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which he continued to pass his water until May 3, when I found but little difficulty in introducing a small elastic catheter through the urethra into his bladder. The canula was then withdrawn from the rectum. There was no further difficulty in the ordinary treatment of this case; and when he left the hospital, five weeks after his admission, he could make water in a full free stream, and was relieved from all his former symptoms. No urine escaped through the puncture after the removal of the canula.

He died of renal disease in May, 1851. On inspection, a faint cicatrix on the mucous surfaces of the bladder and rectum indicated the site of puncture.

Case 3.-J. R., aged 22; admitted into Guy's Hospital, April 28, 1847. Dissolute and intemperate. Has had symptoms of stricture five years, following clap, with occasional attacks of retention requiring the catheter. On his admission he was passing his water with extreme difficulty and distress, and his canal had been much disorganized by previous attempts to pass an instrument. All the usual methods, employed during four days, failed in giving him relief; and on May 2, he having passed no water whatever for twenty-four hours, I punctured the bladder. Three days afterwards an elastic tube was substituted for the silver canula. May 11. An abscess was opened in the perineum.

May 14. The tube was removed, as it had become obstructed, and the water now flowed through the natural passage. He continued to pass a portion of his water for some days through the recto-vesical opening, and left the hospital perfectly well May 19, three weeks after his admission.

Case 4.-J. P., aged 35; admitted into Guy's Hospital, May 21, 1847. A policeman. Between three and four years ago he sustained much injury from a forcible separation of his thighs, and ever since has suffered from gradually increasing symptoms of stricture. Two years ago had temporary retention; and for several months has passed his water by drops, with great difficulty and straining. On his admission was suffering intensely from distended bladder, and the fruitless efforts which had been made to introduce an instrument. After much trouble, a small catheter was passed into the bladder and retained until the next day.

May 24. Total retention, with great distension and distress. The urethra was too much disorganized by previous manipulation to allow of any further attempts at catheterism, and I therefore punctured his bladder. He retained the canula until May 30, when I was enabled to pass a small elastic catheter through the urethra.

June 13. The urethra readily admits a moderate sized catheter, but the bladder has in great measure lost its contractile power, from habitual over-distension. To remedy this his water was drawn off daily. In a few days his bladder regained its tone, and he left the hospital, perfectly well, June 18. I saw him about a year afterwards, and learnt that he had continued free from all symptoms.

Case 5.-J. H., aged 39; admitted into Guy's Hospital, June 25, 1847. Had suffered from stricture many years. Had retention ten years ago, and was probably much injured by unsuccessful attempts to pass an instrument. On his admission his bladder was by no means distended, but the intolerance was extreme, and he passed his water in drops with great difficulty.

The usual palliative treatment, combined with instrumental means, was adopted and continued for a fortnight, at which period (July 8) he first came under my observation. He was then enduring great agony; and although there was neither distension of the bladder nor actual retention, I judged it advisable to give him relief and supersede any further attempts on his urethra by puncturing through the rectum. The bladder only contained about eight ounces of urine; and although the operation at once relieved the intolerance and distress, he continued to suffer from dull, heavy, severe pain about the perineum and rectum. This, however, in a few days became relieved after a free evacuation of the bowels, and at the same time the expulsion of a quantity of grumous coagulated blood from the urethra, no doubt the product of previous violence.

July 14. The canula, which had become coated with calculous matter, and was producing great irritation, was now removed. During the next two weeks, he passed his water principally through the rectum, but also in an improving stream through the urethra; the recto-vesical puncture acting as a safety valve through which the urine gushed out whenever there was any urethral obstruction, or when he strained forcibly to micturate. I now introduced a small bougie into the bladder, and the

case readily yielded to ordinary gentle treatmeut, until he left the hospital quite well, August 17.

