CASE II.-Internal urethrotomy.-S. S., transferred from the nervous to the surgical wards of the Philadelphia Hospital on September 16, 1887, with the diagnosis of stricture. Had gonorrhoea fifteen years ago. For the last three years noticed his stream decreasing in size. When admitted to the nervous ward a No. 15 F. bougie could be passed with difficulty. When referred to the surgical ward his urethra was gradually dilated, until a No. 21 F. bougie could be introduced.

Measurements.-Circumference of penis, three and three-quarter inches; calibre of urethra, thirty-five millimetres; of meatus, twenty-three millimetres; of stricture, twenty-one millimetres, depth three inches from the meatus. He was pre

pared by the routine administration of boric acid internally, 10 grains, three times daily. Previous to the operation 10 grains of quinine sulph. and grain of morphine sulph. were given.

Operation September 25.-Stricture cut as in case 1. Temperature before operation 99.4° F. ; after operation, evening, 98.8° F.

The night following the operation the patient removed the catheter; his temperature rose to 101.4°; catheter was re-introduced under antiseptic precautions; quinine was administered. After this his temperature dropped to 101°, and on the morning of September 26 was 98.6°. On the evening of the 26th the catheter was again removed by the patient, his temperature rising to 101.4°; was treated as on former occasions. After this no difficulty was experienced. One month after the operation a No. 36 F. bougie could be passed with perfect ease.'

CASE III.-Internal urethrotomy.-S. T., white, age 47, a hemiplegic, was transferred from nervous to surgical ward of the Philadelphia Hospital for urethral treatment. The examination as follows: circumference of penis, three and a half inches; calibre of urethra, thirty-four millimetres; of meatus, thirty millimetres. One stricture was found three inches from the meatus. The patient had some difficulty in urinating; complained of reflex symptoms, which were thought to be due to the condition of the urethra. The patient having been prepared as in case 1, and the stricture and meatus divided in the same manner, a No. 34 F. sound was passed through the stricture without any difficulty. A catheter was passed into the bladder and secured. An opium suppository introduced into the rectum and patient returned to bed. Same after treatment given as in the two previous cases. Four weeks after the operation recovery complete.

CASE IV.-Interno-external urethrotomy.-J. W., age 42, white, was admitted into the venereal ward of the Philadelphia Hospital suffering from periodical attacks of retention of urine, with a history of having had several attacks of gonorrhoea, and a stricture. Had external urethrotomy performed some time since; the wound was entirely healed at time of entrance into the hospital. On examining the case a cicatrix was found in the perineum, corresponding to the site of the former operation

Measurements.-Circumference of penis, three and a half inches. Examination by the urethrameter gave a urethral calibre of thirty-three millimetres; meatus, twenty-eight millimetres; and the presence of two strictures in the pendulous uretera, situated two and a quarter and four inches posterior to the meatus, of the calibre of twenty-eight and twenty-six millimetres respectively. The calibre of the stricture in the deep urethra was not measured.

I explained the condition of affairs to the patient and advised radical treatment, to which he gave his consent. An examination of the urine was negative. Boric acid was given internally for four days previous to the operation. The patient

received 10 grains of quinine prior to the administration of ether. The strictures in the pendulous urethra were disposed of as in cases I, II and III. I then divi'ed the stricture in the deep urethra by perineal section. The incision began at the junction of the scrotum and perineum, was continued backward about two inches, taking as my guide the perineal raphe, going through the cicatricial tissue resulting from the former operation. I found the landmarks in this case entirely obliterated, the perineum being infiltrated by the products of inflammation. Cutting through the cicatricial tissue, being careful not to deviate from the median line, I readily exposed the urethra behind the stricture, which was opened and the stricture divided. An ordinary aseptic drainage tube was passed through the pendulous urethra and brought out at the perineal wound. A catheter was introduced into the bladder from the perineal wound and held in position by a suture; the pendulous urethra and bladder were flushed with a 1 to 15,000 bichloride solution; the free ends of the drainage tube were fastened together with a safety pin. Iodoform was freely used in the perineal wound, which was then packed with iodoform gauze, an opium suppository introduced into the rectum, and an antiseptic dressing applied; patient returned to bed. The packing was allowed to remain for three days; when removed, the wound was free from pus and aseptic, the urethra and bladder were irrigated, and the drainage tube and catheter removed; a No. 33 F. bougie was passed. This was repeated every third day for six weeks, by which time the wound in the perineum was entirely healed, the drainage tube and catheter remaining in only three days. The patient left the institution cured.

