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or its appendages.

Second : Often these cases after operation prove more obstinate to
treatment, due probably to absence of ovarian function.



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The American Practitioner and News. 165

Third: The operation often breaks the harmony of the essential
organs and disturbs nutrition, which are two of the most common fac-
tors in causing the condition called neurasthenia.

Fourth : The operation for removal should be performed in patho-
logical conditions only.

Louisville.



SUPRAPUBIC CYSTOTOMY FOR D15EA5B OF THE PROSTATE.

BY J. E. KEMPF, M. D.

Introduction. Suprapubic cystotomy was first performed by Peter
Franco in the second half of the sixteenth century. Since then it has
been frequently performed for stone or foreign bodies in the bladder
and for cystitis, but only during the last few years has the operation
come into use for the relief of the complications of enlarged prostate
gland. It is safe to say that what tracheotomy is to the choking
patient, suprapubic cystotomy is to the old man suflFering from the
complications liable to arise in hyi)ertrophy of the prostate gland.

PcUhology of Enlarged Prostate. During the latter years of adult
male life the prostate gland is frequently enlarged by the growth of
the glandular and the muscular parts of the gland, the enlargement
being adenomyomatous. The adenomatous tissue predominates in the
soft tumor, while in the hard variety the myomatous tissue of the gland
is excessively enlarged. The hypertrophy of the prostate gland, either
hard or soft, may be general, that is, the whole gland may be enlarged,
or it may be an irregular enlargement of the entire gland, or any one of
the three lobes, either lateral one or the middle lobe may be hyper-
trophied.

The enlargement of the prostate gland bulges upward and toward
the front bladder wall, causing the inner opening of the urethral canal
to be prolonged upward and toward the front of the bladder. Behind
the prostatic enlargement the bladder forms a sac, which always con-
tains urine, especially when the patient is in a reclining position at
night. This produces the desire to urinate, which rarely leaves the
patient entirely. The prostatic part of the urethral canal is always
lengthened from two to three inches, and a greater curvature of the
back wall of the urethral canal is produced. This makes it necessary
that in catheterization we make use of a metallic catheter with a greater



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1 66 The American Practitioner and News.

curve than the ordinary catheter, or that we use the soft rubber catheter,
which worms its way through the canal on gentle pressure.

Etiology of Hypertrophy of the Prostate. Age can not be said to be
a cause, because more than twice as many adult males over fifty years
of age have atrophy of the prostate gland rather than hypertrophy.
About one third of all adult males over sixty years of age are afflicted
with hypertrophy of the prostatic gland, and only about one half of
them are ever caused any trouble, consisting of a mechanical disability
to empty the bladder.

Symptoms of Hypertrophy. The patient afflicted with hypertrophied
prostate first notices that he has to urinate more frequently, especially
at night. The next symptom he may notice is a drippling of the
urine, or an involuntary passage of urine. Sometimes dysuria is the
first and most painful symptom. Either the patient can not pass his
urine at all or only in small quantities at a time, as much as a table-
spoonful or less every ten or fifteen minutes. Later on there may
occur incontinence of the urine. Cystitis or septic trouble may com-
plicate the case, and may generally be traced to unclean catheterization.

Diagnosis. The diagnosis of hypertrophied prostate is generally
made positive by a rectal examination with the finger, and the tumor is
thus easily palpated. An examination should also be made by means
of a catheter, and the urine should also be examined. A cystoscopic
examination is also indicated if the doctor is fixed to make it.

Prognosis. Every case is a law unto itself. A cure of prostatic
hypertrophy need not be sought after, as it is not probable, except,
perhaps, in the hands of the most expert operator. But on the other
hand, palliative treatment promises much.

Treatment. Hygienic treatment may consist of directions to the
patient to guard against cold and wet feet, and to guard against
draughts, and to keep from catching cold. The patient has to get up
at night frequently, and he should be warned against walking on a
cold floor with bare feet. He should wear woolen underclothing next
to the skin, and regulate his life so as to eat his principal meal at noon,
to eat an early supper, and not to retire until two hours after supper.
The diet should be regulated, salty, peppery, and spicy foods being
forbidden, especially mustards, pickles, pork, salt fish, beer, wine,
and champagne.

