder by perforation from some other organ, such as the rectum, when it ulcerates from the bladder into the bowel, the patient's condition becomes an extremely distressing one. Whilst urine enters the rectum, flatus and feces find admission into, the bladder, and the most painful symptoms result. Treatment. — In the management of these malignant aft'ections, there is, un- fortunately, little to be done but to palliate with opium or other sedatives, given in sufficient quantities to assuage pain. Chian turpentine has been recently advocated by Dr. Clay, of Birmingham,^ for the treatment of vesical cancer, accompanied with hemorrhage, but it does not appear that much benefit has been derived from its use. When by a cancerous ulceration the bladder and rectum have been made to communicate, the question of lumbar colotomy may be entertained. As a rule, much relief has followed by diverting the flow of feces, and by thus pre- venting the two excretions from falling into a common cloaca. In certain cases of cancer of the rectum, where, from the vesical tenesmus and cystitis, it is evident that the bladder is about to be involved in the cancerous extension, it is well to anticipate by colotomy the formation of a communication between these viscera. In this way much suffering may be saved, though the ultimate result is unchanged. From the study of observations and statistics relating to tumors of the bladder. Dr. Stein^ has formulated the following conclusions : — ■ 1. In a few remarkable instances, in the case of women, apparent recovery seems to have resulted from a spontaneous expulsion of growths from the bladder. But in ' general it may be said that tumors of the bladder, if uninterfered witli, are inevitably fetal ; and, although they may exist for several years without creating much distress, a fatal termination almost invariably ensues in a few weeks or months from the outbreak of active symptoms. 2. Death results most frequently from hemorrhage, and from the effects of mechanical obstruction to the outflow of urine. Hence, the indication would be to remove the growth while the general condition of the patient was yet favorable for an operation ; before the subject had become exhausted from loss of blood, or the kidneys and bladder had become so much diseased as to make recovery impossible, even in the event of the successful extirpation of the growth. 3. In women, because of the accessibility of the bladder to direct exploration, there is no excuse for temporizing, and the surgeon should lose no time in acquiring an exact knowledge as to the existence, nature, etc., of the tumor, and, if practicable, should attempt its removal as early as possible. 1 Lancet," March 27, 1880. » Op. oit., p. 93. TUBERCLE OF THE BLADDER. 363 4. The results thus far attained by surgical interference, in the cases of women, could scarcely be more satisfactory, and, excepting one instance in which the bladder was accidentally perforated, it does not appear that the fatal termination was precipitated by the operation in any of the cases. 5. In the male, the propriety of operative interference must necessarily always be a more serious question, because of the occasional uncertainty of diagnosis, and because of the gravity of the undertaking necessary for the removal of the growth. Nevertheless,. the results thus far attained by operation are most encouraging, and in every way justify a repetition of the same. 6. From a number of autopsies, we learn that the successful operations might have been multiplied, first, in those cases in which no operation was attempted, although the growths could have been easily removed, and with apparently every prospect of success ; and, again, in those in which the operation was too long deferred, and which,, it is reasonable to assume, would have terminated successfully had the same been under- taken at an earlier period. 7. Given a positive diagnosis of tumor, the absence of severe secondary symptoms should be no excuse for deferring the operation. On the contrary, the earlier the growth is removed the better the prospect of complete recovery. With a healthy bladder and kidneys, cystotomy is not so dangerous an operation as to warrant any delay. 8. Evidence strongly pointing to the existence of a tumor, with severe catarrhal symptoms, or with spasm of the bladder and much sutfering, will often justify an opera- tion ; for if a tumor be found, its extirpation will alFord the only chance for life ; and if no growth exist, or the bladder be occupied by an irremovable cancer, the cystotomy may at least afford temporary relief from suffering. lu concluding this description of tumors of the bladder, I wish to lay stress on what Professor Volkmann speaks of as " the bimanual exploration of the bladder." The following is an account of the method, from Mr. Coulson's. work : — ' This is effected by passing 'two fingers of the left hand as far as possible into the rectum, the patient being under the influence of chloroform. An assistant places both hands above the symphysis, and makes pressure downwards and backwards towards the rectum. When the adipose tissue is not very abundant, and the bladder nearly empty^ the superior fundus of the organ is brought near to the fingers. If anything abnormal is felt, the surgeon passes his right hand carefully under the hand of the assistant, and endeavors to ascertain more closely the nature of the object. By this plan Professor Volkmann asserts that he has been able to detect the presence of a calculus no larger than a bean. The manipulation must, however, be conducted as gently as possible. In one case it was evidently the cause of ecchymoses, found after death, in the coats- of the bladder. The introduction of the hand into the rectum for the examination of the bladder has recently been employed. It is a practice which can only be adopted under very exceptional circumstances. Few surgeons possess a hand sufficiently delicate and tapering to permit of their practising this manipula- tion without inflicting considerable damage ; though Dr. Gr. Simon^ asserts- that in no instance has permanent incontinence of feces been the I'esult. For examining the interior of the bladder, we are provided with a variety of sounds and other instruments which it will be unnecessary to describe here. Tubercle of the Bladder. Tubercle of the bladder is to be included among its rarer affections. It is most frequently met with in adult males between the ages of twenty ' Op. eit., p. 31. 2 Archiv fiir klinische Chirurgie, Bd. xv. S. 1. 364 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. and fortj'-five years. It is generally accompanied with similar deposits in other viscera, but its independent existence in the genito-urinary organs has been noted sufficiently often for its being specified as forming one of the exceptions to the well-known law of Louis, according to which tubercles are to be found in the lungs if they are present elsewhere in the body. Hence Ouibhard' classifies cases of this affection as either primary or secondary. The deposit takes the form of miliary tubercles, which are observed chiefly about the neck and base of the bladder. As a rule, the disease appears to extend in the course of the urinary flow — downwards from the kidneys. Coalescence of the various deposits occurs, the mucous membrane breaks down, ulceration follows, and before death takes place large portions of the lining membrane are entirely removed. The disease is of slow progress, and generally proves fatal by its extension to other parts of the urinary tract, or by pulmonary complications. Perforation of the bladder followed by fatal peritonitis as a termination of this disease has been but rarely observed. Such a case is recorded by Sir Prescott Hewett,'' where both an anterior and posterior perforation took place into the rectum. Where repair has followed tubercular ulceration of the bladder, a cretaceous cicatrix has sometimes been the result, a circumstance which has led to the suspicion that the patient was suffering from stone. The symptoms of vesical tuberculosis are in some respects similar to those occasioned by a vesical calculus, and the absence of such a cause for the symp- toms, as determined by the sound, is of considerable value to the surgeon in arriving at a diagnosis. Amongst the earliest manifestations of the disease, it has been pointed out' that attacks of premonitory hsematuria are frequently observed. Aching or burning pain in the hypogastric region, with pain and tenderness referred to the neck of the bladder, are often complained of. More or less pain usually precedes as well as accompanies the act of micturition, and there is the greatest degree of comfort when the bladder has been just emptied, though the expulsion of the last few drops often provokes most distressing spasm. As the viscus refills, the desire to evacuate its contents returns, whence the disorder is generally accompanied with considerable irritability and vesical contraction. _ Dilatation of the ureters is almost invariably met with in these cases ; in one instance of this kind that came under my notice, the uretere were so dilated as to render them capable of acting as reservoirs for urine, the bladder being found studded with tubercle, and so contracted as to resemble a rudimentary organ. The urine is more or less purulent, often contains blood, and sometimes shreds of disintegrated tissue. The use of the sound is generally followed by hemorrhage, but it may I'eveal the existence of some irregularity in the lining membrane of the organ. As the disease advances, it is often accorapEmied with considerable variations of temperature, which, together with the presence of the other symptoms referred to, and the proved absence Of stone, may be said to constitute the points on which a diagnosis is to be founded. In the treatment of this affection, regard must be had to its diathetic •character. It is the local manifestation of a constitutional disorder. Recourse must be had to those general meassres which are recognized as being indi- cated when tubercle is present in any organ of the body. Locally, soothing xneasures, directed to the allaying of pain and irritation, are those which experience commends. For this purpose a milk diet, in connection with ' Etude snr la Cystite Tubercnleuse. Paris, 1878. » Trans. Clin. Soc. Lond., 1874. 3 Tapret, iStude clinique sur la tuberculose urinaire. Archives GSnerales de M^deoine, Mai et Juillet, 1878. Bierry, De la Tuberculose Primitive des Voies Uriiiaires. Paris, 1878. BAR AT NECK OF BLADDER. 365 the use of anodyne suppositories, will be found most serviceable. Where there is hemorrhage from the ulcerating surfaces, the use of a weak injection of nitrate of silver (gr. J-f oj) has proved of much value, although as a rule, after the diagnosis has been made, all instrumental interference yvith the bladder is to be avoided. Bar at Neck op Bladder. An impediment to micturition is sometimes occasioned by a condition to which the term " bar at the neck of the bladder" has been assigned. Though occurring independently of any enlargement of the prostate, it is generally associated with it. A careful analysis of recorded cases warrants the conclu- sion that at 'least three varieties of the aflectiou may be described, namely: (1) spasmodic, (2) mucous, (3) muscular. A spasmodic barrier has long been recognized, chiefly by French authori- ties,^ under the term contracture du col vesical. It may be found where no enlargement of the prostate exists, and appears to consist of an incoordinated or spasmodic action of some of the muscles engaged in the act of micturition. It is almost invariably met with in persons of a rheumatic or gouty 'disposi- tion, who pass highly acid or otherwise disordered urine. Hence its cure lies iii the treatment of the diathetic condition which leads to its production. In addition to the ordinary remedies employed for gout and rheumatism, advantage may often be obtained from a course at certain watering places ; of these may be mentioned Vichy, Vals, Contrexville, and Evian. When the exciting cause of the spasm has been removed, much benefit may be derived from the application to the prostatic urethra of a solution of nitrate of silver \gv. ij-fgj), for the purpose of removing the extreme sensitiveness which sometimes remains. The other two varieties of bar I have never seen apart from enlargement of the prostate, of which condition I regard them as results. Mr. Guthrie appears to have been one of the first to observe these changes, and to suggest means for their relief. The formation of a mucous bar may be well studied in .certain varieties of symmetrical enlargement of the lateral lobes of the prostate. In some of these specimens, a distinct, crescentic duplicature of mucous membrane can be seen guarding, so to speak, the vesical orifice of the urethra ; its connection with the lateral prostatic enlargements may often be rendered very obvious by separating the lobes after the urethra has been opened along its roof, when greater or less distinctness is given to the bar according to the amount of separation eflJ'ected. In fact, a bar may in in this way be artificially produced which does not exist in the undisturbed relations of the parts. That in some cases an impediment to micturition independent of prostatic hypertrophy may be thus produced, is apparent from an examination of the internal meatus before a section of the urethra has been made. This variety of bar may exist when rectal examination ^fiords little evi- dence of prostatic enlargement, the reason being that the latter consists for the most part of a lateral expansion of the gland, which is only indicated by some increase in its breadth, and possibly by a slight obstacle, or hitch, as the catheter reaches the prostatic urethra. It is almost impossible to disassociate it in its symptoms from the hypertrophy of which it is a result. The third variety, or muscular bar, consists of an aggregation of some of the muscular fibres which run transversely across the trigone behind the ' Delefosse, Le90ris Cliniques sur la Contracture du Col Vesical. Paris, 1879. 366 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. prostate. Occasionally the elevation is so marked that it forms, as it were, two compartments, an upper and a lower one, in the wall of the bladder. Although the obstruction is structurally unconnected with enlargement of the prostate, it is rarely seen except in company with it. In explaining the production of this muscular barrier, there are grounds for regarding it as an illustration of a partial hypertrophy of the muscular coat of the bladder. As the prostate enlarges, a pouch often forms immediately behind it, in which urine is disposed to lodge. It is not unreasonable to suppose that, by an increase in the muscular fibres of the trigone, some pi-ovision is made, or a,ttempted, for the evacuation of a part of the bladder, which, by the enlarge- ment referred to, is placed at a disadvantage so far as outlet is concerned. Treatment. — In reference to the treatment of the two latter varieties, it is, as already stated, exceedingly difficult, if not impossible, to disassociate their symptoms from those of the prostatic enlargement which almost invariably coexists. Gruthrie appears to lay most stress, in the diagnosis of this affec- tion, on the detection of an obstacle to the passage of an instrument through the prostatic urethra, in addition to other symptoms of impeded micturition in elderly persons. "Where there are reasons for entertaining the belief that such an obstacle exists, endeavors must first be made to overcome it by the judicious employ- ment of prostatic dilatation, care being at the same time taken to avoid con- sequences arising from urine being retained and allowed to decompose in the bladder. The form of dilator presently to be I'eferred to in connection with the early treatment of prostatic obstruction, will be found best suited for ful- iilliug the object now in view. Where relief is not possible by other means, section of the obstacle by some form of urethrotome, or concealed knife, has been practised and recommended by several surgeons of experience, including Guthrie, Mercier, Teevan, and Gouley. Such operations are not, however, to be lightly undertaken. As this subject will again come under notice in connection with the treatment of enlarged prostate, further reference to it will be for the present postponed. Experience, however, justifies the conclusion that the persistent emploj'ment of suitable bougies, where there is reason to believe that some structural barrier exists, such as a band, an enlarged prostate, or both, is capable, in the great majority of cases, of giving permanent relief without resorting to more strictly operative proceedings. Fissure of the Bladder. A fissure or crack at the neck of the bladder is an occasional cause of much •distress, both to male and female patients ; it is most frequently met with in the latter. The symptoms are very similar to those observed when fissure exists a1 other orifices. There is frequent micturition, with a sensation, often described as resembling alternating dilatation and contraction, at the close of the act which is very significant. Sometimes a few drops of blood escape after the urine has been expelled, followed by a sharp, stinging pain, referred to the neck of the bladder. The pain varies in degree in the same patient, being usually intense when the urine is highly acid, diminishing in severity as neu trality is approached. Examination of the prostate in the male, and of the neck of the bladder in the female, invariably produces, on pressure, a sharp lancinating pain, as if a knife were being inserted, which is very characteris tic of the affection. Similarly, the passing of an instrument into the bladdei is attended with much distress. Occasionally these cases are referred to som( IRRITABLE BLADDER. 