BLISS 
 
 
 
 * * * * *c* *' * - * * * 
 
 
 An inaugural Dissertation 
 
 
 on Permanent Strictures 
 
 
 of the Urethra 
 
 
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 intijeCttptflettigork 
 
 College of 3Pf)p£tctan* anb ^burgeons 
 Htfcrarp 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/inauguraldissertOOblis 
 

 N */ : 
 
 AN 
 
 INAUGURAL DISSERTATION 
 
 ON 
 
 PERMANENT STRICTURES 
 
 OF THE 
 
 URETHRA: 
 
 SUBMITTED TO THE PUBLIC EXAMINATION OF THE 
 
 TRUSTEES AND PROFESSORS OF THE COLLEGE 
 
 OF PHYSICIANS AND SURGEONS IN THE 
 
 UNIVERSITY OF THE STATE OF 
 
 NEW-YORK, 
 
 SAMUEL BARD, M. D. President, 
 
 FOR THE DEGREE OF 
 
 DOCTOR OF MEDICINE, 
 
 ON THE 1ST DAT OF MAY, l8lj. 
 
 BY JAMES C. BLISS, 
 
 Licentiate in Medicine and Member of the American Mfculaftan Society, 
 
 TROY: 
 
 PRINTED BY PARKER AND BUSS. 
 
 April, 1 8 15. 
 

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 ^.3&>x gS 
 
 a. 
 
 
TO 
 
 SAMUEL BORROWE, M. B, 
 
 ONE OF THF SURGEONS OF THE NEW-YORK HOSPITAL, 
 
 Sir, 
 
 Permit me to dedicate this Dissertation to 
 you, as a teftimony of my refpect for your diftin* 
 guifhed profeffional character ; as well as my regard 
 for you as a Gentleman, Friend, and Inftru&or. 
 
 JAMES C. BLISS. 
 
f* 
 
TO 
 
 DR. ELY BURRITT, 
 
 THIS THESIS IS INSCRIBED 
 AS A 
 
 TRIBUTE OF GRATITUDE 
 
 FOR HIS VALUABLE INSTRUCTION IN THE EARLY PART 
 OF MY EDUCATION, 
 
 AS WELL AS AN 
 
 EXPRESSION OF ESTEEM 
 
 FOR HIS PRIVATE VIRTUES. 
 
 JAMES C. BLISS, 
 
DISSERTATION 
 
 ON PERMANENT 
 
 STRICTURE OF THE URETHRA. 
 
 INTRODUCTORY REMARKS. 
 
 LITTLE was known with regard to the nature ©f 
 Stricture, till the accurate inveftigations of Mr. John 
 Hunter were made public. 
 
 This gentleman nut only gave us the firft accurate 
 account of the affection, but fuggefled one of the moft 
 important improvements in its treatment. The bougie 
 was known^as early as the year 1535, as mentioned 
 by Alphonldus Ferrus ; but it does not appear that its 
 ufe was generally adopted till recommended by Daran* 
 Even as late as the year 1750, Mr. Hunter informs us, 
 that the common bougie employed in the firft Hofpi- 
 tals in London, was either a piece of lead or a fmal! 
 wax candle. 
 
 Mr. Hunter has been feconded with much zeal and 
 Induftry, by his kinfman, Mr. Home, who has given 
 to the world one of the moft elaborate and at the fame 
 time the beft practical treatife on the difeafe, which 
 we poffefs. 
 
a 
 
 Few difeafes have more engaged the attention of 
 furgeons, within a few years, than the one now the 
 fubject of remark : hence we have been furnifhed with 
 a great number of publications on Stricture, poifefling 
 various degrees of merit. 
 
 The bold manner in which the cauftic was firft re- 
 commended, gave rife to fome controverfy among fur- 
 geons ; and although much ingenuity has been dif- 
 played and labour expended, yet little practical advan- 
 tage has refulted from this difcuffion. 
 
 Although we muft acknowledge much has been 
 written recently on this fubject, deferving little consid- 
 eration among the great number of publications which 
 have appeared, yet many important obfervations have 
 been made, and valuable inferences drawn well entitled 
 to the regard of the iurgeon. 
 
 Mr. Charles Bell has written an excellent little trea- 
 tife on difeafes of the Urethra ; and has fuggefted 
 fome novel ideas with regard to the nature of Stric- 
 ture and its treatment. * v 
 
 It is proper here, alfo, to mention the excellent pa- 
 thological obfervations of Mr. Ramfden, on difeafes 
 of the Teflicle, as connected with primary affections 
 of the Urethra, in which are developed many impor- 
 tant facts which had before eluded the obfervation of 
 furgeons. 
 
 We are indebted to a furgeon of our own country, 
 Dr. Phyfick, of Philadelphia, for the propofed method 
 of treating Strictures, under certain circumftances, by 
 the ufe of a cutting inftrument : a mode which f he 
 
9 
 
 Doctor himfelf has Jafijpi^fl^put in practice, m a 
 number of inftances. 
 
 Wifeman, firfl fuggefted the ufe of cauftic in the 
 treatment of Stricture, but it does not appear that it 
 was ever employed to any extent, till revived by Mr. 
 Hunter, who is juflly entitled to the credit of origin- 
 ality, for it does not appear that at the time he pub^ 
 lifhed the account of his treatment of Stricture by 
 cauftic that he was acquainted with the fad, that it 
 had before been propofed by Wifeman. 
 
 The introduction of cauftic in the cure of Stricture, 
 was doubtlefs one of the greateft improvements ever 
 made in the treatment of this formidable difeafe, and 
 Mr. Hunter for this, as well as other improvements 
 in furgery, is juflly entitled to the character of a ben^ 
 efactor of mankind. 
 
 B 
 

 M<! 
 
DISSERTATION, &c. 
 
 I. THE Urethra is a tube extending from the neck 
 of the bladder to the extremity of the glans penis, and 
 through the greater part of its courfe runs in the infe- 
 rior part of the penis. It ferves the purpofe of con- 
 veying the urine from the bladder, and the femen to 
 the vagina of the female. 
 
 It is lined by a mucous membrane, fimilar in ftruc- 
 ture to the mucous membranes lining other paffages 
 of the body. Its fenfibility is exceedingly acute, and 
 its fympathies extenfive and remarkable. 
 
 This membrane, from its flructure and office, ex- 
 periences fudden dilatations, as in the expulfion of the 
 urine, &c. and is equally liable to fall into a collapfed 
 ftate, when the diftending caufe is removed. In its 
 collapfed ftate, like the membranes lining the ftomach ? 
 bladder, &c. under fimilar circumftances, it falls into 
 folds, which project into the canal. 
 
 It has been obferved, under certain circumftances^ 
 to poffefs the power of contraction ; this power is re- 
 markable in inflammation attendant on gonorrhea vi~ 
 rulenta, in which difeafe, in fame inftances., the canal 
 
12 
 
 is fo contracted that the urine pafies in a very fmail 
 ftream or by drops. Every furgeon has been accuf- 
 tomed to notice the firm manner in which the bougie 
 is frequently embraced, when an attempt is made to 
 withdraw it after its introduction into the urethra. 
 The ftream of urine, likewife, has long been noticed 
 to be contracted when the acrimony of this fluid is in- 
 creafed by the watery parts of the blood being dimpa- 
 ted, in warm feafons and in warm climates, by per- 
 fpiration. 
 
 From thefe fads has arifen the opinion, that the 
 urethra pofTefles mufcularity. This opinion was par- 
 ticularly advocated by Mr. Hunter. 
 
 It has been urged, that its mufcularity is evinced by 
 fpafms occurring in Stricture and under other circum- 
 fiances. This contraction, however, is evidently anal- 
 ogous to that which takes place in other membranes, 
 when acted upon by a proper ftimulant. 
 
 This is more particularly exemplified in the con- 
 traction of the fkin ; which, in ftructure, is more near- 
 ly allied to the mucous membranes, than to any other 
 membranes of the body. 
 
 The particular form of Stricture, has been mention- 
 ed as another proof of the exiflenceof mufcular fibres^ 
 the canal appearing as if a pack-thread or riband was 
 tied around it. 
 
