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Cystitis, J b. Diseases essentially obstructive. Stricture of the urethra. Hypertrophy of the prostate. c. Calculous Diseases. Of the urethra. Of the prostate. Of the bladder. Of the pelvis of the kidney. d. Tumours—malignant and non- malignant. Of the prostate. Of the bladder. II. Diseases affecting the Secre- ting Organs. All organic changes in the kidney; also those altered conditions of the urine which depend on constitutional disease, such as Bright's disease and saccharine diabetes. 9 DISEASES OF THE URINARY ORGANS. But before commencing, I shall ask you to consider for a moment the title I have affixed to this course—viz., ' The Surgical Diseases of the Urinary Organs.' Now, you may inquire, ' What are the surgical diseases of the urinary organs, and what are not ? ' To my mind it is very easy to tell you what are surgical diseases of those organs, but less easy to tell you what are not so. Look at the list before you, and see where the line should be drawn. Certainly the first division belongs wholly to that class—all diseases of the urinary passages, excluding the kidneys, which we will assume to be secreting organs. Undoubtedly all that part belongs to the surgeon. The phy- sician, conventionally, claims the second ; but since it is impossible to make a diagnosis of any of those diseases without well understanding the whole, and as the physician does not make a physical ex- amination by means of an instrument, I am compelled to regard all affections of the urinary organs as naturally coming within the province of Surgery. This statement may not be universally re- ceived ; but when we have considered the matter, we shall see that it is abso- lutely impossible to make a trustworthy diagnosis of urinary diseases without a practical familiarity with the use of the sound or catheter. I do not say that the physician is incapable of doing this ; but, conventionally, the necessary manipu- lations are not practised by him. And you can no more treat diseases of the urinary organs without the ability to use these instruments, than you can treat diseases of the chest without understand- ing the use of the stethoscope, and without being practically familiar with the indi- cations which it affords. The first step in our course is natu- rally that relating to Diagnosis. I say almost nothing about the pathology and treatment of any one of these diseases to-day. The question before us now is diagnosis; and I need scarcely remind you that this is the most important thing in all diseases—to know accurately what you are about to treat: there is then very little difficulty as to the management. Many books can teach all that is known of one; no book can teach what you must know of the other. The art of diagnosis can only be accomplished by the appli- cation of rules after some practice. It is the first thing to learn and to use; it is the last thing to be perfectly acquired. Indeed, no man, let him live as long as he may, will ever be a perfect diagnos- tician. He may approach perfection; but if he is a diligent student, as he ought always to be, he will improve his powers of diagnosis as long as he lives. That is the reason why age or experience gives value to an opinion. Long and intelligent observation and extensive experience enable a man to arrive at a diagnosis with a greater certainty than the younger practitioner can possibly attain. What is Diagnosis ? It consists, first of all, in the acquisition of facts; and, secondly, in obtaining legitimate infer- ences from those facts. Now, the acquisition of facts is one of the most difficult things in the world. No two persons ever agree in their state- ments descriptive of an occurrence to which they both have been witnesses. If I bring a case of disease before you here, and ask ten of you to take as many histories of it, I will undertake to say that each one will materially differ, and that I shall get ten histories, varying from each other in some important particulars. Each will be approximately true; none will be absolutely correct. You must then diligently learn to observe, and to do so Avell requires special qualities and much practice. Is it not a very striking illustration of what I have said, that if two witnesses relate precisely similar stories of any given event, the suspicion of collusion is always instantly suggested, and is, indeed, very naturally aroused ? It has often struck me that the qualities which men of our profession require, and which we should endeavour to cultivate, are precisely such as are necessary to those who are engaged in the exercise of the legal profession; and the men who are really successful in either profession have much in common in intellectual character and attainment. In our profession, equally with that of the law, careful examination of the statement, acute and subtle cross- examination of the Avitness, and a keen pursuit of the simple fact are essential; and, finally, a calm judicial habit of weighing the facts when obtained. And in both professions the issues raised are equally weighty, and demand in either case the highest qualifications in the individual. But next, I have not only to call your attention to the necessity for making a DIAGNOSIS. O careful and accurate diagnosis, it is equally important that you should learn to make it rapidly. For it must be admitted that our proceedings differ from those of the law in this respect; for while—as we have seen not so long ago—several months may be devoted to the critical investigation of a legal claim, and a considerable period of time must mostly be expended on the proof or disproof of any allegation, our decisions are required without delay. While the doctors are deliberating the patient is dying. Hence the ability to make a diagnosis is not sufficient; the Art of making a rapid diagnosis must also be attained. Thus, when called to the bedside, your action must often depend on the first three or four minutes of your interview. It may be easy to go home, quietly think over the case, pull down the authorities, and say, ' I think the patient has so-and- so.' That will not always do : it may do in some cases, and it had better do than that you should attempt to treat the case with- out having made up your mind as to the diagnosis. But that which will make you successful, that which distinguishes be- tween the intelligent practitioner and him who is not so, is the ability to make a rapid as well as an accurate diagnosis of the case before him. To this end—and Avhat I have to say applies to all departments of our art—I advise you always to pursue a uniform method. Order and uniformity are essen- tial elements in directing the necessary in- vestigation ; and after much thought and experiment, for my own private guidance as well as for yours, I have adopted the following system. Relative to the class of diseases we are studying, there are three methods of obtaining the facts required :—Firstly, by questions of the patient; secondly, by physical examina- tion of the body; thirdly, by examination, chemical and otherwise, of the secre- tions. First, by questions. There are four chief questions which I always employ, and always in the same order. They ought, with the minor inquiries which branch out of them, to determine six out of seven cases which come to you. They relate to four signs and symptoms more or less met with in patients affected with complaint in any part of the urinary organs. Frequent micturition; painful micturition ; deviation in the character of B I the urine itself from the healthy standard; the addition of blood to the urine. The first question, then, which I in- variably ask of any patient so affected is, ' Have you any, and, if any, what fre- quency in passing water?' Then, as a branch of that question, springing out of it, I ask whether the frequency is more by day or by night, or influenced by move- ments, or by any particular circumstance ? How the question applies I will tell you afterwards. ^ Then, secondly, I ask whether there is pain in passing urine ; and whether before, during, or after micturition? Inquire also if pain is felt at other times, and if it is produced or aggravated by quick movements of the body. The locality of the pain is also to be precisely ascer- tained. Then I ask, as a third question, ' Is the character of the urine altered in ap- pearance, or is there anything unusual in the stream itself? Is the urine turbid or clear ? ' Possibly the patient will tell you that it is turbid, but you find, on ques- tioning further, that it was passed per- fectly clear, and only became thick after cooling or standing. Also, as arising out of this, you may often ask, ' Does it vary much in quantity ? ' noting of course the specific gravity. The healthy standard, both as regards quantity and density, however, must be allowed very extensible limits, and both, I need not tell you, are very important elements in regard of renal disease. Then, as regards the stream itself, it may be small, forked, or twisted, or it may stop suddenly when flowing. The fourth and last question is, whether blood has been passed in any way with the urine; whether the mixture is florid or brown, light or dark; whether the blood and urine are intimately mixed, or whether the blood is chiefly passed at the end or at the beginning of making water; or, lastly, whether it issues inde- pendently of micturition altogether. These are the four questions; and let me remark, that the value of the answers you get will depend very much upon the way in which you put the questions. The patient is not always self-possessed, or he does not clearly understand the nature of the question you put. It is necessary to be very precise and very distinct in your questions if you wish to get accurate answers. Now you will say, how do I 2 4 DISEASES OF THE apply these questions to the list of diseases before you ? First question—Frequency of passing water. There is no serious affection of the urinary organs, except one or two which I will name hereafter, in which you have not more or less frequency of passing water. Thus the following is an excep- tion : A man may have stricture to a considerable extent; the stream may be rather narrow, and he may not for some years complain of frequency of passing water, although the symptom will appear sooner or later. Now I wish you to observe that I have classified these diseases that we may deal with them more easily. At the head of our list there are the inflammatory diseases—inflammation of the urethra, of the prostate, and of the bladder. In all these you have frequency in passing water. Not necessarily, however, in urethritis, until it reaches the distant part of the canal near the bladder; and this is the second instance of exception which I referred to just now. I do not propose to enter upon the subject of urethritis here, as you have frequent opportunities of studying it in the out-patients' room. I am now only referring to this symptom of frequency of passing water as existing more or less in all these diseases at some time or another. Firstly; in Hypertrophy of the Pro- state you have it, and it is remarkable that it is more at night than in the day. Secondly ; in Chronic Prostatitis it is usually present to a small extent; in Cystitis it is, of course, a characteristic symptom. I name these together because they are so intimately connected that the bladder can scarcely be affected without the prostate being more or less involved. Thirdly; in Calculous diseases fre- quent micturition is a prominent symptom, and generally its degree is in proportion to the amount of movement permitted to the patient. Fourthly; Tumours, malignant and non-malignant, are of course attended by the same symptom. Fifthly ; in Pyelitis, and in almost all organic changes of the kidney, in Bright's disease, and in Diabetes, there is frequency of making water. Whenever the natural characters of the urine are altered be- fore it reaches the bladder, the secre- tion produces irritation. This fact is URINARY ORGANS. worth dwelling upon for a moment, as it is not uncommonly overlooked. Thus, diluted or watery urine is often regarded as un-irritating; on the con- trary, it is not generally well retained by the bladder. The bladder is, as a rule, never so content as when it contains a urine of average, or more than average, specific gravity. Some persons who are nervous, and particularly hysterical pa- tients, will pass urine which is'quite pale, almost like natural water, and the bladder is always more or less uncomfortable from it. Of course, in Diabetes, you have not only the character of the urine altered, but the quantity much increased, with frequent micturition as the necessary con- sequence. And I may remark that it is chiefly in renal affections that increase in quantity takes place; while, on the other hand, suppression of urine is always a malady of the kidneys. The second question has reference to Pain. The attainment of precise knowledge relative to the nature and seat of pain, will carry you far on your way towards a diagnosis. In Prostatitis there is usually pain at the extremity of the penis, and felt at the end of passing water—less severe, but resembling somewhat that of stone; as the bladder contracts, when empty, on the tender prostate. In Cystitis the pain is usually before micturition, because the inflamed mucous lining of the bladder will not bear much expansion, and is sensitive on being dis- tended, as all mucous membranes are when inflamed [of which a sore throat is a familiar example]; and hence the organ frequently endeavours to get rid of its contents. The usual seat of pain is just above the pubes. When cystitis is acute, pain may be felt in the perineum also; but in chronic or subacute cystitis it is supra-pubic, and not at the end but at the beginning of making water, unless the prostate is affected, and then the tender prostate gives a little pain at the end, as I have just said. In Stricture of the urethra there is often pain about the seat of the obstruc- tion, an idea of which you may obtain by a simple experiment. If, when passing urine with a full stream, you suddenly narrow the passage with your finger so as to diminish the stream to one half or more, you will experience an acute pain. DIAGNOSIS. 5 There may be pain with Hypertrophy of the prostate., inasmuch as this is fre- quently associated with chronic cystitis, when the pain is before making water, and not afterwards—differing in that re- spect from stone. The bladder wants to get rid of its contents, and can do so but slowly, on account of the enlarged pro- state, which stands as a barrier in the way. During it3 first contractions, which expel but little urine, there is often severe pain above the pubes and deep in the perineum ; but when a third or a half of the contents has issued, the patient is re- lieved. When the pain is sudden and very severe before the patient can pass urine, he speaks of it usually as ' spasm.' This term almost always implies that the bladder is distended and urgently demands relief: but the same pain may sometimes be caused in a bladder emptied of urine and containing a foreign body, whence involuntary expulsive efforts are made. I shall not dwell upon Calculous disease of the urethra. The calculus is only a temporary lodger there, and as it can often be felt externally by the hand, there is rarely any difficulty about the diagnosis. Calculous disease of the prostate is also rare. I shall not complicate what I wish to be a simple matter by dwelling upon it, but call your attention to the com- moner condition of Calculus in the bladder. In Calculus of the Bladder the pain is quite distinct in its character: it is felt at the end of passing water, because the bladder being emptied, the rough surface of the stone is left in contact with the mucous membrane, doubtless that cover- ing the neck of the bladder, which is unquestionably a sensitive spot. As soon as sufficient urine has trickled down into the bladder to separate the coats from the stone, relief is obtained. Then the pain is felt at the end of the penis, within -an inch of it, about the base of the glans. Furthermore, the pain is increased by movement; in other complaints it is not necessarily so. Put a patient in a rough- going vehicle, or make him jump from a step, or perform any rapid movement, and instantly he feels severe pain, probably at the neck of the bladder, but also and chiefly at the end of the penis. In prosta- titis, inasmuch as the neck of the bladder is involved, there is usually some pain at the end of the penis, which is a reason why chronic inflammation of the prostate is sometimes mistaken for stone. With regard to calculus of the kidney, I have little to say here. Of course you have pain referred to the locality, right or left, not often to both kidneys; there is tenderness also, and much increase of pain on movement. It is usually on one side only, and perhaps more frequently on the left than on the right side, and it is often felt over the hip and towards the groin of the affected side, although the calculus is fixed, and there may be no reason to be- lieve it will pass by the ureter. In affec- tions of the kidney, too, the pain is sometimes felt only or chiefly about the bladder and urethra, a circumstance never to be forgotten. One cannot, perhaps, say much about any characteristic pain in connection with tumcurs. They may be situated in any part of the bladder; may obstruct the urine more or less; and accordingly as they produce cystitis, and obstruct the flow of urine, pain will be experienced. The third question is as to the charac- ters of the urine itself. Now, suppose your patient has told you that he has frequency in passing water, pain at the end of the penis and at the neck of the bladder, and that the pain and frequency are aggravated by move- ment. You may begin to say to yourself, ' Perhaps the man has stone in the blad- der, and I shall have to sound him.' Two questions only have already put this pro- bability in your way, and you interrogate him as to the character of the urine. See how this carries you a step further. We recommence our list as to this inquiry. A preliminary remark, however, about examining urine. I do not propose to teach you here at present a systematic- mode of doing this ; because it is supposed not to be in my department, and you would only be repeating that which it will be your duty to learn elsewhere, and I hope you will do so thoroughly. But there is this hint which I may at once- give with respect to it. Whenever you want a specimen from your patient to ex- amine, do not tell him to send you a bottle of it passed in the usual way, or you will get a mixture often of doubtful value. What you require is the secretion of the kidneys, plus only anything there may be in the bladder; you do not want it com- plicated with anything which may come from the urethra. Let the man pass two cr three tablespoonfuls through the ure- thra first, so as to sweep out whatever may 6 DISEASES OF THE URINARY ORGANS. be there, which may be thrown away, or be put into a separate bottle, after which you will get a pure specimen—at any rate one of which you will know the source. You will have the renal secretion, plus only whatever deposit may be produced in the bladder. Suppose the patient has gleet or ohronic prostatitis: there will then be a quantity of muco-purulent matter in the urethra. If all this be carried into one vessel with the urine, how will you determine the different products, and de- cide, by the eye or by the microscope, what has come from the urethra, what from the prostate, and what from the kid- neys ? You cannot do it; but if you get rid of the source of error by flushing the urethra, so to speak, by passing the first two or three tablespoonfuls into a wine- glass, while all that follows is passed into a separate vessel, such as a tumbler, you will generally have a sample of urine that you can rely upon for examination. If I felt disposed to indulge you with gossip, I could tell you stories of the gravest blun- ders committed by not attending to that simple point. I can at all events tell you that I have more than once known a patient treated for pyelitis who had no- thing but a profuse discharge from the urethra; the urine had been sent twice a week for examination in a bottle scrupu- lously made clean for the purpose, and because a quantity of pus was found in it, the patient, who had some symptoms corroborating that view, was treated dur- ing some months for pyelitis ; another ob- server at length found out that the whole of the matter came from the urethra, for when the urethra was flushed into the first glass all the matter was there, and the remaining urine was clear and healthy; finally, the ' pyelitis ' soon disappeared under local treatment of the urethra. I do not know whether any one else may tell you of that simple mode of determin- ing this matter; and I will assume that in the future you will none of you make such a mistake as that I have mentioned. I only know too well how necessary it is to call attention to this mode of examining urine, and how seldom it is practised.1 Referring first to prostatitis, it is al- ways associated more or less with shreds in the urine, which come from the pro- static part of the urethra; and if the 1 See further remarks on this subject at the close of the lecture on Hematuria and Renal Calculus. urine is separated in the manner described, you will find that the whole of the thick matter will be in the first glass, while that remaining behind will be clear. How would it be with regard to calculus? You might have muco-pus in the first glass, but you would have more in the second from the bladder. It is not common that there is calculus in the bladder without the production of un- healthy mucus, and also of some pus from the lining membrane of the bladder itself. Occasionally, but rarely, I find a man with stone in the bladder having perfectly clear urine. Not commonly do I sound a man for stone who has clear urine, un- less he has marked symptoms, because the presence of stone in the bladder almost always gives rise to a certain amount of cystitis, and there is deposit in conse- quence. If the patient passes shreds of thick matter in the first glass, and the urine left behind is clear, and has sym- ptoms like those of stone, rely upon it that it is a case of chronic prostatitis. In cal- culus of the bladder there is nothing to note about the nature of the stream, ex- cept that it stops suddenly sometimes; but this is by no means a common sym- ptom. The character of the urine in one of the forms of chronic cystitis is well known. There is at the bottom of the vessel a thick mucilaginous deposit, which does not issue in a stream, but falls out in a mass. In another and very common form of chronic cystitis, it is simply cloudy, without any of the dense deposit described. In acute cystitis the urine is cloudy, and there is a considerable deposit of pus. In stricture of the urethra, unless chronic cystitis has been set up, there is no deposit from the urine ; but there are usually a few shreddy deposits in the first glass. Here the character of the stream is important. If, when the patient is passing urine, you see a very thin, or small twisted stream, or urine issuing only in drops, you will know that there is an obstruction, most likely stricture; be- cause, although in hypertrophy of the prostate, you may have the stream much diminished, it will be a stream which falls downwards from the organ. In stricture, force may be brought to bear on the stream, so that, however small it may be, it is often fairly propelled; but in hypertrophy, in which the expelling ap- I paratus is involved, the muscles cannot DIAGNOSIS. 7 act, and, therefore, however large or small the stream, it generally falls more or less perpendicularly. With regard to the debris of tumours found in the urine, the microscope some- times throws light upon their nature. No doubt you may see villous growth or cancer-cells in the urine ; it is difficult to identify them. I have seen such cells declared to exist by good observers in cases in which cancer was not present. Young pavement epithelium is easily mis- taken for them. Going upwards from the bladder, we may note pyelitis, more or less chronic— a disease in which the condition of the urine is only one symptom among many others which must be observed before arriving at a conclusion. In all cases you will ascertain with precision if albumen or sugar is present in the urine by the appropriate tests. But do not make the very common blunder of inferring organic disease of the kidneys, because you find albumen in the urine, the source of which is pus or blood, which may have issued from any part of the urinary passages. This subject will be fully discussed here- after in the directions for the examination of the urine at the end of this volume. The next question is, 'Do you pass blood ? ' and the answer will enable you to form an opinion on most cases—not quite, because in any case it may be necessary to sound before the diagnosis is complete. In prostatitis there is often a little blood at the end of micturition, as in stone; in cystitis there is not neces- sarily blood, unless it is acute and far ad- vanced ; in stricture of the urethra there is not necessarily blood; and in hyper- trophy of the prostate not necessarily. You may have it often only as the result of instruments. The inquiry respecting blood bears chiefly on the question of stone. Just as in phthisis a large propor- tion of patients have haemoptysis at some time or another; so in about the same proportion of cases—say four out of five— there is some blood observed at some time during the history of a vesical cal- culus. I wish you to pay particular attention to these questions, because I shall assume acquaintance with them to underlie much of what I have to say hereafter. What is necessary to be added with regard to observation by the eye, by the hand, and by instruments, will come under each particular subject hereafter, and I will only briefly allude to it to-day. By the eye you observe mainly whether the bladder is distended or not, and you are assisted in ascertaining this by palpation and percussion. The lower part of the belly is often exceedingly prominent in cases of retention. You examine the perineum and scrotum also, with a view to extravasation of urine, peri- neal abscess, fistula, &c. The condition of the glands in the groin is occasionally a significant fact first noted by the eye. So also is the condition of the external meatus and parts adjacent. By means of touch you attain a know- ledge of the size and form of the prostate on introducing the finger into the rectum; or of tumours adjacent; of the presence of induration ©r fluctuation within reach of the finger ; and of the degree of sensi- bility there. Also of the situation of an instrument introduced by the urethra; the presence of false passages or of fistu- lous openings leading into the bowel. The size and situation of a calculus may be sometimes noted with advantage in this manner. And now Ave come to the question of instruments. The instrument is to be regarded as a long finger, as an extension of tactile sensibility. The finger is not long enough to search the narrow pas- sages, and we lengthen it therefore by means of an instrument. By a similar analogy we may augment our power of vision by means of the endoscope—what- ever that may be Avorth, a matter we shall presently consider. Suppose, then, such a case as that to which I have already referred, in which there are frequency of passing urine, pain at the end of micturition, pain on any considerable movement, thickening of the urine, blood passing occasionally, but more on movement—you regard it as highly probable that the man has stone. You cannot arrive at a certainty without instruments. You may have almost all these conditions produced by certain changes in the kidney and in renal calcu- lus, and you cannot distinguish them un- less you skilfully explore the bladder with a sound. When I claim great value for this instrument, quite understand that I am by no means desirous that in the case of every patient who comes to you and complains of some frequency in making water, or pain in the act, you should 8 DISEASES OF THE say, ' Lie down, and let me pass an in- strument.' Perhaps the surgeon may be a little apt to abuse his power of passing instruments: which are to be applied only when absolutely necessary. I hold that an instrument, per se, is an evil—a very small one or a considerable one, ac- cording to the manner in which it is employed—and that it is never to be used unless there is good reason to believe that a greater evil is present which it may mitigate or cure. But when your patient has the symptoms named, you Avill be doing him an injury unless you resort to it. In cases of stricture the instrument is also necessary, for the purposes not only of diagnosis but of treatment. It is equally necessary in order to ascertain the condition of the bladder itself, as to the presence of tumour, the growth into it of hypertrophied prostate, whether it contains fluid or not in certain conditions, &c. Thus a patient may make water very frequently, exert all his force, be very certain that he has emptied the blad- der, and yet be quite deceived. How can you determine his condition ? There is a prominence above the pubes which you have no doubt is a distended blad- der ; but it is just possible that it may be a solid tumour. You cannot know whether the bladder is emptied unless you pass an instrument. Many a man has had a catheter introduced into the bladder immediately after he has passed as much water as he could, and a quart is found to have been left behind, although his OAvn sensations led him to believe that he had expelled every drop. We shall see more of this when we come to the sub- jects of retention of urine and hyper- trophy of the prostate. Lastly, I Avill take the opportunity of shoAving you that the eye may be assisted to a certain extent by Avhat is called the endoscope, which is dimply an instrument that Ave have long been in the habit of passing into various cavities of the body —the ear, the vagina, the rectum—for the purpose of bringing reflected light to bear upon the interior of those cavities. For some years past this instrument has been employed for the urethra. It is more than thirty years (1882) since I first saw the endoscope so applied. This Avas in the hands of Mr. Avery, of the Charing Cross Hospital. As I was turning my attention somewhat to this subject, he asked me to see some of his patients, and a new in- URINARY ORGANS. strument he was then making. It was a long tube, precisely similar to this which I hold in my hand, with certain arrange- ments enabling one to see deep portions of the urethra. He showed me cases of stricture, but I do not think he looked into the bladder. He paid a great deal of attention to the subject, and the instru- ment was brought by him to a certain state of perfection ; unhappily, however, his death occurred shortly afterwards, and the thing was lost sight of here. Various attempts had been made with the same object, long before, as many have been since, but I do not know that there is anything on this table which is very much superior to what Mr. Avery showed. Within the last few years M. Desormeaux, of Paris, has paid great at- tention to the endoscope, and has per- fected one of his own, consisting of a similar tube, but with different appliances. The various modes in which light is ap- plied constitute the differences between the various kinds of endoscope. In all of them there is a tube of this description to pass into the cavity. Twenty years ago I had an endoscope of M. Desor- meaux's, and exhibited it in the hospital —the instrument which you see here. Dr. Cruise, of Dublin, has brought it to greater perfection, and has produced a better instrument than we heretofore pos- sessed. This also is here, and you have often seen it in the wards, applied by me both to the urethra and to the rectum. I may tell you at once, that if a man ha3 a good and a tolerably practised hand, with a fair share of intelligence, I do not think he will gain a great deal by the endoscope; and if he has not, I think its will be of no use at all. There are some few cases in Avhich he may find it of value; but do not expect that the endo- scope is to work marvels in the diagnosis of surgical diseases of the urinary organs. In ninety-nine cases out of a hundred you can arrive at the necessary information without it. And it is not the easiest thing in the Avorld to apply. As already remarked, a man should not be put un- necessarily to the pain and inconvenience of a sound or a catheter; but examination by the endoscope is a someAA'hat more irri- tating and tedious process. In certain exceptional cases, in which you are un- able to arrive at a conclusion Avithout it, you may perhaps employ it to some ad- I A'antage. Noav, here is a patient on whom DIAGNOSIS. 9 I have never used it, and whose case Avill offer a certain test of its poAver. The man before you had an exceedingly bad stricture of the urethra, Avhich I cut in- ternally last Tuesday week. He is noAv perfectly Avell. He could not pass a drop of urine before the operation, but uoav he is able to pass it naturally ; and you will agree with me that a great deal must have been done since the day named to make that change. I cut through the strictures deeply, and now Ave shall see whether we can find the cicatrices.—You see we have now made a careful and pro- longed examination. The urethra is of a more dusky red about the part which has been affected, but that is all which can be observed. Changes in the colour and texture of the mucous membrane of the urethra are those Avhich are most easily seen, and Avhich it may be some- times of importance to note. The orifice of a stricture may be sometimes seen, but the result is Avithout practical utility. Very little can be seen by it in the blad- der, because more or less urine must always be present, and urine too which is usually cloudy, or containing blood. But the end of the instrument will often produce enough blood to obscure the tiny field of vision available, especially if tumours or other local diseases are present. There is no doubt that a calculus may be easily seen, or rather the small portion of it upon Avhich the end of the sound impinges; but I have never gained anything by the sight. A calculus smaller than a pea may be easily found by delicate sounding, and an audible note elicited from it, more easily than you can see it through the endoscopic sound. I may mention that no one has yet been able by its means to identify the verumontanum, and if you cannot see the verumontanum, I think it is quite possible that minute pathological changes will often escape you. But lately another attempt to improve it has been made. The idea of carrying an electric light into the bladder itself (and also into other cavities) appears to have originated Avith Dr. Nietze, now of Vienna, but its realisation is due to the patience and perseverance of Leitner, the surgical instrument maker of that city. The apparatus consists of a stout wooden table, containing instruments, &c. Attached to it is a light stage, several feet high, supporting a A'essel of Avater ; and on a frame near the floor is the elec- trical battery Avith its appliances. This apparatus is placed by the side of the patient, who should be recumbent on an ordinary operating table, so as to occupy a height convenient for the purpose of examination. It may be thus used in an ordinary Avard, but it is more efficient in a dai-kened room, like that ordinarily em- ployed for the ophthalmoscope. The electrical current is produced by two rather large Bunsen cells, and the positive and negative conductors, two long and slender wires, are attached to a holloAV silver sound of the ordinary form for examining the bladder, by means of a movable collar round its handle, one of the Avires entering a small channel in the sound itself which it traverses to the end. Arriving there it enters a cavity within the beak, and joins a platinum wire there about half an inch in length, the other end of which is soldered to the metal of the sound, and the latter itself forms the connexion with the opposite wire or pole. The platinum, which be- comes incandescent on the completion of the current, is covered by a glass plate isolating it from lateral contact. Finally, the end of the sound which contains the platinum wire has to be kept perfectly cool by special means adapted to the purpose. This consists in the maintenance of a constant current of cold Avater sup- plied from a reservoir, placed seven or eight feet above the operator. The cur- rent descends through a small flexible tube to the collar of the instrument con- nected Avith tAvo capillary channels, only one millimetre and a half in diameter, Avhich pass through the Avhole length of the sound, coursing round the heated wire at its termination, so that the Avater is constantly flowing in by one tube and out by the other, to issue finally drop by drop through the returning tube into a vessel placed to receive it. Holding the collar Avith the left hand, the operator rotates the sound Avith his right, when on looking through a central cavity forming the axi3 of the sound, any portion of organ ad- jacent to the end of the sound is seen to be brilliantly illuminated. A small piece of gravel, a pellet of mucous, the rugaa and sinuses of the mucous lining of the bladder, of its natural tint, or with an inflammatory injection, may all be most clearly seen. As a triumph of mechanical skill over extreme difficulties, it is impossible to 10 DISEASES OF THE URINARY ORGANS. admire the performance too much. But it is necessary to remark that much pre- paration of the bladder itself is necessary; that some irritation of the organ must be regarded as a highly probable result—as, indeed, is often unavoidable from the use of this or of any other endoscope. If the urine is bloody or cloudy with mucus, nothing is visible; the bladder must be washed, and then be partially distended with clear water or with air before the instrument can be applied. If the urine is quite clear no preliminary Avashing is necessary, and a few ounces should be present in the bladder. Having tested the poAver of this in- strument myself, I venture to express in cautious terms my views as to its use. First, I do not regard it as likely to help us in cases of difficult stricture or reten- tion of urine. Nor is it required to explore a bladder for any remaining fragments after the operation of lithotrity. On the other hand, there are some morbid conditions the existence of Avhich Ave sometimes suspect, but cannot positively affirm to exist, whose presence may noAv be ascertained through the agency of the new endoscope. I refer to the identifica- tion of sacculated stone as the cause of persisting and unrelieved symptoms; to the detection of pedunculated growths and of villous disease of the bladder, remov- able by operation; and, lastly, to the investigation of the nature of foreign bodies, other than calculi, Avhich have become lodged there. A precise know- ledge of the nature, size, and position of a foreign body might enable us to devise a safe and certain means of removing it in place of a tentative, uncertain, and hazardous proceeding. All these cases, hoAvever, are more or less rare; nevertheless it is our duty to be provided with every resource, whatever it may be, Avhich en- ables us to deal more effectively than heretofore with conditions on the manage- ment of Avhich grave issues depend. It ought to be added, moreover, that the apparatus is complicated, and requires the expenditure of much time, a practical acquaintance Avith electrical instruments, and great care in Avorking it in order to attain any results. It is impossible to discuss now that large and important department of dia- gnosis Avhich comprehends the various modes of examining the urine. It de- mands a separate and practical demon- stration, to be giA'en at the end of the course. LECTURE II. ON SOME POINTS RELATING TO THE STRUCTURE AND FUNCTIONS OF THE MALE URETHRA. In view of a consideration of the more important affections of the urethra, with which I shall naturally commence, I desire to depart from my usual habit a little to-day, and to speak more at length on a topic Avhich I always allude to slightly, but not otherwise, because it is not part of my plan to teach anatomy and physiology here. But I find it necessary to complain of what I will speak of as the ' too mechanical method' of treating ure- thral diseases, which I think has been obtaining of late in some parts of the Continent, and perhaps in America. What I mean by that will appear as Ave proceed. I always protest against it in this course of lectures, but something more than this appears to me now to be desirable. I dislike to be polemical in this or any other subject, the practical side of Avhich is so important; and I would infinitely rather for my own peace and comfort simply tell you what I think you ought to do in relation to various cir- cumstances Avhich come before you, and not also have to point out treatment pur- sued by others Avhich I think you ought to avoid. However, I have the convic- tion that much of the treatment noAv in vogue is imperfect and less valuable than it might be, since it is founded on views of the urethra itself which are erroneous; or rather, I should say, it originates in a want of consideration Avhich appears very STRUCTURE AND FUNCTIONS OF THE URETHRA. 11 Avidely to exist as to the nature and func- tion of the urethra. The treatment of urethral disease of Avhich I complain has its origin in the notion that the urethra is a mere flexible tube, closed at or near its junction with the bladder by some kind of muscular apparatus, sphincteric or otherwise, through which fluids will pass indif- ferently in either direction. No idea, however, can be more erroneous, and treatment founded on it must be defective. At the outset, then, let me say that it is absolutely essential that you should have a tolerably accurate knoAvledge of the nature and functions of this so-called tube. I draw for you on this board the kind of diagram usually supposed to represent the bladder and male urethra. This dia- Fig. 1.—Anatomical diagram of bladder and urethra. gram has something tc ansAver for in pro- ducing the erroneous views I refer to. It represents the urethra as a tube, and as more or less open. (Fig. 1.) Let me give you an illustration of my meaning, and not an unimportant one. I believe I am correct in stating that al- most every patient who presents himself for treatment of a urethal discharge, when advised to use an injection, gets some such advice as this, when the manner of doing it is explained, as it ought to be, in detail:—He is told to inject a certain quantity of liquid into the passage by means of a syringe of some kind, often one of considerable size, and he is ad- monished that before he does so, he is to make pressure Avith the fingers of one hand on the line of the urethra, about four inches from the external meatus, lest the fluid should pass further doAvn to enter or perhaps irritate the ducts Avhich open into the prostatic portion, and occa- sion inflammation of the neck of the bladder or a swollen testicle. This idea is very far from correct; and such ad- vice simply demonstrates that the person giving it is not really acquainted with the structure or function of the part he is treating. Want of thought originally has produced, and the influence of ancient tradition has perpetuated, the error which vitiates much of our treatment in its various forms. First, let me assure you that the urethra is not a tube at all, in any sense in which we employ that word. It is not like a gas-pipe, or an india-rubber tube, or even a flaccid tube of any membrane whatever. It is rather a continuous closed valve, capable of transmitting fluids and solids in one direction only, and transmitting no- thing whatever in the opposite direction, except in obedience to applied force. Its length in the male makes us think of it as a tube, but this is a mere accident of sex. An inch 'or less is amply long enough for its urinary functions, as in the female; and all the length it possesses above that, although needful to constitute it a spermatic conduit, is quite useless as a urethra proper, and renders it liable to disease and accident—the price, and a heavy one, let me tell you, which the male pays for his specially distinguishing feature. In illustration of this, I have but to refer you to the difficulties and dangers associated Avith stricture, reten- tion of urine, and calculus, which are comparatively almost unknoAvn in the other sex, simply because the outlet from the bladder is a' urethra' and nothing more. But in the male this outlet is a long route or chink, traversing soft and most deli- cate vascular and nervous tissues, its walls or sides always firmly closed, and never opening except for a feAV seconds, during Avhich fluids have to be transmitted from the body. Then, for a few seconds, it is distended more or less, and becomes a tube if you please, for this short time and this only, equalling, perhaps, at most three minutes in the twenty-four hours. All the rest of the time it is firmly closed, and not one drop of fluid can pass from the bladder. Of course, oozing of liquid Avhich is generated in the walls of the tube, as in gonorrhoea, or which enters it by ducts, as spermatic fluids, may es- cape, but always, inevitably, if the passage is healthy, in the outward direction only. I have next to observe that during these few seconds, when the valve may 12 DISEASES OF THE URINARY ORGANS. be said to assume temporarily the form of a tube, it is one marked by great devia- tions in its diameter ; being, in fact, very differently affected at various parts of its course, by the various structures which surround it. This fact has long been theoretically known and generally thus recognised. I will show you illustrations of this statement from the works of Sir Everard Home and of Mr. Guthrie, who made casts of the urethra in wax and other materials. This natural condition of variation in diameter Avhen distended is scarcely less important than the condi- tion of absolute closure Avhich I previously explained. The annexed diagram is re- produced from Sir E. Home's work.1 (Fig. 2.) Having thus far illustrated briefly, and necessarily somewhat imperfectly, the nature of this valvular passage, let us see Iioav far the ideas which I Avant you to ac- quire relative to the urethra affect two I syringe sometimes suffices. Here is one of each size, and it is scarcely necessary to say that these small instruments are much more easily managed by a patient than larger and longer ones. But most pa- tients, unless specially taught to use the syringe, never introduce any injection at all. Unless the orifice of the urethra is carefully closed while the act of injecting is performed, the fluid simply leaves the end of the syringe and Aoavs out by the external meatus. And thus it is that in every case after the injection has been made, the moment the orifice is unclosed the fluid is rapidly expelled by the con- tractile force of the urethra, and no ap- preciable quantity remains within. So much, then for any fear of its running down to the neck of the bladder. Of course, if an injection is too strong—and in my opinion the solutions of metallic salts employed for the purpose in gono- rrhoea and gleet, are generally far too strong 1 Practical Observations. By Sir E. Home. Vol. I. London, 1805. important points in practice. First, that simple matter of making an injection into the urethra. You have to intro- duce a fluid for the purpose of thera- peutic contact Avith the walls of this closed passage; 3rou have to distend it, and some little force is necessary; not a single drop can enter, much less run doAvn into it, unless the liquid is forced in by a piston, while the orifice of the urethra is kept carefully closed around the tube of the syringe introduced. The Avails of the passage lying closely applied to each other become opened only by the pressure of the fluid driA-en in, and they are distended just so much and so far as the quantity employed determines that they must be. Thus you may safely reckon, as the result of my observation, that a syringe containing one fluid drachm or drachm and a half, is amply sufficient, and that it Avill distend the urethra for three and a half or four inches. Even a half-drachm —the anterior part of the urethra is in- flamed, and extension backAvards may easily take place ; but that is no part of our subject noAv. But let me further say that so far from your being able, even Avith the power of the syringe, to send an injection into the prostatic part of the urethra, you will not do so by any ordinary force, un- less you can at the same moment volun- tarily relax the muscles Avhich surround the membraneous urethra, and so alloAV the fluid to pass—a thing perfectly pos- sible Avith very little practice to accom- plish. It is due to the same circumstances that you cannot inject the bladder except by passing an instrument into its cavity. In fact, this A'alvular passage stoutly re- sists all intrusion from Avithout, and ad- mits no fluid except in obedience to pres- sure which the muscles are unable to resist. I must just remark, in order to antici- pate a possible objection to my statement relative to the valvular action of the urethra, and its poAver to transmit bodies in Fig. 2.—Diagram of urethra from Sir E. Home, showing its extensibility. STRICTURE OF THE URETHRA. 13 the outward direction only, that it is well known that certain foreign bodies have been able to pass imvards when introduced by the external meatus. I refer to tAvo typical ones, both of Avhich have been occasionally known to reach the bladder after being fairly lodged within the urethra. I refer to an ear of barley or of rye, both of which you will recollect are bearded, and also to a common hair-pin which is wedge-shaped. Either of these bodies, if completely introduced, and also in such a manner that the beards or the points are directed outwards, Avill traverse the urethra in the direction inward. These, however, you Avill doubtless at once see are not in the least degree ex- ceptions to my statement. It is an old schoolboy's paradox to put an ear of rye in his jacket-sleeve, when, with slight movements of his arm, although directed downAvards, the ear soon finds its Avay up- Avards to his shoulder. If the arm were kept perfectly motionless there Avould be no change of place in the ear of rye. So, when introduced within the urethra, the involuntary movements of the urethral muscles, designed to expel the intruder, In commencing this course, I shall take to-day the subject of stricture ; and I do so because, if not really one of the most common among urinary disorders, it is often supposed to be so. Among the many complaints of this class respecting which you may be consulted, perhaps none will be more talked of than urethral stricture. It does not follow, however, that stricture is really so common; in fact, it is much less so than many suppose. The word happens to have been popu- larised, and therefore Avhen a person ex- periences a little trouble in passing water, he is very apt to say that he has stricture. Certainly, in three out of four cases in Avhich persons do so, I find there is no- thing of the kind, but often merely some temporary cause of iritation. Then it must be confessed that even amongst the profession there is some con- act on the ends of the bearded corn, or on the ends of the hair-pin, and drive it on in the only direction it can travel—namely, inwards. I am not sure that it was neces- sary to mention this, but I have known the peculiar action of these bodies referred to as militating against the uniformity of the action of the urethra referred to, while in fact it does but illustrate its existence. If the urethra submitted tranquilly to the intrusion, and made no expulsive effort at all, the foreign bodies would not travel; as it is they must move, and can only do so in one direction. Of course it is due to this function of the urethra that gravel and small calculi are expelled in great number, and that the morbid excretions in gonorrhoea, &c, always issue externally, and never go backwards to the bladder. The second point of importance in which the structural function of the urethra which I have described should affect our prac- tice is associated with treatment of stric- ture of the urethra. I do but allude to this now, and shall reserve what I have to say on this head until a future lecture, Avhen I shall enter fully on the subject. fusion as to the mode in Avhich the word ' stricture' should be employed. It is said—and formerly I said it myself, because I originally adopted the conven- tional classification—that there are three kinds of stricture—organic, inflammatory, and spasmodic stricture. Now, it would save some confusion if we employed this term for only one kind—namely, organic stricture : and this, indeed, is what I shall propose to do. And what is organic stricture ? It is a deposit of lymph round the canal of the urethra at some point, which, not alloAV- ing the canal to open to the stream, nar- rows the current to that extent. There has usually been some chronic inflamma- tion, most commonly in the bulbous part of the canal, but occurring in the anterior part also, and a deposit of lymph has taken place in the submucous and in the LECTURE III. ON STRICTURE OF THE URETHRA AND ITS NATURE : AND ON THE DIAGNOSIS OF URETHRAL CONTRACTIONS. 14 DISEASES OF THE URINARY ORGANS. vascular tissues surrounding the urethra; this lymph forms fibrous bands, which subsequently become somewhat rigid, while they more or less encircle the pas- sage. We talk of the contraction of the canal; the use of which term is due to a popular and not very correct notion of the matter, as was demonstrated at our last lecture, although it ansAvers well enough for mere practical purposes. You will therefore do well again to remember, in connection with the pathology and treat- ment of urethral diseases that the urethra is not an open tube, except at the mo- ment of its distension by an out-flowing current; it is always absolutely closed by muscular fibres, and only when it is habitu- ally prevented from fully dilating to the stream of urine is it affected by stric- ture. And this organic stricture is a per- manent condition. Once acquired, it can- not be entirely dissipated by any known means. It cannot be removed by absorp- tion, although the contrary has often been affirmed. You may dilate it, you may cut through it, but there, more or less, the morbid elements must always remain. When a man once has organic stricture, he has it for ever. If any exceptions exist, their rarity is so extreme as prac- tically not to invalidate the axiom laid down. Whatever treatment you employ, there is always a greater or less degree of rigidity in the urethral walls ever after- wards, and this increases Avith age. For all the fibrous tissues, as you know, be- come less extensible, as a rule, in advanced years than in youth ; and this influence of age no doubt affects also those morbid tissues which limit the extensibility of the urethra in stricture, and is one reason among others why it so generally becomes less dilatable as the patient advances in years. Now touching ' inflammatory stric- ture ' and ' spasmodic stricture;' what has been termed ' inflammatory stricture' is merely a temporary local inflammation of some part of the canal, which is then narrowed for the time. The patient is unable, as long as that inflammation lasts, to pass water, or at best Avith difficulty. An inflammation with this result affects only the prostatic part of the urethra, which is not, as you know, the seat of organic stricture. If you consent to call this condition stricture, you may as well say that the throat is strictured when it is I partially closed by inflammation, and the tonsils are swollen. We only speak of stricture of the oesophagus or gullet in reference to an obstruction which is or- ganic, when by some deposit the passage is permanently narrowed, and Ave never speak of stricture there under any other circumstances. So Avith regard to Avhat is called spasm. The urethra may be narrowed to a certant extent by spasm—that is to say, the water may be prevented from passing outAvards from the bladder, because there is some irregular action of the muscles around the canal. But the affection is only temporary; it does not necessarily imply any organic change; although sometimes its occurrence depends on the pre-existence of organic change, yet this spasm in itself is by no means to be re- garded as urethral stricture. I will tell you Avhat ' spasmodic stric- ture' often is. It is an exceedingly useful excuse for the failure of instru- ments. It is a refuge for incompetence. When you cannot pass a catheter, when you find it exceedingly difficult to intro- duce any instrument, and in fact wish to relinquish the trial, it is a convenient thing, and has always been so recognised, for the operator to say,' There is spasm.' Indeed, I believe he often persuades him- self that it does exist, although, in my opinion, it does not, or at least very rarely. ' There is spasm,' says he, ' now in the muscles, and it will be prudent at present to desist from further attempts to pass an instrument.' And no doubt Avhen this is said it is so. Now, I do not think that you ought ever to fail in passing an instrument because there is spasm. Spasm may prevent the urine from going out- Avards; I do not know that it ever pre- vents the instrument from going in. In most cases it is failure of the hand, not spasm of the urethra. Still I cannot deny that it is a useful excuse—that it has a sort of foundation in fact, and may thus be often a better explanation for the patient than anything else, when the in- strument does not pass. But now let it be understood that when stricture here is spoken of in future, I shall refer only to organic stricture, in the sense already described. All the mechanical treatment which I shall have to speak 01 will have reference only to that kind of stricture. In 'inflammatory stricture,' of course, you have no occasion for in- STRICTURE OF THE URETHRA. 15 struments, unless retention of urine is present. Now, what are the symptoms of stric- ture ? First, of course, there is the small- ness of the stream, depending upon the narrowed state of the canal. Whatever the narrowing of the canal is, in that pro- portion there must be a narroAving of the stream. Still, it is not to be forgotten that the degree of narroAving varies much at different times in accordance with ex- ternal circumstances, cold, errors in diet, and the like ; one thing only is constant, the stream is always smaller than natural. Next, there is often some straining to pass water, corresponding to the obstruction of the passage ; and the stream itself is flat- tened, tAvisted, or divided. This condition is accompanied by pain at the seat of stric- ture, and sometimes over the pubes, if there is any cystitis also. Associated Avith these, it is common to have a little dis- charge from the urethra; indeed, a gleet is often the only thing Avhich the patient notices at first, and the surgeon, finding that this is not readily cured, uses an instrument and discovers some degree of stricture. Frequency of making Avater, as I told you in the first lecture, is not always present, although it always is so when the case is seArere and of longstanding. Supposing a patient to apply to you with all these symptoms, you will en- deavour to see him pass water. He pro- bably lays some stress on the fact that the stream is twisted or divided. Do not attribute much Aveight to this circumstance by itself, for a stream is often twisted when there is no stricture. This may be due to an alteration in the external meatus; for as the stream issues from the passage it is modified by alterations in the natural shape or extensibility of the external meatus; thus, after repeated inflammation there, the lips of the meatus are sometimes slightly thickened, so that the urine can only iss-ue in a flattened and consequently twisted stream ; a by no means uncommon occurrence. But if there is no other morbid change, however flattened the stream may be, the absolute bulk or .volume of the stream is not diminished, and there is no stricture. The question of diagnosis by physical examination next presents itself. Let me at the outset observe that on almost all occasions of examining a patient for the first time with an instrument, one of-tolerably full size should be selected, say not less than No. 8, 9, or 10 of the English scale. Nothing is better for this purpose than a slightly curved English gum elastic bougie, Avith a blunt and not a tapering end. It is neither necessary nor politic to produce an instrument, at first, of greater calibre. Even then the patient Avill probably remonstrate, and may very likely say, ' Why do you em- ploy so large an instrument?' Soothe his fears by telling him that you do not pro- pose necessarily to pass it, but mainly to learn what is the condition of the canal. For if you use a small instrument at first, it may pass through a stricture, if one exists, Avithout detecting it; but if the large instrument goes on easily into the bladder, you have the satisfaction of in- forming your patient that he has no con- siderable stricture, and you must look further for the cause of the difficulty. Again, let me warn you that, in pass- ing the instrument through a healthy urethra, it is quite common to meet with circumstances which may mislead you. I have spoken to you of error on the part of the patient, and I am bound to say that the surgeon Avho is not much practised in these matters may also be deceived. What are the sources of fallacy to which he is exposed ? Hoav is it that he some- times fancies there is stricture when there is not ? You may be placed in circum- stances hereafter in which opportunities of often seeing this disease do not occur, and in such it is no great discredit to a man to think that he has found stricture Avhere none exists. If, however, he pro- fesses to be an operating surgeon such a mistake would be discreditable. But if he has not had much surgical experience, he may encounter some difficulty with an instrument in the urethra, and may sup- pose, erroneously, that it is due to stric- ture. Now, I want to guard you against this; for, though you may not all be operating surgeons, I wish no one to leave any course of lectures which I may give, without knowing precisely what are the sources of fallacy, so that I may not hear of any of you making hereafter such a mistake as that to which I have referred. First, then, observe that close to the external meatus of the urethra is a source of fallacy—I mean the lacuna magna. Next, at a part of the passage which is about five or six inches further [a diagram referred to], the bulb joins the membranous portion, and the canal, from being wide or 16 DISEASES OF THE URINARY ORGANS. dilatable, becomes less so; a condition not infrequently mistaken for disease. Lastly, there is" a source of difficulty at the neck of the bladder. These are the three points at which persons may be mis- taken in passing an instrument in the healthy urethra, and may form erroneous notions in consequence relative to the presence of stricture. Noav, bear in mind that the urethra is not a tube, but merely a sinuous passage with soft, delicate, and vascular walls lying in close contact with each other; so that nothing is easier, when traversing it with an instrument, than to find some obstruc- tion in the folds or lacunae of the mucous membrane. Thus, as I have said, it is quite possible to find obstruction at the very outset by engaging the point of the instrument in the lacuna magna, an oc- currence which is embarrassing to a be- ginner. Whenever, then, you introduce Fig. 3.—Diagram of urethra in natural condition, a, b, and c representing the prostatic, membranous, and spongy portions respectively.1 an instrument, let your first thought be to keep its point on the floor, so as to avoid that obstacle. You wish, of course, to pass it well for the patient. Perhaps he has had instruments passed before, and you desire to succeed at least as well as the preceding operator. Now, there is nothing which a patient appreciates so much as the easy passing of an instrument. It is a disagreeable operation, and if you pass it more easily than other persons, you Avill probably retain your patient as long as he requires assistance of that kind. If your instrument stops, by getting into the lacuna magna at the outset, he infers you to be a bungler, and perhaps will not ask your services again. Now you see represented in this dia- gram the bulb of the urethra. The canal is more distensible at this point, in front of b, and Avhen it arrives at the deep perineal fascia, the canal is much less dis- tensible ; being closed, indeed, here by a special muscle. Practically, therefore, it is much wider in the bulbous portion than it is at the membranous portion, and Fig. 4.—Bougie, with point turned up. Avhen the instrument arrives there it is apt to meet with obstruction. This is the place Avhere most false passages are made; the instrument is driven out of the canal beloAV the urethra, it being mainly at the floor that the tissues are so distensible. The section of the corpus spongiosum is wider below than above; the texture is soft and spongy. The urethra corre- 1 The urethra should have been shown here as it really is, a closed canal; the line in the bulbous and prostatic portions having been made by me merely a little thicker to mark (diagraimnatically) position and the character of dilatability. This line has been somewhat exaggerated by the artist. sponds in distensibility to the soft struc- ture outside, and although the instrument goes smoothly down to this point, it may not enter the membranous poition. Noav, take care, at first, to have the prJint of the instrument so turned up as to avoM. this lower part. Nothing is so good ,is a\ Avell-curved instrument to escape that obstacle. I have frequently made the following experiment in the out-patients' ward :—Finding a student who has n^ver passed an instrument before, I say to him, ' Pass this bougie (a straight or slightly curved one) into the canal.' He passes STRICTURE OF THE URETHRA. 17 it, and almost invariably, when he arrives at the membranous portion, stops. I then take the same instrument, give its point this form (Fig. 4), and the student im- mediately succeeds in passing it into the bladder. This is the form which is made prominent in the instrument called ' cou- dt'e' by the French, and a very useful one it is. Sir B. Brodie recommended in his lectures the plan of giving a little upward turn to the point of a bougie for the same purpose more than fifty years ago. As the instrument goes in, the point folloAvs closely the roof or upper aspect of the urethra, instead of becoming engaged in the loAver and more distensible part of the bulb. The last obstacle is at the neck of the bladder, and so common is it, that you often hear of ' stricture at the neck of the bladder '—a thing which does not exist. There never Avas a stricture even in the prostatic portion. ' Stricture at the neck of the bladder' Avas a household Avord some years ago, and even now you some- times hear of it; but there is no such thing. The idea has arisen from the cir- cumstance that in using the catheter, obstruction is sometimes encountered at this spot, and ' stricture' Avas erroneously assumed to be the cause. When the difficulty occurs, and it may do so in a perfectly healthy urethra at any age, a Avell-curved or a ' coudee ' catheter -will almost invariably pass Avith ease. Let me recapitulate shortly the three sources of difficulty: First, the lacuna magna, Avhich is avoided by following the floor of the canal; then the narroAv membra- nous portion at the bulb, Avhich is avoided by keeping the point of the instrument Avell up against its roof; and the same management Avill also succeed with ob- struction at the neck of the bladder. So much for the management of an instrument in the healthy urethra. We now have to learn how to make the physi- cal diagnosis of stricture. For this purpose there are two sepa- rate modes to be followed, as there are tAvo different objects to be attained, each of which is quite distinct from the other:— There is, first, a simple examination of the urethra, to be used only for the purpose of verifying the presence or ab- sence of any material deviation from the natural dilatability of the urethra. And there is, secondly, a more minute and exact examination, in order to deter- mine the precise condition of the urethra when it is already known, or there is reason to believe, that long-standing and perhaps considerable obstruction exists. Now, I need hardly say that the first examination is one Avhich is applicable to the vast majority of cases; and that the second is necessary only in a few and exceptional cases. A very simple ex- amination suffices to determine the ques- tion which so frequently comes before us —' Do certain not very considerable de- rangements of the urinary function in any particular patient arise from organic ob- struction, in which case they probably require instrumental interference ; or are they due to some other condition, for which instruments are not merely useless but would probably be injurious ? ' Now, in considering this subject, I feel compelled to express the opinion that there is a tendency at the present day to employ instruments too readily, and in- struments also which are liable to injure the urethra. This over-readiness to inter- fere with the urethra existed at the be- ginning of the present century. The mechanical school, as I shall take the liberty to term those Avho devise and largely employ more or less complex mechanical means for exploration, and for applying dilatation, cutting, or caustic to the urethra, Avas then in the ascendant. I think I could occupy you for hours with the history of the innumerable surgical knick-knacks which have been produced by it. But our time is too valuable, and I Avill content myself Avith one illustra- tion only of surgical practice in this country at the era I speak of.1 Following the period spoken of came the experience of mischief as its result, and a certain healthy reaction in opinion appears to have taken place. The prac- tice of Sir Benjamin Brodie, who was subsequently so high an authority during his long career, was marked by caution and prudence, and his admirable teaching ensured a similar practice among others for some time. I may be allowed to say, perhaps, that my feeble voice has also been raised against the abuse of instru- ments from the first day that I ventured to pen a line on the subject, some five- 1 The lecturer then read some curious reported cases from a work of Sir E. Home, illustrating the extraordinary abuse of the bougie at that time. See Pract. Observations on the Treatment of Stricture. By Sir E. Home. Vol. III. 1821, chapters x. and xi. IS DISEASES OF THE and-twenty years ago. And now I per- ceive a growing disposition to return to the state of things I have referred to. I note an increased tendency to discover stricture, and especially to undertake a considerable amount of operative treatment for strictures of the slightest kind, and sometimes in cases Avhere, in my opinion, no strictures have existed. There seems now to be a school Avhich has determined for itself a very high standard of patency in what we hear called the * urethral tube,' and Avhich is accordingly said to have, or, if it hasn't, that it ought to have, a calibre of so many parts, and very large parts, of an inch, or so many millimetres, as the case may be. Instruments of astounding magnitude are produced, and if one of them cannot be passed, with an ease which contents the operator, through the whole of the urethra, the unlucky patient is pronounced to be the subject of stric- ture ; and probably he is submitted to an operation by no means devoid of risk. Now, I don't know that this fashion has as yet been adopted here, but I do know that it exists elsewhere, and I raise my earnest protest against it. I feel it a matter of duty on my part to say what I think about treatment which I am per- fectly certain neither you nor I would for a moment entertain the propriety of in our own proper persons; that is, if Ave entertain a due respect for the delicate and elaborate structure of the urethra which an intelligent acquaintance Avith it will ensure. Let us for a moment revert to the natural form which the canal takes when it is distended by some fluid material, and observe how unlike it is to the coarse simile of a tube of known uniform diameter. We have already seen that its natural capability for dilatation varies greatly at different points: being much limited at the junction of the membranous and spongy portions; limited again, but less so, and someAvhat irregularly, in the an- terior part; and again at or near the meatus. Let me assure you also that there are few structures more complex than those which constitute the male urethra. Formed of an internal mem- brane of great tenuity, surrounded by elastic and muscular fibres, interpene- trated everywhere Avith ducts, fine blood- vessels, and nerves ; the whole surrounded in front of the prostate Avith one of the most elaborate of vascular structures, URINARY ORGANS. knoAvn as erectile tissue; it possesses also a sensitiveness to pain, in Avhich quality it is not surpassed even by the conjunc- tiva ; as any one may learn for himself by passing the softest intrument he can find. Finally, and more important still, it possesses another form of sensibility, of a much graver kind, which even the last- named membrane does not possess: I mean a strong tendency to arouse, in the entire nervous system, a state of excitement, evidenced by the striking phenomena of rigors and subsequent fever and prostra- tion, when slight mechanical injury has been done to any portion of it. Now let this picture of the urethra as it is never be absent from your mind's eye Avhen you put an instrument into it, and both you and your patient Avill profit. When, therefore, a young man consults you for certain troubles relative to Avhich you de- sire to learn whether urethral obstruction be a cause or not, do not be tempted for Fig. 5.—Blunt-ended bougie. an instant to adopt so unnecessary a course (to say the least) as the introduc- tion of very large instruments, or instru- ments with huge bulbs at the end of them. For sometimes—indeed, not very infre- quently—such an applicant is the subject of some chronic inflammation of the pro- static urethra or neck of the bladder after gonorrhoea; and a certain Avay to make him worse is to pass a large instrument, or, indeed, to pass at this particular juncture an instrument of any size or kind. This is a subject which will be further men- tioned in its place. Supposing, however, that you have satisfied yourself on this head, and intend to examine the urethra, simply take a flexible English gum-elastic bougie, slightly curved towards the point, with a blunt end (since a tapering point, of course, will not mark distinctly the site of stricture), not larger, as a rule, than No. 10 or 11 of our scale (see Fig. 5), and pass it very gently and sloAvly into the bladder. If it goes easily—above all, if it is AvithdraAvn without being held, and slides out with perfect facility, take my word for it he has no stricture, and, quoad obstruction, Avants no use of instruments whatever. STRICTURE OF THE URETHRA. 19 I daresay I shall be told by some one that there may be a urethra through Avhich No. 11 can be made to pass, yet Avhich is, nevertheless, the subject of some degree of stricture Avhich it is necessary to treat. Well, I do not deny the existence of that exceptional case. But such an example is very rare, and, further, no man Avho has the slightest delicacy of tactile sense in his fingers can fail to ob- serve the difference between a No. 11 bougie sliding out with facility, and one which is grasped someAvhat as it is with- drawn. This difference is always mani- fest in the tAvo cases, and is, indeed, very notable. But supposing that the No. 11 stops at any point, and you have assured yourself that it is not one of the natural obstructions to the passage of an instru- ment through the urethra, of Avhich I have already spoken fully, mark accura- tely Avhat is the distance, by inch measure, betAveen the point of obstruction and the external meatus. Next pass a smaller in- strument of the same kind, which may probably pass a little further ; and so on until you have arrived at one which does pass through and inAvards into the bladder. But you may also test your observation by passing a soft tapering French bougie —11 or 12 English size—and if it is a natural obstacle which at first checked your blunt-pointed bougie, the former instrument will probably slip through without trouble. Now, Avith the common exploring in- strument which is formed of a long small flexible bougie terminated by a bulb of considerable size, nothing is more easy, especially with an unpractised hand, than to deceive oneself with respect to the ex- istence of stricture. If not drawn out accurately in the axis of the passage, you may feel a check, and readily find Avhat you believe to be a stricture in the most healthy urethra. And that is precisely what I am so anxious to guard you against; for, in the hands of designing persons, these instruments may be turned to most unworthy purpose. For men out- side the ranks of our profession, or holding a questionable position on its outskirts, these instruments are the very thing. That is an additional reason why Ave should be careful not to encourage their unnecessary use. I have for twenty years past used small bulbous instruments in metal for the diagnosis of narrow and confirmed stricture, on which it is desir- c able to operate, but for slight stricture never; and I have protested against their use on the two grounds already named: first, that for such the instrument inflicts needless pain ; secondly, that it is liable to deceive a young operator not too adroit or familiar Avith its use. But noAv, in the second case—not that of the young man, but of the patient who has a confirmed stricture—the diagnosis has probably to be conducted with more attention to detail. I proceed as follows, making Avhat may be called a ' survey' of the passage. I commence by passing the soft, blunt-headed English gum-elastic bougie as far as it will go, and when this stops, as it may do within an inch or less of the orifice, I make a note of the dis- tance ; and next taking a smaller bougie of the same kind, find what Avill pass with tolerable ease through the obstruction met with. Very likely a No. 4 or 5 will do so, and it may then be carried further to seek another check, which is not unfre- quently met Avith at about five inches from the orifice. Through this, after a trial or tAvo, a very small gum catheter— say No. 1 or 2—may probably be passed into the bladder, enabling me to draw off some urine, and so to be assured of its position. I knoAv then that the patient has, at all events, a narroAving near the orifice and another at the distance named. I may verify this at once Avith a bulbous instrument if I choose ; but as long as the anterior narrowing exists, it is as well to postpone more minute research until it is divided, as considerable narrowing at that part ahvays requires to be. Such an one, indeed, is never advantageously treated by dilatation. This being done, the No. 11 blunt-ended bougie is passed, and will detect any contraction affecting the canal anterior to the stricture already observed at five inches from the orifice. If there is one, the stopping of the bougie will in- dicate its situation. But if the bougie passes easily to the point just named, the canal is sufficiently open, and I have ar- rived at Avhat, in ninety-nine cases out of a hundred, is the only remaining stricture; for it is rare indeed, where a narrow stricture exists at that distance from the meatus, that any other will be found beyond. This has next to be dealt with, and as we are speaking now of old and confirmed cases, there is little doubt that the best treatment will be internal urethro- tomy. How to accomplish that most per- 2 20 DISEASES OF THE URINARY ORGANS. fectly will be discussed in my lecture on that subject. A word or two about the bulbous ex- ploring instrument. It should, in my opinion, be of polished metal mounted on a slender metal rod or shaft, and should be used in several sizes from a bulb of No. 2 up to one of No. 13 or 14 (Fig. 6). No other material slides so easily and smoothly through the urethra; and the necessity for it is, after all, not great, so that to employ one which passes roughly or distends unnecessarily, is to pay too high a price for the small amount of information it may convey. I am free to say that, although I used the metal bulbous instruments in the earlier part of my career, I can now, with more ex- perience, attain all that is necessary with- out them. It is said that they enable you to ascertain the length of a stricture. In reference to this, let me tell you, first, that considerable narrowing very rarely affects the urethra for any great distance. The passage is often partially implicated for half an inch behind and half an inch before the maximum point of narrowing— an important practical point in relation to operation; but the very narrow spot, which is what the exploring bulb indi- cates, is almost invariably short, within a quarter of an inch in extent. Secon dly, Fig. C.—Straight and curved metal exploring bulbous instruments. you must take into consideration the fact that the mobility of the mucous lining of the urethra will deceive you if you are not aware of it. A very little pressure in front, on entering the stricture, or from behind, in withdrawing the exploring bulb, if it comes rather tightly through, changes the situation of the contracted portion considerably in relation to its distance from the external meatus. I repeat, then, if you have to deal Avith a recent stricture, such an one as you naturally intend to treat by dilatation, the introduction of a large bulbous ex- plorer is wholly useless, only produces unnecessary pain, and tends to excite inflammation. But in view of any internal incisions for a confirmed or obstinate case, the important thing is simply to knoAv pre- cisely Avhere the narroAved points of the urethra are, and then it is not difficult to aPP^y your cutting instrument properly to them. The subject of treatment by dilatation will occupy our attention at the next lecture. LECTURE IV. THE TREATMENT OF STRICTURE OF THE URETHRA BY DILATATION, SIMPLE AND CONTINUOUS. Having accomplished our diagnosis, Ave now come to the subject of Treatment. Supposing a man has but one stricture, and that in the bulbous portion, or if he has two, that the anterior stricture is by no means very narrow or resisting ; Avhat are we to propose to do for him ? First and foremost, dilatation—dila- tation always—dilatation without excep- tion, whenever it will succeed. It is always to be tried first, because it is the safest and easiest mode. If you find a man with a stricture which is very narrow, by no means think of operating until dilatation has first been fairly tried. What is dilatation ? A mechanical process of stretching this organised lymph, which forms bands round the canal at the STRICTURE OF THE URETHRA. 21 strictured point. It is often said to pro- duce absorption of this tissue, which I shall not absolutely deny, but only say that there is not the smallest particle of proof to support the notion. Noav, Ave will suppose a case in which, as the result of your exploration of the urethra, you have been able to pass No. 3 bougie or catheter rather tightly through the stricture and into the bladder, draAv- ing off a little urine, in order to be per- fectly sure that all has gone right; you will be able to say to the patient, ' That is enough for to-day; come again in tAvo or three days' time for a larger instru- ment.' Then on this second occasion I advise you not to commence Avith the largest instrument previously passed. Having passed, say, Nos. 2 and 3 on the first occasion, you should now take Nos. 2, 3, and 4; and on the third occasion, 3, 4, and 5; and so on; always beginning beloAv the point you had attained on the previous occasion, making the smaller instrument a sort of avant-coureur for the larger one. This process is always understood as that of' Simple Dilatation.' But further, never let the instrument remain in the urethra; withdraw it at once ; leaving it there for a few minutes simply increases irritation, and does not augment in the slightest degree the di- lating influence. Thus the longer the bougie remains Avithin the urethra the tighter it is held, and the more difficult and painful it is to withdraw. Not until the instrument has remained in the stricture some hours does this begin to relax, as we shall see by-and-by, in con- sidering ' Continuous Dilatation.' Noav comes the question of the kind of instrument to be employed. The great principle Avhich underlies all mechanical treatment of the urinary organs, whether for stricture or for hypertrophied prostate, for retention of the urine or for stone— the one great principle Avhich must decide for us the question of the kind of instru- ment to be employed is this : All instruments are evils, more or less considerable, never to be resorted to unless a greater evil be present, which their employment may probably REMEDY. The passage of an instrument of any kind into the healthy urethra must per se be a source of irritation. Try it yourself; and I advise you to do it, if you Avish to pass an instrument Avell; for I maintain that no man should pass an instrument for another until he has passed one for himself. Of course the amount of irri- tation Avill depend in great part on the manner in Avhich it is passed, and on the kind of instrument employed. Let us consider that in relation to the case of your patient there is, to use a commercial simile, a ' debit and a credit side' to all your treatment. You intend, beyond all doubt, to effect some real good —which is to be a considerable advance to the ' credit side' of the account; but you cannot do it without producing some slight irritation in order to gain your end —that is an entry on the ' debit side.' Be careful, then, that you constantly bear in mind the latter fact, and make it your business to diminish that ' debit' as much as possible. Do not pass an instrument unless there is some good reason, unless there is some evil, for the sake of curing which it is Avorth while to incur a little irritation. Acting upon this principle, you will choose such an instrument as you know by experience or otherwise to produce the least possible irritation. And this leads me to the question of the difference between solid and flexible instruments. Here I feel that I am tread- ing on delicate ground; and I will tell you why. First of all, I was originally, many years ago, an advocate of solid in- struments as against soft ones, being in- fluenced by the traditions of this school, which are entirely in favour of the former. I can give you the reason for that. The great master-spirit of this place, who has been dead some twenty years or more, the man Avho gave the tone to the place, and educated almost all the elder men here— I mean Liston—declared his preference for the solid instrument in very strong terms. It i3 (1882) just thirty-six years ago since I sat in this room and heard him deliver a lecture on that very subject. His powerful advocacy of the silver in- strument, and the contempt he had for others, were matters of notoriety. Start- ing, then, Avith such views, and regarding him—as every one does, to a certain ex- tent, the man who teaches him well and fairly what he learns—for a certain time as an oracle, I Avas strongly in favour of the solid instrument as against the flexible. But what is much more valuable than any oracle, whoever he may be, is a large personal experience; and this has taught me that, beyond all question, the flexible 22 DISEASES OF THE URINARY ORGANS. instrument is the best—if only you know how to use it—for the treatment of stric- ture, and for all maladies of the canal, whenever it is available. I am so certain of this, that I have no hesitation in saying that a great part of the success of any man Avho has much to do Avith such cases Avill depend upon his using flexible instruments instead of rigid ones. No patient will ever alloAv a surgeon to pass for him a solid instrument if you have passed for him a flexible one as easily as you may readily do. It gives so much less pain, and produces so much less irritation. To continue my commercial simile—it puts so much less on the ' debit side' of your patient's case, and thus leaves a larger ' credit;' you get so much more of ad- vantage, and so much less of disadvantage. I confess, then, to a considerable change of opinion ever since I published my first work on the subject; and I do this with- out the slightest shame or the slightest repugnance. I hold that the purpose much in favour of the other. You have my reason; it is simply that I have learned better. There are two kinds of flexible instru- ments, the English and the French. Inasmuch as the French instrument pos- sesses more flexibility than the English, I often prefer it. Perhaps it is right that I should add a word or two to what I have said. I believe the flexible instruments are much better noAv than they were in Liston's time ; and I think that, if he had liAred until now, he might have changed his opinion too. This is the kind of flexible instrument chiefly employed in his time. It is called a ' bougie; ' and properly, since it is simply a kind of wax- candle, and is, in my opinion, a very im- perfect instrument. You can bend it into any form by Avarming, but it is a very inferior implement to those which are generally used noAv. Nevertheless, the term bougie is still retained to describe the modern solid instruments, although they possess characters entirely different from the original production just referred to. of life in this world cannot have been achieved by us if Ave have never changed our opinions. You may rely upon it, with regard to any subject whatever, Avhether concerning politics or religion, or our own proper profession, if Ave hold the same opinion at forty years of age as we did at twenty—and, perhaps, looking forward, I may say, if Ave hold the same opinions at sixty as Ave do at forty—we live to very little purpose. It is an error to look for a life-long ' consistency' in matters of opinion from men who think for themselves, in whatever department their teaching may be. You must ex- pect them to progress, or they will be bad teachers—just as I hope you are progres- sing now. I have said this because I knoAv that much might be quoted from Avhat I held five-and-twenty years ago which is inconsistent Avith what I am now saying. If I did not state this you might ask me why, having said so much in favour of the silver instrument, do I now say so The gum-elastic or English flexible instrument is very valuable on account of one quality Avhich it possesses, and Avhich does not belong to the French instrument —i.e., it will preserve any curve, Avhen cooled, which you choose to give to it under the influence of heat. If I Avish it to possess a certain curve, I place the in- strument in Avarm water, give it the curve required, then put it in cold water, and the curve is fixed or set. The French instrument is exceedingly flexible; a quality Avhich is often of great utility. And it has another valuable character—namely, the peculiar form of its tapering point. Now, in passing through the urethra, a tapering point is often undesirable, because it is very liable to get into some lacuna. It is an advan- tage if you can provide that it does not do so; and this is ensured by constructing a little bulb, at the end (see Fig. 7). The long tapering extremity, terminated by the bulb, escapes the lacuna?, and may be passed through the healthy urethra, or through one not much contracted, with great ease. Such an instrument as that Fig. 7.—Flexible French bougie and catheter, with tapering and bulbous ends. STRICTURE OF THE URETHRA. 