The Case of a Patient, Who Voided a Large Stone Through the Perinaeum from the Urethra. Communicated to the Royal Society by Mr. Joseph Warner, Surgeon, of Guy's Hospital, to Whom This Memoir Was Addressed, for That Purpose, by Dr. Frewen, of Rye in Sussex

XLIX. The Case of a Patient, who voided a large Stone through the Perinaeum from the Urethra. Communicated to the Royal Society by Mr. Joseph Warner, Surgeon, of Guy's Hospital, to whom this Memoir was addressed, for that Purpose, by Dr. Frewen, of Rye in Sussex. Read Nov. 19, 1761. Henry Taught, of Hastings in Sussex, aged seventy-six, a strong hail man, and naturally of a good constitution, was never subject to any nephritic or gravelly complaints for almost seventy years; but enjoyed, for the most part, a good share of health, (though he had been exposed, the greatest part of his life-time, as a mariner, to the irregularities and inclemencies of that element, to which his occupation engaged him) till about six or seven years ago, when he had some gravelly complaints, and uneasiness in making water; which increased upon him progressively; and, for the last two years, he had so much pain in sitting, that he was obliged to use a perforated chair, made for that purpose. But, for some months past, his increased pain would not permit him to sit at all, even at his meals, which he used to take either standing or lying. When he first came to be in this painful situation, there appeared a prominence on the right side of the perineaum, towards the hinder part of the scrotum; which, increasing by degrees, felt hard and superficial for some time; and the parts all about it grew so extremely extremely sore, and tender, that, at length, on the 24th of September last, upon his getting out of bed, a laceration thereof happened; and the stone, here-with shewn to this learned Society, was voided, falling down upon the floor. Five days after this happened, I went to see the patient, in order to get a perfect knowledge of the circumstances of the fact; the particulars of which I then communicated to my worthy friend Mr. Warner, surgeon, of Guy's hospital in London; who returned me a satisfactory account, from his own observations, of the manner by which a stone is contained in the urethra, &c. which I shall take the liberty of inserting, after submitting to the superior judgment of this Society, a short account of what I apprehended to be the original process of nature, in the production of such a phenomenon. Dr. Boerhaave hath observed, from experiment, that if a quantity of recent urine be set, to digest in a tall glass, with a heat no greater than that of a healthy man's body, for the space of three or four days, it will continually grow more and more red, foetid, cadaverous, and alkaline, throwing off a stony matter to the sides of the vessel. From whence we learn, that calculous matter, by too long a detention of this excrementitious fluid in the bladder, may be easily generated; and a small portion thereof, in its discharge from thence with the urine, may happen to be obstructed in the passage of the urethra, so as to be incapable of getting either forward or backward, and thereby become the basis of a stone; which, increasing by the urinous supplies, may be accumulated to as great a bulk as the part containing it will admit of. Now, "the urethra, in cases of this kind," according to the observation of my learned friend, "becomes a cyst, which cyst acquires a great degree of hardness, and remains compact and whole, till an inflammation is produced by its incapacity of admitting any farther distension; which inflammation is soon after communicated to the integuments, by which means they become painful, tender, and are easily lacerated." And this description seems to correspond exactly with what hath happened in the case of this old man. Ever since the stone came away, this patient hath discharged no urine but by the wound; which, when I last saw him, was so much contracted, as to be no bigger than to admit into it a small finger, and the parts were grown callous about it. I would have recommended him to proper care on that occasion; but he would by no means hearken to me; seeming to be very happy in being freed from the cruel burden of the stone; and not regarding, I suppose, at his time of life, whether he could be helped in the discharge of his urine any other way. Hatton-Garden, London, Nov. 12, 1761. As I am desired by Dr. Frewen, in a letter to me, bearing date the 7th instant, to add whatever I shall think expedient to his memoir, I have, in consequence of this request, taken the liberty of observing, from a former letter of Dr. Frewen to me, bearing date the 17th of October last, that when this surprizingly large calculus was first voided, which was on the 24th of September 1761, it weighed six ounces and two drachms; that on the 29th of the same month it weighed six ounces, wanting one drachm and fifteen grains. On the 11th of October following, it weighed six ounces, wanting three drachms and one scruple. On the 17th of the same month, it weighed six ounces, wanting three drachms and half. Give me leave to add farther to this paper, by observing, that, about March last, I produced two very remarkable calculi to the Royal Society, for their inspection; when they did me the honour to desire a written account of the case of the person, in whose urethra they were lodged. The whole of what I think worth troubling the Society with, upon this occasion, is, that they had been for many years lodged in the urethra of one Robert Bolley, a young man, aged about twenty-two, and that they had produced no great inconvenience, or pain, till of late, when the integuments began to inflame; which inflammation commenced not long before he was put under my care. The consequence of this change in the parts was extreme torture, a severe symptomatic fever, great wasting-away of the whole body, and almost a continual and involuntary discharge of small quantities of urine. The miserable object I have been just now describing, was recommended to my assistance, by my ingenious friend and acquaintance Dr. Wollaston, of Bury in Suffolk, in whose neighbourhood this patient lived, and from whence he was conveyed to London in a waggon. The parts were then arrived to so great a degree of distention, inflammation, and tenderness, that, upon the the journey, they burst, and there was discharged thro- an opening made in the perinæum (that is, the space betwixt the anus and scrotum) one of these stones; the other stone remained firmly fixed in the urethra, which I easily removed, having first cut away as much of the diseased integuments of the acceleratores urinæ muscles, and distended urethra, as I judged necessary to be removed for this purpose. After the removal of these parts, I brought together the lips of the wound, and kept them so, by means of that suture which surgeons call the twisted suture, till the parts were united, which was effected in about a fortnight. Before the suture was applied, I introduced a ductile instrument, of a convenient size, through the penis into the bladder, by which means, the passage was kept equally distended. This operation so effectually answered my expecta- tion, as totally to remove the incontinence of urine, as well as every other symptom that had attended the complaint; and the patient was, in a short time, re- stored to his usual healthy state and corpulency. N. B. In the two instances I have just now re- lated, as well as in the case of Thomas Bingham, whose history I communicated to this Society, on the 13th of December 1759, (vide Philosophical Trans- actions for the year 1760.) I must observe, that these patients, according to the best information I could get, were never attacked with a suppression of urine, or a regular fit of the stone; for which reasons, I conclude, that the formation of these calculi did ori- ginally commence in the urethra itself, and that the stream of urine, in its course from the bladder through the penis, had gradually formed those grooves, or channels, so apparent on the surfaces of these compact and hard bodies, over which they occasionally were voided; by this means, a passage for the urine always remained open and unobstructed. [Vide Tab. IX. & X.] Plate IX. represents the size, shape, and appearance, of the stone, in different attitudes, with the grooves on its superior surface, that was voided through a laceration of the perinæum, as has been above described, in the case of Henry Taught, of Hastings in Sussex. Plate X. represents the two stones that were lodged in the perinæum of Robert Bolley, a young man of twenty-two years of age, as has been already mentioned, with their polished surfaces. A and B, where they came in contact with each other. In the same plate, are these two stones joined together, with their several eminences and depressions, and as they lay in contact with each other in the perinæum.