DANBURY, CONN., NOVEMBER 15, 1888. present engaged in a hand to hand con ORIGINAL LECTURES. ANTISEPTIC TREATMENT OF STRICTURE OF THE URETHRA. A Clinical Lecture Delivered at the New York ENTLEMEN:-Last week as you remember we divulsed a stricture in the region of the triangular ligament; using graduated sounds for divulsion, Beginning with a filiform bougie, the urethra at the constricted point was rapidly enlarged to a circumference of 34 m. m. and because the work was done under our modern antiseptic method I felt justified in predicting that the patient would not have to remain away from his business, and that he would have no so called urethral fever, unless a few drops of urine should pass through into the loose cellular tissue about the urethra; in which latter event we should at once perform external perineal urethrotomy for the purpose of drainage. This patient, I am now happy to state has attended to his business as an engraver ever since the operation. He has not had any urethral fever, and he is already free from the perineal neuralgia, the pain in the back, the sciatic pains, and the headaches. that were reflex demonstrations from the stricture. flict with prejudice, and who will later The young man whom I now bring before you complains simply of gleet. He had gonorrhea more than a year ago, and there is still a mucous discharge from the urethra. He went to a physician six months ago, and when after a few weeks of treatment he failed to return, the physician very likely noted a cure, and jotted down in his record book a description of the treat ment that had born him triumphant. But the young man was at this same time consulting another. physician, and since then he has "gone the rounds," as most of these patients do, and finally become discouraged. On waking in the morn Dr. George T. Stevens who is at ing he found at the meatus the eternal drop, and on searching for the two dollar bill in his vest pocket he suddenly remembered that it went to the doctor the day before. The two dollar bill has gone but the doctor and the gleet may still be found. It is almost impossible to cure an ordinary ease of gleet until we have made the urethra of nearly uniform diameter from one end to the other. The natural contraction at the meatus which was furnished by nature for concentrating the forces of momentum and velocity and thereby giving greater projection to the stream of urine, is sufficient to keep a gleety discharge running. Force is transmitted through water equally in all directions and the flow of the descending stream of urine upon the contracted tissues about the waters is transmitted to inflamed mucus membrane in the vicinity and it is difficult for the inflammation to subside. The effect of any stricture at any point of the urethra is similar to that of the constriction at the meatus. There are surgeons who argue that the meatus should not be cut because it is a natural contraction, but we might as well insist that the Devil should not be fought because the Lord created him. If it is difficult for any patient to project the stream of urine after his meatus has been cut, what is the harm? So soon as the gleet is well we can inject a drop of cocain solution at the meatus and by a trifling plastic operation restore the parts to a normal condition. Treatment of gleet I shall refer to further at another time, but we are now to discover some of the causes of the young mans discharge, and to remove them as far as possible. Using Otis' urethral cocaine injector I now wash out the urethra with 1-5000 bichloride of murcury solution and make the mucous surface pretty clean. The urethrometer taken out of the dish of 1-30 carbolic acid solution is now lubricated with a solution of equal parts of boroglyceride and glycerine; for vaseline or oil would carry in ferments. Introducing the instrument as far as the triangular ligament and screwing it up until the bulb begins to bend a little we see that the index registers 37 m. m., and this is approximately the normal urethral circumference in this patient. In slowly withdrawing the instrument it sticks fast at a point three inches from the meatus, and it is necessary to turn the screw until the index registers 24 m. m. before the bulb will slip past the strieture, now it is past and again screwing the bulb up to 37 m. m., I withdraw it to a point three quarters of an inch from the meatus where I must screw the index down to the 25 m. m. point before the bulb will pass. I neither know nor care whether there is a stricture below the parts examined, for if there is one it calls for other treatment at another time. If the strictures would allow the passage of the endoscope I could show you the red unhealthy patches of urethra behind cach constriction. I now ask Dr. Sylvester to compress the penis as far back as possible with his fingers in order to stop the circulation of blood, and then inserting the hypodermic needle into the tissue of the glans penis, I inject there five drops of a ten per cent cocaine solution. In half a minute the whole penis becomes as insensitive as a piece of rope, and it will remain so for fifteen minutes. The dilating urethrotome which I now take out of the 1-30 carbolic acid solution, order to cut up to full size I must again insert the urethrotome and repeat the process. There is now considerable hemorrhage from the penis, and this I control with these two pieces of cigar box. Putting one on the upper and one ou the lower side, I slip a couple of rubber bands over both, and stop the hemorrhage by pressure. If blood should run backwards into the bladder and form clots there it would be a mater of no importance, for an injection of a few grains of pepsin into the bladber would dissolve the clots and they would easily pass away in thin treacly strings at the next urination. The patient will take ten grains of boric acid with every meal, and ten grains at bed time until the wounds have healed. Boric acid is excreted unchanged by the kidneys and it makes an antiseptic dressing of the urine that pases over the wounds. I shall pass a number 37, French sounds in three days, again four days after