367 gouty or rheumatic affection, and are mistaken for a condition, already men- tioned, well known in French literature under the title of contracture du col vesical. As the treatment of the latter affection includes the rendering of the patient's urine more or less alkaline, the local symptoms are thereby improved when a fissure exists, a circumstance which is pointed to as confirmatory of the diagnosis. The improvement, however, only continues as long as the alkaline reaction of the urine is maintained. Vesical fissure, though palliated, is seldom cured by such means. The principles of treatment for this affection are much the same as those recognized when fissure is met with elsewhere. A cure is sometimes effected by keeping the urine neutral or slightly alkaline, combined with the occa- sional application of a weak solution of nitrate of silver (one grain to the ounce) to the prostatic urethra. In other cases permanent benefit is only obtained by establishing a temporary condition of incontinence : this, in the male, may be best accomplished by cystotomy, and in the female, by rapid dilatation of the urethra. I have performed a lateral cystotomy for fissure, where the suffering of the patient far exceeded anything observed when a stone is present in the bladder, and with complete success. Irritable Bladder. This term has been used as expressing a disease rather than a symptom, and hence some confusion has arisen in the application of therapeutics to the conditions on Avhich it depends. By " irritable bladder," it is meant that micturition is performed unnaturally often, without regard to the number of times that a healthy person should urinate in the twenty-four hours. There are variations dependent upon circumstances, and to some extent on individual peculiarities, which would render any attempt to indicate the fre- quency with which urine should be voided, in order to constitute irritable bladder, almost ridiculous ; and therefore, unless a person be in some way inconvenienced thereby, he cannot be regarded as the subject of this condition. Causes. — Irritability of the bladder is generally traceable to one or other of the following conditions, some of which may coexist : nervous influence, habit, reflected action, structural diseases — including tumors and calculous disorders — and an abnormal state of the urine. Unless careful inquiry be made as to the cause of the irritability, treatment must necessarily be em- pirical. There can be no doubt that a considerable number of persons trace the irritability of their bladder to purely nervous causes. It often happens that individuals, in anticipation of a railway journey, for instance, or other occa- sion by which their ordinary habits may be interfered with, for days previously empty their bladders on every possible opportunity. In this way a habit is established, which may eventually become very distressing. ISTearly allied to this is the condition so graphically described by Sir James Paget,^ as " stammering with the urinary organs." Nervousness, and a bad habit combined, are quite sufficient to produce very intractable forms of urinary irritability. In these cases there are, as a rule, no objective symptoms ; the history of the irritability, the circumstances influencing it, and the employment of a process of exclusion, are the points upon which reliance should be placed in forming a diagnosis. In their management, we should not forget that a 1 Clinical Lectures and Essays. 368 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. common-sense explanation in reference to the peculiar dread which the patient has, is often not without avail. The strange vagaries that are sometimes met with under these circumstances, are apt to try the patience of those who have to listen to their narration, and indicate that the head has often more to do with the irritability than the bladder. Such cases are benefited by the various preparations of iron, nux vomica, strychnine, and phosphorus, iu addition to other hygienic measures. Persons who have had reason, how- ever slight, for believing that they suffer from stricture, not unfrequently develop irritable bladder. I have seen this condition follow on all kinds of misapprehension in regard to normal acts of micturition ; upon the unskilful introduction of instruments undertaken with the object of removing the patient's doubts ; or on a groundless dread of inability to void urine, inducing a frequent repetition of the act, which has eventually resulted in the setting up of irritability. It is astonishing how many persons may be completely cured of this symptom by demonstrating to them the ease with which a bougie may be made to enter the bladder. Irritability dependent on reflected action is most commonly met with in children and young persons. An illustration of this cause is furnished by the irritiation attending the presence of intestinal worms ; and similarly, the cutting of a tooth in a child has been known to produce the same eftect. In youths, particularly, and even those of more advanced age, a constant desire to mictu- rate may be kept up by an elongated and contracted prepuce, retaining secre- tions which have excited local inflammation. Irritability dependent upon stniciural changes in the urinary organs, growths, and calculous affections, is a frequent concomitant of those disorders; nor are these causes entirely confined to such diseases of the urinary organs as more commonly come under the notice of the surgeon. Certain forms and stages of purely renal affections do not seldom give rise to this symptom. Similarly, irritation is provoked by enlargement of the prostate, particu- larly at the commencement of the disease. At this stage it would be more correct to speak of it as senile engorgement of the prostatic veins, a condition which often precedes and is mistaken for the structural enlargement of the gland with which we are familiar. The irritability connected with the prostatic engorgement shows itself chiefly at night. The patient is perfectly well during the day, but as soon as he gets into bed he experiences a desii'e to pass water, which further disturbs his rest by provoking other calls after intervals of varying extent ; or it may show itself by inducing a state of more or less priapism, which equally interferes with sleep. During the day, as already stated, the patient is free from irritability- ; it only occurs at night. In this condition, physical examination with the finger in the rectum, or a catheter in the bladder, frequently fails to detect any signs of prostatic hyper- trophy ; possibly all that may be noted is a distended or varicose condition of the veins immediately in front of the finger. Provided, as is most usually the case, that there is nothing in the state of the urine to account for this, some very simple expedients are not unfrequently of service in remedying, if not entirely putting a stop to, this symptom. The wearing of warm socks at night, or the use of a hot bottle to the feet, by determining a flow of blood to the legs has often been useful — a fact which leads to the belief that the appearance of this symptom only at night is due to some alteration in the venous condition of the part, by reason of the change in position. Senile engorgement and hypertrophy, of the gland not only follow in suc- cession, but the two conditions frequently coexist. Irritability of the bladder arising from an enlarging prostate, is usually determined without difBculty by physical examination. It will be noticed that the irritability of hyper- trophy varies somewhat in the precise mode of its causation. In the earlier IKRITABLE BLADDER. 369 stages of the enlargement, especially in gouty subjects passing acid urine, the irritation comes on immediately after the bladder has been emptied, and the desire will remain for an hour or so until the urine has collected, and a water- bed is as it were interposed between the muscular pressure of the bladder and the tender or gouty prostate. Then there is an interval of repose until urine is again passed, when the same process, accompanied by similar sensations, is repeated. The irritability of the subsequent stages of prostatic enlargement is somewhat diflerent in its character, being due to the presence of residual urine, with the chronic cystitis which the pathological state of uncleanliness has engendered. The difference has this import : the former is aggravated by catheterization, as usually practised, whilst the latter is remedied by catheterization, combined with irrigation of the bladder ; and conversely, sedatives and emollients give relief to the first-mentioned form of irritability, whilst in the latter, when employed alone, they are worse than useless — -they are disappointing. Irritability of the bladder in children and adults is a usual symptom of stone, though it varies much both in kind and degree. There is this anomaly in the vesical irritability of stone, which has often struck rne : in most other forms of irritability, a patient gives way to the .desire to urinate with, at all events, a prospect of temporary relief; whilst in stone, on the contrary, it is with the certainty of having his suffering added to until urine collects sufficiently to take the pressure of the calculus from of£ the mucous membrane. /Stricture of the urethra often occasions vesical irritability, either by provok- ing spasm, or by bringing about structural changes in the bladder, by which its capacity is lessened and its walls are thickened. Irritability due to altered and abnormal states of the urine, is not infre- quent, and will necessitate, where there are symptoms to be cleared up, an examination of this excretion. ' The urine least irritating to the normal urin- ary passages, is that which most nearly approaches the healthy standard. The low specific gravity of the urine which is passed so frequently and abun- dantly by hysterical females, no doubt causes the irritability from which they, under these circumstances, almost invariably sufter. Water is more irritating to those passages of the body over which it is not intended to flow, than a saline solution of some density. The abundance of uric acid in the urine of the gouty, undoubtedly explains^ the extreme irritability of the bladder, and the intense irritation and feeling of weight which these persons experience, and refer to the region of the prostate. Gouty manifestations in the parts behind the triangular ligament, are quite as frequent as the more familiar indication of this diathesis which we meet with in an acute form about the ball of the great toe. The benefit which, in these cases, attends the adminis- tration of antipodagric remedies, together with diluents, is most marked. Something similar is seen in individuals who frequently suffer from gouty affections of the skin, such as eczema. Cases are not uncommon of gouty patients who successively suffer from eczema and irritability of the bladdei'. jSTeither is present in any marked degree at the same time, and the aggi'ava- tion of one seems to be the alleviation of the other. There is a form of irritability — for such it certainly is, though manifest- ing itself by morbid actions rather than by morbid sensations — in which the bladder is not under proper control. Reference is made to the nocturnal incontinence of young children ; this may be provoked by any of the causes previously mentioned, which are to be carefully sought for. This §tate is not to be mistaken for the dribbling or running over from a distended bladder, which, by atrophy of its muscular coat or other similar cause, is prevented from expelling its contents. The incontinence of childhood is a very com- YOL. VI. — 24 370 INJUKIES AND DISEASES OF THE BLADDER AND PROSTATE. men and sometimes troublesome complaint, and when not due to any of tl causes indicated, is probably connected with an atonic condition of the wal of the bladder, manifesting itself when the action of the voluntary, contrc ling muscles of micturition is temporarily in abeyance, as in sleep. In tl management of these cases, reliance is chiefly to be placed upon inculcatin habits of regularity, combined with medicinal treatment. Among dru| which may be mentioned, are belladonna and its alkaloid, atropine. Thei seldom fail when employed on the principle " that chronic diseases ne€ chronic therapeutics." Various mechanical means have been adopted for tl treatment of this affection, such as the employment of the jugum, or urethr compressor, and closing the meatus with collodion, as suggested by Sir Dom nic Corrigan.^ Of these, the latter is the least hurtful, and may occasional!, when other means have failed, be resorted to with advantage. Attention to the diet is very necessary in these children ; irregularitie both in eating and drinking, are often attended with a condition of urine thi is likely to provoke incontinence. A strictly milk diet has, in some instance been sufficient to effect a cure. There is a form of irritability of the bladder which is frequently met witl especially in highly intelligent and sensitive children, at about the age of te or eleven years, when they are entering upon the sterner forms of educationi study. On examination of the urine it will be found loaded with phosphate In remedying this condition, the bromides, in combination with opium, wi be found, in valuable. Care must betaken that the child be not submitted 1 an undue amount of nervous tension by reason of his educational studies. Lastly, it must be remembered that irritability of the bladder is a s^'mj torn which is by no means confined to the male sex ; it is frequently met wit in females. In the same manner as already insisted on, the causes of the irritation mus be carefully searched out, not forgetting that in females the condition of th uterus or of the recium frequently affords a sufficient explanation. There : a cause of irritability and spasta of the bladder in females, which, though nc uncommon, is not sufficiently recognized. I refer to fissure at the orifice < the urethra, which is enough to account for the sensitiveness comf)lained o Failing its cure by a few applications of nitrate of silver, rapid dilatation ( the urethra is generally found sufficient to afford relief. We have been accustomed to regard an^irritable bladder as a purely fun^ tional disturbance, as far as this viscus is concerned, and for the most part is so ; but we must not forget that the constant contraction of the bladde may produce changes behind it, which follow as a consequence of the bad ward urinary pressure, and of which dilatation of the ureters and of the ki( ney are examples. These conditions have been noticed where there hs existed nothing to account for them, other than the obstacle to the escape < urine which a constantly contracting bladder has presented. Injuries of the Prostate. "Wounds and ruptures of the prostate from accident are, by reason of tl manner in which the gland is protected, of rare occurrence. Occasionally subacute form of prostatic inflammation is provoked, especially in goul subjects, by contusions such as follow violent concussions of the perineum, i from the pommel of the saddle in riding. The tenderness thus produce generally subsides with rest, in the course of a few days. "Wounds of tl ' Dublin Quarterly Journal of Medical Science, February, 1870. INJURIES OF THE PEOSTATE. 371 prostate are usually inflicted in the course of some surgical procedure, as in lithotomy, or by the penetration of a blunt instrument, as in forced catheteri- zation for prostatic obstruction. Lithotomy-wounds of the gland for the most part heal kindly, and are seldom followed by urinary fistula or by any impediment to micturition. Some ■cases are recorded in which it is probable that contraction of the prostatic cica- trix has resulted in interference with the action of the vesical sphincter, and has caused a more or less permanent condition of urinary incontinence. In Dr. Goodhart's^ case, the prostate, eleven years after a lithotomy, was found much distorted by a large and puckered cicatrix. From an examination of this specimen, the incision into the neck of the bladder appears to have been very extensive. The patient had suffered from incontinence since the operation. As long as the incision is kept within the limits of the proper structure of the prostate, but little constitutional derangement is likely to be occasioned by it. Where, however, the wound extends so as to divide the capsular investment, the most serious complications, including pelvic infiltration, cellulitis, and peritonitis, are likely to follow. The proper incising of the prostate is one of the most important steps in the operation of lithotomy. Lacerated wounds and ruptures of the prostate have been caused by what is termed " forced ■catheterization," undertaken for the relief of retention of urine, when the en- larged gland has formed the obstacle to micturition as well as to the introduc- tion of an instrument into the bladder. Though this proceeding has received the sanction of some surgical authorities, and has been frequently practised with impunity, it is one which cannot commend itself to any scientific prac- titioner of the present day, except under special circumstances. The conse- •quences which sometimes follow the forcing of a catheter through any jportion of the prostate, are very disastrous. Not only may the bladder become in this way filled with blood, which has no way of escape, but the ■damage occasioned to the surroundings of the gland by the force necessary to drive a blunt catheter through such an obstacle, may cause fatal pelvic cellulitis. Improved instruments, as well as improved methods of tapping the bladder, presently to be described, have removed the necessity for a proceeding which ■can hardly be regarded as a legitimate one. When hemorrhage into the bladder follows laceration of the prostate by the catheter, it may be sufiicient in amount to form a hard, globular tumor, immediately above the pubes, which is exceedingly painful on pressure. When this is accompanied by an urgent and ineffectual desire on the part of the patient to micturate, relief may be given by the introduction of a catheter with a large eye, and having for its stylet an accurately fitting gum-elastic bougie. An instrument similar to Clover's catheter for removing debris from the bladder answers the purpose exceedingly well. Aided by the injection of tepid water, the clot may in this way be broken up and dis- charged. Or the aspirator maj' be employed above the pubis. From an observation of Dr. Weiss,^ it appears that not only urine but clots can be removed through a comparatively fine needle. In a case of hemorrhage into the bladder after forced catheterization, where it was found impossible to reintroduce the instrument, rather than repeat the proceeding a median cystotomj' might be practised, with the subsequent introduction of Mr. Buckston Browne's^ tampon, as used for bleeding after lithotomy. Where hemorrhage from the prostate into the bladder is unat- tended, as it most frequently is, with symptoms either of retention or local • Trans. Path. Soo. Loud., 1876. ^ American Clinical Lectures, vol. ii. No. 8. 3 Lancet, September 15, 1879. 