LECTURE By PROFESSOR G. SIMON, of Heidelberg, on the Methods of Rendering the Female Bladder Accessible, and on the Catheterization of the Ureters.

In order to remove calculi and other foreign bodies from the bladder, resort has been had to various operations-bloodless dilatation and section of the urethra, vesico-vaginal, and vestibular section, and the high operation.

Of these methods, only two are recommended for the facility with which they permit, not only foreign bodies to be removed, but diseases to be diagnosticated and treated.

Dilatation may be accomplished gradually, or at once, in a few minutes. The rapid mode is preferable, because the long retention of a bougie is apt to produce inflammation and swelling of the urethra.

The observation that the urethra admitted of dilatation was very early made. Wildt, who describes my procedure, in the "Archiv fur Klinische Chirurgie," gives many citations. I will refer in addition to Franco (Traite des Hernies, 1861), Fabricius. Hildanus, Peter Dionys and Bertrandi. Sir A. Cooper five times removed calculi through dilated urethræ. Hybord (1872) describes the process of dilatation, and declares the introduction of an instrument greater than 3 or 4 Ctm. in circumference impossible. Christopher Heath's plan was to first introduce his little finger, afterwards his index finger, giving it a rotary motion.

Notwithstanding these observations dilatation did not become popular, because of the limited indications, and fear of the resulting incontinence. My method, developed through a long series of experiments, has, I believe, dispelled these objections. The orifice is the narrowest and most unyielding part of the urethra, and it is seldom that the finger can be introduced without using great force. I generally make two incisions in the upper margin of the orifice 1-4 Ctm. deep, and one below 1-2 Ctm. deep. The finger being thicker at its base unless these incisions are made, will lack at least 1 Ctm. of penetrating its en

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tire length.

The incisions are best made with a pair of scissors. No harm can come of this slight operation. Few muscular fibres are divided, the little muscles heal, and in the future they obviate the use of chloroform.

For dilating I use seven sizes of hard rubber bougies, the largest being 2 Ctm. in diameter, the smallest 34 Ctm. After using these I introduce my index finger without difficulty, taking care, at the same time, to introduce my middle finger into the vaginal; for in this way the bladder may be more deeply penetrated, the urethro-vesical septum pressing the commissure of the finger. I also press, with my other hand, upon the base of the bladder.

The fear of incontinence has interfered to such an extent with bloodless dilation, that Hybord, (1872) after careful research, only found twelve cases where the operation had been performed for the extraction of stone. Knowing this, I set to work to discover how far dilation might safely be carried. Hybord and Spiegelberg are the only authors who have given definite estimates. No practical benefit can be derived from their statements, because they differ so widely. Hybord says it is unsafe to dilate beyond 3-4 Ctm. circumference, 1—1.3 diameter; Spiegelberg says 2.5 Ctm. diameter, 7.8 Ctm. circumference, and even beyond this. The bounds prescribed by Hybord are absurd, for even a child's finger is 3 or 4 Ctm. in circumference. My numerous observations have taught me that bougies 1.9—2 Ctm. diameter, 6-6.3 Ctm. circumference, may be used without any disaster worthy of mention. Slight ruptures of the mucous membrane may result, but these heal in a few days. Authors who have mentioned the removal of calculi have invariably neglected to state whether incontinence resulted or not. I have arrived at the conclusion that in girls from 11 to 15 years old the urethra may be dilated 4.7-5.6 Ctm. circumference, 1.5-1.8 Ctm. diameter; from 15 to 20 years, from 5.6 6.3-1.8-2 Ctm. diameter, and that in only exceptional cases. The objects to be attained by dilation are:

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(1.) The diagnosis of diseases of the mucous membrane of the bladder by palpation. Illumination of the interior of the blad

der with the calcium light becomes of practical importance, for the finger having determined the site of the disease, the light can be intelligently directed.

(2.) Very small stones may be felt and removed. Heath sought in vain with instruments for a stone which he easily found and removed with his finger.

(3.) Formerly calculi were sought to be grasped without the guidance of the finger. Now the instrument may be introduced along with the finger. Lithotripsy will be more available, and the dangerous operation of urethetomy will fall into disuse.

(4.) Caustic applications may be made in obstinate cases of chronic vesical catarrh.

(5.) For the cure of fissures of the urethra. Heath adopted with good results, the plan of dilation with cauterization. Spiegelberg pursued the same course. I cannot say that I have been uniformly successful.

(6.) The diagnosis of vesico-vaginal fistula in closed vagina. Wildt mentions a case in which by palpation I pronounced a vesico vaginal fistula curable, opened up the artificially closed vagina, and cured the fistula by bringing its margins together. I have since treated a second case of the kind with good results. (7.) The diagnosis of the location and extent of tumors. and swellings between the bladder and vagina. In the numerous cases of carcinoma of the uterus in which the vesico vaginal septum is implicated, it is important to know whether the mucous membrane of the bladder is involved, for, unless this is intact, the tumor cannot be removed without opening the bladder.

