Part 12

_Rupture of the bladder_ may be caused by a kick or blow over the upper part of the abdomen, or by a wheel passing over it; or it may be a complication of fracture of the pelvis. If the rupture is in that part of the bladder which is uncovered by the peritoneum, the extravasated urine may be cut down upon and let out with good prospect of success; but if the rupture is in the upper or hinder part of the bladder the urine is let loose into the general peritoneal cavity and sets up peritonitis, which is more than likely to prove fatal. If the surgeon knows that the bladder is ruptured he should operate at once in order to provide escape for the urine, and also to sew up the rent. If the possibility of the bladder being ruptured be even suspected, the surgeon should pass a catheter. Perhaps he draws off an ounce or two of blood-stained urine. This makes him doubly suspicious, so he injects into the bladder five, eight or ten ounces of warm boracic lotion, and, leaving it there for a few minutes, he measures the amount which he is able afterwards to withdraw; if he finds that a certain amount is lost he is assured that a leakage has taken place and he at once proceeds to operate. If only the diagnosis is made promptly, and the operation is at once undertaken, the outlook is not unfavourable. A generation or so back nearly all the cases of rupture of bladder ended fatally.

_Villous disease_ of the bladder is innocent; that is to say, it does not spread to the neighbouring structures or implicate the lymphatic glands. The villi are slender, branched, filamentous processes which, springing from the floor of the bladder, float in the urine like seaweed. They are freely supplied with blood-vessels, so that when a piece of a villus is broken off there is likely to be blood in the urine. Indeed, painless haemorrhage is one of the characteristic features of the disease, and when fragments of the "seaweed" are found in the urine the diagnosis is clear. If the bladder is opened from the front, as already described, the villi may be nipped off by special forceps and the disease permanently cured.

_Malignant disease_ of the bladder is almost always the warty form of cancer known as epithelioma. It springs as a sessile growth from the mucous membrane of the floor near the opening of one of the ureters, and, worrying the sensory nerves, causes irritability of the bladder and incontinence of urine. In due course septic germs reach the bladder, either from the urethra, the bowel, the kidneys or the blood-stream, and cystitis sets in. When ulceration has taken place, blood occurs in the urine, and the patient--generally beyond middle age--suffers dull or lancinating pains. Eventually the rectum may also be involved and the distress becomes extreme. The presence of the growth may be determined by sounding the bladder, by the cystoscope, and by the finger in the rectum. If the growth invades the outlet, retention of urine may occur, and the surgeon may be compelled to open the bladder from the front of the abdomen. In cases where operation is out of the question, washing the bladder with hot boracic lotion may give great relief. The treatment of cancer of the bladder by operation is, as a rule, unsatisfactory, because of the close proximity of the growth to the ureters and to the rectum. If, however, the disease were recognized early and had not invaded the neighbouring structures, and if it were upon the upper or the anterior part of the bladder, its removal might be hopefully undertaken.

_Hypertrophy and Dilatation._--When there is long-continued obstruction to the flow of urine, as in stricture of the urethra, or enlargement of the prostate, the bladder-wall becomes much thickened, the muscular fibres increasing both in size and number; the condition is known as "hypertrophy." Hypertrophy may be accompanied by dilatation of the bladder, a condition which the bladder may assume when the voiding of its contents is interfered with for a length of time.

_Paralysis_ of the bladder is a want of contractile power in the muscular fibres of the bladder-wall. It may result from injuries whereby the spinal cord is lacerated or pressed upon, so that the micturition centre, which is situated in the lumbar region, is thrown out of working order. The result may be either retention or incontinence of urine; sometimes there is at first retention, which later is followed by incontinence. Paralysis is also met with in certain nervous diseases, as in locomotor ataxia, and in various cerebral lesions, as in apoplexy.

_Atony_ of the bladder is a paresis or partial paralysis. It is due to a want of tone in the muscular fibres, and is frequently the result of over-distension of the bladder, such as may occur in cases of enlargement of the prostate. The patient is unable to empty the bladder, and the condition of atony gets increasingly worse.

In both paralysis and atony the indication is carefully to prevent over-distension by the urine being retained too long, and at the same time to treat by appropriate means the cause which has produced or is keeping up the condition.

