HYPEREMIA 
OF THE 
VESICO-URETHRAL MEMBRANE 
BY 
W. H. BAKER, M. D. 
BOSTON 
ASSISTANT PROFESSOR IN GYNECOLOGY, HARVARD UNIVERSITY; 
SURGEON TO THE FREE HOSPITAL FOR WOMEN 
REPRINTED FROM VOLUME VII. 
<£5pnccological transaction# 
1883 HYPEREMIA OF THE VESICO-URETHRAL 
MEMBRANE. 
BY W. H. BAKER, M. D., 
Boston. 
The operation of cystotomy, in the treatment of chronic 
cystitis and vesical ulceration, has been well established, 
and the great benefits derived from this method of proced- 
ure in preventing stagnation and decomposition of urine 
in the diseased organ have been almost universally recog- 
nized. A resort to this operation, however, in the treat- 
ment of chronic localized urethritis, or of some other forms 
of intractable urethral disease, as practiced by Dr. Emmet 
and advised by Dr. Skene, has been less generally adopted, 
while in no case that I have seen reported has the forma- 
tion of a vesico-vaginal fistula been recommended in the 
peculiar state of vascularity of the neck of the bladder to 
which I would now call your attention. 
The state of hyperemia of the vesical neck is a usual ac- 
companiment of cystitis in either its acute or chronic form, 
but is less frequently present in an uncomplicated case of 
urethritis ; this condition of increased vascularity, however, 
limited to the vesico-urethral junction, unaccompanied by 
disease of either the bladder or urethra, or even by any 
ulceration, fissure, or swelling of the mucous membrane at 
the point of increased blood supply, is in my experience 
a rare circumstance, but in such few instances a most im- 
portant one to recognize, and often demanding the most 
decided and active treatment for its relief. I would not 
have you understand that by this hyperemic state I refer to 
a hemorrhoidal condition of the part, for there is no such 
collection of veins present in the class of cases referred to ; 2 
neither should it be confounded with the general hyperemia 
found in the swollen, injected membrane of a localized 
urethritis of this point. The cases of vesico-urethral hy- 
peremia to which I would limit the considerations of this 
paper are those where, the mucous membrane of the blad- 
der and the urethra being perfectly healthy except at the 
point of their junction, there exist at this last-mentioned 
site a few tortuous blood-vessels running over an otherwise 
healthy membrane. These blood-vessels are evidently 
veins, as the most careful examination fails to discover in 
them the least pulsation. It seems almost incredible that 
so slight a deviation from a normal condition should create 
so great a disturbance to the nervous system and cause so 
much local pain as I have seen present, yet the result ob- 
tained in the cases which I shall introduce would seem to 
prove the importance of the lesion; and when we remember 
the suffering oftentimes endured by those in whom a slight 
fissure exists at this highly sensitive point, we shall be less 
likely to underrate the importance of the present subject. 
The predisposing causes would seem to be : First, a very 
thin and delicate mucous membrane ; as such are less tol- 
erant, even in certain variations within the limits of health. 
Second’ a highly developed nervous system ; for in such an 
individual we always see the possibilities of hyperemia the 
greatest, since here the stronger stimulus which is possible, 
conveyed through the influence of the vaso-dilator nerve 
fibres, tends at once to increase the amount of blood in the 
part to which these fibres are distributed, and in the case 
in point the hyperemia may be otherwise aggravated by the 
nearness of the blood-vessels to the seat of irritation. Third, 
a state of neurasthenia ; for here the nervous system, be- 
ing continually fatigued, fails to give the proper amount of 
tone to the vaso-contractor nerve fibres, and thus an excess 
of blood is supplied to the part, which, increasing as it does 
the irritability of the neck of the bladder, keeps up or even 
intensifies the neurasthenic condition. In this way it may 
not only be the cause, but likewise become an effect of, 
the hyperemia. Fourth, a continued habit of constipation 
HYPEREMIA OF THE VESICO-URETHRAL MEMBRANE. IV H. BAKER. 
3 
should be mentioned in this connection, as it interferes 
with the free venous return, and thus occasions blood stasis 
throughout all the pelvic viscera. 
Prominent among the exciting causes are acute diseases 
of the bladder or urethra; instrumentation of the urinary 
passages; prolonged retention of the urine; frequent 
spasms of the neck of the bladder, as are often present in 
some abnormal condition of the urine, or dependent on 
nervous excitation ; violence or increased congestion, re- 
sulting from the newly married state; and onanism. Nearly 
all of these, acting either by direct injury or by determin- 
ing an increased flow of blood to the part, may at once be- 
come the immediate cause of this affection. 
The symptoms are more nearly like those present in cys- 
titis than in any other disease. There is the same frequent 
desire to urinate, although in a much more aggravated form 
than I have ever seen in that disease, the patient often be- 
ing obliged to pass urine from twenty to thirty times during 
the night, and quite as many times through the day, until 
she becomes completely worn out from want of rest, and 
resorts to opium in some form to obtain it. There is the 
same sensation of scalding in passing the urine that is 
present in an acute attack of cystitis. Unlike that disease, 
however, there is not the continued sense of weight and 
fullness in the pelvis; and slight jars of the body, as in 
riding or in taking a misstep, or even a person walking 
heavily across the room, is not complained of. In fact, the 
patient is usually able to be about the house, and would ven- 
ture out of doors were it not for the fear that within a few 
moments she must empty the bladder, and the knowledge 
of the great suffering to which she would be exposed if 
she should be where she could not find immediate relief. 
