precise method in which they operate to cause the obstruction,
dilatation, and rupture of the lymphatics is a matter of speculation.
The embryo filariæ are so lithe and small that they move among the
corpuscles {119} apparently without harming them, but the ova in which
the embryos lie coiled up, and which are often discharged unhatched,
are large enough to cause obstruction in the smaller lymphatics and
lymph-passages of the lymphatic glands, and thus cause the phenomena of
chyluria, as well as of the other diseases of the lymphatic system with
which it is often associated, or which may occur independently of it,
such as elephantiasis, cutaneous lymph-vesicles with their chylous and
lymphous discharges, lymph scrotum, chylous hydrocele, and other
diseases of the lymphatics. Indeed, the total number of affections
other than chyluria which are found associated with filariæ exceed
those of chyluria. Among the diseases with which it is said to be
associated is erysipelas.
It is evident, therefore, that notwithstanding the fact that the
discovery of the Filaria sanguinis hominis has shed a flood of light
upon the subject of chyluria, the fact must not be overlooked that not
a few cases of the disease have occurred in which the most careful
search has failed to find this parasite in the blood. Careful
examinations, during waking and sleeping hours, have been made without
result, so that we cannot deny altogether the possibility of the
disease occurring independent of filariæ as the cause. It is common,
therefore, to speak of parasitic and non-parasitic chyluria.
On the other hand, the filaria embryo is often found in the blood of
persons apparently in perfect health. Manson tells us that out of every
ten Chinamen taken at random, at Amoy, the blood of one will contain
filariæ.
MORBID ANATOMY.--There can hardly be said to be any morbid anatomy of
chyluria, unless we regard the lymphatic lesions which sometimes
accompany it as a part of the disease. Again and again do we read the
reports of autopsies at which the kidneys were found normal, and where
lesions have been noted they were such as are found due to other
causes, and the coincidence was accidental.
SYMPTOMATOLOGY.--Apart from the characteristic urine of the condition,
there are no symptoms which can be regarded as in any way peculiar to
the disease. The mode of onset is usually sudden, and yet many patients
experience no symptoms whatever, and would be quite unaware that they
were afflicted in any way, were they not aware of the fact that they
are passing lactescent urine. Since the discharge is, however, a drain
of very valuable nutrient and force-producing material, most patients
sooner or later gradually grow weaker; and this symptom of weakness
becomes sometimes very marked, so that they fall into a condition of
extreme debility, even to fainting on exertion.
Another symptom sufficiently frequent to deserve mention is pain in
lumbar region, sometimes very severe, sometimes on one side, at others
on both.
Painful micturition, due to obstruction, is also a symptom traceable
directly to the condition of the urine. The disposition of chylous
urine to coagulate has already been alluded to. The coagulation taking
place in the bladder, it is the clot which sometimes obstructs the
urethra and makes urination difficult or impossible. Plugs of coagulum
are ejected, sometimes with considerable force, after prolonged
straining, and with this comes relief to the symptoms, which may be
reproduced through the operation of the same cause.
{120} Other symptoms which are occasionally present may have an
accidental relation to the affection, while they may be due to it. Such
are headache, nausea, and other gastric symptoms.
Mention has been made, too, of the concurrence of superficial lymphatic
leakage, especially on the lower part of the abdomen, the thighs, and
the legs. Such leakage is often from little vesicular elevations which
are evidently dilated lymphatic vessels. The presence of such leakage
should suggest the examination of urine for lesser degrees of chyluria.
In like manner, the urine should be examined in case of elephantiasis,
lymph-scrotum, and chylous hydrocele, with which also chyluria is
sometimes associated.
The effect of intercurrent febrile states, whether symptomatic of local
inflammation, as of the lungs, or whether the result of the idiopathic
fevers, has often a singular effect on chyluria in causing its
disappearance for a time. It would seem that states of high vascular
tension, however induced, tend to make it cease.
While chyluria has made its appearance, for the first time, in a number
of cases during pregnancy, this condition in other instances has caused
it to disappear, especially toward the later months; whence it would
seem that the pressure of the rising womb has a favorable effect.
