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vened. Patients have been attacked with a shivering fit theday after the operation : there has been a quick, irritable con-dition of the pulse, accompanied perhaps by profuse per-spiration, and want of sleep. These symptoms have con-tinued, the patient’s tonglie becoming brown and coated, and,in a certain number of cases, the patient has died. On apost mortem examination, some purulent infiltration has I

generally been found about the neck of the bladder, or some secondary inflammation in other parts. Now how are we to account for such different results in the I

practice of various surgeons of equal skill? I believe that

something like a solution may be arrived at by an attentiveconsideration of the description which Mr. Syme has given ofhis operation.In the way in which he performs it, the only fascia concerned,

as he says, is that which lies immediately under the integu-ments. In other words, he divides only the skin, superficialfascia, and the urethra. Now it is clear from this description,that all the strictures which he has operated upon have beensituated anterior to the membranous portion of the urethra;for had he operated upon any stricture in the membranousportion of the canal, even though situated quite at its anteriorpart, he must have been in danger of wounding the deep peri-neal fascia as well as the superficial. Hence, then, arises a prac-tical distinction of the utmost importance. When a strictureis situated in the bulb of the urethra, it may be divided fromwithout, and any urine which escapes from the passage is sureto pass out at the external wound. But the circumstances are- different when the knife, in passing along the grooved directoror sound, perforates the deep perineal fascia, and wounds theurethra as it passes through this part. The urine which escapesfrom the passage may then lodge in the wound made in thedeep perineal fascia, and a drop or two may become infiltratedbehind this dense structure. It will there give rise to inflam-mation, and having no means of escape, will produce violentconstitutional irritation. When once inflammation is establishedin the cellular tissue of this part, its products will permeate theareolar tissue, and may thus propagate the inflammation to theoutride of the bladder, and to the cellular tissue within thepelvis, thus giving rise to the abscesses and the purulent infil-tration which I have mentioned.But where the incision is confined to the superficial fascia,

and to the bulb of the urethra, there is, as I have said, verylittle danger of any of these accidents occurring; and by-e-hoosing his cases, (as it were,) and confining himself to thosein which the stricture is situated anterior to the membranouspart of the urethra, Mr. Syme has met with the success towhich I have alluded.Hence there appear to be two classes of cases: those in which

the stricture is situated in that part of the urethra correspond-ing to the corpus spongiosum, and those in which the strictureis at the anterior part of the membranous portion of the urethra.In the former situation, as far as our present evidence goes, the- stricture may be divided with comparative impunity; in thelatter, most severe and even fatal symptoms have followed.But practically, it will be asked, how are we to know that a

stricture is confined to the bulb of the urethra, or to any partin front of this? Where an instrument can be introduced, thepoint may be made out in this way, and Mr. Syme neveroperates unless he is able first to introduce an instrument intothe bladder.

In the case to which I have drawn your attention, I was ledto believe that I might with impunity divide the stricture, fromthe circumstance of Mr. Guthrie having divided it by internalincision before, without any ill effects. This proved to me,.either that the stricture was confined to the bulb of the urethra,or, if situated farther back, that the surrounding parts were soconsolidated by inflammation as to preclude the danger whichmight arise from infiltration of urine." We now pass to the third case on our list, in which the opera-

tion was performed according to Mr. Syme’s method, with someimprovement, possibly, towards the latter part of the proceeding.

ST. MARY’S HOSPITAL.EXTERNAL DIVISION IN STRICTURE OF THE URETHRA.

(Performed by Mr. COULSON.)RICHARD S-, aged forty-four years, was admitted, Sep-

tember 16th, 1854, with severe stricture. His stream of urinewas very small, being compelled to pass it every hour oroftener in the day, and at night came away involuntarily.The latter fluid was alkaline, and loaded with thick ropymucus. In addition to his local symptoms, the patient hada cough, to which he had been subject for some time past.

