THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES DISEASES OF THE Bladder and Urethra IN AVO M E N BY ALEXANDER J. C. SKENE, M.D., PROFESSOR OF THE DISEASES OF WOMEN IN THE LONG ISLAND COLLEGE HOSPITAL; FELLOW OF THE AMERICAN GYNECOLOGICAL SOCIETY; CORRESPONDING MEMBER OF THE GYNECOLOGICAL SOCIETY OF BOSTON; MEMBER OF THE MEDICAL SOCIETY OF THE COUNTY OF KINGS, AND OF THE OBSTETRICAL SOCIETY OF NEW YORK. Jane and Ktnneth Mackenzie 879ComIsh Drive San Diego, Catifornia 92107 U-SA, Planet Earth NEW YORK WILLIAM WOOD AND COMPANY 27 GREAT JONES STREET 1878 Copyright. WILLIAM WOOD AND COMPANY. 1878. no TO SAMUEL G. ARMOR, M.D., LL.D., PROFESSOR OF THE PRINC PLES AND PRACTICE OF MEDICINE IN THE LONG ISLAND COLLEGE HOSPITAL, THIS VOLUME IS RESPECTFULLY DEDICATED, IN CONSIDERATION OF HIS HIGH SCIENTIFIC ATTAINMENTS. AND IN ACKNOWLEDGMENT OF MANY ACTS OF KINDNESS BESTOWED UPON HIS FORMER PUPIL AND GRATEFUL FRIEND, THE AUTHOR. Brooklyn, L. I., 1878. PREFACE. The following lectures were originally intended for use in the College Class Room, and were de- signed to embody only those things which the stu- dent and general practitioner require to know on the subject, in order to meet the demands of every- day practice. While engaged in this work, the author became impressed with the fact that although numerous valuable publications existed on Veslco-vaginal Fis- tula, medical literature, in the English language at least, contained no systematic work on the many other diseases and functional anomalies of the Blad- der and Urethra. It then occurred to him, that the material collected from the brief articles of various authors added to the results of his own investiga- tions, if put in an available form, might prove of service to others. Having this object in view, the work is now presented to the profession, with a full consciousness of its many imperfections, yet in the hope that it contains sufficient valuable material to vi PREFACE. invite the attention of those who are interested in the subject. The author here records his indebtedness to Professor F. Winckel of Dresden, from whose excel- lent work* much valuable material has been taken. Indeed, some points on Pathology have been freely copied. Acknowledgments are also due to Dr. H. H. Kane for efficient services rendered, especially in the field of Urinary Pathology. A. J. C. S. * Handbuch der Allgemeinen und Speciellen Chirurgie, Billroth und Pitha. Section : Die Krankheiten der weiblichen Harnrohre und Blase. CONTENTS. LECTURE I. PAGE Anatomy of the Bladder and Urethra — Anatomical Relations of the Bladder a»id Uredira — Function of the Bladder — Development of the Bladder and Urethra — Malformations of the Urethra — Malformations of the iiiadder.. I LECTURE IL Functional Diseases of the Bladder — Irritability Due to Abnormalities of the Urine — Paresis, or Paralysis Vesicce — Ischuria and Incontinence, or Enu- resis — Functional Disorders of the Bladder due to Diseases of other Pelvic Organs — Functional Disorders from Anomalies of Position and Form of the Bladder — Extroversion of the Bladder through the Urethra 47 LECTURE III. Organic Diseases of the Bladder — Urinary Analysis and Exploration of the Bladder as Aids to Diagnosis — Hypera^mia — Hemorrhage from the Bladder 109 LECTURE IV. Cystitis — Acute, Sub-acute, Chronic, Catan-hal, Interstitial, Peri and Epi-Cys- titis, Croupous, Diphtheritic, and Gonorrhoeal — Their Etiology, Pathology, and Symptomatology 147 LECTURE V. Treatment of Cystitis — Croupous and Diphtheritic Cystitis — Cystitis with Epi- dermoid Concrement — Vesico-urethral Fissure 19I LECTURE VI. Neoplasms, Cysts, Tubercle, and Carcinoma of the Bladder — Foreign Bodies in the Female Bladder — Hypertrophy and Atrophy of the Bladder — Their Etiology, Pathology, Symptomatology, and Treatment 235 viii CONTENTS. LECTURE VII. PAGB Diseases of the Female Urethra — Urethral Neuroses — Urethritis : Acute, Chronic, and Gonorrhceal ; Circumscribed and Subacute — Urethral Neo- plasms — Vascular Tumors — Areolar, Epithelial, and Compound Neo- plasms — Their Symptoms, Diagnosis, Etiology, Prognosis, and Treat- ment 266 LECTURE VIII. Dilatations and Dislocations of the Urethra — Prolapsus of the Mucous Mem- brane — Foreign Bodies in the Urethra — Stricture of the Urethra — Incom- plete Fistula ot the Urethra 303 Appendix 351 Index 361 The Uro-Cystic and Urethral Diseases of Women. LECTURE I. Anatomy of the Bladder and Urethra — Anatomi- cal Relations of the Bladder and Urethra — Function of the Bladder — Development of the Bladder and Urethra — Malformations of the Urethra — Malformations of the Bladder. Gentlemen — After what you have heard from the chair of General Surgery regarding the various diseases of the urinary organs, you may suppose that anything more on that subject is quite unnecessary. You know, how- ever, that what you have been taught has had special reference to the male ; and to me has fallen the pleas- ant task of telling you of the same and allied diseases in the female. This work is undertaken with some assurance of supplying a want that you will soon be sure to feel. When you engage in active practice, you will en- 2 A.VATOMV OF THE BLADDER. counter a host of cystic diseases amongst your lady patients, many of which will be troublesome, if not impossible to manage. You will, moreover, find but little, in English medical literature at least, to aid you when perplexed with the difficulties of diagnosis and treatment. As we have not sufficient time at our disposal for a complete and thorough consideration of this subject, we will be obliged to omit much, which, though inter- esting, is not absolutely necessary to a clear under- standing of its essential principles. The conflicting views of various authors regarding unsettled questions will, when necessary, be omitted, to make room for the more practical points which you are expected to carry with you to the bedside of your patients. To proceed systematically, we must first take up the structure and function of the bladder and urethra. This may be, in part at least, familiar to you, but as you will lose nothing by going over the ground again, we will briefly review — I St. The form and structure of the bladder and urethra in the female. 2nd. Their topographical anatomy, or the relations of these organs to other organs and tissues of the body. 3rd. Their function. 4th. Their development and deformities. Anatomy of the Bladder. — The bladder is a mus- culo-membranous sac, situated in the anterior part of the true pelvis. Its form varies with age and the AXATOMV OF THE BLADDER. 3 amount of distension. In childhood, the vertical is the longest diameter ; in middle life, the transverse ; and in old age, from dropping of the inferior fundus and gradual atrophy of the pelvic organs, the vertical again becomes the longest diameter. When empty- its walls are closely coapted, and it lies just behind the pubes. When moderately filled it rises slightly above the pubes and attains a somewhat ovoid shape ; the latter, however, being more marked in distension. In the female the bladder has a shorter antero-posterior and a greater lateral diameter than in the male. The bladder in the female, as in the male, is for accuracy and convenience divided into corpus (body), fundus (base), and cervix (neck). The corpus is all that portion of the organ lying above an imaginary line drawn from the ureteric open- ings to the centre of the symphysis pubis. That part lying below is the fundus or base, and is variously divided. That portion of it lying between the vesical openings of the ureters behind and the vesical orifice of the urethra in front, is known as the trigone, or vesical triangle. That portion of the base lying just behind the ureteric openings, is known as the bas fond. It is usually but a slight depression in early and mid- dle life, but disease and age often turn it into a deep pouch or sac. This is more often the case in the male than in the female. The cervix or neck of the blad- der is that funnel-shaped space at the apex of the trigone, where bladder and urethra merge into each other. The bladder has three coats, two complete and one ANATOMY OF THE BLADDER. partial. From without inwards they are the serous (incomplete), muscular, and mucous. The serous in- vestment of the bladder, like that of the other abdomi- nal and pelvic organs, consists of peritoneum, of which Fig. 1. Last Section of Normal Pelvis. (Graj'.) I will speak to you more fully when we come to con- sider the ligaments and topographical relations of this The middle or muscular coat has a peculiarly effi- cient fibre arrangement. Its layers have been divided ANATOMY OF THE BLADDER. . 5 into two, external and internal ; but so frequent and so intimate are their interlacements, that though minutely they are two, practically they act and appear as one. The main direction of the outer fibres is longitudinal ; of the inner, circular. There is also a thin stratum of muscular fibre lying just under the mucous membrane, and continuous with the longitudinal fibres of the urethra. The main fibres are of the unstriped or in- voluntary kind, and take their origin chiefly from the neck of the bladder. According to some authors, the sphincter vesicae is formed by a strong band of muscular fibres, varying from one-eighth to half an inch in thickness. By others, and perhaps the best authorities, it is claimed that there is no anatomical sphincter of the bladder. The function of the sphincter vesicae is said to be per- formed by the closing together of the longitudinal folds of the tissues at the junction of the bladder and ure- thra, or by the transverse semicircular folds that close over each other. At the base of the bladder two little muscular slips arise from the portion usually designated as the sphinc- ter vesicae, and find insertion about the vesical open- ings of the ureters. These muscular fasciculi are but imperfectly developed in the female, and probably have little if any specific action. The lining or mucous coat of the bladder is like that of the ureters and urethra. It consists of a base- ment membrane, supporting two or more layers of epi- thelium, in some parts squamous, in others cylindrical ; the whole lying upon an elastic, cellulo-vascular bed 6 ANATOMY OF THE BLADDER. that Is fitted into the meshes of the reticulated mus- cular coat beneath. This mucous membrane is nowhere attached closely to the subjacent muscular layer, save at the trigone, the neck, and about the orifices of the ureters. Owing to the general looseness of attachment, when the bladder is partially or wholly contracted, the mucous membrane is thrown into rough, uneven folds every- where, save at the points of close attachment already mentioned. In the trigonal space the membrane is thinner, more closely adherent, and the surface epithelium is usually of the medium sized squamous variety. The nerve supply to this small space is very rich, and in consequence it is the most sensitive part of the bladder. Although Savage denies the presence of glands or papillae in the mucous membrane of the bladder, Hol- den and many others maintain (and truthfully, I think) that the membrane is studded with numerous little glands and follicles, whose function it is to supply mucus to the internal surface of the organ. They are most numerous at and about the vesical neck. The trigone in the female is a smaller space, and has less distinctly marked boundaries than in the male. That little elevation of mucous membrane lying at the very apex of the trigonal space, and known as the uvula, is also but little developed in the female. Running between the vesical orifices of the ure- ters Juerie claims to have found what he calls the intcr-ureteric ligament, in the ends of which he asserts that the ureteric orifices are imbedded. To its action ANA TOMY OF THE BLADDER. he attributes the power that the bladder has of pre- venting regurgitation into the ureters. I will speak more fully on this point presently. Fig. 2. Base and Neck of the Bladder. (Savage.) /4, S)miphysis Pubis. I, i, Ureters. 2,3, Uterine Artery and Veins. 4, Outline of Cervix Uteri. 5, Vesical Neck. 6, Arcus Tendineus and Vesico-pubic Muscles. 7, 7, Pubo-coccygeus Muscles. Normally, the bladder has three openings — one for each ureter, and the urethral orifice. The openings of the ureters lie on each side of the median line, at the base of the bladder, about one and a half inches behind the vesical opening of the urethra, and about two inches apart. The ureters pierce the bladder wall obliquely, and their openings are so minute as to be 8. ANATOMY OF THE BLADDER, hardly visible to the naked eye. Their points of en- trance are marked by a slight puckering in the mucous membrane. The third opening is the ostium urethrae internum, which is a diagonal slit at the juncture of the vesical neck and urethra. According to Rutenberg, the color of the vesical mucous membrane, in the living subject, before dilata- tion, is a dirty grayish-red ; but as dilatation proceeds and the irregular folds are straightened out, it becomes gradually a brighter red ; and when complete disten- sion is accomplished, the minute arteries can be seen forminsf a beautiful interlacinsf network on the bands of the muscular reticulse. Whenever it has been my good fortune to see this membrane in the living sub- ject, it has struck me as being of a grayish-pink color, not unlike that of the mucous membrane of the cervix uteri when anaemic. The vascular supply of the bladder is very free, being derived from the superior, middle, and inferior vesical arteries, and branches from the uterine artery. They all arise from the anterior trunk of the internal iliac artery. The anastomoses of the arterial twigs are numerous and free. The veins are also numerous and large, forming by interlacement and connection, thick, tortuous plexi about the base, sides, and neck of the bladder, and finally terminate in the internal iliac veins. This plexus, about the neck of the bladder, communicates freely with that of the labia minora, ute- rus, and rectum. These are the chief elements in the so-called "haemorrhoids of the bladder." In their tortuous course these veins are accompa- ANATOMY OF THE URETHRA. 9 nied by lymphatics that seem to have their origin in the sub-mucous cellular tissue of the bladder. They enter the glands situate about the internal iliac artery, and from there go to the lumbar glands. The nerves of the bladder are of two kinds, spinal and sympathetic. The spinal are branches, usually from the fourth, sometimes from the third, and rarely from the second sacral nerve. They terminate chiefly in and about the neck and base of the bladder. The sympathetic nerves gain their origin from the hypo- gastric plexus, which lies in front of and on the last lumbar and first sacral vertebra. It is formed by a mazy interlacement of numerous ganglionic fibres, and branches from the spinal nerves, especially the second sacral. Ganglia are common, more particularly at the point of junction of the spinal and sympathetic nerves. This plexus sends branches to all parts of the bladder, and to the vagina, uterus, and rectum. This common nerve supply to the various pelvic organs we must bear distinctly in mind, for it will aid us, by and by, in the study of the functional derangements and neuroses of the bladder. Anatomy of the Urethra. — The female urethra is a musculo-membranous canal, from one to two inches in length ; its average being about one and three- eighths inches. Its diameter is greater than that of the male, being about one-fourth of an inch. It lies in the median line, just under the pubic arch, and is held in position by the median pubo-vesi- cal ligament. In the erect position, it has a direction lo ANATOMY OF THE URETHRA. upwards and backwards, and at all times, when nor- mal, its axis closely corresponds to that of the pelvic oudet. It terminates anteriorly at the base of the vestibule by an opening known as the meatus uri- narius, and posteriorly at the neck of the bladder. It has a cellular, a double muscular, and a mucous coat. According to Robin and Cadiat, its mucous membrane is the richest in elastic tissue of any in the body. The epithelial covering of the anterior or lowest portion is of the pavement variety, and closely resem- bles that of the vagina, except that it is not so large. Posteriorly and superiorly it is like that of the bladder — columnar and squamous. Scattered throughout are little papillae, containing blood-vessels ; and, near the meatus, numerous lacunae with villous tufts surround- ing- them. There are also a number of little mucous glands, that in old people often contain small black particles, like the prostatic concretions of the male. The meatus urinarius in the female differs from that of the male in being a puckered and somewhat prominent, rather than a slit-like and depressed open- ing. The mucous membrane of the urethra is thrown into longitudinal folds throughout, save when opened and unwrinkled during micturition or by artificial dila- tation. When at rest it is a closed canal. Beneath the mucous membrane there is a thick fibro-elastic network into which the mucous glands dip. They are lined with cylindrical epithelium and sur- rounded by a network of veins. This sub-mucous areolar tissue has direct vascular connection with the muscular layer that surrounds it, by means of cavern- . ANATOMY OF THE URETHRA. n ous venous sinuses, partly in the muscle and partly in the elastic connective tissue. Thus we gret an arranee- ment, almost exactly like that of the corpus cavernosum penis in the male. The venous plexus of the urethra is situated chiefly at the sides, in what is known as the urethro-pubic space. The muscular layer is double (the outer, circular and spiral, mixed ; the inner, longitudinal), and so close- ly bound together by the cavernous venous sinuses, as to be really one layer. Dr. Uffleman claims to have found an additional external layer, the fibres of which are voluntary. He divides this layer into two — an external and an internal ; the former longitudinal, the latter transverse. These make what he calls the outer or voluntary sphincter of the bladder. From the vesi- cal neck to a point about half way down, it wholly in- vests the urethra, forming only a partial investment from that point to the meatus. Luschka claims to have found a sphincter of the urethra and vaccina. He describes it as beine smooth and circular, from four to seven millimetres broad, ly- ing directly behind the vestibule, and girdling both the vagina and urethra. Its function, he says, is to close the urethra by pressing it on the urethro-vaginal septum. Being closely adjacent to the cavernous ve- nous tissue of the urethra, it locks its fibres posteriorly with those of the musculus transversus profundus. In the female as in the male, the urethra pierces the triangular ligament, two layers of which extend around it ; one backwards and one forwards. There is great diversity of opinion as to the nature 12 RELATIONS OF THE BLADDER AND URETHRA. of the vesical opening of the urethra in the female. According to Winckel and Simon it is a diagonal slit, the mucous membrane of which is longitudinally and superficially corrugated. According to Savage, it is a triangular opening ; and according to Holden and others, a funnel-shaped opening. It of course varies somewhat with age, size of urethra, vesical contraction or quiescence, and in the living and dead subject ; and hence the diverse opinions of the various observers. Anatomical Relations of the Bladder and Ure- thra. — Having discussed the anatomy of the bladder and urethra, we must now examine the topographi- cal relations of these organs. This is very necessary to a proper understanding of the influence of other organs in causing disease and displacements of the bladder and urethra. The bladder of the female lies lower in the pelvis than that of the male, and lies between the pubes an- teriorly, the uterus posteriorly, the vagina and uterine cervix inferiorly, and the small intestines superiorly. The organ, when empty, lies forwards on the symphy- sis pubes, its highest point slightly overtopping it. In this position it occupies but little space. When partially or wholly filled it rises above the pubes to a varying extent. In doing this it alters but slightly the position of the other pelvic viscera, although rel- atively its position is somewhat changed. Anteriorly the bladder is closely attached to the posterior face of the pubic symphysis. Inferiorly, it forms a close attachment to the anterior vaginal wall RELATIONS OF THE BLADDER AND URETHRA. 13 by means of a dense cellular cushion, which increases in thickness from before, backwards. The bladder rests upon this vesico-vaginal septum as far up as the point where the body and neck of the uterus join each other. Posteriorly and somewhat superiorly to the bladder lies the uterus, and superiorly and postero-laterally lie the ovaries and broad ligaments. The close attachment of the vesical neck to the pubes anteriorly and the vagina inferiorly makes a kind of wedge that gives but little surface for bag- ging downwards, if the vagina holds its proper posi- tion. Though imperfectly, still to a certain extent, this arrangement resembles the perinseum in the male. Superiorly, the organ is held in position by a num- ber of ligaments ; five false, and five true. The false ligaments (one superior, two lateral and two pos- terior), are formed of peritoneum. This membrane is reflected from the inner face of the anterior abdominal wall on to the bladder, investing it superiorly, laterally, and, to a certain extent, posteriorly. It joins the organ in front, dipping down just above the pubic summit to the superior vesical surface, and passes as far backward as the point of contact between the vesi- cal base and uterus, which is at the junction of the uterine body and cervix. Although this peritoneal covering of the bladder is firmly adherent, it never leaves its uterine or other attachments, however much the bladder may be distended and rise above the brim of the pelvis. That portion of the bladder lying on the inner face of the pubes, that resting on the vagina and ute- 14 RELATIONS OF THE BLADDER AND URETHRA. rine neck, and a small posterior and lateral space, have no serous investment. The true licfaments are also five in number — two anterior or vesico-pubic, two lateral, and the superior or urachus cord. Laterally, the round ligaments of the uterus pass over the bladder wall, and just below and posteriorly the ureters enter the organ. To do this they incline forwards behind the uterine arteries and veins, and passing forwards and Inwards, behind and then through the utero-vaginal venous plexus, enter the bladder by piercing its coats obliquely. Their points of entrance into the organ are from about one-half to three-quar- ters of an inch in front of the cervix uteri. Just In front of the small lateral space lacking se- rous investment, the obliterated umbilical arteries pass upward and forward to the summit of the organ, reflect- ing the peritoneum, and thus forming a double pouch on either side. The relations of the urethra are these. It lies just under the pubic symphysis, and, piercing the deep perineal fascia, extends from the vesical neck, at the ostium urethrae internum, to the meatus urinarius, or ostium urethrae externum, situate at the base of the tri- angular space known as the vestibule. Its anterior three-fourths Is imbedded in the vaginal wall. The meatus urinarius lies about four-fifths of an Inch below the clitoris, in the vaginal margin of the vestibule. The vesical end of the urethra Is about the same distance below the lower surface of the pubic symphysis. Its course Is upwards and backwards In a very slight curve. FUNCTION OF THE BLADDER. 15 Function of the Bladder. — The function of the bladder is to act as a reservoir for the urine, and at proper intervals to expel it through the urethra. The filling of the organ with urine is a comparatively slow and gradual process, the fluid entering it from the ure- ters drop by drop, or in a very small stream. As it enlarges it does so in the direction of least resistance, viz., laterally and superiorly. The lateral being Its longest diameter, it enlarges first in that direction, until after a time a limit is set by the bony pelvic boundaries, when it rises from the pelvis somewhat, thus escaping from the pressure below. This movement of the blad- der is facilitated by its serous surface gliding easily over that of the adjacent organs. When a certain point in the filling of the bladder is reached, if the organ be in a healthy condition, a sensory influence is conveyed to the brain, which de- velops a motor impulse that causes contraction of the muscular coat of the bladder, by means of which the vesical contents are expelled, through the urethra. There has been considerable discussion amongfst different authors as to whether closure of the vesical urethral orifice is a voluntary or an involuntary act. Witte and Rosenthal maintain that the closure is due to "tonicity from nerve force," which resists the urine pressure. Kupressow holds the same view, basing his opinion on a series of experiments which he made; and further maintains that the sphincter vesicae is at the neck of the bladder to eject the urine completely out of the urethra, in place of standing guard and holding the vesical outlet closed. i6 FUNCTION OF THE BLADDER. On the other side it is claimed that this musculo- elastic rinsf hinders the entrance of urine into the ure- thra, but that the tension of the bladder walls, when the organ is filled, overbalances this elasticity, and a drop of urine escaping into the urethra, the necessity for urination is brought to the senses, and the act then becomes a voluntary one. It has been found, however, in cases of urethro- cystic vaginal fistula, where the upper part of the ure- thra and neck of the bladder were totally destroyed, that after the healing of the parts, the anterior or lower end of the urethra was practically able to control the urine. The act of emptying the bladder is a very impor- tant and interesting process, and is not so simple as you might at first imagine it to be. As the organ has three openings, and is emptied by the concentric con- traction of its muscular coat, we not only have the urine expelled through the urethra, but there is a ten- dency to regurgitation or backward pressure of the fluid into the ureters. This backward flow is effectually pre- vented by a very complete and interesting arrangement. The protection is three-fold. ist. The oblique direction that the ureters take in piercing the vesical wall. 2nd. The two muscular slips, already mentioned, that pass from the sphincter vesicae to the insertions of the ureters. As the bladder gradually fills these slips are drawn "taut," and thus partially or wholly close the ureteric orifices. We may, moreover, presume that as these muscular fasciculi have their origin in the vesi- cal neck, they act most vigorously during urination, FUNCTION OF THE BLADDER. 17 when the bladder pressure tends to cause regurgitation into the ureters. Their greatest use is, in all probabil- ity, during the act of micturition. This view is borne out by the fact that these little muscles are in a rudi- mentary condition in the female, she having but a short urethra, and requiring less force to empty the bladder; and further, by the well known fact that when hyper- trophy of the muscular walls of the female bladder does occur, these fasciculi are proportionately enlarg- ed. 3rd. A ligamentous band, not described in your anatomies, runs from one ureteric opening to the other, enclosing their vesical ends. It is known as the inter- ureteric ligament, already mentioned. Its mode of action is this : As the bladder gradually fills, the open- ings of the ureters are carried farther apart, and with them each end of the ligament. It, being elastic, gives to a certain extent, and after a time, being able to yield no more, pulls upon both openings, closing them more or less completely. During urination the ligament tension gradually decreases, and it is then that the muscular fasciculi and the oblique direction in which the ureters enter the bladder comes into play; the liga- ment being of use only during filling and distension. If from any cause the bladder is not emptied at the proper time, the organ is not only injured by over-dis- tension, but more serious results may follov/ if the re- tention continues for some time, although the bladder is too full to receive any more urine, the kidneys continue to secrete it, until not only the bladder, but the ureters, renal pelves and kidney tubes also become over-filled. When the pressure on the urinary side of the Malpigh- i8 FUNCTION OF THE BLADDER. ian tuft equals that of the blood stream in the glomer- ulus, secretion of urine at once ceases, and we have a mechanical suppression. After death the bladder, ure- ters, and renal pelves are found to be greatly distended, and the kidney pale, of a bluish, pearly color in the cortex, and oozing urine from the cut surface. In the normal condition, the mucous membrane of the bladder is said by some to differ from every other mucous membrane in the body, in that it does not ab- sorb anything. There are those, however, who believe directly the contrary. L. Schafer found that after producing vesico-vaginal fistulae in animals there was an increase of from two to three per cent, and from four to five per cent in the amount of urine passed, over that passed before the fistulae were made ; and he feels convinced that under normal conditions of urinary secretion, the amount of urine in the bladder is gradually diminished by a slight though regular absorption of its watery elements. If this be true, we may look to a too rapid absorption as one of the causes of gravel and urinary calculi. On the other hand, however, Susini found that after injecting Potassium Iodide and Belladonna into his own bladder, and retaining them for many hours, no trace of the former was found in the saliva, and no ap- pearance of the specific action of the latter was made manifest. Ailing agrees with Susini, and the experi- ments of P. Dubelt also support this view. The im- portant point for you to remember is, that, so far as we know, the bladder does not absorb anything, save pos- sibly a little water, unless its epithelial surface is dis- FUNCTION OF THE BLADDER. 