Another symptom sometimes present is the manner in 
which the urine is passed; for after a few drops have 
been expelled a spasm of the neck of the bladder occurs, 
and her suffering is almost intolerable until the remain- 
der of the urine passes, and the straining which she then 
exercises tends really to increase the hyperemia at the 4 
HYPEREMIA OF THE VESICO-URETHRAL MEMBRA HE. 
site of the disease. This spasm may be repeated two or 
three times before the whole of the urine is passed, while 
the great suffering of the patient, together with all the 
efforts which are likely to be made in hot applications, 
changes of position, and the like, so fatigue her that finally, 
when the act is accomplished, she is so exhausted and un- 
nerved that she may cry, or not unfrequently a hysterical 
convulsion may follow. These severer times are more apt 
to ensue if the patient has delayed passing the urine for a 
longer time than usual, on account of some person being 
present that she felt she could not leave from a delicacy of 
feeling, or if she was where she could not reach a suitable 
place to relieve herself. Experience of such times of in- 
creased suffering tends to keep the patient confined to her 
own home, if not to her room, and thus her general health 
is seriously impaired, while her nervous strength becomes 
literally a complete wreck. The urine itself shows no change 
other than that we should expect to see present in a patient 
who had become so hysterical: that is, at one time a greatly 
increased quantity of pale dilute urine, while at another 
time a small quantity of dark concentrated fluid ; no pus, no 
unnatural amount of mucus, no sugar or albumen, no excess 
of crystalline deposit, not strongly acid; in fact, the most 
careful examination of the urine, both chemical and micro- 
scopical, fails to reveal any change from a perfectly normal 
character. Sometimes, however, we find a patient with the 
above-described trouble laboring under the misconceived 
idea that because it causes her such pain to urinate she 
must drink very little, if any, of even the most bland fluids; 
but this only aggravates the symptoms by inducing a too 
concentrated urine, which in itself becomes irritating, and 
which, added to her other difficulties, increases her distress. 
Guided by these symptoms we might fall into error, and 
confound the case with one of chronic contraction of the 
bladder, and thus be led to institute a course of treatment, 
like gradual dilatation of that viscus by injections or by a 
prolonged retention of the urine, which would be not only 
non-beneficial but decidedly injurious. Nothing but the IV. H BAKER. 
5 
most carefully conducted physical examination will enable 
us to make sure the diagnosis, by which alone we can hope 
to treat the case at all satisfactorily. 
For the purpose of examination the patient should be 
first touched bimanually, which will reveal no real sensi- 
tiveness except at the seat of the disease; an apparent 
hyperesthesia, however, may be present, generally distrib- 
uted over the whole abdomen, and involving all the organs 
of the pelvis ; a little care in the manipulation, at the same 
time diverting the mind of the patient, will enable us to 
exclude this sign of disease and to narrow its limits to the 
neck of the bladder, the true seat of the difficulty. The 
result obtained by the passage of the probe or sound into 
the bladder will be very similar to that where fissure exists 
at the same site; no marked tenderness is found until 
the instrument touches the seat of the trouble, but then 
the most excruciating pain is generally created, occasion- 
ing a spasm of the part, which usually grasps the instru- 
ment so tightly that it becomes impossible to remove it 
without doing great injury to the mucous membrane and 
causing greatly increased suffering ; by waiting a few mo- 
ments the spasmodic action subsides, and the instrument 
may be carefully removed. For this reason I have ut- 
terly failed in making a satisfactory exploration with the 
endoscope, except the patient be fully etherized; but by 
its use, the anesthetic having been administered, the most 
perfect inspection can be made and exact diagnosis es- 
tablished. For properly conducting such an examination 
the patient should be on the table in the lithotomy posi- 
tion and fully etherized ; the room should be made abso- 
lutely free from all sunlight, and the gas jet or light from 
the student or ordinary kerosene lamp placed at the side of 
her hips, or in the same relative position that the oculist 
places it for observing the retina; a Skene’s endoscope is 
then lubricated and carefully passed through the urethra 
into the bladder, the rays of light being collected by an 
aural mirror upon the forehead and directed into the in- 
strument. In this way the hands are left free to manip- 6 
ulate it, and, an assistant on either side holding away the 
labia, the most minute exploration of the urethra and neck 
of the bladder can be made. The endoscope mentioned is 
by far the best one for this examination ; it is so simple in 
its construction and easily adjusted that any surgeon pos- 
sessing a reasonable amount of delicacy of manipulation 
can use it readily. Before I was familiar with this most 
valuable instrument I made use of the smaller sizes of Si- 
mon’s urethral plugs for dilating the urethra, and was able 
to make a very satisfactory exploration by their use ; the 
manipulation differing in that the urethral plug was first 
passed into the bladder, and, the inner plug being then re- 
moved, as the outer part or speculum was gradually with- 
drawn, the mucous membrane closing in over its end was 
subjected to the reflected light and thus carefully inspected. 
This was accompanied by considerable inconvenience, while 
viewing the vesical neck, by the flow of urine which would 
occasionally pass through the speculum, a difficulty that is 
.entirely obviated by using Skene’s instrument, which pos- 
sesses the great advantage also of observing each portion 
of the urethra and neck of the bladder as the endoscope is 
introduced, thus enabling the surgeon to see each part be- 
fore it has been disturbed by any other instrumentation, 
thereby determining its more exact appearance. 
After examining in this way a large number of cases 
where no complaint was made, and comparing them with 
the cases under consideration as well as with those where 
other diseases of the urethra and bladder were present, I 
have made, by the aid of Dr. H. P. Quincy, the following 
cuts as illustrative of the disease in question, and of the 
normal appearance of the neck of the bladder ; also, by 
way of comparison, two cuts showing a healthy and dis- 
eased state of the bladder itself, as distinguishable from 
this hyperemia of the vesico-urethral membrane. In illus- 
trations Nos. i and 2 the endoscope must be understood to 
be just opening the neck of the bladder, a small portion of 
bladder membrane falling against its end, while in Nos. 3 
and 4 the instrument is passed nearly into that viscus, thus 
HYPEREMIA OF THE VESICO-URETHRAL MEMBRANE. HEALTHY VESICO—URETHRAL 
MEMBRANE. 
