amuse the patient, whilst the angio-leucitis lasted. Afterwards he was advised to use camphorated oil, and to apply it hot upon the limb. This was beneficial in some degree.

CASES OF CALCULUS IN THE FEMALE,

BY MR. SHARP, F.R.S., M.R.C.S.E.,

Of Rugby.

Cases of Calculus in the female requiring an operation are, happily, rare. This evidently arises from the shortness and dilatability of the urethra, and not from any peculiarity in the kidneys, or in the urine secreted by them. Gravel of considerable size frequently escapes with the urine, and occasionally even large calculi have been expelled without the aid of the surgeon. (For instances see Cooper's Surgical Dictionary.) Sometimes, however, such assistance is needed. Mr. Hey has recorded three cases in which he performed the operation of lithotomy, during his long career at the Leeds infirmary. Two of these were followed by incontinence of urine for a long time, which induced Mr. Hey, in the third case, to endeavour to prevent this great evil by introducing into the vagina "a tent of rolled linen about two inches long and one inch thick, to which was affixed a thread of silk, that it might be extracted with ease if the removal should become necessary. The patient could expel her urine without removing it, yet lay quite dry in bed, as if the operation had not been performed. At the end of the third day the tent came out, but was replaced. On the fifth and eighth days it was again expelled and replaced. On the 10th day it remained out some hours, and finding that she could retain her urine perfectly, and could make water in a natural manner, it was not replaced any more. She returned home about a fortnight after the operation in perfect health." (Hey's Practical Observations, p. 560.)

To avoid so terrible a consequence as an inability to retain the urine, other methods of removing the stone have been devised. Of these, that by dilating the urethra instead of cutting it is the most important. Sir Astley Cooper got Mr.Weiss to make him a dilator for this purpose, which in his hands

answered well. He relates two cases in the 12th vol. of the Medico-Chirurgical Transactions. The first had no incontinence; the second, which was not the removal of a calculus, but of a broken piece of catheter, had incontinence till her next menstrual period.

Mr. Liston recommends the two methods of cutting and dilating to be combined. He says: "Calculus vesica is an exceedingly rare disease in women. The best mode of extracting foreign bodies from the bladder is to widen the urethra gradually by means of the screw dilator (Weiss's), then by the introduction of a straight blunt pointed knife, to notch the neck of the bladder slightly, towards each ramus of the pubes; the dilatation is continued, and in a few minutes the finger can be admitted; the stone can then be readily grasped by a pair of forceps, and it is astonishing how large a body may be removed by these means." (Liston's Operative Surgery, p. 521.)

Notwithstanding these successful results, other surgeons still cling to the more complete operation of lithotomy; so that the question of the best method of removing calculi from the female bladder cannot yet be considered as finally answered. Such being the present state of things, it may not be improper to place on record two cases of this formidable and painful disease which have fallen under my care. It will be seen from them what my own treatment has been and its result.

The first case happened to me some time ago. It was a little girl. The urethra was dilated a little every day for a few days, until the stone could be seized by a very small pair of forceps which I had had made for the purpose, and easily extracted. Incontinence of urine followed for a week or two, but was recovered from.

The second case has just occurred to me, and is as follows:Mrs., aged about 56, residing at Warwick, a patient of Dr. Sutherland's, of Leamington. I saw this lady for the first time on Nov. 8, 1851, at Dr. Sutherland's request. I soon satisfied myself that she was suffering from calculus. She had frequently parted with large gravel, until the last year, during which time none had come away, and her sufferings had in consequence greatly increased, so that now she could not walk

the shortest distance without causing great pain and considerable hæmorrhage from the bladder. She had had but one sister, who also suffered from calculus, and died shortly after an operation for its removal, in London, not long ago. All these circumstances conspired to excite a good deal of alarm in the minds both of the patient herself and of her family. Having described to her the plan I proposed to pursue, she immediately consented, being herself very anxious to avoid any cutting operation.

On the 12th, having sounded the bladder carefully, and felt the stone, I introduced a dilator, and gradually enlarged the opening of the urethra somewhat, but it being very rigid, and the dilatation painful, I did not proceed far, but withdrawing the instrument, I gave some her Arnica, and left her under Dr. Sutherland's care for two days.

