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and this is in accordance with the practice of many of our bestphysicians; therefore, if it be an error, I err in good company.No doubt alcohol relieves the feeling of great depression whichis invariably present in these cases. It causes vaso-motorparesis, quickens the action of the heart, and for a timegives a plentiful supply of blood to that organ and thebrain, and thus a sense of comfort is experienced whichattests to the value of the drug. Soon, however, the effectspass off, leaving the body more exhausted than before, andthus a renewal of the dose is called for. The effects are asevanescent as the Irishman’s experience of champagne : " Itwas a most deceitful sort of drink; when he thought thathe was comfortably drunk for the rest of the evening, hefound that in an hour he was quite sober." When thejaded heart and brain are completely worn out by theserepeated stimulations, if rest will not save them, the desiredend is not likely to be attained by any further whippings.

(To be concluded.)

ABSTRACT OF

The Lettsomian LecturesON

SOME POINTS IN THE SURGERY OF THEURINARY ORGANS.

Delivered before the Medical Society of London,BY REGINALD HARRISON, F.R C.S.,

SURGEON TO THE LIVERPOOL ROYAL INFIRMARY, AND LECTURER ONCLINICAL SURGERY IN THE VICTORIA UNIVERSITY.

LECTURE I. IUrine fever and toxic urine.-The formation of stricture

tissue in reference specially to the treatment oj urethralstricture.

MR. PRESIDENT AND FELLOWS,-Let me, in the first place,thank you for permitting me to address your ancient andlearned Society in the capacity of Lettsomian Lecturer forthe present session, and at the same time ask your indulgencewhilst 1 attempt to follow in the direction selected by manywho in preceding me in this chair have so largely contributedto the practical advancement of medicine and surgery.

It is now some years since my attention was directed tothe circumstances under which fever was occasionally seenin connexion with various lesions involving the urinarytract, and it appeared to me that a further knowledge of theetiology of what I would speak of as urine fever, as opposedto ordinary wound fever, might be of service to us aspractical surgeons. In practice we have long been accus-tomed to recognise after injuries and operations a form ofexcitement which is generally known as wound or traumaticfever, the development of which, since the due recognitionof those principles upon which Listerism is based, has beenconsiderably restricted, if not entirely abolished. In strikingcontrast with this we have a distinct torm of fever, not unlikeague in many important respects, which is alone seen inlesions involving the urinary tract, more especially internalurethrotomy, accidental wounds of the urethra, and theintroduction of a catheter or a bougie.Some years ago, in a case of extremely tight stricture, I

performed an internal urethrotomy on a young and other-wise healthy male. Three hours afterwards he had a rigor,followed by high temperature, convulsions, and suppressionof urine, and in forty-six hours he was dead. Post-mortemexamination failed to prove anything, except that the opera-tion had been properly performed.In the course of last year I saw a boy, eleven years

of age, who, having ruptured his urethra by a fall, hadretention of urine for thirty hours; a catheter was passedand retained. Next day the temperature rose to 10° F. ;the patient had severe convulsions, and became comatose.He died twenty-four hours after the introduction of theinstrument. I could not help observing that so long as this

patient had retention he was comparatively safe ; when,however, an opportunity was afforded to the urine of comingand continuing in contact with the laceration in the urethraby means of the retained catheter, then a process of acute

poisoning seemed to commence, which speedily terminatedin death.

In 1874 a healthy middle-aged man was under my carefor a tight urethral stricture, for which in the course oftreatment, preliminary to dilatation, a metal instrumentcarefully passed was followed by some very slight bleeding.Four hours after this he had a rigor; the temperature wentup to 103° F.; this was followed by a succession of rigors..vomiting, and a very scanty excretion of urine. The pulsewas quick and thready, the tongue dry and brown, andthere was a tendency to drowsiness, with occasionaldelirium. After ten days he recovered, though still com-plaining of muscular pain and prostration.

