[1] The early Greek navigators gave it the epithet of _axenus_, i.e.
unfriendly to strangers, but as Greek colonies sprang up on the
shores this was changed to _euxinus_, friendly to strangers.
BLACK SEA (Russ. _Chernomorskaya_), a military district of the province of
Kuban, formerly an independent province of Transcaucasia, Russia; it
includes the narrow strip of land along the N.E. coast of the Black Sea
from Novorossiysk to the vicinity of Pitsunda, between the sea and the
crest of the main range of the Caucasus. Area, 2836 sq. m. Pop. (1897)
54,228; (1906, estimate) 71,900. It is penetrated by numerous spurs of
this range, which strike the sea abruptly at right angles to the coast,
and in many cases plunge down into it sheer. Owing to its southern
exposure, its sheltered position, and a copious rainfall, vegetation, in
part of a sub-tropical character, grows in great profusion. In
consequence, however, of the mountainous character of the region, it is
divided into a large number of more or less isolated districts, and there
is little intercourse with the country north of the Caucasus, the passes
over the range being few and difficult (see CAUCASUS). But since the
Russians became masters of this region, its former inhabitants (Circassian
tribes) have emigrated in thousands, so that the country is now only
thinly inhabited. It is divided into three districts--Novorossiysk, with
the town (pop. in 1897, 16,208) of the same name, which acts as the
capital of the Black Sea district; Velyaminovsk; and Sochi. Novorossiysk
is connected by rail, at the west end of the Caucasus, with the
Rostov-Vladikavkaz line, and a mountain road leads from Velyaminovsk (or
Tuapse) to Maikop in the province of Kuban.
BLACKSTONE, SIR WILLIAM (1723-1780), English jurist, was born in London,
on the 10th of July 1723. His parents having died when he was young, his
early education, under the care of his uncle, Dr Thomas Bigg, was
obtained at the Charterhouse, from which, at the age of fifteen, he was
sent to Pembroke College, Oxford. He was entered in the Middle Temple in
1741. In 1744 he was elected a fellow of All Souls' College. From this
period he divided his time between the university and the Temple, where
he took chambers in order to attend the law courts. In 1746 he was
called to the bar. Though but little known or distinguished as a
pleader, he was actively employed, during his occasional residences at
the university, in taking part in the internal management of his
college. In May 1749, as a small reward for his services, and to give
him further opportunities of advancing the interests of the college,
Blackstone was appointed steward of its manors. In the same year, on the
resignation of his uncle, Seymour Richmond, he was elected recorder of
the borough of Wallingford in Berkshire. In 1750 he became doctor of
civil law. In 1753 he decided to retire from London work to his
fellowship and an academical life, still continuing the practice of his
profession as a provincial counsel.
His lectures on the laws of England appear to have been an early and
favourite idea; for in the Michaelmas term immediately after he
abandoned London, he entered on the duty of reading them at Oxford; and
we are told by the author of his _Life_, that even at their
commencement, the high expectations formed from the acknowledged
abilities of the lecturer attracted to these lectures a very crowded
class of young men of the first families, characters and hopes. Bentham,
however, declares that he was a "formal, precise and affected
lecturer--just what you would expect from the character of his
writings--cold, reserved and wary, exhibiting a frigid pride." It was
not till the year 1758 that the lectures in the form they now bear were
read in the university. Blackstone, having been unanimously elected to
the newly-founded Vinerian professorship, on the 25th of October read
his first introductory lecture, afterwards prefixed to the first volume
of his celebrated _Commentaries_. It is doubtful whether the
_Commentaries_ were originally intended for the press; but many
imperfect and incorrect copies having got into circulation, and a
pirated edition of them being either published or preparing for
publication in Ireland, the author thought proper to print a correct
edition himself, and in November 1765 published the first volume, under
the title of _Commentaries on the Laws of England_. The remaining parts
of the work were given to the world in the course of the four succeeding
years. It may be remarked that before this period the reputation which
his lectures had deservedly acquired for him had induced him to resume
practice in London; and, contrary to the general order of the
profession, he who had quitted the bar for an academic life was sent
back from the college to the bar with a considerable increase of
business. He was likewise elected to parliament, first for Hindon, and
afterwards for Westbury in Wilts; but in neither of these departments
did he equal the expectations which his writings had raised. The part he
took in the Middlesex election drew upon him many attacks as well as a
severe animadversion from the caustic pen of "Junius." This circumstance
probably strengthened the aversion he professed to parliamentary
attendance, "where," he said, "amidst the rage of contending parties, a
man of moderation must expect to meet with no quarter from any side." In
1770 he declined the place of solicitor-general; but shortly afterwards,
on the promotion of Sir Joseph Yates to a seat in the court of common
pleas, he accepted a seat on the bench, and on the death of Sir Joseph
succeeded him there also. He died on the 14th of February 1780.
The design of the _Commentaries_ is exhibited in his first Vinerian
lecture printed in the introduction to them. The author there dwells on
the importance of noblemen, gentlemen and educated persons generally
being well acquainted with the laws of the country; and his treatise,
accordingly, is as far as possible a popular exposition of the laws of
England. Falling into the common error of identifying the various
meanings of the word law, he advances from the law of nature (being
either the revealed or the inferred will of God) to municipal law, which
he defines to be a rule of civil conduct prescribed by the supreme power
in a state commanding what is right and prohibiting what is wrong. On
this definition he founds the division observed in the _Commentaries_.
The objects of law are rights and wrongs. Rights are either rights of
persons or rights of things. Wrongs are either public or private. These
four headings form respectively the subjects of the four books of the
_Commentaries_.
Blackstone was by no means what would now be called a scientific jurist.
He has only the vaguest possible grasp of the elementary conceptions of
law. He evidently regards the law of gravitation, the law of nature, and
the law of England, as different examples of the same principle--as
rules of action or conduct imposed by a superior power on its subjects.
