Not infrequently peritonitis supervenes, as it did in the case recorded above. Nevertheless Whitehead rightly calls attention to the fact that the general symptoms are often but very slight, in comparison with the gravity of the affection. Eclampsia has occasionally occurred in connec tion with a chronic catarrhal cystitis in gravidity. (See Vinet's case.) Abortion frequently occurs; in Whitehead's case the expulsion of the loosened portions of mucous membmne preceded that of the child by several hours. But there are cases, as one of Haussmann and one of Madurovicz show, in which in spite of the exfoliation of a large part of the mucous membrane of the bladder, and in spite of high fever, the preg nancy is not interfered with.
In unfavorable cases death occurs with urEemic symptoms, or with peri tonitis and collapse. Patients who are seized with severe general diseases, typhus, uterine diphtheria, smallpox, etc., may easily have their vesical symptoms so masked as to be very misleading.
LOwenson's patient only entered the St. Petersburg hospital a few days before her death; she soon sank into a soporose condition, so that the exact symptoms of this remarkable form of chronic cystitis with epider mis production could not be observed.
a woman complains of urinary difficulty an exact digital and specular examination of the internal genitals should be made. The orifice of the urethra should be examined, new growths in it looked for, the catheter introduced and the posterior bladder-wall examined with it. Then the urine that is drawn off should be examined for albumen, vesical epithelium, casts, blood, fat, vibriones, crystals of ammonio magnesic phosphate and membranous shreds. Sometimes the tenderness of the bladder-wall itself will inform us that we have to do with till inflammatory affection of that viscus. To determine its exact seat and extent, and especially to differentiate it from fissure of the neck of the bladder, to which Voillemer, Gueneau de Mussy, and Spiegel berg have especially drawn attention, the urethra must be dilated, and the collum vesicle examined by p'alpation and inspection. At the same time we may make direct medicinal applications, and extract exfo liated portions of the mucous membrane. But most important in all such cases is the microscopic examination of the fragments extracted or passed. That only can inform us whether the material is really a portion of the vesical mucous membrane, whether we find in it pavement epithelium, fibrin threads, mucus or pus cells or smooth muscular fibres, or whether it is material that ha,s come from without, from echinococcus-sacs or ovarian cystomata (containing hair, heaps of epidermic scales, etc.), or
whether even, as I once found, and as did Professor Franz Eilhard Schulze, it is composed of matter containing straight canals, in which we can recognize kidney structure. Since in many of these conditions, as, for instance, in diplitheritis, the vesical walls may be extremely soft, we must refrain from inflating the bladder with air and using the mirror. The lower abdominal region is of course to be examined by palpation, percussion, and auscultation; the amount of distension of the bladder, the tense or relaxed condition of its walls, and the existence of a friction sound are to be thus determined.
In diphtheritic processes in the genitals of puerperal women, in typhus fevers, but especially in retroversion of the pregnant uterus, a constant watch must be kept upon the condition of the urine, lest the beginnings of a croupous or diphtheritic affection of the bladder be overlooked.
Etiology and Occurrence.—Among the 2500 post-mortem examinations of female subjects mentioned on page 25, inflammatory processes of the bladder were found 68 times, 2.7 per cent. of all cases, and 38.3 per cent. of cases in which any anomalies of bladder and urethra were found. Hyperwmia was found alone 4 times, ecchymoses and hemorrhages 21 times, vesical catarrh 16 times, purulent cystitis 16 times, croupous 4, and diphtheritic cystitis 5 times, abscess of bladder 3 times, metastatic abscess once, chronic cystitis 4 times, cedema of vesic,a1 wall and its neighborhood twice, pericystitis once. Thus inflammatory affections of the bladder are important in women, and there is no doubt that it is the puerperal pro cesses especially that predispose them to them. Two conditions are es pecially prone t,o do so. One is retroflexion of the pregnant uterus with retention of urine, and the other is the early ischuria of the puerperal period. Virchow holds that ammoniacal decomposition of the urine from one cause or another must occur before the epithelium can be loosened and the bacilli obtain a lodgment in vesical diphtheria. As May (1869) has proved in dogs, the loosening occurs first at the apex of the bladder. Mucosa and muscularis are separated from one another, and the space between them is filled with blood or serum or urine that has percolated through. The mucosa of the vesical neck is generally preserved, as Schatz has shown, and cure is thus rendered more easy.