[Mr. Cock now relates 38 cases in which perfect success followed the operation of relieving the bladder by puncturing it through the rectum, and which also he believes in many cases to have materially tended to the restoration of the patient, by the less degree of suffering induced, and by the more speedy and effectual relief it afforded. To this paper, in August, 1852, he adds the following postscript:]

The trocar and canula which I am in the habit of using for puncturing the bladder, are essentially similar to those which have been hitherto employed for that purpose; but I have found it advisable to increase their dimensions in length and thickness. I have also added a blunt-pointed or pilot trocar, which very much facilitates the introduction of the canula into the rectum, and its adaptation to the precise spot

intended to be pierced. I likewise found it necessary to adopt some contrivance which should retain the canula in the bladder during change of position or evacuation of the bowels, and which might at the same time prevent the sharp extremity of the instrument from wounding or irritating the lining membrane of the viscus. This double object has been fully accomplished by the introduction of a second tube split at its extremity into three expanding branches, each of which is furnished with a small bulb, and form together a button-like projection at the end of the first canula. A third tube is then introduced through the second to secure it in its place and to prevent the collapse of its branches.

With this apparatus the canula may be retained in the bladder for as long a period as occasion may require.

A small disc of caoutchouc around the second and third tubes, and a plug of gutta percha, render the entire instrument water-tight, when it is considered desirable to allow the urine to accumulate in the bladder.-Medico-Chirurgical Transactions, 1852,

p. 153.

99.-ON A NEW FORM OF DIRECTOR FOR THE REMEDY OF STRICTURE BY EXTERNAL INCISION.

BY PROF. SYME, Edinburgh.

[Mr. Syme states that he has now operated upon eighty cases of obstinate stricture by external incision, without in any case a fatal result ensuing. He thinks the danger of the operation cannot be urged, therefore, as a plea against it. Certainly, in his earlier cases the disease returned, but he is now satisfied that it was from the incision not being sufficiently free by dividing the whole extent of the contracted part of the canal. He now proposes a modification of the apparatus, which he believes will insure the permanent latency of the canal. He observes:]

So long as an instrument employed to explore the urethra does not pass through the stricture, it distinctly determines the seat of obstruction; but so soon as its point gets fairly beyond the contraction, unless there should be a perceptible thickening of the canal, which seldom occurs, except in its anterior part before the scrotum, there is no longer any trace of the stricture that can be detected by the most careful examination, even after the coverings of the urethra have been divided. Hence no doubt the long cherished, and still not entirely abandoned, errors, in regard to the situation of strictures, and especially the mischievous delusion of their occurring at the "neck of the bladder," in the membranous portion of the urethra, or at any point behind the bulb. Hence also the difficulty which has been experienced in passing catheters, after it seemed that the stricture was freely divided; and hence also, no doubt, the imperfect results of some operations performed by myself and others.

Having long experienced the inconvenience attending this uncertainty as to the precise seat of the stricture at the time of operation, I tried the effect of slipping a piece of elastic catheter over the director, so as to leave it exposed three inches from the point, and thence covered up to the handle. As this contrivance was found to answer the purpose in view completely, I had a solid steel director made of the same form, and I may now explain the mode of using it. The slender part having been passed through the contracted part of the canal, the director is confided to an assistant, who keeps it steadily pressed down upon the stricture with one hand, while he holds up the scrotum and penis with the other. The operator then cuts through the integuments and subjacent textures until he distinctly feels the guiding instru ment, when ascertaining at once where the stricture is seated, he inserts his knife in the groove at least an inch below the thick part, runs it forward to the termination, and then, taking the director in his left hand, withdraws it, together with the knife, still held at the extremity of the groove, so as to divide the strictured part completely, which is shown by the thick portion of the instrument freely passing the seat of its previous obstruction, when urged towards the bladder. If the operation has been properly performed, the catheter is then passed with the same facility as in a perfectly sound urethra. During the two months that have elapsed since the adoption of this contrivance, I have employed it in six cases.-Monthly Journal of Med. Science, Aug., 1853, p. 175.

