never causes pain, or, at all events, such a very modified degree of pain as scarcely to be appreciable, whereas the ordinary instrument can be rarely passed without causing considerable pain as it is getting into the bladder. The reason why the olivary bougie causes so very much less pain than the ordinary instrument is simply because it does not evoke so much resistance as the other. The little oval ball at the end of the olivary bougie acts as an "avant courier" for the rest of the instrument; and as its diameter is less than that of the stem, it opens up the urethra for the passage of the body of the instrument. The healthy urethra is in a state of collapse, like an empty vein, and hence it is no longer a tube, as its surfaces are in approximation with each other much in the same way as two leaves of a wet book. The urethra is only tubular when urine is passing through it. It must, therefore, be borne in mind that passing an instrument into the bladder is not so much the passage along a canal, but a separation of surfaces, and the insinuation of something between the approximated surfaces in order to allow something else to follow. Therefore it is clear that the oval ball of the olivary bougie which represents the end of a wedge-shaped instrument is infinitely better for the accomplishment of the end in view than the blunt extremity of the instrument which is uniform in diameter. The transition in size from one English catheter to another is much too abrupt for usefulness. Between every English size an intermediate one is required. Hence the French gauge is more useful than the English. Dilatation ought to be carried up to the largest size the urethra will admit, and if the meatus externus retards the introduction, it ought to be enlarged. In many cases where the stricture is what is called elastic, the leaden bougie will be found more useful. At first a bougie ought to be passed every second day, and left in for ten minutes; as the case proceeds, the introduction ought to be less and less frequent, and when the cure is supposed to be completed a full-sized instrument ought to be passed, either by the surgeon or the patient, once every six months for the remainder of the patient's life. Unless this be done, there is no safety against a relapse. The endoscope is very useful for diagnosing the early stage of stricture, and will often give information as to the exact pathological condition of the mucous membrane of the urethra, which the bougie à boule cannot. But if there are several strictures in a given urethra, the endoscope will usually only detect the one nearest the orifice. Then again, for ordinary hospital practice, the bougie à boule is the preferable instrument. An exploration of the urethra by the bougie à boule can be effected in a minute or so, whereas an endoscopic examination cannot be conducted under one quarter of an hour. The endoscope, consequently, is chiefly of use in exceptional cases of stricture for obtaining knowledge which cannot be afforded by the bougie à boule-such as the appearances of the mucous membrane, whether it is ulcerated or not. For severe strictures, in which it is very difficult to pass an instrument, the aid of the endoscope is invaluable in pointing out the entrance into the strictured part. In the early stage of stricture the urethroscope shows that the mucous membrane is considerably deeper in colour than natural at the strictured part; the injection of the stream of urine against the narrowed spot keeping up a permanent congestion. of the part. On withdrawing the urethroscopic tube the mucous membrane remains stationary, and thus the appearance is altogether different to what takes place in the healthy parts of the tube, where the mucous membrane falls and closes in on the end of the tube as it is being withdrawn. Subjoined are a few cases, out of a great many, illustrating the value of the bougie à boule. CASE 1.-C. K-, a robust-looking postman, æt. 30, came to me (November 3) for a continuous pain in his perineum. He described it as a "burning pain." Gleety discharge of many years' duration, knees trembled when making water, but had no difficulty in the act. Cannot get married on account of his gleet. Passed No. 9 bougie à boule and found two strictures; one in the penile urethra, and the other at the bulb. The instrument caused him much pain when being withdrawn through the stricture. No strictures could be detected when a No. 9 ordinary bougie was passed. This patient was treated by dilatation twice a week, the largest instrument the urethra would admit being passed. On December 9 he was quite free from the gleet and pain, and got married the ensuing month. Comes to me regularly every two months to have an instrument passed. CASE 2.-J. W-, a pale-looking commercial traveller, æt. 26, put himself under my care (April 22) for a gleet of nine months' duration. Passed No. 9 bougie à boule, and found a slight constriction at bulb. He was treated by gradual dilatation once a week, and on May 24 was quite well. CASE 3.-J. M—, a dissipated-looking fishmonger, æt. 26, came under my care, February 23. Complained that he trembled when making water, and suffered from occasional pain in the perineum, but did not experience any difficulty in urinating, neither had he any increased desire to micturate. Had a gleet of four years' duration on him. I examined him with a No. 10 bougie à boule and found three strictures. Was treated twice a week by gradual dilatation, and on May 29 was quite well. CASE 4.--H. H—, a pale-looking carpenter, æt. 28, came to me on December 1 for difficulty in making water. Seven years ago caught a gonorrhoea, which degenerated into a gleet, but has been quite free of it for the last year. Sweats and shakes at knees when urinating. Desires to make water every hour. I passed a No. 9 bougie à boule, found one stricture at bulb and another in penile urethra. Treated by the introduction of the olivary bougie once a week. Was quite well on May 1. CASE 5.-W. N-, a healthy-looking printer, æt. 22, put himself under my care on December 5 for a gleet. Caught his first gonorrhoea nine months ago, which degenerated into a gleet, and remained on him ever since. Passed No. 11 bougie à boule and found a slight constriction in front of bulb. He was treated by gradual dilatation, but not beiug very regular in attendance was not cured till May 29. CASE 6.