_Incontinence of urine_ may occur in the adult or in the child, but is due to widely different causes in the two cases. In the child it may be simply a bad habit, the child not having been properly trained; but more frequently there is a want of control in the micturition-centre, so that the child passes its water unwittingly, especially during the night. In adults it is not so much a condition of incontinence in the sense of water being passed against the will, but is a suggestion that the bladder is already full, 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; a calculus may produce the condition. In the child an attempt must be made to improve the tone of the micturition-centre by the use of belladonna or strychnine internally, and of a blister or faradism externally over the lumbar region, and every effort should be made to train the child to pass water at stated times and regular intervals. 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 before the bladder has filled to overflowing. A soft flexible catheter should be given in preference to a rigid or semi-rigid one. The best form is the red-rubber catheter, and he should be taught the need of keeping it absolutely clean. In the case of children incontinence of urine means irritability; in adults it means overflow.

The condition termed by Sir James Paget _stammering micturition_ is analogous to speech stammering, and occurs in those who are nervous and easily put out. It would seem to be due to the sphincter of the bladder not relaxing synchronously with the contraction of the detrusor, and is sometimes caused by external irritation, such as preputial adhesions. Occasionally not a drop of urine can be passed, or a little passes and then a sudden stoppage occurs; the more the patient strains the worse he becomes, until at last there is complete retention of urine. The trouble can sometimes be cured by the removal of irritating causes, and in these cases, as well as in those in which no such cause can be discovered, care should be taken to avoid those difficulties which have given rise to the patient's worst failures. If at any time he should fail to perform the act of micturition, he ought not to strain, but should quietly wait for a little before making any further effort. Regularity in the times of making water is also of much importance.

_Retention of urine_ may occur in paralysis of the bladder, or in conditions where the patient is suffering from an illness which blunts the nervous sensibility, such as apoplexy, concussion of the brain, or typhoid fever. It is, however, more commonly due to obstruction anterior to the bladder, as in stricture of the urethra or enlargement of the prostate. The distended bladder can be felt as a rounded swelling above the pubes, and perhaps reaching to the level of the navel. Percussion over it gives a dull note. When the bladder is distended, it is necessary to evacuate it as soon as possible. If there is no obstruction to the flow of urine, the retention being due to atony or paralysis, a soft catheter is passed and the water drawn off. But when there is an obstruction which cannot be overcome, aspiration has to be resorted to, the needle of the aspirator being pushed through the abdominal wall into the bladder. The point of puncture in the abdominal wall is in the middle line a few inches above the symphysis pubis. The bladder may be emptied in this way very many times in the same person with only good result.

_Diseases of Prostate Gland._

The prostate gland may become acutely inflamed as the result of the backward extension of gonorrhoeal inflammation of the urethra; it may also be attacked by the germs of ordinary suppuration as well as by the bacilli of tuberculosis. A sudden enlargement of a large gland lying against the outlets of the bladder and the bowel renders micturition difficult, painful or impossible, and interferes with defaecation. Pressure of the seat of the chair upon the perineum also causes distress, so the man sits sideways and on the edge of the seat. If abscess forms, it should be incised from the perineum; if allowed to run its course it may burst into the bladder, the urethra or the rectum, and set up serious complication. The treatment of prostatitis (inflammation of the prostate) consists in rest in bed, sitz-baths and fomentations. If retention of urine takes place a soft catheter must be passed. In the early stage of an acute attack a dozen leeches upon the perineum may do good. The bowels must be kept freely open, and from time to time, as the pain demands, a morphia suppository may be introduced into the bowel.

_Chronic prostatitis_ is a legacy from a recent or long-past attack of gonorrhoea. The enlargement gives rise to a feeling of weight and fulness in the perineum, irritability of the bladder, and a gleety urethral discharge. Manual examination reveals the presence of a large, hard mass in front of the bladder, and in the mass there can often be felt softish or tender areas which seem to threaten abscess. On urine being passed into a glass, a cloudiness is seen, and material like pieces of vermicelli or broken threads may be noticed. These are the castings from the long tubular glands, and are characteristic of chronic inflammation of the prostate. The occasional passage of a large metal bougie, the use of weak lotions of nitrate of silver, the administration of quinine and iron, and the application of blisters to the perineum, may be tried as circumstances direct. The patient should lead a quiet life, free from sexual excitement. Horse-exercise, cycle-riding, rough games and alcohol should be avoided.

