Chicago School of Medicine and Surgery - Medicos Yearbook (Chicago, IL)

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.zauz-q..f.1 .ffff--.-ar..-, - . , -- i LITERATURE Brought to the operating table under favorable conditions we still have the danger of the anesthetic upcpnghe circulatory, respiratory and renal systems and with an unfavorable case the outlook is gloomy in ee . Some months ago I began the use of novocain and suprarenin locally. For this I claim no priority, merely a report of what I have been able to accomplish in a satisfactory manner to myself and patient. Up to the present time I have succesfully used it in twenty-seven cases. l use a solution of 0.5 to I per cent and Where a cystotomy is done only the tissue is injected. In removing the gland I use the parasacral injection and inject about 4C c. c. in either side as well as the supra-pubic tissue. In one case I used a 5 per cent alypin solution in the bladder, but cannot say it was of any benefit. By this method I have never found it necessary to inject the gland itself through the supra-pubic Wound as some advise. A Control ofthe hemorrhage at the time of the operation is best controlled by the placing of a l-Iagner bag. Post-operative hemorrhage is most frequently due to the presence of blood clots in the bladder, blocking the tube and causing the patient to attempt their expulsion by contracting the bladder. 'lhis is guarded against by closely watching the tube and removing any clots that may form. Bleeding from the incisions in the anterior bladder wall will occasionally be met with and should be controlled by ligatures. Suppuration of one oi both testicles is not uncommonly encountered, particu- larly in badly infected bladders, and is a factor in the mortality rate. Of late I have been attempting to prevent this by placing a ligature around the vas deferens as the first step in the operation. This is easily and quickly accomplished under local novocian injection and is of no consequence from the patient's standpoint. The post-operative treatment of the bladder and of the patient is very important. The bladder should be irrigated once or twice daily depending upon the severity of the bladder infection. Fon this I prefer the solution of the oxycyanide of mercury. The patient should be gotten out of bed as soon as the tube is removed and while in bed should only be in the recumbent position during sleeping hours. lVIy conclusions from the standpoint of reducing the mortality in these cases are: First: That supra-pubic cystotomy is to be preferred to repeated catheterization or the self-retaining catheter. Second: That supra-pubic cystotomy and prostatectomy can successlully and safely be done under local injections of novocain-suprarenin solution. Third: That in the employment of conclusion one and two in the hands of competent operators the mortality will be reduced to a minimum. Pagr 175 zrm:r:-wzvxfz. a -

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,...u,c-....n,....n.... ....,. LITERATURE The unserhatiun uf life in the rnstatit ' JOHN s. NACEL, M. D. ' Dean and Professor of Genito-Urinary Diseases. To remove the prostate gland is a comparatively simple operation tohone who has some degree of surgical skill and who thoroughly understands the anatomy of the perirreum, the prostate .and the bladder. To have your patient live and have a functionating bladder is quite another proposition. I have no thought of entering into the etiology, pathology or symptomatology of thesenile hyper- trophied gland, nor do I propose to discuss the advantage of the supra-pubic over the permeal route or vice versa. I, however, wish to call your attention to some points that will help to lower our mortality rate in this class of cases. By the very nature of the condition we are not very often called upon to'treat these cases under the age of 60 years and most frequently between 65 and 75. We have an individual who is undergoing senile decay and we are called upon to give relief by major surgical interference. Infection of the bladder is the one thing above all that we want to avoid, and yet this is not always possible. I-Iowever, this should not deter us from making every effort to prevent it. The primary examination should be done under the most strict aseptic conditions. I want to emphasize this as only too frequently have I seen these cases so badly infected by the first catheterization that their doom was settled then and there. Improper instruments, faulty technique and disregard of asepsis, together with the lack of prop- phylactic remedies against infection increases the mortality percentage by leaps and bounds. I have reference particularly to those cases where the physician is called in an emergency to give relief to an over-distended bladder. There are very few of these cases that will permit of catheterization with the ordinary catheter and usually considerable traumatism is produced by forcing the catheter to glide over the obstruction atthe neck of the bladder to the point where urine will flow. By this time, frequently, the eye of the catheter is plugged by a clot of blood, more manipulation is indulged in and more trauma produced. The hemorrhage from such trauma is many times of serious moment, the bladder filling with clots causing constant straining and tenesmus and the patient is brought to an emergency operation under unfavorable conditions. Again, we may have as the result of this trauma effectual plugging of the neck of the bladder from the edema and inflammatory reaction which necessarily calls for repeated catheterization to relievethe urinary distension. Under my present method of operating, I am convinced that the mortality rate has a direct ratio to the absence or the severity of the infection in the bladder. A clean bladder, a low mortality rate, a badly ,infected bladder, a high mortality rate. Inability to empty the bladder or a large amount of residualurine calls for repeated catheterization or a self-retaining catheter. The former means sooner or later an infected bladder. The latter is tolerated by a very small percentage of patients. The catheter produces constant discomfort and irritation which soon leads to infection. Then we have the class of cases who have never been catherized or instrumentated and yet have an infected bladder due to chemical irritation ofthe bladder from the decomposition of residual urine and the ever present colon bacillus. In all of these cases two problems require our consideration. First, the relief of urinary distress, and second, the restoration of the functions of the bladder. In my mind the first condition is best met by the supra-pubic cystotomy. Constant drainage of the bladder can only be done by the cystotomy or by the self-retaining catheter. I have already stated that few patients tolerate the latter. They are no more free to go about than with the cystotomy and are quite as uncomfortable so far as caring for the urine is considered. Forty-eight hcurs after cystotomy the patient suffers little or no discomfort except the care of the urinary discharge. The bladder is at rest, the patient eats and sleeps normally, all back pressure is removed from the kidneys and the bladder can be easily irrigated and cleansed with- out distress to the patient, and quite as important, one step in the removal of the gland has been accom- plished and the route sealed from infection by the presence of granulation tissue. There is no definite time to complete the operation except to wait until the condition of your patient warrants it. Nfy plan is not to hurry the second step. In one case I found it necessary to wait two months before I felt safe to undertake the removal of the gland. ' ' Page 174 . -,.f........,'-A. , ,.,..,..va-a-.W-f,..... . ., ,.-He.,-.-w,-...- ,..,.Ww-. ..m......-....,,.,.t.,-,n.-- ...... A . .. , it ,,.,,,.. JL., . .l .,a..,,..,.,, .I M: f .,....,:..e. :xt-:r l

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l I Page 176 LITERATURE The Stuhenfs Bilemma CWith apologies to Hamletb To study or not to study, that is the question, Whether 'tis nobler in the mind to suffer The hours of conscientious study Or pursue the delights of pleasure, And by opposing-end them. i To work, to read, No more, and by a decision we hope to end The waste of midnight oil and a thousand cares Which study demands. 'Tis a consummation Devoutly to be wished. To lie, to cheat, 'Twill doubtless help a little, ay there's the' rubg For what of the future To one who shifts this mortal toil? We must give pause, there's the respect That makes the uncertainty of a life of ease. For who will steal and cheat and waste his hours When the opportunity is his. The many failures from countless sins Will come and go and come again And fill his soul with great remorse To give place to the success that might have been Had he devoted more hours to study Instead of wasting these precious hours In useless occupations, Which bring weariness to the soul and deny dreamless sleep Our most esteemed-ye men of wisdom, hear, Such careless ways breed lives that may spoil Your neighbor's child. There was a time-now passed- You were careless of the outcome. Answer me This night, as you will have to answer when you stand Naked and alone before the great white Throne of God: Can you defend, or will you try Your habits for study while in school. T w. R. c.