James M. (James Meschter) Anders.

A text-book of the practice of medicine online

. (page 142 of 178)
Online LibraryJames M. (James Meschter) AndersA text-book of the practice of medicine → online text (page 142 of 178)
Font size
QR-code for this ebook

(in very acute cases the vesical contents may consist of a small quantity
of pure blood only), is of a specific gravity varying from 1005 to 1030
(in the febrile cases), and contains pus-corpuscles, mucous flakes, shreds
of disintegrated and exfoliated epithelium (bladder), and micro-organ-
isms. Thomas R. Brown, ^ in a bacteriological study of 26 cases, found
the exciting causes as follows : bacillus coli communis, 57.7 per cent. :
staphylococcus pyogenes albus, 19.2 per cent. ; staphylococcus pyogenes
aureus. 7.7 per cent. ; and B. pyocyaneus, B. typhosus, and B. proteus vul-
garis (Haiser), each -3.8 per cent.

Gonorrheal infection may invade the vesicle mucosfe when mixed or
pure cultures of this organism are recoverable yfrom the urine ; fungous
mycelial threads and yeast-cells have even been found in certain cases
[mycotic cystitis). The urine is commonly acid in reaction, though
Brown found it alkaline where the excitant was the B. proteus vulgaris.
It may become less acid or alkaline should the condition become modified.*
More or less albumin will be noted, and on standing a dense sediment
forms in the bottom of the flask, which is composed of all the foregoing
substances, as shown by chemical and microscopic examinS,tion. The
total quantity of urine voided in the twenty-four hours may be normal

^ Johns Hopkins Hospital Bulletin, January, 1901, p. 4.


in amount or even slightly in excess of the normal. On the other hand,
if exfoliation of the mucous membrane takes place, there may occur par-
tial or even total suppression of the urine.

Fever, with or without an initial rigor, persists throughout the attack,
but is not of a severe type, save in the septic and malignant (diphthe-
ritic) forms of the disease, when it may reach 103°-105° F. (39.4°-
40.5° C).

Abscesses may form, and betray themselves by localized pain, tender-
ness, and, in some cases, by a circumscribed induration requiring surgical

In the variety associated with extreme exfoliation of the vesical
mucosa grave uremic manifestations follow. These include all the
features of the typhoid state (dry, brown tongue, mild delirium, ner-
vous and muscular twitching ; headache ; gastric disturbances ; and
coma). There is also some degree of malaise and anorexia.

It must not be forgotten that acute cystitis may represent an acute
exacerbation in the chronic form, and at times may assume a severe
type of the disease.

Diagnosis. — Cystitis should be readily recognized from the history
of the case and the frequency of the two almost pathognomonic symp-
toms — suprapubic pain and vesical tenesmus. An examination of the
urine will reveal the characteristic clinical features. The percentage of
albumin is usually much larger in nephritis than in irritability of the
bladder. The differentiation between cystitis and vesical irritability will
be noted under the latter condition. Urethritis may be excluded by
means of the two-glass test. For example, if urination into two glasses
reveals pus in both, after carefully washing out the urethra as far as the
compressor urethrse muscle, it is " very positive proof that cystitis or
some inflammation further up the canal is present " (Greene and Brooks).

The prognosis of the milder grades of cystitis is good ; the septic
and malignant (diphtheritic) cases offer a much graver outlook. Exten-
sion of the process upward toward the kidneys is always serious.

Treatment. — The treatment of acute cystitis includes prophylactic,
hygienic, and medicinal measures.

Prophylactic. — Most important is the prevention of the disease, and
this includes, in addition to the usual care of the body, the observance
of thorough asepsis.

Hygienic. — The cause of the disease, if evident (calculus, external
pressure), should be sought and removed. The patient should at once
be placed absolutely at rest in the recumbent posture. The diet must be
regulated, and all irritating, highly seasoned articles of food must be in-
terdicted. Alcohol in any form is prohibited. An absolute milk diet
will be most beneficial. The patient should be instructed to drink freely
of water and other diluent drinks. The free action of the skin may be
secured by friction and warm bathing.

