THE New Series Vol. XXVIII. A WEEKLY JOURNAL OF MEDICINE AND SURGERY. CINCINNATI, January 9, 1892. I beg the indulgence of the Academy for going back ten years and digging up a single case in my experience to report as an illustration of this method of treatment, for we all know that ordinarily an experience limited to a single case is of very little practical worth. I offer as an excuse for presenting this old case that there are comparatively few references to this method to be found in medical literature. On the contrary, there are very emphatic cautions against this very procedure in almost all surgical text-books and other works treating of diseases of the bladder. I have asked probably twenty of my medical friends their opinion of this method. Their answers have been either "Know nothing about it," or with a look or gesture indicative of the terrible effects that would follow the injection of a grs. xx to 3i to 3i solution of nitrate of silver into the bladder, would say: "Don't you do it, it would be extremely dangerous," etc. I shall never forget the expression of supreme disgust that came over the face of one of our elder surgeons, now dead, whose opinion I greatly prized and whose memory I greatly revere. He seemed Whole Volume LXVII. to think it highly ridiculous that any sane surgeon should advise a procedure that would undoubtedly be followed by such disastrous results. "Why," said into the bladder and you would have a he, "you inject such a strong solution slough of the whole mucous membrane. Whatever you do, don't do that." Taking into consideration the sparsethe apparent general ignorance or strong ness of the literature on this method, condemnation of the practice among my medical brethren, along with the magical effect which the treatment had in my case, made me desirous of hearing the subject discussed by this body. My attention was first directed to this treatment by reading a lecture of Prof. T. G. Richardson, delivered in Charity Hospital, New Orleans, and published in the Medical News, June, 1878, p. 85. I made a note of the lecture in my library index at the time, resolving to try the treatment should a suitable case, rebellious to milder methods, present itself. Richardson says that he had recognized the absurdity of weak injections of nitrate of silver into the bladder twenty years before, having had some experiments made showing that one hundred minims of urine would decompose over two grains of the nitrate. He lays down three rules upon which he places great stress: I. Be sure that you have a genuine case of chronic cystitis. 2. Be equally certain that the exciting cause has been removed or modified so as to exert no further influence on the disease. 3. Never undertake this method unless the urethra is sufficiently dilated to readily admit a No. 9 or 10 catheter. In making the injection the bladder is first washed out with tepid water until it comes away clear. Then at would be unable to make a stream. The least an ounce of a twenty grain solu- urine was very ammoniacal, and of a tion is thrown into the bladder, prefer- milky color. A two-ounce bottleful ably by means of an elastic ball syringe standing over night would have a half holding one or two ounces. If the pain inch of cream-colored sediment, comensuing is very great the fluid had better posed mostly of pus cells, epithelial be withdrawn in three or four seconds; cells, some triple phosphate crystals, but if no severe pain is caused, ten but no tube casts. Frequently mucoseconds may be allowed to elapse. If purulent masses would be voided, obno decided improvement takes place structing for a time the flow. within ten days thirty grains to the ounce is used; and no impression having been made by this strength, even one drachm to the ounce may be used. It is an old rule in treating cystitis to avoid forcible distension of the bladder. The case which I treated by this method was reported in the LANCETCLINIC, July, 1882, p. 97. I first saw him professionally June 23, 1881. He was a squarely built man, thirty-five years of age, weighing 180 pounds. Family history good. Remembers being sick but once, with pneumonia, at the age of fifteen. He had been complaining of too frequent urination followed by pain for ten years. There had also been a progressive decrease in the size and force of the stream, as well as of the suffering. Notwithstanding the fact that he was constantly growing worse he did not consult a physician for five years, when the doctor caused him so much pain by his forcible attempts to introduce an instrument into the bladder that he resolved never to consult one again. After this butchery he lost blood from the urethra, at intervals, for two or three months, but subsequently lost none. He gradually grew worse, but the remembrance of his former experience caused him to stick to his resolution until at the time I first saw him, when he estimated that he had passed his urine on an average of forty times in twenty-four hours, each evacuation being made after much effort, and followed by intense vesical tenesmus. After some minutes of severe straining he succeeded in passing his urine, in a dribbling stream, in my presence. For about two minutes following, his suffering was very severe. Frequently, after most violent efforts, he would be unable to pass a drop, and several times for days at a time he I attempted to pass a No. 10 sound, but was unable to get it further than the last portion of the spongy urethra, when it stopped against a very dense stricture. I was not able to get even the smallest filiform bougie into the bladder. During the week I made four unsuccessful attempts to pass the stricture. On June 30 Prof. Ransohoff saw him with me and we made a protracted effort, under an anesthetic, but failed to get into the bladder. I made five more unsuccessful efforts, but on July 22 succeeded in passing a No. 1 English soft rubber bougie. At three following visits I was unable to raise the size above No. 3, which I tied in the urethra. The bougie seemed to straighten the canal, and he passed his urine much more easily with the bougie than without it. When the bougie was removed it had more resemblance to a cork-screw than a straight instrument. There were three distinct angles, which