Lastly, there was the sodden condition of the scrotum and surrounding parts arising from continued soakage with putrid urine and resembling in this respect a distended sponge.

From these observations it appeared that in an operation undertaken for the relief of extravasation of urine, the following objects should be definitely aimed at.

1. The removal of the stricture by its free division to commence with.

2. The provision of ample and incontinent drainage by means of a suitable drainage tube at the point in the urethra where the extravasation has occurred.

3. The making of suitable incisions where extravasated urine has reached, such as the scrotum and abdominal parietes, and in addition the adoption of means for freeing the tissues at once of the urine they contain.

This as a rule is inefficiently done by is inefficiently done by means of the unaided gravity which incisions alone permit of. The enormously swollen and often tense scrotum and other parts should, after being incised, be squeezed or manipulated by the surgeon on the same plan as a wet sponge is deprived of its contents. In this simple, but often neglected way, the loss of much tissue by sloughing and suppuration may be prevented.

Exception has been taken to the combined operation, on the ground that it entails opening the deep urethra, and that a urinary fistula in this position may be the result.

There is no risk of this if the opening is made in the right direction that is to say, immediately in front of the prostate in the borizontal or membranous portion of the urethra as the patient lies recumbent. Here it is impossible to prevent the wound healing unless a drain tube is retained. On the other hand, if the incision is made entirely in the vertical portion of the canal it is the reverse and healing may be indefinitely postponed.

This deduction admits of easy proof, for assuming the opening to be in the median line of the perineum, though in the vertical portion of the urethra where the stricture may be situated, all that is necessary to se. cure its healing is with a probe-knife to extend the incision in downward direction, so as to throw the lower angle of the wound into the horizontal portion or membranous urethra. Since making this observation, I have never hesitated opening the urethra when I thought it necessary either for the treatment of a stricture or the obliteration of a fistula.

In making incisions to relieve extrava sa tion, care should be taken to place then, if possible, where either in the course of healing or in the scar that foliows, no subsequent trouble is likely to be caused. I have seen

patients suffering from painful sexual inabil. ities by reason of adhesions between the dorsum of the penis and the suprapubic region following openings in these positions. Similarily incisions along the sides of the penis are sometimes followed by contraction of the scars tending to distort the form of the erect organ.

I will briefly state the method of preceding with the combined operation in the case of a middle-aged man suffering from stricture, complicated with perineal abscess and acute extravasation of urine, the latter involving the perineum, scrotum and abdominal parietes.

The patient being anesthetized and the parts involved being shaved, and as far as possible antiseptically prepared, an attempt should be made to pass the filiform guide of the urethrotome and perform an internal urethrotomy on the lines previously described.

Difficulty will seldom be found in doing this, even with the scrotum enormously swollen, as the extravasation seems to take off the extreme degree of tension at or about the point of stricture. The swelling may, how ever, first he removed, if difficulty is experienced at this stage, by freeing the scrotum by an incision on either side of the raphè and squeezing out the urine with the hands. In this way it may be reduced in size in a few minutes.

The internal urethrotomy being completed, a full sized median grooved staff is then passed into the bladder and the patient is placed in the lithotomy position.

Then the next stage of the proceeding is also carried out, as already described in the section relating to external urethrotomy, and an ample drainage tube is placed in the bladder. The whole proceeding need not occupy more than a few minutes.

The tube being secured in situ and tested with a syringe and some boracic lotion as to the efficiency and continuity of the bladder drainage, all that remains is to give vent to urine that may be extravasated in adjacent parts, as indicated by signs of inflammation or urinous emphysema, care being taken at the same time to squeeze and wash out any putrid urine or matter that may be in evidence.

The routine adoption of the practice here described greatly reduced the mortality, and cases of stricture and extravasation of urine were rarely lost except for reasons due to delay in taking action.

