VESICAL DISEASES. The urinary bladder is the temporary reservoir of the renal secretion, and as such contains the urine for longer or shorter periods. In recent years diseases of the bladder have come more than formerly 1 within the scope of operative surgery, owing especially to great advances in the methods of examining the inner wall of the bladder both by sight and touch,—by sight in virtue of the endoscope, an instrument which when introduced into the bladder enables a visual examination of the interior to be made; and by touch, as surgeons do not now hesitate to make incisions into the bladder, either from the perinaeum or suprapubically for purely diagnostic purposes. Further, more careful and improved chemical and microscopical examination of the urine enables the surgeon to judge better than formerly what the condition of the bladder is. Diseases of the bladder may be con-veniently divided into two groups, — (1) those which involve recognizable organic structural change, and (2) those which do not necessarily involve obvious organic structural change (Sir H. Thompson). The more import-ant diseases of the first class are inflammation or cystitis, calculi, and neoplastic growths; but there are also others of less importance, such as hypertrophy, dilatation, and tuberculosis. The diseases of the second group in which no organic structural change can be recognized in the bladder-wall are numerous. In many cases, however, they can scarcely be considered as diseases of the bladder pure and simple, but rather as concomitants or results of other diseases. Moreover, in many cases they give rise sooner or later to diseases which are accompanied by structural changes. Tims " irritable bladder," although at first it may be independent of any such change, soon gives rise to inflammation of the bladder-wall, or cystitis; and many surgeons describe it from the beginning as simple cystitis, while cystitis as described in this article they call catarrhal cystitis. In this division, however, we may describe para-lysis, atony, incontinence of urine, stammering micturition, and retention of urine.

Cystitis.—Inflammation of the bladder may be acute or chronic. Acute It is due in most cases to the presence of irritating matters in the cystitis, urine, produced by decomposition of the urine itself or by morbid admixture. The inflammation may result also from traumatic injury, from cold, or in cases of gonorrhoea from extension of the inflammation along the urethra into the bladder (through continuity of tissue). Although frequently ushered in by rigors, the chief symptoms of acute inflammation are local: there is pain over the region of the bladder and frequent micturition. The desire to pass water is often incontrollable, even before more than one or two ounces of urine have been secreted. The urine is much changed in its character, being cloudy from the presence of epithelial scales, pus, mucus cells, and often blood. At this stage also it may be ammoniacal, though this usually comes on later, and is probably caused by septic decomposition of the urine due to the entrance or introduction of organisms into the bladder. The quantity of blood varies, but may be so large as to give the urine a distinct reddish tinge. As a rule, the mucous membrane at the neck of the bladder is the first part to become inflamed, but the whole of the mucous membrane may be affected ; resolution, however, usually takes place before more than a portion has been attacked. Chronic Chron ic cystitis is one of the most common affections of the bladder, and cystitis, its causes are very various. It sometimes remains after an acute attack has passed off, but more commonly it results from long-continued irritation, such as may be produced by a urinary calculus in or by atony of the bladder. The symptoms are not so severe as in acute cystitis : the urine contains more mucus, but less pus and blood, and there is much less tendency to frequent micturition, the irritability of the bladder being greatly diminished. Frequently very large quantities of mucus are secreted, and the condition is then termed '' catarrh of the bladder." Chronic inflammation is not in itself dangerous ; but the patient, so long as it remains, is liable to an attack of acute cystitis, which, superadded to the pre-existing condition of the bladder, may be very serious. An increase in the fibrous elements of the coats of the bladder and hypertrophy of the muscular fibres are a common result of chronic cystitis.

The treatment m both varieties of the disease consists in giving Treat-rest to the inflamed part and in alleviating fhe pain. Hot sitz- ment of baths may be used two or three times daily for ten minutes or cystitis, a quarter of an hour at a time ; and, if the pain be very severe, hot fomentations with tincture of opium should be applied to the peri-nteum or hypogastric or a hot douche may be used per rectum.

