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ALVEOLAR ABSCESS ; PYÆMIA; EXCISION OF THROMBOSED VEINS; DEATH.
1044
regard the example set me by my two senior colleagues at operations, all of which implicated the peritoneum. Of this the Samaritan Hospital, both of whom were then extremely number, forty-two were undertaken for disease either uncon. careful in thus cleansing the peritoneal cavity at the con- nected with the pelvic organs or, when so connected, of such clusion of an abdominal operation. Such treatment, in com- a nature as not to admit of complete extirpation. Thirty. plicated cases, was usually followed within forty-eight hours three of these patients recovered, and the remaining nine died by a smart rise of temperature to 102° or over, frequently from causes shown in the accompanying table. necessitating the use of an ice cap for its reduction. When TABLE I.-Peritoneal Operations. I began in 1882 to assist Sir Spencer Wells, who then operated with full antiseptic precautions in every respect similar to No. Nature of disease. Cause of death. those employed in the Samaritan Hospital, I soon became 1. Double intra-peritoneal ab. Shock, within six hours. impressed by the fact that complicated cases of ovario- 2. Cancer of both ovaries (parwithin four hours. tial operation). Shock, tomy, where no attempt was made to sponge away the mixture of blood and other fluids remaining in the pelvic 3. Advanced tubercular disease.... Exhaustion, on twelfth day, frori of peritoneum. persistent diarrhoea. cavity at the conclusion of a troublesome operation, 4. General abdominal cancer..... Exhaustion, on eighth day. not unfrequently recovered with but very slight dis- 6. Pelvic cancer..... Exhaustion, on fourth day. turbance of either temperature or pulse, although no 6. on seventh day. tubal origin). Exhaustion, drainage-tube was used. Such results following treatment so 7. Retro-peritoneal sarcoma..... Exhaustion, on third day. opposed to the routine practice in the hospital at that time 8. of intestine, on Perforation Cholecystotomy puzzled me somewhat, until I formed the conclusion that twenty-eighth day. on eighth day avoidance of unnecessary irritation of the serous membrane 9. Hydatid disease of liver. liver. {.... (? hydatid). went have as time to do with might them ; and, something The remaining 141 peritoneat operations were performed on, my views in this direction were materially strengthened by watching the results obtained in cases where the abdomen for disease originating in the uterus or its appendages in the was washed out with warm water instead of being cleansed by following proportions and with the results here shown—viz... I have now myself employed this treatment of 137 recoveries and 4 deaths. sponging. " flushing" with increasing frequency for over four years past, TABLE IL-Peritoneal Operations. and am constantly more and more impressed by its value-as a ready and efficient means of cleansing the peritoneal cavity of ovarian death from pneumonia on cases Eighty-four l . , One tumour. thirteenth day. with the minimum infliction of damage to the delicate epithelial surface of the serous membrane-a fact which from Fifteen cases of chronic One death from intestinal obmatory disease of one or struction on eighth day. my point of view constitutes one of its greatest advantages. As a firm believer in the importance of asepticism I need One death from e.hausti.n hardly add that I consider it advisable always to employ for pregnancy within five hours. neal haemorrhage this purpose water which has been previously sterilised by cases of Thirty supra-vaginal boiling, as the surest means of avoiding the introduction of hysterectomyforfibro-myoma.}..... One death from shock. into the of mischief Seven cases removal of peritoneal cavity. possible uterine appendages for No death. Passing on now to a brief consideration of the third of the myoma. } three objects to be aimed at by the abdominal surgeon, I define it as the "promotion of the subsequent removal by This series of 141 operations performed on the line:) natural or by artificial means of any fluids remaining in the indicated in my paper, with a mortality of under 3 per cent., of the operation. " By the may, I think, be taken as affording some evidence of the cor. pelvic cavity at the conclusion term "natural means " I would imply the early re-establish- rectness of the views advocated with regard to the treatment ment and maintenance of the renal and intestinal eliminatory of the peritoneum in abdominal work ; and, in conclusion,i functions which play so large a part in promoting the absorp- would here venture to express the hope that the record of my tion and subsequent excretion of peritoneal effusions. With- experience in this direction may tend to promote a fuller out dwelling on this subject I will here merely refer to what recognition of the enormous powers for good as for evil I believe to be the extreme inadvisability of the routine possessed by the serous membrane in relation to surgical administration of opium after abdominal operations, owing to procedures involving its cavity. the restraining influence thereby exercised upon these Manchester-square, W. functions ; while further noting the value of repeated small doses of salines administered not with a view to relieving any tendency to obstructive bowel difficulty, but merely EXCISION as promoting renal and intestinal excretion. By the artificial or mechanical means above mentioned I of OF THROMBOSED DEATH. course allude to drainage of the pelvic cavity as best effected BY W. ARBUTHNOT LANE, M.S., F.R.C.S., by the ordinary glass tube whence the accumulated fluid is withdrawn at stated intervals. An objection formerly raised ASSISTANT SURGEON TO GUY’S HOSPITAL AND THE HOSPITAL FOR SICK CHILDREN. against this method of drainage was based on the statement that it was liable to be followed by a ventral hernia at the seat of insertion of the tube. Such a mishap has fortunately H. R-, aged four years, was admitted into Guy’. been extremely rare in my own experience, and I regard its Hospital on Aug. 18th, 1892. He was suffering from a occurrence as indicative of too prolonged retention of the tube. over the left half of the lower jaw, which comIn my opinion all the good derivable from drainage of the swelling menced with toothache about a week before. Five days preperitoneal cavity proper is commonly attained within the first burst into the mouth, and since that time the abscess to forty-eight hours after operation, and any viously an twenty-four further prolongation of the process is but rarely advisable. swelling had diffused itself more extensively. His temperaMy own invariable rule is to remove the tube whenever the ture on admission was 105 4°. There was an alveolar abscess entire amount of fluid accumulated during the previous about a carious second molar tooth. This was removed and twelve hours is found not to exceed two to four drachms, and this quite irrespective of whether the serum then withdrawn the abscess cavity scraped and thoroughly cleaned out undes The boy became jaundiced and suffered from an ansesthetic. be bloodstained or not. In support of the views here expressed I will now very recurring rigors on the 19th, 20th, 21st and 22nd. On briefly summarise the results obtained in my practice from the 22nd I saw the child for the first time and decided December, 1888, when I abandoned the use of the spray, to to make an attempt to stay the progress of the condition the end of July, 1892. During this period of about three thrombosed veins that might exist and years and a half the total of my abdominal operations by excising any amounted to 201 ; but in eighteen of these, chiefly cases of by clearing out the inflamed bone and other tissues. At this pelvic abscess, the serous cavity proper was not invaded,and period the patient was deeply jaundiced and the liver much I shall consequently confine my remarks to the remaining 183 enlarged; he had, however, no apparent renal complication. though there was strong presumptive evidence of patches of pulmonary mischief. The skin was turned back from the 3 The group of eighteen operations above referred to included seventeen anterior triangle and sterno-mastoid when the external jugular recoveries and but one death, which resulted from exhaustion due to diffused pelvic suppuration of some two years standing previous to sur- vein was exposed, and was found to contain a purulent material to within half an inch of its lower end. gical interference.
scess (of septic origin). }....
.
Intra-peritoneal abscess (? of}.....
8. Cholecystotomy. {....
Cerebral disease,
} irflam uterine appendages. both .... ....
Five cases of ruptured tub861
with intra-perito-}.....
the fibro-
ALVEOLAR ABSCESS ; PYÆMIA; VEINS;
1045 There the clot was black, and below this point, at its junction with the subclavian, the external jugular The walls of the vein, vein was tied and divided. with the immediately adjaccnt tissues, were inflamed and thickened. The external jugular vein was then followed upwards into the parotid and forwards to its junction with the facial vein. The latter was dissected out and was found to be filled with a firm pale clot. The branches of the facial vein, with the exception of the distal portion of the submental, The common were filled with clot of the same character. facial vein was also thrombosed, the clot extending for a slight distance into the lumen of the internal jugular vein, which was exposed for a distance of half an inch above and below the point of entry of the common facial vein, and after it had been ligatured at these two points the intermediate portion was excised. Having removed all the thrombosed veins thoroughly on their proximal side their distal distribution was treated in as effectual a manner tiS possible, though it was obvious that this portion of the operation was not as perfect as the rest. The abscess cavity and bone were then cleaned thoroughly and plugged with iodoform. During the course of the operation many inflamed lymphatic glands were removed. The patient seemed better on the day following the operation. The jaundice disappeared almost if not entirely by Aug. 25th. The next day
This diagram illustrates the extent of the thrombosis and the several veins which were removed at the operation. The transverse striation represents the thrombosed area of vessel.
