and offer a complication in perineal section which is as embarrassing as it is unusual. The essence of this particular condition is, I believe, a congenital anatomic aberration of the urethra, in which practically two canals lie side by side for the greater portion of the usual course of the external urinary duct. The cases are as follows:

Case 1.-B., aged 45, lumber merchant. Had had gonorrhea several times, but no history of definite strictural obstruction, urination having always been unimpeded in the slightest degree. Since the last attack of gonorrhea, seven or eight years before I saw the case, he had developed an annoying frequency of micturition. This, from the history, evidently supervened upon prostatic infection. There were no other symptoms, of a subjective character, save, as the patient expressed, "extreme nervousness," in which a lack of confidence in his ability to retain the urine played a large part. To say the least, the case was characterized by extreme neurasthenia. The urine was slightly turbid, and contained characteristic deep urethral products of inflammation. There was no visible urethral discharge.

Exploration of the urethra revealed nothing excepting chronic inflamation of the bulbo-membranous and prostatic regions, with possibly slight narrowing and thickening of the membranous portion, which might have been expected from the prolonged existence of the inflammation. The urethra readily admitted 30 French.

Exploration of the bladder and cystoscopy revealed nothing which would explain the symptoms. Everything else having been tried, without avail, perineal dilation of the vesical neck and prolonged vesical rest by drainage were suggested, and consented to..

Operation. The perineal urethra was opened on a large grooved staff in the usual manner, without any difficulty. The finger readily passed into the vesical neck, which was dilated thoroughly. In passing a pair of long forceps down through the anterior urethra, with the intention of bringing them out of the perineal wound, for the purpose of drawing up through the urethra from behind forward a piece of iodoform gauze for drainage, I found, much to my surprise, that the forceps did not protrude, but passed down by the perineal incision in the urethra, and could be felt by the finger in the perineal wound to have traversed a distinct canal lying side by side with the channel originally opened. This terminated at the bulb in a blind extremity, and be

gan anteriorly at the peno-scrotal angle. I laid the adventitious passage open, tracing it up carefully to its anterior extremity in the posterior portion of the pendulous urethra. It was lined by mucous membrane, quite identical with that of the urethra proper, and was fully as large as the latter. In the absence of any history of forcible instrumentation, and especially in the absence of any necessity for the introduction of small instruments, taken in connection with the large size of the adventitious canal, I believe I am justified in assuming that the urethra in this case was congenitally double for a portion of its extent. The difficulty in outlining the urethra in case the staff had entered the adventitious channel instead of the main one is at once obvious.

Case II.—E. B., carriage worker, 35 years of age. This man gave a history of repeated attacks of urethritis. He had known for some years that he had a severe stricture, but paid very little attention to it. From time to time he had had attacks of retention, which necessitated the passage of a soft catheter. At no time had rough or violent instrumentation been practiced, nor had bleeding followed the introduction of the instrument. He finally concluded to have systematic treatment for the stricture. Examination showed a moderately tight tortuous stricture of the penile urethra, and a close stricture of the bulbo-membranous region. These strictures were hard and resilient, and any attempt at instrumentation produced chill, which was sometimes alarmingly

severe.

Combined internal and external urethrotomy was suggested, and after suitable preparation was performed. The anterior internal urethrotomy was readily performed, but I failed completely in getting a guide through the deep stricture. Filiforms failed to pass even under complete anesthesia. I passed a grooved staff of large size, down to the face of the stricture, as I supposed, and cut directly down upon it. The staff was apparently in the urethra, and I proceeded, after the Wheelhouse method, to search for the opening of the stricture at the bulbo-membranous junction. Failing to find the opening after prolonged search, and with my experience in Case I. in mind, I began to suspect that the channel which I had opened up was not the urethra proper. Withdrawing the staff, I succeeded, after some little search, in finding the anterior opening of a second canal, which began about the middle of the pendulous portion. The bougie pasesd readily down to the bulbo-membranous junction, at which point I cut down upon it, and demonstrated by careful dissection and exploration

by the finger that I had found the urethra proper, after which I had no trouble in reaching the bladder. The operation was completed by laying both canals into one.

Case III.-J. I., aged 46, lawyer. This man had a history of traumatic stricture of twenty-five years' standing. This was followed by periurethral abscess, granting that his history was accurate. He had never been treated systematically, but had had the anterior urethra "opened," as he expresed it, several times to relieve acute retention. Retention had always been relieved by a small flexible bougie. Frequent micturition and lumbar pain finally compelled him to seek relief.

Examination disclosed several very tight strictures in the pendulous urethra, and distinct obstruction of the bulbo-membranous junction.

In view of the history and character of the case, and the limited time at the patient's disposal, combined internal and external urethrotomy was deemed the wisest procedure.

