INFLAMMATION, CATARRH, AND OTHER DISORDERS OF THE BLADDER.
THE female bladder is easier approached than that of the male. This
is clearly illustrated in the anatomical Plate II, which should be
thoroughly studied before this chapter is read.
The bladder lies directly behind the symphysis pubis, above or in
front of the vagina. On account of the comparative shortness of the
female urethra, to that of the male, the cavity of the bladder is also
much more accessible through this channel, and if access through this
communication does not suffice, then the interior of the female bladder
may be exposed by an incision through the anterior wall of the vagina,
but this resource becomes rarely necessary. Formerly we had to content
ourselves with external appearances, that were confined to the external
anatomy of the urinary canal on the anterior vaginal wall, aided only
by a delicate sense of touch. Valuable as these means of examination
sometimes were, they were far from satisfactory to either physician or
patient. Now we are able to examine with the finger, aided with the
eyes, almost the entire lining of the bladder.
Professor Simon, of Heidelberg, was the inventive genius of this
improved method of examination, by means of a series of graded specula
or hard rubber bougies, which are known by his name. The specula are
simply small, smooth, pin-shaped, hard rubber bougies, about three
inches in length, beginning with a size that is three-tenths of an
inch in diameter, to the largest, which is eight-tenths of an inch
in thickness. These are carefully introduced into the urethra,
commencing with the smallest size, which is retained for a few minutes
and then withdrawn, and the next size inserted, and this continued
until the largest one has been inserted, or the required dilatation
accomplished, either for the purpose of introducing the finger into
the bladder, or exposing its lining membrane for inspection. While
this procedure does not fall into the sphere of home treatment, it
is of sufficient interest to women in general that they should know
what can actually be accomplished by the expert specialist. Were I
to review the malformations, or dislocations, of the bladder, or the
history of stones in the bladder, or other foreign bodies, that the
female specialist is very seldom called upon to treat, I should only
worry the patience of the reader with things that she would not readily
understand. The same is true of growths and tumors of the bladder,
which have principally a scientific interest for the practitioner of
medicine, but for the casual reader they are too profound in their
details for a clear understanding.
INFLAMMATION.
Inflammation of the bladder is in medical language termed cystitis.
It presents itself under two varieties or subdivisions, _acute_ and
chronic, depending on the duration, whether recent or protracted.
The disease begins in the mucous membrane, and the acute inflammation
comes on suddenly. It rarely occupies the entire mucous surface of the
bladder, but usually occurs in irregular spots. Some spots are as large
as the palm of the hand, while others are only the size of a ten-cent
piece. The parts that are most frequently affected, are the neck of
the bladder and its posterior wall, although no portion of its lining
membrane is exempt from inflammation.
It rarely happens that the inflammation spreads over the entire extent
of the bladder, or that it invades the muscular tissue; if it should
complicate the latter, it would involve the peritoneum; this would add
a very serious complication, namely, a peritonitis. Cystitis may be due
to an extension of gonorrhœal infection from the vagina and urethra,
or from other purulent affections. Women who are unable to pass water
after confinement, may be liable to the disease from retained urine,
decomposing in the bladder and causing inflammation. On the other
hand, a filthy catheter used by a midwife or doctor who is careless
or ignorant of the necessary antiseptic precautions, and who fails to
brush and boil out the catheters, and uses one catheter on different
patients, without the precaution of even thoroughly rinsing it, may
give rise to dangerous cystitis. The most serious case that I ever have
seen was directly traceable to this cause. If impure air gets into the
bladder this will also excite cystitis; to prevent that, is to close
with the finger the outlet of the catheter that is used for drawing
off the urine, when withdrawing the instrument, a precaution seldom
observed.
Newly-brewed malt liquors, alcoholic stimulants taken in excess,
diuretics of spirits of turpentine and cantharis, or highly-seasoned
and rich food, are among the exciting causes; irritating injections
into the bladder or vagina, and even cold-water injections into the
vagina, must be added as exciting causes of this painful affection.