He propounds in terms the doctrine that municipal or positive laws
derive their validity from their conformity to the so-called law of
nature or law of God. "No human laws," he says, "are of any validity if
contrary to this." His distinction between rights of persons and rights
of things, implying, as it would appear, that things as well as persons
have rights, is attributable to a misunderstanding of the technical
terms of the Roman law. In distinguishing between private and public
wrongs (civil injuries and crimes) he fails to seize the true principle
of the division. Austin, who accused him of following slavishly the
method of Hale's _Analysis of the Law_, declares that he "blindly adopts
the mistakes of his rude and compendious model; missing invariably, with
a nice and surprising infelicity, the pregnant but obscure suggestions
which it proffered to his attention, and which would have guided a
discerning and inventive writer to an arrangement comparatively just."
By the want of precise and closely-defined terms, and his tendency to
substitute loose literary phrases, he falls occasionally into
irreconcilable contradictions. Even in discussing a subject of such
immense importance as equity, he hardly takes pains to discriminate
between the legal and popular senses of the word, and, from the small
place which equity jurisprudence occupies in his arrangement, he would
scarcely seem to have realized its true position in the law of England.
Subject, however, to these strictures the completeness of the treatise,
its serviceable if not scientific order, and the power of lucid
exposition possessed by the author demand emphatic recognition.
Blackstone's defects as a jurist are more conspicuous in his treatment
of the underlying principles and fundamental divisions of the law than
in his account of its substantive principles.
Blackstone by no means confines himself to the work of a legal
commentator. It is his business, especially when he touches on the
framework of society, to find a basis in history and reason for all the
most characteristic English institutions. There is not much either of
philosophy or fairness in this part of his work. Whether through the
natural conservatism of a lawyer, or through his own timidity and
subserviency as a man and a politician, he is always found to be a
specious defender of the existing order of things. Bentham accuses him
of being the enemy of all reform, and the unscrupulous champion of every
form of professional chicanery. Austin says that he truckled to the
sinister interests and mischievous prejudices of power, and that he
flattered the overweening conceit of the English in their own
institutions. He displays much ingenuity in giving a plausible form to
common prejudices and fallacies; but it is by no means clear that he was
not imposed upon himself. More undeniable than the political fairness of
the treatise is its merits as a work of literature. It is written in a
most graceful and attractive style, and although no opportunity of
embellishment has been lost, the language is always simple and clear.
Whether it is owing to its literary graces, or to its success in
flattering the prejudices of the public to which it was addressed, the
influence of the book in England has been extraordinary. Not lawyers
only, and lawyers perhaps even less than others, accepted it as an
authoritative revelation of the law. It performed for educated society
in England much the same service as was rendered to the people of Rome
by the publication of their previously unknown laws. It is more correct
to regard it as a handbook of the law for laymen than as a legal
treatise; and as the first and only book of the kind in England it has
been received with somewhat indiscriminating reverence. It is certain
that a vast amount of the constitutional sentiment of the country has
been inspired by its pages. To this day Blackstone's criticism of the
English constitution would probably express the most profound political
convictions of the majority of the English people. Long after it has
ceased to be of much practical value as an authority in the courts, it
remains the arbiter of all public discussions on the law or the
constitution. On such occasions the _Commentaries_ are apt to be
construed as strictly as if they were a code. It is curious to observe
how much importance is attached to the _ipsissima verba_ of a writer who
aimed more at presenting a picture intelligible to laymen than at
recording the principles of the law with technical accuracy of detail.
See also the article ENGLISH LAW.
BLACK VEIL, in the Roman Catholic Church, the symbol of the most
complete renunciation of the world and adoption of a nun's life. On the
appointed day the nun goes through all the ritual of the marriage
ceremony, after a solemn mass at which all the inmates of the convent
assist. She is dressed in bridal white with wreath and veil, and
receives a wedding-ring, as spouse of the Church. Afterwards she
presides at a wedding-breakfast, at which a bride-cake is cut. She thus
bids adieu to all her friends, and having previously taken the white
veil, the betrothal, she now assumes the black, and for ever forswears
the world and its pleasures. Her hair is cut short, and her bridal robes
are exchanged for the sombre religious habit. Her wedding-ring, however,
she continues to wear, and it is buried with her.
BLACKWATER, the name of a number of rivers and streams in England,
Scotland and Ireland. The Blackwater in Essex, which rises near Saffron
Walden, has a course of about 40 m. to the North Sea. The most important
river of the name is in southern Ireland, rising in the hills on the
borders of the counties Cork and Kerry, and flowing nearly due east for
the greater part of its course, as far as Cappoquin, where it turns
abruptly southward, and discharges through an estuary into Youghal Bay.
The length of its valley (excluding the lesser windings of the river)
is about 90 m., and the drainage area about 1300 sq. m. It is navigable
only for a few miles above the mouth, but its salmon fisheries are both
attractive to sportsmen and of considerable commercial value. The
scenery of its banks is at many points very beautiful.
BLACKWATER FEVER, a disease occurring in tropical countries and
elsewhere, which is often classed with malaria (q.v.). It is
characterized by irregular febrile paroxysms, accompanied by rigors,
bilious vomiting, jaundice and haemoglobinuria (Sambon). It has a wide
geographical distribution, including tropical Africa, parts of Asia, the
West Indies, the southern United States, and--in Europe--Greece, Sicily
and Sardinia; but its range is not coextensive with malaria. Malarial
parasites have occasionally been found in the blood. Some authorities
believe it to be caused by the excessive use of quinine, taken to combat
malaria. This theory has had the support of Koch, but it is not
generally accepted. If it were correct, one would expect blackwater
fever to be regularly prevalent in malarial countries and to be more or
less coextensive with the use of quinine, which is not at all the case.
It often resembles yellow fever, but the characteristic black vomit of
yellow fever rarely occurs in blackwater fever, while the black urine
from which the latter derives its name is equally rare in the former.
