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BY E. L. KEYES, M. D., NEW YORK.
easily passed. Twelve years afterward, no in-
strument having been used during the interval,
a No. 24 entered without meeting an obstruc-
tion. This was a soft stricture, the variety in
which a radical cure was possible by dilatation.

The present paper proposes to discuss only organic stricture of the urethra situated at or beyond the bulbo-membranous junction. No one was yet in a position to say that any operation would radically cure deep urethral stricture, while that of the anterior urethra might be cured.

Three varieties of stricture are encountered clinically in the deep urethra. First the soft stricture, which was a very superficial organic lesion involving only the surface of the mucosa. It follows gonorrhoea, and was generally situated at the bulbo-membranous junction, and might even cause complete retention of urine. Such a stricture would often not admit a filiform bougie, yet a blunt-steel sound of ordinary size might pass in many cases. The second variety was the purely fibrous cicatrical stricture of traumatic origin found in the urethra which had not been the seat of gonorrhoea. It might involve only the mucous membrane or extend through all the tissues of the entire thickness of the perineum. It might be unaccompanied by gleet. It cut like true fibrous tissue. This stricture was linear or annular but clearly defined. The third variety was the nodular stricture, which might supervene after a traumatism notably in strumous subjects, especially where there had been much suppuration or multiple fistulæ. It was often found in cases of stricture following gonorrhoea. This variety was lumpy, ill-defined, irregular, tortuous, never linear. Gleet was the rule, and fistulæ might be present.

The first question which naturally arose was: Does dilatation ever radically cure deep urethral stricture? Cases treated by myself and my former partner, the late Dr. Van Buren, demonstrate the possibility of cure by dilatation. In one case the stricture at first admitted only a No. 14 F. instrument, but after a number of months of treatment was cured, and a No. 28

Amer. Asso. Genito-Urinary Surgeons Trans. Condensed.

Does electrolysis ever radically cure deep urethral stricture? I expressed a decidedly negative opinion on this subject in a paper read before the meeting of this association in Washington last year, and my opinion is the same still. It seems probable that the dilatation produced by the electrolytic instruments caused what improvement there was in the strictures so treated.

Does perineal section ever radically cure deep urethral stricture? The term radical is suited to the operation, as experience showed, since the advantage thus gained must be maintained by means of the sound. The difference of results obtained in different cases did not wholly lie in the extent of the cutting done, but depended much upon the quality of the tissues cut. It was possible, for a purely fibrous stricture might be radically cured by perineal section, but that an inodular stricture usually was not. Two comparatively recent novelties in operative methods for deep-seated stricture merit attention. They are excision of the stricture and transplantation of mucous membrane derived from some outside source. Both seem to offer more chance of radically curing inodular stricture than any other means now possessed. Heusner had reported ("Berl. klin. Wochenschr.") an operation in which he dissected out a strictured area two centimeters in length, including a portion of the bulbous and of the membranous urethra. The divided ends of the urethra were then found to be three centimeters apart. The anterior end was loosened from the surrounding tissues, and the severed ends were drawn together, and held by five points of catgut suture. A catheter was kept

in place for twelve days. No sound was used. On the thirty-fourth day a No. 24 F. catheter passed easily, and a year later the patient reported himself well.

Three cases of impermeable stricture had been operated on by Wolfler of Gratz, in which he excised the diseased segment, and after eight days transplanted strips of mucous membrane to the roof and sides of the granulating area. The strips were cut from some convenient vagina and were several centimeters broad. They were kept in place by a packing of iodoform gauze, no sutures being used. The bladder was carefully drained during the process of union of the graft with the surrounding tissues, A small fistula remained in each case when reported. A year after the operation one of the patients could urinate in a large jet; another could admit a No. 20 F. sound.

It seems to be conclusive; I. There are three forms of deep organic urethral stricturethe soft stricture, the purely cicatricial stricture, and the nodular stricture.

2. That soft strictures are often cured by dilatation.

3. That the fibrous stricture in patients always free from gonorrhea might sometimes be radically cured by longitudinal section of the roof and floor of the canal at the seat of the stricture, followed by the passage of sounds. 4. That nodular strictures op not seem to be radically curable by this method.

5. That nodular strictures might possibly be radically cured by total excision of the diseased tissue and suturing of the ends of the urethra; when approximation of the separated ends was impossible, transplantation of healthy mucous membrane might be employed.

LACERATED AND CONTUSED WOUNDS OF THE HAND AND FINGERS. BY JAS. J. M' KONE, M. D., TACOMA, W. T.