372 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. distress, no interference will be necessary. The clot eventually becomes dis- integrated by the urine, and is then carried off without doing further harm. Prostatitis and Prostatic Abscess. Of all the complex structures which together constitute the genito-urinary tract, from the kidneys downwards, the prostate gland may be regarded as least liable to attacks of acute inflammation ; and in this respect it seems to serve a useful purpose, in acting as a check against the extension of an inflammation from the much-exposed and susceptible urethra below, to the more vital organs above. Structural differences thus play an important though not sumciently appreciated part, in limiting the progress of a variety of pathological actions, which would otherwise, by continuity, spread almost unrestrained. Acute Prostatitis. — The term acute prostatitis includes two varieties, pre- senting distinct pathological features, each disposed to pursue a tolerably definite course, and each determined by different circumstances. The one is an acute, follicular prostatitis ; the other a general, or parenchymatous, inflam- mation of the gland. Acute foUiciuar prostatitis is not uncommon. It is most frequently seen as- a complication of gonorrhoea. A person suffering from the latter affection suddenly finds the discharge either diminished in quantity, or altered in cha- racter, and this is followed by a sense of weight or uneasiness in the peri- neum. On examination, the gland is found to be hot, tender, and swollen. Micturition becomes frequent or impeded, in accordance with the extent to- which the bladder structurally sympathizes, or the swollen prostate obstructs. In some instances there is complete retention. In these cases it will be found that the inflammation is almost entirely confined to the follicles of the gland. These may suppurate individually, or limited abscesses may form by the fusion of two or more of the obstructed follicles. " There is never," as Bum- stead' remarks, " at the outset, one abscess of considerable size. Such occurs only by the coalescence of a number of small ones situated in the follicles. Meanwhile the muscular tissue which constitutes so large a proportion of the prostate is uiiaflected, except that it is in a constant state of contraction, thereby inducing urethral and rectal tenesmus." The follicular is the simple form of acute prostatitis. Though painful and distressing whilst it lasts, the symptoms are not usually i)rotracted, and the prognosis is favorable. Reco- very most frequently follows by resolution, suppuration being the exception and not the rule. When suppuration does take place under these circum- stances, it is to be inferred rather than demonstrated, for rigors are often absent, and the most careful examination with the finger in the rectum fails to discover fluctuation, though an escape of pus by the urethra may almost immediately follow the introduction of a catheter, rendered necessary for the purpose either of completing the examination or of relieving retention. The other form of prostatitis — acute parenchymatous or general prostatitis — is a much more serious disorder. The whole gland within the capsule seems to be at one and the same time invaded by inflammatory action. Suppu- ration usually rapidly supervenes, and unless treatment be prompt and deci- sive on the first appearance of fluctuation, as revealed by rectal examination, the most serious results, both to structure and life, are likely to follow. This form of prostatitis is rare. I can find no specimen of the kind ' Treatise on Venereal Diseases, 4th ed., p. 170. PROSTATITIS AND PROSTATIC ABSCESS. 373 -described in the Transactions of the London Pathological Society since 1865, nor do I see any reference to it in the proceedings of the Clinical Society, since its commencement. Cases of the disease, however, will be found scattered throughout the medical journals, and the experience of all who liave seen much of this class of disorders will include some examples. At the outset, it is not easy to determine which of the two conditions referred to we have to deal with. The exciting causes are in either case much the same, and we must look for other circumstances to determine whether the inflammation will be limited to the follicles, or will involve en masse the entire gland. We shall find that the conditions which favor the latter are such as, did they happen to be present when any part other tlxan the prostate was inflamed, would render the occurrence of suppuration if not ■of gangrene probable. Parenchymatous prostatitis for the most part occurs in persons of a broken-down constitution. It is occasionally seen in tuber- culous subjects who have contracted gonorrhoea. I have had reason to suspect that previous tuberculosis of the gland had determined the result. Again, it is seen in prostates that have been rendered unhealthy by long standing stricture and cystitis, on the application of some fresh exciting cause, such -as a gonorrhoea. Under these circumstances suppuration may be rapidly induced. Gangrene as a result of prostatic inflammation is exceedingly rare, but it ■occasionally occurs. I have seeg it after lithotomy in a very unhealthy adult. There are two conditions simulating prostatitis, which have led to the impression that this aflection is far more common that it really is. The first is inflammation and suppuration around the membranous jDortion of the urethra, as a consequence of urethritis ; and the second, inflammation and plugging of the veins which constitute the prostatic plexus. I have seen many instances of the former, where inflammation and suppuration around the membranous urethra have led practitioners into the belief that the case was one of metastasis of gonorrhoeal inflammation from the urethra to the prostate gland. And the points of resemblance are by no means isolated — - there is in fact a remarkable likeness between the two conditions. In both there is a cessation of, or alteration in, the urethral discharge ; in both there is a feeling of uneasiness and weight about the perineum ; in both there is some difiiculty in micturition, amounting perhaps to retention ; and in both there is some tumefaction to be felt, and much distress is occasioned, by intro- ducing the flnger into the rectum. So painful is this to the patient, that it often leads to an imperfect examination being made, and hence, from not ■exactly fixing the position of the tumefaction, an error in diagnosis arises which might be avoided. It must, on the other hand, be remembered that in inflammation and suppuration around the membranous urethra, although the part lies between the layers of the perineal fascia, there is still more or less perineal tumefaction, and that matter formed there may make its way forward and be discharged through a perineal opening. In acute prostatitis these conditions are not present, whilst in deep-seated peri-urethritis they are usually observed. Considering the relations of the prostate, and the denseness of the fascia in front of it, perineal tumefaction is not to be expected as a consequence of prostatitis, any more than swelling in this locality is to be looked for in connection with senile hypertrophy of the gland. The other condition simulating prostatitis is rare, and, as it is also curious, I will briefly describe the appearance in two cases recently under observation. The primary lesion was plugging of the dorsal vein of the penis, followed by rapid oedema of the prepuce. In the course of a few days each patient com- 374 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. plained of perineal weight, frequent rather than painful micturition, and great uneasiness referred to the neck of the bladder, which led in_ each case to its being suggested that the prostate was inflamed. Both patients were gouty ; in one the oedema was attributed to gonorrhoea, in the other to the use of a strong injection. Though in both these patients there were some- grounds for believing their prostates to be inflamed, it was determined b}- careful rectal examination that the vesical pain and irritability were not due to such a cause, but to an extension of the venous thrombosis to the prostatic plexus. Treatment. — At the commencement of an attack of acute prostatitis, noth- ing gives greater relief than the free application of leeches to the perineum. Some practitioners employ ice by the rectum, but, as a rule, warmth, in the form of hot fomentations and poultices applied over this region, is prefera- ble. Purgatives of all kinds are to be avoided, inasmuch as every movement of the parts greatly aggravates the sufferings of the patient. If a distended rectum require evacuation, a copious warm water enema will be found to answer the purpose. In threatened suppuration of the prostate,, advantage will be found from injecting hot water into the bladder through a soft rubber catheter. Such a measure diminishes the accumulation of mucus within the prostatic urethra, and thus prevents the formation and collection of matter in the follicles. Opium will be found essential in sustaining the powers of the patient, otherwise soon worn down by the irritation and pain which to some degree are always present. By means of alkalies the urine must be kept almost neutral. The occurrence' of suppuration is to be carefully looked for. Experience- warrants the conclusion that any formation of matter in the gland which is not appreciable to the finger in the rectum, may with safety be left to evac- uate itself spontaneously, which it will do by the urethra. When fluctuation is detected by rectal examination, a perineal incision becomes imperative. This can be best made in the median line, with a straight, long-bladed finger- knife, the forefinger of the opposite hand being retained within the bowel. Unless the abscess be opened effectually, matter will most probably find its way into the rectum, and a permanent fistula be the result ; or it may bur- ' row in other directions, in any case with more disastrous results than are- likely to follow from perineal evacuation by the surgeon. Rectal puncture has been practised, but is not to he recommended ; incision, in the case of an acute abscess, is, as a rule, preferable. If there is one point upon which stress should be laid, as bearing both on the diagnosis and treatment of these cases, it is the importance of a thorough examination of the gland by the rectum. Pain, and the tension of the part,, often cause this to be imperfectly conducted, and an error in diagnosis is the result — an error, too, which the use of an anaesthetic would render almost impossible. It must not be forgotten that abscesses, sometimes of very large size, may form within the limits of the prostate without giving rise to those symptoms which they usually provoke. Cases are recorded in which prostatitis has supervened upon attacks of gonorrhoea, and has terminated in suppuration and death, with complete absence of the rigors and other ordinary symptoms of abscess. Chronic Prostatitis. — Cases of chronic inflammation of the prostate are sometimes met with, the gland remaining tender for considerable periods of time after all acute symptoms have passed away. This condition is not unfre- quently complicated with subacute orchitis, the latter being aroused by extra- PROSTATITIS AND PROSTATIC ABSCESS. diO neons sources of irritation, such as the passing of a catheter, its retention in the bladder, or even the passage of urine of a highly acid character. Chronic prostatitis is best relieved by the application of blisters to the per- ineum, and by the internal administration of iodide of potassium. Care should be taken to ascertain whether the urine is in its composition of a nature to irritate the pai'ts over which it flows, and, if so, to correct this condition. Prostatorrhcea. — This term has been used to designate a gleety discharge for which the prostate is regarded as responsible. I believe that it is often a remote consequence of follicular prostatitis, the follicles of the gland remain- ing permanently in a more or less dilated condition, which is favorable both to the production and maintenance of discharge on very little provocation. In enumerating the various exciting causes of this affection. Professor S. W. Gross' observes that they are incapable of lighting up the aftection indepen- dently of some pre-existing inflammation of the prostatic urethra. The dis- ease consists essentially in the flow of a clear viscid fluid from the urethra, following any kind of strain. The absence of spermatozoids serves to distin- guish this fluid from seminal discharges. The treatment consists in the removal, as far as possible, of the general and local causes of excitement. Dr. S. W. Gross speaks favorably of the internal administration of atropia. As the disease is maintained by an atonic and dilated condition of the oriflces of the prostatic ducts, cold sitz-baths, the injection of a solution of nitrate of silver (thirty gi-ains to the ounce), and blisters to the perineum, are means which, as a rule, will be found service- able. The gloomy view which these patients sometimes take of their mal- ady, considerably adds to the difiiculty of curing them. Prostatic Irritation. — There are certain affections of the neck of the blad- der which will be best referred to under this heading. Of these, the most common is that met with in gouty subjects, where the irritation is so intense as almost to amount to an inflammation. Many cases which are described as neuralgia of the prostate, are nothing more than illustrations of tbis afl'ection. It occurs most frequently in individuals who, although possessing the gouty diathesis, either hereditary or acquired, have pi-eviously remained free from the ordinary indications of the disorder. Like gout affecting the great toe, the paroxysm usually comes on at night, and is referred to the neck of the bladder, which is often described as feeling like a hot ball. Though painful, micturition is irresistible, and spasmodic sympathetic pain often attacks one or both testicles, which are sensitive to the touch. The prostate is sensitive to rectal examination. The urine, invariably highly acid, deposits lithates, and contains mucus in excess. During the daytime the symptoms remain in abeyance, to recur at night with unabated force. The disorder usually merges into a chronic form of irritation, which is sometimes very persistent. I believe that the 'affection is provoked in gouty subjects by the extremely irritating nature of the urinary secretion which is in contact with the gland. After an acute attack of this kind, the prostate is often left preternaturally sensitive for a considerable period, and in consequence of this the patient dreads to exercise pressure upon it by completely emptying his bladder. Hence he involuntarily retains a water-bed of urine, so to speak, behind his prostate, for the purpose of protecting it from pressure. This I have fre- quently determined by passing a catheter. Retention of urine under these circumstances is not only a fruitful source of chronic cystitis, but is also favorable to the production of vesical calculi. ■ On Impotence, Sterility and Allied Disorders of the Male Sexual Organs, p. 163. 376 INJUEIES AND DISEASES OP THE BLADDER AND PROSTATE. In the treatment of irritable bladder due to prostatic gout, there are one or two points to which prominence should be given. In the first place, I have never seen it occur except where the urine has been found highly acid, and wherg crystals of uric acid have been present in abundance. The administra- tion of alkalies in this condition can hardly be regarded as other than a natural expedient. It has been asserted that the neutralization of the urinary acid by the alkaline medicine, is little else than masking the disease, as the cause of the acidity still remains untouched. Whether this be so or not under all circumstances, I do not purpose discussing, but it seems reasonable to infer that the artificial diminution of the acid is likely to alleviate the feeling of burning and spasm which attends each act of micturition. Further, the alkalies generally have the ejBt'ect of altering the form of the uric acid crystals. I have observed that in persons passing certain crystals, the degree of vesical and urethral irritation has been intense, whilst in others, where the form of crystal has been difi:erent, the pain and irritation have been slight. The administration of alkalies not only often effects a change in the shape and quantity of these crystals, but also diminishes the severity of the symptoms to which their presence has given rise. The use of a catheter in these at- tacks is not desirable, unless there are reasons to believe that there is a con- siderable accumulation of urine in the bladder, when a rubber instrument may be passed. In the treatment of this form of irritable prostate, both in its acute and chronic stages, reliance must chiefly be placed on the correction of the state of the urine, and on the employment of remedies which relieve the ordinary manifestations of gout. Patients who are in the habit of suffering from attacks of this kind, generally derive benefit from a periodical residence at such watering places as Vichy, Fachingen, or Buxton. Hypertrophy of the Prostate. Hypertrophy or enlargement of the prostate gland, is a condition which is frequently met with in males who have passed their fifty-fifth year. It may be stated generally that the number of persons thus affected amounts to somewhere about one-third of those living after the specified age has been reached, though it is not implied that all who are affected are necessarily conscious of the change that has taken place. Indeed it often happens, as will be presently shown, that some very large prostates occasion few or no symptoms of their presence. The alteration which takes place in the size of the gland is of the nature of a hypertrophy or overgrowth, that is to say, no fresh structural element is imported. The analogy with ordinary hyper- trophies, however, ends here, as, unlike hypertrophy of the bladder or heart, the change in the prostate is apparently purposeless. The hypertrophy may involve either the whole or a part of the gland, or it may be in the form of an isolated growth imbedded in a normal prostate, or, what is still more common, in one that has already undergone some hy- pertrophic change. These isolated tumors are structurally "identical with adenomas, such as are found in the breast, and to these they have many points of resemblance. Whether occurring as independent tumors, capable of being readily separated from their surrounding connections, or as general or partial enlargements, the mass presents, structurally, indications that it consists of varying proportions of the component elements of the normal organ. There has been much speculation as to the causes by which this change is brought about, but as yet no very definite conclusion has been arrived at. It is probable that a solution will be found in the application to the genera- HYPERTROPHY OF THE PROSTATE. 