23 may be passed by the patient himself Avithout difficulty. The merest tyro can pass it in nine cases out of ten, although he may not always succeed. It is a re- markable instance of English conservative feeling or prejudice that these instruments are found in so feAv hands. They are, hoAvever, at last being made here. For years it has been necessary to send to Paris for them; but a demand is arising now, and they are at length manufactured in this country. If you will try the ex- periment on yourselves, you -will find that this instrument traverses the urethra al- most Avithout producing painful sensation ; and no knowledge of the canal is required for the purpose of using it. Now, it may appear to you very heterodox, but I advise you, in passing an instrument, to forget all about your anatomy. You are taught it at the Col- You require an instrument that you can use most delicately, holding it lightly be- tween the finger and thumb, AvithdraAving it or changing its direction as soon as you are able to perceive an obstruction. Your hand is to be educated for the poAver of perceiving Avith facility the characters of the passage by means of the instrument Avithin it; and rarely, if ever, are you to push a solid instrument in any given direction preconceived to be the right one. If you Avish to achieve the maxi- mum amount of dilatation and to produce the minimum amount of irritation, this flexible instrument is unquestionably the one for you to use. There is one other point to notice with reference to French and English in- struments—I mean the gauges. The ordinary range of our number is from 1 to 12: although tAvo or three higher numbers are occasionally used. Here is No. 12; and you generally consider, when you have reached that size, that you have completed the dilatation. In lege, and it is all-important that you should study it thoroughly; but for the purpose of passing an instrument avgII, you Avill only be embarrassed by an en- deavour to be guided by anatomical knowledge of the different regions. Think nothing about the deep fascia, the mem- branous portion, or the compressor ure- thra?. l A solid instrument is especially dangerous in the hands of an anatomist; he Avill push it the way he thinks right, as if all urethras Avere exactly of the same form, and did not vary as much as noses do, or other features. This used to be the pretext for preferring the solid instru- ment ; it was said, ' You want to know exactly your anatomy, and to pass the instrument accordingly.' I pity the patient who has a solid instrument thrust into his body by a man whose action is guided only by a knoAvledge of anatomy. England, we cannot be said to have a uniform scale; all our measurements are very arbitrary. One maker has one scale, and another another; and the Scotch scale differs by one and a half from the English; so that the patient who takes No. 12 Scotch, takes only 10^ English. Our more exact neighbours over the Channel use the millimetre, and the number itself expresses the precise size, so that when the number of any instru- ment which has been used is named, the 1 I ani not surprised that exception has been taken by some writers to thi3 passage. Notwith- standing which, I never felt the truth of it more strongly than I do to day. No one ought to infer from it that I undervalue anatonvy: it is the last thing I should desire to do. But the passing of an instrument well is not in any way an anatomical exercise. It is not an a priori proceeding conducted according to a knowledge of anatomical facts, but according to a deduction from large experience of the practice. Even healthy urethras differ con- siderably ; hut in exploring the passages, whether healthy or diseased, the hand is to be guided wholly by an intelligent appreciation of 'sensations com- municated by the point of the instrument, and not by anatomical knowledge. 2o zr zz 23 24 ZS 26 ooooooo *D la 17 lf> *S 14 is 11 11 O O O 000000 Jo 5 0 7 S 5 4 3 2 1 OO QO OO0000 Fig. 8.—French or ' Charriere' gauge. 24 DISEASES OF THE URINARY ORGANS. exact degree of distention produced is recorded (see Fig. 8). In the French scale also, the sizes are far more numerous than they are in ours. It commences with a smaller instrument and ends with a larger one : besides which, the intermediate stages are more gradual. By permitting only a slight augmentation of size in passing from one number to another, dilatation is rendered more easy, and irritation is avoided. You may pass, for instance, a No. 4 English very easily, and a No. 5 with difficulty, or not at all, while an intermediate size would afford you the means of progress. The French numbers 3 to 21 are about equal to our 1 to 12; which shows how much more gradual the scale is. No. 1 is one milli- metre in circumference ; No. 2 two milli- metres, and so on; so that the increase in size is uniform as well as gradual. If I have a patient whose urethra will admit No. 21, I knoAV that it possesses a calibre of tAventy-one millimetres in circum- ference, and, of course, seven in diameter. I advise you in this, as in other matters, to be cosmopolitan in your vieAvs, and to adopt improvements from all quarters.1 I have told you that simple dilatation consists in passing a larger instrument every two or three days, until you reach the highest. In many cases all goes on smoothly from the beginning to the end. Then you teach the patient to pass the instrument for himself, and he does so afterAvards once a montb, or once in six Aveeks, to maintain a sufficient calibre. A patient who has not long been the subject of stricture may, as a rule, be suc- cessfully treated by simply passing these soft flexible instruments, gradually in- creasing their calibre until that of the healthy urethra is obtained. But these 1 Taking the sizes employed by the chief Lon- don instrument-makers as representing the' English scale,' I have constructed a table, in which the Bizes of the French (' Charriere's') scale from 1 to 24 occupy the upper line, while the sizes of the ' English scale' occupy the under line; so placed that the relation of the two scales may be seen to each other. Note that the numbers do not gene- rally coincide in situation—thus : the English 6 is between 11 and 12 of the French scale, but nearer to the 11 than to the 12, and so on. <££&} 1 2 3 4 5 C 7 8 English Scale. 1 2 3 ohSbU n 10 n 12 13 u 15 le English Scale. 4 5 6 7 8 9 ChSrifcU 17 18 1!) 20 21 22 23 24 English Scale. 10 11 12 13 14 very qualities of softness and flexibility, which diminish so greatly the disagreeable sensation Avhen passing, and the chance of injury to the patient, constitute them in- efficient when you have a case in which the hardness and resistance of the stric- ture are too great for their somewhat feeble power of penetration. What is the next step? What substitute do you employ ? Are you to relinquish the pro- cess of dilatation, and think of performing any operation ? By no means. You will noAv resort to firmer and less flexible instruments; and there are few which are more efficient or easy to pass at this stage, than conical steel instruments, Avhich are all the better when silver plated. The sizes which I should recommend you are not to be small—indeed, none smaller than the following, of which I don't knoAV that the first is not too small for any but very careful hands. The first, say No. 6 (English scale) at the point, gradually increasing to No. 8 at about two inches and a half from it, as represented here. The next, No. 7 at the point, and No. 9 at the largest part. The next, No. 8 at the point, and No. 10 at the largest part. The next, No. 9 at the point, and No. 11 at the largest part. The next, No. 10 at the point, and No. 12 at the largest part. The next, No. 11 at the point, and No. 13 at the largest part, and so on to No. 15. These conical dilators—I scarcely like to call them ' bougies,' a term so inap- propriate for metal instruments, and Avhich certainly, if retained at all noAv that the thing itself, the wax candle of our forefathers, is obsolete, should denote only flexible instruments—may be passed Avith great ease, OAving to their polish and Aveight; while they can scarcely be sur- passed for efficiency in the later stages of dilatation. I recommended them equally thirty years ago, and have in no way changed my mind about them. You should, however, be provided Avith some- thing intermediate between the very flexible bougie and these metallic dila- tors ; and many means for combining the flexibility of the former as to the point, and the stiffness of the latter as to the stem, have been contrived—such as gum- elastic, flexible metal, &c. In France, a stiffer bougie is produced by constructing STRICTURE OF THE URETHRA. 25 the ordinary black flexible one, with a centre core of soft lead wire, and it is a very useful instrument; but since this lead traverses the entire leDgth, the ter- minal portion is rendered as firm as the shaft. Of late I have adopted a plan nating in a fine point, which stops short about four inches and a half from the end of the bougie. Here is a set of them : six in all. The folloAving diagram will flexible (Fig. 10.) Their maximum dia- meters are about 5J, G£, 7, 7f, 8|, and 9£ (English)—a series which may Avell intervene between the soft bougies and the metallic dilators. Capability to pene- trate easily is ensured by the complete flexibility of the point, and the increased firmness of all the rest of the instrument. We will now consider ' Continuous Dilatation;' a term Avhich applies to a useful mode of treating stricture by per- mitting the instrument introduced to remain in the urethra during a consider- able period of time. There is a patient upstairs who is now undergoing this pro- cess successfully. You have tried, we will suppose, the simple dilatation, and have not made the amount of progress desired; or, perhaps, the patient's avo- cations may make it necessary to obtain speedy relief. In either case you may say, ' If you can remain ten or fourteen days in your room, not necessarily in bed, but on the sofa quietly at home, I can almost certainly dilate your stricture from the smallest number up to the highest'— by ' continuous dilatation.' In ' simple dilatation' the instrument is merely in- which I prefer to any of these, and for all sizes from No. 4 to No. 8 or 9 (English) it is perhaps better than any. I have had a short and very soft lead stylet made, to be introduced at pleasure into the interior of the French conical bougie, and termi- explain what I mean. A section shows the movable lead stylet in the interior, but is represented as extending too close to the end, which should be long and troduced, and at once Avithdrawn; in 'continuous,' instruments are tied in, and allowed to remain for several days. But there are certain rules Avhich it is essential to observe in order to attain our object safely and easily. I. The catheter is ahvays, if possible, to be one of gum-elastic, and of English make, which is superior for this purpose to the more flexible French, from its greater power to resist the destructive action of the urine. If, on account of the narroAvness or tightness of the stricture, a small silver catheter only could at first be introduced, of course it must remain for a day or two until it can be replaced by one of gum elastic. II. In tying-in the catheter, take care that the end of it only just lies within the cavity of the bladder. An inch or two of catheter there is a source of irritation to the organ, acting, indeed, like a foreign body, as it is. There is no difficulty in accomplishing this object if, the patient being upright, urine is passed though the the instrument. You "will observe by drawing it out a little, while the urine flows, at what spot the stream stops; and Fig. 9.—Metallic dilators, inappropriately called ' bougies ;' a. point, b. largest part. Fig. 10.—Flexible French bougie, with movable lead stylet. 2G DISEASES OF THE URINARY ORGANS. then reintroducing the instrument a little, you "will secure it precisely when it arrives at the spot at which the stream again floAvs. III. The catheter is always to be small enough to pass easily, so that even when first introduced it lies loosely in the canal. These three conditions being granted, this is one of the safest and best modes of treating some strictures. There is a patient upstairs who has finished the pro- cess, and to-day the house-surgeon tells me that he has passed No. 11, English scale, with ease. The man has been here only a fortnight, and has now not the slightest pain or frequency of making water. He says he is better than he has been for twenty years, and he came here in an exceedingly bad condition. Having been treated as an out-patient, and making no progress, I advised him to come in, and try continuous dilatation. I may here shoAv you what I think the best manner of tying-in a catheter. By the old methods, which involved bandages round the body, groins and thighs, each Fig. 11.—Mode of attaching the catheter. movement of the body exerted some in- fluence on the instrument—an extremely undesirable condition. The object to be attained is a method which permits free movement of the body Avithout influencing, through the medium of the fastenings, the position of the catheter. The most simple and efficient method I can devise is to attach the catheter to the penis and pubic hair by means of soft twine or by 'bobbin,' which is a soft cord made of cotton and not of hemp, and does not irritate the skin. Two separate attachments loosely made in the manner shown at Fig. 11 render the instrument secure, and permits alterations in size to occur without causing discomfort. Of course the patient is not allowed to indulge in much movement, and he requires very little in his chamber?-, or in a ward. But I have known those who have habituated themselves to the use of the catheter in this manner follow their usual avocations for hours, scarcely inconvenienced by the presence of an in- strument thus fastened in its place. I shall now only repeat in reference to this process that three conditions are necessary to success: you must have a flexible instrument; the point must not be far in the bladder, and above all it must not fill the stricture, because, re- member, it is not a mere mechanical process; you do not require, as in ordinary dilatation, to distend the stricture as you might a lady's glove, but to treat it by ensuring the continued presence of a foreign body in the passage. If you leave in only a No. 1 for a sufficient length of time, you will be able, when you take it out to pass No. 10, without using the intermediate numbers. I believe I was the first to demonstrate that curious fact; the knowledge of it at all events reached me by an accidental occurrence in prac- tice. As a rule we do not leave so small an instrument very long in the urethra, because the stream of urine would soon wash it out, and it is desirable to put in a larger one to fill the canal a little more. If, Avhen it is necessary to introduce a larger instrument, you use one which is quite as large as the stricture will admit, pain and irritation will be produced, and the progress will be less satisfactory. Every time the catheter has to be ex- changed for a larger, avoid using one which passes Avith difficulty, but take an instrument Avhich is at least tAvo numbers less than the size which the stricture will absolutely admit. In continuous dilatation, as Avell as in simple dilata- tion, you are to adopt the plan Avhich gives the smallest amount of pain and irritation to the patient, putting as little as possible to the debit side, and as much as possible to the credit. Well, then, having ceased to tie-in any longer—say, at the end of six, eight, or ten days, according to the case—a full calibre having been attained, the instrument should be passed daily for two or three days. Then gradually increase the in- tervals of time, maintaining as much of STRICTURE OF THE URETHRA. 27 the dilatation gained as you fairly can. Most commonly two or three numbers are lost reckoning from the highest point attained by tying-in: thus, if No. 12 Avas so reached, you may perhaps maintain No. 9 or 10; an excellent calibre for a patient Avho commenced with No. 1, and that passed not without difficulty. It is quite common to observe that the patient has a little fever during the pro- cess, but it is rarely considerable. A single rigor, followed by heat and sweat- ing, is not a sufficient reason for suspend- ing the process ; and it sometimes occurs after the tying-in has ceased altogether, and during the first or second subsequent day, Avhen the patient commences to pass water Avithout the instrument. When long-standing organic disease of the ureter and kidney exists, as the result of old and narrow stricture, then continuous dilata- tion may provoke severe and dangerous attacks ; but this is a condition in which all mechanical interference is hazardous. Supposing, however, that the treat- ment has been well supported, and that no such symptoms have appeared, the result of dilatation may nevertheless appear to be only temporary. As a rule, I have observed that the slower the process by which dilatation is accomplished through the continuous process, the more certainly and rapidly will the contraction reappear. On the contrary, if improvement is very rapidly attained, the result will be com- paratively more lasting. There are therefore some cases in Avhich all the advantages gained by the process are speedily lost. Clearly, some other method than dilatation of any kind will be required for these. This subject, which embraces the operative proceedings to be applied to the treatment of stricture, I shall consider in the next tAvo lectures. LECTURE V. ON THE TREATMENT OF CASES OF STRICTURE IN WHICH EXTREME DIFFICULTIES EXIST. You may remember, gentlemen, that at the last lecture Ave considered the treat- ment of stricture by ' ordinary dilatation ' and by ' continuous dilatation.' You un- derstand from the nature of the treatment itself that it Avas taken for granted that an instrument had been passed into the bladder. It is, of course, assumed that in treating a case by means of dilatation, whether continuous or simple, the instru- ment has passed completely through the stricture, otherAvise the stricture is not dilated. But all cases of stricture are not so easily disposed of. It often happens that at the first, second, or even third trial the instrument does not enter, or is not passed through the obstructed part; or it leaves the canal altogether and goes into a false passage. At all events, the instrument does not go through the stricture, and onwards, as it should do, into the bladder. And here I may remark that you are never to feel assured that the stricture has been successfully traversed by an instrument unless it has arrived in the bladder. No test is so complete as the appearance of some urine through the instrument passed, Avhich must therefore for this purpose be holloAV-—in other words, a catheter. Of course if a bougie is employed the test proposed is impossible, and some uncer- tainty as to what has been done is in- evitable. Here, then, is a condition of difficulty which opens a new subject for us to-day. We have noAv to deal Avith more difficult cases, those in which all your care, and all your experience too, if you have any, are needed. It Avas said by Liston, that' the operation of introducing a catheter through what has been called an impermeable stricture, is without doubt the most difficult in the Avhole range of surgical operations, and demands all the prudence, science, and skill of a master.'l That statement is in the latest edition of his work, and you can scarcely have a higher authority for the fact there mentioned. Now, there is one term employed in the foregoing quotation which is often used to describe stricture, to which I take a 1 Practical Surgery. By Robert Liston. Fourth ed., p. 476. London: Churchill, 1846. 28 DISEASES OF THE URINARY ORGANS. great objection, and I think the sooner it is expunged from the vocabulary of surgery the better. Such a stricture as that of which I now speak is often said to be ' impermeable,' or ' impassable.' What is impermeable stricture ? Well, first, since some urine passes through every stricture thus denoted, it is very clear that'impermeability' cannot be held to describe a character, a physical quality, of the stricture itself, but rather indicates the quality of the surgeon who has treated it! For, you see, a stricture may be ' impermeable' as regards A, but not * impermeable' as regards B, who may have passed an instrument fairly through it. But, secondly,' impermeable stricture' is a contradiction in terms. Stricture is a narrowing of the canal; it is not an obliteration of it, which is quite another thing. There must be an opening, and if there be an opening there must be room for an instrument; it cannot be ' imper- meable.' It is only a question of the size of that instrument, and of skill or patience in the management of it. The stricture, as I have said, always admits urine, more or less in quantity, to pass through it, and I maintain the truth of the axiom first enunciated by Professor Syme, that Avhenever urine passes out- wards through a stricture, an instrument ought with care and perseverance to be got in. I advise you to believe in that doctrine, not that it is true as regards yourselves at the present moment, for I will assume that you have not sufficient experience to enable you to pass an instru- ment through a stricture in all cases. If you are able to do so, I can only say that you are quite out of place here, and need not come to learn. Without doubt it is exceedingly difficult to pass an instrument in some exceptional cases, but after a con- siderable amount of experience you will find that there are very few in which it cannot be accomplished. When you have a really difficult case of stricture before you, the success of your treatment will be materially influenced by the belief that it is your own fault if you do not succeed, or, on the other hand, by your adhesion to the dogma that there are a certain number of cases which must be ' imper- meable ' to all surgeons. The man who holds the latter belief will be quite certain in some cases not to succeed, whereas, probably, the man Avho believes that in all cases an instrument may be passed with time and patience will be very likely to succeed in all, and at all events he will succeed better than the other. ' Impermeable ' stricture is not heard of so much now as it Avas twenty years ago. That such a form of obstruction might frequently be met Avith was generally recognised then, and a particular kind of operation to relieve it was often to be seen in the hospitals ; but I will undertake to say that it is much less commonly performed now. The operation consisted in passing a large instrument down to the stricture, and opening" the urethra upon it from the perineum, and then carefully dissecting through the obstruction, or by it in some way, if the operator could, into the urethra beyond, and it was not usually a very successful proceeding. It was ac- knowledged by all authorities at that time as an operation for impermeable stricture, or as ' perineal section.'x I have had occasion to perform it three times only in my fife; two of these being instances of traumatic stricture, and I believe the necessity for it to be excessively rare. I have already given Professor Syme credit for having first enunciated the doctrine that all strictures are permeable to instru- ments, and he ahvays stoutly maintained it, Avithout doubt to the great advantage of patients Avho suffer from severe stric- ture. But you may have complete oblitera- tion of the urethra, which, as before said, is not stricture. This is very rare; but it occasionally happens, and chiefly after injury in the perineum, as by the breaking of a vessel, or any Avound there cutting into or across the urethra. If the opening remains pervious, and gives exit to all the urine, a cicatrix occurs involving the an- terior opening of the divided urethra, which is then closed altogether, and so the canal is obliterated in front of the fistula. I have now to consider the question, How are you to deal Avith a case in Avhich real difficulty exists in passing an instru- ment into the bladder ? Let a case be supposed in which attempts have been 1 I limit the employment of the term ' perineal section' to the operation when no guide has been passed through the stricture. When a stricture is divided by incision through the perineum, upon a guide previously passed into the bladder, it is better, in order to distinguish this operation from the previous one, to speak of it as ' External Urethro- tomy,' or as ' Syme's' operation. For brief sketch of both, see pp. 35-6. STRICTURE OF THE URETHRA. 29 already made, perhaps by others, and hitherto without success. First let me point out in Avhat the chief mechanical difficulties in such a case might consist. There are four. 1. Extreme narrowness of the stric- ture. 2. The stricture may be tortuous. 3. It may be complicated with false passages. 4. The urethra behind the stricture may be irregularly dilated and reticu- lated. Sources of difficulty of another kind, not mechanical, also exist, and are two in number, hereafter to be considered. 1. The stricture may be very resilient, and liable to become rapidly narroAver after full dilatation, and even to produce absolute retention on any instrumental contact; and 2. Any use of the instrument may produce in . the patient an attack of rigors. 1. Let us consider the mechanical causes of difficulty ; of Avhich the first is extreme narrowness. In regard to this, the first thing you must do is to see the patient make water. The failures to pass the instrument may not necessarily have arisen from narrow- ing of the urethra, or from tortuosity : there may be a false passage leading out of the canal. It may indeed be that the urethra is altogether free from stricture. No greater mistakes are made than those Avhich occur Avith patients who have little or no stricture, either from the medical attendant not being familiar Avith the use of instruments, or from the presence of a false passage into which the instrument enters, so that it fails to reach the bladder. You are first, then, to see the stream of water, perhaps on more than one occasion, so as to estimate it fairly, and judge by it Avhat sort of instrument is to be used. And always let the instrument correspond in size with that of the stream which you see. The instrument should correspond only in this way, however—it should be a little smaller than the stream. You, know, of course, that Avhen a current of water passes into a narroAver passage than that in which it has been flowing, the stream is more rapid than before, and when the passage becomes larger it flows slowly again; so that the size of the stream as it Aoavs from the orifice is not to be taken as the precise measure of the calibre of the narrowest part of the canal. You should, therefore, select an instru- ment somewhat smaller than the stream. There is a patient in No. 10 Avard, Avhom some of you have seen, Avho does not pass a stream at all; the urine issues only by drops, a result due to the first cause men- tioned—namely, extreme narrowness of the stricture. How very small, then must the instrument be Avhich is to traverse that channel successfully ! The first step to be taken Avith such a case, after having ascertained, as I assume to have been done, the situation of the stricture (see page 19), is to introduce- very gently the smallest English gum catheter Avithout a stylefc, and try to in- sinuate it through the obstruction. For this purpose I have endeavoured to obtain some exceedingly small instruments, much smaller than any hitherto made.1 This tiny catheter which I show you, capable only of containing a slender steel thread rather than a stylet, may be used either with or Avithout it. The value of this little instrument after its extreme tenuity, is its ability to transmit a drop of urine through its interior, and so assure you of its position when the bladder has been reached; an assurance, I need hardly tell you, of great importance. It is worth while making a careful and somewhat prolonged trial, and if you succeed, the instrument is to be tied-in at once, and the route secured—and it is a great triumph to succeed on such safe and easy terms. But supposing Ave have been unable to pass the slender gum catheter, we should noAv adopt a different system of attack, and employ an instrument, still extremely small but inflexible, a small silver catheter Avhich, unlike the flexible instrument, can be guided altogether by the hand. At the same time it is most important to remember, in connection with all small metal instruments, that no more dangerous Aveapon can be introduced than one of these, unless great care, delicacy, and gentleness are exercised; indeed, it is impossible to be too careful in employing so small a catheter as this is (Fig. 13). You see how easy it must be 1 Messrs. Weiss & Son have taken great pains to accomplish this for me, and have produced some slender, delicate instruments, much smaller than No. 1, which have been of great service. (See Fig. 12, next page.) 30 DISEASES OF THE URINARY ORGANS. with such an instrument to enter one of the lacunae, or into any false passage, or to penetrate the soft walls of the urethra, and even far among the tissues outside. You are never to hold this slender catheter Fig. 12. ii Fig. 13. 12.—Extremely small gum catheter. 13.—Silver catheter, fine at point, shaft increasing in size to afford stability. with a tight hand. You must not hold this as if resolved to carry it through any obstruction; but it must be held so lightly that if it meets any undue resistance it Avill slip through the fingers rather than by any possibility wound the urethra. I certainly cannot advise you to try such an instrument until you have had some fair amount of practice with a larger one. In cases of very great difficulty, a small gum instrument is by no means always success- ful ; but, as I have said, it should always be thoroughly tried at first. Understand that I have been advocating flexible in- struments as the rule; but if you fail to pass them after one or tAvo trials, in deal- ing Avith a very tight stricture, you must then resort to a small silver instrument. Now, one word upon the subject of using force. Under no circumstances whatever should force be used in the intro- duction of an instrument through a stricture or into the bladder. That is the invariable rule for myself, and my counsel to you. Not so many years ago it was a matter of discussion how much force should be em- ployed ; at a more remote period, many surgeons regarded the use of instruments Avith considerable violence as legitimate practice. Now I am perfectly satisfied, and I believe all experienced men of our day will tell you, that no force is to be employed. It is very difficult to say what one means by force; but what you are to understand is, that no kind of Aveight or pressure is to be put on the instrument Avhich can by any possibility carry it out of the canal; and very little force will do that. The more difficult the stricture the less are you to dream of using force. You Avill remember that the urethra is possibly of full size up to the point of narroAving, and hence it may be very difficult to find the opening. If you use force, you will perhaps perforate the soft Avails on either side, and this done, the difficulty is greatly increased; because, if you have made a false passage, the point of the instrument is much more likely to be caught in it than to pass through the strictured part. I may here observe that in using silver catheters of small size an injection of oil is sometimes serviceable. Instead of oil- ing the instrument, commence by slowly introducing from two or three to six or eight drachms of olive oil into the urethra, holding the meatus closely round the syringe. It is easy to insinuate that quantity through a very narrow stricture. The surfaces are lubricated, and sometimes the urethra is slightly distended Avith the oil, so that, if you can cleverly retain it with the finger and thumb, you may STRICTURE OF THE URETHRA. 31 introduce the instrument Avhen you have heen unable to do so in any other way. The plan is not to be tried when there is much bleeding, or the tissues are torn. 2. A stricture may be more or less tortuous. The narrow channel of the stricture does not necessarily follow the original and undeviating line of the healthy urethra. In other Avords, it may be a little on this side of the urethral axis or on that, not necessarily in the middle. You may see this sometimes in a dead body ; and you may infer it from experience on the living. When you have to deal either with a very narrow or Avith a tortuous stricture, there are two quite distinct sys- tems of using an instrument, either of which you may employ. What I have to say then applies to the manipulation necessary in all cases of difficulty under the present and preceding heads; and I have reserved it, therefore, until now. First, the little instrument employed, whatever its nature, may be applied in a Fig. 14.—Small twisted bougies. manner Avhich may be called ' groping ;' that is, by carrying the point in any and every direction, Avith the utmost care of course, until by chance it has entered into the stricture, as you may learn by the sensation of the point being ' held' or ' grasped.' For this purpose very slender solid instruments are made, of gum-elastic, of catgut, covered or not with gum, and of whalebone, since all of these can be produced of rather smaller size than the holloAV instruments which I have just described. In order to add to the chance, as is supposed, of finding the orifice, there are some of the first-named material, the ends of which are formed someAvhat into the shape of a corkscrew, or are otherwise made to deviate from a straight line. All these are of French design and Avorkman- ship ; but none have the advantage of the channel, being hollow so as to be capable of demonstrating their presence in the bladder when they arrive there. (See Fig. 14.) Now, I advise you not to rely much on mere ' groping' to find the orifice; it is exceedingly dull, mechanical work to be constantly groping for a long time. There is a method of search, however, which is conducted on a fixed principle, and this I much prefer, and always em- ploy. I advise you to adopt that, or any other you can devise, provided that it be a systematic one, and also an exhaustive manner of making the necessary explora- tion and research for the orifice of the stricture. Some of you have seen me apply it to a patient in the wards to-day. According to this manner, you proceed on a recognised principle and examine each side of the urethra in its turn. We will suppose the urethra for our purpose to have four sides or aspects which require examination—a roof, a floor, a right side, and a left side, all of which are more or less irregular and require to be traversed Avith the utmost care. You will lightly hold your slender silver catheter and delicately slide its point along one aspect Fig. 15.—Diagrams of stricture. first, say the upper or roof, from near to its commencement at the external meatus slowly down to the obstructed spot and explore this carefully before you repeat the process on another aspect. If the orifice of the stricture is not exactly in the middle line—and we may fairly be- lieve that it rarely is so—then there is one side of the passage Avhich will more easily lead into the narroAV way than another. These diagrams will showAvhat I mean. (Fig. 15.) If the instrument is slipped on this side (indicating the irre- gular side on the diagram) it will pro- bably not pass through the stricture, but if the opposite side is f olloAved the instru- ment has obviously a better chance of succeeding, because you see there is less obstruction on that side. Begin, then, by the roof. The roof is naturally the firm- est part, the least likely to furnish ob- struction in the Avay of ducts and lacunas, and, by following it, you will be most likely to carry the point in. The floor, 32 DISEASES OF THE on the contrary, is the softest, loosest, and most spongy part; and will be most likely to yield to the instrument, and give way. If your first effort does not succeed, take the right side ; if that fails, take the left; if that does not do, try the floor. I know no other method so calculated to help you through a difficult stricture. If you are very careful, you may make the attempt in this manner for thirty or forty minutes without doing any damage; but if the patient suffers much, or bleeds rather freely, or if you are losing patience, give up the task, for, under these conditions, a false passage is easily made, and the diffi- culty may be considerably increased. 3. The existence of false passage lead- ing out of the urethra is another serious obstacle to the introduction of instruments into the bladder. Suppose a case under your care, in Avhich you have reason to believe that false passage exists. I Avill assume, of course, that you have not made it—you have been too careful for that—you are perhaps not the first surgeon who has seen the patient; some one else has seen him before, and may have made a false passage. Indeed, the subject himself may have been the author of it! There is a curious in- stance of this in the ward at this moment, in the person of a man Avho has, according to the history furnished by himself, used instruments habitually and succeeded in forcing one completely into the rectum ! He has used a No. 9 or 10 catheter, and, Avithout proper advice or supervision, has treated himself for stricture. He is cer- tainly an illustration of the old adage, sometimes, but not always, true, that ' he Avho treats himself has a fool for his patient.' By using extreme violence he has actually thrust the instrument out of the urethra through all the tissues betAveen it and the rectum. When he was in the out-patient room he simply complained that Avhen he passed the catheter into the bladder he sometimes found faecal matter in the eye of the catheter. The truth is he never succeeded in arriving at the bladder. I suspected the cause, and, after examining him, verified the condition described. Having, as you knoAV, made two pro- longed attempts, I carried a No. 1 silver catheter into the bladder to-day. You can easily conceive how difficult such a false passage may make the task of passing the instrument, since he really had also a very narrow stricture. URINARY ORGANS. The principle which must guide our action in such circumstances is to be very careful to avoid the side on Avhich the false passage is. A false passage com- mences usually on the floor, and, no doubt for a reason already mentioned—viz., the fact of the strictures below being looser and more delicate than those above. When any patient has a false passage, a catheter introduced may pass with facility up to its very orifice and yet give issue to no urine. Hence has arisen the false notion that stricture may exist at the neck of the bladder. When the instru- ment has thus passed, a finger placed in the rectum will determine instantly whether or no there is a false passage; for, if there be one, the coats of the bowel only, which are very thin, intervene be- tween the finger and the instrument, so that you feel it very distinctly ; and very commonly also that it is not in the middle line, but rather to the right or to the left. But if the instrument is in the right passage, the whole thickness of the pros- tate, not always very considerable, is per- ceived between it and your finger, always quite enough to shoAv Avhen the instru- ment is in the right path. You Avill re- member that it is chiefly in the bulbous portion that the instrument leaves the urethra and passes through the tissues under the prostate. Accordingly you are to Avithdraw the catheter two inches or so, and then to pass it on again, keeping it as close along the upper part of the urethra as possible, ascertaining by means of the finger in the bowel that the instrument is not entering the old route. It -will be very likely to do so, because it is much more easy to pass into a false passage than into the right one. But Avhen false passage exists, it some- times constitutes the chief obstacle to the introduction of an instrument, for, as I have before hinted, the stricture itself may be only inconsiderable. The size of the stream will help to determine this point; and if, so far from being a mere thread, it has a volume equal to a No. 6 or 7 catheter, use a No. 5 silver one, the rigidity of which enables you to guide it, and try each side of the urethra succes- sively, until you discover which it is that enables you to avoid the orifice of the false passage. Remember the result, and you have a key to the difficulty which will enable you to overcome it with ease on the next occasion. STRICTURE OF THE URETHRA. 33 To these hints about manipulation I have only to add my advice that you should never lose an opportunity, Avherever you find one, of examining hospital patients by urethra and by rectum, since practice is absolutely essential to instruct and cultivate your hand. You will often find a case of false passage in the wards, and I Avish you sometimes to verify the position of the catheter when it is in the false passage; to observe, by introducing into the rectum your finger, how very little tissue there is between it and the instrument. On the other hand, when it is properly passed, you feel the thickness of the prostate intervening. You can only appreciate this by the touch, and will learn little more by talking of it. In connection Avith the treatment of a case of very narrow and difficult stricture, let me say very briefly that if the patient is kept at rest in bed for a few days, his diet regulated, with attention to the diges- tive functions and to the action of the boAvels, the chances of success at the sub- sequent application of the instrument Avill be increased. If possible, a few days' rest should elapse after much instrumental Figs. 16 and 17.—Sections of urethra, showing very narrow stricture, and dilated and reticulated membranous and prostatic portions behind it. treatment by others, or by yourself, if you have already made several trials and have failed, or if, after one trial only, the symptoms have been aggravated. You will make your next attempt under more favourable conditions, if you choose a moment when the animal functions generally are well performed, and the signs of local irritation have diminished. 4. Difficulty presented by dilatation and reticulation of the urethra behind the stricture. Suppose next that, following these hints, you have carried the instrument fairly through the stricture, you will be conscious of a hold or grasp of it by the contracted part, which is quite unmistak- able. That is a sensation which you are always very glad to have, because, feeling the catheter ' held ' by the stricture, you know the instrument has passed Avell into or even through it. But that very 'grasp,' which you are so satisfied to feel, makes it less easy to manipulate the point of the catheter beyond the stricture, and you may have a source of danger to encounter in the urethra beyond. Thus, the mucous membrane being sometimes reticulated from the presence of dilated lacunae, the point of the instrument is liable to be en- gaged in one of those, and make a false passage. Besides these, it sometimes happens, as the result of long-continued fluid pressure and straining, that the whole urethra behind the stricture is much dilated, and that its surface is so irregular, that extreme care is necessary in order to traverse it safely. Here, es- pecially Avith a small instrument already grasped, you require all the caution you can command to carry it safely onward into the bladder. I shoAV you tAvo draw- 34 DISEASES OF THE URINARY ORGANS. ings taken from cases which exactly illus- trate this condition. (Figs. 16 and 17.) Let us pursue the case one step further. Suppose you have introduced the catheter safely at last, and after much difficulty. By no means AvithdraAV it. You "will naturally conclude that, after so much risk and trouble, it will be prudent to maintain the advantage gained by fasten- ing the instrument securely in its place. In these circumstances it is most desirable to do so, even although it is a metal instrument; and you may allow it to re- main forty-eight or seventy-two hours before removing it. Do not then be in a hurry to take it out, if the patient is toler- ably comfortable. You will be excessively disappointed if you are unable to pass another in its place—a probable event if the catheter is removed too soon—and are compelled to wait until you can attempt a repetition of the difficult task; a circum- stance wbich would also be no less dis- agreeable to the patient. Keep the origi- nal catheter in the bladder at least three days, and then you will mostly be able to change it easily for a small gum-elastic instrument. After all, it may happen at such a crisis, even to a surgeon of expe- rience, that although he has once intro- duced a small instrument, either catheter or bougie, he is, after withdrawing it, unable to put it in again, or to replace it by another. There are some instances in which such a difficulty becomes the source of serious delay and anxiety. Under these circumstances a little apparatus made on the following plan has been long found extremely useful (see Fig. 18). A very fine flexible bougie or catheter Avith a small socket for a screw at one end (A) —to which a stiff rod of similar calibre, and about 12 inches long (B), can be attached—is employed, and Avhen the small instrument has once been passed, the rod is screAved on, and over it a small gum-elastic tube (C) may be slipped into the bladder and fastened there, when the rod and small instrument are Avithdrawn. On the next occasion of changing the instrument, the rod and small instrument attached are first passed into the bladder through the tube, which is then Avith- drawn and replaced by a larger one slipped over the rod Avhich secures the route as before, and is itself again with- drawn. From this point it Avill be easy to pro- ceed by ' continuous ' dilatation, as already described, increasing the size of the gum catheter from time to time. Having re- tained an inlying catheter, say the size of No. 10, you may rightly tell your patient that this is a great achievement, that you will speedily relieve him from confinement, * C ! Fig. 18.—Oversliding catheters. and only pass an instrument day by day. This is Avhat will happen in the majority of cases; the treatment having been suc- cessful. But not in all, for it may happen in a Aveek or ten days afterwards, perhaps, although this is a rare occuiTence, that STRICTURE OF the stricture will admit nothing larger than No. 2 or No. 3. Such a contingency presents a special form of difficulty encountered in the treatment of stricture, one not of a me- chanical kind, but consisting in a certain organic quality of the obstruction itself, which may be termed ' resiliency,' or strongly marked contractility. Still less of mechanical origin is a tendency in the patient to experience rigors on attempts to treat the stricture by dilating instruments of any kind. I. What is to be done in relation first to the case which has been here termed the ' Resilient Stricture ' ? I will just premise that I desire you to understand that you may have to deal with a very narrow stricture, and be able to dilate it, and the dilatation shall be fairly permanent. On the other hand, you may have a stricture which will admit even No. 5 or No. 6 catheter easily, yet the man will scarcely make a drop of water, and hoAvever carefully you may attempt to dilate, the advance will not am6unt to more than one or two numbers of the scale. We had an instance of this condition in the Avard the other day. Although a No.. 6 instrument could be passed, the patient Avas unable to pass any urine by his own efforts until I had per- formed urethrotomy, and then he was able to do so with ease and comfort. Let me add, that the successful treat- ment of this form of the disease is a prob- lem of very ancient date. These resilient strictures have been the plague of surgeons from time immemorial. If you go back to the old records of surgery—some hundreds of years—you Avill find that these cases have taxed the resources of surgeons down to the present day. All kinds of things have been used in order to overcome the difficulty. I cannot tell you one-half of the various matters which have beep put into the human urethra, for the purpose of curing it. I suppose the human stomach has been made to receive more abominable things than any other receptacle in or out of the human body. But if you consult the old surgical authors, or even some modern works, you will see that the urethra has been used nearly as roughly, and that is saying a good deal. Mercury of course, first; then verdigris, savin and other vegetable irritants, metallic salts in all their variety—in short, everything that has the faculty to inflame, or that could be D THE URETHRA. 35 imagined to be disagreeable, has been em- ployed to cure the unfortunate possessors of these resilient strictures. At the present moment I need not tell you that some surgeons have been in the habit of apply- ing nitrate of silver and caustic potash—not at all mild remedies, either of them. Now, the whole question of chemical irritants, as related to the treatment of stricture, I shall dismiss Avith the following words: I be- lieve them to be unnecessary, undesirable, and often injurious. Most modern sur- geons, both in this country and abroad, have pronounced against the use of caustics and chemical irritants in the treatment of stricture. I am bound to tell you they have still some adA'ocates: what system has not ? I shall not pursue that question further. Then Avhat have Ave left? Several other methods, all of which are mechanical in their nature : we may rupture, or over- extend, or cut these unyielding and con- tractile fibres, which constitute the stric- ture. Urethrotomy, as it is called—that is, division of the strictured urethra by some form of knife—is, perhaps, all things considered, the most universally employed in such cases. Now there are two kinds of urethrotomy—external urethrotomy and internal urethrotomy: the external applied through an incision commencing from the perineum; the internal by means of some instrument introduced and applied within the urethra. Internal urethrotomy, however, is a large subject, requiring much considera- tion, and will occupy a lecture by itself. Accordingly I Avill go on to speak of ex- ternal urethrotomy and of other mechani- cal applications alluded to. External urethrotomy has been per- formed in various Avays, and has been recognised as a surgical operation during more than 200 years. Our oAvn Wise- man in the 17th century describes his method: the French surgeons of the same period have recorded theirs. The opera- tions now sometimes performed are two in number; one for division of a non- dilatable stricture through which an in- strument can be passed, and known as Syme's operation : the other an operation already referred to, adopted only when no instrument can be passed, for the purpose of uniting the urethra before the stricture to the urethra behind, and so establishing continuity of the canal; this is known as ' perineal section.' In performing it, the 2 3G DISEASES OF THE URINARY ORGANS. patient should be secured in the position for lithotomy, facing a good light; a solid metal sound is passed down to the stric- ture, where, of course, it stops. An in- cision is then made from the external surface, usually the anterior part of the perineum, upon the point of the staff, so as to expose it freely, and with it, the an- terior face of the stricture. It is through the minute orifice now found there, that you will endeavour to dissect by means of fine probes, and lay open the narroAved channel—generally not very long—until you reach the healthy urethra behind the stricture, and so restore con- tinuity of the channel through- out. This being fairly done, a full-sized gum catheter is tied in for two or three days, after which it is Avithdrawn, and a bougie is to be simply passed every two or three days, and the wound en- jf couraged to heal. Mr. Wheel- // house, of Leeds, has designed I and employed a special staff J for this operation, which I ,7 cannot here describe, but *^ which facilitates the pro- FlG-19- ceeding, and should always Sv.m8's staff r j ^ J for external be used, as these cases are division. sometimes very difficult to deal with, and are always more or less so, if the operation is necessary. In Syme's operation, a small grooved staff with a shoulder to rest against the face of the stricture (see Fig. 19) is passed into the bladder, incision made in the median line of the perineum, and the stricture freely divided on the staff. There should be a small channel through the staff from the groove, to permit a little urine to pass and show that the instru- ment has reached the bladder. When the operation is completed the staff is withdrawn, and a flexible catheter of full size is passed through the entire urethra into the bladder and kept there two or three days. It is then removed and a large bougie is to be passed every few days. This proceeding is seldom adopted now, although much done twelve or fifteen years ago ; but other means have superseded it. It is usual now to reserve it chiefly for cases in which there are old or large perineal fistula? Avhich may be cxa advantageously laid open at the same time. We next come to the mode by ' rup- ture ; ' and here I will shoAV you an in- strument which bears the | name of Mr. Holt, of the Westminster Hospital. He has brought the instru- ment into notice, and the mode of using it is his own. It Avas invented by M. Perreve, of Paris, about thirty years ago (Fig. 20). He used it mainly, but not altogether, for simple dila- tation ; Mr. Holt uses it otherAvise. He carries it through the stricture, and then, instead of passing at different times a succession of tubes of gradually in- creasing calibre, he takes the largest tube at once, and forces it down the urethra along the central guide, so as at one stroke to split everything that happens to obstruct the passage of the instrument. Mr. Holt does not tie in an instrument afterAvards. When the operation was first intro- duced, I Avas strongly re- pelled by the violence of the proceeding; but I exa- mined some of Mr. Holt's cases Avith him at the West- minster Hospital — now some twenty years ago— and Avas surprised to find that so rough a procedure was not commonly attend- ed Avith any great pain or severe constitutional dis- turbance. Hence I tried the plan, and used it occa- sionally for a urethra which had some two or three contracted points, so as to deal with them all Avith Perreve's dilator, certainty. Further expe- from his trea- rience has, however, shown Pans, that jt ia fry nQ meang without risk, and that the relief afforded by it is often of very brief duration, an objection of a very serious character against any proceeding which, if necessary at all, is so only in the most intractable examples of the Fig. 20. tise. 1857. STRICTURE OF THE URETHRA. 37 disease. The impossibility also of ap- plying the distending force to any portion of the urethra in particular, since the same amount of distention affects equally the Avhole Avhen it is used, suggested to me some years ago a different method— namely, one Avhich I have called ' over- distending ' the stricture. It is simply this. Here are two blades, as in the in- strument used by Mr. Holt, but these two blades can be separated for a considerable interval at one point only, and as slowly or as quickly as you please. I have not used it of late years, but Avhen I did use it, the power, Avhether applied rapidly or sloAvly, was exerted only on that part of the canal in Avhich the stricture was situ- ated. For there is this fact to be noted : I Avish you to remember that the bulbous part of the urethra—the usual position of stricture—is also the most distensible part in the natural condition of the canal. Supposing the external meatus to be about No. 12 (English scale) in calibre, the bulbous urethra admits at least No. 20 or 24. Hence it follows that no kind of dilatation or operation Avhich is limited in extent by the size of the external meatus, more than half restores to its natural size the urethra Avhich has a stric- ture at the bulb. It is on this account that I distend the contracted part to at least this, or even to a larger size, or rup- ture it if I please, by means of the instru- ment in question. I have used it many times, and it has been certainly attended AA'ith fair results. It may be suitable especially for a patient who has a strong objection to a cutting operation. But let it be remarked, that this instrument is to be used only for strictures situated within the bulb. I have heard that it has been employed for those Avithin three inches of the meatus: it is a mistake to use it for such, which, as I said before, ought to be treated by complete division—that is, by internal urethrotomy. The operation Avith the distending instrument requires much more care in the performance than does the proceeding by rupture, Avhich requires neither skill nor caution Avhen the instrument has been properly placed. In performing the operation of rupture, if the tube is properly introduced, a single impulse of the hand forces the tube through ; and on that account it certainly presents a tempting facility in perform- ance to the operator. I am not at all certain, hoAvever, that it is an advantage to the patient that an operation should be so easily applicable by an inexperienced practitioner. The consequence has been, and not so very seldom, that this pro- ceeding has been performed, owing to such inexperience, on patients for whom no operation of any kind was ever neces- sary. But Avhat is much more important in regard of these methods by rupture and over-distention, is, that by neither of them is so long a period of freedom from recontraction to be anticipated as that which usually follows internal urethro- tomy, when Avell performed. No doubt the latter procedure is much more diffi- cult to accomplish, and, without doubt, it requires, like most important surgical operations, a practised hand. II. A few Avords before closing, on the strong proclivity to rigors Avhich occurs in connection with stricture in certain con- stitutions. Examples of this class are generally found among cases of old stand- ing disease, although there are some ex- ceptions to this general rule. Sometimes the attacks are due to recurrence of fever of malarious origin which the patient has previously caught in the tropics or else- Avhere ; and, occasionally, the attacks cease to be induced by instrumental treatment of the stricture, after a course of careful attention to diet and regimen. But for the most part, these cases are best treated by a cutting operation, which often occa- sions less disturbance to the system than a few attempts by simple dilatation. For it has fallen to my lot on several occasions to observe that a patient who may rarely be able to have an instrument passed of sufficient size to dilate, however gently, his stricture Avithout incurring an attack of rigors and fever soon afterwards, has his stricture completely divided without any constitutional disturbance Avhatever. An incomplete division may, on the other hand, arouse an attack; but let the in- cision include the Avhole of the diseased tissue, so that a large instrument can be passed with perfect freedom, and no sub- sequent attack occurs. The question of treatment for this class, no less than that for ' resilient' strictures, leads the way naturally to a study of internal urethro- tomy. The consideration of this I leave therefore to our next meeting, which we shall devote entirely to the subject. 38 DISEASES OF THE URINARY ORGANS. LECTURE VI. ON INTERNAL URETHROTOMY. Gentlemen,—During the last few months many cases of stricture of the urethra have come under our notice, of which the most severe and obstinate have been admitted into the wards. I have employed for several of these cases the operation of internal urethrotomy, because throughout my experience I have found nothing so efficient, so safe, and so certain. I by no means say any kind of urethrotomy. Anything short of complete division of the hardened tissue is not efficient. Over- distend these strictures, or tease them with dilatation in any fashion, and they are sometimes rendered more than ever un- manageable, while a prolonged consti- \ tutional disturbance of a severe kind, as j you have seen, follows the interference. For the operation of internal urethro- j •tomy, Ave have numerous instruments and systems to choose from : their name is legion. Modification after modification has been made of the earlier forms of urethrotome, both by instrument makers and by surgeons, with the view of accom- plishing more perfectly the original design, which is that of ability to divide easily, and more or less freely, the hardened tissue. Before considering these, I may state that the situation of a stricture is an important element in relation to the applicability of internal urethrotomy of any kind, and also as to its necessity as a mode of treatment. Thus :— 1. A stricture at or near the external meatus is always extremely undilatable, Avhile at the same time it may be divided with the greatest ease, precision, and safety. Fig. 21.—A small bistourie cachee. 2. A stricture existing in any part of the anterior three or four inches of the urethra partakes, also, more or less of the intractable quality named, and may be cut with almost as much facility and safety as those in the previous class. As a rule, it may be said, the nearer a stric- ture is situated to the orifice of the urethra, the more necessary it is to cut, and the safer it is to do so. 3. Strictures in the bulbous part of the urethra, which may be considered as generally ranging between four inches and five inches and a half from the ex- ternal meatus, are more amenable to dila- tation than those of the preceding classes. But when necessary to cut them, it is easy and quite safe to do so as a rule, although it is somewhat less so than to cut those in the preceding class; the difference being due, no doubt, to the larger amount of erectile tissue about the bulb, as compared with the anterior part of the urethra. Bleeding, therefore, may be more considerable, and other risks, such as they are, more liable to be en- countered. In treating this subject, let us first deal Avith the strictures situated at or near to the external meatus of the urethra. The best instrument for the purpose of dividing these, although a slender knife will ansAver very Avell, is perhaps the small bistourie cachee, which I hold in my hand (Fig. 21.) All that is necessary is to introduce the end of the instrument into the canal, about an inch or more, according to the extent of the narrowing, then to project the blade and draAV it outwards, dividing the obstruc- tion. Nothing can be more simple. By means of a screw, the blade is made to project to a small or to a large extent. It should be used so as to make a rather free incision, which is perfectly safe. This draAving, from a preparation, shows the condition in question. All strictures, Avhen laid open on examination after ON INTERNAL URETHROTOMY. 39 death, present the appearance of much larger calibre than really existed during life. (See Fig. 22.) For all strictures which are more deeply situated I prefer another proceed- ing, and having disposed of those in the urethra. meatus, I shall devote this lecture to the consideration of those which belong to the former category, and which, indeed, form the great bulk of the cases Avith which we have to do; Avhile they are certainly those which are also of the greatest importance. The instruments employed are, as I have already said, numerous and varied. And there are two distinct methods of than any other ; while Avith slight modifi- cations it has also been used by some surgeons in this country. The instrument of Civiale I have selected because it is the typical one of the other system—viz., that of dividing the stricture from behind forwards. The urethrotome of Maisonneuve consists of a slender guide or conductor in steel, the size and nearly the form of a No. 1 or 2 catheter, but grooved through- out its course. This is first introduced making the incision necessary in order to divide the stricture. This fact enables us to group all these instruments in two separate classes. I. The stricture may be cut from ' before backwards,' on a guide previously passed. II. Or a blade may be introduced through and beyond the stricture, which is then cut from ' behind forwards,' in which case a guide is unnecessary. I show you urethrotomes in great variety here, chiefly of French make, the operation having been largely practised in France long before it was employed here. Modifications innumerable of what Avere originally simple, perhaps we may say rude, instruments, have been made during the present century in that country, and more recently elseAvhere. Most of those known by the names of Stafford, Leroy d'Etiolles, Civiale, Amus- sat, Reybard, Ricord, Trelat, Charriere, Sedillot, Maisonneuve, Voillemier, and others, are before you; there is one also, a recent one, of Dr. Otis, Avhich, like Reybard's, distends the passage at the same time that the incision is made. I select two as types of the two different systems described of using a cutting instrument—the urethrotome of Maisonneuve and that of Civiale. I select the former instrument because it is not only a type of one which cuts from before backwards, but because it has been more largely and generally employed of late years, especially on the Continent, perhaps through the stricture into the bladder. Along this groove slides a blade of tri- angular form, the base of the triangle being attached to a long steel Avire stylet, while the two other sides of the triangle project considerably. This blade can be pushed, by means of a handle attached to the wire, through the whole course of the urethra. (See Fig. 23.) The apex of the triangle, which is the salient part, is blunt, and the lower side of the triangle only is sharp and will cut. In the act of Fig. 23.—The urethrotome of Maisonneuve. 40 DISEASES OF THE URINARY ORGANS. passing the blade, the healthy part of the urethra is protected from incision by the blunting of the apex (like the button of a foil in fencing), while the sharp side divides certain of the hardened tissues which it meets. Noav, my objection to this instrument is simple and distinct, and I do not hesitate to say is fatal to it in respect of its efficiency for a case of confirmed and indurated stricture, such, indeed, as con- stitutes that form of the disease Avhich most requires treatment by incision. It is an axiom accepted by most, if not by all, Avho have carefully observed the results of urethrotomy by any method, that if an incision of stricture is required at all, it is essential that the whole of the obstructing fibres should be divided. No one laid more stress on this doctrine than Syme of Edinburgh, after he had had a considerable experience of his method by external division. The cases of relapse after that operation, he had no doubt were chiefly those in which he had cut insuf- ficiently and left a few fibres undivided. The justice of this observation was verified repeatedly by myself then, and also since in my oAvn practice, with internal urethro- tomy. Noav, what happens with Maison- neuve's instrument? The blunt apex, which enables the blade to pass without injuring the healthy urethra, fails to cut the most elastic or yielding fibres of the stricture, which, by reason of their yield- ing character, permit the blade to pass through by stretching them. The blade incises, no doubt, the strongly marked or narrowest portion of the stricture, but all the obstructing tissue is not divided, especially that for some distance before and behind the maximum point of nar- rowing, and these uncut fibres Avill at no distant period of time show their presence and reproduce contraction. Further, by no manner of using the instrument can you control or regulate its power. It is a mechanical apparatus or machine, which just accomplishes a certain amount of action and no more. This alone is for me a serious ground of objection to any urethrotome. Now, suppose for an instant that it Avere possible for you to have the stricture before you open to your eyes and hands ; you certainly would take a little scalpel and employ it for each case according to its needs, intelligently dividing the ob- structing fibres as much as is necessary, and no more. But with a very little practice it is perfectly easy to do this without seeing the stricture—that is, to apply a little scalpel, dividing where you wish and not elsewhere, just as you divide the constricting fibres at the ring of a hernial sac. And I need scarcely say that this intelligent action of yours will produce something better than the work of a machine which any ignorant person can employ just as well as you. The difference in the two cases resembles that which exists between the music of an organ produced by a handle, and the music which results from the facile hand of a skilful performer. There is a question of no mean im- portance Avhich arises from the comparison of incision made by machinery with in- cision made by the intelligent hand. That is the real question in urethrotomy as presented in these two systems. And the instrument I now show you, which I ahvays use, and have operated with so many times in the Avards here, is the type of the method which affords the opportu- nity of making the incision according to the operator's will and judgment. It Is nothing more than a little knife with a long handle, and is used precisely as we use a scalpel anywhere else. Just as we should use a small knife in tenotomy, without the sense of vision, where it is not necessary, but guided by the sense of touch, so do I advise you to cut in ureth- rotomy. I carry the parallel one step further, and remind you, that just as it is essential in tenotomy to divide completely the tendon, and also any little minor band of constricting tissue which opposes the perfectly free play of the joint, so is it essential to make the same complete divi- sion also in urethrotomy. The ultimate success in either operation depends on attention to these particulars. The instrument Avhich I hold in my hand, and to which I have been referring, is a modification of the urethrotome of Civiale, made shorter for me,with a different handle and a much smaller bulb than it is customary to make in Paris. The shaft of this is about the size of No.. 3, English scale, with an oblong bulb at the end not larger than No. 5 or No. 6. Within this is a little blade which, by a clever contrivance, the operator can make to issue at Avill, as much or as little as he desires, and which he can also sheath instantly at his pleasure. The bulbous ON INTERNAL URETHROTOMY. 41 end gives him the poAver of exploring the urethra at the time of the operation, and of determining precisely Avhere and what he ought to divide (Fig. 24). The bulb is to be introduced, say fully half or three-quarters of an inch be- yond the maximum point of narrowing felt, the blade is then to be projected there, and drawn steadily through the whole of the constricted portion outwards towards the meatus, in which direction the incision is sure to be certain and complete. Now I at once anticipate an objection Fig. 2-i.—Author's urethrotome modified from that of Civiale. which I expect you all to raise. I expect you instantly to exclaim, ' Why, if an in- strument so large as No. 6 can be passed through the stricture, should there be any occasion to cut at all ? Surely it is for small strictures, through Avhich only the finest instruments can be passed, that an operation is necessary, and for such stric- tures this instrument is obviously unfitted by its size ! ' Such criticism is quite natural at the first glance, and from those Avho have not learned by considerable ex- perience certain important facts about confirmed stricture. I reply, first, that the narroivness of a stricture alone, however extreme, does by no means render a cutting operation always necessary. Some of the narrowest strictures I have ever seen have been A'ery successfully and rapidly treated by simple dilatation; although this is admitted to be a rare occurrence. Secondly, the quality Avhich makes incision of a stricture necessary is, as I have previously shown, ' resiliency '—that property Avhich leads it to contract again rapidly after any dilatation. This quality affects strictures which -will admit No. 5, No. 6, or No. 7 quite as frequently as narrower contractions. Thirdly, supposing it is necessary to cut a stricture which is narrow and only admits No. ^ or No. 1, there is never any difficulty in dilating it temporarily up to No. 6 for the purpose of admitting the urethrotome which I recommend. All you have to do is to keep the patient in his room from three to five days with a small soft gum catheter tied in, which produces scarcely any inconve- nience ; and thus by ' continuous dilata- tion ' you can always bring the narroAvest and most resilient stricture to the re- quired size to admit the urethrotome. Having done so, you are able to perform the operation in the best possible circum- stances. And the few quiet days spent in preparation are advantageous rather than otherAvise; the result furthermore being that you can now make an incision in the manner I have described, directed by your intelligence and adapted to the par- ticular case. For safety to the patient and excellence in result, both in regard of his present and future condition, I greatly prefer the operation I have described to any other method I have ever seen. I Avill now briefly detail the stages of the proceeding : First: The situation of the stricture or strictures is, of course, previously as- certained by the necessary examination— that is, their distance from the external meatus. Secondly : It has been ensured, either by tying-in a catheter or otherwise, that at the time fixed for the operation the stricture is sufficiently patent to admit the bulb of the urethrotome to pass through it. The stricture should just admit about No. 6 (English scale). Having given the patient some ether, I withdraw the in- lying catheter, Avhich in almost every case has been necessarily present for a feAV days, and at once pass carefully the bulb of the urethrotome through the stricture, which usually requires a little gentle pressure and management; after which the little bulb is felt free and movable in the urethra on the further side. In this situation, and at least half an inch be- yond, or on the bladder-side of the stric- ture, you make the blade project to the 42 DISEASES OF THE URINARY ORGANS. requisite extent by means of the simple mechanism in the handle which I show you, and directing the edge to the floor of the urethra, you press it firmly there, and draw it boldly outwards, as if you would make an incision, say an inch and a half or two inches in length, so as to divide all the thickened tissues which constitute the stricture. You feel them sometimes offer- ing much resistance. Take my word for it, you need not fear freedom of incision. I never saw any serious harm produced by it, although I have seen less success resulting than I desired where I have not sufficiently divided the stricture, as may have been the case in some of my earlier experiences, and have so left a fibre or tAvo uncut. But I have never had occa- sion to regret a free and complete division. Next, you introduce a No. 13 plated sound, not conical, Avhich should go quite easily into the bladder, and not be in the least degree ' held' in Avithdrawing it: keep along the upper portion of the canal, and the point of the instrument will not get into the incision. If it is ' grasped' or ' held' a portion of the stric- ture remains undivided, and should be at once cut; the same urethrotome, or another with a larger bulb, being intro- duced for the purpose. After which No. 13, 14, or 15 should pass Avith perfect facility. Or, if any other point of nar- rowing be discovered, after the principal one has been cut, it also should be divided. The operator should be provided with a series of metallic exploring instruments, with terminal olive-shaped points, ranging from a small size up to No. 14, so as to be quite certain of the whole canal from the meatus downwards (see page 19). All being completed, you should take a No. 11 or 12 well-curved gum catheter, and pass it into the bladder, tying it there in order to retain it forty-eight hours. It is best to introduce it Avell-curved or upon a stylet in order to avoid the wound, which otherAvise the point of the instru- ment might enter, occasioning you some embarrassment. Of course the stylet, if used, is withdrawn immediately after- wards. Now, as to results: in the operations I have done, about three hundred in num- ber, I have rarely seen any bleeding worth naming—sometimes only a few drops appear; once, and once only, it was severe, although it ceased ultimately, and all went on well; this was in a case I have recently met with. On two occa- sions some extravasation of urine occurred when the catheter became displaced—an ample reason for always employing one— and once only an abscess has followed; but you yourselves can also form a judg- ment, to some extent, of these questions, since you must have seen at least twenty cases of this operation in the Avards during the last tAvelve months. Sometimes there may be a considerable amount of fever, but very seldom, and, still more rarely, cystitis; much depends, I need not say, on the Avay in which the thing is done. Twice only has it been followed by fatal results. The first death occurred in the case of a man in one of my wards here, for whom I performed the operation as a last resource, and the autopsy showed such an advanced stage of disorganisation in the ureters and kidneys, that I am not surprised at the result. The second case, in private, was a very remarkable one, in which death took place from embolism of the heart and great vessels within ten days after the operation, no very obvious sign of local disturbance elsewhere having manifested itself. If anything has sur- prised me, it is the extreme safety of the operation, for my earliest belief about it was that it was by no means free from risk, and I hesitated to employ it except in very urgent cases. Now, Avith my present experience, I never hesitate on the score of danger, for there is almost absolutely none ; of course I speak only of that kind of urethrotomy which I employ, and have described in this and alluded to in the preceding lecture. It is not uncommon, although quite exceptional, to have an attack of fever after the withdraAval of the inlying cathe- ter forty-eight hours after the operation. The first time the patient passes his urine, a drop perhaps enters what remains of the incision, and he has a rigor in an hour or tAvo's time, and that is all. To avoid this as much as possible I always adopt the following plan:—When removing the catheter, forty-eight hours after the opera- tion, I Avithdraw all the urine, order the patient a hot hip-bath for fifteen minutes, and send him back to bed to be Avell covered up, with instructions not to pass water until he feels a manifest desire. This Avill probably not occur until six hours after the instrument was withdraAvn. He then stands up, makes a full stream, is generally very much astonished at its HYPERTROPHY OF THE PROSTATE. 43 volume and the ease with which it Aoavs, and goes back to bed as before for the day. Following these precautions, you may hope he will escape the rigor ; but if not, you know, at all events, that there is no risk, and no ground for anxiety. Some- times, but this is quite exceptional, the fever is someAvhat more severe and pro- longed. The subsequent treatment may be briefly sketched. On the fourth or fifth day after the operation, pass a conical French bougie with a large bulb, so as not to open the little wound. If it does not pass easily and encounters any ob- struction, withdraw, and pass a well-curved metal instrument, wrhich is not conical; the former, hoAvever, usually suffices. Re- peat the proceeding in three or four days, and No. 13 or 14 mostly pass with con- siderable ease. After this, pass the in- struments once a week, and the patient will do so himself at increasing intervals, ultimately arriving at, say, once a month. This operation gives, I believe, more lasting results than any other. You have seen me perform it for cases Avhich have experienced every other known treatment, and in which the stricture had returned as badly as ever. For most of these I think it is the best treatment known. I do not claim for it the power to remove organic contraction. Such a result is im- possible. The treatment has yet to be devised which will remove absolutely, and for ever, the occurrence of recontraction in a patient once the victim of an organic stricture. Thus, in some instances I have repeated this operation for the same patient, when eight or ten years have elapsed, and Avith the best result: and I have had some cases in which I have done it a third time, after a second long interval. I should not hesitate to repeat it as often as might be necessary to remove the serious troubles which an obstinately narroAV passage pro- duces. Briefly let me, at the close of this subject, remind you that, in view of any operation, and indeed in all cases of im- peded micturition, attention to the general health often aids in a considerable degree to mitigate the local troubles. Do not overlook the state of the digestion. If this is unsatisfactory, if the bowels are unduly constipated, the troubles of the bladder and urethra will be much in- creased; and frequently it happens that a mild mercurial, followed by a dose of Glauber's salts, or of Friedrichshall Avater, in the morning, gently unloads the liver and bowels, and greatly relieves the most distressing symptoms. Then take care of what your patient eats, and more especially let his alcoholic drinks, if any, be taken in moderate quantity, and be of the mildest kind. There is only one other Avord to say. I do not seek to make you partisans of any single method. You hear one surgeon say, ' I ahvays follow such and such a method: there is nothing to equal it.' Or another, that he always adopts the proceeding of M. Ricord; and a third that of M. Maisonneuve, and so on. There has been great activity among in- ventors of instruments of all kinds, especially in Paris, and you may see from several of them very excellent results. Do not limit your selection to any method Avhich I or any other may recommend. If you have much to do with stricture, or Avith such complaints, be assured you will Avant all the resources Avithin your reach. Consider them carefully, and select for each individual case that method which appears in your judgment to be best adapted for it. Above all things, be patient, unsparing of time, use a light and cautious hand ; and then, Avhatever instru- ment or method you employ—provided you have confidence and some experience in the using it—it will probably be the best not only for you but for your patient. LECTURE VII. HYPERTROPHY OF THE PROSTATE AND ITS CONSEQUENCES. Gentlemen,—We may pass from the sub- ject of stricture to another very important complaint, and one of common occurrence —viz., hypertrophy of the prostate. It is one which affecs a large number of elderly people, and thus the practitioner 44 DISEASES OF THE URINARY ORGANS. is almost certain to come in contact with it pretty frequently. Hence the necessity for our studying these cases closely, and the more so because we do not see them very often in the hospital beds, many of them being treated as out-patients. I shall commence Avith two or three important generalisations for you in rela- tion to impeded or frequent micturition. Impeded or frequent micturition in an otherwise healthy young man, say from eighteen to twenty-five yeais of age, is more likely to be due to some inflammatory action affecting either the urethra or bladder, than to any other cause. Impeded or frequent micturition in a middle-aged man, say from twenty-five to fifty-five, may be due to the same cause, but is also likely to be due to stricture of the urethra. Impeded or frequent micturition in an elderly man, say at and after fifty-six years, is very often due to hypertrophy of the prostate, and consequent inability to empty the bladder by his oavii efforts. You Avill very rarely find much im- pediment to micturition produced by stric- ture before tAventy-five years; you will never find it due to hypertrophied pros- tate before fifty-five years. Now, I wish to guard you against con- founding this last-named condition, hyper- trophy of the prostate, with enlargement of the organ from any other cause. The enlargement which Ave call hypertrophy is quite ' sui generis.' No other organ of the body is similarly affected. It has no relation to, or affinity with, inflammatory deposits, such as we may observe in the swollen tonsil, or in lymphatic glands. The increase in bulk is due to a neAV for- mation of gland-tissue, either throughout the organ or in isolated portions. I knoAV nothing analogous with it, except the so- called fibroid tumours of the uterus, Avhich consist mainly of an augmented production of the constituent elements of that organ. So that the new product in the prostate is not a neAv formation like cancer or epithelioma, and is, in fact, not a c morbid ' growth at all, although it in- duces diseased conditions of the bladder as a result of the mechanical obstruction occasioned by its presence. I make these remarks because I so often observe con- fusion of ideas respecting hypertrophied prostate. FeAv people appear to know that there is nothing whatever of relation between it and the enlargement resulting from inflammatory deposit, the latter being essentially a phenomenon occurring in the first half of human life, while, as I haA*e already said, the former belongs solely to the latter third. It was formerly stated by Sir Ben- jamin Brodie, that' when the hair becomes grey and scanty .... the prostate gland usually, I might perhaps say in- variably, becomes increased in size; ' and that is the impression which a large portion of the profession has generally entertained. Such was certainly the common belief when I first began to make some special researches in reference to this matter, now some tAventy-five years ago. I was then at the pains to examine after death all the bodies of male patients over fifty- five years of age who died in the Maryle- bone Infirmary ; and afterwards, in Green- wich Hospital, the inquiry was pursued by Dr. Messer and myself. I took care to dissect each prostate very carefully, and I discovered that so far from the pre- sence of prostatic enlargement being the rule, this condition was quite exceptional. I examined about two hundred cases—not picked cases, but all who died consecu- tively within a certain period, and I found that about one in three exhibited after death some enlargement of the prostate. But do not suppose that anything like a large proportion of those manifested any signs of this condition during life; for only about one in seven had any symptoms of obstruction to the floAv of urine, and these were slight. So that you see it is not to more than one in (let me say) fifteen or tAventy men who live beyond fifty-five years of age Avho can be expected to re- quire relief for this affection. The number thus estimated is, no doubt, con- siderable. If you suppose that one man in every twenty who are approaching sixty years of age has symptoms of en- larged prostate, you will see at once how often, if you have anything like a large practice, you may be called to advise these cases. We will now consider one or two anatomical points connected with enlarged prostate. This organ is, as you know, composed of two lobes and a median portion. Noav, the part affected Avith hypertrophy very much influences the results in relation to the function of micturition. It is not necessary that there should be much enlargement of the pro- state in order to produce very severe sym- HYPERTROPHY OJ ptoms. On the other hand, you may have a very large prostate, and may have almost no symptoms. Almost the largest I ever saw, as big as a small cocoa-nut, produced very little obstruction to the Aoav of the urine. On the other hand, the largest prostate I have yet seen had produced absolute retention for about five years before the age of sixty-three, when the Fig. 25.—Diagram of healthy prostate, a, median portion; b and c, right and left lobes. patient died. Thus, if the median portion of the prostate is only slightly enlarged, there may be complete retention. Let this diagram, fig. 25, represent the two lobes, and the median portion. K there is a small nipple-like projection at the median portion just filling the internal Fig. 26.—Diagram representing a tumour filling" neck of the bladder. The line which the catheter may take on either side of it. orifice of the urethra, that may be quite sufficient to prevent every drop of urine passing by the natural efforts. Sometimes a considerable eminence arises here, shown in the diagram fig. 26. Sometimes there is a considerable enlargement on one side, THE PROSTATE. 45 so that the passage is circuitous ; and you will sometimes find the catheter carried to the right or left, according as the prostate Fig. 27.—Section of bladder and prostate ; the former hypertrophied, the latter forming prominent tumours within the bladder. may be large on one side or the other. I show you several examples: two are de- picted at figs. 27 and 28. You will there- Fig. 28.—Section of bladder and prostate, show- ing marked but not great enlargement of lateral lobes and median portion. fore remember that if on examining a patient you find a very large prostate, it does not necessarily folloAV that he should 46 DISEASES OF THE URINARY ORGANS. have great difficulty in passing his Avater ; and, on the other hand, although you may be unable to discover enlargement by rectal examination or otherwise, you may not therefore conclude that all his troubles —and they may be considerable—are not entirely due to this complaint. I will now say a word as to the age of the patients. I never saw an enlarged pro- state (I mean, of course, hypertrophy, not enlargement from inflammation and other causes) until after the age of fifty-four; and if I have not seen such a case, you may say that it never or most rarely occurs. The usual time at which it begins to show itself is from fifty-seven to sixty. If a man has it at all he will have it generally by sixty. If he is free from hypertrophy Avhen over sixty-five or seventy, he may still have it, but in a less degree ; but even this is a very rare oc- currence. I have examined the bodies of men at ninety, without the slightest en- largement. You see, then, that it is by no means necessarily connected with ad- vanced age. The man who escapes it at sixty-five will be not unlikely to escape it altogether, or nearly so. I speak next of the symptoms. An elderly man comes to you and says that recently his water has not passed so easily ; that it has issued in a small and feeble stream, and that he cannot propel it more quickly by his efforts to do so ; that he requires to micturate a little more frequently, especially in the morning— probably two or three times while he is dressing, after which it becomes less troublesome; but during the night it is rather more frequent than during the day. Then if he does not say much about pain —which might naturally excite a sus- picion of calculus, or some other complaint —you Avill say, ' This is probably a case of enlarged prostate.' You do not ne- cessarily proceed at once to pass the catheter, but you will ask the four ques- tions already referred to. You will ask how frequently he makes water, and you Avill observe whether the frequency is greater at night than by day, the reverse being usually the rule in stone in the bladder. I cannot tell you Avhy, but it very often happens that patients with hy- pertrophied prostate pass as large a quantity of urine during the eight hours of night as during the sixteen hours of day, hence the disturbed rest and sleep of Avhich they complain. You will also further inquire whether the Avater ever passes Avithout the patient's knowledge, or without his Avilling it. In many advanced cases, you will find that some urine passes during a violent effort, such as coughing, or Avhen he is unconscious at night, during sleep. If so, the case is probably one of rather long standing. Next, you will inquire for pain, and, if any, whether before, during, or after the passing of water; if before, hyper- trophied prostate is probably the cause. If the pain is after, you may suspect calculus, which comes into contact with the mucous membrane of the bladder when the water has been expelled; whereas, if a distended bladder is present such as fre- quently accompanies enlarged prostate, the pain will occur during distention, and becomes less as the urine passes off. Then you inquire about the character of the urine, whether it is clear or cloudy. In most instances at an early stage it is clear. In a great number of cases of prostatic enlargement, although the blad- der has not been emptied for months or a year or two, the water is still clear. On the other hand, if the case is one of long standing, the water will certainly be cloudy. And making this inquiry will lead you to ask about the characters of the stream itself. Usually it flows in a feeble irregular manner, rather falling directly downwards than flowing in a current, and thus differing from the stream in cases of stricture. In stric- ture the stream is often propelled ex- ceedingly well, although it is no larger than a thread; and so long as there is a stream, the patient can act upon it by will, so as to make it stronger; whereas, strain as he may, in prostatic enlarge- ment, he often cannot influence the stream, except for the worse. It may happen, from the median portion of the prostate being forced by straining into the passage, that the more the patient strains the less well he voids his urine. Generally speak- ing, the expelling apparatus at the neck of the bladder is involved in the enlarged prostate, and ceases to act; so that with all his straining he cannot make much difference, and the stream is not propelled with any force. You may ask the patient to let you see him pass water, if he can, for that will help your judgment mate- rially. Then you ask the fourth question : ' Do you pass blood ? ' Usually, in the HYPERTROPHY OF THE PROSTATE. 