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tence of nephritic calculus and in which a nephrotomy was done and in none of which a stone was found. In eleven of these cases the operation developed absolutely nothing to account for the symptoms. In the others simple displacement existed in some and tubercular abscess in others. An eminent surgeon, with more tact than honesty, advises that when you are about to operate for vesical calculus, you should always have a stone in your pocket to show your patient in case you find none in his bladder. If such a course be advisable in an operation on the bladder, it is doubly so in one done for stone in the kidney.
In view of the uncertainty of diagnosis the surgeon who does a nephrotomy must look upon his operation in the first instance as one simply of an exploratory character. With all that can be said in relation to the advances in kidney surgery within the last few years there are many points in regard to the technique of the different operations upon this organ that are far from being settled; and if one was asked what the classical procedure in any given case should be he would be at a loss to give a positive answer. To expose the organ, however, whether for the purpose of doing a nephrectomy or a nephrotomy, a majority of operators resort to the lumbar incision, viz., laying open the parts from the lower border of the last rib to the crest of the ilium, following as a guide the inner border of the erector spinea muscles. Whatever form of incision is used it should accomplish thoroughly one object, and that is the complete exposure of the organ upon which we are about to operate, so that if necessary it can be examined in its entirety. If, after we have exposed the kidney so that we can palpate every part of its surface, our examination fails to locate the stone that we suppose to exist, what will be our next step in the operation? Here again authorities do not agree. Many advise the use of an exploring needle, which, being introduced at different points deeply into the substance of the kidney, enables us to locate accurately the situation of the calculus. This I believe to be a reprehensible practice, for we are likely, by this maneuver, to do damage to the delicate structure of the organ, and besides if, after practicing this kind of an exploration, we are not able to locate the stone, we would not be justified in abandoning the operation until we had opened
up the kidney and explored every part of its cavity by a digital examination; therefore, I believe that all needling in this operation is superfluous and likely to be harmful.
Another point upon which authorities are at variance is the most desirable portion of the kidney in which to make our incision, if the location of the stone is such as to give a choice. Some claim that a fistula is much less likely to follow the operation if we cut through the body of the organ, than if we cut directly into its pelvis, while others claim that the wound will heal with equal facility whether made in one location or the other. A part of every nephrotomy, if done for the removal of a stone, should be a thorough exploration of the ureter to determine whether or no this canal is perfectly patulous. Whether, after opening up the kidney and removing the stone, we should close up at once the incision in the substance of that organ or pack it and allow it to heal by granulation, is a question upon which authorities do not agree. Köenig, in his late work on surgery, advises the primary closure of the wound if there be no suppurative pyelitis or other septic process connected with the case. However, his statistics show that a permanent fistula is as frequent in the one mode of operation as in the other. In the 27th vol. of Langenbeck's Archiv Für Klinische Chirurgie, Dr. James Israel, in his exhaustive article, "Erfahrungen Ueber Nieren Chirurgie," gives four cases of nephro-lithotomy in which he closed up the incision in the kidney immediately by cat-gut sutures and in none of these cases was there a single drop of urine passed through the wound after the operation. He gives explicit directions that the two cut surfaces of the kidney should be firmly held together by an assistant while putting in and tying the cat-gut so that as little strain as possible will be brought to bear upon the delicate tissues of the kidney. Two months after one of these operations he had to do a nephrectomy on one of these patients on account of an irreparable injury to one of the ureters, and he found the incision that he had sewed up in the kidney so accurately adjusted and healed that it was scarcely possible to detect the slightest cicatrix. On the contrary, Prof. Fenger of Chicago, who is one of the leading authorities on kidney and ureteral surgery in America, does not believe that a kidney, the
seat of a calculus, can be in an aseptic condition, and therefore rules out Köenig's limitation as regards the primary closure of the wound after a nephro-lithotomy. This eminent authority relates a case in which the patient died, evidently as the result of the primary closure of the wound, and has entirely abandoned this mode of operating. He now uses drainage exclusively and allows the parts to heal by granulation.
One of the greatest obstacles to the early progress of renal surgery was fear of the hemorrhage that was likely to follow any incision into this organ, and to avoid this accident some surgeons even now resort to the thermo-cautery. Operators generally open up the kidney with a blunt, pointed instrument, or the finger, and Köenig says that any bleeding can be controlled by fine cat-gut sutures.
