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cautions, and a rubber drainage-tube of moderate size inserted. Gauze dressing was applied and the patient given a dose of morphine. The catheter was used every two hours. The patient was fed carefully and systematically, and was nursed and watched with scrupulous care. There was nothing of especial interest in the after-treatment, except that the drainage tube was aspirated every day, and that the bladder was relieved every two hours on the first day, and then four or five times a day up to the tenth day, when catheterization was discontinued. The temperature never got above 99°2°, and the pulse never went beyond 115. The wound united by first intention. The drainage-tube was left in situ until the sixth or seventh day. The pulse was frequent, but the patient did not seem to be gravely depressed. The most marked indications of shock were the intense pain and the frequency of the pulse.

Sarcoma of the Bladder.-In the June and July numbers of the Medical Chronicle appears a valuable paper by Mr. F. A. Southam. He thinks that sarcoma more commonly affects the bladder than is generally said to be the case, and that such growths are usually primary. They are most common at two periods of life, viz.: under ten and between forty and seventy. Males are more commonly affected than females. The growths usually originate in the connective tissue of the submucous layer and are most often met with at the face or on the posterior wall. They are often multiple, especially in children. The surface of the growths may or may not be villous in character, and the tumours usually remain confined to the walls of the bladder. Secondary deposits in other parts of the body are more frequently absent than present. Evidences of chronic cystitis are found as a rule in the bladder structure. Secondary changes in the kidneys are after a time usually produced, either in the form of distension from ureteric obstruction, or from pyelitis. Secondary deposits are rarely seen in the kidneys. The general symptoms are those of hæmaturia with vesical irritability. In discussing leading signs in detail, Mr. Southam says that hæmaturia is a prominent and often an early symptom. It frequently precedes the signs of

irritability, sometimes it comes on at the same time, and occasionally it follows afterwards, and cases are recorded where it has been altogether absent. Micturition becomes more painful and frequent as the disease progresses. Sudden stoppages sometimes occur when the tumour is pedunculated and is drawn over the vesical outlet. Only when the tumour is of firm consistence can we obtain evidence of its existence by digital examination from the rectum or by careful sounding, Microscopic searching of the urine for small detatched pieces of the growth is of the greatest possible value. A diagnosis of sarcoma from papilloma or cancer is often quite impossible. Untreated cases sooner or later terminate fatally in a period from one to four years. With regard to treatment, Mr. Southam argues that as palliative measures are of little use, the bladder should be explored and an attempt made to remove the growth with forceps, scraping or ecraseur. He gives preference to the suprapubic incision, because of the free access it gives to the whole interior of the bladder cavity. Speaking of recurrence after removal, he says this is to be expected, especially when the growth is sessile and infiltrates the walls. The results of operative interference show that life is undoubtedly prolonged and symptoms much relieved. Whether permanent cure is ever to be obtained, future observation can alone determine.

A case of Typhlitis and Perforation; Laparatomy; Recovery. -Dr. McMurtry brought this case before the American Medical Association at their May meeting. The patient, a young physician, had been subject to short attacks of colic, accompanied by nausea and vomiting, with pain in the iliac region. There was marked dulness on percussion, and on palpation an induration was perceived over the line of the ureter, giving the impression of obstruction of that duct. Later the swelling of the iliac region increased and a tumour of the caputcoli was recognised. An incision was made over the median line, when it was found that there was no general peritonitis. The cæcum was drawn to the opening and the vermiform appendix found normal. Two perforations, as large as silver quarters, on the anterior surface

of the cæcum allowed the contents of the gut to escape. These were made elliptical in shape, and closed with silk sutures. The diseased parts were cleansed, a rubber drainage-tube was introduced, and the wound closed with silk. The bowels were evacuated on the third day, and convalescence proceeded without the temperature rising above 100°, so that on the fourteenth day the drainage-tube was removed. Opium was used very sparingly.

On Whitehead's operation for Hæmorrhoids.-Dr. R. F. Weir (New York Medical Record, July 14) contributes his recent experiences of the above. He tried the operation first, more than a year ago, and abandoned it in favour of Allingham's ligature. A more recent paper by Whitehead however, led Dr. Weir to give the operation another trial, and now through its latest improvements he has become re-converted. He gives the details of six consecutive cases. He concludes that while for the less severe cases of piles the operation of injection with carbolic acid is to be first thought of, and while for the more decided form of this disease, Allingham's method yet stands unequalled; yet for extensive conditions of hæmorrhoidal disease, which have hitherto been treated by tying off three, four, and sometimes more masses, he thinks greater efficacy and greater permanence of cure and less after discomfort will result from Whitehead's operation. Bleeding is trivial in amount, and there is no after tendency to formation of stricture.

