some dull aching over the pubes; together with a general febrile state of the system, often very slight, but corresponding for the most part with the degree of local inflammation. The urine itself is cloudy, and deposits some light mucus on standing, but is not otherwise apparently altered. Under the microscope abundance of epithelium is visible, as well as some pus-cells, and if the affection is severe, a few blood-corpuscles are also present. It may be remarked here that the presence of a few pus-cells in the urine, a fact to which so many practitioners attribute considerable importance, by no means necessarily deserves to be so regarded. The very slightest attack either of this or of the preceding form of cystitis is certain to be attended by the formation of some quantity, however small, of fully-developed pus-cells. Very rarely a false membrane may be produced on the surface of the mucous membrane of the bladder, and may be thrown off almost entire, leading to the belief that the inner coat has itself been exfoliated. In women this membrane has been voided per urethram in a condition for examination; in men this cannot occur, because the urethra is too small to admit of it. Now and then examples of the former have been shown at the Pathological Society of London; and one of the latter may be seen, discovered by operation, in the museum of the Royal College of Surgeons of London. TREATMENT. In the first form of cystitis, the removal of the exciting cause, if possible, is the chief indication. The treatment of the second form should consist of very hot bidets or hip-baths, the former being probably preferable as capable of being used at higher temperatures than the latter; together with large doses of the tincture of henbane, say a drachm, with 10 or 15 drops of liquor opii every two hours while pain is severe; 20 minims of liquor potassæ may be given either simultanesly or alternately, in water or in any bland diluent. The treatment of a well-marked case of the third class consists in absolute rest in the recumtent posture, mild diet, abstinence from all alcoholic stimuli, gentle laxative action of the wels, and the administration of small doses of alkali. The writer prefers liquor potassæ to all others, frequently repeated; and this may be Combined with henbane, or, if micturition is very frequent and painful, with opium or morphia, cr with chlorodyne in small doses. Hot hip-baths cr bidets, followed by hot linseed-meal poultices or fomentations, give great relief. The patient may drink freely of decoction of triticum repens, inseed tea, barley water, or similar demulcents. Elief rapidly follows, but care is requisite to avoid relapse, which easily occurs if exercise be taken too soon, if injections for the gonorvea be resumed too readily, or if alcoholic timulants are freely taken. 2. Chronic Inflammation-Chronic Cystitis.-Chronic inflammation of the bladder is parated from the acute form by very distinct eharacters. It is mostly the result of retained urine from stricture or enlarged prostate; but it may arise from the presence of calculi, or of growths in the bladder; from over-distension, or atony of its coats; from paralysis after injury or diseas, affecting a nervous centre; from disease of neighbouring organs; and sometimes from altered urine: it is also met with in certain affections of the kidney. Sometimes this condition is marked by the presence of a large quantity of viscous mucus, often called 'catarrh'; but more commonly this symptom is absent, and the urine contains merely ordinary mucus or muco-pus, rendering the secretion more or less cloudy and opaque. Perhaps there are some cases in which the inflammation is mainly due to the presence of gout. SYMPTOMS.-The symptoms of chronic cystitis are increased frequency of micturition and pain, but the latter is by no means necessarily present. The urine is always cloudy, and contains some pus-cells. There is often, but not always, some suprapubic uneasiness. The general health does not suffer unless the affection is prolonged or severe. If important causes, as the presence of stricture, calculus, &c., occasion the chronic cystitis, their specific symptoms will predominate. It is not common to find chronic cystitis as an idiopathic disease, although undoubtedly it occasionally is so; so that the writer has always regarded it as a useful maxim, When chronic cystitis is declared to be idiopathic, we may be sure that we have only not yet discovered the real cause.' As a general rule we may be sure that there is inability to empty the bladder, or calculus, stricture, or organic disease of some kind in some part of the urinary tract, when the group of symptoms are present which we denote by the term chronic cystitis.' Respecting the wellknown glairy mucus, which is deposited so abundantly from the urine in some cases, in elderly people almost invariably, it should be said that it appears only in those whose urine is abnormally retained, through atony of the vesical walls, or in consequence of enlarged prostate, or as the result of sacculation of the blad der, and that medicine has little or no effect upon it. TREATMENT.