gery advocates the introduction of systematic cathe- position. The granulation tissue will in a little while terism. unite the walls of the wound firmly and securely to the

.

To proceed with the description of the technique of convolutions and the involutions of the thread cut upon the operation, of course, it must be understood that this drainage tube. You will now observe the acornentourage of the parts has been properly prepared for shaped end of the tube which prevents its escape from the incision which is to be made just above the center the bladder, while on the outer end there is a hard of the crest of the pubes and continued directly upward rubber cap which is adjusted upon the screw device and for say two and a half inches. This dissection is which prevents the tube from dropping wholly into the carried neatly and cleanly down to the bladder wall bladder, and which also protects the outer end from the which is to be exposed longitudinally for at least three- friction of the clothing of the patient when walking fourths of an inch. If the vesical fold of the perito- about. In maturely contemplating and reviewing the neum has been encountered it must receive aseptic pro foregoing remarks, I am convinced that I am almost tection. The wound is now packed with iodoform alone in America in deprecating the operation of prosgauze, over this is placed a fold of absorbing cotton, tatectomy. That I am nearly alone in characterizing and upon this is laid a piece of rubber tissue about the the procedure as an unjustifiable operation and wholly size of the hand, then the whole to be confined by the inimical to the safety and well being of the patients, adjustment of a neatly padded "T" bandage. The where the real indications show that suppurative cystibladder is to be kept drained and as quiescent as tis is present. possible until after the lapse of about forty-eight hours, when the dressings are to be removed together with the gauze tamponade. The walls of the incision wound will then be found to have been closed with granulation tissue and the connective tissue spaces closed in. Two tenacula are now engaged in the muscular wall of the exposed bladder at the margin of the wound upon either side, the handle of the one on the left side of the

ALDE&CO
ST. LOUIS

I, therefore, inveigh against the operation, because instead of affording the patients rest,, it intensifies their sufferings, and may hasten the fatal termination of life, and consequently must be considered unjustifiable, while other more rational and life preserving measures may be instituted and practiced for the relief of these poor sufferers.

In view of these facts, I consider suprapubic drainage the best treatment that can be given these patients; first, because it entails no hardships on them; and second, because it affords them immediate relief from pain and loss of sleep, the effects of which are rapidly destroying them. Hence, the results of my deliberate convictions relative to the subject matter of the foregoing remarks, I desire to epitomize and emphasize in the following conclusion:

The novel points in the procedure advocated by me consist of first making the longitudinal wound just above the pubes and only deep enough to reach the bladder wall as above described, this constitutes the first step. The second step consists in making of a triangular opening in the bladder by means of a trochar as explained patient is passed to an assistant who is to be instructed above. The advantages of the opening made by a to maintain throughout steady traction upward and out trochar for the purpose of permanent drainage of the ward. The handle of the other tenaculum is retained in bladder without leakage must be perfectly apparent to the left hand of the operator; a good sized trochar (this all, as the permanent drainage tube has a thread cut is the one I use and through an opening made by the into its surface to which the walls of the fistulous tract instrument I was enabled to remove a large calculus will become firmly and securely united, thus perfectly from the bladder of the patient) is now thrust through preventing leakage while at the same time the bladder the wall of the bladder midway between the fixed will have complete rest by being constantly and unpoints of the tenacula. We now have a triangular opening into the bladder, with its triangular flaps preserved intact, and directed inwards. The trochar may now be withdrawn and the little or index finger gently insinuated through this opening and the interior of the bladder explored. This exploration is made for the purpose of ascertaining the nature and extent of the cause of the obstruction. When this discovery is satisfactorily established in the mind of the surgeon the finger is withdrawn and the instrument, illustrated, is introduced, while the tenacula are still held securely in

interruptedly drained. These results could not be at tained by means of a longitudinal incision in the bladder, as the walls of the fistulous tract could not become united closely enough, with this or any other drainage tube, to prevent leakage.