The DIAGNOSIS of chyluria consists in the recognition of the chylous
state of the urine. This, ordinarily very easily recognized, might be
taken in its slight degrees for phosphatic or uratic or purulent
conditions of the urine, and vice versâ. The disappearance of the first
on the addition of acids, of the second on the application of heat or
alkalies, will resolve any doubt, while the microscope will detect the
pus-corpuscles in the last. None of the reagents named will dissolve
the fatty molecules of a chyluria, while ether will cause the fluid to
clear up completely.
The PROGNOSIS is usually favorable. Very rarely is an attack fatal, and
when such is the case it is from exhaustion--from the drain to which
the system is subject. Tubercular phthisis is therefore a not
infrequent immediate cause of death.
TREATMENT.--On the supposition that filariæ are the essential cause of
the disease, the rational indication would be first to destroy them by
the introduction into the blood of some parasiticide; and, second, to
repair the lesion of communication between the lymphatic system and the
urinary passages. As yet no agent is known which would not be as fatal
to the host as to the filaria, if used in sufficient quantity to
destroy the latter; nor has it ever been possible to find the point of
communication between the two systems, although treatment has been
directed to producing closure of such communication, and with some show
of success. Thus, in a case under his care Dickinson of London injected
into the empty bladder twelve ounces of a solution of perchloride of
iron, containing at first two drachms of the tincture to the whole
quantity, gradually increased to four drachms. The solution was
retained in the bladder for from eight to twelve minutes with little or
no inconvenience. The operation was repeated almost daily for twelve
days. The effect was always to check the milky flow and to substitute a
clear urine. But after the operation had been repeated a certain number
of times there was a decided rise of temperature, with headache,
nausea, lumbar pain, hæmaturia, and albuminuria which continued a short
{121} time after the hæmaturia ceased. Singularly, too, with the
subsidence of these symptoms, the chyluria remained absent for some
time. The injections were resumed on its return, and each time were
followed by relief. In the course of their use, however, the strength
of the solution was increased to an ounce of the perchloride to twelve
ounces of water, and the strongest solutions were retained in the
bladder for as much as an hour, the weaker longer. Ultimately, however,
the use of the injections became so painful that they had to be
discontinued.
Another measure, employed by Bence Jones, was abdominal pressure by
means of a belt. This also, in his experience, relieved the lumbar
pain. In his case, which was about eight years under observation,
Dickinson applied the pressure by a sort of tourniquet about an inch
below the umbilicus. This lessened, though it did not stop, the
pulsation in the femoral arteries. It also was successful at first, the
chylosity lessening, and finally ceasing, but on the removal of the
belt the chylous character gradually returned, and in sixteen hours was
as bad as before. Repeated trials were followed by the same transient
effect, but no cure. Under this treatment, however, combined with a
liberal diet and rest, the patient gained many pounds in weight, and
was able to leave the hospital and resume her occupation as dressmaker,
the pursuit of which, and the absence of the favorable conditions of
hospital-life, as invariably caused a return of the symptom and its
resulting debility, which again caused her to seek admission.
Rest, therefore, and an abundance of good nourishing food, tend at
least to counteract the exhausting effects of the disease, and even to
cause the discharge to cease. Tonics, and especially chalybeates, are
indicated for the former purpose.
As the relaxing effects of warm climates and warm weather seem to
predispose to the condition and to aggravate it, removal to cooler
latitudes and places is indicated.
Astringents, internally administered, naturally suggested themselves at
an early date, and were used by Prout, Priestley, and Bence Jones. The
latter especially thought gallic acid useful. He reports a case in
which the disease did not return after its long-continued use. Goodwin
of Norwich, England, also reports a case in which the chyluria was
controlled by the gallic acid, but returned in four or five days after
the remedy was discontinued. It again disappeared on resuming the drug,
and the patient could at any time render the urine nearly normal in
appearance by taking it. The case was lost sight of before it could be
regarded as cured. Waters also reports a case which apparently
recovered completely after nine weeks' treatment by gallic acid. He
gave at first 30 grains a day, which were gradually increased to 135 a
day, and then gradually reduced.