19 placed or destroyed. When abrasion does occur, ab- sorption is rapid and its effects marked. The fact that the mucous membrane of the bladder is able to absorb liquids after erosion of its epithelium, throws much light on the cause of some of those peculiar constitutional symptoms accompanying Chronic Cystitis, and known by some authors as Ammonaemia. The mucous membrane of the urethra is said to absorb remedies with moderate freedom, even in its normal condition. The inner surface of the bladder is lubricated by a very thin secretion of mucous. You can satisfy your- selves of this fact by putting some fresh, normal urine in 3, clean bottle. In a short time a slight hazy cloud will settle to the bottom. When examined microscopi- cally it will be found to consist of a few epithelial scales and mucous fibrillae — long, fine, and often interlacing. In disease this secretion becomes greatly increased, and is then thick, viscid, and ropy. The normal se- cretion is slightly alkaline, and when tested chemically is found to contain an abundance of the earthy and alkaline phosphates. A healthy woman urinates from four to six times in every twenty-four hours, and passes in all from thirty- five to sixty ounces of urine, the average being about forty-five ounces. The amount passed varies much with the season of the year, more being passed in win- ter than in summer ; with the amount of fluid ingesta, rest, exercise, &c. Neither limpid nor concentrated urine are well borne by the bladder. The pressure of the urine in the bladder being of 20 FUNCTION OF THE BLADDER. importance in both health and disease, I give you the results of some experiments by Schatz, Odelbrecht, Hegar, and Dubois. These experiments were made with the Manometer, an instrument that, by means of a column of mercury, registers the exact pressure in the bladder. On standing, they found the pressure to be from thirty to forty centimetres, while in the recumbent pos- ture, it was only from ten to fifteen centimetres. The pressure in the recumbent position, Dubois believed to be due not to visceral pressure from above, but to the natural tonicity of the distended organ ; for in the corpse, after removing the other viscera, the pressure in the bladder indicated ten centimetres, plainly due to the elasticity of the organ itself The same has been observed in cystocele, in which the visceral pressure is also absent. The pressure is about the same in both sexes, and at all aees. It was found to rise from one to two cen- timetres with each inspiration, and to fall about the same with each expiration. In laughing, coughing, &c., it rose as high as from fifty to one hundred and fifty centimetres. In diseases of the spinal cord, such as myelitis, and after injuries to the vertebrae, Dubois found a marked decrease in bladder pressure. These curious observations on the varying degrees of pressure arising from change of posture are not without value. They will help you to understand why, in some diseases of the bladder, we direct our patients to maintain the recumbent position. DEVELOPMENT OF THE BLADDER AND URETHRA. 21 Development of the Bladder and Urethra. — With this brief sketch of the structure and function of the bladder and urethra, we may now turn our atten- tion to the development of these organs. It would be very interesting, from a scientific point of view, to examine the process by which the bladder and urethra are formed in the embryo ; but it would, I think, be rather tedious to take up the subject in all its minu- tiae. A few of the more important points in the pro- cess of development must be understood, however, in order to comprehend the malformations which are oc- casionally met with. Most, or at least many, of the malformations of the urinary apparatus, like those of other organs, are, as we shall see, due to arrest of de- velopment at various stages of tt^at process. A clear conception of the normal, then, will help us to a better understanding of the abnormal. The urinary organs are developed in separate por- tions or sections, having distinct points of origin ; and by the union and fusion of these parts, the entire ap- paratus is completed. The bladder, as you may remember, is formed from a portion of the allantois. When the abdominal plates of the embryo close around that portion of the allantois that forms the umbilical cord, it also shuts in a portion which forms the urinary bladder. There remains, for a time, a direct communication between that portion of the allantois from which the bladder is formed and that which makes the cord, it taking the name of the ura- chus. The canal or duct in the urachus is usually obliterated before or soon after birth, so that all that DEVELOPMENT OF THE BLADDER AND URETHRA. remains of it is an impervious cord, known as the superior vesical ligament. Bear in mind, then, that the bladder is developed from the allantois, which may Fig. 3. Development of the Bladder and Urethra. V. Embryonic part of the Allantois Vesica, d. Rectum. Iv. Septum Recto-vagin- ale. C. Anus. F. Fold between the Intestines and the Allantois. S. Sinus Uro-genitalis. In 5) ^ meets upon the Allantois instead of upon the Large Intestines. In 6 and 7) Miiller's Ducts end in the Bladder. In 6) Atresia ani c. Atresia Vaginae Vesicalis. be called one centre of development for the urinary apparatus. The centres of development for the ureters are the same as those for the kidneys. Indeed, the ureters are processes that are developed from the kidneys, and ex- tend downwards until they unite with the bladder and finally open into it. While the bladder and ureters are being thus form- ed, the lower portion of the alimentary canal — that which forms the rectum — becomes separated from the section of the allantois that forms the bladder. Into this space, between the rectum and bladder, Miiller's ducts descend, and uniting, form the vagina. MALFORMATIONS OF THE URETHRA. 23 Posterior to Miiller's ducts, and anterior to the rectum, a mass of tissue is developed which helps to form the recto-vaginal wall above, and the perineum below. Anteriorly Miiller's ducts unite with the lower por- tion of the bladder, and aid in the formation of the ure- thra ; at least the upper portion of its posterior wall. The lower or external portions of the genito-uri- nary organs are formed from an ovoid eminence that appears in the median line of the lower anterior part of the trunk of the embryo. At the lower part of this eminence there appears a fissure, which, incurvat- ing and uniting with the lower portion of Miiller's ducts (vagina), forms the terminal portion of the ure- thra and the introitus vao-inse. From this same centre of development the labia majora and minora and vesti- bule are formed. Malformations of the Urethra. — Malformations, as we have said, are usually the result of arrested de- velopment. Various failures in the processes neces- sary to form the complete urethra, give us a number of malformations. The most important of these may be classified as follows : — I St. Defectus Urethrae Totalis. 2nd. Defectus Urethrse Externus. 3rd. Defectus Urethrae Internus. 4th. Atresia Urethrse. In the first form (Defectus Urethrae Totalis) there is, as the term implies, entire absence of the urethra. It is said to be due chiefly to an arrest in the develop- 24 MALFORMATIONS OF THE URETHRA. ment of the vagina at a point where it should form the main portion of the posterior wall of the urethra. It is very probable that there is, also, an arrest of develop- ment of the clitoral process. Occurring with this malformation other develop- mental defects are generally found, but it has been known to exist with an otherwise perfect genito-urinary apparatus. Petit tells us of the case of a child, four years old, who had neither urethra, clitoris, nor nymphae, but a comparatively wide vagina. Langenbeck also mentions the case of a girl, nineteen years of age, in whom the bladder and vagina formed a common canal. She was incontinent up to the age mentioned, and is reported to have gained control of her bladder after- wards. The second deformity (Defectus Urethrae Exter- nus) is where the lower and anterior portion of the urethra is absent. It has been called hypospadias iit the female. One of the most marked cases has been recorded by Von Mosengeil. The subject was a girl eight years old. The opening in the urethra was situated below a large clitoris, having a very full pre- puce. It was much higher than the normal situa- tion of the meatus urinarius. There was a groove running from the lower border of the vestibule up to the opening of the urethra, and it appeared to be formed from the anterior wall of the urethra. The upper portion of the urethra held its normal relations to the bladder and vagina, and was only one centime- tre long. The bladder, in comparison with the other organs, was larger, and had a number of sacculae. MALFORMATIONS OF THE URETHRA. 25 You will observe that in this case the upper portion of the urethra was complete, and that there were pres- ent in the lower portion of the canal an anterior and two rudimentary lateral walls, the posterior wall alone being absent. There is another form of Defectus Urethrae Exter- nus, or hypospadias, in which the lower part of the canal is entirely wanting". In such cases, there is but one opening between the clitoris and perineum, and but one canal, this dividing into vagina and urethra at some distance from the outer opening. An interesting example of this was observed by Willigk, in a woman who died at the age of forty-six. The uro-genital canal, at its opening, was about the size of a catheter, and ran in a curved direction under the pubes. About an inch and a half from its outer opening it divided into two passages, one anteriorly, \" long — the urethra, and one posteriorly, 2" to 10'' long — the vagina. The third deformity (Defectus Urethrae Internus) is that in which the internal or upper portion of the ure- thra is wanting, and is a comparatively rare affection. The only cases of which I know, are given by Ober- teufer and Duparcque. In Oberteufer's case, as I understand it, the lady was forty- two years of age, and all her life had passed water from the umbilicus. Her vagina was normal, and so were the external genital organs. The upper or internal portion of the urethra alone was wanting. Duparcque's case was one where the urethra was pervious up to the bladder, but was there closed. This case, however, appears to me more properly to come under the head of Atresia Urethra. 26 MALFORMATIONS OF THE URETHRA. The fourth class (Atresia Urethrse) is a compara- tively common affection. There are two forms of con- genital Atresia mentioned by the authorities. The first is produced by imperfect development of the vaginal process, or of both the clitoral and vaginal segments. Duparcque's case was of this kind, the urethra being open up to the bladder and there closed. It was a form of Defectus Urethrse Internus,with Atresia at the upper end of the canal. In this case the bladder and ureters were greatly distended. The other form of Atresia is found when the clit- oral and vaginal processes are both defective. In such cases there is no trace of a urethra, except an imper- fect vaginal wall, which extends obliquely downwards and closes the bladder. E. Rose relates a case of this kind in which the bladder, kidneys and abdomen were filled with water. The urethral malformation was not the only one in this case, the vagina and uterus suffer- ing from an arrest of development ; they being double, or rudimentary. The symptoms that arise from malformation of the urethra are incontinence in the one class of cases, and retention of urine in the other. When the urethra is deficient in part and the bladder perforate, urine constandy escapes ; and from the wetting, the excori- ation, and the odor, the unfortunate subject is kept in continual misery. In cases where there is an abnormal contraction of the vagina, the urine can be retained, partially at least. This is supposed to be effected by the small size of the genito-urinary sinus, and, possibly, a voluntary con- MALFORMATIONS OF THE URETHRA. 27 traction of the sphincter vaginae muscle, which may- act as a sort of sphincter, and aid in the retention of urine. Atresia of the urethra, and the consequent reten- tion of the urine, cause hydrops of the bladder, ure- ters, and kidneys, and also ascites, as we have already mentioned. Distension of these organs occurs in utero, and such malformed children are usually born dead, or die soon after birth. So great is this distension of the bladder and abdomen in some cases, that delivery is difficult or impossible until the fluid is evacuated by puncture. I remember seeing one such case. The head was delivered, but we had great trouble in de- livering the body. The abdomen was enormously en- larged by the over-distension of the urinary organs. The child was very feeble, and after moaning for a few hours, died. No effort to relieve the bladder was made, because a diagnosis was not reached until the little one was dead. This malformation usually leads to fatal results, and our knowledge avails us little, save in accounting cor- rectly for the cause of death. The only natural way that the evil effects of this malformation can be obvi- ated, is by the occurrence of another developmental anomaly, viz., fistula of the urachus, the urine then es- caping from the umbilicus. Atresia is an undoubted factor in the production of urachal fistula. I shall speak more fully of this when we come to vesical mal- formations. When Defectus Urethrse Externus occurs in pa- tients whose uro-genitals are otherwise normal, the 28 MALFORMATIONS OF THE URETHRA. function of the bladder and reproductive organs may all be performed easily and uninterruptedly. Coitus has been possible, and conception has been known to occur in such cases. In making a diagnosis of these deformities, you cannot depend on the symptoms alone. A physical examination of the parts is necessary. You must ob- serve the general relative appearance of the external organs, and, if the vagina be large enough to admit the speculum, you can introduce it, and easily learn if there is any malformation internally, and the exact seat and nature of it. You will have very little trouble with such cases ; but where the entrance to the vagina is so narrow that it cannot be entered by sound or spec- ulum, your diagnostic skill will be taxed. Such cases resemble imperforate hymen, or acquired atresia of the vulva, and one case, at least, was mistaken for an hermaphrodite. Under such circumstances you must try to pass the sound into the bladder, and putting the finger or sound into the rectum, you may be able to make out the presence or absence of a vagina. If the patient is an adult, and the case one of imperforate hymen, you will be likely to find menstrual fluid in the vagina. Should you still remain in doubt, your only resource would be to try dilatation of the introitus va- ginae, and see what lies beyond it. The treatment may be either radical or palliative. Where there is an entire absence of the urethra, with the existence of vesical fissure, or in persistence of the sinus uro-genitalis with partly developed urethra, the production of an artificial canal has been suggested. MALFORMATIONS OF THE URETHRA. 29 This may be done by dissecting, from the vaginal wall, a flap from under the symphysis. It must be from five to eight milHmetres in breadth. It must then be turned, with its epithelial surface inwards, and united with the freshened edges of the vesical fissure. It is objected by some authors that even if the operation is successful, the patient will be but little benefited, her new urethra being devoid of muscular tissue, and consequently lacking the power of contrac- tion. The passing of urine into the vagina, however, will be done away with, and her condition be greatly bettered by the use of an artificial urinal. This of itself is a great point in favor of the operation. Heppner believes that the method of producing an artificial urethra by trocar puncture of the soft tissues and sewing up the vesical fissure, is dangerous, in that vessels of considerable size are liable to be injured ; a further disadvantage being that the canal tends to close. The cases of Carbol and Middleton bearing on this point he throws aside as unreliable. He more- over maintains that reduction of the vesical fissure to the size of the urethra is a disadvantage, since the ante- rior wall of the fissure will be without any muscular tis- sue. The experience of those who have treated fistula has been, so far as he knows, that linear clefts, even of greater caliber, hold back the urine better than round openings of smaller size ; the former allowing more complete coaptation of the edges. In Heppner's case, there being only nocturnal in- continence, he contented himself with applyino- a bandage in the manner suggested by Sawostitzki. A 30 MALFORMATIONS OF THE URETHRA. girdle was put around the lower part of the abdomen, and to it was fastened a little olive-sized compress, by means of a steel spring, something after the manner of a truss. When put into the vagina this compress pushed the posterior vesical wall against the pubic symphysis, thus closing the opening and relieving the incontinence. The patient soon became used to the instrument, and obtained great relief from it. Atresia of the urethra can only be cured by opera- tion. Carbol operated in 1550 on a servant girl in Beaucaire who had had this difficulty from her youth up. Her urine flowed from a coxcomb-like growth, some four fingers in length, on the navel. The stench that arose from her was intolerable. He perforated in the region of the urethra, and successfully ligated off the growth at the umbilicus. In the case of a child, seven days old, who had never passed urine, and whose body was enormously distended with it, Middleton pushed a trocar through in the direction of the absent urethra, emptied the bladder, and kept the opening pervious. Oberteufer's patient, who had atresia urethrae and urachal fistula, relieved herself somewhat by wearing a large sponge, secured in position by a bandage, over the navel. In such cases as this we must bring to bear the apparatus usually employed in urinary fistula. The anomalies known as epi and ana-spadias, all belong under the head of vesical fissures. Before leaving this interesting subject I will men- tion another rare malformation. It is an obstruc- tive anomaly, and consists in a double condition of the MALFORMATIONS OF THE BLADDER. 31 urethra. The only case lately described with any accu- racy is that of Fiirst. He observed in a preparation taken from the body of a young virgin the following peculiarities. In looking at the anterior bladder wall, at the first glance, only one urethral orifice was to be seen, but 0.3 centimetre forward toward the meatus the single urethra was seen to bifurcate ; a fine septum, nearly straight, divided it from right to left into an anterior and posterior half, they continuing with an ever enlarging and diverging septum until they opened into the vagina about 0.2, centimetre apart. In this way they twisted, so that the anterior or superior one open- ed towards the right, while the posterior (the one in the region of the bladder) opened into the vagina on the left. The left urethra opened, with a caliber of 0.5 centimetre, into the median line of the vagina. The right opened on the right of the median line, having a caliber of only 0.3 centimetre. The length of the whole urethra was 2.5 centimetres. It is of very rare occurrence that the double condi- tion of the allantois persists in this manner, and, con- sidering all the changes that the sinus uro-genitalis has to go through, it seems strange that blending did not take place. It is also interesting from the fact that the allantoic openings into the cloaca can only take place by a very rapid and early interruption of development. The uterus and vagina, in this case, were perfectly normal. Malformations of the Bladder. — The most fre- quent and prominent anomaly of development in the 32 MALFORMATIONS OF THE BLADDER. bladder is that of fissure. It consists in partial or com- plete absence of the anterior vesical wall, and is usual- ly accompanied by malformations of the other organs. The anus and navel, as a rule, lie nearer than normal to the pubic symphysis. There are various grades of this affection. There may be simple fissure of the lower part of the bladder, with the opening about 1.5 centimetres in breadth, as has been seen by Desault, Palletta, Gosselin, Coates, and others. In their cases the symphysis pubis was but loosely united. There may also be fissure of the clitoris. A higher grade of malformation is that in which the fissure is near the umbilicus, the lower part of the pelvic cavity and the pubic symphysis being closed, and the lower part of the bladder, urethra, and outer geni- tals normal. This condition is next in order to patency of the urachus — Fistula- Vesico-Umbilicalis. In the latter case, the urachus may remain pervious its entire length, and open into the ring of the umbilicus. The highest grade of vesical malformation is that in which the whole anterior bladder wall seems to be absent. In these cases the inferior abdominal region is generally much shorter, and the navel nearer the base of the pelvis. The abdominal walls are divided, and the resultant fissure is filled up by the bladder wall, the mucous membrane of which is puffed out and red, and gradually merges into the skin of the abdomen. It is often wrinkled, thickened, moist, shiny, and the edges dry and covered with thickened epidermis. On each side of the lower portion of the everted MALFORMA TIONS OF THE BLADDER. 33 bladder are situated the orifices of the ureters. They usually appear as little excrescences, but are some- times hidden in the folds of the membrane. The pubic bones are imperfectly developed, and the pubic sym- physis never closed, save by a ligamentous band, the bones lying from one to eight centimetres apart. These diastases of the ossa pubis, as has been shown by Dubois, Dupuytren, Mery, and Littre, are con- genital. As a rule in such cases, the urethra is absent. The clitoris is either divided, with a portion on each side of the upper part of the imperfectly formed labia, there may remain but a trace, or it may be entirely absent. The hymen can be seen under the fissure. The vag- ina may be absent, as Herder and Eschenbach have seen; and the uterus divided by a septum. Atresia vaginae and imperfect ovaries have also been found in such cases. This grade is known as Eversio or Ex- stropia Vesicae. If there is simply a fissure of the bladder, the organ may be prolapsed through the fissure (Inversio Vesicae cum prolapsu per fissuram). This must be distinguished from Inversio Vesicae cum prolapsu per urethram, and Exstropia from per urachum. That you may clearly understand this, you must observe that inversion of the bladder occurs in three ways : first, by protruding through an opening or fissure in its own walls (the form now under discussion) ; second, inver- sion through the urethra; and third, through the pervi- ous urachus. The ureters, as a rule, are considerably widene(^. 34 ETIOLOGY. Isenflamm found them dilated from nine and one-half to fourteen lines ; Petit as much as two inches ; Fla- gani and Bailie found them four inches ; Desault three . inches ; and Littre two and one-half inches, and con- taining small calculi. Their course, as a rule, is changed, they sinking deeper into the pelvis and thence rising up into the bladder. There are, how- ever, exceptions to their enlargement. Bonn in one case (1818) found their length and breadth normal. Winckel also speaks of a case where both kidneys and ureters were normal. Etiology. — You will remember that the original urinary sac of the embryo is the allantois, which takes its origin as a cul-de-sac from the rectum, and is, con- sequently, an offshoot of the intestinal membrane. It is formed by the bagging of the cloaca, which bagging is due to the collection there of urine from the primi- tive kidneys. This allantois, especially in mankind, is double, and remains only a short time. After the fourth week of embryonic life the layers coalesce and the division ceases. Yet the original double form may remain for some time beyond the normal, if there are any hindrances to union. Roose and Creve maintain that the cause of this malformation is the failure of the pubic bones to unite. Meckel takes exception to this, and says that the blad- der in its primitive condition shows itself as a simple, plain surface, which only becomes a cavity by the growing towards each other and union of its edges. Duncan and, at a later date, A. Bonn, and still later, ETIOLOGY. 35 B. S. Schultze and Thiersch, held that vesical fissure had, as Its primary cause, an atresia of the urethra, with great dilatation of the bladder; the distended organ pushing aside, first the recti muscles, later the cartila- ginous pubic bones, and then bursting. E. Rose, on the contrary, maintains that these cases of bladder fissure are cases of perpetuated urachus, and are due to developmental failure In the bladder itself, it remaining open as far as the urethra. He says positively that the edges of recent preparations of the bladder show a fresh, smooth surface and that there is no trace whatever of any cicatrix or callosity. He mentions one case of tearing and rupture where the evidences of such bursting were plainly to be seen. Moergelln, who was unable to find proof of rup- ture as a cause of this anomaly, says that If there was a quantity of urine in the bladder, greatly distend- ing it, there would be a reopening of the urachus or a bursting Into the abdominal cavity, rather than a rup- ture through the abdominal walls. He looks favorably on the idea of a bursting of the allantols before the abdominal walls have closed In front of it. Against this, however, Is the fact that Hecker ex- tracted a foetus with atresia, having an enormously dilated, unruptured bladder. He found In the abdo- minal walls a cicatrized slit, covered by peritoneum. This makes manifest the possibility of a rupture of the abdominal walls and also of the bladder, occurring at a comparatively late date. In the cases related by Rose, no information is given as to whether there was a aormal navel string ; 36 ETIOLOGY. whether there was any urachal fistula; whether the abdominal ring was closed entirely ; or whether the fissure was confined to the inferior part of the anterior vesical wall, as described by Gosselin, Bertet, and others. In their cases it was not possible for the fissure to have originated by the reopening of the urachus. In any case, most of the late authors are agreed that hindrance to the outflow of urine has most to do with the production of this anomaly, and it may, as Rose has shown, and as it has been said before, arise from atresia or absolute absence of the urethra. Another possible mode of causation is by the falling of some of the larger abdominal organs into the little pelvic cavity, compressing the urethra and hindering its formation. E. Rose once found the riorht kidnev in the pelvis, and Winckel has recorded a case described by one of his students, Dr. Kriiger, where the left lobe of a considerably enlarged liver, and a quantity of small intestines, were so tightly wedged into the pelvis as to cause marked bulging of the perineum. Such a condition, coming at a time when the urachus and urethral end of bladder are firmly closed, must tend to form a vesical fissure. Perfect eversion of the bladder may, however, be found at a very early date, even before the two halves of the allantois are joined, as in cases related by Fried- lander, E. Rose, and Winckel. Lying between and in front of the single or double everted bladder or blad- ders, there are sometimes found, as in Rose's and Winckel's cases, bands of perforated skin-folds, behind which a sound may be passed. Their presence may ETIOLOGY, 37 be explained in this way : that the underlying serous connective tissue (Rathke's membrana reunions infe- rior) which closes the abdominal cavity before the development of the skin and muscular system, is the covering of all urachal fistulae, open bladders, and per- sistent allantois. Then, where the urine pressure is the greatest, the bladders move upon each other, so that no farther development can take place between them ; but the abdominal plates develop themselves around and between them. This intermediate development, owing to the im- perfection of the lower connective tissue, becomes a band or rim where the two conically formed bladders push together, so that they cannot become a symmetri- cal whole, but have an intermediate arch. In these cases the cause probably lies in the patency of the urachus, and the eversion of the bladder ; also the open condition of the abdominal walls, interference with the development of the lower parts of the musculi recti, and, later, the imperfect development of the pelvis. There can, however, be a fissure of the abdominal walls without a fissure of the bladder ; the closed or- gan protruding from the abdominal fissure (Ectopia Vesicae). Lately, Ahfield has brought forward the hypothesis that eversion of the bladder is complicated with and dependent on a pulling downwards of the ductus omphalo-meseriacus, making an obtuse angle inferior- ly, whereby the rectum being pushed forward it pushes the inferior wall of the allantois before it. Communica- 38 ETIOLOGY. tion between the rectum and the allantois ceases, and the allantois, becoming enormously distended, bursts. Ruge and Fleischer contend that in this affection the duct of the umbilical vesicle is implicated, and hold that the tense cord (duct) in question is a continuation of the urachus. Winckel is of the opinion that bursting of the blad- der, at an early stage, from urine-pressure, is the weight- iest cause in the production of bladder fissure. Against the idea of Rose, which is, that eversio vesicae does not take place from rupture, Winckel says that the presence of scars is not absolutely necessary to prove the point, for the abdominal walls are not yet joined, and therefore cannot be ruptured ; and moreover, he has often seen children, immediately after birth, in whom the navel string was normal, and yet an ever- sion of the bladder existed. He raises the query as to why we cannot have rupture of the bladder at an early period, since we know that it occurs later in life, as in women with retroflexion of the eravid uterus. Another fact that he advances in favor of the view that rupture of the bladder is due to urethral obstruc- tion is, that it occurs oftener in males than in females, the former having a canal much more favorable to such obstruction ; for of sixteen cases of vesico-umbilical fistula, given by Stadtfeldt, fourteen were males and two females. Dr. Wiinder of Altenberg (East Germany),' in 1 831 had the cases of two boys (aged respectively eight and eleven), with congenital eversion of the bladder. Their mothers were sisters. The various causes that give rise to vesical fissure, ETIOLOGY. 