DISEASES OF THE URINARY ORGANS IN WOMEN.
BY ALEXANDER J. C. SKENE, M.D.
ORGANIC DISEASES OF THE BLADDER.
Hyperæmia.
This is an acute congestion of the mucous membrane due to a disturbance in the balance of the circulation. It may be common to both bladder and urethra, or limited to either; may terminate within a short period of time (a few hours), or it may go on and end in hemorrhage or inflammation. If the mucous membrane is seen with the endoscope, it appears of a bright-red color; the blood-vessels are distended, more prominent, and apparently more numerous. The arteries are the first to be affected. If the cause is transient, this is all that is seen, the membrane returning to its usual color. When the congestion is of a higher grade, rupture of some of the vessels occurs either on the free surface or beneath the epithelium. The venous side of the circulation now becomes more prominent. In a few cases the above order may be reversed, the veins being the first congested, as in the case of a sudden interference with the portal circulation.
SYMPTOMS.—The attack occurs suddenly. Frequent but painless urination is the most prominent feature. There is a sense of heat and heaviness in the bladder, aggravated by standing. When the urethra is involved the patient complains of scalding during urination. The pulse and temperature are practically normal. The composition of the urine is but little changed; there may be excess of mucus and a few blood-corpuscles.
DIAGNOSIS.—This has to be made by exclusion. It is apt to be confounded with a neurosis of the bladder or a displacement.
ETIOLOGY.—The most frequent cause is exposure to cold, especially during menstruation; over-taxation in walking or using the sewing-machine; excessive venereal indulgence; disorders of the portal circulation; and the use of improper articles of food.
TREATMENT.—Every means should be employed to equalize the circulation. The most important element is rest in the recumbent position. Diaphoretics and warm applications to the feet and epigastrium, and, as a rule, a saline laxative. Where there is frequent urination and vesical tenesmus and pain, Dover's powder and camphor should be given, or a suppository of morphia and belladonna by the vagina.
Hemorrhage.
This is a symptom rather than a disease itself. It is usually due to acute congestion or ulceration occurring in advanced inflammations, new growths, or the lacerations caused by foreign bodies and instruments. Hemorrhoids of the bladder due to obstructed circulation is not infrequently the source of the bleeding. The amount of blood transuded varies very greatly, though it is seldom so great as to prostrate the patient. In all cases when it is considerable it is of great importance to localize the bleeding point. The urethra can be excluded if there is no bleeding between the acts of micturition. The differential diagnosis between hemorrhage from the bladder or kidney is less easy. The old rule, that the blood and urine are more intimately mixed in renal hemorrhage than in cystic, is of little service. Sir Henry Thompson's method of detecting the source of pus in the urine may be employed in cases of hemorrhage. He introduces a soft catheter, and then washes out the bladder gently with warm water; if after a time the water comes out clear, the inference is that the bleeding point is higher up. To make sure, he corks the catheter until a drachm of urine has collected; if this is bloody, the diagnosis of its being extra-cystic is tolerably certain. With the endoscope it is occasionally possible, and always desirable, to locate the bleeding point.
The symptoms in hemorrhage from the bladder, besides the actual appearance of blood in the urine, are much the same as those in hyperæmia. Other symptoms liable to arise are from blood-clots forming and either being passed by the urethra, causing its distension and impeding micturition, or else such clots may be retained and accumulate in the bladder, giving rise to still greater functional disturbance, until they are either broken into small pieces by the surgeon and extracted, or else by the slower agency of decomposition they break down and come away.
TREATMENT.—The first thing is to obtain the advantages, both mechanical and physiological, of the recumbent position. A large number of hæmostatics have been used—tannic and gallic acids, ergot, and aromatic sulphuric acid. These are doubtless of some value, but we prefer giving opium in sufficient doses to allay the desire of too frequent micturition, and at the same time to render the urine more bland by alkaline diluent drinks. When the bleeding points can be discovered with the endoscope, they may be touched with caustic acid, nitrate of silver, or persulphate of iron. But such applications must be made with the greatest care, lest inflammation and ulceration result. Ice in the vagina and at the hypogastrium may be tried when other means fail. When the hemorrhage is hemorrhoidal, due to impeded venous return owing to pressure of the gravid uterus, the treatment will have to be purely palliative in the mean time, as the pathological condition of the veins usually rights itself after delivery. When a large blood-clot forms in the bladder, experience has abundantly shown that it is better not to meddle with it, but to let it break down itself and come away, the patient being kept easy—if necessary by opium and alkaline diluents.
Cystitis.
Inflammation may be limited to the bladder alone, in which case we call it cystitis, or to the urethra alone, when it is termed urethritis. But, practically, the pathological processes and the causes of cystitis and urethritis are so closely allied that it will be convenient in our limited space to consider them together. Like inflammation of other mucous membranes, various forms or degrees of cystitis and urethritis are described: these classifications are useful clinically, but it should not be forgotten that the pathological conditions presented are only different stages of the same process. Inflammations of the bladder are divided according to the cause of the disease and the character of structural lesions into—the acute, including the catarrhal and the suppurative; and the chronic, including the ulcerative, interstitial (and peri-cystitis); and the specific, embracing the gangrenous, croupous or diphtheritic, and gonorrhoeal, in which the inflammation is the result of a special poison.
ETIOLOGY.—The causes of cystitis may be classed under four heads: (1) Direct injuries, such as blows in the vesical region, falls, fracture of the pelvic bones, violent copulation, sudden uterine displacements causing pressure, foreign bodies, rough catheterization, over-distension from retention of urine, and, above all, contusions and injuries during labor. (2) Abnormal urine, from improper food or malnutrition and certain irritating drugs (cantharides) and irritating deposits of urine salts. (3) Certain constitutional diseases (eruptive fevers, gout, ague). (4) Inflammation of adjacent organs, hyperæmia due to cold.
PATHOLOGY.—The acute forms always begin with hyperæmia, then follow swelling, perverted or hyper-secretion, then exfoliation of epithelium, giving rise to a roughened and denuded state of the mucous membrane, particularly on the top of the rugæ, the products of inflammation accumulating within the sulci, and finally the formation of pus. A description of these, the ordinary phenomena of inflammation of mucous membranes, it is quite unnecessary to give here, but there are one or two modifying conditions in cystitis that are of great importance and need consideration. The first of these is the effect which the function of the bladder as a reservoir of urine has on the inflammation. Normal urine is irritating to an inflamed mucous membrane, and in cystitis it soon undergoes decomposition, becomes alkaline, and hence more irritating. The main agent in producing this decomposition is mucus, which is secreted abnormally both in quantity and quality. It acts injuriously in two ways, its fixed alkali tending to neutralize the acid of the urine, which in the early stages of cystitis is often hyper-acid, and in promoting the decomposition of the urea and thereby liberating the volatile carbonate of ammonia. As the urine becomes more alkaline the precipitation of the phosphates of lime and magnesia occurs, and the formation of the triple or ammonio-magnesian phosphate.
