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ternal urethrotomy at the time referred to, One of the earliest communications in ref. by far the larger number of strictures were erence to the nature and prevention of urin. almost indiscriminately treated by some form ary fever as a sequence of surgical interfer. of dilatation with bougies, whilst in the min. ence with the urethra was by Dr. Palmer, of ority of these cases the selection of a more Louisville, U, S.A., in 1867. He showed radical operation was largely determined by by a long series of cases that by sterilizing the mecbanical impossibility of proceeding the urine beforehand with boracic acid given to carry out the former treatment.

by the mouth the liability to urinary fever The objections which were then urged after passing catheters and bougies or causagainst a more general'adoption of uretbrot. ing any lesions of the urethra, was greatly omy were chiefly: The frequency with which diminished. this operation was followed by paroxysms of Dr. Palmer's results in reference to the urethral or urinary fever attended with rigors. sterilization or adulteration of the urine Teevan stated in treating of this subject tbat with certain drugs led me to make some ob. two-thirds of the cases thus operated on suf. servations on more direct means of influencfered in this way and in a much larger pro- ing the excretion. portion than where dilatation was alone prac. For some years past I have made a habit ticed; that greater risk was inourred; and in cases of operation on the male uretbra lastly, on the ground that urethrotomy did suoh as internal urethrotomy, or wbere there not prevent a recurrence of the contraction is reason to beliere that the canal has been or dispose of the necessity for the occasional abraded or actually wounded by the passage use of a bougie subsequently as a preventive along of catheters, bougies or sounds, of fill. of relapse. In tbe light of more recent de ing the bladder with a solution of borio acid velopments having a direct reference to the and asking the patient to retain it for some general recognition of antiseptics I will refer time. to these several considerations.

Thus the first urine that is voluntarily

passed after what may have been done operaURETHRAL FEVER.

tively is not only a diluted specimen of the In the pre-antispetic days the rigors and excretion, but is charged with an antiseptio fever wbich not uncommonly followed surgi. solution. It should be remembered that the cal interference with the urethra bowever earlier rigors oocurring after these lesions slight or transieut it might be, were almost are those whioh are sometimes premonitory universally regarded as of a neurotic origin, of the more serious symptoms that may fol. or as due to shock propagated by the sympa. low, such as suppression. In the few fatal thetio nervous system. It has always seemed cuses I have seen of the latter, after interference to me that there was little or no support for with the urethra, the first rigor happened this explanation,

within a few hours. The rigors and fever There is no analogous example connected whioh ooour after an interval of twenty-four with other injuries or lesions of the body. hours or so following the use of an instruThe rigors and fever which follow and mayment. I have not thought of any moment. reasonably be expected after an internal Since adopting this practice generally I urethrotomy are conspicuous by their absence have found the occurrence of urinary fever where in addition to the urethrotomy a peri. much less common than formerly, and when deal cystotomy is provided for efficient drain. it happened correspondingly less important. age.

For this purpose injections of borio acid soluFurtber, some experiments in sterilizing, or tion seemed more potent than those contain. rather adulterating the urine as will presently ing mercuric preparations. be referred to, are directly opposed to the Where a catheter is retained for some days, neurotic hypothesis.

as after internal urethrotomy, and the escape The only evidence of shock propagated by of urine is controlled by a plug or tap at the the sympathetic nervous system I can recall orifice of the instrument, I have succeeded in connection with surgical lesions of the by repeating these injections into the bladder, genito-urinary apparatus is distinotly at var. of averting these intermittent febrile attacks. iance with such a theory. I refer to the shock wbioh in some

THE RESULTS OF INTERNAL URETHROTOMY degree is obvious both to the operating sur.

RELATIVE TO ITS SELECTION. geon and to the anesthetist, who are both in. In dealing with the uretbrotomies it is not terested in the phenomenon, when, for the re. to be presumed that I undervalue the methods moval of a testis, tbe spermatic cord is liga. of treating strictures by various forms of di. tured and divided. Here beart and breath. latation with bougies. On the contrary, there ing often indicate this. I do not think it can be no doubt (except perhaps, with some necessary to pursue this argument further of the traumatic varieties resulting from

ruptures of the urethra) that all strictures of siderably lessened by giving effect to certain an inflammatory origin bave a place or pre prinoiples of treatment having special referliminary stage of various duration. A period once to injury and repair as uniquely obwhen so to speak they may be moulded by served in connection with some lesions of the the band and instrument of the surgeon or urinary apparatus, and which hitherto have educated patient, as the potter moulds olay not received due consideraticn. while it is impressive.