39 produce also imperfectly developed pelvic bones, dis- location of the head of the femur, and other malforma- tions, from pressure. The excessive dilatation of the bladder drives the horizontal rami of the pubes asunder, and the changed direction and imperfect growth of the pelvic bones cause a lessened acetabular circumfer- ence, and consequent slipping out of the head of the femur. Thus does Voss explain the dislocation occur- ring in one of his cases. It will be found on touching the red mucous mem- brane of an exposed bladder that it is exceedingly sen- sitive. You may also see the urine oozing from the ureters and dribbling- over the surface. The mucous membrane is often protruded and wrinkled up by the movements of the bowels, and can, in case the bladder opening is great, be inverted through the fissure (inversio vesicae fissuram) or through the urachus (inversio vesicae per urachum). If the fissure is small it may remain for years without any inversion. If you replace the prolapsed mucous membrane, and make indirect pressure on the dilated ureters, the urine will spurt from the ureteric ori- fices. Sometimes these patients have partial control over their urine ; as in cases where an umbilical hernia exists with navel fissure, the posterior wall of the bladder being forced into the opening plugs it up. Such a case is described by Paget. The hernial sac, which was about the size of a goose-egg, completely plugged the umbilical foramen, by pressing firmly against the pos- terior bladder wall. If the patient wanted to pass 40 ETIOLOGY. water, the contraction of the bladder caused a gradual disappearance of the hernial tumor ; and when it had entirely disappeared he passed urine from the navel, it also beginning to flow through the urethra. After the urethral flow began, the navel stream ceased, and no urine passed at that point unless strong pressure was made upon the abdomen. Another way in which partial retention, at least, may be accomplished in imperfect eversion, is by the greatly thickened muscular walls acting as a sort of sphincter. Such a case, given by Voss, is that of a female child, twenty months old. When lying down and quiet, the urine did not flow away so freely. The bladder wall was two centimetres in thickness, and the ureters, though from six to seven centimetres broad, were greatly narrowed at their point of entrance into the bladder. In fissures situated low down, there may be coinci- dent inguinal hernia, as is illustrated by a case, related by Bertet. This complication may act so as to aid in the retention of urine. From the constant flow of urine, the inferior end of the fissure and neighboring parts, as a rule, become moist, red, eroded, and sometimes incrusted and ulcer- ated. There may be various painful sensations, as itching, burning, gnawing, &c., and the patient be- comes a nuisance to herself and those about her, from the offensive urinous odor that is constantly given off The edges of the mucous membrane, in time, be- come changed, and approach skin in character. At other points, oftentimes, the membrane is much changed, DIAGNOSIS. 41 having upon its surface loose villous growths, that bleed readily when touched, and give the impression of a malignant new formation. From diastasis of the pelvic bones there is an ir- regular, uncertain gait. The pelvic diametric propor- tions, as observed by Moergelin, are in these cases much changed, the transverse being much greater than the antero-posterior, the dissimilarity increasing as age advances, the proportion being sometimes trebled. Women with these troubles, however, have borne chil- dren. A close inspection of the ureteric openings being possible in these cases, the interesting observation may be made that in action the kidneys seem quite inde- pendent, the one of the other, the right flowing urine and the left none, and vice versa, or both together. Diagnosis. — The diagnosis is comparatively easy, for you distinguish the affection at once by finding the ureteric orifices, with the urine flowing from them. As to frequency, the following statistics are of im- portance. In 12,689 new-born children, Sickles found this malformation to occur twice in 27 cases of develop- mental anomalies. In 3,500 births occurring in the Dresden Institute, from 1872 to 1875, Winckel saw one case. Velpeau, in the year 1833, mentions seeing and finding on record more than 100 cases of this kind. Percy says that he has seen it 20 times in his own practice. Winckel saw 5 cases, 3 of which were girls 42 PROGNOSIS AND TREATMENT. and 2 boys. Phillips saw 21 cases, all girls; but in Wood's 20 cases, only 2 were girls. Prognosis. — The prognosis is usually unfavorable. The children are weak and puny, and as a rule die early. The children, however, are seldom destroyed by the fissure itself. Many of them are born living, can be kept alive, and some attain a fair age. Lebert saw in Salpetriere Hospital, Paris, an old woman with this affection. Operative procedures and the various apparatus to prevent trickling of urine, are of little avail. This, however, is only the case in total eversion. Urachal fistulse, simple fistulae over the pubic symphy- sis, and even those inferiorly, with joined pubis, may be readily cured. Treatment. — Stadtfeldt operated in eight cases of urachal fistula, in seven of which he obtained perfect healing. In deep fistula he recommends freshening of the edges of the skin and mucous membrane, and at- tempting union by the first intention. In cases where the edges extrude themselves very much, he puts on either a clamp or ligature. Winckel favors operative procedure, since in that way you can remove the abnormal protrusion. Some- times, as recommended by Paget, it will be sufficient to freshen the edges, put in insect pins, ligature, and get union in from two to four weeks. In fissura vesicae superior or inferior, you might try to draw the edges together, and even to loosen the skin in front by incision, so as to remove traction TREATMENT. 43 from the edges. In that case it will be necessary to freshen the edges and put in sutures. The result, un- fortunately, is not uniformly successful. In earlier times, in cases of true eversion of the bladder, one dare not operate, and simply had to rely for palliation on urinals. Numerous appliances have been invented, some of them very useful. Gerdy was the first to operate for eversion by closure. Failing to bring an inverted bladder back into place, he tried to form a sufficient sac by partial excision of the ureters. Unluckily, the patient, a man, was attacked with peritonitis and nephritis, and died. Jules Roux, in 1853, proposed cutting out the ure- ters and healing them into the rectum. Simon tried this once, and succeeded ; but the patient died six months after, from peritonitis and exhaustion. Simon, at a later date, again attempted to treat this malformation by operative procedures. He made one inferior and two lateral flaps, but unluckily they became gangrenous. Ten years later, these attempts were more successfully made by John Wood and Holmes. You will find the result recorded by Podruzki. The first one, however, who obtained a perfect result was my colleague. Professor Ayres, of this institution. He cut a long flap from the under and lower side of the abdominal walls, turned the skin side in, and united it with both edges of the bladder.* After him, Wood operated on a girl one and a half years old, whose bladder fissure was continuous with the * For a full account of this case, in Dr. Ayres' own words, with the original illustrations, see Appendix. 44 TREATMENT. uro-genital sinus, so that the os and cervix uteri were always wet. He raised one flap from the neighbor- hood of the navel and another from the soft parts, and turning skin side in, covered them with a larger flap from the other side. The mucous membrane, however, pushed through inferiorly, and broke the fresh adhe- sions. Ashhurst's case was more successful. He cut a piece from under the navel, and joined it with two flaps from the sides (they being somewhat turned), so that their upper edges met each other in the median line. They were joined by sutures, and through each side of the upper flaps two pieces of malleable iron wire were carried, then drawn through the lateral flaps, and twisted over little rolls of plaster. Traction was thus relieved. The flaps healed by the first intention. The sutures were removed on the eighth day. The rest of the wound healed by granulation. When in the upright position, incontinence of urine still continued ; but when lying upon her back, she was able to retain her urine for about two hours, her general condition being thus greatly bettered. Ashhurst also gives a resume of twenty cases of Eversio Vesicae operated on up to his time. Fourteen of these were successful — Ayres, Holmes, Wood, Mo- rey and Barker each being credited with one. Three unsuccessful, by Holmes and Wood; and three with fatal results, by Richard, Pancoast, and Wood. In the last two, death resulted from causes other than the operation. In all cases when the skin is turned in, the growth DOUBLE BLADDER. 45 of hair already there or to come, will be apt to give rise to incrustations. Thiersch in his six cases allowed the flaps to granulate on their raw surface before ap- plying them. When the flap union is perfect, he ad- vises closing completely the upper part of the bladder. Double Bladder. — Cases of double bladder, says Voss, are becoming quite rare as pathological knowl- edge advances, for many of these were, probably, cases of pathological division of the vaginal wall. Mollinetti mentions in his Anatomico- Pathological Dissertations the case of a woman with five bladders, five kidneys, and six ureters. Blasius describes a case of perfect division of the bladder into two halves, which at the vesical neck ended in one common urethra. Each bladder had one ureter. The subject was a male adult. Isaac Cattier has found this anomaly in little chil- dren. One case was that of a child fifteen days old. The bladders were separated by the rectum, so that a fino^er could be laid between them. Soommering found this condition in a child two months old. In one that was born miserably nour- ished, and lived but twelve hours, Schatz found perfect division of the whole genital apparatus, double bladder, and double consfenital vesico-vao-inal fistula. In double bladder, the double allantois, instead of forming one passage, forms two, with a ureter opening into each. Testa gives a case of perfect separation by the va- ginal wall. Scanzoni found, in making a post-mortem 46 DOUBLE BLADDER. examination on the body of a tuberculous woman, a division of the bladder into two lateral halves. He does not say, however, whether the division was com- plete, or whether the septum was pervious. Sometimes horizontal septa are formed that are due, probably, to a crumpling up of a part of the bladder while growing, or a commencing closure of the urachus, lower down than usual. Roser of Marburg had a case of urachal cyst, which, when enormously distended, reached as far as the navel. By means of a small connection with the blad- der, it was filled when that organ contracted, and finally it and the bladder were emptied by contraction of the abdominal muscles. Vesical cysts, diverticula, &c., may be confounded with the anomalies resulting from arrest of develop- ment. The slightest grade of anomaly is that where, as Chonsky has seen, there is no full septum, but simply a band or seam, apparent externally. The diagnosis may be made by urethral dilatation and exploration by the finger and catheter. Destruction of the bladder septa is not to be thought of In case of the existence of urachal cyst causing difficult urination, we might try cyst extirpa- tion by cutting into abdominal walls, freshening and uniting the edges of same with those of the bladder. LECTURE II. Functional Diseases of the Bladder — Irritability Due to Abnormalities of the Urine — Paresis, OR Paralysis Vesica — Ischuria and Inconti- nence, OR Enuresis — Functional Disorders of the Bladder due to Diseases of other Pelvic Organs — Functional Disorders from Anoma- lies OF Position and Form of the Bladder — Extroversion of the Bladder through the Urethra. Gentlemen — Having In our last lecture discussed the anatomy, function, and some of the malformations of the bladder and urethra, we now pass to a consideration of that class of vesical affections known as functional disorders. For a proper understanding of this subject a clear idea of what is meant by the term fimctional disease or disorder is absolutely necessary. It has been the rule to class under this head all af- fections in which no lesion of structure was discoverable in the oroj'ans concerned. AlthouQrh we are still obliofed to accept this nomenclature, the progress of patholo- gical knowledge in the past few years has weeded out many of the so-called functional affections ; and as this knowledge advances, and new and efficient means for 48 FUNCTIONAL DISEASES OF THE BLADDER. observation and study arise, we shall be able to root out many more, thus doing away with much of the vagueness and uncertainty in which this class of affec- tions is shrouded. But even with the improved facili- ties for diagnosis at our command, there are still many diseases in this list Owing to the obscurity at pre- sent surrounding the subject of reflex or sympathetic disorders, i. e., the abnormal condition of an organ or organs, near or distant, affecting the function or nu- trition of another organ, we are obliged to put these affections under this name also. Under this head, then, we will consider all affections due to the following conditions : — I St. Derangements of function in which there is no recognizable organic local lesion. We will here take up the various nervous affections or neuroses of the bladder. We will also introduce, for convenience sake, all abnormalities of vesical function, due to either organic or functional disease of the brain and spinal cord, and to acute and chronic diseases of the general system. 2nd. Diseases of the bladder caused by inflam- matory disorders of neighboring organs, such as Metri- tis, Pelvic Peritonitis, and the like. 3rd. Disorders resulting from uterine displacements or malposition of the bladder itself You will please observe that in this arrangement of the subject, although a number of structural diseases are brought to your notice, they all stand in a causa- tive relation to the disturbed action of the bladder, the latter being free from any organic lesion, and only FUNCTIONAL DISEASES OF THE BLADDER. 49 disturbed in the discharge of its duty by outside Influ- ences. You must fix clearly in your minds the various manifestations of these functional disorders of the bladder, that you may be able to follow me under- standingly in what I am about to say. They are as follows : — 1st. Frequent urination — Polyuria. 2nd. Difficult urination and retention — Ischuria. 3rd. Painful urination — Dysuria. 4th. Pain after urination — Vesical Tenesmus. 5th. Incontinence of urine — Enuresis. These deranged actions of the bladder may be due to organic as well as functional diseases, but for the present we will only discuss the functional troubles. Neuroses, or purely nervous affections of this or- gan, are rather rare, but that they do exist, there is no doubt, for there are certain conditions that seem to de- pend on no other known pathological cause. We learn from our books that V^esical Neuralgia is of this class. It is known by a variety of names, each taking as its key-note some peculiar manifestation or symptom, as Irritable Bladder, Cystospasm, Cystoplegia, Neu- ralgia Vesicae, Tic Doloreaux of the Bladder, &c. You must not confound the term Irritability, so commonly used in speaking of the healthy organ, with the condition known as Irritable Bladder. The former refers to a certain property that the vlscus possesses, by means of which it is able to respond to certain stimuli, while the latter refers to an abnormal 50 FUNCTIONAL DISEASES OF THE BLADDER. condition of sensation, viz., supersensibility or hyperaes- thesia. « Causes. — These neuro-spasmodic affections of the bladder are most common in nervous, excitable, ca- chectic women. In fact all low conditions of the sys- tem predispose to them. As exciting causes may be mentioned great mental trouble, falls, and blows- in the neighborhood of the perineum, supra-pubic region or loins ; exposure during menstruation ; sitting in wet clothes ; lying on the damp ground, or getting the feet wet ; sudden fright ; mas- turbation, and excessive or forcible copulation. It may also come as a sequel of the various lowering systemic diseases. Hysteria holds a prominent place among the causes, the vesical trouble being probably only a fragment of a general neurosis. Acute . and chronic diseases of the brain and spinal cord also produce various vesical troubles of this nature. Any of you who have suffered the mortification of an involuntary evacuation of urine from fear, will understand how the brain and nervous system can influence the bladder. In the variety of conditions grouped under the head of Hysteria, we often observe that frequent urination is a prominent symptom. The cause, in many cases, is the peculiar character of the urine secreted in this disturbed condition of the nervous system. The limpid urine of hysterical patients is deficient in solids, the watery portion being greatly in excess. This unnatural composition renders the urine irritating to the bladder, CAUSES. 51 SO that it cannot be long retained. The quantity of urine secreted is, at certain times, excessive, which, together with its irritating quahty, renders urination necessarily very frequent. But apart from the frequent urination which occurs, for the preceding reasons, in severe attacks of hysteria, we often see cases of frequent evacuation which can only be accounted for by the state of the nerves which govern the action of the bladder. When the quantity and composition of the urine are normal, and the patient can retain it without pain or distress during the night, but has to pass it every hour or two during the day, we may safely conclude that the trouble is functional, and due to a disordered state of the nerv- ous system. The only condition which resembles this history is occasionally seen in prolapsus uteri, the patient being free from trouble while reclining, but having to urinate frequently when in the erect position. Hysterical patients frequently suffer from retention of urine. Some of them complain for a time of diffi- culty in emptying the bladder, and finally fail to do so altogether. At other times they suddenly find that they cannot urinate. There are conflicting views re- • garding the cause of this retention, some believing that such patients cannot urinate, and others that they will not. Those who believe that the trouble is feiened and not real, do so on the ground that in this morbid state of the nervous system the patients enjoy catheter- ization, which would be distressing to any one of heal- thy mind and body. Others claim that in the extreme sexual excitement which occurs in some cases of hys- 52 FUNCTIONAL DISEASES OF THE BLADDER. teria, the chronic erection of the cUtoris makes pres- sure upon the urethra, and prevents the flow of the urine through the then compressed canal. I am satisfied that both kinds of cases occur. There are those who complain of retention when they know that the doctor will use the catheter, but they can urinate easily when they please. Others I have seen who were suffering from excessive and painful disten- sion of the bladder, and would have gladly relieved themselves if they could. Another class of cases resembling the hysterical patients in the frequency of urinating, but differing in every other respect, we find in those who suffer from the habit of masturbation. The constant conges- tion and irritability of the pelvic organs, caused and kept up by the unnatural and excessive exercise of the sexual function, give rise to frequent urination. Such patients complain of general weakness, which is not accounted for by any organic disease of the general system. Nor is there disease of the bladder ; it is simply enfeebled and irritable like the rest of the pelvic organs. To make a correct and positive diagnosis in such cases is by no means easy, because it necessitates our detecting the habit of masturbation, and this is usually one of the most difficult tasks for the diagnosti- cian. It is not always prudent to question the patient regarding the habit ; and even when we do, they fre- quently fail to comprehend the question, or they answer falsely in the negative. We are thus generally left to guess at the truth of the matter The symptoms developed by masturbation are de- CAUSES. S3 pression of the nervous system, manifested by lassitude, sadness, or emotional expressions of joy and sorrow, they being easily affected to smiles or tears. The eyes are dreamy and heavy, and the pupils dilated. Such subjects are excitable, irritable, and easily exhausted. They often have headaches. Nutrition is apparently good in some cases, as shown by the fair supply of flesh ; still they often suffer from acute indigestion, although at times the appetite is remarkably good. The bowels are usually constipated, and the muscles soft and flabby. The exhalations from the skin are sometimes changed so that a peculiar odor is notice- able about such persons. This odor cannot be de- scribed, but when once experienced is easily remem- bered. In all this class of functional derangements of the bladder from neurotic causes, the symptoms vary in severity to a great extent in the same individual. The trouble is by no means regular and constant in its manifestations, as in organic diseases. Whatever dis- turbs the nervous system will increase the disorder. The rule is, that frequent urination is the prominent symptom, but occasionally painful micturition is com- plained of It is then simply a slight scalding pain experienced when the urine is passing over the irri- table or chafed mucous membrane about the meatus urinarius. I must not forget to tell you of another cause which I believe acts through the nervous system, and that is Malaria. The effect of malarial poison on the bladder and urethra is very peculiar. The trouble produced in 54 FUNCTIONAL DISEASES OF THE BLADDER. this way has been called urethral fever, and is described as an inflammation of the mucous membrane of that canal. It might more properly be called malarial fever of the urethra. As I have observed this affection, the bladder and urethra are usually both affected, but I do not consider the disease one of a well-defined in- flammatory character. There are usually symptoms of malaria present, but not necessarily chill and fever. On the contrary, I believe that I have observed the trouble more frequently in remittent than in intermit- tent fever, and very often where the constitutional symptoms were not more than a slight derangement of the digestive organs, with moderate elevation of tem- perature in the after part of the day. The symptoms vary, but usually are as follows : The patient complains of frequent desire to urinate, and some vesical tenesmus ; severe burning pain on passing water, with stinging and burning in the urethra after urination. The history of such cases resembles acute gonorrhoeal urethritis so far as the abruptness of the attack and the tenderness and pain of the urethra are concerned, but there is usually no discharge, or at least very little. In many cases the suffering is great- est in the afternoon and early part of the night. Un- der proper treatment the disease disappears as promptly as it comes on. In disease of the ovaries, we sometimes find that the bladder suffers very much from deranged nerve action. The clearest and best account of this form of functional bladder trouble is given by Fothergill in his paper on " Ovarian Dyspepsia'' published in the CA USES. 55 American Journal of Obstetrics, for January, 1878. In speaking of the derangement of the stomach and pelvic organs he says : " It soon became clear that there was some condition existing which stood in a causative relation to both the dyspepsia and the uterine disturb- ance. That condition was quickly seen to be a state of vascular excitement in one or both ovaries, usually the left ovary. This condition Barnes terms 'oophoria.' In this state there is always more or less pain constant- ly in the iliac fossa, more rarely on the right, much aggravated at the catamenial periods, when the pain shoots from the turgid ovary down the thigh of the corresponding side along the genito-crural nerve. This painful state is otherwise known as 'ovarian dysme- norrhoea.' When pressure is made over this tender ovary during the catamenial flow, acute pain is experi- enced. Pressure also elicits pain during the inter- menstrual interval. At the same time that acute pain is felt, evidence is furnished of emotional perturbation; the patient feels as if about to faint, or ' feels queer all over,' as some express it, and the changes in the patient's courttenance speak of something more than mere pain, pure and simple. It is evident there is a wave of nerve-perturbation set up which excites more than the sensation of pain. Commonly the patient feels sick after the momentary pressure, and asks to be permitted to sit down, alleging that she feels sick and faint. If a careful physical examination be made it will be found that there is an enlarged and tender ovary, which may sometimes be caught betwixt the finger in the vagina and the fingers of the other hand 56 FUNCTIONAL DISEASES OF THE BLADDER. applied to the abdominal wall over the ovary. Such manipulation elicits manifestations of acute suffering from the patient. Frequently the rectus muscle over the tender ovary is hard and rigid, so as to place the organ as perfectly at rest as is possible ; just as we see the rectus to stiffen and become rigid over the liver when there is an hepatic abscess, and thus to secure rest, as regards movement, for that viscus. * * * " Not rarely, too, there is set up a very distressing condition, viz., that of recurring orgasm. This occurs most commonly during sleep, ' the period par excel- lence of reflex excitability.' In more aggravated cases it also occurs during the waking moments ; and this it does without any reference to psychical conditions. "The centres of the pelvic viscera lie near together in the cord, and the condition of one is readily com- municated to another. The brief recurrent orgasm affects the bladder centres, and the call to make water is sudden and imperative, and must be attended to at once or a certain penalty be paid for non-attention. This last is not a common condition, fortunately, but it is a source of great suffering, bodily and mental, when it does occur. The condition of the ovary also acts reflexly upon the uterus, and keeps it in a state of per- sistent erection and high vascularity, with the normal phenomena attendant thereupon." It is evident that this form of bladder trouble can only be relieved by treatment of the ovarian disease, for which the Bromide of Potassium and counter irri« CAUSES. 57 tation are very serviceable, with, of course, attention to the general health. I find the record of some interesting cases, well worth your notice, in the Gaz. Hebdo77i. de Med. ct Chirurg., April 15, 1864, which I 'here present: — A Peculiar Form of Neuralgia not yet Described, Excited BY A Desire to Pass Water and by Micturition. By Dr. PuTEGNAT, of Luneville. The following two cases, out of six published by the author, will give an idea of this peculiar neuralgia, which consists, on the one hand, in a special sensation in the bladder, and on the other, in symptoms of a neurosis of the ulnar nerve. Case i. — M. X , aged fifty, with chestnut hair, of a nervous and sanguine temperament, very abstemious, in affluent circumstances, leading a very active life, occupying very healthy apartments, free from all diathesis, except a slight rheumatic affection, liable to coryza in cold, damp weather, has never had any other nervous complaint beyond headache and occasional gastralgia, after eating dressed salads or raw fruit. From time to time, at varying intervals of weeks, months, and even years, without any apparent physical or moral cause, in all electric, barometric, and thermometric conditions of the atmosphere, as soon as his bladder was full, and he had a strong desire to pass water, he feels along the urinary passages, especially in the perineum, a peculiar sensation of numbness, not very painful, but acute, burn- ing, lancinating, and unpleasant from the accompanying sense of prostration. This strange sensation next affects the shoulders, comes down both arms, along the course of the ulnar nerve only, and gives rise in the forearm, the little and the ring fingers, to the same sensa- tion as when the ulnar nerve is strongly compressed at the elbow. The pain is more acute on the left than on the right side, lasts about twenty or thirty seconds, and after diminishing gradually, disappears without leaving any trace behind it. Case 2. — M. X , of Luneville; living in healthy rooms; very active ; easily moved and excited ; subject to headaches and to rheumatic pains; free from any diathesis; very abstemious; com- 58 FUNCTIONAL DISEASES OF THE BLADDER. plains, for several successive days, but at irregular intervals, and without any known cause, of a strange sensation along the outer border of the left forearm, on the inner side of the thumb and the outer surface of the index finger especially. This sensation he com- pares to the one produced in the last two fingers of the hand by compression of the ulnar nerve at the elbow. The painful sensation only comes on whenever he has a strong desire to pass water, persists during micturition, and ceases completely immediately afterward. On analyzing the six cases of the author, we find four of them to have occurred in females. The mean age of the patients is forty- six : the oldest being fifty-two, and the youngest thirty-six years old. They are all in easy circumstances ; five occupy healthy apartments, the sixth alone, damp rooms on a ground-floor. Three patients have had gastralgia; the fourth, sciatica, and great troubles have shaken his nervous system; the fifth is subject to violent headaches; and the sixth, a female, seems to have epileptiform seizures, and has a double neuralgia. From the above, then, it may be concluded that neuralgia, and great nervous excitability, are predisposing causes of this strange neuralgic affection. In one of the four female patients the catamenia had ceased ; in three they had not, and in two of these the neuralgia showed itself before and during the menstrual periods. Uterine congestion seems then to be a predisposing cause also. Four of the six patients had had rheumatic pains; but the other two having never suffered from such pains, this cannot be considered as the exciting cause of the neuralgic affection. The desire to pass water, and especially micturition, bring on the sensation, which only appears at those stated times, and it reaches its maximum intensity at the beginning of the micturition. It has all the characters of neuralgia, and can even aggravate, as in one case, an already pre-existing neuralgia — that of the median nerve. As to the precise seat of the sensations, we find them affecting the four extremities of one patient, but the upper limbs only of the remaining five. In three cases they simulate to perfection neuralgia of the ulnar; and in two they are felt in the tips of all the fingers. In one case they coincide with and intensify pains in the course of S YMPTOMA TOLOG Y. 59 the median ; and lastly, as in the first case we have given above, they are felt in the distribution of the left radial nerve. The first patient complains of pain in both shoulders, especially the left ; the fourth, of pain in both arms and hands, but chiefly in both breasts, and in the left breast more than the right ; the sixth, again, of pain in both forearms and hands, but more marked on the left side. Hence, the left side of the body would seem to be either the only one affected, or. the one most affected. The patients always distinguished clearly the special painful sensations felt in the urinary passages, from the normal sensations due to a distension of the bladder and the subsequent desire to pass water. Symptomatology. — In almost all of these nerv^ous affections of the urinary organs, pain, and the feel- ing of weight and uneasiness in the region of the bladder, are usually present. Still, the most constant and distressing symptom is the frequent and painful desire to micturate, which the patient tries to relieve by frequent urination ; a few drops only being passed at a time. Of course there are varying grades of this affection, in some of which these symptoms are by no means so troublesome. In some extreme cases, when a little urine collects in the bladder, the pain and irritability are so intense that it is spurted out by a very forcible and painful contraction of the oro-an. The sense of weiofht and bearinsf down are most intense in the upright position. The pains may be local (confined to the neck or base of the bladder), or they may shoot in all directions. The pain in mic- turition may be present at the beginning, but Is usually most severe during and after the completion of the act. The local pain and distress, with the frequent uri- 6o FUNCTIONAL DISEASES OF THE BLADDER. nation and unrest, react upon the general nervous sys- tem, thereby greatly aggravating the original disorder. This lowered systemic condition in turn affects the local disorder, and so the one is continually aggrava- ting the other. In this way, the patient if not relieved goes on from bad to worse, until the host of pheno- mena characteristic of nervous prostration and general ill-health are developed. In certain cases the sufferers are by no means so badly circumstanced, but time and neglect tend to produce these results sooner or later. In some cases again the suffering gradually disappears, and the patient is restored to health without much aid from treatment. The trouble appears to wear itself out. Diagnosis. — The symptoms I have given you are by no means pathognomonic of these affections, the same being produced by organic disease of the bladder, calculi, and various other causes. The diagnosis must be made by exclusion. The first thing for you to do is to make a careful microscopic and chemical analysis of the urine. Not only can local organic trouble be thus eliminated, but important knowledge as to the state of the general system obtained. If no urinary abnormality is discoverable, you should at once proceed to a careful external and in- ternal examination of the organ itself A finger should first be passed into the vagina, and an endeavor made to ascertain, by pressure on the vesico-vaginal septum, whether there is any abnormal sensitiveness of the vesical base or neck, or of both. Then test the PROGNOSIS— TREA TMENT. 