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,LETTERS
THE  DISEASES
URETHRA.^  ^
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BY CHARLES BEX3L
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            AITO EDWARD EA41I-E & CO. PHILADELPHIA,
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       1811.
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LETTERS
C0NCERNIN6
THE  DISEASES
URETHRA,
  Verisiraile est autem, id a quoque pratermissum quod ipse non cognover&t:
a nnllo id quod non vid«rat, fictum.  Celsm.
BY CHARLES BELL.

PUBLISHED BY W. WELLS AND T. B. WAIT & CO. BOSTON:

      AND EDWARD EARLE & CO. PHILADELPHIA.
Thomas B. Wait <tr Co. Printers.
        1811. 
. 
NOTE.
 I have no other apology to offer for  this
 publication  than the  hope of  informing
 some part of the profession of facts regard-
 ing the diseases of the  Urethra, which  I
 believe to be of the first importance in prac-
 tice.   The knowledge  of  these  I have at-
 tained very slowly,  and after repeated dis-
 appointments ; for, at first, I too implicitly
 believed that all the information  necessary
 to practise was already  before the public.
 The  impossibility of reconciling  circum-
 stances which presented themselves, during
 the treatment of these diseases,  with pub-
 lished opinions, and the method of cure
 generally adopted, made it necessary for me
to disregard authority,  and have recourse 
                  NOTE.
to anatomy as  the surest  guide.  I  am
aware of the common opinion, that nothing
new can be said upon  the subject of stric-
ture in the urethra.  This only proves to
me that these observations come before the
public in circumstances  peculiarly disad-
vantageous.  But  it  is  certain  that,  of
many excellent surgeons  in the metropolis,
with whom I  am acquainted, there are not
two  of  them  prosecuting the  same plan
of cure  in  diseases  of the  urethra;  and
many in  the  country believe  that they
are following an established method, when
they are  in truth doing outrage to every
principle deducible from  the structure and
the morbid appearance of the parts  con-
cerned.
   In the following tracts,  I have conducted
all my inquiries upon grounds ascertained
by anatomical investigation. I have brought
forward facts which cannot be questioned; 
                  NOTE.
and on these facts I trust that I have reason-
ed candidly.  I trust also that I have shewn
every where that respect, which I sincerely
feel, for  those whose opinions I have had
occasion to criticise,  and without whose
previous labours mine could have been of
little avail.
   These tracts  are presented in  the form
of letters,  as they were originally written.
The license of  that sort of writing may be
my  apology for defects of  style ;  and this
manner of explaining professional subjects
approaches more nearly  to the nature of
discourse, to which, as a teacher, I have
been accustomed. 
 
CONTENTS.
\* Only  the head title Letter refers to the page—the particular
             enumeration to the paragraph §.

                    LETTER I.
Of the Varieties  of  stricture in the Ure-
  thra .................................. Page 13
     Simple Stricture  ......................     § 2
     Ulcerated  Stricture  ....................     § 3
     Stricture from  inflamed Lacuna.........     § 4
     The  Orifice of the Urethra contracted  ...     § 5
     Dilatable   Stricture  ....................     §  6
     Spasmodic Stricture ...................     § 7
     Stone in the Urethra...................   §8,9
     Of Callosity and double Stricture ........    § 12
     Narrowness of the Urethra, and wasting of
       the spongy Body....................    § 14
     Consequences of Stricture as discoverable on
       Dissection.........................    § 15
     Fistula ...............................    § 16
     Practical Conclusions drawn from these  Dis-
       tinctions ....................from  § 24 to § 30

                    LETTER II.
 On the Dilatable Stricture of the Urethra
                                            Page 62
     History of the Disease.................     § 2
     Examined by the  Bougie  ...............    § 4
     Improper use of the Bougie.............    § 7
     Origin of the Disease  ...................    § 8
     Sometimes cured  by the Use of the Bougie § 13, 14 
CONTENTS.
     The Effects of the Kali purum............     §  16
     This caustic does not destroy a confirmed
       Stricture ...........................     §  17
     Experiments with the caustic........    § 19,  20
     Deductions from these experiments ...    § 21,  22
     Oi the Matter discharged from the Urethra
       in consequence of the application of
       Caustic  ............................     § 23
     Method of Cure ......................      §  26

                   LETTER III.
Of Spasmodic Stricture.................  Page 101
     Experiments on the contractile Power of the
       Urethra............................  § 4, 5, 6
     Opinions regarding the  Muscularity of the
       Urethra further examined............  § 7 to  11
     The Nature of the Spasm attending Stricture   §  13
    Experiments on the Relaxation of Muscles  § 13,  14
    Paralysis of the Urethra................      §18
    Spasm of the Urethra is  properly a disordered
      Action of the surrounding Muscles  ....      §  20
    Effect of great Sensibility in a  Stricture         §  24
    Principal Seat of Sensibility and inflamma-
      tion is behind the Stricture...........      §  28
    Effect of Caustic in subduing the morbid
      Sensibility of the  Urethra...........     § 29
     Of the Period of returning  Sensibility and
       Spasm after the Application  of caustic        §  30
     The Application of Caustic will, in particu-
      lar Circumstances, promote  Abscess and
       Fistula;  and how this Disposition is  to be
       checked, and Spasm  cured ..........     § 31
Explanation of plates ............  Page 157 
LETTERS
                  CONCERNING


   THE DISEASES OF THE URETHRA.



                  LETTER I.

Concerning the varieties of Strictui'e in the Urethra as discoverable
  on dissection, and the means of distinguishing these varieties in
  the living body ; with practical inferences concerning the method
  of cure.

      1.  There is a great inconsistency in

following the same method of cure, in all

strictures of the urethra, when it is demons-

trable that there are many  varieties in this

disease.   Unfortunately when Mr. Hunter

discovered, by dissection, the existence of

stricture, he entertained an ingenious, but

"false, idea regarding the cause  of the dis-

ease.   He conceived that the membrane of

the urethra was  muscular; and that a fibre,

              1 
 14        varieties of stricture
 or a fasciculus of the fibres, of this muscle,
 being contracted, in an inordinate degree,
 or permanently, was the cause of stricture.
 He described  a stricture as resembling in
 effect a thread  tied round the membrane
 of the canal.  Although sometimes a stric-
 ture has this appearance, it is a description
 very imperfect of that stricture which Mr.
 Hunter  has represented in his valuable
 work.   I  have  now, completely to my own
 satisfaction, established that the urethra is
 not muscular;  and that inflammation  is the
 cause  of stricture.*  And as  in   every
 other case of inflammation by which per-
 manent derangement is produced, there is
 a very considerable variety in the conse-
 quences ;  so in the urethra there are cer-
tain important  distinctions to be observed
in the effects of inflammation, both respect-
  * This subject is discussed in the Second Letter on Spasmodic
Stricture.
 
             IN THE URETHRA.           a ~"
ing the nature of the callosity or stricture,
and respecting the extent. Besides the va-
rieties of stricture discoverable on dissec-
tion,  there  are  some other important  cir-
cumstances which appear to me not yet to
be  before the profession; and  on which
depends the efficacy or safety of the reme-
dies to be used in diseases of the urethra.
   2.  I will not deny that stricture has very simple
                                         stricture.
often the  appearance  described  by  Mr.
Hunter,  as if a  thread were tied round
the urethra; and as if there were a mem-
brane tucked, and hanging across the canal.
 In introducing the bougie, or  probe, we
 feel the point start  over the stricture so as
 to  convey to us precisely this notion.  This
 simplest form of stricture I have examined,
 first by  dissection,  and also in  prepara-
 tions.   When a stricture of this kind is of
 long standing, and has no   inflammation
 or coagulable lymph around  it,  there is 
 10        VARIETIES OF STRICTURE
 seen in the substance, or on the surface, of
 the membrane of the urethra, a pure white
 dense fibre. This small fibre is distinguish-
 ed from the soft mucous and dilatable mem-
 brane of the urethra, by its resemblance
 to such  filaments  as form  the  texture of
 the common  fascia.  The term  bride* of
 the French authors must have been appli-
 ed to this appearance.   I have  observed
 that the direction of the fibre is not always
 in the circle of the canal, but often it splits
 and branches, and  sometimes runs nearly
 longitudinally.   Similar  effects to this are
 seen in other membranes to be the effect
 of inflammation, particularly in the perito-
neum.
  When this stricture is newly formed, and
the inflammation continues, there is around
the firm  line of the stricture a  thickened
base ; this remark, however, is made  only
* See La Faye's notes on Dionis. 
             IN THE URETHRA.           17
from the  sensation communicated in  the
examination  of the living.
   If inflammation occurs as a consequence
of this stricture, the stricture itself not only
increases, but the passage is apt to be fur-
ther choaked  by  a  crust of  coagulable
lymph which forms behind. Through this
crust, as it is forming, the urine makes its
way,  and forms a hole corresponding with
the stricture.  Indeed I have proofs before
me that the new  membrane will  become
consolidated, apparently by successive at-
tacks of inflammation behind the stricture,
and, at last, will form of this simple stricture
one more  irregular.  (See further what is
said, in the explanation of the plates.)
   3. Much has been said formerly of stric- ulcerated
                                         stricture.
ture in the urethra being the effect of ul-
cer ; and in truth a cicatrix.*   When Mr.
Hunter proved that  a purulent discharge
          * Dionis and Saviard, and others 
 18        VARIETIES OF STRICTURE
 might come from a surface inflamed, though
 not ulcerated ; and that in gonorrhoea there
 is no ulceration of the urethra,  the  ques-
 tion was held to be put to rest. Gonorrhoea
 was not imagined to be the cause of stric-
 ture.   Stricture was  supposed to proceed
 from  muscular contraction, and the  con-
 nection between the  original  disease and
 its consequences was  almost forgot.  Stric-
 ture,  though occasioned by inflammation,
 will yet be  produced without ulceration.
 But I cannot shut my eyes against the fact
 presented to me by  dissection.  I  have
found a firm stricture, in the centre of which
there  was an excavation by ulceration : and
we  must conclude that either the stricture
 must  have  ulcerated,  or the original ulcer
must have hardened,  so as to condense the
 surrounding cellular membrane,  and pro-
duce a very firm cicatrix and consequent
 stricture. 
             IN THE URETHRA.             x v
  4. A narrowness of the canal, obstructing stricture
                                          from in-
the point of the bougie, and giving, on ex- **™d la
amination, in the living body, the exact feel-
ing of a common stricture, frequently pro-
ceeds from an  inflamed lacuna.  More gen-
eral inflammation of the membrane of the
canal may have subsided, but  still the pa-
tient will  be able  to squeeze  out a  little
thick  purulent matter.   From  there being
no active  disease of the urethra, the sur-
geon will naturally think of introducing a
bougie,  and the  point of  it may suddenly
be obstructed, so  as to give the idea that
there  is a  full circular contraction of  the
canal.  We may often ascertain the nature
of this case by examining with the finger
on the outside.   We feel  a small hard bo-
dy like a seed, or pea, within, or rather at-
tached to, the canal.*  When this part is
  * I imagine that this circumstance gave rise to the opinion which
 Arneau and Petit supported, that the disorder attributed to the ca-
 runcle arose from a tumor in the spongy substance of the urethra. 
20        VARIETIES OF STRICTURE
pressed,  a little  purulent  matter may be
pushed to the point of  the urethra.   If  a
soft bougie is  introduced, in  order to take
the impression of the  stricture, a flatness
will be perceptible on one side of the bou-
gie.   If a small bougie, or probe, be intro-
duced, its point may be made  to hitch or
lodge in the little sac or follicle.
  One of the common lacunae of the ure-
thra, provided for the secretion and lodge-
ment of the mucus, which is sent before the
urine for lubricating the canal, has become
the seat of gonorrhoea,  or of that chronic
inflammation which succeeds to it;  while
the inner surface of the lacuna has assum-
ed the suppurative  action, the surrounding
membrane  has  become condensed, so as
to lose its elasticity, and the canal of the
urethra is consequently incapable of dila-
tation at that part. 
             IN THE URETHRA.            * x
  5. The idea of seeing a stricture of the stricture
                                         near the
urethra is somewhat ludicrous; but the fact ?hrefiureof
                                       .  thra, and
is, that there is a sricture of a very obsti- visible.
nate nature which forms just within the lips
of the  urethra. I have seen it of a gray or
ash colour, and hard as cartilage.  If I mis-
take not, Mr. Home  gives cases  of  this
where the caustic was employed with suc-
cess.   I have used both caustics on this
kind of stricture. A friend of mine ventured
to apply the caustic here, because, seeing
the disease,  he thought he  might risk the
application of the caustic in  the common
way.  But  it produced great distress, and
no  ultimate  benefit.  In consultations, I
have been  persuaded  to cut it, and have
accordingly  made two transverse incisions
upon it.  I have dilated it,  by making the
patient wear a small tube in the urethra,
so  that  what had been a stricture came to
be in truth the widest part of the canal. In
                 2 
Dilatable
stricture.
22        VARIETIES OF STRICTURE
short, in this case, as in many others, we
have attempted to do too much.
  6. There is no  case in which the sur-
geon  is more apt to be confounded, than
when a patient comes to him with a stricture
which  easily yields to the pressure of the
bougie.   He finds that there is,  at first, a
distinct resistance to the point of the bou-
gie, but that the  stricture is not firm, nor
the sides  of the canal callous.   He finds
that although at first he has difficulty, yet
by introducing a  succession of bougies he
is able to pass the largest bougie with ease,
and the contraction seems  to be destroyed.
But although the patient sees a large bou-
gie introduced into his urethra, and cannot
persist in saying that he has a stricture, he
allows himself to be persuaded in opposi-
tion to his feelings; for his uneasiness con-
tinues, and,  after a few days, he returns in
ilis  former condition. This subject of dila- 
             IN THE URETHRA.            *«*
table stricture  I have thought it necessary
to discuss more at length in the next letter.
   7. All strictures are attended with symp- spasmodic
                                         stricture.
toms which would incline  us  to  believe
that they are  liable to spasmodic contrac-
tion.   But the  profession seems to entertain
an opinion that there is a stricture more
highly irritable,  and in which the capacity
for  muscular  action continues: that  this
muscular stricture, contracting in a  degree,
produces difficulty in passing the  urine ;
and that the contraction  is  occasionally,
in a much higher degree, producing total
obstruction.   As I deny that stricture ever
arises from this muscular contraction, I, of
course, cannot believe that there is such a
thing  as a stricture possessing muscular
power.  And, if I use the term spasmodic
stricture, it is only as implying that stricture
which is attended with inflammation; with
high sensibility in its surface, or in  the 
      24        VARIETIES OF STRICTURE
      neighbouring part of the  canal;  and that
      this sensibility  is  attended  with a morbid
      irritability of the  surrounding  muscles.
      The character of this stricture is, that the
      obstruction seems occasionally to give way;
      that there is great pain and  irritation  on
      introducing  the bougie  into the  stricture,
      with heat of urine,  fulness of the perineum,
      and frequently total obstruction for a time.
      The variations  in  the capacity of passing
      urine, while yet the stricture was of a hard
      and rigid nature,  soon brought me to the
      conviction that the term spasmodic stricture,
      as generally used, was improper ; that there
      was no such thing as a muscular power in
      the stricture itself.
of stric-    8.  I have dissected the urethra where a
ture, with
stone in sharp stone  had stuck in it.    The effect of
the ure-      x
      this was to produce stricture. But although,
       during the life of the patient, the resistance
       of the urethra to the progress of the stone 
             IN THE URETHRA.           ^D
forward was such (the case being mistaken)
as to destroy him, it was difficult to pre-
serve any thing of the appearance of stric-
ture in the preparation.   It was not a per-
manent stricture, but an immediate effect of
the loss of elasticity in the inflamed canal
and surrounding membrane.  A little soak-
ing in water removed  all appearance of
stricture in the dead parts.
   A  small stone formed in the bladder may-
 be retained behind a stricture ; but we must
also be aware that a small and rough stone
passing  along the urethra will inflame it,
 make it incapable of dilatation, and, in short,
 produce stricture.  This stricture however
 it will be very possible to dilate rapidly by
 the use  of the bougie,  so as to permit the
 stone to be  discharged by the impulse  of
 the urine.
   9. If the stone be retained in the urethra,
 and the urine allowed to flow past it, the 
26        VARIETIES OF STRICTURE
stone will cause the membrane of the ure-
thra to ulcerate, and it will sink and bury
itself in this ulcer,  so that an instrument
passed into the bladder will grate along the
surface of the stone.  I have found a great
many  stones lodging in  the ducts of the
prostate gland.  I  have  also seen a stone
of the size of a filbert buried in the sub-
stance of the prostate gland.   These stones
form in small particles, and, irritating, pro-
duce ulceration in the surrounding sub-
stance,  and so the  stone and its  sac con-
tinue to enlarge.   But there is  a  circum-
stance connected with this part of the mor-
bid anatomy, which though I do not under-
stand, yet I think it may eventually be of
use to have it  before you.  In  examining
the urethra of a subject,  I  found that at
the caput gallinaginis there was  a hole,
which from its  appearance I should have
said had been formed by the improper use 
               IN THE URETHRA.             27
<sf  a bougie; but on following the canal I
found it open into a smooth round sac. As
this sac could not be formed by the opera-
tion of the bougie, it cannot be admitted that
the perforation of the urethra was  made by
the surgeon.*  In such  sacs stones may
be  deposited  by the lodgment of the urine.
    10.   Stricture  is  sometimes,  as  already PiaCe of
stricture
observed,  seated  iust within the mouth of *nd of iu-
          '          J                          flamma-
 .       ..           r        .   .        .1 tion in tlie
the urethra; more frequently about an men urethra.
and half down, and in the  seat  of the ori-
ginal inflammation of gonorrhoea, or where
the penis takes a  sudden curve  in  hanging
from the pubes.   And lastly, it is very of-
ten found near the bulb,  either immediately
  • In Dr. Donald Monro's " Observations on the Diseases of Sol-
diers," there is such an appearance described. Inflammation and ab-
scess about the prostate is often mentioned in the authors quoted by
Bonetus, which is an additional reason for attending to the subject.
See also La Faye on Dionis. In practice, on introducing a bougie
into the neck of the bladder, I have seen a copious discharge of mat-
ter follow the operation, and I suspect that it proceeds from such
abscesses about the vesiculae seminales as I have here described.
When matter is thus discharged from the  neck of the bladder, the
anterior part of the canal is very irritable. 
28        VARIETIES OF STRICTURE
before the sinus of the urethra, or at the
termination forwards of the membranous
part of the canal.
  When seated midway in the urethra, and
at the part where the penis hangs down,
the stricture often extends only to one half
of the canal, which of course is the lower
half.   The cause of stricture being so fre-
quent  near  the bulb is, that this is really
the  most sensible part of the whole canal.
It possesses a pecular sensibility, to govern
the  action of the muscles seated there, and
this  sensibility gives rise to inflammation
and to morbid irritability of the surrounding
muscles.
  11.  I  have  not  had an opportunity of
examining the urethra by dissection, where
I was certain that there had been a recent
gonorrhsea; but in the subjects of the dis-
secting room,  I have seen inflammation of
the  urethra near the extremity of the penis 
             IN THE URETHRA.            ^
and inflammation also near the neck of the
bladder  and at the bulb, while there was
no unusual appearance in the intermediate
part of the canal.  This fact, in combina-
tion with the circumstances of practice, in-
duces  me  to believe that there is a direct
consent  betwixt the two extremities of the
urethra, and that they sympathize  in dis-
ease ;  that irritation in the fore part of the
canal  is quickly conveyed to the bulb and
neck of the bladder, just as inflammation
seated near the neck of the bladder will
give the sensation of pain in the part of the
urethra behind the glans.
   12.  I do not see any reason for rejecting 9^*})™
the term callosity ; the fact being that, both sS?otur«.
in dissection and in the examination of a
patient, there is evidence of a considerable
portion  of the  canal having become firm
and almost of cartilaginous  hardness.*
  * This state of the urethra is the carnosity of the older authors;
see Wiseman.
                 3 
30        VARIETIES OF STRICTURE
The notion commonly entertained of these
long strictures or callosities is, that there
have been two strictures, and that, the inter-
mediate portion of the canal being no longer
distended with the urine, the channel has
diminished.  This is the explanation given
by Mr. Home in his excellent treatise.  But
it does not accord with  the  circumstances.
For example,  I  have lately examined the
parts  where  the  stricture had absolutely
closed so that not a drop of urine passed
along the urethra.  The bladder had been
punctured, and  the man lived for years
discharging  his  urine  by  the puncture.
Here  it  was curious to abserve that the
part of the urethra, anterior to  the total ob-
struction, was wide or  dilatable as in the
natural  state of the parts.   It is  evident
therefore, that the mere cessation  of the
usual distension of the  urethra will not be
followed by stricture or permanent contrac- 
IN THE URETHRA.
31
tion  of the canal.    These  callosities,  or