To this aspect of the subjects have devoted When, however, this stage has been allowed considerable attention. In 1900 I prepared, to pass by and the obstruction not only dis. by request, a report for the International torts or alters tbe urine stream, but assumes Medical Congress at Paris on the remote efthe characteristics of an increasingly con- fects of structural lesions (interventions santractile svar, section and the introduction of gulantes) in urethro-stenosis. This entailed wbat I shall again refer to descriptively as a a very full investigation, and many persons splice or interval of new tissue becomes a were examined wbo bad undergone operations necessity.

for stricture at varying intervals previously. All strictures are liable to obange as age The conolusions I arrived at were that the advances and to undergo fibrous degenera- normal calibre of the uretbra might be comtion. In this way even after years of careful pletely and permanently restored, and that attention they may become india.rubber-like the absence of recurrence, as demonstrated by and resist treatment which hitherto had been many cases which were carefully investi. carried on with success. It may then, be gated, was not necessarily dependent on th3 necessary to substitute division for dilata. use of a bougie after operation. In several tion.

cases, such as those I am referring to later In determining the time and stage when this on, recurrence was due not so much to the substitution should take place “the whip" or original stricture, but to a general sclerosis graduated bougies* I described many years wbich the entire length of the urethra had ago, and wbioh are now much used for treat. undergone. ing strictures will be found reliable indicators.

THE term "doctor" was invented in the Some perhaps have never heard of these

twelfth century, about the time of the first fiexible instruments, yet I think most sur establishment of universities. The first per. geons will on trial find them a useful addi.

son upon whom this title was conferred was tio to their armementarium, They are particu.

Irnerius, a professor of law at Bologna Uni. larly serviceable in commencing the treat.

versity. The title was created by Emperor ment of striotures which are difficult to enter. Lobaire II. but was suggested by Irnerius In advising an internal urethrotomy as a

himself. The term extended to the faoulty substitute for dilatation I think the follow

of theology, and was first given by the Uni.

of theolo ing paragraphs taken from the Annual Surgi. versity of Paris to Peter Lomburd, the fam. cal Reports of St. Peter's Hospital, London,

ous theologian. In 1329 the College of Asti indicate the favorable opinions that have been

conferred the first title of doctor of medicine formed of this operaton in recent years:

upon William Gordenio. One hundred and thirty-six cases of urethral stricture were admitted (1903) of which CoSTAL OR RIB-BREATHING.–Costal or 92 were operated upon by internal urethroio rib-breatbing is the most efficient. It enables my with one death from acute suppression the singer and the speaker to take in the thirty-six hours after the operation; and 119 greatest amount of breath, and the effort is cases of stricture were admitted (1904), of not great because it is shared by all those these 90 were operated upon by internal muscles whose function it is to pull the uretbotomy with no deatbs.

ribs upward and outward. If the thorax is This gives a total of 255 cases of stricture unconstricted, the greatest expansion will in two consecutive years, of which 182 were be about its lower and middle portions operated upon in this way with one death, where the ribs are more movable and where whilst cases were treated by dilatation and in the angle of their inclination with the spine other ways."

is most acute. Another reason why this Satisfactory as these figures are it has been type of breathing is tbe most effective in that said, “once striotured, always strictured.” this uplifting of the ribs puts tbe thorax into By this is implied that bowever suocessful the best possible position for the expiratory treatment may be, recurrence is liable to take control that follows during the act of vocal. place.

ization. The diaphragm for artistic purposes In the course of these remarks I shall en is not an inspiratory musole; it should be deavor to show that this liability may be con- used only in the expiratory effort of singing • The Lancet, Feb. 3, 1883.

and speaking.

