dense and liable to form tough curds than human milk, has led me to hope that if we partially convert the starch of the barley water it will become not only a mechanical diluent for milk, but a readily absorbable food as well, which will nourish and not give rise to fermentation and flatulence.* Some time since I witnessed several experiments in bread-making made by Mr. C. Von Egloffstein, then of Yonkers, now of Brooklyn, N. Y., to determine the value of diastase in rendering bread more soluble. His conclusions were that the soluble matter in ordinary bread in water at a temperature of 100° F. represented at the end of an hour 15 per cent. whereas when a proper amount of a product containing diastase was added to the bread before baking the soluble matter under the same conditions was 40 per cent. It is more than probable that diastase will play an important part in the therapeutics of the future. RESIDUAL URINE OF THE URETHRA.† By STUART MCGUIRE, M.D., Richmond, Va., Professor of Principles of Surgery in the University College of Medicine, and Surgeon to St. Luke's Home, The Virginia Hospital, and the Home for Incurables. The penis is both a urinary and sexual organ, and, like all compromises, has certain defects which render it liable to disease. Disorders of the kidney and bladder affect its sexual function, and venereal troubles cripple it for the discharge of its urinary duty. So intimately are the two associated, that in treating disease of the one the possible influence of a pathological condition of the other must be constantly considered. There is no condition met with in genito-urinary practice so difficult to cure as chronic posterior urethritis. I do not propose to discuss the disease systematically in this paper, but I want to call attention to the fact that in many cases the condition is maintained and the treatment frustrated by the presence of residual urine in the urethra. It has long been known that a few drops of urine may be retained behind a tight stricture, but I have been unable to find mention of the possibility of a considerable quantity of urine being left in a dilated portion of the urethra, and acting as a causative factor, or as an obstacle to the cure of the disease. The urethra is not a tube of uniform caliber but has points of physiological narrowing. It is divided arbitrarily by anatomists into three portions-the spongy, the membranous, and the prostatic; by surgeons into two—the pars anterior and the pars posterior. The urethra has two curves * See Dr. Chapin's remarks in the discussion following. + Read before Richmond Academy of Medicine and Surgery, December 8, 1896. -one fixed by the prostate, the other movable and depending on the position of the penis. When urine passes through the urethra it is propelled not only by the visa tergo of the bladder, but by the contraction of the various muscles, and the channel is normally emptied of the last few drops of fluid by a progressive wave of blood which flows from the bulb through the corpus spongiosum. A careful study of the anatomy of the urethra will at once suggest the possibility of urine stagnating at certain points; and a review of the physiology of micturition will show how nature has seemed to foresee the evil results which would follow, and guard against its Occurrence. It was my misfortune at the very beginning of my professional life to have several patients with chronic inflammation of the deep urethra. I treated them with indifferent success, and, from my inability to cure them, attributed the symptoms of which they continued to complain, to sexual neurosis or hypochondriasis. Finally, I bought an electric urethroscope, and began to examine systematically every case of chronic urethral trouble that came into my office. At first, I accomplished little; but after I became familiar with the healthy and the diseased appearance of the mucous membrane of the canal, and learned by experience what local applications did most good, my results were very gratifying. In several different cases, when I looked down the tube, I almost invariably found its end filled with fluid, and so constant was this condition that I expected to find it, and had a mop ready to remove it. I did not at the time appreciate its significance, and supposed that I had introduced the instrument too far, and had dilated the sphincter of the bladder. Last winter a patient came to see me, suffering with chronic posterior urethritis, but, in addition to the usual symptoms, he said that after urinating his trouble was greatly increased, and that he could only obtain relief by stroking his perineum firmly with his finger from behind forwards, and thus milking out about half an ounce of urine which remained in the deep portions of the urethra. The passage of a No. 30 sound failed to detect a stricture, and I was forced to the conclusion that the residual urine was not dammed back by an obstruction, but was retained in a dilated and inelastic pouch of the urethra. I have now the record of four other similar cases, the quantity of retained urine varying from one drachm to half an ounce. Residual urine of the urethra may be caused in one of two ways or by a combination of both. Either there may be a stricture of the urethra, and the urine rushing down from the bladder meets with the obstruction, and by hydrostatic laws expands the portion of the canal behind the stricture, and the repeated distention causes the part to lose its elasticity and contractility and remain patent; or there may be no stricture; but a chronic inflammation of the mucous membrane and adjacent structures may so lessen its tone and relax its tissues that dilatation and sacculation follow. In both cases the result is the same; urine is retained in the urethra, and, undergoing decomposition, irritates its sensitive surface and produces distressing symptoms. It is a question whether residual urine in the urethra is the cause or the consequence of posterior urethritis. The practical fact is that the condition cannot be cured till it be removed. The treatment of such cases must be moral, hygienic, constitutional, and local. The patient is in a state of mental depression bordering on sexual neurasthenia. He is as morbid and hysterical as a woman with "womb disease." By kindly sympathy and judicious encouragement, the surgeon should win his confidence and overcome his fears. The patient's diet should be restricted, his bowels regulated, and a moderate amount of exercise advised. If he be married, sexual intercourse need not be interdicted; but if he be single, he should remain continent and carefully avoid all possible sources of