had lacerated rather than cut, that several wounds had been made in various directions, and thus by scar-tissue the obstruction was rather added to than lessened by what had been done. This was probably directly due to faulty instruments in the case of internal urethrotomy, and to want of precision and completeness in carrying out the details of perineal section.

Though some failures may be accounted for in these ways, more were evidently due to the conditions under which healing proceeded after the operation. Many of the incisions that were made for the purposes of internal urethrotomy were inadequately provided with means for proper drainage, having regard to their extent, whilst some cases of perineal section or external urethrotomy, were hardly any better off in this respect.

About the time I commenced to make these observations on a somewhat extended scale, internal urethrotomy was being practiced with a very free hand.

The late Professor Otis, of New York, had recently formulated his views relative to the male urethra, which to some extent were responsible for this. Though fully recognizing the value of his work in demonstrating the greater capacity of the male urethra and the important influence this had on the new lithotrity or litholapaxy which Bigelow was developing in the wake of Otis's investigations, I could not follow him in the practical application of it, in its entirety, to the treatment of stricture. However, it tended in the direction of increasing the ranging of internal urethrotomy as well as the size of the wounds thus made, but I cannot say that it proportionately added to the number of cures in chronic stricture of the deep urethra..

It struck me in examining cases which had thus been operated on some years previously by various surgeons where the stricture had recurred, that the size or depth of the wound so made was out of proportion to the facilities for drainage, whilst healing was going on, which the urethra alone afforded. In the absence of the latter condition I recognized one reason for the contractile condition of the scar that resulted. In arriving at this conclusion I was much influenced by what I had observed in connection with the treatment of accidental lacerations of the deep urethra by perineal incision and drainage.

It may be generally stated that the worst forms of stricture are those following laceration of the urethra, and considering the circumstances under which such lesions usually heal this is not to be wondered at. Repair goes on slowly under the irritating influence of constant contact with confined urine, and excessive exudate takes place about the seat of the wound. This eventually, in conjunction with the irregularity caused by the wound, forms a stricture of the closest and most contractile character.

On the other hand, in cases where perineal section and drainage were applied, this either did not happen at all, or happened only to a more limited extent. In some instances where this principle was adopted in the case of ruptures of the deep urethra, healing took place just as kindly as it usually does after a median cystotomy, and no stricture followed. This I proved in

many instances. It seemed reasonable to conclude that the treatment of stricture by section or division of the stricture might be improved by providing better drainage for urine and the discharges from a wound which can only be imperfectly treated antiseptically.

I am not aware that the influence of urine-drainage and irrigation in relation to the healing of wounds of the urethra and the kind of scar-tissue that results has ever been adequately discussed in connection with the operative treatment of urethral stricture.

With the view of meeting what I consider to be causes of failure and recurrence of some operations, I published* a series of cases and observations where I had combined the principles of internal and external urethrotomy in the treatment of certain forms of urethral stricture, which on the whole have afforded good results. I shall best illustrate this practice by a typical case, which was recorded and watched for a considerable number of years:

A man, aged fifty-one years, whom I saw and operated upon in 1890, had been the subject of a stricture with a strong tendency to contract for some years, and had undergone no less than six operations for it, including a divulsion by Holt's method, and five internal urethrotomies at vari

KRORNE SESEMANN LONDON

FIG. 1.

ous intervals and places. For some months before I saw him the stricture had been contracting and closing in spite of the patient's well-directed efforts with suitable bougies to keep it open. Straining to urinate was constant and prevented continuous sleep, and there was some cystitis with probably pyelitis. I performed an internal urethrotomy with Teevan's modification of Maissonneuve's instrument, as I thought that the latter might not stand the strain put upon it by the cartilaginous character of the tissues which had to be divided. This being done, I passed a full-sized grooved staff (No. 12 English) into the bladder. As the latter was evidently gripped in the deep urethra the patient was placed in the lithotomy position, and I divided in the median line from without inwards such contracted tissue as remained. I thus opened the urethra, and found by passing my finger first into the bladder and then hooking it forward along the urethra in the direction of the penile orifice, that the walls of the canal had now been rendered free and unresisting. A full-sized gum-elastic drainage.. tube (such as I have elsewhere described and figured†) (Fig. 1) was passed into the bladder through the wound and retained. The parts were washed out with a solution of perchloride of mercury (I in 6000). The stiff drainagetube was withdrawn on the sixth day and a soft rubber one (Fig. 2) sub

* British Medical Journal, July 18th, 1885.