Venereal excesses operate in exciting visceral inflammation, and when
the slightest symptoms are felt, prudence and good common sense dictate
continence. The first feeling that manifests itself is a dull, heavy,
aching sensation, immediately after urinating, and an involuntary
inclination to further relieve or empty the bladder by pressing or
bearing down. Soon after the first indication to void urine, there
is another desire to empty the bladder, and the same symptoms repeat
themselves, only in a more aggravated form. The distress of micturition
gradually becomes continuous so that during the short intervals between
the times that urine is voided, and as the disease progresses, the pain
becomes sharper. This is accompanied by a kind of gnawing uneasiness
in the region of the whole bladder, which has intermissions, but
is greatly increased when the desire to make water is felt. If the
disease progresses, the pain is now felt in the neighboring organs and
a general constitutional disturbance manifests itself. The patient
will now generally have a severe chill; this is followed with heat
and thirst and an increase in the pulse. The desire to void urine
at shorter intervals becomes more prominent and only drop by drop,
accompanied with distressing spasm and a burning sensation along the
urinary canal.
The region of the bladder becomes in the advanced stages of
inflammation extremely sensitive and tender, and if the peritoneum is
involved, even the weight of the bedclothes becomes intolerable. The
limbs are drawn up and the body is inclined forward to relieve the
tension of the abdominal muscles and their pressure on the bladder.
The neighboring organs begin to sympathize with the advanced state of
the inflammation at this stage; cutting pains are felt in the rectum,
while darts of pain shoot from the bladder towards the groins and
ovaries.
Owing to the spasmodic action of the urethra, the bladder is never
completely emptied so that the urine gradually accumulates in abnormal
proportions; the retained urea rapidly decomposes into ammonia and the
urine becomes very hot and irritating, thus greatly augmenting the
suffering. Under these circumstances, the bladder may become greatly
distended and feel as a sensitive globular tumor above the pubis. The
retention of the urine may be complete, owing to a partial paralysis of
the bladder and now complicated with spasmodic stricture. Nausea and
vomiting are rarely absent in this stage, the tongue becomes coated and
dry, while the expression is anxious and the fever very high.
In the commencement of the disease there is some difference in the
symptoms of inflammation of the bladder which arises from the nature
and seat of the inflammatory process.
If the neck of the bladder is mainly affected, the spasmodic desire to
urinate is more pronounced, and the pain is felt low down in the vagina
and anus, while the symptoms are higher up in the rectum, with constant
inclination to go to stool, if the base or posterior wall of the organ
is principally involved.
Acute cystitis runs its course in six or eight days; under favorable
circumstances and appropriate treatment all painful symptoms will in
that time have subsided, and the patient will have entered upon a
course of permanent recovery.
If through a constitutional habit, or through neglect or improper
treatment, the disease is not curbed, the result will be quite
different; the inflammation may pass into a suppurative stage or assume
the chronic form.
The treatment in the acute stage will resolve itself into two different
measures of relief; these are first to subdue the spasmodic pain and
nervous excitement, and secondly, to quiet the local irritation.
The pain is best controlled by morphine powders, one-fourth of a
grain each, given every four hours. Warm teas of German chamomile or
flaxseed, so as to dilute the urine, may be freely given. Hot vaginal
injections of borax water have a remarkably soothing influence; the hot
sitz-bath is another useful adjuvant. It has been customary in this
country and England, to apply hot water compresses or hot poultices
over the _hypogastrium_, which is that part of the lower abdomen
corresponding to the region of a distended bladder.
After eight years of extended experience in this country, and a
thorough trial of hot fomentations for inflammatory affections of
the abdomen, I became convinced that the German method of cold-water
compresses gives more relief and is more in the nature of an
_abortive_, hence curative.
I recommend to my patients, instead of the hot-water applications, a
rubber bag, filled with broken pieces of ice, and applied over the
region of the bladder.
