which is shed in the repair of the ulcers left after the separation of the sloughs, which, following an invariable law, as soon as it becomes a part of the organized tissue, slowly but forcibly contracts. This law we may observe in many parts of the body; for instance, when the lymph is shed over the pleura, we find the walls of the thorax yielding to its contraction; and when poured out in the capsule of Glisson, we know with what a powerful grasp it compresses the liver. And in stricture of the urethra, it is the same substance which, shed upon or beneath the mucous membrane, produces such a train of evils by its tendency to close the canal; and tries the patience and skill of the surgeon, in overcoming its constant tendency to contract. Now, the treatment of stricture of the urethra has, for more than 200 years, occupied the attention of surgeons both in this country and on the Continent; and while there has been great diversity of opinion upon many points, I believe I am correct in saying that all the ablest surgeons who have written on the subject agree that, in the great majority of cases, dilatation alone is the safest and the most successful treatment that can be adopted; that in some the use of the knife may be required to obtain a passage, in the first instance, which then must be maintained by dilatation; and that the cases which admit an instrument at all, and will not yield to dilatation, are comparatively very few;-that, in fact, a cutting operation is only occasionally required, while careful and patient dilatation is almost invariably sufficient, either in conjunction with operation or alone, to produce a successful issue. Now, the cause of the contraction in each case being identical, we may with great advantage use the experience which we have gained in the treatment of stricture of the urethra to guide us in the choice of means for overcoming the contraction of the cicatrices of burns, especially when cutting operations have so been freely tried; and when unassisted, or only partially assisted by extension, have failed to produce the desired result.

Whatever mode of treatment we adopt, our great object must be to obtain, if possible, the absorption of the lymph, which is the contracting power: if this be removed, the case is cured. Now, no cutting operation will, of itself, produce this desirable object; on the contrary, it will cause the effusion of more lymph, which, being quite recent, will no doubt be

The following is the first "conclusion" arrived at in Mr. Thompson's well-known Essay on Stricture:-"That the process of dilatation, carefully and perseveringly employed, is the most safe, efficient, and generally applicable of all means for the treatment of organic and permanent stricture."-Pathology and Treatment of Stricture of the Urethra. By Henry Thompson, F. R. C. S. Page 314.

far more amenable to extension than the old cartilaginous lymph; and so cutting may help. But the means which we must trust to, to gain the removal of the cicatrized tissue, is extension; and this, in some cases alone, in others aided by the knife, will, when perseveringly employed, produce the absorption of the tissues of the cicatrix, and so the permanent removal of the deformities dependent upon it.

That the plan of extension which I am advocating is carried out with success in the Orthopedic Hospital, and elsewhere in London, would appear from the following passage, which is taken from "The Lancet" of August 13, 1859. I have not been able to find any more complete account of the treatment adopted there, nor any report of cases since this:-

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Simple extension in Contraction from Burns.-We lately had the opportunity of observing the treatment of a case of deformity, arising from an old burn, in a little boy, nine years of age, under Mr. Coote's care at St. Bartholomew's Hospital. It is a plan, I believe, in use in the Orthopedic Hospital, and consists in the proper application of simple extension perseveringly carried out. The boy was admitted on the 7th of April, with his lips and mouth drawn downwards from a burn in the neck when an infant. The cicatrix preserved the usual characters of hardness and thickening. By suitable appliances, the head and chin were kept extended, with the effect of bringing back the lower lip and jaw to their natural position, and getting rid of the extreme deformity which had before existed. The mouth can now be closed. The effect of extension is to cause the absorption of the adventitious membraneous material present in the cicatrix, and thus permit the latter not only to become soft and extended, but permanently to remain so."

In the following case, it will be seen, I first performed James' operation, and then employed extension, aided by subcutaneous section. From the experience gained in the treatment of this case, I would now begin with extension, carry it on perseveringly for some time; then, if I found it necessary, employ subcutaneous section of the most resisting bands of the cicatrix, and finally resort to the more severe operation, if I found I could not succeed without it.

CASE I.-Isabella M'Owen, a healthy girl, fourteen years. of age, from the County Meath, was admitted into the Adelaide Hospital, upon the 22nd of March, 1860. When about eight years of age, her clothes having caught fire, she was severely burnt about the right side of the neck and head. Her mother had endeavoured to prevent the contraction which she was

told would follow, by placing a stiff leather collar round her neck when the ulcers were healing, and for some time afterwards; the contraction, however, went on increasing in spite of this, and, as the girl began to grow up, she became very much dissatisfied with her appearance, and urgently sought that something might be done for her relief. Her state upon admission is shown in the lithograph (Plate I., Fig. 1), taken from an excellent drawing by Connolly. The cicatrix, as will be seen, occupied the whole of the right side of the neck, its densest and thickest part being close beneath the ramus of the jaw, extending from the lower part of the ear, which was involved in it, to the chin; from this central mass strong fibrous bands extended downwards below the clavicle, and as far forwards as the sternum; superiorly, the skin of the whole of that side of the face was drawn down to it; the angle of the mouth, and the external angle of the eye, being drawn downwards, the latter causing slight ectropium. The head was kept bent down to the right side, and when held straight caused increased distortion of the countenance; but by no effort could the patient turn her head to the left side.

The girl and her parents being very anxious to have something done to relieve her deformity, I determined to attempt it, my colleagues having examined the case, and agreed with me, and having also had the advantage of Dr. Hutton's advice, who kindly gave me his opinion as to the best mode of proceeding.

Upon the morning of the 28th, as soon as the patient was well under the influence of chloroform, I proceeded to operate in the following manner:-An incision was first made along the posterior edge of the cicatrix, from the mastoid process to the acromion, then a second along the anterior or inner edge, from the chin to the sternum; thirdly, another incision was carried across the cicatrix just below its central mass, connecting the two former. The two flaps thus formed were then carefully dissected from their attachments to the parts beneath, which was a matter requiring both time and care, as the skin, platisma, and fascia were all matted together and to the muscles beneath, by the dense fibrous structure of the cicatrix. As soon as this had been satisfactorily accomplished, the deformity of the face was found to have disappeared, and a gaping wound remained, extending from the ramus of the jaw to the clavicle. No vessel required ligature. Lint wet in cold water was laid on the wound, and the patient removed to bed. Considerable constitutional irritation succeeded, which, being followed by an attack of bronchitis, reduced the patient very much, and