-The regular and habitual use of the catheter, and perhaps also injections into the bladder, form the essential mechanical treatment of chronic cystitis in the cases just mentioned. In the few cases in which chronic cystitis is present, and no organic cause, such as those named above, can be discovered-and also as adjuncts to mechanical treatment when these causes do exist-certain medicinal agents are undoubtedly useful: these are buchu, triticum repens, uva ursi, alchemilla arvensis, pareira brava, and the alkalis potash and soda. Buchu is more useful in subacute and recent chronic cystitis than in cases already of long duration. The patient should take not less than ten ounces of the infusion daily. After this, in similar cases, the decoction of triticum repens, made by boiling two to four ounces of the prepared underground stem in a pint or a pint and a half of water, of which six ounces should be taken three or four times in the twenty-four hours, is highly useful. For more chronic cases, where the urine is alkaline and deposits much mucus, and perhaps the triple phosphates also, alchemilla, uva ursi, and pareira brava may be very valuable. The alchemilla is administered in infusion, one ounce of the herb in one pint of boiling water, of which the dose is four to six ounces three times daily; the others according to the directions of the pharmacopoeia. These may be taken alone or combined with potash, which in moderate quantities diminishes the natural acidity of the urine before it enters the bladder; the mucous membrane of which, although accustomed to that condition in health, is perhaps sometimes, when inflamed, irritated by urine of even the ordinary acidity. Whether this be so or not, there is no doubt that alkalis do frequently tranquillise an irritable bladder. They are often given in the form of Vichy water, Vals water, or that of Evian, all strong solutions of soda; but on many grounds the salts of potash are preferable. On the other hand, the mineral acids have been largely administered in cases where the urine is alkaline; although there is no reason to believe that the acid has any direct action through the kidneys, or that it is eliminated by those organs. Alkalinity of the urine in chronic cystitis is almost always due to inability of the bladder to empty itself, and the remedy wanted is not medicine but a catheter, at all events to ascertain whether this be the cause or not. A very small quantity of urine retained in the bladder, say one or two ounces, after every act of micturition, suffices in some cases to maintain an alkaline and otherwise unhealthy state of the secretion: while it is equally true that some patients may habitually, and during long periods of time do fail to empty the bladder, always leaving behind from half a pint to a pint, without losing the acidity of the urine. Of course other signs, and notably great frequency of micturition, are present when such is the case. 3. Neuralgia. It is impossible to deny that the bladder may be, like other parts of the body, subject to symptoms which are described as neuralgia, although the occurrence is an extremely rare one. All the writer can say is, that he has occasionally met with cases in which he has not been able to account, by the existence of any lesion, for pain and frequency in micturition, or for difficulty in performing that act, and where these symptoms have been more or less periodic in their appearance. In such instances he has given quinine, and has occasionally found great relief to follow a few doses; more frequently this has not been the case. rare. But now and then the value of the drug has been so marked as to corroborate a belief in the existence of vesical neuralgia. It must be repeated, however, that examples of such phenomena are extremely The writer has also employed arsenic on the same ground. It is invariably necessary to investigate the general health, as well as the habits and diet of the patient. This, perhaps, may be the place for stating that in all chronic and slight deviations from natural and healthy function in the urinary organs, it is essentially necessary to inquire into the state of the digestive organs, to correct by diet and by medicine when necessary any imperfect action on their part, if possible. Constipation alone, when habitual, may produce considerable irritability of the bladder, so also may the unnecessary use of purgatives. A gentle, easy, and daily action of the bowels, a healthy condition of the primary digestion, the absence of flatulence and distension after food, should be ensured as far as possible in all patients complaining of frequent, difficult, or uneasy micturition; and many such may be completely cured of so-called urinary affections by strict attention to these matters. The writer's strong convictions relative to this fact, grounded on innumerable experiences of its value as an aid in practice, led him nearly twenty years ago to ascertain the great value, for such patients, of Friedrichshall water, now so extensively used; and more than ever he insists on the use of a mild and laxative regimen and diet in