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Medical Societies.ACADEMY OF MEDICINE IN IRELAND.

Treatment of S‘tricture by Internal Urethrotomy.AT a meeting of the Surgical Section on May 22nd

Mr. THORNLEY STOKER read a paper on the Treatment ofStricture by Internal Urethrotomy. He advocated the more

frequent use of that operation in cases of well-establishedorganic stricture, where recurrence took place after gradualdilatation, where that treatment could not be borne owingto the irritation it set up, or where the circumstances of the

patient demanded speedy relief. He had burst eighteenstrictures in his earlier practice, and had been so impressed,both by his own cases and those of other surgeons, with theliability to rapid recurrence after this operation, that he hadrelinquished it in favour of urethrotomy. He had cuttwenty-five cases with Maisonneuve’s instrument, and hadin no instance had a bad result or cause for grave anxiety,except in one case where somewhat severe haemorrhage tookplace and required the retention of a large catheter in theurethra.-The PRESIDENT believed most surgeons wouldconcur in Mr. Stoker’s opinion that internal urethrotomyshould replace the forcible laceration of the urethra. Forhis own part, he would not incur the risk of dealing withstricture by forcible rupture. One of the advantages ofCiviale’s instrument was that the surgeon could divide withit either above or below.-Dr. BARTON said that, contraryto Mr. Stoker’s view that gradual dilatation was a temporarymeasure and in the ultimate result unsatisfactory, his ownexperience was that it was the best treatment if it could beadopted; and year by year, as he treated more difficultcases, he found its scope and range greater than he at firstsupposed. Indeed, he was convinced there was but a limitednumber of cases that could not be treated by gradual dilata-tion, if only the surgeon possessed patience as well as dexterity.Again, despite Mr. Stoker’s remark that internal urethro-tomy was not a dangerous procedure, he had seen fatal resultsfollow. He agreed, however, that that method gave morerapid results, but not more permanent. There were casesin. which gradual dilatation could not be adopted, and inwhich the surgeon had to choose between bursting andinternal urethrotomy. His choice in such cases would bein favour of internal urethrotomy. Both were open to risk,and could not be compared with dilatation. Again, therewere other cases requiring external urethrotomy.—Mr.STOKES said the subject was one which for a number ofyears had engaged his attention. In 1864 he introducedinto Dublin Maisonneuve’s operation, which he had learntfrom the distinguished French surgeon himself. AlthoughMr. Stoker was apparently unaware of the fact, he hadpublished papers in the Medical Press, the Dublin MedicalJournal, the British Medical Journal, and other periodicals,in which he fairly put forward the alleged advantages ofthat operation. Speaking from an experience of sixty-sevencases during the past twenty-one years, although his

opinion of internal urethrotomy was still very high, he didnot think it should be looked upon as a royal road to thecure of urethral stricture. It was the best mode of internaldivision of the stricture. But he agreed with Mr. Bartonthat the chances of recurrence of the disease were notgreater after the old and the safer treatment of gradualdilatation. Mr. Stokes also thought it better to retain acatheter in the urethra for some time after the operation,otherwise the recurrence of the stricture was, as a rule.rapid. In reference to the mode of division, he agreed withMr. Stoker in thinking the upper wall of the urethra was thebest to be divided, not only for the reasons he put forward,but also those of Maisonneuve, that there was much lessdanger of any lodgment in the urethra or any infil-tration taking place after the operation when the upper wallwas divided than when the lower one was. By passing in alarge well-oiled bougie immediately afterwards, tne sides ofthe wound were dilated, assuming a triangular or conicalform, with its base below and apex above. This becamefilled with lymph, and a wedge-shaped cicatrix formed,which was not at all likely to take place if the woundwas allowed to close after the division of the stricture,

Notwithstanding the favourable results he had had, out 01the sixty-seven cases there were only ten in which he was

able, after a considerable period, to determine that no recur.rence of the stricture had taken place. He had performeithe operation on the same individual twice, and yet there wasa recurrence of the stricture, which he subsequently treated bjgradual dilatation. He believed with Mr. Barton that althougtdilatation was the most tedious, it was certainly the safe,method ; and he also agreed with him, with Hutton, andProf. Smith, in maintaining that there was abetter chant,of absorption of the new material by the steady, continuous,gradual pressure caused by the frequent introduction of thinstrument, than by any cutting operation whatever. It wasdangerous to advocate the operation of internal methroto1!lj’to the exclusion of the slower and safer method of gradualdila-dation.-Mr. ORMSBY observed that the treatment dependmore on the patient than on the stricture, some being suitabi.for one and some for another method. Every surgeon agreedthat gradual dilatation, where it could be performed,wasthe best method. But if the patient wanted to have th,treatment carried out rapidly and efficiently, literna!urethrotomy with Maisonneuve’s instrument afforded thebest result. Mr. M. Colles had stated that all stricture,were liable to return. As an instance, he mentioned, in hi:own practice, the case of a man who had had Holt’s opera.tion performed at one hospital, Richardson’s at another,and Maisonneuve’s at a third. It was therefore probable,no matter what method was adopted, that the stricturewould recur if the patient did not take the precaution eitherof going at once to a surgeon or providing himself with abougie to pass occasionally.-Dr. BALL pointed out that inthe use of Maisonneuve’s instrument there was danger oi