LEADING ARTICLES ible and so easy to say, "if you cannot find

the exact condition, open the abdomen and DIAGNOSIS OF PYLORIC STENOSIS.

see exactly what the trouble is.” It must

not be forgotten that it is diffioult through EDWIN WALKER, M. D.

the ordinary opening in the abdomen to fully

explore all parts of the stomach and ulcers EVANSVILLE, IND.

and gross lesions are often overlooked. On ACCURATE knowledge of the pathology, di. the other hand, by careful study of the clipi. agnosis and treatment of diseases_of the cal history, supplemented by modern methods stomach is of very recent origin. The last of physical examination, we will be able, in twenty-five years bave contributed more useful most cases, to accurately diagnose the condi. information than all the time preceding. It tion, and in some of them, better than we is true that Kussmaul gave us the stomacb- could by an exploratory incision. tube in 1869, and in 1871 Leube pointed out I would say, in cbronic organio stomach its importance as a means of diagnosis and diseases, in which stenosis of the pylorus exmade some valuable contributions to our ists, or in cases of chronic ulcers, wbich have knowledge of the motility and secretions of resisted rational treatment, and also in cancer the stomach. In the early eighties, Ewald, of the pylorus, wbere the patient is in fairly Boaz and Riegal studied further the secre- good condition, an exploratory jucision is in. tions of the stomach and many other work. dicated. There probably would still be a few ers joined them and gradually a fairly good other obronio organio cases in which it would knowledge of the chemistry of the gastrio be justifiable, but there would not be many. juices was formulated. But so many were This would leave a comparatively small numthe methods and so extensive was the liter- ber of cases which would require an exploraature in this mass of information. It has ory incisio n, and I venture to predict that been so difficult to get distinctly the essential with the increased knowledge of diseases of points and cuntradictory statements have the stomach, the indications for operative inkept the profession from employing methods terference will be greatly curtailed and the which were useful.

number of operations much smaller, but the The surgeon came to our aid about the results, both as to mortality and benefit of same time; before 1880 few operations bad the patient, will be better than at present. been done. During the five years following, some authors speak of operations for ulcers Billroth, Czerny and Peau bad proven that in a way to leave the impression that is in. surgery was worth investigation and from dicated in a very large proportion of cases, that time a large number of operations were while I know of no recent statistics on which done by many operators. The mortality of to base a conclusion; from my own limited the reported cases was bigb, and doubtless observations I think the percentum would be had all been reported, it would bave been below ten. The older statistics of the cure very much higher, but notwithstanding this, of ulcer by dietetic and medical treatment real progress was made, not only in technique are not to be relied upon, more recent results but in pathology, as well. By the united being much more favorable. Operations for efforts of the internist and surgeon, we are cancer are far from satisfactory; resections slowly clearing the way to a better under are almost without exception a total failure, standing of the indications and limitations and conservative operations offer at best only of surgical interference. Still at this time temporary improvement, and few subjects live the conscientious practitioner finds great more than one year. Cancer of the lesser difficulty in discerning the truth, for the vast curvature represents 80 per cent of all cases, amount of literature is confusing, and it and surgery can do nothing for them. At seems to me that indications laid down by the pyloric end, the condition is more farormost surgeons are not altogether reliable or able both as to early diagnosis and operasafe, and are too often vague and unsatisfac- tion, but operations, so far, have done but tory. For example, we are directed to make little permanent good. an exploratory incision in “chronio stomach I wish, therefore, today to direct your at. troubles” which have resisted treatment for tention to pylorio stenosis for this is the consome months or years. Such directions are dition in which an operation may do good. entirely too indefinite for they would include The benign ones furnish our most satisfactory many functional cases. I admit that an ac. cases and of the malignant ones, while far curate diagnosis is not always possible, but from promising, by early work we may be reit is so in a very large proportion of cases, warded by a small measure of success. the failure being rare exceptions. I think, We must first determine that stenosis of too, that exploratory incisions have been the pylorus exists, then the lesson which given too much prowinence; it sounds plaus. causes it.

