A system of practical medicine. By American authors. Vol. 4

by Unknown

(2) The symptoms accompanying cystitis in women referable to the neighboring organs are of some importance, but they very often arise from some coexisting disease of other pelvic organs. It is therefore needless to give a list of all the pelvic pains coincident with cystitis which have been enumerated in the literature of this subject.

(3) The general symptoms are of two classes, toxic and nervous. While all agree that there is no doubt of direct blood-poisoning in cystitis, there has been a great deal of difference of opinion as to how this is effected. I think that there are various agencies at work in this. First, there may be organic renal disease or sympathetic renal hyperæmia leading to imperfect elimination. In cystitis caused by over-distension from long retention the kidneys simultaneously take on acute inflammation, which usually passes off when the bladder is emptied, but it may continue and give rise to all the constitutional symptoms of renal disease. Again, in chronic cystitis the thickening of the bladder-walls obstructs the ureters, so that the urine is dammed back upon the kidneys. This arrests their function, and in time leads to organic disease with all the consequent derangements of the nutritive and nervous systems. Secondly, absorption of the products of decomposed urine, or of pus and other septic materials the result of decomposing shreds of tissue, may take place.

Anæmia is another of the blood-changes which occur in chronic cystitis. In its origin and continuance it probably is much like anæmia due to long-continued inflammation elsewhere. The only peculiar symptom in this connection is the appearance of urohæmatin in the urine.

With this slow deterioration and poisoning of the blood various symptoms are developed. There is an effort made to eliminate urea by the mucous membrane of the alimentary canal. This is manifested by attacks of vomiting or diarrhoea. But when it does not come to these explosions, there is apt to be lack of appetite, especially at the morning meal, or there are perverted taste and constipation, interrupted by occasional attacks of diarrhoea. The skin in the chronic cases is at times sallow and clammy, and at times there is a distinct urinous odor about the body. Various more or less marked nervous symptoms are apt to be present. One set is characterized by the sluggishness of the patients, an inclination to sleep, despondent spirits, and occasionally dizziness and fainting. There can be little doubt that these and allied symptoms are referable to cerebral anæmia, for they are much aggravated by bromide of potassium, whilst digitalis and out-door life improves them. A second set of nervous symptoms are fairly attributable to blood-poisoning of one kind or another, and in the most severe cases are often promptly relieved by diarrhoea. Finally, a number of the irregular, wandering neuralgic pains and the headache are due to the general depression produced by bladder-pain and loss of sleep.

DIAGNOSIS.—Cystitis is easily made out, except in certain mild cases. Similar symptoms, especially frequent urination, occur in prolapsus uteri, often in anteversion and in cases of pelvic adhesions and pregnancy and abdominal tumors, and lastly in certain neuroses. In most of these the recumbent position lessens the desire for frequent urination much more than when cystitis is present. Again, in the neurosis the attacks are irregular. Tenesmus is usually only present in cystitis, and lastly the examination of the urine and exploration of the parts should settle the question. We have spoken above of the method of differential diagnosis of blood coming from the bladder or the kidneys: the same method applies to localizing the source of pus. Urethritis with fissure at the neck of the bladder simulates cystitis in clinical history, and in the fact that pus in small quantity is found in the urine. To differentiate, the urine examined should be taken directly from the bladder with the catheter, when it will be found free from the products of inflammation. In addition to this, in some cases it will be necessary to make use of the endoscope, by which a good view can be obtained of the whole urethra and a portion of the mucous membrane of the bladder sufficient for diagnostic purposes.

TREATMENT.—The female bladder is so accessible, owing to the shortness of the urethra, that it is peculiarly amenable to local treatment. This is by no means, however, all that is required, for in all forms of cystitis, irrespective of the cause, the urine plays a very important part in keeping up the irritation. There are, therefore, always three indications to be met: (1) Removal of the cause; (2) constitutional treatment (diminishing the irritating character of the urine); (3) the cure of the local lesion.