_Enlargement of the prostate_ exists in a considerable proportion of men of about sixty years of age and onward. It consists of an uncontrolled growth of the normal muscular and glandular tissue of the prostate, interfering with, or absolutely stopping, the outflow of the urine. Gently pushing the bladder upwards and backwards, it increases the length of the urethra, so that in order to draw off retained urine the catheter must be longer than ordinary, but inasmuch as there is no actual narrowing of the passage it may be of full calibre. The beak should be well turned up so that it may ride in front of, and surmount, the median enlargement. Because of the thick, ring-like mass of new tissue around the outlet of the bladder, there is difficulty in micturition, and because the muscular bladder wall is now unable to contract upon all its contents a certain amount of urine is retained. As the enlarged prostate bulges up in the floor of the bladder, a pouch or hollow forms behind it, from which the muscular wall is unable to dislodge the stagnant urine. This keeps up constant irritation, and if by chance the germs of decomposition find their way thither, cystitis sets in and the patient's condition becomes serious, not only because of the risk to which his tired and irritated kidneys are submitted, but because of the possibility of a phosphatic stone being formed in the bladder. The seriousness of enlargement of the prostate does not depend upon the size of the growth so much as upon the inability of the patient to empty his bladder completely.

The surgeon forms his estimate of the size of the prostate by rectal examination. But sometimes a patient has retention of urine from enlarged prostate, when by this method of manual examination the amount of increase appears quite unimportant. The explanation is that the enlargement is chiefly confined to a small piece of the gland which protrudes like a tongue into the water-way. Robert McGill of Leeds was the first surgeon to remove by a supra-pubic operation this tongue-like process of new prostatic growth. Attempts had sometimes been made to get rid of it by instrumentation through the urethra, but they had not met with much success.

When the surgeon has made out the existence of an enlargement of the prostate, the next thing is to find to what extent this interferes with the bladder being emptied. To do this, he asks the patient to pass as much water as he is able, and then with due precautions introduces a soft catheter and measures the amount of urine which he thus draws off--half an ounce, an ounce, two ounces, however much it may be. It is this "residual urine" which causes the annoyance and the danger of enlarged prostate, and unless arrangements can be made for its regular withdrawal serious trouble is almost certain to ensue. The passing of a large catheter may have the effect of so opening up the water-way that, at any rate for a time, the irritability of the bladder may cease, in which case the patient may be instructed in the art of passing a catheter for himself. Or the surgeon may find that in addition to the regular passing of a large catheter an occasional washing-out of the bladder with hot boracic lotion is all that is needed in the way of active treatment. At the same time, however, the patient is placed upon a plain and wholesome diet with little or no alcohol, and he is instructed to lead in every respect a regular and quiet life. To many men with enlarged prostate the passing of an instrument night and morning is no great hardship, while to others the idea of leading what is called a "catheter life" appears intolerable, or, having for a time been patiently carried out, is found not only severely trying but greatly disappointing.

In some people the very first passing of a catheter sets up a local and constitutional disturbance, the bladder being rendered irritable and intolerant, the temperature going up, and shiverings and perspirations manifesting themselves. This condition was formerly called "catheter fever," and was looked upon as something mysterious and peculiar. It is now generally understood to be the result of septic inoculation of the interior of the bladder.

Lastly, in other persons the passing of the catheter is attended with so much difficulty, distress or bleeding, that something more helpful and effectual is urgently called for.

_Operative Treatment._--It has long been known that large tumours of the uterus sometimes dwindle if the ovaries are removed by operation, and Professor William White of Philadelphia thought that prostatic growths might be similarly influenced by the removal of the testicles. Beyond question considerable improvement has followed this operation in cases of enlargement of the prostate, especially where the enlargement seemed to be general, soft and vascular. A similar though perhaps a slower effect is produced when the duct of the testis, the vas deferens, is divided on each side of the body. If there is no great urgency about the case this treatment may well be tried, the bladder being all the while duly emptied by catheter and washed by irrigation. But if the case is urgent, there being difficulty or bleeding with the passing of the catheter, the bladder being excessively irritable and the urine foul, a more radical measure is needed. The best operation is that upon the lines laid down by Robert McGill, who opened the bladder through the anterior abdominal wall and removed that part of the prostate gland which was blocking the water-way. McGill's operation was improved upon by Eugene Fuller of New York, who, in 1895, published a full account of his procedure.[1] Having opened the bladder from the front (as in supra-pubic lithotomy), he introduced his left index finger into the rectum and thrust the prostate gland towards the right index finger, which was then in the bladder. With the nail of that finger, or with the end of a pair of scissors, he made a rent in the mucous membrane of the bladder and the capsule of the gland, and then shelled out the mass of new tissue which had caused the prostatic enlargement. This operation is called "prostatectomy," which means the removal of the prostate gland. The prostate gland, however, is not removed, but only a muscular and glandular mass (adenoma), which, growing within the prostatic capsule, encircles the urethra and squeezes the original gland tissue out of existence. Following on the lines of McGill and Fuller, P.J. Freyer has done excellent work in England towards placing this operation upon a sound basis.