Diluent drinks are given, and tincture of hyoscyamus may be prescribed, as it has a very soothing influence. It may be necessary to give morphia, but generally the pain can be allayed without its use. In chronic cystitis the treatment depends very much on the cause, which must if possible be removed. Thus, if the cystitis is due to a calculus in the bladder, the treatment is to remove the calculus (see below). Very often, however, special remedies are employed to relieve the inflammatory condition, and one of the best is washing out the bladder. This is a simple operation, based on the principle of siphon action with a head of water, and is carried out as follows. A catheter is introduced through the urethra into the bladder, and to it the stem of a T-shaped tube is fixed ; to each end of the horizontal part a piece of rubber tubing is attached, TOO piece terminating in a vessel which contains an aseptic warm lotion and is placed at a higher level than the bladder, while the other is led into a receptacle placed lower than the bladder. Six or eight ounces of the lotion are allowed to flow into the bladder ; then the flow is checked, and the fluid passes out from the bladder through the other tube. Each tube should have a stop-cock, so that the surgeon can open or close it as he desires. Occasionally bladder drainage is resorted to, and is carried out on the principle of siphon action. Internal remedies have to be administered, one of the most valuable being benzoate of soda. The benzoate in its passage through the blood is changed into hippuric acid, and thus tends to render the urine less alkaline. Attention to the diet of the patient is of great importance in both acute and chronic cystitis; it should be very light, easily digested, and nutritious. Diluents are often of much value, lessening the irritability of the bladder. All wines and stimulants should be avoided. Calculi. Calculi. — Important information, as we have already said, is derived both by the surgeon and physician from a careful examina-tion of the urine, whether this be done chemically or microscopic-ally. Not infrequently on such examination crystals, varying in their chemical and physical characters, are found, and if these be in large amount distinct urinary deposits are got from the urine after it has been kept in a vessel for a time. The cause producing these crystals or their presence alone may give rise to disease, as, for instance, oxaluria, a condition in which, in addition to other symptoms, wc find oxalate of lime crystals present in the urine. We have here to deal, however, with more than the mere presence of a few crystals disseminated in the urine, viz., with those con-ditions in which an amalgamation of crystals has occurred, giving rise to a concretion of such deposits into a mass, forming a cal-culus or stone. When such concretions are so small that they can be passed with the urine through the urethra they are known as gravel; but when they are prevented by their size from passing along the urethra they are termed calculi, and the patient is said to sufl'er from stone or calculus. Calculus of the bladder constitutes a most formidable and important disease, and its treatment, either medical or surgical, has probably attracted more attention than that of almost any other disease. Urinary calculi occur in all parts of the world anil affect both sexes. They are much more common, however, in some regions than in others. Thus, in India they are very common, while in Great Britain, although many persons suffer from calculus in Norfolk and the north of Scotland, very few cases occur among people who live on the western side of the island. From the above facts many have attributed the formation of calculi to special climatic or geological influences, but it is probable that diet acts as a chief factor in their production. Calculi are much rarer in females than in males, and this may perhaps be explained by the shortness and more vertical position of the urethra, so that the contents of the bladder can be more easily evacuated, and by the fact that the habits of the female with regard to diet are more regular than those of the male. The cause of the formation of a calculus may be (a) a tendency in the kidneys to precipitate salts to an abnori lal degree, the urine being concentrated and small in amount, ov\b) some abnormal state of the urine in the bladder, or (c) the presence of a foreign body in the bladder. Probably the last is the most common cause ; for very frequently, when a section of a calculus is made, it is found that some form of foreign body has acted as the nucleus round which urinary deposits have become agglutinated. Such foreign bodies may exist in the bladder or may be introduced from without. Occasionally clots of blood have been found as the nucleus ; but one of the commonest is a small uric acid stone, which, having been formed in the kidney, has passed dwn the ureter into the bladder and there been surrounded try deposits of phosphate of lime, &c. Calculi vary much in their physical characters and chemical constitution. Most frequently _only a single stone is present; but very large numbers have been removed from one bladder. The shape of the stone depends on whether it be movable or fixed, and whether there be only one or more in the bladder. A single stone is usually spherical or ovoid, but may be smooth or tuberculated or spinous, this last point being determined chiefly by the composition of the stone ; when there are a number of stones present they are usually faceted or manysided. Some stones are hard ; others are soft. In size and weight they vary very much : we find them as small as a pea and as large as a child's head. The largest stone found in the bladder of a human being is in the Royal College of Surgeons' museum of England ; and in the Edinburgh university surgical museum there is a stone of very large size. The weight depends not only on the size but also on the composition, and varies from a few grains to the heaviest on record, which weighed 6 R> 3 oz.