Fig. I. 
HYPEREMIA OF THE VESICO- 
URETHRAL MEMBRANE. 
Fig. 2. 
Fig. 3. 
Fig. 4. 
HEALTHY BLADDER. 
Membrane seen through the dilated 
Urethra. 
CHRONIC CYSTITIS. 
Seen through the dilated Urethra IV. H. BAKER. 
7 
showing a much larger field of bladder membrane and but 
a small rim of urethral membrane. 
IUmust be evident to all that this disease cannot be diag- 
nosticated except by the most carefully conducted physical 
examination. 
Before entering upon the subject of the treatment of this 
affection I would not have it understood that I advise a re- 
sort to the proposed operative interference for every case 
of irritability of the neck of the bladder, even though this 
state of hyperemia be found present, for I have no doubt 
that very many cases in an acute form occur and are recov- 
ered from, either unaided or by the use of some mild med- 
ication. All must recognize the readiness with which 
hyperemia of one part of the body or another is produced 
and relieved in the neurasthenic patient. It is in the 
chronic form of this disease, when the inefficiency of such 
medication has been proved, and the want of success which 
has followed the milder methods of local treatment, that I 
would urge the importance of recognizing the difficulty 
under consideration, and the institution of the operation to 
be advised, for fear that so slight a deviation from a normal 
appearance should be overlooked, and thus the patient be 
allowed to suffer on indefinitely and unnecessarily. 
The treatment consists, first, in putting the part abso- 
lutely and at once at rest, and thus relieving the great dis- 
tress of the patient ; and, second, in using such means as 
shall hasten the disappearance of the hyperemia. If we try 
to change the order of these steps we shall prolong and in- 
tensify her suffering, for it is utterly impossible for her to 
begin to improve until she can be relieved of the tremen- 
dous nervous strain dependent upon the pain and wearing 
fatigue accompanying the frequent micturition. Rest, then, 
becomes a matter of the first consideration, and this is best 
given by the formation of a vesico-vaginal fistula. If the 
question arise whether this rest can be accomplished by the 
use of opium, and thus the second step taken without sub- 
jecting the patient to the inconvenience naturally resulting 
from the operation suggested, I would answer that in most 8 
[HYPEREMIA OF THE VESICO-URETHRAL MEMBRANE. 
of these chronic cases this drug has already been resorted 
to for the relief of the pain, and in all probability in such 
quantities as to be most decidedly objectionable on account 
of still farther undermining the nervous strength. And if 
this habit had not been formed, or even only a moderate 
amount of the drug taken, I should still object to its use on 
the grounds of its tending to constipate and to diminish 
the secretion of the urine, thus concentrating it, and also of 
the length of time which it would have to be continued and 
increased before any change for the better could at the 
most be hoped for. I am well aware of the relief which a 
patient thus afflicted may realize temporarily from the use 
of this drug, and of the courage and hope which are thus 
given to both physician and patient; but I am as well aware 
of the discouragement and sorrow which are sure to follow 
when its use is discontinued, or its amount diminished, as I 
am also aware of the impossibility of relieving this hyperemic 
state, when thoroughly established, in any other way than 
by first putting the neck of the bladder at rest. While the 
urethra is used each few moments for the passage of the 
urine, and its upper extremity subjected to the straining, 
spasms, and pain which accompany such use, any attempt 
to overcome the difficulty by topical applications can only 
tend to irritate and excite into such spasms all the more, 
and the disease as well as the suffering is increased thereby. 
If, on the other hand, we hope to spare the patient opera- 
tive interference by the adjustment of some form of self- 
retaining catheter, thus keeping the bladder always empty, 
we are, I believe, subjecting her to increased dangers ; 
for although the neck of the bladder may, after a time, 
become tolerant of the presence of the instrument, still it 
can but tend to increase the hyperemia at the seat of the 
disease, which is usually the part depended upon for the re- 
tention of the catheter; and were this not the case, the 
bladder in its emptied state tends to fall against that por- 
tion of the instrument which projects into it, and by this 
friction produce a cystitis. But it may be argued that 
if she remains quietly at rest in bed this irritation is W. H. BAKER. 
9 
either entirely absent or at least reduced to the minimum; 
to which I would reply that the system is already reduced 
to a low state by the long invalidism, both physically and 
mentally, and it is all important that she should be out of 
doors, walking and riding and surrounded by pleasant 
scenes and cheerful company, that the appetite may be im- 
proved, the proper tone and strength given to the muscles, 
and all the processes of the body go on more healthfully; 
for by these means alone shall we restore the body and 
mind to their normal state. The draining the bladder into 
the vagina then becomes at once the most sure and speedy 
method of putting the diseased part at rest. This is best 
done after the plan devised and practiced by Dr. T. A. 
Emmet, which consists in introducing a sound into the blad- 
der, and making the vesico-vaginal septum tense by press- 
ing its point against the membrane just within the neck 
of the bladder ; the patient being in the left semi-prone posi- 
tion, and the vagina exposed with the Sims’ speculum, the 
point of the sound is then cut down upon with bistoury or 
scissors until its point comes through into the vagina in 
the median line ; with a tenaculum the bladder membrane 
is then seized at the lower angle of the wound and held 
tightly forwards, while, with a pair of straight scissors, the 
division is carried upwards for about an inch and a half. 
