means necessarily fatal.[64] These accidents are liable to occur when
the bladder, being adherent to the cyst and carried upward by it, lies
directly under the line of incision, or the bladder may be torn open
while adhesions to it are being severed. The wound should at once be
grasped by a pressure-forceps, the bladder emptied by the catheter, and
the operation proceeded with. When the operation has been completed the
wound in the bladder is attended to, and in one of the following ways:
Either the vesical wound is brought up within the lips of the abdominal
incision, and is closed by being included in the abdominal stitches, or
it is closed by the continuous or Glover's suture, without including
the mucous membrane in the stitches. A self-retaining catheter, such as
the Skene-Goodman, must then be kept in the bladder for at least a
week.
[Footnote 64: Eustache, _Archives de Tocologie_, April and May, 1880,
pp. 193, 277; _Boston Med. and Surg. Journal_, Feb. 16, 1882, p. 153;
_British Med. Journ._, Jan. 28, 1882, p. 115; _Am. Journ. Med. Sci._,
Jan., 1883, p. 123.]
One of the ureters will sometimes be torn across while pelvic adhesions
are being broken up. This accident is most likely to happen during the
enucleation of a cyst growing downward because enveloped in the folds
{337} of the broad ligament. It is almost always fatal, and is usually
not discovered during the life of the patient, and, I am disposed to
think, not often discovered after her death. Sometimes, however, urine
will ooze out of the abdominal wound, and in rare cases the patient has
recovered with a urinary fistula. In such a case Simon[65] successfully
removed the corresponding kidney; Nussbaum[66] constructed an
artificial ureter leading from the fistula to the bladder; and
Tauffer[67] inserted the upper end of the divided ureter into the
bladder by an artificial opening. It, however, failed to unite, and he
later made an artificial ureter.
[Footnote 65: _Annales de Gynécologie_, June, 1877.]
[Footnote 66: _Edinburgh Medical Journal_, July, 1876, p. 1.]
[Footnote 67: _Archives de Tocologie_, Avril, 1880, p. 201.]
When an umbilical or a ventral hernia of moderate size is present at
the time of the operation, efforts should be made for its radical cure.
This is done by cutting out the thinned-out sac by two incisions
meeting below and above, and by bringing together the thick edges of
the abdominal wall in the final closure of the wound.
In cases of ascites complicating ovariotomy the ascitic fluid should
not be wholly removed until the cyst has been cut off and the wound is
ready to be closed. By this means any blood oozing from broken
adhesions, or any fluid escaping from the cyst into the abdominal
cavity, being diluted, is less likely to irritate the peritoneum, the
cavity of which can also be more readily cleansed.
When a patient seems in danger of dying on the table from shock or from
exhaustion the anæsthetic should be withheld while hypodermic
injections of ether and enemata of brandy are given. Warmth should also
be applied to the body by bottles of hot water, or, what is better, by
rubber bags of the same. Theoretically, atropia administered
subcutaneously would be the proper remedy, but I have not yet tested
it. In all cases of ovariotomy, especially if prolonged, the woman
should not be kept profoundly under the influence of the anæsthetic for
any length of time, but should be allowed from time to time to come to
at least enough to make her flinch or move about. This caution should
especially be observed in very feeble patients and in those with very
large cysts.
The Removal of Both Ovaries.
Whenever both ovaries are diseased there can be no question about the
extirpation. But when only one has undergone cystic or other
degeneration the question of the removal of the sound one may come up.
There always is a tendency to the subsequent degeneration of the sound
ovary after the diseased one has been removed. More especially is this
tendency observed in sterile women and in those with malignant
affections of the ovary. Many women, therefore, whose lives should have
been imperilled but once, have been compelled to face the dangers of a
second operation. In view of these facts, it seems to me wise to remove
the sound ovary in all cases of sterility, in every case of malignant
degeneration of one ovary, and in all women who have either passed the
climacteric or are approaching it, provided its removal is not attended
with great additional risk. Double extirpation should also be performed
whenever the womb {338} contains a fibroid tumor or whenever it seems
desirable to hasten on the climacteric. In these convictions I am
further strengthened by the disappointment often expressed to me by my
patients that one ovary had been left behind, and by their great fear
afterward lest the remaining organ should also become diseased. On the
other hand, in women who are in the prime of their menstrual life the
sound ovary should be left untouched, unless there exist grave reasons
for its removal.