In cases where the stricture proves on careful trial impassable to instruments of all kinds, the surgeon will treat them on the lines previously considered in connection with uncomplicated obstructions, vent at the same

time being given to urine, wherever it appears to be extravasated. The after-treatment of these cases consists in scrupulous attention to cleanliness and urine drainage, as the leading principles.

TALKS TO RECENT GRADUATES.

A. L. BENEDICT, M. D.

BUFFALO.

THE HOSPITAL.

IT may seem inopportune to publish this article at a time comparatively far from the usual commencement season, but so many physicians enter upon hospital services or post-graduate courses, or take well earned vacatious immediately after commencement, that there is scarcely a time of year when there is not a large number of young men entering upon their life-work in medicine.

For our present topic, we consider this time as particularly opportune. Those graduates who needed no argument as to the desirability of a hospital service, and who had the opportunity, are already thus engaged. Our words are addressed rather to those who, in the spring, failed to realize the advantage of hospital work or who felt that they could not afford to spend the time or who, for one reason or another, lacked the opportunity.

Along in the early fall there are usually vacancies in hospitals either occurring in regular sequence or from the dropping out of those on the eligible list. Those of you who felt that a hospital service was an unnecessary waste of time and effort have, by this time, learned how sadly lacking you are in just the simple, practical experience which such a service affords, or, if not, you are too collosally ignorant ever to learn the best lesson of medical experience, namely, a humble recognition of human limitations.

Those of you who were deterred from applying for hospital service by financial considerations have, by this time, had a chance to earn a little money in one of various outside employments, or you have seen how little is the reward of medical practice and how much better it is to set aside immediate aspirations for wealth, and to prepare for a more painstaking and less mercenary career. Generally speaking, you will never see more patients nor have better meals and a better appointed office and laboratory or operating-room, than you will enjoy in most well equipped hospitals.

Those of you who simply lacked the opportunity for a hospital service, may be able to

find an opening by correspondence and personal investigation. sonal investigation. Do not despise a small town nor a small hospital. Barring rare cases, a service of ten patients will give you almost as much self-confidence and practical familiarity with disease, as one of a hundred. If you cannot get into even a small hospital, try for the privilege of substitute work for some interne, or for the privilege of visiting the wards with the attending physician, or for assisting some physician with a fairly large practice or for helping in a dis

pensary.

It is frequently and often quite openly charged that hospital appointments go by favor. This is legitimate enough if the hospital is a strictly private institution. If it is in any sense public, especially in the sense of being supported by public charity or of being part of the equipment of a medical school, favoritism in the selection of internes is graft. If appointments are made on examination, the method of choice is fair, although this method often fails to secure the best staff, and though, in general, it excludes those most in need of hospital experience. If an examination is held and then personal influence has a determining voice in the selection, the board responsible for such a disgraceful state of affairs ought to receive the same treatment as public opinion now demands for political tricksters who set aside civil service lists and give official plums to favorites.

It is scarcely necessary to admit that there are exceptions to all rules. Some medical schools now practically include an interneship in the regular course. Some graduates have the opportunity to enter the guidance of a father, uncle or friend and, while no such experience can quite duplicate the educational value of a hospital service, it may represent a practical equipment, and no man has a year of active life to spend in preparation that is not a necessity.

We need not urge upon the young interne the need of such ordinary virtues as industry, integrity and self-respect. There are two thoughts that we would suggest: One is to avoid the megacephalia which attacks so many internes. Your position is one of dignity, responsibility and honor but, at the same time, you are officially the inferior of others, and your office is held by thousands of other young men of no tremendous intellectual prominence. It will be, in no sense, a loss of rank when you step out of the hospital and engage in private practice and, in spite cf a full realization of the dignity of our profession, we cannot afford the effort of constantly carrying this realization with us.

The second thought is that the personnel of a hospital is a social as well as a medical clinic for your instruction. Try to learn why you like one member of the visiting staff and detest another, why one has the esteem of his fellows while another gets his success in the face of hostility and lack of respect, what one man does with drugs, foods and instruments to win confidence, and what another does with the same armamentarium to get the reputation of a putterer and a man who travels on his shape.