Medicinal. — The drugs to be employed are the saline laxatives and the
various mild diuretics and urinary alterants. The reaction of the urine
will indicate the variety of alterant to be employed. If it be acid,
alkaline waters are serviceable, as the soda-preparations, Vichy, or the
potassium salts. In alkaline conditions of the urine probably the most
valuable drugs are benzoic and boracic acid and salol. Benzoic acid is


best administered in the form of ammonium benzoate, whicli may be
given in 10-grain (0.648) doses thrice daily in the compound infusion
of buchu, or in uva ursi. Hot applications and hot local bathing (sitz-
baths) will do much to relieve the pain and tenesmus ; if these be severe,
a rectal suppository of opium and belladonna or an enema of chloral
hydrate will generally give prompt relief. Tincture of cannabis indica,
administered internally, may answer if opium be contraindicated. Under
such a course as the preceding a cure may be expected within eight or
ten days. It is prudent to advise the patients to wear flannel or silk
binders over the abdomen, to avoid chilling of the surface and subse-
quent acute attacks.


Pathology. — The vesical mucosa is not so hyperemic as in the
acute variety, but is of a peculiar muddy or grayish-blue (slate) color,
dotted here and there with patches of erosion or of actual ulceration.
Slight hemorrhages may and do occur. Owing to the slow course of the
disease there follows an immense thickening of the bladder-wall from
hyperplasia, conjoined with more or less edema, of the tissues. The
result is a contraction of the wall with a proportionate diminution in the
vesical capacity. The mucosa may become polypoid in spots, and there
rarely follows obstruction of the ureteral orifices, with consequent dilata-
tion of the ureters and renal pelves from a damming back of the secre-
tion. In the majority of cases, however, the changes will be found on
cystoscopic examination to be limited to the lower portion of the bladder.
The urinary changes are about as in the acute form, save that the reaction
is alkaline and the amount of mucus and pus is proportionately greater.

Ktiology. — Chronic inflammation of the bladder may be the result
of a neglected or oft-repeated acute attack. It may occur from the per-
sistent action of an exciting cause, as the presence of some irritating
substance (calculus) in the bladder, or of some excitant external to that
viscus, as a localized inflammation or a displaced uterus. The tubercu-
lous variety and that due to neoplasmata are insidious in development.

The symptoms and diagnosis difi"er but slightly from those of
acute cystitis, although the pain and tenesmus are less intense. Oppo-
sitely, the amount of albumin in the urine is comparatively large. The
same remark applies to the quantity of mucus and pi/,s {vide Pathology);
indeed, the last-named ingredient often forms a thick gelatinous mass in
the standing urine that tends to adhere to the receptacle. According to
Brown's researches bacterial flora contribute liberally toward chronic cys-
titis : B. coli communis was present in the urine in 55.2 per cent. (50 per
cent, in pure culture, and once combined with B. tuberculosis) ; staphy-
lococcus pyogenes aui'eus, 10.3 per cent.; staphylococcus albus, 6.9 per
cent.; B. proteus vulgaris, 3.4 per cent. The reaction of the urine is
often neutral or alkaline where infection is due to the three last-named
organisms. An alkaline reaction exists in 80 to 90 per cent, of cases.
The cystoscope is an invaluable aid to the recognition of chronic cystitis.
Chronic cystitis is accompanied by debility and emaciation, which, how-
ever, are of slow development.

The prognosis is always serious, and the course of the disease is at
the best protracted.


Treatment. — Very generally, the treatment set down for the acute
disease Avill not answer in the chronic form. Undoubtedly, there will
follow more or less amelioration of the symptoms, but the tendency is
toward a prolonged chronicity. In such cases, after the removal of the
ascertainable causes so far as practicable, we are compelled to resort to
local treatment of the bladder. This includes — (1) Vesical irrigation ;
(2) Topical applications ; (3) Permanent drainage of the bladder.

l^esical irrigation is secured by means of an aseptic soft-rubber
catheter which is connected with a graduated glass funnel : a siphonage
is produced by the alternate elevation and depression of the funnel,
which contains the irrigating fluid. The latter may consist of plain
sterilized (boiled) water, sterile normal salt-solution (40-60 gr. to the
pint — 2.59—4.0 per ^ liter), or a weak solution of mercuric chlorid (1 :
50,000—100,000). The irrigation should be done slowly, and not more
than twice or thrice daily in severe cases, and much less frequently in
ordinary cases, according to the exigencies of the condition.

