analogous changes upon the other mucous membranes: patches of more or
less brilliant uniform or punctate redness, perhaps surrounding small
ecchymotic areas; a softened, swollen mucous membrane; enlarged
follicles near the neck of the bladder, perhaps ulcerated spots;
possibly false or true diphtheritic exudations (such exudations have
been especially noted in cantharidal cystitis); possibly interstitial
abscess of the bladder-wall, or even suppurative phlebitis in the veins
about the prostate and neck of the bladder, as observed by Walsham[1]
in a case of cystitis due to over-distension. This last complication is
happily exceptionally rare.
[Footnote 1: _London Lancet_, May 10, 1879, p. 665.]
The PROGNOSIS varies with the cause of the cystitis, and as the latter
often cannot be entirely removed, the acute cystitis may only be
moderated so as to be made to assume the chronic form. When the cause
can be entirely removed, acute cystitis gets well and leaves the
bladder absolutely sound.
TREATMENT.--Acute cystitis from whatever cause requires a uniform
general line of treatment. Anodynes are essential both for the
patient's comfort and to prevent the constant straining to empty the
bladder to which the unremitting, painful desire to urinate impels him.
Hyoscyamus is a favorite in the form of tincture in minim xx-drachm j
doses, or any of the opiates by the mouth, or in suppository preferably
combined with extract of belladonna in small dose. Sometimes
quarter- or half-grain suppositories of extract of belladonna alone at
intervals of six to eight hours keep the tenesmus more in check than
anything else, but belladonna used too freely may bring on retention by
causing spasm of the cut-off muscles. Camphor is useful, especially in
strangury from cantharides. Rest in bed is essential in most cases,
preferably with the hips raised. Heat in some form, as a hot poultice,
fomentation, spongio-piline, hot-water rubber bottle, etc. over the
hypogastrium preceded by a mustard plaster, gives great comfort.
Hot-water hip-baths of short duration and frequently repeated are of
service in most cases.
Alkalies are valuable, especially in the beginning of an attack--liq.
potassæ minim v-xx doses, citrate of potassium gr. x-xx, combined with
an anodyne or some demulcent drink.
Infusions and extracts of corn-silk, dog-grass root, buchu, pareira
brava, uva ursi, etc. are of some assistance, but generally not so
comforting as some of the bland diuretic waters--Bethesda, Mountain
Valley, Poland, Glenn, Vichy, Wildungen, Buffalo Lithia. Distilled
water or rain-water, especially if taken warm, is a good diluent
diuretic. On the advent of acute cystitis all instrumentation upon the
bladder should, if practicable, be postponed, all stimulating drugs
(cantharides, turpentine, cubebs, alcohol) stopped, and stimulating
foods avoided. Asparagus, coffee, salt, pepper, mustard, acids, and a
highly nitrogenized diet are not allowable. The rectum should be kept
empty and complications treated as they arise.
{128} Chronic Cystitis (Catarrh of the Bladder).
Catarrh of the bladder is chronic inflammation of the mucous membrane
of the urinary reservoir, with more or less thickening of the walls of
the bladder. This malady, so apt to persist for years, is probably more
commonly encountered by the physician than acute cystitis. Acute
cystitis, however, frequently complicates the chronic malady by
occasional outbursts of acute symptoms. Thus an attack of the stone is
acute calculous cystitis interrupting the course of chronic vesical
inflammation due to stone. Catarrh of the bladder may follow acute
cystitis, or it may commence insidiously as a subacute disorder, and be
catarrh, in the popular sense, from the first.
The causes of catarrh of the bladder are never single. It always takes
two causes to produce true catarrh of the bladder--one mechanical, and
one chemical. After a traumatism inflicted on a healthy bladder, with
proper care the patient recovers entirely. If, however, he insists upon
keeping up and about, continues to drink liquor, and does not avoid
straining at urination, the membrane about the neck of the bladder,
irritated by the ammonia from the decomposing urine, secretes an excess
of viscid mucus, the pus becomes gelatinized by the ammonia, the
constant straining leads to hypertrophy of the muscular coat, the
nerves lose their acute sensitiveness, and the milder persistent
malady, chronic catarrh, is set up, to continue perhaps for an
indefinite period.
