Doctor, have you given nasola a trial in your practice? If not, you are overlooking a good thing. Send for a sample, and you will never be without it in your own family. Rectal Irrigation in Entero-Colitis of Children.-Dr. Clarence G. Clark, New York City, reports the following interesting case: Baby D., age four months. History: Child was nursed by mother for one and and a half months but as her milk was of poor quality and the child did not thrive, she was advised by her attending physician to stop the breast and substitute bottle. This she did, feeding the child on a mixture of milk, cream, milk sugar and barley water in a 3-6-1 proportion. The baby thrived on this for about two months, but early in July it developed a diarrhea. The mother gave it home remedies but still continued the milk, feeding it even more frequently than before as the child was fretful and apparently hungry. The stools averaged seven to eight a day and occasionally the child would vomit. I first saw the case on July 16th. Examination: Baby extremely emaciated, and weak; tongue fissured; cheeks sunken; abdomen tympanitic (slight). Temperature 105.2; weight seven pounds; stools ten to twelve daily, full of mucus and curds of undigested milk. I gave the mother a very favorable prognosis but told her to secure a nurse for the baby and we would do all that was possible. Treatment: Milk was stopped at once. Child fed on barley water and albumen water. I then ordered the nurse to wash out the colon twice daily through a catheter with two quarts of a solution containing glyco-thymoline one part and water ten parts. By the mouth I gave 1-20 gr. calomel tablets every hour for ten hours and twenty drops of brandy every two hours. July 17, child in about the same condition except that it had had only nine stools in twenty-four hours and they were of a trifle better color with less mucus and no curds. Continued irrigations, but stopped calomel. Continued with brandy. July 18th. Seven stools, quite watery but of a much better color. Treatment continued until July 24th, at which time the child was much improved, having only three a day and passing very little muOn this date I started the milk again, using a very dilute formula with three ounces of milk sugar and fifteen ounces of boiled water. Continued irrigations with glyco-thymoline,one to eight ounces a day but stopped all other medicine. The baby started to thrive at once and in two weeks more we again weighed the child and noted an increase of three pounds. I gradually increased the strength of his food until at the present time he is taking eight ounces of milk to eleven ounces of water and one ounce of lime water, which is almost the average for a child of his age (5% months). This is only one case of a number that I have treated with nearly the same routine this summer and all with satisfactory results.. In conclusion, I would state that although in this case I did not give much treatment by mouth because the symptoms seemed to point more to a lower bowel affection, yet in many cases where gastric symptoms have been more predominant, I have combined with the irrigation treatment glyco-thymoline in 15-30 M. doses combined with liquor bismuth as follows: cus. Glyco-thymoline. M. Sig. 3 i q. 2-3 h. 3 ss 3 ii This in connection with rectal irrigation with glyco-thymoline in proportion indicated will suffice in nearly all the cases of gastro-enteritis, entero-colitis and enteritis so common in artificially fed infants. Another Phase of the Proprietary Question.-There is at least one phase of the proprietary question which we believe has not been seriously considered, and that is, that while every effort is being made by some of our earnest and really conscientious, though misguided, workers to destroy the faith of the profession in practically all remedies of this class, and to bring them into ridicule, practically nothing has been done to provide satisfactory substitutes for them, except to make the suggestionand excellent one, too-that physicians should familiarize themselves with the official and semiofficial preparations contained in the Pharmacopeia and National Formulary. In making this suggestion they forget to add that a very large share of these "official" preparations are old proprietaries under other names. In other words, the great "reform" consists in the denunciation of such remedies as antiphlogistine, arsenauro, bromidia, lactopeptine, Fellow's hypophosphites, antikamnia and Hayden's viburnum compound, while the use of practically the same things under other names is suggested or advised. In some instances the very formulas are used that proprietors have published or that analytical chemistry has elucidated. There is a reason for the popularity of the proprietaries. Whether many of these were "wonderful discoveries" or not, they have enabled the average physician to secure results more satisfactory to himself and his patients than he was able to secure without them. Very, very few medical men are able to extemporize prescriptions which at the same time are effective, palatable and not uselessly polypharmacal. All doctors ought to be able to do this, but they are not-and whose fault is it? And even if they were, who but the sheerest crank would claim that he could properly write for, or the average druggist dispense, substitutes as elegant, as cheap and withal so satisfactory as many of the best type of the proprietaries? It is best to look all these facts squarely in the face and be sensible in our conclusions. Vol. XXX ST. LOUIS, SEPTEMBER 10, 1906. Papers for the original department must be contributed exclusively to th's magazine, and should be in hand at least one month in advance. French and German articles will be translated free of charge, if accepted. A liberal number of extra copies will be furnished authors, and reprints may be obtained at cost, if request accompanies the proof. Engravings from photographs or pen drawings will be furnished when necessary to elucidate the text. Rejected manuscript will be returned if stamps are enclosed for this purpose. COLLABORATORS. ALBERT ABRAMS, M. D., San Francisco. ARTHUR R