377 tive functions, of the laws which Paget has formulated as the determining ■causes of hypertrophies, or overgrowths, in other parts of the body. These are, (1) the increased exercise of a part in discharge of its natural function, -(2) an increased supply of healthy blood, and (3) an increased accumulation in the blood of the particular materials which such p)art appropriates in its nutrition, or for secretion. It has been objected that an explanation which ■endeavors to connect prostatic enlargement with sexual vigor must fail to suffice, inasmuch as the growth does not commence at a time when the re- productive powers -are active, but rather when they are on the decline. That the withdrawal of a portion of that function of the prostate in which it has been the most vigorously engaged, should be followed by a continued activity in which growth is substituted for secretion, is not, I consider, pathologically illogical ; whatever may be the explanation, my own observation leads me to believe that prostatic hypertrophy is almost always met with in persons whose sexual propensities have been well, if not excessively^, maintained. Symptoms. — In a certain proportion of cases, hypertrophy of the prostate is unattended by any special symptoms pointing to its presence. In fact, the disorder does not come under our notice, except in connection with some derangement in micturition. Even very large prostates have failed to indi- cate their existence otherwise than by causing a mechanical obstacle to defecation. The deductions which may be drawn from cases in which the prostate is large, but does not obstruct micturition, will be referred to in connection with its early treatment under those circumstances. More commonly an enlargement of the prostate shows itself by some inter- ference with the act of micturition, and when this occurs for the first time in a man after he has passed his fifty -fifth year, it is very significant of the aflFection. The first signs have reference usually to the size of the stream of urine, to the patient's diminished power of projecting it, and to the fret[uency with Avhich the act of micturition is performed. As time goes on, the urine becomes altered in character ; it is disagreeable to the smell, and often oifen- sivelj' ammoniacal ; large quantities of mucus are voided with it, and cling tenaciously to the vessel into which it is received. These symptoms are divisible into two classes, (1) those first enumerated, which indicate that the prostate is impeding micturition, and (2) those which I'esult from the decomposition that naturally takes place in a bladder contain- ing stagnant urine. Hence in neai'ly all cases of advanced prostatic hyper- trophy, we have the symptoms of varying degrees of cystitis, superadded to those of obstruction. In the later stages of the disease, these combined conditions bring about a state of the most extreme misery. The bladder becomes absolutely intolerant of urine, and the act of micturition, or the passing of a catheter, has to be per- formed so frequently, both by night and by day, as to prevent the patient from obtaining sufficient, continuous rest. Under these circumstances, a condition of ammonsemia is frequently set up, which almost invariably brings about a fatal termination. Symptoms such as these naturally suggest a careful phy- sical examination of the prostate from the two passages with which it is in relation, namely, the urethra and the rectum. By digital examination of the gland from the rectum, we, shall be able to ascertain whether in this direction there are evidences of its increased growth. Though we cannot here detect any, we are not therefore to infer that none exists, inasmuch as instances are frequent of prostatic enlargement taking place towards the vesical aspect of the gland, which is undetectable from the bowel ; and conversely the gland may be considerably enlarged towards the rectum, and yet, as far as the urethra is concerned, as demonstrated by the use of the catheter, no obstacle may be occasioned. 378 INJUEIES AND DISEASES OF THE BLADDER AKD PROSTATE. Before proceeding further, it will be proper to consider, (1) the circum- stances . which explain non-interference with micturition in some cases of prostatic hypertrophy, (2) the changes which take place in the prostatic urethra as a consequence of prostatic hypertroph}^, with special reference to the expulsion of urine from the bladder. Inquiry in these two directions will be found not unfruitful in leading to conclusions which will be of value when the treatment of this affection comes to be considered. It may be remembered that one of the pleasures connected with pathological inquiries, such as this, lies in the endeavor to discover nature's ways and means of making provision against the arrest of function which appears inseparable from the course of certain structural diseases. (1) From the examination of a considerable number of large prostates which caused no obstruction to micturition, I have observed that there are at least two conditions which may explain the absence of such obstruction. One is where the hypertrophy takes place mainly in the direction of the rectum, in which the relations and dimensions of the prostatic urethra are unaltered : — Some years ago I was examining an elderly gentleman for hemorrhoids, when I accidentally discovered that the prostate was considerably enlarged towards the rectum^ I passed a catheter into the bladder, but could find no obstruction. Not long after- wards this gentleman died from heart disease, and post-mortem examination showed that, although the lower segment of the prostate was considerably enlarged,' the prostatic urethra was unaltered. This patient had never had any symptom of impeded micturition. The other condition referred to is, where the prostate as it enlarges leaves- channels between the hypertrophic masses, along which urine finds its way uninterruptedly. This lobulated form of hypertrophy is by no means uncom- mon. It is referred to by Dr. Messer' as a condition which will serve to- " explain the occasional absence of symptoms of obstruction, in cases where the prostate is known to be considerably enlarged." Fig. 1288. Fig. 1289. Section of normal prostate. Enlargement of prostate towards rectnm. (2) I will next proceed to consider the changes brought about in the pros- tatic urethra by hypertrophy of the gland, as far as they relate to the obstruc- tion of micturition. As already stated, enlargement of the prostate towards the rectum may take place without altering the relations of the canal passing through it. Hence there is no interference with micturition, nor obstacle to the introduction of the catheter into the bladder; this. is shown in the ' Med.-Chir. Trans., vol. xliii. HYPERTROPHY OF THE PROSTATE. 37& annexed sketches. Fig. 1288 represents a section of the normal prostate. In Fig. 1289, though there is enlargement towards the rectum, the relations of the prostatic urethra are unaltered. In Fig. 1290 there is considerable enlargement of the gland toward the bowel, but the line and dimensions of the urethra are thereby but little altered. Fig. 1290. Considerable enlargement of prostate towards rectum with straightening of prostatic urethra. ' Hypertrophy may, however, considerably disturb and disarrange the pros- tatic urethra. Most frequently this is effected by the upward growth of that portion of the gland which, since the days of Sir Everard Home, has received the name of the third lobe ; and it is astonishing how complete an occlusion of the internal urethral meatus may be effected by even a slight elevation of this portion of the -gland, provided that it is central. From the annexed illustrations, taken from specimens which I have examined, it will be seen that in this form of hypertrophy the prostatic urethra is curved upward, and that a distinct obstacle to micturition, or to the passage of an instrument into Fig. 1291. Fig. 1292. Bnlargement of third lobe of prostate In the cases from which these cuts are talsen, little was to be felt from the rectum. the bladder, is thus somewhat abruptly thrown up. It will be noticed that though there is considerable enlargement of the gland, examination by the 380 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. rectum does not necessarily aft'ord evidence of the fact, in this respect con- trasting with the cases iUustrated by Figs. 1289 and 1290. When the hypertrophy is more or less limited to one or other of the Fig. 1293. Enlargement of third lohe of prostate. lateral lobes, the line of the prostatic urethra is deflected somewhat to the opposite side, a point which is to be remembered in the introduction of catheters. Though, as a rule, this form of hypertrophy is attended with Fig. 1294. Normal position of internal urinary meatus. ■difficulty in micturition to whichever side the urethra is deflected; yet com- plete obstruction seldom occurs, unless in addition to lateral hypertrophy there is a corresponding increase in the third lobe. I believe that in these lateral forms of hypertrophy a gum-elastic catheter without a stylet will be found the easiest to introduce. HYPERTROPHY OF THE PROSTATE. 381 In the last place I will mention certain changes which take place in the position of the prostatic opening into the bladder. These can be best studied Uy examining the aperture from the vesical aspect, as was done with the specimens which the following illustrations represent.' Fig. 1294 represents the position of the normal internal meatus ; Fig. 1295, the position of the Fig. 1295. Internal meatus in ordinary form of enlargement of third lobe of prostate. opening in the ordinary form of enlargement of the third lobe, where the prostatic urethra forms an inclined plane ascending backwards. Fig. 1296 Fig. 1296. ^\ -v.^ Pedunculated hypertrophy of third lobe of prostate ; urethra opening on either side. represents a pedunculated condition of the hypertrophied third lobe, where the urethra opens on either side of its base. This is analogous to the chan- nels left for the passage of the urine in the lobulated form of enlargement. ^ I am indebted to my colleague, Mr. Mitchell Banks, for these drawings, which are taken from specimens in my collection, and from rough sketches of my own. 382 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. In such a case, on side section, the urethra would still be found almost hori- zontal, as in the normal state. Fig. 1297 represents a bisected condition of Fig. 1297. Bifid hypertrophy of third lobe of prostate. the hypertrophied third lobe, which was probably the result of constant catheterization.^ The line of the urethra, as in the preceding specimen, still remains nearly horizontal. In the cases from which Figs. 1296 and 1297 are taken, micturition was not interfered with, by reason of the direction and relation of the prostatic urethra being practically unaltered. It will be presently urged that the conditions which existed in these cases are capable of artificial production to a useful extent. Treatment. — Before proceeding to consider the treatment of prostatic hyper- trophy, the question naturally arises as to whether anything can be done to prevent its occurrence. As the cause of the aiFection has not yet been thoroughly determined, it is hardly necessary to say that there are no known means for preventing it, and it is useless, therefore, to discuss a series of sur- mises which have already occupied sufficient attention. If, as there is some reason to infer, this change is I'elated to the natural function of the organ, or is a result of its excessive employment, I am afraid that, although we might have the satisfaction of possessing an explanation of its origin, we should still experience no little difficulty in preventing its occurrence. The treatment of enlargement of the prostate will be considered with reference to the only symptom which, as a rule, leads to its recognition, namely, interference with micturition ; for as long as this act continues to be painlessly and efficiently performed, no one is at all likely to complain of it. As already noted, the earliest symptoms of enlarged prostate usually relate to some gradually increasing difficulty in urination ; either the stream is diminished in volume, or in extent of propulsion, or the act is too frequently performed. These indications point to a physical obstruction, which exam- ination shows to be seated in the prostate. Occasionally under these cii'cum- stances, with little or no warning, and probably owing to some accidental circumstance, such as exposure to cold or an over-indulgence in wine, the ' Harrison, op. cit., p. 18. HYPERTROPHY OF THE PROSTATE. 383 expelling power of the bladder, long perhaps carried on with difScnlty, sud- denly breaks down, and retention of urine occurs. In this way a very large prostate is sometimes discovered. In both of these ways of manifesting itself, prostatic hypertrophy resembles urethral stricture. On the earliest manifestations of prostatic obstruction, mechanical treat- ment should be resorted to with the same diligence that is required in the treatment of other forms of urethral obstruction. If this be not done, it is only postponing the day until the necessity is greater and the difficulty more apparent. .It has already been pointed out that there are at least two condi- tions of the enlarged prostate which are unattended with obstructed mictu- rition, where either channels are formed between the masses of the growth, or the line of the urethra remains unaltered. These conditions may, as I have already said, be artificially produced to an extent capable of being useful. For this purpose I have recently devised' some specially adapted bougies, which I use. They are of gum elastic, from two to four inches longer in the stem than the ordinary instruments, and have an expanded portion, an inch from the tip, which is made to enter the bladder. If dilata- Fig. 1298. Prostatic dilators. tion be not too rapidly proceeded with, no irritation will be aroused ; on the contrary, irritability will subside by reason of the completeness with which the bladder is emptied. Where there is residual urine, catheters of a similar shape may be substituted, thus allowing any water to be drawn otf, whilst at the same time the prostate is subjected to dilatation. The above statements represent briefly my views with regard to the importance as well as the means of endeavoring to secure an unobstructed "water way" on the earliest signs of an increasing prostate impeding mictu- rition. Without wishing to give them undue prominence, I feel that they cannot be passed over without some notice, inasmuch as a considerable expe- rience and its results have justified their claim to consideration. Though the time when mechanical interference is to be systematically employed may be open to question, there can be no doubt about the necessity for it when one of two events, hoth frequent in the history of these cases, occurs, namely, either the bladder incompletely emptying itself, or retention of urine taking place. The former condition has reference to the formation of a poucih behind the upgrowing gland, or to the development of sacculi, in both of which urine remains in the bladder after micturition is apparently completed. The latter arises either from the occlusion of the orifice of the urethra by the prostate, or from incapacity of the bladder to supply the necessary expelling power. Both conditions require mechanical relief. 1 Op., cit., p. 21. 384 INJUKIES AND DISEASES OF THE BLADDER AND PROSTATE. "Where there is residual urine, the fact is indicated by signs of its decompo- sition. It smells oifensive or ammoniacal, becomes alkaline, and contains mucus in excess. Its presence is proved by obtaining urine with a catheter after the patient thinks that he has-emptied his bladder. A persistence of this condition of residual urine invariably ends in the production of chronic cystitis, the management of which has already been described. When the patient is thus prevented from completely emptying' his blad- der, artificial assistance must be rendered. Sometimes an altered position,, such as bending forwards on the knees, is found suflicieut for supplementing- micturition. This may be tried, but as a rule the patient finds greater com- fort and convenience from the use of a well-devised catheter, which he is instructed how to inti-oduce. The flexible-rubber instrument should first be tried. Failing these, a gum-elastic catheter. With one or other of these instruments the patient should be required to draw oflt" his water just as often as he feels a necessity for this relief. A person of ordinary intelligence will soon find this out for himself. It would be just as absurd to prescribe, under these circumstances, how frequently the catheter should be passed, as it would be to indicate how many times in the twenty-four hours a patient should make water. It is astonishing to notice how rapidly- the urine often returns to its normal state, and what comfort the patient, who may have been suffering from extreme irritability of the bladder, will derive from this treatment alone. Where sudden retention of urine occurs in elderly persons, the cause of it will be at once suspected, when, on introducing a catheter, the position of the obstruction coincides with that of the prostate. To overcome this obsta- cle and reach the bladder, it will generally be found that some modification in the form of the instrument is necessary. As a rule, a moderate-sized, gum- elastic catheter, three or four inches longer than that required for retention arising from obstruction in other parts of the urethra, should be selected. Reference is made to the length of the instrument, as surgeons have often failed to relieve retention in pi'ostatic cases, not from making false passages,, but from the catheter being too short. It must be remembered that a large prostate maj' add very considerably to the length of urethra to be traversed before urine flows. Some prefer Mercier's elbowed catheter (Fig. 1299), in Fig. 1299. Mercier*s sonde coudie^ or elbowed catheter. which the end of the instrument is bent at a suitable angle. When the pros- tate is reached, assistance may often be rendered by the finger in the rectum lifting the end of the instrument over the obstruction ; or, again, the expedi- ent of passing down a stiff stylet, bent at an angle, along the catheter, is often successful in causing the point to surmount the enlarged lobe, and so to enter the bladder. The extent to which the bladder may be distended in cases of enlarged prostate, is often very remarkable. Several quarts of urine have been removed at a sitting, and the question as to whether the case was one of ascites or blad- der-distension, has arisen. There is a specimen in the Museum of the Liver- pool Royal Infirmary, of a large prostate with an enormously distended blad- der, which had been tapped, as for ascites. It is stated in the catalogue that twelve quarts of fluid, which turned out to be urine, were removed. It is also added that .the withdrawal of the fluid was followed by hemorrhage into HYPERTROPHY OF THE PROSTATE. 