operation-the patient still continuing his visits for the purpose of observation.

But there was still another objection to Holt's instrument. The size of its point, which equalled No. 7 of the French scale, or No. 1 American, rendered it impossible to use the instrument in very narrow strictures until, by the successive introduction of filiform bougies, the requisite calibre had been attained; and even then the curve of the instrument was such that its insertion was not always an easy matter. Thus, after dilating the stricture with bougies up to No. 7 (French), I often found considerable difficulty in introducing a Holt, especially as the shaft of the instrument rapidly increases in diameter, so that practically a much greater degree of dilatation than No. 7 is required for its insertion to such an extent within and beyond the contraction as to enable us to use it for the purpose intended. This is evident on inspecting the instrument, which will be found to require a calibre of No. 11 (three and two-thirds inillimetres No. 4 American scale) in order that the introduction of either of the tubes along the central wire may have any effect upon the stricture.

To obviate this difficulty, Mr. Stohlmann, of the firm of Messrs. Tiemann & Co., at my request, changed the curve of the instrument, so that it should correspond to what is known as Thompson's curve. I also directed that the point should be made separate, so that it could be unscrewed, and in its place a filiform bougie could be attached, which should possess all the advantages of the conducting bougie of Maisonneuve's urethrotome, and enable me, with a little time and patience, to insert the instrument to the requisite extent in any case of stricture which was at all passable, and at a single session. Again, the central wire is made hollow, and in fact consists of a tube, the vesical opening of which terminates near the extremity of the instrument, anterior to the screw point, so that the flow of urine may indicate when the bladder has been entered. This, however, is a minor consideration with the bougie attachment, since any deviation from the proper course is now almost impossible. These modifications have been found to accomplish all that was desired, and will, I believe, materially increase the value of Mr. Holt's instrument.

I would add that the same bougies may be made to fit on to both Holt and Maisonneuve, so that the choice of the instrument need not necessarily be determined until after the conductor has been passed.

Thebaud's Instrument.—The instrument for the rupture of strictures, invented by my friend, Dr. Julius S. Thebaud, of this city, has not, I believe, been before described. In shape it corresponds to an ordinary sound, but the extremity of the

instrument is split horizontally for a distance of about five inches, forming two blades, which are separated in a vertical direction by turning a screw in the handle. There are two sizes; the point of the smaller has a diameter of four millimetres (No. 12 of the French scale); that of the larger, one of six and two-thirds millimetres (No. 20 of the French scale); hence it is evident that the instrument cannot be used in tight strictures without preliminary dilatation or incision. In using the instrument, the extremity is passed fairly through the stricture, when the screw at the handle is turned until the contraction is felt to "give," or the desired amount of dilatation is effected, as indicated by a scale marked on the screw shaft.

This instrument is one of very great power and capacity. The larger one is capable of rupturing a stricture to a size much exceeding No. 30 of the French scale (No. 18 American). By measurement this power equals a sound of five-eighths of an inch in diameter. Compared with Holt, Thebaud's instrument has therefore the advantage of any desirable amount of dilating and rupturing power, and the disadvantage of not being adapted to tight strictures. The extreme power may render its use dangerous in unskilful hands; and there is the further objection that it requires some care to determine when the stricture is accurately caught to its full extent near the point of the instrument. Still, it is remarkable with what impunity the urethral walls will bear the apparent amount of violence which this instrument can exercise. I have used it in some fifteen to twenty cases, and Dr. Thebaud himself in about double the number, without unpleasant consequences. In one of those rare cases of pure spasmodic stricture which we sometimes meet with, I assisted Dr. Thebaud in introducing his larger instrument into the membranous portion of the urethra, and opening the blades to their fullest extent. The operation was performed on the same principle as leads us to rupture the sphincter ani in irritable conditions of the lower portion of the rectum. The tissues were felt to suddenly yield, doubtless in consequence of their rupture, but there was no subsequent chill, fever, undue hemorrhage, incontinence of urine, or other unpleasant consequence, and the patient was about attending to his business the following day. The spasmodic action was entirely relieved for over a year, but, as I have learned, subsequently returned. For a case of this kind no other instrument that I know of would have served the purpose.

I have found Thebaud's instrument of special value in cases like one before mentioned, in which the stricture had not been sufficiently ruptured by the use of Holt.

Before leaving the subject of instruments intended for the rupture of stricture, it is proper to refer to Mr. Thompson's

instrument, although its inventor designed it rather for the rapid dilatation than actual rupture of the constricting band. I have not as yet made use of this instrument, but the principle of it is excellent, and I should judge it to be of great value whenever a timid patient refuses to submit to what appears to him a more violent procedure. It is evident that the dilatation may be carried to the point of rupture, and thus the same effect be produced as with either of the above-named instruments.

Maisonneuve's Urethrotome.-This instrument is now too well known to require description, and the reader of our current medical literature must have observed the numerous favourable notices of it, emanating from various sources, which have appeared during the last few years. In my own opinion, it is by all odds the simplest and the best urethrotome ever invented. Its filiform attachment enables it to be used in every stricture, however tight, through which the finest bougie can be passed; the bluntness of the apex of its triangular-shaped blades is well adapted to prevent any sound portion of the canal being wounded; and its simplicity renders it easily cleansed, and little liable to get out of order.