 But there appears to be no reafon why this contrac- 
 tion, if it depended upon mufcular action, mould take 
 place in one part, and not another. Further, it is a 
 well known fact, that a very great proportion of Stric- 
 tures of the urethra, do not confift in a diminution of 
 
*3 
 the whole circumference of the canal, but are frequent/ 
 ly confined to a very fmall part of it. Now, it is ve- 
 ry evident, that no action of a tranfverfe or circular 
 fibre, would produce fuch an effect. 
 
 The difference of the ftream in the evacuation of 
 urine, and in the emiffion of femen, has been adduced 
 as another evidence of the mufcularity of the urethra* 
 But this difference can be accounted for by the com- 
 preffion which the canal fuffers in the diftended ftate 
 of the cells of the penis, the ftrong manner in which 
 the prepuce embraces the penis at the corona glandis ; 
 and the violent and convulfive action of the ejaculator. 
 femmis mufcle. 
 
 That the formation of Stricture, near the bulb of 
 the urethra, is influenced by the action of the mufcles 
 connected with this pari is probably true ; as this is 
 one of the moft common feats of Stricture and of 
 fpafm : but it does not neceffarily follow that the for- 
 mation of Stricture depends upon mufcular contrac- 
 tion, or even upon fpafm. 
 
 The urethra has a great number of lacunas open- 
 ing into its paflage. They run in a longitudinal direc- 
 tion, from behind forwards. There are two near the 
 glans penis, more confpicuous than the reft. Thefe 
 lacunae are frequently fo far enlarged by difeafe, as to 
 interrupt the free paffage of the bougie or catheter j 
 the point of the inftrument lodging in them. 
 
 From a caft, which Mr. Home made of the ure- 
 thra of a man at 80 years of age, it appears that this 
 canal is feven-twentieths of an inch in diameter in the 
 
u 
 
 narrowed part, and eleven-twentieths in the wideft. 
 In a fubjed at thirty years, there was fome inconfide- 
 rable variation. 
 
 It appears, alfo, from thefe cafts, that the paflage is 
 moil contra&ed in thofe parts of the canal moft liable 
 to Stricture, viz. at four and a half and feven and a 
 half inches from the external orifice. 
 
 II. The older furgeons had formed a very imper- 
 feci: and indiftin£t notion, with refpecl: to the real na- 
 ture of Stricture. 
 
 They had afcribed it to fungus and caruncles, or 
 flefhy tumours fimilar to the polypus of the note and 
 re&um. * 
 
 It was not till the nature of Stricture was more com- 
 pletely unfolded by morbid diffe&ions, that thefe opin- 
 ions were abandoned. But notwithltanding thefe 
 opinions were relinquifhed, one, perhaps more objec- 
 tionable, was embraced by Mr. Hunter ; which was, 
 that the difeafe confifted in a mere contraction of the 
 fibres of the lining membrane of the urethra. This 
 contraction was fuppofed to be partial, in the firft in- 
 stance, but eventually to become fo confiderable a^ 
 completely to obftrudt the paflage of urine. 
 
 This opinion we do not feel difpofed to admit, for 
 the reafons already given. It can hardly be fuppofed 
 that a Permanent Stricture can be induced in this ca- 
 nal by the contraction of a fmgle or a fet of fibres, if 
 thefe fibres be endowed with the properties of mufcu- 
 larity to which relaxation as well as contraction is ef- 
 fential. This fuppofed unyielding tonic fpafm, has no 
 
15 
 
 analogy with any phenomenon exhibited in any other 
 part of the body, in health or difeafe. 
 
 We fhould, therefore, hardly be willing to admit, 
 even if mufcular fibres were found to exift in this 
 membrane, that their contraction could be productive 
 of Stricture. This opinion is more particularly in- 
 dulged, from taking into confideration the extreme 
 degrees of relaxation and tenfion which this mem- 
 brane in rapid fucceffion undergoes.* We are by no 
 means drove to the neceflity of attributing the forma- 
 tion of this difeafe to fuch a caufe, when we reflect, 
 that in the mod healthy ftate of this canal, this mem- 
 brane is puckered and thrown into a great number of 
 loofe folds, by the compreflion which the canal fuffers 
 from diftenfion of the cells of the penis, when erected, 
 and the violent action of the mufcles furrounding the 
 bulb of the urethra, in the expulfion of the urine and 
 femen. 
 
 The real caufe of the fimpleft form of Stricture, 
 which gives the idea of the paflage being embraced by 
 a cord, appears to be inflammation of the Urethra ;f 
 caufing a thickening of the internal membrane of this 
 paflage. Another confequence of this procefs, and 
 one which contributes to the obftruction, is an effu- 
 fion of lymph exterior to this membrane ; by which 
 
 * In the London Medical Review, vol. 3d, a cafe is related of a boy, 
 3ged four years, in whom the urethra was dilated to fuch an extent by 
 means of fpOnge, that it permitted three calculi of the fize of a large 
 nutmeg to pafs. They were of an irregular wedge-like £hape, and weigh- 
 ed, on an average, from fixty to feventy grains each. 
 
 f This opinion has been advocated by Mr. C. Bell, and other diftin- 
 guifhed Surgeons* 
 
i6 
 
 means adheiions take place, the cells of the penis are 
 glued together, and a ridge is formed which projects 
 into the urethra. The broad or riband Stricture, 
 appears to afiume this form, by a diminution of the 
 canal taking place in the interfpace between two Am- 
 ple Strictures, which previoufly exifted. This kind 
 of Stricture is alfo induced by inflammations \ and, in 
 iome inftances, acquires almoft a cartilaginous hard- 
 nefs, and calls for the moil affiduous perfeverance in 
 the ufe of cauftic for its removal. 
 
 The Stricture in which there is a thickening, of 
 folding of the internal membrane, forming a ridge in 
 the fide of the canal 3 is obvioufly owing to the fame 
 caufe as thofe before mentioned. Two or three of 
 this kind are frequently met with in the courfe of the 
 urethra, and can, in general* be readily diftinguifhed, 
 by the imprefliofi which they make on the bougie. 
 
 Inflammation and fpafm are frequent concomitants 
 of Permanent Stri&ure of the Urethra. The latter 
 probably ariies from the fyrnpathy which exifts be- 
 tween the fphinfter vefic& and the lining membrane 
 of the paffage. Any caufe which gives rife to irrita- 
 tion in the Urethra, will produce fpafm ; as the in- 
 troduction of the bougie,, the application of cauftic^ 
 coition-, intemperance in drinking, expofure to the vi- 
 dfhtudes of weather, violent exertions, non-compli- 
 ance with the calls of nature in evacuating the blad- 
 der, &c. &c* 
 
 When from any of thefe caufes fpafm is induced;, 
 bleeding, the warm bath, and anodynes., generally af- 
 ford relief, 
 
»7 
 
 As has been before obferved, Strictures moft com- 
 monly occur about feven inches from the external 
 orifice, juft at the point where the membranous part 
 of the urethra terminates in the bulb. 
 
 This point, it has been fully afcertained, is the moft 
 irritable part of the urethra. We are in poffeffon 
 of fads which lead to the belief that it is the feat of 
 fpafm in ftrangury, induced from the application of 
 blifters. Another fact which proves this part to be 
 more peculiarly irritable, is, that it is fympathetieally 
 affected, if we may be allowed the expreflion, with 
 inflammation in gonorrhea virulenta, Thefe circum- 
 ftances, without doubt, give rife to the more frequent 
 occurrence of obftructions in this part of the canal. 
 
 The next moft frequent feat of the difeafe, is at the 
 point where the penis takes its bend from the pubis, 
 about four and a- half inches from the extremity of 
 the glans. 
 
 Why this part mould be more than commonly fub- 
 ject to Stricture, is obvious from the circumftance of 
 the canal at this point, inftead of being left loofe and 
 free, as in other parts of its courfe, being fupported 
 by the Ugamentum fufpenforium, by which means an 
 acute bend is made, and this part receives the whole 
 force of the urine in its expulfion. 
 