Vesical medication may be secured by means of the funnel after irri-
gation, the medicating substances being dissolved in a pint of water and
allowed to flow slowly in and out of the bladder. The drugs that may
be used in this manner are silver nitrate or zinc sulphate (1—5 gr. to the
ounce — 0.0648—0.324 to 32.0) or a saturated solution of boric acid. If
the salts of zinc or silver are used, not more than an ounce of the solu-
tion should be allowed to enter the bladder, and much less than this
amount will generally sufiice. In cases in which there exist patches of
ulceration the application must be made directly to these areas through
the endoscope or cystoscope. Stronger solutions may now be employed,
as silver nitrate, 20—30 gr. (1.29—1.94) to the ounce. This application
should be followed by a slight irrigation of the bladder.

When this local medication ftiils to efl"ect a cure, permanent drainage
of the bladder must be secured — in the male by a suprapubic or perineal
incision, and in the female by the establishment of a vesico-vaginal fis-
tula. This places the bladder absolutely at rest, and gives the inflamed
mucosa a chance to heal under proper medication.

As to internal remedies, various agents that possess a local stimulating
effect upon the genito-urinary tract are advised by most authors, but I
think little is to be gained from their employment as compared with the
results achievable from topical treatment. Most eflScacious among inter-
nal remedies are — oil of sandalwood, terebene, urotropin, pichi, buchu
(fluid extract), and the oil of copaiba. If disinfection of the bladder in
loco is not practicable, antiseptics should be given internally, combined
with those stated above. Salol and potassium chlorate are excellent for
this purpose.


Primary new-growths of the bladder are exceedingly rare, occur-
ring, however, with greater frequency in males in about the proportion
of 3 to 1 ; they may be either benign or malignant. On the other hand,
secondar}^ neoplasmata, particularly carcinomata, are relatively common.


The most frequent variety of new-growth encountered is carcinoma, par-
ticularly the so-called villous or papillomatous carcinoma, Williams^ find-
ing in 20 women aifected with bladder-tumor, carcinoma in 16. Other
growths are sarcomatous, fibromatous, cystic, and papillomatous in

The symptoms are the same for all varieties, and include, first and
most commonly, hemorrhage (which is both persistent and free), together
with pain, frequency of micturition, and occasionally the discharge of
detached fragments of the growth. In carcinomatous cases of advanced
standing cachexia will be marked. By means of the cystoscope the nature
of the complaint is disclosed. In the case of secondaiy growths the
primary tumor may often be detected.

The prognosis, of course, will depend upon the nature of the

The treatment is purelv surcrical.


( Vesical Hemorrhoids.)

Hemorrhage of the bladder has been mentioned as a symptom of
various affections, both general and local, among the former being leu-
kemia and malarial hematuria, and among the latter nephrolithiasis and
tuberculosis and carcinoma of the bladder. It is also a prominent mani-
festation in stone in the bladder, and not infrequently appears in preg-
nancy (late). Independently of the operation of all of the above-men-
tioned etiologic factors, hemorrhage has been known to occur from the
bladder, and recent precise methods of exploring the viscus (endoscopic
examination) have shown it to be due to a hemorrhoidal state of the ves-
sels. The hemorrhage may be profuse, and, rarely, even fatal in its

The diagnosis is based in part upon the absence of the more obvi-
ous causes of hematuria and the presence of free bleedings, but chiefly
upon the result of a careful cystoscopic exploration of the bladder.

The prognosis, so far as my experience extends, is eminently favor-
able, though a few fatal cases have been reported.

Treatment. — This is mainly local. The bladder may be irrigated
with an astringent solution (1 per cent, tannic acid, ^ per cent, alum),
and this may be alternated with an antiseptic solution (3 per cent, boric
acid, 1 per cent, salicylic acid). I have recently observed a case in
which recovery followed the internal admission of the extract, hamamelis
fluid. (3j— 1-0), t. i. d.

1 Brit. Med. Jour., 1889.




Definition. — By this term is meant a condition of the bladder in
which there exists an hyperesthesia of the organ, especially of the neck —
that portion surrounding the urethral and ureteral orifices (vesical trigone)
— without the presence of any tangible cause therefor. This must be dis-
tinguished from the irritability that is associated with true organic dis-
ease of the bladder itself, as in the presence of calculi, tumors, or fissure
of the neck, or with disease of the surrounding structures.