The irritant effect of these salts, really deposits of foreign bodies, on the inflamed mucous membrane completes the vicious circle, the effect now aiding the original cause.
Another most important point in the pathology of cystitis is the effect of over-distension of the bladder. This is itself sometimes the primary cause of the trouble, as in certain neuroses, but more frequently it is the effect of certain injuries during delivery. The mechanism of its production is not very clearly made out. It usually follows long, tedious deliveries, during which either the child's head or sometimes the forceps crushes the urethra against the unyielding pubic bones, giving rise to an acute urethritis, with swelling of the membrane and blocking up of the canal, causing retention. The primary injury is not done, as a rule, to the bladder in these cases, for if it were we should find the vesical neck the seat of sloughing of the mucous membrane; but, as a fact, this is the part (owing to its more loose connections with the underlying connective tissue) that most frequently escapes. This danger of over-distension is so clearly recognized that the catheter is nearly always used both before and after delivery if there should be retention. But a condition more apt to mislead both the doctor and the nurse is the urine dribbling away either constantly or intermittently. This is too often ascribed to an irritable bladder causing frequent micturition, when it is a sign of over-distension, the dribbling always occurring as soon as the mechanical pressure of the urine is sufficient to overcome the resistance of the swollen parts.
We have already referred to this condition of over-distension as a cause of inflammation; it will suffice to say that it may, if unrelieved, produce a partial or even total slough of the mucous membrane of the bladder; but, fortunately, this is rare.
Thus far we have spoken of the common forms of acute and subacute cystitis; it only remains to say a word with regard to its rarer manifestations. The inflammation may extend to the submucous coats, becoming interstitial cystitis. Again, this may limit itself here, or it may extend still deeper to the serous coat, in which case it is known as peri- or epi-cystitis. Peri-cystitis is almost always a secondary disease, arising sometimes from deep ulcerations of the inner coats of the bladder, such as occur in chronic cystitis. More frequently it is but a part of a pelvic peritonitis which originated outside of the bladder itself. The final result of peri-cystitis is to form adhesions between the bladder and the neighboring organs, and thereby prevent distension of the bladder.
A very rare form of gangrenous inflammation has been described, but it is more than doubtful if this ever occurs in women except as the result of mechanical violence or pressure, already described. The specific lesion of croupous or diphtheritic inflammation has occasionally been diagnosticated, either from shreds of false membrane passed by the urethra or by means of the endoscope. Gonorrhoeal inflammation of the bladder has been less carefully observed in women than in men. Still, it is known that this specific inflammation extends to the bladder in some cases, but it does not differ essentially in its pathology, history, or treatment from that arising from other causes; hence it is unnecessary to dwell upon it here.
The pathology of chronic cystitis is characterized by ulceration and sloughing of the tissues involved. They do not differ materially from the same processes elsewhere, except that the salts of the urine are apt to be deposited upon the shreds of dead tissue the products of destructive inflammation. The hard masses thus formed are passed with great pain. They block up the urethra, and are only expelled by extra strong efforts which cause intense suffering.
Lastly, the ulceration may extend through the bladder into the peritoneal cavity and give rise to septic peritonitis and death, or the perforation may take place into the cellular tissue of the roof of the pelvis, and cause a fatal cellulitis.
SYMPTOMS.—The various forms of cystitis being but different stages and degrees of the same disease, their symptoms may be discussed all together. For convenience we shall consider them under three heads: (1) Referable to the organs themselves; (2) Symptoms referable to the neighboring organs; (3) General symptoms.
(1) In all forms of cystitis there is more or less derangement of function, as shown by pain, tenesmus, and frequent micturition. In the mildest form of the trouble there is a frequent desire to pass water, which often comes with unusual force. Micturition is followed by a desire to strain, as if the organ was not fully emptied. This sensation may pass off in a few moments, and not arise again till the next micturition, but in the severer cases it may last continuously. When urethritis is also present there is the additional and characteristic symptom of painful scalding as the urine passes over the inflamed track.
In urethritis alone there is often a desire to urinate frequently, but if the desire is resisted it passes off, and the patient can retain the urine for a long time. This symptom should not be mistaken for the tenesmus of cystitis. In the more advanced stages of the disease, especially as ulcerative changes occur, the tenesmus becomes more violent. The pains also are more diffused, often shooting to the umbilical region. There is often a dull, aching pain in the perineum, and in nearly all cases there is continuous backache, or, more correctly, sacral pain.
The composition of the urine is of great importance. The specific gravity in cystitis does not present any constant change, except that in the chronic forms it is often a little below the normal. The reaction in acute cystitis, at first, at least, is usually acid, whereas in the chronic forms it is almost invariably alkaline. The color at first is not particularly altered; later, unless discolored by blood, it is a pale, dirty yellow. The odor is normal in the acute type, unless where retention has been followed by decomposition, but in the chronic form it is not only ammoniacal, but has a characteristic fleshy or organic smell. The sediment in the acute varieties is mainly light and yellowish, composed of mucus, with some pus generally; in addition there may be blood, epithelium, and the amorphous and triple phosphates. In the chronic forms the sediment is usually heavier and of a darker brownish color. Flakes of pus, shreds of tissue, blood, and epithelium in all stages of growth are more or less present, and in the intensely alkaline conditions of the urine the pus and mucus form a jelly-like, ropy, opaque mass.
Albumen will be found if there is pus in the urine without there being any kidney disease. As the result of a careful analysis of a number of cases of chronic cystitis, the amount of albumen varied from one-sixteenth to one-fifth of the volume of urine. Microscopically, in addition to the pus, mucus, organic shreds, phosphatic and other crystals already spoken of, the most interesting appearances are the various kinds of epithelium. In the advanced stages of chronic cystitis epithelial elements of any kind are very rarely found. It is only in the earlier stages that normal and transitional forms of vesical epithelium are present, and again they reappear on the subsidence of the inflammation. This fact is of great importance, because the transitional forms of bladder-epithelium are often indistinguishable from the permanent forms of the urinary tract higher up. It is thus often impossible to make a differential diagnosis between pyelitis and cystitis from this symptom alone. When renal disease is superadded to cystitis, the characteristic casts will be found and albumen will likely be increased in amount.
