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 College of ^i)j>s;ictan£( anl) ^ur^eonsf 
 
DISEASES 
 
 Bladder and Urethra 
 
 WOMEN 
 
 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. 
 
 ILLUSTRATED. 
 SECOND EDITION, THOROUGHLY REVISED. 
 
 NEW YORK 
 WILLIAM WOOD & COMPANY 
 
 56 LAFAYETTE PLACE 
 1^87. 
 

TO 
 
 SAMUEL G. ARMOR, M.D., LL.D., 
 
 PROFESSOR OF THE PRINCIPLES 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. 
 
 Bkooklyx, L. I., 1878. 
 
Digitized by tine Internet Arciiive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/diseasesofbladdOOsken 
 
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 Vesico-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 
 liope that it contains sufficient valuable material to 
 
Ti PREFACE. 
 
 Invite the attention of those who are interested ''n* 
 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. r^, 
 
 Anatomy of the Bladder and Urethra — ^Anatomical Relations of tie Bladder 
 aad Urethra — Fmiction of the Bladder — ^Development of the Bladder and 
 Urethra — Malformations of the Urethra — Malformations of the Bladder.. I 
 
 LECTURE II. 
 
 functional Diseases of the Bladder — Irritability Due to Abnormalities of the 
 Urine — Paresis, or Paralysis Vesicae — 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 — Hypersemia — Hemorrhage from the 
 Bladder , 109 
 
 LECTURE IV. 
 
 •Cystitis — ^Acute, Sub-acute, Chronic, Catarrhal, 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 191 
 
 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 
 
vi-:i CONTENTS. 
 
 LECTURE VII. PAC 
 
 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, Diaq;nosis, Etiology, Prognosis, and Treat- 
 ment 2661 
 
 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 ol the Urethra. 303, 
 
 Appendix 351 
 
 Index 36IV 
 
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 — 
 
 In disease, as in health, the female bladder and 
 urethra demand separate description and study. 
 
 Too often, in anatomical and surgical text-books,^ 
 we find the differences between these organs and 
 those of the male either omitted or so interjected in 
 the work that their high importance is never sus- 
 pected until it is forced upon us at the bedside in 
 actual practice. 
 
 Yet it needs but a glance at the contents of the 
 female pelvis, with its tubular and distensible struc- 
 tures (no one of which has an absolutely stable posi- 
 
2 ANATOMY OF THE BLADDER. 
 
 tion), to prove that vesical derangements among 
 women must be very common and must demand a 
 peculiar surgical treatment. 
 
 I shall aim at conciseness in these lectures, omit- 
 ting all controversial points, mooted questions, and 
 such rare and unique cases as are met with but once 
 in a life-time, in order to give you a thorough prac- 
 tical knowledge of this subject. 
 
 When influencing diagnosis and treatment, and 
 when firmly established, theories will be discussed, 
 but only then. 
 
 Moreover, the work becomes all the more need- 
 ful, to my mind, on account of the poverty of British 
 and American medical literature in treatises on the 
 maladies of the female bladder and urethra and 
 
 allied diseases. 
 
 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 — 
 
 1st, The form and structure of the bladder and 
 urethra in the female. 
 
 2nd. Their topographical anatomy, or the relations 
 of these organs to other ors^ans 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 
 
ANATOMY 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 in close contact, 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-poste- 
 rior 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 tjdgone, 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. It is, in the female, the lowest point of the 
 viscus. 
 
 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. 
 
 Section of Normal Pelvis. (Gray.) 
 
 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 j^eculiarly effi- 
 cient fibre arrangement. Its layers have been divided 
 
AA'ATOMV OF THE BLADDER. 5 
 
 into three, which, although intimately Interlacing, can 
 nevertheless be dissected apart. The external fibres 
 are longitudinal, forming the detrusor urincB ; the 
 internal set is also longitudinal but very delicate ; 
 and the middle fibres are circular and form the 
 .sphincter vesiccF^ described by some as a band of 
 muscular fibres one-eighth to one-half an inch thick, 
 whose activity, according to these observers, prevents, 
 in women, the escape of urine (Coulson). Kuss 
 claims that the " constrictor urethrae " is the effective 
 muscle in this act. In a case of vesico-vaginal 
 fistula where the sphincter vesicae was destroyed, the 
 urine could still be retained, perhaps by the muscu- 
 larity of the urethra. 
 
 All the vesical muscular fibres are involuntary 
 and non-striated. The function of the sphincter 
 vesicae is said to be performed by the closing to- 
 gether of the longitudinal folds of the tissues at the 
 junction of the bladder and urethra, or by the trans- 
 verse 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 three layers of epithe- 
 lium : flat and laminated externally ; pyriform and 
 ^'tailed" beneath these; and, deepest, a layer of 
 
e ANATOMY OF THE BLADDER. 
 
 small round cells between which the ''tails" are 
 received. 
 
 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 i;; 
 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- 
 racemose 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 Ivinor 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 
 inter- ureteric ligament, in the ends of which he asserts 
 that the ureteric orifices are imbedded. To its action. 
 
AXATOMV OF rilE 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.) 
 
 y^, Symphysis 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 ANA TOMV 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 urethrse 
 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 obliterated, it becomes 
 gradually a brighter red ; and when complete disten- 
 sion is accomplished, the minute arteries can be seen 
 forming a beautiful interlacing network on the bands 
 of the muscular reticula. 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 
 tranches 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. The sympathetic system, then, supplies 
 chiefly the upper part of the corpus. 
 
 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 
 
ro ANATOMY OF THE URETHRA. 
 
 upwards and backwards, and at all times, when nor- 
 mal, its axis runs parallel with the plane of the pel- 
 vic brim. It terminates anteriorly at the ba^e 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 somewha.t 
 prominent, rather than a slit-like and depressed open- 
 inof. 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 c> 'M'^ection with tho 
 muscular layer that surrounds it, by uieans of cavern- 
 
AJVATOJ/y OF THE URETHRA. w 
 
 ous venous sinuses, partly in the muscle and partly in 
 the elastic connective tissue. Thus we get an arrange- 
 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 vagina. He describes it as being 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- 
 
:«2 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 
 j)artially or wholly filled it rises above the pubes to a 
 varying extent. The lateral regions of the bladder 
 are covered above and behind with peritoneum ; and, 
 below, are in relation with the levator ani muscles 
 and pelvic fascia. 
 
 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 loose cellular tissue, 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 e*xtent, 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 RELATIOXS OF THE BLADDER AyD URETHRA. 
 
 rine neck, and a small posterior and lateral space, 
 have no serous investment. 
 
 The true liQ^aments 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 
 upw^ard 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 ar*e these. It lies just 
 under the pubic symphysis, and, piercing the deep 
 perineal fascia, extends from the vesical neck, at the 
 ostium urethrse internum, to the meatus urinarius, or 
 ostium urethrse externum, situate at the base of the tri- 
 angular space known as the vestibule. Its anterior 
 three-fourths is imbedded in the vasfinal 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 amongst 
 •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 w^hich 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. 
 
1 6 FUNCTION or THE BLADDER. 
 
 On the other side it is claimed that this musculo- 
 elastic ring 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 vesicse 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. 1 7 
 
 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, 
 enclosino- 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, give^ 
 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 come 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 follow 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 FUXCTIOK 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 rnembrane 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 
 iistulse 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 
 iistulae 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 Ammonsemia. 
 
 The mucous membrane of the urethra is said to 
 be as impermeable to injected fluids, when intact, as 
 that of the bladder. 
 
 The inner surface of the bladder is lubricated by a 
 very thin secretion of mucus. You can satisfy your- 
 selves of this fact by putting some fresh, normal urine 
 in ^ 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 hbrillae — 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, 
 Test, exercise, &c. Neither limpid nor concentrated 
 urine is well borne by the bladder. 
 
 The pressure of the urine in the bladder being of 
 
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 
 v/ith 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 aofes. 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 URETLIRA. 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 that 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, a communication called 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 
 
 ^"^y; 
 
 T-z. 3. 
 
 5 F 
 
 Development of the Bladder and Urethra. 
 
 ■V. Embryonic part of the Allantois Vesica, d. Rectum. A'. Septum Recto-vagin- 
 aJe. C. Anus. F. Fold between the Intestines and the Allantois. 
 .9. Sinus Uro-genitalis. 
 In 5) A' 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 Vaginre 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 Muller'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 
 bek)w. 
 
 Anteriorly Muller's ducts unite with the lower por- 
 tion Df the bladder, and aid In the formation of the ure- 
 thr'a ; at least the upper portion of Its posterior wall. 
 
 The lower or external portions of the genito-uri- 
 nary (jrgans 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 Muller's 
 ducts (vagina), forms the terminal portion of the ure- 
 thra and the introitus vaginae. From this same centre 
 of development the labia majora and minora and vesti- 
 bule are formed. 
 
 Malformafcions 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, produce a number 
 of malformations. The most important of these may 
 be classified as fallows : — 
 
 1st. Defectus Urethrae Totalis. 
 
 2nd. Defectus Urethrse Externus. 
 
 3rd. Defectus Urethrse Internus. 
 
 4th. Atresia Urethrse. 
 
 In the first form (Defectus Urethrse 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 MALFORMATIOXS 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, nornymphae, 
 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 Urethrse Exter- 
 nus) is where the lower and anterior portion of the 
 urethra is absent. It has been called hypospadias hi 
 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 TJ/E 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 Urethrse 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, i" 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, the patient was forty-two years of age, 
 and all her life had urinated 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 Urethrse. 
 
26 MALFORMATIONS OF THE URETHRA. 
 
 The fourth class (Atresia Urethrae) 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 Urethrae 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 
 constantly 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 
 ^enito-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. It 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 millimetres 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, because 
 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 bearinof 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 applying 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 urethrse 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 
 
MALFORMA TIONS OF THE BLADDER. 31 
 
 •tirethra. 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 
 ant irior and posterior half, they continuing with an ever 
 enl'dTging and diverging septum until they opened into 
 the\agina about 0.3 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- 
 tioii 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 
 b)y 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 MALFORMA TIONS 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 adjacent organs. 
 The anus and navel, as a rule, lie nearer than normaJ 
 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- 
 talis normal. This condition is next in order to patency 
 of the urachus — Fistula- Vesico-Umbilicalis. In the 
 latter case, the urachus ma,y 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 reo-ion 
 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 
 
MALFORMATIONS 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 
 said ; 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 widened. 
 
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, \'=\ 
 •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. 
 
 Moergelin, 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 allantois 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 normal 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 right kidney 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- 
 r^an protruding from the abdominal fissure (Ectopia 
 Vesicae). 
 
 Lately, Ahfield has brought forward the hypothesis 
 that eversion of the bladder is complicated with and 
 <iependent 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 betvreen the rectum and the allantois ceases, and 
 the allantois, becoming enormously distended, bursts. 
 Ruo:e 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 gravid 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 havingf 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 iissuram) 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 beeinnine 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 
 j.-ossible in these cases, the interesting observation may 
 l>e made that in action the kidneys seem quite inde- 
 j;>endent, the one of the other, the right flowing urine 
 i>nd the left none, and vice versa, or both together. 
 
 Diagnosis, — The diagnosis is comparatively easy, 
 i*)r 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, nientions seeing and 
 fmding 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 FROGA'OSIS 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 agfe. 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 tractioi> 
 
TREA TMENT. ' 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 an account of this case, with the original illustrations, see Appendix, 
 page 351 
 
■^ TREA TMENT. 
 
 Tjro-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. 
 
 Their wretched condition makes operation upon 
 these patients almost a necessity ; and statistics 
 prove our interference to be justified, 74,^ of opera- 
 tions being successful, loi being fatal, and 16^ being 
 failures from the surgeon's standpoint. 
 
 Ayres, Holmes, Wood, Morey and Barker have 
 operated successfully. Peritonitis and the protru- 
 sion of viscera throucrh the adhesions have been the 
 chief causes of death or failure. 
 
 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. 
 finger could be laid between them. 
 
 Sommering 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 congenital vesico-vaginal 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 ; 
 and this procedure becomes all the more important 
 from the fact of these cysts being favorite loci for the 
 formation of calculi. 
 
 Imperforate bladder is a very rare pathological 
 curiosity. 
 
LECTURE II. 
 
 Functional Diseases of the Bladder — Irritability 
 Due to Abnormalities of the Urine — Paresis, 
 OR Paralysis Vesicae — 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 
 4md 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 functional 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 organs concerned. Although we are still obliged 
 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 
 
FUNCTIOXAL DISEASES OF THE BLADDER. 49 
 
 disturbed in the discharge of its duty by external 
 influences. 
 
 You must clearly fix 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 : — 
 
 I St. 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. The 
 first and perhaps most important of all this class is. 
 vesical neuralgia. 
 
 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 Douloureux 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 viscus 
 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 hyperses- 
 thesia. One is physiological, the other pathological. 
 
 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. Sudden and violent emo- 
 tions may cause it ; and a residence in a very cold or 
 a very hot climate may induce it in one who is un- 
 used to such extremes of temperature. 
 
 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 FUNCTIOXAL DISEASES OF THE BLADDER. 
 
 teria, the chronic erection of the cHtoris 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. 53 
 
 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 
 rsubjects are excitable, irritable, and easily exhausted. 
 They often have headaches. Nutrition is apparently 
 good in some cases, as shown by the fair supply of 
 ilesh ; 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 
 l)ladder 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 ttrethral 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, a 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. 53 
 
 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 countenance 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. Hebdom. de Med. et 
 Ckirurg., 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 V. 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 
 /<?/? 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 nervous 
 affections of the urinary organs, pain, and the feel- 
 ine of weight and uneasiness in the rep-ion of the 
 bladder, are usually present. Still, the most constant 
 md 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 
 oases, 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 
 organ. The sense of weight and bearing 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- 
 
^o 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. Remitting, paroxysmal 
 and agonizing pains (like those of a calculus), lasting 
 from a few minutes to several hours, sometimes 
 occur, and are often connected with a malarial 
 cachexia : at least they are quelled by quinine. The 
 pain involves all the parts around, and there is a 
 feeling of soreness after the attack. At times the 
 neuralgia gradually disappears without aid, although 
 time and neglect are apt to aggravate the mildest 
 forms and induce a host of nervous disorders. 
 
 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 
 t>e 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. 6 1 ■ 
 
 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 dano^er 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 is to be used in any amount. 
 
 The condition of the urinary secretion must be 
 carefully watched, 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 agents. 
 
 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 orsfans. The 
 nerve tone being diminished, 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 Marsh mallow, Triticum Repens, 
 Acacia, Pareira Brava and Buchu act well. Emulsio- 
 
TREA THE NT. 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 
 tirine, 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 
 iDenefit. 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 51 
 or Bij). 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 {^. 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), ^s 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. 6c 
 
 mended by Bricheleau (Archives General de Medicin) 
 for one day, and then in small doses before meals 
 for a week, will usually cut the paroxysm short and 
 prevent its return. The digestive organs require at- 
 tention 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 oriorinal 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 urine, I will not delay 
 you with a review. 
 
 The bladder being made to contain a certain: 
 amount of urine, almost uniform in its composition 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 are more to be dreaded. 
 
66 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 organic 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 it 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 erav- 
 uty, 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 average 
 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 
 <ieposits of Uric Acid, the alkaHne carbonates act 
 •doubly ; first, by neutralizing 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, Siv. 
 
 M. — 
 
 Sig. — Take 5i in half tumbler of water, adding 
 3ij of lemon juice. Drink while effervescing. 
 
 Prof Armor gives some very excellent advice re- 
 garding the management of such cases, which I will 
 •^ive 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. 
 hiofh terms of the followino- combination : 
 
 " Carbonate of Lithium, gss. 
 
 "Benzoic Acid, 5xiij. 
 
 "Dissolve the acid in lo per cent biborate of soda; 
 then add lithia and distilled water to make Byj. 
 
 " 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 : 
 
 ]^. — Acidi Nitro-Muriatici diluti, 5v-vj. 
 Tincturse Nucis Vomicae, 5iij- 
 Olei Gaultherise, mxij. 
 
 Aquae ad., Siij- 
 
 M. — 
 
 Sig. — 5i in water before each meal. In some cases 
 
PARESIS, OR PARALYSIS VESICA, 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. 
 
 Paresis, or Paralysis Vesicae, 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 judice. 
 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 result. 
 
 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- 
 longed use of opium or poisoning by it, as also shock 
 due to over-distension of the organ itself cause it. 
 
 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 
 
PARESIS, OR PARALYSIS VESICAL, 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. Frequent child-bearing, obesity, 
 and the recumbent posture predispose to it. 
 
 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 war. made by Budge. 
 He found that section of the lower part of the spinal 
 
74 FUXCTIOXAL DISEASES OF THE B LA DDE J?. 
 
 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 flows, your diagnosis is at once made. 
 
PARESIS, 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 
 changing 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 
 tinder 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 
 
PARESIS, 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- 
 ranees the circulation as to cause these serious results. 
 
 o 
 
 The sudden removal of pressure from the vesical walls, 
 which that pressure rendered anaemic, 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. 
 
-^8 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 
 without 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 replaces 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 
 
PARESIS, OR PARAL/SIS VESICA, ETC. 79 
 
 Tnonths. 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 
 neighborhood 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 apoplexy. 
 
So 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- Zl^ 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 hyperaesthetic 
 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 cog- 
 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 Hypersesthesia), 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- 
 
82 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 nervous, cross, 
 and fidgety. It may be accompanied by nocturnal 
 ^neuresis. 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- 
 g^erous, 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 hypersesthesia, 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 patient. 
 
 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 Ferri 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. According to Sauvage, 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 eases. 
 
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 Morphise 
 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 
 th*e 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; is 
 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— DISLOCA TION 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 sliorht 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, matting 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 FUNCTIOXAL 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 retroverslo 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- 
 
DISL OCA TIOX BA C Vv'/ / ". / A'DS. 
 
 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. 
 
 Retroversion of the Gravid Uterus. 
 
 {Schatz.) 
 
 The Bladder pulled upward and backward, and the Urethra jiut greatly 
 iipon 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 
 
.^2 FUNCTIONAL DISEASES OF THE BLADDER. 
 
 interest, and may serve to fix more clearly in your 
 jnind 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. 2)^. Married five years, and a 
 
 Avidow 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- 
 tending 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 hypersensitiveness of the whole pelvic organs, I 
 have not always been able to determine. I have. 
 
^ 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- 
 'Cnced. If, however, from the protrusion of the tumor 
 
DISLOCA TION DO WN WARDS. 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 vaginae, 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. e., 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 
 
S YMPTOMA TOL OGY. 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 vaginal 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. 
 
^8 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 
 resfion 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, ursemia. 
 
 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 through 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 
 
loo 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. 
 
 i^^^^^fc ifir^Er ^^^' 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 
 as marked thickening of the vesical and vaginal walls. 
 
I02 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 will be found in my work on 
 Gynecology, or in any standard work. 
 
 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 fo7^ward 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 
 
HE TR O CESSION A ND EOR IV A RD TRAXSrOSiriON. 
 
 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 
 
 Fig. S. 
 
 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- 
 
I04 
 
 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 tlie 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 
 reheved 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 
 iirmly 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. 
 
 Ev'ersion of the bladder, with protrusion through 
 the urethra, is an affection occurring only in females^ 
 and is almost peculiar to children. It may be con- 
 
io6 FUXCTIOXAL DISEASES OF THE BLADDER. 
 
 genital; Streubel, after a careful review of the 
 literature of the subject, was able to find but one 
 case in which the mjcous membrane was alone 
 prolapsed. 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 extroversioft 
 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. 
 
 Symptoms. — 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 at 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 oedematous. 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 
 thickening 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, 
 it 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, anaesthetize 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 lei 
 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 — Hyperemia — 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 
 
4IO 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 Cobr. 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 
 ^ith 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 due 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 laro^e 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 V 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 
 aciditv of the urine. 
 
114 
 
 ORGANIC DISEASE OF .THE BLADDER. 
 
 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 
 Fie. 8. found shrunken and 
 
 with crenated edges. 
 In ammoniacal urine 
 they frequently present 
 
 irreo^ular bulor-inors on 
 their surfaces, and are 
 sometimes found to 
 have ruptured. 
 
 Pus occurs in round- 
 
 ed globules, varying 
 from the i -2500th 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. 
 I, As usually seen in urine (highly mag- 
 nified). 2, After addition of dilute Acetic 
 Acid ; showing nuclei. 
 
URINAR Y ANAL YSIS. 
 
 I '5 
 
 Jts 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 Pig. 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 ORGAXIC 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, ]\Iucous Fibrillse. 
 
 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 a, Fig. lo.) According to Strieker and Beale, the 
 
URINARY ANAL YSIS. 
 
 117 
 
 epithelial layer of the bladder may be double or even 
 triple : the middle layer being pear-shaped or tailed, 
 the other two being of round cells, the superficial 
 by far the larger. At the orifices of the ureters and 
 urethra, the epithelium gradually shades off into that 
 of the columnar variety. 
 
 Fig. U. 
 
 Epithelium, Pus, and Triple Phosphate. 
 
 A, Vesical Epithelium. B, Vaginal Epithelium. C, Ammonio- 
 Magnesian or Triple Phosphate. D, Urate of Ammonia. E, 
 Mucus. 1, Pus Corpuscles. 3, Urethral Epithelium. 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. 11.) 
 
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 
 edofes. In old urine the edg^es are often broken or 
 irregularly chipped. (See c, Fig. 1 1.) 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- 
 
URINAR Y ANA L YSIS 
 
 115 
 
 turn of urine in the test-tube, a cloud appears, it may 
 be either Phosphates or Albumen. If on the addition 
 of a little Nitric Acid it clears up, it consists of the 
 Phosphates ; if, on the contrary, a sediment falls, it is 
 Albumen. Alkaline urine should be acidified 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 very bad 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 averag-e 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 
 vakie of the products of disease found in this fluid, as 
 aids to diagnosis. In order to bring 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, ) ri 
 
 -D 1 ^ ' > or like water. 
 
 Pale straw, ) 
 
 Inflammatory Vesical Affections, Neoplasms, etc. 
 
 Ill 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 Amorphous 
 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, «S: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 Affections, 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, however, 
 being usually masked by the ammonia of decomposition. 
 
URINAR Y ANAL YSIS. 1 2 1 
 
 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 fibrillae, 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 pathognomonic 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 sediment, that settles closely to the bottom of 
 the bottle. It may also consist of two strata; the lower whitish, the 
 oipper 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 mera- 
 
ira ORGANIC DISEASES OF THE BLADDER. 
 
 brane or blood-stained mucus, may also be found. They should be 
 carefully examined. Pure mucous sediments are usiAlly 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. 
 
 Constitutio7ial, Vesical, a7id Urethral Neuroses. 
 The sediment is usually slight, and as a rule consists of mucous 
 fibrillae 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. 
 
 Infiammatory 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, epitlielium and casts from 
 these organs will be found ; also epithelium and pus from the ureters 
 and renal pelves, in Pyelitis. 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. 
 
URINARY ANALYSIS. 12^, 
 
 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 Assimilatioji.. 
 
 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. 
 
 Inflainmatory Affections. 
 
 There may be an excess of the Carbonate of Soda, or the. Phos- 
 phates. 
 
^24 
 
 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 OF NORMAL URINE. 
 
 Roberts. Urinary and Renal Diseases. 
 
 Water 954-8i 
 
 -Solid Matters 45-i9 
 
 lOOO.OO 
 
 )> 6.53 
 
 Urea 21.57 
 
 Uric Acid 0.36 
 
 f Creatine, Creatinine, Ammonia," 
 Hippuric Acid, Xanthin, Hypo- 
 
 jr, , ,. J xanthin. 
 
 Jixtracttves. <^ garcine. Pigment, Unoxidized Sul- 
 phur and Phosphorus, Mucus, 
 &c. 
 
 r Chlorine 
 
 Sulphuric Acid i-3i 
 
 Phosphoric Acid 2.09 
 
 Potash 1-40 
 
 Soda , 7-19 
 
 Lime o-i i 
 
 I Magnesia 0.12 
 
 \ 
 
 I 
 
 4-57 
 
 Havine 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 {b, 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 
 
 Vig 12 
 
 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, 
 
;I26 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 
 
 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 vesical wall 
 against the opening of the speculum. 
 
 Rutenberg conceived the idea of distending the 
 bladder before making an examination, hoping 
 thus to overcome the various drawbacks so com- 
 monly encountered in such under- 
 takings. After considerable experi- 
 menting he found that while water ct- 
 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. 
 
 " Fig. 15. 
 
 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 membraije, 
 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 operation, 
 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 detectino- foreig-n 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 coatinor. 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 Avell 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. Th& 
 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 1 502 (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 t^he extraction of calculi and foreign 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- 
 
PHYSICAL EXPLORATION. 13J 
 
 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 6.2i 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 
 ;lieal 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 
 \s 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. 
 
 Fig. 17. 
 
 Hunter's Uterine Dilator. 
 A A, Fingers. B B, Gloves of hard rubber. 
 
 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. 
 (Fi^s. 1 6 and i 7.) 
 
 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. 16.) 
 
 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. 13S 
 
 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- 
 ing 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 unite 
 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 
 fistulae. 
 
 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. 
 
 enough movement and good 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 or the electric light. 
 
 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. 
 
 I Lente's Caustic Cup. 
 
 1 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 aflection, 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 
 
;I38 ORGANIC DISEASES OF THE BLADDER. 
 
 acute, chronic, catarrhal, suppurative, croupous, diph- 
 theritic, and productive. 
 
 Hjrpersemia. — In all cases, the first perceptible- 
 departure fi'om the normal is a derangement of circula- 
 tion. Hyperaemia 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 bright 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 hypersemia 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 hyperaemia, of which we are now speaking, 
 it being chiefly confined to the smaller vessels, and 
 passive hyperaemia, 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 hyperaemia 
 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. e., 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 pathognomonic. You will be liable to con- 
 found this with sympathetic or other functional de- 
 rangement of the bladder, caused by sudden disloca- 
 tions of the uterus, or by pelvic inflammation, such 
 as pelvic peritonitis, 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. 
 
MO ORGANIC DISEASES OF THE BLADDER. 
 
 Causes. — The causes of hyperaemia 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 and irritant 
 drugs. 
 
 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. Ipec. Co. with Camphor should be given, or 
 suppositories of Belladonna and Morphine intro- 
 duced 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 
 hyperaemia 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 active 
 
HEMORRHAGE FROM THE BLADDER. 14 1> 
 
 hypersemia, 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 dark 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 will 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. When coming 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 
 
J42 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. The exact relation- 
 ship between bloody urine and malaria is unknown. 
 Some claim that the malaria miasm, or germ, or bac- 
 terian disorganizes the red corpuscles ; others that 
 the mucosa of the genito-urinary tract suffers vascu- 
 lar changes resulting in vesical hemorrhage. 
 
 In purpura, the exanthems, 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 ta 
 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 drawing off enough 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 vulvae, and labia, will 
 often be found in the same condition. Occasionally 
 you will also find 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 delivery, espe- 
 cially if there is Cystocele or prolapsus of the bladder, 
 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 hemorrhage occur from this condition of the 
 veins, you may treat it as described when we discuss 
 that subject. 
 
 In this connection I must mention a form of hema- 
 turia, rare except in the tropics, where the mucous 
 membrane of the bladder is thickened, ulcerated, 
 and ecchymotic, and bleeding, on account of the 
 presence in it of a parasite, a fluke, called Bilharzia 
 haematobia. Its eggs are found in the urine. This 
 endemic malady is diagnosticated by finding the 
 ova in the feces or urine. 
 
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. I49 
 
 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- 
 peraemia 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- 
 ilammation. 
 
 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 
 lieads, each of which we will study separately. 
 
ii;o V 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 
 aterus, may act in two ways : first, by pressure on 
 
ACUTE CYSTJTIS— 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- 
 
152 CYSTITIS. 
 
 ed above the umbilicus, and contained about three 
 ordinary pot de chambres 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 ignorant or careless use of instruments during 
 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 
 showing the danger attending 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 
 
A CUTE C YS TITIS— DIRECT INJURIES. 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- 
 <iver 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 congestion ; 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, sometimes 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-Magnesian 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 little 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 slight 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 tjie 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 rriore irritated, until a true Acute Cystitis is 
 set up. Such cases are of almost daily occurrence. 
 
^56 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 Vaginal 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. I<;7' 
 
 gestion, than as exciting causes, and when they da 
 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. Myelitis nearly always causes it. 
 
 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- 
 aemia, 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. 
 
IS8 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 hypersemia. 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 
 l)e 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 sign of an overfilled bladder, and if 
 the patient be not relieved the distension will gradually 
 increase. The organ having 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, 
 
l6o CYSTITIS. 
 
 partial or total death of the membrane occurs, and It Is 
 sooner or later thrown off. Although necrosis 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 done 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 indi- 
 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. i6l 
 
 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. Foetid 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 
 surgeon 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 {loc. cii.) is very instructive. " A woman, set. 
 2 2, had a natural labor with her first child. The blad- 
 <ler was not emptied for sixty-two hours. Five pints 
 of turbid, bloody urine was then drawn off. Cystitis 
 followed, Incontinence of urine, and a train of distress- 
 ing cerebral symptoms, ending In death two months 
 after delivery. The bladder after death was found to 
 contain a detached cast, lying loose, covered with grit- 
 ty deposits of Urates and Phosphates. The walls of the 
 bladder were thick and contracted, the muscular fibres 
 being distinctly visible. The cast resembled degener- 
 ated epithelium. On boiling a piece of it In dilute acetic 
 acid, much of the saline matter became dissolved and 
 some of the tissue became clear, looking like smooth 
 
ACUTE CYSTITIS— PATHOLOGY. 163 
 
 .muscular tissue which had begun to degenerate, as 
 shown by the deposit of fatty or albuminous particles 
 in its substance." 
 
 Further pathological results may follow the pro- 
 longed retention of urine. The bladder having^ reach- 
 ed a certain point where no more urine can enter it, 
 and even before this time, the ureters are filled from 
 the urine above, and as the renal pelves fill, both they 
 and the ureters are put greatly on the stretch. The 
 kidneys continue to secrete urine until the pressure in 
 the urinary tubules equals that of the blood in the 
 glomerulus. At that point all secretion ceases, and 
 pressure on the emulgent veins becomes so great that 
 degenerative changes are apt to take place. In some 
 cases, after the pressure is relieved, Acute Nephritis 
 results. The urine following such a condition of dis- 
 tension is loaded with hyaline, granular and epithelial 
 casts, and epithelial elements from the kidneys. Dr. 
 H. H. Kane, of New York, produced, as nearly as 
 was possible, this same renal pressure from urine in 
 animals, by tying both ureters in rabbits, and the ure- 
 thra in a dog. On section after death, the kidneys 
 were found to be enlarged, deeply congested, and oozed 
 urine and blood from the cut surface. The renal 
 tubules were choked with casts, epithelium, and gran- 
 ular debris. 
 
 The following case, which occurred in the practice 
 of Dr. Geo. W. Gushing, of this city (the doctor hav- 
 ing kindly furnished me with a report of it), may serve 
 as an illustration of what I have been saying : 
 
 "Mrs. S., of New York, set. 26; married 8 years; 
 
i64 CYSTITIS. 
 
 one child ; catamenia regular ; appetite fair ; bowels 
 sluggish ; no dysuria previous to present attack. Has- 
 been under treatment for the past two months for 
 Cervical Endo-metritis. Local applications of mild 
 astringents and Glycerine, with injections of Borax. 
 Tonics and laxatives internally. There being some 
 tendency to Tuberculosis, she was given Cod Liver- 
 Oil. 
 
 " I was called to see this patient May 29, 1877. She 
 told me that she was suffering from internal hemor- 
 rhoids, and that the rectal tenesmus was very distress- 
 ing. She had had similar attacks before, and seemed 
 to have no doubt as to what the trouble was. As 
 she was menstruating I made no examination, but ad- 
 vised rest and a laxative powder, to be followed by 
 Morphia suppositories. 
 
 " May 30. Bowels moved since last visit, with con- 
 siderable pain. Complained of some vesical irritation, 
 but had passed urine. Not much relief. 
 
 ''May 31. No better. An examination showed 
 no hemorrhoids. Menses ceased. Vaginal examina- 
 tion revealed a very sensitive spot, with hardening on 
 the right side, between the rectum and vagina. Pulse 
 and temperature slightly elevated. Vesical and rectal 
 tenesmus, but no trouble in passing water. Made di- 
 agnosis of probable pelvic abscess. Advised poultices 
 to the perineum, warm applications over the abdomen, 
 and gave anodynes. Patient much relieved by the 
 treatment, but still having severe pelvic distress. 
 
 " Jime 2. Condition the same. 
 
 " June 3. Found the vesical distress increased. 
 
ACUTE CYSTITIS— PATHOLOGY. 165 
 
 'Her husband said that she had passed urine during the 
 niofht. Was called to her in the afternoon, and found 
 her in great suffering. Said that her husband had 
 misinformed me, and that she had passed no urine for 
 about thirty hours. I examined the abdomen, and 
 found dullness well up to the umbilicus. Introducing 
 a catheter, I drew off a large quantity of very offensive, 
 high-colored urine, with much relief to the patient. For 
 the next two days I was obliged to use the catheter. 
 An examination of the urine drawn off was made by 
 Dr. H. H. Kane, and showed the presence of renal 
 epithelium, granular, hyaline and epithelial casts, and 
 considerable albumen, as also epithelium from the blad- 
 der and ureters. 
 
 " June 5. I found a tendency of the inflamma- 
 tory products in the pelvis to point about the centre of 
 the perineum, and though not quite sure of pus I punc- 
 tured and evacuated quite a large amount of it. 
 
 " Since then the treatment has been the use of al- 
 kalies and soothing drinks, Tr. Ferri Chloridi, and 
 washing out the bladder with lukewarm water contain- 
 *ng Salt and a little Carbolic Acid. The abscess re- 
 maining open and very sluggish for some time, I put 
 the patient under ether and performed the operation 
 for fistula in ano. At the present writing, Oct. 30, 
 Mrs. S. is in excellent condition, having gained in flesh 
 and strength, and being no longer troubled with the 
 vesical disorder." 
 
 This case is not only interesting as showing the 
 serious changes that may occur in the kidneys frorri 
 ■vesical distension, but as illustrating the occurrence of 
 
i66 CYSTITIS. 
 
 retention of urine from reflex nervous influence. Ab- 
 scesses about the rectum are especially prone to cause 
 retention. Although in this case the mischief done 
 the kidneys was soon righted, it does not follow that 
 it will be so readily accomplished in all cases, especially 
 if the retention continues unrelieved for any length of 
 time. 
 
 Chronic Cystitis — Pathology. — The redness of 
 acute inflammation gradually gives way to a muddy 
 gray color, the membrane being covered in places 
 with a dark yellow muco-purulent secretion. As the 
 disease advances, there is excessive cell growth on the 
 free mucous surface. Patches of ulceration appear here 
 and there, attended with the formation of pus and oc- 
 casional, though usually slight, hemorrhages. Some- 
 times, at the portions destroyed by ulceration, the 
 process of hyperplasia is established, and a polypoid 
 material is developed. These have the appearance of 
 exuberant granulations, as seen on a healing sore. 
 At other times, and even in portions of the same or- 
 gan in which hyperplasia occurs, the process of ulcera- 
 tion advances. The submucous intermuscular tissue 
 partakes of the inflammatory trouble, and thickening 
 of the vesical walls results. The decomposed urine, 
 mixed with pus, mucus, blood, and shreds of mem- 
 brane, forming the chocolate-colored fluid found in the- 
 advanced stages of this disease, acts as an irritant 
 on the mucosa, causing or increasing ulceration. In 
 nearly all cases bacteria are very abundant. 
 
 In advanced cases with deep ulceration, the muscu- 
 
CHRONIC CYSTITIS— PATHOLOGY. 167 
 
 lar fibres (which resist the destructive processes long- 
 est) are occasionally seen, stretching from one side 
 of an ulcer to the other, forming a sort of bridge. 
 When the thick " ribs " of muscular tissue are promi- 
 nent on the inside of the viscus^ we have the colum- 
 nar bladder. In some cases the salts of the urine 
 are deposited, and form incrustations on the ragged 
 mucous membrane. 
 
 ^ I remember that one of my patients frequently 
 passed lumps of material, that on examination proved 
 to consist of all these products of destructive inflamma- 
 tion, amongst which were mixed deposits of the urinary 
 salts, in the form of hard gritty paVticles. 
 
 In cases of long standing, the vesical ends of the 
 ureters are obstructed by swelling and hypertrophy of 
 the bladder walls. This produces obstruction to the 
 free flow of urine, and leads to dilatation of the ureters 
 and renal pelves, and in some cases organic disease 
 of the kidneys follows in the train of pathological se- 
 quences. We will refer to this subject again. 
 
 When the disease has destroyed the mucous mem- 
 brane partially or wholly, and extends to the muscular 
 parietes, we have what is known as Interstitial Cystitis; 
 and if the serous coat becomes involved we have also 
 Peri-cystitis. This latter is simply an inflammation of 
 that portion of the pelvic peritoneum which covers the 
 bladder ; a disease with which you are already familiar. 
 In Interstitial Cystitis, after destruction of portions of 
 the mucous membrane by ulceration, the areolar tissue 
 beneath it and in the muscular walls gives way, the 
 muscular fibre generally becomes thickened and burrow- 
 
i6S CYSTITIS. 
 
 ed by ulcerated cavities, irregular in form, and surround- 
 ed by cicatricial tissue. 
 
 The extreme hypertrophy of the muscular coat 
 found in the bladder of the male, under these circum- 
 stances, does not so commonly exist In that of the 
 female. 
 
 In Epi or Peri-cystitis, the peritoneal coat is found 
 to be hypersemlc and thickened by exudation, and the 
 adhesions which follow bind together the bladder and 
 the neighboring organs. Perforation of the peritoneum 
 sometimes occurs, allowing Infiltration of urine. This 
 usually develops general Peritonitis or Septicaemia (or 
 both), and death almost inevitably follows. 
 
 I have already stated that the walls of the bladder, 
 including the serous coat, may become involved by the 
 extension of a primary inflammation of the mucous 
 membrane. This is undoubtedly the usual mode of 
 occurrence, but in some cases I think that all of the 
 bladder coats may become Inflamed at the same time, 
 making an inflammation in toto. At least it is a fact 
 that in some cases the mucous, muscular, and serous 
 layers of the organ In question become Involved In such 
 rapid succession as to defy our being able to detect 
 its progress from one tissue to another. 
 
 The inflammatory process having traversed the 
 mucous and muscular coats, and involved the serous, 
 especially where ulceration of the mucous membrane 
 accompanies it, is likely to extend to the other portions 
 of the pelvic peritoneum, and cellular tissue, if the pa- 
 tient lives sufficiently long. 
 
 You will please observe that In this condition there 
 
CHRONIC CYSTITIS— PATHOLOGY. 169 
 
 is about the same pathological anatomy as in Pelvic 
 Peritonitis and Cellulitis, where inflammation of the 
 bladder walls is caused by, and consequently secondary 
 to, the pelvic inflammation. In such condition the 
 kidneys and ureters are usually found diseased. In 
 some cases the cellular tissue about the bladder be- 
 comes greatly increased, and occasionally abscesses 
 form, as in ordinary Pelvic Cellulitis. 
 
 I am satisfied that the disease described in some of 
 •our text books as Idiopathic Peri-cystitis, is, in almost 
 all cases, when it occurs in women, a Pelvic Peritonitis 
 originally, the bladder becoming affected secondarily. 
 
 One of the most serious results of intense vesical 
 inflammation is Gangrene. The organ becomes dis- 
 tended from paralysis of its muscular walls, and its 
 contents are found to be a brownish colored fluid, con- 
 sisting of decomposed urine, shreds of broken down 
 mucous membrane, altered blood, pus, epithelial ele- 
 ments, and urinary salts. The mucous membrane is 
 found to be soft, pultaceous, and altered in color, the 
 latter varying from a deep charred black to a dark 
 greenish or greenish yellow color. 
 
 The submucous connective tissue layer and the 
 muscular coat are softened, discolored, and infiltrated 
 with malodorous pus. The peritoneum is also injected, 
 and in places discolored ; sometimes perforated, and 
 having undergone fatty degeneration. This complica- 
 tion usually occurs in the course of Chronic Cystitis, 
 -with considerable ulceration, and upon which an acute 
 inflammation is lighted up, there not being sufficient 
 vitality left to prevent rapid and deep gangrene. 
 
170 CYSTITIS. 
 
 These extreme forms of Cystitis are rare, and occur 
 generally in connection with abnormal cases of labor. 
 A pregnant woman having a Cystitis of a mild form is 
 liable to develop acute general Cystitis at her con- 
 finement. Again, inflammation and gangrene of the 
 bladder sometimes follow instrumental or manual de- 
 livery, in which severe contusions of the bladder have 
 occurred. 
 
 Let us turn our attention now to some of the effects 
 of Cystitis on the ureters and kidneys. That form of 
 vesical inflammation known as Chronic Cystitis may 
 travel up the ureters to the kidneys, producing Ure- 
 teritis, Pyelitis, Pyo-nephrosis, or Renal Abscess. 
 This affection seems more commonly to attack the left 
 ureter and kidney. I say seems, that being simply my 
 opinion, derived from the cases that I have seen or of 
 which I have read. I know of no statistics upon the 
 subject. This complication is not so common in fe- 
 males as in males, which is owing, perhaps, to the fact 
 that their short urethra, being as a rule free from stric- 
 ture, and seldom obstructed otherwise for any length 
 of time, the inflammation of the bladder has less ten- 
 dency to extend, is less severe, and as a rule is earlier 
 and easier treated locally than in the male. 
 
 It cannot be denied that the damming back of 
 urine into the ureters and renal pelves is a factor in 
 the production of disease in these parts. Suppose that 
 an inflamed ureter becomes blocked up from any cause 
 (a mucous, purulent, or blood plug ; by the impaction 
 of a small calculus from the kidney ; thickening of its 
 mucous membrane ; or hypertrophy of the bladder 
 
RENAL COMPLICATIONS. 1 711 
 
 walls), the urine behind the point of obstruction great 
 ly distends the ureter and renal pelvis, decomposes,, 
 and produces Acute Pyelitis, which often leads to de- 
 struction of the kidney on that side. 
 
 In post-mortem examinations of such cases, you 
 will find the mucous membrane of the dilated ureter (or 
 ureters) and pelvis of the kidney, swollen, pulpy, and 
 of a dirty drab, grayish or greenish color, and possibly 
 with incrustations of saline matter upon its surface. 
 The renal pelves may be sacculated, and the pouches, 
 may contain shreds of membrane, thickened, fetid pus, 
 and saline matter. The kidneys, when free from or- 
 ganic lesion, are always sympathetically affected, being 
 enlarged and congested. Abscesses of the kidneys 
 themselves have been found in these cases. 
 
 The inflamed and dilated pelvis of the kidney, 
 gradually enlarging, flattens out and implicates the 
 papillae, and later the pyramids in the inflammatory 
 process, until finally the whole organ is converted into 
 a sacculated abscess. 
 
 When there is destructive inflammation of the kid- 
 ney (the ureter not being obstructed, and the pus hav- 
 ing a free exit), the organ shrinks until it is converted, 
 into a little shrivelled body, weighing from a few 
 drachms to an ounce or two. If the purulent matter 
 has not free exit, it fills the kidney and becomes thick 
 and putty-like, cutting like fresh cheese. This may^ 
 be the case where the purulent matter cannot or does: 
 not escape from the kidney, the ureter being perfectly 
 free throughout. The septa between the sacculi are 
 occasionally ossific. 
 
S72 CYSTITIS. 
 
 The pyramids alone may suffer, their tissues being 
 converted into purulent matter, the whole having the 
 appearance of soft putty, in some cases studded with 
 calcareous masses. When the purulent matter is 
 washed out, the hole left looks as though the pyramid 
 had been punched out, so smooth and clean cut are its 
 edges. 
 
 Again, the kidney may be studded with minute ab- 
 scesses. Where one kidney is wholly or partially de- 
 stroyed, the other, if healthy, is, as a rule, largely 
 hypertrophied. 
 
 In some cases of longstanding, the kidney affected 
 does not break down into purulent matter, but by a 
 slower process, probably that of chronic congestion, 
 b)ecomes granular and contracted. 
 
 The study of renal complication of Cystitis is a very 
 interesting and instructive one, but it is too extensive 
 to permit of anything like a full discussion here. For 
 a more elaborate consideration of the subject, I must 
 refer you to the special books on renal diseases. 
 