On the 14th I again introduced the dilator (Weiss's) and gradually expanding it, as my patient could bear it, in about twenty minutes I found the urethra sufficiently dilated to allow me to introduce a pair of lithotomy forceps. I felt, but could not lay hold of the stone, and therefore withdrew the forceps and introduced the forefinger of my left hand, when, instead of finding the stone in the fundus of the bladder, as might have been expected, I had to turn my finger upwards, and there the stone seemed to rest as it were upon its tip-it being lodged in a cyst immediately behind the pubes. The stone was oblong, and lying across and over the neck of the bladder. It was at once obvious that no forceps could reach it in that position, nor, if they could, would it have been proper to extract it with its length across the blades of the instrument. My first effort therefore was to dislodge it from its resting place with my finger; this, with some manoeuvring, I was not long in effecting. The next step was to alter its position, so that it should lie lengthways, or with its longer diameter in a line with the urethra; this being also accomplished, my finger was withdrawn, and the forceps again carefully introduced, and by the aid of the finger in the vagina, the stone was readily seized in the proper position, and, without further difficulty, extracted. It measured an inch and three quarters in length, and an inch

in breadth. The patient, who had been placed in a position approaching to that for lithotomy, but without anything to restrain her, and without exposure, and only a married daughter near her to support one knee, was returned to bed, and a dose of Arnica given. It was now half-past 3 P. M.

Nov. 15.—On visiting our patient to-day I was much gratified to find that she had slept delightfully for two hours, from 11 till 1, and awoke feeling more comfortable than she had done for a long time. There had been a discharge of urine mixed with blood during the night, but the power of retaining the water had returned before breakfast time this morning, so that the incontinence had continued only sixteen hours. She had taken several doses of Arnica and one or two of Aconite. The pulse was calm, and though there was no inclination for food, she was altogether much more comfortable than might have been expected.

On the 17th I found all going on so well that I took my leave, Dr. Sutherland undertaking to continue his attendance for some time longer. I have since had letters from the daughter, expressing in the strongest manner the gratitude felt for the benefit her mother had received.

This was a case of considerable difficulty, but it was so thoroughly successful that it would not be easy to persuade oneself that any other kind of operation would have been better than the one adopted.

I am of opinion that the after-treatment with Arnica also contributed to the speedy recovery. An opiate, which I should doubtless formerly have given her, would not have relieved the pain so well, would not have contributed to restore the tone of the parts at all, and would have occasioned constipation; this must have led to the administration of other medicines, which, to say the least, it was an advantage to my patient to find that she did not need.

137

CASE OF IDIOPATHIC PHLEBITIS.

BY DR. WALKER, OF MANCHESTER.

G. B., aged 42; active habits; highly nervous temperament; rather spare of flesh, but remarkably well developed chest; a great sufferer from severe headaches and gastric irritation, exhibited in the shape of acidity or pyrosis, was seized on the 16th of August, after a residence of some weeks at a most healthy watering-place, with rigor, followed by well marked febrile symptoms of a remittent type. These were chiefly nocturnal delirium, shooting temporal cephalalgia, white pointed tongue with red tip and edges, epigastric tenderness, eructations or vomitings of acid mucus, and an interesting symptom during the subdelirium, a sense of double consciousness, exemplified by his expression, that in that state he felt that the head that ached so severely belonged to some other individual, although much puzzled to account for his intimate knowledge of that other person's sufferings.

He was treated with Aconite, Bryonia, and Arsenicum, and was perfectly convalescent on the 14th day, and for a week progressed exceedingly well, gaining flesh and strength, although considerably annoyed with pains in the thighs and legs, which appeared to be neuralgia of the sciatic and anterior crural nerves.

At the end of this period (he had been recommended carriage exercise), he was after a short drive on a cold and boisterous day, seized with rigor, and he again relapsed into fever. The symptoms were nearly those of the previous attack, and yielded in the course of six days to Nux vomica B,* and Arsenic 2. Having occasion to leave town, I left him a supply of China to complete the cure, but when visited on the 9th of September by Mr. Harrison, he was found to be suffering from severe pain in the upper part of the thigh, anteriorly, for which Belladonna was prescribed, and on the following day Mr. H. recognized inflammation of the sheath of the great femoral vessels.

On the 11th I found him complaining of occasionally most excruciating and always severe pain, of a burning, shooting and throbbing character, with exquisite tenderness on pressure, in

* A and B mean the 1st and 3rd decimal dilutions.