the table, with good light-we tried to introduce a small silver probe, when she remarked, "I can introduce a knittingneedle myself." Then we said, "Do so," hoping she might, and relieve us of our embarrassment. She retired to another room and, after some time, reported she could not. Now, feeling thoroughly chagrined, we suggested that she wait till the catamenia came on, for at that time there is always more relaxation about these organs, and I remembered she had said that the discharges oozed through this orifice, making its first appearance there, which might enable us to follow the flow to the womb.

Before us we recognized a difficult case. Like the sides of a glove-finger, collapsed and adherent, closing up the original tract, it would be a difficult and delicate task to re-open without cutting through one of the walls; especially so, without some directory.

So on May 7th, 1891, she informed me that the flow had appeared at the small opening. Hastily I got ready and called by for Dr. McM., who was absent; then, not without some trepidation by myself, I was soon at her side. Having kept her on constitutional treatment, I found her general health improved, consequently better able to withstand an operation; but mentally she was a wreck, with no hope, believing that she would sink under the surgeon's knife.

I neglected to state that the former physician recommended vaginal injections with a No. 2 female syringe, and the patient had attempted and did use it with some difficulty for some time, and then the long nozzle of the rubber syringe for a longer time into the bladder.

Unassisted as I was, I got the patient upon the table, with all necessary antiseptic precautions, instruments, etc., ready. I inserted a large catheter into the urethra, and then began to introduce a small bulb-pointed silver probe into the small opening, and, perhaps, after an hour's trial I succeeded. Fitting a grooved probe on the silver, for I feared to withdraw and attempt to introduce again, I followed it up and then withdrew the round one. Pressing, after chloroforming the patient, firmly the back of the probe to the left, I tracked the groove with a long tenotome knife,

cutting to the right, so as neither to cut up into the bladder nor down into the rectum, reaching ample room in about two and one-half inches. Now, turning the groove to the left and pressing to the right, I inserted and carried the knife to the same ample cavity. I then inserted a half-inch rubber drainage tube anointed with vaseline, retaining it in situ by stitching to the bandage. A stream as large as your little finger poured out, until a pint or more of vitiated catamenia had escaped, giving great relief, physically and mentally.

Ordered irrigations twice daily of the following:

M. Sig. One teaspoonful two or three times a day, particularly at night.

On May 10th, returned, found the patient much improved. I dilated by inserting rubber bag covered with a silk sack to maintain hour-glass shape, and inflated with air-pump all she could bear, followed by antiseptic wool tampon immersed in carbolized glycerine, to remain five hours. I remained all night. Next morning repeated dilatation, irrigation and tampon.

May 14th. Patient doing well. Repeated dilatation, irrigation and tampon. Can use much larger sack. Ordered in addition, elixir pepsin, bismuth, iron and strychnine three times daily.

On May 19th, patient much improved. No inflammation, but little irritation. Parts considerably dilated. Now used an anal speculum, which enlarged by screws-gave two turns each day. Ordered patient to use it through the day, withdrawing when it caused too much irritation, and altering with large tampon at night. Irrigation continued.

May 26th. Patient decidedly convalescent; very cheerful. Continued treatment as before.

June 1st. Patient quite lively, and up and around. Advised use of speculum, with full capacity, every other day.

June 12th. Dismissed the case.
The last entry on my books is "By cash

to balance," which entry all physicians gladly make.

This case would not be complete without its sequel. When I dismissed the case, I suggested the adoption of measures to prevent immediate conception, fearing the parturient process might lacerate the new cicatrix before firm healing resulted. Twelve months later all restrictions were removed, and on December 26th, 1893, I waited on her in a very natural labor, terminating in the unassisted birth of a nine-pound boy.

Right here I will say that the forceps are, in my opinion, used too often. In this case the head was hard and round, and required many strong pains to compress into cone shape to enable it to pass through the soft parts.

I have practiced medicine for thirtyfive years and have unwavering and unswerving confidence in nature's works, and this faith, for it amounts to faith, has been confirmed and strengthened by experience; for in all that time I have never used them when called at the inauguration of labor but one time, and then the woman was delivered, after dissecting the child, of a monster of twenty pounds weight. Have used them when called later, after the natural forces were exhausted and the child could not be born otherwise. Perhaps I was fortunate in having easy cases while my competitors had the difficult ones.