long strictures,  are  always  irregular;  and

this  irregularity cannot be  accounted  for

on the  supposition  that the  canal at  this

part has become rigid for want of the usual

distention of the urine.  I entertain no doubt

that  these  contractions  of  the  urethra,

which  extend to  a  considerable  length of

the canal,  are  produced  by more  severe

attacks  of  inflammation than those which

produce the common stricture.*   This sort

  * In most of the older writers, we find a reference to Brunnerus ;
but it is strange that his sensible and evidently accurate observations
did not more influence the general opinion, or, at least, overturn the
fancy about caruncles.  On one occasion, he gives an accurate ac-
count of this kind of stricture as it appears on dissection.  " Incisa
" urethra, nulla excrescentia, aut caruncula apparuit, neque fungus,
" meatum urinse obstruens, id quod oppido mirabatur medicus ad-
" stans, qui sxpius viventi medebatur ; sed mera angustia et coarc-
" tatio urethra hinc inde visa fuit, qualis in vasis umbilicalibus post
" partem obtingeresoletcoalescentibus.".....J. C. Brunnerus de Ca-
runcula in Urethra, Acad. C&sareo-Leopoldinee Ephemer. Cent. I. Ob-
serv. LXXI. & Observ. XCVII.
  Many of the immediate successors of Brunnerus, with this before
them, assert that they have themselves seen caruncula: in the ure-
thra ; but we find that where they have found them they have cured
them also, and that  consequently they have not seen them, but ima-
gined them. Boerhaave Prelect. Acad. g. 209. 
32        V ARIETIES OF STRICTURE
of callosity  of the canal differs from the
more common stricture in this, that in con-
sequence of the spongy body, which sur-
rounds the canal of the urethra, often par-
taking of the effect of the inflammation, the
cells are obliterated; and what was loose,
spongy, and dilatable has become condens-
ed and rigid. This undilatable condition of
the urethra, when examined by the bougie,
or probe, gives  the  sensation of  great ir-
regularity ;  the  point  is interrupted,  and
feels as if it were moving over eminences
on alternate sides of the canal.  When the
ball probe, or urethra sound, is introduced
through the anterior part of the stricture,
there is difficulty in pushing it down, and a
slight impediment is felt in retracting it.
   13. It is in these  callous strictures that
the false passage is apt to be formed; and
this wrong  direction is as apt to  be taken
by the  bougie simply as when the caustic 
              IN THE URETHRA.            33
is  applied.   I dissected the parts, where I
found an irregular  stricture near  the bulb
of the urethra, and  by the side of the stric-
ture  a  passage of  an inch and a half in
length in the spongy substance of the ure-
thra.  This canal was smooth like the nat-
ural urethra.  It was curious to find on in-
quiry that the patient  had experienced re-
lief by the introduction of the bougie  into
this false passage.
   14. There is a state of the canal in which  Narrrow-
                                           ness of the
a  considerable portion  is  diminished in  Sedat~
                                           with wast-
width ; and which does not fall under  any  ingof the
                                         .  spongy bo-
of the foregoing distinctions.  I have found,  dy"
on dissection, from two to three inches of
the  canal much  diminished  in  capacity,
and rigid; and all around this  part of the
urethra the  spongy substance obliterated.*
The effect was, as if the urethra and spon-
  * Morgagni found the urethra contracted a third part of its lenglli.
III. XLII. 39. 
         34        VARIETIES OF STRICTURE
         gy body had suffered by compression; yet
         this could not be the case, and at present I
         do not pretend to explain  the cause.  It
         may have been a  remote consequence of
        inflammation, or an effect of old age when
        there was a cessation of the functions of
        the generative  organs  and  a diminished
        power of the bladder. Yet as a part of the
        urethra behind this  contracted portion of
        the canal was  unusually dilated, and had
        the marks of former inflammation, this lat-
        ter explanation is not so very satisfactory.*
conse-       15. Where there is stricture in the ure-
quences of
as'Ssco!'  tnra5 tnat portion of the canal which is be-
verable on
dissection, twixt the stricture in  the  urethra  and the
        bladder is  much enlarged.   When the pa-
        tient has died,  in consequence of stricture
        and an acute attack  of inflammation, I have
         *  On dissection, or in practice, I find nothing confirming the idea
        of a spongy swelling of the membranes of the urethra, similar to the
        state of the mucous membrane of the nose in Coryza.  (See Petit
        and Arneau.)  The idea has probably arisen from examining the di-
        Litable stricture. 
             IN THE URETHRA.           ° D
found the whole extent  of  the urethra in- urethra
                                        inflamed
flamed, but  chiefly that portion which lay
between   the  stricture  and  the  bladder.
There a  firm coat of  coagulable  lymph
was deposited, which hung fleecy into the
dilated cavity of the canal.  Under this in-
flammatory crust, the proper  surface of the
urethra was  highly inflamed.   In another
instance,  where I was ignorant of the man-
ner of death, I saw behind the stricture a
patch  of coagulable  lymph, and conside-
rable  inflammation around it; but in the
part of the urethra anterior to the stricture,
 there  were no marks remaining of inflam-
 mation.
    In the instance of a  gentleman, who re-
 sisted all means of cure,  and who died of
 inflammation of the bladder,  the coagulable
 lymph formed a dense  coat to the inside of
 the urethra, behind the stricture, so as to 
       36        VARIETIES OF STRICTURE
       close the seminal ducts and mucous fol-
       licles.
Fistula.     16. I have also had an opportunity  of
       observing  the  appearance  of the urethra
       where a fistula had formed in the perinae-
       um, in consequence of stricture in the ure-
       thra.  I had imagined that there would be
       formed only one rough ulcerated hole: but
       if this is the case in the beginning, in one
       instance at least it must have changed; for
       I have seen four holes, with  strong bands
       interlaced, communicating betwixt the carfal
       of the urethra and the cellular substance of
       the perinaeum.  These holes were crowd-
       ed in a small space  behind the  stricture;
       and, as far as I know,  there is no instance
       of a fistulous opening  forming in the ure-
       thra anterior to a stricture.
         17.  In examining the principal anatomi-
       cal collections, both in London and in Scot-
       land, I think it important to observe, that I 
             IN THE URETHRA.           37
did not always  find  that  connection  be-
tween the degree of contraction of the stric-
ture and the violence of the diseased action
behind  the stricture,  which I had led my-
self to expect.  In a stricture which would
have been altogether  neglected,  had it not
been  for  the diseased appearance  inde-
pendent of the contraction,  I  found  the
coagulable  lymph deposited  behind  it.
This  preparation  I  saw  in  Mr.  Fyfe's
hands;  and the younger Dr. Monro shew-
ed  me  a preparation where fistula had
formed,  and  yet  from  appearance one
should  say that  the passage of the  canal
must have been  pretty free.   On a former
occasion I have said that the cure of fistula
in perinseo is to  be effected by the cure of
stricture, implying that the mechanical ob-
struction was the cause of the fistula form-
ing, and is  the  source of its continuing.
This is  so far correct.  But from anatomi-
                4 
       38        'VARIETIES OF STRICTURE
       cal proofs, as well as from facts ascertain-
       ed in practice, I should say that our atten-
       tion ought, in an equal degree, to be turn-
       ed to the state of sensibility and inflamma-
       tion of that  part of the  canal which lies
       behind the stricture ;  and that the inflam-
       mation and danger of fistula does not cor-
       respond with the degree of  narrowness,
       but with the degree of irritation.  This is
       a subject of so  much importance, that  I
       have entered upon the  discussion some-
       what more at large in the Third Letter.
Effects on   On examining: the prostate gland and
the pros-                or        o
 te s an * urethra  behind the stricture,  I have seen
       great  disorder.   Before the irritation pro-
       duces ulceration  and fistula,  cavities  are
       formed in the sides of the canal where  it
       passes through the  prostate gland.  These
       cavities  I believe to  be  only  enlargement
       of the natural ducts of the gland.   I have
       seen them so large as to admit  the end of 
             IN THE URETHRA.           39
the largest bougie in size.  Having observ-
ed that, in bad cases of fistula in perinseo-,
the urine came from the neck of the blad-
der and prostate  gland, I am inclined to
believe that these cavities in the side of the
urethra and prostate gland sometimes ulce-
rate, and produce the worst kind of fistula,
because they receive the urine direct from
the bladder, uninterrupted by the action of
the sphincter.   The incessant infiltration
of the  urine into the cellular texture of the
pcrinseum  is probably the cause that in
most  cases of the kind which  I have seen
there was extensive  mortification.
   I have found in the neighbourhood of a
stricture a very minute crop of  soft warts
growing from the membrane of the urethra.
   18.  On the bladder the effect of stricture of the ef.
                                        „fects of
is always  manifest.   If the  difficulty of stricture
        J                                 on the
passing the urine has been long continued,bladder
the coats of the  bladder  are  very much 
 4^        VARIETIES OF STRICTURE
 thickened; apparently by frequent lesser
 degrees  of inflammation,  but principally
 from the necessity  of increased  force  in
 throwing out the urine, and the consequent
 increase in strength  of the muscular fibre.
 When the patient has been cut off by irri-
 tation more rapidly,  I have found the  fun-
 dus  of the bladder,  on the outside, loaded
 with blood,  and  black with a congeries of
 turgid vessels; on the inside, masses  of
 coagulable lymph, and, in the interstices,
 the natural surface loaded with blood.   If,
 by accession  of inflammation  in  stricture,
 absolute obstruction comes suddenly, the
 bladder suffers an extraordinary degree  of
 distension until the  urine  at  last escapes
 into  the cavity of the abdomen.  On exa-
 mining the fundus of the bladder, I have
 seen dark spots upon it,  and in the centre
 of these dark spots small ragged holes.   If
the bladder had burst, it would have  ap- 
            IN THE URETHRA.             ** A
peared rent.  It has  happened  that the
bladder has been rent by a fall, and in that
case the hand could be put  through the
rupture.*   If it had  gangrened,  it would
have been black over a greater extent, and
inflamed like a  gangrened intestine.  But
as there were more than one small  hole, I
conceive that the urine escapes from  the
fundus of the bladder, as  it does from the
urethra in the more common case of fistula
in perinseo, that is, by ulceration.  Some-
times, it would appear, the urine escapes
 from the bladder without the outer perito-
 neal coat  giving way; then the urine in-
 sinuates itself extensively into the cellular
 substance behind the peritonaeum.  A case
 of this kind has been communicated to me.
    19.  I have seen the effects of a tube re-
 maining for a long time after the operation
 of puncturing the bladder above the pubis.
   * Medical Comm. vol. 2. Bonet. Sepulch. lib. iii. sect. 24, obs. 12. 
 42        VARIETIES OF STRICTURE
 The cellular membrane, which is naturally
 loose  here, had  been condensed so as to
 form a canal of great strength, and perfect-
 ly smooth on its inner surface.   The blad-
 der  was thickened only to a moderate de-
 gree.  I have examined the inside of the
 bladder  after the operation  of  puncturing
 by the rectum.   The hole in the bladder
 was exceedingly small, and had apparently
 been attended with very little inflammation.
 But in this instance  the instrument had
 been withdrawn as soon as the urine was
 evacuated.  After the catheter had been re-
 tained for some time in the bladder, I have
 found, upon dissection, that the back part
 of the bladder was inflamed and ulcerated,
 in consequence of the pressure of the end
of the instrument.
  20. The effect  of stricture on  the ure-
ters is to enlarge them  in a remarkable de- 
             IN THE URETHRA.            ^°
gree. I have seen them as large as a small
intestine, and much inflamed.
   21. On the  kidney,  the effect of stric-on the
                                         kidney.
ture, or any other kind of obstruction to
the course of the urine, is very remarkable.
It suffers great distension; the surround-
ing  cellular membrane is inflamed;  the
substance of the kidney itself is inflamed;
and the pelvis, with its digital processes,
is greatly distended, and  the vessels tur-
gid  with vermilion-coloured blood.   The
quantity of fat surrounding the kidney is
sometimes unnaturally accumulated, if the
irritation has continued long.
   22. The effect of stricture on the blad- 0n th<
                                         brain.
der, ureters, and kidneys combined, brings
on fever, with great irritation, from which,
 at last, there  results an  effusion  on the
 surface of the brain.
   In a child, whose body I dissected,  I
 found many spongy tumors growing  from 
       44        VARIETIES OF STRICTURE
       the inside of the bladder, and much water
       in the ventricles  of the  brain, and  under
       the arachnoid coat.
Effect of   23. The  last fact I shall mention to be
caustic on
stricture. ascertamec[ fr0m the anatomical investiga-
       tion  of  this  subject regards the effect of
       caustic on  stricture;  which I believe few
       have had an opportunity of observing.   In
of lunar  one application of the lunar caustic, an im-
caustic.        x x
       pression  to the depth of an eighth part of
       an inch seemed to have been made.  One
       application  more would have admitted the
       largest bougie into the bladder.  The caus-
       tic had been applied nine days before death.
       The parts were not in a state fit  for  ob-
       serving  the  appearances of inflammation ;
       but, when suspended in fluid,  fleecy loose
       shreds were  seen to hang from  the  ulcer
       produced by the  caustic.   There was no
       mucus or film of coagulable lymph cover- 
I
             FN THE URETHRA.           45
ing the sensible  surface left by the opera-
tion of the caustic.
   I applied the kali  purum three times to of the
a narrow  stricture of the simple kind:  the
patient was relieved of irritation ; but  dy-
ing of another disease, on the examination
by dissection,  the stricture bore no marks
of erosion or even partial destruction* See
Plate III. and  IV.
   These  are the chief facts which I have
been  able to establish by the examination
of the diseased parts after death.  I give
them as the ground-work for future obser-
vation ; and I will, in the meanwhile, draw
some conclusions in  practice.
  If  these  distinctions  in  the nature of
stricture,  drawn from appearances in the
dead  body,  are important,  it is of course
                5 
 46         VARIETIES OF STRICTURE
 equally  necessary to learn to  distinguish
 them in  practice.
   24.  Besides the use of the common bou-
 gie  and  of the  soft wax  bougie,  I  have
 used what I would call the urethra sound.*
 It is by the  use of these.probes that I first
 became  aware of the great variety in the
 forms of stricture, and  of those  essential
 circumstances to be  observed  in  practice,
 which I  have  detailed  in  the  succeeding
 letters.   I allude  more  particularly to the
 exquisite sensibility of the  canal  at parti-
 cular  points,  and especially  behind  the
 stricture.!
   An objection has been  made to this in-
 strument, that it may be apt to  be grasped
  * The term ball probe has been so far misunderstood, that the
instrument makers have had repeated orders for them to be used as
probes for gun-shot wounds.  It is so far well, however, that they
will answer for gun-shot wounds* perhaps better than the gun-shot
probe  commonly used, and are well adapted for the examination of
Cavities or sinuses of any kind.  See Plate II.
  | For a particular account of the manner of using these probes, and
of sounding the urethra, see "System of Operative Surgery founded
on the Basis of Anatomy." Vol. I. p. 100. 
             IN THE URETHRA.           * k
by the membrane of the urethra.   There
is no foundation for this fear ; it has arisen
from ignorance of the nature of the mem-
brane of the urethra.
  One  evident  advantage to be  derived
from the use of these probes is, that they
do  not produce  that  universal  irritation
along; the whole canal of the urethra which
we  find to be the  effect of introducing a
bougie for the first time.  The patient will
often  faint on  introducing a bougie into
his urethra before it  is accustomed to the
sensation.   We cannot keep  a common
bougie long in the urethra, while it is in a
sensible state, without exciting more inflam-
mation, and imposing on the patient the
necessity of submitting to considerable con-
straint  afterwards.  Often patients  have
begged me to introduce  the sound before
the bougie, to take off the unpleasant sen-
sation.  By the use of these probes we can 
48        VARIETIES OF STRICTURE
continue to examine the urethra minutely,
without producing any mischief.
  25. The common example of permanent
stricture, particularly described under the
term  Simple Stricture,* is ascertained, in
the living body, by the use of the soft bou-
gie, and by the circumstance of the ball of
the probe  passing down uniformly,  and
without  obstruction,  till it  reaches  the
stricture ; there meeting with resistance at
last, passing with  a jerk through the stric-
ture,  and then  gliding smoothly onwards.
This  stricture is to be cured  by the opera-
tion of the  caustic.  A  full sized armed
bougie is to be  passed down to it,  so  that
the whole base  of the stricture may be de^-
stroyed; after  which the largest  bougie
may be  carried freely into the bladder.
This  is  the practice of Mr. Home;  and
what carries equal weight with me it is the
              *See above page. 15. 
               IN THE  URETHRA.          ^y
 practice of Mr. Lynn, the most enthusias-
 tic of  Mr. Hunter's  pupils, and one who
 has retained his excellent precepts with the
 truest devotion.  It is the success attend-
 ing the operation of caustic, in cases simi-
 lar to this, that has brought  this method
 of cure into  such general use.   If the idea
 be taken up  that a stricture is to be entire-
 ly eaten away by the operation of the cau-
 stic, it must  be done thoroughly.   For the
 small  remains of a stricture, by impeding
 the course of the  urine, will  produce an
 excitement in the parts, and reproduce the
  stricture.  I wish to  state this  distinctly,
 because  what I  have  to  say concerning
• other cases of stricture might be mistaken
  for a condemnation of this method of cure,
  so admirably adapted to the simple perma-
  nent stricture.
    26. When there is an impediment to the
  passing of the point of the bougie, by the 
 50        VARIETIES OF STRICTURE
 inflammation of a lacuna,  in the manner I
 have already described,  the application of
 the lunar caustic, according to Mr. Home's
 method, would be improperly  severe, and
 perhaps not very effectual, unless, by dis-
 solving, it reached the surface of the lacu-
 na.   The bougie can do no good here, for
 it does not close the lacuna, by pressure ;
 and,  as it does not come in contact with
 the inflamed cavity, it does not  change the
 nature of the  action there.  I have seen
 the tumour formed by the inflamed base of
 the lacuna, cut out by an incision on the
 outside  of the  penis.  But this is a very
 severe operation.   The method I  have
 adopted to destroy the morbid action of the
part is,  first,  to fix the point of my finger
 on the tumor on the penis, and  then in-
troducing one of the small perforated probes
into the urethra, insinuate its point into the
lacuna;  then, withdrawing the probe,  and 
/              IN THE URETHRA.           °L
  arming it with a small portion of the alka-
  line caustic, to introduce it again into the
  lacuna.   This I have found most effectual
  indeed.   The  alkaline caustic, used in Mr-
  Whately's  manner,  is better adapted for
  changing the nature of  the morbid action
  of the lacuna, and  curing the discharge,
  than the more severe operation of the lunar
  caustic.   When the caustic touches the
  surface of  the lacuna, it then changes the
  disposition of  the part, and the discharge
  and tumor diminish.