The bowels should be freely moved with castor oil or a dose of salts
and senna, or by an enema of warm soapsuds.
The food should be bland and of a fluid nature as nearly as possible,
broths with an egg, milk gruels or bread and milk.
CHRONIC CYSTITIS.
If the acute attack of cystitis in the course of eight or ten days
becomes modified, but convalescence is not established, then it is
quite probable that the disease is drifting into a _chronic_ stage.
The mucus or slime that formerly accompanied the urinary discharge
is now assuming the character of matter or has become muco-purulent.
While this is a very rare symptom of the acute variety of cystitis and
usually of brief duration, in chronic inflammation it is one of the
characteristics of the malady, and often lasts for a long time; the
muco-purulent fluid is occasionally remarkably profuse.
The pus is not always furnished by the free surface of the mucous
membrane, but may be traced to small abscesses, situated in the tissue
between the mucous membrane and the muscular wall of the bladder. The
locality for the formation of these abscesses is principally at the
neck of the organ, although there is no part of the organ that is
entirely exempt from them. Fortunately, the abscesses generally point
inwards or towards the cavity of the bladder, but it not infrequently
happens that they break through and empty into the vagina or even into
the adjacent bowel or abdominal cavity.
The occurrence of pus or suppuration is by itself so grave a process
that it is always accompanied with certain well marked and stereotyped
symptoms, which are cold chills, alternating with flushes of heat,
increase of heat or fever, anxiety and restlessness. The pain now
becomes dull and throbbing in character, and the burning or stinging
is only felt when the patient urinates. When there are abscesses, the
nervous derangement may be so great as to cause the mind to wander in
delirium. Before the appearence of pus in the urine, nothing but a
skillful examination can establish the existence of an abscess.
The treatment for suppuration of the bladder, when limited to
the surface of the mucous membrane, is always curable with
intelligently-directed treatment, which is the same as that for chronic
catarrh of the bladder, to be detailed further on.
ULCERATION OF THE BLADDER.
This is perhaps seldom a condition by itself, but rather a complication
of the preceding disease. The ulcers occupy the place of what were
formerly little abscesses, that have broken into the cavity of the
organ. Foreign bodies in the bladder by their direct pressure on the
delicate tissues of the membrane have been the cause of ulcerations,
that gave rise to dangerous hemorrhage. Earthy concretions or stones
will naturally form in the bladder, and the end of a gum catheter
has also been found in the bladder broken off in the bungling act of
drawing off the urine, or, what is more likely, by boring and poking
within the cavity of the bladder, with a catheter or bougie, by persons
ignorant of pelvic anatomy or in the belief that the bougie was in the
cavity of the womb, for the purpose of inducing an abortion.
Ulcerations will always be accompanied with more or less inflammation
or visceral catarrh, so that the symptoms will fall under that head
which has already been considered.
CATARRH OR SUBACUTE INFLAMMATION.
The mucous membrane of the bladder, like that of the nose, mouth or
bronchial tubes, has its natural secretion of healthy mucous. When
any of these membranes become irritated or congested from any cause,
this natural secretion becomes so increased as to make a perceptible
_flow_ of the secretion of mucus, and this is what the term _catarrh_
signifies. Catarrhs always presuppose the existence of inflammation,
which in its nature is subdued or mild, so that it has been qualified
as subacute, which is intended to convey the idea that the tissue need
not be red nor hot and swollen as is always the case in the acute form
of inflammation.
Chronic catarrh of the bladder is traceable to any or all the causes
that have been enumerated in the acute processes, because every acute
inflammation of the bladder may terminate in a chronic form. It occurs
at any period of life, but it is most common in elderly subjects; it
is always an attendant of ulceration of the bladder or some abnormal
growth in the bladder. If the disease is once established and is due
to a complication, it is liable to become aggravated or re-established
after a brief subsidence by exposure to cold, excesses in diet and
drink, or diseases of the vagina, uterus or rectum.
