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The following statement of the average cost A CASE OF RUPTURE OF THE UREof treating patients is interesting:
THRA-TREATMENT BY SUTURE.*
By J. F. H. SUGG, M. D., CLINTON, IOWA.
On the evening of July 7, 1896, I was summoned to Fulton, Ill., and requested to bring instruments suitable to relieve a distended urinary bladder that could not be reached by the catheter. I was met at Fulton by Doctors Ward and Clendenen, of that place, and Dr. Seger of Morrison, Ill. Dr. Ward gave me the following history of the case:
At 5 o'clock that morning, Mr. M. L., aged 55 years, fell astride the door of his ice house.
the perineum and scrotum and inability to pass urine. The doctor endeavored to relieve the patient by catherization, but after a patient trial of two or three hours did not succeed in introducing the instrument into the bladder. He then called Dr. Clendenen in counsel. The patient's sufferings having become more intense, morphine was given hypodermically, but with only slight relief. The two physicians then united their skill in an effort to coax and wheedle a catheter into the bladder, but their efforts were futile, and at 4 o'clock in the afternoon a conclusion was reached that further effort at instrumentation was not advisable, and an unfavorable prognosis was given to the wife and friends. The wife immediately sent for Dr. Seger of Morrison, who reached the patient about 7 o'clock, and at once summoned me.
At 9 o'clock I found the patient wild with pain. He was in the knee elbow position upon a bed, and several men were upon each side to prevent him doing himself violence. He was promptly chloroformed. The perineum, scrotum and penis were intensely ecchymosed and greatly swollen. The scrotum was fully as large as an average foetal head. The bladder was enormously distended, and its dimensions were plainly outlined upon the abdominal wall. A sound carefully introduced into the urethra escaped in the deep part of the tube, passing to the left. The sound was withdrawn until its beak was within the urethra, when it was again gently passed toward the bladder and again escaped from the tube, this time passing to the right. No further attempt was made. The patient's surroundings and other circumstances made it desirable that he should be taken to a hospital. I therefore relieved the bladder by super pubic aspiration-withdrawing five pints of normal urine-and ordered the patient removed to Agatha Hospital at Clinton, Ia. He reached the hospital at 1 o'clock a. m., in good condition and passed the remainder of the night with comparatively little pain.
I saw him at 9 o'clock the next morning. His general condition was good. The perineum and scrotum were swollen and would rival in color the best specimens of an African chief. A well marked epididymitis was present on the left side. The patient was placed under ether and the perineum opened by a median incision. Blood clots were removed and all false passages and pockets washed out.
The urethra had evidently been divided through the posterior part of the bulb. The anterior end of the divided tube was readily found by the use of the sound, but the posterior end could not be detected. The tissues were soft and infiltrated, the different structures could not be distinguished and the parts being evidently infected no attempt was made to repair the injury. I therefore made a median lithotomy incision without a staff and inserted a drainage tube into the bladder, partially closed the perineal wound by suture, packed with gauze and put my patient to bed. No unfavorable symptoms followed. There was some suppuration from the seat of the urethral laceration; the epididymitis gradually improved and by July 23 all swelling and suppuration had disappeared. The patient was on that day again placed under ether and the extent of his injury explored.