Seven different kinds of calculi are described, but only three are Varieties very common. Vesical calculi are classified according to their of cal-composition, and five different forms are very generally recognized ; culi. but layers of different salts may be found in the same calculus.

(1) The first class embraces uric acid and uratic calculi. Pure uric acid stones are small and hard, and usually vary in colour from a reddish orange to a brown tint. They are frequently rough, but may be smooth. Uratic stones are seldom pure. They frequently form the nucleus of calculi the outer layers of which are phosphatic.
(2) Phosphatic and calcareous calculi consist chiefly of calcium phosphate ; stones formed purely of the carbonate of calcium are rare. The stones of this group are white, soft, and friable, especially those composed of phosphate of lime. They frequently attain to a large size, and most commonly occur in persons whose general health has run down to a low ebb. (3) Oxalate of lime calculi are excess-ively hard and dense, of a dark brown colour and tuberculated or spinous on their surface ; hence they are often called mulberry calculi. This is a form which gives rise to great pain and irrita-tion, so that they are generally removed before they become very large. (4) Cystine and (5) xanthin calculi are rare.
When a stone is present in the bladder, whatever its nature, it Diagnos-acts similarly to any other foreign body, and usually gives rise to a ing for series of definite symptoms. The patient complains of pain in the calculi, end of the penis at the completion of micturition. Rough or jolting movements give rise to pain in the region of the bladder. Occasionally there is a sudden stoppage of the flow of urine, which is overcome by a change in position. He suffers from frequency of micturition, just as in any other irritable condition of the bladder. If, in addition to these symptoms, the patient states that at varying intervals he has passed "gravel," the surgeon is almost certain that a calculus is present; but even with all these symp-toms there is only one certain diagnostic sign of the presence of a stone, and that is to feel it. This is done by '' sounding " the bladder with a sound,—an instrument resembling a bougie, but made of steel and with a shorter curve. It can be easily turned from side to side within the bladder, the whole of which must be systematically examined, and not only enables the surgeon to ascertain the presence of a stone but, when judiciously used, assists him in determining the size, mobility, situation, number, and hard-ness of the calculi. This additional information is of the utmost importance in guiding the surgeon to the best method of treatment. In the child the stone can be occasionally felt by passing one finger into the rectum, laying the other hand above the pubes, and pressing ; the stone lies between the two hands. In other cases the size can be gauged with the lithotrite, by observing the distance to which the blades are separated when the stone is grasped.

The treatment of calculi by other means than operative surgery has been found to be of very little value. Attempts have been made to dissolve calculi by internal remedies or by the injection of chemical agents into the bladder; but, although many such methods have been used, and have for a time in many cases been apparently successful, they have without exception been found in the long run to be practically worthless for removing calculi once actually formed. Further, the improvements in opera-tive means for the removal of calculi have advanced to such a degree that it is probably better for a patient, in our present state of know-ledge, to be treated by some one of them rather than undergo any attempt at their removal by other means. Nevertheless much can be done towards preventing the formation of calculi in those who have a tendency to their formation, by attention to diet and by the internal administration of drugs.

Urinary calculi are removed by one of three methods,—(i.) lithotomy or cutting for stone, (ii.) lithotrity or crushing the stone, and (iii.) litholapaxy, a modification of lithotrity, and the method now most commonly adopted. In about nine cases out of every ten the stone may be crushed ; but occasionally there are some circumstances which render the operation of lithotomy preferable to lithotrity. Thus, where the urethra is constricted, as in organic stricture or enlarged prostate, or where the stone is very large or extremely hard, it is right to cut for the stone instead of making any attempt to crush it. Again, in children lithotomy is safer than lithotrity.

