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SUPRA-PUBIC LITHOTOMY CYSTOTOMY.

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the literature of this subject, as published in the New York Medical Abstract, for May, 1883.

I can bear testimony to the justness of Dr. Prudden's criticism of Ehelich's method of staining the bacillus already mentioned, for after repeated trials, in which I was ably and generously assisted by Prof. Wegener, Superintendent West Denver Schools, it was almost by chance that we obtained the specimen I have here to show you. Different degrees of coloration and decoloration by Ehelich's method were carefully tried, and finally this was obtained by using a very thin layer of sputum and twice coloring and each time afterward washing with the nitric acid solution. The magnifying power used is about 500 diameters. When first found there was a beautiful coloring of nearly a hundred bacilli together, but by an accident, the cover glass became disarranged and the bacilli are now mixed up in the field so that only eight to twelve can be seen together.

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SUPRA-PUBIC LITHOTOMY (CYSTOTOMY).

By CHARLES AMBROOK, M.D., BOULDER, COLO. The operation of supra-pubic lithotomy (cystotomy) is, for various reasons, lightly mentioned in the majority of the treatises on surgery, and the prevailing opinion of the operation is but summarized in the language

of an able surgeon of this state, who, in a recent lecture before a medical class said, “Supra-pubic lithotomy is only admissible when the calculus is of enormous size,

prostrate, disproportionately hypertrophied, or there is a saculated calculus. The result is one

, death in about every three and one-half cases. The operation is dangerous on account of peritonitis and urinary infiltration, but is free from hemorrhage, and does not expose the patient to wounds of the ejaculatory ducts or the rectum, which are of minor importance compared with the danger of the escape of the urine into the abdominal cavity, with resulting peritonitis." Notwithstanding these opinions, I will state my experience in operations of this nature.

CASE 1. H. B., male, age 26, German, healthy and well nourished ; has carried in his bladder for three weeks, a piece of glass measuring one and one-eighth of an inch in length, and five-sixteenths of an inch in diameter, which was inserted into the urethra to relieve retention of urine and save physician's fee. The tube disappeared, he has had constant pain and at times some blood in the urine, with an abundance of cheesy looking mucous. I recommended its removal by cystotomy and placed him upon a preparatory treatinent of muriated tincture of iron and sulphate of quinine. Here was a case that the most ardent admirer of lithoplaxy would not dare to recommend. Perineal section is credited with

making eighty-five per cent. of its subjects sterile ; and, as the case bids fair for a long life, sterilitety was too severe a penalty for ignorance of anatomy. Dr. Wohlgesinger of Denver, fortunately called my attention to some statistics regarding supra-pubic cystotomy, upon the strength of which I decided to operate by that method. On September 24th, 1882, I performed the operation, with antiseptic precautions, assisted by Dr. W. and others. In two weeks the patient walked outside the house, and in three weeks he walked to a farm seven miles distant, upon which he proposed to work for his board until able to do the labor of a full hand ; so rapid was his recovery that he was enabled to do a full-hand's work within four weeks from the date of the operation.

CASE 2. H. M., age 19, male, American, externally emaciated, anemic and barely able to walk. At times blood has appeared in the urine, with an excessive quantity of cheesy mucous. Tests showed albumen present ; constant pain in bladder. He has for three months carried a common slate pencil in his bladder, with obtusely pointed extremities; the pencil measuring three inches in length and three-eighths of an inch in diameter at its largest part, where the concretions were the thickest, owing to the excessive constitutional disturbance. It was a very unpromising case, as the length of the foreign body would require frequent divisions ; the diameter of the urethra was small, and the fracture of a pencil would not be likely to result in as small fragments as a calculus that is formed in concentric layers. There was some doubt about lithoplaxy being the best mode of operating ; and, as the results of the preceding case were so satisfactory, that both the attending physician as well as the patient preferred the supra-pubic cystotomy. I was therefore easily persuaded into operating by that method. The operation was performed on November 8th, 1882, at noon, and the same antiseptic precautions were used as in the case before cited with the exception of the spray. The patient walked in three weeks, and made a good recovery, although owing to constitutional disturbance and delicate health the convalescence was somewhat slower than in the preceding case.

