present very rarely resorted to by those operators who use strict
antiseptic precautions, for they contend that septic changes in the
blood do not then take place. Wells and Thornton have virtually given
it up, while Keith, Tait, and Bantock, who have abandoned Listerism,
are warm advocates of it. This question is a very important one,
because a drainage-tube tends to the formation of a ventral hernia,
and, being a foreign body, is in itself hurtful, and therefore should
not be resorted to unless it will do more good than harm.

After a careful consideration of the subject I am forced from
experience to believe that between the two extremes there lies a golden
mean, and that drainage, even when the spray is used, is needed under
the following conditions:

  (_a_) Whenever a purulent or a colloid cyst has burst, and its
          contents have escaped into the cavity of the abdomen, either
          during the operation or some days beforehand.

  (_b_) Whenever the contents of the cyst are putrid or purulent, and
          septic symptoms or those of peritonitis are present.

  (_c_) Whenever a large amount of ascitic fluid is found in the
          abdominal cavity.

  (_d_) Whenever four drachms or more of pure blood, or especially of a
          sero-sanguinolent fluid, can be squeezed out of the sponge in
          Douglas's pouch when removed just before the closure of the
          wound.

  (_e_) Whenever the operator is in doubt what to do.

Should it be deemed needful for some of the above reasons to make use
of drainage, a glass tube, open at both ends and about six inches in
length, is passed through the salicylated cotton or other dressing,
then between the two lowest stitches, down to the bottom of Douglas's
pouch. A wire suture is first introduced between these sutures and left
untwisted, its object being to close firmly the opening left by the
removal of the tube and to hasten its union. Otherwise, a weak cicatrix
results, tending to the subsequent formation of hernia. Keith's
drainage-tube of three sizes is the one that I prefer. Its lower end is
perforated with holes, and its upper end has a shoulder which keeps it
from slipping into the abdominal cavity, and also enables it to hold a
piece of thin rubber sheeting about eighteen inches square. In the
centre of this a small circular hole is made, which, by stretching, is
sprung over the tube. The mouth of the tube is covered by a cup-shaped
sponge wrung out of a 5 per cent. solution of carbolic acid, and over
this the sheeting is folded four times. The flannel binder may either
be pinned over the drainage-tube, or else {333} it may be slit at the
site of the tube and passed on each side of it, leaving the sponge and
rubber sheeting outside of the dressing. They are then best held in
place by a narrow strip of flannel, so as to permit inspection without
interfering with the main dressing. Several times a day the sponge is
removed, squeezed out, cleansed in a 5 per cent. solution of carbolic
acid, and replaced. This in a hospital had better be done under the
spray. Bloody serum collecting in this tube is sucked out either by a
fine rubber tube attached to a syringe, or else by the long nozzle
itself of the ordinary uterine syringe.

To prevent injurious pressure on the rectum, the tube must be lifted up
occasionally about half an inch, and allowed to slip back of its own
accord. It can be removed whenever the discharge has been reduced to
not more than one or two drachms, and this usually happens within the
first forty-eight hours. After its removal the opening left in the
wound is closed by twisting the free ends of the wire suture placed
there for this purpose.

AFTER-TREATMENT.--The subsequent treatment needs the greatest
attention. The first care is to establish reaction. This is best done
by stimulants, such as brandy and whiskey given in iced soda-water.
Enemata of beef-tea and brandy or of milk and brandy will also be of
advantage, while artificial heat is kept up. For the vomiting, which
comes partly from the anæsthetic and partly from shock, repeated deep
inspirations should be tried. They help by getting the blood rid of the
anæsthetic as soon as possible. Chloral may also be given, or small
lumps of ice may be swallowed. Sips of very hot water, or a
tablespoonful every hour of a mixture containing equal parts of
lime-water and of cinnamon-water, may also do good. A hypodermic of
morphia will often allay vomiting, and I have seen it yield to small
doses of atropia, and also to two grains of pure pepsin given every two
hours in a tablespoonful of raw-beef juice. Twenty drops of ether given
by the mouth will sometimes relieve it, and so also will a few drops of
chloroform confined by a watch-glass over the pit of the stomach. In
some cases I have tried, with the best results, the following
effervescent mixture, recommended by Chèron:[59]

  Rx. Potassii bicarb.     |
      Potassii bromidi. aa | gr. xxxij;
      Aquæ,                  fluidounce ij.  M.

  Rx. Acidi citrici, drachm j;
      Syrupi,        fluidounce j;
      Aquæ,          fluidounce iv.  M.

A dessertspoonful of the former is added to a tablespoonful of the
latter, and given every hour. For vomiting, especially of the bilious
variety, Lawson Tait recommends Monson's pepsin wine, given every ten
minutes in drachm doses with a little ice-water.

[Footnote 59: _Archives de Tocologie_, Février, 1883, p. 122.]

Flatus is another annoying symptom, which, however, can very generally
be dispelled by turning the patient over on her side and inserting a
flexible catheter high up in the rectum. If this fails to relieve it,
enemata of turpentine may be tried, or five-drop doses of the tincture
of nux vomica may be given every two hours. Should the abdomen become
painfully bloated, the binder must be loosened and the adhesive straps
{334} nicked in several places. The painful tension on the stitches can
be relieved by drawing the knees up and supporting them over a pillow
doubled on itself. Should the flatus not yield, and symptoms of
obstruction set in, the bowels must be opened at all hazards. Castor
oil and Epsom salts are good cathartics for this purpose. When vomiting
accompanies obstruction, calomel answers best, because it is not so
liable to be rejected.

For the first thirty-six to forty-eight hours after the operation
nothing whatever should be given to the patient excepting cracked ice,
sips of hot tea or of barley-water, and an occasional teaspoonful of
old whiskey. After that time tablespoonful doses of milk, of beef-tea,
of thin oatmeal gruel, or of barley-water can be given every hour or
two. The diet may then be cautiously increased, and especially after
wind begins to escape from the rectum, the patient being enjoined not
to hold it back from motives of delicacy. If the condition of the
patient is such as to demand more nourishment, it had better be taken
by the rectum. For a week the urine should be drawn off by the nurse,
and the bowels kept quiet by a morning and an evening suppository. No
other anodyne need be given unless called for by pain, wakefulness, or
restlessness. Should the body-heat indicate a temperature of 101° or
over, a bladder filled with broken ice, or, what is far better, a
rubber ice-cap, should be kept on the head of the patient as long as it
feels comfortable and does not chill her. If the temperature does not
fall, and peritonitis or other septic symptoms set in, ice should also
be applied to the pit of the stomach. Quinia and morphia must then be
given in very large doses, preferably by the rectum, together with ten
drops of the tincture of digitalis every hour until the pulse-rate is
lessened and the temperature falls.

When a full week has elapsed the bowels should be opened; and, as this
is a matter of importance, and is occasionally attended with symptoms
of obstruction and with a good deal of constitutional disturbance, a
few words will not come amiss. If the hardened feces can be softened
down and dislodged by enemata, this is perhaps the best plan, clysters
of ox-gall and water or of glycerin and water being the most efficient.
But in my experience enemata have so often failed that I rarely resort
to them in the first instance. If the woman's stomach is not irritable,
I prefer to give her an ounce of castor oil. This is disguised in the
compound syrup of sarsaparilla or in some other suitable vehicle, as
warm milk, and is brought to her without any previous warning early on
the morning of the eighth day. Should it be deemed unwise to try the
oil, two Lady Webster pills and two compound cathartic pills can be
given at bedtime of the seventh day, or a pill containing three grains
of the compound extract of colocynth with one grain of the extract of
hyoscyamus may be swallowed every four hours. The compound licorice
powder of the German Pharmacopoeia, to which has been added potassium
bitartrate, also answers well, provided the patient's stomach will bear
teaspoonful doses every four hours. Should these remedies fail to act,
they must be supplemented by enemata.

Fatal obstruction of the bowels from matting or from constricting bands
of organized lymph has been frequently reported. Thus far, I have met
with one fatal case, which, however, passed out of my hands after the
operation. But occasionally I see cases of obstinate {335} constipation
which give me great uneasiness and put me to my wits' ends. In one
case, after the failure of other remedies the obstruction was overcome
by broken doses of calomel combined with sodium bicarbonate, and by the
distension of the lower bowel with very large enemata slowly given.
Another desperate case yielded to repeated doses of tincture of
belladonna. A third case, complicated by obstinate vomiting, was saved
by ten grains of calomel given every two hours until the bowels were
moved. Seventy grains were thus administered before the desired effect
was attained, yet salivation did not occur.

When symptoms of obstruction once present themselves, they are likely
to recur. The contents of the bowel should therefore be kept fluid, and
for this purpose I know nothing better than the German compound
licorice powder, given in teaspoonful doses at bedtime.

Suppression of urine sometimes follows ovariotomy, and in cases of
diseased kidney is an alarming complication for this condition. For
this symptom digitalis and the acetate of potassium should be given.
Thornton treats it by baring the arms and packing them in towels which
are kept wet with ice-water.

Tetanus may destroy the life of a patient while convalescing from the
operation of ovariotomy. J. M. Bennett reports such a case.[60] The
symptoms first showed themselves on the sixteenth day, and the woman
died two days later. Chloral in drachm doses, administered by the bowel
in the yolk of an egg, is perhaps the only remedy from which any good
can be expected.

[Footnote 60: _Lancet_, Dec. 3, 1881.]

Occasionally, a few days after the operation, without any septic
symptoms whatever or without any marked rise in the temperature, the
parotid glands grow tender, swell up, and run through a course
precisely like mumps, ending in resolution. This complication has been
met with so frequently by myself and others that it cannot be a mere
coincidence, but must be due to a reverse sympathy between the ovaries
and these glands. It does not appear to increase the risk of the
patient, for recovery took place in all the reported cases, of which
three occurred in my own practice.[61] Parotid bubo may also take place
after ovariotomy, but this sign of blood-poisoning, being a general
one, happens as well after other grave surgical operations and during
the course of specific fevers. Yet from the sympathetic relation
between the parotid glands and the sexual organs it seems to occur more
frequently in the septicæmia following ovariotomy.

[Footnote 61: Wm. Goodell, _Transactions of American Gynæcological
Society_, 1885.]

Acute mania sometimes follows ovariotomy, especially when both ovaries
have been removed. The attack is usually temporary, but it sometimes
ends in insanity, and even in death, as in one of my own patients.
Keith, Thornton, Tait, and other leading ovariotomists report analogous
cases.[62]

[Footnote 62: _The British Medical Journal_, March 21, 1885, p. 597.]

SURGICAL TREATMENT.--The dressings, being antiseptic, need not, as a
rule, be removed until the day following that on which the bowels are
moved. Every other stitch may then be removed, and especially all that
are loose or are cutting the tissues. The wound is then washed with a
2.5 per cent. solution of carbolic acid, and dressed anew with
salicylated {336} cotton. I usually find the first dressing so sweet
that I am able to reapply the unsoiled portion of it for a second
dressing. A clean binder is now pinned on and the woman's clothing
changed. Three or four days later all the stitches should be removed,
the wound secured by narrow adhesive strips, and dressed as before. For
fear of a weak cicatrix and the formation of a hernia at the site of
the wound, the patient should not get out of bed until fully three
weeks have elapsed, and should for as many months wear some kind of
close-fitting gored binder or abdominal supporter.