According to the modern school of tropical parasitology, blackwater
fever is neither a form of malaria nor produced by quinine, but a
specific disease due to a protozoal parasite akin to that which causes
the redwater fever of cattle.
BLACKWELL, THOMAS (1701-1757), Scottish classical scholar, was born at
Aberdeen on the 4th of August 1701. He took the degree of M.A. at the
Marischal College in 1718. He was appointed professor of Greek in 1723,
and was principal of the institution from 1748 until his death on the
8th of March 1757. In 1735 his first work, _An Inquiry into the Life and
Writings of Homer_, was published anonymously. It was reprinted in 1736,
and followed (in 1747) by _Proofs of the Enquiry into Homer's Life and
Writings_, a translation of the copious notes in foreign languages which
had previously appeared. This work, intended to explain the causes of
the superiority of Homer to all the poets who preceded or followed him,
shows considerable research, and contains many curious and interesting
details; but its want of method made Bentley say that, when he had gone
through half of it, he had forgotten the beginning, and, when he had
finished the reading of it, he had forgotten the whole. Blackwell's next
work (also published anonymously in 1748) was _Letters Concerning
Mythology_. In 1752 he took the degree of doctor of laws, and in the
following year published the first volume of _Memoirs of the Court of
Augustus_; the second volume appeared in 1755, the third in 1764
(prepared for the press, after Blackwell's death, by John Mills). This
work shows considerable originality and erudition, but is even more
unmethodical than his earlier writings and full of unnecessary
digressions. Blackwell has been called the restorer of Greek literature
in the north of Scotland; but his good qualities were somewhat spoiled
by pomposity and affectation, which exposed him to ridicule.
BLACKWOOD, WILLIAM (1776-1834), Scottish publisher, founder of the firm
of William Blackwood & Sons, was born of humble parents at Edinburgh on
the 20th of November 1776. At the age of fourteen he was apprenticed to
a firm of booksellers in Edinburgh, and he followed his calling also in
Glasgow and London for several years. Returning to Edinburgh in 1804, he
opened a shop in South Bridge Street for the sale of old, rare and
curious books. He undertook the Scottish agency for John Murray and
other London publishers, and gradually drifted into publishing on his
own account, removing in 1816 to Princes Street. On the 1st of April
1817 was issued the first number of the _Edinburgh Monthly Magazine_,
which on its seventh number, bore the name of _Blackwood's_ as the
leading part of the title. "Maga," as this magazine soon came to be
called, was the organ of the Scottish Tory party, and round it gathered
a host of able writers. William Blackwood died on the 16th of September
1834, and was succeeded by his two sons, Alexander and Robert, who
added a London branch to the firm. In 1845 Alexander Blackwood died, and
shortly afterwards Robert.
A younger brother, John Blackwood (1818-1879), succeeded to the
business; four years later he was joined by Major William Blackwood, who
continued in the firm until his death in 1861. In 1862 the major's elder
son, William Blackwood (b. 1836), was taken into partnership. John
Blackwood was a man of strong personality and great business
discernment; it was in the pages of his magazine that George Eliot's
first stories, _Scenes of Clerical Life_, appeared. He also inaugurated
the "Ancient Classics for English readers" series. On his death Mr
William Blackwood was left in sole control of the business. With him
were associated his nephews, George William and J.H. Blackwood, sons of
Major George Blackwood, who was killed at Maiwand in 1880.
See _Annals of a Publishing House; William Blackwood and his Sons_ ...
(1897-1898), the first two volumes of which were written by Mrs
Oliphant; the third, dealing with John Blackwood, by his daughter, Mrs
Gerald Porter.
BLADDER (from A.S. _blaeddre_, connected with _blawan_, to blow, cf.
Ger. _blase_), the membranous sac in animals which receives the urine
secreted from the kidneys. The word is also used for any similar sac,
such as the gall-bladder, the swim-bladder in fishes, or the small
vesicle in various seaweeds.
BLADDER AND PROSTATE DISEASES. The urinary bladder in man (for the
anatomy see URINARY SYSTEM), being the temporary reservoir of the renal
secretion, and, as such, containing the urine for longer or shorter
periods, is liable to various important affections. These are dealt with
in the first part of this article. The diseases of the prostate are so
intimately allied that they are best considered, as in the subsequent
section, as part of the same subject.
_Diseases of the Bladder._
Cystitis.
_Cystitis_, or inflammation of the bladder, which may be acute or
chronic, is due to the invasion of the mucous lining by micro-organisms,
which gain access either from the urethra, the kidneys or the
blood-stream. It is easy to see how the diplococci of gonorrhoea may
infect the bladder-membrane by direct extension of the inflammation, and
how the bacilli which are swarming in the neighbouring bowel may find
access to the urethra or bladder when the intervening tissues have been
rendered penetrable by a wound or by inflammation. Sometimes, however,
especially in the female, the germs from the large intestine enter the
bladder by way of the vulva and the urethra.
Any condition leading to disturbance of the function of the bladder,
such as enlargement of the prostate, stricture of the urethra, stone, or
injury, may cause cystitis by preparing the way for bacillary invasion.