It was found that the wound in the neck, whose edges had apparently healed and were devoid of any redness, contained This was all a quantity of yellowish pultaceous material. carefully removed and the wound was thoroughly washed out and packed with iodoform and gauze. He had a gradual rise of temperature to 1054° on the 23rd, but after that it remained at between 101° and 103° till his death. He had no rigor. The child gradually got worse and died at twelve o’clock on the night of the 26th. At the post-mortem examination it was found that the thrombosed veins had been removed very effectually as far as their proximal distribution was concerned, there being no evidence whatever of thrombosis. There were, however, a number of abscesses in the lungs and liver. These had without doubt been produced by septic emboli at a period antecedent to the operation, which was obviously performed too late. Though the result in this case was unsatisfactory as far as the life of the patient was concerned, it was, on the other hand, most satisfactory and instructive as showing that the method of excising "eptically thrombosed veins is as effectual in staying a pyasmic process originating in the lower jaw while it is as yet local and uncomplicated by secondary abscesses as it is a more definite and localised thrombosis of the lateral sinus due to disease of the middle ear. St. Thomas’s-street S.E
A Mirror
HOSPITAL PRACTICE, BRITISH AND FOREIGN. Nulla autem est atia. pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se compare.—MORGAGNI De Sed. et Caus. Morb., iv. Proœmium. —
lib.
WESTMINSTER HOSPITAL. SUPRA-PUBIC
CYSTOTOMY
FOR
CALCULUS.
of Mr. R. DAVY.) of a method of performing the THE following account for the removal of a stone from the supra-pubic operation bladder of the male has one or two points worthy of The performance of the operation without the attention. and without previous distension use of the rectal bag, of the bladder by injection, appears to have been rendered easy and safe by means of the sound described by Mr. Davy. There is no doubt that with the use of this sound the operation was done in less time than is usually required, and therefore was of less severity-a fact of great importance, especially in men of advanced age, for the introduction and filling of the rectal bag and the injection of fluid into the bladder cannot be hurriedly performed without considerable risk. In this case the condition of the urinary passage was such as to have rendered the manipulation of a lithotrite or its introduction difficult, and the danger of bruising the parts, with subsequent swelling and possibly retention, of serious moment. For the notes we are indebted to Mr. H. De Renzi, house surgeon, and Mr. Forsayeth, dresser. J. R-, aged sixty-three, by occupation a carpenter, was admitted into the Westminster Hospital on Aug. 2nd, 1892, and discharged on Aug. 30th. Twenty years ago he spent six months in Derbyshire, but usually has lived in London. In March last he was knocked down by a tram-horse ; the same evening he experienced pain in passing his urine, and a week afterwards he had hasmaturia, sometimes in clots, at other times intimately mixed with the urine. Forty years ago he had gonorrhoea, and since his fall he had suffered from a difficulty in micturition, necessitating the constant use of a catheter. Pain at the bladder and scalding around the On Aug. 6th, on soundanus have been increasing of late. ing, a stone of medium size was detected. The abdominal wall was normal and the patient fairly nourished, there being The urine was no excess of fat in the subcutaneous tissue. strongly alkaline, sp. gr. 1015 ; half albumen was found, and blood, pus and mucus were present. On the 9th supra-pubic cystotomy was performed by Mr. R. Davy. Neither the bladder nor rectum was distended. A conical probe-pointed sound was used, with a groove on its concavity and a hole at its tip. A medium-sized stone was extracted, measuring two inches by an inch and a quarter, weighing seventy-five grains, and composed throughout of soft phosphatic material. The mucous membrane of the bladder was inflamed and sacculated, the No. 4 sound being sufficient to bring the bladder wall well forward after the incision of the abdominal parietes. A silver drainage-tube was passed into the bladder and left in. It appeared that the obstruction to the outflow of urine was due to thickening and hypertrophy of the prostate and spasm of the muscles of the urethra. On the llth the patient passed urine naturally and the drainage-tube came away. On the 19th he was well, and on the 30th he was discharged cured. Remarks by Mr. DAVY.-The supra-pubic operation, in my opinion, was the best suited for this man, and for these reasons: (1) Crushing was out of the question on account of the difficulty in manipulating or even passing instruments in the urethra of the patient ; (2) the high operation, on anatomical grounds, wounds less important structures than those injured in median or lateral operations. In this case neither bladder I wished to operate nor rectum was artificially distended. on the bladder as I found it ; as a rule, I have operated There is neither with the bladder partly full of water. difficulty nor danger in operating without distension if the surgeon bears in mind that the bladder is situated for this intent post- symphysially. I can recall more than
