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was passed almost daily, without pain; and on the 27th, heleft the hospital quite well.

Last week we were present at St. George’s Hospital, whenMr. Caesar Hawkins operated upon a man’s urethra, which hadbeen completely divided across some years before from an in-jury, and followed by stricture and fistulous openings; and onthe 15th of April we again saw Mr. Birkett incise the urethraand perinæum of a boy who had met with a similar accident-complete transverse rupture of the urethra, from a fall over apiece of wood. This at the time was followed by effusion ofblood and urine, which extended up to the umbilicus. The ladhad a narrow escape for his life; but a fistulous epening re-mained in the perinæum, through which the greater part of theurine continually flowed, a small portion only coming by theurethra. His operation consisted in an incision downwardsand backwards, the passage of a grooved director through theback part of the urethra, which was tight, and therefore in-cised upon the groove. A gum-elastic catheter was passeddown the urethra to the fistula, and thence along the grooveddirector to the bladder. Urine then flowed freely. This caseis going on very satisfactorily, and will terminate in perfectcure.

STRICTURE OF THE URETHRA FOR THIRTEEN YEARS ; PUNCTUREOF THE BLADDER THROUGH THE RECTUM FOR RETENTION

OF URINE. AT A LATER PERIOD, ABSCESS IN THE PERI-

NEUM, INCISION OF PERBMEUM AND URETHRA; CURE.

(Under the care of Mr. BIRKETT.)We have here present an example of long-standing stricture

arising from gonorrhoea, with frequent difficulty of passingurine, necessitating frequent visits to several of our large hos-pitals to get instruments passed to relieve retention, which onone occasion had to be relieved by puncturing the bladderthrough the rectum, as the stricture was then impassable. Ona subsequent occasion he sought admission into Guy’s Hospitalfor retention and inflammation of the perinæum, associatedwith well-marked indications of abscess in that region. Avery free section of the urethra and perinæum was made uponthe grooved staff of Mr. Syme, thus opening the abscess, andfreely dividing the stricture at the same time, which wasseated in the anterior part of the canal. This proceeding wasperfectly successful, and was attended by the best results, aperfect cure being effected in the course of six weeks.A man, aged twenty-nine years, a bricklayer by trade, was

admitted into Naaman ward, No. 14, November 8th, 1855.He enjoyed tolerably good health, had been somewhat intem-perate in the use of alcoholic fluids, and he had been troubledwith stricture of the urethra about thirteen years. The historyhe gives of himself is as follows: Thirteen years since, he con-tracted gonorrhœa, which resulted in his having a stricture.He had a catheter passed at the time by a surgeon in thecountry, who had great difficulty in getting it past the stric-ture. He was under treatment for some time, and was consi-derably relieved for five or six years, although during most ofthis time there was a discharge from the urethra. At the endof this period he again contracted gonorrhcea, and the stricturesoon became as bad as ever. He was in the habit of going toGuy’s, Bartholomew’s, and Westminster Hospitals, to have acatheter passed-to whichever hospital was, at the moment,most convenient. Seven years since, he was in Guy’s for twomonths, and was discharged relieved. He was again admittedin January, 1855, on account of retention of urine; and as theurethra was impassable, Mr. Callaway punctured the bladderfrom the rectum. He was in hospital one month, during whichtime a small perineal abscess was opened, and when he wentout he made a good stream of urine with comparativefacility.Two days before admission, on November 6th, he passed

urine as usual, but on the 7th he experienced during the day-time a great deal of pain on micturition, and he passed verylittle at each effort. At night he was unable to void any urine,and he suffered intensely during each attempt; the scrotumbecame red, swollen, and painful. The bladder was distended,and on the 8th, early in the morning, attempts to pass a catheterfailed. He was placed in a warm bath, two grains of opiumwere administered, and in a short time afterwards, he passedsome urine, with much straining in the effort. At half-pastone he was comparatively free from pain; there was consider-able induration of the tissues around the urethra, and in frontof the scrotum, and, in fact, along the whole course of theurethra, through the scrotum, and into the perineum, in whichregion there was inflammation and indications of suppuration.Ordered, twelve leeches to the perinæum; five grains of Dover’s

powder, three times a day; and tartrate of potass, with Min.dererus’ spirit, also three times a day.9th.-Had passed some urine, but with great difficulty.