385 the bladder, which probabl}' contributed towards a fatal result. In cases of largely distended bladder, in enfeebled persons sutiering from prostatic eidarge- ment, it is a point for consideration whether the whole of the urine should be removed at once. Where the distension is great — for instance, when the collection amounts to several pints — it is better not to empty the bladder sud- denly. The objections to the removal of a large quantity of urine at once, are these : in an enfeebled person it is apt to be followed by syncope, or, when the pressure is thus suddenly removed from the bloodvessels of the parts, by passive hemorrhage into the bladder. Such a loss of blood has proved fatal in a few days. These eft'ects are similarly observed after the rapid removal of fluid from other parts of the body. Syncope, after tapping for ascites, is not uncommon, and cases have been observed in which the withdrawal of the ascitic fluid has been immediately followed by fatal hsematemesis. Further, the bladder is more likely to regain its muscnlar power when it is gradually emptied, than when it is suddenly reduced to a flaccid condition. Hence it is a good rule, in the case of a feeble person who, for some days, has been suffering from retention, and whose bladder is considerably distended, to draw off the urine by degrees. The size and direction of the prostatic enlargement sometimes render the introduction of the catheter impossible, and then the question arises as to what had best be done. Forced catheterization — by which is meant driving the instrument through the obstruction, and thus entering the bladder — has been advocated, but is a proceeding not to be recommended. Tapping the bladder, which will be referred to hereafter, is the proper remedy under these circumstances. In cases of difficult and frequently needed catheterization arising from an enlarged prostate, it is the practice of some to retain an instrument in the bladder by tying it in, or by some other contrivance rendering it self-retain- ing. As a rule, this is' not desirable, retained instruments often proving great sources of annoyance to the patient. If, from the extreme irritability of the bladder, it seems desirable to try this plan, it is best efiected by securing the instrument with tapes, and then affixing a piece of rubber-tubing to the end, sufficiently long to permit the urine to be conveyed, as it is secreted, into a receptacle b}^ the patient's bedside. The plan of bladder-drainage advocated by Mr. Chiene, to which reference has already been made, will be found most comfortable, as well as effectual. The annoyance produced by a retained cath- eter can be reduced to a minimum by the observance of scrupulqus care in washing out the bladder, and in removing all extraneous sources of irrita- tion. As a rule, but little advantage will be found in these cases from the various forms of self-retaining instruments, such as winged catheters and the like. Incontinence' of urine is a phrase often made use of in connection with the set of symptoms to which an enlarged prostate gives rise. We understand by it, that the bladder is full — so full that it is actually overflowing ; it is another indication for the use of the catheter. In connection with this subject it may be mentioned that prostatic enlarge- ment may, by inducing certain changes in the urine, lead to the formation of a calculus, the symptoms of which are masked by those of the original dis- order. Further, the hypertrophied gland, by concealing the stone l)ehind it, may prevent the ready detection of the latter by the sound. It is a good rule in all these cases, when the opportunity occurs, to examine the bladder for stone, and not forget to explore, by reversing the searcher, the depression which so frequently exists behind the enlargement. I will now pass on to notice the treatment of those extreme conditions of prostatic hypertrophy in which the enlargement and cj'stitis combined render VOL. VI. — 25 386 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. the patient's life most miserable, and in which he lives, in fact, with little other occupation than endeavoring to pass water, or introducing a catheter. This consists in the establishment of a channel other than the urethra, through which the urine can be more easily voided. Sir Henry Thompson,' a few years since, advocated in these cases puncture above, or rather behind the pubis, the proceeding resembling somewhat the high operation for stone. A permanent opening has thus been established with good results, patients living comfortably, and passing all their urine in this way, for considerable periods of time. [The same surgeon has more recently recommended that an opening should be made in the membranous portion of the urethra, and that a tube should be thus introduced from the perineum.] In a case of large prostate, where catheterism was attended with consider- able difficulty, I tapped the bladder from the perineum through the gland,'' the canula being retained with the greatest relief to the patient for a period of over three months, when he was able to dispense with it. This case will be again referred to. For establishing a permanent opening in cases of advanced prostatic ob- struction, puncture by the rectum is not to be recommended. It is not adapted for anything but very temporary purposes. !N"otice of the various operative proceedings which have been practised for the relief of prostatic obstruction cannot be concluded without a reference to certain proposals which have for their object the section or excision of the obstructing part. This proceeding, advocated and practised by Mercier, has recently received some support from Gouley, in America, and from Teevan, in England. It consists essentially in the division or resection of the obstruct- ing prostate by means of what amounts practically to a concealed bistoury. I do not think that this operation is likely ever to occupy a prominent posi- tion in this department of surgery. The risk of hemorrhage, and the diffi- culty of dealing with it, should it occur, will prevent its performance except under very unusual circumstances. [Amussat divides the obstructing portion of the prostate with the galvanic cautery.] Lateral cystotomy has also been performed to relieve the distress to which an enlarged prostate may give rise. Mr. Lund, of Manchester,' has recorded a case in illustration of this practice, which, under similar circumstances, would be quite worthy of imitation. There are certain points which should be borne in mind in advising pa- tients who have enlarging prostates and probably weakened ' bladders, or rather bladders whose power is readily extinguishable ; these instructions may be briefly sumnied up as follows : — (1) To avoid being placed in circumstances where the bladder cannot be emptied at will. '* (2) To avoid cheeking perspiration by exposure to cold, and thus throw- ing additional work on the kidneys. In a variable climate, elderly persons should, both in winter and summer, wear flannel next to the skin. (3) To be sparing in the use of wines or spirits which exercise a marked diuretic effect, either by their quantity or by their quality. Those should be selected which promote digestion, without palpably affecting the urinary organs. A glass of hot gin-and-water, or a "potent dose of sweet spirit of nitre, will not do anything towards removing the residual urine behind an enlarged prostate. 1 Op. cit., p. 287. 2 British Medical Journal, December 24, 1881, and April 8, 1882. ' Transactions of International Medical Congress. London, 1881. ATROPHY OF THE PROSTATE. 387 (4) To be tolerably regular in the quantity of fluids daily consumed. As -we grow older, our urinary organs become less capable of adapting tlieraselves to extreme vai'iations in excretion. Therefore it is desirable to keep to that average daily consumption of fluids which experience shows to be sufficient and necessary. How often has some festive occasion, when the average quantity of fluid daily consumed has been greatly exceeded, led to the over- -distension of a bladder long hovering between competency and incompetency. The retention thus caused, by suspending the power of the bladder, has been the first direct step in establishing a permanent, if not a fatal, condition of atony or paralysis of the organ. (5) It is important that from time to time the reaction of the urine shorn Id he noted. When it becomes permanently alkaline, or is oflensive to the smell, both necessity and comfort indicate the regular use of the catheter. If practicable, the patient should be instructed in the use of this instrument (6) Some regularity in the times of passing water should be inculcated. "We recognize the importance of periodicity in securing a regular and healthy action of the bowels, and though the conditions are not precisely analogous, yet a corresponding advantage will be derived from carrying out the same principle with regard to micturition. The sum of these instructions is, that, as we cannot arrest the degenerative changes by which the prostate becomes an obstacle to micturition, it is of the first importance that every means should be taken to compensate for this by promoting the muscularity of the bladder, and by thus preventing its being atrophied or paralyzed either by accident or improper usage. Lastly, as to the power of medicines in controlling enlargement of the prostate, there is but little to be said. Ergot and ergotine, administered by the mouth or subcutaneously, have been vaunted as possessing the power, not -only of preventing further enlargement of the gland, but of actually dimin- ishing its size. Dr. Atlee' found considerable advantage from the use of ergot in these cases, and his experience has been to some extent corroborated by that of other practitioners. My observation is favorable to the use of the drug in cases of difficult micturition in connection with large prostate, but 1 believe that the gain comes from the stimulating effect of the ergot upon the mus- cular coat of the bladder, rather than from any diminution which it causes in the size of the obstructing gland. In a communication^ relating to the enucleation of tumors of the prostate in connection with lithotomy, I drew, the following conclusions: (1) That lateral cystotomy may be practised in certain cases of enlarged prostate which are attended with symptoms pro- ducing great distress, with the view of exploring and, if possible, of removing the growth. (2) That in all cases of cystotomy for calculus, where the pros- tate is found to be enlarged, a careful search should be made with the finger with the view of effecting the removal of the growth, should this be found practicable. (3) That in determining the selection of lithotomy or lithotrity in a case of stone in the bladder complicated with enlargement of the pros- tate, regard should be had to the possibility of removing both of these causes of annoyance by the same operation, Atkophy of the Prostate, Atrophy of the prostate is a condition occasionally observed. It has been met with in middle-aged men under circumstances in which there were no ' New Orleans Medical and Surgical Journal, August, 1878. ' Med.-Chir. Trans., vol. Ixr. p. 43, 388 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. grounds for suspecting that any change had taken place in the gland. Struc- turally it appears to consist in the wasting of the glandular element, little remaining behind but what is essentially fibrous. In two instances which I have seen, it occurred in men who, as far as was known, had never had any children, a circumstance which seems to indicate that the condition may be due either to defective development, or to changes occurring at a time of life when the opposite state — that of hypertrophy — is rarely met with. Hence it cannot be regarded as having a distinct relation to advancing age. I have in my collection a specimen of unilateral atrophy of the prostate taken from the body of a man sixty years of age : it is associated with an absence of the ureter on the same side, and with a rudimentary condition of the corresponding seminal vesicle. ]!fothing further is known of the person from whose body this specimen was removed. The removal of the gland, either entirely or in part, by abscesses, prostatic calculi, tubercular deposits, and other conditions implying general waste, in which the prostate seems to share in a degree more than proportionate to its size, can hardly be regarded as illustrations of atrophy in the sense now being considered. Still, it must be remembered that it may be brought about in. these ways. As far as treatment is concerned, there are no special indications to which reference should be made. Assuming that the cause of sterility on the part of a male is probably traceable to an arrested development of the prostate as detected by rectal examination, it need hardlj' be added that the imperfec- tion is one for which no treatment can be of any avail. Atrophy of the normal prostate has occasionally followed its incision, as in the operation of lithotomy ; whether this is due to the destruction of the ejaculatory ducts, as a consequence arising out of the methods employed for the removal of the stone, or to their becoming involved in the cicatrix, are points which cannot at present be regarded as determined. Reference has already been made to a case in which atrophy of the enlarged prostate fol- lowed its puncture by a trocar and canula, and the retention in the bladder of the latter for three months. These circumstances will be again referred to in connection with the subject of tapping the bladder. Though there is little to be said respecting the symptoms or treatment of this condition, its pathological importance is not to be undervalued, on account of the light which its study may possibly throw upon the causation, preven- tion, and management of the commoner and more important afliection — hypertrophy. Tumors and Cancer of the Prostate. ^ Like other portions of the genito-urinary apparatus, the prostate is liable to be the seat of tumors Avhich may be classified as innocent or malignant. The former constitute the more frequent variety, and consist of a structure more or less identical with that of the normal gland. Ordinary hypertrophy of the prostate has already been considered, but it is further necessary to point out the existence of certain growths analogous to hypertrophy, which may be regarded as coming more strictly under the denomination of tumors, rather in regard to certain peculiarities in arrangement than to structure. Fibromas, prostatic tumors, or adenomas as they are variously called, have recently had prominence given to them from their removal having been effected either by accident or design during the performance of lithotomy. Under these circumstances, or in the post-mortem room, they have been met TUMORS AND CANCER OF THE PROSTATE. 389 -with either (1) as isolated tumors imbedded in the gland and readily separa- ble from it, or (2) as growths continuous with the gland, of which condition the pedunculated and enlarged third lobe is an illustration. In the symptoms to which these growths give rise there is nothing to distinguish them from ordinary prostatic hypertrophy, nor can their treatment be regarded as different. When met with in the course of the operation of lithotomy, they have been variously dealt with. In a communication on this subject,' I have narrated two cases of the kind in which isolated tumors were successfully removed by enucleation with the fingers. In neither of these cases did the proceeding entail any serious consequences, the patients being relieved not •only of their calculi but also of their prostatic tumors, which wei'e sufficiently large to occasion inconvenience. Similar cases have been I'ecorded by the late Sir William Ferguson,^ Mr. Cadge,^ and others. When the tumor is under these circumstances found to be continuous with the prostate gland, as, for instance, when the third lobe is enlarged and pendulous, it may be removed by avulsion with the finger ; occasionally it has been brought away accident- ally between the blades of the lithotomy forceps, without an}' ill consequences resulting. I have suggested, in the communication already referred to, that -when, in the course of a lithotomy or a cystotomy, any portion of the pros- tate is found to be pendulous, its removal by means of some simple form of •ecraseur should be undertaken, rather than that it should be left to grow and possibly obstruct micturition. Malignant Tumors. — These are rare, either as primary growths, or as sec- ondary deposits or extensions of tumors primarily affecting other organs, such as the bladder or penis. Of the various forms of carcinoma affecting the prostate, the encephaloid Tariety is generally admitted to be the most common. Cancer of the pros- Ig-te has usually been observed either in early life or after forty years of age. On the authority of Dr. Picard,^ it is stated that, with the exception, of the -eye, cancer, in children, attacks the prostate more frequently than ai}y other organ. The precise origin of the disease is always obscure, as death does not take place until all traces of normal structure are lost. Commencing in the mucous membrane, or in the substance of the gland itself, the tumor takes the form of a circumscribed mass, which in its growth may fill, or even distend, the bladder. ISTor is it confined to the limits of the capsule, for the vesiculfe sem- inales, the rectum, and the ureters, may all become involved. Secondary •deposits are found in the neighboring glands, a point which is of considera- ble importance in enabling the surgeon to arrive at a diagnosis. The con- sistence of the growth, and its appearance, vary much, being determined by its duration and" liability to hemorrhage or disintegration. In a case which I have recorded,' in which the disease was believed to have originated in the pros- tate, the bladder was completely filled with a brain-like substance, which gave prominence both to the perineal and supra-pubic regions. Before the patient's ■death, large sloughy masses of the growth, mixed with bloodclots, escaped freely through a perineal opening which circumstances had rendered necessary. In this case, enough encephaloid matter was expelled from the wound to fill a pint vessel. In the only case of this kind which has come under my obser- vation for some years at the Liverpool Royal Infirmary, the Pathologist, Mr. Paul, reports that secondary deposits were found both in the glands and in ' Loc. cit. ' Lancet, vol. i. 1870. ' Trans. Path. Soo. Lond., vol. xiii. * Traits des Maladies de la Prostate. Paris. ^ Op. clt,, p. 351. 