dences of excrementitious plethora were well expressed in the abundant adipose tissue, coated tongue, constipation, muddy appearance of the eyes, full slow pulse, shortness of breath on exertion, depression of spirits, disposition to sleep, and at times sleeplessness. The urine was examined, and found to be slightly alkaline. The specific gravity was 1030. There was neither albumen nor casts. The salts of the urine were in excess, but as a quantitative analysis was not made the exact composition of the urine was not obtained. The diagnosis of general excrementitious plethora from imperfect elimination was made, and the frequent urination was attributed to the abnormal condition of the urine. Ten grains of pil. hydrarg. and one grain of ipecac were given at bed-time and a Seidlitz powder an hour before breakfast the next morning. This was repeated in five days.

The quantity of food was diminished-she had been taking extra diet to make her stronger-milk was the chief article permitted, with a very little animal food once a day. A Turkish bath twice a week and gradually increased out-of-door exercise. The bowels were kept rather free by giving a dose of Congress water an hour before breakfast every morning. Under this treatment she improved in every way. The irritation of the bladder subsided, and has not returned. The urine is now normal.

Frequent Urination from Abnormal Urine.—An unmarried lady, thirty years old, of good constitution, very ambitious and energetic, overtaxed herself during the winter, and toward the end of the season, began to suffer from frequent urination and a sense of burning heat in the bladder and urethra after urinating. After a time these symptoms became very annoying, and as she was a nervous, sensitive person, she suffered quite severely. She was found to be quite out of health. Her appetite was poor and her digestion impaired; she was constipated, and suffered from rheumatic pains in her joints, and in the back of her neck. In short, she gave a fairly good history of dyspepsia and neurasthenia plus the irritation of the bladder which was her chief source of discomfort. The urine was diminished in quantity, dark in color, very acid, and of high specific gravity; no albumen or casts were found. She had been quite free from any affections of the pelvic organs, the present disturbance of the bladder being the only suffering she had ever had in that regard.

My first impression was that she had cystitis, but there were no products of inflammation found in the urine, and therefore the diag nosis was made as stated above.

Peptonized milk was ordered with raw eggs, and, in addition, barley gruel, clear soups, and bread. Two drops of liquor ammoniæ in a wine-glass of water were given every two hours until the urine became normal. Her bowels were kept regular by small doses of Rochelle salts and cream-of-tartar taken in the morning.

Rest was insisted upon, and massage every third day. As soon as the urine became less acid and dense, she obtained some relief, but was not restored to her usual condition. It was not until her general health had been improved that the urine became normal and the irritation of the bladder finally left. An interesting point in the treatment was observed. For a time she was partially relieved by the alkaline remedies, but, when she ceased taking them, the irritation of the bladder returned.

When her general health was restored by rest and tonics the urine became normal, and the irritation of the bladder disappeared entirely.

At the present time I have a lady under treatment for specific disease of the uterus; during the last four weeks she has had irritation, causing frequent urination. She obtains relief by drinking very freely of lithia water.

Case of Baruria (by Dr. Samuel West).—The patient, aged thirtynine, complained, after catching cold, of pains and aching in her limbs, which became severe enough after a week to keep her in bed. When admitted, these pains continued, but there was swelling of joints. The temperature was 100°, and she perspired freely, but the sweat did not smell sour. The urine had a specific gravity of 1040, and yielded copious crystals of nitrate of urea, with nitric acid. Her appetite had been for some days almost absent, and in the hospital she took but a little milk or beef-tea. For two days the condition of the urine was the same, and the percentage of urea 51. This percentage gradually fell to normal, and, as it did so, all the patient's symptoms disappeared. The case was regarded as one of baruria. The account of the case given by Prout was summarized and compared with the present case, and reference was made to other authors, by some of whom the existence of the affection was questioned, while by others it was not referred to. A somewhat similar case, the result of overfeeding and constipation, has been described, in which like symptoms were associated with a high percentage of urea, and disappeared when the amount became normal.

III. Derangements of Function due to Affections of the Pelvic Organs other than the Bladder.-Functional diseases of the bladder, caused by disorders of the neighboring pelvic organs, are frequently

met with in practice. In this class the vesical trouble is secondary to some primary and more important affection, but the derangement of its function is often the most prominent and troublesome symptom; hence it is important to understand its relation to the primary disease, in order to make a correct diagnosis, and to treat such cases properly.