Other astringents which have been used are tannic acid, matico, or
acetate of lead, nitrate of silver, the mineral acids.
Mangrove was successfully used in a case related by Bunyan of British
Guiana. It was used in the shape of a decoction at the suggestion of a
negress, an ounce being taken four times a day. In seven days the
patient was so much relieved that the remedy was discontinued for two
days, but the symptoms returned. They again disappeared when the drug
was resumed, and two subsequent attacks were immediately cut short by
the remedy. Roberts suggests that it may act as a parasiticide, {122}
and suggests larger and sustained doses of the iodide of potassium for
the same purpose.
Retention of urine, when present, should be treated like the same
symptoms under other circumstances, by catheterization, washing out the
bladder with tepid water, warm fomentations, and similar measures. It
has even been suggested to wash out the bladder with ether under these
circumstances.
As it seems impossible for the embryo filariæ to develop in the human
body into the fully-developed Filaria Bancrofti, it is evident that
with the death of the latter, which must occur sooner or later, the
production of embryos must cease, while those previously produced must
sooner or later also die, and in this way a spontaneous cure take
place--just as a person infested with trichinous disease will
ultimately recover if the introduction of the trichinæ cease and he is
able to survive the irritation caused by the presence of the parasite
in his muscles. In this manner we may account for the spontaneous
disappearance of the disease in so many instances where all treatment
has proved unavailing.
{123}
DISEASES OF THE BLADDER.
BY EDWARD L. KEYES, M.D.
Inflammation.
The bladder is a patient organ, and rather slow to resent injuries from
within or without. It never inflames on account of such general causes
as the influence of cold, anæmia, cachexia, or a depressed state of the
general system. Any of these causes may act as adjuvants, but alone
they are not effective. Thus a chilling of the legs, inoperative upon
an individual with a healthy bladder, is a prime factor in exciting
inflammation in the bladder of an old man with an enlarged prostate;
while the simple passage of a sound upon an individual suffering from
anæmia might provoke a cystitis which the same traumatic cause would
not have produced upon a patient in a thoroughly healthy condition.
Yet inflammation of the bladder is very common. It is sometimes a
malady, more often a symptom produced by some other malady (stricture,
prostatic enlargement, stone), and only to be overcome by detecting and
removing its cause. The causes of inflammation of the bladder therefore
include nearly all the maladies to which the bladder is liable.
The varieties of cystitis take name from that tissue of the viscus
which is involved, and from the modality of the inflammation.
We have--
| suppurative;
| Acute----| diphtheritic;
1. Cystitis mucosa | | gangrenous.
|
| Chronic--| catarrhal;
| membranous.
2. Interstitial cystitis, where the muscular coat of the bladder is
involved.
3. Peri-cystitis, para-cystitis, where the peritoneal surface or
surrounding structures are inflamed.
This short section upon a surgical subject, only being granted a few
pages in a medical work, cannot include a description of all these
conditions, or more than a general outline of acute and chronic
catarrhal cystitis. Suffice it to say for the other varieties that
interstitial cystitis depends upon mucous cystitis or peri-cystitis,
and is an inflammation of the muscular coat of the bladder, sometimes
culminating in abscess, sometimes in concentric hypertrophy--_i.e._
contracture of the bladder. Peri-cystitis and para-cystitis occur in
connection with peritonitis and pelvic cellulitis, and the peripheral
inflammation may extend inward and involve the muscular and later the
mucous coat.
{124} All these conditions are grave only in proportion to the
intensity of the malady causing them and to which they are subordinate.
Gangrenous cystitis occurs after injury, and occasionally in profound
septicæmic conditions (puerperal) or after intense cantharidal
poisoning. It is fatal.
True diphtheria of the bladder occasionally, but very rarely,
accompanies general diphtheritic conditions, and is a very grave
malady. Membranous cystitis is less grave, may be partial or complete.
I have a fibrinous cast of a female bladder which was extruded through
the meatus. This malady occurs sometimes as a late complication of
advanced chronic cystitis mucosa in the male. Recovery is quite
possible.