Illustrations such as these and others that I could quotaseemed to indicate that the presence of urine in a wound,under certain circumstances, was capable of generating anaguish form of pyrexia, which I shall speak of henceforth a&

’..1rine fever. I am aware that some authorities are accus-tomed to epeak of all the phenomena I have just illustratedunder the one name of urethral fever. Such a term, I think,is misleading, inasmuch as it seems to connect the symptoms.produced with the precise part rather than with the process,for wherever throughout the urinary tract urine can b&placed under certain conditions, there can all the phenomenausually associated with the term urethral fever be produced.With the view of endeavouring to throw some light on the-causation of this, I determined some years ago to investi-gate (1) the relationship between urine and a wound whichleads to the development of urine fever, and (2) the probablenature of the influence or material producing it.In the first place, it appeared to me that the development,

of urine fever might be traceable to the kind of contact thatexisted between a wound and the urine. With a view totesting this, I treated a considerable number of urethralstrictures which were unsuitable for dilatation by internalurethrotomy, and followed this immediately by a mediancystotomy, introducing a full-sized drainage tube into thebladder, and I soon found that as was my drainage so was.my freedom from fever; urine fever only occurred wherethe former was imperfect. When urine, even in very smallquantities, was pent up in a recent wound, fever resemblingague invariably followed ; when, on the other hand, urinewas allowed to escape freely and continuously, as after a.

lateral lithotomy, no such symptoms were developed. Itwas further observed that in cases where it was impossibleto obtain perfect urine drainage, the urine might, so to

speak, be sterilised by local or general measures. Solutionof corrosive sublimate injected into the bladder and used toirrigate the wound was found to reduce the frequency ofthe attacks, and boric acid acted in a like manner. In somecases of internal urethrotomy, the production or not of urinefever could be largely influenced by the internal administra-tion of quinine, which is eliminated to a considerable extentby the urinary apparatus. These observations, taken col-lectively, seemed to me clearly to indicate that the kind ofcontact between fresh urine and a recently made woundwas in itself sufficient to determine the occurrence of urine.fever as a consequence.With regard, in the second place, to the nature of the

material by which the fever is produced, some importantinvestigations during the last few years have been maderelative to the development of animal alkaloids, both in thedead and living; and from these researches I do not thinkthere can be any doubt in coming to the conclusion that thesecretions of living beings are capable of forming leuco-maines, alkaloid bodies having poisonous properties, andthat many phenomena connected both with health anddisease may thus be accounted for. That the developmentof urine fever is really due to the absorption of some suchpoisonous compound as an alkaloid, derived either fromurine, tissue, wound decomposition, or all combined, Iconclude from the following deductions, which seem to be-warrantable from what I have already stated-1. That thepresence of urine in relation with a recent wound is necessaryfor the production of what I have spoken of as urine fever-2. That mere contact of urine with a wound is not sufficientfor its production. 3. That the retention of fresh urinewithin the area of a recent wound is almost invariablyfollowed by its development in a greater or lesser degree.4. That where urine is placed under such circumstances as.have been last mentioned, the liability to the developmentof urine fever is greatly diminished when it is sterilised bylocal or general means. 5. That the retention of freshurine, blood, and the débris of damaged tissue in the confines

B 2

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of a recent wound for a certain time, at a temperature ofabout 100° F., could hardly be possible without chemicalchanges taking place in the constituents referred to. 6. Thatthere is a common origin for urine fever is rendered probableby the uniformity of the symptoms attending it, which,though differing in degree, are identical, whether followinga surgical operation or an accidental wound.But objection may be raised against the views I am advo-

cating relative to the way in which urine or urethral feveris developed, by the fact that it sometimes arises undercircumstances where it may be difficult to prove that anyactual breach of surface in the urinary tract has beeninflicted-as, for instance, after the passage of a catheter.It would not be difficult to illustrate every degree of thiscomplication, from the most transient rigor to the severestform of septic intoxication. The epithelial lining of theurethra exerts a considerable protecting power, renderingthe canal water-tight, or, more correctly speaking, urine-tight. In a patient with stricture, if a bougie be passed andthis is followed with a rigor and some fever, what hasactually taken place is that the epithelial lining has beenscraped off at one or more points, and this has permittedurine leakage and absorption to take place at the parts in-jured. If, on the other hand, prolonged attempts at catheter-ism have proved futile, and the bladder is aspirated above thepubes, the urine being drawn off in this way without comingin contact, or remaining so, with any portion of the urethrawhich has been injured by instrumentation, I have neverknown rigors or fever follow, though the urethral lacerationhas been considerable and sanguinary. There can be noother explanation for the absence of characteristic rigorsand fever under these circumstances than the fact thaturine has not been allowed to come and remain in contactwith a freshly made wound. Some have concluded that thebladder is capable of absorbing some of its contents, whilstothers, on the contrary, not only have denied the possibilityof such an inference being drawn, but have pointed out howserious might be the consequences if there was any liabilityto such a contingency. It seems that both of these con-clusions may be true, and the explanation I would offer isthat by injury to, or disease of, its epithelial coat the bladdermay be rendered capable of absorbing what it contains, tothe detriment of the individual, as we see in those casesnow often referred to by the name of "catheter fever." z,