There were well-marked indications of suppuration in the peri-næum. Mr. Birkett passed the No. 3 catheter, and havingdone this, he determined to open the perinseum, and divide theconstricted part of the urethra at the same time. This wasaccomplished by passing the grooved staff invented by Mr.Syme. A very free section of the urethra was made, extendingfrom the front of the scrotum to the membranous part. Pusflowed from the perinæum. A No. 10 silver catheter was easilypassed, and retained in the bladder for about eight hours.Ordered, immediately he was in bed, and had recovered fromthe effects of the chloroform, fifty minims of tincture of opium.The object of the operation was to divide the stricture freely,at the same time that the urinary abscess was opened. Thelast proceeding was absolutely necessary, and the division wasperformed in the hope of curing the stricture, which was seatedin the anterior portion of the urethra, where it traverses the-scrotum.

10th. -The patient passed the last night very comfortably;was free from suffering, and only feels pain when the urinepasses the wound.

11th.—Complains of but little pain; all the urine passesthrough the wound; bowels confined. An aperient wagordered.

14th.—Mr. Birkett passed a large catheter easily.25th.--Urine passed through the urethra and from its orifice

on the glans to-day for the first time since the operation, aswell as through the wound.During the month of December the urine passed through the

wound in the perinæum in decreasing quantities, and but for anattack of diarrhoea, which continued several days, this woundwould probably have healed much earlier.

Dec. 19th.-He was allowed to walk about the ward. Afew days after this date the wound was entirely healed. Henow passed urine in a full stream, and without pain, and hisgeneral health improved rapidly.

Jan. 9th, 1856.-The patient left the hospital.Since this date Mr. Birkett has seen the patient several

times, and has introduced a No. 10 sized catheter with theutmost facility.

April 30th.—This man called on Mr. Birkett to-day. Hepasses urine freely, and, with the view to examine the state ofthe urethra, he passed a No. 7 sound without any difficulty.

ROYAL FREE HOSPITAL.

CHRONIC ABSCESS OF THE THIGH, WITH FISTULOUS TRACKSLEADING TO A NODE ON THE FEMUR; OPERATION; CURE.

(Under the care of Mr. COOKE.)

IN passing through the wards of our large hospitals, and invisiting the out-patients’ rooms, we are often struck withastonishment at the large number of cases of chronic disease ofthe bones which present themselves to the notice of the sur-geon. These do not now depend upon a cause which formerlyused to produce such ravages in the skeleton-namely, the ad-ministration of mercury, but would appear to be the result ofeither syphilis itself, scrofula, or that peculiar condition of thesystem which shows itself in the development of boils, car-buncles, whitlows, and other purulent formations; or even asthe remote result sometimes of injuries sustained months beforethe bone becomes diseased. Poverty and neglect have theirshare in the production, for it is amongst the poor we findthem especially prevalent. The treatment in many of these islong in effecting its proposed object, and the operations thesurgeon is so frequently called upon to perform are often verydelicate, and now and then attended with some risk, thoughgenerally successful. Our " Mirror" contains the records ofnumberless triumphs in this branch of the surgical art. It wasonly the other day we gave an instructive case of the kind atSt. Mary’s, under Mr. Coulson’s care, and to-day we give theparticulars of three cases treated by Mr. Weedon Cooke. Eachcase has its own peculiarities, and illustrates three of the causesof bone disease, and the necessity of operative measures toeffect a cure, conjoined with tonic treatment and good diet.The second case is one of great interest, from the presence of

an abscess between the dura mater and skull, which producedno constitutional disturbance, the mere removal of a piece ofdead bone permitting of the free evacuation of the pus andsubsequent recovery.The last case is one of necrosis of the terminal phalanx of the

544

great toe-an affection very frequently met with amongst thepoor, in the thumb, especially in tailors, shoemakers, andseamstresses. We have seen Mr. Fergusson at King’s College,Mr. Ure at St. Mary’s, and Mr. Cooke at the Royal Free,slightly enlarge the fistulous opening in such cases, and with apair of forceps remove the dead bone, thus leaving the tissuesto contract, producing a very serviceable thumb-an operationwhich, although simple in itself, is one of the most useful andcreditable to surgery.

