of the bladder may last for months and years, and though not dangerous, is exceedingly troublesome. If not of too long standing the prognosis is fair; and even in the worst cases it can usually be cured in time.
T possible, remove the c.auses; excise the hymen in vaginis mus, forbid sexual intercourse, order hot foot baths, stop the use of wine, beer, and tea, and seek to allay vesical irritability by the use of almond milk, one wineglassful three times daily.
At the beginning local opiates will render us most service; and it is best to give at once a ith grain morphine injection in the skin of the vesical region. Less rapid but as sure are suppositories containing ith grain of morphine or grain of extr. of belladonna to 40 grains of cocoa butter. Internally we may use almond emulsion with extract. hyoscyami, 24 grains to S vi.; or opium with lupulin (:3 to 5 grains) several times daily; or extract. cannabis indicie 2i grains, or tinct. cannabis indics3 gtt. 10 to 15 L d. Chloral hydrate is one of the most certain remedies that we possess, and it may be injected into the rectum with a syringe to the amount of 15 grains dissolved in half all ounce of water, or ad ministered internally with syrup of orange peel.
If these means are not sufficient, we must carefully regulate the pa tient's diet and her evacuations. We must use warm baths, and prescribe the free use of carbonated. waters such as Weldmeyer, Biliner, Vichy, soda water, etc. If the malady is still unrelieved we must undertake mechani cal dilatation of the urethra. Hewetson (4, XII., 1875) recently cured a cystospaamus of 15 years' duration in this way, and the method has been hIghly recommended by many authorities, including Teale (Lancet, 27, XI., 1875) Tilloux (Virchow-Hirsch, Bericht filr 1873, p. 184), Spiegelberg (see obid.), etc. Again we may try the introduction of broad soft pessa ries into the vagina, so as to put a moderate pressure on the bladder. Finally we may employ injections of morphine into the bladder with sub sequent c,auterization, as done by Braxton-Hicks (page 185) to relieve the reflex vesical irritability. Debout recommended bromide of potassium internally and also by rectal suppository in combination with tni. opii and ext. belladonna. As a last resort we may try the direct application of e,ocaine to the mucous membrane of the bladder.
2. Weakness and Paralysis of the Bladder.—Paresis et Paralysis resi cm.—.1schuria, Incontinentia, Enuresis.—The physiologists are not agreed as to the exact functions of the two sphincters of the bladder, the internal one of smooth muscular fibres, and the external one of striped muscle. Some, like Budge and Hertzka, deny the efficacy of the external one, holding its function to be merely to assist in the evacuation of urine; while others, like Dittel and Kupressow, hold that the transverse internal muscular fibres of the vesical neck, like the similar fibres found in the urethra, have for their function the closing of the bhulder. From a clinical standpoint, we must agree in the main with the latter opinion, especially after our experience with fistulas of the vesical neck, which may reach to within ith of an inch from the orifice of the urethra, and still afford continence after operation. However that may be, all authori ties are to-day agreed that the evacuation of urine is a reflex act. The spinal and cerebral centres of the vesical mot,or nerves are excited to action, either from the vesical mucous membrane where there is a large collection of urine, or from a drop of urine passing the involuntary inter nal sphincter, and getting into the urethra, or from an effort of the will. On the other hand the will is able to resist the reflex action of urination by contraction of the external sphincter or compressor urethne, as IIertzka calls it.
C'auses.—Weakness and paralysis of the bladder in women may be due to central or to peripheral causes. The peripheral momenta, have been described in the foregoing chapters, and are mostly of a mechanical nature, as from the vesical displacements, so often caused by pregnancy and child-bearing; but especially is it due to that post-partum bending of the urethra which we have spoken of before, causing retention, and after wards weakening of the detrusor vesicle, paresis vesicze. Pressure of quite another kind may, however, cause exactly the same condition. An in terstitial cedema occurs with ulcers of the cervix, with parametritis and peritonitis, and disables the detrusor. This usually occurs in the later days of the puerperal period, and is generally very obstinate.