The

also the so-called expectant plan of treatment. Not less reprehensible, he states, are the remedies in vogue at present, prominently among these, figure the "alkaline diuretics. The author claimes that alkalies when absorbed are completely destroyed as far as the acid radicle is concerned, being converted into normal chlorids or salines and not carbonates, and he states that they exert beneficial effect on the inflamed urethra, not as alkalies, but as diluents and diuretics. The therapeutics value of boric acid and salol is also doubtful; balsamics are condemned, presumable benefit from these remedies being due to the water taken in them. In the acute stage the patient should take plenty of water, avoiding alcohol, tea and coffee, and condiments as well as soups and nitrogenous foods. anterior urethra is flushed with a normal saline solution by means of the Valentine douche or similarly devised apparatus, with a good valve attachment to regulate the flow. The apparatus should not be elevate higher than six feet. The urethra having been cleansed, 20 minims of a solution adrenalin (1:1,000) is instilled through an ordinary bulb eye dropper into the canal, retained five minutes and allowed to escape. The saline irrigations are continued once or twice daily for ten days, after which potassium permanganate is substituted in ascending strength, 1:10,000 to 1:1,000 at the end of the third week. By this time the discharge will have ceased, or nearly so, and a prescription of zinc sulphate, adrenalin and colorless fluid extract of hydrastis in distilled water may be used, which, in a short time, will check it completely. Three weeks suffice in the majority of instances to effect a cure. The treatment of the chronic form of urethritis is more difficult, tedious and complicated than that of the acute variety. The author recommends as an injection a solution of protargol (5 per cent) together with adrenalin chlorid and Magendie's solution of morphine if necessary.

In some cases silver nitrate acts more favorably than other silver compounds. Irrigations with potassium permanganate or zinc sulphate may be useful. The introduction of sounds is indicated: first, in incipient and formative stages of stricture; second, in involvement of the posterior urethra without implication of its adnexa; third, as a powerful stimulant to the urethra in catarrhal treatment affecting its anterior segment, where no gonococci demonstrable. The author recommends urethroscopy for table practice as a means of diangosis and as a therapeutic auxiliary. The value of internal treatment in chronic gonococcic urethritis is questionable. The proper treatment in all cases depends on determina

are

tion of the seat of the lesion. The three-glass test of the urine should be used, and sound introduced to detect strictures and diverticula. cula. Rectal examination is imperative in nearly all cases, and search must be instituted for possible diseased conditions of Cowper's glands as this is apt to cause an obstinate urethrorrhea. Folliculitis of the urethral mucosa may produce a mucopurulent discharge. Meatotomy and circumcision should be performed in proper cases. Affections of the bladder, ureters and pelvis of the kidneys or of the kidney itself must attract attention as possible causes in all ultrachronic cases. Cystoscopy and, if necessary, ureteral catheterization should be performed before definitely arriving at a diagnosis. In conclusion the author remonstrates against unscientific methods of treatment and the failure to recognize the gravity of gonococcic urethritis. The treatment undertaken by the physician must be in conformity with the most modern principles governing it.

Some Observations on Prostatectomy.-L. Bolton Bangs (Med. Record) considers the following factors in deciding whether or not to advise prostatectomy; the general condition of the patient, his social condition and environment, his temperament and his accessiblity to judicious medical advice and assistance; whether or not catheter life is likely to fail, and, if it has failed, in what degree; and, finally, what measure of relief is to be gained if, after the operation, some imperfection should remain which is insignificant in comparison with the prior condition. The writer then gives the histories of a number of patients which show how often significant symptoms are appreciated or overlookled. He speaks of certain cases in which small prostates have been removed when there were few or no signs of obstruction. In these cases it was not recognized that chronic interstitial cystitis had reduced the capacity of the bladder so that frequent urination had become a necessity. Each case must be studied by itself. The final outcome of the operation cannot be foretold definitely, but when the indications are clear it can be wisely advised on account of the great relief and comfort which result.