"Surgical Disorders of the Urinary Organs," fourth edition, and p. 173 (seq.).

stituted, which was worn for a fortnight longer, and then finally removed, when the wound soon healed. Eight years have now elapsed since this

FIG. 2.

operation was practiced. The patient remains in good health and suffers no further inconvenience from his urinary organs than having occasionally to pass a full-sized bougie for himself.

It may be thought that the retention of a catheter in the bladder for some time after an internal urethrotomy has been practiced, is to be preferred to an external urethrotomy, and the insertion of a perineal tube for drainage alone. In some instances the former may suffice, but in the majority of cases, where a urethrotomy becomes necessary, it will be found an imperfect substitute. The mechanism for the retention of a catheter along the whole length of the urethra and the irritation it excites, are often obstacles to the successful employment of this expedient.

The conclusions arrived at from the examination of structural lesions used in the treatment of urethral strictures, as detailed in the foregoing remarks, may be summed up as follows:

First. That there is evidence to show that in peri-urethral strictures of the deep urethra the effects of divulsion as practiced in Perréve's and Holt's operations may be limited to rupturing the dense stricture bands in the submucosa of the urethra, whilst the mucous membrane itself escapes any serious injury or laceration, and is rarely restored by stretching to its original dimensions. Here a permanent cure may result.

On the other hand, where the mucous membrane is in itself the seat of stricture and forms part of the latter structurally, it is necessarily torn or lacerated by the process of a sudden divulsion, and the pathological condition consequently becomes assimilated with that of traumatisms of the urethra from external violence accidentally applied, which are followed by strictures of the most contractile and recurrent form.

Second. That there is evidence to indicate that where the entire thickness of a stricture can be included within an incision of moderate dimensions made by an internal urethrotome, the normal calibre of the urethra may be completely and permanently restored. Where this happens, it may be concluded that all the fibres of contraction constituting the stricture were divided at the time of operation. And further, that the converse is equally true. There is also evidence to show that the absence of recurrence, under such circumstances, is not necessarily dependent on the use of a bougie, though the latter is a precautionary measure which should invariably be advised.

Third. That, in the case of multiple strictures, or strictures of the deep urethra of considerable dimensions, either in their length or thickness, treated by an internal incision of corresponding proportions, apart from

other considerations, the tendency to recontraction and recurrence with an additional amount of cicatricial material, is frequent; the latter being probably due to the circumstances under which healing takes place in wounds of these dimensions so situated.

Fourth. That lesions of the urethra demonstrate in various ways the poisonous effects that unprotected and confined urine is capable of exercising, both on the body generally and on the tissues in contact with it, and that the liability to such effects is greatly diminished where drainage and irrigation render these conditions of the urine unlikely.

Fifth. That in the case of recurring strictures previously treated by incision and in primary strictures of such length or extent as to require an internal section of a corresponding size, or as to which there might be doubt as to whether it would be safely possible so to include them, that for the purposes of the operation and its results such wounds should be made with due regard to other surgical principles, in addition to the one pertaining to the division of the contraction.

Sixth. That there is direct evidence to show that the tendency to recontraction and recurrence of stricture after internal urethrotomy is largely diminished by the concurrent employment of systematic and efficient urine and wound drainage, such as the combination of external urethrotomy, or perineal puncture, affords.

Disinfection of School-rooms and Public Conveyances (Warner, Col. Med. Jour., Feb., 1900).-For disinfection after infectious diseases formaldehyde gas is the most useful agent. To make the gas most efficient it must be generated quickly, and the room. be warm and tightly closed to prevent escape.