 Symptomatology. — The various forms of Cystitis 
 being simply stages of the same disease, I shall speak 
 of their symptoms all under the one head. 
 
 They may, for convenience sake, be divided as 
 follows : — 
 
 1st. Symptoms referable to the organ itself or its 
 contents 
 
 2d. Symptoms referable to neighboring organs, 
 that suffer either from sympathy, or through direct ex- 
 tension. 
 
SYMPTOMATOLOGY. 17J, 
 
 3d. Symptoms referable to various conditions of 
 the general system, as, 
 
 ia) The Vascular System. 
 
 {B) The Digestive Tract. 
 
 {c) The Cutaneous Surface. 
 
 i^d) The Nervous System — Cephalic and Sub^ 
 cephalic. 
 1st. The symptoms referable to the organ itself 
 are chiefly derangement of function, viz., pain, tenes- 
 mus, and frequent urination. The symptoms vary 
 in severity according to the extent and intensity 
 of the Cystitis. In the mildest form of the trouble 
 there is frequent desire to pass water, which often 
 comes with unusual force. Micturition is followed by 
 a desire to strain, as if the organ had not been fully 
 emptied. In the more acute cases this gives rise to 
 the most intense agony, the patient remaining on the 
 vessel for hours at a time. The sensation of a few 
 drops of urine remaining in the bladder may pass off 
 in a few moments, but, as a rule, returns after each 
 micturition. 
 
 As the disease advances, and ulcerative changes 
 take place, the vesical tenesmus returns in full force, 
 and the powerful squeezing together of the bladder 
 walls during and after urination produces intense pain. 
 Sometimes pains shoot up into the breast, or the region 
 of the umbilicus. There is often a dull, dead achine 
 in the perineum. In nearly all cases, there is contin- 
 uous backache, or more correctly, sacral p^in. These 
 pains seem to be most severe in cases of long standing, 
 where upon an already ulcerated surface an acute in- 
 
a 74 
 
 CYSTITIS. 
 
 -flammation is set up by errors in diet, medicines, vio- 
 lence in catheterization, rapid changes in temperature 
 or exposure to wet and cold. 
 
 The condition of the urine in Acute or Chronic 
 Cystitis is of importance, but if you rely upon it alone 
 for a diagnosis you will be doomed to many disap- 
 pointments. The specific gravity is usually low in the 
 more chronic types, varying from 1.005 ^o 1.018, being 
 usually about 1.0 10. In the primary acute form the 
 gravity is little if anything below the normal, and if 
 there is marked fever, may rise as high as 1.030. 
 In acute attacks engrafted on a chronic state, the 
 gravity is usually low. When the specific gravity is 
 low in Acute Cystitis, if not dependent on the diluent 
 drinks and diuretics given, it is probably due to a 
 slight sympathetic hypersemia of the kidneys. The 
 low gravity in Chronic Cystitis is possibly due to the 
 same cause, and a urine not only proportionally but 
 really deficient in the urinary salts is excreted. To 
 this may be attributed many of the uraemic (ammonse- 
 mlc) and ttrincsinic symptoms accompanying the dis- 
 ease, which are supposed by many to be due to absorp- 
 tion of decomposed urine. That such absorption might 
 take place after ulcerative processes had begun, or even 
 slight epithelial erosion had taken place, there can be 
 no doubt ; but it is a question whether we are to look 
 to the absorption from the eroded bladder as the only 
 method of their production. I shall speak of this 
 more fully very soon. 
 
 The reaction of the urine, in acute cases, when the 
 affection is not due to, or accompanied by retention, is 
 
PHYSICAL SIGNS. 175 
 
 at first usually acid. If there be retention, the reaction 
 is usually alkaline, due partly to the fixed alkali of the 
 mucus which is present in excess, but chiefly to the 
 ammonia disengaged in the breaking down of the urea. 
 In Chronic Cystitis, the reaction is almost invariably 
 .alkaline, being intensely ammoniacal. 
 
 In the primary acute form, the color is but slightly 
 ialtered. The presence of a little blood may give to the 
 urine a smoky tint, and if decomposed it will look hazy 
 and perhaps contain sparkling crystals of the Triple 
 Phosphate. In the chronic form the urine is of a pale, 
 dirty yellow hue, and may be of a deep red from the 
 presence of considerable blood. 
 
 The odor is ammoniacal in the acute type, if the 
 urine be decomposed, otherwise it is normal. In the 
 ■chronic form it has not only an ammoniacal but a pecu- 
 liar pungent odor of flesh. This is usually known as 
 .organic, from the fact that it is due to the amount of 
 organic material present. 
 
 The sediment in Acute Cystitis is usually that of mu- 
 cus, sometimes pus (white and clinging to the bottom, 
 or somewhat flocculent). It may be tinged with blood, 
 or rendered denser and whiter from the presence of the 
 Amorphous and Triple Phosphates. In Chronic Cystitis 
 the sediment is commonly heavy, and of a dirty brown 
 or brownish yellow color. Flakes of pus, shreds of tis- 
 sue, as well as blood and epithelial elements, cause it 
 to vary greatly in different cases. When the intense 
 alkalinity of the urine \\2iS jellified t]\Q pus (if I may be 
 permitted to use that expression), the sediment is seen 
 as a ropy, opaque mass, that clings tenaciously to the 
 
176 CYSTITIS, 
 
 bottom of the vessel when inverted, or slides about in 
 a jelly-like mass. 
 
 Microscopically^ this sediment presents a varied and 
 interesting sight. In the acute form, numerous fibrillse- 
 of mucus, a few pus corpuscles, and possibly blood 
 globules are to be seen, and if decomposition has taken 
 place, the Amorphous and Triple Phosphates. 
 
 In Chronic Cystitis pus corpuscles are usually pre- 
 sent In large amount. There is also a varying amount 
 of mucus, Triple and Amorphous Phosphates, spheres 
 of the Urate of Ammonia, organic debris, and in some 
 cases epithelial elements. In the advanced stages of 
 Chronic Cystitis, epithelial elements of any kind are 
 very rarely found. It is only in the earlier stages that 
 normal and transitional forms of vesical epithelium are 
 present. Even then you must not depend upon that 
 alone in making a differential diagnosis, lest you mis- 
 take a Pyelitis for a Cystitis, or vice versa ; the transi- 
 tional forms of epithelium from the bladder, as I have 
 already told you, closely resembling the normal epithe- 
 lium from certain other parts of the urinary tract. 
 The return to a healthy condition is marked by the dis- 
 appearance of pus ; the reappearance of epithelium In 
 the urine ; first transitional, then perfect, while the pro- 
 ducts of inflammation decrease In amount and finally 
 disappear altogether. When there is sympathetic con- 
 gestion of the kidneys, small light granular and hya- 
 line casts may be found. If organic renal disease Is 
 present, large, small, and medium sized hyaline, light 
 and dark granular, or other casts will be found, as also 
 epithelial and blood casts. In some cases, where ex- 
 
ABNORMAL URINE. v,*j 
 
 tensive destructive change has taken place in the kid- 
 neys, no evidences are found in the urine, either during 
 its progress or after its completion. 
 
 Upon testing the urine chemically, albumen will be 
 found in proportion to the amount of pus or blood pre- 
 sent. If renal disease coexist, the amount of albumen 
 will be greatly increased. In Chronic Cystitis without 
 renal disease, the amount of albumen in a number of 
 cases studied, varied from one-sixteenth to one-fifth of 
 the bulk of urine. There is usually a real excess of 
 both fixed and volatile alkaline salts, as also of the 
 earthy and alkaline Phosphates and the Chloride of 
 Sodium. 
 
 In the advanced stages, where there is a poor blood 
 condition, Urohaematin is present in a marked degree, 
 and Urea is either somewhat or decidedly diminish- 
 ed. In other cases, and at first, the Urea may be pre- 
 -sent in normal amount. 
 
 2d. Symptoms Referable to Neighboring Organs. — 
 These are not especially marked. In some cases, with 
 the intense vesical tenesmus, there may exist an irrita- 
 ble condition of the rectum, with some tenesmus and 
 pain on going to stool. 
 
 The uterus is often congested, which causes a free 
 leucorrhcea ; sub-involution often occurs after the con- 
 finement of those who have had Cystitis during preg- 
 nancy. Extension of the inflammation in extreme 
 cases may cause Metritis and Pelvic Cellulitis or Peri- 
 tonitis. The symptoms thus arising will be character- 
 istic of the disease of the organs or tissues involved. 
 
178 CYSTITIS, 
 
 Menstruation may be variously disturbed; Men- 
 orrhagia, Metrorrhagia, or Amenorrhoea resulting, ei- 
 ther from congestion, inflammatory extension, or reflex 
 nervous influence. 
 
 Neuralgia of the uterus or ovaries may also be 
 produced in this way. I have just said that sub-involu- 
 tion of the uterus is almost sure to follow a pregnancy 
 occurring during the existence of a chronic vesical in- 
 flammation, and I am inclined to believe that the same 
 result is produced in some cases by an Acute Cystitis 
 following delivery. 
 
 Renal disturbances, upon which we have already 
 touched, will be spoken of more at length presently. 
 
 3d. Symptoms Referable to Disturbances of the 
 Oeneral System. — These symptoms may be due to 
 reflex nervous influence, or to direct blood poison- 
 ing. For convenience sake we will first turn our at- * 
 tention to 
 
 [a) The Vascular System. — Although there has been 
 much dispute amongst authors as to how and by what 
 the general poisoning is caused, there seems to be no 
 question as to whether such a poisoning really does 
 take place. As general systemic effects may be pro- 
 duced by two separate blood conditions, we will discuss 
 the subject under two heads, prefacing their considera- 
 tion, however, with the remark that, as a rule, the two 
 conditions exist together. They are : 
 
 Abnormal ingredients existing in the blood, and 
 a poor condition of the blood itself (/\n2emia). 
 
 The poisoning of the general system that usually 
 
CONDITION OF VASCULAR SYSTEM. 179 
 
 ■complicates Cystitis of long standing, may be produced 
 in three ways ; viz., 
 
 I. Organic renal disease, or Renal Hypersemia 
 (sympathetic), leading to imperfect elimination of urin- 
 ary salts. 
 
 II. Direct absorption of one or more of the in- 
 gredients of the decomposed urine (Ammonsemia, 
 Urinaemia). 
 
 III. Absorption of pyaemic or septic matter, pro- 
 duced by decomposition of sloughing tissue and organic 
 ■debj' is. 
 
 I St. Probably in almost all cases of Chronic Cys- 
 titis, the kidneys are kept in a more or less actively or 
 passively hypersemic state, usually active ; and while 
 •eliminating a normal amount of fluid, fail to rid the 
 blood of the accumulating salts ; and thereby a slow, 
 -Steady blood and tissue poisoning is brought about. 
 So slow is it, that the system seems to establish a cer- 
 tain amount of tolerance for the poison. 
 
 A French experimenter has found that a small 
 amount of urea is daily eliminated by the mucous 
 membrane of the bowels in health, and we all know 
 that in renal diseases, with partial or total suppression 
 of urine, the bowels are largely concerned in the elimi- 
 nation of the poison from the system. In this manner 
 may be explained the occasional attacks of vomiting and 
 almost uncheckable diarrhoea in bad cases of Cystitis. 
 Of course, when destructive renal disease complicates 
 the Cystitis, the general poisoning is more marked and 
 more readily explained. 
 
 2d. In my lecture on the function of the bladder I 
 
i8o CYSTITIS. 
 
 told you that experimenters had pretty well established' 
 the fact that a normal vesical mucous membrane was 
 unable to absorb anything, beyond possibly a little 
 water, but that where erosion of the epithelial surface- 
 or ulceration existed, absorption was possible. This- 
 being the case, you will at once see how easy it is for 
 a patient suffering with Chronic Cystitis to become- 
 poisoned by the absorption of decomposed ammoniacal' 
 urine in the bladder. Whether the materies morbi be 
 the urea, the ammonia, or all or a part of the urine, is- 
 not as yet definitely settled. This form of poisoning- 
 by absorption has been denied, on the ground that the 
 urine remains but a short time in the bladder, owing- 
 to the intense vesical tenesmus, and that the eroded 
 surface is fairly well shielded from contact with the 
 urine by mucus or jellified pus, and that therefore there 
 is neither time nor opportunity for absorption. As 
 against these arguments, let me say that of all kinds 
 of urine, the highly limpid seems the most easiljr 
 absorbed ; that poisoning is not supposed to be due to 
 the fresh urine that comes directly from the kidneys, 
 but to its decomposing sediment, caught in the meshes 
 of the mucus and muco-pus. Further, the intense 
 vesical tenesmus, while keeping the bladder compara- 
 tively empty, thoroughly mixes the decomposing urine 
 with the mucus, thus at each micturition applying a 
 freshly charged decomposing matter to the eroded 
 and ulcerated surface. It will also be observed that in 
 some cases where, by the use of opiates or in the 
 course of the disease itself, the tenesmus wholly or in 
 part abates, and the urine remains in the bladder for a 
 
AMMON^MIA—URIN^MIA. i8l 
 
 longer period than usual, the patient, while feeling 
 greatly relieved by not having the incessant calls to 
 urinate, still begins to experience a peculiar sensation 
 of sleepiness, and the other manifestations of systemic 
 poisoning. That this is not due to the opiates or other 
 remedies used, is evident from the fact that as largfe or 
 larger doses of the same remedies do not produce these 
 peculiar results when given at times when the vesical 
 tenesmus is marked. It is undoubtedly explained by 
 the fact that the bladder has more time to absorb a 
 part of its contents, which, when absorbed, produce 
 these results. 
 
 3d. Blood contamination due to the absorption of 
 purulent or septic matter. This material may be the 
 liqzior puris, the disintegrated corpuscle of pus, or 
 possibly the whole corpuscle, as also the decomposed 
 shreds of sloughed membrane, and organic debris. 
 
 I think there is little doubt but that such material 
 is at times absorbed, and gives rise to the peculiar sep- 
 ticaemic or pysemic symptoms. The chill, fever, and 
 sweating, with peculiar head symptoms (all to be spo- 
 ken of more fully hereafter), the sudden diarrhoea, with 
 copious black, offensive liquid stools, are probably 
 caused in this way. 
 
 Whether the general symptoms are produced at the 
 time of each absorption, or whether by slow degrees the 
 poisonous material collects, and, tolerance being finally 
 exhausted, nervous disorder, with a powerful effort at 
 -excretion by the bowels, results, we do not know. 
 
 Poor Blood Condition — (Anaemia). — In Cystitis of 
 
1 82 CYSTITIS. 
 
 long standing, owing to frequent hemorrhages, poor 
 digestion, excessive diaphoresis and diuresis, and reflex: 
 nervous Influences, the blood becomes poor In red cor- 
 puscles and fibrin.^ Cuts and Injuries on these persons- 
 do not heal readily, and poor tissue renovation is a. 
 universal accompaniment of this affection. Cerebral 
 anaemia Is an accompanying complication, due to the 
 same cause, and various abnormal nervous phenomena, 
 result from poor nourishment of nerve tissue. All the 
 fluids and solids of the body are but poorly constructed,, 
 and imperfect performance of function necessarily results.. 
 This poor blood condition, as I have already said, is- 
 manifested by the presence of Urohaematin In the urine. 
 (b) The Digestive Tract. — Anorexia, especially 
 at the morning meal, is a common accompaniment of 
 Chronic Cystitis. In some cases this Is the only meali 
 where the appetite does not invite the patient to par- 
 take. A longing for peculiar foods Is also very com- 
 mon, the patient often having lost the desire before- 
 the article in question reaches her. The common, 
 symptoms of disordered digestion are usually present, 
 and the affection may be either of the nervous type, or 
 the chronic catarrhal form, usually a mixture of both. 
 If, as Is believed, the poisonous material absorbed from: 
 the bladder and the non-eliminated urinary salts find 
 vent through the alimentary canal, we have no trouble 
 in finding a cause for the catarrhal disorder. The 
 nervous disorders are readily explained by the effects of 
 the abnormal condition of the blood, and the broken: 
 and sleepless nights which interrupt and retard the 
 nutrition of the nervous system. 
 
CONDITION' OF DIGESTIVE SYSTEM. 183 
 
 The bowels are usually Irregular, generally con- 
 stipated, and requiring daily enemata to open them. 
 This costiveness is occasionally interrupted by a pro- 
 fuse watery diarrhoea, which may, in part, result from 
 the ulceration of the bowel, which is such a common 
 lesion in ammonsemia. It may last for days, or for only 
 a few hours, and the discharges are usually rich in the 
 Carbonate of Ammonia. The septicaemic diarrhoea 
 differs usually In the great prostration accompanying it, 
 the character of the stools (black or greenish black, 
 and very offensive, the organic smell quite or partly 
 hiding the ammoniacal odor), and the fact that it is 
 usually preceded or accompanied by chills, fever, and 
 sweating. If checked too abruptly, head symptoms, 
 mild muttering delirium, etc., are likely to follow. 
 
 The results of imperfect digestion are seen In the 
 poor, unhealthy condition of the patient's flesh and 
 skin, and all the signs of mal-nutritlon present. 
 
 (c) The Cutaneous Surface. — The skin of patients 
 with Chronic Cystitis Is usually sallow, loose, and has a 
 flabby, lifeless feel. Indeed, one might almost make a 
 diagnosis from the complexion alone. Sweating of 
 the palms of the hands and soles of the feet Is common. 
 In low states of the system the patients are especially 
 liable to night sweats. The perspiration sometimes has 
 a urinous odor. I have already spoken to you of the 
 septicaemic diaphoresis. 
 
 (d) The Nervous System. — We will first consider 
 the symptoms appertainimg to the brain and its func- 
 tion, and then to the sub-cephalic nervous system. 
 
 There is a peculiar brain condition, supposed by 
 
i84 CYSTITIS. 
 
 some to be caused by cerebral anaemia ; others say that 
 it is due to a peculiar poison circulating in the blood. 
 By anaemia of the brain in this connection is meant 
 not only a lack of haematic fluid in that organ, but an 
 exceedingly, impoverished condition of the blood there 
 circulating. Those medicines that tend to lessen the 
 amount of blood in the brain, as Bromide of Potassium 
 and Ergot, produce most unpleasant symptoms in 
 these cases, such as dizziness and fainting. Medi- 
 cines which act in a manner to congest the brain, if giv- 
 en in small doses, improve this condition, as also do 
 the ferruginous tonics, especially Iron by Hydrogen. 
 From this it would appear that this peculiar condition 
 is due more to the amount of, and imperfectly constitu- 
 ted blood circulating in the brain, than to the absorb- 
 ed or non-eliminated urinary matter. Against this 
 theory, however, is the fact that when the vesical 
 tenesmus is least and the urine remains in the blad- 
 der longest, and hence the blood poisoning is pre- 
 sumably the greatest, the weak and somnolent feeling 
 is the worst. Both causes probably act to produce 
 this condition. By some, however, this cerebral anae- 
 mia is attributed partly to the poor blood condition, 
 but chiefly to imperfect circulation due to a want of 
 exercise. This view is supported by the fact that 
 Digitalis and exercise in the open air greatly improve 
 these patients. 
 
 When septic complications arise, and the patient 
 becomes very low, or when the septic diarrhoea is 
 checked too suddenly, low, muttering delirium with hal- ' 
 iucination commonly results. This has been alluded 
 
CONDITION OF THE NERVOUS SYSTEM. 185 
 
 to before. The mind is usually markedly affected, the 
 patient feeling "blue," morose, lacking hope, confi- 
 dence, and spirit. At times, indeed, they become so 
 •despondent as to seriously contemplate suicide. The 
 little rest that they get at night is often broken by 
 horrible dreams and nightmare. I am now speaking 
 of the most severe cases. 
 
 The sub-cephalic nervous system is seldom affected 
 beyond occasional irregular action of the heart, chills, 
 fever and sweating, and occasional neuralgia. Pains 
 in the nipple, abdomen, arms, legs, hands and feet, are 
 by no means rare. The vesical pain has already been 
 referred to. Of course all these symptoms that I have 
 spoken of as accompanying Cystitis, do not occur in 
 each case, nor are the greater part of them peculiar 
 to Cystitis alone ; but I give them to you so that you 
 may know with what you are liable to meet, and be able 
 in some manner to understand the method of their pro- 
 duction. We now pass to diagnosis. 
 
 Diagnosis. — The diagnosis of Cystitis is generally 
 easy in marked cases, but in mild attacks care is neces- 
 sary to distinguish it from other conditions that cause 
 similar symptoms. 
 
 Frequent urination, as you know, occurs in many 
 other troubles, such as prolapsus uteri, adhesions from 
 pelvic peritonitis, with abdominal tumors, and in vari- 
 ous neuroses. Pregnancy, also, sometimes gives rise 
 to annoying frequency of micturition. Frequent urina- 
 tion from prolapsus is worse when the patient is stand- 
 ing or walking, and is relieved wholly or to a great 
 
i86 CYSTITIS. 
 
 extent by the recumbent position, while in Cystitis po- 
 sition makes no marked difference. 
 
 I have seen one very interesting exception to this 
 general rule. The lady had a complete prolapsus for 
 many years, and when in the erect position she could re- 
 tain her water for an ordinary length of tim.e, but when 
 she was reclining the most urgent desire to urinate came- 
 on, and she could only retain a very small quantity of 
 urine. The cause of this I found to be inflammation of 
 the neck of the bladder. When in the upright position^ 
 the urine settled down in the dependent portion, but 
 while recumbent the pressure came on the tender part. 
 
 In adhesions from pelvic peritonitis, abdominal 
 tumors, and pregnancy, the desire to urinate only comes 
 on when the bladder is partly filled, and is about the 
 same day and night. Frequency of urination is not 
 usually accompanied by tenesums, except when due to 
 Cystitis. In the various forms of vesical neuroses the 
 frequent urination is very irregular, the patient at times 
 being almost entirely free from it, and at other times 
 very much troubled. 
 
 The frequent and painful urination of Cystitis may 
 be simulated by Urethritis and other painful, irritable 
 conditions of the urethra. The distinction can be made 
 usually, from the fact that in urethral disease there is 
 no vesical tenesmus, or if any, it is much less than in 
 Cystitis. There is acute pain in the act of urination, 
 and a burning sensation in the urethra, which some- 
 times causes sympathetic vesical tenesmus ; but when 
 that passes off the bladder will tolerate distension to 
 the fullest extent. 
 
DIAGNOSIS. l8;t 
 
 The urine should be carefully examined and the re- 
 sults as carefully considered. Implicit dependence, 
 however, as I have before told you, must not be placed' 
 on the condition of the urine. Acute or chronic con- 
 gestion may give considerable mucus, that is some- 
 times mistaken for pus that has been jellified by the 
 action of strong alkali. Pus may be present in the- 
 urine from suppuration of the upper urinary passages 
 (Pyo-nephrosis, Renal Abscess, and Pyelitis) ; from 
 abscesses of neighboring organs or tissues opening 
 into the bladder, as in typhlitis, pelvic cellulitis, etc., 
 When you are in doubt on this point, Sir Henry 
 Thompson's method of procedure (of which I spoke 
 to you in my last lecture, as recommended by Van. 
 Buren and Keyes for detecting the source of blood), 
 should be tried. 
 
 A differential diagnosis between Cystitis and Pye- 
 litis, by means of the urine alone, is almost an impos- 
 sibility, especially in the later stages of the former. 
 Thompson's method, the endoscope, and the presence- 
 or absence of a tumor in the loins, with the general 
 symptoms, must guide you. No dependence can be 
 placed on the epithelium, as transitional forms from 
 the bladder, as already explained, are very likely tO' 
 be mistaken for the normal epithelium of the renal, 
 pelves, and lead you into error. 
 
 To make a positive and reliable diagnosis, you 
 must resort to physical exploration of the organ. The 
 methods of exploration are palpation, percussion, and 
 auscultation of the abdomen ; examination of all the. 
 pelvic organs by the touch and speculum ; and last- 
 
Zi^ CYSTITIS. 
 
 ly, exploration of the bladder by the catheter, or sound, 
 .and endoscope. 
 
 By palpation and percussion of the abdomen you 
 will be able to detect tenderness and distension of the 
 bladder, if either exist. By the same means you may 
 ascertain whether the bladder is contracted and its 
 walls thickened, rigid or relaxed. 
 
 Auscultation will possibly reveal friction sounds in 
 cases where inflammation has extended to the serous 
 coat, and caused roughening by exudation on the peri- 
 toneal surfaces. These may seem to be rather delicate 
 points in examination, but in obscure cases you must 
 avail yourselves of all the means that can give you 
 the slightest evidence pro or co7i. 
 
 Examination of the pelvic organs by touch will de- 
 tect any disease of these organs that may either cause 
 or complicate the Cystitis. Displacements and In- 
 flammatory affections of the uterus, vagina, or rectum ; 
 pelvic peritonitis, or the products of a former attack of 
 that disease ; ovarian diseases and tumors, should be 
 •carefully sought for, and their relations — if there be 
 such — to the vesical trouble, carefully studied. 
 
 Cystitis produced by or producing Pelvic Cellulitis 
 and Peritonitis, has the same symptoms as ordinary 
 purulent vesical inflammation, p/us those of well defin- 
 ed pelvic inflammation. There is usually pain and 
 tenderness of the pelvic organs, and the symptomatic 
 fever of local inflammation. 
 
 In those cases where, from gluing together of the 
 pelvic organs, the bladder walls are separated and kept 
 upon the stretch, incontinence often results, sometimes 
 
DIAGNOSIS. 189 
 
 over-distension with dribbling. In such cases the Cys- 
 titis may be entirely secondary to the pelvic adhesions 
 and consequent vesical distension. The urethra should 
 be examined with care, for some of its diseases present 
 a natural history closely resembling that of some vesi- 
 cal affections. 
 
 By a careful use of the catheter or sound introduced 
 into the bladder you can determine the degree of ten- 
 derness of that organ, and also exclude the pressure of 
 foreign bodies, such as stone in the bladder. The 
 sound being in the bladder, the finger may be intro- 
 duced into the vagina, and the posterior and inferior 
 walls be examined as to their thickness and tenderness. 
 
 The most accurate knowledge of the pathology of 
 vesical troubles may be had from the use of the endo- 
 scope. In this way the urethral surface and interior 
 of the bladder can be seen plainly enough to make a 
 diagnosis. In supposed Cystitis you ought always to 
 examine the neck of the bladder with a view to detect 
 fissures at that point. These fissures give rise to 
 symptoms very closely simulating Cystitis, and the 
 differential diagnosis can only be made by the endo- 
 scope. 
 
 The endoscope affords the only means of ascertain- 
 ing the exact appearance of the interior of the bladder. 
 The extent of congestion, the degree and extent of 
 ulceration and other lesions can be observed in this 
 way, and this instrument should be used in all cases 
 where the dia.gnosis is doubtful, or when the case does 
 not yield to supposed proper treatment. 
 
 When from an examination of the urine or the 
 
190 CYSTITIS. 
 
 symptoms it is impossible to tell whether disease of the 
 kidneys complicates the vesical trouble, recourse may 
 be had to the ophthalmoscope, by means of which 
 renal disease may often be diagnosticated, there being 
 an affection of the retina known as Retinitis Albumin - 
 urica. 
 
LECTURE V. 
 
 Treatment of Cystitis — Croupous and Diphtheritic 
 Cystitis — Cystitis with Epidermoid Concre- 
 ment — Vesico-urethral Fissure. 
 
 Gentlemen — 
 
 Cystitis requires both local and constitutional 
 treatment, and withal it is a troublesome disease to 
 manage, especially in its chronic form. The constitu- 
 tional treatment consists, first of all, in so regulating the 
 •character of the urine that it shall be unirritatinsf to 
 the diseased organ. Pain and vesical tenesmus should 
 be relieved if possible. The skin should be kept in 
 a healthy and active condition, and the bowels regular 
 and free, in order to prevent all straining at stool, and 
 secure free action of the portal circulation. Free elimi- 
 nation by the skin and bowels will give the kidneys and 
 bladder less to do. To overcome existing constipa- 
 tion, saline laxatives should be used. A glassful of pur- 
 gative mineral water, given an hour before breakfast, 
 answers very well in most cases. Cold water enemata 
 are advised by good authorities. 
 
 Winckel recommends the use of saline laxatives, 
 pushed to a point where intestinal hyperaemia is pro- 
 duced and maintained for a time. He believes that the 
 
192 . TREATMENT OF CYSTITIS. 
 
 blood may, in this manner, be to a certain extent divert- 
 ed fromt he bladder ; and I am of the belief that the 
 practice is a sound one. A case of my own is of in- 
 terest as showing the benefit effected (supposedly) in 
 this way. A lady had a catarrh of the bladder of 
 some months' standing, which I had been treating in: 
 the usual way, with only slight benefit. She was one 
 day attacked with Cholera Morbus, with watery purg- 
 ing and vomiting, the former almost as severe as that 
 of Asiatic Cholera. The effect, for a time, M^as to 
 almost suspend the action of the kidneys. When she 
 recovered, she was delighted to find that her Cystitis- 
 had left her. 
 
 Deranged conditions of the system which tend to 
 produce irritating urine should be carefully studied, and 
 if possible remedied. Indigestion is a predisposing 
 cause of bladder trouble, and should be removed as far 
 as possible by proper diet and medication. Being a 
 predisposing cause, you will readily see that Cystitis 
 being once established may be seriously aggravated by 
 it. The same may be said of the rheumatic and gouty 
 diatheses. 
 
 The diet of patients suffering from this disease 
 must be carefully regulated. Milk will be found to 
 agree excellently in most cases. In the hands of Dr. 
 Geo. Johnson, of England, an exclusive milk diet has 
 cured several cases, some of great severity and long 
 standing. 
 
 He says: "The milk may be taken cold or tepid, 
 and not more than a pint at a time, lest a large mass 
 of curd, difficult of digestion, form and collect in the 
 
TREATMENT OF CYSTITIS. 193 
 
 Stomach. Some adults will take as much as a gallon 
 in the twenty-four hours. With some persons the milk 
 is found to agree better after it has been boiled, and 
 then taken either cold or tepid. If the milk be rich in 
 cream, and if the cream disagree, causing heartburn, 
 headache, diarrhoea, or the symptoms of dyspepsia, the 
 cream may be partially removed by skimming. Con- 
 stipation, which is one of the most frequent and trouble- 
 some results of an exclusively milk diet, is to some 
 extent obviated by the cream in the unskimmed milk. 
 When the vesical irritation and catarrh have passed 
 away, solid food may be combined with the milk, and 
 a gradual return made to the ordinary diet." 
 
 I have tried this method of treatment in several 
 instances with decided benefit. 
 
 I may briefly state that the bill of fare should con- 
 sist largely of fluid foods, as milk, yolk of eggs, soups, 
 and beef essence. Lean meat in small amount, and 
 other solid or semi-solid foods that are easily digested 
 and nutritious, may also be allowed. The cause, what- 
 ever that may be, should be removed, if possible ; and 
 the remedies must be adapted to the stage and con- 
 dition of the inflammation. In the acute stage, ag- 
 gravated by exposure to cold, diaphoretics should be 
 freely used, and the patient made to rest as quietly as 
 possible. Diuretics should be given if the urine is 
 loaded with solid material, and the alkaline salts are to 
 be preferred. Vichy water, or flaxseed tea with Ci- 
 trate or Nitrate of Potash, will answer very well at the 
 beginning of the disease. In using such salines, it 
 serves admirably to give them in an infusion of Buchu. 
 
194 TREATME.YT OF CYSTITIS. 
 
 This of itself is a most valuable remedy in almost all 
 bladder troubles. You must be careful, however, not 
 to push your diuretics too far. Sufficient to bring the 
 urine to its normal proportions, and make it slightly 
 alkaline if naturally acid, is all that is required. 
 
 In the early stages of Acute Cystitis, as in Irritable 
 Bladder, Sidney Ringer and other authorities strongly 
 commend the use of minim doses of Tincture of Can- 
 tharides repeated every hour, and even oftener. 
 
 One or two leeches to the anterior vaginal wall 
 may be tried, and hot applications to the epigastrium. 
 To relieve pain, opium is indicated. Dover's Powder 
 is very valuable, and may be given with ordinary doses 
 ■of Camphor. If there is any objection to anodynes 
 ^iven in this way, or if there is sympathetic rectal 
 tenesmus, suppositories of Morphia and Belladonna 
 should be used. 
 
 While I have said that you may use opiates at the 
 onset of acute cases, and to relieve the suffering in old 
 cases that you cannot cure, I must impress upon your 
 minds the great harm that may come from the injudi- 
 cious use of this drug in Cystitis. It deranges the 
 digestive organs and the. secretions generally, especially 
 that of the kidneys ; and, by changing the quantita- 
 tive composition of the urine, renders it irritating to 
 the bladder. 
 
 In some cases, where frequent urination and tenes- 
 mus are very severe, owing to excessive nervous irri- 
 tability, twenty-grain doses of the Bromide of Potas- 
 sium, every four hours until relieved, act very nicely ; 
 indeed it succeeds in cases where opiates fail entirely. 
 
TREATMENT OF CYSTITIS. 195. 
 
 T^ecently I have been using Hydrobromic Acid, and 
 iind that it acts even better than the Bromide of Po- 
 tassium. 
 
 The comparatively new drug, Eucal^/ptus Globulus, 
 is worthy of a trial in obstinate cases. From its well- 
 marked beneficial action in Albuminuria and other af- 
 fections of the urinary tract, my friend Dr. W. Ander- 
 son was led to try it in Cystitis ; and he reports it as 
 decidedly useful. As this remedy has tonic, antiperi- 
 odic, and antiseptic properties, it might be especially 
 suitable in malarious districts. An infusion for injec- 
 tion, in cases where the urine was decomposed, would 
 most probably give good results. 
 
 Benzoic Acid is perhaps the drug that will be found 
 the most use'ful in the largest number of cases. It 
 ■often seems to act like a specific, giving speedy and 
 permanent relief It may be given in about ten-grain 
 doses, in infusion of Buchu, three or four times a day. 
 As the acid is sparingly soluble in cold water, an equal 
 proportion of Borax may be added to the mixture. 
 To insure a perfect solution, you may prescribe the 
 Benzoate of Ammonia, which in the same dose acts 
 admirably, and is more palatable. 
 
 In the more advanced stages of the disease, reme- 
 dies are used for their direct effect upon the mucous 
 membrane, and much good is obtained in this way. 
 The drugs which have the best reputation in Urethritis 
 are employed in Cystitis. Balsam of Peru and of Co- 
 paiba, Oil of Turpentine and Tar Water, are the most 
 important of this class, and should be given in cap- 
 sules, in the same way as for Gonorrhoea. 
 
196 TREATMENT OF CYSTITIS. 
 
 When the pain is not severe, and the urine is load- 
 ed with mucus and pus, astringents should be given^ 
 Tannin, continued for a considerable time, is of ver)'- 
 great value. Decoction of Uva Ursi, in half-ounce 
 doses, may also be used for this purpose. In place of 
 these I have employed, with occasional good effect, a 
 mixture composed of two ounces fluid extract of Buchu, 
 one ounce Tincture of Conium, and one grain and a 
 half Sulphate of Morphia, giving teaspoonful doses 
 every three or four hours. 
 
 My friend Dr. B. A. Segur, of this city, has used 
 Salicylate of Soda in purulent Cystitis, and found that- 
 the quantity of pus in the urine rapidly decreased un- 
 der the use of this remedy. 
 
 Dr. Sansom, of London, found that the administra- 
 tion of Carbolic Acid and the Sulpho-carbolates to an- 
 imals prevented the decomposition of urine, although 
 he could not detect any of the salt in the secretion. 
 He gave the Sulpho-carbolates and afterwards collect- 
 ed and preserved the urine, which after six months had 
 not decomposed. This fact should be kept in mind 
 and turned to account in cases where there is a ten- 
 dency to decomposition from retention or other causes. 
 
 All these remedies may be tried in cases that 
 are seen early ; but when they fail, or when the acute 
 stage of the trouble is long past before advice is sought, 
 then local treatment must be employed. The bladder 
 should be washed out, and medicated injections used. 
 This you will all feel competent to do, no doubt, but I 
 must give you some general directions as to the methods 
 of manipulating, as I feel assured that much of the good 
 
TREATMENT OF CYSTITIS. 197 
 
 effect of this kind of treatment is lost by the ignorant 
 and careless use of the catheter and syringe. 
 
 I would advise you not to use the ordinary metallic 
 catheter, with one or two large openings at the end. 
 The objection to that instrument is, that when the 
 bladder is empty the mucous membrane passes into the 
 opening, and is likely to be injured when the catheter 
 is withdrawn. When the edges of the openings are 
 sharp, as they often are, the membrane is almost cer- 
 tain to be wounded. I have repeatedly seen hemor- 
 rhage follow the use of such instruments. The same 
 objection may be urged against the gum-elastic cathe- 
 ter, as usually made. My method of procedure is as 
 follows : — I employ a Jacques' catheter with the so- 
 called "velvet eye" (made by Tiemann & Co.) and 
 attached to it, by means of a glass rod, a piece of 
 rubber tubing. A funnel is attached to the latter. 
 (See Fig. i8.) The length of the whole instrument 
 is about two feet. 
 
 To use the instrument, introduce the catheter into 
 the bladder and draw the urine by lowering the fun- 
 nel. Then fill the funnel with the solution to be in- 
 jected, holding it below the level of the bladder so 
 that no air is allowed to enter. As we elevate the 
 funnel the solution enters the bladder, and any given 
 quantity may be poured into the funnel and injected 
 into the viscus. Merely depressing the instrument 
 withdraws the vesical contents. After injecting a dis- 
 eased bladder, its contents are usually expelled with 
 force, the walls striking the end of the catheter caus- 
 
I9S 
 
 TREAT MENT OF CYSTITIS. 
 
 ing not only pain, but an actual lesion. These acci- 
 dents are avoided by allowing the last of the fluid ta 
 escape slowly; and the command we have of the fun- 
 nel in the above-described instrument makes this an 
 easy matter. In any event, injury to the mucosa is 
 
 ric. 18. 
 
 Jacques' Catheter, with Skene's Modifications. 
 
 impossible with this instrument. The only objection 
 to it is the difficulty in keeping it clean ; to do this I 
 thoroughly wash it in warm water and then boil it 
 for a few minutes. I then keep it in a solution of 
 carbolic acid until required. The boiling is to be in- 
 sisted upon, for if put into a carbolic acid solution 
 without this precaution, you will find the inner sur- 
 face of the instrument swarming with bacteria, which, 
 to-day, play such an important part in the causation 
 of cystitis. 
 
 In employing a catheter, it is usual to lubricate it 
 
TREATMENT OF CYSTITIS. 199 
 
 with oil, but you will find castile soap and water or 
 Vaseline more cleanly and convenient. The oil is apt 
 to become rancid, and unless you have very hot water 
 at hand the catheter cannot be easily cleaned; both 
 of which objections are avoided by using soap or 
 Vaseline. In order to employ injections successfully, 
 you must, in addition to the catheter described, have a 
 syringe which will fit into it easily and accurately. 
 The fountain syringe is one of the best for this pur- 
 pose, because you can regulate the quantity of fluid 
 used and the pressure employed. 
 
 This operation, simple as it may appear to you, re- 
 quires considerable skill and care in order to do it well. 
 Much good may be accomplished, by the proper use 
 of this means of treament, but great pain and distress, 
 and even real injury, will follow if it be ignorantly em- 
 ployed. Observe, then, carefully these rules: — (i) To 
 inject only one ounce of fluid at a time; the injec- 
 tion may be repeated three or four times in succession, 
 until four ounces in all are used. (2) Inject as slowly 
 as possible, and let the flow be regular, avoiding all 
 sudden jerking. If you use the cylinder and piston 
 syringe, get one that works very easily, in order that 
 you may avoid the objection mentioned. The reason 
 that slow and regular injection is necessary is that 
 the bladder is unaccustomed to sudden distension, and 
 any rapid expansion causes great distress, and really 
 injures the organ. 
 
 Simply washing out the bladder is often benefi- 
 cial, and it ought to be frequently repeated. It should 
 always be done before using any medicated injection. 
 
20O TREATMENT OF CYSTITIS. 
 
 Warm water is usually employed, but the addition of 
 Chlorate of Potash or common salt makes it less irri- 
 tating to the bladder. I prefer the common table salt, 
 using about sixty grains to the pint of water. It is 
 generally conceded that saline water is more accept- 
 able to serous and mucous membranes than any other 
 fluid, because more like the normal secretion of these 
 parts. When there is ulceration or suppuration, Car- 
 bolic Acid and water makes a most valuable wash. A 
 drop to the drachm, or thereabout, is the proper pro- 
 portion. 
 
 Having prepared the bladder for local applications 
 or injections by carefully washing it out, the material 
 to be used may be selected from a long list of reme- 
 dies. I shall only mention a few — those which I be- 
 lieve to be the most valuable. I need hardly tell you 
 that anodynes have been tried most faithfully. The 
 painful character of the disease suggests their use, but 
 you may be surprised to learn that they are neither re- 
 liable nor very effectual. The mucous membrane of the 
 bladder is not intended to absorb, and therefore we get 
 very little of the anodyne effects of opium or any of its 
 preparations, when injected into it, even when the dose 
 is very large. Should there be ulceration, then the 
 local and constitutional effects of Morphia will be pro- 
 duced by absorption. Braxton Hicks uses one or two 
 grains of Morphia to the ounce of water as an injection, 
 allowing the patient to retain it as long as possible, and 
 claims good results from its use. Remedies which pro- 
 duce local anaesthesia do relieve the pain to some 
 extent, but not altogether by an)' anodyne action, such 
 
TREATMENT OF CYSTITIS. 201 
 
 as we get from Opium given by the mouth or rectum. 
 Chloral Hydrate is recommended to relieve the pain 
 of Cystitis. I have used in solution ten to fifteen 
 grains to an ounce of water, and found benefit from it. 
 
 The astringent and alterative injections most bene- 
 ficial and most commonly used are Nitrate of Silver, 
 Sulphate of Zinc, Tannic Acid, and Acetate of Lead. 
 My rule is, to use one or two grains of either to the 
 ounce of warm water, and to increase the quantity if no 
 good effect comes from the small doses, but to carefully 
 avoid injections strong enough to cause much pain. 
 Chlorate of Potash is valuable, and Perchloride of Iron 
 is said to be useful. Infusion of Hydrastis Canadensis 
 has been used, and great virtue is claimed for it. I 
 have tried it, and believe that it acts well in some cases, 
 but still it fails, like the rest, in others. When the 
 urine is alkaline and offensive, from long retention, 
 which is occasionally the case in prolapsus of the blad- 
 der, then Nitro-hydrochloric Acid, of the strength of 
 two minims to the ounce of water, should be used. 
 Whenever pain is caused by any of these astringent 
 injections. Morphia should be used afterwards, as di- 
 rected by Braxton Hicks. 
 
 In obstinate cases a strong solution of Nitrate of 
 Silver is one of the most reliable remedies. Twenty 
 grains to the ounce of water has been used with great 
 benefit, and it does not cause as much pain as you 
 might suppose. Very small quantities, only, can be 
 used at a time, not more than five or ten drops. The 
 •only trouble which I experienced was to be sure of in- 
 jecting that small quantity and no more. My favorite 
 
i02 TREATMENT OF CYSTITIS. 
 
 method of making such apphcations to the interior of 
 the bladder is by instillation, as it is called. I take a 
 glass tube of the size and shape of a number 8 or 9 
 male sound, with a small rubber bulb attached to the 
 straight end. The curved point is introduced into the 
 solution to be used ; the bulb is compressed by the 
 thumb and finger, and then relaxed, which draws up the 
 desired amount. The tube is then carried into the 
 bladder, and by again compfessing the bulb the fluid 
 is easily deposited in the organ. (See Fig. 19.) 
 
 Pig. 19. 
 
 I have also succeeded by the following plan, which 
 I recommend to you. Take a number i or 2 elastic 
 catheter, and attach it to a small graduated syringe, 
 say a hypodermic or hard- rubber syringe ; charge this 
 with your solution of Nitrate of Silver. Introduce the 
 ordinary catheter and draw off the urine, then wash out 
 the bladder with water. Then carry the small elastic 
 catheter through the catheter already in the bladder, 
 and inject the five or ten drops. Remove the catheter 
 attached to the syringe, and inject a little water through 
 the larger catheter. This will force in the last drop of 
 the solution, and at the same time dilute it and prevent 
 any deep or severe caustic action. 
 
