Urethral Caruncle. Pathology. This is a vascular excrescence varying in size from a pin head to a strawberry; it consists of dilated capillaries in connective tissue, the whole being covered with squamous epithelium. Physical Signs. A cherry-red tumour, exquisitely tender and vascular, is seen at the urethral orifice (fig. 355). Symptoms. These are pain on micturition or even retention of urine, pain on coitus. Treatment. Place the patient under chloroform in the lithotomy posture, and destroy the growth by Paquelin's cautery at a dull heat. If bleeding occurs, do not CARUNCLE AT URETHRAL ORIFICE (a) AND, IN ADDITION, NEUROMATA IN SURROUNDING MUCOUS treat it lightly; plug the vagina, bringing the half of the last strips of As regards the other neoplasms, papillomata are painless, sarcomata very rare and their nature settled microscopically, while carcinomata appear as hard peri-urethral tubercles which break down (Skene). In regard to treatment, they may be removed by the curette, or by small loop-snares when high up. We may also have inflammatory changes in Skene's "tubules" (v. p. 31). URETHRITIS. Acute urethritis is usually part of a gonorrhoea. When pus is secreted, the urethra can be felt swollen and tender; the pus can be squeezed out of the urethral orifice by pressure from above downwards; on passage of the sound, pain is felt in the urethra although no cystitis be found. Treatment. Give diluent drinks so as to increase the flow of urine. Copaiba may be given in the form of the well-known Nesbitt's specific:B Liquoris Copaiba Co. (Nesbitt) Sig. Teaspoonful thrice daily. 3ij. Iodoform bougies may be passed in, and counter-irritation applied in the shape of the tincture of iodine over the anterior vaginal wall. DILATATION AND STRICTURE OF THE URETHRA. The urethra may be unusually dilated, a' condition rarely met with; in some cases the dilatation has been caused by coitus, as in malformations of the vagina (v. p. 236). The dilatation may be local or general. When it is general, the cautery may be used to burn a vertical furrow, the rest of the urethra being guarded by a speculum. Stricture of the urethra is a rare condition and readily yields to dilatation by bougies or to incision. DISEASES OF THE BLADDER. Of the diseases of the bladder we shall here consider Displacements, Neoplasms, Stone in the Bladder, and Cystitis. Vesico-vaginal fistula will be considered in a separate chapter (Chap. LIII). DISPLACEMENTS OF THE BLADDER. The female bladder when empty lies between the pubis and usually to one or other side. It is never exactly central. mobility From its loose attachment to the pubis, it is pre-eminently displace- The able. (1) It is drawn up during labour; and (2) is displaced upwards of the by retroversion of the gravid uterus, pelvic ovarian or fibroid tumours, Bladder. and pelvic hæmatocele. (3) It may be adherent to the anterior surface of an abdominal ovarian or fibroid tumour, and may thus be cut into on abdominal section. (4) It is displaced downwards in prolapsus uteri and in cystocele. (5) In utero-sacral cellulitis of the uterus, the bladder is Senile form of Prolapsus. drawn back and fixed; its systole is thus interfered with, which explains some cases of so-called hysterical retention of urine. From this mobility it follows that the height of its fundus above the symphysis gives no indication of the amount of urine in the bladder. CYSTOCELE. By this we understand a pouching of the posterior wall of the bladder downwards and backwards; the uterus and summit of the bladder are in normal position. Many a case, regarded as cystocele, is really part of a prolapsus uteri ; on the other hand, the so-called "senile prolapsus uteri" is really a cystocele; at the menopause the cicatrisation of the vaginal walls chiefly affects the posterior one, and thus the bladder tends to bulge outwards at the vaginal orifice. The diagnosis is easily made by the Bimanual and use of the sound. The treatment consists in the use of a ring pessary with diaphragm (fig. 328) or such a one as is seen at fig. 331. Should these fail, the vagina may be packed with oakum or a raw surface (as shown at fig. 339) may be made and stitches applied. NEOPLASMS OF THE BLADDER. Pathological anatomy. We may have mucous, fibroid or fibro-myomatous polypi. There may also be sarcomatous or carcinomatous disease of the bladder wall, as well as so-called tubercle. The carcinomatous condition is not infrequent, and is termed by some "villous cancer." It is most common at the trigone, and is held by some authorities not to be malignant. The bladder may be