ARTICLE V.-Statement in Reply to Mr Syme's "Case of Stricture of the Urethra Treated by External Incision," Published in the April Number of the Monthly Journal By JAMES MILLER, F.R.S.E., Surgeon in Ordinary to the Queen for Scotland, Surgeon in Ordinary to H.R.H. Prince Albert for Scotland, late Senior Surgeon to the Royal Infirmary, Professor of Surgery in the University of Edinburgh, &c.

In reply to those portions of the paper by Mr Syme, published in the April Number of the Monthly Journal, which seem to require notice by me, I beg to submit the following narrative :—

At a meeting of the Medico-Chirurgical Society, on January 15, 1851, Dr R. Mackenzie read an account of a case of strictured urethra, in which, after the performance of Mr Syme's operation, the patient died of pyæmia. A case closely analogous had occurred to myself, in hospital practice; and, had I been present, I would have communicated the particulars of that case to the Society,as tending to relieve the specialities of the operation from connection with the fatal issue in Dr Mackenzie's patient. Having been absent, I resolved to mention the case at next meeting, and also to embrace that opportunity of stating my views in regard to the question of perineal section in general.

"1

Accordingly, I gave notice of "A Case of Perineal Section "1 for next meeting; and on February 19th, read the following short account of it to the Society :

"The patient was a porter, aged 35, of bulky frame and intemperate habits, admitted into hospital 13th March 1850, on account of stricture, which he declared had proved impenetrable to many surgeons. A hard circumscribed swelling could be plainly felt through the perineum in the region of the bulb, about the size of a hazel nut; and the smallest catheter, passed down to this, obstinately refused to enter any part of the stricture. The swelling, so hard, and circumscribed, and resisting, was thought by myself and colleagues, in consultation, to be a calculus impacted in the urethra; and accordingly it was resolved to cut it out. The patient having been placed as for lithotomy, and under chloroform, a central incision was made; but instead of a stone, I found only gristly induration of the perineal tissues. Accordingly, I immediately changed the plan of procedure; and having, by cautious continuance of the in

1 The phrase "Perineal Section,”-in which there really seems to be nothing very "foolish," and as to whose origin I do not know where the blame or merit rests, I understand to include the whole subject of external incision applied to the cure of stricture behind the scrotum. Mr Syme, though disapproving of the term as "foolish," seems to think, notwithstanding, that when employed it must always mean his particular operation. Others, again, apply the term exclusively to the old operation.-Vide WAKLEY, Lancet, March 22, 1850, p. 315. I have always used it in its general or comprehensive sense.

cision, exposed what I believed to be the shrivelled remains of the urethra-looking like a narrow lacuna,—I divided the whole constricted part, and then had no difficulty in passing a silver catheter of medium size from the orifice of the urethra on to the bladder, retaining it for nearly three days. No bad symptom occurred for five days after the operation, urine flowing freely, partly by the urethra and partly by the wound. On the fifth day, however, symptoms of pyæmia set in with great severity; beginning with rigors and great pain in the calves of the legs, which soon suppurated; running the ordinary course of oppressed respiration, delirium, prostration, leaden colour of face, &c.; and proving fatal on the nineteenth day after the operation. There was no swelling of the perineum or scrotum; and the wound retained a perfectly healthy appearance, presenting no sign of infiltration or abscess. The case seemed one of pure pyæmia, at that time unfortunately prevalent in my wards; and I believe that the unfortunate issue might have resulted as readily from any simple wound as from that of the perineum. The friends obstinately refused to permit post-mortem examination."

To this I added another case, more fortunate in its termination, in which I had performed "the old operation" in March 1847.

"The patient was a gentleman, about 50 years of age, who had laboured under bad stricture for a long series of years, deriving imperfect relief from many surgeons, both here and in London. At last retention occurred, and the surgeon, in passing a small catheter, which he did with difficulty, felt a grating in the passage. On account of this, I was asked to see him; and recognising the presence of a calculus impacted behind the stricture, which was of some extent, and felt dense in the perineum, it was resolved to remove the calculus by excision, and at the same time to cut through the callous stricture in its front. This was accordingly done without difficulty, and a catheter of medium size was retained in the bladder for about two days. On withdrawing it, all advanced favourably; the wound soon healed, health was speedily regained; and although from that day to this no catheter or bougie, so far as I know, has ever been passed, the patient continues in perfect health, without the least feeling of inconvenience from his former ailment."

