The Technique and Possibilities of Endovesical Operative Procedures.

BY LOUIS E. SCHMIDT, M. Sc., M. D.,

CHICAGO.

Read before the Tri-State Medical Society, at Chicago, April 3, 1902.

'HE Bottini operation and the catherization of the ureters have been extensively discussed in the past few years. Strictly speaking these procedures do not belong to the class of operations under consideration, and for this reason I will not discuss them, but will confine this paper to those operative interferences which are performed inside of the bladder under the guidance of the eye, without any previous cutting operation, which is done for making the interior of the bladder accessible. In other words, operations which can be performed with the aid of instruments, which allow of the inspection of the affected areas of the bladder wall, and at the same time admit of the introduction of mechanical appliances which are used for the different operative procedures. These systems of instruments are called operative cystoscopes. Three distinct types of instruments are distinguished from each other.

Not to go into detail, but simply to mention their important points, and thus show their difference, it will be necessary to enumerate.

1. Nitze operative cystoscope. Here the lamp, prism and window are on the concave surface of the beak. In front of the space between the lamp and the window the operative appliances are placed. In fact the operative appliance carries in its hollow shaft the optical apparatus. The latter is movable so that the operative appliance can be brought to different distances and positions from the cystoscope part. These mechanical appliances are galvano-caustic snare, cautery, small forces and lithotriptic forces.

2. Casper operative cystoscope differs from the Nitze cystoscope in that the lamp, window and prism are on the same plane, so that the whole optical apparatus is straight. The operative part is practically similar to the Nitze.

Both of these cystoscopes compel the operator to work under indirect vision.

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3. Kolischer operative cystoscope. With this cystoscope the operator works under direct vision. The lamp and window are situated on the convexity of the beak. To the under part of the cystoscope is attached a canal through which the different instruments are introduced into the visTheir working end appears just below and in front of the window. Considering the merits and demerits of these types it may be stated that the beak of the Nitze instruments is somewhat bulky and clumsy, because in the beak, the operative appliance and lamp are in contact, and must be introduced together. This is avoided in the Casper instrument, as the mechanical appliance is first independently introduced, furthermore the canal of this part is wide enough to allow of thorough flushing of the

bladder between the operative stages. On the other hand, the Nitze instrument is more simple so far as its mechanical settings are concerned. Both instruments have the drawback that the operative beak covers to a great extent the field of operation. It has been admitted that these two types, by allowing of the use of powerful instruments, allow of very energetic and extensive procedures.

The Kolischer cystoscope has the advantage of direct view, and that in consequence of its construction, the working end of the mechanical appliances do not interfere with the clear view of the field of operation. Another advantage is to be found in the variety of instruments. While this instrument also allows the use of both galvano-caustic snare and cautery, it is the only operative cystoscope which permits of the use of curettes, scissors, forceps used for picking up and removing small foreign bodies. But in order to keep the circumference within reasonable limits, it, has but a small lumen so that the usefulness of this instrument is somewhat limited by the small dimensions of the mechanical appliances.

I refrain from giving a minute description of the details of construction, which can be more readily understood by examining the instruments I wish to demonstrate.

In passing it is best to mention that Mirabeau and Latzko constructed small appliances which can be introduced into the bladder independently of the cystoscope, and used under the control of the cystoscope. The limited usefulness of these devices is further reduced by the fact that they are only to be used in the female bladder. The same holds good of the Kelly instruments, which do not approach the perfection of the modern cystoscope.

An important question is one of anesthetics, because a large number of individuals having bladder affections have also kidney diseases, and for this reason it is best to avoid general anesthetics if it is possible.