(Under the
care
regard the example set me by my two senior colleagues at operations, all of which implicated the peritoneum. Of this the Samaritan Hospital, both of whom were then extremely number, forty-two were undertaken for disease either uncon. careful in thus cleansing the peritoneal cavity at the con- nected with the pelvic organs or, when so connected, of such clusion of an abdominal operation. Such treatment, in com- a nature as not to admit of complete extirpation. Thirty. plicated cases, was usually followed within forty-eight hours three of these patients recovered, and the remaining nine died by a smart rise of temperature to 102° or over, frequently from causes shown in the accompanying table. necessitating the use of an ice cap for its reduction. When TABLE I.-Peritoneal Operations. I began in 1882 to assist Sir Spencer Wells, who then operated with full antiseptic precautions in every respect similar to No. Nature of disease. Cause of death. those employed in the Samaritan Hospital, I soon became 1. Double intra-peritoneal ab. Shock, within six hours. impressed by the fact that complicated cases of ovario- 2. Cancer of both ovaries (parwithin four hours. tial operation). Shock, tomy, where no attempt was made to sponge away the mixture of blood and other fluids remaining in the pelvic 3. Advanced tubercular disease.... Exhaustion, on twelfth day, frori of peritoneum. persistent diarrhoea. cavity at the conclusion of a troublesome operation, 4. General abdominal cancer..... Exhaustion, on eighth day. not unfrequently recovered with but very slight dis- 6. Pelvic cancer..... Exhaustion, on fourth day. turbance of either temperature or pulse, although no 6. on seventh day. tubal origin). Exhaustion, drainage-tube was used. Such results following treatment so 7. Retro-peritoneal sarcoma..... Exhaustion, on third day. opposed to the routine practice in the hospital at that time 8. of intestine, on Perforation Cholecystotomy puzzled me somewhat, until I formed the conclusion that twenty-eighth day. on eighth day avoidance of unnecessary irritation of the serous membrane 9. Hydatid disease of liver. liver. {.... (? hydatid). went have as time to do with might them ; and, something The remaining 141 peritoneat operations were performed on, my views in this direction were materially strengthened by watching the results obtained in cases where the abdomen for disease originating in the uterus or its appendages in the was washed out with warm water instead of being cleansed by following proportions and with the results here shown—viz... I have now myself employed this treatment of 137 recoveries and 4 deaths. sponging. " flushing" with increasing frequency for over four years past, TABLE IL-Peritoneal Operations. and am constantly more and more impressed by its value-as a ready and efficient means of cleansing the peritoneal cavity of ovarian death from pneumonia on cases Eighty-four l . , One tumour. thirteenth day. with the minimum infliction of damage to the delicate epithelial surface of the serous membrane-a fact which from Fifteen cases of chronic One death from intestinal obmatory disease of one or struction on eighth day. my point of view constitutes one of its greatest advantages. As a firm believer in the importance of asepticism I need One death from e.hausti.n hardly add that I consider it advisable always to employ for pregnancy within five hours. neal haemorrhage this purpose water which has been previously sterilised by cases of Thirty supra-vaginal boiling, as the surest means of avoiding the introduction of hysterectomyforfibro-myoma.}..... One death from shock. into the of mischief Seven cases removal of peritoneal cavity. possible uterine appendages for No death. Passing on now to a brief consideration of the third of the myoma. } three objects to be aimed at by the abdominal surgeon, I define it as the "promotion of the subsequent removal by This series of 141 operations performed on the line:) natural or by artificial means of any fluids remaining in the indicated in my paper, with a mortality of under 3 per cent., of the operation. " By the may, I think, be taken as affording some evidence of the cor. pelvic cavity at the conclusion term "natural means " I would imply the early re-establish- rectness of the views advocated with regard to the treatment ment and maintenance of the renal and intestinal eliminatory of the peritoneum in abdominal work ; and, in conclusion,i functions which play so large a part in promoting the absorp- would here venture to express the hope that the record of my tion and subsequent excretion of peritoneal effusions. With- experience in this direction may tend to promote a fuller out dwelling on this subject I will here merely refer to what recognition of the enormous powers for good as for evil I believe to be the extreme inadvisability of the routine possessed by the serous membrane in relation to surgical administration of opium after abdominal operations, owing to procedures involving its cavity. the restraining influence thereby exercised upon