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apply a hot bread poultice to the finger and hand, which shecontinued to do until it began to put on a serious aspect, whenI was summored to attend her. The hand, fore-arm, and arm,are very much swelled, hard, and inflamed, the under part ofthe arm being of a bright scarlet colour; complains of greatpain, which she describes of a burning character; the glands ofthe axilla, are enlarged; intense pain in the head; tonguefurred, and very dry ; great thirst; pulse quick and full; skindry ; bowels have not been acted on for three days. She wasbled to sixteen ounces, and the following mixture ordered, andtwo grains of calomel with each dose of the medicine. Sulphateof magnesia, one ounce ; infusion of senna, eight ounces ; makeinto a mixture, and take two large spoonsful every other hour.Cold applications to be applied to the inflamed part.4th.-Patient this morning seems somewhat relieved from

the burning pain which she experienced yesterday; pulse notso quick; thirst still great; the bowels have been well actedupon by the medicine : she states the cold applications give herniore ease than the poultices formerly used; the blood drawnfrom the arm yesterday is cupped and buffed; will not bearfurther depletion; ordered a saline mixture.5th.-Arm still remains hard, and very much swollen; no

quagginess or fluctuation can be detected in any part; thetongue remains furred, and the thirst still continues; pulsequick, but small; she seems to be in a sinking state; medicineto be discontinued; ordered her to take a little port wineoccasionally during the day; she began to sink rapidly, andbreathed her last at five o’clock the following morning.Renaarks.-This case is interesting, as it shows the pernicious

and fatal manner in which" washing soda" (sodabicarbonas)acts upon the human body, when continued to be applied to arecently cut surface. How or in what way it produces itspoisonous effects upon the blood is a mystery that I am unableto solve. I have seen a case where the finger has been ampu-tated in consequence of disease in the joint, which was causedby washing linen in water containing this substance, and I haveno doubt that many of my professional brethren have met withsimilar cases.Brynmawr, Dreconshire, November, 1854.

A Mirr orOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborumet dissectionum historias, tam aliorum proprias, collectas habere et interse comparare.—MORGAGNI. De Sed. et Caus. Morb. lib. 14. Proœmium.

CASES OF EXTERNAL INCISION FOR STRICTURE OF THEURETHRA.

KING’S COLLEGE HOSPITAL ..... MR. FERGUSSON.,, ,, ,, ..... MR. HENRY LEE.

ST. MARY’S ..... MR. COULSON.

(Concluded from p. 417.)

KING’S COLLEGE HOSPITAL.

TREATMENT OF STRICTURE OF THE URETHRA BY THE

EXTERNAL INCISION.

(Under the care of Mr. FERGUSSON.)THIS patient is a man of fair complexion, above twenty-

six years of age, and has had stricture of the urethra for thelast eight years. The affection has caused along the canalthat amount of mischief and disorganization which is so

characteristic of coarctation. About eight years previous tohis admission into this hospital, he suffered from retention,which proved so obstinate that M. Delagarde, of Exeter,punctured the bladder above the pubis. The catheter at thatperiod was only left three days in the canal; and as thenatural outlet probably became tolerably pervious again, thewound was allowed to heal. The cicatrix is now clearlyvisible: it is circular, the size of a fourpenny-piece, and pre-sents a rugose, starry appearance.In spite of the occasional use of instruments, the urethra, some

time after this, was felt to have been narrowed in two places :one a few inches from the meatus, and the other towards themembranous portion of the urethra. The canal now gave way,abscesses formed, and after the pus was discharged, fistuloustracts and openings yielded a passage to the urine each timemicturition took place. In the summer of 1854 the man wasadmitted into this hospital in a weakly state, and the treat-ment by dilatation was systematically pursued for severalmonths with a certain degree of advantage. But the fistrlousopenings showed no tendency to close.Owing to the patient’s weakly state, Mr. Fergusson did not

wish to resort, at that period, to any operative measures ; butwhen the man returned to the hospital, (Sept. 1854,) Mr.Fergusson resolved to treat the stricture by the external in-cision, and freely to lay open the sinuses, so as to afford thepatient a good chance of regaining the integrity of the canal.On the 14th of October the patient was brought into the

theatre, and when examined was found to present severalfistulous openings about the scrotum, one of which was closeto the peno-scrotal angle. When the man had been fullynarcotized by chloroform, he was tied up, as for the operationof lithotomy, and a silver catheter, of about No. 4 size, wasintroduced into the urethra, and glided easily into the bladder.Mr. Fergusson now made the usual incision exactly along theraphe of the perinaeum, and having reached the instrument,carried the knife upwards and downwards for about tLedistance of one inch and a half. The urethra having thus beenfreely laid open, the scalpel was carried along the differentfistulous tracts, which were all largely incised. This mean-

sure caused the escape of a certain amount of urine along withthe blood. The silver catheter was now withdrawn, and anelastic one of a large size introduced.The haemorrhage was very inconsiderable, and when the