The only medical treatment that can prove of any benefit is such
as would be indicated by the symptoms in the case. Flaxseed tea



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hyoscyamus and opium, acetate of potash, buchu, pichi, juniper, etc., are
remedies frequently called for. Iodide of potash, it is supposed, has in
some cases lessened the enlargement. How true this is I can not say,
as I have never seen any benefit from its use.

The use of the catheter promises much if properly done. If the
case is of such a nature that the patient can use the catheter himself,
it is best always to use the soft catheter. The patient, if he wishes
and if it is convenient to do so, can train himself in self-use, and it is
astonishing how expert some of them get, and how much their urethral
canals will stand after they once become habituated to the use of the
catheter.

The metallic catheter with the greater curve, or the so-called pro-
static catheter, should only be used by the doctor. Strict cleanliness so
as to prevent cystitis and sepsis must always be insisted on. Wash
the catheter with soap and water before and after using, immerse it in a
formaldehyde solution, and then rinse it in hot water just before using.
Always wash the hands carefully, and also the head of the penis.

In using the catheter, have the patient to lie on the bed with an
elevated pelvis ; use the catheter skillfully ; empty the bladder slowly
and carefully. If the bladder was very full, do not empty it completely
the first time. If, however, the urine is bloody and thick, remove all
of it, and inject the bladder fiiU with a boric acid solution, which repeat
until the water comes away clear.

In cases where the taking away of the urine with the catheter
becomes impossible, there remains suprabubic aspiration, or supra-
pubic cystotomy.

Operative Treatment. Castration as a cure for hypertrophy of the
prostate need not require our attention, as it has already passed into
merited disuse.

The electric treatment of the disease is a complicated aflFair, because
machinery is necessary that most doctors have not, and if they had it,
they would not know how to use it. Bottini with the galvano-caustic
prostatome claims to have had great success. But the electric treat-
ment of this trouble will for some time remain in the hands of
specialists.

The operations of prostatotomy and prostatectomy, rectal, endo-
urethral, suprapubic, or perineal, are as yet in the experimental stage,
and are performed mainly by skillful surgeons especially trained for
the work.



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The operation of suprapubic prostatectomy, where the middle lobe
of the prostate gland alone is hypertrophied, a rare occurrence, however,
is an operation that is very successful, but only in such cases.

Suprapubic cystotomy is an operation that the most ordinary sur-
geon can perform, and is the operation for the various complications
that may occur in cases of hypertrophy of the prostate, such as
unusual diflSculty in introducing the catheter, or impossibility to intro-
duce it, or septic cystitis, or hemorrhage in the bladder, or of false
passages in the urethral canal, or malignant tumors in or near the
bladder, or disease of the kidneys, or where hypertrophy of the prostate
occurs with some other incurable systemic disease.

The object of the operation is to obtain a fistula in the bladder
in the linea alba immediately above the symphysis pubis. Mode of per-
forming the operation may be divided into three steps: First, prepar-
atory ; second, the operation, and third, the after-treatment.

Preparatory, If possible precede the operation by giving the patient
a general bath. This, however, may depend on the complications of
the disease of the prostate necessitating the operation, and no doubt
must frequently be dispensed with. But the rectum should always be
emptied by an enema, and the bladder, if the use of a catheter is possi-
ble, should be emptied, and then refilled with a four-per-ceut solution
of boric acid. A full bladder is generally necessary, and if the use of
the catheter is impossible, the bladder is probably full to distension.

The pubis must be shaved, and the entire abdomen and the thighs
must be scrubbed and washed with soap and water, then cleansed with
alcohol, and lastly disinfected with corrosive sublimate solution, one to
two thousand. Then give an anesthetic. I prefer chloroform.

The Trendelenburg position is the best, but need not be extreme ;
a raising of the pelvis by means of pillows may be sufficient in an
emergency.

Thorough sterilization of the necessary instruments is necessary,
and gauze, sterilized water, cotton, etc., should be provided by the sur-
geon or his assistants.

The Operation, The cut is made immediately above the symphysis
pubis upward six to eight cm. Skin, linea alba, and transverse fascia
are held apart by means of blunt hooks, and, either with the finger or
the blunt end of the scalpel, the way is easily made clear to the
distended bladder, and the bladder wall is fixed by means of two
sutures entered about one cm. from the median line on each side.