R. A—, aged 25, an excavator, much reduced in strength,was admitted September 7th, 1855, having a diffused super-ficial abscess covering a large portion of the back of the rightthigh, emptying itself by several small openings. The skinwas much indurated and dark coloured, and there were severalcopper-coloured spots upon the rest of the thigh. The patientsaid he had had syphilis a year ago, for which he had beensalivated. The affection of the thigh came on four monthssince. Being in very bad condition, he was ordered full diet,with stout; tincture of cinchona and sulphuric acid, and lin-seed poultices to the thigh; to which were added, on the 13th,small doses of blue pill and heubane each night.

Sept. 16th.—Although improved in general health, the thighremains in the same condition. Mercurial ointment to be ap-plied to the thigh, instead of poultices.

27th.—Some of the fistulous openings healed; less discharge;the induration remains. A blister to be applied to the part,subsequently dressing it with the blue ointment.

Oct. 2nd.-Great diminution of induration; slight line ofredness round the gums.9th.-Some induration remains, as well as two openings.

Repeat the blister and ointment.12th.—Induration again lessened; the probe now passes five

inches into the thick of the thigh, but not touching the bone.Omit all mercurials, and continue the bark and acid only.16th.-Upon careful examination with a long probe, Mr.

Cooke found that the fistulous track led quite down to thefemur; and seeing that the man had been afflicted so long, andthat the disease could not be cured without attacking the boneitself, it was determined to make an incision, and carefullyexamine the state of the bone. Accordingly, chloroform havingbeen administered, he made an incision through the induratedskin three inches in length, and was enabled to pass theindex finger between the muscles, down to the bone, upon theback of which, at about the centre, there was a defined swell-ing, like as it were a limpet upon a rock. Carrying the knifecarefully down, directed by the index finger of the left hand,he cut quite through this swelling, and upon introducing thepoint of the finger between the edges of the thickened perios-teum, the bone felt rough, as though carious. Up to this timevery little bleeding occurred; but upon removing the knife,some branch of the profunda femoris was wounded, and bledrather severely. It being impossible, in this deep situation, totie the vessel, a pledget of lint, steeped in perchloride of iron, ’,was introduced to the bottom of the wound, with other pledgets above it, and over all ’a bandage. No further haemorrhage I

occurred; and on the fourth day after the operation the pledgetswere removed, except the first. Some sesquichloride of ironwas injected, fresh pledgets of lint introduced, and the legagain rolled with a bandage. On the ninth day, all the

pledgets were removed; no haemorrhage occurred, and thewound was found granulating healthily.

30th. -Wound healing fast; very little discharge of pus now.From this time he progressed slowly towards convalescence,and was discharged, cured, December 5th.He went into the country, and soon became better and fatter

than he had ever been, and subsequently presented himselfperfectly well, as he had been ever since he left the hospital.

NECROSIS OF THE OS FRONTIS, THE RESULT OF AN INJURYSIXTEEN WEEKS BEFORE; OPERATION; REMOVAL OF A POR-TION OF NECROSED BONE; RECOVERY.

