I have been surprised at the result; not less surprised than I have been at the fact that the patient, who towards the close of lithotrity, or afterwards, is making urine every hour or so, and who, on passing his catheter, finds only one or two drachms behind, often obtains at once an interval of three hours or more. Such a one should pass his instrument at least three times a day until he regains the power to empty the bladder completely by his own efforts. I confess that formerly so small a quantity of urine did not seem to me worth the trouble of removing; as I assumed, on theoretical grounds of course, that it could not be of any importance. I now know that the practice of removing it constitutes for many cases the difference between a permanent success and an ineffectual result and painful future.

Now then, how does the plan of crushing for cystitis, referred to under the preceding head, affect, as I said it would, also this important question which we are now discussing? Thus it is precisely in those cases where the treatment has been prolonged, or where cystitis, either acute or chronic, has been allowed to go on unchecked, that the inability to empty the bladder is most likely to occur. Again, this inability, once commenced, very rapidly becomes the established order of things in elderly people, unless it is checked at the outset. Once let the bladder be accustomed to the smallest degree of accumulation of urine, and the power to empty itself entirely is, after a certain age, often permanently lost. The best chance of preventing this, and the phosphatic deposit which results, is, in the first instance, to avoid or cut short cystitis during the treatment by lithotrity in the manner described; and, secondly, to teach the patient to empty his bladder himself towards the close of the operative proceedings or immediately after, if the smallest failure to empty it is detected. Once for all, let me say, I cannot exaggerate the importance of these recommendations.

Now, when this tendency to produce phosphatic deposit has been unfortunately established, we are often able to benefit the patient by teaching him to wash out the bladder, by means of an ordinary catheter and bottle, with weak acetate of lead, nitric acid, &c. But of late I have adopted another method, with manifest advantage. I advise the patient (who may or may not be habitually using the catheter to empty his bladder) to use every second or third day the following apparatus:

(1) A black flexible catheter, No. 11 or No. 12 in size, made thin, and with polished interior, so as to facilitate the passage of débris through it (a great improvement on the ordinary French flexible catheters, which are thick and have often rough interiors), and having a large oval eye on the upper surface of its extremity, which is slightly turned upwards (coudée).

(2) An eight-ounce india-rubber bottle, with a brass nozzle which fits over the outer end of the catheter, and not into it. The manifest result of this mode of attachment is, that a powerful uninterrupted current can enter and issue from the bladder; indeed it is scarcely possible that débris should remain in the organ under the influence of the action of this apparatus, as any one can perceive on using it. It may also be used as an aspirator, with a backward and forward current, if desired. For the patient's own use it is even more easy than the ordinary four-ounce bottle, which I have long been in the habit of desiring such to apply, since the size and freedom of the channel-not narrowed at the point of contact between bottle and catheter-permit the fluid to be propelled with very slight pressure.

There is still one admirable remedy for that low chronic cystitis which is associated with the production of phosphatic calculus in the bladder-viz., the injection, every day or every other day, for a short time only, of a very weak solution of nitrate of silver. About half a grain to four or six ounces of distilled water is amply strong enough; and one or two injections sometimes suffice, in these circumstances, to produce a very notable diminution of the muco-purulent secretion. Lancet, Jan. 8, 1876, p. 39.

58. ON THE RETENTION OF BOUGIES INSTEAD OF CATHETERS FOR THE CONTINUOUS DILATATION

OF STRICTURES.

By FURNEAUX JORDAN, Esq., Surgeon to the Queen's Hospital, Birmingham.

Among the various methods of treating stricture of the urethra, that of continuous dilatation is justly held in much esteem. In a few days, and with no risk, a very tight stricture may be dilated so as to permit a large instrument to be passed; hence the treatment may be said to combine the safety of gradual dilatation with the rapidity of incision or rupture. It is not suited to every case. It will not, for example, take the place of internal division in strictures anterior to the scrotum, nor of external division in persistent fistulæ. In a large number of tight-perhaps very tight-old and neglected strictures, with no great irritability or resiliency or attendant induration, the surgeon is glad to get in a fine instrument and leave it in.

Although it may require much patience and skill to introduce the finest bougie, the general custom is to withdraw it and attempt the introduction of a catheter. The effort occasionally fails, and much valuable time is lost. Now, in such cases I have for several years kept in the fine or filiform bougie, and

directed that the urine should be passed from time to time by its side or around it. In every instance in a large number of cases this has been easily done, micturition, as a rule, actually being easier and in a larger stream than when the bougie is out. In twenty-four hours a goodly-sized bougie (not catheter) can be introduced. On the third day I usually put in a No. 12 or even No. 13 bougie or catheter. It is of course in the earliest stages that the superiority of the bougie over the catheter is seen.

