I think few of us are aware of the rapidity I purposely passed my finger round to the with which stones form in the bladder, par- triangular ligament and broke it off, and then ticularly phosphatic stones. I have known a worked the mass towards the bladder. At all stone as large as a pigeon's egg form within events the result was all that could be desired. four months after suprapubic removal of stone. It is also evident that the so-called internal In such a case one could positively swear that sphincter has nothing to do with micturition, no remnant had been left. I have known the nor does micturition depend for its initiatory same thing happen after litholapaxy, and stimulus upon the integrity of the prostatic cystoscopic examination had shown a clean urethra. Freyer, in his reported complete bladder free from débris. removals, has left the urethra, whether from There are just a few points of interest about design or not he does not say. My own imthese cases. Operation has been refused some pression was that a flaccid tag end of urethra prostatic patients because they have had a was far more likely to give rise to stricture than fairly low specific gravity urine with albumen. no urethra at all in a situation where the Four of these patients had urine whose specific narrowing up after the removal of a large gravity was from 1010 to 1013 and a rarying prostate could hardly be so complete as to quantity of albumen, which was of less im- block the passage altogether. Certainly the portance because pus was present also. After result in these cases has been admirable, and recovery the albumen disappeared and the absolutely normal micturition has been estabspecific gravity rose. lished. Some writers, in speaking of this operation, When one considers the condition of these have been somewhat concerned lest the in- poor unfortunates straining to pass urine every tegrity of the prostatic urethra should be hour or half-hour, with painful urethritis and disturbed. Apart from the sexual aspect of foul urine, worried with want of rest and the question, the prostatic urethra without the bodily and mental pain (hardly the conditions prostate seemed to me to be of little value, so one would choose for the performance of a E major operation), the results are very grati- will indicate whether there is a uniform upfying, and the risk would be much reduced if heaval, a central median nodule, or a lateral the prostates could be attacked before instru- excess in growth. Without this evidence the mentation and septic conditions have been prostatic incisor would, indeed, work in the established. dark. It is certainly a poor condemnation of Men are apt to treat too lightly the intro- the instrument to say that it must be used in duction of their patient to a catheter life. For the dark. A man who has not eyes at his my own part I invariably point out to my finger tips would find surgery a very small patient the seriousness of the step, for not only field indeed. A lithotrite is a dreadfulhas it happened in one or two cases of my owy, looking tool which is used very well in the where every conceivable precaution was taken, dark. The obstacle may be first seen, its size but also in the practice of extremely careful estimated, the length of the urethra measured, men, that catheterism in a perfectly clean and the length of the cut measured; in fact, bladder has been followed by death within two when conducted thoughtfully and intelligently or three days or as many weeks; yet such clean there are few operations which are safer and cases do admirably after operative treatment which are attended by more pleasing results ; and free drainage. the results, in fact, give the best reply to the The operation known as Bottini's practically carping critic. aims at cutting with a red-hot platinum blade Willy Meyer, in 1900, reported on a series a channel through the prostate so as to open of unselected cases which were taken as they up the urethra and allow urine to pass out by came; this number has been considerably the low level gutter thus formed. A battery amplified since then. His cures amounted to of 45 to 50 amperes is required to heat this about half, the relieved about 30 per cent., and blade in the damp tissues. The shaft of the the deaths to 10 per cent. These results are instrument is kept cool by means of a water remarkably good when one considers that two jacket. The bladder should contain about five at least of those who recovered suffered from or six ounces of water at the time of operation. pyelitis. Bottini and his disciples claim that this I have so far operated on nine cases, and operation has a lower mortality and a greater they were to a certain extent selected cases. percentage of recoveries than any other opera- 1. A man of 50, with frequency three times tion for the relief of prostatic hypertrophy. in the night, 2 oz. of residual urine and more Some operators met with poor success, but or less constant pain at the neck of the bladder this can hardly be altogether attributed to the and across the loins. Eight hours after operaoperation. My own impression is that the tion he felt a little stinging pain. He was indiscriminate operating on every case has done operated on nine months ago. Since then he more to damage the operation than anything has had no residual urine, and is in good else. The great amount of cutting and the urinary health. large sloughs which must invariably follow such incisions in a very large prostate are 2. A man, 70 years old, with absolute re tention and a rather large prostate cystitis and likely to be a source of danger, partly from the pyelitis. He improved, was able to pass difficulty in getting rid