Chapter VII: Front Matter (7)

The term chyluria is applied to a condition of urine in which the secretion is admixed with fat in a minute state of subdivision, whence the urine acquires a milky or chylous appearance. The proportion of fat varies greatly between such as gives a mere opalescence to the secretion and that which makes it absolutely indistinguishable, in appearance, from milk, while even the characteristic odor and taste of urine are often wanting. The further resemblance of such urines to milk is found in the fact that, on standing, a cream-like substance rises to the surface. On the other hand, a spontaneous coagulation into a jelly-like substance containing fibrin proves an unmistakable relation to blood.

The chemical composition of such a urine, having a specific gravity of 1013 and neutral in reaction, is given by Beale,[1] as follows:

Water . . . . . . . . . . . . . . . . . . . . . . . . . . . 947.4
Solid matter . . . . . . . . . . . . . . . . . . . . . . . 52.6
-----
Urea . . . . . . . . . . . . . . . . . . . . . . . . . . 7.73
Albumen . . . . . . . . . . . . . . . . . . . . . . . . . 13.00
Uric acid . . . . . . . . . . . . . . . . . . . . . . . . 0.00
Extractive matter with uric acid . . . . . . . . . . . . 11.66
Fat insoluble in hot and cold alcohol, but soluble
in ether . . . . . . . . . . . . . . . . . . . 9.20 |
Fat insoluble in cold alcohol . . . . . . . . . . 2.70 | 13.90
Fat soluble in cold alcohol . . . . . . . . . . . 2.00 |
Alkaline sulphates and chlorides . . . . . . . . . . . . 1.65
Alkaline phosphates . . . . . . . . . . . . . . . . . . |
Earthy phosphates . . . . . . . . . . . . . . . . . . . | 4.66

[Footnote 1: _Urinary and Renal Derangements and Calculous Disorders_, Philada., 1885, p. 73.]

Such urines are of course albuminous, as will have been seen from the table. They therefore coagulate when boiled or on the addition of an acid. They also exhibit a tendency to spontaneous coagulation more or less complete, which is apt to be followed by later disintegration of the clot. The proportion of solids is larger than in ordinary urines.

Microscopically, the urine is found to contain, in addition to its usual elements, immense numbers of molecular particles easily soluble in ether, and therefore fatty in their composition. It may be rendered perfectly clear by the addition of ether, and again approximately milky after evaporating the ether and shaking the residue; but now the microscope shows the oil in the shape of oil-drops and not molecules. Oil-drops are also sometimes sparsely present in the fresh fluid, but the fatty particle is commonly molecular. Indeed, the molecules are commonly so small that an {115} aggregated mass of them appears like a delicate cloud under the microscope, rather than a collection of individual particles. Blood-corpuscles may also be present, sometimes in sufficient quantity to produce a distinct pink coloration, but no unusual proportion of leucocytes is common. The pink tinge, and even an almost bloody appearance, is very apt to precede the chyluria. This bloody character sometimes gradually increases until the chyluria has become a hæmaturia, so that we have sometimes a chyluria spoken of as a first stage of hæmaturia. Tube-casts do not occur. Chyluria is seldom constant, and a specimen of urine passed a couple of hours after one white as milk may be, again, perfectly clear and in all respects natural. Thus, a second specimen, passed by the same patient as that of which the analysis is given above, was almost clear. It had a specific gravity of 1010 and a slightly acid reaction, and contained a mere trace of deposit, consisting of a little epithelium, a few cells larger than lymph-corpuscles, and a few small cells, probably minute fungi. Not the slightest precipitate was produced by the application of heat or addition of nitric acid. The following is Beale's analysis:

Water . . . . . . . . . . . . . . . . . . . . . . . . . . . 978.8
Solid matter . . . . . . . . . . . . . . . . . . . . . . . 21.2
-----
Urea . . . . . . . . . . . . . . . . . . . . . . . . . . 6.95
Albumen . . . . . . . . . . . . . . . . . . . . . . . . . 0.00
Uric acid . . . . . . . . . . . . . . . . . . . . . . . . .15
Extractive matters with uric acid . . . . . . . . . . . . 7.31
Fat insoluble in hot and cold alcohol, but soluble in ether|
Fat insoluble in cold alcohol . . . . . . . . . . . . . . | .00
Fat soluble in cold alcohol . . . . . . . . . . . . . . . |
Alkaline sulphates and chlorides . . . . . . . . . . . . 5.34
Alkaline phosphates . . . . . . . . . . . . . . . . . . . 1.45
Earthy phosphates . . . . . . . . . . . . . . . . . . . . .15

DISTRIBUTION OF THE DISEASE.--By far the largest majority of instances of the disease originate in tropical and subtropical climates. Thus, India, China, and South America--and in South America, Brazil, and Guiana--are countries in which it is common. It is said to be rarer on the coast of South America than in the interior; yet it is especially partial to insular countries, and most of the cases observed in this country originate in the West Indies--in Barbadoes and Cuba, in Bermuda and the island of Trinidad. Many cases occur in Bahia, Guadeloupe, Madagascar, the Isle of Bourbon, and Mauritius. Indeed, the first important study of the subject was based on cases observed in the latter island by Chapotin.[2] In Africa both Egypt and the Cape of Good Hope are favorite localities, and in Australia, Brisbane has furnished many cases.

