structures. Among the former, tuberculosis of the kidney and gonorrhea of
the urethra are frequent and important. Infectious processes in the vicinity,
infecting the bladder by continuity of structure ; for example, an appendiceal
abscess which ruptures into the bladder. Cystitis may occur as a rather rare
complication in the course of infectious diseases — typhoid fever, the exan-
themata, apparently as the result of the elimination of bacteria through the
kidnev, the living bacteria in the urine causing infection of the bladder.

Among men, two causes exist far more frequent than all others. They are,
in youth and adult life, gonorrhea and stricture of the urethra; in old age,
enlargement of the prostate gland. Among women, cystitis is exceedingly com-
mon. The causes are to be sought in the frequent occurrence of tumors of the
uterus and the adnexa, producing congestion of the bladder by pressure ; fur-
ther, inflammatory pelvic conditions of all sortsj and gonorrhea. Owing to the
566 "



THE BACTERIA OF CYSTITIS



."d i i




Fig. 171. — [Trtnary Sediment in Chronk l

TITIS WITH AMMON1 MAI, l'l.HMI.N I Al ION. Pus

cills swollen by ammonium carbonate. A
few swollen bladder epithelial cells. Triple
phosphate. Ammonium urate. Amorphous
earthy phosphates. (Ultzmann.)



>lmri urethra, the entrance of infect ing organisms into the bladder i- easy. oh
Btructive lesions are, however, far less common than among men, ami consequent-
ly, though cystitis is frequent among
women, it is far less difficull to cure.

The Bacteria of Cystitis. — The bac-
teria concerned in the production of
cystitis are of varied character. They
may properly be divided into two
groups: ( I ) Those which cause am-
moniacal decomposition of urea, and
(2) those which have a specific inflam-
matory action on the mucous membrane.
Much time and efforl has been ex-
pended on the si ii' I v of the bacteriology <>f
cystitis. Upon certain points the views
of differenl observers are qo1 in accord.
A few facts are, however, well estab-
lished. The gonococcus, alone, may be
the cause of gonorrheal cystitis, though
a mixed infection may occur. The lesion
is confined for the most part to the pros-
tatic urethra and the trigone. In some cases the entire bladder may be involved.
The colon bacillus may dwell in the bladder and cause no cystitis. In other cases

it will produce a cystitis with
acid urine. The tubercle bacil-
lus causes cystitis ; often the in-
fection is mixed. The orifices
of the ureters and the trigone
are the areas first affected in
most of the cases. (See Renal
Tuberculosis.) Numerous bac-
terial forms cause decomposi-
_ a ii'»n of urea, with the produc-
tion of rather sharp crystals
of triple phosphate and the
formation of ammonium car-
bonate. < lystitis of a peculiar-
ly distressing typo accompanies

Fig. rinarv EIediment in Perm,, Cyst a. ammoniacal urine. Whether

Triple phosphates, [b. Bacteria and molecular detritus. ,| l( . f 1V(l ammonium Carbonate

f. Mood corpuscles. (I Itzmanu.)

and the crystals act merely ;is

chemical irritants to the bladder or whether, in addition, the special bacteria
have a specific effect upon the bladder wall, or whether or not the infection
is always a mixed one, is, 1 believe, not definitely known.









'■\



f>v;//i.






< ~mk- . >7 • :v ■'-•' <yi±-'^



568



CYSTITIS



Under special conditions the ordinary pyogenic cocci and the Streptococcus
erysipelatis may cause severe forms of cystitis, the former with actual sup-
puration or necrosis of the bladder wall. In these cases the saprophytes may

add a gangrenous or putrid character
to the inflammation. Some of the forms
causing ammoniacal decomposition of
urea are Bacterium urea? (v. Jaksck),
Micrococcus urea? liquefaciens (Tliig-
ge), TTrobacillus liquefaciens septicus
(Krogius).

Other bacteria associated with some
forms of cystitis are : Bacillus pyocya-
neus, Bacillus typhosus, certain forms
of gas-producing bacteria (Heyse),
| Cystitis emphysematosa), the pneu-
mococcus.

Pathological Anatomy of Cystitis. —




Fig. 173.



•sirs'. (Ultzmann.)



Cystitis usually begins in the trigone,
and may be confined to it and the
prostatic urethra or spread over the entire mucous membrane of the blad-
der, constituting a partial or total cystitis, respectively. The phenomena
are injection, swelling, and congestion of the mucosa, with subsequent des-
quamation of epithelia and exu-
dation of white cells. Ecchy-
motic areas are developed here
and there, and in some cases
superficial erosions of the mu-
cous membrane. The urine
becomes purulent and contains
many epithelial cells and bac-
teria. Its reaction remains
acid or becomes alkaline,
according to the character
of the infection. If cysti-
tis becomes chronic the mu-
cous membrane is thickened,
the veins of the mucosa are
dilated, the submucous tissue
is infiltrated with round cells.
In severe cases the muscular
coat is also involved.

