first, washing away any irritating excretions, and, secondly, giving tone to the vessels of the part.

In the first of the above cases pain was the prominent symptom, and upon superficial considerations might have induced the belief that fissure of the anus was the cause of the suffering. He had violent pains at stool, but it was not of that sharp, smarting character felt at one spot as in the latter affection; he also had aching in the part, occurring at various periods of the day, and not following the act of defecation as in fissure, neither was there spasm of the sphincter ani. The amount of blood lost was trivial, and could have no constitutional effect; his countenance indicated great suffering. That constipation and its concomitants were the cause of the local disorder is evident from the absence of any other source to which to ascribe it, and the result of the treatment verified the conclusion.

The disease in J. S. was chiefly due to the effect of constipation, arising from the very common cause-want of proper exercise, and maintaining the sitting position a number of hours consecutively; biliary congestion had also been induced, and preceded the hemorrhoidal affection. Acting freely on the bowels in the first instance, mild mercurials for a short time, the injection of cold water, and afterwards the use of tonic and purgative medicines combined, so as to give tone and induce a regularity of action of the bowels, restored the patient to health.

The great constitutional effects arising from hemorrhoidal disease, attended with loss of blood, was forcibly marked in the case of A. A. There was the pallid countenance, the colourless lips and gums, the weak and fluttering pulse, the heart excited on the slightest cause, either mental or physical. Here, also, we find constipation the cause of the disease, the removal of which by enemata and laxatives, and afterwards having recourse to tonics, and paying due attention to the regular action of the bowels, had the effect of restoring her to health and comfort.

The case of R. R., presents features not exemplified in the preceding. Besides gain in the rectum and loss of blood, the piles were extended at stool, he was troubled with a constant mucous discharge, and was unable to retain the fæces, when making any exertion, in consequence of relaxation of the sphincter, the reverse of the condition of the muscle in external hemorrhoids, particularly if complicated with fissure, when a preternatural contraction of it exists. Irritation was propagated to the urinary organs; but one of the most important features was the fulness in the head and giddiness of which he complained, and involved some consideration with regard to treatment. From the latter circumstance, he had been advised not to have the hemorrhoidal disease interfered with. But this patient was not plethoric, nor was there any external evidence of cerebral congestion; therefore the symptoms were due to another cause, and examination of the urine revealed the source, arising from a morbid condition of

the blood, occasioned by the imperfect action of the several depurating organs, especially of the skin and kidneys. Having freely unloaded the bowels, and afterwards attending to keep them regular, and by inducing a healthy performance of the functions of the other abdominal organs, no evil followed the cessation of the hemorrhoidal flux; and it is evident, had he been able to lay up for a day or two, an operation would have entirely freed him of the disease, without the slightest fear of mischief occurring to the head; but while he pays strict attention to himself, and nothing of importance takes place to derange his general health, he will continue without other annoyance than the mucous discharge from the bowel soiling his linen.-Lancet, Jan. 14, 1854, p. 36.

118.-ULCER OF RECTUM, TREATED BY SIMPLE INCISION. By WILLIAM OLIVER CHALK, Esq.

[This patient, aged 31, states that he has suffered for many years from habitual constipation and hemorrhoids. But from June 1852, to March 1853, he seems to have suffered from a compound of all the symptoms of ulcer of the rectum and spasmodic stricture of the urethra. Enemata gave him the only, though but slight, relief. His sufferings appear to have been almost intolerable.]

