case shews the powers of nature in recovery from such serious injury, but we question whether amputation would not have been preferable.

The plates are executed in an extremely coarse style. The work is very handsomely dedicated to the governors of the Gloucester Infirmary.

ART. XLVI. Practical Observations on the Treatment of Strictures in the Urethra and in the Esophagus. By EVERARD HOME, Esq. F. R. S. Surgeon to St. George's Hospital. Vol. II. 8vo.

OUR readers are too well acquainted with the former volume of this work to require to be informed of its contents, any further than to remind them, that in it the author treats very fully of the method of removing stricture by caustic first proposed by John Hunter, explains the structure of the parts, gives very full directions for the application of the caustic, and relates a variety of cases, both of the more frequent kind, and where other morbid symptoms accompanied the stricture, and often interfered with the proposed mode of cure. The stricture of the esophagus is also noticed briefly in the first volume.

In the present volume Mr. H. takes a much wider range; he first endeavours to point out a sufficient diagnosis between temporary spasm of the urethra and permanent stricture; after which he assumes the position, that stricture is in itself a primary cause of a great variety of diseases, chiefly of the organs connected with its seat, or contiguous to it, often unsuspected, and often going on to a fatal termination after severe and protracted misery.

The general complexion of the work, therefore, is to direct the attention of the practitioner more particularly to this disease than has hitherto been done, to induce him to bear constantly in mind the possibility of its existence, where any morbid affection of the organs exist; and to lead him to have recourse to the

Hunterian method of cure with caution and perseverance.

The propriety of use of the caustic in the extensive manner in which Mr. H. recommends, and very largely practises, has been, and still is, the subject of much controversy. We do not think it incumbent upon us to enter into it in this place, our present object being briefly to stare the arguments for the practice here brought by its ablest defender.

The author in the preface relates the particulars of a successful case where the caustic was condemned by Mr. Benjamin Bell, the only one of his opposers whom he personally notices,

The first chapter contains general observations upon strictures, from which, as it is in some degree the summary of the opinions afterwards maintained, and unembarrassed by cases, we shall extract several passages.

First, of the symptoms of constitutional diseases, induced by stricture, the author thus speaks.

long to a stricture in the urethra, have been "The constitutional symptoms, which be ease than those of any other local complaint; more frequently mistaken for an original disand it is only within these few years that this error has been detected. I have been enabled to determine, that the following consti tutional affections, which I shall soon mention, occasionally belong to strictures in the is, that patients are liable to them when laurethra, by three different modes. The first bouring under that disease; the second, that they very often are brought on in the course of a few hours after an armed bougie has been applied to the stricture; and whenever they follow such an application, it has been found that the symptom then produced has, at a former period, been met with in the same paof the stricture the symptoms disappear, altient. The third is, that after the removal for a number of years. Such evidence, when though the patient had been liable to them collected upon a large scale by a person of extensive experience, can admit of little if any fallacy."

resembling that of a regular intermit
The particular symptoms are paroxysms
tent, (also often brought on by the ap
plication of caustic,) feverish indisposi
tion, extreme irritability both of mind
and body, derangement in the digestive
organs, sometimes erysipelas, and erup-

tions of the skin.

often changes from being only a mem
The stricture, when of long duration,
branous band to a hard cartilaginous
body, requiring all the skill of the sur-
geon, and we imagine that degree of re-
solute patience in the sufferer, which
would only be endured, generally speak-
The inference, from much experience,
ing, in diseases of the part here affected.
Mr. H. lays down with confidence.

This mode of treating strictures having

HOME'S PRACTICAL OBSERVATIONS ON STRICTURES IN THE URETHRA, &c.

been in use now for eight years, a sufficient time is elapsed to admit of some conclusion being drawn respecting the consequences which are produced by it, and the permanency of its effects; and so great has been the number of those who have submitted to it, that, notwithstanding the many difficulties which still attend the subject, the following conclusions are given as formed upon a very extensive series of observations.