{339}
DISEASES OF THE URINARY ORGANS IN WOMEN.
BY ALEXANDER J. C. SKENE, M.D.
ORGANIC DISEASES OF THE BLADDER.
Hyperæmia.
This is an acute congestion of the mucous membrane due to a disturbance
in the balance of the circulation. It may be common to both bladder and
urethra, or limited to either; may terminate within a short period of
time (a few hours), or it may go on and end in hemorrhage or
inflammation. If the mucous membrane is seen with the endoscope, it
appears of a bright-red color; the blood-vessels are distended, more
prominent, and apparently more numerous. The arteries are the first to
be affected. If the cause is transient, this is all that is seen, the
membrane returning to its usual color. When the congestion is of a
higher grade, rupture of some of the vessels occurs either on the free
surface or beneath the epithelium. The venous side of the circulation
now becomes more prominent. In a few cases the above order may be
reversed, the veins being the first congested, as in the case of a
sudden interference with the portal circulation.
SYMPTOMS.--The attack occurs suddenly. Frequent but painless urination
is the most prominent feature. There is a sense of heat and heaviness
in the bladder, aggravated by standing. When the urethra is involved
the patient complains of scalding during urination. The pulse and
temperature are practically normal. The composition of the urine is but
little changed; there may be excess of mucus and a few
blood-corpuscles.
DIAGNOSIS.--This has to be made by exclusion. It is apt to be
confounded with a neurosis of the bladder or a displacement.
ETIOLOGY.--The most frequent cause is exposure to cold, especially
during menstruation; over-taxation in walking or using the
sewing-machine; excessive venereal indulgence; disorders of the portal
circulation; and the use of improper articles of food.
TREATMENT.--Every means should be employed to equalize the circulation.
The most important element is rest in the recumbent position.
Diaphoretics and warm applications to the feet and epigastrium, and, as
a rule, a saline laxative. Where there is frequent urination and
vesical tenesmus and pain, Dover's powder and camphor should be given,
or a suppository of morphia and belladonna by the vagina.
{340} Hemorrhage.
This is a symptom rather than a disease itself. It is usually due to
acute congestion or ulceration occurring in advanced inflammations, new
growths, or the lacerations caused by foreign bodies and instruments.
Hemorrhoids of the bladder due to obstructed circulation is not
infrequently the source of the bleeding. The amount of blood transuded
varies very greatly, though it is seldom so great as to prostrate the
patient. In all cases when it is considerable it is of great importance
to localize the bleeding point. The urethra can be excluded if there is
no bleeding between the acts of micturition. The differential diagnosis
between hemorrhage from the bladder or kidney is less easy. The old
rule, that the blood and urine are more intimately mixed in renal
hemorrhage than in cystic, is of little service. Sir Henry Thompson's
method of detecting the source of pus in the urine may be employed in
cases of hemorrhage. He introduces a soft catheter, and then washes out
the bladder gently with warm water; if after a time the water comes out
clear, the inference is that the bleeding point is higher up. To make
sure, he corks the catheter until a drachm of urine has collected; if
this is bloody, the diagnosis of its being extra-cystic is tolerably
certain. With the endoscope it is occasionally possible, and always
desirable, to locate the bleeding point.
The symptoms in hemorrhage from the bladder, besides the actual
appearance of blood in the urine, are much the same as those in
hyperæmia. Other symptoms liable to arise are from blood-clots forming
and either being passed by the urethra, causing its distension and
impeding micturition, or else such clots may be retained and accumulate
in the bladder, giving rise to still greater functional disturbance,
until they are either broken into small pieces by the surgeon and
extracted, or else by the slower agency of decomposition they break
down and come away.