A simple look at the accompanying cuts, will establish this fact:

That marked "A" represents the opening made in the bladder by a trochar, the fistulous tract of which will readily unite closely and compactly with the thread cut on the surface of the drainage tube, while

that marked "B" represents an opening into the bladder screw drainage tube during a few months, the longest made by a vertical incision. The latter clearly shows period was seven months (and that patient during this the adaptability of any cylindrical drainage tube to an period of time gained 48 pounds in bodily weight), and opening of that kind. The urine will escape through it now affords me great pleasure and satisfaction to be these triangular spaces above and below the drainage able to state that they are all well and apparently pertube as fast as it finds its way into the bladder in spite fectly and permanently cured. But even should the of every attempt to prevent it, and hence the granula- prostate fail to shrink, it would be better and safer for tion and cicitrization of the track around the tube can the patient to wear the tube permanently than to risk never take place while its raw surfaces are constantly the danger of having a prostatectomy performed upon exposed to the irritating effects of the urine. him.

A

I have also supplied this drainage tube with a plunger or piston with a valvular end which is brought into requisition when the patient gets able to walk about, and is worn intact for the purpose of keeping the lumen of the drainage tube free from any incrustation, and also to keep the urine in the bladder until the patient will wish to void it, which he can do simply by withdrawing the plunger which will enable him to evacuate his bladder complelely and at his pleasure.

Read at the Forty-Third Annual Meeting of the South Carolina Medical
Association, held at Sumter, S. C., April 19, 1893.

CASE I. OSTEO-SARCOMA OF THE LOWER JAW. E. S., colored female, nine years of age, native of Edgefield, S. C., was admitted to hospital, November 1, 1892, in the surgical clinic. The patient had a large tumor of the lower jaw involving the whole of the right half of the bone and extending beyond the symphysis, almost to the attachment of the Masseter. The growth evidently sprung from the bone and had been of gradual development for two years, until, at the time that she presented herself at the clinic, it had attained the size of a large orange. The cheek on the right side was projected considerably and the lips were pushed forward and stretched until they were thin, apparently to the utmost limit. Bstween the lips the tumor presented itself to view. The cavity of the mouth seemed to be almost entirely filled by the growth, and the tongue was displaced upward against the roof and well against the cheek of the left side. On examination by the finger it was found that the tumor extended back into the upper part of the parynx and its posterior limit. could scarcely be reached. The increase in size of the tumor being steady, from day to day, and the condition. of the patient being wretched, from difficulty in swalAfter wearing this screw drainage tube until the lowing, and interference with breathing, it was deterbladder becomes free from all inflammatory and irri- mined to give her such chance of relief as could be tating causes the hypertrophied glandular tissue will afforded by an operation for the removal of the growth. undergo atrophic changes, as it has done in all of my This operation involved the removal of the lower jaw cases, and thus establish a low-level channel, by phy from the temporal articulation on the right side to the siological regression, if you please, and the patient will border of the Masseter on the left of the symphysis. in time be able again to void his urine through the The operation was performed November 4, 1892. The urethra, thus dispensing with the necessity of a pros- usual precautions having been taken to insure asepsis, tatectomy and all of its baneful consequences. The as far as it was possible to attain it, the operation was patients whom I have treated had only to wear the commenced by a preliminary laryngo-tracheotomy. This

B

There was a good deal of oozing from the extensive wound surface, and the patient was, for this reason, unable to rest at night. To control this flow the cavity was injected with a solution of alum and sulphate of zinc.

November 5. The patient was unable to swallow at all and nutritive enemata of milk and yolk of eggs were

The wound was dressed; the tracheotomy wound had almost completely healed.

November 8. Patient was able to take all her nourishment by the mouth in liquid form. November 10. November 11. moved.

November 18.