6l sensibility of the mucous membrane by introduction of the sound. If nothing is determined in this way, one of the various instruments for viewing the interior of the bladder should be used, and the condition of its mucous membrane carefully examined. If sufficient cause be not found in either the urine or bladder, you may set the case down as one of pure neurosis, to be treated as I shall hereafter tell you. Systemic conditions, such as hysteria or chlorosis, should be considered, as they point to a tendency to neurotic difficulties, liable to be localized. Prognosis. — As a rule the prognosis is favorable. This, however, is not always the case. The longer the affection has lasted the harder it is to cure. Most cases may be cured in a few weeks' time, and even the most obstinate in a few months. The danger to the patient lies in the fact that continuance of the disorder is liable to bring on organic lesion ; and whether this result or not, the reaction on the general system tends, in the worst cases, to produce hypochondriasis or even melancholia. Treatment. — This may be classed as general and local. In pure neuroses your attention should be first directed to bettering the general condition of the pa- tient. Cheerful company at meals and at other times, exercise suited to the strength of the patient, daily ablution, and proper regulation of diet. This should be simple and nourishing, and of a kind calculated 62 FUNCTIONAL DISEASES OF THE BLADDER. to produce as little urea and urinary solids as pos- sible. In cases where the urine is limpid, the oppo- site course is to be pursued. Pastry, irritating con- diments, and stimulants, except in rare cases, should be prohibited. The exception to this is where a condition of the system calling for stimulation exists. In such cases the irritation of the bladder produced by their use may be more than counterbalanced by the good they do the system. Tea is better than coffee, but neither are to be used in any amount. The condition of the urinary secretion must be carefully Avatched, and any abnormality quickly and judiciously corrected. Where there is any tendency to excessive acidity, the effervescing waters rich in carbonic acid gas will be found of use. The bowels should be kept moderately well open, but never be irritated with active cathartic ao-ents. Tonics and medicinal stimulants are often of great value when judiciously exhibited. Strychnia in very small doses, does not, as you might suppose, aggra- vate the irritable condition of these organs. The nerve tone being below par. Strychnia, by gradually raising it, is of great service. In large doses it is un- doubtedly hurtful and should never be long continued. Quinine, Iron, and the various simple and compound vegetable bitters, act well in the cases where their exhibition is called for. If the irritation be extreme, various soothing emul- sions and decoctions may be given by the mouth. Of these, preparations of Marshmallow, Triticum Repens, Acacia, Pareira Brava and Buchu act well. Emulsio- TREA TMENT. 63 Amygdalae is much used and highly spoken of by the German authors. Some objections have been raised to the use of these drugs on the score that they increase the flow of urine, thus aggravating the local irritability. The fact is, however, that the presence of fairly normal urine in the bladder in any amount, seems to relieve rather than increase its irritable condition. Your local treatment may be as follows : A cupful of warm hop tea, containing from twenty to forty drops of Laudanum, may be injected into the rectum. Sup- positories containing opium may often be used with benefit. With the opium or morphine in the supposi- tories may be combined Belladonna, Atropine, or Hyoscyamus. Morphine, in the form of Magendie's Solution, may be injected directly into the bladder. There seems to be no especial advantage in this mode of administering anodynes; hypodermic injections of the drug acting as well, if not better. Emulsions, decoc- tions, infusions, &c., of Cannabis Indica, Hyoscyamus, Belladonna, and other like drugs may be used by the mouth, as the case may require. Good effects have followed the use of rectal injec- tions containing Chloral Hydrate (grains 15 to aqua Si or Sij). It may also be given by the mouth, but does not usually act so quickly or have such direct local effect. The injection into the bladder of a solution contain- ing Morphine, followed by cauterization of the mucous membrane, is highly spoken of by Braxton Hicks. He claims in this way to deaden the reflex irritability of the membrane. 64 FUNCTIONAL DISEASES OF THE BLADDER. I must insist on this — that you shall use opium in such cases with great care, and never continue it long. If you fail to observe this rule you will lead many of your nervous patients to contract the opium habit, which disease is worse than irritable bladder. Debout recommends the use of Bromide of Potas- sium by the mouth, and also in suppository, combining with it in the latter Tinct. Opii and Belladonna. I prefer Hydro-Bromic Acid to the Bromide of Po- tassium. When the trouble is due to masturbation, moral and mental influences must be brought to bear, as well as medication and regulation of diet and habits. In these cases the Bromides will be of service. If all other treatment fails to accomplish the desired result, you should resort to mechanical means, viz., the rapid and forcible dilatation of the urethra. Some authors, indeed, think so highly of this method that they boldly assert that time spent in medication is time lost. Astonishing and very gratifying results have certainly followed its use in a number of cases. Hewetson reports in the Lancet {p. 4, vol. 12, 1875) that in this manner he cured a case of Cystospasm of fifteen years' duration. This procedure is spoken of in the highest terms by Teale {Lancet, p. 27, vol. 11, 1875), as also by Spiegleberg, Tillaux, and others. In the cases where this treatment gives relief, I believe that there is some inflammatory condition present, or at least something more than a neurosis. When due to malaria, the treatment is usually sim- ple and satisfactory. Quinine in full doses, as recom- ABNORMALITIES OF THE URINE. 65 mended by Bricheleau (A rckives General de Medicin) for one day, and • then in small doses before meals for a week, will usually cut the trouble short and pre- vent its return. The digestive organs require atten- tion when they are out of order, as they usually are. If due to hysteria, treat the original disease, not, however, neglecting the local trouble. When accom- panying acute or chronic systemic diseases, it is only relieved when the original disease is cured, although in the mean time the annoyance may be greatly alleviated by the treatment already recommended. Irritability Due to Abnormalities of the Urine. — Aberrations of vesical function due to abnormal con- ditions of the urine, though not coming properly under the head of neuroses, still should be classed with the functional disorders ; and as we are now upon the topic of irritable bladder, I think it best to take up and dispose of this class of affections in this place. Taking for granted that you are familiar with the main characteristics of the urien, I will not delay you on that point. The bladder being made to contain a certain amount of urine, almost uniform in its compgsition the year round, it at once feels and responds to any abnormality in this fluid. If the aberration is only oc- casional, the effects are slight and of short duration ; but if the abnormality be constant, or almost constant, or if the altered urine has a hyperaesthetic surface to deal with, the results arc more to be dreaded. C6 FUNCTIONAL DISEASES OF THE BLADDER. Urine too acid or too alkaline, too limpid or too greatly concentrated, acts somewhat like a foreign body — it irritates, and the bladder inclines to expel it. . Deposits of any of the urinary solids in the viscus may produce an irritable condition, and if unchecked, lead to oreanic disease of the bladder. Uric Acid in large or small crystals, in little masses forming gravel and minute calculi ; the Amorphous Urates ; the Triple and Amorphous Phosphates (these as a rule, however, occurring only in decomposition of the urine), and Oxalate of Lime, may give rise to considerable trouble. There are some other desposits, such as Cys- tine, that are of such rare occurrence that they need not be mentioned in this list. In any of these cases, but especially in desposit of Uric Acid, there may be one of two things (and you must understand this in order to treat the case properly): ist, a real excess of the salt in the urine ; and 2nd, a condition of the secre- tion where, whether the amount of salt present be nor- mal, or less or more than normal, it will be precipi- tated in the bladder. As an example of the first may be mentioned some cases of dyspepsia, when, owing to a defect in either primary or secondary assimilation, the salt or salts are eliminated by the kidneys greatly in excess of the normal. Here a normal or even an abnormal amount of water in the secretion could not hold them in so- lution, and they are consequently precipitated. As an example of the second may be taken some cases of hepatic disease, in which, though the salt (Uric Acid) is eliminated in abnormally small amount, it is ABNORMALITIES OF THE URINE. ' 67 precipitated by lack of water, excessive acidity, and, possibly, too rapid absorption of the watery element of the urine while in the bladder. In some cases, with an excess of salt there may be excessive acidity, and lack of water. Some forms of dyspepsia are notable examples of this, and as low nerve condition frequently accompanies these disorders, the abnormal urine meets in the bladder with an irritable mucous membrane. In these cases the acidity is quite as hurtful as the deposit. Deposits of Oxalate of Lime in the bladder are not so common (except in lime-water regions) as those of Uric Acid. In cases of the persistent deposit of Oxalate of Lime in the urine, known as Oxaluria, there is usu- ally marked irritability of the bladder. This has been ascribed by some to the presence of minute octahedra of this salt irritating the mucous membrane. It is more than likely, however, that the derangement of the general nervous system always existing in these cases, stands as a propter rather than a post hoc, and that the bladder difficulty is but a local manifestation of the general disease, and consequently a pure neuro- sis. That the urine of Oxaluria does possess irritant properties, there is but little doubt ; but it is hardly likely that they would produce the symptoms here oc- curring, unless there was already an abnormal condi- tion of the vesical mucous membrane. You are told by many authors that you must not take the high specific gravity of a single specimen of urine as an evidence of concentration, or the low grav- ity, of excessive limpidity of the twenty-four hours 68 FUNCTIONAL DISEASES OF THE BLADDER. urine. This is very true in regard to the total amount passed in a day ; but as the bladder has to do each time only with the urine in it at that time, it will be well in these cases to examine several specimens in a day, rather than to depend for information on the reaction, of the total amount of urine passed. Urine may irritate the same patient at one time from being too limpid, and at another from being too highly concentrated. These variations must be care- fully watched and treated. A bladder that is irritable at all times, and under urine of varying reactions, may be set down as one affected with a pure neurosis, if no organic cause be found, for the urine could not work the mischief continually, if healthy at certain periods. Treatment — The subject of urinary pathology and therapeutics is much too extensive and important to allow of my attempting its discussion here. I will sim- ply point out to you some of the main features, and let you work up the minor points yourselves. In cases of concentration due to acute febrile action, the patient should be liberally supplied with cooling drinks ; and as in these affections the urine is gene- rally too acid, the slightly alkaline, effervescing waters will be found. useful. In digestive troubles, with excessive acidity or saline deposit, attention should be paid to diet, bathing, and regularity of the bowels, as well as the taking of a proper amount of exercise. Where deposits of Uric Acid take place there is usually some defect in either primary or secondary assimilation. This should be ABNORMALITIES OF THE URINE. 69 sought out and remedied. In excessive acidity with deposits of Uric Acid, the alkahne carbonates act doubly ; first, by neutrahzing the acidity of the urine, and second, by acting on the liver, to lessen the Uric Acid produced. The following is a very pleasant and efficient manner of administration : ;^. — Potassii Bicarbonatis, Potassii Citratis, aa Sss. Syrupi Simplicis, giv. M. — Sig. — Take 5i in half tumbler of water, adding Sij of lemon juice. Drink while effervescing. Prof Armor gives some very excellent advice re- garding the management of such cases, which I will give you in his own words : — "When the urine is acid in any of the forms of cystic irritation, great relief is experienced from the use of alkalies, especially when administered in an in- fusion of buchu. I regard buchu as a remedy of un- doubted efficacy in all cases of vesical irritability. It seems to possess similar properties over the urinary tract that bismuth does over the intestinal, and is an admirable vehicle in which to administer the various alkalies. The citrate of potash with buchu is an ex- cellent combination where we desire the joint action of these remedies. The liquor of potash, the bicarbonate and the iodide of potash also possess a high degree of utility in the class of cases referred to, and their thera- peutic action is certainly never disturbed by adminis- tering them in an infusion of buchu. " In irritable conditions of the bladder associated 70 FUNCTIONAL DISEASES OF THE BLADDER. with a gouty and lithic acid diatheses, the carbonate of lithium is a remedy of undoubted efficacy. It perhaps excels the preparations of potash in rendering uric acid and the urates soluble. Dr. Murchison speaks in hisrh terms of the foUowinof combination : " Carbonate of Lithium, gss. "Benzoic Acid, S^iij. "Dissolve the acid in lo per cent biborate of soda; then add lithia and distilled water to make Bvj. " A teaspoonful four times a day, with copious draughts of water." Limpid urine is usually due to some general nerv- ous trouble or cerebral disease. The original disease should here be treated. Deposits of Amorphous or Triple Phosphates are rare, unless there is some organic disease of the blad- der. Where the deposits are not due to decomposition, some decided nerve trouble is usually present, and here, as in limpidity, your attention must be turned to treatment of the general trouble. In Oxaluria attention must be paid to the moral, mental and physical condition, and time must not be wasted in treating mere symptoms. In the way of medication, the following prescription is looked upon by many as almost specific in these cases : I^. — Acidi Nitro-Muriatici diluti, Sv-vj. Tincturse Nucis Vomicae, 5iij- Olei Gaultheriae, mxij. Aqu3e ad., Siij. M. — Sig. — 5i in water before each meal. In some cases PAREISIS, OR PARALYSIS VESICjE, ETC. 71 the pure non-diluted acid, freshly made up, acts better than the dilute. It should be given in smaller doses than the dilute, and in plenty of water at the time of taking it. In all cases of urinary deposits, water should be freely taken, and the greatest attention paid to general hygiene and mental and moral surroundings. Many of the slightly alkaline mineral spring waters will be found of use, acting gently on the liver, flushing the kidneys and urinary organs, and slightly relaxing the bowels. A considerable quantity should be taken in the course of the day, on an empty stomach. Pareisis, or Paralysis VesicsD, Ischuria and Incon- tinence, or Enuresis. — Micturition, as I have already told you, is a reflex act, produced by the passage of a sensation through the vesical nerves to the lumbar portion of the spinal cord, up the cord to the motor centre of the vesical nerves in the brain, from which a motor impulse is sent down the spinal cord through the nerves of the bladder to the muscular coat of that organ, causing a contraction of its walls ; and the will realizing the necessity relaxes the sphincter, and the viscus is thus emptied of its contents. Whether this peculiar sensation that is sent to the brain when the bladder is full, is caused by distension or the escape of a drop or two of urine into the urethra — the involun- tary sphincter having been overcome, is still sub jtidice. At present we are only certain of the fact that such an impulse is conveyed, and such a contraction of the bladder and expulsion of urine results. That the will is concerned in the contraction and 72 FUNCTIONAL DISEASES OF THE BLADDER. relaxation of the sphincter is known to you all by the fact that you are by its aid, able to hold your urine, long after the bladder has begun to clamor for its expulsion. We shall now pass to a discussion of Paralysis of the Bladder. This affection has also been known by the names, Weakness and Palsy of the Bladder, and Vesical Atony. Causes. — The causes are of two kinds: ist, those residing in the organ itself, and 2nd, those due to outside influences. We shall only discuss the latter class here, the former finding a place under another head. Acute and chronic meningitis ; apoplexies of the brain or spinal cord ; sopor ; delirium ; myelitis of the lower part of the spinal cord ; inflammation of any kind primarily affecting or involving in its results either the lumbar nerves or ganglia ; endo-arteritis deformans of the pelvic arteries ; lumbar or renal abscesses ; blows or falls on the loins, supra pubic region, or head ; shock or disease of the vesical or lumbar nerves from the pro- loncred use of opium or poisoning by it, as also shock due to over-distension of the organ itself. Causes coming under the head of the first class will be simply mentioned here, and will not be enlarged upon. They are fatty degeneration and atrophy of the muscular walls of the bladder, so common a cause of paralysis of this viscus in old women ; overstrain of the muscular structure from prolonged retention, voluntary or involuntary ; displacements and inflammations of PAREISIS, OR PARALYSIS VESICM, ETC. 73 neighboring organs affecting its position or nutrition ; and abdominal and pelvic tumors. In fevers of a serious type the power of nerve con- duction may be either lost or impaired, and a partial or total vesical paralysis result, with over-distension and dribbling of urine. Symptoms, — Except in cases of injury of the brain and apoplexies, the invasion of the disease is usually very gradual. This is especially the case in the aged, and is sometimes, though rarely, seen in young people. The patient first observes that the urine is expelled from the bladder with less force than usual ; that the act of emptying the bladder is more slowly accomplish- ed ; that after a time the organ is unable to expel its contents without considerable straining and aid from the abdominal muscles. At a later date, if the disease goes on unchecked, the stream is less and less forcibly ejected, intermits, and the bladder, after much straining, is but partially em.ptied. Finally, partial or complete retention follows. The female bladder seems to be capable of more distension than that of the male. Lieven, in a case of supposed ovarian tumor, removed by catheterization 4,000 grammes of urine. The patient was a woman thirty-three years of age. The fundus of the bladder reached as high as the ensiform cartilage. More than a gallon has been drawn off by Hofmeir and others. A peculiarly interesting experiment bearing upon the dilatability of the bladder was made by Budge. He found that section of the lower part of the spinal 74 FUNCTIONAL DISEASES OF THE BLADDER. cord, when the bladder was considerably distended, allowed increased reflex action of the sphincter, and enormous distension then took place — even more than could be produced by force, after death. This is espe- cially interesting in relation to vesical paralysis and retention due to injury or disease of the lumbar por- tion of the spinal cord. In some cases of over-distension the resistance of the sphincter is overcome somewhat, and a constant dribbling of urine takes place. It has been called by some authors Incontinentia Paradoxa. You must not confound these cases with those of pure incontinence. In rare cases rupture of the bladder may take place ; more commonly dilatation of the ureters and hydro- nephrosis. If the condition of vesical distension be not soon relieved, vesical catarrh, true inflammation, ulcer- ation and death take place. In cases due to injury or disease of the spinal cord, low down, there seems to be a paralysis or peculiar condition of the nerves presiding over the nutrition of the vesical mucous membrane, and destructive changes are not uncommon. Diagnosis. — The diagnosis, though easy, is some- times not made, owing to careless observation, or ignorance. When called to a case where there is sup- posed distension of the bladder, first examine the abdo- men and see if there are signs of a tumor, and then pass a catheter, if that be possible, and determine whether an abnormal amount of urine is present. If this is the case, and the tumor gradually subsides as the urine flow^s, your diagnosis is at once made. PAREISIS, OR PARALYSIS VESICA, ETC. 75 Where a catheter cannot be passed into the viscus, fluctuation should be sought for both through the vagina and on the surface of the tumor. If the diagnosis be still obscure, the aspirator needle should be passed into the tumor and its fluid contents carefully tested. The age of the patient, the duration of the disease, and its time and method of invasion will aid you in settling the question. The trouble may, however, occur at almost any age, and the fact that a little urine has been passed at short intervals will tend to deceive you. In the early stages of the disease an idea can be gained as to its progress, by carefully noting the amount of urine passed at each micturition, the amount passed in twenty-four hours, the length of intervals between urination, the force of the stream, whether the bladder is fully or but partially emptied, and whether the stream intermits. The urine should be examined often, else cystitis may get a firm foothold before you are aware of its existence. In drawing off the urine for testing or other purposes, the catheter should be absolutely clean. Incontinentia Paradoxa must be differentiated from Incontinence due to mechanical causes, such as abnor- mal vesical contents, or the pressure of neighboring organs. Prognosis — If the disease be uncomplicated the prognosis is good. Paralysis of the organ accompany ing the fevers, dysentery, peritonitis, and the like, usually disappears with the cure of the original disease. If the paralysis be accompanied by disease of the 76 FUNCTIONAL DISEASES OF THE BLADDER. bladder walls ; occurs in weak, debilitated constitutions ; has been of long duration ; or occurs in old age, the prognosis is not good. A cure, if effected at all, will be after long and tedious treatment. When due to centric causes ; to serious spinal disease or injury ; in old people ; with Meningitis ; or systemic troubles ; the prognosis is very grave indeed. Treatment. — In all cases where there is fear of vesical distension, empty the bladder at stated intervals. By way of helping the patient to pass water herself, you may try hot hip-baths, fomentation over the blad- der, and let her hear the sound of water falling from one vessel into another. If these means do not suc- ceed, you must use the catheter. If you are called to see a case where there is mark- ed distension, you can usually relieve it by the catheter. In some cases, however, the bladder rises up into the abdomen and puts the urethra upon the stretch, thus chaneinof the direction of its axis from the normal to one from below directly upwards, the canal being closely applied to the posterior surface of the pubic symphysis. In these cases passing the catheter will tax your skill somewhat. Great care must be used to avoid injuring the urethra. In emptying a greatly distended bladder apply a binder to the abdomen, tightening it gradually as the urine flows. It is not safe to draw off all the urine at once. It is better to take away about half, and then, after a time, return and draw it off little by little, until the organ is empty. Syncope and even death, which is PAREISIS, OR PARALYSIS VESICA, ETC, 77 said to have occurred in these cases, after rapid, empty- ing of the organ, is probably due to the sudden removal of the pressure on the abdominal organs, which so de- ranges the circulation as to cause these serious results. The sudden removal of pressure from the vesical walls, which that pressure rendered ancemic, now allows in- tense congestion, and the vesical walls being paralyzed mucous catarrh and cystitis result. Therefore, for many reasons, empty a distended bladder slowly. When, for any reason, a catheter cannot be intro- duced into the bladder, you should try hot hip-baths again, and give opium sufficient to relieve pain and any spasmodic action that may exist. If, after this, you fail to enter the bladder (and it is only in very rare cases that you do fail), you should have recourse to the aspi- rator, and having punctured the tumor, you should draw off the urine slowly and carefully, in the manner I have already told you. Both in cases of the kind of which I have just spoken, in commencing vesical paralysis, and when In- continentia Paradoxa exists or has existed, the patient should be taught to use the catheter herself, several times daily, until the vesical power returns. It is of the utmost importance that the catheter be absolutely clean. After each time that it is used it should be thoroughly rinsed in a chlorine solution and put away in carbolized oil or vaseline. A great deal of vesical catarrh is undoubtedly lighted up by foul catheters. This is especially the case in our hospitals, where the same instrument is used on a number of patients. 