TREATMENT.--The first thing is to obtain the advantages, both
mechanical and physiological, of the recumbent position. A large number
of hæmostatics have been used--tannic and gallic acids, ergot, and
aromatic sulphuric acid. These are doubtless of some value, but we
prefer giving opium in sufficient doses to allay the desire of too
frequent micturition, and at the same time to render the urine more
bland by alkaline diluent drinks. When the bleeding points can be
discovered with the endoscope, they may be touched with caustic acid,
nitrate of silver, or persulphate of iron. But such applications must
be made with the greatest care, lest inflammation and ulceration
result. Ice in the vagina and at the hypogastrium may be tried when
other means fail. When the hemorrhage is hemorrhoidal, due to impeded
venous return owing to pressure of the gravid uterus, the treatment
will have to be purely palliative in the mean time, as the pathological
condition of the veins usually rights itself after delivery. When a
large blood-clot forms in the bladder, experience has abundantly shown
that it is better not to meddle with it, but to let it break down
itself and come away, the patient being kept easy--if necessary by
opium and alkaline diluents.
{341} Cystitis.
Inflammation may be limited to the bladder alone, in which case we call
it cystitis, or to the urethra alone, when it is termed urethritis.
But, practically, the pathological processes and the causes of cystitis
and urethritis are so closely allied that it will be convenient in our
limited space to consider them together. Like inflammation of other
mucous membranes, various forms or degrees of cystitis and urethritis
are described: these classifications are useful clinically, but it
should not be forgotten that the pathological conditions presented are
only different stages of the same process. Inflammations of the bladder
are divided according to the cause of the disease and the character of
structural lesions into--the acute, including the catarrhal and the
suppurative; and the chronic, including the ulcerative, interstitial
(and peri-cystitis); and the specific, embracing the gangrenous,
croupous or diphtheritic, and gonorrhoeal, in which the inflammation is
the result of a special poison.
ETIOLOGY.--The causes of cystitis may be classed under four heads: (1)
Direct injuries, such as blows in the vesical region, falls, fracture
of the pelvic bones, violent copulation, sudden uterine displacements
causing pressure, foreign bodies, rough catheterization,
over-distension from retention of urine, and, above all, contusions and
injuries during labor. (2) Abnormal urine, from improper food or
malnutrition and certain irritating drugs (cantharides) and irritating
deposits of urine salts. (3) Certain constitutional diseases (eruptive
fevers, gout, ague). (4) Inflammation of adjacent organs, hyperæmia due
to cold.
PATHOLOGY.--The acute forms always begin with hyperæmia, then follow
swelling, perverted or hyper-secretion, then exfoliation of epithelium,
giving rise to a roughened and denuded state of the mucous membrane,
particularly on the top of the rugæ, the products of inflammation
accumulating within the sulci, and finally the formation of pus. A
description of these, the ordinary phenomena of inflammation of mucous
membranes, it is quite unnecessary to give here, but there are one or
two modifying conditions in cystitis that are of great importance and
need consideration. The first of these is the effect which the function
of the bladder as a reservoir of urine has on the inflammation. Normal
urine is irritating to an inflamed mucous membrane, and in cystitis it
soon undergoes decomposition, becomes alkaline, and hence more
irritating. The main agent in producing this decomposition is mucus,
which is secreted abnormally both in quantity and quality. It acts
injuriously in two ways, its fixed alkali tending to neutralize the
acid of the urine, which in the early stages of cystitis is often
hyper-acid, and in promoting the decomposition of the urea and thereby
liberating the volatile carbonate of ammonia. As the urine becomes more
alkaline the precipitation of the phosphates of lime and magnesia
occurs, and the formation of the triple or ammonio-magnesian phosphate.
