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DEEP URETHRAL STRICTURES.
ring New York city management of Ward's loonkeepers ineligible to office, it certainly is Island Asylum was as disgraceful as that of not right that an occupation which is responsiany county board.
ble for so much crime and at least one half of Dr. E. C. Spitzka was the first to introduce all insanity in the community, should be so reform measures in this country, and Dr. J. G. largely represented in offices, and allowed to Kiernan has been his faithful coadjutor.
chase its victims to the grave. The faulty It is evident that the saloon influence in primary election methods too often give voters American politics is debasing in the extreme, only a chance to make a choice between two and responsible for much of the degradation in thieves. Reform in this regard, which is in the our public affairs. While it probably might be power of our Legislarure to grant, will result in asking more than will be granted to make sa- great and lasting good.
DEEP URETHRAL STRICTURES.
BY E. L. KEYES, M. D., NEW YORK. The present paper proposes to discuss only easily passed. Twelve years afterward, no inorganic stricture of the urethra situated at or strument having been used during the interval, beyond the bulbo-membranous junction. No a No. 24 entered without meeting an obstrucone was yet in a position to say that any opera- tion. This was a soft stricture, the variety in tion would radically cure deep urethral stricture, which a radical cure was possible by dilatation. while that of the anterior urethra might be Does electrolysis ever radically cure deep cured.
urethral stricture? I expressed a decidedly Three varieties of stricture are encountered negative opinion on this subject in a paper read clinically in the deep urethra. First the soft before the meeting of this association in Washstricture, which was a very superficial organic ington last year, and my opinion is the same lesion involving only the surface of the mucosa. still. It seems probable that the dilatation It follows gonorrhea, and was generally situ- produced by the electrolytic instruments caused ated at the bulbo-membranous junction, and what improvement there was in the strictures so might even cause complete retention of urine. treated. Such a stricture would often not admit a filiform
Does perineal section ever radically cure deep bougie, yet a blunt-steel sound of ordinary size urethral stricture? The term radical is suited might pass in many cases. The second variety to the operation, as experience showed, since the was the purely fibrous cicatrical stricture of advantage thus gained must be maintained by traumatic origin found in the urethra which had means of the sound. The difference of results not been the seat of gonorrhea. It might obtained in different cases did not wholly lie in involve only the mucous membrane or extend the extent of the cutting done, but depended through all the tissues of the entire thickness of
much upon the quality of the tissues cut. It the perineum.
It might be unaccompanied by was possible, for a purely fibrous stricture might gleet. It cut like true fibrous tissue. This
be radically cured by perineal section, but that stricture was linear or annular but clearly de- an inodular stricture usually was not. Two fined. The third variety was the nodular strict comparatively recent novelties in operative ure, which might supervene after a traumatism methods for deep-seated stricture merit attennotably in strumous subjects, especially where tion.
They are excision of the stricture and there had been much suppuration or multiple transplantation of mucous membrane derived fistulæ. It was often found in cases of stricture from some outside source. Both seem to offer following gonorrhea. This variety was lumpy, more chance of radically curing inodular strictill-defined, irregular, tortuous, never linear. ure than any other means now possessed. Gleet was the rule, ånd fistulæ might be present. Heusner had reported (“Berl. klin. Wochen
The first question which naturally arose was: schr.") an operation in which he dissected out a Does dilatation ever radically cure deep urethral strictured area two centimeters in length, instricture? Cases treated by myself and my cluding a portion of the bulbous and of the former partner, the late Dr. Van Buren, demon- membranous urethra. The divided ends of strate the possibility of cure by dilatation. In the urethra were then found to be three centione case the stricture at first admitted only a meters apart. The anterior end was loosened No. 14 F. instrument, but after a number of from the surrounding tissues, and the severed months of treatment was cured, and a No. 28 ends were drawn together, and held by five TAmer, Asso. Genito-Urinary Surgeons Trans. Condensed. points of catgut suture. A catheter was kept in place for twelve days. No sound was used. It seems to be conclusive ; I. There are On the thirty-fourth day a No. 24 F. catheter three forms of deep organic urethral stricturepassed easily, and a year later the patient re- the soft stricture, the purely cicatricial stricture, ported himself well.
and the nodular stricture. Three cases of impermeable stricture had 2. That soft strictures are often cured by been operated on by Wolfler of Gratz, in which dilatation. he excised the diseased segment, and after eight 3. That the fibrous stricture in patients aldays transplanted strips of mucous membrane ways free from gonorrhæa might sometimes be to the roof and sides of the granulating area. radically cured by longitudinal section of the The strips were cut from some convenient roof and floor of the canal at the seat of the vagina and were several centimeters broad. stricture, followed by the passage of sounds. They were kept in place by a packing of iodo- 4. That nodular strictures op not seem to be form gauze, no sutures being used. The bladder radically curable by this method. was carefully drained during the process of 5. That nodular strictures might possibly be union of the graft with the surrounding tissues, radically cured by total excision of the diseased A small fistula remained in each case when re- tissue and suturing of the ends of the urethra; ported. A year after the operation one of the when approximation of the separated ends was patients could urinate in a large jet; another impossible, transplantation of healthy mucous could admit a No. 20 F. sound.
