it done before it was "too late." So, on a memorable day last January I called at the office of the noted specialist at 10.00 A. M., thinking to get there early and avoid the rush. I was somewhat surprised to find that about twenty-five persons with tight sphincters had beat me to it. There were others "wise" enough to have their sphincters dilated. Well I was pleased to see what our public school system of education was doing for the dear people. I figured it out that the physiology teachers were up on this tight sphincter business, and were putting the children hep to it, who in turn slipped the glad tidings to their parents.

I slipped quietly into a chair alongside of a fat sphincterette and resigned myself to my fate as I expected to wait several hours for my turn. Not so, however, for a very beautiful and business-like young lady in a white apron and cap rushed over to me and asked a lot of personal questions-name, age, sex, residence and occupation, and was I a patient, or did I wish to see the specialist on business. I said "patient," and then blushed painfully-I had tipped off my secret to this beautiful young lady. She knew I had a "tight sphincter." But she didn't seem to mind it, just looked at me in a sympathetic sort of way which lead me to believe she belonged to the order, and that some time during her young life she too had had a tight one. She slipped the card with my name and family history through a slot in the door marked private and pushed a button on the wall. I judged that this was an emergency call, for almost instantly the door opened, and the specialist bawled out in a loud voice, "Doctor Wier, come right in, I'll see you at once." I was rather surprised at such quick service. Evidently the specialist knew me, or at least had heard of me. I felt quite flattered, and imagined the other sphincters and sphincterettes cast envious glances at me as I strode proudly into the sanctum sanctorum. The Specialist greeted me very pleasantly, and said, "Well, my dear doctor, what can I do for you?" I confidently and smilingly told him that I desired to have my sphincter "thoroughly dilated." I thought he looked a little disappointed at this, as though he had expected to do a proctotomy or something on me. He came back smilingly, however, and told me to call promptly at nine o'clock the next morning, and then he quickly shunted me out of a side door into the hall

before I even had time to visit with him. Well, I could hardly wait for the morrow. I was anxious to have the thing done. I was like a girl who wants to get married but don't know why. I imagine that getting married and having your sphincter dilated are much the same, they don't come up to our expectations.

Well, I was on hand at nine sharp the next morning and was immediately ushered into the private office. The specialist was waiting for me and had everything ready, so I was not to be kept in suspense any longer. I asked him whether I was to take gas or ether. He said "Pooh, pooh, doctor, you don't need any anesthetic. Why, with this new dilator of mine, 'Patent applied for,' the operation is practically painless." He showed me the instrument, a long ice cream cone shaped affair, with dimensions, I judged to be as follows: apex 34 French, base 500 French. In the light of subsequent events, I consider this estimate altogether too conservative. He explained that by gradually introducing it by easy stages that the transition from the ridiculous to the sublime was scarcely perceptible, as it were. It sounded plausible. But, nevertheless, I must confess that all at once my sphincter felt better than it had for months, and I began to doubt the advisability of having this thing done to me now. Perhaps sometime in the future, but not today. I attempted to explain this to the specialist, but he said "tut, tut, don't get cold feet now. Take off your coat and vest and get ready." His remarks riled me a bit for I objected to his insinuation that I was afraid. So, just to show him I was game I peeled my coat. His operating table was the queerest looking table I ever saw. It was made of heavy oak with leather trappings. It also had side boards and a head board about two feet high. It looked not unlike a wagon box, minus the end-gate. I couldn't imagine what the side boards were for. I was about to ask him when he ordered me to get in. So I crawled into the box on my left side, knees flexed, and strange to say, that box just fit me. My head was against the dash board, and my back and knees tight against the side boards. He said, "Steady now. I am going to introduce the dilator." He gave the thing a push. Suffering punk how it hurt. I said, "that will be enough, don't push it in any further, I don't think I need a complete dilation anyway." He only laughed

