Columbia 29nitJf w^ftp 
 
 intiifCitpoflemgork 
 
 €oUtzt of ^ifv^icimi anb S>urgeonfii 
 Hibrarp 
 

 (?<^-t--V <-'*-''- 
 
 ^ ^J'J'^, 
 
 HUNTERIAN LECTURES. 
 
HUNTERIAN LECTURES 
 
 ON 
 
 SOME OF THE INJURIES AND DISEASES OF 
 
 THE NECK AND HEAD, 
 
 THE GENITO-URINARY ORGANS, 
 
 AND THE RECTUM. 
 
 DELIVERED BEFORE 
 
 '^Mt lineal (^Mt%t 0f ^ur0^0ns of CSnglatttr, 
 
 JUNE, 1885. 
 
 EDWARD LUND, F.R.C.S, 
 
 MEMBER OF THE COUNCIL AND COURT OF EXAMINERS OF THE COLLEGE, 
 
 CONSULTING SURGEON TO THE MANCHESTER ROYAL INFIRMARY, 
 
 PROFESSOR OF SURGERY IN THE OWENS COLLEGE, 
 
 VICTORIA UNIVERSITY, ETC. ETC. 
 
 LONDON : 
 J. & A. CHURCHILL, 
 
 n, NEW BURLINGTON STREET. 
 1 88fi. 
 
■•/S-2.. 
 
 LIT 
 
 MANCHESTER : 
 PALMER AND HOWE, PRINTERS, PRINCESS STREET. 
 
These Lectures, 
 
 being part of the course of 
 
 HUNTERIAN LECTURES, 
 
 DELIVERED BEFORE 
 
 THE ROYAL COLLEGE OF SURGEONS OF ENGLAND 
 
 IN THE YEAR 
 
 1885, 
 
 ARE DEDICATED BY THE AUTHOR 
 
 TO 
 
 JOHN COOPER FORSTER, Esq., 
 
 AT THAT TIME 
 
 PRESIDENT OF THE COLLEGE, 
 
 IN PLEASING RECOLLECTION OF AN 
 
 UNINTERRUPTED FRIENDSHIP 
 
 OF MORE THAN 
 
 FORTY YEARS. 
 
Digitized by tine Internet Arciiive 
 
 in 2010 witii funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/hunterianlectureOOIund 
 
CONTENTS, 
 
 LECTURE I. 
 
 PAGE. 
 
 On Some of the Injuries and Diseases of the Face, 
 
 Mouth, and Neck i 
 
 LECTURE IL 
 
 On Some of the Injuries and Diseases of the Bladder 
 
 AND Genito-Urinary Organs 38 
 
 LECTURE III. 
 
 On So^e of the Injuries and Diseases of the Rectum, 
 
 Perineum, etc 78 
 
iittt^riatt Kntnxts^. 
 
 LECTURE L 
 
 ON SOME OF THE INJURIES AND DISEASES OF 
 THE FACE, MOUTH, AND NECK. 
 
 Mr. President, Vice-Presidents, and Gentlemen, 
 
 I SHOULD not have presumed to accept the post I now 
 occupy as joint lecturer with Professor Wood in the 
 Hunterian Course of Lectures to be delivered in this 
 College during the present year, if I had not been assured 
 by our President, at the time of my appointment, that I 
 might secure your attention to any topic I might select, 
 so long as it referred, in a practical way, to the common 
 work of our profession. 
 
 The difficulty I had in my selection was this, — I felt it 
 was not possible for me to bring before you sufficient new 
 matter in reference to any one surgical subject to fairly 
 occupy the time allowed for my lectures, I might expand 
 any subject indefinitely if I traced the history of it from 
 our earliest records, but this would be waste of time. 
 For when I consider the audience I have the honour to 
 address, — that there are present to-day the elite of our 
 profession, men who have had opportunities far more 
 B 
 
2 HUNTERIAN LECTURES. 
 
 extensive than my own for watching different Hnes of 
 treatment and different classes of surgical disease, — it is 
 hardly possible that I can offer them any new matter 
 worthy of their attention. 
 
 I am constrained, accordingly, to give my subject-matter 
 a very general character, and to approach the details of 
 it by addressing myself chiefly to the members of our 
 college — those who, busily engaged in practice, frequently 
 have to deal with difficult points of diagnosis, or obscure 
 and doubtful cases for treatment, presenting problems of 
 great interest, upon the correct and ready solution of which 
 success or failure may depend. 
 
 I begin by inviting your attention to the consideration 
 of cases of slight scars or injuries of the face which may 
 or can lead to permanent and conspicuous deformity. I 
 was requested more than twenty years ago to attend a 
 little boy, four or five years of age, who had, a short time 
 previously, while running about in a dining-room, tripped 
 his foot upon the carpet, and fallen violently against a 
 sharp projecting portion of furniture, producing a laceration 
 of the skin and subjacent tissues, on one side of the face, 
 just above the malar bone. There was not much haemor- 
 rhage, the wound being a lacerated one, and not much 
 contusion, and so quickly and cleanly had it been made 
 that it seemed more like an incised than a lacerated wound. 
 I proceeded at once to replace the flap of skin and to 
 adjust the edges of the cut as completely as I could with 
 strips of plaister, carefully and accurately applied. 
 
 I fixed the whole with a pad of lint and a light bandage, 
 and thought I had done all that was needful. On the third 
 day — perhaps it may have been the fourth — I removed the 
 dressings, and then, to my regret, discovered the error I 
 had made. Spasmodic action in the marginal fibres of 
 the orbicularis palpebrarum muscle had been at work, and 
 
WOUNDS OF THE FACE, 3 
 
 had drawn the edges of the wound apart, so that although 
 healing was far advanced there was still a granulating 
 surface in the centre between the retracted lips of the 
 wound. It was not long before perfect cicatrization was 
 accomplished ; but there was a scar which it was too late 
 to prevent, and which I felt sure would be permanent. 
 Time has shown that these fears were well founded, for 
 now, — as often as I see this young gentleman it appears 
 as if with every succeeding year the ill effects of my bad 
 treatment become more and more apparent. As Sir James 
 Paget once said, a scar in a child, of the length of its little 
 finger, may grow as the child grows, and eventually equal 
 in length the little finger when he is an adult. Had I 
 remembered at the time of the primary treatment of this 
 wound how intimately the muscles of the face are blended 
 with the skin, in which are truly their points of insertion, 
 I should have done then what I have done ever since 
 under similar circumstances, viz., close wounds upon the 
 face with fine silken sutures, not sparingly, but abundantly 
 inserted, and retained just so long as may be needful to 
 fix the flaps of the wound to the deeper tissues, and keep 
 the edges of the wound as nearly as possible in contact. 
 
 In contused wounds of the face it is very needful, in 
 order to avoid permanent marking, to search with great 
 care for the entrance of and the removal from the wound 
 of any foreign matter, if there be even the smallest breach 
 of surface, i.e., solution of continuity in the parts so injured, 
 I had once a very curious illustration of this, one which 
 made a lasting impression upon me, and which has 
 influenced my practice in many ways. A little boy, 
 running out of the garden into a paved court at the back 
 of a house, fell suddenly, and was found a moment after- 
 wards lying flat upon his face, screaming lustily. He was 
 taken into the house, and it was found that he had struck 
 
4 HUNTERIAN LECTURES. 
 
 his forehead against the flat stone or flag upon which he 
 had fallen, and thus produced a bruised spot exactly in 
 the middle, just, as it would seem, over the frontal vein. 
 The boy had some slight symptoms of concussion of the 
 brain : he vomited, and afterwards became drowsy and 
 indifferent to what was passing, so I was asked to see 
 him. My attention was chiefly given to the brain 
 symptoms, such as they were. But I noticed that the 
 contused part was raised and much discoloured, as if 
 from blood effused beneath the skin, particularly in the 
 centre of the swelling, where the cuticle was slightly 
 abraded. This was all I then noticed. I applied an 
 evaporating lotion to the forehead, and, with care as to 
 quiet and regimen, in a few days the little fellow was well, 
 except that the skin was discoloured, and that there was 
 an unusual prominence at the seat of injury, which I took 
 to be caused by effusion of blood. Not being quite satisfied 
 with this state of things, I ordered a lotion of lead and 
 opium to be applied, not as an evaporant, but by covering 
 the lint with which it was wetted with oil-silk to cause it 
 to bring about a softening of the tissues, and, as I thought, 
 to hasten the absorption, or else the breaking down of the 
 clot. In about five days, say more than ten days from the 
 date of the accident, I examined the skin very minutely, 
 to see if I could discover any actual wound which might 
 have healed prematurely, but without success. I therefore 
 made a small vertical incision into the part with a tenotomy 
 knife, and out dropped, or, rather, I pressed out, with some 
 difficulty, a piece of gravel of considerable size. From 
 that day the swelling subsided, absorption of effused blood 
 and lymph went on, and all did well. Yet I have never 
 forgotten that case. It showed two points of interest. It 
 proved how small a wound may be made in the skin by 
 the rapid transit of a hard resisting body, like this particle 
 
WOUNDS OF THE FACE, 5 
 
 of gravel, by reason of the elastic skin yielding to, then 
 closing over its passage, like the smallness of the aperture 
 of entrance of a bullet of high velocity. It also showed, as 
 I shall have occasion to remark further on, how, where 
 foreign bodies from without are either forced into the 
 interior of the body or become embedded in any of the 
 tissues, the effect of the presence of a body so impacted 
 will depend entirely on its physical composition. If it be 
 porous, so that it can absorb the fluids — the serum, for 
 example — of the part, it will doubtless already have within 
 its pores the factor of putrefactive change ; and thus a 
 septic state of the surrounding tissues is almost sure to 
 result ; whereas, if it be solid and non-porous, as in this 
 instance, it may remain dormant and harmless. We know 
 that such is often the case if a small shot penetrates the 
 skin of the face or other exposed part of the body, and 
 even with a bullet of large size. But in these cases, most 
 probably, the shot or the bullet travelled alone, and in its 
 progress did not carry with it any porous wadding or other 
 material, and thus it has lain harmless in the wound, so 
 far as causing any local poisonous effects. This child fell 
 upon a flat stone, on which there lay, at the spot, a small 
 piece of gravel. It was forced through the skin by stretching 
 it enormously in proportion to its size, and, then slipping 
 within, was buried in the subjacent tissue, and the small 
 wound in the elastic skin closed over it imjnediately. In 
 a manner somewhat similar, particles of dirt will often be 
 driven deeply into the skin but not beneath it, and if not 
 diligently sought for, and thoroughly removed, will leave 
 permanent and ugly marks. Grains of gunpowder, when 
 the force of the explosion is not so great as to injure the 
 tissues severely, will thus become fixed in the skin and 
 produce lasting disfigurement. In this condition of things 
 I have succeeded very well in removing such marks by 
 
6 HUNTERIAN LECTURES. 
 
 this procedure : — The night before the operation (which is 
 to be performed under chloroform) I cause the skin over 
 each of the black dots or marks, or, at any rate, the 
 most conspicuous of them, to be painted with a thick 
 vesicating collodion, which for these and similar purposes 
 answers admirably. This being applied with a camel- 
 hair brush over the marks, the surface is allowed to dry. 
 In ten or twelve hours, the cuticle over the part will be 
 found raised, as in an ordinary blister, only with this 
 difference, that the collodion has strengthened and thickened 
 the epidermis, and it can, from this increased thickness, 
 be torn off with forceps from the spots over which it had 
 been painted. The papillary layer of skin so exposed 
 will most probably have embedded in it the foreign matter 
 which we wish to remove, and this can be done by means 
 of some small scraping instrument, e.g. a Volkmann's spoon 
 in miniature, or a hook or gouge such as is employed 
 for extricating particles of iron or coke from the surface 
 of the cornea. 
 
 In this way, in the case of a little girl, who by falling out 
 of a carriage — the door being imperfectly fastened and the 
 child leaning against it — fell face downwards on to the 
 roadway, which was very muddy, and was dragged along a 
 few paces, the face still resting upon the ground, — I found 
 that although every care had been take to cleanse the 
 wound before it was allowed to heal over by granulation, 
 a very conspicuous deformity was the result. A number 
 of lines were visible, of a light brown colour, where the face 
 had been scratched, and these I was able to remove, after 
 an interval of many months from the date of the accident, 
 by first applying the collodion, not in one large patch, but 
 in a number of fine lines over the marks, waiting for the 
 vesication, removing the cuticle, and carefully tearing away 
 each particle of matter such as mud would deposit, a lens 
 
CICATRICES IN THE FACE. 7 
 
 being used to aid tlie sight. The surface was then painted 
 over with dilute carbolated oil, and allowed to heal ; and 
 in the particular case to which I refer, no permanent mark 
 has resulted. 
 
 We have occasionally to deal with deformities caused 
 by cicatrices in the face, the result of adhesions over the 
 site of carious or necrosed bone, such as in the upper jaw 
 may be found near and around the orbit in strumous sub- 
 jects ; or on or about the lower jaw, where there have been 
 sinuses from disease of the fangs of the teeth after gingival 
 abscess ; or in the neck, as a consequence of abscesses 
 around the glands, or within their substance. These not 
 unfrequently leave very ugly cicatrices, with deep and 
 irregular depressions. 
 
 It is very desirable to correct such deformities, but this 
 is not a very easy matter to accomplish. It is useless to 
 make the attempt while inflammatory action is still going 
 on at the original seat of the disease. If suppuration 
 around the glands in the neck is still present, some other 
 treatment must be resorted to ; and if the action is still 
 proceeding in the sinus leading down to a tooth, or to 
 necrosed or carious bone near the orbit, it is little use to 
 interfere. We must remove the cause if possible, and then 
 wait until all destructive inflammatory changes are in 
 abeyance or perfectly arrested. Then, studying carefully 
 the extent, direction, and depth of the depression, a fine- 
 pointed narrow tenotomy knife should be passed through 
 the skin at about half an inch from the edge of the 
 depression, carried onwards beneath the skin until it 
 reaches the deepest part, but still with its point beneath 
 the cuticle. In this way we can divide subcutaneously the 
 cicatricial bands as well as the adhesions which fix the skin 
 to the bone, without piercing the skin at the bottom of 
 the depression, or producing any counter-puncture, with the 
 
8 HUNTERIAN LECTURES. 
 
 point of the knife. In doing this, blood will escape from 
 the divided capillaries ; but unless a vessel of considerable 
 size should be cut through, the blood so effused will 
 not be excessive, and the operation being performed very 
 slowly, the blood as it escapes will collect beneath, and 
 gradually lift up the skin nearly on a level with the surface 
 around. 
 
 Much will depend upon dividing the skin only at the 
 point of puncture, all else being done subcutaneously. Col- 
 lodion may be applied after the knife is removed ; but 
 ultimate success will be secured by what has been called 
 "organization of clot;" that is to say, the clot of blood 
 which forms in the space or cavity left after the elevation 
 of the scar, becomes partly absorbed, or partly organizes, 
 assisting in the development of new connective tissue, 
 which more or less completely fills up and obliterates the 
 slight depression previously existing. In this way many 
 of these depressed cicatrices may be successfully dealt with. 
 But I must assume that the depression is not very deep, 
 and that the original injury has not occasioned any great 
 loss of tissue. 
 
 Although a surgeon may not practise dentistry, except 
 in its most simple forms, it is very desirable that he should 
 have acquaintance with the phenomena incident to a 
 diseased condition of the teeth, such as may enable him 
 quickly to recognize and to treat, or to direct the treat- 
 ment of such cases. I was once consulted on a case of 
 supposed trismus, in which a young lady was suddenly — 
 that is, in a few hours — seized with inability to open the 
 lower jaw, with intense pain referred to the right temporo- 
 maxillary joint. There had been no premonitory symp- 
 toms, except such as might arise from cold, or exposure to 
 a draught of cold air ; and yet in a few hours the mouth 
 was firmly closed, with complete inability to open it. I 
 
SPASM OF TEMPORAL MUSCLE. 9 
 
 noted, however, that the masseter muscles were not rigid, 
 that there was no sardonic smile, and in no other part of 
 the body, the abdominal wall or elsewhere, was any 
 muscular rigidity to be discovered. She had had slight 
 difficulty in swallowing for a few days previously, and also 
 tenderness in mastication, which was referred to the situa- 
 tion of the last molar tooth on the right side ; and the 
 patient did not know that she had as yet not cut the 
 last molar tooth of that side. Passing my linger along 
 between the teeth and the cheek to the furthest point, I 
 found the gum over the situation of the lower wisdom 
 tooth swollen and tender. Then, with a very long gum 
 lancet set in a handle, which I happened to have with me, 
 I managed to scarify the gum at this spot very freely, 
 causing much blood to flow, and with it a drop or two of 
 pus, to the great relief of the patient, who, in a few hours, 
 with the help of hot water within and fomentations ex- 
 ternally, was able to open the mouth to the fullest extent, 
 and quickly recovered from all other disturbances. No 
 doubt inflammation had existed beneath the gum covering 
 the dens sapiens ; and this, while it had run on to the sup- 
 purating stage, had so excited action in that part of the 
 temporal muscle which lies on the line of the alveolar 
 process, as to set the entire muscle into a condition of 
 general spasm and to cause its sudden and powerful con- 
 traction with insuperable closure of the mouth. I have 
 known a very troublesome ozoena kept up, and much 
 constant mucous discharge from one nostril continue for 
 many weeks, until one central incisor tooth which was 
 tender on percussion and somewhat loose in its alveolus 
 had been removed, and then the discharge from the nostril 
 entirely ceased, as if mischief of an inflammatory nature 
 had existed near to the root or upper end of the fang of 
 the tooth, perhaps with minute perforation of the front part 
 
lO HUNTERIAN LECTURES. 
 
 of the floor of the nostril, so as to excite continual con- 
 gestion in the mucous membrane, and so lead on to 
 the ozoena. 
 
 I also know of a case in which a molar tooth was the 
 cause of a series of nervous symptoms which were very- 
 painful and very difficult to explain, as far as the exact 
 cause was concerned. A lady had had the dens sapiens of 
 the lower jaw, on the left side, carious, for a long while. 
 A dentist prepared and dressed it, and at last she was 
 able to go about as usual, although it was still difficult 
 for her to masticate freely on that side of the mouth. 
 When the more acute symptoms had abated, the cavity 
 of the tooth was filled with amalgam, as a temporary 
 stopping, and all seemed to go on well. But this patient, 
 as I was afterwards informed, soon began to suffer pain 
 in the left shoulder and down the external side of the 
 arm, with a certain degree of weakness on attempting 
 to raise the arm and set the deltoid muscle in action. 
 There was pain alsoi in the left side of the neck, and 
 in the left ear. These symptoms came on very slowly, 
 but were persistent, and were several weeks in reaching 
 their maximum intensity. It was then determined to 
 remove the stopping from the wisdom tooth, although 
 the tooth itself did not seem to be specially tender or 
 painful. As soon as this was done, a gush of foetid pus 
 showed that suppuration had been present beneath the 
 stopping on the surface of the dental pulp ; the escape 
 of the pus gave immediate relief, and in a short time, 
 one or two days, the lady had no more pain, or weakness 
 in the arm. The tooth was not extracted, but refilled 
 with a removable stopping. All these efifects, being due 
 to pent-up secretion and the nerve irritation resulting 
 therefrom, might have been entirely prevented by the 
 adoption of that elegant system of drainage through the 
 
SINUSES IN THE NECK. II 
 
 fang, known to dentists by the name of rhizodontrophy, 
 and which is so pecuharly well adapted to similar cases 
 of irritable pulp. 
 
 Sinuses in the cutaneous tissue of the face, as one of 
 the consequences of inflammation of the dental alveoli, 
 with suppuration and perforation of the wall, may exist for 
 many months before they cause ulceration of the skin, after 
 which we may find that the skin is under-burrowed for some 
 distance beyond the orifice of the sinus. Even if the source 
 of the irritation has been got rid of by the extraction of 
 the tooth, the skin over the orifice of the sinus may remain 
 for a long while in a congested and unhealthy condition, 
 and complete cicatrization cannot be obtained until the 
 skin so undermined has been entirely removed, by clipping 
 it off with scissors, or dividing it with a scapel. 
 
 Sinuses appearing in the neck, among the loose tissues 
 below the jaw, in cases of chronic suppurating glands, 
 require similar treatment. Here the only chance of securing 
 satisfactory healing is to remove the nearly dead loose 
 skin, which will not adhere by reason of the unhealthy 
 granulation tissue which exists beneath it, or on its under- 
 surface. And now I would consider what are the changes 
 which these superficial glands undergo in the progress of an 
 attack of inflammation. The situation of the inflammation 
 is more generally the cellular tissue which forms the 
 capsule of the gland than the interior of the gland itself; 
 so that the suppuration which follows is produced more 
 by a peri-glandular than by an intra-glandular abscess, 
 although this latter condition does, without doubt, some- 
 times occur. Now, it is by reason of the looseness of 
 the structures in which the glands lie, and the frequent 
 movements among the tissues of the neck, that we get 
 this burrowing and general extension of the ulcerative 
 process some distance around the inflamed gland. The 
 
12 HUNTERIAN LECTURES. 
 
 contents of the abscess escape, but the displaced skin will 
 not unite to the subjacent parts by reason of its lowered 
 vitality and insufficient blood supply, and so it remains 
 non-adherent for weeks and months. If at last it does 
 adhere, it will be so drawn in and puckered as to cause 
 a depressed and irregular cicatrix. 
 
 ■ Apart from any effects upon the constitution which may 
 arise from the presence of chronic suppuration, and the 
 dissemination through the system of poisonous influences 
 which may show themselves as tubercular deposits in 
 distant organs, it is always desirable to restrain these 
 morbid changes in the glands where this is possible. 
 
 Long experience in the use of the iodide of potassium, 
 as an external application in these cases, has only con- 
 firmed an opinion previously expressed, that the iodide salt 
 will do all that iodine itself, applied locally, can do, without* 
 that excessive action on the skin which the latter produces. 
 In the very earliest stage of congestion of the glands, 
 before inflammation has really set in, the skin over the 
 glands should be painted many times during the twenty- 
 four hours with an alcoholic solution of the iodide of 
 potassium with the bromide of ammonium, to which is 
 added just enough glycerine, and no more, to prevent the 
 crystallization of the salts on the skin.* In this way to 
 keep the part thoroughly saturated with the saline matter, 
 is of immense importance in controlling the changes going 
 on in the tissues around the glands, and the congestion of 
 the glands themselves. Where this iodide application has 
 failed, I have seen excellent results follow the careful use 
 of the emp. Jiyd. c. ammoniaco applied over the enlarged 
 glands, before suppuration has commenced. It requires, 
 however, to be used very cautiously, or it may expedite 
 
 *R. Potass. led., 7)iv; Amm. Bromid., 3ij; Glycerini, f3j; Aq. 
 Rosse, fgj. Misce et adde Sp. Vin. Rect. q.s. ad fgiv. M. ft. solutio. 
 
'«»•«'• 
 
ABSCESSES IN THE NECK. 1 3 
 
 suppuration instead of averting it. In children it is a good 
 plan to apply the plaister only at night, removing it in the 
 morning, and not to continue its use if irritation of the 
 skin is produced. It should be diluted by the addition of 
 one-third or one-fourth of emp. saponis. 
 
 It is often difficult to determine when and how to open 
 abscesses which form around the inflamed glands of the 
 neck in delicate subjects of the strumous constitution. I 
 always delay the incision until I am satisfied not only that 
 fluid exists, but that it is at least two-thirds in bulk or 
 quantity of the diseased mass. If done earlier than this, 
 the incision will caus.e only a slight diminution of the 
 swelling, and the wound thus produced may excite a fresh 
 course of inflammatory action. As to the mode of puncture, 
 little, in my opinion, is gained by aspiration, even if only 
 on so small a scale as that of puncture by the hypodermic 
 syringe needle, and the removal of the liquid portion of the 
 pus. I always use a very small lancet, with cutting edges, 
 as represented in Plate I., Fig. A. This serves the purpose 
 of an exploring needle, to ascertain if there is really fluid 
 within the swelling ready for evacuation ; and then, by 
 the same instrument, we can enlarge the incision along the 
 lines of the platysma fibres to any extent. So small an 
 incision as this would be quickly closed by adhesive 
 inflammation, unless steps were taken to prevent it. With 
 this object, by means of the flat-ended probe. Fig. C, I 
 pass into the cavity from which the pus has escaped, a 
 small coil of thin silk ribbon, Plate I., Fig. B, moistened with 
 a lotion of nitrate of lead and weak carbolic acid, and allow 
 a part of the ribbon to project beyond the incision, placing 
 over all, the same lotion, with lint and oil-silk. If in a 
 few days subsidence of the swelling does not result, I try 
 to hasten the absorption of the lymph with which the part 
 is infiltrated by having each ribbon-tent moistened with 
 
14 HUNTERIAN LECTURES. 
 
 the tincture or the liniment of iodine, or I dust it with 
 the powder of precipitated iodoform, pressing one end of 
 the ribbon well down to the bottom of the cavity, yet 
 leaving a portion of it outside the wound. By these 
 simple means, in addition to judicious hygienic measures, 
 what are known as strumous glands in the neck may be 
 controlled in their enlargement and progress to a wonderful 
 degree, and the resulting scars and deformities minimised 
 to a great extent — unless the primary lesion has been in 
 the centre of the gland-structure itself, and then I believe 
 the progress is much less manageable, and that the results 
 are much less satisfactory, and more liable to lead to con- 
 stitutional complication. 
 