[Footnote 2: Thèse, _Topographie médicale de l'Ile de France_, 1812.]

At the same time, cases do originate in temperate climates, and although the disease is rare in Europe and North America, Dickinson has collected five cases from his own practice or that of others, which undoubtedly originated in England. I know of but one case of certain North American origin, that of a woman reported by McConnell to the Medico-Chirurgical Society of Montreal, April 27, 1883. She was thirty-three years old, a native of the province of Ontario, and had had the disease eleven years. At the time of her death, which appears to have been from tubercular phthisis, there were cavities in the apices of both lungs.

{116} SUBJECT'S ATTACKED.--There seems no election as to nativity, natives and foreigners being indiscriminately attacked in the countries in which it occurs. There is some difference of opinion as to whether the disease is more frequent in males or females; which is a reason for believing that it occurs with nearly equal frequency in both.

It is more common in middle life, but Prout reports an instance in a child eighteen months old, and Rayer one in a woman at seventy-eight years. She had had it, however, since she was twenty-five, or about fifty-three years. Dickinson was consulted with regard to a boy of five, and mentions a case fatal at twelve. Roberts says: "Chylous urine prevails mostly in youth and middle age."[3] Of 30 cases collected by him, 3 were under twenty; 7 between twenty and thirty; 11 between thirty and forty; 6 between forty and fifty; and 3 over fifty.

[Footnote 3: _Urinary and Renal Diseases_, 4th ed., Philada., 1885, p. 344.]

The subjects of the disease are apt to be pale and relaxed as to their tissues, but while this may be a possible result of the disease, it can hardly be regarded as a predisposing cause.

PATHOLOGY AND ETIOLOGY.--The precise mode in which chyluria is brought about is unknown. It is to be inferred, in view of our existing knowledge, that there has been produced, in some way, in each instance a communication between the urinary and chyliferous systems, although exactly where such communication is has as yet only been guessed at. It may be in the kidney itself, or its pelvis, or the ureter, or in the bladder. Cases originating in the tropics have been found associated with elephantiasis, but this is not very frequent. Dilatation of cutaneous lymphatics, producing cutaneous papules and vesicles and a discharge of lymph from them, has also been noted coincident with chyluria.

Prout,[4] among the earlier writers on this subject, and more recently Bence Jones,[5] Waters, Bouchardat, Robin, Bernard, and Egel, did not consider a positive lesion necessary, but ascribed the condition to a vice of nutrition and blood-making, accompanied by a slight consequent textural alteration in the blood-vessels of the kidney, through which the elements of the chyle transuded. Waters[6] says that "the main pathological feature of the complaint is a relaxed condition of the capillaries of the kidney," which permits the transudation.

[Footnote 4: _Stomach and Renal Diseases_, 4th ed., London, 1843.]

[Footnote 5: _Lectures on Pathology and Therapeutics_, 1868, p. 256.]

[Footnote 6: _Med.-Chir. Trans._, vol. xiv. p. 221, 1862.]

The results of examination of the blood, in cases of chylous urine, by Bence Jones, Rayer, and Crevaux, who found in certain instances an excess of fat, have been quoted in support of these views, but these examinations seem to have been microscopical and not chemical, and the results have not been confirmed by recent observers. Such views were also upheld on theoretical grounds by Bouchardat,[7] based on the greater commonness of the disease in warm climates. He reasoned that when the heat-producing elements, whether absorbed from food or produced by metamorphoses of other proximate principles, are in excess, and an elevated external temperature does not favor their consumption, their elimination is attempted by certain organs, notably the liver and kidneys. The effort by the kidneys seems, however, to be attended by a structural change in the blood-vessels, as the result of which blood is {117} eliminated with fat, especially at the beginning of the disease. Later the blood disappears, but the albumen remains some time longer, disappearing finally with the fat.

[Footnote 7: _Ann. de Thérapeutique_, 1862.]

Bernard and Robin also compared the blood of such cases to that of geese artificially fattened, being that condition of blood which is normal after digestion but transient. Egel also held similar views, ascribing the imperfect elaboration to the effect of hot climates.

Gubler[8] first suggested that chylous urine was due to a passage of chyle directly into the urinary passages, and that this was immediately preceded by a dilatation of the renal lymphatics similar to that known to occur on the surface of the body and attended by the local flow alluded to.

[Footnote 8: _Gazette médicale de Paris_, 1858, p. 646.]

Vandyke Carter,[9] of Bombay, suggested that the communication was between the lacteals and lymphatics of the lumbar region and those of the kidney. Those who have seen the semi-diagrammatic drawing of a dissection of the lymphatics as seen from behind, in the remarkable case of Stephen Mackenzie,[10] cannot fail to be impressed with the probability of such communication.