these Manchester-square, W. functions ; while further noting the value of repeated small doses of salines administered not with a view to relieving any tendency to obstructive bowel difficulty, but merely EXCISION as promoting renal and intestinal excretion. By the artificial or mechanical means above mentioned I of OF THROMBOSED DEATH. course allude to drainage of the pelvic cavity as best effected BY W. ARBUTHNOT LANE, M.S., F.R.C.S., by the ordinary glass tube whence the accumulated fluid is withdrawn at stated intervals. An objection formerly raised ASSISTANT SURGEON TO GUY’S HOSPITAL AND THE HOSPITAL FOR SICK CHILDREN. against this method of drainage was based on the statement that it was liable to be followed by a ventral hernia at the seat of insertion of the tube. Such a mishap has fortunately H. R-, aged four years, was admitted into Guy’. been extremely rare in my own experience, and I regard its Hospital on Aug. 18th, 1892. He was suffering from a occurrence as indicative of too prolonged retention of the tube. over the left half of the lower jaw, which comIn my opinion all the good derivable from drainage of the swelling menced with toothache about a week before. Five days preperitoneal cavity proper is commonly attained within the first burst into the mouth, and since that time the abscess to forty-eight hours after operation, and any viously an twenty-four further prolongation of the process is but rarely advisable. swelling had diffused itself more extensively. His temperaMy own invariable rule is to remove the tube whenever the ture on admission was 105 4°. There was an alveolar abscess entire amount of fluid accumulated during the previous about a carious second molar tooth. This was removed and twelve hours is found not to exceed two to four drachms, and this quite irrespective of whether the serum then withdrawn the abscess cavity scraped and thoroughly cleaned out undes The boy became jaundiced and suffered from an ansesthetic. be bloodstained or not. In support of the views here expressed I will now very recurring rigors on the 19th, 20th, 21st and 22nd. On briefly summarise the results obtained in my practice from the 22nd I saw the child for the first time and decided December, 1888, when I abandoned the use of the spray, to to make an attempt to stay the progress of the condition the end of July, 1892. During this period of about three thrombosed veins that might exist and years and a half the total of my abdominal operations by excising any amounted to 201 ; but in eighteen of these, chiefly cases of by clearing out the inflamed bone and other tissues. At this pelvic abscess, the serous cavity proper was not invaded,and period the patient was deeply jaundiced and the liver much I shall consequently confine my remarks to the remaining 183 enlarged; he had, however, no apparent renal complication. though there was strong presumptive evidence of patches of pulmonary mischief. The skin was turned back from the 3 The group of eighteen operations above referred to included seventeen anterior triangle and sterno-mastoid when the external jugular recoveries and but one death, which resulted from exhaustion due to diffused pelvic suppuration of some two years standing previous to sur- vein was exposed, and was found to contain a purulent material to within half an inch of its lower end. gical interference.
scess (of septic origin). }....
.
Intra-peritoneal abscess (? of}.....
8. Cholecystotomy. {....
Cerebral disease,
} irflam uterine appendages. both .... ....
Five cases of ruptured tub861
with intra-perito-}.....
the fibro-
ALVEOLAR ABSCESS ; PYÆMIA; VEINS;
1045 There the clot was black, and below this point, at its junction with the subclavian, the external jugular The walls of the vein, vein was tied and divided. with the immediately adjaccnt tissues, were inflamed and thickened. The external jugular vein was then followed upwards into the parotid and forwards to its junction with the facial vein. The latter was dissected out and was found to be filled with a firm pale clot. The branches of the facial vein, with the exception of the distal portion of the submental, The common were filled with clot of the same character. facial vein was also thrombosed, the clot extending for a slight distance into the lumen of the internal jugular vein, which was exposed for a distance of half an inch above and below the point of entry of the common facial vein, and after it had been ligatured at these two points the intermediate portion was excised. Having removed all the thrombosed veins thoroughly on their proximal side their distal distribution was treated in as effectual a manner tiS possible, though it was obvious that this portion of the operation was not as perfect as the rest. The abscess cavity and bone were then cleaned thoroughly and plugged with iodoform. During the course of the operation many inflamed lymphatic glands were removed. The patient seemed better on the day following the operation. The jaundice disappeared almost if not entirely by Aug. 25th. The next day
This diagram illustrates the extent of the thrombosis and the several veins which were removed at the operation. The transverse striation represents the thrombosed area of vessel.