     27.  I have  said that  there is a stricture
  of a very troublesome kind near the orifice
  of the urethra, and visible.   I have done
  all kinds of  authorized  violence  to this
  stricture by the  knife and caustic,  and,
  after all, I have been obliged to have re-
  course to the bougie.  From a case of this
  kind, I was confirmed in my opinion that a
  bougie should not be kept in  the  urethra 
  3^       VARIETIES OF STRICTURE
  for any considerable  time, as is  the prac*
  tice ;  but that the fullest effect is procured
 by merely passing in a bougie which is a
 little tight in the stricture, and withdraw*
 ing it after two minutes.   By this method
 I have seen  this  callous  hardening in the
 orifice of the urethra enlarged, and the ne-
 cessity of introducing the bougie become
 less and less, until at last it was only ne-
 cessary that the patient should himself in-
 troduce the bougie once in the space of a
 week.   By this simple method all incon-
 venience was removed, after the knife and
 caustic had been tried in vain.  I  had un-
 der my care a young gentleman, who after
 repeated gonorrhoeas and a gleety discharge '
 from the  urethra, continuing  at  intervals
 for years, came to me to have the urethra
 examined.  He  had a discharge from the
 urethra, a fullness in the perinseum, a feel-
ing as if a tumor were there, and heat of 
             IN THE URETHRA.           53
urine.   I found that the ball probe passed
through a firm cartilaginous stricture with-
in a quarter of an inch of the orifice of the
urethra.  But on passing it farther  down
into the canal, and near the bulb of the
urethra, I found  a great tenderness in the
canal,  and that here was a difficulty even
in passing  down  this small probe.  Here
in  short was a stricture forming, and in
what may be considered as its inflamma-
tory stage.   I removed it in the manner I
have described as best adapted to the dila-
table stricture; which I  could not  do by
any of the usual methods of  cure, seeing
that in the orifice  of the urethra there was a
very firm undilatable stricture.  After re-
moving all urgent symptoms and all uneasi-
ness from my patient, I consulted with a pro-
fessor of surgery, who gave it as his opinion
that this stricture in the orifice should be
forcibly broken down by the  silver probe.
                 6 
54        VARIETIES OF STRICTURE
Another surgeon of celebrity advised me
to cut it with the knife.   And for my own
part I concluded that if ever there was a
callous stricture which could be destroyed
by caustic this was the very case.  I appli-
ed the caustic,  but did not succeed in re-
moving the stricture.  I introduced a small
knife, and cut it across in two places, and
then used the bougie.   Still the white cal-
lous surface and the disposition to contract
remained. I then used a hollow tube which
remained, allowing the patient to pass urine
through it. I introduced successively larger
tubes, until the passage  was so wide that I
might almost have introduced my little fin-
ger. Yet the white sloughy appearance of
the urethra remained; and it soon contract-
ed again.  I was now satisfied that violent
methods would not do.   I proposed merely
that I should at the interval of some  days
introduce  a  smooth  bougie.   The confi- 
             IN THE URETHRA.           ° °
dence my patient had in me was not yet
exhausted;  but a  friend carried him to
another surgeon, who certainly in this case
preferred the bougie to the caustic;  and if
the patient  is not  now perfectly relieved
from all tendency in the stricture to return,
he feels no  inconvenience, the contraction
being enlarged by the occasional use of the
bougie.  It will be a^t once manifest,  that
in detailing this case, I can have no motive
of vanity ; but as it seemed to me that there
was a distinction between the practice and
the written opinions of the gentleman un-
der whose care the patient was ultimately;
 and as  I have thus learned to put more
 trust in my own experience than  in the
 written opinions even of the most eminent
 surgeons, so I  conceive that you may also
 find the hint useful.
   28.  Of the dilatable stricture I need say
 nothing here, as I have devoted an entire 
56        VARIETIES OF STRICTURE
dissertation to the subject.   For the same
reason I shall not add any thing to what I
have said on spasmodic stricture.
  29. The facts established in § 10,  11,
that inflammation and high irritation will
be  produced at the sinus  of the urethra
and orifice of the seminal vessels by an in-
flammation of the anterior part of the canal,
accords with our observation in the living
body.   I think it very likely, that the con-
tinuance of  irritation  and  inflammation,
near the neck of the bladder and seminal
vessels, may terminate in suppuration, and
that sacs of pus may form and communi-
cate with the  urethra.   Inflammations  re-
maining in the neighbourhood of the caput
gallinaginis  and neck of the bladder pro-
duce great distress ; there is severe scald-
ing pain when the urine flows through the
prostate gland and membranous part of the
canal;  on introducing the urethra  sound, 
              IN THE URETHRA.          °'
as the ball approaches the neck of the blad-
der, there is a burning pain, and, on with-
drawing the instrument, the ball brings out
matter from the urethra.  The  sensibility
of this part of the  canal, and the circum-
stance of this part being  surrounded by
powerful muscles,  causes a distressing de-
rangement of the  action of  the  bladder.
When these  symptoms are a  consequence
of inflammation of the urethra forward, they
will yield to leeching, fomentation, and mild
purges, and the use of the bougie. If a large
bougie can not be kept in the urethra, owing
to stricture or inflammation forward in the
canal, the ball of the urethra  sound, being
introduced and moved in the irritable part,
will essentially serve to diminish the in-
flammation and   unpleasant   sensations.
Stricture  and inflammation in any part of
the urethra are apt to produce inflamma-
tion and  irritation near  the  neck of the 
 58        VARIETIES OF STRICTURE
 bladder,  and it is a great  relief to  the pa-
 tient, during the progress  of cure, to have
 this accessary  source of uneasiness dimin-
 ished.*
    30. Of all the diseases of the urethra,
 that  more  severe  effect  of inflammation
 which I  have  described under  the  head
 callosity or long stricture of the  canal, is
 the most  difficult to manage.   The nature
 of this disease  is ascertained by the intro-
 duction of the ball probe.   The resistance
 felt is abrupt:  and it is possible to distin-
guish the almost cartilaginous hardness of
 the canal by this instrument.   When  we
have selected a ball of that size which will
pass through the anterior part of the stric-
ture, we find there is still a resistance, and
  * Most of the confirmed opinions of the older writers are founded
in observation.  When they distinguished gonorrhoea by its seat, first
as being of a milder kind when seated a little behind the glans in the
lacunae of Morgagni, and in the second place as more malignant and
more apt to erode the parts when seated in Cowper's glands, they
were certainly correct in fact, though their reasoning was erroneous. 
             IN THE URETHRA.            ^ J
that, although the ball is not grasped, yet
there is a degree of interruption to its fur-
ther introduction.   When we move it on-
ward, there is an irregular interrupted mo-
tion.  I have said that the common method
of introducing the armed bougie,  so admi-
rably described by Mr. Home, is adapted
to the  first and  commonest  kind  of stric-
ture.  But I have no hesitation in saying
that the application  of the caustic in that
manner to a stricture of this kind makes  a
tedious cure,  and is full of danger. As we
have to make our way through an inch per-
haps of the length of the canal, it must be
evident that the operation must be difficult,
to carry the caustic in an undeviating line,
especially at  the curvature of the urethra.
I shall by and by prove that the caustic
has a double effect, first, As it destroys the
sensibility and corrects  the  morbid  irrita-
bility so  distressing in  the  first  instance. 
60       VARIETIES OF STRICTURE
and so sure a harbinger of incteased  ob-
struction.   Secondly, as  it  destroys  the
callous part,  or  stricture,  by killing  the
part,  and by producing a necessity for  the
living surface beneath to  throw  off in
slough the portion touched by the caustic.
Now, I think we have good reason to avoid
this last operation of the caustic, and con-
fine it to the mere effect of subduing  the
sensibility of the  part, and facilitating  the
operation of dilatation by the bougie.   To
this end certainly, in such a case, the alka-
line caustic  is well adapted.
   31. That narrowing of the canal through-
out a  considerable part of its extent,  which
is  attended  with wasting  of the spongy
body of the  urethra, may be readily remov-
ed by the occasional use of the bougie.
   32.  The  fact that the  inflammation is
principally behind the stricture,  and that
fistulous openings behind the stricture  are 
             IN THE URETHRA.           ° x
found  to  follow more as a remote conse-
quence than as a direct  effect of the  stric-
ture, and to proceed from this inflammatory
irritation, is I conceive the  most important
circumstance in all the morbid anatomy of
the urethra.  It is a neglect of this circum-
stance, and the consequence of the neglect,
which has led some absolutely to reject the
use of the caustic in all cases; when,  if the
matter had been understood, it would have
confirmed the superiority of the operation
of caustic in  this  particular state of the
parts.   Often it happens that,  during the
operation of the caustic, this source of irri-
tation  being neglected, the  process of ulce-
ration is  fostered and brought rapidly for-
ward,   so that fistula in perinseo is pro-
duced.   This subject is so important as to
deserve more  particular  consideration in a
subsequent letter.
                 7 
               LETTER II.
        On the dilatable Stricture of the Urethra.
   1. I mean,  in  this letter, to communi-
cate to  you some observations on a com-
plaint, which, were  I to attempt to define
it by a name,  I should  call it the dilatable
stricture of the urethra.  I  shall not detail
here the origin and  progress of stricture :
nor attempt to trace back effects to their
causes, as in a formal treatise. I mean at
present only to state a case : but one which
has  very frequently occurred to  me  in
practice, and which, I  must suppose, has
often fallen in the way of every surgeon
who is  much  consulted in  diseases of the
urethra.
   2.  The account which the patient gives
of himself is nearly  this : That, some time
before, he had a  severe  gonorrhoea; that 
        OF THE DILATABLE STRICTURE.      O^
being particularly circumstanced, he could
not so well observe the directions of his
medical attendant  as perhaps the  case re-
quired ;  that  the  disease  continued  long
severe,  and he doubts even  now whether
he be entirely well: for he has observed
that,  although the  discharge sometimes
disappears, and he is free from any unea-
siness,  yet occasionally the symptoms re-
turn ; at which time he has been  sensible
of a  fulness in the perinseum, while,  even
during the absence of the discharge, there
is still a heat of urine, and he has imagin-
ed a  diminution  of the  stream of urine;
that of late the call  to make  urine has be-
come frequent, and he does not see what a
young fellow has to do rising three times in
the night  to make water; and that when-
ever  he exceeds in wine, or takes  unusual
exercise,  or has connection with women, 
64      OF THE DILATABLE STRICTURE.
the symptoms increase with a considerable
discharge from the urethra.
   3. Sometimes  a  patient comes to  us
with this complaint, imagining that he has
got  a  recent gonorrhoea;  but, although
there be discharge from the urethra, there
is no redness or swelling of the lips of the
urethra, or  inflammation of the  glans or
prepuce (la  gonorrhee habituelle benigne).
  4. When  the  urethra thus  affected is
examined by the bougie, it is found to be
unusually sensible;  and when  we carry
the bougie down to the stricture,  there is
severe  pain, and the patient shrinks from
the hand.   If he allows us to persist, we
shall be sensible of resistance to the point
of the  bougie;  and if we force the instru-
ment on, we shall  feel it grasped as by a
common stricture.
  When the urethra-sound represented in
the plate is used, I find that, as the ball is 
        OF THE DILATABLE STRICTURE.      6 5
passed into the  urethra, there is much in-
creased  sensibility near  the  glans;  that
having passed the ball a little way down
the canal, the patient ceases to complain of
it;  but when in its progress the diseased
part is touched,  and the ball passes through
the stricture, there is pain and a feeling of
soreness.
   5.  This state of the urethra differs  from
that of proper stricture, in being less  rigid
and firm.    If,  after examining a patient,
whose urethra is in this state, you call the
disease stricture, and  he happens  to con-
sult another surgeon,  he will be told that
it is no stricture, and to prove this, one of
the  largest bougies is passed with exulta-
tion !  But this  dilatation  is not a cure of
the disease ; on the contrary, every unplea-
sant  symptom is often aggravated by the
violence which has been used. 
 ^>^>      OF THE DILATABLE STRICTURE.
   6.  The  state of the urethra which I have
 here  described  may  continue for  a long
 time;  the symptoms neither increasing in
 severity,  nor  altogether  subsiding.   A
 young gentleman had these symptoms for
 eighteen months before he came to me.  I
 sounded the urethra of an officer,  to ascer-
 tain the cause of many uneasy symptoms
 previous to his going to  Portugal:  I felt
 my bougie obstructed;  but  the  stricture
was dilatable, and I became sensible of the
 state of the canal.  At that  time I could
not do any thing for his permanent  relief,
and after a campaign  of some  months, he
complained of the same uneasiness, and an
obstruction was felt in the same  spot.   I
have had many patients  to whom  it seem-
ed  difficult to  remember  the  time  when
they were  entirely  free from  uneasiness
and occasional discharge ;  and yet I found
that their  complaints were not  absolute, 
        OF THE DILATABLE STRICTURE.     ° '
confirmed stricture, such as I shall by and
by describe to  you,  but only through  a
part of the canal the bougie passed with
difficulty.  When, however, the complaint
is of long standing, there are often several
parts of the canal inflamed ; perhaps one of
these spots gives proof of an unelastic and
confirmed  stricture  having been formed.
I have  found a dilatable stricture deep in
the urethra, and near the bladder, while
there was  a confirmed cartilaginous stric-
ture near the extremity of the urethra. In-
deed, when there are two  or  three stric-
tures in the  urethra, we are  sure to find
 some   of  them more dilatable  than the
others.  The original and first formed stric-
ture is firm, and the  resistance it gives is
 abrupt; while  the others  partake more of
 the nature of the disease which I have here
 described. On one occasion, I found seve-
 ral parts of the canal inflamed, contracted. 
68      OF THE DILATABLE STRICTURE.
and unnaturally sensible:  after the  lapse
of nearly a year, I found the anterior  of
these spots of the urethra confirmed into a
rigid  stricture, having  lost that elasticity
which enabled me by gentle and continued
pressure to dilate it.
  7. I have already observed, that if, in the
circumstances described,  I say my patient
has stricture, he may probably be told by
another surgeon that I have been deceived,
and that there is no stricture in the case ;
and to prove this, the surgeon takes a large
bougie and passes it directly into the blad-
der, regardless of the pain which he occa-
sions.  It is by much too common an error
to force a bougie into the inflamed urethra ;
and surgeons are induced to  this, from the
appearance of greater skill which is given
by the dextrous  introduction  of the bougie
where others  have failed.  Sometimes in-
deed  a young man, ignorant of the struc- 
        OF THE DDLATABLE STRICTURE.      OV
ture of the urethra, introduces a  bougie
with a small point, which he allows to en-
ter into one of  the lacunse, or to hitch
against a fold of the urethra under the arch
of the pubis. A surgeon, aware of the pos-
sibility  of this failure, and well  instructed
in the anatomy of the parts, gives to a large
bougie  its proper curve ; turns up the point
of it, so that it escapes the fold of the ure-
thra on passing under the pubis ; and thus
with real dexterity introduces a very large
bougie  where others have  imagined,  and
made the patient  believe, that there was a
stricture.   But it is quite a different matter
when the surgeon  forces one of his large
bougies through  a urethra  narrowed by
such a  stricture as I have described above.
This unmeaning  cruelty,  in driving in a
bougie  by main force, is generally followed
by great increase  of the discharge, some-
times with  absolute obstruction of urine.
                 8 
 70      oF THE DILATABLE STRICTURE.
 I  am not to learn that the disease which I
 have described may be cured by the use of
 the bougie alone; but it is not in this way
 that we are to proceed.  Even in a healthy
 state of the uretha, the introduction of a
 very large bougie  will produce  a violent
 inflammation and discharge.
   Captain-----of  the Guards  had been
 formerly under the  operation of the caus-
 tic, and was  entirely free from complaint;
 but, being ordered  abroad, he thought of
 introducing a bougie, to ascertain the state
 of the   passage.  He  took  the largest he
 could find in  the shops ; he felt an obstruc-
 tion which he overcame by force ; the conse-
 quence  of which was, that he was attacked
 with a violent discharge, and came to me to
be cured of stricture.   On examination I
found that he had mistaken the fold of the
urethra, at the termination of the bulb back-
wards,   for a stricture; and that he  had 
        OF THE DILATABLE STRICTURE.      ' i
forced in a bougie larger than the natural
canal could allow to pass without injury.
This force,  and this injury to the canal,
when diseased in the manner which I have
described, will sometimes bring on severe
inflammation with swelled testicle ; some-
times the complaint is permanently increas-
ed ; it happens, though very rarely, that the
discharge entirely disappears, when the in-
flammation thus excited subsides.  I hope
to suggest a milder, more effectual, and cer-
tain cure, than the use of the common bou-
gie affords.
   8. Reflecting on the symptoms which I
have described, I think you will be apt to
conclude that all this is a consequence of
gonorrhoea.    Certainly this  state  of the
urethra occurs  very frequently after gonor-
rhoea.  But as it follows irritation of the
bladder, as it is produced by debauchery
independent of  infection,  by whatever pro- 
72      OF THE DILATABLE STRICTURE.
duces an irritable  state of the urethra, by
all  the  causes which produce confirmed
stricture,  I am bound to consider it under
a distinct  head.
  9. Knowing how inaccurate I think the
observations  to be which have led to  the
notion that  stricture is produced by mus-
cular contraction of the membrane of the
urethra; being aware too of the full mean-
ing of the term spasmodic stricture ; you
will even,  from what I have said already,
suspect that I am  describing  the first or
inflammatory stage of stricture.  The pro-
priety or truth of  this you might question
however,  and so  we  should  be led into
controversy.  I mean only to state the facts
as  they  occur, and the  method of cure
which I have found to be  successful; re-
serving the other part of the discussion for
a future opportunity.*
 * The question of the origin of stricture is discussed in the third
letter. 
        OF THE DILATABLE STRICTURE.      '3
   10. If we consider the structure of the
urinary canal, and  the  effects of inflam-
mation, together with the history of this
complaint which I have called the dilatable
stricture,  we  shall have  no  difficulty,  I
think, in forming an opinion of the state of
the part when thus diseased.  The urethra
is a dilatable  tube, but it has in itself no
power of expansion. It is distended only
by the force of the bladder, and by means
of the urine flowing from the bladder: and
to facilitate this  operation it is elastic,  and
very easily stretched. Inflammation changes
the natural structure of all the parts of the
body; the hard bone by inflammation be-
comes soft; the firm tendon becomes spon-
gy ; the  transparent membrane becomes
thick and opaque ; and pliant parts become
firm.   So  when  the urethra is inflamed
there is a diminution of its natural elastici-
ty ;  and a greater force  of the bladder is 
 74      OF THE DILATABLE STRICTURE.
 necessary to the discharge of urine through
 the inflamed part  of the passage.  When
 the  general  state  of inflammation of the
 urethra subsides, if it has not been violent
 or of long continuance, the membrane re-