Subsequently to the operation the bladder enjoys complete and needful rest, and the kidneys, which previously were in a condition of perpetual disturbance, improve in working power. The wound in the bladder and in the abdominal wall gradually closes; the function of the bladder returns, and the patient is soon able to go back to his usual occupation in greatly improved health and vigour. The operation is, necessarily, a serious one, and the age of the patient, the condition of his bladder, of his kidneys, and of his blood-vessels, require to be taken into consideration; still, the operation gives an excellent account of itself in statistics, and if a practical surgeon advises a patient to accept its risks his counsel may well be followed.

_Malignant disease of the prostate_ is distinguished from senile glandular enlargement by the rapidity of its growth, by the freeness of the bleeding which is associated with the introduction of a catheter, and by the marked wasting which the individual undergoes. Unfortunately, by the time that the cancerous nature of the disease is definitely recognized, the prospect of relief being afforded by operation is small. (E. O.*)

FOOTNOTE:

[1] _Diseases of the Genito-urinary System_, by Eugene Fuller, M.D. (London and New York, 1900).

BLADDER-WORT, the name given to a submerged water plant, _Utricularia vulgaris_, with finely divided leaves upon which are borne small bladders provided with trap-door entrances which open only inwards. Small crustaceans and other aquatic animals push their way into the bladders and are unable to escape. The products of the decay of the organisms thus captured are absorbed into the plant by star-shaped hairs which line the interior of the bladder. In this way the plant is supplied with nitrogenous food from the animal kingdom. Bladder-wort bears small, yellow, two-lipped flowers on a stem which rises above the surface of the water. It is found in pools and ditches in the British Isles, and is widely distributed in the north temperate zone. The genus contains about two hundred species in tropical and temperate regions.

[Illustration: A, Bladder of _Utricularia neglecta_ (after Darwin), enlarged. B, stellate hairs from interior of bladder of _U. vulgaris_.]

BLADES, WILLIAM (1824-1890), English printer and bibliographer, was born at Clapham, London, on the 5th of December 1824. In 1840 he was apprenticed to his father's printing business in London, being subsequently taken into partnership. The firm was afterwards known as Blades, East & Blades. His interest in printing led him to make a study of the volumes produced by Caxton's press, and of the early history of printing in England. His _Life and Typography of William Caxton, England's First Printer_, was published in 1861-1863, and the conclusions which he set forth were arrived at by a careful examination of types in the early books, each class of type being traced from its first use to the time when, spoilt by wear, it passed out of Caxton's hands. Some 450 volumes from the Caxton Press were thus carefully compared and classified in chronological order. In 1877 Blades took an

## active part in organizing the Caxton celebration, and strongly supported

the foundation of the Library Association. He was a keen collector of old books, prints and medals. His publications relate chiefly to the early history of printing, the _Enemies of Books_, his most popular work, being produced in 1881. He died at Sutton in Surrey on the 27th of April 1890.

BLAENAVON, or BLAENAFON, an urban district in the northern parliamentary division of Monmouthshire, England, 15 m. N. by W. of Newport, on the Great Western, London & North Western and Rhymney railways. Pop. (1901) 10,869. It lies in the uppermost part of the Afon Lwyd valley, at an elevation exceeding 1000 ft., in a wild and mountainous district, on the eastern edge of the great coal and iron mining region of Glamorganshire and Monmouthshire. There are very extensive iron and steel works, with blast furnaces and rolling mills in the district, which employ the large industrial population.

BLAGOVYESHCHENSK, a town of East Siberia, chief town of the Amur government, on the left bank of the Amur, near its confluence with the Zeya in 50 deg. 15' N. lat. and 127 deg. 38' E. long., 610 m. by river above Khabarovsk. Founded in 1856, the town had, in 1900, 37,368 inhabitants, and is the seat of the bishop of Amur and Kamchatka. There are steam flour-mills and ironworks. It is a centre for tea exported to Russia, cattle brought from Transbaikalia and Mongolia for the Amur, and for grain.