secondarily affected in carcinoma uteri (v. p. 433). Symptoms. These are disturbances of micturition, with bloody and phosphatic urine. Physical signs. The passage of the index finger into the bladder will show the position, shape, and other characters of the growth. Treatment. This will vary according to the position, nature, and pediculation or non-pediculation of the growth. Thus it may be twisted off by narrow polypus forceps, snared by a loop of fine catgut, or removed by incision into the posterior wall of the bladder and use of the galvanocautery or curette (v. Stone). Nature. CYSTITIS. An acute or chronic inflammatory affection of the mucous membrane of the bladder. Pathological anatomy. In the acute catarrhal form, we have congestion of the vessels and loss of epithelium; in the chronic catarrhal form, the congestion is duller and there is marked rugosity of the lining of the bladder. The submucous and even the muscular tissues also become affected. The mucous membrane may be ulcerated and the muscular tissue exposed. The inflammatory process may extend deeper, to the muscular tissue (interstitial cystitis) or to the peritoneum (pericystitis). Occasionally, though rarely, we may have diphtheritic inflammation. In advanced cases, the patient is usually septicæmic and there is often Results of hydro-nephrosis. Cystitis. In some cases of prolonged retention the mucous membrane may slough off and be passed per urethram, but may be regenerated. Etiology. The causes are as follows:-Gonorrhoea; latent gonorrhoea ; exposure to cold; injury from coitus; prolonged parturition; introduction of septic matter by catheter or bougie; prolonged retention of urine. Symptoms. In acute cystitis the patient has very frequent and painful micturition. In chronic cystitis also, there is frequent micturition but accompanied with less intense pain; there are, further, shooting pains with secondary phenomena-septic, vascular and nervous. Physical signs. (a) Acute cystitis. The urine has a low specific gravity and acid reaction; the colour is little altered, and mucus is present in excess. On vaginal examination, pain is not felt when pressure is made on the posterior vaginal wall but is felt severely when the anterior wall is touched. of Urine in (b) Chronic cystitis. The urine has a low specific gravity, is usually Characters alkaline, and is often offensive; it contains pus, epithelium, phosphates Cystitis. and bacteria; albumen, derived from the pus, is present. The vaginal examination gives the same results as in acute cystitis. If the finger be passed through the urethra (v. p. 571), the roughened condition of the lining membrane is felt; crystals of phosphate and marked rugosities can also be detected. Prognosis. In both acute and chronic cystitis, the prognosis is not good; the treatment is difficult, and in bad chronic cases the patient's strength sometimes becomes exhausted and septicemia may cause death. Treatment. (a) Acute cystitis. Put patient on milk diet, and give Treatment Friedrichshall or Carlsbad water freely. Diluent drinks may be taken ad libitum. of Acute Cystitis. Treatment The following prescription is useful. B Potassæ Bicarbonatis Tincturae Hyoscyami Infusum Buchu vel Pareirae vel Uvæ Ursi ad Sig. Tablespoonful thrice daily. 3 iss. 3 vj. In gonorrhoeal cystitis, the following may be substituted: B Liquoris Copaiba Co. (Nesbitt) Sig. Teaspoonful thrice daily. 3ij. If the pain is very acute give morphia suppositories (4 grain) at night, omitting the mixture with the hyoscyamus if necessary. For (b.) Chronic cystitis, we recommend the following treatment of Chronic seriatim. Cystitis. 1. Put on milk diet with abundant fluids, and purge freely. Give The hyoscyamus eases the pain; and the nitric acid corrects the alkaline phosphatic urine, for which also benzoate of ammonia is admirable. The benzoate of ammonia is converted into hippuric acid and corrects alkalinity. Nesbitt's specific is also useful. FIG. 356. THE SKENE-GOODMAN SELF-RETAINING CATHETER; AN INDIA-RUBBER BAG CAN BE WORN WITH IT (Skene). 2. If this fail, then wash out bladder as often as possible by means of double catheter, such as Skene's; use weak boracic lotion, or carbolic lotion; inject with the douche or Higginson's syringe. Paint anterior vaginal wall with tincture of iodine. 3. A long (winged) india-rubber catheter may be kept in the bladder so as to drain off the urine constantly and give the bladder rest. The patient need not remain in bed if the Skene-Goodman catheter (fig. 356) is used. 4. In obstinate cases, the formation of an artificial vesico-vaginal |