Pathology. — Cystoscopic examination of the bladder may reveal a
sliirht increase in the vascularity of tiie mucous membrane. The condi-
tion of irritable bladder in women, which has previously been held to be
a purely functional derangement, is now regarded by Dacheux and
Zuckerkandl as a localized hyperemia, especially at the bas fond, and
less often at the beginning of the urethra.^

Ktiology. — While in many instances no well-defined causal relations
can be determined, it is very generally true that the patients who are the
subjects of vesical irritability are individuals of a neurotic temperament,
very often manifesting strong hysteric tendencies. They are generally
ill-nourished, fretful, irritable, peevish, suflfering almost constantly from
vague neuralgic attacks in difi'erent portions of the body (cephalalgia, tic
douloureux, lumbo-sacral pain), and in a chronic condition of physical
prostration. Frequently they eventually develop a true hypochondriasis
or melancholia. In others there may be found a history of extreme men-
tal and physical tire, overwork, business anxiety, over-indulgence in ven-
ery, menstrual irregularity, dysmenorrhea, ovarian or uterine disorders,
long-continued gastro-intestinal disturbance (dyspepsia), improper hy-
gienic surroundings, improper regimen, indulgence in late hours, and a
general lack of will-power. It must, however, be remembered that sub-
jects of chronic malarial intoxication very often manifest all the symp-
toms of vesical irritability, marked, it may be, by a feature of more or less
periodicity. This has been termed by some malarial fever of the urethra
and bladder. Lithemic individuals also are very prone to develop a pro-
nounced vesical irritability, the affection in them probably resulting from
the local action of the hicrhlv concentrated and irritatincr urine. The con-
dition must commonly, however, be regarded as belonging essentially to
the large group of neuroses.

In a certain percentage of cases the bladder-trouble is a reflex mani-
festation of some disease of an adjacent organ, as the urethra, ureter, va-
gina, rectum, anus, or the internal organs of generation. These are not,
however, to be looked upon as cases of true neurotic vesical irritability.

Symptoms. — The symptoms of irritable bladder are mainly extreme
painfuhiess and frequence/ of mietiirifion. associated with marked vesical
and rectal tenesmus. The dvsuria is not always or altogether relieved by
micturition: indeed, the pain may be just as severe, or even worse after,
than before, the voiding of the urine. Especially is this true when there
coexists a more or less spasmodic muscular action of the bladder-walls,

^ The American Year-Book of Medicine and Surgery, 1897, p. 576.


the hypersensitive mucosa then being squeezed, and the patient suffering
at times to such an extent as to be thrown almost into a state of collapse.
There is usually a sense of weight or pressure in the pubic region, which
is largely relieved when the patient assumes the recumbent posture. Uri-
nation is often performed spasmodically, or there may be a spasm of the
urethra and neck of the bladder resulting in an utter inability to perform
the act. The urine may be normal in appearance and amount. Very
often it is increased in quantity (liysterie polyurici), and at times the op-
posite may be true and more or less suppression be noted. In lithemic
cases the urinary characteristics already mentioned under that condition
will be present {vide p. 438).

Diagfnosis. — Very frequently will simple vesical irritability be con-
founded with true cystitis. The points of differentiation, however, are as
follows :

Irritable Bladder. Cystitis.

The patient is of a neurotic tempera- May occur in any individual, irrespective

ment, and generally gives no history of temperament. It frequentlv follows

of organic bladder-disease nor of ope- catherization, sounding, or other trau-

rations upon the bladder. matism.

Pain is severe, and often worse after mic- The pain is usually much relieved by

turition. micturition.

The constitutional symptoms are those of The constitutional symptoms are not

nervous depression. marked, save in grave cases.

Never results fatally. May result fatally.

The urine does not present any marked There are always present marked and

alteration in its physical or chemical characteristic alterations in the physi-

qualities. It may show hyperacidity, cal and chemical qualities of the urine,
or extreme concentration, or dilution.

The appearance of the mucosa is negative Cystoscopic exploration reveals the angry

in true neurosis. and diseased mucosa, and may show

the cause (calculus, tumor).

The duration is always protracted. The duration of acute attacks may be


Prognosis. — Good as regards life ; doubtful as regards the ultimate
cure of the patient.