 sumes its pliancy.  But it often happens
 that a part of the canal continues more per-
 manently inflamed; a residue  as it were of
 the more general inflammation.  This part
 does not yield to the impulse  of the urine
 (and the urine  being of necessity driven
 more forcibly against this contracted  part,
 is, no doubt, one cause of the  continuation
of the inflammation), and the bougie which
 passes easily along that part  of the canal
 which is not inflamed,  is resisted by this
 inflamed part of the canal.  I had  almost
 said by this contracted part: but the word
 contracted is improper as applied to stric-
 ture of the urethra,  for the  sides of the
 urethra are  always in contact, and cannot 
        OF THE DILATABLE STRICTURE.      ' 3
be brought closer by the formation of a
stricture.   A stricture  is only a loss  of
elasticity, which prevents the due disten-
tion of the part when the push of urine is
made, or the bougie is introduced.
   11. I hope you will now agree with me,
that the  obstruction to the passing of the
urine, of which I have detailed the symp-
toms in the first part of this letter, must be
occasioned by this loss of elasticity—this
inaptitude of the canal to dilate, which pro-
ceeds from  vestiges of inflammation in a
part of the canal,  after a more general  in-
flammation  has subsided; and which  at-
taches to distinct places of the canal.
    12. In proposing a cure for this disease,
 we should naturally suppose it possible to
remove it, by putting the patient upon low
 diet; confining  him to his sofa ; leeching
 the perinseum ;  fomenting or applying wet
 cloths, &c.   I shall not say that this prac- 
76      OF THE DDLATABLE STRICTURE.
tice may not be beneficial in  some cases ;
but I am also well assured, that the patient
may be  long confined and greatly reduced,
and yet  after all derive but slight and tem-
porary benefit  from this severe treatment.
   13. In the use of the  bougie, we have
the means of applying pressure, and at the
same  time  distending the inflamed mem-
brane ; by which the low chronic  inflam-
mation is disturbed and remedied.   Being
assured that the violence of inflammatory
action is gone, if it ever was  violent, we
take a large sized bougie, introduce it, and
press it until it passes the stricture; we let
it remain there two or three minutes.  On
the fourth day we  introduce  it again ; and
this is  repeated until  the  bougie passes
without pain and  the  stream  of urine  is 
        OF THE DILATABLE STRICTURE.      * '
full.  But the use of the bougie  in this
state  of the  canal  is  a  painful remedy.
Sometimes the inflammation does not dimi-
nish, but is greatly increased,  and there
follow swelled testicle and all the train of
distressing symptoms, which delay the cure
and irritate the patient.
   14. But  in this effect of  the bougie, in
the  case of  dilatable  stricture, there  is
much which deserves your attention. Some
very incorrect opinions  are received and
acted upon, which have no foundation but
in this fact.   Some have advised that  the
stricture of the urethra be forcibly torn up
by the use of a  metallic probe, and they
have successful instances to bring  in  vin-
dication of the practice.  So have surgeons
in all ages brought cases to vindicate their
practice  and substantiate  their opinions.
Formerly it was no uncommon  practice to
break down the carunculse and  fungous
                  9 
78      OF THE DILATABLE STRICTURE.
excrescences of the urethra ; and the cases
given in former  times, to prove the pre-
sence and destruction of carunculae, were
just as worthy  of  credit as  those now
brought forward to prove the possibility of
breaking  through a stricture.  The stub-
born fact which opposes our belief, is that
the confirmed  stricture is the firmest and
densest part of the canal,  and we can not
thus break  through  it.   Doing what  the
old surgeons supposed had  the effect  of
bruising the caruncula, that is,  pushing a
probe or bougie into the urethra, has  the
effect merely of stretching and doing vio-
lence to a dilatable stricture ; and the issue
of  this is for  the  most  part  beneficial.
When  this same  process of cure is  tried
with a  firm and rigid stricture, the conse-
quences are, intolerable pain, inflammation,
and ultimate  spasm.  On  observing  the
benefit resulting from this violence done to 
        OF THE DILATABLE STRICTURE.      79
a stricture, Mr.  Flunter  has this expres-
sion :  "This I  suppose either tore  the
stricture,  or weakened it by stretching it
suddenly  so  as  to render  it  unable to
recover its  cotractile power for a  consi-
derable time.  I have seen (he  continues)
where  this produced good effects, and  for
a time removed the permanent stricture
and prevented spasm from  taking  place."
In the  succeeding letter,  I hope to prove
satisfactorily that a stricture is not mus-
cular,  and that this reasoning is therefore
incorrect.
  In the mean time, the explanation which
I have to  offer is  this,  viz.  that it is  the
pressure on the inflamed surface, and most
of all  the stretching of the inflamed mem-
brane,  which disturbs the chronic  inflam-
mation of the part;  pain,  even swelling,
and an increased soreness are  the effects
of this  practice ;  but with this new distur- 
 80      OF THE DILATABLE STRICTURE.
 bance, the peculiar irritability depending
 on the former morbid  state is diminished.
 I shall state shortly to  you, as my memory
 serves,  the circumstances  which have led
 me to this opinion.   You know the follow-
 ing to be a daily occurrence.   N— came
 to me, complaining that although the vio-
 lence of his  gonorrhoea was subdued, and
 he had been  comparatively well  for some
 time, yet there  remained a clear gleety dis-
 charge.   I prevailed with  him to let  me
 introduce the bougie.   I  introduced one
 of the largest size, he fainted during the
 operation, from that indescribable nervous
 sensation, which will sometimes creep over
 a man, who  has a  bougie  introduced  for
 the first time.  The resistance to the bou-
gie was only such  as  indicated  that the
 membrane of the urethra was  fully on the
 stretch. There  succeeded to this a copious
purulent  discharge,  which  subsiding left 
        OF THE DDLATABLE STRICTURE.      ° L
him free of all complaint: repeated expe-
rience then  establishes this  fact.   D (9)
came with symptoms of stricture: a resis-
tance was felt near the bulb to the intro-
duction of the bougie, and there was  ex-
treme tenderness.   Notwithstanding  the
sufferings of the patient  the bougie was
forced in.  A similar  operation was per-
formed on the  3d day after, on the 7th,
and on the 12th,  when the bougie passed
without pain, and the urine flowed  freely
without heat or spasm.   During this in-
quiry,  we  find  in  the  observations  of
 Bruninghausen*  something  worthy of at-
 tention.
    He made his patients dilate the canal of
 the  urethra  with the urine, by stopping
 the  orifice and forcing with the bladder:
 he gives several  cases in  proof  of  his re-
 markable success  in destroying strictures
              * Biblioth. German. Vol. I. 
 82     OF THE DILATABLE STRICTURE.
 by this method of distending the canal. I
 have no doubt but  that in some  instances
 this  practice  succeeded,  from what I have
 done with the injecting syringe.  A patient
 has used a strong injection for weeks,  and
 returned to me no better.  I  have shown
 him  how to distend the urethra, and  keep
 it  distended  for a few minutes ; when the
 consequence  was apparent, after once using
 the syringe.
   15.  In all  these examples, there is a de-
 gree of violence done to the membrane of
the urethra,  and neither  the  bougie, nor
 the urine, nor even the injection,  has any
thing medicinal  in it: there is only a dila-
tation of the  canal,  and a pressure on its
 surface.  We might  be  inclined  to  say,
that  the contact of  the foreign body was
the cause of  the salutary change, if in the
 two last instances the contrary  was  not
proved, viz. that, unless the membrane of 
        OF THE DILATABLE STRICTURE.      83
the urethra be stretched, the  change does
not take place.
   My conviction is, that Bruninghausen,
like those who use the  metallic bougie to
destroy stricture,  do  not cure  the firm
stricture of the urethra, but  only subdue
the remaining inflammation which produ-
ces and accompanies this dilatable stricture.
You may imagine, after what I have said,
that I wish to recommend this  manner of
destroying the disease by violence.  I have
stated the facts as they bore on this point,
but not the  whole truth.  The  effect of
this violent introduction of the bougie  is
irregular, not  sufficiently within  our con-
troul, and  sometimes  it is  ineffectual  in
eradicating the disposition to inflammation
and stricture, and sometimes,  as  might be
imagined, it  aggravates the disease.
    I have a milder and more  effectual re-
medy in the use of caustic;  and notwith- 
 84      OF THE DILATABLE STRICTURE.
 standing the hardy manner in which some
 men have spoken of  the caustic, as being
 full of danger and very painful, with con-
 fidence I say, that we  have a milder and
 more effectual remedy in the caustic  than
 in the bougie.
   16.  In applying the kali purum, or alka-
 line caustic, to the common stricture,  as
 recommended by Mr. Whately, I had in
 several cases been agreeably surprised at
 the rapid amendment of my patients.  For
 example,  I found that, after a single ap-
 plication of the kali purum, one patient said
 that he had no kind of uneasiness remain-
 ing ; another, that if he had felt previously
 as he did then,  I should never have seen '
him.  I found that, instead of dreading the
application of the caustic, my patients re-
lied upon it for the removal of all unplea-
sant symptoms ; that they discharge the
urine more freely  in  consequence of the 
        OF THE DILATABLE STRICTURE.     ° 3
application ; and that, in having connection
with women,  the functions  of the parts
were less disordered.  One gentleman re-
turned to me, making the  impudent  re-
quest that I would  apply the  caustic for
this last  specific purpose! a  request with
which you  may well imagine  I did  not
comply.
   17. Further experience, however, of the
effects of this alkaline caustic did  not ac-
cord with my first success.   I  found that,
wherever there  was a confirmed and hard
stricture, its application was  little more
than  innocent.   I  found that,  after  fre-
quent applications,  although  the  urgent
symptoms were kept under,  yet the stric-
ture was not destroyed ;  that, after repeat-
ed applications  of this  caustic, on intro-
ducing a soft bougie into the  canal, the
indentation  upon it shewed the stricture to
have preserved  its firmness; I  may even
                 10 
86      OF THE DILATABLE STRICTURE.
say, its sharpness.   After several applica-
tions of the caustic in Mr. Whately's man-
ner, I have found on dissection no trace of
its operation on the stricture.  See Plate IV.
  18.  On revolving these circumstances
in my mind, and particularly considering
that this  caustic took  off the  sensibility
from the part of the canal which it touch-
ed,  and thereby diminished the  irritability
of the parts, but did not destroy the  stric-
ture, I set about  a comparative trial of the
effects  of the two caustics, the kalipurum,
and the argentum nitratum.
  19.  I found that,  although the alkaline
caustic was particularly strong  when ap-
plied to a living surface, and its  influence
confined to that surface, yet, when a small
portion of it was inserted into the end of a
bougie, it became,  even during  that ope-
ration, moist  and soft  by the absorption
from the  atmosphere ;  and that, further, 
        OF THE DILATABLE STRICTURE.      ° >
when the point of the bougie, thus loaded,
was dipt in oil, or covered with soap, the
caustic  was  rendered mild;  and,  by the
time it was carried through the urethra to
the stricture, it was little else than a liquid
soap with a large proportion of alkali.
   20. I  took off a small portion  of the
cuticle from my arm,  and applied  the lu-
nar caustic to the part during half a mi-
nute.  A deep slough formed, accompa-
nied with a kind of soreness and sensibility
over the arm.   A fortnight afterwards I
tore up the slough, which was dried and
hardened, and a small but deep hole was
left.  I applied the kali purum in the same
way; that is to say,  I cut off  a portion of
the  cuticle from my arm  until the surface
bled.  I introduced a small  portion of the
 alkali into the end of a bougie, dipped the
 end of the bougie in oil,  then  moistened it
 with saliva,  and  applied  it to my  arm, 
 oo     OF THE DILATABLE STRICTURE.
 taking as nearly as I could the usual time
 occupied in the operation  on the urethra.
 The pain was sharp; but  there was less
 swelling,  less  blush  of redness round the
 spot where  it was  applied,  than in  the
 former instance.   These effects soon sub-
 sided, leaving no unpleasant sensibility on
 the  arm,  as the former caustic had done ;
 and  the  vascular surface  was not cover-
 ed with a slough : although a certain trans-
 parent whiteness was on the surface, yet
 the small vessels could be seen.  On drop-
 ping a little diluted  nitrous  acid, which
 happened to  stand by me, on the  spot,
 there was no pain ; but on  touching with
 the  acid  a part of the skin to which the
 caustic had not been applied, but of which
 the  cuticle was  taken off,  the  pain was
 exquisite.
   21.  These  experiments,  though on a
very trifling scale, were yet quite sufficient 
        OF THE DILATABLE STRICTURE.     ° J
to explain to me the effect of the  appli-
cation of the kali purum to stricture  in the
urethra. In the way in  which it is applied,
it becomes a weak caustic,  flowing  out as
it is dissolved;  deadening the surface of
the urethra, and  subduing the inflamma-
tion, but not sufficiently powerful to bring
a deep slough  from  the  firm  stricture.
Now the portion of the urethra which is in
a state  of inflammation is very sensible to
the urine passing over it; to the touch of
the point of the bougie ; or to the action of
 the muscular fibres which surround the
 urethra.   But when, by the operation of
 this milder caustic, the  sensibility of the
  surface is  diminished, then  the urine or
  semen is  emitted without  pain,  and  even
  the bougie can be introduced.  When the
  bougie is introduced into a man's urethra,
  he is more sensible  of the degree of  force
  than the surgeon is; he judges  of  the vio- 
 yU      OF THE DILATABLE STRICTURE.
 lence by the  pain.  And  here a  surgeon
 who is so disposed  may have an opportu-
 nity of deceiving his  patient.   When  a
 bougie of a small size is resisted by a stric-
 ture, and gives  pain, he may yet assure
 the  patient, that if he will submit to  the
 caustic, he will introduce a much larger
 bougie  with less pain,  and  that immedi-
 ately after the application of the  caustic.
 The reason  is that,  the sensibility being
 diminished, the  patient does not shrink
 from the  hand; and now the dilatation of
 the part of the passage suffers the instru-
 ment to enter,  and the patient thinks that
 the stricture is destroyed.   This is one of
 many occasions which exposes the patient
 to deception,  and makes it  of importance
in the cure of this disease, above all others,
that  the sufferer should be satisfied of the
honour  and the fair professional  fame of 
        OF THE DILATABLE STRICTURE.      y *■
his surgeon, before he entrusts himself to
his hands.
   22.  In contrast with  the effects of the
kalipurum, thus  applied in  a mild form,
observe what are  the effects of lunar caus-
tic on  the urethra.  When a part is touch-
ed by  the caustic it does not at  once  be-
come  loose: the  dead slough remains at-
tached to  the remaining part;  and  the
obstruction*  for the  time is necessarily
greater.  The obstruction is greater,  be-
cause  it is sufficiently evident that  the
union of the  caustic  with the  substance
touched produces a sponginess  or expan-
 sion in it.   It is  by a change taking  place
 in the living part that the dead  comes  off
 in a slough.   This operation, the effect of
 an excited action of the living  vessels, is
 necessarily slow.   If the application of the
   * The mechanical obstruction, not the spasmodic difficulty of pas-
 sing the  urine. 
 92      OF THE DILATABLE STRICTURE.
 caustic  has been  gentle, the dead matter
 comes away insensibly ;  or only some very
 small shreds or filaments are observed in
 the urine.   If the application of the caus-
 tic has been more severe, a distinct pellet
 of slough will be pushed off with the urine
 about the fourth day.
   23. As to the white matter  which is at-
 tached to the lunar caustic on withdrawing
                                      o
 the bougie,  I know not what to think of a
 surgeon who can suppose this concrete to
 be a true slough.  The matter discharged
 from  the urethra in consequence of intro-
 ducing the  lunar caustic is of three kinds ;
 1. The coagulated secretion of the urethra
 which attaches to the end of the bougie;
 2. Coagulable  lymph ; which is  one effect
 of inflammation,  and  therefore   an after
 process;  3.  and lastly, The proper slough
from the  stricture or membrane of the ure-
thra, which  has been injured and disorga- 
        OF THE DILATABLE STRICTURE.      y^
nized by the operation of the caustic, and
is thrown off by the living surface.   Some
authors have spoken of keeping the lunar
caustic in  the urethra for a few minutes,
as if a minute more or less was of little
consequence !   I kept  the  armed bougie,
as it is termed, one minute introduced into
the sheath, or prepuce, of a ram ;  on kill-
ing the animal on the  fourth day, 1 found
a deep slough, of double the diameter of
the caustic employed, almost detached, and
leaving a deep ulcer.   I applied the caus-
tic to the  stricture  of  a young gentleman
for a minute;  on the fourth day his ure-
thra was plugged, until  the uirine  forced
off a large membranous slough.  It is the
coagulated matter  attached to  the face of
the caustic which prevents the  entire  des-
truction of the  urethra, when  the  armed
bougie is kept more than a minute  in the
canal.
              11 
 94      OF THE DILATABLE STRICTURE.
   24.  These  are facts which I believe will
 not be contradicted.  Consider then how
 it happens that, in certain cases on record,
 the caustic goes through the stricture even
 during its  application as a caustic.   Con-
 sider also  the instances  frequently men-
 tioned, where the bougie is described as
 going into  the bladder  twenty-four  hours
 after the application of the caustic.   What
 can  we understand  to happen in  such
* cases, but  that the  surgeon is  deceived
 by the circumstance I have just  explained ?
 that the diminished sensibility of the pas-
 sage, and the  greater force  which the pa-
 tient can permit to be employed  after the
 use of the caustic, enables the  surgeon to
 pass  the bougie ?  I must here express my
 conviction, that neither the abettors of the
 use of the  alkaline,  nor of the metallic
 caustic, have explained  the  cause of that 
         OF THE DILATABLE STRICTURE.      95
 relief, which the  patient experiences,  on
 its true principle.
   An important distinction betwixt the use
 of the kali, and  of the argentum nitratum,
 as caustic, is, that a  certain lubricity is
 given to the  urethra, by the solution of the
 former forming a soap with the secretions,
 so as readily to admit  the bougie into the
 narrow part of the canal :' but the argentum
 nitratum  coagulates  the secretions,  and
 when it has been applied to a stricture  with
 the intention of burning it,  eating deep,
 and acting as a caustic, the part touched by
 the caustic is dead, rough, and no longer
 smooth and lubricated;  it ought not to be
 disturbed by the  introduction  of a bougie,
 for the bougie readily strikes upon this part;
 the slough, instead of separating by the na-
 tural process, is torn off, and hsemorrhage is
the consequence.  Blood follows when the
 surface of the canal only is torn off; if the 
36      OF THE DILATABLE STRICTURE.
slough be deeper, the spongy sub stance of
the urethra is opened, and the bleeding is
profuse.—If, after a severe application of
the lunar caustic, the patient feel as if some-
thing plugged the urethra at the part,  an
effect of the partial loosening of the slough,
he must be  cautioned against forcibly ex-
pelling his urine, for this is apt to tear  up
the connections and produce  hsemorrhage.
Allow the natural  process of sloughing to
go on, and there will be no breach either
of the vessels or of the cells.
   25. The supposition that the kali purum
abrades and  takes off the surface of the
stricture appears to me to be without foun-
dation ; that soap which is formed is by the
union of the caustic with the secretion of
the urethra.  By this union, and the mix-
ture with the oil in which the bougie is dip-
ped, the caustic is made mild ; and having
the quality of lubricating the strictured part 
          OF THE DILATABLE STRICTURE.       97
of the canal, I have used it  much where I
wished to introduce the bougie at the  same
time.*
    Having  explained what I conceive to be