78 FUNCTIONAL DISEASES OF THE BLADDER. In cases of commencing or established paralysis you may try the effect of the induced electric current. Place one pole (thoroughly insulated up to the point to be used) in the bladder, and the other pole over the pubic symphysis and loins, letting the current flow in various directions, through, over, and into the affected organ. The German authors, especially Winckel, by whom it is highly recommended in this and like affections, say that the sitting should last but about five minutes. Forcibly distending the urethra and washing out the bladder with a solution containing salicylic acid has been tried and recommended. I cannot see the expe- diency of this, unless vesical catarrh exists ; and even then washing must be done gently and carefully, and Avithout previous dilatation of the urethra. Attention should be paid to the general health. The food should be good and nourishing, and the ali- mentary canal kept in a proper condition to receive and attend to it. Wines, especially champagne, beer and ale, will be of use. I can at least say that if you ever give stimulants in diseases of the bladder, let it be in cases like those now under consideration. These patients are usually more comfortable in the standing or sitting, than in the prone posture, because then the weight of the abdominal viscera replace to a certain extent the natural tonicity of the organ. As they are usually worse in winter than in summer, it is advisable, if the case is chronic, the patient able to bear transpor- tation and rich enough to meet the expense, to send her to a moderately warm climate during the winter PAREISIS, OR PARALYSIS VESICM, ETC. 79 months. This will apply in most of the diseases of the bladder. If the trouble be purely atonic, you may use in- ternally Camphor or Musk. Tincture of Cantharides, in from five to twenty drop doses, three times a day, has been recommended as a vesical excitant. I cannot indorse its use without cautioning you, that besides the tendency to irritate the kidneys and produce congestion and nephritis, it may light up a severe cystitis. In these cases it may produce serious trouble without giv- ing rise to much pain to warn you of the danger, as the paralysis lessens the sensitiveness of the bladder, so that destruction of tissue may occur without producing the usual pain and suffering. Strychnia has been extensively used in this com- plaint, and with good results in some cases. Its failure to do good in many instances is undoubtedly due to the fact that it was not given in sufficiently large doses. It may be safely pushed as high as the one- twentieth of a grain, three times a day, stopping for a few days if any of its characteristic symptoms ap- pear. It has also been used hypodermically in the neiofhborhood of the bladder. Ergot has been found useful in cases where the paralysis was due to exposure to cold, or prolonged re- tention from any cause. The fresh powder may be given in doses of from eight to sixteen grains, four or five times daily. It is more pleasant, and probably as effective, to give its equivalent of the fluid extract. Alliers has used it with decided success in cases of vesi- cal paralysis due to centric troubles, such as apoplex}-. 8o FUNCTIONAL DISEASES OF THE BLADDER. He has used as high as forty-five grains in the twenty- four hours. It is highly spoken of also by Roth, Jacksch, and others. Rutenberg has lately (in Wiener Med. Wochen- schrift, 1875, No. 2)1^ recommended, in cases where there is destruction of muscular tissue or incurable para- lysis from any cause, to make an opening into the blad- der just above the pubic symphysis, keeping the fistula open and closing the urethra by operative procedures. The urine could thus be retained, unless the patient bent forwards and downwards or lay upon her abdo- men. A urinal would of course be necessary to protect the patient. I think I should, prefer to produce a vesico-vaginal fistula, and fit an apparatus to receive the urine. Incontinence of Urine. — Enuresis Nocturna is usu- ally an affection of childhood, but has been known to persist up to the age of thirty years. In some chil- dren it is hereditary, the mother having suffered in early years, and all the children born to her being affected in the same way. Of all cases, these are the hardest to treat. They generally persist until puberty, when they recover of themselves. The subjects of this affection are usually of the weak, nervous type, although apparently healthy children have been known to suffer from it, but usually only at intervals. We may divide these cases of incontinence into two distinct types or classes. First, the anaesthetic type. The wetting the bed and diapers by infants up to a certain age is an excellent example of this class. In INCONTINENCE OF URINE. Si the infant, of course, it is no disease ; it being simply a good normal example of this condition; and the in- continence of severe fevers illustrates the abnormal phase of the same thing. Second, the hypersesthetic form, which is really nothing more than irritable blad- der. Each class may exist alone, or both be combined in the one case. In the first class the retaining power is defective ; the resisting power of the sphincter being insufficient to retain the urine or wake the child. When it is put to bed it sleeps soundly through the night, and the nerve susceptibility to urine pressure on the neck of the bladder being lowered beyond the normal degree, fails to wake the little subject and impress it with the necessity of voluntarily calling the sphincter muscle into action sufficiently to resist the expulsive power of the bladder walls. In short, in sound sleep, the bal- ance between the resisting power of the sphincter and the contractility of the walls of the bladder is disturbed, and the urine flows away without the child's even dreaming of its unfortunate behavior. In other forms of this affection the brain takes coof- nizance of the desire to urinate, but too late to control the act. This is seen in children who awake, crying, when urination is but just begun or half finished. In this case the fault probably lies in the vesical nerves. In the second class there is an irritable condition of the bladder (Vesical Hyperaesthesia), which renders the expelling power greater than that of resistance or retention ; and while the will and cerebration general- ly are lost in sleep, the contents of the bladder are un- 2,2 FUNCTIONAL DISEASES OF THE BLADDER. consciously passed before the subject wakes to resist the act. Closely allied to this is the peculiar affection known as Vesical Chorea, in which the child, while awake (in school, in church, or at play), suddenly has the sensation that it is about to make water ; but be- fore it is possible to resist, the urine is forcibly spurted out. There are usually choreic movements of other muscles or groups of muscles. This affection is the most annoying when the little ones are ner\^ous, cross, and fidget3^ It may be accompanied by nocturnal eneuresis. It is apparently more common in the male than in the female child. An irritable condition of the bladder may co-exist with an anaesthetic condition of the sphincter vesicae, i. e., the two causes of incontinence may be combined. Irritable bladder, you should remember, may be due to some systemic condition (a simple neurosis), to abnormal urine, or reflex irritation from anal fissure, ascarides in the rectum, fistula in ano, hemorrhoids, or vulvitis. Enuresis Nocturna is not only a filthy habit, and a source of great annoyance to parents, but moreover, by keeping the genitals wet and irritable, strongly predisposes to masturbation. Then, too, other serious results may happen. The constant wettings are dan- gerous, in that they may produce many serious com- plaints from causing the child to " take cold." Prognosis. — In some cases the cure is easily and speedily effected ; in others, the disease cures itself at or just after puberty ; but in a few — a very small per- PROGNOSIS— TREA TMENT. 83 centage — no medical or other means seem to aid the sufferer at all. Treatment — That the treatment is not uniformly satisfactory, is seen by the number of remedies that have been tried. The proper way — and I cannot re- mind you of it too often — here, as elsewhere, is to find the cause producing the disease, if it be discoverable, and it generally is. Your treatment will, of course, differ in the two classes, and be greatly modified by diathesis and idiosyncrasy. In anaesthesia, local or general, stimulate. In hyperaesthesia, allay irritability. Winckel, Barclay, and Brugleman speak very highly of the use of the Syrupus Ferri lodidi, the last named gentleman having by its use cured a girl perfectly, of incontinence in the short space of fourteen days. This result was probably due more to the effect of the medi- cine on the blood and general system, than to any specific action on the bladder. The syrup of the iodide may be given in from ten to thirty minim doses, three or four times daily, according to the age of the offender. Although Belladonna has been lauded by many as a specific in this disorder, its success, as many of you know, is by no means universal. The drug has usually been given by the mouth, in from five to twenty drop doses of the officinal tincture. You had better begin with small doses in young children, and gradually increase them ; for though no serious results may come from its exhibition in the routine dose (ten drops), you may greatly alarm the parents by the peculiar redness of the skin, produced in some cases. It is maintained 84 FUNCTIONAL DISEASES OF THE BLADDER. by some medical men that the good effects are not obtained unless the administration be pushed to the appearance of the scarlet rash. There is, I think, no proof of the correctness of this statement. A combination of Belladonna and Chloral Hydrate has been used and well spoken of Winckel, however, though using them in certain cases for a long time, and daily increasing the amount of chloral, has had but poor results ; and even in those cases where the pa- tients improved, the benefit was seldom permanent. These drugs may be given singly or together, in sup- pository, or by the mouth. If you give them together, do not combine them until you are ready to administer, lest the chloral lose its power. Narcotics, with Tinctura Ferrl Chloridi, have been recommended by Campbell Black. Winckel speaks well of five to ten drop doses of Tinctura Thebacia (to child from ten to fourteen years of age) just before retiring. Accordino; to Sauvas'e, cold baths and cold douches to the spine at night have proved of great service. In those cases where the vesical irritability is due to abnormality of the urine, such as lithiasis, oxaluria, and acidity, they should be corrected in the manner I have already pointed out. If to ascarides, anal fissure, and that class of rectal diseases, when you remove the cause the result will usually disappear. In irritability the usual soothing and demulcent drinks, such as have been already recommended, should be used. Oil of Sandal-wood has acted remarkably well in some of these cases. TREA TMENT. 85 In the first class, where the anaesthesia is more or less marked, you should use special or local and gen- eral stimulants. Narcotics are as hurtful here, as they are useful in the other class. Strychnia by the mouth, in suppository, or hypodermically, often produces good results, as also Quinine, whether you suspect the pres- ence of malaria or not. Tonic and astringent injections into the bladder are sometimes of service. In cases of abnormally small bladder, forcibly washing it out (dis- tending the organ a little more each time) is well spoken of In one such case, where there was irrita- bility, Winckel produced a cure by first injecting a solu- tion of Argenti Nitras, and following it with Morphiae Sulphas. This, however, applies more to the irritable than the anaesthetic type. You will find your little patients very hard to operate upon ; and unless you are very careful, you will do mischief by local treatment. Winckel claims good results from the use of the electric current, applied in the manner I have spoken of under the head of Paresis Vesicae. When the bed-wetting is due to pure carelessness, laziness, fear, or dread of the cold air in rising, in idiots and half-witted children, much may be gained by proper education. There is a general plan of prophylaxis recommend- ed to you by your common sense, viz., the heartiest meal in the middle of the day ; but little water towards evening; plain, unseasoned food; regularity of the bowels ; no coffee or tea ; put them to bed early, being assured that the bladder is first thoroughly emptied ; let them lie upon a hard bed, with not too much covering ; 86 FUNCTIONAL DISEASES OF THE BLADDER. have the air in the room fresh and pure ; keep the genitals clean and dry ; take them to no places of amusement after dark; wake them occasionally to urinate, especially at about the time the parents are going to bed. When it is discovered that they have wet the bed, awake them and talk to them. Reason with them, if they are able to comprehend what is said and meant. Do not let children go to school too early, or stay too long. If the enuresis be due to masturbation, you must caution the parents to watch closely and use every means in their power to stop it. Never let a child be whipped for the offence or misfor- tune of wetting the bed, unless the incontinence be due to pure laziness. Functional Disorders of the Bladder due to Dis- eases of Other Pelvic Organs — Functional diseases of the bladder caused by disorders of the neighboring pelvic organs are frequently met with in practice. In this class the bladder trouble is secondary to some primary and more important affection ; but the derange- ment of its function is often the most prominent and troublesome symptom ; hence it is important to under- stand its relations to the primary disease, in order to make a correct diagnosis, and treat such cases properly. This class of functional disorders frequently resem- ble in history some of the organic diseases of the bladder, so that care is necessary to distinguish the one from the other. What I may say upon the sub- ject will have reference to diagnosis only. When we know that the bladder trouble is due to disease of some DISEASES OF OTHER PELVIC ORGANS. 87 Other organ, attention is at once turned to the primary affection. We must keep these facts in mind, and not mistake the symptoms for the true disease. Diseases of the rectum affect the bladder sympa- thetically. Irritation and pain in the rectum, from any cause, affect the bladder more or less. Chronic hemorrhoids will cause frequent urination, and so will rectal fissure, especially after defecation. Abscesses in the neighborhood of the rectum will frequently cause retention of urine. One very interesting case of this kind occurred in the practice of my assistant, Dr. Gushing. The lady had an abscess in the neighborhood of the rectum, which caused retention of the urine, it in turn caus- ing acute renal disease. After the bladder had been emptied and kept from over-distension for some time, the urine was examined, and found to contain albumen and casts. She made a rapid recovery, and all evidence of kidney disease soon disappeared. Very troublesome vesical irritation may come from ascarides. The itching of the anus and rectum caused by these troublesome little worms, keeps up an almost constant desire to urinate. Children are troubled the most with these parasites, but women often suffer in the same way. Marion Sims points out the interesting fact that almost all cases of Vaginismus are accompanied by an irritable condition of the bladder ; and that, as the terminal fibres of the hymen often extend from the meatus to the vesical neck, cystospasm may in these cases be due to reflex nerve irritation. An attempt to 88 FUNCTIONAL DISEASES OF THE BLADDER. catheterize these patients is as liable to cause spasm of the bladder, as an analogous attempt to examine the uterus would be to produce vaginismus. In these cases the hymen should be excised, and the vaginismus treated after the usual methods. Acute Pelvic Peritonitis and Cellulitis cause great distress in many cases by their effects on the bladder. A constant desire to urinate, without the ability to make straining efforts to accomplish the object, are very often observed in all these acute pelvic inflamma- tions. The disturbance of the bladder is, of course, only a symptom of the primary and more important trouble, and simply requires to be mentioned here. The after effects of pelvic peritonitis are what I espe- cially desire to call your attention to at present. The adhesions formed by the products of the inflammation of the pelvic peritoneum, are in some cases sufficient to prevent the normal filling of the bladder, and frequent urination then becomes a neces- sity. This derangement of function generally exists alone. The urine is retained without trouble up to a certain amount ; it is passed without pain, and no vesical tenesmus follows evacuation. Unless the con- traction of the bladder is great, and the frequent neces- sity to urinate very troublesome, patients rarely consult us for it. Paralysis of the bladder with retention may be caused by a peculiar condition of oedema by which the detrusors are rendered powerless to act. It is usually caused by disease of the cervix uteri, para-metritis, or peritonitis. ANOMALIES OF POSITION— DISLOCATION- UPWARDS. 89 Functional Disorders from Anomalies of Position and Form of the Bladder. — Dislocations of the bladder may be of six kinds, as follows : — i. Upwards ; 2. Back- wards ; 3. Forwards; 4. Laterally; 5. Downwards; 6. Inversion. Some of these are, even in their worst form, not true dislocations, but represent some hin- drance to the proper expansion or position of the ex- panded organ. Of all dislocations, the most important are the upward, backward, and downward. All of them, however, interfere more or less with the vesical function. Marked dislocation of a healthy bladder often gives rise to less disturbance than slight dislocations of an already irritable organ. Dislocations of the bladder have various causes, the most common and troublesome beine abnormalities of structure and position of the uterus and vagina. Dislocation Upwards. — The upward dislocation of the bladder may be caused by the dragging up of the organ by the gradual rise from the pelvis of the gravid uterus. This, however, is a rare affection, and only occurs, I think, in cases where there has been previous inflammatory action in the pelvis, gluing the parts together. In most pregnancies the bladder retains what is, under the circumstances, its normal position. Bands of adhesion passing from the bladder to the various abdominal and pelvic viscera, may, when short- ening takes place, produce this dislocation. It may also be produced by a malposed loop of intestine, ova- rian tumors, as also in some cases of uterine retroflexion and retroversion. The dislocation accompanying the 90 FUNCTIONAL DISEASES OF THE BLADDER. last two affections is, however, usually more backward than upward. The other most likely causes are tumors about the neck or base of the organ, tumors of the cervix uteri, pelvic deformities, and pelvic exostoses. The symptoms are usually those of irritable blad- der. In some cases of pelvic tumor the pressure on the urethra, forcing it against the pubes, produces retention. This is, you observe, purely mechanical. In other cases, where there is no obstruction to the out- flow, but pressure on the bladder, there may be incon- tinence; and again, from traction on the muscular walls, they are unable to contract and expel the vesical contents, and retention results. Dislocation Backwards — This dislocation stands next in order of importance and troublesome results to downward dislocation. It may be caused by tumors of the abdomen, or pelvic adhesions ; but the most frequent cause is backward dislocation of the uterus, such as retroflexio and retroversio uteri. Retrover- sion affects the bladder the same as prolapsus, except when the uterus is very much enlarged, and is thrown backward and impacted in the pelvis, so that the cer- vix presses firmly on the urethra. In such cases urination is impossible. Examples of this are seen in retroversion occurring in the early months of pregnancy or after delivery. Schatz gives a case due to retro flexion of the uterus during pregnancy, producing the same trouble in the bladder as retroversion. Winckel saw a case in the body of a non-puerpe- DISLOCATION- BACKWARDS. 91 eral woman, in which the uterus was lying almost horizontally in the pelvis, with its fundus adhe- rent to the rectum. That part of the bladder that Fig. 4. I Retroversion of the Gravid Uterus. i^Schaiz.') The Bladder pulled upward and backward, and the Urethra put greatly upon the stretch. was drawn most backward had a diverticulum, containing a calculus. The neck of the bladder was fastened down posteriorly by tight bands of adhesion that passed from it, over the uterus, to the rectum. In retro-displacements of the bladder, with no pres- sure on the vesical neck, the symptoms are usually those of irritation. I give you the following cases, as they are of 92 FUNCTIONAL DISEASES OF THE BLADDER. interest, and may serve to fix more clearly in your mind the general points. The first is a case of chronic retroversion of the uterus, causing marked vesical trouble in a nervous woman. The cause of the bladder trouble is here double — ist. Vesical neurosis; 2nd, Displaced uterus. Mrs. H , set. '^^. Married five years, and a widow three years, of a marked nervous temperament. Has never been pregnant. Menstruation always nor- mal, and general health fair in early life. Her general system has been much reduced by nursing her husband, who died of Phthisis. Nervous system also much impaired. When first seen all the functions except those of the bladder were performed well. She suffer- ed night and day from frequent urination ; but there was no pain either during or after the act, unless she tried to hold her water for a few hours, when there was great pain after the completion of evacuation. Nervous excitement, pleasant or unpleasant, made the trouble much worse. Her urine was normal. On examination we found complete retroversion of the uterus, shortening of the anterior vaginal wall, and the bladder much contracted, but otherwise normal. The uterus was restored to its place, and held there by a pessary. Hydro-bromic acid in thirty minim doses was given four times a day. She made a rapid recovery. Case 2. — Mrs. G., set. 43, the mother of four chil- dren. Widow for several years. She was a strong, healthy lady, and had been on her feet all day at- tendins^ to her household duties, and in the evening, DISLOCA TION FOR WARDS. 93 while hanging some pictures on the wall, slipped from a chair, and fell heavily to the floor, striking on her feet. She was at once seized with a desire to urinate, and soon after pelvic tenesmus came on. The desire to urinate was constant, and after strong expulsive efforts she was able to pass a little from time to time, but without relief The bowels became distended and tympanitic. On the following day she was ordered anodynes, but they gave very little relief On the next day she was examined, and the uterus was found to be completely retroverted. Replacing the uterus gave her great relief at once, and she has remained well and free from all bladder trouble since, the accident having occurred some two years ago. This, you see, was a case of Acute Retroversio Uteri, producing an intensely painful affection in a normal bladder. Dislocation Forwards. — Forward dislocation of the bladder, unless it be through the open abdominal walls, is very rare. Some change in its shape, from pressure of organs or tumors from behind, may occur, but this is really not a true displacement, except in some rare and marked cases. The most frequent cause is pressure from the anteflexed or anteverted uterus, in either the virgin or puerperal state. Anteversion of the uterus usually causes frequent urination, perhaps more so than prolapsus ; but whether this frequency is due to the fundus uteri resting on the bladder, or to the supersensitiveness of the whole pelvic organs, I have not always been able to determine. I have 94 FUNCTIONAL DISEASES OF THE BLADDER. inclined to believe that the latter was the case. In this displacement (anteversion) the uterus is generally- enlarged and elevated, so that the body and fundus rest upon the bladder and impede its distension. True dislocation of the bladder forwards is the rarest of all dislocations, only three cases being on record. It has been variously called Ectopia of the Unfissured Bladder, Ectopia Vesicae Totalis, and Prolapsus Vesi- cae Completus per Fissuram Tegumentorum Abdom- inis. The first name is too vague, the last best of all, but rather lengthy for every-day use. The three cases on record are by G. Vrolik, Stoll, and Lichtenheim. In all these cases the bladder was protruded through a small slit in the abdominal wall, and appeared as a bright red rounded tumor at the lower and anterior part of the abdomen. In Lichtenheim's case, only, was the tumor reducible. The pubic bones laid apart about five centimeters. The urine could be held perfectly, and the patient was able to micturate in a thin stream. Microscopic examination of the outer covering of the bladder walls, proved it to be mucous membrane like that lining the interior of the organ. In G. Vrolik's case, according to Winckel, there is doubt as to whether it was a true vesical ectopia. He believes it to have been a gaping of the fissured ab- dominal walls over a dilated urachus, the latter com- municating with the bladder by a small opening. In Lichtenheim's patient no operative measures were thought of, for, beyond a little excessive secretion of the external mucous surface, no trouble was experi- enced. If, however, from the protrusion of the tumor DISLOCA TION DOWNWARDS, 95 or Other cause, difficulty in passing or retaining urine be present, you should make an attempt to close the abdominal fissure. If it be large, two or more flaps may be needed to accomplish the desired result. The operation is very like that for fissure, described in my last lecture, only more simple. I doubt if you will ever see such cases. If an operation is not desired or consented to, the patient should wear a concave compress, and by atten- tion to bandaging keep the surface of the organ in as nearly a normal condition as possible. Lateral Displacements. — Lateral displacement of the bladder is not very often met with. It is generally due to inguinal or femoral hernia, or hernia of the for- amen ovale, tumors at the side and base of the organ, and contracting pelvic adhesions. There is generally more or less distortion of the urethra, that may hinder the outflow of urine or prevent the easy introduction of a catheter. Irritability may result, but is not so com- mon as in the other varieties, the organ being gener- ally but slightly displaced, and soon getting used to the disturbing cause arising from the malposition. Dislocation Downwards- — I have reserved this malposition to the last, because it is the most important. There are various grades of the dislocation, the most marked of which is known as Cystocele Vaginalis. Its causes are of two kinds— predisposing and exciting. Of the predisposing, the most common are a loose, flabby condition of the vesico-vaginal septum, excessive 96 FUNCTIONAL DISEASES OF THE BLADDER. venosity of same (these may be due to pregnancy, or to a general systemic condition), abnormally capacious vagina, unusually large introitus vagince, total or par- tial loss of perineal body, and the tendency of the blad- der to pouch inferiorly, as age advances. As exciting causes, we have violent expulsive ef- forts, as in defecation, lifting heavy weights, and espe- cially child-bearing. The latter is probably one of its most common causes, for not only do we have expul- sive efforts of the most violent kind, but a lax, spongy condition of the vesico-vaginal septum, i. c, the ante- rior vaginal and posterior vesical walls, which are pushed downwards before the advancing head. Another common cause is prolapsus uteri, though in many cases the Cystocele precedes the prolapse of the womb. Whichever is the case, the one aggravates the other. In slight prolapse of the uterus the vesical symptoms are only those of irritation ; and it is a strange fact that the irritation is often as great in the first degree of prolapse as in the third. Other less frequent causes of Cystocele may be tu- mors in the posterior vesical or anterior vaginal wall, stone in the bladder, vesical diverticuli, violent efforts at urination, and marked pressure from above. That the bladder begins to sag inferiorly as age advances, you already know, and consequently the tendency advances as does the age. The number of pregnancies may, however, have more to do with the frequency than the tendency to pouching in old age. Pathology — This affection may be conveniently SYMPTOM A TOLOG V. 97 divided into three grades. In the first, there is but a slight bagging of the organ. In the second, about one- half the bladder lies below the normal level of the an- terior vaginal wall, giving the organ an hour-glass shape, the urethra entering the upper segment just above the point of partial constriction. In the third or highest grade, the whole bladder lies below the level of the normal anterior vaccinal wall. The urethra in these cases has a direction from above backwards and downwards. The ureters in the last two grades are so bent and obstructed by pressure, that dilatation and hydro-nephrosis may result. Such instances are given by Phillips, Froreiss, Virchow, Braun, and Winckel. The vesico-uterine pouch is, in cases of marked vesical and uterine prolapse, greatly increased in size, and may contain a loop of intestine. In some rare cases it may become constricted superiorly, and exist as a closed sac. In chronic cases the vesical mucous membrane becomes hypertrophied, and, in the lower segment especially, congested and oedematous. To this may be superadded Cystitis, and ulceration, which often fol- low in cases of long standing. Symptomatology. — In the first grade of downward dislocation the symptoms are those of irritable blad- der, such as frequent and possibly painful urination. When the displacement has existed for a considerable time, the bladder seems to accommodate itself to the new relations, and the calls to urinate become less frequent. 98 FUNCTIONAL DISEASES OF THE BLADDER. In complete prolapsus of the uterus and bladder, we find instead of frequent urination, difficult urination, and in the worst cases, retention. Partial retention always occurs in the marked cases, and the urine remaining in the bladder decomposes, and in time causes Cystitis, which greatly aggravates the patient's sufferings. Such cases are very like those occurring in old men, and due to retained urine by reason of an enlarged prostate gland. There is usually a dragging pain experienced in the reeion of the umbilicus, which is due to traction on the urachal cord, and also a constant sense of pain and uneasiness, due partly to the vesical and partly to the uterine malposition. To fully empty the bladder, in the worst cases, it is necessary to relax the parts by lying down and then force out the urine by pressure on the vaginal tumor. Cystitis is a common secondary affection, and is due, as I have said, to decomposition of the retained urine, and to chronic congestion with oedema and hypertrophy of the mucous membrane. Winckel's experience has, however, differed from that of most observers, he having failed to find a single instance of Cystitis in sixty-eight cases of Cystocele. From pressure on the ureters, as I have told you, there may result dilatation and Hydro-nephrosis, and if marked or long continued, uraemia. There may also be set up that condition known as Peri-cystitis, and the lower vesical segment be render- ed irreducible, owing to the formation of adhesions. If Cystocele occur in a patient already suffering DIAGNOSIS— PROGNOSIS. 