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Vol. XXX


No. 6

Papers for the original department must be contributed ex- forming the contraction, otherwise the operclusively to this magazine, and should be in hand at least one month in advance. French and German articles will be trans

ation will be of little permanent advantage. lated free of charge, if accepted.

A liberal number of extra copies will be furnished authors, and Operation. The uretbrotome I have used reprints may be obtained at cost, if request accompanies the proof.

for many years is that known as MaisonEngravings from photographs or pen drawings will be furnished when necessary to elucidate the text. Rejected manu. neuve's. Some improvements in the instruscript will be returned if stamps are enclosed for this purpose.

ment have recently been made by Mr. ThompCOLLABORATORS.

son Walker.

It is adapted to the narrowest ALBERT ABRAMS, M. D., San Francisco.

and most intricate forms of contraction, and M. V. BALL, M. D., Warren, Pa. FRANK BILLINGS, M. D., Chicago, Ill.

as a rule requires no preliminary dilatation CHARLES W. BURR, M. D., Philadelphia. C. G. CHADDOCK, M. D., St. Louis, Mo.

by other instruments.
S. SOLIS COHEN, M. D. Philadelphia, Pa.

Further, it can be made to complete its ob-
N. S. DAVIS, M. D., Chicago.

ject by a single linear incision of sufficient
ARTHUR R EDWARDS, M. D., Chicago, Iu.
FRANK R. FRY, M. D., St. Louis.

depth to provide by careful after-treatment,
Mr. REGINALD HARRISON, London, England. as will be described, for the introduction of
RICHARD T. HEWLETT, M. D., London, England.
J. N. HALL, M. D., Denver.

an ample splice of new tissue for the perma-
HOBART A. HARE, M. D., Philadelphia.
CHARLES JEWETT, M. D., Brooklyn.

nent enlargement of the contracted portion of THOMAS LINN, M. D., Nice, France.

the urethra. Multiple internal incisions are FRANKLIN H. MARTIN, M. D., Chicago, E. E. MONTGOMERY, M. D., Philadelphia.

to he avoided as tending to increase the NICHOLAS SENN, M. D., Chicago. FERD C. VALENTINE, M. D., New York.

amount of cicatrix.
EDWIN WALKER, M. D., Evansville, Ind.

After many years' trial, I have not found
H. M. WHELPLEY, M. D., St. Louis.

Maisonneuve's operation open to objections
WM. H. WILDER, M. D., Chicago, Ill.

that have been raised against it.

These are

that it may divide tissues unnecessarily or on CLINICAL LECTURE.

the other hand, insufficiently. Though I have been in the habit of using the larger

blade which cuts up to No. 23 Charriere (No. INTERNAL AND EXTERNAL URETHROT

14 English) I am not aware of there being OMIES. *

any evidence of this having been excessive.

On the other hand, when by the use of test REGINALD HARRISON, F.R.C.S.

bougies im wediately after the section has

been made, and before the patient leaves the Consulting Surgeon to St. Peter's Hospital.

room, there are indications that the stricture

has not been sufficiently freed, a supplementINTERNAL URETHROTOMY.

ary division of any remaining fibres or bands It is a good plan for patients about to

may be readily made by the use of Civiale's undergo this operation or any other involving urethrotome, which will now enter easily.

If at the time of operation, the surgeon a possible wound of the urethra to have their urine sterilized or adulterated with

finds it impossible in one or both of these

some preparation of borio acid, as mentioned prev

ways to quite free the stricture, he should not iously. The magnesian boracite (vide Mar

hesitate to perform in addition an external tindale's extra Pharmacopeia) will be found

urethrotomy on the lines which will be de. preferable for this purpose to pure borio acid

scribed in cases where the combined operawhich often causes indigestion. The former

tion is premeditated. This further proceedmay be given in teaspoonful doses in plenty ing in no way adds to the risk, whilst it of water three times a day, for three or four

greatly favors the prospect of success. days preceding the operation.