Perhaps for the first time in your life, you will have to combine social and business or professional relations with women. Again, if you have finished your medical course at a comparatively early age, you may be somewhat puzzled at having to read just your relations to the world at large so as to include all ages above that of maturity on a level. That is to say, you will find men and women who, five years earlier would have treated you as a child, and whom you would have treated with the heartless aristocratic intolerance of youth, now expecting you to have as much knowledge of the world as themselves, to meet them on the same plane of maturity, and yet to recognize the faint shades of respect for age and position that society still demands.

Both medically and socially, you must learn not to generalize, but to rate each case and each person at the proper value. You will find some very vulgar and dangerous women in the private rooms and some very sweet and refined unfortunates in the wards. In a sense you must treat all alike: in another sense, you must learn to yield to true gentility, in man or woman, that suggestion of deference which is its due and you must, equally, learn to draw that line of reserve about yourself which the under world dares not pass and which is still so faint as not to be a barrier which they can resent.

In the nurses, you will find startling differences of social and intellectal standing. Avoid either extreme of regarding them with a sentimental way as angels, with a halo materialized into a gauze cap, or as menials. Unfortunately, all nurses are not alike, from any standpoint, yet, in theory at least, you must treat them as intelligent gentlewomen studying for a profession which is necessarily subordinate to our own, and usually with the object of earning a living, and yet, a profession of dignity and practical value. Officially, you should treat them as you would like to have the visiting staff treat you, remembering that a nurse who will submit to more than temporary indignities is not of he class of women competent to assume the grave responsibilities of her profession.

The relations between medical and nursing staffs should be friendly and yet, it is obviously impossible to maintain the discipline of a hospital of any considerable size if this friendly relation degenerates into even ordinary familiarity.

If the propensity for tale-bearing, making mischief for others and whining about your own troubles has not been licked out of you at some of the schools that you have attended, try to get rid of it under the ample opportunities that your bospital life will afford for resisting temptations of this kind. Don't excuse your own sins by the numerous examples that you can cite from among your acquaintances, and don't expect a woman to understand by honor just what a man does.

In short, as you gain practical medical experience in a hospital, try to learn the lesson of living with other persons of the most varied types. How to do this you will bave to work out for yourself, but a simple rule is to be square and yet not to push the corners of your squareness into others.

INDIA'S DEATH-RATE FROM WILD BEASTS. -Statistics published in India show that in 1904 there were killed in that country by snakes and wild beasts 24,034 persons-21,880 by snake bites, 79 by tigers, 399 by leopards, and the rest by other animals. The number of cattle killed was 98,582. The other side of the account shows that 65,146 snakes and 16,121 wild animals were killed, for which rewards of £7,313 were paid.

TUBERCULOSIS IN ST. LOUIS.- Statistics have been compiled by the clerk of the St. Louis board of health, showing the number of cases of tuberculosis and the deaths from that disease in each of the seven sanitary districts. The third district, located east of Jefferson Avenue and between Franklin and Chouteau avenues, shows a greater aggrega. tion of cases and deaths than any other district. In the first district, with a population of 77,075, there were 243 cases and 182 deaths; in the second, with a population of 98,336, there were 249 cases and 178 deaths; in the third, with a population of 68, 159, there were 267 cases and 190 deaths; in the fourth, with a population of 119,056, there were 246 cases and 183 deaths; in the fifth, with a population of 77,522, there were 192 cases and 130 deaths; in the sixth, with a population of 130,975, there were 271 cases and 187 deaths, and in the seventh, with a population of 123,895, there were 260 cases and 162 deaths.

SELECTED ARTICLE

THE IDEAL ATTITUDE OF THE PHYSICIAN TOWARD ALCOHOL, AS A MEDICINE, A FOOD AND AS A BEVERAGE.*

WM. EBERLE SHAW, M. D.