Alternate sutures were removed.
All the remaining sutures were re-

was done partly to permit the continuous administration operation, but was attached with plaster to the neighof the anesthetic without interference with the field of boring integument to prevent interference with respiraoperation, but chiefly to prevent suffocation by the pastion. sage of blood into the air passages. The pharynx was then packed with sponges to which strings were attached to permit their ready removal. The tongue was secured by a silk ligature passed through it, near the tip, to keep it from falling backward, when the attachment to the bone was severed. These preliminaries having been accomplished, a pause had to be made to permit the recovery of the regularity of the respiratory administered. movements that were much interfered with by the first November 6. She took small quantities of fluid by inhalations of the anesthetic through the tracheotomy the mouth, but not enough to permit the omission of tube, artificial respiration being necessary for a few the enemata. minutes to insure it. An incision was made commencing on the right side in front of the ear, over the temporo-maxillary articulation, and carried through the tis sues down to the bone, along its ramus and body, to a point corresponding to the anterior border of the Masseter muscle of the left side. Another incision, vertical in direction was made, commencing at the middle of the free border of the lower lip and carried downward, until it joined the first incision. With scissors, the flaps so marked out, were raised to the right and left; the former was carried upward to the point where the first incision was commenced; the latter to its point of termi nation. The vessels were taken up by the assistant with hemostatics who followed up the dissection of the flaps. The bone was divided on the left side of the symphysis, partly through with a Hey's saw, and its section completed with the chain saw. The bone was then seized with the Lion forceps and the deeper attachments were divided with scissors. The bone was readily disarticulated and removed; very little blood having been lost during the operation. The vessels were tied with catgut. The pterygoid process on the right side having been exposed and projecting into the cavity, was nipped off with the bone forceps. The sponges having been withdrawn from the pharynx, the wound was closed with silk sutures. The tracheotomy tube was removed at the conclusion of the operation, and the effort was made to close the wound in the crico thyroid membrane with sutures, but the attempt had to be abandoned on account of the depth of the wound from the surface.

The occurrence of emphysema in the tissues in the neighborhood of the tracheotomy wound presented another difficulty which was overcome by suturing the cutaneous margins to the deeper structures. The tumor after removal measured four and a half inches in length, three and a half inches in width and three inches in thickness; its weight was one pound and three-fourths

ounces.

It was submitted for examination in the laboratory of the Medical College of the State of South Carolina, and it was pronounced to be an "osteo sarcoma."

The wound was dressed as usual, with iodoform and bichloride gauze and absorbent cotton. The loop in the tongue was not removed for twenty-four hours after the

Fourteenth day; the wound was entirely healed; the mouth could be closed and the lips brought into even apposition. The tongue could be freely used and the soft food could be taken without difficulty. The deformity was little to be noted. November 19. Discharged.

CASE II. SUPRAPUBIC LITHOTOMY.

Julia J, white, ten years of age, had been suffering from stone in the bladder for six years.

Three years after the trouble first made itself manifest, she was brought to me by her parents and the diagnosis clearly established. Operation for removal of the stone was recommended, but her parents refused to have any operative interference, and from then, until February, 1893, they have tried various plans of treat ment, suggested by their friends, for the removal of the stone, by other means than the knife.

The sufferings of the child having become aggravated from day to day, they again sought my advice after three years delay. At this time the bladder had become very much contracted and so irritable that the calls to pass water were frequent and the effort intense. ly painful. On examination with a searcher the stone was easily discovered. On February 1, 1893, after the usual preparations to insure asepsis, the supra-pubic op eration was performed. The effort was made to distend the bladder with four ounces of water previously boiled, but not more than two ounces could be retained. The rectum was distended with a rubber bag inflated. An incision three inches long was made in the middle line, the center of which correspond to the upper border of the pubis The pyramidal muscles were separated and the dissection carried down in search of the bladder through the cellular tissues. It was soon discovered but there was no portion of the bladder to be found above the pubis, the organ being contracted and

CASE III-COMPOUND FRACTURE OF THE SKULL.-
OPERATION.

He

out of view. In the search for the bladder the peritoneal cavity was opened and the omentum escaped through the wound. It now became an important quesA. N., white, adult, Italian, forty-one years of age, tion to decide whether the high operation should be abandoned and another method adopted to avoid the was brought to the City Hospital on the morning of risk of opening the bladder into the peritoneal cavity. a contused and lacerated wound on the forehead just December 14, 1892, from the Ashepoo Mines. He had It was decided to proceed with the operation. The above the superciliary ridges, about two inches in bladder was drawn up from the pelvis into the wound by a tenaculum opened, and the stone readily removed. length, its center being above the nasal eminence. was said to have been struck by a locomotive while The edges of the opening in the bladder were sutured with a chromocized catgut to the abdominal wound; the walking across the Pon Pon Bridge, early in the morn cutaneous surface not being included. The bladdering of the day of admission. The patient was anesthetized and examined, and a fracture of the skull discovered. The wound was lengthened by an incision extending an inch on either side and the flap turned up. On February 4, the strip of gauze was removed. The of the frontal bone, and the displaced fragment was The fracture was found to involve the vertical portion progress of the case was most favorable, the tempera-driven in and pressing upon the dura mater. The fragture ranging between 99° and 100°. On February 8, the temperature having reached 101° the bladder was ment, about the size of silver dollar, together with the washed out daily with a solution made from Dr. Carl Crista-Galli and Cribiform plate of the ethmoid being perfectly detached, were removed. A portion of the Steiler's antiseptic tablets. horizontal plate of the frontal, about the size of a silver quarter of a dollar, being detached from the roof of the

