Part 11

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.