deviated from the axis of the instrument one-fifth of an inch. The largest bougie that could be introduced was left in over night for four nights, when I was able to introduce a Holt dilator and rupture the stricture, after which a No. 15 steel sound was easily introduced into the bladder. There was no stone in the bladder, and I gave my patient the hope of soon being better. He had been taking medicine a month when the stricture was ruptured, and for six months following I gave him medicine, in the language of the immortal Mulberry Sellers, "internally, externally and eternally," washing out the bladder and using every means that offered the least hope, except the one under consideration, which had been frightened. from my armamentarium by my medical friends, and especially by my old friend the venerable gray-haired professor. | have to urinate more than once from 9 Prof. Conner saw the patient with me p.m. to 5 a.m.; frequently sleeps all and can bear testimony to the extreme night without waking. Has had no obstinacy of the case, his great suffering vesical pain since a few hours after and exquisite sensitiveness to the intro- the injection, excepting once, for a duction of any instrument into the few seconds, while riding on a street bladder. I gave the case a great deal of car. He was very much alarmed, fearattention, and feel justified in saying ing a return of his difficulty at the next that he received all benefit that could be urination, but his fears were groundgiven him by the internal administration less. He thinks his health perfect, exof medicines, as well as from the injec- cepting a lumbago which has troubled tions ordinarily advised in the text him occasionally for two or three years. books. Urine, normal color, acid, sp. g. 1024, no albumen, showing crystals oxalate of lime under microscope. I saw the case first June 23. The following January he was as bad as he had been at any time. Nothing appeared to have the least effect except ing large doses of morphia. The persistence of the disease was telling upon his robust constitution as well as upon my patience, so on the 23d of January (lacking but one day of seven months of continued treatment without benefit to the cystitis) I screwed up my courage, notwithstanding the many warnings I had received, and armed myself with the twenty-grain solution of nitrate of silver, and with trepidation called upon my patient. The urine contained about the same quantity of muco-pus as when I first saw him. I introduced a No. 10 Jaques catheter, washed out the bladder as best I could, and threw into the viscus an ounce of the solution. The injection immediately excited great suffering. I removed the pressure from the bag and withdrew the solution in about six seconds. The pain produced was intense, and I quickly gave a hypodermic injection of gr. of morphia. Patient was comfortable in fifteen minutes. Upon entering his room the next morning he greeted me with "I'm nearly well." His urinations during the night had been followed by very little pain. Instead of the long-accustomed milk sediment thickly covering the bottom of the vessel it was barely perceptible. I I saw him next five days after the injection, and he claimed to be wellpassed urine without a particle of tenesmus, which he had not done before for ten years. I next saw him May 10, nearly four months since his cure. He does not Having some curiosity to know Professor Richardson's present views, and glad to communicate the good results of the treatment, I wrote him, and in his letter of reply he says: "It has now been quite twenty years since I began this plan of treatment, and in no single case have I had reason to regret its application. The injection is, of course, very painful in many cases, but as this is of short duration, and can be easily controlled by chloroform or morphia, it is a small consideration in view of the remarkable relief which soon succeeds. I have never been so fortunate as to cure a case by a single injection, but a lady now under my care has been so signally relieved after seven years of suffering that she declines a repetition of the operation. My patients have usually required from three to four applications, beginning with 20 grains to the ounce, gradually increasing the strength to 35 or 40 grains. In a few cases I have been obliged to use 60 grains to the ounce. In the hands of a skillful surgeon the operation is entirely free from danger. The text-books that I have seen, viz.: Holmes, 1879, advises / gr. to 3i.; Roberts, 1890, 1 gr. to 3i; Hamilton, 1886, 1 gr. to 3i; Ernst Fenger, 1889, 1/85 gr. to 3i; Mansell Mouillon, 1891, just mentions the remedy; Ashurst, 1889, 11⁄2 gr. to 3iv; neither Wyeth nor Walsham mention the remedy in this connection; Skene, in his “Diseases of Women," gr. 1 to 2 to 3i, increase strength gradually, but avoid a strength that causes severe pain. He says that i to 3i solution may be used His third case was the mother o seven children; cystitis for two years Was a very obstinate and painful case vomiting ropy, bloody mucous afte much straining at each frequent urina tion. She was treated with the strong injection; suffered considerably for time, but the cure was perfect, and on year afterward she was still well. with great advantage, but cautions | tion. One year afterward the case against more than 5 or 10 drops being was still perfectly well. used, laying down the rule of Professor Gouley on this point: "If a strong solution, use but a few drops; if the injection be large, the strength should be mild." Coulson," Diseases of Bladder," 1/4 gr. to 31; Phillips, gr. 1 to 2 to 3i, but makes a reference to Reeve's cases in Lancet, Vol. I, 1853, where he reports on using successfully i to 3i. Bryant does not mention the remedy. Samuel W. Gross, 1876, recommends weak injections, saying that he has always been afraid of the strong injections recommended by McDonald and Hicks, although I think before his death that he strongly advised the strong solutions. The first reference to anything like strong injections which I have found is an article published in the British-American Journal of Medical and Physical Science, 1847, Vol. III, p. 113, where Dr. R. S. McDonald reports using grs. iv. to 3i. In the London Lancet, Vol. I, 