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169



This gives the operator control of the bladder, and by means of the two
sutures the bladder wall is drawn out even with the skin, and with a
narrow scalpel an incision is made between the two sutures into the
bladder wall about one and a half to two cm. long. The contents of
the bladder now flow away, and if necessary an examination may be
made of the bladder by the finger of the operator.

The next step is to introduce the catheter, which has a T shape,
Fig. I, and which is easily made of a soft rubber catheter. It is self-
retaining, does not hurt the bladder, and may remain in the bladder
until the fistula has formed, which is about two weeks.





Fio. I.



Fig. 2.



The margins of the bladder wound and the abdominal wound are
united with silk sutures, three on each side. Fig. 2, and the balance of
the incision in the abdominal wall is brought together by silk or silk-
worm gut sutures.

Should the peritoneum have been cut, suture it with catgut.

Distension of the rectum is not necessary, and the skillful surgeon
may even dispense with a distension of the bladder.

Dust the wound with iodoform, wrap some iodoform gauze around
the catheter, and absorbent cotton around this. Retain the dressing to
the abdomen by means of adhesive strips. Whenever soiled, the
dressing should be renewed.



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170 The American Practitioner and News.

After'treatmenL Join a rubber tubing several feet in len^h to the
catheter by means of a glass tube, and place the end of the rubber
tubing in a vessel under the bed. The urine will drain away very
nicely unless the urine is thick or full of pus. Then washing out of
the bladder through the catheter must be performed daily for several
days until the cystitis is better, or, at least, until the urine becomes clear.

The sutures are removed on the eighth day, when the granulating
wound may be treated with antiseptic salve. The catheter is left in



Fig. 3. Fro. 4.

the wound about two or three weeks, until the fistula in the bladder
begins to contract, then it is removed, and a larger catheter may take
its place. Fig. 3 shows a patient with a medium-sized soft rubber rectal
tube in the fistula.

A plug of soft rubber may be inserted into the fistula to keep it open,
and this may be retained by means of adhesive strips (see Fig. 4), which
shows a patient on whom Dr. J. P. Salb and myself operated over seven
years ago. The patient is still living, and enjoys life better than before
the operation.

The Effects of the Operation. The eflFects of the operation are always
beneficial, when one remembers the condition of the patient demanding



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The American Practitioner and News. 171

tlie operation. The difficult, or perhaps the ineflFectual or impossible
catheterization may l>e dispensed with, and the vesicle tenesmus is
always relieved, or, at least, urinating is made easier. Rest and sleep
return, and pain disappears. The cystitis and the hypertrophy improve,
the former frequently disappearing entirely.

During the first five days after the operation the urine flows away
constantly ; after that the patient can control it somewhat. Later on, if
a plug is used, the patient can drain off the contents of the bladder by
means of a catheter at frequent intervals, or a Senn catheter, which is
self-retaining, may be used.

Jaspbr, Ind.



SUDDEN DEATH FOLLOWINQ REMOVAL OF TONSILS.*

BY J. A. STUCKY, M. D.

J. A., aged fifteen, consulted me February 21, 1899, giving the fol-
lowing history : Had been in bad health for past two months, though not
confined to bed or house ; been at school most of the time. Had been
suffering with " sore throat, tonsillitis, and quinsy." Had been much
worse for past two weeks, the throat trouble being aggravated by
" hacking cough." He had been referred to me to have his tonsils and
adenoid removed.

Patient showed evidence of genuine illness ; rigors and hot flashes
at short intervals ; palor, hectic, pulse quick and full ; temperature 101°
F. ; constant headache ; characteristic appearance of mouth-breather
from adenoid obstruction. Left tonsil enormously enlarged, protruding
beyond the median line, of soft, spongy, and fungous appearance, crypts
and follicles filled with pus, evidently oozing from a chronic periton-
sillar abscess. Vault of pharynx filled with adenoid vegetations
covered with offensive discharge, similar to tonsil. Tongue coated and
breath offensive. There was no evidence of active inflammation, but
on the contrary, a diagnosis of general septicemia due to absorption
of retained pus and muco-pus in tonsillar, peritonsillar, and adenoid
tissue was made, and removal of diseased and suppurating tissue ad-
vised. This was consented to, and patient sent to St. Joseph's Hospital.