The bacilli of tuberculosis and of typhoid fever may set up cystitis by
coming down into the bladder from the kidneys with the urine, or they
reach it by the blood-stream, or invade it by the urethra. Another way
of cystitis being set up is by the introduction of the germs of
suppuration by a catheter or bougie sweeping them in from the urethra;
or the instrument itself may be unsterilized and dirty and so may
introduce them. It used formerly to be thought that wet or cold was
enough to cause inflammation of the bladder, but the probability is that
this acts only by lowering the resistance of the lining membrane of the
bladder, and preparing it for the invasion of the germs which were
merely waiting for an opportunity. In the same way, gout or injury may
lead to the lurking bacilli being enabled to effect their attack. But in
every case disease-germs are the cause of the trouble, and they may be
found in the urine. The first effect of inflammation is to render the
bladder irritable, so that as soon as a few drops of urine have
collected, the individual has intense or uncontrollable desire to
micturate. The effort may be very painful and may be accompanied by
bleeding from the overloaded blood-vessels of the inflamed membrane. In
addition to blood, pus is likely to be found in the urine, which by this
time is alkaline and ammoniacal, and teeming with micro-organisms. As
regards _treatment_, the patient should be at once sent to bed in a warm
room, and should sit several times a day in a very hot hip-bath. When
he has got back to bed, a fomentation under oil-silk, or some other
waterproof material, should be placed over the lower part of the
abdomen. The diet should be milk (diluted with hot or cold water),
barley-water, and bread and butter; no alcoholic drink should be
allowed. If the urine is acid, bicarbonate of soda may be given, or
citrate of soda; if alkaline, urotropine--a derivative of formic
aldehyde--may prove a useful urinary disinfectant. If the straining and
distress are great, a suppository of 1/4 or 1/2 a grain of morphia may
be introduced into the rectum every two or three hours. The bowels must
be kept freely open. If the urine is foul, the bladder should be
frequently washed out by a soft catheter and two or three feet of
india-rubber tubing with a funnel at the other end, weak and abundant
hot lotions of Sanitas or Condy's fluid being used.
_Chronic cystitis_ is the condition left when the acute symptoms have
passed away, but it is liable at any moment to resume the acute
condition. If the cystitis is very intractable, refusing to yield to hot
irrigations, and to washings with nitrate of silver lotion, it may be
advisable to open the bladder from the front, and to explore, treat,
drain and rest it.
In _tuberculous cystitis_ there is added to the symptoms the discovery
of the bacilli of tuberculosis in the urine, and cystoscopic examination
may reveal the presence of tubercles of the mucous membrane or even of
ulceration. The patient is probably losing weight, and he may present
foci of tuberculosis at the back of the testicle, the lung or kidney, or
in a joint or bone, or in a lymphatic gland. _Treatment_ is rebellious
and unpromising. Washings and lotions give but temporary relief, and if
the bladder is opened for rest, and for a more direct treatment, the
germs of suppuration may enter, and, working in conjunction with the
bacilli, may cause great havoc. Koch's tuberculin treatment should
certainly be given a trial. This consists of the injection into the body
of an emulsion of dead tubercle bacilli which have been sterilized by
heat. As a result of this injection the blood sets to work to form an
"opsonin"--a protective material which so modifies the disease-germs as
to render them attractive to the white corpuscles of the patient's blood
(phagocytes), which then seize upon and destroy them. Sir A.E. Wright
has devised a delicate method of examination of the blood (the
calculation of the opsonic index) which tells when the tuberculin
injections should be resorted to and when withheld (see BLOOD).
Stone.
_Calculi and Gravel._--Uric acid is deposited from the urine either as
small crystals resembling cayenne pepper, or else, in combination with
soda and ammonia, as an amorphous "brick-dust" deposit, which, on
cooling, leaves a red stain on the bottom of the vessel, soluble in hot
water. These substances are derived from the disintegration of
nitrogenized food taken in excess of demand, and from the breaking down
of the human tissues. They occur therefore in fevers, in wasting
diseases, and in the normal subject after excessive muscular exercises,
especially if these exercises have been accompanied with so much
perspiration that the excess of water from the blood has escaped by the
skin rather than by the kidneys. The abundance of this deposit is in
accordance with the amount of heat developed and work done in the body,
and corresponds with the dust and ashes raked out of the fire-box of the
locomotive after a long run. But supposing that the uric acid debris
continues to be excessive, the risk of the formation of renal or vesical
calculi becomes considerable, and it may be advisable to place the
patient on a restricted nitrogenized diet, to induce him to drink large
quantities of water, and to keep his bowels so loose with watery
laxatives, such as Epsom salts or sulphate of soda, that the waste
products of his body are made to escape by the bowels rather than by the
kidneys. In addition to the salts just mentioned, an occasional dose of
blue pill will prove helpful. A course of treatment at Contrexeville or
Carlsbad may be taken with advantage.
Alkaline urine is unable to hold the phosphates of ammonia and magnesia
in solution, so they are deposited in abundance either in the kidney or
bladder. If the voided urine is allowed to stand in a tall glass they
sink to the bottom with pus and mucus in a cloudy deposit. To remedy
this condition it is necessary to treat the cystitis with which the
bacterial decomposition of the urine is associated. It may be that a
calculus of acid urine, such as one of uric acid or oxalate of lime, has
been resting in the bladder and keeping up incessant irritation, and
that the micro-organisms of decomposition or suppuration have found
their way to the mucous lining of the bladder from either the bowel, the
urethra or the blood-stream; undergoing cultivation there they break up
the urea into carbonate of ammonia and so render the urine alkaline.
This alkaline urine deposits its phosphates, which light upon the
calculus and encrust it with a mortary shell, which may go on increasing
in size until it may even fill the bladder. Sometimes the nucleus of a
calculus is a chip of bone or a blood-clot, or some foreign substance
which has been introduced into the bladder. Sooner or later the urine
becomes alkaline and the calculus is encrusted with lime salts.
When urine contains a larger amount of chemical constituents than it can
conveniently hold in solution, a certain quantity crystallizes out, and
may be deposited in the kidney or in the bladder. If the crystals run
together in the kidney the resulting concretion may either remain in
that organ or may find its way into the bladder, where it may remain to
form the nucleus of a larger vesical calculus, or, especially in the
case of females, it may, while still small, escape from the bladder
during micturition.
In children, in whom there is a rapid disintegration of nitrogenized
tissues, a uric acid calculus in escaping from the bladder may block the
urethra and give rise to sudden retention of urine. On introducing a
metal "sound," the surgeon may strike the stone, and if it happens to be
near the bladder he may push it back and subsequently remove it by
crushing. But if it has made its way some distance along the urethra, so
that he can feel it from the outside, he should remove it by a clean
incision.