[Footnote 9: _Med.-Chir. Trans._, vol. xlv., 1862.]

[Footnote 10: _Trans. Path. Soc. of London_, vol. xxxiii. p. 394, 1882.]

That a chylous urine is the direct result of a discharge of chyle into the urinary passages at some point between the kidney and the neck of the bladder, is further rendered likely by the experience of W. H. Mastin of Mobile, Alabama, with a case of chylous hydrocele: W. H. W., a native of Alabama, aged twenty-two, presented himself with a hydrocele. Mastin tapped the sac and drew off a white milk-like fluid, which was sent to me for examination. It was perfectly white and undistinguishable by the eye from milk. Upon microscopical and chemical examination, I found it presented all the physical and chemical characters of chyle. Six months later, the sac having refilled, Mastin evacuated eight ounces more of the same fluid--some of which was again sent to me--and then laid open the sac freely. Examining the cavity carefully, he found it smooth, polished, and pearly white, but at its upper portion, just where it began to be reflected over the testis, was a small, round, granular-looking mass about the size of an ordinary English pea. This he sliced off with a pair of scissors, and at once recognized the patulous mouths of three or four small vessels which did not bleed. These he dissected back for a short distance, and found that they passed into the connective tissue around the upper border of the testis. He then passed a ligature around the mass and brought the ends of the ligature to the outside, excised all the front wall of the tunica, and closed the sac. The patient recovered, and there was no return of the hydrocele. Although it is to be regretted that the patulous vessels were not watched for a few minutes, I do not think there can be any reasonable doubt that there was here a lymphatic varix, and that the chylous fluid in the tunica was the result of leakage through its walls. Since the patient had had gonorrhoea, Busey,[11] in his remarks on this case, suggests that the obstruction to the onward movement of the lymph, and the cause, therefore, of the dilatation and rupture, was inflammation attacking a single gland or an area of lymphatics.

[Footnote 11: _Occlusion and Dilatation of Lymph-Channels_, by Samuel C. Busey: A series of papers reprinted for private distribution from the _New Orleans Medical and Surgical Journal_, from Nov., 1876, to March 1878.]

{118} If it be acknowledged, then, that in chyluria some direct communication must exist between the lymphatic and urinary systems, how is this communication brought about? Various causes have been supposed at different times to be responsible for this condition, among them traumatism in its various modes of occurrence, such as being thrown from a horse. Mental shock has also been held responsible. So, also, syphilis and hereditary tendency. But most cases still remained unaccounted for when, on August 4, 1866, Wücherer first detected in the chylous urine of a woman in the Misericordia Hospital at Bahia an unknown worm. In 1872 it was announced that Timothy R. Lewis had found in the blood, and also in the urine, of a person suffering with chyluria in Calcutta, a delicate thread-like worm about 1/70 of an inch long and 1/3500 of an inch wide. This observation was confirmed by Palmer and Charles. Lewis named it Filaria sanguinis hominis. Since then the filaria has been found in the blood and urine of many cases. Lewis found six in a single drop of blood from the ear, and estimated 700,000 as approximately correct for the whole body. But Mackenzie calculated that there were in the blood of his patient from 36,000,000 to 40,000,000 embryo filariæ. These minute nematodes, discovered by Wücherer and Lewis, proved to be, as was indeed early suspected, the larvæ of a larger filaria which was discovered by Bancroft of Brisbane, Queensland, Australia, in December, 1876, first in a lymphatic abscess in the arm, and afterward in the fluid of hydrocele of persons infested with the smaller worm. The parent worm is about the thickness of a human hair and three or four inches long. It was named, by Cobbold, Filaria Bancrofti. Lewis himself found, in August following, a male and female of the parent worm, in a scrotum infiltrated with chylous fluid, in a case of elephantiasis. The female contained ova with embryos precisely like those found in the blood and urine. The worms are viviparous, but abortions seem frequent, ova being frequently discharged unhatched.

It has been rendered highly probable, by the researches, first, of Manson in China, and later of Lewis in India and Sonsino in Egypt, that the filaria in its fully-developed form is introduced into the stomach and intestines of man with water. Thence it makes its way into the blood and lacteal system, where it reproduces the embryo filariæ. These embryonic or larval filariæ are taken from the human blood by a mosquito, in the body of which it undergoes further development, after which the perfect Filaria Bancrofti is deposited in water, through which it again reaches the stomach of man, and thus the disease is perpetuated.

One of the most singular features in the history of the filaria is its nocturnal habit. It is found in the blood only at night, unless, as Mackenzie has shown, night be converted into day--that is, if the hours of sleeping and waking be reversed. In Mackenzie's case the worms appeared about seven o'clock in the evening, increased up to midnight, and disappeared by eight or nine o'clock in the morning. What becomes of them at the time when they are undiscoverable in the blood is as yet unknown.

