John Chiene

“ In adults it is not so much a condition of incontinence in the sense of water being passed against the will, but is rather due to a difficulty in retaining the urine in consequence generally of an over-full bladder, the water which passes being the overflow from a too full reservoir. It is usually caused by an obstruction external to the bladder, e.g., enlarged prostate or stricture of the urethra. Occasionally the presence of a calculus may produce the condition. ”

“ A lithotomy tube is now passed through the wound into the bladder and fixed in position; the patient is untied and carried back to bed. The operation of lithotomy is not a difficult one to perform, nor is it in itself dangerous; sometimes, however, there is a fatal termination, due commonly to one or other of the following causes—hæmorrhage (either primary or secondary) , organic disease of the urinary organs, or blood poisoning. ”

“ The patient must be kept in bed for some days after the operation, and in cases where the stone has been large and the bladder irritable the surgeon should insist on him remaining in bed for at least a week. Judging by statistics, the dangers of the operation, if it be gone about with care, are not nearly so great as those of lithotomy, and certainly in those cases which go on favourably the patients are much sooner able to perform their ordinary duties. ”

“ The two common primary forms of club-foot are talipes equinus and talipes varus. These two varieties are frequently combined ; the deformity is then termed talipes equino-varus. A shortening or contraction of one group, or of allied groups, of muscles is always to be observed ; as, for instance, in talipes equinus, to which the muscles of the calf are con tracted, or in talipes varus, in which the group of muscles which turn the foot inwards are contracted, or in talipes equino-varus, in which both sets are at fault. ”

“ The third and fourth varieties are so rare that they are of no practical interest, and need not be further alluded to. It is possible to confound true talipes valgus with flat-foot, a deformity which is the result of undue stretching, from weakness, of the fascial and ligamentous structures which maintain the arched form of the foot. In flat-foot the arch is lost, the patient is splay or flat-footed, and as a secondary deformity the foot is turned outwards, resembling and often confounded with true talipes valgus. ”

“ Neoplastic growths .Neoplastic Growths.—The commonest neoplasms found in the bladder are vascular fibromata (often called villous cancers) and epitheliomata; more rarely malignant growths occur. The symptoms produced by tumours vary; but they may cause obstruction to the flow of urine and chronic cystitis, with more or less severe pain. The most important signs are the passage of blood and the presence of tumour cells in the urine. Frequently, however, microscopical examination of the urine fails to discover the presence of tumour cells. ”

“ Fatal terminations, however, do now and again occur, sometimes as a result of injury to the bladder-wall setting up inflammation, which extends to the kidneys, sometimes from suppression of urine. Those cases in which there has been a fatal result most frequently have been complicated with old-standing kidney disease. ”

“ When such a diagnostic incision is made, the surgeon must be prepared to remove the tumour, should one be present and capable of removal. Usually the diagnostic incision is perineal; but, if the bladder is capacious, or if the perinæum is deep and narrow, a more complete examination can be made by a suprapubic opening. The treatment of neoplasms is, as a rule, unsatisfactory. If the growth be pedunculated, it can be removed without great risk to the patient ”

“ The diseases of the second group in which no organic structural change can be recognized in the bladder-wall are numerous. In many cases, however, they can scarcely be considered as diseases of the bladder pure and simple, but rather as concomitants or results of other diseases. ”

“ The patient having been anæsthetized, the urethra is dilated by the passage of large-sized bougies. Then a few ounces of a warm neutral aseptic fluid are injected into the bladder, and the crushing instrument, the lithotrite, is passed along the urethra into the bladder. The lithotrite has two blades,—a "male" and a "female,"—the latter fenestrated, the former solid with its surface notched; these blades can be approximated both by a sliding and a screwing movement. The sliding movement is used to grasp the stone ”

“ They are much more common, however, in some regions than in others. Thus, in India they are very common, while in Great Britain, although many persons suffer from calculus in Norfolk and the north of Scotland, very few cases occur among people who live on the western side of the island. From the above facts many have attributed the formation of calculi to special climatic or geological influences, but it is probable that diet acts as a chief factor in their production. ”

“ In the adult the cause which produces the over-distension must be removed if possible; but as a rule the patient has to be provided with a catheter, which he can pass into his bladder and thus thoroughly empty it before it has filled to over-flowing. A soft flexible catheter should be given in preference to a rigid or semi-rigid one. The best form is the red-rubber catheter.
Stammering micturation.The condition termed by Sir James Paget stammering micturition is frequently seen in young men, more rarely in children and adults. ”

“ Very usually such errors in micturition can be cured by the removal of irritating causes, if they exist, and in these cases, as well as in those in which no such cause can be discovered, great care should be taken to avoid those difficulties which have given rise to the patient's worst failures. ”

“ In the child an attempt must be made to improve the tone of the micturitory centre by the use of belladonna or strychnia internally and of a blister or faradism externally over the lumbar region, and every effort should be made to train the child to pass its water at stated times and regular intervals. ”

“ Eecognition of club-foot is of import ance, because if not treated early a change takes place in the shape of the bones of the foot, which renders treatment much more difficult, and in some neglected cases it is impos sible to restore the foot to its normal shape. ”