His countenance was pale and anxious; his flesh and strengthmuch reduced. He had been suffering from stricture for manyyears past, and an attack of retention having come on, heapplied at this hospital.No. 2 catheter was then passed with much difficulty, and

the urine drawn off. After a short stay in the hospital, hisgeneral health improved considerably, and dilatation has beenrepeatedly tried, but no instrument, however small, after the firstweek, could be got into the bladder. The stricture was situatedat the bulb, and on pressing the perinasum, it felt like a hardcartilaginous ring; and from repeated attempts at dilatation,a false passage just in front of the stricture had been made.

In consequence of the character, extent, and duration of thestricture, Mr. Coulson proposed external division as the coursemost likely to afford the patient relief.

October 11th. - After considerable difficulty, Mr. Syme’ssmallest grooved staff was passed through the stricture, andthe contracted part divided upon it.

Mr. Coulson commenced his incision in the median line,terminating it half an inch in front of the anus, the incisionbeing nearly two inches in length. The staff was soon reached,and the knife passed along it, from behind forward, cuttingthrough a gristly, unyielding substance, of which the stricturewas composed. A straight grooved director was then passedunder the staff into the bladder. The staff was withdrawn, anda No. 8 catheter introduced without difficulty.The catheter was now firmly fixed by tapes, and the patient

removed to bed. During tse operation, which occupied lessthan two minutes, Mr. Coulson kept the thumb and forefingersof the left hand on either side of the raphe, so that the incisioncould not deviate from the central line, a point to which heattached much importance.

Before the staff was withdrawn, Mr. Coulson passed, as

stated above, a grooved director from the external wound intothe bladder, which instrument served as a guide to the intro-duction of the catheter. This latter plan may be of essentialservice in obviating any difficulty which might arise in reach-ing the distal extremity of the urethra.The elastic catheter, thus introduced with the aid of the

director, was retained fifty-four hours, and then withdrawn.It was introduced again at the end of a fortnight, since whichit has been passed twice a week.The patient’s general health has considerably improved, he

passes urine in a good stream, and a No. 10 catheter can beintroduced into the bladder without the least difficulty.

This was clearly a case in which dilatation could not anyfurther have been tried with any chance of success. Thehardness and extent of the stricture, the difficulty of gettingeven the smallest instrument through it, and the existence ofthe false passage, would have been insuperable difficulties inthe way of this plan of treatment.

In concluding the relation of this case, and of the series, wewould just remark, that the more we see of stricture of the

urethra and its disastrous consequences, the more we areinclined to hail those operative measures which, broughtforward by men of experience, hold out a prospect of givingrelief to a class of patients whose sufferings are very great.Let not, however, the profession be exclusive; let us examinewith impartiality the remedial means which are proposed, and,as there is considerable variety in the cases brought beforesurgeons, they should be acquainted with the different lines ofpractice which have been proposed. We shall not add a wordto the remarks we made last week respecting the merits of theinternal or external incision ; and shall only express the hopethat the treatment of stricture may be conducted with allthe vigour and decision which are imperatively called for in soannoying and dangerous an affection.That stricture of the urethra is really an affection which

eventually puts the patient’s life in great peril, is well knownto every member of the profession; we shall, however, merely,by way of illustration, adduce two aggravated cases, in whichthe fatal consequences could not be averted by the best effortsof the surgeon. The details were drawn up by Mr. Holmes,surgical registrar to the hospital; and the post-mortem exami-nations made by Dr. Ogle and Mr. Gray, conservators of themuseum.

ST. GEORGE’S HOSPITAL.ENLARGEMENT OF THE PROSTATE GLAND; BLADDER DILATED,

HYPERTROPHIED, AND SACCULATED; PERFORATION OF THE

ENLARGED PROSTATE BY THE CATHETER.

(Under the care of Mr. TATUM.)JoHX S-, aged seventy-seven, was admitted May 9th,1854. This old man when admitted was in a state of senile