Operation. The operation in this case was similar in its essential features to the one preceding. After the division of the strictures in the anterior urethra, it was found impossible to pass a guide through the deep stricture. The grooved staff was, therefore, passed down to its face and the urethra opened directly upon it. I found what was apparently the urethra deflected markedly to the left of the median line, and terminating below and behind the bulbo-membranous junction in a cul de sac formed by rigid and unyielding structures, in which the triangular ligament played a prominent part. Prolonged search failed to find an opening in this cul de sac corresponding to the deep urethra.

I had determined to do a suprapubic cystotomy and retrograde cateheterization later, and with this in view passed a urethrotome to the perineum from the meatus, with the intention of bringing it out through the wound for the purpose of grasping a piece of gauze to be pulled forward into the anterior urethra to provide for drainage. The urethrotome failing to emerge through the perineum as expected, I found that it had entered a canal lying parallel with the one first opened, and had penetrated as far as the opening in the triangular ligament. This canal I found, on exploration, to be the urethra proper, and I had no special difficulty in dividing the deeper stricture. The adventitious canal was lined by mucous membrane, and was considerably larger than the urethra proper.

DOES VACCINATION PREVENT SMALL-POX?

By E. STUVER, M.D.,

Fort Collins, Colorado.

Does vaccination prevent small-pox, and is it a public benefit? The only way to come to a just conclusion in the determination of any question is calmly, impartially and judicially to investigate the facts on which its merits depend.

As small-pox and vaccination occupy a prominent place in the public mind at the present time, and, as widely divergent views are being expressed as to the utility of vaccination as a preventative measure against small-pox, as well as the danger of conveying other diseases by means of vaccination, I desire briefly to discuss the subject.

Physical good and evil are comparative terms, and a preventive measure which will save ten, a hundred, or a thousand lives for one that is lost through its employment, especially when the one would in all probability have succumbed to the disease had no such preventative been used, should be regarded as a most beneficent boon to humanity, and receive the hearty support of every right-thinking person.

How will the beneficence and utility of vaccination stand such a test as this? Living as the people of the civilized world have for the last hundred years, under the safety and security conferred by vaccination, and knowing the horrors of smallpox only as an echo from the dead past, it is necessary, in order to get anything like a clear conception of the subject, to go back in history to the time before the discovery of vaccination, when small-pox was king of diseases, and swept over the most civilized countries, leaving death and desolation in its track. Indeed, so great were its ravages that not only did hundreds of thousands die from it, but, as we are informed by the historian, Macaulay, at one time scarcely a person could be found in London not disfigured or marked by this dread disease.

With the general introduction of vaccination, however, all this has so changed that wherever vaccination and re-vaccination have been thoroughly carried out, small-pox has disappeared, and at present scarcely figures in mortality statistics.

O, but says some hypercritical opponent: "Vaccination did not do that; it was accomplished by the general improvement in sanitary science."

If this be true, how does it happen that of persons living under exactly similar sanitary surroundings, small-pox attacks those who have not been vaccinated, or insufficiently vaccinated, and that those vaccinated escape? How does it happen that antivaccination communities, and those where people have become careless about vaccination, are those where small-pox secures a foothold and cannot be stamped out until the people have been rendered immune by vaccination?

The annual report of the Iowa Health Board shows that, of 143 cases of small-pox since June, 1899, not one had been successfully vaccinated inside of sixteen (16) years, and only seven had any trace whatever of vaccine scar. How does it come that the English, French, German or American soldiers who have been properly vaccinated can be brought face to face with smallpox in the unhealthy tropics, in places reeking with filth, and all sanitary conditions much worse than the London described by Macaulay, and these soldiers be almost immune against the disease?

Does the sanitation of the countries from which they come, thousands of miles away, protect these men in the midst of health-destroying environments, against a disease which is destroying thousands of acclimated natives? Why is it that even the opponents of vaccination in the face of an epidemic of smallpox resort to this preventive measure to protect themselves? If disinfection, fumigation, swallowing the virus, and similar measures will save them, why do they not stick to these things in the face of real danger?

The fact is that vaccination is the only thing that will really prevent small-pox, and many anti-vaccinationists know it, and take advantage of its protection while declaiming against it.

I have often thought that through generations of vaccination a vital resistance has been created, and a partial immunity established, so that when small-pox attacks even those who have not been personally vaccinated, owing to the mitigating influences of vaccination in their ancestors, the disease assumes a milder form.

The universal verdict of boards of health, sanitary experts and physicians, who have made a thorough study of the subject, and are competent to give an opinion worthy of confidence and acceptance, all over the civilized world, is that vaccination is the only real preventive, and the only measure that can control.