The technique of Maisonneuve's urethrotIn selecting this operation, the surgeon

omy commences with the introduction of the should satisfy himself beforehand as far as

fine filiform guide. To save time, this may it is possible to do, by the examination of previously be passed in the ward, but where the stricture and the perineum, that the

there is difficulty or bitching this maneuvre U retbrotome may be made to cover the full

be greatly facilitated by including it whilst extent, in depth and length, of the tissue

the patient is under the anesthetio.

When the position of the guide is verified *This is No. 2 of a series of lectures on this subject, deliv. by the ease with which it moves it is secured ered at the London Post-Graduate College. The Urethrotomies, appeared in the issue of September 10. on the metal director, and then the latter is

(3) TheCombination of External and Internal Urethrotomy.

made to follow its leader into the bladder;


No. 1, on

To follow:





this is usually indicated by the escape of a rotomy has for its object the conversion of little urine along the groove.

the cleft made by the liner incision along If the stricture is extremely tight and the strictured roof of the urethra into an in. there has been some hesitation in following tegral portion of the canal so as to add to its up the guide to the bladder, the deposition permanent dimensions. This is shown in of the director or metal portion should be these sections of the urethra, sketched at tested by introducing the finger into the rec- different periods. tum. By this ineans the relationship of the instrument to the canal can be readily ascertained or adjusted.

If this prove correct, the uretbotome blade should be placed in the groove of the director and gently and but firmly pushed along until the stricture is divided. Care should be taken to hold the director in correspondence In this way it bas been been demonstrated with the median line of the body, as taken that endoscopically it is possible pot merely from the umbilicus downwards.

to stretch a stricture, or to suddenly enlarge The operator should not do more than di. it by cutting it across, but to introduce a vide the stricture, avoiding touching the in. splice or interval of new tissue correspondternal sphincter of the bladder, which though ing with the area of the cleft. never strictured is usually temporarily con- With this object in view and after the tracted around the instrument. Therefore stricture has been divided in the manner de. when the stricture is felt to be divided the scribed and the completeness of the division surgeon should stop short of pushing the fully tested provision should be made for the knife to other end of the groove or staff. retention of a catheter for some days. Un.

In Mr. Walker's modification of this less this is done there is no guarantee that uretbrotome the groove stops at the curve the incision may not close, either partially in the director, so that any risk of wound- or in whole. The occasional introduction of ing the neck of the bladder or prostate is a bougie as a substitute for the retained avoided. I have rarely seen much hemor. catheter is no safeguard against this liabil. rhage when this precaution is taken. On ity, and the intermittent use of this instruthe other hand, considerable bleeding may ment is in itself a cause of irritation, which follow the unnecessary lesion of the prostatio a properly adjusted retained catheter should ring.

be free from. The completeness of the operation should Ererything depends upon the manner in then be tested by the successive introduction which a catheter is tied in. If it is done well of bougies. For this purpose Lister's metal it proves a comfort to the patient in voiding bulbous instruments may be used, begin- urine, if on the other hand, it is not artisti. ning for instance, with No. 12 (English) and cally planned it is the reverse. A little trou. gradually running up to No. 15. A catheter ble on the part of the surgeon makes all the should then be passed-metal for preference difference. --and the parts well sluiced with boric solu. The catheter should be made of the finest tion with which the bladder is finally filled. silk be coated with the best varnish suited And now commences that part of the treat

for this purpose.

After many trials I have ment which is as important as the complete found the French make of catheters for this division of the stricture. As I can find little purpose, as a rule, better than the English. or no reference in text-books to the object I have frequently retained the former for ten now aimed at it will be necessary to describe days without removing them. Others' in it in detail. It relates to the permanent en- similar cases, I have had to withdraw in largement of the strictured portion or por. forty-eight hours, and found them corroded tions of the urethra.

and commencing to be covered with phosBy the incision which has been made the phates. This should not happen with good urethra is at once enlarged at its strictured tying-in catheters. portion, so as to permit a bougie not less A retained catheter must be as correctly iban the normal size of the urethra being adjusted as a tracheotomy tube. Its length readily passed into the bladder. Otis dem- within the bladder should be carefully de. onstrated that the normal size of the urethra termined by means of a syringe before it is was considerable larger that tbat usually ac- fixed. It should not project too much within cepted. On this discovery modern litho. the bladder, or it will excite irritation; on trity, as invented by Bigelow and universally the other hand it should be sufficiently practised, is used.

within the bladder so as not to occasion The after-treatment of an internal ureth. retention.