 the  nature of the dilatable stricture of the

 urethra,  and  shewn  in a general way the

 operation of the bougie and of the  caustic,

 it  remains  for me  to  speak  to you more

pointedly of the means  of cure.

  * In conclusion on the effects of caustic, it must be evident to any
 one who turns over the leaves of the  books on this subject, that
 there is nothing  new in the practice, and no claim of originality
 can be raised by any one of late years ;  and even authority may be
 found  for the application of the lapis infernalis in M. Daran ; and in
 Paree, Hildanus, S. Vander Wiel (Med. Anat. Chirurg.), Astruc, and
 many others, were it worth any man's time to inquire,  we have suf-
 ficient proof that  escarotics and caustics were in common use. Their
 notion of the disease indeed naturally  led them to that practice in
 former times—The old surgeons sometimes used a canula to convey
 the escarotic, oftener a  bougie.  They used  corrosive sublimate,
 red precipitate, verdigris, burnt alum, lunar caustic, lapis infernalis ;
so that there can be nothing new in the  practice, unless it be in the
intention with which the caustic is applied, or the dexterity of the
application. 
 98     OF THE DILATABLE STRICTURE.
   26. The plan of cure which I pursue on
the principles  I have stated is this.  I as-
certain by means of the ball probe the place
of the urethra which* is inflamed and nar-
rowed.   I take one of the ball probes, *
with a hole drilled in it, and load it with a
small portion of the kali  purum.   I pass
the ball down to the obstruction, and allow
it to  remain until the  alkali  is disolved :
of course it flows out upon  the inflamed
surface.
  27.  The  patient has no  unpleasant sen-
sation on the introduction of this instru-
ment ; a  warmth not rising to pain is  the
only sensible effect.   When  the  alkali is
dissolved, a bougie of such a size as gently
to dilate the stricture, is introduced for the
space of  a  minute.   The bougie  glides
easily into the  stricture now ; because  the
parts  are soaped by  the dissolution of  the
            * See the Plate of Instruments. 
     OF THE DILATABLE STRICTURE.         y y
alkali,  and the sensibility of the  surface
deadened by the operation of the  caustic.
The result of this treatment is a relief  of
the urgent symptoms.  The application is
repeated at the end of three days.  After
three or four applications of the caustic, the
bougie alone is to be used, and the caustic
to be had recourse  to only if the diseased
irritability and sensibility of the passage are
unsubdued.   I trust that you will not sup-
pose me to have fallen into the vulgar error
of imagining that there is here a  specific ef-
fect produced by the use of the  alkaline
caustic.   I have said that it deadens the
surface, and that the cure is accomplished
by this effect,  and the consequent destruc-
tion of the morbid irritability and pain which
keep up the disease.  This effect of late I
have found to be as  surely produced by the
use of the lunar caustic as by that of the
kali purum.  It  was impossible to  observe 
  1UU      OF THE DILATABLE STRICTURE
 the effects of the lunar caustic used for the
 purpose of destroying an obstinate stricture,
 without being convinced that the immediate
 good consequences resulted from its dead-
 ening the morbid surface, not from its de-
 stroying  the stricture and carrying off the
 solid substance. By applying it in the same
 way in which I had used the alkaline caus-
 tic,  or by inserting a very small portion  of
 it in the end of the bougie,  I found that I
 could allay the irritation, and in  the end
 subdue the inflammation, which produces
 the dilatable stricture; indeed I have used
 the  lunar caustic  with immediate benefit
 when I thought the cure proceeding slowly
under the use  of  the alkaline  caustic.  I
 shall consider  this  subject further in the
next letter. 
LETTER III.
            Of Spasmodic Stricture.
  In entering upon this subject, it will be
necessary to examine and refute the opi-
nions of some authors who are now alive.
This  I should regret,  if I did not know
them to be men in high estimation with the
public,  and who well deserve the respect
and  reputation they enjoy; if I were not
persuaded that, being men of science, they
will court rather than shun a fair and can-
did discussion; and if I were not quite sure
that  I am incapable  of dropping any ex-
pression unbecoming  their character or my
own honour. I enter upon the controversy,
because,  if I  cannot shew the fallacy of
some commonly received opinions on this
subject, I must not only entirely fail in the
object of my inquiry, but have the addi-
               12 
102        SPASMODIC STRICTURE.
tional mortification of thinking that I have
been practising our art in a manner which
cannot be justified.
   1. I  take  my  ground on the basis of
morbid anatomy.   Wherever this has been
steadily adhered  to as the foundation of
observation and reasoning in our science,
that  science  has  been progressive : it has
been interrupted in its course, even  amidst
the most  brilliant reputation of its  profes-
sors, wherever men have arisen whose in-
ventive powers have led them to reject,
rather  than  to seek, the aid of anatomy.
In perusing books on this subject of stric-
ture in the urethra, you will have particular
occasion to observe,  that ignorance of the
appearance of disease kept surgeons for a
long time  undecided and wavering in their
opinions,  and feeble and inefficient in their
practice ; while Mr. Hunter, by establishing
one distinct fact, regarding the nature of 
           SPASMODIC STRICTURE.        J-uo
this very common complaint,  did infinitely
more good than even by the hint of prac-
tice which he left in legacy to the profes-
sion ; or than has been done by all the au-
thors before or since his time.
  2. The stricture which I have represent-
ed to you * is of the most common kind.
You will be satisfied, on examining it, that
the white condensed substance which con-
stitutes the  stricture, must be equally in-
capable of yielding to pressure, and of spas-
modic action.   The fact brought forward
by  Mr. Hunter which  proves the firm na-
ture of stricture; the confirmation of that
fact by others since his  time ; and these ex*
amples which I have given you in the draw-
ings,  are in my mind sufficient to prove that
a stricture cannot be spasmodic; that even
allowing the part of the  urethra diseased
to have been originally  muscular and con*
              * See Plate I. & IV 
104         SPASMODIC STRICTURE.
tractile, this condensation and callosity must
be attended with loss of the contractile pow-
er.  We hear perpetually of spasmodic stric-
ture,  and of spasmodic obstruction in the
stricture.  There remains not a doubt in my
mind that this is an error; and that it is an
error of great consequence,  as it leads the
surgeon off from the principle  and sure
guide in practice. I purpose, therefore, tho-
roughly to examine this subject: for while
I deem it  in my own  mind quite  sufficient
that all strictures are attended with a degree
of spasm, although it is demonstrable that
some of them are as firm as cartilage, and
that they cannot in themselves contract or
be dilated, yet I would not have you to rest
satisfied with this argument.
  3.  The notion  that the occasional ob-
struction to the discharge  of urine, when
there is stricture in the urethra, arises from
spasm, is  very natural.   When the patient 
           SPASMODIC STRICTURE.         105
is unable  to  expel, his  urine, and feels a
girding, and tension,  and pain in the seat of
the stricture,  he attributes these  indirect ef-
fects to  the stricture primarily.   But this
belief on his part must not satisfy us.  Nei-
ther, I hope, will you take implicitly the ef-
fect of heat and cold  on the stream of urine
as evidence of the varying state of the stric-
ture ; since it occurs  equally  in  health and
disease.   I believe it  to be a very erroneous
opinion, that there is relaxation of the stric-
ture when the bougie is allowed to remain
in contact with it.  There are two circum-
stances which have given origin to this opin-
ion,  that  the stricture  spontaneously  re-
laxes.  If a bougie of the common sort rest
against a stricture, it  is sometimes prevent-
ed from  passing by its stiffness ; and when
it softens and becomes pliant, the  point takes
the due  turn  and passes the obstruction.
Again, the first  touch given to the sensible 
106         SPASMODIC STRICTURE.
stricture,  however  slight, gives the  most
acute pain,  that marrow-piercing irritation,
which is so  insufferable to the patient: but
on continuing the gentle pressure, the pa-
tient is at last able to bear the increase of
it until the point passes the stricture.  This
is called the relaxing of the spasm in stric-
ture.  The  feeling as  if  the  bougie were
held and  grasped by the stricture is the
greatest when the bougie has been  suffered
to remain in the urethra some time ; and is
occasioned by the stricture making an in-
dentation on the soft bougie, or by  the bou-
gie becoming dry at that  part where it is
most firmly  wedged.
  4. I shall now endeavour to  shew you
how this  idea of the spasmodic nature of
a stricture has arisen; and that  it  has pro-
ceeded  on  false  data.  By  confounding
the  effect of the proper muscles of the ure-
thra,  the  whole lining  membrane of that 
           SPASMODIC STRICTURE.        1U/
canal has beeen imagined to possess a mus-
cular property.  I made the following sim-
ple experiment, in order to put this to the
test.  I got a small ivory ball, to which I
attached a thread.   I introduced the ball
into  the  urethra; I made  the man endea-
vour all he  could to  push it out, but he
could not: neither was it retained in the
slightest degree when pulled by the thread.
I thought it  might be more satisfactory if
I imbued the ball with something stimu-
lating.   I tried coarse  soap  and spirits;
but still there was no power in the urethra
to retain the  ball, or to push it forth. This
could be done only by the urine behind it,
and  the  operation of  the bladder,  or  the
ejaculator seminis.   I need not  add that
this  experiment was  made upon a part of
the urethra anterior to the seat of the eja-
culator seminis.  In the course of practice,
I find that, when the silver ball is introdu- 
 108        SPASMODIC STRICTURE.
ced down to the ejaculator  seminis, it is
resisted by  that muscle (especially when
the parts are irritable.)  I find it sometimes
thrown out of the grasp of the muscle, but
when  pushed fairly into  the sinus of the
urethra,  which is into  the middle of the
muscle, the ball is allowed to remain.
   5. I wished also to have the fact of the
action of the urethra on fluid before you.
This was easily done.   I employed a glass
tube to throw an injection into the urethra,
the extremity of the tube being adapted to
pass into the extremity of the urethra. Pres-
sure was made on the urethra five inches
down.   By  elevating the  tube or column,
in the manner of the  mercurial injecting
apparatus, the fluid distended the urethra  ;
but no irregularity in the height of the fluid
in the  tube indicated any muscular power
in the urethra to  discharge its contents.
When the urethra was distended, the slight- 
          SPASMODIC STRICTURE.         LKJV
est  touch upon it with  the finger  elevated
the fluid in the tube: but no effort of the
patient produced the effect. When he made
the effort it was with the ejaculator seminis
behind the part of the urethra compressed
by the fingers.
  6. Here is a simple detail of facts, which
are in themselves conclusive on this point,
viz. that the part of the canal anterior  to
the muscles which surround it  has no mus-
cular power.  If we examine the structure
of the canal of the urethra anatomically,
we  shall be irresistibly led  to  the  con-
clusion that  it is  merely elastic ; and that
where muscular action is required there
are superadded muscular fibres embracing
the proper canal.   I have carefully exam-
ined the membrane of the urethra through
its  whole extent.  I find it very thin and
delicate ; but I see no appearance of mus-
cular fibres  transverse or longitudinal. I
           13 
HO        SPASMODIC STRICTURE.
Iiave examined, by dissection, the part of the
urethra in the neighbourhood of stricture ;
but in circumstances of long continued  ir-
ritation, and where the muscular coat of the
bladder was greatly increased in strength,
I have not found a corresponding  change
on the urethra.  Mr. Chevalier  imagines,
that in  cases where there has been much
irritation from  blisters  preceding  death,
the muscularity of the urethra has become
evident.  Although  there are few  whose
opinion would influence me more than this
gentleman, yet  I can  see  nothing  in his
preparation but the effect of corrugation ;
a semblance of  fibres which would  disap-
pear on  stretching  the canal.   At most,
what are seen on dissection  are but fibres;
and in the  simplest  membrane,  as  in the
peritoneum, fibres are always to be seen
on minute inspection, where  nevertheless
there is no muscular power. 
           SPASMODIC STRICTURE.        1X1
  7. The following is the form of argu-
ment in favour of the muscular contraction
of the -urethra : "  That  the membrane
" which  forms the lining of  the  urethra
" does occasionally contract when stimula-
" ted,  may be illustrated by  a  variety of
" instances both in  health and disease.—
" In hot weather when the urine contains
" a greater porportion of salts, from an un-
" usual quantity of the watery parts of the
" blood being carried  off by perspiration,
" and  the stream is rendered smaller than
" common, by the stimulating quality of the
" urine producing contraction in the inter-
" nal membrane  of the  urethra—when a
" portion of  this membrane is in an infla-
" med state from gonorrhoea, its surface is
" more readily stimulated, and the urine,
" even when diluted, by the patient taking
" watery fluids frequently into the stomach,
" which pass by the kidneys, causes it to 
 112        SPASMODIC STRICTURE.
 " contract so much, that the urine comes
 " away  only in drops, or a very  small
 " stream;  in this state of the parts, if the
 " penis be immersed  in warm water, the
 " effect of the stimulating urine is less sen-
 " sibly felt by the membrane of the urethra,
 " which frequently  becomes  relaxed, and
 " the water passes more freely.  After the
 '* inflammation of gonorrhoea is gone off,
 " and stimulating injections are used, with
 " a view to stop the discharge which con-
 " tinues; in  many instances where the in-
 " jection stimulates the parts to a great de-
 " gree, it will not pass on towards the blad-
 " der, but produces so  strong a contraction
 " in the membrane,  as entirely to obstruct
 " the course  of the injection, and frequent-
 " ly reject it altogether with  considerable
" velocity."
      Practical Observations by E. Home, Esq. Vol. I. p. 16.
  8. Now I  ask you, are such arguments
as these sufficient to  account for the for- 
           SPASMODIC STRICTURE.          liJ
mation of stricture  by the spasmodic ac-
tion of a fibre of the membrane of the ure-
thra ;  when the doctrine  and practice are
so intimately connected as on this occasion
they are ? The answer to all that is  here
transcribed is this: That five inches of the
canal  by  measurement is surrounded by
strong and proper muscles.  We find the
accelerator urince, or ejaculator  seminis ; the
sphincter vesica? ; the compressor  prostata ;
the  levator  ani; clinging around the canal
of the urethra.*  It must never  be forgot-
ten, that it is the sensibility of the urethra
which governs  the  contraction of these
muscles.   I trust that  I have  proved  to
you the  part of the urethra  which is an-
terior to  the muscles, and which is not em-
  *  Indeed when we look to Haller, Soemmering, Santorini, Win-
slow, and Albinus, who describe the minute muscles about the pros-
tate and membranous part of the urethra, and add to these the des-
cription of Mr. Wilson, of Windmill-street, we can be at no loss to
account for spasm and irregular action in the posterior part of the
urethra. 
114         SPASMODIC STRICTURE.
braced by them, to have no power of con-
traction.  Who indeed  ever experienced
an obstruction from muscular action to pas-
sing the bougie into the mouth of the uire-
thra ? Yet this is sometimes the seat of an
obstinate stricture.
  9. In a great measure from the proofs I
have  already laid  before you, but princi-
pally from the symptoms of the disease it-
self,  I object to the following reasoning:
  " This contraction  and  relaxation are
" the natural and healthy  actions of the
" urethra ; but this membrane, like every
" other muscular structure,  is liable to a
" spasmodic action which produces  a de-
" gree of contraction beyond the natural;
" and in that state the canal'looses the pow-
" er of relaxing till the spasm is removed.
" When this happens it constitutes disease,
" and is termed a spasmodic stricture. 
          SPASMODIC STRICTURE.         AiJ
  " While a stricture is in this stage,  it is
" only a wrong action of the membrane of
" the urethra;  and if the parts could be
" examined,  in their relaxed state, there
" would be no appearance of disease.
  " When a portion of the urethra is dis-
" posed to contract beyond its natural  easy
" state, this  disposition  commonly increa-
" ses till the part becomes incapable offall-
u ing back into a state of complete relaxa-
" tion, and  the canal remains always nar-
" rower at that part.
  "  In this  stage  it is both  a permanent
" stricture, and a spasmodic one.   It  is so
" far permanent, that it is always narrower
" than the  rest of the  canal;  and so far
" spasmodic,, that it is liable to contract oc-
" casionally  in a still greater degree.
  "  A stricture in the urethra,  whether in
" the spasmodic or permanent state, is  a
" contraction of  the  transverse  fibres of 
 116         SPASMODIC STRICTURE.
 " the membrane, which forms that canal."
   10.  In the first place,  notwithstanding
 the confident manner in which this account
 of  the formation of  stricture is delivered,
 I hope you see that it is but hypothetical,
 and established on no proof.  For my own
 part, I confess my wonder that men in a
 profession like ours, whose business leads
 them  to  observe and reason continually,
 should first take  it for granted, that there
 were circular muscular fibres in the mem-
 brane  of the  urethra : then that one  of
 these fibres could obstinately and perma-
 nently  contract:  Nay  further,  as a stric-
 ture is often on  one part of the circle of
the canal only, that  the third part of this
 circular  fibre  contracts thus to  form  a
 stricture;  we  find  them  even implicitly
 believing that this  single  fibre, or third
 part of a fibre, could  take  a " wrong ac-
tion," and become occasionally contracted 
            SPASMODIC STRICTURE.         A x *
so as to be a spasmodic stricture ; then per-
manently  contracted to  a certain degree;
and at the same time capable of a further
occasional  contraction,  so as to  become
" both a permanent stricture and a  spas-
modic one."*
   11. Having proved by  experiment that
the membrane of the urethra  is not muscu-
lar ; by dissection,  that  there are no  mus-
cular  fibres discernible; and that a  stric-
ture is a callous part, incapable of contrac-
tion or  relaxation ;  I leave this part of the
subject to examine the true nature and  cause
of spasm attending stricture in the urethra.