It is a fact that most of these endovesical operations can be done under a carefully given local anesthetic. The correct application of a local anesthetic is an important necessity. It is best to state at once the great danger of cocainization of the bladder. As a local anesthetic a highly concentrated antipyrine solution is to be recommended. It must not be forgotten that it requires ten minutes, or even longer until antipyrine gives the desired affect, hence must be done at the proper time. The urethra should be anesthetized by cocainization. While it is easy to do this within the pendulous urethra it is best to apply cocaine into the posterior urethra with the Ultzman capillary catheter. After injecting along the entire urethra the external urethral orifice is held fast to prevent the escape of the cocaine solution, and the entire urethra is massaged so as to bring the solution into intimate solution into intimate contact with the mucous membrane of the entire urethra. The disagreeable sensations in the prostatic urethra, caused by the stretching of the deeper layers, cannot be overcome by the superficial cocaine anesthesia, but must be overcome with a morphine and atropine rectal suppository.

Previous to any operative step it is advisable to have the bladder in as good a condition as it is possible to bring it with the usual irrigations,

instillations and internal medications. This procedure not only makes the bladder less sensitive, but also brings the localized centres of the pathological changes into prominence.

One of the most frequent indications for this method of treatment are the stubborn cases of cystitis. Under this are comprised not only the inflammation of large areas, but also small localized inflammation as fissures, ulcerations, as remnants of cystitis of the adjacent parts are free from pathological changes. Granulating cystitis is not an uncommon condition, and I wish to state most emphatically that these cases do not respond to the ordinary treatment, but require surgical intervention. The method of procedure is to remove these granulations by curettement, and the method of choice is with the aid of the operative cystoscope. The subsequent hemorrhage is as a rule exceedingly slight. If of any severity nitrate of silver irrigations will cause it to subside. It is my routine to inject, and to leave in, iodoform emulsion after such curettage, on account of the antiseptic and soothing effect

Fissures which if located in the bladder neck cause very annoying symptoms, can readily be healed with a single treatment consisting of an energetic cauterization.

A very important chapter of vesical diseases is the ulcer which follows a gonorrheal cystitis. The frequency of these and the importance of their treatment, has become more recognized since systematic cystoscopy has been practised amongst genito-urinary surgeons. The coating and the granulations which cover it must be thoroughly curetted, and prompt cure follows. It has become recognized that patients of this class can be treated for years without any results, and, one single treatment, with the operating cystoscope, will cure these individuals.

The standpoint of the endovesical operator toward tumors of the bladder should be carefully discussed. Nitze claims that even malignant tumors ought to be operated with the operative cystoscope, pointing out, that definite results even after suprapubic cystotomy and extensive resection are far from satisfactory, and that even large malignant tumors can be removed by the galvano-caustic snare, down to their bases. This standpoint is certainly not approved of by the large majority of surgeons. Under our present view malignant tumors will always call for radical operations after cystotomy. It must be mentioned, however, that if these cases are beyond operation or refuse such a step an endovesical cauterization often gives great relief, especially after necrosis has set in. This interference can be repeated if necessary. I think the proper limitations for the operative cystoscope in cases of tumors, are furnished by the following points: The tumor should show no signs of malignancy. The tumor should not be so large as to interfere with the ease of manipulating the cystoscope. The tumor ought to be pedunculated, although it has to be admitted that even tumors with a large base can be removed with the oper. ative cystoscopes, by removing them in sections. It is remarkable how large pieces can be urinated spontaneously. If single pieces are too large they can be removed by the evacuator, by first cutting them with cystoscopic scissors. There are benign tumors which become incrusted to such

an extent that they cannot be operated with the operative cystoscope, for they are too hard, but must be removed by resection of the bladder wall. Nodular varicosities of the superficial veins which give rise occasionally to severe hemorrhages, are easily removed by cauterization with the galvano-cautery.

Small foreign bodies and immigrated ligatures, needles and hair pins have been repeatedly removed by means of the operating cystoscope. Foreign bodies of some considerable size should not be thus removed on account of the unnecessary traumatism.

The operative cystoscope plays an important role in the after control of litholapaxy. The cystoscope makes possible the minute and exact supervision of the bladder, and the small lithotriptor or forceps of the oper ative cystoscope is a reliable means of crushing small splinters and removing them. The latter procedures become more important if the sharp splinters become imbedded in the bladder wall. This condition is very dangerous because of the imminent possibility of perforation and suppur ation, while even a powerful pump will not remove them.