Treatment. — Since the condition is largely one of neurotic origin,
the attention of the physician must be directed mainly toward a bet-
terment of the state of the nervous system. Absolute rest, physical
and mental, must be insisted upon, and the patient must be subjected to
a course of strict moral suasion whenever this may be deemed necessary.
Any cause of reflex irritation must be removed, and a cai'eful search
should be instituted for some such condition as cervical stenosis, uterine
displacements, anal fissure, hemorrhoids, stricture of the rectum, vaginitis,
urethritis, tuberculous infection of Skene's glands of the urethra, chronic
gastro-intestinal catarrh, and the like. The habits of the patient must
be inquired into, and late hours, the eating of improper and unwholesome
articles of food, masturbation, or the reading of sensational and trashy
literature corrected. In many instances the pronounced neurasthenic
condition demands a course, more or less protracted, of the Weir Mitchell
rest-treatment {vide Neurasthenia, p. 123-1). The urine should be care-
fully examined for lithemic and other pathologic features, and by an ap-


propriate course of treatment it should be rendered a? bland and unirri-
tating as possible. Large draughts of diluent drinks may be of benefit,
and if these be combined with the prolonged administration of nerve-
sedatives and antispasmodics, a marked amelioration of the patient's con-
dition may be secured. In cases associated with spasmodic muscular con-
traction it mav become necessary to employ an occasional suppository of
opium and belladonna, or an enema of chloral hydrate. Change of air
and scene, regulation of the diet, the institution of a proper course of
gymnastics, mental and physical, and the observance of a happy and
cheerful atmosphere will generally do much to improve the patient's con-
dition. The administration of tonics (strychnin, iron) and the prevention
of constipation are very essential. Especially must it be remembered
that in all these cases of simple vesical irritability physical exploration
of the bladder is absolutely contraindicated. The patient's mind must be
directed awav from the bladder in order to secure good results.


1. Incontinence of Urine (Enuresis). — An inability to retain the
urine. This may arise from a number of causes. Frequently it is the
result of some lesion of the spinal cord involving the sphincteric cen-
ter of the bladder; this is known as paralytic incontinence, and is to
be recognized by a constant dribbling, alternating with spurts of urine
when voluntary or involuntary muscular action is brought into play,
as in the act of coughing, sneezing, or bending forward of the body.
It may be the result of a general bodily weakness or after prostrating
diseases (typhoid, late stages of pulmonary tuberculosis). Again, it
mav result from some local condition in the bladder or urethra. Here
may be mentioned paralysis of the urethra from over-dilatation or from
traumatism, or that due to pressure of the fetal head in a prolonged labor ;
imperfect vesical innervation ; over-distention of the bladder, producing
a paresis of its walls ; or from some temporary obstruction at the urethra
or base of the bladder, such as a tumor or a sharply retroflexed uterus.
It may be a result of over-distention of the bladder, with partial paral-
ysis of the sphincter, the bladder remaining overfilled, while there is a
constant escape of a few drops of urine {incontinence of retention). It
may follow some local causes of irritation, as the presence of vesical cal-
culi, pressure from an anteflexed uterus upon the fundus of the bladder,
cystitis, and parasites. The condition known as spasmodic incontinence
is that due to an over-action of the compressor muscle of the bladder, as
a consequence of which there is a diminution of the vesical capacity, the
urine being forcibly and involuntarily ejected at irregular intervals.
Finally, nocturnal enuresis is that variety which is so common in young,
delicate, and often neurotic children : this is usually noticed in the early
hours of sleep, and is often the result of some local irritation acting upon
a hypersensitive organism, such as the presence of oxyuria, an elongated
prepuce, contraction of the urethral meatus, or masturbation. Bierhoft"*
is of the opinion that the essential or ultimate condition is hvperesthesia
of the deep urethra or sphincter from hyperemia or inflammation.
Xocturnal incontinence may be a manifestation of nocturnal epilepsv or
^ Fhila. Med. Jour., May 26, 1900.


of incipient cerebral or spinal disease (Fitz). Adenoid vegetations may
bear an indirect causative relation to the condition. In the female,
urethral papillomata and caruncles have been assigned as causes. The
hyperacidity, of the urine associated with podagra may also excite enuresis.
The constant escape of urine in the paretic cases is apt to result in exten-
sive excoriation of the parts.

The treatment varies according to the cause. The enuresis of chil-
dren, if left alone, will eventually cure itself as the age and strength of
the patient increases, though obvious exciting causes, if present, should
be removed if not impracticable. Good hygiene, systematic evacuation

Online LibraryJames M. (James Meschter) AndersA text-book of the practice of medicine → online text (page 142 of 178)