47 early stages, the reply will be in the nega- tive, although a little may appear after much exercise, so far suggesting the pre- sence of stone; but haemorrhage is by no means usual. Then you complete your diagnosis by mechanical means, and for this purpose a catheter is first to be used. You should invariably make the patient pass Avater be- fore the instrument is passed, because your object is not merely to ascertain whether enlarged prostate exists, but, what is much more important, namely, how far it is a barrier to the exit of urine from the bladder. The important fact for him and for you is not the exact size, condition, or shape of the prostate, but to Avhat extent it hinders the exit of urine. And it is the quantity of urine invariably left be- hind which Avill chiefly determine the future treatment. But the patient often objects to the use of the instrument, erroneously thinking that the frequency of his calls to pass water indicate that he is already passing too much urine, and not the use of the catheter to withdraw still more! Now, with regard to the employment of the instrument for patients with the symptoms described, whatever they may think, you are not to forget that undue frequency of passing water, and still more the passing of it involuntarily, indicate the necessity for the catheter. First, in relation to frequency : it is not uncommon for the practitioner to be misled by a fact often associated Avith it—viz., that the daily quantity of urine passed is quite equal, if not more than equal, to the healthy average. I have often heard this assigned as a sufficient reason for not using a catheter in these cases. It is urged, with a certain show of plausibility, that ' a suffi- cient quantity being passed every day, how can there be habitually retained urine in the bladder ? ' A moment's thought will prove that the question of habitual in- ability to empty the bladder is not in the slightest degree affected by an observa- tion of the quantity of urine passed, this indicating solely the activity or the re- verse of the excretory function—that is, the action of the kidneys. The reservoir —in other words, the bladder—may be always half-filled, or even more, with urine, Avhenever the act of micturition ceases; but it none the less serves to re- ceive and to transmit the daily two or three pints. The reservoir is diminished in capacity, just so much as equals the space occupied by the constantly retained urine, and frequent micturition is the necessary consequence; that is all. In short, the amplitude of the quantity passed daily is not to be regarded as affording the slightest evidence in relation to the in- quiry, ' Is the bladder emptied or not by its OAvn natural efforts ? ' Secondly, in relation to involuntary micturition, so often miscalled ' incon- tinence ; ' it is really remarkable how common are the errors, not merely of patients, but of practitioners on this point. They are apt to be misled by the fact that the patient insists,' I do not make too little Avater; I am making water too frequently, and too much of it, and even against my will, and therefore my bladder must be empty. Tell me hoAv to retain my water, and I shall be much obliged to you. Don't think of drawing it off.' It is surprising how that sometimes influences the practitioner. Nevertheless, these are the very circumstances in which you should pass the catheter and ascertain the real condition of the organ. Always bear this in mind (and I wish, figuratively speaking, to render that sen- tence in the largest capitals), that in- voluntary MICTURITION INDICATES RETEN- TION, AND NOT INCONTINENCE. There are a few exceptions to the rule, but very few. Most of the mistakes that are made on this point arise from the use, or, as I shall show you, the abuse, of the word ' incontinence,' which means, of course, that the bladder is empty; and certainly, when the bladder cannot hold its contents, its condition is rightly de- scribed by the word incontinence. Now, that happens only in very uncommon, but well-defined circumstances, such as in some cases of cerebral or cerebro-spinal paralysis, and in rare injuries to the neck of the bladder; and in these the urine runs off as fast as it comes from the ureters, the bladder having ceased to act as a reservoir. You see this one external physical sign is the same in these cases and in those in Avhich the bladder is over- distended with urine—that is, there is urine dribbling off by the urethra. But mark how totally different are the two conditions in question : in one the bladder is full, in the other the bladder is empty. Whenever, then, you meet Avith this in- voluntary floAV of urine miscalled ' incon- tinence,' do not confound it Avith the con- 48 DISEASES OF THE URINARY ORGAN: dition in which the bladder is empty. Rely upon it the bladder is full, and the only Avay of relieving the patient is by the use of the catheter. I lay great stress upon this, because I have seen liA-es sacri- ficed to a forgetfulness of this point. I have made post-mortem examinations of persons who have died solely from the effects of undiscovered retention, the existence of this fatal condition not having been suspected during life, because the urine constantly passed off, as it Avas sup- posed, ' so freely.' Noav, Ave know that our views of things and our consequent acts, are very much determined by the manner in which we use and apply words respecting them, and it is impossible to be too clear and defined in all our language, especially in that which relates to pathological conditions and surgical practice. I cannot express to you how strong my sense is of the impor- tance of this matter; hence I have made it my constant business to point out the common misuse of terms in connection with this subject. First, then, the term incontinence, which means the bladder is empty, or ' cannot contain,' should never be employed by you to denote the phenomenon that the patient's urine flows involuntarily ; for, as we have seen, in that condition the bladder is generally full. It is better to speak of it as 'involuntary micturition,' Avithout reference to the cause, and Avhen this is found to be distended bladder, to use the term ' overflow.' Then, remembering always my maxim, that ' involuntary mic- turition indicates mostly retention, not incontinence,' you will never make the fatal blunder I have spoken of, and which I assert to be so common. This, too, assimilates our usage very nearly to that of French surgeons. The French, with their more logical use of language, speak of the bladder as ' engorged ' and ' over- flowing,' but never as ' incontinent,' except to denote that rare condition in which the ^ Fig. 29.—The French coudee catheter. bladder is always perfectly empty. I have, therefore long been in the habit of denoting a bladder Avhich is full, but allows surplus urine to run off little by little against the will of the patient, as an ' engorged' bladder, and the phenomenon thus de- scribed as ' overflow ;' and I hope you Avill do so too. This brings us, by the Avay, to another common instance of the misapplication of terms. In this country, the condition of the organ just alluded to is often called ' paralysis' of the bladder, and the un- fortunate word leads to mistakes in prac- tice. The bladder is rarely paralysed. I know nothing of it except as an effect of spinal or cerebral changes. The bladder is never by itself the subject of paralysis, meaning, of course, an affection of the nerves, either central or peripheral. It may be unable to expel its contents, be- cause there is mechanical obstruction, as enlarged prostate, stricture, or impacted stone, or because the muscles have lost their power of contracting from long over- distension, a condition more properly to be spoken of as ' atony.' But in none of these cases i3 the inability due to im- paired nervous supply, and consequently the use of the term ' paralysis' is umvar- ranted and misleading. The condition to which that term is rightly applied will be considered at some subsequent meeting. [Vide Lecture XXII.] After this digression, Avhich its im- portance must excuse, Ave shall now con- sider the physical diagnosis of hyper- trophied prostate. Immediately before commencing, the patient is to pass urine to the extent of his ability, and as soon as he has finished, introduce a flexible catheter; if an English gum let it be Avell curved, and about 8 or 9 in size. Better still is the French coudee catheter, say about 14 to 16 of that scale (see Fig. 29). In using the last-named instrument let it be passed in a downward direction (the patient being upright) for the first half of its course, gradually descending to the horizontal line as it is about to enter the bladder. If you use an English gum catheter, remove the stylet, and keep the shaft, in passing it, well back in the groin, so as to maintain the curve. In either case, as soon as you have arrived at the bladder, carefully empty it, and note the quantity Avithdrawn. It may vary greatly, HYPERTROPHY OF THE PROSTATE. 49 from an ounce up to almost anything you please. I have drawn off six pints, but that is a very large amount. You may find commonly from six to twenty ounces. To this urine, Avhich you have removed by instrument, and which the patient could not pass by his oAvn efforts, I apply the term ' residual urine,' and shall thus speak of it hereafter. Next, the patient lying on his back, you may place your finger in the rectum, and examine the size of the prostate, for any deviation from its natural form and size, and if the latter is augmented, Avhether the enlargement is more on the right or the left side. Of course you do this as gently as you can. The finger should be covered with grease and very sloAvly introduced; or you may produce considerable and unnecessary pain. Make pressure on the prostate at different points, noting if it is uniform in consistency, or more tender in one spot than in another. The position described is preferable to any other, because you can make gentle pressure with the unemployed hand above the pubes, and so bring the bladder and prostate near the finger in the rectum, a material assistance sometimes in your en- deavour to ascertain their condition. Such are the inquiries which it is desirable to pursue, and beyond these it is not usual or desirable to carry your investigation. We now come to the Treatment. The Medicinal Treatment of hypertrophied prostate may be dismissed in a few Avords. Medicine is poAverless to diminish the hypertrophy. There may often be tem- porary enlargement from congestion ; and that you can diminish by treatment. But true hypertrophy cannot be diminished by any known means. Numerous agents haA'e been employed, both internally and as local applications; for both of which, as might be supposed, preparations of iodine and of mercury have been particu- larly vaunted. And, notwithstanding all that has been claimed for such agents in certain quarters, I assure you with regret, but with the most complete confidence, that neither iodine nor mercury does anything but mischief, hoAvever employed. Besides these, other remedies, as hemlock, hydro- chlorate of ammonia, liquor potassae, &c, have been tried. Nevertheless, I have simply to say that, for the present, we know no means of checking the progress of hypertrophic enlargement. Then, again, the effect of pressure has formerly been regarded as of some value. It has been applied in various Avays; perhaps in no form better than by water- pressure through the agency of a syringe, exerting expansive force, within an india- rubber tube previously placed in the pro- static urethra—a method tried by myself some five and twenty years ago, but ultimately laid aside as producing irrita- tion without any sensible improvement. I just allude to this fact, as I regret to observe that a recent attempt to revive the practice has been made; especially as there is not the slightest foundation for hoping to attain any advantage, at all events for the patient, by that process. On the other hand, it is in our poAver to render the subject of hypertrophied prostate most valuable service : so much may be done to palliate the distressing results of his malady. They arise from mechanical obstruction to the outflow of urine, and the remedy therefore consists chiefly in the use of mechanical appliances. The first object of treatment is to relieve the partial retention of urine by the catheter. There are two causes which produce this retention of a certain portion of urine, and Avhich no efforts on the part of the patient enable him to pass; and these I shall ask you to consider. The first is, as you know, the obstruction of the enlarged prostate itself at the neck of the bladder. But there is, moreover, an inability of the muscular coats of the bladder to contract and expel its contents, and it happens thus :—In order to over- come an obstacle to the outflow of urine the muscular fibres are greatly increased, and hypertrophy of the vesical coat results to a large extent, just as the walls of the heart thicken when obstruction exists in one of its main outlets. The thickened bladder is much less distensible than the bladder of normal character, and the organ is often equally disqualified for retaining much urine or for expelling it entirely; the cavity of the bladder being diminished, and its function as a reservoir impaired, in part by the protrusion of enlarged prostate into the interior, and in part by the rigidity of the coats, as above ex- plained. It is in such cases that the habitual use of the catheter is necessary. Often, as long as the patient lives, he will withdraw more or less of the urine, some- times all of it, by the catheter. And such a patient may continue to do this for many years, and at the same time remain 50 DISEASES OF THE URINARY ORGANS. actively engaged in the business of life. And it is by no means certain, if he is Avell taken care of, that his days are much, if at all, shortened as a consequence. One thing is essential, as in all instances where a daily catheterism is necessary—namely, that the instrument employed, and the mode of using it, should be those which effect the object with the minimum of trouble and irritation. The more fre- quently it is necessary to introduce the catheter, the more essential it is that the easiest manner of doing it should be ascer- tained and followed. In almost all cases—although an occa- sional exception appears in which a silver instrument is preferable—a soft flexible catheter achieves its object in the best curved to its very point. The following is an excellent plan for treating the English Fig. 31.—A catheter mounted for use on an over- curved stylet. gum-elastic instrument so as to prepare it for successful action when it is wanted :— manner. And the most generally suc- cessful, and the most easy, is the French coudee catheter. Its turned-up point passes over whatever eminence is present at the neck of the bladder more readily than any other instrument, as a rule. In some cases the English gum catheter compares with it advantageously, when well curved and properly managed; but some preparation of the instrument is neces- sary to elicit its best qualities. The instrument-maker generally curves the catheter pretty much in this way (see Fig. 30): the point straight and not well curved—the worst form in which a catheter can be placed for use. For the purpose of passing easily over a prostatic enlargement, a catheter ought to be well Let it be mounted on a strong iron stylet, greatly over-curved (see Fig. 31), for a month or so before it is wanted :— I may say here, that if you require simply an inflexible instrument, a silver catheter should, as a rule, be selected—not an elastic catheter Avith a stylet in it. To return: your object is to carry the in- strument easily and safely over an ob- struction formed by the enlarged prostate: and as the heat of the urethra always relaxes the curve of a flexible instrument, in its progress towards the neck of the bladder, the ordinary gum catheter be- comes nearly straight, and will not pass over the enlargement. But, Avhen you have a catheter which has been well over- curved in the manner described, wait until the moment before using it to re- move the stylet and turn back the shaft, so as to convert the extreme curve into an ordinary one. And what happens when you pass it ? In spite of the heat of the urethra, the catheter has a tendency to curve more, instead of less, as it passes down the passage. And this tendency often makes precisely the difference be- tween success and non-success. That little manoeuvre I regard as of extreme Fig. 30.—Example of badly-curved catheter for enlarged prostate. HYPERTROPHY C value. It is very simple: but, I repeat, keep the catheter over-curved—not for stricture, but for enlarged prostate : then turn back the shaft immediately before using. The curve gradually increases as it goes onwards, and it passes over the enlargement into the bladder. This is so simple that it may seem to you scarcely worth so much attention; but I can assure you that I know feAv practical hints that exceed it in value. But the English gum-elastic catheter may be rendered very effective by another while the instrument is passing through the anterior part of the canal, for it is at the posterior part that this form is required; the shaft of the catheter must be kept closely back in the groin, and the penis brought round the curve, so as to preserve the latter until it reaches the deep urethra, when, by well depressing the shaft, the point will rise over any obstruction into the bladder. I have just described and recom- mended to you the French coudee catheter. A not very important variety of this in- 51 mode of using it. It possesses a quality just referred to, which is found in no other. If put for a minute or two into hot water it becomes quite soft, and may then be bent into any required form, adapted, it may be, for the necessities of some par- ticular case ; and this form becomes nearly permanent if the instrument is plunged into cold Avater, care being taken while doing so to preserve the desired form. But the best form so produced may easily be spoiled by your mode of using it. Of course, the curve must not be altered strument may just be named: the addition of a second bend or elbow to it, from which circumstance it is distinguished as the ' bicoudee' catheter. Noav and then a case occurs in which a silver catheter passes with greater ease and safety than any other, and such in- struments should be accessible in two or three forms and sizes. A prostatic silver catheter should be one or two inches longer than the ordinary catheter: very rarely it is necessary to employ one that is four inches longer. The curved portion, 2 Fig. 32.—a, Gum catheter mounted on a stylet of the proper curve for use ; b, c, d, silver prostatic catheters of different curves. The Nos. 1, 2, and 3 of the instruments which I emplov. THE PROSTATE. 52 DISEASES OF THE URINARY ORGANS. tco, is often prolonged—that is, it em- braces a larger arc—say, more than a fourth—of the circle. (See Fig. 32.) The size should rarely be less than No. 10. The general or constitutional treat- ment of your patient is by no means to be disregarded ; but I shall defer a good deal of Avhat I might otherwise say until Ave discuss the subject of chronic cystitis, which Avill occupy a subsequent lecture. Cystitis is associated with so many diseases of the urinary organs, that I may as well refer to the treatment under that head, in- stead of taking it separately, and recapitu- lating it in connection with each disease. Here, however, let me remark, that in the general management of those who are the subjects of prostatic hypertrophy, one of the main objects is to prevent the occur- rence of local congestions of the organ. You must tell the patient above all things to avoid chills affecting the pelvic region —such as might be produced by sitting on cold seats, exposure to cold; too much excitement, sexual or otherwise; pro- longed journeys, or jolting carriages—all liable to aggravate his symptoms; since the prostate Arery readily becomes tempo- rarily inflamed and swollen, and many of the troubles which the patient experiences depend upon that condition. A useful agent in these cases, when there is frequent micturition at night, or when pain is distressing at any time, or interferes Avith the rest, is, of course, opium in some form. The salts of morphia, in small doses by the mouth, sometimes con- duce greatly to a patient's comfort. Some- times, a suppository, containing from one- third to two-thirds of a grain of the acetate of morphia, in cocoanut butter, renders essential service. A more certain method is subcutaneous injection, often, hoAvever, less convenient to resort to. Some have advised combination of bella- donna with morphia in the suppositories ; it is always a mistake in relation to the prostatic patient Avith difficulty in empty- ing the bladder. Belladonna has a special power to paralyse the vesical expulsive muscles, and when irritation, or want to make Avater, arises from the pressure of urine Avhich the bladder fails in expelling, the difficulty is only aggravated by bella- donna. I have seen some painful illus- trations of this error. In the use of opiates of all kinds, you must never forget to inquire for their effects on the appetite and digestion and on the state of the boAvels —in some cases considerable. There is great difference in the ability to tolerate opium, in different individuals ; although there are \rery feAV who are not constipated by it, and Avho require therefore some laxative medicine. I must not omit to say how important it is in all cases to attend to the action of the bowels. The patient's comfort is sometimes ensured by regulating their function, for if he is the subject of habi- tual constipation, and prone to retain scybala? in the rectum, his urinary sym- ptoms are mostly much aggravated. Some- times a simple enema of warm Avater gives relief; but, if necessary, the daily gentle action of the bowels must be pro- vided for by means of mild laxatives, such as senna, manna, bitartrate of potash, sul- phur, rhubarb and soda, or by Friedrichs- halle or other bitter Avaters, or by sul- phate of soda ; Avhatever will act mildly, quickly, and Avithout irritation, will keep him in a very different condition from that which is associated Avith habitual constipation. On the other hand, drastic purgatives produce great discomfort, and are to be avoided. I Avill dev%te the feAV minutes which remain to the consideration of those cases of prostatic enlargement in which the difficulty of passing the catheter is con- siderable, and where retention of urine is more or less imminent. It is by no means uncommon for a patient who has long been the subject of hypertrophied prostate to be attacked suddenly Avith complete retention of urine, from the rapid occur- rence of congestion and swelling produced by some of the causes above alluded to. The condition is one of extreme distress, often, indeed, of imminent danger. When called to treat such a case it can rarely be a question of Avaiting, but only of hoAV best to proceed so as to relieve the patient at once. There is mostly evidence of dis- tended bladder in the form of SAvelling and dulness on percussion above the pubes. You Avill particularly notice if the SAvel- ling is high in the belly and very promi- nent. I think you would mostly be right in trying first the French coud£e catheter; if that failed, the over-curved English, and the same result folloAving it, the well- curved silver prostatic catheter. With this instrument it is easier to avoid false passages Avhich may have been made by the hands of the patient himself, or by HYPERTROPHY OF THE PROSTATE. 53 others who have failed in a previous attempt. And in using it always remem- ber that anything felt at the end of the instrument like obstruction can only denote that you are not in the right route, or are leaving it. No force is to be applied in such circumstances. The urethra is not narrowed, it may be some- times a little close and rigid, perhaps, when you reach the prostate ; but if you find any obstruction, you should withdraw and find another route, to the right or to the left. But in applying a catheter in these cases, remember that the position of the patient himself is by no means a matter of indifference : I mean only in the pre- sence of signs that the bladder is greatly distended. If these are strongly marked I advise you to pass the instrument Avith the patient in the lying position. On the other hand, if the bladder is not much dis- tended, perhaps it is as Avell, or better, to pass the catheter standing, in which posi- tion the viscus is more readily emptied. I have known great danger arise in re- moving a large quantity of Avater from a patient Avhen in the standing position. I have even known death occur suddenly from this cause. Had I time, I could tell you the history of a case in Avhich a charge of manslaughter Avas brought against a surgeon in a court of justice in relation to such an occurrence. The circumstances Avere all Avell known to me, for I Avas sumnjoned to defend a brother practitioner, who Avas unjustly charged in connection Avith the case. It Avas the fact that a catheter had been passed in the upright position, and that the patient fell dead from syncope Avhen six pints of urine had passed; just as a patient Avith ascites might do if you tapped the abdomen in the same position. No doubt it Avas an error, but nothing could be more mon- strous than to make it the ground of a criminal action. It is a very instructive case, and I mention it to sIioav that Avhen the bladder is large, especially in old men, you may have fatal syncope, arising in the Avay I have described. 1 always take care, if I find the bladder is very large, to pass the catheter when the patient is lying down. It is advisable also, in these cir- cumstances, to draw off only part of the urine; and after a quart or so has passed, to wait a little before the bladder is com- pletely emptied. It may be said, ' Why, in describing the treatment of prostatic retention have you not mentioned hot baths and opium ? ' I reply that I have not done so in these particular circumstances, because they by no means favour the hope of good results from delay, or from expectant treatment; and furthermore, it is necessary to have regard not only to the present state, but to Avhat may be the future condition of the bladder, after the emergency has dis- appeared. Thus, it is by no means un- likely that if the bladder is permitted to remain over-distended, say for a day or two, it Avill not readily contract again. In the case of an old man's bladder, thoroughly distended by long retention, it is very likely not to recover its powers. Although the patient may have made water fairly up to the time of retention, if you leave him to the influence of opium, hot baths, and treatment of that kind, and the bladder is permitted to dis- tend meantime, you will very likely have more serious chronic retention afterwards than if the instrument had been used at the outset. Again, if you have had a great deal of trouble in passing the catheter, I suppose you had better leave the instrument safely tied in ; but it is not always the most desir- able course in these cases. If there is not much difficulty you should rather with- draw it, and use it again; because the prostate is irritated, perhaps injured by an inlying catheter. Unlike stricture, which is often well treated by an inlying catheter, the prostate is always more or less disturbed by it; but less harm accrues from a flexible than from a silver instrument. Better still if you can pass a vulcanised india-rubber catheter, which is the only one which lies harmlessly in the urethra in a case of prostatic enlarge- ment. It may sometimes be insinuated by a series of short, quick pushes, thus [illustrating the method] ; or, failing in that manner, by mounting it on a stylet of any curve Avhich may be desired, and subsequently withdrawing the stylet. It is not difficult to keep it in its place if properly tied-in, using the supra-pubic hair for the purpose, as you have so often seen (see Fig. 11, p. 26); and the instru- ment has the merit of rarely becoming encrusted Avith phosphates, while its flexi- bility permits the patient to move about his room. A short metal tube Avithin the stem renders it more secure ; or the upper five inches may be stiffened by coating it with collodion, and it can then be easily 54 DISEASES OF THE URINARY ORGANS. secured by tying-in. Some have been made Avith ' Avings' at the vesical ex- tremity in order to retain it in place, but these mostly irritate the urethra and in- crease the difficulty in passing it. In short, the vulcanised catheter is sometimes of great service. After a severe attack of retention of urine, and when the patient has recovered from the fever or shock which often ac- company it, we become anxious to observe if the bladder is regaining power, or whether this is entirely lost, or whether the hypertrophied prostate will constitute in future a complete barrier to the out- floAv of urine by the natural efforts. The inlying catheter being removed, we shall soon discover if catheterism is necessary, and if so, uoav often it must be resorted to. If any considerable quantity of re- sidual urine is retained, it usually appears to be cloudy and decomposed, and asso- ciated with some symptoms of chronic cystitis, often spoken of in these circum- stances as ' catarrh of the bladder.' A consideration of the questions Avhich arise in connection with the need of daily catheterism for such cases is sufficient to occupy us at the next lecture. LECTURE VIII. RELATIVE TO THE EMPLOYMENT OF CATHETERISM FOR HABITUAL RETENTION FROM HYPERTROPHIED PROSTATE. We discussed at the preceding lecture the phenomena associated Avith Hypertrophy of the Prostate, and especially referred to that one Avhich is almost invariably the chief result of this organic change of structure in the organ—namely, an in- ability, either partial or complete, to empty the bladder by the natural efforts. This inability exists in very different degrees in different cases, and is associated Avith other circumstances Avhich have an im- portant bearing on the treatment to be pursued. In almost all cases the treatment will sooner or later consist in the employ- ment of artificial means of removing from the patient the ' residual' urine. We will therefore commence the consideration of this subject by proposing the question: ' What are the circumstances Avhich should determine us to employ habitual catheter- ism for a patient whose hypertrophied prostate prevents him from emptying the bladder by his own efforts ? ' I reply that there are at least two principal facts relating to the local sym- ptoms which must be noted in arriving at a ^ judgment for any particular case. Firstly, we must know the amount of ' residual urine ' habitually present—that is, the quantity left behind in the bladder after the patient has passed all he can by his own efforts; and, secondly, Ave must observe the degree of frequency, by day and by night, Avith which he passes water, but especially during the latter period. In reference to the first particular, the amount of ' residual urine,' you will of course not always judge from one trial of the catheter. Where there is nothing to disturb the function of micturition—and it is very easily disturbed, as by the presence of a stranger, or by the require- ment to perform the act for purpose of experiment Avhen a natural want is not present—the amount of urine left in the bladder is pretty uniform on each occasion of micturition with most patients; the conditions just referred to often tem- porarily impairing the expulsive power, and rendering therefore the residual por- tion on the occasion of examination rather larger than usual. This understood, let us suppose a case in Avhich eight ounces always remain behind. That quantity suffices, in my opinion, to make it desir- able that the patient should at once com- mence the daily use of the catheter. But you may find a much smaller quantity ; and you are entitled to ask me —indeed, I expect you to do so—' What is the point in regard to quantity at which the line is to be draAvn ? When can I say, With this quantity a catheter is quite un- necessary ; or, With such a quantity there is no doubt the catheter must be used ? ' No ansAver can be given to these questions. HYPERTROPHY OF The data from Avhich to form a correct judgment are not contained within the terms of the proposition. Other facts are to be ascertained. I have heard it laid doAvn, indeed, as an axiom, that so long as the urine is clear, no matter what the quantity retained, no instrument ought to be em- ployed. A certain amount of a priori reasoning may be urged in behalf of such a rule, but it Avill not bear the test of large experience. The problem presented for solution in this, as in most other cases where surgical interference is imminent, is far too complex to be solved by one un- varying rule. Like the statement respect- ing quantity referred to above, the single fact that the urine is clear does not suffice to govern your decision. A large quantity of residual urine, much more than a pint, may exist, clear and acid in certain cases, but which, nevertheless, as Ave shall here- after learn, ought certainly to be draAvn off by catheter. But let us see what this rule of never withdrawing the urine Avhile it is clear means or involves. It means neither more nor less than waiting for the occurrence of chronic cystitis before we use an in- strument ! No other inference is possible. And why should we Avait for chronic cystitis ?—a condition which of all others it is highly desirable to avoid in an old and already incompetent bladder, and which Avill sooner or later produce thick- ening of tissues and loss of extensibility on the part of the organ. Is it not, on the contrary, the very condition we desire to avoid, and do mostly avoid, by commenc- ing the use of the catheter at a sufficiently early period ? Of course I knoAV full well that in past days, when catheterism necessarily meant the use of the large me- tallic instrument, often painfully passed, to say the least, chronic cystitis was an ordinary and frequent result of catheter- ism. But it rarely is so now, Avith the soft and flexible intrument of moderate size, if only it is used at an early period in the case, and before considerable accumu- lation of urine has taken place ; the re- moval of a large quantity being mostly, I do not say invariably, followed by local and general disturbance. For it is not very common to find a patient whose re- sidual urine has, from neglect of catheter- ism at an early period, reached the quantity of twenty ounces or more, Avho does not suffer somewhat severely from both chronic cystitis Avith purulent urine, i1 THE PROSTATE. 55 and febrile attacks with resulting debility, whenever the daily use of the catheter has to be commenced. Furthermore, at this advanced stage of chronic retention, a slight accident of some kind readily occasions complete retention, or nearly so ; and then it is no longer a question of using or not using the instrument, since the condition is now one which impera- tively demands a catheter. In these last- named circumstances, chronic cystitis is almost sure to follow—an occurrence which most probably Avould not have taken place had there been an earlier resort to the instrument. And so it happens, in the management of these cases of continued and chronic retention due to slowly ad- vancing hypertrophy of the prostate, that the longer the use of the catheter is post- poned after the early stage of the malady is passed, the Avorse will be the symptoms.. And it happens also, unhappily not seldom, that these serious symptoms following the use of the catheter bring undeserved dis- credit on the surgeon who first employs it —a discredit really attaching solely, and very gravely too, to the adviser who un- wisely prevented an early resort to its aid. So that I beg you to understand that with a quantity of habitually retained urine amounting to eight or ten ounces, whether it be thick or clear, there is no question in a vast majority of cases that the time for the catheter to be used at least once, probably twice a day, has arrived. But what other circumstance has also to be taken into account ? A very im- portant one—viz., the frequency with which the patient passes urine, and which differs greatly in different cases. It is much more to the purpose for your deci- sion to note Avhether the patient is dis- turbed six times in the night or only twice, than Avhether his urine is clear or cloudy, or even Avhether the residual urine amounts to four ounces or to twelve. If you find him affected by loss of rest— one of those things Avhich sap the founda- tions of life in elderly men—pass the catheter the last thing at night for him, and mark the result. If he obtains four or five hours of continuous sleep after the bladder has been emptied—a common occurrence—you have reason enough for persevering, aud he Avill learn to use the instrument himself every night, and will be exceedingly grateful to you for the re- lief he has obtained. So also the avoidance of pain and spasm achieved by this treat- 5G DISEASES OF THE ment—a result Avhich is often to be noted —renders the catheter highly desirable, whether the quantity drawn off be small or large, transparent or clouded by mucus. Taking into consideration these dif- ferent phenomena, which vary so widely in different constitutions, you will have no difficulty in arriving at a correct judgment for each individual case, pro- vided you give to each sign or symptom its due importance, and do not rest your decision on any one in particular, unless that one—in regard of quantity, for ex- ample—is sufficiently marked to leave no ground for doubt as to your course. I revert to a fact, already alluded to, Avhich is one of considerable importance, that although the urine may have been quite clear before the catheter was em- ployed, yet in some instances, after its habitual use has been continued for a short period, the secretion becomes cloudy, and the patient is feverish and unwell. A stage of constitutional derangement, more or less marked, has sometimes to be passed by those persons Avho, having long ex- perienced difficulty, suddenly change from their usual mode of micturition to the artificial one. It requires some judg- ment, as I have already pointed out, to decide Avhen this change should be made, but having made it, the phenomena de- scribed occur in a few exceptional in- stances ; and this fact you should be aAvare of, and you should Avatch the result of the daily catheterism. Sir Benjamin Brodie was the first to remark it, and in his valu- able lectures called attention to the cir- cumstance that patients might even sometimes gradually succumb with sym- ptoms of low or irritative fever a few weeks after beginning to use the catheter. Bear- ing this in mind, our mode of proceeding may be advantageously modified in rela- tion to those patients Avhose amount of residual urine is large. It is then un- desirable to empty the bladder completely on every occasion of catheterism durino' the first few days. If the patient ha* URINARY ORGANS. been in the habit of retaining perhaps a pint of urine, or even more, after he has made water, it is a serious change for the bladder to be suddenly and completely emptied two or three times a day; the organ soon becomes irritable, the urine is charged Avith pus, and the patient loses appetite, becomes feverish, and there is sometimes considerable danger to life. The rule under such circumstances is to proceed cautiously. Instead of removing the entire quantity, leave some urine behind; and thus a compromise is made between the exigencies arising in this condition of the bladder and the usually absolute rule that it should be emptied. DraAV off half or only two-thirds of a pint; you will thus relieve the organ partially, and in the course of a Aveek or sooner you may gradually accomplish the entire emptying of the bladder, and all -will probably go well. And it conduces greatly to success to permit no outdoor movement to such a patient, but to confine him to his room, in a warm temperature, if the Aveather be cold, or even to his bed for a few days. The probationary period, while the use of the catheter has to be learned, and the onset of chronic cystitis with constitu- tional disturbance, is to be feared, is more safely passed if absolute rest and quiet are accepted as necessary conditions by the patient. It is only Avithin the last few years that I have pursued this course, and I cannot speak too highly of the results. Nevertheless, very rarely, notwithstanding every precaution, you will find a case in which during this process the tongue grows slowly more red, dry, and con- tracted ; the powers of life gradually fail; the senses become impaired, and the patient sinks. You will always find in such cases, if an autopsy is made, old- standing pyelitis, Avith dilatation and marked degeneration of the renal struc- ture, and you will know that in no cir- cumstances could the patient have long survived. RETENTION OF URINE. 57 LECTURE IX. RETENTION OF URINE. Gentlemen,—Retention of urine is our subject to-day ; and if we at all realise Avhat the condition of a patient is Avho experiences complete or almost complete retention, accompanied as it is by severe pain and great anxiety, Ave shall feel how important it is to relieve him, not only as easily, but as quickly as is possible. And there are very few cases in Avhich you will meet Avith more gratitude if your treatment is skilful and prompt. For not merely are the patient's physical suf- ferings extreme—and I suppose every man Avho has been so situated as to be unable to relieve a distended bladder, even for a short time, has had some glimpse, though only a faint one, of the distress occasioned by inability to pass water for seA'eral hours, or even days— not only, I say, is the pain intense, but there is extreme anxiety of mind also. He fears that the bladder may burst (a circumstance, hoAvever, of exceeding rarity), and he ahvays looks forward Avith gloomy forebodings to the consequence of not obtaining relief. Now, Avhile retention of urine is very common in the hospital, it is not so in private practice. The circumstances of exposure through the more hazardous callings of the men who become hospital patients, determine this difference; Avhen, therefore, retention is met with among the higher classes it is always a very grave matter, and in all circumstances, wherever encountered, will exercise your highest skill and judgment. Then, again, if you are successful, the relief which you afford is instantaneous. It is not like the ques- tionable result of a dose of medicine, which a sceptical patient may persist in attributing solely to our great ally—the curative poAver of nature. There can be no uncertainty as to the result of the treatment if, after twenty-four hours of agony, relief folloAVS your dexterous use of the catheter, and Avhen the two or three pints which the patient Avas unable to void are Avithdrawn by your hand. He tells you that he is in ' heaven '—a com- mon expression with such patients—and he never will doubt for a moment that you Avere the author of his ' translation.' Retention comes before us in three typical forms, each requiring a different species of treatment. There may be some instances which cannot absolutely be so classed, and some the characters of which belong equally to two forms; still, for convenience, it is Avell to adopt this classification. First of all, you may have retention occurring in a young and healthy man who has no stricture, but who is the sub- ject of temporary local inflammation; next, it may occur in an older man who is the subject of confirmed organic stric- ture ; and, lastly, it may occur in a man who is neither young nor hale, and who has no stricture, but has an enlarged prostate. Of the last I have nothing to say ; we have already discussed that sub- ject, and the mode of relieving retention in connection with hypertrophied prostate. But I shall ask your attention to the tAvo other conditions—namely, retention from inflammatory swelling, and retention arising from organic stricture. With regard to the first kind, you will probably learn a history something like the following :—Within a month or six Aveeks the patient, who is generally a young man, has had gonorrhoea. He has obtained considerable relief from treat- ment, and has in consequence allowed himself some relaxation of the regimen to Avhich he has been lately submitting. Thus, perhaps, he has recently indulged in the use of alcoholic stimulants, has taken some unusual amount of exercise, a game of cricket or the like, and, after being over-heated, has been sitting on a cold stone or damp grass ; or, lastly, he may have exposed himself to some strong emo- tional excitement. Under those circum- stances, what has been called ' inflam- matory stricture' may be produced. Noav let me say, repeating what I have said in a previous lecture, that that condition has no right to the name of stricture. An inflammation affects the prostatic region of the urethra, and involves therefore the 58 DISEASES OF THE URINARY ORGANS. neck of the bladder; a region in Avhich you know stricture is never found. The result of this soon is, some fulness or SAvelling of the prostate, as may be ascer- tained by rectal examination, a condition not in the least resembling stricture—that is, it is not a circumscribed narrowing at a particular part of the passage, but a tumefaction of the gland, which more or less closes the canal, and prevents the expulsive apparatus of the bladder acting and discharging its contents. Such is usually the condition in what is called inflammatory or spasmodic retention. This condition of the prostate re- sembles that Avhich affects the tonsils, and which we call inflammatory sore throat. Both complaints consist in the enlarge- ment of glands which more or less sur- round narrow passages, and Avhich thus interfere with the functions of those pas- sages ; both occur rapidly, and may be produced by unusual exposure to external cold. Now, what are the early signs of in- flammatory retention ? First, there is usually some cessation of the gonorrhceal discharge. Just as in the case of orchitis, where the urethral inflammation is sup- posed to subside and to attack one of the testes, the inflammation of the prostate is similarly associated with diminished dis- charge, and if you examine by the rectum, a tender and swollen condition of the prostate will be discovered. Then the stream of urine groAvs smaller and smaller, and in a very short time the patient loses altogether the power to relieAre himself. He is feverish, restless, and suffers severe pain about the lower part of the abdomen and in the perineum. Those Avho are the subjects of stricture may have become in some measure accustomed to difficult micturition, but Avhen an active young fellow is thus attacked for the first time, he is in a state of extreme distress. Now, as to the treatment of such a case. The patient desires ardently to be relieved immediately, and declares he cannot endure his sufferings. You see him bent nearly double in order to relieve the pressure of the abdominal muscles on the bladder, and he is even breathing shortly and quickly to avoid their action there. The old treatment in such cases —the classical treatment of forty years ago—was bleeding from the arm or peri- neum, repeated hot baths, and large doses of opium, so as to enable the patient to bear the pain and dispense Avith the catheter. The reason assigned Avas, that in an inflamed state of the canal,^ you might do more harm than good Avith a catheter, and that it Avas therefore better to mitigate pain by the means described. I have told you that I dissent from that treatment altogether, although it is still employed to some extent. For, first, you must not only regard the present emer- gency, but also the possible occurrence of serious after consequences; for if a young man is allowed to remain for thirty-six or forty-eight hours with an unrelieved bladder, because you fear to use an instru- ment, permanent mischief may be done. I have seen patients who have been unable to empty the bladder for years after treat- ment of this kind. Extreme and continued distention of that organ sometimes de- stroys or permanently diminishes its con- tractile poAver, and produces a condition which is properly termed ' atony of the bladder.' Therefore, if you pass the catheter, even at the risk of doing a little mischief to the urethra, I am disposed to think you would be Avise in incurring that little risk rather than expose the patient to the other danger. But then it ought to be done Avithout such risk. For my own part, I always take a small flexible catheter—one not above No. 6 (English scale), as a large one gives in these circumstances unnecessary pain— which has been tolerably well curved in the way I have before described, since it has to enter over a swollen prostate. Or, you may use a French one Avith a bulbous end, or Avith the end ' coudee.' With the latter instrument especially there is generally no difficulty in relieving the patient, who is exceedingly grateful for Avhat you have done ; whereas, if you put him through the long process, and he relieves himself ultimately, he thanks you for little, comparatively speaking, and he runs the 'risk to which I have referred. But lastly, in the event of flexible catheters not passing, you should try a silver catheter of the same size. I believe one of the first persons to denounce the old plan of bleeding and hot bathing Avas the late Mr. Guthrie. If you turn to the racy Avritings of that experienced and practical surgeon, you will find an anecdote in connection with this subject. He relates the account of a visit which he paid to a patient in the circumstances of retention I have de- RETENTION OF URINE. 59 scribed, and also the reasons, in strong and graphic language, Avhy he then gave up for ever the bath and bleeding practice, and passed the catheter at once for such cases in future. So much for the inflammatory condition of the prostate producing obstruction to micturition. I need not refer at any length to spasmodic retention, Avhich rarely happens. At the same time it may be admitted that there is no doubt that when an inflamed condition of the urethra exists, spasm of the muscles may co-exist; but the precise share Avhich each takes in contributing to the result will not influence the treatment. Now I come to the second form of retention—viz., that depending upon organic stricture. Here we generally have to do with an older man, because it is rare to find a young one suffering from confirmed organic stricture. As a rule, to Avhich there are exceptions, such a patient mostly has stricture ten or tAvelve years before he is the victim of complete retention. First of all you have to ascer- tain that the cause is certainly stricture. You will probably find that he suffers less acutely than the patient just described, although his condition is a painful one; for the progress of the case has been more gradual, and the derangement has not necessarily been brought on by any great or sudden imprudence. He has been passing Avater with difficulty for weeks or months, and at length some slight cause perhaps has produced almost absolute retention; the ' last ounce,' so to speak, ' has broken the camel's back.' Or it may not be absolute retention as before ; there may be some dribbling, indeed the patient may have been relieving himself in that inefficient Avay for days, but the bladder is greatly distended, and to all intents and purposes his case is one of urgent retention. You find probably also that the patient is accustomed to instru- ments. Noav, Avhat you have to do is to take an instrument of middle size, and pass it doAvn to the seat of obstruction, in order to learn where it is. You will probably find it four or five inches from the external meatus. You should then take the finest gum catheter and endeavour to insinuate it into the bladder, and if you are sufficiently fortunate to accom- plish this, you should tie it in at once, so that you may have no further trouble. But that is not a very difficult case of retention. Supposing you are unable to pass the gum catheter, I should then recommend a small silver one, either No. 1, or smaller, and use it in the manner I described to you in Lecture V. Notwithstanding all your skill, and that, perhaps, of friends whom you may have called in, the instrument is still not passed. There may have been false passages (it is very easy to make them), and there may be such difficulty that it is almost impossible for any one to pass a catheter after your failure. We then come to the question : What is to be done next ? No doubt for some of these cases much may be effected by opium and hot baths. Suppose the water is dribbling off, and you shrink from the last resource—that is, punctur- ing the bladder, or other operation to relieve the retention of the urine—a safe middle course may still exist for some of these cases. The patient up to this time may have been exposed to cold; if so, he should have the benefit of a warm bed and hot baths, with large doses of opium —and you must be very liberal with opium if you use it at all—so as materially to mitigate the involuntary straining, which he can no more help than he can help breathing, and which is utterly unsuccessful as regards the contents of the bladder, often making matters rather worse than better. The result may be that the water will dribble off more freely than before, and you may find, after two or three days, that it will come in a larger stream, and that then you can pass the instrument without much difficulty. The patient may often be saved an operation thus, if there are grounds for declining to perform it. On the whole, however, I do not advise Avaiting very long; still it is better that the patient should be temporised with in that Avay than that he should be damaged by an unsafe hand, either with knife or catheter. Most men, indeed, are quite sufficiently confident in their ability to use instru- ments when they have a patient that cannot make water. Still, if you are convinced that you are not doing any good with the catheter—still more that you are doing mischief—you can in most of these cases successfully employ opium or an inhalation of ether, with hot baths and fomentations—that is, as regards the immediate and urgent condition. But we will assume that you have 60 DISEASES OF THE URINARY" ORGANS. done all that you can do in this Avay, and that the question of relief by some other means must be met. The bladder is increasing in size, notwithstanding your treatment. You examine the supra-pubic region carefully, and find a tense and perhaps large tumour there, reaching to the umbilicus, or nearly so, more like a uterus than a bladder. Now, a method has been devised within the last feAV years, by which you can at all events easily, speedily, and safely afford tempo- rary relief. I refer to Dieulafoy's capil- lary trocar and exhausting syringe. By means of a puncture above the pubes, the distended bladder may be emptied Avhen the condition described has been reached, or even sooner if thought necessary. And it is an operation which may be repeated, daily a feAV times during an emergency, affording time, possibly, for the stricture to become less tight and for a catheter to be introduced. But if this treatment does not meet the exigencies of the case, a more permanent opening into the bladder must be made by some other operation. Furthermore, it is not to be forgotten in examining the patient with this view, that in some old cases of stricture there is not necessarily large supra-pubic dulness, for the bladder is thickened and contracted. Introducing the finger into the rectum, a swelling there may be found, produced by the distended bladder, and here you are to seek the sensation of fluctuation. If, placing my hand above the pubes, 1 feel a distinct wave communicated to my other index finger in the bowel, I know that to be a point at which the trocar can be inserted with safety; and if a well- marked rounded tumour over the pubes which is dull on percussion does exist, with the bowel-note around it clear and distinct, I have reason to believe that an operation over the pubes Avould be suc- cessful. But then another question naturally arises: Why not attempt to relieve the bladder by a dissection to the urethra itself from the perineum, so as, if possible, to cure the stricture, and at the same time relieve the bladder ? Might it not be wise in this manner, as it were, to kill two birds Avith one stone, and not to be content Avith merely puncturing the bladder by the rectum or above the pubes ? At this point let me revert to the different practice and different experience of surgeons in relation to this matter. Let me giA-e you the experience of the late Mr. Liston. He once said, from this chair, that during the whole of his con- nection Avith the Royal Infirmary of Edinburgh, and subsequently with this hospital up to the time at which he spoke —namely, three or four years before his death—he had never punctured a bladder for retention of urine. On the other hand, there are men living in this town who have punctured a bladder fifty times or more. Mr. Liston intended to imply that a good surgeon ought rarely to find it necessary to resort to any other means than the catheter in circumstances of retention. But do not suppose for a moment that the gentleman I spoke of who has punctured a bladder fifty times, does so because he fails to pass the catheter under those circumstances; he operates thus because he thinks it wiser to puncture than to persevere too much Avith the catheter. Then, again, both Liston and Guthrie occasionally performed the perineal operation just spoken of. From the perineum the urethra may be reached behind the stricture. Now, without entering into a long discussion on the subject, I may say that this mode has lost favour of late years. It is no easy thing to find the urethra behind the stricture ; and a man may make a serious wound in the perineum, and never arrive at the urethra at all. Then it does not folloAV that it should be necessary to divide the obstruction, so far as its cure is concerned ; for the stricture, Avhen the time comes to treat it, may be amenable to dilatation. The reason why punctur- ing through the rectum has been done so often by Mr. Cock, of Guy's Hospital, is that he conceives it to be an excellent kind of treatment. He says : ' Let us withdraw the urine from the urethra altogether for a few days, and the urethra Avill recover itself, so that Ave may be able to cure the stricture with ease.' And that is often true. He punctures the bladder by the rectum under the circum- stances I have mentioned ; and this is his instrument for doing it. On his system, all the water passing by the rectal tube, the urethra is lying fallow, so to speak ; and in a short time the instrument can be passed—say No. 2, or 3, or 4 catheter, although before you could not pass No. 1. This, then, is a species of treatment of stricture Avhich Mr. Cock has introduced; RETENTION OF URINE. 61 and, at all events, he has proved hoAV easily and safely this operation may be performed: he has, in fact, familiarised us with a proceeding Avhich before was often supposed to be a hazardous and serious affair. My own experience of puncture of the bladder for retention of urine, is, for prostatic enlargement twice, and for retention from stricture, four times, besides using Dieulafoy's instrument tAvice only: this is during a period of above thirty years. One of the former was a supra-pubic puncture, all the others were by the rectum; on all other occasions I have succeeded by means of the catheter. I should add, that two of the rectal punctures were on the same individual, once in 1859 and again in 1870, he particularly requesting me to operate on the latter occasion as I had done on the first, because the relief was so speedy and complete. But for this circumstance it is almost certain I should have succeeded with the catheter. No doubt the rectal puncture is the safest operation in most cases Avhen the bladder has to be opened. On the other hand, a very considerable enlargement of the prostate makes the supra-pubic operation necessary. In the one case in Avhich I did it for retention, the prostate filled the Fig. 33.—A section of the pelvis showing bladder and rectum. pelvis: it Avas the largest I ever saAV : the bladder had long been emptied only by a fourteen-inch catheter, and Avith diffi- culty. Following a suggestion made many years ago, I once punctured through the pubic symphysis—a method I shall not further allude to—and failed to find urine.1 I punctured immediately after by rectum and gave relief, the patient recovering. There remain then for consideration the puncture by the rectum, and that 1 It may be as Avell to state what was the pro- bable cause of the failure. A puncture through the symphysis, which is solid bone in an elderly man, blunts the trocar so much that when the point arrives at the soft tissues and bladder on the other side, it will not penetrate but pushes them away. At least this is what happened in three experiments I made on the dead body, for the pur- pose of observing the result. above the pubes (see Fig. 33). By carry- ing into the bowel your finger—a reason- ably long finger—you arrive at a point just behind the prostate. The other hand is placed above the pubes, that the Avave of fluid, by its pressure, may be distinctly felt by the finger in the rectum. You are then quite certain of what you are going to do. Along this finger, kept firmly in place, your trocar is slipped, and then boldly, but carefully, pushed into the bladder. This is always an anxious moment, because, if you have not hit the bladder, it is a serious matter to have thrust this long instrument into the centre of the body and to find no urine escaping. The best position for the patient is sitting on the edge of a bed, his back supported by pilloAvs behind, the legs apart, each on a chair ; an assistant by him placing one 62 DISEASES OF THE URINARY ORGANS. hand on either side above the pubes, so as to steady the bladder, and press it down towards the rectum. It is well to re- member, that if the canula slips out sub- sequently, you will not be able to get it into the same opening again. The mus- cular fibres of the bladder instantly close, and you have to make another puncture— not a matter of much consequence, but better avoided. For the supra-pubic operation you divide the structures in the middle line until you reach the linea alba. Then carefully making your way deeper, you will soon discover fluctuation; and having the bladder steadied as before, you will thrust the trocar slightly downwards. In this case you retain the silver canula for tAvo or three days; but you may soon substitute a gum instrument. Noav, sup- posing there is a probability that your patient may require this artificial relief by tube for some time, you will, of course, prefer the situation above the pubes, Before commencing the subject of urinary fistulas, I shall briefly allude to a condition closely related to retention, just con- sidered — viz., extravasation of urine. And it is related in this way :—Suppose that from bad treatment, neglect, or other- wise, the patient suffering Avith retention from stricture has had no relief, and that when you are called to see him, the ques- tion of puncturing the bladder no longer arises, since the urethra has been already opened by natural means—that is, Nature has herself taken a step towards accom- plishing a cure ; clumsily and roughly it is true, but she has nevertheless made an effort to preserve life. And, undoubtedly, although it is true that many subjects of stricture or retention, without surgical aid must therefore certainly lose their lives, nevertheless a few are saved by extrava- sation of urine taking place. What then happens is, that a portion of the urethra gives way behind the stricture, perhaps during some violent act of straining, and through the rent so made, a quantity of urine is driven with great force into the because it is much more easy to Avear the tube there than it is in the rectum, where it interferes with the functions of the bowel, and is otherwise much in the way. I have known patients who have passed all the urine through a tube above the pubes from ten to fifteen years, having been punctured for stricture, and who led active and comfortable lives in conse- quence, the urethra being completely ob- structed. One of them, who had suffered greatly before, and was noAv in perfect comfort, told me that ' he did not know whether this mode of passing Avater was not preferable to the original one!' That, however, I conceive, is quite a matter of taste. The operation of opening the bladder above the pubes is still further considered, especially in relation to the relief of patients suffering severely from habitual inability to pass any urine except by catheter, from chronic cystitis, contracted bladder, &c, in Lecture XX. cellular interspaces. You know of course where, from the anatomical disposition of the fascia, the fluid must go—viz., into the scrotum, up into the groin above Poupart's ligament, rising upwards over the belly. Occurring, as it usually does, in the bulbous part of the urethra, where the walls of the canal are weak, the urine cannot pass backwards behind the scrotum, or the back part of the perineum ; neither can it get into the thighs, because it is checked by Poupart's ligament. I have seen it rise as high as the chest, and I have made incisions to evacuate it, in a severe case of extravasation, as high as this point. When, therefore, this accident has taken place, it follows that at every action of the bladder more urine is driven out with force, so that the cellular inter- spaces are separated, and the fluid gradually finds its way upAvards. Generally, you ought to knoAV at once, by the appearance of the patient, what has happened, although it is possible some- times to confound the condition I speak of with ordinary inflammatory oedema of the LECTURE X. EXTRAVASATION OF URINE AND URINARY FISTULJE. EXTRAVASATI scrotum, for extravasation may commence gradually and insidiously. In ordinary cases, you see a hard perineum, a large red tense scrotum, the penis greatly swollen, and a red blush perhaps rising over the pubes. In order to ascertain the true state of things, you must ask for the antecedents, and you will probably learn that there was great difficulty in passing urine, followed by rather sudden relief. When a man has had retention for some days, and extravasation suddenly takes place, instant relief is experienced—the frightful want to make water disappears as soon as the fluid finds its way into the scrotum; but he soon feels new pains, not necessarily very severe, and what is Avorse, constitutional symptoms rapidly set in. The poisonous fluid quickly destroys the cellular tissue, so that sloughing soon begins. After forty- eight hours or so, gangrenous discolora- tions appear, and the urine may find its way into the corpus cavernosum, when a dark spot appears on the glans, showing that the structure of the penis itself is infiltrated, and that mortification of a portion has taken place. Without describing further this con- dition, which you must have seen for yourselves, and which may be seen noAv to some extent in a patient in the ward up- stairs, let me say, do not in such a case be afraid of the knife. You have no occasion for a catheter; the urine has found its way into the cellular tissue, and you must let it out as freely as possible. On each side of the perineum and scrotum make a deep incision. You need not limit the incision to two or even three inches, because you are really cutting into urine, not into flesh. The structure is so enormously distended, that there is but little flesh to divide; and although the incision may appear very deep and long, when the Avater has run out, the wound will be comparatively small. The in- cisions generally bleed rather freely at first, and, from three or four, a patient may soon lose a pint of blood. The urine runs out also, and as the distention goes off, the vessels contract better; but if you see any little vessel spouting, tie it at once. An incision should be made on each side of the penis, because there is not sufficient communication for an in- cision on the one side to relieve the other. Do not be extravagant in these incisions; still it is better to err on the side of freedom 03 than to be too niggardly in the use of the knife. The next day, if the case has done well, you will find the scrotum much re- duced in size, and the parts altogether much less swollen and inflamed. You have now a direct communication through the cellular tissue from the bladder, by means of an opening from the urethra behind the stricture, and you will, as a rule, be safer without a catheter, and per- mitting the water to drain off. What happens ? Why, just Avhat happens after puncturing the bladder. When the urine flows by' another passage, the urethra begins to improve, and in three or four days you will probably have no difficulty in passing a No. 3 or 4 catheter. Patients even with very considerable extravasation, prostrated as they are when you see them, if promptly treated by the knife, and well supplied with nutriment and some wine, often exhibit striking and rapid recoveries. The whole scrotum may slough away, and the testicles may be seen uncovered in the wound, and yet all may heal up soundly and well. This leads us to the next subject. After the exit of the urine by these artificial channels, some of them fail to heal, and remain patent, and thus form what are termed urinary .fistulae. Let me remind you that this day week there were in my ward three patients illustrating this condition, rather exceptionally obstinate cases. One was caused by extravasation of urine, and the other two by the more usual and common cause—stricture of the urethra. We have spoken of extravasation as a cause of fistula; but how does stricture give rise to it ? Thus : in some patients, when a stricture has existed some time, and has had no treatment, or bad treat- ment, it is not uncommon for chronic abscess to form, say in the perineum, between the urethra and the surface. In time this opens externally, and a few days afterwards a little urine finds its way through it, and passes at each time of making water. If no relief is afforded to the patient, another abscess forms; and so several sinuses may arise, and other openings in various and surrounding parts, all giving exit to the urine. These fistulae may take place in a great number of situations, such as in the penis, in the scrotum, in the perineum, in the groin, and in the rectum ; but the two latter situa- tions are very rare. ON OF URINE. 64 DISEASES OF THE URINARY ORGANS. We will consider the first four by themselves, because fistulae which open into the rectum require a different treat- ment altogether. Then, respecting their specific characters, I shall make three classes, examples of which may be found in any of the localities named. First: Fistulae may consist of simple openings or channels between the urethra and the external surface. Secondly, they may be surrounded with inflammatory induration, Avhich is an obstacle to their healing. Lastly, they may be complicated with loss of substance from sloughing, so that even a portion of the urethra itself may have been destroyed; and these are the most difficult cases to deal with. Hence these fistulae classify themselves naturally as simple, indurated, and fistulae with loss of substance. I. I will deal briefly with the ' simple urinary fistula.' First, I beg you to ob- serve that Avhatever part of the canal it is connected with, fistula mostly heals, if the stricture Avith Avhich it is associated is dilated. Patients, especially in private practice, are often extremely anxious about the result of an opening in the perineum or elsewhere through which any urine passes; and it is right that you should assure them that if the stricture is thoroughly dilated, the unnatural passage will almost certainly heal of itself. But there is an important point to be con- sidered in connection with this subject— viz., the quantity of urine passed by the fistula, compared with the quantity passed by the natural passage. Of course the gravity of the affection depends very much on the relative proportions passed by the two ways. Usually the greater part of the urine passes by the right way, and one- fourth or less by the Avrong passage. If a large quantity—say three-fourths—passes by the unnatural opening, then probably a considerable amount of obstruction is present. Nevertheless, as the stricture is dilated, you will see that the propor- tion of urine passing through the fistula gradually diminishes and finally ceases as the sinus soundly heals; but this latter result is achieved only on the con- dition that the stricture is thoroughly dilated. II. We come to fistulae which are associated Avith much inflammation and induration in the perineum. These may be multiple; in which case you may frequently find five or six openings. I have known a man with twice as many, so that instead of the urine being discharged by one stream, it flows as from a watering- pot. Even this condition very much im- proves as the stricture is dilated, and may thus get quite well ; but this is not always the case. Then there are some instances looking less formidable, like those now in the ward, with perhaps only two or three fistu- lous openings, through Avhich the greater part of the water has passed for a long while. You recollect that we fully dilated the stricture in each case; but still no improvement as regards the Aoav of urine through the fistulae took place. A No. 12 catheter was passed ; but the patients were not cured. The condition of the perineum improved very much; but still more than one-half the urine obstinately held its erratic course through the perineal open- ings. Now, what is commonly done in such circumstances ? Usually operative proceedings of some kind are resorted to; or, if these have been postponed or re- jected, a rather tedious process has been employed. The principle laid down— and I have myself applied it successfully— is, that it is necessary to take care that the external openings of the fistulae should be very free, and to ensure this condition, either by means of the knife, or by po- tassa fusa, or by some other means; so that the urine may not be detained in its course from the urethra to the external surface, causing fresh induration or thick- ening. When this has been done we should revive the internal surface of the fistula by introducing a hot wire, or a solu- tion of cantharides or of nitrate of silver. No doubt this treatment sometimes suc- ceeds; but it is at best a tedious pro- cess. Then it Avas sometimes attempted to cure such fistulae by tying-in a gum catheter for a period of Aveeks, or even of months, Avith the view of transmitting the urine from the bladder to the surface without contact Avith the urethra and fistulae. But this plan generally fails; and for this reason: that urine always finds its way by the side of the catheter, along the urethra, and so into the fistulae by the force of capillary attraction or otherwise ; and disappointment Avas almost invariably the result of such treatment. The practical surgeon soon discovers that tying-in an instrument never ensures the transit of all the urine through it; some EXTRAVASATION OF URINE. 65 will always escape by the side and defeat his purpose. I have, therefore, adopted the plan of teaching the patient to pass the catheter himself and use it for every act of micturition; and this is by far the most rapid and the most certain method. With regard to the two cases upstairs, ten or fifteen years ago I should have applied potassa fusa or the galvanic cautery, or something of that kind; but the fistulae have soundly healed, through ensuring, by using the catheter every time the urine is to be passed, that the current should cease altogether to pass through the fistulous passages. You "will first teach the man to pass a No. 7 or 8 gum catheter—an easy matter enough. He then agrees to pass it every time he requires micturition, night and day. On no occasion is he to permit the urine to flow spontaneously—say, during five or six Aveeks—not even when he goes to stool; and this is avoided by always using the catheter immediately before his bowels are opened. That plan has been followed in each one of the three cases in question without difficulty and with perfect success ; for each man has a sound perineum, and has now relinquished the use of the instrument. III. We arrive at the third form of fistula, that in which there is loss of sub- stance. This class must be dismissed rather briefly, because its full consideration would involve a tedious detail of many dif- ferent surgical procedures. Where you have this loss of substance, a plastic opera- tion of some kind is generally required, to fill up the gap which exists. When the opening is small, you may contract it very materially by the heated wire or galvanic cautery, or by any mode which tends to produce a contraction of the tissues. You know that cicatrices which result from burns contract considerably, and you avail yourself of that action in this in- stance. Most commonly, however, if the soft parts have been largely destroyed, some plastic operation is required for the cure. Thus, on passing a silver catheter, when a portion of the urethra has sloughed away, you may see perhaps a quarter, or a third, or even half of an inch of the catheter exposed in the wound. The suc- cessful treatment of such cases demands much care and nice management. They do not often come under our notice, and less often are they completely cured. I have had in the hospital three or four such cases, but these, by means of plastic operations, have been entirely re- stored. Some of you saw one last winter —a man who was the subject of a con- siderable open wound, situated just be- tween the angle of the penis and the scrotum, and showing at least a third of an inch of the catheter, the Avhole of the floor of the urethra having sloughed away. The operation in that case was one of the most successful I ever saw. The first operation completed it, Avith the exception of an opening not larger than a pin-hole. What Avas done was to pare the edges all round, then to raise a flap of skin from the scrotum below, which was brought up to cover in completely the wound, the margins being carefully attached by a number of little silk sutures. That fistula healed perfectly. And Avhy did it heal ? Here is the important point: there was one condition necessary, without which it would have failed. A week or two before performing this operation, I made the patient learn to pass the catheter habitu- ally, so as to draw off every drop of urine; and finding him thoroughly expert, I per- formed the operation; and for a month he never allowed any urine to pass other- wise than by the catheter. Had I tied the catheter in, it would not have been sufficient, because the water, as I have told you, always finds its way by the side sooner or later. Luckily, he performed his part of the compact to the letter for the stated term, so there was no reason why the Avound should not heal there as well as anywhere else. The little tiny opening which remained was perfectly closed with the heated wire, and the urethra can now perform all its functions perfectly well. You know there is another very important function connected with this canal, besides that of micturition. I do not know how you may estimate the value of that function, but it is one which may involve very important considerations in cases where the transmission of a great family name or title or estates depends on it. Whether this motive be present or not, there is no doubt that every man con- ceives the ability to perform that function a matter of importance to himself; and in the case before us there could be no such ability until the abnormal opening had been closed. If I were to illustrate the subject of urethro-plastic surgery, a lecture or tAvo Avould scarcely suffice to describe the different kinds of operations which are 66 DISEASES OF THE performed in different spots. I have taken the case described as a typical one. It is one of the most difficult to close. The penis is liable to differences in form : the patient may be troubled with erec- tions, which may damage any operation, and there is often very little flesh to fur- nish flaps. But in the perineum and scrotum the effect of erection has little influence, and materials for our purpose may generally be found. A word or two about urinary fistula opening into the rectum. You remember that I made an exception in reference to fistula connecting the urethra with the rectum. There is a case upstairs in which it occurred from the patient himself thrusting a bougie from his urethra into the rectum. More commonly it occurs from prostatic abscess. In these cases, at each act of micturition, urine passes into the rectum—often a very troublesome, even distressing circumstance. The bowel becomes excoriated, and the patient is obliged very frequently to go to stool. I shall say very few words about it, because each case must be treated on its own merits. I will give you the result of my own experience, for I do not know that there are any published records respecting such cases. They are very few in num- ber, but they are very important when they do occur, I cured one case solely by the influence of position. It was the case of a young officer whom I saAv in private practice (I have not met with a precisely similar one in the hospital, and must therefore refer to it), who passed three or four tablespoonfuls of urine into the bowels at each act of micturition, after having had some abscesses there which I did not see. It occurred to me, after some wholly inadequate treatment by other means, to tell him to lie down on his face and make water in that position, never alloAving a drop of urine to pass in any other way. In a feAV weeks he was quite cured—very fortunately for him on such easy terms. If you ever meet Avith such a case the plan is Avorth trying. I have had two other such cases since, but it has not succeeded. In the successful instance to Avhich I refer, it occurred to me that the force of gravity Avould carry all the urine by the proper channel. None passed into the rectum, and at the end of six weeks the patient Avas Avell. I sa;v him some years afterwards, and he was soundly cured. But were I to meet with a | URINARY ORGANS. similar case now I should desire the patient to pass all his urine by the catheter, and I have no doubt it would be successful. Unless there is a loss of substance, this method usually cures the patient; but if there is much loss of substance, and, worse still, if the opening is from the bladder into the rectum direct, it is neces- sary first to examine the opening thoroughly as to its size and situation. Put the patient on his back, as for lithotomy, and intro- duce into the rectum a duck-bill vaginal speculum, which you must have seen me do, so as to get a good light thrown upon the upper wall of the bowel. If the fistulous opening is sufficiently large to require a plastic operation, I should not hesitate to perform the same operation that is done for openings between the bladder and vagina—that is, to pare the edges, and stitch them together with silver or hard silk sutures—only it is more diffi- cult, as there is les3 room in the rectum for manipulating than in the vagina. In the vagina there is plenty of space for the work; but I have done it also in the male in one case. I found it possible to do, though difficult; and I believe that is the best plan when these cases occur with loss of substance. If the opening, however, is very small, it may be greatly diminished in size, if not closed, by applications of the galvanic cautery, as I have repeatedly done. Such a condition sometimes happens after the operation of lithotomy. A lad was here not long ago—many of you re- member him—who had been cut in the country some years before Avith success, except that the rectum had been opened ; a fistula had existed ever since, and he was sent up for me to close it if possible. I placed him in the lithotomy position, under chloroform; emptied the bladder by a catheter; and with the vaginal speculum above mentioned we could all see an opening in the upper and left part of the bowel Avhich admitted a number nine silver catheter. Having ready pre- pared a large double wire connected with a poAverful battery, the wire was first shaped and placed within the fistulous canal, and then, the current being turned on, the sides were freely touched Avith the heated Avire. This proceeding Avas re- peated about once a week or ten days, the quantity of urine passed by rectum steadily diminishing. I never, hoAvever, could altogether close the track, although STONE IN THE BLADDER. 67 I reduced the rectal urine to a trifle, and so made the patient comfortable. He no longer wetted the bed against his will at Gentlemen,—I wish to give you to-day a sketch in outline, embracing all the prin- cipal points, if I can, of a very large and important subject—viz., stone in the bladder of the adult male. I shall subse- quently briefly treat the subject of stone in children, and also that of stone in women. First of all, in what classes of cases is stone most common ? Contrary to current opinion on the subject, it is most common in individuals from fifty to seventy. By writers generally, it is stated to be most common in children. Perhaps it is so if you take the number of cases in children as compared with the number of cases in elderly adults, although this is by no means certain, but not if you take the number of individuals affected, in either class relatively to the numbers of that class living at the time. I think it may be said that the most favourite period for calculus is from about fifty-five to seventy-five; the next in order is that below puberty, and the most rare period is that of middle age. Treat- ing numerically hospital cases alone, you may put it down as a general rule that half the total number are those of indivi- duals below thirteen years of age. I can- not refer you to any more exact researches than those Avhich were made Avith great labour some years ago by myself. Out of 1,827 such cases, each one of which was reported to me in writing, and of Avhich I knew all the principal particulars, one- half occurred before the age of thirteen. Observe that this is the proportion met Avith in hospital practice, which affords very different cases from those seen in private. For example, the operation for stone is excessively rare among children of the middle and upper classes. I don't know any disease which marks more dis- tinctly, or more curiously, its relations Avith class than this. So common is stone in the children of the poor, comparatively night—an occurrence which forms one of the most troublesome features in these unfortunate cases. speaking, that at Guy's Hospital, sur- rounded as it is by a very large neigh- bourhood, densely populated by some of the Avorst-nourished classes of the com- munity, quite one-half the cases admitted are children. Among the same classes, however, it is rare at the other end of life ; very feAV elderly Avorking men in London being afflicted with it. On the other hand, among the Avell-to-do and Avell-fed, while almost never found in childhood, it is com- paratively common at advanced age. This fact has been very much overlooked, and the frequency of calculus at this period is greater than most people be- lieve.1 The varieties of renal and vesical cal- culus are not numerous, and a few details suffice to describe them. I shall regard three chief classes as the most important to consider in relation to the practical management and the removal of stone in the bladder. That which is most fre- quently met Avith there is formed of uric acid and its combinations; the second is that in which phosphoric acid is combined with volatile alkali and the alkaline earths; and lastly, there is oxalate of lime. For all practical purposes those are the three great divisions. Among these, uric acid and the urates form about three-fifths in number, a feAV of these having a slight admixture of phosphates ; while nearly tAvo-fifths are phosphates, either alone or in combination with some uric acid, in which latter case the term ' mixed' is applied; lastly, about three per cent, of the entire number are com- posed of oxalate of lime. It is necessary only to remember further, that very rarely a calculus may be formed of pure phos- phate of lime or of cystine. It has fallen to my lot to operate on one case of each in my life. Next, Avhat is the ordinary history of 1 See further observations on this subject in Lecture XIX. 2 LECTURE XI. ON STONE IN THE BLADDER. 68 DISEASES OF THE URINARY ORGANS. stone? You know Avell, of course, that the appearance of a stone of some size in the bladder is not the first stage of the malady. The stone begins always—I am now speaking of uric acid—as fine sand or gravel, to use popular terms : that is to say, there is an excess of urates, which, perhaps, steadily persist; then, possibly, of uric acid, in characteristic cayenne- pepper-like masses of crystals ; then there are small rounded bodies of this latter ag- gregated Avithin the kidney, about the size of shot, or someAvhat larger, of Avhich you have very good specimens here. An acid calculus, then, is always formed Avithin the kidney ; and occasion- ally—but happily this is a comparatively rare circumstance—it is retained there and becomes a renal calculus, the. occasion of great misery, a condition for which sur- gical treatment, until lately, has rendered very little service. Of late, however, the operations of nephrotomy and nephrec- tomy have enabled us to afford complete relief to some who suffer from immovable calculus impacted in the renal region (see Lecture XXIII.). Happily, however, a renal calculus generally comes doAvn into the bladder, and is passed—say in ninety- nine cases out of a hundred—without any operation Avhatever. The patient has an attack of severe pain in the back, over the hip, in the groin and testicle, lasting for some hours, and mostly accompanied by vomiting, which symptoms commonly dis- appear Avith the descent of the calculus from the kidney to the bladder. Having arrived there, it is generally expelled by the urethra, either at once or after the lapse of a day or two, and there is an end of the matter for the present at all events. But the patient ought to knoAV, or must be told, that this occurrence shows a strong proclivity in his constitution tOAvards the formation of stone, and he should imme- diately do all he can to prevent its con- tinuing, as in the nature of things it will do (on this subject see Lecture XV.). But if the bladder is unable to expel the calculus, it soon increases in size by de- posit on its surface of acid from the urine, and a very hard but rather brittle stone is formed in the course of time. All the stones which you see in this box have been passed through the urethra by the natural efforts; and it is Avorth knoAving hoAv large a stone may be so passed in some cases. Usually, Avhen they become as large as some of these, they fail to pass, and then some operation must be per- formed for their removal. The phosphatic calculus is not often formed in the kidney; it is so sometimes, but is more commonly produced in the bladder. In the mucus of a diseased bladder much phosphate of lime is formed, and this, meeting with phosphate of mag- nesia, a constant urinary product, together Avith ammonia from decomposed urine, a new combination results—viz., the am. moniaco-magnesian or ' triple' phos- phate. This, again, with the phosphate of lime, makes ' fusible calculus,' the commonest form met with. The structure of these calculi is not dense, and they are easily crushed. The oxalate of lime, or mulberry cal- culus, I need not tell you, is not originally formed in the bladder, but in the kidney, and it is the hardest in structure and the roughest in external surface of all. Now, what are the symptoms of stone? These we will seek, if you please, by means of the four questions always to be used. A patient tells you, perhaps, that he has passed some gravel for a year or two, and may show you some small stones which he has passed. For the last feAV months, perhaps he has not seen any—a good sign he thinks, but to him a delu- sive one ; for during that period he has had some pain, perhaps difficulty in pass- ing his water, circumstances Avhich will strongly excite your suspicion. First, you will commence Avith an in- quiry as to frequency of micturition. The patient has for some time had more or less undue frequency, but it is increased during the day Avhen moving about, and is less observed at night, Avhen he is at rest. This is contrary to Avhat usually takes place in prostatic enlargement, and hence it is a useful diagnostic sign. You next ask for pain. The patient with calculus of the bladder almost always feels pain at one particular spot, the lower part of the glans penis, about an inch or less from the external meatus. Remember, you may have some pain there when there is no stone in the bladder, as in chronic prostatitis and in some affections of the bladder ; but in stone it is almost always present, and is usually severe. Further, with regard to pain, the question should be asked, whether the patient feels it before, during, or after making water. He Avill tell you that it is during and after; Avhereas you know, in hypertro- STONE IN THE BLADDER. 