390 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE, the lungs, and that histologically the new growth was a large-cell spindle- celled sarcoma. The patient was 61 years of age. The following is a description of the appearances : — The prostatic portion of the urethra and neck pf the bladder were entirely surrounded by a soft, encephaloid new growth, which formed a round, elastic swelling as big as a medium-sized orange, between the bladder and the rectum, and which had evidently commenced in the prostate. The growth was almost in a sloughy state, and so friable that it could be squeezed through an incision as easily as the contents of a sebaceoum cyst. The bladder itself was fairly healthy. In children these growths usually advance with great rapidity, whilst in adults their progress may be slow. Symptoms. — As the disease has been known to occur in a prostate already hypertrophied, the early symptoms may be very obscure. They are, gener- ally associated with some impediment tp micturition. As a rule, the disease develops with far greater rapidity than any other form of prostatic growth. There is irritability of the bladder, and often repeated and considerable hem- orrhages at the close of micturition. Rectal examination usually discloses some prostatic in-egularity or outgrowth, very unlike what is met with in the innocent forms of enlargement. In addition, some glandular swelling- may be detected. When the tumor assumes a considerable size, symptoms- resulting from pressure on the rectum, such as a distended colon, may arise. Under these circumstances colotoray has been suggested.' As the disease advances, the appearance to which the term "cancerous cachexia" has been, applied, becomes marked. In the case observed in my own practice, to which I have referred, on passing a cath- eter for the purpose of exploring the bladder, the instrument became blocked with a brain-like substance, which could be afterwards squeezed through the urethra by press- ure on the prostate from the rectum. Scirrhous carcinoma is still less frequently observed than the encephaloid variety. Of my own personal knowledge, in a district which furnishes abundant cases of every form of cancer, I am aware of only three instances. Two occurred in my own practice in the Liverpool Royal Infirmary, the post- mortem and histological examinations having been made by Mr. Rushton Parker. Though presenting a resemblance to ordinary hypertrophy of the prostate, the induration of the gland, coupled with the discovery of secondary deposits — in one instance in the liver,, and in the other in the lung — left no doubt as to the nature of the disease. The third, instance I have elsewhere recorded.'' The distinguishing feature of scirrhus of the prostate is its extreme hard- ness, which is generally associated with irregularity in outline, as detected by rectal examination. The early symptoms of the disease are vaejue, and^ beyond what may be revealed by the finger, are not distinguishable from those of prostatic hypertrophy. A case of colloid scirrhus of the prostate has recently been reported by Mr. S. Boyd.* The symptoms had extended over two years. The prostate was found infiltrated by a. new growth, which extended back and implicated the bladder, leaving only the poste- rior part of that viscus unaffected ; both vesiculae serainales were filled with colloid ma- terial, and the opening of each ureter was situated at the summit of a nodule of the growth. The microscopical examination showed the growth to consist of a fibrous- stroma, with numerous alveoli ; the stroma was nowhere so dense as in scirrhus of the- breast; there was extensive colloid degeneration. In the treatment of malignant growths of the prostate, beyond relieving- the symptoms of obstruction to micturition which may arise, there is nothing ' Lancet, June 24, 1882. = Op. cit., p. 3.^1. ' Trans. Path. Soo. Lond., 1882. TUBERCLE OF THE PROSTATE. 391 to be done but to palliate witb anodynes, and sustain with nourishraent. I am not aware that excision of the prostate has ever been practised, nor is it a proceeding to be advocated. » A case in which an attempt was made to remove a sarcomatous growth of the prostate by perineal incision, is recorded by Mr. Spanton.^ The previous symptoms had been chiefly those of obstruction to the rectum upon which the growth pressed so as to flatten it. This occasioned distension above, and an incessant but ineffectual desire to evacuate a stool. It was found impossible to remove more of the tumor tlian that in contact with the rectum, as it extended behind the pubis. The proceeding was attended with con- siderable hemorrhage, and the patient died on the following day. An autopsy showed that the tumor so overlapped the bladder, behind and above the pubis, as to conceal it. Tubercle of the Prostate. In the course of urinary tuberculosis the prostate may become involved, but it is rare to find the disease limited to the gland. In the more advanced illustrations of the aiiection, the deposit is found in the kidneys, testicles, and vesiculse seminales, as well as in the lungs. The tubercles take the form of small gray points scattered throughout the glandular tissue ; these may coalesce, and ultimately fo^-m abscesses. In this way the whole of the pros- tate has, in some instances, been converted into a pultaceous mass of pus and tubercle, which may be discharged either through the urethra or through the rectum. As tubercle of the prostate almost invariably exists in connection ^ith a similar deposit in some other organ, such as the kidney or testicle, where the diagnosis can be made with greater certainty, the occurrence under such circumstances of vesical irritability which can only be referred to the neck of the bladder, must be regarded as an indication that the prostate is probably becoming involved. It is almost imjDossible to indicate any special symptoms which may be said to determine the existence of tubercle at an early stage. So frequently does tuberculosis of the prostate coexist when the testicle is simi- larly affected, that in all cases of the latter the prostate should be carefully explored by rectal examination, when distinct points where tubercular deposit has taken place, may be detected. It has been remarked by Fleming,^ that these cases are usually referable to protracted gonorrhoea occurring in stru- mous subjects, in whom that disease is often very uncertain and slow in its progress. The treatment of this affection resolves itself into the employment of gene- ral measures directed towards arresting the progressive development of the tubercular state. These include the administration of cod-liver oil, steel, and a nutritious diet. Tepid sea-water bathing is often of considerable ser- vice in this class of affections. Locally, anodyne applications to relieve pain and vesical irritability will be necessarj'. As the symptoms sometimes simulate those of vesical calculus, the intro- duction of a sound into the bladder may be required for the purpose of estab- lishing a diagnosis. As a rule, however, instrumental interference with the urethra in these cases should be avoided. Tubercular abscesses of the pros- tate have sometimes opened into the rectum. Should fluctuation be detected from the bowel, it would be better to puncture in this position rather than permit the matter to burrow in other directions. In cases where fluctuation is not detected by the finger in the rectum, should an abscess form, it will ' Lancet, June 24, 1882. 2 Injuries and Diseases of tlie Genito-Urinary Organs. Dublin, 1877. 392 INJURIES AND DISEASES OF THE BLADDEK AND PROSTATE. probably discharge spontaneously into the urethra. By urine finding its way into and being retained in the cavity of such an abscess, further inflammation and suppuration will probably be set up, and a communication may be ulti- mately established between the urethra and the rectum. This has on several occasions been noted as a termination of tuberculous prostatitis. Cysts op the Prostate. Cysts, varying in size from that of a millet-seed to that of a pea, are often observed when a section is made through the prostate. It seems probable that they take their origin in an obstruction of one or more of the gland ducts. The contents generally resemble viscid mucus, and minute calculous particles may sometimes be felt. As a morbid condition little is known of these cysts, nor are there reasons for believing that they ever occasion any inconvenience. There is a form of cyst which has been described by Dr. Englisch,* of Vienna, which appears to be due to an occlusion of the orifice of the sinus pocularis in the prostatic urethra, and an accumulation of the secretion from the glands opening on its inner surface. Such cysts, according to these observations, have not only occasioned diificulty in micturition, but have led to other changes, such as distension and hypertrophy of the bladder, with remoter effects, due to urinary back-pressure on the kidneys. As Dr. Gross^ remarks, " a knowledge of this variety of tumor is not devoid of practical interest, since a part at least of the cases of retention of urine in the new-born child may Ije traced to this "cause." Prostatic Calculus. Like other gland structures, the prostate is liable to the formation of calc.u- lous concretions which will require special consideration. In structure they are entirely different from other calculi met with in the urinary organs, and appear to consist of the natural secretion of the gland in an altered form. The relation of the minute concretions so frequently met with in almost all prostates with the rarer affection of prostatic calculus, is well described in the following passage : " The prostate gland, like other glands, is liable to an inspissation of its secretion, producing small, yellow, sometimes red, or coloi'less bodies, scattered throughout the follicular structure. These, at first, are said to consist of organic matter which Virchow believes to be derived from a peculiar, insoluble protein substance mixed with the semen ; but sooner or later these formations are believed to irritate the mucous membrane, caus- ing phosphatic depositions which become encrusted upon the organic matter ; and thus the genuine prostatic calculi are formed.''^ . In this waj' prostatic calculi take their origin, their number, shape, and size varying in individual cases. It will be readily understood that the smaller foi^mations in their chemical composition almost entirely consist of organic matter, whilst in the larger ones phosphate of lime largely pre- dominates. Although taking their origin in the ducts of the gland, these concretions may assume a considerable size by their aggregation. In this way the pros- tate has, in some rare instances, been converted into a stony mass, the fibi-ous capsule alone of the original structure remaining. Amongst these cases must 1 Strieker's Med. Jahr. Heft i. 1873, mid Heft ii. 1874. 2 Op. cit. v. 413. " Poland, Holmes's System of Surgery, vol. iv. PROSTATIC CALCULUS. 393 be mentioned one recorded by Dr. Barker, of Bedford, England,' in which the calculus weighed three ounces and a half, and consisted of twenty-nine pieces of a whitish color, and porcelainous lustre and hardness, closely soldered together and measuring nearly five inches in length. It was removed from a man twenty-nine years of age, who had suffered from incontinence of urine from his fourth year. A somewhat similar case is recorded by Mr. Benjamin Gooch, of ITorwich.^ In some cases it has been observed that the several fragments composing the mass have been dove-tailed together with most remarkable accuracy. These concretions have occasionally made their escape from the prostate, and have been voided with the urine. Symptoms. — When small, these concretions seldom occasion any inconve- nience ; they have been frequently found after death in large numbers when previously there had been no reason to suppose that there was anything amiss with the prostate. On the other hand, there can be no doubt that their presence serves to explain the existence of irritability and pain about the neck of the bladder, which is otherwise unaccountable. In some instances they give rise to symptoms precisely similar to those occasioned by stone in the bladder. Under these circumstances, the presence of calculi within the limits of the prostate may be determined by the use of the sound combined with digital exploration ifrom the rectum. When existing, as they often do, in Fig. 1300. Poland's case of prostatic calculus. conjunction with stone in the bladder, stricture, or prostatic hypertrophy, they are often overlooked, and under almost all circumstances their recogni- tion is attended with considerable difiiculty. Digital examination of the pros- tate by the finger in the rectum, is a proceeding which must not be overlooked ' Trans. Prov. Med. and Surg. Assoc. 1847. 2 Cases and Practical Remarks in Surgery, p. 57. 394 INJUKIES AND DISEASES OF THE BLADDER AND PROSTATE, where this condition is suspected. Gross very properly lays stress upon the circumstances that the concretion is invariably fixed; that it is only to_ be felt at one spot ; and that it does not, like a vesical calculus, alter its position with the various movements of the body. Treatment. — Should troublesome urinary symptoms be distinctly traceable to the pressure of a prostatic calculus, means must be taken to remove it. This can probably be best efl:eeted by a median perineal incision ; in this way risk of hemorrhage will be avoided, whilst sufficient room will be afforded for the necessary manipulations with the finger or the forceps. Some very remarkable cases have been recorded in which almost the whole of the prostate gland has been removed by the pressure of dumb-bell-shaped calculi, situated partly within the bladder and partly within the prostate. In these instances the urethra has remained pervious. This condition is well illustrated by a case recorded by Mr. Poland' (Fig. 1300). These calculi, however, are not in their origin of the nature of those now under considera- tion. Reference is made to them for the purpose of showing how, in another waj^, the place of the prostate may, either in part or in whole, be occupied by material very different from that composing the normal gland. HEMATURIA. Hsematuria, or the presence of blood in the urine, is a symptom which is common to many affections of the urinary system. Its appearance is gener- ally unmistakable, and'naturally creates much apprehension in the mind of the patient, even though it may be connected with some disorder which is easily remediable. Occurring as frequently as it does,, it is a symptom which requires the fullest consideration, inasmuch as a careful examination of the circumstances attending its appearance, continuation, or cessation, as well as the form in which it presents itself, often throws considerable light on the precise nature of its cause. Like some other affections — for instance, irritability of the bladder — it is as a symptom that we must study it, rather than as in itself constituting a disease. It is as well to remember that not only by its presence does it often materially assist the practitioner in making a diag- nosis, but its absence is frequently a determining feature in a doubtful case. As hsematuria is capable of being produced by a variety of circumstances acting from the kidneys downwards, it will be necessary to analyze carefully the several conditions under which it presents itself to our notice. Blood is met with in the urine, either uniformly tinging it, or in clots. When intimately mixed, it produces various shades of discoloration of the fluid, sufiicient in extreme cases to produce what is known as smoky urine, an appearance which is often referred to as being characteristic. When the amount of blood is small, it may only be detected by the microscope, a means of investigation which should never be omitted. Albumen has sometimes been found in the urine and attributed to some renal disorder, when its presence has been really due to blood proceeding from another source, and undetected by the test-tube. In normal urine the blood-corpuscles are visible, and retain their shape, for several days ; when the specific gravity is low, or the urine ammoniacal, they rapidly disappear. " The marks by which blood-corpuscles are distinguished from other cells found in the urine, are, the extreme tenuity of their outline, the absence of visible cell-contents and especially of a nucleus, and their 1 Guy's Hosp. Reports. 1857. HiEMATUKIA. 395 feeble refractive power. When the bi-concave form is preserved, this of course is diagnostic."' Heematnria must not be confounded vs'ith another condition, to which the term htematinuria (more correctly hsemoglobinuria) has been applied. In the latter, the urine becomes highly discolored with hsemoglobin, but na blood-corpuscles are to be detected. " It is caused by rapid destruction of the blood-disks in the bloodvessels, such as occurs in that state which is known as a ' dissolved state of the blood,' in septic, pyferaic, and putrid fevers, and in some extreme cases of scurvy and purpura. In such cases hee- matine is set free by the disintegration of the red disks, and appears in the urine. Vogel found that inhalation of arseniuretted hydrogen produced an intense (but temporary) degree of hsematinuria."