(8.) The extirpation of tumors, especially of papillomata in the walls of the bladder.

(9.) Renal calculi which happen to be arrested near the orifices of the ureters may be diagnosticated and removed, either by incising the orifice of the ureter or by making an incision through the mucous membrane of the bladder.

(10.) The opening of an Hæmatometra, whose evacuation between the bladder and rectum is impossible or too dangerous, on account of the congenital absence of the whole or a part of the vagina. In such cases Scanzoni evacuates the collected menstrual blood through the rectum. The peritoneum is invariably wounded by long incisions, and openings by trocars close, and relapse occurs. If opened through the bladder the peritoneum is unharmee. Noggerath's trocar is very useful for the

purpose.

(11.) The cure of the painful and otherwise ultimately fatal vesico-intestinal fistulæ of large and small intestines. A fistula is easily found by the finger passed through the dilated urethra, and caustic applications made, guided by the finger or endoscopic illumination. (Translated from Volkmann's Sammlung Klinischer Vortrage, for the St. Louis Medical and Surgical Journal.)

MEDICATED ICE IN SCARLATINA.

In a short communication to the Lancet (Jan. 8, 1876), Mr. Edward Martin says: "Every practitioner has at times to face the difficulties of the scarlatinal throat in young children. It may sadly want topical medication; but how is he to apply it? Young children cannot gargle, and to attempt the brush or the spray often fills them with terror. In many cases neither sternness nor coaxing avails. If the doctor thinks it his duty at all hazards not to leave the throat untouched, the child is subjected to a struggle and a fright which probably render the proceeding more productive of harm than good. If, on the other and more wiser side, he, when persuasion fails, goes no further, he is haunted by the feeling of not having done all that might have been done for the case. Most of us at times have been impaled on the horns of this dilemma. Yet these little ones in almost every case will greedily suck bits of ice, as I doubt not most of your readers can testify. This has long been my chief resource where I could not persuade the child to submit to the sulphurous acid spray. Lately I have been trying an ice formed of a frozen solution of the acid (or some other antiseptic), and I think my professional brethren will find it a valuable addition to their means. Though, of course not so tasteless as pure ice, the flavor is so much lessened by the low temperature, and probably also through the parched tongue very little appreciating any flavor whatever, that I find scarcely any complaint on that score from the little sufferers; they generally take to it very readily. The process of making it is so simple that a few directions to any intelligent nurse will quite suffice; or in urban practice the chemist who dispenses the other prescriptions will undertake this one also. A large test-tube immersed in a mixture of pounded ice and salt is the only apparatus required, and in this the solution is easily frozen. When quite solid, a momentary dip of the tube in hot water enables one to turn out the cylinder of ice as the cook turns out her mould of jelly. I have tried the three following formulæ, all of which answer, though I think I prefer the first:

"1. Sulphurous acid, half a drachm; water, seven drachms and a half: mix and freeze.

"2. Chlorate of potass, one scruple; water, one ounce dissolve and freeze.

"3. Solution of chlorinated soda, half a drachm; water one ounce; mix and freeze.

"However, the form is of secondary importance, and each practitioner can construct his own. Boracic acid, salicylic acidor any other harmless antiseptic with not too much taste, would, doubtless, be as useful as those I have indicated. It is the idea of applying them in the shape of medicated ice' that I recommend to the profession, with the belief that it is of practical value."-Monthly Abstract Med. Science.

Öphthalmology and Ýtology.

MYRINGITIS.-A Clinical Lecture by Prof. Joseph Gruber, of the Imperial University, Vienna. (Allg. Wien. Med. Ztg.) Translated from the German by A. G. Sinclair, M. D., Ophthalmic and Aural Surgeon to Harper Hospital, Detroit.

Among the cases which I have exhibited to you in this clinic you have rarely seen a normal membrana tympani. In nearly all, and as you are aware our clinical material is very great, the drum membrane was found to have undergone changes attributable either to an antecedent or still progressive attack of inflammation. We are, therefore, justified in classing inflammation of this membrane with the most common forms of aural disease. If, however, we limit the term to those cases in which the inflammation is confined to the drum membrane, we must admit that as a primary, idiopathic disease,myringitis is of very rare occurrence, so rare, indeed, that many of the older aurists denied its existence. If one read carefully the writings of those who entertained the opposite opinion, he will readily perceive that these authors classed other and very different forms of disease under this head.

The first aurist who diagnosticated and in a measure correctly described this disease, was Kramer of Berlin. The picture which he presented cannot, however, be accepted as true in the light which more recent investigations have thrown upon the nature of this disease. Indeed he is placed in a peculiar light as an observer when we find in his clinical reports the statement that a few days are sufficient for the healing of a perforation the size of a pea "in the antero-inferior segment," resulting from such inflammation. When we know how slowly such extensive perforations heal, usually requiring months for complete recovery, we must, however unwillingly, believe that many cases