symptoms are developed. There is an effort made to eliminate urea by
the mucous membrane of the alimentary canal. This is manifested by
attacks of vomiting or diarrhoea. But when it does not come to these
explosions, there is apt to be lack of appetite, especially at the
morning meal, or there are perverted taste and constipation,
interrupted by occasional attacks of diarrhoea. The skin in the chronic
cases is at times sallow and clammy, and at times there is a distinct
urinous odor about the body. Various more or less marked nervous
symptoms are apt to be present. One set is characterized by the
sluggishness of the patients, an inclination to sleep, despondent
spirits, and occasionally dizziness and fainting. There can be little
doubt that these and allied symptoms are referable to cerebral anæmia,
for they are much aggravated by bromide of potassium, whilst digitalis
and out-door life improves them. A second set of nervous symptoms are
fairly attributable to blood-poisoning of one kind or another, and in
the most severe cases are often promptly relieved by diarrhoea.
Finally, a number of the irregular, wandering neuralgic pains and the
headache are due to the general depression produced by bladder-pain and
loss of sleep.
DIAGNOSIS.--Cystitis is easily made out, except in certain mild cases.
{345} Similar symptoms, especially frequent urination, occur in
prolapsus uteri, often in anteversion and in cases of pelvic adhesions
and pregnancy and abdominal tumors, and lastly in certain neuroses. In
most of these the recumbent position lessens the desire for frequent
urination much more than when cystitis is present. Again, in the
neurosis the attacks are irregular. Tenesmus is usually only present in
cystitis, and lastly the examination of the urine and exploration of
the parts should settle the question. We have spoken above of the
method of differential diagnosis of blood coming from the bladder or
the kidneys: the same method applies to localizing the source of pus.
Urethritis with fissure at the neck of the bladder simulates cystitis
in clinical history, and in the fact that pus in small quantity is
found in the urine. To differentiate, the urine examined should be
taken directly from the bladder with the catheter, when it will be
found free from the products of inflammation. In addition to this, in
some cases it will be necessary to make use of the endoscope, by which
a good view can be obtained of the whole urethra and a portion of the
mucous membrane of the bladder sufficient for diagnostic purposes.
TREATMENT.--The female bladder is so accessible, owing to the shortness
of the urethra, that it is peculiarly amenable to local treatment. This
is by no means, however, all that is required, for in all forms of
cystitis, irrespective of the cause, the urine plays a very important
part in keeping up the irritation. There are, therefore, always three
indications to be met: (1) Removal of the cause; (2) constitutional
treatment (diminishing the irritating character of the urine); (3) the
cure of the local lesion.
(1) In many cases, of course, the cause is transient. The injury is
done, and the inflammation resulting runs its course, longer or shorter
according to the modifying influence of treatment. In a smaller number
of cases, again, the cause is not removable, as in certain
constitutional diseases or permanent pelvic adhesions, tumors, and the
like. In such cases of course the treatment is but palliative, and,
while relieving the immediate symptoms, aids the organs till a certain
amount of toleration of the abnormal conditions is established. But in
a large class of cases the cause, though more or less persistent, is
removable. This includes the numerous cases of uterine displacement.
Lastly, there is a certain number of uncomplicated cases which tend to
recovery without treatment.