Care must be taken that one blade of the scissors enters 
the bladder, and that both vaginal and bladder membranes 
are divided, for it otherwise will not infrequently happen 
that one blade will be inserted between these membranes 
and thus only the vaginal one be cut. The edges of the vagi- 
nal and bladder membranes are then to be united by suture 
all around the incision ; for this purpose I prefer to use cat- 
gut, sewing it over and over, as it does not require to be 
disturbed subsequently, and as the salts of the urine are 
less likely to be deposited on it. The patient is to be kept 
in bed for a few days until the edges have united. Nap- 
kins are to be used to take up the urine until she begins 
to move about, when some one of the various urinals can 
be adjusted for collecting it. The patient does not always 10 
HYPEREMIA OF THE VESICO-URETHRAL MEMBRANE. 
realize the full relief from this operation until she is able 
to move about, as it sometimes happens that while lying 
in bed either the swelling of the tissues around the fistula 
tends to close it, thus allowing a sufficient amount of urine 
to collect in the bladder, which, pressing against the hy- 
peremic neck, occasions the same pain as formerly com- 
plained of, or that the posterior vaginal wall is pressed so 
tightly against the fistula as to have the same effect in 
closing it. If this latter cause be present a slight change 
of position is sufficient to relieve the pressure and allow 
the urine to flow freely; this method of relief she soon 
finds out for herself, and generally makes use of it before 
there is time for its suggestion. After the edges of the 
fistula have healed she is to be taught to pass the fore- 
finger through it, which she is instructed to do once 
each day in order to keep it well open. This method of 
keeping the fistula patent is far preferable to any of the 
devices of studs or tubes, which serve for a point of deposit 
for the salts of the urine, and thus become a source of irri- 
tation. The fistula must be carefully watched until its edges 
are thoroughly healed, and if any phosphatic deposit appears 
it must be at once scraped away and an application made to 
the denuded surface of a solution of nitrate of silver. 
The first step having been taken, and the diseased part 
put at rest, let us consider what may be done still farther 
to facilitate the disappearance of the hyperemia. The 
proper use of hot water will accomplish the greatest amount 
of good, and to be most beneficial should be applied 
directly to the diseased spot for a length of time. This is 
best done by the patient lying on the bed-pan, with the 
hips raised a little higher than the shoulders, in order that 
as much as possible of the water may be retained in the 
vagina and bladder, as well as to prevent any straining 
effort, which is least likely in that position. A fountain 
syringe should be provided, which is less liable to carry air 
into the bladder, filled with water at a temperature of from 
1050 to 1 io°, and placed at a height that will require twenty 
minutes for it to empty itself, and fitted with a small straight IV. H. BAKER. 
nozzle of metal or hard rubber, which should be a quarter 
of an inch shorter than the urethra and made perfectly 
smooth on its surface. We thus have a means of applying 
heat to the neck of the bladder without disturbing the part; 
for the nozzle, introduced its whole length, is not able to 
reach the diseased spot, and the force of the water is suf- 
ficient to open the remaining quarter of an inch of the 
urethra, and finds an exit through the bladder and fistula 
into the vagina; all of this the patient may be taught to 
accomplish properly. After using the hot water in this 
way for two or three weeks, we can add to it a very little 
alum, tannin, or zinc, and thereby gain an additional effect 
from their astringent action; but if the solution is at all 
strong it will occasion a return of the pain. This treatment 
must be persisted in for several months, four or six at least, 
or until all evidence of the hyperemia has disappeared, as 
shown by examination with the endoscope ; or the tolerance 
of the neck of the bladder may be tested by discontinuing 
the opening of the fistula by the passage of the finger, when 
it will become so small within two or three weeks that a 
large part of the urine will be passed through the urethra, 
particularly at night or after lying down. When it is thus 
proved that the diseased part is restored to its normal state, 
we may consider the expediency of closing the fistula. The 
tendency will be to resort to this operation too quickly; for 
the inconvenience of the patient in being continually wet 
and of wearing urinals will cause her to urge it, and the 
surgeon, seeing the greatly improved condition of his pa- 
tient, will be likely to yield to her entreaties. Before clos- 
ing the fistula there are two things to be considered : first, 
the permanent establishment of the nervous strength, so 
that the operation will not prove too great a strain for it, 
and thus one of the causes of a relapse be instituted; and 
secondly, the full restoration of the physical strength, or, in 
other words, that the patient should be in a good state of 
health, in order that the union of the denuded surfaces of 
the fistula may be insured when the operation is performed. 
The latter of these considerations will probably be accom- 
11  HYPEREMIA OF THE VESICO-URETHRAL MEMBRANE. 
12 
plished long before the former, for we all know how long a 
time is required to recover nervous strength, and the still 
longer time necessary for its permanent establishment. 
If, after carefully weighing these considerations in our 
mind, we decide that it is proper to close the fistula, there 
are but two points that I would urge the importance of in 
its performance and in the subsequent care, namely, placing 
the sutures very thick, at least a third more than would or- 
dinarily be used, and doing away with the use of the cathe- 
ter afterwards. By these means the wound will be better 
able to bear the strain of the bladder expelling its contents, 
and there will not be the irritation of the catheter to tend 
to reproduce the disease. 