The irritant effect of these salts, really deposits of foreign bodies,
on the inflamed mucous membrane completes the vicious circle, the
effect now aiding the original cause.
Another most important point in the pathology of cystitis is the effect
of over-distension of the bladder. This is itself sometimes the primary
cause of the trouble, as in certain neuroses, but more frequently it is
the {342} effect of certain injuries during delivery. The mechanism of
its production is not very clearly made out. It usually follows long,
tedious deliveries, during which either the child's head or sometimes
the forceps crushes the urethra against the unyielding pubic bones,
giving rise to an acute urethritis, with swelling of the membrane and
blocking up of the canal, causing retention. The primary injury is not
done, as a rule, to the bladder in these cases, for if it were we
should find the vesical neck the seat of sloughing of the mucous
membrane; but, as a fact, this is the part (owing to its more loose
connections with the underlying connective tissue) that most frequently
escapes. This danger of over-distension is so clearly recognized that
the catheter is nearly always used both before and after delivery if
there should be retention. But a condition more apt to mislead both the
doctor and the nurse is the urine dribbling away either constantly or
intermittently. This is too often ascribed to an irritable bladder
causing frequent micturition, when it is a sign of over-distension, the
dribbling always occurring as soon as the mechanical pressure of the
urine is sufficient to overcome the resistance of the swollen parts.
We have already referred to this condition of over-distension as a
cause of inflammation; it will suffice to say that it may, if
unrelieved, produce a partial or even total slough of the mucous
membrane of the bladder; but, fortunately, this is rare.
Thus far we have spoken of the common forms of acute and subacute
cystitis; it only remains to say a word with regard to its rarer
manifestations. The inflammation may extend to the submucous coats,
becoming interstitial cystitis. Again, this may limit itself here, or
it may extend still deeper to the serous coat, in which case it is
known as peri- or epi-cystitis. Peri-cystitis is almost always a
secondary disease, arising sometimes from deep ulcerations of the inner
coats of the bladder, such as occur in chronic cystitis. More
frequently it is but a part of a pelvic peritonitis which originated
outside of the bladder itself. The final result of peri-cystitis is to
form adhesions between the bladder and the neighboring organs, and
thereby prevent distension of the bladder.
A very rare form of gangrenous inflammation has been described, but it
is more than doubtful if this ever occurs in women except as the result
of mechanical violence or pressure, already described. The specific
lesion of croupous or diphtheritic inflammation has occasionally been
diagnosticated, either from shreds of false membrane passed by the
urethra or by means of the endoscope. Gonorrhoeal inflammation of the
bladder has been less carefully observed in women than in men. Still,
it is known that this specific inflammation extends to the bladder in
some cases, but it does not differ essentially in its pathology,
history, or treatment from that arising from other causes; hence it is
unnecessary to dwell upon it here.
The pathology of chronic cystitis is characterized by ulceration and
sloughing of the tissues involved. They do not differ materially from
the same processes elsewhere, except that the salts of the urine are
apt to be deposited upon the shreds of dead tissue the products of
destructive inflammation. The hard masses thus formed are passed with
great pain. They block up the urethra, and are only expelled by extra
strong efforts which cause intense suffering.
{343} Lastly, the ulceration may extend through the bladder into the
peritoneal cavity and give rise to septic peritonitis and death, or the
perforation may take place into the cellular tissue of the roof of the
pelvis, and cause a fatal cellulitis.
SYMPTOMS.--The various forms of cystitis being but different stages and
degrees of the same disease, their symptoms may be discussed all
together. For convenience we shall consider them under three heads: (1)
Referable to the organs themselves; (2) Symptoms referable to the
neighboring organs; (3) General symptoms.
(1) In all forms of cystitis there is more or less derangement of
function, as shown by pain, tenesmus, and frequent micturition. In the
mildest form of the trouble there is a frequent desire to pass water,
which often comes with unusual force. Micturition is followed by a
desire to strain, as if the organ was not fully emptied. This sensation
may pass off in a few moments, and not arise again till the next
micturition, but in the severer cases it may last continuously. When
urethritis is also present there is the additional and characteristic
symptom of painful scalding as the urine passes over the inflamed
track.