The secretion of catarrh is white and glairy and resembles the
discharge of leucorrhœa or whites. When disassociated with acute
inflammation of the bladder, it comes on gradually, or in a slow,
insidious manner; for this reason the term subacute inflammation is
sometimes employed by authors, because there are no fiery symptoms at
the onset of the affection.
The urine is always more or less altered in character, because the
inflamed mucous membrane predisposes the urine to speedy decomposition.
There is frequent and difficult micturition, and the entire region, but
in particular the affected organ, is more or less sensitive and sore.
The quantity of mucus which passes off with the urine varies greatly
at different periods and in different cases. In the early stages it
may entirely escape notice, being so small that if the urine is not
saved in a vessel and accumulated for the twenty-four hours the mucus
can hardly be detected; thus, the entire quantity of the above period
may often not exceed two teaspoonfuls. When the disease becomes more
advanced, the quantity of mucus may be equal to the quantity of urine
that passes. The secretion is very thick and sticky, and settles to the
bottom of the vessel or adheres to its surface. If there is pus mixed
with the mucous secretion, it becomes a more serious question, and it
may then be inferred that other organs are involved, the conductors
of urine from the kidneys to the bladder, for instance, or the kidneys
themselves. If the disease is confined to the bladder, the prospects
for a cure are very favorable; only when diseases of other organs in
the neighborhood are the exciting causes of the malady are the chances
for a cure correspondingly limited.
The success of any treatment will depend in a great measure upon the
nature of the exciting causes. These require to be removed, if within
the possibility of medical skill, before the catarrh can be made to
subside.
Should the mucous or muco-purulent secretion be very abundant, the
bladder must be thoroughly rinsed out; first once every twenty-four
hours, and afterwards every other day, so that the mucous membrane will
be cleansed from all foreign irritating elements. I am employing for
this purpose Thiersche’s Boro-Salicylic solution. This of course can
only be carried out by a skillful physician.
When the disease is in its incipient stage it is amenable to
intelligently-directed home treatment.
The most perfect rest of mind and body is one of the essentials to
success, the entire suspension of stimulating drinks of an alcoholic
nature, of which beer is the most irritating, and tea or coffee must be
discarded. A milk and vegetable diet is the most beneficial to subsist
on, and all condiments, even salt, must be dispensed with.
If the bowels are costive they must be regulated either by means of
enemas of warm water, or what may prove of greater and more lasting
benefit is the use of Femina laxative tablets. One tablet should be
taken every night at bedtime, and if one operates too much, then one
every other night may be all that is required.
Demulcent drinks of flaxseed tea, or slippery-elm water, should
be drunk freely, and for the catarrh of the bladder there is no
prescription that ever gave me the same satisfactory results as this
one:——
NO. VI.
Take: Borate of soda 2 drams
Fluid ex. of gelseminum 1 dram
Fluid ex. of belladonna x drops
Fluid ex. of buchu 1½ ounces
Fluid ex. of senna 1½ ounces
Distilled water 2 ounces
Syrup of orange peel sufficient to make 8 ounces
Mix, and take a tablespoonful or less three times a day.
Wear flannel drawers and woolen hose, so as to guard against sudden
changes of the weather.
NEURALGIA AND NERVOUS IRRITABILITY.
The bladder is often the seat of functional derangements that are
characterized by a morbid sensibility and pain.
The principal symptom of this disease is a frequent desire to urinate.
A careful examination of the urine reveals nothing abnormal in the
fluid that would point to the slightest affection of the bladder, nor
are any of the symptoms that characterize inflammation present. There
is no mucous sediment, but in a large proportion of cases there is an
abnormal deposit of the phosphates that would point to nerve waste.
There is often a similar irritability in the vaginal canal, in fact,
there is such a mutual sympathy between the two, which can hardly be
located in any one particular organ.
Hemorrhoids and constipation are sometimes found to be the cause.
