you in my last lecture, of purulent infection being induced by the simple use of a bougie? Tetanus, as you know, may likewise occur after trifling operations; it has followed the extraction of a tooth: yet who would think of rejecting the operation because of the accident? In like manner, erysipelas, hospital gangrene, &c., may set in after a trifling operation, and carry off your patient. These are facts familiar to every one; and nothing but the most determined prejudice could induce certain persons to reject an operation because it may possibly be followed by secondary effects, which no surgical foresight can prevent or avoid. Such a mode of reasoning is at once unscientific and disingenuous. If it were admitted, the progress of surgery must be arrested at once. not mean to affirm that you are to undertake rashly every operation which may be proposed; but, on the other hand, you are not to reject, without weighty reasons, a mode of treatment which has been followed by the most beneficial results in the hands of our most distinguished surgeons. I do In cases of old and obstinate stricture, which have resisted all other methods of treatment, and where the health of the patient is about to give way, you are bound to ask yourselves, Shall we allow the disease to progress until it becomes irremediable, entailing misery on the patient, endangering his life, and probably rendering another operation (puncture of the bladder) ultimately necessary under unfavourable circumstances; or shall we attempt to relieve and cure the patient by a simple operation, which holds out every prospect of success? I would unhesitatingly answer in the affirmative. When extensive practice shall have made you acquainted with the effects of severe stricture, you will be better prepared to understand the impolicy of allowing things to go too farof delaying until relief becomes impossible. In the case before us, I have no doubt but that the complication which proved fatal may be mainly attributed to the condition of the urethra, produced either by the original disease, or the treatment employed before the operation. The whole surface of the urethra in front of the stricture was inflamed, and contained numerous abscesses; and from the general history of purulent infection, we know that the presence of an abscess in any part of the genito-urinary system is a determining cause of purulent infection after operations performed on the bladder or urethra.-Lancet, June 19, 1852, p. 578. [Mr. Coulson having remarked upon the concurrence of Mr. Wade in the operation of perineal section for stricture of the urethra, that gentleman, in a letter to the editor of the 'Lancet,' states his views somewhat more fully, lest he should have been misapprehended. The following are his observations, which, he says, were only partially quoted and commented upon by Mr. Coulson.] In some strictures, from mechanical injury of the urethra, followed by more or less sloughing of the injured parts, a hard, gristly cicatrix will often be left, while the greater portion of the urine may be passed through fistulous orifices in the perineum. In such a case, dilatation, as well as caustic, will very probably fail in the best hands, and division of the obstruction, by perineal section, be the only chance of relief for the patient. Where the urethra has been divided by a wound in the perineum, a hard cicatrix may be formed at the seat of injury, and if the contraction cannot be kept sufficiently open by other means to ensure the patient from danger, division by the knife may become advisable, although that proceeding will not always be successful; for so strong a tendency have cicatrices to contract, that although great care be taken, by constant introduction of instruments, to preserve the advantage which has been gained, yet the stricture may return nearly, if not quite, as bad as ever. In a case of hard contractile stricture, not the result of mechanical injury, which has long remained impermeable to all milder means of treatment, and where the patient's general powers are suffering severely, the operation by perineal section may probably be advisable. I believe, however, that such instances will be of rare occurrence. I have stated the above as cases in which perineal section may possibly be necessary; for although the potassa fusa has succeeded in many such instances, who can calculate upon invariable success with any one method of treatment? I believe, however, with the exception of cases in which a portion of the urethra is obliterated after the sloughing of a part of the canal, or when a hard, contractile cicatrix is left, from complete division or laceration of the tube, that perineal section will rarely be necessary. With regard to Mr. Syme's operation, it is at present my conviction, that where an instrument, however small, can be passed into the bladder, the persevering application of caustic potash will accomplish more enduring good for the patient,-that is, if there be time for its operation, and life be placed in no immediate peril,-than can be effected by perineal section,-and without the slightest risk of a fatal Occurrence. My reasons for such an assertion are, that I have lately, by the application of potassa fusa, succeeded in several cases where no hope had been held out to the patients but perineal section, and in two of them both nitrate of silver and potassa fusa had been used, but the latter neither with that confidence nor perseverance requisite for its efficient action in such cases. Further experience has but confirmed my opinion of Mr. Syme's operation, expressed more than two years ago,viz., that "its performance can only be justifiable in cases of immediate or imminently impending danger, and that it cannot be depended upon as a permanent cure of bad cases of urethral obstruction."