All the structures except the skin and superficial layer of the superficial facia had been divided by the accident down to and including the urethra at the posterior part of the bulb. The posterior end of the urethra was not difficult to find, although separated from the anterior end fully one inch. When the two ends of the divided tube were brought together over a sound, I discovered that a part of the floor of the posterior section had been destroyed, leaving a quadrilateral opening three-fourths of an inch in length, one-fourth inch wide anteriorly, and three-sixteenths of an inch wide posteriorly, and involving the membranous urethra in more than half its length. I also discovered that in making the lithotomy incision my knife had wandered to the left of the median line and had penetrated the prostate just to the left of the urethra and thence had passed into the prostatic portion of the canal-a fortunate circumstance under existing conditions. I now freshened all divided surfaces and divided the remaining portion of the posterior part of the urethra into three equal segments, by two longitudinal incisions extending from its free end backward three-fourhs of an inch-being on a level with the posterior limit of laceration. The incisions were carried through all the urethral coats for the first third of their length, after which their depth gradually lessened and at their posterior limit little more than the mucous membrane was divided. The end of the tube was now spread like a fan, until the distance across the free ends of the three segments
equaled the circumference of the anterior end of the urethra. With interrupted sutures of catgut I fastened the middle segment in its normal position to the anterior end forming the roof of the urethra. The sutures were carried through all the urethral structures and tied within the tube. A soft rubber bougie, No. 16 American, was then passed through the penile urethra and well past the urethral laceration. The remaining two segments were brought round the bougie and united by a catgut suture passed near their upper and inner margin. Each segment was then sutured with catgut to the anterior end of the urethra.
I had now converted the one large quadrilateral opening into three small V-shaped wounds, each three-fourths of an inch in length. The lateral ones each with a base one-eighth of an inch directed anteriorly; the third situated on the urethral floor with a base three-sixteenths of an inch directed posteriorly. The divided structures were now sutured over the urethra with catgut and the external wound closed by silkworm gut-care being taken to have a free opening from the wound in the urethral floor to the external cutaneous surface, in which a small gauze drain was placed. The perineal tube was again secured in the bladder and the bougie gently pressed against it and then fastened in the penis, and the patient returned to his bed.
Recovery was uneventful. On the fourth day I removed the bougie and irrigated the urethra with a hot boric acid solution. On the tenth day I removed the perineal tube, and a No. 13 American sound passed along the urethra into the bladder without interruption or causing pain, and the same day about onefourth of the urine flowed through the natural channel. Three days after the drain was removed from the bladder, the opening through which the tube passed was closed. Urine continued to escape in decreasing quantity through the opening left opposite the laceration in the urethral floor for ten days after the vesical drain was removed, when the fistula closed and all the urine passed through the natural channel. August the 11th I passed, at one sitting, sounds from No. 17 to 20 American without difficulty or causing pain, except at the meatus.
At this date the patient is apparently fully recovered. He has neither pain nor tenderness and can retain his urine normally, and
voids it in a full stream and with natural force. The caliber of the urethra is full size and accepts a No. 18 American sound without complaint. I admit that it is too soon to make claim for permanence, but I am convinced that the conversion of the one larger opening into three smaller one, with healthy and normal tissues separating them, will in no small degree obviate the tendency to stricture. In anticipation of criticism I wish to say that I am aware that it is considered good surgery to make immediate repair of a ruptured urethra. In this case so much damage by attempts at instrumentation and infection being present, I deemed it wise to postpone an attempt to restore the urethra until the parts were in a healthy condition.
RESECTION OF ARTERIES AND VEINS INJURED IN CONTINUITY-END TO END SUTURE-EXPERIMENTAL AND CLINICAL RESEARCH.
DISCUSSION OF DR. MURPHY'S PAPER (Published in the last issue of The Railway Surgeon).
Dr. A. I. Bouffleur: I feel that this is one of the most important subjects that has been presented to the Association, and I desire to add a little testimony of my own relative to such experiments. Some two or three years ago, when connected with the anatomical department of a college in Chicago, I made a number of experiments in regard to the matter of injection. We would sometimes get subjects whose vessels had been injured, and the thought occurred to me that I might utilize the same principle in treating an injured vessel of large size that we employ in the treatment of injuries of the intestines. My experiments were carried out on the cadaver, not on the dog. The lateral (Lembert) suture was used as in the intestine. I was enabled by means of injection to bring more pressure to bear than the heart gives and was unable to force the injection fluid through the line of suturing. The invagination experiments, made at that time, were limited, but we were enabled to demonstrate that by invaginating the proximal end into the distal, we could. use considerable force without leakage, and without putting in a large number of sutures. The lamented Dr. Parkes sutured one of the lateral sinuses and I
believe it has been done successfully a great many times since. I, therefore, see no reason why we should not be able to employ something of this sort in restoring injured arteries.
