from some injury inflicted by the instrument, although it may also be from tumour of the vesical walls. Here you will keep the patient on his back, and forbid the upright position, or any straining, so far as you can prevent it, in passing water. To this end give opium liberally, to subdue the painful and continued action of the bladder. Apply cold by means of bags of ice to the perineum and above the pubes. Better still, introduce small pieces of ice into the rectum. Do not use an instrument if it is possible to do without it. There is a great dread in some people's minds about the existence of a large coagulum in the bladder. I have even known a bladder to be opened above the pubes by the surgeon for the mere purpose of evacuating a mass of clotted blood. Leave it alone; it will gradually be dissolved and got rid of by the continued action of the urine; while if you are in haste to interfere, and are very successful in removing it, you will succeed also most probably in setting up fresh hemorrhage. The bleeding vessels have a far better chance of closing effectually if they are not subjected to mechanical interference. Meanwhile, support the patient's powers by good broths, &c.

But it sometimes happens that hemorrhage occurs in a patient who has long lost all power of passing urine except by catheter. This is a very different position. Here the coagulated mass which fills the bladder must sometimes be removed, or no urine can be brought away. Thus, you introduce a catheter and none appears, for the end of the instrument passes into a mass of coagulum, and nothing can issue. Sometimes sufficient may be removed by attaching to a large silver catheter a six-ounce syringe or a stomach-pump. Clover's lithotrity apparatus has answered remarkably well with me in two or three instances. Let me caution you never to inject styptics into the bladder; the irritation does more harm than good.

In passing to another subject I beg to call your attention to a glass before you containing some urine of a dark and somewhat unnatural tint. Let us interrogate the case of the patient from whom it came. In obtaining this specimen I took care that he should first pass about an ounce into a separate vessel to clear his urethra-a precaution always absolutely necessary to avoid error, as I have before warned you-and the remainder into this. It is less translucent than average healthy urine is, and has a deeper colour. The hue is not red, but slightly orange, with a dirty brownish tint, commonly and very well distinguished by the word "smoky." That tint denotes blood to an ordinarily practised eye. Why is it not red? Because blood after a certain term of contact with urine loses its red colour and becomes brown; and you see it in that condition, or according to the quantity, producing any depth of hue from this up to that of London porter. Put it under the microscope, and you will find plenty of blood-corpuscles. We get this broad principle, then, to start with: bleeding from the more distant parts of the urinary system, unless in very large quantity, will almost certainly make the urine brown, while urine which contains red blood has almost certainly issued recently from some source in the bladder, probably at or near its neck, these being the more common sites of vesical hæmaturia.

In the case before us, then, we proceed easily and rapidly to eliminate many of the sources of bleeding by physical exploration, and by the account which he gives of his sensations. He makes a good stream when a fair amount of urine has accumulated in his bladder, but this does not often happen, for he passes it every two hours or less in the day, not so frequently at night; no straining is necessary. Pain in the course of the urethra is experienced during and after micturition; not severe. He is uneasy about the pelvis and loins on taking exercise, and more blood passes afterwards. He is somewhat emaciated, and so presents a good condition for examination by the hand. He is subject to variation in the intensity of the symptoms, having now and then attacks of a few days' duration, in which they are aggra vated, and he dates their commencement in an attack which occurred seven years ago. His age is forty-five years. He has never passed gravel. He is much less robust than formerly; his digestion is not good. A full-sized bougie passes easily into the bladder; no stricture; hypertrophy of prostate at his age not possible. On sounding he is manifestly more tender than

usual; nothing is felt, nor any deviation from the natural condition by simultaneous examination by the rectum. Palpation of lower part of abdomen shows nothing. Arriving close under the last ribs of left side with one hand, the other pressing firmly on left renal region, he flinches unmistakably; that is the spot, he says, where he feels pain at times and on movement: right side nothing. We examine his urine: sp. gr. 1018, acid, small brownish deposit on standing; under microscope, blood-corpuscles, some pus-corpuscles, epithelium, no crystals, no casts; albumen a little; corresponding with organic matters present.