EDWARDS, M._D., Chicago, Ill. Mr. REGINALD HARRISON, London, England. HOBART A. HARE, M. D., Philadelphia. UNDER the title of the urethrotomies I propose taking a review of their application to some diseases and injuries of the male urinary organs. It will be convenient to consider in the first place those specially applicable to stricture, namely: (1) Internal urethrotomy; (2) external urethrotomy, otherwise called perineal section, and (3) the combination of these two proceedings. It is hardly necessary to point out the serious effects that are liable to follow any permanent obstruction to the discharge of urine along the urethra. In this way may be brought about all degrees of disorganization of the urinary apparatus from the kidneys downwards as well as various local effects about the seat of stricture which include inflammation, suppuration, extravasation of urine and mortification. These consequences will be found illustrated and described in *This is No. 1 of a series of lectures on this subject, delivered at the London Post-Graduate College. To follow: (2) Internal and External Urethrotomy. (3) The Conbination of External and Internal Urethrotomy. No. 5 various works on pathology, to which reference should be made. It will however, be remarked that included in the inflammatory processes may be recognized means by which nature provides a way of liberating urine that is suddenly extravasated and imprisoned. It is well known that there is no animal fluid so destructive to normal tissues as urine charged with ammonia by the decomposition of urea. SO Though these effects by their violence are not infrequently in themselves fatal they have occasionally by mortification liberated pentup urine saturated with ammonia and proved the means of saving life, though at the cost of much suffering and permanent damage to the parts, which by timely surgical aid might have been prevented. This urea may be said figuratively, to furnish the dynamite for this purpose. I think that urea has justified its existence as a natural constituent of the urine by providing for a contingency in connection with obstructed micturition which has proved occasionally of no little service. I have met with several instances of persons who, in places far beyond the reach of surgical aid, have suffered from extravasation of urine and sloughing whose lives were undoubtedly saved in this way. Further I have recorded a caset where apparently by the absence of urea extravasated urine was rendered chemically harmless to the tissues which confined it. INTERNAL URETHROTOMY. In looking back at surgical opinion and practice which prevailed about the time prior to the general adoption of antiseptics it could hardly be said that this operation was favorably regarded, though numberless instruments were devised for this purpose, and some important observations were made on the subject. Amongst the latter I would include the almost forgotten work of the late Dr. Fessenden Otis, of New York, who demonstrated the larger dimensions of the male urethra, and thus exercised not only a marked influence on the treatment of stricture, but led up to the great improvements that followed in connection with the removal of stone from the bladder by Dr. Bigelow of Boston. Notwithstanding the various communications which were made on the subject of in + Surgical Disorders of the Urinary Organs. Fourth Ed. p. 133. ternal urethrotomy at the time referred to, by far the larger number of strictures were almost indiscriminately treated by some form of dilatation with bougies, whilst in the minority of these cases the selection of a more radical operation was largely determined by the mechanical impossibility of proceeding to carry out the former treatment. The objections which were then urged against a more general adoption of urethrotomy were chiefly: The frequency with which this operation was followed by paroxysms of urethral or urinary fever attended with rigors. Teevan stated in treating of this subject that two-thirds of the cases thus operated on suffered in this way and in a much larger proportion than where dilatation was alone practiced; that greater risk was incurred; and lastly, on the ground that urethrotomy did not prevent a recurrence of the contraction or dispose of the necessity for the occasional use of a bougie subsequently as a preventive of relapse. In the light of more recent developments having a direct reference to the general recognition of antiseptics I will refer to these several considerations. URETHRAL FEVER. In the pre-antispetic days the rigors and fever which not uncommonly followed surgical interference with the urethra however slight or transient it might be, were almost universally regarded as of a neurotic origin, or as due to shock propagated by the sympathetic nervous system. It has always seemed to me that there was little or no support for this explanation. There is no analogous example connected with other injuries or lesions of the body. The rigors and fever which follow and may reasonably be expected after an internal urethrotomy are conspicuous by their absence where in addition to the urethrotomy a perineal cystotomy is provided for efficient drainage. Further, some experiments in sterilizing, or rather adulterating the urine as will presently be referred to, are directly opposed to the neurotic hypothesis. The only evidence of shock propagated by the sympathetic nervous system I can recall in connection with surgical lesions of the genito-urinary apparatus is distinctly at variance with such a theory. some I refer to the shock which in degree is obvious both to the operating surgeon and to the anesthetist, who are both interested in the phenomenon, when, for the removal of a testis, the spermatic cord is ligatured and divided. Here heart and breathing often indicate this. I do not think it necessary to pursue this argument further. One of the earliest communications in reference to the nature and prevention of urinary fever as a sequence of surgical interference with the urethra was by Dr. Palmer, of Louisville, U. S.A., in 1867. He showed by a long series of cases that by sterilizing the urine beforehand