Acknowledging filariæ to be the essential cause of chyluria, the precise method in which they operate to cause the obstruction, dilatation, and rupture of the lymphatics is a matter of speculation. The embryo filariæ are so lithe and small that they move among the corpuscles {119} apparently without harming them, but the ova in which the embryos lie coiled up, and which are often discharged unhatched, are large enough to cause obstruction in the smaller lymphatics and lymph-passages of the lymphatic glands, and thus cause the phenomena of chyluria, as well as of the other diseases of the lymphatic system with which it is often associated, or which may occur independently of it, such as elephantiasis, cutaneous lymph-vesicles with their chylous and lymphous discharges, lymph scrotum, chylous hydrocele, and other diseases of the lymphatics. Indeed, the total number of affections other than chyluria which are found associated with filariæ exceed those of chyluria. Among the diseases with which it is said to be associated is erysipelas.

It is evident, therefore, that notwithstanding the fact that the discovery of the Filaria sanguinis hominis has shed a flood of light upon the subject of chyluria, the fact must not be overlooked that not a few cases of the disease have occurred in which the most careful search has failed to find this parasite in the blood. Careful examinations, during waking and sleeping hours, have been made without result, so that we cannot deny altogether the possibility of the disease occurring independent of filariæ as the cause. It is common, therefore, to speak of parasitic and non-parasitic chyluria.

On the other hand, the filaria embryo is often found in the blood of persons apparently in perfect health. Manson tells us that out of every ten Chinamen taken at random, at Amoy, the blood of one will contain filariæ.

MORBID ANATOMY.--There can hardly be said to be any morbid anatomy of chyluria, unless we regard the lymphatic lesions which sometimes accompany it as a part of the disease. Again and again do we read the reports of autopsies at which the kidneys were found normal, and where lesions have been noted they were such as are found due to other causes, and the coincidence was accidental.

SYMPTOMATOLOGY.--Apart from the characteristic urine of the condition, there are no symptoms which can be regarded as in any way peculiar to the disease. The mode of onset is usually sudden, and yet many patients experience no symptoms whatever, and would be quite unaware that they were afflicted in any way, were they not aware of the fact that they are passing lactescent urine. Since the discharge is, however, a drain of very valuable nutrient and force-producing material, most patients sooner or later gradually grow weaker; and this symptom of weakness becomes sometimes very marked, so that they fall into a condition of extreme debility, even to fainting on exertion.

Another symptom sufficiently frequent to deserve mention is pain in lumbar region, sometimes very severe, sometimes on one side, at others on both.

Painful micturition, due to obstruction, is also a symptom traceable directly to the condition of the urine. The disposition of chylous urine to coagulate has already been alluded to. The coagulation taking place in the bladder, it is the clot which sometimes obstructs the urethra and makes urination difficult or impossible. Plugs of coagulum are ejected, sometimes with considerable force, after prolonged straining, and with this comes relief to the symptoms, which may be reproduced through the operation of the same cause.

{120} Other symptoms which are occasionally present may have an accidental relation to the affection, while they may be due to it. Such are headache, nausea, and other gastric symptoms.

Mention has been made, too, of the concurrence of superficial lymphatic leakage, especially on the lower part of the abdomen, the thighs, and the legs. Such leakage is often from little vesicular elevations which are evidently dilated lymphatic vessels. The presence of such leakage should suggest the examination of urine for lesser degrees of chyluria. In like manner, the urine should be examined in case of elephantiasis, lymph-scrotum, and chylous hydrocele, with which also chyluria is sometimes associated.

The effect of intercurrent febrile states, whether symptomatic of local inflammation, as of the lungs, or whether the result of the idiopathic fevers, has often a singular effect on chyluria in causing its disappearance for a time. It would seem that states of high vascular tension, however induced, tend to make it cease.

While chyluria has made its appearance, for the first time, in a number of cases during pregnancy, this condition in other instances has caused it to disappear, especially toward the later months; whence it would seem that the pressure of the rising womb has a favorable effect.

The DIAGNOSIS of chyluria consists in the recognition of the chylous state of the urine. This, ordinarily very easily recognized, might be taken in its slight degrees for phosphatic or uratic or purulent conditions of the urine, and vice versâ. The disappearance of the first on the addition of acids, of the second on the application of heat or alkalies, will resolve any doubt, while the microscope will detect the pus-corpuscles in the last. None of the reagents named will dissolve the fatty molecules of a chyluria, while ether will cause the fluid to clear up completely.

The PROGNOSIS is usually favorable. Very rarely is an attack fatal, and when such is the case it is from exhaustion--from the drain to which the system is subject. Tubercular phthisis is therefore a not infrequent immediate cause of death.