 There is one rule that you should follow in using 
 Nitrate of Silver in the treatment of Cystitis, which is 
 
TREATMENT OF CYSTITIS. 203; 
 
 this : if a strong solution is used, employ only a few 
 drops ; and if a large injection is made, the solution, 
 should be mild. Prof. W. H. Thomson advocates 
 injecting sulphate of quinine (gr. j.- § j.) ; "it de- 
 stroys white corpuscles and stops movements of bac- 
 teria." 
 
 Normal urine has been highly recommended as an 
 injection in Cystitis. The urine from a healthy person 
 is obtained and used in the same way as the other in- 
 jections described. I have always looked upon this- 
 treatment with a little suspicion. It may be of value 
 in cases where, from some derangement of the general 
 system, the urine secreted is abnormal, and therefore 
 irritating to the bladder, and where constitutional 
 treatment cannot remove that condition. When the 
 urine secreted can be kept in a normal state, it must, 
 it seems to me, be as acceptable to the bladder as 
 the same kind of urine from another person. Theo- 
 retically you would expect that healthy urine poured 
 into the bladder from the kidneys would be more likely 
 to cure Cystitis than if it were injected through the 
 urethra. However, this method may be of value ; but 
 one thing is certain — it fails like all other injections ia 
 certain cases. 
 
 Iodoform has been used locally in Cystitis, and 
 with good effect ; but I regret to say that I have not 
 used it enouo^h to test its merits. 
 
 One great obstacle often met with in using injections, 
 is a tender or inflamed urethra. I will reserve what I 
 have to say on this subject until I take up the diseases 
 of the urethra, but meantime give the following excel- 
 lent suggestion of Braxton Hicks in treating such a 
 
204 TREATMENT OF CYSTITIS. 
 
 complication. When the introduction of the catheter 
 is very painful, he advises carrying it up to the sphinc- 
 ter, and then by gentle yet firm pressure forcing the 
 injection into the bladder. This is a valuable practical 
 point well worth remembering. When the urethra is 
 so tender as to preclude the use of the catheter, I have 
 managed to inject the bladder in the following way : 
 I take a syringe vv^ith a large nozzle, and placing it over 
 the meatus urinarius, and holding it firmly there, force 
 the injection into the bladder. 
 
 A valuable addition to these direct methods of treat- 
 ing the bladder is employed by my friend Dr. Robert 
 Newman, of New York, who has made some useful 
 contributions to the therapeutics of vesical disease. He 
 employs the endoscope of Desormeaux to make the 
 -diagnosis, and makes direct applications to the diseased 
 parts through that instrument. In ulceration, he has 
 l>een very successful in his practice. He applies a solu- 
 tion of the Nitrate of Silver (twenty grains to the drachm 
 of water) to the ulcerated surface, and by carefully 
 regulating the amount, finds that the pain is less than 
 when a weaker solution is used in the ordinary way. 
 I have done the same thing with greater facility by 
 using the endoscope which I have described to you. 
 The instrument is introduced and the ulcerated part 
 found ; the glass tube is drawn out, and the application 
 made directly to the diseased part, through the rubber 
 speculum. 
 
 With all the means of treatment yet described you 
 will be unable to cure some of your worst cases of 
 •Chronic Cystitis. Indeed, you will fail sometimes even 
 
TREATMENT OF CYSTITIS. 205; 
 
 to relieve the suffering. Such unfortunate subjects 
 have usually been set aside as incurable, and even now 
 we have cases which surpass our skill. But a great 
 advance has been made in the treatment of those ob- 
 stinate cases, by using measures to fulfill the chief in- 
 dication in the therapeutics of inflammation — rest. 
 The ereat trouble has been to secure sufficient rest to 
 the bladder. Dr. Emmet has accomplished this by 
 establishing a vesico-vaginal fistula, which maintains 
 complete drainage. Relief is at once secured for the 
 patient, and the inflamed and ulcerated surface, whick 
 is no longer fretted by the urine, heals up in the course 
 of four or six months. The fistula is then closed by 
 the usual operation. This may well be considered a 
 great triumph of science, but unfortunately it is rather 
 too complicated a measure to become general. Making 
 a vesico-vaginal fistula, and then closing it, are opera- 
 tions easily performed by Dr. Sims or Dr. Emmet, with 
 the assistance of trained hospital nurses ; but many of 
 you would find it no easy task. Taking this view of 
 the subject, that plan of treatment ought not to be tried 
 until all other means have failed, and then only by 
 those who have had practice in that department of 
 surgery. 
 
 At the Woman's Hospital of New York, where the 
 best operators, skilled nurses, and constant care were 
 had, the following results were obtained: Cystotomy 
 was performed for the relief of Cystitis in seventeen 
 cases, of which four were cured and thirteen improved. 
 
 It has been found that one great obstacle to cure 
 by this method is the tendency which the artificial 
 
2o6 TREATMEXT OF CYSTITIS. 
 
 opening has to close. Dr. Montrose A. Fallen claims 
 to have overcome this difficulty by operating with the 
 thermo-cautery. I will give you his own description, 
 taken from a paper on this subject, recently read 
 before the New York Obstetrical Society. 
 
 Fig. 20. 
 
 Tiemann's Thermo-cautery.* 
 
 "The main difficulty hitherto has been to keep the 
 incision open after the use of the scissors or knife. 
 Artificial means must be resorted to, such as an India- 
 rubber tube passed from the urethra through the open- 
 ing, which is annoying and painful ; or a glass button 
 introduced, which is difficult to retain, and when re- 
 tained is apt to beget vesical tenesmus. I believe that 
 the use of the actual cautery at a red heat will be found 
 to answer all purposes. If the platinum tip is at a 
 white heat it cuts through too rapidly, and we are apt 
 to have as much hemorrhage as with the knife or scis- 
 sors. Hemorrhage is sometimes quite serious after in- 
 cision of the vesico-vaginal septum, particularly if the 
 scissors or knife strikes the tortuous, enlarged veins of- 
 
 * The mechanism of this instrument is as follows : A hard-rubber bulb is filled with wool and a 
 small quantity of gasoline poured into it. To one end of this reservoir a tube and soft-rubber bulb is at- 
 tached. To the otlier end another tube is attached, which leads to a small metal tube, whiuh passes through 
 the handle and up to a platinum cup-shaped tip. No. i. Fig. 21. By compressing the bulb marked with the 
 arrow, air is forced through the wool, and gasoline vapor is carried forward and projected into the platinum 
 cup. Holding the platinum tip in the flame of a lamp, the gasoline v,ipor is ignited, and heats the cup, 
 and keeps it heated as long as desired. Figures 2, 3 and 4, represent the various forms of platinum tips. 
 
TREATMENT OF CYSTITIS. 207 
 
 ten ramifying upon or under the mucous membrane of 
 the bladder. If the platinum tip of the cautery be heat- 
 -ed to a white heat, it cuts through as rapidly as the 
 knife, and therefore the hemorrhage is to be expected ; 
 besides, the thin pellicle of slough following the white- 
 lieat tip soon peels off, and union might ensue. To 
 avoid both bleeding and contraction, the red-heat tip 
 should be slowly passed along the site of the proposed 
 ■openi^tg, dividiitg first the 7nucous inembrane of the vag- 
 ina, and then resting fo7^ a mo7nent or so, to allow the 
 adjacent vessels to contract and become thrombotic. The 
 submucous connective tissue is then burned, and after- 
 wards the bladder wall itself Extreme delicacy of 
 manipulation is required upon the part of the surgeon, 
 lest he burn directly into the cavity of the bladder, 
 which should be avoided if he wants to make sure of a 
 result that will prevent hemorrhage, contraction, and 
 subsequent union. 
 
 " The care after an operation of this kind, consists in 
 daily cleansing the bladder thoroughly with demulcent 
 warm fluids, such as starch or flaxseed water. The 
 pain in the bladder following the burning, is compara- 
 tively slight, and usually subsides within thirty-six or 
 forty-eight hours." 
 
 Another objection to cystotomy is, that while the 
 patient is relieved from pain she is made distress- 
 ingly uncomfortable by the constant trickling of urine 
 from the fistula. I tried to obviate this trouble to some 
 extent by using a hollow globe pessary, made of hard 
 rubber, with a tube attached to it. The globe is nu- 
 merously perforated with small holes all around, ex- 
 
2o8 TREATMENT OF CYSTITIS. 
 
 cept for about half an inch from where the tube begins. 
 The globe is introduced into the vagina, and the tubq 
 projects through the introitus. The urine collects in 
 the globe, and escapes through the tube ; and by at- 
 taching a piece of flexible tubing to it the urine can be 
 conveyed into a vessel. When the introitus vulvae is 
 small and the sphincter vaginae perfect, this answers 
 very well, especially during the night, when the patient 
 is in the horizontal position. When worn during the 
 day, it is necessary to have a rubber bag attached to 
 the leg of the patient, to act as a receptacle. 
 
 Encouraged by my success with the globe pessary, 
 I had another made, shown in Fig. 21. It is the or- 
 
 r>. r,i 
 
 Skene's Urinal Cup Pessary. 
 
 a. Represents the posterior portion which surrounds the Cervix Uteri; b. The 
 cup ; and c. The tube which conveys the urine from the cup to the urinal. 
 
 dinary Smith's pessary, with an oblong cup on the up- 
 per anterior portion of it, which fits over the fistula, 
 and collects the urine and guides it out to a urinal. 
 In artificial fistula, made in the centre of the vagina, 
 this pessary answers a most valuable purpose. 
 
 I was led to devise this way of relieving patients 
 with vesico-vaginal fistulae by having one under my 
 
TREATMENT OF CYSTITIS. 209 
 
 care who was in no condition to be operated on for the 
 cure of fistula, owing to general ill health. She also 
 had severe Vulvitis, and the urine constantly passing 
 over the inflamed surface drove her almost insane. Her 
 suffering was terrible ; so to relieve her until I could 
 operate I had made the perforated stem globe pessary, 
 or whatever you may see fit to call it. In case you 
 ever should have to make a fistula for the cure of Cys- 
 titis, you can try this method of keeping your patient 
 clean and comfortable. 
 
 I come now to what I believe to be another impor- 
 tant part of the treatment of these obstinate cases. I 
 allude to drainage by means of the self-retaining cath- 
 eter. About four years ago I had a very troublesome 
 case of Cystitis, which I faithfully tried to relieve by all 
 the means at my command, but without success. My 
 patient was obliged to urinate every fifteen or twenty 
 minutes, day and night, and the pain and want of rest 
 were fast wearing her out. In the hope of securing 
 rest at night I introduced a Sims' self-retaining cath- 
 eter, with a rubber tube attached, to convey the water 
 to the urinal. The result was very gratifying. She 
 could sleep well, and gained in health and strength 
 rapidly, and the Cystitis gradually improved. Since 
 that time I have resorted to drainage in all the cases 
 which resisted the ordinary treatment. 
 
 A description of this plan of treatment will be found 
 in the Proceedings of the New York Obstetrical Soci- 
 ety, recorded in the. American yournal of Obstetrics for 
 February, 1874. This method has been successfully 
 practiced by Hunter McGuire ; a complete history of 
 
2IO TREATMENT OF CYSTITIS. 
 
 his case "being published in the Richmond and Louisville- 
 Medical Journal ior June, 1874. Dr. McGuire took a 
 piece of tubing, about twelve inches long, and made 
 holes in about four inches of the end of it with a shoe- 
 maker's punch. He passed a silver tube into the blad- 
 der, and then pushed the gum tube through it until the 
 perforated four inches were coiled in the bladder. 
 This was retained in place by tapes fixed to the tube, 
 and to a bandage passed around the patient's body. 
 The tube became obstructed by mucus, but was easily 
 cleared by injecting warm water through it. But this 
 long piece of tubing being frequently expelled by the 
 bladder, the doctor tried a shorter piece, and found it 
 Avas more readily retained. The patient, after a time, 
 went about and attended to her household duties while 
 wearing the tube, and in about four months made a 
 perfect recovery. 
 
 This method of drainage is an improvement on 
 Sims' catheter, but still is not all that we require. 
 Since my first case I have found that a good self- 
 retaining catheter for this purpose is Holt's, made of 
 perfectly flexible rubber ; and in place of an eye in the 
 point, is cut into strips near the end, and made to 
 spread out like an umbrella. (See Fig. 22.) 
 
 Another instrument for drainage is a catheter de- 
 vised by Professor Goodman, and described in the 
 Richmond and Louisville Medical Journal for Febru- 
 ary, 1869, as being used in the treatment of vesico- 
 vaginal Fistula; and I have recently learned that he 
 has used it for years in treating Cystitis. The follow- 
 ing is Dr. Goodman's description of his catheter: "It 
 
TREATMENT OF CYSTITIS. 
 
 Is about two inches in length, and bent to correspond 
 to the curvature of the urethra ; at the lower or exter- 
 nal end there is a button ten-sixteenths of an inch in 
 
 Pig. 22. 
 
 Holt's SELK-RETAi.NiiNu \^ArHh:TER, and Modification. 
 
 diameter, and at the other or internal end a shouldered, 
 cup-shaped expansion, varying from hve-sixteenths to 
 seven-sixteenths of an inch in diameter, and bevelled 
 on the convex aspect of the instrument, in order to 
 make it easier of introduction, and perforated with a 
 number of small holes. The stem, intervening between 
 these two portions, is one and one-half inch in length, 
 a quarter of an inch in diameter, with as large a bore 
 as is compatible with the requisite strength. This 
 catheter is self-retaining in all positions of the patient ; 
 first, by reason of the bulb at its upper extremity, 
 which passes beyond the urethra into the bladder ; 
 secondly, on account of its curved shape ; and thirdly, 
 in consequence of the button being overlapped and 
 grasped, as it were, by the vulva. At the lower end 
 
212 TREATMENT OF CYSTITIS. 
 
 there Is a slight projection or knob, over which an 
 India-rubber tube may be shpped ; this being inserted 
 into a bottle at night or into a urinal when the patient 
 is up, her person may thus be kept perfectly clean," 
 I like this instrument for the purpose of draining the 
 bladder, when the patient can tolerate it; but I believe 
 that the sharp point of the conical end which rests in 
 the bladder is objectionable, and I can see no good 
 reason for having it so. At any rate, I had the point 
 
 Fig. 23. 
 
 Skene's Modification of Goodivian's Self-retaining Catheter. 
 
 made larger and more round (see Fig. 23), and' found 
 that it answered certainly as well, and was easier to 
 introduce. 
 
 In drainage by any method, you must remember 
 that the instrument should be frequently removed and 
 cleaned, and the bladder may occasionally be washed 
 out at the same time. 
 
 Fortunate it is that we have this method of treat- 
 ment now at our command. By this means we can 
 restore to health and comfort many of those cases which 
 have hitherto been considered hopeless. 
 
 As a preliminary to drainage, you must see that 
 the urethra is healthy. Owing to the presence of Ure- 
 thritis, drainage in this way is often impossible. When 
 there is any tenderness of the urethra the patient can- 
 not tolerate the presence of a catheter. I believe that 
 
TREATMENT OF CYSTITIS. 
 
 213 
 
 this form of treatment would be more popular if this 
 point had not been overlooked. Another method of 
 treatment, having for its ground-work the same princi- 
 ple, viz., drainage, with relief of spasm, is rapid and for- 
 cible dilatation of the urethra. It has been practiced 
 more extensively abroad than in this country. I have 
 given you a full description of the method already, in 
 connection with exploration of the bladder, and I think 
 nothing further need be said. While we have such 
 excellent methods of drainage at our hands, I think it 
 hardly advisable to resort to this procedure, unless 
 • other plans for relief have failed. Despite what has 
 been said to the contrary, incontinence is to be feared, 
 if a sufficiently full and thorough dilatation is accom- 
 plished. In four cases of Cystitis at the Woman's Hos- 
 pital of New York, two were cured and two improved 
 by this treatment — really excellent results. Some 
 .authors claim everything for and nothing against it. 
 Such claims, however, require to be verified by longer 
 experience. 
 
 It should always be borne in mind that in making 
 
 ■ extreme dilatation there is great danger of lacerating 
 the urethra — an accident that is exceedingly unfortu- 
 nate. You might suppose that with due care this 
 
 ■ could be guarded against, but the experience of the 
 most skillful operators (among whom I may mention 
 Thomas Addis Emmet) shows that it will occur when 
 ■every effort is made to prevent it. The dilatability of 
 the urethra varies greatly in different persons, so that 
 what is safe in one will cause complete laceration in 
 .another. It has been found that in some cases the tis- 
 
214 TREA TMENT OF CYSTITIS. 
 
 sues give way suddenly, where the operator was pro- 
 ceeding carefully, and prepared to suspend dilatation 
 when the tissue began to tear. When this laceration 
 occurs, it produces incontinence of urine ; and what is 
 worse, restoration of the urethra does not restore the 
 retaining power of the bladder. Permanent injury is- 
 the result, you observe, at least this has been so in. 
 most of the cases recorded. The only safety, then, 
 is to avoid extreme dilatation. 
 
 When the Cystitis is due to or is accompanied by 
 prolapsus of the bladder, the pessary already described, 
 should be used to keep the organ in place. Sometimes 
 you will find a case where this cannot be accomplished, 
 by any mechanical support. Under these circum- 
 stances elytrorrhaphy is necessary, i, e., a section of the 
 anterior vaginal wall should be removed, and the edges 
 of the wound brought together in the way devised by 
 Dr. Noeggerath, and described in The New York- 
 Medical Record. 
 
 Where there is hemorrhage into the bladder, you, 
 are to follow the rules given you in my last lecture. 
 
 In cases of exfoliation of the whole or a part of the 
 mucous membrane of the bladder, and the organ is 
 evidently trying to expel its contents, the urethra 
 should be sufficiently dilated to allow the mass to 
 pass ; or it may be removed by the forceps, if you can 
 do so without force. After its extraction, antiseptic 
 and disinfectant measures should be resorted to. In- 
 jections of Lime Water, weak solutions of Carbolic 
 Acid or Salicylic Acid should be used, and the orgaa 
 washed out once or twice daily with warm water.. 
 
PROGNOSIS. 215 
 
 Above all, do not allow urine to remain in the tendei 
 organ for any length of time. 
 
 In passing the catheter, especially in cases where 
 the bladder is bound to neighboring organs, be careful 
 to let no air enter, for Winckel has seen Vesical Ca- 
 tarrh follow its introduction, and makes it a point, even 
 after using Rutenberg's apparatus, to wash out the 
 organ with some antiseptic. 
 
 Prognosis. — In Acute Cystitis occurring in a healthy 
 subject, the outlook is good, cure being usually at- 
 tained in from one to three weeks. When occurring in 
 the course of pregnancy, or after delivery, the prog- 
 nosis is not so good, there being a tendency for 
 the disease to become chronic, and, even if cured, it 
 leaves the organ predisposed to inflammation. The 
 prognosis in Diphtheritic and Croupous Cystitis de- 
 pends mainly on the systemic disorder, and is there- 
 fore grave. 
 
 When due to displacements of the gravid uterus, 
 the prognosis will of course depend on the ability to 
 replace the womb. In Cancer of the womb, vagina, 
 anterior vaginal wall, or of the bladder itself, the prog- 
 nosis is the same as in malignant disease generally. In 
 Chronic Cystitis, with ulceration, the prognosis is very 
 serious ; for with the tendency to hemorrhage, exten- 
 sion to the peritoneum, perforation, blood poisoning, 
 with low systemic condition, extension to the renal 
 pelves, and destruction of one or both kidneys, a fatal 
 termination comes sooner or later, and may come when 
 we least expect it. 
 
2 1 6 TREA TMENT OF C YS TITIS. 
 
 About one-half the cases of exfoHation of the vesical 
 mucous membrane have recovered. Gangrenous in- 
 flammation, involving as it usually does all the coats 
 of the bladder, is the most speedily and certainly fatal 
 of all the forms of Cystitis. 
 
 Hygiene. — There are certain points to be consider- 
 ed in the management of all cases where there is a 
 tendency to vesical trouble; where from a complication 
 of circumstances vesical trouble is to be expected; and 
 also where vesical disease already exists. 
 
 In pregnant women, where the pelvic organs are 
 constantly tending to congestion, attention should be 
 given to the patient's circulation : friction to the legs, 
 feet, and arms, daily warm baths, moderate exercise, 
 and astringent or saline vaginal injections should be 
 employed. Upon the least suspicion of malposition of 
 the uterus, that organ should be examined, and if mal- 
 posed, replaced. The diet should be bland and unir- 
 ritating, yet nourishing, and any indigestion corrected 
 as speedily as possible. An occasional saline laxative 
 will prove of use when there is constipation. Tonics 
 will be found serviceable in some instances. 
 
 In women not pregnant, where there is a tendency 
 to vesical disease, the same plan should be followed, 
 Avith the addition of injections of water, as hot as can 
 be borne, into the vagina, every night, as recommended 
 by Dr. Emmet. Not less than a gallon should be 
 used. 
 
 Where, from any cause, retention exists, or there 
 is a tendency thereto, you should draw off the water 
 
CROUPOUS AND DIPHTHERITIC CYSTITIS. 217 
 
 -carefully, with a soft catheter, well soaped, being sure 
 that your catheter is perfectly clean, and that no air is 
 permitted to enter the viscus ; why, I have already 
 told you. Winckel believes that in every institution 
 for lying-in women, each patient should either have a 
 brand-new catheter assigned to her, or one rendered 
 absolutely clean by some efficient chemical process. 
 To the enforcement of this rule Winckel attributes the 
 great exemption from vesical inflammation enjoyed by 
 the patients in the Dresden House for Child-bearing 
 Women. 
 
 I most fully endorse the teaching of this great au- 
 thority. I have seen so much bladder trouble brought 
 on by the careless use of foul catheters, that I have 
 come to look upon clumsy operators and unclean in- 
 struments as one of the most fruitful causes of Cystitis. 
 
 In weakness of the detrusor vesicae (which is not 
 an uncommon affection in pregnant women), Winckel 
 has achieved great success with injections of simple 
 warm or medicated water into the bladder. 
 
 In irritable bladder, with a tendency to conges- 
 tion, a solution of Borax may be injected with good 
 results. 
 
 Everybody, even at the risk of offending company 
 or neglecting important duties, should evacuate the 
 bladder regularly, and never long resist the desire to 
 urinate. 
 
 Croupous and Diphtheritic Cystitis.— Croupous and 
 Diphtheritic disease of the bladder are very rare, and 
 therefore require but a brief notice here. From the 
 
2l8 TREATMENT OF CYSTITIS. 
 
 difficulties that have existed in the way of detecting the 
 exact pathological conditions in diseases of the bladder, 
 we may presume that mild attacks of these affections- 
 have been overlooked or not correctly diagnosticated. 
 But even granting this, we are compelled, from the few 
 recorded cases, to believe that Croup and Diphtheria 
 of the bladder seldom occur, the former never. 
 
 What little exact knowledge we possess on this sub- 
 ject has been obtained to a great extent from post- 
 mortem examinations, and from this statement you will 
 infer, and correctly too, that these diseases, especially 
 Diphtheria, tend to end fatally. 
 
 From the names employed you would naturally 
 suppose that these affections were exactly the same as 
 the diseases of the mucous membrane of the air pas- 
 sages, known as Croup and Diphtheria. Be that as it 
 may, it will suffice for my present purpose to have you 
 understand that in these diseases of the bladder there, 
 is developed an exudation or membrane like that of 
 Croup or Diphtheria. 
 
 The pathology of the local lesions of these two dis- 
 eases differs only in the depth of tissue involved and 
 in the character of the membranous formation. Thus 
 in Croupous Cystitis, the false membrane, while moder- 
 ately adherent, is usually on the surface, covers the 
 whole or most of the mucous membrane of the blad- 
 der, and sometimes portions of the outer genitals, and 
 is fibro-epithelial in structure. 
 
 The Diphtheritic membrane, on the contrary, dips 
 deeply Into the mucous membrane of the bladder, ex- 
 ists usually in scattered j)atches, and is denser and 
 
CROUPOUS AND DIPHTHERITIC CYSTITIS. 219. 
 
 more fibrous in character, its interstices being filled with 
 little rounded cells and some fatty and granular matter. 
 Exfoliation of the affected portions of the vesical, 
 mucous membrane usually results from this Diphtheritic 
 inflammation, as in the analogous affection in the; 
 throat. When the membrane comes away, ulcers of 
 varying size and depth are left to mark its former site. 
 The destructive processes are not alone confined to the 
 mucous and submucous tissues, but in some cases in- 
 volve the muscular coat of the organ. The whole ves- 
 ical surface, not involved in the membranous patching, 
 is of a deep red color, and in some places ecchymotic, 
 especially about the exudation. The inflammation is 
 truly acute, and passes rapidly from the stage of mu- 
 cous exudation to that of epithelial exfoliation and pus. 
 formation. 
 
 Symptoms — The symptoms in no way differ from 
 those of Acute Cystitis, save that as a rule they are- 
 more intense, and the constitutional symptoms are more 
 severe. The nervous system is usually profoundly af- 
 fected. There is pain before, during, and after mic- 
 turition ; pain that may be purely local, felt in the outer 
 genitals, or radiate in all directions. 
 
 When the shreds of broken-down membrane sepa- 
 rate, they may block up the urethra and cause retention 
 and decomposition of urine. Retention, however, may 
 be produced at any time by intense inflammatory tume- 
 faction of the urethra, which is often involved. 
 
 You must not confound this exfoliation of false 
 membrane with the sloughing of the mucous membrane 
 
220 TREATMENT OF CYSTITIS. 
 
 of the bladder caused by pressure from over-distension 
 or very severe inflammation. 
 
 Treatment. — As the symptomatology and treatment 
 of these diseases are very much the same as those of 
 Acute and Chronic Cystitis, it may be best not to 
 enlarge upon them here, as that would involve much 
 useless repetition. 
 
 Keep the patient perfectly quiet, let the diet be 
 the most sustaining, the drinks free and bland, and 
 keep the bladder pretty well emptied. Allay the pain 
 and spasm by the judicious exhibition of narcotics, 
 preferably by the vagina, in suppository. The bladder 
 should be washed out daily with warm water, contain- 
 ing a little of Labarraque's solution or a little Carbolic 
 Acid. Much relief of both pain and spasm will thus be 
 afforded, even when the inflammation is at its highest. 
 
 Tissue shreds should be removed as soon as their 
 presence is ascertained. 
 
 Diagnosis. — Microscopical examination of the urine, 
 but more especially of the tissue shreds, will afford 
 much reliable information. When you find a mem- 
 brane consisting of fibrillae interspersed with numer- 
 ous small nucleated cells, fattily degenerated, and in- 
 volving the superficial mucous or muscular layer, you 
 may set the case down as one of Diphtheritic Cystitis. 
 The urine rarely affords any positive information ; and 
 really it is useless to attempt to make a differential di- 
 agnosis between these diseases and ordinary Cystitis 
 in which there is much destruction of tissue. 
 
EPIDERMOID CONCREMENTS. 2it 
 
 Thus far I have had no opportunity of examining. 
 Croupous or Diphtheritic disease of the bladder with 
 the endoscope, and cannot say how much information 
 could be obtained in this way. I presume that much 
 could be gained by this instrument, and I base this 
 opinion upon the examination of several cases of ca- 
 tarrhal and croupous inflammation of the rectum. In 
 these cases the distinction between catarrh and croup- 
 could be easily and positively made by the endoscopic 
 appearances, and I believe that what has been done in 
 determining rectal disease could be accomplished in 
 diseases of the bladder. 
 
 In these cases the vesical walls are very fragile, and 
 this should be borne in mind in using either catheter or 
 endoscope. This condition would preclude the disten- 
 sion of the bladder with air and examination with Ru- 
 tenberg's apparatus. 
 
 The Prognosis is very grave indeed. 
 
 Cystitis with Epidermoid Concrements. — This is 
 a very rare affection of the bladder, and I only men- 
 tion it to you as a pathological curiosity. Rokitansky 
 supposes it to be due to, or a sequence of, Chronic 
 Cystitis. It consists in an unusually rapid formation 
 of epithelium by the vesical mucous membrane, result- 
 ing in the shedding of quite large white, shining plates 
 or bodies of this caked scale. The following case, 
 related by Lowenson (1862), is thus given by Winckel. 
 The patient spoken of by him, suffered from mitral 
 stenosis, and came into hospital in a moribund condition. 
 
4222 TREA TMENT OF CYSTITIS. 
 
 After death her bladder was found to be enormously 
 dilated. From it were taken a great number of small 
 rounded yellow masses, and lying between, a number of 
 plates of ocherous color, the general appearance being 
 that of yellow pea- soup, with some of the hulls left in. 
 The whole of the internal surface of the bladder was 
 covered with flakes, many of them having these little 
 balls interposed and superimposed. Their diameter 
 varied from one millimetre to one centimetre. These 
 attached flakes were tolerably firm and bright, some- 
 thing like mother of pearl. On the mucous membrane 
 itself, after removal of these flakes, pieces of membrane 
 could be stripped off. Except in these places the 
 mucous membrane seemed all right. The urethra and 
 ureters were normal, but the kidneys were in the con- 
 dition of granular atrophy. 
 
 On microscopic examination it was found that the 
 young, oftentimes fattily degenerated epithelial cells (in 
 the commencement), as they approached the surface, 
 took on gradually all the changes of the very large 
 epidermic cell, becoming unnucleated and granular. 
 The little balls consisted of grains of fat, calciform con- 
 cretions, little nuclei, and epidermic cells. There was 
 considerable stearin but no cholesterin. Reich 
 claims lately, however, to have found the latter in the 
 vesical mucous membrane of a man fifty-six years old, 
 who suffered from catarrh of the bladder. 
 
 Treatment — Of course I have no experience, never 
 having seen a case, but on general principles I would 
 suggest that the treatment would be to relieve any in- 
 
VESICO-URETIIRAL FISSURE. 223 
 
 ilammation or Irritation that may be present, the exhi- 
 bition of alkalies and Arsenic (in small doses) by the 
 mouth, daily washing out of the bladder, removing all 
 scales or plates that form, and the application of a 
 strong alkaline solution to the diseased surface. 
 
 I am unable to give you the symptoms of this dis- 
 ease. The same may be said of the diagnosis. I pre- 
 sume, however, that an examination of the urine would 
 enable us to determine the nature of the trouble. 
 
 Vesico-Urethral Fissure. — Just at this point I 
 think it will be advisable to bring to your notice the 
 subject of Fissure of the neck of the bladder. This 
 affection holds a kind of intermediate position between 
 Cystitis and Urethritis, and, in its symptomatology, 
 bears a marked resemblance to both. I am fully satis- 
 fied that it is often mistaken for inflammation of the 
 bladder or urethra. 
 
 It is only within the last few years that this trouble 
 has been brought to the notice of the profession, and 
 hence there is very little in our literature on the subject 
 On this account I shall be obliged, in describing this 
 disease and its various symptoms, to draw largely 
 from my own observations. This affection has hereto- 
 fore been called Fissure of the neck of the bladder. 
 Were we to name it according to its location, we should 
 say Vesico-urethral Fissure, for its usual site is at the 
 point of junction of the two organs. 
 
 The lesion, as the name indicates, Is a crack or As- 
 sure of the mucous membrane, produced by ulceration. 
 It runs lengthwise on the urethra, and Is situated in one 
 
224 VESICO-URETHRAL FISSURE. 
 
 of the sulci or folds of the membrane, formed by the 
 corrugations which always exist when the urethra is not 
 distended. It is usually spoken of as situated in the 
 vesical neck, but as a rule you will find that two-thirds 
 of it are situated in the urethra, the upper end of it 
 only extending into the bladder. 
 
 It may occur at any part of the circumference of the 
 urethra. In the majority of the cases that I have ex- 
 amined it has been situated on the right anterior side. 
 Those of you who are familiar with fissure of the rec- 
 tum will understand that fissure of the vesical neck 
 is exactly the sam.e in appearance, save that it is 
 much smaller. It is from a quarter to three-eighths of 
 an inch in length, and one or two lines in width at the 
 centre, but tapering off at each end. 
 
 The deepest part has a yellowish gray color, like 
 that of an indolent ulcer, while the edges are red and 
 actually inflamed, like those of an irritable ulcer. 
 When seen through a large endoscope that puts the 
 parts upon the stretch, it may appear freshly torn and 
 bleeding. The edges are usually abrupt, elevated, and 
 indurated, and of a dark or bright red color. This 
 shades off gradually into the normal membrane of the 
 urethra. 
 
 The importance of this lesion depends upon its site. 
 An ulcer or fissure of the same size, if situated in any 
 other portion of the urethra, would cause little suffer- 
 ing beyond a smarting sensation during micturition. 
 But occurring at the union of the bladder and urethra it 
 is submitted to constant though slight pressure, which 
 causes severe and continuous pain. I believe that the 
 
SYMPTOM A TOLOG V. 225 
 
 very great suffering caused by this disease Is due large- 
 ly to the fact that these parts of the bladder and ure- 
 thra are by far the most sensitive, and that the upper 
 portion of the fissure, which extends into the bladder, 
 is exposed to the irritation of the urine, which excites 
 the constant desire to urinate. The pain which is thus 
 produced causes excessive contraction of the urethra 
 and bladder, and this contraction again causes pain ; 
 " the vicious circle," as it is termed, being thus estab- 
 lished. In other words, the cause produces an effect, 
 which in turn acts as a cause, and aggravates the 
 original disorder. 
 
 Symptomatology, — The symptoms of Fissure are a 
 constant desire to urinate, and a feeling of burning 
 pain at the neck of the bladder. There is acute pain 
 both during and immediately after the act of micturi- 
 tion, and severe tenesmus, which causes the patient to 
 make voluntary straining efforts at evacuation after the 
 bladder is empty. Immediately after urination the 
 pain and burning are often intense. After a time it 
 partially subsides, but again commences when a little 
 urine collects in the bladder. 
 
 When the patients resist the desire to urinate (as 
 they often do at night when unwilling to get up), the 
 distress is much aggravated. You will recognize the 
 fact that all the symptoms given are much the same as 
 those presented in Cystitis, and on that account are not 
 reliable guides in diagnosis. Urethritis also gives rise 
 to many of the symptoms named above, and might be 
 mistaken for Urethro-vesical Fissure. 
 
226 VESICO-URETHRAL FISSURE 
 
 There are, however, some points of difference be- 
 tween the symptoms of these three affections that are 
 deserving of notice. In Fissure the pain is, as a rule, 
 more circumscribed than in either Cystitis or Urethritis, 
 and in many cases more acute. Urination in Fissure 
 is always followed by the maximum of pain, while in 
 Cystitis there is a slight sense of relief In Urethritis 
 the greatest pain is experienced during the act of urina- 
 tion ; it then subsides gradually, and is usually absent 
 before the next evacuation of the bladder. 
 
 Diagnosis. — The question of diagnosis will usually 
 rest between Fissure, Urethritis, and Cystitis. The 
 latter can be easily and positively excluded by an ex- 
 amination of the urine. Passing a catheter into the 
 bladder and allowing a little urine to flow through it, 
 will wash away any pus or mucus that may have been 
 ■caught up in its introduction. The remaining urine 
 should be saved for examination, when if Fissure alone 
 exists, it will be found free from all the products of 
 Cystitis. 
 
 The exclusion of Urethritis and the detection of 
 fissure are accomplished by the endoscope, and on the 
 use of this instrument you must rely for a diagnosis. 
 I have already described the method of using my endo- 
 scope, but there are a few points in the examination 
 for Fissure to which I have yet to call your attention. 
 In the first place, you must find the neck of the blad- 
 der exactly, and to accomplish this you must use the 
 instrument when there is, at least, a small quantity of 
 .urine in the orofan. 
 
DIAGNOSIS. 227 
 
 First introduce the tube far enough to be sure that 
 it enters the bladder. Next, pass in the mirror, and, 
 as you do so, you will see that when it enters that part 
 ■of the tube surrounded by urine, it becomes black, i. e., 
 the wall of the urethra (which was reflected as you 
 passed the mirror in) disappears, and nothing can be 
 seen. By slowly withdrawing the mirror the upper 
 end of the urethra will come into view, and by moving 
 it backwards and forwards and turning it round, the 
 whole circumference of the vesico-urethral juncture 
 can be clearly seen, and the fissure distinctly observed. 
 
 The service rendered me by this instrument in 
 studying this affection has been very great. Indeed, I 
 have never been able to detect a Vesico-urethral Fis- 
 sure until I used this endoscope to look for it. I have 
 tried repeatedly to find a fissure with the ordinary 
 •open-tube endoscope, and have invariably failed, and 
 for these reasons : Fissure, as I have told you, lies in 
 a longitudinal sulcus of the mucous membrane, and is 
 hidden from view at the upper or open end of the tube. 
 It can only be brought to light by distending the 
 urethra at the point to be observed, and that cannot be 
 done with the instrument in question. 
 
 Again, when you carry the open tube up to the 
 neck of the bladder, where the fissure is situated, the 
 urine flows into the tube and puts a stop to your ob- 
 servations. 
 
 The description of the appearance of Fissure, al- 
 ready given, was taken from my own observation with 
 the endoscope, and therefore need not be repeated 
 here. 
 
228 VESICO-URETHRAL FISSURE. 
 
 Etiology. — The cause or causes of Fissure here are 
 not well understood. At least, I have not been able- 
 to find anything in my books that is clear and definite 
 on the subject. 
 
 From a careful study of the cases which have come 
 under my observation, I am satisfied that Fissure (or 
 irritable ulcer) is developed from Urethritis. We will 
 suppose that a woman gets Urethritis, from any cause, 
 and that it extends to the neck of the bladder, and dips 
 down into the folds of the mucous membrane. You 
 can well understand that the pressing together of the 
 two infiamed surfaces of the membrane in these folds 
 will increase the irritation and keep up the disease. 
 Urine, mucus, pus, and exfoliated epithelium are liable 
 to lodge in this location, and add very much to the ir- 
 ritation. All this leads to ulceration, and when this is 
 established it remains, with no tendency to recover. 
 Even if the parts were inclined to heal, the irritation of 
 the urine and inflammatory products, as well as the con- 
 traction of the inflamed surfaces upon each other, would 
 prevent, or at least hinder, recovery. 
 
 You can see that an Urethritis might end promptly 
 in recovery (either by the natural tendency of mucous 
 inflammation to return to health, or under the influence 
 of treatment), except at the point of fissure, where the 
 conditions named tend to produce ulceration, and,, 
 when once developed, to keep it up. 
 
 Injuries during confinement, displacements of the 
 bladder, indeed injuries of any kind that are sufficient 
 to cause inflammation at the vesico-urethral juncture,, 
 doubtless tend to the establishment of Fissure. 
 
TREA TMENT. 229 
 
 Bungling" or careless use of the catheter, or injec- 
 tions into the bladder or urethra, might have the same 
 evil effects. 
 
 I suspect, but am not quite sure, that calculi pass- 
 ing along the urethra may be a cause of this trouble. 
 This supposition is based on a case which occurred in 
 my practice. Its history is this. The lady had a 
 vesico-vaginal fistula, and after it was closed she had 
 catarrh of the bladder. During the course of that dis- 
 ease she was taken with hemorrhage, which lasted some 
 days. She then had violent pain in urinating, and 
 passed several lumps, which were composed of mucus 
 and some of the salts of the urine. These pieces were 
 rough, gritty masses, which no doubt scratched her 
 urethra as they passed out. Soon after this she was 
 found to have a fissure that tormented her to an extent 
 beyond description. Dilatation of the urethra and top- 
 ical applications relieved her. 
 
 Treatment. — The subject of the management of 
 Vesico-urethral Fissure is one of interest and impor- 
 tance ; as much so as anything in surgery. On the one 
 hand you have the terrible suffering of your patient, and 
 on the other you have many difficulties to encounter in 
 your efforts to relieve her. The demand for treatment 
 being urgent, and skill in the highest degree being 
 necessary to accomplish a cure, I shall ask your undi- 
 vided attention to a careful study of the subject. 
 
 I must first tell you what you ought not to do in 
 ihese cases, and thereby guard you against making 
 tthem worse instead of better, as it has been my mis- 
 
230 VESICO-URETHRAL FISSURE. 
 
 fortune to do on more than one occasion. As a rulcj, 
 all injections and instillations, such as I have recom- 
 mended in Cystitis, and shall advise you to use in Ure- 
 thritis, do harm in Fissure. I have used injections of 
 mild solutions of Nitrate of Silver, and the application 
 of stronger solutions to the diseased part, with the in- 
 variable result of increasing the spasmodic contraction^ 
 of the bladder and aggravating the suffering of my 
 patients. 
 
 While such applications are useful in inflammation 
 of the bladder and urethra, they do harm in Fissure. 
 This I have repeatedly proved to my own satisfaction, 
 and the facts accord with our experience in other de- 
 partments of practice. You may know that Nitrate of 
 Silver and Nitric Acid have been applied to ulcerations- 
 of the rectum with marked benefit, and without being 
 followed by pain of any account ; but the same applica- 
 tion made to a fissure within the grasp of the sphincter 
 ani does little if any good, and usually increases the 
 suffering of the patient. The same is true of the fis- 
 sure under discussion. When you have made a diag- 
 nosis of Vesico-urethral Fissure, beware of the usual 
 local treatment. At least, do not employ active meas- 
 ures in the way of powerful applications. 
 
 Soothing applications, alterative in their action, are 
 worthy of trial. Exposing the fissure with the fenes- 
 trated speculum, and dusting it over with Calomel or 
 finely pulverized Iodoform, sometimes gives relief. 
 Sub- Nitrate of Bismuth may be used in the same way 
 in the hope of doing good. There is one great Doint. 
 to be remembered in using these remedies, and that is,. 
 
TREA TMENT. 
 
 231 
 
 that if they fail to accompHsh the desired end, they do 
 no harm. 
 
 I have used with benefit the modified stick of Ni- 
 trate of Silver. It consists of one part of Nitrate of 
 Silver to two or three parts of the Nitrate of Potash. 
 Drawing a fine point of this through the fissure causes 
 sharp pain at the time, and is often followed by pain, 
 burning, and tenesmus, which, however, soon subside. 
 In some cases the trouble is relieved by this treatment. 
 Incisinof the fissure in the manner that sursfeons treat 
 the same disease of the anus, has been followed by 
 great relief; but I do not believe that I ever cured a 
 case in this way. For this operation I use a small 
 knife, which is represented in Fig. 24. 
 
 Skene's Fissure Probe and Knife. 
 
 In the employment of this local treatment you will 
 find the most annoying difficulty in getting at the dis- 
 eased spot. You can easily see the fissure through the 
 glass tube of the endoscope, but to expose it and make 
 applications to it are exceedingly difficult tasks. I have 
 tried in a variety of ways to do this, but have found 
 that the only satisfactory way is by means of the endo- 
 scope, consisting of the glass tube, hard-rubber external 
 tube, and mirror, which F fully described in Lecture III. 
 This combination of speculum and mirror answers very 
 well in applying such remedies as Bismuth, Calomel, 
 
232 VESICO-URETHRAL FISSURE. 
 
 and the like ; but you will find that skill and patience 
 are required to touch the fissure with the Nitrate of 
 Silver stick, or to incise the part as already advised. 
 
 The method which I employ is this : — a small silver 
 probe is bent into the shape shown in the figure (Fig. 
 24), and its point is coated with the material to be used. 
 It is then introduced through the speculum and drawn 
 slowly through the fissure, so as to produce superficial 
 cauterization of the ulcerated part. The point of the 
 probe is coated by melting the "modified" stick of 
 Nitrate of Silver in a platinum cup, into which the 
 probe is dipped and the coating allowed to cool. The 
 dipping may be repeated as often as is necessary to 
 get the required amount of caustic or coating on the 
 probe. 
 
 Before applying the caustic you must sponge away 
 any mucus or serum that may be in or about the fis- 
 sure. This you may do by wrapping a piece of absor- 
 bent cotton on the end of a probe, and using it as a 
 sponge. 
 
 You will observe that I condemned caustics in the 
 treatment of Fissure, and still advise cauterizing the 
 diseased part with Nitrate of Silver. The point is 
 simply this : that caustics applied by injection to the 
 neck of the bladder, in which there is fissure, do harm, 
 but caustic applied to the fissure only, does good. 
 
 I have observed that pain follows the application 
 of caustics, but if the diseased portion and nothing more 
 is thoroughly touched, relief follows. The old trouble 
 and pain are, however, liable to return in time. The 
 same may be said of incision, viz., that relief is but tem* 
 
TREATMENT. 233 
 
 porary. I think that the bleeding which Is caused, re- 
 lieves irritation and congestion for a time, but I cannot 
 say that I have ever seen a permanent cure follow this 
 treatment, except in a few cases, where the treatment 
 was begun early in the course of the disease. 
 