The special interest and importance to the medical man in this case is the remarkable dilatability of the urethra, the wonderful control of the vesical sphincter, and, I might say, the astonishing ease with which the vagina dilated and how soon it resumed its normal functions. J. T. RUSSELL, M. D.

Monroeville, Ala.

Stricture of the Male Urethra. Strictures of the male urethra are divided into two classes: true or organic, false or spasmodic. A permanent diminuation of the caliber of this canal as a result of an inflammatory process constitutes a true or organic stricture; a spasmodic stricture exists when the normal caliber is diminished as a result of contraction of the voluntary or involuntary muscular elements connected with the urethra. Congenital or non-inflam

matory narrowing of the meatus does not constitute a stricture. The normal contraction of the compressor urethra, or cut-off muscle, is also excluded in the definition of spasmodic stricture.

An organic stricture may be annular, tortuous, single or multiple. In annular or ring stricture, the cicatricial contraction involves the entire circumference; it may vary in width from a line to one inch. In tortuous or irregular stricture an inch or more of the urethral canal is involved. Two or more annular or lateral strictures may unite and form a tortuous stricture.

The pathology of stricture of the urethra is that of an inflammation of variable intensity, involving the epithelial and submucous basement membrane of this canal, together with the deeper tissues of the corpus spongiosum, and occasionally of the corpora cavernosa. This process usually begins from within, but may originate in the deeper tissues of the penis and involves the urethra secondarily. Among the causes of stricture, specific urethritis ranks first; and it is highly probable that the precedence which gonorrhea enjoys in the etiology of stricture, is due rather to improper management of the urethritis than to the effects of inflammation proper. The employment of corrosive and irritating injections; the introduction of instruments (syringe nozzles, bougies, etc.) upon the inflamed surface, together with the unnecessary exposure of the person in the uninterrupted pursuit of business or pleasure, combine to make gonorrhea one of the most dangerous of venereal diseases. Chancroidal ulcer within the meatus is a rare cause of this lesion.

The most frequent seat of organic stricture is the portion behind the compressor muscle and in front near the suspensory ligament, at the junction of the penile with the perineal urethra. Stricture of the prostatic region is rare.

Diagnosis. The symptoms are: A gleety discharge, interference with the escape of urine and semen, pain, a mucopurulent discharge continuing for several months is almost pathognomonic of this lesion, a twisted or forked stream with a diminished volume in the size of the flow.

Instrumental exploration is necessary

in order to determine the location and situation of the stricture. For this purpose, the bulbous bougie is invaluable; in the effort to locate a stricture the different diameters of the normal urethra at various points in the canal must be borne in mind. Immediately behind the meatus there is an expansion into the fossa navicularis, and from this point to the suspensory ligament the diameter is about the same, behind the membranous portion there is a second expansion in the prostate.

After the fact has been established that a stricture exists, the mode of treatment should be decided upon. There are two modes of treatment; one by division and the other by dilatation. In division, the stricture is divided internally (internal urethrotomy), or incised from without (external urethrotomy). Dilatation is obtained by the use of bougies or sounds; it may be immediate or continuous. Immediate dilatation is seldom justifiable, besides it is an unscientific and unsafe procedure. First use the bougies and try to dilate the strictured surface before resorting to internal or external urethrotomy.

For internal urethrotomy, I like Otis' dilating urethrotome. The urethra should be well prepared for a painless operation by local anesthesia. This may be obtained by the use of an ordinary hypodermic syringe with Otis' cocaine needle. Having injected one-half drachm of a four per cent solution of cocaine into the urethra,the stricture should be accurately located and its diameter and extent obtained with bulbous wire bougies. Hemorrhage after internal urethrotomy is usually slight; it may be readily arrested by turning the penis upon the abdomen, laying a handful of cotton or gauze over the organ and bandaging it. Not infrequently within twenty-four hours after internal urethrotomy, or the introduction of sounds or other instruments, the patient is seized with a rigor or pronounced chill; thermometer registers 100° F. Administer antipyretics in ten or twenty grain doses, repeated every three hours till the temperature falls below 100°. The repeated introduction of steel sounds or gum bougies is essential to success in the treatment of internal urethrotomy. If cystitis or epididymitis or orchitis

should ensue, all operative measures should be discontinued till the symptoms subside.