I propose to give a general report of a number of lacerated and contused wounds of the hand and fingers. No attempt will be made at classification or at the description of any individual case, as without the presentation of the patients themselves the cases lose half their interest. A great many cases occured among the laboring classes, and on admission the wounds were filled with dirt or oil and grease, and in many instances domestic hæmostatics, such as cobwebs, sawdust and tobacco juice had been used.

my

After removing all foreign bodies first object was to cleanse the parts of all dirt and grease as thoroughly as possible. The wounds were then soaked in warm water, then washed with a solution of hot bichloride 1 to 500, which acts as an excellent styptic; the wounds then closed with an antiseptic silk or catgut, a few strands of catgut being placed in the bottom of the wound for drainage in small, and a rubber tube in larger wounds. In the treatment of these cases as to amputation due regard was had to the patient's social condition. Where the prognosis of a finger was doubtful, and time was a great object, and the patient cared little for personal appearance, I had no hesitation in removing the finger. And again, in mechanics a stiff finger is sometimes quite a hindrance in their work, and I have been called upon in several instances to resort to subsequent removal. Still in doubtful cases in private practice I would hesitate to remove a finger where there was a chance of saving it even in an anchylosed condition. Enough bone

was always removed to make suitable flaps, exception being made in the index finger, as there every sixteenth of an inch counts; the bone was always cut across and the wound left to granulate. When possible I always made flaps from this palmar surface to retain tactile sensation, but would not sacrifice a portion of bone for the object. It is a question when the third phalanges require amputation at their middle portion, whether it would not be better to go higher and remove the head of the metacarpal bone. I have generally left the phalangeal stump if the patient were a laboring man, as it gives more strength to handle the pick and shovel, but if the patient were a lady or a man engaged in some light employment, then symmetry was more desirable, and the metacarpal bone was removed. On the same principle the index and little fingers may be dealt with.

In amputating at a joint, it is necessary to remove the articular cartilage to prevent suppuration. When tendons of the hand were divided they were always stitched, when possible. This is not always an easy thing to do, as they become retracted on the proximal side. In this case the wound was always enlarged in the longitudinal direction to facilitate the operation. After uniting the tendons all hope of success depends on union by first intention. After amputation hæmorrhage was controlled by torsion, though sometimes a ligature was thrown around the vessel. Hæmorrhage from the palmar arch sometimes gives considerable trouble. In these cases it is sometimes impossible to control the hæmorrhage by ligature or torsion.

SURGICAL TREATMENT OF GANGRENOUS HERNIA.

When this has occurred I have packed the wound firmly with antiseptic gauze and let it remain for some time. A plan often employed, but one which I consider cannot be too strongly condemned, is the employment of Monsell's solution in these cases. To be sure it often controls the hæmorrhage, but you prevent union by first intention and run the risk of secondary hæmorrhage and suppuration, after which the tissues become so soft they tear when you attempt to seize the bleeding vessels. When all ordinary means fail to check the hæmorrhage there is nothing left but to tie the brachial which I prefer to ligature of radial and ulnar. The dressings, always antiseptic, were left until the sixth or seventh day. In the redressing we should be as particular about antiseptics as in the first instance, as failure to do this often defeats our object.

The results were excellent, primary union

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being obtained in nearly all the cases, failure occurring chiefly in those cases where there was considerable laceration of tissue, as from the bursting of firearms in the hand. Many cases of lacerated wounds were not seen until suppuration had set in. In such cases, after giving free vent to the pus, hot poultices of flaxseed and charcoal were applied until pus discharged freely, and the parts began to look pale. I think I can safely say I have witnessed the loss of several fingers from the too persistent use of, when properly applied, so valuable adjuncts to treatment. After removal of the poultices Balsam Peru on oakum was substituted. As an anesthetic cocaine was used, when only one or two fingers were to be removed, but for the hand or several fingers, ether was preferred. No bad effects from the use of either the general or local anesthetic were observed.

SURGICAL TREATMENT OF GANGRENOUS HERNIA1.
BY M. H. RICHARDSON, M. D., BOSTON.

The following cases illustrate the treatment which has given the best results.

Bowel was Death from

Case 1. A young woman with right femoral hernia strangulated for a week. found gangrenous, and excised. shock the next day.

Case 2. Woman aet. sixty-five years, left inguinal hernia. On opening the sac the bowel was found strangulated and dark in color. The hernia was reduced but the symptoms of obstruction continued and five days later the sac was opened, and the intestine found strangulated by a band within the ring. The bowel was drawn out, the strangulated portion excised and the ends sutured. The patient died of shock.