(2) The constitutional treatment should be first directed to reducing
the amount of work the bladder has to do. For this purpose the bowels
should be kept rather freely open, saline laxatives being the most
valuable for this purpose. The skin too should be kept healthy and
active. Next, the character of the urine should be as bland as
possible. Food and drugs which are known to cause or keep up cystitis
should be carefully avoided. Milk diet has proved successful in the
hands of George Johnson. In all cases the diet should be carefully
attended to, and should consist largely of fluid foods--milk, yolk of
eggs, soups, etc. Lean meat in small amounts and easily-digested solids
are allowable. Articles such as asparagus, alcohol, beer, and wine
generally are to be avoided. Fruits, such as lemons and oranges, are
usually grateful and at least harmless. The alkaline diluents, such as
citrate of potassium or the alkaline mineral waters (Vichy), answer an
admirable purpose. An infusion of buchu is an excellent agent, and may
be combined with nearly {346} all other drugs employed in treating
cystitis. Where pain is an urgent symptom in acute cases, it should be
relieved by hot applications and by anodynes. Dover's powder is an
excellent form in which to give opium. To relieve tenesmus vaginal
suppositories of morphia, with or without belladonna, may be given. But
in certain cases twenty-grain doses of potassium bromide every four
hours relieve pain where opium fails. Benzoic acid or benzoate of
ammonium in ten-grain doses in infusion of buchu, three times a day, is
a most valuable remedy. The usual remedies, such as balsam of Peru or
copaiba, oil of turpentine, etc., which are given in gonorrhoeal
inflammation, are very useful in the chronic catarrhal forms of
cystitis. To prevent or lessen the decomposition of the urine a vast
number of remedies have been employed, all of the astringents and most
of the antiseptics, but as a rule these remedies are much better
administered locally than constitutionally. In various acute and
transitory cases the constitutional remedies above described will be
all that is necessary, but in the greater number local treatment is
absolutely required.
(3) In local treatment the first point is not to do harm to the parts
by the use of instruments. Dirty catheters and rough catheterization so
often cause cystitis that it is easy to see that the same causes often
perpetuate the mischief. Great care, then, should be used in selecting
instruments for injecting. The ordinary metallic catheter with one or
two large openings is much more liable to wound the sensitive mucous
membrane than one with a number of small holes made either of hard or
soft rubber. It should have a stopcock or something similar at the
outer end, the better to regulate both the injections and the escape of
the solution injected. In ordinary injections only about an ounce at a
time should be in the bladder; this can be repeated four or five times,
and the injection should be as slow as possible. To meet these
indications I use a double perforated catheter made as follows: A small
tube runs from one of the bifurcations to the extreme point. This is
the supply-tube, and the catheter acts as the exhaust. The central tube
can be removed for the purpose of cleaning the instrument. A piece of
rubber tubing attaches the supply-tube to a fountain syringe, and this
completes the whole apparatus. The calibre of the supply-tube being
small and that of the exhaust large, a great quantity of fluid can pass
through the bladder without distending it. The fingers can pinch the
rubber tube and act as a stopcock to regulate the entrance and escape
of the fluid used.
An injection of borax and water is often highly beneficial, and is
alone sufficient in many cases. It should be frequently employed. It
should always precede any topical application or medicated injection.
Lukewarm water alone is employed, but the addition of a little salt
(drachm j to pint j) or chlorate of potassium renders it more bland.
Very often hot water is a most useful application. Of the medicated
injections a vast number might be described, but they are referable to
two classes, anodyne and astringent. The painful nature of cystitis
suggests the use of opium preparations and chloral hydrate for
injections, and they do give some relief. They should be well diluted
to prevent their causing irritation.
Of the astringents, acetate of lead, sulphate of zinc, tannic acid,
nitrate of silver are the most valuable. Many others--perchloride of
iron, chlorate of potassium, hydrastis canadensis, salicylic acid and
its preparations, carbolic acid, etc.--have been commended. In all
cases the strength of {347} the injection should be short of causing
the patient much pain. It is always best to begin with a mild solution
and gradually feel the way up to stronger ones. Of all the astringents,
I prefer nitrate of silver, which I use in strengths varying from one
grain to twenty to the fluidounce. The general rule to be observed, if
a strong solution is used, is to employ only a few drops; if a large
injection is made, the solution should be weak.
Various antiseptics--iodoform, salicylate of sodium, etc.--have been
used to prevent the decomposition which so complicates obstinate
cystitis; but, as a rule, I think frequent washings out and astringent
applications act much better. One of the most distressing obstacles
encountered in making any such injections is where there is a tender or
inflamed urethra. It is well then to carry the catheter only up to the
sphincter of the bladder (as advised by Braxton Hicks), overcoming its
resistance by the pressure of the injection. As a rule, the urethritis
will not long survive the cystitis, but in some cases it exists as an
independent affection; it is then usually gonorrhoeal, and should be
treated as in the male. But when not, the same principles apply as in
the local treatment of the bladder. Great care is needed, as the female
urethra will only hold ten or fifteen drops at a time, and if a large
injection is used it is almost sure to enter the bladder. To meet this
difficulty I devised a reflux catheter for douching the urethra. It is
grooved on the outside, and at the point there is an opening in each
groove which lets a jet of the fluid used flow outward, bringing the
injection in contact with all parts of the urethra.