I seldom tie in a catheter larger than No. is undilatable and outside the reach of in9 or 10 English. These sizes are more com

ternal urethrotomy. fortable to the patient than bigher numbers. These cases may be subdivided into two: Their object is to keep apart the sides of the (1) When the patient is able to void urine incision through the stricture until some de. with difficulty and pain and with a liability gree of healing has been obtained. This usu- to attacks of sudden retention, and where ally occupies from three to ten days when the the urethra is instrumentally impassable; catheter may be dispensed with. The section and (2) when the conditions are similar, with of the stricture relative to the retained cathe. this difference, that the strictured canal is ter is bere shown. The catheter will be seen open to some small instruments. maintaining the cleavage.

This two-class division is obviously an arbitrary one, dependent for the most part on varying degrees of contractility, spasm, the presence of false routes or passages, and also the individual skill of the operator.

Impassable strictures (not occasioned by

prostatic bypertrophy) must be regarded from The mode of fastening the catheter in when two points of view: First, in respect to temits length for drainage purposes has been ac- porary measures which may be necessary for curately determined by trials with a syringe relieving urgent retention of urine; and is by securing it with stout silk to the penis secondly, relative to the radioal treatment of by one or two circles of rubber plaster.

the stricture. The escape of urine should be controlled It must be remembered that no stricture by a movable plug of ivory or hard wood re- can be striotly regarded as impassabla

"'' movable when necessary by the patient or

wbich admits or has recently admitted prior his attendant. It is of great importance in to a complete retention of urine the passage all these cases to obtain a nurse who has of urine naturally, even in drops or in a fine been well trained in surgery of this kind. stream. These persons are by no means too abun. This knowledge should serve as an incentdant.

ive to endeavoring patiently and with gentleAs long as the catheter is retained it ness to reach the bladder by the natural should be washed out together with the blad. though contracted channel, and later on to der at least twice a day with warm borio solu- attempt if necessary, the restoration of the tion, and care should be taken to have a suit. latter by a more radical proceeding. able bed and mattress for bladder drainage The great improverpent that has taken purposes. A patient who lies in a hole will place in the means for relieving retention of not drain well.

urine by catheterism during recent years bas After the retained catheter is finally with largely reduced the number of so-called im.

. drawn, a point which is usually determined passable strictures. In fact it may be said by the feeling of freedom with which the in- that no stricture can be regarded as imperstrument may be moved relative to the meable, unless the patient is or has been for urethra, the use of a bougie is not resorted to some time provided with a urinary fistula. for some days, when a trial examination way In practice, however, this refinement in referbe made with a soft instrument. In a con- ence to the term 'impassable'' cannot always siderable proportion of

thus dealt be acted on. A sudden retention of urine with it will be found that no further instru- occurs, the bladder becomes painfully dis. mental treatment is necessary.

tended, and by no ordinary methods can the A precaution and until proof of the cure is practitioner give relief artificially in the diwell established, the occasional use of a rection of the natural passage. bougie is recommended. All patients who Urgenoy of this kind is best temporarily bave once had stricture should be instructed relieved not by forcible catheterism, but by how to use

a bougie. The failures to cure tapping the bladder with an aspirator or fine strictrue are for the most part traceable to trocar, preferably in the form of pneumatic the want of such treatment as I have de- aspiration, immediately above the pubes scribed after the division of the stricture bas where it is uncovered by peritoneum.