The

Case 3. Woman aged forty-two years. She had been treated by Christian scientists for five days. There was a large umbilical hernia with gangrenous intestine. The sac was filled with fæcal matter. The constriction was found and the bowel drawn out and excised beyond the constriction, and the ends united. The patient recovered perfectly, and has remained well. Case 4. A woman with enormous umbilical hernia, with strangulation and gangrene. fæcal abscess opened by natural processes and the woman has been in perfect health since with the exception of the artificial anus, which will soon be relieved. In the two cases of excision, the time required for the passage of the sutures was twenty minutes, the whole operation did not exceed one hour. The longer the operation the less are the chances. The bone-plates of 1American Surgical Association Trans. Condensed.

Every

Senn and the catgut rings of Abbe may do more in these cases than anything else. case must be decided on its merits. The danger to life of resection in suitable cases is probably not greater than the danger of artificial anus with the dangers attending the subsequent closure of the same. The danger of the latter operation is especially great when the opening is near the stomach. Artificial anus is also objectionable on account of the excoriation of the skin which attends it, and also the risk of giving way of the sutures. It seems to be the general opinion of surgeons everywhere, that under some circumstances excision and sutures are justifiable. The primary operation should only be done where all the conditions are favorable. It is pre-eminently a hospital operation. Every appliance and preparation should be ready for its most perfect performance, It is an operation not to be recommended to the general practitioner, or to the unqualified operator. It depends for success more often upon rapid and skillful execution than almost any other operation.

There is no doubt that in some cases this procedure is imperative where the part necrosed is too high up for intestinal nutrition to be maintained. The difficulty of course is to recognize this state of things. Even when it can be demonstrated that the jejunum is gangrenous, excision is not justifiable unless the patient's condition offers some hope, and there is a chance that the relief of the symptoms of obstruction may be followed by sufficient improvement to make a secondary operation possible.

MAMILLAPLASTY.

BY WM. L. AXFORD, M. D., CHICAGO, ILL.

In the April number of the "Annals of Surgery," I described an operation for the relief of depressed and useless nipples which had been successfully practiced by myself and, so far as I know, was originated by myself at the suggestion of Dr. F. B. Norcom.

For the benefit of readers who have not access to the "Annals," the operation may be briefly described as follows: An assistant with a pair of vulsella forceps seizes the nipple and drags it out to a length somewhat greater than natural, the operator with a pair of curved scissors beginning at a point about one-third of an inch from the apex excises a dime shaped piece of skin extending out at the breast about two and one-half inches, and about one-half to threefourths of an inch broad at its center.

The fat is cleaned away down to the fascia which protects the ducts from injury. Three such areas of denudation are made. Beginning in the denuded area, a cat-gut suture is passed in and out through the fascia, purse string fashion, emerging at the point of entrance and encircling the base of the newly designed nipple. This is now tied snugly, and if properly passed ill hold the nipple out well after the vulsella has been renewed. The denuded areas are now covered (as is the cat-gut suture and its knot) by drawing the skin of the lime shaped incision together with silk. A dressing is now applied

so as to keep the breasts as much at rest as possible when union by first intention is usually found to have occurred.

A more extended experience with this operation has convinced me that treatment must not cease with the withdrawal of the sutures, but that the nipples must be protected by a suitable shield. The reason of this is as follows: The corset usually worn by the American woman will surely press in the new nipple so that it will be inverted through the cicatrical ring formed by the catgut suture, and the result will thus be lost. The catgut suture I am inclined to regard as the keystone of the operation, and if its effect be lost, the operation will be a failure. To obviate this difficulty a pair of shields made from felt with a narrow washer of the same material inside the hole for the nipple has been found most efficacious, and seems to keep all the surgeon has gained, as well as to give symmetry and shape to the nipple. I use the Russian silk, cut it in circles about four inches in diameter, fitted to each breast while softened, and have it worn inside the corsets. The narrow washer inside is of the greatest value.

Applying the principles of the plastic operation as above described, and following it up with the shield, I have succeeded in making a pair of nipples in what was apparently the most hopeless of cases.

EXTRA-UTERINE PREGNANCY-RECTAL DELIVERY'.
BY J. H. TUTTLE, M. D., NEW YORK.

The following case illustrates the difficulties of diagnosis in abdominal gestation. A fortyfive-year-old lady had been in delicate health for many years; her stomach had always been sensitive and liable to attacks of nausea. She had had what she called "falling of the womb," and had at times missed a period. Considering the antecedent history, the suspension of menstruation, followed by a persistent discharge, nausea, and a feeling of heat in the vagina, had not been regarded as specially significant. Extreme constipation and paroxysms of pain, referred to the rectum, which sometimes occurred, had been thought due to what seemed a gravid and retroflexed uterus bearing backward upon the rectum.

