{352} abnormal constituents in the urine. As was mentioned above, these
may be so grave or their irritant action continued so long as to give
rise to cystitis. In the slighter forms, due to transient cause, the
local trouble will speedily right itself, but in other cases, such as
those dependent on functional derangements of other organs, as
dyspepsia, the irritation is apt to return at varying intervals. In
almost all these cases the immediate mechanism of the trouble is the
presence of some urinary deposits. To this may be added the
constitutional impairment, as in oxaluria, when the minute octahedral
crystals are probably not more to blame for the local difficulty than
the impairment of the nervous tone. Similarly, the poison of malaria
and of certain of the exanthemata, and of many diseases marked by
faults of assimilation and elimination, causes functional disturbance.
The prime indication in treating these cases is to render the urine
more bland by dilution. For this purpose water, aided by the salts of
potash and the alkaline mineral waters, is the best. This should always
be given on an empty stomach, and the addition of infusion of buchu is
excellent. In the condition known as oxaluria the alkaline salts are
not called for, but instead thereof acids. Nitro-muriatic diluted and
tincture nucis vomicæ tend to correct the faults of nutrition, and they
should be largely diluted to relieve the local condition.
The last class of functional diseases are caused by lesions of position
either of the bladder or of some of the neighboring organs. Here,
again, we have conditions which if sufficiently prolonged may lead to
organic vesical changes or may simply be temporary or intermittent. By
far the greater number of these are dependent on malpositions of the
uterus, which either drags or presses on the bladder. Either of these
classes may be complicated with adhesions arising from a former
cellulitis or pelvic peritonitis, the adhesions resulting therefrom
maintaining a fixation of the pelvic organs which impairs the functions
of the bladder.
Other causes of displacements are uterine and ovarian tumors, pelvic
deformities, and fecal impactions of the rectum. Of the various
displacements of the bladder it is needless to speak in much detail.
The most important is the downward one. Various degrees of this are
found up to complete cystocele, most commonly associated with prolapsus
uteri. The bladder naturally sags inferiorly as age advances, and by
far the most potent agent in causing this to become pathological is
repeated pregnancy and injuries during labor.
It is a well-known fact that the first stage of vesicle prolapsus is
apt to be marked by as great discomfort as the third, for after a while
the organ seems to become accustomed to its altered relations. The
treatment of this condition is difficult. The bladder should be
replaced and kept there. As this usually necessitates the reposition
and maintenance of the displaced uterus, it is extremely difficult, and
in case of existing adhesions it is impossible. A great variety of
mechanical means have been tried to furnish an artificial support to
keep the parts in position. If the bladder alone is prolapsed, the
pessary used for anteversion of the uterus will sometimes answer. The
instruments devised by Thomas, Grailly Hewett, and myself are most
commonly used.
{353} Acute Urethritis; Inflammation of the Urethra.
This affection may be simple or gonorrhoeal, and it is often difficult
to tell the one from the other. There is a difference in history when
we can get correct testimony from the patient. Simple urethritis
usually comes on gradually, and is often preceded by symptoms of
uterine or vesical disease, while gonorrhoea comes on rather abruptly,
and is preceded or attended by acute vaginitis and vulvitis. The chief
symptom is painful urination. Sharp scalding is produced by the urine
passing over the tender surface. There is often a frequent desire to
urinate, but not so urgent as in cystitis. In some cases the urine is
retained for a long time, evidently from a dread of the pain caused in
passing it. In quite a number of cases I have noticed hemorrhage, the
source of blood being evidenced from the fact that it was not
intimately mixed with the urine, and after micturition it oozed from
the meatus urinarius.
An examination of the parts will show signs of inflammation about the
meatus, with or without the same condition of the vulva. Occasionally
there is a discharge seen coming from the urethra, but if the parts
have been recently bathed this may not be apparent. Introducing the
finger into the vagina and pressing upon the urethra from above
downward will cause a discharge, unless the patient has passed water
immediately before. The appearance of the discharge corresponds to that
of gonorrhoea in its various stages.
Cystitis, which is liable to be confounded with urethritis, may be
excluded by using the catheter, and, after letting urine flow for a
time, collecting the remainder for examination. The mucous membrane, as
seen through the endoscope, is of a deep red, with pus or mucus lodged
in its folds. The instrument cannot be used in all cases, owing to the
acute tenderness of the parts. Bleeding is very likely to occur in the
examination, simply from the contact of the endoscope.
The TREATMENT of acute urethritis, whether specific or not, may be
conducted on the same principles as that of gonorrhoea in the male,
using the same constitutional remedies, local baths, etc. This will
suffice in most cases of acute disease, but when it assumes the
subacute form from the beginning, then the use of injections becomes
necessary. I have seen much benefit derived from douching the urethra
with water as hot as the patient could bear it. For this purpose I use
a catheter made like the fluted roller of a crimping-machine. The
catheter conveys the water to the rounded point of the instrument.