69 phied prostate, and in all cases in which Avater is retained, the pain is before passing water, from distention of the bladder, and the pain is relieved by the act of empty- ing it. A man with stone feels pain after making water, because the foreign body is then left in contact with the lining of the bladder, and being carried to its neck, severe pain and a strong desire to mictu- rate are felt, perhaps for four or five minutes after he has ceased to do so, until fresh urine entering, the coats of the bladder are separated from the stone. Then you ask as to the condition of the urine. In nine cases out of ten you find that there are a little muco-pus, and sometimes streaks of blood. There is almost always, but not inA'ariably, more or less clouded or muco-purulent urine with calculus, if the patient's habits are active. Then, lastly, you ask the patient if he has seen blood in the urine. Almost without exception blood has been passed c at some time, and is seen in the urine by the naked eye: and almost invariably, even when no blood-tint is observed, a few corpuscles will be found by the micro- scope. But it is generally apparent after exercise, and therefore he can rarely ride on horseback or in a jolting vehicle with- out communicating a tinge of blood to the urine; nor without considerable pain. On the other hand, the bleeding caused by calculus is rarely considerable, such for example, as is sometimes seen in prostatic disease, and in tumour of the bladder. Finally, all the symptoms of calculus are much intensified by any quick movements of the body. A patient, therefore, pre- senting himself with the conditions de- scribed ought ahvays to be sounded. Then, how do you sound? You should employ an instrument like this, Avith a small short curved beak, because it can be turned in any direction. (Fig. 34.) If you use an instrument with a large curve, like a catheter, you are un- l'i<;. 31. able to rotate it in the bladder, and hence it cannot explore sufficiently. When I entered this room, you heard me ask for the hospital sounds, for I knew I should find among them a good example of what a sound ought not to be. Here is one, for example, Avhich no one could rotate in the bladder, or eAren find a small stone behind an enlarged prostate with, except by sheer accident. It has precisely the form of a common catheter, and. its only claim to existence noAv is as an ex- ample of antiquated and obsolete instru- ments in a museum of surgical history. You will say, naturally enough, ' Why are such sounds here, and Avho has used them ?' They were used formerly, and found a good many stones, too, in the hands of our illustrious predecessors. But I will answer for it, they have missed a good many stones also; and those, the small ones, which especially, as Ave shall see hereafter, are those Avhich it is of the last importance not to miss ; and such is precisely the error which I trust you will not make—is precisely Avhat I want you not to do. I have no hesitation Avhatever in saying that more stones are missed in sounding than are found by the ordinary methods still adopted, I regret to say, in this country ; and that must be the ease if a sound of the form of the common catheter is relied on for the purpose. But Avith an instrument Avhich has this small beak at the end of it, you can search in every direction (see Fig. 35). If there is a large stone, of course you can usually find it Avith any instrument; but our great object is to detect the small stones. As a rule, anybody can find a large stone ; the delicate and rightly trained hand is necessary to ensure the discovery of a small one. It is most important to find a small stone, because if overlooked it will groAv large, and may be very formidable to deal Avith; Avhereas, when it is small 70 DISEASES OF THE URINARY ORGANS. its removal is a far less serious matter. You may promise the patient, in the case of a small stone, that it may be removed without risking his life; whereas, in the case of a large stone there is always some risk, often considerable danger. It is im- possible to overrate the importance of finding all stones when small,1 and this you can only ensure with an appropriate sound, rightly applied. In the next place, how are you to use this instrument ? First of all, it is not to be introduced in the same way as the ordinary catheter. With the ordinary catheter it is the cus- tom in this country to stand at the left side of the patient, and make a gentle SAveep thus into the bladder. With the sound you stand at the right side, and use a different manipulation, which I shall show you when introducing the lithotrite, the form of which is similar, upon the living patient, at another lecture, postpon- ing, therefore, my remarks on the subject until then (vide Lecture XIII.). But merely to discover the presence of stone in a patient's bladder is by no means all that is necessary. It is essential to possess other particulars respecting it, because the nature of the operation to be performed will depend on them. First of all, you must know what is the size of the stone, before you decide on what you will do with it. From the note elicited by merely striking it, and by the sensation communicated to the hand, you can obtain some indication of its size; certainly Avhether it be large or small, a distinction not ahvays sufficiently precise for our purpose. There is a more exact, and at the same time a simple, method of determin- ing size, sufficient for most cases, Avhich 1 have long employed myself and more recently have introduced to the profession. It is far less irritating to the bladder than is the action of any measuring sound Avith two blades which I formerly used, or of the lithotrite, which is the same thing on a larger scale. It consists in the mere addition to any ordinary sound of a little ring or collar Avhich slides along the shaft, and Avhich by proper manipulation, en- ables me to ascertain very nearly the size of a stone, as you have frequently seen in the wards. (Fig. 35.) The manner of using it is this. Introduce the sound, feeling the stone as the end passes over it 1 See also Lecture XIX. o .5 by a succession of delicate taps, until you have placed the end of the instrument distinctly beyond the farther or distant extremity of the calculus as it lies in the bladder. This done, slide the 'collar' doAvn the shaft to the end of the penis, so that it touches the external meatus. Noav draw the end of the sound outwards over the stone, delicately tapping as before, until you have reached its near extremity, which is most likely close to the neck of the bladder. The distance of the 'collar5 from the end of the penis is the diameter of the stone in the direction passed over. There is nothing painful or irritating in this pro- cedure if conducted, as it always ought to be, with a light and delicate hand. Then there is the other Avay, already mentioned. You may introduce a litho- trite and seize the stone in two or three directions, so as to ascertain its dia- meters. This proceeding, however, sometimes occa- sions considerable distur- bance to the patient, and should be accomplished Avith as little manipulation as is possible. At the same time it is desirable to ascertain the nature of the calculus. A phosphatic stone gives a very different note when struck Avith a sound from that given by the others. The specimen before me is dry, and, therefore, Avill not give the note to Avhich ^ I refer. When wet, it is spongy and soft, Avith a rough surface, and always gives a dull note when struck; whereas the uric-acid stone gives a note which is clear and sonorous. Then you will judge partly by the condition of the urine. If the urine is acid, and if, also, uric acid is throAvn doAvn, you may con- clude that the patient has a uric-acid stone. If so, you may find on inquiry that he has passed small calculi before; and seeing Avhat these are, you may pretty JStg I "J STONE IN THE BLADDER. 71 safely infer that all belong to the same variety. In such a case also it is probable that the patient empties his bladder per- fectly by his own efforts. On the other hand, if the urine is alkaline, and deposits phosphatic matter ; also, if the patient is unable to empty his bladder by his own efforts, and requires a catheter, you may conclude that it is a phosphatic stone, or, at all events, that it is covered with phosphates. I have spoken of uric-acid and of phosphatic calculi. But Ave may have to deal with an oxalate-of-lime stone—a fact which it is very important to ascertain. You will examine the urine, and observe if it contains much oxalate of lime deposit. The patient may have passed a small mass of oxalate of lime before, and it may be thence inferred that an oxalate-of-lime calculus exists now; but it may have an external coating of phosphates, and thus its real nature may be hidden. The fol- loAving is a case in point. I had some time ago to operate on a large stone in the bladder of a private patient. I crushed the stone four times, bringing away a good deal of phosphatic material. I soon noticed that my lithotrite never went through the stone : it always Avent a certain way, and then there was a hard mass. After four sittings I could not crush any more. It was clear that there Avas a very hard centre stone, on which my strongest litho- trite made no impression, the crust only having been removed. I knoAV, from ex- perience, the recoil of the lithotrite from an oxalate-of-lime stone so Avell, that I had no hesitation in saying such an one was present. Accordingly I performed litho- tomy, and removed a large and well- marked specimen of that kind. In such a case, there would not be oxalate of lime in the urine, but a large deposit of phos- phates. It is Avorth remarking here, that in dealing Avith the hardest uric-acid stone in a lithotrite, an impression Avill be made by a turn of the screAV, the jaws of the lithotrite will make some impression on the stone even if they do not crush it; but an oxalate-of-lime stone communicates a sensation when grasped by the instru- ment as if you were laying hold of a piece of iron—you make little or no impression upon it until considerable force be ap- plied. The number of calculi present is the next thing to be ascertained. Usually there is only one, but occasionally there are more. There is a patient here on whom I shall perform lithotrity to-morrow, who has two rather large uric-acid stones in the bladder. You may determine that point thus: Having seized one in the lithotrite, move it gently in every direc- tion as a sound for others. If then you encounter one on one side and one on the other, you knoAV that there must be at least three stones. There is a source of deception here Avhich it is necessary to guard you against. While retaining the stone between the blades of the lithotrite, and moving the instrument from side to side in search for another, a rattling sound is easily produced which resembles very closely that of contact with another stone. This arises because the stone seized is not closely fixed between the blades of the lithotrite, and it rattles between them. I have seen the error committed of inferring a second stone from this cause. Sometimes a great number of small calculi are present, varying between the size of a small nut and that of a pea, so that the rattle of several is heard, and, I may add, felt. These are favourable cases for operation, Avhen compared Avith those in which a single calculus is present, taking equal weights. The large stone on being crushed results in large hard and sharp fragments. The small stones may be regarded as fragments already made, and also possessing a much less irritating form. Of course much less mechanical work is necessary to crush and remove the calculous matter in the last-named condition. In the patient's interest I would rather remove six drachms of such small calculi, than four drachms in the form of a single stone. Having obtained all these data, the important question is, What operation is to be performed ? Are you to perform Lithotomy or Lithotrity ? You knoAV there are only two modes of removing the stone. You must make an opening sufficiently large to admit of its withdrawal at once, or you must crush the stone into small fragments, so that they may be removed by the natural pas- sage. It was far less important to make a diagnosis of all the points named, Avhen there was but one operation—namely, that of cutting. Formerly, whether the stone was large or small, the patient was always cut. There was no other way of removing it. Now that we have two operations, it is very necessary that we 72 DISEASES OF THE URINARY ORGANS. should choose the right oue; because— and let me impress on you the importance of the fact—if you do not determine pretty accurately the characters of the stone, and select the right operation, you may do more harm than if you cut every patient who comes to you. Thus, if you crush the very large stone, and cut for the very small one, you may have greater mortality than if you simply resorted to the one operation of cutting in all cases. When lithotrity was first introduced, it was unquestionably a rather clumsy opera- tion ; and when the cases were not judi- ciously selected, when surgeons operated without making a diagnosis relating to the points I have enumerated—crushing stones that ought really to have been cut, and cutting for stones Avhich might have been crushed—the entire mortality re- sulting from operations for stone was greater than it had been previously, when every case Avas cut. I cannot give you a stronger argument for the necessity of choosing in each case the operation judi- ciously. Now, without taking up your time too much, I will lay doAvn Avhat you will understand to be the axioms Avhich should direct you, in a general Avay, in making your choice between the two operations. First of all, I Avill say that all patients with stone, under puberty, with very few exceptions, are to be cut. Under fourteen or fifteen years of age, stones occurring in the male are to be removed by cutting unless they are very small, and can be easily crushed—say, in one operation; because lithotrity is not a very easy or successful operation in children, the urethra being small and the bladder very irritable; Avhereas, as is well known, lithotomy is a very successful operation in their cases. We scarcely want a better operation, com- paratively speaking, and may be content to let well alone. Not more than one death in fifteen or sixteen cases occurs from lithotomy in children. I do not think, therefore, we can do better than cut in these cases, as a rule. If, hoAvever you have in a child of, say, three or four years old or upwards, a stone no bigger than an orange-pip, you may very pro- bably succeed in crushing it, under ether, at a single sitting; and this it is usually advisable to do, employing, of course, a lithotrite of suitable—that is, of small- size. That leaves us all the cases above puberty; and here lithotomy is only ex- ceptionally available. To facilitate our consideration of the subject I will state, thus, in general terms that the cases of stone occurring in patients Avho have passed the age of puberty are to be operated on by lithotrity, with now only few exceptions. These exceptions arise firstly, in re- lation to some character of the stone itself ; and secondly, from some condition of the bladder or adjacent organs. Exceptions may consist of stones too hard or too large to be crushed. Well, at the present day, whatever may have been said some years ago, it is very cer- tain there are not many specimens which cannot be crushed. Thanks to the ex- perience derived from performing litho- trity by the single-sitting method, we have attained a confidence in applying it to calculi much larger than we ventured to attack before. I used to perform litho- tomy for a hard uric-acid calculus, above an ounce in Aveight, so far as I Avas able to judge; and for an oxalate-of-lime cal- culus when someAvhat smaller. Phos- phatic calculi might be crushed of much greater size. But since I have adopted the operation referred to, I have crushed with complete success a hard uric-acid stone weighing no less than 2f ounces; a proceeding which occupied 70 minutes. It is very difficult to say Avhere Ave are to stop; Avhere Ave are to draAv the line, and say, Avith this weight Ave will do litho- trity ; and with this Aveight, lithotomy must be performed. In fact, such com- plete rules cannot be laid down. Much must depend on the patient's condition : still more, as we shall see hereafter, on the qualifications of the surgeon. At all events, the great majority of calculi, omitting only the very large ones, must be regarded as removable by lithotrity, and Avith every prospect of success, in the hands of an experienced operator. Now, Avhat are the conditions on the part of the organs which Avill make it necessary for you to cut instead of crush ? They are very feAV indeed. Formerly, almost any kind or degree of disease in the urinary organs Avas held to contra- indicate lithotrity. I think it has fallen to my lot chiefly to demonstrate that this was an error. First of all, I Avill name certain dis- eased conditions which are not excep- tions to the rule, and Avhich you need not STONE IN THE BLADDER. 73 necessarily regard as disqualifying the patient for lithotrity, although held to do so by some authors, and perhaps I may say, by many of the profession still. In presence of stricture of the urethra it is commonly said that lithotrity is of course impossible. Also, that in marked hypertrophy of the prostate it is difficult and undesirable. That if the bladder is very irritable—that is, if the calls to pass Avater are exceedingly frequent and pain- ful—lithotrity is a most unpromising opera- tion. That in any. severe disease of the bladder, it is out of the question; and finally, that in disease of the kidneys, it is more dangerous than lithotomy. I reply first, in relation to stricture of the urethra, that our ability to crush a stone iB thereby limited, but that small stones may be safely dealt with. I have recently crushed a uric-acid stone in a case of organic stricture with small instru- ments made for the purpose; but the stricture was not a very narroAv one. And more recently I have crushed stone in two cases in the wards, Avhere confirmed stricture has existed, by the following method :—I retained a catheter for a few days, and dilated the stricture thus to No. 10 ; then placed the patient under chloro- form and introduced a lithotrite of mode- rate size, removing as much debris as possible. I then re-introduced the catheter, and Jet it remain there for three or four days, until the patient Avas ready for another sitting, and so on until all was removed. This plan ansAvered well for two men who Avere not in condition for so formidable an operation as lithotomy, and whose calculi Avere not large. Secondly, in marked hypertrophy of the prostate, I make no difference Avhat- ever, and would almost as soon crush in the presence of this condition as in a younger patient without it. If the hyper- trophied prostate occurs in a man who has had instruments passed, he will have become habituated to them, and is some- times, therefore, a better subject than a healthy one Avho has not been so accus- tomed. If [he requires very frequent catheterism, his case is one of somewhat increased hazard; still, if the bladder becomes much inflamed subsequently, and catheterism not only becomes more fre- quent but difficult, the condition is very serious. In these circumstances, Avhen the bladder is wholly unable to relieve itself by natural efforts, I have adopted two methods successfully : one is to remove the stone by lithotrity, and to introduce a tube into the bladder by a very small opening above the pubes, in the manner described in Lecture XX. The other, Avhich I have employed Avith excellent result, is to make a small perineal opening into the prostatic urethra, and tie an English gum catheter in the bladder through the perineal wound, which gives the patient little or no inconvenience, and saves all the frequent and painful cathe- terism which had previously been neces- sary, lithotrity being first performed of course as in the preceding instance. Thirdly, in relation to the bladder Avhich is merely atonied, and unable to void its contents by its OAvn poAver, all the urine being drawn off by means of a catheter; lithotrity is often preferable in this case also, and for the reason just assigned—that is, the bladder and the urethra are habituated to instruments. Fourthly, irritability or extreme sen- sibility of the bladder is not an insuper- able objection. It used to be said that if the bladder could not hold above three, or four, or five ounces of urine, there Avould be no room for the lithotrite to work satisfactorily, and therefore the surgeon must perform lithotomy. I make no ob- jection even to considerable irritability of the bladder, because this is due to the presence of stone; and as soon as you have removed the stone, the irritation diminishes or almost disappears. Besides, it is not necessary for the operation to have four ounces of water in the bladder; one ounce is ample. The presence of four or five ounces was thought to be necessary Avith the large and clumsy lithotrites of former days, but Avith modern instruments the bladder even Avhen empty is scarcely in any danger. When instruments were used that were apt to lay hold of the coats of the bladder, a quantity of Avater in its cavity was a desirable protection; but a well-made lithotrite will not injure the bladder, and with such an instrument there is no difficulty whatever in crushing with a single ounce of water. I am in- different Avhen operating, whether the bladder is quite empty, or contains two or three ounces of water ; and I only dislike to have the organ distended by six inches or more—nothing is more embarrassing than a large quantity of fluid; currents are produced by the lithotrite, which catch the stone, or the fragments, roll them 74 DISEASES OF THE URINARY ORGANS. about anywhere rather than between the grasp of the instrument, and seizing them is rather a game of chance than of skill. Fifthly, as to advanced disease of the bladder, each case must be dealt with according to its particular merits. In cases of notable tumour of the bladder, complicated Avith calculus, which are very rare, the propriety of any operation must be doubtful. I once in this hospital greatly mitigated, for the feAV weeks he had to live, the sufferings of a poor felloAV Avith cancer in the bladder, by crushing a phosphatic calculus. No one certainly could ever have dreamed of submitting him to a formidable cutting operation. Sixthly, as to the comparative applica- bility of the two operations in the presence of the various form s of renal disease—a very large subject—I must defer the considera- tion of it to a separate lecture (see Lecture XXIL). Suffice it to say here, thatmodern lithotrity will in most cases be safer than lithotomy. Some years ago the contrary decision would no doubt have been more judicious. You see, then, that the exceptions are rare, and limited almost entirely to those cases which are difficult or hazardous, be- cause the stone is unusually hard or large. Indeed, there are not many adult cases which cannot be advantageously treated by lithotrity, provided proper care and attention are afforded. If surgeons of the present generation now groAving progress, as they must, and become more intelli- gent and more careful than those who have gone before—if they are better acquainted with the subject than their predecessors were, as in the nature of things they must be, as our sons will be wiser than ourselves and our grandsons wiser than they, there Avill be fewer and fewer exceptions. For it is certainly true I think that the best Avay of commencing our study of lithotrity is to give you a brief sketch of the history of the opera- tion, and of the steps by which the original that if the stone is discovered before it is large, it can always be crushed ivith an almost certain chance of success; lithotomy, therefore, for adults must at some day disappear, except for those cases in which the symptoms have been greatly neglected by the patients themselves, or the pre- sence of stone has been overlooked by the medical attendant. A rather large uric-acid stone is the growth of several years; a large phos- phatic stone is perhaps the growth of two or three years; an oxalate-of-lime of full size, say from seven to ten years; and it is A'ery hard if, long before the expiration of such periods, the stone cannot be found and disposed of by lithotrity. It is cer- tain, if a calculous patient has the benefit of intelligent oversight and treatment, that his stone Avill be ahvays discovered, when it can be crushed with almost a certainty of success; so that the only cases in Avhich lithotomy will have to be performed are those in Avhich the patient has neglected himself, and although suffer- ing severely for years, has not sought professional aid. But such cases must be few indeed. I believe that in future lithotomy for adults will be a rare opera- tion in surgery. I cannot say that I regard this result with unmixed pleasure; for lithotomy is a grand operation, de- manding skill, self-command, and some- times all the resources of an experienced and able man. The successful perform- ance of the operation is one of the highest practical achievements of a good surgeon, and so considered, one shrinks from de- siring its complete extinction; but it will gradually disappear, or nearly so, and speedily; and as Ave believe such a con- summation to be beneficial to humanity, Ave must acquiesce in the result. and primitive instruments attained, through progressive improvements, the high de- gree of power and capability which the modern lithotrites and aspirators possess. LECTURE XII. ON LITHOTRITY, ITS HISTORY, AND ON THE INSTRUMENTS EMPLOYED IN THE OPERATION. LITHOTRITY 75 Lithotrity, as an operation, owes its existence to the French surgeons, mainly to Civiale; but the labours of Leroy d'Etiolles, Amussat, and others Avere not without value in developing a system. My old friend Civiale, who died in 18G7, at a good old age, and full of honours, was the first surgeon to crush a stone successfully ; and this he did in the year 1824, Avith in- struments which he had designed in 1817. No doubt something resembling the pro- cess had occasionally been accomplished by patients themselves. In one instance a man had managed to grind doAvn with a small file a little stone in the bladder, a circumstance which has been dignified with the title of an operation of lithotrity. But the first man Avho designed and per- formed a systematic operation on the living patient was Civiale, and he operated on his first two patients before a committee of the Academy of Medicine, with this instrument that I hold in my hand. You see hoAv different it is from anything Ave noAv employ. It is a straight instrument, with a central axis and three claws, Avhich were made to project after its introduction into the bladder. [The manner of using it is shown.] You see what a very differ- ent mode, of proceeding that is from the method noAv adopted. It consisted in drilling holes in the calculus in various directions until it gave Avay, and each fragment was subjected to a similar pro- cess, until the Avhole Avas converted into debris. Notwithstanding the tedious char- acter and the difficulty of the procedure, it was, to a certain extent, a successful operation. I cannot now describe to you all the varied proposals made about and soon after this time, but the most impor- tant change was the production of an instrument in which pressure betAveen two blades placed at nearly a right angle \vith the shaft, constituted the agency by which force is applied. This was a great im- provement, to Avhich the profession is in- debted to a late Mr. Weiss, of London, at so early a period as the date of Civiale's first operation (1824). This system of crushing soon replaced the perforator, and although Weiss's instrument has since been modified in several particulars, his system is still the favourite one Avith all operators. While the method of Civiale was originally perforation and grinding, lithotrity became after Weiss's instru- ment Avhat it still is, a process of crush- ing. Let me here ask you to observe that a lithotrite always consists of two chief parts: viz., the prehensile part, which deals with the calculus ; and the power- regulating part, or that which receives and distributes the force applied by the hand. It was the first-named part above referred to, which had at this early period so nearly approached perfection. The next im- provements were those which related to the opposite end of the instrument which transmits the force to the crushing blades. Various ways of aiding and modifying this were tried : in one, the patient being fas- tened to a special bed, the lithotrite, which Avas extremely large and clumsy, was fixed in a vice, and the force Avas communicated by the blows of a hammer. [Baron Heurteloup, 1832.] The screw was used also in some form at or before this period— it is said first at the suggestion of Mr. Hodgson, of Birmingham. Costello sub- sequently made mechanical modifications in the details of the screw lithotrite, which still continued to be an umvieldy and dangerous instrument. Mr. L'Estrange, of Dublin, also made a useful alteration in it. The apparatus thus gradually im- proved, and used here long after this time (1840-55), is the next which I show you. It has become somewhat smaller, and therefore less likely to injure the urethra than its predecessors, but the power is applied only by means of a thumb-screw, Avhich Avorks very slowly. Nevertheless, it is the instrument with which Sir B. Brodie earned his success, and it is handled thus. [Explanation.] You see how much time is wasted, not only in the action of screwing home to crush a fragment, but in unscreAving in order to prepare the blades to seize another. No amount of crushing worth the performance could be executed in less than a quarter of an hour, and sittings of a much longer duration than this Avere quite common in using this instrument in order to reduce a small stone. Another change, useful in its day, was that in which the power Avas regulated by means of the rack and pinion; this was due to Sir William Fergusson, who used it almost to the end of his career, and by its means he shortened the process con- siderably. The next improvement was a very great one, and is due to Civiale and to the late M. Charriere, of Paris. An ingenious mechanism in the handle, moved by a disc there, enables the operator to exchange 76 DISEASES OF THE URINARY ORGANS. the screAV-movement for a sliding one at will, and vice versa. This saved all the time lost by the slow process of unscreAV- ing, necessary to open the blades of the previous instruments every time they have been closed. (Fig. 36.) f ■f Fig. 37.—Lithotrite with cylindrical handle. i- n^ t-i.i.„ A, wheel-shaped end of slid- *I*°-.° Tn- ■«£ "»g ^aft, held in the ope- tnte of Civiale ^ ^ h&n Y and Charnere. (,irects ^ moven;entg of the male hlade E. 1$, The screw. D, The hutton Avhich throws the screw into gear or releases it, as desired. C, The cylindrical handle attached by cuter shaft to the female blade Y. We now come to the lithotrite before you, the cylindrical handle of which is my own suggestion and design (Fig. 37); while the new mode of changing screwing into sliding action is due to Messrs. Weiss, and is much more convenient than the action of the disc in the instrument just described. And this combination has been adopted almost universally throughout Europe; and of course, as Avould naturally happen, various ' modifications' of it have been made by instrument makers and others, with the result only, as far as I have seen, of impairing its poAver in some way, such changes having evidently been devised through ignorance of the proper mode of using the original instrument. The principle of the cylindrical handle which I introduced, and for the importance of which I contend, is, however, retained in all the varieties—among others, in the lithotrites which Professor Bigelow has lately devised—and this circumstance is the best tribute which could be paid to its value. In what respect does it differ from pre- viously constructed handles? It enables you in the search for a small stone or small fragments, to execute rapid and delicate movements, which would be im- possible Avith an instrument without the cylindrical handle. It also enables us to operate in less time and with less disturbance to the bladder than any other instrument. Anything that will diminish the duration of the operation, and the amount of movement and con- cussion to the organs concerned, will necessarily give a greater prospect of success. I next call your attention to the blades of the instrument by which the calculus is to be seized and crushed; and you will observe that of these there are two specific varieties, termed fenestrated and non- fenestrated. Usually, Avhen the stone is large and hard, it is necessary to begin with the fenestrated instrument—one in Avhich the female blade is entirely per- forated, allowing the male blade to pass through it. This mode of construction furnishes the most poAverful lithotrites, with Avhich the most work can be done, while no blocking of the blades can occur, because all debris is driven through the opening, or falls aAvay right and left on the outside. The edges should be well bevelled, and the general contour should be such as to avoid all possible contact betAveen its toothed or cutting parts and the walls of the bladder. Forms may be seen below of tAvo LITHOTRITY. 77 varieties, one more, one rather less com- pletely fenestrated. (Figs. 38, 39.) After a large calculus has been broken into numerous small fragments by these in- struments, the crushing into debris suffi- ciently small to pass through a large evacuating catheter, is best accomplished by means of non-fenestrated, or flat-bladed lithotrites. Such instruments—or a modi- fication in Avhich a small opening exists in the female blade, Avhich is preferable—are adapted also to the majority of cases, in Fig. 38.—A fenestrated lithotrite. which the stone is of small size, or, indeed, of any size up to that, say, of a filbert, or an almond in its shell. They are more convenient and manageable than large and heavy instruments, and their blades are so flat that little space in the bladder is required to include a stone between them, beyond that which the stone itself requires. When closed, the edges of the blades, which are well bevelled, do not Fig. 39.—Another form of fenestrated lithotrite. meet, and the male blade is always nar- rower than the female, so that a groove exists all round between them, by Avhich included debris, Avhen too much is pre- sent, can be expelled. Pressure of the stone between such blades has a tendency to produce small debris rather than large fragments. But there are two chief varieties of these instruments, adapted for two different results required. (1) The Fig. 40.—Lithotrite with male blade very slightly wedge-shaped : the opening in the female blade should be rather larger than represented here. male blade may be made narrower than usual, and more or less Avedge-shaped, and then the function of the instrument is that of dealing Avith the rather larger and harder stones, and to make large frag- ments. (Fig. 40)l Such an one should be also a little fenestrated, and it should, 1 Only slight approximation to the form of the Avedge in the opposing surface of the male blade is permissible. If it has an angle, say of 90 degrees, 78 DISEASES OF THE URINARY ORGANS. of course, be rather stouter than the ordi- nary model. (2) The male blade may be made almost as wide as the female, and then the function of the instrument is to make fine debris; and its use is to complete the work commenced by the first. (Fig. 41.) The wider the blades are, the more liable they are, of course, to become impacted with debris in the blad- der. At the angle of the female blade Fig. 41.—Lithotrite with flat blades; the opening in female blade should be larger. there should always be some opening as large as can be made without materially weakening the instrument there, in order to permit impacted debris to escape, as at this point it is most effective for mischief; while, as I show you, rapid backward and forward rotary movements of the wheel at the handle (the screAV being in gear) will expel much of the debris at the sides. A collateral advantage of this flat-bladed in- strument is that it will hold a good deal of fine debris without undue augmentation of its size, so that not a little can be safely brought away by the urethra if desired, whenever the instrument is withdrawn. Such instruments should be made of steel of the finest temper, cut from the solid block (not forged), so as to be completely trustworthy. The power and leverage of the screw in the handle should correspond with the strength of the blades, and therefore with the amount of work they have to do. One lithotrite of each kind, the narrower and the wider male blade, suffice for all cases of moderate- sized stone in the adult. The next instruments we have to speak of are evacuating catheters and aspirators. Very early in the history of lithotrity, it was apparent enough to the surgeon that he might render his patient essential service if he could remove the debris, as Avell as crush the stone. Some of it of course might pass by the expulsive action of the passages, which is considerable; some danger is incurred; it may be driven through almost any stone, it is true, but the fragments will fly off right and left with prodigious force, even in fluid, and injure the coats of the bladder. Also, when the male blade has the form of a rather sharp wedge, the calculus is seized and retained with greater difficulty than with a male blade which is less salient. but a fragment was often impacted in the urethra, or several were irritating the neck of the bladder, and occasioning great trouble both to the patient and his attendants, to say nothing of the risks to life, by no means infrequent, occasioned by the presence of these foreign bodies. So large catheters were introduced, and a strong current of Avater was injected from an eight-ounce syringe, but often with Fig. 42.—Sir Philip Crampton's aspirator. results less efficacious than one might have expected. Heurteloup, particularly, employed means of this kind—1840-50. It was always a disappointing process: hence some other mode of suction was sought, and brought to bear on the contents of the bladder. Thus Sir Philip Crampton of Dublin used a glass receiver exhausted of its air, and attached it to a large catheter, with a result which was to LITHOTRITY. 79 a certain extent successful (1846). This was the first aspirator (Fig. 42). Soon afterwards Mr. Clover designed an india-rubber aspirator Avith a glass cylinder, trapped to prevent reflux of fragments, Avhich answered its purpose exceedingly well. The evacuating cathe- Fig. 43.—Clover's aspirator. ters were silver, Nos. 12 and 13 in size (Fig. 43). This apparatus was much used by myself at an early period to supplement the action of the bladder, and has been largely used by me ever since. In 1878 an important change was proposed, as is well known, by Professor Bigelow, of Harvard, U.S. He advised that the stone, however large, and without respect to the presence of cystitis or other considerations, should be invariably removed at one sitting, by means of more powerful lithotrites, larger evacuating ca- theters, and a stronger india-rubber bottle than had before been used; no matter how long the time which might be necessary to accomplish the task. He believed that less damage would be inflicted upon the bladder and related organs by a long single sitting, provided the viscus was completely emptied of debris thereby, than by the old process of taking away a little and often, but leaving fragments in the cavity, often causing continued and serious irritation. In order to carry out his idea he designed an aspirator with a long tube attached to the upper end of it, a method Avhich in practice does not answer well, from the constant presence of air at this part. For the purpose of the new procedure I constructed one ^specially adapted to it, light and small, so as to be easily grasped and governed by one hand, but with an opening at the top, by which Fig. 44.—Original aspirator of the author. it can be filled with water, to which all air accidentally admitted, if any, will arise, and by which it can escape. The Fig. 45.—Kecent change in the situation of the trap. loAver part is connected with the evacu- ating catheter by the shortest route to the bladder, and in such a manner that the aspirator can be detached with ease, and 80 DISEASES OF THE URINARY ORGANS. without loss of any contained water in so doing. Lastly, there is a trap into which all fragments must fall, and by which they are securely retained (see Fig. 44). Quite recently a little alteration has been suggested, as shown at Fig. 45, which is identical with Fig. 44 in every particular, except that the cylindrical receiver, which is in Fig. 43 directly under the bottle, and may be slightly influenced by currents, is removed to the front of it, in Avhich situation the receiver and its contents are less influenced by the backAvard and forward currents pro- duced by the hand of the operator, than in the original instrument. In neither Fig. 44 nor Fig. 45 is any stand required, and the connection with the bladder is the shortest and simplest possible. The connection of the aspirator with the bladder is also cut off in both instruments by the taps (*). The evacuating catheter to be attached tothe aspirator should be as large as the of instruments, or by the action of the calculous fragments Avhich are produced. That is Avhat Ave have to aim at, and if accomplished success is certain. Now, I need not say that by any cutting operation such a solution of the problem is impossible. There is at the outset a severe injury to the patient in the shape of a large and deep wound, and this necessarily constitutes a considerable risk. Let us see how far we can hope to solve the problem by lithotrity. I have said that all the chances of injury possible arise from these two sources: the stone itself, and the instruments used to ex- tract it. First, the stone. In its natural con- dition, as we know, it occasions no dangerous injury to the bladder, although it causes much pain, and ultimately chronic disease of the organs Avhich are concerned Avith it. But Avhen the stone is broken up into large angular fragments with sharp edges, these become a source of injury, and severe cystitis is readily induced by their presence. Hence it has ' urethra Avill admit; usually Nos. 15 or 16 of the English scale may be used Avithout any danger. Sometimes Nos. 17 or 18 are admissible ; but such sizes are quite unnecessary for small stones, and may produce mischief: hence they are only to be used Avhere the presence of a large stone demands corresponding instru- ments. The curves employed differ, and the apertures may vary in situation ; a choice of varieties should be available for different cases (see Fig. 46). Having thus described briefly the armamentarium Avhich modern lithotrity demands for its proper performance, we may ask next, so that we may obtain a clear idea of the object before us : What is the problem which this operation proposes to solve ? I reply, that it is the removal of a calculus without inflicting injury on the urinary passages; and if we reflect we shall find that injury is possible by this proceeding from two sources only—either in the employment always been an established principle directing all our proceedings, that the process of crushing the stone shall be conducted (so far as it is possible to do so) in such a way as not to produce and leave Avithin the bladder numerous sharp fragments. And if the calculus requires more than a single sitting to remove it, this system must be pursued. Now, hoAvever, that we adopt the method of emptying the bladder at one sitting, this danger from the broken stone no longer exists. In fact, it is the avoidance of the evils produced by broken stone when remaining in the bladder which constitutes the superiority of the one-sitting opera- tion. Secondly, the instrument used, and the method of manipulating it, may be productive of much injury, both to the bladder and to the urethra. It has, there- fore, been an object with me, first, to render the action of the lithotrite itself as easy and speedy as possible; and, secondly, to lessen, as far as I could, the number of instruments employed, the amount of Fig. 46.—Evacuating catheters. LITHOTRITY. 81 manipulation applied to them, and the time devoted to the process. I have shown you how, in conformity Avith this prin- ciple, I have endeavoured to design an instrument which should produce the least possible irritation. And I Avill only add, that if we can get an instrument which will do its work with less disturbance still, it will be, pro tanto, a valuable step in advance. Now, as to diminishing the number of instruments used. Formerly it was laid down as an axiom that you should never use a lithotrite in a patient's bladder unless it contained a knoAvn quantity of urine or other fluid. Hence the urine Avas always withdraAvn before introducing the lithotrite, and four or five ounces of water Avere injected. I have shoAvn that these preliminary injections are Avholly unnecessary, and I never use them—never even asking a patient to hold his Avater beforehand, nor Avhen he micturated last. It is said, ' If there is only a small quan- tity of water, how can you be sure that you Avill not injure the coats of the bladder in endeavouring to seize the stone ?' There is no difficulty in that respect, because these instruments are so con- structed that you can scarcely lay hold of the bladder with them, as we shall see, if you try to do so. When instruments were used in which the edges of the blades closed upon each other accurately it was different. But these edges never do so, they are Avell bevelled, and do not quite meet; hence the safety of the instrument. Then there is another species of me- chanical irritation which maybe metAvith. It Avas common—and it is so still, I be- lieve, with some surgeons—to withdraw large fragments of stone from the bladder through the urethra. The surgeon Avould lay hold of them with the forceps, or with some other contrivance, and Avould really seem to think he had achieved a feat of dexterity if he drew from the bladder a calculus as large as a bean. Now, in order to draw out such a calculus, it must first be seized; Well, if you have once seized it, Avhy not give it one turn of the screAv and reduce it to powder ? Why subject the neck of the bladder and the urethra to pain and injury by forcibly dragging through the latter a sharp an- gular fragment of stone. Never, on any pretence, Avithdraw a lichotrite with such a fragment, or overloaded with debris, if you can possibly avoid the necessity for doing so. Our object is to crush the stone into debris capable of being ex- tracted, safely through the evacuating catheter. Such are the instruments required for the modern operation of lithotrity. Acces- sory ones are, large conical metal bougies to ascertain the size of the urethra, in relation to the evacuating catheters which may be required, or to facilitate their in- troduction. Also a scalpel or short urethro- tome, to divide the external meatus, should be at hand, which may be necessary Avhen the latter is narrow. Urethral litho- clasts and other contrivances, to remove fragments impacted in the urethra, will not be wanted if we remove the debris artificially, as now ought almost in every case to be accomplished. I shall illustrate the actual perform- ance of the operation at our next meeting. subsequently when passing Avater. It Avas not until this process had been greatly improved that anaesthesia was discovered ; and after its introduction, Civiale, Avhose experience was the most considerable of any living surgeon, still preferred to crush without the aid of ether. By degrees, however, anaesthesia Avas gene- DIRECTIONS FOR PERFORMING We saw at the last lecture that the his- tory of Lithotrity Avas to a great extent identified Avith a history of perfecting the instruments employed. It commenced Avith drilling and grinding a small calculus by a slow and difficult process, a little fine debris only being made at each time, or sitting, which debris the patient voided LECTURE XIII. DIRECTIONS FOR PERFORMING THE OPERATION OF LITHOTRITY. 82 DISEASES OF THE rally adopted on this side the Channel, and one consequence was that Ave gradually ventured to crush more than formerly at each sitting, and more largely adopted the aspirator. We adhered more or less to the master's cautious style, and, unless the calculus was small, folloAved him in em- ploying three, four, or more sittings before emptying the bladder. For myself, as is Avell knoAvn, I have used chloroform (now ether), almost Avithout exception, for the last tAvelve years or more; and further, Avhenever severe .cystitis has appeared after the first or second sitting, I have operated at once, removing the whole of the calculus if possible, as the best means of treating the inflammation. But, during the last three or four years, I have carried out fully the principle proposed by Bigelow, of removing all the debris at one sitting, however large the stone, and have at- tained a remarkable success, as I shall have to show you at another time. Pro- fessor Bigelow gave to his procedure, already referred to, a new name, and not perhaps a very euphonious one, viz., Litholapaxy. I do not object to it on this ground, however, but I do for a more serious reason—namely, because the term was de- signed on the assumption that artificial ' evacuation of the stone ' (XlOos, a stone, and Aa7ra£is, evacuation) Avas a new pro- ceeding. Noav, this is not at all the case ; Ave have both crushed and ' evacuated' the stone for many years, and Ave had called the combined processes ' lithotrity,' a term thoroughly well and everywhere understood. But Ave had, as a rule, not completed the operation at one sitting. That is BigeloAv's idea, and an excellent one it is. Hence I proposed, and ahvays employ, the term ' Lithotrity at one sitting,' or ' at a single sitting,' to distinguish his operation, as conveying accurately the essential change Avhich he proposed; and I think it is noAv pretty generally accepted. It is this method which alone I have noAv to bring before you. Instead of taking aAvay, little by little, a portion of the stone, at five or six successive sittings of not more than three to six minutes each, per- formed every third or fourth day, until the Avhole Avas removed, the operation is completed at the first sitting. Formerly, Ave used the most delicate lithotrites, hand- ling them often in the lightest manner, Avith an eye on the patient's countenance, Avhose consciousness enabled us to know how far we might tax his endurance. URINARY ORGANS. Noav, Ave employ heavier instruments, and while care is as necessary as ever, and experience and tact in the management of them more than ever valuable in dealing with unusually hard and large examples, the amount of Avork to be done, especially in such cases, demands a vigorous hand and Avrist, strong, Avell-made apparatus, and as large as the urethra will fairly admit. Supposing Ave have decided to perform the one-sitting operation for any given patient, with a stone of average size; if he has never had any instrument in his bladder before, and the urethra is not very capacious, a young surgeon may do well to pass a bougie once or twice before operating, to make certain of a good route into the bladder. Such a proceeding, however, is rarely necessary. Then you should not be indifferent to the state of the patient's general health. You ought not to operate when there is an attack of fever, nor unless the digestion is in fair order, and the boAvels are acting tolerably Avell. Take care that you have the local organs, and the whole system, in as favour- able a state as possible at the outset. If his habits have been of necessity too active, as in the case of the labouring man who has been compelled to work almost up to the time of his admission to the hospital, a feAV days' quiet in bed, or nearly so, are useful before commencing operations. The Operation. The patient can be in no better situation than lying in his bed warmly covered, Avith long Avoollen stock- ings to protect the lower extremities from chill in case of long exposure; the mat- tress beneath should be firm. If a long operation is anticipated on account of the size of the stone, the warmth of the bed and the coverings referred to are im- portant. The operating table ordinarily employed is too high for the surgeon's convenience, and the air of an operating theatre is often less desirable than the Avarmth of the Avard or bedroom, together with that of the bed itself—for a rather large stone may demand twenty or thirty minutes. The longest term I have occu- pied has been seventy minutes; it was for a hard uric-acid calculus, of Avhich the debris weighed 2f ounces; the whole was completely removed in that time, and no untoward symptoms folloAved. But let me tell you that Avas one of the hardest labours of a manual kind Avhich ever fell to my lot: the amount of force Avhich must be expended on such a stone is very considerable indeed; LITHOTRITY. 83 and an exposure to cold air or draughts during such periods of time, might of itself imperil some patients' lives : hence the im- portance of these suggestions at the outset. The next point to be observed is the position of the patient. He should lie close to the edge of the bed, so that his right side is easily accessible to the operator; a small pillow should support the head, not the shoulders, Avhich should rest flat on the bed itself; a firm flat cushion, about three or four inches thick, should be placed under the pelvis: the knees should be moderately raised and flexed, and kept Avide apart—held thus, if necessary, by an assistant on the side opposite to the operator. The ether having been administered, I always take a conical steel bougie or dilator, about, say, 12 at the point and 15 or 16 two or three inches higher up and pass it through the urethra. If the meatus does not admit the bougie, at once divide the floor of the urethra there with a scalpel or urethro- tome. If the bougie now passes Avith per- fect ease the required space exists and the operation commences; if not, a smaller one is employed, and dilatation by means of two or three of these instruments passed one after another will probably accomplish all that is necessary. Of course, if any notable stricture is present it must be dealt with as such; moreover, its presence ought to be determined beforehand, and is not to be first discovered when an operation for crushing is arranged to commence. The lithotrite has noAv to be intro- duced. I have already mentioned that there Fig. 47.—Manner of handling the lithotrite in the bladder when searching is a difference in the mode of introducing the lithotrite and the catheter. You know that in passing a catheter, we, in this country, stand on the left side of the patient; in France, the surgeon stands on the right side. In passing the silver catheter for a recumbent patient, you hold it somewhat horizontally, draAv the penis gently over it, slowly raising the handle to the vertical position and then Avith a gentle SAveep depressing it toA\rards or between the thighs, Avhen the extremity of the instrument rises into the bladder. In passing the lithotrite a different movement is required. You may stand on either side, but it is better to be on the right side, as already directed, because that is the convenient side for operating, Avhile it looks awkward and wastes time to go round from the left to the right of the patient to operate after having passed the lithotrite. Well, then, standing at his right side, and partially turning your left shoulder to his face, you hold the lithotrite horizontally in your right hand, introduce the blades, gently drawing the penis over them as you sloAvly traverse the urethra with the instrument some four inches, during which the shaft gradu- ally rises nearly to the vertical position. Arrived at this point, you retain it in that position for a few seconds, allowing it to go on sinking, as it were, by its OAvn Aveight, still vertical, until the blades have slipped beneath the pubic arch. This done, you gently depress the handle towards the thighs, and the opposite end slides readily into the bladder. There is no more easy instrument to pass than the lithotrite with proper management. Having thus introduced the lithotrite, I have now to find the stone and seize it. In order to do this, I hold the cylinder lightly but firmly in my left hand, taking the Avheel-shaped handle of the sliding shaft Avhich is attached to the male blade in my right, and draAV it outAvards so as to open the blades Avithin the bladder 2 84 DISEASES OF THE URINARY ORGANS. (Fig. 47). Having done so, I then merely press it inAvards and close the blades; and almost certainly that simple action ensures that the stone will be found between them. I then draAv to- wards me the little button on the cylinder Avith the thumb of the right hand, which fragment into powder. Fig. 48 shows the position o£ the patient, and Fig. 49 the action of both hands, when holding firmly and crushing. This process is repeated several times until a fair quantity of debris has been made, and, if the lies someAvhat deeply behind an enlarged prostate. Or the stone may be small and lie there, escaping your search. You open and close the blades, and find nothing. Turning them to the right, and to the left, you still find nothing. You must then depress the handle of the lithotrite, and turn it half way round, action changes the sliding movement into a screwing one, turn the handle and crush. I then push back the button, again open and close the blades, and again have a fragment between them, when, by moving the button, the screw is again at my service and I crush the stone is not a large one, no pieces are seized which appear to be too large to issue by the evacuating catheter. In this manner, some eight or ten minutes may have been occupied. Sometimes a fragment escapes the lithotrite because it so that the blades are reversed and point downAvards; you will open and close, and then perhaps seize a small fragment deep behind the prostate. (See Fig. 50.) Noav, let me give you a hint about crushing, which is a very useful one. Whenever you have found a stone, or a good-sized fragment, and have crushed it, / \______________ Fig. 48.—Ordinary position for lithotrity. Lithotrite open and closed on a stone: shoAving relations of parts. Fig. 49.—Holding the lithotrite firmly and crushing. LITHOTRITY. 85 keep the lithotrite exactly in that place, and although you may have had some trouble in finding the calculus, you will now continue to find it several times running. It has often reminded me of fishing for perch ; when you have caught one, you may catch, perhaps, twenty or thirty more out of the same hole, if you will but stop there, and not go fishing about among the shallows. So in litho- trity, you may continue to seize and crush if you contrive to keep the litho- trite precisely in the same place. In fact, there is what may be called a certain favourite ' area' in every bladder in which to operate—a certain spot Avhich is a favourite haunt, so to speak, for frag- ments of stone. If you find that out in each bladder, you Avill always be able to crush the fragments; if you do not, you may often have some difficulty in dis- covering them. The area -will, of course, vary somewhat with the position of the patient. When the patient is standing, for instance, the area is not the same as when he is in a lying posture. It is then desirable to raise the pelvis two or three inches, in order to get an area for operating which is not too close to the neck cf the bladder. The neck of the bladder is a very sensitive part, and you should always avoid injuring it, and in drawing out the male blade you may easily hurt the neck of the bladder if you are not careful. One of your maxims in lithotrity should be never to pull out forcibly the male blade. You should pull it out carefully and delicately, so as Fig. 50.—Litliotrite with reversed blades in searching for small fragments. to feel the neck ; and it is a bad lithotrite, if the male blade does not slide Avith perfect ease; so as to enable you to perceive the slightest contact with the neck of the bladder Avhen, in opening the jaws, the male blade is drawn towards it. The diagrams Fig. 48 and Fig. 50, with the lithotrite in the bladder, will sIioav what I mean by the area for operating. If the patient is lying Avithout a cushion, it Avill be nearer the neck of the bladder than if the pelvis is Avell raised. It is more essential in the case of an enlarged prostate to put a high cushion under the pelvis, in order to throw back the frag- ments to the posterior part of the bladder, so that the area may be as far from the neck as possible. I will noAv suppose that the stone has been reduced to debris, or apparently so; the lithotrite is withdrawn, and an evacu- ating catheter, say No. 16, is passed into the bladder, from Avhence issue probably an ounce or two of urine, carrying with it some pulverised material into the vessel Avhich should be ready placed to receive it. Holding the end of the catheter in the left hand, the aspirator, ready filled with warm Avater, is taken in your right and attached to the catheter, the communicating tap is turned, and the right hand makes pressure and drives 86 DISEASES OF THE URINARY ORGANS. part of its contents into the bladder. On relaxing pressure the outward rush is seen into the spherical glass receiver, and usually numerous fragments, often most numerous at the Arery end of the current. This alternate entry and exit of fluid is maintained by the right hand several times, Avith a feAV moments of interval between each, by which time there is often a goodly collection of debris in the receiver, and the action is repeated until debris ceases to pass, or nearly so. Now, there are two or three maxims for the management of this apparently simple proceeding. First, let the act of injecting water into the bladder coincide with the act of expiration of breath by the patient, especially Avhen the respiration is deep and full, as it often is when ether is inhaled, and you Avill find no resistance to the hand. If, on the contrary, you attempt to inject during an act of deep inspiration, you will encounter obstruction to the entry of fluid and Avill do violence to the bladder. In obedience to the same law, let the expansion of the aspi- rator, and consequently the exit of the injected water, take place synchronously with an act of inspiration, and you will find the current and the passage of debris greatly promoted. When the breathing is very shalloAv and tranquil, there is no occasion to regard it. Secondly, When after crushing there is much debris still unremoved, do not let the end of the evacuating catheter rest on the floor, but let it be at about the centre of the bladder. On the contrary, when most of the debris is removed, and you are seeking a remaining fragment or tAvo, the end of the catheter should be slighty depressed on the floor of the bladder. Thirdly, If you perceive a sudden check to the outfloAV of the current to- wards the aspirator, and that the india- rubber reservoir suddenly ceases to distend, you may infer that a small rounded calculus, or a fragment nearly filling the channel of the catheter, stops the Avay. In these circumstances, press rather smartly on the aspirator tAvo or three times, so as to expel a strong current of Avater, and this will most likely displace the obstructing body and reopen the channel. Lastly, It is Avorthy of note that the action of the aspirator often enables us to decide whether the last fragment has been removed or not. The rattle of fragments against the end of the evacu- ating catheter in the bladder is very distinctly heard and felt; and as these become removed, the rattle diminishes, until at last a single tap perhaps only is felt, proceeding from a single piece just too large to enter the aperture of the evacuating catheter. This may be crushed and Avashed out, and then, if nothing whatever can be felt or heard, a strong presumption exists that all has been removed. In short, the instrument is an excellent test of a completed oper- ation, as Avell as an excellent means of rendering it complete. The proceeding which I have thus de- scribed is adapted to the great majority of calculi met Avith in the adult male: that is of uric acid or oxalate of lime weighing from one to about five or six drachms. Such require for removal a term varying from seven or eight to tAventy minutes or more, according to the size and to the facility of the operator. Phosphatic calculi are more easily disposed of. With the larger examples of the group above indicated, a strong fenestrated lithotrite should be used at first to break up the mass into fragments, and then a semi-fenestrated one may follow Avith ad- vantage. To avoid possibility of blocking, this should be withdrawn after using it four or five minutes, and be reintroduced: and Avhen the stone is large, say from six to ten drachms, the evacuator should be used to Avithdraw a quantity of debris before the crushing is completed. Thus the lithotrite may be changed three or four times perhaps, and the evacuator applied afresh tAvo or three times, before the operation is finished; while stones of larger size may be treated on the same principle, by a still larger number of in- troductions, if deemed necessary. One of the most important rules I can give you is, ahvays to employ instruments which are proportioned in size to the stone which is to be removed. The larger the litho- trite, the more irritating it is to the passages: hence it should never be larger than the Avork to be done requires. I have seen great mischief, and even a fatal result occasioned, by employing a large lithotrite Avhich has split the urethra, in order to remove a stone Avhich might have been easily and safely disposed of by a lithotrite of small appropriate size. I cannot too strongly reprobate such ill- LITHOTRITY. 87 judged or careless proceedings, which are not only disastrous to the unhappy subject of them, but discredit one of the most safe and certainly successful operations, Avhen properly conducted, in the Avhole domain of surgery. Immediately after a sitting, a hot lin- seed poultice may be placed above the pubes, and is a comfort to the patient. Pain and irritation are always much re- lieved by the repetition of this, or by very hot fomentation-flannels to the parts. The boAvels should act the day before or on the morning of the sitting, so that the patient may not have to rise soon after the operation and make efforts at stool. But if he is suffering severely, say three or four hours after the operation—a condition, by the Avay, which is quite uncommon—a hot hip-bath, as hot as he can bear it for fifteen minutes, gives great relief. The treatment for the first three or four days in cases of large calculus is that of a mild acute cystitis: recumbent position, ex- ternal warmth, frequent hot hip-baths, and small but frequent doses of solution of potash, just to neutralise the acidity of the urine. If the urethra is over-stretched or bruised, an india-rubber catheter may be tied in for twenty-four hours or so, but this is not frequently necessary ; Avhile if the bladder had previously lost the poAver of emptying itself, such an inlying catheter for a day or tAvo is mostly better than frequent catheterism. There is one rather remarkable cir- cumstance which I have met Avith in a considerable number of the cases referred to, and which I confess I am not quite able to account for. It happens in a large proportion during the three or four days immediately following the operation, that the relief is considerable, that the urine is clear, that the bladder tolerates a large quantity, and the aspect of the case is one of rapid and unchecked convalescence. But on the fourth or fifth day a little ex- citement appears, the bladder becomes Fig. 51.—Long urethral forceps for removing fragments. irritable, the urine is cloudy, and after tAventy-four hours or so subacute cystitis is established, often destined to be trouble- some for a week or two. I have remarked these phenomena so frequently that it is impossible not to look for their occur- rence ; and I am satisfied now that they appear in spite of precautions, and are by no means necessarily the result of an im- prudence on the part of the patient. The liability pointed out, however, indicates that it is most desirable to enjoin the re- cumbent position, confinement to the room, a Avarm temperature (in cold weather), and care in every particular of manage- ment for at least some days after crushing a calculus, whatever its size. One troublesome circumstance that very rarely happens is the impaction of a fragment: and I think if you adopt the system of lithotrity Avhich I have endea- voured to expound, you will very seldom meet Avith it. I have never had to open the urethra to remove a fragment in my life. I have occasionally had to remove one by the forceps, but that is very rare ; and among the many complicated instru- ments which have been invented for this purpose, I know nothing so good as the common long forceps Avhich I shoAV you here. (Fig. 51.) During the last seven years, certainly, I have not had occasion to use them. The more thoroughly you crush and remove the stone, the less use there will be for forceps. Here is a bottle containing Avhat I will venture to call a well-broken stone. You see it is almost powder: a very different product from that in the other bottle, Avhere you see a number of large fragments that Avere pro- bably passed Avith difficulty. It is an old saying, ' A carpenter may be known by his chips :' certainly the skill of the litho- tritist may to some extent be known by the debris he makes. With large evacu- ating catheters and a good aspirator, such complete crushing is no longer so neces- sary. It has been objected to lithotrity—and there was some truth, perhaps, in the alle- 88 DISEASES OF THE URINARY ORGANS. gation formerly, but not noAv, if the opera- tion is well done—that one is never quite certain of getting rid of the last fragment; that a portion may remain and become the nucleus of a future stone. But there is very little more difficulty in removing the last fragment than any other, pro- vided Ave pursue the proper course. Generally speaking, in nine cases out of ten, the last fragment is removed as the preceding have been—that is, by the aspi- rator, which is now the chief agent in re- moving all debris from the beginning to end of the case. But suppose you have reason to believe that a fragment remains just too large to pass, judging from the continuance of pain, &c.—youthen take a lithotrite Avith short wide-rounded blades, with which you can explore easily in the reversed position. With this instrument or fulcrum (see Fig. 52). With this form of handle, and with no other that I have seen, is this possible. "By one or other of the means pointed out there ought to be no difficulty in de- tecting and removing the last remnant of a crushed calculus from the bladder. Nevertheless, it is true that when this has been done slight troublesome symptoms may still continue. This subject Avill be fully considered at our next lecture. I may here state, in reply to a ques- tion often put to me, that for the purpose of acquiring the practice necessary to qualify you to operate, there is no doubt some advantage in becoming familiar with the proper mode of handling a lithotrite by using it in the dead body. But you will find a great difference between the sensations communicated to your hand by the movements of the instrument and the stone in the living and in the dead body. The sensations in the latter case you may thus search the whole floor of the bladder Avith perfect safety. And for this purpose the cylindrical handle es- pecially is of great value. It is quite easy to procure an audible note from a fragment no bigger than a split pea, as I have times Avithout number demonstrated in the wards and elseAvhere, withdrawing the little bit entire after it has been struck for the purpose of verify- ing the observation. The handle of the lithotrite should be depressed, the beak turned downwards behind the prostate, and the forefinger of the left hand placed on the shaft an inch below the handle. Very slight and quick rotary movements, alternately right and left, should be made with the right fingers lightly holding the cylindrical handle, Avhile the shaft turns on the end of the left index as on a pivot are simply those of a stone lying in obedience to gravity at the bottom of a flaccid bag, Avhich has no life of its OAvn, nor any power of movement, and is sub- ject simply to mechanical laws. In such a cavity the foreign body is uniformly found at one place, and cannot be missed. Totally different is the sensation of en- countering a similar body in a living bladder. By no means does the stone appear always to obey the force of gravity, and to lie at Avhat you believe to be the bottom of the viscus. Sometimes, indeed, it seems strangely otherwise. The bladder has movements of its own, which are doubtless aroused or called into a2tivity by undue disturbance occasioned by in- struments : and the result of these at times is strangely to displace, as one must imagine, the calculus sought. This is one of the reasons Avhy a stone is more readily and certainly seized, when the lithotrite has been very quietly and easily intro- Fig. 52.—Mode of searching for the last fragment ; the blades turned doAvnwards. LITHOTRITY. 89 duced, Avithout the disturbing influence of a preliminary injection; Avithout, so to speak, awakening the resentment, if I may use the term, and reflex contractions of the bladder which it occasions. I must briefly mention certain con- tingencies that occasionally arise in con- nection with the operation of lithotrity, some of which will be considered in their appropriate places in subsequent lectures. The first contingency to be referred to is fever; the second is bleeding; the third is cystitis just referred to ; the fourth is orchitis; the fifth is retention of urine (see next lecture) ; and lastly exhaustion may occur Avhich is sometimes fatal. What is usually termed ' fever' is a series of phenomena, Avhich denote a peculiar disturbance of the nervous sys- tem, the product of mechanical inter- ference with the male urethra. Thus a slight over-dilatation of the canal with a bougie, and still more the occurrence there of some considerable lesion, may produce a febrile attack; Avhile, on the other hand, severe injuries may be in- flicted without any fever following. So in performing lithotrity by several sittings a febrile attack is by no means an unfre- quent occurrence, although sometimes a patient passes through all his sittings without it. The attack, Avhich usually commences Avithin three or four hours after the occurrence Avhich has provoked it, often directly after the first act of micturi- tion which follows, is announced by a rigor lasting from ten to tAventy minutes and per- vading the whole body. The patient then gradually becomes hot, is flushed, restless, and thirsty, complains of pains in the head and back, or in the extremities, and of feeling Aveak. After an hour or two sweating takes place, and Avith it comes sensible relief to pain and restlessness, but the patient remains always more or less Aveakened by the attack. What I have now chiefly to 'say is, do not ' meet the symptoms' by a too active treatment. I can recommend no drugs in these circum- stances as a rule; a moderate dose of opium being perhaps almost the only exception, since, for some, by no means for all, it acts as a restorative. When the patient is in the stage of rigor, let him be Avell covered Avith blankets, and let hot water-bottles be applied liberally: some hot tea is better than brandy and water, the popularremedy in these circumstances, as in many others where it is not merely harmless but prejudicial. As he becomes warm, remove the coverings cautiously, and let him have soda-water and seltzer, or toast and water freely, to quench the thirst Avhich accompanies this stage; effervescing citrates are also agreeable and may be prescribed. The patient will have no relish for any solid food until the attack has passed off, and the pulse and temperature, Avhich rapidly rise and which almost as rapidly fall, have nearly reached the accustomed standard again. Herpetic eruption about the mouth often folloAVS. The phenomena so described are not to be regarded as ' fever' at all, in the sense in Avhich it is employed by the physician as denoting a specific malady. They simply indicate that a struggle, to speak roughly, is taking place in the sys- tem with greater or less vehemence against some poison Avhich is in the process of being eliminated. The attendant has mainly to take care that the hygienic con- ditions are good, and that the patient's strength is restored, as far as possible, by mild nourishing diet and auxiliary treat- ment. However, there can be no doubt that one of the advantages attained by the one-sitting method, is the diminished fre- quency of these ' feverish ' attacks. They arose, no doubt, from the cystitis set up by remaining fragments; for it is quite common now to remove large quantities of debris with a good deal of mechanical disturbance, and if the bladder be com- pletely emptied, to find the patient free from any attack of the kind described. Bleeding, as a result of the operation, is very rarely troublesome, and does not require much treatment. Cystitis gives a little trouble occasionally, and is to be treated in the ordinary way described in due course. Inflammation of the testicle requires us to desist for a time from operating. Chronic retention of urine is apt to occur very insidiously—not abso- lute, but partial retention. Always be on the Avatch for it after any sitting, if frequency of micturition increases, and the urine contains much muco-pus, and particularly if it becomes alkaline; in Avhich case pass a soft flexible catheter with all the gentleness you are master of. If you find that the bladder does not empty itself by its OAvn power, you must repeat the process once, twice, or more frequently, according to circumstances, in the twenty-four hours. If, however, the freshly passed urine is decidedly acid, 90 DISEASES OF THE URINARY ORGANS. however frequently it is passed, you may spare the patient the catheter, and the pain Avhich it is apt to cause in these con- ditions. Sometimes a patient's strength has been miscalculated, or repeated attacks of fever have undermined it, and he suc- cumbs without other knoAvn cause. Phle- The most common course of a patient's history subsequent to the operation of lithotrity is—and I say this after an ex- perience as you know embracing many hundred cases carefully watched and inquired after—a complete immunity from the reappearance of calculus, and immunity also from troublesome urinary symptoms. There are literally scores of men now en- joying life, free from their former symptoms, in each of whom a successful operation of lithotrity has checked, once for all, the pain and danger incident to the presence of a stone in the bladder. Besides these, there is a certain proportion of patients in whom stone re-appears; a circumstance more commonly observed, indeed, of neces- sity more evident, since the introduction of lithotrity than before. These form two very distinct classes: the one consist- ing of individuals with a strongly-marked tendency to produce uric acid, and who continue to form calculi of that material during many years. On several patients I have operated for no less than three consecutively formed uric-acid calculi; intervals of three or four years elapsing between the formations of these calculi, while in two patients I have done this four times; one of the last-named in- stances is living and engaged in an active mercantile life at this moment (1882) at the age of seventy-four years. When lithotomy was the only mode of removing stone, these patients were unable to sub- mit so frequently to operation as they now are; moreover, it Avas much oftener fatal than is lithotrity, and, therefore, but too effectually sometimes prevented the possi- bility of fresh formation ! bitis occasionally appears; and with, or Avithout it, deposits may occur in various parts of the body as the result of blood- poisoning. Such conditions are almost invariably fatal. Happily these are rare and exceptional circumstances, which litho- trity, like other operations, is liable to produce. The other class consists of that large number of persons who, most commonly from the presence of hypertrophied pro- state, have lost the power of emptying the bladder by the natural efforts, and habitu- ally retaining decomposed and alkaline urine, sometimes become the subjects of phosphatic calculus. This although re- moved entirely by the lithotrite often re- appears in spite of much precaution ; and many persons now owe their lives entirely to the fact, that once or twice a year some phosphatic matter, a small concretion or a semi-solid mass, not worthy to be regarded as a calculus, is easily and safely removed by the lithotrite and aspirator. And many a man's life is prolonged and ren- dered tolerable on such conditions; a re- sult which also was not possible when the only mode of removing this material Avas a resort to the knife. I referred in our last lecture to the continuance of frequent and painful mic- turition—to the persistence, indeed, of slight chronic cystitis—as a phenomenon occasionally met Avith after lithotrity; and this, notAvithstanding that Ave have satis- fied ourselves by sufficient exploration, that every fragment has been completely removed from the bladder. Cases of this kind form another class closely connected with the last named as we shall see, and it is Avith their management that Ave shall occupy ourselves to-day. The first inquiry you are to pursue under these circumstances consists in ascertaining Avhether the patient quite empties his bladder. Let him first pass all the urine he can, then introduce a soft catheter, and mark how much is left LECTURE XIV. CONDITION OF PATIENTS AFTER LITHOTRITY IN GENERAL--RESULTS OF THE SINGLE-SIT- TING OPERATION IN PARTICULAR, IN REGARD FIRST, OF MORTALITY ; SECONDLY, OF THEIR SUBSEQUENT CONDITION. RESUME OF EXPERIENCE RESPECTING IT. LITHOTRITY. 91 behind. If you draw offonly three drachms of urine, Avhich may be a little cloudy perhaps, you will probably afford him relief, and may clear up the case. It is quite remarkable how small a quantity of residual urine will give rise to pain and irritation, and that so insignificant an amount may, if neglected, gradually in- crease and form a nidus for the deposit of a phosphatic stone, and so lead to bitter dis- appointment in the place of what might have been satisfaction at a successful result. Let me say at once that negli- gence in relation to this matter is the chief cause, beyond all question, of the subsequent troubles which occasionally become evident at an early period after the stone has been removed, and Avhich have constituted, in a certain proportion of cases in elderly men, sources of dis- credit to the crushing operation. In the cases referred to, the calculus may have been removed easily enough, some little cystitis, but no other trouble having occurred during the procedure; but it becomes evident afterwards that the fre- quency of passing Avater is not remedied, and small pains and discomforts still con- tinue. The patient leaves his surgeon, and reappears in a few months, or even Aveeks, passing clouded, perhaps alkaline, urine, depositing triple phosphates, and with his local symptoms aggravated. These phenomena may sometimes be due to the escape of a small fragment into a sacculus in the bladder, where it becomes the source of irritation, phosphatic deposit, and occasions the formation of a fresh vesical calculus, Avith ceaseless discomfort and requiring repetitions of the crushing process to relieve it. In a large majority of cases, however, this is not the cause, and the symptoms in question are due to another cause, which is often in a great de- gree preventible. For these after-troubles may appear in patients who have had very little uneasiness antecedent to the operation. Their stones have been small, and their bladders have been in excellent condition ; no ground, therefore, can exist for supposing such patients to be the sub- ject of sacculus in the bladder. Every presumption, indeed, is opposed to that vieAV, because sacculi, as a rule, do not form without the existence of an obstruc- tion to the outflow of urine, Avhich has been in operation for a long period of time. Now, the particular fact Avhich I am going to state is one I was scarcely aware of twelve years ago. I have long been aware of the necessity of carefully watching patients during lithotrity for any sign of inability to empty the bladder, have long also invited attention to the insidious manner in Avhich that inability com- mences, and pointed out that it must be dealt with by the habitual use of the catheter. But I have only learned during the last few years how extremely small a quantity of urine habitually left behind in an elderly patient's bladder after each act of micturition, provided that he is undergoing, or has just undergone, litho- trity, suffices to lead to phosphatic deposit and to chronic cystitis. You will scarcely believe me that one drachm, or one drachm and a half, only of this residual urine is enough in exceptional cases to produce the condition so feared and detested by every lithotritist; ' and I now add, that if the condition is detected early, and this small quantity is promptly and frequently re- moved by the patient himself, Avhich he can easily do with a soft coude'e catheter, almost certainly the dreaded symptoms will not appear. I have been surprised at the result; not less surprised than I have been at the fact that the patient who toAvards the close of lithotrity, or afterwards, is making urine every hour or so, and who, on pas- sing his catheter, finds only one or two drachms behind, often obtains at once an interval of three hours or more. Such an one should pass his instrument at least three times a day until he regains the power to empty the bladder completely by his own efforts. I confess that formerly so small a quantity of urine did not seem to me Avorth the trouble of removing ; as I assumed, on theoretical grounds of course, that it could not be of any impor- tance. I now knoAV that the practice of removing it constitutes for many cases the difference between a permanent success and an ineffectual result and painful future. Now then, how does the plan of crush- ing for cystitis, referred to under the pre- ceding head, affect, as I said it would, 1 It is not to be supposed that I regard so small a quantity as equally important in a patient whose urine is clear, who is not the subject of any chronic cystitis, and who is not undergoing lithotrity. In an elderly man the presence of a drachm or two of ' residual' urine suggests that at some future time he may require the catheter, but certainly it would not yet be necessary. 92 DISEASES OF THE URINARY ORGANS. also this important question Avhich Ave are now discussing ? Thus : it is precisely in those cases Avhere the treatment has been prolonged, or Avhere cystitis, either acute or chronic, has been allowed to go on unchecked, that the inability to empty the bladder is most likely to occur. Again, this inability, once commenced, very rapidly becomes the established order of things in elderly people, unless it is checked at the outset. Once let the blad- der be accustomed to the smallest degree of accumulation of urine, and the power to empty itself entirely is, after a certain age, often permanently lost. The best chance of preventing this, and the phos- phatic deposit which results, is, in the first instance, to avoid or diminish cystitis during the treatment by lithotrity in the manner described ; and, secondly, to teach the patient to empty his bladder himself towards the close of the operative pro- ceedings or immediately after, if the smallest failure to empty it is detected. Once for all, let me say, 1 cannot exagge- rate the importance of these recommenda- tions. Noav, when this tendency to produce phosphatic deposit has been unfortunately established, Ave are often able to benefit the patient by teaching him to wash out the bladder once or twice a day with Avarm water. For this purpose the four-ounce india-rubber bottle, Avith brass nozzle and stopcock fitting the catheter usually em- ployed, is the best instrument—one-third only of its contents is to be injected at a time, and this quantity is to run out be- fore the suceeding third is introduced. To the Avater should be always added either carbolic acid in the proportion of one grain to the ounce, or the solution of the permanganate of potash (Condy's), six or eight minims to the ounce. Either of these disinfectant solutions, the first-named being perhaps mostly preferable, should be employed as preliminary to all other in- jections; they are not in the slightest degree irritant to the bladder, and they deodorise and cleanse the interior. Fur- ther, and this is a fact of some importance, carbolic acid does not decompose any solution of metallic salts which it may be desirable to inject afterwards or in combination. The bladder being thus kept in good sanitary condition, the next consideration is, what agents are to be employed to promote healing action in the diseased mucous membrane ? The best are salts of silver, copper, and lead, very weak solutions of Avhich should be used at the first occasion of applying them ; A\ratching carefully the result before augmenting their strength, and doing so very gradu- ally. The nitrate of silver should not at first exceed in strength the proportion of one grain to four ounces of distilled water; even one to six ounces is preferable if a patient is more than usually susceptible. It should ahvays be preceded by a cleans- ing or deodorising injection to remove from the surface to be acted upon the muco-pus Avhich is coagulated by the solution of silver, and tends to hinder contact between the mucous membrane and the agent. If very little inconve- nience folioavs, a slightly stronger solution should be used after an interval of two or three days, always avoiding an increase in strength sufficient to produce any severe or long-continued pain. But of late I have adopted a further extension of this method, and Avith mani- fest advantage. I advise the patient (who may or may not be habitually using the catheter to empty his bladder) to use every second or third day the following apparatus:— (1) A black flexible catheter, No. 11 or No. 12 in size, made thin, and with polished interior, so as to facilitate the passage of debris through it (a great im- provement on the ordinary French flexible catheters, Avhich are thick and have often rough interiors), and having a large oval eye on the upper surface of its extremity, which is slightly turned upAvards (coude'e). (Fig. 53). (2) An eight-ounce india-rubber bottle, with a brass nozzle (B) Avhich fits over the outer end of the catheter, and not into it. The manifest result of this mode of attachment is, that a powerful uninter- rupted current can enter and issue from the bladder; indeed, it is scarcely possible that debris should remain in the organ under the influence of the action of this apparatus, as any one can perceive on using it. It may also be used as an aspirator, with a backward and forward current, if desired. For the patient's OAvn use it is even more easy than the ordinary four-ounce bottle, Avhich I have long been in the habit of desiring him to apply, since the size and freedom of the channel —not narroAved at the point of contact betAveen bottle and catheter—permit the LITHOTRITY. 93 fluid to be propelled with very slight pressure. I come now to a very important sub- ject in relation to the practice of that particular form of lithotrity Avhich I have taken upon myself to commend to you, as a great improvement of the old operation conducted at several sittings : I mean the operation which is completed, in almost every case, at a single sitting, and ends with the entire removal of the stone. I could not recommend the operation to you until I was warranted in doing so by a considerable experience. I dare not years, without any exception. During this term I have operated on 112 consecutive cases of elderly men—that is, on 112 sepa- rate individuals, no one individual having required during that period to be operated on a second time.1 I have included no case of mere phosphatic concretions, Avhich frequently require to be crushed for patients who pass all their urine by 1 Eighty-nine of these cases were reported, each one with the weight of stone and name of his medical attendant with whom 1 saw the case, in my paper on the subject at the International Medical Con- gress in August last. The twenty-three remaining cases have been operated on since. take so weighty a responsibility on my shoulders, unless I could produce before you results, not only on a large scale, but results of a very unmistakable kind. The points before us now are :— First, what is the mortality following the operation ? secondly, what is the sub- sequent condition of the bladder, at some distance of time after the operation has taken place ? In relation to the question of mortality I may say, that during the last three and a half years, I have employed this method almost entirely; and fcr the last ■ two catheter—urine which is alkaline and liable to deposit phosphates. These are not cases of ' stone in the bladder,' and have no right to be so regarded. The mean age of the 112 individuals is over sixty- two years and a half. The number of uric-acid calculi is sixty-four, of oxalates four, of mixed calculi fourteen, and of phosphates thirty. The number of deaths is three only. This is a better result than I have ever before accomplished. I have operated on a similar number by the old method, once with six deaths, but the average of upwards of 400 cases reported Fig. 53.