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normal and normal things called abnormal by inexperienced manipulators of the instrument. When doing this work I sometimes think of the words of Dr Lydston and the truth of them, that in the hands of the unpracticed man the cystoscope is more or less of a surgical toy.

Dr

I heartily agree with Dr Allen that on account of the various methods devised for protatectomy it shows that none of them are very satisfactory. I noted the case in which Dr Ricketts reported the removal of the prostate 30 easily and nicely without ligature or hemorrhage. You may do this with a case once in a while, but the great majority of these cases are attended with hemorrhage, more or less traumatism, great shock, and many of them die. I have seen the removal of the prostate without the necessity of a ligature, and it is a simple operation. The matter of vesicorectal anastomosis is something which is practically new. Frank, in his work on ureterointestinal anastomosis in dogs found this form best. Ureterointestinal anastomosis in dogs is very difficult, but an anastomosis in which the trigonum is included the results are much better. In a number of dogs killed afterward, after vesicorectal anastomosis, there was absolutely no ascending infection. In the simple implantation ascending infection was always present. Frank at that time predicted that vesicorectal anastomosis would be as common an operation as that of gastroenterostomy. The way to do it is not to go in through the rectum, as Dr Ricketts advised, but to make a laparotomy using either a Frank coupler, or Murphy button, placing one portion into an incision in the bladder and the other portion of the coupler or button in its rectum, this forming the connection.

Regarding Dr Allen's discussion, I would say that the Doctor's case of ureterointestinal anastomosis has become one of the classics in this subject and he is quoted very frequently in this connection. In this case he stated that 29 plastic operations had been made to cover the defect in the bladder-wall by the old method of operating in cases of exstrophy and that he was able to save the genitals. In my case a great many more plastic operations had been made previous to his coming under my observation. In these plastic operations the genitals with the exception of one testicle had been removed.

One of the interesting features of my case is the disappearance of albumin from the urine after the operation.

I cannot explain this unless it be that the ureteral orifices now in the rectum are in a better situation as far as infection is concerned than when they were in the exstrophied portion of the bladder and continually bathed in pus.

Dr William E. Lower, Cleveland: I desire in closing to thank the Association for the kind discussion of my paper. I am sure that all who are doing operative work on the prostate will be very glad to have this subject cleared up. There has been a very great uncertainty as to the best operative method to pursue. I formerly did the suprapubic operation for removal of the prostate. I am inclined now to believe that the perineal method is better.

The Bottini operation, as Dr Jacobson has stated, will always have a place, for it does give relief in a goodly number of cases. The case of exstrophy of the bladder which the Doctor reported is very interesting. I had a similar case in a child, upon whom I first did a plastic operation and succeeded in getting a very excellent result. Of course this operation did not furnish a sufficient reservoir for the urine. Shortly after Dr Allen's favorable report of the Maydl operation appeared, and I decided to do a second operation, which I regret to say ended fatally, the child dying of shock about six hours after the operation. I believe this operation should not be attempted in so young a subject.

Dr B. Merrill Ricketts, Cincinnati: Concerning the use of the cystoscope as suggested by Dr Lower, I would say that it is not without its dangers and uncertainties. Ureters are not always normal in structure, number or position, or the ureters may be crossed, or several ureters may connect to form one common ureter to enter the bladder or any point.

The extracting of urine from either side of the bladder does not always indicate that urine comes from any particular kidney. The work of Dr Lower, however, should be highly praised for it has added much to the treatment of and disposition of diseased kidneys.

I do not see how Dr Allen could infer from my remarks that I would advise vesicorectal anastomosis in all cases of hypertrophy of the prostate. At present I think that it is but the few that should be so treated, but I believe that it will be more frequent than ever, especially in the aged and those in which great trauma has been done, and in which quick

work is demanded. I absolutely condemn the so-called Bottini operation believing that it does not have any place whatever in prostatic surgery even when the cautery is applied through an open perineal or suprapubic incision. Dr Jacobson mentions anastomosis with the appendix. The urine would cause irritation of Gerlack's valve to such a degree that would cause stenosis of that valve and subsequent complete obstruction. Complications would then arise that would tax the most ingenious. His method of implanting sections of the bladder-wall with the ureter is certainly the best. Infection is less likely if the ureter is implanted in the rectum, and the dangers increase as the implantation is made higher up in the gut. Drainage is better in low implantation and there is less danger of feces entering the bladder. Herein are the advantages of uretero- or vesicorectal implantation.