 I come now to dilatation of the urethra as a means 
 of relieving Fissure. Although I have left this until 
 the last. It is really the first in importance in the treat- 
 ment of this affection. Indeed, I am inclined to think 
 that it is of much more value in the treatment of Fis- 
 sure, than in that of either Cystitis or Urethritis. 
 
 I have already warned you against the two great 
 dangers of dilating the urethra, viz., rupture and in- 
 continence, and incontinence without rupture. Both 
 accidents are liable to occur in dilating the urethra, but 
 they only occur when the dilatation Is carried to a great 
 extent ; sufficient, at least, to admit the ordinary sized 
 Index finger. 
 
 This extreme dilatation is not necessary in the treat- 
 ment of Fissure. I generally ascertain what sized 
 sound can be passed with ease, and then dilate suffi- 
 ciently to admit one three or four sizes larger. This 
 is usually all that Is necessary. 
 
 Before dilating you must see that the urine is nor- 
 mal in character, or as nearly so as you can make It by 
 general treatment. Then dilate the urethra, keep your 
 patient at rest, and make the urine as bland as possible 
 with diluent drinks. 
 
 In case that Incontinence should follow (though I 
 presume that you will not be troubled In that way), you 
 should at once commence its treatment, by supporting 
 
234 VESICO-URETHRAL FISSURE. 
 
 the urethra in the way that I have advised, viz., with. 
 the pessary for that purpose. I believe that if taken 
 in hand within three or four days after it occurs, the: 
 incontinence can be r"eHeved. 
 
 Should the treatment that I have thus far recom- 
 mended fail, then a vesico-vaginal fistula should be 
 made, the bladder and urethra be washed out, and if 
 need be, medicated. The fistula may be allowed to 
 close of its own accord, as it usually will do. By the 
 time the fistula closes, the fissure will have healed. In 
 making a vesico-vaginal fistula to cure Fissure, the 
 knife or scissors should be used, and not the cautery ; 
 because it is not necessary to maintain the opening in 
 the bladder for a very long time ; and if it closes of its 
 own accord, a very important operation is avoided. 
 
LECTURE VI. 
 
 Neoplasms, Cysts, Tubercle and Carcinoma of the 
 Bladder — Foreign Bodies in the Female Blad- 
 der — Hypertrophy and Atrophy of the Blad- 
 der — Their Etiology, Pathology, Symptomato-- 
 logy and Treatment. 
 
 Gentlemen — 
 
 Owing to the very imperfect facilities for observing^ 
 the internal surface of the bladder during life, the study 
 of vesical tumors, up to a few years ago, was chiefly 
 post-mortem, and of course their therapeutics was. 
 almost nil. At the present time, however, the endo- 
 scope, microscope, and cystotomy, have opened to us. 
 more accurate ways and means of clear diagnosis, 
 and rational and successful treatment. 
 
 We shall consider the subject, for the sake of clear- 
 ness and convenience, under four heads, viz. : — 
 
 I. Mucous Polypi, Polypoid Hypertrophies of 
 the Mucous Membrane, Fibromata, Myo-fibromata. 
 II. Cysts. 
 
 III. Tubercle. 
 
 IV. Malignant Growths, as Sarcoma, Villous Can- 
 •cer, and Scirrhus or True Cancer. 
 
 Tumors of, and deposits in the bladder walls are by 
 
:236 NEOPLASMS OF THE BLADDER. 
 
 no means common, and those of a benign nature are less 
 common than those that are mahgnant. There has 
 been some dispute as to whether some of these neo- 
 plasms are or are not malignant. This is especially 
 the case in regard to the Villous Tumors ; the German 
 and some English authorities ranking them as essential- 
 ly malignant, while some American authors, as Van 
 Buren and Keyes, deny in toto that they have any such 
 property. More will be said of this when I come to the 
 fourth class, where I have placed them. I need only 
 mention here that enchondromata have been found 
 in two instances in the bladder. They were the re- 
 sult of extension from the pelvic bones. 
 
 I. Mucous Polypi and Polypoid Hypertrophies, 
 
 ■while having nearly the same anatomical characters, 
 are really different affections, as regards etiology, 
 ■symptomatology, prognosis, and treatment. 
 
 Mucous Polypi are isolated hypertrophies of the 
 ■mucous membrane, varying in size, and giving rise to 
 trouble only in proportion to their size. They may 
 €xist at birth, or be developed at any time during life, 
 being more common, however, in youth and middle 
 asfe. The mucous membrane coverinsf them is thick- 
 ened and spongy, and that about their base and in their 
 immediate neiehborhood is somewhat thickened and 
 more vascular than normal. If the Polypi are situated 
 at or near the neck, or in other portions of the bladder 
 where their long, narrow pedicles admit of a blocking 
 •of the urethra, the entire mucous membrane of the or- 
 igan suffers, as in all cases of retention and decompo- 
 
POLYPI AND HYPERTROPHIES. 23^ 
 
 sition of urine. If the obstruction be great, and the 
 organ requires spasmodic and irregular muscular effort 
 to empty it, there will be, sooner or later, not only Cys- 
 titis, but muscular as well as mucous hypertrophy. 
 
 They may be as small as the head of a pin or as 
 large as a goose-egg, and consist of hypertrophied and 
 hyperplastic connective tissue, covered by soft, pulpy, 
 very vascular mucous membrane, that bleeds easily on 
 touch. They may coexist with uterine fibroids. Their 
 favorite seat is the posterior wall of the bladder. 
 
 General Polypoid Hypertrophy of the mucous 
 membrane consists in an irregular thickening of the 
 mucous membrane throughout, accompanied, as a rule, 
 by hypertrophy of the muscular and serous coats. 
 There is an increased blood supply, the membrane be- 
 ing a bright red, the capillaries dilated, and the whole 
 bleeding easily on touch. It has something the 
 appearance of fresh granulations. Upon the free sur- 
 face of the mucous membrane, there is, as we should 
 expect, an excessive cell proliferation, these cells being 
 in a transitional condition, z. e., occupying the niche 
 between imperfect and perfect, and not all of the same 
 degree of perfection or imperfection of development. 
 There may be either serous or gelatinous infiltration, 
 giving it a heavy, sodden feel. Upon the surface are 
 often found incrustations of the urinary salts. 
 
 It appears to me that there has been an undue 
 complexity of classification of this subject, especially 
 amongst our German brethren, some of whose differ- 
 ences are too minute to be of any practical value, from 
 either a pathological, diagnostic, or remedial point of 
 
1238 NEOPLASMS OF THE BLADDER. 
 
 view. Tumors which they call villous, or Papilloma 
 Vesicae, are in many if not all respects identical with 
 the so-called Polypoid Hypertrophy of the vesical mu- 
 cous membrane. For all practical purposes they are 
 essentially the same. 
 
 They have been described as enlarged papillae, the 
 vessels of which are dilated, and their walls thinned. 
 They only differ from the Polypoid Hypertrophy in in- 
 crease of vascularity, and the fact that they are usually 
 limited to the trigone. Underlying and about them is 
 a thin, wavy stroma of connective tissue, that becomes 
 increased as the disease advances. 
 
 The surface of these growths varies very much in 
 •different cases ; in some looking like large granulations, 
 in others having more body, being more compact, and 
 looking something like a raspberry or mulberry. Occa- 
 sionally they are slightly pedunculated. Their surface 
 has an epithelium resembling the superficial bladder 
 layer, unless proliferation is very rapid, when the cells 
 lose their identity and take a multiplicity of forms, to 
 which may be attributed, perhaps, their having some- 
 times been mistaken for cancer cells when found in the 
 urine. Fatty degeneration of the topmost cells is by no 
 means uncommon. As the villi increase in size and 
 number, the connective tissue stroma, while increasing 
 about their base, diminishes in the prolongations them- 
 selves, leaving little besides a mass of tortuous, thin- 
 walled, dilated vessels hanging free in the bladder. The 
 rest of the mucous membrane is usually soft and hyper- 
 plastic, and if there be any stoppage to the free outflow 
 of urine, inflammation may coexist, with incrustations. 
 
POLYPI AND HYPERTROPHIES. 239 
 
 and possibly dilatation of the ureters. The muscular 
 coat is also usually slightly hypertrophied. 
 
 Fibroid tumors and myo-fibromata are very rarely 
 found in the bladder. When they do exist they have 
 all the characters of the Fibroma or Myo-fibroma 
 when found elsewhere, and give rise to the same 
 changes in the vesical walls and ureters that other 
 tumors do, viz., retention, with hypertrophy, or dilata- 
 tion, cystitis and ureteritis. They may have their 
 seat in any part of the bladder wall, and occur at any 
 period of life. 
 
 Etiology. — The causes of these neoplasms are very 
 obscure ; indeed no definite facts can be adduced in 
 favor of any of the causes given by the various authors. 
 Some speak of the irritation of calculi, calculous frag- 
 ments, and incrustations. These, however, as you all 
 know, may be readily secondary to and produced by 
 the neoplasm, being the effect rather than the cause. 
 Moreover, it is known by us all that while persons car- 
 rying foreign bodies of various kinds in the bladder for 
 a length of time, are very apt to have Cystitis, neo- 
 plasms are seldom found, and at any rate are very rare 
 in any case. 
 
 Some authors look, with a show of reason, I think, 
 to the irritation of blood transudations into the bladder 
 walls, as a cause. This is borne out by two well-au- 
 thenticated cases occurring, one in the practice of 
 Hutchinson of England, the other in that of Winckel 
 of Germany. The etiology of these neoplasms need.s 
 further careful study, before any cause or causes can 
 
240 NEOPLASMS OF THE BLADDER. 
 
 be pronounced upon with certainty. The. free and 
 intelligent use of the modern means of physical ex- 
 ploration in all affections of the female bladder will in 
 a few years throw much light upon this subject. At 
 least we hope so. 
 
 Symptdmatology. — The symptoms of vesical neo- 
 plasms are divisible into local and constitutional ; the 
 former being by far the more important. The local 
 symptoms, if the tumors be of any size, are those pro- 
 duced by any foreign body in the organ, viz., irritation,, 
 and sooner or later, inflammation. 
 
 Obstruction to urination sometimes occurs when the 
 tumors are in a position to block the urethra, and by 
 the sloughing off or detachment of small fragments, 
 which may or may not be incrusted. These are forced 
 into the urethra and obstruct the outflow of urine. 
 
 Pain in one form or another is almost always pre- 
 sent. It may consist of a simple uneasiness in the hy- 
 pogastric region, or amount to actual pain. It may 
 have its seat in the hypogastric region, in the perineum, 
 or more rarely at the end of the urethra. It may also 
 be felt in the loins, or along the thigh and knee. It is 
 usually more intense, as all the symptoms are, during 
 the menstrual flow. This is not so in all cases. 
 
 Frequent urination and vesical tenesmus are, as a 
 rule, present, but are not proportionate to the size of 
 the tumor ; a very small neoplasm often giving rise to 
 most intense spasm. 
 
 Hemorrhage is by no means infrequent, and in 
 some cases is very severe, and not readily checked ; in 
 
POLYPI AND HYPERTROPHIES. 241 
 
 Others it is slight, simply tinging the urine or imparting 
 to it a smoky appearance, that is characteristic of the 
 presence of a small amount of blood in an acid urine. 
 When the hemorrhage is extensive, and the bladder is 
 distended by the fluid or clotted blood, retention of 
 urine is apt to occur, and sometimes obstructive sup- 
 pression, that may lead to most serious results. 
 
 Hsematuria is as liable to occur with the benign as 
 with the malignant growths, and consequently is of 
 little value in differential diagnosis. The effects of pro- 
 longed or repeated hemorrhage upon the constitution 
 are often most serious, and the patients are apt to be 
 anaemic and also cachectic in appearance. 
 
 The presence of the foreign body in the organ 
 soon gives rise to inflammation, which is seriously ag- 
 gravated if retention accompany it. The urine is 
 found loaded with mucus, muco-purulent or purulent 
 matter, epithelial scales, tissue shreds, bits of tumor^ 
 and the Triple and Amorphous Phosphates. 
 
 Intense and repeated vesical tenesmus aggravates 
 the inflamed condition of the membrane, and after a 
 time leads to muscular hypertrophy and increased 
 hemorrhage. 
 
 In these cases, as in Cystitis from any other cause,, 
 dilatation of the ureters, with a traveling upwards of 
 the inflammation and destruction of the kidney, may 
 result. This dilatation and the evil after-results are 
 more apt to occur if the neoplasm be of sufficient size 
 to obstruct the free outflow of urine, as at every spas- 
 modic and forcible contraction of the hypertrophied 
 organ some urine is dammed back in the ureters, di- 
 
242 NEOPLASMS OF THE BLADDER. 
 
 lating them gradually. When the ureteric openings 
 are dilated, so that urine regurgitates at each vesical 
 contraction, serious lesions result, as Ureteritis, Pyo- 
 nephrosis, Renal Abscess, or, if the process be slow, 
 gradual Renal Atrophy, Uraemia, and finally death. 
 
 The general system may or may not suffer se- 
 verely for a long time. In most cases it does. The 
 usual train of symptoms, such as loss of sleep, digestive 
 disorder, sweating, and blood contamination, are devel- 
 oped in regular order. The patients become thin, and 
 have a worn, anxious expression, and, as I have al- 
 ready said, are apt to be both anaemic and cachectic. 
 If renal troubles complicate this affection, casts, 
 
 epithelium, and albumen may appear in the urine. 
 In Renal Abscess, Atrophy, or Pyo-nephrosis, however, 
 the urine may be examined for weeks without showing 
 
 any albumen, casts, or epithelium, there being simply 
 
 an abundance of pus. 
 
 Diagnosis The diagnosis of vesical neoplasms is 
 
 made chiefly by physical signs. The methods em- 
 ployed In their Investigation we will arrange under two 
 heads. 
 
 Direct. — Speculum, Endoscope, Curette, Catheter, 
 Palpation. 
 
 Indirect. — Urine. 
 
 Direct. — An intelligent employment of the meth- 
 ods classed under the first head is all that is neces- 
 sary to make a clear diagnosis in some cases. The 
 use of the endoscope will show you at once the ap- 
 
POLYPI AND HYPERTROPHIES. 243 
 
 pearance of the tumor, if it is favorably located, and 
 scraping away a little with the curette (through the 
 speculum), you may discover its nature by a micro- 
 scopical examination. 
 
 The use of the catheter or finger in the bladder, or 
 one in the bladder and the other in the vagina, may be 
 resorted to in cases where the diagnosis is difficult. 
 But these are extremely painful manipulations, are not 
 free from danger, and, consequently, should not be re- 
 sorted to unless you fail by other means. 
 
 Indirect. — An examination of the urine in these 
 •cases will lead you to suspect the presence of some 
 neoplasm in the bladder, from the occurrence of tissue 
 shreds and bits of the tumor in this fluid. A piece of 
 tumor will sometimes become detached and be expelled 
 with the urine, and if you are on the watch you may 
 find it. This can be placed under the microscope, and 
 "by examining it you may be able to tell exactly what 
 ^kind of a growth you have to deal with. 
 
 Prognosis. — With our present means for exploring 
 and operating upon the inside of the female bladder, 
 the prognosis of benign neoplasms is very good, if the 
 operation for removal be performed early enough in 
 the disease. Operation, however, at any time gives 
 promise of good result. 
 
 There is danger of relapse, as we learn from the 
 •cases of Simon, Hutchinson, and others. If the opera- 
 tion be carefully done, even incontinence of urine may 
 be avoided, and complete and permanent recovery fol- 
 
244 NEOPLASMS 01 THE BLADDER. 
 
 low. Without operation patients have lived as long as-, 
 nineteen years, in some cases suffering but little ; and 
 it may be well to tell you that not all of these cases- 
 are accompanied by Cystitis, a little pus and blood in. 
 the urine at intervals, with occasional fragments of 
 tumor, being all that is found. 
 
 Treatment. — There is really but one form of treat- 
 ment for these benign neoplasms, viz., removal. The- 
 method will differ with the size of the growth. If the- 
 tumor be not of large size, it may be seen, reached, 
 and removed through the urethra. This may be ac- 
 complished by twisting it off by means of a pair of 
 forceps, ligating its pedicle, and allowing it to slough, 
 off, or by passing the wire of the galvano-cautery^ 
 around it. If the pedicle be not sufficiently distinct, 
 or the mass too soft to come away in whole, it may be 
 broken down and removed in pieces, either by the 
 finger and forceps or by the curette and forceps. The 
 hemorrhage, which as a rule is not great, may be con- 
 trolled by injections of iced water, ice to the pubes, and 
 sometimes by tamponing the vagina. Some operators 
 have found it necessary to apply directly to the bleed- 
 ing surface the Liquor Ferri Sesqui-Chloridi (Brax- 
 ton Hicks). 
 
 The after-treatment consists in washing out the 
 organ thoroughly yet carefully with warm water, to 
 which may be added Salicylic Acid (i part to 60). 
 The pain may be controlled by Opium, either by the 
 mouth or rectum. The urine should be kept slightly 
 alkalized and under no circumstances allowed to re- 
 
CYSTS. 24s 
 
 main in the bladder long enough to decompose and 
 irritate or over-distend it. 
 
 If the tumors are too large to admit of removal 
 per urethram, Simon's operation should be resorted to. 
 Also in cases where the tumor is so situated as to be 
 beyond the operator's reach through the urethra. I 
 have already fully described this operation. A T inci- 
 sion is made into the anterior vaginal wall, the bladder 
 opened, inverted through the opening, and the tumor 
 is thus brought into easy position for any operative 
 procedure. When removed, its base may be cauter- 
 ized and the bladder replaced. When the surface has 
 entirely healed, the wound in the vesico-vaginal sep- 
 tum may be closed. Union soon takes place in most 
 of these cases, if not interfered with. The after-treat- 
 ment should be the same as when the lumor is re- 
 moved through the urethra. 
 
 I need hardly remind you that when the general 
 system is cachectic, it should be attended to. 
 
 II. Cysts of the Bladder. — This is leally a very rare 
 affection. That Cysts ever originate in the bladder is 
 ■doubted by some and denied by others. In most cases 
 where they are found in this organ, they can be traced 
 to the bursting or ulceration of dermoid Cysts of the 
 ovary into it, giving rise to the presence of hair, teeth, 
 and other tissues in this viscus. These things are never 
 found there unless such a Cyst has opened into the 
 bladder. The contents of these dermoid Cysts may 
 'become nuclei for calculi, and lead to serious trouble. 
 
 I think that there can be no doubt but that some 
 
246 NEOPLASMS OF THE BLADDER. 
 
 of the Cysts found in this organ have their origin there- 
 Mucous follicles certainly do exist, are liable ,to have- 
 their orifices blocked or occluded, and by secretion 
 behind the point of obstruction gradually form a Cyst. 
 Interesting cases where the Cysts evidently had their- 
 origin in the bladder itself are related by Paget, Liston, 
 Campa and Erichsen. 
 
 Cysts of the ureters and urachal Cysts may open 
 into the bladder. Hydatid Cysts have been found, but 
 are less frequently seen in this country than in almost. 
 any other. Iceland is especially cursed with them, 
 about one-sixth of the population suffering from them 
 in some part of the body. They may appear in the 
 urine, white and pearly in appearance, and are diag- 
 nosticated by the microscopical appearance of the 
 hooklets of the echinococci. 
 
 Treatment. — These Cysts or their contents, if giving 
 rise to any trouble, should be treated in the same man- 
 ner as the neoplasms of which I have just spoken. 
 
 In the treatment of hydatid cysts, injections of 
 iodine have been especially recommended. Having 
 never had occasion to use it for this purpose, I can say 
 very little for or against it. 
 
 III. Tubercle of the Bladder. — Tubercle of the fe- 
 male bladder is a comparatively rare affection. Win- 
 ckel of Germany, in 2505 autopsies, found it but four 
 times. Though not often existing as an accompani- 
 ment of Pulmonary Tuberculosis, it does not occur 
 alone, but is usually accompanied by similar deposits, 
 in the intestines, kidneys, liver, and elsewhere. It is- 
 
TUBERCLE. 247 
 
 usually found in early life, though cases have been 
 given where it occurred as late as the sixty-fifth year. 
 
 The favorite site for its first appearance is at the 
 vesical neck, or about the meatus urinarius ; these 
 places being rich in minute glands and follicles. The 
 deposits appear as minute gray or yellowish white 
 points on a red, indurated base. After a time, owing 
 to their coalescing and breaking down, large spots of 
 ulceration result, surrounded by a puriform catarrh. 
 
 With these deposits in the bladder, ws are very apt 
 to have the same in the kidneys and ureters, giving 
 rise to destruction of the former and Tubercular Pyeli- 
 tis in the latter. 
 
 Symptoms. — The symptoms are at first those of 
 irritation, and later of true Cystitis, with ulceration, 
 induration, and hypertrophy, or of stone. 
 
 Diagnosis. — The diagnosis may be made by means 
 of the endoscope, if you have opportunity to make 
 early and repeated examinations. If you chance to see 
 the deposits, and watch them going on to ulceration, 
 the diagnosis is not difficult. The history of the case 
 and the presence of the tubercular diathesis will also 
 aid you in your final conclusions. The urine at most 
 gives a granular matter mixed with the pus of Cystitis, 
 or contains cheesy matter and elastic fibres. 
 
 Prognosis. — The prognosis is bad, as there usually 
 exists serious trouble of the same nature elsewhere, 
 and as local treatment accomplishes very little, the 
 
248 NEOPLASMS OF THE BLADDER. 
 
 •end comes much sooner if the kidneys and ureters 
 are involved in the disease. 
 
 Treatment. — Local treatment is out of the question, 
 except such as may allay the irritation or inflammation 
 to a certain extent, and prevent undue pain and spasm. 
 This is not readily done. Daily cleansing of the vis- 
 cus with warm water, Opium and Belladonna supposi- 
 tories, or enemata of Atropine, are the best. 
 
 Warmth, attention to diet, general tonics, Cod Liver 
 Oil, and the various remedies used in Phthisis Pulmo- 
 nalis, should be given. 
 
 IV. Carcinoma of the Bladder. — Vesical Carcinoma 
 is not a common disease, although occurring more often 
 than the benign growths. Carcinoma, here, is usual- 
 ly secondary, and may be of diflerent varieties, as 
 hard or scirrhus, encephaloid, epithelial, villous, 
 and even colloid cancer. Chronic or scirrhus, 
 colloid, and epithelioma are very rare ; encephaloid 
 and villous are more common. 
 
 Diagnosis. — The only means of making an abso- 
 lute diagnosis is by using the endoscope and removing 
 a bit of the tumor with the curette, and submitting it to 
 a microscopical examination. Villous and Scirrhus 
 may exist either as distinct tumors or as diffused in- 
 durations. The Encephaloid usually grows rapidly, 
 and is very soft and easily broken down. I have 
 already told you that Cancer of neighboring organs 
 may open into the bladder and produce most serious 
 
CARCINOMA. 249 
 
 results, sooner or later involving the bladder tissue in 
 the destructive process. In any case, adhesion to the 
 neighboring organs takes place, and the disease is 
 liable to extend. Thrombosis of the veins of the vesi- 
 cal neck is apt to occur, and lead to embolism else- 
 where. Peritonitis is a frequent accompaniment. 
 
 The favorite seat of Cancer, especially of the Villous 
 form, is at the trigone. Some authors deny the existence 
 of Villous Cancer, saying that it is simply a luxuriant 
 growth of vesical papilloma, and base their non- 
 cancerous ideas on the fact that " There is nothinsf 
 cancerous about their structure. They never lead to 
 secondary cancerous deposits elsewhere. They do 
 not spontaneously ulcerate. .The lymphatic glands are 
 not implicated. There is no characteristic cachexia. 
 When they kill, death seems due purely to loss of 
 blood and exhaustion from pain." Any form of 
 cancer may be covered with a villous fungoid mass. 
 
 Most German authors claim that sarcoma is 
 malignant, but we do not regard them as cancerous. 
 The only case recorded was one in a female who 
 died during its removal. It was lobular and pedicu- 
 lated. 
 
 Symptoms.— The symptoms are the same as those 
 of the benign tumors in the bladder, differing only in 
 the greater extent and severity of the pain, and, as a 
 rule, less hemorrhage. The condition of the general 
 system is usually low, the patient soon becoming feeble 
 and cachectic. Cancerous deposit in the kidney, and 
 •extension of the inflammation up the ureters, may pro- 
 duce renal destruction and consequent Uraemia. 
 
250 NEOPLASMS OF THE BLADDER. 
 
 Treatment. — If the disease is not too far advanced^ 
 extirpation or breaking down of the tumor may be 
 advisable, but except in the case of epithehoma and 
 the so-called Villous Cancer, but little good is to be 
 hoped for. 
 
 When their removal is not advisable, we must look- 
 to narcotics and tonics to prolong the patient's life, 
 and relieve the intense pain and tenesmus. 
 
 If the tumor is generally distributed throughout the 
 bladder, or has its origin in a neighboring organ, ex- 
 tirpation is out of the question. 
 
 Foreign Bodies in the Female Bladder. — Foreign 
 bodies found in the female bladder are divided into 
 three classes, by Winckel, as follows : — 
 
 1st. — Those that come from the body, entering the 
 bladder by perforation. 
 
 2d. — Those which have their origfin in the bladder.. 
 
 3d- — Those that are introduced from without. 
 
 We will adopt this classification, believing it to be 
 the most natural and convenient. 
 
 1st. Those that Come from the Body. — I have 
 already spoken to you of some bodies that find their 
 way into the bladder by perforation of its walls, as 
 cysts of the ovary, and hydatids. Various parts of the 
 fcetus have found their way into the bladder, by ulcer- 
 ation in extra-uterine pregnancy ; and pieces of ulcer- 
 ated intestine, masses of fseces, faecal concretions, and 
 gall concretions, are some of the curious things that 
 have been found in this organ. In gunshot and other 
 
FOREIGN BODIES IN THE FEMALE BLADDER. 251 
 
 injuries to the pelvic bones, osseous splinters have 
 found their way into the viscus and been evacuated, 
 through the urethra, or into the vagina or rectum by 
 ulceration, or have remained, forming nuclei for cal- 
 culi. 
 
 Various parasites may penetrate the walls from 
 the immediate tissue or neighboring organs, or come 
 down from the kidneys, as the Echinococci, already 
 spoken of; the Distoma Haematobium, the Filaria- 
 Sanguinis Hominis, and Leptothrix. Joints of 
 tape-worm, the Ascaris Lumbricoides, and the thread 
 or seat worms have also been found here, enterine 
 either through a fistulous opening existing between the 
 bladder and intestine, or by crawling in through the 
 urethra. 
 
 In acute destructive change in the kidneys (Pyo- 
 nephrosis and Abscess), pieces of renal tissue are not 
 infrequently carried down into the bladder, and may, 
 by lamellar incrustation with the urinary salts, result 
 in the formation of calculi. Of themselves they give 
 rise to very little if any irritation, and are consequently^ 
 of no importance save in relation to the destructive 
 changes going on in the kidney, of which they tell the 
 story. 
 
 Renal calculi may become dislodged and be swept 
 down into the bladder, there to enlarge by further in- 
 crustations or to pass out through the urethra. 
 
 Symptoms — The symptoms of the various foreign, 
 bodies in the bladder differ only in degree. They are 
 at first those of irritation, later those of acute or sub- 
 
252 NEOPLASMS OF THE BLADDER. 
 
 acute inflammation. Bodies round, smooth and soft, 
 of course are less irritant than rough or sharp bodies, 
 Cysts, therefore, bits of flesh and their Hke, as a rule, 
 give rise to no very severe symptoms, while splinters of 
 bone and calculi occasion much more severe manifes- 
 tations. Pain and tenesmus will vary with the charac- 
 ter of the offending body. If the mucous surface be 
 abraded or torn, Hsematuria will result ; and if the 
 body remains in the organ and continues to irritate it, 
 . Cystitis will follow, and the patient suffer increased 
 agony. 
 
 The extension of the inflammation upwards, and 
 involvement of one or both kidneys, will give rise to 
 pain in the back, hectic fever, partial or total suppres- 
 sion of urine, and consequent ursemic symptoms, end- 
 ing fatally. 
 
 The urine shows the various appearances of Cysti- 
 tis, with which you are familiar, as also signs of renal 
 involvement, if such be present. 
 
 Treatment. — Any foreign body, when known to be 
 present in the bladder, should be removed at as early a 
 •date as possible. In the adult female this may be 
 readily accomplished by dilatation of the urethra, or 
 if the body be too large, by Simon's vesico-vaginal 
 section. 
 
 In cases of fistulous communication between the 
 bladder and intestine or other organ, an attempt should 
 be made, in the manner already spoken of, to close the 
 opening. 
 
 Echinococci and other parasites should be treated 
 
BODIES ORIGINA TED IN THE BLADDER. 2$^ 
 
 with the various remedies recommended for their de- 
 struction elsewhere, always, however, removin^j the 
 offending body from the bladder first, and trying to 
 prevent further invasion by proper medication. 
 
 If Cystitis be present, you will attend to that in the 
 prescribed way. 
 
 We come now to the second class. 
 
 2d. Bodies Having their Origin in the Bladder 
 Itself. — Under this head come Calculi, which, as you 
 know, may be of various kinds, as Uric Acid, Triple 
 and Amorphous Phosphates, Oxalate of Lime, or 
 Cystine. The latter are quite rare. Again, the Cal- 
 culi may consist of more than one of these ingredients. 
 
 Time will not allow me to enter into the extensive 
 field embracing the etiology and treatment of stone. 
 For a comprehensive study of this matter, I must refer 
 you to any of the many excellent works on that 
 subject. 
 
 Calculus. — I shall only speak to you of one or twO' 
 points that are of especial interest in the study of dis- 
 ease of the female bladder. Stone in the bladder is 
 not so common among women as among men. This, 
 I presume, is owing to the large and easily dilatable 
 urethra of the female, which permits small renal Cal- 
 culi to pass out ; Calculi of the same size in the male 
 being retained in the bladder, and serving as nuclei 
 for large Calculi. 
 
 The causes of stone in the bladder in both sexes 
 are about the same, and so we need not dwell long on 
 
-254 NEOPLASMS OF THE BLADDER. 
 
 this part of the subject. I may call your attention to 
 one cause of the formation of stone in the bladder of 
 the female. In Cystocele, a mass of mucus or shreds 
 of membrane and Triple and Amorphous Phosphates 
 gradually collect in this abnormal pouch, and form 
 a nucleus for stone. It is a curious fact, too, that 
 women are particularly liable to have stone after the 
 operation for closure of Vesico-vaginal Fistula. There 
 has been considerable discussion of late as to whether 
 Calculi discovered soon after this operation existed un- 
 observed in the bladder before the operation, or were 
 formed rapidly after it. Henry F. Campbell, M.D., 
 of Virginia, relates one case in favor of the former 
 view, and Dr. T. A. Emmet several in favor of the 
 latter. 
 
 The belief has been advanced that irritation In the 
 bladder modifies the urinary secretion sufficiently to 
 cause deposit of the urinary salts, and thus account 
 for the formation of stone after the operation for fistula. 
 It Is claimed that reflex nerve action is excited by the 
 operation, the Inflammatory action about the edges of 
 the wound, or by Cystitis, already existing. 
 
 This idea that the reflex nerve Influence modifies the 
 urinary secretion sufficiently to result in the formation 
 of stone In these cases, is, I think, hardly tenable ; 
 for In many hundreds of cases of Cystitis, where the 
 reflex action does undoubtedly exist, no stone Is 
 formed. Then, too, the secretion Is as a rule ren- 
 dered more watery. Instead of concentrated, a con- 
 dition in which precipitation of the urinary salts would 
 be very unlikely to take place. 
 
BODIES ORIGINATED IN THE BLADDER. 255 
 
 A middle course on this question seems to me to 
 be the most rational, and stones found after operations 
 for closing fistula might be due to any one of three 
 causes. 
 
 i^d) Stone already existing in the bladder, escaping 
 detection by being pocketed, or so small as to lie be- 
 neath a mucous fold, and rapidly increasing in size after 
 operation, due to the retention of the salts of the urine 
 (deposited by decomposition) that formerly escaped by 
 means of the fistula. 
 
 {b) Calculi, small or large, existing in the kidneys 
 or renal pelves, and washed down after the operation 
 by the increased flow of limpid urine : these, too, in- 
 creasing in size by incrustation. 
 
 {c) Stones, the formation of which commences di- 
 rectly after closure of the wound, due partly to retained 
 products of decomposition, possibly to modified secre- 
 tion, to small nuclei swept down from the kidney, or, 
 much more likely, to nuclei of pieces of mucus, shreds 
 of membrane, or possibly incrustations on one or all 
 of the sutures. 
 
 Symptoms. — The symptoms are simply those of a 
 foreign body in the bladder, varying with the size, 
 shape, and number of the stones, as also their rough- 
 ness of surface. Frequent urination, tenesmus, pain 
 both before, during and after urination, sometimes in- 
 continence, and always more or less Cystitis, Hsema- 
 turia is not at all infrequent, and the urine presents all 
 the characters of bladder inflammation, as shown by 
 the presence in it of pus, epithelium, and, sooner or 
 
256 NEOPLASMS OF THE BLADDER. 
 
 later, numerous crystals of the Triple and Amorphous' 
 Phosphates. 
 
 The constitution suffers from the constant pain and 
 frequent urination, and the patient gives all the symp- 
 toms of a severe Cystitis. 
 
 Prognosis. — The prognosis in vesical Calculi ia 
 women is good, provided the kidneys be not seriously 
 disordered. The Cystitis usually disappears soon after 
 removal of the foreign body, under proper treatment ; 
 and even if renal disease exists, it may also subside. 
 
 Diagnosis. — This is comparatively easy in the fe- 
 male bladder, for between the judicious use of the sound, 
 conjoined manipulation (with the finger in vagina and 
 sound in bladder), and the bladder speculum, a stone 
 can hardly escape detection unless it be completely 
 encysted. 
 
 Treatment — The female bladder presents an invit- 
 ing field for experiments on the treatment of stone by 
 solvents ; but as the operation here is so easy and its 
 results so good, it seems hardly justifiable to recom- 
 mend any other method of treatment. In patients, 
 however, who object to the operation, it may be tried. 
 For a full and interesting account of experiments and 
 statistics on the solvent method, I refer you to Mr. 
 Roberts' most excellent work on Urinary and Renal 
 Diseases. 
 
 The stone being found, and its size determined, 
 you may either remove it by cystotomy or crush it. 
 
BODIES INTRODUCED INTO THE BLADDER. 257 
 
 If the stone be small and soft, it may be advisable to 
 crush it, washing out the fragments through the open 
 speculum in the moderately dilated urethra, thus sav- 
 ing the urethral mucous membrane from laceration by 
 the sharp fragments. 
 
 If much Cystitis be present, however, or if the stone 
 be large, it is advisable to perform Vaginal Cystotomy. 
 In this way a stone of large size may be removed from 
 any part of the bladder, and an opening for drainage 
 is left to act beneficially on the inflamed organ by 
 giving vent to the urine and its sediment. The blad- 
 der should be carefully washed out daily with a warm 
 solution of Salicylic Acid (i to 600 or i to 400). If 
 drainage is desired, care must be taken to keep the 
 incision open, for it closes very readily. 
 
 I have spoken to you several times already as to 
 how the operation of Vaginal Cystotomy should be 
 performed. Emmet dwells especially and justly on the 
 necessity of fixing the vesico-vaginal wall firmly with 
 a tenaculum before commencing the incision, which 
 may be made with either a knife or scissors. Calculus 
 or calculi in the bladder, if interfering with labor, or if 
 liable to be caught between the child's head and the 
 pubes, should, if possible, be pushed up out of the way* 
 This is seldom successful, and as much damage may 
 be done the bladder by the crushing of its walls, it is 
 best to puncture and remove the stone at once. 
 
 3d. Foreign Bodies Introduced into the Bladder. — 
 
 It may be truly said that " their name is legion," for 
 in the literature of the subject we find recorded a most 
 
258 NEOPLASMS OF THE BLADDER. 
 
 numerous and diverse list of objects found in the blad- 
 der of the female. Some of these objects were forced 
 into the bladder by accidents, such as falls or blows ; 
 others were intentionally introduced into the urethra 
 for the purpose of masturbating, and then pushed or 
 drawn into the bladder. The same may occur in auto- 
 catheterization, the instrument being sometimes broken 
 off in, and at others, drawn bodily into the viscus. 
 
 Hysterical and foolish women, with or without the 
 intention of masturbating, have passed all manner of 
 things into the bladder, as pins, needles, matches, sand, 
 charcoal, bits of glass, bodkins, and tooth-brush han- 
 dles. 
 
 Masturbators have also forced in various articles, 
 such as twigs, small wax candles, penholders, nails, 
 pencils, and the like. Catheters and clay-pipe stems, 
 that have been used for purposes of catheterization, 
 have been broken off and left in the bladder. 
 
 Pessaries, which have been badly fitted or worn too 
 long, have passed by ulceration from the vagina into 
 the bladder. 
 
 Symptoms. — The symptoms need not be given 
 you in detail, as they are the same as those caused by 
 any foreign body, usually aggravated, however, if the 
 body be sharp and have jagged edges. Bleeding is 
 not uncommon, and pain varies in amount and severity 
 with the kind, size, and shape of the foreign body. 
 Hysterical women have been known to conceal the 
 pain and tenesmus for a long time. If the bodies be 
 •.small and blunt, they may give rise to but little pain or 
 
HYPERTROPHY OF THE BLADDER. 259 
 
 tenesmus, and remaining in the bladder undisturbed, 
 form nuclei for calculi, or be thoroughly incrusted. I 
 doubt if a modification of the urinary secretion by re- 
 flex nerve influence (excited by these bodies) is neces- 
 sary to cause incrustation or form calculi. The hyper- 
 secretion of mucus and decomposition of urine are all 
 that is required. 
 
 Treatment. — The treatment is summed up in two 
 words — remove it. This must first be tried by the ure- 
 thra. A pair of forceps (those known as the alligator 
 forceps being the best) are guided to the object w^hich 
 is to be seized and removed. If this is difficult, you 
 may operate through the speculum. If the bodies be 
 small, they may possibly be washed out. If they are 
 so situated that their removal by the urethra is impos- 
 sible, you may perform Vaginal Cystotomy, and re- 
 move them, using proper after-treatment. 
 
 Hjrpertrophy of the Bladder. — Hypertrophy of the 
 bladder may be partial or total; may be confined to 
 the muscular, mucous, or connective tissue. In using 
 the term hypertrophy of the bladder, we usually refer 
 to an increased thickness of the mtisczcla?^ walls alone. 
 There usually co-exists with this condition (which is 
 partly hypertrophy, partly hyperplasia) increase in 
 thickness of the various other structures of the organ. 
 This may or may not be the case, and when existing 
 it is more hyperplasia than hypertrophy. The terms 
 partial and total have been used to convey the idea of 
 •hypertrophy of a part or parts of the muscular tissue, 
 
26o HYPERTROPHY OF THE BLADDER. 
 
 and do not usually refer to the number of coats involv- 
 ed. The truth is, however, that one part of the mus- 
 cular tissue of the organ seldom becomes hypertro- 
 phied to any extent without involving the other parts ^ 
 the increase in one part simply being greater than in 
 another. 
 
 This affection is much less frequent in the female 
 than in the male, owing to her exemption from the 
 more common causes of it. Any obstruction to the 
 outflow of urine, as tumors of the urethra or bladder,, 
 partly or wholly blocking the passage, Cystocele, by 
 preventing complete evacuation, inflammatory or nerv- 
 ous troubles, causing unusually active muscular con- 
 traction continuing for some time, all may produce 
 muscular hypertrophy. Inflammation of the mucous- 
 membrane is almost always present ; sooner or later,- 
 that membrane becomes, to a certain extent, thickened^ 
 and may go as far as the production of tufty, polypoid 
 hyperplasia. Civiale mentions hypertrophy, chiefly 
 of the anterior vesical wall, and due to chronic inflam- 
 mation or tubercular infiltration — evidently not simple 
 hypertrophy. 
 
 As the production of Hypertrophy is almost always 
 due to some obstruction to the outflow of the urine, di- 
 latation after a time occurs, and we then have Eccen- 
 tric Hypertrophy. When dilatation does not occur,, 
 we have Centric Hypertrophy. In these cases of 
 muscular hypertrophy, in which great force is required 
 to expel the urine, pouches are sometimes formed, usu- 
 ally at the inferior fundus, caused by the pushing of the 
 mucous membrane between the enlarged muscular 
 
HYPERTROPHY OF THE BLADDER. 261 
 
 £bres. These diverticula are comparatively rare in 
 the female. A sagging or dislocation of the entire 
 posterior inferior bladder wall need not be discussed 
 here, as it has been already disposed of 
 
 Symptoms. — In centric Hypertrophy there is 
 usually vesical spasm, some pain, and forcible ejection 
 of urine. A certain amount of Cystitis almost always 
 accompanies this affection, and surely aggravates the 
 original disorder, by which it is itself further aggrava- 
 ted. In the eccentric form the symptoms are almost 
 the same, there being sometimes superadded those of 
 •over-distension. 
 
 Diagnosis — This is readily made by introducing 
 the finger into the vagina and the sound into the blad- 
 der, by which means you can measure the capacity of 
 the organ and the thickness of its walls. It is not 
 tmusual in the concentric form for the sound to be 
 forcibly expelled from the bladder by a sudden con- 
 traction of that organ. The capacity of the viscus 
 can be further measured by noting the amount of 
 urine held before each micturition, or by injecting into 
 it some bland solution, such as salt and lukewarm 
 water. 
 
 If necessary, use the speculum, or dilate the urethra 
 and introduce the finger. But you may never be re- 
 quired to do this. 
 
 Treatment. — The treatment must be directed to the 
 Temoval of the cause, where that is possible. If due to 
 
262 ATROPHY OF THE BLADDER. 
 
 the presence of tumors, their removal is to be consid- 
 ered ; if to Cystocele, replacement and retention in; 
 place by a proper pessary, and other measures, of whicb 
 I have spoken fully in a previous lecture, must be- 
 adopted. 
 
 If due to functional disorder, as Neuralgia or ex- 
 cessive irritability, the proper treatment of those affec- 
 tions should be at once instituted. 
 
 When existing in the eccentric form, an abdominal) 
 belt, cold baths, cold douches to hips, astringent injec- 
 tions into the bladder, and electricity, should be tried, 
 having first, where possible, removed the cause and: 
 palliated or cured the aggravating complications. Daily- 
 catheterization in cases of obstruction to the outflow 
 of urine, or where, without obstruction, there is liability 
 to over-distension, is of great importance, and should- 
 be borne in mind. 
 
 Atrophy of the Bladder.-.-So far as we know, this- 
 is not a common disease. Its recognition during life 
 being by no means easy, and but little attention being 
 paid to the bladder in autopsies, very little knowledge- 
 of its frequency is had. I am inclined to believe, how- 
 ever, that it exists much oftener than is commonly sup- 
 posed. Its causes may be ranged under two heads,, 
 viz.. Constitutional and Local. 
 
 Constitutional. — In most women from fifty years of 
 age upwards, degenerative changes take place in the- 
 bladder, as in the other pelvic organs, and are per- 
 fectly natural processes. In this condition the several 
 coats are found proportionally changed, the threesome- 
 
ATROPHY OF THE BLADDER. 263 
 
 times forming a wall not thicker than fine writing paper. 
 This, however, is extreme and uncommon. The pro- 
 cess causing atrophy is one of fatty and granular 
 degeneration, and often at this age the epithelial cells 
 of the bladder found in the urine are fatty and granu- 
 lar, as is also the case in both the vesical and vaginal 
 epithelium of some women just after parturition. 
 
 Walls thus thinned by the degenerative changes of 
 ao-e are of course much more liable to be still further 
 
 o 
 
 altered by various causes, such as Paralysis or over- 
 distension. Winckel attributes the Cystocele of aged 
 women to atrophy of the bladder walls, and the result- 
 ing retention of urine. 
 
 In soft, flabby and debilitated women, as also in 
 men, an atrophied condition of the bladder walls often 
 exists, and may lead to rupture. " Bonnet, Hauf, and 
 Hunter (quoted by Pitha) give examples of sudden 
 rupture of the bladder in young persons from this 
 cause (atrophy). Civiale gives the caution of avoiding 
 pressure on the bladder walls during catheterization, 
 for fear of perforation." (Van Buren and Keyes.) 
 