If, before the week is over, the dressings become soiled or give out a
bad odor, they should be at once renewed. They should also be removed
whenever a high temperature, without being accompanied by tympanites,
leads to the suspicion of cutaneous abscesses.

THE ACCIDENTS AND COMPLICATIONS OF OVARIOTOMY.--When by the breaking up
of adhesions to it the liver is wounded, the bleeding surface can
usually be stanched, as Koeberle has shown, by the ferric subsulphate
applied to the raw surface by the finger. If this fails the actual
cautery at a dull heat should be used.

If, unfortunately, an adherent portion of the bowel is torn open, the
wound should be carefully closed with very fine silk by the continuous
suture. The sutured portion is then fastened to the lower angle of the
abdominal wound as a safeguard in case of the subsequent formation of
stercoral fistula.[63] Should the intestine be injured to any extent,
the wound must be closed by two sets of fine silk sutures, the first
set uniting the mucous edges of the wound by the continuous suture, the
other set uniting one serous coat to the other at a line about one
quarter of an inch distant from the wound. An ordinary cambric needle
with fine sewing-silk will answer admirably for this purpose. In small
wounds one continuous suture, carried through all the coats but the
mucous, will suffice. A mere puncture can be closed by hooking it up
and surrounding it by a single fine ligature.

[Footnote 63: "Discussion on a Paper by Garrigues," _Am. Gynæcol. Soc.
Trans._, 1881.]

Wounds of the bladder have frequently happened, but they are by no
means necessarily fatal.[64] These accidents are liable to occur when
the bladder, being adherent to the cyst and carried upward by it, lies
directly under the line of incision, or the bladder may be torn open
while adhesions to it are being severed. The wound should at once be
grasped by a pressure-forceps, the bladder emptied by the catheter, and
the operation proceeded with. When the operation has been completed the
wound in the bladder is attended to, and in one of the following ways:
Either the vesical wound is brought up within the lips of the abdominal
incision, and is closed by being included in the abdominal stitches, or
it is closed by the continuous or Glover's suture, without including
the mucous membrane in the stitches. A self-retaining catheter, such as
the Skene-Goodman, must then be kept in the bladder for at least a
week.

[Footnote 64: Eustache, _Archives de Tocologie_, April and May, 1880,
pp. 193, 277; _Boston Med. and Surg. Journal_, Feb. 16, 1882, p. 153;
_British Med. Journ._, Jan. 28, 1882, p. 115; _Am. Journ. Med. Sci._,
Jan., 1883, p. 123.]

One of the ureters will sometimes be torn across while pelvic adhesions
are being broken up. This accident is most likely to happen during the
enucleation of a cyst growing downward because enveloped in the folds
{337} of the broad ligament. It is almost always fatal, and is usually
not discovered during the life of the patient, and, I am disposed to
think, not often discovered after her death. Sometimes, however, urine
will ooze out of the abdominal wound, and in rare cases the patient has
recovered with a urinary fistula. In such a case Simon[65] successfully
removed the corresponding kidney; Nussbaum[66] constructed an
artificial ureter leading from the fistula to the bladder; and
Tauffer[67] inserted the upper end of the divided ureter into the
bladder by an artificial opening. It, however, failed to unite, and he
later made an artificial ureter.

[Footnote 65: _Annales de Gynécologie_, June, 1877.]

[Footnote 66: _Edinburgh Medical Journal_, July, 1876, p. 1.]

[Footnote 67: _Archives de Tocologie_, Avril, 1880, p. 201.]

When an umbilical or a ventral hernia of moderate size is present at
the time of the operation, efforts should be made for its radical cure.
This is done by cutting out the thinned-out sac by two incisions
meeting below and above, and by bringing together the thick edges of
the abdominal wall in the final closure of the wound.

In cases of ascites complicating ovariotomy the ascitic fluid should
not be wholly removed until the cyst has been cut off and the wound is
ready to be closed. By this means any blood oozing from broken
adhesions, or any fluid escaping from the cyst into the abdominal
cavity, being diluted, is less likely to irritate the peritoneum, the
cavity of which can also be more readily cleansed.

When a patient seems in danger of dying on the table from shock or from
exhaustion the anæsthetic should be withheld while hypodermic
injections of ether and enemata of brandy are given. Warmth should also
be applied to the body by bottles of hot water, or, what is better, by
rubber bags of the same. Theoretically, atropia administered
subcutaneously would be the proper remedy, but I have not yet tested
it. In all cases of ovariotomy, especially if prolonged, the woman
should not be kept profoundly under the influence of the anæsthetic for
any length of time, but should be allowed from time to time to come to
at least enough to make her flinch or move about. This caution should
especially be observed in very feeble patients and in those with very
large cysts.

The Removal of Both Ovaries.

Whenever both ovaries are diseased there can be no question about the
extirpation. But when only one has undergone cystic or other
degeneration the question of the removal of the sound one may come up.
There always is a tendency to the subsequent degeneration of the sound
ovary after the diseased one has been removed. More especially is this
tendency observed in sterile women and in those with malignant
affections of the ovary. Many women, therefore, whose lives should have
been imperilled but once, have been compelled to face the dangers of a
second operation. In view of these facts, it seems to me wise to remove
the sound ovary in all cases of sterility, in every case of malignant
degeneration of one ovary, and in all women who have either passed the
climacteric or are approaching it, provided its removal is not attended
with great additional risk. Double extirpation should also be performed
whenever the womb {338} contains a fibroid tumor or whenever it seems
desirable to hasten on the climacteric. In these convictions I am
further strengthened by the disappointment often expressed to me by my
patients that one ovary had been left behind, and by their great fear
afterward lest the remaining organ should also become diseased. On the
other hand, in women who are in the prime of their menstrual life the
sound ovary should be left untouched, unless there exist grave reasons
for its removal.

{339}

DISEASES OF THE URINARY ORGANS IN WOMEN.

BY ALEXANDER J. C. SKENE, M.D.

ORGANIC DISEASES OF THE BLADDER.

Hyperæmia.

This is an acute congestion of the mucous membrane due to a disturbance
in the balance of the circulation. It may be common to both bladder and
urethra, or limited to either; may terminate within a short period of
time (a few hours), or it may go on and end in hemorrhage or
inflammation. If the mucous membrane is seen with the endoscope, it
appears of a bright-red color; the blood-vessels are distended, more
prominent, and apparently more numerous. The arteries are the first to
be affected. If the cause is transient, this is all that is seen, the
membrane returning to its usual color. When the congestion is of a
higher grade, rupture of some of the vessels occurs either on the free
surface or beneath the epithelium. The venous side of the circulation
now becomes more prominent. In a few cases the above order may be
reversed, the veins being the first congested, as in the case of a
sudden interference with the portal circulation.

SYMPTOMS.--The attack occurs suddenly. Frequent but painless urination
is the most prominent feature. There is a sense of heat and heaviness
in the bladder, aggravated by standing. When the urethra is involved
the patient complains of scalding during urination. The pulse and
temperature are practically normal. The composition of the urine is but
little changed; there may be excess of mucus and a few
blood-corpuscles.

DIAGNOSIS.--This has to be made by exclusion. It is apt to be
confounded with a neurosis of the bladder or a displacement.

ETIOLOGY.--The most frequent cause is exposure to cold, especially
during menstruation; over-taxation in walking or using the
sewing-machine; excessive venereal indulgence; disorders of the portal
circulation; and the use of improper articles of food.

TREATMENT.--Every means should be employed to equalize the circulation.
The most important element is rest in the recumbent position.
Diaphoretics and warm applications to the feet and epigastrium, and, as
a rule, a saline laxative. Where there is frequent urination and
vesical tenesmus and pain, Dover's powder and camphor should be given,
or a suppository of morphia and belladonna by the vagina.

{340} Hemorrhage.

This is a symptom rather than a disease itself. It is usually due to
acute congestion or ulceration occurring in advanced inflammations, new
growths, or the lacerations caused by foreign bodies and instruments.
Hemorrhoids of the bladder due to obstructed circulation is not
infrequently the source of the bleeding. The amount of blood transuded
varies very greatly, though it is seldom so great as to prostrate the
patient. In all cases when it is considerable it is of great importance
to localize the bleeding point. The urethra can be excluded if there is
no bleeding between the acts of micturition. The differential diagnosis
between hemorrhage from the bladder or kidney is less easy. The old
rule, that the blood and urine are more intimately mixed in renal
hemorrhage than in cystic, is of little service. Sir Henry Thompson's
method of detecting the source of pus in the urine may be employed in
cases of hemorrhage. He introduces a soft catheter, and then washes out
the bladder gently with warm water; if after a time the water comes out
clear, the inference is that the bleeding point is higher up. To make
sure, he corks the catheter until a drachm of urine has collected; if
this is bloody, the diagnosis of its being extra-cystic is tolerably
certain. With the endoscope it is occasionally possible, and always
desirable, to locate the bleeding point.

The symptoms in hemorrhage from the bladder, besides the actual
appearance of blood in the urine, are much the same as those in
hyperæmia. Other symptoms liable to arise are from blood-clots forming
and either being passed by the urethra, causing its distension and
impeding micturition, or else such clots may be retained and accumulate
in the bladder, giving rise to still greater functional disturbance,
until they are either broken into small pieces by the surgeon and
extracted, or else by the slower agency of decomposition they break
down and come away.

TREATMENT.--The first thing is to obtain the advantages, both
mechanical and physiological, of the recumbent position. A large number
of hæmostatics have been used--tannic and gallic acids, ergot, and
aromatic sulphuric acid. These are doubtless of some value, but we
prefer giving opium in sufficient doses to allay the desire of too
frequent micturition, and at the same time to render the urine more
bland by alkaline diluent drinks. When the bleeding points can be
discovered with the endoscope, they may be touched with caustic acid,
nitrate of silver, or persulphate of iron. But such applications must
be made with the greatest care, lest inflammation and ulceration
result. Ice in the vagina and at the hypogastrium may be tried when
other means fail. When the hemorrhage is hemorrhoidal, due to impeded
venous return owing to pressure of the gravid uterus, the treatment
will have to be purely palliative in the mean time, as the pathological
condition of the veins usually rights itself after delivery. When a
large blood-clot forms in the bladder, experience has abundantly shown
that it is better not to meddle with it, but to let it break down
itself and come away, the patient being kept easy--if necessary by
opium and alkaline diluents.

{341} Cystitis.

Inflammation may be limited to the bladder alone, in which case we call
it cystitis, or to the urethra alone, when it is termed urethritis.
But, practically, the pathological processes and the causes of cystitis
and urethritis are so closely allied that it will be convenient in our
limited space to consider them together. Like inflammation of other
mucous membranes, various forms or degrees of cystitis and urethritis
are described: these classifications are useful clinically, but it
should not be forgotten that the pathological conditions presented are
only different stages of the same process. Inflammations of the bladder
are divided according to the cause of the disease and the character of
structural lesions into--the acute, including the catarrhal and the
suppurative; and the chronic, including the ulcerative, interstitial
(and peri-cystitis); and the specific, embracing the gangrenous,
croupous or diphtheritic, and gonorrhoeal, in which the inflammation is
the result of a special poison.