and said, "Why, it's only in two inches. Lie still now, it don't hurt"; and then he gave it another push. Ye Gods! I nearly died right there. Talk about the tortures of the inquisition. They were kindergarten stuff compared to this. It's lucky for their victims that those old cusses were not on to dilating the sphincter ani as a means of torture. It has any stunt they ever pulled, backed off the boards. I said to myself that this fiend in human form was trying to kill me. I pleaded with him to take it out, but he said, "No, no, keep still now, be game and take a little more." "Never" I yelled and made a lunge forward to get over the dash board, but it was no use it was too high, and I nearly broke my neck in the attempt. So I tried to back out. This evidently was what he was waiting for. He gave it a terrific push, and everything turned first black and then red before my eyes. The pain was too terrible for words. I yelled murder, police and cursed and threatened to lick him. This must have frightened him for he withdrew the king pin of torture, and I slowly backed out. My heretofore perfectly good legs seemed to have turned into rubber, they went round in circles and my knees cracked together and my feet refused to move. The specialist helped me to a chair and opened the window, and while the cold Lake Michigan breeze fanned my face, the cold sweat poured off my brow in streams. I knew then that he wasn't afraid of me, for had he offered to pitch me out the window I wouldn't have resisted in the least. I finally recovered sufficiently to stagger to the door. He asked when he could have the pleasure of seeing me againsome people have queer ideas of pleasure. I said, "Never, Damn you, never." I bribed the elevator boy to help me into a taxi, and the ten blocks to my room was the roughest ride I ever took in my life. It seemed like the pavement was all torn up, and every time we bumped the bumps I could feel that patent dilator punching me in the stomach. I felt certain that he had left it in. Well, after what seemed a thousand years, I arrived at my destination.

Well, suffice it to say that after applying a hot water bottle affectionately to my poor maltreated sphincter ani for about a week I was able to navigate once more, a sadder but wiser man. No matter what kind of a stunt my sphincter ani pulls off in the future, I have taken a solemn vow that

it will never be treated to another dilatation-yea verily, never again. Joplin, Mo.

AMMONIACAL URINE IN INFANTS

A condition almost entirely overlooked in medical periodicals is the fact that very small infants pass a discharge of the urine that turns the diaper yellow and smells very strongly of ammonia. All cases where the urine has this ammoniacal smell should have simple treatment. The retaining of the urine in contact with the skin produces irritation sometimes extreme. Furthermore, the condition may be a precursor of pyelocystitis.

In many cases the infant screams or cries out, and later the mother finds that the child has just urinated. Consequently, there are reasons for believing that the urination is painful often. This condition is most common in artificially-fed infants. There are a few cases in which the ammonia is only liberated in the diaper after the urine has passed. In these cases the irritation is all external, but in any case for the excess of ammonia there is no harm in giving the patient some very mild remedy.

Ten drops of hydrangea in two ounces of water, a teaspoonful every hour or two, is sometimes of very excellent service. Chimaphila is also a good remedy. Couch grass or horse mint may be given in small doses to very young infants.

I have reason to believe that the preparation I prescribe for the same condition in the aged will be found very useful in infants. I believe if twenty grains of benzoic acid be dissolved in four ounces of distilled water, and its solution enforced by thirty grains of borate of sodium, that this could be given in teaspoonful doses to an infant under one year of age with the result that but a few doses would temporarily correct the condition. Then use one or two small doses a day, and the relief can be made permanent.-Ellingwood's Therapeutist.

STRICTURE OF THE URETHA (Abstract of clinical lecture given in Long Island College Hospital)

BY HENRY H. MORTON, M. D., F.A.C.S. Clinical Professor of Genitourinary Diseases, Long Island College Hospital; Genitourinary Surgeon, Long Island College and Kings County Hospitals, and the Polhemus Memorial Clinic, etc.

CASE 1, MALE, 45, SAILOR-Gonorrhea many years ago. External urethrotomy for stricture ten years ago. No sounds passed after operation. Second external urethrotomy eight years ago. Passed bougie on himself for 6 months. Admitted to hospital for acute retention with bladder distended to umbilicus. Whalebone guide could not be introduced, so suprapubic puncture was done, and subsequently external urethrotomy without a guide.