Let us briefly enumerate the cases. We have broad costal angle, the distance from the umtemporary stenosis from inflammatory swell. bilious to the ensiform is less than the dising in acute gastritis; this is usually easily tance from the middle line to the anterior determined from the symptoms and the transi- auxillary line, seldom suffer with functional tory character and need not concern us at tbis diseases, but are the victims of organio dis. time. A foreign body may become lodged ease. If, therefore, you find the greater our. in the pylorus. The latter will normally al. vature below the umbilicus, and the patient low a silver dollar to pass (Cohnheim). Col. presents the "babitus enteroptoticus," the lections of hair and gall.stones, as well as probability is that gastresctasia does not expolypus of the stomach have also caused ob- ist. In fact, we cannot say a patient has di. struction. An ulcer with thickened walls latation until we demonstrate that stagnation often causes stenosis; in some uf these cases exists. The stomach is like the heart, when a tumor is distinctly palpable. Small ulcers, there is obstruction to the outflow, the mus. by induoing spasm of the pylorus, may also cular wall hypertrophies and furnishes the cause stenosis, likewise a cicatrix of a healed necessary force to empty the organ, and when ulcer. The latter contracts, gradually nar the obstruction becomes so great that the rowing the orifice and often years pass before power of the muscle is insufficient, the organ symptoms indicate the condition. A tumor dilates. The stomach, like the heart, dilates external to the stomach and adhesions may when muscular insufficiency exists. So long, com press, and thus narrow or occlude the then, as the stomach is able to overcome the pylorus. Also, in gastroptosis, acute kink- obstruotion, neither gastrectasia or stagnation ing of the stomach and the duodenum may are found, even if the pylorus is narrowed. also cause stenosis. These are the causes in In these cases if the passage of food through the benign cases, and the malignant ones are, the pylorus is markedly compromised, the with rare exceptions, carcinoma. Ulcer, or quantity of urine decreases, and when the the cicatrix following and caroinoma are the total quantity for twenty-four hours falls becauses in almost all cases.

low 500 co. (one pint), and this is not in. Now, how are we to diagnose stenosis? creased by proper diet, it is an indication This depends on tbe establishment of two that operative interference offers the only conditions, stagnation and gastrecasia. By hope of relief (Cobnheim). stagnation we mean that the stomach does not When we have established the existence of empty itself in seven or eight hours. Much pyloric stenosis we must determine whether bas been written about atony as a cause of the lesion causing it is benign or malignant. stagnation, and I am not prepared to say it This is done in part by the bistory, but more does not do so in rare cases, but I do say that surely by the examination of the secretions. when you find stagnation, in almost all cases, Benign cases are of longer duration, do not you bave a stenosis of the pylorus. If, there. 80 markedly affect the general health, and fore, you find in the stonach in the morning, while great emaciation may exist, there is no food which was taken the evening before, you caobexia. The benign cases also usually give are practically certain that there is an ob. history of ulcer, or some acute inflammatory struction at the pylorus.

disease or of some lesion outside of the stomIf, in addition to this, you find the stom. aob. The malignant cases are attended by aob dilated, the diagnosis of stenosis is com- more rapid emaciation, cachexia, pain, vom. plete. Let me here direct your attention to iting of blood and mucus, and the developa few points too often overlooked. If you ment of tumor. The secretions, bowever, find the greater curvature below the umbili. give us rery reliable information, and while cus, it does not follow that you have dilata. not pathognomonic, is nearly so. tion; it may mean that the normal position if stenosis exists and there is an excess of of the stomach is more nearly vertical. This hydrochloric acid, free and combined, the is true in those who have the "babitus en case is benign; if it is diminished or absent, teroptoticus' first pointed out by Stillen. it is malignant. A carcinomatous ulcer at the This be used to designate those individuals pylorus is an exception to this rule, and I who had an acute costal angle, and the dis. have seen two cases in which the excess of tance from the umbilicus to the ensiform car. hydrochloric acid persisted to the end, but tilage was greater than from the middle line these are comparatively rare exceptions. to the anterior axillary line, and also a float. Still more rare is a benign obstruction develing tentb rib. Such individuals are usually oping in a patient who has chronic acid gas. under-nourished, and are prone to displace- tritis with atrophy of glands, in which the ment of viscera, including stomach, liver, hydrochloric acid is diminished. These es. kidney and uterus, and they, as a rule, suffer ceptions should not divert you from the fact from functional diseases. On the other band, that tbe rule given above is true in probably those who have the normal habitus, viz., a 98 to 99 per cent of all cases.