A stone in the bladder worries the nerves of the mucous membrane, and,
giving them the impression that the bladder contains much water, causes
the desire and need for micturition to be constant. The irritation
causes an excessive secretion of mucus, just as a piece of grit under
the eyelid causes a constant running from the eye. So the urine, if
allowed to stand, gives a copious deposit. During micturition the
contracting bladder bruises its congested blood-vessels against the
stone, so that towards the end of micturition blood appears in the
urine. Lastly, cystitis occurs, and the urine contains fetid pus. A
stone in the bladder gives rise to pain at the end of the penis, and it
is apt suddenly to stop the flow of urine during micturition.
The association of any of these symptoms leads the surgeon to suspect
the presence of a stone in the bladder, and he confirms his suspicions
by introducing a slender steel rod, a "sound," by which he strikes and
feels the stone. Further confirmation may be obtained by the help of the
X-rays, or, in the adult, by using a cystoscope. In a child the stone
may often be felt by a finger in the rectum, the front of the bladder
being pressed by a hand on the lower part of the abdomen. The
_cystoscope_ is a straight, hollow metal tube about the size of a long
cedar pencil, which the surgeon introduces into the adult bladder, which
has already been filled with warm boracic lotion. Down the tube run two
fine wires which control a minute electric lamp at the bladder end of
the instrument. At that end also is a small glass window which prevents
the fluid escaping by the tube, and also a prism; at the other end of
the tube is an eye-piece. By the use of this slender speculum the
practised surgeon can recognize the presence of tubercle or tuberculous
ulceration of the bladder, stone, or other foreign material, and
innocent or malignant growths. He can also watch the urine entering the
bladder by the openings of the ureters, and determine from which kidney
blood or pus is coming.
The _treatment_ of stone in the bladder is governed by various
conditions. Speaking generally, the surgeon prefers to introduce a
lithotrite and crush the stone into small fragments, and then to flush
out the fragments by using a full-sized, hollow metal catheter and an
india-rubber wash-bottle. Even in children this operation may generally
be adopted with success, the stone being crushed to atoms and the
fragments being washed out to the last small chip. But if the stone is
a very hard one (as are some of the oxalate of lime calculi), or if it
is very large, or if the bladder or the prostate gland is in a state of
advanced disease, or if the urethra is not roomy enough to admit
instruments of adequate calibre, the crushing operation (_lithotrity_)
must be deemed unsuitable, and the stone must be removed by a cutting
operation (_lithotomy_).
_Lithotomy_.--Cutting for stone has been long practised; but up to the
beginning of the 19th century it was performed only by a few men, who,
bolder than their contemporaries, had specially worked at that operation
and had attained celebrity as skilful lithotomists. Patients went long
distances to be operated on by them, and certain of the older surgeons,
as William Cheselden, performed a large number of operations with most
excellent results. The operation was by an incision from the perineum,
and is ordinarily spoken of as _lateral_ lithotomy. It was splendidly
designed, and gave good results, especially in children. But it is now a
thing of the past, having almost entirely given place to the _high_ or
_supra-pubic_ operation. In the high operation the patient, being duly
prepared, is placed upon his back and the bladder is washed out with hot
boracic lotion, and when the lotion returns quite clean a final
injection is made until the bladder is felt rising above the pubes. Then
the india-rubber tube is removed from the silver catheter by which the
injection has been made, and the end of the catheter is plugged by a
spigot. An incision is then made in the middle line of the abdomen over
the bladder region. The incision must be kept as low as possible, so
that the bladder may be reached below the peritoneum, which, higher up,
gives it an external, serous coat. As the bladder is approached, a good
many veins are seen to be in the way, some of which have to be wounded.
The bladder-wall is recognized by its coarse network of pale muscular
fibres, through which, on each side of the middle line, a strong suture
is passed, so that when the bladder is opened and the lotion comes
rushing out, the opening which has been made into the bladder may not
sink into the depths of the pelvis. A finger introduced into the bladder
makes out the exact size and position of the stone, or stones, and the
removal is effected by special forceps. Bleeding having ceased, the
bladder-wound is partly or entirely closed by sutures and allowed to
fall into the pelvis, the catheter having been removed. It is advisable
to leave a drainage tube in the abdominal wound for a while, so that if
urine leaks from the bladder-wound it may find a ready escape to the
dressings.
_Litholapaxy_.--Lithotrity consists of two parts--the crushing of the
stone, and the removal of the detritus. The two stages are now carried
out at one "sitting," without an interval being allowed between them, as
was formerly the practice, and the term "litholapaxy" designates this
method. The patient having been anaesthetized, 10 oz. of hot boracic
lotion are injected, and the crushing instrument, the lithotrite, is
then passed into the bladder. The lithotrite has two blades, a "male"
and a "female," the latter fenestrated, the former solid with its
surface notched. When the stone is fixed between the blades the screw is
used, and great pressure is applied evenly, gradually and continuously
to the stone. The lithotrite is made of very tough steel, so that hard
stones may be crushed without danger of the instrument breaking or
bending. Care must be taken not to catch the bladder-wall with the
lithotrite. This danger is avoided by raising the point of the
lithotrite immediately after grasping the stone and before crushing. The
stone breaks into two or more pieces, and these fragments must be
crushed, one by one, until they are powdered fine enough to escape by
the large evacuating catheter. If the stone be large and hard, half an
hour or longer may be required to crush it sufficiently fine. When the
surgeon fails to catch any more large pieces, the presumption is that
the stone has been thoroughly broken up. The lithotrite is then
withdrawn and the detritus is washed out by an "aspirator," which
consists of a stiff elastic ball which is connected with a trap, into
which fragments of stone fall so as not to pass out on the instrument
being used at later periods in the operation. A large catheter, with the
eye very near the end of the short curve, is passed into the bladder;
the aspirator, full of boracic lotion, is attached to the catheter, and
a few ounces of the fluid are expressed from the aspirator into the
bladder by squeezing the rubber ball. When the pressure is taken off the
ball, it dilates and draws the fluid out of the bladder, and with it
some of the detritus, which falls into the trap. This is repeated until
all the fragments have been removed. After the operation the patient
sometimes suffers from discomfort. His urine should be drawn off by a
soft catheter at regular intervals for a few days. If the pain be
severe, it can generally be relieved by fomentations. The patient must
be kept in bed after the operation, and in cases where the stone has
been large and the bladder irritable, the surgeon should insist on his
remaining there for at least a week; in those cases which go on
favourably the patients are soon able to perform their ordinary duties.
