In conclusion, I hope that every member of this Society, who attends pregnant women, will consider thoughtfully the suggestions of this paper; and if, in the slightest degree, the practice of obstetrics shall be made more successful, the object of the writer will have been attained.

[2005 Victor Street]

Report of a Case of Irritable Urinary
Bladder Relieved by Rapid
Dilatation of Urethra.1

history and fortify patients against probable or possible Catheterization had always to be preceded by injections difficulties. The patients, too, seem pleased to receive of oleate of cocaine into urethra, but even that seemed such extra professional attention, and willingly pay a to have but slight effect in quieting the pain. The sogood round fee for the same. called "tripod of treatment"-rest, opium, alkalies, was tried faithfully. Various local applications were equally ineffectual. The patient could obtain only comparative ease from the constant influence of morphia. When this was discontinued the trouble again returned. Urethral suppositories containing chloral hydrate, bis. muth subnitrate and morphia sulphate were used with some apparent benefit for a time, but soon lost their soothing effect. The patient was losing ground rapidly from the constant strain, and it was evident that some. thing must be done, and that quickly, to afford relief. Two courses of treatment suggested themselves—one, to buttonhole the bladder, thus giving the tender urethra time to heal; the other, to dilate the urethra forcibly, under anesthesia, thus overcoming the spasmodic action of the vesical sphincter. The former course was strongly Widow, aged 54 years; occupation, school-teacher; objected to by the patient, and to my mind also prefamily history, negative; previous history, during child sented no encouraging outlook. A vesical fistula as we hood, good health. Menstruation, normal. No disturb all know, is not an easy matter to close when it becomes ance at menopause. After a forceps delivery some necessary, and a permanent fistula is by no means a twenty-five years ago, suffered from urinary retention pleasant memento of surgical skill to leave with a paand cystitis. This cystitis persisted for about three tient. On the other hand, the possibility of a permamonths. At the time of her delivery she suffered from nent incontinence, in case the urethra should be dilated hemorrhoids which were removed by ligature the same too forcibly, presented itself. After careful considerayear. Subsequent health good, until a comparatively tion, the latter method was chosen. recent period. During last few years has suffered from recurring attacks of appendicitis.

BY M. GEORGE GORIN, M.D., sг. LOUIS.

Present trouble began during the summer of 1897, when she complained of spasmodic dysuria and frequent micturition. This trouble was not sufficiently severe as to cause her to seek relief from her physician, but was considerably aggravated when she resumed her work in the fall. During the month of October she was seized with an attack of appendicitis, which was treated palli atively and patient recovered sufficiently to resume her

duties at school after a month's time.

The patient was anesthetized and Kelly's conical cali. brator introduced into the urethra to the full extent. This stretched the meatus to the diameter of 19 milli.

meters. The calibrator having been removed, sizes 9, 10, 11 and 12 of the cylindrical urethral dilators were successively introduced, and lastly the forefinger, care being taken to thoroughly overcome the action of the vesical sphincter. A small roll of iodoform gauze

anointed with carbolized vaseline was then introduced

well into the channel, and allowed to remain there for eight hours

The

During a subsequent attack of appendicitis, in DecemAt the end of this time the gauze was removed. Be ber, dysuria became so pronounced and painful as to re. yond a feeling of soreness, patient experienced no pain. sult in complete retention. Attempts at micturition Patient could sleep spasms had entirely ceased. were attended with agonizing spasms, which were with most of the night, which she had been unable to do for great difficulty subdued, or even palliated to any degree. several weeks previous. There was, however, almost Catheterization was extremely painful. On examination, complete incontinence, and I felt no little anxiety as to a sessile vascular growth was found at entrance of the ultimate result. Nevertheless, by degrees the bladurethra, and extending well back into the channel. On der began to regain its normal tone, and within a week consultation with Dr. Tuholske, it was decided to re- after dilatation, involuntary passages of urine had move this growth with curette and cautery. Patient almost ceased. Occasionally, when the patient would was anesthetized, the growth curetted, and base cauter be sleeping, involuntary evacuation of the bladder would occur. Within two weeks she could retain urine ized with chromic acid (40 grains to the drachm). This afforded great relief for about a week, when, after sep for three hours at a time and pain on urination had enaration of the eschar, micturition again became painful tirely ceased. and vesical spasms returned. The sufferings of the pa tient were most intense. The usual remedies for relief of the condition were tried, with little or no benefit.

1Read before the Medical Society of City Hospital Alumni, Thursday Evening, December 15. 1898.

Eight months have elapsed since the operation and none of the distressing bladder symptoms has returned.