1853, p. 536, Mr. Wm. Reeves, M.R.C.S., Lond., reports the cure of three cases of obstinate cystitis by using injections of nitrate silver i to 3i. He does not claim originality, but refers to some French surgeon whose name he had forgotten. tion His first case, Reeves says, "had suffered twenty years, and consulted many physicians without benefit. He passed urine very frequently in quantities of not more than 3i. Life had become such a burden that he was willing to submit to any treatment that promised improvement. The xx gr. soluwas injected, after which he walked home-a mile-in great agony, which lasted for a few hours, after which he was free from all symptoms for six months, when he had a relapse, and came asking that the injection be repeated. A few months afterward it was repeated for the third time. Three years afterward the patient said he was still well, and never felt better in his life. "'" The second case, Reeves says, was a very agonizing one of one month's duration, and was cured by one injec Braxton Hicks reports the use of from 5 to 15 grs. to 3i in the British Med ical Journal, 1874, Vol. II, p. 30, laud ing the treatment in stubborn cases this disease. Ricord has an article i the Gaz. d' hospital, 1850, on th strong solution, and it is probable tha it is to his article Mr. Reeves refers Besides the lecture of Prof. T. G. Rich ardson in the Medical News, 1878, h also has a lecture published in the Ne Orleans Medical and Surgical Journal 1875, Vol. II, p. 832, where he report a case of chronic cystitis of many years standing cured by three injections of nitrate silver, i and 3ss to 3i. speaks of this patient as having been o a very roving disposition, having bee treated in many different cities-having been treated at one time by Dr. Reube Mussey, at the old Commercial Hos pital in this city. All treatment was o no avail until Dr. Richardson saw him first using ǝi to 3i, and one week late 3ss to 31, repeating the same at th end of the second week, when a per fect cure was accomplished. H Gentlemen, if I have succeeded i impressing upon your minds that thi mode of treatment is not only legitimat in these obstinate cases of chronic cys titis, but the best treatment for most o the cases, I would be glad to hear o its more extended use. SUPRA-VAGINAL HYSTER ECTOMY. A Paper read before the Philadelphia County Medical Society, December 6, 1891, BY J. M. BALDY, M.D., Professor of Gynecology in the Philadelphia Polyclinic; Surgeon to Gynecean Hospital; Gynecologist to St. Agnes's Hospital. It is not the object of this paper to discuss the different methods of surgical treatment for uterine tumors, nor to more than incidentally touch upon their medicinal treatment. My personal practical experience in the surgical direction has been wholly that of supra-vaginal amputation, excepting in those cases of small uterine fibroids where it has been found advisable to remove the appendages only. In this connection I may say that where the opportunity presents to choose between the removal of the appendages and the enlarged uterus itself, I always favor the removal of the diseased uterus, along with the tubes and ovaries. The one and only point which comes into consideration in this decision is whether or not the uterus is large enough to be delivered through the abdominal incision. If it can be delivered, the hysterectomy is always performed. To my mind one of the great advantages gained in hysterectomy, by the extra-peritoneal method, over oophorectomy, is that no stump or raw surface is left in the peritoneal cavity to become the seat of suppuration, or to whose freshened surface loops of intestine can become adherent. In uncomplicated cases the operation amounts to little more than an exploratory incision, and in my opinion is as safe as an ovariotomy. I have operated fifteen times for large uterine tumors. In fourteen cases the uterus was removed, but in the remaining case the operation was ended as an exploration. Of the fourteen finished operations, two died. The patient whose tumor was not removed was a white woman about thirty-five years of age. The growth had existed for more than ten years. When she was first seen she was in bed, where she had been for some weeks, with an attack of abdominal pain. For months she had only been able to be about at odd times, and considered her life a burden. An operation had been proposed to her a short time before, and its dangers brought vividly before her eyes. She had continued to suffer from pain and hemorrhage, until, in spite of her former fears, she was, at the time I saw her, determined to have the operation performed at all hazards. In spite of her long suffering, she was still a strong, hearty-looking woman. The abdomen was opened at the Gynecean Hospital before a number of physicians, and the tumor found to extend above the pelvic brim. The intestines. were adherent over it at various points, and had to be torn loose in order that a careful exploration could be made. The growth was found to be in the broad ligament, and was consequently immovable. The only adhesions which existed were the intestinal ones, which had been torn through. The removal of the tumor meant a complete enucleation of a solid growth, with all the chances of death from hemorrhage which such procedure entails. It was decided wise to end the operation, explain the condition to the woman, and let her decide whether or not she desired to risk its removal at some subse quent time, or preferred a trial at electro-puncture. The result was a complete symptomatic cure. It is now some five or six months since the operation, and the woman declares she has never been so well in her life; she attends to all her duties, goes to dances, and in all other ways leads an active life. She declares that the tumor is rapidly decreasing in size, and is most confident that it will disappear altogether. She looked at me most sceptically when I told her it would not go away, and that some day all her old symptoms would come back. The last time I saw her-a month ago I was considerably staggered by the fact there was an undoubted decrease in the size of the enlargement. It is barely possible that it may eventually turn out to be another example of a solid tumor becoming absorbed after |