Dr. P. Daugherty: In the ligation of large veins Dr. Murphy spoke of the procedure as being very dangerous. I would like to ask him what veins he had in view when he made this statement.
Dr. Murphy: I had in view the femoral, subclavian and axillary veins.
Dr. W. B. Outten: Our president, Dr. Murphy, has given us an excellent paper, and while I am not competent to disagree with him regarding certain points, I want to say that, so far as these experiments go, there is one point which struck me very forcibly in connection with stitching these vessels. When he said that he was able to stitch the veins, then I said he has found the solution to a serious problem. But I do not believe that the doctor has demonstrated the possibility of suturing arteries, and I will give you my reasons as clearly as possible. In the operation for the radical cure of hernia you and I know that it depends upon one single fact, that is, the deposition of a certain amount of cicatricial tissue-connective tissue, if you please—which may be so continuous and solid as to stand the test of time until certain serious trouble occurs, when its absorption takes place, and today there is not a man living who will dare to say that he has performed an operation for the radical cure of hernia, which was radical per se and for all time to come. Is it possible to place cicatricial tissue in an artery? Is it possible to keep it there with the heart eternally pounding against it? It may be that the doctor has arrived at that point in which experience will prove that he can get rid of the cumulative force of the heart beat, and that the cicatricial tissue cannot be shaken. My doubt occurs in this way: Anybody who has investigated the healing of wounds knows that there is no such thing as ideal first intention; that a wound heals by first intention by the interposition of a certain amount of embryonic tissue. If we have the formation of cicatricial tissue in connection with an arterial wound, it appears to me that the continuous pounding of the heart will ultimately make it give way.
Dr. James T. Jelks: I desire to take issue. with Dr. Outten in his criticism of Dr. Mur
phy's staement. By the demonstration, artery is invaginated within artery, and there is practically no formation of cicatricial tissue to dilate and cause aneurism later. The two ends are interlaced, hence union takes place promptly. There will be a small amount of embryonic deposit, but there will be no aneurism. I desire to say that this operation is a pathfinder in arterial surgery.
Dr. McCrae: I would ask Dr. Murphy if, in case the carotid should be incised very close to its bifurcation, what means would he employ then.
Dr. James B. Hungate: I would like to say that in this city in the spring of 1888 at the Woman's Hospital a clinic was given by Dr. Walter B. Dorsett. The case was one of extirpation of cancer of the breast. The operator accidentally wounded the subclavian vein. on the left side. saw that the patient's life hung by a thread. He became excited. The blood was oozing out of the incised wound in the large vessel. Every man present said something, or suggested some plan to control the hemorrhage. The wound was not sutured as suggested by the president, but someone. caught the vessel with forceps and tied it laterally. A lateral incision of probably threeeighths of an inch in length was made and the vessel tied laterally with the hope that it would hold, and still leave enough lumen for the return of blood to the heart. The woman died later of phlebitis. We must have some kind of operation to successfully cope with these emergencies.
Dr. J. B. Murphy (closing): Suturing of the sinuses has been carried on for a great many years, in fact, I do not know how far back it goes. I remember in my very early practice I had a laceration of one of the sinuses and removed a large portion of bone and resorted to suturing. Ligation of the side of the vein is of rather common occurrence. The surgeon who frequently operates for removal of enlarged cervical glands, particularly since the fad or injecting them with iodoform has come into vogue, not infrequently cuts into the jugular vein, and in order to guard against the admission of air he ligates the vein temporarily, and instead of suturing, he mererly picks up the large vein with forceps and puts on a ligature. I have seen the evil results following this method. Without an infection you
have union of veins, and there is no danger of thrombosis. But where we have infection, then we have failure of union, the same as in cases of infection in other parts of the body, and we have secondary hemorrhage from the arteries.