CASE V.-External urethrotomy.-W. J., age 17, white, was admitted to the surgical ward of the Philadelphia Hospital suffering from retention of urine. Gave a history of having fallen astride a rail when thirteen years of age. On entrance to the hospital an attempt to pass a catheter by my resident failed; neither was he able to pass a filiform bougie, Failing myself to pass an instrument, I had the patient etherized. Under the influence of the anesthetic I succeeded in passing a No. 12 conical steel bougie, French scale. As the patient desired permanent relief, and the stricture (traumatic) was situated in the deep urethra, I performed perineal section. An incision, beginning at the junction of the scrotum with the perineum, was carried back in the median line or the perineal raphe for two and a half inches, when by a careful dissection through the deep structures, the urethra, which was infiltrated to a considerable extent with inflammatory material, was exposed. A small opening was now made in the urethra, through which a grooved director was passed into the bladder, from which a large amount of urine escaped.

The opening in the urethra was extended anteriorly through the stricture. A sound, No. 40 F., could now be passed through the urethra and into the bladder. From the perineal wound a catheter was passed into the bladder, which was held in place by a suture; a drainage tube passed through the urethra; the wound thoroughly irrigated, dusted with iodoform, and packed with iodoform gauze; a suppository of 10 grains of quinine and 1 grain of opium was introduced into the rectum, the wound dressed antiseptically, and the patient placed in bed. The dressing was allowed to remain for four days, when the packing with the catheter was removed, and both wound and bladder thoroughly irrigated with a solution of boric acid. A sound, No. 40 F., was passed with the same ease at the time of the operation. The wound was again lightly packed and dressed antiseptically. The patient was dressed every three days, and a No. 40 F. bougie passed at the

time of the dressing. Five weeks and three days after the operation the wound in the perineum had entirely healed. There was no difficulty experienced in passing a No. 40 F. bougie. The patient was discharged cured.

CASE VI.—Perineal section and internal urethrotomy for an impermeable stricture of almost the entire pendulous urethra with distension of the bladder, resulting in incontinence of retention, the latter having been present for two years.-W. A., contracted gonorrhœa in 1883, since which time he had more or less trouble in voiding urine, becoming decidedly worse in 1888. For the past two years there has been a continuous flow of urine (incontinence of retention), and for the last year has suffered, in addition to incontinence, with vesical and rectal tenesmus. October 17, 1890,

W. A. was brought to my office by my friend, Dr. J. Howe Adams, when examination revealed a constant dribbling of urine with the accompanying urinal odor, blocking of the urethra, commencing one-half inch within meatus, a distinctly indurated condition of the entire pendulous urethra, inability to engage the smallest instrument in the diseased portion of the urethra, and the presence of a tumor in the hypogastric region, extending almost to the umbilicus, flat upon percussion and giving the sense of fluctuation. Examination of the urine made by Dr. Adams showed the presence of a small amount of albumen and pus; no casts.

I advised that which in my judgment seemed to be the proper course, namely: perineal section and internal urethrotomy. The question of supra-pubic drainage for immediate relief and subsequent attention to the strictured urethra, I thought of, but dismissed it, believing this course the simplest, at the same time safest and most acceptable to the patient. A supra-pubic operation would not have relieved the patient of a subsequent perineal section and internal urethrotomy, owing to the involvement of the bulbous portion of the pendulous urethra. I would not have it inferred from the above that I am not an advocate of supra pubic drainage, for I am thoroughly so, yet, I think the cases require discretion and judgment in their selection.