^ A careful examination of the urine with the microscope, immediately after it has been passed, will enable the practitioner not only to detect blood, should it be present in any form in the excretion, but to distinguish any coloration which may exist from that caused by hfemoglobin. In connection with these remarks on the importance of the use of the mi- croscope for detecting blood in the urine, reference may be made to an excep- tional case of recurring h?ematuria recorded by Dr. W". Roberts,^ in which chains of micrococci were in this way discovered immediately after the urine had been passed. Dr. Roberts concludes his observations by suggesting that this ease may furnish a key to others of a similar kind in which the cause for the hemorrhage seems inexplicable. Other means for the detection of blood in urine are the guaiacum test of Dr. John Day, of Geelong, and the spectroscopic examination of the fluid. The former depends on the hEemoglobin of the blood setting free ozone, which colors the precipitated resin of guaiacum, a bright sapphire blue. Plac6 a drop or two of the suspected urine in a small test-tube, add a drop of recently prepared tincture of guaiacum and a few drops of ozonic ether, agitate, and allow the ether to collect at the top. If blood be present, the ether acquires a blue color, leaving the urine below colorless. No saliva must be mixed with the urine, and the patient must not be taking a salt of iodine. The presence of much pus or mucus will cause the development of the reaction, even if blood be absent. For the spectroscope, the urine, if turbid, should be filtered, and if very dark should be diluted until of a faint red color, when, being placed in a test-tube, and the light pass- ing through it being examined by means of an ordinary spectroscope, it will be seen that the blue end of the spectrum is darkened. Two absorption -bands are visible just below Frauenhofer's line [), in the yellow half of the green. The band nearer the violet end is about twice as broad as the other. If any doubt be entertained as to the position or appearance of the bands, add to the fluid a very little ammonia, then a small quantity of the double tartrate of sodium and potassium, and finally a small fragment of ferrous ammonium-sulphate. Stir the solution, close the tube, and examine with a spectroscope ; when, in place of the two bands, a single fainter but broader band, intermediate in posi- tion between the two which it has replaced, will be found. In dealing with small quantities, the micro-spectroscope may be used with advantage. "With respect both to the guaiacum and spectroscopic tests, it is to be remembered that they only show the presence of the coloring matter of the blood, and not of the blood-corpuscles, and that consequently they do not serve to distinguish between hasraaturia and hfemoglobinuria. The other form in which blood is found in the urine is where it is clotted and not uniformly mixed with the fluid. Clots in urine should always be carefully examined, as they may indicate ' Koberts, Urinary and Renal Diseases. ' Ibid. ' British Medical Journal, October 15, 1881. §96 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. by" their form from whence the escape of blood is taking place. In reference to the importance of this, Mr. Hilton remarks :* " Swim out in water all clots whose origin is doubtful, in order that you may see the shape. Over and over again you will find yourself able to diagnose the case by this simple, common-sense expedient." Blood which has been clotted in the ureters is sometimes seen in the form of worm-like casts of those tubes. I will now proceed to consider, in their order from the kidneys downwards, the various circumstances which give rise to hsematuria, and any special indications, as bearing upon diagnosis, which an examination of the urine may furnish. As already observed, there is no symptom coimected with the diseases of the urinary organs, which, in its thorough investigation by all the means at our disposal, is more likely to furnish a clue to diagnosis than that now under consideration. Kidney. — Hemorrhage from the kidney may proceed either from the secreting portion of the gland, from the pelvis, or from the ureter. It may be caused by a variety of circumstances, including injuries of all kinds applied to the back or loins, the presence of calculi, the deposition of tubercle or cancer, and still more rarely parasitic affections, as in the endemic hsematuria met with at the Cape of Good Hope, in Egypt, and elsewhere. Further, hsematuria of renal origin is frequently' met with as a symptom of other diseases which do not come within the scope of a surgical treatise. Amongst these may be mentioned Bright's disease, certain eruptive fevers, scurvy, purpura, and other causes of renal congestion. Where the hemor- rhage proceeds from the secreting portion of the gland, it is generally found uniformly mixed with the urine, giving it a smoky appearance. When in addition blood=casts are discovered by the microscope, a diagnostic symp- tom of great value in indicating the precise nature of the lesion is afforded. J31ood-casts in the urine have been frequently found following injuries to the back, where there were reasons for believing that the kidney had been ruptured. In wounds of the kidney hsematuria is generally found to be a ■constant symptom. In ten cases described by Dr. Gustav Simon,^ it invaria- bly occurred, and in several in very considerable quantities. A hsematuria for which the kidney is responsible may sometimes be trace- able to the existence of a stricture of the urethra. I have seen it occur undei these circumstances, and completely disappear on the removal of the urethral obstruction. I need hardly remark that in this category I do not include those cases of hsematuria which are due to the escape of blood from the urethra as a consequence of either congestion or ulceration behind the stric- ture, or of the use of instruments. The cases to which I here refer are, ] believe, the result of back pressure on the kidney, and are remediable bj mechanical treatment. Persons who are liable to attacks of oxaluria, sometimes suffer from slight hsematuria due to the mechanical action of the crystals in their passage along the renal tubules. In this way, as Vandyke Carter' has pointed out, a nucleus is furnished for the formation of a mulberry calculus by the concurrence ir the kidney of a colloid and crystals. Many cases of persistent renal hsema- turia have been explained and remedied through the discovery of these crystals in the urine. Bladder. — Hemorrhage from the bladder is frequently found attending th( presence of calculi and various vesical growths; of the latter, the villous tumoi or papilloma is probably the most frequent. Where blood proceeds from sucl a tumor, it is generally discharged in large quantities, more or less clotted, anc 1 Guy's Hospital Reports, 1868. 2 Die Chirurgie der Nieren. 1876. 3 Op. eit., p. 39. HiEMATURIA. 39T often in a pure stream at the conclusion of micturition. Hemorrhage, when it proceeds from the bladder, is almost invariably attended with considerable irritability as far as micturition is concerned, a circumstance which is toler- ably sure to lead to an exploration for stone being made. Such an explor- ation, when made carefully and at the same time thoroughly, is justifiable as often furnishing not only negative evidence, but positive information as to the cause on which the hemorrhage depends. It is hardly necessary to add that a single exploration ought to suffice, for, however valuable the information which the sound is capable of aflbrding, it is not invariably obtained without some cost. Hence this examination should not be too hastily made, and every precaution should be taken to prevent any ill consequences arising therefrom. When a patient is sufieriug from hsematuria, the result of a villous growth, an ulcerating tumor, or a tubercular deposit, not only can the absence of a stone be ascertained, but often the growth, or a ragged surface, can be distinctly felt. When a villous growth has been the cause, a portion has sometimes been brought away in the eye of the catheter used for the purpose of sound- ing, or has been subsequently passed with the urine. Where hemorrhage is due to any of the causes last mentioned, the ex- amination is almost invariably followed by a considerable increase in the quantity of blood discharged ; for this, both patient and practitioner should alike be prepared, and every care should be taken, by rest and the application of cold to the region of the bladder, to moderate the hemorrhage. Direct exploration of the bladder with the iinger has been practised in cases in which there have been reasons for believing that the hemorrhage has proceeded from some undiscovered, abnormal condition of the viscus. In the female, this can be readily done by rapid dilatation of the urethra. In the male, such an exploration may be made by opening the membranous urethra in the median line. In the normal condition of the parts the interior of the bladder can in this way be reached, and the examination may be aided by bimanual manipulation, as practised by Volkmann. Sir Henry Thompson^ nas recently reported some cases illustrative of this method of exiamination, where hsematuria, having probably a vesical origin, was a prominent symp- tom. Vesical hemorrhage is sometimes met with in cases of enlarged prostate where there has been very great distension. If, in such a case, the whole of the urine be at once drawn off and pressure suddenly removed, passive hem- orrhage is apt to occur. In this way the bladder may become filled with clot, which not only causes great distress to the patient, but is exceedingly difficult to remove. To guard against this it is better to withdraw the urine gradually, and thus permit the distended organ somewhat to recover its tone before rendering it fiaccid. Urethra. — Hemorrhage from the ui-ethra is most frequently due to an acute gonorrhoea. It has been known to follow the forcible straightening of the penis of a person suffering from chordee. In young male children, it has been occasioned by the impaction of a calculus in the canal. Ulceration within the meatus of the urethra, most commonly of a syphilitic nature, may also give rise to this symptom. When hsematuria has its source in the urethra, not only does the blood escape as an independent flow during micturition, but also at intervals apart from that act. In connection with the subject of hffimaturia, it should be remarked that its association with injuries of the pelvis or of the perineum should lead to a most careful investigation with the catheter of the bladder and urethra. Fractured pelvis and ruptured urethra * On Digital Exploration of the Bladder through. Incision of i the Urethra from the Perineum. Lancet, May 6, 1882 ; On Tumors of the Bladder, etc. London, 1884. S98 INJURIES AND DISEASES OP THE BLADDER AND PROSTATE. may both give rise to this symptom. If the cause of the heematuria be not at once referred to its proper source, and means taken to prevent extrava- sation of urine, the most serious, if not fatal, results may ensue. In connection with injuries to the kidneys giving rise to hsematuria, the question may suggest itself whether the whole of the albumen contained in the urine under such circumstances is thus accounted for. Such a case came under my notice in conjunction with my colleague, Mr. Mitchell Banks. Here the patient, after an injury to the back, was subject at varying intervals to attacks of hsematuria. After an interval of some months it was observed that, though evidences of blood in the urine were seldom wanting on microscopic examination, yet the quantity of albumen, as compared with red blood-corpuscles, was so great, except at the times when a paroxysm of hemorrhage was taking place, as to lead to the inference that structural changes, such as are observed in certain forms of Bright's disease, had also been brought about. The relative quantities of the constituents of the blood, as far as they can be determined by actual examination, is a point of some importance in the investigation of certain cases of haematuria. Some curious forms of vicarious hsematuria have been described. Roberts' mentions a case in which it alternated with epistaxis and intracranial hemor- rhage. There are other instances in which hsematuria has supplemented a hemorrhoidal flux, and other examples are recorded in which the menstrual flow has been diverted to the urinary organs, and has taken the form of a periodical hasmaturia. Lastly, it must be remembered that there are certain drugs, such as cantharides and some of the terebinthinates, which by pro- voking congestion of the kidneys are capable of occasioning hsematuria. Treatment. — The treatment of hsematuria can only be here referred to in general terms, as it is a symptom rather than a disease. I shall therefore not do more than endeavor to indicate the principles which experience has shown to be serviceable in restraining it. When blood proceeds from the kidney, the means employed to arrest it are local and general. In the congestive forms of hsematuria, dry cupping over the loins is often of value, whilst after injuries, and in passive congestion, much reliance may be placed in the application of cold in the form of ice- bags or bladders over the part. Of the internal hsemostatics, mention should be made of the acetate of lead, alum, ergot of rye, turpentine, and matico. Acetate of lead, in combination with opium, was a favorite remedy of the late Dr. Golding Bird. Eest in the recumbent position will of course be enjoined. "Where the hemorrhage from the kidney has been probably of a pas- sive nature, I have more than once seen immediate benefit follow the placino- of the patient in a horizontal position, but more or less lying on the belly. Some of the hemorrhages connected with the kidney are undoubtedly the result of hsemostatic pressure, and may be favorably influenced by position. In prescribing a diet for a patient sufi'ering from this form of bleeding, I have often found alum-whey, administered ad libitum, both pleasant and ser- viceable. Hemorrhages from the bladder are associated with causes which may or may not admit of removal. When due to the presence of a stone, its re- moval is an obvious expedient. When due to tumors or ulceration, such a course is less obvious, though the cause may have been determined by dig- ital exploration of the viscus, as already referred to. • More precise means of diagnosis would, no doubt, bring many more of these conditions within the grasp of surgery. The most hemorrhagic tumor of the bladder— I refer to ' Op. oit., p. 135. RETENTION AND INCONTINENCE OE URINE, ETC. 399 the papilloma or villous growth — is probably fatal only by reason of the bleed- ing which it occasions, and not through any other character of malignancy. When hemorrhage from the bladder proceeds from causes beyond the reach of operative surgery, reliance must chiefly be placed on the styptics already men- tioned. Cold externally, in the form of ice-bags, is often of service. I have sometimes found, in hemorrhage proceeding from malignant and tubercular ulceration, great benefit from irrigating the bladder with hot water — water at a temperature of 105° Fahr., gradually raised to 120°. The value of hot water in blanching tissues, and thus restraining the hemorrhage, is not sufli- ciently recognized in this class of affections. When employed with a suita- ble^ apparatus, and a gentle hand, it is capable of affording much relief, not only by arresting this symptom, but by controlling the cystitis which so fre- quently accompanies it. Reference has already been made to the best method of dealing with blood clotted in the bladder, when it occasions symptoms demanding its removal. Hemorrhage from the urethra, when constituting hsematuria, hardly requires any special reference, as it is as a rule easily detected, and readily remedied by some modification in the treatment appropriate to the condition which gives rise to it. The injection of a little iced water up the urethra, and the suspension of other local treatment, are in the great majority of instances quite sufficient to cause the hemorrhage to cease. When it occurs in gonorrhoea, it is, as a rule, traceable to the extreme anxiety evinced by the patient to get rid of this affection by the too frequent use of an injection. Retention and Incontinence of Urine; Paralysis and Atony; Spasm and Neuralgia oe the Bladder. Retention and incontinence are conditions which may coexist and be dependent upon one cause. A patient, for reasons pi'csently to be mentioned, may be physically incapable of expelling the urine which has collected in his bladder ; eventually an overfiow takes place, and thus incontinence becomes substituted for the previous inability to micturate. Hence incontinence, or the dribbling away of urine in the adult, almost invariably means that the bladder is so full that it is actually overflowing. In the child, incontinence may have a very different signification. Retention of urine is, as a rule, readily recognized. It is often the term- ination of gradually increasing difficulty in micturition, and is at once obvi- ous both to the patient and the practitioner. In other instances it is less apparent, especially in the case of individuals who, by reason of an enlarging prostate, have long been unable completely to empty the bladder. Here it may not be discovered until incontinence or overflow actually occurs. In other cases the retention is sudden and abrupt, and appears to have been pre- ceded by no symptoms of significance. Retention of urine may be overlooked in certain conditions in which the patient is incapable of giving expression to his sensations ; hence in persons who have been suddenly rendered insensible by injuries or by disease, as in apoplexy and sometimes in the insane, reten- tion may remain unobserved, and eonsiderable damage may be occasioned thereby. In addition to the sensations of the patient, coupled with the fact that urine has not been passed for a certain period of time, retention is indicated by a more or less distended condition of the bladder. This presents itself as a globular, or rather egg-shaped, tumor immediately above the pubis, some- times extending up to the level of the umbilicus. It may be here remarked 400 INJUKIES AND DISEASES OF THE BLADDER AND PROSTATE. that the necessity for the use of the catheter must not be judged of by the siz which the bladder has attained. If one man is so insensitive as to require relie by the catheter only when the fundus of his bladder reaches to the umbilicus w^e must not infer that another needs it less, because this line has not ye1 in his case, been reached. Powers of endurance in this respect are ver diflerent. The patient with a small, contracted bladder, from long-standin, stricture, suffers all the horrors of retention long before the indicated limi has been reached. The amount of distension has, in some instances, bee very remarkable, so as even to have suggested to the practitioner that som error in diagnosis had been made. A case is recorded by Dr. Murchison in which an abdominal enlargement in the male, believed to be a hydati( tumor of the liver, turned out to be a distended bladder, holding twentj; four pints of urine. Another case is narrated by Jaccoud,^ in which a tumo occupying the hypogastric and umbilical regions in a young woman, wa at first thought to be an ovarian cyst. Other instances are to be foun( in which a distended bladder has been mistaken for pregnancy. Illustration such as these do not, as a rule, indicate that there is any real difficulty ii making a diagnosis between a tumor and a distended bladder, but rather th' caution which is necessary in accepting the statements of persons as to thei ability to micturate, and as to the completeness of the act. Because a patien passes water, we are not, therefore, justified in assuming that he can empt; his bladder. When the retention is extreme and the prostate is not large, the distendec bladder can generally be felt from the' rectum ; fluctuation may also b^ detected here by palpating above the pubis. In very corpulent persons, i may be almost impossible to determine the precise condition of the bladder when retention is suspected, by abdominal examination ; hence, in, cases o doubt, the catheter should be passed. As already observed, retention of urine may, by reason of an overflow o incontinence being induced, be prevented from doing serious mischief; it i remarkable in some cases how long such a condition may continue. Wher ulceration of the bladder exists, or the urethra is dilated, or weakened behind a stricture, the patient is exposed to the danger of a sudden ruptur taking place, and of extravasation of urine occurring. In some of the case recorded as spontaneous rupture of the bladder from retention, this acciden had probably been preceded by ulceration. Suppression of urine is not to be mistaken for retention ; in the formei we have an empty bladder and no urine, by reason of the kidneys failing ti excrete. Retention of urine may be due to a variety of causes, which may b included under four headings: (1) causes indirectly connected with th urinary organs, (2) structural changes in the bladder or the presence withii it of abnormal contents, (3) causes originating in the prostate, (4) urethra obstruction. These conditions will require special consideration. (1) Amongst the causes of retention indirectly