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 num- was always removed to make suitable flaps, exber of lacerated and contused wounds of the ception being made in the index finger, as there hand and fingers. No attempt will be made at every sixteenth of an inch counts; the bone was classification or at the description of any indi- always cut across and the wound left to granuvidual case, as without the presentation of the late. When possible I always made flaps from patients themselves the cases lose half their in- this palmar surface to retain tactile sensation, terest. A great many cases occured among the but would not sacrifice a portion of bone for laboring classes, and on admission the wounds the object. It is a question when the third phawere filled with dirt or oil and grease, and in langes require amputation at their middle pormany instances domestic hæmostatics, such as tion, whether it would not be better to go higher cobwebs, sawdust and tobacco juice had been and remove the head of the metacarpal bone. used.
I have generally left the phalangeal stump if the After removing all foreign bodies my patient were a laboring man, as it gives more first object was to cleanse the parts of all dirt strength to handle the pick and shovel, but if and grease as thoroughly as possible. The the patient were a lady or a man engaged in wounds were then soaked in warm water, then some light employment, then symmetry was washed with a solution of hot bichloride i to 500, more desirable, and the metacarpal bone was which acts as an excellent styptic; the wounds removed. On the same principle the index and then closed with an antiseptic silk or catgut, a little fingers may be dealt with. few strands of catgut being placed in the bottom In amputating at a joint, it is necessary to of the wound for drainage in small, and a remove the articular cartilage to prevent suprubber tube in larger wounds. In the treat- puration. When tendons of the hand were ment of these cases as to amputation due re- divided they were always stitched, when possigard was had to the patient's social condition. ble. This is not always an easy thing to do, Where the prognosis of a finger was doubtful, as they become retracted on the proximal side. and time was a great object, and the patient In this case the wound was always enlarged in cared little for personal appearance, I had no the longitudinal direction to facilitate the ophesitation in removing the finger. And again, eration. After uniting the tendons all hope of in mechanics a stiff finger is sometimes quite a success depends on union by first intention. hindrance in their work, and I have been After amputation hæmorrhage was controlled by called upon in several instances to resort to torsion, though sometimes a ligature was thrown subsequent removal. Still in doubtful cases in around the vessel. Hæmorrhage from the palmar private practice I would hesitate to remove a arch sometimes gives considerable trouble. In finger where there was a chance of saving it these cases it is sometimes impossible to coneven in an anchylosed condition. Enough bone trol the hæmorrhage by ligature or torsion. SURGICAL TREATMENT OF GANGRENOUS HERNIA.
When this has occurred I have packed the being obtained in nearly all the cases, wound firmly with antiseptic gauze and let it failure occurring chiefly in those cases where remain for some time. A plan often employed, there was considerable laceration of tissue, as but one which I consider cannot be too strongly from the bursting of firearms in the hand. condemned, is the employment of Monsell's Many cases of lacerated wounds were not seen solution in these cases. To be sure it often until suppuration had set in. In such cases, controls the hæmorrhage, but you prevent union after giving free vent to the pus, hot poultices by first intention and run the risk of secondary of flaxseed and charcoal were applied until pus hæmorrhage and suppuration, after which the discharged freely, and the parts began to look tissues become so soft they tear when you at- pale. I think I can safely say I have wittempt to seize the bleeding vessels. When all nessed the loss of several fingers from the too ordinary means fail to check the hæmorrhage persistent use of, when properly applied, so valthere is nothing left but to tie the brachial which uable adjuncts to treatment. After removal of I prefer to ligature of radial and ulnar. The the poultices Balsam Peru on oakum was subdressings, always antiseptic, were left until the stituted. As an anæsthetic cocaine was used, sixth or seventh day. In the redressing we should when only one or two fingers were to be rebe as particular about antiseptics as in the moved, but for the hand or several fingers, ether first instance, as failure to do this often deieats was preferred. No bad effects from the use of our object.
either the general or local anæsthetic were obThe results were excellent, primary union served.
SURGICAL TREATMENT OF GANGRENOUS HERNIA1.