(2) The symptoms accompanying cystitis in women referable to the neighboring organs are of some importance, but they very often arise from some coexisting disease of other pelvic organs. It is therefore needless to give a list of all the pelvic pains coincident with cystitis which have been enumerated in the literature of this subject.
(3) The general symptoms are of two classes, toxic and nervous. While all agree that there is no doubt of direct blood-poisoning in cystitis, there has been a great deal of difference of opinion as to how this is effected. I think that there are various agencies at work in this. First, there may be organic renal disease or sympathetic renal hyperæmia leading to imperfect elimination. In cystitis caused by over-distension from long retention the kidneys simultaneously take on acute inflammation, which usually passes off when the bladder is emptied, but it may continue and give rise to all the constitutional symptoms of renal disease. Again, in chronic cystitis the thickening of the bladder-walls obstructs the ureters, so that the urine is dammed back upon the kidneys. This arrests their function, and in time leads to organic disease with all the consequent derangements of the nutritive and nervous systems. Secondly, absorption of the products of decomposed urine, or of pus and other septic materials the result of decomposing shreds of tissue, may take place.
Anæmia is another of the blood-changes which occur in chronic cystitis. In its origin and continuance it probably is much like anæmia due to long-continued inflammation elsewhere. The only peculiar symptom in this connection is the appearance of urohæmatin in the urine.
With this slow deterioration and poisoning of the blood various symptoms are developed. There is an effort made to eliminate urea by the mucous membrane of the alimentary canal. This is manifested by attacks of vomiting or diarrhoea. But when it does not come to these explosions, there is apt to be lack of appetite, especially at the morning meal, or there are perverted taste and constipation, interrupted by occasional attacks of diarrhoea. The skin in the chronic cases is at times sallow and clammy, and at times there is a distinct urinous odor about the body. Various more or less marked nervous symptoms are apt to be present. One set is characterized by the sluggishness of the patients, an inclination to sleep, despondent spirits, and occasionally dizziness and fainting. There can be little doubt that these and allied symptoms are referable to cerebral anæmia, for they are much aggravated by bromide of potassium, whilst digitalis and out-door life improves them. A second set of nervous symptoms are fairly attributable to blood-poisoning of one kind or another, and in the most severe cases are often promptly relieved by diarrhoea. Finally, a number of the irregular, wandering neuralgic pains and the headache are due to the general depression produced by bladder-pain and loss of sleep.
DIAGNOSIS.—Cystitis is easily made out, except in certain mild cases. Similar symptoms, especially frequent urination, occur in prolapsus uteri, often in anteversion and in cases of pelvic adhesions and pregnancy and abdominal tumors, and lastly in certain neuroses. In most of these the recumbent position lessens the desire for frequent urination much more than when cystitis is present. Again, in the neurosis the attacks are irregular. Tenesmus is usually only present in cystitis, and lastly the examination of the urine and exploration of the parts should settle the question. We have spoken above of the method of differential diagnosis of blood coming from the bladder or the kidneys: the same method applies to localizing the source of pus. Urethritis with fissure at the neck of the bladder simulates cystitis in clinical history, and in the fact that pus in small quantity is found in the urine. To differentiate, the urine examined should be taken directly from the bladder with the catheter, when it will be found free from the products of inflammation. In addition to this, in some cases it will be necessary to make use of the endoscope, by which a good view can be obtained of the whole urethra and a portion of the mucous membrane of the bladder sufficient for diagnostic purposes.
TREATMENT.—The female bladder is so accessible, owing to the shortness of the urethra, that it is peculiarly amenable to local treatment. This is by no means, however, all that is required, for in all forms of cystitis, irrespective of the cause, the urine plays a very important part in keeping up the irritation. There are, therefore, always three indications to be met: (1) Removal of the cause; (2) constitutional treatment (diminishing the irritating character of the urine); (3) the cure of the local lesion.
(1) In many cases, of course, the cause is transient. The injury is done, and the inflammation resulting runs its course, longer or shorter according to the modifying influence of treatment. In a smaller number of cases, again, the cause is not removable, as in certain constitutional diseases or permanent pelvic adhesions, tumors, and the like. In such cases of course the treatment is but palliative, and, while relieving the immediate symptoms, aids the organs till a certain amount of toleration of the abnormal conditions is established. But in a large class of cases the cause, though more or less persistent, is removable. This includes the numerous cases of uterine displacement. Lastly, there is a certain number of uncomplicated cases which tend to recovery without treatment.
(2) The constitutional treatment should be first directed to reducing the amount of work the bladder has to do. For this purpose the bowels should be kept rather freely open, saline laxatives being the most valuable for this purpose. The skin too should be kept healthy and active. Next, the character of the urine should be as bland as possible. Food and drugs which are known to cause or keep up cystitis should be carefully avoided. Milk diet has proved successful in the hands of George Johnson. In all cases the diet should be carefully attended to, and should consist largely of fluid foods—milk, yolk of eggs, soups, etc. Lean meat in small amounts and easily-digested solids are allowable. Articles such as asparagus, alcohol, beer, and wine generally are to be avoided. Fruits, such as lemons and oranges, are usually grateful and at least harmless. The alkaline diluents, such as citrate of potassium or the alkaline mineral waters (Vichy), answer an admirable purpose. An infusion of buchu is an excellent agent, and may be combined with nearly all other drugs employed in treating cystitis. Where pain is an urgent symptom in acute cases, it should be relieved by hot applications and by anodynes. Dover's powder is an excellent form in which to give opium. To relieve tenesmus vaginal suppositories of morphia, with or without belladonna, may be given. But in certain cases twenty-grain doses of potassium bromide every four hours relieve pain where opium fails. Benzoic acid or benzoate of ammonium in ten-grain doses in infusion of buchu, three times a day, is a most valuable remedy. The usual remedies, such as balsam of Peru or copaiba, oil of turpentine, etc., which are given in gonorrhoeal inflammation, are very useful in the chronic catarrhal forms of cystitis. To prevent or lessen the decomposition of the urine a vast number of remedies have been employed, all of the astringents and most of the antiseptics, but as a rule these remedies are much better administered locally than constitutionally. In various acute and transitory cases the constitutional remedies above described will be all that is necessary, but in the greater number local treatment is absolutely required.
(3) In local treatment the first point is not to do harm to the parts by the use of instruments. Dirty catheters and rough catheterization so often cause cystitis that it is easy to see that the same causes often perpetuate the mischief. Great care, then, should be used in selecting instruments for injecting. The ordinary metallic catheter with one or two large openings is much more liable to wound the sensitive mucous membrane than one with a number of small holes made either of hard or soft rubber. It should have a stopcock or something similar at the outer end, the better to regulate both the injections and the escape of the solution injected. In ordinary injections only about an ounce at a time should be in the bladder; this can be repeated four or five times, and the injection should be as slow as possible. To meet these indications I use a double perforated catheter made as follows: A small tube runs from one of the bifurcations to the extreme point. This is the supply-tube, and the catheter acts as the exhaust. The central tube can be removed for the purpose of cleaning the instrument. A piece of rubber tubing attaches the supply-tube to a fountain syringe, and this completes the whole apparatus. The calibre of the supply-tube being small and that of the exhaust large, a great quantity of fluid can pass through the bladder without distending it. The fingers can pinch the rubber tube and act as a stopcock to regulate the entrance and escape of the fluid used.
An injection of borax and water is often highly beneficial, and is alone sufficient in many cases. It should be frequently employed. It should always precede any topical application or medicated injection. Lukewarm water alone is employed, but the addition of a little salt (drachm j to pint j) or chlorate of potassium renders it more bland. Very often hot water is a most useful application. Of the medicated injections a vast number might be described, but they are referable to two classes, anodyne and astringent. The painful nature of cystitis suggests the use of opium preparations and chloral hydrate for injections, and they do give some relief. They should be well diluted to prevent their causing irritation.
Of the astringents, acetate of lead, sulphate of zinc, tannic acid, nitrate of silver are the most valuable. Many others—perchloride of iron, chlorate of potassium, hydrastis canadensis, salicylic acid and its preparations, carbolic acid, etc.—have been commended. In all cases the strength of the injection should be short of causing the patient much pain. It is always best to begin with a mild solution and gradually feel the way up to stronger ones. Of all the astringents, I prefer nitrate of silver, which I use in strengths varying from one grain to twenty to the fluidounce. The general rule to be observed, if a strong solution is used, is to employ only a few drops; if a large injection is made, the solution should be weak.
Various antiseptics—iodoform, salicylate of sodium, etc.—have been used to prevent the decomposition which so complicates obstinate cystitis; but, as a rule, I think frequent washings out and astringent applications act much better. One of the most distressing obstacles encountered in making any such injections is where there is a tender or inflamed urethra. It is well then to carry the catheter only up to the sphincter of the bladder (as advised by Braxton Hicks), overcoming its resistance by the pressure of the injection. As a rule, the urethritis will not long survive the cystitis, but in some cases it exists as an independent affection; it is then usually gonorrhoeal, and should be treated as in the male. But when not, the same principles apply as in the local treatment of the bladder. Great care is needed, as the female urethra will only hold ten or fifteen drops at a time, and if a large injection is used it is almost sure to enter the bladder. To meet this difficulty I devised a reflux catheter for douching the urethra. It is grooved on the outside, and at the point there is an opening in each groove which lets a jet of the fluid used flow outward, bringing the injection in contact with all parts of the urethra.
In cases of ulceration, such as occur in bad cases of cystitis, applications should be made, if possible, to the part affected only. This can be accomplished by means of the endoscope when the ulceration is seated where it can be reached. Having located the point exactly by means of the endoscope, the inner or glass tube is withdrawn, and the application made directly to the required spot through the rubber tube. A glass pipette properly curved or any ordinary insufflator will answer perfectly, and when a solid is used a delicate long curved forceps will answer.
In chronic cases of cystitis in which all the above methods of treatment fail, it becomes necessary to give the parts complete rest by securing continuous drainage of the urine and products of inflammation. There are two ways of doing this—the one, to use a self-retaining catheter which may keep the bladder empty: this method answers very well when the inflammation is confined to the upper portions of the bladder, but when the neck of the bladder is involved the presence of the catheter gives rise to pain and irritation and cannot be tolerated. The other plan is to establish an artificial vesico-vaginal fistula, and keep it open for some months, until the bladder-walls have become normal again. This secures efficient rest to the inflamed parts; complete drainage is established, the patient wearing a cup, as she would a pessary, to catch the urine. If the inflammation is limited to the upper portion of the bladder, the drainage by the fistulous opening is all that is required; but if the neck of the organ is involved, frequent and continued medication will be required. This can be done by injecting through the urethra and letting the fluid escape through the opening in the bladder. This is not the place to discuss the steps of the operation or the indications when and how to close the artificial fistula. For these the reader is referred to works on this department of surgery.
Suffice it to say, in conclusion, that this by no means easy operation should be only undertaken as a last resort, but that if properly done in well-selected cases it will cure where all other known methods of treatment have failed even to relieve.
Hypertrophy of the Bladder.
This lesion may be partial or total, involving any or all three coats of the viscus. But the term usually refers more particularly to increase of the muscular walls. As a rule, the hypertrophic changes are not confined to one portion of the viscus, all being more or less affected. The affection is much less frequent in the female than the male.
ETIOLOGY.—There are two varieties of this affection—one, concentric hypertrophy, in which the bladder is contracted as well as having its walls thickened; the other eccentric, in which there is dilatation. Its principal causes are—obstruction to the outflow of urine from stricture of the urethra, tumors, or foreign bodies; cystocele, preventing complete evacuation; cystitis, causing too frequent or too forcible contraction; and irritable bladder in certain of the neuroses. Accompanying such dilatation diverticulæ are sometimes formed, though rarely in the female.
SYMPTOMS.—There is sometimes present vesical spasm, some pain, and forcible ejection of urine. A certain amount of cystitis is almost always present, aggravating the original disorder. In the eccentric form there are sometimes superadded symptoms of over-distension.
DIAGNOSIS.—This is readily made by measuring the thickness of the bladder-wall between the finger in the vagina and the sound in the bladder. The capacity of the bladder is easily noted by measuring the urine passed at each micturition or by injecting a bland solution of salt and lukewarm water.
TREATMENT.—The treatment should be directed to the removal of the cause. When this is not possible, palliatives may be sought for in the use of the catheter, at regular intervals, to prevent over-distension. Cold baths, astringent injections, and electricity are often of use. By these means the evil results of the disease may be overcome, but the hypertrophy is usually permanent.
Atrophy.
Atrophy of the bladder is a rare disease in early life. In women, in addition to the ordinary decay of age, there is a special predisposition to degenerative changes in the pelvic viscera, the bladder-walls included, after the menopause. Extreme distension of the bladder is usually the exciting cause, giving rise to temporary or even permanent paralysis, and eventually causing either inflammation or atrophy and fatty degeneration. Interrupted nutrition, due to impaired circulation, is the immediate cause, but such altered nutrition may be purely nervous and due to atrophy of certain ganglion-cells in the spinal cord.