their manage ment. 4. Where obstruction to the outflow of urine exists (stricture of the urethra, most forms of enlarged prostate, other tumours, &c.), the muscular walls of the bladder become the seat of Hypertrophy, which is a condition of compensation, therefore, and not of disease in or by itself. But such changes in the interlacing mus cular fibres existing, Sacculation readily occurs, by protrusion of the lining membrane between the bands so produced. On the other hand, most commonly when the prostate is hypertrophied, the bladder becomes gradually distended, its coats become expanded, thinned and weakened, and a certain degree of Atrophy takes place. The power of the organ to expel urine is lost or diminished; and micturition being a function of simply mechanical nature, the circumstances of the case demand only a mechanical remedy, viz. the catheter. No medicine can restore power and exercise of function under these circumstances. But atrophy and loss of power may occur from complete or partial loss of nervous influence to the bladder, as in those who are the subjects of paralytic states commencing in the spinal cord or brain. When the paralytic state follows accident causing injury to a nervous centre, the nature of the case is obvious enough. But sometimes the onset and progress of chronic disease in these organs are very slow and insidious; the urinary troubles, as manifested by slowness or difficulty in passing urine, or by urine clouded through inability of the bladder to empty itself, may be the earliest signs of the nervous lesion. On the other hand, impaired gait, and other evidences of central mischief, may be and mostly are earlier phenomena, the derangement in the_urinary function appearing at a later stage. For such patients, the habitual use of the catheter is often necessary [always of course when unable to empty the bladder by the natural efforts]; while such constitutional treatment as is indicated by the cerebral or cerebro-spinal lesion present will comprehend that which the bladder demands. It is therefore unnecessary to allude further to that subject in this article. The same remark also applies to those few examples of Tubercular disease of the urinary organs, which is always a local expression of a general constitutional state sufficiently considered under its proper head in this work. All other treatment of this malady is local and surgical. 5. Relative to Tumours, the varieties of which have already been enumerated, no medical treatment other than that of chronic cystitis is to be thought of. With almost all affections of the bladder, simple or malignant, ulcerative or associated with fistula, cystitis to some extent and in some form co-exists. It is this which gives rise to the presence of an undue quantity of mucus in the crine; it is often the source of pus, sometimes of blood in small quantity. Thus in all the abovementioned diseases, some degree of cystitis appears sooner or later. HENRY THOMPSON. BLADDER-WORMS.-Entozoa having the character of cysts or vesicles, and being at the same time more or less transparent. This general term embraces a variety of parasitic forms, such as Echinococci, Canuri, and Cystierci, all of which are the larvæ of different species of tapeworm. Practically, it is important to know the origin of every kind of human Bladder-worm, since the adoption of appropriate hygienic measures may prevent infection by each of the various species. See ECHINOCOCCUS, CYSTICERCUS, HYDATIDS, MEASLE, TENIA, and TAFEWORM. T. S. COBBOLD. BLAIN.-A blister, as in the case of chilbain. According to Mason Good, blains are orbicular elevations of the cuticle, containing & watery fluid.' BLEB.-A large vesicle or bulla, containing for the most part a serous fluid, as in pemphigus, erysipelas, or burns and scalds. See BLISTER. BLENORRHOEA, BLENORRHAGIA (BAérva, phlegm, and péw, I flow; Bλévva, phlegm, and hyvu, I burst out). These terms are most correctly used to express excessive flow of mucus from any mucous surface. By means of an affix, the locality or nature of the discharge is expressed: e.g., blenorrhea oculi, nasalis, urethralis. More commonly, however, and less accurately, tenorrhoea is employed as synonymous with gonorrhea in the male or female. BLEPHARITIS (Bλèpapor, an eyelid). In fammation of the eyelids. See EYE and its Appendages, Diseases of. BLEPHAROSPASM (Bλépapov, an eye21, and ordoua, a spasm). Spasmodic movement or contraction of the eyelids. See EYE and its Appendages, Diseases of. BLINDNESS.-Loss of sight. See AMAUSIS, and VISION, Disorders of. BLISTER. SYNON.: Bleb; Bulla; Fr. Bulle; Ger. Blase. DEFINITION.-A vesicle of the skin, caused by the separation of the horny cuticle from the rete Ecosum by the transudation of serous lymph Beneath the former. ETOLOGY.-Blisters may be idiopathic, as in pemphigus; or symptomatic, as in erysipelas. They are met with under the influence of any se which depresses the vitality of the integument, as in some forms of prurigo, in chilblain, and in carbuncle; in scalds and burns; and as an ert of powerful irritants, such as cantharides or the aniline salts. DESCRIPTION.