   12.  I am confident that the profession
will  come to as full a conviction that the
  * The term organic stricture is used in contradistinction to spas-
modic stricture. In the language of pathology, organic derangement
means a defect visible  on dissection, while  the diseases of nerves
and muscles may have existed without presenting the defect to the
eye.
            14 
118        SPASMODIC STRICTURE.
sole  origin of all strictures in the urethra
is  inflammation, as that  adhesions  of the
pleura are caused by inflammation.  For
the most  part the cause of stricture is go-
norrhoea : But this  specific kind of inflam-
mation  is not always the  occasion of it:
It  has  its source  in whatever produces
continued irritation to the parts ;  previous
disease  in the bladder, for example, will
produce  it.   Most  commonly,  however,
the course of the disease is this:  The go-
norrhoea has  gone  on unchecked until the
inflammation  being at its height, there  is
purulent  secretion and  chordee; the dis-
ease which was originally seated near the
orifice of the canal has  been propagated
backwards: The real inconvenience now,
the pain and alarm, make  it necessary to
use proper remedies, and for the time se-
cure continence  and care on the part  of
the patient.  The  symptoms  are amelio- 
          SRASMODIC STRICTURE.         1Xi/
rated,  but the irritation does not entirely
subside.   The inflammation is  only more
partial.  Still the patient  has  pain  and
heat in urine, and there still from time to
time flows a gleety discharge.  This gleet,
it appears, is not, as often supposed, the
effect of mere relaxation of  the  vessels af-
ter inflammation,  allowing  too  profuse a
discharge ; but the vestiges of inflammation
in a  milder  and more chronic  form.   If
this state  of  the parts be permitted to con-
tinue,  a firm stricture will in the end be
formed.   The degree and  firmness of the
contraction will  be found to hold a strict
relation to the length of time, and the fre-
quency of the occasional increase of the ir-
ritation, pain and discharge.   The effect
of the inflammation in producing stricture
varies somewhat, as I  have taken an op-
portunity of already explaining to you.. 
L*V         SPASMODIC STRICTURE.
   13. I have now to  state to  you how it
happens that  there is spasm and difficult
flow of urine attending  all the  stages of
stricture ;  from the first  inflammation, till
the disease is confirmed,  and the contrac-
tion  becomes  firm as cartilage.  But to
have the whole of this subject fully before
us, I must draw your attention to the clas-
sification of muscles, and to the sympathy
and consent which unites them  in  func-
tion.
   In the voluntary motions  of our limbs
there  are  two distinct states  of muscular
action necessary to the movement.   If the
finger or hand is extended, or closed, it is
not by the mere contraction of one muscle
forcibly elongating its antagonist, nor does
the relaxation of the one follow the con-
traction of the other; but if the action be to
bend the finger, the  same influence which
is exerted to excite the flexor to contraction 
          SPASMODIC STRICTURE.         121
is also exerted to relax the extensor.  To
bring this to demonstration I made the fol-
lowing experiment:—
   14. I cut the skin over the strong exten-
sor tendon of a  cat's leg.  I cut through
the tendon, and drawing it out, I tied a fine
silk thread to it; and to  the thread I  at-
tached  a weight (such as to  stretch the
muscle gently) and hung it over the table.
I now set about observing the effect of the
action of the leg, and with considerable satis-
faction, I observed,  that when the  flexors
acted, the weight appended to the extensor
tendon descended.  I  extended the leg of
the animal, and  I found that the  weight
rose, and the tendon was drawn into  the
wound. I bent it, and the weight descen-
ded, and the tendon was drawn out of the
wound. It appears then that a necessary
concomitant of the contraction of one set of
muscles is the  relaxation of their oppo- 
 122        SPASMODIC STRICTURE.
nents or antagonists.   That there is a con-
catenated state of the two classes of mus-
cles in every natural action ; that, however
strange it may appear, there is no perfect
relaxation but in consequence  of motion;
for that state of the limb which we call rest
is but an equipoise of the force of the two
classes of muscles.   It is only when there
is  a contraction of one set of muscles that
there  is a perfect and entire relaxation of
the other.   As  this state of relaxation of
one muscle  is as necessary to the motion
as  the  forcible contraction of the  other,
I may call  this influence  exerted on the
yielding class of muscles a  negative  ac-
tivity.
   15. When  we  have  ascertained that
there is this very peculiar relation existing
between the two classes of muscles thus
combined in  function, our  next inquiry
should  be directed to  find what muscles 
          SPASMODIC STRICTURE.         123
are antagonists of each other.  Of the vo-
luntary muscles there are two classes ; and
by the  direct influence of the will  we call
one set into activity, and the other indirect-
ly into a state of relaxation  or negative
activity.  Perhaps  I ought rather  to say
that we are equally ignorant of the operation
of the mind on either set of muscles;  but
being taught by experience to observe the
contraction of one set of muscles followed
by the motion of the member, while we do
not see the necessity of the voluntary yield-
ing of the opposite class, we improperly call
this  last an  indirect  operation of the will,
since the change in the state of the two clas-
ses of muscles is  synchronous and conco-
mitant,  and  proceeds in both directly from
the agency  of volition.   It is, however, a
subject which I mean not at present to pur-
sue,  since  I have got exactly the proof 
124          SPASMODIC STRICTURE.
we required to enable us to proceed in our
inquiry.
   16. There  are some classes of muscles
over which we have no direct power of the
will to make  them relax, or certainly not
without calling for the activity of their an-
tagonists : For example, the muscles be-
twixt  the sternum and larynx are in per-
manent  action when  the throat is at rest;
and the change which we observe them sub-
ject to,  is from action to relaxation.   But
to produce this relaxation we have to bring
into contraction their opponents, viz. those
which arise from the jaw, and are inserted
into  the larynx, and which  in  the act of
swallowing draw up  the  throat while the
lower muscles relax and are stretched. All
the  sphincter muscles are of this class:
Their more  permanent state  is firm con-
traction, and their powers are not exhaus-
tible like those of the muscles of voluntary 
                 SPASMODIC STRICTURE.         ■L-J
      motion.  By  their contraction they retain
      the contents of the hollow viscera.  These
      hollow viscera are surrounded with a mus-
      cular coat,  which is of course the opponent
      of the respective sphincter muscles.  And
      now you will  readily understand that  the
      sphincter does not yield up its office, or re-
      lax, unless there be a corresponding con-
      traction in the muscles of the  hollow vis-
      cus.  Thus the sphincter to the  lower ori-
      fice of the stomach will  not  cease to reject
I     the matter offered to be  transmitted to  the
      intestines, unless the stomach contract  na-
      turally ; and the natural contraction of  the
      stomach must be preceded by the full and
      natural digestion of the food.  Often, there-
      fore, the food, being of an indigestible kind,
      is retained loading the stomach.  In the rec-
      tum, the effort  to evacuate, viz. the con-
      traction of the gut, is attended necessarily
      with the perfect relaxationof the sphincter
                 15 
 126        SPASMODIC STRICTURE.
 ani.  For example, if ever you had a tedi-
 ous operation to perform  in  the rectum,
 whether the examination of a fistula, or the
 extirpation of a  tumor within the gut, or
 the management  of scirrhous contraction,
 you must  have  observed  that whenever
 there was an action of the higher part of
 the gut, the  tightness of the sphincter ani
 was relaxed.  So exactly it happens in the
 womb during delivery ; the orifice and fun-
 dus of  the womb have antagonist  fibres,
 and the contraction of the body  and  fun-     #
 dus of that viscus is attended with relaxa-
 tion and distention of the orifice.
   17. Now we approach the subject of our
 discussion  with  facts  established.    The
 bladder is  surrounded  with ifs muscular
 coat, the detrusor urinax; the  neck  of the
 bladder is surrounded with the sphincter;
 the prostate gland embraced with the com-
pressor prostata ; the membranous part  of 
          SPASMODIC STRICTURE.          L^*
the urethra, besides having circular fibres,
is pressed by the levator ani;  and the  si-
nus, and a considerable part of the urethra,
is  surounded  by  the  ejaculator seminis.
These last four muscles are all opponents
to the muscular coat of the bladder, and are
in sympathy with it.   Not that sympathy
which combines in simultaneous  action,
but that connection which  exists  betwixt
flexor and extensor muscles, and which pro-
vides that  the action  of the one shall be
attended with, the  relaxation of the other.
   18. The  paralysis  of  the urethra has
been treated as a disease*: the incontinence
of urine  is considered as an  effect of the
diseased inactivity  of the muscles of the
urethra.   This is  a  short-sighted  view of
the symptoms. The disease is in the over
 action  and irritability of the coat of  the
bladder ; the smallest quantity of urine fall-
       * See Hunter on the Venereal Disease, p. 16S. 
 128         SPASMODIC STRICTURE.
 ing down into the bladder produces an ac-
 tion there, and consequent relaxation of the
 sphincter; and the water dribbles insensibly
 away.  The disease is of the same nature
 with that which produces the relaxed anus
 and pendulous gut of a child whose rectum
 is irritated by ascarides.   Blisters, tincture
 of cantharides, spices,  and steel medicines,
 are  improperly given  on the idea of exci-
ting the  relaxed sphincters : whereas the
 attention  should  be directed to  ascertain
 the cause of the contraction of the bladder.
 Whenever we are perfectly aware that the
 contraction of the bladder and the relaxa-
tion of the urethra, or the contraction of
the urethra and quiescence of the bladder,
form one combined action, we comprehend
how a blister to the sacrum or pubes will
sometimes produce  stranguary, sometimes
incontinence  of urine ; for it produces an
immoderate irritation on the parts which 
           SPASMODIC STRICTURE.         129
stand united in function, disordering their
natural relations.
   19. When the bladder is distended with
urine,  and the  muscular coat has no dis-
position to contract, the introduction of the
bougie into the urethra will cause the urine
to flow.   The reason is, that the muscles
of the urethra being distended with the
instrument, this state of forcible distention
calls the muscular coat of the bladder into
action—without which no distention of the
urethra  would  procure evacuation.   We
may observe that,  when  a bougie is intro-
duced  into the urethra a few inches only,
there is no consent with the bladder; but
when the point of the  bougie reaches the
sphincter muscles,  and  even when it dis-
tends only the fore part of the ejaculator
seminis, the desire of passing urine is very
great. 
130        SPASMODIC STRICTURE.
  20. Spasm  of the urethra is supposed
to be directly the reverse of paralysis  in
the urethra.  But I have now to shew you
that, in spasm also, the bladder and  the
muscles  surrounding the  urethra are still
engaged together, and are mutually disor-
dered as antagonist muscles.
  21. If you look into  authors,  you will
find that the urine is said  to be obstructed
from many causes ; from debauch, indu-
cing spasm in  the neck  of  the  bladder;
from fulness in the vessels of the neck of
the bladder ;  from  stricture ;  from piles ;
from injury to the  perinseum, or disease of
the prostate gland.   In all these instances,
the obstruction to  the  flow of urine  is in
a great measure owing to  the  diseased
action  of the  muscles ; in some of them
it is entirely to be  attributed to this cause.
   22.  I shall  state the simplest and least
equivocal case. A young  man, through 
          SPASMODIC STRICTURE.         131
false  modesty, being in the company  of
ladies, resists the urgent call to make urine;
at last he escapes, and thinks to evacuate
the whole contents of the bladder, but can-
not pass a drop of urine.
   A woman in labour has the neck of the
bladder pressed by the head of the child,
so that the bladder suffers great distention.
After the delivery I  have  seen it  distend
the belly to a degree as great as before la-
bour commenced,  and still  the urine did
not flow.
   23.  In these cases the distention of the
bladder has too far stretched the muscular
coat; and by this  distention the muscular
fibres  have suffered a kind of paralysis,
and are incapable of contraction.  But this
is not all; the antagonist sphincter muscles
will not relax,  or but  very irregularly;
there is  a spasm and girding  of the mus-
cles of the  urethra: and pressure on the 
 l->^         SPASMODIC STRICTURE.
 belly  will  not  empty the  bladder;  the
 catheter must be  introduced.  Now  this
 pure case, if I may use the expression,  is
 sufficient to shew us, that, however ob-
 struction of urine may commence, in the
 end the muscular apparatus is engaged,
 and becomes a cause of increased difficulty
 of passing  the  urine.   This is especially
 the case in stricture of the urethra ;  and
 while the  stricture  is  stationary, neither
 contracting nor relaxing, it has the effect
 of  disordering the natural  sympathy of
 the muscles, and  of inducing  contraction
 of the sphincter fibres  and impeded urine.
  But there is  another and  a more  fre-
quent cause of spasm in the urethra  and
neck  of the  bladder, the consideration
of which is my principal object in this
letter. 
SPASMODIC STRICTURE.
133
  24. In the diseases of  the  urethra, as
in other  parts  of the body, inflammation
precedes or accompanies  increased sensi-
bility.   Where  stricture is, there is much
increased sensibility  ; and wherever the
stricture is  exquisitely sensible,  there we
are sure to find the function of the muscles
deranged, forming the case which is called
spasmodic  stricture.   This spasm is pro-
duced by the acrid urine coming in contact
with the sensible surface  of  the urethra,
which being inflamed is not embued with
its sheathing secretion: instantly the mus-
cles are  called  into action  ; the ejaculator
seminis contracts by  impulse,  as is its na-
ture when excited ; and the other sphincter
fibres contract  firmly: so there is frequent
call, and frequent stoppage, of the urine,
with painful contractions of the  fibres on
           16 
 134        SPASMODIC STRICTURE.
 the  inflamed and  excited parts.  This ac-
 tion of the muscles of the urethra does not
 merely obstruct  mechanically the flow of
 urine, but by the sympathy existing betwixt
 these  muscles and  the detrusor  urina, or
 muscular coat of the bladder, the contrac-
 tion of the bladder ceases.
   25.  Thus, out of  a party of men drink-
 ing together, there will often  be  one  who
 before evening cannot pass  a drop of urine.
 On inquiry, you will find that he has had
 slight disorder in the urethra,  perhaps the
 remains of gonorrhoea.  It  is  a mistake to
 suppose,  in such a case, that  the fulness
 of the vessels  has closed  the passage to
 the urine ; the same cause  which has in-
 flamed his countenance  adds to the in-
 flammation and sensibility  of  the urethra,
 and the first drop of acrid urine is followed
by contraction  and  spasm, and obstruc-
 tion. 
          SPASMODIC STRICTURE.         XOD
  26. I trust you will  now entertain no
doubt that  the apparent changes in the
stricture of the urethra are  attributable to
the disorder of  the neighbouring muscles,
muscles which  surround the stricture, if it
be seated within  five inches of the blad-
der.   But the subject is further worthy of
your utmost attention.
   27. There seems to be no stricture with-
out more or less accompaniment of inflam-
mation.   This  is the reason why strictures
are so seldom stationary; for, being origi-
nally produced by inflammation, the con-
tinuance of inflammation, even in a slight
degree, increases the stricture.   This also
explains why a stricture becomes progres-
sively worse, and why  it returns after the
apparent cure  of it by the bougie.
   28. Of the existence of inflammation in
 stricture we are informed by the introduc-
tion of the bougie: for the stricture, or the 
136          SPASMODIC STRICTURE.
part in the immediate neighbourhood of it,
is exquisitely  sensible.  I need  not enter
here into the proof that no sensibility exists
without increased vascular action.   When
I pass the ball probe down to the stricture,
there is great pain: but, when the ball has
passed the  stricture, the pain ceases.   In
bringing the ball  back again  towards the
stricture,  the  pain is felt as on the  first in-
trusion of it,  when it approached the fore
part of  the stricture.  This  pain  on the
back part of  the stricture proves that the
inflammation  attending  the disease is  in
equal degree behind as on the fore part of