This been made.

is a rapid and painless process, and may be

repeated almost indefinitely-thus the paEXTERNAL URETHROTOMY.

tient is immediately relieved, time is proThis operation is applicable to exception. vided for reflection as to what is best to be ally contractile strictures and to others where done of a more radical nature, and no further the urethra, perineum, and even the scrotum, damage is inflicted on the already disordered may be included in a cicatricial mass which urethra.



Instances are not infrequently met with

LEADING ARTICLES where the removal of tension in this way en. abled the bladder to regain its power over the

OUR DUTY TO PROSPECTIVE MEDICAL stricture, and dilatation with some form of

STUDENTS. instrument was again resorted to with satis. . factory results.

A. L. BENEDICT, M. D. Should, however, this not prove so, and the urethra continues to be fitful, and at times impermeable both to urine and cathe. The complaint is sometimes made that the ters or bougies, the operation known as medical profession is being crowded beyond “Wheelhouses' for impassable stricture may the limit of tolerance, by recent graduates, be advised. This proceeding is so well ap- sought by the colleges for mercenary reasons, preciated, and is to be found in all text-books and to the disadvantage of the existing medi. that I need not refer to it at lengtb.

cal body. Whatever trutb there may hare I have not bad much experience with it, as been in this complaint, in the past, the presbeing brought up somewhat skeptical about ent is no time for reorimination. Never be impassable strictures, unassociated with one fore bas the medical profession been so well or more urinary fistula, I have generally suc- organized nor possessed of so great influence. ceeded in overcoming difficulties by patience, For approximately fifteen years, it bas been oil and filiform guides and so dealt with the impossible for anyone, not reasonably well stricture on the lines advocated in the pre- qualified according to both general educa- . vious article. Wheelbouse's operation, which tional and technical standards, to graduate is that of choice in impassable strictures, may in medicine, excepting by gross evasion of be stated as consisting in opening the normal the law or by seeking states and colleges noof the urethra on a special staff, half an inch toriously behind the times in their require. in front of the stricture in searching by sight ments. During these fifteen years, approxi. and probe-director for its contracted orifice, mately a quarter of the medical profession, as and having found it, dividing the stricture it existed at the beginning of the period, of the director thus used, and so restoring bave passed away and, without malice, it the canal to its norioal dimensions.

may be said that many of the funerals were The stricture having thus been divided a

urgently needed. In many ways conditions drainage tube is introduced and the case have been modified so as to tend to restore treated on the lines described in the prev. the influence of the practitioner of medicine, ious article.

to restrict the teaching of medicine to a Wheelbouse's operation, having for its ob. class of teachers, and to render this class ject the relief of retention where a stricture independent of the fees of students, but, on is im passable, may be made to answer the the contrary, dependent for their tenure of purposes of a perineal section, as described prestige, if not actually of their positions, and applied in the next section to the com. upon the quality of the students graduated. bination of the two urethrotomies.

These tendencies have not reached the point External urethrotomy, or perineal section of actual fulfilment of ideals and, still, they without a guide in the form of a grooved are genuine and they have already reached metal staff passed fairly along the contracted a point at which optimism is warranted. urethra into the bladder upon which the di- Speaking approximately by statistics, the vision of the stricture can be safely accom- United States now bas a few less than 180 plished, is an obsolete operation, which is medical schools, with an average attendance not to be advised.

of 150 students. In the aggregate, these For instrumentality impassable strictures schools graduate about 5,000 annually, re. it bas given place to Wheelhouse's method, ceiving, each year, about 7,000 new matricu. whilst strictures which are passable, though lants, of whom 2,000 are estimated to be for definite reasons requiring external sec. weeded out by one process or another, before tion, are best treated by the combined oper- the completion of the course. Very few of ation which will next be described.

the 7,000 fail to come under the influence, at one time or another, of some of the bundred thousand and more practitioners of medi.

cine. Thus, the onus of the complaint can DR. ALBERT H. DOLLEAR, some time as

and should be referred back to its source. sistant to Dr. F. P. Norbury at Maplewood First of all, each one of the army of more Sanatorium, Jacksonville, Iů., has been ap- than a hundred thousand medical men, pointed assistant physician to the Western should realize his personal influence and reIllinois Hospital for the Insane at Water- sponsibility in the matter. Not only in an town.

