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New England Medical Monthly

umes

GE

DANBURY, Conn., NOVEMBER 15, 1888. present engaged in a hand to hand con

flict with prejudice, and who will later ORIGINAL LECTURES.

rank among the greatest relievers of ANTISEPTIC TREATMENT OF human suffering, has shown us that eye STRICTURE OF TIIE URETIRA. strain is responsible for more reflex dis

turbances than any other one cause; A Clinical Lecture Delivered at the New York but we shall find that urethral irritation Post-Graduate Medical College, by Instructor Robert T. Morris, M. D., June 19th, 1888.

stands close to eye strain as a disturber Reported for The New ENGLAND MEDICAL of nerves. Men

may write whole volMONTHLY by Frank E. Sylvester, M. D.

upon

the First Clinical Assistant.

treatment of ENTLEMEN:-Last week as you re- hysteria, neuralgia, neurasthenia,

member we divulsed a stricture in chorea, and “headaches,” without referthe region of the triangular ligament; ing to the eye, or to the urethra, except using graduated sounds for divulsion.

in a casual way, and yet these two Beginning with a filiform bougie, the widely different structures should have

been given position of paramount imurethra' at the constricted point was

portance. With urethral strictures of rapidly enlarged to a circumference of large caliber and of short duration we 34 m. m. and because the work was

may have distressing neuralgias of done under our modern antiseptic

different sorts, irritable genito-urinary method I felt justified in predicting organs, and a long train of symptoms that the patient would not have to

that are relieved as by magic by one remain away from his business, and that touch of Otis' wand. he would have no so called urethral

The young man whom I now bring fever, unless a few drops of urine should before you complains simply of gleet. pass through into the loose cellular He had gonorrhea more than a year tissue about the urethra; in which latter ago, and there is still a mucous disevent we should at once perform external charge from the urethra. He went to a perineal urethrotomy for the purpose of physician six months ago, and when drainage. This patient, I am

aft a few weeks of treatment he failed happy to state has attended to his busi

to return, the physician very likely

noted a cure, and jotted down in his ness as an engraver ever since the operation. He has not had any urethral

record book a description of the treat

ment that had born him triumphant. But fever, and he is already free from 'the

the young man was at this same time perineal neuralgia, the pain in the back, consulting another. physician, and since the sciatic pains, and the headaches then he has "gone the rounds,” as most that were reflex demonstrations from

of these patients do, and finally become the stricture.

discouraged. On waking in the mornDr. George T. Stevens who is at ing he found at the meatus the eternal

now

drop, and on searching for the two 1-5000 bichloride of murcury solution dollar bill in his vest pocket he suddenly and make the mucous surface pretty remembered that it went to the doctor

clean. The urethrometer taken out of the day before. The two dollar bill

the dish of 1-30 carbolic acid solution has gone

but the doctor and the gleet is now lubricated with a solution of may still be found.

equal parts of boroglyceride and glyIt is almost impossible to cure an ordinary ease of gleet until we have cerine; for vaseline or oil would carry made the urethra of nearly uniform in ferments. Introducing the instrudiameter from one end to the other.

ment as far as the triangular ligament The natural contraction at the meatus and screwing it up until the bulb begins which was furnished by nature for con

to bend a little we see that the index centrating the forces of momentum and registers 37 m. m., and this is approxivelocity and thereby giving greater mately the normal urethral circumferprojection to the stream of urine, is suf- ence in this patient. In slowly withficient to keep a gleety discharge run- drawing the instrument it sticks fast at ning. Force is transmitted through a point three inches from the meatus, water equally in all directions and the and it is necessary to turu the screw flow of the descending stream of urine until the index registers 24 m. m. before upon the contracted tissues about the the bulb will slip past the strieture, now waters is transmitted to inflamed mucus it is past and again screwing the bulb membrane in the vicinity and it is diffi- up to 37 m. m., I withdraw it to a point cult for the inflammation to subside. three quarters of an inch from the The effect of any stricture at any point meatus where I must screw the index of the urethra is similar to that of the down to the 25 m. m. point before the constriction at the meatus.

bulb will

pass.

I neither know nor There are surgeons who argue that

care whether there is a stricture below the meatus should not be cut because it the parts examined, for if there is one is a natural contraction, but we might it calls for other treatment at another as well insist that the Devil should not

time. If the strictures would allow the be fought because the Lord created him. passage of the endoscope I could show If it is difficult for any patient to

you the red unhealthy patches of urethra project the stream of urine after his behind each constriction.