was washed out from the urethra through the abdominal wound and a tent of iodoform gauze passed into the

organ.

This procedure reduced the temperature to normal in the course of a few days.

On February 25, the wound was completely closed

and the patient was discharged cured, March 3, 1893. REMARKS.—This case is reported because of the diffi-culties encountered in an operation now regarded as comparatively simple and as one that is giving good re

sults.

Ordinarily, in cases in which the bladder is not contracted, there is simple room to work without endangering the peritoneum; indeed, this membrane is not often seen in the operation. When the bladder and rectum are empty, the peritoneal fold on the anterior surface of the bladder is a little below the upper edge of the symphysis. When the summit of the bladder is two inches above the pubis and the organ is pressed against the abdominal wall, the reflection of the peritoneum is about three-fourths of an inch above the symphysis. Distention of the bladder alone will elevate the folds

of the peritoneum from one half to three fourths of an inch. Distension of the rectum, although it has no effect upon the reflection of the peritoneum, pushes up the distended bladder against the abdominal wall, and the three-fourths of an inch of space, uncovered by peritoneum, may be increased from one and a half to three and a half inches. In the case in hand, all of this was changed by the contraction and non distensibility of the bladder from the long presence of the stone, greatly complicating the operation and converting it into an extra-peritoneal procedure.

The case demonstrates, however, that with strict asepsis a successful result may be attained, even after the opening of the peritoneal cavity.

P. S.-The stone removed was irregularly oval in shape, of a grayish color, and weighed one drachm and a half. Upon chemical examination it was found to be composed of a nucleus of oxalate of lime with a phosphatic crust.

orbit, was likewise taken away. The superciliary ridges

on both sides were loosened, but as the attachment was

thought sufficient to insure their vitality, and as they were left in position. The wound was cleansed, washed were not exerting pressure on the parts beneath, they with a 1 to 4,000 solution of bichloride of mercury, packed lightly with iodoform gauze and sewed up with silk sutures, space being left at the center to move and replace the tent.

An antiseptical dressing was applied and a bandage adjusted. A simple fracture of the left clavicle about its middle, was also discovered and put the 19th, the fifth day after the injury, the temperature up after Sayre's method. The patient did well until having only once reached about 100°. On the fifth day however, he became very restless, complaining of very reached 103°. The wound was examined and dressed, severe pain in the head, and the temperature at 8 A. M. charge or pus. The patient gradually sank and died on but there was no visible bagging or collection of disthe 22nd, the eighth day.

The post mortem showed that death resulted from suppurative meningitis-probably septic in its nature.

CASE IV.-HEAD INJURY.-TREPHINING.

A white adult, male, was admitted into the City Hos pital, January 10, 1893. The patient was sent in with a history of having been struck on the head by a railroad train, one week previously. After receiving the injury, he got up and walked home, but then became unconscious and had remained in that condition. The patient was unconscious when admitted; his extremities were cold, respiration slow, pupils dilated, and there was right hemiplegia.

During the night of admission he became collapsed and it was necessary to give whiskey hypodermatically and to surround him with bottles of hot water.

