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371 evidence of the elastic catheter having reached its destination. I have also had the instrument made with the cutting edges both above and below, instead of at the sides; but, for reasons which I need not now state, I have adopted the latter construc- tion. Finally, it is obvious that a like principle may be applied to instruments for dividing indurated strictures in other canals. It is also evident that it may be adapted to blades capable of being concealed or projected, or to a hlade sliding over a smaller guide which has been previously passed. .Savile-row, March, 1860. A Mirror OF THE PRACTICE OF MEDICINE AND SURGERY IN THE HOSPITALS OF LONDON. Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum et dissectionum historias, tam aliorum proprias, collectas habere et inter se com- parare.-MORGAGNI. De Sed. et Caus. Morb., lib. 14. Proœmium. ST. BARTHOLOMEW’S HOSPITAL. STONE IN THE BLADDER OF A GIRL; REMOVAL BY DILATA- TION AND INCISING THE URETHRA UPWARDS. (Under the care of Mr. STANLEY.) WHEN recording examples of stone in women and female children, we have generally adverted to the fact of the rarity of the affection in their sex, at least in London, as contrasted with males; for amongst the large number of patients annually cut for stone in our hospitals an isolated instance only is here and there met with in females. Most of these have been noticed in our pages, the majority occurring in little girls, and bnt few of them in adults. (See THE LANCET, vol. ii. 1857, p. 444, for an account of three patients-two children and one woman-operated upon by Mr. Hillman, at the West- minster Hospital, with a reference to preceding cases; also vol. ii. 1858, p. 500, for details of the case of a female child Operated upon by Mr. Moore, at the Middlesex Hospital.) We have often heard the question asked why women are so much less subject to stone than men. Mr. Coulson, in his work on "Lithotomy and Lithotrity," gives the mean result in a number of tables as one woman to every twenty cases of males; but he believes the proportion to be greater than this, for the reason that delicacy prevents numbers of females labouring under urinary diseases from applying for medical relief. However true this may be with regard to adults, it will hardly apply to children. But we think an explanation is afforded by the fact of the facility with which a stone passes from the female bladder, owing to the shortness of the urethra and its general elasticity, and the almost impossibility, there- fore, of the calculus remaining to attain a large size. We know, also, that sometimes even pretty large stones pass spon- taneously from the female bladder, and are assisted in their exit by the finger of the patient. We now record two examples, in girls aged thirteen and six years respectively, from each of whom a stone was re- moved by dilatation and incision of the mucous membrane. In the first case, Mr. Stanley performed dilatation with a Weiss’s dilator after dividing the upper and anterior part of the urethra for half an inch, cutting towards the pubes, and removed a stone as large as a pigeon’s egg. This direction of the incision is that practised by Sir Benjamin Brodie, and occasionally adopted by other surgeons. Thus, Mr. Hillman in one case (already referred to) incised the urethra directly upwards, in the direction of the symphysis pubis, to the extent of a quarter of an inch, and the stone was readily extracted. In the second example, Mr. Canton grasped the stone by means of a small pair of nasal polypus forceps, in its with- drawal gently dilating the urethra; but he was obliged to divide a small portion of the lower wall of the urethra to per- mit of complete extraction. No bad consequences resulted. For the notes of the following case we are indebted to Mr. Rogers, house-surgeon to the hospital :- E. H-, aged thirteen, a sallow, cachectic, and rather idiotic-looking child, was admitted into Sitwell ward for great pain in micturition, and pain in the groin and back. Her mother stated that for the last twelvemonth she had been fall- ing off, and had become more and more emaciated. No pieces of gravel had ever been passed. The child had had sudden stoppage of urine, but this, apparently, was more from pain than real obstruction. A fter her admission the specific gravity of the urine was 1018, but it contained neither mucus nor pus. She was placed on a nutritious diet; steel wine was given; and she was directed to have a hip-bath every night. Under this treatment she improved, became more cheerful, and suf- fered less pain. In January last, however, the pain returned, and was not now relieved by the warm bath. The urine was high-coloured, and mixed with thick ropy mucus, pus, and abundance of triple phosphates. A calculus was now detected. On February 1st, nitric acid, with decoction of pareira brava, were ordered. Under this treatment, with opiates at night and the continued use of the hip-bath, she again improved. On the 19th, cod-liver oil was ordered. She continued to gather strength. The urine improved very much, containing less pus and mucus. On March 1st, Mr. Stanley performed lithotomy. The girl having been placed under the influence of chloroform, a grooved staff was introduced into the urethra, with the groove upwards. With a blunt pointed bistoury passed up the groove of the staff, Mr. Stanley divided the parts above the urethra for about half an inch, cutting in a direction directly upwards towards the pubes. By this incision the lower border of the triangular ligament was freely divided; but Mr. Stanley stated that he did not cut the sphincter of elastic tissue immediately sur- rounding the neck of the bladder. The incision having been made, the next point was to introduce the dilator without in- jury to the wound. This was done by turning the staff with its groove downwards, so that a Weiss’s dilator could be slipped along the latter. The dilatation was accomplished slowly, and with great care. As soon as the dilatation had proceeded suffi- ciently to admit of the finger being introduced, the instrument was withdrawn. The stone was now easily detected, and was by means of a pair of forceps, but with some difficulty, extracted. At first the soft coating of the calculus gave way, but the whole mass was finally removed. The calculus turned out to be lithate of ammonia, and was nearly as large as a pigeon’s, egg. A piece of wet lint was placed on the wound, and poppy- fomentations were directed to be applied to the abdomen. She improved rapidly, and by the 12th regained completely the power of retaining her urine. Her recovery was a good one. CHARING-CROSS HOSPITAL. STONE IN THE BLADDER OF A GIRL AGED SIX YEARS; EXTRACTION; RECOVERY. (Under the care of Mr. CANTON.) HARRIET J-, aged six years, a pale and emaciated child, a native of Scotland, but has lived in London during the last four years. She cut her teeth at an unusually late period, and with very great difficulty, and was unable to walk alone until she was two years of age. The mother states that her daughter was always a long while in passing her urine, but it was not until six weeks ago that she complained of pain on micturition; the flow of urine was then noticed to be occasionally stopped with abruptness. Complete retention, for the first time, occurred two days previous to her admission into the hospital, but was overcome by the use of a warm bath and the administration of a dose of castor oil. Retention took place again the next day, but the above measures having been resorted to without suc- cess, the patient was placed under the care of Mr. Canton. Seen at first by Mr. Travers, the house-surgeon, (to whom we are indebted for these notes,) the child presented a pale and most anxious expression of countenance, which had a sickly, sallow hue; the body was much wasted; great pain was com- plained of in the lower part of the abdomen, and especially at the pubic region, where the bladder was found to be much dis- tended, no urine having been voided for thirty hours pre..