I now ask meatus has been cut, what is the harm? Dr. Sylvester to compress the penis as So soon as the gleet is well we can inject far back as possible with his fingers in a drop of cocain solution at the meatus

order to stop the circulation of blood, and by a trifling plastic operation restore and then inserting the hypodermic the parts to a normal condition. Treat- needle into the tissue of the glans ment of gleet I shall refer to further at penis, I inject there five drops of a another time, but we are now to discover

ten per cent cocaine solution. In half a some of the causes of the young mans minute the whole penis becomes as indischarge, and to remove them as far sensitive as a piece of rope, and it will as possible.

remain so for fifteen minutes. The Using Otis' urethral cocaine injec- dilating urethrotome which I now take tor I now wash out the urethra with out of the 1-30 carbolic acid solution,

DR.

the

was boiled for five minutes this morn- riedly for a few days. One thing I ing. It is now lubricated with the anti- would mention before the bell rings. septic boroglyceride solution and in- In a large number of cases of enlarged serted. Dilating the instrument as far prostate I find that urethral strictures as possible I cut the deeper stricture have existed for many years and I canand then in turn the anterior one. In

In not help thinking that prostatic hyperorder to cut up to full size I must trophy may be frequently induced by again insert the urethrotome and repeat

the irritations caused by these stricthe process. There is now considerable

tures, just as the sister tissues of the

uterus seem to become hyperplastic hemorrhage from the penis, and this I control with these two pieces of cigar

more rapidly in cases in which metritis

and endo-metritis have persisted for box. Putting one on the upper and one ou the lower side, I slip a couple of many years. rubber bands over both, and stop the hemorrhage by pressure.

If blood

ORIGINAL COMMUNICATIONS. should run backwards into the bladder

SURGICAL TREATMENT FOR and form clots there it would be a

LACERATIONS OF THE mater of no importance, for an injection

PERINEUM AND THE of a few grains of pepsin into the blad

PELVIC FLOOR. ber would dissolve the clots and they by

WM. H. WATHEN, LOUISVILLE, would easiiy pass away in thin treacly Professor of Gynecology in the Kentucky School

of Medicine; Chairman of the Section on strings at the next urination. The

Obstetrics and Gynecology in patient will take ten grains of horic American Medical Association, Etc.

Abstract of a paper read at the Association of acid with every meal, and ten grains at

Obstetricians and Gynecologists, at the bed time until the wounds have healed.

Congress of Physicians and Surgeons,

Washington, D. C., Sept. '88. Boric acid is excreted unchanged by the

E kidneys and it makes an antiseptic dress

treatment of laceration or injuries ing of the urine that pases over the

of the muscular and aponeurotic strucwounds.

tures that form the floor or diaphragm I shall pass a number 37, French

of the pelvis. He said there is probsounds in three days, again four days ably no other subject in gynecology after that, then five days, later still; about which so much has been written once a week for a month, and once a that is of no real value, and that a relamonth for a year. The patients stric- tively simple operation had been made tures have been cut without causing him to appear so complicated that it is sela particle of pain. The work has been dom correctly performed. He passed done antiseptically so that he will not by much of this immensity of pseudohave urethral fever. Hemorrhage is scientific rubbish, and took a practical controlled by the simple device that the view of the subject. patient can reapply after urination, and

He said that the muscles and the I shall ask the patient to keep about his fascia in the perineum give it strength, business as though nothing had hap- and when they are lacerated no operapened. He will of course use a certain tion that does not primarily tend to redegree of caution about walking hur- unite them is logical, or will be followed

He spoke especially of the surgical

We may

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by permanant good results.

fascia. This cannot be done by the have prolapsus of the uterus, with rec usual method of denudation, but is actocele and cystocele, resulting from sub- complished by a splitting process. The cutaneous rupture of these structures incisions should go deep near the anus with no laceration or injury of the on the lateral borders of the vulva, and mucous membrane or other parts of the the recto vaginal septum should be split perineum. This condition is usually through the connective tissue between not diagnosticated by the attending the vaginal and rectal layers, so that the physician, and the woman is subjected vaginal flap may be thick enough to to various plans of treatment to hold prevent sloughing. the parts in position and relieve the an 1.Ile did not think it necessary to give noyance from pressure, weight, etc., the reasons why the primary operation all of which give but little relief; nor should be performed, as there are but can we cure her except by an operation few men of recognized ability in obsteto bring together and reunite the terries or gynecology, who are opposed ends of the muscles and fascia GTON MER. Op we are not a little surprised

