IMAGE EVALUATION TEST TARGET (MT-3) /. £e. m 1.0 I.I ■-His ^ us, 12.0 2.5 2.2 1.8 • 1.25 1.4 1.6 < 6" ► Photographic Sciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 CIHM/ICMH Microfiche Series. CIHM/ICMH Collection de microfiches. Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiques 1 Technical and Bibliographic Notas/Notas techniquaa at bibiiographiquas Tha Institute has attempted to obtain the best original copy available for filming. Features of this copy which may be bibliographically unique, which may altar any of the images in the reproduction, or which may significantly change the usual method of filming, are checked below. Coloured covers/ Couverture de couleur I — I Covers damaged/ n n n n D Couverture endommagie Covers restored and/or laminatid/ Couverture restaurie et/ou pelliculAe I I Cover title missing/ Le titre de couverture manque Coloured maps/ Cartes giographiques en couleur □ Coloured ink (I.e. other than blue or black)/ Encre de couleur (i.e. autre que bleuA ou noire) □ Coloured plates and/or illustrations/ Planches et/ou illustrations en couleur Bound with other material/ ReWi avec d'autres documents Tight binding may cause shadows or distortion along interior margin/ La re liure serr^e peut causer de I'ombre ou de la distorsion le long de la marge intdrieure Blank leaves added during restoration may appear within the text. Whenever possible, these have been omitted from filming/ II se peut que certaines pages blanches ajouties lors d'une restauration apparaissent dans le texte. mais, lorsque cela 6tait possible, ces pages n'ont pas 6t6 filmAes. ■ - ■ - ' ^ ■■v.. Additional comments:/ Commentaires suppldmentaires: L'Institut a microfilm^ le meilleur exemplaire qu'il lui a iti possible de se procurer. Les details de cet exemplaire qui sont peut-Atre uniques du point de vue bibliographique, qui peuvent modifier une image reproduite, ou qui peuvent exiger une modification dans la mithode normale de filmage sont indiquAs ci-dessous. D D D n Coloured pages/ Pages de couleur Pages damaged/ V Pages endommagees Pages restored and/or laminated/ Pages restaur^es et/ou pelliculdes Pages discoloured, stained or foxed/ Pages d6colorAes, tachetdes ou piqudes Pages detached/ Pages d6tach6es Showthrough/ Transparence Quality of print varies/ Qualiti inigale de I'impression Includes supplementary material/ Comprend du matdriel suppl^mentaire Only edition available/ Seule Edition disponible Pages wholly or partially obscured by errata slips, tissues, etc., have been refilmed to ensure the best possible image/ Les pages totalement ou partieilement obscurcies par un feuillet d'errata, une pelure, etc., ont itA filmde& d nouveau de facon d obtanir la meilleure image possible. This item is filmed at the reduction ratio checked below/ Ce document est filmd au taux de reduction indiqu6 ci-dessous 10X 14X 18X 22X -■ ■ 26X SOX y ' ■'.: '':'.' 12X 16X ■ 20X 24X 28X ''. ■ ■■;■. 32X Th« cony film«d h«r« has iistn rsproducad thank* to tha ganarosity of: Medical Library IMcGill University IMontreal Tha imagas appaaring hara ara tha baat quality possibia conaidaring tha condition and lagibiiity of tha originai copy and in icaaping with tha fiiming contract spacificationa. Original eopiaa in printad papar covars a»a filmad baginning with tha front covar and anding on tha last paga with a printad or illuatratad impraa- sion, or tha bacic covar whan appropriata. All othar originai eopiaa ara filmad baginning on tha first paga with a printad or illuatratad impraa- sion, and anding on tha last paga with a printad or illuatratad impraasion. L'axaniplaira fiimi fut raproduit grica it la ginirositt da: Medical Library McGill University Montreal Laa imagaa suivantaa ont M raprociuitaa avac la plus grand soin, compta tanu da la condition at da la nattati da I'axamplaira filmA. at •n conformity avac laa conditiona du contrat da filmaga. Laa axamplairaa originaiix dont la couvartura mn papiar ast imprim^a sont filmis an commanpant par la pramiar plat at an tarminant soit par la darniira paga qui comporta una amprainta d'imprassion ou d'illustration, soit par la sacond plat, salon la caa. Toua laa autraa axamplairaa originaux sont fiimis an commandant par lb pramlAra paga qui comporta una amprainta d'imprassion ou d'illustration at an tarminant par la darnidra paga qui comporta una talla amprainta. Tha laat racordad frama on aach microflcha shall contain tha symbol —^(moaning "CON- TINUCD"). or tha symbol y (moaning "END"), whichavar appliaa. Un daa symbolaa suh/ants apparattr^ sur la darnlAra imaga da chaqua microfScha, salon la caa: la symbols —»• signifia "A SUIVRE", la symbols V signifia "FIN". Maps, piataa, charts, ate, may ba filmad at diffarant raduction ratioa. Thoaa too larga to ba antiraly includad in ona axposura ara filmad beginning in tha uppar laft hand cornar, laft to right and top to bottom, aa many framaa aa raquirad. Tha following dlagrama illuatrata tha mathod: Laa cartaa, planchaa, tablaaux, ate, pauvant Atra filmte A das taux da rMuction diff^rants. Loraqua la documant aat trop grand pour Atra raproduit an un saul clichA, II aat film* A partir da I'angia supAriaur gaucha, da gaucha A droita. at da haut an baa, an pranant la nombra d'imagas nteassaira. Laa diagrammaa suivants illuatrant la mAthoda. 