—A, the catheter described. The actual measure of the drawing is No. 9. It will be understood that the size indicated is usually No. 12. B, the nozzle of the bottle, which fits over the end of the catheter, A. 94 DISEASES OF THE to the Royal Medical and Chirurgical Society was 7\ per cent, mortality. I am sanguine enough, therefore, to hope, judging from this experience, that the mortality of the stone operations is redu- cible by the single-sitting method mate- rially below that of any previous one. Never, I believe, has it in the history of surgery hitherto fallen to the lot of any man to operate for the stone on 112 elderly male patients Avith only three fatal cases. The once famous eighty-four cases of Martineau, with tAvo deaths, contained only twenty-four over fifty years of age (only eleven indeed over sixty) and in these the two deaths occurred. A feAV among the rest were young men, the ma- jority were children, and in these no deaths took place. Among Martineau's elderly patients the mortality Avas fully 8 per cent., an excellent result, and rarely attained by any of the older operators. The mortality now recorded in consecu- tive adult cases of under 3 per cent, is, I confess, a better achievement than I had ever ventured to hope for. We devoted the former part of this lecture to a consideration of the condition of patients after lithotrity, from a long ex- perience of that operation as it has hitherto been performed. And we have seen that in a certain limited number of instances, chronic cystitis with phosphatic deposit occurs. Even after lithotomy this event is not unknown, although it is very un- common. I have at this moment under my care an obstinate case which I cut eighteen months ago, the primary results being excellent. Noav, what is our experience of this complaint after lithotrity at a single sitting? It has been said, but I fear hastily, that this operation has banished these unhappy cases from practice. I regret to say, indeed, that so great an ad- vance, cannot be affirmed. I think one of the worst, one of the most persistent, examples of phosphatic cystitis I have seen of late years folloAved an operation in which I removed with great ease a small uric-acid calculus (eighty-four grains) in six minutes, not quite tAvo years ago. Gradual improvement has taken place, but for a few months frequent micturition, much pain, and repeated production of phosphatic deposit Avere experienced. A similar case occurred about the same time, but this recovered soundly by the follow- ing spring. In four other cases of the URINARY ORGANS. series referred to there Avas persisting cystitis for three or four months after the operation, but not longer. All these are cases in which the calculus Avas uric acid, and cystitis was not present before the operation. When the calculus has been phosphatic, removed from a bladder habitually emptied by the catheter on ac- count of large hypertrophy of the prostate, and cystitis has pre-existed, it is almost invariably much lessened by the operation; but its continued existence in such a case to some extent is often a necessary con- comitant of the organic changes in the organs, and involves no discredit to the surgical procedure. But I think I am justified in conclud- ing that the occurrence of the morbid con- dition of the bladder following lithotrity for uric-acid and oxalate-of-lime calculi in previously healthy organs is observed less frequently than heretofore. I venture to believe that the improvement in this respect may be considerable. In order to guard against the danger, our first care should be to avoid in every case where it is possible to do so, the use of instru- ments, whether for crushing or evacuating, which over-distend and irritate the urethra and neck of the bladder. At least our rule must be not to employ larger instruments than the size of the stone demands. I cannot too earnestly warn the inexperienced lithotritist against the needless risk he incurs Avhen, in pre- sence of a small or moderate-sized stone (and the majority met Avith belong to one of these two categories), he uses the heavy lithotrite and the large evacuating tubes which have of late been introduced into this country. In order to remove two or three hundred grains of calculous matter from the bladder—and many calculi Aveigh less than a hundred grains, while all ought to be found before they attain that Aveight —it is wholly unnecessary, I will even say it is unwarrantable, to introduce litho- trites and evacuators with the diameter of No. 18 or 20 English scale into the bladder. I am certain that the mere splitting, for it is not dilatation, of the urethra and neck of the bladder, which sometimes follows the introduction of such instruments, has sufficed to produce sym- ptoms often distressingly painful, some- times obstinate in duration, occasionally fatal. Surely it is more prudent to bestow two or three minutes more on the work, to ensure more complete crushing, so that LITHOTOMY. 95 the debris may be removed by a tube of 15 or 16 English diameter, than to crush coarsely and use an evacuator which in- fallibly inflicts serious mischief in a certain proportion of cases. I will briefly sum up our subject thus : Lithotrity completed at a single sitting is in experienced hands an operation un- equalled in its safety for the patient. It appears also to produce less subse- quent persisting irritation of the bladder than the operation by several sittings. No new form of instrument is required by this operation. The value of the proceeding lies alto- gether in the removal of all the foreign matter from the bladder at once, so that nothing remains to excite inflammation in an organ already irritated by the process. And the less irritating the operation has been, the more certain and more speedy will be the recovery. It should be employed by beginners only for calculi of moderate size when hard. If calculi are large as well as hard, a young surgeon will probably proceed more safely by lithotomy. In friable phosphatic calculi, size offers a much less serious difficulty. Lithotrity at a single sitting for a hard calculus, upAvards of an ounce in weight, and a fortiori, when double that weight, certainly demands an experienced operator. LECTURE XV. ON LITHOTOMY IN MEN, AVOMEN, AND CHILDREN. Gentlemen,—It Avas understood, as the result of our discussion in the first lecture on Stone in the Bladder, that all cases below the age of puberty, Avith Arery feAV exceptions, should be cut; those only in which the stone is extremely small being reserved for lithotrity. Then there were certain adult cases, where the stone is very large, or other difficulties exist, in which the operation of cutting must be performed. Hence we have next to study the operation of lithotomy, and this ad- vantageously follows the consideration of lithotrity. The proceeding of ' cutting for the stone' has always been a subject of ex- treme interest; indeed, you will find no operation that has a greater fascination for the veteran operator, while there is none which more excites the ambition of young surgeons. There is no achievement which a former student is so ready to come here to tell his teacher of, as this, ' I have just successfully cut my first stone case down in the country,' and he does so with laudable pride and a happy sense of neAvly acquired power. On the other hand, the true surgeon who loves his art is always profoundly inter- ested when the theme of discussion em- braces thehistory and practice of lithotomy. And as 1 believe that some acquaintance with the former is one of the best ways of commencing a study of the latter, I Avill give you a slight sketch of this extensive subject (for its entire literature would suffice to stock a library)—that is, of the different stages by which lithotomy has arrived through earlier periods at its present condition. The first description Ave possess of the operation of lithotomy appeared in the Augustan era, at which time it had been performed some hundreds of years, among the Greeksand Romans. I shall speak, there- fore, first of lithotomy under the Classic pe- riod ; and the operation then described con- tinued to be performed, as far as we know, throughout the Middle Ages. Secondly, I shall give a sketch of improved methods which arose with the revival of letters; and lastly, of the operations adopted during the last and present centuries, marked as this period is by disregard of ancient authority as the sole and sufficient guide in all matters Avhich are determinable by experiment and observation. I dare say there was an earlier period than any of these, and if some enterprising Lyell in relation to surgery, Avould make the in- quiry, he might find traces of a pre-histo- ric period: because, wherever there are human remains, calculi must exist. I do not knoAV hoAV long uric-acid stones might 96 DISEASES OF THE be expected to endure. We knoAV that the excreta of fishes have been preserved for many thousands of years, and I doubt not that some of these human excreta might be found also, and that oxalate-of- lime calculi, at least, must exist among other ^human remains. As so many ob- servers are seeking the early records of the human race, I throw out the hint ; and certainly, if I were so searching, I should not forget to seek, among other things, the matters in question. Whether we shall thus ever find any instruments which could be identified as the means by which those stones may have been re- moved is extremely doubtful. We will, however, not occupy our time with speculation, but will be satisfied to begin Avith such facts as we can find, say about 2,300 years ago. The first allusion on record is in the works of Hippocrates [born B.C. 460], who obliged his pupils to take an oath that they would never practise lithotomy, but leave the operation to those who Avere in the habit of performing it; thus indicating his sense, at all events, of the gravity of the proceeding, which he appeared to think too hazardous for men to undertake Avho were not specially trained for the purpose. To such he recommended that stone cases should be left; it is clear, therefore, that at this early period the operation Avas recognised as an established surgical pro- cedure. But it was practised, not as any part of general surgical duty, but as an occupation by itself, and, at any rate in the estimation of physicians, not a very exalted one, being only in the hands of certain itinerant performers. After this, Celsus, who probably flourished about the commencement of the Christian era, de- scribed the operation as it was practised by these men. In his seventh book he gives the details, and termed it ' cutting on the gripe.' The method was simple, and so Avere the instruments, on which account they were long afterwards termed the 'apparatus minor,' to distinguish them from the ' apparatus major' of another operation, which came into vogue in the second period. The ancient or classical method was thus conducted. The opera- tor commenced by placing his patient, usually a boy, upon the knees of a man who was seated. If it was an adult patient (but such Avere rarely cut), two men sat side by side (their legs forming the operating table), so that their arms URINARY ORGANS. might clasp the patient and control his struggles. The operator used no staff whatever, but inserted two or three fingers into the rectum, and endeavoured so to feel the stone, which he could only do Avhen it was large. If he succeeded in recognising it, he firmly fixed, or ' griped ' it Avith the ends of his fingers—hence the term ' cutting on the gripe; ' and pressing it down towards the perineum, he made a semi-lunar cut with a broad scalpel until he reached it. Then, if unable to press it out Avith his fingers, he drew it out Avith a hook. Now, this very rough pro- ceeding universally prevailed until about the sixteenth century ; indeed, up to the seventeenth century it Avas largely prac- tised in Europe. Even in the latter part of the seventeenth century, when Frere Jacques appeared, the ancient mode of cutting on the gripe Avas chiefly practised. We now reach the second period, or that of the Renaissance, when at least three different operations appeared. Ap- propriately enough, too, a brother of one of those monastic orders which had che- rished and exercised most of the arts hitherto, figures now as the most famous operator. First, we will consider the ' Marian method' or ' apparatus major'—a median operation, originated by Johannes de Romanis, but receiving its name from his pupil, Marianus Sanctus, Avho published the first account of it a.d. 1524. It is called the' apparatus major' because, Avhile ' cutting on the gripe ' required only a knife and a hook, this small table would be scarcely large enough for the instruments employed for the Marian operation. They are not here, but you may see them at the College of Surgeons. By this method, a simple cylindrical staff having been intro- duced into the bladder, a vertical incision was made by the side of the raphe, and the urethra was opened on the staff at about the membranous portion. A dilator was then passed into the wound, and upon that another (male and female dilators they Avere called), and the canal and the neck of the bladder were torn asunder with great rudeness. Its only resemblance to the present median operation is, that the incision is in nearly the same place. But anything more barbarous than the practice you can hardly conceive. The stones were larger then than they are now, and the incision Avas small; and in order to dilate it and extract the stone, various instruments Avere devised or* modified from still earlier forms, some of them being the origin of several surgical instruments now in use. But in practice, the Marian proved to be a very unsuccessful operation, and was gradually abandoned in conse- quence. Still it held its ground in places, and for certain cases, as late as to a part of the eighteenth century. Next I shall name the high or supra- pubic operation, Avhich appeared at the end of the sixteenth century, and, being useful in a few exceptional cases, has maintained a position of greater or less importance to the present day. More than that I shall not say noAv, as Ave concern ourselves mainly Avith perineal lithotomy. I now come to a neAv proceeding, Avhich rudely shadowed forth our present lateral operation. It Avas performed on a staff, Avhich Avas not grooved as now, but yet it roughly served as a guide into the bladder. The operator commenced by thrusting a long knife into the ischio- rectal fossa, and so on into the bladder behind the prostate, and, cutting fonvard, he made the entire AA'ound at one incision. Invented, as it Avas believed, by Pierre Franco (about the middle of the sixteenth century), its apostle and promulgator Avas the celebrated Frere Jacques, Avho flourished in the latter part of the seven- teenth century, and is said to have cut 5,000 times for stone. It is far more than probable that he did not cut 500; but an error of a cipher more or less Avas a trifle for the inexact and credulous mind of the period. Like others of his craft he Avas an itinerant operator, not at first em- barrassed with too much knoAvledge of anatomy, although later in life he studied it seriously in Paris; after Avhich, it is said, his operations were less successful. He then pursued his practice mainly in France; and subsequently, a similar operation Avas performed by Rau, in Holland, Avho obtained much celebrity there. It Avill be interesting to you to know Avhat Avas going on meantime in our OAvn country. Most patients, up to the end of the seventeenth century, Avho were cut, submitted either to the old operation ' on the gripe,' or to the ' Marian.' In tho beginning of the eighteenth century the supra-pubic operation Avas first prac- tised here. At this period there came to London a Leicestershire lad, subsequently 97 known as Cheselden, the celebrated sur- geon of St. Thomas's Hospital; and he at first, like others, performed the high operation. But he had heard of the recent successes of Frere Jacques' method, and tried it, modifying it as an increasing experience suggested, until he performed almost exactly Avhat we now call the lateral operation, and Avith the best results. His success Avas so great, that in 1729, Avhen he had performed the operation several years, and cut about one hundred patients— a very large majority of whom, by the way, Avere children—Morand, the French surgeon, Avas sent from Paris to see him operate, and report upon the subject. He remained here for some time, Cheselden collecting a number of cases and operating on them before him. Morand then re- turned, and reported to the French Aca- demy so favourably on the subject, that Cheselden's operation became generally accepted there as the best. When ope- rating on the adult, Cheselden made the deep incision, if possible, strictly within the limits of the prostate gland, and in- volving its left side only, using a scalpel of moderate size, and cutting imvards along the groove of the staff. A feAV years after- wards Cheselden retired, having cut 213 patients, of all ages, Avith ten deaths.1 Those are the first figures that Ave can depend upon in connection Avith the operation, for, as I have told you before, the figures of the mediaeval period are monstrous and incredible; for not only Avas the famous monk said to have cut 5,000, but to have lost ' scarcely any.' Cheselden, Avho had carefully studied and improved the method, and who, like Frere Jacques operated on a feAV adults, but chiefly on children (Avhose cases you know are rarely fatal) met with barely five per cent, of deaths, which Avas a most successful result, and no doubt the best that had been yet made.2 1 Of these 213 cases, no less than 105 were under 10 years of age, of whom 3 died; 62 were between 10 and 20 years of age, and of these 4 died ; only 4(i were above 20 years of age, and of these 13 died.— Cheselden's Anatcmy, oth edition, 1740, pp. 322-3. 2 There is also a famous series of stone opera- tions which is very frequently referred to as per- haps the most successful on record, performed bv Martineau, of Norwich, and reported in the Medical and Chirurgical Transactions, vol. xi. p. 402 1821. The number of patients was 84; amongst whoni there were only 2 deaths. The operation was, of course, in all, lithotomy. They occurred between 1804 and 1820 inclusive—a period of seventeen years. In arriving at the exact results, it appears that here also a very large proportion were children, TOMY. 98 DISEASES OF THE At this point the operation continued for some years until the end of the century, and then ' the gorget' came into fashion. A feAV years ago a patient Avas rarely cut Avithout it; now, I suppose, few of you know what it is. Originally one of the directors used in the. ' apparatus major,' its edges Avere sharpened for the pur- pose of making the deep incision through the prostate. This Avas the idea of Sir Caesar Hawkins, Avhose name Avas affixed to it; but subsequently almost every surgeon had his OAvn gorget, making it Avider or narroAver, or altering it in some fashion or another. A great deal of mystery has been made of this instrument, but it is simply a Avide knife Avith a beak or probe-point at the end, Avhich is care- fully maintained in the groove of the staff. In employing the ordinary knife, if you require a deep incision, the blade must perhaps leave the staff a little. The object of the gorget is to make an incision sufficiently deep Avithout leaving the staff. Here is one which formerly belonged to Scarpa, the celebrated anatomist, and here are others which, having been used by many celebrated operators, have fallen into my hands, and they are leading types of the instrument. In France at this time the lithotome cache of Frere Come Avas much used, and Avith the same object in A'ieAv, viz., of attaining certainty and precision in the extent of the incision through the prostate. The practical difference betAvecn it and the gorget is, that in the latter the division of tissues is made by pushing inAvards a while 6 were females ; deducting these latter, there remain 78 male cases, of which not less than 34 were under 15 years of age, leaving only 44 adults. Of these 44 adults, no mor? than 11 were upwards of til) years of age ; only 24 were 50 years old and upwards giving for the latter a mean age of 62£ years; the 2 deaths occurred anions them. No error is more common than that of compar- ing lists of cases without noting this most impor- tant element of age. Death after lithotomy in children is notoriously infrequent ; indeed, it is a result scarcely to be expected, unless under circum- stances of some rarity. During middle life, also, lithotomy is a very successful operation; but at the ntje of sixty and upwards it is one <-f considerable iik. Hence, unless an exact statement respecting the patient's age is afforded, no inference can be drawn from any number of cases of which the results are reported. A mere statement of the number of patients operated on, with the proportion of recoveries and deaths, is absolutely valueless, and is often misleading. For comparison between these results and those of modern lithotrity see previous Lecture, p. 93, Avhere in 112 cases of male adults (children being entirely excluded), with a mean age of 62A years, there were only 3 fatal cases, or a mortality of 2$ per cent. URINARY ORGANS. sharp blade of knoAvn Avidth through them : and that in the former a sharp blade is opened to a known extent at the farthest limit of the parts to be cut, and is drawn outwards to the operator, dividing them. In 181C, Dupuytren, of Paris, not being content Avith the lateral, introduced his bilateral operation. His object Avas to make the deep incision by a cut on each side of the prostate, instead of a large one on the left side only. And he, Avith the same view of limiting accurately the extent of the Avound, designed a special in- strument for the purpose. This, the ' two- bladed lithotome,' is also a member of the ancient surgical armamentarium, made more elegant and manageable by modern skill. Here again, instead of making the internal incision by pushing a cutting blade inAvards, as Avith the knife or gorget, you carry this instrument [shoAving it] into the bladder along the staff, there open its tAvo concealed blades, and draAV- ing it towards you, these cut their Avay outAvards. The blades can be arranged so as to have the incision as Avide or as narrow as you please. In 1825 or 1830, the ' median opera- tion,' often loosely spoken of as a revived Marian operation, came into some note in this country, Avhile in Italy it had been long previously employed Avith much suc- cess. In the meantime Civiale, in Paris, combined the median and bilateral opera- tions in one proceeding, which he called the medio-bilateral; and you have seen me frequently perform both of them here; they shall be briefly described hereafter. Subsequently, Neiaton devised an opera- tion to Avhich he gave the name of ' pre- rectal.' This may be fairly described as a bilateral operation, conducted by means of a carefully made dissection for the purpose of obtaining more space between the rectum and the bulb of the urethra, and especially to avoid Avounding the latter. More recently still, the late M. Dolbeau, of Paris, adopted a method, by no means before untried, of making a median perineal opening into the prostatic urethra, Avhich he dilated by expanding metallic dilators, crushing the stone through it, and removing all the debris at one operation. It has generally proved to be a tedious pro- ceeding, requiring much instrumental contact Avith the bladder after all the urine has escaped; and it is there- LITHOTOMY. 99 fore somewhat hazardous for large stones, I I now come to the mode of performing ■while it is quite unnecessary for small the lateral operation; that method Avhich ones. j after all, is most trusted and mos> Fig. 54.—Bones and ligaments of the pelvis in the position for lithotomy. practised by the surgeons of Europe and I many details, let us try to revert to first America at the present day. As I have principles, and define clearly the object said before, when Ave have to do Avith J we aim at. Fk:. 55.—Dissection, showing the bulb. I told you that the object] of lithotrity I instrument. In lithotomy you must have is to remove the stone Avithout injury to a wound, and the object is to make it so the patient, either from the stone or the j that it shall least endanger the blood- u 2 100 DISEASES OF THE URINARY ORGANS. vessels, the rectum, and the neck of the bladder; next to remove the stone through the opening thus made with as little mis- chief as possible to any of those parts. When that problem is best solved, we shall have the best form of lithotomy. It is open to discussion whether Ave have yet found out the best way, although we have been 2500 years—to say nothing of the pre-historic period—in coming to our present position. Noav, in order to aid you to solve the problem for yourselves, I have placed before you a diagram draAvn accurately from the preparation, showing the bones and ligaments of the pelvis, in the position for lithotomy. (Fig 54.) The lower out- let is opposite to us; it is in the patient filled by soft parts, and it is the opening into Avhich you have to cut, and through • which you must remove the stone, and in all that you do, you must of course be limited by its boundaries of bone. I like to have that in my mind's eye when the patient is tied up and I take my seat to operate. Here also is a diagram showing the deep dissection of the soft parts Avhich fill the opening or space. (Fig. 55.) But I take it for granted that you knoAV your anatomy too Avell to require any detailed account here of the important structures involved in the operation. I shall simply name those Avhich concern us. First, there is the pudic artery, safely sheltered under the pubic ramus on your right; but it gives a branch to the bulb, a vessel to be avoided at the upper part of the space. Then vertical in the middle line is the bulb of the urethra, Avhich is not to be thought lightly of; indeed, it is the source of some of the chief dangers; it is a vascular structure, communicating freely Avith the vessel named, and a deep incision into it is as bad as cutting the vessel itself, if not worse. Next, there is the rectum in the middle and lower part, Avhich it is also important to avoid. Deeper in just beloAv the bulb is the situation of the prostate, which must be divided in the deep incision. I will now very briefly touch on the principal steps of the operation. A mild aperient has probably been taken the day before, and has acted moderately; but two hours previous to operating a small enema of warm Avater should be given to empty the lower bowel. Take care that it has acted, before the patient comes to the table, where I haAre seen the result take place to the annoyance and sometimes embarrassment of those concerned. As to the state of the bladder, you need be under no concern; nothing is gained by its being full of urine, although some have thought this condition highly de- sirable. Cheselden, on the other hand, preferred it to be empty, saying that the stone was then easily found close to the neck of the bladder. I have seen great pains taken to inject the bladder before operating: but the unconscious patient has usually succeeded in emptying it, in Fig. 56.—The staff. spite of tying the penis, and of similar precautions. The patient being placed on the table, ether is to be administered; but before tying him in position, the operator is first to pass a full-sized staff with a deep groove (Fig. 56), into the bladder, and Avith it carefully to strike the stone. Never think of operating on a man if you are not fully satisfied that the very staff on which you propose to cut, is in contact Avith the stone; although you may have sounded the day before, and are morally certain it is in the bladder. Frightful blunders have been made through in- LITHOTOMY. 101 difference to this rule. Suppose, for example, the staff has passed into a false passage, and is not in the bladder at all; one shudders at the idea of an operation performed on it Avhen so placed; yet these are conditions which must some- times be encountered, unless the rule laid doAvn is rigidly adhered to. Such a result is distressing to all concerned, calamitous to the operator, and probably fatal to the patient. A distinctly audible note of contact betAveen the stone and the staff is to be clear to yourself, and to one Avitness at least; and then the staff itself is to be entrusted to the hand of your best friend, who is to attend implicitly to your instructions, and to no others, Avhatever they may be. The patient is then to be tied up firmly, each hand to the corre- sponding foot; but this is better done by the leather anklets and Avristbands, devised by Mr. Prichard, of Bristol, because they truly realise the proverb, ' fast bind, safe find,' which our old friends the garters often did not. (Fig. 57.) Noav, what are the instructions to your friend, the staff-holder ? You want it held firmly, and, of all things, not to leave the bladder. I don't think you Avill gain much by cultivating a fancy for any particular spot, such as right or left, or projecting in the perineum. If it is to be steady, always in one place, which is the main thing, there must be a point of support for it to rest against, and there is but one such spot in the whole region. Rely upon it, then, you had better tell him to keep it close to the arch of the pubes, Avell hooked up, Avith the handle pretty nearly vertical. And he is to be Fig 57.—Lithotomy anklet and wrist-piece. mindful not to depress the handle so as to earry the point of the staff up to the top of an empty bladder, or through it, as I have known thus to be done ! Now take your seat at an easy distance, facing the perineum of the patient, Avhose buttocks should be brought forward until they slightly overlap the margin of the table; an assistant holding a foot and knee on either side, and taking care that they are symmetrically placed and range in one plane before the operator. This done, your arm, when extended horizontally, should be on a level Avith the upper part of the perineum, which region you are to traverse Avith the fingers of both hands, finding the lines of the rami; then introduce the left index into the rectum to verify the condition of the bowel, Avhether it is empty or the reverse, noting also the size and situation of the prostate. Noav, relative to the first incision, different authorities advise different places at which to enter the scalpel and com- mence it. Without discussing these, let me say that, as a rule, the usual point should be, for an adult, about an inch and a half in front of the anus, a third of an inch to the left side of the raphe. Having placed the fingers of the left hand on the upper part and right side (patient's right) of the perineum to steady the skin, enter the knife boldly, in a straight line, pointing neither upAvards nor doAvnAvards, aiming at and approaching the staff, and cut less deeply as you descend, emerging about two and a half inches loAver down towards the margin of the tuber ischii. You may sometimes even touch the staff" in that first incision, although this is by no moans necessary ; but it saves some trouble and uncertainty to approach it 102 DISEASES OF THE URINARY ORGANS. nearly, which you should always do; for a timid shallow cut which merely divides the skin leaves a young operator some- times uncertain as to his route to the staff. Then introduce the left index finger into the wound, and separate the cellular connections, Avhen the staff should be felt; and a touch or two with the point of the knife should bring your finger almost or quite into contact. Fix your finger-nail on the inner edge of the groove tolerably far back, so as to avoid the bulb as much as possible; and at the same time guard the rectum with the body of the finger. Slide the point of the knife along your nail into the groove, and enter it firmly, feeling that you divide the tissues and have unmistakable contact between the point and the metal of the staff (Fig. 58). Then run the point firmly and steadily on in contact with the staff, so as to divide a portion of the Fie. 58.—The incision through the prostate. prostate. Keep the point up, and always in the groove, and you will be safe; let it doAvn, and you may slip out and get it into the rectum, or nobody knows Avhere. Simply go on, letting the blade be more horizontal as it proceeds until the point has just entered the bladder, still not letting the knife leave the staff. The depth of the incision will depend upon the angle which the knife makes Avith the staff as it passes through the prostate : if the knife is maintained close to or parallel with the staff, of course you Avill only make a wound the Avidth of the knife ? but if the angle between it and the staff is increased, the width of the incision Avill be increased also. Finally, withdraAV the knife without adding to the wound, unless you see reason to do so, in Avhich case, if the edge is directed outwards and downwards against the soft parts, Avith a light hand, as you come out, you will make a freer and cleaner opening. It is better to be rather free in cutting than LITHOTOMY. 103 otherwise [the presence of a large stone is assumed], but you must not make the incision too wide. There has been a great deal of good advice expended upon this subject—the extent of the deep incision—but it is mani- festly impossible for one man to make another understand exactly Avhat he means or what he does by any amount of talk. My belief is, however, that the result of our anxious care about this matter is, practically, that we are apt to cut rather too little than too much, and that the neck of the bladder, in consequence, re- ceives severer injury from the stone and forceps when the wound is narrow, than would be the case Avere the prostate freely divided by the knife. This observation relates, of course, to adults; for in children you can scarcely find the prostate—it Fig. 59.—The lithotomy knife. w Fig. GO.—The lithotomy forceps. weighs but a few grains, and does not re- quire a moment's consideration, in regard to incision, for the knife goes beyond its limits; yet these little patients are the safest to cut. Of course there is an essential difference in susceptibility to danger at the two ages, due to the Avidely differing conditions of puberty and child- hood. To return. The incision being com- pleted, your left index finger immediately follows close along the staff into the bladder, where you will probably just touch the stone. Order then your assist- ant to withdraw the staff. The finger goes firmly and deeply in, stopping the urine perhaps, to some extent in its out- flow, and accomplishes the first dilatation of the parts. Then you slide the forceps closely along the palmar surface of the finger, and insinuate them over it into the bladder, which makes dilatation Ul.—The blunted gorget. number two. Then taking lightly and delicately one handle in either hand, you have, as a rule, but to open the instrument carefully, yet Avidely, one blade flat at the bottom of the bladder, the other tOAvards the top, on closing the blades, to find the stone between them. If it seems that you have a good hold, draAV gradually out- wards and downwards, easing or adjusting, if you can, with the left index, so that the long axis of the stone may correspond with the long axis of the blades, Avhich it is by no means always possible to accom- plish ; and so you make the third and last dilatation. Remember that you are not to pull out horizontally and bruise the soft parts against the pubic arch, but downwards into the widest part of the lower pelvic aperture. And don't be hurried for the sake of anybody else in order to make a rapid operation. You and your patient are to be, for you, at this moment, the only persons present, and your responsibility to him must never be forgotten for an instant through any influence of bystanders and lookers-on. But I sometimes meet with a very stout patient, or one who has a very large 104 DISEASES OF THE URINARY ORGANS. prostate, and the consequence is that my finger will not reach and enter the neck of the bladder; in this condition, after making the deep incision, I pass carefully along the groove of the staff, the blunted gorget (Fig. 61), the narrower side to- Avards the staff, until it enters the bladder, and on this I slide in the forceps, directing the staff to be Avithdrawn. Feeling my forceps free within the cavity of the bladder, I remove the gorget and seek the stone as just directed. In rare cases the gorget is thus a very useful instrument, but it should not have a cutting edge; a thin edge, but blunt, is the best. Your next duty is to introduce by the Avound an ordinary sound, and ascertain Avhether there is another stone; but if any considerable vessel is spouting within view, it is, of course, first to be tied. Severe haemorrhage ahvays demands in- stant attention; it is sometimes consider- able, and no pains should be spared to arrest it by the ligature if possible. Sometimes the point of a well-curved tenaculum may" be carried under an arterial jet high up, Avhich you have failed to tie. Pulling the instrument gently towards you, a ligature may be made to encircle the tissue laid hold of, and then the tenaculum may be left in place. I have one from Avhich the handle may be removed by unscrewing, made expressly for this purpose, and it has been a very useful aid on tAvo or three occasions (Fig. 62). Subsequently inject a large syringe- Fig. G2.—The tenaculum, which unscrews near the handle. ful or tAvo cf cold Avater through a long bulbous-ended tube into the bladder, from Avhich it returns in a current; and place a gum-elastic tube in the Avound if the oozing of blood is rather free. The *ube is provided Avith a kind of ' petti- may be removed in forty-eight hours or so, taking out first the lint, little by little, and finally the tube itself. If there is Fig. G3.—The tube, Avith ' petticoat.' coat' of thin cotton material round it, into which you can tightly squeeze some strips of lint, and so make pressure on the bleeding surface (Fig. 63). The tube Fig. G4.—The Air Tampon. A, The tube. H, Thin india-rubber bag, undistended. C, Line indicating form of bag when distended by air. D, Flexible tube, with stopcock for inflating bag. E, Tapes to fasten tube in place. only slight bleeding, I prefer to have no foreign body in the wound, and no dress- LITHOTOMY. 105 ing of any kind. But the most certain mode of dealing with severe bleeding, the ligature failing or being insufficient, is the addition of an inflatable thin india-rubber bag to the tube, so arranged around it that, Avhileits draining action is left intact, the bag can be distended with air, through a small flexible tube provided with a stop- cock. (See Fig. 64). It should be intro- duced so far that the whole cut surface is exposed to the action of the bag ; indeed, the further end of this should just pro- trude slightly into the bladder itself. This done, and inflation being made, the dis- tended bag product's pressure on every portion of the Avound's surface, closing every inequality, and effectually stopping all the haemorrhage. After twelve or twenty-four hours or so, a little air is allowed to escape and the pressure is gradually relaxed, until the apparatus can be removed altogether. It Avas designed by my assistant, Mr. Buckston BroAvne, and is knoAvn as the ' dilatable air tam- pon.' It is, in my opinion, the most efficient means Ave have to control bleed- ing after lithotomy of any kind : no one certainly ought to perform that operation Avithout one of these instruments at his side. This matter settled, the patient should be carefully carried from the table to his bed, placed on his back, Avith one or two pillows under each ham, and the parts in- volved exposed to air and light, so that you can see hoAv the urine flows. The less meddling afterAvards generally the better. The severe pain Avhich is usually felt for a feAV hours after should be mitigated Avith full doses of morphia or opium. I have sometimes put a suppository, containing onegrain of the former, into the bowel of an adult patient before he leaves the operat- ing table. I have only time to say a Avord or two about the median and medio-bilateral operations. For the median an incision is made in the line of the raphe from about two inches and a half above the anus, doAvnAvards as near to its margin as is safe, for you Avant all the space you can get. Dissect doAvn to the staff, Avith a finger in the rectum, Avhich enables you to avoid it, and take care also to incise the bulb of the corpus spongiosum as little as possible. Then open the urethra with a long straight pointed bistoury in the mem- branous portion or thereabout, and carry a director on into the bladder; your finger follows and dilates, and then the forceps is to be introduced on that. The operation is more generally performed by thrusting the straight bistoury, with its back dowmvards, in front of the anus, into the staff, and cutting upwards and outwards at one incision. I prefer the other mode. Manifestly this operation will not do for very large stones, which mainly, thanks to lithotrity, are those which only have to be provided for by lithotomy. Hence the applicability of the ' median ' may be somewhat extended, by making it ' medio-bilateral,' and in this manner : Having performed the median, as just described, up to the point of open- ing the urethra, instead of introducing a director, you introduce the two-bladed lithotome, and when it is in the bladder you open the blades, and tAvo moderate incisions are made, one right, the other left, as you draw the opened instrument outwards in the groove of the staff. A larger opening is, of course, insured in this manner than by the simple longitu- dinal incision, and a someAvhat larger stone can thus be removed. These two operations I have performed about thirty times, and I do not know that there is any reason for preferring them to the 'lateral.' To make an ac- curate estimate, at least 100 cases of each operation by the same hand are required. Nevertheless, I may say a Avord on the principle Avhich essentially distinguishes these operations. They OAve their ex- istence to the result of opposite convictions respecting the hazard of the knife. There is a set of men to AArhom anatomy is a bug- bear, and Avho are afraid of cutting as much as is absolutely necessary; and there are other men less fearful—mind, I don't say less cautious—who regard the larger and freer style of operating as better than the small or timid style. All sur- geons, of course, tend more or less to fall into one of these tAvo classes. The ana- tomical school have devised a variety of median operations in order to avoid certain blood-vessels, &c, and they sacrifice space in doing so. They ansAver exceedingly Avell for small and medium-sized stones ; but these are, or should be, removed by crushing noAV, and we do not want any cutting operation for such stones. The perineal operation which offers the most room, the recto-vesical excepted, is the lateral operation. All the others named are essentially median operations. Noav, 106 DISEASES OF THE I am bound to say that formerly, judging theoretically, I had a leaning to median methods, being disposed to think that they Avould be attended with less haemorrhage than the others. But I do not find this so in practice, and 1 have arrived at the conclusion that there is quite as much bleeding in median as in lateral opera- tions. I attribute this to incision of the bulb, which I regard as a large artery to all intents and purposes. You cut into that spongy tissue—not in all cases, but in some—and there is as much bleeding as if you had cut the artery of the bulb, and there is more difficulty in controlling the flow. The bulb is likely to be cut more or less in the median operation. The pro- blem is how to reach the bladder without wounding the bulb, its artery, and the rectum; and I believe that a well-per- formed lateral operation more nearly attains that object, Avhere a free opening for a large stone is required, than any other. I cannot tell you which of these tAvo operations is the easier of performance; if anything, perhaps, the lateral. But here is the important fact, which is only beginning to be realised by the profession —viz., that the exceptional cases of very large stone in the adult alone require any cutting operation, since all the small and middle-sized and even large ones can be much more safely removed by the crush- ing process. And it is this fact, the demonstration of which is of compara- tively recent date, that is bringing these various forms of lithotomy under the serious consideration of surgeons at the present day from a new and different point of view. The operation of lateral lithotomy is less easy of performance for children than for adults : on the other hand, it is very rarely fatal, and these small patients usually recover rapidly. It is more diffi- cult because the staff must be small, especially for a boy of two or three years; the tissues are soft and delicate, and the outlet of the pelvis is very limited in size. The points to be attended to are as folloAvs :—First, let your knife, the blade of which must be narroAV in proportion to the size of the patient, have a keen point and edge; a blunt knife Avill push its Avay Avithout accurately dividing the tissues before it, which it is essential that it should do. Secondly, having made an URINARY ORGANS. opening into the urethra, and assured yourself that the staff is Avell exposed, place the point of a small and somewhat tapering gorget clearly in the groove of the staff and push it along the groove into the bladder. If you attempt to use your left index finger for this purpose, as in the operation on the adult, you may, instead of entering the urethra, push before you the prostate and bladder en masse, separating them from the urethra, into which the point of your finger is too large and blunt to be easily insinuated. Such an occurrence is highly dangerous, and may prevent your reaching and ex- tracting the stone. Having then safely introduced the gorget, let the staff be withdrawn, and on the gorget introduce a pair of small forceps, rather upwards be- hind the pubic symphysis, remembering that the child's bladder lies more in that direction than the bladder of the adult does. Take care to remember also how small the space and distance are in which you have to work. The division of the prostate gland is not a matter of concern; it is so rudimentary in children that the incision necessarily passes beyond its limits, and in doing so produces no evil result. No tube is required in the wound aftenvards. The median operation may be em- ployed for children also, and is to be per- formed Avith the gorget in the same Avay. I have done both, and have very little preference for one over the other. In the preliminary sounding of a child, be perfectly certain, and let a pro- fessional friend be satisfied too, that a stone is present before you decide on operating. It is not difficult to strike the Avail of the pelvis from the interior of a child's bladder, and to produce an audible note—such has often been mistaken for calculus. It has happened by no means unfrequently that a child has been cut for stone, and none has been found Avhen the bladder has been explored. In cases of calculus in the female, it is very rarely necessary to use the knife. Up to the size of a large walnut, a uric- acid stone—any other variety is rare in the female—may be crushed, the d6bris being removed by the aspirator at one sitting. If of the size of a large bean or nut, it may be withdraAvn by careful traction, by* means of a small forceps or flat-bladed lithotrite, Avithout injuring the urethra. But the withdraAval of a rather large stone LITHOTOMY OR LITHOTRITY IN RENAL DISEASE? entire, by this method, is more likely to produce incontinence of urine than when a moderate incision of the urethra is made. If the stone is larger than a chestnut, say of a flat oval form, the long diameter of Avhich measures tAvo inches or more, I have hitherto always made a lateral incision from the urethra outAvards to my right on a grooved staff, and to the depth of half or three-quarters of an inch, and removed the stone with a lithotomy forceps. I have then put two carefully adapted sutures deeply through the margins of the incision, and placed in the urethra a large gum-elastic catheter, about five or six inches long, so that all the urine may drain away continually for three, four, or five days. It is the business of a watch- Gentlemen,—During the last ten weeks of the year 1872 eight cases of stone in the bladder Avere admitted to my Avards. Of these, seven Avere adults, chiefly of adA'anced age; lithotrity Avas performed for all, and each patient has been dis- charged cured. The eighth case was that of a lad aged ten years; for him I per- formed lithotomy, and he also Avent out well. Towards the end of January, 1873, I returned to my duties here, and found a case just admitted, Avhich possesses cha- racters of considerable interest. I pro- pose therefore to make it the subject of this lecture. The man Avas sixty years of age. His first calculous symptoms appeared nearly three years ago. He was admitted to a hospital last summer Avith a rather large phosphatic stone, for Avhich litho- trity Avas performed. He left relieved, but passed portions of phosphatic matter occasionally, obliging him to use a cathe- ter sometimes to remove them. His blad- der was in that condition in which phos- phates are rapidly formed. Present state (Jan. 24).—Passing urine every half-hour day and night, Avith much straining and great pain: compelled always to leave his bed for the purpose. ful nurse to see that the catheter is not blocked up, and that there is always a free passage through it. You may reckon, then, on avoiding permanent incontinence afterwards in most cases. Sometimes the retaining power of the bladder is some- what impaired for a few months after the: removal of a large stone by any method,. and this is almost the only untoward result to be anticipated. I have lost only one- case, among many, of operations for stone on women, and in that case it occurred from pyannia. But I do not doubt that a stone of the size described above, would noAv be most safely dealt Avith by a power- ful lithotrite and the aspirator, Avhich we have learned to use so successfully in the male subject. Urine pale, turbid, alkaline; specific gravity 1009; a granular cast found at first examination. General condition ex- tremely feeble. You will remember that I made long. clinical remarks in the Avard, stating that the patient Avas the subject of chronic renal disease, discussing the influence this condition must have on the course to be pursued, Avere there still a stone in the bladder; and that I should make a care- ful attempt to remove any fragment or phosphatic matter Avhich might be the cause of his sufferings. I did so, taking aAvay a Email quantity of this Avithout difficulty. On Jan. 26th he had passed a little debris, and the intervals of mictu- rition Avere prolonged. On the 28th I removed one very small piece. On the 31st I made another short examination, discovering nothing. That very afternoon, contrary to orders and in the absence of the nurse, he went out of doors into the cold air in the yard. On February 2nd he had a rigor, temperature rising to 103°^ On the 3rd another. On the 4t.h he Avas droAvsy and incoherent. I ordered hot linseed poultices sprinkled Avith mustard to be applied frequently to the loins. Pulse Avas about 100; temperature 100° j LECTURE XVI. OX THE INFLUENCE OF RENAL DISEASE ON THE CHOICE OF OPERATION FOR STONE IN THE BLADDER. 108 DISEASES OF THE urine but little diminished in quantity. This condition continued about two days, vyhen he Avas much less sleepy, his intel- ligence returned, the tongue (which had been loaded) began to clean, and he took food very fairly. We had quite given him up, as you know, on the 4th, and now began to hope he would rally for a time. But on the 8th and 9th he Avas not so well; the urine acquired a marked blood-tint. Hot poultices to the loins Avere followed by manifest improvement on the 11th and 12th. On the 13th the urine was again worse, the patient weaker and indisposed to take food. On the 17th the drowsiness and incoherence reap- peared ; temperature Avas below natural; pulse weaker; urine more bloody. He gradually sank, dying in the evening of the 19th. At the autopsy Ave found conditions of which the folloAving is a very brief resume: —Bladder thickened; grey discolouration of mucous lining; patches of false mem- brane adhering. Very marked bar across its neck uniting lateral lobes of prostate ; deep pouch behind, containing a f eAv small phosphatic concretions, weighing 12 grains. Ureters someAvhat dilated; the left more so than the right. Kidneys surrounded by fat, vascular and indurated, attached to the capsule, which peeled off with renal substance adhering, and opened tiny abscesses. Surface lobulated, minutely granular. Size normal, as if a granular contracted kidney had been temporarily enlarged by inflammatory action. Surface of right greatly congested, haemorrhage in places; left less so. Cortical portion in both thin ; in left particularly so. Section broAvnish, with small, pale, yellowish spots interspersed; the pyramids intensely congested. The pelves dilated; lining membrane deeply injected throughout. Microscopic sections were made, and on examination the tubules were seen in some parts to be filled with granular epithelium. The Malpighian bodies were surrounded by croAvds of young cells re- sembling corpuscles. On microscopic examination of a section of the kidney hardened in alcohol, the tubules of the cortical part were found to be irregular in size; some dilated, some nanwed. In the dilated tubules the epithelium Avas granular, the cells being shrunken and atrophied. The epithelium had entirely disappeared in some tubules, and the lumen was filled with granular debris. URINARY ORGANS. Between them, in all parts of the kidney, Avere crowds of young cells. Around the Malpighian bodies these Avere accumulated five or six deep. In some parts in the immediate neighbourhood of the small abscesses the structure of the kidney Avas undistinguishable, and its place occupied by masses of young rounded cells. For this poor felloAV the only question to be entertained Avas Iioav best to relieve or palliate the painful complication of his fatal malady : advanced Bright's disease, the one; diseased bladder, containing phosphatic matter, the other. It Avas not a question of cure, nor could there be any prospect of it. His stone had been previously removed ; but the decomposed urine and mucus together Avere daily forming phosphatic deposits, which, co- hering and drifting into the urethra, oc- casioned intense pain. Such a subject is only one of several Avhich are naturally suggested by the case before us. I shall, therefore, take the opportunity of dis- cussing briefly a large theme arising out of this, which may be thus stated. When stone in the bladder coexists Avith any disease of the kidney, hoAV does this influence the decision in regard to operative proceedings for the former ? 1. I must first define Avhat is to be understood here by the term ' disease of the kidney.' It is a comprehensive one, and is apt to be employed somewhat loosely. It embraces, of course, all the morbid affections to which the kidney is liable. These I shall endeavour to classify in a broad and general Avay ; and in doing so will first put aside, as obviously foreign to the subject in relation to operative measures, the malignant diseases of the organ. (a) Those chronic changes in the kidney-structure associated with constitu- tional cachexia, of which they may be more a local expression than a cause, and Avhich are comprehended under the term ' Bright's disease,' form an important pro- portion of the maladies in question. In the dead-house you know that Ave meet Avith kidneys differing very much in ap- pearance, size, and structural characters, all yet furnishing examples of different kinds of Bright's kidney, or, in some cases, of different stages of the same kind of disease. Most are included under the distinct types of ' the granular contracted kidney,' like that of our patient, and ' the large, smooth, white kidney.' Not to LITHOTOMY OR LITHOTRITY IN RENAL DISEASE? 100 overlook a much more rare condition, I just name the Mardaceous' or so-called * amyloid' degeneration. Now, the symp- toms which denote Bright's disease are, for the most part, sufficiently clear and distinct during life, as you know; and the amount or stage of disease is, within certain limits, fairly calculable after some knowledge of the patient. (b) Another kind of change which is wholly distinct from the foregoing occurs in kidneys Avhich are either frequently or for a considerable time the seat of calculus. The presence of minute foreign bodies, for the most part aggregations of uric-acid crystals, in the uriniferous tubes, at their orifices and around them, in the calices, is a cause of injury to the structure affected in a degree corresponding to the duration and the magnitude of the deposited matter. Any degree of injury, from a circumscribed and temporary inflammation of the lining membrane of the pelvis caused by a large quantity of rapidly formed crystals, up to almost entire de- struction of the organ from the presence of a large renal calculus, may be observed. Happily, the latter condition is rare. On the other hand, the former is very common. I doubt Avhether any man passes much concrete uric acid for a few months without some very slight damage to the kidney. Certainly, during the process blood is almost always to be found in the urine by the microscope; and it must be inferred that when the habit of periodi- cally passing uric-acid calculi has existed for some years, a certain degree of perma- nent deterioration has been suffered by the kidneys. There are no other special signs of this condition. The patient's general health is often very good. There is no cachexia as in the class of diseases (morbus Brightii) just referred to. On the contrary, the patient is often hale and hearty in appearance. The characters of the urine are good; quantity abundant; specific gravity full average; no albumen, but urates often in excess, and blood-discs are present, insufficient to affect the naked- eye tint of the urine. Pain about the renal and sacral regions and the hips is often complained of. But I have fre- quently remarked to you that such patients sometimes exhibit considerable febrile phenomena on instrumental inter- ference, and that, although they look so Avell, more than ordinary caution is neces- sary in dealing with their calculi. (c) I name without further allusion to it here, saccharine diabetes, Avhich cartnot be passed over Avhile considering renal diseases. To save returning to the subject, let me eay that there is no ques- tion that for this and the preceding class, in Avhich patients Avith vesical calculus are usually elderly, lithotrity is certainly preferable to lithotomy, unless the stone is large. The exercise of caution on the part of the operator to employ instrument* as little and as gently as possible is essen- tial. I have operated on tAvo patients with success who Avere the subjects of marked saccharine diabetes, one of them Avithin the last month; both were very sensitive to mechanical interference. Since this I have operated on tAvo more, in both of Avhom the diabetes Avas of long stand- ing : on one by lithotrity, on the other by lithotomy; both patients were seventy years of age, and both died shortly after the operation. I think that advanced diabetes renders the case unusually hazar- dous in relation to operations for stone: and in all cases occurring in elderly people, of kidneys long troubled by the presence of renal calculi, more or less increased risk is likeAvise incurred in performing grave operations on the urin- ary passages. (d) The last class of renal changes Avhich I have to consider are those result- ing from diseases Avhich habitually ob- struct the outflow of urine. These affections also are not uncommon, and have an intimate relation to our subject. Many years ago I described the pro- cess by which such renal changes occur. The principal conditions Avhich originate them are, stricture of the urethra, enlarge- ment of the prostate, large vesical calculus, and, less commonly, atony of the bladder. The order of enumeration is also the order of numerical frequency as a cause. Stric- ture always constitutes an obstruction to the outflow of urine commensurate with the degree of the narrowing. Consider- able prostatic enlargement is a cause also, but notably less powerful than the pre- ceding. Vesical calculus sometimes acts in the same way, but by no means as a rule ; on the contrary, it is an exceptional circumstance when it does so, depending on certain conditions Avhich vary with the •individual, such as the habitual position it occupies in the bladder, its size, its liability to roll to the neck, &c. This, however, is certain, that in cases 110 DISEASES OF THE of long-standing calculus, an autopsy Avill sometimes shoAv only slight signs of renal changes produced by obstruction, while in another case those changes will be remark- able for their extent and degree. In no instance, be it remarked, do such changes occur apart from obstructed micturition in some form, and always of long standing. The changes I refer to are dilatation of all the urinary passages behind the point of obstruction. Thus, in stricture of the urethra, Ave may observe dilatation of the urethra itself and of its glands; protrusion of the mucou3 lining of the bladder through the interlacing fibres of the muscular coat, producing ■ sacculi; •dilatation of the ureters, of the pelvis of the kidney, of the proper renal structure, and thinning by pressure of the renal substance itself; so that the organ has the appearance of a series of cysts, which formerly Avas really supposed to be its pathological condition. I may refer to a Avork published in 1854, Avherethe details were given by me Avith considerable minuteness of the changes which occur through the influence of fluid pressure.1 Let us consider for a moment the mechan- ical process by which this remarkable series of changes is effected. You know that hydraulic pressure is equal in every ■direction. Thus, if I make pressure on a flexible bag filled with fluid, that pres- sure is exerted equally at every point of the periphery; and if tubes are inserted, say in a vertical position at opposite sides, the fluid will rise and issue with equal force from each. Now, Avhat happens in the flexible bag which constitutes the human bladder when obstruction exists in the form of stricture, enlarged prostate, or calculus ? More force than natural is of course exerted to accomplish the act of micturition; the patient ' strains,' as he says, to pass his water, and sometimes, if the obstruction is considerable, the force exerted is very great. You see at once that this tells not only in the anterior direction upon the obstruction itself, but also on the ureters which enter the bladder from the kidney behind. Let us say that the ordinary pressure required to pass Avater in the healthy organs is one pound to the square inch (one number being, for the sake of illustration, as good as another), when obstruction is present the pres- 1 Stricture of the Urethra, first edition, pp. 64- 70. URINARY ORGANS. sure may certainly be increased, two, three, five times, or more. Further, the act of relieving the bladder, instead of occurring only five times in the twenty- four hours, and being speedily completed, may recur ten or tAventy times, and the duration of the act may be greatly in- creased also. It is not necessary to ex- plain to you hoAV this state of things must act, and how that after a time (for the mouths of the ureters, not being so patent as the inner orifice of the urethn, do not easily yield to pressure) every act of straining tells on the passages, and dilata- tion advances by degrees until at last even the kidney suffers from the continued pressure and from the inflammatory pro- cess Avhich necessarily accompanies it; for the ureters and pelves of the kidney may become supplementary reservoirs to the bladder, and are sometimes found filled with decomposed and ammoniacal urine. Long before this stage arrives inflamma- tory action invades these parts, a condition recognised, as you know, as pyelitis [diagram of dilated organs made]. By some this condition has been called ' surgical kidney,' a phrase Avhich others have applied to denote the acute suppura- tive nephritis which sometimes closes the scene for a patient who has long had renal disease. I was glad to find Dr. Dickinson proposing at the Medico-Chi- rurgical Society to abolish so unphilo- sophical a term. It is one I never use and have a strong objection to. Why ' surgi- cal' kidney indeed? Certainly in one sense only—namely, that it is for Avant of surgical aid that the organs have come to the state in which they are. If that aid were rendered early in the history of the case, Avhether it be stricture or stone, no such condition would ever arise. Never was the proverb truer that ' a stitch in time saves nine'—a surgical stitch, you understand. The pathological condition thus attained might Avell be termed ' mechanical dilatation' of the ureter and kidney, as being mainly, although not en- tirely perhaps, produced by the physical process described. Let me uoav inquire what are the symptoms Avhich it produces during life ? I know of none Avhich are distinct and significant. I made this, I had almost said, humiliating admission, nearly three years ago (1873) at the Medical and Chirurgical Society, laying much stress on the fact for the express purpose of inviting LITHOTOMY OR LITHOTRI' attention to it.1 I have long sought for some sign that should indicate the presence of extensive pyelitis and dilatation, but in vain. Such a patient presents no sign of change in the urine itself. It is of full specific gravity, abundant in quantity, Avithout albumen, except that Avhich the presence of pus and blood accounts for, and such pus and blood are commonly found as vesical products formed by irri- tation from the calculus in cases where no renal disease exists. Whenever you have stone of more than small size you may have such products, and Ave are bound to expect them if the patient has any sym- ptomsof oystitis,and some cystitis is always present in these cases of dilatation. Again, there is nothing Avhich Ave can identify as disintegrated portions of renal tissue—no casts of tubes, nothing but pus and blood- discs—nothing, in short, distinctive. Then at no stage of the disease is there any dropsical effusion, no habitual dryness of the skin, not necessarily any marked feverish state, constant or intermitting. Nor is there any diminution of weight; on the contrary, the patient may have gradu- ally acquired fat. But he is always, if the condition is advanced, in feeble health, is Avorn, and easily exhausted—signs Avhich impress you with nothing so much as his obvious inability to bear any severe test of his physical powers, from all of Avhich, however, nothing absolutely dia- gnostic can be inferred. 1 Referring to it, I said:—' It must be admitted that at present we ha\re not an unfailing means of ascertaining the existence during life of these con- ditions. There may be no albumen in the urine, and not necessarily arc there any deposits signifi- cant of the renal affection. The urine of a cal- culous patient frequently contains mucus, pus, and blood; but Avhether the origin of these is in the bladder (naturally its most common source from the irritation of the calculus) or in the organs above, it is impossible always to determine ; and usually there are no casts or other pathognomonic signs of disorganising renal structure. I n fact, neither physi- cal signs nor subjective symptoms are by any means frequently present, and yet advanced pyelitis, and even sometimes chronic nephritis, may exist..... Could the existence of these conditions be accu- rately diagnosed beforehand, it might become a question Avhether the crushing operation, or anv operation at all, should be performed. For there in little doubt that the existence of such organic changes is almost as surely a source of fatal issue in lithotomy as in lithotrity. Now, in the twelve cases before us, one or other of these conditions cer- tainly existed in five; and had it been possible to be aware of them the operation might not have been performed, and the patient might have lived a little longer, with much suffering, it is true, and lie ultimately must have died at no distuit period.' Hoyal Medical and Chirurijicul Transaction*, vol. liii. pp. 13G-7, 1870. rY IN RENAL DISEASE? Ill But it has been said, and Avith some plausibility, if the kidney is much damaged by disease, the urine will cer- tainly shoAv a deficiency of urea. Prac- tically that is not so. Practically, with much pyelitis and dilatation, urea is suffi- ciently eliminated. Two half-kidneys, to speak roughly, will probably do the neces- sary elimination for the system in circum- stances of quiescence, just as two half- lungs may suffice for a patient in very favourable circumstances; and failure to excrete urea is only manifest Avhen the action of those two moieties of kidney is suddenly interfered with, by disturbance from external cold, &c, or by the inflam- mation propagated by means of an opera- tion on the urethra or bladder. Practi- cally, again, if I examine the urine of a patient in order to determine the amount of urea, and find it manifestly insufficient, is it not the fact that my patient must at that moment be to some extent in a condi- tion of urasmic poisoning, and that he wilL certainly shoAV some clinical sign thereof? Is not the fact that no such sign is present the only real proof that urea is sufficiently eliminated ? Once the urinary constituents begin to be retained in the blood, the moment is at hand Avhen symptoms of poisoning will appear. The chemical test alone must not be relied on in practice. When a patient passes abundance of urine of specific gravity 1018 to 1025, Avithout casts, Avith no albumen except that which is due to the blood and pus found in the secretion, we have no ground for believing that any advanced organic renal disease exists, unless we obtain evidence of its presence from other sources. Now, I never operate for stone without first ascertaining Avhether the condition of the urine is that above described; so that if I undertake an operation for a patient manifestly the subject of renal disease, it is in full view of that fact, and because it may be absolutely necessary that surgical relief must be attempted at all hazards. Of this I have to speak by-and-by. No one Avould be more ready than mysslf to obtain further aid from chemical tests. I only fear that none are knoAvn Avhich can aid us to demonstrate the presence of the mechanical dilatation to Avhich I have referred. Again, it has been said, Can you not by palpation or percussion demonstrate the existence of this disease ? I answer for myself distinctly 'No.' A foreign 112 DISEASES OF THE authority demanding the utmost respect has recently affirmed that it is possible. With great deference, and after giving much special attention to the matter for some years, I emphasise my dissent on this point. I have long recognised this condition as one of the great stumbling- blocks, perhaps the greatest noAv existing, in our way to diminish the mortality after operations for vesical calculi of large size. Had I any means of certainly ascertaining that a patient with such a stone had ureters and kidneys largely dilated, I would advise him not to submit to any operation, and I Avould do all I could to prolong his life and make it tolerable— a condition within certain narroAV limits to be attained. Something may be done under these circumsDhnces to accomplish this end—more, perhaps, than is often believed, of which I have seen some remarkable instances; but sometimes, it must be confessed, such palliative measures are useless, and the patient demands relief from sufferings which are intolerable, no matter what the risk may be. Can Ave under such circumstances humanely refuse him? To return, however : let us inquire Avhat we can accomplish by palpation or percussion. First, I have determined the fact beyond all question, that there is by no means necessarily much, if any, tenderness in the regions of the ureter and kidney—that is, acute suppuration, active inflammation, or renal calculus not being present. You are accustomed to see how often I examine those regions in the wards. And you know how efficiently one may do it Avith a patient who is thin and spare; and also how particularly unsatisfactory is the examination when the patient is corpulent. Now the former condition is one you can by no means always reckon upon; on the contrary, I affirm that the. latter condition must be more commonly expected in these cases. For a year or two, perhaps, the patients have been inactive, and fat has accumu- lated ; and then you can learn little about the ureters by palpation. Again, the condition of the organs, even in the spare subject, offers no objective sign to physi- cal examination. Let us suppose a ureter as big as the aorta, or larger still: Is it a tube filled Avith air like an intestine Avhich will give yon a corresponding note? 13 it filled with fluid, and will it thus give you a line of dulness which | URINARY ORGANS. may be traced ? By no means; it is a flaccid sheath with thin yielding walls, transmitting fluid it is true, but you can no more isolate it by percussion from the adjacent structures, so as to demonstrate its size, than you can isolate by a similar process—let me say, the lumbar plexus. Of the kidney itself the same thing must be affirmed. You may, if fairly practised, determine the solid mass of an enlarged kidney; but there is no way of demon- strating the existence of a dilated pelvis or of thinned kidney-structure by any physical examination. No doubt you may guess—shrewdly perhaps sometimes ; but it is no place or time for guessing when life or death hangs on the decision. There is a field here for further research; the door is open for investigation. For, you may rely on it, no method of arriving at anything like a certain diagnosis of pyelitis with mechanical distention is at present known. 2. But I have uoav to consider what influence ascertained disease of the kidney exercises on the prognosis, when the subject of it has also a stone in the bladder, and the question of operating for its remoA'al has to be considered. Let me first say that when the stone is small —the size of a small nut—whatever the condition of the kidneys, there is no very great risk from lithotrity if well per- formed. But it is by no means always that we are so fortunate as to find the patient with a small stone. It may be large, and do what you will, the patient is in a position of danger; the only question for us is—by what treatment Avill that danger be least ? I have operated certainly in three cases in Avhich advanced Bright's disease Avas known to be present, but in which the sufferings of the patient Avere so great that an operation Avas most desirable. In each the stone Avas phosphatic ; in the first and second it was large, in the third of medium size.1 The first. Avas a gentleman Avhom I saAv Avith Dr. Sharpe, of Norwood, in 1865. With extreme care I removed the whole in eight sittings, Avith great relief to the patient. His urine, although fairly clear, Avas of Ioav specific gravity, and charged Avith albumen. The subse- quent part of his life—I believe about 1 Bv 'medium size' I intend always a stone which "measures about, an inch as the mean of its two diameter.-. LITHOTOMY OR LllTlUlRITY IN RENAL DISEASE ? Ho ■six or nine months—Avas rendered com- paratively comfortable. The second case Avas in this hospital in 1870. He Avas also handled Avith the utmost caution, having five sittings in ten weeks, owing to the severe rigors and prolonged fever Avhich folloAved some of them; but he Avent out marvellously improved, and lost all his calculous symptoms. I saAV him three months after, and he fully main- tained all he had gained. I have heard nothing since. The last of the three occurred about the same time, also in the hospital. His disease Avas more adA'anced than that of the preceding case. Only on his very urgent solicitation I consented to try lithotrity. I could not resist the appeal to diminish his suffering, if possible; that he must die at no distant time both lie and I kneAV. With his pallor, debility, and uniformly rapid pulse, lithotomy could not be thought of for an instant. I kept him three weeks before touching liim, in the hope of improving his con- dition. Five sittings sufficed to remove nearly all the stone; but the last was lblloAved by severe shivering and vomiting, and death in a feAV days. Should I have done lithotomy in any of those cases ? I ansA\-er unhesitatingly, in not one of them Avas it possible to submit, Avith any chance of success, men in such a feeble state to any severe cutting operation. Nothing but lithotrity could offer the slightest chance, and it saved two of them from the anguish of stone, and from the additional proclivity to death Avhich it entailed. But these, you say, Avere examples of knoAvn ' morbus Brightii,' and you natu- rally enough demand if I should be guided by the same principle in a case of mechanical dilatation and pyelitis if I knew beforehand that I had to deal Avith such an one? To this I can only say that the patients Avhom I have seen, and Avhose autopsies have demonstrated that they were the subjects of that condition, have been manifestly defective in vital poAver—patients for Avhom I should certainly shun a cutting operation of any kind if possible. Although, as I said on another occasion, had Ave the means of identifying an advanced example, I should gladly avoid either lithotomy or lithotrity, still I believe that I have employed the latter with success for a feAV. I have thus operated three times in cases of bad old-standing stricture of the urethra (maintaining the urethra Avell dilated by a catheter permanently tied-in for the purpose, as you have seen), in Avhich I have no doubt that considerable mechanical distention of all the passages existed. But these people Avere so miserably feeble that nothing Avould have induced me to cut them, nor do I think that any man Avould have ventured to do so. But you might still rejoin, and you would be quite right in doing so, ' surely it has been said by surgeons of experience in the past, that Avhen " renal disease " ex- ists, it is better to remove the stone by one operation, although severe, than to attempt it by a process Avhich requires repeated introdu^i^s of a lithotrite, and more or less continued irritation from fragments ? ' The fitting reply to-day, as it appears to me, is, that although this Avas undoubtedly true some thirty years ago, it is by no means necessarily true now, Avhen the relative capabilities of the tAvo operations of cutting and crushing have so greatly changed. The operation of litho- tomy had arrived at its present perfection before lithotrity Avas invented. No results more perfect than had been attained by its means have ever been accomplished by it since. On the other hand, the perfecting of lithotrity has been a progres- sive process from fifty years ago to this very da)'; and thus it is that the axiom about renal disease, right as it might have been in the past, has been groAving less so year by year. I believe it is reversed for stones which may be easily crushed. In support of this conviction I have called before you six unimpeachable Avitnesses— I might easily have called more—six patients Avho could not have been cut. To have placed those feeble and pallid frames on an operating table for lithotomy would have been to slaughter them out- right. Of those six, five Avere saved. I believe, then, that for any stone of almost any size in a patient of broken health from ' advanced renal disease, if any chance exists from operation at all, it will be by lithotrity; and that in such a case litho- tomy will be surely fatal. The choice in a bad case is lithotrity or palliative treat- ment ; Avith a very large stone not easilf crushed, it is lithotomy or palliative treat- ment, probably the latter. But then it is impossible to overlook one condition, and it Avould be useless 114 DISEASES OF THE URINARY ORGANS. affectation to do so. I mean by lithotrity an operation carefully done by an ex- perienced hand. Rather than have it done in any other fashion, let lithotomy be selected by all means. It is impossible to compare these two operations as Ave do some others—as we can, for example, any tAvo modes of amputating a limb. Nor may we blink the fact that, Avhile the lithotomy practice of one good surgeon may not differ greatly in the long run from that of another, it is impossible to deny that the lithotrity of the two may be wide as the poles asunder in its quality as an operation, and as to the chances which it may offer to a patient. Thus it is that a bold, Avell-performed lateral lithotomy is quite possible to the young surgeon at the outset of his cai^fcr, while nothing but considerable experience can make him a good lithotritist. The tAvo operations can never be compared, nor their capabilities estimated, Avithout keeping in view this fact. You whom I address had better, Avhen in practice in the country, decide in difficult or doubtful circumstances to cut rather than to crush, until you have ac- quired some facility in the practice of the latter art, unless, indeed, the stone be quite small. Do not touch Avith the lithotrite in any circumstances a stone Avhich is de- cidedly large until you have had experience with a small one or two. Gentlemen, one great practical poiat remains, always recurs, and at last conies uppermost, on Avhatever side the great subject is considered. It is this :—Detect the existence of a stone in the bladder early; it is ahvays somebody's fault if not found early. The stone will then be small. It may be crushed at a short single sit- tiug, and with almost no risk. No question of cutting need ever arise; the presence of kidney disease need scarcely trouble you. I have never lost a patient after lithotrity, Avhen the stone was small; nor in such circumstances do I expect ever to lose one. [This Lecture related to the case of the Emperor Napoleon III.; a patient in the hospital at that tin* (Jan. 1870) furnishing the theme.] LECTURE XVII. EARLY HISTORY OF CALCULOUS DISEASE, AND THE TREATMENT BEST ADAPTED FOR ITS PREVENTION. Gentlemen,—We have recently studied together and discussed very fully the various operations Avhich are practised for the removal of stone from the bladder. and you have had the opportunity of seeing them performed many times, not less than eleven cases having passed through my Avards during the last few Aveeks, each one Avith a successful result. But, satisfactory as such a result is, it suggests very strongly to my mind that there still remains an important question for us to consider ; as important, indeed, as any of the preceding subjects, and one Avhich must naturally arise in all thinking minds. The question is this: Is there not a period anterior to the stage of the malady already examined—a time at ,#vbich we might prevent the formation of stone in the bladder, and so get rid of the necessity for mechanically removing it ? Admirable as the results of operative means have been—perfect (one may almost say) as they hnve become, at all events so far as regards the crushing operation—great as is the triumph which surgery has achieved in the art of remov- ing stone from the bladder—I take it there are very few men Avho would desire,. if they could help it, to exhibit that triumph in their OAvn persons; and Avho Avould not be infinitely better satisfied if we were able to prevent the formation of stone, and not merely to accomplish its removal, hoAvever satisfactorily the opera- tion for that purpose might be performed. This, then, leads me to the consideration of an important inquiry—Can we do any- thing to prevent the formation of stone in the urinary passages ? It is, in fact, the earliest stage of this malady that will be the subject of our lecture to-day. I commence by saying that I think a great deal may be done. But at the out- set of the inquiry Ave naturally ask, What is the kind of stone (for there are several kinds) the formation of which Ave may hope to do most in preventing ? All cal. EARLY IUSTORY OF CALCULUS. 115 culi are either of local or of constitutional origin. By ' local,' I mean formed by disease in the bladder itself, and not de- pending upon any constitutional condi- tions ; by ' constitutional,' I mean formed by some vicious action, some error of assimilation inherent in the system. Noav, the large majority of stones are of con- stitutional, and not of local origin. When they are local, you know that we cannot prevent their formation except by me- chanical means. Calculous matter, the elements of which are produced in the bladder, may be Avashed out, or be broken or dissolved, and then Avashed out. But Avhen stones are of constitutional origin— and we are going to refer entirely to these to-day—their component elements are separated from the blood, and no me- chanical mode of preventing their pro- duction can by any possibility be avail- able. Now, from observation, we know that nineteen out of twenty of such stones have uric acid for their basis, the remain- ing one in twenty being oxalate of lime; * andvless commonly still, there are phos- phatic stones Avhich are of constitutional origin also. Therefore, practically, to all intents and purposes, the problem be- fore us is contained in the question:— Hoav may we best prevent the formation of uric-acid calculus. Let us examine the early history of a case of persisting uric-acid deposit. First of all, let me say, going back to the root of the matter, that this marked tendency is generally more or less hereditary. As an illustration on the spot, let me recall the man we have just seen Avith uric-acid calculus in the ward, of whom we learned that his father had ' gravel or stone for the last twenty years of his life.' And a very common experience it is, that either calculus or gout—more commonly the latter—has been observed in the family of ■ the patient Avho comes to me with one of these formations in his bladder. I believe it, then, to be strongly hereditary. We speak of tubercular disease and of cancer as being transmitted by blood relation- ship, especially the former; but I doubt if it is so certainly hereditary as the dis- position to uric-acid deposits in one form cr another. I make a point of asking the 1 The deposits of oxalate of lime and of uric acid so often replace each other that the considera- tion of the latter hecomes practically generally sufficient for our purpose. question of all patients Avho come to me with this complaint; and although I can- not at present furnish you with an exact numerical statement, I do know that in a large majority either gravel or gout (for I Avish to show you the identity as to origin of these two complaints) has existed in the preceding generation ; indeed, it is not common to find it otherwise. This hereditary tendency varies in force or strength in different families. You will find some persons with persisting uric- acid deposits at thirty years of age or sooner, others at forty, others at sixty. Of course, the earlier the time at Avhich it appears, the stronger you will infer the hereditary disposition to be, and the more obstinate, probably, will be its tendency to persist. What, then, are the first signs of this condition in the patient ? Usually, the first sign is that the urine deposits pinkish matter, on cooling, at the bottom of the vessel, or that the secretion has merely become cloudy when cold. Sometimes, too, a delicate film or pellicle covers the surface, Avhich faintly exhibits the pris- matic colours. The urine has been passed originally quite clear, becoming cloudy only Avhen it has acquired the surround- ing temperature. This phenomenon, therefore, may appear more frequently in winter than in summer, because the ex- ternal temperature is loAver. It is simply a deposit of salts from a hot solution, as the liquid cools; the deposit being easily dissolved by raising the temperature of the liquid to that at which it was origi- nally passed. The condition of urine here described, very often and very un- necessarily excites much anxiety on the part of the patients; but only a persist- ing condition of it can be regarded as a sign of Avhat is called ' the uric-acid diathesis.' Mind, I mean strictly persis- tence, or at all events frequency of occur- rence : for you or I, with no hereditary predisposition, may take a little more beer, or a heavier dinner, than usual, or an extra glass of champagne, or a glass or two of extraordinary port, and may find next morning a considerable quantity of this pinkish deposit, the urine looking almost like pea-soup, but not so thick, or like a mixture of rhubarb and magnesia; and when the vessel is tilted on one side, a tidal mark, so to speak, is seen, showing the height at which the liquid stood; all this, as I said before, being redissolved by 2 116 DISEASES OF THE heat. The opacity of the liquid, as Avell as its tint, which may vary from fawn to dull red, are due to the unduly large pro- duction of the mixed urates; that is, urates of soda, potash, lime, &c. But if, Avithout any errors of diet, among which, any but a very small allowance of alco- holic drink is only one, a patient habitu- ally passes this kind of urine—if in time there frequently arrives also a deposit of uric acid, manifested by the presence of little crystals, looking like particles of cayenne pepper, at the bottom of the vessel—Avhen this occurs rather early in life, say before forty, we cannot doubt that there is a strong tendency to produce uric acid, either inherited or acquired. For this tendency may to a certain extent be acquired, or a pre-existing habit may be intensified; but, as I have before said, it is mostly inherited. I now show you a specimen of urine quite cloudy with mixed urates, although you must be familiar Avith it in the Avards, and also with the fact that on heating the liquid it again becomes clear, and that in a short time, Avhile Ave are talking, it again be- comes cloudy on cooling. Let me once more remind you that this may happen with the most healthy individual; and it is only the persistence of the symptom, Avithout errors of diet, which should lead you to suspect a constant condition that requires treatment. We have followed the complaint up to the formation of cayenne-pepper crystals. Of this deposit I have some very good specimens here, Avhich have been collected from patients who passed it habitually. These consist mainly of the transparent rhomboidal uric-acid crystals—which you know to be very beautiful objects under the microscope. They may be passed almost daily and habitually by some per- sons, and without any sense of discomfort, or occasion for complaining. Other per- sons may pass this material periodically in large quantity, little or none of the deposit being observed during the interval. At such periods, the patient often ex- periences pain in the back, or over one hip, with uneasiness extending to the groin and testicle, all this perhaps accom- panied by sickness or nausea; and he may then be said to have an attack of sand or gravel. He feels relieved after the occurrence, Avhich, just as a storm is said to clear the air, has freed him from an accumulation in the system. I have satis- URINARY ORGANS. fied myself that many patients Avho have had symptoms commonly denoting the passage of renal calculus, have been merely the subjects of a ' uric-acid storm,' if I may use the expression; and that much calculous matter has been eliminated in a soluble condition, not necessarily always in the concrete form of gravel, although the process has been accom- panied by pains sufficiently severe to arouse the suspicion that a calculus has been passed. These phenomena occur at varying intervals, and usually become more frequent or severe, unless the patient does something to prevent their occur- rence. Subsequently, he may pass tiny calculi, rightly termed gravel, Avhich seem to be rounded or irregular aggregations of the same crystals; and these little bodies tend in time to become larger, sometimes as large as small peas, or even beans; and they are still specimens of the same product—that is, of uric acid, associated more or less with some alkaline base, such as those above named. These attacks are usually accompanied by excruciating pain in the regions already mentioned, and by severe vomiting, lasting a few hours; after which relief often occurs someAvhat suddenly. The urine is at times scanty, and at times deposits blood in that dark form which is described as resembling ' coffee grounds.' Here, let me recall for one moment what I said as to the relation between gout and uric-acid deposit. I have some- times seen these tAvo complaints alterna- ting, comparing one generation with another ; gout appearing in the one, gravel in the second, and then gout in the third. But the same individual may also have alternating attacks of gout and gravel. I have seen a patient suffering for years from gout, which ceased for several months, when he developed for the first time a uric-acid stone in the bladder. Lastly, the so-called ' chalk-stones,' which you have often seen infesting the knuckles and disfiguring the hands of elderly people in advanced stages of gout, are composed of the same material—that is, of uric acid, usually as urate of soda. The identity of the two things, then, is unquestionable; they constitute tAvo different series of phenomena, but both spring from one and the same root. Now, Avhat is to be done for these cases ? What mode of treatment will help to prevent the arrival of at least the EARLY HISTORY OF CALCULUS. 