ETIOLOGY.--The causes of cystitis may be classed under four heads: (1)
Direct injuries, such as blows in the vesical region, falls, fracture
of the pelvic bones, violent copulation, sudden uterine displacements
causing pressure, foreign bodies, rough catheterization,
over-distension from retention of urine, and, above all, contusions and
injuries during labor. (2) Abnormal urine, from improper food or
malnutrition and certain irritating drugs (cantharides) and irritating
deposits of urine salts. (3) Certain constitutional diseases (eruptive
fevers, gout, ague). (4) Inflammation of adjacent organs, hyperæmia due
to cold.

PATHOLOGY.--The acute forms always begin with hyperæmia, then follow
swelling, perverted or hyper-secretion, then exfoliation of epithelium,
giving rise to a roughened and denuded state of the mucous membrane,
particularly on the top of the rugæ, the products of inflammation
accumulating within the sulci, and finally the formation of pus. A
description of these, the ordinary phenomena of inflammation of mucous
membranes, it is quite unnecessary to give here, but there are one or
two modifying conditions in cystitis that are of great importance and
need consideration. The first of these is the effect which the function
of the bladder as a reservoir of urine has on the inflammation. Normal
urine is irritating to an inflamed mucous membrane, and in cystitis it
soon undergoes decomposition, becomes alkaline, and hence more
irritating. The main agent in producing this decomposition is mucus,
which is secreted abnormally both in quantity and quality. It acts
injuriously in two ways, its fixed alkali tending to neutralize the
acid of the urine, which in the early stages of cystitis is often
hyper-acid, and in promoting the decomposition of the urea and thereby
liberating the volatile carbonate of ammonia. As the urine becomes more
alkaline the precipitation of the phosphates of lime and magnesia
occurs, and the formation of the triple or ammonio-magnesian phosphate.

The irritant effect of these salts, really deposits of foreign bodies,
on the inflamed mucous membrane completes the vicious circle, the
effect now aiding the original cause.

Another most important point in the pathology of cystitis is the effect
of over-distension of the bladder. This is itself sometimes the primary
cause of the trouble, as in certain neuroses, but more frequently it is
the {342} effect of certain injuries during delivery. The mechanism of
its production is not very clearly made out. It usually follows long,
tedious deliveries, during which either the child's head or sometimes
the forceps crushes the urethra against the unyielding pubic bones,
giving rise to an acute urethritis, with swelling of the membrane and
blocking up of the canal, causing retention. The primary injury is not
done, as a rule, to the bladder in these cases, for if it were we
should find the vesical neck the seat of sloughing of the mucous
membrane; but, as a fact, this is the part (owing to its more loose
connections with the underlying connective tissue) that most frequently
escapes. This danger of over-distension is so clearly recognized that
the catheter is nearly always used both before and after delivery if
there should be retention. But a condition more apt to mislead both the
doctor and the nurse is the urine dribbling away either constantly or
intermittently. This is too often ascribed to an irritable bladder
causing frequent micturition, when it is a sign of over-distension, the
dribbling always occurring as soon as the mechanical pressure of the
urine is sufficient to overcome the resistance of the swollen parts.

We have already referred to this condition of over-distension as a
cause of inflammation; it will suffice to say that it may, if
unrelieved, produce a partial or even total slough of the mucous
membrane of the bladder; but, fortunately, this is rare.

Thus far we have spoken of the common forms of acute and subacute
cystitis; it only remains to say a word with regard to its rarer
manifestations. The inflammation may extend to the submucous coats,
becoming interstitial cystitis. Again, this may limit itself here, or
it may extend still deeper to the serous coat, in which case it is
known as peri- or epi-cystitis. Peri-cystitis is almost always a
secondary disease, arising sometimes from deep ulcerations of the inner
coats of the bladder, such as occur in chronic cystitis. More
frequently it is but a part of a pelvic peritonitis which originated
outside of the bladder itself. The final result of peri-cystitis is to
form adhesions between the bladder and the neighboring organs, and
thereby prevent distension of the bladder.

A very rare form of gangrenous inflammation has been described, but it
is more than doubtful if this ever occurs in women except as the result
of mechanical violence or pressure, already described. The specific
lesion of croupous or diphtheritic inflammation has occasionally been
diagnosticated, either from shreds of false membrane passed by the
urethra or by means of the endoscope. Gonorrhoeal inflammation of the
bladder has been less carefully observed in women than in men. Still,
it is known that this specific inflammation extends to the bladder in
some cases, but it does not differ essentially in its pathology,
history, or treatment from that arising from other causes; hence it is
unnecessary to dwell upon it here.

The pathology of chronic cystitis is characterized by ulceration and
sloughing of the tissues involved. They do not differ materially from
the same processes elsewhere, except that the salts of the urine are
apt to be deposited upon the shreds of dead tissue the products of
destructive inflammation. The hard masses thus formed are passed with
great pain. They block up the urethra, and are only expelled by extra
strong efforts which cause intense suffering.

{343} Lastly, the ulceration may extend through the bladder into the
peritoneal cavity and give rise to septic peritonitis and death, or the
perforation may take place into the cellular tissue of the roof of the
pelvis, and cause a fatal cellulitis.

SYMPTOMS.--The various forms of cystitis being but different stages and
degrees of the same disease, their symptoms may be discussed all
together. For convenience we shall consider them under three heads: (1)
Referable to the organs themselves; (2) Symptoms referable to the
neighboring organs; (3) General symptoms.

(1) In all forms of cystitis there is more or less derangement of
function, as shown by pain, tenesmus, and frequent micturition. In the
mildest form of the trouble there is a frequent desire to pass water,
which often comes with unusual force. Micturition is followed by a
desire to strain, as if the organ was not fully emptied. This sensation
may pass off in a few moments, and not arise again till the next
micturition, but in the severer cases it may last continuously. When
urethritis is also present there is the additional and characteristic
symptom of painful scalding as the urine passes over the inflamed
track.

In urethritis alone there is often a desire to urinate frequently, but
if the desire is resisted it passes off, and the patient can retain the
urine for a long time. This symptom should not be mistaken for the
tenesmus of cystitis. In the more advanced stages of the disease,
especially as ulcerative changes occur, the tenesmus becomes more
violent. The pains also are more diffused, often shooting to the
umbilical region. There is often a dull, aching pain in the perineum,
and in nearly all cases there is continuous backache, or, more
correctly, sacral pain.

The composition of the urine is of great importance. The specific
gravity in cystitis does not present any constant change, except that
in the chronic forms it is often a little below the normal. The
reaction in acute cystitis, at first, at least, is usually acid,
whereas in the chronic forms it is almost invariably alkaline. The
color at first is not particularly altered; later, unless discolored by
blood, it is a pale, dirty yellow. The odor is normal in the acute
type, unless where retention has been followed by decomposition, but in
the chronic form it is not only ammoniacal, but has a characteristic
fleshy or organic smell. The sediment in the acute varieties is mainly
light and yellowish, composed of mucus, with some pus generally; in
addition there may be blood, epithelium, and the amorphous and triple
phosphates. In the chronic forms the sediment is usually heavier and of
a darker brownish color. Flakes of pus, shreds of tissue, blood, and
epithelium in all stages of growth are more or less present, and in the
intensely alkaline conditions of the urine the pus and mucus form a
jelly-like, ropy, opaque mass.

Albumen will be found if there is pus in the urine without there being
any kidney disease. As the result of a careful analysis of a number of
cases of chronic cystitis, the amount of albumen varied from
one-sixteenth to one-fifth of the volume of urine. Microscopically, in
addition to the pus, mucus, organic shreds, phosphatic and other
crystals already spoken of, the most interesting appearances are the
various kinds of epithelium. 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, and again they {344} reappear on the subsidence
of the inflammation. This fact is of great importance, because the
transitional forms of bladder-epithelium are often indistinguishable
from the permanent forms of the urinary tract higher up. It is thus
often impossible to make a differential diagnosis between pyelitis and
cystitis from this symptom alone. When renal disease is superadded to
cystitis, the characteristic casts will be found and albumen will
likely be increased in amount.

(2) The symptoms accompanying cystitis in women referable to the
neighboring organs are of some importance, but they very often arise
from some coexisting disease of other pelvic organs. It is therefore
needless to give a list of all the pelvic pains coincident with
cystitis which have been enumerated in the literature of this subject.

(3) The general symptoms are of two classes, toxic and nervous. While
all agree that there is no doubt of direct blood-poisoning in cystitis,
there has been a great deal of difference of opinion as to how this is
effected. I think that there are various agencies at work in this.
First, there may be organic renal disease or sympathetic renal
hyperæmia leading to imperfect elimination. In cystitis caused by
over-distension from long retention the kidneys simultaneously take on
acute inflammation, which usually passes off when the bladder is
emptied, but it may continue and give rise to all the constitutional
symptoms of renal disease. Again, in chronic cystitis the thickening of
the bladder-walls obstructs the ureters, so that the urine is dammed
back upon the kidneys. This arrests their function, and in time leads
to organic disease with all the consequent derangements of the
nutritive and nervous systems. Secondly, absorption of the products of
decomposed urine, or of pus and other septic materials the result of
decomposing shreds of tissue, may take place.

Anæmia is another of the blood-changes which occur in chronic cystitis.
In its origin and continuance it probably is much like anæmia due to
long-continued inflammation elsewhere. The only peculiar symptom in
this connection is the appearance of urohæmatin in the urine.

With this slow deterioration and poisoning of the blood various
symptoms are developed. There is an effort made to eliminate urea by
the mucous membrane of the alimentary canal. This is manifested by
attacks of vomiting or diarrhoea. But when it does not come to these
explosions, there is apt to be lack of appetite, especially at the
morning meal, or there are perverted taste and constipation,
interrupted by occasional attacks of diarrhoea. The skin in the chronic
cases is at times sallow and clammy, and at times there is a distinct
urinous odor about the body. Various more or less marked nervous
symptoms are apt to be present. One set is characterized by the
sluggishness of the patients, an inclination to sleep, despondent
spirits, and occasionally dizziness and fainting. There can be little
doubt that these and allied symptoms are referable to cerebral anæmia,
for they are much aggravated by bromide of potassium, whilst digitalis
and out-door life improves them. A second set of nervous symptoms are
fairly attributable to blood-poisoning of one kind or another, and in
the most severe cases are often promptly relieved by diarrhoea.
Finally, a number of the irregular, wandering neuralgic pains and the
headache are due to the general depression produced by bladder-pain and
loss of sleep.