There are two points, however, that I have failed to speak 
of which are of great importance in securing comfort to 
the patient, thereby insuring nervous quietude during 
the time that the fistula is kept open : these are the collec- 
tion of the urine and the care of the skin. There is no 
style of urinal which can be applied to every case: in one 
Skene’s would work admirably ; in another the same in- 
strument would press against the tender neck of the blad- 
der and be not only intolerable but harmful. In another 
case the external soft rubber urinal would be most com- 
fortable and unirritating to the skin of the groins and 
inner portions of the thighs, usually its greatest objec- 
tions ; while in still another case neither of the above-men- 
tioned can be used, and the ingenuity of the surgeon may 
be taxed to the utmost in the proper adjustment of some 
form of urinal to make the condition of his patient more 
bearable. I am well aware that among the working class 
suffering from vesico-vaginal fistula there is comparatively 
little inconvenience from the use of napkins to catch the 
urine, but the wealthier classes will not be content with 
this means. In the latter class the nervous system is 
much more highly developed, and the effect of this is often 
seen when that system is debilitated by the greatly in- 
creased amount of urine which is secreted. In such a case 
I have repeatedly seen over a hundred large, thickly IV. H. BAKER. 
13 
folded napkins wet through and through in a single night, 
thus keeping a laundress busily engaged continuously in 
providing napkins for the patient. A urinal which I have 
devised and used with good results in some cases is com- 
posed of an ordinary Meigs ring 
pessary, with a funnel-shaped por- 
tion of pure rubber sheeting ce- 
mented to it, the upper part of 
the cone encircling the pessary, 
while to its lower end or apex is 
cemented a piece of ordinary rub- 
ber tubing; the upper end of 
this tubing should pass into the 
cone nearly to the top, and its 
sides perforated like a drainage 
tube, thus preventing its being oc- 
cluded by bending, and the lower 
end of the tube is to be attached 
to a rubber receptacle which is 
strapped to the leg. This cone 
should be longer behind than in front, in order to more 
nearly conform to the vagina. Figure 5 will serve to illus- 
trate this urinal. 
By some such device we can often make our patient 
comparatively comfortable, or at least reduce the nec- 
essary inconvenience to the minimum. The condition 
of the skin will need constant attention, particularly if 
napkins or the external soft rubber urinal are used. Fre- 
quent bathing and applying oxide of zinc ointment or vase- 
line to the exposed surfaces, with an occasional application 
of powdered tannin, zinc, and starch, will tend to toughen 
the skin. If the patient lives at a distance from the sur- 
geon it is very important that she learn just how to take 
care of herself in regard to these various details, before she 
is sent home, to wait several months before having the fis- 
tula closed. 
I wish now to present five cases, which are all of this 
class that have come under my observation, and although 
Fig. 5. 14 
HYPEREMIA OF THE VESICO-URETHRAL MEMBRANE. 
the last two are not yet complete, as the fistulae still exist, 
they may serve in some measure to illustrate the subject of 
this paper. 
Case I. — Miss C. P., aged fifty-eight years, entered the 
Woman’s Hospital in the State of New York in 1874, during 
my house-surgeonship there, in the service of Dr. J. Marion 
Sims. She had complained for eight years of frequent micturi- 
tion ; immediately preceding such act there occurred a spasm or 
cramp, beginning in the urethra and extending over the lower 
part of the abdomen. Until within a year previous to her admis- 
sion to the hospital voiding the urine would relieve her for a short 
period, but since that time the pain had continued somewhat after 
micturition. The physician who referred her to the hospital had 
considered it a case of malignant disease of the bladder. The 
uterus was found retroverted, and Dr. Emmet, who saw the case 
in consultation with Dr. Sims, thought possibly this accounted for 
the frequent micturition by the traction thus occasioned on the 
anterior vaginal wall and urethra. Neither confirmed the diag- 
nosis of malignant disease. The uterus being kept in position 
by a Hodge closed pessary, some relief was obtained; that is, she 
was obliged to get up less frequently at night, although the pain 
was unrelieved when she urinated. 
October 4, 1879. —She entered my service in the Free Hospi- 
tal for Women, suffering as much as ever from the pain formerly 
complained of, which had troubled her more or less since her dis- 
charge from the hospital in New York. 
October 16. — She was examined under ether with Skene’s en- 
doscope, and the diagnosis made of hyperemia of the vesico- 
urethral membrane ; the other parts of the urethra and bladder 
were perfectly healthy. She had continued to wear the Hodge 
pessary, as she found from its use relief to her backache. For 
the next two months applications of tannin and glycerine, iodo- 
form, impure carbolic acid, and a ten per cent, solution of nitrate 
of silver were in succession made to the diseased part, either ap- 
plied on a bit of cotton wound on the applicator, or in urethral 
suppositories, or by means of a fine spray. These local treat- 
ments were given at intervals of a week, but had not the slightest 
beneficial effect; on the contrary, the patient’s suffering seemed 
to be increased. 
Early in December, 1879, I made a vesico-vaginal fistula, after the manner already described, except, on account of the great 
laxity of the tissues, there was an unusual amount of oozing of 
blood, and the thermo-cautery was applied to the edges of the 
wound. There was a slight discharge of blood from the wound 
for four days, but the pain .was relieved from the first establish- 
ment of the fistula. Considerable difficulty was experienced in 
keeping up a free flow of urine, on account of the firm closure of 
the ostium vaginas and the laxity of the vaginal membrane, which 
often closed the fistula, or retained a large amount of urine in the 
vagina that caused some discomfort; but it was always quickly 
relieved by passing the finger into the vagina, and thus allowing 
the urine to escape. An attempt was made to overcome this dif- 
ficulty by adjusting a tube in the vagina, the outer end of which 
projected beyond the labia; but it became rapidly coated with 
phosphatic deposit, thus irritating the parts to such an extent that 
its use was discontinued, and the only additional treatment given 
was the hot-water douche through the urethra. 