it.  But there is a proof of  its being grea-
ter on the back part than on  the anterior
part of the stricture ; a fact in  which we
cannot be deceived,  since it is brought to
demonstration on the dissection of the parts.
I have said, in  my first letter, that I have
seen, on  dissection,  inflammation  and co- 
          SPASMODIC STRICTURE.         x ° '
agulable lymph behind the stricture, when
there was  none betwixt the stricture and
mouth of the urethra ; and when the urethra
has  been  inflamed in all its length, I have
found it always most  inflamed behind the
stricture.   When ulceration   takes  place
in a case of stricture, it is behind the stric-
ture, not on the part of the urethra anterior
to the stricture.   We cannot have a better
proof  of  previous irritation  and inflam-
mation than in the formation of an  ulcer.
 Indeed we might a priori conclude that,
 where  the difficulty is felt, and the push of
 urine  is  made, there would the  principal
 irritation be. The inflammation which, in a
 lesser  degree,  produces ulceration behind
 the  stricture,  and fistula  in  perinseo, will
 sometimes,  by  a more rapid course,  be
 propagated backwards ;  and the distention
 of the  bladder, ureters, and kidneys,  and
 their ineffectual struggles to unload them- 
 138         SPASMODIC STRICTURE.
 selves, having prepared them for partaking
in the same inflammation, the patient is cut
off.  To understand the  symptoms of in-
flammation,  when propagated towards the
bladder, ureters,  and kidney,  ought to be
the first object of every one who attempts
the cure of diseases of the urethra, and
especially by the application of the caustic.
He ought to know how caustic will some-
times act like a charm in relieving the com-
plaints concomitant with  stricture;  how it
will, on the contrary, sometimes bring for-
ward the fistula  in perinseo, sometimes
hasten the death of the patient.   I thank
God that I have  no cases of the latter des-
cription to relate from my own practice ; but
the books on the subject of stricture leave
practitioners  open to  this  terrible  mis-
fortune, for  want (as I take  it)  of suf-
ficient discrimination in the  cases brought
forward. 
          SPASMODIC STRICTURE.         ljy
  29. To understand the effect of caustic
in subduing irritation in the urethra,  in
cases of stricture,  we  may take the fol-
lowing conclusive example.   If a man has
an ulcer in the pellucid cornea of the eye,
the ulcer keeps up a great deal of inflam-
mation and irritation in the whole eye ; but
if we apply caustic  to  the bottom and ten-
der part  of this ulcer, the irritation and
inflammation of the eye  quickly  subsides.
When  we  examine  the circumstances  of
this case, we find that the ulcer  is highly
irritable, and that the acrid tears flowing
into it are a principal cause of the contin-
uance of the disorder.  The touch of the
caustic deadens the surface ; then the tears'
are no longer a cause of irritation, and the
general  inflammation  and  pain  therefore
subside.   The effect of the caustic applied
to the eye in this manner is however  only
temporary; the surface  touched by the 
 I4U         SPASMODIC STRICTURE.
 caustic is thrown off, and exposes a  sen-
 sible granulating surface; the  tears  now
 having access to this new surface, the  pain
 and  irritation return in  a certain degree:
 a second touch of the caustic again destroys
 the sensible surface, and, before it be again
 exposed,  the hollow  of  the ulcer is nearly
 filled up,  and a healthy or a more natural
 state of the  part  is  substituted for  the
 eating sore.   Several  such gentle applica-
 tions of  the  caustic  do not  prevent  the
 ulcer from filling, and a  cicatrix  at length
 forming.
   The application of the caustic  to  the
 urethra has an effect very similar to this
 The stricture is  exquisitely sensible, and,
 when the  urine comes in contact with it,
 there is such an excitement as is  necessa-
 rily attended with spasm.  The first effect
of the  caustic is to  destroy the sensibility,
 and then the urine passes without, exciting 
           SPASMODIC STRICTURE.         X"*-L
spasm.   In explanation of the circumstance  *
that the caustic has not always this effec:
of subduing spasm and irritability,  let  me
observe to you, what  is too little attended
to, but which I have no doubt you will  at
once allow to  be just  ; that, if only the
fore part of  the  stricture  is  touched by
the caustic, the principal source of irritation
remaining behind the  stricture, the patient
will find no relief.   You may  perhaps say
that the caustic is in no instance  applied
to the back of the stricture, and that  still
the irritation is subdued.  I have little hesi-
tation in answering, that often the caustic
does more than the  surgeon  intends, and
that by dissolving and flowing through the
stricture  it  diminishes  the sensibility of
the surface  in  the whole   extent  of the
disease.
   30. It is manifest that  there must be a
period after the application of the  caustic
           17 
 142        SPASMODIC STRICTURE.
 when the irritation will return ; and this re-
 turning irritation will be  in  proportion  to
 the severity of the application.  In Plate V,
 we have the appearance of a stricture after
 the operation  of  the lunar caustic upon  it.
 In the appearance of the parts from which
 I took  this drawing there  were  several
 things worthy of notice.   In  the first place,
 behind the stricture we see a very peculiar
 furrowed appearance : this  is  owing to a
 thick layer of coagulable  lymph deposited
 there ; and from the  density  and  pearly
 whiteness of this portion of the coagulable
 matter, it must have been deposited before
 the more extensive accumulation of the in-
 flammatory crust in  the bladder and part
 of the urethra.   In the front of the stric-
 ture we see the effect of the caustic :  the
 stricture is in part eroded, and delicate flee-
cy membranes hang from the part, like
what we see in a dead  ulcer when  in/na- 
          SPASMODIC STRICTURE.         143
ceration. The stricture is not entirely des-
troyed; and  the  flow  of the urine must
have been as much impeded by the stric-
ture as ever ; yet  immediately after the ap-
plication of the caustic the symptoms were
remarkably relieved.  The patient had suf-
fered  long in extreme agony : he  at last
unwillingly submitted to  the application  of
the caustic ;  and from its effects  we see
this application to have been  a very effec-
tual one.   Where  the slough formed  in
consequence  of the  application of the caus-
tic has  thrown off, and  an  ulcerated and
sensible surface is exposed,  there must  be
a new and aggravating cause of pain and
spasm.   So  in this case, as often it hap-
pens, the man at first expressed  himself
highly delighted with the effects of the ope-
ration ;  but in a  few  days the spasm was
increased in an extraodinary degree, and the
whole  man  became  so  irritable  that  he 
 144         SPASMODIC STRICTURE.
 Would allow nothing to be done  further*
   31.  Fistula in  perinseo is frequently oc-
 casioned, or suddenly brought forward, by
 the improper  use of caustic.  A gentle-
 man of  rank  and talents,  which should
 have secured to him the first advice in the
 city where he lived, consulted me here in
 town.  He informed me he had a stricture
 to which the lunar caustic  had been  ap-
 plied;  and whilst his  surgeon was  in a
 course of operations upon him, there came
 a swelling  in the perinseum, which sup-
 purated  and formed  a  fistulous  opening.
 But his surgeon,  resolute in his purpose,
 persevered in the application of the caustic
 until the stricture gave  way, and then the
 sore in the perinseum healed.
   When this gentleman came to me, he
 was with difficulty conveyed from his car-
 riage ;  bent with pain, and having a spasm
which  had prevented the discharge of urine 
          SPASMODIC STRICTURE.         145
lor twelve hours before.   I made him se-
lect a bougie of such  a  size as had been
passed formerly: I passed a small bougie
with great ease into the  bladder.   I with-
drew it slowly, cast a little cold water on
his thighs, when he passed his urine in a
tolerable stream.
   When I say that I passed  the  bougie
with great ease, I mean  to say that there
was  no resistance  to my hand; but there
were great tenderness and pain to the pa-
tient.   This gentleman  was,  in short, ex-
actly in the  circumstances  which precede
tumor  and suppuration in the perinseum.
He  said  he was afraid  there  was  still a
stricture.  He complained of shooting pain
 in the perinaeum; he had a feeling of fulness
 as if there was a tumour betwixt his thighs ;
 he had occasional  fever and flushing; he
 rose often in the night to make water, but
 sometimes could not make a drop.  Had I 
146       SPASMODIC STRICTURE.
in these circumstances applied a large caus-
tic, with the avowed intention of those who
have published on the subject, viz. to cau-
terise and eat  away the constricted part of
the canal,  I should certainly have produced
such an aggravation of the irritation behind
the stricture as must have terminated a se-
cond time in  fistula.  In such  a case  the
frequent pressure of a bougie would pro-
bably have taken  off the irritation; but
sometimes  this  practice has an  opposite
effect, and I did what experience taught me
was  safe  and effectual.   I introduced  a
very small piece of caustic buried in  the
end of a soft bougie, so that it could effect
the stricture only  in  solution,  and not in
strength to form  a  slough.  This gave
great relief for four and twenty  hours.   I
repeated the application then gently ; often
at the same time passing the bougie through
the stricture, but keeping it only about two 
          SPASMODIC STRICTURE.         ■*•*'
minutes  dilating the passage.   In a few
days the disposition to spasm was  entirely
done away, and the urethra became so ac-
customed to the operation, that with perfect
safety I could  have  employed the caustic
to the  entire destruction  of the stricture.
But my patient, in the mean time perfectly
relieved, went into the country.
   32.  There occur to my recollection se-
veral cases, in which the principle I have
laid down may be further illustrated.
   There came to me  a purser in the navy,
who had been  long  in  the West Indies.
He was greatly reduced, and had  suffered
much, as he said, by  the ague  and fever.
The truth was, that he had a very narrow
stricture, attended with  great irritation in
the canal; and, as often happens  in these
circumstances,  there came  on  frequent
paroxysms  of  fever,  with a distinct cold
and hot  stage.  He  came  home among 
 140         SPASMODIC STRICTURE.
kind friends, and to the company of a young
wife ; in consequence of which there were
several total obstructions.  I relieved him
by the use of the bougie, leeches, and opi-
ate  clysters ; but I could not allay the con-
tinual irritation, which  appeared to me to
be principally  seated behind the stricture.
At length, this  patient,  on his going a lit-
tle way into the country, and neglecting
the  palliative means by  which I hoped to
gain upon the stricture, and take off this dis-
position, produced tumor and fistula in pe-
rinseo.   I had not at that time  ascertained
the  propriety of the means I have recom-
mended above.
  About the same time I succeeded no bet-
ter with a poor  man who was nearly in the
same circumstances.   I did him so little
good, that I set anxiously about the obser-
vations  which  I have  in part detailed to
you. 
           SPASMODIC STRICTURE.        X*J
  33. More lately, a gentleman returned
from Madeira, whither he had been sent on
account of pulmonary complaints ; and im-
mediately on being settled in his hotel sent
for me.   He was very ill, and much redu-
ced in flesh and strength;  his water came
from him in drops, and his pulse was quick
and irritable.   He told me that I must not
expect  to pass  a bougie, for the passage
would not admit one.   The smallest wax
bougie  could not be passed through the
stricture.  I however promised him relief.
I passed a middle-sized soft bougie into the
urethra,  and pressed  it gently against the
 stricture.   I  found the stricture very ex-
 quisitely  sensible.  I continued the pres-
 sure some time.  I then took a very small
 catgut bougie,  and passed it through  the
 stricture.  All this day and  the  next  he
 had less irritation.  I twice  repeated this
  operation, until  I found the passage  ac-
            18 
 150        SPASMODIC STRICTURE.
 customed to the bougie, the severity of the
 symptoms considerably relaxing.   I then,
 on my fourth visit, took a common bougie,
 and with a  pin sunk a hole in the point of
 it, into which I introduced a  very  small
 piece of caustic.   I introduced this bougie
 down to the stricture  much  in the  usual
 manner.  As  the  caustic dissolved I pres-
 sed more forcibly ; when I thought it might
 be entirely dissolved I withdrew the bougie.
 " Now," says my patient, tc I'll be corked
 up  for  these  two days."   I  assured him
 that he would not suffer;  for  I  knew that
 the solid caustic had  not touched the ure-
 thra ; that  as  it  dissolved, my pressure
 against the stricture  squeezed the  sides of
 the little cavity of the bougie  together;
 and that the dissolved caustic flowed upon
tbe stricture, but not with strength suffi-
cient to produce a slough and  consequent
swelling of the membrane.  The irritation 
          SPASMODIC STRICTURE.         xi>x
on  this day was in a  remarkable degree
subdued: the urine flowed in a jet from the
penis; and  instead of rising  four times in
the night he had no  occasion to  rise till
the usual hour in the morning.  By these
gentle  means, and the occasional introduc-
tion of a bougie, I took off  the source of
fever in the urinary organs, and left the
physician to do his business on the  res-
piratory organs.  You may say that in this
case the dilatation  of the  stricture by the
catgut bougie  was the principal means of
relief.   Take care how you fall  into the
belief  that you can dilate a stricture of this
kind with a  catgut  bougie.  The conse-
quence of  the attempt I have  seen to be
total obstruction, and the death of the pa-
tient.   If I had used the bougie armed in
the usual way, and applied  it to this ure-
thra for the space of a minute, I  might have
had to boast that in three  applications the 
152         SPASMODIC STRICTURE.
bougie went into the bladder ; but the pro-
bability is  fully as great  that  the  patient
would have had  to  submit  to have  the
bladder punctured,  or  have been in his
grave.
  I have fixed upon this case, not because
it is out of the usual course, but because
it is exceedingly common.   Another recurs
to my recollection,  where the  symptoms
were  nearly the  same,  but where  there
was a second stricture- a short way  behind
the first.   It was in this  second stricture
that the obstruction was chiefly seated, and
there  also the principal seat of sensibility
was.  This sensibility,  and consequently
the difficulty of voiding the urine, and the
spasm, would have increased, if the  caustic
had been applied in  the  degree  sufficient
to have produced a slough on the anterior
stricture. 
          SPASMODIC STRICTURE.         x 0J
   34.  There is a period of spasm and irri-
tation when the slightest increase of inflam-
mation will form fistula, or burst the urethra.
A domestic of Lord  M. came to my house
one morning, with great irritation in  the
urethra, with fulness in the perinseum, and
throbbing, and  a flushed face.  I passed a
bougie, ordered him a smart  purge and an
anodyne clyster, and explained to him his
danger.   Some  days after, I  was sent  for,
and found his scrotum as large as his head:
the ulcer  behind the  stricture had  given
way, and the urine distended the cellular
membrane.  I found this man to be a very
indispensable person of the establishment,
and that whilst in this state of irritation he
had cooked a dinner for a great party ; soon
after which the  urine burst  into the scro-
tum.   I have perhaps used the term burst-
ing of the urethra  improperly, since you
know very well that this is  the effect of 
 154      SPASMODIC STRICTURE.
 ulceration, and is often brought suddenly
 on by excess in wine.   It was remarkable
 in this man's case, that the stricture was
 by no means of* an obstinate kind, and al-
 lowed the bougie to pass, and the urine to
 flow, whilst this ulcer broke out as I have
 described.
   35. I intended to have written  a letter,
 and  I have given  a long treatise ; but there
 is one remark more, which I think impor-
 tant.  You are aware  that I have not been
 describing the entire manner of destroying
 stricture, but only treating of that stage and
 symptom which I think has been so imper-
fectly  explained—the inflammatory  and
spasmodic state of stricture ; and which, if
misunderstood, is so full of danger.  The
fact to which I allude is this,  that whilst I
only endeavoured to correct the most urgent
symptoms, I sometimes cured the disease ;
that  by relieving the  patient from  time to 
          SPASMODIC STRICTURE.         J-3 3
time I found an unexpected ease in intro-
ducing the bougie ; and that by  subduing
the inflammation, the firmness of the stric-
ture itself gave way.
i 
-7.1.
>.&.
Bell del 
JPietlrlJL.
Wia.i.
My.tf.
Hell dit
J.rney si 
> 
-'
W.Gibson,  del
JLenev. fc. 
Plate BY*
Sii
Bell. del. 
Plafc.V.
SeU.dei*
'l%*^*i.<. A
ju en ey.se. 
y&rfr.V.
Bell del/
.etury. 
EXPLANATION  OF PLATES.
                    PLATE  I.