BY M. H, RICHARDSON, M, D., BOSTON. The following cases illustrate the treatment Senn and the catgut rings of Abbe may do which has given the best results.
more in these cases than anything else. Every Case 1. A young woman with right femoral case must be decided on its merits. The danhernia strangulated for a week. Bowel was ger to life of resection in suitable cases is probfound gangrenous, and excised. Death from ably not greater than the danger of artificial shock the next day.
anus with the dangers attending the subsequent Case 2. Woman aet. sixty-five years, left in- closure of the same. The danger of the latter guinal hernia. On opening the sac the bowel operation is especially great when the opening was found strangulated and dark in color. The is near the stomach. Artificial anus is also obhernia was reduced but the symptoms of ob- jectionable on account of the excoriation of the struction continued and five days later the sac skin which attends it, and also the risk of giving was opened, and the intestine found strangulated way of the sutures. It seems to be the genby a band within the ring. The bowel wa eral opinion of surgeons everywhere, that under drawn out, the strangulated portion excised and some circumstances excision and sutures are the ends sutured. The patient died of shock. justifiable. The primary operation should only
Case 3. Woman aged forty-two years. She be done where all the conditions are favorable. had been treated by Christian scientists for five It is pre-eminently a hospital operation. Every days. There was a large umbilical hernia with appliance and preparation should be ready for gangrenous intestine. The sac was filled with its most perfect performance,
It is an operafæcal matter. The constriction was found and tion not to be recommended to the general practhe bowel drawn out and excised beyond the titioner, or to the unqualified operator. It deconstriction, and the ends united. The patient pends for success more often upon rapid and recovered perfectly, and has remained well. skillful execution than almost any other operation.
Case 4. A woman with enormous umbilical There is no doubt that in some cases this hernia, with strangulation and gangrene. The
procedure is imperative where the part necrosed fæcal abscess opened by natural processes and is too high up for intestinal nutrition to be mainthe woman has been in perfect health since with tained. The difficulty of course is to recognize the exception of the artificial anus, which will this state of things. Even when it can be demsoon be relieved. In the two cases of excision, onstrated that the jejunum is gangrenous, exthe time required for the passage of the sutures cision is not justifiable unless the patient's conwas twenty minutes, the whole operation did dition offers some hope, and there is a chance not exceed one hour. The longer the operation that the relief of the symptoms of obstruction the less are the chances. The bone-plates of may be followed by sufficient improvement to 1American Surgical Association Trans. Condensed. make a secondary operation possible.
BY WM. L. AXFORD, M. D., CHICAGO, ILL. In the April number of the “Annals of Sur- so as to keep the breasts as much at rest as gery,” I described an operation for the relief of possible when union by first intention is usually depressed and useless nipples which had been found to have occurred. successfully practiced by myself and, so far as I A more extended experience with this operaknow, was originated by myself at the suggest- tion has convinced me that treatment must not ion of Dr. F. B. Norcom.
cease with the withdrawal of the sutures, but For the benefit of readers who have not that the nipples must be protected by a suitable access to the "Annals,” the operation may be shield. The reason of this is as follows: The briefly described as follows: An assistant with corset usually worn by the American woman a pair of vulsella forceps seizes the nipple and will surely press in the new nipple so that it will drags it out to a length somewhat greater than be inverted through the cicatrical ring formed natural, the operator with a pair of curved scis- by the catgut suture, and the result will thus be sors beginning at a point about one-third of an lost. The catgut suture I am inclined to regard inch from the apex excises a dime shaped piece as the keystone of the operation, and if its effect of skin extending out at the breast about two be lost, the operation will be a failure. Το and one-half inches, and about one-half to three- obviate this difficulty a pair of shields made from fourths of an inch broad at its center.
felt with a narrow washer of the same material The fat is cleaned away down to the fascia inside the hole for the nipple has been found most which protects the ducts from injury. Three efficacious, and seems to keep all the surgeon such areas of denudation are made. Beginning has gained, as well as to give symmetry and in the denuded area, a cat-gut suture is passed shape to the nipple. I use the Russian silk, cut in and out through the fascia, purse string it in circles about four inches in diameter, fitted fashion, emerging at the point of entrance and to each breast while softened, and have it worn encircling the base of the newly designed nipple. inside the corsets. The narrow washer inside This is now tied snugly, and if properly passed is of the greatest value. will hold the nipple out well after the vulsella Applying the principles of the plastic operahas been renewed. The denuded areas are now tion as above described, and following it up covered (as is the cat-gut suture and its knot) with the shield, I have succeeded in making a by drawing the skin of the lime shaped incision pair of nipples in what was apparently the most together with silk. A dressing is now applied hopeless of cases.
EXTRA-UTERINE PREGNANCY-RECTAL DELIVERY'.
