URETHROSCOPY.*

BY WILLIAM R. BLUE, M. D.

To the untiring efforts of Grunfeld, of Vienna, Fenwick, of London, and Otis, of America, is due the position the urethroscope now holds as a means of diagnosis and treatment of urethral diseases. As a diagnostic agent, what does it do? First, with a proper light it enables us to see the entire urethra and locate any abnormal condition of same. Second, with it and only with it are we able to differentiate positively between organic and spasmodic stricture. This I consider of great importance, especially if a radical operation is advised for the treatment of the stricture. There is no doubt in my mind that thousands of spasmodic strictures are incised annually when such an operation is not indicated. It is really harmful, and could be prevented by the use of the urethroscope. Third, some of you have met with cases of close stricture in which you have been unable to pass the smallest filiform bougies after a lengthy trial, though an opening be present. By illumination with the urethroscope pressing against the band, in all of these cases you are sure to find the opening and pass the bougie into the bladder, thus saving the patient an external operation.

As an aid in treating chronic urethral diseases, I can not say too much in its praise. I have had a number of cases in which it has enabled me to effect a cure when all of the other modes of treatment had failed. With the urethroscope we can see and treat the following conditions as well as if they were on exposed surfaces: Granulations, mucous patches, urethral chancroids, hypertrophied follicles and abscesses, nodular strictures, curvatures of the penis, and polypi.

I will cite only two of the many (to me) interesting cases I have treated. Without the urethroscope these patients would still be sufferers:

CASE 1. Mr. X., from western part of the State, aged thirtyeight years; married; has two children. First attack of gonorrhea at eighteen years of age. Discharge ceased after eight weeks' treatment. At twenty-four years he had a second attack. This stayed with him for two years. Consulted physician, who located three strictures. Radical operation was performed. The patient stated that the surgeon cut the entire pendulous urethra on roof. Hemorrhage was profuse. He was sounded for two months at intervals. Has had slight discharge since.

*Abstract of paper read before the Kentucky State Medical Society, May, 1901.

Following the operation pain came on, which was referred to the bladder neck. This had been present ever since. He consulted another surgeon for his complaint. After carelessly examining him he pronounced it neuralgia of the prostate. He was advised to avoid sexual excitement, and told that the pain would "wear off" in time.

Eighteen months ago he came to me for treatment. Examination of his urine found it to be normal, barring a few pus and epithelial cells. Boric acid was given in five-grain doses every four hours for twenty-four hours before the examination, and kept up during the entire treatment. Patient was cocainized and 30 F. urethroscope introduced. Four inches back an ulcer was found on the roof of the urethra about an inch long and one eighth of an inch wide at its widest point. After mopping it off I carried my index finger along the lower surface of the penis to the end of the urethroscope; there I exerted pressure with the end of my finger and told the patient that was the seat of the trouble. He remarked that I was right, and that it was the first time it had been located. Application of stick sulphate of copper was made to the ulcer daily with no change. I curetted it under cocaine and applied the copper as before. In three weeks the ulcer healed, only a slight scar remaining. Saw the patient in March; there has been no return of his symptoms.

CASE 2. Mr. W., local, single, aged twenty-six years. First attack of gonorrhea at twenty-two years of age. This was complicated with chordee, which he broke. Wound healed, leaving the penis curved downward and slightly to the right. After preparatory treatment similar to Case 1, he was cocainized and examined with No. 22 F. urethroscope. One inch from the meatus I found a stellate cicatrix. Curettage of cicatrix relieved the curvature, wound healing quite promptly. Patient has since married and has an heir.

As to urethroscopes: I have tried nearly every kind on the market. The most satisfactory one is the Schall. With this instrument you can study the urethra as a cylinder, and not as a collapsed tube with its many folds, as you see it with other makes. This is a very important point, for frequently the diseased condition lies lurking in the urethral folds, and is often overlooked with other makes of the urethroscope.

LOUISVILLE.

OPPOSING THE ROUTINE REGIMEN ADOPTED IN THE MANAGEMENT OF CHRONIC BRIGHT'S DISEASE.*

BY LEON L. SOLOMON, A. B., M. D.

In preparing this short paper it has been chiefly my aim to call your especial attention to several salient facts, namely, first, in the management of a given case of so-called chronic Bright's disease (without stopping now to differentiate between the several inflammatory and degenerative types which mark a great difference in the exact pathological anatomy of the case) it is always essential to remember that the slow smouldering fire may from time to time become a bright red flame; in other words, to care for a chronic exudative nephritis or a chronic interstitial nephritis (so-called non-exudative) is to manage the respective acute exacerbations which will occasionally occur in the course of these two chronic ailments. Second, to relieve the kidneys of all possible overwork—on the one hand by a carefuì regulation and supervision of the habits of life, the diet, clothing, baths, exercise, sleep, stool, etc., and to restore and preserve the proper excretory function of the organis an all-important duty, which, if accomplished, may mean for our patient many months, if not years, which he may often spend in the quiet and peaceful enjoyment of life, and in fair health. Third, let us remember the presence or absence of albumin in the urine is not all of Bright's disease, though the case can often be approximately measured and the prognosis fairly estimated and gauged by this important adventitious ingredient.

