CHAPTER XXIV THE DIAGNOSIS OF DISEASES OF THE BLADDER (Part 3)

noting the CYSTITIS 473 thickness of the tissues between the tip of the sound in the bladder and the vaginal finger; a contracted bladder may be felt as a hard, irregular lump. In acute cystitis vaginal palpation shows that the bladder is the seat of extreme tenderness, but further than that palpation is not available without an anesthetic. Cystoscopy. — Cystoscopy may be employed in all cases of cystitis except in the most acute stages. Here it is wiser, generally, to make soothing treatments until the active symptoms of fever, strangury, and excessive tenderness have abated, before using the cystoscope. The use of cocaine in the urethra and the knee- chest position as described in Chapter VIII., page 110, best facili- tate inspection of the interior of the bladder. In the case of trigo- nitis and the milder grades of bladder inflammation the artificial anemia caused by the high position of the pelvis, coupled with the air distention of the viscus, tend to do away with the character- istic signs, therefore in these cases the raised pelvis dorsal position should be used. All parts of the bladder should be examined systematically in order. Free blood is wiped off the surface by minute pledgets of cotton held in the alligator forceps and thus is made plain the difference between blood on the surface of the mucosa and blood effused in the tissues. Collected urine is removed by the suction- tube and bits of urinary salts obstructing the view are taken away with the alligator forceps. If the disease is localized the congested, diseased areas of the bladder wall are contrasted with the paler, healthy parts. Cultures are made from ulcerated areas, the ure- teral orifices are inspected, and the character of the fluid issuing from them is noted. It is never justifiable to pass a ureteral catheter into a presumably healthy ureter in the presence of acute or sub- acute cystitis, until the nature of the infection in the bladder is known, because of the great danger of carrying infection into the ureter, and until all other attainable facts as to the existence of kidney disease are in hand the physician should be content not to invade the ureters. In the presence of infection the bladder should be irrigated with sterile one-per-cent boric acid solution before ureteral catheters are passed and such an irrigation should be the last step in the cystoscopy. 474 DISEASES OF THE BLADDER VARIX OF THE BLADDER Varicose veins of the bladder is a very rare condition, although from a priori considerations it should be common. It has been found in men associated with rectal hemorrhoids. Knorr shows in his book a beautiful plate of a varix in the neighborhood of the right ureteral orifice as seen through the electric cystoscope. Hem- Fig. 188. — Varix of the Bladder near the Opening of the Right Ureter. (Knorr.) orrhage from the bladder is the chief symptom, and difficulty of urination may be present. Cystoscopy affords the only opportunity for an exact diagnosis. FISTULA OF THE BLADDER A vesical fistula is an abnormal channel of communication between the bladder and an adjacent organ. Fistulse are of three sorts: — 1. Vesico- vaginal, 2. vesico-uterine, 3. vesico-intestinal and other fistula?. 1. Ves ico- Vaginal Fistula Frequency, Etiology, and Pathology. — Vesico- vaginal fistulse vary in size from a pin-point opening to a large hole involving the entire base of the bladder. The cervix may be involved, in which FISTULA OF THE BLADDER 475 case the fistula becomes vesico- uterine as well as vesico-vaginal. The opening is generally situated in the median line in the case of a fistula involving the cervix as well as the vagina, according to Thomas Addis Emmet ("Vesica- Vaginal Fistula/' 1868). In other fistula? the opening may be in any part of the vesico-vaginal septum. It is irregular in outline in the months following its formation and the edges are thickened and ulcerated; later, the opening is circular or oval and the edges are smooth, thin, and hard, the tendency of the fistula being to close by granulation and cicatrization. A clean-cut fistula formed artificially by operation for the purpose of draining the bladder in cases of cystitis will close spontaneously in a short time unless the operator takes the pre- caution to stitch the cut edges of the bladder mucosa to the edges of the vaginal mucous membrane. A small opening which has been caused by sloughing may close of itself, but, in many cases, these are the fistula? that persist for years. In the case of large fistula? there may be present cicatricial bands radiating from the fistula over the bladder walls. Vesico- vaginal fistula? are the most common of the fistula? of the genital tract. They are not nearly so common as they used to be forty years ago. During the first twelve years of the Woman's Hospital in the State of New York up to the year 1868, Dr. Emmet had under his charge 296 cases of genital fistula?, including in this number the cases of vesico-uterine and recto-vaginal fistula, the last, however, forming only about six per cent of the whole. At the present time I venture to say that few gynecologists having an active hospital service and a large private practice see more than two or three cases of vesico-vaginal fistula in the course of a year. A perusal of the recent annual reports of half a dozen metro- politan hospitals having large gynecological clinics reveals the fact that in no one hospital were more than three cases of vesico-vaginal fistula seen during any one year. The cause of vesico-vaginal fistula is, in a vast majority of cases, ischemic necrosis of the vesico-vaginal septum due to impaction of the child's head in the pelvis during prolonged labor. Very rarely fistula may result from the use of the obstetric forceps. Emmet saw only three cases where this had occurred. It is possible that at the present time when forceps are used more frequently and women are neglected in labor less often, injuries from instruments 476 DISEASES OF THE BLADDER may occur with relatively greater frequency. If the forceps or other instruments cause the fistula there will be a discharge of urine immediately after labor, otherwise not until the slough has separated — in a week or ten days. In two cases that I operated on for extensive vesico-vaginal fistula there was a history of incon- tinence of urine following immediately after a difficult forceps Fig. 189.