Two objections to this method occur to us: (1) Whoever has performed or witnessed supra-pubic cystotomy, either for the purposes of removal of a calculus or a neoplasm from the interior of the bladder, must have been struck by the difficulties in the way of a thorough appreciation of the condition of its posterior wall low down, or of the cystic neck. Unless specially devised instruments are available for each particular form of prostatic enlargement, it would seem to be a matter of great uncertainty as to just how much of the growth is removed. (2) Until satisfactory granulation of the wound surfaces has been accomplished, drainage, to be efficient, must be facilitated by placing the patient upon one or the other side, a position difficult to maintain, particularly in old people.
RESEARCHES UPON THE VAGINAL PROCESS OF THE PERITONEUM AS A PREDISPOSING CAUSE OF TENDENCY TO EXTERNAL INGUINAL HERNIA.
H. Sachs (Archiv. f. Klinisch. Chirurgie, Band xxxv., p. 321–372) advocates quite decidedly the view, basing his opinions upon preparations of the spermatic cord examined and upon microscopic examinations of cross sections of the latter, particularly as to the relations of the vas deferens and the vessels to the vaginal process of the peritoneum, that the latter is formed before the beginning of the descent of the testicle rather than as a portion of the abdominal wall formed or dragged into position by the testicle in its descent. In proof, he alleges that he has always found, in cases of incomplete descent of the testicle, that organ upon the posterior wall of the vaginal process, and not on the floor of the same. In females, the formation of the canal of Nuck cannot be said to be due to any dragging.
The entrance to the opening of the vaginal process is found covered by a valve arrangement, and the same is particularly noticeable in the canal of Nuck. The opening of the vaginal process can be caused to gape through a spreading out of the mesentery attached to the ilium or that of the sigmoid flexure. The diameter of the opening is, in general, greater on the right side than on the left in boys, while in girls this difference is not observed. Further, the different forms of the incompletely obliterated opening of the vaginal process agrees with the most frequently occurring forms of the hernial sac in inguinal hernia. The relations of the vaginal process to the elementary parts of the spermatic cord are not constant. On the contrary, the relations which the smooth muscular structures of the cord bear to the vaginal process, in so far as their arrangement into bundles, and their positive relation to the posterior and lateral walls of the same are concerned, are quite constant, and almost form an integral part of the same. The obliteration of the vaginal process depends upon a granulating process, which begins in the middle third of the funnicular portion, and from thence proceeds more rapidly in a downward than in an upward direction. This granulation formation takes place essentially during the first ten to twenty days after birth; after this time it takes place more slowly. The canal of Nuck, on the contrary, is found to have almost entirely disappeared at the time of birth. They are both found to be more frequently open upon the right side.
From these observations it would appear that it is not essential to the production of inguinal hernia that a broad and short inguinal canal should be present. The only essential predisposing cause, in children at least, depends upon the condition of the vaginal process of the peritoneum itself.
The question of the legal responsibility of employers is an interesting one, in connection with this question. Hernia cannot be considered as an accident, in the surgical sense, according to Socin (Korrespondenzblatt f. Schweizer Aertze, 1887, No. 18), but is really a slowly occurring disease, to which certain well-defined anatomical peculiarities act as predisposing causes.
ACID SUBLIMATE SOLUTION IN SURGERY.
E. Laplace (Deutsche Med. Wochenschrift, No. 40, 1887), after repeated and careful examinations and experiments, became convinced that dressing materials consisting of wood-wool, made with sublimate in the usual manner, were far from being germless themselves, much less efficient as antiseptic applications. Gauze, however, showed much better results, but were far from realizing an idealistic asepsis. He likewise found that ordinary sublimate, in the presence of albuminous material, is quickly precipitated and becomes at once ineffective. L. experimented at first with hydrochloric acid as a means of preventing changes in the sublimate from occurring in the presence of organic matter, and particularly albuminous material. But, as hydrochloric acid itself was far from possessing the stability needful for the purpose of preparing dressings, he substituted for it, with the most gratifying results, tartaric acid. The proportions are as follows: sublimate, 1 part; tartaric acid, 5 parts; distilled water, 1,000 parts.
OPERATIVE TREATMENT OF PYOTHORAX.
E. Rochelt (Wiener med. Presse, No. 32 and 38, 1887). The expansion of the lung is greatly impeded after the usual operation for empyema by incision, by the free entrance of air in the pleural cavity. Mader, Subbolik and Immerman devised means for preventing this. R. operates by first resecting a rib, leaving the periosteum intact, and subsequently opening the pleural cavity by means of a trocar and canula. A drainage tube accurately filling the latter is now introduced, through which a disinfecting fluid is injected and its outer opening closed by means of a spring clamp. The tube is connected to an aspirating bottle, into which the pus is discharged. The tube is again clamped, and the bottle into which the pus has been aspirated removed, being replaced by another containing a sublimate solution, 1 to 500. Removal of the clamp and raising and lowering the bottle thoroughly irrigates the pleural cavity. This being accomplished, the patient holding his breath in expiration, and the clamp again applied, the irrigating bottle is removed, and a short hard rubber tube connected to the outer end of the drainage tube. This hard rubber tube has a soft rubber diaphragm which acts as a check valve, effectually preventing the ingress of air during inspiration, but in no wise interfering with the egress of fluid from the pleural cavity during expiration, fits of coughing, etc. For purposes of further irrigation the short rubber tube containing the valve may be removed after guarding against the entrance of air by clamping the drainage tube beyond, and the washing bottle reapplied. During the intervals of irrigation, absorbent antiseptic dressing are kept applied.