DIAGNOSIS.--Cystitis is easily made out, except in certain mild cases.
{345} Similar symptoms, especially frequent urination, occur in
prolapsus uteri, often in anteversion and in cases of pelvic adhesions
and pregnancy and abdominal tumors, and lastly in certain neuroses. In
most of these the recumbent position lessens the desire for frequent
urination much more than when cystitis is present. Again, in the
neurosis the attacks are irregular. Tenesmus is usually only present in
cystitis, and lastly the examination of the urine and exploration of
the parts should settle the question. We have spoken above of the
method of differential diagnosis of blood coming from the bladder or
the kidneys: the same method applies to localizing the source of pus.
Urethritis with fissure at the neck of the bladder simulates cystitis
in clinical history, and in the fact that pus in small quantity is
found in the urine. To differentiate, the urine examined should be
taken directly from the bladder with the catheter, when it will be
found free from the products of inflammation. In addition to this, in
some cases it will be necessary to make use of the endoscope, by which
a good view can be obtained of the whole urethra and a portion of the
mucous membrane of the bladder sufficient for diagnostic purposes.

TREATMENT.--The female bladder is so accessible, owing to the shortness
of the urethra, that it is peculiarly amenable to local treatment. This
is by no means, however, all that is required, for in all forms of
cystitis, irrespective of the cause, the urine plays a very important
part in keeping up the irritation. There are, therefore, always three
indications to be met: (1) Removal of the cause; (2) constitutional
treatment (diminishing the irritating character of the urine); (3) the
cure of the local lesion.

(1) In many cases, of course, the cause is transient. The injury is
done, and the inflammation resulting runs its course, longer or shorter
according to the modifying influence of treatment. In a smaller number
of cases, again, the cause is not removable, as in certain
constitutional diseases or permanent pelvic adhesions, tumors, and the
like. In such cases of course the treatment is but palliative, and,
while relieving the immediate symptoms, aids the organs till a certain
amount of toleration of the abnormal conditions is established. But in
a large class of cases the cause, though more or less persistent, is
removable. This includes the numerous cases of uterine displacement.
Lastly, there is a certain number of uncomplicated cases which tend to
recovery without treatment.

(2) The constitutional treatment should be first directed to reducing
the amount of work the bladder has to do. For this purpose the bowels
should be kept rather freely open, saline laxatives being the most
valuable for this purpose. The skin too should be kept healthy and
active. Next, the character of the urine should be as bland as
possible. Food and drugs which are known to cause or keep up cystitis
should be carefully avoided. Milk diet has proved successful in the
hands of George Johnson. In all cases the diet should be carefully
attended to, and should consist largely of fluid foods--milk, yolk of
eggs, soups, etc. Lean meat in small amounts and easily-digested solids
are allowable. Articles such as asparagus, alcohol, beer, and wine
generally are to be avoided. Fruits, such as lemons and oranges, are
usually grateful and at least harmless. The alkaline diluents, such as
citrate of potassium or the alkaline mineral waters (Vichy), answer an
admirable purpose. An infusion of buchu is an excellent agent, and may
be combined with nearly {346} all other drugs employed in treating
cystitis. Where pain is an urgent symptom in acute cases, it should be
relieved by hot applications and by anodynes. Dover's powder is an
excellent form in which to give opium. To relieve tenesmus vaginal
suppositories of morphia, with or without belladonna, may be given. But
in certain cases twenty-grain doses of potassium bromide every four
hours relieve pain where opium fails. Benzoic acid or benzoate of
ammonium in ten-grain doses in infusion of buchu, three times a day, is
a most valuable remedy. The usual remedies, such as balsam of Peru or
copaiba, oil of turpentine, etc., which are given in gonorrhoeal
inflammation, are very useful in the chronic catarrhal forms of
cystitis. To prevent or lessen the decomposition of the urine a vast
number of remedies have been employed, all of the astringents and most
of the antiseptics, but as a rule these remedies are much better
administered locally than constitutionally. In various acute and
transitory cases the constitutional remedies above described will be
all that is necessary, but in the greater number local treatment is
absolutely required.

(3) In local treatment the first point is not to do harm to the parts
by the use of instruments. Dirty catheters and rough catheterization so
often cause cystitis that it is easy to see that the same causes often
perpetuate the mischief. Great care, then, should be used in selecting
instruments for injecting. The ordinary metallic catheter with one or
two large openings is much more liable to wound the sensitive mucous
membrane than one with a number of small holes made either of hard or
soft rubber. It should have a stopcock or something similar at the
outer end, the better to regulate both the injections and the escape of
the solution injected. In ordinary injections only about an ounce at a
time should be in the bladder; this can be repeated four or five times,
and the injection should be as slow as possible. To meet these
indications I use a double perforated catheter made as follows: A small
tube runs from one of the bifurcations to the extreme point. This is
the supply-tube, and the catheter acts as the exhaust. The central tube
can be removed for the purpose of cleaning the instrument. A piece of
rubber tubing attaches the supply-tube to a fountain syringe, and this
completes the whole apparatus. The calibre of the supply-tube being
small and that of the exhaust large, a great quantity of fluid can pass
through the bladder without distending it. The fingers can pinch the
rubber tube and act as a stopcock to regulate the entrance and escape
of the fluid used.

An injection of borax and water is often highly beneficial, and is
alone sufficient in many cases. It should be frequently employed. It
should always precede any topical application or medicated injection.
Lukewarm water alone is employed, but the addition of a little salt
(drachm j to pint j) or chlorate of potassium renders it more bland.
Very often hot water is a most useful application. Of the medicated
injections a vast number might be described, but they are referable to
two classes, anodyne and astringent. The painful nature of cystitis
suggests the use of opium preparations and chloral hydrate for
injections, and they do give some relief. They should be well diluted
to prevent their causing irritation.

Of the astringents, acetate of lead, sulphate of zinc, tannic acid,
nitrate of silver are the most valuable. Many others--perchloride of
iron, chlorate of potassium, hydrastis canadensis, salicylic acid and
its preparations, carbolic acid, etc.--have been commended. In all
cases the strength of {347} the injection should be short of causing
the patient much pain. It is always best to begin with a mild solution
and gradually feel the way up to stronger ones. Of all the astringents,
I prefer nitrate of silver, which I use in strengths varying from one
grain to twenty to the fluidounce. The general rule to be observed, if
a strong solution is used, is to employ only a few drops; if a large
injection is made, the solution should be weak.

Various antiseptics--iodoform, salicylate of sodium, etc.--have been
used to prevent the decomposition which so complicates obstinate
cystitis; but, as a rule, I think frequent washings out and astringent
applications act much better. One of the most distressing obstacles
encountered in making any such injections is where there is a tender or
inflamed urethra. It is well then to carry the catheter only up to the
sphincter of the bladder (as advised by Braxton Hicks), overcoming its
resistance by the pressure of the injection. As a rule, the urethritis
will not long survive the cystitis, but in some cases it exists as an
independent affection; it is then usually gonorrhoeal, and should be
treated as in the male. But when not, the same principles apply as in
the local treatment of the bladder. Great care is needed, as the female
urethra will only hold ten or fifteen drops at a time, and if a large
injection is used it is almost sure to enter the bladder. To meet this
difficulty I devised a reflux catheter for douching the urethra. It is
grooved on the outside, and at the point there is an opening in each
groove which lets a jet of the fluid used flow outward, bringing the
injection in contact with all parts of the urethra.

In cases of ulceration, such as occur in bad cases of cystitis,
applications should be made, if possible, to the part affected only.
This can be accomplished by means of the endoscope when the ulceration
is seated where it can be reached. Having located the point exactly by
means of the endoscope, the inner or glass tube is withdrawn, and the
application made directly to the required spot through the rubber tube.
A glass pipette properly curved or any ordinary insufflator will answer
perfectly, and when a solid is used a delicate long curved forceps will
answer.

In chronic cases of cystitis in which all the above methods of
treatment fail, it becomes necessary to give the parts complete rest by
securing continuous drainage of the urine and products of inflammation.
There are two ways of doing this--the one, to use a self-retaining
catheter which may keep the bladder empty: this method answers very
well when the inflammation is confined to the upper portions of the
bladder, but when the neck of the bladder is involved the presence of
the catheter gives rise to pain and irritation and cannot be tolerated.
The other plan is to establish an artificial vesico-vaginal fistula,
and keep it open for some months, until the bladder-walls have become
normal again. This secures efficient rest to the inflamed parts;
complete drainage is established, the patient wearing a cup, as she
would a pessary, to catch the urine. If the inflammation is limited to
the upper portion of the bladder, the drainage by the fistulous opening
is all that is required; but if the neck of the organ is involved,
frequent and continued medication will be required. This can be done by
injecting through the urethra and letting the fluid escape through the
opening in the bladder. This is not the place to discuss the steps of
the operation or the indications when and how to close the artificial
fistula. For these the reader is referred to works on this department
of surgery.

{348} Suffice it to say, in conclusion, that this by no means easy
operation should be only undertaken as a last resort, but that if
properly done in well-selected cases it will cure where all other known
methods of treatment have failed even to relieve.

Hypertrophy of the Bladder.

This lesion may be partial or total, involving any or all three coats
of the viscus. But the term usually refers more particularly to
increase of the muscular walls. As a rule, the hypertrophic changes are
not confined to one portion of the viscus, all being more or less
affected. The affection is much less frequent in the female than the
male.

ETIOLOGY.--There are two varieties of this affection--one, concentric
hypertrophy, in which the bladder is contracted as well as having its
walls thickened; the other eccentric, in which there is dilatation. Its
principal causes are--obstruction to the outflow of urine from
stricture of the urethra, tumors, or foreign bodies; cystocele,
preventing complete evacuation; cystitis, causing too frequent or too
forcible contraction; and irritable bladder in certain of the neuroses.
Accompanying such dilatation diverticulæ are sometimes formed, though
rarely in the female.

SYMPTOMS.--There is sometimes present vesical spasm, some pain, and
forcible ejection of urine. A certain amount of cystitis is almost
always present, aggravating the original disorder. In the eccentric
form there are sometimes superadded symptoms of over-distension.

DIAGNOSIS.--This is readily made by measuring the thickness of the
bladder-wall between the finger in the vagina and the sound in the
bladder. The capacity of the bladder is easily noted by measuring the
urine passed at each micturition or by injecting a bland solution of
salt and lukewarm water.

TREATMENT.--The treatment should be directed to the removal of the
cause. When this is not possible, palliatives may be sought for in the
use of the catheter, at regular intervals, to prevent over-distension.
Cold baths, astringent injections, and electricity are often of use. By
these means the evil results of the disease may be overcome, but the
hypertrophy is usually permanent.

Atrophy.

Atrophy of the bladder is a rare disease in early life. In women, in
addition to the ordinary decay of age, there is a special
predisposition to degenerative changes in the pelvic viscera, the
bladder-walls included, after the menopause. Extreme distension of the
bladder is usually the exciting cause, giving rise to temporary or even
permanent paralysis, and eventually causing either inflammation or
atrophy and fatty degeneration. Interrupted nutrition, due to impaired
circulation, is the immediate cause, but such altered nutrition may be
purely nervous and due to atrophy of certain ganglion-cells in the
spinal cord.