—J. C—, a pale thin-looking man, æt. 26, lately in the marines, applied to me (March 27) for "irritability of bladder." Last October was discharged from army for inability to hold his water. Three years ago contracted his first and only gonorrhoea, which degenerated into a gleet and remained on him ever since. Has been seventeen weeks in a military hospital, and an out-patient at two of the metropolitan hospitals. Cannot hold water for a longer period than two hours, and if he takes beer wants to urinate every ten minutes. I examined him with a No. 9 bougie à boule, and found three strictures. He suffered much pain on withdrawal of instrument. I treated him by passing the olivary bougie twice a week, and by May 22 he was quite well. He is now a stoker at the gas works. All the above cases were, during their treatment, submitted by me to many medical gentlemen for examination. ART. VI. Note on the Regulation of the Pressure on the Artery in the Application of the Sphygmograph. By BALTHAZAR W. FOSTER, M.D., M.R.C.P.L., Physician to the Queen's Hospital, Birmingham. THE sphygmograph of Marey has already won a high position as an instrument of physiological and clinical research, but it nevertheless possesses imperfections, especially in the means afforded for regulating the pressure upon the artery under examination. All who have worked with the instrument with any constancy must have regretted the inefficiency of the pressure screw (vis de réglage," Marey), but as yet no satisfactory alteration has been suggested. In using the instrument as hitherto sold, it is often necessary after its application to vary the amount of pressure exercised upon the vessel by means of the pressure screw, in order to obtain a fair average trace of the pulse movements. When the sphygmograph is applied to the forearm, this screw certainly enables us to increase the pressure by causing the descent of the spring which rests upon the artery, but it affords us no information concerning the amount of extra weight thus bearing upon the vessel, and it gives us no aid in ensuring the exercise of the same pressure in any two unconnected observations. A practised observer can no doubt soon regulate the instrument so as to obtain the most perfect trace, but the unskilful hand finds no small difficulty in so doing; and owing to the great modifications in the trace which may be produced by varying degrees of pressure, often obtains imperfect or erroneous results. And as the screw has to be readapted in nearly every case, no amount of practice can enable the experimenter in making a second observation after any interval, to exercise with certainty, exactly the same amount of pressure, unless the screw has meanwhile been carefully retained in its position, a condition incompatible with frequent use. In consequence of these difficulties, I suggested some months' back an addition to the screw, which I have since had applied and used with advantage. The woodcuts represent two views of the pressure screw (B), as placed in Marey's sphygmograph, and show also the additions I have made. These consist in connecting an index (A) with the screw, around which a circle has been described and graduated. The index moves along with the screw, and indicates on the circle the pressure equivalent in any observation. By this simple arrangement, without any alteration in its form, the sphygmograph may be made much more reliable in the hands of beginners, for each one will be able to record at the side of the pulse trace, the pressure exercised upon the artery beyond that necessitated by the application of the instrument. 1 Physiological section, British Association Meeting, Nottingham, 1866. 16 Moreover, in making a series of observations1 in the same or even in different cases, the spring can be fixed at that point which allows it to follow most accurately the movements of the vessel, and the conditions in all being thus rendered practically the same, the conclusions based upon a comparison of the traces become much more trustworthy. In cases of aortic aneurism, there can be no doubt that the most valuable assistance in diagnosis may be occasionally obtained from a careful comparison of the pulse traces collected on opposite sides of the body; and as important conclusions may be drawn from very slight deviations in form, we can scarcely overrate the value of any addition to the sphygmograph which will increase the accuracy of the conditions of application in the two observations. The modification in the screw will also aid in the determination of the effects of increased pressure in influencing certain parts of the pulse trace. Marey has, for instance, pointed out that the arterial tension may be estimated in this way, and, I believe, we may also obtain very useful information concerning the force of the ventricular systole. In conclusion, I may observe that while ordinarily the use of the pressure screw brings an unusually large extent of the spring in contact with the vessel, this may be avoided in the case of the radial, by a little attention to the relations of the artery (Wolf, op. cit.) An increased prominence of the ivory pad which rests upon the vessel, or a slight alteration in the curve of the spring, would, however, obviate this difficulty. I am aware that the slight addition suggested in this note by no means dissipates all the difficulties surrounding this question of pressure, but it will, I hope, be found useful in increasing the accuracy of the application of the sphygmograph. I have now used this plan for twelve months, and if its description leads to the proposition of any more perfect arrangement, it will certainly not have been devised in vain. 1 Mr. Meyer, of Great Portland Street, made the above-described alterations for me, and calculated the equivalents of pressure to be as follows: When the index points to 5, the extra pressure equals 20 grammes in weight. K A scale increasing more gradually would no doubt be preferable. This could be easily arranged, as every instrument would elasticity of its spring. I have remarked in examined a wide difference in this respect. in his 'Charakteristik des Arterien Pulses.' have to be graduated according to the |