Dr. John Scott, after examination of the patient, said there was no
contra-indication to administration of anesthetic, and gave him chloro-
form, after parts had been thoroughly cleansed with antiseptic solution

* Read before the Lexington and Payette County Medical Society.



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172 The American Prdctitioner and News.

by means of atomizers. Very little anesthetic was needed, and was
taken without an unpleasant symptom. The throat being large, every
step of the operation was easily and quickly done. The tonsil was
removed with tonsillotome, adenoid with Gottstein's curette. There
was little more than the usual hemorrhage, and, after spraying parts
with iced dioxide hydrogen solution, the patient was put to bed in good
condition. On account of the general septic condition, and suspecting
him to be "a bleeder," I remained an hour and a half after he
recovered from the anesthetic, and left him in good condition and
quite cheerful. Instructions were left with the nurse to use iced spray
(25 per cent hydrogen dioxide in Sieler's solution) if there was any free
oozing of blood.

Within thirty minutes after leaving a hurried telephone message
was received, saying patient had just vomited, and was bleeding pro-
fusely from nose and mouth. I was at his bedside within ten or fifteen
minutes ; the bleeding had checked considerably under the use of the
spray. Pulse was quick, expression anxious, great restlessness, and
every indication of impending collapse. A hypodermic injection of
ergotine, y*^ gr. ; strychnia, ij^ gr., and morphia, \ gr. was ordered,
while I proceeded to thoroughly remove all blood and clots. Examina-
tion revealed no special bleeding point, but a very general oozing of
venous blood; very little arterial oozing was found.

Most of the bleeding was from the tonsillar and post-pharyngeal
surface. After drying the parts, an application of McKenzie's styptic
solution, followed by sol. ferri per. sulph., applied by means of cotton-
covered probe, eflFectively stopped all bleeding.

Before completing this treatment Drs. Scott, Kinnaird, and Patter-
son arrived, approved of the treatment pursued, and agreed with me
that the patient would probably soon react and rally if there was no
further bleeding.

After waiting a few moments, the pulse being fairly good, though
weak and irregular, it was decided to use transfusion of hot normal salt
solution. Within three hours three pints were used subcutaneously
and readily (apparently) absorbed. Whisky, strychnia, and digitalis
were also given hypodermatically as indicated.

EflForts to sustain life by these means failed, and the patient died
nine hours after the operation, and seven hours and a half after the
secondary hemorrhage had been entirely controlled. As to the impera-
tive and immediate indication for the operation, there is in my mind no



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The American Practitioner and News. 173

doubt. I am equally positive that death in this case was coincident with
the operation, the latter being the exciting, not the immediate cause.

It is well known that no operation (when indicated) gives such
remarkable results as that for removal of adenoid tissue; also, their
removal is always accompanied by very free venous bleeding. In this
case the loss of venous blood at the time of the operation was little
more than is usually the case, and all bleeding stopped within a short
time without the use of any styptic except iced spray of dioxide hydro-
gen and alkaline antiseptic solution.

Within a few moments after appearance of secondary hemorrhage
I thoroughly cleansed all bleeding surface, nearly all of which was
venous, there being no evidence of a vessel of any size being severed ;
there was no special bleeding point discovered, but instead a very
rapid, free oozing of venous blood, which was easily controlled by the
applications of the styptics referred to.

The most plausible theory to my mind as to the cause of death is
the entire system, with all its recuperative force, had been so exhausted
and undermined by sepsis that reaction was impossible, though every
facility for promoting this was easily at hand and freely used. I know
of no other way to account for the result, because I do not think
enough blood was lost to cause death, and this did not occur for seven
and a half hours after the bleeding was completely controlled.
Admitting the hemorrhagic diathesis does not account for the unex-
pected and terrible result.

I am forced to the conclusion in this case I was dealing with a
septic condition of aflFairs, that nothing short of what was done would
have relieved the patient, complicated with a hemorrhagic diathesis,
and " that something which passeth understanding.'*

Lexington, Ky.