Further, it is important to notice that when a urine fistulais transformed into a permanent urine channel, as afterCock’s operation, we find the passage becomes lined, like theurethra, with epithelium, and thus it acquires the power oftransmitting urine without leakage.A stricture of the urethra is generally considered to be

due to a more or less prolonged inflammation of the liningmembrane of the canal, leading ultimately to the depositionin the peri-urethral tissues of organised lymph, whichbecomes converted into a dense connective tissue showing aremarkable tendency to contract, and interfering with theescape of urine from the bladder by preventing a properexpansion of the canal. Now all this, though very true onthe whole, does not enter into details with which weshould be acquainted for the prevention and treatment ofthe disorder.Acute gonorrhoea, unless care be taken, is apt to become

merged into the condition commonly known as chronicgranular urethritis. By the latter term we are to understandthat at one or more spots within the urethra the epitheliumhas become so damaged, as a consequence of the prolongedinflammation, that it ceases to render the canal urine-tight,and a slow process of escape of some of the constituents ofthe urine into the tissues comprising the urethra and sur-rounding it takes place. As a consequence of this, andto prevent urine soaking further into the tissues, inflamma-tory exudation is excited, and barriers of lymph, whichultimately become organised, are thrown out opposite theplaces where the leakages take place. Thus splints ofplastic tissue are formed, strengthening the urethra at thedamaged spots. This is at first a beneficial conservativeaction, but eventually certain inconveniences follow whichconstitute, as it were, an independent disease. The follow-ing considerations seem to indicate that the peri-urethralexudation results from the interstitial leakage of some

of the constituents of the urine through the walls ofthe canal :-(1) The mucous membrane, though chieflyinvolved in the primary inflammation, is, as. a rule,not contracted, and only secondarily implicated in thestricture-forming process, so that it is possible often

to split a stricture without necessarily damaging the liningmembrane of the canal; (2) the plastic exudation whichmakes up a stricture differs from other exudations pro-voked in other parts of the body by inflammation in thedegree of its density and tendency to contract; (3) theresisting and contractile character of the cicatrix which isformed in connexion with ruptures and lacerations of theurethra unmistakably shows the effect produced in thehealing process of a recent wound which is constantlysubmitted to the action of more or less pent-up urine.The irregular, rarely annular form in which stricture tissueis deposited and ultimately exercises contractile pressureon the urethral passage is strongly suggestive that, inthe first instance, it served the purpose of strengthening thewall of the canal, and thus prevented further leaking atpoints where the epithelial coat had been more or lesspermanently damaged.To the objection that urine leakage, as in extravasa-

tion, is invariably followed by acute forms of inflamma-tion, I would reply that the process of urine transitionthrough the damaged urethral mucous membrane isextremely gradual, and time is permitted for that adapta-tion which the human tissues are proved to be so capable of.But the exudation which a damaged epithelium may permitof does not necessarily imply that all the constituents of theurine are thus brought into contact with the tissues undercircumstances where the most active and destructive formsof inflammatory mischief must inevitably be aroused. Isaw some years ago a case of stricture with extravasationoccurring in a person suffering from Bright’s disease. Therewere no signs of inflammatory action and commencinggangrene, and the fluid which escaped from the incisionsthat were made had not that strong ammoniacalodour which is usually so perceptible in such cases.

In the urine which trickled through the wounds,and in that drawn off by the catheter, there was analmost complete absence of urea, and this, to my mind, solvedthe mystery, for it rendered the fluid chemically harmlessto the tissues with which it came in contact. In the sameway, and by a process of leakage, I apprehend, may beexplained some of those rare cases which have been describedas scrotal or perineal urinary cysts. Those cases of multiplestricture caused by spots of induration in various parts ofthe canal, chiefly in relation with its floor, can only beexplained on the supposition that the urethra has almostentirely lost its normal power of conducting urine in thecourse of a long gleet, and that these numerous centres ofinduration and contraction mark the spots where leakageof some of the constituents of the urine has been permittedto take place; and what applies to the plastic form ofexudation applies equally to the suppurative.The knowledge that certain relations between a wound