In doing a nephro-lithotomy in cases where the kidney has undergone an extensive degeneration owing to the presence of suppuration the question of the removal of the entire organ is one that often presents itself to the surgeon. A revolution has taken place in this field during the last few years almost as great as that in regard to the removal of the ovaries; kidneys are now drained and left that a decade ago would have been sacrificed, thanks to the new discoveries that have been made as to the power of this organ to regenerate itself, even when a large part of its substance has been destroyed. In 1878, while following the work of Prof. Martin in Berlin, I saw him remove a good many kidneys for no other cause than that they were displaced and that the patients suffered from the usual symptoms that accompany this trouble, a procedure that this great surgeon would not think of to-day.
In the history of thirteen cases of suppurative nephritis, given in the St. Bartholomew hospital reports, where nephrectomy was done, it is stated that eleven died, but in the two cases where the operation was abandoned and the kidney packed and drained, the patients recovered; an example of the superiority of conservative surgery as applied to our dealings with the kidneys.
DISCUSSION OF DR. CALDWELL'S PAPER. Dr. James T. Jelks: It has not been many years that surgeons would undertake any operative interference in kidney troubles, or upon calculi within the kidney. It should be
the dictum that every man with kidney calculus should be subjected to operative interference to get rid of it. There is no middle ground; no hope for the patient outside of surgical interference.
I had the pleasure of seeing a case with Dr. Murphy where a man had been carrying a calculus for months, but he will not continue to carry it. The probabilities are that he will submit to a radical operation for its removal. We should settle the point in our own minds firmly that there is no middle ground; that medicines cannot reach these cases; that nothing we can give the patient will dissolve a stone in the kidney or bladder. There is but one way to remove it, viz., by operation. As a matter of course, if we undertake to remove a calculus from the kidney it should be by the lumbar operation. There is one trouble we have to contend with, viz., that when we open the kidney for calculus we sometimes do not find it. We should bear in mind the fact that
in many cases of calculus of the kidney the pain is not in the kidney, which is the habitat of the stone. In other words, we have a crossed pain, so to speak. The man may complain of pain in his right kidney and have the stone in his left. We can make a differential diagnosis by palpation, and can settle the point as to which kidney is involved, outside of the patient's complaints, by taking each kidney between the fingers and resorting to bimanual manipulation. This will settle the diagnosis. Having done so, the question then is one of operation, and the authorities of the profession have decided that the operation upon the kidney should not involve the pelvis, but should go through the tissue of the kidney proper, because of the fact that if the operation is made in the pelvis of the kidney it is always followed by fistulous tracts and we subject the patient later to nephrectomy, and we may happen to remove the only kidney the patient has had.
Our president has reported two cases upon which he has operated, and removed two stones by cutting through the pelvis and stitching up the parts, getting union by first intention. We may explore the calices of the kidney and find the stone with our fingers, but not with the needle. The finger is the best probe we can use. Then, making an incision. in the pelvis of the kidney, we may explore the whole body of the organ, locate the stone and
remove it through a cut in the kidney tissue. We will have considerable hemorrhage, as a matter of course, but it is easy to control it by a little pressure.
When we find a man with a uric acid diathesis and a history of nephritic calculi, and the calculi have been emitted by passing from his bladder, we should teach him so to live as not to have any more trouble with nephritic calculus. We can prevent the formation of nephritic calculi by teaching people how to live; that is, to get rid of their uric acid or oxalated lime as fast as it accumulates. In the winter time we manufacture more uric acid than we discharge and store it in the economy. In the summer time we are supposed, by the sweating we undergo, to throw off the uric acid, hence the balance is kept between winter and summer. We should teach patients so to live that the output will equal the manufacture. When people come to us with a history of having had renal calculus and colic, we should absolutely prohibit their partaking of meat, particularly until we have eliminated the stored-up uric acid by the administration of salicylates and alkalies. These patients should be put upon a vegetable, milk and fruit regimen. After a preliminary course to dissolve the stored-up uric acid, we can promise a patient that he will have absolute relief in the future from renal colic.
ARTIFICIAL CLIMATE FOR TUBERCULAR CASES; IS IT PRACTICABLE?
BY DR. H. C. HIMOE, KANSAS CITY, Mo.
In entering upon the consideration of this subject, I am aware that I will be met with opposition, on the ground that the scheme I am about to propose is a chimerical one; but I am convinced that it is only by a thorough discussion of any subject, that we can arrive at definite conclusions as to its practicability, and that it is only by a free and open argument of the subject in hand, that we can formulate definite plans for the amelioration of that most unfortunate class of human beings-sufferers from tuberculosis.
