Two head-mirrors on same strap, three and one half inches and one and one half inch.

Skene's bivalve urethral specula.

Ordinary urethral endoscopes, modified by Skene.

Two rectal endoscopes (long and short), with fenestrated rubber specula.

Three urethral endoscopes (Nos. 13, 15, 17, American), with bev eled rubber specula.

Two beveled urethral endoscopes (Nos. 19, 21, American), with fenestrated rubber specula.

One brush for cleaning endoscopes.

Having described the important methods to be employed in phys ical exploration of the bladder, I now pass to a consideration of the organic diseases of the bladder and urethra.

CHAPTER XL.

ORGANIC DISEASES OF THE BLADDER.

HAVING treated of the methods of physical exploration of the bladder and urethra, I now invite attention to the organic diseases of these organs, and shall first describe those which affect the bladder. These may conveniently be divided into three classes:

I. Inflammatory; II. Non-inflaminatory; and III. Neoplasms, hyperplasia, and atrophy.

I. Inflammation of the bladder, or cystitis :

Under this head I shall include all forms of deranged nutrition which produce disorders of function, temporary or permanent lesions of structure, and the morbid material known as the "products of inflammation."

Well-defined typical inflammation presents during its course certain peculiarities which are characteristic of the affection, and without the existence of which the disorder can not be called true inflammation. Inflammation, however, varies in character with the tissue or organ involved and the extent or intensity of the disease; and, while there is really but one process of inflammation, as that process is often interrupted, prolonged, or modified in various ways, its products must necessarily vary greatly.

Its divers grades or forms are distinguished as acute, chronic, catarrhal, interstitial, suppurative, croupous, diphtheritic, and gonorrhæal.

Before entering upon the consideration of cystitis in its many forms, I desire to speak of hyperæmia and hæmorrhage of the bladder. This latter affection might more properly, perhaps, be considered under another head, but it is so closely connected with hyperæmia and inflammation that I prefer to treat it here.

Hyperæmia. In all cases the first perceptible departure from the normal is a derangement of circulation. Hyperæmia of the mucous membrane is observed, and with it disorders of innervation, as is evidenced by derangement of function and sensation.

In hyperemia of the mucous membrane of the bladder the bloodvessels are distended, and, becoming prominent and apparently more numerous, give to it a bright-red color. The arteries are the first to be affected. If the hyperemia is not marked, or is produced by some transient cause and not aggravated, it may pass off in a short time, and leave the membrane in its normal condition. If it is of a high grade, however, rupture of some of the vessels may occur, the hæmorrhage taking place either on the free surface of the membrane or beneath its epithelial layer. Should this condition continue, the hyperemia which began in the arteries extends to the venous side of the circulation, and the vessels become more prominently and uniformly distended. The congestion may also begin on the venous and extend to the arterial side, as in sudden interference with portal circulation. As a rule, however, it begins in the arteries.

A clear distinction must be made between the acute congestion of which I am now speaking, and which is chiefly confined to the smaller vessels, and passive congestion with a varicose or hæmorrhoidal condition of the veins about the neck of the bladder. This hæmorrhoidal condition I will speak of later.

Symptomatology.-The symptoms of acute congestion of the bladder, as a rule, occur suddenly. Frequent but painless urination is the principal symptom. There is often a sense of heat and heaviness in the region of the bladder, which is greatly aggravated by standing or walking. When the urethra is involved, the patient complains that the urine "scalds" her.

The general system is not disturbed-i. e., the pulse and temperature remain normal. The physical signs are mostly negative. The composition of the urine is unchanged, save that there may be an excess of mucus and a few blood-globules present. There may be some tenderness on pressure over the bladder. The endoscope (when there is an opportunity to use it, which is very rare in this trouble) shows an increased redness of the mucous membrane, with occasionally an excess of mucus on its surface.

Diagnosis.-The diagnosis has to be made by exclusion, the natural history of the affection having in it nothing pathognomonic. It is liable to be confounded with sympathetic or other functional derangement of the bladder, caused by sudden dislocations of the uterus or by pelvic inflammation, such as pelvic peritonitis and its results. The former can be excluded by an examination of the pelvie organs, and the latter by the constitutional symptoms of inflammation and the signs of such pelvic disease.