 Scalds and burns in children, or even in the adult, are a 
 frequent source of deformity in the face and neck, as they 
 may be, in fact, in any part of the body. I cannot enter 
 into all the various modes of overcoming deformities pro- 
 duced by these accidents when they are very extensive 
 and the contraction of the scar-tissue is very complete 
 and firm, since various plans of treatment are open to the 
 consideration of the surgeon. For where the true tissue of 
 the skin has been destroyed, even the most cleverly designed 
 operation for correcting the deformity will occasionally fail. 
 I would rather comment upon the method of treatment to 
 be resorted to with the best prospect of success at the 
 moment of the injury, or as quickly afterwards as possible. 
 In scalds and superficial burns upon the face and neck in 
 young children, I have seen such admirable results from 
 the application of treacle, or molasses, directly over the 
 surface as a continuous dressing to the scald or burn until 
 complete cicatrization is effected, that I would place this 
 first on the list of remedies in such cases. It has this 
 great recommendation, that it is a domestic remedy, 
 inasmuch as it is a substance found in nearly every house 
 
SCALDS AND BURNS. 1 5 
 
 where children abound, and therefore it can be quickly- 
 applied. It excludes the air from contact with the highly- 
 sensitive papillary layer of the skin, and so diminishes 
 in a marked degree the burning pain which attends these 
 injuries. The best mode of applying it in scalds and 
 burns on the face and neck is to take blotting-paper, or 
 soft flexible cap-paper, torn into pieces, each about half 
 an inch by an inch and a half, as these will have their 
 edges more fluffy and absorbent than if the paper is cut 
 with scissors. Then dip the pieces of paper into the treacle, 
 and so lay them on the part, one by one, as to cross in 
 every possible direction, that by mutual overlapping and 
 entanglement they may unite and form a closely-fitting 
 mask or shield to the part. If the scald or burn is on the 
 face treacle has this advantage in children, that if a little 
 of it runs down into the angles of the mouth it is not 
 distasteful, but rather agreeable to the little patient ; and 
 if it has been applied immediately after the injury, the 
 air and its constituents will not have access to the wound 
 so as to set up septic action in the secretions of the part. 
 If the treacle be in excess round the edges of the dressing, 
 it may be removed by wiping with a dry cloth ; and the 
 edges may then be dusted with flour, powdered oxide of 
 zinc, bismuth, or other drying material. Possibly this 
 treacle-dressing acts simply as an air-excluder ; it is 
 neutral in its reaction, and causes no pain ; and, like all 
 saccharine preparations, it has in some way the power of 
 controlling oxidizing changes, as is seen in such pharmaceu- 
 tical preparations as the saccharine carbonate of iron and 
 the syrup of the iodide of iron, both of which are salts of 
 very unstable composition, yet they may be preserved 
 unchanged while in contact with sugar. 
 
 For scalds and burns on larger surfaces than those of 
 the face and neck, I employ the ointment I recommended 
 
1 6 HUNTERIAN LECTURES. 
 
 many years ago in my report on hospital practice, and 
 which is, in substance, resin ointment, with oxide of zinc 
 and carboHc acid in the proportion of a drachm of each 
 of the two latter substances to an ounce of the cerate.* I 
 have never known injurious effects follow the use of this 
 preparation of carbolic acid in the way of carbolic poisoning, 
 melanuria, and the like, and that it has a sedative or 
 anaesthetic effect on the tender surface of the skin cannot 
 be doubted. The shock to the nervous system incident 
 to larger burns and scalds is propagated chiefly along the 
 sympathetic nerves, and depends greatly on the particular 
 part of the body injured and its extent of area. Yet the 
 continuance of this state of things, the prolonged pain, 
 and the nervous restlessness which results from it, are 
 caused, I believe, mainly by prolonged contact of the 
 injured surface with the air, where the applications made 
 use of do not effectually exclude it. 
 
 As to the effects of burns in regard to the contraction of 
 tissue which follows them, I have long considered that this 
 is very much influenced by the intensity and duration of 
 the inflammatory action which attends upon the injury. 
 Where the effused lymph and the cicatricial tissue which it 
 helps to form are deposited under conditions of high 
 vascularity and vital action, firm and irresistible contraction 
 of tissue results much more certainly than, ccBteris paribus, 
 where, from the careful treatment of the wound, the process 
 of repair has been accomplished without much local 
 disturbance, or without intense vascular congestion in 
 the granulations, and, possibly, abundant secretion of pus. 
 
 In fact, our treatment of scalds and burns must be 
 
 *R. Resinge flavse, giv; Cerge flavse, 5XX (in winter, gx); Olei 
 Olivte, fgxx (in winter, fgxxx) ; Terebinth. Chiae, gviij ; Picis 
 Burgund., ^iv; Zinci Oxidi, giv; Acid. Carbolic, puri (Calvert's 
 liquid), fgj. Misce, fiat unguentum. 
 
SCALDS AND BURNS. 1 7 
 
 conducted in obedience to the laws which regulate the 
 avoidance of septic changes in wounds in general, by 
 whatever cause produced ; and we know that this state 
 of things may be secured by various means, and it is not 
 right to limit our application of the antiseptic treatment 
 of wounds to the exclusive use of the many preparations of 
 carbolic acid. 
 
 It has often been noticed by those who are earnest 
 followers of true Listerism, that in their amputation- 
 wounds, and those occasioned by the removal of tumours, 
 the resulting cicatrices are much more pliable and elastic 
 than after other dressings ; and my own observations on 
 the progress of scalds and burns when so treated, is quite 
 in accordance with such remarks. 
 
 As to the mechanical means by which we may avert 
 the tendency which cicatrices following scalds and burns 
 constantly exhibit to produce permanent deformity by 
 contraction of tissue, I believe there is one cause in 
 action which, if admitted, will guide our treatment under 
 such circumstances. It is the habitual position assumed 
 by the body during sleep, in children especially. In a 
 child, this means of course the posture of the body in at 
 least one-third part of the twenty-four hours. It is best 
 observed in the limbs. If the back of the arm or fore- 
 arm be the seat of the future cicatrix, it will, by the 
 naturally flexed position of the limbs in sleep, be submitted 
 every night to a certain amount of extension or stretching ; 
 and here an apparatus may hardly be needful ; but with 
 an equal extent of injured surface on the palm of hand, 
 or front of fore-arm and arm, the parts would be so 
 circumstanced during the hours of repose as to facilitate 
 contraction, which we must therefore carefully correct by 
 the use of some extending apparatus at that particular 
 time. The same in the cicatrix resulting from a scald or 
 C 
 
18 HUNTERIAN LECTURES. 
 
 burn beneath the chin, for example, or on the front of the 
 neck. It is rarely that we see a child in the attitude of 
 sleep with the head thrown back and the neck extended. 
 Far more frequently the neck is bent and the chin rests on 
 the front of the chest. 
 
 Here much may be done by the patient wearing at 
 night a collar of leather, or a stiff bandage, on which the 
 chin can rest, and the structures in front of the neck be 
 restrained from undue contraction. It may be prudent 
 in such a case, to wear the collar constantly day and 
 night ; but if relaxation from this is permitted, it is in 
 the night-time rather than the day that its use will be 
 found to be the more urgently required. 
 
 Before I leave the subject of the primary treatment of 
 burns, I must mention a means of diminishing the con- 
 stant tendency exhibited by newly-formed fibrous tissue 
 to contract and thus distort the part, which I believe will 
 often prove successful. It is as soon as cicatrization is 
 completed, to apply to the yet tender surface, a weak 
 mercurial ointment in some of its forms — the mild mercurial 
 ointment, or the ointment of the ammonio-chloride of 
 mercury. I have reason to think that in cases of burns on 
 the hand and fingers, this treatment, persevered in for 
 some weeks, has caused the resulting cicatrix to be more 
 yielding to gradual extension, and less firm and rigid. 
 
 I will now relate my experience of the success attending 
 the early treatment of two very frequent diseases of the 
 skin of the face, lupus and epithelioma. Practically, if 
 early seen, and the true nature is suspected, the local treat- 
 ment, I take it, should be identical for both. For lupus 
 attacking the nose and the skin of the upper lip near 
 to it, scraping by a Volkmann's spoon, so as to remove 
 every particle of diseased tissue, and a fair amount, beneath 
 and around, has so often proved successful that I have 
 
EARLY LUPUS ON THE FACE. 1 9 
 
 thought my diagnosis was at fault, and that I dealt rather 
 with some low form of ulcerative action than with truly- 
 destructive lupoid disease. But where the patch of ulcera- 
 tion is smaller, less diffuse, and spreads less rapidly than 
 in lupus, and the disease attacks a patient after the middle 
 period of life, then anticipating a more positively epithelial 
 proclivity, I have found no treatment so good as the use 
 of escharotics, and of these, none so generally efficient 
 as the potassa fusa. I know how much the chloride of 
 zinc and the acid nitrate of mercury have been used, and 
 advocated on great authority ; but my attention was 
 first drawn to the superiority of potassa fusa by the late 
 Sir Erasmus Wilson, very many years ago. It does its 
 work less painfully and more quickly, and leaves behind 
 it a softer and more pliable cicatrix than follows the 
 application of any other caustic. There is only this one 
 condition for its safe and certain use. The part acted 
 upon must be thoroughly dried, and kept perfectly dry as 
 soon as the corroding action of the salt has been completed. 
 A small piece oi potassa fusa is melted in a porcelain spoon 
 over a spirit-lamp ; the end of a probe, itself previously 
 warmed in the flame, is dipped into the fused salt, and 
 twisted round until, as it cools, it encases and coats the 
 bulbous extremity of the probe. 
 
 The surface to be destroyed is gently rubbed with the 
 probe so coated until, after a few minutes, it assumes a 
 brownish, burnt-like appearance; and while this is going on, 
 if by chance too much fluid is formed by the liquefaction 
 of the dissolved tissues in the strong alkaline solution so 
 produced, great care must be taken to absorb, with pieces 
 of white blotting-paper, or fine filtering paper, all this fluid, 
 lest it trickle down and act corrosively on the surrounding 
 skin, beyond the limits already designed. It is a little 
 difficult to define how deeply or how widely the caustic 
 
20 HUNTERIAN LECTURES. 
 
 should be applied, but I might suggest that its action, with 
 all our care, is apt to extend a little further circumferen- 
 tially than its immediate effect would indicate, so that 
 allowance must be made for this contingency. As soon 
 as the caustic action ceases, the next important element of 
 treatment commences ; that is, the thorough drying of the 
 surface with the strictest attention to this particular. It 
 is from not taking pains to dry the part afterwards that 
 potassa fjisa has lost its repute as an escharotic. The way 
 to secure this drying action is by the liberal use of strips of 
 bibulous paper, applied at first around the margin of the 
 space ; and, as moisture ceases to exude, at the end, it may 
 be, of twenty or thirty minutes, to touch repeatedly the 
 central part, until the surface has been rendered absolutely 
 dry. If needful, longer time must be given to secure this 
 indispensable condition. So little pain, if any, accom- 
 panies the use of potassa fnsa as a caustic, that it is very 
 easy to get the patient himself to persevere in the appli- 
 cation of the strips of paper, until absolute dryness is 
 attained. One of the first cases in which I used potassa 
 fiLsa as an escharotic, was in the removal of a hair-mole 
 from the side of the face in a young woman, who came 
 as an out-patient to our Infirmary, a long way from the 
 country. I removed the mole by rubbing the caustic over 
 it in the way I have described, and she did not leave until, 
 as I thought, the surface was completely dry. I did not, 
 however, tell her to test this by repeated applications of 
 paper for some hours afterwards, lest, more serum being 
 secreted, it might carry with it some of the free caustic, 
 and so injure the surrounding skin. The crust or scab 
 which formed over the original site of the mole remained 
 dry and adherent for several days ; it peeled off, and a 
 good cicatrizing surface was exposed, which shortly healed 
 and left a very soft, pale scar. 
 
N^VI ON THE FACE. 21 
 
 But, running down from it on the cheek for nearly an 
 inch, the highly alkaline serum which escaped from beneath 
 the scab had produced a mark which remained red and 
 conspicuous for many weeks after the entire healing of 
 the mole-mark itself This case taught me a lesson the 
 value of which I am anxious to impress upon others, for 
 with strict observance of this point of thoroughly drying 
 the surface after the use of potassa ftisa, it will be found, 
 I believe, the most effective destroyer of early epithelial 
 growths. 
 
 I will now speak of naevi on the face, as found in infants 
 and very young children, and the treatment I would 
 recommend. I cannot here deal with large naevi in this 
 region, because they require more energetic measures for 
 their arrest or cure than I have now to offer. It is rather 
 to suggest a line of treatment so simple in principle 
 that all may resort to it, and thus, as soon as ever a 
 tendency to grow is exhibited by these marks, something 
 should be attempted, and that efficiently, to check their 
 advance. I will say nothing as to the possibility of 
 atrophy of these deformities by degeneration. No doubt 
 it does occur, and some remarkable cases are on record 
 in proof of this, and possibly a tendency to atrophy may 
 be excited by early treatment, and be one of the chief 
 factors in obtaining, by simple means, permanently good 
 results. 
 
 The two means of cure on which I rely for small naevi 
 on the face, neck, and neighbouring parts are vaccination 
 and, failing this, the needle cautery. To vaccinate over 
 the naevus, as well as to vaccinate the child in three or 
 four spots on the arm, is excellent practice where it can 
 be done. 
 
 It is prudent to vaccinate the patient on the arm as well 
 as over the naevus, that we may watch, in the usual way. 
 
2 2 HUNTERIAN LECTURES. 
 
 the progress of the local changes there occurring, and 
 reason therefrom how far constitutional results may follow. 
 We vaccinate over the naevus, to set up in the skin and 
 the tissues beneath, inflammatory action and effusion of 
 lymph, which by its contraction shall strangle the arterioles 
 and capillaries of the growth, and restore the vascularity 
 of the part to its normal state. I have had some very 
 successful cases, but many of them at first — that is, for 
 months after the operation — were disappointing in their 
 progress. The effects of vaccinating a naevus are very 
 gradual. At first the redness of the part seems to be the 
 harbinger of ill, and to forebode a return of all the trouble. 
 But it is well to know that if the action — that is, the 
 pustulation with its attendant inflammation — is well estab- 
 lished, sooner or later contraction will follow ; and with 
 this peculiarity, that, as we see in the ordinary vaccination, 
 although the cicatrix or mark is very conspicuous for some 
 years, it has a tendency to fade away, I presume, by the 
 very slow absorption of the effused lymph-bands within it. 
 This occurred to me with a large nsevus on the upper 
 eyelid and brow of a boy nearly four years old, who 
 had never been vaccinated, and in whom for months after 
 vaccination over the nsevus, the part remained red and 
 swollen, and then at last slowly contracted. When he 
 was eight years old, it left so little trace of deformity that 
 it was hardly possible to say on which side of the face 
 it had existed. 
 
 After this operation, however, it is very desirable to 
 preserve as anhydrous a state of the vaccinated surface as 
 possible. The only case among many which gave me 
 much trouble in the primary stage of treatment by 
 vaccination, was in a very young infant with a large veno- 
 cutancous nsevus beneath the chin. I vaccinated it 
 liberally ; an abundant crop of pustules formed, which 
 
N^VI ON THE FACE. 23 
 
 by neglect in nursing were allowed to get wet and sodden 
 by the saliva dribbling from the mouth ; and the whole 
 became one large suppurating surface, to the child's great 
 distress. Yet as time went on, the surface healed, and I 
 have been assured, quite recently, by the medical man who 
 had charge of the case that no scar whatever now exists, 
 and the skin is as healthy there as in the surrounding 
 parts. In vaccinating over a nsvus I much prefer to 
 use a vaccinating pen rather than a lancet, to tattoo the 
 
 EXACT SIZE. 
 
 part with the vaccine lymph, taken if possible, direct from 
 the arm of a healthy child, and I regulate the depth of the 
 punctures by the weight of the pen allowed to fall on the 
 part from a short distance, so as just to penetrate the 
 epidermic layer, and yet, if possible, not cause bleeding. 
 
 The other method which I have to suggest for dealing 
 with small and early n^vi, where vaccination has already 
 been performed, is by the use of the needle-cautery. The 
 same thing can be done with a galvano-needle puncture ; 
 but, as I am anxious here to show simple rather than 
 complex means of cure in surgical disease, it is more easy 
 to employ for the obliteration of naevi, needles of the 
 ordinary form, heated to redness in a spirit-flame, than 
 the galvano-puncture, which can hardly be said to possess 
 any superiority on the score of special blood-coagulating 
 power, apart from the heat of the needle itself To make 
 this more intense and more constant, I fix on each needle 
 a small sphere of steel, which is placed some distance from 
 the point, Plate I., Figs. D D. While the needle is being 
 heated, the steel ball also becomes hot, and acts as a reservoir 
 of heat, by which the needle does not so quickly become 
 
24 HUNTERIAN LECTURES. 
 
 cooled, or if it has to be again heated by the flame, this 
 can be done more rapidly. There was a difficulty at first 
 in the use of needles so heated which made me think 
 them less suitable than the galvano puncture, and that 
 was their liability to become oxidised when hot, and so 
 to form flakes of black oxide of iron on the surface, 
 which, when the needle was again introduced into the 
 part, were separated by contact with the skin, and produced 
 a black or dark-coloured ring. I overcome this, however, 
 by rubbing the needle in emery-dust from time to time 
 before its re-introduction. The number of the punctures, 
 their position and direction, must all depend upon the 
 extent and depth of the naevus. It is better to make 
 too many than too few, so as to have as many lines of 
 contraction as possible along the surfaces so burned. It 
 is not necessary, I find, to carry the needle completely 
 through the naevus from one side to the other, but rather 
 to direct each line of puncture from the periphery in a 
 converging direction towards the centre of the naevus, 
 and then to make a few punctures perpendicularly to the 
 surface through the thickness of the naevus. There is 
 rarely any haemorrhage from the punctures if the needle 
 is not too hastily withdrawn. It should be held steadily 
 in the exact position in which it was introduced until 
 it is evident that all the redness has ceased, when it must 
 be slowly removed by a very gently rotatory movement, 
 and very gradually. If, in spite of all our care, some of 
 the punctures give trouble, and slight oozing of arterial 
 blood follows the removal of the needle, it may be re- 
 warmed, introduced a second time through the opening, and 
 there held until, by a lower heat, it seals more effectually 
 the bleeding points. Or, if the oozing should be specially 
 difficult of control, I make use of styptic discs, formed 
 by soaking bibulous paper in a strong alcoholic solution 
 
CHRONIC FISSURE OF THE LIP. 25 
 
 of tannin, 45 grs. to each fluid drachm of absolute alcohol, 
 and allowing it to dry. The paper thus prepared, cut 
 into pieces of convenient size, one or two of them being 
 placed over the nsevus, and fixed by gentle pressure, will 
 certainly stop the bleeding if only of an oozing nature. 
 These tannin discs are exceedingly useful, and for more 
 trivial accidents, as in a razor-cut in shaving or in arresting 
 the bleeding from a leech-bite, which are at times trouble- 
 some to deal with, I much prefer them to the perchloride 
 of iron. Tannin is more cleanly to use, and does not excite 
 any ulceration of the part, as the iron salt is apt to do on a 
 tender surface. There is this practical advantage in the 
 tannin discs; they are not at all hygrometric or deliquescent, 
 so they are always ready for use and of constant strength. 
 Theoretically, the hot needle acts upon principles similar 
 to vaccination in destroying naevi or arresting their growth. 
 The effects of the needle-cautery on naevi are not immediately 
 apparent, yet the action, I have noticed, is more rapid and 
 direct than when vaccination has been employed. The 
 cicatrix from vaccination may, by lapse of time, be less 
 conspicuous than that from the needle-cautery, but of this I 
 am not quite positive, yet by one or both of these methods 
 we may generally succeed in the treatment of small recent 
 nsevi. 
 
 While speaking of deformities of the face, I would refer 
 to one which is not congenital in its origin, and is seen 
 more frequently in the adult than in the child — that is, 
 chronic fissure of the lip. It is usually found on the lower 
 lip, in the centre of the prolabium, and is not only unsightly 
 and painful to the subject of it, but is peculiarly hurtful to 
 one of a joyful or hilarious temperament, for it frequently 
 cracks, and perhaps bleeds, when the sufferer indulges in 
 laughter and the like. It is very generally associated in 
 some way with disordered digestion, and may possibly be 
 
26 HUNTERIAN LECTURES. 
 
 one expression of an eczematous tendency, and itself a 
 manifestation of eczema fissum. It may, on such principles, 
 be controllable, if not curable, by constitutional and dietetic 
 means. But it is to the local treatment in very trouble- 
 some cases that I wish now to invite your attention. 
 The first time I adopted it was experimentally, but it 
 succeeded so well that I have constantly recommended 
 it in other instances. The case was that of a young lady 
 who had suffered from fissure of the lower lip — I might 
 almost say for years — disappearing and returning from 
 time to time without known cause, and as she was about 
 to be present at some fashionable assembly, where personal 
 appearance was a cardinal point of interest, she consulted 
 me about it a few days previously, anxiously seeking for 
 some immediate remedy. I told her I could offer only 
 one method, which I knew would seem to be severe, and 
 might be painful for the instant. It was to incise the 
 part, as I told her, to make it bleed for a few moments, 
 and then perhaps it would quickly heal. With a thin and 
 very sharp scalpel, drawing it along the fissure, I cut into 
 the substance of the submucous tissue and fibres of the 
 orbicularis muscle for rather more than an eighth of an 
 inch. The bleeding, which was free, was encouraged by 
 bathing with warm water, and when it ceased nothing was 
 applied beyond an occasional touch of a handkerchief. 
 Yet within twenty-four hours, by the perfect rest thus 
 given to muscular tension in the part, the incision had 
 united perfectly. No trace of crack or fissure could be 
 seen ; my patient was not a little delighted, and went to 
 the party quite happily. 
 
 On the subject of hare-lip, I wish to speak only of the 
 more simple cases, in which none of those graver complica- 
 tions and deformities are present which render operations 
 for the relief of such defects some of the triumphs of 
 
HARE-LIP. 27 
 
 plastic surgery. My remarks will have reference to cases in 
 which the fissure exists on one side only of the mesial line of 
 the lip, and does not penetrate far upwards into the depth 
 or breadth of the lip — such a case as any tyro in surgery 
 might undertake to treat without the slighest hesitation ; 
 and yet such cases, if sought for and watched carefully, 
 years afterwards as the child grows up, will often disappoint 
 the operator by the reappearance of the notch as the 
 lip developes in the general progress of growth. Two 
 causes, I have noted, conspire to this untoward result. 
 The comparative thickness of the extreme edge of the 
 two sides of the fissure is rarely equal, so that the lip on 
 one side of the resulting cicatrix will be thinner and less 
 actively nourished than the other. And as soon as union 
 is effected after the operation, there will be a tendency 
 in the lineal cicatrix so formed to undergo contraction in a 
 longitudinal direction — that is, upwards towards the nostril. 
 Thus, year by year, from one or both of these causes, an 
 unsightly and conspicuous notch will be formed. To avoid 
 this, I often adopt the following device. In paring the 
 edges of the cleft in the lip, I remove, as far as possible, 
 so much of the edge of the thinner piece as to reach a part 
 of the lip nearly equal in thickness to the other side. In 
 doing this, I refresh this edge at the expense of its mucous, 
 rather than its cutaneous surface, the thicker edge being 
 refreshed in the opposite direction at the expense of the 
 skin surface. Thus, instead of two squared edges being 
 brought into contact, part of the edge of the thicker arm 
 of the cleft lies behind or beneath the thinner, to pack 
 it up and help to thicken it. Then I so refresh the 
 extreme edge of the lesser arm of the cleft, as to affix to 
 it some of the prolabial portion of the other side, crossing 
 the extreme lower end of the cleft, and here for the time 
 producing a very distinct nodule or projection of mucous 
 
28 HUNTERIAN LECTURES. 
 
 tissue. This, I confess, produces a very ugly appearance, 
 not only as soon as the parts are brought together, but 
 for a very long time afterwards. If the friends of the 
 patient protest against the unsightliness of this nodule of 
 mucous tissue projecting on the centre of the prolabium, 
 I endeavour to allay their fears by assuring them that 
 if it should become permanent, it can at any time be sliced 
 off, so as to make the whole surface level. 
 
 But in a number of cases which I have watched for 
 more than a year, and in one case for four years after the 
 operation, this nodule of mucous tissue remained projecting 
 in a diminishing degree, and served as a means of blocking 
 up what would otherwise have been a depression in the 
 edge of the lip by the upward lineal contraction of the 
 cicatrix itself The plan, therefore, consists mainly in 
 leaving untouched this mucous tubercle, and being content 
 to have an abnormal fulness or projection at this part, 
 which in nearly all of the cases I have seen so managed, 
 never requires to be cut off, but in twelve or eighteen 
 months slowly contracts to its proper level. I do not 
 employ pins, except during the operation, and until the 
 sutures have been duly fixed. Then the pins are removed, 
 and I place some fine sutures within the mouth on the 
 mucous surface, to fix the inner flap. To keep the surface 
 as dry as possible on its cutaneous aspect, is the only mode 
 of after-dressing which I have ever found needful. 
 