By May 3, 1880, the endoscope showed the neck of the 
bladder so nearly well that no attempt was made to keep the fis- 
tula open, and the use of the hot water was given up. Within a 
month the fistula had so nearly closed that it was with difficulty 
that the point of a Simpson’s sound could be passed through it. 
At night, and after lying down during the day, nearly all of the 
urine was passed through the urethra without causing the patient 
discomfort. Examined with the endoscope the vesico-urethral 
membrane looked perfectly healthy, all appearance of the hyper- 
emia having disappeared. 
June 3, 1880, the fistula was closed, eleven silver sutures 
being used for the purpose. A week later, on removing the 
stitches, the operation was found to have been unsuccessful, and 
she was discharged June 22, to be readmitted in the fall. 
October 22, 1880, she having entered the hospital a few days 
previously, another attempt was made to close the fistula by the 
use of nine silver sutures, which resulted in a perfect union, and 
the urine being passed perfectly naturally she was discharged, 
cured, November 26, 1880. 
Case II. — Mrs. P. J., thirty-five years of age, had given birth 
to no children, but had had an abortion at the third month about 
a year after marriage. She had been under the care of Dr. Sims 
for anteversion of the uterus at intervals for three years, who had 
relieved her of the symptoms from which she then suffered by 
W. II. BAKER. 
15 16 
HYPEREMIA OF THE VESICO-URETHRAL MEMBRANE. 
the use of a modification of an Albert Smith’s pessary. After 
wearing this support for about two years she began to complain 
of some frequency in passing the urine, she having formerly been 
able to go all day without urinating. On consulting Dr. Sims 
she was told “ that she had worn the pessary too long a time,” 
and it was therefore removed. But the frequency in the micturi- 
tion steadily increased, and within a few months there was added 
to this symptom dysuria, and being obliged to wait some time be- 
fore she could accomplish the act after the desire to urinate was 
felt. Dr. Sims then found it necessary to dilate the urethra, 
which gave the patient complete relief for six weeks, when all the 
symptoms returned as severe as ever. Within a year previous to 
my seeing her, the urethra had been dilated three times by a 
most eminent surgeon of Boston, but without benefit; in fact, she 
thought herself a greater sufferer after the dilatations. 
March 20, 1879, I was asked to see her in consultation with 
Dr. S. G. Webber, of Boston, who had carried out most faithfully 
and successfully a course of treatment for the building up of her 
general nervous strength, which was in a most deplorable condi- 
tion ; the frequent and painful micturition still continuing he de- 
sired my counsel. She was then obliged to pass the urine each 
hour through the day, and from sixteen to twenty times at night, 
being awakened from a sound sleep by the strong desire to 
urinate. Finding that not only was she relieved of the pain by 
the use of morphine, but that the interval of voiding the urine 
was lengthened to two or three hours, she had made use of this 
drug, and Dr. Webber had had the greatest difficulty in its dis- 
continuance. A physical examination showed no sensitiveness, 
either bimanually or on the passage of the sound into the blad- 
der, and I was inclined to consider the case one of chronic con- 
traction of the bladder, particularly as careful inquiry revealed 
the fact that there was never more than a very small quantity 
of water passed at any one time, irrespective of the interval. I 
therefore advised gradual dilatation of the bladder, by injections 
of warm water, and the correction of the anteversion, which still 
existed, by the adjustment of a support. 
October 7, 1880, the patient came under my immediate care, and 
a careful revision of the history of her case showed that for about 
four months after the use of the warm water in the bladder, as 
well as for a very short time while having electricity applied to 
the neck of the bladder, in Paris, she was somewhat relieved W. H. BAKER. 
17 
from the pain and other inconveniences, but with the excep- 
tion of those periods she had steadily grown worse. It also re- 
vealed the fact that to her knowledge, with all the various sur- 
geons, both in this country and abroad, under whose care she 
had been, none had visually examined the neck of the bladder. 
This was accordingly done by the aid of Skene’s endoscope, 
and a very vascular state of that part found, although all the 
other portions of the urethra and bladder were healthy. For the 
next five weeks efforts were made to overcome the hyperemia 
by local applications given in the form of spray, in order to 
reduce to the minimum the amount of necessary irritation result- 
ing from the treatment; but all to no purpose, for she grew 
steadily worse. I then made a fistulous opening into the 
bladder, through the vagina, which gave relief as soon as the 
swelling dependent upon the operation had subsided. She was 
instructed in the use of the hot water through the urethra, but, 
as the fistula showed no tendency to close, it was thought unnec- 
essary to pass the finger through it. A very troublesome thing 
in the subsequent treatment of this case was the great irritability 
of the skin and the vaginal membrane, which made it extremely 
difficult to adjust any urinal, while most of the remedies which 
are usually relied upon to protect or toughen the skin only added 
to the irritation. Great suffering was induced by the urine flow- 
ing over the skin, which seemed to her like fire, in spite of 
every attempt to make it bland by medication, and by the press- 
ure against the neck of the bladder when any attempt was made 
to stop the flow of urine through the fistula and collect it in the 
bladder, in order temporarily to shield the skin. I can truly say 
that I have seldom seen a patient in so pitiable a condition. It 
was not, then, without strong misgivings of the success of the 
treatment, that I consented to close the fistula on the ist of 
June. This I should have been unwilling to do had I not felt 
that, as the hot weather approached, the irritability of the skin 
would be likely to increase. It was utterly impossible to keep 
the patient quiet after the operation, and on the 9th of June, 
when the sutures were removed, I was not surprised to find that 
a small opening still existed, though so small that it barely ad- 
mitted the finest probe. Within a month, however, this minute 
fistula had closed, and the patient was passing the urine free from 
pain, but still with some frequency. Through the summer she 
gained much in nervous strength and physical health, and quite 18 
HYPEREMIA OF THE VESICO-URETHRAL MEMBRANE. 
recently I have heard that she is in better health and more free 
from local disturbances than she has been for years. 