This class of functional disorders frequently resembles in history some of the organic diseases of the bladder, so that care is necessary to distinguish the one from the other. What I may say upon the subject will have reference to diagnosis only. When we know that the bladder trouble is due to disease of some other organ, attention is at once turned to the primary affection. These facts must be borne in mind, and the symptoms not mistaken for the disease.

Diseases of the rectum affect the bladder sympathetically. Irritation and pain in the rectum from any cause affect the bladder more or less. Chronic hæmorrhoids will cause frequent urination, and so will rectal fissure, especially after defecation. Abscesses in the neighborhood of the rectum will frequently cause retention of urine.

One very interesting case of this kind occurred in the practice of my friend Dr. Cushing. The patient had an abscess in the neighborhood of the rectum which caused retention of the urine, and this in turn caused acute renal disease. After the bladder had been emptied and kept from overdistention for some time, the urine was examined and found to contain albumen and casts. She made a rapid recovery, and all evidence of kidney-disease soon disappeared.

Very troublesome vesical irritation may come from ascarides. The itching of the anus and rectum, caused by these troublesome little worms, keeps up an almost constant desire to urinate. Children are most troubled with these parasites, but women often suffer in the same way.

Marion Sims points out the interesting fact that almost all cases of vaginismus are accompanied by an irritable condition of the bladder, and that, as the terminal fibers of the hymen often extend from the meatus to the vesical neck, cystospasm may in these cases be due to reflex nerve irritation. An attempt to catheterize these patients is as liable to cause spasm of the bladder as an analogous attempt to examine the uterus would be to produce vaginismus. In these cases the hymen should be excised, and the vaginismus treated after the

usual methods.

Acute pelvic peritonitis and cellulitis cause great distress in many cases by their effect on the bladder. A constant desire to urinate, without the ability to make sufficient straining effort to accomplish

the object, is very often observed in all these acute pelvic inflammations. Thedisturbance of the bladder is, of course, only a symptom of the primary and more important trouble, and simply requires to be mentioned here. The after-effects of pelvic peritonitis are what I especially desire to call attention to at present.

The adhesions formed by the products of the inflammation of the pelvic peritonæum are in some cases sufficient to prevent the normal filling of the bladder, and frequent urination then becomes a necessity. This derangement of function generally exists alone. The urine is retained without trouble up to a certain amount; it is passed without pain, and no vesical tenesmus follows evacuation. Unless the contraction of the bladder is great, and the frequent necessity to urinate very troublesome, patients rarely consult a physician for it.

Paralysis of the bladder with retention may be caused by a peculiar condition of oedema, by which the detrusors are rendered powerless to act. It is usually caused by disease of the cervix uteri, parametritis, or peritonitis.

CHAPTER XXXIX.

METHODS OF EXPLORATION OF THE BLADDER AND URETHRA.

PREPARATORY to the study of organic diseases of the bladder and urethra, I desire to call attention to the methods and means of exploring the bladder and urethra, and to some of the physical signs of disease obtained thereby.

In all cystic affections the urine should be carefully examined, both chemically and microscopically. It is not necessary for me to describe the methods to be employed in this examination; they will be found in the various books published on that subject.

If an examination of the urine does not make the diagnosis clear, attention should be directed to a physical exploration of the bladder and urethra. For this purpose either a digital or an endoscopic examination may be made. Digital examination per vaginam is one of the most valuable means of investigating the bladder and urethra. By this and by the bimanual touch the physical signs of many of the affections of these organs can be readily obtained.

The method of making these examinations is exactly the same as practiced in examining the uterus. The vaginal touch reveals the position of the bladder and urethra, the degree of their sensitiveness. the location of tenderness, if any is present, the increase or diminution of elasticity, and the state of their walls, as regards thickening or irregularity. Distortions of the urethra from neoplasms or the products of inflammation can also be detected in this way.

The bimanual touch will show whether the bladder is full, empty, or partially distended, and any foreign body of considerable size can be felt in the bladder in case the abdominal walls are not too rigid. As a means of detecting stone in the bladder of women, the bimanual touch is the easiest, safest, and surest of all methods of exploration. The presence of neoplasms can be discovered in this way, although their composition can not be clearly made out. In some cases it is necessary to give an anesthetic to relax the parts before