TREATMENT.--On the supposition that filariæ are the essential cause of the disease, the rational indication would be first to destroy them by the introduction into the blood of some parasiticide; and, second, to repair the lesion of communication between the lymphatic system and the urinary passages. As yet no agent is known which would not be as fatal to the host as to the filaria, if used in sufficient quantity to destroy the latter; nor has it ever been possible to find the point of communication between the two systems, although treatment has been directed to producing closure of such communication, and with some show of success. Thus, in a case under his care Dickinson of London injected into the empty bladder twelve ounces of a solution of perchloride of iron, containing at first two drachms of the tincture to the whole quantity, gradually increased to four drachms. The solution was retained in the bladder for from eight to twelve minutes with little or no inconvenience. The operation was repeated almost daily for twelve days. The effect was always to check the milky flow and to substitute a clear urine. But after the operation had been repeated a certain number of times there was a decided rise of temperature, with headache, nausea, lumbar pain, hæmaturia, and albuminuria which continued a short {121} time after the hæmaturia ceased. Singularly, too, with the subsidence of these symptoms, the chyluria remained absent for some time. The injections were resumed on its return, and each time were followed by relief. In the course of their use, however, the strength of the solution was increased to an ounce of the perchloride to twelve ounces of water, and the strongest solutions were retained in the bladder for as much as an hour, the weaker longer. Ultimately, however, the use of the injections became so painful that they had to be discontinued.

Another measure, employed by Bence Jones, was abdominal pressure by means of a belt. This also, in his experience, relieved the lumbar pain. In his case, which was about eight years under observation, Dickinson applied the pressure by a sort of tourniquet about an inch below the umbilicus. This lessened, though it did not stop, the pulsation in the femoral arteries. It also was successful at first, the chylosity lessening, and finally ceasing, but on the removal of the belt the chylous character gradually returned, and in sixteen hours was as bad as before. Repeated trials were followed by the same transient effect, but no cure. Under this treatment, however, combined with a liberal diet and rest, the patient gained many pounds in weight, and was able to leave the hospital and resume her occupation as dressmaker, the pursuit of which, and the absence of the favorable conditions of hospital-life, as invariably caused a return of the symptom and its resulting debility, which again caused her to seek admission.

Rest, therefore, and an abundance of good nourishing food, tend at least to counteract the exhausting effects of the disease, and even to cause the discharge to cease. Tonics, and especially chalybeates, are indicated for the former purpose.

As the relaxing effects of warm climates and warm weather seem to predispose to the condition and to aggravate it, removal to cooler latitudes and places is indicated.

Astringents, internally administered, naturally suggested themselves at an early date, and were used by Prout, Priestley, and Bence Jones. The latter especially thought gallic acid useful. He reports a case in which the disease did not return after its long-continued use. Goodwin of Norwich, England, also reports a case in which the chyluria was controlled by the gallic acid, but returned in four or five days after the remedy was discontinued. It again disappeared on resuming the drug, and the patient could at any time render the urine nearly normal in appearance by taking it. The case was lost sight of before it could be regarded as cured. Waters also reports a case which apparently recovered completely after nine weeks' treatment by gallic acid. He gave at first 30 grains a day, which were gradually increased to 135 a day, and then gradually reduced.

Other astringents which have been used are tannic acid, matico, or acetate of lead, nitrate of silver, the mineral acids.

Mangrove was successfully used in a case related by Bunyan of British Guiana. It was used in the shape of a decoction at the suggestion of a negress, an ounce being taken four times a day. In seven days the patient was so much relieved that the remedy was discontinued for two days, but the symptoms returned. They again disappeared when the drug was resumed, and two subsequent attacks were immediately cut short by the remedy. Roberts suggests that it may act as a parasiticide, {122} and suggests larger and sustained doses of the iodide of potassium for the same purpose.

Retention of urine, when present, should be treated like the same symptoms under other circumstances, by catheterization, washing out the bladder with tepid water, warm fomentations, and similar measures. It has even been suggested to wash out the bladder with ether under these circumstances.

As it seems impossible for the embryo filariæ to develop in the human body into the fully-developed Filaria Bancrofti, it is evident that with the death of the latter, which must occur sooner or later, the production of embryos must cease, while those previously produced must sooner or later also die, and in this way a spontaneous cure take place--just as a person infested with trichinous disease will ultimately recover if the introduction of the trichinæ cease and he is able to survive the irritation caused by the presence of the parasite in his muscles. In this manner we may account for the spontaneous disappearance of the disease in so many instances where all treatment has proved unavailing.

{123}

DISEASES OF THE BLADDER.

BY EDWARD L. KEYES, M.D.

Inflammation.

The bladder is a patient organ, and rather slow to resent injuries from within or without. It never inflames on account of such general causes as the influence of cold, anæmia, cachexia, or a depressed state of the general system. Any of these causes may act as adjuvants, but alone they are not effective. Thus a chilling of the legs, inoperative upon an individual with a healthy bladder, is a prime factor in exciting inflammation in the bladder of an old man with an enlarged prostate; while the simple passage of a sound upon an individual suffering from anæmia might provoke a cystitis which the same traumatic cause would not have produced upon a patient in a thoroughly healthy condition.

Yet inflammation of the bladder is very common. It is sometimes a malady, more often a symptom produced by some other malady (stricture, prostatic enlargement, stone), and only to be overcome by detecting and removing its cause. The causes of inflammation of the bladder therefore include nearly all the maladies to which the bladder is liable.

