Special Notices.

A Word of PRAISE.-It gives me pleasure to say a kind word for Sanmetto-it surely deserves praise. I have been using Sanmetto in all affections of the genito-urinary tract, and it is by far the most reliable and unfailing agent of its class known to me in thirty-one years' experience as a medical practitioner. Vivat Sanmetto !

Scott, La.

H. D. GUIDRY, M. D.

I HAVE no hesitation in saying that I consider Peacock's Bromides invaluable, and have for years used it exclusively in my sanatorium when bromides were indicated. Commercial bromides are crude and rank as compared with Peacock's. The greatest danger of injury to the patient and the product lies in substitution. I now only buy from my wholesale druggist in dozen lots. ALLAN MOTT RING, M. D.

Arlington Heights, Mass.

I AM more than pleased with the physiological action of Seng in the treatment of chronic indigestion. It seems to nicely restore the action of the stomach, re-establish perfect digestion, and its good effect is quickly evidenced by the general improved appearance of the patient. J. CARL LUDWIG, M. D.

Cincinnati, Ohio.

ANTIKAMNIA AND HEROIN TABLETS IN Prevalent GRIPPAL CONDITIONS.-Thos. G. Rainey. M. D., L. R. C. P., resident physician, British Medical Institute, Atlanta, Ga., in a recent article states that the comparatively new combination of drugs-antikamnia and heroin tablets-which has been so largely used for the control of cough, is also being successfully employed to a large extent in the treatment of nearly all affections of the respiratory tract which are accompanied by dyspnea and spasm, namely: asthma, bronchitis, laryngitis, pneumonia, phthisis, whooping cough, hay fever, la grippe, etc. In cases in which the patients were suffering from the severe attendant pain of these diseases, it was found that this combination acted most satisfactorily. Each tablet contains five grains of antikamnia and one twelfth grain heroin hydrochloride. One tablet was followed by a rapid diminution of pain, and after the third tablet the pain entirely disappeared. In treating the affections enumerated above, the dose is one tablet every two, three, or four hours, according to indication.

"MEMORIA IN ÆTERNA."-As time flies by, amid the rush and bustle of this eminently practical work-a-day world, one unconsciously displaces from the mind of to-day the remembrances of the happenings of yesterday; there are, however, some things which should remain "in everlasting remembrance." The gentleness, strength, and beauty of the personal character of William McKinley, and the inestimable value of his services to the nation and the world at large, should not be consigned to the mental dust-heap of oblivion, but should be cherished as a precious heritage by every patriotic American, whether native or foreign born. Feeling confident that their friends in the medical profession will appreciate at its proper worth a souvenir which shall serve as a constant reminder of the life, character, and services of our third martyr President, the Arlington Chemical Company has prepared for gratuitous distribution a magnificent enlarged reproduction (17 x 13) of one of the finest and most faithful portraits in existence. Competent critics who have seen this reproduction have expressed themselves as surprised at the faithfulness with which the beautiful Rembrandt effect has been carried out, with its rich dark sepia tints, and with the general artistic worthiness of the portrait as a whole. The advertisement of Liquid Peptonoids is so unobtrusive as to be entirely unobjectionable. The Arlington Chemical Co., Yonkers, N. Y., will be pleased to send a copy to any physician who may have failed to receive one, together with suggestions for proper method of framing.

THE

VOL. XXXIII.

"NEC TENUI PENNÂ.”

LOUISVILLE, KY., FEBRUARY 15, 1902.

No 4.

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than any thing else.-RUSKIN.

Original Articles.

SURGERY OF THE URINARY BLADDER.*

BY JOHN R. WATHEN, A. B., M. D.

Clinical Professor of Gynecology in Kentucky School of Medicine; Visiting Surgeon to Louisville City Hospital and Kentucky School of Medicine Hospital; Member Kentucky State Medical Society, Louisville Society of Medicine, and Louisville Clinical Society, etc.

This is a department of surgery which has been greatly neglected in the past, and only of late have we turned our attention to so important a field for operative work. Operations for stone, wounds or ruptures and enlarged prostate were quite common, but surgery for tumors, benign or malignant, and cancerous infiltration of the bladder walls from malignant structures in its vicinity was not often undertaken. Before considering the surgical treatment of the tumors, I will briefly allude to the diagnosis.

We have been aided in this by superior instruments and more careful pathologic investigations, and are fast reaching accurate and positive conclusions. In no class of diseases have we worked so much in the dark, and acquired so little real or valuable knowledge to aid us in our treatment.

One of the earliest signs of a tumor of the bladder is known as symptomless hematuria. When we have to deal with this condition the electric cystoscope is indispensable. "The cystoscope will often enable the skilled observer to pronounce upon the character of the tumor, or to say definitely whether operative interference will or will not lengthen the life of the patient, and whether it will alleviate or aggravate his suffering." (Fenwick.)

* Read before the Louisville Clinical Society. For discussion see p. 242.

The introduction of sounds into the bladder to discover tumor is worse than useless, and often positively detrimental to the patient.

The first examination of the patient should be a rectal or vaginal examination of the bladder wall, according to whether the subject be male or female.

When we inspect the bladder with the cystoscope, we may encounter two well-marked varieties of vesical tumors-the villus-covered and the bald. The villus papilloma may be malignant or benign, but the bald is always malignant, and particularly so if the patient is over forty-five years of age. The villus papilloma resemble chorionic villi, and are of a light fawn color, showing beautifully the capillary circulation. They float about in the urine, and resemble sea-weeds under the water. Their attachment to the bladder wall is almost always outside the trigonal area, to the outer side of the orifice of the ureter, and more often in front of it, while sometimes they arise from the true lip of the ureter itself, and thus have probably been caused by some direct irritation of an unusual kind from the urine of the kidney on that side.