The method of rapid dilatation of the female urethra for relief of irritable bladder is by no means a recently discovered one, but I believe has been resorted to more generally by English surgeons than by Americans. Sir

James Simpson, shortly before his death, suggested to Urinary Calculi.- With Report of Two Lawson Tait the advisability of creating vesico-vaginal Cases, and Presentation of Specimens.1 fistulæ in this class of cases in order to give rest and drainage. In 1884, T. Prigdon Teale, of London, discovered in a purely accidental manner, the efficacy of rapid dilatation of the urethra in producing the same results. From an exploratory dilatation, to his very great surprise, an obstinate cystitis of several years' duration was completely and permanently relieved. During the next two years he treated successfully more Urinary calculi are formed in the kidneys and blad. than thirty cases in the same manner. Heath and der by the aggregation and consolidation of certain Hewetson also, shortly afterwards, reported several constituents of the urine which, under normal conditions, cases treated with good results in the same manner. the kidneys eliminate and the bladder finally expels. Skene, in his recent work, refers to the record of the English surgeons in this line, but does not mention the operation.

tion, stopping the flow of urine, and bringing about the been suspected and constant vigilance had been observed destruction of the kidney itself.

to detect either it or sandy particles in the urine. But, A large proportion of cases of bladder-stone will be failing in this, and considering the apparent relief found to have had their origin in the kidney. The pas- afforded by quinine, and also the fact that some years sage of the stone thence to the bladder is usually marked previously he had had a severe attack of malarial fever, by an attack of renal colic, and the patient will proba it was concluded that his hematuria and pain were due bly give a graphic description of a terrible attack of to the same trouble. While on a pleasure trip down the pain which occurred weeks or months previously, and St. Lawrence River in the summer of 1896, patient had which was followed by freedom from suffering until another attack of hematuria, with slight and poorly de the bladder began to give trouble. Chronic cystitis fined renal colic. This caused him to visit White Sulshould excite suspicion of stone, for it may be either the phur Springs where he spent several weeks. During result or the cause of a calculus. The irritation set up his stay there hematuria and pain were in less evidence, by a stone invariably produces cystitis. The existence and regardless of the fact that no fever accompanied of cystitis, on the other hand, is attended with copious these phenomena, his physician there concurred with secretion of mucus or muco pus, affording the colloid him in the opinion that they were also of malarial ori material which binds together the particles that form gin. Soon after returning home the severity and frethe nucleus of a stone. Enlargement of the prostate is quency of the attacks of colic and hematuria increased, another powerful predisposing cause, owing to the and patient consulted me early in October with refer. changes which take place in the urine and in the bladence to his case. The hemorrhages occurred with more der as a result of obstruction to the flow of urine and or less periodicity, appearing about once in four or five the consequence of that obstruction, viz., atony and re days and usually between the hours of 1 and 6 o'clock tention. For similar reasons inflammation or catarrh of in the morning. The quantity of blood varied greatly but any part of the urinary tract is a predisposing cause of was continuously visible from twelve to thirty-six hours stone. The lithemic subject, and persons who have after each attack, following which there was usually an been suffering from gout and rheumatism, are particu. interval of comparatively clear urine. Pain always pre larly liable to urinary calculus, and a history of either ceded and accompanied the hematuria and varied in inof these diseases should arouse our suspicion and receive tensity from a dull ache to sharp shooting paroxysms due consideration. through the ilio-lumbar region, extending into the scro

As regards age, childhood and advanced life afford tum and down the thigh. The colic was confined to the the largest number of cases.

Children suffer from uric acid, old men from phosphatic calculi. The over-indulgent youthful and middle-aged subjects are the most frequent sufferers from oxalatic stones. Females, on account of the shortness of the urethra, and the freedom from causes of obstruction, rarely suffer from stone in the bladder, and are sufferers in only about 5 per cent of all cases of urinary calculi.

CASE I.-A. G. C., American, aged 51 years, lawyer, married; no hereditary history; habits luxurious-a high liver.

During childhood, in connection with an attack of scarlatina, he had some involvement of the kidneys, and twenty years ago he had a slight attack of hematuria, which lasted only a few days.

Ten years ago he was awakened one morning by se vere pain in the renal region. It lasted about two hours and suddenly abated, returning again the next day, and after three hours again subsided. These attacks were accompanied by hematuria. Another, similar attack, occurred six years ago, which, after a week's duration, culminated in a severe renal colic, relieved only by hypodermatics of morphine. A few weeks later the hematuria rapidly increased to an alarming extent, the urine becoming thick and almost pasty with blood. As it was accompanied with a chill and fever, the physician in attendance at that time gave him quinine, 25 grains daily, shortly after which both fever and hematuria sub sided. For some time before that renal calculus had

left side and the more severe attacks were frequently accompanied by rigors and cold sweating. Fever was never present. Repeated urinalysis revealed the constant presence of blood in varying quantities, and a relatively large number of calcium oxalate crystals which showed a tendency to cluster. Urine was otherwise normal, but was passed frequently and in small quantities.

