CASE OF SUPRA-PUBIC LITHOTOMY.

By A. JACOBI, M.D.,

NEW YORK.

TIMOTHY CORNELL, six years, United States, was admitted to the Children's Ward of Mount Sinai Hospital (No. 16,567) on April 28, 1880. The boy had measles two years ago. With this exception he has always had pretty good health, although he at times during the past four years has evinced trouble in passing his water, such as pain and sudden interruption of the stream, when he would run about the room crying until the passage was clear again. Nine months ago a small amount of blood was passed with the urine. Urine has been of a high color, and contains a considerable urate sediment. Passes water six or seven times during the day, and always more than once during the night.

On admission the child was rather thin, somewhat anæmic, face rather drawn, suggestive of pain and greater age. Appetite good; bowels regular; temperature, pulse, and respiration normal.

May 5th, 4 o'clock P. M. Operation of epicystotomy performed. Boy chloroformed. Bladder well distended with lukewarm water to the extent of 200 to 220 grammes. Abdomen washed with a three per cent. solution of carbolic acid. A linear incision of two inches nearly midway between the umbilicus and superior border of the penis. The distended vesical wall was readily reached; picked up with a hook and small incision; snipped with scissors; several ounces of water escaped from the bladder; retractors were introduced, and the vesical opening enlarged to permit the entrance of stone forceps, with which the stone was at once grasped and withdrawn. The wound was touched gently with a five per cent. solution of ziuc chloride. After operation ordered tr. opii gtt. v every two hours, and spts. frumenti 4.0 every two hours. Temperature 8 P. M. 99.2°; 10 P.M. 100.6°.

6th. Temperature 1 A. M. 101; 5 A. M. 101.5; 8 A. M. 103.5; 12 M. 103.2; 5 P. M. 102.4; 9 P. M. 102; 12 P. M. 101.2. Child slept well after the operation. This morning pulse 140, wiry and jerky. Respiration 30. Abdomen tympanitic, tender to touch. Urine constantly dribbling from the wound. Tongue coated, moist. Ordered tr. opii gtt. vj each hour. Ice cold cloths applied to abdomen every ten minutes, day and night, with carbolized sponge over the wound to absorb urine, also repeatedly changed.

7th. Temperature 3 A. M. 101.3; 9 A. M. 102.5; 2 P. M. 101.5; 5 P. M. 100.9; 12 P. M. 100.2. This morning the patient has passed about four ounces of bloody urine per urethram; very little dribbling through the wound. Boy passed a moderately good night. Pulse 150; respiration 30. Continued treatment.

12 o'clock M. Bladder washed out with 0.5 per cent. solution of carbolic acid warm; water escaping both by wound and through the catheter.

2 P. M. Pulse 138; respiration 30. Boy says he feels pretty well, suffers no pain when undisturbed.

5 P. M. Pulse 132; respiration 30. This afternoon boy complains of pain in abdomen, which is more distended.

8th. Temperature 4 A. M. 99.4; 8 A. M. 100.5; 4 P. M. 101; 8 P. M. 100.1; 12 M. 99.8. Last night boy slept well, but complained of pain each time he awoke. Ordered tr. opii gtt. x each hour. This did not relieve pain. Ordered dose to be increased to gtt. xv each hour for two hours; if borne well, and yet failed to relieve pain, dose to be increased to gtt. xx each hour. Then the child slept more steadiy, but vomited medicine several times. Ordered small pieces of ice after medicine. Icecold cloth applications still continued every ten minutes day and night.

9 A. M. Boy sleeping quietly. Bladder washed out after a small quantity of urine was drawn.

4 P. M. Urine drawn by catheter perfectly clear. Pulse 130; respiration 30. Continue tr. opii gtt. xx each hour, and spts. frumenti 4.0 each hour.

8 P. M. No change; has passed 3 ounces through the penis. 12 o'clock P. M. Pulse 112; respiration 24. Pupils mode

rately contracted. Patient has been sleeping.

9th. Temperature 4 A. M. 99.8; 8 A. M. 99; 1 P. M. 101.2;

4 P. M. 101.4; 8 P. M. 101.8; 12 P. M. 101.

8 A. M. Respiration 26; pulse 126, good. Pupils moderately contracted. Did not vomit at all during the night.

1 P. M. Slightly diminished tenderness of abdomen. Veins on abdomen very prominent. Patient has passed about two ounces of urine through urethra. Four ounces more were drawn by catheter. Sleeps a good deal; wound looking nicely.

4 P. M. Pulse 125; respiration 24. Urine still dribbles in drops from the wound. Tr. opii now given gtt. xv each hour. Tongue coated, but moist. Vomiting was relieved by teaspoonful doses of ice-cream given after the medicine.

5 P. M. Bowels have moved once. Evacuation was of a thin, yellowish character; child very quiet, but complains only of dryness of the mouth. Drew off about six ounces of clear urine. Ordered opium to be suspended for two hours on account of drowsiness.

8 P. M. Pulse 135; respiration 24. Ordered return to tr. opii. 11 P. M; pulse 130; respiration 21.

10th. Temperature 4 A. M. 101; 8 A. M. 100.9; 1 P. M. 101.2; 5 P. M. 102.3; 8 P. M. 102.8, 12 P. M. 103.8. Child rested quietly during night, but had two stools diarrhoeal in character. This morning tongue thickly coated. Pulse 133; respiration 30. Abdomen less sensitive to touch, still distended, and superficial veins yet prominent. Slight infiltration about the wound. No vomiting during the night or this morning; five ounces of urine drawn off. Urine contains several small pieces and flakes. Has been taking gtt. xv tr. opii every hour.