and the urine may cause and keep up urine fever will Iroveof service to us in practice, as I will illustrate in the followingway. Three hours after dilating a urethral stricture by Holt’smethod of rapid divulsion the patient had a severe rigor anda temperature of 105° F. On the following day this wasrepeated with almost complete suppression of urine, and Ithen performed a free median cystotomy and put a drainagetube into the bladder. There was nothing to indicate thatsuppuration had occurred, the time being too short for itsdevelopment and the symptoms being clearly due to urinepoisoning. After this there was neither rigor nor fever, and

urine was again rapidly excreted. By thus suddenly alteringthe relations of the wound with the urine the whole com-

plexion of the case was immediately changed for the better,and the patient made a good recovery.A due recognition of the function of the epithelial lining

of the urethra shows that there is a right and a wrong wayin making use of dilatation in the treatment of strictures. Iam sure that more good follows the daily introduction of a

i bougie which passes quite easily, than when a larger size isfless frequently used with some force. When a stricture hasi become, or is, so contractile and dense as to render dilata-tion out of the question, if not impossible, then I believe theL open method of treatment is the safest and affords the best-permanent results. In collecting and noting’many hundredt. cases this method has furnished the largest proportion ofa permanent cures. And in reference to this point, I mustE take exception to a statement which is frequently made tothe purport, " once stricture, always stricture." I could, furnish many examples following the open treatmentwhere a contractile stricture necessitating the constanti use of the bougie has been so influenced by what has been

59

done as to render any further use of this instrumentunnecessary, and that after some years the urethra can beproved to be structurally and functionally normal. In the

majority of these cases the perineum has been opened forstricture complicated with abscess and extravasation ofurine. It must, however, be borne in mind that a perinealsection is seldom resorted to until the urethra is largelyimpregnated, so to speak, with old cicatricial tissue of acontractile nature, which, notwithstanding the longitudinalsplice of sound tissue introduced by the operation, mustremain behind to contract and to mar to some extent theresult obtained. The conditions which the operation mustnecessarily fulfil are complete division of the stricture andthorough urine drainage.In wounds of the urethra, made either accidentally or in

the course of surgical operations, which by the nature ofcircumstances have to be treated without due regard forurine drainage, means should be more systematically takento prevent the development of urine fever, as well as theformation of a dense contractile cicatrix. In promotingthese objects much may be done by local irrigation and byinternal administration of drugs eliminated by the urine.

Lastly, we must remember that the prevention of strictureis withm our scope. If, as I have urged, stricture is theresult of urine leakage following inflammation in one

instance, whilst in another it is brought about by theconstant contact of the excretion with an internal wound,then the importance in the one case of irrigation and inthe other of free urine drainage is at once evident. It is inconnexion with ruptures of the urethra that we see exempli-fied the most disastrous effects of permitting a wound toheal subject to the irritation that constant contact withpent-up urine is capable of exercising, and I have not theleast doubt that those do best which are treated by perinealsection and drainage without reference to the question ofextravasation, the wound healing with a scar that showsbut little tendency to subsequent contraction. And whatapplies to the healing of wounds inflicted accidentally uponthe urethra internally, applies equally to others similarlyinflicted on the canal for surgical purposes. The testimonythat I have gathered from the examination of manyhundred cases is certainly not favourable either to the per-manency or the character of the relief that internal urethro-tomy usually affords. Amongst the worst cases of stricturethat I have thus met with have been those treated by an in-ternal section. If there is any force in the observations Ihave brought before the Society this evening, I do not thinkthere should be any difficulty in explaining how thishappens, and of recognising the importance of applying tothe treatment of wounds of all kinds involving the urethrathose principles which are the basis of Listerism--namely,drainage and cleanliness. There is no part of the humanbody which by disregard of these conditions is more likelyto be attended with disastrous consequences, whether wehave regard to the present or to the future. In conclusion,gentlemen, most speakers commence their discourse with atext; I prefer concluding with one: Urine cau spoil tissueas well as blood.

ON THE ELECTRICAL BASIS OF VITALMOTION.

BY C. B. RADCLIFFE, M.D., F.R.C.P.,CONSULTING PHYSICIAN TO THE WESTMINSTER HOSPITAL, PHYSICIAN TOTHE NATIONAL HOSPITAL FOR THE PARALYSED AND EPILEPTIC, ETC.

