malady, deserving especial prominence in the nosology of diseases of the bladder, which seriously disturb the functions of this sensitive viscus. There is the additional reason, also, for reporting the experience which I have had of this peculiar and interesting disorder, in the fact that much obscurity yet surrounds the entire subject of disturbance of the functions of this organ in the female, the integrity of which is so vital to the comfort, happiness, and safety of the individual.

Moreover, such conditions often tax the diagnostic acumen of the physician to the utmost, and even when by the exclusive method, rigorously employed, many causes of irritation of the bladder may be eliminated from the problem in hand, there will yet remain in particular cases, other causes which may elude discovery, thus obscuring the pathogeny and defeating every measure of treatment which is attempted.

About March 1st, of the present year, a lady, whose health has been uninterruptedly good, thirty-seven years of age, the mother of six children, the last of which being an infant of four months, applied to me for treatment for what she considered the ailment to be, incontinence of urine. She stated that the condition had come on gradually, at the first amounting to a mere frequency of urination during the day, without any attendant pain or other symptom which attracted her attention. This frequency had increased, however, to such an extent as to seriously embarrass her in the performance of domestic duties, and prevent her from visiting friends, or doing necessary shopping. Moreover, she soon became troubled at night, often rising six or, perhaps, a dozen times, in obedience to the urgent calls for micturition. The amount of urine passed at each discharge was not large, but exceeded in quantity that ordinarily retained in cases of acute cystitis, which the affection in many respects closely resembled.

There were no deposits in the urine worth noting. It appeared to be somewhat higher colored than normal. There was also a superabundance of mucus, in the form of large flocculi, but no pus or blood.

As the case progressed, the desire to evacute the bladder was preceded by a sharp twinge of pain, which the patient averred was "low down at the very neck of the bladder," but which was inmediately relieved on emptying the viscus. There was no tenderness at any point except a slight pain experienced when the neck of the bladder was firmly pressed toward the pelvis.

The frequency of micturition increased to almost constant drib

bling from the bladder, both daily and nocturnally the cloud of mucus in the urine was much augmented, and while the color appeared to remain unchanged, there was evidently a large excretion of solid matter composed probably of phosphates.

The uneasiness elicited at the neck of the bladder by pressure on this part soon changed to actual soreness. At the end of the second week the case had passed into one of apparently serious import, and was operating with telling effect on the vitality and mental equipoise of the patient.

The tripod of treatment, namely, rest, opium, and alkalies, upon which Van Buren and Keyes cogently protest the successful management of cystitis rest, was relied on to relieve what I now feared was a case of this distressing disease, the cause of which I could not then determine. The constitutional effect of belladonna was evoked also to mitigate the symptoms, and finally hot-water vaginal injections were employed for their well-known analgesic and antiphlogistic effects upon the pelvic viscera.

Such measures gave only temporary relief, the features of the case resuming their original character whenever the effect of medication—which was occasionally suspended to ascertain the status quo of the disease-had passed off.

At the beginning of the third week from the first appearance of the symptoms, the patient complained of slight chilliness toward evening, and it was observed that this was followed by fever, the thermometer in the mouth registering 101. These symptoms were interpreted to indicate the constitutional expression of the local inflammation existing in the bladder. Hence, no special attention was directed toward them. The chilliness was repeated, however, on the third evening, and on the fourth day at the same hour reappeared as the prodrome of a marked rigor, followed by an abrupt rise of temperature of 103° succeeded by sweating and a return to the normal temperature in about four hours, thus clearly demonstrating a well-defined periodicity of the febrile movement.

Suspicion being now aroused as to the essential nature of the case, the patient was promptly placed on ten-grain doses of the sulphate of quinine, to be taken every four hours with mercurial and saline purgatives, the latter being indicated by the appearance of the tongue and the confined state of the bowels, which was due not altogether to the opium administered, since this physical modifier had been exhibited both freely and simultaneously.

The substitution of the quinine for the treatment previously pursued, like the fabled wand of the magician, broke the spell of

enchantment, which, by its subtle and potent influence bad held the patient with relentless grasp for three weeks and had transformed a hopeful and contented disposition into one of melancholy and apprehension.

At the end of four days from the administration of the first dose of quinine the patient was virtually convalescent. During this period no opiate was employed nor any other medicine but quinine taken, save an occasional dose of neutral mixture, chiefly for its sudorific effect. Nevertheless the irritation of the bladder did not return, and the close of the week found the patient, although debilitated by the trying ordeal through which she had passed, enabled to resume her accustomed duties.