SYMPTOMS AND DIAGNOSIS.--Patients complain of difficulty in emptying
their bladders, the urine coming away in interrupted jets. They are
{349} apt to be irregular in their times of urinating, and are liable
in consequence at times to have retention and over-distension. Pain and
sometimes a slight cystitis are present. Finally, they completely lose
the power of urinating and a catheter has to be used. The diagnosis is
to be made as in hypertrophy, by a finger in the vagina and a sound in
the bladder.

TREATMENT.--Regular catheterization, strychnia in full doses,
electricity, and tonics, combined with washing out the viscus. Where
the atrophy is due to nerve-degeneration these measures are purely
palliative, in other cases they are of more avail.

FUNCTIONAL DISEASES OF THE BLADDER.

Under the name of functional diseases of the bladder are included a
large number of varied affections of which the pathology is as yet very
obscure. Where there are marked symptoms of vesical disorder, while no
organic lesions are found in the tissues of the bladder, the affections
must be classed under the name of functional derangements. As our
knowledge increases the number of these is constantly diminished, and a
still further and more rapid diminution will occur as the physiology
and pathology of the nervous system innervating this viscus become
better known. These diseases are much more common in children and women
than in men--in children, because the controlling power of habit is
only in process of formation; and in women, mainly because of the more
complex organization of the genito-urinary organs, which are the more
easily exhausted and deranged, especially by the functions of
maternity. True, neuralgia of the bladder has been described under a
variety of names, irritable bladder, cysto-spasm, etc., but it is
rather a rare affection. The most prominent symptom is the painful
micturition, and attendant on this a desire to pass water too
frequently.

There is no particular change in the character of the urine, and no
appreciable visible alteration in the appearance of the parts, though
they are more sensitive than normal to the touch. This condition is
best met by warm fomentations locally and sedatives either locally or
generally, while nutrition is improved by appropriate tonics, nervines,
and by the use of the galvanic current.

A much more common class of affections of the bladder accompany
hysteria, sometimes grouped under the name of hysterical bladder. A
great number of pathological conditions are grouped under this vague
term, but they are held together by all having, as a more or less
prominent symptom, varying degrees of incoördination. The disturbing
effect of strong sudden emotion, as fear, upon the bladder is familiar
to all, and in various organic diseases of the spinal cord and brain,
such as myelitis and locomotor ataxia, a disturbance in the functional
action of the bladder is among the first symptoms. It then becomes a
matter of great difficulty, and yet of great importance, to make a
differential diagnosis.

In hysteria the urine usually diminishes in specific gravity; it is apt
to be increased in quantity, and, though clear in appearance, is
irritating {350} to the mucous membrane. In such cases frequent
urination, sometimes almost continuous, sets in; but it is an important
point that during sleep the patient retains her urine the normal time.
In others we get, on the contrary, retention, and this may be due to
various causes. In some it is doubtless involuntary, as they say they
cannot urinate, but in others it is assuredly will not. Many of these
latter derive a morbid pleasure from catheterization. These are the
patients who are given to the introduction of hair-pins, slate pencils,
etc. etc. into the urethra.

Some authors claim that in the intense sexual excitement of hysteria
the chronic erection of the clitoris makes pressure on the urethra, and
so prevents the escape of urine, but this seems somewhat apocryphal.

Another class of cases resembling the hysterical in the frequency of
urination are those addicted to masturbation; these are, fortunately,
not very common.

In all of these cases the frequency and irregularity of urination is a
much more prominent symptom than the pain. This latter is usually a
slight scalding from the urine passing over the chafed and irritable
urethra, especially at the meatus. (These symptoms sometimes occur in
the miasmatic affections.) A number of neuroses of the bladder are
reflex and dependent on peripheral irritation elsewhere. A typical
example of this class of affections is what has been described under
the title of ovarian irritation. In this condition there is very much
heightened reflex irritability accompanying the increased tenderness
and vascular engorgement of the affected ovary. It is difficult to
explain the bladder symptoms which sometimes accompany the recurring
crises of this disease, except as due to a nervous excitation spreading
from the ovarian centres in the spinal cord to the adjacent bladder
centres.

The diagnosis of this group of affections must be made by exclusion. We
have some of the same symptoms--increased frequency of micturition,
pain during and after the evacuation, tenesmus and shooting pains in
the pelvis--as in organic disease. The most important guide is a
careful examination of the urine, which shows the absence of abnormal
constituents, thereby excluding organic disease. This diagnosis will be
much strengthened by a digital examination, by the vagina, of the neck
of the bladder, and the passage of a urethral sound, neither causing
pain, as they would do in cystitis.

The PROGNOSIS is usually good, but it depends upon the length of time
the affection has lasted.

The TREATMENT is mainly tonic and nutritive. The diet should be
nutritious and simple, and the bowels regulated by mild purgatives.
Constitutionally, small doses of strychnine are most valuable in
improving the nerve tone; so also the constant electric current is of
service. Locally, sedative suppositories in the vagina or enemata are
advantageous, conium combined with belladonna or hyoscyamus seeming to
act best. The liberal use of the bromides gives good results in some
hysterical cases.

Paralysis of the Bladder.

This is the most grave of the functional affections, and, like
paralysis elsewhere, it may be either peripheral or central. When the
latter, as in {351} certain injuries of the brain or in certain
well-marked lesions of the spinal cord, it hardly calls for more than
mention here. Often, however, the cause is not recognizable in any
organic lesion either of the bladder-walls or the central nervous
system, and is to be sought for in more temporary and transient
influences; thus as a result of over-distension most frequently, of
impaired or lost nerve-conduction in fevers involving serious
derangements of nutrition, all of which may be described as functional
or temporary paralysis.

The invasion is usually gradual, except in apoplexy or traumatism. The
patients, who are usually advanced in years, first observe that the
urine is expelled from the bladder with less force than usual; the
stream is smaller and comes slower, and straining takes place, the aid
of the abdominal muscles being invoked. After a while the stream
intermits, and finally partial or complete retention occurs. Then, if
this condition continues, the sphincteric resistance gives way and
constant dribbling occurs. In rare instances dilatation of the
bladder-walls takes place, and finally cystitis. Dilatation of the
ureters and hydro-nephrosis are not uncommon under these conditions.

Where the condition of retention obtains the DIAGNOSIS ought never to
be difficult; the introduction of a catheter will conclusively settle
it.

The PROGNOSIS in uncomplicated paralysis is usually good. When
accompanying fevers, dysentery, peritonitis, etc. it usually disappears
with the original disease. When due to centric lesions the outlook is
about hopeless.

In all cases the bladder should be emptied at stated intervals. If the
patient cannot do this herself, the surgeon should resort to the
systematic use of the clean soft Jacques catheter. A most important
point, too often overlooked, is the method of emptying an
over-distended bladder. It is not safe to empty the bladder at once:
the patient ought to be tapped at intervals, an abdominal binder being
gradually tightened meanwhile. The too sudden removal of pressure from
the vesicle walls which have been rendered anæmic allows of intense
congestion, and in a condition of paralysis is the sure prelude to
cystitis. The diet in these cases should be generous and stimulants are
not contraindicated.

I cannot agree with those authors who recommend washing out the bladder
with medicated solutions and forcibly distending the urethra, nor with
those who use tincture of cantharides as a vesical excitant. Both plans
are apt to produce cystitis. A far more rational though somewhat
impracticable treatment is the use of electricity as recommended by
Winckel--one pole (thoroughly insulated up to the point) in the
bladder, the other on the symphysis or loins. The sitting should last
about five minutes. But by far the most valuable therapeutic agent is
strychnia, which should be exhibited in full doses, many of the
reported failures with this drug being due to too small doses. In
urinating the upright position is generally preferable to lying down,
as the pressure of the abdominal organs to some extent compensates for
the lack of tonicity in the bladder-walls.

Lastly, in these hopeless cases of complete paralysis an artificial
vesico-vaginal fistula and the adaptation of an apparatus to catch the
urine may be of service.

Functional disorders of the bladder are frequently met with, due to
{352} abnormal constituents in the urine. As was mentioned above, these
may be so grave or their irritant action continued so long as to give
rise to cystitis. In the slighter forms, due to transient cause, the
local trouble will speedily right itself, but in other cases, such as
those dependent on functional derangements of other organs, as
dyspepsia, the irritation is apt to return at varying intervals. In
almost all these cases the immediate mechanism of the trouble is the
presence of some urinary deposits. To this may be added the
constitutional impairment, as in oxaluria, when the minute octahedral
crystals are probably not more to blame for the local difficulty than
the impairment of the nervous tone. Similarly, the poison of malaria
and of certain of the exanthemata, and of many diseases marked by
faults of assimilation and elimination, causes functional disturbance.

The prime indication in treating these cases is to render the urine
more bland by dilution. For this purpose water, aided by the salts of
potash and the alkaline mineral waters, is the best. This should always
be given on an empty stomach, and the addition of infusion of buchu is
excellent. In the condition known as oxaluria the alkaline salts are
not called for, but instead thereof acids. Nitro-muriatic diluted and
tincture nucis vomicæ tend to correct the faults of nutrition, and they
should be largely diluted to relieve the local condition.

The last class of functional diseases are caused by lesions of position
either of the bladder or of some of the neighboring organs. Here,
again, we have conditions which if sufficiently prolonged may lead to
organic vesical changes or may simply be temporary or intermittent. By
far the greater number of these are dependent on malpositions of the
uterus, which either drags or presses on the bladder. Either of these
classes may be complicated with adhesions arising from a former
cellulitis or pelvic peritonitis, the adhesions resulting therefrom
maintaining a fixation of the pelvic organs which impairs the functions
of the bladder.

Other causes of displacements are uterine and ovarian tumors, pelvic
deformities, and fecal impactions of the rectum. Of the various
displacements of the bladder it is needless to speak in much detail.
The most important is the downward one. Various degrees of this are
found up to complete cystocele, most commonly associated with prolapsus
uteri. The bladder naturally sags inferiorly as age advances, and by
far the most potent agent in causing this to become pathological is
repeated pregnancy and injuries during labor.

It is a well-known fact that the first stage of vesicle prolapsus is
apt to be marked by as great discomfort as the third, for after a while
the organ seems to become accustomed to its altered relations. The
treatment of this condition is difficult. The bladder should be
replaced and kept there. As this usually necessitates the reposition
and maintenance of the displaced uterus, it is extremely difficult, and
in case of existing adhesions it is impossible. A great variety of
mechanical means have been tried to furnish an artificial support to
keep the parts in position. If the bladder alone is prolapsed, the
pessary used for anteversion of the uterus will sometimes answer. The
instruments devised by Thomas, Grailly Hewett, and myself are most
commonly used.

{353} Acute Urethritis; Inflammation of the Urethra.

This affection may be simple or gonorrhoeal, and it is often difficult
to tell the one from the other. There is a difference in history when
we can get correct testimony from the patient. Simple urethritis
usually comes on gradually, and is often preceded by symptoms of
uterine or vesical disease, while gonorrhoea comes on rather abruptly,
and is preceded or attended by acute vaginitis 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 hemorrhage, the
source of blood being evidenced from the fact that it was not
intimately mixed with the urine, and after micturition it oozed from
the meatus urinarius.