of so much necrotic urine, with still 2 oz. of residual urine. Six material and partly on account of the hæmorr- weeks after operation he died of pneumonia hage likely to take place on their separation. following influenza. The larger the prostatic mass the greater would be the difficulty in obtaining a good 3. A man of 62 years of age, with 4 oz. of result by this method, though, at the same residual urine, and passing urine every two time, the amount of obstruction to micturition hours at night. He now has about 2 drachms of residual urine and feels quite well, having must by no means be measured by the amount no nocturnal frequency. of residual urine. An examination should be conducted with the cystoscope, and if it is 4. This patient was 83 years old, with foul impossible to mount over the prostate so as to urine and 13 oz. residual, with all the attendant see the bladder wall, it may, as a rule, be misery which usually accompanies such a case. taken for granted that the prostate is a large He was getting about the ward at the end of Rectal examination will probably confirm three weeks after operation, with clear urine this. A very fair conclusion may be arrived and 1} oz. residual urine, when he fell and at by simple examination with a short-beaked bruised himself so extensively that he died in sound combined with the evidence obtained by a few days. His urinary health remained good passing the finger into the rectum. until his death. If the hypertrophy be not great, the cysto- 5. This patient had submitted to a partial scope is extremely valuable, inasınuch as it prostatectomy when suffering from complete one. an success. prostatic retention. He recovered to the extent amount of inconvenience and danger to the of having 4 oz. of residual urine, which did not patient, and the greatest amount of satisfaction improve. Within two weeks of the operation to the operator. by the Bottini method he had perfect urinary Whether the prostate is completely removed health, and was able to completely empty his or not, matters little. I think it is plain to bladder. anyone who examines these specimens that all 6. This man had three ounces of residual the prostate that could be left might be repreurine. I failed on the first occasion to make a sented by the thickness of a piece of brown sufficiently thorough cutting away of the paper; at all events, it would not be likely to inprostate, so that he still had an ounce and a terfere with the restoration of normal micturition. half of residual urine, though he felt extremely The truth may be arrived at some day when free from the pain and very great frequency some patient dies and his pelvis is examined. which had worried him so much of late. In I hardly like to complete this record without fact, he stated that he used to pass his urine referring to our indebtedness to Freyer for from ten to 20 times every night. While in having brought so prominently before the prohospital it varied from ten to 12 times between fession the complete removal of the prostate. nine o'clock and daylight. After the second He may not have been the first to remove the operation the residual urine was reduced to prostate completely, but he was certainly the one and a half drachms. I think it very pro- first to recognise what such a complete removal bable that this will still further diminish. meant-to recognise the fact that he could in The 7th, 8th and 9th were cases of complete selected cases set out to effect a complete reand partial retention; the cure was absolute in moval, and with excellent prospect of two, and almost absolute in the other. It certainly does appear that some degree of To the advocates of catheterism let me say finality is being arrived at with regard to the one last word: I simply speak from my own operative treatment of prostatic hypertrophy. experience. experience. The bladder of prostatic patients The operations of vasectomy and orchectomy will always be found to be aseptic unless stone will bring about the reduction of the normal is present or an instrument has been passed. prostate, and are of service in in reducing There is every probability that prostatic patients the size of congested and irritable prostates; suffering from vesical stone owe its presence to but I know from my own observation that they the fact of a stone having arrived from the have but little effect on the prostate whose kidney or to cystitis having been induced in a increase depends on adenomata, and some other healthy bladder by the introduction of a foreign well-established pathological changes. body. There is every reason to believe that Bottini's operation seems to be particularly stones do not originate in the bladder unless adapted to early cases. The risk is slight, the sepsis or a foreign body is present. recovery rapid, and the pain which follows is (Read before the New South Wales Branch British Medical Association.) wonderfully little. If recurrence should take place the operation may be repeated. The measure of success which attends the operation A CASE OF PLACENTA PRÆYIA WITH must depend to a great extent upon the CONTRACTED OS AND RIGID CERYIX. tor's knowledge of the precise character of the obstruction to be attacked, and if the gland be By C. E. Todd, M.D., and H. A. Sweetapple, M.D., Adelaide. so large that cystoscopic examination is impossible, it would certainly be wiser to adopt a suprapubic or perineal operation, partly because MIDWIFERY cases in which placenta prævia a removal of a portion, or preferably the whole of occurs always cause considerable anxiety, and the gland, would bring about a more certain when to this condition a rigid cervix and cure, and partly because it