Fatal terminations, however, do now and again occur from suppression of
urine, the result of the old-standing kidney disease which so often
complicates these cases.
To Brigade-Surgeon Lieutenant-Colonel Dennis Francis Keegan, of the
Indian Medical Service, is due the fact that the operation of crushing
and promptly removing all fragments of a vesical calculus is as well
suited for boys as for men. In entire opposition to long-standing
European prejudices, Keegan's operation is now firmly and permanently
established. The old operation (Cheselden's) of cutting a stone out
through the bottom of a boy's bladder is now seldom resorted to, and if
a stone in a boy is found too large or too hard to lend itself to the
crushing operation, it is removed by a vertical incision through the
lower part of the anterior wall of the abdomen, as described above. For
a successful performance of the crushing operation in a boy a small
lithotrite has, of course, to be used, and it must be of the very best
English make. The operation has to be done with the utmost gentleness
and thoroughness, not a particle of the crushed stone being left in the
bladder, since otherwise the piece left becomes the nucleus of a fresh
stone and the trouble recurs.
The treatment of vesical calculi by other means than operative surgery
is of little value. Attempts have been made to dissolve them by internal
remedies, or by the injection of chemical agents into the bladder; but,
although such methods have for a time been apparently successful, they
have invariably been found worthless for removing calculi once actually
formed. Nevertheless, much can be done towards _preventing_ the
formation of calculi in those who have a tendency to their formation, by
attention to diet, by taking proper exercise, and by the internal
administration of drugs.
_Rupture of the bladder_ may be caused by a kick or blow over the
upper part of the abdomen, or by a wheel passing over it; or it may be
a complication of fracture of the pelvis. If the rupture is in that
part of the bladder which is uncovered by the peritoneum, the
extravasated urine may be cut down upon and let out with good prospect
of success; but if the rupture is in the upper or hinder part of the
bladder the urine is let loose into the general peritoneal cavity and
sets up peritonitis, which is more than likely to prove fatal. If the
surgeon knows that the bladder is ruptured he should operate at once
in order to provide escape for the urine, and also to sew up the rent.
If the possibility of the bladder being ruptured be even suspected,
the surgeon should pass a catheter. Perhaps he draws off an ounce or
two of blood-stained urine. This makes him doubly suspicious, so he
injects into the bladder five, eight or ten ounces of warm boracic
lotion, and, leaving it there for a few minutes, he measures the
amount which he is able afterwards to withdraw; if he finds that a
certain amount is lost he is assured that a leakage has taken place
and he at once proceeds to operate. If only the diagnosis is made
promptly, and the operation is at once undertaken, the outlook is not
unfavourable. A generation or so back nearly all the cases of rupture
of bladder ended fatally.
_Villous disease_ of the bladder is innocent; that is to say, it does
not spread to the neighbouring structures or implicate the lymphatic
glands. The villi are slender, branched, filamentous processes which,
springing from the floor of the bladder, float in the urine like
seaweed. They are freely supplied with blood-vessels, so that when a
piece of a villus is broken off there is likely to be blood in the
urine. Indeed, painless haemorrhage is one of the characteristic
features of the disease, and when fragments of the "seaweed" are found
in the urine the diagnosis is clear. If the bladder is opened from the
front, as already described, the villi may be nipped off by special
forceps and the disease permanently cured.
_Malignant disease_ of the bladder is almost always the warty form of
cancer known as epithelioma. It springs as a sessile growth from the
mucous membrane of the floor near the opening of one of the ureters,
and, worrying the sensory nerves, causes irritability of the bladder
and incontinence of urine. In due course septic germs reach the
bladder, either from the urethra, the bowel, the kidneys or the
blood-stream, and cystitis sets in. When ulceration has taken place,
blood occurs in the urine, and the patient--generally beyond middle
age--suffers dull or lancinating pains. Eventually the rectum may also
be involved and the distress becomes extreme. The presence of the
growth may be determined by sounding the bladder, by the cystoscope,
and by the finger in the rectum. If the growth invades the outlet,
retention of urine may occur, and the surgeon may be compelled to open
the bladder from the front of the abdomen. In cases where operation is
out of the question, washing the bladder with hot boracic lotion may
give great relief. The treatment of cancer of the bladder by operation
is, as a rule, unsatisfactory, because of the close proximity of the
growth to the ureters and to the rectum. If, however, the disease were
recognized early and had not invaded the neighbouring structures, and
if it were upon the upper or the anterior part of the bladder, its
removal might be hopefully undertaken.
_Hypertrophy and Dilatation._--When there is long-continued
obstruction to the flow of urine, as in stricture of the urethra, or
enlargement of the prostate, the bladder-wall becomes much thickened,
the muscular fibres increasing both in size and number; the condition
is known as "hypertrophy." Hypertrophy may be accompanied by
dilatation of the bladder, a condition which the bladder may assume
when the voiding of its contents is interfered with for a length of
time.
_Paralysis_ of the bladder is a want of contractile power in the
muscular fibres of the bladder-wall. It may result from injuries
whereby the spinal cord is lacerated or pressed upon, so that the
micturition centre, which is situated in the lumbar region, is thrown
out of working order. The result may be either retention or
incontinence of urine; sometimes there is at first retention, which
later is followed by incontinence. Paralysis is also met with in
certain nervous diseases, as in locomotor ataxia, and in various
cerebral lesions, as in apoplexy.