CASE 2, BOY, 15, U. S.-Seven years ago ruptured urethra by jumping into milk can. Eight operations have been performed, last one two years ago. Sounds passed every week for one year.

On admittance it was found that a filiform guide was all that would pass through stricture. Tunnelled sounds could not be passed, because of density of stricture. Operation would probably leave a permanent perineal fistula. Treatment by continuous dilatation was decided upon.

The filiform guide was left in place for 48 hours, then a small flexible bougie could be passed. This was left in place for 48 hours, and then a larger size passed and left in the canal. Now the patient wears a 26 flexible bougie. Sounds will be passed from this time till stricture is well dilated.

The urine is voided around the bougie in the urethra.

TEST FOR ALBUMIN IN URINE

Heat and nitric acid, simple and combined, with contact test, remain the reliable means for the recognition of albumin in the urine. All other tests are objectionable in some respect and the findings with them are subject to misinterpretation. The The tests for albumin should be made, when possible, with fresh urine. It is customary with some insurance companies to have the urine sent to a central laboratory. Boric acid is added to the urine as a preservative, and it is probably as good as any, but many of the samples when examined, contain more or less bacterial growth. It is the rule to heat such urines with strong alkali, filter and test the filtrate with heat and nitric acid. The alkali dissolves the bacterial proteins and the filtrate gives an albumin test even when there was none in the urine when passed. This accounts for the high precentage of albuminuria reported from some of these central laboratories. The method is to be condemned. It seems difficult for some medical men to get away from the idea that bacteria are vegetable organisms. They consist mostly of protein, soluble in strong alkali, especially on the application of heat. The test, applied in the way mentioned above, gives no reliable information and is misleading. It has been suggested that the urine containing bacteria should be passed through a Berkefeld filter and the heat and nitric acid tests applied to the filtrate. This is open to two sources of In the first place, albumin when present, may be held in the filter and thus escape detection. In the second place, some of the bacterial proteins may be in solution without the addition of alkali and may pass through the filter. Dr. Vaughan, in the Journal of Laboratory and Clinical Medicine.

error.

PNEUMONIA

Ten per cent. of the deaths in the United States result from pneumonia. It is estimated that during January last this rate has been doubled in some sections. Tuberculosis and heart disease, each causing one-ninth of all fatalities, are the only diseases which outrank pneumonia among the legion of the men of death, but in certain cities pneumonia is steadily increasing and even has surpassed the mortality from tuberculosis. Seventy per

cent. of all cases occur between December and May. It is distinctly a cold weather infection, seemingly brought by wintry blasts, but especially prevalent during the winter season only because its victims are rendered more susceptible at that time by exposure, debilitating influences and the presence of predisposing infections.

Pneumonia principally affects those at the extremes of life, but no age is exempt. It is invariably a germ disease. The predisposing and exciting organisms are so numerous that it would be futile to attempt their enumeration. Many of them are constantly present in the mouths and throats of healthy persons and it is only through the aid which we unwittingly extend to them that they are transformed from harmless organisms to one of man's most powerful enemies.

The presence of other diseases is the great predisposing cause of pneumonia. They prepare the soil for invasion. Holding first rank in this category is influenza, the increased incidence of pneumonia at this time being largely due to the present epidemic of la grippe. Individuals suffering from this infection are peculiarly susceptible to respiratory complications and should properly observe every hygienic rule. Inflammation of the upper air passages, pharyngitis, bronchitis and tonsillitis, often predispose to the development of the disease, particularly among the aged and infirm. The acute contagious diseases of childhood, more especially measles and whooping cough, frequently prepare the way for pneumonia. Anyone who through neglect or carelessness permits the spread of these infections is therefore open to the severest condemnation. Exhausting disease of whatever nature, is often sufficient to so reduce our resistance that we are unable to cope with organisms which should

be easily overcome, and hence predisposes to the infection.