SYMPTOMS AND DIAGNOSIS.—Patients complain of difficulty in emptying their bladders, the urine coming away in interrupted jets. They are apt to be irregular in their times of urinating, and are liable in consequence at times to have retention and over-distension. Pain and sometimes a slight cystitis are present. Finally, they completely lose the power of urinating and a catheter has to be used. The diagnosis is to be made as in hypertrophy, by a finger in the vagina and a sound in the bladder.
TREATMENT.—Regular catheterization, strychnia in full doses, electricity, and tonics, combined with washing out the viscus. Where the atrophy is due to nerve-degeneration these measures are purely palliative, in other cases they are of more avail.
FUNCTIONAL DISEASES OF THE BLADDER.
Under the name of functional diseases of the bladder are included a large number of varied affections of which the pathology is as yet very obscure. Where there are marked symptoms of vesical disorder, while no organic lesions are found in the tissues of the bladder, the affections must be classed under the name of functional derangements. As our knowledge increases the number of these is constantly diminished, and a still further and more rapid diminution will occur as the physiology and pathology of the nervous system innervating this viscus become better known. These diseases are much more common in children and women than in men—in children, because the controlling power of habit is only in process of formation; and in women, mainly because of the more complex organization of the genito-urinary organs, which are the more easily exhausted and deranged, especially by the functions of maternity. True, neuralgia of the bladder has been described under a variety of names, irritable bladder, cysto-spasm, etc., but it is rather a rare affection. The most prominent symptom is the painful micturition, and attendant on this a desire to pass water too frequently.
There is no particular change in the character of the urine, and no appreciable visible alteration in the appearance of the parts, though they are more sensitive than normal to the touch. This condition is best met by warm fomentations locally and sedatives either locally or generally, while nutrition is improved by appropriate tonics, nervines, and by the use of the galvanic current.
A much more common class of affections of the bladder accompany hysteria, sometimes grouped under the name of hysterical bladder. A great number of pathological conditions are grouped under this vague term, but they are held together by all having, as a more or less prominent symptom, varying degrees of incoördination. The disturbing effect of strong sudden emotion, as fear, upon the bladder is familiar to all, and in various organic diseases of the spinal cord and brain, such as myelitis and locomotor ataxia, a disturbance in the functional action of the bladder is among the first symptoms. It then becomes a matter of great difficulty, and yet of great importance, to make a differential diagnosis.
In hysteria the urine usually diminishes in specific gravity; it is apt to be increased in quantity, and, though clear in appearance, is irritating to the mucous membrane. In such cases frequent urination, sometimes almost continuous, sets in; but it is an important point that during sleep the patient retains her urine the normal time. In others we get, on the contrary, retention, and this may be due to various causes. In some it is doubtless involuntary, as they say they cannot urinate, but in others it is assuredly will not. Many of these latter derive a morbid pleasure from catheterization. These are the patients who are given to the introduction of hair-pins, slate pencils, etc. etc. into the urethra.
Some authors claim that in the intense sexual excitement of hysteria the chronic erection of the clitoris makes pressure on the urethra, and so prevents the escape of urine, but this seems somewhat apocryphal.
Another class of cases resembling the hysterical in the frequency of urination are those addicted to masturbation; these are, fortunately, not very common.
In all of these cases the frequency and irregularity of urination is a much more prominent symptom than the pain. This latter is usually a slight scalding from the urine passing over the chafed and irritable urethra, especially at the meatus. (These symptoms sometimes occur in the miasmatic affections.) A number of neuroses of the bladder are reflex and dependent on peripheral irritation elsewhere. A typical example of this class of affections is what has been described under the title of ovarian irritation. In this condition there is very much heightened reflex irritability accompanying the increased tenderness and vascular engorgement of the affected ovary. It is difficult to explain the bladder symptoms which sometimes accompany the recurring crises of this disease, except as due to a nervous excitation spreading from the ovarian centres in the spinal cord to the adjacent bladder centres.
The diagnosis of this group of affections must be made by exclusion. We have some of the same symptoms—increased frequency of micturition, pain during and after the evacuation, tenesmus and shooting pains in the pelvis—as in organic disease. The most important guide is a careful examination of the urine, which shows the absence of abnormal constituents, thereby excluding organic disease. This diagnosis will be much strengthened by a digital examination, by the vagina, of the neck of the bladder, and the passage of a urethral sound, neither causing pain, as they would do in cystitis.
The PROGNOSIS is usually good, but it depends upon the length of time the affection has lasted.
The TREATMENT is mainly tonic and nutritive. The diet should be nutritious and simple, and the bowels regulated by mild purgatives. Constitutionally, small doses of strychnine are most valuable in improving the nerve tone; so also the constant electric current is of service. Locally, sedative suppositories in the vagina or enemata are advantageous, conium combined with belladonna or hyoscyamus seeming to act best. The liberal use of the bromides gives good results in some hysterical cases.
Paralysis of the Bladder.
This is the most grave of the functional affections, and, like paralysis elsewhere, it may be either peripheral or central. When the latter, as in certain injuries of the brain or in certain well-marked lesions of the spinal cord, it hardly calls for more than mention here. Often, however, the cause is not recognizable in any organic lesion either of the bladder-walls or the central nervous system, and is to be sought for in more temporary and transient influences; thus as a result of over-distension most frequently, of impaired or lost nerve-conduction in fevers involving serious derangements of nutrition, all of which may be described as functional or temporary paralysis.
The invasion is usually gradual, except in apoplexy or traumatism. The patients, who are usually advanced in years, first observe that the urine is expelled from the bladder with less force than usual; the stream is smaller and comes slower, and straining takes place, the aid of the abdominal muscles being invoked. After a while the stream intermits, and finally partial or complete retention occurs. Then, if this condition continues, the sphincteric resistance gives way and constant dribbling occurs. In rare instances dilatation of the bladder-walls takes place, and finally cystitis. Dilatation of the ureters and hydro-nephrosis are not uncommon under these conditions.
Where the condition of retention obtains the DIAGNOSIS ought never to be difficult; the introduction of a catheter will conclusively settle it.
The PROGNOSIS in uncomplicated paralysis is usually good. When accompanying fevers, dysentery, peritonitis, etc. it usually disappears with the original disease. When due to centric lesions the outlook is about hopeless.
In all cases the bladder should be emptied at stated intervals. If the patient cannot do this herself, the surgeon should resort to the systematic use of the clean soft Jacques catheter. A most important point, too often overlooked, is the method of emptying an over-distended bladder. It is not safe to empty the bladder at once: the patient ought to be tapped at intervals, an abdominal binder being gradually tightened meanwhile. The too sudden removal of pressure from the vesicle walls which have been rendered anæmic allows of intense congestion, and in a condition of paralysis is the sure prelude to cystitis. The diet in these cases should be generous and stimulants are not contraindicated.