Parenchymatous Cystitis. — The color of the mucous membrane changes
from bright red to dirty grayish-red. The surface of the mucous membrane
is coated with adherent flakes of pus. In severe cases minute abscesses may




Fig. 174. — Cicatricial Bladder. (After Guyon.)



PATHOLOGICAL ANATOMY OF CYSTITIS



569



form in the bladder wall, or larger abscesses may form, perforate the bladder,
and produce a pericystitis, or the process may end shorl of suppuration and
produce adhesions of the bladder to surrounding structures. In other cases the
end resull is cicatricial contraction of the bladder ( contracted bladdi r, atrophied
bladder, Schrumpf Blase of the Germans, chronic interstitial cystitis).

Severe infections may produce gangrene and necrosis of the bladder wall.
In such cases the urine is foul with gangrenous shreds of mucous membrane,
[in-, blood, and detritus.

Membranous Cystitis (Croupous Cystitis). — A membranous cystitis, with
the evacuation of bladder casts, has been observed, as well as true diphtheria
of the Madder. Isolated ulcers of the bladder, oontuberculous in character,
have been observed associated with cystitis.

When obstructive lesions complicate cystitis, the muscular wall of the blad-
der undergoes hypertrophy; the muscular ridges stand out prominently with
deep sulci between them, constituting
the trabeculated bladder. Such blad-
ders may be larger than normal — i. e.,
dilated — eccentric hypertrophy, and
are often insufficient, or smaller than
normal — conccii/ric hypertrophy. In
either case the mucosa may bulge
through ;i thinner portion of the mus-
cular wall, and form a sort of hernia,
or pocket, sometimes of large size,
communicating with the remainder of
the bladder by a larger or smaller
opening, constituting a diverticulum
of the bladder.

/ nt e is/ i Hal Cystitis. — In cases of
interstitial cystitis, usually due to
gonorrhea, the inflammatory process
runs its course, and after ;i long peri-
od may result in atrophy of the blad-
der wall. The ridges and sulci dis-
appear, the mucous membrane again
becomes smooth, the wall of the bladder scarcely thicker than normal: but the
bladder bus censed to be an elastic, niiiscubir, contractile organ. It is converted
into a mere leathery sack of dense connective (issue, ami can no longer, by any
mean-, be dilated lo ;i normal degree. These bladders may hold only an ounce
or two of urine. The possessor of such an atrophied bladder suffers much
discomfort The bladder can usually be emptied, or nearly so, by the patient.
The residual urine rarely amounts lo more than a drachm or two.

Hypertrophy of the Bladder. — Hypertrophy of the bladder of both the
dilated and contracted forms is usually seen in old men as the result of pros-




l'h.. 17"). — Concentric Hypertrophy op thi
Bladder. (After Guyon.)



570



CYSTITIS



tatic obstruction, less frequently in young manhood and middle age as the
result of chronic gonorrhea and stricture. Chronic gonorrhea of the bladder
produces more often, when of a severe type, the cicatricial bladder without
hypertrophy of the muscular coat.

Eccentric hypertrophy is associated with insufficiency. The amount of
residual urine is large. In thin persons the enlarged and thickened blad-
der is palpable, even
when empty, by com-
bined rectal and ab-
dominal touch. A
searcher introduced
after voluntary urina-
tion reveals a consid-
erable cavity, with
marked ridges project-
ing from its walls.

In concentric hy-
pertrophy the capacity
of the bladder is small.
Attempts to inject a
large quantity of fluid
into the bladder are
futile. The water runs
out alongside the cath-
eter. The walls of the
bladder are hard and
ridged. The quantity
of residual urine is




Fig. 176.



-Eccentric Hypertrophy of the Bladder.
(After Guyon.)



trifling.



Atrophied Bladders. — Atrophied bladders, the result of interstitial cystitis,
are small. They cannot be dilated. Their walls are smooth, hard, and in-
elastic. There is little or no residual urine. These patients may be obliged
to urinate every few minutes ; many of them are obliged to wear a urinal.
They sometimes have nocturnal incontinence. In some cases pyuria is marked,
in others very slight. Attempts to increase the capacity of these bladders by
forced injections are rarely successful. During the injections the patients
suffer much pain.