Debility, either temporary or chronic, developing from any cause, increases susceptibility. Because of this the disease most often attacks those at the extremes of life. Among debilitating influences must be mentioned cold, exposure to penetrating winds, and the chilling of body surfaces as a result of wetting. The combination of lack of food and fatigue proves particularly disastrous during the winter season and is a condition to be avoided whenever possible. Bad housing, mental or physical harassment, and overwork are alike advance agents of the infection. Overcrowding, in street cars, theatres, and other public places, is unquestionably in part responsible for the spread of pneumonia in cities, as far greater opportunity is thus offered for the dissemination of the predisposing diseases through indiscriminate coughing and other means of droplet infection, as well as the directly injurious effects which inevitably result from exposure to such environment. The overheating of rooms is also seemingly harmful. Promiscuous expectoration may be, and probably is, a factor in infection and consequently should be avoided by every citizen. A remaining most important agent should be mentioned-alcohol. It is in truth the handmaiden of pneumonia, and there is none more certain or more sure of success, especially if liberally and continuously used.

While the foregoing facts constitute in part our knowledge of the reasons for the widespread dissemination of an infection which carries with it a mortality of from ten to thirty per cent., it should be remembered that our scientific data are not yet complete. There are problems connected with immunity, predisposition, and the occurence of epidemics which are yet to be solved. It is known that pneumonia frequently attacks those who are perfectly well, and who apparently have observed every hygienic rule. Whether this is due to the increased virulence of the organism or to other causes is unexplained. It is, however, recognized that avoidance of the factors so briefly enumerated will in a large part diminish individual susceptibility and therefore the incidence of the disease.

Strychnine arsenate is the tonic par excellence in pneumonia. It may be combined with aconitine and digitalin. Try it.

OBSTRUCTION AT NECK OF BLADDER

B. Tenney of Boston says: Prostatic obstruction without enlargement may be due to

1. Dense layer of new-formed connective tissue below the mucous membrane and infiltrating the internal sphincter-the fibrous ring.

2. The same process with chronic inflammation of the submucous gland tissue-the bar.

3. Hypertrophy of submucous gland tissue involving the suburethral or subtriagonal groups or both-the hypertrophy in miniature.

4. Connective tissue replacing the glan dular below the internal sphincter musclethe fibrous prostate.

5. Congenital malformation.

Clearly, the conditions here suggested do not call for the same treatment. When the obstruction is small and strictly confined to the region of the internal sphincter, it is possible to get good results by methods that do not apply to the general condition which we know as the small fibrous prostate. In this condition we are practically dealing with scar tissue which must be stretched or cut through or removed as completely as possible. Con- ' nective tissue with its tendencies to contraction, reproduction, and occasional hypertrophy is poor material for surgical work. A result which is satisfactory at first may be quite the reverse after a few months of neglect; and permanently good functional result, whatever the operation, depends on the patient's faithful attention to his sounds.

Of the sixty-four cases reported to Tenney, forty-six were operated on through the bladder and thirteen through the perineum. There were four deaths, three of which followed perineal section; but some of these cases were attempts to remove the hard fibrous prostate, and this operation is often long and difficult. They cannot fairly be compared with a list of cases whose lesions were confined to the region of the internal sphincter. The results of the operative treatment of these cases were satisfactory in fortyseven, unsatisfactory in eleven, death in four, not given in two cases. Unsatisfactory results followed the perineal approach seven

times, the suprapubic operation three times, and the Bottini cautery once.-(Surg., Syn. & Obst., Aug. 1915.)

THE CONTROL OF PERSISTENT COUGH

Dr. John B. Todd, of Syracuse, N. Y., writes that persistent cough, caused by streptococcic infections which are characteristic of grippe and infectious colds, is often difficult to control. The cough itself is a cause of prolonging its own existence and often produces pleuritic pain, headache, and inability to sleep. Todd has found the greatest relief can be obtained by the simplest of measures. A few doses of sodium salicylate increase the resistance of the system, and repeated small doses of mineral oil soothe the throat and relieve the cough.

The following Todd has found to be a good combination that is taken readily by children as well as adults: