Treatment.
—When the occurrence of cystitis is imminent prophylactic or preventive treatment is recommended. This should consist in administration of large quantities of fluid, with urinary antiseptics, in lavage of the bladder itself, and in reliable antiseptic precautions in catheterization. Thus to operate upon a bladder which has long held seriously infected or decomposed urine, without previously cleansing it as much as possible, is simply to invite further trouble.
The medicinal treatment of cystitis, on which we mainly rely, consists in dilution of the urine by large amounts of fluid ingested, in overcoming hyperacidity by the administration of alkalies, and in combating putrefactive conditions, so far as possible, by antiseptics which are eliminated through the kidneys. Balsams have been long held in great repute; but remedies like urotropin and other synthetic compounds have taken their place. Of them all, and especially in the presence of ammoniacal urine, urotropin and the alkaline salts of benzoic acid seem most reliable. Excessive irritability may be overcome by local measures, such as frequent hot rectal douches, hot sitz baths; by quieting irritation of the genitospinal centres by administration, e. g., of cannabis indica, in doses pushed to the physiological limit; by local anodynes, as by opium suppositories, or in extreme cases by general anodynes like morphine.
Theoretically a seriously infected bladder should be washed out and cleansed as any other pus cavity, but when so inflamed the bladder becomes so intolerant and exquisitely irritable that the mere act of washing can only with difficulty be borne by the patient. Retention of a catheter, which might be advisable under most circumstances, may also be impossible for the same reason. The condition of a patient under extremes of this kind is pitiable, and resort to general anodynes unavoidable. Still it is possible with patience and the use of selected drugs to gradually allay even a most acute cystitis. Confinement in bed and an almost fluid diet are also necessary features of treatment.
If the introduction of an instrument can be borne it may be possible to leave in the bladder some soothing solution after it has been washed, such as a mild cocaine solution containing a little morphine, or olive oil containing orthoform, or a mild preparation of ichthyol. Even if these be retained but for a short time they will usually afford relief.
Finally in severe forms of cystitis the bladder may be opened for the purpose of giving it physiological rest, selecting either the suprapubic or the median perineal route. The relief thus afforded is usually gratifying, while drainage may be maintained until the local treatment has been sufficiently effective to permit either spontaneous closure of the drainage opening or its repair by suture. This measure is known as cystostomy for the relief of cystitis.
Obviously if cystitis be due to the presence of any foreign body its treatment becomes necessarily surgical, the same being true of those forms due to or connected with hypertrophy of the prostate. It is impossible to accomplish a cure here until the mechanical difficulty is first overcome.
VESICAL CALCULUS.
In the urinary bladder as well as in the gall-bladder mineral elements held in solution by the contained fluids are precipitated, the consequence being the formation of calculi or stones in the bladder, which vary in size from the smallest concretions to those weighing many ounces, and in number from one to scores, a large proportion of these representing original concretions passed down from the kidneys, i. e., minute renal calculi. Every calculus has a nucleus, and in many instances this may be a clot, or clump of cells encrusted with salts, which have formed within the bladder and not come down from above. Such foreign bodies will become the nidus for a calculus, while in vesical calculi are frequently found pieces of catheter, of straw, chewing-gum, hairpins, and the like, which have been introduced from without. These stones are constituted mainly of the ordinary urinary salts, i. e., phosphates, urates, or oxalates, deposited as described above. Much more rarely cystin and xanthin are found. Instead of urates crystallized uric acid will be occasionally seen. The oxalates are mostly those of calcium, while the phosphates are those of calcium, magnesium, or ammonium, more or less combined. The first requisite for a calculus is a nidus, the second the deposition of one or more of these salts. Calculi are sometimes composite in structure, some having a uric or urate nucleus becoming later encrusted with phosphates. The oxalic calculi are exceedingly hard and usually rough, being often spoken of as mulberry. They rarely attain large size. The rapidly forming phosphatic calculi are often so small as to disintegrate or break in the process of removal. Thus there may be great differences in density of these stones. Their formation is particularly favored by retention of alkaline urine, as in many cases of prostatic enlargement.