Fig. 1. In this figure is represented a firm stricture with
  an irregular ulcerated surface.  The whole penis is not
  represented, but only the spongy body of  the urethra,
  and a few inches of the canal.
A A. The corpus spongiosum urethrae.
   B. The  urethra  cut up to  show  the lacunae and the
         stricture.
   C. The  part of the urethra below  the stricture.
   D. The stricture with a peculiar  reticulated surface,
         the effect of ulceration.
 E E.  A callous portion of the spongy body of the urethra.
         The cells being condensed and closed, and now
         forming the principal seat of the stricture.
 Fig. 2. This figure was taken from Mr. Hunter's work
   before I had ascertained its incorrectness.  I thought
   that the  form of the spongy body at the place of stric-
   ture was a consequence of the stricture, but on examin-
   ing the preparation, I find it to be a pure example of the
   stricture, by a bridle or  small filament, as expressed in
   plate  IV. fig. 1. B.
 A A. Corpus spongiosum urethrae.
 B B. The internal surface of the urethra.
   C. The structure.
              19 
EXPLANATION  OF PLATES.
                     PLATE II.
 Fig.  1. The urethra cut  open to shew a long contiaction
   in it, and a wasting of the spongy body.
   A. The urethra anterior to the stricture.
 B C. The urethra contracted for near three inches in its
        extent.
   D. The urethra very dilatable behind the  contraction.
 Fig. 2. Urethra sounds of different sizes : the wire is made
   of silver, and of the length of a common bougie, the ball
   is rivetted on, a perfect globe, and highly finished; the
   balls ought to be of various sizes, from the diameter of
   the largest to the smallest bougie,  but four sizes will
   generally be found sufficient.
Fig. 3. The urethra sounds having the balls perforated for
   the  lodgement of a  small portion of lunar or alkaline
   caustic.
The intention of this instrument is to introduce the caus-
   tic  upon the dilatable stricture,  or to a common stric-
   ture, where the object is to let a certain portion of caus-
   tic  dissolve and come in contact with the urethra in so-
   lution, the advantage  of the ball probe or sound, in this
   case, over  the bougie, as employed by Mr. YVhately is,
  that we are better enabled  to ascertain the place of the
   stricture, and therefore  to apply the caustic  more accu-
   rately.
Fig. 4. This is a urethra probe, where, instead of a ball,
  there is a pyriform knob; the curve given to the wire
   enables us to introduce  it into the neck of the bladder,
   and I have used it with  much advantage in allaying the
   irritation at the neck of the bladder ;  for this purpose I
  have gently introduced it  along  the canal,  and  then 
               EXPLANATION OF PLATES.
  moved it several times through the further part of the
  cana'.

                    PLATE III.
Fig. 1. In this rough etching there is represented a stric-
  ture of the oesophagus, to shew  that the narrowing of
  the passage was not a consequence of the muscular coat
  contracting, but a deposition of  coagulable lymph be-
  twixt the inner coats: the oesophagus  is cut directly
  across  at the  contracted part.
A. The muscular coat, or tunica vaginalis gulae.
B. The thickened internal coats.
C. The passage diminished, so as not to admit  a crow
      quill.
Fig. 2. This represents the effect produced upon the ure-
  thra, by a stone sticking in it.
A A. The body of the penis.
B B. The corpus spongiosum urethrae.
  C. The place of the urethra in which the round stone
         stuck.
D D. Shreds of coagulable lymph which were thrown out
         on all the surface of the urethra, a sufficient proof
         of the  violence of that inflammation, which reach-
         ing the bladder, occasioned ■ the patient's death.

                    PLATE IV.
Fig. 1. This plate represents a considerable portion of the
  urethra, with its surrounding spongy body and the pros-
  tate gland.
A A. The urethra.               * 
EXPLANATION OF PLATES.
   B.  Two filaments forming a stricture, which during
         life powerfully resisted the introduction of a large
         bougie.
   C. Another stricture of the same kind, behind which
         there is  the appearance of a little sac into which
         the bougie often hitched.*
   D. Another little cord on the nearer side of the urethra:
         it will be observed, however, that this  cord did
         not stand across the urethra, as might be imagin-
         ed from the appearance presented here,  it was
         like B or C ;  but to demonstrate the firm nature
         of it, I cut away the membrane of the urethra.t
   E. Little warty excrescences, which, however, the en-
         graver has but very imperfectly represented, they
         ought to have been more agminated and promi-
         nent.
   F. The ducts  of tlie prostate gland enlarged into great
         cells, which would very readily receive  the point
         of the largest catheter.   Such  cavities I believe
         to be the source of the worst kind of fistula in
         perinaeo.
  * This is of the nature of the folds of  the membrane of the ure-
thra, resembling the valve of a vein which has been described by
Goulard and Desault.
  ■j- After much doubt of the accuracy of my first observations re-
garding the nature of this stricture, and at last having repeated op-
portunities of satisfying myself, both of its existence and its very fre-
quent occurrence, I find by turning my attention to Desault traite1 des
Maladies des votes urinaires, that  I might have saved myself any
anxiety on this point, for there I find a very accurate description of
this obstruction to the urine, 'par des brides' But he considers these
ligamentous filaments to be an effect of ulceration, condemns the use
of the caustic, and recommends the use of the elastic gum bougie. 
EXPLANATION OF PLATES.
   G. The caput gallinaginis.
Fig. 2. Represents the point of the bougie, as it often ap-
  peared when introduced during the patient's life. I saw
  the danger of forming a false passage in this indication
  of a sharp line cutting the point of the wax bougie
Fig. 3. The bougie, as it often appeared when withdrawn
  from the urethra of the same patient.   In this case the
  point  had not entered the proper passage, nor struck
  against the ligamentous filament, but had gone betwixt
  ' the filament and the side of the urethra,  so as to make a
   sac (c. fig. I.)  If this had been persevered in, a false
  passage would inevitably have been formed.  To avoid
   this, I was careful never to allow  the bougie to remain,
   unless the resistance to withdrawing it  proved it to be
   wedged in the proper canal.
The appearance of a valve is probably formed by the point
   of the bougie pressing betwixt the filament and side of
   the urethra.
The kali purum was applied three times to this stricture,
   but no sloughing or erosion, or effect of any kind is ap-
   parent.

                      PLATE  V.
:  This represents the urethra slit up to show the effects
of the lunar caustic on stricture.
A A. The glans penis.
 B B. The body of the penis.
C C. The spongy body of the urethra.
   D. The urethra behind the stricture.
   E. The stricture. 
                EXPLANATION  OF PLATES.
   F. Coagulable lymph accumulated behind the stricture,
         a certain proof of their having been much inflam-
         mation there.
   G. Loose shreds of a very fine membrane, where  the
         caustic had been applied.  It would appear from
         this case, that if the proper stricture had been  de-
         stroyed,  still the coagulable lymph accumulated
         behind, would have been a cause of obstruction to
         the urine.  The inflammation on the part of the
         urethra behind the  stricture, and  on the inside of
         the bladder, produced  such  irritation that the pa-
         tient died.

                     PLATE VI.
   This etching represents the  effect of  stricture on the
 bladder.
 A A. The walls of the bladder  greatly thickened.
   B. Much coagulable  lymph behind the  stricture of the
        urethra, and at  the neck of the bladder.
   D. Membranes  formed of coagulable lymph hanging
        from the inside  of the bladder.
E E. Firmer masses of coagula attached  to the inside of
        the bladder.
  These are sufficient indications of the degree of inflam-
mation and the suffering of the  patient.  Disease to such
an extent as this reduces the patient to a state of irritability
that  will permit nothing to be done. 
                ADVERTISMENT.

             T. B. WAIT AND COMPANY.
                    (OF  BOSTON,)
 Have just published, and offer for sale in the principul
            bookstores in the United States.
                  Price S 4,  bound.

   The  American  New  Dispensatory,
 Containing—General Principles of  Pharmaceutic Che-
 mistry.   Pharmaceutic Operations.   Chemical Analysis
 of the Articles of Materia Medica.   Materia Medica,
 including several new and valuable Articles, the Produc-
 tion of the United  States.   Preparations and Composi-
 tions.   With an Appendix,  Containing—Medical  Pre-
 scriptions.   The Nature and Medical Uses of the Gases.
 Medical  Electricity.  Galvanism.  An Abridgement of
 Dr.  Currie's Reports on  the Use of Water.  The Culti-
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 Opium.   And several Useful Tables.   The whole Com-
 piled from the most  Approved Authors, both European
 and  American.   By James Thacher, A. A. & M. S. S.

               RECOMMENDATION.
 Report of a Committee  of the Massachusetts Medical
                       Society.
   THE Committee appointed by the Massachusetts Medical Soci-
 ety, to examine  a manuscript submitted to their inspection by
 Doctor James Thacher, under the title of t\\i American New
 Dispensatory,  have performed that service as minutely as their
 various avocations would admit ; and are of opinion, that a work
of this  kind is much wanted at the present period, on account of
 the improvements and  important  discoveries, which  have been
made inchemical science within a few years, by which the existing-
publications have been in some measure superseded. 
ADVERTISMLM
  Dr. Thacher appears to have  made  his compilation from the
most approved modern publications, and to have adapted it to the
purpose of " a standard work, exiiibiting, in familiar language and
a concentrated form, the principles of modern pharmacy, chemis-
try  and materia medica."
  Many  of the ancient pharmaceutical articles and preparations,
which experience has proved to possess little or no value, have been
left out of the work,  by which  means it is compressed  into a
smaller compass, and rendered less expensive than most European
publications  of the same kind.
  A number of indigenous substances are  introduced  into the
Materia  Medica,   which have been hitherto unknown, or which,
though  their properties are in some instances highly active, have
never been brought into general  use.
  As it appears to  have been a principal object of Dr. Thacher to
adapt the work to American practice ; and, as he  has adopted  for
the basis of his work the Pharmacopoeia of Massachusetts, lately
published by the Medical  Society, and recommended  for general
use, they are  of opinion, that it will co-operate with the views
of the Society in that publication, especially as " its nomenclature
and order of arrangement seem to be strictly observed"  in the
manuscript.
  Tliey therefore conclude, that it will be for the interest of medi-
cal  science in this country, to encourage the work, and that it may
be the means of exciting a more general attention to the medicinal
virtues  f American productions,  many of which might be introdu-
ced into the Materia Medica, and advantageously, as well as ceco-
nomically, supply the place of foreign articles.
                                     JOHN WARREN.
                                      AARON DEXTER,
    Boston-, October 14, 1809.         JOS1AH BARTLETT.


 From the Ncxc York Medical Repository  for June and
                        July, 1810.
   After  quoting Dr. Thacher's  Preface entire,  and particularly
enumerating the r.umberof detached parts of which the Appendix
is composed, the Editors say,
   " We consider  this work as entitled to much respect and com-
•' mendation.  While the author, with modesty and ingenuousness,
" speaks of it as a compilation only,  we must do him the  justice
" to observe that it appears to us to be a compilation executed with
" much  diligence of research and much care and judiciousness o'.'
" selection.   And  it will afford us pleasure to see him reaping the
"reward of his exertions  in the general circulation and respectful
 "estimate of  this   Dispensatory among the  discerning and liberal
 "membersof the   profession." 
 
 
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