would be impossible tightly contracted os are added, the to negative the presence of a post-prostatic stone. becomes at once not alone extremely difficult to Those large adenomatous prostates which are the accoucheur but dangerous in no slight so satisfactorily removed by the suprapubic degree to the patient. If one may judge by method in one mass are just the cases which the number of examples of this condition are attacked with the least satisfaction by the published in the medical journals, one would Bottini method. No doubt the great difficulty come to the conclusion that such cases to be contended with is the reluctance of patients not very rare. Up to the time that this case and medical men to submit cases of early pro- occurred in my own practice I had come to the static trouble to operative treatment, though conclusion, on thinking over papers on the undoubtedly this is the time when operative subject, that if an anesthetic had been pushed treatment may be carried out with the smallest to the full extreme, the os and cervix would have а case were were dilated or at least be easily dilatable, and that delivery could be accomplished with comparative ease. This I have always found to be the case, and I think with very few exceptions it is the rule. However, this is not always so. Mrs. C. I., æt. 24, was eight months pregnant with her first child. After some unusual exertion she felt an abdominal pain, and had a slight blood-stained vaginal discharge. When I saw her a few hours after the commencement of her symptoms she was in bed, and the pain and bleeding were very much diminished. Per vaginam the os was tightly contracted, and the presentation could not be accurately made out. She was ordered to keep her bed, and when I visited her in two days' time I found that all pain and bleeding had ceased. As a precaution another two days' rest was enjoined. The next afternoon she got out of bed to pass urine, and while doing so felt a sharp abdominal pain, with faintness. She was lifted back into bed, and a considerable amount of blood came from her vagina. On my visit, two hours afterwards, I found the patient blanched and faint. Hæmorrhage was still going on, and the os was about the size of a florin. The cervix was not at this time rigid; it appeared to be dilating, and on introducing two fingers I could feel the placenta presenting. This I was able to separate some two inches up from the os, and on the left side I came upon the free placental margin. The bleeding was at once diminished, and henceforth was not a cause of urgent anxiety. As labour pains were increasing in severity and frequency and the head was presenting, I waited an hour in the hope that labour would terminate naturally. At this time the os and cervix felt moderately soft, and as bleeding still persisted, I decided to give ether and deliver. I anticipated no difficulty, but after getting the patient completely under an anæsthetic I found, on vaginal examination, that the cervix had elongated and that the os was now hard and almost closed. I directed the experienced nurse, who was continuing the ether, to push it still further, but even then only with the greatest difficulty could I insinuate my two fingers into the cervix. All attempts to introduce a blade of the forceps were fruitless. Still thinking that if the ether had been pushed to the full extent dilatation would be possible, I sent round for Dr. Sweetapple, who gave the anaesthetic fully, but the cervix and os remained as rigid as before. Neither Dr. Sweetapple nor I could dilate sufficiently to get more than two fingers into the uterus. We decided, therefore, to desist and to give 20 grains of chloral every hour for three hours. On our return the patient had taken 60 grains. Dr. Sweetapple decided to give chloroform, and on examination I found the cervix and os somewhat softer, but still I could not dilate sufficiently to introduce the forceps. As my hands rather cramped I took over the administration of the chloroform, and Dr. Sweetapple, after many efforts, at last succeeded in getting the instruments on, and I delivered without any great difficulty. The placenta followed immediately on the birth of the child, which was dead. The patient made an excellent recovery, and I got a teno-synovitis of my right wrist, which kept it stiff for at least three weeks. This was a case unique in my rather long experience of midwifery. As I have stated, I have hitherto always thought that all that was necessary to enable the os uteri to be dilated fairly easily was that an anesthetic, ether or chloroform, should be pushed to the extent of producing complete muscular relaxation. I would like to hear the experience of those present on this point, but I have always found it so in practice. The question arises as to what would have been the right course of treatment if we could not have dilated sufficiently to apply forceps, Dr. Sweetapple, to whom I feel much indebted for advice and assistance in this case, and I came to the conclusion that there were two courses open to us. One was to leave the case for some time in the hope that the os and cervix would finally soften and dilate, and that then we could apply instruments or let delivery take place in the natural way. Against this, of course, was the fact that the woman was exhausted, and that bleeding was still going on a little. We could, of course, check the hæmorrhage by gauze plugging, but this is not a very efficient means of controlling bleeding in a case of this sort. The other course of treatment, which I think was the one we had decided upon, would have been to put the patient up in the lithotomy position in a good light, make a final effort