He said that when any or any of them to find ik this list the name of the disperineal union of the museli For FEB og tilegghed Professor, A. Carpentier, of fsacia, are lacerated, unless a donce united Paris. Iris objections are illogical and

sustained in actual practice

R tions continue to widen the distance were the operation is correctly done. tween the torn ends, so that the vulva Ile had done the primary operation gradually becomes enlarged laterally. often, without a failure; in fact he The extent of this lateral separation is thought the success is usually more pergoverned by the degree of laceration feet than in the secondary operation. and the length of time since it occured. The torn ends of the muscles and fascia If the above is correct, then no opera are now easily held in apposition and tion will succeed that fails to bring unite within a few days. He reported these torn ends together so as to reunite a typical case upon whom he operated them. This is a simple question that a few weeks ago for his friend Dr. holds good in all operations to restore

The woman was (elivered of the perineum in complete or incomplete a large child when 16 years old, and ruptures, and if we are controlled by was torn through into the rectum for it, and are familiar with the technique over an inch, and the vaginal wall and of the operation, success will nearly the connective tissues were torn two always crown our efforts.

incher further up. The operation was He did not know of any operation done about one and one-half hours after that is not faulty in this particular, but delivery. Ile used about 15 sutures in the operations that accomplish this pur the vagina and the perineum. The vay. pose

best are performed by Tait, Dun- inal tear was united by silk sutures, and (an, Simpson, Langenbeck, Saenger, the perineal by a silver wire and silkllart and Barbour; but if he understood worm gut, using only one silver wire their methods correctly, they do not as a base suture to hold together the fully appreciate the importance of dis- ends of the sphincter muscle. The secting up and uniting the muscles and sanitary and hygienic surroundings

muscular

1

were not good and she had but little liquid and solid, and of inability to drink after attention. She passed her urine, cold water or other cool drink. It was the vagina was washed out but a few first noticed that food would not move times, and her bowels moved daily, on in response to the usual movements after the second day. At no time was of deglutition, and that its onward prothere any pus, and the entire laceration gress was assisted by a few gentle rajis healed by first intention.

on the back. This symptom first showIf the operation is well done he ed itself about six years ago. From doubts the necessity of drawing the this slight difficulty in the passage of water or tying the legs. Nor is it solid food to the stomach, the patient necessary to wash out the vagina often. gradually found herself compelled to The urine and the lochia are not poison- subsist wholly on liquid foods, and ous, especially after the second day, if these could be retained only when taken strict asepsis has been observed in the at a certain warm temperature. Neither operation.

water at orduary temperature, nor cool Where any form of an aseptic animal drink or any sort, nor solid food, had suture is used the needle should be in- entered the stomach in a period of years. troduced and brought out just within She was emaciated and destitute of the lower or external edges of the raw physical vigor. surfaces so that when they are united An examination of the esophagus the sutures will be concealed or buried with a bougie proved the existance of a in the tissues. Sometimes a few super- band, which would resist the further ficial sutures will be requireil. The progress of the instrument till the consutures should be so introduced as to be striction willed to give way, when the entirely covered by the tissues and to bougie would easily slip into the stombring the surfaces into even and exact | ach. Neither had the diameter of the apposition. If the sphincter ani is rup bougie. nor the flexibility of a tube, nor tured he always uses the base suture force, seemed to have anything to do after the fashion of Emmet.

with passing through the constricting He does not destroy any tissue except riny. Passage beyond the constriction jagged edges in some complete ruptures; could be made only when the ring was the dissected part assists in protecting the wounded surface against the dangers

so disposed and inclined. There had of infection from uterine or vaginal been no pain or hemorrhage. There secretions, snd also increases the thick- was no history of the introduction of a ness of the perineum. He had never foreign body and its impaction, or of had a recto-vaginal fistule after an oper- the swallowing of a strong acid ation for complete ruptures nor did he strong alkali. No aneurism was evident. believe it will often occur, if the opera- There is no history of carcinoma. The tion is correctly done, after his method. constriction was sixteen inches from (ESOPIIAGEAL STRICTURE.

the lower incisors. Dysphagia and reBY E. T. PAINTER, M. D., PITTSBURGH, PA. gurgitation, which prevented the patiA paper read at Allegheny County Medical Society. ent retaining sufficient nourishing food,

'HE patient, aged about thirty-eight, were the only symptoms given. complained of difficulty in swallow- As drugs, massage, the passage

of ing food and its regurgitation, both flexible tube, and the Faradic current

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