-Lancet, July 3, 1852, p. 19. 93.-REMARKS ON THE LIMIT WHICH MAY BE GIVEN TO DILATATION OF THE URETHRA. By JOHN HILTON, Esq., F.R.S. [The remarks of Mr. Hilton upon this subject cannot be better illustratated than by the following cases, which he has related and commented upon.] A gentleman in my neighbourhood applied to me, a short time ago, with a stricture situated at the bulb. At first I could only pass a catgut bougie, but subsequently succeeded in introducing Nos. 5, 6, and 7. The latter number was passed through the meatus urinarius with difficulty, and gave the patient pain; it produced a good deal of irritation, and I am confident that a considerable amount of mischief would have been done by going beyond No. 7. Indeed, using that number at all was wrong. Nos. 5 and 6 were this patient's size, and by adhering to them, he recovered perfectly, and is now quite well. He passes now and then No. 5 for himself before going to bed, and leaves it in the urethra about a quarter of an hour. It would have been quite absurd to have gone on increasing the size of the bougies and the number of my fees; such a course would have been a great injustice to the patient, and very discreditable to myself and my profession. This case reminds me of an analogous one, in which the patient came from a distant part of the world. He brought to London letters of introduction to two surgeons of whom I was one; and he first applied to the other. He was, however, not benefited, and as he wanted to return to Ceylon, the surgeon finding the meatus narrow (it would admit Nos. 5 and 6), slit it open, so that Nos. 9 and 10 could be easily introduced. These numbers were persevered in, in spite of the stretching pain, and uneasiness felt by the patient; but as no real beneficial progress had been accomplished by the first surgeon, he made use of his second note, and came to me, tormented by urethral pain and inconvenience, with great depression of spirits. I found the corpus spongiosum, containing the urethra, as hard as a stick, tender on pressure; a pretty constant discharge of mucus from the urethra, frequent desire to pass urine, always accompanied by pain in the penis, which was rigid and hanging down, not erect, the corpora cavernosa not being involved in the mischief or excitation; the urine emerged very sluggishly, great expulsory efforts being required to insure even its slowly draining from the penis; the canal seemed almost obliterated, notwithstanding the calibre of the instruments which had been forced along its length with assiduity and energetic perseverance. Reflecting on these conditions, and the description which the patient gave me of his state before the employment of large instruments, I concluded that he had had sounds of too large a size passed. The urethral canal being thus considerably hardened, I interdicted the use of instruments, and prescribed mercurial and iodine ointment to be rubbed along the perineum and the whole course of the urethra, to aid or induce interstitial absorption. In about ten days, the induration had materially diminished; and after consulting with Mr. Bransby Cooper, who fully coincided with me in my view of the case, it was agreed that the patient should be placed constitutionally under the influence of mercury, for the purpose of diminishing the size of the corpus spongiosum, and I also began dilating the urethra de novo, keeping at last within No. 8. In the course of a few weeks I could make No. 8 go into the urethra beyond the meatus (which you will recollect had been slit open to a larger size), but it required more force than was right to be employed, so I advised him never to attempt himself, nor to let any one else be trying to pass instruments beyond No. 6. By pursuing the constitutional treatment which has been mentioned, by blistering the urethral portion of the penis, and carefully using this number or size, the most satisfactory results were obtained, and the gentleman left for Ceylon, delighted at the comfort and improved condition he was experiencing. I advised him to pass No. 6 (for that was his size, and not No. 10 or 13) occasionally, or once a week, and to blister the urethra if he felt much uneasiness or inconvenience in that canal when on his journey. You see, then, that I apprehend the surgeon who first treated the patient had done too much; he had gone too far, and had, in his anxiety to enlarge the urethra, excited mischief. I repeat it, the best single criterion of the natural size and calibre of the whole canal is the meatus urinarius, provided that be obviously healthy. Take, then, a good measure of that aperture, and you will have a tolerably reliable guide as to what extent you should push the dilatation in treating strictures of the urethra. The next question now is this-When may a stricture of the urethra be considered cured? This question should, however, be restricted to patients who are