 Local Causes. — Extreme distension of the bladder, 
 leading to temporary or permanent paralysis, or par- 
 alysis with resulting over-distension, may lead to fatty 
 degeneration and atrophy, as well as inflammatory 
 trouble. Interrupted nutrition, due to shutting off the 
 circulation, is the usual method of causation. Nutritive 
 changes may also be due to lack of, or perverted inner- 
 vation. When atrophy occurs in women under fifty 
 years of age, who are in otherwise good health, and of 
 o^ood constitution, I believe that it is due to habitual 
 
264 ATROPHY OF THE BLADDER. 
 
 retention of urine, and over-distension of the blad- 
 der. I have recently seen a case which I think illus- 
 trates this. 
 
 The lady was thirty-three years of age, large and 
 Avell developed, except that her heart and arteries were 
 rather small. Her uterus was also undersized. She 
 began to menstruate at fifteen years of age, and her 
 menses were irregular in recurrence and duration, and 
 always attended with pain. 
 
 Early in life she became a school teacher, and had 
 followed that profession up to the time that I saw her. 
 She fell into the habit of retaining her urine for long 
 periods, and for several years urinated only twice In 
 each twenty-four hours. 
 
 For some time she had noticed a growing difficulty 
 in emptying her bladder, and five months before con- 
 sulting me she found that she had lost the power of 
 urinating altogether. Her physician used the catheter 
 regularly for a time, and then taught her to use it her- 
 self Under this treatment, with tonics and sedatives, 
 she gradually regained a partial control of her bladder ; 
 but with it came an irritable condition of that oro-an 
 and the urethra, which caused an almost constant de- 
 sire to urinate. 
 
 When I examined her I found slight prolapsus of 
 the base of the bladder, and by passing a sound into 
 it, and a finger in the vagina, I found the posterior 
 bladder wall quite thin. There were also indications 
 of a slight catarrh of the organ, doubtless brought on 
 by the continued over-distension and prolonged use of 
 the catheter. She told me that she had to make stron-o: 
 
ATROPHY OF THE BLADDER. 265 
 
 ■efforts to pass her water, and that it came away In in- 
 terrupted jets. 
 
 My impression of this case is, that her constant 
 neglect of the bladder function caused over-distension, 
 which led to atrophy and further distension. The use 
 of the catheter permitted the organ to partially regain 
 its muscular power, and also excited some catarrh. 
 Passing the water in spurts or jets was due, I presume, 
 to her voluntary muscular efforts. 
 
 An unrelieved urethro-vaginal fistula may lead to 
 extreme atrophy. 
 
 Treatment. — Daily use of the catheter, Strychnia 
 in pretty full doses, electricity, building up of the gen- 
 eral system, and gentle washing out of the organ with 
 warm medicated solutions may be tried. But little can 
 be done when the degeneration is due to age. 
 
LECTURE VII. 
 
 Diseases of the Female Urethra — Urethral Neu- 
 roses — Urethritis: Acute, Chronic and Gon- 
 orrhceal — Circumscribed and Subacute — Ure- 
 thral Neoplasms — Vascular Tumors — Areolar,. 
 Epithelial and Compound Neoplasms — Their 
 Symptoms, Diagnosis, Etiology, Prognosis and' 
 Treatment. 
 
 Gentlemen — 
 
 You will occasionally read and hear of Urethral 
 Neuralgia ; and you may meet a case, among your 
 lady patients, in which you will find pain and tender- 
 ness of the urethra, with frequent desire to urinate, and 
 pain in doing so. In short, you will obtain a history of 
 Subacute Urethritis ; but upon the most careful exam- 
 ination that you can make, with all the means at your 
 command, you will fail to find any lesions to account, 
 for the symptoms present. To this condition the name 
 Neuralgia has been applied, rather improperly, no 
 doubt From my own observations of this affection, 
 in which there are well-marked symptoms with nO' 
 apparent anatomical lesions, I have been led to the 
 conclusion that it is a disease of the nerves of the part — 
 one of the Heteroses, as they are called. It is quite 
 
DISEASES OF THE FEMALE URETHRA. 267 
 
 possible, however, that progress in the diagnosis of 
 urethral diseases may yet enable us to find lesions other 
 than of the nerves to account for the symptoms present- 
 ed by the disease in question. But for the present, 
 we must class it among the Neuroses. 
 
 So far as I know, it is an affection peculiar to 
 women. I have at least only seen it among young 
 married women of marked nervous temperament, and 
 who have not borne children. In some of the cases 
 observed, it was associated with an irritable condition 
 of the introitus vulvae. 
 
 The symptoms are such as occur in a great variety 
 of pathological conditions, and are therefore of little 
 value in guiding us to a correct idea of the real trouble ; 
 and, as there are no diagnostic physical signs present, 
 the diagnosis must be made by exclusion. The most, 
 thorough examination of the urine should be made, 
 and the urethra and neighboring organs should be care- 
 fully investigated. Perhaps the greatest liability to- 
 error lies in mistaking this condition for reflex irrita- 
 tion of the urethra and bladder arising from ovarian, 
 uterine, or rectal disease. You should therefore care- 
 fully inquire into the condition of those organs before 
 concluding that the disease is of the urethra itself. 
 
 The affection is fortunately rare as well as obscure. 
 I will therefore relate the history of some cases, which. 
 will give you the facts as they were observed clin- 
 ically. 
 
 One was a lady of a highly nervous temperament, 
 whose parents died of Tuberculosis. She was twenty- 
 six years of age, and had been married three years. 
 
^68 DISEASES OF THE FEMALE URETHRA. 
 
 From the time of her marriage she began to suffer from 
 painful menstruation and Uterine Leucorrhoea. She 
 attributed her trouble to getting cold while driving in 
 an open carriage behind a fast horse. She had an 
 Anteflexion of the Uterus and Cervical Endo-metritis. 
 The right ovary was large, tender, and prolapsed. 
 Before, during, and after her menses, she had smarting 
 and burning pain in the urethra, with a feeling of spas- 
 modic contraction, which sometimes rendered urination 
 , difficult and painful. In the interval between the 
 menstrual periods she had tenderness of the urethra, 
 and discomfort in passing water. 
 
 The urethra was examined with the endoscope 
 throughout its whole extent, repeatedly, but no disease 
 could be found, save tenderness and spasmodic action. 
 
 She derived relief from suppositories of Morphine 
 and Belladonna ; but when last seen she still had at- 
 tacks of the same trouble. It was supposed at first 
 that her urethral trouble was due to the disease of the 
 uterus ; but the former persisted after the latter was 
 relieved. 
 
 A lady aged twenty-nine had been married for 
 seven years, but had never been pregnant. She was 
 of a highly nervous temperament, but her general 
 health had always been good. She began to menstruate 
 at fourteen years of age, and continued to do so regu- 
 larly but scantily. For several years she had suffered 
 from backache and slight Uterine Leucorrhoea, and 
 coitus had always been painful. She had frequent and 
 painful urination. The uterus was small ; in fact, all 
 her reproductive organs were undersized. There was 
 
DISEASES OF THE FEMALE URETHRA. 2691 
 
 marked tenderness of the introitus vulvae. The remains 
 of the hymen were very tender ; and at the meatus 
 urinarius and on the vestibule there were a num- 
 ber of quite small papillomata (of the same color as the 
 mucous membrane), that were also exceedingly tender. 
 These were destroyed by applications of equal parts of 
 Carbolic Acid and Tincture of Iodine, and her leuc- 
 orrhoea arrested by the usual treatment. This relieved 
 her of all her symptoms except those of the urinary 
 organs. Her urine was examined repeatedly, and was 
 found to be normal. The urethra was also investigated, 
 but nothing wrong was found there, except that the 
 papillae appeared . to be unusually prominent. We 
 learned also that if she retained her water for an hour 
 or two the desire to urinate passed off, and did not re- 
 tjrn until the bladder was fully distended. When she 
 did urinate, the desire to empty the bladder continued, 
 i. e., she had vesical tenesmus ; and if she indulged 
 this feeling by passing the urine repeatedly, this tenes- 
 mus continued, but if she resisted the desire, it gradually 
 subsided. This proved conclusively that the cause of 
 her frequent urination was due to the condition of the 
 urethra. 
 
 Quite a variety of agents, which I need not give 
 in detail here, were tried in this case. Suffice it to say 
 that she only derived benefit from coating the enttre 
 mucous membrane of the urethra with dry Sub-Nitrate 
 of Bismuth once a day for a week, and then applying 
 equal parts of Tincture of Aconite and aqueous Ex- 
 tract of Opium twice a week for a time. A steel sound 
 was also passed once a week, and allowed to remain 
 
270 DISEASES OF THE FEMALE URETHRA. 
 
 in place for about five minutes. This gave pain at the 
 time, but relief followed. During the local treatment 
 she took good food, Iron, and Arsenic. She may be 
 said to have recovered ; but over- taxation, mental or 
 physical, would bring back her trouble In a slight de- 
 gree for a short time. 
 
 Urethritis: Acute, Chronic, and Gonorrhoeal. — 
 Acute Urethritis, though not a very frequent disease 
 among women, Is a very distressing one to the patient, 
 and often difficult to relieve. In many cases you will 
 find the pathology specific, i. e., due to Gonorrhoea ; 
 and I would treat this subject as Gonorrhoea in women, 
 were it not that it is often difficult to tell a specific or 
 Venereal Urethritis from simple inflammation of that 
 portion of mucous membrane. There Is a difference 
 in history when we can get correct testimony from the 
 patient. Simple Urethritis usually comes on gradu- 
 ally, and is often preceded by symptoms of uterine or 
 vesical disease ; while Gonorrhoea comes on rather 
 abruptly, and is preceded or attended by Acute Va- 
 ginitis and Vulvitis. The chief symptom is painful 
 urination. Sharp scalding Is produced by the urine 
 passing over the tender surface. There is often a 
 frequent desire to urinate, but not so urgent as in 
 Cystitis. In some cases the urine Is retained for a 
 long time, evidently from a dread of the pain caused 
 in passing it. 
 
 In quite a number of cases I have noticed hemor- 
 rhage. You can tell that the blood comes from the 
 urethra by the fact that it is not intimately mixed with 
 
DISEASES OF THE FEMALE URETHRA. 271 
 
 the urine ; and after micturition it will ooze from the 
 meatus urinarius. 
 
 An examination of the parts will show signs of in- 
 flammation about the meatus, with or without the 
 same condition of the vulva. Occasionally there is a 
 ■discharge seen coming from the urethra, but If the 
 parts have been recently bathed this may not be ap- 
 parent. Introducing the finger into the vagina and 
 pressing upon the urethra from above downwards, the 
 discharge can be started, unless the patient has passed 
 water immediately before. The appearance of the dis- 
 charge corresponds to that of Gonorrhoea in Its various 
 stages. 
 
 Cystitis, which is liable to be confounded with Ure- 
 thritis, may be excluded by using the catheter, and, 
 after letting urine flow for a time, collecting the remain- 
 der for examination. The mucous membrane, as seen 
 through the endoscope, is of a deep red, with pus or 
 mucus lodged in its folds. The instrument cannot be 
 used In all cases, owing to the acute tenderness of the 
 parts. Bleeding Is very likely to occur in the exami- 
 nation, simply from the contact of the endoscope. 
 
 The treatment of Acute Urethritis, whether specific 
 or not, may be conducted on the same principles as 
 that of Gonorrhoea in the male, using the same consti- 
 tutional remedies, local baths, etc. This will suffice In 
 most cases of acute disease ; but when It assumes the 
 subacute form from the beginning, then the use of in- 
 jections becomes necessary. 
 
 My friend Dr. B. A. Segur. of Brooklyn, finds that 
 the discharsfe of Gonorrhoea Is markedlv lessened. 
 
2-2 DISEASES OF THE FEMALE URETHRA, 
 
 and sometimes cured, by ten-grain doses of Salicylic 
 Acid, given in solution several times a day. You 
 might try it. 
 
 I have seen much benefit derived from douching the 
 urethra with water as hot as the patient could bear it. 
 For this purpose I use a catheter made like the fluted 
 roller of a crimping machine, with the appearance 
 of which you doubtless are familiar. (See Fig. 25.) 
 Inside of the catheter there is a small supply tube, 
 which conveys the water to the rounded point of the 
 instrument. Behind the point of the catheter, where 
 the grooves terminate, there is a perforation in each 
 
 Fig. 25. 
 
 Skene's Reflux Catheter. 
 
 groove through which the water returns. By this 
 arrangement the water, as it flows back through the 
 grooves, is brought in contact with every portion of 
 the mucous membrane. The instrument is passed 
 up to the neck of the bladder, and a fountain syringe 
 attached to it, and the water as it flows away is 
 caught in a cup. 
 
 The injection of solutions of Nitrate of Silver, Sul- 
 phate of Zinc, and the like, will often prove useful. 
 You must bear in mind that the female urethra will 
 not hold more than ten or fifteen drops, and if more 
 is used it will enter the bladder, even where very 
 
DISEASES OF THE FEMALE URETHRA. 273 
 
 slight force is employed while injecting. I use a large 
 syringe, placing the nozzle over (not in) the meatus, 
 and inject slowly and without force a small quantity. 
 When the case is of long standing, and the neck of 
 the bladder appears to be involved also, I use a mild 
 injection of one or two grains of Nitrate of Silver to 
 the ounce, and inject it through the urethra with force 
 enough to enter the bladder, and let it remain there, 
 to be passed off when the patient urinates. In old 
 cases, which began by a severe acute attack, and where 
 the walls of the urethra are very much thickened and 
 the canal contracted, dilatation with bougies does much 
 good. While the bougie is passed once or twice a 
 week, I apply to the vaginal portion of the urethra 
 Oleate of Mercury or the Unguentum Hydrargyri. 
 This will often suffice to stop the gleety discharge, as 
 well as remove the thickening of the urethrae walls. 
 
 Another very troublesome affection of the urethra 
 which results from Urethritis, or may appear without 
 any previous disease, is granular erosion, as it is called. 
 The mucous membrane is covered with young, imper- 
 fectly developed epithelium ; the papillae are hyper- 
 trophied and extremely sensitive. This gives rise to 
 the most excruciating pain during micturition, and 
 generally keeps up a distressing tenesmus. This dis- 
 ease is fortunately not very common. Old people are 
 most liable to suffer from it. The diagnosis is made 
 from the history and appearance of the urethra. The 
 treatment which is most reliable, is cauterization of 
 the whole surface. The milder washes and injections 
 do not accomplish much. Pure Carbolic Acid may 
 
274 DISEASES OF THE FEMALE URETHRA. 
 
 be tried first, brushing it over the surface, and re- 
 peating it in eight or ten days. This is the least pain- 
 ful application, and answers in some cases. When 
 it fails, a solution of Nitrate of Silver (one drachm to 
 the ounce) should be used ; and when that does not 
 suffice, Nitric Acid or the actual cautery may be 
 employed. In some cases it is desirable, before using 
 strong caustics, to dilate the urethra, and then touch it 
 with Carbolic Acid in a mild solution. 
 
 Urethritis : Circumscribed and Subacute. — Amonof 
 the inflammatory affections of the female urethra you 
 "will quite often see mild forms of the trouble that fall 
 short of well-marked Urethritis. Indeed, some of these 
 attacks amount to little more than congestion or slight 
 catarrh. In others you will find circumscribed patches 
 of the urethra inflamed, and the rest of the canal 
 normal. 
 
 There is little, if anything, in our medical works on 
 the subject of this mild yet troublesome affection, and 
 I hope that you will gain a sufficiently clear idea of the 
 subject from some cases that I am about to relate. 
 
 A young married lady had been under my care for 
 Dysmenorrhcea caused by anteflexion. She had re- 
 covered sufficiently to believe that she was well enough 
 to go to a party and dance to excess, which she did, 
 and caught cold on her way home. On the second 
 •day after, I was called to see her, and found her with 
 the usual symptoms of an ordinary cold, that caused 
 her little anxiety. But she was suffering severely from 
 frequent and painful micturition. I found slight gen- 
 
URETHRITIS: CIRCUMSCRIBED AND SUBACUTE. 275 
 
 ■«ral congestion of the uterus and vagina, and suspect- 
 ed Cystitis, but her urine was normal. I then exam- 
 ined her urethra, and found it congested throughout, 
 • and with streaks of mucus lodged in the folds of the 
 membrane. There was neither erosion nor ulceration. 
 
 I directed her to rest quietly in bed and drink freely 
 ■of Flaxseed Tea and Spiritus ^theris Nitrosi. A 
 .suppository containing Extract of Belladonna and Sul- 
 phate of Morphia was directed to be introduced into 
 the vagina at bedtime. Under this simple treatment 
 -she rapidly improved. Twelve days after the date of 
 my first visit she called to see me, and I then found that 
 :she could retain her urine for hours, but still had slight 
 pain and burning during micturition. The urethra was 
 .again examined with the endoscope, and a few red 
 patches found scattered here and there along the canal. 
 This was all that remained of the trouble. Liquor 
 Bismuthi was injected into the urethra every second 
 -day for a week, when she declared herself quite well. 
 
 I will give you the history of another case. A 
 young lady, healthy and active, was head saleswoman 
 in a department of a large dry-goods establishment. 
 During the holidays, from Christmas to New Years, 
 she was on her feet from eight in the morning until ten 
 •or eleven at night. On the last day of the year she 
 was seized with pain and burning in the urethra, and 
 soon after she began to suffer from frequent and pain- 
 ful micturition. 
 
 Three or four days after the attack I examined the 
 ■urethra, and found several small ecchymoses at various 
 parts of the mucous membrane, the highest one being 
 
276 DISEASES OF THE FEMALE URETHRA. 
 
 near the neck of the bladder. These spots were due- 
 to hemorrhages that had taken place into the mucous- 
 membrane, beneath the epithelial layer. The spots- 
 were dark, almost black in the centre, and surrounded 
 by an inflamed border, which was bright red at the in- 
 ner margin, but gradually shaded off into the natural- 
 color of the surrounding mucous membrane. 
 
 My idea of the pathology of this case is, that the- 
 congestion arising from the lady being obliged to re- 
 main so long in the erect position caused some of the 
 small vessels to give way, and the hemorrhage intO' 
 the membrane produced little circumscribed spots of 
 ecchymosis. 
 
 She was directed to rest in the recumbent position 
 and drink freely of Vichy water. This she did, and 
 made a good recovery ; but it was six or eight days- 
 before the pain in urinating left her entirely. 
 
 You will observe that these cases were both acute, 
 and recovered very promptly ; and I could give you' 
 several more histories, which might lead you to sup- 
 pose that such trivial ailments of the urethra are not 
 of much importance after all. You also might pre- 
 sume that this form of urethral disease would disap- 
 pear in most cases without being diagnosticated or 
 treated. This is no doubt true ; but I can assure you 
 that they do not all recover spontaneously. Some of 
 these mild cases tend to continue. They become 
 chronic, and if neglected will continue for years, to the 
 great annoyance of the subject. Of the chronic or 
 continuous form of Subacute Urethritis, the following 
 may be given as good examples : 
 
URETHRITIS: CIRCUMSCRIBED AND SUBACUTE. 277 
 
 A single lady, thirty years of age, had for ten 
 years been occupied as dressmaker, and was in the 
 Jiabit of operating a sewing-machine occasionally. 
 Her general health had always been excellent, but she 
 consulted me for what she supposed to be an affection 
 of the kidneys. She said that for five years she had 
 been annoyed with painful and frequent micturition. 
 She was obliged to urinate every two or three hours 
 •during the day, and several times in the night. Stand- 
 ing, walking, or exposure to cold invariably made her 
 worse. 
 
 An examination of her pelvic organs revealed slight 
 catarrh of the cervix uteri, and a mild vaginitis, limited 
 to the upper and posterior portion of the vagina, most 
 marked behind the cervix. Her urine was examined 
 •carefully and found to be normal. The urethra was 
 then examined by the endoscope, which brought to 
 view a highly inflamed spot on the anterior wall of the 
 ■urethra, and an inflamed ulcer on the posterior wall. 
 The disease was limited to the middle third of the 
 oirethra, and while extending all around, was most 
 marked anteriorly and posteriorly. The ulcer, which 
 lay in the posterior wall or floor of the urethra, was 
 superficial, and appeared through the endoscope as a 
 gray spot surrounded by a bright red areola. It bled 
 on contact with or stretching by the instrument. The 
 -color of the upper and lower third of the urethra was 
 somewhat darker than usual, but otherwise normal. 
 
 The recovery in this case was somewhat tedious, 
 iDecause it was one of my first cases, and my treatment 
 was experimental and not always beneficial. First, .1 
 
27S DISEASES OF THE FEMALE URETHRA. 
 
 touched the inflamed parts with a solution of Nitrate- 
 of Silver (one drachm to the ounce), using just enough 
 to whiten the surface. This gave her rather sharp' 
 pain, which passed off, however, in a few hours. After 
 this she had much pain in passing water, but the fre- 
 quency was about the same as before the application.. 
 About ten days after using the solution, the parts,, 
 though still inflamed, were much improved. 
 
 This advantage gained suggested a repetition of 
 the application, which I made. It was followed by 
 very severe pain, that lasted two days and nights be- 
 fore it subsided. There was no improvement. After" 
 this I injected into the urethra, twice a week, a solu- 
 tion consisting of 
 
 !l^. — Zinci Sulphatis, gr. iv. 
 
 Fl. Ext. Hydrastis Canadensis, gi. 
 Aquae, Siij- 
 
 This was continued for about a month with marked' 
 benefit. At the end of that time she could rest all. 
 night without urinating, and had to micturate only about 
 every four hours during the day, and had very little 
 pain. Injection of Liquor Bismuthi was then begun, and. 
 continued twice a week for three weeks, when she was- 
 free from all trouble, but was obliged to urinate every 
 four or seven hours, from habit, I suppose. 
 
 One other case may be given, to show the disposi- 
 tion of the urethral trouble to continue. This patient, 
 was thirty-nine years of age, and had been a widow 
 for sixteen years. Her only child was a grown-up' 
 woman. Four years before I saw her she had a ca- 
 tarrh of the bladder, for which she was treated by a 
 
URETHRAL NEOPLASMS. 279 
 
 skilled physician. She recovered from that after a 
 time, her urine becoming normal and her ability to re- 
 tain it excellent. She continued, however, to have 
 pain in passing water ; but as there was no trouble at 
 any other time, she was satisfied to tolerate that. 
 
 Being troubled with constipation while traveling, she 
 was taken with agonizing pain after defecation, con- 
 tinuingf to suffer with it for several months. She then 
 applied to me for relief She stated that the pain during 
 micturition had been much worse since the develop- 
 ment of the rectal trouble. The rectum was examined 
 with the endoscope (the same instrument used in explor- 
 ing the bladder and urethra, but of larger size), and a 
 well-dehned fissure detected. This explained the rectal 
 symptoms, and it is fair to suppose that the urethral 
 trouble was aggravated by it, sympathetically. The 
 lower third of the urethra was found to be inflamed, 
 and, in places, eroded. The anal fissure was relieved 
 by the usual operation, and the urethra was treated 
 with applications of Nitrate of Silver (one grain to the 
 ounce). Recovery was speedy and satisfactory. 
 
 Urethral Neoplasms. — A knowledge of the urethral 
 neoplasms is by no means confined to recent times, 
 but up to a late date they had not been studied as 
 closely as they deserved to be, or classified in a com- 
 prehensive and scientific manner. The various tumors 
 have frequently been confounded with one another, by 
 various authors and observers, and much confusion and 
 confused statement resulted in regard to symptomato- 
 logy, pathology and treatment. 
 
:zSo DISEASES OF THE FEMALE URETHRA. 
 
 These growths have been variously known as Car- 
 unculae, Cellulo-vascular Tumors, Fleshy and Vascular 
 Growths, Fungoid Excrescences, Strawberry and Rasp- 
 berry Tumors ; each name sometimes having been used 
 to cover the whole class. 
 
 Winckel's division and classification is most excel- 
 lent, and to some extent I shall follow it in this lecture. 
 We will arranee these tumors in classes, as follows : — 
 
 Papillary Condylomata. 
 
 i Cysts. 
 Glandular < Myxo-Adenomata. 
 
 ( Mucous Polypi. 
 
 i Angiomata. 
 Vascular < Varices. 
 
 ( Phlebectases. 
 
 . Areolar-Connedive Tissue. | s^j.^°|j;j[a! 
 
 r^.^j J. J ( Epithelioma. 
 
 ^Pi^^'^'^^ \ circmoma. 
 
 ^ , i Papillary Polypoid Angiomata. 
 
 Compound { Erectile Tumors. 
 
 Neoplasms of the urethra are more common in the 
 female than in the male, and of course easier of diag- 
 nosis and treatment. 
 
 Under the first head, or that of Papillary, you will 
 see Condylomata, a low-grade growth, of a warty ap- 
 pearance. The surface may be a bright red, or partly 
 whitish, from epithelial aggregation. They are pain- 
 less, and do not bleed on touch or handling. They 
 may or may not be pedunculated. They may occur 
 singly or in clusters, and be wholly within the urethra 
 or projecting from the meatus. 
 
GLANDULAR TUMORS. 281 
 
 They consist of somewhat dilated capillaries, set in 
 a toug-h, homogeneous net-work of connective tissue, 
 the whole having a thin epithelial covering, that may 
 at times be increased by an unusually rapid epithelial 
 proliferation. This only occurs when the tumors are 
 much irritated. 
 
 Glandular. — Cysts of the female urethra are not 
 common, and are not confined to any period of life, 
 having been found in a fcetus of from six to seven 
 months, and in all periods of life later on. 
 
 They are in early age situated in - the anterior or 
 meatal portion of the passage, but later in life nearer 
 the vesical neck. They may or may not project from 
 the urethra ; in all cases, however, they cause a greater 
 or less obstruction to the free outflow of urine. They 
 are usually formed by the occlusion of the orifice of 
 the small urethral ducts or glands, and in some cases, 
 a black speck upon the surface of the cyst indicates 
 the seat of the former orifice. 
 
 By bagging of the mucous membrane and absorp- 
 tion of the contents, these small cysts may be trans- 
 formed into polypi. 
 
 Winckel says that the internal wall of the cyst usu- 
 ally shows numerous small papillae, and is lined with 
 pavement epithelial scales. 
 
 My xo- Adenomata are quite rare. They are small, 
 (the largest being seldom larger than a small hazelnut,) 
 of a bright scarlet color, and quite vascular. They 
 consist of a number of vessels set in partly destroyed 
 ^land tissue, and small meshes containing myxomatous 
 
282 DISEASES OF THE FEMALE URETHRA. 
 
 matter. The whole Is contained In the meshes of a. 
 soft, loose connective tissue. 
 
 Polypi coming under this head are those formed by- 
 occlusion of the orifices of one or more of the ducts or 
 follicles of the urethra. The other forms of polypi will, 
 be considered under their proper heads. 
 
 Vascular Tumors. — Angioma, Phlebectases, and 
 Varices, are really different names for about the same 
 condition, viz., an increase in the calibre of the veins 
 and venous radicles, allowing an over-distension, at 
 first intermittent, and later chronic. They appear as 
 bunches or bundles of worm-like, irregularly distended 
 dark blue or bluish red vessels. There is more or 
 less thickening of the mucous membrane and con- 
 nective tissue about them, they being really in all re- 
 spects analogous to rectal hemorrhoids. 
 
 They may occupy any part of the urethra, but 
 usually select the floor of the canal. The trouble they 
 cause depends on their size. If large, they obstruct, 
 the urethra. Sometimes the vessels rupture, and the: 
 blood Is poured out beneath the mucous membrane. 
 Tumors resulting from rupture of such varices under 
 a normal mucous membrane have been known to some 
 authors under the name of Haematoma Polyposum. 
 Urethrse, which describes the condition resulting very 
 well. 
 
 Some of these vascular tumors have been found to- 
 be erectile, the anatomical peculiarities of which struc- 
 ture you are already familiar with. 
 
 Virchow believes these tumors to be a combination 
 
AREOLAR NEOPLASMS. 283: 
 
 of urethral hemorrhoids and remnants of embryonal 
 dupHcity of the vagina. 
 
 Areolar Neoplasms. — These new growths are ei- 
 ther fibromata or sarcomata. 
 
 The fibromata may lie within the canal of the ure- 
 thra or be imbedded in its walls. When in the urethra 
 or protruding from the meatus, they are pedunculated, 
 and have been known as Urethral Polypi. They vary 
 in size from that of a pea to that of a goose-egg. They 
 consist of numerous densely packed fibres, that give 
 the same appearances as fibromata elsewhere. 
 
 They have been found in several cases at birth, but 
 are of rare occurrence at any age. When congenital, 
 they have been known as Congenital Polypoid Excres- 
 cences. The tumors are usually covered with several 
 layers of pavement epithelium. 
 
 Sarcoma UretJirce is an extremely rare affection, 
 but one or two cases being on record. One case by 
 Beigel is described by Winckel. It was tri-lobed, 
 about the size of a walnut, and was situated about the 
 edge of the external meatus. It was in part hard, in 
 part soft, the harder portion consisting of a fine fiber 
 net- work, the interstices of which were filled with small 
 cells. In some places the cells were absent and the 
 stroma more dense ; and in the peripheral parts the 
 net- work, while coarser, was firmer, and presented cav- 
 ities filled with a colloid material. The tumor was ex- 
 tirpated, but nothing is said about its return. 
 
 Epithelial. — The existence of cancerous disease of 
 
:284 DISEASES OF THE FEMALE URETHRA. 
 
 the female urethra as a primary affection is greatly- 
 doubted by many authors, but it probably does exist 
 in a few cases. Indeed, as a secondary disease it is 
 •quite rare, for when extending from the uterus or 
 neighboring organs to the bladder, death, as a rule, 
 results before involvement of the urethra takes place. 
 In those cases where life is unusually prolonged, the 
 disease seldom attacks more than the vesical portion 
 of the canal. 
 
 Extension from the outer genitals, which are very 
 rarely affected with cancerous disease, is still more un- 
 common, possibly has never occurred. One case is 
 recorded, however, in a woman who had long suffered 
 from uterine prolapse, where an oval tumor depended 
 from the fraeniculum clitoridis and had invaded the 
 meatus urinarius. Under the microscope it proved 
 to be a flat-celled Epithelio-cancroid. 
 
 We have the record of cases of peri-urethral can- 
 cers, that appeared at the introitus vulvae near the 
 meatus, and in the connective tissue about the urethra, 
 as small, hard, painless tubercles, the urethra or its 
 membrane not being involved. 
 
 Pain is the exception rather than the rule in this 
 affection ; but in some instances acute lancinating 
 pains are present. 
 
 At first the tubercles are small, hard, and usually 
 painless, but after a time they soften, ulcerate, and 
 bleed freely. The vestibule and urethral mucous mem- 
 brane are usually involved in th(; mischief 
 
 The affection has been divided into three grades, 
 an the first of which, according to Winckel, "but half 
 
COMPOUND NEOPLASMS. 285; 
 
 the length and depth of the urethra is invaded by the 
 cancerous tubercles ; in the second, the vesical neck 
 and pelvic fascia ; and in the third degree the pubic 
 symphysis, descending pubic rami, and the closely 
 blended connective tissue, are involved." 
 
 Compound Neoplasms. — The most common and 
 consequently the most interesting form of urethral neo- 
 plasm, is the Papillary Polypoid Angioma. 
 
 These tumors vary in size from a pin-head to a 
 hickory-nut, and may be either multiple or single, but' 
 usually single. They vary in color from a pale to a 
 bright red, and may or may not be pedunculated. Their 
 favorite seat is on the posterior wall of the anterior 
 half of the urethra, very near to or at the meatus. 
 This neoplasm is popularly known among us as 
 urethral caruncle, or vascular tumor of the urethra, 
 and is described very fully in most of the books- 
 on diseases of women. Indeed, it is the only abnor- 
 -mal growth of the female urethra that I ever read or 
 heard of in my student days. There are very good 
 reasons for this trouble having claimed early attention 
 from gynecologists. It occurs frequently, and near- 
 ly always causes great suffering, and is easily detected, 
 because it grows at the meatus urinarius, where it can 
 be seen. 
 
 They consist of bunches of dilated capillaries set 
 in a moderately dense stroma of connective tissue, and 
 covered with mucous membrane, that has the usual 
 pavement epithelium. One case, however, is recorded 
 where the pavement was replaced by columnar epithe-^ 
 
286 DISEASES OF THE FEMALE URETHRA. 
 
 lium. The vessels are greatly dilated and very tortuous 
 in some cases, in others much less so. 
 
 In some cases these tumors partake of the erectile 
 element, being markedly increased in size at the men- 
 strual period and at other times. '. 
 
 Occasionally small tumors of this kind are found 
 singly in the vestibule. As a rule, they bleed very 
 easily on touch, and are exquisitely seiisitive. Ob- 
 servers differ as to whether the nerve supply to the 
 tumor is marked, some claiming to find a large nerve 
 distribution, others to find none. As they are exceed- 
 ingly tender, we may infer that the opinion held by 
 the former is correct. 
 
 Symptoms. — Unless the tumors be of large size, the 
 patient may go on for a long period without suspect- 
 ing anything more than a slightly irritable condition 
 •of her urethra. When, however, the tumors become 
 large, or are of the Polypoid Angioma variety, the pain 
 is markedly increased, and the obstruction to urine 
 outflow becomes very apparent. These tumors, by 
 constant moisture and friction, become eroded on their 
 surface, and these ulcerations, being constantly aggra- 
 vated, give rise to usually slight hemorrhage ; in- 
 creased pain and retention of urine may result from 
 their closing the urethra. 
 
 Of all the urethral neoplasms, however, the Papil- 
 lary Polypoid Angiomata are the most intensely pain- 
 ful, patients retaining their water for a long time to 
 avoid the agony that is produced by passing it. The 
 pain is in some cases present at all times, and is greatly 
 
SYMPTOMS. 287 
 
 aggravated by sitting or lying down. The clothes com- 
 ing in contact with the exquisitely sensitive surface 
 often produce vaginal and anal spasm. Coition is 
 sometimes impossible. A case is related of an old 
 woman thus affected, who, though married some thirty 
 years, was still a virgin. Indeed, this affection is some- 
 times mistaken for Vaginismus, and treated accord- 
 ingly. The directions which I shall give you under 
 the head of diagnosis will, I think, enable you to avoid 
 such mistakes. 
 
 Even when these tumors are too small to obstruct 
 the urethra themselves, obstruction occurs from severe 
 spasm due to the pain caused in the act of micturition. 
 
 Bleeding is not uncommon from these tumors, but 
 it seldom amounts to much, and is easily controlled. 
 
 The pain in any of these new growths is not always 
 confined to the urethra, but may be felt in the back, 
 hips, supra-pubic region, thighs, knees and feet. In 
 the Carcinoma, lancinating pains may be present, but 
 this is by no means the rule. 
 
 As the tumors increase in size, the urethra becomes 
 gradually dilated, and the mucous membrane eroded, 
 hypersemic and catarrhal. Its structure may become 
 loose, flabby and vascular, and a pouching behind the 
 tumor result. If far enough back to interfere with 
 perfect closure of the vesical neck, incontinence may 
 occur, and inconvenience and distress the patients 
 greatly. 
 
 Sometimes the bleeding is severe, and the patient 
 suffers from anaemia caused by loss of blood. This is 
 jnore usually the case if, in the destructive process 
 
288 . DISEASES OF THE FEMALE URETHRA. 
 
 attending Carcinoma, any fair-sized artery is opened 
 into — an accident, however, which rarely occurs. 
 
 In the extremely painful neoplasms, the patient's- 
 face gives evidence of constant pain, distress, and anxi- 
 ety ; and in the most aggravated forms they are pale, 
 emaciated, and extremely low-sprited, often wishing 
 . earnestly for death to relieve their sufferings. 
 
 If the tumor be of sufficient size to be a serious bar 
 to free micturition. Cystitis, Pyelitis, and more serious 
 results, as renal destruction, are to be feared. 
 
 The presence of small and even large tumors in the 
 urethra and about the meatus often gives rise to in- 
 creased sexual desire, that may be gratified in the 
 young girl by masturbation. 
 
 The urine is normal, save that it contains the pro- 
 ducts of urethral disease, viz., epithelium, pus, mucus, 
 and sometimes blood. Small pieces of the tumor, small 
 cysts, or polypi, the pedicles of which have died or 
 been torn through, are sometimes found in the urine. 
 
 In cancerous neoplasms, as the disease invades the 
 tissues to the second and third desfrees mentioned in 
 connection with malignant tubercle, the patients gradu- 
 ally sink and die from exhaustion from severe bleed- 
 ings, loss of rest, and general cachexia. Some cases, 
 however, do not succumb until long after the third de- 
 gree has been reached, with extensive destruction of 
 tissue. 
 
 Diagnosis. — The diagnosis of urethral neoplasm is 
 really quite easy, provided the investigation is thor- 
 oughly and intelligently conducted. When a woman 
 
DIAGNOSIS. 289 
 
 comes to you complaining of pain on micturition, pain 
 in sitting, obstructions to or interruptions in the flow 
 of urine, you should at once proceed to a thorough in- 
 vestigation of the parts, first by the eye and touch, and 
 secondly by the aid of the speculum, endoscope, and an 
 examination of the urine. If the tumor presents at the 
 meatus, it will of course be readily seen, and can be 
 easily diagnosticated. 
 
 If in the urethra, the finger passed along the course 
 of the urethra in the vagina, and some dilatation of the 
 meatus, will discover it. If of small size, the endoscope, 
 with a strong light, will give you an excellent view of 
 it. If the tumor be exquisitely sensitive, as some are, 
 the patient should be wholly or partially anaesthetized, 
 and then the examination can be fully and freely made. 
 Vaginismus may be excluded by passing the finger into 
 the vagina, away from the urethra, when no spasm will 
 take place ; but if the urethra is touched, the spasm is 
 at once produced. 
 
 To determine whether the inflammatory mischief, 
 when it exists, resides in the urethra alone, the patient 
 should be directed to pass one-half of her urine into 
 one vessel and the other into another. If the trouble 
 is seatfed in the urethra only, the last urine passed will 
 be totally or almost wholly free from the inflammatory 
 products. The same may be accomplished also by 
 drawing off the urine with a clean catheter. 
 
 In some cases the varicose condition of the vessels 
 of the mucous membrane, with considerable swelling, 
 may simulate prolapse of the mucous membrane. If, 
 however, you bear in mind the blue discoloration, the 
 
290 DISEASES OF THE FEMALE URETHRA. 
 
 elastic feel, and the reduction in size under compression 
 of the urethral hemorrhoids, you will seldom err in 
 your diagnosis. Of course, prolapse of the mucous 
 membrane and a varicose condition of the urethral 
 veins sometimes exist together, and must be borne in 
 mind. 
 
 Tumors, usually those of large size and peduncula- 
 ted, often cause some degree of prolapse of the mucous 
 membrane, by constant dragging. A prolapsus of the 
 mucous membrane may also simulate a tumor. The 
 feel, the position of the meatal orifice, and the fact that 
 it can be reduced, will distinguish the prolapse. 
 
 To distinguish one kind of tumor from another is 
 not always easy, but with a little care it can be accom- 
 plished. The Condyloma you will recognize from its 
 painlessness, its warty, cracked, pinkish white or white 
 surface, and similar growths being usually found on the 
 vestibule. The Polypoid Angiomata will be known 
 from their bright red surface, their tendency to bleed 
 easily, and the exquisite pain produced by touching 
 them. The sarcomata will be readily confounded 
 with the angiomata, but you know that they are very 
 rarely found here ; and if you are in doubt, a little 
 piece maybe scraped off with thecurette and exaVnined 
 tnicroscopically. Should you still remain in doubt, the 
 history and progress of the disease will soon determine 
 the nature of the trouble. The malignant tumor will 
 g-row much faster than the other. The varices can be 
 told by their bluish color, and shrinking under pressure, 
 and the cysts and fibromata by their smooth, painless 
 .surface, normal mucous surface and their consistence. 
 
ETIOLOGY. 291 
 
 Carcinoma appears, as I have already told you, as 
 "hard tubercles (usually peri-urethral), which after a time 
 break down. When this occurs, the endoscope, the 
 lancinating pains (if present), the rapid invasion of 
 neighboring tissue, and the composition of the diseased 
 .mass, under the microscope, will tell the story. 
 
 Etiology. — The cause or causes of the various neo- 
 plasms are not yet clearly made out, and will not be, I 
 think, until more extended observations are made on 
 this subject. Even then it is more than probable that 
 the cause of some of these abnormal growths will re- 
 :main obscure. 
 
 The predisposing causes are a lax condition of the 
 urethral tissues, with a tendency to a varicose condition 
 ■of the parts usually found in old age ; a general ten- 
 dency to venous stagnation, catarrh of the mucous 
 ;membrane, and dislocation of the urethra, partial or 
 complete. 
 
 As a proof that no single special cause produces 
 these conditions, it may be said that these growths 
 liave been found congenitally, and at every period 
 during life, as late indeed as the ninety-second year. 
 
 The exciting causes are given variously by different 
 authors. 
 
 1st. Temporary or chronic congestion of the ure- 
 thra during pregnancy, uterine and ovarian tumors, and 
 obstructed portal circulation. 
 
 2d. Injuries to the parts during labor, external vio- 
 lence, the irritation of Chronic and Acute Urethritis, 
 {specific or simple), syphilitic poison, and masturbation. 
 
292 DISEASES OF THE FEMALE URETHRA. 
 
 Of course, the Carclnomata, Cysts, and simple Mu- 
 cous Polypi, are not here included, although some of 
 the above causes might aggravate if not produce them, 
 for we have already spoken of their method of causatioa 
 as far as we know it. Cancer occurs by extension, 
 of the disease from other parts ; Cysts and Mucous- 
 Polypi by occluded duct orifices. This narrows the list 
 to the nervous class and the compound, viz., the Poly- 
 poid Angiomata. And of these we may venture to say 
 that any cause, such as constant irritation, sudden in- 
 jury, or slow congestion, may produce these conditions, 
 especially in those who are somewhat predisposed ; but 
 that any one cause, such as the Gonorrhoeal poison, is. 
 sufficient to produce these growths, in all cases, is more; 
 than doubtful. 
 
 Most of these tumors occur in married women, botli 
 in those who have and those who have not borne chil- 
 dren. 
 
 You might be led to suppose from all that has been- 
 said upon this subject that urethral neoplasms are very 
 common. On the contrary, they are very rare, with the 
 exception of Polypoid Angiomata. 
 
 Prognosis. — The simple forms of urethral tumors 
 are easily removed, and do not return. As a rule^ 
 therefore, the prognosis is good. Of this class are 
 Cysts, Condylomata, Mucous Polypi, and Fibromata. 
 
 The Angiomata are of a more serious nature, as by 
 the pain and suffering which they cause the constitu- 
 tional condition is usually low ; and though they may 
 be extirpated, they are likely to return and rapidly in- 
 
TREATMENT. 293 
 
 <:rease in size, even in from one to three months' time. 
 Although the bleeding from these tumors is rarely 
 very great, still there may be numerous small hemor- 
 rhages and at times severe ones, either from the urethra 
 •externally or into the bladder. Under proper treat- 
 ment, however, there is always a possibility and in 
 ■some cases a surety of cure. 
 
 In Carcinoma there is no hope of effecting a cure, 
 although the patient's condition may be much bettered 
 in some cases. Death usually ensues before the third 
 ■degree is reached. Almost the same may be said of 
 Epithelioma, unless it is treated in the early stages of 
 the disease. 
 
 Treatment. — The treatment of these cases is, in 
 ■most instances, entirely surgical, but when the gen- 
 eral system is deranged in any way it should receive 
 careful attention. If there is a congested condition of 
 the urethra, the portal circulation should be kept in a 
 normal state by securing a healthy action of the liver 
 and bowels. The condition of the circulation in the 
 part involved may possibly be influenced by constitu- 
 tional medication. For this purpose. Ergot, Digitalis, 
 and Nux Vomica, in small doses regularly repeated, 
 may be of service. At least these remedies will aid in 
 securing a good general circulation, and may influence 
 favorably the local affection. If there is local conges- 
 tion, due to pressure on the pelvic vessels, the cause, 
 interfering with the return circulation, should be re- 
 moved, or remedied, if possible. 
 
 The local treatment recommended by the various 
 
294 DISEASES OF THE FEJE4LE URETHRA. 
 
 authors differs widely, but has the same end in view,,, 
 viz., destruction or removal of the abnormal growth. 
 The various methods of extirpation employed are: 
 ligation, torsion, excision by the knife, scissors, curette, 
 ecraseur, galvano-cautery, caustics, and electrolysis. 
 Any of these methods may be made to answer in 
 all cases, but a judicious selection, according to the 
 location and nature of the neoplasm, is advisable. A 
 combination of means is best at times : say, excision 
 by the scissors and cauterization afterwards. 
 