117 advanced condition—namely, that of cal- culus too large to be voided by the patient ? Generally speaking, I think such patients come under observation in a tolerably early stage, although this is by no means always the case. Some are much alarmed at a very early period, Avhen the urine is only occasionally thick Avith urates. You will of course disabuse such patients of their false impressions, because numbers of persons mistake such thick urine for highly organised matter. I have knoAvn persons to become almost hypochondriac through not knoAving that such deposits are of little consequence at first, and can be easily treated. But what are Ave to do for those who habitually pass the cayenne-pepper crystals of uric acid or small calculi ? You -will first seek the patient's antecedents, and learn all that he has to tell you of his habits, his diet, and his family history; and your mode of treatment will be determined accordingly. First of all, let me speak of the general principles upon which the treatment should be conducted. A very simple rule—indeed, too simple, I think— is often adopted. When the urine has persistently and habitually throAvn down acid deposits, the patienthas generally been prescribed alkalies: if, on the contrary, he has had alkaline deposits, he has been treated with acids. That simple mode has too often formed the main portion of the treatment. In the former case he has soda or potash largely administered, or he has been told to drink so many glasses of Vichy Avater, Avhich is mainly a strong solution of carbonate of soda, only it is a natural instead of an artificial one. Noav, it is quite true that with alkalies, provided enough be taken, these deposits will dis- appear; the uric acid will no longer be deposited ; the urine will become less irri- tating ; the annoying symptoms will be di- minished or got rid of. And of course the patient is very much pleased Avith this new condition of clear urine and disappearance of all deposit. And you will say, ' What more can be desired ? ' Much : you have merely made his enemy disappear; he is by no means rid of its presence : for you have not checked the acid formation. The uric acid is there, and probably in quantity as much as ever; but the uric acid and the urates are soluble in alkali, and you have only rendered them invisible. You really have the same condition as that of the fabled ostrich, Avhich is said to put its head in the bush Avhen pursued by hunters, and, no longer seeing them, to believe itself secure. Just such is the security of the patient with uric acid who trusts solely to alkalies or to Vichy water. His surplus deposits have become un- recognisable by vision; nothing more. I do not say the alkalies have been abso- lutely unserviceable as regards his con- stitutional state, but they will not improve it to any great extent; and when he leaves them off the acid shows itself again. And further, I believe there is reason to conclude that large quantities of alkali habitually taken, exercise an injurious influence on the viscera. Diuretics must be regarded in the same light. In those cases which are treated with diuretics, such as nitrate or acetate of potash, &c, the secretion of water is no doubt increased quoad the amount of solids, and the solids are thus dissolved. The same thing hap- pens Avith that infinitely more popular one, so punctually and faithfully swallowed by the patient who has once obtained any medical sanction for its use—I mean whiskey and Avater. In all such instances, what you have chiefly done has been to stimulate the kidneys, already over- worked, to do more. You have by no means cured the patient of his gravel, and may be happy if he is no worse for the remedies. Next, let U3 ask Avhat is the real pathology of these cases, and then I think I shall be able to show you a more effi- cient remedy. The problem has presented itself to me with great force and frequency, because people, naturally fearing they may arrive at the stage of calculous forma- tion, come for advice in the earliest stages, and with the strongest desire to avoid the advanced one of stone in the bladder. So far from its being desirable to send them to Vichy, or to give them alkalies, I believe such patients can be more effectually dealt Avith by a different mode of treatment. Let me premise in broad and simple terms —as our time here, and, I may perhaps add, the extent of our knowledge, will not permit me to be more minute or exact in detail—that the origin of Avhat we call gouty symptoms, as well as of a super- abundant uric-acid deposit in the urine, is due to defective assimilation on the part of organs associated with or forming the primse via?. I am quite aware that it is common in practice to speak somewhat confidently of the liver, its action, and its 118 DISEASES OF THE 1 states, although Ave have still a good deal to learn about all this. Some years ago Ave talked and acted as if Ave were thoroughly acquainted Avith the liver and its functions; but during the last fifteen or tAventy years neAv light has been thrown upon the subject by Bernard, Pavy, and other workers in the same field, and we have learned that the more Ave inquired the less did we certainly knoAV of its natural functions, still less of its action in I disease. Thus, if one thing Avere more settled than another, at least since the time of Abernethy, it was that mercury had a specific influence on that organ ; but now we find that there may be grounds for believing that the action supposed has no existence at all. There Avere other agents, indeed, Avhich Avere vaunted to take the place of mercury, but no one ever thought of disputing the fact that you could augment at will the bile secretion by administering that famous drug. I am not here to say whether that is so or not, but it seems to have been proved that there are substantial reasons for doubting if our ancient faith in that dogma be tenable. In speaking, then, of the ' de- fective action of the liver,' or of < torpor of the liver,' I merely use provisional terms, Avhich most will easily understand as indi- cating more or less distinctly a certain set of symptoms. Let them be briefly described as mainly consisting of a con- stant, or almost constant, deficient ex- creting function by the boAvels, sometimes, but by no means always, associated with impaired appetite and slow or uneasy digestion ; these latter being often absent if the diet is carefully selected, or if the patient lives in the open air and takes much exercise. On the other hand, considerable and multiform symptoms of disturbed digestion may be frequently present. I cannot positively state Avhether those phenomena are really due to in- activity of the organ in question; prac- tically, for us to-day, this does not signify much, but the current terms are still convenient formularies until better ones can be substituted for describing the con- dition in question. Now, at the bottom of this tendency to uric-acid production there often lies what is thus understood as inactivity of the liver; and the true rationale of the unduly large format'on of the urinary salts appears to be that, the liver or some allied organ not doing its duty as an [JRINARY ORGANS. excreting organ, the kidneys have more work than is natural throAvn upon them. Thus the solid matters of the urine, or rather some of its ordinary constituents, are augmented—not all of them, for urea is not necessarily increased, but uric acid is largely produced, and is eliminated not only in solution but in crystalline forms. Uric acid is very insoluble in water ; and although the quantity throAvn out may be quite soluble at the natural temperature of the urine (100° Fahr.), when this diminishes to 00°, 50°, or 40°, the acid is deposited, and w?hen the quantity becomes larger still, even the ordinary amount of fluid associated with it at a temperature of 100° will not suffice to dissolve the whole, and solid uric acid is deposited in some part of the urinary passages. This deposit may take place in the kidneys themselves, giving rise, if not thrown off, to the formation of calculus, at first renal, but sooner or later mostly becoming vesical. Now, if all this be so, the formation of uric acid gravel is not by any means to be regarded as necessarily disease of the kidney ; on the contrary, it is the result of an active and capable organ A'icariously relieving some other organ, the function of Avhich is torpid. The true remedy, therefore, is not to stimulate the kidneys, already overworked —not, to use a familiar simile, to lash that horse of the team Avhich is already doing too much Avork, but you are to seek the cause in that other one of the team Avhich is doing deficient Avork, and that is almost invariably the liver, in the sense already explained. The treatment, then, which I advise you to pursue is to employ such agents as Avill stimulate the excretory action by the prima? vise Avithout depressing vital poAver. No doubt that a poAverful agent for the purpose is mercury; and it is quite un- questionable that relief of the symptoms above alluded to is to be obtained in a remarkable manner by occasional small doses of that drug. For our purpose, however, it is not always necessary, nor can it be considered so harmless for pro- longed action, as another class of agents—I mean, certain kinds of natural mineral Avaters. These I also regard as greatly superior, in these maladies, to taraxacum, nitric acid, alkalies, and the other substi- tutes, as they have been termed, for mercurial remedies, in promoting the function of the liver. Now, the mineral EARLY HISTORY OF CALCULUS. 119 waters which I am about to describe belong to a group of springs all containing sulphate of soda, and some of them sul- phate of magnesia also, in solution. In studying these Avaters, I Avish you to look Avith me at the composition of them, and at the same time to dismiss from your mind entirely those views of medicinal doses Avhich you have acquired in the dispensary, and Avhich necessarily belong to it, since small quantities of drugs, as they exist in mineral waters, Avill act more freely than Avill those quantities combined after the ordinary pharmaceutical method. You ask me for a demonstration, and I am quite ready to give it you. At the same time, let me caution you against regarding the small doses of mineral -waters as having any affinity, either in the matter of quantity or by manner of administration, with Avhat is understood as ' infinitesimal' doses. Thus, for ex- ample, you know that you may give A an ounce of salts, or B half an ounce, and you purge them; but you may obtain the same effect with one-fifth of those quan- tities if the patient takes it as prepared in Nature's laboratory—that is, in the form of mineral Avater. It is a curious fact, Avhich I give as an ultimate one, and Avithout speculating here on the cause of •the difference. As a proof of the superior force of the saline combinations found in natural springs, I may refer you to the following experiment. If you will reduce by careful evaporation, as I have done, such mineral Avaters to their pharmaceuti- cal condition of crystallised salts, you Avill find them possessing little, if any more, poAver than similar salts as obtained by the ordinary processes, and met with in every chemist's shop. They no longer do their Avork on the same terms as when administered in the original Avater before they were separated by evaporation. You Avill therefore readily understand how essential to our end it is to employ the natural mineral waters; since what are called ' artificial Avaters,' hoAvever admir- ably prepared, are simply pharmaceutical products, and are destitute of the very quality which distinguishes the remedies -they are designed to imitate. Here is a table of the waters which I refer to, with a comparative synopsis of their distinguishing saline contents, re- presenting the number of grains (without chloride of sodium and other less active agents which afe also present) in an English pint. Below these I add two well-known alkaline Avaters. Sdline; I'iillna . Hunyadi Janos Friedrichshalle Marienbad (Kreuz) farh-bad (Spiiidel) Franzensbad . AI'haline : Vichy (Ce'.estins) ) about . . J Vals (Magdc- 1 leine) about . 1 154 1.30 r.8 4« 25 30 a a a cj o 3 * JJ 3C Other Ingredients Hrs. Grs. 110 — 148 — 49 — f Little — 1) I iron — 13 < Little — G 1 iron — 47 (Little t iron — 05 i is established it may be removed and re- placed easily enough. A very important injunction is to make the Avound as small as possible so as to be nearly filled by the tube. A large wound is more painful,. and is constantly traversed at first by the urine. I will now briefly sketch the five cases in which I have done this, and give you the results. The first patient Avas a man sixty- three years of age, admitted into this hos- pital January 1869. He had for several years passed all his water by catheter, and for a long period had done so every hour and a half day and night, sometimes oftener. Examination by rectum showed the existence of a large prostate, the coats of the bladder were thickened, the urine charged Avith inflammatory pro- ducts. He remained three months, and notAvithstanding rest and treatment, made little improvement. It was evident that his troubles Avere not due to temporary irritation, but to organic changes greatly diminishing the capacity of his bladder as a reservoir. I need hardly enlarge on the importance of carefully drawing this distinction. Having explained to him fully in presence of the class the nature of his case and the design of my opera- tion, he gladly accepted my proposal that I should do my best to relieve him. The operation Avas easily performed on the 12th of May, in the manner described, Avith immediate relief to the patient. Un- luckily, on the third or fourth night the tube escaped, and the house-surgeon was unable to introduce it. The urine issued freely by the Avound. The next day, at my visit, it Avas but too obvious that the Avails of the neAv passage had not been yet sufficiently consolidated to protect the surrounding parts, and that extravasation had taken place into the scrotum. I at once made free incisions and tied-in a catheter. It Avas a severe trial for the patient, but he came triumphantly out of it. The folloAving six weeks, however, were occupied with this unfortunate acci- dent and its results; meantime I had at an early period, and without difficulty, put the tube in its place, and made it fast there by tapes and plaster. A week or tAvo after, the route was established and ADVANCED PROSTATIC DISEASE. 143 the tube was removed, Avashed, and re- placed Avith the greatest ease every day. During the summer his health continued feeble; no catheter was necessary, the urine passing by the tube, but from in- sufficient attention to changing and clean- ing it, phosphatic deposit formed on it, and gave much trouble. I lost sight of him in July, and he gradually failed in strength, and died in September. The second case Avas that of an old and well-knoAvn medical friend, on whom in 1867 and in 1869 I had successfully operated by lithotrity. For a long period he had passed all his urine by instrument; he Avas now upAvards of seventy-five, and had, after many years of trouble, arrived at the latest stage of frequent and painful catheterism. I Avas called to him in January 1870, suffering from such ex- treme sensibility that he dreaded passing the catheter, Avhich Avas necessary twelve times in the day and night. He was clearly approaching his end, and I agreed to perform this operation solely Avith the vieAv of making his last days more com- fortable. Mr. Clover gave him chloro- form, and I did it on February 7th. All went well j. he never required the catheter again; he kept his bed, Avas comparatively free from suffering, and died three weeks afterwards. The third case Avas probably seen by some of you here last spring. E. P----, aged fifty, Avas admitted to this hospital ' April 22nd, 1874, having suffered from severe symptoms four years, the last two and a half of Avhich he has withdraAvn all his urine by catheter. Of late his suffer- ings have been great; his catheter is passed every half-hour in the day, and he sometimes retains one for a part of the night.' The prostate Avas 'hard, nodu- lated, and enlarged'—a condition of very bad augury, occurring as it did before the age at which hypertrophy of the prostate appears. On May 7th I performed the operation described, Avith the view of diminishing his pains and affording him rest. It Avas followed by relief, especially after the first day or two, and he gained long periods of sleep, which he had not had for months before. Nine or ten days after the operation he showed signs of failing strength, and he sank on the 21st instant. The autopsy showed cancer of the prostate and part of the bladder, of the scirrhus kind—which, affecting the pro- state, is very rare. The iliac glands, those about the base of the lungs, and the lungs themselves, shoAved the presence of the same deposit to a considerable extent. The only other authentic case on record is that reported by Mr. John Adams.1 The word ' scirrhus ' has, it should be remem- bered, been often erroneously used, par- ticularly by ancient authors, to denote organs Avhich are enlarged by ordinary hypertrophy. Case four, T. R. C----, aged forty, consulted me for attacks of hematuria, the cause of Avhich was obscure; but in April 1877, he found some small portions of solid matter in his urine, which I identi- fied under the microscope as portions of villous tumour. He continued his busi- ness occupations in the City all the sum- mer, although often hindered by severe pain and by haemorrhage. Towards the end of 1877 his sufferings, his frequent micturition and inability to pass urine Avithout a catheter, which he often required every tAvo hours, confined him to his room; and he took very large doses of morphia by subcutaneous injection, to render life endurable. He was evidently drawing near his end, but catheterism became increasingly painful; I therefore on January 7th, 1878, opened the bladder above the pubes and introduced the small tube, Mr. Clover giving ether. This afforded considerable relief, less than in the preceding case ; but it rendered the catheter unnecessary. He died on the 31st. At the autopsy, a pedunculated villous groAvth was found springing from the base of the bladder. The size of this tumour was equal to that of a large walnut; it Avas the largest example of this kind I have seen. Case five, H. C----, aged sixty-eight. During the last twelve years, he had con- sulted me occasionally relative to retained urine from hypertrophied prostate; for which I taught him about ten years ago to pass a catheter; and during the greater part of this period little or no urine has been passed by his own efforts. The last year or two his complaint has become increasingly painful, and catheterism more frequent. In February 1878, he came from Ireland to consult me in reference to this condition; and I found that he re- 1 The Lancet, 1833, vol. i. p. 394. I made the most careful researches several j'ears ago in relation to this subject Avith the result stated above. En- cephaloid cancer of the prostate is far less rare. 144 DISEASES OF THE URINARY ORGANS. quired to use the catheter sixteen times in the twenty-four hours, passing it Avith pain, and sometimes with much difficulty. His sufferings were great during the in- tervals, and his sleep almost lost at night. A soft india-rubber catheter Avas tied-in, but this rather aggravated than relieved his condition. Accordingly, on March 2nd, I did the operation described, Mr. Clover giving ether. This was at once followed by great relief, as he could now enjoy sleep during several consecutive hours, for the first time for one or two years at least. The appetite also im- proved, but he was very weak and was confined to his room. It soon appeared that his constitution was worn out, al- though no active disease was present. He lived about six weeks after the operation almost free from pain, gradually sinking about the middle of April. I have thus put the bare facts before you relative to these five cases. Little need exists for remark. In three of them at least, the second, third, and fifth, the operation was adopted solely as a last re- source, to mitigate the sufferings of patients AA-hose fate was already sealed. In the first I operated at a somewhat earlier period, Avith the vieAV of prolonging and rendering more comfortable a possible year or two of life. The unfortunate accident of extravasation was too great a demand upon the resources of the patient, and, although he recovered, yet his stock of vitality was largely exhausted. We must recollect that it Avas the first expe- rience, and I gathered from it useful lessons. I made the opening much smaller afterwards, have taken more care to retain the tube at first, and subsequently I should in such a case remove and wash it daily. The operation itself, properly performed, makes little or no demand on the patient's powers. I shall now, lastly, call your attention to an operation Avhich I have more re- cently adopted in some of these cases Avith a certain advantage; more particularly in those which have been complicated with the presence of calculus. When symptoms have not disappeared after re- peated examinations by the sound and lithotrite in patients previously operated on for stone, and who have long passed all their urine by catheter, it is natural to infer that the presence of impacted calcu- lus or of tumour may possibly be the cause of their distressing condition. I have then proceeded as follows:—The patient being placed and secured as for lithotomy, I make a median incision from the peri- neum, opening the urethra on a grooved staff at the membranous portion, suffi- ciently to admit my forefinger to pass through it into the bladder Avithout in- cising the prostate. I can thus fully explore the neck of the bladder, and by making at the same time firm pressure above the pubes, I am able to reach, with the tip of my finger, the whole of the upper surface of the bladder, besides ex- ploring the lateral Avails and the fundus and trigone, the last named more com- pletely by placing the other finger in the rectum. I have done this now in six cases: in one removing a tumour, with perfect recovery folioAving (see Lecture XXII.) ; in another removing Avith my finger-nail an adherent scale of phosphatic calculous material: this patient, Avho had lost blood daily, often in considerable quantity, from that time ceased to pass any. A notable amount of improvement occurred in tAvo cases; the other two were not benefited. In each one I permitted all the urine to Aoav by the wound for from six to ten days afterwards, so as to afford complete repose to the bladder and urethra, of itself a treatment of some value. Regarding these results, I cannot hesitate to believe that in a feAV appropriate cases this procedure Avill be useful. In no case has the operation been fatal, nor can it, if done with care, be considered a dangerous procedure. You Avill understand, of course, that either of these operations can only be adopted as expedients to relieve when all other resources of our art have failed to do so. ON CYSTITIS AND PROSTATITIS. 145 LECTURE XXI. ON CYSTITIS AND PROSTATITIS. Gentlemen,—It is quite possible that you may see little or nothing, even during a considerable experience of general prac- tice, of those diseases which have occupied our last feAV lectures. Some men never meet with a case of stone in the bladder during a lifetime, and of those who do, very fe\v undertake themselves to treat it. But the very reverse of this is the case Avith the subject Avbich comes before us to-day. Fraught with much less of Avhat one calls ' interest' for an operator, its attractiveness to the student must be found in the fact that cystitis, or inflammation of the bladder, is the commonest affection of that organ, that it is certain to occur in his practice, and probably not unfre- quently. For Avhatever else you may have to treat in connection with the urinary organs, you are certain to have cystitis. If a man has stricture severely, or disease of the kidney, or disease of the prostate, sooner or later he has cystitis, either acute 01 chronic, the symptoms of Avhich are often the most prominent features in all those diseases. Then I beg you to remember that cystitis has almost always some ascer- tainable cause, and that it very rarely indeed appears in what is called an idio- pathic form. You Avill find that there is, or has been, gonorrhoea, or stricture, or disease of the prostate, or retained urine, or urine altered in character, or some other such cause ; and if you have readily come to the conclusion that any case be- fore you is ' idiopathic,' suspect that you have not discovered the cause; for the probability is that you have not searched deeply or carefully enough. Noav and then, but not frequently, the true patho- logy of such a case may elude our best efforts. Possibly you may be forced to attribute it to a gouty diathesis. A very refuge in time of trouble for practitioners of feeble diagnostic power is gout, par- ticularly ' suppressed gout;' therefore beware of it. And while I think it must be admitted that inflammation, either of the urethra or of the bladder, may be sometimes a mere local development of the ubiquitous influence so named, I am sure that this cause is of exceedingly rare occurrence. Certain irritant poisons also —amongst Avhich cantharides is the most prominent and likely to be met with—■ occasion cystitis, which I have seen severe in character, and lasting from ten to twenty hours, as the effect of an ordinary blister.1 First, then, I shall call your attention to acute cystitis, and secondly, and chiefly, to chronic cystitis. Acute cystitis appears in two very distinct forms: one severe and dangerous; the other form is much less so. The dangerous form is that which accompanies the most severe lesions to Avhich the bladder is exposed. The first breaking up of a large and hard stone into fragments, either spontaneously or by the lithotrite, has sometimes caused it; injury to the bladder in lithotomy and in other circumstances are causes. Rigors, bloody urine, extreme pain and irritabi- lity of the organ announce the fact, and unless the patient is soon notably relieved it is probable that he will succumb in a feAV days. At the autopsy the lining membrane is seen to be of a dark crimson hue throughout, or nearly so, and there are often spots where it appears to be sloughing, and the muscular fibres are exposed. The less severe form of acute cystitis is common enough. There is reason to believe that the neck of the bladder is the part mainly affected in these cases; and the reason for this is, that Avhat we call cystitis is often really inflammation of the prostate mainly, or of the urethra passing through it, entirely so perhaps at first, the mucous membrane of the bladder becom- ing affected by extension. And as, ana- tomically, I don't know how we can make an accurate separation of these two organs, it is often legitimate to speak of this affec- tion as ' inflammation of the neck of the bladder.' After gonorrhoea, or from ex- ternal cold and damp, and in connection 1 I think it may be useful to suggest that this possibly never occurs, except where the blister is applied to a cutaneous surface which has previously been broken, or from which the epithelium has been previously removed. The only instance in which I have seen it—referred to in the text—was one in which the blister was applied over a knee- joint, the cutaneous surface of ^which had been previously inflamed by iodine. 146 DISEASES OF THE URINARY ORGANS. with many circumstances of no apparent importance, a man becomes the subject of frequent and painful micturition, and has a sense of aching or gnawing pain above the pubes ; while the urine is cloudy from an increase of the natural mucus of the bladder (not necessarily the tenacious viscid secretion, which being more com- mon there, I shall speak of under the head of Chronic Cystitis); and there is usually some constitutional sympathy with the local inflammation, evinced by loss of appetite and feverishness. I am afraid it is sometimes caused by the unnecessary and umvise use of instru- ments. When gonorrhoea exists, or when there is an irritable condition of urethra following it, the obvious signs of the original complaint having passed off. a patient sometimes presents himself to his surgeon, talks of difficult micturition, and of ' stricture,' of which latter perhaps there is no evidence whatever, and an in- strument is passed, perhaps a little thought- lessly, for him. It then sometimes hap- pens, especially if the instrument was a rigid one, or not very gently passed, that a severe attack of cystitis follows. I name this as Avarning, for such a case some- times is very damaging to the practitioner, as it certainly is to the patient. The treatment of ordinary acute cystitis consists, first, in maintaining the urine at a neutral or very slightly acid reaction, by just enough alkali, in small doses, fre- quently repeated, to produce that effect. To all other forms of the agent I prefer the liquor potassae. Give it in barley water, or decoction of Triticum repens. Hot hip-baths, from 100° to 108° for ten or fifteen minutes, two or three times daily, afford great relief. Laxatives for the boAvels, light food, together Avith local poultices and anodynes if necessary; and rest in the recumbent position as far as possible. Besides these, the use of certain infusions and decoctions, of Avhich I shall speak hereafter. But that Avhich most requires our attention is the chronic form of the dis- ease. It is that which requires the most care and judgment, and for Avhich Ave have most to do in the shape of treat- ment. Chronic cystitis also appears in two distinct forms. In the simpler form of chronic cystitis, there is little else than some increase of the natural mucus from the bladder mixed with the urine. Just as when you have a common cold there is inflammation of the mucous membrane of the nose and towards the frontal sinuses, Avith increase of its secretion, so the inflamed mucous membrane of the bladder adds a quantity of mucus to the urine; and the mucous membrane in this condition, being more sensitive, will not permit itself to be much extended by accumulating urine, but forces the bladder to expel it as soon as possible : hence the frequency of making water. But, besides this, there is another form of chronic cystitis, in which the mucus has a distinct character. It is often spoken of, and not very Avisely, as' catarrh of the bladder '—another example of an unfortunate term leading to error in practice. The mucus is very tenacious, and if you empty a vessel containing the urine of such a patient, it runs off first, and then a quantity of ropy mucus folloAVS in a mass. You may see a pint or more of this material passed in the course of the day, and it acquires the A'iscid charac^- ter on standing. Some patients pass it for months together, and such are said, espe- cially abroad, to have ' catarrh of the bladder,' which, and often very unneces- sarily, is declared to be a very dangerous or an incurable disease. Indeed, to tell such a patient that he has ' catarrh of the bladder' generally occasions him much anxiety. Now, this is because it is com- monly regarded as being an obstinate and chronic disease in itself, instead of as a symptom of some lesion, for the most part easily curable. Catarrh of the blad- der is no more to be regarded as a disease than, for example, is dropsy. Formerly, you know, dropsy was talked of as a for- midable malady, and it still is so to the popular mind ; but no intelligent student would noAv, I suppose, be satisfied to think of it except as a symptom. He would say: 'What is the cause of it? Is it due to cardiac, to renal, or to hepatic disease? ' Precisely so it is with this ' catarrh of the bladder.' You inquire Avhat is the cause of it, and you will find in nine cases out of ten there is a very distinct cause, and mostly a removable one. Your investi- gation of a case is not to be prevented by the existence of this nosological term, ' catarrh,' so that you have only next to demand, ' What is the best treatment of " catarrh " ? ' but you must carry the diagnosis further, and ascertain the condi- ON CYSTITIS AND PROSTATITIS. 147 tion which has occasioned the symptoms. And the most common cause is one but too often overlooked, as I shall repeat— viz., inability of the bladder, either from atony of its coats or prostatic obstruction, to get rid of all the urine it contains. This peculiar muco-purulent secretion, called 'catarrhal,' is, however, by no means always present in these circum- stances, and I cannot tell you here how it happens that in some cases of retained urine, otherAvise apparently similar, it contains only some light flocculent mucus, and that in others there shall be a very large quantity of the characteristic tena- cious matter. With regard to the treatment, the first thing is to take care that the bladder washed utensil would have attained in like circumstances—a useful and suffi- ciently accurate illustration for the lay understanding—and he will appreciate it readily when he finds, as he probably will, that the mucus diminishes considerably after a few days of this treatment. But suppose it does not do so, or does so but slightly, what then ? I will tell you what sometimes happens, and I am not sure that the fact I am about to ask your attention to has been observed or re- corded. It is this : you cannot completely empty every bladder with the catheter. When the prostate is irregular in shape, is emptied by a catheter once, twice, or three times a day, in the easiest manner possible, as treated of in the seventh lec- ture (pp. 50 and 55). And this is neces- sary because decomposing urine is a source of great irritation to the mucous mem- brane. The urea contained in the secre- tion which enters by the ureters in a healthy state meets Avith stale urine and mucus in the bladder, and soon becomes decomposed into carbonate of ammonia, which salt is an acrid and irritating sub- stance, and aggravates the already dis- eased mucous lining of the viscus/ You explain to your patient that his bladder, not having been emptied for many months perhaps, has acquired a condition somewhat resembling that which a badly- and throws out protuberances into the bladder, there are sinuses or spaces be- tween them, which retain one, two, or even more drachms of urine. Again, there are not unfrequently numerous small sacculi in the coats of the bladder which become charged with urine and act in the same way. When obstruction at the neck has existed some time, the daily straining— although not considerable—necessary to expel the urine, produces hypertrophy of the bands which form the muscular coat of the bladder. Now, you know that hydraulic pressure is equal in every di- rection, and in course of time the expul- 2 Fig. 67.—Section of bladder and prostate. A large sac of the former, marked b, produced by long-standing unrelieved retention of urine; a bougie lies in the small opening by which it communicated with the bladder, a, a, Enlarged prostate laid open. 148 DISEASES OF THE URINARY ORGANS. sive act, more powerful when obstruction is present than in health, gradually forces the mucous lining between the interlacing muscular bands, and little pouches result. In these it is not very uncommon for calculi to secrete themselves, and thus in time encysted calculus is formed. In any case, however, those pouches form recep- tacles for urine, which becomes stale and irritating in consequence; and not at all unfrequently they attain a large size, such an one is depicted at Fig. 67. Noav, the mere withdrawal of the urine by catheter by no means empties the reservoir in these circumstances, and enough of noxious fluid is left in these pouches or sacculi to maintain the unhealthy condition of the lining membrane. What you have to do, is to wash out the bladder at least once a day with a little warm water, if it contains a trace of carbolic acid so much the better, before the catheter is removed. I am very particular indeed as to the manner of doing this. Washing out the bladder may be a very valuable mode of treatment, or a mere contrivance for seriously irritat- ing that organ, according to the mode in which it is performed. A common mode —indeed, that which I always saw em- ployed some years ago—was to attach to the catheter (Avhich was often of silver, and it is unnecessary to repeat my views about the superiority of flexible instru- ments) a large metal syringe, and to throw in with considerable force six or eight ounces of water. I Avish you to cherish a wholesome horror of that proceeding, which can in no case be necessary. A healthy bladder, and much more a tender one, can only be disturbed and pained by such a proceeding. This sensitive organ is only accustomed to be distended gradu- ually by the continued percolation into it of urine from the krdneys. Let your washing-out conform at least in some respect to that process. Never, under these circumstances, throw in more than two ounces: and even this quantity, for efficient washing, is sometimes too large. Proceed then as follows: You have a flexible catheter in the bladder; have ready a four-oimce india-rubber bottle— with a brass nozzle and stopcock, the nozzle long and tapering, so as to fit a catheter of any size between Nos. 5 and 10—filled with warm water, say at 100° Fahr. Attach the nozzle gently to the catheter, and throAv in slowly a fourth of the contents; let that run out—the fluid will be thick and dirty, no doubt; then inject another fourth, which will be less so; again another, Avhich will return clearer than the preceding; and the fourth portion Avill probably come aAvay nearly clear. Now, these four separate washings of an ounce each will have been really more efficient than tAvo washings of four ounces each; and you Avill, in obedience to my never-failing injunction, have reduced the amount of instrumental irritation to a minimum. Ten to one but the patient will find the performance soothing to his feelings. There are other methods of effecting the object, but this is the principle I Avant you to understand ; and the mode of carrying it out which I have described is one of the simplest. What if this washing-out has not ac- complished all we wish ? We may then, and often Avith great advantage, try medicated injections. Perhaps the best mild astringent, when the urine is alkaline and depositing phosphates, is the acetate of lead, in the proportion of one grain to four ounces of warm Avater, not stronger; to be used once a day. After this comes the dilute nitric acid; one or tAvo minims to the ounce of water; or dilute phos- phoric acid, three or four minims to the ounce ; or acetic acid, four minims to the ounce, with acetate of lead, and, if you like, Avith a grain of acetate of morphia also. A solution of tannic acid, of one grain to the ounce, is a useful astringent in some cases of abundant mucous de- posit. Then you may try nitrate of silver in small quantity—certainly not more than one grain to four ounces to begin with; even half a grain to that quantity sometimes answers better, increasing gradually, if necessary, to about half a grain, or three-quarters of a grain at most, to the ounce. You may also use, especially where the urine is offensive, carbolic acid; one or tAvo grains of the medicinal acid, Ph. B. to four ounces of water is quite strong enough. Then there is a soothing injection well Avorth your re- membering—viz., biborate of soda and glycerine. It may be used where there is no great occasion for an astringent, or it may be combined with one. The value of this for sore mouth suggested to me its use for an irritable bladder, and experience has confirmed my expectation. Here is my formula: Tavo ounces of glycerine will hold in solution one ounce of biborate of soda; to this add two ounces of water. ON CYSTITIS AND PROSTATITIS. 149 Let this be the solution, of Avhich you add half an ounce to four ounces of warm water. I arrange all these solutions for four ounces, because the four-ounce india- rubber injecting bottle already described is a convenient and portable instrument. SomeAvhat recently much has been said of the value of a solution of quinine as an injection, from one to two grains to the ounce of Avater, Avith a drop or two of acetic acid to insure solution, in presence of mucous and offensive urine. I have tried it, and cannot say that it is better than any of the above named. In circumstances of great pain, you may inject anodynes into the bladder if you please ; but they are of little value. And you need not be afraid of the quantity ; for the mucous membrane of the bladder appears to have no absorbing poAver, unlike the neighbouring tissue Avhich lines the rectum.1 The latter cavity in- deed, is your place for action, if spasm and pain greatly disturb the patient; a suppository of cocoa-nut butter, contain- ing from half a grain to a grain of morphia, being often of great service. Counter- irritants play a small part among our remedies; perhaps the best and safest is a hot linseed poultice, well sprinkled with strong flour of mustard, above the pubes. I cannot recommend croton oil, or nitrate of silver, as counter-irritants there. Hot fomentations, in the form of bran or sand-bags, hot flannels, &c, alleviate pain materially ; so also do hot hip-baths and the hot bidet. Then there is a host of infusions and decoctions reputed to exercise a beneficial influence in cystitis. I will name some of them in Avhat I think to be about the order of their value for the cases one commonly meets with : Buchu, Triticum repens, Alchimella arvensis, Pareira brava, 1 Some one thought proper to question, in one of the journals, the accuracy of this statement relative to the effect of narcotic injections into the bladder, and even to caution my readers against relying on me too implicitly. It might have seemed otherwise almost unnecessary to say, that this particular statement presented the result of very numerous experiments and observations ; and its object Avas of course to show that such injections were of small service, and, therefore, not to be re- commended. My onlv reply to the critic was to in- ject four drachms of Liq. opii sed. into the bladder of a patient with chronic cystitis, in one of my wards in Univ. Coll. Hospital, on four separate occasions, in presence of the students, who verified for themselves the absence of any sign of the pre- sence of opium in the system. Subsequently, a dose (by mouth) of twenty minims for the same man, produced notable contraction of the pupil. and Uva ursi. Now, for the doses of these, your conventional tablespoonful is a miserably inefficient measure. Of the first, fourth, and fifth, give half a pint daily; of the second and third, a pint, that is, of their infusions or decoctions, as the case may be. The underground stem of the Triticum repens, or common couch grass, Avas in- troduced some years ago by myself. Of this I will only say that it maintains its credit, and is undoubtedly very useful in many cases. For use, boil slowly from two to four ounces in a quart of water until reduced to a pint; the strained liquor to be taken by the patient in four doses in the twenty-four hours. It was a favourite remedy in the old herbals ; and it formed the staple medicine against what was called ' strangury,' which, a few cen- turies ago, meant everything like pain or difficulty in making Avater, no matter what the cause; for the art of diagnosis was then in its earliest infancy. The ' Parsley piert' (derived from ' percer la pierre,' and not a parsley or umbelliferous plant at all), or Alchimella arvensis, has proved in my experience an admirable remedy in obscure cases. Use it as an infusion : one ounce to the pint. Buchu, Pareira brava, and Uva ursi are as you knoAV officinal in the British Pharma- copoeia : the first seems to act by reason of the volatile oil it contains, which, by the way, makes it often disagree with a delicate stomach, in which case do not continue to administer it. In any case, Buchu should not be given for any long period of time. The other tAvo agents may be taken for several weeks if necessary ; but they cannot be regarded as valuable remedies. Besides these there are the resins, Avhich have a certain amount of influence upon the mucous membrane of the bladder; such, for instance, as co- paiba, sandalwood oil, Venice turpen- tine, &c. You should not, however, give the dose which you would give in gono- rrhoea. Five minims of copaiba, three or four times a day, in mucilage, is some- times useful. I may say the same of the oil of cubebs. One Avord about alkalies. As a rule, no doubt, alkalies, in neutralising acid urine, greatly help to control chronic cystitis; and I prefer the liquor potassae, to the bicarbonates, tartrates, and citrates, which appear to have more diuretic action, and to increase the quantity of urine, an 150 DISEASES OF THE action you would rather avoid, so as to lessen the frequency of micturition. The old combination of liquor potassae and henbane, affirmed to be a union of in- compatibles, nevertheless seems to me one of the most valuable forms in practice. It is affirmed on high authority that both hyoscyamus and belladonna are deprived of certain specific qualities when mixed with liquor potassae. Chemical changes undoubtedly are thus produced. But I am perfectly satisfied that this combina- tion materially controls painful and fre- quent micturition in the complaint we are considering. Hence I have continued to employ it, and for the reason stated. Now as to acids. Remember that these are by no means the complement of alkalies in relation to their influence on urine. BeAvare of the current notion that it is possible to produce an acid re- action on urine by giving mineral acids by the mouth. By giving alkalies, you can make the urine neutral or alkaline to any extent you please, but you cannot do the converse Avith these acids. Yet I constantly hear it said, ' The patient's urine is very alkaline; had we not better order acids ? ' The reply might be, ' By all means; give an ounce daily, if you like, but it will not change the reaction of the urine.' I have given that very quantity, greatly diluted, of course, with- out the slightest effect on alkaline urine. No doubt mineral acids are sometimes useful ' tonics,' and may do some good; but don't prescribe them Avith the view of directly acting on the urine. The acids that do act on the urine are benzoic acid and citric acid, but you have to give so much of these that I do not know Avhether the remedy may not cause discomforts equal to those which arise from the disease. The benzoic acid has also some balsamic character, and is doubtless useful in some cases of chronic cystitis. The best way to give it is in pills, as it is not soluble in Avater. Three or four grains, with one drop of glycerine, is a good form ; and you must give as many as ten or tAvelve pills a day to attain a good re- sult. At all events, it is useless to give less than six ; that Avould be twenty-four grains in the day. Lemon-juice has also an acid influence on the urine, and if it agrees Avith the stomach, may be taken in large quantity. But here is the impor- tant fact for you to remember: Surplus of acid in the urine is a constitutional JRIXARY ORGANS. error, and it enters the urinary passages at the kidney. It requires constitutional treatment, that is, of the digestive rather than of the excretory organs, and mere alkaline treatment does but neutralise and mask the acid—does not prevent its pro- duction. You have to remodel the patient's habits, control his diet, and take care that his liver and bowels act freely. On the other hand, persistent alkali in the urine is, in nineteen cases out of twenty, a local formation in the bladder. If you take pains to get a specimen of the urine direct from the kidney before its alteration in the bladder, you will mostly find it acid. Such alkaline urine requires local treatment, as by catheter and inject- ing-bottle, and not physic. Now and then you meet with neutral or alkaline urine, milky-looking, with amorphous phosphates, as a constitutional condition ; but this occurrence is rare in comparison Avith the cases I am now describing. Before quitting the subject of cystitis, let me say it is important for you to knoAV that this affection appears sometimes to originate by contagion—through the em- ployment of instruments not properly cleaned. Happily the outward flow of urine through a catheter prevents what might otherAvise be a frequent means of conveying infectious matter to the bladder. To avoid this danger, all flexible instru- ments should be placed in a bath of Avater containing a little carbolic acid: and all metallic instruments should be plunged into boiling water for a few seconds. All should be lubricated on every occasion with olive oil, in which have been dis- solved ten grains of carbolic acid to the ounce; a combination Avhich is Avholly unirritating to the urethra. It is quite common for human urine to be loaded with bacteria, as it comes from the bladder; and it has been even supposed by some persons, that the pre- sence of the bacteria is a common cause of cystitis, and that the proper treatment con- sists in septic injections to get rid of them. I think I can confidently say, there is not the smallest foundation in fact for that theory. Almost all urine in chronic cystitis contains bacteria; I have seen them in the freshly-passed urine of an individual Avho has never had a catheter passed into his bladder; for it has been naturally supposed that catheterism is the means which leads to their produc- tion in that cavity. Whether that be so ON CYSTITIS AND PROSTATITIS. 151 or not, I think it wise to add a trace of carbolic acid, to almost all the injections used for it, as a matter of precaution. I shall close this lecture with some brief remarks on acute and chronic pros- tatitis. Acute prostatitis occurs in different degrees of severity, and often comes first before the practitioner's notice Avhen it causes retention of urine by obstructing the neck of the bladder. How this emergency is to be met I have described at some length in the ninth lecture (page 58). The organ is usually considerably swollen and very tender; besides this, the inflammation may sometimes give rise to abscess in the substance of the gland, or adjacent to it; and the matter may burst either into the urethra, its most common course, or into the rectum. Chronic inflammation of the urethra, passing through the prostate, and more or less affecting the prostate itself, is a condition less generally known or recog- nised. Nevertheless, it is a common and important affection. We see it frequently, but not invariably, as the result of obsti- nate gonorrhoea. I have already referred to it as the cause of symptoms resembling, more than any other malady, those of calculus in the bladder when mild in degree. Thus a patient of tAventy or thirty years of age tells you that the fol- lowing symptoms have rather gradually appeared :—Undue frequency of micturi- tion ; pain following the act, and felt in the end of the penis; occasionally a little blood seen Avith the last few drops of urine, which may be somewhat cloudy with muco-purulent deposit; a sense of heat and Aveight in the perineum and rec- tum ; there is, perhaps, also some gleety discharge in the urethra. All these con- ditions are aggravated by exercise. You see he gives you a complete sketch of the early symptoms of calculus; and how are you to distinguish them? By the history and by sounding. Thus, there is no history of the descent of calculus from the kidney, nor of gravel previously passed. But there is the fact of a chronic gonorrhoea resisting, perhaps, months of treatment. And if the patient shows no improvement, you must not decline to sound him. You do so, then, if really doubtful as to the nature of the case—not otherAvise—and will find nothing, but that the prostatic urethra is very sensitive, and you make him worse, perhaps, for a day or two. Therefore avoid the process, unless you are really in doubt whether the symptoms are not due to stone. What is to be done ? First and fore- most, as a rule, having thus settled the question, abjure all instruments, which, in most cases can only do mischief. Treat it as you Avould a chronic inflammation of the ear or eye—i.e., blister an adjacent surface ; make a small blister every four or five days on either side of the raphe" of the perineum, by applying with a brush the liq. epispast. of the British Pharma- copoeia (a solution of Cantharides in ether), not so freely as to distress him or prevent locomotion, and continue the plan for four or six weeks. I have found the best results from this method, com- bined with a tonic medicine and regimen; and you will find the patient himself gladly exchanging the dull weary aching in the perineum for the smart of the blister, and cheerfully noticing how the former gradually subsides under the in- fluence of the latter. In exceptional cases—and these really belong to another class, those in which constant chronic gleet is a prominent symptom—the appli- cation of a solution of nitrate of silver, not more than one to five grains to the ounce of Avater, to the prostatic urethra, may be very serviceable, if applied with care and all the gentleness you are master of, by means of an instrument fitted for the purpose. I shall in my next lecture proceed Avith diseases of the bladder. 152 DISEASES OF THE URINARY ORGANS. LECTURE XXII. DISEASES OF THE BLADDER : PARALYSIS ; ATONY ; JUVENILE INCONTINENCE ; TUMOURS. Gentlemen,—Two patients have been recently admitted to my ward, and both were affirmed to have ' paralysis of the bladder ;' such, at least, is the statement that accompanied them here. On ex- amining one of them, Ave found a not un- healthy-looking elderly labouring man, from whom, by much questioning, we elicited the folloAving facts: That he is nearly sixty years of age; that he has passed his Avater much too frequently for four or five years; that he was much disturbed at night to do it, although lately it has come away Avithout his knowledge during sleep; that Avhen he makes an effort at Avork the same thing often happens; that the stream is Aveak. falling almost perpendicularly; that he has ' no particular pains,' but is not so strong as formerly, having become weaker of late ; and that for the last few months the urine has been cloudy, and has had a disagreeable smell. With all this his ordinary functions had been fairly per- formed, and he had followed his daily labour until three Aveeks ago. The man Avas desired to unfasten his dress; as he did so you remarked a urinous odour, and that certain cloths, which did duty for an india-rubber receptacle—a luxury beyond the means of our patient—Avere Avet with the secre- tion. Two conditions only could cause this unhappy stale of things : either the bladder was incapable of performing its office as a reservoir, and permitted the urine to escape as fast as it entered from the ureters ; or the viscus was unable to expel its contents, so that it was over- distended by them, the surplus oozing out, or being forced out, in the manner de- scribed. Now, a glance of the eye might have nearly sufficed to settle this question. I pointed out a marked protuberance above the pubic symphysis; and after placing the patient on his back, the dulness by percussion corresponding with that spot, and the clear bowel-note all round, diminished the doubt that this was a collection of fluid, if any such doubt yet existed. Still this was not quite all that it was necessary to know; it Avas just possible that the swelling might be a solid tumour of the bladder, occupying its proper space and much more, and so destroying its function as a reservoir. To the hand, hoAvever, the protuberance was clearly made up of fluid; but even an opinion so formed falls short of absolute demonstration, for the most practised hand has been known sometimes to ' lose its cunning,' or to have found a too deceptive quality in the object handled. Finally, you saAV that a well-curved gum catheter glided into the bladder, and that upwards of 40 ozs. of somewhat stale urine floAved off. I then examined the prostate, and found no very obvious enlargement. Noav, Avas this a case of ' paralysis of the bladder'? Certainly not. The history of the patient showed that he had had no seizure of any kind, and I beg you to understand that Avithout some change in a nervous centre there is no paralysis of the bladder. Recall, if you please, Avhat I said in my seventh lecture (p. 48) on this subject. This term is applied, or rather misapplied, every day to such cases as the one before us, and with the result not merely of masking the true patho- logical state, which ought ahvays, if possible, to be indicated by a nosological term, but of misleading the inquirer, since it indicates a condition Avhich by no means exists. What, then, is the defect or disease occasioning the symptoms in this case ? Probably, atony of the bladder. I will speak presently with more precision. The bladder fails to expel its contents in the two following conditions : either a groAvth from the ^prostate, by no means neces- sarily large, obstructs the neck, Fso that the natural poAver of a healthy bladder— or even of one reinforced against the ob- struction by hypertrophy—cannot propel the urine by or over the enlargement into the urethra; or, no prostatic obstruction being present, these muscular fibres of the bladder have become so enfeebled, or even atrophied, that their propelling power is lost or greatly diminished, and the organ is merely a thin flaccid bag, unable to exercise expulsive force upon its contents. The two conditions, hypertrophied prostate and atonied bladder, naturally, DISEASES OF THE BLADDER. 1;33 often coincide. While hypertrophy of the bladder more commonly takes place in connection Avith obstruction caused by urethral stricture; it also sometimes accompanies enlargement of the prostate. On the other hand, the latter condition, prostatic obstruction, is frequently asso- ciated Avith thinning, dilatation, and atony of the coats of the bladder. But atony may be sometimes produced when there is no disease of the prostate, and then mainly from the subject of it having been placed in circumstances which obliged him to retain his urine for a too considerable period, so that the bladder became over-distended, and has failed subsequently to regain its tone. Unfor- tunately, a single error of this kind Avill sometimes produce an atony, which becomes irremediable if discoArered too late. Noav, on further questioning our patient, Ave did not find that he could recall any such instance, or that he had ever formed the habit of permitting such over-distention. Neither did the affection occur suddenly; on the contrary, the symptoms appeared gradually. What is still more significant is, that they occurred at that time of life Avhen prostatic hyper- trophy mostly commences, if it appears at all. Still, the prostate Avas not obviously large on examination by the bowel. We arrive, then, at the following conclusions:—That this man has some enlargement of the prostate, Avhich, though not obvious in the rectum, consists in a small nipple-like projection of the median portion, occluding the neck of the bladder, and that, from the size of the bladder, as just now demonstrated by percussion and by its contents, its Avails are thin, and have lost their contractile poAver; in other Avords, are in a condition of atony. I think there is no escape from these conclusions, and I beg that you Avill not only never permit yourselves to allude to this condition as ' paralysis/ but that you will protest against so loose and improper a use of the term Avhen you hear it thus applied by others. Now, true paralysis of the bladder occurs from injury to the spine, and also as one of that large group of symptoms which results from disease in the cerebral or cerebro-spinal centres. Tou will then probably find it associated •with impaired poAver of movement or an unsteady gait, with defective articulation, or with some of the slighter signs of such central mischief, as Avell as with those which are more obvious ; and I have even found it persisting after all other signs have nearly—I cannot say quite—dis- appeared. In all cases, as in that of this patient in the Avard, it is essential to empty the bladder by means of the gum catheter three or four times daily, to remove the urine completely, and at least to afford the muscular coat a possibility of re- acquiring poAver, which does not exist so long as that coat remains constantly distended by the retained urine. Next, for the treatment of pure atony and for slight paralysis, uncomplicated with prostatic enlargement, a little aid may be sometimes afforded to the patient through the agency of electricity, by cold douches and injections, and by tonics; but less advantage is to be derived from these remedies, in my opinion, than some have appeared to believe, although I by no means say they are not sometimes serviceable. I have seen an increase of expulsive power attained rapidly during the daily application of an electro-magnetic current to the bladder, made in the following manner:—To one pole the ordinary handle and moist sponge are attached, Avhich is placed over the lumbar vertebrae; an elastic bougie, containing a conducting wire, and tipped Avith metal, is attached to the other pole, and is intro- duced into the bladder. A weak current is set going, and its effects watched, as at first a slight sensation only is to be pro- duced. This accomplished, you should move the bougie about gently in contact with the Avails of the ^bladder, the urine having been just withdraAvn; and, finally, let it rest a little in the neck of the bladder, Avhere greater discomfort is felt: in all, alloAving the current to pass for eight or ten minutes before withdraAving. In no case is any notable irritation to be produced by this agent. A very different condition from that just described sometimes results after severe local injury to the bladder—viz., inability on the part of the organ to act in any Avay as a reservoir. In this un- fortunate "situation the urine leaves the organ by the urethra as fast as it enters by the ureters. This is complete incon- tinence, in the true sense of the term. Little else than mechanical contrivances are of any avail. And these consist of making an artificial reservoir of some 154 DISEASES OF THE URINARY ORGANS. kind, mostly of india-rubber, outside in- stead of inside the body; one Avhich can be emptied at the patient's will. Happily, such cases are very rare. But there is a partial incontinence which is very common, and which is, moreover, amenable to treatment. You will be consulted by an anxious mother Avho, bringing her boy or a girl, of any age below puberty, and occasionally above that period, tells you that every night, or nearly so, this young person Avets the bed. Examples of this are frequently seen in my out-patient room. You know that, in a child with a busy, excitable brain, muscular movements occur during sleep of a much more active character than those which usually occur in the adult, or in children of a more placid temperament. Anything up to somnam- bulism may take place during sleep in a child whose physique is weak, and who is the subject of a restless, ceaseless activity of mind; and micturition during sleep often occurs in connection Avith this state. Clearly, however, not only in such cases; for in some very dull and stupid children, in Avhom intelligence appears to be below the average, the same thing may happen. And it must also be admitted that there are cases which do not fall into either of these classes. For the cure of these un- fortunate patients all sorts of remedies and all kinds of management are adopted, including even a periodical employment of the birch—a species of' cytisus' which I trust you will never admit into your own therapeutic scheme. Depend upon it that ' punishment' for this form of youthful frailty will not answer; and whatever of strength to the moral faculty may be communicated in obedience to the ancient injunction not to spare the rod— a question beyond our province to discuss —do not regard it as binding on us Avho practice the healing art. The child's at- tendants often lose patience at the per- petual recurrence of the disagreeable infirmity, and believe it to be the result of wilfulness or of carelessness. I have seen much cruelty practised, even by the nearest relatives of these unhappy offenders. Give it no countenance what- ever. Noav for treatment, to be considered briefly, and as much as I can on general principles. For class the first, you will cultivate the physical side of life; remove as much as possible the sources of over- mental stimulation; strengthen the con- stitution through the agency of diet, country air, or sea-bathing, if possible, and give steel-Avine and cod-liver oil. For class the second—those of torpid and deficient intelligence—you must show the importance of developing mind. En- deavour to call the will into play as much as possible, and enlist it to aid you in preventing the act. These are the chil- dren who are usually ill-treated, and often made worse in consequence; instead of which they are rather to be made sensible of the importance of losing the habit, so as to get a stimulus for volition in relation to it. Here remedies which act specifi- cally on the organs are most appropriate; although these agents are useful in both classes. First and chiefest is belladonna ; which apparently paralyses the expulsive muscles of the bladder and the sensitiveness of the organ at the same time. Thus, in elderly people, who have feeble power to expel the urine, a dose often produces complete retention, lasting occasionally some time, and unaccompanied at first by conscious- ness of inconvenience from it. To these young patients you should give small doses, at first, of the tincture, in the after- noon and at bedtime, increasing them gradually to a considerable extent, if necessary, until the influence of the drug is quite manifest. If thus the bladder is made to retain the urine all night for a time, a new habit is formed in place of the old one, and it is probable that retaining power will persist on discontinuing the medicine, which, however, should be done by degrees. This remedy is so excellent a one that it has almost superseded blisters to the sacrum and such counter-irritants. After it, nux vomica may be tried. A combination with belladonna of strychnia, say 1-48 to 1-36 of a grain, has suc- ceeded with me after failure by'the latter alone. Then, for confirmed cases, after the failure of other treatment, espe- cially for those who have arrived at puberty, or thereabouts, a mild caustic solution to the prostatic urethra—say ten grains to the ounce of water—has answered in my hands; to be repeated Avith a stronger solution if necessary. This for either sex; but I have found for boys the frequent passing of a soft bougie, which is left in the urethra for two or three minutes at a time, suffice to arrest the habit. When the prepuce is very long TUMOURS OF THE BLADDER. 155 and cannot be easily retracted, a complete circumcision should be performed. In all cases inquire carefully for de- rangements of digestion, in all its stages, from primary stomach symptoms to worms in the lower boAvel—not unfruitful in their adverse influence. Of course you will take care that the child has not too much fluid, either in the form of beer or of tea, nor partakes largely of solid food containing much Avater in its composition, during the latter third of the day; and that it is taken up to pass water late in the evening, when the attendant goes to bed. A short sketch of Tumours proper to the bladder and prostate will finish this part of our subject. First, you are dis- tinctly to understand that all those out- groAvths from the prostate which really come under the head of hypertrophy, since they are more or less composed of structure identical Avith, or very similar to, the tissues of the organ itself, however much the outgrowths may project into the cavity of the bladder, are not to be in- cluded in the class of vesical tumours; although it is not an uncommon error to confound such prostatic products with the above-named groAvths. Tumours proper to the bladder are of rare occurrence. I wish you to know Avhat they are—what it is possible you may meet with, so that you may have the chance of recognising an example if it falls in your way. As with those in other parts of the body, they are classified according to the amount of force Avhich they manifest to invade surrounding structures, or to reproduce themselves elsewhere. Thus, first, Ave have simple fibrous growths, chiefly in the form of polypi, springing from the Avails of the bladder, and Avholly unassociated Avith the prostate ; the rarest of all forms—in short, exceed- ingly rare, known to me personally only by three or four specimens in museums. There are, very rarely, also some forma- tions so small as to be merely mucous papillomata, consisting of little outgrowths from the mucous membrane only. Secondly, there is the ' villous or vascular tumour' cf the bladder, miscalled ' villous cancer;' for I have no hesitation in saying that the villous growth has no invading or reproductive poAver beyond the organ in which it arises, although the contrary has been alleged. This perhaps is the most common form in adults. Its appearance after death, when rather fully developed, is something like that of a small strawberry, and more than one, especially if the case is long continued, may exist in the same bladder. I have seen one example as large as a chestnut and pedun- culated. Thirdly, there is epithelioma—the lowest type of malignant formation, and the slowest of development. Fourthly, true scirrhus occurs in the Avails of the bladder ; it is more common than the preceding, and nearly as much so as the villous tumour. Encephaloid cancer sometimes is met with, but very rarely. Respecting the prostate, it may suffice to say here that the tumour to which it is chiefly subject, the tumour-form of hypertrophy put aside (vide pp. 45-C), is a malignant tumour, and that of the en- cephaloid variety. True scirrhus is so rare that I have seen but one case in my life, and knoAV but of two others besides that. There are no examples in any of the museums. Common hypertrophy has often been termed ' scirrhus' in error. Now, putting the first form of vesical tumour, or polypus, out of the question, it may be said in general terms of all the rest, that the single and most certain characteristic of the presence of a tumour is persistent vesical hematuria, no calculus or other obvious cause existing. But never arrive hastily at the con- clusion in your oavii mind, nor even too readily admit the suspicion, that tumour is present: for you will remember, in the first place, that it is exceedingly rare, compared with other causes of similar symptoms; and, secondly, that there are no early positive signs, or almost none which can be so regarded, of its existence. It is only by a long process, and after much careful Avatching of any case, and consequently when the disease is in a somewhat advanced stage of development, that you can, and mainly per viam exclu- sions, conclude Avith some reason that a tumour is present. The symptoms of vesical tumour are almost identical Avith those of calculus, and the patient is certain to be sounded more than once or twice before tumour is even suspected. Suppose,then,thatyouhave verified the absence of stricture, of pro- static enlargement, of chronic retention of urine, of calculus, of primary renal disease, 156 DISEASES OF THE URINARY ORGANS. and you are at a loss to know why your patient passes water with great frequency and pain, the secretion containing more or less muco-pus, and having blood in it often or continuously, the quantity of which is increased by exercise—you direct your inquiries to the existence of vesical tumour. And you will proceed thus: First 3'ou Avill introduce your finger into the rectum and ascertain whether there is manifest hardness and thickening in the situation of the bladder: especially you Avill note if any deposit so found has a hard or knotted feel, and irregular out- line, running back, perhaps, beyond the prostate. If these characters are obvious, you have almost certainly a case of scirrhus to deal Avith. You may further, if in doubt, introduce into the bladder the short-beaked sound, and with the finger in the rectum carefully explore the thick- ness of the structures intervening between the finger and the sound. Next, the sound being still in the bladder, or the finger being placed in the rectum, you will not find much difficulty, provided the patient is thin, in gaining some informa- tion of a like kind by palpation above and deep pressure behind the pubic symphysis. Then, by movements of the sound itself, you may be able to detect a hard mass of scirrhus on either side of the vesical walls, the sound not turning over readily to the left or right, as the case may be. You will not discover a villous tumour thus, for it is much too soft, and will elude the most delicate traversing of the cavity which can be achieved. Even an epithe- lial growth, which is usually wide in its base, of flocculent surface, and sprouting into the cavity, although not very luxu- riantly, is so deficient in induration as not to be readily discoverable. It scarcely de- stroys the flexibility of the vesical coats, which is the fact you have to ascertain. In nine cases out of ten you will, as the case advances, discover by rectal ex- amination a mass in the bowel, not globu- lar and homogeneous in density, like most hypertrophies of the prostate, but a dense, knotted, or irregularly formed tumour, by no means symmetrically placed, and ex- tending far back, often beyond the poAver of the finger to define. Inequality in sur- face a? you explore it, and unevenness in texture, Avhile it is for the most part hard and unyielding to pressure, are the charac- ters which will compel you to form the gravest conclusion as to the nature of the groAVth. Most rarely, the tumour is at the apex of the bladder, and beyond our reach in the boAvel. Almost invariably is that portion of the bladder involved which can be touched by the finger. I have lately verified the fact of exception in one case, and therefore record it. You may find also by searching late- rally within the bowel, or externally in the groin and iliac regions some indurated glands, but they are palpable only in ad- vanced cases of scirrhus; and you may also obtain such light on the subject as a search for cancerous groAvths in other parts of the body majr afford you. Thus, not long ago, I had my diagnosis of cancer of the bladder in the case of an elderly patient made certain by the appearance of a secondary groAVth, springing from the cranium. Again, you will repeatedly and care- fully examine the deposits in the urine for the appearance of organic materials cast off from the groAVth, which may serve to indicate its nature. Thus I have de- tected under the microscope the peculiar structure Avhich the processes of the villous tumour present to the eye. But Avhat of the cells of epithelioma, and Avhat of ' cancer-cells' ? I am compelled to resign to others—and I am well aware that several writers on this subject have pro- claimed the value of microscopic examin- ation of the urine in vesical cancer—the good fortune of absolutely identifying malignant disease by this means. First, suppose you have caught your ' cancer- cell,' are you prepared to swear to its identity ? As students, I Avill assume you have examined, say a few hundred specimens of urine, not many, but enough, at all events, for my purpose, and that you have, therefore, not a little perplexed yourselves, if you are of an inquiring turn, with all that fruitful progeny of cells, epithelium of different parts and in all stages of groAvth, &c, Avhich are desqua- mated in health, but especially under the influence of any morbid action in those passages, and which appear therefore in the urine. Some of the best ' cancer- cells' I ever saw in my life Avere collected from a patient's urine, and placed under the microscope by a practised microscopic observer, for the purposes of a very im- portant consultation, at which 1 assisted. After a careful local and general examina- tion of the patient, and due observation of the very complete microscopic illustration, CANCER-CELLS IN THE URINE. 157 I was compelled on general grounds to doubt the existence of cancer in the blad- der ; and the ultimate result, happily for the patient, confirmed that view, and disproved the cell. Most valuable as is the microscope in this great class of maladies—ranking next, and very near to, the sound itself—never let it obscure for you those broad features of the case which are to be determined by the unassisted eye and touch, as applied to the body, and to the urinary secretion itself through the means of reagents. But Avhen you find, as sometimes happens, dis- tinct masses of soft, almost semi-trans- lucent structure of considerable size, passed by the urethra at micturition, and discover on examination that these evi- dently consist of rapidly-formed cell groAVth, the cells of large dimensions, and containing two or three nuclei, the obser- vation Avill go far to confirm your suspi- cions of cancer aroused by pre-existing symptoms. Lastly, you Avill, in endeavouring to determine the particular kind of growth, observe the nature of the haemorrhage and the character of the pain. In malig- nant disease, the haemorrhage is irregular in its occurrence, long intervals being sometimes obserA'ed in which no bleeding appears; and when it does take place it is often in considerable quantity, and it may persist for some time ; moreover, the blood is usually of a florid colour. In villous growths the urine is generally more persistently coloured, and presents a reddish tint, resembling the juice of raAV meat, although there may be intervals without the tint; but it is rarely dark or smoky in hue; occasionally, however, considerable haemorrhage takes place. The pain of cancer is more constant and severe than that of villous growth, the latter not being necessarily accompanied with great pain, unless obstruction to the outflow of urine is produced by the tumour. One important and unmistakable symptom of malignant disease is always present in these cases—viz., large and often rapid loss of weight by the patient. If this is not present in a doubtful case I can afford to take generally a hopeful vieAV: if, on the contrary, it is manifest, the case is graver. What shall I say here respecting the treatment of vesical tumour? It must be regarded from two points of view: first, as palliative in its object, in relation to the existence or predominance of certain symptoms, which may be regarded as three in number: haemorrhage; painful and frequent micturition; reten- tion of urine. Secondly, in relation to the question of extirpation by some operative measures. For the treatment of haemorrhage, I shall first name the internal astringents, I mean those administered by the mouth, as gallic and tannic acids and the acetate of lead, for which I have little to say by Avay of commendation. The agents Avhich have been most valuable in my experience are alum, iron alum, and an infusion of matico—of these the alums have been associated with the best results; you may give from ten to fifteen grains of either three times a day, Avith ten, fifteen, or twenty minims of sulphuric acid, adding syrup to make it palatable; and. it cer- tainly is so, and does not generally de- range the stomach at all, which cannot be said of gallic acid or of lead. Of the in- fusion of matico, not less than two ounces should be taken every three or four hours if bleeding is considerable. For the local treatment of vesical haemorrhage, Avhen it is chronic and con- stant, I knoAV of nothing so good as injec- tions into the bladder of nitrate of silver, commencing Avith one grain to four ounces of distilled water, most gently and care- fully used, for it is almost unnecessary to state that by such local treatment, if your handling is rough, it is very easy to in- crease the bleeding. You may throw in an injection daily, in the manner before described (page 148), permitting an ounce to remain when the catheter is withdrawn: and the quantity may be augmented gradually as far as to one grain to the ounce, provided that undue pain is not caused. Few can bear this quantity with- out considerable uneasiness, and this sign of its action should, I think, be reached if the bleeding remains still unchecked. When haemorrhage is considerable, abso- lute rest in bed, cold applications, and avoidance of instrumental interference, unless absolute retention renders it neces- sary, are the main additional elements of treatment. If instruments are really necessary to withdraAv blood and urine, then the sIoav injection of iced Avater, or better still, of iced infusion of matico, may be useful. A solution of the tinc- ture of the perchloride of iron as a cold 158 DISEASES OF THE injection I have knoAvn in more than one case to succeed Avhen all others have failed. The proportion is from thirty minims to a drachm of the tincture to four ounces of water. For alleviation of pain or frequency of micturition do not spare opiates—try- ing any form, or all forms in turn, until you find that Avhich most assuages it and least disturbs the digestive organs. Give them by mouth, subcutaneously, or by suppository. Never mind hoAV much, in order to act efficiently. It is not a ques- tion of saving life, but a question of miti- gating that most frightful of human miseries—prolonged, continuous, severe bodily suffering; and this for a patient whose doom is certain, and to whom life has come to be for the most part a dire calamity. While you are bound, therefore, on the one hand jealously to guard life, I hold that you are equally responsible, on the other, that it shall be rendered fairly endurable. I confess that I have felt sometimes almost indignant at the sight of a poor fellow-creature, worn out with anguish, praying for death, who, thanks to a well-meaning but weak timidity, is permitted only such small comfort as fifteen or twenty minims of liquor opii, or of a solution of morphia, once or twice in the twenty-four hours, can afford. For the relief of chronic retention of urine, such catheterism must be applied as the case requires, whether periodically or continuously, as the comfort and the exigences of the patient render desirable. But I venture to hope that mere palliative measures are, in the future, by no means to form the whole of our the- rapeutic scheme for vesical tumours. There are a few cases which have recently occurred, both in males and females, where the tumour has been sought in the bladder, by way of incision, and has been removed with complete success. Professor Humphrey, of Cam- bridge, removed one thus in the year 1877 from a young man whose symptoms were very severe, and to which there appeared to be no clue. It was a pedunculated tumour and a good but sIoav recovery followed. But very recently the following case has occurred in my own practice in London, and it happened that Professor Seegen of Vienna and Dr. Poggi of Florence were in town, and witnessed the proceeding in November 1880. A man aged 29, had been the subject URINARY ORGANS. of small calculus, partly oxalate, partly phosphate, and I had removed it in the preceding spring by lithotrity at one sitting. The symptoms, however, did not disappear, but rather gradually increased. I crushed a phosphatic concretion for him once or tAvice subsequently, but found Avithin the blades of my lithotrite on the last attempt, a mass which I could neither crush nor remove. I accordingly advised him to submit to an exploration of the bladder, making the incisions usually adopted in the median operation for stone. I searched the bladder thoroughly with my finger, having pressure firmly made by my assistant above the pubes, so as to bring down the upper part of the bladder within the reach of the end of my finger. I soon detected the presence of a rounded tumour, the size of a large chestnut, coated with calculous matter; introduced a small lithotomy forceps, and twisting it, ruptured the peduncle and brought away the mass without difficulty. The man had not a bad symptom, made a speedy recovery, and is in perfect health at this moment. I presented him to the Royal Medical and Chirurgical Society on April 11, 1882, just one year and a half after the operation. In the course of my experience, I have now and then made the autopsy of a patient whose symptoms were obscure during life, resisted treatment, and termi- nated only in a premature and miserable death; and I have recognised too late the condition, which in the case just related Avas happily understood in time. I see no reason why the failure should be repeated. Careful and delicate sounding with a light flat-bladed lithotrite ought to go far in detecting such growths; but an explora- tory incision like that I have referred to, and described at page 144, Lecture XX. is by no means dangerous. When therefore the evidence is strong in favour that some undiscovered cause exists in the bladder of a man Avhom, after careful examination, you can assert to be free from all the ordinary causes of severe vesical sym- ptoms, the propriety of exploring the bladder by perineal incision should be considered. While such a proceeding is not to be too lightly undertaken, I believe that we shall do well to put it in execu- tion when we have before us a patient evidently doomed, if Ave have nothing to offer him in the way of treatment but merely palliative measures. ON ILEMATURIA AND RENAL CALCULUS. 159 05f HEMATURIA AND RENAL CALCULUS, Gentlemen,—I propose to-day to com- plete the programme I originally designed for this course by considering a pheno- menon of common occurrence known as Hematuria. Let us define the term. What is Haematuria ? The outflow of urine con- taining blood in admixture. Thus bleed- ing from the penis at other times than that of micturition is of course not haematuria. Bleeding coincident with micturition from chordee or operation, or from any known injury in the course of the urethra, is also not to be included in the meaning of the term. The blood in these circumstances usually issues by the side of the stream of urine, and is only partially mixed at its line of contact, or it may follow rather than accompany the urine. Haematuria, then, is a symptom. Its presence is, in all cases of urinary disease, to be sought. Hence the inquiry forms one question—the third—of the necessary four which I instructed you always to ask in forming a diagnosis. Here is a glass of urine, evidently containing an admix- ture of blood. What is the source of it ? Now, it is often not an easy thing to state at once what point of that long and com- plicated organic apparatus, which com- mences in the Malpighian corpuscles and ends at the external meatus, is the source of the blood in question. Sometimes it is exceedingly difficult to define its source. Thus it is that in medicine you Avill often find some symptom, the pathological cause of AA'hich is not very obvious, getting a specific name, and coming at length to be erroneously regarded as a distinct disease ; and just as you will be asked, as I told you the other day, what is good treatment for dropsy, you may also be asked Avhat is good treatment for haemat- uria. Noav, the consideration of this question, besides affording us new material for in- quiry, Avill bring us again upon ground we have already travelled over together. I don't regret that—for your sakes I mean. It will stand in the same relation to the past as the arithmetical ' proof ' does to the already worked sum. It is in some respect a synthetical operation following an analvtical one. When, therefore, you XXIII. ND THE OPERATIONS FOR REMOVING IT. see a specimen of urine containing blood, you will, as a matter of course, make a rough mental note of the proportion of blood present, and you will mark the colour. And as you can count on your fingers the ordinary sources of blood, these will pass rapidly in review at the same time. Let us name them as fol- lows :— 1. The kidneys; Avhere haematuria may arise from diseased action more or less temporary, as inflammation ; or from disease more or less persisting, as degene- ration of structure; or from mechanical injury, as by calculus there; or by a strain or a blow on the back. If the haematuria is the result of inflammation, there will be general fever denoting its presence; if produced by slow organic change, there will be the history of failing health, and probably urine changed in quality otherwise than by the mere ad- mixture of blood. When blood is inti- mately mixed in very small quantity, as it is sometimes, note the characters of the urine proper—it may be of low specific gravity, pale, with albumen in greater proportion than blood or pus will account for ; perhaps renal casts may be found— and inquire for the existence of dropsies in any form or degree. In the preceding conditions described, if blood is present, it will give a ' smoke' tint to the secre- tion. Perhaps it may be affirmed that such urine, associated with very little if any local pain, is more likely to come from the kidney than elsewhere. In malignant renal tumour, blood may be large in quantity at times; the rapidity of growth and considerable size attained are the marked characteristics of the dis- ease. If mechanical injury be the origin of haematuria, there will be the history of a blow or strain ; or there may be the signs and symptoms of renal calculus, of which more detail presently. 2. Then, putting aside the ureters, you will remember the bladder as the second source of haemorrhage; and here it may be due to severe cystitis, calculus, or tumour. The first is obvious enough from muco-pus in the urine, and other signs; while the second may well be suspected by the symptoms, and its pre- 160 DISEASES OF THE sence realised by the sound. Here the haemorrhage is usually florid, and in pro- portion to the patient's movements. But the third condition—namely, that the haemorrhage arises from tumour—is not always so readily to be affirmed. As a rule, however, blood from such a source is larger in quantity than from stone, and may be associated Avith less of muco- pus. If the tumour is malignant, it may be felt by rectal or suprapubic examina- tion, and the pain is often severe ; if villous, it gives an even pale-red tint for days together to the urine; and in both cases the blood is florid, unless it is long retained in the bladder, Avhen dark sanies, Like coffee-grounds, resuJts. 3. In haemorrhage from the prostate, the third principal locality or source, a deep dark tint is often observed, if the organ is hypertrophied and the blood is retained ; but here the age of the patient, thehistory of gradually increasing trouble, and the ascertained condition of the organ from the bowel, aid the diagnosis. A slight appearance of blood mixed Avith the last feAV drops of urine is not a rare occur- rence in chronic prostatitis; this of course in younger subjects. 4. When bleeding arises from stricture of the urethra, the patient's history and the cause of the bleeding, almost always following the use of instruments, leave no room for doubt. From the use of instru- ments also in the bladder, haemorrhage sometimes arises. 