The prognosis after urethrotomy should be guarded. Many cases do not recur, but stricture of long-standing and extensive induration, no matter how thoroughly divided, tends to recur.

I hope to hear from some of the many readers of the BRIEF on stricture of the male urethra.

Best wishes to our editor and good old BRIEF. GEO. F. CRAWFORD, M. D. Chulahoma, Miss.

Climate of Central America for Consumptives.

ARTICLE No. 2.

Ever since my article on the above subject was published in the May number of the BRIEF (1893), I have been receiving letters from all over the United States asking me for information, and this letter I have intended as an answer to many of the questions asked. I believe, however, that the BRIEF must be taken by over half the doctors in this country.

Many things are to be considered when we advise persons where it would be best for them to go when the question of a change of location comes up on account of lung troubles, and especially for consumption. Some of the needed requisites are: Even temperature; sunshiny days; work to do; moist salt air; plenty of oxygen or ozone; altitude not too high; fruit and food; near home.

No one will dispute the fact than an even temperature is of the highest consideration, and I do not know of any place in this country where such may be found. The temperature of neither 90° F. nor 70° F. are of themselves bad, but where we get such a change of 20° inside of a few hours it taxes the system to accommodate itself, and is harmful. In Central and South America there are sections of country where from the beginning to the end of the year the temperature will not vary four degress from 72° F., day or night, and such a climate can not help but be delightful and healthy every way. The reason for this equable temperature, which is had mostly on the

narrow parts of the isthmus, is because that as soon as the sun begins to warm up the earth the heated air rises, and the air coming in from either ocean, from one to two hundred miles away, creates a breeze sufficient to even up again. For this reason, too, the air becomes moist and salty.

I read only a few days ago in some medical journal where a doctor said "that the air ought to be dry for a consumptive;" but I certainly would differ, and I do not know of a single form or phase of the disease where the moist air would not be preferable, and when I am called to see a case at home always advise that water be kept on the stove evaporating, as it makes respiration easier, and certainly makes expectoration very much easier.

Sunshiny Days.-Everyone knows, of course, that near the equator there are virtually but two seasons, the wet and the dry. In the dry season I think that I never saw three days in succession without a shower, and so the grass never becomes dry and brown; and in the wet reason it does not rain all the time, but comes in showers, and very seldom those after eleven P. M. or before ten A. M., and one can always get around nicely between showers.

Work.-Every doctor knows how hard it is for a consumptive to give up work. He is always sanguine that he will get well, and must have some work to busybody and mind about. Simply swinging clubs or going for a walk never takes the place of something with an object in view, and in this country there are always sunshiny hours enough in every day to allow him all needed time for work.

Pure Air.-In this section of the country it is so very rugged and rough with mountain peaks that very little of the ground can be used with profit, consequently the number of people can never become excessive, and with an ocean close by on either side the air can never become polluted, but is of the purest and full of ozone. Nor can the air become contaminated by the smoke of factories, as it will always be cheaper for goods to be made close to the source of supplies. These mountain tops, although looking high as they stand alone, are by no

means as high in actual feet as are our Colorado peaks, and are never of such an altitude as to either prevent sleep, to cause hemorrhage, or weakness and palpitation of the heart.

Fruits and Food.-The sick person nearly always likes fruits, and they are really good for him, though, of course, he needs also good, nourishing, easily digested foods. There most fruits are good and cheap; as for instance, every morning by going to the market one can buy for three cents from five to twenty oranges, a good sized pineapple for ten cents, and a large one for fifteen to twenty-five cents, owing some to time of year. There are many other fine wholesome fruits that do not bear shipping well, and so are but seldom seen here, as the mango, called also stomach-ache fruit, the anona, cocoanut, alligator pear, and many others I am unable now to recall. As to general food, one can have as fine and good as can be had anywhere for money, only limited by the length of one's purse, or by living as do the natives mostly on vegetables, can get along extremely cheap.