99 from Cystitis, the original trouble is of course greatly aggravated. Cystocele may interfere with delivery during child- birth. In one such case, McKee, being unable to push a catheter into the bladder, punctured the tumor with a lancet, and delivery was rapidly accomplished. In another case, a certain physician mistook the vesical tumor for the bag of waters and punctured it. Diagnosis. — This is readily made. Place the pa- tient upon her back, with thighs flexed on the body. If the tumor be already down, examine it carefully, and also the position and condition of the neighboring or- gans. If possible, pass a catheter into the bladder, and see if it enters the tumor, and observe the direction it takes in so doing. Compress the tumor, and notice whether the urine flows from it throuMi the catheter. Also try to reduce it. The urine should be carefully examined for pus, mucus, albumen, epithelial ele- ments, and the amount of urea. Prognosis. — The prognosis is generally good ; but in giving an opinion you must be careful to take into consideration the degree of dislocation, the size of the tumor, the condition of its mucous membrane, whether it is reducible or not, the age of the patient, and the gravity of the producing cause. In young patients, Sims, Simon, Hegar, Verf and others claim to have obtained radical cures. Some of these cures were not, however, lasting. Scanzoni claimed that he had never seen an operation for this 100 FUNCTIONAL DISEASES OF THE BLADDER. trouble that had permanent success. He said that his own operations were by no means satisfactory. Treatment. — The treatment consists in reposition and retention. The former is easy, the latter hard to accomplish, as prolapsus uteri and cystocele generally go hand in hand ; to treat the one you must treat both. Having pushed the uterus up into position, emptied the bladder and replaced it, you should seek some me- chanical means to retain one or both organs in place. For the purpose of supporting the prolapsed blad- der I devised the pessary shown in Fig. 5, and it has been found to accomplish that object satisfactorily, _. , It is made in two Fig. 5. ^^^ ^^^1^ iKMb^\ ^ BBL ^ cervix uteri, and b sup- thra. The other part, cc, joins the main portion in front of the uterus, and at the anterior end of the instrument, and rests on the posterior wall of the vagina. The two parts are held together by passing the pointed ends of the V-shaped portion, cc, into perforations in aa, and a small peg at D, which passes into a hole at e. The instrument is introduced as follows : The patient being on the left side, the main portion of the pessary is inserted in the usual manner. The perineum is then elevated by a Sims' speculum, and the other portion, cc, introduced into the openings in a, and TREA TMENT. loi the point pressed up into the opening at e. This locks the two portions, and binds them together as one instrument. By reversing the manipulations just de- scribed, the instrument is easily removed. The facility of introduction and removal is one of the minor, but by no means unimportant, qualities of this pessary. Several sizes are made, which answer in most of the forms of displacement of the bladder ; but a case will occasionally occur in which it is necessary to first take measurements, and have the instrument made ex- actly to suit. This can be easily done. You place the patient on her left side, and after introducing the spec- ulum, restore the uterus and bladder to their proper positions ; then take a thin strip of sheet lead and bend it to the size and shape of the anterior walls of the va- gina and cervix uteri. This form will enable the instru- ment maker to produce the required size and shape of the pessary. In cases where a pessary fails to accomplish the desired result, and the case grows daily worse, you may try the operation, first done by Joubert, then by Baker Brown, and carried out and improved by Sims and Emmet. It consists in the excision of an elliptical or V-shaped piece from the anterior vaginal wall, and bringing the edges together by sutures. When heal- ing has taken place the vagina is markedly narrowed, and the bladder has an improved, if not a perfect floor to rest upon. This operation is seldom called for, and I believe that it should be limited to cases where there is marked thickening of the vesical and vaginal walls. 102 FUNCTIONAL DISEASES OF THE BLADDER. When the operation has been performed, I have found it necessary to use a pessary, to prevent a return of the prolapsus. If there be laceration of the perineum, this too is to be remedied. A fuller and better descrip- tion of this operation than I can here give you will be found in Prof Thomas's excellent work on the Diseases of Women. In cases of but slight downward dislocation, and where, from a relaxed condition of the vaginal wall and septum, vesical prolapse is to be feared, the employ- ment of a proper pessary will suffice. Retrocession and Forward Transposition of the Bladder. — The various forms of displacement of the bladder described thus far, are usually associated with uterine dislocations, and are familiar to those who have given attention to gynecology. There remain to be noticed two forms of displacement of the uterus not generally described by authors, but which markedly disturb the functions of the bladder, viz., retrocession, and forward transposition. In the first form, the ute- rus, without any change in the relation of its axis to the plane of the superior pelvic strait, is found to rest far back in the pelvis, and is fixed there. In the second form, the reverse of this exists, the uterus rest- ing just behind the pubes. Figs. 6 and 7 will show these conditions. The best example of retrocession I have ever seen, was in a patient who had had a severe pelvic peritoni- tis some time before she came to me. The uterus was firmly fixed in the posterior portion of the pelvis, and RETROCESSION AND FORWARD TRANSPOSITION. 103 the bladder was drawn backward, and exceedingly irri- table, which gave her great trouble, as she could never completely empty it, except when the catheter was used. Owing to the fixation of these organs in their rig. G, Forward Transposition of the Uterus. The Bladder will here be seen somewhat flattened against the Pubes, and the Urethra pushed out of its axis. malposition, it was impossible to relieve her from the frequent and difficult urination, and she remained a great sufferer, until she died of Phthisis Pulmonalis. To illustrate the forward transposition, I may men- 104 FUNCTIONAL DISEASES OF THE BLADDER. tion a case that came under my notice several years after she had had an intra-peritoneal pelvic hemato- cele. Her physician told me that she had severe inflammation following the internal hemorrhage, and Fig. 7. Retrocession of the Uterus. The Vagina is here found lengthened, and the Bladder and Urethra pulled upward and backward. nearly lost her life therefrom. She was confined to her bed for many months, and after recovery she suf- fered from frequent urination. Night and day she was obliged to pass water every two hours, and if she EXTROVERSION OF THE BLADDER. 105 went longer than that, she had pain which was not relieved till some time after emptying the bladder. The uterus was situated at its proper elevation, and was just behind the pubes. The bladder was com- pressed from before backward, and, as the uterus was firmly fixed in its forward position, of course it could never be fully distended. There was no disease of the bladder, so far as could be ascertained from an exam- ination of the urine, or of the organ itself No treatment that was employed gave anything more than temporary relief Extroversion of the Bladder through the Urethra — This affection stands next in rarity of occurrence to Prolapsus Vesicae Completus per Fissuram Tegumen- torum Abdominis. It is also known by the names, Inversio Vesicae Urinae cum Prolapsu, Exocyste, and Cystoplosis. By some authors it is supposed to be a simple pro- trusion of the mucous coat of the bladder through the urethra, but by others to be a prolapse of the whole organ. In support of the latter belief is the fact that after death, Joubert, Rutly and Leoret found a sinking In or partial inversion of the whole organ. More- over, Meckel claims to have found under the labia minora, and protruding from the meatus, a mass of tis- sue that on careful examination proved to consist of all the elements of the several coats of the bladder. Burns thinks it much easier for a prolapse of the whole organ to take place, than a separation and pro- lapse of the mucous membrane alone. Streubel, after I06 FUNCTIONAL DISEASES OF THE BLADDER. a careful review of the llteratpre of the subject, was able to find but one case in which the mucous mem- brane was alone jDrolapsed As the posterior vesical wall, in the empty organ, lies over the vesical opening of the urethra, it is easy to comprehend how this dis- location might occur from sudden straining efforts, pressure of the overloaded colon, or pressure of a heavy uterus. Vesical tumors with long pedicles, coming out through the urethra, by weight or from traction, might produce this result. The process of extroversion is generally slow. De Haen, quoted by Streubel, gives a case, however, where from force, the bladder, rectum and vagina were all prolapsed together. You will un- derstand that in order to have the bladder turned in- side out, the urethra must be abnormally dilated. It may occur at any age. Weinlecher saw it in a child but nine months old; Oliver in one of sixteen months ; Crobs in one from two to three years ; Streu- bel in a girl fourteen years old, and Thomson and Percy in women aged respectively forty and fifty-two. Sjmaptoms. — The patients, even before the tumor appears, feel strong pressure in the organ on urination, and may have stoppages in the stream, and reten- tion. After a time, these symptoms becoming ag- gravated, a small red tumor appears af the meatus, and with each urination enlarges. With the appearance of the tumor comes pain. In some cases, when the de- sire to urinate is felt, severe contraction of the bladder takes place, but no urine flows. Then suddenly the little tumor disappears inside, and the urine flows freely. SYMPTOMS— DIAGNOSIS. " 107 With each appearance of the tumor there is consider- able constitutional disturbance, and after a time the appetite is lost, and the sufferers emaciate rapidly. From continual traction on the ureters they may be- come inflamed, as also the kidneys, and uraemia super- vene. Blood is sometimes passed with the urine. Cystitis may occur, which increases the suffering and danger. The mucous membrane may become hyper- trophied, congested, and even cedematous. The con- stitutional symptoms bear no relation to the amount of tissue extruded or the area of mucous surface exposed. Diagnosis. — Luckily this affection is a rare one, for the diagnosis is by no means easy. The surface of the tumor should be examined, and the nature of its epi- thelium carefully noted. Reduction should be tried, and if successful, examination by the sound in the organ and the finger in vagina or rectum (the latter in infants) be used to ascertain if possible whether there be any thickeninof of the membrane or a tumor in the viscus. If on the surface of the protrusion the orifices of the ureters can be found, the diagnosis is at once settled. Polypoid projections of mucous membrane must be differentiated from protrusion of the viscus itself Such cases are described by Baillie and Patron. From prolapsus of the urethral mucous membrane, that I shall tell you of in another lecture, this condition is to be differentiated by the absence in the latter of the ureteric openings, and the position of the meatus urinarius. In urethral prolapse the orifice is situated either centrally or superiorly, while in vesical protru- io8 FUNCTIONAL DISEASES OF THE BLADDER. sion the meatus surrounds the pedicle. In the latter there is a large strong pedicle ; in the former none. Treatment. — The treatment naturally divides itself into prophylactic and curative. To prevent partial ex- troversion from becoming complete, narcotics and de- mulcents should be given by the mouth and rectum, or injected into the bladder. Opium, Hyoscyamus, and Belladonna may all be tried. Local cauterization and washing out with tonic injections might prove service- able. These preventive means are usually sufficient, provided the urine is normal and the mucous mem- brane healthy. If either of these abnormalities exist, they should be corrected. If the tumor is down, its reposition should be at- tempted. Gentle manipulation with the fingers should be tried, and if the mass cannot be put back in this way, a well-oiled blunt catheter should be used, making press- ure with it in the direction of the axis of the urethra. If this is very painful, and there are spasmodic contrac- tions of the abdominal muscles, which prevent replace- ment, ansesthetize the patient, and you may thus succeed. She should be on her back, or in the Sims position. To prevent prolapse after reduction, you may let the catheter remain in situ for a time, or use the col- peurynter or tampon. Schatz's pessary for urinary in- continence may be used advantageously, as its use tends to contract the vesical neck. The use of cauter- ization to accomplish contraction is not well spoken of Astringent injections may be used. No operative pro- cedure is to be thought of. LECTURE III. Organic Diseases of the Bladder — Urinary Anal- ysis AND Exploration of the Bladder as Aids TO Diagnosis — Hyper^emia — Hemorrhage from THE Bladder. Gentlemen — We come now to the study of those diseases of the bladder characterized by lesions of structure. These affections, known as organic diseases, follow in natural order the purely functional troubles, the discussion of which we have just finished. Preparatory to the study of this class of cystic dis- eases, I propose to call your attention to some of the methods and means of exploring the bladder and ure- thra, and some of the physical signs of disease obtained thereby. In all cases of cystic difficulty, the urine should be carefully examined, both chemically and microscopically. Let the patient urinate into a perfectly clean bowl or vessel, and from that fill a clean (4 to 6 oz.) bot- tle with the urine. Ascertain, if possible, the amount passed in twenty-four hours. The bottle should then be allowed to stand quietly for a few hours, until the sediment, if there be any, has settled to the bottom. For convenience and accuracy in examining the 110 ORGANIC DISEASES OF THE BLADDER. urine and recording the results, you will find it best to have some regular plan or system of proceeding. The recording blank which I here show you is as service- able as any, and exhibits in small compass what I wish to show. ANALYSIS OF URINE OF M. _ _„ Date, Temperature, Color, Specific Gravity, Odor, Reaction, _ Sediment, Am^t 24 hours, MICROSCOPICAL EXAMINATION. CHEMICAL ANALYSIS. Color. — First, carefully observe the Colo7\ The color of normal urine is usually a pale amber. In organic vesical disease it is, as a rule, either a pale or a dirty yellow. This is especially marked if ammonia- cal decomposition has taken place. From a slight admixture of blood it gains a smoky tint ; and if the blood be present in large amount, a yellowish or bright red color. From the presence of pus it may take on a dirty yellow or slightly greenish hue. Odor. — If ammoniacal decomposition has taken place, the smell will be that of ammonia. Pus In con- siderable amount, as also blood and tissue shreds, give URINARY ANALYSIS. ill rise to a peculiarly fleshy smell, known commonly as organic. In an acid urine with pus, the odor is usually rather sweet. Sediment. — Epithelium alone gives rise to a slight whitish deposit ; with a large amount of mucus the sediment closely hugs the bottom of the bottle ; while with a small amount of mucus it exists as a filmy arched cloud. If pus be present in large amount, it usually settles down as a white flocculent sediment. Tissue shreds are of a pale red or pinkish-white color. Blood gives a light or dark red, or even blackish sediment, generally closely adherent. Mucus, when in large amount, is very tenacious, and clings to the bottle, even when turned upside down. The Triple and Amor- phous Phosphates form a close white sediment, some- times sparkling. As they are but rarely found in any save distinctly ammoniacal urine, the dirty brownish masses of the Urate of Ammonia are commonly found with them. The Amorphous Urate deposit is of a pinkish or light fawn color. The Oxalate of Lime makes a beautiful, soft, undulating-surfaced sediment; Uric Acid, a reddish granular sediment ; or may appear as specks on the side of the glass or bottle. Reaction. — The reaction may be acid, neutral, or alkaline. When alkaline it may be due to a fixed or volatile alkali. If, when the discolored litmus paper be held to the heat, the blue color gradually fades away and is replaced by the original red, it is due to a volatile alkali ; when no change takes place, to a fixed alkali ; 112 ORGANIC DISEASES OF THE BLADDER. and when but partial clearing up, to both a fixed and volatile alkali. In the primary or acute stages of cystic disease, the urine may be normally or even abnormally acid, but sooner or later it becomes alkaline. The alkalinity in these cases is due in greater part to the ammonia set free in decomposition in the viscus, but may in part be due to the fixed alkali of the mucus which is secreted in excess. That the mucous membrane of the bladder (in disease at least) secretes a highly alkaline mucus, has been claimed by Dr. Owen Rees. He cites a case of extroversion of the bladder where the mucus was so strongly alkaline that it neutralized the acid urine flowing over it. Dr. Roberts, in a similar case, was able to verify Dr. Rees' observations, but could not determine positively whether the alkalinity was clue to the mucus or to exuded blood serum. The alkaline reaction from volatile alkali, met with in most cases, is produced as follows : There being an inflammatory condition of the organ, the mucous mem- brane seeks to shield its irritable surface with a bland secretion, and pours out an excess of mucus. Mucus or other organic material having the power of de- composing Urea, such a decomposition takes place, and Carbonate of Ammonia in large amount is set free. This, partly by further alkalizing the urine, causes a precipitation of the Phosphate of Lime and Phosphate of Magnesia, and partly by union with the Phosphate of Magnesia, forms the Triple or Ammonio-Magne- sian Phosphate. We thus have a deposit of the Amorphous Phosphate of Lime and the Phosphate of URINAR Y ANAL YSIS. 1 13 Magnesia, the Triple or Ammonio-Magnesian Phos- phate, and the Urate of Ammonia. Before taking the specific gravity of the urine, you should examine the sediment microscopically. This may be done in the following manner : Microscopical Examination. — Having your micro- scope, glass slide, cover and pipette clean and ready, remove the cork from the bottle, and passing the pi- pette (the upper end of which is carefully closed by the forefinger of the hand in which it is held) into the sediment, gradually relax the finger, and moving the tube slowly about allow some of the sediment to rise into it. This being accomplished, remove the tube (the finger still closing the orifice) from the bottle, wipe the outside dry, and putting the lower end on the slide, relax the finger gradually and allow a few drops to run out. Over this put a thin glass cover, remove the su- perfluous urine about the edges by means of a soft cotton cloth, and then put the slide upon the stage of the microscope, and proceed to examine. A power of about 450 diameters is all that is usually necessary. The most important products of cystic disease found in the urine are mucus, pus, epithelium, and sometimes blood. The latter, however, is rare, unless there be intense congestion with capillary rupture ; de- struction of tissue by ulceration ; or in cancerous dis- ease. If blood is present, it may be of a bright red tint, and is generally diffused ; or it may be in clots, and of a brownish or blackish color, from excessive acidity of the urine. "4 ORGANIC DISEASE OF THE BLADDER. Pig. 8, The value of blood in the urine as a sign of disease depends on our ability to determine from what portion of the urinary canal it comes. Various rules are given by which we can distinguish the location of the bleeding. I will not burden your minds with them at present, but will refer to this point at another time. Blood globules, as found in the urine, may have their natural shape, viz., that of bi-concave disks, from the I -3000th to the i -4000th of an inch in diameter, and of a pale yellow color. In limpid urine the cor- puscles, after standing a short time, may imbibe water and swell to two or even three times their natural size. In the latter state they have something the shape of an apple. In concentrated urine the corpuscles are often found shrunken and with crenated edges. In ammoniacal urine they frequently present irregular bulgings on their surfaces, and are sometimes found to have ruptured. Pus occurs in round- ed globules, varying from the 1-2 500th to the I -2000th of an inch in diameter. Their sur- faces are either mark- edly or slightly granu- lar. That they are pus corpuscles may be readily determined by letting a drop of dilute acetic acid find Pus Corpuscles. 1, As usually seen in urine (highly mag- nified). 2, After addition of dilute Acetic Acid; showing nuclei. URINAR Y ANAL YSIS. "S its way under the edge of the glass cover, when, if it be pus, the granular surface will immediately clear up and from one to four nuclei become apparent. (See Fig. 8.) Acid not sufficiently dilute will cause rupture of the corpuscles and escape of the nuclei. Mucus usually occurs as fibrillated bands and shreds, and is easily recognized. Epithelium of various kinds may be found in the urine in this class of affections. If we had only the heal- thy bladder and urethra rig. 9. with which to deal, we might locate the source of the various forms of epithelium with com- parative ease. In this class of diseases, how- ever, owing to the ab- normally rapid and consequently imper- fect growth and ex- foliation of epithelium, we get a multiplicity of form ; and a cer- tain transitional form from one locality often closely resembles the normal type from another, which would lead to serious mistakes in diagnosis and endless con- fusion if we relied upon this sign alone. A familiar example is found in those cases where epithelium from the bladder, in a transitional state of development, closely resembles normal epithelium from the pelvis of the kidneys. Knowing this fact, never Some Transitional Forms of Vesical Epithelium. Ii6 ORGANIC DISEASES OF THE BLADDER. attempt to locate the seat of inflammatory trouble from the character of the epithelium alone. Epithelium from the body of the bladder is usually of the flat squamous variety, about one size smaller than the vaginal epithelium, and one size larger than that Fig. 10. Epithelium. A, Vesical Epithelium. B, Vaginal Epithelium. C, Epithelium from Meatus. D, Epithelium from Urethra. E, Mucous Fibrillae. from the meatus urinarius. It has a nucleus a little smaller than a blood globule, and its surface is often slightly granular. This form is that known commonly as vesical epithelium. (Roberts, Bird, Prout, &c.) (See ay Fig. lo.) According to Strieker and Beale, the URINAR Y ANAL YSIS. "7 epithelial layer of the bladder may be double or even triple ; a layer of columnar cells usually being firmly set into the under surface of the squamous plates, that lock on their edges. As you reach the neighborhood of the orifices of the ureters and urethra, the epithelium gradually shades off into that of the columnar variety. Fig. 11. Epithelium, Pus, and Triple Phosphate. A, Vesical Epithelium. B, Vaginal Epithelium. C, Ammonio- Magnesian or Triple Phosphate. D, Urate of Ammonia. E, Mucus. I, Pus Corpuscles. 3, Urethral EpitheUum. 4, Epithe- lium from Meatus. The epithelium of the urethra and ureters is of the cylindrical type, the former being usually larger than the latter. (See c and d, Fig. lo, and 3 and 4, Fig. 1 1 .) Ii8 ORGANIC DISEASES OF THE BLADDER. At the meatus urinarius it is usually of the tesselated or small squamous variety. This form may also be found scattered throughout the canal. Epithelium is usually found in the urine only in the first stages of inflammatory bladder trouble. In the advanced stages the mucous membrane is either de- stroyed in whole or in part, or is so busy making pus that it produces no higher formations. The Amorphous Phosphates appear, as the name implies, as a granular, amorphous deposit, of a light color. They are readily dissolved by a few drops of acid. The Triple or Ammonio-Magnesian Phosphate appears usually as large triangular prisms with beveled edges. In old urine the edges are often broken or irregularly chipped. (See c. Fig. ii.) Of the method of their formation and deposit I have already told you. The Urate of Ammonia usually appears in the shape of round brownish or blackish balls, varying from the I -500th to the I -2000th of an inch in diameter. (See D, Fig. II.) As the other urinary sediments do not especially concern us just now, I refer you to your text books for their consideration. Specific Gravity. — In diseases of the bladder the specific gravity of the urine is generally low, even when febrile symptoms are present. The vesical irritation seems to act on the kidneys as a diuretic. The gravity, except in the first stages, usually varies from about 1. 010 to 1. 016. Chemical Analysis, — If on boiling the upper stra- VRINARY ANALYSIS. "9 turn of urine in the test-tube, a cloud appears, it may be either Phosphates or Albumen. If on the addmon of a little Nitric Acid it clears up, it consists of tae Phosphates; if, on the contrary, a sediment falls, it is Albumen. Alkaline urine should be aodified before boiling with a few drops of Acetic Acid, or else the albu- men may not coagulate with heat. A more delicate test is to put a few drachms of urine into the test-tube, and allowing Nitric Acid to trickle slowly down the side and to the bottom of the tube, watch the line of con- tact between the acid and urine, when, if albumen be present, there will be found a more or less marked cloud or white stratum. , . , ^ , On adding Nitric Acid to urine rich in the urates, a white cloud may fall to the bottom, and closely resem _ ble albumen. It consists of Uric Acid crystals, and was first spoken of by Lionel Beale. If the urine is cloudy at first, and clears up as heat is applied the cloudiness is due to the presence of the urates. They are readily reprecipitated by cold. Blood and pus in the urine are always accompanied by a certain amount of albumen. This varies with the quantity of these ingredients present, and no specific rule of proportions can be laid down to guide you From the presence of pus alone in -ery ^ad cases of Cystitis it may run as high as one-fifth of bulk, and even higher, if blood be present. From one-twentieth to one-eighth of bulk are the degrees of variation in the average cases. _ , , _ In telling you how to examine urine, and what you may find in it. I may have failed in my main object, 120 ORGANIC DISEASES OF THE BLADDER. which was to impress upon your minds the relative value of the products of disease found in this fluid, as aids to diagnosis. In order to brino- the matter before you in a shape that you can remember easily and em- ploy practically, I have arranged the subject under different heads, as follows : — COLOR. Vesical Neuroses — Constitutional Neuroses. Pale amber, ) i-i <. - Ti 1 ^ ' > or like Avater, Pale straw, ) Inflammatory Vesical Affections, Neoplasms, etc. In chronic cases, usually of a pale yellow or greenish yellow color, and somewhat turbid. Usually dark amber in acute attacks or acute engraftments on chronic disease. Reddish or blackish from admixture of blood, the latter in intensely acid urine, or when the blood has formed in clots in the bladder. From dyspepsia or fever may show a pinkish deposit, due to precipitation of the Amoq^hous Urates. May be a dirty greenish white, from precipitation of Mixed Phosphates with Urate of Ammonia. The color may be changed by the elimination of various drugs, as yellow from Rhubarb, oily yel- low from Santonin, &c. ODOR. Vesical and Urethral Neuroses — Constitutional Neuroses. Seldom any. If any, it is usually slightly sweetish, or may be perfectly normal. Urine takes different odors from drugs, as that of violets from Copaiba, &c. Inflammatory AffectioJis, Neoplasms, etc. In the decomposed urine of Cystitis or Retention, the odor is am- moniacal. If containing much pus, or other organic substance, it has a peculiarly fleshy smell, known to some as organic. Deposits of phosphates may give an earthy smell. Seldom found, howeveiv being usually masked by the ammonia of decomposition. URINARY ANALYSIS. J21 SEDIMENT. Vesical, Urethral, and Constitutional Neuroses, Disorders of Digestion, etc. The most reliable method of studying sediments is under the mi- croscope. Gross appearances are hard to describe, and often decep- tive. The average nervous urine usually deposits a slight cloud for a sediment, that consists of mucous fibrillse, and a few epithelial scales from both bladder and vagina. The Oxalate of Lime, so common in nervous dyspepsia and errors in secondary assimilation, is usually mix- ed with a little filmy mucus, and gives an undulating-surfaced, velvety cloud that is almost pathonomonic of this deposit. Uric Acid, also found in disorders of primary and secondary assimilation, gives a sed- iment consisting of minute red specks or dots. It may be deposited on the sides as well as the bottom of the bottle or glass. The Phos- phate of Lime, or the Triple Phosphates, which are occasionally de- posited in the slightly alkaline urine of nervous women, or by the use of drugs, gives a dead white, even-surfaced sediment. It may be glis- tening from the crystals of the Triple Phosphate. Sometimes in irritable bladder, a heavy white sediment, consisting of nothing but vesical epithelium and a little mucus, will be found. Inflammatory Affections, Neoplasms, etc. In Cystitis, with decomposition of urine, there is usually quite a mixed sediment, consisting of pus or muco-purulent matter, Amor- phous Phosphate of Lime, and crystals of the Ammonio-Magnesian Phosphate, with possibly some epithelial scales from the vagina and . bladder. The gross appearance of such a deposit is a heavy green- ish, yellow or grayish sedimen, that settles closely to the bottom of the bottle. It may also consist of two strata; the lower whitish, the upper a dirty greenish or gray. In acid urine of inflammatory affections, the pus alone precipitates, making a more or less thick greenish white or dirty white deposit. This, as also the mixed deposit, may be tinged red or blackish red by blood, or veiled by a superior stratum of the Amorphous Urates. Blood may also appear in little rounded or irregular red or black bodies. Fleshy bodies, that may be bits of tumor, shreds of mucous mem- 122 ORGANIC DISEASES OF THE BLADDER. brane or blood-stained mucus, may also be found. They should be carefully examined. Pure mucous sediments are usually of a yellow- ish color, and appear like a mass of jelly in the bottom of the bottle. The mass clings tenaciously to the bottle or vessel when it is in- verted. MICROSCOPICAL EXAMINATION. Constitutional, Vesical, and Urethral Neuroses. The sediment is usually slight, and as a rule consists of mucous fibrillse and epithelium from the bladder or urethra. There may be dumb-bells or octahedra of Oxalate of Lime, or the many-formed crystals of Uric Acid. There may possibly be crystals of the Stellar Phosphate of Lime, consisting of stars, or bundles of rods, and crys- tals of the Triple Phosphate. The Amorphous Phosphate appears as a light granular deposit. Vesical epithelium is seldom absent, and a few scales of vaginal epithelium are usually found. Inflammatory Affections, Neoplasms, etc. Pus is always present ; epithelium from the bladder in the earlier stages ; usually none at a later stage. Bits of tissue, consisting of dead mucous membrane, or pieces of tumor, may also be present. Mucus, blood, and the phosphates are common. Blood globules are especially common with the neoplasms ; sometimes blood in large amount. If the kidneys are involved, pus, epithelium and casts from these organs will be found ; also epithelium and pus from the ureters and renal pelves, in PyeHtis. In decomposed urine the Urate of Ammonia crystals are not uncommon. Assimilative defects may give us Uric Acid or Oxalate of Lime crystals. CHEMICAL ANALYSIS. SPECIFIC GRAVITY. Constitutional, Vesical, and Urethral Neuroses. Errors of Assimilation. Gravity usually low, ranging from i.ooi to 1.012. Assimilative errors give either a normal or a moderately high gravity — 1.025 to 1.030. Urine of nervous affections may have a normal gravity. URINAR V ANAL YSIS. 123 Inflammatory Affections, Neoplasms, etc. In chronic vesical disease, the gravity is usually about i.oio. Acute disease or acute engraftments may raise it to 1.015 or 1.020. A high gravity in these affections usually means some fault in the se- cretive power of the kidneys. REACTION. Constitutional, Vesical, and Urethral Neuroses, and Errors of Assimilation. Reaction in nervous affections usually normally acid ; sometimes neutral or slightly alkaline from fixed alkali. In digestive trouble, usually abnormally acid, leading to deposit of Oxalate of Lime or Uric Acid, even when these bodies are not in excess. Inflammatory Affections, Neoplasms, etc. Reaction usually acid in acute affections at first, then alkaline from fixed alkali of mucus or the ammonia of decomposition. In chronic inflammatory disease the urine is usually alkaline, from am- monia; sometimes from fixed alkali of mucus or of blood, when present in large amount. EXCESS OP CONSTITUENTS. Constitutional, Vesical, and Urethral Neuroses. Errors of Assimilation. In all the neurotic troubles there is usually an excess of the Alka- line Phosphates — occasionally of the earthy. Not necessarily any precipitation. Usually accompanied by an excess of the carbonates. In assimilative errors there may be an excess of Uric Acid. This may only be apparent, not real ; apparent, from its existence as a deposit, due to either too little water to hold it in solution, too great acidity, or both together. The same applies to the Oxalate of Lime, which is not a normal constituent. Oxalic Acid is said by some to exist in the human urine. Liflammatory Affections. There may be an excess of the Carbonate of Soda, or the Phos- phates. 