1 2 3 1 2 3 4 5 6 >^ >J 1 [E TREATMENT OP TUBER- CULOSIS OF THE BLADDER THROUGH A SUPRAPUBIC SECTION. BT JAMES BELL, M.D. SurKeon to the Montreal General Hospital and Associate Professor of Clinical Surgery McGlll University. REPRINTED FROM THE JOURNAL OF CUTANEOUS AND GENITO-URINARY DISEASES FOR AUOUtT, 16K. ' / ' i i^iMtiJiy liWK^UMHflldillllfittitMilllllMIMIiiiil ■iMiiiiiMiiiMlfitiiiiiiHiaiMHili -^pv«^^wa«^^«^^^^^^^|^ ^^^^^ ^TT^^^-'^^^^ip^^^^^^^^^wpi ■ . i. ] THE TREATMENT OP TUBERCULOSIS OP THE BLADDER THROUGH A SUPRA-I cBIC SECTION. BT JAMES BELL, M.D. Surf^eon to the Montreal (}eneral Hospital and Associate Professor of Clinical Surgery McGiU University. THAT the bladder is frequently the seat of tuberculosis, either primary or secondary, is a well established fact, and observation shows that generally speaking the pro- gress of the disease in this situation does not materially differ from its progress in other localities. Its favorite site is in the trigone and around the neck of the bladder, while the disease remains for a long time confined to the mucous membrane, and only in advanced cases are the deejjer tissues invaded. The di- agnosis i3 difficult, and often a positive diagnosis is impossible, for the bacillus is frequently to be found only after repeated examination, or not at all. The disease may be primary and confined to the bladder, but is usually associated with, and probably most frequently, secondary to tubercular lesions else- where, especially in other parts of the genito-urinary system — notably in the kidneys or testicles. I do not propose to discuss the many interesting problems in connection with the etiology and mode or modes of transmission and extension of the dis- ease, nor to deal with other methods of treatment than that designated in the title of this paper ; but to limit the discus- sion to those severe and advanced cases in which general medi- cal and local treatment have failed to give relief, and in which the pain and frequent or constant desire to micturate have ren- dered the patient's life useless, if not burdensome. Such are the following cases : Case I. W. K., set. 26, laborer, was admitted to the Mon- treal General Hospital on December 26, 1889, suffering from frequent and painful micturition — the urine containing blood and pus. The patient, who had been absolutely deaf from the age of six years, was much emaciated and wore an expression of great suffering. He attributed his deafness to a severe ill- i h 2 Ohioinal Communication. ness which foHowecl ji kick from si horse on tlie tibia when he was six years old (pyjomia i). Patient had always lived a regu- lar life, and had never had venereal disease in any ff)rm. There was no family history of tubercle. Present illness began twelve months prior to admission to hospital with frequent micturition, straining, pain at the point of the penis, and the ex[)ulsion of a few drops of blood at the end of the act of mic- turition. About two months after the onset of his illness he first noticed cloudiness of the urine, which had continued uj) to the time of admission. All these symptoms increased in sever- ity, and at times, especially after exertion, the tiow of blood was considerably increased, although it had never been great. The symptoms were also more severe in day time, and when the patient was actively emi)loyed. Patient also stated that at about the same time as the beginning of the urinary symptoms he had suffered from cough and some niglit-sweating. His con- dition when admitted is described as follows in the case book : "Patient is greatly emaciated; is in constant pain; mictur- ates about every half hour — at times as often as every ten min- utes. Micturition is followed by tenesmus, and the evacuation "^ of a few drops of blood. Deep pressure above the pubes causes j pain. The urine deposits a considerable quantity of niuco- i pus, is neutral in reaction and yields to boiling and nitric acid a deposit of albumen, — about per cent, by volume in the test tube. The (quantity of urine is difficult to estimate, but is probably about forty ounces daily. Patient is so disturbed at | night that he gets hardly any sleep. The heart and lungs are normal, the pulse rapid, temperature generalh' normal, but | with slight occasional rises of a degree or two. Constipation i and diarrh(i)a alternating." Patient was etherized and the bladder explored. It was found