An examination of the parts will show signs of inflammation 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 apparent. Introducing the
finger into the vagina and pressing upon the urethra from above
downward will cause a discharge, unless the patient has passed water
immediately before. The appearance of the discharge corresponds to that
of gonorrhoea in its various stages.

Cystitis, which is liable to be confounded with urethritis, may be
excluded by using the catheter, and, after letting urine flow for a
time, collecting the remainder 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
examination, 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 constitutional 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 injections becomes
necessary. 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. The
catheter 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 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 and sulphate of zinc
will often prove useful. It must be borne 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 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 {354} of long standing, and the neck of the
bladder appears to be involved also, I use a weak injection of one or
two grains of nitrate of silver to the fluidounce, 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 urethral walls.

Inflammation of the Urethral Glands.

These glands rarely, if ever, take on inflammation primarily, but
vulvitis and vaginitis, especially if gonorrhoeal, often extend into
them. When they do become inflamed, the disease usually remains without
any tendency to subside. More than that, when a gonorrhoea affects
these glands the inflammation will remain there after all traces of the
disease have left the vagina, vulva, and urethra, and in time the
discharge from these glands will light up the original vaginitis and
vulvitis again. The symptoms of this inflammation are not diagnostic.
The physical signs are the swelling and redness around the mouths of
ducts which are located just within the labiæ of the meatus urinarius.
This give a general redness to the meatus. By pressure made upon the
urethra from above downward a purulent discharge from the ducts will be
produced and can be seen escaping. The only effective treatment is to
lay open the glands their whole length. They run upward in the
posterior wall of the urethra, so that by passing a fine probe-pointed
scissors they can be laid open on the vaginal surface. Care should be
taken to prevent the incision from reuniting, and if the inflammation
does not promptly subside applications should be made, as in the
ordinary treatment of inflammation.

Another very troublesome affection of the urethra which usually results
from urethritis is granular erosion, as it is called. The mucous
membrane is covered with young, imperfectly-developed epithelium; the
papillæ are hypertrophied and extremely sensitive. This gives rise to
the most excruciating pain during micturition, and generally keeps up a
distressing tenesmus. This disease is rarely seen except among old
people. The diagnosis is made from the history and appearance of the
urethra. The treatment is cauterization of the whole surface. The
milder washes and injections do not accomplish much. Pure carbolic acid
may be tried first, brushing it over the surface and repeating it in
eight or ten days. This is the least painful application, and generally
answers very well. When it fails a solution of nitrate of silver (one
drachm to the fluidounce) should be used. In obstinate cases it is
desirable, before using strong caustics, to dilate the urethra, and
then touch it with a 50 per cent. solution of carbolic acid.

{355} Circumscribed and Subacute Urethritis.

Among the inflammatory affections of the female urethra there are mild
forms which fall short of well-marked urethritis. Indeed, some of these
attacks amount to little more than congestion or slight catarrh. In
others circumscribed patches of the urethra become inflamed, the rest
of the canal remaining normal.

The cause of this affection is generally some inflammation of other
pelvic organs, such as cellulitis. In one case it occurred in a
saleswoman who had been upon her feet many days from early morning
until late at night. I found several small ecchymoses on several parts
of the mucous membrane with zones of inflammation around them. The
long-continued passive congestion had caused some of the small vessels
to rupture, and the small blood-clots started the inflammatory process.

These cases tend to recovery if the patient is placed under favorable
conditions. If there is much pain, and if the trouble appears to be
tending to become chronic, mild injections may be employed.

Dilatation of the Urethra.

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,
it is not, as a rule, uniformly so. In general, the urethral walls and
the urethro-vaginal septum are usually enlarged, relaxed, and flabby.
After a considerable time they may become indurated by infiltration or
hyperplasia of the connective tissue. The mucous membrane is usually
soft and loosely adherent to the subjacent tissues. Beneath the
membrane there are sometimes 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, nothing 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. The dilatation can
be easily detected, even when the meatus is normal in size, by
observing that the sound 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 it is usually elastic and compressible. Through Sims's
speculum the abnormal fulness or bulging of the anterior vaginal wall
can be plainly seen and distinguished from displacement of the urethra.
The points of difference between dilatation and displacement will be
brought out more in detail farther on.

When the dilatation has existed for any length of time, the mucous
membrane is usually hyperæmic, 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 it can be seen through the
{356} 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 the urine passing over it.

Dilatation of the anterior or lower third is the rarest of all 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 or may not
include the meatus. In rare cases it does not at first, but in time the
enlarged mucous membrane slowly, sometimes 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 urethra.
When the dilatation is due to any new growth in the urethra, the tumor
can be seen on inspecting the parts.

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 consulted 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 concentric 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 admitted 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 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 dislocations of the urethra.

Dilatation of the middle third of the urethra is more common than that
of any other portion of the canal. In this form the anterior wall of
the urethra maintains its normal position, but the central position,
being distended, settles down, so that in time the urethra, in place of
being a straight or slightly curved canal, becomes triangular, the
upper wall being the base, and the central portion of the wall (that
is, midway between the neck of the bladder and the meatus) the apex. A
sac or cavity is thus formed in the central portion of the urethra.

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 part of the canal and the neck of the bladder
become dislocated downward, 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
irritation, 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 {357} urination, or from extension of the
inflammation from the urethra to the bladder, is a question.

ETIOLOGY.--The hyperæmia of the urethra which occurs in pregnancy, and
which tends to produce over-distension of the veins, favors dilatation
of the whole urethra. There is an apparent increase 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
enlarged 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 enlargement of the membrane by swelling
still further increases the calibre of the canal.

The dilatation caused by the passage of 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 frequent causes of dilatation.

I have already stated that dilatation of the lower third of the urethra
is rare, and is usually due to inflammation 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 urethra, I am inclined
to believe that it occurs in consequence 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 originally, 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
accompanying relaxation of the urethral walls may be sufficient to
cause the dilatation. In all the cases that I have critically examined
there has been displacement as well as dilatation, and the whole
trouble could invariably be traced to childbearing 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 affection--that is, narrowing of the lower end
of the urethra. This does not explain the etiology of all cases,
however, for I have seen this form of dilatation where there was no
stricture or hypertrophy of the lower end of the urethra. In such cases
I have traced the cause to childbirth, during which the posterior wall
of the urethra had been pushed downward and contused, while the upper
remained in its normal position. The relaxation 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 hypothetical, 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.

{358} SYMPTOMATOLOGY.--The symptoms vary according to the extent of the
dilatation, the portion of the urethra involved, and the condition of
the mucous membrane. When the whole urethra is dilated the only symptom
present may be frequent urination. When there is inflammation or
prolapsus of the mucous membrane, 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, and painful
urination certainly. The symptoms in this form of dilatation are less
marked than in the other varieties.

When the trouble is located in the upper third of the urethra, the
symptoms are sometimes very distressing. 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 distresses the
patient very greatly. 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 of mind is
sometimes more distressing than the physical suffering.

The symptoms occuring in dilatation of the middle portion of the
urethra are the same as those already given, with the addition of a
slight mechanical 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
obstruction 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 muscular
hypertrophy found in those 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 affections. In fact, the symptoms here given may all be
produced by other pathological conditions, and consequently cannot
alone guide to a correct diagnosis. The true character of the trouble
can only be discovered by physical exploration.

DIAGNOSIS.--A digital examination by the vagina will detect the
increased space occupied by the urethra. The canal encroaches upon the
anterior vaginal wall, and feels like a ridge extending 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 standing
the tissues are firm to the touch, but still the canal is compressible.
The extent of the dilatation, if general or located in the lower parts,
can be measured by the size of the sound that can be easily passed. If
at the middle or upper portions, an ordinary female catheter or sound
may be used to explore it. By introducing that instrument and pressing
it first against the anterior wall and then upon the posterior, the
distance between {359} the two can be approximately made out. While the
catheter or sound is in the urethra the finger should be introduced
into the vagina to ascertain the thickness of the urethral wall. This
will differentiate between dilatation and hypertrophy.

When the meatus is dilated and the mucous membrane and enlarged vessels
are prolapsed, care is necessary to distinguish that condition from
urethral neoplasm. This can be done by observing that in prolapsus the
opening is situated either at the upper side or in the centre of the
protruding mass, whereas in abnormal growths of the urethra the meatus
surrounds the tumor or its pedicle. More than that, by making pressure
the distended vessels can be reduced in size and the prolapsed membrane
pushed up into the canal. This cannot usually be accomplished with
tumors.

PROGNOSIS.--There is no natural tendency to recovery in these
affections. If left alone they generally get worse. Recovery under
treatment depends upon the location of the dilatation and the duration
of the trouble. The conditions upon which an unfavorable prognosis is
to be based are--bladder complications, inflammation 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
complications a complete recovery may be expected. 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
attention should be given to any inflammation of the mucous membrane
that may exist, employing the usual treatment. When there is a relaxed
and prolapsed condition of the mucous membrane, astringents should be
used. 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 the long pointed tip of the instrument
should be used, 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 pieces of normal membrane are left between the portions cauterized,
which prevents stricture from occurring after healing--a misfortune
which is sure to follow if the mucous membrane is destroyed by
cauterization all around.

In excising the prolapsed portion I prefer to remove one or more
V-shaped portions on opposite sides and bring the edges together by
sutures. This is preferable 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 perchloridi.
He repeated this operation several times on the same patient, who
experienced little or no inconvenience from the proceeding and made a
good recovery.

Dilatation of the lower third of the urethra is usually secondary to
some other trouble, as I have already stated; and all that is necessary
{360} 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 consists simply in
supporting the parts. This can be effectually done by using the pessary
already recommended for the relief of prolapsus of the bladder. It may
be necessary to have the instrument so formed as to bring the pressure
where it is required. This is done by placing the pessary in position
and observing what change of form, if any, is necessary, and then
directing 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, it may be necessary to remove that before using the pessary;
otherwise the pressure of the instrument may cause pain and aggravate
the inflammation.

In dilatation of the middle third Bozeman has proposed to make 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 products of
inflammation which accumulated there before. This, with appropriate
cleansing and topical applications, 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 recent cases of less
magnitude I have obtained satisfactory results by dilating the lower
part of the urethra and supporting the dilated portion either with a
pessary 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.

Dislocations of the Urethra.

This is one of the affections most frequently met with in practice. 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 dislocated, 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
either may take place alone.

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
downward the upper two-thirds of the urethra are prolapsed, so that the
direction of that portion of the canal is backward, instead of curving
upward, as in the normal condition. In complete prolapsus the urethra
runs from the meatus (which is in its normal position) backward, and
rests upon the {361} perineum, or in extreme cases, accompanied with
prolapsus of the bladder and uterus, its direction is backward and
downward, the 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.