Although I have given but a short sketch of the more important oper ative interferences I hope it has been of sufficient detail to impress all of the advantages of these procedures. I have attempted to give the fairly exact limitations, and have not been too enthusiastic in advocating its general adoption.

ACCORDING to statistics, the number of female physicians throughout the world is about 8,000, two-thirds of whom live in America.

ACCORDING to a recent report from Geneva, 119 adventurous mountain climbers lost their lives in the Swiss Alps during the year 1901, the fatalities being double those of the precious year. The number of deaths from this cause has largely increased during the past few years.

INSANITY IN DETROIT, MICH. Recent investigations by Dr. J. B. Kennedy of the Health Board show that one person becomes insane every other day in the city of Detroit. He found that, during the year 1901, 180 persons were declared insane. Since 1894 the number of insane people in Detroit has increased over 100 per cent. This is far in excess of the increase of population during the same period.

CHOLERA IN THE PHILIPPINES.-In Manila the number of cases of cholera has been constantly decreasing. There were but 3 deaths from that disease reported September 13. Four deaths from bubonic plague were also reported that day. Six additional cases of cholera, with one. death, have developed among the enlisted men on the U. S. transport Sherman, in quarantine at Nagasaki, Japan. Up to September 16, it is estimated that 59,759 cases of cholera, with 41,804 deaths, had occurred in the Philipines. Between September 1 and 15, 9 deaths occurred among the troops from cholera.

THE

Hypnotics in General Medical Practice.

BY S. E. LUCKETT, M. D.,

CAMPBELLSBURG, IND.

HERE is perhaps no disorder that will at times so harass a patient and so severely try the skill of the physician as a refractory case of insomnia. In the past it was customary to rely chiefly upon the bromides, chloral and opium in the drug treatment of sleeplessness. Experience, however, showed that the bromides possess hypnotic powers to a very limited extent, and can be utilized only in exceptional cases of mild insomnia. Chloral is a cardiac depressant, and is capable of producing alarming results in some persons. Opium and its alkaloids are only admissible in certain cases of insomnia due to severe pains, owing to their many unpleasant after-effects and the danger of habituation.

In later years chemistry has provided us with a number of hypnotics of greater or less efficiency from which to make a selection, of which trional, sulfonal, paraldehyde, hyoscin, hydrobromate, and chloralimid are the best known. While these drugs serve a useful purpose, the tendency at the present time is to resort to the systematic use of hypnotics only in cases in which other measures to induce sleep have failed, such as hygienic regulations, hydrotherapy, rest cure, etc. Church and Peterson in their new work on nervous diseases wisely observe "that any drug that sufficiently masters the organism to produce sleep is a dangerous remedy, and should be used with circumspection and only as a last resort. While this statement is true in a general way it applies more particularly to the older hypnotics, and certainly not, in my opinion, to methylproylcarbinol urethane, or hedonal, to which I shall now call attention.

During the use of the older hypnotics there was always a risk of creating a habit, which when once established was very difficult, if not impossible, to overcome. Their use was at times attended with alarming and dangerous symptoms, and continued for any length of time they had the tendency to disturb the digestion, impair the appetite, or otherwise interfere with the bodily functions.

According to my experience hedonal is free from these disadvantages. It is very quickly absorbed and is rapidly eliminated without leaving behind any traces, this being due to its complete oxydation in the system, the products of which are urea, water, and carbonic acid, that is to say, products normally eliminated by the organism in varying quantities. It is absolutely devoid of any toxic effects in any size doses that would be necessary to administer. Since commencing my studies of hedonal I have kept a careful record of its effects and compared them with the experiences of other observers. A careful study of 843 cases in which this remedy was employed by physicians in this country and abroad failed to show a single instance in which its use was attended with any alarming symptoms. In a few cases emesis and languor were mentioned, but no deleterious influence upon the circulation and respiration, and no habituation is recorded, although it was administered in some cases continually for periods.