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Patient was placed in Fowler position and proctoclysis used for nearly three days. Hypodermoclyis used at operation.

Patient made good recovery without hernia although infection was present and affected abdominal incision. Six months later patient had a rekindling of appendicitis and trouble with right tube.

A second operation was performed October 16, 1909, median incesion dissecting out old scar, intestines adherent to right tube, uterus and old sight of ectopic pregnancy, appendix adherent to right tube and ovary.

Adhesions broken up, right tube, ovary and appendix removed. The tube was more than one inch in diameter at fimbriated extremity and filled with a clear fluid which was probably purulent at first, having undergone a change from its primal development before removal. Patient made an uneventful recovery, proctoclysis being used as in former operation.

In closing this report I desire to stress the importance of drainage, Fowler position and proctoclysis in critical cases of abdominal section with or without infection.

As ordinarily used proctoclysis is not of much benefit and very unsatisfactory even in hospital work.

To obviate this difficulty and get the full benefit of the Murphy method I have devised this apparatus which is simple, easily regulated and solution easily kept warm.

The aparatus can be used equally well in private as in hospital work and by any nurse of ordinary intelligence.

SIMULTANEOUS

CATHETERIZATION

OF THE

URETERS.

Alfred L. Fowler, M.D., Atlanta, Ga.

The brilliant results in kidney surgery, now being reported from all over the world, are due largely to our greater precision in renal diagnosis. Ureteral catheterization has made this possible.

Before the advent of ureteral catheterism the principal reasons for post-operative deaths were:

(1.) Congenital absence of a second kidney, and

(2.) A diseased kidney incapable of proper functionating capacity sufficient to preserve the patient after the operation.

Ureteral catheterism discloses if both kidneys are present, tells us from which kidney the pus comes, enables us to determine the functionating capacity of each kidney, points out from which kidney comes the hemorrhage, and with the wax-tipped catheter detects stone in the kidney pelvis and, lastly, stricture of the ureters.

The bladder mucosa and ureteral openings, as viewed through the cystoscope, disclose a great amount of information to the trained eye. For this reason we study the bladder membrane well before engaging the catheters and passing them up to the kidney pelvus. Catheterizing the ureters, is exact, practical and safe and out of more than a thousand cases that I have catheterized I have not observed a single instance where the slightest harm has come from the procedure.

In illustration of the practicability of the method together with its usefulness I cite you as follows:

A recent case, referred by Dr. A. P. Flowers, gave a history of a sudden attack coming on at night of painful and frequent micturition, without any assignable cause.

The doctor treated him for cystitis, and as the condition failed to clear under appropriate treatment he very rightly presumed his patient's kidneys were at fault. There was no pain in the kidney region.

I cystoscoped him and found the mucosa on the right of the trigone injected, in well isolated areas, a beefy red with many patchy necrotic areas. The right ureter opening on this side dilated and contracted normally, as did its fellow, but was a little injected.

After passing the ureteral catheters to the kidney pelvis we found the separate specimens to show milk tinted urine from right kidney and clear amber colored urine from left. "T. B." bacillia were detected with microscope and the injected urine into abdominal cavity of guinea pigs killed them in four and five weeks and whose peritoneal cavities were found to be studded with tubercles.

A recent case referred by Dr. E. D. Highsmith, was one of hematuria, without any symptoms of cystitis. Cystoscopy showed normal bladder mucosa and normal ureter openings. We catheterized the ureters and scarlet urine drained from patients right kidney while clear and normal urine came from its fellow and which determined absolutely the source of the hemorrhage.

A more recent case, referred by Dr. C. W. Strickler, had pain in right side, inner side of right thigh, an intense cystitis, and marked pyuria. Cystoscopy showed a "golf hole" ureter on right and numerous erosins of bladder mucosa.

Ureteral catheterization disclosed a suppurating pyelitis on right while the urine coming through the other catheter was normal. Urea estimation two per cent. Patient consented to a nephrotomy which I did two weeks ago. The intense cystitis and pain in thigh and kidney region have entirely cleared.

A patient referred by Dr. J. S. Todd and Dr. H. F. Harris had marked cystitis, much tenesmus and had recently lost fast in weight. A perineal drainage done by

another physician had given him no relief.

I cystoscoped him and found his bladder walls literally hung with long lacy processes and it was with difficulty that I catheterized the ureters, so marked were the changes.

I sent the separate urines from the two kidneys to Dr. Harris informing him that clinically we had to do with a cancer of the bladder. The doctor found the urine normal.

All three of us agreed that suprapubic cystotomy for permanent drainage was loudly indicated, to which patient consented. I opened the bladder by the high route, gave a specimen of the tumor to Dr. Harris, and established permanent drainage. The doctor pronounced the specimen carcinomatous.

A very interesting case that came into my hands through Dr. Swain, was that of a man forty-two years of age. Pain in left kidney region, also near end of penis and in inner side of left thigh with a history of polyuria. and occasionally cloudy urine. Cystoscope showed left ureter gaping and injected, bladder mucosa otherwise normal.

A No. 6 ureteral catheter was passed easily up to right kidney pelvis but a like catheter met with obstruction three inches from mouth of left ureter. I then attempted to pass a smaller one, No. 4, but failed.

After trying with a small whalebone or filiform, No. 2. I finally passed the obstruction and as I did so a pure jet of cloudy urine appeared continously for about a minute. I decided to leave the filiform in place as long as the patient proved uncomplaining, but after about four hours he complained of severe pain in left testicle and the testis on that side was found drawn clear up to the internal abdominal ring, so the filiform was removed.

This obstruction proved to be a stricture of left ureter. With patience and persistence I have dilated gradually this ureter once in ten days during a period of five months, up to a No. 8, French. His urine is clear and today the patient states he is free from any pain.

DIPHTHERIA AND ITS RELATION ΤΟ THE

LABORATORY.

K. R. Collins, M.D., Atlanta, Ga.

A disease corresponding in its description to dipththeria occurred in the earliest Babylonian days. No mention of such disease, however, is found in the history of the Greeks. Hence, it is supposed to have been introduced into the European countries from Egypt. Much controversy arose during the Sixteenth century concerning the pharyngeal type of the disease, especially its relation to membranous croup. This discussion took place principally in France, where the disease made great ravages. A nephew of Napoleon, son of the King of Holland, died of croup and later the Empress Josephine. Napoleon offered a reward at different times to anyone who would establish the relation between these two diseases. Many observers attempted a solution of the problem, but it was not until 1821 when Bretonneau published an essay so complete in its observations that little was added until the diphtheria bacillus and its relation to the disease was established in 1883, first by Klebs and later confirmed by Loeffler. From this time on the therapy and etiology of the disease has been thoroughly studied, so that at the present day with a specific cure in our hands, an understanding of the etiology and the method by which it is spread, the disease is comparatively little to be dreaded excepting in a few instances. Prompt action in the administration of antitoxin early in the disease and rigorous methods resorted to for the prevention of contagion are the chief requisites to place it in the roll of amenable diseases.

The chief sources of infection are from human to human, or from articles of clothing, pencils, etc., that are

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