DISEASES OF THE BLADDER.
BY EDWARD L. KEYES, M.D.
Inflammation.
The bladder is a patient organ, and rather slow to resent injuries from within or without. It never inflames on account of such general causes as the influence of cold, anæmia, cachexia, or a depressed state of the general system. Any of these causes may act as adjuvants, but alone they are not effective. Thus a chilling of the legs, inoperative upon an individual with a healthy bladder, is a prime factor in exciting inflammation in the bladder of an old man with an enlarged prostate; while the simple passage of a sound upon an individual suffering from anæmia might provoke a cystitis which the same traumatic cause would not have produced upon a patient in a thoroughly healthy condition.
Yet inflammation of the bladder is very common. It is sometimes a malady, more often a symptom produced by some other malady (stricture, prostatic enlargement, stone), and only to be overcome by detecting and removing its cause. The causes of inflammation of the bladder therefore include nearly all the maladies to which the bladder is liable.
The varieties of cystitis take name from that tissue of the viscus which is involved, and from the modality of the inflammation.
We have—
| 1. Cystitis mucosa | Acute | suppurative; diphtheritic; gangrenous. |
| Chronic | catarrhal; membranous. | |
| 2. Interstitial cystitis, where the muscular coat of the bladder is involved. | ||
| 3. Peri-cystitis, para-cystitis, where the peritoneal surface or surrounding structures are inflamed. | ||
This short section upon a surgical subject, only being granted a few pages in a medical work, cannot include a description of all these conditions, or more than a general outline of acute and chronic catarrhal cystitis. Suffice it to say for the other varieties that interstitial cystitis depends upon mucous cystitis or peri-cystitis, and is an inflammation of the muscular coat of the bladder, sometimes culminating in abscess, sometimes in concentric hypertrophy—i.e. contracture of the bladder. Peri-cystitis and para-cystitis occur in connection with peritonitis and pelvic cellulitis, and the peripheral inflammation may extend inward and involve the muscular and later the mucous coat.
All these conditions are grave only in proportion to the intensity of the malady causing them and to which they are subordinate.
Gangrenous cystitis occurs after injury, and occasionally in profound septicæmic conditions (puerperal) or after intense cantharidal poisoning. It is fatal.
True diphtheria of the bladder occasionally, but very rarely, accompanies general diphtheritic conditions, and is a very grave malady. Membranous cystitis is less grave, may be partial or complete. I have a fibrinous cast of a female bladder which was extruded through the meatus. This malady occurs sometimes as a late complication of advanced chronic cystitis mucosa in the male. Recovery is quite possible.
Cystitis mucosa is a common disorder, constantly encountered by the physician as well as the surgeon. The irritable bladder, sometimes called cystitis, demands description here, as it may go on to become subacute or even acute cystitis of the vesical neck.
Irritability of the bladder is a neurotic and not an inflammatory condition, although it may lead to the latter state and terminate in it. The bladder is said to be irritable when the calls to urinate are too frequent, generally with little or no pain. As a rule, the urine is clear, containing no pus or a quantity entirely disproportionate to the frequency of the call to urinate.
In true irritability of the bladder the patient sleeps all night, although he may have to empty his bladder every hour or two by day. There is sometimes a sense of weight, heat, or throbbing, more or less intense, in the perineum; the desire to urinate is normal but imperious; the satisfaction after the act is complete, and no pain accompanies its performance.
This condition of things is generally either neurotic directly, or indirectly (reflex). In children it may be caused by a tight prepuce, especially if irritated by retained smegma, by teething, by the existence of intestinal worms; and it may accompany chorea. It gets well by lapse of time or is cured by removal of the cause. In the adult it is most common in young men and recent widowers, and is often an expression of sexual distress due to sexual stimulation without relief, to sexual excess, or to improper sexual hygiene. The irritation of acrid urine will also cause it, as well as such peripheral troubles as a narrow meatus urinarius, a tight prepuce, urethral stricture, moderately enlarged prostate, kidney irritation (stone in the kidney, etc.). It appears in old men, sometimes, apparently, as a forerunner of organic prostatic changes.
Such stimulation as a glass of wine or beer, pleasant company, absorbing occupation, may cause it to disappear temporarily. It is habitually better in dry, clear weather, and worse in damp seasons when the wind is east. Worry, anxiety, fatigue, depression of spirits, and similar causes aggravate the condition. It is better for the first twenty-four hours after sexual intercourse, and worse than it was before during the next following twenty-four hours.
The SYMPTOMS of pure irritability are simply a frequent desire to urinate during the waking hours, the act not being attended by pain and the urine being reasonably clear.