 From hare-lip one passes on naturally to the study of 
 cleft palate and its general treatment. There are a few 
 remarks which I desire to make while passing this subject 
 hastily in review. The cases most favourable in my 
 experience for closure of the hard palate in childhood 
 or in adolescence, are those in which the bony arch of the 
 palate is high and narrow as compared with cases in which 
 it is flat and broad ; and in spite of the clever procedure 
 
HARE-LIP. 29 
 
 of Sir William Ferguson to crush in the bony roof of the 
 palate on either side towards the fissure, and so diminish 
 its width, yet the flaps of fibro-mucous membrane which 
 have been detached from it, fall together much more 
 easily, and can more readily be brought into contact from 
 a high, than from a flat or low palate. With regard to 
 the suturing of the sides of a cleft of the soft palate, and 
 the importance of not drawing the sutures too tightly, 
 it has always seemed to me that while this was objec- 
 tionable, from the chance of its producing a strangulation 
 of the part and ulceration of the suture-holes by undue 
 pressure, yet there was another fact to be observed in it of 
 equal importance. 
 
 We know on the surface of the body, where all is clear 
 and visible, how apt we are in tightening up our sutures to 
 disarrange the relative position of the edges of the wound, 
 and to find that here and there, between the sutures, there 
 is inversion of the skin, by which two epidermic surfaces, 
 coming into contact, union is impossible. This may be due 
 either to tying too tightly, or to mal-apposition. Now, a 
 similar condition occurs often in the adjustment of the 
 two sides of the refreshed fissure of the soft palate in tying 
 the sutures. What we chiefly require is the direct appo- 
 sition of the cut surfaces on the edges of the cleft. What 
 we often have, by misadventure, is an inversion at one or 
 more points of the mucous aspect which then lies surface 
 to surface, and can never unite. An adept at this operation 
 will rarely do this. He avoids it instinctively, perhaps 
 without knowing it. But the occasional operator, or he 
 who has not had much operative experience, will often find 
 that the edges of the cleft which he has carefully refreshed, 
 and which he fairly hopes will unite, cannot do so for the 
 reason I have stated. We owe very much to Sir Spencer 
 Wells for his valuable discovery of the readiness with 
 
30 HUNTERIAN LECTURES. 
 
 which the surfaces, and not the edges, of a divided serous 
 membrane will unite by plastic lymph in an incredibly 
 short time. The same distinguished operator has also 
 shown us that mucous surfaces, when so circumstanced, 
 conduct themselves quite differently. Here the surfaces, 
 when in contact, will not unite, but the cut edges will. 
 So that careful attention to this little matter may prove 
 to be one of the turn-points of success. 
 
 Lastly, for those whose experience in this operation is 
 not very great, and who desire to secure by every means, 
 the greatest amount of rest for the sutured palate, as well 
 as rapid union, and to diminish the tension on the opposed 
 edges of the wound, the most simple and the best of all 
 the different methods is that practised by Mr. Bryant, 
 which consists in making an incision into the pendulous 
 palate, by scissors or otherwise, nearly parallel to each side 
 of the proposed line of union. The first time 1 did this 
 it was with great hesitation, as I could not see at the 
 moment how nature could be equal to the demand made 
 upon her to unite the sutured edges of the cleft, as well 
 as to close up the gaping notches which I had made on 
 either side of it. But a very little thought convinced me 
 that I had nothing to fear. My case did well, and I had no 
 trouble with my lateral gaps. I called to mind another 
 operation in which an incision is made very similar in its 
 relations to those in the sides of the soft palate. Only 
 it is designed with the object of permanently separating 
 two surfaces, and it invariably fails to do so, unless certain 
 precautions have been taken. I recollected that with an 
 ordinary incision to divide congenital webbing of the 
 fingers, it is impossible to prevent re-union ; the cut so 
 made will close up at the converging angle of the wound, 
 however much we may try to prevent it by separating the 
 fingers ; and so with the incisions into the palate, they 
 
EXCISION OF THE TONSILS. 3 1 
 
 never fail to close slowly yet surely, and at a stage of the 
 healing process subsequent to that of the union of the 
 central wound. 
 
 Whilst speaking of operations on the palate, in which 
 we now rarely hesitate to resort to anaesthetics, let me 
 put in a plea for the administration of chloroform in that 
 simple operation, the excision of the tonsils, particularly 
 in the young. It would almost seem as if, in times past, 
 the influence of fashion had occasionally been at work 
 in surgery as well as in medicine. It must be within the 
 memory of many surgeons, that there was a time when 
 enlarged tonsils were always to be removed, and long 
 uvulae always to be shortened, the possible evils resulting 
 from either condition being no doubt greatly exaggerated. 
 It is to be hoped that we now have clearer and sounder 
 notions as to when either of these operations is actually 
 required. As to abscission of the uvula, or a portion of one 
 tonsil, the operation being done very quickly, and by one 
 act, an anaesthetic may be dispensed with. But in the 
 case of a child, say of five to eight years of age, with two 
 large tonsils, so large as to impede respiration, and thus 
 check the full development of the chest and the propor- 
 tionate expansion of the lungs, in harmony with the height 
 and growth of the body, I am sure it is the proper thing 
 to place the child under the influence of an anaesthetic, so 
 that we may remove more deliberately and precisely the 
 requisite quantity of tonsil structure, and without terror 
 and distress to a patient of such tender age. It is curious 
 to note how very slightly some children suffer in the act 
 of deglutition from the presence of immensely enlarged 
 tonsils. It is the respiratory tract which is the far more 
 frequently incommoded by their presence. 
 
 The occasional accident of swallowing artificial teeth, 
 the plate supporting them no longer fitting the gums from 
 
32 HUNTERIAN LECTURES. 
 
 absorption of the alveoli, and so becoming loose in the 
 mouth, is apt to produce serious symptoms, in reference 
 to which I would now say a few words. I have two cases 
 which illustrate these points practically. A young man, 
 in a very responsible situation as clerk to a solicitor, 
 had worn in the upper jaw, for some years, until it no 
 longer fitted the gum, a small gold plate, supporting three 
 or four artificial teeth. One night he woke suddenly, and 
 finding that the plate had slipped, he believed that he 
 had swallowed it. In his distress a surgeon was sent for, 
 who, after passing his finger into the pharynx, felt the 
 edge of the plate, and tried to withdraw it by the 
 forceps ; this failing after many attempts, he pushed what 
 he believed was the plate down into the oesophagus, and 
 thus by a bougie into the stomach. The next day I was 
 consulted on the case, and as there was no difficulty in 
 swallowing, I contented myself with recommending careful 
 dieting, the use of large quantities of porridge and other 
 bulky farinaceous food, so as to facilitate the passage of the 
 foreign body through the intestines, the rate of transit not 
 being in any way accelerated by the use of aperients, 
 which were strictly forbidden. This plan was very carefully 
 followed. Every effort was made, by the most scrupulous 
 inspection of the excreta, to find the gold plate, but 
 although this was done for many months, the patient 
 being extremely frightened about its non-appearance, at 
 last the search was discontinued. He resided some distance 
 from Manchester, and I heard nothing of him for rather 
 more than two years from the time of the accident. I 
 then received a message to say that after repeated attacks 
 of pleurisy and broncho-pneumonia, he died suddenly, and 
 it had been his own wish, as well as that of his friends, 
 that I should inspect the body, and clear up the mystery 
 as to what had become of the teeth. Accordingly, I went to 
 
SWALLOWING ARTIFICIAL TEETH. 33 
 
 the house, and made a prolonged post-mortem examination 
 in the presence of the surgeon who had attended him 
 almost continuously from the night of the accident. As 
 there had never been any urgent dysphagia, I proceeded 
 to open the abdomen, and to trace the course of the 
 intestines from below upwards. In the rectum, sigmoid 
 flexure, caecum and appendix, the large and small intestines, 
 and the stomach itself, all which parts were thoroughly 
 examined, no teeth could be found. Having carefully 
 examined the lungs and heart, and noted the disorganized 
 condition of the former, I laid open the oesophagus from 
 where the stomach had been cut away along its entire 
 length, until I entered the pharynx from below. No 
 sooner had I done this, and introduced my finger from 
 below upwards into the mouth, than I exclaimed to my 
 friend, " Here they are, lodged firmly on the front of the 
 pharynx, below the tongue ! I can feel the two ends of 
 the narrow plate quite smooth and firm!" Alas, my 
 diagnosis was at fault. It was not the plate at all. It 
 was vthe two cornua of the os hyoides, felt from ' within the 
 pharynx, which had thus deceived me. More minute 
 inspection with the finger, both when introduced through 
 the mouth and carried well backwards and downwards, 
 and then curled forwards ; and when passed upwards 
 along the oesophagus, gave quite the impression to the 
 touch of the presence of a foreign body with smooth firm 
 edges. We never found the teeth, and no one knows 
 where or how they went. But I learned a fact of some 
 value, which has served me well on other occasions. For 
 it was not very long afterwards that in our accident-room 
 at the hospital I found one of the house-surgeons with 
 forceps in hand, and the finger resting on the pharynx, 
 trying to grasp what he thought was a tooth, or the corner 
 of an artificial plate, in the throat of a young woman who 
 D 
 
34 
 
 HUNTERIAN LECTURES. 
 
 was said to have swallowed such a substance ; and I was 
 then able to convince him by defining the two cornua, one 
 on each side, with a space between, and also their relations 
 to the larynx, that within this living subject I had met 
 again this i^tis fatiius of the cornua of the hyoid bone. 
 
 One word more, and I will pass on to the last subject of 
 to-day's lecture. In all cases of asserted swallowing of 
 artificial teeth and the plate which supports them, be sure 
 that you can depend upon the declaration of the patient, 
 and that they really have been so swallowed, for the 
 sensation of their changed position in the mouth may be 
 emotional or imaginary, as this case will show. 
 
 On visiting our Infirmary one morning, I was told that 
 soon after midnight a case of swallowed teeth had been 
 admitted, although not into one of my wards. It was 
 placed, if I remember rightly, under the care of my col- 
 league, the late Mr. Dumville. It was a young married 
 woman who had worn artificial front teeth for some years, 
 and the plate had become loose, as such plates are apt to 
 do. She had gone to bed as usual, and awoke suddenly 
 after her first sleep, crying out that she had swallowed her 
 teeth and could feel them fixed in the throat, and could 
 hardly breathe, and she should die. Her husband got up 
 immediately, hired a cab, and brought her to the hospital, 
 where she arrived about two a.m. The house-surgeon on 
 duty passed his finger into the throat, felt what he supposed 
 was the edge of the plate, or the end of a tooth, and 
 applied the forceps with all due energy, producing some 
 haemorrhage, from injury to the mucous membrane. He 
 thought he had dislodged the teeth ; he passed a large 
 bougie into the stomach, and the patient was somewhat 
 relieved. When I saw her the next morning, she was 
 sitting up in bed, having a very anxious countenance, 
 fearing every moment the return of the spasmodic dyspnoea, 
 
DELUSIVE IMPRESSIONS. 35 
 
 but yet able to swallow fluids and soft solids, though 
 with a great deal of pain, no doubt from the instrumental 
 proceedings to which she had been subjected. She 
 remained in much the same state the whole of the day. 
 She spoke only in a whisper, and remained nervously 
 excitable in spite of the use of sedatives and the like. 
 The next morning I visited her with Mr. Dumville, if I 
 remember, about ten a.m., which would therefore be about 
 thirty-two hours after her admission. We were discussing 
 how we could best diet her and watch the case, so as to 
 trace the expulsion of the teeth, when suddenly her husband 
 rushed upstairs into the ward, in the greatest agitation, 
 saying they had found the teeth ! She had never swallowed 
 them ; for he told us that only a short time previously, on 
 moving a looking-glass on the dressing-table in her bed- 
 room, there were the artificial teeth, plate and all ! It was 
 quite evident she had taken them out as usual at night to 
 clean them ; they had slipped under the frame of the 
 looking-glass ; she had got into bed without them, and 
 fallen asleep, never discovering what she had done, 
 and becoming conscious only of the mistake when she 
 awoke suddenly in the night, and no doubt by some 
 rapid movement of the tongue, in an otherwise empty 
 mouth, became the subject of an irresistible erroneous 
 impression. It is well, therefore, always to be certain that 
 the circumstances of an accident are truthfully narrated. 
 
 We ought occasionally thus to place on record our 
 mistakes and failures, for by these we often learn more 
 than by success. In the former, difficulty has still to be 
 contended with ; in the latter, it has been overcome. 
 
 The last subject upon which I wish to speak to you 
 to-day is the operation for the removal of the tongue. 
 And as it will be impossible for me to treat of it in all its 
 aspects, I must needs confine my remarks to only a few of 
 
36 HUNTERIAN LECTURES. 
 
 the points of interest connected with it. First, as to the 
 diagnosis of the disease for which the operation has to be 
 practised, and next as to its mode of performance. I 
 cannot conceive the possibiHty of more than two conditions 
 under which this very formidable and serious operation 
 would be undertaken ; and they are either chronic or 
 subacute enlargement of the tongue, macroglossia, or the 
 early advent of malignant disease. I say " early advent," 
 because it can only be at that stage of the disease that the 
 removal of the tongue is justifiable, unless in very excep- 
 tional cases, where from intense pain, and perhaps from 
 the size of t!ie diseased growth, it might be resorted to as 
 a palliative measure. 
 
 Severe pain in this complaint can generally be relieved, 
 if not removed, by section of the gustatory nerve. It is 
 a procedure which may be regarded, with great propriety, 
 as the rule of practice for this special symptom. But, as 
 to the malignancy : where the case has advanced so far 
 that the glands are affected, we can never be positive 
 whether this state is occasioned by simple congestion, 
 irritation, or infiltration with secondary malignant deposit. 
 If the glands are enlarged from the latter cause, although 
 we remove the entire tongue, little benefit ultimately results, 
 seeing that here, as with other malignant growths and 
 secondary gland complication, unless the glands them- 
 selves are removed at the time of the operation, they 
 increase in size more rapidly afterwards than they would 
 have done if the primary growth itself had not been 
 touched. 
 
 It is only in the pre-glandular stage that I have seen 
 good permanent results from the removal of the entire 
 tongue. We may fail to find the enlarged glands if their 
 natural size is not much augmented. They may not be 
 perceptible to the touch when examined externally, either 
 
EXCISION OF THE TONGUE. 37 
 
 at the side, or somewhere below the chin. But by placing 
 one finger within the mouth beneath the tongue on 
 the floor of the cavity, and a finger of the other hand 
 opposite to it on the skin, a diseased condition of the 
 gland may be detected which would otherwise have been 
 easily overlooked. Yet I think in doubtful cases the best 
 method of investigation is to slice off" a portion of the 
 growth, examine it microscopically, and let the histological 
 evidence thus obtained decide its true nature, which the 
 naked eye could never discover. 
 
 In respect to the particular operation which we should 
 select, according as the removal of the tongue is to be 
 partial or complete, and the mode of its performance, 
 I can only say I still adhere to the remarks made in my 
 little monograph on the removal of the entire tongue,* in 
 which I advocate the method suggested by Mr. Walter 
 Whitehead, and greatly simplified in his hands. In this 
 as in many other operations, the principle upon which it 
 is to be conducted having been admitted, next come the 
 details, and these, as laid down by him, should be religiously 
 adhered to. 
 
 This is an operation which, more than most others, must 
 be done slowly and with deliberation ; each stage or step 
 should be completed before the next is entered upon. And 
 then it will be found to be an operation in the performance 
 of which, to use the words of Hilton, it may truly be said, 
 " Confiding in your anatomy, you have nothing to fear." 
 
 *" On the Removal of the Entire Tongue by the Walter White- 
 head Method" (1880). 
 
LECTURE II, 
 
 ON SOME OF THE INJURIES AND DISEASES OF THE 
 BLADDER AND GENITO-URINARY ORGANS. 
 
 IF there is one condition of the bladder which will give 
 a surgeon annoyance and distress, it is when he dis- 
 covers, either from some fault of his own, from neglect 
 in nursing, or from ignorance of those in attendance on the 
 patient, that he has to deal with a case of extreme disten- 
 sion with overflow, which has been overlooked. 
 
 I will relate three cases which have occurred to me, 
 and which will illustrate such a possible mistake and its 
 consequences. 
 
 Some years ago a medical practitioner whom I knew 
 very well, as very observant and attentive in his practice, 
 called upon me to arrange a consultation with this object. 
 He said a young lady was the subject of acute peritonitis, 
 and that he feared ascites had supervened, and, as she was 
 much inconvenienced by the distension of the abdomen, 
 paracentesis would be required for her relief. He told 
 me that he had been called to see her about five days 
 previously, when he found her in a feverish condition, in 
 great pain, and the abdomen intolerant of pressure. She 
 
SPASMODIC RETENTION OF URINE. 39 
 
 had on the previous day been at a pic-nic party in the 
 country, and might have sat upon damp grass, or in some 
 way received a chill or cold. He had collected some of 
 her urine, which now passed away from her involuntarily, 
 and found it slightly albuminous ; and he concluded that 
 she was the subject of chronic renal disease, and that this 
 might account for the rapid effusion of serum into the 
 peritoneal cavity. I therefore went to the house with all 
 the necessary appliances for tapping the abdomen. I 
 found the abdomen much distended, and, to all appearance, 
 equally so in all its diameters ; and I noted that poultices 
 were still applied to the surface, which was abundantly 
 covered with the bites of leeches, which had been freely 
 used. On pladng my hand upon the abdomen I was 
 horrified to feel what for the moment I thought might be 
 the outline of a distended uterus in the last month of 
 gestation, and that we had before us a case of concealed 
 pregnancy in an advanced stage. The needful inquiries 
 as to the catamenia soon disposed of that possibility, and 
 I then asked as to the passage of the urine. I was told 
 there had been difficulty in micturition for some days, and 
 even when first seized in the night with rigors and other 
 symptoms of distress, there was difficulty in passing water, 
 and the urine was voided frequently and in small quantities. 
 I suggested that I should use the catheter as a preliminary 
 means of diagnosis. Fortunately I had with me a female 
 catheter, which with some difficulty I passed into the 
 bladder, and then commenced an outflow of urine, which 
 did not cease until seven pints of dark-coloured and slightly 
 ammoniacal fluid had been removed. All the swelling, 
 I need not say, quietly subsided, and the patient was 
 immensely relieved. But there was another side of the 
 picture. The mother of the young lady was present in 
 the room and saw exactly what had occurred, and it 
 
40 HUNTERIAN LECTURES. 
 
 required all my ingenuity, in tracing the relation of cause 
 and effect, to shield my friend from the open accusation 
 that he ought to have done the same thing himself, and 
 that there had never been any peritonitis, but only from 
 the commencement, spasmodic retention of urine, caused 
 perhaps by exposure to cold, and paresis of the bladder 
 from over-distension. I heard no more of the case, except 
 that the patient quickly got well. 
 
 My next case was rather more complicated. I was 
 asked to go some distance into the country to see what 
 was said to be a tumour in the pelvis pressing upon the 
 rectum, and causing some abnormal symptoms. The 
 patient, a man of unhealthy aspect, was about sixty years 
 of age, and had suffered from pain in ^the back, and 
 difficulty in defecation for many months, and recently he 
 had had what, I was told, seemed to be dysentery, much 
 rectal tenesmus, and the passage only of mucus, with 
 which pus seemed to be mixed ; and on one occasion, a 
 few days before my visit, the pus was so much in excess 
 of the mucus, it was thought an abscess might have formed 
 and burst into the bowel. The surgeon in attendance had 
 attempted to make a rectal examination with the finger, 
 but the pain to the patient was so great he desisted, and 
 this caused him to think that the abscess theory was correct 
 But there was a peculiar feature in the case, to which we 
 could not but attach great importance. The patient had 
 been under observation for about three weeks. At the 
 end of the first week, that is about a fortnight before I 
 was called to see him, it was discovered that he had a 
 swelling on the left side of the pelvis, which could easily 
 be felt externally, and which had slowly increased in size, 
 more on the left than on the right side. It was painful on 
 pressure, and the point on which my opinion was asked 
 was as to its true nature, seeing that it had become larger 
 
SPASMODIC RETENTION OF URINE. 4 1 
 
 from day to day, like a rapidly growing tumour, possibly 
 cystic, possibly malignant. It was quite fixed, and so 
 tender on pressure that the existence of a pelvic abscess, 
 starting near the rectum and side of bladder, was still 
 open to discussion. On inquiry as to the passage of the 
 urine, it was admitted that for a very long time, far beyond 
 the date of the present illness, he had just that delay 
 and difficulty in micturition which attends upon enlarged 
 prostate in a man of his age, but there was no more 
 difficulty in this respect than there had been previously, 
 except that an attempt to void the urine brought on the 
 rectal tenesmus. I was shown a quantity of urine which 
 he had passed in the last twelve hours, and I could detect 
 nothing in its physical condition suggestive of bladder 
 complication. Still I thought it best to pass a catheter 
 to be sure on this point, for I was told this had not been 
 done because the disturbance seemed to originate chiefly 
 in the rectum. I had not with me a prostatic catheter, but 
 only the ordinary screw-up silver catheter which is carried 
 in a pocket-case, and this I much regretted, as I was some 
 distance in the country, several miles from where a prostatic 
 catheter could be procured. However, with great care and 
 gentleness I passed the instrument, and drew off nearly a 
 quart of urine, feebly acid, but decidedly not alkaline nor 
 ammoniacal ; and, as I did this, the one-sided tumour in 
 the pelvis entirely disappeared. I could then pass my 
 finger into the rectum, and found the prostate gland swollen 
 and tender, but not unusually so. It projected into the 
 rectum so as to form an obstacle to the descent of much 
 hard feculent matter collected above it. The true nature 
 of the pelvic swelling being thus disclosed, the after-treat- 
 ment of the case was not difficult. The condition of the 
 bladder was watched, the catheter was passed occasionally 
 to test the presence of retained urine, the movements of the 
 
42 HUNTERIAN LECTURES. 
 
 bowels were so regulated as to prevent undue accumulation 
 of hardened faeces, and all the more urgent symptoms were 
 permanently disposed of. 
 
 The third case I have to mention was much more acute 
 in its manifestations, and they also were such as naturally 
 to divert from, rather than to direct attention to, their true 
 cause. A gentleman, also about sixty years of age, a 
 foreigner, who could not describe his symptoms very 
 clearly in the English language, was on a certain day at 
 work writing, or talking, in his office, when he was seized 
 suddenly with vertigo, and afterwards with rigors, followed 
 by profuse perspiration. He explained that lately he had 
 often had rigors and perspiration, but it was the dizziness 
 and almost temporary, or very evanescent, loss of con- 
 sciousness which had now alarmed him. He was very stout, 
 and of full habit of body, and it was therefore feared that 
 he might be in danger of some cerebral symptoms of a 
 serious nature. He was taken home, and a physician was 
 sent for. Soon after the patient reached home and was 
 put into bed, he was very sick, and vomited a good deal, 
 and either from this cause, or from general distension of 
 the abdomen, he had severe pain in each groin. The 
 doctor in attendance, fearing the presence of hernia, sought 
 my assistance. I soon decided, in spite of his stoutness, that 
 none of the ordinary forms of external hernia were present, 
 and immediately began to inquire as to the condition of 
 his bladder. I was told he had passed an unusually large 
 quantity of urine, as was his habit, although he had lately 
 had increasing difficulty in so doing ; that is to say, the 
 act was unusually prolonged, but yet with a small stream, 
 he managed to evacuate great quantities of urine. In fact, 
 I was shown so large a quantity which he had recently 
 passed, that I could only get the medical attendant, also 
 a foreigner, to consent to my passing the catheter that we 
 
SPASMODIC RETENTION OF URINE. 43 
 
 might have the contested point finally settled, for I could 
 not pledge myself that any considerable amount of urine 
 was retained, since by reason of the obesity, neither per- 
 cussion nor palpation over the bladder yielded any positive 
 signs. However, from the previous case I had learnt 
 experience. I now had with me a vulcanized india-rubber 
 catheter, which I had made a part, and a very essential 
 part, of my surgical armamentoria. This I passed pain- 
 lessly into the bladder, and drew therefrom very nearly 
 five pints of urine, that is, an ordinary chamber utensil 
 almost full. The difficulty of breathing, and the feeling 
 of distension immediately subsided, and the patient, by a 
 series of expressions indicative of the deepest gratitude, 
 showed to me how much relief had accrued to him by this 
 simple procedure. The quantity of fluid which he drank, 
 and the quantity of urine which he passed were now 
 carefully watched, yet, in about three days, he was again 
 seized with the same symptoms of rigors, perspiration, etc. 
 I was sent for to relieve the bladder, but on this occasion 
 not so large a quantity of fluid had collected, and, after 
 this, his own attendant repeated the catheterism at shorter 
 and regular intervals, and the patient, by careful nursing, 
 ultimately did well. 
 