These locations, then, are not so far away as to need a fortune in order to go, being only about ten days from New York, or from four to six days from New Orleans, and costing from fifty to ninety dollars from New York or from twentyfive to fifty dollars from New Orleans, and being near by one can easily return home if desired; and though a long sea voyage has always been held good, on account, of course, of the sea air, one gets this same air as it blows from the sea across the land.

In the May, 1893, number of the BRIEF, page 556, there was an article of mine on this country for lung troubles, and I have received letters from all over the United States (showing to what an immense circulation the BRIEF has) with questions of all kinds about the country, and though I answered some, most of them wanted to know more about how they could make money then about health, and I hope this letter may give information to many that I could never answer by letter, as some of such letters would have required hours to answer and be anyways correct.

I do not remember to have seen, during

my residence there of two years, a case of sore throat, or cough, or of any lung trouble except in one American there who had consumption when he came, and at the end of two years looked no worse, and the people there were as afraid of him as here they would be of a case of small-pox, and would not wash his clothes, cook for him, or give him a room, and would cross a street to avoid meeting him. Even the milk boys would leave his milk on a post away from the house, and he was obliged to cook and wash for himself. Can anything show better how seldom the people there saw a case of consumption, to be afraid to come near one?

The water in the streams is as clear as glass, and plenty cold enough to drink without the use of ice. The streams come from the mountains; and in many cities are strong enough to run all the small works and such larger ones as the electric lights, the street cars, etc.

Diseases.-The diseases most prevalent are those of the bowels, such as dysentery, etc., caused by eating too much fruit and vegetables, unripe or poorly cooked, but these are usually easily cured by a proper attention to diet for a few days. There are also some fever districts in the swampy sections, but no worse than are found in the bottom lands of the large rivers in the southern section of this country. At all the ocean ports in those countries they try to be extremely careful that no yellow fever shall get in, and quarantine is very strict. In Port Limon, the Atlantic port for Costa Rica, there had been only four cases in seven years, and when sick myself I stayed in the hospital there for over a month without fear, even though I was from the north. Even should it get in there the settled or residence portion would not be affected, being over eight hundred feet above sea level. Scrofula, syphilis, and other blood diseases, are very prevalent, and must cover many generations.

There are in such a country almost as many kinds of climate as there are localities, and an invalid should hardly leave a good home anywhere without having some idea of where the best place for him is. The climate of the seacoast suits many the best, and is far different from

that a short distance inland, where, if anywhere, it is unhealthy, and the mountain districts are different from either, and while one person may improve rapidly in a given locality another might decline still more rapidly.

As nearly every letter received by me asks about business, I will say this: No one should think of going there without having money enough for at least a year without work, unless they can talk Spanish, for those who can interpret have to attend to their own business and have no time for others, and to employ an interpreter would be very expensive. If one has plenty of capital he can find places to use it there to good advantage, as well as elsewhere.

When I went there I was in very poor health, having been traveling for a manufacturing chemical house a long time in Texas, but regained my health rapidly there, and should have been there yet. but for an unfortunate accident, a fall, from which I have been very slow in recovering. I intend now to get back as soon as my affairs are satisfactorily arranged, which probably will not be long.

I am willing to give all the information I can in regard to the different places as regards health, and what locality would likely suit best any individual case, or, when I go, would be willing to take any one with me; or, of course, would even go with and care for, any one able and willing to pay for such services.

To practice medicine in any of these places requires the same qualifications as here, and, besides, every country has a board called the Board of Proto-Medicato, which one must pass, but when one passes in any one State he is allowed (by courtesy) to practice in any other of the five Central American and some of the South American States. Every doctor has his own drug store, and dispenses by himself, or by his clerk, all his own prescriptions.

Law is rather arbitrary in all those countries, but a person never will be disturbed if he minds his own business and does not meddle in their political affairs. I was never treated better anywhere, and was granted greater favors than I could have asked. If a foreigner, though, is a rough and a drunkard he will be given hours to get away, and