In women of a nervous temperament the bladder often becomes the seat of
a steady neuralgic pain. Sometimes this pain is periodical, recurring
every day and about the same hour and lasting the same period. This
pain is of a lancinating character, and radiates from the bladder to
the neighboring organs. I have noticed these symptoms, particularly in
women who had lived in malarial districts, and whose blood had become
impoverished by malarial fevers, or from excessive hemorrhages due to
some uterine trouble.
Sexual excesses and other abuses that lower the tone of the nervous
system will also develop a neuralgic condition of these parts. Persons
who seek relief from this distressing complaint must first abandon
their vices before they can expect alleviation from any treatment. This
affection is not in itself dangerous, but the frequent recurrence of
paroxysms of pain render life miserable. If the general system requires
toning up, I would recommend the iron pills after Formula I, with a
good liberal diet of eggs and milk. For immediate relief of the painful
spasms, the sitz-bath and hot vaginal injections are of great value.
And for the irritable bladder I can recommend:——
NO. VII.
Take: Bromide of sodium 3 drams
Fluid ex. of gelseminum 1 dram
Water sufficient to make 8 ounces
Mix, and take a tablespoonful three times a day.
The gouty and rheumatic bladder is so very rare that a detailed
description is hardly necessary. But it might be well to remind the
reader that if she is of a gouty or rheumatic disposition and has also
bladder trouble, it may be due to the bladder being compromised or
influenced by gout or rheumatism. In that case, appropriate treatment
directed to the rheumatic diathesis will also cure the bladder.
PARALYSIS.
The female bladder becomes paralyzed from various causes; some of these
are located in the organ itself, while others are due to disease of
the brain or spinal cord. An obstruction to the flow of urine through
the urethra causes the bladder to become overdistended with urine and
induces paralysis. A prolonged pressure from the child’s head during
delivery is oftener the cause of transient paralysis than any other. It
happens that lying-in women cannot pass their urine for several days
after confinement. Violence from without, as a blow or a kick, may have
a similar effect. This results from the pressure to which the bladder
was subjected. Operations on the rectum, vagina, or any of the pelvic
organs, are frequently followed by a partial or complete paralysis. In
all these cases, there is only one precaution to observe, and that is
to draw off the urine at regular intervals so as to avoid an enormous
accumulation of fluid.
The paralysis becomes dangerous and obstinate to treatment, in
proportion as the bladder becomes abnormally distended, and the length
of time that the muscular tissues are under the excessive strain.
In those cases where the paralysis is due to spinal or brain disease,
there is little prospect of a cure. In other cases, as for instance
after confinement or an operation on the rectum for piles or fistula,
it generally passes off in a few days.
Great care and cleanliness must be exercised in using the catheter,
so that the bladder is not infected from filth or virus from another
patient. A catheter that has been employed on a patient who had her
urine drawn off while she suffered from purulent catarrh or puerperal
fever, will inoculate a healthy person with the same disease, and in
this manner diseases are often communicated. The bladder is exceedingly
liable to infection.
HEMORRHAGE.
A discharge of blood from the bladder is not of frequent occurrence,
but it occurs often enough to make it noteworthy, and women should
at least know that there is such a thing. It oftener takes place in
men than in women, as a symptom of some grave or serious disease, or
it may be only a trivial disorder. Hemorrhage of the mucous membrane
takes place very readily, owing to the delicacy of the tissues and the
great vascularity of the submucous layer, and there is a much greater
tendency to hemorrhage in some persons than in others.