He has lately obtained slight relief by sitting on a piece of cork, so made as to push up and support the anus; but his sufferings have become so insupportable, that, unless they are speedily mitigated, he must, he says, give up his occupation, which is that of watch-pallet making. His general health is bad; the digestive functions are much impaired; tongue covered with a thick buffy fur, and red at its point; there is great epigastrial tenderness; pulse 84, full and jerking; skin hot and dry, especially in the palms of the hands; he is often assailed with severe abdominal pains, nausea, loss of appetite, and occasional vomiting of undigested food when the pains in the rectum are violent. He is subject to severe headaches. A consideration of the local symptoms here narrated, led me to conclude that they were occasioned chiefly by an ulcer of the rectum, which there was no difficulty in discovering. It was situated near to the point and to the right of the coccyx, of irregular form, as near as one could estimate by the touch, the size of a shilling, and excruciatingly painful under the examination. The sphincter was very unyielding, and there was a deep fissure on the right side extending to the verge of the anus. It would occupy too much space in these columns to describe the local and general treatment that preceded the operation; it need only be said, that his health was greatly improved, and the ulcer slightly. On the 23rd of April, chloroform being previously administered without bringing the patient fully under its influence, an incision was made into the mucous membrane beyond the ulcer, and

carried through it and the fissure, in the manner recommended by Mr. Quain in his lectures, thus avoiding the more formidable proceeding of dividing the sphincter ani. A very small loss of blood ensued from the operation. The patient was directed to remain in bed, and an opiate draught to be taken at bedtime. On my visit the following day, at eleven o'clock a.m., I found him suffering severe pain, much excited, hot and feverish, complaining of headache, and possessed with the idea that the operation had proved abortive. I learned that about six o'clock a.m., his bowels were naturally and freely relieved with little pain (a small coagulum of blood having passed with the motion), and again at nine o'clock, but that time a large pile descended, and made its appearance at the right side of the anus; it was excessively tender, very tense, and of a livid red colour. This circumstance sufficiently explained the cause of his suffering. Some days elapsed before the effects of this accident were remedied, after which the success of the operation became manifest by the subsidence of all the distressing symptoms under which he had laboured so long. On the 13th of June I received a visit from my patient; his general appearance had greatly altered for the better; he said he had not been so well for years, and that he had resumed his occupation.

Were further testimony wanting than that already adduced by Mr. Quain of the thorough efficacy of simply dividing the mucous membrane for the cure of ulcers of the rectum, it would be afforded by the case narrated above, which was interesting from the more than usual severity of the accompanying symptoms, and its complication with hemorrhoids. The ulcer was larger than usual, and the reflex actions resulting therefrom complex and severe; the general health, too, was much deranged,—an unusual occurrence, according to Mr. Quain. From the history of the case, it would seem that constipation and the continual loss of blood was the proximate cause of ulceration,— at all events, the indications of it, (viz., the "bearing down, aching, and smarting," &c.,) did not come on until after the hemorrhage had ceased, that event being marked by an accession of symptoms more especially referable to ulcer of the rectum. It is difficult, as Mr. Quain observes, to assign any reasonable cause for the periodicity in the cessation of pain after an evacuation observable in these cases. this instance, it generally extended to five minutes only, and never exceeded ten; but whatever it may be, this peculiar symptom, apart from the rest, may almost be considered pathognomonic of the disease. With respect to the contraction of the sphincter ani, it must, I think, be conceded, that the conclusion arrived at by this gentleman is essentially correct, viz., that the condition of the muscle is no more the actual disease than the spasm of the orbicularis in strumous ophthalmia. Of the operation may be said that which can scarcely be affirmed of any other involving a corresponding amount of relief, that the subsequent inconvenience arising out of it is so trifling, as scarcely to be regarded by the patient, while the subsidence of extreme suffer

In

ing is almost immediate. Henceforth, in all probability, the division of the sphincter ani for this disease will give place to the simpler and safer plan of incising the mucous membrane only; but if otherwise, it is sufficiently obvious, from the successful issue of the cases recorded, that, as a general rule, recourse should be had, in the first instance, to it, and not to the more serious proceeding of dividing the muscle.— Medical Times and Gazette, Dec. 10, 1853, p. 599.

ORGANS OF URINE AND GENERATION.

119.-ON STRICTURE OF THE URETHRA, AND ITS TREATMENT BY DILATATION.