124 ORGANIC DISEASES OF THE BLADDER. Presence of Abnormal Substances. Urohaematin (Harley) is sometimes found in chronic cases of inflam- matory trouble, in any one with poor blood condition, or when " blood drainage " is taking place. Albumen is always found in the urine in small amount, when blood or pus is present, usually from one-twentieth to one-eighth of bulk, varying with the amount of these substances in the fluid. If above one-tenth of bulk, casts should be searched for. This should always be done, if possible. CONSTITUENTS OP NORMAL URINB. Roberts. Urinary and Renal Diseases. Water 954-8i Solid Matters 4S-i9 lOOO.OO Extractives. < Urea 21.57 Uric Acid 0.36 f Creatine, Creatinine, Ammonia, ' Hippuric Acid, Xanthin, Hypo- xanthin. Sarcine, Pigment, Unoxidized Sul- phur and Phosphorus, Mucus, I &c. ) ( ' Chlorine Sulphuric Acid Phosphoric Acid Potash 1.40 Soda 7-19 Lime o-n Magnesia 0.12 6.53 4-57 2.09 Having obtained all the Information that an ex- amination of the urine affords, you will next, if neces- sary, turn your attention to a physical exploration of the bladder and urethra. For this purpose I have devised an Endoscope, which, to the investigator of bladder and urethral diseases, has proved to be what Sims' Speculum is to the gynecologist. THE ENDOSCOPE. 125 \ This instrument is composed of three parts. A glass tube {a, Fig. 13) is shaped Hke the ordinary test- tube used by chemists, except that the mouth is a Httle more flaring. The second part (^, Fig. 13) is composed of two pieces — a mirror and the arrangement which holds it. A piece of very thin silver plate is made to fit nearly the whole length of the inside of the glass tube, and about one-third of its circumference. To one end of this arrangement the mirror is attached, at an Tigi^ angle of about 100 degrees. At the other end a deli- cate handle projects at an obtuse angle. This part of the instrument looks like a section of a tube that has been divided into three equal parts by longitudinal section, with a mirror attached at one end and a han- dle at the other. This piece is made perfectly black on the inside, and answers two purposes — it holds the mirror, and when placed in position for use, darkens one side of the glass tube. It will be seen that the mirror can be moved for- ward or backward and turned around ; so that when the tube is introduced into the urethra or bladder, 126 ORGANIC DISEASES OF THE BLADDER. the exposed internal surfaces can be brought into view by moving the mirror while the tube remains stationary. Fig. 1 2 shows the glass tube placed inside of a fen- estrated hard-rubber speculum ; and Fig. 14 shows the glass tube inside of a speculum that is open and bevel- ed at the end. These specula are used in making applications to the urethra and bladder, as will be described hereafter. The method of using this instrument is as follows : The tube, with the mirror inside, is introduced into the urethra, and bladder also, if an examination of the latter be desired. Light is then thrown into the tube by the aid of a concave mirror. This shows that por- tion of the interior of the urethra or bladder which is opposite the mirror ; and by moving the mirror back- ward and forward the whole of the parts to be exam- ined are brought to view in regular succession. Sunlight can be used, and when it can be favorably controlled it answers better than any other. It very often happens, however, that the light is insufficient. Dark, cloudy days, or the unfavorable position of the office window, often make it impossible to employ sun- light for endoscopic examinations. On this account I prefer to use gaslight. For this purpose I use a gas bracket which is movable in every direction — up, down, forward, backward, outward or inward, and which can be fixed in any position desired. By this means the light is easily adjusted to the position of the patient on the examination table. An Argand burner with the ordinary condensing attachment is used, which gives a THE ENDOSCOPE. 127 very strong, yet soft, steady light. There is one objec- tion to the condenser, and that is the difficulty of getting the light in the exact place where you want it. On this account I prefer the ordinary argand burner with the glass chimney, such as oculists em- ploy when using the ophthalmoscope. The color of the mucous membrane lining the urethra and bladder has already been described ; but I must tell you that the endoscope modifies the color to some extent. This is especially so when examining the urethra. If a large-sized tube is used, the parts are put upon the stretch, and the pressure of the glass on the mucous membrane interrupts the capillary circula- tion to some extent, and renders the color as seen in the mirror a pale pinkish white. This does not inter- fere with the examination, as it only tends to make the contrast between the normal and diseased tissues more marked. The only condition where the endo- scope might lead to error is in acute general congestion of the urethra. The pressure of the instrument causes the congestion to disappear in part, and gives the idea of less disease than there really is. In such cases I use the speculum and tube shown in Fig. 14, and thereby remove all possibility of error. By a little practice in managing the light, you can soon acquire enough dexterity to examine the female bladder thoroughly and intelligibly. To get a good view of the centre of the fundus, I use an endoscopic tube closed at the end by a clear thin glass, through which the mucous membrane at this point can be plainly seen. By using a closed tube we 128 ORGANIC DISEASES OF THE BLADDER. are enabled to prevent the flow of urine into it, the presence of which would obstruct the view. After dilatation of the urethra (an operation to be discussed hereafter), a tube as large as the index finger can be used. Indeed, my first experience in this direc- tion was accomplished in this way : I took an ordinary test-tube, introduced it through the dilated urethra, and pushing it upward I elevated the fundus vesicae a little, so as to bring its walls closely about the tube. Light having been thrown in from a concave mirror, a small laryngoscopic mirror was introduced into the tube, and being turned about and moved backwards and forwards I was able to inspect the whole cavity of the bladder in the most satisfactory manner. With this simple instrument I can accomplish all that is to be desired ; but that you may choose for your- selves, I shall mention instruments used by others for the same purpose. My friend Dr. Robert Newman has used Desor- meaux's instrument with great success. The main ob- jections to it are that it is costly, and requires a great deal of practice before it can be used with any good re- sults. Moreover, it is complicated and apt to get out of order. Indeed, I have never been able to explore the bladder with it at all satisfactorily. Grunfield, whose testimony is supported by that of Fiirtz and Ultzman, claims excellent results from the use of his (Grunfield's) speculum. This instrument consists of a simple straight tube, open at both ends, and somewhat flanged or funnel-shaped at its anterior or external end. He says that by this alone he is able THE ENDOSCOPE. 129 I to explore various parts of the bladder, and note finest shades of color in its mucous membrane, or of the urethra. By the use of Simon's mirrors, with artificial, light, a clearer and more complete view is to be had, than if the speculum alone is used. Even with Simon's mirrors, however, you will be unable to obtain a good view of the ante- rior and lateral walls of the organ, and will more- over be inconvenienced by contractions of the bladder and falling of the posterior vesicle wall against the opening of the speculum. Rutenberof conceived the idea of distendinor the bladder before making an examination, hoping thus to overcome the various drawbacks so com- monly encountered in such under- f^^^ takings. After considerable experi- fCJ ^^^ menting he found that while water 6r — answered the purpose, air was in many respects much better, as the medium for accomplishing distension. The speculum that he uses consists of two parts — the speculum proper and the " extension." The latter is screwed on to the former, and when so secured the whole is perfectly air-tight. It consists entirely of metal, save at either end, where there is a glass window. On one side is a short pipe, to which is fixed a piece of rubber tubing, by means of which air may be forced in- to the bladder. At the other side is an air- tight piston, to which a mirror may be at- tached at will. The extension is merely to give the examiner something by which to hold, and thus facilitate manipulation. the that 130 ORGANIC DISEASES OF THE BLADDER. In examining a patient after this method, it is nec- essary to etherize her, for dilatation of the bladder by air has been found to be extremely painful, and even if this were not so, involuntary contraction of the abdom- inal walls would be sure to prove a troublesome inter- ference. The apparatus may be used with or without dilatation of the urethra. The main objections to this method of examination are, first, that while it gives a comparatively free and distinct view of the interior of the bladder, it alters considerably the appearance of the mucous membrane, both as to color, thickness, and degree of vascularity. Moreover, it is intensely painful, and requires ether- ization, which many patients, especially those whose systems are broken by serious cystic disease, dread in- tensely. Also, under the strong pressure of air, escape of some into the ureters and pelves of the kidneys, with resulting Pyelitis and Pyo-nephrosis, is to be feared. Indeed, distension by its normal contents is very apt to produce vesical catarrh. Winckel says that he has used Rutenberg's method in ten cases, and in some cases re- peatedly, without any serious results, and thinks it a valuable aid in the diagnosis of vesical troubles. My friend Dr. Noeggerath maintains that these examinations are followed by various urinary distur- bances, such as vesical catarrh, incontinence, severe pelvic pains, and, in rare cases, peritonitis. Winckel says that although he has frequently known severe pain, dysuria, and smarting, to follow the ojDeration, he has seen but one case of vesical catarrh resulting therefrom ; and as these results are simple and yield PHYSICAL EXPLORATION. 131 readily to treatment, and as the results obtained are of great value, both in diagnosis and treatment, he claims that they are not worthy the rank of serious objections. Matthews Duncan uses a simple mirror in an ob- liquely cut speculum, which is mirror-lined ; and I may say that I looked upon his as the best in use until I devised the one above described. W. Donald Napier has invented a probe that is of use in detecting foreign bodies in the bladder. No dilatation of the urethra is needed for its use. It con- sists of a beaked sound, the vesical end of which is covered with pure metallic lead. This having been carefully polished with soft leather, it is dipped into a one per cent solution of Nitrate of Silver, which gives it a beautiful black coating. ' Before use it should be carefully examined with a lens, to see that its surface is perfect. When introduced into the bladder, if any hard body be present, such as calculus, against which it strikes, an obvious impression is made upon the pol- ished surface. The Manometer is an apparatus for determining the urine pressure in the bladder. Schatz's method, which is the one generally followed, consists in the introduc- tion of a metal catheter into the bladder. By means of a small glass pipe the catheter is connected with a straight glass tube, 1 50 centimetres long. A graduated measure, whose zero point is at the pubes, gives the hight of the urine above the symphysis, as well as the pressure of the urine in the bladder. The results ob- tained by this instrument I have already given you in my first lecture. 132 ORGANIC DISEASES OF THE BLADDER. Exploration of the bladder by dilatation of the ure- thra is a rather new and most valuable means of diag- nosis. It may be employed in various degrees. The urethra may be enlarged only sufficiently to admit a fair-sized endoscopic tube, or be dilated sufficiently to admit the finger. I will first give you the methods that are commonly in use, and then show you the plan I usually employ. Although we have records of blood- less dilatation of the urethra as far back as 1502 (Ben- ivienni), 1506 (Marcus Sanctus), and 1561 (Franco), we know that up to a late date the operation was not a common one. Franco used an instrument of his own for effecting dilatation. In the early part of the present century, dilatation by means of compressed sponge, and Weisse's metal dilator, was somewhat used, but more for the extraction of calculi and foreiofn bodies than for puposes of diagnosis. To Simon, however, belongs the honor of improv- ing the means employed and introducing the subject to the profession. His method is this: He makes a sin- gle incision superiorly, or two slightly laterally, in the wall of the meatus, about one-fourth centimetre in depth. He also snips the urethro-vaginal septum to the depth of about one-half centimetre. This is done to relax and prevent irregular tearing of the meatal portion of the urethra, which is the most rigid and undilatable part of the canal. He next introduces a somewhat cone-shaped hard- rubber speculum, the cut end of which is protected by a rounded piece of wood within. His largest speculum has a diameter of two centimetres, his smallest of three- PH YSICAL EX PL OR A TION. 133 fourths centimetre. After the introduction of the lar- gest one, the finger can be readily passed into the bladder and its interior explored, save the antero-lateral portion high up and lying against the bony surface of the pelvis. The narrowest urethra may in this manner be sufficiently dilated in from five to ten minutes. Simon found that, without any bad results following, an adult woman could bear the introduction of a spec- ulum having a circumference of from 6 to 6.26 centi- meters, and when the necessity for marked dilatation was urgent, and the possibly resulting incontinence of comparatively little importance, a cone having a cir- cumference as high as from 6.5 to 7 centimetres might be employed. In girls, specula having a circumference of from 4. 7 to 6.^^ centimeters may be used. For most diagnostic and therapeutic purposes, instruments not large enough to produce incontinence are usually sufficient. Winckel has used Simon's method seven times, and has had excellent results ; and he says that although the incisions made at the meatus are sometimes opened still further, and that a fresh one may appear under the clitoris, it is of little moment, as the presence of the dilator stops all hemorrhage, and the incisions heal readily. In none of Winckel's cases, although he watched them for weeks, was there any incontinence. Heath, in digital dilatation, found usually a tearing of the mucous membrane under the pubic arch, and incontinence was generally present for at least twenty- four hours. A particular advantage of Simon's method is that the operator is able to introduce instruments 134 ORGANIC DISEASES OF THE BLADDER. into the bladder while the finger is already there. This cannot be done easily in digital dilatation, as, in the first place, there is seldom room for an instrument beside the finger ; and secondly, the finger is very soon tired out. Fig. 16. Hunter's Uterine Dilator. A A, Fingers. B B, Gloves of hard rubber. C, Blades expanded. IV, Wedge which separates the fingers. Instead of incising the meatus, I generally dilate it slowly, using for this purpose the uterine dilator of Dr. Hunter, of which I here show you a drawing. (Fig. i6.) ^ You will observe that the blades, which are small, are covered at the end with a piece of rubber tubing, giving the whole very much the appearance of an elas- tic catheter. This instrument is introduced, and the blades expanded to the desired extent. (Fig. i6, c.) In cases where extreme dilatation of the urethra does not prove sufficient for the desired end, you resort to the method of opening into the bladder through the vaginal wall, as recommended by Simon. He makes an incision from right to left into the anterior vaginal PHYSICAL EXPLORATION. I3S wall, just in front of the os uteri. From the centre of this incision another is carried forward, about two cen- timetres in length, in the line of the urethra, thus form- inof a T incision. Fine tenacula are then fastened into the bladder wall, through the incision, and with one hand press- ing the abdomen and by traction on the tenacula, the bladder is pulled down through the incision and open- ed. After all necessary procedures are completed, the edges should be carefully secured by sutures, and the parts will heal kindly. The bladder walls coapt readily and accurately. You will understand that this important operation is only to be performed for the purpose of detecting and removing foreign bodies and abnormal growths from the bladder ; possibly to close vesico-intestinal fistulse. Rapid dilatation of the urethra is chiefly useful for the purpose of allowing the extraction of foreign bodies and moderate sized calculi ; for cauterizing the mu- cous membrane ; opening haematoceles (Spiegleberg) ; allowing the introduction of endoscopic tubes of large size, and with them diagnosticating cystitis, calculi (vesical and ureteral), ulceration, vesico-intestinal fistu- la, polypi, papilloma, etc., and for the local treatment of these. Incision into the bladder, on the other hand, is use- ful in cases where calculi or other bodies are too large for safe removal by the urethra ; the removal of tumors situated high up anteriorly or antero-laterally ; in oper- ations of various kinds where the urethra precludes free 136 ORGANIC DISEASES OF THE BLADDER. enouofh movement and orood illumination, as in sewing up large vesico-intestinal fistulae. I may observe, in passing, that in performing operations through the incision, artificial light might be thrown into the blad- der by means of a small curved endoscopic tube and concave mirror in the urethra. In cases of Cystitis and vesical ulceration, this op- eration has been done, by Sims, Emmet, Bozeman, Simpson, Hegar, and Simon, to prevent the stagnation and decomposition of urine in the diseased organ. Catheterization of the ureters has been performed by Simon and Winckel, but as it is difficult, not with- out danger, and of little practical value, I shall not dwell upon it here. In connection with the subject of physical explora- tion, I show you here the various instruments that I find of use in examining and operating upon the blad- der and urethra. They are in a compact velvet-lined morocco case, and are as follows : 2 Skene's Sims' Specula. I Folsom's Speculum. (Modification.) I Skene's Reflux Catheter for Bladder. 1 Skene's Reflux Catheter for Urethra. 2 Silver Probes. I Sponge Holder. (Steel.) I Knife. I Blake's Polypus Snare. (Ear.) 1 Allen's Polypus Forceps. (Ear.) 2 Glass Pipettes, 6 inches long. 2 Head Mirrors, on same strap, 3^^ in. and i^ in. 1 Lente's Caustic Cup. 2 Skene's Self-retaining Catheters. (Modification of Goodman's.) PHYSICAL EXPLORATION. 137 2 Rectal Endoscopes (long and short), with Fenestrated Rubber Specula. 3 Urethral Endoscopes (13, 15, 17, American), with Beveled Rub- ber Specula. 2 Beveled Urethral Endoscopes (19, 21, American), with Fenestrated Rubber Specula. I Brush for cleaning Endoscopes. The above, as well as all other instruments de- scribed in this book, are made by Geo. Tiemann & Co., to my entire satisfaction. Having given you the important facts in regard to physical exploration of the bladder, and the urinary analyses bearing on vesical diseases, I now pass to a consideration of the inflammatory diseases of the blad- der; and that you and I may ^understand each other clearly, let me say that under this head I shall include all forms of deranged nutrition which produce disor- ders of function ; temporary or permanent lesions of structure ; and the morbid material known as the " products of inflammation." Well-defined typical inflammation presents during its course certain peculiarities which are characteristic of the affection, and without the existence of which the disorder cannot be called -true inflammation. Inflam- mation, however, varies in character with the tissue or organ involved, and the extent or intensity of the dis- ease ; and, while there is really but one process of inflammation, as that process is often interrupted, pro- longed, or modified in various ways, its products must necessarily vary greatly. Its divers grades or forms are distinguished as 138 ORGANIC DISEASES OF THE BLADDER. acute, chronic, catarrhal, suppurative, croupous, diph- theritic, and productive. Hyperssmia. — In all cases, the first perceptible departure from the normal is a derangement of circula- tion. Hypersemia of the mucous membrane is observ- ed, and with it disorders of innervation, as evidenced by derangement of function and sensation. In hypersemia of the mucous membrane of the bladder, the blood-vessels are distended, and becoming prominent and apparently more numerous, give to it a briofht red color. The arteries are the first to be affected. If not marked, or when produced by some transient cause and not aggravated, this may pass off in a short time, and leave the membrane in its normal condition. If of a high grade, however, rupture of some of the vessels may occur ; the hemorrhage tak- ing place either on the free surface of the membrane or beneath its epithelial layer. Should this condition continue, the hyperaemia which began in the arteries extends itself to the venous side of the circulation, and the vessels become more prominently and uniformly distended. The congestion may also begin on the venous and extend to the arterial side, as in sudden interference with portal circulation, etc. As a rule, however, it begins in the arteries. You must make a clear distinction between the acute congestion, of which we are now speaking, it being chiefly confined to the smaller vessels, and passive congestion, with a varicose or hemorrhoidal condition of the veins about the neck of the blad- HYPEREMIA. 139 der. This hemorrhoidal condition I will speak of by and by. Symptoms. — The symptoms of acute congestion of the bladder, as a rule, occur suddenly. Frequent but painless urination is the principal trouble. There is often a sense of heat and heaviness in the region of the bladder, which is greatly aggravated by standing or walking. When the urethra is involved, the patient complains that the urine " scalds " her. The general system is not disturbed, i. c, the pulse and temperature remain normal. The physical signs are mostly negative. The composition of the urine is unchanged, save that there may be an excess of mu- cus and a few blood globules present. There may be some tenderness on pressure over the bladder. The endoscope (when you have an opportunity to use it, which is very rare in this trouble) shows an increas- ed redness of the mucous membrane, with occasionally an excess of mucus on its surface. Diagnosis. — The diagnosis has to be made by ex- clusion, the natural history of the trouble having in it nothing pathonomonic. You will be liable to confound this with sympathetic or other functional derangement of the bladder, caused by sudden dislocations of the uterus, or by pelvic inflammation, such as Pelvic Per- itonitis, and its results. The former you can exclude by an examination of the pelvic organs, and the latter by the constitutional symptoms of inflammation and the signs of such pelvic disease. I40 ORGANIC DISEASES OF THE BLADDER. Causes. — The causes of hypersemia of the bladder are, exposure to cold (especially during the menstrual period) ; wetting the feet ; over-taxation in walking or using the sewing machine; excessive venereal indul- gence ; constipation of the bowels from torpor of the portal circulation ; the excessive use of stimulants ; and the use of improper articles of food. Treatment. — The treatment should be directed to equalizing the circulation. Diaphoretics, warm, stimu- lating foot baths, hot applications over the epigastrium, and above all, rest in the recumbent position. If the bowels are confined they should be emptied by saline laxatives. When there is much irritation of the blad- der, causing frequent urination and vesical tenesmus, Pulv. Doveri with Camphor should be given, or sup- positories of Belladonna and Morphine introduced into the vagina. Under this treatment the trouble will usually pass off in a short time. It may go on to the development of Cystitis. Occasionally, bleeding occurs in active or acute cono-estion of the bladder, and that leads us now to speak of Hemorrhage from the Bladder. Hemorrhage from the Bladder. — Hemorrhage from the Bladder, or (if you will allow me to coin a word) Cystorrhagia, is usually due to some important disease of the bladder, and is therefore rather a symptom than a disease. For this reason I will at present confine my remarks to hemorrhage when caused by acute HEMORRHAGE FROM THE BLADDER. 141 congestion, which we have just considered, or to vari- cose veins of the bladder. The bleeding may take place from the free surface of the mucous membrane, and mingle at once with the urine, or coagulate in the bladder. It may also take place beneath the surface of the mucous membrane and form ecchymoses, like the black spots seen beneath the skin in Purpura. The quantity of blood varies greatly in different diseases, and in the same disease in different persons. In congestion of the bladder you w^U often find blood globules in the urine only on microscopic examination, while at other times it will have the appearance of being all blood. Again, the blood may coagulate and be passed in clots, or the coagula may remain in the bladder, finally break down, and be passed as a choc- olate-colored or blackish material. Symptoms. — The symptoms of hemorrhage do not differ from those of congestion or the onset of Cystitis, except when small clots form, distending the urethra and causing trouble in urinating. It is very rare that bleeding from these causes is sufficient to prostrate the patient. As bleeding may take place at any point in the uri- nary tract, it is important always to locate the hem- orrhage. Whencoming from the bladder in any quan- tity, it is usually passed in small clots, and is seldom so intimately mixed with the urine as when it comes from the kidneys or ureters. This is not reliable, and at best gives but a probable idea of the bleeding point. 