The PATHOLOGY of this affection is not definitely known. It seems to be an essential neurosis involving the sensitive nerves of the deep urethra and neck of the bladder, attended, if long continued, by surface congestion of the deep urethra and neck of the bladder, and ultimately the phenomena of inflammation; for the very mechanical act of allowing the bladder incessantly to empty itself too often, and to squeeze its own neck, will, in many cases, after a time, lead to traumatic inflammation of mild type.
TREATMENT.—Marriage is a very effective treatment of pure vesical irritability when there is a sexual element in the case.
If any peripheral or local cause exists (stricture, contracted meatus, dense acid urine), its removal will effect a cure. Alkaline diluents, notably the citrate of potassium in gr. v-xxx doses, administered midway between meals, copaiba, or cubebs in moderate doses, often gives relief. Tonics, the tincture of the chloride of iron, and arsenical preparations are often of great value. The tincture of hyoscyamus in minim x-lx doses may be combined advantageously with any of these remedies.
One of the most efficient of all methods of treatment is the use of the conical steel sound, as large as the urethra will admit without violence. The sound should be warmed, lubricated, and gently carried into the bladder at intervals of two to four days. The daily passage of the sound is objectionable, even if it gives relief at first, for it is liable to kindle a slow inflammation in a urethra unaccustomed to its use. When a sound is inserted it should not be left an instant in the bladder, but should be gently withdrawn as soon as it has been fully inserted. If left in the urethra, it does no good, and may act upon the cut-off group of muscles in the membranous urethra, causing them to contract spasmodically, as in the physiological performance of the coup-de-piston after urination. Such contraction bruises the sensitive mucous membrane of the urethra against the hard sound, and does mechanical damage.
The sound acts in three ways: It (1) mechanically distends the irritable contracted cut-off muscle and seems to quiet its contractile tendency. It (2) squeezes all the blood from the passively congested vessels of the irritated mucous membrane, thus ensuring a new supply of blood to the part and an improved circulation in the reaction which follows the irritation. It (3) mechanically, by contact, blunts the sensibility of the terminal sensitive nerves in the mucous membrane of the deep urethra. In this way the sound acts, and its effects generally last several days, often a week. Its good effect is also instantaneous. The slight feeling of weight and discomfort in the perineum which the patient has before its use is gone instantly, and replaced by a feeling of comfort. When this immediate sense of relief is not experienced, it is doubtful whether such a case will yield to the simple treatment by sounding.
It is a mistake to suppose that any ointments smeared upon a sound do good in this condition. Mercurial, belladonna, and other ointments are used, but they are all and entirely rubbed off the sound before it reaches the deep urethra, and their good effect probably resides solely in the imagination of the physician and the credulity of the patient. Ointments are undoubtedly of service in some obstinate cases, notably strong tannic-acid mixtures, and sometimes iodoform, but these cannot be carried to the deep urethra by being rubbed upon a sound. The cupped sound may be used to effect this very neatly, the little cups on the sides of the curve of the sound being filled with the ointment which it is proposed to carry down and apply to the affected spot. A few drops of a mild nitrate-of-silver injection also give decided good results in some cases. The solution should vary between two and ten grains in the ounce of water, and may be accurately applied by means of a Bigelow or an Ultzmann syringe, a few drops being thrown into the membranous urethra. After the application, which should be made only when the patient has a full bladder, urination will wash out the canal and good effects may be looked for—not immediately, as after sounding, but after the irritation produced by the stimulating application has subsided.
Acute Cystitis.
Acute cystitis sometimes involves only the neck of the bladder; in other cases the whole mucous lining of the bladder is included in the morbid process.
The causes of acute cystitis may be grouped under six heads:
1. Traumatic.—Under this head may be ranged all injuries from without, with or without fracture of the pelvic bones—wounds, rupture of the bladder, the pressure of the child's head during labor; injuries from within, as during the use of instruments, by stone, or pedunculated tumor. The list may be increased by such chemical traumatisms as those produced by ammoniacal urine in cases of atony or paralysis, by excessively acid urine in neurotic conditions of the neck of the bladder. Such chemical causes, it will be observed, commonly act in conjunction with another cause. Irritating injections without any co-operative cause are capable of lighting up acute cystitis.
2. Extension of neighboring inflammation—gonorrhoeal cystitis and that attending prostatic inflammation, pelvic abscess, pelvic cellulitis, peritonitis from neoplasms growing at the vesical neck, tubercle, cancer, etc.
3. Medicinal—from cantharides, sometimes cubebs or turpentine.
4. Specific—in diphtheritic, puerperal, septicæmic conditions.
5. The influence of cold when chronic inflammation already exists.
6. Neurotic—actual, from extreme and long-continued neuralgia of the vesical neck; reflex, from irritation at a distance, tight meatus, stricture, inflammation of the seminal vesicles, kidney irritations.