 Irritation and inflammation from gonorrhaa, or any 
 other caufe, extending to this part, is kept up by this 
 means, and refults in the formation of Stricture. Ob- 
 ftructions very frequently occur within two or three 
 Inches of the extremity of the urethra ; the occur- 
 C 
 
i8 
 
 rence of them at this part is doubtlefs owing to its 
 being the ufual feat of inflammation in gonorrhoea. 
 
 Befides thofe parts already mentioned, Strictures 
 fometimes take place juft at the extremity of the ca- 
 nal ; but thefe cafes are comparatively rare. 
 
 III. From the view which we -have taken of the 
 fubject, it is obvious that Stricture may arife from any 
 caufe producing inflammation of the urethra. 
 
 One of the mod common caufes, therefore, is gon- 
 orrhoea virulenta. This fo commonly gives rife to it, 
 that we may venture to aflfert, that five cafes out of 
 fix arife from this difeafe. The effects of it are pre- 
 cifely fuch as we have defcribed as producing Stric- 
 ture. In the firft inflance, a thickening of the mem- 
 brane takes place \ the inflammation extending deeper 
 into the reticular membrane of the penis, an effufion 
 of lymph follows, adhefions form, and the fides of the 
 canal are thrown into more immediate contaft. When 
 irritation has once begun, it is kept up ; the Stricture 
 becomes firmer and more perfect, till an almoft total 
 interruption to the paflage of urine is induced. 
 
 Another very common caufe of Stricture, is the ufe 
 of ftrong injections, or the employment of them at 
 an improper period for the cure of gonorrhoea. 
 
 The paflage of calculi through the urethra, which 
 from the mechanical violence produced, caufes in- 
 flammation, though feldom acknowledged as a caufe 
 of Stricture, is doubtlefs much more common than is 
 generally admitted. 
 
 Frequent and long continued action of the mufcles 
 turrounding the urethra, as in difficult mi&urition. 
 
*9 
 and in coifu, becomes likewife another fource of Stric- 
 ture, from the irritable and inflamed ftate of the ure- 
 thra induced thereby. The intemperate ufe of vinous 
 and fermented liquors, the mechanical violence done 
 to the parts, and the formation of abfcelTes in the pe- 
 nis, have been frequent caufes of Stricture. 
 
 Deep and foul chancres have in fome inftances 
 been followed by Stricture, in confequence of the in- 
 flammation extending to the lining membrane of the 
 urethra. The unnatural vice of felf-pollution, alfo, 
 hsemorrhois, and other affections of the rectum, 
 may be included among the caufes of this difeafe. 
 
 LV. It has been generally remarked, tfiat the fymp- 
 toms of Stricture in the firft inflance, give fo little in- 
 convenience that they pafs unnoticed by the patient. 
 A diminution in the ftream of urine, with more fre- 
 quent calls than natural to evacuate the contents of 
 the bladder, uneafinefs experienced in the courfe of 
 the urethra and at the neck of the bladder, and a 
 gleety difcharge from the canal, are among the fymp- 
 toms which firft excite the patient's attention,. 
 
 Mod of thefe fymptoms are aggravated by any 
 thing which produces irritation in thefe parts ; as ex- 
 ceffes in drinking ; violent exercife^, particularly on 
 horfeback, or in a carriage ; indulgences with wo- 
 men ; difob^iience to the calls of nature in evacuat* 
 ing the bladder ; an attack of gowrrhaa ; expofure 
 fo cold, &c. &c* 
 
 Thefe caufes frequently give rife to fpafm, and a 
 total fuppreffion of urine is the confequence. A very 
 painful fenfation is fometimes experienced in the 
 
20 
 
 courie of the urethra, in the act of coition, and the 
 femen inftead of paffing in its proper channel is thrown 
 back into the bladder. 
 
 In other inftances, confiderable finarting takes 
 place, and a difcharge from the urethra follows, 
 which is liable to be miftaken for gonorrhea. The 
 Stricture becomes more complete, the patient is con- 
 tinually harraffed with a defire to pafs urine ; which 
 is evacuated in a fmall ftream or by drops, and is 
 obliged frequently to rife from bed in the courfe of 
 the night. 
 
 Violent pain is experienced in the fmall of the back 
 and in the loins : uneafinefs in the groins perinaeum 
 and upper part of the thighs. 
 
 The patient has involuntary emimons of femen ; 
 and very frequently, from lofs of power in the blad- 
 der, has incontinence of urine. The fyftem at large 
 partakes of difeafe from fympathy. A paroxjrfm of 
 fever, refembling, in every effential point, an attack 
 of intermittent, very frequently occurs in thofe affect- 
 ed with Stricture. Any flight excefs, expofure to vi- 
 ciflitudes of weather, undue exertions of body, the 
 introdu&ion of a bougie and application of cauftic, 
 may all be exciting caufes of a fit. 
 
 Other very common attendants are, derangements 
 of the ftomach, want of appetite, naufe^and vomit- 
 ing. To thefe may be added, thofe peculiar fenfa- 
 tions which are the ufual accompaniments of nervous 
 difeafes. 
 
V. Strictures of the urethra frequently throw the 
 unfortunate patient into the moil dangerous and loath- 
 fome ftate. 
 
 The portion of the canal between the Sri&ure and 
 bladder becomes dilated, from the circumftance of its 
 experiencing, in a greater degree, the expulfive efforts 
 of the bladder. Inflammation follows ; fometimes fo 
 acute as fpeedily to deftroy the patient. Under other 
 cireumftances, it is more flow in its progrefs : ulcera- 
 tion is produced ; the urine becomes effufed into the 
 furrounding cellular membrane ; foul and floughy 
 abfeefies form, which burn: externally and form fiftu- 
 3ae, through which the urine conftantly efcapes. Thefe 
 fiftulae are frequently extended by the formation and 
 burfting of new abfcefles. 
 
 The patient's general health, under thefe circum- 
 fiances, fuffers to a great degree. He has repeated 
 paroxjfms of fever, lofs of appetite, profufe fweats, 
 great debility, and not unfrequently this complicated 
 fuffering is terminated by death. 
 
 In fome inftances, the urine becomes fo extenfively 
 
 effufed into the cellular membrane, that inftead of a 
 
 e 
 
 formation of matter being the confequence, fphacilus 
 is immediately induced, and the patient is at once de- 
 ftroyed. 
 
 One effect of Permanent Stricture, is to increafe 
 the thicknefs of the coats of the bladder. This is 
 probably, in part, to be afcribed to irritation or a lefs 
 degree of inflammation being produced by diftention 
 of the bladder, and the frequent efforts which are 
 made to pafs urine : but, it appears, in a jgreat meaf- 
 
22 
 
 ure, owing to the increafe of power requifite for the 
 expulfion of the urine, and the confequent increafe of 
 the mufcular fibres of this organ. 
 
 When a total obftru&ion to the paffage of urine oc- 
 curs, great diftention of the bladder, inflammation and 
 fphacilus, are frequent confequences. Ulceration of 
 the bladder, in fome inftances, alfo takes place, and is 
 accompanied with a difcharge of pus with the urine. 
 The ulceration, it appears from difieftions, has extend- 
 ed quite through the coats of the bladder, and the 
 urine has been effufed into the cavety of the abdomen. 
 In other ijiftances it has not extended through the pe^ 
 ritoneal coat, but the urine has pafled into the cellular 
 fubftance behind this membrane. 
 
 The effects of firicture frequently extend beyond 
 the bladder. The ureters becnme much enlarged, 
 and at times very much inflamed. The kidneys like- 
 wife become diltended and inflamed, by the aqjumu- 
 lation of urine, and the inflammation not unfrequent- 
 ly extends to the furrounding cellular membrane. 
 
 The fever confequent to bbftru&ions in the urethra, 
 and accumulation of urine, has frequently terminated 
 in eftufions on the brain. The fluid thus effufed has 
 alfo, in fome inftances, been obferved to have a urin- 
 ous fmeil. 
 
