After the bladder has been washed out in this way, applications may be made to the interior by pouring through the funnel the desired medicated solution, the most useful one being a weak solution of nitrate of silver (gr. j or ij to ℥j). This solution should be retained in the bladder for a few minutes, and should then be withdrawn.
A solution of sulphate of copper (gr. j-iv to ℥j) is also useful.
At first daily irrigation and application should be thus practised. As the case improves the intervals between the treatments should be lengthened.
This local treatment should always be combined with the general treatment already prescribed—rest in bed if possible, a milk diet, and the administration of boracic acid internally.
Application through the Endoscope.—If the endoscope is used in the first place for diagnosis in a case of chronic cystitis, much time that might otherwise be wasted in unnecessary or useless forms of treatment may be saved. The condition of the parts maybe accurately determined, and the proper form of treatment may be instituted. It may, for instance, be seen that deep ulceration is present, or that other lesions of the bladder are so extensive that the quickest plan of cure will be to proceed immediately to the formation of a vesico-vaginal fistula, without attempting to treat the disease by applications.
Applications may be readily made through the endoscope to any part of the interior of the bladder. Applications made in this way are most useful when the disease is localized. Stronger solutions may be used on the affected areas than when the application is made to the whole surface of the organ.
When the disease is limited to the vesical triangle or to local areas situated elsewhere, the inflamed spots should be touched with a solution of nitrate of silver (gr. v-xx to ℥j). Much benefit is frequently derived from one such application, in connection with the general treatment already indicated. The applications may be made every few days. The procedure causes less discomfort to the woman as she becomes accustomed to it.
Cystotomy.—In cases of ulceration of the mucous membrane, or when the disease has resisted the milder forms of treatment, it may become necessary to perform cystotomy, to furnish an opening for the continuous drain of the urine, and to put the bladder at rest by relieving it from all functional action. This is a most valuable therapeutic operation in cases of obstinate cystitis.
In performing cystotomy the anatomical relations of the ureters and the internal orifice of the urethra must be kept in mind. It will be remembered that the ureters terminate in the bladder at points situated from ½ to ¾ of an inch from the median line.