SYMPTOMS.—The symptoms of acute cystitis are (1) frequent painful urination by night as well as by day, the pain being greatest at the close of, and immediately after, the act, and the pain persisting more or less between the acts, radiating from the perineum; (2) moderate fever, sometimes announced by chill; (3) commonly great despondency and a depression of spirits totally disproportionate to the degree and significance of the local inflammation; (4) the urine invariably is milky, with pus: it may at first be acid and of normal odor; it is often tinged with blood, especially toward the end of the act of urination. In extreme cases the urine may contain membranous or sloughy shreds or gangrenous gases. The urine eventually becomes alkaline, and finally deposits lumps of pus and abundant triple phosphate crystals.
Complications occurring with the cystitis yield appropriate symptoms. Such possible complications are congestion and engorgement of the prostate, possibly going on to abscess; epididymitis, orchitis, inflammation of the seminal vesicles, inflammation running up the ureters, pyelitis, surgical kidney; abscess in the walls of the bladder or in the connective tissue about the same; very rarely peritonitis or suppurative phlebitis in the veins about the neck of the bladder.
The pathological changes produced by acute cystitis are similar to analogous changes upon the other mucous membranes: patches of more or less brilliant uniform or punctate redness, perhaps surrounding small ecchymotic areas; a softened, swollen mucous membrane; enlarged follicles near the neck of the bladder, perhaps ulcerated spots; possibly false or true diphtheritic exudations (such exudations have been especially noted in cantharidal cystitis); possibly interstitial abscess of the bladder-wall, or even suppurative phlebitis in the veins about the prostate and neck of the bladder, as observed by Walsham1 in a case of cystitis due to over-distension. This last complication is happily exceptionally rare.
1 London Lancet, May 10, 1879, p. 665.
The PROGNOSIS varies with the cause of the cystitis, and as the latter often cannot be entirely removed, the acute cystitis may only be moderated so as to be made to assume the chronic form. When the cause can be entirely removed, acute cystitis gets well and leaves the bladder absolutely sound.
TREATMENT.—Acute cystitis from whatever cause requires a uniform general line of treatment. Anodynes are essential both for the patient's comfort and to prevent the constant straining to empty the bladder to which the unremitting, painful desire to urinate impels him. Hyoscyamus is a favorite in the form of tincture in minim xx-drachm j doses, or any of the opiates by the mouth, or in suppository preferably combined with extract of belladonna in small dose. Sometimes quarter- or half-grain suppositories of extract of belladonna alone at intervals of six to eight hours keep the tenesmus more in check than anything else, but belladonna used too freely may bring on retention by causing spasm of the cut-off muscles. Camphor is useful, especially in strangury from cantharides. Rest in bed is essential in most cases, preferably with the hips raised. Heat in some form, as a hot poultice, fomentation, spongio-piline, hot-water rubber bottle, etc. over the hypogastrium preceded by a mustard plaster, gives great comfort. Hot-water hip-baths of short duration and frequently repeated are of service in most cases.
Alkalies are valuable, especially in the beginning of an attack—liq. potassæ minim v-xx doses, citrate of potassium gr. x-xx, combined with an anodyne or some demulcent drink.
Infusions and extracts of corn-silk, dog-grass root, buchu, pareira brava, uva ursi, etc. are of some assistance, but generally not so comforting as some of the bland diuretic waters—Bethesda, Mountain Valley, Poland, Glenn, Vichy, Wildungen, Buffalo Lithia. Distilled water or rain-water, especially if taken warm, is a good diluent diuretic. On the advent of acute cystitis all instrumentation upon the bladder should, if practicable, be postponed, all stimulating drugs (cantharides, turpentine, cubebs, alcohol) stopped, and stimulating foods avoided. Asparagus, coffee, salt, pepper, mustard, acids, and a highly nitrogenized diet are not allowable. The rectum should be kept empty and complications treated as they arise.
Chronic Cystitis (Catarrh of the Bladder).
Catarrh of the bladder is chronic inflammation of the mucous membrane of the urinary reservoir, with more or less thickening of the walls of the bladder. This malady, so apt to persist for years, is probably more commonly encountered by the physician than acute cystitis. Acute cystitis, however, frequently complicates the chronic malady by occasional outbursts of acute symptoms. Thus an attack of the stone is acute calculous cystitis interrupting the course of chronic vesical inflammation due to stone. Catarrh of the bladder may follow acute cystitis, or it may commence insidiously as a subacute disorder, and be catarrh, in the popular sense, from the first.