 VL Whatever might have been the opinions, exift- 
 ing formerly, relative to the treatment of Strictures ,• 
 there can be but one, at prefent, among the intelli- 
 gent of the profeflion. The bougie and the cauftic 
 have rendered the treatment of this difeafe fo fafe, and 
 at the fame time fo perfect, that we can not look for 
 
2 3 
 
 any material improvement. Perhaps in no furgical 
 difeafe involving fuch important confequences, is the 
 treatment more perfect and fo much to be relied on, 
 
 The commonly received opinion, that the bougie 
 operates by dilating a Permanent Stricture like the 
 operation of a wedge, is evidently erroneous : nor, 
 perhaps, is the opinion that itsfuccefs depends on the 
 production of ulceration, lefs exceptionable. Believ- 
 ing, as we do, that Permanent Stricture does not de- 
 pend upon the contraction of a fmgle or a fet of fibres., 
 we cannot, for one moment, fuppofe, that its cure is 
 attributable to the dilatation of a contraction which 
 never exifted. 
 
 That ulceration, in fome inftances, takes place by 
 the ufe of the bougie, and that a cure is by this means 
 effected, is without duubt true $ and it is equally true 3 
 that when a cure is thus effected, an unwarrant- 
 able and even a hazardous degree of violence muft 
 have been employed. 
 
 The fimple fact appears to be, when the bougie iV 
 judicioufly employed, that the preffure of the inftru* 
 ment caufes an abforption of the new formed fub~ 
 fiance, between the folds of the lining membrane 
 forming the ridge in the canal. The effect of pref= 
 Aire, in promoting abforption, is very remarkable, 
 and well illuftrated in anurifm and in an ulcerated 
 leg. In the latter inflance, the luxuriant granulations 
 are abforbed, and the remote edges brought into more 
 immediate contact, by abforption from the cellular 
 membrane of the matter producing fwelling ; both of 
 which effects are brought about by the equal and gm~ 
 
24 
 
 tie preffure of a roller bandage. By this fttode of 
 ufing the inflrument, a very large majority of Stric- 
 tures may be overcome ; whilll thofe dreadful evils ? 
 which are the refult of the mod undue and barbarous 
 violence, are avoided. It is by ufing the bougie in 
 fuch a manner as to produce the effect above men- 
 tioned, that the furgeon is freed from the cenfure 
 of having made falfe paffages ; of having laid the 
 foundation of incurable fiflulas, and of having paved 
 the way to a fatal mortification of the parts. It is by 
 the adoption of fuch pra&ice alone, that he can be ac- 
 quitted of the imputation of cenfurable ignorance. 
 
 Perhaps in every cafe where a bougie can be paiTed 
 into a Stricture, and the irritation is fuch as to be ea- 
 fily borne, this inflrument ought to be relied on for 
 its removal. 
 
 It is true that this mode of treating Stricture ren- 
 ders the cure tedious ; and it is equally true, that the 
 permanency of the cure is in fome meafure uncertain. 
 Yet the prejudices of patients are fo ftrong againft 
 the ufe of cauflic, that in general it is better to give 
 way to them and adopt this mode of practice, in pre- 
 ference to giving alarm and exciting unneceiTary fears. 
 
 The gum elaflic bougie, in general, may be prefer- 
 red, for the cure of Strictures fituate in the part of the 
 canal anterior to the bulb of the urethra ; but for thoft 
 beyond this point the common plafter bougie is pre- 
 ferable ; as it more readily takes the curve in the ure^ 
 thra, and is lefs liable to find for itfelf a new palfage. 
 
 As it regards the length of time the bougie fhoulc? 
 be permitted to remain in the urethra, wfe ought, in 
 
*5 
 
 every inftance, to be governed by the degree of irrita- 
 tion which is produced, and the fenfibility of the pa- 
 tient to its application. It may, in general, be laid 
 down as a rule, that the longer the inftrument can be 
 retained without material inconvenience, the better. 
 The urethra, mod: generally, in a fhort time becomes 
 accuftomed to its ftimulus, and the cure advances with 
 much more rapidity than when it is applied at long 
 intervals and for a fhort period of time. 
 
 But whilft the perfevering application of the bougie 
 is thus infifted upon, in thofe cafes in which the irri- 
 
 . tation in the urethra is flight and the inconvenience 
 of the application inconfiderable, yet, whenever much 
 pain is excited, followed by inflammation, the further 
 ufe of it becomes a queftion. There can be little doubt, 
 that in many inflances, it aggravates the difeafe for the 
 
 . eure of which it is employed. 
 
 A pretty accurate opinion can be formed of thena- 
 
 . ture of the Stricture, by the impreflion .made on the 
 
 .point of the inftrument, and by the fenfation commu- 
 nicated to the finger. If it mould be one in which 
 the diminution is equal throughout the whole circum- 
 ference of the canal, the impreflion will correfpond on 
 the point of the inftrument. 
 
 In like manner, if but a part of the circumference 
 is difeafed, but a part of the circumference of the bou= 
 gie will receive the impreflion. If the Stricture is un- 
 ufually indurated, a fenfation will be communicated to 
 the finger as if the inftrument encountered a hard re- 
 filling body. This fenfation is fimilar to that which 
 ivould be communicated by the inftrument coming in 
 
contact with a piece of cartilage. This variety of the 
 difeafe, if it exift to great extent, is feldom materially 
 benefitted by the bougie ; it rarely yields but to the 
 ufe of cauftic. 
 
 VIII. The application of cauftic, to a part of fuch 
 importance as the urethra, is well calculated to excite 
 alarm in the minds of thofe unacquainted with its 
 operation. This alarm would not probably be leffen- 
 ed from obferving the acute fenfibility of this canal 3 
 and the intimate relation its healthy ftate has with im- 
 portant functions of the body. 
 
 So ftrong have been the prejudices againft this rem- 
 edy, that notwithftanding the undeniable teftimony we 
 have of its fuperior efficacy, we are not wanting in men, 
 Handing high in the profeffion, who would mrink from 
 its employment. 
 
 Like many other new remedies, it has without 
 doubt, in many inftances, been abufed. It has like 
 moft new remedies been ufed almoft indiscriminately ; 
 and we are not to be furprifed that its ufe mould in 
 fom-e inftances have been attended with injurious con- 
 iequences. But this does by no means militate againft 
 its general efficacy and value as a remedy. 
 
 Much of the oppofition to it has unqueftionably 
 arifen from a miftaken notion relative to its operation^ 
 as well as a want of experience with regard to its ef- 
 fects : Hence, thofe whofe obfervation and experience 
 have been moft extenfive, have been the moft ftrenu- 
 ous advocates for its employment. 
 
 In thofe cafes in which a bougie can not, without 
 violence, after perfevering efforts, be pafled through 
 
27 
 
 a Stricture, there can be no doubt that cauftic deferves 
 the precedence. The irritation confequent to its ap- 
 plication, bears no comparifon to that which follows 
 the violence ufually employed in pafling the bougie 
 into this kind of Stricture. 
 
 There are cafes in which the fmallefl fized inftru* 
 ment can not even be parted into the Stricture. Un- 
 der thefe circumftances, the bougie ought to yield to 
 the more efficacious and even fafe application of the 
 cauftic. Every practitioner who has had much expe- 
 rience in this difeafe has met with cafes in which there 
 was an extremely irritable ftate of the ftrictured part,. 
 
 This peculiar ftate of the canal frequently remains 
 obftinately unyielding to the ufe of the moft effica- 
 cious remedies ordinarily employed for its relief. The 
 ufe of the bougie, under thefe circumftances, aggra- 
 vates the affection to an almoft infupportable degree. 
 But this irritation will frequently yield to one or two 
 applications of the cauftic, by which means the fenfi- 
 bility of the part is deadened in the fame manner as 
 the pain of an extremely irritable ulcer is removed 
 by the ufe of the fame remedy.* 
 
 There is yet another kind of Stricture, which can 
 be dilated to a certain extent, but which will again re- 
 cover itfelf and refift our perfevering efforts with the 
 bougie. This form of Stricture requires for its radi- 
 cal removal the cauftic. Some remarks on the ope- 
 ration of this remedy would not perhaps be improper 
 in this place. 
 
