joint ticket. The Lister Institute of Preventive Medicine and the School of Tropical Medicine will, however, well repay a visit.

There is no city in the world-not even Paris-where there is a greater wealth of clinical material than in London, and there is no medical center in which it is more readily accessible. In October last, about a hundred and fifty French physicians and surgeons were entertained in London by their English colleagues, and although their visit was a very short one, they were delighted with all they saw. The patients are everywhere well cared for, the wards are brightly decorated, and gay with flowers, and the nurses are by no means wanting in good looks. Everything is done to make the patients happy. As my friend, and former teacher, Dr. Lucas-Championnière, of the Hotel-Dieu, said to me after his recent visit to London: "En certains points peut-être y a-t-il une tendence au luxe un peu exagerée," but if so it is a fault on the right side.

[Written for the MEDICAL BRIEF.] The Pain Following the Clamp and Cautery Operation.

BY CHARLES B. KELSEY, M. D., Formerly Professor of Rectal and Abdominal Surgery at the University of Vermont and the New York Post-Graduate Medical School and Hospital. New York City.

In a recent article we find this statement: "It is well-known that for several days after the usual clamp-and-cautery operation, pain and edema contribute greatly to the distress of the patient." This is unquestionably true, and yet it is because of the comparative absence of pain that we have always advocated this operation in preference to others. While I would not seem to imply that my own way of operating is any better than that of other surgeons, it is certainly a fact that my patients generally suffer only slight inconvenience, seldom or never require any anodyne, and usually enjoy their meals within a few hours after the anesthetic. And yet the patients of other men tell me the suffering was unendurable, so intense, in fact, as to make them advise their friends on no account to submit to an operation.

The suffering must, indeed, be a serious element in the case when the same writer advises the following means of preventing it: "Immediately after the clamping and burning have been completed, six or seven radiating incisions through the skin, well into the subcutaneous tissue, are made with scissors."

Here, then, we have an operation which is almost painless in the hands of some, attended by such suffering in the hands of others that a second operation almost as serious as the first is advised to overcome it, and the only possible explanation is to be found in the technique.

I can hardly add anything to the description of the operation as done by myself that will make it any plainer. The technique is hard to convey in words, and should be seen. But the chief difference between operators lies in the way the clamp is used, and I may convey a new idea on this point when I say that I have often done the clamp operation without the clamp at all, but with an ordinary pair of broad-ligament forceps, just strong enough to hold the stump while it is being sealed with the cautery. Again, I have many times put the clamp gently on to a large prolapsing pile, cut it off, and cauterized the stump in my office without even a local anesthetic, and without sufficient after-pain to confine the patient to the house. And I have seen exactly the opposite of this-a strong man get a portion of the rectum into the clamp, and lay out his strength upon it, until no amount of local anesthesia would control the deadly suffering at the time, or the bruised pain for days afterward. It is, in fact, the clamp and not the cautery or the cutting which causes the pain when the operation is done without general anesthesia, and the patient can describe his own sensations; and it is the clamp which causes the bruising and the edema; and no such use of this powerful instrument is necessary. It would be very easy to invent a much less powerful instrument which would answer the purpose equally well, and do less harm, for no more pressure or power is necessary to control bleeding from a pile than from a small artery anywhere else which has been cut, and is seized with artery forceps, and held till tied. This is the only

function of the clamp, except that because we use the cautery a forceps with broad blades is a convenience and protection to adjacent parts.

Another point in technique which can not be too strongly insisted upon is that the clamp and cautery operation is essentially a cutting and dissecting procedure as is the ligature, and not a crushing, squeezing and burning method.

Before the clamp comes into play at all the pile should be freely dissected from the submucous layer with scissors, beginning at the lower part of the tumor and working freely upward until only a pedicle remains in which are the chief vessels. On this pedicle only is the clamp to be used, and to it is the cautery applied. A ligature answers as well, and if my own operations were followed by any such suffering as is described, I should abandon the clamp forever in favor of the ligature, because it is only to avoid pain that I use the cautery in preference to the ligature at this stage. Of course it is plain that performed in this way only the upper end of the incision is cauterized and clamped, and that is all that is necessary. It may be that this is the usual technique with my confreres. I am not in the habit of seeing them operate and I do not know. If it is, I cannot understand the suffering, and I have heard curious stories of seizing large masses of tissue at the margin of the anus with the clamp, cutting them off and cauterizing the stump, without any previous dissection; and I can imagine no method more likely to cause intense after suffering. Another little point is the time and trouble spent in screwing the blades of the clamp tightly home, as though if this were not done there might be fatal hemorrhage. My own clamp became minus the screw attachment several years ago, and it has never been replaced.