The advantages of the treatment I have just described are these:-A more rapid and complete dilatation, due to the hydrostatic pressure of the urine along the exterior of the bougie; a bougie is more easily introduced than a catheter; when the finest bougie is once in, it need not be taken out-no slight boon; the ordinary acts of micturition are preserved; every kind of apparatus for keeping the bed dry, or for any other purpose, may be dispensed with.-Lancet, Jan. 29, 1876, p. 169.

59.-IMPROVED CATHETER FOR BED-RIDDEN PATIENTS.

SALT & SON BIRMINGHAM

Messrs. SALT & SON, Surgical Instrument Manufacturers, Birmingham, write to us:-"In a paragraph which appeared in the British Medical Journal, January 1st, 1876, you mention a suggestion of Dr. George for rendering a catheter more convenient for use with bed-ridden patients, by the attachment of a piece of india-rubber tube connecting the catheter with the pôt de chambre. The engraving above will show the plan we recently devised for accomplishing this purpose.

To an ordinary catheter we attach a curved tube, on the end of which the india-rubber tube is slipped, having at its other end a small weight to prevent the tube from leaving the vessel. The distal end is made to act as a syphon; the flow only takes place when the sliding tube is drawn out about half an inch. By this arrangement, the bed-clothes and the surgeon's hands are protected from the fluid."-Brit. Med. Journal, Jan. 8, 1876.

60.-ON PUNCTURE OF THE BLADDER PER RECTUM. By RICHARD DAVY, Esq., Surgeon and Lecturer on Anatomy at the Westminster Hospital.

[There is scarcely any operation so devoid of danger as puncture per rectum. The instruments usually used are a solid trocar and cylindrical canula, the latter being retained in the bladder by tapes.]

In 1870, being impressed with the disadvantages of retaining for any length of time an unyielding tube per rectum et vesicam, I introduced the instrument (Fig. 1), in which the steel slotted

cylinder is outside, and acts as a perforator, carrying the elastic catheter as an inside passenger. Fig. 2 shows the catheter withdrawn, also the reduplication of the tip of the catheter, by means of which it is retained in the bladder. The patient is placed after the operation on a mattress having a circular hole corresponding to the buttocks; the end of the catheter falls through this hole, and conducts the urine into a receiving vessel on the floor below. Fæces also are thus passed without moving the patient.

Fig. 2.

I have yet further applied this principle of giving the urethra rest to those cases of obstinate perineal fistula that are not dependent upon an obstructed urethra for their persistence. I am of opinion that a simple operation like puncture per rectum is more effectual and easy than periodic introductions of a

catheter; the object being in both cases to avert the irritating urine from the damaged urethra and fistulæ, especially so because in some cases men have not the power of retaining their urine; and it is impossible by the most skilful catheterisation to avoid some disturbance to the urethra, and some extravasation of urine over the exposed surface of it and the fistulæ.

I have been in the habit of comparing the rationale of puncture per rectum in fistulous cases to the method pursued by workmen when repairing the damaged banks of a running stream. Their first object is to completely divert the stream from the seat of their repairs, so that one day's wash shall not outweigh one day's work; and this argument applies with double pathological force to the irritating urine as compared with the pure water. But a moment's reflection makes a surgeon see how inapplicable Cock's method would be for opening an empty bladder; and, at the risk of the charge of superfluity, I venture to bring you acquainted with a new instrument, and a new method of operating on this much operated on human perinæum. The instrument consists of a staff, on which slides a silver cylinder, and a removable handle. (Fig. 3.) The silver tube runs from the bulge at the right end of the staff to the commencement of the curve on the left. The thin stem underneath the handle is for the attachment of a retentive catheter.

SAVICNY & CL

Fig. 3.

New Method of Operating.-First introduce the staff into the bladder; turn the tip of the staff towards the base of the bladder and rectum; feel for the point with the finger in the rectum, and carefully cut the recto-vesical tissues until you can pass the staff out at the anus. Next unscrew the handle and affix the stem of one of Napier's retentive catheters to the thin end of the staff; soap well the india-rubber; then, holding the silver tube firmly in one hand, draw the catheter (excepting its bell-shaped end) completely into the silver tube by withdrawing the staff at the anus. Lastly, draw back the silver tube and catheter through the urethra into the bladder; push in the catheter, and free the silver tube by also withdrawing it through the rectum out at the anus. The campanulate end of the catheter unfolds itself in the bladder, and its stem loosely hangs at the anus.-Brit. Med. Journal, Dec. 4, 1875, p. 697.