In urethritis alone there is often a desire to urinate frequently, but
if the desire is resisted it passes off, and the patient can retain the
urine for a long time. This symptom should not be mistaken for the
tenesmus of cystitis. In the more advanced stages of the disease,
especially as ulcerative changes occur, the tenesmus becomes more
violent. The pains also are more diffused, often shooting to the
umbilical region. There is often a dull, aching pain in the perineum,
and in nearly all cases there is continuous backache, or, more
correctly, sacral pain.
The composition of the urine is of great importance. The specific
gravity in cystitis does not present any constant change, except that
in the chronic forms it is often a little below the normal. The
reaction in acute cystitis, at first, at least, is usually acid,
whereas in the chronic forms it is almost invariably alkaline. The
color at first is not particularly altered; later, unless discolored by
blood, it is a pale, dirty yellow. The odor is normal in the acute
type, unless where retention has been followed by decomposition, but in
the chronic form it is not only ammoniacal, but has a characteristic
fleshy or organic smell. The sediment in the acute varieties is mainly
light and yellowish, composed of mucus, with some pus generally; in
addition there may be blood, epithelium, and the amorphous and triple
phosphates. In the chronic forms the sediment is usually heavier and of
a darker brownish color. Flakes of pus, shreds of tissue, blood, and
epithelium in all stages of growth are more or less present, and in the
intensely alkaline conditions of the urine the pus and mucus form a
jelly-like, ropy, opaque mass.
Albumen will be found if there is pus in the urine without there being
any kidney disease. As the result of a careful analysis of a number of
cases of chronic cystitis, the amount of albumen varied from
one-sixteenth to one-fifth of the volume of urine. Microscopically, in
addition to the pus, mucus, organic shreds, phosphatic and other
crystals already spoken of, the most interesting appearances are the
various kinds of epithelium. In the advanced stages of chronic cystitis
epithelial elements of any kind are very rarely found. It is only in
the earlier stages that normal and transitional forms of vesical
epithelium are present, and again they {344} reappear on the subsidence
of the inflammation. This fact is of great importance, because the
transitional forms of bladder-epithelium are often indistinguishable
from the permanent forms of the urinary tract higher up. It is thus
often impossible to make a differential diagnosis between pyelitis and
cystitis from this symptom alone. When renal disease is superadded to
cystitis, the characteristic casts will be found and albumen will
likely be increased in amount.
(2) The symptoms accompanying cystitis in women referable to the
neighboring organs are of some importance, but they very often arise
from some coexisting disease of other pelvic organs. It is therefore
needless to give a list of all the pelvic pains coincident with
cystitis which have been enumerated in the literature of this subject.
(3) The general symptoms are of two classes, toxic and nervous. While
all agree that there is no doubt of direct blood-poisoning in cystitis,
there has been a great deal of difference of opinion as to how this is
effected. I think that there are various agencies at work in this.
First, there may be organic renal disease or sympathetic renal
hyperæmia leading to imperfect elimination. In cystitis caused by
over-distension from long retention the kidneys simultaneously take on
acute inflammation, which usually passes off when the bladder is
emptied, but it may continue and give rise to all the constitutional
symptoms of renal disease. Again, in chronic cystitis the thickening of
the bladder-walls obstructs the ureters, so that the urine is dammed
back upon the kidneys. This arrests their function, and in time leads
to organic disease with all the consequent derangements of the
nutritive and nervous systems. Secondly, absorption of the products of
decomposed urine, or of pus and other septic materials the result of
decomposing shreds of tissue, may take place.
Anæmia is another of the blood-changes which occur in chronic cystitis.
In its origin and continuance it probably is much like anæmia due to
long-continued inflammation elsewhere. The only peculiar symptom in
this connection is the appearance of urohæmatin in the urine.