After narrating these cases, I entered upon the general subject of external incision applied to the treatment of stricture, and dwelt especially on the modern variety of the operation proposed by Mr Syme, not to decry it, but, while speaking in its praise, expressing, at the same time, fear lest it should be applied more extensively than circumstances absolutely required. In noticing the risks to which such procedure seemed liable, I alluded to a case in which Mr Syme and myself had a common interest; the patient having all along

1 I may mention, that some days before the meeting of the Society, I consulted two professional friends, in whose opinion I place great confidence, as to

been (and still remaining) under my care, but Mr Syme having performed the operation at my suggestion. Some time before the meeting, I had asked the patient-having unqualified confidence in his accuracy and intelligence-to furnish me with his own narrative of what occurred in the course of his cure. This narrative I read to the Society, pledging myself to its correctness, explaining those parts where explanation seemed necessary, and observing that I preferred it to any statement of my own, on account of its being more likely to be regarded by my hearers as beyond the possibility of bias or partiality. A short discussion followed, some account of which is published in the April Number of the Monthly Journal, p. 383. At this meeting Mr Syme was not present.

Having been assured that, in the opinion of those well qualified to judge, this paper was of such importance as to justify, or even require, publication, I prepared a digest of it, and communicated this to the "Lancet," in which Journal it appeared March 22d.

On March 6th, the following correspondence commenced :—

No. 1.

"Rutland Street, 6th March 1851. "MY DEAR SIR,--I have been informed that, at the last meeting of the MedicoChirurgical Society, you stated that I had of late years resorted on one occasion to the old operation' for the remedy of 'impermeable stricture.' I beg you will have the goodness to acquaint me with what this statement referred to. I have also to beg that you will favour me with the address of Mr whose stricture I divided. Yours very truly, "JAMES SYME. "James Miller, Esq."

No. 2.

"51, Queen Street, 6th March 1851. "MY DEAR SIR,-At the last meeting of the Medico-Chirurgical Society, at which I am sorry you were not present, I stated that you had performed the 'old operation' for impermeable stricture, with the questionable exception of rendering the incision subcutaneous instead of direct. My ground for that statement is your paper in the Monthly Journal, October 1844, p. 821. Mr's1 present address is Yours very truly, "JAS. MILLER.

"Jas. Syme, Esq."

No. 3.

"Rutland Street, 7th March 1851. "MY DEAR SIR,-In the case to which you refer, there was a stricture at the distance of two inches from the orifice of the urethra, so tight as not to admit even a probe, and which I attempted to divide without the assistance of a director, by guiding a knife through the contracting ring, while it was held between my finger and thumb. This surely was not the old operation,' which essentially

whether or not I should formally acquaint Mr Syme of my intention of alluding, illustratively of the general question, to the case of my patient on whom he had been asked to operate. They both agreed that such a step on my part was not necessary; that the ordinary intimation of my paper in the billets of the Society was enough. And that they were right in this advice, Mr Syme himself seems to have established; by showing that he at least suspected that the "Case of Perineal Section" announced by me in the Society's circular referred to the patient on whom he had himself operated, instead of (as was really the fact) to a case exclusively my own.

consists in trying to find the canal by cutting upon the point of an instrument passed down to the seat of obstruction. On the contrary, it was a proceeding, I believe, altogether unprecedented in the practice of any other surgeon, founded upon a principle entirely different from that of the old operation, and which proved the happy step that led to the method at present employed by me. For you will remark, that the result was not satisfactory, in consequence of a tendency to contraction, which soon appeared, and which I attributed to the incision not having been carried completely through the indurated textures surrounding the contraction,' and that being thus induced to distrust the plunge of a sharp-pointed knife, as a secure means of attaining this object, I resolved upon all future occasions to take the assistance of a grooved director. Accordingly, in the next case, related at page 822, where the stricture was also in the anterior part of the canal, and no less tight than in the former one, after trying various instruments without success, I passed an exceedingly slender catgut bougie through the stricture, and then a succession of larger ones, until at length a metallic bougie of the smallest size could be introduced,' when finding that no more ground could be gained by dilatation, I passed a grooved director, such as the contracted urethra admitted, and upon it divided the stricture.

"I am quite sure that you could not intend to mislead the Society, but have ascertained that you certainly did leave an impression to the effect, that after establishing the principle of treating all strictures as permeable, I had been forced to perform the old operation. The cavils, misrepresentations, and falsehoods of those base spirits in our profession, who have vainly attempted by these means to resist a great practical improvement, gave me little concern. But the statements of a colleague, and especially one who teaches the elements of surgery, cannot be treated with disregard. I beg, therefore, you will remark that the case which you quote as a dereliction of my principle, was precisely that which led to the establishment of this principle.-I remain yours very truly, "James Miller, Esq."

