A gradual entry of foreign bodies from the vagina, as occurs from the perforation of pessaries, we have already considered under vesico-vaginal fib-tula, (page 10 L.) As to the symptoms of these vesical ingesta, they may be said to be fre quent urination, ha3maturia, and strangury. Gradually the foreign bodies become encrusted with salts, and cause vesical catarrh, ulcerations, and perforation of the bladder-wall. Occasionally, if they are not too large and are not impacted in the wall of the viscus, they may be sponta neously evacuated; this occurred 31 times in DenucA's 440 cases. If the vesico-vaginal wall is pierced, the foreign body, if not too much encrusted with salts, may pass off per vaginam, often leaving behind a large vesico vaginal fistula. If the foreign body is not removed it may exhaust the patient by reason of the pain it causes, and the vesical catarrh it sets up; and abscess, phlebitis, gangrene of the bladder-wall and death of the patient may occur.
The treatment of this class of cases has been much simplified since we have learned the distensibility of the female urethra. Besides Simon's specula and forceps, we need only a pair of toothed forceps. As soon as we have recognized with the metallic catheter the existence of a foreign body in the bladder, we antesthetize the patient, dilate the urethra accord ing to rule, find the foreign body with the finger and fix its lower end, and, passing a pair of forceps in alongside, seize and extract it. In Octo ber, 1881, I extracted in a few minutes in this way the ivory handle (2.8 inches long) of a crochet needle. Complicated apparatuses, like those of Biauchetti, are no longer necessary; we can introduce in a very short time instruments .8 inch in diameter, while his tubes are only 3 to 4 lines across. If there is any difficulty in getting the end of the object which the forceps has seized into the urethra, a finger in the vagina will assist in turning its long axis parallel to that of the canal. Or the largest sized speculum may be pressed against the body, which is seized by the forceps paased through the speculum, and the forceps gradually worked to the lower end of the foreig-n body. If the body in the bladder is difficult to seize, it is often useful to fill it with lukewarm salicylated water and then extract If the object is barbed, like a crochet needle, Denuc6 recommends forcing it through into the vagina; the resulting fistula soon heals spon taneously. If the foreign body is impacted in the vesical walls, or is very large, we may endeavor to dislodge it or diminish its size with Hourteloup's Civiale's lithotrite. Thus, Henry Smith had to break a bone nail cleaner into pieces in this way before he could get it out. If the body haa pierced the vesietil wall, and if the portion in the bladder has become so encrusted with salts that it cannot be withdrawn through the original opening, we must enlarge it with a blunt-pointed bistoury, as Jobert de Lambslle had to do with a lead pencil and Mytterhoeven with a pessary% If extraction is not possible in this manner, cystotomy is indicated.
Nevertheless we must not too readily have recourse to it; it is more dan gerous than the former plan, which has often succeeded after days and weeks. 1Vhere cystotomy is really necessary, it should be done in adu:ts by vesico-vaginal incision (see page 15) whenever it is possible; in very young girls it will be necessary to do the suprapubic operation. The prognosis of the two operations is very different. According to Denuce in 34 cystotomies done in females for the extraction of foreign bodies, 22 were done by the vaginal method, and 12 by suprapubic incision; of the former 15 or 70 per cent. got well, of the latter 2 or hardly 17 per cent. The after-treatment is that described for vesico-vaginal fistula, pages 114 and 134.) 3. resical Calculus in Women.—Podrazky has thoroughly discussed the subject of lithiasis in the 3d volume of this work, and we will simply recapitulate briefly what he has said, adding whatever has been done in the 13 years since his monograph was written.
Etiology.—Vesical calculi are formed upon all bodies that reach the bladder cavity from without, or from within the body-, or upon promi nences of the vesicular wall (comp. page 167), or finally they arise from the spontaneous precipitation of the urinary salts. They may occur at any age. but are found most frequently in childhood. They are mnch less common in the female than in the male, from the shortness of their urethra and the consequent rarity of stricture and facility for the cure of vesical catarrh. Dr. Klein found in the Moscow city hospital from 1822 to 1860, among 1792 cases of vesical calculi, only 4 occurring in females. The lithotomist of Upper Swabia, Michael Lett, in his practice of 57 years, did 106 lithotomies in men, and only one in a woman. I have ex amined about 10,000 women and girls in Berlin, Rostock, Dresden and Munich from 1860 to 1884, and, save in the case already recorded under No. 15, I have only once found a calculus, and this was small and easily extracted per urethram. Among the 3500 autopsies done upon women at the Dresden city hospital, stone in the bladder WWI found 6 time& Walter Coulson calculates that for 100 cases in males there occur 5 in females. Even in childhood there is a marked difference between the sexes. Giralch*Js says that vesical e,alculus occurs 24 times more frequently in boys than in girls.