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The incision in the medio-bilateral operation possesses a marked advantage in opening up the shortest and most direct route to the bladder, thus facilitating the manipulation of instruments and the removal of stones.

The rapidity with which the medio-bilateral operation can be done by an experienced operator is an argument in its favor, though the necessity for quick operations does not now exist as before the age of anesthesia. I have seen the operation completed in forty seconds, while lateral lithotomy, performed in my presence by one of the most skillful lithotomists in this country, required fifteen minutes for its completion.

Another strong argument in favor of the medio-bilateral operation is its low rate of mortality as compared with that furnished by other methods.

The operation is done as follows. The parts having been previously prepared and the bowel cleared out some hours before by an enema, the patient is anæsthetized and secured in the lithotomy position, the buttocks being brought down close to the end of the table. The grooved staff, the size of which is as large as the urethra will admit, is passed into the bladder and brought in contact with the stone. This instrument is then entrusted to an assistant, who is directed to draw it well up under the pubic arch and to hold it exactly vertical and accurately in the median line. He is also to grasp the scrotum and draw it well up upon the staff so as to render the integument of the perineum tense and to elongate the membranous portion of the urethra as much as possible, thereby carrying the bulb further out of harm's way. The surgeon seats himself before the patient and introduces his left index finger into the rectum, so as to cause it to contract, and to draw it somewhat backward. A narrow, sharp-pointed knife is entered in the raphe, three or four lines anterior to the anus and pushed directly forward to the groove of the staff. then carried forward on the staff so as to open the membranous urethra to the extent of three or four lines. Withdrawing the knife, the incision of the superficial parts by a division of the raphe upwards to the extent of an inch and a half or two inches was effected.

Another method of operating is by dissection, an incision

being made in the raphe, commencing an inch and a half above the anus and carried downwards to within a few lines of the anus. In the posterior part of this incision a careful dissection is made, successively dividing the tissues in the median line down to the staff, and the urethra opened. The beak of the cystotome is now introduced into the groove of the staff, passed along the staff into the bladder, disengaged and withdrawn open, so that its blades divide from within outward the deeper parts to the extent of three lines on each side. The finger is then carried along the staff into the bladder and the stone touched. The staff is then withdrawn. The wound is then slowly and gently, but fully dilated with the finger. A pair of light forceps is passed on the finger into the bladder, and the stone being grasped is drawn downward in the axis of the pelvis by gentle but firm traction. After the extraction of the stone, the bladder is thoroughly irrigated with an antiseptic solution. Then an india-rubber tube, a quarter of an inch in diameter, should be carried into the bladder through the wound and iodoform gauze packed loosely around it. The tube and packing should be removed in thirty-six or forty-eight hours. The wound usually heals rapidly, and in the majority of cases is entirely closed in ten days.



Dick Mc., male, aged 5 years, fourth child of the family. I took charge of the case early in January last. He was a strong, rubust, well-grown boy for his age. His father had had gonorrhoea three or four times, and had lived a dissipated life generally.

The following were the most conspicuous symptoms: Subjective, a ravenous appetite, slept well at night, had four to six fits during the day, bowels and kidneys acted irregularly. Fits began three weeks prior to my first visit.

Objective. He always gave the initial cry (aura epileptica) before having a fit. He would stagger and fall (sometimes into the fire). His eyes would widely open and the pupils would largely dilate. The circulation was almost imperceptible at the wrist in the attacks but normal during the intermission. The duration of each fit was from one-half to two minutes. When one of the "spells" had ended, if asked if anything hurt him, he would say that his head hurt and that the house was turning over. He would resume his play as soon as the "spell" was off. His prepuce was partially attached to glans penis.

Treatment. This is a malarial section, hence I prescribed, first, antimalarial medicines, preceded by a mercurious chloride purge; after which I put him on the bromide of sodium and potassium, for doses per day. The quantity was increased up to 50 grains per dose, in order to obtain the desired physiological effect. I detached the adhered prepuce from the glans. I had him thoroughly bathed three times a week. Had his diet regulated, and all the laws of domestic sanitation observed. I gave him daily four large doses of hyoscyamus and cannabis

indica. I tried large doses of antipyrine, and also of the acetanilide compound.

After a thorough and heroic trial of all the above mentioned remedies, the little patient was no better. In fact, he wa growing worse every day. The fits were getting longer, harder and more frequent-twenty to twenty-five during the day and night. The parents and grandparents were frenzied over the condition of the hoy and the result of my treatment. At this stage, I ordered him a six-day's treatment of oxide zinc (3 grs. t. i. d.) and sulfonal-Bayer—(10 grs. in warm water at bedtime). Before the six days had expired, he had slept all night without an attack, and had only three or four during the day. Not knowing which remedy was doing the good work, I suspended the sulfonal and kept him on the zinc oxide for four weeks. The little man is now fat and saucy, and has not had a fit in over two months.

The zinc oxide did the work.

Selected Articles.




Professor of Surgery in the New York School of Clinical Medicine, Surgeon to St. Marks's Hospital, Etc.

The classical words of Billroth, "Medicine must become surgical," were never better illustrated than by the modern treat. ment of cholelithias's. The celebrated master's demand is justifiable to a great extent; yet I should rather maintain that nowadays surgery must become internal; in other words, that only a good internist can do good surgery. The old saying, Qui bene diagnoscit, bene medebitur, was never more appropriate than at the present, and particularly to the question of the treatment of gallstones, which is entirely decided by diagnostic considerations.

The important point is that, while in the majority of cases the diagnosis of cholelithiasis is easy, there remain still a large number of cases in which it is extremely difficult, if not at times impossible. And even then, when the diagnosis is made, it is still sub judice lis which plan of treatment, whether medical or surgical, should be followed.

Fürbringer, the internist, says: "Still the results of the internists are not bad enough and those of the surgeon not good enough to justify the delivery of the domain of cholelithiasis to

* Read before the Section in General Surgery of the New York Academy of Medicine, March 8, 1897.

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