The causes of catarrh of the bladder are never single. It always takes two causes to produce true catarrh of the bladder—one mechanical, and one chemical. After a traumatism inflicted on a healthy bladder, with proper care the patient recovers entirely. If, however, he insists upon keeping up and about, continues to drink liquor, and does not avoid straining at urination, the membrane about the neck of the bladder, irritated by the ammonia from the decomposing urine, secretes an excess of viscid mucus, the pus becomes gelatinized by the ammonia, the constant straining leads to hypertrophy of the muscular coat, the nerves lose their acute sensitiveness, and the milder persistent malady, chronic catarrh, is set up, to continue perhaps for an indefinite period.
Infiltrations of the bladder-walls with tubercle or cancer, urinary calculus, and, notably, enlarged prostate, stricture of the urethra, tumors of the bladder, hernia of the bladder, exstrophy, over-distension of the bladder from stricture, spasm of the urethra, coma, paralysis, or other cause, may be the traumatic element, while the liberated ammonia from the alkaline decomposing urine furnishes the chemical element; and the two causes, if continued, occasion and maintain the condition known as chronic catarrh of the bladder. In coma or the delirium of typhoid fever or paraplegia or hemiplegia (sometimes) the bladder becomes over-distended and atonied, perhaps paralyzed. Here the use of the catheter appropriately, with great gentleness, may relieve the patient without even the intervention of acute cystitis; while, on the other hand, acute cystitis may come on and be cured, or, if ammoniacal urine be allowed to accumulate and the bladder be not washed out so long as it is unable to entirely expel its contents, chronic cystitis, catarrh, results. I have known several cases of partial paraplegia and other disorders in which the patient could void no drop of urine except through a catheter, where there never had been any chronic catarrh, no stringy mucus, hardly a pus-corpuscle, through long years of the disability, owing to intelligence in the attention to emptying and washing out the bladder instituted by the physician having first charge of the case.
As prominent among the causes of chronic catarrh in a purely medical aspect it may be well to insist upon the ease with which this condition is sometimes brought about by the physician himself. A man with a weakened bladder may carry a pint or much more clear urine in his bladder constantly during many years as a residual deposit which his weakened bladder cannot throw off. Excess over the fixed residuum produces a desire to urinate, and the patient, mainly by voluntary contraction of the abdominal walls, voids that excess. If now the physician finds this globular accumulation in the patient's belly, and in his zeal to do all that is possible forgets his caution, he may throw the patient first into an acute cystitis (if haply he escapes collapse), and then into chronic vesical catarrh—an affair perhaps of a lifetime. Surgeons have noticed, and especially Sir Henry Thompson has pointed out, that a dirty catheter may poison the urine and bring about a cystitis which otherwise might have been avoided; and observers from all time have noticed that the sudden entire evacuation of the contents of a bladder long accustomed to over-distension is in itself a grave cause of serious inflammatory disturbance to the mucous membrane of the bladder. Recently much attention has been called to this condition and its possible fatal termination by Sir Andrew Clarke, under the name of catheter fever.
The deductions from a knowledge of these facts are obvious: they are—(1) always to thoroughly cleanse, and then to disinfect, a catheter on each occasion before its use; and (2) never to empty entirely at a first sitting a bladder which has been long habituated to over-distension; and when, finally, the bladder is emptied, always irrigate it with a disinfecting solution (borax) after each emptying.
SYMPTOMS.—Chronic cystitis varies in grade, and its symptoms vary with the grade of the inflammatory process. There is probably no pain more intense than that endured by a man with severe general cystitis in its last stages, when the unceasing tenesmus wrings groans from his lips, the sweat from his body, doubles his frame in agony, and converts his facial expression into a distorted tragedy. The sight is pitiable and never to be forgotten. On the other hand, a man may continue about and at his work with a patient flabby bladder containing constantly more or less stringy mucus and ammoniacal urine, suffering little or no pain or tenesmus, and perhaps having no subjective symptoms except a slight sense of weight in his lower belly and a rather frequent desire to urinate.
Between these limits the symptoms range, but in a general way it may be said that the symptoms of chronic vesical catarrh are these: frequent calls to urinate, attended by more or less pain, especially toward and after the termination of the act. The sense of satisfaction normally felt after urination is generally absent. Motion, particularly jolting as in rough riding, causes pain. This pain is referred to the lower part of the belly, to the perineum, to the end of the penis, the urethra, the anus. The straining after urination may be absent or of the most intense character, leading to prolapse of the rectum and causing excruciating torture. The urine always contains pus scattered through it, and generally also more or less pus in that semi-solid condition known as stringy mucus. Stringy mucus is pus gelatinized by the ammonia of the decomposing urine. These clots of muco-pus contain gritty crystals of the ammonio-magnesian phosphate. More or less blood is to be found in the urine, especially during acute paroxysms. Pure blood sometimes follows the urine after each act of urination. Bacteria abound in the fluid, which varies in odor greatly in different cases, not always strictly in accordance with the severity of the actual inflammatory process. Thus, the urine may be simply sweetish in its odor, ammoniacal, flat, and stale, or be possessed of a putrid, sickening sweetness of indescribably nauseating power. Again, it may be rankly rotten. The bottom of the chamber in some cases becomes covered with a thick coating of the viscid muco-pus, which strings out and reluctantly follows the fluid when the vessel is inverted. Sometimes the urine contains shreds of false membrane or putrid masses of sloughy tissue.