-A blister ranges in size from that of a pea to a turkey's egg; it is more or less eonvex according to the amount of exudation; sad conforms in colour with that of its contents, being sometimes yellow or amber-coloured and transparent, like serum, sometimes opalescent | from the presence of pus, and sometimes red or purple from admixture with blood. The fluid of a blister, generally limpid and free, is sometimes held in the meshes of a delicate network, result. ing from the stretching of the connecting cells of the rete mucosum and horny epidermis. This is peculiarly the case in blisters developed under the influence of acute inflammation, and especially in Dermatitis anilina. Blisters may be dispersed, or aggregated, or even single, as in Pemphigus or Pompholyx solitarius. TREATMENT.-Blisters are essentially asthenic in their nature, and call for corroborant therapeutical treatment. Locally they should be punctured so as to admit of the gradual escape of their contents, and then dusted over with some absorbent powder, such as oxide of zinc, fuller's earth, or cinchona. ERASMUS WILSON. BLISTERING.-A therapeutic measure which consists in the artificial production of blisters on the skin. See COUNTER-IRRITATION. - BLOOD, Abstraction of.-SYNON.: Bleeding; Blood-letting. Fr. La Saignée: Ger. Der Aderlass. DEFINITION. The withdrawal of blood from the body, either (a) from the general circulation, by arteriotomy or phlebotomy; or (b) locally, by leeches, scarifications, or wetcupping. It is to the first two of these methods of abstracting blood that the term 'bleeding,' or blood-letting,' has by common usage been restricted. The topical abstraction of blood by means of leeches, scarifications, and cupping, though often valuable, is of secondary importance. The present article will, therefore, chiefly be devoted to general bleeding. were General Bleeding.-This art, practised for centuries more or less universally, has of late years in this country fallen into disfavour. Much discussion has been raised as to the grounds for so great a difference. It has been attributed— change; (2) to mere fashion or caprice; (3) to a (1) to the type of disease having undergone a ing us that its processes were of a lowering or better knowledge of the nature of disease, teachdepressing character, which were to be overcome, not by the abstraction of blood, but rather by the use of stimulants and support. It is highly probable that several causes have contributed to the undoubted change which has taken place. The year 1830 and subsequent years marked by the epidemic visitation of cholera and of influenza. These diseases were characterised by extreme depression. If antiphlogistic measures were adopted, they proved failures, and taught the physician that blood-letting was not the universal panacea it was supposed to be. By degrees it ceased to be practised as it used to be. A new generation which knew not the past has sprung up; and, as in all reactionary movements, the practice has become at length as limited as it formerly was universal. It is almost certain that in either extreme there is an evil, and that we may have recourse in certain cases to abstraction of blood with some degree of that success which formerly led to its extensive use, if not its abuse. It will be well to consider the subject at some little length, and under the following heads: 1. The effect of moderate losses of blood on the healthy economy. 2. The value of bleeding as a remedy in disease, together with the indications for its employment in various affections. 3. The method of performing the operations of opening an artery-arteriotomy; and opening a vein-phlebotomy. 1. EFFECTS.-We have first, then, to consider the effect of moderate losses of blood upon the healthy economy. Upon this point we have abundant evidence, for the custom of regularly bleeding healthy people had reached such a point during the earlier half of this century that in country districts it became a practice for adults to be bled as regularly as they went to market. No better testimony regarding the effects of this practice could be adduced than that of Sir James Paget, who, when referring to these customary venesections, says: I can regard those as a series of venesections fairly performed for the determination of what is the influence of the removal of blood up to the point of syncope upon a comparatively healthy person. I think I can say surely that not one of these persons suffered harm.' To this might be added other and abundant testimony to the harmlessness of venesection on the healthy economy. 2. INDICATIONS AND USES.