The pedicle of this variety of tumor varies in size from a mere thread to that of a quill, and the larger the pedicle, or base, the more liable it is to become malignant. The multiplicity of villus papilloma also tends

toward malignancy.

The first symptom of hematuria is often followed by an impediment to urination and to mechanic obstruction of the orifice of the urethra. Later we have the kidney-ache, which is cause by the ascending inflammatory changes, and is felt on the side on which the tumor is located. These symptoms are sooner or later followed by a cystitis, unless great care is exercised in the management of the case. This confuses the diagnosis, complicates the disease, and may eventually end the life of the patient by developing a pyonephrosis.

The benign papilloma is very liable to undergo a gradual malignant transformation of the stalk or pedicle. The villus malignant papilloma or carcinoma is less liable to be single, and occasionally a certain proportion are partly free from villi, and approach the bald type. These have a large base or pedicle, and show a tendency toward infiltrating the bladder wall. They are more often situated on the right side near the orifice of the ureter, and the first symptoms of hematuria occur usually between forty-five and sixty years, while the benign appear earlier. The bald type is the most malignant of the bladder tumors, and differs from the two preceding forms in that it tends to involve the

bladder wall, is not so prominent on the surface, and the rapidity with which other vesical symptoms appear-as cystitis, pain, etc., after the initial hemorrhage. These tumors also appear near the ureters, and present a bald, irregular, nodular growth of a dull red color similar to that of the inside of the mouth. It is in strong contrast to the white color of the posterior wall.

Pain is a more prominent symptom in the bald type of tumor, and the extent of involvement of the bladder is better told by the extension of the pain than by the hardness of the vesical wall.

In summing up the points of differential diagnosis of tumors of the bladder, the following are the principal facts to consider: The benign villus appears between thirty and forty-five; the initial hemorrhage is rarely severe; fragments are often evacuated, and the prognosis as regards length of life is good.

The malignant villus appears between fifty and sixty, hemorrhage is very rarely severe, fragments evacuated are common, and the average life is about eight years.

The bald malignant appears between fifty-five and sixty-five, hemorrhage is commonly severe, fragments are. rarely evacuated, and the average life is a little over two years. The softer tumors have longer periods of hemorrhage, while the denser ones exert their energy in infiltrating the vesical wall.

"Most tumors, whether benign or malignant, terminate the existence of the patient by inducing renal complications." (Fenwick.)

The larger and thicker the stem or pedicle of the tumor, the more malignant it is liable to be and the sooner will result infiltration of the bladder wall, followed by irritability, pain, cystitis, pyonephrosis, and death.

In regard to the operative interference with vesical growths we should be guided by the extent and character of the tumor. When the bladder wall has been infiltrated, so as to be felt per rectum, we should not attempt to remove the tumor unless we remove the entire bladder, and if this is impracticable we may substitute a supra-pubic incision to relieve the pain and for better drainage. Most operators condemn the perineal route in this condition, as it increases the pain and vesical spasm, and Fenwick says that "Perineal cystotomy for a radical attack on vesical tumors does not deserve the name or cloak of surgery."

When we have a single villus-covered pedunculated tumor, with unilateral renal pain, or causing an obstruction of the urethra, we should make a small supra-pubic incision and remove the growth. But if the

tumor is large and so fills the bladder that we can not use the cystoscope we should first open the bladder above, and if a small pedicle is found remove the growth, or if the pedicle is very large we may have to open the abdominal cavity and resect a large area of the bladder wall.

As to the technique of the removal of these growths in the male, we should first make a very small incision as near the pubic bone as possible, and just large enough to admit the finger for exploration of the bladder after it has been distended with water.

Pedunculated tumors may be removed by first twisting the pedicle and then slipping a delicate curved clamp down on the pedicle as close to the bladder wall as possible and finally cutting away the growth above the forceps. This instrument is allowed to remain in the bladder for about twenty-four hours, and then removed. The supra-pubic incision into the bladder should always be as small as possible, and by the use of retractors, or, better still, a caisson-tube, as Fenwick recommends, we can conduct most of the operations required on small growths. Gentle manipulations should be the rule in bladder surgery, and we should avoid making traction on a tumor or its pedicle, as the mucous membrane of this viscus bleeds readily and the hemorrhage is hard to control. Never crush a bladder growth, but completely remove it if possible. We should never try to bring the tumor into view in the supra-pubic wound, as the hemorrhage resulting from the tear of a soft pedicle may be quite severe. Often the peritoneum can be dissected off the bladder and a large area of the bladder wall removed without endangering the peritoneal cavity to infections. The bladder is best sutured by separate

transverse stitches which pass involving the mucous membrane.

through the muscular layer without

In the female, the bladder opening can be made through the vaginal wall and the growth removed with more ease, or even through a Kelly endoscopic tube. After all operations for vesical growths we should employ free drainage.

The mortality for removal of these tumors is not great, as Fenwick reports 135 operations out of 500 cases, with only five deaths due to the operation. The first operation for removal of the entire bladder in the male was performed in 1888 by Bardenheuer, and in the female by Pawlik in 1889, but statistics of late are rapidly increasing. Pawlik used the vagina as a receptacle for the urine. The technique of the operation as advised by Dr. Mann is as follows:

Technique of Operation. The patient having been prepared in the usual manner for abdominal section, the urethra is dilated to admit the