_Atony_ of the bladder is a paresis or partial paralysis. It is due to
a want of tone in the muscular fibres, and is frequently the result of
over-distension of the bladder, such as may occur in cases of
enlargement of the prostate. The patient is unable to empty the
bladder, and the condition of atony gets increasingly worse.
In both paralysis and atony the indication is carefully to prevent
over-distension by the urine being retained too long, and at the same
time to treat by appropriate means the cause which has produced or is
keeping up the condition.
_Incontinence of urine_ may occur in the adult or in the child, but is
due to widely different causes in the two cases. In the child it may
be simply a bad habit, the child not having been properly trained; but
more frequently there is a want of control in the micturition-centre,
so that the child passes its water unwittingly, especially during the
night. In adults it is not so much a condition of incontinence in the
sense of water being passed against the will, but is a suggestion that
the bladder is already full, the water which passes being the overflow
from a too full reservoir. It is usually caused by an obstruction
external to the bladder, e.g. enlarged prostate or stricture of the
urethra; a calculus may produce the condition. In the child an attempt
must be made to improve the tone of the micturition-centre by the use
of belladonna or strychnine internally, and of a blister or faradism
externally over the lumbar region, and every effort should be made to
train the child to pass water at stated times and regular intervals.
In the adult the cause which produces the over-distension must be
removed if possible; but, as a rule, the patient has to be provided
with a catheter, which he can pass before the bladder has filled to
overflowing. A soft flexible catheter should be given in preference to
a rigid or semi-rigid one. The best form is the red-rubber catheter,
and he should be taught the need of keeping it absolutely clean. In
the case of children incontinence of urine means irritability; in
adults it means overflow.
The condition termed by Sir James Paget _stammering micturition_ is
analogous to speech stammering, and occurs in those who are nervous
and easily put out. It would seem to be due to the sphincter of the
bladder not relaxing synchronously with the contraction of the
detrusor, and is sometimes caused by external irritation, such as
preputial adhesions. Occasionally not a drop of urine can be passed,
or a little passes and then a sudden stoppage occurs; the more the
patient strains the worse he becomes, until at last there is complete
retention of urine. The trouble can sometimes be cured by the removal
of irritating causes, and in these cases, as well as in those in which
no such cause can be discovered, care should be taken to avoid those
difficulties which have given rise to the patient's worst failures. If
at any time he should fail to perform the act of micturition, he ought
not to strain, but should quietly wait for a little before making any
further effort. Regularity in the times of making water is also of
much importance.
_Retention of urine_ may occur in paralysis of the bladder, or in
conditions where the patient is suffering from an illness which blunts
the nervous sensibility, such as apoplexy, concussion of the brain,
or typhoid fever. It is, however, more commonly due to obstruction
anterior to the bladder, as in stricture of the urethra or enlargement
of the prostate. The distended bladder can be felt as a rounded
swelling above the pubes, and perhaps reaching to the level of the
navel. Percussion over it gives a dull note. When the bladder is
distended, it is necessary to evacuate it as soon as possible. If
there is no obstruction to the flow of urine, the retention being due
to atony or paralysis, a soft catheter is passed and the water drawn
off. But when there is an obstruction which cannot be overcome,
aspiration has to be resorted to, the needle of the aspirator being
pushed through the abdominal wall into the bladder. The point of
puncture in the abdominal wall is in the middle line a few inches
above the symphysis pubis. The bladder may be emptied in this way very
many times in the same person with only good result.
_Diseases of Prostate Gland._
The prostate gland may become acutely inflamed as the result of the
backward extension of gonorrhoeal inflammation of the urethra; it may
also be attacked by the germs of ordinary suppuration as well as by the
bacilli of tuberculosis. A sudden enlargement of a large gland lying
against the outlets of the bladder and the bowel renders micturition
difficult, painful or impossible, and interferes with defaecation.
Pressure of the seat of the chair upon the perineum also causes
distress, so the man sits sideways and on the edge of the seat. If
abscess forms, it should be incised from the perineum; if allowed to run
its course it may burst into the bladder, the urethra or the rectum, and
set up serious complication. The treatment of prostatitis (inflammation
of the prostate) consists in rest in bed, sitz-baths and fomentations.
If retention of urine takes place a soft catheter must be passed. In the
early stage of an acute attack a dozen leeches upon the perineum may do
good. The bowels must be kept freely open, and from time to time, as the
pain demands, a morphia suppository may be introduced into the bowel.
_Chronic prostatitis_ is a legacy from a recent or long-past attack of
gonorrhoea. The enlargement gives rise to a feeling of weight and
fulness in the perineum, irritability of the bladder, and a gleety
urethral discharge. Manual examination reveals the presence of a
large, hard mass in front of the bladder, and in the mass there can
often be felt softish or tender areas which seem to threaten abscess.
On urine being passed into a glass, a cloudiness is seen, and material
like pieces of vermicelli or broken threads may be noticed. These are
the castings from the long tubular glands, and are characteristic of
chronic inflammation of the prostate. The occasional passage of a
large metal bougie, the use of weak lotions of nitrate of silver, the
administration of quinine and iron, and the application of blisters to
the perineum, may be tried as circumstances direct. The patient should
lead a quiet life, free from sexual excitement. Horse-exercise,
cycle-riding, rough games and alcohol should be avoided.
_Enlargement of the prostate_ exists in a considerable proportion of men
of about sixty years of age and onward. It consists of an uncontrolled
growth of the normal muscular and glandular tissue of the prostate,
interfering with, or absolutely stopping, the outflow of the urine.