PATHOLOGY.—In chronic cystitis the mucous membrane of the bladder undergoes gradual thickening, loses its pink salmon tint, and becomes gray in color. The thickening extends to the submucous layer, and more or less to the muscular walls as well. In cases of prolonged chronic cystitis attending atony of the bladder, notably with hypertrophied prostate, the cavity of the organ is large, its walls seemingly thinned and flabby, its internal coat roughened by the crossing of bundles of muscular fibres or perhaps perfectly smooth. In other conditions (concentric hypertrophy), where there has been a serious obstacle to the free outflow of urine without any atony of the muscular coat (stricture of the urethra, some cases of stone and of enlarged prostate), the walls of the bladder may be enormously thickened to the extent of an inch or more, the inside surface rough, perhaps ulcerated.
The thickening of the muscular bands within the bladder often causes them to stand out in bold relief, like the muscular bundles in the heart-cavity. These prominent bundles enclose spaces of various sizes and shapes, and from the bottoms of these spaces sometimes the mucous membrane protrudes between the muscular bands and forms pouches of varying size (sacculated bladder). These pouches consist of mucous membrane alone covered with peritoneum, and may become the seat of encysted stone.
If there has been a subacute grade of the surface inflammation before death, there may be livid spots on the mucous surface of the bladder, punctate or larger ecchymoses, reddened areas from which the epithelium is more or less detached, ulcers with or without sloughs or diphtheritic covering, perhaps perforations of the bladder and infiltration of urine, enlarged mucous follicles, granulations, fungosities, etc. Heterologous deposits, tumor, cancerous and tubercular ulcers, cysts, stone, complete the possibilities of what may be encountered in the bladder at an autopsy upon a patient with chronic cystitis.
The chronic like the acute varieties of cystitis may involve the whole of the inside of the bladder or only a portion of it.
The PROGNOSIS, like that of acute cystitis, varies mainly with the cause. If the latter can be entirely removed (stone), the bladder gets perfectly well. Not so, however, unless all the causes are removed. Thus, a phosphatic stone may grow in a bladder as a result of enlarged prostate and chronic cystitis. The presence of the stone excites the chronic cystitis, and subjects the patient to a crisis of acute cystitis from time to time. The removal of such a stone will by no means cure the chronic cystitis; its removal is only one step in the treatment of the cystitis.
As far as life is concerned, the prognosis of chronic cystitis is good. A patient may live many years with chronic cystitis, particularly if he treats his bladder properly. Although, as generally encountered, chronic cystitis is not curable, few maladies yield results to treatment more gratifying to the physician and the patient than the one under consideration.
The legitimate ultimate termination of chronic cystitis is by chronic inflammation of the ureter and pelvis of the kidney on both sides, interstitial kidney changes, and finally death by suppression. Generally, this end may be almost indefinitely postponed by well-directed efforts of palliative treatment.
TREATMENT.—The acute outbursts of inflammatory disturbance occurring during the course of chronic cystitis require the same means for their relief as those already indicated when considering the treatment of acute cystitis—all the prohibition of stimulants, the use of bland mineral waters, demulcent decoctions, infusions, and alkaline draughts. The anodynes, the rest, the heat, the hip-bath, are all indicated here for the acuter symptoms, just as they are in the acute malady, but very much more can be done both in a prophylactic and in a curative way. A milk diet, even an exclusive milk diet, is an element of great value in cases of chronic cystitis. I have two patients, both old men, now under observation, one of whom recovered entirely from cystitis with complete atony, necessitating the constant use of the catheter, by means of an exclusive milk diet. He takes one gallon of milk a day, and nothing else, and lives among his fellow-men at his work and amusements in entire contentment. He has remained absolutely well on this diet during many years. The other patient could not take milk after fair trial, but gradually emerged from the very jaws of death, due to prolonged chronic cystitis and double pyelitis, by the free use of koumiss, which his wife daily prepared for him. Vichy and milk in equal parts, taken cold, is another form of using the milk diet, and the more modern peptonized milk another.