CINCINNATI.

There was read before this society, at its meeting September 4, 1899, a paper on "Alcohol and Alcoholism," by a very learned and honored member, which began with this sentence: "For several years of late certain members of the medical profession have earnestly, if not clamorously, agitated the subject of alcohol and alcoholism, making assertions and promulgating ideas that should not go unchallenged as being either accurate or wise." The writer speaks of these "would be reformers of medical practice and practitioners" and their claims, and adds: "Considered in the light of facts and of reason and common sense, 1 regard this movement as one of those sincere exaggerations of superficially apparent truth, characteristic of fanaticisin, that is equivalent to falsehood."

The paper contains a severe arraignment of thousands of brave, true and well-developed specimens of manhood who choose to deny themselves the sensual pleasures of wine,. when he says that " banquet without wine. is practically intolerable to other than abnormally or eccentrically developed men out of harmony with their environments.' Speaking of alcohol as a medicine, the doctor said: "Other physicians of equal reputation profess and do treat the same variety of diseases successfully without alcohol, but this should not discredit its reputation and usefulness as a medicine.”

Dr. T. J. Hillis read a paper before the New York State Medical Society, October 24, 1899, in which occurs this remarkable encomium to whisky: "It may here be stated, without the likelihood of contradiction, that if whisky was properly ripened, or aged, before being exposed for sale by distilleries and saloons, two-thirds of the crime and threefourths of the insanity charged to the account of alcohol would disappear from the indictment, so bulky and so terrible, that stands against it on the statute books of society. It is the quality of the alcoholic product, and not the quantity, that must be taken into consideration."(?)

I was recently called to see a man, fifty years old, who was sick with pneumonia for three days. I was called because the physician who had been treating him could not be found, and had not seen him for twenty-six

Abstract of a paper read befor the Academy of Medicine of Cincinnati.

hours. The sick man was with difficulty aroused from a stupor, which seemed parThe patient was tially, at least, alcoholic.

not a drinker; he was taking no medicine except whisky, which the doctor had ordered to be given in large quantities, "as much as they could get into him." The man died twelve hours afterwards. I am much inclined to think the whisky hastened his death. (The patient was not near a crisis). I was credibly informed a few days afterward that the physician who had preceded me was in one of our hospitals, suffering with acute alcoholism.

I had under observation for eighteen months a refined, devoted wife and mother, a grandmother, who had been the innocent sufferer for the sins of her husband from many of the symptoms of that hydra-headed punisher of violators of the seventh com. mandment. The husband has always been considered a very moral and upright man, as well as a devoted husband For many years he has been a moderate user of alcoholics. He told me before this calamity befell him that "he always knew when to stop;" in fact, he possessed all the virtues which so many moderate drinkers arrogate to themselves. "He could drink or he could let it alone." This man, in his perfectly sober moments, I believe, would sooner have lost his right arm than to have violated his sacred martial vows. One evening he did what so many moderate drinkers do, "got out with the boys," and without being what any of them considered intoxicated, drank enough to lose his good judgment and discretion and finer sense of right. With these faculties gone-and they are the first to be affected a man is a rudderless ship. This man on that evening drifted from his moral moorings and not only wrecked his peace of mind for all time, but most seriously damaged his own health, as well as that of his innocent, trusting wife, whom he had most solemnly promised to love and cherish.

So long as such favorable opinions of alcoholics are presented for the consideration of medical societies, so long as instances of bestiality occur among medical men, degrading the profession and destroying the holiest things of the family and of the home, so long will there be some of the so-called "would-be reformers of medical practice and practitioners" in evidence to call a halt to the pernicious ideas that alcohol is either a harmless universal panacea or an advisable food or beverage.

The physician who uses narcotic drugs with a careless hand, regardless of the possible contraction of the drug habit by his patient, is a dangerous man to be loose in any com

munity, and he ought to be muzzled, for he is more to be feared than a rabid dog.