 It is only those who have long journeys to take for 
 professional purposes, away from the means of help which 
 are ever present in large towns, who can tell the comfort 
 of feeling, when called upon to perform an operation, that 
 they have with them all the requisites for success. 
 
 Among things which, when absent and most required, 
 would be most heartily welcome, is an efficient means of 
 emptying an over-distended bladder, in the male patient, 
 when a practitioner is many miles from home. Such an 
 instrument is shown in Plate II., Fig. A., packed up so 
 portably that no surgeon should travel without it. 
 
44 HUNTERIAN LECTURES. 
 
 These cases, you will observe, have been illustrations of 
 distended bladder with overflow ; but cases of absolute 
 retention, in which the bladder is full, and no urine can 
 pass, or does pass per urethram, will of necessity require a 
 different line of treatment. I will not stop to speak of 
 spasmodic retention, without or with physical contraction 
 of the urethral canal, but will proceed to say that where, 
 from any cause with a distended bladder, we cannot pass a 
 catheter, the operation of puncture of the bladder must be 
 performed, and it is open to the judgment of the surgeon 
 to decide which particular method he will adopt — puncture 
 per rectum, or puncture above the pubes. From my own 
 experience I incline very decidedly to the latter operation, 
 as it is the more cleanly of the two. You can see so easily 
 what you have to do, and how to do it ; and an instrument 
 with suitable appliances, can be much more easily retained 
 in the bladder through the front of the abdomen, than 
 through the bowel where the rectum is liable to be disturbed 
 in the performance of its functions. I have for many years 
 substituted the supra-pubic for the rectal puncture. In 
 either operation it is essential for its safe performance 
 that we should be positively certain the bladder is full. I 
 venture to make this remark because it does sometimes 
 happen that where a patient has suffered from chronic 
 disease of the genito-urinary tract, with previous attacks of 
 retention of urine, for which the catheter has been the relief, 
 a time has come in which he suffers from suppressed secre- 
 tion ; the kidneys have " struck work," as damaged kidneys 
 often will, and there may be little or no urine in the bladder, 
 and yet the absence of its expulsion has been put down to 
 retention in the bladder, whereas all the while it was really 
 caused by non-secretion from the kidneys. 
 
 When, however, there is unmistakable and complete 
 distension of the bladder, the operation of puncture above 
 
PUNCTURE OF THE BLADDER. 45 
 
 the pubes is neither dangerous nor difficult. I use for this 
 purpose a trochar and canula of special form, as seen in 
 Plate II., Fig. B., just long enough to secure their entrance 
 into the bladder, and with the cutting end of the trochar 
 so fashioned that it will make a lineal, vertical, and not a 
 triangular cut, which is then stretched into a circular form 
 by the progress of the instrument. The canula is made 
 large enough to permit the passage through it, on the 
 withdrawal of the trochar, of a vulcanized india-rubber 
 tube, Figs. C C, which can lie smoothly in the bladder, 
 and to which we can firmly fix a plate or shield, Figs. D D, 
 moulded to the curvature of the abdominal wall, and there 
 retained by elastic bands. To prove to you how long the 
 bladder will tolerate the presence of such a tube without 
 pain or inconvenience to the patient, in one case, in hospital 
 practice, where the patient was the subject of retention from 
 an extremely fine stricture, the supra-pubic paracentesis 
 was performed for his relief Five weeks subsequently I 
 performed internal urethrotomy, dilating his urethra up to 
 the capacity of a No. 16 English catheter, the intervening 
 time (during which the india-rubber tube was worn above 
 the pubes) being occupied by dilatation of his urethra, 
 from a condition almost impervious, to one sufficient to 
 permit the passage of the guide-bougie in advance of the 
 urethrotome. 
 
 In another case in private practice, in a gentleman with 
 immensely distended bladder, from large swollen prostate, 
 which resisted all attempts at catheterism, I punctured 
 above the pubes, and he wore the tube for thirteen weeks, 
 going to and from his business by railway. Eventually 
 the tube was removed, the resulting fistula closed, and 
 he can now empty his bladder very satisfactorily, although, 
 as a precautionary measure, a flexible catheter is passed 
 occasionally to measure the quantity of retained urine, and 
 
46 HUNTERIAN LECTURES. 
 
 to note how far it preserves its healthy acid reaction. It 
 has been remarked by those who have hesitated to puncture 
 the bladder per rectum, that they feared they might leave 
 their patient with a permanent recto-vesical fistula ; but 
 the reply has always been that such fear is groundless, the 
 difficulty being, not to secure, but oftener to prevent, the 
 closure of the rectal puncture ; for if the tube falls out, it 
 is not easily replaced. The same observation would apply 
 to the supra-pubic puncture. I have done it many, very 
 many, times, and I never knew the resulting fistula fail 
 to heal. The only practical objection I have known urged 
 against supra-pubic puncture of the bladder, is that the 
 opening is not so favourably placed as that per rectum for 
 the drainage of the bladder. Assuming that the patient, 
 after the operation, is to remain always upon his back, 
 there is great force in this objection. But with the supra- 
 pubic puncture it is not difficult to set up an arrangement 
 of elastic rubber tubing on the syphon principle, which will 
 drain off the urine so completely as to leave the bladder 
 practically dry. Or, if the patient lies on his side, the 
 drainage can still go on, the instrument being safe from 
 injury. The bladder, moreover, is not punctured near to 
 its most sensitive part, as by the rectal operation, but on 
 its anterior wall, where it is endowed with the least amount 
 of sensitiveness. There is a modification of the rectal 
 operation, where the bladder is entered at the lower and 
 posterior part, which I have performed on two occasions, 
 once with great success, but in the other it failed. The 
 patient sank in a few days from uremic mischief There is 
 another more recent method of puncturing the bladder 
 in prostatic retention, recommended by my friend Mr. 
 Reginald Harrison, of Liverpool, in which, without any 
 preliminary incision, he drives a long trochar and canula 
 through the perineum and the prostate gland, until the 
 
INFANTILE PHYMOSIS. 47 
 
 bladder is reached. The canula is then replaced by a silver 
 tube, the latter can be borne easily by the patient, and 
 will form a ready means of emptying the bladder, to his 
 immense relief. I wish to invite attention to this mode of 
 operating, because Mr. Harrison's observations lead to the 
 conclusion that direct puncture of the prostate gland may 
 subsequently induce atrophy and general wasting of that 
 organ, and so ultimately restore to the prostatic portion 
 of the urethra some of its normal capacity. So that as 
 in the case of the gentleman I have already mentioned, 
 the urethral canal, especially in its prostatic portion, being 
 spared for many weeks or months, the incessant irritation 
 of the passing urine, the chronic congestion of the part 
 may subside, and a more free and capacious condition be 
 restored to it. It is the possibility of such a happy 
 result following upon Mr. Harrison's operation that has 
 led me to watch, with great interest, how far extended 
 experience shall confirm this opinion. 
 
 Early in life, obstruction to the passage of the urine 
 may be caused by contraction of the orifice of the prepuce. 
 This is liable to increase rather than diminish as the infant 
 grows, from the circumstance that every time the urine is 
 passed a drop or two remains in the space which exists 
 between the glans penis and the prepuce. Here the stag- 
 nant urine is apt to undergo ammoniacal changes, and then 
 it inflames the delicate epidermis, which is quickly shed 
 off, and not unfrequently adhesions result between the two 
 surfaces, still further complicating the case. Circumcision 
 in the child, and for the adult, that modified operation for 
 division of the prepuce so well suggested by Mr. Furneaux 
 Jordan, of Birmingham, will at once get rid of any impedi- 
 ment to micturition due to such causes. In an infant, a 
 contracted prepuce, like a strictured urethra in an adult, 
 must cause straining in the evacuation of the bladder. This 
 
48 
 
 HUNTERIAN LECTURES. 
 
 in early life, may lead to inguinal hernia on one or both 
 sides, where the funicular process of the peritoneum has not 
 been firmly closed. It is, therefore, at all times prudent, as 
 a preventive measure, to circumcise a child in whom the 
 prepuce balloons out while the urine is passing, as such a 
 condition indicates obstruction to its outflow. 
 
 Hernia in very early life, that is, in an infant aged only 
 a few months, is difficult to treat with an ordinary truss, 
 the pressure and the counter pressure 
 to be exerted being so much more 
 than can be tolerated by the tender 
 skin. The wetting of the parts by 
 the urine is another great difficulty, 
 although here modern science has 
 helped us immensely. When urine 
 becomes alkaline it irritates the sur- 
 faces with which it comes in contact, 
 '1 but this can be so perfectly prevented 
 V by the use of boracic acid in powder, 
 .'\ or in solution, that this one difficulty 
 , may be said to be thoroughly disposed 
 of. The truss, or the mechanical 
 appliance which I would specially 
 recommend for the relief of inguinal 
 hernia in the infant, is certainly the 
 worsted truss, a mode of treatment 
 little known I have reason to believe, but yet very simple 
 and effective. It is described in Ranking's Abstract, vol. ix., 
 p. 131. I have used it in several cases where I have been 
 consulted on the subject of the early appearance of inguinal 
 hernia in young infants. Worsted known as " Berlin wool" 
 is made into a skein of twenty threads, which, stretched 
 out straight, shall be about twenty-two inches long, the 
 threads being tied across at intervals of two or three inches 
 
HERNIA IN THE INFANT. 49 
 
 to keep them together. One end of the skein is placed 
 over the abdominal rings through which the hernia has 
 escaped ; or, if scrotal, it must be reduced, and, if the child 
 should cry much, pressure made over the spot. The folded 
 worsted is passed horizontally across the abdomen over the 
 line of the crest of the pubes, to the opposite side, round 
 the hip behind the pelvis, and over the hip on the side of 
 the hernia. The folded end is then passed through the 
 loop of the skein, and will here form a knot or bulged 
 portion, which must then be carefully adjusted so as to lie 
 against the hernial opening, and being carried down the 
 upper part of the thigh, between it and the scrotum, if it is 
 a male child, it is brought round the external side of the 
 thigh, near to the top of the great trochanter, and there 
 tied, or fixed with a safety pin, to the band of worsted 
 already round the pelvis. With a little care this arrange- 
 ment of the worsted may be used as an excellent defence 
 against the distension of a weak inguinal canal, and the 
 descent of a hernia into the scrotum. It is not powerful 
 enough, nor could it easily be kept in position when the 
 child is old enough to run about; but, on the principle that 
 prevention is better than cure, it is a means of relief to 
 which we can have recourse at a very early date, certainly 
 before we could submit the infant to the pressure of an 
 ordinary hernia truss, however weak the spring might be. 
 It has this one advantage, that the infant can be washed 
 with the truss still on. A fresh truss can then be appHed, 
 the old one cleansed, and used again. 
 
 While upon the subject of hernia in infants, I may refer 
 to the management of umbilical hernia, a very common 
 affection, generally treated by pressure of a pad of ivory 
 or other hard material, over the opening, to prevent the 
 protrusion of the bowel. It is quite evident that this is 
 wrong in principle, as it must tend to enlarge the opening, 
 E 
 
50 HUNTERIAN LECTURES. 
 
 although it may prevent increase of the hernia. As the 
 probable cause of this protusion is undue space between 
 the recti muscles near to the umbilical aperture, the hernial 
 protrusion can be controlled with perfect certainty by 
 drawing the two recti muscles together, and thus closing 
 the opening. To effect this, take two strips of adhesive 
 plaister, each about three-quarters of an inch wide, and six 
 to seven inches long, the plaister being of such a quality as 
 shall adhere firmly, and place one on each side of the 
 abdomen, as shown in the woodcut, one half only of each 
 being first applied to the skin ; then, if after reducing the 
 hernia, the strips are drawn tightly across the abdomen. 
 
 and so fixed, perfect closure will result. They ought to be 
 renewed frequently, and not placed every time exactly on 
 the same line of skin, lest it become abraded. 
 
 The diagnosis of calciUiis vcsiccB or the presence of a 
 foreign body in the bladder introduced from without, and 
 the fact denied or concealed from the surgeon, is occa- 
 sionally a difficult and delicate subject for investigation. 
 It is of the gravest importance that we should not be led to 
 declare, trusting only to the subjective indications of the 
 case, that a foreign body or calculus is present, unless the 
 proofs be beyond the possibility of doubt. Far better to 
 say, " A calculus or foreign body may be present, but as 
 yet I cannot get absolute proof thereof," than to say, " This 
 
CALCULUS VESICAE. 5 1 
 
 patient has a foreign body or calculus in the bladder," then 
 proceed to operate, and have at last to admit an error of 
 diagnosis made too hastily. Usually, the pain produced 
 by the presence of a foreign body or a calculus, comes 
 on when the bladder is emptied, and the sensitive portion 
 of its interior surface is pressed powerfully against the 
 substance, or it is intensified by the act. But there may 
 be sources of error. I once had under my care a man 
 about sixty-four years of age with vesical disease, due to 
 enlarged prostate, with all the usual signs and symptoms. 
 The abnormal condition of the prostate could easily be 
 verified by digital examination per rectum ; but it was one 
 of those cases in which the prostatic symptoms masked the 
 vesical — that is, he had frequent and urgent desire to pass 
 urine, which was almost intolerable if not indulged in ; but 
 as soon as an ounce or two of urine had been voided, all 
 pain ceased, and he had immediate relief The power also 
 to void the urine was good, and in proof that the urethral 
 canal, in its prostatic portion, had not been much distorted 
 or disturbed from its natural course, there was no hitch or 
 difficulty in passing a full-sized silver catheter, and the 
 urine was clear and with fair acidity. There was no pain 
 at the close of micturition, no interruption in the outflow 
 when once established, and there was ease from trouble 
 when the bladder was empty. 
 
 Yet with these negative signs of stone in the bladder, 
 careful examination with a short-beaked sound, turned 
 backwards towards the rectum, gave the usual click indi- 
 cative of calculus. The calculus was removed by lateral 
 lithotomy, and it was found to have been so moulded to 
 the neck of the bladder above the base of the prostate, as 
 to have been protected from pressure on the collapse of 
 the bladder, and perhaps kept permanently in one place 
 by its peculiar shape. It was a calculus chiefly composed 
 
52 HUNTERIAN LECTURES. 
 
 of uric acid and urates, with a thin layer of phosphates, 
 which might soon have increased in thickness, had active 
 cystitis been set up. This fixing of a calculus in the 
 bladder, not due to sacculation of the bladder, while 
 masking the symptoms, may save the patient great increase 
 of pain in the ordinary movements of the body. I have 
 observed in young subjects, that a mulberry calculus, with 
 many spicula present upon the surface, may not occasion 
 those severe shooting pains every time the patient moves, 
 which occur so frequently where the calculus^ is smooth, 
 and can roll about freely in the bladder. 
 
 But a contrary condition may exist. There may have 
 been the symptoms of calculus without its presence. In 
 advancing age, and even in the young, there may be a 
 combination of circumstances which will bring about 
 symptoms collectively very suggestive of stone in the 
 bladder, yet due only to chronic inflammation of the 
 mucous membrane of the prostatic portion of the urethra. 
 This I have seen come on in the middle-aged, where a 
 stricture existing far back in the membranous portion of 
 the urethra had caused such stretching and dilatation of 
 the prostatic portion, as to set up signs and symptoms of 
 stone in the bladder, all of which subsided permanently on 
 the division of the stricture, and the re-establishment of 
 full calibre to the urethra. 
 
 A foreign body may have been passed into the bladder ; 
 its presence there may set up cystitis and many urgent 
 symptoms, and the patient may deny the possibility of 
 such an accident, and thus, the diagnosis being obscure, 
 effective treatment may be delayed. I know of two such 
 cases, A boy about ten years old, out of mere wantonness 
 of purpose and sheer thoughtlessness, imagined he could 
 pass a piece of india-rubber tubing along his penis, and 
 propel urine through it to intensify the natural jet d'eau. 
 
I 
 
FOREIGN BODIES IN THE BLADDER. 53 
 
 He did this, as he afterwards confessed, in a dark closet, 
 and while he was so occupied he thought either that the 
 piece of tubing fell out of the penis, and was lost with the 
 outgoing stream of urine, or that it had slipped into the 
 bladder. Twelve hours afterwards he had acute retention 
 of urine. A surgeon was sent for ; he drew off a large 
 quantity of urine with an ordinary metal catheter, detecting 
 nothing unusual, as the boy had not then confessed what 
 he had done. Soon afterwards he began to suffer much 
 pain in the region of the bladder, and he was sent into the 
 hospital. 
 
 On the most careful sounding nothing could be felt. But 
 fortunately, just at this time. Dr. Cruise, of Blackrock, near 
 Dublin, had selected for me one of his endoscopes of a very 
 complete form, and I used it in this case, while the patient 
 was under chloroform, with great success. I could see that 
 there was a foreign body in the bladder, but I could not 
 then say what it was, for the boy told me he had passed a 
 piece of india-rubber tubing such as is used for feeding- 
 bottles for infants, and I expected to find it of a black or 
 grey colour, whereas what I saw through the window of 
 the endoscope-tube was decidedly red or yellow. The 
 boy's description of what had really happened was so 
 inconsistent in many respects that I began to doubt the 
 whole statement, and to think the "tale of the tube" was a 
 fabrication, and that it was a case of one or more calculi 
 somehow so fixed in the bladder as not to be easily touched 
 by the sound. 
 
 All doubt was removed when I had performed external 
 urethrotomy, and with fine long forceps drawn out a piece 
 of india-rubber tubing of a red colour, which, when laid on a 
 flat surface, was found to have been curved so as to present 
 part of a circle five inches in diameter, Plate III., Fig, A. 
 When he was examined, the end of the beak of the sound, 
 
54 HUNTERIAN LECTURES. 
 
 revolving within the limits of this circle, could not touch 
 the tube, or, if it did so, it would not encounter any 
 resistance, or produce any audible impression. 
 
 It is worthy of remark that this tubing, which had been 
 in the bladder nearly thirty-nine days, had not become 
 encrusted with phosphates or any secretion from the urine 
 to an appreciable amount, for, if such had been the case, 
 the rough surface thus produced would have enabled us to 
 detect its presence when it was touched by the sound.* 
 Vulcanized india-rubber being almost imporous, will not 
 retain any urine to undergo ammoniacal changes. This is 
 a circumstance of some interest in connection with the 
 toleration by the bladder of foreign bodies introduced 
 from without, of which the following case will afford an 
 illustration. 
 
 Many years since, a gentleman over twenty years of age, 
 being of a nervous, excitable temperament, imagined that 
 he had stricture, because, when wishful to pass water, if 
 others were present, he could not do so. In a moment of 
 weakness he wrote a full description of his symptoms to 
 one of those rascals who, under the cloke of professional 
 position, impose shamefully upon the unwary, to their own 
 advantage. A long correspondence from some part of 
 Yorkshire with a quack in London was the result, and 
 being told that if he would come to London he could be 
 cured by passing instruments to dilate the water-passage, 
 he attempted the same himself by the introduction of 
 a short piece of ivory, which was intended to be used 
 as the handle of a crotchet-needle. By some mishap the 
 ivory slipped along the urethra beyond his reach, and 
 passed into the bladder. I was consulted on the case, and 
 with the information given to me, and the fact of the 
 hardness of the ivory securing a proper ring or click, I was 
 
 * "British Medical Journal," July 31st, 1869. 
 
FOREIGN BODIES IN THE BLADDER. 55 
 
 certain that the foreign body was in the bladder, where it 
 seemed to have placed itself crosswise in the cavity. There 
 was this difficulty in the management of the case. The 
 patient being greatly ashamed of what he had done, I was 
 earnestly requested not to mention the circumstance to 
 any of his friends ; but if possible, by any means, to extract 
 the ivory from the bladder. I, therefore, as expense was 
 no object, placed myself in correspondence with Mons. 
 Charriere, the celebrated instrument-maker, in Paris, and 
 obtained from him forceps of various forms, which by 
 ingenious construction could be made to place such an 
 object as a piece of tobacco-pipe, or this ivory rod, in the 
 same line as the axis of the forceps, even if seized at first 
 transversely, and so it was to be drawn out of the bladder 
 per urethram. I need hardly say all our efforts failed to 
 remove the ivory in this way, and at last it was thought 
 best to desist from further attempts, and to await results. 
 Now, a curious point in the case was the absence of pain, 
 and the absence of any of the usual symptoms of cystitis. 
 If I had not had the history of the case before me, and 
 the physical sign of the sounding, I should have thought, 
 for the time at least (this was from two to three weeks 
 after the occurrence), that it was a case of malingering or 
 imposture, had there been any possible incentive to such a 
 course. The patient went home, into Yorkshire, and there 
 remained for nearly five months, when, having after this 
 long interval begun to develope distinct bladder symptoms, 
 in the way of frequent desire to pass urine and pain after 
 the act, he was brought to me by his friends as if it had 
 been a fresh case, and I immediately arranged to operate for 
 stone, which I at once diagnosed. When the time arrived, 
 lithotomy was performed, and I found much phosphatic 
 deposit around the piece of ivory, which I likewise removed, 
 Plate III,, Fig. B., and in due course he went home per- 
 
56 HUNTERIAN LECTURES. 
 
 fectly well. The phosphatic deposit was shown to his 
 friends as an example of a stone as soft as mortar, and it 
 was only the patient who, to his great delight, saw the 
 piece of ivory, and the medical man who attended the 
 family, and who had come a long distance, expecting to 
 witness an ordinary operation for stone. 
 
 My object in thus minutely describing the progress of this 
 case is to show that as the ivory was a hard, compact sub- 
 stance, it did not absorb into its pores the old or stale urine 
 which remained around it every time the bladder contracted. 
 Thus the ivory produced at first a very slight amount of 
 irritation, at any rate not enough to excite inflammation of 
 the mucous lining of the bladder and ammoniacal changes 
 in the urine ; and the patient went on tolerating the presence 
 of this foreign body in the bladder for a far longer time than 
 ever could have occurred, had it been of a soft absorbent 
 nature, and constantly saturated with retained urine. 
 
 I mentioned this case to the late Mr. Propert, and he 
 told me of one very similar in its progress, which he had 
 known in his own practice. A young gentleman, as Mr. 
 Propert said, for reasons best known to himself, passed a 
 small stick of red sealing-wax up his urethra ; a portion of 
 it broke off, and was in some way carried onwards into the 
 bladder. He came to Mr. Propert, the medical attendant 
 of the family, and made a full confession of his misfortune. 
 He was taken to Sir Benjamin Brodie, who made several 
 attempts either to crush or remove the sealing-wax, and in 
 some way failed to do so. Here also, the true state of 
 things was concealed from the friends of the patient, who 
 was engaged to go out to India, and as nothing could be 
 done for him, and he hardly suffered any inconvenience, 
 he went abroad. Nothing was heard from him of an 
 unfavourable nature until he had been in India for several 
 months, and then a report arrived that the youth was said 
 
SUPPOSED CALCULUS VESICA. 57 
 
 by some doctor whom he had consulted in India, to be the 
 subject of stone in the bladder in its early stage, or at any 
 rate to have many of the symptoms of it. Mr. Propert 
 was asked what should be done ; and he replied, " Let him 
 return at once to England, and consult Sir Benjamin 
 Brodie." This was done, and I need not say, as the 
 anecdote was told me about the year 1849, that travelling 
 from India was in those days a more tedious proceeding 
 than at present. On his arrival in England, after due 
 preparation. Sir Benjamin Brodie cut into the bladder, and 
 removed therefrom a mass of phosphatic concretion, with 
 the piece of sealing-wax as its nucleus. The patient made 
 a good recovery, and so ended the romantic history of 
 a very remarkable case. 
 
 This reminds me of what I said in my former lecture, in 
 regard to the little boy with a pebble for so many days 
 beneath the skin of his forehead, without visible signs of 
 irritation. The absence of symptoms of its presence must 
 have been due to the solid compactness of the foreign body 
 there placed. Had it been soft or spongy, or if, in its 
 intrusion, it had carried such matters with it, it would 
 doubtless have set up inflammatory action, running quickly 
 on to suppuration or ulceration. 
 
 Lastly, there are cases in which, unless certain precau- 
 tions are observed, the diagnostic sign of a metallic click 
 being taken as a positive proof of the presence of a calculus 
 in the bladder, may give a deceptive impression, and lead 
 to erroneous conclusions. This, in my experience, has 
 only occurred in the female bladder, and from the nature 
 of things, and the special conditions necesssary to its pro- 
 duction, could hardly happen in the male subject. I refer 
 to the fictitious production of a metallic click in the female 
 bladder, under such circumstances, with entire absence of 
 any calculus or foreign body within. I will relate a case. 
 
