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

by Unknown

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.