Who are those medical gentlemen who are so shocked by a discussion of this subject, which reaches over into the ethical field? You will invariably find them to be habitual users of acloholic beverages, many of whom honestly believe that it is nobody's business what they eat or drink so long as they show no unmistakable signs of intoxication, which latter statement may contain a great deal of truth, for, understand me, I am an abstainer of my own free will, and not by compulsion. The time was when I myself deemed cpposition to a very liberal use of alcohol in medicine as the "frantic efforts of well-meaning but illy-informed enthusiastic reform ers," as the learned friend puts it. At that time I was practically iguorant, as I believe thousands of the profession are today, of what Richardson, in Enlgand, and N. S. Davis, Reuben Mussey and so many other pioneers in this field has done in the study of this question, and in the advocacy of total abstinence as a salutary measure in the profession.

Disgusted with the abuses of the drink habit in the neighborhood where I live, the conviction was driven upon me that I could not longer indorse the habit, be it ever so temperately, by being myself a consumer, especially when I occupied a position toward the community as a conservator of the health of the people.

Notwithstanding the fact that I, at that time, recognized and occasionally enjoyed its use as a delightful luxury, I plainly saw. that it was so dangerous to so many that it was my bounded duty to willingly forego any selfish pleasure that I might have in its use, that my influence upon the young men around me would be to lead them away from an indulgence that would certainly very seriously damage many and utterly destroy some of them.

I recognized the wisdom of that part of the Hippocratic oath, viz., "I will follow the system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, abstaining from whatever is deleterious or mischievous."

It will be a great satisfaction to every man if, at the end, he can say he never put a young man on the wrong path. I felt that in advocating and practicing total abstinence I could make no mistake, for I would be occupying the ideal attitude of a medical or any other man to this question.

I am the father of two boys and surrounded and watched by many other boys, and this position forced itself upon me; there was no escape without seriously offending the best

part of myself. Woe to the man who persistently offends his conscience; he is most irretrievably damaged in the finest mechanism of his being! I wish to insist that I am defining my own individual convictions and position on this question, and no other man's, and I wish to do it without exciting a single suspicion of cant or Lypccrisy.

Every individual must reach his own final convictions of right and duty before the bar of his own conscience; if your ultimate conclusions on this or any other subject should radically differ from mine, it would certainly be exceedingly unbecoming in me or any one possessing the true instincts of a gentleman to refuse fellowship or good will on account of differing opinions. It is my duty as a member of society to defend my honest convictions and convince, if possible, that I am right, but it is despicable in me to hate my neighbor because his opinions differ from mine.

I realize how very difficult it is to define an ideal position in ethics without making use of expressions that leave the flavor of phariseeism, and I shall constantly bear it in mind during this discussion.

I believe that total abstinence from any. thing for conscience sake is a virtue, but true nobility of character is so very composite in its nature, and depends so largely for its development upon strong, positive inspirations, that negative denials are minor traits in com. parison. A man might possess all the negative points of an ideal character and still be as a pigmy in the presence of a noble-hearted, positive, large-souled drunkard even. I want to be liberal-minded and at the same time exercise that highest type of charity, tolerance for the opinions of those who differ from me, but at the same time I do not want to forget that warning given by the greatest ethical writer of any age: "Take heed lest by any means this liberty of yours become a stumbling-block to them that are weak." may class me as a radical on this question, but please do not use that vituperant epithet, fanatic, for you well know my position is impregnable.

-

You

There are hundreds of young men in this city-and they are found in every community who have within them elements of success that would make them useful citizens had they sufficient force of character to resist the invitations, so numerous on every hand to take a social drink, especially difficult when proffered by those whom they honor, respect or love.

I feel very thankful for the influences that made me a total abstainer, for the blood of these men who go down by alcohol is not on my hands, and besides, I have the satisfac