connected with the urinar apparatus, we must include injuries by which their innervation is more o l§ss destroyed, or their muscular mechanism interfered with. Injuries to th spine or cord — such as fracture, dislocation, or concussion — are frequently fo] lowed by temporary or permanent retention of urine, due to the injury of th nerves or spinal centres by which paralysis is induced. Concussion of th spine rarely occasions more than very temporary retention, although cor siderable weakness of the bladder, in relation to its command over the urine may remain for some time. Paralysis of the bladder, retention, and subse 1 Diseases of the Liver, p. 460. ' Le Progrfes Medical, 15 Mai, 1875. RETENTION "AND INCONTINENCE OF URINE, ETC. 401 qiient incontinence of urine, almost invariably attend fracture or dislocation in any part of the spinal column. As a rule, chronic cystitis rapidl}' super- venes on the retention, and phosphates are deposited in abundance, sufficient, in some cases, to form stone. Under these circumstances the disease is rarely completely recovered from ; if the injury be not safficiently high up to occa- sion speedy death, the future comfort of the patient will, in a great measure, depend on the care displayed in the management of his bladder-affection. There are other changes occurring in the cerebro-spinal centres, which may ultimately cause the bladder to fail in discharging its contents. In these the process is a gradually increasing one, but the ultimate results, as far as this viscus is concerned — the rendering of the urine alkaline, the production of phosphates, and the deposition of ropy mucus in excess — are similar to those observed after injuries to the spine. Retention of urine frequently occurs in the course of fevers, such as typhus, where the functions of the nerve-cen- tres are more or less in abeyance. Reflex irritation, as, for instance, that occasioned by the ligature of hferaorrhoids, sometimes leads to retention. It will not be necessary to further illustrate causes of retention other than those in which the urinary oi'gans are immediately concerned. Under this heading, however, it should be mentioned that injuries to the abdomen, in which the muscles only are involved, sometimes require the use of the catheter, the blad- der being rendered unable to expel its contents by reason of the pain which is produced on the patient's attempting to make expulsive efforts. Similarly, I have seen the same thing happen in a case of extravasation of urine largely occupying the abdominal parietes, where muscles, cellular tissue, and sldn, were all involved in the sloughing and suppuration which ensued. (2) Retention due to changes in the wall of the bladder by which it is rendered structurally incapable of performing its function, will be hereafter considered in speaking of vesical atony. The other causes of retention which depend on changes in the walls or contents of the bladder, include growths and calculi. The latter, by occasionally becoming impacted in the orifice of the urethra, may cause retention ; a sudden stoppage in the stream of urine has often been noted as a symptom of stone. (3) The most frequent cause of retention of urine is hypertrophy of the prostate gland. Reference has already been made to the precise changes which take place in the prostatic urethra as a consequence of this hyper- trophy, whereby micturition is obstructed. "When retention of urine occurs in males of advancing age, it is almost invariably due to this cause, a circum- stance which must be borne in mind both in the selection of a catheter and in the manner of its introduction. Certain inflammatory changes in the prostate are sometimes the cause of retention. Of these, mention may be made of the follicular form of prostatitis, which is not uncommonly seen as a consequence of gonorrhoeal urethritis. Such a retention may require the use of the catheter for its relief, and often this proceeding not only discloses the cause of the impediment, but removes it, by leading to the discharge of pus into the prostatic urethra, with immediate and permanent I'emoval of the retention. (4) An obstructed urethra may occasion retention in various ways. In young children it is most frequently due to the impaction of a calculus; if this be overlooked and not removed by incision, extravasation of urine may occur, and the calculus may make its escape by sloughing, as I have seen, into either perineum or scrotum. More rarely, retention in the infant is caused by the almost complete occlusion of the preputial orifice. In the adult, either a gonorrhceal or a traumatic stricture is the more frequent cause of retention. It not unfrequently happens that a complete stoppage to the discharge of urine suddenly takes place in a person who is suffering from VOL. VI. — 26 402 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. • stricture, and it generally happens in the following way. Every person who suffers from stricture finds out by experience the maximum quantity of urine over which he can successfully exercise expulsive power ; and as long as this quantity is not exceeded, the ability to expel the urine remains, although the stream may be exceedingly small or may even issue in drops. Should urine, however, from any cause, be allowed to collect in the bladder beyond the accus- toined limit, the propulsive apparatus becomes disarranged by being called upon to do unaccustomed work, and irregular, spasmodic efforts take the place of that combined muscular action, which is necessary in the case of a person who, at the best of times, voids his urine under difficulties. This con- sideration is offered as explaining how retention may be regarded as an acci- dent occurring in the course of a case of stricture, and how it is that spasm becomes superadded to permanent urethral obstruction. Urethral spasm, independent of any organic change in the walls of the canal, is quite capable of occasioning retention of urine. Instances of this form of retention are most frequently seen in young men who, when suffering from gonori'hoea, have indulged freely in intoxicating liquors, or have exposed themselves to cold, as by lying or sitting on the grass or upon a damp seat. Spasm is thus excited in the muscles surrounding the membranous portion of the urethra ; a condition not unlike that which we speak of as cramp, is aroused; the mechanism connected with micturition is disorganized; and thus the bladder is rendered incapable of voiding its contents. A predisposing cause to this variety of retention is a highly acid condition of the urine. Similarly, I have seen the same effect produced in the gouty by the passing of urine highly charged with crystals of uric acid, of a shape such as to irritate the mucous membrane and produce spasm of the muscular walls of the canals along which they have to pass. Hence, in all cases of this kind, it is important to free the urine from all probable causes of irritation. Retention may be caused by infiammation and suppuration around the urethra; these effects are most frequently seen in cases of acute gonorrhoea, and are often traceable to the use of irritating or too potent injections, or to the employment of bougies or other such like instruments during the acute stage of the disorder. Amongst the rarer causes of retention may be mentioned the pressure of a displaced kidney. Dr. Gouley^ has illustrated this by a case in which com- pression was exercised on the ureter (there being only a single kidney), partly by the kidney and partly by the bladder. After death the pelvis of the kidney was found et2ormously dilated and filled with urine, and encroaching upon the space behind the bladder. Hysteria sometimes takes the form of retention of urine ; numerous instances are recorded of deception with reference to this symptom, evidently prompted by the mental condition which in a large measure constitutes this peculiar neurotic disorder. It is sufficient to mention them.. Treatment. — When the bladder is incapable of being emptied spontaneously, it must be relieved artificially of the urine which it contains. Though the condition of the urine is frequently sufficient to convert impeded micturition into complete retention, the circumstances are exceedingly exceptional, under which treatment other than that of catheterization should be employed. After retention has once been relieved by the introduction of an instrument into the bladder, medical treatment may prevent the recurrence of such an emergency. It has been remarked by Sir James Paget, that " one of the best things about strictures to be learnt in the out-patient room, is the value of medical treatment, and of rules of living, in alleviating the occasional urgen- cies of the disease, and in enabling the patient to live in comfort and without ' Diseases of the Urinary Organs, p. 235. fiTC. 403 «atheters."' In some cases, when the symptoms of retention are not pressing, and when the history of the case warrants the assumption that the impedi- ment depends upon some temporary occlusion of the urethra by inflammatory engorgement of the mucous membrane, to which spasm has been superadded, a hot bath and a full dose of laudanum, followed by wrapping the patient in warm blankets, are means which are sometimes successful in bringing about ja natural discharge of the urine. Such treatment, however, is not to be recommended or to be continued when the symptoms of retention are at all urgent. When the case is further complicated by the existence of an organ- ized stricture of some standing, delay may lead to serious consequences which might perhaps be averted by the timely use of the catheter. The late Mr. Gruthrie^ was in the habit of enforcing the use of the catheter by some very humorous and characteristic illustrations, concluding his observations on this subject with the remark, " I have always made it a rule to try and pass a catheter in every case of retention of urine. If it passes, so much the better ; if it does not, the patient submits more cheerfully to the longer course of treatment." There is a verj^ simple expedient which often suffices in cases of retention due to organic stricture, which is not sufficiently resorted to. In many of these -cases, the absolute occlusion of the urethra is, I believe, determined by the impaction within the stricture of a small fragment of inspissated mucus. I have frequently found that urgent retention may be relieved by the passage of a fine, filiform bougie. On withdrawing it, urine flows, and the patient, if placed in a warm bed, is able slowly but effectually to empty his bladder. Then, as a rule, medical treatment having reference to the allaying of spasm and inflammation, and to the correction of the condition of the urine, comes in most serviceably before any other treatment is required. In many cases I have found this proceeding successful even after ordinary catheterization has failed to give relief. When retention is not occasioned by any object situated anterior to the bladder, catheterization will not be attended with any special difficulty. As -a rule, the flexible or rubber instruments will be found admirably adapted for these purposes ; not only do they occasion no damage to the parts along which they have to pass, but, should it be desirable, patients may be readily instructed in their use. In senile retention due to an enlarging prostate, an appropriate instrument, either flexible or metallic, will most probably be required. These have already been described. In employing catheters under these -circumstances, practitioners will not forget the great assistance which they may obtain from tilting the end of the instrument over the obstructing portion of the gland, by means of the finger in the rectum. In retention arising from the various forms of stricture of the urethra, it may be necessary to employ instruments of very small calibre. These will be referred to in connection with the treatment of stricture of the urethra. When fine metallic instruments have to be used for this purpose, care must be taken that no force be exercised in introducing them, as otherwise a false passage may easily be made. I shall not further refer to the varieties of catheter used in the treatment of retention due to stricture, except to remark on the great usefulness of the tunnelled catheter introduced by Dr. Gouley {Pig. 1301). There have been very few cases of retention from stricture, in which I have not been able to introduce the fine whalebone guide into • On some Aflfections of the Urinary Bladder and Urethra. Med. Times and Gazette, April 10, 1858. ' Op. cit., p. 89. 404 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. the bladder. When this is accomplished, there is very little difficulty experi- enced, or skill required, in sliding the fine catheter that accompanies the in- 'strument through the obstruction, and thus withdrawing the urine. Fig. 1301. Gouley's tunnelled catheter. To patients who are very intolerant of catheterization, or in whom there is spasmodic resistance to passing an instrument, an ansesthetic may be administered with advantage. As a rule, for these cases, I prefer chloro- form to ether, as with the latter the stage of excitement is usually more prolonged — a point worthy of consideration where we have a distended blad- der. I mention this, because I prefer, for surgical operations generally, ether to chloroform. In using anaesthetics for this purpose, Sir Henry Thomp- son's' observation should be borne in mind: "Let it be remembered that chloroform is administered, not for the purpose of permitting the instrument to be used with greater force than before, but in order to produce perfect ansesthesia and relaxation of the muscles." Retention of urine is far less common in females than in males ; this is of course due to the comparative immunity of their short urethras from obstructive disease taking origin in the canal itself, or in the glands associated with it. The introduction of the female catheter, under ordinary circumstances, is an operation of no difficulty. In cases of distention of the bladder caused by uterine and ovarian tumors which are fixed in the pelvis. Sir Spencer Wells^ observes that a small and long elastic catheter is sometimes required. Such an instrument is especially necessary in cases of tumor of the uterus, in which it is not rare to find the bladder drawn up nearly to the level of the umbilicus. It will hardly be necessary to lay stress on the extreme gentleness with which all mechanical proceedings for the withdrawal of retained urine from the bladder, should be conducted. The employment of force is, under all cir- cumstances, unjustifiable. Though retention of urine is an evil, unskilful catheterization may be a greater. If the catheter cannot be introduced with tolerable readiness, and without hemorrhage of any moment, an operator would be likely to do less harm by selecting one of the simpler methods of tap- ping the bladder presently to be described, than by persevering in his efiibrts to force an instrument in a direction supposed to correspond with that of the natural passage. When the bladder is once relieved, as for instance by the fine needle of the aspirator, the most important obstacle to catheteri- zation — viz. tension — is at once removed, and will, most probably, not be allowed to recur. In conclusion, it may be mentioned incidentally that patients have some- times found themselves suffering from most urgent retention, under circum- stances in which they have been unable either to introduce a catheter or to obtain professional assistance. I know cases in which the wire from a soda- water bottle and an iron skewer, each has done duty in "forcing" a stricture. A bougie made from an old clock-pendulum was recently shown me by a sailor, as an instrument modelled by himself, with which he had suc- ' Op. oit., p. 178. 2 On Ovarian and Uterine Tumors, p. 143. 1882. RETENTION AND INCONTINENCE OF URINE, ETC. 405 cessfully combated an obstinate stricture that had previously resisted the attacks made on it with a gum-elastic catheter. It is not a long time ago that a man was admitted into my wards with retention, and a badly lacerated urethra, as a consequence of an attempt on the part of the mate of his ship to reach the bladder by the aid of a pointed piece of wood, roughly adapted to the shape of a bougie. Here the operator was more than professionally interested, inasmuch as he had occasioned the retention by kicking the pa- tient behind the scrotum. The most remarkable piece of ingenuity of the kind that I can remember was in a case in which, after a patient had endured the unspeakable agonies of retention for over three days, an endeavor had been made to introduce through the urethra a piece of gas-piping, which had been devised, in extremis, for the purpose by the engineer of the ship. Unfor- tunately, however, this failed to effect its object. When I saw the patient, immediately on his arrival, I found the urethi'a much lacerated, and it was with considerable difficulty that I introduced a catheter, and removed a large quantity of the most fetid urine imaginable. Relief, however, came too late, the man dying shortly after his arrival, with convulsions and ursemic poi- soning. Other cases are on record, in which, all such rough expedients having failed to relieve persons suffering from urgent retention, they have actually opened their bladders or urethras with knife or stylet, by either supra-pubic or perineal incision. A case is narrated by Mr. Treves,^ in which a seaman deliberately punctured his bladder in the median line above the pubis, with the small blade of a pen-knife, allowed the water to run out by the side of the knife, and then introduced a catheter into the bladder, through the wound. There he retained it until he found that he could pass an instrument by the urethra. The wound subsequently healed well, and the man recovered without a bad symptom. Incontinence of urine has been noticed as indicating the overflow of an already distended bladder, and also as a symptom of vesical irritability. In ■connection with the latter, it is most frequently met with in young children. Here incontinence is, for the most part, traceable to a variety of causes capa- ble of disturbing, chiefly by reflected action, the innervation of the bladder. IFor the treatment of this form of incontinence, which is chiefly nocturnal, xeference should be made to the section relating to irritability of the bladder. There are other forms of incontinence which will require a brief notice. There is that of young adults, which seems as if it had grown up with them. Met with in such persons, it is productive of very great distress. In the case of domestic servants, it may become an insuperable objection to their obtain- ing employment. In many of these case's it is impossible to discover any , tangible cause for its continuance. If it is merely a habit, it differs from others by the impossibility of breaking it off by any manner or kind of expe-