ETIOLOGY.--Utero-gestation and delivery are the most important causes
of this affection. In the advanced months of pregnancy I have observed
that while the bladder rose above the pubes the urethra was pushed
slightly downward by the settling of the enlarged uterus into the
pelvis. In such cases when labor occurs the head of the child
dislocates the urethra still more by pushing it still farther down.
This process I have often watched in forceps delivery. When there is a
partial prolapsus of the urethra existing before labor, the urethra and
anterior vaginal wall are forced down before the advancing head, and
that, too, while the attendant is making counter-pressure to prevent
it. The displacement produced in this way is often restored during
convalescence if proper care be taken to push the parts back into place
and the patient is kept at rest until the tissues regain their
tonicity. 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 it will slowly increase until the dislocation is
complete. This will surely be the case if there is any loss of
perineum. Indeed, rupture of the perineum is an accident which permits
the urethra to descend from its place. The perineum supports the
vaginal walls, which in turn support the urethra; and if it be 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.

SYMPTOMATOLOGY.--The symptoms arising from displacement of the urethra
are much the same as those 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, for example, the urine
will escape. This loss of control does not exist, as a rule, in
complete displacement. On the contrary, there is usually difficult
urination, which requires increased voluntary efforts to empty the
bladder. In all degrees of displacement 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 touch or speculum,
will reveal the downward projection of part or all of the urethra,
which will show that there is either dilatation or prolapsus. The
change in the direction of the canal will be shown by passing 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 the sound passes in the normal direction, but
is arrested at a 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 direction.

PROGNOSIS.--Uncomplicated displacement of the urethra can be remedied
in the great majority of cases. By placing the parts in proper {362}
position, and holding them there, the relaxed tissues will usually
contract sufficiently to support themselves. Should they fail to do so,
the patient can at least be made comfortable by wearing some supporter.

TREATMENT.--When the displacement of the urethra is caused by any other
trouble, such as defective perineum 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 bladder. Prolapsus of the upper part of the urethra can be
relieved in this way quite satisfactorily. When the whole urethra is
displaced, this pessary, while it supports the upper part, will still
permit the middle portion of the urethra to settle down. This
difficulty may be overcome by making the anterior portion of the
pessary long enough to engage in the introitus vulvæ, and in that way
keep the whole canal where it should be. Should this cause the patient
much discomfort, a tampon of marine lint should be used to keep the
parts in position until some restoration of the parts is obtained, and
then the pessary will complete the treatment.

Prolapsus or Inversion of the Urethral Mucous Membrane.

The prolapse may be limited to one side or extend all around the canal.
The size and extent of the protrusion 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 become red and
oedematous. When the meatus is small these changes occur sooner and in
a more marked degree, because the prolapsed portion is partially
strangulated. The longer the membrane remains exposed the more
sensitive it becomes, and the frequency of urination 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 that closely resemble those of irritable growths at
the meatus urinarius, and, so far as history is concerned, it is not
easy to make a differential diagnosis. To do this it is necessary to
make a local examination. The physical 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 causing frequent urination and
vesical tenesmus. Chlorotic and greatly debilitated 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 urinary organs.

PROGNOSIS.--This disease does not yield promptly to mild treatment,
{363} unless it is seen early in its progress; 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 to remove any
inflammation or other complicating conditions. The prolapsed membrane
should be replaced, and the patient kept quiet in bed to favor the
retention of the parts in situ. Astringents, such as tannic acid, alum,
or persulphate of iron in a weak solution, should also be used. Should
these fail, the prolapsed portion of the membrane should be removed.
The methods of doing this (by excision and the thermo-cautery) have
already been described.

Stricture of the Urethra.

PATHOLOGY.--Obstruction of the urethra by narrowing of its calibre is a
much less common affection in the female than in the male. Still, it
occurs sufficiently often to demand attention. There are some facts in
the pathology of urethral stricture peculiar to women which we will
first notice. Passing over congenital narrowing 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
inflammatory products beneath the mucous membrane, which by gradual
contraction constricts the canal. Ulceration 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 childbirth. Stricture may also be produced by bands
of scar-tissue formed in the anterior vaginal wall and stretching
across the urethra. Contraction of the whole canal occasionally occurs
in cases of vesico-vaginal fistula of long standing. There the
narrowing is simply the result of disuse. The form of stricture that
most frequently comes under observation is 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 subacute
urethritis, sometimes ulceration. In those cases where the calibre of
the canal is diminished by cicatrices of the vaginal walls, and in
general contraction of the urethra in vesico-vaginal fistula of 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. In almost all cases of
stricture the subject has at some previous time suffered an injury at
childbirth, urethritis, or something to which the origin of the
stricture can be traced. The previous {364} history of cases in which
stricture is suspected will aid 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 compressing the urethra can be detected in the same way.
The use of the sound will determine the location of the stricture and
the extent to which the canal is contracted. When the stricture is at
the meatus it can be found with facility; but when it is located higher
up the largest sound that can be introduced without force should be
passed 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.

The affections which are liable to be mistaken 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. The former can be excluded by a vaginal examination, and the
latter can also be detected by the sound, used as directed while
discussing the diagnosis of the dilatations.

PROGNOSIS.--Stricture of the urethra usually yields very 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, it is
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 forcibly stretched with the dilator. When due to bands
of scar-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, forcible and rapid dilatation, as practised on the male
subject, will answer well if the proper cases are selected for this
form of treatment. Dilatation should be made 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 extent. As soon as the stricture has given way dilatation should
be suspended.

Incising the stricture from within outward, according to the method
commended by surgeons for the cure of stricture in the male, will no
doubt answer a good purpose. In fact, I am inclined to believe that
this plan of treating this affection is the best, but my own experience
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 dilatation 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 follow the treatment. It is well
also to keep such patients under observation, and pass the sound from
time to {365} time to see if there is any tendency of the stricture to
return. The brilliant results obtained in the treatment of stricture in
the male with electrolysis by Robert Newman should warrant a more
extended trial of this method.

Stricture at the Junction of the Urethra and Bladder.

This form or location of stricture is, so far as I know, peculiar to
women, and its influence on the function of the bladder has not been
clearly pointed out. In fact, no distinction has been made between the
pathology 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 mentioned this form of stricture. My own
observations 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.

The causes are the same which give rise to stricture elsewhere; hence
nothing requires to be said on this point. The point of most importance
is the fact that stricture at this part of the urethra will cause
difficult urination out of proportion to the extent of the narrowing of
the canal. Contraction of the canal in a slight degree will cause great
difficulty in urination, and frequently retention. This is contrary to
the history of stricture of the urethra at other points. 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 is possible that the original
stricture causes spasmodic contraction, or in some way disturbs the
normal action of that portion of the canal which performs the function
of a sphincter vesicæ.

The symptoms presented in this form of stricture are difficult
urination and in some cases complete retention. I have also noticed, in
one case, that there was a frequent desire to urinate, but that was
accounted for by a slight catarrh of the bladder. These symptoms are
such as occur in other conditions, such as atrophy and paralysis of the
bladder, obstruction of the urethra from tumors, calculi, the pressure
of the displaced uterus, and prolapsus of the bladder.

In this form of stricture there are thickening 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 marked. Our main reliance
must be placed upon the exclusion 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 excluded the possible existence of either of these conditions,
the only two affections which are to be confounded with this form of
stricture are atrophy and paralysis of the bladder. To distinguish
these from the stricture, the catheter should be passed when the
bladder is well {366} distended, and the character of the flow of urine
watched, when it will be observed that in stricture the urine comes
away with the usual force. The bladder contracts normally and with its
natural vigor, and sends the urine out in a well-sustained stream
through the catheter, if there is only 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, the diagnosis may be confirmed by testing the dilatability of
the urethra. This can be done by passing a dilator along the urethra
and gently testing the resistance of the walls of the canal. There is a
slight yielding at all points except at the stricture, where a decided
resistance is met.

Regarding the management of stricture at the junction of the urethra
and bladder, I am obliged to say that my experience has not yet been
sufficient to enable me to speak definitely. Rapid and free dilatation
is not sufficient to effect a cure; at least it has failed in one case.
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 this 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 that is all
that I have to offer on this subject.

{367}

DISEASES OF THE VAGINA AND VULVA.

BY EDWARD W. JENKS, M.D., LL.D.

DISEASES OF THE VAGINA.

The subject will be considered in the following order: Anatomy,
Vaginitis, Atresia, Prolapsus Vaginæ, Cicatrices, Double Vagina,
Growths, and Vaginismus.

Anatomy.

The vagina is a musculo-membranous canal extending from the neck of the
uterus--which it embraces--to the vulva. It is usually attached to the
uterine neck at a point midway between the os internum and the os
externum. This canal is composed of three layers or coats: the outer
one is of fibrous and elastic tissue; the middle, of unstriped muscular
fibre and fibre-cell; the inner coat or lining is mucous membrane,
composed of connective tissue and elastic fibre and covered with
squamous epithelium. The outer and middle coats spread out at the upper
portion of the perineum, making the perineal septum, and attach
themselves to the ischio-pubic rami. One of the peculiarities of the
middle coat is that during utero-gestation it becomes much
hypertrophied like the same structure in the uterus, and following
labor undergoes a similar process of involution. The inner or lining
coat extends to the fourchette.

Savage[1] has described the general form of the vagina as similar to
that which would be assumed by a flexible tube if shortened to nearly
half its length by a cord passed from end to end through one of its
sides. The ridge thus formed is called the anterior column of the
vagina, and marks the vesico-vaginal septum; it is about two inches
long, while the posterior wall or posterior column is twice that
length. The anterior column or cord causes the investing mucous
membrane to be puckered and thrown into folds or rugæ which run
transversely toward the posterior column. "This mucous membrane is
studded with papillæ which are covered with pavement epithelium. The
papillæ of the vagina, which were first fully described by Franz
Kilian, were regarded by him as having for their function the
transmission of sensation. He represents them as being thread-like and
filiform."[2]

[Footnote 1: _Anatomy of the Female Pelvic Organs_, London, 1870.]

[Footnote 2: Thomas on _Diseases of Women_, Philada., 1880.]

Anatomists have differed regarding the existence of muciparous glands
{368} in the folds of the vaginal mucous membrane, some asserting that
they are present, and others being equally positive that there are
none. Notwithstanding this lack of uniformity, the fact that some have
discovered muciparous follicles, while others have failed, enables
recent writers to state that there is no doubt of their existence.

The vagina is lined with mucous membrane and covered with pavement
epithelium, studded with projecting filiform papillæ. This membrane
lies in folds, between which are numerous muciparous follicles.

Vaginitis.

DEFINITION.--Vaginitis is a term used to designate inflammation of the
mucous membrane of the vagina.

SYNONYMS.--Colpitis, Elythritis.

VARIETIES.--Three distinct varieties of vaginitis are met with--viz.
simple, specific, and granular.

ETIOLOGY.--Predisposing Causes.--Young girls are not unfrequently the
subjects of vaginitis in consequence of want of cleanliness, exposure
to cold, ascarides migrating from the rectum into the vagina, or the
introduction of foreign substances. It also frequently appears in
consequence of smallpox, measles, and scarlatina. In adults it may be
caused by exposure to cold or wet, more particularly at or near a
menstrual period. The insertion of a sponge into the vagina, as is not
uncommon for the purpose of topical medication or uterine support, acts
as an irritant if allowed to remain a few days, which may cause severe
inflammation. Pessaries, irritating vaginal injections, gonorrhoeal
infection, certain conditions of the urine, as in diabetes, acrid
uterine discharges, childbirth--more particularly if there has been
retention of putrefying secretions--and chemical agents used in
treatment of uterine diseases, are sometimes causes. Uterine discharges
which cause vaginitis are not generally irritating until they reach the
vulva, where by exposure to the air they become changed, first causing
vulvitis, and next inflammation of the vaginal mucous membrane.