Pericystitis. — Inflammation of the subserous connective tissue may be sec-
ondary to parenchymatous cystitis with the formation of small abscesses in
the bladder wall. It is apt to occur around inflamed diverticula. It may be
due to trauma — i. e., to wounds of the bladder wall produced by the blades
of a lithotrite — and to other extraperitoneal wounds or ruptures of the bladder.
In some cases it is due to inflammations of the surrounding viscera — the pros-
tate, the uterus and adnexa, and the appendix. If suppuration occurs, infiltra-



SYMPTOMS AND DIAGNOSIS 01 CYSTITIS



571



ti.ui of urine and fatal sepsis of purulenl peritonitis may result. In some
:m abscess forms, which ruptures Into the bladder, the rectum, the vagina, or
appears in the perineum. The - iiri 1 ~ and symptoms of pericystitis are more
or less marked sepsis. Retention of urine is common. Locally, a tender, pain-
ful mass will be palpable, either in the middle line above the pubes or to one
side of the bladder. 1 1' the bladder i~ emptied by catheter the tumor remains.
There is continuous pain in the region of the bladder, with dysuria or reten-
tion. It' the process started outside the bladder, the urine may be clear, [f
secondary to cystitis, there will be pyuria. The formation of an abscess is
attended by increased septic symptoms. It' the abscess approaches the skin
of the abdomen or perineum, localized swelling, edema, redness and brawny
induration will develop or, later, fluctuation. Rupture into the rectum is
followed by the discharge of pus from the boweL Rupture into the bladder
i- indicated by the sudden evacuation of much pus with the urine. Such pus
often lias a fecal odor. Actual communication between the bladder and the
bowel is shown by the discharge of feces or gas, or both, with the urine. The
fanner indicates a large opening; the latter alone a small one.

Suppurative pericystitis is a very dangerous disease. A large proportion
of these cases are fatal.

The Symptoms and Diagnosis of Cystitis. — The cardinal symptoms of cystitis,
of whatever origin, are three: frequent urination, pain, and pyuria. Cystitis




Fig. 177. — Epithet. ia fiwm tiik Female Ure- Fig. 178. — Epithf.lia from the Male Ure-
thra Above, from the Vagina Below. tiira Above, from Littke's Gland Below.



may be either acute or chronic. The latter form often follows the first, and
during a chronic cystitis acute exacerbations are frequent. Severe constitu-
tional symptoms are no1 commonly present, even in the acute form, unless the
inflammation be of a septic or gangrenous type. Gonorrheal cystitis is occa-
sionally ushered in by chilly sensations and a moderate rise of temperature.

(See, however, I'rcthral ('hill and Fever.)



572 CYSTITIS

Acute cystitis is accompanied by a more or less constant desire to pass
water, and the act, when accomplished, is attended by pain. In severe cases
the patient must urinate every few minutes. The pain is of a spasmodic
character, and is felt before and during urination, but is most severe at the
end of the act, when the vesical sphincters close on the inflamed mucous mem-
brane of the trigonum and prostate. The pain is referred to the glans penis,
to the perineum, prostate, and rectum. In gonorrheal cystitis, the prostatic
urethra and trigonum being chiefly involved, the passage of the last few drops
of urine is attended by an acute spasm of pain, and these drops are often
bloody.

Between the acts of urination a dull, heavy pain is felt in the sacral region.
When the cystitis is general, pain is also felt in the suprapubic region, and
the bladder is tender on palpation. In some cases of acute cystitis severe spasm
of the sphincters leads to complete or partial retention of urine. The patient
may be able to urinate a little from time to time with painful effort, but he
cannot empty his bladder, since no sooner does the stream of urine start than
it is checked by the painful, spasmodic contraction of the sphincters. In some
of these cases catheterization is difficult, and may require the use of morphin
and hot baths, or of cocain anesthesia. In less severe cases of acute cystitis
the patient may urinate every hour or half hour. The pain, though similar
in character, is not so intense. In chronic cases the symptoms of pain and
frequency will vary within wide limits. (See Cystitis due to Special Causes.)

Pyuria is the third essential symptom of cystitis. It is always present,
although at the beginning of an acute attack the amount of pus in the urine
is small. If we exclude the cases of cystitis accompanying injuries and dis-
eases of the spinal cord with paralysis of motion and sensation, in which
naturally there is neither pain nor desire to urinate, we shall find in every
case of cystitis the three cardinal symptoms : frequency, pain, and pyuria.
The diagnosis of the anatomical origin of pus in the urine is discussed else-
where. (See Gonorrhea, Thompson's Test, True and False Albuminuria,
Cystoscope, Ureteral Catheterization.)



