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der. He states that on several occasions, he has been unable to pass any water for several hours. On the 9th day of June, 1854, I was called to see him, when he stated that he had not passed any urine for two days; that this morning, when making a violent effort to do so, he felt something give way in his belly, and“ felt a snap;" since which he has felt no desire to urinate, but the pain is very great over the belly.
I endeavored to pass a catheter into the bladder, but found it impossible to do so. He was put in a warm bath, a large anodyne administered, and a warm poultice applied over the abdomen.
June 10th. He slept some last night, but otherwise remains in the same state, except that the abdomen was not swollen. I could not make
any other diagnosis than that some portion of the bladder had given way when he felt the "snap;" and that the effusion of urine into the cavity of the abdomen accounted for the subsidence of the desire to make water, and also caused the other symptoms.
I requested Dr. Willard Parker to meet me, who, on examination, concurred with me as to the nature of the case, and of its desperate character.
On consultation, we agreed that the only chance for the man (and that a very small one), was to open the abdomen above the pubis, cut into the bladder, and pass a catheter, if we could, from within out through the penis, and re-establish a passage in that way.
To cut into the bladder from the perineum was useless, as the effusion was above the pelvic fascia; and a puncture through the rectum was impracticable, as the bladder was empty, and could not be felt.
The case was fully stated to the patient, who requested me to "cut
After shaving the pubis, I made an incision about four inches long, from the pubis upward in a line with the linea alba, dividing the fibres of the pyramidalis; then very carefully divided the tendon beneath, and with a director dilated it freely. The urine flowed out abundantly from the wound. There was but little hæmorrhage. The bladder was deep, and firmly contracted bebind the pubis, and so altered in appearance that it could not be recognized as that organ. I pushed up the perineum with one finger, whilst Dr. Parker, with a hook drawing up the bladder, I punctured it with a bistoury; on dilating this opening with the finger, the internal surface was found corrugated and thickened. The opening into the urethra could not be felt, so that the original design of forcing a passage from within outwards, could not be done. Whilst my finger was retained in the bladder, Dr. Parker accordingly passed a grooved sound into the penis, down to the strictured part, and forced it forward until the point was felt by my finger through the thickened coats of the bladder, which were so tough I could not tear it with the nail, but cut upon the end of the sound, with a probepointed bistoury, carefully passed along the finger.
The wound made in the abdomen was brought together by a single suture; a catheter introduced through the false passage made into the bladder, a large anodyne given to the patient, and he placed in bed as soon as the operation was completed; he felt greatly relieved, and soon fell asleep.
June 11th. The patient says he feels pretty comfortable; he only complains of the general soreness of the belly. The urine flows from the wound, and also from the catheter.
June 12th. Had a bad night; pulse, 130; abdomen tender; urine flows as yesterday; bowels not opened; vomits a green matter; skin hot; but says " he shall get well," which opinion he stuck to throughout. Gave him opium grs. iij., with calomel grs. viij., and directed a pill of calomel gr. ij. and opium į gr. to be given every two, three, or four hours, according as he is restless ; diet accordingly, with poultice to abdomen.
June 12th. Passed a more comfortable night; the vomiting has ceased; bowels freely purged; pulse, 130; abdomen tender; wound healing above the suture, whilst the urine flows from the lower part above the pubis, and through the catheter; continue the calomel and opium every four hours. The constant dribbling of the urine over the scrotum has produced excoriation, which annoys the patient more than his other troubles. This was relieved by simple cerate, and the parts protected from the urine by an oiled-silk bag.
June 13th. Patient attacked with violent hiccough, from which he suffers dreadfully. This symptom caused great distress, and continued without intermission for an entire week. Nothing seemed to do any good, and all remedies for it were abandoned, except a pill of opium three or four times a day; the calomel was omitted on account of his gums being sore. The symptoms of peritonitis are subsiding.
June 21st. The subsidence of the hiccough was a great relief. The patient began to show his sufferings. Beef-tea and milk punch were ordered, and a general supporting regimen was followed throughout the remainder of the treatment, with quinine.
A slough came out of the wound above the pubis, about the size of a pullet's egg, leaving a clean, granulating sore, which healed kindly. On the 27th day after the operation, the wound had entirely closed, and the urine passed through the penis in a fuller stream than it has done for years. The patient entirely recovered, and engaged in his laboring business as a journeyman butcher.
I am not aware that a case similar to this is recorded ; cases occasionally occur of ruptured bladder from external violence, which have always proved fatal. Will not the result of this case justify in them a similar operation above the pubis, to allow the escape of the extravasated urine ?
In recording this case I should fail in my duty, did I not acknowl. edge the able assistance rendered during the operation by Professor Willard Parker.
Carcinoma of the Bladder. By W. K. Brown, M.D., of Brooklyn, L. I.
As cases of cancer of the bladder, though not of very rare occurrence, have been but seldom reported in the journals, the following account may not be without interest.