The Erasion of Carbuncles.-Dr. Weir (loc. cit.) details four cases of carbuncle treated by excision. The slough was exposed by the scalpel or Volkmann's sharp spoon and the affected parts scraped out in a very elaborate manner. The bleeding is apt to be profuse, but is easily checked by pressure. The immediate effect by the treatment is to change at once the character of the pain from that of a burning type to the smarting of an ordinary wound, which speedily passes away with or without the use of anodyne. The temperature, if previously elevated, also fails, and the other constitutional symptoms ameliorate. In one instance, Dr. Weir has supplemented this treatment, and with

advantage apparently, by injecting into the reddened inflamed tissue, beyond the reach of the sharp spoon, a solution of 1 to 20 carbolic acid, covering by these injections an area more or less completely surrounding the carbuncle. The risks of pyemia, septicemia and exhaustion are very much lessened by this treatment and repair is more rapidly established.

An appliance to prevent Masturbation.-Dr. Sorrell Flood details a case of Onanism (Boston Med. Surg. Journal, July 12), which was cured by the following means. The mechanical appliance was a plaster bandage arranged as follows:-" A sheath of oil silk was first made, to cover the penis and project an inch beyond, the limp organ hanging straight down between the thighs; then a layer of cotton wadding covered in the scrotum and buttocks, leaving a triangular opening, three inches on each side for defecation. The plaster bandage then covered all, and went down around the penis and up about the waist, making when hard a complete casing, so that the boy's frontals might have been in the next county for all the sensation his hands could communicate." He managed well at stool, suffered no chafing from the edges between the thighs, walked freely enough and urinated while standing and holding the vessel under the projecting oil-silk.

A case of Excision of a Dislocated Spleen and subsequent expectoration of the ligature of the pedicle.-Dr. T. A. McGraw, of Detroit, details (Medical Record, June 30) the above case. A woman aged 40 years had suffered from "malarial fever" eighteen years before, and the spleen enlarged at this time. The splenic tumour had been a frequent source of trouble ever since. In June, 1887, Dr. McGraw excised the dislocated spleen, ligaturing the pedicle with stout braided silk. The patient did well for several days, and then developed symptoms of pleuro-pneumonia in the left chest. On August 13th she had completely recovered and left the hospital. Seven months later she began to suffer from pain in the left side and hæmoptysis, and on April 1st, more than nine months after the operation, she expectorated the braided silk

ligature which had secured the pedicle. There could be no question of deception as to the ligature, and Dr. McGraw considers that it escaped via the lungs rather than the stomach. The patient soon afterwards made a complete recovery.

A proposal for the Treatment of Gangrenous Intestine in Hernia. ―(Central. f. Chirurg., 1888, No. 22).-Rosenberger recommends the establishment of an artificial anus. Suture of the intestine at the point of perforation after excision of the gangrenous part, and circular resection of the intestine, have so far given anything but satisfactory results. He recommends that on opening the hernial sac the stricture is to be divided by multiple small incisions and the gangrenous gut fixed to the sac by a few sutures. The loop in its entirety is then to be excised, and a large drainage-tube inserted into both openings in the gut. The wound is then nearly closed, sufficient room being left for the drain-tubes. These are removed after two, or at the latest, three days. Three cases are given, two recoveries—one after six weeks, the other after four months; one death, a woman aged 77 and very weak.

Gunshot wound of Stomach and Liver treated by laparotomy and suture of visceral wounds, with recovery.—The above brilliant case is recorded by Dr. Dalton, of St. Louis (Annals of Surgery, Aug. 1888). A coloured man, 22 years of age, was shot in the abdomen with a revolver. The wound of entrance was five inches to the left of the median line, and two inches above the umbilicus. It was found that the bullet had entered the abdominal cavity, and median laparotomy above the umbilicus was at once performed. Two holes were discovered in the stomach, the one of entrance in the anterior surface three inches below the cardia; that of exit in the superior portion of stomach, about an inch and a half from the pylorus. The bullet ploughed through the lower margin of the left lobe of the liver at a point an inch and a quarter from the fissure, leaving a V shaped gap a half inch in depth. The stomach wounds were sutured with thin dyed silk Lembert sutures, and that in the liver with one stout catgut stitch passed very deeply. Whole

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