Finally, we must decide whether one or several calculi are present, whether they are free or fixed (see Heath's case in 1871 in a girl 11 ymrs old), or whether they are in a depression (compare Sentin's case page 154), which perhaps leads to a canal communicating with the ovary or a fcetal sac, or whether they are in a diverticulum. We will, therefore, fill the bladder with lukewarm salicylated water, and then atiempt to displace the stone from the vagina or with the catheter. If this is not sufficient, we will dilate the urethra, and examine the stone with finger and sound.
Prognosis.—The smaller and softer the stone, and the earlier its pres ence is recognized, the better the prognosis. Calculi .8 of an inch in diameter are the largest that can pass through the urethra without sub sequent incontinence. Soft calculi are always more favorable, since their size can easily be diminished. Those over 1.2 inch in diameter and not suitable for lithotrity are more serious, since they necessitate vesico vaginal incision. In very young girls the prognosis is less favorable from the smallness of the parts; but in a general way the prognosis of stone in the bladder is far more favorable in women than in men, and has been much improved recently by the introduction of Simon's rational method of urethral dilatation. And in addition, small fragments left in the blad der after operation are far less likely to cause a new formation of stone iu women than in men, since they are much more likely to be passed spon taneously.
Nevertheless, neglected calculi in the female may cause severe suffer ing, exhausting hemorrhages, fistuhe, and death. This is sufficiently proven by numerous cases, among others by those of Fabricius Hildanus, Conradi, Denman, Fox, and Denaux. Cure is often slow, and spontane ous evacuation through a non-dilated urethra may cause incurable incon tinence, as is seen in the cases of Garden, Howship, Nankiwell, Mendel, and many others. The general health may suffer severely from the urinary trouble and the hsematuria. Pregnancy may be interfered with. Walsham found that among 55 girls under fifteen years of age, who had stone, 3 died after operative procedures, and 5'2 were cured; but of these 52, 9 had permanent and 3 temporary incontinence afterwards. Thus 23 per cent. of all were left with an incurable and often fatal trouble. (Comp. pages 107 and 112.) This frequent occurrence of incontinence is to be explained by the use of unsuitable instruments, of dilators such as those of Weiss, which do not dilate evenly, and by the fact that we have only recently learned the limits to which dilatation can be pushed without fear of incontinence. And since we now know how to lessen the calibre of the urethral canal by operation, the prognosis has become much better. But the malady is not an unimportant one, and we should be chary in giving a good prognosis.
In conclusion it is of great interest to note that the vaginal incision for the extraction of foreign bodies from the bladder often closes spontane ow3ly without further treatment. Bouqu6 cites the cases of France (1808), Cli.mot (1817), Cittadini (1826), Bellini (1827), Grillo (1827), Rigal and Blandin (1830), Tommaso (1836), Rossini (1847), Marzuttini (1862), de Luca (1863), Montini (1863), Burci (1866), and Denaux (1872), where this occurred. Such a mord speaks strongly for the vesico vaginal operation.
is but one indication as soon as a c,alculus is recog nized in the bladder, and that is, to remove it as speedily as possible. But the physician should prevent the formation of stone. This is to be done by the careful treatment of hyperremias and vesical catarrhs, by the re position of displacements of the viscus, by remedies directed against kid ney trouble and gall stones, and by frequent washings of the bladder where there has occurred perforation from a neighboring organ. It has been proposed, where decomposition of the urine is occurring, to use carbolized injections, and thus form the carbolate of ammonia. But we know that we cannot expect to accomplish anything by the injection of substances to dissolve the stone, as Millot has proposed to do by means of gastric fluid, or by electrolytic methods.
The following are the methods for the removal of vesical calculi from the female bladder: 1. 'Urethral dilatation, and extraction with forceps. 2. Lithotrity or litholapaxy. 3. Vesico-vaginal incision. 4. Vestibular incision. 5. The lateral incision; and 6, the suprapubic incision.
1. The operation of urethral dilatation in women, for the extraction of stone is, as has been mentioned before, an old one. Benevieni recom mended it in 1502, Marianus Sanctus described it in 1526, Peter Franco in 1561 proposed a special instrument for its accomplishment, and Alpin relates that in 1591 ' an Arabian whom he knew, named Haly, dilated the female urethra by means of tubes of increasing diameter, which were inflated with air. Later Solinger (1698), Douglas, Bertrandini (1769), at tempted to dilate the urethra in the course of 7 to 8 days by means of tents formed of sponge covered with parchtnent. Bromfield used the processus vermiformis of a small animal, which he introduced with a sound, filled with water and tied. Thomas (1815) dilated with compressed sponge, as did Astley Cooper, John Wright, and others. Instrumental dilators were described by Peter Franco ' (in 1666), his instrument being like an aural speculum, while Fabricius Hildanus (1628) has one which is like the old four-leaved specula. Mazzoti (Florence, 1770) proposed a tri cuspid dilator. But all these instruments are long since obsolete. In England, however, there is still much in use an instrument made by l'4eiss of London, after Astley Cooper's model. It consists of two leaves, each like one half of a metallic catheter, and separated from each other by a screw. It is not only useless, but may do injury, thus causing in Brodie's case incontInence, which lasted fourteen days. Rapid dilatation may be done even in children under fifteen years of age. In 7 cases it has been done in children successfully; by Curling, Heath, Hillmann, Gwiune, Davey, Lolly, and Wakley (cf. Walsham); and the incontinence which twice occurred is to be ascribed to improper methods, such as di latation with the finger, or with a pair of forcers. In 15 cases of gradual dilatation there was failure to extract the stone in one only, the child dying of kidney disease; all the others recovered without incontinence. On the other hand, dilatation with incision, or incision alone as practised by the English surgeons, has proved to be dangerous; in 17 cases 7 had sub sequent incontinence. There is no danger of this if Simon's method be carefully carried out.