I placed the patient on anti lithemic remedies-lithia waters, etc., and a rigid diet, with sufficient quantity of morphia to relieve the pain at night.

After a short period of such treatment a mulberry oxalate calculus the size of a large grape seed was passed per urethram. Immediately preceding the pass. age of the stone patient had a severe attack of colic and hematuria, both of which terminated abrubtly. Since then, with the exception of times when he oversteps the bounds of moderation in diet, increasing his lithemic state and bringing on oxaluric crystals with urinary irritability and other symptoms of a similar kind, he has been well and free from hematuria and pain.

On several occasions during the last two years it has been clearly demonstrated in this case that the patient's diet has a great influence upon his urinary symptoms and general health. My experience with his and similar cases give me positive assurance that the lithemic state is often the cause, not only of renal calculus, but of irritability or even inflammatory changes in the genito urinary tract.

CASE II.-A. B. K., aged 42 years, American, sleep

ing car conductor; family history good, both parents the wound was kept anointed with unguentine to prebeing still alive, healthy and active. Patient had measles vent scarification and the dressings were renewed whenand scarlatina in childhood and gonorrhea once in early ever saturated. manhood. For the last twenty years or more he has been Patient's convalescence was perfect, the drainage tube rather a high liver and an excessive drinker, going on being removed on the thirteenth day and the wound closfrequent periodical debauches. Seven years ago he was ing to vessical drainage on the nineteenth day after optreated for a week or so for, what his physician termed, eration. Patient was discharged from the hospital on irritability of the bladder. During that time micturition the twenty-sixth day, the wound being completely was frequent and the qaantity of urine small. The flow of urine was occasionally completely shut off during urination as from the sudden closure of the urethra. Otherwise his health has been excellent. Patient con sulted me in December, 1897, complaining of irritability of his bladder, stating that his suffering was much aggravated by the motion of his car, and that he was compelled to get up once or twice at night to void small quantities of urine. The character of his pain was that of a dull aching sensation about the neck of his bladder and at the "fossa navicularis" of the urethra with more or less frequent sharp shooting pains terminating at the latter point. These pains were always increased by physical activity and vesical tenesmus was quite marked

at the end of micturition.

closed with exception of the cutaneous covering about the size of a ten cent piece. The seven days following sufficed to complete the skin closure and patient was discharged as well and resumed his former occupation. His urine, after the operation and final irrigations of the bladder, which were continued daily through the drainage tube until its removal, was completely free of pus and mucus, 'and at the time of his discharge from the hospital urinalysis showed it to be normal both in quantity and constituency. No pain or tenesmus has been in evidence since the day of the operation and patient is, to all appearances, in perfect health.

The calculus is of the ammonio-magnesian phosphate and phosphate of lime variety with a probable uric acid nucleus. Its shape is almost precisely that of a porcelain door knob, measures 15 5 cm. in its greatest circumference, and weighs 78 grms.

Judging from the history of this case and the large size of the stone, it is evident that the patient carried it in his bladder for at least six or seven years prior to its removal. When patient consulted me he had suffered absolutely none from his trouble up to the five or six weeks immediately preceding, except for the few weeks seven years previously already mentioned.

Urinalysis revealed a neutral reaction, 1/10 of 1 per cent of albumen, a considerable quantity of pus, blood cells, bladder epithelium and mucus. Pure blood in small quantities was occasionally observed immediately after urination. Urine in other respects showed no va riation from the normal. A No. 30 F. sound was easily admitted by the urethra, although it, as well as a No. 16 soft catheter, met with considerable resistance at the prostate. Their passage through the prostatic urethra occasioned considerable pain and tenesmus which lasted for only a few seconds, the latter of which explains the ap parent obstruction. Urine stream was of normal size and conformation, and palpation of the prostate per rectum revealed no hypertrophy. On introducing Andrews' searcher, a stone, evidently of considerable size, was felt lying in its nest at the base of the bladder. It was movable and could be indefinitely felt by rectal palpa. tion. After a few weeks preparatory treatment, looking to both his general condition and that of his blad der, patient was sent to hospital. On the morning of January 3, I operated for removal of the stone, selecting Examination for Embalmers.-The Illinois the suprapubic operation in preference to the perineal, State Board of Health will hold an examination for because of the apparently large size of the stone, the

It is quite remarkable that so sensitive and active an organ as the bladder should assume such a degree of tolerance for a calculus until its growth should reach such large proportions, and the fact stands out in vivid and striking contrast to the great physical suffering occasioned by the passage of the renal stone herein reported.