What is the seat of the lesion in his case? Perhaps the bladder: we found it tender to the sound, and it acts with undue frequency. Yet remember this is by no means evidence of any primary morbid change there, such conditions constantly accompanying diseases affecting primarily the kidneys or the upper part of the ureter. Much more probably the kidney. The manifest local tenderness, the repeated attacks, the impaired health, the history, the absence of all the more common causes of cystitis in any form, point to the left kidney as the seat of mischief. The absence of albumen and of renal casts a fact of not much weight, although their presence is of the utmost importance-lead us to believe him free from organic changes affecting the renal organs. I conclude that his left kidney is the seat of calculus. although he has never passed one, and has at present no crystalline deposit in his urine-a fact by no means essential to the diagnosis; and that this calculus is the source of the blood and pus found in his urine.

It is sometimes not easy to say what kind of calculus exists in these cases, of which this is a fair type. When any calculous matters have been passed which can be examined, or when the crystalline deposit in the urine is constant, the inference is pretty clear. Add to this that the probability in any case is strong in favour of uric acid, from its known frequency of occurrence-taking large numbers, say at least fifteen to one as compared with oxalate of lime.

For treatment: Alkaline diuretics and diuretic vegetable infusions, before named, for a period of time; attention to the digestive functions and to that of the skin, for the kidneys are probably working too much vicariously for some other function acting lazily; moderation in highly nitrogenized food; mild alcoholic drinks, perhaps in most cases permitting only a light and mild Bordeaux. Of all medicinal remedies, perhaps none are so valuable as mineral waters, especially those which have sulphate of soda largely diluted as the main ingredient. Take Carlsbad as a type. For two well-known remedial agents, which are very popular, each among its class, I am bound to tell you I have very small esteem. In town, it seems to me that every man advises his neighbour, and on every pretext, to drink Vichy water-advice which is cheap, and of which the value in most instances by no means exceeds the cost. In the country, where perhaps the fairer sex more usually dispense similar aid to their suffering neighbours, the prescription is mostly ginand-water. Of the first, or natural product, which is a strong solution of carbonate of soda, I must say that, if not absolutely injurious, it is at least greatly inferior to potash; and of the second, or artificial one, that it is about as serviceable to the kidneys as a pair of spurs is to a jaded horsemakes him travel for a time, but takes it out of him in the long run. For the paroxysms of severe pain which denote the passage of a renal calculus, it must suffice here to name, hot hip-baths with diluents, and anodynes in liberal quantity.

I shall here, by way of episode, refer to a mode of determining the true characters of a patient's urine, which is of extreme value in some doubtful cases-a mode which has never to my knowledge been recommended or practised, and which I have systematised for myself. I have already told you how essential it is to avoid admixture of urethral products with urine, if you desire to have a pure specimen. It is sometimes quite as essential to avoid its admixture with products of the bladder. And I defy you to achieve an absolute diagnosis-by which I mean a demonstration, and never be satisfied with less if it be practicable,--in some few cases, without following

the method in question. When therefore it is essential to my purpose to obtain an absolutely pure specimen of the renal secretion, I pass a soft gum catheter of medium size into the bladder, the patient standing, draw off all the urine, carefully wash out the viscus by repeated small injections of warm water (before shown to be rather soothing than irritating in their influence), and then permit the urine to pass, as it will do, guttatim, into a test tube or other small glass vessel for purposes of examination. The bladder ceases for a time to be a reservoir; it does not expand, but is contracted round the catheter, and the urine percolates from the ureters direct. You have, indeed, virtually just lengthened the ureters as far as to your glass. And now you have a specimen which, for appreciating albumen, for determining reaction, and for freedom from vesical pus and even blood, and from cell growths of vesical origin, is of the greatest value, and has often furnished me with the only data previously wanting to accomplish an exact diagnosis. Mind never to be satisfied to guess at anything; make, very cautiously if you will, your provisional theories about a doubtful case-indeed, the intellectual faculty will do this constantly, and without reference to the will,-but arrive at no conclusion, take no action, except so far as you are warranted by facts.Lancet, Aug. 22, 1868, p. 241.

70.—STRICTURE OF THE URETHRA TREATED BY CAUSTICS. Under the care of HENRY SMITH, Esq., at King's College Hospital.