58 HUNTERIAN LECTURES. 
 
 I was requested to visit, in consultation with a physician, 
 a lady who had suffered from bladder-symptoms such as 
 are associated with calculus, and arranged to go to her 
 house, and examine her, with the object, if possible, of 
 deciding the question, stone or no stone, and the cause 
 of her distress. I found a married lady, aged about forty 
 years, the mother of several children, who had been 
 confined to bed for some weeks, with many hysterical 
 symptoms, and among others, great frequency in the 
 desire to pass the urine, and great pain and straining 
 afterwards. After a general examination of the case and 
 learning its history, I passed an ordinary nearly straight 
 female catheter, that is, one curved on a section of a circle 
 of about ten inches in diameter, and drew off an ounce or 
 two of urine already in the bladder, for special examination. 
 I then injected warm water through the catheter, and 
 I believe, that as it was a female bladder, and I myself 
 was a little thoughtless in the matter, I injected more than 
 was needful. I have no doubt it was nearly ten or twelve 
 fluid ounces. This having been done, I removed the 
 catheter, and introduced a sound, but with all my care, no 
 click could be obtained, and no calculus felt. I withdrew 
 the sound, saying to the doctor who was standing near 
 the foot of the bed, how satisfactory it was, and that it 
 simplified the case, as no special operation would be re- 
 quired. I then proposed that I should draw off the water 
 I had injected, so as to save the patient the pain of passing 
 it. Accordingly I re-introduced the same metal catheter. 
 I placed my forefinger at the end of the catheter until a 
 small vessel could be procured into which to receive the 
 water I was about to withdraw. I lifted my finger ; the 
 water escaped with some force, the bladder contracting 
 powerfully. I again put my finger on the end of the 
 catheter to stop the stream, when just as I suppose I was 
 
SUPPOSED CALCULUS VESICA. 59 
 
 using the instrument as a sound to strike any loose material 
 floating in the stream of water, an audible click was heard, 
 not only by myself, but by the doctor at the foot of the 
 bed, four or five feet distant. This I repeated two or three 
 times, and every time with a distinct click and rebound, as 
 if something had suddenly struck the end of the catheter. 
 We felt therefore, now, that there was no doubt that a 
 calculus was present, and it ought to be removed. A day 
 was fixed — the next day, or the day after, and the patient 
 was placed under chloroform in the lithotomy position. I 
 passed the sound into the nearly empty bladder; no indi- 
 cation of the presence of stone was manifested. I then 
 injected the bladder through the catheter, used it as a 
 sound, and got repeated audible indications of what all 
 thought was due to the presence of calculus. I incised the 
 upper wall of the urethra, dilated it slowly with Weiss's 
 dilator, introduced the forefinger into the bladder, explored 
 it in every possible direction ; but neither stone, nor con- 
 cretion, nor foreign body, could be discovered. After these 
 fruitless efforts, in a very desponding state of mind as 
 you can well imagine, I gave up the search, made the best 
 explanation I could to the friends, and retired. The urine 
 passed away from the patient involuntarily for several 
 days, then the natural power of retention returned ; and, 
 whether from the excitement of the operation, with the 
 preparations beforehand and the treatment afterwards, I 
 know not, but so it was; she lost all her bladder symp- 
 toms, and at last completely recovered ; but certainly it 
 was not from any calculus that I had removed ; nor had 
 she, to the best of my belief, ever had one. 
 
 You may be sure I lost no time in making experiments 
 to see how such an error could have been made, and by 
 what combination of circumstances so fallacious a sig-n 
 could have been created. 
 
6o HUNTERIAN LECTURES. 
 
 The conditions, you note, were these : the instrument 
 in the bladder when the dick was heard, was the catheter 
 used as a sound, and as it was hollow, and very slightly 
 curved, the water in the bladder could pass along it with 
 little resistance. The bladder was irritable, and possessed 
 great expulsive power. So long as the water flowed out 
 freely in a continuous stream, no concussion was produced ; 
 but, as I afterwards proved most indisputably, every time 
 I suddenly stopped the outgoing stream by touching the 
 mouth of the catheter with my finger, an audible concussion 
 was produced to a degree no one, I am sure, who had not 
 heard and felt it, could credit without direct demonstration. 
 I repeated the experiment several times on various patients 
 in the hospital, and always with the same results, provided 
 the expulsive power was great, and the stream of fluid 
 which escaped was flowing rapidly at the moment of 
 arrest. 
 
 I may say that these are conditions similar in principle 
 to the rebound and noise occasioned in an ordinary water- 
 pipe, where a shut-off tap is suddenly closed while from 
 high pressure in the water-main the water is escaping with 
 great force. I have never been able to produce this 
 condition when using a long male catheter, with the usual 
 right-angled curve ; but with a nearly straight female 
 catheter, under the circumstances referred to, it might 
 become to others, as it was to me, a source of fallacy, if, 
 forgetful of what I have said, they were content to sound 
 a female bladder with a hollow sound, and to allow any of 
 the fluid to escape while manipulating with the instrument. 
 
 I desire now to make a few remarks on the subject of 
 Stricture of the urethra, to which the attention of surgeons 
 is often directed. First, as to its etiology. Where it is the 
 result of injury, we can easily understand how the capacity 
 
STRICTURE OF THE URETHRA. 6 1 
 
 of the canal should suffer, by the slow and inevitable 
 contraction of the cicatrix produced at the injured part. 
 And this will remind us of the interesting fact that while 
 wounds of the urethra, the result of accident, are constantly- 
 followed by slow contraction of the canal, wounds made in 
 operations on the urethra, as in the removal of small calculi 
 fixed in some part of the spongy portion, or median 
 lithotomy, which is really external urethrotomy of the 
 membranous portion, and the incisions made internally in 
 internal urethrotomy, are not necessarily productive of the 
 same permanent contraction. To account for this, it is 
 supposed that when the urethra is ruptured, the laceration 
 usually occurs in the membranous portion, and transversely 
 to the direction of the canal. This causes contraction, 
 whereas all the other forms of wounds being parallel to its 
 axis, are not succeeded by permanent narrowing of the 
 urethra. 
 
 It has occurred to me that some other factor or cause 
 must be sought for to explain the contractions which 
 follow injury, as compared with wounds made in operations. 
 The membranous portion, the part most frequently torn 
 in injury, is surrounded by muscular fibres, which have 
 naturally a tendency to compress the tube, as well as to 
 sling it and draw it up under the pubic arch. These fibres, 
 at the moment of the injury, will be so displaced as to lift 
 or pull a part only of the canal upwards, while the other 
 portion may remain unchanged in its position. Here a 
 difficulty is at once created, either for the outflow of the 
 urine, or for the passage inwards of an instrument along 
 the urethra, because at the injured part the two portions 
 of the tube so broken have ceased to be opposite to each 
 other, or in one continuous line. How far these changes 
 may be due exclusively to muscular action, or whether or 
 not, in some cases, effusion of blood outside the urethra, in 
 
62 HUNTERIAN LECTURES. 
 
 the deep parts of the perineum through which the urethra 
 passes, may contribute to the displacement, are questions 
 very difficult to answer. Most probably it is because the 
 two portions of the tube are no longer, after injury, exactly 
 opposite to each other, that it is so difficult to pass the 
 instrument along a urethra so damaged. 
 
 This accident often happens to young boys, from their 
 walking on the edge of palings or on narrow beams, and 
 then suddenly falling astride of them. Here, after all 
 immediate treatment has ceased, it is at all times the duty 
 of the surgeon in attendance, to urge upon the parents of 
 the child the grave necessity of constant attention to the 
 condition of the canal, so as to avert, if possible, the con- 
 traction which will almost inevitably result. And this 
 advice will be more important, and its observance is more 
 likely to be attended by good results, if it is followed out 
 just as the boy approaches the age of puberty. 
 
 I have watched the progress of many such cases for 
 years after the accident — several in hospital, some few in 
 private practice. In many of these cases, where it has 
 been only possible at intervals of four or five months to 
 pass a small No. 4 English catheter — and even this with 
 difficulty, — I have noticed as soon as the boy began to 
 grow, and there were the usual signs of puberty, then was 
 the time specially to persevere in dilating the urethra, and 
 so to secure a more capacious and extensible canal. It is 
 just at this period of life that I have found the treatment 
 by gradual dilatation to be the most successful ; whereas, 
 if then neglected, and adolescence is attained, the cicatricial 
 contraction follows the law I have already mentioned. It 
 grows with the growth of the subject of it, and it is apt 
 to retain its proportionate or relative size. 
 
 Thus much for traumatic stricture, and its certain conse- 
 quences if not contended with by art. It is essentially 
 
STRICTURE OF THE URETHRA. 63 
 
 Cicatricial in its progress, and the question arises how far are 
 all urethral contractions similar in nature, only varying in 
 degree. No doubt the canal of the urethra becomes con- 
 tracted, and loses its expansibility, at certain spots where 
 previously there had been intense inflammatory action, 
 and this narrowing of the lumen of the urethra may be 
 due to deposit of lymph outside the mucous membrane in 
 the sub-mucous tissue, as a ring or band around it ; and 
 this, in course of time, may contract so as to form a smaller 
 ring, and so compress the urethral channel still more 
 positively. 
 
 It has often been observed that stricture of the urethra, 
 as one of the sequences of urethritis, much more frequently 
 occurs in cases in which the inflammatory changes have 
 been present for weeks or months, than in cases in which 
 it was much the more intense, but lasted for only a fraction 
 of the time. It is highly probable that in the tedious cases 
 the influencing changes have advanced to the destructive 
 stage of ulceration in one or more of the tissues involved ; 
 and that, as a result of this, when at last they have ceased, 
 the part so injured has been left in a condition practically 
 comparable to that of the cicatrix of a scald or burn, with 
 all its tendency to steady contraction. 
 
 There is yet another process by which the urethra may 
 have become strictured as the result of previous inflam- 
 mation, where that process has run on to the destructive 
 or ulcerative stage. We must not forget that all mucous 
 canals, except those belonging to the respiratory system, 
 have their opposing surfaces in near, if not in actual contact, 
 except when the canal is in a condition of functional 
 activity. The urethral canal is no exception, but rather a 
 good illustration of this condition. In a state of rest, no 
 urine passing along the passage, and no foreign body or 
 exploring instrument being within it, the two surfaces of 
 
64 HUNTERIAN LECTURES. 
 
 the flattened canal are in immediate contact. It is true 
 that the line of the folded portion is not in the entire length 
 of the canal placed in the same direction as at the orifice 
 and for a short distance within it. When traced backwards 
 from the orifice, it is first placed vertically in the axial line 
 of the body; but after this, the direction of the fold is 
 transverse, and the urethra is compressed so as to present 
 one surface which may be called pubic, resting in contact 
 with another, which is perineal. 
 
 Now, imagine, as a consequence of destructive inflam- 
 matory changes, that the epithelial layer of the mucous 
 membrane at one or more spots has been destroyed ; and 
 that, as a still further result of the inflammation, the papil- 
 lary layer has also given way, and even the sub-mucous 
 tissue has been laid bare. If these surfaces can touch each 
 other, and remain in contact, hour after hour, in the intervals 
 of micturition, when, by the outflow of the urine, a partial, 
 not perhaps a very extreme separation of the surfaces 
 will occur — we cannot wonder if they unite by adhesive 
 action, and thus form either a bridle of new tissue extend- 
 ing between them, or lead to a perfect fusion of the surfaces, 
 with diminution in the expansibility of the canal. And it 
 is very probable, I think, that such is the case, and that 
 from the folded form of the urethra in its quiescent con- 
 dition, such adhesions are more likely to occur at the sides, 
 where the angles of the fold exist, than in the centre. 
 Thus would I explain the fact that in a tightly-strictured 
 urethra, where we can barely pass a small flexible bougie, 
 it may require to be guided alternately to one or the other 
 side of the urethra before it can be made to reach the 
 bladder. This, I believe, is the true etiology of stricture ; 
 it is not a simple pushing in of the mucous membrane 
 towards the centre of the canal by the deposit of lymph 
 on its exterior surface, the result of inflammation in the 
 
STRICTURE OF THE URETHRA. 65 
 
 sub-mucous layer ; but it is rather destruction of tissue, 
 followed by cicatrization and contraction. I would not say 
 that such lymph-deposit may not exist, and that by a 
 process of healthy absorption the lymph so effused may not 
 subsequently be removed, and the canal restored completely 
 to its former capacity. Yet I fear this happy result is of 
 very rare occurrence, and the old remark, "Once strictured, 
 always strictured," is not far from the truth. 
 
 It is not needful to enumerate all the changes which 
 creep on insidiously in these cases, slowly advancing 
 year by year to the inevitable result of damaged urethra, 
 damaged bladder, and damaged kidneys. I would rather 
 suggest a method of dealing with them by employing 
 what I would call " the treatment by anticipation," so as 
 to check, in the earliest stage, the commencement of such 
 dangerous effects. 
 
 Independently of traumatic causes, stricture of the 
 urethra may be produced organically, as it is called, as 
 a consequence of some previous inflammation, most usually 
 that of gonorrhoea. 
 
 The longer this inflammatory condition has lasted, the 
 more likely is the subject of it to suffer from contracted 
 urethra. The inflammation is said to depend on a specific 
 cause, which is eminently infective, and in which there 
 exists a septic condition of the mucous membrane. 
 
 The most successful agents which we employ in the 
 treatment of specific urethritis are in their nature more or 
 less antiseptic. To prove this point, I need only name 
 the chloride of zinc as an injection of carefully adjusted 
 strength in acute cases, and the bichloride of mefcury in the 
 more chronic. Even with regard to copaiba, so often given 
 internally to control the inflammation and thus to moderate 
 the excessive secretion of the muco-purulent discharge, it 
 is very probable that the influence it exerts is due to the 
 F 
 
66 HUNTERIAN LECTURES. 
 
 volatile essential oil which it contains, and which, like that 
 of the eucalyptus, has antiseptic properties. The essential 
 oil of the copaiba, excreted by the kidneys along with the 
 urine, acts antiseptically by washing the surface of the 
 inflamed urethra over which it passes every time the patient 
 micturates. For I have repeatedly observed that where 
 copaiba has been relied upon exclusively to restrain the 
 discharge of gonorrhoea and no injections have been used, 
 it does not produce a curative effect until its presence' can 
 be recognized by a distinct and peculiar smell in the freshly 
 secreted urine. 
 
 In chronic catarrh of the bladder I have seen excellent 
 results follow the internal use of copaiba given each night 
 in the form of capsules, the exact dose or quantity of the 
 drug so taken, being regulated entirely by the odoriferous 
 effect which it produces on the urine, which thus becomes 
 a medicated fluid brought into contact with the mucous 
 surface of the bladder. 
 
 In septic as contrasted with aseptic inflammations, 
 the changes which result from the intensity of the inflam- 
 mation, run on to the destructive stage, and advance 
 very rapidly ; therefore, if these conditions be prolonged, 
 ulceration and subsequent contractile cicatrization must 
 follow. The entire cessation of discharge from the mucous 
 surface marks the close of the period of ulceration. The 
 discharge may continue after superficial ulceration is at an 
 end ; but if all discharge has ceased, it is very probable 
 that cicatrization is in progress, if not already completed. 
 The contraction of the cicatrices, for there will generally be 
 more thant)ne spot or portion of the urethra so attacked, 
 is very gradual — so gradual as to be overlooked by the 
 patient himself until certain signs, in the way of delay in 
 the act of micturition or the diminished stream of urine, 
 attract his attention. The symptom which is often the 
 
STRICTURE OF THE URETHRA. 67 
 
 earliest seen and complained of by the patient, is the 
 drop of urine which collects near the orifice of the urethra, 
 and escapes after what has been thought to be the entire 
 completion of the act. This, viewed as a physical sign of 
 stricture, has always seemed to me to show this one thing — 
 that in such a case, from diseased action, the extreme orifice 
 of the urethra is no longer, as it is naturally, the narrowest 
 portion of the canal. But under the conditions of stricture, 
 some other portion, say the posterior spongy or the mem- 
 branous part, being reduced in capacity, the accelerator 
 urinse muscle, weakened possibly by continued and unavail- 
 ing action, no longer expels efficiently the few drops of 
 urine which remain in the urethral tube when the bladder 
 has emptied itself, and which it is the function of the 
 accelerator muscle to eject suddenly, by compressing the 
 bulbous portion of the canal. A very little urine is thus 
 held for a moment in the urethral tube, and dribbles out 
 afterwards, when the urethra ought to have become 
 perfectly dry. 
 
 If there is one mode of dieting more than another which, 
 theoretically, would be liable to prolong an inflammatory 
 action in the mucous membrane of the urethra, and to 
 cause the lymph in the cicatrized surfaces to contract more 
 energetically^ and so hasten the production of stricture, it 
 is the use of alcohol in any of its forms. The reason is 
 obvious. At all times where alcohol is taken, as in ardent 
 spirits, wines, or even malt-liquors, only a portion of it is 
 really metamorphosed by the digestive processes. That 
 which escapes the action of digestion may pass away by 
 the skin or by the mucous membrane of the respiratory 
 organs ; and a certain part may still be excreted through 
 the kidneys, almost unchanged in its nature, and separable 
 from the urine by chemical process. Now, this un- 
 combined — it might almost be called free — alcohol must 
 
68 HUNTERIAN LECTURES. 
 
 irritate the whole of the urinary tract, and where its use is 
 constant the efifects cannot be slight or unimportant. Ask 
 any patient who has recently had acute urethritis, but in 
 whom, for a time, the inflammation of the urethra has so 
 far subsided that the discharge has nearly ceased, and with 
 it all pain in the act of micturition. Tell him to take, by 
 way of experiment, a single glass of some highly alcoholic 
 wine, as sherry, or some spirit and water, and learn from 
 him how he will certainly experience an immediate, though 
 only a temporary, return of all his previous symptoms, viz., 
 pain and difficulty in micturition for hours afterwards, 
 until his urine no longer contains the useless excess of 
 alcohol which his kidneys are laboriously striving to 
 expel from his system. 
 
 Now, imagine this state of things going on from day to 
 day in an habitual drunkard, or even in a man who only 
 indulges moderately in alcoholic drinks, and we can see 
 how largely such habits must contribute, if not to the 
 actual production of stricture, certainly to the promotion 
 of just that state of the mucous membrane which must 
 accelerate its formation. 
 
 Thus, to warn a patient predisposed to stricture from a 
 directly inflammatory cause, to desist from spirit-drinking, 
 even in its mildest forms, is an imperative necessity. 
 
 But there is another mode of treatment equally preven- 
 tive and prophylactic in its action, and that is the early 
 and regular dilatation of the passage, so as to prevent 
 the cicatricial contraction, which is the very essence of the 
 cause of the production of stricture. 
 
 Where a surgeon has treated a patient, the subject of 
 gonorrhoea, and, by judicious measures carefully followed 
 out, all inflammatory changes have subsided and all 
 discharge has ceased, it ought to be the rule of practice 
 that he should still regard it as his duty before the treat- 
 
STRICTURE OF THE URETHRA. 69 
 
 ment is concluded, to introduce a gum-elastic catheter, 
 or still better, a flexible ball-bougie, Plate III., Figs. C C, 
 so as to gauge the urethra, and ascertain if there be any- 
 contracted or specially tender spots, where probably a 
 hyperaemic state may still exist. If either of these con- 
 ditions be present, he ought to carefully watch the case, 
 and by dilatation at regular intervals, to keep in view the 
 probability of further contraction, and so prevent it. The 
 proper instrument for this purpose is the ball-bougie, the 
 bougie a boule, for, as it travels along the urethra, it only 
 stretches, for the moment, the part which is too small for 
 it, the rest of the canal undergoing no distension by 
 reason of the narrowness of the stem of the bougie. This, 
 in fact, is the true preventive treatment of stricture of the 
 urethra, and " treatment by anticipation" for it may extend — 
 it must extend — over months, or even years, but the 
 good results which follow upon it, as compared with 
 those engendered by neglect and inattention, ought to be 
 regarded as more than counterbalancing any trouble con- 
 nected with it. 
 
 How rarely are we able so to watch a patient for whose 
 ultimate recovery we feel responsible, yet how necessary it 
 is that such treatment should be practised ! 
 
 How much more frequent is it, the first time we see a 
 patient who has stricture, that we find it not only advanced 
 but very advanced, and very confirmed in its condition. 
 The amount or the degree of change, we will assume, in 
 some typical case is very excessive, so that complete reten- 
 tion is imminent but not yet present, and the stricture, on 
 examination, is pronounced to be very nearly what is called 
 an impassable stricture. What is to be done .? What is the 
 best treatment in such a case .'' 
 
 One word would suggest it : the first indication is that 
 of Rest. Without Rest, in the most comprehensive mean- 
 
70 HUNTERIAN LECTURES. 
 
 ing of the word, it is difficult, if not impossible, to overcome 
 the most prominent symptoms incident to the presence of a 
 confirmed and tightly contracted stricture. The horizontal 
 position alone, when preserved for some hours, as com- 
 pared with the erect posture, will do much to diminish that 
 congestion of the venous plexuses in and around the 
 urethra which adds to the swollen state of its mucous 
 membrane, and so further encroaches upon the capacity 
 of the canal. 
 
 To these two means of relief for the acute congestion 
 of which the urethra is then the subject, may be added the 
 administration internally of mild saline aperients, such as 
 sulphate of magnesia, in small doses, repeated regularly, 
 and combined with sweet spirits of nitre and nitrate of 
 potash, so as to solicit such action in the kidneys as will 
 augment the volume of urine, and help to carry off, in a 
 soluble form, the various compounds of urea. 
 
 Again, the increased action of the skin which takes 
 place in bed, as contrasted with the chance of cold and 
 chills when the patient is moving about, especially if aided 
 by an occasional warm bath, will spare the kidneys some 
 excess of action, which, in confirmed cases of stricture, 
 they are generally very ill able to bear. 
 
 All these means should be tried, and persevered with 
 for two or three days, if the bladder is not painfully or 
 extremely distended, before any attempt is made to pass 
 an instrument into the bladder, however fine and delicate 
 such instrument may be. 
 
 I need not specify any particular form of instrument 
 to be used, whether solid or hollow ; and certainly, if we 
 have reason to believe, from the history of the case, both 
 past and present, that the contraction is excessive, the 
 instrument should be proportionately small, and perfectly 
 pliable. 
 
STRICTURE OF THE URETHRA. 7 1 
 
 The channel through which we have to guide it, is certain 
 to be tortuous and not straight, and the sides of it inflamed, 
 tender, and-lacerable on the application of any force. 
 
 The old method of forcible catheterism in an inflamed 
 stricture of the urethra is, I trust, for ever discarded. Our 
 object is, in every case, to find an instrument small enough 
 to pass through the strictured canal, not to press or strike 
 against the contraction. If we do the latter, as doubtless 
 often has been done, we are apt, not to pass it through the 
 narrow passage, but rather to push forward the hardened 
 tissue which causes the contraction, stripping a portion of 
 it from the sides of the canal, and perhaps piercing the 
 side with the point of the instrument, and so making a 
 false passage, which will permanently complicate the case. 
 
 Arte noil vi must be the watchword, and success will 
 eventually reward our patience and our care. A very little 
 practice and light manipulation with a fine pliable bougie 
 will soon tell us, by the gradual cessation of resistance, 
 when we have really traversed the narrow passage, and 
 reached the wider space beyond. It is here, in this 
 expanded and thinner portion of the urethra, that we have 
 the internal orifices of fistulse which have resulted from the 
 giving way of the urethral wall at one or more spots, partly 
 from the undue pressure to which it was exposed, and 
 partly from the fact that an ulcerated opening has been 
 formed, as a consequence of destructive inflammatory 
 changes. If the escape of urine has been gradual, lymph 
 may have been deposited around and beyond it and, by 
 the continuance of this process, a fistulous track is formed, 
 opening externally through an ulcerated spot of skin. But 
 the same changes occurring suddenly, with little if any 
 effusion of limiting lymph, set up the acute and dangerous 
 symptoms due to extravasation of urine, which require 
 prompt and energetic treatment. 
 
72 HUNTERIAN LECTURES. 
 
 Now, where we have to deal with a case of stricture, with 
 chronic perineal fistulae, as a rule, if by any means we can 
 restore the urethra to its natural capacity, or, in other words, 
 relieve the stricture — I will not say cure it permanently — 
 resistance to the natural outflow of the urine in mictu- 
 rition being overcome, the urine will cease to enter the 
 internal orifices of these fistulae ; they will gradually close 
 up if the urine can pass freely, and without the exercise 
 of undue pressure by the patient. 
 
 But we may have to deal with a case of multiple perineal 
 fistulae, with a fully capacious urethral canal, which will 
 admit, with ease, a bougie catheter or equal to No. 12, 
 English scale ; and the fistulae are apt to remain unhealed 
 in spite of this condition of the canal. I suppose such 
 a case will remain unrelieved, from the circumstance that in 
 it the urethral orifice of the chief fistula, of which the others 
 may be branches, is unusually large — too large to be closed 
 by adhesive inflammation. 
 
 In a case which I had the opportunity of watching, 
 the man had rested in bed, and worn a very large catheter 
 constantly for many weeks, almost months in the aggre- 
 gate, the fistulae being still unclosed, I adopted as a last 
 resource an opposite line of treatment, and, happily, with 
 success. I gradually diminished the size of the retained 
 catheter from 12, to 11, 10, 9, and so on, the urethra 
 contracting until it had arrived at the size of No. 4, 
 English scale ; and then I found that no urine entered 
 the fistula, and it healed completely. After this, I let 
 him alone for some months, only passing, occasionally, 
 a catheter of this diminished size. And then, when I 
 thought perfect cicatrization of the internal orifice of the 
 fistula had been accomplished, I very slowly re-dilated 
 the urethra to the moderate size of a No. 6 or 8 catheter, 
 and all went well. 
 