 Whatever method you may choose, you will first 
 place the patient in the lithotomy position, or in Sims' 
 position, on the left side, which I prefer, and by a spec- 
 ulum expose the part to be removed. 
 
 There are two instruments which I use for this pur- 
 pose. The first IS here shown. (Fig. 26.) It is made 
 on the principle of Sims' speculum, the ends being of 
 different sizes. An elevator is attached at the central 
 
 Fig. 26. 
 
 Skene's Urethral Speculum. 
 
 portion between the blades, and so arranged that when 
 it is closed on one blade it Is thrown out from the 
 other. This is seen in the figure. The elevator is 
 pressed down on the blade, and the instrument intro- 
 duced, and then by pressing on the other end of the 
 elevator the urethra is distended to its full natural 
 capacity. When it is necessary to expose one side of 
 
TREATMKXT. 295 
 
 the urethra completely, the elevator should be removed, 
 and the instrument used in the same way that we em- 
 ploy Sims' speculum in examining the vagina. 
 
 The other instrument is a modification of Folsom's 
 Nasal Speculum, made of wire. (See Fig. 27,) By 
 turning the nut of the screw the blades are closed, and 
 the instrument is Introduced; and by unscrewing it 
 
 Pig. 27. 
 
 Skene's Modification of Folsom's Nasal Speculum. 
 
 the elasticity of the handle throws the blades apart. 
 This instrument answers well when the tumor to be 
 removed is small, and you are obliged to operate with- 
 out assistance. It is self- retaining. The other specu- 
 lum is preferable in most cases, but in operating 
 through it you require some one to hold it for you. 
 
 When the tumor is at or near the meatus, and has 
 a large base, or if it is vascular and you fear trouble- 
 some hemorrhage, removal by ligature is preferable. 
 Having exposed the part with the speculum, transfix 
 the base of the tumor by passing a needle from with- 
 out inwards, parallel to the axis of the urethra; pass 
 your ligature round under the needle, then grasp the 
 tumor with a forceps and make traction, so as to bring 
 
■296 DISEASES OF THE FEMALE URETHRA. 
 
 the sides of the base within the grasp of your Hgature, 
 and then tie it slowly and as tight as you possibly can 
 without cutting the tissues. By taking all these 
 precautions you will be sure to get your ligature to 
 include all the abnormal tissue — a very important ac- 
 complishment indeed. If the base of the growth is too 
 large to be included easily in one ligature, you can 
 transfix with a needle armed with a double thread, and 
 tie its two halves. 
 
 In choosing the material for a ligature, I would ad- 
 vise you to use fine plaited silk, boiled in a mixture 
 of beeswax. Carbolic and Salicylic Acids. A ligature 
 prepared in this way ties easily, does not stick and 
 jerk like the ordinary ligature; and more than that, 
 it does not slip. 
 
 If the tumor is within easy reach and is peduncu- 
 lated, you can seize the pedicle with a small forceps, 
 and taking the tumor in a polypus forceps remove it by 
 torsion. Or you can cut it off with the knife or scissors, 
 and if the pedicle inclines to bleed, touch it with caus- 
 tic. You will find Allen's Polypus Forceps for the ear 
 one of the most convenient instruments for takingf hold 
 of these little tumors. (See Fig. 28.) 
 
 In cases where there are several small orowths hipfh 
 up in the urethra, they can be removed with the curette, 
 and when the hemorrhao^e has subsided the base of 
 each should be cauterized. 
 
 But little difficulty will be experienced in operating 
 in the various ways described when the neoplasms are 
 low down in the urethra, where they can be easily seen 
 and handled. When they are high up in the canal. 
 
TREA TMEiVT. 
 
 297 
 
 then skill and care are required to remove them. In 
 such cases you will succeed best with the ecraseur, or 
 
 Fig 23. 
 
 Allen's Polypus Forceps, 
 
 the instrument known as Blake's Polypus Snare, used 
 for removing polypi from the ear. (See Fig. 29.) 
 
 It is simply a very delicate ecraseur, the chain or 
 wire of which is tightened by the finger in place of a 
 
 Pig. 23. 
 
 O^ 
 
 G. T I EM ANN ACQ. 
 
 Blake's Polypus Snare. 
 
 screw. You will find that instead of the wire commonly 
 used, catgut is better ; it is stronger and more pliable, 
 yet stiff enough to be manageable. My friend Dr. 
 
298 DISEASES OF THE FEMALE URETHRA. 
 
 John W. S. Gouley was the first to use this instrument 
 for removing tumors of the urethra, and I can testify- 
 to its great value in such operations. 
 
 In operating with the snare, the tumor is exposed 
 with the urethral speculum ; and if the growth is 
 pedunculated, the loop of catgut is passed over it, and 
 removal effected by constriction. When there is a 
 broad base, the whole mass is seized with the polypus 
 forceps, and the snare is then passed over it and tight- 
 ened until it comes away. 
 
 There is one accident that very often occurs in this 
 operation, and that is breaking of the wire or catgut. 
 This takes place usually just when the tumor is almost 
 cut off, and it annoys and hinders the operator, but does 
 not spoil the operation, as a new piece of catgut can 
 be used and the operation completed. You can often 
 avoid this accident by taking time. The base or pedicle 
 of most of these growths will give way under long 
 continued pressure, but the wire or catgut will break 
 if you hurry too much. 
 
 In order to operate high up in the urethra, it is 
 sometimes necessary to dilate the lower portion of it. 
 A convenient way to do this is the following : — take a 
 piece of fine rubber tubing, and draw it over the blades 
 of the Folsom Speculum, and then introduce the in- 
 strument into the urethra. Open the blades, and let it. 
 distend the urethra as far as it can. To produce the 
 extra dilatation, take a series of graduated sounds or 
 dilators — wood or hard-rubber will answer — and force 
 one of these in between the blades of the speculum ; 
 remove that one and use a size larger, and so on until 
 
TREATMENT. 299, 
 
 you obtain the requisite amount of dilatation. The 
 blades of the speculum and the rubber tubing protect 
 the mucous membrane of the urethra from injury in 
 passing in the dilator. The danger of incontinence 
 of urine, which is liable to follow from forcible dilata- 
 tion, can be avoided by distending the lower portion of 
 the urethra only. 
 
 To obtain sufficient light for operating high up in 
 the urethra, it is necessary to have clear sunlight ; or 
 if that is not obtainable, gaslight should be used ; and 
 in either case the concave head mirror should be em- 
 ployed. 
 
 Of late years the galvano- cautery has been very 
 extensively used in surgery generally, and has been 
 recommended for the removal of urethral tumors. As 
 a means of removing large and vascular growths from 
 the meatus, it has high claims, but for general use you 
 will find that it is objectionable. In removing tumors 
 from the interior of the urethra with this cautery, it is 
 impossible to avoid cauterizing portions of the normal 
 membrane, unless extraordinary skill is employed. 
 This unfortunate liability, and the difficulty in keepings 
 the instrument in good working order, stand in the 
 way of this means of operating ever becoming popular 
 in this department of surgery. 
 
 Caustics have been more extensively used than any 
 other means of removing urethral neoplasms, and I 
 know of no better way of destroying small growths. 
 Of all the agents used, I prefer pure Nitric Acid, which 
 I use as follows : — exposing the tumor with the specu- 
 lum, represented by Fig. p. 272. I wrap a little cotton 
 
joo DISEASES OF THE FEMALE URETHRA. 
 
 around a probe, and dip it into the acid, and apply it to 
 the part to be destroyed, taking care not to touch any 
 of the normal tissues. The speculum recommended 
 has the advantage of protecting one side of the canal, 
 and by exercising care in handling the acid, accidents 
 may be avoided. 
 
 We come now to the last method of removing 
 these tumors which I shall mention, viz., electrolysis. 
 This means of treating abnormal growths has been 
 .employed so much lately that I need not detain you 
 with any description of the modus operandi, but simply 
 tell you that those tumors that recur, and those that 
 you suspect to be malignant, and those also that are so 
 high up in the urethra as to be difficult to remove, 
 should be treated by electrolysis. Two long slender 
 needles should be insulated by coating them with col- 
 lodion, except at the points. These are attached to the 
 ■electrodes of a galvanic battery, and their points in- 
 troduced into the base of the tumor, and the current 
 passed through until the whole of the abnormal tissue 
 is decomposed. I prefer to use a current sufficiently 
 strong to char the tumor, and thereby completely de- 
 stroy it. 
 
 There is one rule which I would urge you to keep 
 in mind in treating tumors of the urethra, and that is, 
 to be sure to remove all the abnormal tissue. What- 
 ever method you employ, do not leave any portion of 
 that which ought to be removed. I am confident that 
 much of the trouble experienced by these growths re- 
 turning again and again might be avoided by a careful 
 ■observance of this rule. 
 
TREATMENT. 301. 
 
 Urethral catarrh or inflammation, which frequently 
 accompanies abnormal growths, usually subsides after 
 their removal. In some cases it persists, and then it 
 should be treated according to the methods already 
 given. 
 
 There are many who prefer to perform Emmet's 
 button-hole operation for the diagnosis and treat- 
 ment of urethral tumors to dilatation of the urethra. 
 
 You will find that an examination of the parts 
 will be greatly facilitated by the application of the 
 hydrochlorate of cocaine ; and this may also be 
 employed in the removal of any painful tumor, or 
 whenever pain is so prominent a factor as to demand 
 separate attention. 
 
LECTURE VIII. 
 
 Dilatations and Dislocations of the Urethra — 
 Prolapsus of the Mucous Membrane — Foreign 
 Bodies in the Urethra — Stricture of the 
 Urethra — Incomplete Fistula of the Urethra. 
 
 Gentlemen — 
 
 Changes In the caliber of the female urethra occur 
 in two forms — dilatation and contraction ; but neither 
 of these is very often met with in practice. Of the 
 two, dilatation is the more common, and we will there- 
 fore take up that subject first. The increase in the size 
 of the urethra may involve the whole canal, or be 
 limited to a portion of it. I will first speak about 
 dilatation of the whole urethra, and then, dividing 
 the canal into thirds, consider the affection of each 
 portion. 
 
 Dilatation of the Whole Urethra. — You will under- 
 stand that dilatation to such an extent as to have the 
 canal open and its walls separated is an unknown con- 
 dition. We might more correctly express the true 
 state of things by calling it an abnormal dilatability. 
 The tissues of the walls of the urethra are in such a re- 
 laxed condition as to admit of extraordinary distension 
 
DILATATION OF THE WHOLE URETHRA. 303 
 
 Avithout injury. Dilatation of the whole urethra is not 
 so common as dilatation of a portion of it. Even when 
 the whole canal is larger than it should be, you will 
 o-enerally find that it is not uniformly so. Some por- 
 tions of it you will find more distended than the others. 
 The extent to which this dilatation may occur is very 
 ^reat. A number of cases are recorded, especially in 
 the German literature of this subject, where copula- 
 tion took place for years in the urethra instead of the 
 vagina. In these cases the dilatation was extreme. 
 
 In this affection the urethral walls and the urethro- 
 vaginal septum are usually enlarged, relaxed, and 
 ilabby. After a considerable time they may become 
 indurated by infiltration, or hyperplasia of the connec- 
 tive tissue. The mucous membrane is usually soft and 
 loosely adherent to the subjacent tissues. Beneath the 
 membrane you will sometimes find masses of enlarged 
 veins, which give a dark bluish appearance to the 
 parts. If the meatus be distended like the rest of the 
 urethra, the mucous membrane with the large veins 
 beneath it may protrude and form a tumor or tumors, 
 which have quite the appearance of rectal hemorrhoids. 
 This is especially so when the veins are large and 
 numerous, and the mucous membrane thin, so that the 
 color of the veins can be seen through it. On the 
 other hand, if the meatus remains normal in size, noth- 
 ing will be seen by the examiner until the catheter or 
 sound is passed into the urethra, when the distended 
 or distensible condition of the canal will be detected. 
 You can easily make out the dilatation, even when the 
 meatus is normal in size, by observing that the sound 
 
304 DILATATION OF THE WHOLE URETHRA. 
 
 can be moved about in the urethra, conveying the same 
 impression obtained when the sound passes into the 
 bladder. By making a digital examination of the 
 vagina, the enlarged urethra can be felt, and is usually 
 elastic and compressible. Through Sims' speculum the 
 abnormal fullness or bulging of the anterior vaginal 
 wall can be plainly seen, and distinguished from dis- 
 placement of the urethra. The points of difference be- 
 tween dilatation and displacement will be brought out 
 more in detail further on. 
 
 When the dilatation has existed for any length 
 of time, the mucous membrane is usually hypersemic^ 
 and sometimes catarrhal, secreting a muco-purulent 
 material, which may be seen escaping from the meatus,, 
 or lodged in the folds of the membrane, where you can 
 observe it through the endoscope. When the mucous 
 membrane is prolapsed and forms a tumor outside of 
 the meatus, it soon becomes fissured and ulcerated, and 
 consequently very tender and painful. This condition 
 is produced by the retarded circulation, chafing, and 
 the irritation from exposure to the air, and wetting 
 from the urine passing over it. 
 
 Dilatation of the Anterior or Lower Third. — This 
 is the rarest of all the forms of urethral dilatation, and 
 occurs usually as a consequence of some enlargement 
 or swelling of the mucous membrane, neoplasm of the 
 urethra, or mechanical dilatation. The dilatation may 
 include the meatus, or it may not. In rare cases it 
 does not at first, but later in the course of the trouble 
 the enlarged mucous membrane slowly, sometimes 
 
DILATATION OF THE LOWER THIRD. 305 
 
 rapidly, dilates the orifice. The general appearances 
 of the parts are the same as those of which I have 
 spoken under the head of dilatation of the whole ure- 
 thra. When the dilatation is due to any abnormal 
 growth from the urethra, the conditions presented will 
 be the same as those already described under the head 
 of Urethral Neoplasms. 
 
 I have only seen one case where the lower end of 
 the urethra was dilated without any recognizable cause 
 for it. This was a single lady, thirty-five years of age, 
 a school teacher. She had displacement of the uterus 
 and catarrh of the cervical canal, for which she consult- 
 ed me. She had no trouble with her urinary organs. 
 While examining the uterus I noticed that the meatus 
 urinarius was peculiarly formed. In place of the con- 
 centric corrugations of the mucous membrane which 
 form the closed meatus, the orifice was funnel shaped^ 
 and lay open when the labia minora were separated. 
 About half an inch of the lower end of the urethra ad- 
 mitted a No. 21 (Eng.) sound. The remainder of the 
 urethra was normal, and there were no signs of disease 
 about the mucous membrane of the dilated portion. I 
 could obtain no history which pointed to the origin of 
 the trouble, and it caused no discomfort to the patient. 
 
 Dilatation of the Posterior or Upper Third. — This 
 form of dilatation usually occurs in connection with 
 other pathological conditions, such as prolapsus of the 
 bladder and urethra. On this account we will defer 
 what is to be said on this subject until we come to dis- 
 locations of the urethra. 
 
3o6 DILATATION OF THE URETHRA. 
 
 Dilatation of the Middle Third of the Urethra.— 
 Dilatation at this part of the urethra is more common 
 than that ifi toto or in any other portion of the canal. 
 Do not understand me that it is confined to exactly the 
 middle third of the urethra, or that the other dilatations 
 are confined to thirds only. It is about a third ; and I 
 use the division to fix the idea clearly in your minds, 
 and for convenience of description. 
 
 In this form of dilatation the anterior wall of the 
 urethra maintains its normal position, but the central 
 portion of the canal being distended settles down, so 
 that in time the urethra, in place of being a straight 
 or slightly curved canal, becomes triangular; the up- 
 per wall being the base and the central portion of the 
 wall (that is, midway between the neck of the blad- 
 der and the meatus) the apex. A cavity is thus formed 
 in the central portion of the urethra. Fig. 30 will 
 convey the idea of the anatomical appearances of this 
 affection. 
 
 This form of dilatation has been called Sacculated 
 Urethra and Urethrocele. You will find a valuable 
 article on this subject in the Americaii Journal of 
 Obstetrics for February, 1871, by Nathan Bozeman, 
 M.D. Some of the cases related there by him are, in 
 my opinion, not simply urethral dilatation alone, but 
 •dilatation and dislocation combined. However, his 
 description of this form of trouble is the best that I 
 have even seen, and I prefer to give it to you in his 
 own words. It is as follows : — 
 
 " In the study of Urethrocele, anatomical points to 
 be considered are, the triangular ligament and Its rela- 
 
DILA TA TIOX OF THE MIDDLE THIRD. 
 
 307 
 
 tions with the urethra ; the muscular structure of the 
 urethra, and the different relations of the urethra to the 
 vagina in the upper and lower parts of its course. 
 
 "These anatomical peculiarities exert a marked in- 
 fluence on the etiology of the lesions in question, and 
 
 Fig 30 
 
 Dilatation of Middle Third of the Urethra (Urethrocele). 
 
 A. Symphysis Pubis. B. Bladder. C. Urethra (dilated). D. Uterus. 
 E. Large Intestine. 
 
 tsupply the first links in the long chain of morbid results 
 indicated by the histories of the cases above cited, and 
 others known sometimes to follow. 
 
 " In the male, stricture, although not the first mor- 
 bid alteration, denotes the first serious interruption of 
 the stream of urine, and superinduces morbid changes 
 
3oS DILATATIOX OF THE URETHRA. 
 
 in the urethra above the prostate gland, in the bladder,, 
 the ureters, and the kidneys. 
 
 "In the female, rare as it is to meet with organic 
 stricture of the same kind as in the male, the caliber 
 of the canal is quite as often, if not oftener, comprom- 
 ised, and with due allowance for the anatomical differ- 
 ences of sex, the pathologic sequences observe the 
 same order. 
 
 " The starting point of urethral and vesical lesions 
 in the female is to be sought in the lower half of the 
 urethra, closely related in front with the triangular 
 ligament, and blending behind with the spongy erectile 
 tissue of the vagina. 
 
 " The caliber of the urethra may be transiently 
 narrowed by congestion of its mucous lining, or per- 
 manently narrowed by infiltration of coagulable lymph: 
 into the underlying cellulo-elastic tissue, which consti- 
 tutes properly the so-called organic stricture, as in the 
 male, and which, however seldom met with, is liable 
 to the same sequences. 
 
 " Infiltration into the spongy erectile tissue outside 
 the urethra, by plastic lymph, is, I believe, by far the 
 most common beginning of the morbid process, what- 
 ever be the cause that produces it. This interrupts 
 the stream of urine, either by encroaching on the cali- 
 ber of the urethra, or by deflecting it beneath the 
 triangular ligament; both cases being attended with 
 more or less dilatation above. 
 
 " The next step in sequence is increased functional 
 activity of the urethral muscular coat in overcoming the 
 obstruction to the flow of urine. The result upon its- 
 
DILA TA TIOIK OF THE MIDDLE THIRD. 309 
 
 :structure Is Hypertrophy, and this will be of the eccen- 
 tric type, thickening the urethral walls, while enlarging 
 the caliber. Hence the ease with which large catheters 
 •of a proper curve pass at all stages of the disease. 
 False and true Hypertrophy here coexist. The true 
 Hypertrophy increases pari passtc with the muscular 
 contraction, and is followed by still greater distortion 
 •of the canal, at an angle more and more acute, as it 
 turns the triangular ligament, and with corresponding 
 coarctation of its walls at that point. This mechanical 
 impediment below, coincides with the increased weight 
 and volume of the stream of urine above, to put the 
 ■walls of the urethra on the stretch in the upper part of 
 its course. 
 
 " Thus is gradually formed the urinous tumor, 
 which drags down in front the adjacent vaginal wall, 
 .appearing as a prolapsus between the nymphae, and 
 -filling up the ostium vaginae. 
 
 " The looser attachment of the urethra to the vag- 
 ina in the upper part of its course facilitates this result. 
 Such is the condition of the parts to which I apply the 
 term Urethrocele. Often confounded with Cystocele, 
 it is really distinct. 
 
 " The arrest and retention of but a few drops of 
 urine at first, goes on until this may amount to a tea- 
 spoonful or more. It is then decomposed in this 
 pocket, becomes alkaline, and by its irritation pro- 
 vokes congestion of the urethral mucous membrane." 
 
 In the earlier stages of this affection the urethra 
 in front and behind the pouch is really or apparently 
 contracted ; but as the disease progresses the upper 
 
310 DILATATION OF THE URETHRA. 
 
 part of the canal and the neck of the bladder be- 
 come dislocated downwards, and finally the upper 
 portion of the urethra becomes also dilated to some- 
 extent. 
 
 There is in this, as in the other forms of urethral; 
 dilatation, frequent urination, usually more marked, but 
 unlike the others, there is difficulty in passing water.. 
 This frequency of urinating, and the straining efforts- 
 necessary to do so, affect the bladder, producing irrita- 
 tion, and, in time, hypertrophy of its walls. Cystitis- 
 also follows in the order of morbid developments ; but 
 whether that comes from the frequent and difficult uri- 
 nation, or from extension of the inflammation from the- 
 urethra to the bladder, is a question. One thing we- 
 know, and that is, that if this form of urethral dilata- 
 tion goes on without treatment, Cystitis will, sooner or- 
 later, make its appearance. 
 
 Etiology. — The hypersemia of the urethra which, 
 occurs in pregnancy, and which tends to produce over- 
 distension of the veins, favors dilatation of the whole- 
 urethra. It is not uncommon to find an apparent in- 
 crease of tissue in the walls of the urethra during- 
 utero-gestation, and the dilatability of the canal is 
 often increased also. Now this condition of the parts- 
 disappears during the involution which takes place 
 after delivery ; but when from any cause the process- 
 of involution is interrupted, the enlaro-ed vessels and 
 relaxed condition of the urethral walls remain and 
 sometimes increase. When to this state of the parts a 
 catarrh of the mucous membrane is added, the enlarge- 
 
DILATATION OF THE MIDDLE THIRD. 311 
 
 ment of the membrane by swelling still further increases 
 the caliber of the canal. 
 
 The dilatation caused by passing calculi may remain 
 permanently, and the same may be said of the use of 
 large sounds. Neoplasms obstructing the meatus, or 
 stricture at that point, may so obstruct the escape of 
 the urine as to cause dilatation at all points above. 
 This is no doubt one of the most important and fre- 
 quent causes of dilatation. Indeed, the recognition of 
 this fact has led to the suggestion of treating stricture 
 of the upper portions of the urethra by compressing 
 the meatus, and then forcing the urine into the urethra, 
 and retaining it there. 
 
 I have already stated that dilatation of the lower 
 third of the urethra is rare, and is usually due to in- 
 flammation of the mucous membrane at that point, or 
 to abnormal growths : the distension remaining after 
 the causes that produced it have been removed. This 
 and mechanical dilatation from any cause cover the 
 etiology of this form of the trouble. Baker Brown 
 says that the meatus is always dilated when there is 
 stone in the bladder. 
 
 Regarding dilatation of the upper third of the ure- 
 thra, I am inclined to believe that it occurs in conse- 
 quence of a partial prolapsus of the bladder and the 
 upper end of the urethra. The displacement of these 
 parts implies a relaxation of the tissues, caused origin- 
 ally, it may be, by injuries during confinement, and the 
 prolapsus permits an unusual pressure of the urine upon 
 the upper end of the urethra, and dilatation is the result. 
 On the other hand, the prolapsus and the accompany- 
 
312 DILATATION OF THE URETHRA. 
 
 ing relaxation of the urethral walls maybe sufficient to 
 cause the dilatation. In all the cases that I have crit- 
 ically examined, there has been displacement as well 
 as dilatation ; and the whole trouble could invariably 
 be traced to child-bearinor- or anteversion of the uterus. 
 One cause of dilatation of the middle third of the 
 urethra (Urethrocele) has been sufficiently dwelt upon 
 in Bozeman's description of the pathology of that affec- 
 tion — that is, narrowing of the lower end of the urethra. 
 This does not explain the etiology of all cases, how- 
 ever, for I have seen this form of dilatation where there 
 was no stricture or h3^pertrophy of the lower end of the 
 urethra. In such cases I have traced the cause to 
 childbirth, during which the posterior wall of the ure- 
 thra had been pushed downwards and contused, while 
 the upper remained in its normal position. The relax- 
 ation caused by this over-stretching of the urethral 
 wall formed a small pocket in the central portion, which 
 gradually dilated more and more by the pressure of 
 the urine until the Urethrocele was fully developed. 
 This explanation of the cause may be rather hypo- 
 thetical, but, so far as my observations go, it agrees 
 with the facts found in those cases which cannot be 
 accounted for by Bozeman's views on the pathology of 
 this affection. 
 
 Symptoniatology. — The symptoms vary according 
 to the extent of the dilatation, the portion of the ure- 
 thra involved, and the condition of the mucous mem- 
 brane. When the whole urethra is dilated, the only 
 symptom present may be frequent urination. When 
 
DILATATION OF THE MIDDLE THIRD. 313 
 
 there is inflammation or prolapsus of the mucous mem- 
 brane, then pain will be caused by passing water, and 
 the desire to do so will be more urgent and frequent. 
 The patient may also be annoyed by a slight loss of 
 control of the water, under the pressure of lifting heavy 
 weights, coughing, or the like. 
 
 Dilatation of the lower third of the urethra does not 
 cause any derangement of function, unless accompanied 
 with inflammation or ulceration ; then there will be 
 frequent urination possibly, painful urination certainly. 
 The symptoms in this form of dilatation are less mark- 
 ed than in the other varieties. 
 
 When the trouble is located in the upper third of 
 the urethra, the symptoms are sometimes very distress- 
 ing. In addition to the frequent — it may be constant 
 — desire to pass water, the patient is tormented with 
 partial incontinence. Coughing, laughing, sneezing, 
 stooping to lift anything, a jar on stepping from the 
 ■curbstone in crossing the street, causes an escape of 
 urine. This, as you can readily see, distresses the 
 patient very greatly. • She is all right so long as she 
 keeps quiet, or at least she has only the trouble of fre- 
 quent urination ; but as soon as she undertakes the 
 usual duties of exercise or enjoyment, then this partial 
 incontinence makes her miserable. From the constant 
 wetting of the external parts they become inflamed, 
 unless very great care is taken to keep them dry and 
 clean. In some of these cases the mortification is 
 sometimes more distressing than the physical suffering. 
 
 The symptoms occurring in dilatation of the middle 
 portion of the urethra (Urethrocele) are the same as 
 
314 DILATATION OF THE URETHRA. 
 
 those already given, with the addition of a slight me- 
 chanical obstruction, which causes difficult urination^ 
 That is, more voluntary effort is necessary on the part 
 of the patient to empty the bladder. The forcing, 
 straining efforts made by some of these patients while 
 urinating are even greater than the mechanical obstruc- 
 tion appears to account for. This may be due to the 
 accumulation of urine in the urethra, which excites- 
 extra reflex action in the bladder and urethra out of 
 proportion to the obstruction. This is the only way- 
 that we can account for the difficult urination and mus- 
 cular hypertrophy found in these cases in which there 
 is no great obstruction from stricture. 
 
 The constitutional symptoms arising from these 
 urethral troubles are the same as those produced by- 
 Urethritis, and are not peculiar to this class of affec- 
 tions. In fact, you will observe that the symptoms- 
 here given may all be produced by other pathological 
 conditions, and consequently cannot alone guide us to^ 
 correct diagnoses. The clinical history in such cases- 
 leads us to suspect the nature of the disease, but the 
 true character of the trouble can only be discovered by 
 physical exploration. 
 
 Diagnosis. — In dilatation of the whole urethra, a. 
 digital examination will detect the increased space oc- 
 cupied by the urethra. The canal encroaches uponi 
 the anterior vaginal wall, and feels like a ridge ex- 
 tending from the meatus to the neck of the bladder^ 
 This elevation or thickening of the urethra is elastic 
 and compressible in recent cases; in those of long^ 
 
DILATATION OF THE MIDDLE THIRD. 315-. 
 
 Standing, where there is hypertrophy, the tissues are 
 firm to the touch, but still the canal is compressible. 
 The extent of the dilatation can be measured by the 
 size of the sound that can be easily passed. If you 
 have even the ordinary female catheter at hand, you 
 can get an idea of the size of the canal. By intro- 
 ducing that instrument and pressing it first against the 
 anterior wall and then upon the posterior, the distance 
 between the two can be approximately made out. 
 While the catheter or sound is in the urethra, you 
 should introduce the finger into the vagina and ascer- 
 tain the thickness of the urethral wall. This will en- 
 able you to judge of the increase of tissue from in- 
 flammatory products or hypertrophy. 
 
 When the meatus is dilated and the mucous mem- 
 brane and enlarged vessels are prolapsed, you must be- 
 careful to distinguish that condition from urethral neo- 
 plasm. This you can do by observing that in pro- 
 lapsus the opening Is situated either at the upper side 
 or In the centre of the protruding mass, whereas in ab- 
 normal growths of the urethra the meatus surrounds: 
 the tumor or its pedicle. More than that, by making 
 pressure on the distended vessels you can reduce the 
 size of the prolapsed membrane and push it up into the 
 canal. This you cannot usually do with tumors. 
 
 Dilatation of the lower third of the urethra Is easily^ 
 diagnosticated. A large sound will pass In as far as 
 the dilatation extends, and will be arrested when you 
 come to that portion of the canal which has a normal 
 caliber. 
 
 You will encounter great difficulty In detecting dl- 
 
.3i6 DILATATION OF THE URETHRA. 
 
 latatlon of the upper third of the urethra, but by at- 
 tention to the following points you will usually succeed. 
 By using the sound, you will observe that while the 
 lower portion of the canal hugs the instrument firmly, 
 the point of it can be moved freely in the upper part 
 of the passage. The same impression is conveyed 
 through the instrument as that which enables you to 
 tell that you have entered the bladder ; only in dilata- 
 tion of the upper portion of the urethra, the motion of 
 the point of the sound is, of course, more limited. 
 Again, by introducing a curved sound, and with it 
 holding the anterior wall of the urethra well up under 
 the arch of the pubes, and theni carrying the finger of 
 the other hand alono- the anterior vaccinal wall, the 
 posterior wall of the urethra will be found to hug the 
 sound until you come to the dilated portion, which will 
 be felt to lie away from the instrument. By pushing 
 up the vaginal and urethral wall at the point of dila- 
 tation until they touch the sound, and then by remov- 
 ing the pressure and allowing the parts to recede from 
 the sound, the relaxation can be easily detected. 
 
 In some well-marked cases of dilatation complicated 
 with prolapsus of the upper portion of the urethra, the 
 diagnosis can be clearly made, by slowly introducing the 
 catheter until the urine begins to flow, and then mark- 
 ing the catheter at the meatus urinarius and withdraw- 
 ing it. The distance from the mark made to the upper 
 edge of the eye of the catheter indicates the length of 
 the normal portion of the urethra. If that is subtracted 
 from the normal length of the urethra, the remainder 
 Avill indicate the length of the dilated portion. 
 
DILATATION OF THE MIDDLE THIRD. 317 
 
 Dilatation of the middle third of the urethra — Ure- 
 throcele — is most likely to be confounded with thick- 
 ening of the urethro-vaginal septum. The diagnosis 
 is made by observing that the enlargement due to 
 dilatation corresponds to the central portion of the 
 urethra, and that it yields to pressure more or less. 
 Also, by passing a curved sound with the point up- 
 wards, the anterior wall of the urethra will be found 
 to occupy its normal position. Withdrawing the 
 sound, and again introducing it with the point down- 
 wards, it will pass inwards and then down into the 
 pocket found at the point of dilatation, where it can 
 be felt through the vaginal wall. 
 
 In all cases except one that have come under my 
 observation, the diagnosis has been easily made by 
 this method of examination. The exception referred 
 to was a case of peri-urethral inflammation, in which 
 an abscess formed in the urethro-vaginal septum and 
 discharged into the urethra. A fistulous opening from 
 the floor of the urethra into the sac of the abscess re- 
 mained. The urethra occupied its normal position, 
 and admitted the sound easily; and by introducing it 
 with the point downwards it passed into the sac of the 
 abscess, thus giving the physical signs of Urethrocele ; 
 but the small size of the opening in the floor of the 
 urethra, the marked infiltration and induration of the 
 tissues, and the history of the case, led to a diagnosis 
 of its true character. 
 
 Prognosis. — There is no natural tendency to recov- 
 ery in these affections. If left alone they generally get 
 
^i8 DILATATION OF THE URETHRA. 
 
 worse. Recovery under treatment is modified by the 
 location of the dilatation and the duration of the trou- 
 ble. The conditions upon which an unfavorable prog- 
 ,nosis is to be based are, bladder complications, inflam- 
 xnation or ulceration near the neck of the bladder, 
 great varicosity of the veins, and fatty degeneration of 
 the muscular tissue. In the absence of all these com- 
 plications a complete cure can be obtained. In all 
 cases great relief can be secured by treatment, and the 
 patient guarded from getting worse. 
 
 Treatment. — In the management of all forms of 
 urethral dilatation, you should first attend to any in- 
 flammation of the mucous membrane that may exist, 
 employing the usual treatment of Urethritis. When 
 there is a relaxed and prolapsed condition of the mu- 
 cous membrane, astringents should be used to over- 
 come that trouble. Tannic acid or Alum will answer 
 well. When these fail, the redundant membrane 
 should be retrenched, either by touching it with the 
 thermo-cautery or excising a portion with the scissors. 
 In employing the cautery for this purpose, you should 
 take the long pointed tip of the instrument, which is 
 used for cauterizing hemorrhoids by puncturing, and, 
 having protected one side of the urethra with the 
 speculum, cauterize a narrow strip of the membrane 
 parallel to the axis of the canal. Two or more of these 
 cauterizations may be made at points equidistant on 
 the circumference of the urethra. By operating in 
 this way you leave pieces of normal membrane between 
 the portions cauterized, which prevents stricture from. 
 
DILATATION OF THE MIDDLE THIRD. 319 
 
 (Occurring after healing — a misfortune which is sure to 
 follow if the mucous membrane is destroyed by cauter- 
 ization all round. 
 
 In excising the prolapsed portion, I prefer to re- 
 move one or more V-shaped portions on opposite sides, 
 and bring the edges together by sutures. This is pre- 
 ferable to clipping off the whole of the protruding mass, 
 because the cicatrices left are less likely to give after- 
 trouble. 
 
 When the dilatation is caused by varicose veins, it 
 may be well to follow the example of Gustave Simon. 
 He exposed the vessels by cutting through the vaginal 
 wall, ligated the largest, and arrested the hemorrhage 
 from the smaller ones by applying Liquor Ferri Per- 
 chloridi. He repeated this operation several times on 
 the same patient, who experienced little or no incon- 
 venience from the proceedings, and made a good re- 
 covery. 
 
 Dilatation of the lower third of the urethra is usu- 
 ally secondary to some other trouble, as I have already 
 stated ; and all that you will usually be called upon to 
 do for such cases, is to remove the cause and treat any 
 inflammation that may exist. The dilatation will then 
 disappear; and if it does not, but little if any trouble 
 will be caused by it. 
 
 The treatment of dilatation of the upper third con- 
 sists simply in supporting the parts. This you can ef- 
 fectually do by using the pessary already recommended 
 for the relief of prolapsus of the bladder. You may 
 find it necessary to have the instrument so formed as to 
 bring the pressure where it is required. This you can 
 
320 DILATATION OF THE URETHRA. 
 
 easily do by placing the pessary In position and observ- 
 ing what change of form, If any, Is necessary, and then, 
 directino- the Instrument maker to make the alteration. 
 If the parts are well supported In this way, recovery 
 will follow, unless atrophy of the muscular wall has 
 previously taken place. Even then the patient can be 
 kept comfortable by wearing the pessary. If there is- 
 Urethritis present, you may find It necessary to remove 
 that before using the pessary ; otherwise the pressure 
 of the Instrument may cause pain, and aggravate the 
 inflammation. 
 
 This brings us to the only remaining form of this 
 trouble to be mentioned — dilatation of the middle third, 
 or Urethrocele. Dr. Bozeman has proposed making 
 an opening Into the most dependent part of the urethra, 
 through the vaginal wall, and maintaining It until all 
 Inflammation has been relieved, and then closing the 
 opening by the usual plastic operation. By this means 
 the urethra is perfectly drained of urine and the pro- 
 ducts of Inflammation, which accumulated there before. 
 This, with appropriate cleansing and topical applica-' 
 tlons, soon restores the mucous membrane to Its normal 
 condition ; and the removal of the redundant tissue 
 during the operation of closing the opening, effectually 
 cures the whole trouble. This treatment Is admirably 
 adapted to marked cases of long standing, and should 
 be employed. By using the thermo-cautery to make 
 the opening, the operation is easily performed. In re- 
 cent cases of less severity, I have obtained satisfactory 
 results by dilating the lower part of the urethra, and 
 supporting the dilated portion either with a pessary 
 
DISLOCATIONS OF THE URETHRA. 321 
 
 or a tampon of marine lint. This permits the urethra 
 to keep itself empty ; and then, by frequently washing" 
 it out and applying such remedies as will cure the 
 Urethritis, recovery will sometimes follow. You can 
 try this treatment, and if it fails, you can resort to 
 Bozeman's method. 
 
 Dislocations of the Urethra. — This is one of the 
 affections that you will frequently meet with in practice, 
 although you will find very little in your text-books on 
 the subject. I have found very few cases recorded in 
 medical literature. This neglect of the subject by 
 authors is perhaps due to the fact that in many cases 
 of displacement of the urethra the bladder is also dis- 
 located, and the whole trouble is described under the 
 head of Vesicocele or Cystocele. Now it is true that 
 displacement of the two occurs together, but you will 
 also find that either may take place alone. It is not 
 by any means uncommon to find prolapsus of the 
 bladder while the urethra is in its normal position, and 
 occasionally you will meet a case where the urethra 
 is prolapsed while the bladder remains in its proper 
 place. 
 
 The urethra is subject to displacement upward and 
 downward. In pelvic tumors the bladder is sometimes 
 pushed up out of the pelvic cavity, and- the urethra 
 dragged along with it. Usually no harm comes from 
 this displacement, except that it may cause some 
 trouble in using the catheter, should this be necessary ; 
 hence we need not dwell on this part of the subject. 
 Dislocations downward concern us most, because they 
 
322 
 
 DISLOCATIONS OF THE URETHRA. 
 
 occur more frequently, and almost invariably cause suf- 
 fering to those so affected. 
 
 The extent of displacement varies exceedingly, but 
 I shall describe only the partial and the complete. A 
 clear comprehension of these two degrees will cover all 
 intermediate forms. In partial displacement down- 
 wards, the upper two-thirds of the urethra are prolaps- 
 ed, so that the direction of that portion of the canal 
 is backwards, instead of curving upwards, as in the 
 normal condition. Fig. 3 1 will convey the idea of this 
 degree of dislocation. 
 
 rig. 31. 
 
 Dislocation of the Upper Third of the Urethra. 
 
 A. Symphysis Pubis. B. Bladder. C. Prolapsed Portion of Urethra. D. Uterus. II. Large Intestine. 
 
 In complete prolapsus the urethra runs from the 
 meatus (which is in its normal position) backwards, 
 and rests upon the perinaeum ; or in extreme cases, 
 accompanied with prolapsus of the bladder and uterus, 
 
DISLOCATIONS OF THE UKKTIIKA. 
 
 323 
 
 its direction is backwards and downwards ; tlie position 
 of the vesical end of the urethra being below the level 
 of the meatus. In this degree of displacement the 
 urethra and bladder can be seen presenting at the 
 vulva, or lying between the labia minora. The urethra 
 is usually shortened considerably when the prolapsus 
 is marked. Fig. 32 illustrates complete dislocation. 
 
 Fig. 32. 
 
 Complete Dislocation of the Urethra with Dilatation. 
 A. Bladder. B. Symphysis Pubis. C. Uterus. D. Large Intestine. E. Urethra. 
 
 Etiology. — Utero-gestation and delivery are the 
 most important causes of this affection. In the advanc- 
 ed months of pregnancy I have observed, that while 
 the bladder rose above the pubes, the urethra was 
 pushed slightly downwards by the settling of the en- 
 larged uterus into the pelvis. In such cases, when labor 
 
324 DISLOCATIONS OF THE URETHRA. 
 
 occurs, the head of the child dislocates the urethra stilf 
 more, by pushing it still farther down. This process I 
 have often watched in forceps delivery. When the 
 child's head is large, and there is a partial prolapsus of 
 the urethra existing before the forceps are applied, you 
 can see while you make traction that the urethra and- 
 anterior vaginal wall are forced down before the ad- 
 vancing head, and that, too, while you are making 
 counter pressure to prevent it. The displacement pro- 
 duced in this way is often restored during convales- 
 cence, if proper care be taken to push the parts back. 
 into place, and the patient is kept at rest until the tis- 
 sues regain their toiticity. But in many cases the 
 trouble is overlooked, and by permitting the patient to 
 get up and be on her feet while there is still prolapsus, 
 the trouble will slowly increase, until the dislocation is 
 complete. This will surely be the case if there is any 
 loss of perinaeum. Indeed, rupture of the perinseum Is 
 an accident which permits the urethra to descend from 
 its place. You know that the perinaeum supports 
 the vaginal walls, which in turn support the urethra ; 
 and if the perinaeum is lost, even in part, the vaginal 
 walls become relaxed, or perhaps never regain their 
 tonicity after delivery, and settling down more and 
 more, carry the urethra with them. I need hardly 
 tell you, what you already know, that displacements 
 of the uterus often cause malposition of the bladder 
 and urethra. 
 
 Symptoraatology. — The symptoms arising from 
 displacement of the urethra are much the same as those 
 
DISLOCATIONS OF THE URETHRA. 325 
 
 found in dilatation and other urethral diseases. I need 
 -not, therefore, repeat them in detail. Suffice it to say, 
 "that in dislocation of the upper portion of the canal, 
 there is, in addition to frequent urination, a partial loss 
 of control of the bladder. Under the extra pressure of 
 coughing or sneezing, the water will escape. This 
 loss of control does not exist, as a rule, in complete 
 displacement. On the contrary, there is usually diffi- 
 -cult urination, which requires increased voluntary ef- 
 forts to empty the bladder. In all degrees of dis- 
 placement, the symptoms are increased in the erect 
 position, and are markedly relieved on the patient's 
 lying down. 
 
 Diagnosis. — An examination of the vagina, either 
 by the touch or speculum, will reveal the downward 
 projection of part or all of the urethra, which will sat- 
 isfy you that there is either dilatation or prolapsus. 
 You can then distinguish between the two conditions 
 by the use of the sound. The change in the direction 
 of the canal will be shown as you pass in the sound, 
 and dilatation can be excluded by observing that the 
 urethra grasps the instrument firmly at all points. In 
 ■dislocation of the upper two-thirds of the urethra, you 
 will find that the sound passes in the normal direction, 
 ■^but is arrested at half or three-quarters of an inch from 
 the meatus ; but by pushing up the vaginal wall and 
 the urethra, the sound will then pass into the bladder. 
 When the prolapsus is complete, the instrument passes 
 in easily, but takes a downward and backward direc- 
 ■tion. 
 
326 DISLOCATIONS OF THE URETHRA. 
 
 Prognosis. — Uncomplicated displacement of the 
 urethra can be remedied in the great majority of cases. 
 By placing the parts in proper position, and holding 
 them there, the relaxed tissues will usually contract- 
 sufficiently to support themselves. Should they fail to 
 do so, the patient can be, at least, made comfortable by 
 wearing some supporter. 
 
 Treatment. — When the displacement of the urethra, 
 is caused by any other trouble, such as defective peri- 
 nseum or prolapsus uteri, then these things should first- 
 be attended to. Should there be Urethritis, that also 
 should receive appropriate treatment. But the chief 
 indication is to retain the urethra in place ; and this can: 
 be easily accomplished by using the pessary which has- 
 been recommended for supporting the prolapsed blad- 
 der. You can remedy prolapsus of the upper part of 
 the urethra In this way quite satisfactorily. When the 
 whole urethra is displaced, you will often find that this 
 instrument, while It supports the upper part, will still, 
 permit the middle portion of the urethra to settle down. 
 This you may be able to remedy by making the ante- 
 rior portion of the pessary long enough to engage in 
 the introltus vulvae, and in that way keep the whole- 
 canal where it should be. Should this cause the 
 patient much discomfort, you may tampon the vagina, 
 with marine lint, and in that way keep the parts in. 
 position until you have partially overcome the trouble, 
 and then the pessary will complete the treatment. 
 