The patient, a clergyman, fifty-six years of age, stout-built, muscular, of high nervous temperament, energetic, active, and abstemious, had enjoyed tolerable health until within the two years previous to November, 1853, when I first saw him professionally, and but once. His complaints then were general debility, loss of appetite, much flatulence, dull pain in the back, especially on the region of the kidneys; calls to pass water very frequent, but without pain or straining. Urine feebly acid, coagulable by the usual tests, and containing fluid blood, with small cylindric coagula-specific gravity not noted. Informing him that he probably had congestion of the kidneys, and would be injured rather than improved by the stimulating diuretics which he seemed disposed to make use of, I took my leave; nor did he again come under my observation until the 18th of October last, when the following symptoms were noted: no pain on the region of the kidneys, even on pressure ; dull pain deep in the left pelvis and over the pubis ; and a most violent, agonizing paroxysmal pain opposite the sacrum and last lumbar vertebra, which he described by the terms, cutting, wrenchirg, as if the bones were being torn asunder. He had passed two and a half pints of
urine in the preceding twenty-four hours; a small quantity only at once, and with great straining and pain, which he refers to the neck of the bladder and urethra. Under the microscope the urine shewed blood discs, oil globules, crystals of the triple phosphate, and epithelial scales. At this time there are neither pus nor mucous corpuscles to be seen ; specific gravity 1026. On examination per rectum, the tissues anteriorly so far as they could be reached by the finger, were found to be of almost schirrous hardness, including the prostate, the limits of which were not well defined; pulse 80—no fever; appetite and digestion good. He had been sounded for calculus some months before, but without discovering any.
On carefully considering all the circumstances of the case, I concluded that the affection of the kidneys, of whatever nature it might be, was of but little importance compared with the later and more formidable disease of the bladder. Nor could I imagine that the patient's extreme sufferings could be due to a simple cystitis, acute or chronic; the duration of the disease in the one case, and the absence of mucus in the urine in the other, with the remarkable induration of the posterior wall of the bladder, forbidding such a supposition. Reserving for the time an opinion as to the exact nature of this disease of the bladder, the present and pressing indication was to relieve the patient's sufferings, it being obvious that unless they were mitigated, he could not long survive. Ordered a large poultice of ground flaxseed to the lower part of the abdomen for the night, and twenty drops of Majendie's Solution.
October 22d.-Patient, who was so dull and desponding yesterday, is animated and cheerful to-day-has bad, for him, a good night-slept two hours without being disturbed, and passed water not more than four of five times, instead of fifteen to twenty, as he has done for many previous nights-thinks the morphine will cause him headache and loss of appetite. A suppository, of belladonna and morph. sulph. was now substituted, poultices and fomentations continued, and infus. calumbo with nitric acid ordered. To assuage the lumbar pain, a liniment of chloroform and tinct. of aconite was directed; diet to be generous, with light wine, if desired.
Nov. 1st. Though the patient has been well supported by a good diet, and his pains controlled by opiates, his strength has visibly declined. Pulse 90 and weak; slight subsultus-hemorrhage from the bladder, amounting to more than a half-pint in the last twenty-four hours; all the water passed contains blood in almost equal proportion. Urine is neutral: contains pus globules and crystals of triple phosphate, with a few large oil globules. Complains less of lumbar pain, but suffers intensely from pain referred to the fundus of the bladder, and perineum. Considering the disease to be a bleeding fungus of the bladder, and therefore utterly incurable, the palliative treatment only was continued, and an attempt made to moderate the hæmorrhage by gallic acid in mucilage, five grains every two hours, but without effect.
Nov. 3d. Dr. G. Buck, of New York, now saw the patient in consultation, and considered it a case of cancer of the bladder. Gallic acid, tinct. ferri, sesquichlorid. and other styptics, having failed to stop the flow of blood, resort was had to an alum injection into the bladder, 3 j. to a pint of tepid water; injection gave no great pain, but decidedly moderated the flow of blood, which soon after nearly disappeared.
Nov. 8th. About this time, patient was seen by a medical friend of the family, who considered the case to be an “acute, supervening on a chronic inflammation of the bladder," and advised the application of leeches, &c., &c. From this time the patient rapidly declined, and on the morning of the 18th, when my attendance ceased, it was evident that he could not continue more than three or four days. He expired on the 23d.
Autopsy.-Forty hours after death. Present, Drs. Wendell, Parker, Bulkley, Ball, Enos, and others. External appearance of body natural, but rather sallow, fat on the abdominal walls about one and a half inches thick. The bladder extends to within an inch and a half of the umbilicus, bring distended with eight or ten ounces of old and somewhat bloody urine. The coats were thickened, and the inner surface was of a dark brown or blackish color, except a spot (five inches in diameter, when the bladder was laid open) embracing the orifices of the urethra, and of both ureters. This spot was circular in shape, with a well-defined and elevated margin, and presented a surface composed of soft and raggedly uneven elevations and depressions. Four-fifths of this spot were of a dark-bluish gray color, and the other fifth was of a dirty cream colour or drab.
The left kidney was about half the natural size, and was lobulated like a cirrhosed liver. Its capsule was opaque and thickened, and several of the pyramids were obliterated; the cortical portion nearly gone, being less than a line in thickness. The mucous membrane lining the pelvis was opaque, and very much thickened, the whole showing the effects