Infiltrations of the bladder-walls with tubercle or cancer, urinary
calculus, and, notably, enlarged prostate, stricture of the urethra,
tumors of the bladder, hernia of the bladder, exstrophy,
over-distension of the bladder from stricture, spasm of the urethra,
coma, paralysis, or other cause, may be the traumatic element, while
the liberated ammonia from the alkaline decomposing urine furnishes the
chemical element; and the two causes, if continued, occasion and
maintain the condition known as chronic catarrh of the bladder. In coma
or the delirium of typhoid fever or paraplegia or hemiplegia
(sometimes) the bladder becomes over-distended and atonied, perhaps
paralyzed. Here the use of the catheter appropriately, with great
gentleness, may relieve the patient without even the intervention of
acute cystitis; while, on the other hand, acute cystitis may come on
and be cured, or, if ammoniacal urine be allowed to accumulate and the
bladder be not washed out so long as it is unable to entirely expel its
contents, chronic cystitis, catarrh, results. I have known several
cases of partial paraplegia and other disorders in which the patient
could void no drop of urine except through a catheter, where there
never had been any chronic catarrh, no stringy mucus, hardly a
pus-corpuscle, through long years of the disability, owing to
intelligence in the attention to emptying and washing out the bladder
instituted by the physician having first charge of the case.
As prominent among the causes of chronic catarrh in a purely medical
aspect it may be well to insist upon the ease with which this condition
is sometimes brought about by the physician himself. A man with a
weakened bladder may carry a pint or much more clear urine in his
bladder constantly during many years as a residual deposit which his
weakened bladder cannot throw off. Excess over the fixed residuum
produces a desire to urinate, and the patient, mainly by voluntary
contraction of the {129} abdominal walls, voids that excess. If now the
physician finds this globular accumulation in the patient's belly, and
in his zeal to do all that is possible forgets his caution, he may
throw the patient first into an acute cystitis (if haply he escapes
collapse), and then into chronic vesical catarrh--an affair perhaps of
a lifetime. Surgeons have noticed, and especially Sir Henry Thompson
has pointed out, that a dirty catheter may poison the urine and bring
about a cystitis which otherwise might have been avoided; and observers
from all time have noticed that the sudden entire evacuation of the
contents of a bladder long accustomed to over-distension is in itself a
grave cause of serious inflammatory disturbance to the mucous membrane
of the bladder. Recently much attention has been called to this
condition and its possible fatal termination by Sir Andrew Clarke,
under the name of catheter fever.
The deductions from a knowledge of these facts are obvious: they
are--(1) always to thoroughly cleanse, and then to disinfect, a
catheter on each occasion before its use; and (2) never to empty
entirely at a first sitting a bladder which has been long habituated to
over-distension; and when, finally, the bladder is emptied, always
irrigate it with a disinfecting solution (borax) after each emptying.
SYMPTOMS.--Chronic cystitis varies in grade, and its symptoms vary with
the grade of the inflammatory process. There is probably no pain more
intense than that endured by a man with severe general cystitis in its
last stages, when the unceasing tenesmus wrings groans from his lips,
the sweat from his body, doubles his frame in agony, and converts his
facial expression into a distorted tragedy. The sight is pitiable and
never to be forgotten. On the other hand, a man may continue about and
at his work with a patient flabby bladder containing constantly more or
less stringy mucus and ammoniacal urine, suffering little or no pain or
tenesmus, and perhaps having no subjective symptoms except a slight
sense of weight in his lower belly and a rather frequent desire to
urinate.