I cannot but feel that it was a fortunate thing in this case that 
the operation for closing the fistula did not entirely succeed, for 
I believe that thereby the strain was much diminished in the 
force of the urine coming against the neck of the bladder, and a 
month of time was gained in gradually securing the tolerance of 
that part, during which the small fistula acted as a safety valve 
to the bladder. 
Case III. — March 9, 1880.—Mrs. D. S. consulted me and 
gave the following history : She was twenty-five years of age, had 
been married five months, but had never been pregnant. She 
had been employed as a teacher, and was accustomed to hold the 
urine all day without inconvenience. On her wedding journey, 
a long and very fatiguing one, she had an attack of diarrhea, 
for which she took medicine. This was followed by an obstinate 
constipation, lasting five days; during this time she went fre- 
quently to the water-closet, and strained a great deal in her at- 
tempt to defecate, which finally she accomplished by the aid of 
some cathartic ; then for the first time she complained of pain in 
passing the urine; this she thought might have been immedi- 
ately excited by the dyspareunia which she suffered. The dysuria 
followed the act of micturition, and at first lasted but three or 
four minutes, but gradually increased, and then the frequency be- 
gan, and she was obliged to urinate every ten or fifteen min- 
utes. Returning home as speedily as possible, she went through 
the different stages of an attack of acute cystitis, for which she 
was treated by different physicians, and which finally yielded, 
as was evidenced by the condition of the urine, although the 
pain which she suffered was as severe as at any time, occurring 
more particularly just before and after the act of micturition; 
the frequency in passing the urine still, however, annoyed her. 
I advised an immediate examination of the urethra and blad- 
der with the endoscope, which was acceded to March 13, and the 
patient was accordingly etherized, when the condition of hyper- 
emia of the vesico-urethral membrane was found to exist, and 
the bladder membrane also looked slightly injected. An appli- 
cation of a ten per cent, solution of nitrate of silver was made 
to the neck of the bladder. For two days after this treatment 
the patient was comparatively comfortable, but then all the symp- 
toms returned. March 21 she was etherized again, and rapid dilatation of 
the urethra was performed with Simon’s plugs, which instead of 
benefiting her unfortunately made her so much worse that within 
a few days the act of micturition was accompanied by such severe 
pain that it became necessary to administer ether whenever the 
urine was to be passed. I advised the formation of a vesico-vag- 
inal fistula, which operation Dr. J. C. Warren kindly performed 
for me, as I felt it unwise to operate myself, having the care of a 
case of septo-pyemia at the time. The relief, although not as 
immediate as in the other cases, was realized within a few days; 
but the pain was started up again when the attempt was first 
made to use the hot water through the urethra. The edges of 
the fistula healed readily, and there was very little tendency to 
phosphatic deposit. Having been taught to keep the fistula open 
and to use the hot douche, she was sent into the country to rest 
and regain nervous strength until the following fall, a urinal hav- 
ing been adjusted by Dr. Bullard, to whom I was greatly indebted 
for assistance in the care of the case. 
November 5, 1880, the patient returned to the city looking 
fat and exceedingly well. She had repeatedly tested the toler- 
ance of the neck of the bladder by keeping the finger over the 
fistula until an amount of urine had collected in the bladder, 
when it was forced through the urethra without causing the 
slightest pain. 
Noveviber 8 the fistula was closed with silver sutures; sub- 
sequently there was some indication of an attack of acute cysti- 
tis, occasioned by the operation ; it was, however, controlled 
by the free use. of benzoate of ammonium. On removing the sut- 
ures, on the eighth day, a minute opening was found still to 
exist at the anterior angle of the wound. Two months later the 
operation was repeated, resulting in a complete success. Five or 
six months, however, were required for her to regain the nervous 
strength which she lost by the two operations and the necessary 
confinement, but subsequently she made no complaint of her 
former troubles, and in July, 1882, I was assured by Dr. H. J. 
Barnes, who had then recently had charge of her in a supposed 
miscarriage, that there had been no return of the former irrita- 
bility of the bladder. 
Case IV. — Mrs. S. F. was thirty-seven years of age, and had 
been married sixteen years. She had one child four years after 
marriage, and one abortion at the third month two years later. 
W. H. BAKER. 
19 20 
There was a history of phthisis on her father’s side, but the pa- 
tient had always enjoyed good health up to two years previous to 
her consulting me, November 8, 1881. Her strength was at that 
time much taxed by the care of her mother through a serious ill- 
ness which required her to be lifted a great deal, and it was to 
this severe exertion that she attributed the beginning of her 
trouble, for then began pain on passing the urine, at first con- 
fined to the act, but gradually extending after micturition, until 
within six months she suffered almost constantly with severe pain 
in the bladder. The process of urinating was also very frequent, 
and the pain was not at all relieved by that act. It was only with 
the greatest difficulty that she could walk, and she could not take 
an erect position on account of the greatly increased pain which was 
thereby occasioned. Her physician had repeatedly examined the 
urine for pus, so exactly like cystitis were her symptoms, but had 
as frequently failed to find evidence of that disease. She had 
resorted to morphine to control the pain, which she was obliged 
to take in large quantities, for it was only when thoroughly under 
its influence that she could be made at all comfortable. Under 
ether, by the aid of Skene’s endoscope a diagnosis similar to the 
other cases reported was made. As the patient could not then 
remain for treatment, she was advised to return as soon as possi- 
ble and have the operation for fistula performed, if the milder 
applications should prove ineffectual. 