Behind the point of the catheter, where the grooves terminate, there is
a perforation in each groove through which the water returns. By this
arrangement the water, as it flows back through the grooves, is brought
in contact with every portion of the mucous membrane. The instrument is
passed up to the neck of the bladder, and a fountain syringe attached
to it, and the water as it flows away is caught in a cup.
The injection of solutions of nitrate of silver and sulphate of zinc
will often prove useful. It must be borne in mind that the female
urethra will not hold more than ten or fifteen drops, and if more is
used it will enter the bladder, even where very slight force is
employed while injecting. I use a large syringe, placing the nozzle
over (not in) the meatus, and inject slowly and without force a small
quantity. When the case is {354} of long standing, and the neck of the
bladder appears to be involved also, I use a weak injection of one or
two grains of nitrate of silver to the fluidounce, and inject it
through the urethra with force enough to enter the bladder, and let it
remain there, to be passed off when the patient urinates. In old cases
which began by a severe acute attack, and where the walls of the
urethra are very much thickened and the canal contracted, dilatation
with bougies does much good. While the bougie is passed once or twice a
week, I apply to the vaginal portion of the urethra oleate of mercury
or the unguentum hydrargyri. This will often suffice to stop the gleety
discharge, as well as remove the thickening of the urethral walls.
Inflammation of the Urethral Glands.
These glands rarely, if ever, take on inflammation primarily, but
vulvitis and vaginitis, especially if gonorrhoeal, often extend into
them. When they do become inflamed, the disease usually remains without
any tendency to subside. More than that, when a gonorrhoea affects
these glands the inflammation will remain there after all traces of the
disease have left the vagina, vulva, and urethra, and in time the
discharge from these glands will light up the original vaginitis and
vulvitis again. The symptoms of this inflammation are not diagnostic.
The physical signs are the swelling and redness around the mouths of
ducts which are located just within the labiæ of the meatus urinarius.
This give a general redness to the meatus. By pressure made upon the
urethra from above downward a purulent discharge from the ducts will be
produced and can be seen escaping. The only effective treatment is to
lay open the glands their whole length. They run upward in the
posterior wall of the urethra, so that by passing a fine probe-pointed
scissors they can be laid open on the vaginal surface. Care should be
taken to prevent the incision from reuniting, and if the inflammation
does not promptly subside applications should be made, as in the
ordinary treatment of inflammation.
Another very troublesome affection of the urethra which usually results
from urethritis is granular erosion, as it is called. The mucous
membrane is covered with young, imperfectly-developed epithelium; the
papillæ are hypertrophied and extremely sensitive. This gives rise to
the most excruciating pain during micturition, and generally keeps up a
distressing tenesmus. This disease is rarely seen except among old
people. The diagnosis is made from the history and appearance of the
urethra. The treatment is cauterization of the whole surface. The
milder washes and injections do not accomplish much. Pure carbolic acid
may be tried first, brushing it over the surface and repeating it in
eight or ten days. This is the least painful application, and generally
answers very well. When it fails a solution of nitrate of silver (one
drachm to the fluidounce) should be used. In obstinate cases it is
desirable, before using strong caustics, to dilate the urethra, and
then touch it with a 50 per cent. solution of carbolic acid.
{355} Circumscribed and Subacute Urethritis.
Among the inflammatory affections of the female urethra there are mild
forms which fall short of well-marked urethritis. Indeed, some of these
attacks amount to little more than congestion or slight catarrh. In
others circumscribed patches of the urethra become inflamed, the rest
of the canal remaining normal.
The cause of this affection is generally some inflammation of other
pelvic organs, such as cellulitis. In one case it occurred in a
saleswoman who had been upon her feet many days from early morning
until late at night. I found several small ecchymoses on several parts
of the mucous membrane with zones of inflammation around them. The
long-continued passive congestion had caused some of the small vessels
to rupture, and the small blood-clots started the inflammatory process.
These cases tend to recovery if the patient is placed under favorable
conditions. If there is much pain, and if the trouble appears to be
tending to become chronic, mild injections may be employed.
Dilatation of the Urethra.
Dilatation of the whole urethra is not so common as dilatation of a
portion of it. Even when the whole canal is larger than it should be,
it is not, as a rule, uniformly so. In general, the urethral walls and
the urethro-vaginal septum are usually enlarged, relaxed, and flabby.