[In a letter to the editor of the 'Medical Times and Gazette,' DR HENRY DICK observes that though he sincerely admires the skill and success of Mr. Syme in his operation, he yet thinks the subcutaneous incision would render it still more simple. Hoping to dwell larger upon it at another time, he scarcely more than alludes to it now. He relates the following case:]

A young Italian was under my care for a stricture in the membranous portion of the urethra. I explored the canal, and examined the form of the stricture after the method of Ducamp; I then passed a caoutchouc catheter with its stilet No. 1, and succeeded in passing it through the stricture; but my patient had not the opportunity of remaining long enough in England to enable me to cure his stricture by this slow method, and, having heard of Mr. Syme's operation, was anxious it should be performed: I yielded in part to his wish. Having placed my patient in the position as for lithotomy, and having passed a grooved sound through the stricture with a scalpel, I divided the skin, making a very small opening, and in the same manner the urethra. I then introduced into the opening of the urethra a small curved tenotome, and without further division of the integument, divided the stric

ture from before backwards. Lastly, with the sound, I assured myself that the stricture was perfectly divided. This operation is readily imitated on the dead body. A curved needle and thread may be passed around the urethra, beneath the skin, the needle being brought out at the point of entrance. Thus, a loop will be formed, which, being tightened around a grooved staff, will perfectly represent a stricture. I term this operation subcutaneous, because it is in reality so. After the operation, the catheter was not left in the bladder, but passed when required to empty the bladder. After its use, warm water was injected. I preferred this mode of treatment for the following reasons:-When the catheter is left in the bladder, some drops of urine will dribble along it to irritate the wound. Those who have operated for laceration of the perineum know that cicatrization is prevented, and ulceration produced by contact of the urine. Mr. Baker Brown places his patient on the knees and hands during the catheterization, to prevent the urine coming in contact with the wound. By the introduction of a catheter well adapted to the urethra, and by injection of water, I endeavour to prevent the contact of urine with the wound. The small external incision heals almost by the first intention. As to the interior wound, I would not hazard an opinion as to the time of its closure; after six weeks, however, my patient had neither pain nor difficulty in micturition; nor was there at this time sensible trace of the stricture on using the catheter. I therefore presume cicatrization to have been, then, complete. Future observation will prove which operation is the best, the subcutaneous incision or that of Mr. Syme. It will, perhaps, be objected, that, to pass a catheter daily, would cause irritation, and prevent cicatrization, or, perhaps, lacerate the urethral wound. I would reply, that the urine in passing through the urethra is a foreign agent, charged with its proper salts, which produce irritation, far different to that of a well adapted metal catheter.-Med. Times and Gaz., May 28, 1853, p. 559.

100.-CASE OF URIC ACID CALCULUS, WHICH APPEARED TO HAVE BEEN DISSOLVED IN THE BLADDER BY ALKALINE REMEDIES.

By F. A. BULLEY, Esq., Surgeon to the Royal Berkshire Hospital.

[On November 15, 1847, the patient, a delicate-looking, scrofulous boy, was admitted into the hospital for symptoms resembling stone in the bladder, which had increased in intensity during the previous six months. The disease had been about three years in its duration. The urine contained a whitish gritty sediment, and much tenacious mucus. He had neither pain at the end of the penis, nor sudden stoppage of urine, but his previous medical attendant had satisfied himself of the presence of stone in the bladder. Mr. Bulley proceeds:]

An examination which I now made with a metallic sound, left me no room to doubt the nature of his complaint, the unmistakable feeling of a stone in the bladder being clearly perceptible; and the patient was, therefore, other circumstances being favourable, admitted as a fitting case for the operation of lithotomy. Having, however, just previously become acquainted with the particulars of a case of stone which had apparently been dissolved by the employment of saline medicines, which, I understood, had been procured from a person living somewhere in Warwickshire, and having, principally through the kindness of my friend, Mr. Adams, of the London Hospital, succeeded in obtaining a knowledge of the probable composition of the remedy, which I was told was generally known by the name of Constitution Water," I determined to employ some analogous preparation in the present case, although, I must confess, but with little hopes of success.