URINARY FISTUL/E. 73 
 
 No doubt, in the early stage of treatment in this case, 
 by over-eagerness to dilate the urethra, I had really pre- 
 vented the closure of the internal opening of the fistula, 
 which would have shut off the entrance of urine and thus 
 secured its obliteration. 
 
 This plan of treatment I have adopted in other cases 
 where urinary fistulae have remained patulous, after full 
 dilatation of the urethra has been obtained. 
 
 As soon as we can pass an instrument easily through 
 the contracted portion of the urethra, we have to decide 
 upon one of two courses — either continuous or intermittent 
 dilatation — as may be the more applicable to the particular 
 circumstances of the case. Where the pain is not great, 
 and the patient is neither restless nor irritable, continuous 
 dilatation is the quicker and the more successful of the two 
 plans. This may be effected by a succession of small 
 filiform or gradually tapering bougies, one being retained 
 for a few hours, or until by its presence or by the subsidence 
 of swelling in the lining of the urethra, it is found to be no 
 longer tightly gripped, and that it can be freely moved to 
 and fro in the passage ; then it is to be removed, and a 
 larger size substituted for it, always following the French 
 gauge, so as to make the transition from size to size as 
 gradual as possible, until it be equal to No. 5, or even 
 No. 6, French scale. 
 
 It is often difficult to pass a larger filiform bougie 
 just as we have removed a smaller, for there may still be 
 much tortuosity in the canal, and its introduction not easily 
 insured, I have used with great advantage the very long 
 tapering bougie which Mr. Reginald Harrison has contrived 
 for this special purpose, and which he calls the "whip 
 bougie," Plate III., Figs. D D. This instrument, once 
 through the narrow canal, may hour by hour be gently 
 pressed onwards, and without removal and re-introduction 
 
74 HUNTERIAN LECTURES. 
 
 it acts as a long conical wedge with which to dilate the 
 passage. It is a very ingenious and useful instrument. 
 
 It is at this stage of expansion of the canal that we may- 
 discuss the propriety of performing internal urethrotomy, 
 and the cases to which it is applicable. With so small 
 a guide as is furnished by a bougie of No. 6, French scale, 
 if it can be passed along the whole length of the urethra, 
 and if we are sure it has not entered a false 'passage 
 instead of the bladder, or gone out of the urethra through 
 one sinus, and come into it again through another nearer 
 the bladder — these possible errors in direction being care- 
 fully avoided — we may proceed to the operation of internal 
 urethrotomy. This consists in a series of operations 
 beginning with the passage of a No. 6 bougie, and 
 culminating in the introduction into the bladder of a 
 catheter equal to No. 34, French scale, through which 
 the urine can be withdrawn. 
 
 At every successive stage we have ample proof whether 
 or not we are proceeding rightly; and if there is a sus- 
 picion that some departure has been made from the true 
 line of the passage, it is easy as well as prudent to desist 
 for the time, and on some future occasion to complete the 
 urethrotomy. To prove that we have the power of so 
 verifying the correctness of our advance, lest any such 
 error should have been made, I may enumerate the various 
 steps to be taken. To begin with, we introduce, and we 
 assume we are able to pass effectively tine bougie conduc- 
 trice, and to this we screw on an exceedingly small silver 
 tube, fashioned as a catheter, and this is led onwards into the 
 bladder.* If this stage is reached, urine will flow through 
 this little catheter, confirming our impression that the 
 instrument is really within the bladder. But if this should 
 
 * Vide my pamphlet on Internal Urethrotomy, with its modern 
 improvements, Plate II., Figs. B. and A. (1879.) 
 
INTERNAL URETHROTOMY. 75 
 
 not occur, by reason of the tube being stopped up by blood 
 or mucus, or because there is not sufficient urine in the 
 bladder, we can inject warm water with a fine syringe, and 
 wait for its discharge. 
 
 Then, this fine silver tube, stiffened by a steel rod 
 screwed into it, becomes at once a safe guide for a set 
 of tubes with conical ends, of increasing size, to be passed 
 over it, by which the canal can be dilated up to the equiva- 
 lent of No. 12, French scale. The catheter, steel rod, and 
 the largest tube are then withdrawn from the passage, as 
 far as the metal mount of the bougie, from which they 
 are unscrewed, but the guide-bougie itself is left in the 
 urethra. 
 
 Lastly, the urethrotome is screwed on to the bougie, 
 which, in its turn, serves as a guide for the introduction 
 completely into the bladder, of the central portion of the 
 urethrotome, along which the cutting part slides. I have 
 the blade made self-sheathing, so that there is no danger 
 of the urethra being cut on the removal of the instrument 
 or at any other moment, except when by pressure on the 
 handle, the edge of the knife is exposed. 
 
 Internal urethrotomy, as I would advocate it, is an 
 operation for which we must select our cases. It is not 
 applicable to every case of stricture. The four cardinal 
 points to be remembered in an attempt to carry cases of 
 internal urethrotomy to a successful issue are these : — 
 (i) There must be no probability of renal insufficiency 
 following the operation. The urine must be carefully 
 examined in this respect. It must show an average 
 specific gravity in proof of the urea compounds which 
 it contains being duly excreted in normal proportion. 
 (2) There must be no purulent discharge from the urethra ; 
 or, if such a discharge has existed recently, it must have 
 been rendered perfectly aseptic and innocuous by the use 
 
76 HUNTERIAN LECTURES. 
 
 of antiseptic injections, such as a weak solution of chloride 
 of zinc, before we touch the urethra or wound its delicate 
 absorbent surface, with any cutting instrument. (3) At the 
 time of the operation and afterwards, care must be taken 
 that we do not expose the patient to the risk of chill, by 
 undue exposure to cold, not only of the region of the 
 bladder and the abdomen generally, but also of the lower 
 limbs, this being a very fruitful source of urethral fever after 
 such operations, although not the only one. (4) Lastly, we 
 must strive to avert the occurrence of febrile excitement 
 by promptly administering quinine after the operation, as 
 soon as the effects of the anaesthetic have subsided. The 
 quinine should be given in large doses, in the form of pill, 
 so mixed as to quickly dissolve in the stomach,* and with 
 it, opium, always in solution,*!* not in a solid form, in order 
 that it may be easily absorbed, and not delayed in its 
 action : otherwise it might suddenly produce severe soporific 
 effects. 
 
 With these precautions, cases of internal urethrotomy will 
 show, I believe, a good percentage of favourable results. 
 Yet with regard to the mechanism of this operation, I 
 know it may be objected to it that our incisions being 
 made only along the upper or pubic wall of the urethra, 
 they can not thereby divide all the bands or adhesions 
 which have diminished the capacity of the canal. 
 
 This, I fear, is an insuperable objection. But I know 
 not of any other operation for stricture in which we can be 
 sure that this great difficulty has been overcome. We can 
 
 *1J;. Quinse Sulph. pulv., gr.xx; mellis, gr. x. vel. ^.j-. ut fiat 
 massa, in pil. xij sequales dividend. One pill every hour or 
 second hour. 
 
 t R. Tinct. Opii, f^j ; Acid. Sulphuric, dil., foj ; Syr. Aurant, 
 f3ij ; Aquce q.s. ad fsvj. M., fiat mist. One tablespoonful with 
 each quinine pill. 
 
INTERNAL URETHROTOMY. "]*] 
 
 only rely, therefore, upon the effect of forcible dilatation of 
 the canal by the large conical metallic bougie which we 
 pass at the end of the operation. After this, the perma- 
 nency and success of the case will depend entirely upon 
 our power to preserve the enlarged calibre of the canal, 
 until a cicatricial splice of new tissue shall have increased 
 the general circumference of the urethra. 
 
 And here I am reminded of a very pertinent and 
 thoroughly practical remark which you made yourself, Sir, 
 in a discussion on the subject of the treatment of stricture 
 at one of our medical societies some years since — namely, 
 that in dealing with a case of stricture of the urethra, said 
 to have been cured by any particular surgical proceeding, — 
 knowing how prone such cases are to undergo secondary 
 contraction, the important question must be asked ere the 
 verdict of success is recorded, " How long is it since the 
 operation was performed .'' " 
 
LECTURE III. 
 
 ON SOME OF THE INJURIES AND DISEASES OF 
 THE RECTUM, PERINEUM, ETC. 
 
 OF the many surgical ailments in this region of the 
 body, which the surgeon in general practice has to 
 treat, if we except the haemorrhoidal condition of 
 the rectum, fistula in ano is the most commonly met with. 
 It is often difficult to make out why a patient should be the 
 subject of this malady, or to explain its progress, how far 
 it portends greater evil in the chest with proclivity to 
 phthisis, or the actual presence of constitutional cachexia 
 associated with tubercular changes in distant organs. 
 Besides the cause, and the diagnosis, there is yet the 
 question of treatment, whether in every case we are bound 
 to operate, and, if so, in what manner, and with what 
 prospect of success. 
 
 First, as to the cause of fistula in ajio. The most 
 common will be abscess produced by inflammation in the 
 ischio-rectal space, which, unrelieved, travels towards the 
 cylinder of the tectum, as a point of less resistance than the 
 skin and its subjacent tissues. A frequent origin of such an 
 abscess in those who are robust and otherwise healthy, is, 
 
FISTULA IN ANO. 79 
 
 in my opinion, habitual constipation, whereby, in the 
 powerful straining action resorted to for the emptying of 
 the bowel, the cellular tissue around is unduly compressed, 
 bruised and injured, and cellulitis is set up. Or, as I have 
 sometimes known, where from circumstances the patient 
 with a loaded rectum, and every desire to empty it in 
 obedience to the call of nature, thoughtlessly postpones 
 the act, the swollen bowel slowly produces, by prolonged 
 distention and pressure, the same injury to tissues and the 
 same result, as if it had taken place more rapidly. 
 
 We know, in patients disposed to phthisical disease, how 
 irritable the mucous membrane of the intestines often is, so 
 that just an opposite condition, a tendency to diarrhoea, can 
 quickly be established. For, as in the advanced stage of 
 phthisis, we frequently have diarrhoea connected with 
 ulceration of the colon, so in the earlier stages there may be 
 a similar yet milder state, an aphthous condition possibly 
 of the rectum, with here and there more positive congestion 
 and inflammatory change, which may extend from the 
 interior to the exterior of the bowel, in a direction contrary 
 to what happens in cases preceded by constipation. 
 
 At last, this excessive action in the mucous membrane 
 of the rectum and the tissue beneath it, terminates in 
 abscess, which either bursts spontaneously, generally into 
 the bowel, or is opened artificially by the surgeon to relieve 
 the pain ; and thus a second opening is produced and a 
 fistula established. 
 
 So that it is possible that while in the one class of cases, 
 constipation has preceded the formation of the abscess 
 antecedent to the fistula ; in the other class, a relaxed 
 condition of the bowel may have existed, and yet a result 
 nearly similar in each has been brought about. 
 
 It is notorious that in some cases of ischio-rectal abscess, 
 where we open the abscess, it heals, and no fistula follows ; 
 
8o HUNTERIAN LECTURES. 
 
 while in other cases, however early we make our external 
 incision, freely, and with good effect as far as escape of 
 pus is proof, yet a fistula forms, and will remain unhealed 
 in spite of every treatment short of its complete division. 
 
 Now, in my experience it is the patient with the previously 
 irritable bowel in place of constipation, who is the more 
 liable when an abscess has formed near the rectum, and it 
 has been opened, to have a fistula follow as an inevitable 
 consequence. And I have in a few instances noticed this 
 particular condition of things. A person in delicate health, 
 perhaps liable to diarrhoea, but certainly not the subject of 
 habitual constipation, is suddenly attacked with pain in or 
 near the rectum, increased by pressure, and with constitu- 
 tional symptoms indicative of purulent formation near 
 the bowel. An incision is made with proper care, and pus 
 evacuated. Up to this time no trace of blood or muco-pus 
 has passed per aninn. We refrain from passing any probe 
 or director into the wound, lest we may pierce the bowel ; 
 yet, the next day, or two days afterwards, blood-stained 
 mucus, or pus, is seen escaping through the anus ; and 
 it is then too evident that what most probably was at 
 the time of the incision through the skin, a small slough 
 on the mucous surface of the rectum over the projection of 
 the abscess, has now separated, an ulcerated aperture has 
 been formed, and a fistula established from the skin to 
 the interior of the bowel, as the director or the probe will 
 then prove. 
 
 With regard to diarrhoea, and irritability of the lower 
 bowel, considered in regard to their surgical relations, 
 with the ultimate object of surgical treatment, I cannot 
 urge too strenuously on the surgeon, the duty of always 
 making, in such cases, a careful rectal digital examination, 
 when the cause of the irritability is obscure, or when it 
 resists the more ordinary modes of treatment, 
 
FISTULA IN ANO. 8 1 
 
 We are all ready enough, I take it, to examine a patient 
 by the rectum, if constipation, difficulty or pain in defecation, 
 is the subject of complaint. But I doubt not, there are 
 many surgeons who would think themselves excused from 
 doing so, if what the patient complained of was chiefly a 
 too frequent action of the bowels — in fact a form of chronic 
 intractable diarrhoea. 
 
 Yet, without adopting those heroic methods of treatment 
 or of physical investigation which some have advocated, in 
 which, under the influence of an anaesthetic, we endeavour 
 to pass the hand and wrist, and even part of the fore- 
 arm into the rectum for the purpose of exploration, I 
 am sure we may often derive much valuable and positive 
 information by rectal examination in doubtful cases; and 
 even in those of ordinary occurrence, it is a very proper 
 thing to do. 
 
 One case occurred to me which was as instructive as it 
 was annoying, for I had misunderstood the case until a 
 rectal examination revealed its nature. 
 
 A maiden lady, nearly fifty years of age, consulted me 
 for this simple ailment, to all appearance irritability of the 
 lower bowel, occurring only at night, and greatly disturbing 
 her sleep. She told me she generally had the usual morn- 
 ing evacuation after her first meal, and throughout the rest 
 of the day, no further action. As soon, however, as she 
 got into bed, and laid down, and was just passing into sleep, 
 up she must get, with an urgent desire to relieve the bowels, 
 which for the time gave her ease. This would recur two or 
 three times in the night, and it was for this I was consulted. 
 
 Of course I looked fully into the question of diet, the 
 time of her meals, the food taken on going to bed, and 
 other such generalities ; but with all my suggestions the 
 trouble went on. In the day-time, quiet and rest; at night, 
 ceaseless, or at least frequent, disturbance, 
 G 
 
82 HUNTERIAN LECTURES. 
 
 This went on for many months, and she was content 
 to bear the annoyance, although very little if at all relieved 
 by the careful use of opium, and some astringents taken at 
 bed-time. 
 
 She then consulted a London physician of great eminence, 
 and, as he said to me afterwards, he was himself not a little 
 puzzled, at his earlier visits, by what the patient described 
 as her symptoms. But he soon followed his invariable rule 
 in cases of irritable bowel or chronic diarrhoea, namely, to 
 make a rectal digital examination ; and then he found, in 
 this lady, a fibroid tumour loosely placed in the pelvis, 
 attached possibly to the back of the uterus, or to some part 
 of its appendages, which in the upright, or in the sitting 
 posture, fell away from the bowel to one side of the pelvis, 
 and there, for the time gave no special sign. But as soon 
 as the horizontal position was assumed, the mass fell back- 
 wards on the rectum and so pressed upon it as to congest 
 the mucous lining, and excite a desire to evacuate ; and 
 thus my patient was suffering from a mechanical cause, 
 which, although evident in its effects, it was impossible to 
 remove. 
 
 There is another condition, usually in children, where a 
 rectal examination will often explain the cause of a per- 
 sistently irritable bowel, which nothing else might show in 
 its early stage, and that is, in mucous polypus of the 
 rectum. 
 
 It is quite true that before this has long existed, prolapsus 
 of the bowel may come on, and reveal its presence : still, 
 the finger can discover it at a much earlier period. 
 
 Where fistula in ajto, or rather fistula in recto exists, when 
 it is chronic and confirmed, much may be done in deciding 
 as to its cause and its progress, by a digital examination of 
 the rectum before the probe or the director is used. 
 
 The practice formerly in examination of a case of fistula 
 
FISTULA IN ANO. 8;^ 
 
 in ano was first to pass the probe, note if it travels towards 
 the rectum, then introduce the index finger into the bowel, 
 and try to feel the end of the probe, that you mcty know if 
 the fistula is complete. 
 
 But, I would say in every case, settle the question as to 
 the condition of healthiness or otherwise of the bowel 
 before you do anything towards the exploration of the 
 fistula. 
 
 I have known a surgeon of good experience, asked to go 
 and operate on a case oi fistida in ano — an operation, it 
 may be said, of no great severity — taking for grantee! that 
 it would be a case suitable for operation, have everything 
 ready, pass a director along the fistula, follow it by the 
 finger in the rectum, and then discover, for the first time, 
 an unexpected state of things, viz., the presence of an 
 epitheliomatous deposit with contraction of the bowel and 
 corresponding dilatation above, with ulceration and abscess 
 as a starting point for the fistula, by which complications 
 the intended operation was rendered altogether useless. 
 
 I once met with a case in a young woman in whom 
 cicatricial contraction of the rectum had followed upon 
 chronic dysentery, and no fewer than eleven fistulous open- 
 ings had formed in the perineum and around the anus. In 
 this case it was thought when the first abscess formed, and 
 a fistula followed, that it was from constitutional and not 
 from local causes. This should remind us that in every 
 case of chronic fistula near the rectum, the fistula, which 
 at first was simple, may have branched out in various 
 directions, and so multiplied itself by repeated attacks of 
 intercurrent inflammation. Each line or branch of the 
 fistula must be separately divided at the time of the 
 operation, or trouble will subsequently arise. 
 
 Then, as to the duration of a fistula communicating with 
 the bowel, and the risk of allowing a suppurating surface. 
 
84 HUNTERIAN LECTURES. 
 
 such as the lining of a fistula must always represent, to 
 exist in any person for an indefinite period. I knew a lady 
 who had a fistula in ano, with an opening upon the skin 
 about an inch and a half from the anus. She was to all 
 appearance healthy, and free from any signs of lung com- 
 plication. She would not consent to be operated on, but 
 was content to let this condition of things remain unrelieved 
 for nearly three years, when, catching cold, I believe through 
 fatigue and exposure to rain while upon a journey, acute 
 pyaemic symptoms set in; viz., high pyrexia with delirium, 
 pain over liver, frequent vomiting, and distended abdomen, 
 and she died within a week from the commencement of 
 her illness. 
 
 I was present at the post-mortem inspection, when we 
 found in the liver an immense abscess, containing much 
 more than a pint of pus, which, had we known to exist 
 during life, or if the history of the case had suggested it, 
 we might possibly have opened. Yet with the presence of 
 general septicaemia, I fear no good result would have 
 followed. 
 
 In a complete fistula the internal opening may not be in 
 the same plane, or in a direct line with the external. It 
 may pass partly round the bowel, in the sub-mucous tissue, 
 and pierce the mucous membrane at a distant spot. Or it 
 may dissect up the mucous membrane, and travel high up 
 by the side of the rectum, still outside its cavity, and at 
 length enter it at a spot far beyond ordinary reach. This 
 is apt to occur with abscesses and fistulae attendant upon 
 strictured bowel from dysenteric ulceration and cicatriza- 
 tion, or from malignant disease. But where it occurs in an 
 ordinary case of large abscess followed by fistula, for which 
 an operation has to be performed, the question may arise, if 
 the internal end of the fistulous track be high up, are we 
 to trace it upwards, and there divide it ? Or, supposing it 
 
FISTULA IN ANO. 85 
 
 is really so situated, may we content ourselves by piercing 
 the wall of the sac of the old abscess at a convenient 
 distance within the bowel above the deeper fibres of the 
 sphincter ? A complete outlet being thus obtained for the 
 secretions of the sac, and rest for the edges of the divided 
 fistula, will the progress of the case be satisfactory ? 
 
 As a general rule, the remark of the late Professor Syme 
 is strictly correct, that in spite of this extension upwards of 
 the sac of the abscess, the point at which the bowel has 
 been perforated by the ulcerative changes is much lower 
 down, and must be sought for nearer the anal opening than 
 might be expected. 
 
 If such an internal opening can be discovered, the 
 director should be passed through it, and the structures 
 divided, regardless, for the time, of the height of the 
 abscess ; for by the freedom thus afforded for the escape 
 of the secretions, and by careful dressing, perfect healing 
 may result, and possibly no further incision be required. 
 
 Yet I have known a case in which a man was operated 
 upon for fistula in ano in the usual way. Care was bestowed 
 on the after-treatment of the case, but yet a troublesome 
 muco-purulent discharge remained, to the great annoyance 
 of the patient. He was about thirty years of age, very 
 stout, in excellent health, and free from indication of visceral 
 disease. I was assured that at the time of the operation the 
 internal opening of the fistula was easily reached, but the 
 abscess had dissected up the bowel for a great distance, 
 and left, after the operation, what used to be called a 
 "night cap," a pouched cavity opening downwards towards 
 the anus. Yet there was nothing at the time of the 
 operation to suggest the presence of this pouch. 
 
 When the bowel was dilated with a trivalve speculum, 
 a probe could be passed upwards for an inch-and-a-half, 
 beneath the mucous membrane. With a long pair of narrow- 
 
86 HUNTERIAN LECTURES. 
 
 bladed scissors this was divided, — the edges gaped widely, 
 being stretched by the action of the speculum, — -a little of 
 each lip of the wound thus made was cut away, to retard 
 re-union, and the result was most satisfactory, considering 
 for how long a period after what was accounted the end of 
 the first operation, he had suffered from continuance of the 
 trouble in the rectum. 
 
 The case led me to adopt this as a rule of practice, very 
 rarely to be departed from ; after the operation for fistula 
 in ano, no matter what care had been exercised in dressing 
 the case up to what is presumed to be complete healing, — 
 not to give an opinion as to the probable success of the 
 treatment until the patient has been examined with the 
 speculum. The lateral fenestra of the instrument should be 
 placed over the line of the incision, and a long and straight 
 probe being directed towards the upper angle of the cut, 
 we must satisfy ourselves that the incision is completely 
 closed, and that no cavity exists in that direction. 
 
 This being done, another probe is used, bent at an angle 
 as shown in Plate IV., Fig. A A, and laid on the line of 
 the cicatrix. It is lightly drawn along it towards its lower 
 end, to ascertain whether at that spot any portion remains 
 unhealed, whereby a small pouch might be formed, opening 
 upwards towards the bowel, yet closed below, in which 
 rectal mucus or thin faecal matter might collect, and cause 
 recurrent attacks of inflammation. 
 
 It is not until this has been done that I feel confident of 
 the condition of my patient ; so often have I known of 
 relapses after the operation for the division oi fistula in ano, 
 or of cases which are said not to have been successful only 
 because every portion of the divided surface had not been 
 thoroughly and firmly cicatrized. 
 
 If I find such a pouch at the lower angle of the operation- 
 wound, I can with the instrument shown in Plate IV., Fig. 
 

FISTULA IN ANO. 87 
 
 B B, which I have called a guarded hooked knife — this, 
 when closed, being of the same size and curve as that of the 
 probe — divide the pouch from within outwards, and by a 
 single movement in the handle, change the blunt hook 
 into a cutting instrument. It is quite easy to use the 
 closed knife as a probe in the first instance, and the ex- 
 istence of such a small pouch or fold being demonstrated, 
 the blade of the knife is unsheathed, the cutting surface 
 brought into action, and as the instrument is withdrawn, 
 the pouch will be opened by the incision, and the wound 
 dressed as the fistula had been previously. 
 
 There is this advantage in the instrument I here show. 
 It can be used with the speculum, and the sinus can be 
 explored while the patient is on his left side, without the 
 use of any anaesthetic. Nothing can then be more favour- 
 able for the division of the fistula, for you have only to draw 
 back the knife, as soon as the cutting edge is free, and if 
 the patient makes a plunge, or tries to start away from. 
 you, instead of frustrating your efforts, he will just do what 
 will assist you in the complete division of the pouch. 
 
 This hooked knife is very useful for the division of small 
 internal blind fistulae, more properly called sinuses, which 
 are found occasionally just within the areola of the anus. 
 The presence of such internal blind fistulae can first be 
 proved by the use of this instrument, and then they can be 
 divided. Internal blind fistulae begin as small abscesses in 
 the pouches which exist naturally in the rectum, where 
 the mucous membrane is loosely folded, just within the 
 sphincter. 
 
 An internal blind fistula in ano, or, to speak more 
 exactly, a sinus leading out from the rectum, with only 
 one discoverable opening, and that within the bowel, 
 occasionally takes very strange and curious courses, which 
 may obscure the diagnosis very considerably. Such a case 
 
88 HUNTERIAN LECTURES. 
 
 once occurred to me in this way. I was requested to give 
 an opinion as to the nature of a small tumour which a 
 gentleman had on one buttock. It was on the right side, 
 at the back part, too high up to be touched in the sitting 
 posture, but yet giving much inconvenience by the friction 
 of his dress. He had travelled much in hot climates, had 
 ridden on camels and the like, and also had experience of 
 the bites of poisonous animals, and of scratches and wounds 
 of all sorts. 
 