young, or in the middle period of life, and who have no other disease of their urinary organs. You observe I intentionally exclude the aged or prematurely old in answering this very pertinent but practical question: the reason is, that with such patients there are usually structural changes going on in the urethral walls, prostate gland, and bladder, which may be said to be natural to that period or condition of life, and which produce and cause the persistence of some of the symptoms of a strictured urethra, in spite of any and every effort made by the surgeon to stay or avert them. Confining ourselves, therefore, to the young and middle-aged, we may say that the patient is cured-1. When (assuming there be no local disease, such, for example, as the cicatrix of a chancre, causing contraction at the meatus of the urethra) a catheter or sound which fills the end of the urethra can pass through its whole length without any except muscular interruption. 2. When the water flows freely and with force during micturition, without pain or smarting in the urethra. Here you should notice that the force with which the urine is expelled is a good criterion of the powers of the bladder and healthy urethra. The actual size of the stream is not so trustworthy a sign as the vigour just mentioned, for the urethra (and consequently the stream) may be naturally large. But the force with which the expulsion is performed shows whether there is an impediment in the way or not. Another point of importance is, that the urine should be voided without pain, for where micturition causes uneasiness there is certainly something wrong, about the bladder or canal, and the patient cannot be considered as cured. 3. When the bladder empties itself completely, and the act of micturition is not followed by any dribbling; for if any such dribbling take place, it will point to a kind of atony in the muscles of the urethra, lately found and described by a very intelligent surgeon, Mr. Hancock, of Charing-cross Hospital. 4. The urine should not emit an ammoniacal odour. 5. There should be no mucus or pus in it. 6. There should not be any habitual discharge from the urethra. are many physical circumstances to be taken into consideration for pronouncing a patient cured, besides the free passage of the instrument along the urethra.-Lancet, Sept. 11, 1852, p. 234. 94.-On Stricture of the Urethra, with a New Method of Treating the Disease. By W. J. MOORE, Esq., late Resident Surgeon at the Queen's Hospital, Birmingham.-Having, during the last three years, paid considerable attention to diseases of the genito-urinary organs, particularly stricture of the urethra, I am induced to lay before the profession a means of treatment by dilatation, which, so far as I am aware, has never before been practised or proposed. Although so much has of late been said on the subject, it is generally admitted that all the varied plans now advocated are open to serious objections. The treatment by dilatation as ordinarily practised often fails; frequently a catheter of even moderate size may be passed one day, and on the next, owing to spasm, congestion, or subacute inflammatory action, no instrument can be used. Retaining the catheter in the passage is also unsafe; inflammation of the bladder, peritonitis, abscess, &c., not unfrequently arising. The caustic treatment is now almost universally deprecated. Professor Syme's plan is only applicable to certain obstinate cases, where the passage of instruments cannot be borne, or when such treatment has failed. The metallic stricture dilator, lately brought forward, is open to the objection of expanding more in the anterior part of the urethra than the posterior, in which latter portion of the passage it is evident the expansive force is mostly required. Mr. Wakley's instruments are certainly the best yet in general use, and have proved, in my hands, productive of much good; but the interior of the urethra is liable to suffer by the passage of the hollow tubes over the straight staff. From a consideration of these and other circumstances, I came to the conclusion, that could a thin, expansible substance, be introduced into the urethra, to serve as a sort of false lining membrane, dilatation might might be practised to any extent by expanding (with a larger instrument, sound, or catheter) the expansible material already introduced. Under this impression, I applied to several manufacturers of guttapercha and India-rubber articles, and finally obtained some tubes from Messrs. Mackintosh, of Liverpool, which partly answered the purposes required. They were, however, too thick and clumsy in every way, so that it was necessary to have a new set prepared on a smaller scale. The material used in their manufacture is, I believe, a mixture of gutta percha and caoutchouc, with here and there a thread introduced for security and strength. The tubes themselves are rather longer than an ordinary catheter, and the smallest very thin, and of sufficient calibre inside to receive a small wire stilet. The stilet, thus enclosed in the expansible case, is carried through the stricture into the bladder; the wire is then withdrawn, and a larger wire, catheter, or sound, well oiled, passed in its stead within the expansible case already present for its reception. Thus dilatation may be carried to any extent without risk of producing |