Referring to the operation for extrophy of the bladder, I would say that Dr Jacobson is to be congratulated upon the most excellent results obtained in the patient he presents to us today. Dr Vance, of Louisville, has done some excellent work in this line.

I myself, 15 years ago, made two attempts to remedy extrophy of the bladder but failed. They are desperate cases to deal with, but we now have means at our command that enable most radical work and the most promising results.

A Simple Method for the Control of
Anal Hemorrhage

BY THOMAS CHARLES MARTIN, M. D., CLEVELAND

Anything that will stop bleeding is worth consideration. That a simple method may be described briefly is not to its demerit. Given a hemorrhoid removed, the wound should be lightly cauterized and closed by the buttonhole stitch. The suture should be set with a long free end attached at the upper angle of the wound. Should there subsequently develop a hemorrhage, the resident surgeon or trained nurse, or whoever is in charge, should draw the Sims' postured patient to the bed's edge, take the suture (which is attached to the upper end of the wound) in the

left hand and a pair of opened hemostats in the right; then, at the moment when the patient, in obedience to a command, strains as at defecation and the pelvic floor descends and anus everts, the attendant should draw taut the suture-end and hold exposed and accessible to his forceps the entire length of the wound. No attempt should be made to individualize the bleeding points; the wound should be clamped throughout its length.

One Thousand Abdominal Closures by a New Method Without a Known Hernia

BY J. F. BALDWIN, A. M., M. D., COLUMBUS

Surgeon to Grant Hospital; Fellow American Association of Obstetricians and Gynecologists, Etc.

A half dozen, or less, ventral hernias out of a hundred abdominal sections, will give a surgeon far more annoyance, embarrassment and worry than an equal number of fatal results. In regard to his fatal cases he may justly feel that all was done that human power could do, and that the result was inevitable; but with hernias he cannot but feel that with greater care, or by a different procedure, the unfortunate result might have been obviated, and the unhappy patients and their friends are very apt to take the same unfavorable view of it.

According to the statistics carefully collected by Dr W. D. Haggard, of Nashville, in an excellent article on the methods of closing abdominal incisions in American Medicine (February 7, 1903), it is probably fair to assume that about 10% of abdominal sections closed by prevailing methods result in subsequent hernias. If the incision becomes infected, then at least 50% of hernias will follow. It would seem as though methods should be devised which would greatly reduce this percentage.

In a personal experience covering over 2,000 celiotomies, I have used all the methods that have ever been seriously suggested, but have finally adopted a method

which, in something over 1,000 cases, has failed to show a single known hernia.

The through-and-through suture is recognized by all as giving unsatisfactory results, and it makes no difference whether silk, silk-worm gut, or wire is used as the suture material. That method entirely fails to secure anything like coaptation of the fascia, unless it be by the merest chance, and a weak abdominal wall is almost a necessary consequence.

Buried silver wire, while securing accurate coaptation and ideal immediate results, is entirely unsatisfactory in the end. That the silver wire is sterile, or easily made so, is of course true, but the statement sent forth from Johns Hopkins that the silver salts resulting from the contact of the tissues with the wire are slightly antiseptic, cannot be believed by those who have had any extended experience in the use of this material. It has happened scores of times in my work with silver wire that six months to a year after apparently perfect union, the wire has become the source of suppuration, with the formation of an abscess which only healed after the wire was fished out. My experience with silver wire was absolutely and unequivocally disgusting, and I was not surprised when told by one of the leading surgeons of the Johns Hopkins Hospital, at the Philadelphia meeting of the American Medical Association, that that material was no longer so used at that institution. I have seen no published statement, however, to that effect.

Silk-worm gut as a buried suture has all the disadvantages of silver wire, besides some peculiar to itself. Its ends cannot be bent down flat, and its surface may become quite rough. It is as unabsorbable as wire. A number of years. ago I reopened an abdomen some five years after the appendages had been removed by a surgeon in southern Ohio. For some reason he had used silk-worm gut in closing the tops of the broad ligaments. There had been no infection, but there had been constant discomfort in the pelvis during the intervening years, and at the operation the broad ligaments,

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