to be small with rigid walls, and bled freely on the introduction of a sound. Bleeding was so easily excited that the cystoscope could not be used. Pa- tient was kept in bed on bland liquid diet, soothing anodyne local applications and morphia in the form of rectal supposi- tory and hypodermically for five weeks without improvement when I decided to operate. His condition at this time was thoroughly miserable. He could get no sleep even with large doses of morphia .and equally welcomed tlie proposal to operate as a chance of giving him relief. On February 4, 1890, the bladder was opened above the pubes in the ordinarj^ way with the patient in the Trendelenburg position, and a Petersen's bag in the rectum. On opening the bladder the mucous mem- I .t« k The Trealment of Tiiberculnala of tJie Bladder. 3 brane throughout was found to be of a deep livid red color, but free from ulreratiou except in the neighborhood of the urethral outle*^. By means of a bivalve s[)eculun» and a Hniall electric lamp the whole interior of the bladder was carefully in- spected. A fringe of irregular superlicial ulceration encircled the urethral orifice and oozed blood Avith considerable freedom. There was no induration surrounding these ulcers which vveie limited to the mucous coat and did not extend to the walls of the viscus. They were each carefully cauterized with the Paqiielin Theiino-Cautery ; the bladdei- flushed with a solution of salicylic acid and borax (I-IOOO), and a large drainiigv tube placed in the wound. There was a good deal of abdoniiiuil tenderness for three or four days after the operation wjiicli I attributed to the fact that the pre-vesical peritoneal fold had been stripi)e(l back for nearly an inch to allow sufficient space for oi)ening the bladder. The urine now flowed away through the drainage tube quite clear and free from blood, and in a cou- ple of days the old pain about the neck of the bladder and the point of the i)enis had entirely disappeared. In ten days the temperature, which had risen after o[)eration to 102"-' F. had settled down to the normal, and the patient began to improve in every way. He could now sleep without opiates; his ;ipi)e- tite improved and he declared himself freer fi'om i)aiii and dis- comfort than he had been for more than a year. The diniiuige tube, was removed thirty-six days a 'Iter oi)eralion, and tlie wound had closed completely three W3eks later. Patient was then allowed up. He could hold his water for an hour, and when passed it was acid, transparent and free From pus and albumen. He was discharged three months after operation in good general health ; free from pain and irritation about the bladder ; greatly increased in weight and able to retain his urine for nearly two hours in day time and somewhat longer at night. Unfortunately the record of this case ends here, as I have been unable to find any trace of the patient since he left the hospital. I have gone very fully into details in reporting this case, as I think it may be considered fairly typical, al- though tubercle bacilli were not found in the urine. In fact the urine was not as carefully and systematically examined in this respect as it should have been. Case II. H. P. age 33, farmer. Had suffered for three years with frequency of micturition and muro-pus in the urine. The symptoms had gradually increased in severity, and for a year b:fore operation patient had occasionally found some blood at Okioinal Commfnication. the end of the stream. For aV)out six months the symptoms had been very urgent. He was obliged to pass water about every half hour, and suffered from incontinence at night. TI»ere was constant pain about the neck of the bladder. The urine was acid, containing a varying quantity of muco-pus, in whicha moderate number of tubercle bacilli were discovered. Patient had never had any venereal disease, and there was no family history of tuberculosis. The lower half of the left testicle and epididymis was occupied by a hard smooth mass (tubercular disease of tlie testicle). The other organs were healthy. On the 9th of Oc- tober the bladder was opened above the pubes, as in the preced- ing case. The appearances were also very similar to those al- ready described, — a contracted bladder with thick walls, deeply congested mucous lining, and superficial ulceration in the trig- one and around the urethral orifice. These were scraped with a Volkmann's spoon and cauterized with the thermocautery. The immediate result exceeded my expectations. The patient re- covered from the anfesthetic with the bladder pain completely relieved. Not a bad symptom followed ; clear acid urine flowed through the drainage tube, which was removed three weeks after operation. Patient returned to his home in the country five weeks after operation in good health and free from bladder irritation, but with a