injuring other portions of the urethra by the sharp edge ofthe knife. He knew of a fatal case in which the post.mortem examination showed that the entire length of

the urethra from the meatus to the bladder was slit, with the instrument, the wound being deepest in the; healthy parts. That danger, however, was obviated, by a modification invented by Teevan of London-L namely, a triangular sheath over the cutting edge.-. Mr. CORLEY spoke from twenty-seven years’ experience,. since he was a pupil of the late Mr. Taggart, who was a. thick-and-thin advocate of gradual dilatation as the safe:;3 method, and was so particular and careful that he would

have the word " gentleness " inscribed on the handle mevery catheter that the junior practitioner used. With his

experience of the three methods he had come seriously andfairly to the conclusion that the cutting operation, as doneby Maisonneuve, was the best and safest, and obviated tnumber of inconveniences that certainly belonged to gradualdilatation. There were several cases met with in which a

long period of trial occurred before getting in the catheter;fo’instance, one in the Richmond Hospital, given up as hopelessafter six weeks, when Mr. Stokes succeeded in introducinga catheter.-Mr. THOMSON said the real question to decidtwas whether stricture was curable, or, rather, hownear could they approach to the condition of gettigrid of the possibility of its return. All the spethBagreed that strictures returned whether the operation wasone of cutting or of bursting, although some surgedhad invented appliances which they claimed cut thestrictures so as to prevent their return. Mr. Corleyhad stated an important point-that they were not to con-sider gradual dilatation as a method altogether free from

risk. He had himself seen a patient who, on the intro’duction of a catheter, was seized with ureemic convulsion,and died of suppression of urine. The same happened afterinternal urethrotomy in a case of his own. Therefore, theywere not to base objection to a line of treatment on the fall,of a death occurring now and again. But the question wasthis, When the surgeon came to deal with a case of stricturi,what method was the best for the patient, what gave theleast risk, and what gave the best chance of stavin of theevil day ? ? In the great majority of cases dilatation wasthat method. It was essentially the least irritating,properly carried out. By using a cutting instrument,severe wound was inflicted upon a very sensitive part, withthe risk of setting up irritation of the sympathetic, whichso often followed cutting operations. Hence the advantageof gradual dilatation. But there were cases in which r’v

amount of gradual dilatation was satisfactory. There""a form of stricture which might be dealt with by iiretwtomy, internal or external, as not usually yielding vYgradual dilatation-namely, traumatic stricture. So, too.case suffering from rigors after the bougie would be we

treated by internal urethrotomy, no greater disturbance being

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caused than by the passing of the bougie. As to methodsof cutting, he was entirely in favour of Maisonneuve’s. -Mr. WHEELER said recent cases were suitable for gradualdilatation, but old callous strictures were not. He couldnot concur in the statement that the return of contrac-tion was more rapid after divulsion than after internaldivision. When there was rapid contraction it was becausethere had not been sufficient dilatation by which thestricture would be fairly ruptured. Contraction did notrecur more rapidly after this treatment than after internalurethrotomy.—Dr. FALCONER suggested that a drug recentlybrought before the profession-namely, cocaine - should beinjected into the urethra before operating, instead of placingthe patient under an anæsthetic.— Mr. HAMILTON said Mr.Stoker had not removed from his mind two convictionsimpressed upon it by observation and practice: one, that astricture once formed could never be removed; and theother, that the vast majority of strictures were ame-

nable to, and ought to be treated by, the process of

gradual dilatation. He was in the habit of teaching hisclass and telling the patients that no matter what planwas adopted the stricture would return. His experiencewas, that he was able to succeed with gradual dilatation inten days or a fortnight. The object was to get an instru-ment first, no matter how small; and he maintained,with Syme, that there was no stricture through which asurgeon could not pass an instrument, if he only hadthe patience, and, above all things, gentleness. Mr.THORNLEY STOKER, in reply, said his paper, read over

.again, would answer most of the objections raised, andtherefore he would leave it to answer for itself. In replyto the President’s question, he advocated the incision ofthe roof of the urethra in preference to the floor, becausehe considered he was cutting into healthier tissue. It wasmatter of observation to those who dissected diseasedurethræ that the floor was much more frequently the seat- disease than the roof. That gradual dilatation was thesafest method of treatment no man of common sense couldfor a moment deny, or that it was the method applicable tothe greater number of organic strictures. But lie contendedthat urethrotomy might be more generally practised thanat present.

