It is, as will be seen, a long, catheter-like rubber tube, with a bulb located at about the middle of it. The segment of the tube marked A in the illustration communicates with the interior of the bulb. The segment of the tube marked B does not communicate with the bulb, but has lateral openings for drainage three or four in number,

B

G

A

Illustration No. 3

Combined Syphonage and Irrigation Tube close to its junction with the bag. The free end of the tube A is slipped over the end of the irrigating catheter still in the bladder, and with it as a guide the hemostatic tube is drawn down into the bladder, on into the prostatic wound and again on into and through the urethra until it emerges at the meatus. Further traction upon it draws the bulb down through the suprapubic wound into the bladder and finally into the cavity from which the prostate has been enucleated. Now, with a good piston syringe, force water into tube A until, with the forefinger, the bulb can be felt dilated sufficiently to

fill the prostatic cavity. Couple the irrigating nozzle onto segment B and let the water run. If, after a few moments, the return flow is clear, it shows that the pressure of the hemostatic bag is adequate. If, on the contrary, there is still a positively bloody tinge to the return flow, force a little more water in through A and apply the same irrigation test. When all is right double over the end of A, tie with a silk ligature and strap firmly to the B patient's thigh in a way so there will be a moderate tension upon it, sufficient to hold the hemostatic bag in place.* Apply temporarily a posterior knee splint.

The end B protrudes from the abdominal wound, and is to serve for syphon drainage as will be described hereafter. The sutures adjusted near each angle of the abdominal. wound are now tied. The usual dressings are adjusted, the tube B protruding laterally through the binder, and the patient is removed to his bed where, previously the syphon drainage apparatus, set forth in Ill. No. 5 has been arranged. It consists of a syphon pump C actuated by a column (Illustration 6) of water from the jar D. The tube B coming from the wound is coupled on to the pump at E. Water from the jar D is controlled by a stopcock at F. Now turn on the water and all urine is lifted out of the bladder as fast as it accumulates, and deposited in a jar under the bed..

This syphon drainage apparatus is kept going through the first week or ten days of the patient's convalescence, or until time enough has elapsed to ensure that granulation has become established in both the prostatic and abdominal wounds. One change only is made. At the end of four hours the hemostatic tube is removed, and a combined irrigation and syphon drainage tube, such as is figured in Ill. No. 3, is substituted for it. This tube is like a double length rubber catheter with a stop at G and lateral openings, four in number each side of the stop.

The change is made by first drawing off the water which distends

This idea of applying temporary pressure to the prostatic wound to control bleeding and maintaining the same by a cord passing out through the urethra, originated as far as the writer knows, with Sir William Thompson, (British Medical Journal, April 1903.) His device consisted of a rubber disk held in place by a silk cord. This was found impractical in the writer's experience because the silk cord cut and irritated the urethra beyond toleration. For this was successfully substituted a smooth rubber tube as large as the urethra would easily take. To Dr. J. Emmons Briggs belongs the priority of adding thereto a rubber bulb or bladder (New England Medical Gazette, April, 1906) which is a distinct improvement over any device heretofore used.

the hemostatic bulb-deflate it. Now couple one end of the combined irrigation and syphonage tube onto the end A of the hemostatic tube. With this as a guide, pull gently on tube B which emerges from the abdominal wound. This, if rightly manipulated, finally draws the collapsed bulb out through the abdominal wound and the new tube in place, which should be so that one end protrudes from the abdominal wound, the other from the penis, and the stop G is at or about opposite the prostatic wound. Couple the abdominal end of this tube onto the pump as before. Couple the penile end of the

tube on to the tube of an irrigation bag adjusted at the foot of the bed as at H in illustration No. 6. Use a warm irrigating fluid of boracic acid or any other mild antiseptic and with a stop cock control at I, adjust the inflow so that it will go at the rate of about forty drops a minute. The syphon will take care of all this inflow, and all the pus and discharge and urine which becomes mixed with it in the bladder.

You will ask, "Does all this trouble of care, of assembly of apparatus and of accuracy of adjustment pay?" I will only answer, anything pays which saves a human life, anything pays which makes a patient's convalescence more comfortable.

A constant irrigation of the bladder is the most positive assurance of cleanliness and an approximately aseptic convalescence. Syphon drainage through the abdominal wound ensures to the patient comparative dryness of his person during convalescence in place of the constant and offensive wetness without it.

It is a great saving of dressing material and of attention on the part of the nurse.

Scarcely a perceptible foul odor is noticeable even about the worst cases of cystitis.