Cystitis mucosa is a common disorder, constantly encountered by the
physician as well as the surgeon. The irritable bladder, sometimes
called cystitis, demands description here, as it may go on to become
subacute or even acute cystitis of the vesical neck.
Irritability of the bladder is a neurotic and not an inflammatory
condition, although it may lead to the latter state and terminate in
it. The bladder is said to be irritable when the calls to urinate are
too frequent, generally with little or no pain. As a rule, the urine is
clear, containing no pus or a quantity entirely disproportionate to the
frequency of the call to urinate.
In true irritability of the bladder the patient sleeps all night,
although he may have to empty his bladder every hour or two by day.
There is sometimes a sense of weight, heat, or throbbing, more or less
intense, in the perineum; the desire to urinate is normal but
imperious; the satisfaction after the act is complete, and no pain
accompanies its performance.
This condition of things is generally either neurotic directly, or
indirectly (reflex). In children it may be caused by a tight prepuce,
especially if irritated by retained smegma, by teething, by the
existence of intestinal worms; and it may accompany chorea. It gets
well by lapse of time or is cured by removal of the cause. In the adult
it is most common in young men and recent widowers, and is often an
expression of sexual distress due to sexual stimulation without relief,
to sexual excess, or to improper sexual hygiene. The irritation of
acrid urine will also cause it, as well as such peripheral troubles as
a narrow meatus urinarius, a tight prepuce, urethral stricture,
moderately enlarged prostate, kidney irritation (stone in the kidney,
etc.). It appears in old men, sometimes, apparently, as a forerunner of
organic prostatic changes.
Such stimulation as a glass of wine or beer, pleasant company,
absorbing occupation, may cause it to disappear temporarily. It is
habitually better in dry, clear weather, and worse in damp seasons when
the wind is east. Worry, anxiety, fatigue, depression of spirits, and
similar causes aggravate the condition. It is better for the first
twenty-four hours after sexual intercourse, and worse than it was
before during the next following twenty-four hours.
The SYMPTOMS of pure irritability are simply a frequent desire to
urinate during the waking hours, the act not being attended by pain and
the urine being reasonably clear.
The PATHOLOGY of this affection is not definitely known. It seems {125}
to be an essential neurosis involving the sensitive nerves of the deep
urethra and neck of the bladder, attended, if long continued, by
surface congestion of the deep urethra and neck of the bladder, and
ultimately the phenomena of inflammation; for the very mechanical act
of allowing the bladder incessantly to empty itself too often, and to
squeeze its own neck, will, in many cases, after a time, lead to
traumatic inflammation of mild type.
TREATMENT.--Marriage is a very effective treatment of pure vesical
irritability when there is a sexual element in the case.
If any peripheral or local cause exists (stricture, contracted meatus,
dense acid urine), its removal will effect a cure. Alkaline diluents,
notably the citrate of potassium in gr. v-xxx doses, administered
midway between meals, copaiba, or cubebs in moderate doses, often gives
relief. Tonics, the tincture of the chloride of iron, and arsenical
preparations are often of great value. The tincture of hyoscyamus in
minim x-lx doses may be combined advantageously with any of these
remedies.
One of the most efficient of all methods of treatment is the use of the
conical steel sound, as large as the urethra will admit without
violence. The sound should be warmed, lubricated, and gently carried
into the bladder at intervals of two to four days. The daily passage of
the sound is objectionable, even if it gives relief at first, for it is
liable to kindle a slow inflammation in a urethra unaccustomed to its
use. When a sound is inserted it should not be left an instant in the
bladder, but should be gently withdrawn as soon as it has been fully
inserted. If left in the urethra, it does no good, and may act upon the
cut-off group of muscles in the membranous urethra, causing them to
contract spasmodically, as in the physiological performance of the
coup-de-piston after urination. Such contraction bruises the sensitive
mucous membrane of the urethra against the hard sound, and does
mechanical damage.
The sound acts in three ways: It (1) mechanically distends the
irritable contracted cut-off muscle and seems to quiet its contractile
tendency. It (2) squeezes all the blood from the passively congested
vessels of the irritated mucous membrane, thus ensuring a new supply of
blood to the part and an improved circulation in the reaction which
follows the irritation. It (3) mechanically, by contact, blunts the
sensibility of the terminal sensitive nerves in the mucous membrane of
the deep urethra. In this way the sound acts, and its effects generally
last several days, often a week. Its good effect is also instantaneous.