The varieties of cystitis take name from that tissue of the viscus which is involved, and from the modality of the inflammation.

We have--

| suppurative;
| Acute----| diphtheritic;
1. Cystitis mucosa | | gangrenous.
|
| Chronic--| catarrhal;
| membranous.

2. Interstitial cystitis, where the muscular coat of the bladder is
involved.

3. Peri-cystitis, para-cystitis, where the peritoneal surface or
surrounding structures are inflamed.

This short section upon a surgical subject, only being granted a few pages in a medical work, cannot include a description of all these conditions, or more than a general outline of acute and chronic catarrhal cystitis. Suffice it to say for the other varieties that interstitial cystitis depends upon mucous cystitis or peri-cystitis, and is an inflammation of the muscular coat of the bladder, sometimes culminating in abscess, sometimes in concentric hypertrophy--_i.e._ contracture of the bladder. Peri-cystitis and para-cystitis occur in connection with peritonitis and pelvic cellulitis, and the peripheral inflammation may extend inward and involve the muscular and later the mucous coat.

{124} All these conditions are grave only in proportion to the intensity of the malady causing them and to which they are subordinate.

Gangrenous cystitis occurs after injury, and occasionally in profound septicæmic conditions (puerperal) or after intense cantharidal poisoning. It is fatal.

True diphtheria of the bladder occasionally, but very rarely, accompanies general diphtheritic conditions, and is a very grave malady. Membranous cystitis is less grave, may be partial or complete. I have a fibrinous cast of a female bladder which was extruded through the meatus. This malady occurs sometimes as a late complication of advanced chronic cystitis mucosa in the male. Recovery is quite possible.

Cystitis mucosa is a common disorder, constantly encountered by the physician as well as the surgeon. The irritable bladder, sometimes called cystitis, demands description here, as it may go on to become subacute or even acute cystitis of the vesical neck.

Irritability of the bladder is a neurotic and not an inflammatory condition, although it may lead to the latter state and terminate in it. The bladder is said to be irritable when the calls to urinate are too frequent, generally with little or no pain. As a rule, the urine is clear, containing no pus or a quantity entirely disproportionate to the frequency of the call to urinate.

In true irritability of the bladder the patient sleeps all night, although he may have to empty his bladder every hour or two by day. There is sometimes a sense of weight, heat, or throbbing, more or less intense, in the perineum; the desire to urinate is normal but imperious; the satisfaction after the act is complete, and no pain accompanies its performance.

This condition of things is generally either neurotic directly, or indirectly (reflex). In children it may be caused by a tight prepuce, especially if irritated by retained smegma, by teething, by the existence of intestinal worms; and it may accompany chorea. It gets well by lapse of time or is cured by removal of the cause. In the adult it is most common in young men and recent widowers, and is often an expression of sexual distress due to sexual stimulation without relief, to sexual excess, or to improper sexual hygiene. The irritation of acrid urine will also cause it, as well as such peripheral troubles as a narrow meatus urinarius, a tight prepuce, urethral stricture, moderately enlarged prostate, kidney irritation (stone in the kidney, etc.). It appears in old men, sometimes, apparently, as a forerunner of organic prostatic changes.

Such stimulation as a glass of wine or beer, pleasant company, absorbing occupation, may cause it to disappear temporarily. It is habitually better in dry, clear weather, and worse in damp seasons when the wind is east. Worry, anxiety, fatigue, depression of spirits, and similar causes aggravate the condition. It is better for the first twenty-four hours after sexual intercourse, and worse than it was before during the next following twenty-four hours.

The SYMPTOMS of pure irritability are simply a frequent desire to urinate during the waking hours, the act not being attended by pain and the urine being reasonably clear.

The PATHOLOGY of this affection is not definitely known. It seems {125} to be an essential neurosis involving the sensitive nerves of the deep urethra and neck of the bladder, attended, if long continued, by surface congestion of the deep urethra and neck of the bladder, and ultimately the phenomena of inflammation; for the very mechanical act of allowing the bladder incessantly to empty itself too often, and to squeeze its own neck, will, in many cases, after a time, lead to traumatic inflammation of mild type.

TREATMENT.--Marriage is a very effective treatment of pure vesical irritability when there is a sexual element in the case.

If any peripheral or local cause exists (stricture, contracted meatus, dense acid urine), its removal will effect a cure. Alkaline diluents, notably the citrate of potassium in gr. v-xxx doses, administered midway between meals, copaiba, or cubebs in moderate doses, often gives relief. Tonics, the tincture of the chloride of iron, and arsenical preparations are often of great value. The tincture of hyoscyamus in minim x-lx doses may be combined advantageously with any of these remedies.