By WILLIAM COULSON, Esq., Surgeon to St. Mary's Hospital. [Mr. Coulson still adheres to the opinion that the perineal section is only adapted to certain cases of obstinate stricture, and that these cases are the exception to the rule. He believes dilatation to be the most simple and efficacious plan, and, in this paper, he considers the kinds of cases in which dilatation may be most successful. He says:]

It is hardly necessary for me to remind you that permanent stricture of the urethra means a contraction or narrowing of the canal at some point, caused by change of structure, from inflammation or the healing of an ulcerated surface. The effects of inflammation, then, in giving rise to permanent changes of structure, are the immediate means by which the narrowing of the canal is produced; and to understand or appreciate the advantages of any mode of treatment it is obviously necessary for you to be acquainted with, and ever to bear in mind, the changes of the different tissues which accompany and give rise to stricture of the urethra. The changes now alluded to present great varieties in their seat and extent. They may be confined to the mucous lining of the urethra, or may implicate that membrane and the subjacent tissues at the same time. Sometimes the effects of inflammation are slight, though the difficulty of passing a bougie may have been great. The mucous membrane of the urethra is perhaps injected at certain points, thickened, and has lost its natural elasticity, In some cases, as Mr. Hancock has recently shown, the narrowing of the canal is produced by the deposit of an organised false membrane on the surface of the mucous lining. When the disease has lasted for any length of time, the morbid changes are seldom confined to the lining membrane of the urethra, but extend to the deeper-seated tissues. I shall now merely invite you to remember that as the inflammation extends to the sub-mucous cellular tissue, this structure becomes condensed, from the agglutination of its interstices by organised lymph; it is also more or less increased in bulk, and when the swelling with condensation has continued for any length of time, the

new tissue is converted into a dense, fibrous mass of great resisting power. In some cases it may be so callous and resisting that, on dividing it with the knife, a noise produced as if one were cutting through a portion of cartilage. This is particularly seen in cases where the inflammation has involved the spongy tissue surrounding the bulb of the urethra, when the whole mass may be found changed into a dense ligamentous substance, or into a "hardened callosity," in which no distinction of parts can be traced. The extent to which these changes occur vary in every individual case. Sometimes the chronic induration and thickening occupy the whole diameter of the urethra, and give rise to a circular contraction of its canal, the stricture appearing as if caused by a mere thread, or extending to half an inch or more of the circumference. In other cases this thickening is irregular and tortuous, or it may occupy only one part of the circumference of the canal. It is also important to remember that there may be several strictures at the same time, one or two occupying the anterior portions of the urethra, and a third seated at the point of union between the bulbous and membranous parts.

The symptoms of stricture are, generally speaking, sufficiently obvious, but I shall not dwell on them at present, as my object is to explain to you the principles on which dilatation should be conducted. Before we have recourse, however, to any method of treatment, it will be prudent to employ certain preliminary measures for the purpose of reducing any excess of irritation or inflammation that may exist. Unless this be done, the use of instruments may give rise to very unpleasant, if not dangerous symptoms; the cure will be greatly retarded, and the hopes of both surgeon and patient sorely disappointed. Having then subdued any inflammatory complications which may exist, your first care will be, by careful examination, to ascertain the seat, nature, and extent of the stricture-circumstances absolutely necessary to be known before you undertake any means whatsoever for its removal.

Various methods have been employed for making the preliminary exploration of the urethra now alluded to, and writers are by no means agreed on the best kind of instruments to be used. Sir C. Bell recommended a ball-headed probe for the purpose, but this instrument does not justify the favourable opinion of it formed by its author, and is now, I believe, entirely abandoned.

Dr. James Arnott invented a particular kind of exploring sound, which was afterwards adopted and modified by Ducamp. Dr. Gross employs a common silver catheter or a graduated bougie, the end of which is tipped with cobbler's wax. When the stricture is not very narrow, M. Civiale informs us that a small gum-elastic bougie covered with soft wax may sometimes be used with advantage, but he prefers for general use very soft wax bougies, with which, according to him, the most exact marks of the stricture can be obtained.

Dr. Bigelow, of the Haward University, United States, strongly