BY J. H. TUTTLE, M. D., NEW YORK. The following case illustrates the difficulties pulse and stomach, and still flowing. At one of of diagnosis in abdominal gestation. A forty- these electrical seances there had been a severe five-year-old lady had been in delicate health for hæmorrhage, with the discharge of clots. The many years; her stomach had always been sen- patient became considerably better for a time, sitive and liable to attacks of nausea. She had and the condition was then thought to be fibroid had what she called "falling of the womb," and tumor, or hæmatoma between the uterus and had at times missed a period. Considering the the rectum. She had insisted on going about antecedent history, the suspension of menstru- again, although the flow had persisted in spite ation, followed by a persistent discharge, nausea, of internal medication and external applications. and a feeling of heat in the vagina, had not been The tumor in the pelvis had meanwhile grown regarded as specially significant. Extreme con- steadily, sagged lower and lower in the pelvis stipation and paroxysms of pain, referred to the and become softer. rectum, which sometimes occurred, had been Later on, hæmorrhage had been gradually thought due to what seemed a gravid and retro- checked by applications of persulphate iron. flexed uterus bearing backward upon the rectum. Shortly after and quite suddenly, during an ef
The patient had refused to be examined under fort at stool, a fætus had come away through a ether, and had put herself in the hands of an rent into the rectum, from which latter it was electrician, who, after many applications of va- expelled, dead, but not altered beyond slight rious currents had left her with a very weak maceration. The woman had been put under IN. Y. Academy of Medicine Trans., Condensed.
ether, and an attempt made to remove the plaEXTRA UTERINE PREGNANCY-RECTAL DELIVERY.
centa through the rent. The shock produced eral expert physicians during five months preand the hæmorrhage had been so great, that vious to operation had turned out to be due to it became necessary to desist. No operative in- hæmatocele, pyosalpinx and ovarian abscess on terference could have been endured at that time both sides. The patient slowly sunk, and died in collapse. Dr. H. C. Coe cited an instance in which a Impregnation had probably occurred at the left fætus of about four months had been discharged ovary, or in the left tube, the fætus escaping from the rectum after an attack of localized perafterward into the broad ligament, and from itonitis. In this case the woman had been marthere by efforts at stool, breaking through the ried nineteen years, had not missed a period to thinned rectal wall into the rectum itself.
her knowledge, and when the sac came away Dr. R. A. Murray reported a case where he it had been supposed to be a fibroid of the uterus. had operated, expecting to find extra uterine The fætus had evidently been dead a long time. pregnancy, impelled to surgical interference by Dr. A. F. Currier said electricity in suspected the constant pain and loss of flesh from which extra uterine gestation might do great harm if the patient had suffered. Both ovaries had been some other conditions were present, such as pyfound tightly bound down by extensive adhe- osalpinx. Its use was advocated in the first sions, in which both dissected free with great three months of the gestation, when the likelicaution, and in spite of much hæmorrhage. A hood of a successful result by laparotomy was fold of the broad ligament had to be sewed to- greatest, but would be lessened if electricity had gether on itself before hæmorrhage was checked. been used previously. The patient had recovered. All her symptoms Dr. A. P. Dudley remarked that one source of had ceased. Her face had no longer the painful error was due to the fact that adhesions between expression it had once worn. The symptoms the intestines in the pelvis often caused nausea simulating pregnancy which had deceived sev- 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 appeared, but no signs of constitutional syphiHunterian chancres but are not followed by in- is had yet made their appearance.
The lesion duration of the lesion. Certain indurated sores had been observed sixteen months ago. of venereal origin are not followed by signs of Another physician had a suspicious interconstitutional syphilis.
course which was duly followed by a typical leIn one case a physician presented himself for sion presenting the usual characteristics of an examination with a typical indurated chancre infecting chancre. After five months he showed situated in the sulcus coronarius. At first this no signs of syphilis, although no specific treatlesion was only an excoriation, but it progres- ment had been used. sively increased in strength and in depth. The Ringer has attempted to explain the occurpatient had done nothing to the sore beyond ence of such induration of non-syphilitic sores keeping it clean. The lymphatic glands in the by invoking a peculiar arrangement of the blood left groin were hard and enlarged. I prescribed vessels of the region, or a local artificial irritasimple lotions, with a twenty per cent. solution tion of the lesion. I do not believe that induraof salicylic acid. At the end of three months tion took place by local irritation when the syphthe enlargement of the glands of the groin dis- lilitic 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 urine or other liquids from within. Outward urethra as the true neck of the bladder which discharges which appear on the meatus are he would include between two sphincters, the probably due to the existence of inflammation internal at the vesical orifice, the external being somewhere in the front of the triangular ligathe compressor urethra. The latter is much ment, while those found in the urine are to be more powerful in its resistance either to fluid referred to inflammation posterior to that point. injected from without or to the passage of The compressor urethræ do not form an absoGenito-Ur. Surgeons' Trans Condensed.
2Amer. Genito-Ur. Surg. Trans.