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

by Unknown

As prominent among the causes of chronic catarrh in a purely medical aspect it may be well to insist upon the ease with which this condition is sometimes brought about by the physician himself. A man with a weakened bladder may carry a pint or much more clear urine in his bladder constantly during many years as a residual deposit which his weakened bladder cannot throw off. Excess over the fixed residuum produces a desire to urinate, and the patient, mainly by voluntary contraction of the abdominal walls, voids that excess. If now the physician finds this globular accumulation in the patient's belly, and in his zeal to do all that is possible forgets his caution, he may throw the patient first into an acute cystitis (if haply he escapes collapse), and then into chronic vesical catarrh—an affair perhaps of a lifetime. Surgeons have noticed, and especially Sir Henry Thompson has pointed out, that a dirty catheter may poison the urine and bring about a cystitis which otherwise might have been avoided; and observers from all time have noticed that the sudden entire evacuation of the contents of a bladder long accustomed to over-distension is in itself a grave cause of serious inflammatory disturbance to the mucous membrane of the bladder. Recently much attention has been called to this condition and its possible fatal termination by Sir Andrew Clarke, under the name of catheter fever.

The deductions from a knowledge of these facts are obvious: they are—(1) always to thoroughly cleanse, and then to disinfect, a catheter on each occasion before its use; and (2) never to empty entirely at a first sitting a bladder which has been long habituated to over-distension; and when, finally, the bladder is emptied, always irrigate it with a disinfecting solution (borax) after each emptying.

SYMPTOMS.—Chronic cystitis varies in grade, and its symptoms vary with the grade of the inflammatory process. There is probably no pain more intense than that endured by a man with severe general cystitis in its last stages, when the unceasing tenesmus wrings groans from his lips, the sweat from his body, doubles his frame in agony, and converts his facial expression into a distorted tragedy. The sight is pitiable and never to be forgotten. On the other hand, a man may continue about and at his work with a patient flabby bladder containing constantly more or less stringy mucus and ammoniacal urine, suffering little or no pain or tenesmus, and perhaps having no subjective symptoms except a slight sense of weight in his lower belly and a rather frequent desire to urinate.

Between these limits the symptoms range, but in a general way it may be said that the symptoms of chronic vesical catarrh are these: frequent calls to urinate, attended by more or less pain, especially toward and after the termination of the act. The sense of satisfaction normally felt after urination is generally absent. Motion, particularly jolting as in rough riding, causes pain. This pain is referred to the lower part of the belly, to the perineum, to the end of the penis, the urethra, the anus. The straining after urination may be absent or of the most intense character, leading to prolapse of the rectum and causing excruciating torture. The urine always contains pus scattered through it, and generally also more or less pus in that semi-solid condition known as stringy mucus. Stringy mucus is pus gelatinized by the ammonia of the decomposing urine. These clots of muco-pus contain gritty crystals of the ammonio-magnesian phosphate. More or less blood is to be found in the urine, especially during acute paroxysms. Pure blood sometimes follows the urine after each act of urination. Bacteria abound in the fluid, which varies in odor greatly in different cases, not always strictly in accordance with the severity of the actual inflammatory process. Thus, the urine may be simply sweetish in its odor, ammoniacal, flat, and stale, or be possessed of a putrid, sickening sweetness of indescribably nauseating power. Again, it may be rankly rotten. The bottom of the chamber in some cases becomes covered with a thick coating of the viscid muco-pus, which strings out and reluctantly follows the fluid when the vessel is inverted. Sometimes the urine contains shreds of false membrane or putrid masses of sloughy tissue.

PATHOLOGY.—In chronic cystitis the mucous membrane of the bladder undergoes gradual thickening, loses its pink salmon tint, and becomes gray in color. The thickening extends to the submucous layer, and more or less to the muscular walls as well. In cases of prolonged chronic cystitis attending atony of the bladder, notably with hypertrophied prostate, the cavity of the organ is large, its walls seemingly thinned and flabby, its internal coat roughened by the crossing of bundles of muscular fibres or perhaps perfectly smooth. In other conditions (concentric hypertrophy), where there has been a serious obstacle to the free outflow of urine without any atony of the muscular coat (stricture of the urethra, some cases of stone and of enlarged prostate), the walls of the bladder may be enormously thickened to the extent of an inch or more, the inside surface rough, perhaps ulcerated.

The thickening of the muscular bands within the bladder often causes them to stand out in bold relief, like the muscular bundles in the heart-cavity. These prominent bundles enclose spaces of various sizes and shapes, and from the bottoms of these spaces sometimes the mucous membrane protrudes between the muscular bands and forms pouches of varying size (sacculated bladder). These pouches consist of mucous membrane alone covered with peritoneum, and may become the seat of encysted stone.

If there has been a subacute grade of the surface inflammation before death, there may be livid spots on the mucous surface of the bladder, punctate or larger ecchymoses, reddened areas from which the epithelium is more or less detached, ulcers with or without sloughs or diphtheritic covering, perhaps perforations of the bladder and infiltration of urine, enlarged mucous follicles, granulations, fungosities, etc. Heterologous deposits, tumor, cancerous and tubercular ulcers, cysts, stone, complete the possibilities of what may be encountered in the bladder at an autopsy upon a patient with chronic cystitis.

The chronic like the acute varieties of cystitis may involve the whole of the inside of the bladder or only a portion of it.

The PROGNOSIS, like that of acute cystitis, varies mainly with the cause. If the latter can be entirely removed (stone), the bladder gets perfectly well. Not so, however, unless all the causes are removed. Thus, a phosphatic stone may grow in a bladder as a result of enlarged prostate and chronic cystitis. The presence of the stone excites the chronic cystitis, and subjects the patient to a crisis of acute cystitis from time to time. The removal of such a stone will by no means cure the chronic cystitis; its removal is only one step in the treatment of the cystitis.

As far as life is concerned, the prognosis of chronic cystitis is good. A patient may live many years with chronic cystitis, particularly if he treats his bladder properly. Although, as generally encountered, chronic cystitis is not curable, few maladies yield results to treatment more gratifying to the physician and the patient than the one under consideration.