Some women have slight attacks of vaginitis after each menstrual
period, but they are generally slight and soon subside; others will
have attacks after each coition or after great physical exertion, but
with such patients the disease is not severe, and usually passes off
without any signs remaining. It is quite common among prostitutes,
independent of specific causes, in consequence of excessive coition.
Chronic vaginitis or vaginal leucorrhoea is not uncommon with
newly-married women in consequence of excess or awkwardness in coition.

Granular vaginitis is generally caused by pregnancy, but occasionally
it seems to be produced by simple or specific vaginal inflammation. A
strumous diathesis or a disordered state of the blood, as in phthisis
or other constitutional disorders, are predisposing causes.

Mention has been made by some writers of diphtheritic and senile
vaginitis. Diphtheritic inflammation of the vagina is sometimes seen
during epidemics of the disease or among puerperal women in crowded
lying-in hospitals. Senile vaginitis is occasionally met with in women
after the climacteric period. Its cause is wholly in consequence of the
physiological retrogressive processes incident to the change of life.
The {369} epithelium is shed in patches, and, according to Hildebrandt,
the raw surfaces adhere, causing contraction of the vagina.

SYMPTOMATOLOGY, COURSE, DURATION, PATHOLOGY, TERMINATION, AND
COMPLICATIONS.--The subjective symptoms of the three varieties of
vaginitis which have been mentioned are nearly identical, but in their
physical signs a marked difference is perceptible. In the outset there
is a sense of heat and burning in the vagina, a feeling of pain and
weight in the perineum, and a frequent desire to urinate. The passage
of urine causes pain and a feeling of scalding in the urethra. It is
believed by many authorities that the sense of scalding is more
pronounced in the specific variety. Not unfrequently there are backache
and pain radiating down the thighs into the hips, along the spine, and
into the head. Sometimes, with the other symptoms mentioned, there will
be a decided febrile disturbance, chilliness alternating with heat, a
rapid pulse, and a foul tongue. With such symptoms the thermometer will
show an elevated temperature. Coincident with the beginning of pain and
irritation the patient has an itching sensation, which sometimes
becomes intolerable, and is generally worse at night when she is warm
in bed. Emmet states that some cases are so severe as to require
anæsthetics before relief can be obtained. After the lapse of from
twenty-four to seventy-two hours these symptoms subside, and there is a
profuse purulent discharge, yellowish or greenish in appearance and of
an offensive odor. In many cases the discharge is of so acrid a
character that it excoriates the vulva and surrounding parts. Walking,
or even standing, is often painful, particularly the former, owing to
the attrition of the inflamed or excoriated surfaces.

A physical examination causes pain, and if the inflammation has
extended to the vulva, urethra, or the vulvo-vaginal glands, it will
often produce intense suffering. When the vaginitis is acute, the labia
are swollen, the vagina assumes a more or less intense red color in
place of the light or pale rose-color of health; it will also be
swollen, and at the beginning seem unnaturally dry, but very soon,
although still red, it will be covered with a yellowish or
greenish-yellow, muco-purulent discharge of an offensive odor. By
careful examination with the speculum the vaginal canal will be seen to
have a congested appearance, with abraded points, and sometimes
follicular ulceration will be found. Generally, the appearance of thick
mucus within the os uteri indicates an extension of the inflammatory
process into the cervical canal.

Sometimes in gonorrhoeal vaginitis the full force of the disease seems
to be chiefly expended in the urethra; when this is the case, and
patients complain of intense scalding in passing urine, a finger
pressed against the anterior vaginal wall will usually cause pus to
exude from the urethral canal.

The duration of vaginitis depends largely upon the treatment. If
appropriate treatment is begun early in the course of the disease, a
cure can be effected in two or three weeks. On the other hand, it may
continue an indefinite length of time or assume a chronic form,
constituting a catarrhal condition of the vaginal mucous membrane, or
vaginal leucorrhoea.

Sometimes inflammation of the lining of the vagina, more especially
specific vaginitis, extends beyond the cervix into the cavity of the
uterus, {370} along the Fallopian tubes to the ovaries and to the
pelvic peritoneum, or it may travel along the mucous membrane until it
reaches the lining of the bladder, causing a cystitis, or in a similar
manner involve the vulvo-vaginal glands.

It is not unusual after all the signs of a vaginitis have entirely
disappeared that the inflammation recurs without any apparent exciting
cause, but wholly in consequence of a diseased condition of the mucous
lining of the cervix uteri, designated cervical endometritis, chronic
inflammation, or uterine catarrh. In consequence of this there is an
increased and changed secretion, which acts as an irritant and causes
vaginitis. These recurrent attacks of vaginitis can be prevented only
by a successful treatment of the cervical disease.

Chronic vaginitis or vaginal catarrh occurs after repeated attacks of
the acute form in persons of a strumous diathesis, and from uterine
disorders, such as catarrh, displacements, or polypi of the uterus.

Vaginal catarrh from any cause may lead to other difficulties; thus, if
it is the primary affection it may lead to catarrh of the uterus and of
the Fallopian tubes. Its long continuance with or without the
co-existence of uterine disorders may lead to relaxation and subsequent
prolapsus of the vaginal walls.

In the beginning of vaginitis, as in inflammations of mucous membranes
elsewhere, the vaginal lining becomes first very vascular, presenting a
congested and swollen appearance, with a diminution in the quantity of
normal secretion; but within a few days portions of the epithelium are
cast off, leaving abraded spots which sometimes ulcerate and become
covered with exudation. Occasionally complete casts of the epithelial
lining of the vagina are desquamated. In lieu of the natural
secretions, within thirty-six hours after the inception of the disease
the vagina is filled with an acrid, foul-smelling muco- or
sero-purulent fluid, having the appearance of unhealthy pus. The
discharge consists of serum, numerous epithelium cells, pus-corpuscles,
blood-globules, and infusorial animalculæ designated Trichomanas
vaginalis, and mucus. When an attack is very severe a true phlegmonous
inflammation is often developed in consequence of the submucous
cellular tissue first becoming involved.

In specific vaginitis it not infrequently occurs that the disease is
confined to the vaginal cul-de-sac--a fact which, according to
Guérin,[3] explains how sometimes apparently healthy women communicate
gonorrhoea to the male.

[Footnote 3: _Mal. des Organes génitaux_, Paris, 1864.]

In granular vaginitis the mucous membrane extending throughout the
entire canal and over the neck of the uterus is covered with numerous
minute elevations or granulations of about the size and shape of half a
millet-seed. Thomas says: "This variety of the disease appears to bear
about the same relation to simple vaginitis that follicular vulvitis
does to the purulent form of that affection."[4] The same author
mentions having seen a patient with granular vaginitis so striking in
its features that the family physician believed it to be malignant
disease developing, until convinced to the contrary.

[Footnote 4: Thomas on _Diseases of Women_, 5th ed., p. 219.]

Simple acute vaginitis frequently causes and remains associated with
{371} vulvitis, urethritis, and less frequently endometritis,
salpingitis, and pelvic peritonitis. The chronic form is not
unfrequently complicated with uterine catarrh. Acute specific vaginitis
is often complicated with buboes from inflammation of the femoral and
inguinal glands and inflammation and abscess of the vulvo-vaginal
glands. This variety more frequently than the others is liable to give
rise to violent urethritis, cystitis, salpingitis, ovaritis, and pelvic
peritonitis.

DIAGNOSIS.--If one is familiar with the symptoms which have been
mentioned, the diagnosis of vaginitis is not a difficult task; but it
is sometimes not only difficult, but quite impossible, to determine
whether a case is one of simple inflammation or of gonorrhoeal
contagion.

The symptoms which are most liable to lead one to decide that a case is
specific are their severity, the sudden development of virulency, the
scalding micturition, urethritis with pus in the urethra, the
greenish-yellow discharge of a foul odor, the very irritating quality
of this causing gonorrhoeal ophthalmia if applied to the conjunctiva or
gonorrhea in the male following coition; the occurrence of buboes,
inflammation of the vulvo-vaginal glands, peritonitis, and salpingitis.
We meet with cases where it is extremely difficult to decide as to the
nature of the disease, and especially when we have every reason for
believing that the subject herself is chaste; on the other hand, the
mere fact of a woman infecting her husband and causing him to have a
urethral discharge is not always sufficient proof of her having
gonorrhoea, as it is well established that certain forms of leucorrhoea
will produce such a result. It is not necessary for us always to
express an opinion of the character of the disease, even when convinced
that it is specific, but it is always our duty "to lean to the side of
charity when the question is one of chastity."[5]

[Footnote 5: Edis, _Diseases of Women_, Philada., 1882.]

PROGNOSIS.--If appropriate treatment is instituted, the disease will
usually subside in the course of a few weeks, or it will assume a
chronic form, lasting indefinitely.

Acute vaginitis causes more pain and actual suffering than the chronic
variety, but is less rebellious to means of cure. Simple vaginitis, of
itself, cannot be considered a grave disease, but the consequences may
prove of a most serious character--viz. extension of the inflammation
to the bladder, uterus, Fallopian tubes, ovaries, and peritoneum.

Specific vaginitis is more virulent than the other varieties, and
consequently there is more tendency to the extension of inflammation
than with them. Sterility is not infrequently a sequel of specific
vaginitis in consequence of contiguous parts, more especially the
Fallopian tubes, being implicated in the disease. Such patients, even
long after the acute symptoms have passed, are unfavorable subjects for
surgical operations, even of a trivial character.

TREATMENT.--The treatment of acute vaginitis is the same in the
different varieties. From the commencement of the attack until the
severest symptoms have subsided patients should rest in a recumbent
position, walking and coition being forbidden. If the inflammation is
severe, with febrile symptoms and a furred tongue, saline laxatives,
cooling drinks, and a non-stimulating diet should be prescribed. If
pain exists, anodynes of some kind should be given. The best mode of
administering {372} anodynes is by means of rectal suppositories. Warm
hip-baths every six or eight hours for the first twenty-four hours of
the disease ought to be employed, and at the same time quite warm water
should be thrown into the vagina with a syringe; this is beneficial in
curing the disease and contributing to the patient's comfort.

A much better mode of irrigating the inflamed parts is as follows: The
patient is to be placed on her back with her hips slightly elevated
over a bed-pan, and then by means of a syringe a stream of warm or hot
water should be thrown into the vagina for fifteen to thirty minutes.
It has been advised by Emmet that the temperature of the water should
be raised rapidly from blood-heat to 110° F., or as hot as the patient
can well bear. By elevating the hips venous congestion is considerably
lessened through gravitation of the blood, and, the hot water causing