CHAPTER XXVII

THE NEUROSES OF THE BLADDER
(Functional Disturbances of the Bladder Due to Nervous Caui

Among these conditions are included: ( 1 ) Cystospasm, ot urina spastica;
(2) spasm of the vesical sphincters; (3) paresis and paralysis of the detrusor,
insufficient bladder; (4) paralysis and paresis of the vesica] sphincters;
incontinence of urine, enuresis.

The motor disturbances of the bladder are often combined with sensory
disturbances; thus, with cystospasm we of ten rind hyperesthesia "1' the bladder,
and motor paralyses are often combined with loss of sensibility. These disturb-
ances of the bladder are in part due to central causes — i. c, injuries and dis-




Fig. 170. — Kpitiii i.ia from the Prostate.



Fig. ISO. — Kpithei.ia from the Bladder.



eases <d the spinal cord and cerebrum, and in part to local lesions of the penis,
urethra, prostate, kidney, or the bladder itself.

Cystospasm — Urina Spastica — Bladder Cramp — Irritable Bladder. — In this
condition the individual suffers from an uncontrollable frequency of urination,
solely during his waking hours and not accompanied by pain. The quantity
of urine may be normal or increased. The reaction is often neutral or feebly
a.id. Phosphaturia, oxaluria, and indicanuria are frequently present The
condition is observed in hysterical and neurasthenic individuals and among

57 ■



574



THE XEUEOSES OF THE BLADDER



normal persons "who are undergoing extreme anxiety or who are suffering from
severe mental shock. In these cases the causes are purely central. In some of
them the desire to urinate is not only frequent but peremptory; when they
desire to urinate they must seek some suitable place at once, or make other
arrangements. The desire may be excited by the sound of running water, a
draught of cold air, or by the mere thought of the condition of the bladder.
Such impulses may occur every hour or more frequently, perhaps every ten
minutes. The characteristic feature is that the frequency occurs only when
the patient is awake. During sleep there is no frequency. When due to purely
neurotic conditions the urine is free from catarrhal ingredients.

Among the local causes of urina spastica are fissure of the anus, hemor-
rhoids, excessive coitus, and masturbation. The two last may cause hyperemia,
congestion and hyperesthesia of the veru montanum (caput gallinaginis), and
entire prostatic urethra : even a mild catarrhal condition. This local irritation
may reflexly excite the bladder to empty itself with undue frequency. As a
consequence of gonorrhea, complicated by posterior urethritis, this condition




Fig. 181. — Epithelia from the Pelvis of the
Kidney and Ureter. (After Ultzmann.)



Fig. 182. — Kidxet Epithelittm. The cylindrical
cells corne from the neighborhood of the papillae.
The cubical from deeper portions of the straight
tubules. (After Ultzmann.)



of irritable bladder is by no means rare, even after the signs of urethritis have
long disappeared. In many of these cases, however, examination of the urine
will show the presence of thick compact shreds of pus, originating in the pros-
tatic urethra, indicating that the process is not entirely healed. When these
patients are examined with a sound, the posterior urethra will be found ex-
tremely sensitive. The diagnosis of the purely neurotic cases is made chiefly
by exclusion. We find merely a neurotic individual with normal urine who
has passed through some nervous strain or is neurasthenic from one cause or
another. Tabes should be sought for and excluded — i. e., loss of patellar tendon
reflex. Contracted pupils, insensitive to light. There may or may not be pain,



SPASM OF THE VESICAL SPHINCTER



575



:m«l the condition often occurs in the preataxic stage. (See also Paresis "I the
Bladder.) The therapy "f irritable bladder consists of general tonics and
bromid of potassium internally, Locally, the passage "I large sounds every
two days; and this hilling, astringent irrigations or cauterizations of the pros-
t;ii ic urethra.

Spasm of the Vesical Sphincter.— These patients complain not of frequent
urination, hut of difficulty in starting the stream. They may have t«i strain




I'm. 183. — Hyaline Cast:



(After Ultzmann.) Fig. 1S4. — Finely Grant/lab Casts. Advanced
chronic diffuse nephritis. (Ultzmann.)