The treatment of stricture at the present day resolves itself into three chief methods, each one having its staunch upholders. There is the gradual dilatation of the contracted passage; sudden dilatation, as practised by Mr. Holt, of the Westminster Hospital; and there is the mode of cure, more particularly advocated by Mr. Wade, by the application of caustic to the face of the stricture, causing, first, abatement of the irritability of the urethra; secondly, "actual absorption" of the thickened tissue; and thirdly, and lastly, direct destruction of the thickened walls of the passage. This author states that he has never noticed any slough come away with the urine after caustic has been applied to the stricture, thus leading one to suppose that the potassa fusa does not destroy the tissue with which it comes in contact; but, as Mr. Henry Smith observes in his work on stricture of the urethra, "there is no reason to doubt that it has some destructive agency upon a stricture, knowing, as we do, its powerful effect upon other tissues; and I think the effect which is produced after a free application to a stricture can hardly be explained upon the principle of absorption alone."

The following cases have all three been treated by the last-mentioned method-i. e., caustic (potassa fusa) was applied-and all three have recovered remarkably well; and there seems to be no tendency to return of the constriction in Case No. 1. However, a sufficient time has not elapsed to allow of a verdict. We shall be glad to report the further progress of the

cases.

No doubt caustic cannot be used in every case of bad stricture of the urethra, but it appears to be clearly indicated in those cases where there is a great deal of irritability of the urethra; in those cases where only a small catheter can be passed, owing to the "density or irritability" of the stricture; and in those cases, happily very rarely met with, where a long constriction of the passage exists of so irregular and roughened a character as to preclude all hopes of restoring it without having recourse to perineal section. Case 1.-James R., aged 32, a labourer, living at Isleworth, was admitted into King's College Hospital, August 28, 1867, suffering from severe stricture of the urethra. The man states that twelve months before he applied at the hospital he fell while conducting a team of horses, and was run over by the cart which they were drawing. The wheels passed over the lower part of his abdomen. After this accident he was placed in bed, and next morning found he was unable to pass his urine. A surgeon was sent for, who, by an

instrument, drew off his water, and left the catheter three days in the bladder. From this time the man has had much difficulty in making water, and though on several occasions surgeons have attempted to pass an instrument for his relief, all efforts have been unsuccessful to introduce a catheter into his bladder. When admitted into King's College Hospital, Mr. Henry Smith failed in attempting to push through the stricture the smallest-sized catheter. There was much thickening of the urethra in the region of the perineum, and the patient at times complained of great pain, while the urethra was exceedingly irritable. As no instrument could be passed into the bladder, and as the man was in much pain, several leeches were applied to his perineum, and these gave great relief. The swelling subsided to a considerable extent, and he was able to pass his water in a fuller stream.

August 31. More leeches were applied, and relief afforded.

September 6. Similar treatment, accompanied by similar results.

The excessive sensibility of the urethra having been by this time allayed, Mr. Smith, on September 19, passed a bougie armed with a piece of potassa fusa down to, and applied it to the face of the stricture for half a minute.

September 20. Not so much pain, and stream of water slightly increased in volume.

The potassa fusa was applied in a similar manner, at intervals of two days, up to October 1, when Mr. Smith succeeded in introducing a No. 2 catheter through the stricture and into the bladder.

October 7. Catheter No. 3 passed.

12th. Catheter No. 5 passed.

The man wished much to leave the hospital, and was made an out-patient on October 23, when No. 7 catheter was passed.

The stricture had shown no sign of returning when the man ceased his attendance.

Case 2.-Henry S., aged 40, a stableman, was admitted into the Victoria Ward with stricture of the urethra, April 27, 1868. The man stated that he had gonorrhoea nearly twenty years ago, but that the difficulty in passing his water commenced about seven years since. Instruments had been at various times passed, and two years before applying at King's College he was in another hospital, where he said he underwent the "splitting-up" operation. On admission it was found that he could hardly pass his water at all, in so small a stream did it come. But the urethra was not very irritable, though no catheter could be passed through the stricture.

April 28. A bougie armed with caustic potash was introduced into the urethra, and pressed for a short space against the face of the stricture. Not much pain was felt by the patient at the time, and none afterwards, except when he passed his water.

May 2. The caustic potash was again applied. No pain was felt, but some muco-purulent discharge was caused, which lasted till

May 4, when Mr. H. Smith passed a No. 4 catheter with little trouble. After the introduction of the catheter, a pill of quinine and opium was administered.