In cases of ulceration, such as occur in bad cases of cystitis,
applications should be made, if possible, to the part affected only.
This can be accomplished by means of the endoscope when the ulceration
is seated where it can be reached. Having located the point exactly by
means of the endoscope, the inner or glass tube is withdrawn, and the
application made directly to the required spot through the rubber tube.
A glass pipette properly curved or any ordinary insufflator will answer
perfectly, and when a solid is used a delicate long curved forceps will
answer.
In chronic cases of cystitis in which all the above methods of
treatment fail, it becomes necessary to give the parts complete rest by
securing continuous drainage of the urine and products of inflammation.
There are two ways of doing this--the one, to use a self-retaining
catheter which may keep the bladder empty: this method answers very
well when the inflammation is confined to the upper portions of the
bladder, but when the neck of the bladder is involved the presence of
the catheter gives rise to pain and irritation and cannot be tolerated.
The other plan is to establish an artificial vesico-vaginal fistula,
and keep it open for some months, until the bladder-walls have become
normal again. This secures efficient rest to the inflamed parts;
complete drainage is established, the patient wearing a cup, as she
would a pessary, to catch the urine. If the inflammation is limited to
the upper portion of the bladder, the drainage by the fistulous opening
is all that is required; but if the neck of the organ is involved,
frequent and continued medication will be required. This can be done by
injecting through the urethra and letting the fluid escape through the
opening in the bladder. This is not the place to discuss the steps of
the operation or the indications when and how to close the artificial
fistula. For these the reader is referred to works on this department
of surgery.
{348} Suffice it to say, in conclusion, that this by no means easy
operation should be only undertaken as a last resort, but that if
properly done in well-selected cases it will cure where all other known
methods of treatment have failed even to relieve.
Hypertrophy of the Bladder.
This lesion may be partial or total, involving any or all three coats
of the viscus. But the term usually refers more particularly to
increase of the muscular walls. As a rule, the hypertrophic changes are
not confined to one portion of the viscus, all being more or less
affected. The affection is much less frequent in the female than the
male.
ETIOLOGY.--There are two varieties of this affection--one, concentric
hypertrophy, in which the bladder is contracted as well as having its
walls thickened; the other eccentric, in which there is dilatation. Its
principal causes are--obstruction to the outflow of urine from
stricture of the urethra, tumors, or foreign bodies; cystocele,
preventing complete evacuation; cystitis, causing too frequent or too
forcible contraction; and irritable bladder in certain of the neuroses.
Accompanying such dilatation diverticulæ are sometimes formed, though
rarely in the female.
SYMPTOMS.--There is sometimes present vesical spasm, some pain, and
forcible ejection of urine. A certain amount of cystitis is almost
always present, aggravating the original disorder. In the eccentric
form there are sometimes superadded symptoms of over-distension.
DIAGNOSIS.--This is readily made by measuring the thickness of the
bladder-wall between the finger in the vagina and the sound in the
bladder. The capacity of the bladder is easily noted by measuring the
urine passed at each micturition or by injecting a bland solution of
salt and lukewarm water.
TREATMENT.--The treatment should be directed to the removal of the
cause. When this is not possible, palliatives may be sought for in the
use of the catheter, at regular intervals, to prevent over-distension.
Cold baths, astringent injections, and electricity are often of use. By
these means the evil results of the disease may be overcome, but the
hypertrophy is usually permanent.
Atrophy.
Atrophy of the bladder is a rare disease in early life. In women, in
addition to the ordinary decay of age, there is a special
predisposition to degenerative changes in the pelvic viscera, the
bladder-walls included, after the menopause. Extreme distension of the
bladder is usually the exciting cause, giving rise to temporary or even
permanent paralysis, and eventually causing either inflammation or
atrophy and fatty degeneration. Interrupted nutrition, due to impaired
circulation, is the immediate cause, but such altered nutrition may be
purely nervous and due to atrophy of certain ganglion-cells in the
spinal cord.