I cannot agree with those authors who recommend washing out the bladder with medicated solutions and forcibly distending the urethra, nor with those who use tincture of cantharides as a vesical excitant. Both plans are apt to produce cystitis. A far more rational though somewhat impracticable treatment is the use of electricity as recommended by Winckel—one pole (thoroughly insulated up to the point) in the bladder, the other on the symphysis or loins. The sitting should last about five minutes. But by far the most valuable therapeutic agent is strychnia, which should be exhibited in full doses, many of the reported failures with this drug being due to too small doses. In urinating the upright position is generally preferable to lying down, as the pressure of the abdominal organs to some extent compensates for the lack of tonicity in the bladder-walls.
Lastly, in these hopeless cases of complete paralysis an artificial vesico-vaginal fistula and the adaptation of an apparatus to catch the urine may be of service.
Functional disorders of the bladder are frequently met with, due to 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.
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 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.
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 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 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.
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 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.
When the meatus is dilated and the mucous membrane and enlarged vessels are prolapsed, care is necessary to distinguish that condition from urethral neoplasm. This can be done by observing that in prolapsus the opening is situated either at the upper side or in the centre of the protruding mass, whereas in abnormal growths of the urethra the meatus surrounds the tumor or its pedicle. More than that, by making pressure the distended vessels can be reduced in size and the prolapsed membrane pushed up into the canal. This cannot usually be accomplished with tumors.
PROGNOSIS.—There is no natural tendency to recovery in these affections. If left alone they generally get worse. Recovery under treatment depends upon the location of the dilatation and the duration of the trouble. The conditions upon which an unfavorable prognosis is to be based are—bladder complications, inflammation or ulceration near the neck of the bladder, great varicosity of the veins, and fatty degeneration of the muscular tissue. In the absence of all these complications a complete recovery may be expected. In all cases great relief can be secured by treatment and the patient guarded from getting worse.
TREATMENT.—In the management of all forms of urethral dilatation attention should be given to any inflammation of the mucous membrane that may exist, employing the usual treatment. When there is a relaxed and prolapsed condition of the mucous membrane, astringents should be used. Tannic acid or alum will answer well. When these fail, the redundant membrane should be retrenched, either by touching it with the thermo-cautery or excising a portion with the scissors. In employing the cautery for this purpose the long pointed tip of the instrument should be used, and, having protected one side of the urethra with the speculum, cauterize a narrow strip of the membrane parallel to the axis of the canal. Two or more of these cauterizations may be made at points equidistant on the circumference of the urethra. By operating in this way pieces of normal membrane are left between the portions cauterized, which prevents stricture from occurring after healing—a misfortune which is sure to follow if the mucous membrane is destroyed by cauterization all around.
In excising the prolapsed portion I prefer to remove one or more V-shaped portions on opposite sides and bring the edges together by sutures. This is preferable to clipping off the whole of the protruding mass, because the cicatrices left are less likely to give after trouble.
When the dilatation is caused by varicose veins it may be well to follow the example of Gustave Simon. He exposed the vessels by cutting through the vaginal wall, ligated the largest, and arrested the hemorrhage from the smaller ones by applying liquor ferri perchloridi. He repeated this operation several times on the same patient, who experienced little or no inconvenience from the proceeding and made a good recovery.
Dilatation of the lower third of the urethra is usually secondary to some other trouble, as I have already stated; and all that is necessary to do for such cases is to remove the cause and treat any inflammation that may exist. The dilatation will then disappear; and if it does not, but little if any trouble will be caused by it.
The treatment of dilatation of the upper third consists simply in supporting the parts. This can be effectually done by using the pessary already recommended for the relief of prolapsus of the bladder. It may be necessary to have the instrument so formed as to bring the pressure where it is required. This is done by placing the pessary in position and observing what change of form, if any, is necessary, and then directing the instrument-maker to make the alteration. If the parts are well supported in this way, recovery will follow unless atrophy of the muscular wall has previously taken place. Even then the patient can be kept comfortable by wearing the pessary. If there is urethritis present, it may be necessary to remove that before using the pessary; otherwise the pressure of the instrument may cause pain and aggravate the inflammation.
In dilatation of the middle third Bozeman has proposed to make an opening into the most dependent part of the urethra through the vaginal wall, and maintaining it until all inflammation has been relieved, and then closing the opening by the usual plastic operation. By this means the urethra is perfectly drained of urine and the products of inflammation which accumulated there before. This, with appropriate cleansing and topical applications, soon restores the mucous membrane to its normal condition, and the removal of the redundant tissue during the operation of closing the opening effectually cures the whole trouble. This treatment is admirably adapted to marked cases of long standing, and should be employed. By using the thermo-cautery to make the opening the operation is easily performed. In recent cases of less magnitude I have obtained satisfactory results by dilating the lower part of the urethra and supporting the dilated portion either with a pessary or a tampon of marine lint. This permits the urethra to keep itself empty, and then, by frequently washing it out and applying such remedies as will cure the urethritis, recovery will sometimes follow.
Dislocations of the Urethra.
This is one of the affections most frequently met with in practice. I have found very few cases recorded in medical literature. This neglect of the subject by authors is perhaps due to the fact that in many cases of displacement of the urethra the bladder is also dislocated, and the whole trouble is described under the head of vesicocele or cystocele. Now, it is true that displacement of the two occurs together, but either may take place alone.
The extent of displacement varies exceedingly, but I shall describe only the partial and the complete. A clear comprehension of these two degrees will cover all intermediate forms. In partial displacement downward the upper two-thirds of the urethra are prolapsed, so that the direction of that portion of the canal is backward, instead of curving upward, as in the normal condition. In complete prolapsus the urethra runs from the meatus (which is in its normal position) backward, and rests upon the perineum, or in extreme cases, accompanied with prolapsus of the bladder and uterus, its direction is backward and downward, the position of the vesical end of the urethra being below the level of the meatus. In this degree of displacement the urethra and bladder can be seen presenting at the vulva or lying between the labia minora. The urethra is usually shortened considerably when the prolapsus is marked.