Lithotomy.—Cutting for stone has been very long known and Lithe-practised by surgeons ; but up to the commencement of the 19th tomy, century it was performed only by a few men, who, bolder than their contemporaries, had specially worked at it and had attained celebrity as skilful lithotomists. Patients went very long distances to be operated on by them, and certain of the older surgeons, as I Cheselden, performed a large number of operations with very successful results. The operation is usually performed by an incision from the perinaeum ; but sometimes it is necessary to adopt the high or suprapubic incision. The former method is termed perineal lithotomy, and, as the incision most commonly made by the surgeon is a lateral one, it is ordinarily spoken of as lateral lithotomy. Lateral lithotomy consists of two distinct stages,—(i.) cutting into the bladder and (ii.) removing the stone. The patient is placed on a table and brought under the influence of an anaesthetic. A grooved staff is passed along the urethra into the bladder to act as a guide for the knife, and the patient is then "tied up in the lithotomy position." An assistant holds the staff in the middle line of the body and the surgeon makes an incision an inch and a half in length deeply into the perinaenm, until the knife enters the groove of the staff, and then passes it along the groove, thus making an opening through the bladder-wall. The bladder having been thus cut into, a pair of lithotomy forceps is introduced by the perineal wound, and the stone is caught and removed by gently withdrawing the forceps by a rotatory movement. A lithotomy tube is now passed through the wound into the bladder and fixed in position ; the patient is untied and carried back to bed. The operation of litho-tomy is not a difficult one to perform, nor is it in itself dangerous ; sometimes, however, there is a fatal termination, due commonly to one or other of the following causes—haemorrhage (either primary or secondary), organic disease of the urinary organs, or blood poisoning. Haemorrhage may be the result of unskilful operating, the incision having been incorrectly made ; or one of the larger vessels in this neighbourhood may have had an abnormal distribution, so that, lying in the line of the incision, it was divided and gave rise to the bleeding which proved fatal. If the stone be a very large one, or the perinaeum very narrow, it is necessary to perform the suprapubic operation. Litho- Litholapaxy.—Lithotrity too can be best described if considered iapaxy. under two headings,—(i.) the crushing of the stone and (ii.) the removal of the detritus. The two stages are now carried out at "one sitting," instead of allowing an interval to elapse between them, as was formerly the practice, and the term litholapaxy is used to designate this method. The patient having been anaesthetized, the urethra is dilated by the passage of large-sized bougies. Then a few ounces of a warm neutral aseptic fluid are injected into the bladder, and the crushing instrument, the lithotrite, is passed along the urethra into the bladder. The lithotrite has two blades,—a "male"and a "female,"—the latter fenestrated, the former solid with its surface notched; these blades can be approximated both by a sliding and a screwing movement. The sliding movement is used to grasp the stone ; but when the stone is fixed between the blades the screw action is used, as it enables great pressure to be applied evenly, gradually, and continuously. The lithotrite is made of very tough steel, so that even very hard stones may be crushed without any danger of the instrument breaking. It is passed into the bladder with its blades closed ; they are then opened and an attempt made to grasp the stone. The stone having been fixed between the blades by the sliding movement, it is then crushed with the screw action, great care being taken not to catch the bladder-wall with the lithotrite. This danger is avoided by raising the point of the lithotrite immediately after grasping the stone and before crushing is begun. The stone breaks into two or more pieces, and these fragments must next be caught and crushed one by one, until they are all reduced to a very small size. If the stone be large and hard, half an hour or longer may be required to crush it sufficiently. When the surgeon fails to catch any more large portions of stone, the presumption is that it has been broken up into small enough pieces ; the lithotrite is then withdrawn and the second stage of the operation must be begun. This consists in removing the detritus by means of an aspirator, the best form of which is that invented and used by Sir Henry Thompson. It consists of an elastic bag connected with a trap, into which fragments of stone will fall and not pass out again on the instrument being used at later periods in the operation. A large catheter, with the eye very near the distal end of the short curve, is passed into the bladder; the aspirator, full of an aseptic fluid, is attached to the catheter, and a few ounces of the fluid are expressed from the aspirator into the bladder by squeezing the india-rubber bag. When the pressure is taken off the bag, it dilates and draws by suction the fluid out of the bladder, and with it some of the detritus of the crashed stone, which falls into the trap, and is not expelled on the fluid being re-introduced into the bladder. This manoeuvre is repeated again and again, until all the fragments and detritus of the stone have been removed. After the operation the patient sometimes suffers from pain and discomfort; but these are not at all severe unless some fragments have been left in the bladder. If the pain be severe, it can very generally be relieved by hot fomentations or a sitz-bath. The patient must be kept in bed for some days after the operation, and in cases where the stone has been large and the bladder irritable the surgeon should insist on him remaining in bed for at least a week. Judging by statistics, the dangers of the operation, if it be gone about with care, are not nearly so great as those of lithotomy, and certainly in those cases which go on favourably the patients are much sooner able to per-form their ordinary duties. Fatal terminations, however, do now and again occur, sometimes as a result of injury to the bladder-wall setting up inflammation, which extends to the kidneys, sometimes from suppression of urine. Those cases in which there has been a fatal result most frequently have been complicated with old-stand-ing kidney disease.

