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48 THE INDIAN MEDICAL GAZETTE.

[Fei. 1904. fiable on account of the shock of an additional wound. The complete closure of the bladder wound without the use of a drainage tube I regard as more likely to lead to sloughing of the prevesical tissues in these cases than when a tube is used. These bladders are usually infected, and a certain amount of contamination of the external wound is inevitable in most cases, hence the necessity of drainage and a partly open wound. Once sloughing begins in these old patients the healing process is apt to be both tardy and treacherous. These weak points in the suprapubic operation appear to commend the perineal route by which many of them are likely to be obviated.

(4) The temporary effect of vasectomy as in Case V is tobe noted. It gave relief for a year. Tn this case the enlargement was of the “glandular” variety, the cases which are said to be relieved by vasectomy. The gland was entirely as large, if not larger, than it was when the patient came to the hospital the first time @ year previously,

(5) The complication of an obstinate diarrhoea occurring in Case III is to be carefully guarded against and promptly treated. The diarrhoea appears to be due to the absorption of urine through the wound in the perineal tissues. I recall having had a patient die as the result of the exhaustion from diarrhea which baffled every attempt to check it. The case was one in which a suprapubic cystotomy had been done for stone, and there was consi- derable sloughing of the wound from escape of urine iu the raw tissues. Granulation tissue forms slowly in these old subjects, and it takes a considerable time before absorption of urine into an open wound js checked; hence the desirability of securing complete drainage of the bladder.

(6) The diagnosis in all the cases was posi- tively made by the history, symptoms and examination per rectum, and by the use of a stone searcher. A cystoscope was not available, and therefore was not used. The distance on the catheter at which urine begins to flow gives a fair idea of the amount of intravesical Projection of the enlarged prostate. In Case II the flow began at twelve inches. The ordinary metal or gum elastic catheter failed to completely empty his bladder. This accounts for the fact that he experienced only partial relief when catheterized in another hospital where a catheter of ordinary length was used. An unusually long catheter with a large curve was necessary to satisfactorily catheterize and wash out his bladder.

(7) An important point in the after-treatment is the getting of these old patients into a sitting posture as soon as possible after the operation.

 

acting as Deputy Sanitary Commissioner, Eastern Bengal Circle, I was deputed to proceed to Puri to supervise the arrangements made for the Rath Jatra festival and suggest other precautions necessary to prevent the spread of cholera.

In Puri town and district and throughout Orissa, cholera shows itself year after year regularly over a defined area, and from this “infected focus” the disease invades the same bazaars and villages, leaving the greater part of the district: untouched.

The usual course of the disease is intimately connected with the pilgrimages.

In Orissa, cholera is more or less endemic from January to August, during which period there are four pilgrimages, viz., in March the Dol-Jatra, in April the Baisack, in June the Snan-Jatra, and in July the most important of all, the Rath-Jatra.

Previous to the opening of the railway to Puri, cholera abounded along the pilgrim route, especially on the Cuttack-Puri road and adjoining country ; the outbreaks were always worst at the period when the pilgrims were passing in the greatest numbers to and from the shrine of Juggernath.

Since the opening of the railway on the 1st February, 1897, it is computed that only about one-tenth of the pilgrims now travel by road; and as the remainder travel by rail, the danger of epidemic cholera being widely disseminated over India from its home in Orissa during the time the pilgrims are returning from the Puri fairs has enormously increased.

The Sanitary Commissioner's Return of the relative intensity of cholera in each district shows that Puri cholera frequently becomes epidemic, and that when the mortality there is high it is also high in Cuttack, Balasore and Howrah, all traced to importation by pilgrims from Puri.

In 1901 the Puri district was placed first with the high death-rate of 9.20 per 1,000 of population, an increase of 5.44 as compared with the average of the previous ten years.

In 1902 isolated cases occurred for weeks previous to the great festival, both in Puri town and district, but some pilgrims were attacked on the way from their homes to the railway station, others on the railway, and from the 2nd to the 7th July in all some 12 cases were removed from the train, most of them in a moribund condition.

This indicates one of the ways in which the disease becomes disseminated, as not; only, are 