patient was removed, Mr. Fergusson stated that the presentcase was one of no common interest, as the numerous fistulxwith which the patient was affected had resisted various kindsof treatment ; he had suffered severnlattac’ks of retention of urine,for one of which the bladder had been punctured over the pubis.It had been evident, through the operation, that a pretty largeinstrument could pass; but it was doubtful whether it had runthe right course, for there existed a pouch towards the prostategland. He (Mr. Fergusson) had been very careful to avoid thislarge sinus, so as to secure the correct division of the stricturedportion of the urethra. By laying open the fistulous tracts,the urine lying in them (which is very liable to cause calcareousdeposits) was freely evacuated, and as the instrument was tobe left in the urethra, there was every likelihood that thewounds made in the scrotum, in different directions, wouldlead to an eventual cicatrization of the parts. In fact, it wasall-important to this patient that the abnormal communicationsbetween the scrotum and urethra should be closed up, as for along time he had passed all his urine from the scrotum.The patient progressed pretty favourably after this operation,

and the elastic catheter (No. 10) which had been passed intothe bladder, was left for eleven days, when it was found some-what incrustated with calcareous deposits.One month after the operation the perineal wound had not

yet completely cicatrized, and the urine passed through it, as swell as through an aperture situated at the root of the scrotum.At this period, it appeared as if urine had again irritated someportion of the perinaeum, as pain and heat were felt towards theanal region, the usual forerunners of a purulent collection.

This patient is evidently one of those who try all the

ingenuity of the surgeon, and upon whom the value of suchoperations as the external incision may fairly be tested. The

case, according to the views generally entertained, should dowell, for the sinuses were freely incised, the urethra largelydivided, and the instrument left in the bladder for eleven days,a period of time nearly sufficient for complete cicatrization andre-formation of the canal.One circumstance should, however, be taken into account--

viz., the broken health of this patient, which must materiallyinterfere with the work of repair, upon which the success ofthis operation mainly depends. The latter may emphaticallybe called Mr. Syme’s, as there was no difficulty in passing thesilver catheter, and the operative proceeding was conductedexactly as directed by the originator of the operation. WouldReybard’s have offered some chance of success? We thinknot; for, in a canal so deeply affected, the internal incisicn,and the possible unconcern with respect to the sinuses, mighthave been inadequate to lead to a favourable issue. * Mr.

Fergusson had, of course, no trouble in finding the urethra, asa tolerably sized instrument was placed in the canal. Can thesame operation be performed when no instrument will pass ? ?

’ * Since the above was written, the patient has died of purulent deposit.

436

It would appear, from Mr. Lee’s case, which stands next onour list, that such is the case, and we proceed to enter into afew particulars.

Before doing so, however, we would just state that Mr.Fergusson had, a short time ago, an opportunity of presentingto the pupils a seafaring man upon whom he had performed

EXCISION OF THE ELBOW-JOINT

two years previously.* * He said that there were few cases in

England like the one now before the pupils, and that the manenjoyed now a fair amount of motion in the elbow-joint, afterhaving had all the bones of the articulation consolidated inconsequence of a fall from a mast. In fact, the elbow had beenanchylosed in a very awkward position, and the arm was useless.

In that state the patient had applied to various hospitals, asalso to a bone-setter, (who twice disturbed the anchylosedsurfaces.) When the man came before Mr. Fergusson, thelatter thought the only way of dealing with thi stiff joint wasto follow the method of Mr. Barton, of America, who had cut outa wedge-shaped piece from the front of the tibia, and created,in some degree, a new joint below the anchylosed knee. Mr.Mackenzie had applied the same method to the elbow, and he(Mr. Fergnsson) had thought that this operation was the surestmeans of giving some mobility to the stiff elbow-joint of thispatient.He accordingly had cut out a large portion of the end of the

ulna, radius, and humerus, and the amount of bone takenaway was rather considerable, as there had been much hyper-trophy of bone, or rather formation of new osseous tissue.The operation was, in fact, a re-section of an anchylosed joint.The subsequent treatment was simple, and the patient had leftthe hospital with the wounds cicatrized, and some motion inthe joint. Now, two years after the operation, the mobilityof the arm was considerably increased, and it was satisfactoryto have a living proof of the great amount of benefit whichmay be obtained by the adoption of decisive measures in casesof this kind. The patient had been reported to be dead, buthe stood here to prove the contrary.

STRICTURE OF THE URETHRA OF TWENTY YEARS’ STANDING;EXTERNAL INCISION WITHOUT GUIDE.

(By Mr. HENRY LEE.)THIS patient is a hair weaver, about forty years of age, of a

thin, sickly look, and observed the first symptom of stricturetwenty years before his present admission. At that periodretention of urine suddenly came on, when a personal friend ofthe patient, seeing the state he was in, shaped a piece of whale-bone from an umbrella into the form of a bougie, and passed itup the urethra. Immediately after the operation, the urineRowed copiously.The patient now remained well for three or four years, when

symptoms of stricture again presented themselves, but not tosuch a degree as to cause him much inconvenience, the use ofthe catheter being, however, now and then required.