To put the thing in a word, my own clamp is used only as a broad headed artery forceps, and is not meant to crush or to squeeze beyond the amount necessary to keep an artery from spouting until it can be sealed by the cautery.

There is but one other point which occurs to me as a source of suffering-the packing of the rectum with gauze, which I am told is often done. In my own prac

tice, no dressing is used except a little cotton over the anus, tied in place by a T bandage. The cutaneous edges of the dissection I make will bleed unless pressure is applied, hence the pad, which will always check any hemorrhage at the margin of the anus. As for bleeding within the rectal pouch, I never see it; because the work with the cautery is thoroughly and carefully done; therefore, I never provide against it; and therefore, there is no wad of gauze inside the rectum to cause suffering by its presence and greater suffering by its removal.

I can only express the hope that these simple statements may do good, as I believe I have had much to do with popularizing this particular method in America. But I only took it up in preference to the ligature because with me it caused less after suffering; and if this is not the case with others, I should certainly advise for them a return to the other method. The clamp operation is no safer, no more radical than the ligature, and when followed by such pain as is described, it is inferior to that procedure. With me it is still the ideal treatment, having but one objection, the necessity for general anesthesia.

After a good deal of experience, when a patient wishes to be cured of his piles at once and forever, with the minimum of pain, and the greatest certainty as to time, suffering, and permanent result, if he submits to my advice, and does not balk at "operation," he goes through the clamp and cautery operation. And this is not because I am not quite conversant with all the other makeshifts, in the way of local anesthesia, and office treatment, many of which are most satisfactory up to just a certain point.

Given a prolapsing pile, nothing is easier than to inject it with water, or cocaine, or eucaine, and tie it off or burn it off, and the result as to that particular pile is perfectly satisfactory.

Given a case of several piles, which do not protrude, with varicose condition of the cutaneous margin of the anus, which will swell up on straining to the size of your thumb, piles which are not isolated, nor, so to speak, pedunculated, and which can not be properly reached and handled without a preliminary dilatation of the

sphincter, and twenty-five years of practice has failed, as yet, to show me any method of treatment as painless, and as satisfactory as the clamp and cautery. 18 East Twenty-Ninth St.

[Written for the MEDICAL BRIEF.] Prostatic Hypertrophy: Its Relief by Perineal Operation.

BY BRANSFORD LEWIS, M. D., President of the Mississippi Valley Medical Association; Professor of Genito-Urinary Surgery, Marion-Sims-Beaumont Medical College; Genito-Urinary Surgeon to Deaconess' Hospital; Consultant in Genito-Urinary Surgery to the Female Hospital, City Hospital, Rebekah Hospital, etc.; Member of the American Medical Association; Member of American Association of Genito-Urinary Surgeons, American Urological Association, etc. St. Louis, Mo.

The general practitioner in a given case of urinary disturbance wants to know whether it is a case of prostatic hypertrophy with obstruction, or of stricture of the urethra with obstruction, or simply inflammation of the bladder without obstruction. These are the three conditions which he wishes to differentiate in cases of elderly patients suffering from urinary troubles.

Fortunately it is not difficult to arrive at a diagnosis in these respects. Where prostatic hypertrophy is suspected the finger is introduced into the rectum, and it is easy to determine whether the prostate is larger than normal or of a normal size and outline. If one finds that it is considerably hypertrophied that does not always denote obstruction. A patient may have a hypertrophied prostate with absolutely no obstruction from it. To determine, then, whether there is obstruction, we have the patient void his urine (all of it that he can) into two glasses. Immeately afterwards he is placed on a table and a soft rubber catheter of good size, say 25 F., is introduced into the bladder and the extent of obstruction is shown in the amount of urine that has been retained. If three ounces of residual urine are drained off by these means, that indicates only a moderate amount of obstruction. If fifteen ounces are retained after a voluntary effort at urination, that indicates an obstruction considerably greater

in degree. If a soft rubber catheter is passed easily through the urethra without meeting any obstruction, that in itself eliminates stricture of a degree sufficient to account for that much residual urine.