No. 4.

JAS. SYME.

"51, Queen Street, March 7, 1851. "MY DEAR SIR,-To my apprehension, the essential difference between the 'old operation, and your own, is two-fold:-1. In yours, the stricture is cut on a director; in the old, there is no such guide. 2. Yours is applied to permeable strictures; the old has been reserved for those found to be impermeable.

"According to this view, I was surely warranted in calling the case to which you refer, an example of the 'old operation.' The stricture was found to be impermeable; the smallest probe could not be passed through;' and the incision was accordingly made without any guide in the contracted part.

"Literally, it was the old operation,' with two points of exception: viz., the cut was subcutaneous, and there was no sound introduced to indicate the anterior termination of the stricture.

"The want of success seems to me to have depended on imperfect division of the stricture, arising from your having been trammelled and deceived by the subcutaneous puncture. Had the incision been open and direct, I am strongly inclined to infer that the result would have been otherwise.

"As to your next case, you assume that the stricture was no less tight than the former;' and you argue that because the one yielded to instruments, the other would have done so likewise. Forgive me for saying, that this reasoning seems to me altogether inconclusive; and that I feel myself fully warranted in still considering your first case as an example of 'impermeable stricture.'

"You say that I have left an impression (in the Medico-Chirurgical Society), to the effect, that after establishing the principle of treating all strictures as permeable, I (you) had been forced to perform the old operation.' This misapprehension must surely be the fault of the Society itself. How is it possible for me, or any one else, to lay to your charge' dereliction of principle' in regard to an operation, at a time anterior to the adoption and enunciation of that principle by you?

NEW SERIES.NO. XVII. MAY 1851.

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"Rest assured, I have entered on the public discussion of this question solely under a sense of duty; anxious, on the one hand, to assist in securing for my colleague the merit which is justly his due; and, on the other hand, to adduce arguments for restraining the operation within narrower limits than those which the enthusiasm natural to the originator might wish to assign.-Believe me, my dear Sir, very truly yours,

"Jas. Syme, Esq.”

"JAS. MILLER.

"P. S.-By a note this evening, Dr Robertson informs me that you still wish, through me, to have access to Mr -'s MS. In consequence, I have returned it to Mr- from whom, I have no doubt, you will at once receive it, on application being made. I prefer this to sending the MS. to Dr Robertson, for several reasons; and all the more, because, in the same note, he complains of having been already much troubled by this matter.

"I write this late; consequently it will not reach you till Monday morning."

No. 5.

"Rutland Street, 10th March 1851. "MY DEAR SIR,-If you merely wished to inform the Society that I at one time believed in the impermeability of stricture, and practised accordingly, I think you might have chosen a better text, than the one selected, from the following extract of my 'Principles of Surgery':

"If the urethra is altogether obstructed anterior to the fistula, so that even the smallest instrument cannot be passed through it, the only remedy is to introduce a catheter as far as the canal permits, and then cut upon its extremity from the fistula, so as to allow its passage into the bladder.'

"Like my neighbours, I did formerly believe in the existence of 'impermeable strictures,' and have performed the old operation. But ever since adopting the principle that every stricture, through care and the use of sufficiently small instruments, might be rendered permeable to a grooved director, I have not met with one which proved impermeable or required the old operation.-Yours very truly, "JAMES SYME. "James Miller, Esq.".

No. 6.

"51, Queen Street, March 13th, 1851. "MY DEAR SIR,-A smart attack of illness has prevented my acknowledging your last note (March 10th) till now.

"One of my objects certainly was to prove that 'impermeable' strictures had occurred, and might be expected to occur again, even in the ablest hands. And, had I observed the quotation which you give from your 'Principles,' I would most probably have used it as an additional weight to my argument.

"I dread much any broad announcement that all strictures are permeable to very small instruments.' For these, we know, in inexperienced hands, are apt to go without much pressure where no canal previously existed. In your hands, of course, I do not doubt their safety; but I candidly confess that I expect to hear some day that, even with them, you have again encountered an 'impermeable stricture.'-I am, my dear Sir, very truly yours,

"J. Syme, Esq."

"JAS. MILLER.

No. 7.

"Rutland Street, 15th March 1851.

"MY DEAR SIR,-I think it right to acquaint you, that I propose to give the Society my account of Mr -'s case; and also to read the letters which have passed between us relative to impermeable' strictures.-Yours very truly,

"Jas. Miller, Esq."

"JAS. SYME.