Persons who are weak and debilitated bleed much easier than strong,
vigorous ones, because the blood may become so thin or poor in fibrin
that it greatly loses its property of coagulating. Some diseases
bring this particular diathesis about, such as scurvy, also measles,
scarlatina or smallpox. Worms have been found to make their way from
the rectum into the cavity of the bladder, and caused profuse and even
fatal hemorrhage. A violent fall of the body, rupturing an artery in
the bladder, severe horseback riding, and venereal excesses, have all
caused almost fatal hemorrhages, to which must be added ulceration of
the mucous membrane. The most profuse hemorrhage of the bladder that I
was ever called upon to witness, followed drinking a strong decoction
of wormwood; irritating diuretics, like spirits of turpentine or
tincture of cantharides, are also liable to cause bleeding. Hemorrhage
is always accompanied with frequent desire to pass urine and spasmodic
pains at the neck of the bladder. The blood may also coagulate in the
bladder, causing an obstruction. The treatment consists principally
in keeping the patient very quiet, and a rubber ice bag should be
applied over the region of the bladder; nothing but bland liquid food
is advisable, but no hot drinks are permissible. If the urine does not
pass, a soft rubber catheter should be employed for the purpose of
drawing it off.
Hemorrhages of the mucous membrane, whether of the bladder, the bowels
or lungs, generally yield to the following mixture:——
NO. VIII.
Take: Gallic acid 4 scruples
Tr. of digitalis ½ ounce
Fluid ex. of ergot 1 ounce
Simple syrup ½ ounce
Mix, and give a teaspoonful in a little water every four hours;
children in proportion.
URINARY FISTULA.
By this is meant a permanent unnatural opening into the bladder from
without, through which urine escapes.
The situation of the female bladder, just in front and over the vagina,
and also its attachment to a portion of the cervix or neck of the womb,
exposes it to injuries, especially from pressure of the child’s head
during delivery. By referring to Plate II, it will be seen at a glance
how easily an accident can take place from this cause. It was at one
time supposed that delivery by forceps was the most fruitful cause of
this lesion. That this is likely to happen only where the instrument
is in incompetent or bungling hands, there is no reasonable doubt. A
thorough acquaintance with the entire subject has proved that there are
other causes that are the mainspring of this, sometimes very serious
accident.
Indeed, the opposite view is now entertained by the profession; that
is, that prompt delivery by forceps will prevent the parts from being
injured, when the soft parts, and particularly the bladder, is under
severe and prolonged pressure by the child’s head. There is no question
that there is greater peril to the mother and child, in undecisive
delay, provided the attendant has the requisite judgment and experience
to act intelligently.
The hypothesis upon which this is based is the restorative property
that living tissue possesses, to regain its vitality, after it has been
subjected to severe and inordinate pressure. This we may observe in
our daily experience; when, for instance, we jamb or crush our finger,
or a child has its fingers momentarily crushed between a closing door,
the fingers are sometimes crushed flat, but upon being released,
they rapidly regain their shape and vitality. If the pressure were
continued for any length of time, the blood in the tissues would have
become congealed, and the circulation permanently shut off, so that
recuperation would have been impossible, and the tissues would have
sloughed or mortified.
If the bladder, under the direct pressure of the child’s head against
the pubic bone, be subjected too long, the same results would
naturally follow: the tissues could not regain their vitality, and they
would either tear or subsequently slough or mortify, which causes the
_fistula_.
The vagina and bladder, like every other tissue of the body, except
that of the brain or nerves, will suffer a great deal of contusion for
a short time, but if protracted beyond a reasonable length of time, it
will be permanently destroyed or injured.
A urinary fistula is always a serious malady, since it exercises a
deleterious influence upon the patient’s health. If the opening is
only small, a spontaneous cure may take place, but if it reaches
considerable dimensions, it requires to be accurately adapted and
stitched together. The best time for the repair of the injury, is six
to eight weeks after the receipt of the injury.
Rupture of the female bladder is comparatively rare, for the reason
that women are not exposed to the same serious accidents as men; but
if women will persist in doing everything that men ought to do for
them, the statistics may be reversed. When the bladder is distended
and violence is brought to bear on the abdominal walls, corresponding
to the region of the filled bladder, a rupture is likely to result.
Surgical measures should at once be resorted to, so that the injury can
be repaired before inflammation of the peritoneum sets in.