If we consider the normal figure of the empty bladder and its relations to the uterus (see Figs. 1 and 2), it is easily seen that the posterior vesi cal wall, which lies above the orificium vesicale, may be forced into the urethra by a certain amount of pressure coming from above where there is some relaxation of the walls of the organ and some dilatation of the calibre of the urethra. These three conditions are MI necessary for inver sion of the bladder per urethrarn, as they are for inversion of the uterus. The pressure from above may consist of an abnormal use of the abdomi nal muscles, of an over-filled and sunken cseettm, or of the uterus. In most cAses the trouble begins gradually. It can only occur suddenly when for instance a pedunculated nevi,' growth suddenly prolapses through the urethra, dragging the bladder with it; or when, as in de Haen's ease (see Streubel) the inverted bladder together with vagina and rectum prolapse in consequence of a sudden fall. It may occur at any time of life. Weinlechner saw it at 9 months, Oliver at 16 months, Crosse at 3 years, Streubel at 14 years, Thomson at 40 years, and Percy at 5'2 years.
The first symptoms, which in isolated cases may be present months and years before any others, are frequent desire to urinate, sometimes reten tion, and especially a sudden interruption in the stream. Then the patients notice, generally after an unusually persistent attempt to urinate, the appearance of a tumor. This tumor disappears at times, and then returns; and its return is accompanied with dragging pains in the hip and the back, and with fever. If the urine now collects in the bladder, and if the patient can withstand the tenesmus, as Percy saw, the tumor may gradually disappear, and the flow of urine begin. Sometimes, when the mucous membrane has become eroded, a few drops of blood may appear with the urine. As the tumor grows the troubles it causes increase, pain becomes severer, the appetite less, the kidneys irritable from the dragging upon and dilatation of the ureters. The patient becomes more and more emaciated, and dies of urEemia if her trouble is not relieved. It makes no difference in the symptoms whether the entire vesical wall, or only the mucous membrane, is prolapsed.
The recognition of inversion of the bladder through the urethra is not always easy. We must take into consideration the surface of the tumors (also its microscopic characters), their consistency, pedicles, ease of reduc tion, and finally the presence of the urethral openings. The finding of the latter of course render the diagnosis easy. If they cannot be found, the attempt should be made to replace the tumor with a catheter; and then from the vagina, or in young girla from the rectum, we can feel whether the vesie,a1 wall is thickened or not. If the vagina is large, and the inversion is chronic, we might attempt to replace the bladder from the vaginal vault, or to feel the depression. If we do not discover the nature of the tumor by these methods, we must endeavor to pass a finger into the bladder alongside the tumor, and try to find out whether we are dealing with a tumor springing from the inner surface of the bladder, or whether after reposition the prominence has disappeared. An overgrowth of the
vesical MUC0118 membrane, as Baillie has several times seen it, and consist ing of mucosa, submucosa, and abundant fat has been observed by Patron in one case prolapsed through the urethra. Patron tied it successfully. Inversio vesica3 per urethram differs from prolapse of the urethral mucous membrane, in that the position of the lumen of the urethra, which in the latter cases is either central or in the upper part of the tumor, in the former may be shown by the catheter to encircle it. Besides this, the prolapsed bladder wall has a thick pediele, whereas with prolapse of the urethral mucous membrane one is hardly demonstrable.
Therapy.—To prevent vesical prolapse we can treat the symptoms of dysuria and tenesmus vesicEe which usually precede it with warm baths, warm fomentations, inunctions with narcotic salves, (extr. opii gr. xxv.; vaseline E i.), liniments (ol. hyoscyam 3 i., chloroform gtt. xv.); and in ternally with almond milk, emulsions with ex:r. hyoscyami (gr. xxv. 3 vi.), or with tra. thebaica. Or we may use per rectal injection 5, 10 to 20 drops of laudanum, and suppositories containing extract belladonna gr. and ol. theobrom. 30 grs. once or twice a (lay. These measures are usually sufficient so long as the urine is clear and the vesical mucous membrane not notably affected. If this latter does occur, we must use weak soluttons of nitrate of silver (1-2-5:500) as injection, or salycilic acid (1-1000), or mucilaginous drinks, linseed tea, etc.
When vesical dislocation has occurred reposition must first be attempted. If the tumor be large, this may be attempted with the little or index fin ger, since the urethra will be so dilated as to admit them. If it be smaller, we must use a moderately thick and well-oiled catheter, and first com pressing and replacing as much as possible with the fingers, shove back the rest of the tumor with the aatheter into the bladder. If the patient presses down on account of the pain you cause, and renders the opera tion difficult, she should be amesthetised. Any position will do; but one which renders the intra-abdominal pressure as small as possible is prefer able. Hence the lithotomy position, or the knee-elbow position when no anEesthetic has been used, is the best.
To prevent a return of the prolapse the catheter might be left in place for a time; but it causes a good deal of trouble to many patients. It has therefore been advised t,o cauterize the neck of the bladder and the orifi cium vesicale urethree, so as to cause increased contraction and vigorous resistance to further prolapse. But this is more uncertain and less pleas ant than to effect contraction of the neck of the bladder, by the use of the colpeurynter, or cotton tampons, or Schatz's pessaries for incontinence of urine. If frequent relapses occur, astringent vesical injections should be used to overcome its relaxed condition.
Weinlechner claims to have prevented the return of the prolapse by means of sticking plaster; his patient was nine months old.
An operation is only to be thought of when the tumor is recognized as a polypus of the hypertrophied vesical mucous membrane. The method of extirpation will be described in Chapter IV.