Light white and red wines, or even a little gin or old brandy, are of decided advantage in the majority of enfeebled old men with chronic cystitis. The patient should be clothed with the utmost care. The feet and legs should be clad in wool unless in the very hottest season, and flannel should constantly encase the belly and loins. Nothing is more detrimental to chronic cystitis than chilling the legs.
Another word is necessary in favor of the internal use of alkaline remedies. Even where the urine is alkaline, ammoniacal, putrid, if the stomach will take an alkaline medicine kindly the effect is generally beneficial, for the urine, especially in old men who are prone to these maladies, is quite certain to be acid at the fountain-head. And even if the urine is immediately altered by chronic pyelitis through ammoniacal decomposition before it enters the ureter, yet it will generally irritate the pelvis of the kidney and the ureter and the bladder less if it be secreted in a bland alkaline state than if it be discharged into the irritated area full of uric acid.
Turpentine, copaiba, cubebs, and the muriate of iron are of service in selected cases, but ordinary astringents seem to possess little or no value. Benzoic acid, in ten-grain doses in capsules, sometimes improves the ammoniacal condition of the urine, but the stomach often rejects it. Boracic acid, which has of late been much talked about, in five- to ten-grain doses in water, three or four times a day, is of value occasionally. Quinine is serviceable where the nerve-force is failing. I have been unable to procure any very decided advantage from the use of salicylic acid or the salicylate of sodium by the mouth.
The most important general surgical principle in connection with chronic vesical catarrh is that which concerns emptying the bladder thoroughly and ensuring its cleanliness. In many, perhaps most, conditions of chronic inflammation of the bladder from atony, paralysis, obstruction, or other cause the bladder fails to empty itself entirely. There remains, therefore, a fixed residuum always in the bladder; and although this is diluted and partly evacuated at each act of urination, yet some of the pus, the bacteria, the ammoniacal ferment, remains constantly in the bladder ready to contaminate each new portion of urine as it descends from the kidneys. This must be disposed of, and the bladder washed out, if a permanently satisfactory treatment is to be instituted.
The soft-rubber catheter is to be preferred where it will pass, otherwise the woven silk or the French Mercier instrument, and the bladder should receive attention at least once in the twenty-four hours, and oftener if required. The last drops of urine should be drawn off and the bladder washed with water at about 100° F., in which is dissolved some borax—a heaping teaspoonful to the pint—or other substance capable of disinfecting the contents or mildly stimulating the circulation of the bladder.
Carbolic acid has not yielded good results in my hands. A host of remedies have been employed, but it is doubtful whether anything can do more good than the water mechanically, borax as a disinfectant, dilute nitric acid, minim i-x to the pint, as a stimulant, or, in some cases, nitrate of silver, gr. ½-x to the ounce, used with caution. The injections should be practised through the catheter which withdraws the urine, and repeated according to their effect. For cleansing purposes an injection of simple warm water may be used at each introduction of the catheter. A fountain syringe with two-way stopcock is the most convenient instrument to use for the purpose of simply washing the bladder, because the wash may be repeated indefinitely until it returns clear, without readjusting the nozzle in the catheter.
Very extreme, long-protracted cases of chronic vesical catarrh justify the performance of lateral cystotomy for their relief, or the modification quite recently proposed by Thompson2—a median perineal incision involving only the membranous urethra, through which a large soft-rubber catheter is passed and tied in for a few days or longer.
2 Brit. Med. Journ., Dec. 9, 1882, p. 1131.
Neurosis of the Bladder.
The most common vesical neurosis is neuralgia of the neck of the bladder, with or without the accompaniment of irritability of the bladder, spasmodic stricture, or vesical spasm. Irritability of the bladder has been already considered at the beginning of the section on Cystitis. The other neurotic conditions are always more or less interwoven with each other, and they may each and all of them complicate inflammatory states of the deep urethra, prostate, and vesical neck.
The CAUSES of this set of affections are most varied, and range from irregular sexual hygiene (the most common of all) through inflammatory local conditions, peripheral irritations (the most obstinate of which is chronic inflammation of the seminal vesicles, with or without true spermatorrhoea), up to organic changes in the spinal cord and brain.
The PROGNOSIS in neurotic states varies with the cause. Some cases are easily controlled; others absolutely defy all and every treatment of which I have any knowledge.
The TREATMENT involves a removal, if possible, of the cause. Local measures which have been found most effective in subduing the deep urethral irritation are—(1) the gentle passage of a soft bougie or conical steel sound into the bladder at intervals of one to seven days. The instrument should be removed at once. Sometimes it is necessary to cut a narrow meatus or a stricture in the pendulous urethra in order that a sound of large-enough size may be employed to put the sensitive deep urethra sufficiently on the stretch. (2) The application to the deep urethra and prostatic sinus of pastes of tannin or iodoform with the cupped sound or other apparatus, or the injection of the deep urethra with strong solutions of tannin or mild solutions (gr. i-x to ounce j) of nitrate of silver. (3) In the most extreme cases, those furnishing all the symptoms of stone, even cystotomy is justifiable. It nearly always furnishes a temporary, sometimes permanent, relief.