One of the most efficient of all methods of treatment is the use of the conical steel sound, as large as the urethra will admit without violence. The sound should be warmed, lubricated, and gently carried into the bladder at intervals of two to four days. The daily passage of the sound is objectionable, even if it gives relief at first, for it is liable to kindle a slow inflammation in a urethra unaccustomed to its use. When a sound is inserted it should not be left an instant in the bladder, but should be gently withdrawn as soon as it has been fully inserted. If left in the urethra, it does no good, and may act upon the cut-off group of muscles in the membranous urethra, causing them to contract spasmodically, as in the physiological performance of the coup-de-piston after urination. Such contraction bruises the sensitive mucous membrane of the urethra against the hard sound, and does mechanical damage.

The sound acts in three ways: It (1) mechanically distends the irritable contracted cut-off muscle and seems to quiet its contractile tendency. It (2) squeezes all the blood from the passively congested vessels of the irritated mucous membrane, thus ensuring a new supply of blood to the part and an improved circulation in the reaction which follows the irritation. It (3) mechanically, by contact, blunts the sensibility of the terminal sensitive nerves in the mucous membrane of the deep urethra. In this way the sound acts, and its effects generally last several days, often a week. Its good effect is also instantaneous. The slight feeling of weight and discomfort in the perineum which the patient has before its use is gone instantly, and replaced by a feeling of comfort. When this immediate sense of relief is not experienced, it is doubtful whether such a case will yield to the simple treatment by sounding.

It is a mistake to suppose that any ointments smeared upon a sound do good in this condition. Mercurial, belladonna, and other ointments are used, but they are all and entirely rubbed off the sound before it reaches the deep urethra, and their good effect probably resides solely in the imagination of the physician and the credulity of the patient. Ointments are undoubtedly of service in some obstinate cases, notably strong tannic-acid mixtures, and sometimes iodoform, but these cannot be carried to the deep urethra by being rubbed upon a sound. The cupped sound may be used to effect this very neatly, the little cups on the sides of the {126} curve of the sound being filled with the ointment which it is proposed to carry down and apply to the affected spot. A few drops of a mild nitrate-of-silver injection also give decided good results in some cases. The solution should vary between two and ten grains in the ounce of water, and may be accurately applied by means of a Bigelow or an Ultzmann syringe, a few drops being thrown into the membranous urethra. After the application, which should be made only when the patient has a full bladder, urination will wash out the canal and good effects may be looked for--not immediately, as after sounding, but after the irritation produced by the stimulating application has subsided.

Acute Cystitis.

Acute cystitis sometimes involves only the neck of the bladder; in other cases the whole mucous lining of the bladder is included in the morbid process.

The causes of acute cystitis may be grouped under six heads:

1. Traumatic.--Under this head may be ranged all injuries from without, with or without fracture of the pelvic bones--wounds, rupture of the bladder, the pressure of the child's head during labor; injuries from within, as during the use of instruments, by stone, or pedunculated tumor. The list may be increased by such chemical traumatisms as those produced by ammoniacal urine in cases of atony or paralysis, by excessively acid urine in neurotic conditions of the neck of the bladder. Such chemical causes, it will be observed, commonly act in conjunction with another cause. Irritating injections without any co-operative cause are capable of lighting up acute cystitis.

2. Extension of neighboring inflammation--gonorrhoeal cystitis and that attending prostatic inflammation, pelvic abscess, pelvic cellulitis, peritonitis from neoplasms growing at the vesical neck, tubercle, cancer, etc.

3. Medicinal--from cantharides, sometimes cubebs or turpentine.

4. Specific--in diphtheritic, puerperal, septicæmic conditions.

5. The influence of cold when chronic inflammation already exists.

6. Neurotic--actual, from extreme and long-continued neuralgia of the vesical neck; reflex, from irritation at a distance, tight meatus, stricture, inflammation of the seminal vesicles, kidney irritations.

SYMPTOMS.--The symptoms of acute cystitis are (1) frequent painful urination by night as well as by day, the pain being greatest at the close of, and immediately after, the act, and the pain persisting more or less between the acts, radiating from the perineum; (2) moderate fever, sometimes announced by chill; (3) commonly great despondency and a depression of spirits totally disproportionate to the degree and significance of the local inflammation; (4) the urine invariably is milky, with pus: it may at first be acid and of normal odor; it is often tinged with blood, especially toward the end of the act of urination. In extreme cases the urine may contain membranous or sloughy shreds or gangrenous gases. The urine eventually becomes alkaline, and finally deposits lumps of pus and abundant triple phosphate crystals.

Complications occurring with the cystitis yield appropriate symptoms. {127} Such possible complications are congestion and engorgement of the prostate, possibly going on to abscess; epididymitis, orchitis, inflammation of the seminal vesicles, inflammation running up the ureters, pyelitis, surgical kidney; abscess in the walls of the bladder or in the connective tissue about the same; very rarely peritonitis or suppurative phlebitis in the veins about the neck of the bladder.

The pathological changes produced by acute cystitis are similar to analogous changes upon the other mucous membranes: patches of more or less brilliant uniform or punctate redness, perhaps surrounding small ecchymotic areas; a softened, swollen mucous membrane; enlarged follicles near the neck of the bladder, perhaps ulcerated spots; possibly false or true diphtheritic exudations (such exudations have been especially noted in cantharidal cystitis); possibly interstitial abscess of the bladder-wall, or even suppurative phlebitis in the veins about the prostate and neck of the bladder, as observed by Walsham[1] in a case of cystitis due to over-distension. This last complication is happily exceptionally rare.