Gently pushing the bladder upwards and backwards, it increases the
length of the urethra, so that in order to draw off retained urine the
catheter must be longer than ordinary, but inasmuch as there is no
actual narrowing of the passage it may be of full calibre. The beak
should be well turned up so that it may ride in front of, and surmount,
the median enlargement. Because of the thick, ring-like mass of new
tissue around the outlet of the bladder, there is difficulty in
micturition, and because the muscular bladder wall is now unable to
contract upon all its contents a certain amount of urine is retained. As
the enlarged prostate bulges up in the floor of the bladder, a pouch or
hollow forms behind it, from which the muscular wall is unable to
dislodge the stagnant urine. This keeps up constant irritation, and if
by chance the germs of decomposition find their way thither, cystitis
sets in and the patient's condition becomes serious, not only because of
the risk to which his tired and irritated kidneys are submitted, but
because of the possibility of a phosphatic stone being formed in the
bladder. The seriousness of enlargement of the prostate does not depend
upon the size of the growth so much as upon the inability of the patient
to empty his bladder completely.
The surgeon forms his estimate of the size of the prostate by rectal
examination. But sometimes a patient has retention of urine from
enlarged prostate, when by this method of manual examination the
amount of increase appears quite unimportant. The explanation is that
the enlargement is chiefly confined to a small piece of the gland
which protrudes like a tongue into the water-way. Robert McGill of
Leeds was the first surgeon to remove by a supra-pubic operation this
tongue-like process of new prostatic growth. Attempts had sometimes
been made to get rid of it by instrumentation through the urethra, but
they had not met with much success.
When the surgeon has made out the existence of an enlargement of the
prostate, the next thing is to find to what extent this interferes
with the bladder being emptied. To do this, he asks the patient to
pass as much water as he is able, and then with due precautions
introduces a soft catheter and measures the amount of urine which he
thus draws off--half an ounce, an ounce, two ounces, however much it
may be. It is this "residual urine" which causes the annoyance and the
danger of enlarged prostate, and unless arrangements can be made for
its regular withdrawal serious trouble is almost certain to ensue. The
passing of a large catheter may have the effect of so opening up the
water-way that, at any rate for a time, the irritability of the
bladder may cease, in which case the patient may be instructed in the
art of passing a catheter for himself. Or the surgeon may find that in
addition to the regular passing of a large catheter an occasional
washing-out of the bladder with hot boracic lotion is all that is
needed in the way of active treatment. At the same time, however, the
patient is placed upon a plain and wholesome diet with little or no
alcohol, and he is instructed to lead in every respect a regular and
quiet life. To many men with enlarged prostate the passing of an
instrument night and morning is no great hardship, while to others the
idea of leading what is called a "catheter life" appears intolerable,
or, having for a time been patiently carried out, is found not only
severely trying but greatly disappointing.
In some people the very first passing of a catheter sets up a local
and constitutional disturbance, the bladder being rendered irritable
and intolerant, the temperature going up, and shiverings and
perspirations manifesting themselves. This condition was formerly
called "catheter fever," and was looked upon as something mysterious
and peculiar. It is now generally understood to be the result of
septic inoculation of the interior of the bladder.
Lastly, in other persons the passing of the catheter is attended with
so much difficulty, distress or bleeding, that something more helpful
and effectual is urgently called for.
_Operative Treatment._--It has long been known that large tumours of the
uterus sometimes dwindle if the ovaries are removed by operation, and
Professor William White of Philadelphia thought that prostatic growths
might be similarly influenced by the removal of the testicles. Beyond
question considerable improvement has followed this operation in cases
of enlargement of the prostate, especially where the enlargement seemed
to be general, soft and vascular. A similar though perhaps a slower
effect is produced when the duct of the testis, the vas deferens, is
divided on each side of the body. If there is no great urgency about the
case this treatment may well be tried, the bladder being all the while
duly emptied by catheter and washed by irrigation. But if the case is
urgent, there being difficulty or bleeding with the passing of the
catheter, the bladder being excessively irritable and the urine foul, a
more radical measure is needed. The best operation is that upon the
lines laid down by Robert McGill, who opened the bladder through the
anterior abdominal wall and removed that part of the prostate gland
which was blocking the water-way. McGill's operation was improved upon
by Eugene Fuller of New York, who, in 1895, published a full account of
his procedure.[1] Having opened the bladder from the front (as in
supra-pubic lithotomy), he introduced his left index finger into the
rectum and thrust the prostate gland towards the right index finger,
which was then in the bladder. With the nail of that finger, or with the
end of a pair of scissors, he made a rent in the mucous membrane of the
bladder and the capsule of the gland, and then shelled out the mass of
new tissue which had caused the prostatic enlargement. This operation is
called "prostatectomy," which means the removal of the prostate gland.
The prostate gland, however, is not removed, but only a muscular and
glandular mass (adenoma), which, growing within the prostatic capsule,
encircles the urethra and squeezes the original gland tissue out of
existence. Following on the lines of McGill and Fuller, P.J. Freyer has
done excellent work in England towards placing this operation upon a
sound basis.
Subsequently to the operation the bladder enjoys complete and needful
rest, and the kidneys, which previously were in a condition of perpetual
disturbance, improve in working power. The wound in the bladder and in
the abdominal wall gradually closes; the function of the bladder
returns, and the patient is soon able to go back to his usual occupation
in greatly improved health and vigour. The operation is, necessarily, a
serious one, and the age of the patient, the condition of his bladder,
of his kidneys, and of his blood-vessels, require to be taken into
consideration; still, the operation gives an excellent account of itself
in statistics, and if a practical surgeon advises a patient to accept
its risks his counsel may well be followed.
_Malignant disease of the prostate_ is distinguished from senile
glandular enlargement by the rapidity of its growth, by the freeness
of the bleeding which is associated with the introduction of a
catheter, and by the marked wasting which the individual undergoes.
Unfortunately, by the time that the cancerous nature of the disease is
definitely recognized, the prospect of relief being afforded by
operation is small. (E. O.*)