5. Lastly, it is not to be forgotten that occasionally blood is found in the urine from the action of violent diuretics, from purpura, in fevers, and in the hemorrha- gic diathesis. Now for the treatment of haemorrhage. When you have determined that its source is above the bladder—that is, in the kidney or in its pelvis, probably the first and most influential remedial agent is rest in the recumbent position. Whether from a lesion affecting the intimate struc- ture, or from the mechanical irritation of a calculus in any part of the organ, rest is the first and the essential condition. The patient is, moreover, to be maintained in as cool and tranquil a state as possible. It is in renal more than in any other form of haematuria, perhaps, that direct or internal astringents or styptics are useful. I shall do no more than name those Avhich are most commonly used—namely, alum, gallic and tannic acids, lead, and turpen- UR1NARY ORGANS. tine; equal to them is, I think the infu- sion of matico, say in doses of tAvo ounces every tAvo or three hours. The tincture of the perchloride of iron, and also sul- phuric acid may sometimes be taken with advantage. But see page 157 in the pre- ceding lecture. It is, however, in cases of severe hae- morrhage from the bladder, or more com- monly from an enlarged prostate, that active and judicious treatment is neces- sary. You will be called sometimes to a patient whose bladder is distended Avith coagulated blood, or who is passing fre- quently a quantity of fluid in Avhich blood is the predominating element. Usually this has arisen from some injury inflicted by the instrument, although it may also be from tumour of the vesical Avails. Here you will keep the patient on his back, and forbid the upright position, or any straining, so far as you can prevent it, in passing water. To this end give opium liberally, to subdue the painful and continued action of the bladder. It has ahvays been the rule of practice to apply cold by means of bags of ice to the perineum and above the pubes: it is more to the purpose to introduce small pieces of ice into the rectum. But I doubt very much the value of ice applica- tions, externally, for vesical haemorrhage. One thing is quite certain, that the cold has no penetrating power from the surface to that organ : and that the ice does not ab- stract a single particle of caloric therefrom. A thermometer in the bladder is not lowered a single degree by all the ice-bags j you can apply. Whether it is of value by | any indirect agency is another question; perhaps the spine would be a better local- ity if ice is to be used at all. When bleeding is severe, do not use an instru- ment if it is possible to do Avithout it. There is a great dread in some people's j minds about the existence of a large co- agulum in the bladder. I have even , known a bladder to be opened above the pubes by the surgeon, for the mere pur- pose of evacuating a mass of clotted blood. Leave it alone: it -will gradually be dis- solved and got rid of by the continued action of the urine; while if you are in haste to interfere with instruments, and are very successful in removing it, you Avill very probably also succeed in setting up fresh haemorrhage. The bleeding vessels have a far better chance of closing effectually if they are not subjected to ON H/EMATURIA AN1 mechanical interference. Meanwhile sup- port the patient's powers by good broths, or any nutritious food he can most easily digest. J But it sometimes happens that haem- orrhage occurs in a patient who has long lost all power of passing urine except by catheter. This is a very different position. Here the coagulated mass which fills the bladder must sometimes be removed, or no urine can be brought aAvay; none issuing even if a catheter is passed, for the end of the instrument enters a mass of dense coagulum, and nothing escapes. Sometimes a portion of semi-liquid clot can be removed by attaching to a large silver catheter a six-ounce syringe or a stomach-pump. The lithotrity aspirator has answered remarkably well Avith me in two or three instances. Let me caution you, as a rule, not to inject styptics into the bladder in these circumstances; the irritation so produced generally does more harm than good. There are some feAV exceptions, but the injection of apoAverful styptic into the bladder often produces painful spasm, a condition in which haem- orrhage is more commonly increased than diminished. In passing to another subject, I beg to call your attention to a glass before you containing some urine of a dark and someAvhat unnatural tint. Let us inter- rogate the patient from Avhom it came. In obtaining this specimen I took care that he should first pass about an ounce into a separate vessel, to clear his urethra—a precaution always absolutely necessary to avoid error, as I have before warned you —and the remainder of his urine into this. It is less translucent than average healthy urine is, and has a deeper colour. The hue is not red, but slightly orange, with a dirty grey-brownish tint, com- monly and very well distinguished by the word ' smoky.' That tint denotes blood to an ordinarily practised eye. Why is it not red ? Because blood, after a certain term of contact with urine, loses its red colour and becomes broAvn; and you see it in that condition, or according to the quantity, producing any depth of hue from this up to that of London porter. Put it under the microscope, and you will find abundance of blood corpuscles. We get this broad principle, then, to start with: bleeding from the more distant parts of the urinary system, unless in very large quantity, will almost certainly make the > RENAL CALCULUS. 161 urine broAvn ; Avhile urine which contains red blood has almost certainly issued from some source in the bladder, probably at or near its neck, these being the more common sites of vesical haematuria. In the case before us, then, we proceed easily and rapidly to eliminate many of the sources of bleeding by physical ex- ploration, and by the account which the patient gives of his sensations. His age is forty-five years. He makes a good stream Avhen a fair amount of urine has accumu- lated in his bladder, but this does not often happen, for he passes it every two hours, or less, in the day, not so frequently at night; no straining is necessary for the purpose of emptying the bladder. Pain in the course of the urethra is experienced during and after micturition ; not severe. He is uneasy about the pelvis and loins on taking exercise, and more blood passes aftenvards. He is someAvhat emaciated, and so affords a good condition for exam- ination by the hand. He is subject to variation in the intensity of the symptoms, having now and then attacks of a few days' duration, in which they are aggra- vated, and especially the left renal pain, which is sometimes very severe; and he dates their commencement from an attack which occurred seven years ago, which was accompanied by vomiting; this or nausea has recurred sometimes on these occasions since. He has never passed gravel. He is less robust than formerly; his digestion is not good. A full-sized bougie passes easily into the bladder; no stricture; hypertrophy of prostate at his age is not possible. On sounding he is manifestly more tender than usual; no- thing is found in the bladder, nor is any deviation from the natural condition felt by simultaneous examination by the rec- tum. Palpation of lower part of abdomen shoAvs nothing. Arriving close under the last ribs of left side with one hand, the other pressing firmly from the front on left renal region, he flinches unmistakably; that is the spot, he says, Avhere he feels pain at times and on movement; on right side, nothing observable. We examine his urine : sp. gr. 1*018, acid, small brown- ish deposit on standing: under micro- scope blood-corpuscles, some pus-corpus- cles, epithelium, no crystals, no casts; albumen, a little, but only corresponding with organic matters present. What is the seat of the lesion in his case ? You say, perhaps, the bladder : 162 DISEASES OF THE URINARY ORGANS. Ave found it tender to the sound, and it acts with undue frequency. Yet re- member this is by no means sufficient evidence of any primary morbid change there, this symptom constantly accompany- ing diseases affecting primarily the kid- neys or the upper part of the ureter while the bladder is healthy. Much more probably the kidney. The history, the manifest local tenderness, the repeated attacks of pain there accompanied by nausea, the impaired health, the absence of all the more common causes of cystitis in any form, point to the left kidney as the seat of mischief. The absence of al- bumen and renal casts—a fact of not much weight, although their presence is of the utmost importance—lead us to be- lieve him free from organic changes affect- ing the renal structure. I conclude that his left kidney is the seat of calculus, al- though he has never passed one, and has at present no crystalline deposit in his urine—a fact by no means essential to the diagnosis; and I do not doubt that this calculus is the source of the blood and pus found in his urine. It is sometimes not easy to say what kind of calculus exists in these cases, of which this man's is a fair type. When any calculous matters have been passed which can be examined, or when the crystalline deposit in the urine is con- stant, the inference is pretty clear. Add to this that the probability in any case is strong in favour of uric acid, from its knoAvn frequency of occurrence—taking large numbers, say at least fifteen to one as compared with oxalate of lime. For treatment: Alkaline diuretics and diuretic vegetable infusions, before named, for a period of time; attention to the digestive functions and to that of the skin, for the kidneys are probably work- ing too much vicariously for some other function acting insufficiently ; some mild form of counter-irritation over the renal region, moderation in highly nitrogenised food, a considerable proportion may be advantageously vegetable ; mild alcoholic drinks if any—in most cases none should be permitted—and then only a light and mild Bordeaux. Of all medicinal reme- dies, perhaps none are so valuable as mineral Avaters, especially those which have sulphate of soda, largely diluted, as the main ingredient. For two well- known remedial agents, which are very popular, each among its class, I am bound to tell you I have very small esteem. Here in town it seems to me that every man advises his neighbour, and on every pretext, to drink Vichy or some other popular Avater, but always one that has been rendered so by dint of advertising— advice which is cheap, and of which the value in most instances by no means exceeds the cost. In the country, where perhaps the fairer sex more usually dis- pense similar aid to their suffering neigh- bours, the prescription is mostly gin-and- water. More recently, I regret to observe that even among our own profession, the recommending of Avhiskey has of late be- come a fashion. As for the well-knoAvn mineral water first named, which is a strong solution of carbonate of soda, I must say that, if not absolutely injurious, it is at least greatly inferior to potash. In regard of the two alcoholic agents, it is impossible to say more, or indeed less, than that they are about as serviceable to the kidneys as a pair of spurs to a jaded horse—makes him travel for a time, but takes it out of him in the long run. The subject has, hoAvever, been treated in de- tail in the sixteenth lecture. For the paroxysms of severe pain which denote the passage of a renal cal- culus, you will find hot hip-baths, pro- longed or often repeated, of the greatest service; the temperature may be in- creased to anything the patient can bear. The application of a hot linseed poultice, the surface of Avhich has been sprinkled Avith strong flour of mustard, an excellent rubefacient at all times for this region, may intervene, or be substituted for the bath. The patient should be al- lowed large doses of opiate, also, to assuage severe pain; and abundance of barley- water, potash-water, or the like, for drink. Now, if the pain of renal calculus long persists and is severe, the patient's acti- vity becomes so impaired as to interfere greatly with the necessary occupations of life. He is disqualified for pursuing his labour, whether physical or mental, and until late years it must be confessed that no alternative but to Avait, Avith such patience as he could, has been afforded him. But latterly, much has been done in the way of exploring, cutting down upon, and removing impacted renal calculus from its seat in the kidney, or in the pel- vis, as the case might be. Moreover, the utn n^ALAiuuiA AND RENAL CALCULUS. 163 simple operation of making an incision down to the kidney, and removing a small stone is not necessarily a dangerous one ; Avhile there are cases on record in Avhich, although no stone has been found, much relief has followed the incisions made. The operations of nephrotomy, nephro- lithotomy, and of nephrectomy, are differ- ent forms of procedure by which renal calculi (as well as tumours) have been removed. I will briefly advise you as to what experience has taught us in relation to this important subject; and let me add that my friend Mr. Barker, assistant surgeon to our hospital, has contributed very considerably to our knoAvledge re- specting it. When in a patient of either sex, or at any age, there is reasonable ground for the belief that renal calculus exists, and is the cause of much and persistent suffer- ing, an incision should be made in the situation for the performance of lumbar colotomy on the affected side. A nearly vertical incision should be made through the integuments of the space betAveen the last rib and the crest of the ilium, followed by dissection through the tissues about the line of the anterior border of the quadratus lumborum. The fat surrounding the kidney is identified, and finally the kidney itself; and it suffices at first to lay bare the organ only to a small extent. By palpation Avith the finger, a hard body may be felt; if not, puncture should be made Avith a long needle in different directions for the purpose of detecting the hard body. This found, a slight incision may be made upon the needle tOAvards the calculus, for on divid- ing the renal tissue blood flows very freely, soon ceasing however; but the in- cision should be further dilated, by means of the dressing forceps, and if the calculus can be removed, all is well. A drainage tube is introduced to carry off urine, &c, and the wound is plugged round it. Thus much suffices for neph- rotomy and for nephrolithotomy. When the stone is very large, or branched, or Avhen the kidney is involved in a con- siderable tumour, removal of the entire organ will alone suffice ; if the operation is to be carried further, in which case liga- tures must be carefully applied to the renal blood-vessels, and to the iireter. But this operation for the removal of the kidney, or nephrectomy, may be also suc- cessfully completed by the abdominal section, which ought to be an antiseptic procedure, in the strictest sense of the term. For most cases, I think surgeons Avill prefer the external route, unless it is for some special reason impracticable, be- cause it avoids the risks of opening the peritoneal cavity. I shall here, by way of conclusion, refer to a mode of determining the true characters of a patient's urine, which is of value in some doubtful cases—a mode Avhich has never to my knowledge been hitherto recommended or practised, and which I have systematised for myself. I have already told you how essential it is to avoid admixture of urethral products with urine, if you desire to have a pure specimen, and hoAv you may attain this object by the use of two glasses. It is sometimes quite as essential to avoid its admixture Avith products of the bladder, And I defy you to achieve an absolute diagnosis—by Avhich I mean a demon- stration, and never be satisfied with less, if it be practicable—in some few excep- tional cases, without folloAving the method in question. When, therefore, it is essen- tial to my purpose to obtain an absolutely pure specimen of the renal secretion, I pass a very soft flexible catheter, of me- dium size, into the bladder, the patient standing, draw off all the urine, carefully Avash out the viscus by repeated small in- jections of Avarm Avater (before shoAvn to be rather soothing than irritating in their influence), and then permit the urine to pass, as it Avill do, guttatim, into a test- tube, or other small glass vessel, for pur- poses of examination. The bladder ceases for a time to be a reservoir; it does not expand, but is contracted round the catheter, and the urine percolates from the ureters direct. You have, virtually indeed, just lengthened the ureters as far as to your glass. And now you have a specimen which, for appreciating albumen, for determining reaction, and for freedom from vesical pus, and even blood, and from cell-growths of vesical origin, is of considerable value, and has often fur- nished me with the only data previously Avanting to accomplish an exact diagnosis.1 1 Noav and then, although very rarely, in some states of the bladder, the presence of the gum catheter itself -will occasion a little blood to exude from the mucous membrane lining the cavity. This being obvious to the eye will show a source of fallacy, and it is never to be forgotten that a very amah" proportion of blood-admixture with urine will give rise to a large albumen deposit, on the ap- plication of the usual tests. The value of the 2 164 DISEASES OF THE URINARY ORGANS. Mind never to be satisfied to guess at any- thing ; make, very cautiously if you will, your provisional theories about a doubt- ful case—indeed, the intellectual faculty must constantly do this, and without re- ference to the will—but arrive at no con- clusion, take no action, except so far as you are warranted by facts. I have reserved these few Avords to the last, as the most important. The first Avords I uttered in this course Ave re designed to convey to you my strong sense of the importance of acquiring the habit of making an accurate diagnosis, and a rapid one, if possible. My last shall be to express once more the same conviction. Not because I undervalue the subject of treatment, but precisely with the opposite view; being anxious, experiment, howe\'er, is not in the way of making manifest the presence of albumen in any doubtful case, but in showing that when it is largely pre- sent in the urine ordinarily passed, the urine drawn direct from the kidney may, nevertheless, be Avith- out a trace of it—a most important fact to deter- mine. above all things, that you and I should afford some essential service to those who have confided to us the care of their maladies. I adjure you to spare no pains to obtain the most complete knoAvledge of the complaint itself, since it is the only mode of arriving at a knoAvledge of what Avill be sound and efficient treatment. I beg to thank you for the extreme attention and assiduity Avith which you have folioAved me during this course, and to assure you that such a manifestation on your part has rendered our meetings for these colloquial discourses some of the most agreeable relaxations which have fallen to my lot, to vary the routine of an anxious and very active professional life. [The next lecture, so called here, was not adapted for oral delivery, but is the reprint of directions for the examination of the urine Avhich I drew up several years ago and printed separately for the use of my class.] LECTURE XXIV. THE EXAMINATION OF URINE FOR CLINICAL PURPOSES. Healthy Urine. The common or generally prevailing characters of healthy Urine may be first stated, as affording the standard of com- parison by Avhich to estimate deviations existing in any specimen submitted for examination. Healthy urine, recently passed, is trans- parent ; possesses an amber colour, which may be faint, pale, full or dark, with a tint of orange-red, according to the degree of dilution in which the colouring matter exists. While fresh and Avarm, it has a characteristic odour. After standing a feAV hours, a faint light cloud is seen in the liquid, occupying about the loAver fourth or third of the vessel in Avhich it stands. Its specific gravity, at G0° Fahr., may be approximately regarded as varying be- tween 1-010 and 1-030 ; the mean density being from 1-015 to 1-020. Its reaction is slightly acid, and re- mains so until decomposition of the organic matter contained in the liquid lias com- menced. Heated to ebullition, its trans- parency remains. Mineral acids throw doAvn no precipitates. The quantity voided varies in dif- ferent individuals, and in the same individual at different times, from the in- fluence of season, food, exercise, &c. &c. From tAventy-five to forty ounces in sum- mer, and from thirty to fifty ounces in Avinter, may be considered as the average quantities ; but considerable variations in quantity are consistent with perfect health. The solid matter contained in either case generally ranges between 700 and 900 grains in weight. Rules for Examining Urine. I.—The urine to be examined should be in quantity not less than tAvo or three fluid ounces, and for the most part a portion of that which has been passed on first rising in the morning (urina san- guinis). Or a specimen of that which has been made at night (urina chyli) may be preserved also. But no specimen is Avorth examining, inasmuch as it cannot be relied on as affording trustworthy indications, unless the urine has been separated, in the act of passing by the patient, into two portions. The first portion is to consist of a small quantity—say an ounce or so—sufficient to clear the urethra of any discharge which may happen to be in the canal. The second quantity is to consist of all that remains, which being passed through a urethra just flushed by the preceding portion, will be the true product of the kidneys, plus only any matters derived from the bladder itself. This is the por- tion which is to be submitted to the test hereafter described. Purulent matter originating in the urethra is often mixed Avith specimens of urine sent for examina- tion, in which case it may be erroneously estimated as albumen by the chemical test; or as pus under the microscope may be supposed to have its origin from the deeper passages. II.—Supposing it to be contained in a glass bottle, let the vessel be placed up- right, with the cork downwards, allowing it to stand at least an hour, or two if convenient, for the purpose of permitting matters held in suspension by the urine to subside and adhere to the end of the cork: better still, place the urine in a tall conical glass; the deposit can be easily obtained by a glass pipette. But before the fluid is disturbed, let the following particulars be noted from simple inspection by the naked eye :— The colour of the liquid ; which may be pale straw, yellow, orange, red, or brown. The degree of transparency. The characters of the deposit; such as, Avhether it be floating, flocculent, and scanty; ropy, viscid, and tenacious; dense, heavy, and abundant; dark or light in colour. Its composition may frequently be predicted from this inspection alone by attention to rules hereafter given. III.—Next, remove the cork carefully, to the under surface of Avhich a portion of liquid and deposit will be found ad- hering, sufficient in quantity for examina- tion under the microscope. Transfer it by dabbing the wet cork upon a glass slide; immediately cover it with a piece of thin glass, and view under a good half * OF URINE. 165 or quarter inch object-glass. Generally speaking, I prefer the latter power, under which the accompanying illustrative figures Avere made. IV.—We may now proceed to test the bulk of the urine as follows:— Decant it into the ordinary hydro- meter glass, observing the odour, which may be fresh and normal, ammoniacal or ' fishy,' or foetid. Determine the reaction by litmus paper, which, if the urine be acid, will be turned red; the intensity of the colour corresponding with the amount of free acid present. If reddened litmus be restored to its natural colour, or turmeric paper be rendered broAvn, the urine is alkaline. But urine Avhich is acid when passed, may become alkaline by keeping, from the decomposition of the urea, and the consequent production of carbonate of ammonia. When mucus is present this change takes place with greatly in- creased rapidity. But sometimes urine Avill become more acid by keeping. The urine passed shortly after a large quantity of tea or coffee has been taken is often neutral, or slightly alkaline. Take the specific gravity, bearing in mind the influence of temperature if very accurate observations are required. For example, there is a difference of G° in the sp. gr. of the same urine, at the two temperatures of 40° and 70° Fahr., which may be considered as representing those of winter and summer respectively Temperature of 60° is always understood in all urinary reports. The specific gravity of healthy urine generally rangf s between about 1-010 and 1-030. If the sp. gr. be lower than DO 10, water is pre- sent in large proportion to the solid mat- ters, a condition very commonly occurring in health. The urine should next be examined for albumen in solution, the presence of Avhich may be ascertained by adding nitric acid, or by applying a temperature of not less than 160° or 170° Fahr. In either case albumen is deposited in an in- soluble form. The best method of ap- plying these tests is, first, to heat a small quantity of the urine in a test-tube over the flame of a lamp, to the boiling point; if a flocculent whitish precipitate falls, i i is either coagulated albumen, or an ex- cess of earthy phosphates. Determine which, by adding a little nitric acid. which instantly dissolves the phosphate , 166 DISEASES OF THE URINARY ORGANS. but has no such effect on the albumen; bearing in mind that when the latter is present in very small quantity, too much nitric acid Avill dissolve the precipi- tate. But when urine is alkaline, albumen is not precipitated by heat; in which case a small drop of nitric or of acetic acid— that is, just sufficient to faintly acidify the mixture—should be added. For it is not sufficiently pointed out in the directions ordinarily given for the performance of this test, that the presence of free nitric acid, in the proportion of one or two per cent, in albuminous urine, will prevent coagulation taking place when heat is applied. But if the necessary acidifica- tion is made with acetic acid, no difficulty will arise, as the presence of this acid will not hinder the coagulation of albu- men. In all cases where the presence of albumen is suspected, the application of both heat and nitric acid is to be made, the effect of either being insufficient alone to constitute unquestionable evidence of its existence. The quantity of albumen may be approximately determined by observing the proportion Avhich the coagu- lated deposit bears to the supernatant fluid, after the test-tube and its contents have been set aside for a time ; and the time should be a constant one, such as fifteen minutes, to obtain similarity of results. If the sp. gr. be high, as 1-030 or more, either the presence of sugar or excess of urea may be suspected. Or the urine may in such case be only a con- centrated specimen, in which the fluid constituents exist in small proportion to the solids. Diabetic urine has generally a sp. gr. of 1-030 to 1-045 or 1-050. Moore's test is a simple and efficient one for sugar. Boil the urine in a test-tube, Avith nearly half its bulk of pure liquor potassa? for two minutes, when, if sugar be present, the liquid acquires a broAvn colour of greater or less intensity. Trommer's test, consists in the addition of about a third of its bulk of a solution of sulphate of copper [10 grains to one ounce of dis- tilled water] to the urine in a test-tube. Sufficient liquor potassas must then be added *to produce a precipitate of the oxide of copper, and to re-dissolve it. The greenish-blue liquid is heated until it boils, when, if grape sugar be in solu- tion, a red precipitate of the suboxide of copper is thrown doAvn. But a more cer- tain test than Trommer's, is Fehling's standard copper solution, by which also the sulphate is reduced to the dark orange sub-oxide, by the presence of grape sugar. The most convenient mode of employing it clinically, is in the dry form of ' pel- lets,' which are portable ; each containing enough for solution in one drachm el- water in a test tube. A little of the sus- pected urine is added to this, the mixture is boiled, and the presence of sugar is shown by the precipitate described. There is also the fermentation test, by which the presence of Torula cere- visiae is determined when sugar is present; but it is unnecessary to describe the pro- cess here. The presence of urea is thus deter- mined. To a small quantity of urine in a test-tube, add half the quantity of pure nitric acid. Place the tube in cold water; flat rhomboidal or hexagonal crystals of the nitrate of urea soon appear in the fluid, if urea is present in excess. The acid gives no such result in urine of the normal composition. If the urine be unusually high in colour, the cause may be an admixture of blood, Avhen it will be either red or broAvn; or of bile, Avhen it Avill have an orange or a bright' burnt sienna ' tint. If it be due to the presence of blood, the colour, which may vary between that of porter and the faintest tint of red, dis- appears on simply boiling some of the fluid in a test-tube, the contents of which at the same time become opaque, and a deposit of dark coagula will take place, proportioned in amount to the quantity of albuminous matter present. Blood cor- puscles will always be seen under the microscope. If not due to blood, wet the surface of a white plate Avith some of the urine to be examined, and let fall a few drops of nitric acid upon it, and if the colouring matter of bile be present, a brilliant play of colours (green, violet, red) around the acid will be instantly observed, which is transient in its duration. But if the bile be small in quantity, the appearance de- scribed will not be well exhibited unless the urine be concentrated by evapora- tion. V.—Examination of the depbsit by the naked eye. If a dense deposit be white, yellowish, or pink, and disappear by heat, it is almost EXAMINATION OF URINE. 167 certainly urate of soda. Sometimes this deposit has a dark red or brown colour. The urine in any case is almost invariably acid. The deposit of urate of soda com- pletely disappears on heating the urine containing it. If a dense white deposit do not dis- appear by heat, it is almost certain to be composed of the triple phosphates, in which case it will be dissolved by either acetic or nitric acid, and remain unaltered by the addition of ammonia or liquor potassae. The urine is generally neutral or alkaline. An orange or red deposit, which is visibly granular, sandy, or crystalline, is uric acid. Oxalates do not form a visible deposit, although when large and numerous, the naked eye will often detect innumerable small glittering points of light floating throughout the specimen containing them. They differ from the triple phosphates, small crystals of Avhich they might be perhaps confounded with, by being in- soluble in acetic acid, although dissolved by nitric and hydrochloric acids. If a deposit be slight and flocculent, and unchanged by nitric acid, it consists chiefly of healthy mucus and epithe- lium. If a pale, opaque, homogeneous layer, easily miscible with the urine, settle to the bottom of the vessel, and the urine be acid or neutral, it is almost certainly pus. If so, albumen may be detected in the de- posit by heating it, and adding nitric acid, and in the supernatant fluid also, in small quantity. Lastly, agitate an equal quan- tity of liquor potassaa with a portion of the deposit, and if the latter be pus, a dense gelatinous mass will result; while if it be merely mucus, it Avill be less dense than before. If the deposit be more or less transparent and gelatinous, ropy, glairy, and tenacious, perhaps containing minute air-bubbles, and is not miscible with the urine, it is probably mucus or muco-pus only, and the urine is generally alkaline. If the urine is acid, such a de- posit is certainly mucus. But in alkaline urine, pus forms an opaque and glairy de- posit. A glairy deposit may be opaque from the presence of phosphates; if so, a drop or two of nitric acid will dissolve them and render the deposit comparatively clear. The microscope will most readily decide the question, especially when the deoosit is small in quantity. Liquor puris contains albumen. Liquor muci does not. Acetic acid has no visible effects upon an admixture of pus and urine. Added to urine containing mucus, a wrinkled membrane-like matter is seen floating through it, presenting a very characteristic appearance. VI.—In examining the deposit under the microscope, any doubt respecting its elements will be cleared up. Under the quarter-inch object-glass, the ordinary appearance of the deposits commonly met with are as follows :— Uric Acid. (Fig. 68.)—Primary form, rhombs, of which numerous modifica- tions are seen (a a); the most common exhibiting angles which are truncated or Fig. 68. obtuse. It occurs most commonly in lozenge-shaped crystals, and rhomboidal prisms, of Avhich the size and thickness vary greatly. Colour, usually pale amber, like that of barley-sugar, but the tints range between faint straAV and deep orange-red. Sometimes in shapeless masses of cohering prismatic, or lozenge- shaped crystals (b b) ; these are the * red sand' and ' cayenne pepper' deposits which are seen by the naked eye. Urate of Soda generally appears as a dark amorphous deposit which a high power shows to consist of minute particles cohering to a greater or less extent, in strings or masses. Fig. 70 (a a).—This is, perhaps, the most frequently occurring precipitate Avhich is deposited from the urine. Rarely it assumes the form of 168 DISEASES OF THE URINARY ORGANS. minute opaque balls of a reddish or reddish-yellow colour, either with or without little projecting spiculae, which Idish or prisms, or as a rosette, where the crystals with or are acicular and [in great number. Very ;, which rarely the neutral triple phosphate appears in double penniform crystals. * The bibasic form of the triple phos- phate occurs in foliaceous and stelliform crystals, and is found in stale and highly alkaline urine, never in that Avhich is acid. It appears to be a secondary for- mation occurring in the urine after it has been passed, and very frequently to be developed from pre-existing prismatic crystals of the neutral phosphate by gradual change. First, the prismatic crystal becomes cleft at each extremity, then slight indications of the foliaceous markings are seen diverging from near the centre to each angle, so that by degrees four branches are developed, somewhat in the form of a cross, while the angular outline of the original crystal disappears. Tavo new branches are fre- quently added afterwards, and thus the six-rayed form of this salt is produced ; a, a, a, a, indicate these crystals in different stages of development, sketched by myself from two specimens at different periods in the course of three days. Phosphate of Lime occurs sometimes as a pellicle on the surface of alkaline urine, usually of minute granules; and it is often deposited with crystals of the neutral triple phosphate, adhering to them, and lying free in the field. Fig. 69. Oxalates.—Common in sharply-de- fined octahedral forms, colourless and transparent; of all sizes, some being exceedingly minute. (Fig. 70). Very rarely, indeed, in a dodecahedral form, c. This deposit is sometimes replaced and sometimes accompanied by small crystal- line bodies, described as possessing a ' dumb-bell' form (d). Their appearance is rare as compared Avith that of the octahedra. Probably their constitution is not the oxalate, but the oxalurate of lime, a closely-allied salt. Red Blood Corpuscles.—Small circu- lar flattened disks, with a faint yellowish tint; smooth, semi-transparent, and non- granular ; slightly concave on each face, but plump and almost spherical in urine ofloAv specific gravity from endosmosis; sometimes shrivelled, with serrated edges, or burst. The diameter is about the -^Vo of an inch in the natural flattened state, but when distended, in urine, is some- Avhat less. There is no nucleus in the red corpuscle. The white blood cor- Fig. 69. latter appear to be composed of l (b). Small globular masses with hooked projections have been re as urate of soda; these are rare : The Phosphate of Ammonia a: nesia, or Neutral Triple Pb —In colourless, transparent, th] prisms, usually of large size, not mistake. (Fig. 69, b.) The sui these crystals exhibit great varie Fig. 70. form and number of their fac casionally it occurs in the stel from the coherence of sevei Fig. 69. latter appear to be composed of uric acid (b). Small globular masses with irregular hooked projections have been recognised as urate of soda; these are rare : b. The Phosphate of Ammonia and Mag- nesia, or Neutral Triple Phosphate. —In colourless, transparent, three-sided prisms, usually of large size, not easy to mistake. (Fig. 69, b.) The summits of these crystals exhibit great variety in the Fig. 70. form and number of their facets. Oc- casionally it occurs in the stellar form, from the coherence of several small EXAMINATION OF URINE. 169 puscle is larger, varying in size from the ]nrcro" to the ^^ of an inch in diameter; it exhibits a tripartite nucleus on the ad- dition of acetic acid. (Fig. 71, c and d.) Pus Corpuscles. (Fig. 71,a, a.)—Vari- able in size, generally larger than blood corpuscles; from about ^roVo"to Wtnr °f an inch in diameter, white, rather opaque, Fig. 71. granular aspect externally, Avith two or three nuclei, sometimes four, often faintly seen, but made distinct by the addition of acetic acid (ft). Mucus contains no specific corpuscle. Any such bodies in it are probably pus corpuscles, Avith which it is most fre- quently mixed. Epithelium is often found in consider- Fig. 72. able quantity in the urine, and it offers bodies of various form to the observer: flat and spheroidal; the former largely in the urine of women; round, oval, and cau- date, frequent in that of men. (Fig. 72, a). From parts of the bladder and the ureters, the epithelium is often prismatic or caudate (b) or oval. Small rounded epithelium, and the caudate or spindle-shaped variety, have often led inexperienced observers to form conclusions in relation to the presence of cancer, which have not been warranted; a subject referred to at page 156, Lecture XXII. Urinary Casts of the uriniferous tubes of the kidney. (Fig. 73.)—In acute nephritis, epithelial casts are always thrown off in abundance ; and blood cor- puscles may often be found in the cast. The character of the cast is more ' granu- lar,' Avith less of epithelium, in chronic nephritis. In fatty degeneration of the kidney, the cast contains oil globules. A semi-transparent cast, containing few or no organic corpuscles, known as the ' hyaline ' or ' waxy cast,' appears in renal changes of a chronic kind. No doubt an occasional cast may be found in the ab- sence of renal disease; but when their appearance is persistent, some organic change, either acute or chronic, is certainly present. Pigment.—Little bodies of irregular form, of an orange or orange-red colour, are frequently seen in urine. Some of these are partially transparent; and some opaque, and thus almost black. They are sometimes confined by a cell-wall, and some- 170 DISEASES OF THE URINARY ORGANS. times they present an amorphous character. They are evidently pigmentary in their nature, and have no pathological import. Spermatozoa are frequently to be found in the urine of those who are per- fectly healthy. When their presence is constant, and then only, is the circum- stance to be attributed to disease. Vegetable Fungi appear in urine very soon after it is passed, in certain condi- tions. In acid urine, the l Penicilium glaucum ' appears: the ' Torula cerevisiae,' or yeast-plant, in diabetic urine. Vibriones appear very quickly in urine soon after it has been voided, espe- cially in hot weather. Under this term are included both vegetable and animal organisms, endowed with spontaneous movements. In some specimens of urine they exist before it leaves the bladder. Accidental Bodies, met with in the microscopical examination of the urine, are chiefly hair, cotton, and flax fibres, feathers, woollen, silken, and woody fibres, forming dust introduced into the vessels which contain the specimen to be exa- mined. When these have been once seen and identified they cease to puzzle the student; and as they are very abundant there is no difficulty in observing their specific characters. INDEX. Accuracy in diagnosis of stone Acetate of lead, as injected into bladder Acids, effect of, on urine . „ in cystitis .... Administration of mineral waters . Advanced prostatic disease . Age, in stone operations . Albumen in urine Alchimella arvensis .... Alcohol in the diet of calculous patient Alkalies as solvents of stone „ in cystitis .... Alkaline treatment of gravel Anaesthetics in lithotrity Anklets, use of, in lithotomy Anodynes in the bladder Antiseptics in catheterism ' Apparatus Major' Aspiration of bladder in retention Aspirator of Sir P. Crampton „ of Clover .... „ of author „ use of..... Atony of bladder .... „ „ treatment of simple Author's stricture dilator. „ lithotrite .... „ aspirator .... „ washing-out apparatus Avery, endoscope of . 93, Bacteria in the urine . Badly curved catheter Belladonna..... Benzoic acid .... Biborate of soda and glycerine injected into bladder..... Bigelow, aspirator of Dr. . „ his proposals Bilateral lithotomy . Bile in urine..... Bistourie cachee Bladder, aspiration of . „ rectal puncture of. „ sacculation of . „ washing out... ., opening above pubes. „ anodynes for. Blades of lithotrite described . Bleeding after lithotomy . „ „ lithotrity Blister, effect of a . Blistering in prostatitis Blood in urine „ in prostatitis „ in cystitis ,, in stricture . „ in calculus . • , • poisoning after lithotrity . Border ground between lithotomy and lithotrity Bougies, how to pass them in healthy urethra flexible, French..... PAGE 134 148 150 150 121 139 97, 98 165 149 122 127 149 118 82 101 149 150 96 BO 78 79 73 85,86 152 153 37 76 79 93 PAGE Bougies, flexible, French, with lead stylet . 25 „ small twisted.....81 Bright's disease......10K Brodie, Sir Benjamin ... 17,44, 75 Brown's dilatable air tampon . . . 104 Buchu........119 Bulbous bougies in stricture . . . .19 „ exploring instruments for stricture 20 150 56 154 150 148 79 82 98 166 38 60 61 91 148 140 149 77 104 89 145 151 3 160 160 '-69 90 134 16 22 Cadge, on median lithotomy. Calculus, vesical (see Stone) Cancer-cells in urine .... Cantharides, effect of Carbolic acid, injection into bladder of . Carbolised oil for instruments . Carlsbad water..... „ salts ..... „ dietary..... Cases of supra-pubic opening of bladder Casts, reuai...... Catarrh of bladder .... Catheter, how tied in ... „ very fine gum . „ slender silver ., oversliding.... „ coude'e..... „ over-curved gum ,, moulding of . „ silver prostatic . „ bicoudee..... „ vulcanised india-rubber „ cleaning of ... Catheterism, constant . . . 5 „ in partial retention . „ when necessary „ results of . „ exceptional dangers of . Caustics in stricture .... Celsus on lithotomy .... Chemical agents in stricture . „ varieties of stone Cheselden's lithotomy .... Children, stone in „ lithotomy in . „ gorget for lithotomy „ sounding .... Choice of operation for stone . Chronic retention..... „ „ is catheter to be used in Citrate of potash as a solvent . Citric acid...... Civiale's urethrotome ,, medio-bilateral lithotomy „ lithotrite .... Cleaning catheters .... Clover's aspirator .... Clots of blood in bladder Cock, Mr., on rectal puncture of bladder Colic, nephritic..... Conical steel bougies .... Constant catheterism. . . .55, Constitution water..... 132 156,169 145 148 150 120 122 123 140 169 146 26 30 30 34 48 50 51 51 51 53 150 139,147 55 55 56 56 35 96 35 67 97 7,106 106 106 106 71, 72 49 54-56 128 150 41 98,105 150 79 160-1 60 116 24 139,147 . 126 172 INDEX. PAGE Construction of lithotrite.....76 Continuous dilatation.....25 „ „ fever after . . . 27 Copaiba........149 Couch grass.......149 Coude'e catheter......48 Counterirritants in cystitis . . . . 149 Cruise's endoscope......8 Crushing the stone......84 Cubebs........149 Cutting on the gripe......96 Cvsts of bladder......148 Cvstitis........145 „ after lithotrity.....87 „ chronic, after lithotrity . . . 90 „ causes of......145 „ severe acute......155 „ from contagion.....150 „ ordinary acute.....145 „ treatment of.....146 Danger from using large lithotrites Debris, withdrawal of Decoctions, various Deposits in urine .... „ phosphatic Desormeaux, endoscope of Diabetes..... Diagnosis..... „ method in „ the four chief questions in „ instruments necessary for ,, of a simple case of strictur „ „ confirmed ., „ of hypertrophy of prostate „ of stone „ of tumours ,, of renal calculus . Diet in uric acid diathesis „ at Carlsbad .... Dieulafoy's aspirator Difficulties in treating stricture . Digital exploration of the bladder Dilatability of urethra Dilatation of stricture „ simple „ continuous „ of urethra behind strictur „ of ureters Dilating instruments . Dilators, metallic Directions for using aspirator Dissection for lithotomy . Dolbeau's operation Dupuytren's lithotomy Early detection of stone . . . 135-7 Electricity as a stone solvent . . . . 130 Encephaloid of bladder.....157 Endoscope, the .... „ of Avery . „ of Desormeaux „ of Cruise , . . . 8 „ of Leitner.....9 English gauge......23 „ lithotrites......76-7 Engorgement of bladder .... 48 Epithelioma of bladder.....157 Evacuating catheters.....80 Evian water.......120 Examination of urine .... 5, 164 „ per rectum for enlarged prostate 49 „ „ for tumours in blad- der ... 158 Exploration of bladder through the perineum 144 Exploring instruments in stricture . . . 20 94 '8,86 149 167 92 8 109 1 2 3 8 18 19 47 69, 184 155 161 122 123 61 .29 144 36 20 21 25 33 110 24 25 86 99 98 98 External meatus, stricture at ,, urethrotomy „ „ without a guide „ „ with a guide . Extravasation of urine . „ „ signs . „ treatment. False passages..... Favourite crushing ' area' in bladder Fehling's test for sugar in urine Ferguson's lithotrite Fever after lithotrity. „ continuous dilatation . Fibrous growths simple in bladder . Fine gum catheters „ silver „..... Fistula;...... „ simple urinary „ indurated „ . . . „ with loss of substance . „ treatment of „ urethro-rectal. Flat-bladed lithotrite . Fomentations in cystitis . Food and diet .... Forceps, long urethral „ lithotomy Foreign bodies in urethra, expulsion of Four questions for diagnosis . Fragment, search for last. „ impacted in urethra Franzensbad water .... French coudee catheter. „ olivary instruments „ gauge .... Frequent micturition Frere Jacques' operation Friedrichshalle water Fungi in urine .... Galvanic cautery . Gauges...... Glauber's salts, value of . Glycerine and borax, injection of . Gorget—the cutting . „ the blunt.... „ for children . Gout...... Gravel, early history of . „ treatment of Gripe, cutting on the Guthrie, Mr...... H.kmaturia..... „ persistent vesical „ sources of ,, treatment of „ after lithotomy Haemorrhage from vesical tumour „ „ kidney. „ „ prostate . „ „ stricture of urethra „ „ bladder . Hand, sensitive and educated, importan Hawkins, Sir Caesar, gorget Heurteloup..... Hippocrates' allusion to lithotomy . Holder of staff in lithotomy . Holt's operation .... Hot fomentations . . How to obtain a fair specimen of urine „ pass a bougie in healthy urethr „ pass a lithotrite PAGE ;;« 35 36 86 02 62-3 63 16,32 INDEX. 173 „ PAGE How to sound for stone . . . .69,136 >» seize a stone in lithotrite . . 84 Hunyadi Janos water.....119 Hypertrophy of prostate . . • .43 >> „ importance of age in diagnosis . . . 44 ;> ,, diagrams of .45 .. ,, symptoms of . . 46 ,, „ physical diagnosis . 47 ., „ treatment. . .49 ., „ retention from . . 49 „ ,, history of a case of . 139 „ „ aggravated symptoms 140 Impermeability of stricture . . . . 28 Incision in lateral lithotomy . . . 101-2 Incontinence of urine......47 „ „ after lithotomy in women 107 India-rubber catheter.....53 Indigestion.......,118 Inflammation of prostate causing retention . 57 Infusions, various......149 Injections for the bladder.....148 „ for urethra.....11 of oil.......30 140 21-2 21-2 38 39 Insertion of tube into bladder above pubes . Instruments, dilating..... „ flexible or inflexible . . . Internal urethrotomy..... „ „ instruments used in . . „ „ how it should be per- formed Involuntary micturition..... Juvenile incontinence..... treatment of . . . 154 154 107 163 163 103 Kidneys, disease of, in stone operations „ „ operations on „ calculus in ... Knife, lithotomy .... Large lithotrites to be avoided unless neces- sary ........It Last fragment.......f° Lateral lithotomy, origin of. . . • J< anatomy of the operation of " " J * (jg_100 „ preliminary treatment of |, patient tor. . . • 100 passage of the staff in . 100 position of patient in . . 101 incision in • • iui-^ T' introduction of forceps in . 103 haemorrhage in after treatment in Lead','acetate of, as an injection for bladder „ stylets...... Leitner's endoscope..... Lemon juice . List of subjects dealt with Liston, Mr.....• Litholapaxy, term inappropriate . Lithotome cache- of Frere Come . Lithotomy, early history of . • ' cutting on the gripe Marian operation . supra-pubic . " lateral, early origin of " median bilateral medio-bilateral. pre-rectal lateral, for adults forming in children . in women . Lithotomy, in presence of renal disease „ forceps .... „ knife .... „ or lithotrity ? . Lithotrite, of Civiale and Charriere „ author's model „ fenestrated „ flat-bladed „ construction of „ passing a . ., short-bladed . Lithotrity at one sitting „ its history „ details of the operation of „ at a single sitting . „ Bigelow's proposal of „ position of patient ,, seizure of the stone . „ crushing the stone ,. employment of aspirator . ,, search for small fragments ,, number of sittings . „ operation at a single sitting able .... „ cystitis after „ on dead body ,, contingencies possible after ., after-treatment „ results of . ,, in presence of renal disease „ the operation of the future 104 . 105 . 148 . 21 . 8 . 150 1 27, 60 . 82 . 98 . 95 . 96 . 96 . 97 . 97 98, 105 . 98 . 98, 105 . 98 mode of per- . 100-4 . 106 . . 106 PAGE . 113 . 103 . 103 . 72 . 76 . 76 . 77 . 78 .77-8 . 83 . 88 . 82 . 75 . 82 . 82 . 82 . 84 . 84 . 84 85, 86 . 85 . 82 prefer- 82 .93-5 . 87 93-4 . 107 . 139 Maisoxneuve's urethrotome . . .39 Male blade of lithotrite, wedge-shaped . . 77 Marian operation......96 Marienbad water......120 Martineau's cases......97 Median lithotomy......98 ,. „ performance of . . . 105 Medio-bilateral......97, 105 Micturition, involuntary . . . .47 Mineral waters...... . 119 „ „ course of for calculous patients 121 Mode of tying-in catheter . . . .26 Moore's test.......166 Morphia as an injection for bladder . . 148 Movement of foreign bodies in urethra . . 13 Natural history of an acid calculus Neck of bladder, stricture at „ „ inflammation of . Nelaton's pre-rectal lithotomy . Nephrectomy...... Nephrotomy...... Nephrolithotomy..... Nephritic colic...... Nitrate of silver, injection of, into bladder Nitric acid, injection of, into bladder 137 17 145 98 163 163 163 116 148 148 Obliteration of Urethra..... Oil, injection of...... Operations for stone in the future . . . „ on the kidney . . . . Operation for discovery and removing tumours of the bladder..... „ case of ...... Organic stricture...... Over-curved gum catheter . „ distension of urethra..... „ sliding catheters..... Oxalates........ 28 30 131 163 144 143 13 50 37 34 168 Painful micturitition,in relation todiagnosis 3 Paralysis of bladder . . . .48,152 n „ signs of true, and its treatment . . . 153 174 INDEX. Pareira brava.......W9 Passages, false......•'»"- Passing a lithotrite......88 Pathological history of uric-acid deposits 116-18 Pedunculated tumour of bladdei, case of operation for Pelvic outlet . Perineal section „ operation for examining the bladder Perreve, dilator of . Phosphate of lime .... Phosphatic deposits .... „ „ treatment of Pigment in urine .... Plastic operations for urinary fistula Pliny mentions solution of stone Polypi in bladder . Position of patient in lithotrity Pre-rectal lithotomy Prevention of calculus Prichard's anklets Prostate, hypertrophy of . „ diagram of „ advanced disease of . „ operations for Prostatic retention . „ treatment of . „ silver catheters . . . „ tumours Prostatitis .... „ urine in chronic „ acute „ chronic . „ symptoms of „ treatment of Piillna water .... Puncture of bladder per rectum Pyelitis..... Reaction of urine.....164 Kectal examination.....49,158 „ puncture of bladder .... 61 Renal calculus .......161 „ „ diagnosis of . . . .161 „ „ removal of from kidney . . 163 „ casts.......169 ,, disease, operations in presence of . . 107 ' Residual urine'......54 „ how determined . . . 54 „ is catheter necessary ? . 55 „ cautions in relation to the use of catheter for . 56 Results of lithotrity at a single sitting . . 93-4 Resilient stricture......35 Resins, the, in cystitis.....149 Retention, prostatic......50 „ chronic.....54 „ typical forms of . . . . 57 „ in young men .... 58 „ from inflamed prostate . . . 58 „ from stricture .... 59 „ after lithotrity . . . . 91 Return of stone after operation . . . 90-1 Rigors in cases of stricture . . . . 37 Roberts, Dr., on stone solvents . . .128 Rupture of stricture by operation . . . 36 Sacculated bladder . Sacculi, small..... Scales, French and English compared Scirrhus and encephaloid of bladder Seizing the stone in lithotrity Sensibility of urethra Sensitive and educated hand Short-bladed lithotrite Silver prostatic catheters 91 148 23-4 155 83-4 18 23 88 51 into bladder Simple dilatation Single sitting, lithotrity at Size of stone, importance of Sliding catheters . Small fragments, seizing . Soda and glycerine, injection of, Solution of phosphatic calculi Solvents for stone . Sounding for small stones „ for stone „ children for stone Sounds ..... „ how to use „ round handled . „ forms of. Spasmodic stricture Specific gravity of urine . Spermatozoa .... Staff lithotomy „ Syme's .... „ Wheelhouse's . Steel's dilators Stephens, Mrs., stone solvent Stone in the bladder „ age at which most common „ in children . „ history of formation „ varieties of . „ symptoms of . „ sounding for „ determination of size of „ multiple calculi . „ lithotrity . „ seizing the, in lithotrity „ return of, after operation „ in women and children „ preventive treatment of „ solvents for . ' Storms' of uric acid Stream of urine Stricture of urethra . „ organic . „ spasmodic . „ symptoms of . „ diagnosis of „ at neck of bladder . .. dilatation of „ simple dilatation . „ metallic dilators for ., continuous dilatation ., impermeability of ., tortuous. „ resilient „ external division of „ rupture of . „ over-distention of . „ internal urethrotomy „ at external meatus Styptics .... Sugar in urine . Suppositories, morphia Supra-pubic opening of bladder „ „ instruments for „ „ alter treatment ,, „ tube . . . „ „ cases of „ lithotomy Surgical diseases of urinary organs Syme's axiom about impermeable stricture „ staff and operation . Synopsis of subjects..... Tampon, the dilatable air . Tannic acid, as an injection for bladder Tapping bladder over pubes ,, „ per rectum . . Tenaculum, use of, in lithotomy . 28 36 1 104 148 62 60 104 INDEX. 175 Tortuous strictures .... PAGE . . 31 Treatment of stricture .... . 20 ;, difficult stricture . . 27 „ prostatic hypertrophy . 49 „ extravasation of urine . . 63 „ retention of urine . . 58 ,, cystitis . . 147 „ dietetic, of calculous patients . 122 ,, prostatitis, chronic . . 151 „ juvenile incontinence . 154 „ hematuria . 157-160 Triple phosphate .... . 168 Triticum repens .... . . 149 Trommer's test..... 104 Tumour debris in urine 7, 156, 169 Tumours of the bladder . . . 155 ,, „ diagnosis of . 158 ,, ,, operation for re- moving . < 158 Turpentine, Venice .... . 149 15 Tying in a catheter .... . 26 168 166 Ureters, dilatation of . . 110 Urethra not a tube .... . . 11 „ physiologically considered . 11 „ stricture of . . . 13 „ inflammatory stricture of. . 14 „ spasmodic .... . . 14 „ diagram of healthy . 16 „ dilatability of strictured . . 17 „ sensibility of . . 18 . . H „ how to inject properly 11 „ long forceps .... . . 87 „ fistulas .... 62 Urethro-rectal fistulae . . 66 ;J „ treatment of . 66 „ after lithotomy . . 66 Uric-acid crystals . • „ deposits „ ,, history of . „ „ treatment of . Urinary deposits . „ diseases, chiefly surgical Urine...... „ how to obtain a specimen „ cause of error in examining „ in prostatitis .... „ in cystitis .... „ in stricture . . . • „ in pyelitis .... „ retention of „ in malignant disease of bladder „ in Bright's disease . „ in saccharine diabetes . „ extravasation of „ healthy . „ to obtain proper specimen „ examination of . Uva ursi...... Vals water..... Venice turpentine Vesical tumours, history and diagnosis „ „ treatment of . „ „ operation for Vibriones...... Vichy water..... Villous tumour, supra-pubic opening in case ot „ „ of bladder Vulcanised india-rubber catheter . 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Biddle, Materia Medica, Eighth Edition. £4.00 Royle & Harley, Materia Medica and Therapeutics. 139 Illustrations. £5-oo Stocken, Dental Materia Medica and Therapeutics. Second Edition. £2-25 Thorowgood, Guide to Materia Medica. £2.00 MEDICAL JURISPRUDENCE AND TOXICOLOGY. Ogston, Medical Jurisprudence. Illustrated. £6.00 Tanner, Poisons and Their Antidotes. Fourth Ed. .75 Woodman & Tidy, Medical Jurisprudence and Toxicology. Illustrated. Cloth, £7.5°; sheep, £8.50 MICROSCOPY. Carpenter, The Microscope and Its Revelations. Sixth Edition. 500 Illustrations. £5-5° Beale, How to Work with the Microscope. Fifth Edition. 400 Illustrations. #Z'5.° -------, The Microscope in Medicine. Fourth Edi- tion. 500 Illustrations. $7-5° Marsh, Section Cutting. Illustrated. _ .75 Martin, Microscopic Mounting. 140 Illustrations. Second Edition. £2.75 Macdonald, Microscopical Examination of Water. 20 Plates. £a.7S Wythe, The Microscopist. Fourth Edition. 252 Il- lustrations. 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Allingham, Diseases of the Rectum. Fourth Edition, Enlarged. [In Press. Cripps, Cancer of the Rectum, and Treatment. £2.40 SKIN AND HAIR. Anderson, Eczema, Its Treatment, etc. £2.50 Buckley, Aid to Study of Skin Diseases. Paper, .30 Cobbold, Parasites and Entozoa. 85 Illus. £S-oo Cottle, The Hair in Health and Disease. .75 Fox, Tilbury, Atlas of Skin Diseases. 72 Quarto Colored Plates. 18 Parts, each £2.00; or, One Vol- ume, Cloth. 4to. £30.00 Wilson, Healthy Skin and Hair. Eighth Ed. £1.00 STIMULANTS AND NARCOTICS. . Anstie, Stimulants and Narcotics. £3°o Kane, The Opium, Chloral, Morphine and Hashisch Habits. Illustrated. £1.50 Lizars, On Tobacco, Its Use and Abuse. .50 Miller, On Alcohol, Its Place and Power. .50 Sansom, Chloroform. Its Administration. £1-50 Turnbull, Artificial Anaesthesia. 2d Ed. Illus. £1.50 STOMACH. Fenwick, The Stomach and Duodenum. Illus. £4.25 --------.Atrophy of the Stomach. Illustrated. £3.20 Habershon, Diseases of the Stomach. 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Third Edi- tion. Illustrated. I.2.00 Mackenzie, The Throat and Voice. Author's Edition. With Original Plates. Volume 1 ready. 112 Illus- trations. £4-00. Volume 11. [In Press. --------, Diphtheria. -75 —----, Growths in the Larynx. £2.00 --------, Pharmacopoeia. Fourth Edition. £1.25 Thompson, Coughs and Colds. .60 THERAPEUTICS. (See also Materia Medica and Action 0/Medicine.) Kidd, The Laws of Therapeutics. £1.25 Kirby, On Phosphorus. Fifth Edition. £1.00 Kane, Drugs That Enslave. The Opium, Chloral and Other Habits. Illustrated. £1.50 Mays, The Therapeutic Forces. £t-25 Waring, Practical Therapeutics. A Text-book. Third Edition. Cloth, £4.00; sheep, £5.00 URINE AND URINARY ORGANS. Acton, On the Reproductive Organs. Fourth Ed. £2.50 Black, Renal.Urinary and Reproductive Organs. £2.00 Beale, Illustrations of One Hundred Urinary Deposits. On two Sheets. Each £1.00; or, Mounted, £1.25 Curling, On the Testis, Spermatic Cord and Scrotum. Fourth Edition. Illustrated. 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For 25 Patients weekly. Tucks, pockets, etc So " " ** " 75 50 2 Vols. 2 Vols. i Jan. to June ) 1 July to Dec. \ Jan. to Jjine ) £1.00 1.25 i-5° 2.00 2.50 5° 1.25 1.50 3.00 •75 £4.00 £1.00 £2.75 £1.50 £2.25. (uly to Dec INTERLEAVED EDITION. For 25 Patients weekly, interleaved, tucks, etc. 5° " " " " " so ANSTIE, STIMULANTS AND NARCOTICS. With special researches on the Action of Alcohol, Ether and Chloroform on the Vital Organism. By Francis E. Anstie, m.d. 8vo. Price $3.00 " He is an original worker and independent thinker. His opinions and conclusions are valuable, and cannot be neglected. —American Medical yournal. ATTHILL, DISEASES OF WOMEN. Clinical Lectures on Diseases Peculiar to Women. By Lombe Atthill, m.d. 5th edition, revised and enlarged, with numerous illustrations. i2mo. Cloth. Price $2.25 "It is the concentrated essence of the knowledge of one who has become wise by reason of long and well- digested experience in the subjects treated."—American yournal of Medical Science. 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By a Physician. This book has been written, first, to im- part In a popular and condensed form the elements of Hygiene; second, to show how varied and important are the Health Hints contained in the Bible, and third, to prove that the secondary tendency of modern Philosophy runs in a parallel direction with the primary light of the Bible. i2mo. Price $1.00 " The scientific treatment of the subject is quite abreast of the present day, and is so clear and free from unne- cessary technicalities that readers of all classes may peruse it with satisfaction and advantage."—Edinburgh Medical yournal. BIDDLE, MATERIA MEDICA. Eighth Edition. Materia Medica for the Use of Students. By John B. Biddle, m.d., Late Pro- fessor of Materia Medica at Jefferson Medical College, Philadelphia. 8th edition, Revised, Enlarged and Illustrated. 8vo. 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PRESLEY BLAKISTON' S BLACK, THE REPRODUCTIVE AND RENAL ORGANS. The Functional Diseases of the Renal, Urinary and Reproductive Organs, with a General View of Urinary Pathology. By D. Campbell Black, m.d., F.R.C.S. i2mo. Price $2.00 " The title of this book sufficiently indicates its character and scope. Some of the chapters are almost ex- haustive of their topics. Thus, in the chapter on spermatorrhoea, the whole philosophy and therapeutics of this vexatious condition is given with unusual clearness."—Cincinnati Lancet and Observer. BY SAME AUTHOR. DISEASES OF THE KIDNEYS. Lectures on Bright's Disease of the Kidneys. Delivered at the Royal Infirmary, Glasgow. With 20 illustrations. 8vo. Price $1.50 BLOXAM. CHEMISTRY,Inorganic and Organic. Fourth Edition. With Experiments. By Charles L. Bloxam, Professor of Chemistry in King's College, London, and in the Department for Artillery Studies, Wool- wich. Fourth edition. With nearly 300 Engravings. 8vo. Price $4.00 A most complete Text-Book for Schools and Colleges. " Professor Bloxam has given us a most excellent and useful practical treatise. His 666 pages (now 700) are crowded with facts and experiments, nearly all well chosen, and many quite new, even to scientific men . . . It is astonishing how much information he often conveys in a few paragraphs. We might quote fifty instances of this."—Chemical News. BLOXAM. LABORATORY TEACHING. Fourth Edition. Progressive Exercises in Practical Chemistry. By Charles L. Bloxam, Professor of Chemistry in King's College, London, etc. Fourth edition. With 89 engravings. i2mo. Price $1.75 This work is intended for use in the Chemical Laboratory, by those who are commencing the study of Practical Chemistry. It contains:— 1. A series of simple Tables for the analysis of unknown substances of all kinds. 2. A brief description of all the practically important single substances likely to be met with in ordinary analysis. 3. Simple directions and illustra- tions relating to Chemical Manipulation. 4. A system of Tables for the detec- tion of unknown substances with the aid of the Blowpipe. 5. Short instructions upon the purchase and preparation of the tests intended for those who have not access to a Laboratory. " A great amount of valuable practical information is here condensed into a book of 260 pages, such as only a practical teacher could prepare. —New England yournal of Education. BRUEN. PHYSICAL DIAGNOSIS. Just Ready. A Pocket Book of Physical Diagnosis, for Physicians and Students. By Edward T. Bruen, m.d., Asst. Prof, of Clinical Medicine, University of Penn'a. Illustrated by Original Wood Engravings. i2mo. Extra Cloth. Price $2.00 BENNETT. NUTRITION IN HEALTH AND DISEASE. A Contribution to Hygiene and Clinical Medicine. By J. Henry Ben- nett, m.d. Third Edition, Revised and Enlarged. Cloth. Price $2.50 BY SAME AUTHOR. THE TREATMENT OF PULMONARY CONSUMPTION BY HYGIENE, CLIMATE AND MEDICINE. With an Appendix on the Sanitaria of the United States, Switzerland and the Balearic Islands. Third Edition much Enlarged. Price $2.50 "'Any physician may take it up with every feeling of confidence that the views enunciated by the author will be found to be able, honest and orthodox."—Medico-Chirurgical Review. BERKART, ASTHMA. The Pathology ahd Treatment of Asthma. By Joseph B. Berkart, m.d. Svo. Price $2.50 PUBLIC A TIONS. 7 BEALE ON SLIGHT AILMENTS. Slight Ailments, Their Nature and Treatment. By Lionel S. Beale, m.d., f.r.s., Professor of Practice, King's Medical College, London, nmo. Price #1.75 OUTLINE OF CONTENTS. Introductory. The Tongue in Health and Slight Ailments. Appetite. Nausea. Thirst. Hunger. Indigestion, its Nature and Treatment. Constipation, its Treatment. Diarrhoea. Vertigo. Giddimsss. Biliousness. Sick Headache. Neuralgia. Rheumatism. The Feverish and Inflammatory State. Of the Actual Changes in Fever and Inflammation. Common Forms of Slight Inflammation, etc., etc. "_ We venture to say that among the numerous medical publications issued during 1880, there has been none which will prove more useful to the young general practitioner, for whom it is really intended, than this volume, while the time of the older physician might be much more unprofitably spent."—American yournal of Medical Science, BY SAME AUTHOR. ON LIFE AND VITAL ACTION IN HEALTH AND DISEASE. l2mo. Price $2.00 THE USE OF THE MICROSCOPE IN PRACTICAL MEDI- CINE. For Students and Practitioners, with full directions for examining the various secretions, etc., in the Microscope. Fourth Edition. 500 Illustrations. Much enlarged. 8vo. Price $7.50 " We have before us Prof. Bealb's work, The Micro- I "As a microscopical observer, and a histological scope in Medicine, a book which it gives us pleasure to manipulator, his (Dr. Beale) skill and eminence are recommend to every student of microscopy, whether he generally conceded."—Popular Science Monthly. be a physician or naturalist."—yournal of the Frank- lin Institute, Philadelphia. \ HOW TO WORK WITH THE MICROSCOPE. A Complete Manual of Microscopical Manipulation, containing a full descrip- tion of »any new processes of investigation, with directions for examining ob- jects under the highest powers, and for taking photographs of microscopic objects. Fifth Edition. Containing over 400 Illustrations, many of them colored. Octavo. Price $7.50 "The Encyclopaedic character of this last edition of Dr. Bealb's well known work on the Microscope renders It Impossible to present an abstract of its contents; suffice it to say, that anything in his department upon which the physican can desire such information will be found here, and much more in addition. It is, moreover, a store- house of facts, most valuable to the physician, and is indispensable to every one who uses the microscope."— American yournal of Medical Science. BIOPLASM. A Contribution to the Physiology of Life, or an Introduction to the Study of Physiology and Medicine, for Students. With numerous Illustrations. Price $2.25 PROTOPLASM ; or MATTER AND LIFE. Third Edition, very much enlarged. Nearly 350 pages. Sixteen Colored Plates Part 1. Dissentient. Part 11. Demonstrative. Part in. Suggestive. One volume. Price #3-°o LIFE THEORIES; Their Influence upon Religious Thought. Six Colored Plates. Price $2-°° ONE HUNDRED URINARY DEPOSITS, On two sheets, for the Hospital, Laboratory, or Surgery. Each Sheet $1.00, or • on Rollers, Price $1.25 BERNAY, CHEMISTRY. Notes for Students in Chemistry. Compiled from Fowne's and other manuals. By Albert J. Bernay, ph.d. Sixth Edition. i2mo. Price $1.25 BOCK, ANATOMY. An Atlas of- Human Anatomy. By Prof. C. E. Bock, of Berlin. Thirty-seven Colored Plates, containing about 200 figures. Quarto. Half Roan. Price $15.00 This is one of if not the best Anatomical Atlas now to be had, and its produc- tion in Germany makes it certainly the cheapest. , 8 PRESLE Y BLAKISTON'S BEASLEY. THE BOOK OF PRESCRIPTIONS. Containing over 3100 Prescriptions, collected from the Practice of the most Eminent Physicians and Surgeons—English, French and American; a Com- pendious History of the Materia Medica, Lists of the Doses of all Officinal and Established Preparations, and an Index of Diseases and their Remedies. By Henry Beasley. Fifth Edition, Revised and Enlarged. Price $2.25 BY SAME AUTHOR. THE DRUGGIST'S GENERAL RECEIPT-BOOK. Comprising a copious Veterinary Formulary; numerous Recipes in Patent and Proprietary Medicines, Druggists' Nostrums, etc.; Perfumery and Cos- metics; Beverages, Dietetic Articles and Condiments; Trade Chemicals, Scien- tific Processes, and an Appendix of Useful Tables. Eighth Edition. Price $2.25 THE POCKET FORMULARY and Synopsis of the British and Foreign Pharmacopoeias. s Comprising Standard and Approved Formulae for the Preparations and Com- pounds Employed in Medical Practice. Tenth Edition. 511 pp. i8mo. Price $2.25 BENTLEY AND TRIMEN'S MEDICINAL PLANTS. A New Illustrated Work, containing full botanical descriptions, with an account of the properties and uses of the principal plants employed in medicine, especial attention being paid to those which are officinal in the British and United States Pharmacopoeias. The plants which supply food and substances required by the sick and convalescent are also included. By R. Bentley, f.r.s., Professor of Botany, King's College, London, and H. Trimen, m.b., f.h.s., Department of Botany, British Museum. Each species illustrated by a colored plate drawn from nature. In Forty-two parts. Eight colored plates in each part. Price $2 each, or handsomely bound in 4 volumes, Half Morocco, $90.00 " It would be impossible to enumerate all the new plants that are here delineated. The result is a work which, from all points ofview,isa credit to the scientific literature of the day."—London Lancet. "It Is an indispensable work of reference to every one interested in pharmaceutical Botany."—London Phar- maceutical yournal. BRADLEY, ANATOMY. Comparative Anatomy and Physiology. By S. M. Bradley, f.r.c.s. Sixty Illustrations. Third Edition. Price $2.00 BRUNTON, ACTION OF MEDICINES. Experimental Investigation of the Action of Medicines. Part I, Circulation. By T. Lauder Brunton, m.d., f.r.s. Second Edition. [Preparing. BYFORD. DISEASES OF WOMEN. New Revised Edition. The Practice of Medicine and Surgery, as applied to the Diseases of Women. By W. H. Byford, a.m., m.d., Professor of Obstetrics and The Diseases of Wo- men and Children, in the Chicago Medical College. Third Edition. Revised and Enlarged, much of it rewritten, with numerous additional illustrations. Price, in Cloth $$.00; Leather, $6.00 " This work may be recommended as a most useful one to druggists, and all who desire to be familiar with the Botany of Medicinal Plants."—Druggists' Circular. " The work when complete (it is now complete) will be the most valuable compend of Medical Botany ever published."—Boston yournal of Chemistry. " The treatise is as complete a one as the present state of our science will admit of being written. We commend it to the diligent study of every practitioner and student, as a work calculated to inculcate sound principles and lead to enlightened practice.— New York Medical Record. " The author is an experienced writer, an able teach. er in his department, and has embodied in the present work the results of a wide field of practical observa- tion. We have not had time to read its pages critically, but freely commend it to all our readers, as one of the most valuable practical works issued from the Ameri- can press."—Chicago Medical Examiner. BY SAME AUTHOR. ON THE UTERUS. The Chronic Inflammation and Displace- ment of the Unimpregnated Uterus. An Enlarged Edition, with Illustrations. 8vo. Price $2.50 "A good book from a good man."—American Journal Medical Science. " Itis a sensible,'practical work, and cannot fail to be read with Interest and profit."—Boston Medical and Surgical yournal. PUBLICA TIONS. BRAUNE, TOPOGRAPHICAL ANATOMY. An Atlas of Topographical Anatomy. Thirty-four Full-page Plates, Photo- graphed on Stone, from Plane Sections of Frozen Bodies, with many other illus- trations. By Wilhelm Braune, Professor of Anatomy at Leipzig. Translated and Edited by Edward Bellamy, f.r.c.s., Lecturer on Anatomy, Charing Cross Hospital, London. Quarto. Price, Cloth, $10.00; Half Morocco, $12.00 . " As * whtle the work.cannot fa'l to meet with a hearty reception by every progressive student of the human body, to the surgeon it is a contribution to the study of topographical anatomy which needs to be known to be properly appreciated To such practitioners who reside in large cities, where anatomy can be studied upon the cadaver, it will aflord a valuable aid, while to those who are without such means of study it is an almost indis- pensable addition to a working library."—New York Medical Record. " We commend the book most heartily to the Profession."—American Journal of Medical Science. BUCKNILL AND TUKE ON INSANITY. A Manual of Pyschological Medicine: containing the Lunacy Laws, the Nosology, (Etiology, Statistics, Description, Diagnosis, Pathology (including morbid Histology), and Treatment of Insanity. By John Charles Bucknill, m.d., F.r.s., and Daniel Hack Tuke, m.d., f.r.c.p. Fourth Edition, much enlarged, with twelve lithographic plates, and numerous illustrations. Octavo. Price $8.00 We have read no book in any language, and certainly none in English, which ought to be preferred to this for a text book, by those who wish to make a thorough study of the subject.—Edinburgh Medical yournal. " We can heartily commend the work.—American yournal of Insanity. BURDETT, HOSPITALS. Pay Hospitals and Paying Wards throughout the World. Facts in support of a rearrangement of the system of Medical Relief. By Henry C. Burdett. 8vo. Price $2.25 " Mr. Burdett displays and discusses the whole scheme of Hospital accommodation with a comprehensive understanding of its nature and extent.—American Practitioner. BY SAME AUTHOR. COTTAGE HOSPITALS. General, Fever, and Convalescent: their Progress, Management, and Work. Second Edition, rewritten and much Enlarged, with many Plans and Illustra- tions. Crown 8vo. Price $4.50 Contents.—Chap.—1. Origin and Growth of the Cottage Hospital System. 2. Comparative Success of Treatment in large and small Hospitals. 3. Finance. 4. Cottage Hospital Construction and Sanitary Arrange- ments. 5. The Medical and Nursing Departments. 6. Domestic Supervision and General Management. 7. Cottage Hospital Appliances and Fittings. 8. Cottage Fever Hospitals. 9. Midwifery in Cottage Hospitals. 10. Remunerative Paying Patients. 11. Convalescent Cottages. 12. Cottage Hospitals in America. 13. Mortu- aries. 14. A more Detailed Account of certain Cottage Hospitals, with Plans and Elevations. 15. Selected and Model Plans criticised and compared, with a detailed description of various Hospitals. 16. Peculiarities and Special Features in the Working of Cottage Hospitals. With an Appendix containing much statistical and useful information. " Mr Burdett's book contains a mass of information, statistical, financial, architectural, and hygienic, which has already proved of great practical utility to those interested in cottage hospitals, and we can confidendy recom- mend this second edition to all who are in search of the kind of Information which it contains."—Lancet. BUZZARD, SYPHILITIC NERVOUS AFFECTIONS. Clinical Aspects of Syphilitic Nervous Affections. By Thos. Buzzard, m.d. i2mo. Price *»-75 CARPENTER, THE MICROSCOPE. Sixth Edition. ms. By W. B. Carpenter , with over 500 Illustrations. "As a text book of Microscopy in its special relation to natural history and general science, the work before us stands confessedly first, and is alone sufficient to supply the wants of the ordinary student."—American The Microscope and its Revelations. By W. B. Carpenter, m.d., f.r.s. Sixth Edition. Revised and Enlarged, with over 500 Illustrations. Price $5.50 '* Not only the student of medicine, but amateurs, and others interested in the study of natural history, will find this volume one of great practical value. — New York Medical yournal. " It is by far the most complete and useful treatise now accessible to the student."— The Technologut. supply die wants of the ordinary student. yournal of Microscopy. ro PRESLEY BLAKISTON'S Cazeaux's Great Work on Obstetrics. THE MOST COMPLETE TEXT-BOOK NOW PUBLISHED. GREATLY ENLARGED AND IMPROVED. CONTAINING 175 ILLUSTRATIONS. k Theoretical and Practical Treatise on Midwifery, including the Disease* of Pregnancy and Parturition, by P. Cazeaux, Member of the Imperial Academy of Medicine; Adjunct Professor in the Faculty of Medicine of Paris, etc., etc. Revised and Annotated by S. Tarnibr, Adjunct Pro fessor in the Faculty of Medicine of Paris ; Former Clinical Chief of the Lying-in-Hospital, etc., etc. Sixth American from the Seventh French Edv Hon. Translated by Wm. R. Bullock, M. D. In one volume Royal Oc- tavo, of over 1100 pages, with numerous Lithographic and other Illustra tions on Wood. Price, bound in Cloth, bevelled boards, . . $6.00 " " Leather, . .....7.00 M. Cazeaux's Great Work on Obstetrics has become classical in its character, and almost an Encyclopaedia in its fulness. Written expressly for the use of students of medicine, and those of midwifery especially, its teachings are plain and explicit, present- . ing a condensed summary of the leading principles established by the masters of tbe obstetric art, and such clear, practical directions for the management of the pregnant, parturient, and puerperal states, as have been sanctioned by the most authoritative practitioners, and confirmed by the author's own experience. Collecting bis materiale from the writingsof the entire body of antecedent writers, carefully testing their correct- ness and value by bis own daily experience, and rejecting all such as were falsified by the numerous cases brought under his own immediate observation, he has formed out of them a body of doctrine, and a system of practical rules, which he illustrates and enforces in the clearest and most simple manner possible. OPINIONS OF THE PRESS. " It is unquestionably a work of the highest excellence, rich in information, and perhaps fuller in detailt than any text-book with which we are acquainted. The author has not merely treated of every ques- tion which relates to the business of parturition, but he has done so with judgment and ability." British and Foreign Medico- Chirurgical Review. " The translation of Dr. Bullock is remarkably well done. We can recommend this work to those especially interested in the subjects treated, and can especially recommend the American edition." Medical Timet and Gazette. " The edition before us is one of unquestionable excellence. Every portion of it has undergone a • thorough revision, and no little modification; while copious and important additions have been made to nearly every part of it. It is well and beautifully illustrated by numerous wood and lithographic engravings, and, in typographical execution, will bear a favorable comparison with other works of the same class."—American Medical Journal. " In the multitudinous collection of works devoted to the propagation of human beings, and to t-ht details of parturition, none, in our estimation, bears any comparison to the work of Cazeaux, in its entire perfectness; and if we were called upon to rely alone on one work on accouchments, our choict would fall upon the book before us without any kind of hesitation."— Wett. Jour, of Med. and Surgery "We do not hesitate to say,That it is now the most complete and best treatise on the subject in th* English language."—Buffalo Medical Journal. "We know of no work on this all-important branch of our profession that we can recommend to th* undent or practitioner as a safe guide before this."—Chicago Medical Journal. PUBLICA TIONS. CHARTERIS, PRACTICE OF MEDICINE. Hand-Book of the Practice of Medicine. By M. Charteris, m.d., Member ot Hospital Staff and Professor in University of Glasgow. With Microscopic and other illustrations. Price $2QO prac^ce/?-W°?en mCt WUh a b°°k Whkk Can b° S0 confidentlv recommended to physicians or men in general " The style in which it is written is clear and attractive. The illustrations are a marked feature in it. It can be recommended as a very reliable, handy book, well adapted for ready reference."—New Remedies. CHAVASSE ON CHILDREN. The Mental Culture and Training of Children. By Pye Henry Chavasse. I2mo- Price $1.00 The mental culture and training of children is of immense importance. Many children are so wretchedly trained, or rather not trained at all, and so mismanaged, that a few thoughts on this subject cannot be thrown away, even upon the most careful. CLAY ON OBSTETRIC SURGERY. Third Edition. A complete Hand-Book of Obstetric Surgery, with Rules for every Emergency and Descriptiens of the more difficult as well as the every day operations. By Charles Clay, m.d., with numerous illustrations. From the Third London Edi- tion. i2mo. Price $2.00 " It is a useful and convenient book of reference; the illustrations are good, and the book will be found of value to the student and young practitioner, as well as to the skilled Obstetrician."—American yournal of Obstetrics. ^CLEVELAND, POCKET DICTIONARY. A Pronouncing Medical Lexicon, containing correct Pronunciation and Defi- nition of terms used in medicine and the collateral sciences. By C. H. Cleve- land, m.d. Twenty-sixth Edition. i6mo. Price, Cloth, 75 cents ; Tucks with Pocket, $1.00 This is a most convenient size for the pocket, and contains all the principal words in use, together with rules for pronunciation, abbreviations used in prescriptions, list of poisons, their antidotes, etc. COHEN, INHALATION. Enlarged Edition. Inhalation, its Therapeutics and Practice, including a Description of the Ap- paratus Employed, etc. By J. Solis Cohen, m.d. With cases' and Illustrations. A New Enlarged Edition. 8vo. Price $2.50 " The book has the merit of containing much information that cannot be found elsewhere."—A^ Y. Medical yournal. " One of the best treatises we have seen on this subject."—Medical Times and Gazette. BY SAME AUTHOR. CROUP, In its Relation to Tracheotomy. 8vo. Price $1.00 CLARKE, SURGERY. Outlines of Surgery and Surgical Pathology, including the Diagnosis and Treatment of Obscure and Urgent Cases. By F. LeGross Clarke, f.r.s. Second Edition. 8vo. Price $2.00 COBBOLD, PARASITES. A Treatise on the Entozoa of Man and Animals, including some account of thrEctozoa. By T. Spencer Cobbold, m.d., f.r.s. With 85 illustrations. 8vo. vy PRESLEY BLAKISTON'S DAY ON CHILDREN. A SECOND EDITION. JUST READY. The Diseases of Children. A Practical and Systematic Treatise, for Practitioners and Students. By Wm. Henry Day, m.d. Second Edition. Enlarged. 8vo. 752 pp. Price, Cloth, $5.00; Sheep, $6.{ De- cay in Teeth below Medium in Structure, and to Difficult and Inaccessible Cavities in Teeth of all Grades of Structure. With some beautifully executed Illustrations. By J. Foster Flagg, d.d.s., Professor of Dental Pathology and Therapeutics in Philadelphia Dental College. Octavo. Price $3.00 Contents.—Introductory. Article i. Plastic Filling. 2. Amalgam. 3. Amalgam continued. 4. Amalgam continued. 5. Attributes of Metals used for Amalgam Alloys. 6. The Making of Amalgam Alloys. 7. Tests for Amalgam. 8. Preparation of Cavities. 9. The Making of Amalgam. 10. Instrument for the Insertion of Amalgam Fillings. 11. The Insertion of Amalgam Fillings. 12. General Considerations Pertaining to Amalgam. 13. Gutta-percha. 14. Oxy-chloride of Zinc. 15. Oxy-sulphat« of Zinc. 16. Zinc Phosphate. 17. Temporary Stopping. 18. Technicalities. Conclusion. FOSTER, CLINICAL MEDICINE. Lectures and Essays on Clinical Medicine. By Balthazar Foster, m.d. Illustrated. 8vo. Price $3.00 " No one can peruse the thoughtful comments of our " It is the record of honest work, such as Dr. Foster author upon every subject he considers, without feeling may be proud of; we can recommend it to the profession; himself a wiser man for his pains."—N. Y. Medical it may be read with profit and advantage by both prac- yournal. titioner and student.— Edinburgh Medical yournal. FOX, ATLAS OF SKIN DISEASES. Complete in Eighteen Parts, each containing Four Chromo-Lithographic Plates, with Descriptive Text and Notes upon Treatment., In all 72 large colored Plates. By Tilbury Fox, m.d.,f.r.c.p., Physician to the Department for Skin Diseases in University College Hospital. Folio Size. Price $2.00 each, or complete, bound in cloth, $30.00 No Atlas of Skin Diseases has been issued in this country for many years, and no complete work of the kind is now procurable by the Profession. This one, brought out under the editorial supervision and care of Dr. Tilbury Fox (the most distin- guished writer on Cutaneous Medicine now in the English language), is partly based upon the classical work of Willan and Bateman (now entirely out of print), but com- pletely remodeled, so as to represent fully the Dermatology of the present day. " Preference will be given to this work over Hebra; not simply, however, because it is a home production, but by reason of the manner of its execution, the excellent delineation of disease, and the natural coloring of the plates. . . . The letter-press is entirely new. In the accuracy of the latter the subscriber may have the fullest confi- dence, since it is from the pen of Dr. Tilbury Fox."—British and Foreign Medico-Chirurgical Review. FRANKLAND, WATER ANALYSIS. Water Analysis, For Sanitary Purposes, with Hints for the Interpretation of Results. By E. Frankland, m.d., f.r.s. Illustrated. i2mo. Price $1.00 " The author's world-wide reputation will commend I " The work is one which physicians practicing ia this manual to all sanitarians, and they will not be dis- the country and in villages and towns remote from appointed in finding all the essentials of the important medical centres cannotafford to be without."—Medical subject of which it treats."— The Sanitarian. | and Surgical Reporter. BY SAME AUTHOR. CHEMISTRY. How to Teach Chemistry, being Six Lectures to Science Teachers. Edited by G. George Chaloner, f.c.s. Illustrated. i2mo. Price $1.25 PUB LICA TIONS. 17 FOX, WATER, AIR AND FOOD. Sanitary Examinations of Water, Air and Food. M.D. 94 Engravings. 8vo. By Cornelius B. Fox, Price $4.00 GALLABIN, DISEASES OF WOMEN. The Student's Guide to the Diseases of Women. By A. Lewis Gallabin m a m.d., f.r.c.p. Illustrated with 63 Engravings. i2mo. Price'$2.00 "Among all the various works on diseases of women with which we are acquainted, there is none which so nearly approaches the perfection of what a student's The work is well illustrated.' " Its style is clear, elegant, and concise. It contains a great amount of information; indeed, we do not think the student or practitioner will find any book which will convey to him in so small a compass so much accu- rate knowledge about the pathology and diagnosis of the diseases peculiar to women."—Medical Times and Gazette. text-book should be —Students' yournal. " Though the book is a small one and the subject ex- tensive, yet so admirable is the style of the writer, and so careful his selection of words, that each disease is thoroughly treated of."—Philadelphia Medical Times. , GROSS, BIOGRAPHY OF JOHN HUNTER. John Hunter and His Pupils. By S. D. Gross, m.d., Professor of Surgery in Jefferson Medical College, Philadelphia. With a beautifully executed full length Portrait of the Author in his Study. A Handsome Octavo volume. Bound in Beveled Cloth. Price $1.50 "It is refreshing to read the story of a life so fully devoted to science, and the reader will readily appreciate Professor Gross's enthusiasm for his subject, which led him to extend what was originally intended for an essay to its present size. ''The phototype of Sharp's well-known engraving of Sir Joshua Reynold's portrait is an excellent reproduction, and forms a fitting and handsome frontispiece. " The volume will prove an ornament to the study table, where it will be a constant incentive to whatever is best and noblest in a noble profession."—Boston Med. and Surgical yournal. BY SAME AUTHOR. AMERICAN MEDICAL MEN. American Medical Biography of the Nineteenth Century, with portrait of Dr. Benjamin Rush. Large 8vo. Price $3.50 GANT, A SYSTEM OF SURGERY. Enlarged Edition. The Science and Practice of Surgery, including Special Chapters by different Authors. By Frederick James Gant, f.r.c.s., Senior Surgeon to the Royal Free Hospital. Second Edition, rewritten and much enlarged throughout. Illustrated by 969 wood engravings. In two Octavo volumes. Price, Cloth $11.00; Leather $13.00 " After the most patient analysis our limited time has permitted, we fsel compelled to say that this book is a valuable and eomprehensive addition to the surgical literature of the profession and a monument to the care- ful, conscientious and painstaking industry of the author."—Cincinnati Lancet and Observer. " This new and magnificent work on surgery sup- plies all that can be required, whether for the most com- plete study or for constant reference in practice."— London Medical Press and Circular. " The reader has the advantage of mature experience in treating of special subjects, that are either omitted or very lightly referred to in ordinary works on sur- gery."—London Lancet. BY SAME AUTHOR. ON THE BLADDER AND PROSTATE. Diseases of the Bladder and Prostate Gland and Urethra, including a Practical View of Urinary Diseases, Deposits and Calculi. Fourth Edition, Revised and Enlarged, with New Illustrations. i2mo. Price $3.00 GIBBES, STUDENT'S PATHOLOGY. Practical Histology and Pathology. By Heneage Gibbes, m.b. nrao. Cloth. Price $1.00 Chap. i. Introduction. 2. On Preparing Tissues for Examination. 3. On Cutting Sections. 4. On Staining. 5 On Double Staining. 6. On Mounting. 7. Method of Obtaining Animal Tissues, etc. Practical Histology, Pathology, Memoranda and Formulae. " This excellent little work is admirably adapted to fulfill the purpose for which it has been written. It is short clear, and eminently practical. The author is evidently an accomplished histologist, and Ms book conveys the impression that it is based upon his own personal experience. — The London Medical Record. i8 PRESLEY BLAKISTON'S GODLEE'S ATLAS OF HUMAN ANATOMY. Illustrating most of the Ordinary Dissections and many not usually practiced by the Student. Accompanied by References and an Explanatory Text. Com- plete. Folio Size. 48 Colored Plates. By Rickman John Godlee, m.d., f.r.c.s. Forming a large Folio Volume, with References, and an Octavo Volume of Letter-press. Price of the two Volumes, Atlas and Letter-press, Cloth, $30.00 " It is likely to prove as useful to the physician and I " The explanatory text is concise, well written, and surgeon as to the anatomist."—Medical Times and contains many valuable suggestions for the surgeon." Gazette. \ —London Lancet. GOWERS, SPINAL CORD. Diagnosis of Diseases of the Spinal Cord. With Colored Plates and Engrav- ings. A Second Edition. Revised and Enlarged. By William R. Gowers, m.d., Assistant Professor Clinical Medicine, University College, London. 8vo. Price $1.50 BY SAME AUTHOR. OPHTHALMOSCOPY. A Manual and Atlas of Medical Ophthalmoscopy. With 16 Colored Auto" type and Lithographic Plates and 26 Wood Cuts, comprising 112 Original Illus- trations of the Changes in the Eye in Diseases of the Brain, Kidneys, etc. 8vo. Price $6.00 GREENHOW, BRONCHITIS. On Chronic Bronchitis, especially as connected with Gout, Emphysema, and Diseases of the Heart. By E. Headlam Greenhow, m.d. i2mo. Price $1.50 BY SAME AUTHOR. ADDISON'S DISEASE. Being the Croonian Lectures, delivered before the Royal College of Physi- cians, London. Revised and Illustrated by Plates and Reports of Cases. 8vo. Price $3.00 "The book forms a most interesting and valuable monograph, comprehensive and exhaustive."—British Medical yournal. GLISAN, TEXT-BOOK OF MODERN MIDWIFERY. A Text-Book of Modern Midwifery. By Rodney Glisan, m.d., Emeritus Professor of Midwifery and Diseases of Women and Children in the Medical Department of Willamette University, Portland, Oregon, and Late President of the Oregon State Medical Society. With 129 Illustrations. One Volume, octavo, 624 pp. Price, in Cloth $4.00; in Leather $5.00 Many years have elapsed since the appearance of an original American text-book of obstetrics. The author of this one, believing that there is a demand for a work thoroughly representing American obstetrical practice, ventures to present this con- densed treatise to the medical students and practitioners of his own country. Many years' experience as a practitioner and several as a teacher of midwifery, warrants this effort to supply the demand for a book fully brought up to the present time, faithfully representing the peculiarities of American practice, and adapted to the wants of obstetric teachers and busy practitioners. The book is freely illustrated wherever its value and usefulness can be thus en- hanced, and being brought out—owing to the unavoidable absence of the author— under the supervision of the well-known obstetrician, Dr. Robert P. Harris, of Philadelphia, the publishers very confidently anticipate for it a favorable reception. GILL, ON INDIGESTION. Second Edition. Indigestion; What It Is; What It Leads To ; and a New Method of Treating It. By John Beadnell Gill, m.d. Second Edition. i2mo. Price £1.3$ PUBLICA TIONS. 19 HABERSHON, ON THE STOMACH. On Diseases of the Stomach—The Varieties of Dyspepsia—Their Diagnosis and Treatment. By S. O. Habershon, m.d., f.r.c.p., Senior Physician to, and Late Lecturer on, the Principles and Practice of Medicine at Guy's Hospital. Third Edition, Revised. Crown 8vo. Price $1.75 " ASutn e^Pre"ion of the results of long personal experience in both hospital and private practice, conveyed in agreeable though not always perspicuous diction, this contribution of Dr. Habershon's has special value of its own, and is so far entitled to the favorable consideration of the practitioner, as is already testified by a demand for a third edition. —American yournal of Medical Sciences. "It is divided into twenty chapters, fifteen of which are devoted to a consideration of the different forms of Dyspepsia, while the remaining treat of Degeneration, Ulceration, Cancerous DUeases, and Spasms of the btomach. We can cordially recommend this book of Dr. Habershon's to the profession."