SYMPTOMS AND DIAGNOSIS.--Patients complain of difficulty in emptying
their bladders, the urine coming away in interrupted jets. They are
{349} apt to be irregular in their times of urinating, and are liable
in consequence at times to have retention and over-distension. Pain and
sometimes a slight cystitis are present. Finally, they completely lose
the power of urinating and a catheter has to be used. The diagnosis is
to be made as in hypertrophy, by a finger in the vagina and a sound in
the bladder.
TREATMENT.--Regular catheterization, strychnia in full doses,
electricity, and tonics, combined with washing out the viscus. Where
the atrophy is due to nerve-degeneration these measures are purely
palliative, in other cases they are of more avail.
FUNCTIONAL DISEASES OF THE BLADDER.
Under the name of functional diseases of the bladder are included a
large number of varied affections of which the pathology is as yet very
obscure. Where there are marked symptoms of vesical disorder, while no
organic lesions are found in the tissues of the bladder, the affections
must be classed under the name of functional derangements. As our
knowledge increases the number of these is constantly diminished, and a
still further and more rapid diminution will occur as the physiology
and pathology of the nervous system innervating this viscus become
better known. These diseases are much more common in children and women
than in men--in children, because the controlling power of habit is
only in process of formation; and in women, mainly because of the more
complex organization of the genito-urinary organs, which are the more
easily exhausted and deranged, especially by the functions of
maternity. True, neuralgia of the bladder has been described under a
variety of names, irritable bladder, cysto-spasm, etc., but it is
rather a rare affection. The most prominent symptom is the painful
micturition, and attendant on this a desire to pass water too
frequently.
There is no particular change in the character of the urine, and no
appreciable visible alteration in the appearance of the parts, though
they are more sensitive than normal to the touch. This condition is
best met by warm fomentations locally and sedatives either locally or
generally, while nutrition is improved by appropriate tonics, nervines,
and by the use of the galvanic current.
A much more common class of affections of the bladder accompany
hysteria, sometimes grouped under the name of hysterical bladder. A
great number of pathological conditions are grouped under this vague
term, but they are held together by all having, as a more or less
prominent symptom, varying degrees of incoördination. The disturbing
effect of strong sudden emotion, as fear, upon the bladder is familiar
to all, and in various organic diseases of the spinal cord and brain,
such as myelitis and locomotor ataxia, a disturbance in the functional
action of the bladder is among the first symptoms. It then becomes a
matter of great difficulty, and yet of great importance, to make a
differential diagnosis.
In hysteria the urine usually diminishes in specific gravity; it is apt
to be increased in quantity, and, though clear in appearance, is
irritating {350} to the mucous membrane. In such cases frequent
urination, sometimes almost continuous, sets in; but it is an important
point that during sleep the patient retains her urine the normal time.
In others we get, on the contrary, retention, and this may be due to
various causes. In some it is doubtless involuntary, as they say they
cannot urinate, but in others it is assuredly will not. Many of these
latter derive a morbid pleasure from catheterization. These are the
patients who are given to the introduction of hair-pins, slate pencils,
etc. etc. into the urethra.
Some authors claim that in the intense sexual excitement of hysteria
the chronic erection of the clitoris makes pressure on the urethra, and
so prevents the escape of urine, but this seems somewhat apocryphal.
Another class of cases resembling the hysterical in the frequency of
urination are those addicted to masturbation; these are, fortunately,
not very common.
In all of these cases the frequency and irregularity of urination is a
much more prominent symptom than the pain. This latter is usually a
slight scalding from the urine passing over the chafed and irritable
urethra, especially at the meatus. (These symptoms sometimes occur in
the miasmatic affections.) A number of neuroses of the bladder are
reflex and dependent on peripheral irritation elsewhere. A typical
example of this class of affections is what has been described under
the title of ovarian irritation. In this condition there is very much
heightened reflex irritability accompanying the increased tenderness
and vascular engorgement of the affected ovary. It is difficult to
explain the bladder symptoms which sometimes accompany the recurring
crises of this disease, except as due to a nervous excitation spreading
from the ovarian centres in the spinal cord to the adjacent bladder
centres.