Medical measures include all the bland diluent mineral waters, alkaline and tonic remedies, already considered in discussing Irritability of the Bladder.
Atony and Paralysis.
Atony of the bladder is more or less lack of expulsive force, due to failure in power of the muscles of the bladder, the nerves remaining sound. Paralysis is the same condition perhaps more pronounced, but due to central origin. A patient may be unable to pass water in more than a dribbling stream, but if he has true organic stricture or spasm of the deep urethra, the muscular coat of his bladder may perhaps not be to blame for his imperfect urination. The question of atony may be decided in such a case by introducing a catheter of any size that will pass. If there is atony, the stream flows sluggishly from the mouth of the catheter, and toward the end is influenced by the breathing of the patient. If there is no atony, the stream rushes through the catheter, and maintains its force until the last drop flows away. In paralysis and extreme atony the influence of the descent of the diaphragm during inspiration is noticed during the whole course of the flow of the sluggish stream through the catheter.
The CAUSES of atony are over-distension of the bladder, voluntary (by persistently neglecting the call to urinate), involuntary retention (from fever, coma, stricture, large prostate), and a certain intrinsic, sometimes inherited, tendency to weakness on the part of the bladder, noticed by some people during their entire lives.
Atony is most common, often a part of their malady, in old men with enlarged prostate. Paralysis of the bladder accompanies certain organic changes due to injury or disease in the spinal cord or brain. Both in atony and in paralysis the bladder may be constantly distended to a certain extent, perhaps to its utmost limit, as a passive sac, and the excess of urine over this uniform residuum may dribble away involuntarily (false incontinence), or may be expelled in small portions by repeated acts of urination performed in the ordinary way or by the aid of great straining and assistance from the voluntary contractions of the muscular walls of the abdomen. No condition of incontinence of urine can be considered proved until demonstrated by the passage of a catheter. Both atony and paralysis may get well under proper treatment in favorable cases. Many cases are incurable, but the discomfort they tend to cause may be almost entirely counteracted.
TREATMENT.—Under all circumstances where the bladder cannot empty itself, the catheter should be used, and the bladder should be washed out, kept clean, and disinfected. All the suggestions laid down for catheterization and vesical injection in the section on Chronic Cystitis are applicable here and need not be repeated. It is particularly necessary to disinfect the catheter on each occasion before it is introduced. This is best effected by washing the catheter outside and inside with a 5 per cent. solution of carbolic acid in water, and finally washing it outside with clean water, before its introduction. If the bladder is over-distended, it should not, as a rule, be entirely emptied at the first introduction of the catheter, for fear of possible collapse, or, what is more to be dreaded, setting up acute cystitis by suddenly taking off all the internal pressure from the vessels in the walls of the weakened bladder, to which pressure the circulation has become accustomed. If, therefore, the bladder is emptied inadvertently, it is better to inject a few ounces of warm water containing borax in solution (a teaspoonful to the pint), and leave it in until the next catheterization. The quantity left in may be reduced at each sitting. By careful attention to these means most cases of over-distension due to atony or paralysis may be relieved without the intervention of cystitis, or with so little that it does not become a serious factor in the case.
The medical treatment of these cases is less important than the mechanical. Under the latter alone and improvement in general health curable cases often get well. Milk diet is of service, and iron and tonics of considerable value in proper cases. Electricity has not yielded satisfactory results in my hands, and I have not derived the advantage from ergot which is often claimed for it. In cases of atony I think I have seen good results sometimes follow the use of strychnine internally in pretty full doses. The same remedy under the skin acts more promptly and more effectively if it is to do any good at all. In true paralysis of central origin the cure of the bladder depends upon relief of the original disease and local treatment to the bladder.
Hysterical women sometimes feign paralysis in order apparently to secure the sympathy and personal attention of the physician. The application of the actual cautery above the pubes, and entrusting a female nurse with the function of catheterization, is generally effective treatment in these cases.
Hemorrhage from the Bladder.
After all sorts of wounds and injuries to the bladder, and in cases of rupture of the viscus, blood is found in the urine. In certain medical conditions, in scurvy, hemorrhagic eruptive diseases, cases of vicarious menstruation, it has been noticed. In strangury due to cantharides, or in any condition of acute or chronic cystitis with considerable spasm of the bladder, the urine contains more or less blood. Especially is this true if ulceration exist at or near the neck of the bladder, as in tubercular or cancerous cystitis.