The kind and shape of outgrowth from the prostate that is producing this obstruction can only be determined definitely by means of a cystoscope. I have had one constructed for this purpose which gives a retrospective or backward view. It is placed in the bladder and enables one to look toward the prostate, and plainly shows the outlines of the prostatic overgrowths, their location, and whether the projection causing the obstruction is on the right or left side, or is posterior or anterior to the urethral opening; its size and other characteristics are thus determined by the cystoscope before we enter the bladder by incision.

As to the accompanying conditions that are often not only so troublesome, but so dangerous to the individual, we must diagnose involvement of the bladder, inflammation of the kidneys, in relation to infection and inflammation; in other words, surgical Bright's disease, etc., etc. This is determined by a microscopic and chemical examination of the urine. If there is a large amount of albumen present, low specific gravity, and a large quantity of pus, of renal epithelium and casts, it is certain that the kidneys are involved to a serious degree. If there are no albumen present and no casts, a normal specific gravity, and a plentiful quantity of urine, then, even though there may be considerable pus in the urine, serious involvement of the kidneys is not necessarily indicated, as the pus present under such circumstances probably comes from the bladder, due to the inflammation and infection of that organ.

These points necessarily have a bearing on the determination as to whether an operation is advisable or necessary. If there is serious involvement of the kidneys, that causes us to defer an operation, or possibly resort to palliative measures. It is a fact that latterly palliative measures have been used, by which patients are improved sufficiently to bring them within the scope of an operation. I refer to regular catheterization or washings of the bladder, or leaving a soft rubber catheter

within the bladder for several days at a time, temporarily restoring the patient to a condition to meet the depressing effects of a more radical curative operation. We cannot expect to reclaim an old patient permanently from his prostatic condition by any such palliative measures. Possibly we can prevent his growing worse and give him a certain degree of comfort, but palliative measures cannot be relied upon as offering any promise of cure. If patient wishes to be cured he must be operated upon by one of the various methods now in use. Fortunately, modern surgery has so simplified technique and lessened the depressing effects of operation that vastly greater satisfaction is derived from operative measures with much less serious effects than was formerly the case; and benefits are now offered to men above the eighties in age, and to old men in a serious state of depression from prolonged disease effects, and they are carried through to a successful termination and restored to a condition of health that is highly gratifying, not only to them, but to the surgeon. A number of old men Lave expressed themselves after they have recovered from operative measures as being able to urinate as freely, satisfactorily and comfortably as ever before in their lives.

Operative measures resolve themselves into three classes. First choice, perineal prostatectomy; second choice, suprapubic prostatectomy, and third choice, electroincision, the latter including the Bottini operation as practiced by Freudenberg, of Berlin; and perineal electro-cauterizations, as practised by Wishard, of Indianapolis. Castration is not worthy of further investigation or discussion.

Perineal prostatectomy offers by far the best chance of these three for a permanent cure, and is probably the safest operation.

After general anesthesia with the patient in the extreme lithotomy position, a sound is placed in the urethra as a guide, and an inverted V incision is made downward through the skin, and by blunt dissection we reach the urethra, open it by a longitudinal incision of three-quarters of an inch, withdraw the sound from the urethra and pass the index finger through the urethra into the neck of the bladder.

We usually find a marked constriction of the neck of the bladder, in addition to the variously-shaped outgrowths from the prostate; this constriction is removed by the use of a uterine dilator, rendering investigation with the index finger easier and more complete. A Young's tractor is inserted through the opening in the urethra into the bladder, is opened and then drawn on to bring the prostate further down into the perineal wound. This permits of satisfactory exposure of the prostate. The capsule is incised longitudinally on each side of the urethra, the incision being deep enough to get through the capsule, then with periosteal elevator the capsule is freed from the periosteal tissue, first on one side then on the other. In some cases this enucleation process is quite easy, in others extremely difficult, and may have to be replaced by other measures, such as biting or gouging out with forceps. However, the endeavor is made to peel out or enucleate the two lateral lobes, at first by the periosteal elevator, and later by means of the index finger, counter pressure being made all this time by the tractor, which is retained in the bladder. When the lateral lobe, first attacked, is separated on all sides except that next to the urethra, it is severed at this point by means of a scissors, unless it peels out easily. Then the opposite lateral lobe is attacked and removed in a similar manner. Usually there is a third point of obstruction to be removed, the so-called middle lobe, that is depressed into the opened prostatic capsule by means of the left index finger inserted into the bladder, and is peeled out in the same manner. Continuous drainage for the bladder is obtained in the following manner: Two soft rubber catheters, a large one and a small one, are tied together by means of a silk ligature, and inserted into the urethral opening into the bladder; plain antiseptic gauze is packed into the cavities left by the removal of the three portions of the prostate. This packing must be sufficiently tight to prevent any oozing of blood but not tight enough to cause pressure on the rectal wall. This is especially important because a continuous pressure of such gauze packed to an undue degree is likely to cause a slough of the bowel wall

