Seven of the 23 cases did have spontaneous delivery; but some of them were badly injured in the process.
1. Guillemeau. Reposition of the stone, which fell back again; contu sion of the bladder-wall and perforation. 2. Smellie; the head drove the goose-egg sized stone down before it, and both were delivered. Conse quence, incurable incontinence. 3. Lowdell extracted a stone Which had caused a vesico-vaginal fistula during delivery. Baker Brown found a vesico-vaginal fistula caused by a stone, extracted one 2 inches long, 1 inch broad and 3i inches in circumference through the dilated uretha, and cured the fistula afterwards. 5. Henry Jackson removed by urethral incision a round stone 44 inches in circumference, which was impacted in the urethra, and prevented delivery. 6. Cohn was about to do a Cesarean section on account of pelvic exostosis, when the woman was suddenly confined spontaneously, and a day later spontaneously passed a calculus inches in length, I inch broad, and inch thick. 7. L. Bourgeois extracted a stone from the bladder of a woman who had been naturally confined 3 months before.
Eight times obstetric operations were rendered necessary, because of calculi, in the cases of Willoughby, Arnaud (extraction with the liand), P. Dubois, Richard, Nsegeli (forceps), and Erichsen (perforation).
Operations for stone were done 8 times during labor, by La Gouche, Levret (extraction), Denman, Monod (vesico-vaginal incision). Monod has twice done the vesico-vaginal incision in pregnant women, in 1849 in a primipara forty years old, and in 1857 in a primipara twenty-four years old. In the latter case reposition did not succeed, and delivery was ac- . complished with the forceps after the stone had been removed. The fistula healed spontaneously in 20 days.
The successful reposition of a stone inter partum, has occurred but once, and by P. bubois.
We may add here a case of Sainclair's in which a gravid woman with large vesical calculus and suffering from pain, fever, incontinence and. cystitis, had a premature delivery. Three months later she spontaneously expelled a stone of mixed phosphates, oxalates, and urates 2.8 inches long, 1.2 thick, and 1.6 broad. The calculus passed out through a large vesico vaginal fistula, which was cured later.
Thus there have been recorded until now 29 cases of vesical calculi in pregnant women, and in all there has been a more or less serious inter ference with the reproductive process.
Diagnosi 8. —One would not think that it would be difficult with the vaginal touch and the vesical catheter to recognize the existence of a calculus in a female. Yet mistakes have occurred from forgetfulness to thoroughly examine the bladder. The unusual body which was felt has been taken for a pelvic exostosis (cases of Sainclair and of Cohn), or for an ovarian tumor if it is situated to one side (Threlfall's case), or as a tumor springing from the symphysis (case of P. Dubois). Besides, echinococci have been found located between bladder and uterus (case of Birnbaum), which might be another source of error. If we feel per vaginam a tumor through the anterior vaginal wall, we should never omit to pass a metallic catheter, and, fixing the stone from the vagina, en deavor to get the peculiar sound and feeling of a calculus. William Donald Napier has given us a sound which gives us ocular demonstration of the presence of calquli; it is described on page 21. Before introducing it we must examine the point with a magnifying glass, to make sure that there are no marks upon it. If there still remains doubt, urethral dila tation and direct palpation of the internal surface of the bladder will almost always give us a certainty. At the same time we can recognize the seat, size, and surface of the stone, though this c,an be done fairly well from the vagina. In every respect the diagnosis is easier than it is in the male. Sometimes the first symptom which leads us to examine for stone, is the passage of one or more concretions spontaneously. In a cystocele we may be able to feel the stones in the tumor, which is visi ble between the labia minors. (Normen's case.) If after a successful operation for vesico-vaginal fistula, there set in symptoms of vesical catarrh, or luematuria, or dysuria, we may suspect that fragments of sutures or vesical pockets have caused the formation of a stone, and we must carefully examine the bladder with catheter and finger.