I desire to call attention especially to the first of these advantages which is also shared by my own modification of Holt, as before described. A patient comes to your office with what appears at first to be an impassable stricture. After a while, however, you succeed in engaging the point of the filiform extremity of one of Maisonneuve's bougies within the contraction. Your patient is allowed to remain for half an hour, when the bougie will enter still further, and thus by the process of what has been called continuous dilatation, the apparently impassable stricture is soon enlarged sufficiently for the full and free passage of the fine bougie. This is now screwed to the end of the metallic shaft of Maisonneuve or Holt, which by the aid of one finger in the rectum may now be guided into the bladder, within which the bougie-conductor coils itself up as the shaft advances. It remains only to thrust down the knife or tube, as the case may be, and your patient is relieved of his stricture before leaving your office. This may seem to be making light of a serious operation, but it is what I have often done, especially with patients from a distance, whose stay in the city was necessarily limited. A hackney coach may be called to take the patient to his lodgings, and twenty-four hours' quiet in his room is usually sufficient.

[After the operation, the parts should be interfered with as little as possible for the first few days. Either before the operation or immediately afterwards, it is a good plan to divide the meatus a little so as to allow of the use of the largest-sized sound.]

I am not over-sanguine with regard to the permanence of the cure after any mode of treatment, in the absence of prolonged attention. It is true that I have still patients under observation, operated upon four or five years ago, in whom there is no tendency to relapse, as shown by the size of the stream and the freedom with which a sound may be passed. But from what we know of the pathological anatomy of strictures, and from the evidence afforded by casts of the canal some time after the pas-sage has been freely opened, it is evident that the tissue of new formation does not entirely disappear even on the supposition that it is materially dlminished. Moreover, cases will return to disappoint us when we had hoped for better things.-American Journal of Medical Science, Oct. 1868, p. 321.

70.-ON SPASM OR EXCESSIVE CONTRACTION OF THE MUSCULAR COAT OF THE URETHRA, COMMONLY CALLED SPASMODIC STRICTURE.

By WILLIAM S. SAVORY, Esq., Surgeon to St. Bartholmew's Hospital.

[Since it has been known that the urethra in its entire course is invested by muscular fibre, it has been admitted that spasm may occur in any portion of the canal. The opinion, however, seems. very common that the so-called compressor urethra muscle is the chief agent in the production of spasmodic stricture, and that it is, therefore, usually limited to, and always most intense at the membranous portion of the urethra. But this view is not borne out either by observation or analogy.]

That spasm or muscular contraction of any degree is in its very nature transitory there can be no doubt; but yet cases occur in which all the symptoms of stricture endure for years, but in which, nevertheless, there is clear evidence to show that it entirely depends on muscular contraction.

In the following case the spasm very closely simulated organic stricture.

A man between thirty and forty years of age, whose health for some time previously had been unsatisfactory, complained of considerable difficulty in passing urine. Very much straining was needed to relieve the bladder, and then the urine only in part escaped in a very slender stream, and the rest dribbled away. The gentlest introduction of any instrument always gave acute pain, and the point was arrested at a variable distance, but usually within some four or five inches of the orifice. So sensitive was the urethra that the canal could not be fairly examined without chloroform, and even then, on almost every occasion, the instrument was arrested before it reached the

bladder. Only once or twice was this accomplished in the earlier part of the case, and then an instrument of moderate size-No. 7 or 8 was carried through with facility. This state of things endured for many months, and it was observed that the condition of the uretbra always varied with the general health. Now and then, to the man's astonishment, the urine would pass freely in a full stream, but in spite of every apparent precaution the amendment was only transitory; in a few hours the difficulty and distress was as great as ever. After a time all attempts to pass an instrument were given up except when some fresh surgeon was consulted, who of course did not believe in the difficulty until he himself had made an unsuccessful attempt to overcome it. Then, sometime after the urethra had been left to itself, the symptoms gradually abated. The first indication of improve ment was that during a loose action of the bowels, after aperients, the urine would escape in a full stream without difficulty. At times a tolerably free stream would flow for days together, and then again, perhaps from some indiscretion in diet, the condition of parts would become as distressing as ever. Even to the last any attempt to introduce an instrument was always unsuccessful and mischievous. But at length the evil gradually abated, and for the last year or two the urine has been passed freely in a full stream.

In the Lancet of April 13, 1867, Mr. Campbell De Morgan has recorded a case of what may well be called permanent spasmodic stricture, inasmuch as it was of some twenty years' duration.

The explanation of these and of many other cases more or less persistent and unyielding, I take to be this: The muscular coat of the urethra cannot always be in a state of spasmodic or inordinate action, but is immediately excited to contract unduly by any impression upon the mucous membrane of the urethra or adjacent parts: so the contact of urine, or still more of an instrument, at once provokes it. Thus, as the canal is almost always more or less contracted by the passage of urine, and still more completely closed by any attempt to pass an instrument, evidence of stricture always exists when its condition can be examined, and thus, so far as every appearance is concerned, the contraction is persistent, but in all probability there is in intervals of complete quietude more or less complete relaxation.

The influence of chloroform is sometimes very great in these cases, and its value twofold-in diagnosis and in treatment. It is not always, however sufficient to cause thorough relaxation of' these muscular fibres.

When spasm is associated with organic contraction or inflammation or congestion, either alone, or still more when combined,