(1) In many cases, of course, the cause is transient. The injury is done, and the inflammation resulting runs its course, longer or shorter according to the modifying influence of treatment. In a smaller number of cases, again, the cause is not removable, as in certain constitutional diseases or permanent pelvic adhesions, tumors, and the like. In such cases of course the treatment is but palliative, and, while relieving the immediate symptoms, aids the organs till a certain amount of toleration of the abnormal conditions is established. But in a large class of cases the cause, though more or less persistent, is removable. This includes the numerous cases of uterine displacement. Lastly, there is a certain number of uncomplicated cases which tend to recovery without treatment.

(2) The constitutional treatment should be first directed to reducing the amount of work the bladder has to do. For this purpose the bowels should be kept rather freely open, saline laxatives being the most valuable for this purpose. The skin too should be kept healthy and active. Next, the character of the urine should be as bland as possible. Food and drugs which are known to cause or keep up cystitis should be carefully avoided. Milk diet has proved successful in the hands of George Johnson. In all cases the diet should be carefully attended to, and should consist largely of fluid foods—milk, yolk of eggs, soups, etc. Lean meat in small amounts and easily-digested solids are allowable. Articles such as asparagus, alcohol, beer, and wine generally are to be avoided. Fruits, such as lemons and oranges, are usually grateful and at least harmless. The alkaline diluents, such as citrate of potassium or the alkaline mineral waters (Vichy), answer an admirable purpose. An infusion of buchu is an excellent agent, and may be combined with nearly all other drugs employed in treating cystitis. Where pain is an urgent symptom in acute cases, it should be relieved by hot applications and by anodynes. Dover's powder is an excellent form in which to give opium. To relieve tenesmus vaginal suppositories of morphia, with or without belladonna, may be given. But in certain cases twenty-grain doses of potassium bromide every four hours relieve pain where opium fails. Benzoic acid or benzoate of ammonium in ten-grain doses in infusion of buchu, three times a day, is a most valuable remedy. The usual remedies, such as balsam of Peru or copaiba, oil of turpentine, etc., which are given in gonorrhoeal inflammation, are very useful in the chronic catarrhal forms of cystitis. To prevent or lessen the decomposition of the urine a vast number of remedies have been employed, all of the astringents and most of the antiseptics, but as a rule these remedies are much better administered locally than constitutionally. In various acute and transitory cases the constitutional remedies above described will be all that is necessary, but in the greater number local treatment is absolutely required.

(3) In local treatment the first point is not to do harm to the parts by the use of instruments. Dirty catheters and rough catheterization so often cause cystitis that it is easy to see that the same causes often perpetuate the mischief. Great care, then, should be used in selecting instruments for injecting. The ordinary metallic catheter with one or two large openings is much more liable to wound the sensitive mucous membrane than one with a number of small holes made either of hard or soft rubber. It should have a stopcock or something similar at the outer end, the better to regulate both the injections and the escape of the solution injected. In ordinary injections only about an ounce at a time should be in the bladder; this can be repeated four or five times, and the injection should be as slow as possible. To meet these indications I use a double perforated catheter made as follows: A small tube runs from one of the bifurcations to the extreme point. This is the supply-tube, and the catheter acts as the exhaust. The central tube can be removed for the purpose of cleaning the instrument. A piece of rubber tubing attaches the supply-tube to a fountain syringe, and this completes the whole apparatus. The calibre of the supply-tube being small and that of the exhaust large, a great quantity of fluid can pass through the bladder without distending it. The fingers can pinch the rubber tube and act as a stopcock to regulate the entrance and escape of the fluid used.

An injection of borax and water is often highly beneficial, and is alone sufficient in many cases. It should be frequently employed. It should always precede any topical application or medicated injection. Lukewarm water alone is employed, but the addition of a little salt (drachm j to pint j) or chlorate of potassium renders it more bland. Very often hot water is a most useful application. Of the medicated injections a vast number might be described, but they are referable to two classes, anodyne and astringent. The painful nature of cystitis suggests the use of opium preparations and chloral hydrate for injections, and they do give some relief. They should be well diluted to prevent their causing irritation.