First, we are led to inquire, what it is in climates that gives immunity, at least in part, from the terrible sufferings of tubercular patients, and, in some cases, performs a cure.
The essential features, that give this relief, in such a climate are: dryness of atmosphere and the presence in it of large quantities of ozone, that life-giving principle that conduces to a healthy condition of the lung tissues, and enables them to throw off the morbid products of disease and resist a further invasion
of disease germs. Those physicians who
have practiced in a climate where cases of tuberculosis are finally sent, are at once impressed by the almost hopelessness of many cases that have been sent on long, exhausting journeys, when their vital powers were already well nigh spent, either to die en route (as I have too often witnessed), or, even if they should arrive at their journey's end alive, to succumb sooner or later to the terrible ravages of the disease, far from the comforts of home and the ministrations of loving friends. I do not mean, in this connection, to disparage the several climates that are lauded as the sine qua non for cases of tuberculosis, but merely to point out the countless errors that are made by well-meaning and learned physicians, who send their dying tubercular cases to climates many hundreds of miles away. They sometimes think it is their only recourse, and their mistakes are rather "of the head than of the heart." When we recall that tuberculosis originates in these very climates, paradoxical though it may seem, among people who were born and raised there and have never been away from home, is it any wonder that so many who go there in search of health find only a sad and lonely death? Such, alas! is the truth, and although well meant on the part of the physician, it has always seemed to me a cruelty to send poor unfortunates thus away to die.
It is useless, however, to point out an evil without suggesting a remedy, and this I will attempt to do without trespassing too much upon valuable space.
"Charity begins at home"-that goes without saying, and, no doubt, philanthropists can be found who will hasten to contribute their means to a plan that will at least mitigate the sufferings of their fellow-men, if, indeed, it does not contribute to the cure of that dread disease.
It is a well-known fact that the majority of sufferers from tuberculosis seek a change of climate only when it is too late to stay the
progress of the disease; some, because they hesitate to leave the comforts of home, to live alone many miles away; others, because they have not the means to procure such a change. The latter class comprises by far the larger number of tubercular cases.
Now, I firmly believe that, by the construction of immense buildings, covered in part by roofs of glass to admit sunlight in abundance; containing an atmosphere which has been purified, filtered and dried, kept at an equable temperature, and constantly renewed by means of appliances similar to those used for the ventilation of certain factories-an atmosphere that is charged with ozone in definite quantities by using modern electrical contrivances we have imsolution of this most portant question. These conditions furnish all that changes of climate accomplish; that much must be admitted. There is no specific principle in mountain air that destroys the tubercle bacillus.
By the plan suggested, cases of tuberculosis could be properly isolated, they would not be banished like lepers from their friends, who will never see them alive again, and, being taken in their initial stages, would give some promise of ultimate cure.
It has not been my intention to enter into detail of construction of these mammoth sanitariums, but merely to call the attention of the profession to a question that demands their most earnest attention, and the consummation of which would be hailed with delight, not only by themselves, but by humankind with one accord the world over.
The advantages claimed for this system are: First: Cases would be taken at their inception and hence give greater promise of a cure.
Second: A greater number of those afflicted with tuberculosis would be able to avail themselves of the treatment by climate. Third: Isolation would be complete, and the spread of tuberculosis by infection would be reduced to a minimum.
Fourth: Patients would not have to travel long distances from home and be separated from their families.
Fifth: Patients would not be subject to the vicissitudes of weather that are invariably encountered in all climates.
Sixth: The time required for a cure, in favorable cases, would be much less.
SOME AMPUTATIONS PERFORMED DURING THE PAST YEAR.*
BY HOWARD J. WILLIAMS, A. M., M. D., MACON, GA.
Since March 26, 1895, I have performed nine major amputations on eight patients, and as many more of minor interest. Five were for traumatisms and four were for disease. The former were railroad injuries; of the latter two were in cases of chronic ulcer; one for tuberculosis of the knee, and one for conical stump. Two were reamputations; one a double amputation, and one a shoulder-joint operation. Recovery followed in all, primary union failing in three.
The first case I present is an amputation of the thumb and two first fingers with all the corresponding metacarpal bones. While not generally considered a major operation, it was more extensive than an amputation in the middle of the forearm, and certainly more difficult.