Patients still in good bodily vigor at the time of the operation will get well without any of this elaborate after-treatment, but nevertheless their convalescence is made very much more comfortable with it.

Aged and feeble patients bear the vicissitudes of sepsis poorly. With this method of after-treatment there is no sepsis and no sloughing of the tissues of the wound.

If the patient die, he dies neither from loss of blood nor sepsis. An advantage of the long through and through tube is that it is self-retaining. A catheter fastened in the urethra by any of the commonly used methods is a source of discomfort to the patient, and has not a few times, produced much irritation and discomfort for my cases. Whatever retaining device is used quickly becomes

soiled and offensive.

After the lapse of ten days if everything has gone well and the external wound shows healthy granulation, irrigation and syphonage is dispensed with, the long tube is withdrawn, but in withdrawing it is used as a guide to introduce an ordinary soft catheter, into the tip of which a Pagenstecher thread has been tied. The catheter is conducted down through the abdominal wound into the bladder, and on through the urethra until it is properly adjusted. The thread now hangs out of the abdominal wound and is tied over a cross-bar anchor of soft rubber tubing. This catheter is thus held in place by the anchor thread and serves for periodical irrigation for another week.

After the fourth day the patient is encouraged to sit up in bed daily, and after the continuous irrigation and syphonage is dispensed with he sits out of bed daily.

Diet is an important consideration in these cases.

The inclina

tion is, I think, to push it too much. In these aged patients the daily waste is small, and the digestive system is often delicate. If food be forced upon the patient too frequently or in too great quantity annoying gastric disturbances are likely to arise.

Milk, therefore, is my chief reliance, and is the unvarying diet unless some idiosyncrasy of the individual contra-indicates it. If ordinary milk disagrees, some modification of it is resorted to with the view of meeting the patient's requirements. To some patients the addition of a small quantity of milk sugar makes it palatable and grateful. To others, a little sodium chloride gives zest and seems to aid in its digestion. Variation of the proteid and carbohydrate elements of the milk are also often advisable. One patient will do better on milk containing a high percentage of fat, while another will

need to have it reduced. An increased proportion of proteids and carbohydrates may be added, and in a way usually grateful to the patient, by making a paste from well-cooked barley, oat-meal, wheat or rice, and stirring it into raw milk. Cooked milk or any invalid food made with cooked milk as a base is an abomination. It has been well demonstrated that cooked milk loses some vital quality and is no longer a substance which will sustain life indefinitely. Therefore, milk fed to these aged and feeble patients should be raw milk unchanged by heat. It may be gently warmed, if more grateful to the patient, but never scalded or boiled.

Medical Treatment, Stimulants and Tonics. Conditions calling for medical treatment are various, but scarcely ever relate immediately to the parts operated on. Sometimes it is faulty heart's action calling for digitalis, glonoin, arsenicum iodid, cactus, strophanthus, or spigelia. Sometimes sleeplessness, for which coffea, gelsemium, conium, belladonna, or aconite is administered. Sometimes there is extreme nervousness and apprehension, which can usually be allayed by ignatia, moschus, nux moschata, agaricus, sulphuric acid or cicuta virosa. Opium is not used except in the first few hours after the operation, to alleviate the immediate pain of operation and traumatism.

Stimulants are used very cautiously and only in cases in which marked depression of vitality exhibits itself, or the patient has the habit established prior to the operation.

If a tonic seem called for the following combination is given three or four times daily:

Claret, 2 ounces.

Aqua bul., 2 ounces.

Saccharum lactis, 2 ounces.

Boil five minutes, to evaporate the excess of alcohol, and adminster hot.

ÆTIOLOGICAL FACTORS OF ACUTE ARTICULAR
RHUEMATISM.*

BY EGBERT GUERNSEY RANKIN, M.A., M.D., PROFESSOR OF THEORY AND PRACTICE OF MEDICINE NEW YORK HOMŒOPATHIC MEDICAL COLLEGE, VISITING PHYSICIAN TO THE METROPOLITAN HOSPITAL DEPARTMENT OF PUBLIC

CHARITIES, AND TO THE FLOWER HOSPITAL NEW YORK.

The wide-spread prevalence of acute articular rheumatism, its frequent occurence and ultimate course, have so long been recognized that it is superfluous to dwell upon these features at any length; but in regard to its ætiology, that most essential feature in the study of diseases, we have been, as it were, long groping in the dark, a darkness through which the light of bacteriology is now shining.

While not a frequent direct cause of death, as only about two per

*Read before the Bureau of Clinical Medicine and Pathology, International Homocpathic Congress, Sept. 13, 1906.