 By way of illustrating what has been said on this 
 subject, I shall give you the history of a case, which. 
 
DISLOCATIOXS OF THE URETHRA. 327 
 
 may be accepted as a fair representative of such as you 
 will oftentimes find in practice. 
 
 A lady, fifty-seven years of age, who had borne 
 seven children, and possessed excellent general health, 
 was very much troubled by a partial loss of control 
 over her bladder. While at rest she had no difificulty, 
 but on coughing, laughing, stooping, or lifting any 
 heavy weight, her urine would escape in spite of her 
 efforts to control it. I found the upper two-thirds of 
 her urethra displaced downwards. Upon separating 
 the labia, the urethra and vaginal wall presented just 
 within the introitus, like the tumor seen in prolapsus of 
 the anterior vaginal wall. Introducing the catheter, I 
 observed that it passed in the usual direction for about 
 three-eighths or half an inch, and then turned down- 
 wards and backwards, in the direction of the hollow of 
 the sacrum. I also satisfied myself that the urethra 
 was not dilated, by observing that it grasped the cathe- 
 ter rather firmly throughout its whole extent. It was 
 shortened to about an inch. This I ascertained by 
 slowly passing the catheter until the urine began ta 
 flow, and then withdrawing the instrument, and meas- 
 uring from its eye to the point marked at the meatus 
 urinarius. 
 
 A pessary was fitted to keep the parts in place, and 
 very marked relief was at once secured. 
 
 From the nature of the dislocation, and the very 
 prompt relief following the treatment, I am inclined to 
 think that the incontinence in such cases is due to the 
 settling down of the upper portion of the urethra, by 
 which the pressure of the bladder contents falls directly 
 
•328 DISLOCATIONS OF THE URETHRA. 
 
 •on the sphincter vesicae, and overcomes its resisting 
 power. Whether this is the correct explanation or 
 not, one thing is certain, and that is, that cases Hke the 
 foregoing are often met with in practice, and the treat- 
 ment of restoring the dislocated urethra gives prompt 
 relief 
 
 You must not suppose, from what has been said 
 about this case, that the partial loss of retentive power in 
 the bladder so frequently met with in women who have 
 borne children, is always due to dislocation of the 
 urethra. The following case will illustrate sufficiently 
 well a class whose symptoms might lead you to sus- 
 pect dislocation of the urethra when it did not exist : — 
 
 A lady fifty- five years of age, the mother of six 
 children, came to consult me on the subject of her urin- 
 ary troubles. She said that she was obliged to urinate 
 oftener than she used to, and that she could not stand 
 or walk for any length of time without being annoyed 
 by the dribbling of urine. 
 
 She was rather out of health generally. Her di- 
 gestion was labored, and she was anaemic and easily 
 fatigued. Dislocation of the urethra was suspected, 
 but upon examination the pelvic organs were all in 
 proper position and free from disease, except that 
 there was a want of muscular tonicity of the perinseum 
 and vagina. The urethra was congested throughout 
 its entire extent, and hypersensitive, especially at its 
 upper portion. There was also some slight dilatation, 
 or abnormal dilatability, of the upper two-thirds of the 
 canal. 
 
 She was treated with vaginal injections of cold 
 
PROLAPSUS OF THE MUCOUS MEMBRANE. 329 
 
 ivater, the application of tannin in solution to the 
 urethra, and tonics, including small doses of Nux Vom- 
 ica. As her general health improved, her urinary 
 troubles gradually left her. You will observe that this 
 case belongs to the class of dilatations,' but is given 
 here to show its resemblance to that of dislocations. 
 
 Prolapsus or Inversion of the Urethral Mucous 
 Membrane. — Having disposed of dislocations of the 
 urethra, we must now refer briefly to prolapsus of its 
 mucous membrane. This subject has been already 
 •spoken of in connection with urethral dilatations, and 
 little more need be said about it, except to mention that 
 it occasionally occurs as a distinct affection. In fact, 
 the membrane cannot become inverted unless there is 
 a change in its structure and its relations to the tissues 
 beneath it : hence it must in all cases be a secondary 
 affection. The membrane must be increased in extent 
 of surface, either from relaxation of its fibres or hyper- 
 plasia, and its basic attachments be loosened, before it 
 can be prolapsed. These changes are doubtless the 
 result of mal-nutrition (in the form of degeneration) 
 or inflammation. 
 
 The prolapse may be limited to one side, or extend 
 all around the canal. The size and extent of the pro- 
 trusion vary considerably. If the meatus is of full size, 
 the prolapsed portion will usually preserve its natural 
 color for a time ; but after a little, from chafing when 
 wet with urine, and especially if not kept clean, it will 
 l^ecome red and oedematous. When the meatus is 
 small, these changes occur sooner and in a more mark- 
 
330 PROLAPSUS OF THE MUCOUS MEMBRANE. 
 
 ed degree, because the prolapsed portion is partially 
 stran ovulated. 
 
 The longer the membrane remains exposed, the 
 more sensitive it becomes, and the frequency of urina- 
 tion and pain attending it increase. It also becomes 
 very tender and painful to the touch. In marked cases 
 the ordinary movements of the body irritate the parts, 
 and in that way render walking painful. 
 
 These are symptoms, you observe, that closely re- 
 semble those of irritable growths at the meatus urina- 
 rius ; and so far as history is concerned you will not 
 be able to make a differential diag-nosis. To do this it 
 is necessary to make a local examination. The physi- 
 cal signs and the points in the diagnosis between this 
 affection and other diseases have been given briefly but 
 sufficiently under the head of dilatations of the urethra, 
 and need not be repeated here. 
 
 The causes of prolapsus of the urethral mucous 
 membrane are numerous ; but those that are best, 
 known are long continued congestion of the membrane, 
 urethral and cystic irritation, keeping up frequent urin- 
 ation, and vesical tenesmus. Chlorotic and greatly de- 
 bilitated women are said to be predisposed to it, as also- 
 old prostitutes. The few cases that I have seen were 
 in women over fifty years of age, and all of them were 
 weak, nervous patients, who had suffered from some 
 organic disease or functional derangement of the uri- 
 nary organs. 
 
 Prognosis. — This disease does not yield promptly tO' 
 mild treatment, unless it is seen early in its progress ; 
 
STRICTURE OF THE URETHRA. 
 
 33^ 
 
 and if it does yield to mild, soothing and astringent 
 applications, it is liable to return. But in case there is- 
 no other disease present that tends to keep it up, it. 
 can usually be cured by surgical means. 
 
 Treatment. — When a case is first seen, it is well ta 
 remove any inflammation or other complicating condi- 
 tions. The prolapsed membrane should be replaced, 
 and the patient kept quiet in bed, to favor the reten- 
 tion of the parts in situ. Astringents, such as Tannic 
 Acid, Alum, or Persulphate of Iron, in a mild solution, 
 should also be used. Should these fail, you must then 
 resort to the operation for removal of the prolapsed 
 portion of the membrane. The methods of doing this- 
 (by excision and the thermo-cautery) have already 
 been described. 
 
 It only remains for me to tell you that Winckel 
 operates by clipping off the prolapsed portion of the 
 membrane, and then stitching the internal edge of the- 
 membrane to the edge of the meatus with silver wire, 
 allowing the sutures to remain in place for from five to- 
 seven days. If you operate in this way you must keep- 
 your patient under observation, and see if contraction 
 of the meatus takes place ; and if it does so, treat it 
 by dilatation. 
 
 Stricture of the Urethra: Pathology.— Obstruction 
 of the urethra, by narrowing of its caliber, is a much 
 less common affection in the female than in the male. 
 Still it occurs sufficiently often to demand your atten- 
 tion. There are some facts in the pathology of ure- 
 
332 STRICTURE OF THE URETHRA. 
 
 thral stricture, peculiar to women, which we will first 
 notice. Passinsf over conorenital narrowino- of the 
 urethra, by simply saying that such a malformation 
 has been known, we find that stricture is developed in 
 the female, as in the male, by the deposit of inflam- 
 jmatory products beneath the mucous membrane, which 
 by gradual contraction constricts the canal. Ulcer- 
 ation of the membrane in a marked degree produces 
 the same results. The inflammation and ulceration 
 ^ which end in the formation of stricture are usually 
 specific in character ; but the same may follow from 
 the too free use of caustics, and injuries during child- 
 birth. Stricture may also be produced by bands of 
 new tissue formed in the anterior vaginal wall and 
 stretching across the urethra. Contraction of the 
 whole canal occasionally occurs in cases of vesico-vag- 
 inal fistula of long standing. There the narrowing is 
 simply the result of disuse. The form of stricture that 
 will most frequently come under your observation will 
 be a contraction of the meatus urinarius, produced in 
 many cases by the too liberal use of caustics in the 
 treatment of abnormal growths at the lower end of the 
 urethra, or from Vulvitis. This form of stricture is 
 the least troublesome, and is easily relieved. When 
 due to the results of former Urethritis or Peri-urethritis, 
 the walls of the urethra are thickened and indurated 
 •at the point of the stricture, and there is usually 
 Sub-acute Urethritis; sometimes ulceration. In those 
 cases where the caliber of the canal is diminished 
 by cicatrices of the vaginal walls, and in general 
 contraction of the urethra in vesico-vaginal fistula of 
 
STRICTURE OF THE URETHRA. 333, 
 
 long standing, the mucous membrane may be perfectly 
 normal. 
 
 Symptomatology. — Frequent and difficult urination 
 are the chief troubles caused by stricture of the urethra. 
 The stream becomes smaller, and may be twisted or 
 flat, but this is rarely observed. Patients as a rule only 
 notice that they require to urinate more frequently, and 
 that they have to make more voluntary efforts to empty 
 the bladder than were necessary before. You will also 
 find, in almost all cases of stricture, that the subject has 
 at some previous time suffered an injury at childbirth, 
 Urethritis, or something to which the origin of the stric-^ 
 ture can be traced. Be careful, then, to get the pre- 
 vious history of cases in which you suspect strictures- 
 It will aid you in settling the diagnosis and etiology. 
 
 Diagnosis. — A digital examination by the vagina 
 will reveal thickening and induration, if the stricture is 
 due to that cause. Cicatrices of the vaginal wall com- 
 pressing the urethra can be detected in the same way. 
 The use of the sound will enable you to determine the 
 location of the stricture, and the extent to which the 
 canal is contracted. When the stricture is at the mea- 
 tus you can find it with facility, and measure the size 
 of the opening with equal ease ; but when it is located 
 higher up, you should first pass the largest sound that 
 can be introduced without force up to the point of 
 stricture. This will localize it ; then by using a sound 
 that will pass through it, the extent of the constriction 
 will thus be ascertained. 
 
234 STRICTURE OF THE URETHRA 
 
 The affections which you are Hable to mistake for 
 •stricture are retention of urine or difficult urination 
 from pressure on the urethra by the displaced gravid 
 uterus, pelvic tumors, and dislocations of the urethra. 
 You can exclude the former by a vaginal examination, 
 and the latter can also be detected by the sound, used 
 as directed while discussing the diagnosis of the dila- 
 tations. 
 
 Prognosis. — Stricture of the urethra usually yields 
 Tery promptly to treatment, so that the prognosis is 
 good. The only exceptions are where the stricture 
 has existed, in a marked degree, long enough to cause 
 dilatation of the ureters and disease of the kidneys. 
 Chronic Cystitis or Urethritis, occurring as a result of 
 the stricture, or coincident with it, may so complicate 
 matters as to make recovery slow or even impossible. 
 In cases where the whole urethra is contracted because 
 of the existence of a vesico-vaginal fistula of long 
 standing, there you may find it extremely difficult to 
 restore the tissues of the urethral walls to their normal 
 •state. 
 
 Treatment. — The treatment of stricture will depend 
 upon its location and cause. If it is situated at the 
 meatus, it can be divided by the urethrotome, or for- 
 'cibly stretched with the dilator. When due to bands 
 of new tissue in the vagina, they should be divided at 
 several points, and the urethra dilated by repeatedly 
 passing the sound. When it Is owing to deposition of 
 the products of inflammation in the submucous tissue. 
 
A T JUNCTION WITH THE BLADDER. 335 
 
 forcible and rapid dilatation, as practiced on the male 
 subject, will answer well if you select the proper cases 
 for this form of treatment. Remember, while opera- 
 ting in this way, to make your dilatation carefully, with 
 a view to breaking up the constricting tissue without 
 lacerating the mucous membrane. To do this it is 
 not necessary to dilate the urethra to any great ex- 
 tent. As soon as you feel that the stricture has given 
 way, suspend your dilatation. 
 
 Incising the stricture from v/ithin outwards, accord- 
 ing to the method commended by Otis for the cure of 
 stricture in the male, will no doubt answer a good pur- 
 pose. In fact, I am inclined to believe that this plan 
 ■of treating this affection is the best ; but my own ex- 
 perience with this operation on the female urethra is 
 not sufficient to warrant my speaking positively. 
 
 In contraction of the whole urethra, arising from 
 disuse in cases of vesico-vaginal fistula, gradual dila- 
 tation with graduated sounds answers very well. This 
 should be attended to before closing the opening in the 
 bladder. In all cases, attention should be given to any 
 inflammation that may accompany the stricture or fol- 
 low the treatment. It is well also to keep such pa- 
 tients under observation, and pass the sound from time 
 to time, to see if there is any tendency for the stricture 
 to return. 
 
 Stricture at the Jxinction of the Urethra and 
 Bladder. — Your attention is' specially called to this form 
 or location of stricture, because it is, so far as I know, 
 peculiar to women, and its Influence on the function 
 
336 STRICTURE OF THE URETHRA 
 
 of the bladder has not been clearly pointed out. In: 
 fact, no distinction has been made between the patho- 
 logy or clinical history of stricture at the upper end 
 of the urethra and elsewhere in the canal. At least, I 
 am not aware that writers on this subject have men- 
 tioned this form of stricture. My own observations oa 
 this subject have been limited, but sufficient, I think, 
 to warrant me in saying that stricture does occur at 
 the junction of the bladder and urethra, and that it 
 behaves differently from ordinary stricture at other 
 parts of the canal. 
 
 From the study of the cases which have come un- 
 der my notice, I have been led to the conclusion that 
 stricture at this point may be produced by the causes 
 which give rise to the same affection elsewhere. The 
 upper portion of the urethra is liable to the same trau- 
 matic affections and inflammatory troubles as the rest 
 of the urinary organs ; and the same products or re- 
 sults of disease which cause stricture of the other por- 
 tions of the urethra act just the same at the point in 
 question. We need not, therefore, dwell on the ana- 
 tomical lesions found in this affection. The point of 
 most importance to which I desire to call particular at- 
 tention is the fact that stricture at this part of the ure- 
 thra will cause difficult urination out of proportion to 
 the extent of the narrowing of the canal. In other 
 words, thickening of the tissues at the union of the 
 urethra and bladder, with contraction of the canal in a 
 slight degree, will cause great difficulty in urination, 
 and frequently retention. This, you see, is contrary to 
 the history of stricture of the urethra at other points^ 
 
AT JUNCTION WITH THE BLADDER. 337 
 
 In such cases there is no retention of urine until the 
 stricture closes the canal, or very nearly so ; but I have 
 seen retention in cases of stricture at the neck of the 
 bladder while a medium-sized catheter could be passed 
 with ease ; thus showing that the narrowing of the canal 
 was not alone the cause of the deranged function. It 
 would appear that the change in structure of the tissues 
 prevented the normal action of that portion of the canal 
 which performs the function of a sphincter vesicae. 
 You remember that when discussing the anatomy and 
 function of the bladder and urethra, I stated that the 
 process of closing and opening the neck of the bladder 
 was not fully understood, and I must acknowledge a 
 like inability to explain the disturbance of function 
 which is caused by partial stricture at this point. 
 Spasmodic stricture suggests itself as the explanation 
 of the symptoms presented in such cases ; but it is 
 excluded by demonstrating the presence of organic 
 narrowing of the canal. 
 
 The symptoms presented in this form of stricture 
 are difficult urination, and in some cases complete re- 
 tention. I have also noticed, in one case, that there 
 was a frequent desire to urinate ; but that was account- 
 ed for by a slight catarrh of the bladder. 
 
 These symptoms, you will observe, are such as 
 we find in other conditions, such as Atrophy and Para- 
 lysis of the bladder ; obstruction of the urethra from 
 tumors ; Calculi ; or the pressure of the displaced 
 uterus, and prolapsus of .the bladder. We cannot, 
 therefore, detect the affection from the phenomena 
 presented. 
 
338 STRICTURE OF THE tJRETHRA 
 
 Diagnosis. — In this form of stricture tliere is thick* 
 ening and induration of the neck of the bladder, which 
 may be detected by digital examination of the vagina. 
 The sound will also reveal a narrowing of the canal at 
 the vesical neck, but the contraction may not be mark- 
 ed. Our main reliance must be placed upon the exclu- 
 sion of all other conditions which can produce the same 
 symptoms. Pressure upon the urethra and prolapsus 
 of the bladder can be excluded by an examination of 
 the pelvic organs ; and the use of the sound will show 
 anything like complete obstruction of the canal. 
 
 Having cleared away the possible existence of 
 either of these conditions, we come to the two affec- 
 tions which are most likely to be confounded with this 
 form of stricture, viz.. Atrophy and Paralysis of the 
 bladder. To distinguish these from the stricture, the 
 ■catheter should be passed when the bladder is well 
 distended, and the character of the flow of urine watch- 
 ed, when you will observe that in stricture the urine 
 comes away with the usual force. The bladder con- 
 tracts normally and with its natural vigor, and sends 
 the urine out in a well-sustained stream through the 
 catheter, if there is stricture. On the other hand, in 
 Paralysis and Atrophy, the stream is slow and without 
 force, so much so that voluntary effort, or the pressure 
 of the hand on the abdomen, is sometimes necessary 
 to empty the bladder. This is especially so when the 
 •catheter is used while the patient is in the recumbent 
 position. Finally, you can confirm your diagnosis by 
 testing the dilatability of the urethra. This you can do 
 by passing a dilator (say Hunter's) along the urethra, 
 
A T JUNCTION WITH THE BLADDER. 339 
 
 and gently testing the resistance of the walls of the 
 •canal. You can in this way observe a slight yielding 
 at all points until you come to the stricture, and then 
 you will meet with decided resistance. By careful at- 
 tention to these points in the investigation, I believe 
 ;^ou will be able to make a diagnosis with reasonable 
 certainty. 
 
 The history of a case or two will serve to make this 
 subject more clear. 
 
 Mrs. D. S., aged thirty-two; married fourteen 
 years, and has had three children; tke eldest twelve 
 years, and the youngest four years. Thirteen years 
 ago she had typhoid fever, and during her fever had 
 retention of urine, which necessitated the use of the 
 catheter for about two weeks. After recovering she 
 was able to empty the bladder without difficulty, but 
 5he suffered from frequent and painful urination. After 
 the birth of her second child, eight years ago, her blad- 
 der trouble became much worse, and she has been 
 ^obliged to use the catheter almost daily ever since. 
 When comparatively free from pelvic pain and tender- 
 ness (a relief that she seldom enjoys, except for a few 
 -days at a time), she can empty the bladder by making 
 strong voluntary efforts; but the rule is that she is 
 obliged to use the catheter about every four or five 
 hours. The bladder and urethra were In their normal 
 positions, but there was slight thickening and indura- 
 tion of the tissues, at the union of the urethra and 
 bladder. A No. lo (Eng.) sound passed easily up to the 
 neck of the bladder, where It was arrested. A No. 8 
 (Eng.) was then used, and it entered the bladder after 
 
340 STRICTURE OF THE URETHRA 
 
 encountering a little resistance at the point named. 
 The catheter was then introduced, and the urine flowed 
 freely and rapidly, the bladder contracting promptly 
 and with its normal visfor. While the instrument was 
 still in place a vaginal examination (by the finger) was 
 made, and the enlargement and induration of the ure- 
 thral wall were distinctly felt. Dilatation of the ure- 
 thra was then tried, and the canal yielded readily at all 
 parts except its extreme upper end, where it was found 
 wanting in elasticity. There was slight catarrh of the 
 bladder, as shown by an excess of mucus in the urine. 
 The urethra was also congested. The patient was 
 very weak, nervous and dyspeptic. She was put upon 
 a course of tonic treatment, and the canal slowly dila- 
 ted by passing, twice a week, graduated conical sounds, 
 each one being allowed to remain in place for five or 
 ten minutes at a time. She improved, but when last 
 seen she still had difficulty in passing her water. 
 
 Other cases might be given from my own records, 
 but I prefer to present one the history of which was 
 given to me by my friend Dr. Paul F. Munde. I do 
 not wish you to understand that the only difficulty in 
 the following case was stricture ; I only desire to call 
 attention- to the fact that she had retention of urine 
 and also stricture at the neck of the bladder. Still I 
 am aware that the retention may have been due to 
 some other cause — perhaps paralysis of the bladder. 
 There are some points in the history of the case which 
 do not pertain to the question now under discussion, 
 but I prefer to give the full record in the doctor's own 
 words : — 
 
A T JUNCTION WITH THE BLADDER. 341 
 
 " Lizzie C, twenty-two years of age, single; admitted to 
 Woman's Hospital Dec. 27, 1876. Menstruated first at twelve. 
 The menses since have been irregular, amount small and always 
 with pain in back and hypogastrium, through whole flow of 
 two days. General health always good until she had a ' bilious 
 attack,' six years ago. Four years ago the flow became more 
 and more scanty, and finally ceased entirely three years ago, 
 since which time she has not menstruated at all. Four years 
 ago, after a ' bihous attack,' she had retention of urine for 
 three days, at which time the catheter was used. She had sev- 
 eral attacks of retention thereafter, at intervals, then micturated 
 naturally for one year, but for the past three years has not 
 been able to empty her bladder without the aid of a catheter, 
 which she introduces herself habitually three times in the 
 twenty-four hours. She has no desire to micturate, and can 
 hold her urine twenty-four hours without discomfort, save a 
 slight sense of distension. She has leucorrhcea. Has slight 
 menstrual molimina every four weeks, backache, hypogastric 
 pain, and soreness in breasts, constant pelvic weight and 
 dragging. Bowels constipated. General health good. There 
 is now frequent nausea. 
 
 " Physical Exaininatioji. — ^There is anteflexion ; depth of 
 the uterus 2^ inches; both ovaries prolapsed and tender; 
 right enlarged. 
 
 " Treatment. — Hot vaginal douche. Strychnia, Benzoic 
 Acid ; later, daily washing out of bladder with acidulated 
 warm water (Ac. Muriat. dil. gtt. ij to Oj). Urine contains a 
 large quantity of mucus and Triple Phosphates. Washing 
 out of bladder gives no rehef Phosphoric Acid mixture with 
 Ergot and Iron were given for months with no benefit. Cups 
 to lumbar region ; galvanic current through pelvis twice a 
 week. 
 
 ^' Feb. 3, 1877. Bladder washings omitted, as they caused 
 pain. Large doses of Ergot were given for two months (the 
 
342 STRICTURE CF THE URETHRA. 
 
 Strychnia being omitted after four months' trial), but without 
 benefit. Faradic and galvanic current also used alternately- 
 every day for months without benefit. Discharged unimprov- 
 ed in any way, May 30, 1877. 
 
 '' Readmitted October, 1877. Condition the same. 
 
 " Oct. 31. Urethra dilated under ether; finger introduced 
 into bladder, which was found flaccid, and did not contract on 
 the finger, which, however, was so closely constricted at the 
 sphincter vesicae as to leave a circular ring on the finger, the- 
 distal portion of which appeared blue and almost numb on- 
 being withdrawn, after about five minutes. During the intro- 
 duction of the finger the greatest amount of opposition felt was- 
 at the sphincter ; therefore the supposition was expressed that 
 the retention might be due to spasmodic contraction of the 
 sphincter (hysterical, probably, connected with and dependent 
 on the amenorrhoea, or deficient pelvic innervation), accom- 
 panied by atony of the detrusor from the same causes. 
 
 " On examining the pelvic cavity with the finger in the 
 bladder, the left ovary was found normal in position, but small- 
 er than it should be, being about the size of a shelled almond ; 
 the right, however, was distinctly felt as a globular body of 
 the size of an English walnut While practicing bi-manual 
 palpation on this ovary, it suddenly collapsed under the 
 fingers and entirely disappeared, and could not be found 
 on careful palpation. The explanation doubtless is that a 
 cyst had been ruptured, and a partial cause at least for 
 the amenorrhoea was thus discovered. Peritonitic symptoms- 
 were feared, and ice and Opium given ; but, save some 
 supra-pubic soreness, no inflammatory reaction followed. Re- 
 tention persisted, and urine had to be drawn the afternoon of 
 the dilatation. 
 
 " Nov. 9. Goodman's self-retaining catheter, with rubber 
 tubing attached, was introduced for the purpose of allowing 
 the urine to dribble off into a urinal, and thus give the bladder 
 
FOREIGN BODIES IN THE URETHRA. 343 
 
 a chance to 1 ecover its tone. But the catheter caused so much 
 pain that it had to be removed after several days. 
 
 "Nov. 19. Soft-rubber catheter was introduced, with 
 tubing, etc., for hke purpose, and is now retained and on 
 trial. This also caused pain, and was removed. Subsequent- 
 ly vaginal cystotomy was performed by Dr. Emmet, but 
 without avail; and the patient, after months of ineffectual 
 treatment, was finally discharged uncured." 
 
 Treatment. — Regarding the management of stric- 
 ture at the junction of the urethra and bladder, I am 
 obliged to say that my experience has riot yet been 
 sufficient to enable me to speak definitely. You will 
 see by the history of Dr. Munde's case that rapid and 
 free dilatation is not sufficient to effect a cure; at least 
 it did not relieve his patient. Division of the stricture 
 by incision suggests Itself; but I am confident that that 
 operation would be unsatisfactory, because of the great 
 irritation which always occurs when there Is a solution 
 of continuity at that point. My practice, therefore, 
 has been to produce slow and gradual dilatation by the 
 use of graduated sounds, and the application of Oleate 
 of Mercury or Iodine to the anterior vaginal wall at the 
 site of the stricture. More extended observation may 
 develop other and better methods of treatment, but for 
 the present this is all that I have to offer on this subject. 
 
 Foreign Bodies in the Urethra. — Having spoken 
 to you at some length upon the subject of foreign 
 bodies In the bladder, I shall confine myself chiefly to 
 the practical points relating to foreign bodies In the 
 urethra. The character of the bodies and their classl- 
 
344 FOREIGN BODIES IN THE URETHRA. 
 
 fication are the same as these given while discussing" 
 foreigfn bodies in the bladder. 
 
 Symptoms. — The chief symptom, if the body be of 
 any size, is retention of urine. In some cases the ob- 
 struction is complete, in others the urine comes away 
 in drops. In all cases there is pain and spasmodic 
 action of both the bladder and the urethra. If the body 
 be rough or pointed, it will injure the urethral wall, 
 and there will usually be hemorrhage, and later, inflam- 
 mation, possibly peri-urethral abscess. If not pointed, 
 but hard and rough, it may ulcerate through the ure- 
 thral wall, causing considerable hemorrhage. When 
 the obstruction is kept up for any length of time, the 
 greatly distended bladder becomes very painful, and 
 may be felt as a hard tumor above the pubes. 
 
 If obstruction occurring from this cause be neg- 
 lected, such injuries of the bladder and kidneys as 
 have already been described will ensue. 
 
 Diagnosis. — The pain and retention will lead you 
 to examine the urethra, first by catheter or sound, and 
 then by the finger in the vagina. In this way the for- 
 eign body is readily detected, unless it be very soft, in 
 which case it seldom produces retention, being usually 
 washed out by the urine. 
 
 Treatment. — .The foreign body being detected, its 
 extraction should be attempted, first by seizing it with 
 a pair of long-bladed forceps, keeping it firmly in place 
 by a finger pressed on the urethra (through the vagina) 
 
INCOMPLETE FISTULA OF THE URETHRA. 345 
 
 behind it. If this is not successful, you may try to 
 hook it out with a wire loop. 
 
 I have seen two cases of Calculi lodged in the ure- 
 thra. The first one was detected by using the cathe- 
 ter to relieve the retention of urine, and the other was 
 felt through the vaginal wall, while exploring with the 
 finger to determine the cause of the pain in the ure- 
 thra and the inability to pass water. 
 
 The first one, which was lodged near the meatus, 
 was removed as follows: — the forefinq-er of the left 
 hand was introduced into the vagina, and pressed 
 above the calculus to steady it. A wire curette was 
 then passed beyond the stone above, and by making 
 traction with the curette and pressing with the finger 
 from above downward, the body was extracted. 
 
 The other was lodged higher up in the urethra, and 
 was removed by the same method, only I used the al- 
 ligator forceps instead of the curette. 
 
 If it cannot otherwise be reached, you may dilate 
 the urethra up to the point where the body is lodged, 
 and then try your skill at extraction. If still unsuccess- 
 ful, you have your choice of cutting into the urethra 
 and removing it, or of pushing it back into the bladder 
 and then performing lithotripsy. To me the former 
 :seems preferable. 
 
 Incomplete Internal Urethral Fistula. — This is one 
 of the rather rare affections, but it deserves a brief 
 notice here, because you will find little, if anything, 
 said about it in your books, and you will very likely 
 meet with it some time in practice. 
 
346 INCOMPLETE FISTULA OF THE URETHRA. 
 
 The Pathology is pretty clearly indicated by the 
 name. It is simply an opening in the urethra which 
 leads into the walls of the urethro-vaginal septum, but 
 does not open into the vagina. It is the reWt of some 
 pre-existing disease. 
 
 The causes which produced this affection in the 
 cases which I have seen (I recall only two that have 
 come under my notice) were, in the first, a peri-urethral. 
 inflammation which suppurated and discharged into the 
 urethra, and in the second, a cyst which formed in the 
 urethro-vaginal septum, which also opened into the ure- 
 thra. In the first case, I suspect that the patient had^ 
 Gonorrhoea during pregnancy, and after confinement 
 an abscess formed in the anterior vaginal wall, and 
 opened into the urethra, as I have already stated. The 
 walls of the abscess contracted, but instead of healing 
 completely, there remained a sinus which communicat- 
 ed with the urethra. This much was inferred from the 
 history obtained regarding its origin. When she was 
 first seen, the fistulous opening was found in the floor 
 of the urethra, and it led into the thickened and indu- 
 rated septum between the urethra and vagina. 
 
 The other case was developed under my own obser- 
 vation in the following way: — the lady was pregnant, 
 and during that time observed that there was some 
 enlargement just within the introitus vaginae. On ex- 
 amination, a cyst was found in the anterior vaginal wall 
 at the middle of the urethra. She was at the eighth, 
 month of utero-gestatic^ when this diagnosis was made^ 
 and we decided to let the matter rest until her confine- 
 ment. Immediately after the birth of her child, inflam- 
 
INCOMPLETE FISTULA OF THE URETHRA. 347 
 
 mation was set up in the cyst, and suppuration follow- 
 ed. An opening was made into the cyst from the 
 vagina, and pus was freely discharged. At the same 
 time pus began to flow from the urethra. The dis- 
 charge continued from both openings for some time,, 
 and then the vaginal opening closed, but pus continued 
 to flow from the urethra for many weeks. A probe 
 could be passed from the fistulous opening in the ure- 
 thra into the sac, which slowly contracted, and finally, 
 at the end of six months, closed entirely, and the pa^ 
 tient completely recovered. 
 
 Ssmiptomatology. — There is pain during urination^ 
 and heat and aching distress in the urethra ; and if the 
 opening is near to the neck of the bladder, frequent 
 urination and vesical tenesmus. Pus is discharged 
 from the urethra during urination, and is found in the. 
 urine. It also oozes away at all times. In some cases, 
 the urine enters the fistula and causes smarting, burn- 
 ing pain during and for some time after urination, by- 
 distending the sac or burrowing in the tissues. 
 
 Diagnosis. — Examining the vagina by the finger 
 will enable you first to detect the thickening and indu- 
 ration of the walls of the urethra and vagina at the 
 seat of the fistula ; and by making pressure with the 
 finger, from above downwards, pus and urine can be 
 pressed out, and may be seen as they escape from the 
 meatus urinarius. You should then take a small probe 
 with a bulbous point, and making a short curve at the 
 end of it, pass it into the urethra, with the curve direct- 
 
348 INCOMPLETE FISTULA OF THE URETHRA. 
 
 ed to the floor of the canal ; and by moving it to and 
 fro you can usually find the fistula. The point of the 
 probe will get caught in the opening, and by carrying 
 it downwards the point of it can be felt through, the 
 wall of the vagina. 
 
 The only condition which is liable to be confounded 
 with fistula is Urethrocele, but by keeping in mind the 
 physical signs of that affection you will be able to make 
 the distinction. Should you be in doubt, use the endo- 
 scope to examine the urethra. This will enable you 
 to find the fistula, and then by using the speculum you 
 can probe the opening through it. A flexible gum 
 catheter may be used, if you cannot succeed with the 
 silver probe. 
 
 Treatment. — The cases that have come under my 
 care were treated by washing out the urethra with warm 
 water and Borax several times a day, and keeping the 
 sac emptied as completely as possible by making pres- 
 sure on the urethra, through the vagina, with the fin- 
 ger. Both cases were very tedious, and required much 
 care and long treatment. This experience has satis- 
 fied me that the management of such cases ought to 
 be altogether different from that which I employed. I 
 am confident that better and more prompt results would 
 be obtained from converting the incomplete into a com- 
 plete fistula. This could be easily accomplished by 
 passing a probe into the opening as far as possible and 
 then cutting down upon it through the wall of the va- 
 gina. By this operation a urethro-vaginal fistula is 
 made, and by proper treatment it will close of its own 
 
INCOMPLETE FISTULA OF THE URETHRA. 349. 
 
 accord. During the after-treatment the patient should 
 wear a self-retaining catheter, or, what is still better, 
 have the bladder emptied regularly by the catheter. 
 This will keep the urine from getting into the fistula 
 and so prevent healing. Care should be taken to 
 keep the opening in the vagina from uniting before the 
 urethral opening is healed. This can be accomplished 
 by passing the probe into it from time to time. The 
 whole fistula should be kept clean by injecting water 
 into the urethra and letting it flow through the fistula 
 into the vagina. In case the tissues are so indurated 
 and changed in character as to refuse to heal under 
 this treatm.ent, then you will be obliged to close the 
 fistula by the usual operation. The method of operat- 
 ing is the same as in vesico-vaginal fistula, a descrip- 
 tion of which you can find in any of your modern 
 works on Gynecology. 
 
APPENDIX TO LECTURE I. 
 
 EXTROVERSION OF THE URINARY BLADDER. 
 
 BY DANIEL AYRES, M.D., LL.D. 
 
 The patient, whose case is referred to on page 43, was 
 28 years of age ; and entered the Brooklyn City Hospital 
 — two months after she gave birth to a healthy child — 
 because of a complete prolapsus uteri. She was dis- 
 charged in about the same condition as she entered (see 
 Virg. Med. jfotirn., January, 1859). -N*^ pessary could sup- 
 port the womb, and the parts were intensely irritated. 
 
 Fig. I represents the case as shown at the L. I. C. Hosp. 
 The prolapse remained reduced as long as she was in the 
 recumbent posture. The distance between the pubic 
 abutments was about three inches. 
 
 The bladder {a) forming an oval, elliptical tumor, mam- 
 millated upon the surface, which, in the recumbent position, 
 measured two inches in its long, and one and a quarter 
 inches in its short diameter. This was soft, elastic, of 
 bright vermilion color, and covered with a thick tenacious 
 mucus ; bleeding readily when rudely handled, and so 
 exquisitely sensitive, that whilst under the full influence of 
 chloroform, and insensible to the knife, a sponge passed 
 over the exposed bladder excited reflex motions. 
 
 The integuments immediately surrounding the bladder 
 
352 
 
 APPENDIX TO LECTURE I. 
 
 were found red and puckered, hut very soft, delicate, and 
 free from hair between the bladder and point of sternum. 
 The labia majora {o, d) thick, fleshy, and luxuriantly cov- 
 ered with hair, were gathered into folds, swelling away 
 towards either thigh. 
 
 Here, then, we had to contend with two formidable 
 
 Fig. 1. 
 
 a. Bladder Exposed, forming a Bright Vermilion Tumor ; b, b, Nymphse, or 
 Labia Minora ; o, o, Labia Majora ; c, Vagina ; d, Anus. 
 
 difficulties, either of which was a problem in itself, viz., 
 aggravated prolapsus from an entire absence of anterior 
 support, added to the original congenital malformation. 
 
 The indications which it was proposed to follow were: 
 
 1st. To form an anterior wall for the exposed bladder. 
 
 2d. To restore the urinar}^ canal. 
 
 3d. To establish the anterior fourchette of the vulva. 
 
APPENDIX TO LECTURE I. 
 
 553 
 
 4th. To supply means to prevent the prolapsus, and to 
 collect the renal secretions. 
 
 The delicate character of the integument above the 
 bladder, and its well-known transmutability into the con- 
 ditions of a mucous membrane, peculiarly adapted it to 
 supply the anterior cystic wall, and thus fulfill the primary 
 indication. 
 
 Fig. 2. 
 
 e, Linear Cicatrix, formed by the Flaps covering the Bladder; h, b, Nymphse 
 brought together, and enclosed by the Vulva. 
 
 With these objects in view, the operative proceedings 
 were divided into two stages. 
 
 The first consisted in raising a flap from the anterior 
 portion of the abdomen, including the superficial fascia, 
 turning its cuticular surface down over the exposed blad- 
 der as far as its inferior border, and securing the lateral 
 union of the flap in that position, whilst a free exit below 
 
354 
 
 APPENDIX TO LECTURE I. 
 
 was maintained for the urinary discharge ; an important 
 result, still further assisted by the dependent situation of 
 the outlet of the ureters already alluded to. 
 
 By these means it was proposed to accustom the highly 
 sensitive bladder to a gradual and methodical compres- 
 sion, whilst the flap itself was insured ample space to 
 
 rig. 3. 
 
 a, Bladder ; b, b, Nymphse ; c, Vagina ; d. Anus. 
 
 undergo such swelling as might be anticipated from its 
 new position, and the unusual stimulation of a new secre- 
 tion. Time was likewise given for the necessary trans- 
 mutation of tissues to make some progress. 
 
 The steps of this procedure will perhaps be better 
 understood by a more detailed statement of the first 
 operation, in connection with the diagrammatic plates. 
 Figs. 3 and 4. 
 
APPENDIX TO LECTURE /. 
 
 355 
 
 It was performed on the i6th of November, 1858, the 
 patient being- thoroughly under the influence of chloro- 
 form, and a sugar-loaf shaped flap having been previously 
 marked out upon the abdominal integument; its base, e,f, 
 three inches in width, was situated three-fourths of an inch 
 above the cystic tumor, and extended five inches in length, 
 with its apex towards the ensiform cartilage. The dark 
 
 Pig. 4. 
 
 a. Bladder, covered by deep Flaps ; b, b, lymphse; c. Vagina; d, Anus. 
 
 line, e, h, g, i,f{¥\g. 3), indicates its form, position, and the 
 line of incision. 
 
 This flap being left sufficiently large to meet the ele- 
 vated form of the bladder, and allow for shrinkage, was 
 quickly but carefully separated from its cellular attach- 
 ments, down to the line e,f, whilst two lateral incisions, 
 e^J, and f, k, were continued directly downwards and 
 
356 APPENDIX TO LECTURE I. 
 
 towards the nymphas, to serve as beds for receiving the 
 sides of the new flap. 
 
 The integuments covering the lateral and inferior por- 
 tions of the abdomen, extending from ^ to/, on one side, 
 and from ^ to k, on the other, were now sufficiently sepa- 
 rated from their cellular attachments to the muscles 
 beneath to insure their sliding freely, and meeting without 
 tension at the mesial line, g, n (Fig. 4). When brought 
 into this position they completely covered from view the 
 raw surface of the flap already turned over, and investing 
 the bladder, with the exception of a triangular space,/, «> 
 k (Fig. 4), formed by the coaptation of the lateral flaps ; 
 this was temporarily covered by reflecting back upon itself 
 the corresponding triangular free end of the deep Hap, 7* 
 c, k (Fig. 4), and attaching it along the line 7', n, k. Numer- 
 ous points of interrupted suture were used to retain the 
 parts in situ, assisted by long strips of adhesive plaster, 
 compresses, and a retentive bandage around the body. 
 It will be observed that the lower portion of the cystic 
 tumor was thus temporarily left free and partially ex- 
 posed, whilst no portion of cut or denuded surface re- 
 mained uncovered. 
 
 The patient received a large dose of opium, and was 
 strictly maintained in the recumbent position upon a bed, 
 properly protected ; such additional measures being 
 adopted as would secure cleanlines s. 
 
 As the parts subjected to operation began to swell, she 
 complained of irritation and pressure upon the bladder, 
 which, however, was promptly met with morphine alone 
 and subsided in the course of a few days. Now was ex- 
 hibited the great importance of leaving the tumor partially 
 uncovered, whilst all the cut surfaces were in close con- 
 tact, and thus freed from the action of irritating secretions. 
 
APPENDIX TO LECTURE 7. 357 
 
 On the fourth day after the operation all sutures were 
 removed, the wounds having- healed by first intention or 
 primary adhesion, with the exception of a spot, the size of 
 a ten-cent piece, situated just above the point of the tri- 
 angle, and where the deep flap had been reflected over the 
 bladder. At this point the lateral abdominal flaps were 
 necessarily raised up from the tissues beneath, and could 
 not be brought into contact even by the use of compresses. 
 This, however, granulated kindly, and was nearly cicatrized 
 on the 7th of December, when the second and last opera- 
 tion was performed as follows : 
 
 The patient, being under the influence of chloroform, 
 the lower triangular flap, j\ n, k (Fig. 4), was dissected 
 from its recent and temporary attachments, both lateral 
 and deep, and turned down over the vulva, as indicated 
 by the dotted line,/, c, k. 
 
 Two incisions, y, /, and k, in, were now carried from the 
 external angles of this triangle, perpendicularly towards 
 and terminating just behind the nymphce, b, b. 
 
 The lateral flaps bounded by the lines n,j\ /, and ;/, k, in, 
 and including the labia majora, were then freely dissected 
 from over the abutments of the pubic bones, until they 
 could be readily slid to meet each other at the central line, 
 n, c, which, being a continuation of the line g, n, reduced 
 the whole to a single linear wound, occuping the " linea 
 alba." See Fig. 2. 
 
 During the operation several arterial branches bled 
 freely, and were arrested by torsion and the free applica- 
 tion of ice, after which the flaps were confined at the 
 mesial line by points of interrupted suture ; the most infe- 
 rior one, viz., at / and w, being made to include the apex, 
 c, of the triangular flap. 
 
 Fearing to depend on sutures alone to secure the ap- 
 
2Si APPENDIX TO LECTURE I. 
 
 proximated flaps, and the use of adhesive plaster being^ 
 excluded by the irregularity and position of the parts, the 
 whole surface between the points of suture was hermeti- 
 cally encased by strips of patent lint, soaked in collodion,, 
 and accurately applied. In addition to this, pieces of 
 muslin were by the same method firmly attached to the 
 labia majora at some distance from the mesial line, and to 
 these sutures silk was fastened in such manner as to form 
 a lacing across and over the wound. By means of this 
 dressing all tension was removed from the sutures, urine 
 was totally excluded, whilst rapid and perfect adhesion 
 soon followed. 
 
 Thus a urinary canal was formed, which would admit, 
 the little finger to be passed up one and a half inches. 
 The anterior fourchette of the vulva was firmly established, 
 and the mons veneris assumed its prominent and natural 
 appearance. 
 
INDEX. 
 
 A. 
 