ETIOLOGY.—Utero-gestation and delivery are the most important causes of this affection. In the advanced months of pregnancy I have observed that while the bladder rose above the pubes the urethra was pushed slightly downward by the settling of the enlarged uterus into the pelvis. In such cases when labor occurs the head of the child dislocates the urethra still more by pushing it still farther down. This process I have often watched in forceps delivery. When there is a partial prolapsus of the urethra existing before labor, the urethra and anterior vaginal wall are forced down before the advancing head, and that, too, while the attendant is making counter-pressure to prevent it. The displacement produced in this way is often restored during convalescence if proper care be taken to push the parts back into place and the patient is kept at rest until the tissues regain their tonicity. But in many cases the trouble is overlooked, and by permitting the patient to get up and be on her feet while there is still prolapsus it will slowly increase until the dislocation is complete. This will surely be the case if there is any loss of perineum. Indeed, rupture of the perineum is an accident which permits the urethra to descend from its place. The perineum supports the vaginal walls, which in turn support the urethra; and if it be lost, even in part, the vaginal walls become relaxed, or perhaps never regain their tonicity after delivery, and, settling down more and more, carry the urethra with them.
SYMPTOMATOLOGY.—The symptoms arising from displacement of the urethra are much the same as those found in dilatation and other urethral diseases. I need not, therefore, repeat them in detail. Suffice it to say that in dislocation of the upper portion of the canal there is, in addition to frequent urination, a partial loss of control of the bladder. Under the extra pressure of coughing, for example, the urine will escape. This loss of control does not exist, as a rule, in complete displacement. On the contrary, there is usually difficult urination, which requires increased voluntary efforts to empty the bladder. In all degrees of displacement the symptoms are increased in the erect position, and are markedly relieved on the patient's lying down.
DIAGNOSIS.—An examination of the vagina, either by touch or speculum, will reveal the downward projection of part or all of the urethra, which will show that there is either dilatation or prolapsus. The change in the direction of the canal will be shown by passing the sound, and dilatation can be excluded by observing that the urethra grasps the instrument firmly at all points. In dislocation of the upper two-thirds of the urethra the sound passes in the normal direction, but is arrested at a half or three-quarters of an inch from the meatus; but by pushing up the vaginal wall and the urethra the sound will then pass into the bladder. When the prolapsus is complete the instrument passes in easily, but takes a downward and backward direction.
PROGNOSIS.—Uncomplicated displacement of the urethra can be remedied in the great majority of cases. By placing the parts in proper position, and holding them there, the relaxed tissues will usually contract sufficiently to support themselves. Should they fail to do so, the patient can at least be made comfortable by wearing some supporter.
TREATMENT.—When the displacement of the urethra is caused by any other trouble, such as defective perineum or prolapsus uteri, then these things should first be attended to. Should there be urethritis, that also should receive appropriate treatment. But the chief indication is to retain the urethra in place; and this can be easily accomplished by using the pessary which has been recommended for supporting the prolapsed bladder. Prolapsus of the upper part of the urethra can be relieved in this way quite satisfactorily. When the whole urethra is displaced, this pessary, while it supports the upper part, will still permit the middle portion of the urethra to settle down. This difficulty may be overcome by making the anterior portion of the pessary long enough to engage in the introitus vulvæ, and in that way keep the whole canal where it should be. Should this cause the patient much discomfort, a tampon of marine lint should be used to keep the parts in position until some restoration of the parts is obtained, and then the pessary will complete the treatment.
Prolapsus or Inversion of the Urethral Mucous Membrane.
The prolapse may be limited to one side or extend all around the canal. The size and extent of the protrusion vary considerably. If the meatus is of full size, the prolapsed portion will usually preserve its natural color for a time; but after a little, from chafing when wet with urine, and especially if not kept clean, it will become red and oedematous. When the meatus is small these changes occur sooner and in a more marked degree, because the prolapsed portion is partially strangulated. The longer the membrane remains exposed the more sensitive it becomes, and the frequency of urination and pain attending it increase. It also becomes very tender and painful to the touch. In marked cases the ordinary movements of the body irritate the parts, and in that way render walking painful.
These are symptoms that closely resemble those of irritable growths at the meatus urinarius, and, so far as history is concerned, it is not easy to make a differential diagnosis. To do this it is necessary to make a local examination. The physical signs and the points in the diagnosis between this affection and other diseases have been given briefly but sufficiently under the head of Dilatations of the Urethra, and need not be repeated here.
The causes of prolapsus of the urethral mucous membrane are numerous, but those that are best known are long-continued congestion of the membrane, urethral and cystic irritation causing frequent urination and vesical tenesmus. Chlorotic and greatly debilitated women are said to be predisposed to it, as also old prostitutes. The few cases that I have seen were in women over fifty years of age, and all of them were weak, nervous patients who had suffered from some organic disease or functional derangement of the urinary organs.
PROGNOSIS.—This disease does not yield promptly to mild treatment, unless it is seen early in its progress; and if it does yield to mild, soothing, and astringent applications, it is liable to return. But in case there is no other disease present that tends to keep it up, it can usually be cured by surgical means.
TREATMENT.—When a case is first seen it is well to remove any inflammation or other complicating conditions. The prolapsed membrane should be replaced, and the patient kept quiet in bed to favor the retention of the parts in situ. Astringents, such as tannic acid, alum, or persulphate of iron in a weak solution, should also be used. Should these fail, the prolapsed portion of the membrane should be removed. The methods of doing this (by excision and the thermo-cautery) have already been described.
Stricture of the Urethra.
PATHOLOGY.—Obstruction of the urethra by narrowing of its calibre is a much less common affection in the female than in the male. Still, it occurs sufficiently often to demand attention. There are some facts in the pathology of urethral stricture peculiar to women which we will first notice. Passing over congenital narrowing of the urethra by simply saying that such a malformation has been known, we find that stricture is developed in the female, as in the male, by the deposit of inflammatory products beneath the mucous membrane, which by gradual contraction constricts the canal. Ulceration of the membrane in a marked degree produces the same results. The inflammation and ulceration which end in the formation of stricture are usually specific in character, but the same may follow from the too free use of caustics and injuries during childbirth. Stricture may also be produced by bands of scar-tissue formed in the anterior vaginal wall and stretching across the urethra. Contraction of the whole canal occasionally occurs in cases of vesico-vaginal fistula of long standing. There the narrowing is simply the result of disuse. The form of stricture that most frequently comes under observation is a contraction of the meatus urinarius, produced in many cases by the too liberal use of caustics in the treatment of abnormal growths at the lower end of the urethra, or from vulvitis. This form of stricture is the least troublesome and is easily relieved. When due to the results of former urethritis or peri-urethritis, the walls of the urethra are thickened and indurated at the point of the stricture, and there is usually subacute urethritis, sometimes ulceration. In those cases where the calibre of the canal is diminished by cicatrices of the vaginal walls, and in general contraction of the urethra in vesico-vaginal fistula of long standing, the mucous membrane may be perfectly normal.