Reviews and Notices of Books.The Regimen to be adopted in cases of Gout. By Dr.WILHEm EBSTEIN. Translated by JoHN ScuTT, M.B.London: J. and A. Churchill. 1885.

Gout and its Relations to Diseases of the Liver and Kidneys.ByRoBSON ROOSE, M.D. London: H. K. Lewis. 1885.

A Treatise on Gout and Rheumatism. By PETER HOOD,ILD. Third Edition. London: J. and A. Churchill. 1885.

WORKS on gout multiply upon us, in spite of the fact thatthe disease in its acute and frank form has considerablydiminished during the present century. This attention toa disease which in its typical aspect is continually becomingrarer can only be accounted for by the supposition that thehumoral pathologists of the present day regard uric acidas dominating nearly all the chemical processes going onwithin the body. Of late, it is true, symptoms of revolthave shown themselves against the hypothesis of uric acidbeing the keystone of chemical pathology, and some writershave ventured to point out that mere variations in reactionof the blood, or the presence in excess or diminution of oneor other of the principal alkaline bases of the organism, maycause profound disturbance in the chemistry of nutrition,and give rise to conditions very similar to those that arecommonly called gouty.In the works before us, however, we are pleased to find

the authors mainly confine themselves chiefly to a con-sideration of true gout, such as ia characterised by theactual deposit of sodium urate, and we are spared thosepurely hypothetical disquisitions on the "gouty" statewhich of late have become rather too prominent. WithrëgarJ to the first author on our list, we find that Ebsteindoes not regard increased formation of uric acid as adequateto explain the development of the whole range of gouty

symptoms, nor does he think (Jarrod’s theory of the reten-tion of uric acid can be maintained. His view may be

briefly stated as follows: In gout there is an anomalousformation of uric acid occurring especially in the musclesand medulla of the bones; if, then, any hindrance occurs tothe circulation of the fluids of the body, such hindranceshows itself by the deposition of uric acid and its salts inthose parts of the body which are most distinguished by the,slowness of their circulation, such as the small joints,cartilages of the ear, &c. The effect of the hindrance ofcirculation in causing gouty deposits he aptly illustrates byquoting Charcot’s observations on a patient with hemiplegia,in whom the majority of the joints on the affected side werefound infiltrated with uric acid salts. Ebstein, however,does not allude to the other factor, which plays, withretardation of the circulation, an important part in thephenomena of a gouty attack--namely, diminished alkalinityof the blood, a condition which renders the highly insolubleuric acid salts still more insoluble, and thus brings abouttheir deposition. Ralfe, in this country, has especiallyinsisted on the part played by diminished alkalinity of theblood in the causation of uratic deposits; whilst Virchow,in views recently expressed with regard to the evolutionof the gouty kidney, is disposed to relegate uric acidto quite a secondary place, since, as he points out, thechronic inflammatory changes begin in the cortex at a

distance from the seat of the deposit of urates in the

straight portion of the tubes, from which he argues thatthe primary step in the process is the exudation of highlyacid urine, which induces interstitial nephritis, and it is nottill the function of the kidney in getting rid of uric acid isimpaired that uratic deposit occurs. Ebstein reviews care-

fully the various dietetic systems that have been proposedfor the treatment of gout, which are as various as the viewsadvanced to explain the causation of the disease. Ebstein’sown view is thus concisely expressed: " Sweets apart our

gouty friend may be as ticklish as he likes, but he mustnever be a glutton"---a conclusion in close accordance withthat expressed by Sydenham two centuries ago, in the fol-lowing words : " Therefore moderation in eating and drinkingis to be observed, so as, on the one hand, to avoid taking inmore aliment than the stomach can conveniently digest, andof course thereby increasing the disease; and, on the otherhand, defrauding the parts by immoderate abstinence of thedegree of nourishment requisite to keep up the strength,which will weaken them still more." An opinion in whichwe heartily concur.

Dr. Roose is fully convinced that functional disorder ofthe liver underlies the majority of gouty manifestations,and that the kidneys are only secondarily implicatedThis view, which Murchison supported in his famousCroonian Lectures on Functional Derangements of the

Liver, has of late been questioned, since it has beenshown that uric acid is not necessarily an antecedent ofurea in the body. Indeed, as stated above, the view is

gradually but steadily gaining ground that the chief signifi-cance of uric acid in relation to gout refers rather to theconditions that increase its insolubility---such as local stasisand diminished alkalinity of the blood-than to its increasedproduction in the system; and it is to this view we our-selves most incline. Dr. Roose’s work, however, is a clearand concise statement of the opposite doctrine and as suchdeserves attention.

Dr. P. Hood’s work is already well known, having reacheda third edition. He, too, is a supporter of the view that" uric acid is the penultimate and urea the ultimate productof oxidation," and believes that excess of uric acid in theblood and textures depends on excess,of animal or vegetablealbuminous tissue or on arrest of oxidation. As stated

above, uric acid is not a necessary antecedent of urea;indeed, there is good evidence to show that the probable