Periodical Attacks of Frequent and Painful Urination and Vesical Tenesmus caused by Malaria.-About two years ago a patient came to my college clinic complaining as follows: In the afternoon of each day she experienced a sense of heat and burning in the bladder and urethra, with a frequent and irresistible desire to urinate. Evacnation of the bladder, attended with a great deal of smarting and pain in the urethra, did not give complete relief but left some vesical tenesmus which increased in severity as the bladder became distended. These symptoms persisted during the night and kept her awake, but toward morning her sufferings entirely left her, and she became quite comfortable until the next afternoon. This condition had existed for nearly two months, and accordingly her digestion became impaired and her strength diminished. This was attributed by her to the want of sleep, and no doubt in part was due to this cause. The urine was examined, and found to be normal except that it contained a slight excess of phosphates. She was carefully examined, and no evidence of organic disease was found. While she always enjoyed full health and had been a vigorous woman, she had had an attack of malarial fever about six months before I saw her, and about the time this bladder trouble came on she said she had symp toms of her former ague. From the facts in her history I ventured to state to my class that this was a functional derangement of the bladder and urethra caused by malaria, which would promptly yield to judicious doses of quinine. I accordingly prescribed twenty grains of quinine to be taken between early morning and noon, to be followed by two-grain doses before meals with four drops of Fowler's solution of arsenic after meals. She was ordered to report at the clinic the following week. She did so, and declared that she had been perfectly well since the first day she took the medicine. The quinine and arsenic in small doses were continued for three

weeks, at the end of which time she reported herself as having been well and free from all irritation of the urinary organs.

No change in the character of the urine could have occurred to produce such marked periodicity in the functional derangement of the bladder and urethra; moreover, the urine was found to be normal, and she completely recovered on the use of quinine.

Vesical Tenesmus and Frequent Urination due to Prolapsus and Inflammation of the Ovaries.-In prolapsus of the ovaries and inflammatory affections of these organs irritation of the bladder often occurs. This is illustrated by the following case:

A young girl of twenty-one was brought to me suffering from great distress in the pelvis, which was much aggravated by standing or walking. Her suffering was constant, but was tolerable when she remained in the recumbent position. She began to complain about six months before I saw her, and about the same time she found that she was obliged to urinate too often, and that there was an uneasy feeling in the bladder most of the time, a feeling as if the bladder had not been fully evacuated.

She was much worse at her menstrual periods. Upon a thorough examination I found both ovaries prolapsed, slightly enlarged, and exceeding tender. In every other respect she was perfectly well. In consultation with her physician, a course of treatment for the ovarian disease was decided upon. This was fully and faithfully tried for over one year, but at the end of that time she was worse.

She was then quite impatient, being very nervous and irritable from her confinement and suffering. Her parents and friends were quite weary of seeing her suffer. Her bladder irritation was no better; in fact it was a great source of suffering. She could not urinate without getting up, and the erect position increased her ovarian pain. The ovaries were still prolapsed and just as tender, in fact, more so than they had been.

The complete failure of treatment so far indicated that removal of the ovaries was the only thing that promised to give her relief. Accordingly the ovaries were removed, and she made a rapid recovery from the operation and was completely relieved not only from her ovarian pain but also from the frequent urination and vesical

tenesmus.

It should be stated that at no time was there any evidence of cystitis found upon frequent and careful examinations.

CHAPTER XXXVIII.

FUNCTIONAL DISEASES OF THE BLADDER (CONTINUED).

HAVING Considered the vesical derangements in which there is no recognizable organic lesion, and which may be local neuroses, or may be due to hysteria, disorder of the sexual function, malarial or ovarian affections, I will now invite attention to the second class of these disorders.

I. Derangements of function due to diseases of the nutritive and nervous systems, or to abnormal conditions of the urine which result therefrom.

This class naturally subdivides itself into:

1. Derangements occurring in both acute and chronic diseases. 2. Derangements due to consequent abnormal conditions of the urine.

1. Of the derangements which occur in the course of acute diseases, such as retention and incontinence of urine and frequent urination, nothing more than the mere mention is necessary. They rarely require any treatment, except possibly in the case of retention, when catheterization is to be employed, and they cease as soon as the acute stage is passed. Those, however, which are due to chronic affections of the nutritive and nervous systems are more permanent, and often tax the resources of the physician to the utmost. The two most important are:

(a) Paralysis of the bladder, and, (b) Incontinence of urine.

(a) Paralysis of the Bladder.-This affection has also been de scribed under the names of weakness or palsy of the bladder, and vesical atony. It occurs in two forms: First, from causes residing in the organ itself; second, from those due to ontside influences. As affections in the first form will be fully described in another place I shall here simply mention them. They are: Fatty degeneration and atrophy of the muscular walls of the bladder, a common