No. 6

May 6. The urethra bled a little after the catheter was passed. introduced. Was at this date made an out-patient, as which he has been treated ever since. Now a No. 8 catheter passes easily (June 11).

Case 3.-Thomas R., a lighterman, living at Brentford, was admitted, under Mr. H. Smith, into King's College Hospital on May 7, 1868. The patient stated that he had much difficulty in passing his water for five years, and that some obstruction in the passage had existed long before. Six months since he had been, he said, an inmate of the Westminster Hospital, and was under the care of Mr. Holt, who performed an operation upon him, and greatly relieved him for a time; but the passage gradually contracted again, and on admission into King's College Hospital he could only pass a few drops of urine after violent straining, while at times he had retention.

May 8. As no instrument could be introduced, the caustic potash was applied in the usual manner to the face of the stricture, and a good deal of pain was complained of, both at the time and afterwards, by the patient, but no

bleeding ensued, and tinct. opii îxx. given at night made the man quite comfortable.

10th. Potassa fusa again applied. This time there was but little pain accompanying the operation, and none afterwards.

12th. Catheter No. 2 passed without very much difficulty, and without pain.

13th. Catheter No. 4 passed easily.

15th. It was attempted to introduce a No. 5, but the attempt gave so much pain that it was thought advisable to desist, and No. 4 passed readily.

This man has since been attending as an out-patient, and on May 29 No. 7 was introduced, giving no pain. The patient stated that he made water in a "regular good stream."

These three patients were suffering from stricture of so bad a character that no instrument could be passed, and therefore it was deemed advisable to use caustic as an auxiliary to gradual dilatation in the way of cure; but in most instances, without doubt, at least a temporary relief from the affliction can be afforded by the catheter alone. And finally, great caution should be employed in the use of caustic, both in its actual application and also in the selection of the class of cases for which it is necessary.-Medical Times and Gazette, July 4, 1868, p. 3.

71.-CURIOUS CASE IN WHICH INCONTINENCE OF URINE WAS THE FIRST AND ALMOST THE ONLY SYMPTOM OF PROSTATIC RETENTION WITH SECONDARY DISEASE OF THE KIDNEYS.

By JONATHAN HUTCHINSON, Esq.

[The patient was seen by Mr. Hutchinson only a week before his death. He was 54 years of age. He had suffered for six months from involuntary discharges of urine. It would escape as he was walking in the street, and also in large quantities when asleep in bed. He had no other paralytic symptoms. He could void urine when he wished to do so. Three weeks before his death Dr. Peacock saw him, and advised the use of catheters, and by the first instrument passed a large quantity of urine was drawn off. After this an instrument was passed once a day, and Mr. - ceased to suffer from incontinence, but also ceased to be able to pass urine voluntarily.]

As I was assured that Mr. was rapidly failing in strength, we were obliged to give a very unfavourable prognosis, at the same time we could find nothing to account for his condition. The urine was normal, and he had had no suffering in connection with attacks of retention. Paralysis of the bladder was suggested, yet as soon as the catheter entered the viscus, the stream was expelled with great force. That disease of the prostate should destroy life in so insidious a manner, without cystitis, &c., seemed incomprehensible.

Having got weaker and weaker, Mr. at length passed into a heavy, sleepy condition, in which, on Oct. 29th, he died. The autopsy cleared up what of mystery had surrounded his symptoms, and confirmed our conjectures. We found both ureters as large as small intestines, the right kidney a mere bag containing half a pint of fluid, but without any remains of renal tissue, the left kidney much enlarged and inflamed, its cortical structure everywhere infiltrated with grey deposit, its pelvis dilated, and its capsule firmly adherent. Scarcely a portion of healthy kidney structure remained. On seeking for the cause of this in the bladder, we found that organ of large size and with thick fasciculated walls. The prostate was moderately enlarged, and projecting from it into the bladder was an almost pedunculated lobe, the size of one's thumb, which stood up in such a manner that it must have formed a close-fitting valve over the entrance to the urethra, whenever the bladder contracted. This lobe presented a smooth surface, and as it overhung backwards, and had a sloping direction forwards, it would cause no difficulty in the introduction of a catheter.

No doubt the whole kidney mischief was secondary to concealed and un