—Medical Record. HALE, ON CHILDREN. The Management of Children in Health and Disease. A Book for Mothers. By Mrs. Amie M. Hale, m.d. Abounding in valuable information and com- mon-sense advice. New Enlarged Edition. i2mo. Price .75 " We shall use our influence in the introduction of this work to families under our care, and we urge the profession generally to follow our example."—Buffalo Medical and Surgical yournal. HARDWICH AND DAWSON, PHOTOGRAPHIC CHEMIS- TRY. Hardwich's Manual of Photographic Chemistry. Illustrated. Eighth Edition. Rearranged by G. Dawson. i2mo. Price $2.00 HARDWICKE, MEDICAL EDUCATION. Medical Education and Practice in All Parts of the World. Containing Regulations for Graduation at the Various Universities throughout the World. By Herbert Junius Hardwicke, m.d., m.r.c.p. 8vo. Price $3.00 " Dr. Hardwicke's book will prove a valuable source of information to those who may desire to know the conditions upon which medical practice is or may be pursued in any or every country of the world, even to the remotest corners of the earth. The work has been compiled with great care, and must have required a vast amount of labor and perseverance on the part of its author."—Dublin Medical yournal. HARRISON, STRICTURE OF THE URETHRA. On Stricture and Other Diseases of the Urinary Organs. By Renegall Harrison, f.r.c.s. With numerous Illustrations. 8vo. Price $2.75 HAYDEN, ON THE HEART. The Diseases of the Heart and Aorta. By Thomas Hayden, m.d. With 81 Illustrations. 2 vols. 1232 pp. 8vo. Price $6.00 " The author evidently has had a very wide and well used experience in that of which he writes ; is well versed in modern physiology and pathology, and holds a fluent pen, consequently the book is an excellent one, and as the teachings of the text are abundantly illustrated by the reports of one hundred and fifty cases, Dr. Hayden's effort will probably attain the popularity it deserves."—Philadelphia Medical Times. "There is not an unnecessary page in Dr. Hayden's work."—N. Y. Medical Record. HOLDEN, HUMAN OSTEOLOGY. Sixth Edition. Comprising a Description of the Bones, with Colored Delineations of the At- tachments of the Muscles. The General and Microscopical Structure of Bone and its Development. By the Author and A. Doran, f.r.c.s., with Lithographic Plates, etc. By Luther Holden, f.r.c.s. Numerous Illustrations. Sixth Edition, carefully Revised. Price $5.50 by same author. ANATOMY. Manual of Dissections of the Human Body. Fourth London Edition. With 170 Illustrations. Price $5.50 LANDMARKS. . Landmarks Medical and Surgical. Third London Edition. Revised and Enlarged. Price $1.25 " Mr HolJ< n is the happy possessor of the faculty of writing interesting works on Anatomy. A part of the charm consists in the frequent references to practical points, and in the explanation of the advantages and objects of details of structures."—Boston Medical and Surgical yournal. 20 PRESLEY BLAKISTON'S HEATH'S OPERATIVE SURGERY. A Course of Operative Surgery, consisting of a Series of Plates, each plate containing Numerous Figures, Drawn from Nature by the Celebrated Anatomi- cal Artist, M. Leveille, of Paris, Engraved on Steel and Colored by Hand, under his immediate superintendence, with Descriptive Text of Each Operation. By Christopher Heath, f.r.c.s., Surgeon to University College Hospital, and Holme Professor of Clinical Surgery in University College, London. One Large Quarto Volume. Price $14.00 The author has embodied in this work the experience gained by him during twenty years of surgical teaching. It comprises all the operations that are required in ordinary surgical practice. He has selected for illustration and description those methods which appear to give the best results in practice, referring to the errors likely to occur and the best methods of avoiding them. BY SAME AUTHOR. THE STUDENT'S GUIDE TO SURGICAL DIAGNOSIS. i2mo. Price $1.50 " Mr. Heath is so well known, both as a practical surgeon, teacher and writer, that anything from his pen re- quires no introduction from the hands of reviewers, and scarcely any notice but the announcement of the fact that he has written a. book."—Medical Record. A MANUAL OF MINOR SURGERY AND BANDAGING. Sixth Edition, Revised and Enlarged. With 115 Illustrations. i2mo. Price $2.00 "This excellent work should not be termed a ' Minor' Surgery, but it really consists of the sum and substance of Practical surgery. We would not exchange it for any book in our possession."—Southern Clinic. HEATH'S PRACTICAL ANATOMY. Fifth London Edition. Practical Anatomy. A Manual of Dissections. Fifth London Edition. 24 Colored Plates, and nearly 300 other Illustrations. Just Ready. Price $5.00 INJURIES AND DISEASES OF THE JAWS. The Jacksonian Prize Essay of the Royal College of Surgeons of England, 1867. Second Edition, Revised, with over 150 Illustrations. Octavo. Price $4.25 HOOD, ON GOUT AND RHEUMATISM. A Treatise on Gout, Rheumatism, and the Allied Affections. Their Treat- ment, Complications, and Prevention. By Peter Hood, m.d. Second Edi- tion, Revised and Enlarged. With some Considerations on Longevity. Octavo. Price $3.50 " The Observations on Treatment are specially to be commended."—London Lancet. HOLDEN, THE SPHYGMOGRAPH. The Sphygmograph. Its Physiological and Pathological Indications. By Edgar Holden, m.d. Illustrated by Three Hundred Engravings on Wood. 8vo. Price $2.00 HOLMES, THE LARYNGOSCOPE. A Guide to the Use of the Laryngoscope in General Practice. By Gordon Holmes, m.d., Physician to the Throat and Ear Infirmary. i2mo. Price $1.00 BY SAME AUTHOR. VOCAL PHYSIOLOGY. Vocal Physiology and Hygiene. With reference- to the Cultivation and Preservation of the Voice. Illustrated. i2mo. Price $2.00 HOFF, ON HEMATURIA. Haematuria as a Symptom of the Diseases of the Genito-Urinary Organs. By O. Hoff, m.d. Illustrated. i2mo. . Price .75 PUBLICA TIONS. 21 HUNTER, MECHANICAL DENTISTRY. A Practical Treatise on the Construction of the Various kinds of Artificial Dentures, with Formulas, Receipts, etc. By Charles Hunter, d.d.s. ioo Illustrations. i2mo. Price $2.25 '* It is the outcome of his own experience of some twenty years as a Mechanical Dentist, and contains, moreover much derived from practical knowledge of other dentists. The value of the book is also much added to by illus- trations. It will be very useful to the Dental Student, and to all Mechanical Dentists."—London Medical Times *nd Gazette. HUTCHINSON'S ILLUSTRATIONS OF CLINICAL SUR- GERY. First Volume Complete. Consisting of Plates, Photographs, Woodcuts, Diagrams, etc. Illustrating Surgical Diseases, Symptoms, and Accidents; also Operations and other Methods of Treatment. With Descriptive Letter-press. By Jonathan Hutch- inson, f.r.c.s., Senior Surgeon to the London Hospital, Surgeon to the Moor- fields Ophthalmic Hospital, and to the Hospital for Diseases of the Skin, Black- friars. In Quarterly Fasciculi. Imperial 4to. Volume 1. (Ten Fasciculi) bound complete in itself. Price $25.00. Parts Eleven, Twelve, Thirteen, and Fourteen of Volume 2, Now Ready. Each $2.50 HEWITT, DISEASES OF WOMEN. Third Edition. The Diagnosis, Pathology, and Treatment of Diseases of Women, Including the Diagnosis of Pregnancy. Founded on a Course of Lectures Delivered at St. Mary's Hospital Medical School. By Graily Hewitt, m.d., Lond., m.r.c.p., Physician to the British Lying-in Hospital; Lecturer on Midwifery and Diseases of Women and Children at St. Mary's Hospital Medical School; Honorary Secretary to the Obstetrical Society of London, etc. The Third Edition. Re- vised and Enlarged, with New Illustrations. Octavo. Price, Cloth $400; Leather $5.00 " The excellent work of Dr. Hewitt presents—in a form well adapted to conduct the student to a knowledge of the Diseases of Women, and to assist the young practitioner in his study of these diseases at the bedside of the patient—a very full and clear exposition of the views entertained by the most authoritative teachers as to their pathological treatment and their correct Diag- nosis."—Amer. Med. yournal. HAY, SARCOMATOUS TUMOR. History of a Case of Recurring Sarcomatous Tumor of the Orbit in a Child. By Thomas Hay, m.d. Illustrated. Paper. Price .50 HEWSON, EARTH IN SURGERY. Earth as a Topical Application in Surgery, Being a Full Exposition of its Use in Cases Requiring Topical Applications. By Addinell Hewson, m.d. Illus- trated. 8vo. Price $2.50 HODGE, ON ABORTION. On Foeticide or Criminal Abortion. By Hugh L. Hodge, m.d. Price, Paper, .30; Cloth, .50 HODGE, CASE-BOOK. Note-Book for Cases of Ovarian Tumors. By H. Lennox Hodge, m.d. With Diagrams. Price, Paper, .50 HIGGINS, DISEASES OF THE EYE. A Hand-Book of Ophthalmic Practice. By Charles Higgins, f.r.c.s. Ophthalmic Assistant Surgeon at Guy's Hospital. Second Edition. i6mo. Price .60 Contents.—Section i. Discharge from the Eyes. 11. Intolerance of Light, in. Iritis and Glaucoma, iv. Diseases of the Eyelids, v. Watering of the Eye. vi. Acuteness of Visioa, Field of Vision, Anomalies of Re. fraction, Astigmatism, Accommodation, Presbyopia, vn. Disturbance of Vision, Use of the Ophthalmoscope, Normal and Morbid Appearances, vm. Injuries. "We have rarely seen so much important information condensed in so short a space."— American Medical yournal. "Readers of the former editions will not require to be told that the additions now made are of the highest possible excellence."— Times and Gazette. " It is one of the most useful, practical, and compre- hensive works upon the subject in the English language, a true guide to the student, and an invaluable means of reference for the teacher. "-N. Y. Medical Record. 22 PRESLEY BLAKISTON'S HARRIS, THE PRACTICE OF DENTISTRY. Tenth Edition. The Principles and Practice of Dentistry. Tenth Revised Edition. In great part Rewritten, Rearranged, and with many new and important Illustrations. By Chapin A. Harris, m.d., d.d.s. Edited by P. H. Austen, m.d., Professor of Dental Science and Mechanism in the Baltimore College of Dental Surgery. With nearly 400 Illustrations. Royal Octavo. Price, Cloth, $6.50; Leather, $7.50 This new edition of Dr. Harris' work has been thoroughly revised in all its parts, more so than any previous edition. So great have been the advances in many branches of dentistry that it was found necessary to rewrite the articles or subjects, and this has been done in the most efficient manner by Professor Austen, for many years an associate and friend of Dr. Harris, assisted by Professor Gorgas and Thomas S. Latimer, m.d. The publishers feel assured that it will now be found the most complete text-book for the student, and guide for the practitioner in the English language. BY SAME AUTHOR. MEDICAL AND DENTAL DICTIONARY. Fourth Edition. A Dictionary of Medical Terminology, Dental Surgery, and the Collateral Sciences. Fourth Edition, Carefully Revised and Enlarged. By Ferdinand J. S. Gorgas, m.d., d.d.s., Professor of Dental Surgery in the Baltimore College, etc. Royal Octavo. Price, Cloth, $6.50; Leather, $7.50 This Dictionary, having passed through three editions, and been for some time out of print, has been again carefully revised'by F. J. S. Gorgas, m.d., Dr. Harris' successor as Professor of Dental Surgery in the Baltimore College of Dental Surgery. In his preface to this new edition, the editor says :— " The object of the reviser has been to bring the book thoroughly up to the pres- ent requirements of the profession, the Medical portion having been as carefully re- vised and added to as that devoted more especially to Dental Science, while a number of obsolete terms and methods have been omitted. In nearly every one of the seven hundred and forty-three pages of the former edition corrections and addi- tions have been made, and many new processes, terms and appliances described, some of which are not found in any other work published." HANDY, ANATOMY. Text-Book of Anatomy and Guide to Dissections. For the Use of Students. By W. R. Handy, m.d. 312 Illustrations. Price $3.00 HILLIER, DISEASES OF CHILDREN. A Clinical Treatise on the Diseases of Children. By Thomas Hillier, m.d. 8vo. Price $2.00 HUFELAND, LONG LIFE. The Art of Prolonging Life. By C. W. Hufeland. Edited by Erasmus Wilson, m.d. i2mo. ^ Price $1.00 " We wish all doctors and all their intelligent clients would read it, for surely its perusal would be attended with pleasure and benefit."—American Practitioner. " It certainly should be in the library of every physician."—Medical Brief. HUNTER, PORTRAIT OF. Portrait of John Hunter. From Sharp's well-known Engraving; a copy of Sir Joshua Reynold's Portrait. For Framing. Large size, 9x11; sheet 16 x 20. Price, in the Sheet, sent free by mail, 50 cents; or, Handsomely Framed Price $2.00 PUB LICA TIONS. *3 HEADLAND, THE ACTION OF MEDICINES. Sixth Edition. On the Action of Medicines in the System. By F. W. Headland, m.d. Sixth American Edition, Revised and Enlarged. 8vo. Price $3.00 " It displays in every page the evidence of extensive knowledge and of sound reasoning ; it will be useful alike to thos* who are just commencing their studies, and to those who are engaged in the active pursuits of pro- fessional life."—Medical Times. " The very favorable opinion which we were amongst the first to pronounce upon this essay has been fully confirmed by the general voice of the profession, and Dr. Headland may now be congratulated on having pro- duced a treatise which has been weighed in the balance, and found worthy of being ranked with our standard medical works."—London Lancet. JAMES, SORE THROAT. On Sore Throat, Its Nature, Varieties and Treatment, Including its Con- nection with other Diseases. By Prosser James, m.r.c.p. Fourth Edition, Revised and Enlarged. With Colored Plates and Numerous Wood-cuts. i2mo. Price $2.25. " We can confidently recommend his therapeutic teachings as well worthy of the careful consideration of the Profession, for they set forth the practice of an enthusiastic worker, whose special experience has been large and lengthened."—British Medical yournal. " The practitioner who buys Dr. James' unpretending little book will provide himself with a wise and practical clinical commentary, and with a well arranged digest of long and varied experience."—Westminster Review. BY SAME AUTHOR. LARYNGOSCOPY AND RHINOSCOPY. Including the Diagnosis of Diseases of the Throat and Nose. Third Edition. With Colored Plates. i8mo. Price $2.00. " It gives in a succinct form the approved methods of examination and treatment of diseases of the nose, throat, and larynx. The plan pursued is one well adapted to the needs of the general practitioner."—American Medical yournal. JONES, AURAL ATLAS. An Atlas of Diseases of the Membrana Tympani. Being a Series of Colored Plates, containing 62 Figures. With appropriate Letter-press and Explanatory Text. By H. Macnaughton Jones, m.d., Surgeon to the Cork Ophthalmic and Aural Hospital. 4to. Price $6.00. " The cases are well selected, the drawings executed from life, highly artistic and very conscientious, and the commentaries indicate familiarity with the subject and good judgment in dealing with it."—British Medical yournal. BY SAME AUTHOR. AURAL SURGERY. A Practical Hand-Book on Aural Surgery. Illustrated. i2mo. Price $1.50. JONES, SIEVEKING AND PAYNE, PATHOLOGICAL AN- ATOMY. * A Manual of Pathological Anatomy. By C. Handfield Jones, m.d., and Edward H. Sieveking, m.d., Physician to St. Mary's Hospital. A New En- larged Edition. Edited by J. F. Payne, m.d., Lecturer on Morbid Anatomy at St. Thomas' Hospital. With Numerous Illustrations. Demi 8vo. Price $5.50. JONES, ON SIGHT AND HEARING. The Defects of Sight and Hearing, their Nature, Causes, and Prevention. By T. Wharton Jones, m.d. Second Edition. i6mo. Price .50. KIRBY, ON PHOSPHORUS. Fifth Edition. Phosphorus as a Remedy for Functional Diseases of the Nervous System. By E. A. Kirby, m.d. Fifth Edition. 8vo. Price $1.00 KOLLMEYER, KEY TO CHEMISTRY. Chemia Coartata, or Key to Modern Chemistry. By A. H. Kollmeyer, m.d. With Numerous Tables, Tests, etc. Price $2.25 KIRKE, PHYSIOLOGY. Revised up to 1881. A Hand-book of Physiology. By Kirke. Tenth London Edition. By W. Morrant Baker, m.d. 420 Illustrations. Price $5.00 24 PRESLEY BLAKISTON'S KANE, THE OPIUM, MORPHINE AND SIMILAR HABITS. Drugs that Enslave. The Opium, Morphine, Chloral, Hashisch and Similar Habits. By H. H. Kane, m.d., of New York. With Illustrations. Price $1.50 " It contains a large amount of information collected with much labor and presented tn a systematic Manner. The subject of the chloral habit has not been investigated by any one, we believe, so thoroughly as Dy Dr. Kane." —Medical Record. " It deserves to be read by those who feel an interest in discouraging ehe use of these dangerous drugs. The book is embellished by an excellent phototype frontispiece of Laocoon."—American yournal of Pharmacy. " A work of more than ordinary ability and careful research. . . . For the first time, reliable statistics on the use of chloral are classified and published, . . . and it is shown that the use of chloral causes a more complete and rapid ruin of mind and body than either opium or morphine."—Druggists' Circular and Gazette. KIDD, THERAPEUTICS. The Laws of Therapeutics; or, the Science and Art of Medicine. By Joseph Kidd, m.d. i2mo. Cloth. Price $1.25. Dr. Joseph Kidd, who, "by the way, was Lord Beaconsfield's medical adviser, and an eminent physician of the regular school, briefly but clearly sketches the history of medicine from the earliest period. He shows that the chief mistakes have been made through deference to theory and negligence of the teachings of facts. Thence he passes to an assertion of the value of the homoeopathic principle of similia simili- bus in the treatment of many diseases. He is not a follower of Hahnemann, and does not believe in infinitessimal doses, but he claims, and enforces his position by the citation of cases in his own practice, that the homoeopathic principle has performed wonders where that of his own school was much less successful. " Dr. Kidd acknowledges two laws—that of contrariacontrariis a.ndsimilia similibus; but the cases he gives in his chapter on ars medica show that, like a sensible" practitioner, he does not allow himself blindly to follow either the one or the other, but seeks out the cause of disease, and tries by rational measures to remove it. The cases arc the most valuable part of the book."—London Practitioner. LEGG, ON THE URINE. Practical Guide to the Examination of the Urine, for Practitioner and Student. By J. Wickham Legg, m.d. Fifth Edition, Enlarged. Illustrated. i2mo. Price .75 This little work is intended to supply the Physician or Student with a concise guide to the recognition of the different characteristics of the urine, and though small and well adapted to the pocket, contains, probably, everything that could be gleaned from a larger work. LEARED, IMPERFECT DIGESTION. / The Causes and Treatment of Imperfect Digestion. By Arthur Leared, m.d. The Sixth Edition. Revised and Enlarged. i2mo. Price $1.50 LIEBREICH, ATLAS OF OPHTHALMOSCOPY. An Atlas of Ophthalmoscopy, containing 12 Full-page Chromo-Lithographic Plates, with 59 Figures. By R. Liebreich, m.d. Second Edition, Enlarged. Large Quarto. Price $12.00 LIVEING, ON SICK HEADACHE. Megrim, or Sick Headache and Some Allied Disorders. By Edward Live- ing, m.d. With Plates, Tables, etc. 8vo. Price $5.50 LEBER AND ROTTENSTEIN, DENTAL CARIES. Dental Caries and Its Causes. An Investigation into the Influence of Fungi in the Destruction of the Teeth. By Drs. Leber and Rottenstein. Illustrated. 8vo. Price $1.25 " The work gives the result of patient observation, presents the deductions of its authors with a perspicuity and modesty calculated to secure for its positions a thoughtful consideration. We heartily commend it as an educa- tional worlf."—Dental Cosmos. PUBLICA TIONS. 2J LEWIN, ON SYPHILIS. k TA\Tr^atment 0f SyPhilis; B7 Dr- George Lewin, of Berlin. Translated trated. i^mo^^' "*" ^ G^' MD" SurgC°nS U" S" Army illus Price $1.50 "When such authorities as Dr. Drysdale (as we quoted a few weeks apol condemn th.„*~~r ■ v,- as " too dangerous," while, on the other hand, eminent surgeons sucrf is PrSn,r?seof m.frcurym syphihs without that drug, general practitioners will gladly welcom!UnymeZv^ wlftft alUheTood'effecrfnf sss^^syixS5?fl^^r,,'appeanng-This is what is *aa £jmi?£ LIZARS, ON TOBACCO. The Use and Abuse of Tobacco. By John Lizars, m.d. i2mo. Price .50 LONGLEY, POCKET MEDICAL LEXICON. Students' Pocket Medical Dictionary, Giving the Correct Definition and Pro- nunciation of all Words and Terms in General Use in Medicine and the Collate- ral Sciences, with an Appendix, containing Poisons and their Antidotes, Abbre- viations Used in Prescriptions, and a Metric Scale of Doses. By Elias Longley 24mo- Price, Cloth, $1.00; Tucks and Pocket $1.25 This is an entirely new Medical Dictionary, containing some 300 compactly printed 24tno pages, very carefully prepared by the author, who has had much ex- perience in the preparation of similar works, assisted by the Professors of Chemistry and of Botany in one of our leading medical colleges. " It is, we believe, also the only lexicon in existence in which the pronunciation of words is fully and dis- tinctly marked."— Canada Medical Review. " This is avery compact a.nd complete little diction- ary. We commend it as particularly useful to students." —New York Medical yournal. ' This little book will be welcomed by students in medicine and pharmacy as a convenient pocket com- panion, giving the pronunciation, acceptation, and definition of medical, pharmaceutical, chemical and botanical terms."—American yournal of Pharmacy. " It would seem to be just the book for dental and medical students."—Dental Advertiser. MARTIN, ATLAS OF GYNAECOLOGY. An Atlas of Obstetrics and Gynaecology. By Prof. A. Martin, of Berlin. Translated and edited from the Second German Edition, with additions, by Fan- court Barnes, m.d., m.r.c.p. With 98 Full-page Lithographic Plates, con- taining over 400 figures, many being colored. With full letter-press references to and explanations of each figure ; forming a thick quarto volume. Bound in heavy beveled boards. Sold only by subscription. Price $12.00 "This valuable and classic series of illustrations includes 98 pages of plates, with an average of 5 illus- trations on each, many of which are colored, and some drawn on a large scale, so as to occupy the whole page. The subjects treated range through the whole of mid- wifery and gynaecology, beginning with normal and ab- normal pelvis, and ending with illustrations of some of the most important obstetric gynecologic instruments used in Germany and in this country. The de- scriptive letter-press is very full and accurate, and the whole makes an extremely handsome volume."—Brit- ish Medical yournal, July 10th, 1880. " The atlas is the most complete and comprehensive work of its kind. . . Nearly every point, anatomi- cal, physiological, obstetrical, and gynaecological, is illustrated in the best way, by well known authors, from whose works the late Dr. Martin culled his illus- trations. As a work of reference, to the practitioner, the atlas is invaluable ; while to the student who wishes to refresh his memory in the readiest way and in the shortest time, it will be very useful."—London Medi- cal Record, July 15th, 1880. MACDONALD, MICROSCOPICAL EXAMINATION OF WATER. A Guide to the Microscopical Examination of Drinking Water. By J. D. Macdonald, m.d. With Twenty Full-page Lithographic Plates, Reference Tables, etc. 8vo. Price $2.75 " The volume is an excellent hand-book and will greatly facilitate the study of the subject."—Popular Science Monthly. MACEWEN, ON OSTEOTOMY. An Inquiry into the Etiology and Pathology of Knock-knee, Bow-leg and other Osseous Deformities of the Lower Limbs. By Wm. Macewen, m.d. Il- lustrated. 8vo. Price $3.00 26 PRESLEY BLAKISTON'S MACKENZIE, ON THE THROAT AND NOSE. Including the Pharynx, Larynx, Trachea, OZsophagus, Nasal Cavities, and Neck. By Morell Mackenzie, m.d., London, Senior Physician to the Hos- pital for Diseases of the Chest and Throat, Lecturer on Diseases of the Throat at London Hospital Medical College, etc., etc. Vol. I, containing the Pharynx, Larynx and Trachea, with 112 Illustrations. Now ready. Price, Cloth, $4.00; Sheep, $5.00 8^"Author's Edition, with the Original Illustrations. Published from early sheets, by arrangement with Dr. Mackenzie. Vol. 2 in preparation. "We have long felt the want of a thoroughly practical and systematic treatise on diseases of the throat and nasal passages. Admirable essays have from time to time appeared ; no standard work has been written. Any one familiar with laryngoscopic work must appreciate the valuable addition now made to this special department in the work before us. The entire work will include the consideration of affections of the pharynx, larynx, trachea, oesophagus, nasal cavities, and neck. The matter now presented complete for the first time is the result of the author's large and unrivaled experience, both in hospital and private practice, extending over a period of twenty years. There can be but one verdict of the profession on this manual—it stands without any competitor in medical literature, as a standard work on the organs it professes to treat of."—Dublin yournal. " It is both practical and learned ; abundantly and well illustrated ; its descriptions of disease are graphic, and the diagnoses the best we have anywhere seen. To give examples of the thoroughness of Dr. Mackenzie's book, we may cite the chapter on diphtheria, which embraces 47 pages. The chapter on non-malignant tumors of the larynx would appear to be absolutely exhaustive. Nowhere else have we seen so elaborate a statement of the sub- ject. We can predict for this work a high position, and congratulate its distinguished author upon its appear- ance."—Philadelphia Medical Times. BY SAME AUTHOR. THE PHARMACOPOEIA of the Hospital for Diseases of the Throat and Nose. The Fourth Edition, much enlarged, containing 250 Formulae, with Directions for their Preparation and Use. i6mb. Price $1.25 DIPHTHERIA. ITS NATURE AND TREATMENT. i2mo. Price .75 Contents.—1. The Definition and History. 2. The Etiology. 3. The Symptoms. 4. The Paralyses. 5. The Diagnosis. 6. The Pathology. 7. The Prognosis. 8. The Treatment. 9. Laryngo-Tracheal Diphtheria. 10. Nasal Diphtheria. 11. Secondary Diphtheria. "The terse remarks on prognosis are excellent; and what the Author says of treatment, general and local, and tracheotomy, we commend most cordially."—New York Medical yournal. GROWTHS IN THE LARYNX. Their History, Causes, Symptoms, etc. With Reports and Analysis of one Hundred Cases. With Colored and Other Illustrations. 8vo. Price $2.00 MACNAMARA, DISEASES OF THE EYE. A Manual of the Diseases of the Eye. By C. Macnamara, m.d. Third Edition, Carefully Revised; with Additions and Numerous Colored Plates, Dia- grams of Eye, Wood-cuts, and Test Types. Demi 8vo. Price $4.00 "As a book of ready reference on diseases of the eye it has no superior, and we may safely say, no equal in our language."—Cincinnati Lancet and Observer. BY SAME AUTHOR. ON THE BONES AND JOINTS. Lectures on Diseases of the Bones and Joints. Second Edition. Demi 8vo. Price $4.25 MADDEN, HEALTH RESORTS. Health Resorts for the Treatment of Chronic Diseases. A Hand-Book, the result of the author's own observations during several years of health travel in many lands, containing also • remarks on climatology and the use of mineral waters. By T. M. Madden, m.d. 8vo. Price $2.50 " Rarely have we encountered a book containing so much information for both invalids and pleasure seekers." — The Sanitarian. PUB LICA TIONS. 27 MARSHALL & SMITH, ON THE URINE. The Chemical Analysis of the Urine. By John Marshall, m.d., and Edgar F. Smith, m.d., of the Chemical Laboratory, Medical Department, University of Pennsylvania. Illustrated by Phototype Plates. i2mo. Price $1.00 MARSHALL, ANATOMICAL PLATES; Or Physiological Diagrams. Life Size (7 by 4 feet) and Beautifully Colored. By John Marshall, f.r.s. An Entirely New Edition, Revised and Improved, Illustrating the Whole Human Body. The Set, Eleven Maps, in Sheets, Price $50.00 handsomely Mounted on Canvas, with Rollers, and Varnished, Price $80.00 An Explanatory Key to the Diagrams, Price .50 Dr. Marshall's Plates, from their size and perfection of drawing and coloring, excel any diagrams that have been published. They have proved invaluable in Medical Schools and Lecture Rooms. The low price at which they are offered brings them within reach of all. No. 1. The Skeleton and Ligaments. No. 2. The Muscles, Joints, and Animal Mechanics. No. 3. The Vis- cera in Position—The Structure of the Lungs. No. 4. The Organs of Circulation. No. 5. The Lymphatics or Absorbents. No. 6. The Digestive Organs. No. 7. The Brain and Nerves. No. 8. The Organs of the Senses and Organs of the Voice, Plate 1. No. 9. The Organs of the Senses, Plate 2. No. 10. The Microscopic Structure of the Textures, Plate 1. No. 11. The Microscopic Structure of the Textures, Plate 2. MARSDEN, ON CANCER. A New and Successful Mode of Treating Certain Forms of Cancer. By Alex- ander Marsden, m.d. Second Edition. Colored Plates. 8vo. Price $3.00 MARTIN, MICROSCOPIC MOUNTING. A Manual of Microscopic Mounting. With Notes on the Collection and Ex- amination of Objects, and upwards of 150 Illustrations. B> John H. Martin. Second Edition, Enlarged. 8vo. Price $2.75 MORRIS, ON THE JOINTS. The Anatomy of the Joints of Man. Comprising a Description of the Liga • ments, Cartilages, and Synovial Membranes; of the Articular Parts of Bones, etc. By Henry Morris, f.r.c.s. Illustrated by 44 Large Plates and Numerous Figures, many of which are Colored. 8vo. Price $5.50 MUTER, MEDICAL AND PHARMACEUTICAL CHEMIS- TRY. An Introduction to Pharmaceutical and Medical Chemistry. Part One.— Theoretical and Descriptive. Part Two.—Practical and Analytical. Arranged on the principle of the Course of Lectures on Chemistry as delivered at, and the Instruction given in the Laboratories of, the South London School of Pharmacy. Bv Tohn Muter, m.d., President of the Society of Public Analysts. A Second Edition Enlarged and Rearranged. The Two Parts bound in one large octavo volume.' Price $6.00 Part Two.__Practical and Analytical. Bound Separately, for the Special Con- venience of Students. Large 8vo. Cloth. Price $2.50 MAC MUNN, THE SPECTROSCOPE. The Spectroscope in Medicine. By Chas. A. Mac Munn, m.d. With 3 Chromo-lithographic Plates of Physiological and Pathological Spectra, and 13 Wood Cuts. 8vo. P"c^3,°? " ThU book is without question, the best that has yet been published on the subiect; to those not familiar with PhJiolofricalT Spectroscopy it will prove interesting, while to those who are worfcng m th.s field it is a necey Btty."—New York Medical yournal. 28 PRESLEY BLAKISTON'S It is eminently a book which will teach the Student.—Practitioner. It forms one of the most convenient, practical, and concise books ye* published on the subject. — London Lancet. MEADOWS' MANUAL OF OBSTETRICS; THE THIED EEVISED AND ENLAEGED EDITION, NOW EEADY. with one hundred and forty-five illustrations. INCLUDING THE SIGNS AND SYMPTOMS OF PREGNANCY, Obstetric Operations, Diseases of the Puerperal State, &c, &c By Alfred Meadows, M. D., Physician to the Hospital for Women, to the General Lying-in Hospital, &c, &c. Revised and Enlarged Edi- tion. With numerous Illustrations. Price #2.00 In this new edition,.. .not merely is the practical treatment of Labor, and also of the Dig- eases and Accidents of Pregnancy, well and clearly taught, but the anatomical machinery of parturition is more effectively explained than in any other treatise that we remember; besides this, the book is honorably distinguished among manuals of Midwifery by the fub ness with which it goes into the subject of the structure and development of the ovum. On all questions of treatment, whether by medicines, by hygienic regimen, or by mechanical or operative appliances, this treatise is as satisfactory as a work of manual size could be; student* and practitioners can hardly do better than adopt it as their vade-mecum.—The Practitioner. Upwards of ninety new engravings have been inserted in this edition, and, with a view to, facilitate reference, the author has furnished it with a very full and complete table of contents and index. We can cordially recommend this manual as accurate and practical, and as con- taining in a small compass a large amount of the kind of information suitable alike to the student and practitioner.—London Lancet. It is concise, well arranged, and remarkably complete, as a guide to the student during his lecture term; and as a ready reference to the Physician, no work of similar character equals it in value.—Buffalo Medical Journal. The systematic arrangement of subjects, and the concise, practical style in which it is written, make the work especially valuable as a student's manual, while a very full table of contents and index renders it easily accessible as a work of reference.—Chicago Medical Examiner. There can be no doubt that this manual will be generally accepted as a brief, convenient, and compendious guide to the study and practice of the Obstetric Art.—Richmond and Louisville Medical Journal. We cannot but feel that every teacher of obstetrics has good caus.e to congratulate himself on being able to put in the hands of the student a book which contains so much valuable and reliable information in so condensed a form.—Philadelphia Medical Times. It is concisely and clearly written, and the information is on the whole on a level with the most recent knowledge of the day.—British and Foreign Medical Review. A work which embodies a larger amount of practical information than any other book on the subject.—Pacific Medical and Surgical Journal, It is with great gratification that we are enabled to class Dr. Meadows' Manual as a rare exception, and to pronounce it an accurate, practical, and creditable work, and to unhesi- tatingly recommend it to both student and practitioner.—American Journal of Obstetrics. It is a book of decided merit: every page teems with sound, practical common sense, advice and suggestions.—Kansas City Medical Journal, PUBLICATIONS. *9 MENDENHALL, VADE MECUM. The Medical Student's Vade Mecum. A Compend of Anatomy, Phvsioloev Chemistry, The Practice of Medicine, Surgery, Obstetrics etc BvGeS Mendenhall, m.d. Eleventh Edition. 224 Illustrations Svo.' Price £2 00 MEIGS AND PEPPER, DISEASES OF CHILDREN. FennPwanfCtblTre niSe °n Jh|uDi!e?ses of Children. By J. Forsyth Meigs, m.d., Pfpp™ MTf SUe*? °f F\S1C1*™ of Philadelphia, etc., etc., and William pf™ 1 ' PchyS1C1unJ?- -the Phlladelphia Hospital, Provost University of Pennsylvania. Seventh Edition, thoroughly Revised and Enlarged. A Royal Octavo Volume of over 1000 pages. Price, Cloth, $6.00; Leather, #.00 easerofVhifdren6"-^Tj*Me&&r\\\Tme* ^ ** ^ ™* "^ ^P^-e work, on Dis- y'o'urnalhe regarded M the most complete work on Diseases of Children in our language."-^;,,^^ Medical ^nlllfC^blteJr)^?1 ^ * teXt-book so comPlet«. ^ just and so readable as the one before ^."-American MATHIAS, LEGISLATIVE MANUAL. A Rule for Conducting Business in Meetings of Societies, Legislative Bodies Town and Ward Meetings, etc. By Bent. Mathias, a.m. Sixteenth Edition. l6mo- Price .50 MORTON, REFRACTION OF EYE. The Refraction of the Eye. Its Diagnosis and the Correction of its En ors. With Chapter on Keratoscopy. By A. Stanford Morton, m.b., f.r.c.s. i2mo. Price $ 1.00 ** The author has not only given very thorough rules for the objective and subjective examinations of the eye in the various condiuons of refraction which present themselves, but has entered into an explanation of the phenom- ena observed, which is at once scientific and elementary."—Edinburgh Medical yournal. MEARS, PRACTICAL SURGERY. Practical Surgery. Including: Part 1.—Surgical Dressings; Part 11.—Band- aging ; Part in.—Ligations ; Part iv.—Amputations. With 227 Illustrations. By J. Ewing Mears, m.d., Demonstrator of Surgery in Jefferson Medical Col- lege, and Professor of Anatomy and Clinical Surgery in the Pennsylvania Col- lege of Dental Surgery. i2mo. Price $2.00 "It contains a great deal of information upon the subjects of which it treats, in a convenient and con- densed form. Each division is well illustrated, thereby rendering the text doubly clear."—New York Medical Record. " Professor Mears has written a convenient and use- ful book for students. We can most cordially endorse it as fulfilling well the promise made in its modest pre- face."—Cincinnati Lancet and Clinic. OLDBERG, PRESCRIPTION BOOK. Three Hundred Prescriptions, Selected Chiefly from the Best Collections of Formulae used in Hospital and Out-patient-practice, with a Dose Table, and a •Complete Account of the Metric System. By Oscar Oldberg, phar. d., Late Medical Purveyor, United States Marine Hospital Service; Professor of Materia Medica, National College of Pharmacy, Washington, D. C.; Member of the American Pharmaceutical Association, and of the Sixth Decennial Committee of Revision and Publication of the Pharmacopoeia of the United States. i2mo. Price $1.50 The prescriptions given in this work are selected from the Pharmacopoeias and formularies of the great Hospitals of New York, Philadelphia, Boston and London, or contributed from the practice of medical officers of the United States Service. The Dose Table includes nearly all of the remedies that have a place in the current Materia Medica. 3° PRESLEY BLAKISTON'S BY SAME AUTHOR. THE UNOFFICIAL PHARMACOPCEIA. Comprising over 700 Popular and Useful Preparations, not Official in the United States, of the various Elixirs, Fluid Extracts, Mixtures, Syrups, Tinct- ures, Ointments, Wines, etc., etc., in constant demand throughout the country. Thick i2mo. 503 pp. Half Morocco. Price $3.50 Sold by Subscription. S^-It Will Prove a Useful Supplement to the Pharmacopceia of the United States ; the aim has been to make it as complete as practicable. The form- ulas can, with a minimum of labor, be used with any system of weights and meas- ures. The virtual adoption of the metric system in the forthcoming Pharmacopceia of fhe United States will account for the preference given to that system in this vol- ume, which, however, does not prevent the ready use of the book with apothecaries' weights and measures. An extended account of the metric system has been given, accompanied by full tables of equivalents. The sources from which the formulae have been gathered are believed to be the best. They include the Pharmacopoeias of England, Germany, France and Sweden. The book is practically equivalent to the possession of these various Pharmacopoeias, and the formulae were selected with reference to their popularity, usefulness, and interesting character. " This volume is one of the most practical and valuable contributions to Pharmaceutical work of recent publica- tion. It has received high commendation from many of our best pharmacists."—LazeII, Marsh &» Gardiner, Wholesale Druggists, New York City. OTT, ACTION OF MEDICINES. The Action of Medicines. By Isaac Ott, m.d., late Demonstrator of Experi- mental Physiology in the University of Pennsylvania. With 22 Illustrations. 8vo. Price $2.00 " This work is the only one in the English language which can offer, with any degree of completeness, that assist- ance and instruction so essential to the correct and successful study of pharmacology. Filling, as it does, this gap in medical literature, we have a work which cannot fail to be of the greatest value to students. " From the pen of a man himself no novice in the subject of which Tie treats, it bears upon it the impress of relia- bility, due to the author's own experience, a virtue too often wanting in mere compilations of the works of oth- ers."—American yournal of Medical Sciences. PAGET, SURGICAL PATHOLOGY. Lectures on Surgical Pathology, Delivered at the Royal College of Surgeons. By James Paget, f.r.s. Third Edition. Edited by William Turner, m.d. With Numerous Illustrations. 8vo. Price, Cloth, $7.00; Leather, $8.00 PARKES, PRACTICAL HYGIENE. Fifth Edition. A Manual of Practical Hygiene. By Edward A. Parkes, m.d. The Fifth, Revised and Enlarged Edition. With Many Illustrations. 8vo. Price $6.00 "Altogether it is the most complete work on Hygiene which we have seen."—New York Medical Record. " We find that it never fails to throw light on any hygienic question which may be proposed."—Boston Medi- cal and Surgical yournat. " We commend the book heartily to all needing instruction (and who does not), in Hygiene "—Chicago Medi- cal yournal. PIESSE, THE MANUFACTURE OF PERFUMERY. Fourth Edition. The Art of Perfumery; or the Methods of Obtaining the Odors of Plants, and Instruction for the Manufacture of Perfumery, Dentifrices, Soap, Scented Pow- ders, Odorous Vinegars and Salts, Snuff, Cosmetics, etc., etc. By G. W. Septi- mus Piesse. Fourth Edition. Enlarged. 366 Illustrations. 8vo. Cloth. Price $5.30 " An excellent book."— Commercial Advertiser. " Exceedingly useful to druggists and perfumers."— "It is the best book on Perfumery yet published."— yournal of Chemistry. Scientific American. " Is in the fullest sense, comprehensive."— Medical Record. PUBLICA TIONS. 3' PENNSYLVANIA HOSPITAL REPORTS. Edited by a Committee of the Hospital Staff. J. M. DaCosta, m.d., and William Hunt, m.d. Vols, i and 2, containing Original Articles by former and present Members of the Staff. With Lithographic and other Illustrations. %vo- Price, per volume, $2.00 These volumes consist of papers of a practical character, based chiefly on obser- vations made at the Hospital, but containing the further experience of the Members of the Staff. In issuing the second volume the Editors express their acknowledg- ments for the very favorable reception of the first by the profession and press of this country and Europe. PEREIRA, PRESCRIPTION BOOK. Sixteenth Edition. Physician's Prescription Book. Containing Lists of Terms, Phrases, Con- tractions and Abbreviations used in Prescriptions, Explanatory Notes, Gram- matical Construction of Prescriptions, Rules for the Pronunciation of Pharma- ceutical Terms. By Jonathan Pereira, m.d., f.r.s. Sixteenth Edition. Price, Cloth, $1.00; Leather, with tucks and pocket, $1.25 PIGGOTT, ON COPPER. Copper Mining and Copper Ore. With a full Description of the Principal Copper Mines of the United States, the Art of Mining, etc. By A. Snowden Piggott. i2mo. Price $1.00 PRINCE, ORTHOPEDIC SURGERY. Plastic and Orthopedic Surgery. By David Prince, m.d. Containing a Report on the Condition of, and Advance made in, Plastic and Orthopedic Sur- gery, etc., etc.. and Numerous Illustrations. 8vo. Price $4-5° PHYSICIAN'S VISITING LIST, PUBLISHED ANNUALLY. THIRTY-FIRST YEAR OF ITS PUBLICATION. SIZES AND PRICES. For 25 Patients weekly. Tucks, pockets, and pencil, - $1.00 50 «« .... ...... I2S 75 " " .... ...... T.50 100 5° 2.00 "2 vols {Jan. to June) ,. .... 2,0 2 vols. | July tQ Dec | ^.50 .< i ( Jan. to June) ,, « __, 100 " "2 vols. {julvtoJDec.{ - .-- 3-00 INTERLEAVED EDITION. For 2; Patients weekly, interleaved, tucks, pockets, etc., .... 1.25 * « " - ...... .... 1.c0 5° 1.50 '•■2 vols {Jan. to June) ., .... 7.00 5° 2 vols- | July to Dec. j 5 The Visiting List contains a New Table of Poisons and their Antidotes. The Metric or French Decimal System of Weights and Measures. Posological Tables, showing the relation of our present system of Apothecaries' Weights and Measures to that of the Metric System, giving the Doses in both. This last is a most valuable addition, and will materially aid the Physician. So many writers now use the metric system, especially in foreign books and journals, that one not familiar with it is constantly confused, and in many cases unable to understand the measurements or doses. "It is certainly the most popular Visiting List ex- " The book is convenient in form, not too bulky, and . » » fj^vLh Medical Journal n every respect the very best Visiting List published. 1 "htTSJ^contt^nce^arrangement, dur- -Canada Medical and Surgical yournal. ability andPneatne!s of manufacture have everywhere " This standard Visiting List, for completeness .om. fifed* it a preference."-Canada Lancet. reTthe^Tef.n^S^Kr^. * 32 PRESLEY BLAKISTON'S POWER, HOLMES, ANSTIE AND BARNES {Drs.). Reports on the Progress of Medicine, Surgery, Physiology, Midwifery, Dis- eases of Women and Children, Materia Medica, Medical Jurisprudence, Ophthal- mology, etc., etc. Reported for the New Sydenham Society. 8vo. Price #2.00 PURCELL, ON CANCER. Cancer. Its Allies and other Tumors, with Specia Reference to their Medi- cal and Surgical Treatment. By F. Albert Purcell, m.d., m.r.cs. Surgeon to the Cancer Hospital, Brompton, England. 8vo. Price #3.75 RADCLIFFE, ON EPILEPSY. On Epilepsy, Pain, Paralysis, and other Disorders of the Nervous System. By Charles Bland Radcliffe, m.d. Illustrated. i2mo. Price $1.50 "To no authority can the medical inquirer turn for an analysis of the phenomena of epilepsy with more satisfac- tion than to the admirable essay of Dr. Radcliffe."—American yournal Medical Sciences. ROBERTS, MANUAL OF MIDWIFERY. The Student's Guide to the Practice of Midwifery. "By D. Lloyd Roberts, m.d., f.r.c.p., Physician to St. Mary's Hospital, Manchester, etc., etc. Second Edition. With 95 Illustrations. i2mo. Price $2.00 "As an obstetrical manual, we think that of Dr. Rob- I "The present edition has been very thoroughly re- erts one of the best now offered to the Profession, as it vised, some chapters having been entirely re-written. comes with authority, and he possesses the ability to For its size, it forms a remarkably complete compendi- condense, and at the same time present a subject clear- um of the subject, and can hardly be surpassed in the ly."—American yournal of Medical Science. simplicity and clearness of its explanations."—Obstet- "Concise, clear, and practical."—Medieal Press rical yournal of Great Britain and Ireland. and Circular. REYNOLDS, ELECTRICITY. Lectures on the Clinical Uses of Electricity. By J. Russell Reynolds, m.d., f.r.s. Second Edition. i2mo. Price $1.00 " It is thoroughly reliable as a guide, very concise, and will be found exceedingly useful to the general practi- tioner."—Canada Lancet. RICHARDSON, MECHANICAL DENTISTRY. Third Edi- tion. A Practical Treatise on Mechanical Dentistry. By Joseph Richardson, d.d.s. Third Edition. With 185 Illustrations. 8vo. Price, Cloth, $4.00; Leather, $4.75 " Taken as a whole, Professor Richardson's work is a valuable contribution to the dental art, and is beyond all question the best treatise extant upon the general subject of Mechanical Dentistry."—Dental Cosmos. RIGBY AND MEADOWS, OBSTETRIC MEMORANDA. Dr. Rigby's Obstetric Memoranda. Fourth Edition. Revised. By Alfred Meadows, m.d. 321110. Price .50 RINDFLEISCH, PATHOLOGICAL HISTOLOGY. A Text-Book of Pathological Histology. By Dr. Edward Rindfleisch. Translated by Drs. Wm. C. Kolman and F. T. Miller. 208 Illustrations. 8vo. Price, Cloth, $5.00; Leather, $6.00 Recommended as a Text-Book at the University of Pennsylvania and other Med- ical Schools. " To be up with the times our Pathologists must make themselves familiar with the thorough, clear and almost exhaustive teachings of Professor Rindfleisch."— Ohio Medical and Surgical Reporter. " In conclusion we cordially recommend it as the best treatise on the subject."—American yournal of Medi- cal Science. RYAN, ON MARRIAGE. The Philosophy of Marriage. In its Social, Moral and Physical Relations, and Diseases of the Urinary Organs. By Michael Ryan, m.d. Member of the Royal College of Physicians, London. i2mo. Price $1.00 PUBLICA TIONS. 33 ROBERTS' PRACTICE OF MEDICINE. A New Enlarged Edition, JUST READY. Uniformly commended by the Profession and the Press. A HAND-BOOK OF THE THEORY AND PRACTICE OF MEDI- CINE. By Frederick T. Roberts, M.D., M.R.C.P., Assistant Pro- fessor and Teacher of Clinical Medicine in University College Hospital, Assistant Physician in Brampton Consumptive Hospital, &c, &c. Third Edition. Octavo. Price, in cloth .... $5.00 leather . 6.00 The Publishers are in receipt of numerous letters from Professors in the various Med- ical Schools, uniformly commending this book; whilst the following extracts from the Medical Press, both English and American, fully attest its superiority and great value not only to the student, but also to the busy practitioner. • This is a good book, yea, a very good book. It is not so full in its Pathology as " Aitken," so charming in its composition as " Watson," nor so decisive in its treatment as " Tanner;" but it is nfore compendious than any of them, and therefore more useful. We know of no other work in the English language, or in any other, for that matter, which competes with this one. —Edinburgh Medical Journal. We have much pleasure in expressing our sense of the author's conscientious anxiety to make his work a faithful representation of modern medical beliefs and practice. In this he has succeeded in a degree that will earn the gratitude of very many students and practition- ers: it is a remarkable evidence of iudustry, experience, and research. — Practitioner. That Dr. Roberts's book is admirably fitted to supply the want of a good hand-book of medicine, so much felt by every medical student, does not admit of a question. — Students' Journal and Hospital Gazette. Dr. Roberts has accomplished his task in a satisfactory manner, and has produced a work maiuly intended for students that will be cordially welcomed by them ; most of the observa- tions on treatment are carefully written and worthy of attentive study; the arrangement is good, and the style clear and simple. — London Lancet. It contains a vast deal of capital instruction for the student, much valuable matter in it to commend, and merit enough to insure for it a rapid sale.—London Medical Times and Gazette. There are great excellencies in this book, which will make it a favorite both with the accurate student and busy practitioner. The author has had ample experience.—Richmond and Louisville Journal. We confess ourselves most favorably impressed with this work. The author has performed his task most creditablv, and we cordially recommend the book to our readers. — Canada Medical and Surgical Journal. A careful reading of the book has led us to believe that the author has written a work more nearly up to the times than any that we have seen ; to the student, it will be a gift of priceless value. — Detroit Review of Medicine. Our opinion of it is one of almost unqualified praise. The style is clear, and the amount of nseful and indeed, indispensable information which it contains is marvellous. We heartily recommend it to students, teachers, and practitioners. — Boston Med. and Surgical Journal. It is of a much higher order than the usual compilations and abstracts placed in the hands of students. It embraces many suggestions and hints from a carefully compiled hospital experience; the style is clear and concise, and the plan of the work very judicious.—Medxcal and Surgical Reporter. It is unsurpassed by any work that has fallen into our hands as a compendium for students preparing for examination. It is thoroughly practical and fully up to the times.—The Chrnc. We find it an admirable book. Indeed, we know of no hand-book on the subject just now to be preferred to it. We particularly commend it to students about to enter upon the practice of their profession. — St. Louis Medical and Surgical Journal. If there is a book in the whole of medical literature in which so much is said in so few words it has never come within our reach. So clear, terse, and pointed is the style; so accurate the diction, and so varied the matter of this book, that it is almost a dictionary of practical medicine. — Chicago Medical JournoL 34 PRESLEY BLAKISTON'S SANDERSON AND FOSTER, THE PHYSIOLOGICAL LA- BORATORY. A Hand-book of the Physiological Laboratory. Being Practical Exercises for Students in Physiology and Histology. By J. Burdon Sanderson, m.d., E. Klein, m.d., Michael Foster, m.d., f.r.s., and T. Lauder Brunton, m.d. With over 350 Illustrations and Appropriate Letter-press Explanations and Ref- erences. Price, Two Volumes, Text and Plates, separate, ... $7.00 " One " " bound together, Cloth, 6.00 Leather, 7.00 Adopted as a Text-book at Yale College, and used at other Medical Schools in America and England. " Recognizing the fact that Physiology is emphatic- ally an experimental science, it furnishes minute in- structions for performing a great variety of exper- iments. A student could scarcely desire a better guide." —Boston Medical and Surgical yournal. " We confidendy recommend it to the attention of all who are interested in the wide and fertile field of Phy- siological research."—New York Medical yournal. " This is a most superb bonk, and fills a hiatus which every physiological student has lamented."—Chicago Medical yournal. SANDERSON, PHYSIOLOGY. Second Edition. A Syllabus of a Course of Lectures on Physiology. By J. Burdon Sander- son, m.d. For the Use of Students. Second Edition. 8vo. Price $ 1.50 SANSOM, PHYSICAL DIAGNOSIS. Third Edition just ready. The Physical Diagnosis of Diseases of the Heart. Including the Use of the Sphygmograph and Cardiograph. By Arthur Ernest Sansom, m.d. Third Edition. Revised and Enlarged. With Illustrations. i2mo. Price $2.00 " Dr. Sansom is favorably known, and the little work he here presents reflects creditably on his skill in pre- senting with singular clearness, one of the most difficult branches of diagnosis."—Philadelphia Medical and Sur- gical Reporter. BY SAME AUTHOR. ON CHLOROFORM. Chloroform. Its Action and Administration. i2mo. Price $1.50 SMITH, MANUAL OF GYNECOLOGY. Practical Gynaecology. A Hand-book of the Diseases of Women. By Hey- wood Smith, m;d. Physician to the Hospital for Women and to the British Lying-in Hospital. With Engravings. Price $1.5 The object of the author has been to present the busy practitioner with a book systematically arranged, burdened with no discussions on vexed questions of pathol- ogy, and giving at a glance the salient points of diagnosis and treatment with clear- ness and brevity. Contents.—Chapter 1. On the Means of Diagnosis: On Touch—immediate and intermediate. On Sight —immediate and intermediate. On Hearing.—immediate and intermediate. 2. General Diseases. 3. Local Diseases—Diseases of the Ovary. 4. Diseases of the Oviduct. 5. Diseases of the Broad Ligament. 6. Diseases of the Uterus (unimpregnated). 7. Diseases of the Vagina. 8. Diseases of the Vulva. 9. Diseases of the Mam- ma. 10. Functional Diseases, xr. Diseases connected with Pregnancy. 12. Diseases connected with Parturi- tion. 13. Diseases consequent on Parturition. Appendix of Remedies. BY SAME AUTHOR. DYSMENORRHEA. Just Issued. Its Pathology and Treatment. i2mo. Price $2.50 SMITH, RINGWORM. The Diagnosis and Treatment of Ringworm. By Alder Smith, f.r.c.s. With Illustrations. i2mo. Price $1.00 SMITH, ON NURSING. The Efficient Training of Nurses for Hospital and Private Practice. By Wil- liam Robert Smith. Illustrated, izmo. Price $2.00 PUB LICA TIONS. 35 " Students and others interested in the subject of medicine will find a digest of the entire controversy (between the various schools of medicine) presented in this volume."—yournal of Education. " Professor Smythe has succeeded in writing a brief, clear, and interesting sketch of the evolution of medical eccentricities, and of modern homoeopathy, its facts and SMITH, ON CHILDREN. Clinical Studies of Diseases in Children. By Eustace Smith, m.d. i2mo. Price $2.50 MEDICAL HERESIES, HISTORICALLY CONSIDERED. A Series of Critical Essays on the Origin and Evolution of Sectarian Medi- cine, embracing a Special Sketch and Review of Homoeopathy, Past and Pres- ent. By Gonzalvo C. Smythe, a.m., m.d. Professor of the Principles and Practice of Medicine, College of Physicians and Surgeons, Indianapolis, Indi- ana. i2mo. Cloth. Price $1.25 " This book gives, in a small compass, an excellent I history of medicine, from its earliest day to the present time."—Buffalo Medical and Surgical Journal. "Cannot fail to be of interest, not only to the medi- cal profession, but to the general reader."—Baltimore Gazette. " The work is pleasantly written, in an easy, familiar style, and has cost the writer much literary research." fallacies. —Philadelphia Medical Times —New York Medical Journal. SAVAGE, FEMALE PELVIC ORGANS. Author's Edition. The Surgery, Surgical Pathology and Surgical Anatomy of the Female Pelvic Organs. In a Series of Colored Plates taken from Nature, with Commentaries, Notes and Cases. By Henry Savage, m.d., f.r.c.s. New Edition. Issued by arrangement with the Author, from the original Plates. Quarto. [Preparing. SAVORY & MOORE, DOMESTIC MEDICINE. A Condensed Compend of Domestic Medicine, and Companion to the Medi- cine Chest. By Drs. Savory and Moore. Illustrated. i6mo. Price .50 SCHULTZE, OBSTETRICAL PLATES. Obstetrical Diagrams. Life Size. By Prof. B. S. Schultze, m.d., of Berlin. Twenty in the Set. Colored. Price, in Sheets, $15.00; Mounted on Rollers $25.00 SCANZONI, DISEASES OF WOMEN. A Practical Treatise on the Diseases of the Sexual Organs of Women. By Dr. F. W. Von Scanzoni. Translated by A. K. Gardiner, m.d. 8vo. Price $5.00 SIEVEKING, LIFE ASSURANCE. The Medical Adviser in Life Assurance. By E. H. Sieveking, m.d. i2mo. Price $2.00 SHEPPARD, ON MADNESS. Madness, in its Medical, Social and Legal Aspects. A Series of Lectures de- livered at King's Medical College, London. By Edgar Sheppard, m.d. 8vo. Price $2.25 STOCKEN, DENTAL MATERIA MEDICA. Second Edition. The Elements of Dental Materia Medicaand Therapeutics with Pharmacopceia. By James Stocken, d.d.s. Second Edition. i2mo. Price $2.25 The first edition of this book was disposed of in a little less than four months. In making this revision the author has endeavored to make it still more useful by the addition of considerable new matter. SUTTON VOLUMETRIC ANALYSIS. Fourth Edition. A Systematic Handbook of Volumetric Analysis, or the Quantitative Estima- tion of Chemical Substances by Measure, Applied to Liquids Solids and Gases. Rv Francis Sutton, f.c.s. Fourth Edition. Revised and Enlarged with Illus- ny 1 ivrt^v. {Preparing. trations. 8vo. v r & 36 PRESLEY BLAKISTON'S " A valuable book for the general Practitioner who s in want of a practical manual relating especially to diseases of the teeth."—Medical Brief . SEWELL, DENTAL ANATOMY AND SURGERY. A Manual of Dental Anatomy and Surgery, Including the Extraction of Teeth. By H. E. Sewell, d.d.s., m.d. With "j-j Illustrations. i2mo. Price $1.50 " It will be found useful to the general Practitioner in the management of many incidental affections connected with the teeth and mouth, which cannot always be handed over to the specialist."—Pacific Med. yournal. STILLE, ON MENINGITIS. Epidemic Meningitis, or Cerebro-spinal Meningitis. By Alfred Stille, m.d., Professor of Practice at the University of Pennsylvania. 8vo. Price $2.00 " The name of the author is a sufficient guarantee that this monograph is elegant in style, exhaustive of its sub- ject and rich with practical suggestions."—Philadelphia Medical and Surgical Reporter. STOKES, DISEASES OF THE HEART. The Diseases of the Heart and Aorta. By William Stokes, m.d. Thick 8vo. Price $3.00 SWAIN, SURGICAL EMERGENCIES. Surgical Emergencies: Concise Descriptions of the Various Accidents and Emergencies, with Directions for their Treatment. By Wm. Paul Swain, f.r. C.s. Eighty-two Illustrations. i2mo. Price $2.00 Contents.—'Chapter I. Injuries to the Head. II. Injuries to the Eye. III. Injuries to the Mouth, Pharynx, CEsophagus, and Larynx. IV. The Chest. V. The Upper Extremity. VI. The Abdomen. VII. The Pelvis. VIII. The Lower Extremity. IX. Emergencies connected with Parturition. X. Poisoning. XI. Antiseptic Treatment. XII. Apparatus and Dressing. " Many surgeons will thank Dr. Swain for the trouble he has taken to put them easily in possession of this re- fresher of half forgotten knowledge.— The Practitioner. SWERINGEN, PHARMACEUTICAL LEXICON. A Pharmaceutical Lexicon or Dictionary of Pharmaceutical Science. Contain- ing explanations of the various subjects and terms of Pharmacy, with appropriate selections from the Collateral Sciences. Formulae for Officinal, Empirical, and Dietetic Preparations, etc., etc. By Hiram. V. Sweringen, m.d. 8vo. Price, Cloth, $3.00; Leather, $4.00 " It is worthy of a welcome, and sure of a ready recognition of its merits."—London Pharmaceutical yournal. " It will prove of great service to the pharmaceutical student, apprentice, pharmacist, druggist and physician, as a book of ready reference and as an aid to the study of scientific works."—American yournal of Pharmacy. THOMPSON, LITHOTOMY AND LITHOTRITY. Practical Lithotomy and Lithotrity; or, an Inquiry into the best Modes of Removing Stone from the Bladder. By Sir Henry Thompson, f.r.c.s., Emer- itus Professor of Clinical Surgery in University College. Third Edition. 8vo. With 87 Engravings. Price $3.50 " The chapters of most interest are those in which Bigelow's operation is discussed, and the final one, in which is a record of 500 operations for stone in cases of male adults under the author's care. Such a table has never before been compiled by any surgeon."—Lancet. BY SAME AUTHOR. URINARY ORGANS. Diseases of the Urinary Organs. Clinical Lectures. Fifth Londoa Edition. 8vo. With 2 Plates and 71 Engravings. Price $3.50 ON THE PROSTATE. Diseases of the Prostate. Their Pathology and Treatment. Fourth London Edition. 8vo. With numerous Plates. Price $4.00 CALCULOUS DISEASES. The Preventive Treatment of Calculous Disease, and the Use of Solvent Remedies. Second Edition. i6mo. Price $1.00 "Catholic in his investigation of the fruit of the labor of others, cautious in all his deductions, rejecting all spe- cious theories in the effort to obtain practically useful results, as clever with his pen as he is with the sound or lithotrite, one can scarcely wonder that he is'esteemed the master that he is."—American yournal qf Medicat Science. PUBLICA TIONS. 37 TROUSSEAU'S CLINICAL MEDICINE. COMPLETE. In Two Large Royal Octavo Volumes. EMBRACING ALL THE LECTURES CONTAINED IN THE FIVE VOLUME EDITION AS ISSUED BY THE SYDENHAM SOCIETY. Price, handsomely bound in cloth......% 8.00 leather.....10.00 Lectures on Clinical Medicine. Delivered at the Hotel Dieu, Paris, by A. Trousseau, Professor of Clin- ical Medicine to the Faculty of Medicine, Paris, &c, &c. Translated from the Third Revised and Enlarged Edition by P. Victor Bazire, M. D., London and Paris; and John Rose Cormack, M. D., Edinburgh, F. R. S., &c. With a full Index, Table of Contents, &c. Trousseau's Lectures have attained a reputation both in England and in this country far greater than any work of a similar character heretofore written, and, notwithstanding but few medical men could afford to purchase the expensive edition issued by the Sydenham Soci- ety, it has had an extensive sale. In order, however, to bring the work within the reach of al] the profession, the publishers now issue this edition, containing all the lectures as contained in the five-volume edition, at one-half the price. Below are a few only of the many favora- ble opinions expressed of the woik : " It treats of diseases of daily occurrence and of the most vital interest to the practitioner. And we should think any medical library absurdly incomplete now which did not have alongside of Watson, Graves, and Tanner, the ' Clinical Medicine' of Trousseau. ' " The work is full of the results of the richest natural observation, and is the production of one who was enlightened enough to combine with new methods of investigation the vigor- ous and independent ideas of the old physicians whom he so eloquently magnifies. It is an extremely rich and valuable addition to the library of p uysicians and practitioners generally." — London Lancet. " This book furnishes an example of the best kind c f clinical teaching. It deserves to be popularized. We scarcely know of any work better fi ited for presentation to a young man when entering upon the practical work of his life. Tie delineation of the recorded cases it graphic, and their narration devoid of that prolixity w.'iich, desirable as it is for purposes of extended analysis, is highly undesirable when the object is to point to a practical lesson."— London Medical Times and Gazette. " The publication of Trousseau's Lectures furnishes medical men with one of the best practical treatises on disease as seen at the bedside. The conversational style adopted by the author lends animation to the work, and the translator deserves credit for having so wel] preserved the easy and ready style of the original." — British and Foreign Medico-Chi/rut gical Review. " The great reputation of Prof. Trousseau as a practitioner and teacher of Medicine in all its branches, renders the present appearance of his Clinical Lectures particularly welcome." — Medical Press and Circular. " A clever translation of Prof. Trousseau's admirable and exhaustive work, the best book of reference upon the Practice of Medicine." — Indian Medical Gazette. \ ffi PRESLEY BLAKISTON'S TILT, THE CHANGE OF LIFE IN WOMEN. The Change of Life in Health and Disease. A Practical Treatise on the Diseases Incidental to Women at the Decline of Life. By Edward John Tilt, m.d. Third London Edition. 8vo. • Price $3.00 bv same author. UTERINE THERAPEUTICS AND DISEASES OF WOMEN. A Hand-book of Diseases of Women and Uterine Therapeutics. Fourth London Edition. i2mo. Price $3.50 TOMES, DENTAL ANATOMY. New Edition. A Manual of Dental Anatomy, Human and Comparative. By C. S. Tomes, d.d.s. With 179 Illustrations. Second Edition. i2mo. [Preparing^ TOMES, DENTAL SURGERY. A System of Dental Surgery. By John Tomes, f.r.s. The Second Edition, Revised and Enlarged. By C. S. Tomes, d.d.s. With 263 Illustrations. i2mo. Price $5.00 " We rejoice that such books as these (Dr. Tomes' Works) are demanded by the profession, and that the men to write them are furnished by the profession."—Dental Cosmos. TAFT, OPERATIVE DENTISTRY. Third Edition. A Practical Treatise on Operative Dentistry. By Jonathan Taft, d.d.s. Third Revised and Enlarged Edition. Over 100 Illustrations. 8vo. Price, Cloth, $4.25 ; Leather, 5.00 "All the important operations, in all their modifica- I "It is a thorough and complete treatise on the Art tions, are clearly discussed by the author, and the I of Practical Dentistry."—London Medical Times and work is highly practical throughout."—Dental Regis- I Gazette. ter. TANNER, INDEX OF DISEASES. Second Edition. An Index of Diseases and.their Treatment. By Thos. Hawkes Tanner, m.d., f.r.c.p. Sixth Edition. Revised and Enlarged. By W. H. Broadbent, m.d. With Additions. Appendix of Formulae, etc. 8vo. Price $3.00 By this useful hand-book the character of any disease may be determined in a moment, and the general outline of treatment pursued by the best authorities made apparent. *' This work, like others from the gifted author, has | " Finally, a chapter on the climates, countries, mine- already won for itself a reputation." . . . " It is i ral springs, etc., best adapted to the various classes of in truth what its title indicates."—New York Medical j invalids, makes this work the most complete practi- Record. doner's manual that we have yet seen.—Chicago Medi- | cal Tirnes. BY SAME AUTHOR. THE DISEASES OF INFANCY. A Practical Treatise on the Diseases of Infancy and Childhood. Third Edi- tion. Carefully Revised and much Enlarged. By Alfred Meadows, m.d. 8vo. Price $3.00 Recommended as a Text-book at Jefferson Medical College and other schools of Medicine. "One of the most careful, ornate, and accessible I " We consider the views of the author on the subject manuals on the subject."—London Lancet. of therapeutics as rational in the highest degree."— | Boston Medical and Surgical yournal. MEMORANDA OF POISONS. A Memoranda of Poisons and their Antidotes and Tests. Fourth American from the Last London Edition. Revised and Enlarged. Price .75 This most complete Toxicological Manual should be within reach of all physi- cians and pharmacists, and as an addition to every family library, would be the means of saving life and allaying pain when the delay of sending for a physician would prove fatal. PUBLICA TIONS. 39 TIBBETS, MEDICAL ELECTRICITY. A Hand-book of Medical Electricity. Giving full -directions for its Applica- tion, etc. By Herbert Tibbets, m.d. 64 Illustrations. 8vo. Price $1.50 TOLAND, PRACTICAL SURGERY. Lectures on Practical Surgery. By H. H. Toland, m.d., Professor of Surgery University of California. Second Edition. With Additions and Numerous Illus- trations. 8vo. Price, Cloth, $4.50; Leather, $5.00 TRANSACTIONS OF THE COLLEGE OF PHYSICIANS. The Transactions of the College of Physicians of Philadelphia. New Series Vols. 1, 11, in, iv and v. 8vo. Price, per volume, #2.50 TYSON, BRIGHT'S DISEASE AND DIABETES. A Treatise on Diabetes and Bright's Disease. With Especial Reference to Pathology and Therapeutics. By James Tyson, m.d., Professor of Pathology and Morbid Anatomy in the University of Pennsylvania. With Colored Plates and many Wood Engravings. 8vo. Price $3.50 " This volume is the outcome of some fifteen years' j special study and observation, and will be found to be a very well prepared monograph.......His direc- tions are clear and minute.—Med. and Surg. Reporter. " The symptoms are clearly defined, and the treat- ment is exceedingly well described, so that every one reading the book must be profited."—Cincinnati Lan- cet and Clinic. BY SAME AUTHOR. GUIDE TO THE EXAMINATION OF URINE. A Practical Guide to the Examination of Urine. For the use of Physicians and Students. With Colored Plate, and Numerous Illustrations Engraved on Wood. Third Edition. i2mo. Price $1.50 Advantage has been taken, in bringing out a new edition of this work, not only to correct the previous one, but to make such additions of new Facts and Processes as would add to its value without materially increasing its size. " Dr. Tyson commences with a short account of the theory of renal secretion, the physical and chemical charac- ters of the urine, and the reagents and apparatus used in its analysis. Excellent rules are then given for detecting the presence of albumen, sugar, coloring-matters, bile, urea, uric acid, chlorides, phosphates and sulphates ; and minute instructions for approximative and quantitative determination of most of those ingredients by volumetric analysis are supplied."—Philadelphia Medical Times. "We have experienced both pleasure and profit ftom the perusal of this book. It is agreeably written, contains much practical information, and is, we believe, a reliable and satisfactory guide to the clinical examination of airine. We can recommend Dr. Tyson's book as one that amply supplies the clinical needs of the physician."— Dublin yournal of Medical Science. ^ THE CELL DOCTRINE. Second Edition. The Cell Doctrine. Its History and Present State. With a Copious Biblio- graphy of the subject. Illustrated by a Colored Plate and Wood Cuts. Second Edition. 8vo. Price $2.00 TURNBULL, ARTIFICIAL ANESTHESIA. The Advantages and Accidents of Artificial Anaesthesia; Its Employment in the Treatment of Disease; Modes of Administration ; Considering their Rela- tive Risks; Tests of Purity; Treatment of Asphyxia; Spasms of the Glottis; Syncope, etc. By Laurence Turnbull, m.d., ph.g., Aural Surgeon to Jeffer- son College Hospital, etc. Second Edition. Revised and Enlarged. With 27 Illustrations of Various Forms of Inhalers, etc. i2mo. Price $1.50 " Anaesthesia is a subject of great interest and importance to physicians and dentists, and everything that will aid them in better understanding the subject is sought with great avidity. This work we regard as the best aid in the study of the subject, and it presents the subject up to the present hour. —Dental Register. TEALE, DANGERS TO HEALTH. Third Edition. A Pictorial Guide to Domestic Sanitary Defects. By T. Pridjin Teale, m.d., f.r.cs. With Colored Plates. 8vo. Price $3.50 4o PRESLEY BLAKISTON'S VACHER, CHEMISTRY. A Primer of Chemistry, Including Analysis. By Arthur Vacher. l8mo. Price .50 VIRCHOW, POST-MORTEM EXAMINATIONS. Second Edi- tion. Post-mortem Examinations. A Description and Explanation of the Method of Performing them in the Dead House of the Berlin Charite Hospital, with especial reference to Medico-legal Practice. By Prof. Virchow. Translated by Dr.'T. P. Smith. Second Edition. i2mo. With 4 Plates. Price $1.25 " A most useful manual from the pen of a master. . . . . For thorough and systematic method in the performance of post-mortem examinations, there is no guide like it."—Lancet. " Its low price and portability make it accessible and convenient to every surgical registrar and practitioner." —British Medical yournal. WAGSTAFFE, HUMAN OSTEOLOGY. The Student's Guide to Human Osteology. By William Warwick Wag- staffe, f.r.c.s. With 23 Lithographic Plates of the Bones, Showing Muscle Attachments, and 60 Wood Engravings. i2mo. Price $3.00 WALTON, DISEASES OF THE EYE. Third Edition. A Practical Treatise on Diseases of the Eye. By Haynes Walton, m.d. Third Edition. Rewritten and Enlarged. With five plain and three colored full-page Plates; and many other Illustrations, Test Types, etc. Nearly 1200 pages. 8vo. Price $9.00 WARNER, CASE TAKING. The Student's Guide to Medical Case Taking. By Francis Warner, m.d., m.r.c.p., etc. i2mo. Cloth. Price $1.75 General Diseases.—Class i. Class 2. Arthritic Diseases. Diseases of the Nervous System. Of the Vas- cular System. Of the Respiratory System. Of the Digestive System. Of the Liver. Of the Urinary System. Instruction for Case Taking. WATERS, DISEASES OF THE CHEST. Second Edition. The Diseases of the Chest. Their Clinical History, Pathology and Treat- ment. By A. T. H. Waters, m.d., Fellow Royal College of Physicians. With Numerous Illustrative Cases and Lithographic Plates. 8vo. Price $4.00 "The present edition contains new chapters on haemoptysis, hay fever, aortic regurgitation, mitral constriction, thoracic aneurism, and the use of chloral in certain diseases of the chest; other chapters have received additions of cases and remarks on treatment. Some characteristic sphygmographic tracings have also been added."—Bos- ton Medical and Surgical yournal. WEDL, ATLAS OF THE TEETH^ An Atlas of the Pathology of the Teeth. By Prof. Carl Wedl, of Leipsig. 16 Full-page Lithographs, containing many figures, some colored. Quarto. Price $10.00 BY SAME AUTHOR. DENTAL PATHOLOGY. With Special Reference to the Anatomy and Physiology of the Teeth. With Notes by Thos. B. Hitchcock, m.d., of Harvard University. 105 Illustra- trations. 8vo. Price, Cloth, $3.50; Leather, $4.50 WHITTAKER, ON THE URINE. Student's Primer on the Urine. By J. Travis Whittaker, m.d., Physician to Anderson's College Dispensary. With Illustrations Etched on Copper. i6mo. Price $1.50 Physiological Study of Urine—Sensation in Passing. Quantity. Color. Odor. Specific Gravity. History and Behavior. Sediment or Deposits. Chemical Study of Urine—Reaction. Albumen. Chlorides. Ammonia. Urea. Phosphates. Blood. Sugar. Bile. Microscopical Study of Urine and Urinary Deposits—Amorphous Urates. Uric Acid. Triple Phosphates. Phosphate of Lime. Feathery Phosphates. Oxalate of Lime. Urate of Soda and of Ammonia. Cystine. Tyrosine. Leucine. Cholesterine. Epithelium. Fat Globules, etc. "The plates are possessed of great versimilitude, as well as in other respects admirable."—Med. Times. " Neat and concise, and the illustrations are very good testimony of the claim which he makes of the suitability of the etching needle for delineation of microscopical appearances."—Boston Med. arid Surg, yournal. PUBLICA TIONS. 41 WEST, THE DISEASES OF WOMEN. Fourth Edition. Lectures on the Diseases of Women. By Charles West, m.d. Fourth London Edition. Revised and in part re-written by the Author. With Numer- ous Additions by J. Mathews Duncan, m.d., Obstetric Physician to St. Bar- tholomew's Hospital 8vo. Price $5.00 Drs. West and Duncan are, perhaps, the most celebrated London physicians giving attention to the Diseases of Women, and together have made a most com- plete work, either for the physician or student. WILKES, PATHOLOGICAL ANATOMY. Lectures on Pathological Anatomy. By Samuel Wilkes, f.r.s. Secend Edition. Revised and Enlarged by Walter Moxon, m.d., f.r.s., Physician to and Lecturer at Guy's Hospital, London. 8vo. Price $5.00 BY SAME AUTHOR. DISEASES OF THE NERVOUS SYSTEM. Lectures on Diseases of the Nervous System, Delivered at Guy's Hospital, London. New Edition, with Additions, Numerous Illustrative Cases, etc. 8vo. [Preparing. "A book of great value, embodying as it does the results of the experience and observation of one of the most accomplished of the London Hospital Physicians."—American yournal of Medical Science. WRIGHT, ON HEADACHES. Ninth Thousand. Headaches, their Causes, Nature and Treatment. By Henry G. Wright, m.d i2mo'. Price .50 WILSON, ON DRAINAGE. Drainage for Health; or, Easy Lessons in Sanitary Science, with Numerous Illustrations. By Joseph Wilson, m.d., Medical Director United States Navy. One Vol. Octavo. Price $1.00 " Dr. Wilson is favorably known as one of the lead- ing American writers on hygiene and public health. The book deserves popularity."—Medical and Surgi- cal Reporter. " Well written and well illustrated. Attention to its teachings may save much disease and perhaps many lives."—Cincinnati Gazette. " Interesting as well as useful."—Philadelphia Led- ?". BY SAME AUTHOR. NAVAL HYGIENE. Naval Hygiene, or, Human Health and Means for Preventing Disease. With Illustrative Incidents derived from Naval Experience. Illustrated. Second Edition. 8vo., Price $3.00 WILSON, DOMESTIC HYGIENE. Health and Healthy Homes. A Guide to Personal and Domestic Hygiene. By George Wilson, m.d., Medical Officer of Health. Edited by Jos. G. Richardson, m.d., Professor of Hygiene at the University of Pennsylvania. 314 pages. i2mo. Price $1.00 Chapter i.—Introductory, page 17. n. The Human Body, 33. in. Causes of Disease, 66. iv. Food and Diet, 119. v. Cleanliness and Clothing, 169. vi. Exercise, Reoreation and Training, 187. vii. Home and Its Surroundings^ Drainage, Warming, etc., 221. vm. Infectious Diseases and their Prevention, 269. " A m^t iispftil and in every way, acceptable book."— New York Herald. " Marked throughout by a sound, scientific spirit, and an absence of all hasty generalizations, sweeping asser- tionsandabuse of statistics in support of the writer s particular views. . Ve cannot speak too h.ghly of a work which we have read with entire satisfaction.' -Medical Times and Gazette. BY SAME AUTHOR. A HAND-BOOK OF HYGIENE And Sanitary Science. With Illustrations. Fourth Edition. Revised and Enlarged. 8vo. Price £2.75 " Easily understood, and briefly and concisely pre- sented."—Providence yournal. " Will be found of value."—Boston Transcript. " Worthy of praise as a popular statement of the subject."—Boston yournal of Chemistry. " Will be sure to be a harbinger of good in every fam- ily whose good fortune it may be to possess a copy."— Builder and Wood Worker. 42 PRESLEY BLAKISTONS WILSON, HUMAN ANATOMY. Tenth Edition. The Anatomist's Vade-Mecum. General and Special. By Prof. Erasmus Wil- son. Edited by George Buchanan, Professor of Clinical Surgery in the Uni- versity of Glasgow; and Henry E. Clark, Lecturer on Anatomy at the Royal Infirmary School of Medicine, Glasgow. Tenth Edition. With 450 Engravings (including 26 Colored Plates). Crown 8vo. Price $6.00 Recommended as a Text-book at Rush Medical College, Chicago ; Bellevue Hos- pital, New York; St. Louis Medical College; Yale and Dartmouth Schools; and many other Colleges. "The present edition of the 'Anatomist's Vade-mecum,' has been prepared under the same editorial control as the Ninth Edition. " Numerous additional wood cuts have been introduced, and full-page engravings of the bones, which have been drawn and engraved with great care, to secure ac- curacy, and to make them not mere anatomical diagrams, but artistic pictures." BY SAME AUTHOR. HEALTHY SKIN. Eighth Edition. A Practical Treatise on the Skin and Hair; their Preservation and Manage- ment. Eighth Edition. i2mo. Paper. Price $1.00 WILSON, SEA VOYAGES FOR HEALTH. The Ocean as a Health Resort. A Hand-book of Practical Information as to Sea Voyages, for the Use of Tourists and Invalids. By Wm. S. Wilson, l.r.c.p. Lond., m.r.c.s.e. With a Chart showing the Ocean Routes, and Illustrating the Physical Geography of the Sea. Crown 8vo. Price $2.50 Chapter 1. Curative Effects of the Ocean Climate. 2. The Various Health Voyages. 3. Time of Starting— Choosing a Ship. 4. Preliminary Arrangements. 5. Life at Sea. 6. Climate and Weather. 7. Management of the Health at Sea. 8. Occupations and Amusements at Sea. 9. Objects of Interest at Sea. 10. End of the Voyage—Future Plans. 11. The Homeward Voyage. 12. Australia: its Climate, Cities, and Health Resorts. 13. South Africa and its Climate. 14. The Meteorology of the Ocean. Appendix A.—Outfit Required for a Voyage to Australia. B. Names and Addresses of some of the Principal Shipping Firms. "All the information is supplied by, or based upon, the actual experience of the author; and the book may be confidently recommended to all who have to undertake, without previous experience, a sea voyage of any length. Medical men may consult it with advantage, and commend it to those patients whom they may advise to try the effect of a long voyage at sea."—Medical Times and Gazette. " We have read every page of this book, and have derived both instruction and amusement."—Lancet. WELLS, OVARIAN AND UTERINE TUMORS. The Diagnosis and Surgical Treatment of Ovarian and Uterine Tumors. By T. Spencer Wells, m.d. [ To be issued shortly. So long a time having elapsed since Dr. Wells has collected the results of his large experience in book form, the present volume will be eagerly looked for by all interested in this very important subject. WOLFE, ON DISEASES OF THE EYE. A Practical Treatise on Diseases and Injuries of the Eye. Being a Course of Systematic and Clinical Lectures to Students and Medical Practitioners. By M. Wolfe, f.r.c.p.e., Senior Surgeon to the Glasgow Ophthalmic Institution, etc. With 10 Colored Plates, and numerous other Illustrations. Octavo. Price £7.00 WALKER, INTERMARRIAGE. Intermarriage, or, The Mode in which, and the Causes why, Beauty, Health and Intellect result from certain Unions; and Deformity, Disease and Insanity from others. Illustrated. i2mo. Price $1.00 PUB LICA TIONS. 43 WOODMAN and TIDY, MEDICAL JURISPRUDENCE. Forensic Medicine and Toxicology. By W. Bathurst Woodman, m.d., Physician to the London Hospital, and Charles Meymott Tidy, f.c.s., Pro- fessor of Chemistry and Medical Jurisprudence at the London Hospital. With Chromo-Lithographic Plates, representing the Appearance of the Stomach in Poisoning by Arsenic, Corrosive Sublimate, Nitric Acid, Oxalic Acid; the Spectra of Blood and the Microscopic Appearance of Human and other Hairs; and 116 other Illustrations. Large octavo. Price, Cloth, $7.50; Medical Sheep, $8.50; Law Leather, $8.50 " We have no hesitation in pronouncing the work to be one of unusual merit. More readable than Taylor, more systematic in its arrangement, and more practical in its instruction, it will prove to the medical jurist, not less than to the general practitioner, a storehouse of useful knowledge, conveyed in an unusually graphic style."— Dublin yournal of Medical Science. The authors of this truly great work have largely supplied the want felt, sooner or later, by almost every doctor.' —Cincinnati Lancet and Observer. " All the best known works on Medical Jurisprudence have been laid under contribution for the production of the present volume. It contains almost everything that can be found in other works on the subject; but it is no mere compilation. Dr. Woodman and Dr. Tidy have both thought out the subject for themselves, and, with rare industry and acumen, have brought together a mass of facts which is little short of astounding. The book is worthy to take its place alongside of any work on the same subject, and must prove of great use to all who prac- ticein criminal courts, and to all medical practitioners. We have no hesitation in recommending it to our read- ers."—London Lancet. " Altogether the work will rank with the best of its class as a medico-legal hand-book, and cannot fail to gain a wide popularity."—New York Medical Record. " It cannot be otherwise than a valuable contribution to the boundless subject of medical jurisprudence."— Albany Law yournal. "The scope of this book is very wide, and its execution worthy of all commendation."—Philadelphia Legal Intelligencer. WYTHE, ON THE MICROSCOPE. The Microscopist. A Manual of Microscopy and Compendium of the Micro- scopic Sciences, Micro-Mineralogy, Micro-Chemistry, Biology, Histology, and Practical Medicine. By Joseph H. Wythe, a.m., m.d. Fourth Edition. 252 Illustrations. 8vo. Price, Cloth, $5.00; Leather, $6.00 An Index and Glossary have been combined in this edition, so as to be a source of valuable information. Notices of recent additions to the microscope, together with the genera of microscopic plants, have been given in an Appendix. " From what we knew of the author of this work, as a skilled practical Microscopist, a successful teacher of the science, and a practitioner of medicine and surgery oflongand varied experience, we had a right to expect a good book from his hands. Our expectations are fully realized in the volume before us. The style is clear and distinct, and one reads the book with the utmost facility of comprehension. It is the more valuable to the physician and medical student on account of its closer application of the microscope to medical subjects than we find elsewhere. The numerous plates, many of which are beautifully colored, are not to be excelled. We feel proud of it as an American production."— Pacific Medical and Surgical yournal. " This is one of the most valuable text-books on mi- croscopy ever offered to students or practitioners of medicine. This edition has been greatly enhanced in value by the addition of chapters on the use of the microscope in pathology, diagnosis, and etiology, and numerous new illustrations, some of which are from Rindfleisch. " The author very carefully brings out every neces- sary fact and principle relating to the use of the micro- scope, and now that this instrument has become an es- sential part of every practitioner's armamentarium, a practical guide and reference book is also a necessity, and we are fully warranted in reiterating the statement that this is one of the most valuable text-books ever offered to students and practitioners of medicine."— The Cincinnati Lancet and Clinic. BY SAME AUTHOR. DOSE AND SYMPTOM BOOK. Eleventh Edition. The Physician's Pocket Dose and Symptom Book. Containing the Doses and Uses of all the Principal Articles of the Materia Medica, and Original Prepara- tions. Eleventh Revised Edition. - Price, Cloth, $1.00; Leather, with Tucks and Pocket, $1.25 " The chapter on Dietetic Preparations will be found useful to all practicing physicians, most of whom have but little acquaintance with the modeiof preparing the various articles of diet for the sick."—Boston Medical and Surgical yournal. " Many a hard-worked practitioner will find it a useful little work to have on his study table."—Canada Medical and Surgical yournal. 44 PRESLEY BLAKISTON'S PUBLIC A TIONS. WHEELER, MEDICAL CHEMISTRY. Medical Chemistry, Including the Outlines of Organic and Physiological Chemistry. By C. Gilbert Wheeler, m.d. Second Edition. i2mo. Price $3.00 WOAKES, ON DEAFNESS AND GIDDINESS. On Deafness, Giddiness and Noises in the Head. By Edward Woakes, m.d., London, Surgeon to the Ear Department of the Hospital for Diseases of the Throat and Chest. Second Edition. Revised and Enlarged, with additional Illustrations. i2mo. Price $2.50 " This book, although small, is evidently the result of much careful thought and observation. . . We cordially recommend the work as original and suggest- ive, and as being likely to prove very useful in explain- ing both the causation of symptoms otherwise puzzling, and their appropriate treatment."—Practitioner, July, 1879. " The early demand for a fresh edition of Dr. Woakes' volume is a sufficient criticism of its merits. . . . No brief summary of his views could do full justice to the cogency and subtlety of his reasons. We prefer to commend the whole work to the thought- ful perusal of all intelligent medical practitioners who desire to rise above the level of mere routine empiri- cism."—Lancet, August 28th, 1880. ILLUSTRATED BOOKS. MEDICINAL PLANTS. Being Descriptions, with original Figures, of the Principal Plants employed in Medicine, and an account of their Properties and Uses. By Robert Bentley, f.l.s., Professor of Botany in the King's College, and to the Pharmaceutical Society, and Henry Trimens, m.b., f.l.s., late Lecturer on Botany at St. 'Mary's Hospital Medical School. In 42 Parts, each, $2.00, or in 4 vok., large 8vo, with 30p" Colored Plates, bound in half morocco, gilt edged. $90.00 AN ATLAS OF TOPOGRAPHICAL ANATOMY. After Plane Sections of Frozen Bodies. By William Braune, Psofessor of Anatomy in the University of Leipzig. Translated by Edward Bellamy, f.r.c.s., Sur- geon to and Lecturer on Anatomy at Charing Cross Hospital. With 34 Photo- lithographic Plates and 46 Wood cuts. Large imp. 8vo. $10.00 ATLAS OF SKIN DISEASES. Consisting of a Series of Illustrations, with Descriptive Text and Notes upon Treatment. By Tilbury Fox, m.d., f.r.c.p., late Physician to the Department for Skin Diseases in University College Hospital. With 72 Colored Plates, In 18 Parts, each, $2.00 or, 1 Vol., Royal 4to, Cloth. $30.00 AN ATLAS OF HUMAN ANATOMY. Illustrating most of the ordinary Dissections, and many not usually practiced by the Student.. By Rickman J. Godlee, M.S., f.r.c.s., Assistant Surgeon to University College Hospital, and Senior Demonstrator of Anatomy in Universi- ty College. With 48 imp. 4to Colored Plates (112 Figures), and a volume of Ex- planatory Text. $30.00 A COURSE OF OPERATIVE SURGERY. By Christopher Heath, f.r.c.s., Home Professor of Clinical Surgery in Uni- versity College, and Surgeon to the Hospital. With 20 Plates drawn from Nature by M. Leveille, and colored by hand under his direction. 4to. $14.00 ILLUSTRATIONS OF CLINICAL SURGE/RY. Consisting of Plates, Photographs, Wood cuts, Diagrams, etc., etc., illustrat- ing Surgical Diseases, Symptoms, and Accidents; also Operative and other Methods of Treatment, with Descriptive Letterpress. By Jonathan Hutchin- son, f.r.c.s., Senior Surgeon to the London Hospital. Vol. I, containing fas- ciculi I to X, bound, with Appendix and Index. $25.00 Fasciculi XI to XIV. Ready. Each, $2.50 The Microscopist. FOURTH EDITION-. WITH TWO HUNDRED AND FIFTY ILLUSTRATIONS, AND Greatly Enlarged by the Addition of oyer 200 Pages of New Matter. By J. H. WYTHE, A.M., M.D., Professor of Microscopy and Histology in the Medical College of the Pacific, San Francisco, California. This Manual of Microscopy and Compendium of the Microscopic Sciences, Micro-Mineralogy, Micro-Chemistry, Biology, Histology, and Practical Med- icine, in which the Practice of Medicine receives the largest attention, makes this work one of the most complete Text-Books known on the sub- ject. Matters of mere curiosity have been but briefly referred to, while every necessary fact or principle relating to the microscope has been care- fully stated and classified. The chapters on the use of the microscope in Pathology, Diagnosis, and Etiology, which have been added to this edition, have been largely illus- trated with wood-cuts from Rindfleisch. The Index and Glossary have been combined in this edition so as to be a source of valuable information, and notices of recent additions to the mi- croscope, together with the genera of microscopic plants, have been given in an Appendix. No pains have been spared to render this manual a useful companion to the student of Nature, and an aid to the progress of real science. Cloth, $5.00; Sheep, $6.00. "From what we knew of the author of this work, as a skilled practical Microscopist, a successful teacher of the science, and a practitioner of medicine and surgery of long and varied experience, we had a right to expect a good book from his hands. Our ex- pectations are fully realized in the volume before us. In a little over 400 pages he has condensed almost everything of importance relating to the subject. The style, though almost aphorismal, is clear and distinct, and one reads the book with the utmost facility of comprehension. It is the more valuable to the physician and medical student on account of its closer application of the microscope to medical subjects than we find else- where. Too much praise cannot be bestowed on the mechanical execution of the volume. The numerous plates, many of which are beautifully colored, are not to be excelled. Added to this, the large and clear type and the fine quality of paper make it a most comely book. We feel proud of it as an American production, dividing its authorship and execution between the extreme west and east territorial limits of the Republic."— Pacific Medical and Surgical Journal. "This is one of the most valuable text-books on microscopy ever offered to students or practitioners of medicine. This edition has been greatly enhanced in value by the ad- dition of chapters on the use of the microscope in pathology, diagnosis, and etiologyr and numerous new illustrations, some of which are from Rindfleisch. " The author very carefully brings out every necessary fact and principle relating to the use of the microscope, and now that this instrument has become an essential part of every practitioner's armamentarium, a practical guide and reference book is also a ne- cessity and we are fully warranted in reiterating the statement that this is one of the most valuable text-books ever offered to students and practitioners of medicine."—Th*) Cincinnati Lancet and Clinic. P. BLAKISTON, SON & CO., Publishers, PHILADELPHIA. MEDICAL TEXT-BOOKS PUBLISHED AND FOR SALE BY P. Blakiston, Son & Co., 1012 WALNUT STREET, PHILADELPHIA. Day, Diseases of Children. A Practical and Systematic Text-book. 8vo. Cloth, #5.00* leather, #6.00. Mackenzie, Diseases of the Throat and Nose. 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