Neoplastic Growths.—The commonest neoplasms found in the Neo-bladder are vascular fibromata (often called villous cancers) and plastic epitheliomata; more rarely malignant growths occur. The symptoms growths, produced by tumours vary ; but they may cause obstruction to the flow of urine and chronic cystitis, with more or less severe pain. The most important signs are the passage of blood and the presence of tumour cells in the urine. Frequently, however, microscopical examination of the urine fails to discover the presence of tumour cells. The passage of blood may be very intermittent and small in amount; but this intermittent bleeding is one of the most character-istic signs of the existence of a tumour. When the presence of a tumour is suspected, the sound is passed and an attempt made to feel it. Sometimes it can be felt, but more often doubt remains as to whether a tumour does really exist or not. In such cases the endoscope may be had recourse to; but the information derived from its use is not always satisfactory, and a diagnostic incision must then be made into the bladder to verify the diagnosis. When such a diagnostic incision is made, the surgeon must be prepared to remove the tumour, should one be present and capable of removal. Usually the diagnostic incision is perineal; but, if the bladder is capacious, or if the perinaeum is deep and narrow, a more complete examination can be made by a suprapubic opening. The treat-ment of neoplasms is, as a rule, unsatisfactory. If the growth be pedunculated, it can he removed without great risk to the patient; more commonly, however, the tumour cannot be removed, and then only palliative measures can be adopted, such as allaying the pain and checking the haemorrhage. Great relief is often given by wash-ing out the bladder; but this must be done with very great care, a soft flexible catheter being used, if it can he passed into the bladder, in preference to a rigid one.

Hypertrophy and Dilatation.—When there is long-continued obstruction to the flow of urine, as in stricture of the urethra, enlarged prostate, &c, the bladder-wall becomes much thickened, the and muscular fibres increasing both in size and number ; the interstitial fibrous tissue is also increased. The wall on its inner surface becomes rugose, and the condition is technically known as hypertrophy. Hypertrophy may be accompanied by dilatation of the bladder, a condition which the bladder may assume when from any cause the evacuation of its contents is in terfered with for a length of time.

Paralysis of the bladder is a want of contractile power in the muscular fibres of the bladder-wall. It may result from injuries of whereby the spinal cord is lacerated or pressed upon at or below bladder, the micturitory centre situated in the lumbar region. The result may be either retention or incontinence of urine : sometimes there is at first retention, which later on is followed by incontinence, while in other cases incontinence results in the first place and then reten-tion. Paralysis is also produced in certain nervous diseases, as in locomotor ataxia, and in various cerebral lesions, as in apoplexy.