that, then five days, later still; once a week for a month, and once a month for a year. The patients strictures have been cut without causing him a particle of pain. The work has been done antiseptically so that he will not have urethral fever. Hemorrhage is controlled by the simple device that the patient can reapply after urination, and I shall ask the patient to keep about his business as though nothing had happened. He will of course use a certain degree of caution about walking hur HE E spoke especially of the surgical treatment of laceration or injuries of the muscular and aponeurotic structures that form the floor or diaphragm of the pelvis. He said there is prob ably no other subject in gynecology about which so much has been written that is of no real value, and that a relatively simple operation had been made to appear so complicated that it is seldom correctly performed. He passed by much of this immensity of pseudoscientific rubbish, and took a practical view of the subject. He said that the muscles and the fascia in the perineum give it strength, and when they are lacerated no operation that does not primarily tend to reunite them is logical, or will be followed by permanant good results. We may 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 anHe 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 tornries or gynecology, who are opposed ends of the muscles and fascia we are not a little surprised He said that when any or all of the to find in this list the name of the disperineal union of the muscleor FEB tilhed Professor, A. Carpentier, of fsacia,are lacerated, unless at once unitedParis. His objections are illogical and and held together, the STON MERION tions continue to widen the distance be tween the torn ends, so that the vulva gradually becomes enlarged laterally. The extent of this lateral separation is governed by the degree of laceration and the length of time since it occured. If the above is correct, then no operation will succeed that fails to bring these torn ends together so as to reunite them. This is a simple question that holds good in all operations to restore the perineum in complete or incomplete ruptures, and if we are controlled by it, and are familiar with the technique of the operation, success will nearly always crown our efforts. He did not know of any operation that is not faulty in this particular, but the operations that accomplish this pur agat sustained in actual practice where the operation is correctly done. He had done the primary operation often, without a failure; in fact he thought the success is usually more perfect than in the secondary operation. The torn ends of the muscles and fascia are now easily held in apposition and unite within a few days. He reported a typical case upon whom he operated a few weeks ago for his friend Dr. The woman was delivered of a large child when 16 years old, and was torn through into the rectum for over an inch, and the vaginal wall and the connective tissues were torn two incher further up. The operation was done about one and one-half hours after delivery. He used about 15 sutures in the vagina and the perineum. The vaginal tear was united by silk sutures, and the perineal by a silver wire and silkworm gut, using only one silver wire as a base suture to hold together the ends of the sphincter muscle. The sanitary and hygienic surroundings were not good and she had but little after attention. She passed her urine, the vagina was washed out but a few times, and her bowels moved daily, after the second day. At no time was there any pus, and the entire laceration healed by first intention. If the operation is well done he doubts the necessity of drawing the water or tying the legs. Nor is it necessary to wash out the vagina often. The urine and the lochia are not poisonous, especially after the second day, if strict asepsis has been observed in the operation. liquid and solid, and of inability to drink cold water or other cool drink. It was first noticed that food would not move on in response to the usual movements of deglutition, and that its onward progress was assisted by a few gentle raps on the back. This symptom first showed itself about six years ago. From this slight difficulty in the passage of solid food to the stomach, the patient gradually found herself compelled to subsist wholly on liquid foods, and these could be retained only when taken at a certain warm temperature. Neither water at ordinary temperature, nor cool drink or any sort, nor solid food, had entered the stomach in a period of years. She was emaciated and destitute of physical vigor. progress Where any form of an aseptic animal suture is used the needle should be introduced and brought out just within the lower or external edges of the raw 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 required. The 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 ring. Passage beyond the constriction could be made only when the ring was so disposed and inclined. There had been no pain or hemorrhage. There was no history of the introduction of a foreign body and its impaction, or of the swallowing of a strong acid or strong alkali. No aneurism was evident. There is no history of carcinoma. The constriction was sixteen inches from the lower incisors. Dysphagia and re He does not destroy any tissue except jagged edges in some complete ruptures; the dissected part assists in protecting the wounded surface against the dangers of infection from uterine or vaginal secretions, and also increases the thickness of the perineum. He had never had a recto-vaginal fistule after an operation for complete ruptures nor did he believe it will often occur, if the operation is correctly done, after his method. CESOPHAGEAL STRICTURE. BY E. T. PAINTER, M. D., PITTSBURGH, PA. gurgitation, which prevented the pati A paper read at Allegheny County Medical Society. HE patient, aged about thirty-eight, complained of difficulty in swallowing food and its regurgitation, both ent retaining sufficient nourishing food, were the only symptoms given. As drugs, massage, the passage of a flexible tube, and the Faradic current |