I am convinced that we are often guilty of managing Bright's disease in a routine if not desultory fashion; in attaching to the presence of proteid matter in the urine, with or without the additional presence of renal derivatives (as revealed by the microscope), too much importance, and of reaching too positive and convincing conclusions that the patient is doomed to sooner or later meet his just retribution in a different atmosphere, simply because of this one ingredient; and then when the diagnosis is once fairly fixed, I make bold to admit we are very often too lax in the regimen we adopt for the future welfare of the case. A work carelessly done were often better undone or not done. This statement particularly applies to the management of morbus Brightii, which, though the morbid process itself rarely requires or even justifies

* Read before the Kentucky State Medical Society, May, 1901.

vigorous measures, surely is always deserving of careful and individual treatment. It is not my province, in this symposium which your secretary has arranged, to discuss the etiology of any of the Bright's diseases, but in so far as certain causative factors have their positive bearing on the therapy of the disease, I wish, at least, to mention several.

It has been said by Prof. George Johnson that renal degeneration is a consequence of long-continued elimination through the kidneys of products of faulty digestion, and since his time it has been demonstrated conclusively that the elimination of products of malassimilation is productive of granular degeneration in these organs. Fothergill looked upon liver incapacity favoring faulty digestion and assimilation as the foremost etiological factor, to which Allbutt added mental worry and overstrain (by arresting secretion) as most likely to provoke such incapacity. Furthermore, we are now aware that over-indulgence in animal food is a direct cause, and that excrementitious products in the circulating fluid, such as are present in tuberculosis, syphilis, diabetes, gout, chronic rheumatism, scarlatina, measles, diphtheria, etc., are each of some moment in at least starting the process or predisposing to it, and our therapy is incomplete if it does not recognize the part these one or more etiological factors play. It is, then, not sufficient to instruct the patient to avoid condiments and highly seasoned foodstuffs, nor viands, nor to restrict the amount of meat and institute a skim-milk diet, or some other plan, but the whole dietary and habits of life must be interpreted for the patient, and as carefully studied as is now done by the Walker Gordon laboratory method devised by Professor Rotch for selective infant-feeding. Ordinarily it is wise to restrict the meat diet, allowing only white meat in small quantity, with fish; also soups, broths, gruels, and fruits in abundance, but no greater error, it is now considered by text-books on dietetics, can be committed than to compel the general run of sick people-diabetics, for example-to adopt a fixed, inflexible diet list; and this applies also to Bright's, for is it not found that some cases not only tolerate but actually thrive on certain prohibited and interdicted articles of food?

Now, just so wide a scope of latitude as characterizes the case of glycosuria with reference to food also asks for consideration when the case of Bright's is before you. And just here I wish to emphasize the frequent good from the administration of fats, which not a few of the cases we meet can readily digest and assimilate. It must be borne in mind that our therapy is useless in the constitutional diseases if, not

withstanding, nutrition suffers and strength fails. Every fifteen grains of fat assimilated results in nine calories of heat, transposable into energy or vital force; the same amount of carbohydrate yields but four calories, and by the strict routine regimen we are prone to remove the greater per cent of albuminous food, which yields a like four calories for each fifteen grains assimilated. Stop, I ask, long enough to make a calculation. Man is but an engine; he requires 2,500 to 3,000 calories to run him from 4 o'clock to-day to 4 o'clock to-morrow, or through any other given twenty-four hours. Whence the source of this energy? Where is he to get his units if you deprive him of the raw material wherein latent energy resides?

Finally, to sum up the meaning of this paper, I ask for the case of Bright's not only a consideration of the points made, but a keener appreciation of the influence exerted by the disease on the blood-pabulum proper (with its consequent profound anemia), and also on the heartmuscle and arteries, and if these receive your vigilant attention I am constrained to say the therapy of chronic Bright's disease is otherwise, as a rule, simple.

LOUISVILLE.

Reviews and Bibliography.

Progressive Medicine, 1901. Diseases of the Thorax, Heart, Lungs, Blood-Vessels, Skin, Nervous System, and Obstetrics. Edited by HOBART AMORY HARE, M. D., Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia; Physician to the Jefferson Medical College Hospital; Laureate of the Royal Academy of Medicine in Belgium, of the Medical Society of London; Corresponding Fellow of the Sociedad Espanola de Higiene of Madrid; Member of the Association of American Physicians, etc. Assisted by H. R. M. LANDIs, M. D., Assistant Physician to the Out-Patient Medical Department of the Jefferson Medical College Hospital. Price, per annum, 4 cloth-bound volumes, $10.00. Philadelphia and New York: Lea Brothers & Co. 1901.

The September volume of this excellent series of books is before us, and is fully in keeping with those of the past. The subjects treated in this issue of the work are as follows: Diseases of the Thorax and its Viscera, including the Heart, Lungs, and Blood-Vessels; Dermatology and Syphilis; Diseases of the Nervous System, and Obstetrics.

We commend this volume to our readers as being an excellent one in every particular. The chapter devoted to diseases of the viscera is alone worth the price of the book.