excitement. Tonics are frequently useful; if the patient be weak and has no appetite, give him a bitter stomachic like tincture of cinchona; if he be pale and anæmic, give him large doses of tincture of the chloride of iron. Direct him to "strip" his urethra after emptying his bladder; and if his urine is concentrated or irritating, instruct him to drink large quantities of some pure light water. Salol, or some other drug which is eliminated by the urine and by its antiseptic properties prevents its decomposition, may be frequently used with benefit. The local treatment is of great importance. The first point to be determined is the presence or absence of stricture. If it be present, it should be dilated by the systematic use of large sounds. If it be absent, or if the symptoms continue after it has been removed, the case should be treated by making stimulating applications directly to the diseased area. The whole length of the urethra should be rigidly inspected with the urethroscope, and the congested spots, granular patches, or superficial ulcers, accurately located and carefully touched with a solution of nitrate of silver, the strength being varied to suit the requirements of the individual case. Before the developments of urethroscopy, urethral lesions were un relieved because unrecognized. We live in an age of accuracy and precision, and with modern instruments have no excuse for empiric practice. SELECTIONS. LECTURES ON ANGINA PECTORIS AND ALLIED STATES. Professor of Medicine, Johns Hopkins University, Baltimore. Lecture VII.-Diagnosis, Prognosis, and Treatment of Angina Pectoris. Treatment. "The first and great object of the practitioner on being called on to treat a case of angina will be to make himself acquainted with its individual character. Beginning with the early history of the disease, he will trace it to its present stage, and will endeavor, from the narrative of the patient and from the observation of the whole phenomena presented to him, to form a clear judgment respecting the local condition of the organs in which the characteristic symptoms have their site, and the state of all the other parts of the system which can in any way influence these; in other words, he must endeavor to ascertain the species or variety of angina, according to the distinction formerly pointed out." This clear statement of Sir John Forbes forms a fitting introduction to the discussion of this part of our subject. Successful treatment depends often upon correct diagnosis; but there are cases of angina pectoris brought to the consultant in which diagnosis and prognosis in themselves constitute the treatment. To a man who has felt that judgment has been given against him, the doom pronounced, and whose mind is haunted with the dread of sudden death, the assurance that the condition is functional and curable comes as a reprieve, and may be the one thing necessary to effect a cure. True Angina.-Determine in the first place, if possible, the existence of any constitutional disease, as syphilis, gout, or diabetes, and the presence or absence of valvular lesions. (a) General Management.-Inquire carefully about the exciting causes of the attacks, which differ in different cases. Usually the patient has learned by bitter experience his limitations in certain directions, and knows much better than you can tell him just what to avoid; but you can emphasize the importance of mental worry, exercise, and diet, the three chief factors. Quiet of mind, avoidance of worries and cares, the cultivation of a calm equanimity-with these, or such like phrases, we try to impress a poor victim who, to previous anxieties has now the added burden of a disease, the terrible character of which he can appreciate but cannot understand. Our words often seem a mockery, and yet they may be helpful in persuading a man to cast off all unnecessary business and to live a life in which there shall be a minimum of friction. Time, too, with its soothing deception, comes to allay the access of early apprehension, and as succeeding attacks pass there may be less and less mental distress. An important question arises here, Shall a man with angina give up his business? In a majority of cases this sacrifice is unnecessary; the literature abounds with examples of men who, like John Hunter, have done the best work of their lives after the onset of angina. There is so much uncertainty that no rule can be laid down; each individual case must be considered separately. The patient's age, occupation, and, above all, the condition of the vascular system, must be taken into account. Even after a most severe attack, followed by a cardiac breakdown of several months' duration, a man may be able to resume work, and, as in Case V, referred to in Lecture III, be benefited by the steady occupation. Exercise must be taken within the limits which each individual soon learns to recognize. In severe recurring attacks, induced by slight muscular efforts, a period of absolute rest should be enjoined. The sudden, quick movements which rapidly increase the blood pressure and throw a strain upon the heart are the most dangerous; and most of all those with which are associated strong emotions. The patient should be urged to walk on the level, in the literal as well as metaphorical meaning of the phrase. He should learn "to live within the income of his circulation," with which wise saw from the lips of the late Dr Sibs on a friend with organic heart disease has been comforted and sustained for a quarter of a century. Steady, quiet exercise should be encouraged, except, of course, when there are special signs of cardiac weakness, in which case the resistance gymnastics of the Schott method may be tried. Diet is in many cases the central point in the treatment. The subjects of angina are often men with large appetites, accustomed to eat freely of rich and strong foods. First, limit the amount taken, which in most persons above forty years of age is far too great; second, see that the quality is suitable by excluding from the dietary rich, highly seasoned foods and those which favor fermentation; and third, arrange the hours for eating. The subjects of angina are usually aware of the necessity of limiting the quantity of food and drink taken at one time. So soon as the stomach is distended there may be warnings of distress about the heart, or in aggravated cases a full meal may always cause an attack. As one patient expressed it, "Had I not to eat, I would never suffer." Light meals should be the rule in all cases; at breakfast and at midday dinner more may be taken than at the evening meal. Late suppers should be interdicted-there |