Antistreptococcus Serum in Measles,-Gillrie (Canad. Pract. and Rev., April, 1900) reports a case of measles in a child of six years treated with this serum. The disease was of a very severe type, pulse 160, temperature 104° F., respiration 55 per minute and the patient delirious. She continued to grow worse, there was a fall in temperature to 100 and great prostration. Fifteen c.c. of the serum were injected in two doses, and almost immediately improvement followed. Other treatment was continued. A rise of temperature of 3 followed the injection. There was no local reaction whatever.

The Demand for a Wider Use of Antitoxin (editorial in Med. Age, April 25, 1900).-Although the mortality has been greatly reduced by the use of antitoxin, it is still unnecessarily high. It should be remembered that membranous croup and diphtheria are identical in etiology. The symptoms are unlike those of diphtheria, except for the laryngeal obstruction, and owing to lack of facilities for bacteriological diagnosis the true nature of the trouble is often not recognized. The mortality is very high in these cases, and it would be far better to give antitoxin in all cases of laryngeal obstruction. No harm can result, and many lives may be saved by this practice.

I

DISEASES OF THE LUNGS AND PLEURA.*

A Series of Papers written expressly for this magazine, by

BY ALBERT ABRAMS, A. M., M. D. (Heidelberg),

SAN FRANCISCO, CAL.

Consulting Physician for Diseases of the Chest, Mt. Zion Hospital and the French Hospital.

CHAPTER II.-PULMONARY ATELECTASIS.

HAVE frequently directed attention in the literature to constant areas of diminished lung resonance varying from dullness to flatness as obtained by percussion.† In number and situation, these areas vary, but they admit in the aggregate of definite localization. These areas of dullness or Atelectasis Zones, as I have called them, possess one characteristic feature, they may be dispelled by repeated forced inspirations. By this simple maneuver, resonance will supplant dullness. The atelectatic zones are dependent on circumscribed pulmonary atelectasis or collapse of limited portions of the lung, and dissociated with any demonstrable lesion. it is true from the standpoint of the physiologist, that the lungs are in a stretched condition, it is equally true from the position of the clinician that certain portions of the lungs are collapsed and deprived of sufficient air to yield a dullness, and in some instances, a flatness of percussion. The atelectatic zones vary in size from a twenty-five cent piece to a dollar in size, or even more, and are permanently absent when the lungs are emphysematous and temporarily so, after repeated deep inspirations, but they reappear in a few minutes when tranquil breathing is resumed.

In the accompanying illustrations (Fig. 2 and 3), I have projected a composite picture defining the situation of the atelectatic zones based on an examination of over one hundred apparently healthy persons, children as well as adults. On the posterior surface of the chest, the zones are more frequently encountered, and admit of more definite localization than those on the anterior surface of the thoracic wall. Since the advent of the Roentgen rays I have observed the following:

(1) Atelectatic zones throw circumscribed shadows on the fluoroscope, which will vary according to the degree and area of the pulmonary atelectasis. (2) The shadows cast by the atelectatic zones can be made to disappear by continuous forced breathing, and they will reappear after a variable period when quiet breathing is resumed. (3) Before deciding whether the shadow cast on the fluoroscope is really due to pulmonary consolidation, the subject should be instructed to make forced inspiration; if the shadow disappears and is supplanted by a bright reflex, it is due to atelectasis; if the shadow persists, pulmonary consolidation may safely be concluded to exist, excluding, of course, other anatomic conditions that

* The first paper of this series, on "Coug," appeared in our issue of August 25th. The subjects for subsequent papers are as follows: Pulmonary Anemia,"" Pathology of the Blood," " The Heart and Lung Reflexes," Pulmonary Resonance,' Meteorismus and Its Influence on the Thoracic Viscera."

+Abrams: Report of ico cases treated by the Pneumatic Cabinet, Pacific Medical Journal, September, 1891. Pulmonary Atelectasis as a Cause of Anemia, Transactions of the Medical Society of the State of California, April, 1892. Observations on Pulmonary Atelectasis, ibid., session of 1894. Medicine, December, 1895. New York Medical Journal, June, 13, 1896. Philadelphia Medical Journal, November 26, 1898.