After a considerable time they may become indurated by infiltration or
hyperplasia of the connective tissue. The mucous membrane is usually
soft and loosely adherent to the subjacent tissues. Beneath the
membrane there are sometimes masses of enlarged veins which give a dark
bluish appearance to the parts. If the meatus be distended like the
rest of the urethra, the mucous membrane with the large veins beneath
it may protrude and form a tumor or tumors, which have quite the
appearance of rectal hemorrhoids. This is especially so when the veins
are large and numerous and the mucous membrane thin, so that the color
of the veins can be seen through it. On the other hand, if the meatus
remains normal in size, nothing will be seen by the examiner until the
catheter or sound is passed into the urethra, when the distended or
distensible condition of the canal will be detected. The dilatation can
be easily detected, even when the meatus is normal in size, by
observing that the sound can be moved about in the urethra, conveying
the same impression obtained when the sound passes into the bladder. By
making a digital examination of the vagina the enlarged urethra can be
felt, and it is usually elastic and compressible. Through Sims's
speculum the abnormal fulness or bulging of the anterior vaginal wall
can be plainly seen and distinguished from displacement of the urethra.
The points of difference between dilatation and displacement will be
brought out more in detail farther on.
When the dilatation has existed for any length of time, the mucous
membrane is usually hyperæmic, and sometimes catarrhal, secreting a
muco-purulent material, which may be seen escaping from the meatus or
lodged in the folds of the membrane, where it can be seen through the
{356} endoscope. When the mucous membrane is prolapsed and forms a
tumor outside of the meatus, it soon becomes fissured and ulcerated,
and consequently very tender and painful. This condition is produced by
the retarded circulation, chafing, and the irritation from exposure to
the air and the urine passing over it.
Dilatation of the anterior or lower third is the rarest of all forms of
urethral dilatation, and occurs usually as a consequence of some
enlargement or swelling of the mucous membrane, neoplasm of the
urethra, or mechanical dilatation. The dilatation may or may not
include the meatus. In rare cases it does not at first, but in time the
enlarged mucous membrane slowly, sometimes rapidly, dilates the
orifice. The general appearances of the parts are the same as those of
which I have spoken under the head of dilatation of the whole urethra.
When the dilatation is due to any new growth in the urethra, the tumor
can be seen on inspecting the parts.
I have only seen one case where the lower end of the urethra was
dilated without any recognizable cause for it. This was a single lady,
thirty-five years of age, a school-teacher. She had displacement of the
uterus and catarrh of the cervical canal, for which she consulted me.
She had no trouble with her urinary organs. While examining the uterus
I noticed that the meatus urinarius was peculiarly formed. In place of
the concentric corrugations of the mucous membrane which form the
closed meatus, the orifice was funnel-shaped and lay open when the
labia minora were separated. About half an inch of the lower end of the
urethra admitted a No. 21 (Eng.) sound. The remainder of the urethra
was normal, and there were no signs of disease about the mucous
membrane of the dilated portion. I could obtain no history which
pointed to the origin of the trouble, and it caused no discomfort to
the patient.
Dilatation of the posterior or upper third occurs in connection with
other pathological conditions, such as prolapsus of the bladder and
urethra. On this account we will defer what is to be said on this
subject until we come to dislocations of the urethra.
Dilatation of the middle third of the urethra is more common than that
of any other portion of the canal. In this form the anterior wall of
the urethra maintains its normal position, but the central position,
being distended, settles down, so that in time the urethra, in place of
being a straight or slightly curved canal, becomes triangular, the
upper wall being the base, and the central portion of the wall (that
is, midway between the neck of the bladder and the meatus) the apex. A
sac or cavity is thus formed in the central portion of the urethra.
In the earlier stages of this affection the urethra in front and behind
the pouch is really or apparently contracted; but as the disease
progresses the upper part of the canal and the neck of the bladder
become dislocated downward, and finally the upper portion of the
urethra becomes also dilated to some extent.
There is in this as in the other forms of urethral dilatation frequent
urination, usually more marked, but, unlike the others, there is
difficulty in passing water. This frequency of urinating, and the
straining efforts necessary to do so, affect the bladder, producing
irritation, and in time hypertrophy of its walls. Cystitis also follows
in the order of morbid developments; but whether that comes from the
frequent and difficult {357} urination, or from extension of the
inflammation from the urethra to the bladder, is a question.
ETIOLOGY.--The hyperæmia of the urethra which occurs in pregnancy, and
which tends to produce over-distension of the veins, favors dilatation
of the whole urethra. There is an apparent increase of tissue in the
walls of the urethra during utero-gestation, and the dilatability of
the canal is often increased also. Now, this condition of the parts
disappears during the involution which takes place after delivery; but
when from any cause the process of involution is interrupted, the
enlarged vessels and relaxed condition of the urethral walls remain and
sometimes increase. When to this state of the parts a catarrh of the
mucous membrane is added, the enlargement of the membrane by swelling
still further increases the calibre of the canal.
The dilatation caused by the passage of calculi may remain permanently,
and the same may be said of the use of large sounds. Neoplasms
obstructing the meatus or stricture at that point may so obstruct the
escape of the urine as to cause dilatation at all points above. This is
no doubt one of the most important and frequent causes of dilatation.
