penis. Dribbling of urine from the ureters was constant. Under chloroform incisions were made on either side through the integument and superficial fascia just forward of the anterior superior spine of the ilium two inches upward, to secure relaxation; the edges of the fissure were then pared and fastened together with harelip pins with intermediate sutures, and the wound dressed with oxide of zinc and absorbent cotton, a drainage-tube for the urine being left in the wound. The penis was not touched, being reserved for a secondary operation. The recovery was rapid and perfect. The child died from convulsions two months later, before the operation upon the penis could be performed.

CHAPTER XXXVI.

FUNCTION OF THE BLADDER.

THE function of the bladder is to act as a reservoir for the urine, and at proper intervals to expel it through the urethra. The filling of the organ with urine is a comparatively slow and gradual process, the fluid entering it from the ureters drop by drop, or in a very small stream. As it enlarges it does so in the direction of least resistance, viz., laterally and superiorly. The lateral being its longest diameter, it enlarges first in that direction, until after a time a limit is set by the bony pelvic boundaries, when it rises from the pelvis somewhat, thus escaping from the pressure below. This movement of the bladder is facilitated by its serous surface gliding easily over that of the adjacent organs.

The bladder receives its nervous supply partly from the mesenteric ganglia of the sympathetic, and partly from the lumbar portion of the spinal cord it has therefore nerve-filaments from both the cerebro-spinal and sympathetic systems. The sphincter vesicæ is in health in a state of tonic contraction which results in retaining the urine in the bladder. This act is entirely involuntary and unconscious and is performed in a perfect manner both during the waking and sleeping hours. When it is desired to evacuate the bladder this sphincter is relaxed by an act of the will conveyed through the cerebro-spinal fibers, but this relaxation once accomplished, the further act by which the organ is emptied is performed without the intervention of the will. The experiments of Kupressow demonstrate conclusively that the nervous center which presides over contraction and relaxation of the sphincter vesicæ is located in the lumbar region of the spinal cord. And it may be accepted that with other functions of a protective nature the spinal cord maintains the normal action of the urinary organ.

There has been considerable discussion among different authors as to whether closure of the vesical urethral orifice is a voluntary or

diseases of the spinal cord, such as myelitis, and after injuries to the vertebræ, Dubois found a marked decrease in bladder pressure.

These curious observations on the varying degrees of pressure arising from change of posture are not without value. They help one to understand why, in some diseases of the bladder, patients should maintain the recumbent position.

CHAPTER XXXVII.

FUNCTIONAL DISEASES OF THE BLADDER.

It has been the rule among pathologists to class under the head of functional diseases all those in which no lesion of structure was discoverable in the organs concerned. Although we are still obliged to accept this nomenclature, the progress of pathological knowledge in the past few years has weeded out many of the so-called functional affections and as this knowledge advances, and new and efficient means for observation and study arise, we shall be able to root out many more, thus doing away with much of the vagueness and uncertainty in which this class of affections is shrouded. But even with the improved facilities for diagnosis at our command, there are still many diseases in this list. Owing to the obscurity at present surrounding the subject of reflex or sympathetic disorders, i. e., the abnormal condition of an organ or organs, near or distant, affecting the function or nutrition of another organ, we are obliged to put these affections in this class also. Under this head then will be considered:

I. Derangements of function in which there is no recognizable organic lesion.

II. Derangements of function due to diseases of the nutritive and nervous systems, and to abnormal conditions of the urine resulting therefrom.

III. Derangements of function due to inflammatory and other affections of the pelvic organs, such as metritis and pelvic perito

tonitis.

It will be observed that in this arrangement of the subject, although a number of structural diseases are considered, they all stand in a causative relation to the disturbed action of the bladder, the latter being free from any organic lesion, and only disturbed in the discharge of its duty by influences outside of itself.

Before discussing these functional disorders in detail, it will be

necessary to fix clearly in the mind their various manifestations; these are: frequent urination, or polyuria; difficult urination and retention, or ischuria; painful urination, or dysuria; pain after urination, or vesical tenesmus; and incontinence of urine, or enuresis. These deranged actions may also be due to organic diseases of the bladder, but they will at present only be discussed in connection with the three classes of functional derangements of that organ just referred to:

I. Derangements of function in which there is no recognized organic lesion. There are five of these derangements which demand special consideration.

1. Neuroses, pure and simple.

2. Derangements due to hysteria.

3. Derangements due to disorders of the sexual function.

4. Derangements due to malaria.

5. Derangements due to ovarian affections.

1. Neuroses. By this term I refer to purely nervous affections of this organ. They are rather rare, it is true, but that they do exist there is no doubt, for there are certain conditions that seem to depend on no other known pathological cause.

We learn from the books that vesical neuralgia is of this class. It is known by a variety of names, each taking as its key-note some peculiar manifestation or symptom, as irritable bladder, cystospasm, cystoplegia, and neuralgia vesicæ.

The term irritability so commonly used in speaking of the healthy organ must not be confounded with the condition known as irritable bladder. The former refers to a certain property that the viscus possesses, by means of which it is able to respond to certain stimuli, while the latter refers to an abnormal condition of sensation, viz., super-sensibility, or hyperæsthesia.

2. Derangements due to Hysteria.-Hysteria holds a prominent place among the causes of functional derangement of the bladder, the vesical affection being probably only a fragment of a general neurosis. Acute and chronic diseases of the brain and spinal cord also produce various vesical difficulties of this nature, but these will be discussed under another class. Any one who has suffered the mortification of an involuntary evacuation of urine from fear, will understand how the brain and nervous system can influence the bladder.

In the variety of conditions grouped under the head of hysteria, it is often observed that frequent urination is a prominent symptom. The cause, in many cases, is the peculiar character of the urine se