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The after-care of the patient consists in catheterization every six or eight hours for the first few days; after that, seeing that no urine escapes upon the line of union, and to move the bowels on the third or fourth day. This is best done by the administration of salines in small doses every hour, and the administration of an enema of warm water to soften the fecal matter as soon as the patient feels a desire to defecate. The sutures can be removed on the tenth day. I make it a rule to keep the patient in bed for two and a half to three weeks.
The point in the operation to which I would especially call your attention is the method of suturing, it differing from that originally devised by Emmet. In all operations heretofore there has been no fixed point, hence no "lifting up." The sutures introduced in the manner described have the lateral walls as a point toward which traction is made, and thus overcome this heretofore mechanical defect of the operation. It is for just this reason that the old operation gave only cosmetic effects, unless the perineum has been built up layer by layer from below, as has been and is still done by some operators, uniting the structures separately.
The repair of median lacerations is so simple and easy that little will be said upon that subject. I would only state that all scar tissue must be gotten rid of, and that if the laceration extends any distance up the vagina, be sure to unite the mucous surfaces and avoid all pocketing; pass the sutures well out and well under the raw areas.
If the sphincter muscle is involved, its retracted ends can be located by feeling upon each side a pit-like depression. You will find that the corrugation, which is normal about the anus, will have disappeared except over an area corresponding to the area of the retracted muscle. The ends of the muscle must be denuded by picking up the tissue with forceps and snipping it out. The sutures are then passed upon the skin side well out, going through the muscle up under the mucous membrane to the border of the rectal mucosa, and out at a corresponding point on the other side. When these two sutures are tied, the rectum may seem to be drawn backward; a suture may even disappear within the anal orifice. We may know that the muscle has been caught and the torn ends approximated by recognizing a restoration of the anal corrugation. If the mucous membrane of the bowel is torn through, it must first be united with buried catgut sutures before the perineum is restored, and it is well in cases of this sort not to allow the bowels to move until about the fifth day.
There is just one condition that sometimes follows laceration of which I desire to say a few words, that is prolapsus uteri. If the prolapsus is slight and the organ has not descended much, repair of the perineum in this manner will often answer every purpose and effect a permanent cure; in some cases, after the perineum is repaired, ventro-suspension should be done. If the cervix is elongated, it should be amputated. If the prolapsus is complete, the only thing, in my opinion, that can be done is an hysterectomy. Ventro-fixation, ventro-suspension, nor any other operation will retain these uteri in their normal position; prolapsus will recur sooner or later, and the woman will continue to lead a miserable existence until the organ is completely removed.
WILLIAM LANE LOWDER, B. S., M. D.
Ego dieta curari incipio; chirurgiæ tædit."—Cicero.
[I begin to be cured by diet; I am disgusted with surgery.]
This exclamation, though uttered by the world's greatest orator nearly two thousand years ago, can be truly echoed in this, our passing day. If it is not the substance of truth, it is at least the shadow of truth. Nevertheless medical writers of the present age are ever wont to bestow all credit of advance in the profession upon surgeons. The surgeon's work is of inestimable value in many places and at many times, for
"A wise surgeon, skilled our wounds to heal,
But he who prevents causes must always be of more value to humanity than he who only removes effects or results. The century, which in a year or two will have rolled on to the eternal past, has placed in the magnificent temple of surgery many pillars of surpassing beauty and grandeur, while the stately columns of sanitary science have risen high Heavenward, where as gilded towers they fain would vie with the God-given sunshine in dispelling the chill and gloom of human agony. Isaac Disraeli, one of England's greatest ministers, once pronounced these memorable words: "The public health is the foundation on which repose the happiness of the people and the power of
An address delivered before the Lincoln County, Ky., Medical Society, at Stanford, Ky., January
a country. The care of the public health is the first duty of a statesman."
A few years ago a writer to The Scotsman objected to the appointment of medical men engaged in practice as health officers on the ground that "no sane body of men can bring themselves to believe that medical practitioners, whose livelihood depends upon sickness, are likely to exert themselves in exterminating it."
Our poet-physician once humorously said: "Physicians desire for their patients great longevity with frequent illness."
As to these last two suggestions we have an abundance of proof sufficient to refute them. It may, perhaps, be justly said that no class or profession has contributed as much as the medical profession to the advance of civilization, to the prosperity of nations, and to the preservation and prolongation of human life, all of which are closely related to the vast contributions to the progress of civilization which have been made by sanitary science. The history of sanitary science is indissolubly related to the history of medicine, and its achievements may almost be written in the recital of the work, investigations, and discoveries of medical men. Sanitary science aims to prevent disease. In former times at least four fifths of all deaths were due to preventable causes, and even now, when the death-rate has been reduced to a quarter of what it once was, still one third of the deaths occurring in our cities are due to diseases that are distinctly preventable. If it is the duty of the minister of the gospel to define moral and social evils, and to point out the way to avoid or forsake them, it is equally the duty of the physician to sound a clear note of warning, when, through ignorance or false economy, the authorities of his town or city fail to provide for the proper drainage of the streets and alleys, for the removal to safe places of all garbage, for measures giving to its citizens an abundance of pure water, for properly quarantining against all epidemics, for adequate and proper ventilation in public halls and school buildings.