 The tumour, of a somewhat circular form, an inch and 
 a half in diameter, raised above the skin, which was 
 thickened and polished over it, was quite hard to the 
 touch, painless on deep pressure, but very sensitive to light 
 pressure across its surface. As far as he could tell, it had 
 existed for two years, and had commenced as a small 
 nodule in the skin. During the last few months it had 
 enlarged considerably. 
 
 The patient was out of health from worry and hard work 
 in business, and the medical man in attendance asked me 
 to remove the growth, for the patient was constantly 
 referring to its presence, fearing it might take on malignant 
 action. 
 
 I hesitated to give an opinion as to the true nature of 
 the tumour, for I observed that the inguinal glands on the 
 same side were enlarged and indurated ; yet there was no 
 pain in them, or in the swelling itself, except as I have 
 stated. 
 
 In my note-book I entered it as " Keloid growth on 
 buttock.? Query, malignant degeneracy .?" The day came 
 for the operation. The patient was placed under the 
 influence of an anaesthetic, and I made a large elliptical 
 incision, so as to remove healthy skin around the mass. 
 The tumour seemed to dip some distance into the fat of 
 the buttock, and this also I removed. I then found that 
 
FISTULA IN ANO. 89 
 
 the under-surface of the mass was very soft, as if composed 
 of the remains of an old abscess, with flaky masses closely 
 packed together, and some serum or serosity between them, 
 but no recent pus could be recognized. At the lower 
 part of the wound there was a depression, and into this I 
 passed a long thick probe which readily glided on towards 
 the bowel. 
 
 I put my finger into the rectum, and there I felt the 
 point of the probe beneath the mucous membrane, not 
 with any opening — at least I could not find any — but with 
 the membrane so thin as to be readily transfixed. A cut 
 was then made into the bowel by the side of the probe, as 
 in an ordinary fistula operation, laying open a sinus nearly 
 five inches in length, and dividing the sphincter of the 
 bowel rather more than an inch within the rectum. It was 
 evident, therefore, that this patient had been the subject of 
 a very chronic and slowly advancing internal blind fistula; 
 that the progress having been gradual, the fistula had not 
 branched laterally, but its extreme end had excited just 
 enough inflammation and thickening of the skin and 
 subcutaneous tissue, as to imitate a keloid growth, for which 
 I had at first mistaken it. The patient made a good 
 recovery, and the theory of malignancy was happily 
 dispelled. 
 
 There may be a difficulty in making a positive diagnosis 
 in a case where a suspected fistula in recto appears as an 
 external blind fistula, and the question to be decided is 
 whether or no it is a sinus succeeding a surface-abscess 
 of the part, running parallel to the wall of the rectum ; or 
 whether it has perforated the bowel. 
 
 This once occurred to me under peculiar circumstances, 
 and I will relate the case. A lady, the widow of a solicitor, 
 was compelled under the terms of his will, to assure her life 
 for a very large sum, I believe it was either ten or twelve 
 
90 HUNTERIAN LECTURES. 
 
 thousand pounds, so that in the event of her death, the 
 money thus secured might go to their children, she having 
 only a life interest in some property. 
 
 She applied, in the ordinary way, to an assurance office. 
 The medical officer discovered, on putting certain questions 
 to the applicant, that she had suffered from abscess near 
 the rectum, and that possibly she had fistula in recto. There 
 was an external opening two inches from the anus, and a 
 probe, passed carefully along it, took a direction nearly 
 parallel to the bowel ; yet by no process of manipulation 
 could the probe be felt through the wall of the rectum, or 
 anywhere beneath its mucous membrane. 
 
 It was doubtful, therefore, if it was a sinus only, or a fistula 
 of which the patient was the subject. She experienced no 
 inconvenience from its presence, except that at times the 
 sinus became distended, and then subsided spontaneously. 
 The decision of the assurance company was this : — that so 
 long as this sinus existed there would be increased risk as 
 to the expectancy on the duration of her life, and she must 
 pay a higher yearly premium, which, however, would be 
 reduced to the ordinary rate, if she would consent to be 
 operated on, and produce a report that a satisfactory cure 
 had been effected. This was the state of things when the 
 case came under my observation ; and I was told she had 
 been seen by several eminent surgeons, some of whom 
 thought that the sinus was due to bone irritation, either in 
 the coccyx, or in the tuber ischii, but no one could say 
 positively that it communicated with the rectum, and that 
 the ordinary operation for fistula in recto was needful or 
 justifiable. 
 
 The friends informed me that in a pecuniary sense, it 
 was a matter of great importance for this lady to be relieved 
 of the high rate of premium she had to pay, which was 
 about ;^i5o per year in excess of the usual rate. 
 
FISTULA IN ANO. 9 1 
 
 From my experience of the case of the lady with pyaemia 
 and acute abscess of the liver, to which I have already 
 referred, I could not but feel that the assurance company 
 was acting prudently. 
 
 Therefore, being as unsuccessful as my predecessors in 
 tracing the path of the fistula with the probe, and being 
 unable by this means to say that it communicated with the 
 bowel, I had recourse to a simple expedient, which answered 
 perfectly. I made a small tampon, or plug of slips of lint 
 well soaked in white starch and water, tied them together, 
 and let them dry into the form shown in Plate IV., Fig. C, 
 taking care that the plug was not so bulky as to distend 
 the rectum, and compress and close the fistula. The 
 plug thus made, when quite dry and hard, I smeared over 
 with glycerine (not oil, lest it might vitiate the experiment), 
 and passed it up the rectum, and there held it firmly while 
 I gently injected, by means of a syringe with a fine nozzle 
 fitting accurately the orifice of the fistula, a small quantity 
 of tincture of iodine, taking care that none of it escaped 
 externally. I then withdrew the plug from the rectum, 
 and on it there was a distinct mark of the iodide of starch, 
 which gave unmistakable evidence that, although the internal 
 orifice might be small, there was really a complete fistulous 
 track, and the operation was immediately proceeded with. 
 I had much trouble in securing perfect healing of the 
 incision, for I believe the original difficulty in the case was 
 occasioned by the irregular course the fistula had taken. 
 Still, a very satisfactory result was at last attained. The 
 patient got quite well, and at the end of twelve months from 
 the time at which I had given it as my opinion that the 
 disease was cured, two surgeons were deputed by the 
 assurance company to confirm my opinion, and this being 
 satisfactory, the future annual premium on her life was 
 accepted at the usual rate. 
 
92 HUNTERIAN LECTURES. 
 
 I may here observe that this plan is also applicable to 
 urinary fistulae, where, after perineal section, we hesitate 
 to remove the catheter, the operation-wound having healed 
 but not the sinuses, and we desire to know if the urethral 
 orifice of one or more of them be still unclosed. By passing 
 a starched bougie along the urethra, and injecting iodine 
 along the sinus, the presence of such a communication, if it 
 exists, can be demonstrated. 
 
 Before I approach the subject of the after-treatment of 
 fistula in ano, where an operation has been performed, 
 I should like to repeat a remark once made to me by 
 Mr. Curling, no slight authority in reference to diseases 
 in this region of the body. He told me that he had for 
 many years advised that the surgeon who operates for 
 fistula should be his own dresser ; in other words, that he 
 should be extremely careful how he deputes to another the 
 after-management of the case, for unless great care be taken, 
 the fistula-incision may heal badly, or not heal at all, because 
 the principles of right treatment have been overlooked. In 
 this as in many other instances in surgery, the operation is 
 but the beginning of the treatment. 
 
 I have rarely been content with Professor Syme's plan of 
 simply preventing the possible re-closure of an incision made 
 in the line of the fistula, by drawing the probe along its 
 track from day to day, until finally healed. This mode of 
 treatment may in some instances be sufficient, but it is not 
 always successful. 
 
 My method, in all such cases, is twofold — first, in regard 
 to the application used to the wound ; and next, as to the 
 particular mode of dressing. 
 
 While the incisions are being made, I avoid the use of 
 water or wet applications to the part. Any blood or pus 
 which may escape I have removed by pieces of dry lint or 
 linen cloth, and then, after the operation from first to last. 
 
FISTULA IN ANO. 93 
 
 I used the carbolated castor-oil to protect the freshly cut 
 surfaces from the irritation of feculent matter or mucus, or 
 flatus escaping from the rectum. This oil, if so prepared 
 that it is clear and bright, showing that the carbolic acid 
 is perfectly dissolved in it, is a very soothing and com- 
 fortable application for the patient.* 
 
 If the oil is applied freely, no washing of the part with 
 water or with soap and water, for the purpose of cleanliness, 
 being on any account permitted, the faeces, if they escape, 
 can be removed from the surface, already well oiled, by 
 pieces of lint likewise soaked in the oil. 
 
 This method, if steadily pursued, will prevent further 
 secretion of pus ; and even in the deepest incisions required 
 for the treatment of this affection, the whole surface may heal 
 up entirely by granulations, in which the vascular excite- 
 ment is so well controlled that very little pus is formed. 
 
 Now, as to the mode of dressing, I have just one sugges- 
 tion to make of practical value, in regard to prevention of 
 pain to our patient. 
 
 Patients who have been operated on for fistula in ano, 
 often complain bitterly of the pain which they suffer every 
 time lint is pressed deeply into the recesses of the wound, 
 when the wound is dressed. 
 
 Supposing only one fistula has had to be divided (and 
 the remarks would apply equally to each wound if there 
 were several), the plan is this : The patient lies on his left 
 side, in what we may term the obstetric position, with his 
 
 * R. Acid Carbolic puri (dry crystals), gss.; 01. Ricini, fgij. 
 Solve leni calore, at adde Olei Amygdalar. dulc. q.s. ad fsviij. 
 Occasionally, patients are found, in whom, from some special 
 idiosyncrasy, the skin will not tolerate the application of carbolic 
 acid, even when mixed with oil in the most dilute form. In such 
 cases, I have employed with advantage, olive oil, in every fluid 
 ounce of which five grains of precipitated iodoform have been 
 dissolved. 
 
94 HUNTERIAN LECTURES. 
 
 back to the surgeon. As the previous dressings are removed, 
 the exposed surface is quickly and freely covered with the 
 carbolated oil, applied by means of a full-sized camel-hair 
 brush. A strip of lint, half an inch wide and ten inches 
 long, or say the length of the breadth of ordinary lint, is 
 then taken, well saturated with oil. It is folded over the 
 end of a short square-ended flat probe, seen in Plate IV., 
 Fig. D, and held in the right hand, so as to firmly fix it ; 
 or two, three, or more strips maybe oiled, folded, and placed 
 over the end of the probe. The surgeon then prepares the 
 fore-finger of his left-hand by smearing it well with the oil, 
 having, if needful, as an additional precaution, previously 
 filled up the under-surface of the nail with soap or some 
 thick cerate. He than passes the finger up the bowel, 
 being exceedingly careful to direct the pad of the finger 
 on its palmar aspect towards the line of the incision which 
 was made in the operation, and in this way he protects the 
 tender part by gently pressing the finger in its whole 
 length against it. 
 
 He then passes the probe loaded with the strip or strips 
 of oiled lint over the back of his finger (its dorsal aspect), 
 until he knows the probe has entered well into the rectum 
 beyond the end of the left fore-finger ; in fact, beyond the 
 extreme end of the incision. When this is done, the finger 
 is slowly withdrawn and then the probe, leaving the strip 
 of lint well fixed by one end high up in the bowel. After 
 this, the lower portion of the lint, which still lies outside the 
 bowel, is guided on to that portion of the cut which appears 
 externally. It is thus gently pushed or packed into place ; 
 no pain is experienced by the patient, as none of the 
 dressings are dragged over the tender and inflamed surface 
 to which they might have a tendency to adhere. 
 
 On the external surface of the anus, some lint soaked in 
 the oil is then placed ; on it a piece of gutta-percha tissue, 
 
FISTULA IN ANO, 95 
 
 and over this a pad formed of a small folded towel or 
 napkin, kept in position by a broad T bandage, and still 
 further secured by four safety-pins placed at the distant 
 corners of the pad, so as to prevent, by the rolling up 
 of the T bandage, that terrible rope-like disposition of it 
 which is so often seen on removing the dressings in these 
 cases, and which is not half so comfortable or easy to the 
 patient as the gentle pressure of a wide soft pad. 
 
 In every case oi fistula iti ano, even where the healing 
 process has gone on rapidly, and with perfect ease to the 
 patient, I would advise the surgeon, before the case is 
 discharged as cured, to assure himself, by examination with 
 the speculum recti, that the entire length of the incision he 
 has made is firmly healed. If this were done more usually, 
 we should not hear so often of patients requiring what is 
 called a second operation, after an interval in which the 
 direct surgical supervision of the case has been suspended 
 for a time and then resumed. With the plan I advocate, it 
 is one continuous and successful process. 
 
 The surgeon is occasionally asked by the physician to 
 examine and report whether, by reason of certain signs 
 and symptoms, a patient is the subject of early obstructive 
 disease of the lower bowel, benign or malignant. 
 
 I have known such cases, in which an opinion has been 
 given that no obstruction existed in the rectum, at least 
 at the time of the examination, and yet the progress of 
 the case threw doubt on the diagnosis, for, in truth, the 
 existence of the obstruction had not been detected, or 
 the first observer had failed to find it, when another, 
 examining the patient shortly afterwards, could prove its 
 existence. 
 
 This, in some cases I have known of, was due to a 
 peculiar condition of the rectum in early obstructive 
 disease, which I believe is worthy of consideration. 
 
96 HUNTERIAN LECTURES. 
 
 It is this. We pass the finger into the rectum in such a 
 case, move it freely about within its cavity, withdraw the 
 finger, and say there is no obstruction, it is rather a large, 
 loose rectum, and if there is contraction, it is high up and 
 beyond reach. Or, an opinion is expressed that the cause 
 of the obstruction is not organic, but rather functional, as 
 far as the rectum is concerned, for it is so large and loose. 
 
 Now, here it is that the source of error comes in. A 
 more careful examination will show that the enlarged, 
 almost dilated condition of the rectum, just within reach 
 of the finger, was caused by an obstruction higher up in 
 the bowel, which by its resistance to the passage of the 
 faeces had produced such violent expulsory efforts to be 
 made, that there was a descent of the obstructed portion of 
 the bowel into the part beyond, which became thereby 
 stretched and dilated. There had been, as it were, a sort 
 of commencing intus-susception, or involution of the bowel, 
 and the dilated part below the contraction, had conveyed 
 the idea to the finger of the surgeon in making his 
 examination, that the bowel higher up was also large and 
 loose. I have so often found this state of things on 
 examining the rectum in suspected contraction, that where 
 I find the ampulla of the rectum thus unusually capacious, 
 so that the finger, moved sideways, does not easily touch 
 the walls of the bowel, I always suspect contraction higher 
 up, perhaps not beyond the limits of the rectum, and I 
 have generally, by more careful exploration, proved such 
 to be the case. Sometimes this may be done by asking 
 the patient at the moment to press powerfully downwards, 
 imitating for the time the involuntary expulsory move- 
 ments of which he is sometimes the subject, and so the 
 mass of diseased growth may be brought within reach. 
 The same may be effected by change of position of the 
 patient, for in one case, during dorsal decubitus, the 
 
STRICTURE OF RECTUM. 97 
 
 thickened mass may be more easily felt; in another it may 
 be best reached in the lateral position; or even, in some 
 cases, by placing the patient in the upright posture. 
 
 At any rate, I would suggest that this dilated state of 
 the bowel just within the anal orifice must be regarded as 
 a sign of rather doubtful import, as regards the natural 
 patulency of the canal higher up, and perhaps just beyond 
 the limits of our examination. Now this is not a matter 
 of mere curiosity, in which we can afford to wait until by 
 the increase of the contraction, and the distension of the 
 bowel above it, we have revealed its true position ; for the 
 sooner we learn that we have to do with mechanical 
 obstruction, and not merely with atony of the bowel, the 
 better for our patient, since to persevere in the use of 
 powerful aperients in the former case is not only wrong in 
 principle but hurtful in practice. 
 
 Some would say, surely this can be decided by the use 
 of the rectal bougie. This will always establish the fact 
 of stricture, or no stricture, high up in the bowel. 
 
 But like many other signs in surgical practice, this is 
 positive rather than negative in its indications. 
 
 If a large olivary-bougie of moderate size can be passed 
 without resistance eight or ten inches up the rectum, just 
 into the sigmoid curve of the bowel, it is pretty certain 
 that thus far, at least, no stricture exists, nor any contrac- 
 tion of the bowel to a practically serious degree. 
 
 The information thus obtained is positive as far as 
 showing that there is no special contraction of the canal ; 
 whereas, in a case of acute obstruction, if a bougie of 
 average size, or the long O'Beirne's tube, will not pass, or 
 cannot by ordinary pressure be made to pass, this does 
 not supply conclusive evidence that organic contraction 
 is present, that there is stricture of the bowel, or that the 
 canal is permanently narrowed from any insuperable 
 H 
 
98 HUNTERIAN LECTURES. 
 
 cause. The bougie, if not very pliable, and carelessly 
 directed, may impinge upon the front of the sacrum, or, 
 if this bone is more than usually curved, may strike against 
 the upper projecting part of it, and, so failing to pass, 
 simulate the presence of contraction. Or, if the bougie be 
 too soft and flexible, it may have its extremity caught 
 in a fold of the mucous membrane, and there resting 
 awhile may bend upon itself, still passing on into the 
 interior ; and, as I have seen with a long enema-tube, 
 it has curled upon itself so that a great part of the fluid 
 injected through it was shot out of the rectum, in a power- 
 ful stream directly against the operator. 
 
 Therefore, as I have just said, the evidence furnished by 
 the passage of rectal bougies and such-like instruments 
 must be regarded as of value in cases of suspected obstruc- 
 tion, only in a negative sense. If they pass easily for a 
 certain distance, with no indications of having been curled 
 up or bent out of the nearly straight line, well and good ; 
 there can be no obstruction, so far, in the bowel, and the 
 evidence is valuable. But the difficulty experienced in 
 passing such bougies may be apparent rather than real, 
 and so it should always be received with great caution as 
 positive proof of contraction. 
 
 In suspected cases of disease of the rectum, much may 
 be learnt as a preliminary sign, by observing the condition 
 of the anus in reference to size and distance from the 
 surface of the perineum, estimated in its relation to a 
 transverse line between the tubera ischii. 
 
 Here I would confine my remarks to the changes in the 
 condition of the male rather than the female perineum. 
 In the female, from displacements of the uterus and 
 changes incident to parturition, the anal portion of the 
 perineum is often very considerably altered in form. 
 
 Unless in any given case there is some natural peculiarity 
 
STRICTURE OF RECTUM. 99 
 
 of formation, I have noticed very generally that, where the 
 cause of the trouble in the lower bowel was rather one of 
 irritation and spasm than of relaxation and debility of the 
 parts, when the patient is examined while placed on his 
 side, the anus will be seen to be contracted and drawn 
 high up in the perineum, which has therefore a conical 
 configuration, and the anus is held there by undue action 
 of the levator ani, and the closing fibres of the sphincter. 
 There is often, however, an opposite condition of things ; 
 the perineum in its anal portion may be unusually flat, the 
 anus low down, large and protruding, and this will indicate 
 neither spasm nor over-action of the levator, but an opposite 
 condition which permits a falling of the bowel and its 
 passive dilatation, with the commencement, possibly, of 
 slight prolapsus of the gut. 
 
 Obviously the treatment required in these two classes 
 of cases will be different. In the one we must allay irrita- 
 bility by the removal of its cause; or by diminishing, if 
 possible, the sensitiveness of the part in the other, we 
 must endeavour to give strength and tone to the structure, 
 so as to counteract the mischief already done, or limit 
 its advance. 
 
 In the former class we often find a fissure of the anus, or 
 an irritable ulcer of the rectum. Here a digital examination 
 without an anaesthetic is almost an impossibility, for it can 
 rarely be borne by the patient. Yet it may sometimes be 
 effected, and then where the patient can or will consent, if 
 we doubted which of these two forms of disease we had to 
 deal with, I have observed a very simple means of deciding. 
 If it be a case of irritable ulcer in the rectum, generally, I 
 think, on its posterior wall, you may with great gentleness 
 manage to pass the finger into the bowel ; and so long 
 as you do not press sharply or deeply on the ulcer, the 
 pain is bearable. And I have also noticed that you may 
 
lOO HUNTERIAN LECTURES. 
 
 rotate or turn round your finger when it is so placed and 
 still within the rectum, and no special increase of pain is 
 experienced, or perhaps none at all. But not so in the 
 fissured anus or the fissured rectum. In this terribly painful 
 affection, you may, with great gentleness, having the finger 
 well lubricated, get it through the powerfully contracted 
 sphincter, and then, not moving it for a time, the patient 
 may at last tolerate its presence ; but the moment you 
 begin to rotate or twist your finger round, that instant he 
 will call out in great agony, and we know how piteously 
 sometimes such patients express the fearful pain they then 
 experience. 
 
 Fissure of the anus may be easily and certainly relieved 
 by section of the mucous and sub-mucous tissue, without 
 much distress to the patient at the moment of its division ; 
 but an ulcer of the rectum requires a longer and deeper 
 cut, and this can hardly be done without the use of the 
 speculum, and unless the patient be in a state of complete 
 anaesthesia. It may also require constitutional as well as 
 local treatment for its cure. 
 
 I now wish to say a few words on that common condition 
 of the lower bowel, so often brought under the notice of 
 the surgeon, sometimes in an early stage, but perhaps more 
 frequently as a subject for operative interference, and that 
 is the presence of haemorrhoids, or piles, in their various 
 stages or degrees of development. In considering the 
 ways in which piles are formed, we must remember that 
 there is generally, in severe cases, a certain predisposition 
 or proneness to their formation, either independently of, 
 or in addition to, those special habits or modes of living 
 which are said to be their chief cause. 
 
 Whatever these may be, either taken singly or collec- 
 tively, there arc instances to be found of persons who ought, 
 
H/EMORRHOIDS. lOI 
 
 upon all principle, to have had piles, and yet are free from 
 their presence ; and others who have been the subject of 
 them, either at a much earlier period of life than might 
 have been expected, or under conditions of health and 
 habits which ought not to have led to their early 
 development. 
 
 I am inclined therefore to think, from inquiries I have 
 made of patients under my care, that the production of 
 piles, as life advances, is peculiar to some persons under 
 whatever circumstances they may be placed ; and that in 
 these, as compared with others, there appears to be a sort 
 of hereditary tendency to this malady. 
 
 Looking at the subject mechanically and anatomically, 
 I am of opinion that a natural looseness and relaxed 
 condition of the sub-cutaneous and the sub-mucous tissue, 
 in and about the rectum and its neighbourhood, is the chief 
 predisposing cause to the production of external and 
 internal piles. This will be a local cause, while a more 
 distant and more general one must be referred to pressure 
 in advance of the returning current of venous blood in the 
 mesentery, the portal system, or the heart. 
 
 There is of necessity a considerable diiference in the 
 expansible capacity, and in the power of subsequent con- 
 traction exhibited from time to time, by the various tissues 
 placed around the aperture of the bowel, and chiefly those 
 of the deeper layers of the skin. Consider the difference 
 there must be in the condition of the parts surrounding the 
 anus, when it expands sufficiently to permit the passage of 
 a large mass of hardened fseces, as compared with its normal 
 state of rest, or when the aperture is so effectually closed 
 by muscular action that, as Hilton puts it, the mighty power 
 of the sphincter prevails, and flatus is retained within a 
 distended rectum, or is expelled through an aperture too 
 small to allow the passage with it of liquid faeces. 
 
I02 HUNTERIAN LECTURES. 
 
 Now, after these repeated stretchings and expansions of 
 the part, the subcutaneous fibres of the superficial sphincter 
 are the first to suffer, and in process of time they fail to 
 gather up in radiating folds the skin with which they 
 are so intimately incorporated. The skin, left thus 
 loosely disposed around the anal orifice, soon becomes 
 the subject of oedema, which in its earlier stages may 
 subside, to return under similar conditions, until, at last, 
 other causes contributing to the same result, it is not 
 simple oedema which invades the part, but a more inflam- 
 matory condition, with lymph in addition to serum, and a 
 hardening and thickening of the tissue, thus producing a 
 true external pile. 
 
 We owe to Hunter our knowledge that in external piles, 
 frequently but not necessarily, we have a large varicose 
 vein at the base of the pile, and within this vein a clot 
 which gives firmness and definity to the growth, and renders 
 its ultimate subsidence difficult. 
 