 * An ulceration of the cornea which is. rendered extremely irritable 
 and painful by the ccnflant pafTage of the teara over the part, is alio re- 
 lieved by cauftic. 
 
The effect of the cauftic commonly employed, is not 
 to produce a deep and extenfive flough of the parts to' 
 which it is applied. Its operation is more fuperficiaL 
 When applied to a fungous excrefence, it appears rath- 
 er to operate by ftimulating the abforbent veffels to : 
 remove the part, than by producing an abfolute de- 
 struction in the living principle. 
 
 Its effects are well illuftrated on that kind of ulcer 
 which has a furface covered with fpongy and luxuri- 
 ant granulations. 
 
 Thefe granulations will rapidly difappear by the ufe 
 of cauftic, and a florid healthy furface is prefented, 
 ilrongly difpofed to heal. 
 
 In an ulcer of an indolent character, in which the 
 difcharge is thin and gleety, and the granulations lan- 
 guid and flabby, by its ftimulating operation it con- 
 verts the difeafed part into a fimple purulent ulcer, 
 difcharging well formed pus and throwing up healthy 
 granulations. 
 
 It would appear, therefore, from thefe fads, that its 
 operation does not wholly confifl in caufing a deftruc- 
 tion of parts, but that it has the peculiar effect of chang- 
 ing the difeafed action, and of promoting the abforp- 
 t^on of morbidly formed parts. 
 
 The manner of applying this remedy, as commonly 
 recommended, is perhaps, generally fpeaking, unex- 
 ceptionable. We firft pafs a moderate fized bougie, 
 well befmeared with oil, down to the Stricture, and 
 mark on the inftrument the diftance of the Stricture 
 from the external orifice. After the bougie is with- 
 
29 
 
 drawn we oil the armed inftrument, and having given 
 it the proper curve, introduce it into the urethra and 
 pafs it fteadily forward till it encounters the Stricture, 
 
 The length of time the cauftic fliould be permitted 
 to remain in contad with the Striclure, mull be in-, 
 fluenced altogether by the fenfibility of the patient to 
 its application. In general, half a minute will be fuf- 
 ficient ; in fome inftances it cannot be retained fo long, 
 whilft in other cafes no great inconvenience is experi- 
 enced from its being applied a greater length of time. 
 
 Whilft houfe furgeon to the New-York hofpital, F 
 had an opportunity of obferving the effects of another 
 mode of applying cauftic, which was firft fuggefted 
 and employed by the diftinguimed and practical fur- 
 geon doctor Richard S. Kiflam* one pf the furgeons 
 &£ that institution. 
 
 This^ method of applying cauftic does not, in princi- 
 ple, eftentially differ from thofe which have heretofore 
 been recommended ; but under certain circumftances 
 it appears to poffefs a decided fuperiority. It confifts 
 in firft dipping the extremity of a fmall fized gum elaf- 
 tic bougie into a faturated folution of cauftic. The 
 inftrument is then to be laid afide, for a fhort time, 
 that the cauftic may concrete. A canuia is after- 
 wards introduced into the urethra, and carried down 
 to the obftruction, and the bougie thus armed is paifed 
 through this inftrument into the Stricture. 
 
 In Strictures extending fome diftance in the courfe 
 of the canal, this manner of employing cauftic prom* 
 ifes to be peculiarly ufeful. 
 
Many of thefe Strictures are remarkably firm and 
 indurated, and their cure by the application of cauftic* 
 in the common manner, is often tedious and protract- 
 ed. This can in a great meafure be obviated by em- 
 ploying the bougie dipped in a cauftic folution. 
 
 It poffefles all the combined advantages of the cauf- 
 tic and common bougie, and not only operates in de- 
 ftroying the ftricture in the fame manner as the com- 
 mon armed inftrument, but it alfo a&s laterally on the 
 ftri&ured part, by which means the difeafe is cured 
 with much more facility than when the ordinary me- 
 thod is employed. 
 
 The application of the common armed bougie is 
 fometimes followed by a total fuppreffion of urine 9 
 which not only creates material inconvenience, but in 
 fome inftances ferious apprehenfions for the fafety of 
 the patient.* This effect is caufed by the Hough which 
 is feparated by the cauftic ; and probably, alfo, by the 
 effufed lymph obftru&ing the canal. As far as my 
 obfervation extends, this effect never has nor is likely 
 to follow the ufe of the bougie, armed with the cauftic 
 folution. 1 think I am further warranted in faying, 
 that the irritation which follows the ufe of cauftic 
 in this way, is confiderably lefs than what follows that 
 of the common armed inftrument. This probably is 
 owing to the remedy being applied more extenfively 
 to the irritable furface, by which means its fenfibilitj 
 is diminifhed to a greater extent than by a more par- 
 tial application of cauftic. There is another mifchiev- 
 
 * See cafe in the appendix. 
 
3* 
 ous~ effect avoided ; which is, the flipping of the cauk 
 tic from the bougie into the urethra, during its appli- 
 cation. 
 
 This mode of ufmg cauftic is more particularly ap- 
 plicable to Strictures fituate anterior to the membran- 
 ous part of the urethra ; but it may be applied be- 
 yond this point, without difficulty, if a filver or gum 
 elaftic catheter, the extremity of which has been re- 
 moved, be ufed for a canula. 
 
 A folution of the lunar cauftic may be employed 
 for arming the bougie, or the corrofive muriate of 
 mercury, both of which folutions mould be faturated 
 in excefs, in order that a concretion may readily take 
 place on the inftrument. 
 
 Another cauftic, and one which appears preferable 
 to either of the above, is formed by the union of equal 
 parts of the corrofive muriate of mercury and water, 
 with the additition of fufficient of the muriate of am- 
 monia to render the fublimate foluble. By dipping 
 the extremity of the inftrument into this folution, a 
 fmall quantity remains on it and afiumes a cryftalized 
 form. 
 
 It perhaps might be objected, that this cauftic would 
 probably be productive of too violent effects on fo ir- 
 ritable a part as the urethra ; but the fmall quantity 
 of cauftic which adheres to the inftrument, will effect 
 ually prevent any of thofe bad confequences which 
 might be naturally apprehended. 
 
 I feel perfuaded, from the trials which I have made 
 of it, that if it is cautioufly employed it h Ids likely 
 
.3 2 
 
 to be followed by inflammation than when the com- 
 mon mode of applying cauftic is adopted. 
 
 With refpect to the cauflic potalh, which has been 
 fo favorably fpoken of by Mr. Whately, its ufe has 
 been fo limited in this country, as hardly to admit of 
 an opinion being formed from the experience of our 
 own furgeons. Its efficacy, however, has been fully 
 tefted by the furgeons of Europe, and it does by no 
 means appear to have equalled the expectations form- 
 red of it upon the recommendation of fo refpectable 
 authority. 
 
APPENDIX. 
 
 1 he following cafes are fubjoined more particularly 
 for the purpofe of illuftration, than from any peculiar cir- 
 cumstances attending them : for this reafon the more prom- 
 inent circumftances are briefly noticed, in preference to en- 
 tering into a more minute detail. There are feveral, how- 
 ever, which may not be wholly uninterefting to thofe whofe 
 obfervation has been confined to the cafes which ordinarily 
 occur in private practice. 
 
 Cafes of Simple Striclure, in which the common Bougie was 
 employed* 
 
 P — r D y, aged 59 years, feaman, was admitted 
 
 into the New- York hofpital, Auguft 30, 1814, with Stricture 
 of the urethra. He had been affected with the difeafe 1 5 
 years. He voided his urine fome times by drops, at others 
 in a forked ftream. 
 
 The ufe of the common bougie was directed night and 
 morning for his relief : the employment of the inftrument 
 was followed by confiderable hemorrhage from the urethra, 
 at every application, but no material irritation enfued. 
 