3 o'clock P. M. Respiration 36; coarse mucous râles heard over anterior thoracic wall; slight dulness at the right apex. Ordered tr. digitalis gtt. j each hour; continue gtt. xv tr. opii each hour.

11th. Temperature 4 A. M. 102.4; 8 A. M. 102; 12 M. 101.4; 1 P. M. 100.8; 8 P. M. 100.8; 12 P. M. 100.8; pulse 130, strong. Drew about six ounces of urine, containing white tissue flakes in otherwise clear urine; abdomen less tender; bowels moved once; child is coughing a little; tongue coated.

P.M. Drew off about two ounces of urine. Ordered quinine sulph. 0.20 each hour. Later, vomited two doses. Pulse 120; respiration 20. Ordered tr. opii gtt. xv each hour; tr. digitalis gtt. j each hour.

12th. Temperature 4 A. M. 99.8; 8 A. M. 100.4; 11 P. M. 101.2; one stool during the night; passed urine himself in bed ;

about 1 ounces of urine drawn by catheter at 10.30 A. M. Pulse 1.30; respiration 30. Vomited opium and quinine. Abdomen much less sensitive and tympanitic. Tongue still thickly coated; breath bad; mucous râles in chest less loud; cough looser and less. Increase tr. opii to gtt. xx each hour.

2 o'clock P. M. Pulse 108; respiration 40. 10.15 P. M. Attempting to pass catheter, found, on introducing finger in rectum, a large impaction of semi-solid feces, which prevented catheter from entering the bladder. Gave a series of small, warm injections, when, after considerable straining and digging with the finger, feces in large quantity were detached and passed. After passage of first large piece, boy made water freely through penis. Pulse 126; repiration 28.

13th. Temperature 4 A M. 100.2; 8 A. M. 100.8; 1 P. M. 100.1; 5 P. M. 100.8; 8 P. M. 100. Patient slept well during the night. Passed about two ounces of urine, which contained amorphous granular urates, urates of soda, and mucus in quantity; also considerable vesical epithelium and number of puscorpuscles.

12 o'clock M. Pulse 120, irregular; respiration 20. Abdomen only slightly distended, and but slight tenderness, except about vesical region; boy moves about in bed without pain.

10 o'clock P. M. Pulse 120; respiration 38.

14th. Temperature 8 A. M. 100.5; 4 P. M. 100.6. Vomited once; has had a stool. Boy evidently improving.

15th. Temperature 3 A. M. 99.2; 8 A. M. 98.9; 2 P. M. 99.5. Vomited twice to-day after medicine; no pain. Less tympanites; sleeps a great deal. This morning drew off about two ounces of urine, and washed out the bladder with a very weak solution of carbolic acid. Tongue still thickly coated. Pulse 120, rather weak; respiration 30. Urine still dribbling from wound. When boy cries, urine wells up in quantity from the wound. Had two stools, thin and yellowish in character. Discontinued tr. opii. Crdered bismuth subnit. 0.30, three times a day. Temperature 5 P. M. 99.8; 9 P. M. 100.

16th. Temperature 2 A. M. 98.5; 7 A. M. 98.8; 1 P. M. 99.6; 5 P. M. 99.7. This morning, pulse 130, fair. On introduction of catheter very little urine came through it. On washing out the bladder the water flowed freely from the wound, carrying with it a thick deposit of phosphates of ammoniacal odor. Boy is still troubled with slight diarrhea and gastric irritability.

Ordered barley water with milk and creta and bismuth subnit. Patient has vomited three times to day, and has had three stools in the last twenty-four hours. Is taking spts. frumenti 4.0 each half hour.

17th. Temperature 5 A. M. 98.9; 8 A. M. 99; 5 P. M. 99.2; 9 P. M. 99. Diarrheal discharges have ceased; has had one fair stool; child looking better; cough has ceased.

18th. Temperature 3 A. M. 99.1; 8 A. M. 99.2; 1 P. M. 99.6; 5 P. M. 99.8; 12 P. M. 99.2. This morning wound is looking healthier; beginning granulations, of good color. Urine, on being drawn, showed less sediment than heretofore. Pulse 132, good.

19th. Temperature 8 A. M. 98.9; 2 P. M. 100.8; 5 P. M. 99.8; 12 P. M. 99.4. About three ounces of urine drawn from bladder, containing numerous flakes. Tongue less coated; wound looking well. Vomited once during the night. Has had two semi-solid stools. Pulse 120; respiration 20.

P. M. Has vomited once to-day. Bowels have moved once. Child has a good appetite; wants more to eat. No pain in abdomen, except in small circuit about the bladder.

20th. Temperature 8 A. M. 99; 2 P. M. 100.8; 5 P. M. 99.9. Passed a large piece of white tissue material of densely clotted mucus through wound with urine this morning. When the catheter is passed, child cries and strains, causing quite a flow. of urine, thickly mixed with mucus, pus, and vesical epithelium, from wound. The sponge kept over the wound is constantly changed, but always has a greater or less quantity of this thick material adherent. Child had one stool last night; he has not vomited.

21st. Temperature 8 A. M. 99; 2 P. M. 99.6; 5 P. M. 99.5. Had one good stool this morning. Child is improving.

22d. Temperature 1 A. M. 99.6; 8 A. M. 99.2; 1 P. M. 99.9; 5 P. M. 100. Wound granulating nicely. Boy has passed no water through urethra except by catheter for over a week. Boy's condition improving daily. Appetite excellent; eats raw meat and toast. Urine is, as always, alkaline. Pulse 100; respiration 30.

23d. Temperature 7 A. M. 100.9; 4 P. M. 99.9.

24th. Temperature 8 A. M. 99.2; 1 P. M. 100.2; 5 P. M. 100.5. Pulse this A. M. 118, good. The discharge of thick pus from the wound is still more copious when the boy strains his abdo