NEUROSES OF THE FEMALE BLADDER They consist of vesical spasm, and vesical paresis and paralysis. In many, even in most of these cases, there is in addition some local disease of the tissues, and the neurotic disturbance is but a symptom. There is no doubt that the more we make use of urethral dilation as a method of examination, the more cases of what we used to call primary vesical neuroses do we recognize as secondary' ones. Thus several writers have lately described fissure of the vesical neck as the cause of cystospasmus. We should be cautious, there fore, in diagnosing neuroses of the bladder, and should arrive at them only by process of exclusion.
1. Vesical Spasm, Cystoepasmus, Neuralgia Vesica3.—Causes are chiefly nervous. Very excitable women easily have spasm of the bladder. Strong mental emotions, onanism, violent coitus, cold, especially at the menstrual epoch, sitting upon the damp ground, wetting the feet; all these may cause it. The free use of various drinks, as of several kinds of beer, and of new sour wine, has induced it, probably from chemical action of the kidney secretion upon the sensitive nerves of the vesical mucous membrane, causing hypermmia of the latter. Playfair found in a number of women during the latter months of pregnancy, a continual desire to urinate, even at night, with a cloudy urine, which resisted all manner of medicinal treatment. He believed that in these cases the fietus was in faulty position, that its shoulder pressed against the mother's bladder; and he found that upon manually altering the position the dis order vanished. As a secondary affection neuralgia of thebladder occurs in almost all the diseases of the bladder which we have described.
Symptoms. —The first and most important symptom of cystospasmus is the frequent occurrence of cramping pains and pressure in the vesical region, and especially at the vesical neck. When the bladder is full there is moderate tenderness; and the pain is worst at the beginning of the act of urination, which may be repeatedly unsuccessfully attempted or avoided fear. The urine is pale, non-albuminous, contains no sugar, pus, blood, urates, or foreign bodies. There may be large quantities of it,
though only passed in drops. Occasionally the passage of a metallic cathe ter through the urethra and into the vesical neck is dreadfully painful. Twelve years ago, before we were acquainted with the method of rapid urethral dilatation, I endeavored for months to relieve an affection of this kind in a moderately stout patient; relieved for a time, it always returned, until finally she left me, I suppose cured. I now believe that she had erosions or fissures, and that the remedies which I applied in the form of bougies to the urethra and the vesicollum, did no permanent good, be cause they did not act long enough. I once had an opportunity to con vince myself at the autopsy of a puerpera who had suffered from ischuria and intense pain on catheterization, that at the neck of the bladder there was an ulcer the size of a pea. She had died of septic peritonitis. Here also the cystospasmus was only secondary. The pains sometimes radiate in all directions, and cause excitement, fear, cold sweat, nausea, anorexia, and sleeplessness. If they persist, they may exhaust the patient and actually cause melancholia. Marion Sims (Clinic of Uterine Surgery, p. 248, 1864) has pointed out that abnormal irritability of the bladder occurs with vaginismus; and it is well possible that the cystospasmus is here due to extension through the upper part of the hymen into the urethra and the vesical neck. The attempt to pass a catheter upon one of these pa tients causes symptoms analogous to those of vaginismus.
the urine is normal, the urethra healthy; if there are no abnormalities detectable in the blood supply or texture of any part of the vesical wall when examined with the finger and with the eye; if after specular dilatation of the urethra the anterior vesical wall has been ex amined with Rutenberg's speculum and found normal; then and then only can we diagnose a primary spasm of the bladder. For not one of the above-mentioned symptoms is pathognomonic.