Between these limits the symptoms range, but in a general way it may be
said that the symptoms of chronic vesical catarrh are these: frequent
calls to urinate, attended by more or less pain, especially toward and
after the termination of the act. The sense of satisfaction normally
felt after urination is generally absent. Motion, particularly jolting
as in rough riding, causes pain. This pain is referred to the lower
part of the belly, to the perineum, to the end of the penis, the
urethra, the anus. The straining after urination may be absent or of
the most intense character, leading to prolapse of the rectum and
causing excruciating torture. The urine always contains pus scattered
through it, and generally also more or less pus in that semi-solid
condition known as stringy mucus. Stringy mucus is pus gelatinized by
the ammonia of the decomposing urine. These clots of muco-pus contain
gritty crystals of the ammonio-magnesian phosphate. More or less blood
is to be found in the urine, especially during acute paroxysms. Pure
blood sometimes follows the urine after each act of urination. Bacteria
abound in the fluid, which varies in odor greatly in different cases,
not always strictly in accordance with the severity of the actual
inflammatory process. Thus, the urine may be simply sweetish in its
odor, ammoniacal, flat, and stale, or be possessed of a putrid,
sickening sweetness of indescribably nauseating power. Again, it may be
rankly rotten. The bottom of the chamber in some cases becomes {130}
covered with a thick coating of the viscid muco-pus, which strings out
and reluctantly follows the fluid when the vessel is inverted.
Sometimes the urine contains shreds of false membrane or putrid masses
of sloughy tissue.
PATHOLOGY.--In chronic cystitis the mucous membrane of the bladder
undergoes gradual thickening, loses its pink salmon tint, and becomes
gray in color. The thickening extends to the submucous layer, and more
or less to the muscular walls as well. In cases of prolonged chronic
cystitis attending atony of the bladder, notably with hypertrophied
prostate, the cavity of the organ is large, its walls seemingly thinned
and flabby, its internal coat roughened by the crossing of bundles of
muscular fibres or perhaps perfectly smooth. In other conditions
(concentric hypertrophy), where there has been a serious obstacle to
the free outflow of urine without any atony of the muscular coat
(stricture of the urethra, some cases of stone and of enlarged
prostate), the walls of the bladder may be enormously thickened to the
extent of an inch or more, the inside surface rough, perhaps ulcerated.
The thickening of the muscular bands within the bladder often causes
them to stand out in bold relief, like the muscular bundles in the
heart-cavity. These prominent bundles enclose spaces of various sizes
and shapes, and from the bottoms of these spaces sometimes the mucous
membrane protrudes between the muscular bands and forms pouches of
varying size (sacculated bladder). These pouches consist of mucous
membrane alone covered with peritoneum, and may become the seat of
encysted stone.
If there has been a subacute grade of the surface inflammation before
death, there may be livid spots on the mucous surface of the bladder,
punctate or larger ecchymoses, reddened areas from which the epithelium
is more or less detached, ulcers with or without sloughs or
diphtheritic covering, perhaps perforations of the bladder and
infiltration of urine, enlarged mucous follicles, granulations,
fungosities, etc. Heterologous deposits, tumor, cancerous and
tubercular ulcers, cysts, stone, complete the possibilities of what may
be encountered in the bladder at an autopsy upon a patient with chronic
cystitis.
The chronic like the acute varieties of cystitis may involve the whole
of the inside of the bladder or only a portion of it.
The PROGNOSIS, like that of acute cystitis, varies mainly with the
cause. If the latter can be entirely removed (stone), the bladder gets
perfectly well. Not so, however, unless all the causes are removed.
Thus, a phosphatic stone may grow in a bladder as a result of enlarged
prostate and chronic cystitis. The presence of the stone excites the
chronic cystitis, and subjects the patient to a crisis of acute
cystitis from time to time. The removal of such a stone will by no
means cure the chronic cystitis; its removal is only one step in the
treatment of the cystitis.
As far as life is concerned, the prognosis of chronic cystitis is good.
A patient may live many years with chronic cystitis, particularly if he
treats his bladder properly. Although, as generally encountered,
chronic cystitis is not curable, few maladies yield results to
treatment more gratifying to the physician and the patient than the one
under consideration.
The legitimate ultimate termination of chronic cystitis is by chronic
{131} inflammation of the ureter and pelvis of the kidney on both
sides, interstitial kidney changes, and finally death by suppression.
Generally, this end may be almost indefinitely postponed by
well-directed efforts of palliative treatment.
TREATMENT.--The acute outbursts of inflammatory disturbance occurring
during the course of chronic cystitis require the same means for their
relief as those already indicated when considering the treatment of
acute cystitis--all the prohibition of stimulants, the use of bland
mineral waters, demulcent decoctions, infusions, and alkaline draughts.
