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it was necessary to change the dressings every four hours at first, and at each dressing the wound and tube were washed out with a warm solution of chlorinated soda, 1-20. For ten days, one or two grains in weight of grit were found on the cotton at each dressing. The operation lasted one hour and a half. Shock was marked. Brandy was given by the rectum, and the patient was put to bed with hot bottles to keep up warmth. The evening temperature was 104°, pulse 145; but the next morning the temperature was 99° and the pulse 120. The following table shows the records of the temperature, pulse, urine, and pus:
TABLE SHOWING THE VARIATIONS IN TEMPERATURE, PULSE, URINE, AND PUS.
1 Increased by stimulants.
2 The day was sultry, and the patient perspired profusely.
TABLE SHOWING THE VARIATIONS IN TEMPERATURE, ETC.-(Continued.)
33 33 34 32
The second day, the patient passed about six fluid ounces of urine by the urethra, but the dressings were drenched, and, after the sixteenth day, the urine and pus were regularly measured. The tube was removed the tenth day after the operation. The convalescence was slow but quite steady, and seven weeks after the operation the patient rode out, and the eighth week was walking, free from pain and in better health than for months before the operation, and constantly improving. There still remains a sinus which discharges about half an ounce of pus daily.
As to the merits of the operation, I am more than satisfied. The question was whether extirpation (nephrectomy) or simple incision and drainage (nephrotomy) should be the operation;
and I decided upon the latter for the following reasons: First, the far greater danger of primary nephrectomy, fifty per cent dying from the primary operation, according to Mr. Clement Lucas; second, the possibility that nephrotomy would secure the end desired; third, the fact that, in case of failure of nephrotomy, the chances of a successful nephrectomy would be markedly better. This procedure is strongly advised by Mr. Clement Lucas, on the ground that the subsequent removal of the shrunken kidney is far less dangerous, because of the smaller cavity left by the operation, all of his own six cases recovering. As to the loin or abdominal incisions, I should' in any subsequent case prefer the loin, whether for the simple incision and drainage or for the extirpation of the organ, because-1. It does not open the peritonæum. 2. That by it room enough can be obtained for the removal of any growth by making, as advised by Billroth, in addition to the incision parallel to the quadratus lumborum muscle, a second incision parallel, at one centimetre's distance, to the crest of the ilium, and extending, if necessary, as far as the spermatic cord. With this incision there is no necessity of excising the last rib and incurring the risk of collapsed lung. 3. By reason of the position of the wound, drainage is favored. 4. There is, with the lumbar incision, no danger of the formation of bands within the abdomen, which may become the cause of intestinal obstruction, as has occurred where, after nephrectomy, the ureter has been stitched into the abdominal wound.1
In sounding the kidney for stone, I think the fine aspirator needles are much easier to manipulate than a needle and forceps, being fine, light, and their large shoulder giving a good control of the needle without taking up much room in the wound, as is the case with a needle-holder. The incision should be through the parenchyma, and not through the pelvis; and, although the hæmorrhage is sharp when the kidney-substance is incised, it is easily arrested by sponge-pressure, and tearing to enlarge the wound will greatly lessen the danger from this source.
1 Morris's discussion of Thornton's paper on "Nephrotomy and Nephrectomy." International Medical Congress. Copenhagen, 1884.
A SUCCESSFUL CASE OF EXCISION OF THE RECTUM.
By WILLIAM WOTKYNS SEYMOUR, M. D., of Rensselaer County.
I FIRST saw the patient, J. C., August 11, 1884. He is a farmer, aged sixty-six years, always of good habits, and never the subject of a severe illness save an attack of entero-colitis a year ago. His mother had a cancerous tumor removed from between the shoulder-blades forty years ago, and died, aged sixtysix, a year later, of its recurrence. A brother's daughter has a cancer of the breast. For a year and a half, the patient has experienced pain and difficulty on defecation, together with a grumous discharge from the bowel, which was attributed to hæmorrhoids; and for six months past the pain had been constant, and so excruciating that the patient besought me to kill him rather than to allow it to continue. Examination under ether revealed irregular nodular masses in the rectal walls, beginning about an inch above the anus and extending almost as high as the finger could reach on the anterior wall, when strong supra-pubic pressure was made. The caliber of the bowel was diminished, but the whole mass was movable, and the perinæum was lax. My diagnosis was cancer of the rectum, and the prognosis, of course, unfavorable. The patient was told that, for the relief of the increasing difficulty and pain on defecation, either curetting, linear rectotomy, or colotomy could be done, but that neither of these operations would remove the disease, although it might prolong life for a considerable time; but that, on the other hand, excision of the rectum, which was much more immediately dangerous, gave a faint chance of cure, or, if
immediately successful, quite as long relief as either of the other procedures.
The patient decided wisely, I think, for excision, which I proceeded to perform on the 6th of September, 1884. I was assisted by the family physician, Dr. C. A. Winship, of Eagle Mills, and by Dr. John Morris, of Troy, Mr. Hermon Gordinier, medical student, and Mr. David Winship. None of my assistants had ever seen the operation. The patient's bowels had been moved the morning of the operation by injection. Brandy was given by the mouth, ether was used as the anesthetic, the patient was put in the exaggerated stone position, and the parts were scrubbed with carbolic soap and a nail-brush and then shaved. I then introduced a tampon into the bowel and made an elliptical incision half an inch from the anus, continuing it by incisions in the median line to the coccyx and just behind the scrotum. The posterior portions of the bowel were first freed, and then a sound was introduced into the bladder as a guide for the separation of the anterior wall from the prostate and bladder. All vessels were immediately seized with artery clamps, and the dissection was made with fingers and knife-handle, and, where the tissues were tough, by blunt scissors, between double ligatures. When the artery clamps became too many, the vessels were tied, at first with Kocher's catgut and afterward with silk boiled in a solution of bichloride of mercury. In this wise, little blood was lost, but considerable time was consumed. Much to my gratification, the bowel was easily separated from the bladder, and I finally was able to drag down the gut so as to get an inch of apparently sound tissue above the growth without opening the peritonæum. In this sound tissue, I made a transverse incision and removed the mass, the upper limits of which extended nearly five inches on the posterior wall and four inches on the anterior wall from the anus. During and after the operation, irrigations of the wound with a hot solution of salicylic acid were used. After searching for suspicious tissue in the opening and stopping all oozing, the anterior and posterior median portions of the wound were closed with silk sutures, and the end of the bowel was pulled down and stitched on with silk, a large, rubber drainage-tube being inserted at the posterior part of the wound. Iodoform was dusted over the wound, and a pad of absorbent cotton and T bandage were applied. Shock being marked, brandy was given subcutaneously and by the mouth.