A system of practical medicine. By American authors. Vol. 4

by Unknown

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.