at dilatation, and if this was impossible, to make what incisions were necessary into the os to enable the forceps to be applied. We should then have stitched up the cervix and os as in an ordinary Emmet operation. No doubt some of the members here to-night will have had similar cases, and we shall be glad to hear how they conducted them. (Read before the South Australian Branch of the British Medical Association.) In the New South Wales prisons steps are being taken to establish a new system of criminal identification on the lines of the combined Bertillon and Galton methods. A comprehensive criminal register is in course of compilation, and already the anthropometrical lines of a large number of prisoners have been taken. PLACENTA PRÆYIA. that a sudden hæmorrhage had occurred about By H. A. Sweetapple, M.D., B.S., L.R.C.P., &c., 20 minutes before the patient collapsed. Adelaide. 2. Mrs. H., æt. 40, in the eighth month of her ninth pregnancy. This case I was called DOUBTLESS there are cases of placenta prævia to one night when acting as locum in Dunproducing abortion in the earlier months of mow, Essex. Considerable hæmorrhage had occurred, which caused much alarm. There pregnancy which have been unobserved, and was a history of slight hæmorrhages having cases in which the placenta is situated low occurred at intervals since the sixth month. enough in the uterus to produce slight On examination I found the os widely dilated, hæmorrhage during uterine contractions of the the liquor amnii evacuated, a partial placenta first stage of labour, yet too high to be felt by the examining finger. prævia, and the head presenting. Pains were infrequent and feeble, and hæmorrhage occurThe cases, however, which now concern us ring with each pain, the uterus appearing very are those in which the placenta is implanted fabby. I at once applied a tight binder, gave wholly or partially over the internal os uteri. ergot (Richardson's), and terminated labour by The interesting case reported by Dr. Todd, applying the forceps. and which I had the opportunity of observing, 3. Mrs. B., æt. 30.—This patient sent for me is in my experience far from common. Here, at the seventh month on account of slight where I should have expected to find relaxation of cervix and os produced by the loss of blood, hæmorrhages occurring every four or five days since the sixth month. the condition was quite the reverse, ; the lower uterine segment was one of the most unyielding pains and hæmorrhage when I arrived. This was her fourth pregnancy. She had I I have met. This state of things also was little examined the os, but could not insert much altered either by the action of chloral or more than the tip of the index finger. I then chloroform. When, however, the os did seem and there plugged the vagina with boiled cotton to relax, many attempts were made to insert the forceps, but the rigidity would simply return, wool, and instructed the patient to rest in bed. Four or five hours afterwards I removed the as though to mock one. At length the instruments were applied, and Dr. Todd carefully plugs. The os was just large enough to feel a delivered. We both agreed that the labour part of the placenta. I again plugged, and on should be terminated as speedily as posible, removing these some hours afterwards was and I consider that the proper course prepared to rupture the membranes and turn, but found the hæmorrhage entirely stopped and adopted in applying the forceps in this case. Firstly, because, though the membranes were the os firmly closed. From this time the patient ruptured, and the placenta separated as far as never had a return of the hænorrhage until at full term, when there was a slight return which possible, the patient was still in great danger from hæmorrhage, and it was impossible to was stopped by rupture of the membranes, labour terminating shortly afterwards. bring down a foot. Secondly, because it appeared certain that the child was being 4. Mrs. O'D, æt. 27 (her third pregnancy), asphyxiated. sent for me at about the seventh month. The I have notes of a few cases of placenta patient was losing a great deal of blood per previa which I have met with since being in vaginam. On examination the os was found about the size of a crown and was completely practice, and which may be of interest. blocked by the placenta. On rupturing the 1. Mrs. B., æt. 28, living about three miles membranes the pains became strong; the out of Maidstone, Kent, engaged Dr. Plomley, placenta was partially forced through the os at whom I was assisting in that town, to attend in each uterine contraction, and I had no difficulty, her third confinement. after giving the patient chloroform, in extractOne morning, when about full term, a ing the whole of the placenta. I was then able message came to go to the case. My principal to bring down a foot, and the rest was easy. asked me to attend. On my arrival at the The uterus was washed out with 1 per cent. house about an hour after the message came, I creolin lotion, and she made a very good was told that the patient was dead. recovery. I found the woman lying on her back in a In the four cases I have reported, the first large pool of blood, and on examination found would show how rapidly placenta prævia may the foetus in utero, the os only large enough to prove fatal, and how needful for medical skill feel that the placenta was partially covering when hæmorrhage occurs. The second would the internal os, and the membranes unruptured. remind us, as in Dr. Todd's case, that severe On inquiry from the old monthly nurse I learnt hæmorrhage may continue even though the was |
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