66

Taking for granted that the gritty sediment, which had been occasionally observed in the urine, was principally composed of lithic acid, and having no doubt that the stone was formed of the same material, and, moreover, as the boy seemed, from his general symptoms, to be the subject of the lithic acid diathesis, which I supposed to be the only constitutional condition likely to be affected by solvent remedies of any kind I ordered him to take the following powder, dissolved in half a pint of tepid water, twice a day, strictly enjoining him to take no other kind of fluid, with the exception of a glass of rain-water whenever he might feel thirsty, which being frequently the case from the salt drink, he generally took from a pint and a half to

two pints, and sometimes more, during the day; the use of vegetable food was strictly prohibited:

B. Potassa bicarb. gr. x.; sodæ carb. gr. xij.; potassæ nitratis gr. viij.; Ft. pulv. To be dissolved in a tumblerful of tepid water, and taken twice a day.

As his skin generally appeared to be habitually dry, and secerning very imperfectly, and as the cutaneous capillary circulation was extremely languid, I ordered his body to be sponged daily with tepid water, followed by dry rubbing; and he was made to walk briskly for an hour or two in the hospital garden twice a day.

He continued this treatment, with occasional interruptions from disorder of the bowels, for about a month, at the end of which time it was found that he had lost, in a great measure, the irritability of the bladder under which he had previously been labouring. Considerable quantities of thick gritty matter had been at times observed in his urine, which, upon examination, were found to consist of amorphous lithic acid, with some mucus, but not nearly so much of the latter as he used to pass before he came to the hospital.

His general health had improved in proportion; and, notwithstanding the occa sional diarrhoea to which he had been subject, he had gained strength and flesh, and his skin had become habitually moist and perspiring, which had not been the case for a long time previous to admission; and he appeared to be gradually losing the symptoms of his disease.

February 3, 1848.-He has been gradually improving in his health since the last report; he has now almost completely lost the irritability of the bladder, and he passes his water, which is still, however, thick at times, without pain or inconvenience. He was, therefore, discharged from the hospital, with directions to continue the treatment some time longer.

April 16, six weeks since his discharge from the hospital. He says he now feels no pain, either in making water or after doing so; he sleeps well at night, and is not obliged to get out of bed oftener than any other boy in health; he looks better and feels stronger, and goes to farm work regularly every day without inconve nience. I now carefully examined the bladder with a variety of instruments, but failed in detecting the stone; but there was a kind of hard, gristly feeling of the lining membrane, near the fundus, on rotating the instrument, such as is not uncommonly met with in a bladder which has been for any considerable time under irritation from the presence of a calculus. He was ordered to take the medicine only once a day for a short time longer.

April 18, 1850, two years and two months from the date of his discharge from the hospital, I received the following communication from the patient's mother:"With pleasure I inform you that my son Henry is perfectly recovered." I have, since this, had no opportunity of ascertaining whether or not he has had any return of the disease.

Speaking of the so-called "Constitution Water," Dr. Golding Bird remarks:"There can be no question of the advantage that has resulted, in some cases, from the use of this remedy, nor, on the other hand, can there be any doubt of the injury it has inflicted when improperly administered. The secret of its success in uric acid gravel (the only class of cases in which it should be employed) depends upon the large quantity of alkaline salt administered in twenty-four hours. Our doses are generally too small when alkalies are administered in such cases. I certainly owe the knowledge of this fact to some successful cases of the so-called 'Constitution Water.' I do now constantly prescribe, with very great advantage, especially in cases of pisiform uric acid gravel, in which patients will pass scores of calculi, of the size and appearance of mustard seed, at a time, in imitation of this preparation, from two to four drachms of bicarbonate of potass dissolved in thirty or forty ounces of water in the course of twenty-four hours."-Med. Times and Gazelle, June 11, 1853, p. 600.

101.-Collodium in Cases of Inflammation of the Epididymus. By Dr. LANGE, of Konigsberg.-Collodium, which Dr. Piachaud ("Arch. Gen.," Sept. 1852) recommends as extremely useful in arresting incipient erysipelas, by causing contraction of the vessels of the skin when applied externally, has been employed at Konigs