In cases of stone in the bladder one of the cardinal symptoms is vesical hæmaturia, while in villous growth often the only symptom of the malady is repeated attacks of more or less profuse bleeding from the bladder coming on unexpectedly, without obvious exciting cause, and showing no regularity in the length of the intervals between the hemorrhages or the intensity or duration of the latter. Outbursts of unexpected hemorrhage are not uncommon in connection with some cases of enlarged prostate and chronic cystitis, while these outbursts are the rule, sooner or later, in most cases of true cancer of the bladder.
The DIAGNOSIS is often very important—that is, in a given case to decide whether the blood comes from the bladder or from the kidney. This may usually be ascertained by a very simple manoeuvre, especially when the flow of blood is not excessive: a silver catheter of short curve is introduced and the urine drawn off, the bladder gently washed several times without moving the catheter, and the shade of red in the wash noted. Now, the bladder being slightly distended with warm water, the point of the catheter is moved somewhat roughly in all directions and made to touch different portions of the wall of the bladder. The water is now allowed to escape, and its deepened color will decide that the hemorrhage has a vesical origin, for manipulations of a silver catheter in a healthy bladder will not occasion a flow of blood. In doubtful cases on two occasions I succeeded in locating the point whence the blood escaped as follows: In one I passed a soft catheter, and washed the bladder until the wash escaped nearly clean; I then withdrew the catheter until the point reached the membranous urethra (the bladder having been left full of clean water), and immediately passed the instrument again and withdrew the contents of the bladder, which were now brilliantly colored, thus locating the bleeding point in the prostatic sinus. In the other case, that of a young man with moderate stricture, whose urine was nearly solid with blood, I noticed that no blood escaped by the meatus between the acts of urination; therefore the bleeding point was posterior to the membranous urethra. Was it in the prostate, the bladder, or the kidney? To decide this I passed a soft catheter and washed the bladder until the wash flowed clear. I then injected some warm water, withdrew the catheter, and caused the patient to empty the bladder. The flow was brilliant with blood. In both these cases I effected a cure by one application of solid nitrate of silver through the urethra to the prostatic sinus.
The TREATMENT of vesical hæmaturia is the treatment of the cause, which, if possible, must be ascertained. For the symptom itself the internal use of iron, turpentine, opium, gallic and tannic acids, are of service. I have not derived any advantage from ergot. Locally, rest in bed, ice over the region of the bladder, and avoidance of straining at urination are generally all that is necessary. I have had good results from injecting the bladder with a solution of alum, gr. i-ij to ounce j of warm water, and cures have been effected by injecting nitrate of silver in solution. It is not well to inject iron in solution, since this substance makes a hard clot, and a soft clot is preferable. When the bladder fills up with a solid clot of blood, the best treatment, according to my experience, is to administer opium freely and diluent drinks. The urine slowly dissolves the clot, which has already arrested the hemorrhage, in most cases by its pressure, and the blood flows away as a dark coffee-ground material, sometimes nearly black. If the catheter is used, the clot broken up or dissolved with pepsin or other substance, and washed or pumped out, a new clot is apt to form at once; and although this treatment is based on high authority, and is often practised successfully, it is a question whether the patient would not in many cases do as well, or better, by being let alone, soothed by opium, until the urine dissolves the clot and nature relieves him.
New Growths in the Bladder.
These belong strictly to the province of surgery, but they fall also under the notice of the physician. Tubercular disease may involve the whole mucous surface or only the neck of the bladder; cancer may infiltrate its walls or grow out as a solid tumor in the vesical cavity; fibrous, sarcomatous, and myomatous new formations, polypi, and cysts, simple and hydatid, have been encountered; villous growths, both benign and cancerous, may occur. These morbid deposits give rise either to recurrent hemorrhage or to varying grades of chronic cystitis. The diagnosis is often difficult, the treatment generally palliative. Much has been done of late in an operative way for the relief of tumors of the bladder, and some brilliant results have been secured by operations through the perineum as well as above the pubes. A tumor of moderate size may be detected by the searcher within the bladder, and often may be grasped in a lithotrite and measured. Such a tumor can generally be plainly felt by conjoined palpation in a thin subject, one hand pressed firmly down behind the pubes and two fingers of the other hand passed into the rectum. Recently, Sir Henry Thompson has advocated vesical exploration for purposes of diagnosis through a median incision in the perineum, as for median lithotomy, and has practised it a number of times with a large measure of success. I have made the same exploration several times, and have encountered and successfully removed one tumor. The expedient is worth bearing in mind for use in any obscure cases. It is probably less objectionable and more likely to yield valuable information than the exploration by introducing the whole hand into the rectum (Simon's method).