There

mosis and swelling of the right eye had occurred. Upon further examination it was found that there was a depressed fracture of the skull. There was some hemor rhage from the nose, but there were no symptoms indicating compression or other injury of the brain. The wound was cleansed and dressed antiseptically, and the patient was put to bed. On January 29, the patient was anesthetized, the usual precautions taken to insure asep. sis, and the wound was enlarged to expose the seat of fracture. From the frontal eminence, about one and a half inches to the right of the median line, the fracture extended downward and inward to the nasal eminence, to the supra orbital arch, down to the ethmoid. By means of the elevator and ronguer forceps the fragments of bone were removed; the portion of the frontal from the frontal eminence to the supra-orbital arch,— also a piece of the ethmoid, and with this, a portion of the nasal eminence. Beneath these fragments of bone was a layer of clotted blood, and when this was removed the duramater was brought into view, uninjured. The cavity was lightly packed with iodoform gauze to control oozing and the wound was dressed antiseptically.

was no wound of the scalp and the ecchymosis from the to the roof of the nose. Already considerable ecchyblow was very diffuse in the left side. There was no evidences of the skull to be elicited by palpation, and there were none of the symptoms ordinarily regarded as indicative of fracture of the base. The symptoms of compression of the brain were, however, marked, and the history of the case, his ability to rise and walk af. ter the injury, and the gradual supervention of the in sensibility and hemiplegia on the right side, pointed to hemorrhage within the skull, as the probable cause. With this theory in view it was determined to make an exploratory trephining with the hope of relieving the pressure. The head having been shaved and the usual precautions taken to insure asepsis, an incision was made following somewhat the direction of the temporal ridge on the left side, terminating about one and one-half inches in front of the ear. The tissues constituting the flap were reflected, the pericranium raised and the crown of the trephine applied a little in front and below the parietal eminence. A button of bone having been re moved, a large quantity of dark blood escaped. This blood had evidently been effused for days, between the dura and the skull. The dura bulged up into the opening made by the trephine and was found to be tense when pressed upon with the finger. The dura was now taken up carefully with dissecting forceps and cut through with scissors. As soon as the membrane was opened, blood with small portions of brain substance, escaped. The finger was introduced into the opening and entered a cavity that had been formed by the effu sion of blood into the brain substance. The cavity ad mitted the whole length of the little finger and extend ed downward and backward when a limiting wall was distinctly encountered. This cavity having been cleansed of clot and effused blood, was syringed out with a bo. CASE VI.-COMPOUND FRACTURE OF THE SKULL. OPERracic acid solution. A drainage tube was carried to the bottom of the cavity, held in place by a silk suture passing through the flap, and brought out at the posterior extremity of the incision.

February 2. Patient had no rise of temperature; the gauze tent was removed. February 4. . Sutures removed; there was still some bloody discharge from the nose.

February 9. A small collection of pus was discov. ered beneath the cicatrized wound and evacuated. February 16. Wound was entirely healed and the patient was discharged. No trouble has since been experienced by this patient.

ATION BY TREPHINING.-RECOVERY.

J. D., colored, male, twenty-five years of age, was admitted into the City Hospital at 7:30 P. M., on February 5, 1893. He is an hostler and while attending to his du ties received a kick on the right side of the head. The blod lacerated the scalp, severed part of the temporal muscle and fractured the skull. The fracture was situ ated three inches above the external auditory meatus and two inches posterior to and above the external an gular process on the right side. The patient presented no symptom of compression or any interference with It is a matter of regret that no post-mortem was per the functions of the brain. The wound was dressed mitted.

The wound was now closed by means of interrupted silk sutures; the head dressed, and the patient put to bed. After the operation the patient became semi conscious, but there was no material improvement in his condition. The temperature ran up to 101° and the pulse became feeble. The patient gradually sank and died on January 13.

CASE V.-COMPOUND FRACTURE OF THE SKULL

OPERATION.-RECOVERY.

antiseptically and he was put to bed.

On February 7, although no symptoms of compression had developed, the patient was brought into the clinic and it was decided to make an exploratory opera. S., colored, male, twenty-one years of age, native of tion. The patient having been anesthetized and the South Carolina, was admitted about 4:30 P. M. on Janu- usual precautions having been taken to insure asepsis, a ary 28, 1893, into the City Hospital. The patient was semi-circular incision was made around the seat of inled in by two other negro men who said that he had jury and the flap so fashioned was reflected downwards. just received a blow on the head with a brick bat. The area of fracture having been thus freely exposed There was a contused and lacerated wound just above and the pericranium raised, a stellate fracture, with the right eyebrow, about two inches in length, extend- considerable depression of the fragments, was discov. ing diagonally across the forehead, towards and almost ered.