The anodynes, the rest, the heat, the hip-bath, are all indicated here
for the acuter symptoms, just as they are in the acute malady, but very
much more can be done both in a prophylactic and in a curative way. A
milk diet, even an exclusive milk diet, is an element of great value in
cases of chronic cystitis. I have two patients, both old men, now under
observation, one of whom recovered entirely from cystitis with complete
atony, necessitating the constant use of the catheter, by means of an
exclusive milk diet. He takes one gallon of milk a day, and nothing
else, and lives among his fellow-men at his work and amusements in
entire contentment. He has remained absolutely well on this diet during
many years. The other patient could not take milk after fair trial, but
gradually emerged from the very jaws of death, due to prolonged chronic
cystitis and double pyelitis, by the free use of koumiss, which his
wife daily prepared for him. Vichy and milk in equal parts, taken cold,
is another form of using the milk diet, and the more modern peptonized
milk another.
Light white and red wines, or even a little gin or old brandy, are of
decided advantage in the majority of enfeebled old men with chronic
cystitis. The patient should be clothed with the utmost care. The feet
and legs should be clad in wool unless in the very hottest season, and
flannel should constantly encase the belly and loins. Nothing is more
detrimental to chronic cystitis than chilling the legs.
Another word is necessary in favor of the internal use of alkaline
remedies. Even where the urine is alkaline, ammoniacal, putrid, if the
stomach will take an alkaline medicine kindly the effect is generally
beneficial, for the urine, especially in old men who are prone to these
maladies, is quite certain to be acid at the fountain-head. And even if
the urine is immediately altered by chronic pyelitis through ammoniacal
decomposition before it enters the ureter, yet it will generally
irritate the pelvis of the kidney and the ureter and the bladder less
if it be secreted in a bland alkaline state than if it be discharged
into the irritated area full of uric acid.
Turpentine, copaiba, cubebs, and the muriate of iron are of service in
selected cases, but ordinary astringents seem to possess little or no
value. Benzoic acid, in ten-grain doses in capsules, sometimes improves
the ammoniacal condition of the urine, but the stomach often rejects
it. Boracic acid, which has of late been much talked about, in five- to
ten-grain doses in water, three or four times a day, is of value
occasionally. Quinine is serviceable where the nerve-force is failing.
I have been unable to procure any very decided advantage from the use
of salicylic acid or the salicylate of sodium by the mouth.
The most important general surgical principle in connection with {132}
chronic vesical catarrh is that which concerns emptying the bladder
thoroughly and ensuring its cleanliness. In many, perhaps most,
conditions of chronic inflammation of the bladder from atony,
paralysis, obstruction, or other cause the bladder fails to empty
itself entirely. There remains, therefore, a fixed residuum always in
the bladder; and although this is diluted and partly evacuated at each
act of urination, yet some of the pus, the bacteria, the ammoniacal
ferment, remains constantly in the bladder ready to contaminate each
new portion of urine as it descends from the kidneys. This must be
disposed of, and the bladder washed out, if a permanently satisfactory
treatment is to be instituted.
The soft-rubber catheter is to be preferred where it will pass,
otherwise the woven silk or the French Mercier instrument, and the
bladder should receive attention at least once in the twenty-four
hours, and oftener if required. The last drops of urine should be drawn
off and the bladder washed with water at about 100° F., in which is
dissolved some borax--a heaping teaspoonful to the pint--or other
substance capable of disinfecting the contents or mildly stimulating
the circulation of the bladder.
Carbolic acid has not yielded good results in my hands. A host of
remedies have been employed, but it is doubtful whether anything can do
more good than the water mechanically, borax as a disinfectant, dilute
nitric acid, minim i-x to the pint, as a stimulant, or, in some cases,
nitrate of silver, gr. ½-x to the ounce, used with caution. The
injections should be practised through the catheter which withdraws the
urine, and repeated according to their effect. For cleansing purposes
an injection of simple warm water may be used at each introduction of
the catheter. A fountain syringe with two-way stopcock is the most
convenient instrument to use for the purpose of simply washing the
bladder, because the wash may be repeated indefinitely until it returns
clear, without readjusting the nozzle in the catheter.