Causes. The causes of hyperemia of the bladder are exposure

to cold (especially during the menstrual period), wetting the feet, overtaxation in walking or using the sewing-machine, excessive venereal indulgence, constipation of the bowels from torpor of the portal circulation, the excessive use of stimulants, and the use of improper articles of food.

Treatment. The treatment should be directed to equalizing the circulation. Diaphoretics, warm, stimulating foot baths, hot applications over the epigastrium, and, above all, rest in the recumbent position. If the bowels are confined, they should be emptied by saline laxatives. When there is much irritation of the bladder, causing frequent urination and vesical tenesmus, pulv. doveri with camphor should be given, or suppositories of belladonna and morphine introduced into the vagina. Under this treatment the trouble will usually pass off in a short time. It may, however, go on to the development of cystitis.

Occasionally bleeding occurs in active or acute congestion of the bladder, and that leads me to speak of hæmorrhage from the bladder.

Hæmorrhage from the Bladder.--Hæmorrhage from the bladder, or (if I may be allowed to coin a word) cystorrhagia, is usually due to some important disease of the bladder, and is, therefore, rather a symptom than a disease. For this reason I will at present confine my remarks to hæmorrhage when caused by acute congestion, which I have just considered, or to varicose veins of the bladder.

The bleeding may take place from the free surface of the mucous membrane, and mingle at once with the urine or coagulate in the bladder. It may also take place beneath the surface of the mucous membrane, and form ecchymoses, like the spots seen beneath the skin in purpura. We may also have a condition known as hæmoglobinuria, in which only the coloring matter of the blood is found in the urine; in such a case we should, of course, find no blood-corpuscles.

The quantity of blood varies greatly in different diseases, and in the same disease in different persons. In congestion of the bladder blood globules will often be found in the urine only on microscopic examination, while at other times the urine will have the appearance of being all blood. Again, the blood may coagulate, and be passed in clots, or the coagula may remain in the bladder, finally break down, and be passed as a chocolate-colored or blackish matter.

Symptomatology.-The symptoms of hæmorrhage do not differ from those of congestion or the onset of cystitis, except when small clots form, distending the urethra, and causing pain in urinating. It

is very rare that bleeding from these causes is sufficient to prostrate

the patient.

As bleeding may take place at any point in the urinary tract, it is important always to locate the hæmorrhage. When coming from the bladder in any quantity, it is usually passed in small clots, and is seldom so intimately mixed with the urine as when it comes from the kidneys or ureters. This statement is not exact, and at best gives but a probable idea of the true facts. To complete the diag nosis, we must resort to something more trustworthy. Sir Henry Thompson gives a very ingenious method for determining as to whether pus found in the urine comes from the kidneys or bladder, and Van Buren and Keyes advise the same plan for detecting the source of hæmorrhage.

The method is this: "A soft catheter is gently introduced first within the neck of the bladder, the urine drawn off, and the cavity washed out very gently with tepid water. If the water can not be made to flow away clear, the inference is that the blood comes from the cavity of the bladder. If it will flow away clear, then the catheter is closed for a few moments, the patient being at rest, and the few drachms of urine which collect may be drawn off and examined. The bladder is now again washed out, and if, after a single washing, the second flow of injection is clear, while the drachm of urine was bloody, the inference is again complete that the blood comes from one or the other kidney."

When it is known that the patient has had no kidney-disease, nor symptoms of renal calculi, the endoscope may be employed, and possibly the bleeding-point found. This has been done with the instrument which I have described, but one may fail to find it if it be high up laterally or antero-laterally, or be covered by a fold of the mucous membrane.

Hæmorrhage from the urethra might mislead, but is easily detected if it is remembered that in this case bleeding occurs between the acts as well as during micturition. It may also readily be discovered with the endoscope, provided the tube be not too large.

Causation. The causes of vesical hæmorrhage, or cystorrhagia, are numerous. Congestion, varicose veins, villous cancer, lesions of structure, as in ulceration and sloughing of mucous membrane from injury or cystitis, and obstruction to, or interference with, the portal circulation. This may possibly explain the fact that hæmorrhage occasionally occurs in those suffering from malaria. Perhaps the vesical hæmorrhage occurring in the intense heat of summer in the tropics may be thus explained. In malaria the obstruction to the