[Footnote 1: _London Lancet_, May 10, 1879, p. 665.]

The PROGNOSIS varies with the cause of the cystitis, and as the latter often cannot be entirely removed, the acute cystitis may only be moderated so as to be made to assume the chronic form. When the cause can be entirely removed, acute cystitis gets well and leaves the bladder absolutely sound.

TREATMENT.--Acute cystitis from whatever cause requires a uniform general line of treatment. Anodynes are essential both for the patient's comfort and to prevent the constant straining to empty the bladder to which the unremitting, painful desire to urinate impels him. Hyoscyamus is a favorite in the form of tincture in minim xx-drachm j doses, or any of the opiates by the mouth, or in suppository preferably combined with extract of belladonna in small dose. Sometimes quarter- or half-grain suppositories of extract of belladonna alone at intervals of six to eight hours keep the tenesmus more in check than anything else, but belladonna used too freely may bring on retention by causing spasm of the cut-off muscles. Camphor is useful, especially in strangury from cantharides. Rest in bed is essential in most cases, preferably with the hips raised. Heat in some form, as a hot poultice, fomentation, spongio-piline, hot-water rubber bottle, etc. over the hypogastrium preceded by a mustard plaster, gives great comfort. Hot-water hip-baths of short duration and frequently repeated are of service in most cases.

Alkalies are valuable, especially in the beginning of an attack--liq. potassæ minim v-xx doses, citrate of potassium gr. x-xx, combined with an anodyne or some demulcent drink.

Infusions and extracts of corn-silk, dog-grass root, buchu, pareira brava, uva ursi, etc. are of some assistance, but generally not so comforting as some of the bland diuretic waters--Bethesda, Mountain Valley, Poland, Glenn, Vichy, Wildungen, Buffalo Lithia. Distilled water or rain-water, especially if taken warm, is a good diluent diuretic. On the advent of acute cystitis all instrumentation upon the bladder should, if practicable, be postponed, all stimulating drugs (cantharides, turpentine, cubebs, alcohol) stopped, and stimulating foods avoided. Asparagus, coffee, salt, pepper, mustard, acids, and a highly nitrogenized diet are not allowable. The rectum should be kept empty and complications treated as they arise.

{128} Chronic Cystitis (Catarrh of the Bladder).

Catarrh of the bladder is chronic inflammation of the mucous membrane of the urinary reservoir, with more or less thickening of the walls of the bladder. This malady, so apt to persist for years, is probably more commonly encountered by the physician than acute cystitis. Acute cystitis, however, frequently complicates the chronic malady by occasional outbursts of acute symptoms. Thus an attack of the stone is acute calculous cystitis interrupting the course of chronic vesical inflammation due to stone. Catarrh of the bladder may follow acute cystitis, or it may commence insidiously as a subacute disorder, and be catarrh, in the popular sense, from the first.

The causes of catarrh of the bladder are never single. It always takes two causes to produce true catarrh of the bladder--one mechanical, and one chemical. After a traumatism inflicted on a healthy bladder, with proper care the patient recovers entirely. If, however, he insists upon keeping up and about, continues to drink liquor, and does not avoid straining at urination, the membrane about the neck of the bladder, irritated by the ammonia from the decomposing urine, secretes an excess of viscid mucus, the pus becomes gelatinized by the ammonia, the constant straining leads to hypertrophy of the muscular coat, the nerves lose their acute sensitiveness, and the milder persistent malady, chronic catarrh, is set up, to continue perhaps for an indefinite period.

Infiltrations of the bladder-walls with tubercle or cancer, urinary calculus, and, notably, enlarged prostate, stricture of the urethra, tumors of the bladder, hernia of the bladder, exstrophy, over-distension of the bladder from stricture, spasm of the urethra, coma, paralysis, or other cause, may be the traumatic element, while the liberated ammonia from the alkaline decomposing urine furnishes the chemical element; and the two causes, if continued, occasion and maintain the condition known as chronic catarrh of the bladder. In coma or the delirium of typhoid fever or paraplegia or hemiplegia (sometimes) the bladder becomes over-distended and atonied, perhaps paralyzed. Here the use of the catheter appropriately, with great gentleness, may relieve the patient without even the intervention of acute cystitis; while, on the other hand, acute cystitis may come on and be cured, or, if ammoniacal urine be allowed to accumulate and the bladder be not washed out so long as it is unable to entirely expel its contents, chronic cystitis, catarrh, results. I have known several cases of partial paraplegia and other disorders in which the patient could void no drop of urine except through a catheter, where there never had been any chronic catarrh, no stringy mucus, hardly a pus-corpuscle, through long years of the disability, owing to intelligence in the attention to emptying and washing out the bladder instituted by the physician having first charge of the case.

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 {129} 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 {130} 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.