Four years before his admission here, the distress from thestricture became suddenly so great as to induce Mr. Guthrie,under whose care he then was, to divide the stricture withStafford’s instrument. After this operation, the patient passedhis urine freely, for a short time, but soon the stricture returned,and he has been suffering from it more or less up to his admis-sion. When first seen in the hospital, September 14th, 1854,there was pain in the lower part of the abdomen, and across theloins, and the bladder could be distinctly felt, through theparieties of the abdomen, to be hard and full. There was totalinability to pass urine, which fluid only came in drops. Theendeavours to introduce a catheter, both without and within thehospital, having proved useless, Mr. Lee had the patientbrought into the theatre, passed down an instrument as far asthe obstacle, and with no better guide than the end of thecatheter, freely divided the urethra. When this perineal sectionwas accomplished, No. 6 catheter was introduced into thebladder, and there retained for five days.The urine a few days afterwards passed both through the

wound and the urethra, and the patient after remaining severalweeks in the hospital is on the point of being discharged. Thewound is all but healed, and scarcely any urine escapes throughthe perinaeum.

Mr. LEE. in a clinical lecture on this case, after giving asketch of its principal features, and having pointed out the dif-ferent kinds of unpleasant consequences following stricture,and the various methods which have been devised for the cureof coarctation, said-

* An account of this case will be found in a former "Mirror." (THBLAtfc.ET, vol. ii. 1852, p. 518.)

" The plan of dividing stricture by instruments passed downthe urethra has been variously modified; sometimes an instru-ment of the shape of a trocar has been made to protrude fromthe end of a catheter, so as to perforate the stricture; some-times the instrument used has been made in the shape of alancet, and sometimes a long very thin knife has been passeddown to the stricture upon a director. Another plan has.

lately been adopted in France where an instrument could beintroduced into the bladder. The instrument used resembles-in construction a lithotrite, but the blades are capable of beingseparated from each other to the extent of about a quarter ofan inch. The instrument is then introduced, and the bladessuddenly separated, so as forcibly to tear open the stricture.Now all these plans have the disadvantage, besides that of

endangering the vitality of a portion of the mucous membraneof the canai, of not providil1g an escape for any portion ofurine which may flow from the urethra through the openingwhich they make. Under these circumstances it has beenproposed to make an incision in the perinaeum, and to dividethe stricture from without. This plan, of which I now proposeto speak, has at least the advantage, when properly performed,of being free from the dangers arising from making falsepassages, extravasation of urine, and purulent deposits.The cases for which this operation has been recommended

are of three kinds:-1. Where -the stricture presents an extreme degree of’

irritability, and resents, by violent local and constitutional dis-turbance, any efforts to produce dilatation.

2. Cases in which the stricture, when dilated, rapidly con-tracts again.

3. Cases in which, after the dilatation of the passage, mic-turition is nevertheless painful, difficult, and uncertain.To these three classes we may add a fourth, not admitted

by some surgeons-namely, cases in which no instrument canbe passed into the bladder.For these affections a free incision of the contracted part of

the urethra has been maintained to be the proper mode oftreatment, and to be in fact required.The mode of performing this operation, as described by Mr.

Syme, is as follows:-A grooved director is first introduced through the stricture,

where this can be done, (and Mr. Syme is of opinion that, withcare and attention, there is no stricture through which aninstrument may not be made to pass.) The patient then beingplaced upon his back, at the edge of the table, with his legsbent, as in the operation for lithotomy, an incision, about oneinch and a half in length, is made exactly in the raphe of theperinaeum. The whole of the thickened, indurated, and con-tracted texture is then divided upon the director, to the extentof an inch or two, or more if necessary. A No. 8 silvercatheter is then passed into the bladder, and allowed to remainthere for at least two, and not more than three days.

Great stress is laid upon the fact of the incision being madeexactly in the middle line of the perinasum, in order to avoidthe artery of the bulb which lies by the side of the canal.The only sources of danger alleged to exist are, haemorrhage

and extravasation of urine. But if the knife is kept exactlyin the median line, the only vessels that are likely to bleed are,.the smallest branches of the superficial perineal artery, and thecells of the corpus spongiosum; the bleeding from these maybe checked, should it be desirable, by placing a piece of foldedlint between the edges of the wound, and applying the slightestdegree of pressure for a few hours.The liability to extravasation of urine after this operation, I

will presently consider, reserving it for separate remarks, as Iconceive the liability or otherwise to its occurrence forms thegrand distinction as to this operation being admissible or not.

After the operation of perineal section, the catheter is tied imthe bladder, and the patient put to bed. At the end of forty-eight hours the catheter may be removed. A full sized bougieshould be introduced once a week for three or four weeks, andthen at more distant intervals, according to circumstances.

’

Now this operation, as I have described it, appears a verysimple affair, and if this were all, there is little doubt which isto be preferred, the pain and inconvenience, (to say nothing ofthe danger of a stricture) or the simple operation of dividing a,portion of the urethra on a grooved director. But, un-

fortunately, the operation has not been found to be one of sucha very simple nature in its consequences, even where an in-strument could be got into the bladder, much less in caseswhere no staff could be passed.Mr. Syme, of Edinburgh, asserts that he has performed thisoperation a great number of times, without any ill effects, ex-cepting only some consequent symptoms of nervous irritation.But in other hands the most serious mischief has often super-