 On the 4th of September, the Stricture was patted, and 
 on the 28th the patient was difcharged. At this time he 
 could pafs his urine in as full a ftream as ever, although a 
 boUgie of the largeft fize had not been pafTed into the bladder, 
 
 J — — n R_e, born in Scotland, aged 42 years, was 
 received into the New-York hofpital April 12, 1814, with 
 Stricture. He began to experience difficulty m difcharging 
 E 
 
34 
 
 urine nine years before, and for the laft fix had paflfed it 
 guttatim* 
 
 A Stricture was encountered at about five and a half inch- 
 es from the extremity of the glans penis. By the afliduous 
 employment of the elaftic gum bougie, one of a fmall fize 
 was paused through three days after his admiffion, A larger 
 inftrument was then ufed, and the fize gradually increafed. 
 On the 23d of April he was difcharged from the hofpital. 
 Five months after this period he had no return of difficulty 
 in evacuating his urine. 
 
 B e H d, born in the ifland of Cape de Verd, 
 
 aged 33 years, feaman, was admitted June 16, 181 4, with 
 Stricture of the urethra, and fyphilis. The Stricture was fit- 
 uate about fix inches from the extremity of the glans. He 
 palTed his urine frequently and in a fmall ftream ; had pain 
 in the loins, &c. He was put on the ufe of the ufual rem« 
 edies for the cure of fyphilis, which difeafe he had in the 
 form of chancre and bubo. 
 
 After the difappearance of thefe fymptoms, a fmall fized 
 gum elaftic bougie was panned through the Stricture with 
 fome difficulty, and from the little irritation which the in- 
 ftrument produced, he was able to retain it in the urethra 
 almoft uninterruptedly. 
 
 At the time he was difcharged, (July 27,) a bougie of 
 large fize could be readily introduced into the bladder, and 
 the urine was difcharged in a full ftream. 
 
 j s O'B n, born in Ireland, aged 4 1 years, waiter, 
 
 was admitted into the New- York hofpital May 4, 18 14, 
 with Stricture. He contracted gonorrhoea about twelve months 
 previoufly, and had experienced difficulty in evacuating his 
 urine ever fince that period. He had Stricture fituated about 
 two inches from the extremity of the penis. This one could 
 be pafTed by a fmall fized bougie. There was alfo another 
 about fix inches from the external orifice. The patient had 
 
35 
 pain in the lumbar region, and in the perineum, a flight 
 difcharge from the urethra and fcalding in making water. 
 
 The common bougie was employed in the ufual manner 
 for his relief, and on the 19th of May a fmall one was paff- 
 ed into the bladder. This inftrument was afterwards ex- 
 changed for one of a larger fize, and the patient was fo com- 
 pletely relieved, that he was difcharged from the hofpital on 
 the 13 th of June. 
 
 J n H n, aged 26 years, was admitted on the 8th 
 
 of November with Stricture. He had -been laboring under 
 the difeafe for two or three years. He paffed his urine in 
 a very fmall ftream, with much difficulty, and had occafion- 
 al attacks of ague with fever. A Stricture was paffed at 
 about fix inches from the external orifice, by «a moderate 
 fized bougie. Its further prqgrefs was interrupted at about 
 feven, by another Stricture. The bougie was feveral times 
 pafied into this, by which means the patient was enabled to 
 evacuate his urine with freedom. The inftrument, however, 
 was never introduced into the bladder. The patient having 
 been fo materially relieved, refufed to remain in the houfe 
 till a cure could be effected. 
 
 Cafes of Strifiure with Fifluia relieved by the Bougie, 
 
 J n P— — s, bom in Grenada, aged 27 years, a col- 
 ored fervant, was admitted February 5, 18 14. The patient, 
 at the time of his admiflion, had incontinence of urine. He 
 had alfo a fiftulous opening a little anterior to the fcrotum, 
 through which the greater part of the urine was difcharged. 
 There was confiderable hardnefs and thickening about the 
 opening. The fcrotum was fwollen, thickened and hard ; 
 and the prepuce had undergone the fame change and pro- 
 jected about two inches beyond the glans penis, The patient 
 complained of great pain and forenefs of the parts. This 
 'rate of parts, it appeared from the patient's own account,. 
 
36 
 had arifen from the dFufion of uriiie into the cellular mem- 
 brane. He had, with his other fymptoms, great pain in the 
 loins and perinaeum. His general health rather impaired. 
 On paffing a bougie into the urethra a Stricture was found 
 to exift three and a half inches from the external orifice. 
 He had been affected with clap fix years before, and began 
 to experience difficulty in difcharging his urine fix or eight 
 months before his admiffion, attended with frequent and 
 urgent defire to evacuate the contents of the bladder. Six 
 weeks before he was admitted, the difficulty became fo great 
 that the urine could only be pafTed in drops, and in a fhort 
 time he pafTed it involuntarily. About three weeks after 
 this, ulceration took place, and the urine was difcharged 
 through the opening anterior to the fcrotum. About this 
 time the fcrotum and prepuce became fuddenly fwollen, and 
 from this period to that of his admiflion into the hofpital, 
 he experienced much pain. A fmall fized bougie was pafTed 
 into the Stricture, and directed to be retained as long as the 
 ftate of the parts would permit. The ufe of the inftrument 
 was continued till the i oth of February, at which time one 
 Stricture was overcome : but another was immediately en- 
 countered, fo that the fymptoms of the patient were in n# 
 way relieved. On the 16th of February, he was directed to 
 take of the Spir. Terebin. one drachm in an emulfion of 
 gum Arabic daily ; and a blifter was applied to the perinae- 
 um. On the 2 oth he had not been benefitted by the rem- 
 edies directed on the 1 6th. He complained of confiderable 
 pain at the neck of the bladder, which he attributed to his 
 medicine. At this time the bougie could be introduced a 
 little further. On the 17 th of March a fmall fized inftru- 
 ment was palled into the bladder. On the 23 d he was able 
 to retain his urine half an hour, and but little was difcharg- 
 ed by the fiftulous opening. At this time a bougie of con- 
 fidcrable fize was pafTed into the bladder, The fiftulous 
 
37 
 opening was completely healed on the 9th of April. On 
 the 1 6th of May, three and a half inches of the prepuce 
 which had become elongated and converted into a peculiar 
 ligamentous fubftance, was cut off. After this period a tu- 
 mor made its appearance at the part where the opening had 
 previoufly exifted, anterior to the fcrotum. This tumor 
 fuppurated and prevented the patient's being difcharged till 
 the 5th of Auguft. 
 
 C — — s K— y, born in England, aged 68 years, (hoe- 
 maker, was admitted into the New-York hofpital Auguft 5, 
 18 14, with fiftuU in perin<£Q) connected with finufes in the 
 neighboring parts. The urine was difcharged in considera- 
 ble quantities through the opening, and the patient's gener- 
 al health confiderably impaired. There was djfttric'ture fit- 
 uate about four inches from the external orifice. He had 
 once been affected with gonorrhoea. He was firft affected 
 with fiftula three years before he was admitted, and it had 
 been healed feveral times, and again broken out. After h^.s 
 reception the fiftula was freely dilated to give a ready exit to 
 the pus and urine. A bougie, alfo, of fmall fize, was paffed 
 into the Stricture, and in the courfe of one week, by its cau- 
 rious application, the Stricture was overcome. This was 
 followed by immediate relief in all the fymptoms of the pa- 
 tient ; the fiftula rapidly healed, and he was difcharged on 
 the 30th of Auguft. 
 
 Cafes of Stritlure with JFijlula in Perinteoy in which the common 
 armed Bougie was employed. 
 
 V— — s J ff, born in Germany, aged 53 years, who 
 followed the profeflion of porter, was admitted 1 7th Decem- 
 ber, 18 1 3, with Stricture. In July of the fame year, the 
 patient received a very fevere injury in the perinseum, by 
 falling aftride the chime of a ca£k. This injury was follow- 
 M by effufion of urine, and Houghing of the perineum and 
 
3» 
 urethra. The urine was difcharged through an opening in 
 perinxo two or three weeks after this period, but he was (6 
 far recovered as to be difcharged from the hofpital on the 
 i oth of September following. The perinaeum was feveral 
 times ulcerated after he left the hofpital, but he did not ex- 
 perience any material obftruction in the paffage of his urine, 
 till four days previous to his fecond admiffion. The com- 
 mon bougie was firft employed. On the firft of January 
 the obftruetion ftill continued, and the old fijlula in perina* 
 had again opened. The cauftic at this time was directed to 
 be ufed. The patient was difcharged from the hofpital on 
 the 1 1 th of March, cured of both affections. 
 