"That it does not dispose the parts to take on any other disease is sufficiently established, as there is no one instance within my observation in which that has been the case.

"That the parts recover themselves after the use of caustic, and acquire the natural smooth surface they originally possessed in common with the rest of the urethra, is also completely ascertained.

"That removing the strictures restores the parts to all their natural functions has been proved by the effect on patients in a married state, who had for years palliated the symptoms by means of bougies, and during that period had not begot children; but who were afterwards capable of doing so during the same marriage.

"These are the essential points which could not be determined by any reasoning, and were therefore only to be ascertained by experience."

Several causes of what may be called spurious stricture, or temporary obstruction of the urethra, are related, all of which have been mistaken for true stricture, and occasionally have exposed the sufferers to the use of the caustic, where by extreme mischief has been produced and the practice itself brought into discredit. A most calamitous case is related of inflammation of the bladder producing permanent obstruction of urine and constant pain, which had so much the appearance of stricture as to induce the surgeon to apply caustic several times, and with temporary relief to the strangury. The latter part of the case is so instructive, that we must relate it in the author's words.

"In this state he came to town, and put himself under my care. He was now very much emaciated, and appeared to be in a state beyond recovery, independently of the state of the complaint in his bladder. Upon examining the urethra by a bougie, this could not be passed beyond the bulb of the urethra; I could not, however, procure any impression upon the point of it, so as to satisfy my mind of the real state of the part He requested me to use the caustic, as the only means of giving him ease, from the distressing pain he had at the glans penis; and upon applying it, he found himself next day easier. I made several attempts to get an impression

777

of the stricture upon the bougie, but in vain ; and always applied the caustic, to give my patient a temporary relief. After using the bougie four or five times, I passed a silver catheter, of a size larger than the bougie I had used, and found it went with perfect case into the bladder. This explained to me the present state of the case; and I informed the patient, that there was now no stricture, the passage was perfectly open, and the whole of the remaining disease was in the internal membrane of the bladder, and therefore the only object was to enable the parts to recover themselves by soothing them, and to strengthen the constitution by nourishment. He became, however, weaker and weaker, and in the course of three months died.

"During this period he had frequent rigors and cold sweats, which are common attendants upon diseases of the bladder; but the symptoms of which he died were wasting of flesh, loathing of food, occasional sickness, without his being aware of his gra dual decay. At last he was so weak as scarcely to bear being moved. He had his faculties perfectly clear, and his recollection complete, till within a few hours of his death.

"Upon inspecting the parts after death, it appeared that there had been no stricture in any part of the urethra. The internal membrane of the bladder was in a state of ulceration, particularly the lower part, where the ureters enter into it, except a line not broader than the eighth of an inch, extending from each ureter to the middle line, where of the ureters were in a state of ulceration, the two streams would unite. The orifices and inflammation had extended itself along the internal surface of the left ureter to the kidney, the pelvis and infundibula of which

were in a state of ulceration.

"The use of the caustic had made five different holes through the membrane of the urethra, of the size of the end of a common bougie, at a small distance from each the perinæum and buttock, into which the other; a large abscess had formed between urine escaped by these orifices. The immediate cause of his death, I should believe, was the state of the kidney, having seen two other cases in which a diseased state of the pelvis of the kidney produced similar symp toms,"

A more instructive warning against the rash application of the caustic could hardly have been found; and notwithstanding the original disease of the bladder and kidney, we can hardly refuse to attribute a very large share of the fatal event to the caustic itself, the dreadful effects of which Mr. H. has so candidly related.

In such cases as these it does not ap pear that the author has any other cri terion of the existence of stricture than

the impression made on the point of the bougie.

The author next relates several very interesting cases of strictures requiring an unusual number of applications of the caustic for their removal. He attributes this to a change in the texture of the original stricture, and a supposed complication of action and re-action between old and new strictures. In one of the cases the caustic had been applied during six years no less than 486 times. The final success was considerable and probably would be compleat, and a just observation is added which will apply to many of these excessively tedious cases.