IN muscles, and in the nerves belonging to them, -whilealive and at rest, are unmistakable signs of electrical chargeand current which are not met with after death. These

signs, which are exactly similar in nerve and muscle, differin a very marked manner in the opposite states of rest andaction. When the state of rest changes into that of actionthe charge is diccharJed, and the current undergoes a changewhich is spoken of as " negative variation," and which oughtto be spoken of as simpll’! diminution of current. Usinga galvanometer with a very lligk degree of resistance in thecoil, it is easy to detect the current of nerve and muscle,and to follow the "negative variation" which happens whenthe state of rest is made to change into that of action, but notso when the galvanometer has a coil with a very /o?c degreeof resistance in it. Indeed, in this latter case there is-

what there never is when the galvanometer with a highdegree of resistance in the coil is used-discharge li7ce thatof the torpedo (Matteucci) and contraction, which contrac-tion is also witnessed when the connexion between theends and sides of the fibres is made by a short piece ofwirp, or any good conductor. And so it is that I am readyto believe that the whole case may be greatly simplifiedby looking upon the charge and discharge as the onlyphenomena which have any claim to be regarded as primary,;the current and its " negative variation " being in realityno more than the accidental result of the discharge beingpassed through a galvanometer with a degree of resistancein the coil sufficient to bridle down the discharge into thequieter pace of the current, which in reality is only a slowand almost silent discharge.Again and again, by using the new quadrant electrometer

of Sir William Thomson or the electrometer of ProfessorLipmanu, the reality of the charge and discharge is madevery apparent. Again and again, by using the highlyresisting galvanometer of Protessor Da Bois-Reymond orSir William Thomson, I have been able to verify all thatProfessor Du Bois-Reymond has said about the current andthe "negative variation" of the current. In a detachedpiece of nerve or muscle the current passes from the sidesto either of the two ends of the fibres, and, as may beexpected in such a case, the former surface is found to becharged positively, and the latter negatively. And thisstate of things admits of explanation, if only it be assumedthat the sheaths of the fibres, which are more or lessdielectric, because they are composed of tissue more or lessakin to ligamentum nuc7ze, which is highly dielectric, arecharged in a double fashion, as Leyden jars are charged;that ordinarily the exterior of the sheaths is +, and theinterior - ; that in a detached piece of nerve or muscle thesides of the fibres are +, and the ends -, because thenegatively electrified interiors of the sheaths make themselvesfelt at the opened-out ends ; and that the state of relaxationin muscle may be produced by the repellant action of thecharge upon the muscular molecules; that the state of con-traction in muscle may be owing to the discharge, whichhappens then, having given over these molecules to theaction of the attractive force which is inherent in theirphysical constitution.

I am not at a loss when I try to understand how the stateof charge may be brought about. On the contrary, thecharge, as it seems to me, may be looked upon as thenatural result, not of any electrical action confined to themuscular system, but of an electrical action extending tothe whole solar system, and not limited to it. At spring-tide and at neap-tide, when the action of the sun and moonare most differentiated, there are variations in terrestrialheat which show very plainly that the moon as well as thesun is directly concerned in producing these variations.There are variations in terrestrial magnetism at the same’time which as clearly tell the same story. And there arecotemporaneous variations of the same sort in atmosphericpotential, only as yet not so clearly made out as thevariations in heat and magnetism. And the deficiency inthe evidence here is supplemented by the presence of thebelt of terrestrial magnetism, and by the requirements ofthe doctrine of the correlation of the physical forces: bythe presence of the belt, because the very existence of mag-netism is inconceivable apart from electricity; by therequirements of the doctrine, because these oblige me toregard heat and light, and electricity and magnetism, andthe other forms of physical forces, as mere modes of one andthe same force. Indeed, there is, as I have attempted toshow elsewhere,1 good reason to believe that the earth iscontinually acted upon by electricity which has its source inan electrical interaction which is always going on between thesun and moon on the one hand and the earth on the other.and that this electricity is manifested in the form ofcurrents across the earth from the sun and moon, thecase being really one in which it is easy to believethat the dielectric sheaths of the fibres in nerve and musclemay be charged, as Leydon jars are charged, by thesecurrent, and that this charge will be instantly renewedafter discharge. Nor can it be said that these currents arenot powerful enough to do all this, for, ag atmosphericpotential is equal to several hundred volts at a short distanceabove the earth, and to still more than this as this distanceinerp.a,qpp. and as thA iJiTPp.tive DOWAr of tPrraatrial mnnnpti cm

1 Behind the Tides. London: Macmillan and Co. 8vo. 1888.