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188 feeble, with a furred tongue; full, rapid, irregular pulse; and considerable atheromatous rigidity of the arteries. Percussion of the abdomen gave a dull nnte for two inches above the pubee, and manipulation discovered a round firm mass, feeling somewhat like an orange, in the mesial line above the pubes. If this mass were pressed down while the finger was in the rectum, irregular fluctua- tion could be just felt behind a prostate enlarged appa- rently to double the normal size. Attempts to pass a catheter, after prolonged trial on the 1mh, failed. An incision on each side of the middle line into the abscesses and eedematous tissue of the perineum and scrotum was made, and stimulating and nutritious food was given, and warm poultices applied to the perineum. The next day the patient was easier ; hsd had some sleep in the night, and taken plenty of food. The urine, passed three times in the night in a, stream, was dark, fetid, with moderate deposit of pus. Perineal swelling less brawny; matter weeping from the incisions, but apparently no urine escaping by that way. The succeeding day the swell- ing had increased again ; urine passed only in small quanti- ties and with great effort. Another attempt to pass a catheter failed to do more than insinua,te a No. silver partly through the stricture; when it had penetraterl some distance, the stem was blocked so firmly in the indurated tissue of the stricture as to become immovable by any force it was thought prudent to employ. The patient’s strength was less than on the previous day, the swel1ing in- creasing, and the bladder slowly getting more and more distended. The patient was put under chloroform, and the bladder punctured per rectum. The long distance of the bas fond from the anus allowed very little of the cannula to project into the bladder; a flexible catheter was passed through it, and, with the cannula, fastened to the buttocks in the ordinary manner. The urine ran freely through this tube, and the patient remained free from pain until the next morning, when he complained of pain at the anus, which was attributed to the cannula, and an attempt was made to withdraw it while leaving the catheter in situ. This failed, and the urine, which bad continued to run away freely through the catheter since its insertion, and become clear, acid, and free from pus or smell, ceased to flow. Thie condition remained unchanged till 5 p Mr , when Mr. Hill, on his visit, ascertained the cannula and catheter had escaped from the bladder into the rectum, the latter instrument being doubled backwards at the point where it had pro. jected into the bladder beyond the cannula. In addition tc this, the inflammatorycedema of the scrotum had now passed to the buttocks and half way down the inner side of the right thigh, with an abrupt, irregular line of demarcation, and herE and there vesication. Temperature 103&deg; F. No tenderness of abdomen, which was soft and yielding. The bladdei could not be distinguished now through the abdominal wal’ or per rectum. Patient bad no desire to pass water. A1 10.30 P.m. the patient was suffering go! eq,t pain. Tempera, ture 103&deg; F. Abdominal walls flaccid, not tender; thE bladder could be indistinctly felt. The patient was pu; under chloroform, and the rectum trocar inserted a seconi time into the bladder. Urine flowed in fair stream, an( the trocar was fastened in. Little improvement followe( this; and the next morning the erysipeia.toDS blush extende< over the left buttock, the thigh, and the flank. Two day later the patient died. At the post-mortem examination extersive general peri tonitis was found, most intense at the pelvis. The pelvi, viscera were removed in one mass. The recto-vesical poucl of the peritoneum (very long) was found to extend com pletely past the trigone of the bladder and to reach quit up to the prostate; accordingly, both the pm?cknres fron the anterior wall of the rectum to the trigone of the bladde passed twice through the peritoneum. A very tigb stricture occupied the membranous and bulbous part of th urethra, which only admitted a fine probe. A shor false passage passed into the dense tissues surrounding th urethra. The tissues of the perineum were immensel thickened, and traversed by a narrow fistula from th urethra just behind the stricture to the wound in the peri neum. The prostate was enlarged ; the bladder distende hypertrophied, and sacculated. The mucous membrane wa dark. coloured from old cystitis; it was mark ed with two troca punctures at the trigone, about half an inch in front of tb orifices of the ureters, but near the middle line, and half a a inch behind the prostate. The oreters and pelves of the kidneys were also greatly enlarged, the kidneys much wasted by interstitial nephritis. WEST LONDON HOSPITAL. STRICTURE OF THE URETHRA AND PERINEAL FISTUL&AElig;; INTERNAL URETHROTOMY ; PERMANENT CLOSURE OF FISTUL&AElig; THREE DAYS AFTER OPERATION. (Under the care of Mr. TEEVAN.) E. H&mdash;&mdash;, aged twenty-six, miller, of thin and dejected appearance, was admitted into the hospital on May 9th, 1876. The patient stated that he had an attack of gonor. rhcea nine years ago, for which he took medicines, and that he was afterwards long troubled with a gleet. About eight years ago he noticed that the stream of urine began to get smaller, and that he had to strain during micturition. He then commenced to suffer from frequent attacks of reten. tion of urine, which were relieved by the catheter. One year and a half ago the perineum began to swell, an abscess formed and burst, and the patient afterwards passed nearly all his urine through the fistul&aelig; which remained. On examination a tough. stricture, only admitting a small catheter, was found four inches and a half from the meatus externus. There were also three ring strictures of large calibre in the penile urethra. The centre of the perineum was much indurated, and in the raphe were two fistulous openings about one inch apart from each other. On May 10th Mr. Teevan passed a small elastic olivary catheter and left it in for fifteen hours: its retention pro- duced much soreness and discomfort. On May 23rd he divided all the strictures from before backwards, and having passed a No. 26 bougie, to show that all the urethra was clear, he immediately withdrew it. The patient had no rigor nor bleeding after the operation, and three days later the house-surgeon (Mr. Alderton) reported that the passage was quite water-tight. The patient was then allowed to get up and go about. On June lst, 4th, 7th, and 10th No. 25 metal bougie olivaire a ventre was introduced. The man was afterwards taught to pass a large olivary catheter for himself, and on June 14th left the hospital quite well. Mr. Teevan remarked that the case showed what internal uretbrotomy could achieve, and he was not aware of any other means which could have effected the desired object in so short a period. The chief stricture was of too chronic and indurated a character to have been successfully en. larged to the size it had been without causing much pain and local irritation, and he had therefore divided all the contractions. As a rule, fistulea would rapidly close if the strictured urethra, were enlarged to its normal diameter; , but if nothing bigger than a No. 12 English was aimed at, disappointment, he alleged, would probably result, as the canal was only half opened up. The action of the ope- ration was purely mechanical. The fistulas were kept open by the obstruction in front of them not allowing the urine to escape, and distending the urethra posteriorly with great force. So soon as the obstacle was removed, the openings quickly closed of their own accord. It was of great import- ; ance to pass a very large instrument after the operation to show that the work had been thoroughly done, and in the present instance he had introduced No. 26, which lay quite loosely in the urethra when passed. BRADFORD INFIRMARY. ULCERATIVE MYOCARDITIS, ENDOCARDITIS, PERICARDITIS, AND DOUBLE PLEURO-PNEUMONIA. (Under the care of Dr. REGINALD ALEXANDER.) ELIZABETH B-, a housemaid, was admitted at the request of Dr. Bronner, April 10th, 1875. There was ! nothing worthy of note in either her family or personal - history, having enjoyed good health until a month ago, when she began to suffer from pains in the shoulders, which becoming worse, confined her to bed for a week. About the 1st of April she first began to notice shortness of breath and pain i of a. clicking character over the lower part of the