CASE I-COMPOUND FRACTURE OF THE LEFT
Henry B., male, 26 years of age, negro coupler, was injured while coupling cars July 26, 1895, near Lumber City, Ga. He was transferred to Macon and placed in the hospital July 27. The wound had not been entirely covered, nor had any antisepticism been used, hence it was infected with maggots when received in the hospital eighteen hours after the accident. The wound was undressed and efforts were made to remove the maggots with chloroform, carbolic acid, etc. On the third day gangrene began, blebs forming on the fingers. The temperature on admission was 102, on the third day it reached 104.4. It then gradually declined and by August 10 was normal.
August 27 the line or demarcation having completely formed, with the assistance of Dr. McHatton I amputated the thumb, first two fingers and corresponding metacarpal bones, The anesthetic was ether; antisepsis was observed, but no drainage used. A small slough formed on the dorsal portion of the wound. The patient was dismissed from the hospital Sept. 12, 1895, with the wound granulating at the point of sloughing, and the ring and
* Read before the Central of Georgia Railway Surgeons' Association, at Augusta, Ga., April 14, 1896.
little fingers bent and permanently ankylosed. This case illustrates the results that will follow carelessly applied primary dressings. The wound, though extensive, would never have become gangrenous if it had been completely covered with proper antiseptic dressings. One-half of an inch being exposed to the air, it was promptly fly-blown, hence the of gangrene. The bones the thumb and fingers were broken, but had antisepsis been used and the hand placed on a splint, there would have been a good chance of saving the fingers. We thought for a time that the entire hand would have to come off, but by waiting and watching the case, we were able to save a portion of it. The remaining fingers are ankylosed, yet the man gets considerable use out of the stump, carries his dinner basket and uses it in various ways. CASE II-COMPOUND COMMINUTED FRACTURE OF
THE LEFT HAND.
Wm. H., male, 25 years of age, negro coupler. This man was injured while coupling cars, Oct. 26, 1895, at 3:20 a. m., at the Macon yards. He was admitted to the hospital and The the operation was performed at 6 a. m. hand was amputated two inches above the wrist. The anaesthetic was ether; antiseptics were used but no drainage. The temperature when the operation was performed was 98.6; on the second afternoon it was 102, and rapidly declined, being normal the next day. The dressings were removed on the eighth day, primary union being found, except in one point, from which was discharged an aseptic mucilagenous fluid. On the twelfth day the patient was dicharged, with primary union.
The interest in this case rests upon the fact that no drainage was used, and that on opening the dressings on the eighth day, a thin pinkish mucilagenous discharge escaped from the wound. This was not pus, nor was it septic, simply a change in the consistency of retained exudations. I am never alarmed by this discharge, as it occurs often when no drainage is employed, and it does not interfere with union.
CASE III-COMPOUND COMMINUTED FRACTURE OF LEFT FOREARM AND ARM-LIMB
Chas. S., male, 18 years of age, negro, a driver of a baggage wagon, fell from his
wagon, his arm being caught under the wheels of a slowly passing engine, on March 26, 1895, at 10`p. m. He was placed in the hospital and an operation performed at midnight. The amputation was two inches below the shoulder-joint. The anesthetic used was ether. Antiseptics were employed, but no drainage. The temperature was normal when the operation was performed. It was 102.4 twelve hours later, and gradually declined by the third day. Dressings were removed on the sixth day and the stitches taken out. The wound was uniting. Patient was discharged on the fifteenth day, primary union being the result.
The point at which this operation was performed is the more interesting feature, viz., near the shoulder-joint, and not in it. If it is possible to avoid an operation in this joint, it is our duty to do so. For by so doing we preserve the symmetry of the shoulder, and add to the comfort of the patient, as the stump aids in holding the clothing in place. Had the engine been moving rapidly, it would have been necessary to go into the joint, as the destruction of the tissues above the point of crushing by the wheels would have reached even up to the axilla. My flaps were very near the crushed tissues.
Wm. H., male, 32 years of age, negro tramp. This man was injured by falling under the car wheels, while stealing a ride near James Station, Ga., on Nov. 13, 1895, at 8:30 p. m. I was telegraphed for next morning and found him lying on a mattress in the agent's office, his foot bound up in old cloths, but no dressings on the arm. The operations were performed in the agent's office. Amputation of the leg was made at the junction of the middle and lower third; the arm was amputated in the lower third. The anesthetic was ether. Antiseptics and drainage tubes were used. The temperature at the time of operation was 100 degrees. The patient was made comfortable for the time in the office, and transferred the next morning to his home at Thomson, Ga., 75 miles further down the road. As the company was not liable for his injury, he was