LEADING ARTICLES.

On the Treatment of Stricture of the Urethra. In a paper read before the Medical Society of the State of New York, Prof. Otis emphasized the importance of determing the exact seat of the stricture or strictures, before an operation is done or dilatation is commenced. This can be ascertained by using the urethrometer, or bougie-à-boule, and by their use the author found that in one thousand cases critically examined, less than ten per cent. were located at a point beyond four inches from the urethral orifice.

It is thus seen that if dilatation is practised without locating the depth of the stricture, in the great majority of cases the dilating instrument would be passed beyond the stricture, unnecessarily irritating the membranous and prostatic portions of the urethra where the greatest dangers of gradual dilatation reside.

In cases where the chief symptom of stricture is difficulty in urination, and only small flexible instruments can be passed, the fact is often overlooked that, while there is obstruction in the deeper urethra, this may be due to spasmodic contractions. of the membranous portion brought about by the presence of organic strictures nearer the meatus. If these anterior strictures are discovered and removed, a full-sized sound may be made to pass with ease into the bladder, as the author has proved in several cases.

"It will sometimes occur that strictures may be traversed by filiform instruments, and can be located by very delicate bulbous instruments, but where the calibre of the stricture is too small to admit the smallest guide bougie of the urethrotome of Maisonneuve. In such cases, where

1 New York Med. Jour., Feb. 19, 1887.

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immediate operation has become necessary, the only resource is an external urethrotomy. For aid under such conditions, I have had constructed, and have frequently used with much satisfaction, a miniature Maisonneuve, of scarcely more than half the size of the ordinary instrument, carrying a blade of not more than three or four millimetres' breadth. This, with due care, may readily pass a stricture where no other cutting instrument can, and subsequently the ordinary-sized urethrotome of Maisonneuve may be readily entered.

"This little instrument in my hands has, in repeated instances, saved the patient an external urethrotomy, when without it such an operation would have been unavoidable."

Permanence of results after operations on deep strictures depends, as in the case of anterior strictures, upon completeness of division. Complete sundering at some point is essential to radical cure.

It has been proved to be essential to the cure of deep strictures to cut all anterior strictures, and the writer quotes Sir Henry Thompson as saying that if one stricture is cut all should be likewise divided.

Dr. J. W. S. Gouley, in an article in The Medical Register protests against the indiscriminate cutting of the meatus to enable large sized instruments to be passed through deep-seated strictures, believing that over-distension does more harm than good.

In cases of prostatic obstruction to urination, if the meatus is small it is proper to incise it enough to admit freely catheters of proper size.

So, too, in chronic gonorrhoea in the balanic region, if the meatus is small it should be incised to allow the introduction of sounds. But the doctrine that the meatus

not enter it even for exploratory purposes, unless you think it absolutely necessary to do so. First explore the anterior urethra and relieve, as far as practicable, any abnormal condition that may exist there. Keep out of the bladder, if possible. It is the disposition of the profession all over the world, when exploring a urethra or dilating a stricture, to pass the instrument on into the bladder. Now, there is absolutely no danger in passing an instrument gently down to the membranous junction, but there is always danger in passing an instrument beyond that point on into the bladder. Death has occurred in more than one instance from suppression of urine through a reflex irritation, caused by gently passing a bougie into the bladder, where disease of the kidneys and bladder was present. I have known many cases of swelled testicle that occurred simply from the passage of a sound through the deep urethra, and at least one case where the loss of a testicle was directly due to introduction of bougies for dilatation of stricture, thus setting up an orchitis which finally ended in an abscess which destroyed that organ."

He advises in cases when the urethra is sensitive that five or ten grains of quinine be given one or two hours before passing the instrument, to lessen the tendency to urethral fever and, in sensitive cases, rest in bed following the operation.

Dr. Bangs' strongly urges early performance of external urethrotomy in minor traumatisms of the urethra. He asserts that in recent cases, before pathological changes have taken place, the operation is not a difficult one although in old cases where there is cicatricial tissue it may be difficult of performance.

In the discussion following the reading. of Dr. Bang's paper. Drs. Otis, Keyes, and McBurney agreed with the author that where an injury to the perineum was followed by swelling or signs of inflammation or difficulty in passing both large and small sized sounds to the bladder, external urethrotomy should be at once performed.

be found very serviceable. Being connected with a dispensary where thirty or forty cases of diarrhoea presented themselves daily for treatment during the months of August and September, and where a great variety of remedies were tried, so great was the superiority of Indian hemp above the others, that the patients themselves got to know it, and invariably asked for the green medicine."