I am aware how little the citation of two cases is able to prove the value of an operation, but, in the light of this limited experience, were I obliged to decide between the two operations in my own case, I would chose the supra-pubic in preference to the perineal section, for the following reasons : The certainty of the procreative powers being left intact; the few instruments required in the operation; the less skill necessary to perform it; the fact that if necessary the bladder can be thoroughly examined with the finger and eye; the ease with which all fraginents can be removed, (for the syringe can be inserted into the wound and the fluid allowed to flow out, carrying with it all debris); the in

SUPRA-PUBIC LITHOTOMY CYSTOTOMY.

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creased chance of recovery, owing to the small amount of blood lost i the minor importance of the tissues cut through, practically reducing the danger to shock only.

The following is a summary of the salient points in the two cases : The temperature and pulse of the first case by the sixth hour rose to 101, 7°, pulse 82 ; dropping by the seventeenth hour to 99.8°, pulse 80; then gradually rising until at the thirtieth hour it reached 102.3°, pulse 85; then falling to 100°, pulse 80, by the forty-eighth hour; rising again to 102.5°, pulse 88, at the fifty-eighth hour; falling by the sixty-eighth hour to 100.7°, pulse 72. Thus in sixty-eight hours from the operation the temperature steadied to 100.7°, and from that time to the end of the first week fluctuated from that point to 99.5°, pulse 63, eventually at the end of the second week arriving at its normal temperature and pulse,

In the second case the temperature rose to 99°, pulse 60, by the cighth hour; rising to 100°, pulse 96, at the forty-ninth hour; gradually rising until the fifty-fifth hour when it reached 101.6°, pulse 114; then dropping to a normal temperature and a pulse of go at the seventy-ninth hour, after which it fluctuated for a few days between normal and 99.7°, pulse 84, subsequently varying but little from normal to dismissal of the

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case.

Pain.—The pain in both cases, for the first forty-eight hours, was paroxysmal and spasmodic in character, sometimes accompanied by contractions of the bladder, causing the urine to ooze out of the urethra, even passing around the catheter as well as through it, if one happened to be inserted. A tinge of blood was apt to accompany the urine during these pains, but clots never appeared. These pains and the appearance of blood could easily be provoked, if, by careless manipulations the catheter was introduced too far, i. e. so as to touch the wound of the bladder, or if the patient was negligent in drawing off the urine. Experience indicated that the urine should not be allowed to accumulate longer than from forty minutes to one hour; in fact, the removal of the urine is the vital point in the after treatment, both as to pain as well as prevention of infiltration. In the first case but one dose of anodyne was used, (hypodermic of morphia, thirty hours after the operation); in the second case, in as much as the patient had but little stamina, it was used several times, and as occasion required.

URINE.—The urine in both cases secreted freely, varying from two to nearly three ounces each hour. Its specific gravity was at first 10.24, but it soon fell and fluctuated between 10.20 and 10.22. Immediately after the operation the color was dark from blood, but after using the catheter a few times it became lighter, and in thirty hours entirely disappeared, only to reoccur from carelessness in not removing the water, or in the introduction of the catheter. Mucous slowly disappeared from the urine in two weeks' time. It was found unwise to leave the catheter in position for the purpose of draining the bladder, for the mucous clogged it up at times, and the irritation caused a mild urithritis.

Bowels.—Flatulence, and some tympanites occurred in both cases on the second day, requiring an anodyne and carminatives, with enemas and cathartics on and after the third day. This lasted to some extent throughout the first week.