small fistulous opening remaining where the drainage tube had been. On February 9, 1891, patient re- turned to have the testicle removed, as I had advised. In the meantime he had not suffered from bladder symptoms, beyond the discomfort of the urinary fistula which had increased in size. On the 19th of February the testicle was removed and the bladder sinus scraped and packed with iodoform gauze. He remained seven weeks in hospital, during which time he was quite free from bladder irritation. The urine was clear, acid and normal in every respect with the exception of a little ex- cess of mucus. The sinus had nearly closed — only a few drops of urine oozing out at times. For my latest report of the patient I am indebted to Br. T. L. Brown, of Melbourne, who visited him at my request and wrote me as follows on the 9 th of August last (1891): "The supra-pubic wound is not yet entirely healed, but the opening is very minute — about large enough to pass a fine straw through. He has very little difficulty with his urine. It never trickles out of the opening when walking, but does so slightly when he is either sitting or lying down. When tired it will pass involuntarily by the natural channel in small quanti- ties, otherwise it does not bother him. He never suffers pain Jfe->- * *>-.•* Tht Tiialnient of Tiiherculusifi of the Bladder. S unless he retains the urine too long, and even then pain is slight. His general health is much improved, being stronger as well as better in appearance than before the operation. He rests well and has little or no trouble at night. He has a good appetite, and attends to his farm work, doing light work in the haytield, etc. On the whole he is well satisfied with his condition, and thinks that if he could only have the small sinus closed perma- nently he would have little to wish for. The urine is clear and apparently normal." Since writing the above I have received the following report from Mr. Brown, who again visited him at my request. He says : " I saw P yesterday (April 21, 1892). He is still gaining in strength ; is able to do a good day's work, and feels that he has a good lease of life yet. The opening above the pubes has practically closed ; only very occasionally it leaks a little. Ordinarily there is no sign of an opening, and for a long time he considered it completely closed. He is still troubled a little with incontinence, but reports a great improvement in that respect also. His virile powers are as good as ever they were.' ' Case III. A. M. set., 25, carriage maker. Was admitted to the Montreal General Hospital on September 2, 1890. He was a man of regular habits ; had never had venereal disease, and had no tubercular history. He had suffered for five years from frequent and painful micturition, with pus and occasionally small quantities of blood in the urine. Patient is described on admission as "pale and emaciated, but free from fever. Mic- turates every few minutes, and suffers from constant pain about the bladder, and at the point of the penis. Urine is acid and contains muco-pus and albumen. Left testicle is hard, swollen and adherent to the scrotum, through which a couple of sinuses discharge each a drop or two of sero-pus. The swelling of the testicle, which has been very gradual, began about three years ago. Heart and lungs normal." A perineal cystotomy was performed on the 9th September (1890) and a large soft rubber catheter tied into the wound. This operation afforded little or no relief and on September 28d the catheter was removed. On the 1st of October the patient first came under my care. The perineal wound was then nearly closed, and the symptoms and general conditions were about as described in the above extract from the case book. The patient's sufferings were severe and continuous, so that he could not sleep. After a month of obser- vation and local treatment I opened the bladder above the pubes (November 1, 1890) and explored it carefully by the aid of the 6 OuioiNAL Communication. electric lamp. The trigone and a band of about an inch in depth around the urethral orifice were the seat of many super- ficial ulcers, varying in size from that of a split pea to irregular j)atcheM as large as a live cent piece. The mucous nu3ml)rane of the whole fundus of the bladder was also studded with small tuber(!les which had not advanced to the stage of ulceration, nor indeed even to tlie length of showing signs of caseation. Tlie ulcerated patches were scraped and cauterized, but the little non-ulcerated tubercles were loft untouched. They were so numerous that it would have been impossible to deal with each one singly. A large tube was left in the wound and the symp- toms were for the time almost entirely relieved. The patient's general health improved as well as all the symj)toms except that the uiine still (contained i)us. On a