and a recto-urethral fistula, which is very difficult to manage. A pad of gauze and cotton and a T bandage completes the dressing, and the patient is quickly removed to his bed. Continuous drainage is provided by attaching rubber tubing to the smaller catheter, which conducts warm water from a water bag into the bladder, the outflow is through the larger catheter, and this is connected by rubber tubing, emptying into a large bottle. The fluid is allowed to flow in а slow stream for the next twenty-four hours. This is a delightful provision, as it not only prevents the formation of clots in the bladder, which may become a very troublesome affair, but provides against the lodgment or retention of infective materials, either pus or blood, so that under this arrangement there is no elevation of temperature, much less any danger of chill or fever. The patient revives from his operation, and in two or three days will feel better than he has, perhaps, felt for months. He is usually able to sit up in bed after the third day, and may be removed to a rolling chair after a week. The drainage tubes are removed in from four to seven days. The urine then draining for a time through the perineal opening wets the dressings and a transitory stage of discomfort is reached. With the gradual closure of the perineal wound this discomfort is ended, so that in a week or ten days the passage of urine is intermittent, and more or less under the control of the patient.

The next point of importance is the closure of the wound itself, which permits the urine to go out by the normal route, through the urethra. At the same time measures must be taken toward securing regularity and smoothness of the urethral channel in the prostatic neighborhood, especially if a considerable portion of the prostatic urethra has been removed with the obstructing outgrowths. This is secured by the regular use of sounds of good size, every three or four days. If success has been attained by the operation the patient is not only able to hold his urine until convenience permits of evacuation, but he is able to void it, something he may not have been able to do for years. As to whether he does empty his bladder

or not can be easily determined by using a soft rubber catheter after voluntary micturition. A half ounce of residual urine is not objectionable; indeed, such residue may be often found in persons with no urinary trouble. The test of success in operation, therefore, is as to whether the patient empties his bladder with satisfaction, urinates less frequently than formerly say five to eight times in twentyfour hours-and is free from his various symptoms. It may be necessary for him to wash the bladder for some time after such operation. That is easily accomplished and is not a troublesome affair under the new conditions prevailing. consists in simply applying the nozzle of a fountain syringe to the meatus, allowing warm solutions to pass into the bladder, without the necessity of using a catheter or other surgical appliance. This treatment the patient can carry out in his own home.

Century Building.

[Written for the MEDICAL BRIEF.] Lung Development-The Lungs Both Give and Take.

It

BY THOS. BASSETT KEYES, M. D., Of Butternut, Wis., during the summer months; of El Paso, Texas, during the winter months; Professor of Tuberculosis, Jenner Medical College; Chairman of the First Organization Committee American Congress of Tuberculosis, and one of the Vice-Presidents of the International Congress of Tuberculosis, St. Louis, 1904; Editor of "The Tubercle" (a journal on Tuberculosis) from 1897 to 1902; Medical Director Camp Keyes, an Out-of-Door Camp for the Tubercular, in the Piney Woods of Northern Wisconsin (established 1900), etc. Chicago, Ill.

[Warfare-Paper No. 4.]

It is agreed that when the lungs once become actively diseased any exercise which is at all violent, or if carried too far, will result in injury, as it will often produce fever and extension of the discase; on the other hand, if the disease is not active he may do much to develop the capacity of the remaining healthy tissue, and the elasticity of the chest walls and articulations of the ribs.

Healthy lungs are often exercised too much and their vitality injured. At the meeting of the State Medical Society of