APPETITE.--Patients had but little appetite during the first four or five days. Milk seemed to agree the best with both,

OPERATION.-Shave the parts; thoroughly wash out the bladder with (1 to 40) solution of carbolic acid, then distend the bladder to elevate it out of the pelvic cavity; cut on median line at os pubes, extending the incision upwards from two to two and a half inches, so as not to go far enough to penetrate peritoneal cavity. Dissect down to the bladder, which after it is thoroughly exposed will swell up into the wound; then have the assistant firmly grasp the bladder at the upper angle of the wound with a large pair of Vulsellum forceps, and keep it constantly and firmly held up and against the wound during the entire subsequent steps. I consider this the vital point in the operation; of course assuming that the peritoneum has not been penetrated. The bladder being firmly held with the forceps, plunge the knife perpendicularly into the bladder, and cut down towards the pubic bone as far as required, (the fluid in the bladder will overflow through the wound,) insert the finger and examine, and remove the foreign body with lithotomy or other appropriate forceps. In closing the wound bring up the two edges of the bladder flat together, (the ligature will roll the edges towards each other as it is tied,) put in about four stitches to the inch, close the superficial wound with several deep stitches, so as to support the bladder wound, placing in between the deep stitches enough shallow ones to approximate the skin and secure as inuch union by first intention as possible, which will be about four-fifths ; the lower fifth will be held open by the bladder ligatures keeping up a slight discharge, until they come away, which will be in from eight to fourteen days. Should some of the bladder stitches fail of their duty, and the urine be allowed to accumulate in the bladder, a swelling up of the urine through the sinus may occur, but unless it occurs very early in the case it will not necessarily be troublesome, at least it so proved in my second case where it occurred in the second week, and probably delayed the healing of the sinus a few days; beyond the anxiety it gave me that was all the results that I saw.

DRESSINGS.— I used several thicknesses of patent lint moistened with a (1 to 40) solution of carbolic acid laid immediately over the wound,

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and over that layers of carbolated, absorbant cotton soine three inches thick, extending well over the abdomen and down over the groins and pubes, which was well held in place with bandages around thighs and abdomen. There appeared to be no reason for disturbing these dressings for the first forty-eight hours or more after the operation; a few times a little powdered idoform was dusted upon the wound; of course to those with every facility for operating, and the necessary instruments and experience in their use, the foregoing will be of little interest, but to those in the sparsely settled portions of our State, without those facilities, it may be of benefit.

THE POWER OF ALCOHOL OVER THE NATURE OF MAN AS DISPLAYED BY THE MODIFICATIONS OF MIND, MORALS, AND THE PHYSICAL CONSTITU

TION INCIDENT TO ITS USE. BY T. L. WRIGHT, M.D., BELLEFONTAINE, O. After occupying considerable space in describing the facts and prin. ciples attending the alcoholic impressions to which the human constitution is susceptible, both in the acute and chronic aspects of the subject, I am drawing towards several points of final conclusion, which when once stated will fitly close the present discussion.

In the first place, something additional may be said respecting the outcome of a moral nature impaired by the physical injuries to the brain consequent upon hyperplasia of its interstitial tissue and the changes consequently induced. The way by which alcohol may destroy the moral sense through physical changes produced in the brain has been pointed out. There are some in whom the progress to the final catastrophe of paralytic dementia becomes arrested, and who remain in a certain deteriorated condition of brain and mind. It is true that Dr. Mickle says: "It is the duty of the physician to declare that a case of progressive paresis is without hope." It has been my fortune to see at least two cases, which presented all the gathering and progressive symptoms of this disease, which were arrested in mid-career; and they have remained stationary for from five to seven years (Detroit Lancet, Nov., 1882, p. 202). One of these patients was considerably paralytic, with incapacity of speech also to that extent, that he was compelled for two or three years to communicate by writing. The ætiology in this case, was a combination of alcohol and syphilis.

Now it is true of course, that there cannot be any reproduction of destroyed nerve tissues, and yet the fact remains that there may be a very considerable resumption of functions that had been impaired, and even

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