 C— ee W - v, d, born in Africa, was admitted into the 
 hofpital A9IMP25, 1814. Tne patient, at the time of his 
 admiffion, had a fiftulous opening in the perinaeum, through, 
 which the urine conftantly efcaped, and he paffed it alfogwf- 
 iatim by the natural paffage. He was unable to give any 
 fatisfadtory account of his previous difeafe. A Stricture was 
 found to exift five inches from the extremity of the penis. 
 A bougie of fmall fize was introduced into the Stricture, and 
 kept applied for fome time every day. On the fourth day 
 the Stricture was paffed ; a larger fized inftrument was then 
 employed. The fijlula in perinao was healed in a fortnight 
 after his admiffion, and he was difcharged from the hofpital 
 on the 28th of June. On the 16th of September the pa- 
 tient again returned to the hofpital, with fijlula in perinao 9 
 and difficulty in paffing his urine. With thefe fymptoms 
 he alfo had occafional febrile paroxifms. The common bou- 
 gie was again reforted to, and was employed for fome time 
 with very little advantage : it was then laid afide, and the 
 cauftic applied. On its fecond application the principal 
 Stricture, fituate at about {even inches from the external or- 
 ifice, was paffed. The opening in the perinaeum was very 
 foon after this clofed. In October, an ordinary fized cathe- 
 
39 
 
 ter was introduced into the bladder with eafe. By the in* 
 cautious ufe of the bougie, by himfelf, after this period, con- 
 iiderable inflammation was produced, which was fucceeded 
 by the formation of another fiftulous opening in the perinse- 
 um. The patient was difcharged from the hofpital on the 
 1 8th of January, 1815, at which time the fiftula had healed 
 and he difcharged his urine without difficulty, 
 
 Cafes of Strifture with incontinence ofnrine, treated by Cauflic. 
 
 W- m D — — n, born in the ftate of Delaware, aged 
 
 39 years, feaman, was admitted 18th of January, 18 14. He 
 complained of incontinence of urine, and had a gleety di£» 
 charge from the urethra. The patient alfo had pain in the 
 loins and forenefs of the groins and perinseum, with a fenfe 
 of dragging and weaknefs. The progrefs of the bougie was 
 flopped at four and a half inches from the extremity of the 
 penis. The patient was affected with clap in February, 18 13* 
 for the cure of which he employed an injection, but with 
 very little benefit. The difeafe was attended with violent 
 cberdee, which (as the patient fuppofed) caufed a rupture of 
 the urethra, and was followed by copious hemorrhage. He 
 entered on board the frigate United States in the month of 
 April ; foon after which period the difcharge from the ure- 
 thra began to diminifh, and at the fame time he obferved that 
 the ftream of urine was decreafed in fize. In July he had 
 an attack of nervous fever ; during which period the diffi- 
 culty in difcharging urine was increafed, attended with great 
 pain and frequent and urgent calls to evacuate the bladder. 
 The bougie was employed a few times at this period, with- 
 out any advantage. Soon after he began to pafs his urine 
 involuntarily, became much debilitated, and was difcharged 
 from the frigate unfit for duty. After his admiffion, the 
 common bougie was employed for fome time without afford- 
 ing hiav any relief j from this circumftance it was thought 
 
40 
 
 advifable to apply the cauftic. It was accordingly employed,, 
 and on the third application the Stricture was overcome, 
 The pain in the loins, incontinence of urine, and other dif= 
 treffing fymptoms, from this period left him, and he was 
 difcharged from the hofpital on the 1 8th of February. Nine 
 months after this period, he had experienced no difficulty 
 from his previous difeafe. 
 
 P- -o B— — y, born in Philadelphia, aged 36 years, fer- 
 
 vant, was admitted nth of February, 18 14, with Stricture, 
 He had incontinence of urine, pain in the loins and perine- 
 um, and whenever the urine was difcharged by voluntary 
 exertions, it was in drops and with violent {training. The 
 Stricture was fituate three and a half inches from the ex- 
 tremity of the urethra. He had been affected with gonor- 
 rhoea five or fix times. In March, 1813, he began to expe- 
 rience difficulty in paffing his urine, which was difcharged 
 in a fmall ftream, whilft his calls to pafs it were very fre- 
 quent. His difeafe was alfo attended with an ague and fe- 
 ver, as he termed it. Sometime in the following autumn he 
 loft the power of retaining his urine altogether. After his 
 admiffion, the common bougie was directed. This inftru- 
 ment was employed about a fortnight, without any benefit. 
 The cauftic was then directed to be applied, and after three 
 applications he was enabled to retain his urine for a fhort 
 time, and paned it in a fmall ftream. By the 19th of March 5 
 one inch had been gained on the Stricture ; his complaints 
 much as before. In April the principal Stricture was pafTed ; 
 but another prefented at about fix inches from the extremi- 
 ty of the canal. The common bougie was employed to over- 
 come this obftruction. On the 4th of May the patient had 
 fuppreffion of urine, which continued about twenty-four 
 hours, but which yielded to the ufe of anodynes, warm bath 
 and the bougie. Two days afterwards, a fmall inftrumem 
 was introduced into the bladder, with but little difficulty. 
 
4* 
 
 The irritation in the urethra, however, became fo great, that 
 it required the ufe of the bougie to be fufpended till the *8th. 
 On the 20th a pretty large bougie was pafled into the blad- 
 der. The patient was difcharged from the houfe on the 
 ioth of Jure. 
 
 Cafe of Striclure with mortification of the fcrotum y in confequence 
 of the effufion of urine. 
 
 W m H s, a coloured man, born in Maflachufetts, 
 
 aged about 50 years, was admitted into the New- York hot* 
 pital June 3d, 18 14. The patient had Stricture fituate about 
 feven inches from the external orifice. He had been twice 
 affected with clap, had experienced difficulty in pafling his 
 urine twelve years, and had been under furgical treatment. 
 ♦Two or three days previous to his admiflion, he had more 
 than ufual difficulty in paffing his urine, to relieve which he 
 employed a bougie himfelf, but did not fucceed in getting it 
 into the bladder. The application of the inftrument was 
 made with fuch violence as to give great pain, and was fol- 
 lowed by hemorrhage. After its introduction there was a 
 total fupprefSon of urine, and after draining violently to 
 evacuate the bladder, the cellular membrane of the fcrotum 
 perineum, &c. became much diftended with urine, in which 
 {late it was at the time of his admiflion. The patient had 
 great pain in the parts, with forenefs to the touch. The ab° 
 domen likewife was tenfe and painful on being prefled, and 
 he had general febrile fymptoms. The urine, at this time 
 was difcharged by drops, by violent exertions. After his 
 admiflion the fcrotum was freely punctured with a lance^ 
 by which means a very confiderable quantity of urine was 
 difcharged from the cellular membrane. A fpirituous lotion 
 was directed to be applied to the part, and the bowels open- 
 ed by an enema. After this, a fmall bougie was pafled through 
 the Stricture, which had the effect of producing a pretty 
 F 
 
42 
 
 free flow of urine. Three or four days after his admiffioi^ 
 an extenfive mortification of the fcrotum took place. He 
 was then put on the ufe of bark, wine and a nutritious diet, 
 and had the uiual local applications to the mortified part. 
 The bougie was at the fame time ufed daily, to keep the ure- 
 thra pervious. On the 15 th of July, the fcrotum was com- 
 pletely healed, and he was able at that time to difcharge his 
 urine in a full ftream. On the 8th of Auguft he was dif- 
 charged from the houfe. 
 
 Cafes of Stri&ure in ivhich the bougie armed with the caufiic fo- 
 lutiotiy nvas employed. 
 
 It may be proper to premife, that in the following cafes 
 the cauftic employed was formed of equal parts of the corro- 
 five muriate of mercury, muriate of ammonia and water. 
 