WEST LONDON HOSPITAL

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188

feeble, with a furred tongue; full, rapid, irregular pulse;and considerable atheromatous rigidity of the arteries.Percussion of the abdomen gave a dull nnte for twoinches above the pubee, and manipulation discovered around firm mass, feeling somewhat like an orange, in themesial line above the pubes. If this mass were presseddown while the finger was in the rectum, irregular fluctua-tion could be just felt behind a prostate enlarged appa-rently to double the normal size. Attempts to pass acatheter, after prolonged trial on the 1mh, failed. Anincision on each side of the middle line into the abscessesand eedematous tissue of the perineum and scrotum wasmade, and stimulating and nutritious food was given, andwarm poultices applied to the perineum.The next day the patient was easier ; hsd had some sleep

in the night, and taken plenty of food. The urine, passedthree times in the night in a, stream, was dark, fetid, withmoderate deposit of pus. Perineal swelling less brawny;matter weeping from the incisions, but apparently no urineescaping by that way. The succeeding day the swell-ing had increased again ; urine passed only in small quanti-ties and with great effort. Another attempt to pass acatheter failed to do more than insinua,te a No. silverpartly through the stricture; when it had penetraterl somedistance, the stem was blocked so firmly in the induratedtissue of the stricture as to become immovable by anyforce it was thought prudent to employ. The patient’sstrength was less than on the previous day, the swel1ing in-creasing, and the bladder slowly getting more and moredistended. The patient was put under chloroform, and thebladder punctured per rectum. The long distance of thebas fond from the anus allowed very little of the cannulato project into the bladder; a flexible catheter was passedthrough it, and, with the cannula, fastened to the buttocksin the ordinary manner. The urine ran freely throughthis tube, and the patient remained free from pain until thenext morning, when he complained of pain at the anus,which was attributed to the cannula, and an attempt wasmade to withdraw it while leaving the catheter in situ.This failed, and the urine, which bad continued to run awayfreely through the catheter since its insertion, and becomeclear, acid, and free from pus or smell, ceased to flow. Thiecondition remained unchanged till 5 p Mr , when Mr. Hill, onhis visit, ascertained the cannula and catheter had escapedfrom the bladder into the rectum, the latter instrumentbeing doubled backwards at the point where it had pro.jected into the bladder beyond the cannula. In addition tcthis, the inflammatorycedema of the scrotum had now passedto the buttocks and half way down the inner side of the rightthigh, with an abrupt, irregular line of demarcation, and herEand there vesication. Temperature 103&deg; F. No tendernessof abdomen, which was soft and yielding. The bladdeicould not be distinguished now through the abdominal wal’or per rectum. Patient bad no desire to pass water. A110.30 P.m. the patient was suffering go! eq,t pain. Tempera,ture 103&deg; F. Abdominal walls flaccid, not tender; thEbladder could be indistinctly felt. The patient was pu;under chloroform, and the rectum trocar inserted a seconitime into the bladder. Urine flowed in fair stream, an(the trocar was fastened in. Little improvement followe(this; and the next morning the erysipeia.toDS blush extende<over the left buttock, the thigh, and the flank. Two daylater the patient died.At the post-mortem examination extersive general peri