I have already stated that dilatation of the lower third of the urethra
is rare, and is usually due to inflammation of the mucous membrane at
that point or to abnormal growths, the distension remaining after the
causes that produced it have been removed. This and mechanical
dilatation from any cause cover the etiology of this form of the
trouble. Baker-Brown says that the meatus is always dilated when there
is stone in the bladder.
Regarding dilatation of the upper third of the urethra, I am inclined
to believe that it occurs in consequence of a partial prolapsus of the
bladder and the upper end of the urethra. The displacement of these
parts implies a relaxation of the tissues, caused originally, it may
be, by injuries during confinement, and the prolapsus permits an
unusual pressure of the urine upon the upper end of the urethra, and
dilatation is the result. On the other hand, the prolapsus and
accompanying relaxation of the urethral walls may be sufficient to
cause the dilatation. In all the cases that I have critically examined
there has been displacement as well as dilatation, and the whole
trouble could invariably be traced to childbearing or anteversion of
the uterus.
One cause of dilatation of the middle third of the urethra
(urethrocele) has been sufficiently dwelt upon in Bozeman's description
of the pathology of that affection--that is, narrowing of the lower end
of the urethra. This does not explain the etiology of all cases,
however, for I have seen this form of dilatation where there was no
stricture or hypertrophy of the lower end of the urethra. In such cases
I have traced the cause to childbirth, during which the posterior wall
of the urethra had been pushed downward and contused, while the upper
remained in its normal position. The relaxation caused by this
over-stretching of the urethral wall formed a small pocket in the
central portion, which gradually dilated more and more by the pressure
of the urine until the urethrocele was fully developed. This
explanation of the cause may be rather hypothetical, but, so far as my
observations go, it agrees with the facts found in those cases which
cannot be accounted for by Bozeman's views on the pathology of this
affection.
{358} SYMPTOMATOLOGY.--The symptoms vary according to the extent of the
dilatation, the portion of the urethra involved, and the condition of
the mucous membrane. When the whole urethra is dilated the only symptom
present may be frequent urination. When there is inflammation or
prolapsus of the mucous membrane, then pain will be caused by passing
water, and the desire to do so will be more urgent and frequent. The
patient may also be annoyed by a slight loss of control of the water,
under the pressure of lifting heavy weights, coughing, or the like.
Dilatation of the lower third of the urethra does not cause any
derangement of function, unless accompanied with inflammation or
ulceration; then there will be frequent urination possibly, and painful
urination certainly. The symptoms in this form of dilatation are less
marked than in the other varieties.
When the trouble is located in the upper third of the urethra, the
symptoms are sometimes very distressing. In addition to the
frequent--it may be constant--desire to pass water, the patient is
tormented with partial incontinence. Coughing, laughing, sneezing,
stooping to lift anything, a jar on stepping from the curbstone in
crossing the street, causes an escape of urine. This distresses the
patient very greatly. From the constant wetting of the external parts
they become inflamed, unless very great care is taken to keep them dry
and clean. In some of these cases the mortification of mind is
sometimes more distressing than the physical suffering.
The symptoms occuring in dilatation of the middle portion of the
urethra are the same as those already given, with the addition of a
slight mechanical obstruction which causes difficult urination; that
is, more voluntary effort is necessary on the part of the patient to
empty the bladder. The forcing, straining efforts made by some of these
patients while urinating are even greater than the mechanical
obstruction appears to account for. This may be due to the accumulation
of urine in the urethra, which excites extra reflex action in the
bladder and urethra out of proportion to the obstruction. This is the
only way that we can account for the difficult urination and muscular
hypertrophy found in those cases in which there is no great obstruction
from stricture.
The constitutional symptoms arising from these urethral troubles are
the same as those produced by urethritis, and are not peculiar to this
class of affections. In fact, the symptoms here given may all be
produced by other pathological conditions, and consequently cannot
alone guide to a correct diagnosis. The true character of the trouble
can only be discovered by physical exploration.
DIAGNOSIS.--A digital examination by the vagina will detect the
increased space occupied by the urethra. The canal encroaches upon the
anterior vaginal wall, and feels like a ridge extending from the meatus
to the neck of the bladder. This elevation or thickening of the urethra
is elastic and compressible in recent cases; in those of long standing
the tissues are firm to the touch, but still the canal is compressible.
The extent of the dilatation, if general or located in the lower parts,
can be measured by the size of the sound that can be easily passed. If
at the middle or upper portions, an ordinary female catheter or sound
may be used to explore it. By introducing that instrument and pressing
it first against the anterior wall and then upon the posterior, the
distance between {359} the two can be approximately made out. While the
catheter or sound is in the urethra the finger should be introduced
into the vagina to ascertain the thickness of the urethral wall. This
will differentiate between dilatation and hypertrophy.