142 ORGANIC DISEASES OF THE BLADDER. To complete the diagnosis we must resort to something more trustworthy. Sir Henry Thompson gives a very ingenious method for determining as to whether pus found in the urine comes from the kidneys or bladder, and Van Buren and Keyes advise the same plan for detecting the source of hemorrhage. The method is this : " A soft catheter is gently in- troduced first within the neck of the bladder, the urine drawn off, and the cavity washed out, very gently, with tepid water. If the water cannot be made to flow away clear, the inference is that the blood comes from the cavity of the bladder. If it will flow away clear, then the catheter is corked for a few moments, the patient being at rest, and the few drachms of urine which col- lect may be drawn off and examined. The bladder is now again washed out, and if, after a single washing, the second flow of injection is clear, while the drachm of urine was bloody, the inference is again complete that the blood comes from one or the other kidney." When you happen to know that the patient has had no kidney disease, nor symptoms of renal calculi, you can employ the endoscope, and possibly find the bleeding point. This has been done with the instru- ment which I have shown you, but you may fail to find it if it be high up laterally or antero-laterally, or be covered by a fold of the mucous membrane. Hemorrhage from the urethra might lead you as- tray, but is easily detected if you bear in mind that in this case bleeding occurs between the acts as well as during micturition. You may also readily discover it with the endoscope, provided the tube be not too large. HEMORRHAGE FROM THE BLADDER. 143 Causes — The causes of vesical hemorrhage, or Cystorrhagia, are numerous. Congestion, varicose veins, villous cancer, lesions of structure, as in ulcera- tion and sloughing of mucous membrane from injury or Cystitis, and obstruction to, or interference with the portal circulation. This may possibly explain the fact that hemorrhage occasionally occurs in those suffering from Malaria. Perhaps the vesical hemor- rhage occurring in the intense heat of summer in the tropics may be thus explained. In Malaria the ob- struction to the circulation through the portal system, acting as a predisposing cause, the intense conges- tion of all the internal organs during a chill or from exposure to cold, would certainly tend to produce Cystorrhagia. In Purpura, the Eruptive, Typhus and Typhoid Fe- vers, bleeding from the bladder may occur ; but as it is there secondary to the main disease, nothing need be said about it in this connection. The most marked predisposing cause of Cystor- rhagia in women is a tendency to the hemorrhagic diathesis, so common amongst chlorotic females. Treatment. — The treatment must largely depend on the cause. In all cases, rest in the recumbent posi- tion should be insisted on. A large number of hemo- statics have been recommended, and some of them, such as Aromatic Sulphuric Acid, Tannic and Gallic Acids, in moderate doses, are doubtless of some value. I have, however, depended chiefly on doses of Opium suffi- ciently large to quiet the desire to urinate, and alkaline 144 ORGANIC DISEASES OF THE BLADDER. diluents to render the urine non-irritant, when it was found to be super-acid. If the bleeding point or points can be discovered with the endoscope, applications of Acetic Acid, Per- sulphate of Iron, or Nitrate of Silver, may be made. Great care must be taken in using these remedies, lest inflammation and ulceration of the bladder result. Nitrate of Silver and strong Acetic Acid are more to be feared than the others. When the hemorrhage is so free as to excite fears of prostration, ice may be employed. Small, smooth pieces should be introduced into the vagina at regular intervals, as long as the patient can comfortably bear it. Ice may also be applied to the hypogastrium. When the blood coagulates and forms a large clot in the bladder, it should be allowed to remain until it breaks down and comes away of itself The experi- ence of surgeons is that there is much more danger in attempting to remove the clot than in letting it alone. There are two dangers in removing coagula from the bladder. One is, that in doing so you will almost cer- tainly start the bleeding again; and the other is, liabil- ity to injure the bladder and cause inflammation. Let the clots take care of themselves, keeping the patient quiet and comfortable (with Opium if necessary) until the coagula are disposed of In one case of traumatic vesical hemorrhage that came under my care, a large clot formed in the blad- der, and urination was completely arrested. I was unable to determine whether the inability to urinate was due to the presence of the clot or to loss of con- HEMORRHAGE FROM THE BLADDER. 145 tractile power of the vesical walls from the injury. The patient suffered so much, however, from the pain caused by retention, that I was obliged to use the catheter. I employed the flexible instrument of Jaques, and by carefully worming it in past the clot, I succeeded from time to time in drawinsf off enouo^h of the urine and broken-down clot to relieve the lady until she was able to relieve herself I was careful not to disturb the clot. Allusion has been made to Varicose Veins of the bladder, called by some, Hemorrhoids of the Bladder. This condition is chiefly found in pregnant women, especially those who have borne several children. The cause is interruption of the venous circulation by pressure of the gravid uterus. The veins of the anterior vaginal wall, introitus vulvse, and labia, will often be found in the same condition. Occasionally you will also And prolapsus of the bladder. This affection gives rise to those symptoms of pelvic distress and frequent urination, that are so troublesome in some pregnant women. You must keep in mind, however, that the same symptoms may come from pressure which does not produce varicose veins. If you find that the patient feels relieved, to some extent, in the recumbent position, and the urine is normal, you may suspect this trouble, and if the symptoms are sufficiently urgent, make a local exami - nation, which will reveal a varicose condition of the ves- sels of the urethra and vaginal walls, and from this you may infer that the same condition exists in the bladder. 146 ORGANIC DISEASES OF THE BLADDER. If the diagnosis is still doubtful, the endoscope will aid you in settling the question. This affection is relieved or passes off altogether after confinement, and the best that can be done usually is to give rest and try to make the patient comfortable until the end of her " term." Should the trouble continue after deliver)^ espe- cially if there is Cystocele or prolapsus of the blac|der, you can do much good by restoring and keeping the organ in place. This you can best accomplish by using the cotton pessary, or a roll of marine lint packed loosely into the vagina, like a tampon. The patient can be instructed to use this herself Attention should be given to the general health, and particularly to the condition of the bowels and portal circulation. Rest in bed, and the use of cool water as a vaginal injec- tion, may also be of use. Should hemorrhao^e occur from this condition of the veins, you may treat it as described when we discuss that subject. LECTURE IV. Cystitis — Acute, Sub-acute, Chronic, Catarrhal, Interstitial, Peri and Epi-cystitis, Croupous, Diphtheritic, and Gonorrhceal — Their Etio- logy, Pathology, and Symptomatology. Gentlemen — We will now turn our attention to the. subject of Inflammation of the Bladder, a disease that is much more common amongst women than is generally sup- posed. It is a disorder with which you will frequently meet in every-day practice, if you give a due amount of care and attention to your female patients. If, however, you do not understand, or neglect the peculiar symp- toms of this affection, satisfying yourself by referring all pelvic pain and distress to some disease of the uterus or its appendages, you will neither do justice to yourself nor your patient. It behooves us therefore to inquire carefully into the etiology, pathology, and therapeutics of this affection, which causes great suf- fering on the part of the patient, and taxes the highest skill of the ablest sursfeon. To the several forms, grades, or degrees of this disease, various names have been given, such as Acute, Sub-acute and Chronic Cystitis, Cystitis Mucosa (catarrh of the bladder), Interstitial Cystitis, Peri and 148 CYSTITIS. Epi-cystitis, Croupous, Diphtheritic, and Gonorrhoea! Cystitis. Do not let this medley of names confuse you, but bear this fact firmly fixed in your mind, that, with the exception of the last three (the etiology and pathology of which are somewhat different), they are simply steps in a general process. Thus, a patient may have received a severe blow over the partially filled bladder, causing an Acute Cystitis. This may end in convalescence, or merge slowly into the more chronic form, having very likely as an intermediate step, Cystitis Mucosa. This, too, may go on to recovery ; but if the process extends and its severity increases, ulceration takes place, and the submucous and intermuscular tissues become involved, giving us Interstitial Cystitis. If the inflammation extends still further, and involves the serous coat of the bladder, either by extension or ulceration, with or without perforation, we shall have Peri or Epi-cystitis. In this example I hope you have clearly seen the fact that names are only given to denote the degree of inten- sity of the inflammatory process, and the character and extent of the tissue involved. Inflammation of the mucous membrane alone is by far the most common form, and hence in using the term Cystitis we usually refer to inflammation of that membrane only. When other tissues are involved, or the character of the disease is peculiar, we add some qualifying word to distinguish it. Acute inflammation of the bladder, other than that due to local causes, is emphatically denied an existence by many authors. The statements made are usually ACUTE CYSTITIS—ETIOLOGY. 149 too broad and sweeping to be sustained by the facts observed in actual practice. I am inclined to believe that cases of Acute Cystitis, from exposure to cold and wet, do occur. It must, however, be admitted that such cases are very rare, and some that have been con- sidered Acute Idiopathic Cystitis, may have been but a development of acute inflammatory disease upon a pre-existing abnormal condition. It is also possible that those who deny the existence of Acute Idiopathic Cystitis, may base their belief upon the fact, that in what is called acute inflammation of the bladder, all the phenomena of well-defined in- flammation are not present, while others consider hy- persemia of the mucous membrane and derangement of bladder function all that is necessary to constitute Cystitis. Thus, the apparently different opinions that exist amongst authors upon this subject may arise from conflicting views as to what really constitutes in- flammation. I prefer to class this condition (of congestion, hy- persecretion of mucus, abnormal exfoliation of epithe- lium, and irritability) among the inflammatory affections, and call it Acute Cystitis. Such an affection as this is met with in every-day practice, and I know of no bet- ter name for it. With this understanding, then, we will pass to a short discussion of Acute Cystitis. Acute Cystitis — Etiology — The causes of Acute Cystitis may, for convenience, be classed under five heads, each of which we will study separately. 150 CYSTITIS. I St. Direct injuries, such as blows in the vesical region, falls, fractures of the pelvic bones, violent cop- ulation, sudden uterine displacements and pressure therefrom, contusions and injuries during labor, foreign bodies, rough catheterization, and over-distension from retention of urine. 2d. Abnormal urine. 3d. Inflammation of adjacent organs. 4th. Constitutional diseases. 5th. Drugs, improper food, and the virus of Gon- orrhoea. These causes also pertain to Chronic Cystitis, whe- ther it begins as an acute or sub-acute affection. 1st. Direct Injuries. — Blows over the vesical region, falls, and especially fracture of the pelvic bones, being caused by some great force, usually produce acute in- flammation of the bladder, with or without rupture of that organ. The bladder, when full, is of course more readily ruptured than when empty, rupture in the lat- ter condition being almost an impossibility. You can turn this item of knowledge to practical use, and ad- vise your patients, and remember yourselves, in travel- ling, either by rail or water, to frequently empty the bladder. In Cystitis, from severe and direct injury, even without any perceptible traumatic lesion of the mucous membrane, there is apt to be marked hemor- rhage, much greater, indeed, than in Cystitis from other causes. Sudden displacement of other pelvic organs, as the uterus, may act in two ways : first, by pressure on ACUTE CYSTITIS— DIRECT INJURIES. 151 the bladder, or by dragging it out of place ; second, by blocking the urethra by pressure. These displace- ments may be due to falls or blows, and it is not an uncommon occurrence for the gravid uterus to topple over by its own weight. Supposing a retroversion of the gravid uterus, the cervix would compress the ure- thra against the pubes, while the utero-vesical liga- ment would drag the upper part of the bladder down- wards and backwards. Even after the uterus has been replaced, and the pressure on the urethra removed, with relief of the vesical over-distension, the retention is likely to persist and over-distension recur, for, by the pressure, the urethra becomes much tumefied, and the muscular and elastic tissue of the vesical walls over- stretched and partly paralyzed. If the distension has been great and prolonged, there may be partial or total sloughing of the vesical mucous membrane. In retention of urine and consequent over-disten- sion of the bladder, during or after labor, from either injury or carelessness. Acute Cystitis is very apt to oc- cur. Here injury of a serious nature may be done to the urethra, by pressure against the pubic bones by the child's head, with or without the intervening soft cushion of the anterior uterine lip. This is especially the case in slow, tedious labors, where the pressure is almost continuous. The extent to which the bladder may be distended without rupturing is quite wonderful. My friend Dr. Bodkin recently invited me to see a lady with him in consultation, who went without urinating for four days and nights after her confinement. The bladder reach- IS2 CYSTITIS. ed above the umbilicus, and contained about three ordinary pot dc chainbrcs full of decomposed urine, which was drawn off by the catheter. The bladder remained paralyzed for three months afterwards, but finally regained its expelling power. At the time I saw her, she was suffering from Cystitis, brought on by the maltreatment. In justice to the medical pro- fession, I ought to say that this lady was attended in her confinement, and for a time after, by a member of the so-called new school of medicine. The iofnorant or careless use of instruments durlngf delivery Is also a cause of serious vesical Inflammation. In all these cases the catheter should be used several times daily, and with great care, until the organ has regained its power and the contused urethra fully re- covered itself When there is any trouble in passing the metallic Instrument, try the small soft ones, for I have to mention as another cause of Acute Cystitis the forcible or improper use of catheters. In cases where the bladder has been perfectly healthy, and the catheter passed a number of times by way of experiment, the points of membrane with which the instrument had come In contact were abraded and congested, thus showine the danger attendlno- the unskillful use of this instrument. If the frequent introduction of the instru- ment into a healthy bladder produces these results, how easily must the bladder of a pregnant woman be inflamed under such treatment ; for the organ has been, for a time, more or less congested, and during labor, perhaps severely bruised. The question has been raised as to whether the ACUTE CYSTITIS— DIRECT myURIES. 153 Irritation and Inflammation following catheterization In some cases, Is not due to the introduction (during manipulation) of air, either pure or containing germs that will cause decomposition of the urine. The ex- periments of P. Dubelt, In which air was injected into the bladder, show that it is perfectly harmless. More- over, the same experimenter found that the injection of decomposing urine into the bladder did little or no harm, unless the mucous surface was abraded. What- ever may be the effect of such things on a healthy blad- der, I do not doubt but that the introduction of germs by means of air, or a dirty catheter, decomposing urine, or the rough or too frequent use of a catheter, would produce an acute exacerbation, in an organ already diseased. The influence of decomposed or decomposing urine in producing Inflammation of the bladder, will be more fully spoken of again. Forcible and excessive copulation Is a decided ex- citing as well as predisposing cause of Acute or Sub- acute Cystitis, and if persisted in, a chronic inflamma- tion of the bladder is usually the result. Foreign bodies In the bladder, such as pieces of wood, pins, needles, hairpins, bodkins, and the like, that are sometimes slipped In there by hysterical girls, and those who masturbate, excite acute inflammation If not speedily removed. 2d. Abnormal Urine. — No known abnormality of the urine will, I think, excite acute inflammation in a perfectly healthy bladder. In a bladder, however, that 154 CYSTITIS. is suffering from chronic cons^estion; in one whose walls bear deposits of tubercle; in cases where some slight degree of inflammation already exists, then abnormal urine may and does give rise to marked inflammatory trouble. As a rule, however, inflammatory vesical disease precedes urine decomposition. In Cystitis following over-distension, the retained urine, being mixed with mucus thrown out by the distressed and tense mucous membrane to shield itself, rapidly decom- poses, and still further aggravates the abnormal condi- tion of the membrane. Ladies, sorrietimes from abnormal modesty, more often from lack of opportunity, retain their urine until the bladder is distressingly over-distended, and the urine partially decomposed. Of course this is wrong, and can generally be avoided, but is nevertheless a frequent cause of disease of this organ. Where there is considerable suppuration of the upper urinary passages (Renal Abscess, Pyelitis or Pyo-nephrosis), the acid urine loaded with pus has, or seems to have, an Irritating effect on the vesical mu- cous membrane, and in some instances probably lights up a Cystitis, and certainly aggravates one when al- ready existing. Deposits of the Amorphous Phosphate of Lime or the Ammonio-Magneslan Phosphate often greatly aggravate and render serious a previously mild Cys- titis, but seldom If ever produce acute Inflammation In a healthy bladder. This may be said also of Uric Acid gravel, and other crystalline urinary sediments, they being, at most, only able to produce some hyper- ACUTE CYSTITIS— ABNORMAL URINE. 155 semia of the membrane with a Httle excess of the mu- cous secretion. Urine which is already decomposed, or decompos- ing, can, as I have already said, only produce Acute Cystitis in an already diseased bladder, or in one where abrasions of the epithelial surface exist. To show you how some of these causes may com- bine to produce Cystitis, let us take, for example, the bladder of a pregnant woman, which has for some time shared congestion with the other pelvic organs. Re- tention and some distension of the bladder occur from some cause ; a clumsy physician attempts to pass a metallic catheter, and does it roughly and rapidly, and relieves the viscus of its contents. A sliMit catarrh of the mucous membrane, the surface of which is somewhat abraded, ensues. By the catalytic action of the mucus present in it, the urine is rapidly decomposed. Carbonate of Am- monia, being set free from the broken down Urea, assists in alkalizing the fluid, precipitating the Amor- phous Phosphates thereby, and forming, with the Phos- phate of Magnesia already present, the Ammonio-Mag- nesian or Triple Phosphate. The urine is further alka- lized by the alkali of the mucus. The bladder walls not having fully regained their tone, a little decomposed urine remains after each micturition, and aids in decom- posing that which is next secreted, and would otherwise be normal. The mucus increases in amount, the am- monia is more rapidly set free, and the mucous membrane more and more irritated, until a true Acute Cystitis is set up. Such cases are of almost daily occurrence. IS6 CYSTITIS. The decomposed urine alone, mark you, however produced, without the over-distension, or without the abrasion, would not have occasioned a true Acute Cys- titis, but might possibly by slow gradations have worked up a Sub-acute Cystitis. The rule, if it may be called such, is the one that I have already given you, viz., that some abnormality of the urinary organs (as catarrh) almost invariably precedes urinary decomposition. 3d. Inflammation of Adjacent Organs. — Acute Cystitis may arise from the extension of inflammation from neighboring organs, as in Vaginitis, Metritis, Uter- ine and V^aginal Cancer, Perforating foetal sac. Abscesses of colon or other organs opening into bladder. Pelvic Peritonitis, Cellulitis, etc. Gonorrhoeal inflammation of the urethra may extend to the bladder. As Gonorrhoea of the female urethra is comparatively rare, you will seldom meet with the effects of such an extension. When it does invade the urethra it is very apt also to extend to the bladder, and is very severe. Inflamma- tion of the renal pelves and ureters may extend to this organ and cause Cystitis, the usual course, however, being from the bladder to ureters and the kidneys. 4th. Certain Diseases of the General System af- fect the bladder, such as the eruptive fevers. In Scar- let Fever, and Measles especially, I have noticed that the mucous membrane of the bladder suffers, to some extent, like the mucous and tegumentary tissues else- where. Diseases of the heart and liver act more as predisposing causes, by producing chronic vesical con- ACUTE CYSTITIS— DRUGS, ETC. 157 gestion, than as exciting causes, and when they do produce Cystitis it is usually of a low chronic type. Old age, when the bas fond is greatly deepened, acts more as a predisposing cause, by allowing the collec- tion and decomposition of urine. Paraplegia and other affections of like nature, by allowing over-distension and decomposition, as a rule produce Cystitis, but of a low form. 5th. Drugs, Improper Foods, and the Virus of Gonorrhoea. — Of all drugs, Cantharides is undoubtedly the most active in producing true Acute Cystitis. In many cases it produces simple irritation and hyper- semia, stopping short of actual inflammation. Arsenic and Turpentine also produce irritation and active hyperaemia, but seldom if ever go further. Alcoholic beverages persisted in for a length of time act more as predisposing than as exciting causes. They may, however, produce a low grade of Cystitis, or, like the medicines given above, light up an acute process in an already diseased vesical membrane. Dr. A. Jacobi has seen aggravated cases of Cystitis caused by the free and long continued use of large doses of the Chlorate of Potassa. The various foods cannot produce Acute Cystitis in a healthy bladder, but may aggravate an already diseased condition. The prohibition therefore of stim- ulating condiments, alcohol, asparagus, and onions, in these diseases, will at once occur to you. We have already spoken of Gonorrhoea as a cause of Cystitis, and need not dwell on it here. 158 CYSTITIS. Pathology. — As Acute Cystitis soon terminates in resolution or merges gradually into Chronic Cystitis, I think it best to give you the pathology of both dis- eases at once, they being, as I have already told you, simply different in degree of intensity and duration. The morbid anatomy of Cystitis is the same as that of inflammation of mucous membranes in other parts of the body. In the more acute forms the membrane is swollen and relaxed, and of a bright or deep red color, from hyperaemia. The surface is partially or entirely covered with a thick tenacious mucus. There is exfo- liation of the epithelium, as shown by the partially denuded condition of the membrane, especially at the top of the rugae, and pus and loose cells are found in the sulci between the folds. In some instances, especially in cases of Acute Cystitis caused by extreme over-distension due to me- chanical or other retention, there may occur a throwing off of a whole or part of the mucous membrane of the bladder. This is more apt to occur when the retention and over-distension are caused by various accidents of the puerperal state or during delivery. That the sep- aration of the mucous membrane is not due to direct injury done by the child's head or instruments careless- ly used, but to the effects of over-distension, is evidenced by the fact that the vesical neck, which is subject to the most direct injury, seldom shows separation of its mu- cous membrane. That injury done the organ may pre- dispose to separation, or even determine it when already predisposed by some other cause, there can be no doubt. Most of these cases of separation of the mu- ACUTE CYSTITIS— PATHOLOGY. 159 cous membrane have occurred in women, and almost all followed delivery. The bladder which has partici- pated in the general congestion of the pelvic organs incident to the puerperal state is in an excellent condi- tion to allow such separation to take place. The modus operandi of its production is probably as follows : A woman at full term is delivered after a long and tedious labor, with or without the use of instruments, of a healthy child. The child's head or the forceps may have done violence to the urethral mucous membrane, by crowding the urethra against the unyielding pubic bones. Swelling of the mucous membrane results, and retention of urine (if the patient be not relieved by the catheter) follows, and persists for a varying length of time. The doctor, the nurse, and the patient herself are often led to believe, from the constant or intermittent dribbling of urine, that there is an irritable condition of that organ, with frequent urination. The truth is, that this dribbling (stillicidium) is almost a certain siofn of an overfilled bladder, and if the patient be not relieved the distension will gradually increase. Theorgfan havinof reached its limit of disten- sion, or being stretched to its utmost, the pressure within is so great as to cut off the supply of blood to the sub- mucous tissue, and thus to the mucous membrane itself. This is the more readily accomplished, as the muscular fibres are pulled apart and the mucous membrane thereby allowed a certain amount of bulging, by which its blood supply is seriously interfered with. If the distension be relieved early enough, nothing worse than an Acute Cystitis results; but if it be not relieved, i6o CYSTITIS. partial or total death of the membrane occurs, and it is sooner or later thrown off. Although death of the membrane may not take place in every case, or in one- half of the cases of over-distension, it is no argument against this method of its production. Nor yet is it an argument in favor of the idea that it is caused by in- strumental violence to the body as well as the neck of theviscus; for that the latter cannot be the only cause, may be seen from the fact that it has occurred in the male (Liston per Barnes). It is probable that there are several causes, and that one or more may work to- gether to produce the result. The uniform exfoliation would look, however, as if the most important cause was a uniform pressure cutting off the blood supply and thus causing death of the part. It is even to be conceived that where marked injury has been clone the membrane by over-distension (though not sufficient in itself to cause death), too rapid relief of retention caus- ing congestion, irritation by catheter, peculiar systemic conditions, and the intense inflammation which follows, may finish the work, viz., fully carry out the impression already made by the over-distension. This affection is not a common one, and though you may never meet with a case, let it impress upon your mind the great importance of paying strict and ziidi- vidual attention to the condition of the urinary organs in pregnant and parturient women. The catheter can tell you more of your patient's bladder in such cases than any nurse, and can do no harm whatever when a soft or even a metallic instrument is used with care. Experiments on dogs have proved that the detach- ACUTE CYSTITIS— PATHOLOGY. i6i ment of the membrane begins at that part of the blad- der just opposite the vesical neck. At this point the membrane bulges out with a collection of blood and serum beneath it, and this bulging gradually extends to other parts. Meantime, in the bladder, the mucus poured out to shield the membrane causes the urine to decompose, and incrustations of Amorphous and Triple Phosphates are often found on the surface of the ex- foliated membrane. The color of the mucous mem- brane is usually either a deep red, greenish red, or black, and it may come away either in pieces or as a whole. In some cases (Mr. Wells' second case, Barnes) part of the muscular as well as the mucous tissue sloughed off and came away. In Mr. Liston's case, the entire mucous membrane came away through a supra-pubic opening made by that gentleman to re- lieve retention. This occurred in the case of a male adult. Some of these patients have recovered, and it is be- lieved by Schatz that the reproduction of the mem- brane commences at that portion of it always left at the vesical neck. That the completion of the sloughing does not take place until some time after the injury done, and that the membrane itself may block the urethra and cause further retention, is illustrated by the following case, taken from Barnes' able lecture (in the Lancet, Jan. 2, 1875). The case was under the care of Dr. Wardell, at the Infirmary, Tunbridge Wells. "A woman was admitted with retention of urine. FcEtid urine was drawn off. A foetus of three or four months was 1 62 . CYSTITIS. expelled, followed by its placenta. Then incontinence ensued. The urine was still offensive, and loaded with mucus. Twelve days later she was seized with great, pain over the pubic region. Next morning the house surofeon was called to see her on account of excessive pain. He felt a substance being expelled, and saw a mass protruding through the meatus urinarius. This was expelled in half an hour. At the moment of ex- pulsion the urine gushed out in great force and in large quantity. Instant relief followed, and she perfectly re- covered. The substance looked as if it were the whole mucous coat of the bladder. Its inner surface was coat- ed with gritty deposits. Its minute structure is not de- scribed." Barnes has no doubt but that the retention was in this case caused by retroversion of the gravid uterus. One of Mr. Spencer Wells' cases, also cited by Barnes (/