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

by Unknown

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 Having located the point exactly by means of the endoscope, the inner or glass tube is withdrawn, and the application made directly to the required spot through the rubber tube.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.