with boracic acid given by the mouth the liability to urinary fever after passing catheters and bougies or causing any lesions of the urethra, was greatly diminished. Dr. Palmer's results in reference to the sterilization or adulteration of the urine with certain drugs led me to make some observations on more direct means of influencing the excretion. For some years past I have made a habit in cases of operation on the male urethra such as internal urethrotomy, or where there is reason to believe that the canal has been abraded or actually wounded by the passage along of catheters, bougies or sounds, of filling the bladder with a solution of boric acid and asking the patient to retain it for some time. Thus the first urine that is voluntarily passed after what may have been done operatively is not only a diluted specimen of the excretion, but is charged with an antiseptic solution. It should be remembered that the earlier rigors occurring after these lesions are those which are sometimes premonitory of the more serious symptoms that may fol low, such as suppression. In the few fatal cases I have seen of the latter, after interference with the urethra, the first rigor happened within a few hours. The rigors and fever which occur after an interval of twenty-four hours or so following the use of an instrument I have not thought of any moment. Since adopting this practice generally I have found the occurrence of urinary fever much less common than formerly, and when it happened correspondingly less important. For this purpose injections of boric acid solution seemed more potent than those containing mercuric preparations. Where a catheter is retained for some days, as after internal urethrotomy, and the escape of urine is controlled by a plug or tap at the orifice of the instrument, I have succeeded by repeating these injections into the bladder, of averting these intermittent febrile attacks. THE RESULTS OF INTERNAL URETHROTOMY RELATIVE TO ITS SELECTION. In dealing with the urethrotomies it is not to be presumed that I undervalue the methods of treating strictures by various forms of di latation with bougies. On the contrary, there can be no doubt (except perhaps, with some of the traumatic varieties resulting from ruptures of the urethra) that all strictures of an inflammatory origin have a place or preliminary stage of various duration. A period when so to speak they may be moulded by the hand and instrument of the surgeon or educated patient, as the potter moulds clay while it is impressive. When, however, this stage has been allowed, to pass by and the obstruction not only distorts or alters the urine stream, but assumes the characteristics of an increasingly contractile scar, section and the introduction of what I shall again refer to descriptively as a splice or interval of new tissue becomes a necessity. All strictures are liable to change as age advances and to undergo fibrous degeneration. In this way even after years of careful attention they may become india-rubber-like and resist treatment which hitherto had been carried on with success. It may then. be necessary to substitute division for dilatation. In determining the time and stage when this substitution should take place "the whip" or graduated bougies* I described many years ago, and which are now much used for treating strictures will be found reliable indica tors. Some perhaps have never heard of these flexible instruments, yet I think most surgeons will on trial find them a useful additio to their armementarium. They are particu. larly serviceable in commencing the treatment of strictures which are difficult to enter. In advising an internal urethrotomy as a substitute for dilatation I think the following paragraphs taken from the Annual Surgical Reports of St. Peter's Hospital, London, indicate the favorable opinions that have been fcrmed of this operaton in recent years: "One hundred and thirty-six cases of urethral stricture were admitted (1903) of which 92 were operated upon by internal urethroiomy with one death from acute suppression thirty-six hours after the operation; and 119 cases of stricture were admitted (1904), of these 90 were operated upon by internal urethotomy with no deaths. This gives a total of 255 cases of stricture in two consecutive years, of which 182 were operated upon in this way with one death, whilst cases were treated by dilatation and in other ways. Satisfactory as these figures are it has been said, "once strictured, always strictured." By this is implied that however successful treatment may be, recurrence is liable to take place. In the course of these remarks I shall endeavor to show that this liability may be con The Lancet, Feb. 3, 1883. siderably lessened by giving effect to certain principles of treatment having special reference to injury and repair as uniquely observed in connection with some lesions of the urinary apparatus, and which hitherto have not received due consideration. To this aspect of the subjects have devoted considerable attention. considerable attention. In 1900 I prepared, by request, a report for the International Medical Congress at Paris on the remote effects of structural lesions (interventions sangulantes) in urethro-stenosis. This entailed a very full investigation, and many persons were examined who bad undergone operations for stricture at varying intervals previously. . The conclusions I arrived at were that the normal calibre of the urethra might be completely and permanently restored, and that the absence of recurrence, as demonstrated by many cases which were carefully investigated, was not necessarily dependent on the use of a bougie after operation. In several cases, such as those I am referring to later on, recurrence was due not so much to the original stricture, but to a general sclerosis which the entire length of the urethra had undergone. THE term "doctor" was invented in the twelfth century, about the time of the first establishment of universities. The first person upon whom this title was conferred was Irnerius, a professor of law at Bologna University. The title was created by Emperor Lobaire II, but was suggested by Irnerius himself. The term extended to the faculty of theology, and was first given by the University of Paris to Peter Lombard, the famous theologian. In 1329 the College of Asti conferred the first title of doctor of medicine upon William Gordenio. COSTAL OR RIB-BREATHING.