"In 1803 this patient continued free from any relapse, but was under the necessity of passing a bougie daily, and leaving it in the urethra for half an hour, to keep the canal in a state of tranquillity; for he found that when he omitted to do so, occasional symptoms

of irritation came on.

patient thus describe his feelings and his sentiments.

"Now for the bright side of the picture; my general health is so much improved, that I am congratulated by all my acquaintance upon my appearance. I can ride ten miles with much satisfaction, and whenever I difficulty. I feel no pain of any kind; in have a call to make water, it passes without short, could I surmount the frequency of making water, there would be very few mea of my age (sixty-five) more robust. This amazing change from a life of pain and misery I attribute entirely to the operation of the caustic. This copy of the journal, which I kept during the operation, I give to Mr. Home, and hope he will be pleased to consider it as an acknowledgment of his professional abilities, and of my grateful remembrance of their exertion."

Four years afterwards this patient died. The irritability of the bladder, which had never left him, encreased, calculous concretions formed, and his complicated sufferings put an end to his existence. On dissection the cause of death was traced to the bladder, but the urethra remained sound and uniform through its whole extent.

"On contemplating the sufferings of the patient during so long a period as six years, it may be observed, that few men would have had the same degree of perseverance, and that a cure was hardly worth so dear a price. This, however, is not by any means a just view of the case, since the whole time he was under this treatment he suffered less, Our limits will not allow us to exaboth in body and mind, from the effects of mine the other cases of disease occasionthe caustic, than he had done from the symp-ed by and accompanying stricture. toms of the disease previous to its being adopted, and the degree of relief he received from the immediate effect of the applications upon the parts irritated, was more than sufficient to counterbalance the local pain it pro

duced."

A very long and very prolix but highly valuable case is given by the patient himself, a general officer, past the middle age, who had long suffered under severe stricture, that had baffled Daran, Hunter, and many of the men of peculiar eminence in diseases of this organ. The case is a daily register for five months of incessant application of caustic at as short intervals as could possibly be allowed of, and attended with the final success of making a complete passage through a great variety of strictures into the bladder.

After this point was secured, the patient recovered to so great a degree as to enjoy life very considerably, though the power of retaining urine was so much impaired as to prevent him from mixing freely in society, and a mucous discharge from the bladder remained. It is flattering to the practitioner, after so long and assiduous attendance, to have his

in the second volume of the transactions A valuable chapter, already published of a society for promoting medical and chirurgical knowledge, is here very properly inserted, containing cases in which suppression of urine, in consequence of stricture, has required puncturing the bladder.

Some cases are given of strictures in the esophagus, cured by the bougie simple, or armed with caustic. The fol lowing valuable diagnostic remarks we shall transcribe. Besides the stricture, the esophagus is liable to two other diseases, both of which produce difficulty of swallowing.

"One of these is a thickening of the coats of the esophagus, which extends to the surrounding parts, and in the end generally becomes cancerous, or, in other words, an incurable disease: the other is an ulcer on the

lining of the esophagus; this last is commonly a little below the seat of the stricture, and is upon the posterior part which lies on the vertebrae of the neck. Both of these produce a difficulty in swallowing, and in their early stages are only to be distinguished from stricture by an examination with the bougie; when the disease is more advanced, the other

ART. XLVII. Facts and Observations respecting the Air-Pump Vapour-Bath in Gout, Rheumatism, Palsy, and other Diseases. By RALPH BLEGBOROUGH, M. D. Member of the Royal College of Surgeons, London. Svo.

ART. XLVIII. Practical Observations in Surgery, illustrated with Cases. By WIL LIAM HEY, Esq. F. RS. Member of the Royal College of Surgeons in Londes; bonorary Member of the Royal Medical Society of Edinburgh, and of the Literary and Philosophical Society of Manchester; and senior Surgeon of the General Infirmary a Leeds. 8vo. pp. 537.