We have been in the habit of prescribing it in nearly all forms of diarrhoe with marked benefit, combined with medium doses of morphine. In summer diarrhoea the effects are very striking. There is no necessity to record cases; they are all very much alike; the great depression, the frequent watery stools, the vomiting and the cramp-like pains are very quickly relieved, the appetite speedily returns, and by the following or third day the cases are practically well, except for some weakness and debility. The formula we generally use for an ordinary adult is :

To be repeated every 1, 2, or 3 hours according to circumstances. Directions: No food for several hours, but a little brandy and water. We have not seen one case run on to a fatal issue under this treatment.

It appears to act by increasing the astringent and anodyne properties of the morphine (the dose of morphine would have very little effect alone), by its stimulant effect on the nervous system, improving the tone, and by improving the appetite; thus enabling the system to quickly overcome the marked depression and exhaustion. Most remedies in this disease rather retard the return of the digestive functions, but from our experience Indian hemp markedly accelerates it. Indian hemp seems also to frequently counteract the bilious action of

morphine, as well as the loss of appetite, and allows it to be given where it otherwise would not be tolerated.

In other forms of gastro-intestinal disturbance it is also valuable, probably for the same reasons. It was of marked use in a case of subacute gastro-enteritis, which had existed for a few weeks before it came under our care,in a girl aged 13 year, showing the following symptoms: marked anæmia, which had gradually come on after the other symptoms; constant pain over the abdomen, especially in the epigastric region, increased on pressure and after food; tongue covered with yellowish-white fur; loss of appetite; vomiting at variable times after food of partly digested material; diarrhoea, six or eight stools in the day, which were watery and green, containing partly digested foodmaterial; some rise in temperature-a little over 100° F. She was first treated with bismuth, then with effervescing mixtures, with no benefit; then with the cannabis mixture (modified to suit her age), and the symptoms very quickly subsided, the vomiting and diarrhoea were checked, the pain ceased, and the appetite returned. By the end of the week all the symptoms had disappeared except the anæmia, which persisted for a short time longer.

In cases of tuberculous diarrhoea we have not seem much benefit, beyond a slight relief of symptoms for a short time, though we have not had sufficient experience in this type; nor in the excessive diarrhoea in typhoid fever.-Practitioner, July, 1887.

Lee (H.) on the Use of the Actual Cautery in Surgical Operations.-Before the introduction of anæsthetics in surgical operations the use of the actual cautery was justly regarded as a barbarous and cruel practice. The traditions of one age descend to the next, and the application of a hot iron to the body is thought of by the public, and even by some members of our profession, as a thing not to be tolerated in scientific surgery. All objections to the use of the actual cautery, however, vanish as soon as it can be said that it gives no pain. We may therefore now fairly consider its advantages as compared with other modes of arresting hæmorrhage.

Since the year 1853 I have been in the habit of sealing bleeding vessels with the actual cautery in all kinds of operations. Amputation of the thigh was performed in one case with excellent result, a single ligature being placed on the femoral artery.

In three cases of amputation of the leg the actual cautery alone was used.

The application of the cautery coagulates the albumen in the blood, and in the tissues to which it is applied, and if used at a proper temperature the parts will adhere firmly to the iron and to each other. The heat will also coagulate the blood in the vessels. A very superficial layer (if any) of the parts to which the cautery is applied is actually killed, and any part so killed is charred, so as to become not readily liable to septic decomposition.

The actual cautery has the great advantage of closing the veins as well as the arteries, and inasmuch as the great dangers in surgical operations arise from the absorption of septic agents through unclosed veins, it obviates one of the surgeon's greatest anxieties. The ligature of a vein, as is well known, is not free from risk, and the obvious reason is that during the time the ligature is separating a certain amount of suppuration necessarily takes place, and the products of that action may give rise to septic absorption. The same dangers, although to a much less degree, obtain, when an artery is tied in its continuity. In one case the current of blood is towards the centre of the circulation, and in the other from it. When mischief arises from the cause mentioned after ligature of an artery in its continuity, the results are manifest in the peripheral circulation, and not in the central organs. It is not improbable that gangrene of an extremity after the ligature of the principal artery of a limb may arise more often from the circulation of vitiated blood than from want of blood. Simple want of blood is indicated by paleness of the skin. In the majority of cases of gangrene the skin contains far more blood than nsual, and is of a dark brown color.