— Diagrammatic Representation of the Different Sorts of Genital Fistulae. (Dudley.) delivery in each instance. Embryotomy had been performed in one. Other causes of vesico-vaginal fistula are: sloughing resulting from cancer of the bladder, from a large vesical calculus or from an ill-fitting pessary, or the burrowing of a pelvic abscess. Symptoms.— The symptoms of vesico-vaginal fistula consist of a constant dribbling of urine, beginning at once after the receipt of the injury if it is due to forceps or other obstetrical instruments FISTULA OF THE BLADDER 477 and in a week or ten days if due to a slough from prolonged pressure and ischemia of the vesico- vaginal septum. In the latter event we expect to find present a rise of temperature and a purulent vaginal discharge. The skin of the vulva, perineum, and the insides of the thighs is excoriated, reddened, and, in cases of long standing, thickened. The hairs of the vulva and the edges of the fistula are encrusted with urinary salts. The patient suffers extremely from the irritation caused by the urine and from being constantly wet and deprived of proper rest, so that the nervous system is deranged and in many cases she becomes melancholic. The nutrition is impaired, and cachexia and poor health result. If the vaginal outlet is uninjured, as occasionally happens, some patients with vesico- vaginal fistula are able to retain a considerable amount of urine in the vagina while lying down, the urine being passed when the patient assumes the erect posture. The subject of a vesico-vaginal fistula may become pregnant, an event that occurred in a patient who was under my observation, and Winckel has reported an instance of a woman with a vesico-vaginal fistula who became pregnant, was delivered at term, and subsequently the fistula healed spontaneously. Diagnosis. — The patient should be placed first in the dorsal position. If there is dermatitis of severe grade it will be advisable to treat this condition before making an exact diagnosis. To this end the urinary salts should be removed carefully, the parts bathed in boric acid solution — one per cent — and thoroughly dried with soft lint, a pledget of cotton being placed temporarily in the vagina if necessary to prevent urine from coming out until the parts are dry. Then all the region of the vulva and insides of the thighs and also the introitus vagina) should be smeared with a freshly made ointment of oxide of zinc. This treatment should be repeated twice a day and the vulva should be constantly covered with soft napkins of washed cheese cloth or old linen, the attempt being made to keep the parts as dry as possible. Prolonged, hot six-quart vaginal douches should be given twice a day before the drying and the treatment with the ointment. Dr. Emmet always laid much stress on the douches and said that his good results with vesico-vaginal fistula depended in large measure on the faith- fulness of the nurse. The urine should be kept diluted by giving 478 DISEASES OF THE BLADDER much fluid by the mouth — milk is especially valuable in these cases — and rendered unirritating and aseptic by the adminis- tration of urotropin, ten grains every four hours. With the patient in the Sims position and with a Sims speculum in the vagina the fistula may be inspected, note being taken of its size, the condition of the edges, whether inflamed and thickened, or encrusted with salts, or cicatricial and thin. The situation of the ureteral orifices should be determined in every case so that they may not be included in the line of sutures when repair is undertaken. Also, if the opening is of sufficient size, the condition of the bladder wall may be seen, whether free from lime salts and how much inflamed and the openings of the ureters may be in- spected directly. The capacity of the bladder, whether contracted or not, is determined by passing a sound through the urethra and, in the case of a large opening, by exploration with the finger passed through the fistula. In the case of very small fistula? nothing but a fine probe can be passed through the opening. In this event the probe is intro- duced into the bladder through the urethra and an attempt is made to cause its point to emerge in the vagina. In these cases it is well to put the patient in the elevated pelvis position and perform cystoscopy in an attempt to see the fistulous opening and probe it with the ureteral searcher. At the same time the condition of the bladder mucosa is inspected. In the case of minute fistula? which can not be found with the probe, inject the bladder with milk and water or with aniline blue and water, the patient being in the dorsal position and a speculum in the vagina, and watch for the appearance of the colored fluid from the opening in the vaginal wall. Knowing the situation of the fistula a fine probe can almost always be passed through it. The amount of scar tissue in the vagina must be determined carefully because the repair depends on the amount of freely movable tissues at the disposal of the operator. The scar tissue is felt by the palpating finger as a hard- ened and roughened area. The finger introduced through a fistulous opening into the bladder feels the velvety mucous mem- brane of the bladder and also the rough lime salts, if they are present. Differential Diagnosis. — A vesico-vaginal fistula must be differ- entiated from a ureteral fistula into the vagina. FISTULA OF THE BLADDER 479 In the latter event there will be a history of discharge of urine in the natural way and also of a more or less constant leaking. Injecting the bladder with milk and water and drying the vagina, search is made for an opening in the vaginal vault that gives exit to fluid having the odor of urine. If urine escapes from the os uteri, a vesico-uterine fistula is the diagnosis. In cases of doubt inject the bladder with milk and water and then see it issue from the os. Don't pass a ureteral catheter or probe into a suspected ureteral fistula nor into the ureteral orifice in these cases, because of the danger of infecting the ureter and causing ureteral and renal disease. 