Paralysis of the bladder also occurs not infrequently from peripheral causes in typhus, and in dysentery, due to fatty degeneration of the mus cular coats of the bladder.
In the same way paralysis of the bladder occurs in old women from myopathic processes; and in young individuals acute paralysis of the bladder has set in from over-distension in consequence of exc,essive mod esty.
The central and more general causes for vesical weakness and paralysis are cold, blows, falls, acute meningitis and encephalitis, myelitis of the lower part of the spinal cord, neuritis propagata from extension of inflam mation from kidney and bladder to the plexus sacro-lumbalis (Kussmaul) large doses of opium, and finally, endarteris deformans of the pelvic ves sels. Disturbance of consciousness in brain diseases (apoplexy), sopor, delirium, and high fever paralyze the detrusor, remove the influence of the will, and, overcoming the reflex contraction of the sphincter muscle, cause the urine to flow off involuntarily.
Symptoms.—The first sign of vesical weakness is increased difficulty in voiding urine. It becomes difficult to empty the bladder, the accessory abdominal muscles are put int,o requisition, and finally, the bladder can no longer be emptied, and retention of urine, ischuria, sets in. This may lead to enormous accumulations of water in the female. Lieven drew 128 ounces of clear transparent urine from the bladder of a woman thirty three years old, in whom the distended organ formed a tumor as large as the uterus at six months, and who had been supposed to have an ovarian cyst. Others have emptied 16 beer-bottles full; Schatz, in the patient mentioned in page 178, drew 9 pounds of urine; and Hofmeier 4-11 quarts from a bladder which was distended until it reached the navel. Budge showed the reason for this enormous distensibility of the viscus in a beau tiful experiment. He cut the dorsal cord across, and proved that there ensued great vesical distension with increased reflex contraction of the sphincter vesime.
After the dilatation of the bladder has gone on to a certain extent, the resistance of the sphincter is usually overcome, and the urine partially flows off. The bladder is, however, not much diminished in size, and the condition known as ischuria paradoxa has set in.
If this condition lasts long, and if repeated introduction of the catheter becomes necessary, there soon arise vesical catarrhs, inflammations of the ureters, pyelitis, urEemic symptoms, and death. Or perhaps portions of
the vesical wall begin to ulcerate, and perforation with peritonitis or fistulie may occur. In very rare cases there occurs rupture of the bladder.
Incontinence of urine is a special form of vesical weakness, chiefly occur ring in children. But it may persist after adolescence, and in one form, enu reais nocturna, sometimes remains after marriage. It is very apt to occur in scrofulous, cachectic, hysterical, delicate, pale individuals, and is some times more or less hereditary. In some cases it leads to serious catarrhal troubles, from the continuous wetting and catching cold, so that we may have in consequence inflammatory conditions of the bladder, rectum, lungs, and bronchi. Undoubtedly the non-efficient exercise of will power is of great importance in the causation of this affection; many authors explain enuresis nocturna by the absence of will control over the sphinc ters, which is the condition in deep sleep. If the incontinence lasts for a length of time, the muscular fibres are gradually weakened, and the in voluntary evacuations may occur also during the day. Some authorities, and among them B. Erdmann, regard enuresis nocturna as an incom plete anEesthesia of the sensitive vesical nerves. The sensation caused by the filling of the bladder is present; but it is not strong enough to wake the child out of ita ordinary sleep. Reflex evacuation then takes place.
Diagnosis of Vesical Weakness and must first decide in any case of difficulty in urination whether the bladder is filled and tense, and whether its walls are tender. This is to be ascertained by the physical examination of the lower abdomen, percussion of the vesical region, vaginal, or in very young girls rectal exploration. Then the ure thral opening must be examined, the catheter introduced, and the strength and rapidity of the flow of urine observed. The inner vesical surface is then to be examined as to sensibility with the catheter. Then the urine is to be examined; and it must be decided whether the bladder is ever in a contracted state, and if so, how long it takes t,o fill up again. In enuresis infrequent urination is a sign of deficient action; too frequent action is a symptom of paralysis of the detrusor.