It is quite possible, as experience has but too often proved, that a septic action commenced around a ligatured artery may be communicated to surrounding parts, and from these septic absorption may take place. This, in fact, is one of the most fruitful sources of pyæmia.

The actual cautery may be applied sometimes where a ligature cannot be; as, for instance, in wounds of the deep palmar arch; and, on the other hand, a tenaculum will sometimes reach a vessel to which the actual cautery cannot be applied. In one case where a very large tumor was removed from his back, the vessels were all sealed

by the actual cautery, except one, which bled persistently. The reason of this became immediately apparent. The projecting posterior edge of the scapula prevented the cautery from coming fairly into contact with the bleeding vessel, I have now used the actual cautery in a great variety of operations, and during the last thirty-five years in a large number of cases of hemorrhoidal tumors, and have as yet had no case of purulent absorption. Recently I assisted in removing a cancerous growth from the inner canthus of the eye. The bleeding was free and general. The surface was touched with the cautery, and the bleeding immediately ceased. The patient, next day, said he felt more comfortable than he had done for a long time previously.

I prefer the common iron cautery to the benzoline knife, if no dissection has to be made. The oxide of iron appears to exercise a direct influence in producing coagulation of the blood. Many years ago, when engaged in some physiological researches, I received some blood from a horse that was being bled into an old iron vessel, coated on its inside with the red oxide of iron, and was surprised to find that the whole mass of blood became immediately coagulated. Another minor advantage of the cautery is that it can be applied much more quickly than the ligature. Where many vessels have to be dealt with at the same time, this is by no means unimportant. Practically, it is difficult not to use the cautery too hot. If it kills the parts to which it is applied the intended result is not produced. A good test of the amount of heat required may be obtained by dabbing the cautery on a wet sponge until very little steam is produced. In cases where it is important that no oozing of blood should take place after the application of the cautery, it is well to allow it to remain in contact with the divided vessels for about fifteen seconds.

Where the actual cautery can be fairly applied it has proved, as far as my experience goes, the best antiseptic.-Medical Press, June 15, 1887.

Mays (T. J.) on the External Treatment of Pulmonary Consumption. We have, in the majority of instances in this disease, a condition which is a deposit of inflammatory products in the lung, differing essentially in nowise from a similar deposit in any other part of the body; and it is very natural to suppose

that that which does good in the one condition will also be useful in the other. You know as well as I can tell you that the application of moist heat and of passive motion are of inestimable value in producing reabsorption of chronic inflammatory deposits in joints and in other parts of the body-usually the result of injury; and in keeping with this idea, I have for a number of years been in the habit of applying hot flaxseed-meal poultices, as well as friction, to the chest in such affections, and I believe with the most gratifying results. According to my view these external applications have the power of increasing the circulatory, the lymphatic, and the cellular activity of the circumference of the infiltrated lung tissue, and, by their operation on the surroundings of the diseased centre, they gradually reduce and remove the consolidation.

The flaxseed meal is boiled and spread three-quarters of an inch thick between two pieces of flannel cut in the shape of a jacket, which is well fitted to the top, front, and back of apex, as well as to the anterior and posterior aspects of the affected lung. It is then adjusted to the chest, and the outside well covered with oiled silk or oiled muslin. It must be changed every two or three hours, or sooner if it becomes cool. If it is made properly, it will remain warm for three hours. This process is to be continued from morning until night, when the poultice is taken off, and the chest is well wrapped with woolen flannel for the night, in order to avoid a sudden disturbance of bodily temperature during the sleeping hours. The next morning the same programme is begun, and it is continued in the same way for at least three weeks, or as much longer as is necessary. It is much more expedient to poultice during the day only, and allow the patient to rest during the night. After the patient has been poulticed for five or eight days a change in the physical signs begins to manifest itself. Where previously there was heard nothing but a roughened or bronchial breating, subcrepitation, probably crepitation, and mucous râles show themselves, leading one to suspect that the disease is advancing instead of improving. Subsequent experience teaches, however, that these superadded signs are due to the process of resolution which is taking place. The patient experiences greater freedom in breathing, his cough becomes easier, and