IN protracted cases of summer complaint give freshly pressed grape and other juices to prevent scurvy.

FOR toothache nothing is better than oil of cloves and tincture opium, equal parts, applied to the aching tooth on a pledget of cotton, says Dr. J. L. Fennel.

THE MEDICAL FORTNIGHTLY

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MEDICAL MISCELLANY

LEPROSY HOSPITAL IN THE HAWAIIAN ISLANDS. Dr. Walter R. Brinckerhoff, of the Harvard Medical School, has received the appointment as director of the United States Government Leprosy Research Leprosy Research Hospital which is established on Molokai, the island on which the lepers are now segregated. Dr. Brinckerhoff lately sailed and is now in charge at Molokai.

SUIT FOR CERTIFYING TO GONORRHEA. The annual report of the London and Counties Protection Association contains, as usual, an account of various actions taken or threatened against physicians, which as a rule the association was successful in defending. One case, which was unsuccessfully defended, is of particular interest. A physician wrote on a certificate the fact that a member of a sick club was suffering from gonorrhea and gave this certificate to the secretary of the club. The member brought an action for libel and slander. The physician pleaded that the communication was privileged, but the jury decided against him and awarded $750 damages to the plaintiff. The case shows that a physician should never give his opinion of the nature of an ailment to any one but the patient without the latter's consent in writing or in such form as to be capable of legal proof. The solicitors of the association state, in commenting on the case, that when a physician, in the course of his duties has to fill up a club certificate, and the ailment is on

the disclosure of which would constitute a libel, he ought to give the certificate to the patient (not to a third party, as in this case). Then any responsibility for disclosure to others would not rest entirely with the patient.-J. A. M. A.

PHARMACOPEIAL OR PROPRIETARY PREPARATIONS: WHICH? Dr. J. Ritter, Chicago (Jour. A. M. A., Sept. 1), discusses the task confronting the medical profession of providing an effective method of checking the practice now in vogue with many of its members of prescribing and recommending various proprietary preparations, many of which are fraudulent. It is difficult, he states, to draw hard and fast lines regarding what constitutes an ethical preparation in contradistinction to the so-called nostrums. He declares that it is not good practice to condemn in toto, as undoubtedly even some nostrums possess therapeutic properties, since in their composition well-known drugs are used. Ritter states that it would be a good plan for physicians and druggists alike to look into the composition and combination of all new chemical and synthetic and Galenical preparations, not excluding the "patented" nostrums which from time to time are offered to physicians as therapeutic agents. He refers to the claims made for the various cod-liver oil preparations on the market and states that by the addition of expectorants, anodynes and corrigents a pleasant-tasting elixir, cordial or tonic is made which does not contain a trace of cod-liver oil. He advises physicians to devote about half an hour daily to study. ing the Pharmacopeia, a good dispensatory, or the National Formulary, in order to acquaint themselves with good, reliable and accurate formulae and remedies.

CAUTION.-The season is approaching when sudden changes may endanger the health of your delicate patients, especially those suffering from bronchial and pulmonary troubles. In addition to giving good advice as to proper clothing and the importance of keeping the feet dry and warm, prescribe McArthur's syrup of hypophophites for the convalescent, and thus forestall any tendency towards tuberculosis, and promote a prompt return to health.

MR. GARDNER: "Well, dear, how are the tomatoes you planted?"

Mrs. Gardner: "Oh, John! I'm afraid we'll have to buy what we need this year.

Mr. Gardner: "Why, how's that, Mary?" Mrs Gardner: "I recollected today that when I did the planting I forgot to open the

cans!"

Vol. XXX

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COLLABORATORS.

ALBERT ABRAMS, M. D., San Francisco.
M. V. BALL, M. D., Warren, Pa.
FRANK BILLINGS, M. D., Chicago, Ill.
CHARLES W. BURR, M. D., Philadelphia.
C. G. CHADDOCK, M. D., St. Louis, Mo.
S. SOLIS COHEN, M. D., Philadelphia, Pa.
ARCHIBALD CHURCH, M. D., Chicago.
N. S. DAVIS, M. D., Chicago.