The patient had refused to be examined under ether, and had put herself in the hands of an electrician, who, after many applications of various currents had left her with a very weak IN. Y. Academy of Medicine Trans., Condensed.

The

pulse and stomach, and still flowing. At one of
these electrical seances there had been a severe
hæmorrhage, with the discharge of clots.
patient became considerably better for a time,
and the condition was then thought to be fibroid
tumor, or hæmatoma between the uterus and
the rectum. She had insisted on going about
again, although the flow had persisted in spite
of internal medication and external applications.
The tumor in the pelvis had meanwhile grown
steadily, sagged lower and lower in the pelvis
and become softer.

Later on, hæmorrhage had been gradually checked by applications of persulphate iron. Shortly after and quite suddenly, during an effort at stool, a foetus had come away through a rent into the rectum, from which latter it was expelled, dead, but not altered beyond slight maceration. The woman had been put under ether, and an attempt made to remove the pla

EXTRA UTERINE PREGNANCY-RECTAL DELIVERY.

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and the hæmorrhage had been so great, that it became necessary to desist. No operative interference could have been endured at that time The patient slowly sunk, and died in collapse. Impregnation had probably occurred at the left ovary, or in the left tube, the fœtus escaping afterward into the broad ligament, and from there by efforts at stool, breaking through the thinned rectal wall into the rectum itself.

Dr. R. A. Murray reported a case where he had operated, expecting to find extra uterine pregnancy, impelled to surgical interference by the constant pain and loss of flesh from which the patient had suffered. Both ovaries had been found tightly bound down by extensive adhesions, in which both dissected free with great caution, and in spite of much hæmorrhage. A fold of the broad ligament had to be sewed together on itself before hæmorrhage was checked. The patient had recovered.

All her symptoms

had ceased. Her face had no longer the painful expression it had once worn. The symptoms simulating pregnancy which had deceived sev

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eral expert physicians during five months previous to operation had turned out to be due to hæmatocele, pyosalpinx and ovarian abscess on both sides.

Dr. H. C. Coe cited an instance in which a fœtus of about four months had been discharged from the rectum after an attack of localized peritonitis. In this case the woman had been married nineteen years, had not missed a period to her knowledge, and when the sac came away it had been supposed to be a fibroid of the uterus. The foetus had evidently been dead a long time.

Dr. A. F. Currier said electricity in suspected extra uterine gestation might do great harm if some other conditions were present, such as pyosalpinx. Its use was advocated in the first three months of the gestation, when the likelihood of a successful result by laparotomy was greatest, but would be lessened if electricity had been used previously.

Dr. A. P. Dudley remarked that one source of error was due to the fact that adhesions between the intestines in the pelvis often caused nausea and other symptoms like those of pregnancy.

INDURATION OF VENEREAL SORES NO EVIDENCE OF SYPHILIS'.

BY E. C. BURNETT, M. D., ST. LOUIS.

There are sores which present symptoms of Hunterian chancres but are not followed by induration of the lesion. Certain indurated sores of venereal origin are not followed by signs of constitutional syphilis.

In one case a physician presented himself for examination with a typical indurated chancre situated in the sulcus coronarius. At first this lesion was only an excoriation, but it progressively increased in strength and in depth. The patient had done nothing to the sore beyond keeping it clean. The lymphatic glands in the left groin were hard and enlarged. I prescribed simple lotions, with a twenty per cent. solution of salicylic acid. At the end of three months the enlargement of the glands of the groin dis

appeared, but no signs of constitutional syphiis had yet made their appearance. The lesion had been observed sixteen months ago.

Another physician had a suspicious intercourse which was duly followed by a typical lesion presenting the usual characteristics of an infecting chancre. After five months he showed no signs of syphilis, although no specific treatment had been used.

Ringer has attempted to explain the occurence of such induration of non-syphilitic sores by invoking a peculiar arrangement of the blood vessels of the region, or a local artificial irritation of the lesion. I do not believe that induration took place by local irritation when the syphlilitic virus was not present.

RELATION OF THE PROSTATE TO CHRONIC URETHRAL DISCHARGE 2

BY J. WILLIAM WHITE M. D. OF PHILADELPHIA.

Ultzmann long ago described the prostatic urethra as the true neck of the bladder which he would include between two sphincters, the internal at the vesical orifice, the external being the compressor urethra. The latter is much more powerful in its resistance either to fluid injected from without or to the passage of

1Genito-Ur. Surgeons' Trans. Condensed.

urine or other liquids from within. Outward discharges which appear on the meatus are probably due to the existence of inflammation somewhere in the front of the triangular ligament, while those found in the urine are to be referred to inflammation posterior to that point. The compressor urethræ do not form an abso2 Amer. Genito-Ur. Surg. Trans.

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