for several minutes, and when finally urination is started the stream is small
and without force. As they proceed the stream becomes larger, of normal size,
lmt again diminishes, and when they think they have finished and button their
trousers they find that some urine still escapes and wets them or their garments.
The cause of this condition lies in hyperemia, congestion or catarrh of the
prostatic urethra, and is dependent upon an imperfectly cured posterior ure-
thritis more often than anything else. A contracted meatus urinarius, mastur-
bation, excessive coitus, and prolonged ungratified sexual excitement may he
responsible in certain cases. These patients are also extremely sensitive to the
passage of a sound, and its introduction, however gentle, is often followed upon
withdrawal by a few drops of blood. In some of these eases the symptoms are
really severe, the patients may suffer from retention of urine, and catheteri-
zation may he difficult. When the point of the instrument touches the external
sphincter (compressor urethra' muscle) a spasm is excited which prevents its
further passage. The condition is a true spasmodic stricture. Should the sur-
geon now exert strong pressure or move the beak of the instrument about in
order to find the opening, the spasm will l>e increased. Extreme gentleness
and patience will alone overcome the difficulty. A large, rather than a small,
instrument should be chosen. A large, blunt, metal sound or catheter is far
safer than a small one, and soft instruments will not, as a rule. pa<s in these



576



THE NEUROSES OF THE BLADDER



eases. An injection of thirty minims of a four-per-cent coeain solution into
the meatus, rubbed" backward toward the deep urethra, and left for five minutes,
is useful. The sound or catheter should be introduced continuously but very
slowly ; when its tip reaches the junction of the bulbous with the membranous
urethra, gentle direct pressure with the forefinger on the perineum will often
succeed in overcoming the spasm. The surgeon feels the instrument slip by the
obstruction, and upon sinking the shaft it slips readily into the bladder. These
cases are often diagnosticated by the inexperienced as tight strictures of the





Fig. 185. — Waxy Casts. Amyloid degeneration Fig. 1S6. — Epitheliat. Casts. Desquamative
of the kidnej'. (Ultzmann.) nephritis. (After Ultzmann.)

membranous urethra. I have seen such cases prepared for operation. Under
ether a full-sized instrument slipped easily into the bladder. The treatment
consists in the introduction of full-sized sounds three times a week. The sound
should be left in the bladder five minutes or more. Cauterizations are also
useful.

True cicatricial contraction of the prostatic urethra, the result of chronic
gonorrhea, is regarded by some surgeons as an important lesion, often con-
founded in elderly men with prostatic enlargement. Keyes considers that the
three characteristic phenomena are: (1) chronic unconquerable posterior ure-
thritis; (2) imperative urination; (3) dysuria. The treatment of this condi-
tion is perineal section and the introduction of the forefinger through the
prostatic urethra into the bladder.

Paretic and Paralytic Conditions of the Detrusor Muscle and of the Vesical
Sphincter. — Inability to completely empty the bladder in the absence of any
organic obstruction is known as paresis of the bladder. Total inability is
paralysis. They depend upon partial or total loss of contractility in the detru-
sor muscle. Such impairment may be due to defective innervation or to degen-
erative changes in the muscle itself. Paresis or partial impairment is seen in
diseases of the spinal cord, in acute febrile diseases in which cerebration is



PARALYTIC CONDITIONS OF THE DETRUSOR MUSCLE 577

dull, and as the resull of overdistention. of the bladder. The last two are usu-
ally temporary conditions, though a Bingle great distention may l«- folli
in some eases by permanenl atony.

In old age, even in the absence of prostatic hypertrophy, partial paralysis
of the detrusor is by do means rare, due to Benile degeneration of the muscular
u:ill of the bladder. The paresis is often combined with 1" - of power in the
vesical sphincter, and is sometimes accompanied by Benile atrophy of the pros
tate. In diseases of the spinal cord the paresis may be « ! • n - to tabes or to com-
bined sclerosis— i. e., :i diffuse sclerotic degeneration of the posterior and Lateral

columns of the cord, resulting in a combination of Bympl s, in pari those of

locomotor ataxia, in pari those of spastic paraplegia, sometimes t" the pressure
of ;i tumor of the cord. In addition to motor paresis, disturbances of sensation,
either hyperesthesia or diminished sensation may be observed. The hitter may
be combined with abnormal sensations, pain, a sensation of distention of the
bladder, etc. Tims in tabes the patients may have a diminished sensibility of
the bladder so that they do not know when ii i- distended, or they ma\
thai the bladder is full when it is not. Often they suffer from the symptoms
resembling those of spasms of the vesica] sphincter, so that they have difficulty
in starting the stream. They must strain or press upon the abdominal wall
or assume some nnnsnal attitude before they can urinate. In addition there
is often an actual loss of power in the detrusors, so thai these patients gradually
develop insiitlieient Madders. This may be combined, as I have seen in a
number of cases, with paresis of the sphincter, so that after the bladder contains
a eertain amount of urine, they begin to dribble, and are forced to wear a
urinal. These patients are not in my experience much benefited by local treat-
ment. They randy need to ho catheterized, and if this is done they are very