The diagnosis of this group of affections must be made by exclusion. We
have some of the same symptoms--increased frequency of micturition,
pain during and after the evacuation, tenesmus and shooting pains in
the pelvis--as in organic disease. The most important guide is a
careful examination of the urine, which shows the absence of abnormal
constituents, thereby excluding organic disease. This diagnosis will be
much strengthened by a digital examination, by the vagina, of the neck
of the bladder, and the passage of a urethral sound, neither causing
pain, as they would do in cystitis.
The PROGNOSIS is usually good, but it depends upon the length of time
the affection has lasted.
The TREATMENT is mainly tonic and nutritive. The diet should be
nutritious and simple, and the bowels regulated by mild purgatives.
Constitutionally, small doses of strychnine are most valuable in
improving the nerve tone; so also the constant electric current is of
service. Locally, sedative suppositories in the vagina or enemata are
advantageous, conium combined with belladonna or hyoscyamus seeming to
act best. The liberal use of the bromides gives good results in some
hysterical cases.
Paralysis of the Bladder.
This is the most grave of the functional affections, and, like
paralysis elsewhere, it may be either peripheral or central. When the
latter, as in {351} certain injuries of the brain or in certain
well-marked lesions of the spinal cord, it hardly calls for more than
mention here. Often, however, the cause is not recognizable in any
organic lesion either of the bladder-walls or the central nervous
system, and is to be sought for in more temporary and transient
influences; thus as a result of over-distension most frequently, of
impaired or lost nerve-conduction in fevers involving serious
derangements of nutrition, all of which may be described as functional
or temporary paralysis.
The invasion is usually gradual, except in apoplexy or traumatism. The
patients, who are usually advanced in years, first observe that the
urine is expelled from the bladder with less force than usual; the
stream is smaller and comes slower, and straining takes place, the aid
of the abdominal muscles being invoked. After a while the stream
intermits, and finally partial or complete retention occurs. Then, if
this condition continues, the sphincteric resistance gives way and
constant dribbling occurs. In rare instances dilatation of the
bladder-walls takes place, and finally cystitis. Dilatation of the
ureters and hydro-nephrosis are not uncommon under these conditions.
Where the condition of retention obtains the DIAGNOSIS ought never to
be difficult; the introduction of a catheter will conclusively settle
it.
The PROGNOSIS in uncomplicated paralysis is usually good. When
accompanying fevers, dysentery, peritonitis, etc. it usually disappears
with the original disease. When due to centric lesions the outlook is
about hopeless.
In all cases the bladder should be emptied at stated intervals. If the
patient cannot do this herself, the surgeon should resort to the
systematic use of the clean soft Jacques catheter. A most important
point, too often overlooked, is the method of emptying an
over-distended bladder. It is not safe to empty the bladder at once:
the patient ought to be tapped at intervals, an abdominal binder being
gradually tightened meanwhile. The too sudden removal of pressure from
the vesicle walls which have been rendered anæmic allows of intense
congestion, and in a condition of paralysis is the sure prelude to
cystitis. The diet in these cases should be generous and stimulants are
not contraindicated.
I cannot agree with those authors who recommend washing out the bladder
with medicated solutions and forcibly distending the urethra, nor with
those who use tincture of cantharides as a vesical excitant. Both plans
are apt to produce cystitis. A far more rational though somewhat
impracticable treatment is the use of electricity as recommended by
Winckel--one pole (thoroughly insulated up to the point) in the
bladder, the other on the symphysis or loins. The sitting should last
about five minutes. But by far the most valuable therapeutic agent is
strychnia, which should be exhibited in full doses, many of the
reported failures with this drug being due to too small doses. In
urinating the upright position is generally preferable to lying down,
as the pressure of the abdominal organs to some extent compensates for
the lack of tonicity in the bladder-walls.
Lastly, in these hopeless cases of complete paralysis an artificial
vesico-vaginal fistula and the adaptation of an apparatus to catch the
urine may be of service.