SYMPTOMATOLOGY.—Frequent and difficult urination are the chief troubles caused by stricture of the urethra. The stream becomes smaller, and may be twisted or flat, but this is rarely observed. Patients, as a rule, only notice that they require to urinate more frequently, and that they have to make more voluntary efforts to empty the bladder than were necessary before. In almost all cases of stricture the subject has at some previous time suffered an injury at childbirth, urethritis, or something to which the origin of the stricture can be traced. The previous history of cases in which stricture is suspected will aid in settling the diagnosis and etiology.
DIAGNOSIS.—A digital examination by the vagina will reveal thickening and induration if the stricture is due to that cause. Cicatrices of the vaginal wall compressing the urethra can be detected in the same way. The use of the sound will determine the location of the stricture and the extent to which the canal is contracted. When the stricture is at the meatus it can be found with facility; but when it is located higher up the largest sound that can be introduced without force should be passed up to the point of stricture. This will localize it; then by using a sound that will pass through it the extent of the constriction will thus be ascertained.
The affections which are liable to be mistaken for stricture are retention of urine or difficult urination from pressure on the urethra by the displaced gravid uterus, pelvic tumors, and dislocations of the urethra. The former can be excluded by a vaginal examination, and the latter can also be detected by the sound, used as directed while discussing the diagnosis of the dilatations.
PROGNOSIS.—Stricture of the urethra usually yields very promptly to treatment, so that the prognosis is good. The only exceptions are where the stricture has existed in a marked degree long enough to cause dilatation of the ureters and disease of the kidneys. Chronic cystitis or urethritis, occurring as a result of the stricture or coincident with it, may so complicate matters as to make recovery slow or even impossible. In cases where the whole urethra is contracted because of the existence of a vesico-vaginal fistula of long standing, it is extremely difficult to restore the tissues of the urethral walls to their normal state.
TREATMENT.—The treatment of stricture will depend upon its location and cause. If it is situated at the meatus, it can be divided by the urethrotome or forcibly stretched with the dilator. When due to bands of scar-tissue in the vagina, they should be divided at several points and the urethra dilated by repeatedly passing the sound. When it is owing to deposition of the products of inflammation in the submucous tissue, forcible and rapid dilatation, as practised on the male subject, will answer well if the proper cases are selected for this form of treatment. Dilatation should be made carefully, with a view to breaking up the constricting tissue without lacerating the mucous membrane. To do this it is not necessary to dilate the urethra to any great extent. As soon as the stricture has given way dilatation should be suspended.
Incising the stricture from within outward, according to the method commended by surgeons for the cure of stricture in the male, will no doubt answer a good purpose. In fact, I am inclined to believe that this plan of treating this affection is the best, but my own experience with this operation on the female urethra is not sufficient to warrant my speaking positively.
In contraction of the whole urethra arising from disuse in cases of vesico-vaginal fistula gradual dilatation with graduated sounds answers very well. This should be attended to before closing the opening in the bladder. In all cases attention should be given to any inflammation that may accompany the stricture or follow the treatment. It is well also to keep such patients under observation, and pass the sound from time to time to see if there is any tendency of the stricture to return. The brilliant results obtained in the treatment of stricture in the male with electrolysis by Robert Newman should warrant a more extended trial of this method.
Stricture at the Junction of the Urethra and Bladder.
This form or location of stricture is, so far as I know, peculiar to women, and its influence on the function of the bladder has not been clearly pointed out. In fact, no distinction has been made between the pathology or clinical history of stricture at the upper end of the urethra and elsewhere in the canal. At least, I am not aware that writers on this subject have mentioned this form of stricture. My own observations have been limited, but sufficient, I think, to warrant me in saying that stricture does occur at the junction of the bladder and urethra, and that it behaves differently from ordinary stricture at other parts of the canal.
The causes are the same which give rise to stricture elsewhere; hence nothing requires to be said on this point. The point of most importance is the fact that stricture at this part of the urethra will cause difficult urination out of proportion to the extent of the narrowing of the canal. Contraction of the canal in a slight degree will cause great difficulty in urination, and frequently retention. This is contrary to the history of stricture of the urethra at other points. In such cases there is no retention of urine until the stricture closes the canal, or very nearly so; but I have seen retention in cases of stricture at the neck of the bladder while a medium-sized catheter could be passed with ease, thus showing that the narrowing of the canal was not alone the cause of the deranged function. It is possible that the original stricture causes spasmodic contraction, or in some way disturbs the normal action of that portion of the canal which performs the function of a sphincter vesicæ.
The symptoms presented in this form of stricture are difficult urination and in some cases complete retention. I have also noticed, in one case, that there was a frequent desire to urinate, but that was accounted for by a slight catarrh of the bladder. These symptoms are such as occur in other conditions, such as atrophy and paralysis of the bladder, obstruction of the urethra from tumors, calculi, the pressure of the displaced uterus, and prolapsus of the bladder.
In this form of stricture there are thickening and induration of the neck of the bladder, which may be detected by digital examination of the vagina. The sound will also reveal a narrowing of the canal at the vesical neck, but the contraction may not be marked. Our main reliance must be placed upon the exclusion of all other conditions which can produce the same symptoms. Pressure upon the urethra and prolapsus of the bladder can be excluded by an examination of the pelvic organs, and the use of the sound will show anything like complete obstruction of the canal.
Having excluded the possible existence of either of these conditions, the only two affections which are to be confounded with this form of stricture are atrophy and paralysis of the bladder. To distinguish these from the stricture, the catheter should be passed when the bladder is well distended, and the character of the flow of urine watched, when it will be observed that in stricture the urine comes away with the usual force. The bladder contracts normally and with its natural vigor, and sends the urine out in a well-sustained stream through the catheter, if there is only stricture. On the other hand, in paralysis and atrophy the stream is slow and without force—so much so that voluntary effort or the pressure of the hand on the abdomen is sometimes necessary to empty the bladder. This is especially so when the catheter is used while the patient is in the recumbent position. Finally, the diagnosis may be confirmed by testing the dilatability of the urethra. This can be done by passing a dilator along the urethra and gently testing the resistance of the walls of the canal. There is a slight yielding at all points except at the stricture, where a decided resistance is met.
Regarding the management of stricture at the junction of the urethra and bladder, I am obliged to say that my experience has not yet been sufficient to enable me to speak definitely. Rapid and free dilatation is not sufficient to effect a cure; at least it has failed in one case. Division of the stricture by incision suggests itself, but I am confident that that operation would be unsatisfactory, because of the great irritation which always occurs when there is a solution of continuity at this point. My practice, therefore, has been to produce slow and gradual dilatation by the use of graduated sounds, and the application of oleate of mercury or iodine to the anterior vaginal wall at the site of the stricture. More extended observation may develop other and better methods of treatment, but for the present that is all that I have to offer on this subject.