Let me briefly report a case to illustrate not carcinoma. I did a pylorectomy after the mode of procedure:

tbe method of Kocher. She made a full and The patient in question was a lady,55 years complete recovery, and since that time has of age; she was married and bad two obild. been entirely well. ren; family history was good and her own My object in writing this paper is to bring health had been excellent, excepting at her distinctly to your mind the symptoms wbich fifteenth year she had some trouble with her will enable you to make tbe diagnosis of py. stomach, which was attended with daily pain loric stenosis, and also to differentiate the and occasional vomiting. This continued malignant and benign, and not to enter into about one year, after which she fully recov a discussion of the technique of operation. ered and had no illness of any character until the present trouble. Three years ago she nuticed that she would occasionally become bloated and there was rumbling in the bowels, THE TREATMENT OF CHLOROSIS. and fourteen months ago she began to vomit. The powiting would recur daily, sometimes

GEO. F. BUTLER, M. D. once and occasionally two or three times

CHICAGO, ILL. daily, usually four or five hours after meals, and the quantity ejected was generally large. THERE are four important things to do. About this time she began to use lavage There may be otbers. 1. Eliminate. 2. which was continued for one year, giving her Regulate diet. 3. Rest, in plenty of fresh temporary relief. The vomitus often con air and sunlight. 4. Administer hematics. tained food taken the day before, and the The bowels must be kept open. Constipaquantity sometimes was as much as a gallon. tion with its accompanying autotoxemia preShe bad never vomited blood, and never had disposes to anemia, and if it continues, makes any severe pain; her bowels were generally the condition worse. constipated. Her normal weight was 206 A saline laxative should be given every pounds, and at the time she applied for treat morning. Aloin or some pill containing it ment she weighed just 100 pounds. On phy. is often of great value. A good combination sical examination I note first that she had is: Aloin gr. 1-25, strychnine 'sulphate gr. 1a normal babitus, the abdominal wall was 500, atropine sulpbate gr. 1-2500, oloeresin flaccid and through it, the dilated stomach capsicum gr. 1.500; emetine gr. 1.500, with and the peristaltic wave could be distinctly a trace of bile. From three to six of these seen, the greater curvature was four finger- may be given three times a day. They will breaths below the umbilicus.

tone up the bowels and serve to overcome The contents of the stomach was 120 cbronio constipation. ounces and was removed eight hours after tak. The diet should be light, nutritious and ing food. In this the free aoid was 50, and capable of easy digestion. Milk is an exthe total acidity 120. I then washed out her cellent food, but falls short in that it constomach thoroughly, and that evening had tains too little iron, and large quantities ber eat a few raisins; the next morning gave must be taken to satisfy the patient. Animal her a test breakfast (two oz. of bread with food, soups and broths, are indicated in small four-fifths pint of water) and an hour after, quantities often repeated. Farinaceous food removed the specimen for examination. The alone will not suffice. The blood must be raisins were found and the stomach contents built up by an increase in the formation of yielded a free acidity of 40, total acidity of 90 blood corpusoles. To secure this the diet and the repnin test was 50 per cent above must be fairly riob in nitrogen. normal. At that time she declined any oper. It should be gradually made more stimulatative interference, and I put ber on a stenosis ing, and a little burgundy, port, or maderia diet, that is, a diet in which the articles are wine may be profitably given. soft and fluid; under this diet she gained in Rest in bed in a well-ventilated and well. flesh and strength for a short time, but soon lighted room, or on a couch out of doors, grew worse, lost weight, and finally decided must be insisted upon for a while. It should to submit to an operation :

be remembered that in oblorosis the cardiao In this case you will note that in the first muscle underoes fatty changes, and if the place she had stagnation, for we found the heart-wall is to recover itself and perform its articles from the day before. She bad gas function nornally afterwards it must bave trectasia, which was easily discerned by in. as much rest as possible during the treatment. spection and palpation. We know also there As the patient improves, change of place was insufficiency because of the stagnation and scenery, with out-of-door exercise, wbioh and know, too, from the fact that the total ac- inspire the psychical impulses and give a new idity was above normal, that the disease was direction to the thoughts, are all very useful.

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