The danger which my colleague, Dr. Outten, fears, I consider one of the least important, theoretically. When I first considered this subject this point came up, and I could see in my mind these aneurisms occurring from slight wounds, but I have found experimentally that the conditions are different. There is a difference in the condition. It is exactly the same as in other portions of the body. Physiology is right if we interpret it properly. When we have destruction of tissue, if we bring it into close apposition with similar tissue we have at first a deposit of connective tissue, which instead of expanding, contracts and contracts, in spits of the physiological functions performed by the part wounded or united. The danger is not from expansion. Where we get aneurisms which Dr. Outten alludes to, the wall of the vessel is divided, and there is the formation of a plug of blood clot in the opening. It is in such cases that we must expect to have the formation of an aneurism. I believe that aneurism will be the last thing to happen in the practical working out of this branch of surgery.
With regard to the bifurcation of the carotid, my experiments along this line had not advanced to the degree that I anticipated when I had a case. The carotid was divided within half an inch of the subclavian, and in that way I could not use it for the purpose of invagination as it is situated too deep in the neck. If the injury be high up, where you have division of the carotid, the internal artery is the one you want for invagination, keeping up the current on the inner side, and the collateral circulation to the side of the face will be found sufficient to preserve it from gangrene.
A Simple but Successful Treatment of Colles' Fracture.
In the Archiv fur klin. Chirurgie, vol. liii, p. 336, the results of a simple method of treatment of Colles' fracture of the radius, as carried out in the Königsberg Polyclinic, are. given by Storp. This treatment is essentially the same as was advocated many years ago by Sir Astley Cooper, viz., the suspension of the arm by the wrist, the hand being allowed to
drop sharply to the ulnar side. Storp insists that attention should be directed especially to the complications of a Colles' fracture, and not to the fracture of the radius. In almost any decently applied apparatus the bone unites. rapidly and firmly. On the other hand, the complications, such as rents in the joint-capsule, made by splinters of bone, or openings into the posterior or anterior tendon-sheaths, or injury to the triangular ligament or its attachments should be attended to. In all such cases, if the hand remain too long in splints, organization of blood clots and the formation of adhesions in joint or tendon sheath delay complete recovery, or possibly permanently disable the hand. To avoid this, the fingers are now almost universally left free, and massage applied at an early date.
Storp has treated 104 patients in this manA strip of rubber plaster, two and onehalf inches wide, is wound about the arm just above the wrist joint. A second piece is placed exactly over the first, a fold being made in it on the radial side, which stands out far enough from the arm to allow a large hole to be made in it. Through this hole a string is passed, and the arm is held high up on the chest, the hand dropping downward toward the ulnar side.
The treatment is at first rather painful, but if the arm is kept high up venous congestion is avoided and the pain becomes much less. The plaster is removed in ten days and the hand simply placed in a sling while the patient is advised to use it carefully. In a few of Storp's cases, in which there was extensive hemorrhage, massage was employed. The average duration of treatment was three weeks, while fourteen to eighteen days sufficed in patients under twenty years of age.
The results were exceptionally good. Of the ninety-five cases in which directions were carried out, the arms of ninety-one were completely restored in appearance as well as function; in the other four the functional result was a good one, but there was a slight radial deformity in three cases, and a rather marked radial deformity in the fourth.-Medical News.
Dr. H. L. Getz of Marshalltown, Ia., has been appointed chief surgeon of the Iowa Central Railway, to fill the vacancy made by the resignation of Dr. A. D. Bevan of Chicago. the resignation and appointment taking effect January 1, 1897. Dr. Getz has been for some years local surgeon for the Iowa Central at Marshalltown. He is also district surgeon for the Chicago & Northwestern, and local surgeon for the Chicago Great Western, and for the M. L. P. at that point.