-Costal or rib-breathing is the most efficient. It enables the singer and the speaker to take in the greatest amount of breath, and the effort is not great because it is shared by all those muscles whose function it is to pull the ribs upward and outward. If the thorax is unconstricted, the greatest expansion will be about its lower and middle portions where the ribs are more movable and where the angle of their inclination with the spine. is most acute. Another reason why this type of breathing is the most effective in that this uplifting of the ribs puts the thorax into the best possible position for the expiratory control that follows during the act of vocalization. The diaphragm for artistic purposes is not an inspiratory muscle; it should be used only in the expiratory effort of singing and speaking. LEADING ARTICLES DIAGNOSIS OF PYLORIC STENOSIS. EDWIN WALKER, M. D. EVANSVILLE, IND. ACCURATE knowledge of the pathology, di. agnosis and treatment of diseases of the stomach is of very recent origin. The last twenty-five years have contributed more useful information than all the time preceding. It is true that Kussmaul gave us the stomachtube in 1869, and in 1871 Leube pointed out its importance as a means of diagnosis and made some valuable contributions to our knowledge of the motility and secretions of the stomach. In the early eighties, Ewald, Boaz and Riegal studied further the secretions of the stomach and many other workers joined them and gradually a fairly good knowledge of the chemistry of the gastric juices was formulated. But so many were the methods and so extensive was the literature in this mass of information. It has been so difficult to get distinctly the essential points and contradictory statements have kept the profession from employing methods which were useful. The surgeon came to our aid about the same time; before 1880 few operations had been done. During the five years following, Billroth, Czerny and Peau had proven that surgery was worth investigation and from that time a large number of operations were done by many operators. The mortality of the reported cases was high, and doubtless had all been reported, it would have been very much higher, but notwithstanding this, real progress was made, not only in technique but in pathology, as well. By the united efforts of the internist and surgeon, we are slowly clearing the way to a better understanding of the indications and limitations of surgical interference. Still at this time the conscientious practitioner finds great difficulty in discerning the truth, for the vast amount of literature is confusing, and it seems to me that indications laid down by most surgeons are not altogether reliable or safe, and are too often vague and unsatisfactory. For example, we are directed to make an exploratory incision in "chronic stomach troubles" which have resisted treatment for some months or years. Such directions are entirely too indefinite for they would include many functional cases. I admit that an accurate diagnosis is not always possible, but it is so in a very large proportion of cases, the failure being rare exceptions. I think, too, that exploratory incisions have been given too much prominence; it sounds plaus ible and so easy to say, "if you cannot find the exact condition, open the abdomen and see exactly what the trouble is." It must not be forgotten that it is difficult through the ordinary opening in the abdomen to fully explore all parts of the stomach and ulcers and gross lesions are often overlooked. On the other hand, by careful study of the clinical history, supplemented by modern methods of physical examination, we will be able, in most cases, to accurately diagnose the condition, and in some of them, better than we could by an exploratory incision. I would say, in chronic organic stomach diseases, in which stenosis of the pylorus exists, or in cases of chronic ulcers, which have resisted rational treatment, and also in cancer of the pylorus, where the patient is in fairly good condition, an exploratory incision is indicated. There probably would still be a few other chronic organic cases in which it would be justifiable, but there would not be many. This would leave a comparatively small number of cases which would require an exploraory incisio n, and I venture to predict that with the increased knowledge of diseases of the stomach, the indications for operative interference will be greatly curtailed and the number of operations much smaller, but the results, both as to mortality and benefit of the patient, will be better than at present. Some authors speak of operations for ulcers in a way to leave the impression that is in. dicated in a very large proportion of cases, while I know of no recent statistics on which to base a conclusion; from my own limited observations I think the percentum would be below ten. The older statistics of the cure of ulcer by dietetic and medical treatment are not to be relied upon, more recent results being much more favorable. Operations for cancer are far from satisfactory; resections are almost without exception a total failure, and conservative operations offer at best only temporary improvement, and few subjects live more than one year. Cancer of the lesser curvature represents 80 per cent of all cases, and surgery can do nothing for them. At the pyloric end, the condition is more favorable both as to early diagnosis and operation, but operations, so far, have done but little permanent good. I wish, therefore, today to direct your attention to pyloric stenosis for this is the condition in which an operation may do good. The benign ones furnish our most satisfactory cases and of the malignant ones, while far from promising, by early work we may be rewarded by a small measure of success. We must first determine that stenosis of the pylorus exists, then the lesson which causes it. |