 The author has had an opportunity of obferving the ef- 
 fects of a folution of the nitrate of filver and of the corrofive 
 fublimate, and can fpeak confidently of their efficacy ; but 
 as has been before obferved, the folution of the triple fait of 
 muriate of mercury and ammonia, is preferred. 
 
 N m O d, born in Canada, aged 3 2 years, car- 
 penter, was admitted March 8th, 1814. At the time of his 
 admiffion he had incontinence of urine, complained of pain 
 in the back and loins ; general health unimpaired. On in- 
 troducing a bougie into the urethra, it was (topped by a 
 ftricture three inches from the orifice, which could not be 
 paSed by the fmalleft inftrument. He had been affected 
 with gonorrhoea four of five times. The laft time he had 
 the difeafe, it was followed by a dark coloured tumour on 
 the dorfum of the penis, which fuppurated, and was opened 
 with a lancet. He began to experience difficulty in difcharg- 
 ing his urine, immediately after the ulcer on his penis heal- 
 ed j and the power of retaining it was loft about two and a 
 half years before his admiffiorh On the 10th of March, the 
 
4$ 
 
 common armed bougie was introduced, and applied about 
 half a minute. The application was attended with confider- 
 able pain, and was followed by a fuppreffion of urine and 
 diftention of the abdomen. He took a large anodyne at a 
 late hour in the night, without any relief in his Symptoms, 
 and from his violent efforts to relieve the bladder the urine 
 became effufed into the cellular fubftance of the prepuce. 
 This was freely punctured to permit the efcape of the effu- 
 fed urine, and a fmail fized bougie was paffed into the Stric- 
 ture, and permitted to remain. In a few minutes the inftru- 
 ment was withdrawn, and the urine was afterwards difcharg- 
 ed with tolerable freedom. Preventive means having been 
 employed, no material inflammation of the penis fupervened. 
 The cauftic was again applied feveral times in the courfe of 
 the month, and the firft Stricture was overcome. After this 
 the common bougie was employed to overcome a Stricture 
 of very great firmnefs. This inftrument was exchanged on 
 the 8th of May, for the bougie dipped in the cauftic Solu- 
 tion. A confiderable quantity of ftringy matter was dis- 
 charged with the urine, after the ufe of it. By the 20th, 
 after repeated applications of the bougie dipped in the cauftic 
 folution, an inftrument could be paffed two and a half inches 
 further. The ufe of this cauftic was continued till the 30th, 
 at which time a bougie could be paffed within a fhort dis- 
 tance of the bladder. On the 2d of June, a common bou- 
 gie of confiderable fize was introduced into the bladder. 
 This inftrument was ufed till the 14th of June, at which 
 time he was difcharged. 
 
 R d H— n, born in New- York, aged 28 years, Sea« 
 
 man, was admitted July 8th, 18 14, with gonorrhoea and 
 Stricture. The patient had not been free from clap in eight 
 months. He had been affected with the diSeaSe five differ- 
 ent times and had experienced difficulty in discharging urine 
 three months. At th- time of his admiffion he paffed urine 
 
44 
 by drops, and occaiionaily in a fmall ftream. He complain- 
 ed of pain in the loins, and a fenfe of weaknefs and forenefs 
 of the perinseum. The ufual remedies for gonorrhoea were 
 firft employed, and after the fymptoms of this difeafe were 
 fubdued, the common bougie was reforted to. By the ap- 
 plication of this inftrument, five different Stri&ures were 
 P aiTed. Another one obftructed the paffage at feven inches 
 from the extremity of the penis. The common bougie was 
 ufed twenty days to overcome this obftruction, without ef- 
 fect. The bougie armed with the cauftic folution was then 
 employed, and after two applications the Stricture was over- 
 come. The common bougie was again employed for two 
 weeks and the patient was difcharged on the 14th of Sep- 
 tember. 
 
 H h L !~h, a patient labouring under difeafed liver 
 
 and dropfy, had alfo Stricture of the urethra. The latter 
 affection caufed much inconvenience. He had frequent and 
 urgent calls to make water, and was generally out of bed eve- 
 ry half hour for this purpofe. His urine paffed by drops for 
 the moft part, but at times in a very fmall ftream. The 
 bougie was interrupted in its courfe, four inches from the 
 extremity of the urethra, by a Stricture. This was paffed 
 by the bougie \ but another obftructed its further progrefs 
 at feven inches. An attempt was made to pafs this alfo, by 
 a fmall fized inftrument, but without fuccefs. The bougie 
 armed with the cauftic folution was then ufed, and on the 
 fecond application the Stricture was paffed. Confiderable 
 hemorrhage followed, but the patient experienced very great 
 relief immediately afterwards, and was able to pafs his urine 
 with much freedom. After the irritation confequent to the 
 ufe of the cauftic had fublided, a catheter of moderate fize 
 was introduced into the bladder, 
 
45 
 
 M b B a, a native of France, aged 20 years, mar- 
 iner, was received from the medical department of the houfe 
 April 14th, 1814. He had a firm Stricture fituate two and 
 3 half inches from the orifice of the urethra. Cmplained of 
 pain and weakneis in the fmall of the back, He had expe- 
 rienced difficulty in paffing his urine five or fix years, and 
 had been twice affected with gonorrhoea. His urine was dis- 
 charged by drops, and at times in a very fmall ftream. The 
 common bougie was employed for a confiderable length of 
 timeVithout material benefit. In May the bougie dipped in 
 the cauftic folution was employed a number of times, with 
 the moft decided advantage. Three Strictures were in fuc- 
 ceffion encountered and pafled. On the firft of June the 
 bougie could be introduced fix incHpc, »»<* <> n the 2 2d of the 
 fame montk cmotkc* very confiderable Stricture was over- 
 come by the above mentioned inftrument. In September a 
 large fiiver catheter could be pafled very readily into the 
 bladder. 
 
 W -m W bb, born in Salem, Maflachufetts, aged 
 
 42 years, feaman, was admitted 1 6th of Auguft, 18 14, with 
 fyphiiis and a firm Stricture juft at the extremity of the 
 urethra. 
 
 He had, according to his own account, been affected with 
 the venereal difeafe above thirty times, and the glans penis 
 had been deftroyed by previous chancre. He had experienc- 
 ed no very material inconvenience in paffing urine, till a few 
 days previous to his admiliion. 
 
 After his chancres had healed, a very fmall bougie, arm- 
 ed with the cauftic folution, was pafled into the Stricture. 
 The application of the cauftic was feveral times repeated, 
 till the paflage of a moderate fized bougie could be admitted. 
 Two Strictures were afterwards encountered and overcome 
 by this inilrument. 
 
4 
 
 The patient was detained in the houfe -titl the 2 2d of 
 November, on account of an inflamed eye. At this time 
 he difcharged his urine with freedom. 
 
 -W- — — m B- h, born in Connecticut, aged 27 years, 
 
 feaman, was admitted on the 6th of September, with rheu- 
 matifm and Stricture of the urethra. He had experienced 
 difficulty in paffing urine about four months. Previous to 
 this period he had been affected with fyphilis. A very foul 
 chancre behind the corona glandis fo completely deftroyed 
 the parts, as to make an opening quite through into the 
 urethra, and the urine was difcharged by this opening, as 
 well as by the natural paffage, for a fhort time. The pa- 
 tient had been affected four or five times with gonorrhoea. 
 When he was admit tod, *He urine was paffed with much 
 difficulty in drops, or in a fmall inccn uptcd ftream. 
 
 There was a firm Stricture in a fituation correfponding 
 with the corona gtandis, in the courfe of the urethra, which 
 could not be paffed by the fmaileft bougie. For this reafon 
 an inftrument armed with the cauftic folution was had re- 
 courfe to, and on the third application the Stricture was 
 paffed. It was afterwards applied twice, by which means a 
 moderate fized bougie could be admitted into the canal. 
 
 Three Strictures were afterwards met with in the courfe 
 of the urethra, which readily yielded to the common bougie. 
 The patient was difcharged from the hofpital on the 29th 
 of November, cured of both difeafes. 
 
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