The public health bears quite as close a relation to public morality as to general material prosperity. Sickness brings in its trail, especially among the poor, uncleanliness, poverty, misery, wretchedness, destitution, and death. The physical and the moral man are mutually dependent. That which degrades one degrades the other; individual exceptions to the rule do not invalidate its force. Thus it will be seen that the earliest practitioners of medicine in this country seem to have
been the clergy-the functions of the physician and divine were performed by the same individual. This combination has not been uncommon in the history of the countries of the Orient. In the early dawn of medicine the priests of Egypt and Greece collected and preserved what was known of the healing art, and in the infancy of every country the same association will probably be found to exist. Nor is it by any means an unnatural one. Physical and moral evil are so intimately connected, that those who are administering relief to the one can not be regardless of the other. The most casual review of history shows in a striking manner the extraordinary improvement which has taken place in the public health in modern times. The plague and the other great epidemic diseases of the Middle Ages, which decimated and sometimes well-nigh exterminated the human race, are vanquished; smallpox, typhus fever, epidemic dysentery, and cholera have been restricted to the narrowest limits. The prevalence, in temperate climates and under favorable sanitary conditions, of yellow and typhoid fevers has been diminished to a small fraction of what it was formerly. Hydrophobia and diphtheria are at present absolutely preventable; and even the less alarming, because more familiar but hardly less fatal diseases, measles, scarlet fever, whooping cough, and summer diarrhea —a formidable array of preventable diseases—have been confined by the perseverance and activity of the medical sanitarian to much narrower limits or boundaries than formerly.
England has long been regarded as the birth-place and habitat of sanitary science. English methods in sanitation have been the models for the world. No other country has had in modern times so high a standard of public health and such low death-rates. The province of medicine is not only to furnish medicines and measures to relieve present disease, but to disseminate the great principles of hygiene and sanitation. In an address at the dedication of the McDowell monument at Danville, Ky., in 1879, the "Father of American Surgery," Samuel D. Gross, of Philadelphia, said: "Young men of America, listen to the voice of one who has grown old in his profession, and who will probably never address you again, as he utters a parting word of advice. The great question of the day is not this operation or that-not ovariotomy, or lithotomy, or a hip-joint amputation-which have reflected so much glory on American medicine, but preventive medicine: the hygiene of our persons, our dwellings, our streets-in a word, our surroundings, whatever or wherever they may be, whether in city, town, hamlet, or
country. This is the problem of the day-the question which you, as the representatives of the rising generation of physicians, should urge in season and out of season upon the attention of your fellow-citizens— the question which above and beyond all others should engage your most serious thought and elicit your most earnest co-operation. When this great object shall be attained, when man shall be able to prevent disease and to reach with little or no suffering his three-score years and ten, so graphically described by the Psalmist, then, and not till then, will the world be a paradise." Noble words of advice and wisdom, albeit uttered twenty years ago, at a time when many of the causes of diseases now known to be preventable were still concealed in mystery, when hygiene was unwillingly admitted as a branch of medicine in our colleges, and boards of health were scarcely known; or, if known, were the exception and not the rule.
The prevention of diseases by means of sanitation, enlightened hygiene, is wherein medicine has made its greatest advance and achieved its grandest triumphs.
The advance of physiology and histology has been such that the disturbances in the action of the whole body or any of its parts are seen to occur in orderly series, and hence disease is no longer presented to us as an enigma, but as a problem. Its study is but the study of nutrition and the influences which modify it. Its study is now carried on mainly from the standpoint of life, and not, as of old, from the standpoint of death. And yet, strangely enough, so far are some people from recognizing this wonderful advance, that we still hear "Morbid Anatomy" styled Pathology; but Pathology and Necrology are not synonymous terms. The study of the ruins which death causes is well enough as an abstract study; but the phenomena of health and disease physiology demonstrates are manifested among the atoms of the living, and not by the gross results of death and decomposition. Vivisection gives sunlight where the dead mass under the scalpel yields the dim phosphorescence of the grub-worm. Since bacteriology has thrown so much light upon the causation of disease the field of preventive medicine has become gigantic, and can be entered upon with far greater chances of success than formerly. The wide existence of contagious diseases, their fatality and their sequelæ, renders the subject of prevention and sanitation one of the greatest importance. Before proceeding further, a word about infection and contagion may not be inappropriate. T. Mitchell Prudden says that an infectious disease is.