-Concluding, then, that the abstraction of a limited quantity of blood has no deleterious effect upon the healthy organism, we will next set forth the general indications for the use of bleeding in disease, and briefly refer to the various affections in which it may most suitably be employed. Broadly stated it may be said that bleeding is indicated when there is evidence of marked over-distension either of the arterial or of the venous system. In either case the result will be cardiac distension-in the former case of the left, and in the latter of the right chambers of the heart. In such conditions general bleeding restores the lost equilibrium of the vascular system, and relieves the heart and the other parts concerned in the circulation of the blood. : cases of uræmic asthma, when the arterial system is turgid almost to bursting, while the veins are comparatively empty. Hardness' of the pulse is usually said to be an indication for bleeding, and in certain associations it is so; but it is necessary to discriminate carefully between the 'hardness' due to 'tension' of the sound artery arising from (a) excessive contraction (the small, hard, wiry pulse), and (b) overfulness (the full, bounding pulse) on the one hand; and that due to arterial degeneration with more or less hard deposit in the walls of the vessels, on the other. In doubtful cases inquiry should be made into the state of the brachial artery at the bend of the elbow. This can readily be done by flexing the limb, when, if calcareous degeneration have taken place, the vessel will be thrown into serpentine folds, visible, except in fat people, to the eye, and cord-like and rigid to the touch. The temporal artery is a less safe guide, but neither it nor an arcus senilis should be overlooked in this connexion. A visible and tortuous pulse in a young person may indicate aortic regurgitant disease: the age of the patient must therefore be taken into consideration. Dilatation of the arterioles would permit of the rapid passage of arterial blood into the veins: under such circumstances, therefore, we should expect the blood issuing from a cut vein to present a more florid appearance than under ordinary conditions. Bleeding here should be undertaken with considerable circumspection, and not be pushed very far, for collapse out of proportion to the amount of blood abstracted might ensue. On the other hand, when there is spasm of the arterioles, and the abstraction of blood is deemed advisable, it would be well to resort to arteriotomy rather than venesection. The best guide here would be the sphygmograph, but, as few persons are yet accustomed to use it, the full, hard, bounding pulse must be relied on when found in association with corroborative symptoms. It Whatever leads to over-engorgement of either side of the heart may render bleeding necessary. If the left side of the heart be over-full, arteriotomy is indicated; if the right, venesection. The arterial system may be in a state of aug- The object of the withdrawal of blood from mented tension from two causes: (1) contrac- the general circulation is the direct relief of tion of the arteries (the smaller vessels) them- the overburdened heart. Whether the right or selves with a diminished amount of blood in the left chambers be taxed the immediate effect is arterial system; and (2) engorgement or dis- the same; they are over-distended, and cannot tension of the arteries from spasm of the arte- get a grip upon their swollen currents. rioles both may be regarded as vaso-constrictive is with the embarrassed heart as with other neuroses. In the first case there may be engorge-hollow muscular organs-the bladder and uterus. ment of the venous system and embarrassment of the right heart, calling for abstraction of blood by venesection; or visceral fluxion, the skin being pale: and in the second, relative emptiness of the veins with overfulness of the larger arteries, calling for blood-letting by arteriotomy. In the former condition there would be, in bed-side language, a small hard or wiry pulse, and in the latter a full and hard or bounding pulse. In the former the surface of the body may present one of the two following conditions: either the skin is injected and, perhaps, dusky, and this appears to be the case ordinarily; or it is pale and cool, the blood having receded inwards, chiefly to the abdominal viscera. The second condition obtains and is well seen in Over-distension paralyses them by removing the On this subject we may refer to the eminently practical remarks of Sir Thomas Watson, who says: 'I hold it, then, to be certain, that for some special morbid conditions, which inflammation may or may not accompany, general blood-letting, and especially venesection, is a potent and life Always it is necessary to consider the age, the sex, the general temperament and condition of the sick person, when we are turning over in our minds the expediency of abstracting blood. The very young, the old, the feeble, the cachectic, do not bear well the loss of much blood. This consideration is not to deter you from bleeding such persons topically when they are attacked by dangerous inflammation, but it especially enforces, in regard to them, the golden rule that no more blood should be abstracted than seems absolutely requisite to control the disease.' The following are some of the affections under which blood-letting would seem to be more or less indicated: Pneumonia.