Atony of the bladder differs from paralysis in being only a paresis or partial paralysis. It is due to a want of tone in the bladder, muscular fibres, and is most frequently the result of habitual over-distension of the bladder, such as may occur in cases of enlarge-ment of the prostate. The patient is unable to empty the bladder, and the condition of atony gets increasingly worse.

In both paralysis and atony the indication is to carefully prevent over-distension of the bladder by the urine being retained too long, and at the same time to treat by appropriate means the cause which has produced or is keeping up the condition.

Incontinence of urine may occur in the adult or in the child, but is due to widely different causes in the two cases. In the child it may be simply a bad habit, the child not having been properly trained ; but more frequently there seems to be a want of control in the micturitory centre, so that the child passes its water un-wittingly, especially during the night. In adults it is not so much a condition of incontinence in the sense of water being passed against the will, but is rather due to a difficulty in retaining the urine in consequence generally of an over-full bladder,--the water which passes being the overflow from a too full reservoir. It is usually caused by an obstruction external to the bla< der, e.g., enlarged prostate or stricture of the urethra. Occasionally the presence of a calculus may produce the condition. The treatment differs in the case of the child and of the adult. In the child an attempt must be made to improve the tone of the micturitory centre by the use of belladonna or strychnia internally and of a blister or faradism externally over the lumbar region, and every effort should be made to train the child to pass its water at stated times and regular intervals. In the adult the cause which produces the over-distension must be removed if possible ; but as a rule the patient has to be provided with a catheter, which he can pass into his bladder and thus thoroughly empty it before it has filled to overflowing. A soft flexible catheter should be given in preference to a rigid or semi-rigid one. The best form is the red-rubber catheter.

The condition termed by Sir James Paget stammering micturition is frequently seen in young men, more rarely in children and adults. This stammering of the urinary apparatus is analogous to speech stammering, and occurs chiefly in those who are nervous and easily put out. It would seem to be due to incoordination of the sphincter and detrusor of the bladder, the former not relaxing synchronously with the contraction of the detrusor, or vice versa, and is sometimes caused by external irritation, such as preputial adhesions. Occasionally not a drop of urine can be passed, or a little passes and then a sudden stoppage of the flow occurs, and the more the patient strains the worse he becomes, until at last there is complete retention of urine. Very usually such errors in micturition can be cured by the removal of irritating causes, if they exist, and in these cases, as well as in those in which no such cause can be discovered, great care should be taken to avoid those difficulties which have given rise to the patient's worst failures. If at any time he should fail to perform the act of micturition, he ought not to strain, but should quietly wait for a little before making any further effort, after which he will often succeed. Regularity in the times of making
water is also of much importance.

Retention of urine cannot be called a disease of the bladder, but may be the cause of, or result from, bladder disease. It may occur in paralysis of the bladder, or in conditions where the patient is suffering from an illness which blunts the nervous sensibility, e.g., typhoid fever. It is, however, much more commonly due to obstruction in some part of the urinary passage anterior to the bladder, as in stricture of the urethra or enlargement of the prostate. The patient can usually tell when he last passed any urine ; but, even when no such information can be obtained, there are signs which lead the surgeon to a correct diagnosis. Thus, the bladder if much distended can be felt as a rounded swelling above the pubes, and it may even have passed to the level of the umbilicus. Percussion of the hypogastrium gives a dull note. When retention of urine occurs and the bladder is over-distended, it is necessary to evacuate its contents as soon as possible. If there is no obstruction to the flow of urine, the retention being due merely to atony or paralysis of the bladder, a flexible soft catheter is passed into the bladder and the water drawn off. But, when there is an obstruction which cannot be overcome, aspiration of the bladder has to be resorted to, the needle of the aspirator being pushed through the abdominal wall into the bladder. The point of puncture in the abdominal wall is in the middle line just above the symphysis pubis. The bladder has been aspirated in this way very many times in the same person without any evil result. But in all cases strict antiseptic precautions must be adopted. (J. C. )



Footnotes

See "The Bladder Drainage," by Prof, Chiene, in Edin. Med. Journ., vol. xxvi., part i., 1880-81.