 Abnormal urine, causing irritability 
 
 of the bladder, 65 
 Abscess of the kidney, 170 
 Absorption by urethral mucosa, 19 
 
 by vesical mucous membrane, 19 
 Acid, uric, real and proportional ex- 
 cess of, 66, 67 
 
 deposits, treatment of, 68, 69 
 
 urine, irritating, 155 
 Acute congestion of bladder, 138 
 
 diagnosis, 139 
 
 etiology, 140 
 
 symptoms, 139 
 
 treatment, 140 
 Acute cystitis, 149 
 
 etiology, 149 
 
 pathology, 158 
 
 treatment, 191 
 Acute nephritis from damming back 
 of urine in kidneys, 163 
 
 case of, 164 
 Acute urethritis, 270 
 
 treatment, 271 
 Ahfield on eversio vesicae, 37 
 Albumin in urine, test for, 119 
 Alcohol, action on mucous membrane 
 
 of the bladder, 157 
 Allen's polypus forceps, 297 
 Ailing on absorbent power of vesical 
 
 mucous membrane, 18 
 Amenorrhoea from cystitis, 178 
 Ammonsemia, 183 
 
 Amount of urine in twenty-four 
 
 hours, 19 
 Ansemia, general, in cystitis, 178, 181 
 
 cerebral, in cystitis, 182, 184 
 Anatomical relations of bladder and 
 
 urethra, 12-15 
 Anatomy of the bladder, i-io 
 
 of the urethra, 9-12 
 Anderson, Dr. W. A., eucalyptus 
 
 globulus in cystitis, 195 
 Angioma of the urethra, 282 
 Anteflexions and anteversions of the 
 
 uterus, 93 
 Appendix, 351 
 
 Areolar neoplasms of the urethra, 283 
 Arsenic, action of, on vesical mucous 
 
 membrane, 157 
 Arteries of the bladder, 8 
 Ascarides, a cause of incontinence of 
 
 urine, 84 
 Ashurst, operation for vesical fissure, 
 
 44 
 
 Atresia urethrae, 26 
 
 Atrophy of the bladder, 262 
 treatment, 265 
 
 Ayres, Dr. Daniel, operation for ex- 
 troversion of the bladder, 351 
 
 B. 
 
 Bacteria in cystitis, 203 
 Bailie on extroversion of 
 through the urethra, 107 
 
 bladder 
 
36o 
 
 INDEX. 
 
 Bailie on dilatation of ureters in vesi- 
 cal malfonnations, 34 
 
 Barclay, treatment of incontinence, 83 
 
 Barnes, shedding of vesical mucous 
 membrane, 159, 161 
 
 Bas fond, 3 
 
 modified by age and disease, 3, 
 
 157 
 Beale, Lionel, epithelium of the blad- 
 der, 116 
 precipitation of uric acid by nitric 
 acid, 119 
 Benivienni, on dilatation of the ure- 
 thra, 132 
 Biegel, case of sarcoma of urethra, 
 
 283 
 Bilharzia haematobia, I46 
 Bladder, absorption by mucosa of, 18 
 anatomical relations of, 12 
 atrophy of, 262 * 
 
 treatment, 265 
 cancer of, 248 
 carcinoma of, 248 
 diagnosis, 248 
 symptoms, 249 
 treatment, 250 
 centric hypertrophy of, 261 
 coats of, 3-5 
 color of mucosa of, 8 
 " columnar," 167 
 cysts of, 245 
 
 treatment, 246 
 development of, 21-23 
 dislocations of, 89 
 backwards, 90 
 downwards, 95 
 forward, 93 
 laterally, 95 
 upwards, 89 
 distention of, 17, 73 
 divisions of, anatomical, 3 
 double, 45 
 ectopia of, 37 
 
 unfissured, 94 
 cnchondromata of, 236 
 
 Bladder, epithelium of, 5, 115 
 
 exfoliation of mucous membrane 
 
 of, 152, 214 
 extroversion of, 33, 349 
 extroversion of, through urethra, 
 
 105 
 extroversion of, through urethra, 
 
 diagnosis, 107 
 extroversion of, through urethra, 
 
 symptoms, 106 
 extroversion of, through urethra, 
 
 treatment, 108 
 fissure of, 32, 223 
 foreign bodies in, 250 
 foreign bodies in, symptoms, 251, 
 
 255, 258 
 foreign bodies in, treatment, 252, 
 
 259 
 
 foreign bodies in, varieties, 250 
 
 form of, 3 
 
 form of, modifications of, by age, 
 sex, and contents, 3, 157 
 
 forward transposition of, I02 
 
 functional diseases of, 47 
 
 functional diseases of, causes, 50 
 
 functional diseases of, classifica- 
 tion, 48 
 
 functional diseases of, diagnosis, 
 60 
 
 functional diseases of, prognosis, 
 61 
 
 functional diseases of, symptoms, 
 
 59 
 functional diseases of, treatment, 
 
 61-65 
 functions of, 15-21 
 hemorrhage from, 140 
 causes, 143 
 symptoms, 141 
 treatment, 143 
 hemorrhage from, and malaria, 
 
 143 
 hemorrhoids of, 145 
 hyperaemia of, 138 
 causes, 140 
 
INDEX. 
 
 361 
 
 Bladder, hypersemia of, diagnosis, 139 
 
 symptoms, 139 
 
 treatment, 140 
 hypertrophy of, 259 
 
 diagnosis, 261 
 
 symptoms, 261 
 
 treatment, 261 
 
 varieties, 260 
 imperforate, 46 
 
 inflammation of, see Cystitis, 147 
 irritability of, 49, 81 
 
 treatment, 58 
 ligaments of, 13 
 lymphatics of, 9 
 malformations of, 31-46 
 mucous membrane of, 5 
 mucous polypi of, 239 
 
 causes, 239 
 
 diagnosis, 242 
 
 prognosis, 243 
 
 symptoms, 240 
 
 treatment, 244 
 neoplasms of, 234-260 
 nerves of, 9 
 neuralgia of, 5 1 
 openings into, 7 
 organic disease of, 109 
 paralysis of, 71 
 
 causes, 72 
 
 diagnosis, 74 
 
 prognosis, 75 
 
 symptoms, 73 
 paralysis of, treatment, 76 
 parasites in, 251 
 paresis of, see Paralysis, 71 
 perforation of, 169 
 retrocession of, 102 
 rupture of the, 263 
 serous investment of the, 4 
 situation of the, 2, 12, 13 
 sphincter of the, 5 
 stone in the, 253 
 
 prognosis, 256 
 
 symptoms, 255 
 
 treatment, 256 
 
 Bladder, tubercle of the, 246. 260 
 symptoms, 247 
 treatment, 248 
 tumors of the, 235-260 
 veins of the, 8 
 washing out of the, 196 
 Black, Campbell, treatment of incon- 
 tinence, 84 
 Blood in urine, I14 
 Bloodless dilatation of urethra, 132 
 Bodkin, Dr., case by, 151 
 Bonn, dilatation of ureters, 34 
 
 fissura vesicae, 34 
 Bonnet, rupture of the bladder, 263 
 Bozeman, Dr. Nathan, cystotomy in 
 cystitis, 136 
 causes of urethrocele, 306 
 treatment of urethrocele, 320 
 Braun, hydronephrosis in cystocele, 97 
 Bricheleau. treatment of malarial neu- 
 roses of the bladder, 65 
 Brown, Baker, operation for cystocele, 
 
 lOI 
 
 Brugleman, treatment of incontinence, 
 
 83 
 Budge, experiments of, 74 
 Burns, on extroversion of bladder 
 
 through the urethra, 105 
 
 C. 
 
 Calculi, renal, 251 
 urethral. 345 
 vesical, 253 
 
 diagnosis, 256 
 prognosis, 256 
 symptoms, 255 
 treatment, 256 
 Campa, cysts of the bladder, 246 
 Campbell, H. F., relation of the oper- 
 ation for vesico-vaginal fistula to 
 the formation of calculi, 254 
 Carbol andMiddleton, cases of, 19, 30 
 Caruncle of urethra, 285 
 Carcinoma vesicas, 248 
 
362 
 
 INDEX. 
 
 Carcinoma vesicse, diagnosis, 248 
 symptoms, 249 
 treatment, 250 
 
 Carcinoma urethrse, 284 
 
 Casts in the urine of cystitis, 176 
 
 Catarrh of the bladder, 149 
 
 Catheter, dirty, a cause of cystitis, 217 
 Goodman's self-retaimng, 210 
 Holt's self-retaining, 211 
 Jacques' with Skene's modifica- 
 tion, 198 
 necessity for cleanliness of , 75. 77 
 
 217 
 
 Skene's reflux, 197 
 double perforated. 198 
 modification of Goodman's, 212 
 Catheterization of the ureters, 136 
 Cattier, Isaac, case of double bladder, 
 
 45 
 
 Centric hypertrophy of the bladder, 
 260 
 
 Chemistry of the urine, 118, 122 
 
 Cholera morbus a cure for cystitis, 
 case of. 192 
 
 Cholesterine in vesical mucous mem- 
 brane, 222 
 
 Chonsky, case of double bladder, 46 
 
 Chorea vesicae, 82 
 
 Chronic cystitis, 166 
 
 Circumscribed urethritis, 274 
 treatment. 277 
 
 Civiale, rupture of the bladder, 263 
 
 Clot in the bladder, treatment of, 144 
 
 Coates, observations of, 32 
 
 Coats of the bladder, 3, 4, 5 
 
 Cocaine, hydrochlorate of, in urethral 
 examinations, 301 
 
 Color of urine, no, 120 
 
 Color of vesical mucous membrane, 8 
 how modified, 127 
 
 Columnar bladder, 167 
 
 Condition of digestive tract in cystitis, 
 182 
 of mind and nervous system in 
 cystitis, 184, 185 
 
 Condition of vascular system in cysti-- 
 
 tis, 178 
 Condylomata of urethra, 280 
 Congenital polypoid excrescences of 
 
 urethra, 283 
 Congestion of the bladder, 138 
 cause, 140 
 diagnosis, 319 
 symptoms, 139 
 treatment. 140 
 Constipation in cystitis, 183 
 Constituents of urine, 124 
 Creve on fissura vesicae. 34 
 Crobs, extroversion of bladder through 
 
 urethra, 106 
 Croupous cystitis, 217 
 diagnosis, 220 
 prognosis, 221 
 symptoms, 219 
 treatment, 220 
 Cushing, Dr. Geo. W., cases by, 87,, 
 
 164 
 Cutaneous surface in cystitis, 183 
 Cystitis, 147-221 
 acute, 149 
 
 diagnosis, 185 
 etiology, 149 
 pathology, 165 
 prognosis, 215 
 symptoms. 172 
 treatment, 191 
 chronic, 166 
 
 croupous and diphtheritic, 217 
 forms, 147 
 hygiene, 216 
 in cystocele, 98 
 interstitial. 167 
 simulating vesico-urethral fissure, 
 
 226 
 with epidermoid concretions, 221 
 treatment, 222 
 Cysts, hydatid, 246 
 ovarian, 245 
 urethral, 281 
 vesical, 245 
 
INDEX. 
 
 363' 
 
 Cystocele vaginalis, 95, 321 
 
 causes, 96 
 
 diagnosis, 99 
 
 interfering with delivery, 99 
 
 pathology, 96, 97 
 
 prognosis, 99 
 
 symptoms, 97 
 
 treatment, 100 
 Cystorrhagia, 140 
 
 causes, 143 
 
 symptoms, 141 
 
 treatment, 143 
 Cystoplegia, 71 
 Cystoplosis, 105 
 Cystotomy, by thermo-cautery, 206 
 
 for cure of vesico-urethral fissure, 
 
 234 
 vaginal, 134, 205, 234 
 
 D. 
 
 Debout, treatment of irritable blad- 
 der, 64 
 Defectus urethrae externus, 24, 25 
 internus, 25 
 totalis. 23 
 De Haen on extroversion of bladder 
 
 through the urethra, 106 
 Desault, observations of, 32 
 dilatation of ureters, 34 
 Development of the bladder, 21, 23 
 
 of the urethra, 21, 23 
 Diarrhceaof cystitis, 183 
 
 septic, 184 
 Diet of cystitis patients, 192. 
 Digestive tract in cystitis, 182 
 Digital dilatation of the urethra, 133 
 Dilatation of the anterior or lovv^er 
 
 third of the urethra, 304 
 Dilatation of the middle third of th^ 
 
 urethra, 306 
 Dilatation of the posterior or upper 
 
 third of the urethra, 305 
 Dilatation of the ureters, 241 
 Dilatation of the urethra, artificial, 
 13s, 213, 233 
 
 Dilatation for cure of fissure, 233 
 of the urethra, 132, 213, 233 
 diagnosis. 314 
 etiology, 310 
 prognosis, 317 
 symptoms, 312 
 treatment, 318 
 Diphtheritic cystitis, 217 
 diagnosis, 220 
 prognosis, 221 
 symptoms, 219 
 treatment, 220 
 Dislocation of the bladder, 89 
 backwards, 90 
 downwards, 95 
 forwards, 93 
 laterally, 95 
 upwards, 89 
 Dislocation of the urethra, 321 
 etiology, 323 
 prognosis, 326 
 symptoms, 322, 325 
 treatment, 326 
 Distention of the bladder, 17 
 Distoma haematobium, 251 
 Diuretics in cystitis. 193 
 Divisions of the bladder, 5 
 Double bladder, 45 
 urethra, 30, 31 
 Downward dislocation of the blad- 
 der, 95 
 Drainage in the treatment of cystitis,. 
 
 209 
 Dribbling of urine after cystotomy, 
 
 207 
 Dubelt, P., opinion of, 18 
 
 on effects of air in the bladder, 
 
 153 
 Dubois, experiments on urine pres- 
 sure, 20 
 observations of, 33 
 Duncan, Matthews, fissura vesicae, 34 
 
 urethral speculum, 131 
 Duparcque, case by, 35 
 Dupuytren, observations of, 33 
 
364 
 
 INDEX, 
 
 Eccentric hypertrophy of the bladder, 
 
 260 
 Echinococci in the bladder, 251 
 
 of the unfissured bladder, 94 
 Ectopia vesicae, 37 
 
 totalis, 94 
 Electric light in physical explorations, 
 
 136 
 Electricity in the treatment of para- 
 lysis of the bladder, 78 
 Electrolysis in the treatment of ure- 
 thral neoplasms, 300 
 Elytrorrhaphy, 214 
 Emmet, Dr. T. A. , button-hole opera- 
 tion, 301 
 cystotomy, 205 
 
 in cystitis, 136 
 on laceration of the urethra in 
 
 dilatation, 213 
 operation for cystocele, loi 
 stone in the bladder, 254 
 vaginal injections of warm water, 
 216 
 Enchondromata, vesical, 236 
 Endemic haematuria, 146 
 Endoscope, Skene's, 125 
 
 in cystitis, 189 
 Eneuresis, 80 
 
 prognosis, 82 
 treatment, 83 
 varieties, 80 
 Epi-cystitis, 167. 168 
 Epithelium of the bladder, 5, 6, 115 
 of the ureters, 117 
 of the urethra, 10 
 transitional forms of, 115, 176 
 Epidermoid concrements in cystitis 
 
 221 
 Epithelioma of the urethra, 284 
 Erectile tumors of the urethra, 286 
 Ergot, peculiar action of, in cystitis, 
 
 184 
 Eschenbach, observations of, 33 
 
 Eversio vesicae, 33, 349 
 
 statistics of, 44 
 Exfoliation of vesical mucous mem- 
 brane, 158, 214, 216 
 Exo-cysts, 105 
 
 diagnosis, 107 
 
 symptoms, 106 
 
 treatment, 108 
 Exstrophia, 33 
 Extroversion of the bladder, 33, 349 
 
 through urethra, 105 
 
 F. 
 
 Fibroid tumors of the bladder, 239 
 Fibroma of the urethra, 283 
 Filiaria sanguinis hominis, 251 
 Fissura vesicae, 33 
 
 diagnosis, 41 
 
 etiology, 34-41 
 
 prognosis, 42 
 
 statistics of, 41 
 
 treatment, 42 
 Fissure, vesico-urethral, 223 
 
 symptoms, 225 ' 
 Fistula, vesico-umbilical, 32, 33 
 Fistula of the urethra, incomplete in- 
 ternal, 345 
 
 diagnosis, 347 
 
 pathology, 346 
 
 symptoms, 347 
 
 treatment, 348 
 Fistula, vesico-urethral, 223 
 
 etiology, 228 
 
 symptoms, 225 
 
 the endoscope in, 229 
 
 treatment, 229 
 Flagani, dilatation of the ureters, 34 
 Fleische, Dr., views of, 38 
 Folsom's nasal speculum, modifica- 
 tion of, 295 
 Foreign bodies in the bladder, 250 
 
 kinds, 250 
 
 symptoms, 251, 255, 258 
 
 treatment, 252, 256, 259 
 
INDEX. 
 
 365 
 
 Foreign bodies in the urethra, 343 
 diagnosis, 344 
 symptoms, 344 
 treatment, 344 
 Form of the bladder, 3 
 modified by age, 3 
 
 by amount of contents, 3 
 by sex, 3 
 Forward dislocation of the bladder, 
 
 93 
 
 transposition of the bladder, 102 
 Fothergill on ovarian dyspepsia, 54 
 Franco, dilatation of the urethra, 132 
 Froreiss, hydro-nephrosis in cystocele, 
 
 97 
 Function of the bladder, 15-21 
 Functional diseases of the bladder, 47 
 
 causes, 50 
 
 classification, 48, 49 
 
 diagnosis, 60 
 
 due to anomalies of form and 
 position of the bladder, 89 
 
 due to disease of other organs, 86 
 
 prognosis, 61 
 
 symptoms, 59 
 
 treatment, 61-65 
 Furst, case by, 31 
 Furtz, on the urethral speculum, 28 
 
 G. 
 
 Gangrene of vesical mucous mem- 
 brane, 169 
 Gerdy, operation for fissura vesicae, 
 
 43 
 Glandulai neoplasms of the urethra, 
 
 281 
 Gonorrhoea as a cause of acute cysti- 
 tis, 157 
 Gonorrhoeal urethritis, 270 
 
 poison as a cause of urethral neo- 
 plasms, 292 
 Goodman's self -retaining catheter, 210 
 Gouley, Dr, John W. S., removal of 
 urethral tumors by curette, 298 
 
 Gouley, Dr. John W, S., on injec- 
 tions of nitrate of silver in cys- 
 titis, 203 
 
 Gosselin, observations of, 32 
 
 Grunfield's speculum, 128 
 
 H. 
 
 Haematoma polyposum urethrae, 282 » 
 Haematuria, endemic, 146 
 
 from foreign bodies in the blad- 
 der, 241, 252, 256 
 Haemorrhage from the bladder, 140 
 from mucous polypi of bladder,. 
 240 
 Haemorrhoids of the bladder, 145 
 Hauf, rupture of the bladder, 263 
 Heath, digital dilatation of the ure^ 
 
 thra, 132 
 Hecker, case by, 35 
 Hegar, experiments on urine pressure, 
 20 
 cure of cystocele, 99 
 cystotomy in cystitis, 136 
 Heppner, on the production of an 
 
 artificial urethra, 29 
 Herder, observations of, 33 
 Hewetson, treatment of cystospasm,. 
 
 64 
 Hicks, Braxton, treatment of cystitis, 
 201, 203 • 
 on mucous polypi, 244 
 Hofmeir, capacity of the female 
 
 bladder, 73 
 Holmes, operation for fissure of the 
 
 bladder, 44 
 Holt's self-retaining catheter, 211 
 Hooklets of echinococci in urine, 246 
 Hunter's dilator, 134 
 Hunter, rupture of the bladder, 263 
 Hutchinson, mucous polypi of the 
 
 bladder, 239, 243 
 Hydatid cysts, 246 
 Hyperaemia of the bladder, 138 
 cause, 140 
 
366 
 
 INDEX. 
 
 Hypersemia of the bladder, diagnosis, 
 
 139 
 symptoms, 139 
 treatment, 140 
 Hyperaesthesia of the bladder, 49, 81 
 Hyperplasia of the vesical mucous 
 
 membrane, 166 
 Hypertrophy of the bladder from 
 
 vesical neoplasms, 241 
 Hypertrophy of the bladder, 259 
 eccentric and centric, 260 
 diagnosis, 261 
 symptoms, 260 
 treatment, 261 
 Hypospadias, 24 
 
 1. 
 
 Imperforate bladder, 46 
 
 Incomplete internal urethral fistula, 
 
 345 
 
 diagnosis, 347 
 
 pathology, 346 
 
 symptoms, 347 
 
 treatment, 348 
 Incontinence, varieties, So 
 Incontinentia paradoxa, 75 
 
 prognosis, 82 
 
 treatment, 83 
 Instillation tube, 202 
 Interstitial cystitis, 167 
 Interureteric ligament, 6 
 Inversio vesicae cum prolapsu per fis- 
 suram, 33 
 
 urethram, 33 
 Inversio vesicae urinae cum prolapsu, 
 
 105 
 Inversion of mucous membrane of the 
 urethra, 329 
 
 prognosis, 330 
 
 treatment, 331 
 Irritability of the bladder, 49, 81 
 
 definition of, 49 
 
 due to abnormalities of urine, 65 
 
 treatment of, 68 
 Ischuria, 71 
 
 Isenflamm, on dilation of ureters, 34. 
 
 J. 
 
 Jacobi, Dr. A., cystitis from use of 
 
 potass, chloral., 157 
 Johnson, Dr. Geo., treatment of cys- 
 titis by milk diet , 129 
 Joubert, operation for cystocele, loi 
 on extroversion of bladder 
 through the urethra, 105 
 
 K. 
 
 Kane, Dr. H. H., experiments on 
 
 renal pressure in animals, 163 
 Keyes, Dr. E. L.. hypertrophy of 
 the bladder, 260 
 method for determining the 
 source of blood in the urine, 
 142 
 villous tumor of bladder, 235 
 Kidney, abscess of, 170 
 
 diseases of, in cystitis, 176, 179 
 malposition of, 36 
 secondary destructive changes in, 
 241 
 Kruger, Dr., case by, 36 
 Kupressow, on the function of the 
 sphincter vesicae, 15 
 
 L.. 
 
 Labor, causing cystitis, 159, 170 
 Laceration of urethra from dilatation, 
 
 213 
 Langenbeck, case by, 24 
 Lateral displacement of the bladder, 
 
 95 
 Leoret, on extroversion of the bladder 
 
 through the urethra, 105 
 Leptothrix, 251 
 Lichtenheim, on ectopia of the iMifis- 
 
 sured bladder, 94 
 Ligament, interureteric 6 
 triangular, 11 
 
INDEX. 
 
 367 
 
 Ligaments of the bladder, 13, 14 
 Listen, cysts of the bladder, 246 
 
 shedding of vesical mucous mem- 
 brane, 159 
 Littre, observations of, 33 
 
 dilatation of the ureters, 34 
 Local rest in the treatment of cystitis, 
 
 205 
 Lowenson, case of cystitis with epi- 
 dermoid concrements, 221 
 Luschka, on the sphincter urethrse, 11 
 Lymphatics of the bladder, 9 
 
 M. 
 
 Malaria and hemorrhage from the 
 
 bladder, 143 
 Malarial neuroses of the bladder, 53, 
 
 54 
 
 Malformations of the bladder, 31-46 
 
 Malformations of the urethra, 23-32 
 
 Manometer, the, 20, 131 
 
 Masturbation as a cause of vesical 
 neuroses, 52 
 
 Masturbation incited by urethral tu- 
 mors, 288 
 
 Masturbacors, tricks of, 258 
 
 McGuire, Dr. Hunter, on drainage in 
 the treatment of cystitis, 209 
 
 McKee, puncture of cystocele in la- 
 bor, 99 
 
 Measles, mucous membrane of blad- 
 der in, 156 
 
 Meckel, on fissura vesicae, 34 
 
 on extroversion of the bladder 
 through the urethra, 105 
 
 Menstruation, how disturbed by cys- 
 titis, 178 
 
 Mental condition in cystitis, 185 
 
 Mery, observations of, 33 
 
 Method of analyzing urine, 109 
 
 Method of washing out the bladder, 
 197 
 
 Metritis in cystitis, 177 
 
 Metrorrhagia in cystitis, 178 
 
 Microscopical examination of urine, 
 
 114, 122 
 Middleton, cases of, 29, 30 
 Milk diet in cystitis, 192 
 Mineral waters in the treatment of 
 
 vesical irritability, 70, 71 
 Moergelin, on fissura vesicae, 35 
 
 on pelvic diametric proportions 
 in fissura vesicae with pelvic 
 diastases, 41 
 Mollinetti, case by, 45 
 Mucous membrane of the bladder, 5 
 absorption of purulent matter 
 by, 180 
 ' anatomy of, 5 
 color of, 8 
 condition of, in scarlet fever, 156 
 
 in measles, 156 
 gangrene of, 169 
 glands of, 6 
 hyperplasia of, 166 
 shedding of, 158, 214 
 Mucous membranes of the urethra, 10 
 inversion of the, 329 
 prognosis, 330 
 treatment, 331 
 prolapse of the, 329 
 Robin and Cadiat on, 10 
 Mucous polypi of the bladder, 239 
 diagnosis, 242 
 etiology, 239 
 symptoms, 240-243 
 treatment, 244 
 Mucous polypi of the urethra, 282 
 Mucus in the urine, 115 
 
 catalytic action on urea, 155 
 Munde, Dr. Paul F., case of vesico- 
 urethral stricture, 331 
 Myo-fibromas of the bladder, 239 
 Myxo-adenoma of the urethra, 281 
 
 N. 
 
 Napier's probe, 131 \ 
 
 Neck of the bladder, fissure of the, 
 189 
 
368 
 
 INDEX. 
 
 Noeggerath, Dr., on the use of the 
 urethral speculum, 130 
 
 on elytrorraphy, 214 
 Neoplasms, areolar, 283 
 
 compound, 284 
 
 epithelial, 283 
 
 glandular, 281 
 
 papillary, 280 
 
 urethral, 279 
 
 classification, 280 
 
 vascular, 282 
 
 vesical, 235-260 
 
 classification, 235 
 Neoplasms — 
 
 diagnosis, 288 
 
 etiology, 291 
 
 prognosis, 292 
 
 symptoms, 286 
 
 treatment, 293 
 Nerves of the bladder, 9 
 Nervous system, condition of, in cys- 
 titis, 183 
 Neuralgia of the bladder and body, 
 cases, 57 
 
 of uterus and ovaries due to cys- 
 titis, 178 
 
 urethral, 266 
 Neuroses of the bladder, 51 
 
 from masturbation, 52, 53 
 
 from ovarian disease, 54, 55 
 
 in hysteria, 51. 52 
 
 malarial, 53, 54 
 Newman, Dr. Robert, treatment of 
 cystitis, 204 
 
 Desormeaux endoscope, 128 
 
 O. 
 
 Oberteufer, cases by, 25, 30 
 
 Obstructive suppression from hemor- 
 rhage into bladder, 241 
 
 Odelbrecht, experiments on urine 
 pressure, 20 
 
 Odor of urine, iio, 120 
 
 (Edema of the bladder, 88 
 
 Oliver on extroversion of the bladder 
 
 through the urethra, 106 
 Openings of the ureters, 7 
 Operation for vesico-vaginal fistula a 
 
 cause of stone, 254 
 Ophthalmoscope in diagnosis of renal 
 
 disease, igo 
 Organic disease of the bladder, log 
 Ostium urethrse internum, H 
 Ovarian cysts, 245 
 Oxalate of lime, 69, III 
 Oxaluria, 67 
 
 treatment, 70 
 
 P. 
 
 Paget, case by, 39 
 
 cysts of the bladder, 246 
 Fallen, Dr. Montrose A., cystotomy 
 
 with the thermo-cautery, 206 
 Palletta, observations of, 32 
 Pancoast, operation for fissura vesicae, 
 
 44 
 Papillary neoplasms of the urethra, 
 
 280 
 Papillary polypoid angiomas of the 
 
 urethra, 285 
 Paralysis of the bladder, 71 
 causes, 72 
 diagnosis, 74 
 prognosis, 75 
 symptoms, 73 
 treatment, 76 
 Parasites in the bladder, 51 
 Paresis, see Paralysis 
 Patron, extroversion of the bladder 
 
 through the urethra, 107 
 Pelvic peritonitis and cellulitis in cys- 
 titis, 177, 188 
 causing irritable bladder, 88 
 their relation to epi-cystitis, 169 
 Percy, extroversion of the bladder 
 
 through the urethra, 106 
 Peri-cystitis, 167 
 
 Pessaries, ulceration of into the blad- 
 der, 258 
 
INDEX. 
 
 369 
 
 Pessary, Skene's for cystocele, loo 
 Skene's urinal cup, 208 
 Skene's globe, 207 
 Petit, case by, 24 
 
 dilatation of ureters, 34 
 Phillips on hydronephrosis in cysto- 
 cele, 97 
 cases of fissura vesicae, 42 
 Polypi of the bladder, 236 
 diagnosis, 242 
 etiology, 239 
 prognosis, 243 
 symptomatology, 240 
 treatment, 244 
 of the urethra, 282 
 Polypoid hypertrophy of the bladder, 
 
 237 
 Polypus forceps, Allen's, 297 
 
 snare, Blake's, 297 
 Pressure of urine in the bladder; ex- 
 periments by Hegar, Schatz, Du- 
 bois, and Odelbrecht, 20 
 Probe, Napier's, 131 
 Production of an artificial urethra, 29 
 Prolapse of the urethral mucous 
 membrane, 329 
 prognosis, 330 
 • treatment, 331 
 
 Prolapsus vesicae completus cum flssu- 
 
 ram tegumentarum abdominis, 94 
 Pubic diastases, 41 
 
 Purulent matter, absorption of, in cys- 
 titis, 180 
 Pus in urine, 114, 187 
 
 jellified in cystitis, 175 
 Putegnat, cases of vesical and general 
 
 neuralgia, 57 
 Pyelitis, 170, 173, 187 
 
 tubercular, 247 
 Pyo-nephrosis, 170, 173, 187, 242, 251 
 
 Quinine injections for bacteria, 203 
 
 R. 
 
 Rapid dilatation of the urethra, 213 
 Reaction of the urine, iii, 123 
 Rees, Owen, on the alkali of vesical 
 
 mucus, 112 
 Reflux catheter, Skene's, 272 
 Reich on cholesterine in vesical mu- 
 cous membrane, 222 
 Renal abscess, 170, 172, 242, 251 
 atrophy, 170, 242 
 calculi, 251 
 
 disease, diagnosis of, by the oph- 
 thalmoscope, 180 
 hypersemia in cystitis, 179 
 Retention of urine, voluntary, evil 
 effects of, 155, 217 
 hysterical, 51 
 
 in imperfect eversion of the blad- 
 der, 40 
 Retinitis albuminurica, 180 
 Retrocession of the bladder, 102 
 Retroversion of the gravid uterus, go- 
 Ringer, tincture of cantharides in the 
 
 treatment of cystitis, 194 
 Roberts on the alkali of vesical mucus,. 
 112 
 solvent treatment of calculi, 256' 
 Rokitansky on cystitis with epider- 
 moid concrements, 221 
 Roose on fissura vesicae, 34 
 Rose, E., case by, 26 
 on fissura vesicae, 35 
 malposition of kidney, 36 
 Rosenthal on the function of the- 
 
 sphincter vesicae, 15 
 Roser, case of urachal cyst, 46 
 Roux, Jules, operation for fissura ve- 
 sicae, 43 
 Ruge, Dr., views of, 38 
 Rupture of the bladder, 263 
 Rutenberg's speculum, 129 
 
 operation in paralysis vesicae, 80 
 Rutly, on extroversion of the bladder 
 through the urethra, 105 
 
370 
 
 INDEX. 
 
 S. 
 Sacculated urethra, 306 
 Sanctus Marcus, 132 
 iSansom, action of carbolic acid and 
 
 sulpho-carbolates on decomposing 
 
 urine, 196 
 Sarcoma of the urethra, 283 
 Sauvage, treatment of incontinence, 
 
 84 
 
 Scanzoni, case of double bladder, 46 
 result of operations for the radi- 
 cal cure of cystocele, 99 
 Scarlet fever, mucous membrane of 
 
 the bladder in, 156 
 Schafer, L., experiments of, 18 
 Schatz, experiments on urine pre3- 
 sure, 20 
 method of using the manometer, 
 
 131 
 
 on the reproduction of vesical 
 mucous membrane, 171 
 Schatz's pessary in extroversion of the 
 
 bladder through the urethra, 108 
 Schultze. B. S. , on fissura vesicae, 35 
 Sediments, urinary, in, 121 
 Seegur, Dr. B. A., salicylic acid in 
 gonorrhoea, 272 
 salicylate of soda in cystitis, 196 
 Separation of mucous membrane of 
 
 the bladder, 158, 214 
 Septic diarrhoea in cystitis, 184 
 Septicemia in epi-cystitis, 168 
 Sex, bladder modified by, 3 
 Shedding of the vesical mucous mem- 
 brane, 158, 214 
 Sickles, statistics by, 41 
 Simon, catheterization of the ureters, 
 136 
 cure of cystocele, 99 
 dilatation of the urethra, 132 
 extent of safe dilatation of the 
 
 urethra, 133 
 mucous polypi, 243 
 operation for removing foreign 
 bodies from bladder, 252 
 
 Simon, operation for vesical fissure, 43 
 
 vaginal cystotomy, 134, 135, 245 
 Simon's mirrors, 129 
 Simpson, cystotomy in cystitis, 136 
 Sims, J. Marion, cure of cystocele, 
 
 99 
 
 cystotomy in cystitis, 136 
 
 operation for cystocele, lOl 
 
 vaginismus, 87 
 Situation of the bladder, 2, 12, 13 
 Skene, cases by, 92, 102, 186, 263 
 
 cases of urethral neuralgia, 267 
 
 cases of urethritis, 274 
 
 cases of dilatation of the urethra, 
 
 327 
 Skene's double perforated catheter, 
 198 
 fissure probe and knife, 231 
 globe pessary, 207 
 modification of Folsom's nasal 
 
 speculum, 295 
 modification of Goodman's cathe- 
 ter, 212 
 reflux catheter, 197, 272 
 urethral speculum, 294 
 urinal cup pessary, 208 
 vesico-urethral instrument case, 
 136 
 Solvent treatment of calculus, 256 " 
 
 Sbmmering, case of double bladder, 45 
 Source of blood in urine, method of 
 
 determining, 142 
 Specific gravity of urine, 118, I22 
 Speculum, urethral, Skene's, 294 
 Sphincter of the bladder, 5 
 
 urethrae, Luschka, ir 
 Spiegelberg, on opening hgematocele 
 through dilated urethra, 135 
 treatment of cystospasm, 64 
 Stadtfeldt, cases of vesico-umbilical 
 
 fistula, 38 
 Stearine in epidermoid concrements, 
 
 222 
 Stillicidium a sign of over-filled blad- 
 der, 159 
 
INDEX. 
 
 371 
 
 Stoll, ectopia of the unfissured blad- 
 der, 94 
 Stone in the bladder, 253 
 
 diagnosis, 256 
 
 prognosis, 25*) 
 
 symptoms, 255 
 
 treatment, 256 
 Streubel, extroversion of the bladder 
 
 through the urethra, 105, 106 
 Strieker, epithelium of the bladder, 
 
 116 
 Stricture at the junction of bladder 
 and urethra, 335 
 
 cases of, 339 
 
 diagnosis, 338 
 
 treatment, 343 
 Stricture of the urethra, 331 
 
 diagnosis, 333 
 
 pathology, 332 
 
 prognosis, 334 
 
 symptoms, 333 
 
 treatment, 334 
 Subacute urethritis, 274 
 
 treatment, 277 
 Subinvolution of the uterus due to 
 
 cystitis, 177 
 Susini, experiments of, 18 
 Syringe, fountain, 199 
 
 T. 
 
 Teale, treatment of cystospasm, 64 
 Tenesmus, vesical, in cystitis, 173 
 in polypi of the bladder, 240 
 Testa, case of double bladder, 45 
 The manometer, 20 
 Thermo-cautery in performing cystot- 
 omy, 206 
 Thiersch on fissura vesicae, 35 
 Thompson, Sir Henry, on means of 
 determining the source of blood 
 in the urine, 142 
 same method applied to determin- 
 ing the source of pus, 187 
 Thomson, extroversion of bladder 
 through the urethra, 105 
 
 Tillaux, treatment of cystospasm, 64 
 Topography of the bladder and ure- 
 thra, 12-15 
 Trigone vesicae, 3 
 Triple phosphate, in, 118, 154 
 Tubercle of the bladder, 246, 260 
 
 symptoms, 247 
 
 treatment, 248 
 Tubercular pyelitis, 247 
 Tumors of the bladder, 235-260 
 
 classification, 235 
 Turpentine, action on the mucous 
 membrane of the bladder, 157 
 
 U. 
 
 Uffleman, Dr., on the muscles of the 
 
 urethra, 11 
 Ulceration of the vesical mucous mem- 
 brane, 173 
 Ultzman, on the urethral speculum, 
 
 128 
 Upward dislocation of the bladder, 
 
 89 
 Urea, elimination of, by stomach and 
 
 bowels, 179 
 Ureteritis, 242 
 Ureters, catheterization of, 136 
 
 dilatation of, in vesical malfor- 
 mations, 33, 34 
 obstruction by swelling of vesical 
 
 mucous membrane, 167 
 openings of, 7 
 Urethra, absorption by mucosa of, X^ 
 anatomy of the, 9, 12 
 atresia of the, 26, 27 
 coats of the, 10, 11 
 developments of the, 21-23 
 dilatation of, 302 
 dilatation of anterior or lower 
 
 third of the, 304 
 dilatation of, for cure of vesico- 
 urethral fissure, 233 
 dilatation of middle third of the, 
 306 
 
372 
 
 INDEX. 
 
 Urethra, dilatation of posterior or 
 upper third of the, 305 
 direction of the, 9 
 dislocation of the, 321 
 
 diagnosis, 325 
 
 etiology, 323 
 
 prognosis, 326 
 
 symptoms, 322 
 
 treatment, 326 
 double, 30, 31 
 foreign bodies in the, 343 
 
 diagnosis, 344 
 
 symptoms, 344 
 
 treatment, 344 
 laceration of the, 213 
 malformation of the, 23-32 
 mucous membrane of the, 10 
 position of the, g 
 rapid dilatation of the, 132, 213 
 relations of the, 14 
 sacculated, 306 
 
 diagnosis, 314 
 
 prognosis, 317 
 
 symptoms, 306 
 
 treatment, 318 
 stricture of the, 332 
 
 diagnosis, 333 
 
 pathology. 333 
 
 prognosis, 334 
 
 symptoms, 333 
 
 treatment, 334 
 veins of the, 11 
 Urethral calculi, 345 
 caruncle, 285 
 endoscope and speculum, 127, 
 
 128 
 fibroma, 283 
 fistula, incomplete internal, 345 
 
 diagnosis, 347 
 
 pathology, 346 
 
 symptoms, 347 
 
 treatment, 348 
 mucous membrane, prolapse of 
 the, 329 
 
 prognosis, 330 
 
 Urethral mucous membrane, prolapse 
 of the, treatment, 331 
 neoplasms, 279 
 areolar, 283 
 compound, 284 
 diagnosis, 288 
 epithelial, 283 
 etiology, 291 
 glandular, 281 
 papillary, 280 
 prognosis, 292 
 symptoms, 286 
 treatment, 295 
 vascular, 282 
 neuralgia, 266 
 polypi, 282. 283 
 sarcoma, 283 
 varices, 282 
 Urethritis, acute, 270 
 
 treatment, 271 
 circumscribed and subacute, 274 
 
 treatment, 277 
 gonorrhoeal, 270 
 
 treatment, 271 
 preventing drainage in cystitis, 212 
 simulating vesico-urethral fissure, 
 225 
 Urethrocele, 306 
 Uric acid, 66, 67, 69, iii, 154 
 excess of, 69 
 
 treatment, 69 
 real and proportional excess of, 
 66, 67 
 Urine, abnormal, producing irritable 
 bladder, 65 
 amount in twenty-four hours, 19 
 bloody, 114 
 
 casts in the, in cystitis, 176 
 chemical analysis of the, Ii8, 122, 
 
 177 
 color of the, no, 120, 175 
 constituents of the, 124 
 dribbling of the, after cystotomy, 
 
 207 
 epithelium in the, 115 
 
INDEX. 
 
 373 
 
 Urine, evil effects of voluntary reten- 
 tion of the, 155 
 excess of, constituents of the, 123 
 incontinence of, 80 
 prognosis, 82 
 treatment, 83 
 varieties, 80 
 method of analyzing, 109 
 microscopic examination of the, 
 
 113, 122, 176 
 mucus in the, 115, 155 
 odor of the, no, 120, 175 
 of cystitis, 174 
 
 pressure of, in the bladder, ig, 20 
 pus in the, 114, 175 
 reaction of the, in, 123, 174 
 recording blank for, no 
 retention of, in hysteria, 51 
 sediment of the, ill, 121, 175 
 specific gravity of the, 67, 118, 
 
 122, 174 
 triple phosphate in the, m, 118, 
 
 154, 155 
 urate of ammonia in the, ill, 
 
 118, 154 
 uric acid and oxalate of lime in 
 the. III 
 Urinaemic symptoms of cystitis, 174 
 Urohaematin in urine, 182 
 Uterus, displacement of the, 93 
 
 neuralgia of the, due to cystitis, 
 
 178 
 subinvolution of the, due to cys- 
 titis, 177 
 Uvula vesicae, 6 
 
 V. 
 
 Vaginal cystotomy, 134, 205 
 
 for removal ot foreign bodies 
 , from the bladder, 252 
 Van Buren, source of blood in the 
 urine, 142 
 and Keyes, villous tumor of the 
 
 bladder, 236, 249 
 hypertrophy of the bladder, 260 
 
 Varices of the urethra, 282 
 Varicose veins of the bladder, 145 
 Vascular system, condition of, in cys- 
 titis, 178 
 supply of bladder, 8 
 tumors of the urethra, 282 
 Veins of the bladder, 8 
 
 plexus at neck, 8 
 of the urethra, 10, il 
 Velpeau, statistics of vesical fissure, 41 
 Verf, cure of cystocele, 99 
 Vesical atrophy, 262 
 calculi, 253 
 carcinoma, 248 
 diagnosis, 248 
 symptoms, 249 
 treatment, 250 
 ectopia, 37 
 epithelium, 116 
 fissure, 32 
 hyperaemia, 138 
 causes, 140 
 diagnosis, 139 
 symptoms, 139 
 treatment, 140 
 hypertrophy, 259 
 malformations, 31 
 mucous membrane, 5 
 epithelium of, 5 
 shedding of, 158 
 neck, 3 
 
 neoplasms, 235-260 
 nerves, 9 
 neuroses, 47 
 causes, 50 
 
 classificationj 48, 49 
 prognosis, 61 
 symptoms, 59 
 treatment, 61 
 paresis, 71 
 sphincter, 5 
 
 tenesmus from polypi, 240 
 trigone, 3 
 Vesico-urethral fissure, 223 
 diagnosis, 226 
 
374 
 
 INDEX 
 
 Vesico- urethral fissure, etiology, 228 
 
 symptoms, 225 
 
 treatment, 229 
 
 iicpfulness of endoscope in 
 diagnosticating, 227 
 stricture, 335 
 
 cases of, 339 
 
 diagnosis, 338 
 
 treatment, 343 
 Vesicocele, 321 
 
 Villous tumor of the bladder, 236; 249 
 Virchow, hydronephrosis in cystocele, 
 
 97 
 Von Mosengeil, case by, 24 
 Voss, case by, 40 
 Vrolik, G., on ectopia of the unfis- 
 
 sured bladder, 94 
 
 Wardell, Dr., case of shedding of the 
 
 mucous membrane of the bladder, 
 
 161 
 Washing out of the bladder, 196 
 Weinlecher on extroversion of the 
 
 bladder through the urethra, 106 
 Weisse's metal dilator, 132 
 "Wells, Spencer, on shedding of the 
 
 mucous membrane of the bladder 
 
 161 162 
 
 Willigk, case by, 25 
 Winckel, catheterization of the ure- 
 ters, 136 
 dilatation of the ureters in vesical 
 
 malformations, 34 
 hydronephrosis in cystocele, 97 
 mucous polypi of the bladder, 239 
 on bursting of the bladder as a 
 
 cause of vesical fissure, 38 
 on cystocele due to atrophy of the 
 
 bladder, 263 
 on dirty catheters as a cause of 
 
 cystitis, 217 
 on the after-effects of using ure- 
 thral specula, 130, 133 
 the statistics of vesical fissure, 41 
 treatment of cystitis, 191 
 treatment of eneuresis, 83, 84 
 tubercle of the bladder, 246 
 Witte, on the function of the sphinc- 
 ter vesicas, 15 
 Woman's Hospital (N. Y.), cases of 
 rapid dilatation of the urethral 
 213 
 statistics of cystotomy, 205 
 Wood, cases of fissura vesicae. 42 
 
 operation for fissura vesicae, 43,,. 
 44 
 
Skene 
 
 Copy 2 
 
 Diseases nf" +Vio u-i..j>i