[3860 Olive Street]

minimum risk of inflicting serious injury to the bladder such funeral directors and embalmers as desire to receive appendages and because in careful hands the drainage the certificate of the Board entitling them to prepare may be made equally as good. The parietal incision, for the transportation bodies dead of contagious dis three inches in length, was made in the usual way, the eases, in the Lovington building, East St. Louis, on margins separated by flat retractors, the bladder lifted Tuesday, January 24. Another examination will also gently by a sharp hook inserted at each angle of the be held in Chicago in the Great Northern Hotel about wound and incised. On inserting my finger I found the February 14. At the examination held December 6 and stone to be of large size, and seizing it with lithotomy and 7, in Chicago, 340 candidates presented themselves. forceps lifted it out. The margins of the bladder wound Of these 34 arrived too late, and 306 took the examinabeing secured by silk ligatures, the bladder was thor- tion. Of this number 263 passed successfully. Six oughly irrigated, a rubber drainage tube inserted, the passed the written examination, but have not as yet wound left wide open and dressed with an abundance of done the practical work required, while 37 applicants gauze and cotton. The skin immediately surrounding | failed to pass.

MEDICAL REVIEW.
REVIEW.

L. T. RIESMEYER, M.D., Editor.

Department Editors:

Dr. F. J. LUTZ, General Surgery. Dr. E. C. RUNGE, General Medicine,
Dr. W. B. DORSETT, Gynecology and Obstetrics.

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ST. LOUIS, MO.: JANUARY 7, 1899.

EDITORIALS

Meat Poisoning.

Pneumonic conditions may be common, little marked or absent. Herpes labialis, rashes, desquamation (about fourteen days after the attack) on the hands and feet, jaundice, and great thirst have been observed. The onset is often sudden with nausea, headache, great pain in the joints, limbs, back-symptoms which may lead to a diagnosis of influenza. The symptoms may be ushered in by a rigor. The fever, if present, generally lasts but a few days. In almost all cases there is very great weakness, and convalescence is slow, lasting from three to six weeks. The more protracted cases may simulate typhoid fever. The clinical symptoms caused by the botulinus bacillus differ from those usually produced by the bacillus enteritidis and consist in constipation and nervous disorders.

With regard to bacillus enteritidis infections, the kinds of animals which have been proved to be at fault are especially the cow and calf; while the horse, pig, and goat have also contributed to fatal infections. Parrots have also been implicated in the dissemination of infections with the bacillus enteritidis and the disease caused by it in these animals has been styled in France "psittacosis." Durham suggests that the parrots, which were brought over to France from Buenos Ayres and among whom psittacosis broke out, may have been, as is usually the case on board ship, near the "butcher's shop." The bacillus botulinus was found by Ermenghem and others in ham.

Durham also calls attention to the fact that the disease

of which the bacillus enteritidis is the infectious agent may possibly also be communicated to man by the milk of the cow, but the bacteriologic evidence of this statement is incomplete. He also points out the fallacy of the belief that this class of illness occurs especially during the summer months, since several of the epidemics which have been bacteriologically examined have occurred in winter or autumn. The meat may be perfectly fresh and harmless as far as a macroscopic inspection is able to detect and yet harbor the bacillus enteritidis-a most emphatic additional argument in favor of a careful examination of all cattle and other animals furnishing meat before they are slaughtered.

Evidence is accumulating that all cases of meat poi soning are due, not to the partaking of meat which has undergone putrefactive changes, but to infections with pathogenic bacteria which, according to the dose and virulence, and susceptibility of the patient, may produce anything from a slight passing illness to a severe and rapidly fatal attack. The microbes which have been identified with the causation of meat poisoning are the bacillus botulinus of Ermenghem and the bacillus enteritidis first described by Gärtner. The latter is, according to Herbert E. Durham,' the most important and has been found in more than a dozen epidemics. The bacillus has been isolated from the organs of fatal cases as well as from the suspected meat. In all cases in which the source of the illness could be traced out, the animal which supplied the meat was itself in a diseased condition. The symptoms and lesions caused by the bacillus enteritidis vary, according to Durham, as The Role of the Buckeye and Rabbit's in the case of most other bacterial diseases, to a con siderable extent. Diarrhea is usually present, but it may be slight, or it may be replaced by constipation. Vomiting may be extremely intense or it may be absent.

'British Medical Journal, December 17, 1898, page 1797.

Foot in Preventing Disease.

"What can I do to protect myself against an attack of the grippe," is a question which has been frequently asked of doctors during the grippe epidemic in this city. The most appropriate answer is the advice, which