2. Vesico-uterine Fistula This form of fistula is not so common as vesico-vaginal fistula and is more often due to a direct tear from the uterus into the bladder during labor, than to sloughing following bruising of the tissues. The lower portion of the tear through the cervix generally heals, leaving a fistulous opening above. The symptoms are dribbling of urine more or less constantly. Some of the urine may be passed through the urethra and yet there may be a leaking. Filling the bladder with milk and water and noting that the white fluid comes from the os uteri establishes the diagnosis, also passing a sound or probe through the urethra, the end is passed through the bladder fistula into the uterus. Another sound passed into the uterine cavity through the cervical canal meets the first sound with a metallic click and imparts a sensation of contact to the first sound or probe. Vesicc-utero-vaginal fistula consists of an opening between bladder, cervix, and vagina resulting from extensive injury of the cervix. Emmet thought it of more frequent occurrence in women who have borne a number of children and have relaxed abdominal walls. The defect is apt to be found partially bridged over by granulation and cicatrization, or it may be entirely closed with the exception of a small fistula in the lower cervix. 3. Vesicointestinal and Other Fistula Cases of communication between the bladder and the intestine have been reported but they are rare and most commonly follow 480 DISEASES OF THE BLADDER operative procedures. R. Harrison reported a case of fistula between the colon and the bladder in which bubbles of gas escaped through the urethra, and C. P. Noble published a case of recto- vesical fistula following an ischio-rectal abscess, which had existed five years before. Gas and pieces of fecal matter were passed per urethram. An abscess of the Fallopian tube or of the ovary may open into the bladder, and not very infrequently a suppurating dermoid tumor discharges in this way. The presence of cystitis and finding the contents of a dermoid, such as teeth, bone, or hair, in the bladder, or if passed from the urethra, points to the seat of fistula. Bone from a macerated extra-uterine fetus has been known to find its way into the bladder and to form the nucleus of a stone. The sudden appearance of a large amount of pus in the urine together with the symptoms of acute cystitis should lead to the suspicion that a tubo-ovarian or other pelvic abscess has dis- charged into the bladder. If the patient has been under previous observation and an abscess has been diagnosed, palpation will show it to be collapsed. Cystoscopy is the only sure means of making a diagnosis of fistula in such cases, the opening being found and probed by sight. Bimanual palpation shows the pres- ence of an inflammatory mass adjacent to the bladder wall in this class of fistulse. NEW GROWTHS OF THE BLADDER Neoplasms of the bladder are either secondary to a malignant growth in an adjacent organ, — perhaps by direct extension, as in the case of carcinoma of the cervix, or perhaps by metastasis from cancer of a distant organ, — or they are primary in the bladder itself. Primary tumors of the bladder are relatively rare, being from three to five times less frequent in women than in men. They are most often observed between the ages of forty and sixty, but may occur at any age, though of very unusual occurrence before thirty. Nothing is known of their causation. They are to be classed as benign and malignant. The benign are: papilloma, fibroma, myoma, and adenoma; the malignant are: malignant papilloma, carcinoma, and sarcoma. The tumors may spring from NEW GROWTHS OF THE BLADDER 481 the mucosa, from the submucosa, or from the muscular layer, and they are more apt to be situated on the base or on the posterior wall, and show a tendency to be single rather than multiple. E. Hurry Fenwick, whose experience with bladder tumors has been extensive, says: — " Broadly speaking, the cystoscopist will en- counter two well-marked varieties of vesical tumors: the villus- covered and the bald. Those clothed with villous processes may be benign or they may be malignant, but the smooth-surfaced groups are almost always malignant, more especially if they occur after the age of forty-five." Symptoms. — The symptoms of bladder tumors in general are, sudden stoppage of the urine with resulting pain (in the case of pedunculated growths), and intermittent hemorrhage at the end of urination, or mixed with the urine. Renal pain in the kidney whose ureteric orifice is nearer the tumor in the bladder is a not uncommon symptom. Spontaneous coagulation of the urine in a vessel (fibrinuria) due to the excess of fibrin discharged with the blood in the urine has been observed only in the case of bladder tumors. Cystitis is a late manifestation. Frequent micturition is common, especially if the base of the bladder and the trigone are affected. Diagnosis. — The diagnosis depends on the