CASE IL —I saw a man in 1887, aged 50, who two years previously suffered from some obscure abdominal symptoms in the region of the bladder, attended with acute pain, since which he had noticed fecu lent matter in the urine and the discharge of air at the close of mic turition. Examination of the rectum disclosed nothing worthy of note further than that I was able by pressing on the prostate and pos terior wall of the bladder to make urine mixed with feculent matter exude from the orifice of the penis. In all other respects this patient seemed to enjoy excellent health, and there was no evidence pointing to malignancy. I have seen him on two or three occasions since in consequence of his suffering from an acute paroxysm of pain over the region of the bladder. Each time I found the pain was due to the blocking of the prostatic urethra with a hardened nodule of fmc,es and the rapid distention of the bladder with air. Immediate relief was given by passing a catheter, which afforded vent to some feculent urine and a large amount of pent-up gas. This patient's symptoms were always intensified when diarrhoea was present. Though much annoyed at times by these local symptoms, he continues, I under stand, to enjoy good health and to lead an active life.
Case 3.-A man, aged about 60. His last illness commenced a short time before I saw him, with intense pain down the course of the right sciatic nerve, which lasted for rather more than a week; then retention of urine supervened from enlarged prostate, in addition to some urethral stricture which necessitated daily catheterism. In the course of a few days the pain in the back and leg entirely ceased, coincident with the appearance of pus in considerable quantity in the urine. The urine as soon as it became purulent was rendered most offensive, in spite of the bladder being washed out with disinfectants. He appears to have experienced some difficulty in urinating for several years, a circumstance which was probably due to the stricture in the urethra. He had not lost flesh and there was no evidence of malig nant disease. The urine continued to be horribly offensive, as large quantities of gas and faeces were constantly mixed and discharged with it in spite of all the means that were used. He remained much in this way for about two months after I first saw him, and then lapsed into a comatose state, from which he never rallied. He was unwill
ing to submit to such operative measures as were proposed for his relief. The patient stated that when he was about 20 years of age he suffered from an abdominal abscess' of some kind, when it was be lieved that a communication had taken place between the bladder and intestines, as pus, and what he thought was feculent matter had been at times discharged with the urine, but never sufficiently to cause him inconvenience. He had occasionally passed air at the close of mic turition, which he likened to the expiring efforts of a siphon soda water bottle. In all other respects he appears to have enjoyed good health. His urine was on several occasions examined for me by Sir William Roberts, and showed unmistakable evidence of intestinal contamination. The autopsy showed an opening near the top of the bladder, looking as though it had alwaT existed, lined with mucous membrane, not patent but contracted, and resembling a miniature anus. No. 8 catheter passed easily through it into a cavity surrounding the descending colon, and formed by adhesions to the adjacent parts, which were with difficulty separated. This space contained no fecal matter, but was rough from inflammatory products, and communi cated by several openings with the intestine. The colon took an un usual course; instead of passing down into the left loin, it curved across the lower part of the abdomen in front of the small intestines, and disappeared a little to the right side and under the bladder to its termination in the anus.
In reviewing cases of this kind, more particularly in reference to the question of treatment, we can divide them into two classes : (1) those where the inconvenience resulting is so slight as would hardly warrant the adoption of any important surgical interference; and (2) those where the inconvenience is an increasing one, either by a gradual process or by the intercurrence of acute symptoms, or where the condition of the bladder by decomposition of the urine be comes such as seriously to jeopardize the health of other parts of the urinary apparatus, especially tile kidneys. I think it will be found that the cases quoted illustrate in some degree these deductions.