-Blood-letting in pneumonia, as in many other inflammations, is most useful in the early stages. It is indicated in healthy patients suffering from uncomplicated acute sthenic pneumonia, if they happen to be seen early enough. It relieves pain, abates fever, and if it does not arrest the disease, it certainly appears to lessen its duration. It may also be alled for when there is severe pain and evidence of cardiac embarrassment. It did good, and will stil do good, in cases of pneumonia, attended by embarrassment of the circulation, and that in truth is the indication for bleeding in this disease. Apoplexy. The same may be said with reference to cerebral apoplexy. The old belief is the importance of letting blood' in cases of apoplexy was, if possible, stronger than in Cases of pneumonia. But here again more accurate clinical and more extended pathological knowledge have taught us to look upon 'apoplexy' very differently to our forefathers. Recognising the escape of blood from the bursting of a brittle atry as a common cause of apoplectic fits,' we the futility of venesection when the 'stroke' sft is due to a lesion of this kind. Nor will Feeding unstop an artery when it is plugged by at embolus, or carry nutriment to the region abereft of vital fluid. On the other hand have learnt to recognise the value of Weeding in another class of cases of so-called poplexy'-those which are unaccompanied y effusion of blood or lesion of the nervous e, but depend on rapidly occurring compression of the nervous centres from sudden equal increase in the volume of any portion of the cranial contents; or in certain eclamptic as from the circulation of blood poisoned by eliminated urinary excreta. In cases of this Ccription, when the right heart and venous 7em are engorged, phlebotomy acts well; the ertor will cease, the purple face resumes its taral hue, the clouded intelligence becomes ar, and the impending danger is for the time ed. This has not cured the patient, howTer, it has only obviated the tendency to Path: it has saved the patient's life, though tay ultimately die of the disease which te him. Where we meet with evidence of cerebral congestion accompanied by fulness of the veins, a dusky countenance, and a slow full pulse, bleeding may most usefully be resorted to. In a word, although bleeding will not remove the effused blood in cases of cerebral hæmorrhage, it may sometimes be usefully em-. ployed to prevent further escape, when the heart is acting too forcibly; but it is altogether forbidden when that organ is enfeebled. The pulse at both wrists should be attentively examined before bleeding, in cases of cerebral hæmorrhage, for as a rule it is larger on the paralysed than on the sound side. Eclampsia. Indiscriminate bleeding in eclamptic seizures would be a grievous error. It would not relieve, but rather would probably intensify, convulsions of reflex origin, as in certain cases of puerperal convulsions. On the other hand, cases of puerperal convulsions accompanied by great turgescence of the vascular system, whether venous, (as is commonly the case) or arterial, would be immensely benefited by the withdrawal of blood from the general current, either by venesection or by arteriotomy, according to the indication. This treatment may serve to stop the convulsions, and though that may be far from curing the disease, it may, nevertheless, be of the utmost value, for in the first place the fits themselves may kill by their violence or frequent repetition; whilst, secondly, time may be gained for the employment of other measures calculated to relieve the oppressed system, as, for example, purging by hydragogue cathartics, vapour baths, cupping the loins, &c. This gain may be immense; for bleeding may avert impending dissolution. Moreover, permanent good may ensue, inasmuch as bleeding reduces temperature, and in the eclampsia of pregnancy the temperature is usually high. In this it contrasts with pure uræmic convulsions, in which there is lowering of temperature. Venous Engorgement.-Engorgement of the venous system arising from chronic disease, e.g. pulmonary emphysema or heart-disease, does not call for bleeding, unless the condition be acutely intensified by some intercurrent mischief, such as acute bronchitis; for, as the derangement is slowly produced, the organs and structures învolved learn to accommodate themselves more or less to the altered conditions. It is only when vascular engorgement suddenly occurs in apparently healthy subjects, or, as stated above, there is acute intensification of a chronic condition, that bleeding is required. Thus, in cases where mediastinal tumours impede the return of blood from the head and upper portion of the body, the condition is ordinarily of such comparatively slow production, that bleeding is seldom urgently called for; and, moreover, it would be of but small service, for the obstruction is irremediable The lividity of the face which accompanies all fits should not be confounded with the duskiness due to engorgement of the venous system generally. Uremia.-In pure uræmia bleeding is useful; the kidneys being especially in default. For venesection answers a double purpose, by not only relieving the engorged right heart and venous system, but removing from the body a certain amount of poisoned blood-blood that is charged with urinary excreta. Doubtless, it does |