The slight feeling of weight and discomfort in the perineum which the
patient has before its use is gone instantly, and replaced by a feeling
of comfort. When this immediate sense of relief is not experienced, it
is doubtful whether such a case will yield to the simple treatment by
sounding.
It is a mistake to suppose that any ointments smeared upon a sound do
good in this condition. Mercurial, belladonna, and other ointments are
used, but they are all and entirely rubbed off the sound before it
reaches the deep urethra, and their good effect probably resides solely
in the imagination of the physician and the credulity of the patient.
Ointments are undoubtedly of service in some obstinate cases, notably
strong tannic-acid mixtures, and sometimes iodoform, but these cannot
be carried to the deep urethra by being rubbed upon a sound. The cupped
sound may be used to effect this very neatly, the little cups on the
sides of the {126} curve of the sound being filled with the ointment
which it is proposed to carry down and apply to the affected spot. A
few drops of a mild nitrate-of-silver injection also give decided good
results in some cases. The solution should vary between two and ten
grains in the ounce of water, and may be accurately applied by means of
a Bigelow or an Ultzmann syringe, a few drops being thrown into the
membranous urethra. After the application, which should be made only
when the patient has a full bladder, urination will wash out the canal
and good effects may be looked for--not immediately, as after sounding,
but after the irritation produced by the stimulating application has
subsided.
Acute Cystitis.
Acute cystitis sometimes involves only the neck of the bladder; in
other cases the whole mucous lining of the bladder is included in the
morbid process.
The causes of acute cystitis may be grouped under six heads:
1. Traumatic.--Under this head may be ranged all injuries from without,
with or without fracture of the pelvic bones--wounds, rupture of the
bladder, the pressure of the child's head during labor; injuries from
within, as during the use of instruments, by stone, or pedunculated
tumor. The list may be increased by such chemical traumatisms as those
produced by ammoniacal urine in cases of atony or paralysis, by
excessively acid urine in neurotic conditions of the neck of the
bladder. Such chemical causes, it will be observed, commonly act in
conjunction with another cause. Irritating injections without any
co-operative cause are capable of lighting up acute cystitis.
2. Extension of neighboring inflammation--gonorrhoeal cystitis and that
attending prostatic inflammation, pelvic abscess, pelvic cellulitis,
peritonitis from neoplasms growing at the vesical neck, tubercle,
cancer, etc.
3. Medicinal--from cantharides, sometimes cubebs or turpentine.
4. Specific--in diphtheritic, puerperal, septicæmic conditions.
5. The influence of cold when chronic inflammation already exists.
6. Neurotic--actual, from extreme and long-continued neuralgia of the
vesical neck; reflex, from irritation at a distance, tight meatus,
stricture, inflammation of the seminal vesicles, kidney irritations.
SYMPTOMS.--The symptoms of acute cystitis are (1) frequent painful
urination by night as well as by day, the pain being greatest at the
close of, and immediately after, the act, and the pain persisting more
or less between the acts, radiating from the perineum; (2) moderate
fever, sometimes announced by chill; (3) commonly great despondency and
a depression of spirits totally disproportionate to the degree and
significance of the local inflammation; (4) the urine invariably is
milky, with pus: it may at first be acid and of normal odor; it is
often tinged with blood, especially toward the end of the act of
urination. In extreme cases the urine may contain membranous or sloughy
shreds or gangrenous gases. The urine eventually becomes alkaline, and
finally deposits lumps of pus and abundant triple phosphate crystals.
Complications occurring with the cystitis yield appropriate symptoms.
{127} Such possible complications are congestion and engorgement of the
prostate, possibly going on to abscess; epididymitis, orchitis,
inflammation of the seminal vesicles, inflammation running up the
ureters, pyelitis, surgical kidney; abscess in the walls of the bladder
or in the connective tissue about the same; very rarely peritonitis or
suppurative phlebitis in the veins about the neck of the bladder.