It was found that the wound in the neck, whose edges had apparently healed and were devoid of any redness, contained This was all a quantity of yellowish pultaceous material. carefully removed and the wound was thoroughly washed out and packed with iodoform and gauze. He had a gradual rise of temperature to 1054° on the 23rd, but after that it remained at between 101° and 103° till his death. He had no rigor. The child gradually got worse and died at twelve o’clock on the night of the 26th. At the post-mortem examination it was found that the thrombosed veins had been removed very effectually as far as their proximal distribution was concerned, there being no evidence whatever of thrombosis. There were, however, a number of abscesses in the lungs and liver. These had without doubt been produced by septic emboli at a period antecedent to the operation, which was obviously performed too late. Though the result in this case was unsatisfactory as far as the life of the patient was concerned, it was, on the other hand, most satisfactory and instructive as showing that the method of excising "eptically thrombosed veins is as effectual in staying a pyasmic process originating in the lower jaw while it is as yet local and uncomplicated by secondary abscesses as it is a more definite and localised thrombosis of the lateral sinus due to disease of the middle ear. St. Thomas’s-street S.E
A Mirror
HOSPITAL PRACTICE, BRITISH AND FOREIGN. Nulla autem est atia. pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se compare.—MORGAGNI De Sed. et Caus. Morb., iv. Proœmium. —
lib.
WESTMINSTER HOSPITAL. SUPRA-PUBIC
CYSTOTOMY
FOR
CALCULUS.
of Mr. R. DAVY.) of a method of performing the THE following account for the removal of a stone from the supra-pubic operation bladder of the male has one or two points worthy of The performance of the operation without the attention. and without previous distension use of the rectal bag, of the bladder by injection, appears to have been rendered easy and safe by means of the sound described by Mr. Davy. There is no doubt that with the use of this sound the operation was done in less time than is usually required, and therefore was of less severity-a fact of great importance, especially in men of advanced age, for the introduction and filling of the rectal bag and the injection of fluid into the bladder cannot be hurriedly performed without considerable risk. In this case the condition of the urinary passage was such as to have rendered the manipulation of a lithotrite or its introduction difficult, and the danger of bruising the parts, with subsequent swelling and possibly retention, of serious moment. For the notes we are indebted to Mr. H. De Renzi, house surgeon, and Mr. Forsayeth, dresser. J. R-, aged sixty-three, by occupation a carpenter, was admitted into the Westminster Hospital on Aug. 2nd, 1892, and discharged on Aug. 30th. Twenty years ago he spent six months in Derbyshire, but usually has lived in London. In March last he was knocked down by a tram-horse ; the same evening he experienced pain in passing his urine, and a week afterwards he had hasmaturia, sometimes in clots, at other times intimately mixed with the urine. Forty years ago he had gonorrhoea, and since his fall he had suffered from a difficulty in micturition, necessitating the constant use of a catheter. Pain at the bladder and scalding around the On Aug. 6th, on soundanus have been increasing of late. ing, a stone of medium size was detected. The abdominal wall was normal and the patient fairly nourished, there being The urine was no excess of fat in the subcutaneous tissue. strongly alkaline, sp. gr. 1015 ; half albumen was found, and blood, pus and mucus were present. On the 9th supra-pubic cystotomy was performed by Mr. R. Davy. Neither the bladder nor rectum was distended. A conical probe-pointed sound was used, with a groove on its concavity and a hole at its tip. A medium-sized stone was extracted, measuring two inches by an inch and a quarter, weighing seventy-five grains, and composed throughout of soft phosphatic material. The mucous membrane of the bladder was inflamed and sacculated, the No. 4 sound being sufficient to bring the bladder wall well forward after the incision of the abdominal parietes. A silver drainage-tube was passed into the bladder and left in. It appeared that the obstruction to the outflow of urine was due to thickening and hypertrophy of the prostate and spasm of the muscles of the urethra. On the llth the patient passed urine naturally and the drainage-tube came away. On the 19th he was well, and on the 30th he was discharged cured. Remarks by Mr. DAVY.-The supra-pubic operation, in my opinion, was the best suited for this man, and for these reasons: (1) Crushing was out of the question on account of the difficulty in manipulating or even passing instruments in the urethra of the patient ; (2) the high operation, on anatomical grounds, wounds less important structures than those injured in median or lateral operations. In this case neither bladder I wished to operate nor rectum was artificially distended. on the bladder as I found it ; as a rule, I have operated There is neither with the bladder partly full of water. difficulty nor danger in operating without distension if the surgeon bears in mind that the bladder is situated for this intent post- symphysially. I can recall more than
(Under the
care