ARTHUR R EDWARDS, M. D., Chicago, Ill.
FRANK R. FRY, M. D., St. Louis.

Mr. REGINALD HARRISON, London, England.
RICHARD T. HEWLETT, M. D., London, England.
J. N. HALL, M. D., Denver.

HOBART A. HARE, M. D., Philadelphia.
CHARLES JEWETT, M. D., Brooklyn.

THOMAS LINN, M. D., Nice, France.

FRANKLIN H. MARTIN, M. D., Chicago.
E. E. MONTGOMERY, M. D., Philadelphia

NICHOLAS SENN, M. D., Chicago.

FERD C. VALENTINE, M. D., New York.
EDWIN WALKER, M. D., Evansville, Ind.
REYNOLD WEBB WILCOX, M. D., LL. D., New York
H. M. WHELPLEY, M. D., St. Louis.
WM. H. WILDER, M. D., Chicago, Ill.

CLINICAL LECTURE.

INTERNAL AND EXTERNAL URETHROTOMY COMBINED.*

REGINALD HARRISON, F. R.C.S.

LONDON.

Consulting Surgeon to St. Peter's Hospital. THIS Combination is suited to some cases of stricture where an instrument can be passed into the bladder.

In 1885† I described an operation under this title for various purposes connected with the bladder and urethra. At this time I was unaware that Dr. Annandale, of Edinburgh, had anticipated me, and thus I omitted to acknowledge my obligations to him for his important communication. Though applicable to strictures not amenable to dilatation or to internal urethrotomy alone, where a guide can be passed into the bladder, the combination of internal with external urethrotomy is specially adapted to strictures complicated with acute extravasation of urine.

The reasons for this are as follows:

*This is No. 3 of a series of lectures on this subject, delivered at the London Post-Graduate College. No. 1, on The Urethrotomies, appeared in the issue of September 10. No 2, on Internal and External Urethrotomies, appeared in the issue of September 25.

+British Medical Journal. It occurs to me that a somewhat similar operation had been performed by Dr. R. A. Kinlock of Charleston, S. C.

No. 7

1. The perineal section that immediately follows the internal incision is made on a large grooved staff instead of a small one. This renders the operation easier and further guarantees its completeness.

2. It enables the surgeon to divide what remains of any stricture tissue that the internal urethrotomy has not included.

3. Repair is effected by the introduction within the obstructed portion of the canal of new tissue which shows no tendency to contract. In this respect resembling the healing by granulation and cicatrization which usually follows lithotomy and other well drained wounds of this part.

4. It deals radically with the stricture, invariably a serious one, and provides a direct escape of urine which otherwise is liable to be diverted by the irregular channels and sinuses that the first rush of extravasation has made under the pressure of the muscles concerned in the act of a very forcible attempt at micturition.

During the earlier portion of my professional life as surgeon to two general hospitals in Liverpool, I had ample facilities for seeing cases of this kind. Many of these patients were landed from ships not having doctors. Not infrequently the penis, scrotum and adjacent parts were mortifying from the effects of confined and ammoniacal urine.

The cases were treated as a rule by incisions into the swollen perineum, scrotum and neighboring tissues, but the mortality was considerable and much in excess of what it should be.

I examined after death many of these persons to ascertain how far the perineal and other incisons which had been made where urine was extravasated, had been sufficient in providing drainage.

In a number of instances it was found that the central perineal incision in the direction. where the leakage from the urethra first occurred often failed to provide incontinent drainage, and that extravasation into the sur. rounding tissues continued to go up to death.

These examinations also showed how circuitous the sinuses connected with the surrounding incisions as drains for urine often were, and their liability to become blocked by sloughs and pus.

In the next place the stricture, invariably an old one, was often found unrelieved, and as much an obstacle to the natural flow of urine along the urethra as before the extravasation had occurred.