 Tracing the alterations which occur in the perivenous 
 tissues, we can understand from recent observations, how 
 an intra-venous clot is hastened in its formation by changes 
 in the endothelium of the vein itself which favour the 
 clotting of the blood. The veins in their upward passage 
 along the walls of the bowel, interlaced with, and surrounded 
 by, the muscular fibres, are already charged with blood which 
 cannot escape. These changes do not so readily occur if 
 the cellular tissue around is not superabundant, but of firm 
 and strong consistence. The same with regard to the 
 earliest formation of internal piles. Here the looseness of 
 the submucous tissue is the great predisposing cause as 
 far as local changes are concerned. We may regard the 
 mucous lining of the lower bowel, for the purpose of marking 
 the changes incident to the growth of haemorrhoids, as a 
 cylinder with two coverings, or rather as three cylinders, 
 
HEMORRHOIDS. IO3 
 
 one within the other, the mucous and the muscular, with 
 the cellular coat between them. In the latter space the 
 vessels, nerves, and lymphatics ramify, and especially the 
 veins, and these lie closely beneath the mucous coat itself. 
 From a variety of causes, such as pressure from above 
 restraining the free return of venous blood, or sudden 
 compression by muscular action, these veins beneath the 
 mucous membrane are rendered tense and swollen, and 
 drag upon the connective tissue which should retain them 
 in position. Thus a temporary bulging and enlargement 
 of the veins is produced, which by repetition becomes 
 permanent ; the blood, which at first was retained within 
 them for only a moment, now no longer leaves them, or if it 
 does, after each act of defecation it escapes more and more 
 slowly, and thus the swelling is perpetuated, and changes 
 are set up which at last culminate in the production of the 
 true hsemorrhoidal tumour, the internal pile. 
 
 But these observations apply chiefly to the alterations 
 which occur in the contour of the veins producing these 
 growths, and do not refer to those arterial vascular tumours 
 of the rectum which, being formed principally by dilated 
 arterial capillaries, and almost naevoid in their character, 
 are the seat of frequent arterial hsemorrhages. 
 
 While we classify piles as either external or internal, if 
 we deal only with their composition, we regard the one as 
 cutaneous, and the other as mucous. But to comprehend 
 their mode of growth, the ultimate consequences, and the 
 part the loose cellular tissue takes in their formation, we 
 must look to the muco-cutaneous pile and observe its mode 
 of development. 
 
 Where a patient has long sufTered from external piles, 
 he may not experience much inconvenience from them 
 by the imperfect action of the sphincter, until the fold of 
 skin increases inordinately, and until there is likewise a 
 
I04 HUNTERIAN LECTURES. 
 
 certain descent of the mucous membrane. This does not 
 return into the bowel, but remains outside. 
 
 Now begins a series of changes which will attract the 
 attention of the sufferer, and surely lead him to seek 
 advice. The portion of the mucous membrane remaining 
 outside, being exposed to contact with the air and to 
 friction of the dress, will become so congested and inflamed 
 as to secrete mucus far exceeding what might be thought 
 possible from so small a surface. The result is that from 
 this rectal blenorrhagia, if I may so term it, there is 
 constant moisture of the part, and with it, very often, 
 superficial ulceration, either of the mucous surface itself, 
 or of the border line of skin near to it. 
 
 This state of things, when once established, will inevi- 
 tably increase. The prolapsus, small as it is, goes on 
 enlarging, and a constant dragging action will be per- 
 petuated, not only by the expulsory movements of the 
 bowel when it will be most excessive, but likewise in the 
 intervals. This is particularly the case where the erect 
 position of the body is long maintained, or where, from 
 fatigue in walking or from any great exertion, the muscular 
 system is exhausted, together with the fibres of the external 
 sphincter, which ought to resist the dropping of the part 
 in the early stage of prolapse. 
 
 I have known patients who have referred their first 
 symptoms of prolapsus or excessive protrusion of the 
 mucous membrane of the rectum to some great exertion, 
 a walk of several miles, or some unusual muscular strain. 
 
 This prolapse of the bowel would be much less likely to 
 occur, if the layer of cellular tissue beneath the mucous 
 membrane were not so excessively loose as to permit its 
 descent, or if the descent of mucous membrane with the 
 enlarged veins beneath it, did not drag upon and elongate 
 the fibres of the cellular tissue itself 
 
PROLAPSUS RECTI. IO5 
 
 These changes, it will be found as the disease progresses, 
 advance with accelerated velocity. The greater the quantity 
 of tissue forced down beyond the line of the external 
 sphincter and held there, the greater will be the actual size 
 of the prolapsus, and of the veins contained within it. 
 
 I do not refer to cases of simple prolapsus recti, such as 
 are seen in children born in hot climates, or who have lived 
 there from an early age. No doubt, with them the looseness 
 of the sub-mucous tissue is the proximate cause of the 
 prolapse, as well as of the atony of the sphincter muscle 
 which should restrain it. But, in these cases, there is no 
 special enlargement of the veins beneath the membrane. 
 If any vessels are enlarged they are the fine arterioles, and 
 hence the scarlet-red colour of the prolapsed part. These 
 remarks apply to cases of ordinary hsemorrhoidal tumour, 
 and the observations I am about to make on the best 
 method of treatment refer entirely to the condition of the 
 sub-mucous tissue. 
 
 First, as to palliative measures for the treatment of piles ; 
 and next, as to the curative, with the best to be selected. 
 Among our preventive and palliative treatment of a general 
 or constitutional nature, we must place foremost on the 
 list, diet and habits of life. These, so far as they lead to 
 plethora and over-distension of the venous system and of 
 the hsemorrhoidal plexuses, will obviously require chief 
 attention ; and where the employment or particular work, 
 in which the patient is engaged, seems to have a tendency 
 to lead to such venous congestion, either general or local, 
 it must, if possible, be corrected. If I might mention any 
 special medicine, or any set of medicines, which I have 
 found to fulfil the conditions requisite to the relief of 
 hsemorrhoidal disorder, with a tendency to constipation, 
 with which it is so generally associated, I would specify a 
 combination of remedies consisting of sulphate of magnesia 
 
 H2 
 
I06 HUNTERIAN LECTURES. 
 
 in moderate doses, with dilute nitric acid to increase its 
 aperient action ; and to give to it a more decidedly 
 chologogue influence, taraxacum as a diuretic, and quinine 
 as a stomachic tonic, for the purpose of correcting that 
 debility of the digestive organs so often the result of the 
 prolonged use of aperients. This is the formula,* and it 
 has often happened to me when consulted by a patient 
 anxious to be relieved by operation of the constant fret 
 and trouble of piles, that, having prescribed this medicine 
 as a preliminary treatment, the effect has been so marked 
 in the way of relief, he has declined the operation, and 
 gone on very well without it. So that I often hesitate to 
 prescribe it, lest the patient should postpone the operation, 
 where I believe, from the frequent recurrence of haemorrhage, 
 an operation would be the proper treatment for the case. 
 
 Where the liver is sluggish, the urine high-coloured, and 
 the alvine secretions are abilious, with nausea or vomiting 
 of bile, I add to the persistent use of the laxative mixture 
 an occasional dose of blue pill, with the dried carbonate of 
 soda which, I believe, assists the action of the mercurial, 
 and enables us to deal with a smaller dose. 
 
 Then for preventive and palliative treatment of a local 
 nature, — to avert a relaxed condition of the sub-mucous 
 tissue, — the daily ablution of the perineum with cold soap 
 and water, applied quickly so as to induce rapid contraction 
 of the capillaries and of the muscular fibres, is, in my 
 opinion, far superior to immersing the buttocks and the 
 pelvis in cold water, as in the cold sitz bath so often 
 
 * R. Quinse Sulph., gr. xij ; Magnes. Sulph., 5J ; Acid. Nitric, 
 dil., f3iij ; ^ther Chloric (Duncan's), f 3iij J Succ. Tarax., f^iss ; 
 Syr. Aurant, f3vi; Aquae g.s. ad fsxij. A wineglassful every 
 morning, an hour before breakfast. 
 
 R. Pil Hydr., gr. iv; Sodae Carb. exsiccat, gr. viij ; Ext, 
 Hyoscy, gr. xij. M. ft. massa in pil. viij equales dividend. One 
 pill at bedtime, occasionally, for three nights in succession. 
 
PROLAPSUS RECTI. IO7 
 
 prescribed. This latter plan may be of service, but has this 
 possible disadvantage, that the vessels on the surface covering 
 so large an area, being suddenly contracted and emptied, the 
 blood is driven from the surface into the veins which corre- 
 spond to the parietal branches of the internal iliac system, 
 the gluteal, sciatic, and internal pudic arteries, producing 
 for the moment, congestion of the visceral plexuses, from 
 which we can never be sure that an effective re-action will be 
 established. Failing this, it is very questionable to me, 
 whether more harm than good is not done by the use of the 
 cold hip-bath, in many haemorrhoidal affections occurring 
 in subjects with feeble circulation and imperfect powers of 
 re-action. Cold applied effectively to a small rather than 
 to a large surface, and that directly in the region where it 
 is intended to act, is not only safer, but much more likely 
 to be beneficial. 
 
 Sir Benjamin Brodie had a plan which was quite in 
 harmony with these principles. He used to instruct his 
 patients with relaxed bowel and tendency to prolapsus and 
 internal piles, to inject a small quantity of very cold water 
 into the empty rectum after each act of defecation, but to 
 use no more in quantity than could be retained with 
 comfort. 
 
 I have found it very beneficial in such circumstances 
 to substitute for the plain water a very weak solution of 
 alum or of tannin, as being of immense service, as a palliative 
 measure, to restrain the enlargement of the veins within the 
 bowel and their subsequent protrusion externally. And 
 in addition to other local applications which I have 
 found very convenient and useful for external piles, I would 
 mention an ointment made of vaseline, in which there 
 are ten grains to the ounce of tannin ; or another, in which 
 finely-powdered nitrate of lead is substituted for the tannin. 
 Where ulceration of the surface does not exist, I prefer to 
 
I08 HUNTERIAN LECTURES. 
 
 use the tannin-ointment, as it is an elegant substitute for 
 the old gall-ointment ; but if the surface of the external, or 
 of the muco-cutaneous, pile is inflamed, the ointment of the 
 nitrate of lead will prove more suitable. 
 
 For the radical cure of hsemorrhoids by their entire 
 removal, while I might enumerate a great number of methods, 
 some of ancient, some of modern adoption, I will content 
 myself with describing one only, which I have found so 
 generally successful as to cause me to discard the others, 
 although perhaps each of the many plans now used by 
 surgeons may have something to be said in its favour. 
 
 For the removal of external piles — that is, the cutaneous 
 pile — I have nothing to add in regard to our ordinary 
 mode of operating, whether done by one cut with the 
 scalpel, or by many cuts with scissors. 
 
 But when we have to treat an advanced case of the 
 muco-cutaneous pile, or a number of internal piles with 
 more or less prolapsus, then their removal, which I strongly 
 advocate, must be proceeded with in a certain orderly 
 manner. 
 
 The means of removal — that is, the instrument used in 
 the operation up to a certain stage, is the scissors, and in 
 this I follow, as I have done in the operation for the 
 removal of the tongue, the method introduced by Mr. 
 Walter Whitehead, who has employed it in the anal region 
 as well as in the mouth. 
 
 I know the prejudice which exists in the minds of many 
 surgeons against the use of scissors, compared with the 
 scalpel, in the removal of parts to be operated upon ; but 
 assuredly where the parts are very vascular, or are liable to 
 be so in certain portions of their structure, a succession of 
 small clips or cuts with scissors, by dividing only minute 
 portions of tissue at a time, with an interval in which we 
 can observe the amount of haemorrhage and deliberately 
 
OPERATION FOR II/EMORRHOIDS. IO9 
 
 control it, is safer in the end than where many blood-vessels 
 are dividedly rapidly with each sweep of the scalpel, and 
 excessive bleeding follows. The scissors which we use 
 should have the end of each blade well rounded (Plate IV., 
 Fig. E), so that it may not scratch or puncture the part 
 against which it is pressed, but only cut across it, somewhat 
 parallel to the surface. The condition of the scissors 
 should be tested beforehand, to prove that they will cut 
 well up to the extreme end ; and this may be done on 
 wetted paper or leather, to imitate the flaccid, yielding 
 structures with which we have to deal. 
 
 The patient being prepared by having had the bowels 
 emptied by the use of gentle aperients for some days pre- 
 viously (rather than by one large dose just on the day of 
 the operation), and an injection of glycerine and warm 
 water an hour before, I place him in the lithotomy position, 
 and secure the limbs with anklets and wristlets in the usual 
 way. The first tlq^ng is to dilate the anus, and to draw 
 down so much of the lining membrane of the bowel, with 
 the enlarged veins beneath it, as will enable us to judge 
 accurately of the size and extent of the growths. I have tried 
 many plans for this purpose, but none have answered with 
 me so well as to pass an ordinary bivalve rectal speculum 
 well into the bowel, expand the blades, and while so 
 expanded withdraw the instrument. The mucous mem- 
 brane, if it is at all loose, can then be completely drawn 
 out by two or three of such manipulations. This done, 
 and the prolapsed bowel being kept outside the anus, I 
 proceed to make a number of cuts with the scissors just 
 within the line of junction between skin and mucous mem- 
 brane — that is, in the mucous membrane itself — passing 
 round the bowel, except perhaps at one or two places 
 where the continuity of the circle thus formed may be 
 interrupted by little bridges of the muco-cutaneous mem- 
 
no HUNTERIAN LECTURES. 
 
 brane. This is not needful if the cutaneous tissue around 
 the anus has been much relaxed ; but if it is at all tight 
 and unyielding, it is prudent to do so, to prevent the 
 formation of an uninterrupted annular cicatrix, which 
 by its firmness might afterwards interfere with the free 
 expansion of the external orifice of the bowel. 
 
 After cutting round the anus in this manner, going on 
 more and more deeply in every succeeding circuit, the 
 scissors will get into the cellular space between the mucous 
 membrane and the muscular wall of the lower part of 
 the rectum. 
 
 We know that we are within it when we see the muscular 
 fibres ; and we take care not to go too near to the mucous 
 membrane, nor to cut through it. 
 
 As this is being done, we see the haemorrhoidal growths 
 lying on the outer surface of the separated inner cylinder. 
 Here and there in this cellular space a small vessel may 
 be wounded. If this is done, as we watch carefully the 
 effect of each clip of the scissors, it is easy to seize the 
 bleeding point with Sir Spencer Wells' very useful pressure- 
 forceps. To stop the bleeding for the moment we may 
 twist the vessel there and then. 
 
 Having thus separated the mucous cylinder with the 
 haemorrhoidal enlargements and the companion vessels, 
 from its attachments, we divide it into several smaller 
 portions, each of which will contain a bunch of vessels 
 as an haemorrhoidal growth. 
 
 These being still further isolated by one or more cuts in 
 the mucous membrane, we twist off" each separately, with 
 torsion-forceps, curved and fashioned as seen in Plate 
 IV., Figs. F F, having made the base narrow enough for 
 that purpose, and any bleeding being stopped by the means 
 already mentioned. 
 
 When two or three of these small masses have been so 
 
OPERATION FOR IlyEMORRHOIDS. Ill 
 
 removed, we seize the mucous membrane left above them, 
 and sew it by means of a needle curved, as in Plate IV., 
 Fig. G, which serves as a hook to draw down the mucous 
 membrane, as well as to pierce the skin around. In the 
 plate, this needle is shown loaded with a fine ligature of 
 considerable length, which has been passed through the 
 eye of the needle, then through a fine loop of steel above 
 its angle, and, lastly, through a hole drilled obliquely 
 through the handle itself.* In this way we can make 
 several stitches, cut off each in succession without reloading 
 the needle with thread, and so save much time at this 
 stage of the operation. 
 
 If we do not secure the mucous membrane in this way 
 before all the masses have been twisted off, we lose com- 
 mand over it, and it slips out of convenient reach. This 
 plan, which is of Mr. Whitehead's suggestion, is of very 
 great practical importance. 
 
 When the last hsemorrhoidal mass has been thus 
 separated, and the mucous membrane has been fixed to 
 the skin, not too tightly lest the sutures holes might 
 ulcerate too rapidly, a perfect ring is left at the orifice 
 of the bowel, with some eversion or out-rolling of the 
 mucous lining, which serves to determine the escape of 
 any discharge from the rectum while the parts are healing. 
 This disposition of the mucous membrane secures the 
 important fact, that the only part from which haemorrhage 
 can arise after the operation, being in the space between 
 the mucous cylinder and the one formed by muscular 
 structure, all the bleeding that may occur must be external 
 and visible, and proper measures can be had recourse to 
 for its control. There can be no concealed or internal 
 haemorrhage, but whatever blood or serum may escape 
 
 * This can be traced in the Plate with the help of a magnifying 
 lens. 
 
112 HUNTERIAN LECTURES. 
 
 after the operation will show itself externally, where it 
 can be easily and effectually dealt with. 
 
 The next step is to place a morphia suppository within 
 the rectum, and lodge it high up in the bowel by a 
 proper instrument, and then to smear the divided surfaces 
 with the carbolated oil. The after-treatment of the case 
 locally, consists in the free and persistent application of 
 the oil to the part, so that it may serve as a means of 
 protection from the air, and from the irritation or poisonous 
 action of any of the discharges from the bowel. It will 
 be found to be as successful here as in the after-treatment 
 of cases of operation for fistula in ano. 
 
 I will not go into the merits of this particular mode of 
 operating as compared with other methods. I will only say 
 I believe it to be very safe and very effective. It is a 
 tedious operation — that is to say, it takes much time ; but 
 if rapidity in operating is no longer our test of excellence, 
 I am sure this plan of removing internal piles by torsion 
 will meet the approval of all who will give the operation 
 a fair trial. 
 
 Thus have I brought to an end the lectures I have had 
 the honour to give as Hunterian Professor in this College, 
 and it only remains for me to thank you with all sincerity 
 for your attendance here, and the considerate way in which 
 you have listened to my remarks. 
 
 I fear that to many it may seem as if much I have said 
 has been so self-evident and so generally admitted as to 
 render its repetition quite unnecessary ; but, as far as mere 
 detail is concerned apart from theory or special views in 
 the practice of a surgeon, nothing which may help to 
 bring about successful results can be called needless or 
 unimportant. 
 
 The surgeon may devise an operation of great utility ; — 
 
CONCLUSION. 113 
 
 the architect may design a house in all its due proportions: 
 but in either case it is by detail, and by detail alone, that 
 success is secured; safety to the patient, or perfection in 
 the building, in which every stone and beam shall have 
 been so fashioned beforehand as to contribute, however 
 slightly it may be, to the completeness and security of 
 the whole. 
 
 I know there are some who always very lightly value 
 minutiae, and are apt to advocate plans of action founded 
 upon general principles alone, regardless of detail ; but as 
 the whole is made up of its component parts, so our 
 proceedings can only be rendered certain in effect by 
 watching every point, however seemingly trivial, with 
 scrupulous care. 
 
 If we contemplate the artistic skill exhibited by Sir 
 Wm. Ferguson in his operations on the palate; the bold yet 
 quiet work of Sir Spencer Wells in his abdominal sections ; 
 or the thoughtful ingenuity of Sir Joseph Lister in 
 designing his operation for the excision of a diseased 
 wrist-joint, or in wiring a fractured patella — men worthily 
 decorated by Her Majesty in acknowledgment of their 
 high professional reputation — we may safely adopt as our 
 motto, Chirurgiis ornatus magims est in magnis, maximns 
 in minimis. 
 
INDEX. 
 
 Abscesses in neck, Treatment of, 13 
 Alcohol as an agent in the advance of 
 
 Stricture, 68 
 Artificial Teeth, Cases of swallowing, 
 
 31 
 
 ,, Delusive ideas as to 
 
 having swallowed, 
 
 35 
 Atrophy of Prostate after puncture, 47 
 
 B 
 
 Bladder, Chronic Catarrh of, 66 
 ,, Foreign bodies in the, 53 
 ,, Supra-pubic puncture of the, 
 
 45 
 Burns and Scalds, Treatment of, 15 
 
 Calculus lodged behind large Prostate, 
 
 51 
 
 Cancer of the Tongue, Diagnosis of, 37 
 ,, Division of the 
 
 gustatory nerve in, 36 
 Catheter in its most portable form, 43 
 Cervical glands. Sub-acute enlarge- 
 ment of, 12 
 Cicatrices from Burns, General treat- 
 ment of, 16 
 ,, in urethra, a cause of 
 Stricture, 64 
 Cleft palate and its treatment, 28 
 
 ,, with Bryant's lateral inci- 
 
 sions, 30 
 
 Epithelioma on the face, 18 
 Etiology and Causes of urethral Stric- 
 ture, 61 
 
 Face, Unsightly cicatrices upon the, 7 
 ,, Wounds of the, 2 
 
 Fictitious metallic click in Bladder, 
 
 Cause of a, 57 
 Filiform Bougies, Size of, to be very 
 
 slowly increased, 73 
 Fissure of Anus and ulcer of Rectum, 
 Diagnosis between, 100 
 ,, of the Lip, Treatment of, 25 
 Fistula in ano. Causes and progress of, 
 78 
 ,, How to examine with 
 
 accuracy, 83 
 ,, Obscure cases of, 89. 
 
 ,, lodineinjectiontotrack 
 
 the sinus in casps of, 
 91 
 ,, Mode of dressing after 
 
 operation for, 93 
 Fistulje, Treatment of urethral, 72 
 Foreign body in Bladder seen through 
 Endoscope, 53 
 
 Gonorrhoea, Antiseptic treatment of, 
 
 65 
 Gunpowder, Removal of marks caused 
 
 by, 5 
 
 H 
 
 Htemorrhoids, Causes and progress of, 
 
 lOI 
 
 ,, associated with prolap- 
 
 sus recti, 104 
 , , Palliative treatment of, 
 
 107 
 ,, Operative treatment of, 
 
 108 
 ,, Removal of, by W. 
 
 Whitehead's method, 
 no 
 Hare-lip in its simple forms, 26 
 Harrison's Whip-bougie in the treat- 
 ment of fine strictures, 73 
 Herniaa in infants. How to treat, 50 
 
ii6 
 
 INDEX. 
 
 I 
 
 Internal Urethrotomy, Stages to be ob- 
 served in the operation 
 of, 74 
 ,, Precautions necessary 
 for safe performance 
 
 of, 75 
 „ Careful after-treatment 
 essential in, 76 
 Ivory as a centre for phosphatic deposit 
 in the Bladder, 56 
 
 Lip, Chronic fissure of the, 25 
 Lupus on the face, 18 
 
 M 
 
 Metallic click in Bladder may be simu- 
 lated, 59 
 
 N 
 
 Nrevi on the face, 21 
 
 ,, Treatment by Vac- 
 
 cination, 22 
 
 ,, Treatment by the 
 
 Needle-cauteiy, 23 
 
 Os hyoides, Cornua of, to be felt 
 
 through the pharynx, 33 
 Ozoena caused by irritation in tooth, 9 
 
 Paresis of shoulder muscles from tooth- 
 
 iiTitation, 10 
 Phymosis in infants as a cause of 
 
 Hernia, 47 
 Potassa fusa as an escharotic, 19 
 Prophylactic treatment of Stricture. 
 
 Early dilatation, 69 
 
 Rectal Bougies, True value of evidence 
 
 produced by, 98 
 Rectum dilated below a contraction, 
 96 
 ,, Prolapsus of, 104 
 
 Scalds and Bums, Treatment of, 14 
 
 Sealing-wax as a centre for phosphatic 
 deposit in the Bladder, 57 
 
 Sinuses on Face and Neck, 1 1 
 
 Stricture of Urethra; its insidious pro- 
 gress, 65 
 
 Strictured urethi-a rarely straight, but 
 tortuous, 71 
 
 Supra-pubic puncture of the Bladder 
 in retention, 44 
 
 Supra-pubic puncture of the Bladder 
 in the treatment of Stricture, 45 
 
 Tannin discs for oozing haemorrhages, 
 
 25 
 
 Teeth, Consequences of irritation from 
 carious, 9 
 
 Temporal Muscle, Spasm of, from 
 Tooth-irritation, 9 
 
 Tongue, Removal of the entire, by 
 W. Whitehead's method, 37 
 
 Tonsils, Removal of, under chloro- 
 form, 31 
 
 Traumatic Stricture to be treated, if 
 possible, before puberty, 62 
 
 u 
 
 Umbilical hernia in infants, 49 
 
 Urethra, Stricture of the, 60 
 
 Urine, Retention of, with overflow, 39 
 
 W 
 
 Worsted truss. The, in infants, 48 
 Wounds, Foreign bodies in, 3 
 
 Palmer &= Howe, Printers, yj, 75, and yy, Princtss Street, Manchester, 
 
7^ 
 
COLUMBIA UNIVERSITY LIBRARIES 
 
 This book is due on the date indicated below, or at the 
 expiration of a definite period after the date of borrowing, as 
 provided by the rules of the Library or by special arrange- 
 ment with the Librarian in charge. 
 
 
 
 
 
 DATE BORROWED 
 
 DATE DUE 
 
 DATE BORROWED 
 
 DATE DUE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 C28(i14i)mIOO 
 
 
 
 
IID521 
 Lund 
 
 f?T>s-^l 
 
 1.97 
 
 c. r\ttiC> C\XL — txlfi 
 
 COLUMBIA UNIVERSITY LIBRARIES (hsLstx) 
 
 RD521L97C.1 
 
 Huntenan lectures on some of he iniur 
 
 2002231344