R. C; aged thirty-one, cabman, was admitted April 12th.Sixteen weeks ago, in a scuffle with a carpenter, he received awound of the scalp and skull with a screwdriver, in the situa-tion of the anterior fontanelle. The wound was at first strappedby a druggist for a fortnight, after which being in much pain,he applied to one of the large hospitals, where he was orderedlinseed poultices and tonics, which he continued for twelveweeks, all this time continuing his occupation. He sufferedfrom severe pain in the head and face, with loss of appetite,increasing debility, and some swelling about the left ear. Puswas discharged into the poultices from the wound. The sightand hearins were unaffected. and there was nn naralvtic affec-

tion of any kind. Upon examination with the probe, therewas evidently a fracture of the cranium, admitting of the pas-sage of the instrument down to the dura mater, and between itand the inner table of the skull an inch and a half each way.Suspecting, from the purulent discharge, the presence of a por-tion of necrosed bone, Mr. Cooke, upon the 14th of April, madea crucial incision to expose the condition of the skull, andfound a loose piece of bone, the size of a horsebean, which heremoved. The dura mater was seen pulsating beneath this,having attached to it two small points of bone; these Mr.Cooke very gently attempted to detach, but finding themfirmly fixed upon the dura mater, he decided to let themremain, to act, probably, as centres of ossification for filling upthe vacancy. In the course of the operation, about a table-spoonful of laudable pus escaped from between the bone anddura mater ; about one ounce of florid blood escaped likewise.The patient was rather faint, but bore the operation remark-ably well, chloroform not having been administered, owing toa desire to have the man’s intelligence and feelings as a guideto the operative proceedings. The wound was not broughttogether by sutures, but gently covered with water dressing.

April 21st.-No untowardsymptom has since occurred. Thepain in the head was immediately relieved by the operation;has slept well, and taken food (meat and porter) capitally. Hehas been for the last two days up and about the square of thehospital. Laudable pus continues to be discharged from thewound. Owing to the severe illness of his wife, he left thehospital to attend to her, but came as an out-patient on May3rd, with the wound very nearly healed. The probe passesdown to the dura mater, but not now between it and the skull.The discharge of pus has almost ceased, and the poor man,from having been pale and distressed, is getting ruddy andcheerful, and is gaining flesh.ULCERATION OF THE METATARSO-PHALANGEAL ARTICULATION,

WITH CARIES OF THE ENDS OF THE BONES OF THE GREAT

TOE; SINUSES; OPERATION.

John G--, aged sixty years, miller, admitted as an in-patient November 19th, 1855. States that he has had a bunionon the great toe for some years; last March it inflamed verymuch, the skin broke, and it has been discharging ever since.He cannot remember having received any injury to the foot tocause it to become inflamed. The great toe and anterior partof the foot are now much enlarged, and very painful whenhe attempts to walk. Ordered, a linseed poultice; cod-liveroil and compound infusion of gentian three times a day, withfull diet and porter.

Dec. 3rd.--Considerable diminution of size of foot. Continuethe medicines, and apply dilute mercurial ointment everymorning.

17th.—On passing the probe into the wound, it impingesupon denuded bone. Linseed poultice. Continue the treat-ment.

Jan. 1st, 1856.-The foot was benumbed with ice, when Mr.Cooke made a crucial incision over the junction of the meta,tarsal bone and first phalanx of the great toe, and finding thecartilages destroyed, and the heads of the two bones denuded,with a small saw he removed about an inch of the metatarsalbone and the head of the phalanx. The integument wasbrought together by three stitches.He went on well for three days, when some slight erysipelas

arose round the toes. This was subdued, but followed, in ashort time, by a streak of inflammation up the leg to the groin,in the course of the absorbents. For a day or two there wassickness, shivering, and a brown tongue. With purgativesand brandy, this subsided; and now (Jan. 16th) he is going onwell, the wound healing by granulation.21st.-Continues to progress well.26th.-Wound healing kindly; tongue clean; all doing well,

except that there is some œdema at the ankle. To have gentianmixture.29th.-Pus has formed at the external malleolus. It was

lanced and about an ounce and a half of laudable pus escaped.Continue poultice and medicine.

31st.—Serous discharge from external malleolus; wound of £foot healing. To have two grains of quinine three times a day.

Feb. 25th.-Wound at foot nearly healed. Water-dressing.Repeat the quinine.March 27th.—Being weak, and having no home, he has been

kept in until this date, but is now discharged with the foot quitewell. He subsequently came to the hospital much improvedin general health, the foot remaining quite well, and he con-templated returning to his occupation, after being disabled fora twelvemonth.