She entered the Free Hospital for Women April 12, 1882, suf- 
fering more, if possible, than when seen in November. On 
reexamining the case by the vagina I found great sensitiveness 
at the neck of the bladder, and by the endoscope a similar con- 
dition to that found before. From April until May applications 
were made once a week with the atomizer, as in other instances, 
but without the slightest benefit resulting. 
May 1 an artificial vesico-vaginal fistula was made, and the 
relief was immediate and perfect. She required no more mor- 
phine, she was able to sleep, her appetite returned, and she became 
one of the most cheerful as well as grateful patients that I had 
ever seen. Eleven days after the operation she began to com- 
plain of great irritation and soreness 'of the passages, and on 
examination I found that the wound had not been well cared for 
by my house surgeon, and was thickly coated with phosphatic 
deposit. On removing some of this, together with considerable 
thick mucus from the vagina, several small superficial sloughs 
HYPEREMIA OF THE VESICO-URETHRAL MEMBRANE. IV. H. BAKER. 
21 
were found about the wound, which had undoubtedly occurred 
from the low state of vitality of the patient, and to the resulting 
denuded surface were attached quantities of the same deposit from 
the urine. Much patience and care were required in removing 
this irritating substance. By a generous amount of cod-liver 
oil, iron, quinine, and stimulants, as well as food, it was astonish- 
ing how rapidly the local condition improved ; for within three 
weeks she was sent home, the wound having entirely healed, and 
she having learned the necessary care of herself in order to de- 
rive the permanent benefit to be realized after the fistula should 
be closed. I have recently heard that she is steadily gaining, and 
hopes to come to the city, for the closure of the fistula, during 
the fall of the present year. 
Case V. — Mrs. H. M. F. consulted me February n, 1882. 
She was twenty-five years of age, and had been married two and 
one half years. She had never been pregnant. Her family his- 
tory was good, and her own health was excellent up to her 
twenty-first year, when she fell on the ice, and was ill in bed for 
three months with “ some nervous and spinal trouble.” About 
that time she traveled in Europe for five months, but returned 
worse than when she left home, her great complaint being con- 
stant pain in the lower part of the back, “ at times streaming up 
the spine,” both symptoms being increased by exercise. These 
discomforts were present when she was married, and two weeks 
after that event, while journeying abroad, having retained the 
urine one day a very long time, she suffered great distress from 
so doing, and from that period complained of an almost constant 
desire to pass the water, which was very much aggravated if any 
attempt was made to retain it even a moment after this desire 
was experienced. She was obliged to urinate as often as every 
ten minutes during the day, and from twenty to thirty times at 
night. Pain was felt just before and at times during the act of 
micturition. During the preceding two years there had been two 
attacks after taking cold, when urinating was “like the passage 
of fire.” A physical examination of the patient showed the 
usual tenderness over the spine present in a neurasthenic case, 
while by the vagina pressure of the neck of the bladder gave ex- 
treme sensitiveness. A somewhat concentrated urine was cor- 
rected by diluents, without affording any relief, and February 24 
ether was administered and the urethra and bladder were examined 
with Skene’s endoscope. This revealed a very hyperemic state 22 
HYPEREMIA OF THE VESICO-URETHRAL MEMBRANE. 
of the vesico-urethral membrane, which was otherwise healthy. By 
means of an atomizer a ten per cent, solution of nitrate of silver 
was applied to the diseased part. One week later, no relief having 
been experienced from the treatment, under ether a vesico-vaginal 
fistula was established. There was entire relief from pain from 
the time of the operation, and on March 20, the patient having 
been taught the usual details of the care of her case, and a uri- 
nal having been adjusted, she was sent home to carry out the 
treatment for some months. Some delay in the healing of the 
edges of the wound was experienced from the great tendency to 
the formation of phosphatic deposit. July 15, 1882, word was 
received that the patient was doing very well; that she had in- 
creased in flesh and strength, and would consider herself well 
except from the inconvenience of the constant flow of urine, 
which she desired to have overcome by the closure of the fistula. 
She was advised, however, to wait two months longer. 
Several details in the preceding cases, being common to 
all, have been omitted, as it was thought their considera- 
tion would be facilitated by a postponement of them until 
the individual cases were completed; to these, together 
with facts which have been suggested by the histories and 
treatment of these five patients, I would now invite your 
attention. 
A careful analysis of the urine was made in each case, 
and it was found either absolutely normal or simply con- 
centrated, the latter condition being readily overcome 
by diluents. In all except Case I., where menstrua- 
tion had ceased, the dysuria was intensified for a few 
days before the catamenia, and greatly relieved while 
the activity of the flow continued. Cases I. and II. 
were the only ones where any uterine disease existed as a 
complication, and in these the rectification of the misplace- 
ment failed to relieve the patient. In all except Case IV. 
the patients were naturally of a very nervous temperament. 
The mucous membrane in every case was very thin and 
delicate. In each case the patient was relieved by the 
establishment of the fistula. In no case where the fistula 
was closed was the catheter used after the operation. W. H. BAKER. 
As a summary of this paper I would present the follow- 
ing conclusions : — 
In every case where a chronic state of irritability of the 
vesical neck is present, a careful examination with the en- 
doscope should be made. 
Before resorting to rapid dilatation of the urethra for the 
relief of a supposed fissure, make sure of the diagnosis. 
In cases of hyperemia of the vesico-urethral membrane 
that do not yield speedily to mild local treatment, put the 
part at absolute rest by the formation of a vesico-vaginal 
fistula. 
The fistula once created, do not allow it to close until the 
hyperemia has entirely disappeared, and the nervous 
strength of the patient has become thoroughly established. 
23