Action of Potassium Iodide upon the Blood of Syphilitics.—
Colombini and Geruli. Action of potassium iodide upon the blood of
syphilitics. (Giom. ital d, Mai. vener, 1897. fasc. i.) Iodide of potassium
given during the early stage of syphilitic infection causes an increase in the
number of red corpuscles and^in the amount of hemoglobin. Continuing
the administration one sees a diminution, and then again an increase. On
stopping the iodide the number of red corpuscles and the amount of hemo-
globin tend at once to diminish, but there then follows a rise. The iodide
serves to overcome the gravest syphilitic anemias. With the improvement
of the condition of the blood there is a marked increase in body weight.
{From Arch, itaL de BioL v. 29, 1898, p. 216.) — The Dominion Medical
Monthly.



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2leports of Societies*



THE LOUISVILLE MEDICO-CHIRURQICAL SOCIETY.*

Stated Meeting, February lo, 1899, Thomas Hunt Stucky, M. D., President, in

the chair.

Purpura Hemorrhagica, Dr. H. C. Sharp, of JeflFersonville : This
boy, aged four years, I first saw on December 27, 1898. Dr. Graham
had seen him two days before. Then his limbs were slightly edema-
tous, and about the buttocks, legs, arms, etc., were maculae purplish or
a bright red. Pain was intense throughout the abdomen ; there was
diarrhea and loss of appetite ; the urine was scanty. It contained no
albumen; reaction hyperacid. In time the eruption became papular,
and was accompanied by much itching. About three weeks ago
pain developed in the joints ; the eruption was then confined to the
legs; the scrotum was edematous; the abdomen in a condition of
ascites. The pain in the joints was aggravated by pressure or move-
ment. Last Monday a swelling appeared upon the left side of the head ;
other swellings have since appeared along the spine, and now one may
be observed on the right side of the forehead. These tumefactions
become greenish in color and finally pass away. Another swelling
appeared to-day upon the back of the left hand. Last Wednesday
there was a slight hemorrhage into the conjunctiva (right) which has
not yet been entirely absorbed. The eruption may still be observed
upon the buttocks, back, and arms. The boy's temperature throughout
has ranged from normal to 102° F., but most of the time it has been
normal.

The small swellings mentioned appear first in one place and then
disappear ; then reappear in other situations.

Discussion, Dr. William Bailey : I would unhesitatingly say this
is a case of purpura hemorrhagica not presenting unusual features.
The pseudo-rheumatic pains are often present. I will not speak as to
the pathology, whether it is simply a change in the blood or the ves-
sels, whether of nervous origin or what not. The treatment is largely
to improve the condition of the blood, control the hemorrhages by the

* Stenographically reported for this journal by C. C. Mapes, Louisville. Ky.



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The American Practitioner and News. 175

administration of ergot, the use of muriated tincture of iron internally.
These measures, I think, would relieve the case in a short time.

Maiformation of the Genitals, Dr. Thomas Hunt Stucky : This case
is one of malformation of the genitals in which there has been a great
deal of discussion as to whether the individual is an hermaphrodite or
not. I will ask Dr. Cartledge to demonstrate the condition present.

Dr. A. M. Cartledge : Some months ago this individual was referred
to me by Dr. Vance with a letter from Dr. Phillips, of St. Louis, also
letters from other physicians who believed it was probably a repre-
sentative of a class of individuals we have usually regarded as possess-
ing duality of sex — hermaphrodites. Of all such cases I have seen,
this seems to be the nearest approach to an hermaphrodite, although I
am not sure that this individual is one, or that such a case ever existed,
that is, one possessed of both male and female organs. I consider this
an unusual case of hypospadias, and in my opinion the cul-de-sac is an
exaggerated urethral pouch. There is a distinct depression at the
vaginal site, but it is merely a depression, as there is no perforation of
the skin or fascia. There is a rudimentary penis, perhaps three
quarters of an inch in length, with a distinct foreskin. The tes-
ticles are found upon each side in what would be the labiae of
the female, and there is no vestige of a scrotum. The pubic hair and
general contour of the pelvis is distinctly female. The mammary
glands are well developed, about what we would expect to find in a
female of sixteen years. The individual claims to be about thirty years
of age.

If the case is simply an unusal hypospadias, you may ask how I
account for the development of the mammae? At first sight that
might appear puzzling, but it must be remembered that excessive



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