The result in this case proves the correctness of my opinion. I will not enter here into the indications and contra indications to supra-pubic drainage, but suffice to say, that certain complications arising in a case like this, as advanced age, unquestionably advanced Bright's disease, multiple perineal or urethral fistulæ, and the presence of pre-vesical abscess, which latter may be brought about by frequent aspiration of the bladder for the relief of the retention caused by impermeable stricture, if present, and which I have seen, would make me decide in favor of the supra-pubic to the perineal operation.

October 20 patient was etherized and placed on the table in the lithotomy position, when I did perineal section without a guide, as is my usual practice, in this manner relieving the distended bladder, which contained a large amount of foul smelling urine. I next prepared to do an internal urethrotomy with Maisonneuve's urethrotome, but was not able to pass the filiform bougie belonging to the same, through the urethra by the way of the meatus. With a very delicate eyed probe, I succeeded in traversing the urethra from behind forwards, engaging the instrument in the orifice of the urethra presenting anteriorly, and at the bottom of the perineal wound, when I threaded it with the silk attached to the smaller of the blades shown in the drawing, and to which are attached the larger blades. In this way I was able without any difficulty to draw the knives through after the probe, thus making the calibre of the urethra twenty millimetres, after which I completed the restoration of the urethral calibre to its normal standard, thirty millimetres,

with the dilating urethrotome.

I have found that in a certain number of cases,

when the filiform bougie of Maisonneuve's urethrotome cannot be engaged by the way of the meatus, it is possible to traverse the urethra from behind forwards with a delicate probe, as was done in the above case, and in this way, with the separated blades, divide the strictured portion.

The usual dressing and after treatment which I recommend and practice was carried out here most rigidly. The operation was not followed by a bad symptom, notwithstanding kidney complications might be expected from the prolonged retention and consequent damming back of urine, thus endangering these organs. Patient was confined to bed but eighteen days. The catheter which had been passed into the bladder through the perineal wound was removed the fourth day, from which time on the patient had perfect control of the flow of urine, demonstrating that the membranous urethra and consequently the compressor urethra muscle had been left intact. From the fourth day following the operation until recovery, November 25, I passed a No. 30 F. steel sound every fourth day.

ACID BICHLORIDE OF MERCURY AS AN ANTISEPTIC.

ITS APPLICATION TO SURGICAL PRACTICE.

BY ERNEST LAPLACE, M.D.

WHEN my first article upon the superiority of an acidified solution of bichloride of mercury over other antiseptics was originally published (Deutsche Med. Woch. 1887, No. 40) in Berlin, but a few cases were cited to prove its efficiency in surgical practice. To-day, after three years trial in hospital and private practice, I feel warranted in making known the results obtained by its judicious use; confirming the hopes at first entertained, that an acid solution of bichloride of mercury possessed all the advantages of the ordinary solution of sublimate, without causing such a coagulation of the albumen of the blood, as would detract from the antisepsis expected of the solution. Furthermore, the antiseptic action of an acid sublimate solution is much more powerful than a non-acidulated one.

Repeating the experiments which I originally published in 1887, we find the following experiment as the basis of the question of acidifying sublimate solutions:

In a number of test-tubes, containing 5 c. c. m. of a 1-1000 sublimate solution, add respectively, 25, 16, 1, 1, 1, 1, 11, 2, 21, etc., c. c. m. of ox serum. A heavy precipitate will form in the first tube; a heavier precipitate forms in the second tube, and so on, until the tube containing 2 c. c. m. of serum, when this precipitate begins to dissolve itself again. The tube containing

c. c. m. of serum developed bacteria; and it followed that c. c. m. of serum was already sufficient to precipitate so much of the sublimate as would leave the resulting mixture entirely devoid of antiseptic properties.

Should the supernatant liquid be decanted, it will be found possible to grow the bacillus pyoceaneus, both in the decanted