tonitis was found, most intense at the pelvis. The pelvi,viscera were removed in one mass. The recto-vesical pouclof the peritoneum (very long) was found to extend completely past the trigone of the bladder and to reach quitup to the prostate; accordingly, both the pm?cknres fronthe anterior wall of the rectum to the trigone of the bladdepassed twice through the peritoneum. A very tigbstricture occupied the membranous and bulbous part of thurethra, which only admitted a fine probe. A shorfalse passage passed into the dense tissues surrounding thurethra. The tissues of the perineum were immenselthickened, and traversed by a narrow fistula from thurethra just behind the stricture to the wound in the perineum. The prostate was enlarged ; the bladder distendehypertrophied, and sacculated. The mucous membrane wadark. coloured from old cystitis; it was mark ed with two trocapunctures at the trigone, about half an inch in front of tborifices of the ureters, but near the middle line, and half a a

inch behind the prostate. The oreters and pelves of thekidneys were also greatly enlarged, the kidneys much wastedby interstitial nephritis.

WEST LONDON HOSPITAL.STRICTURE OF THE URETHRA AND PERINEAL FISTUL&AElig;;

INTERNAL URETHROTOMY ; PERMANENT CLOSUREOF FISTUL&AElig; THREE DAYS AFTER OPERATION.

(Under the care of Mr. TEEVAN.)E. H&mdash;&mdash;, aged twenty-six, miller, of thin and dejected

appearance, was admitted into the hospital on May 9th,1876. The patient stated that he had an attack of gonor.rhcea nine years ago, for which he took medicines, and thathe was afterwards long troubled with a gleet. About eightyears ago he noticed that the stream of urine began to getsmaller, and that he had to strain during micturition. Hethen commenced to suffer from frequent attacks of reten.tion of urine, which were relieved by the catheter. One

year and a half ago the perineum began to swell, an abscessformed and burst, and the patient afterwards passed nearlyall his urine through the fistul&aelig; which remained. Onexamination a tough. stricture, only admitting a smallcatheter, was found four inches and a half from the meatusexternus. There were also three ring strictures of largecalibre in the penile urethra. The centre of the perineumwas much indurated, and in the raphe were two fistulousopenings about one inch apart from each other.On May 10th Mr. Teevan passed a small elastic olivary

catheter and left it in for fifteen hours: its retention pro-duced much soreness and discomfort. On May 23rd hedivided all the strictures from before backwards, and havingpassed a No. 26 bougie, to show that all the urethra wasclear, he immediately withdrew it. The patient had norigor nor bleeding after the operation, and three days laterthe house-surgeon (Mr. Alderton) reported that the passagewas quite water-tight. The patient was then allowed toget up and go about. On June lst, 4th, 7th, and 10thNo. 25 metal bougie olivaire a ventre was introduced. Theman was afterwards taught to pass a large olivary catheterfor himself, and on June 14th left the hospital quite well.

Mr. Teevan remarked that the case showed what internaluretbrotomy could achieve, and he was not aware of anyother means which could have effected the desired object inso short a period. The chief stricture was of too chronicand indurated a character to have been successfully en.larged to the size it had been without causing much painand local irritation, and he had therefore divided all thecontractions. As a rule, fistulea would rapidly close if thestrictured urethra, were enlarged to its normal diameter;

, but if nothing bigger than a No. 12 English was aimedat, disappointment, he alleged, would probably result, as

’ the canal was only half opened up. The action of the ope-’ ration was purely mechanical. The fistulas were kept open

by the obstruction in front of them not allowing the urineto escape, and distending the urethra posteriorly with greatforce. So soon as the obstacle was removed, the openingsquickly closed of their own accord. It was of great import-

; ance to pass a very large instrument after the operation toshow that the work had been thoroughly done, and in the

present instance he had introduced No. 26, which lay quiteloosely in the urethra when passed.

BRADFORD INFIRMARY.ULCERATIVE MYOCARDITIS, ENDOCARDITIS, PERICARDITIS,AND DOUBLE PLEURO-PNEUMONIA.

(Under the care of Dr. REGINALD ALEXANDER.)ELIZABETH B-, a housemaid, was admitted at the

request of Dr. Bronner, April 10th, 1875. There was

! nothing worthy of note in either her family or personal- history, having enjoyed good health until a month ago,’ when she began to suffer from pains in the shoulders, which becoming worse, confined her to bed for a week. About the

1st of April she first began to notice shortness of breathand pain i of a. clicking character over the lower part of the