Very extreme, long-protracted cases of chronic vesical catarrh justify
the performance of lateral cystotomy for their relief, or the
modification quite recently proposed by Thompson[2]--a median perineal
incision involving only the membranous urethra, through which a large
soft-rubber catheter is passed and tied in for a few days or longer.
[Footnote 2: _Brit. Med. Journ._, Dec. 9, 1882, p. 1131.]
Neurosis of the Bladder.
The most common vesical neurosis is neuralgia of the neck of the
bladder, with or without the accompaniment of irritability of the
bladder, spasmodic stricture, or vesical spasm. Irritability of the
bladder has been already considered at the beginning of the section on
Cystitis. The other neurotic conditions are always more or less
interwoven with each other, and they may each and all of them
complicate inflammatory states of the deep urethra, prostate, and
vesical neck.
The CAUSES of this set of affections are most varied, and range from
irregular sexual hygiene (the most common of all) through inflammatory
local conditions, peripheral irritations (the most obstinate of which
is {133} chronic inflammation of the seminal vesicles, with or without
true spermatorrhoea), up to organic changes in the spinal cord and
brain.
The PROGNOSIS in neurotic states varies with the cause. Some cases are
easily controlled; others absolutely defy all and every treatment of
which I have any knowledge.
The TREATMENT involves a removal, if possible, of the cause. Local
measures which have been found most effective in subduing the deep
urethral irritation are--(1) the gentle passage of a soft bougie or
conical steel sound into the bladder at intervals of one to seven days.
The instrument should be removed at once. Sometimes it is necessary to
cut a narrow meatus or a stricture in the pendulous urethra in order
that a sound of large-enough size may be employed to put the sensitive
deep urethra sufficiently on the stretch. (2) The application to the
deep urethra and prostatic sinus of pastes of tannin or iodoform with
the cupped sound or other apparatus, or the injection of the deep
urethra with strong solutions of tannin or mild solutions (gr. i-x to
ounce j) of nitrate of silver. (3) In the most extreme cases, those
furnishing all the symptoms of stone, even cystotomy is justifiable. It
nearly always furnishes a temporary, sometimes permanent, relief.
Medical measures include all the bland diluent mineral waters, alkaline
and tonic remedies, already considered in discussing Irritability of
the Bladder.
Atony and Paralysis.
Atony of the bladder is more or less lack of expulsive force, due to
failure in power of the muscles of the bladder, the nerves remaining
sound. Paralysis is the same condition perhaps more pronounced, but due
to central origin. A patient may be unable to pass water in more than a
dribbling stream, but if he has true organic stricture or spasm of the
deep urethra, the muscular coat of his bladder may perhaps not be to
blame for his imperfect urination. The question of atony may be decided
in such a case by introducing a catheter of any size that will pass. If
there is atony, the stream flows sluggishly from the mouth of the
catheter, and toward the end is influenced by the breathing of the
patient. If there is no atony, the stream rushes through the catheter,
and maintains its force until the last drop flows away. In paralysis
and extreme atony the influence of the descent of the diaphragm during
inspiration is noticed during the whole course of the flow of the
sluggish stream through the catheter.
The CAUSES of atony are over-distension of the bladder, voluntary (by
persistently neglecting the call to urinate), involuntary retention
(from fever, coma, stricture, large prostate), and a certain intrinsic,
sometimes inherited, tendency to weakness on the part of the bladder,
noticed by some people during their entire lives.
Atony is most common, often a part of their malady, in old men with
enlarged prostate. Paralysis of the bladder accompanies certain organic
changes due to injury or disease in the spinal cord or brain. Both in
atony and in paralysis the bladder may be constantly distended to a
certain extent, perhaps to its utmost limit, as a passive sac, and the
excess of urine over this uniform residuum may dribble away
involuntarily {134} (false incontinence), or may be expelled in small
portions by repeated acts of urination performed in the ordinary way or
by the aid of great straining and assistance from the voluntary
contractions of the muscular walls of the abdomen. No condition of
incontinence of urine can be considered proved until demonstrated by
the passage of a catheter. Both atony and paralysis may get well under
proper treatment in favorable cases. Many cases are incurable, but the
discomfort they tend to cause may be almost entirely counteracted.