aggregate, economic sense, but in an individ


ual, professional sense, does the status of the manded of the physician. Some one has well profession depend upon the thorougbness said that the physician must practice with with which each physician does his duty in bis heart as well as his head, and many men, controlling medical matriculations.

well enough adapted to a useful and honest Secondly, while the economic problem of business life, are not capable of the self-sacdemand and supply ought to be considered by rifice, attention to details and disregard of every trade and profession, this problem personal convenience, which are part of the should not be studied in the narrow way of physician's duty. financial competition. There are undoubtedly Physical vigor is a desideratum for the too many physicians in the country-at least physician, and yet, in this age of the world, half of the existing body could be removed many men of delicate health manage not only without overtaxing the strength of the other to do useful work in medicine, but to acquire half to care for the health of the country. At a state of health not anticipated in their least a thousand of the five thousand annually youth. More important is mental health and added to the profession, represent a surplus strength, for, incidental to the practice of beyond the vacancies created by death in the medicine are many emergencies and experi. profession and by additions to the population. ences which call for ingenuity and clear

Still, conditions are by no means so acute headedness and which work disastrously upon as to justify or even to excuse the attempt, A neurotic taint. The time is past when the arbitrarily to exclude worthy aspirants from fool of the family should be selected to study pursuing a medical course.

medicine and the strain and actual exposure It is proper, however, to set before each of medical studies demand at least a reasonprospective medical student, a candid presen- able degree of physical and mental stamina, tation of the facts governing the financial and and the absence of positive disease and morbusiness status of the medical profession. A bid tendencies. considerable proportion of the young men It is, at once, the right and the duty of who contemplate medical practice have no every physician to demand that the young special predilection for the work. They are man to whom he stands in the place of a seeking a dignified, not tco laborious, and preceptor-however much the old legal status well paid occupation. Without being either of the preceptorship, has been modified lazy, actuated by false pride, or mercenary shall somewhat exceed the striot legal reqirethey select medicine as a life work, largely on ments of the matriculant. The time is not business principles such as govern purchase ripe to require more than a high school eduand investment of any kind. If the real facts cation preliminary to admission to the mediwere presented to them, without prejudice, cal school. Yet, the individual preceptor they would, in a large number of individual may and should insist that any student for cases, choose some other profession or busi- whom he is morally responsible should give ness, and in so doing, a substantial benefit an overflowing measure. It may not be wise would accrue both to themselves, to our own for any physician to say to every student, profession and to the community generally. that he must take a full college course, but

In other cases, special reasons yeuder it ad. it is feasible to point out to bim the broadenvisable that a given youth should be directed ing influence of at least a year of scientific into other channels of activity. It often hap- and literary study in advance of the legal pens that medicine is chosen because certain requirements. Too often, the preceptor asscientific studies, in which the high school or sumes the narrow view that his student ought college student is especially interested, bear not to know more than he himself does. But upon the practice of medicine. In many such advance is the spirit of the age and the wise cases, the abilities of the individual are of father, preceptor or advisor, realizes tbat such a rank that he could do better work more is expected of the present than of past and attain a better standing by confining generations. Medicine, in particular, has hinself to the particular science in question developed in very recent years so largely

. In other cases, aside from a reasonable als along scientific lines, that further progress, or lowance for the carelessness of youth, the even the proper use of what we have already boy who would like to study medicine is so gained in principles, demands a broader and heedless and so utterly unable to do things in longer course of preliminary training tban the right way that it is a mercy both to him- could have been considered necessary even self and to others, to direct him toward lines ten years ago.

Moreover, attainment is of activity in which mistakes may involve purely relative and the conditions at present only slight commercial loss and not danger to are such that a college education demands no human life.

greater sacrifice and places a man in no Again, with due allowance for immaturity, higher grade than an academic education a some boys lack the moral nature which is de- generation ago.

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