The legitimate ultimate termination of chronic cystitis is by chronic inflammation of the ureter and pelvis of the kidney on both sides, interstitial kidney changes, and finally death by suppression. Generally, this end may be almost indefinitely postponed by well-directed efforts of palliative treatment.
TREATMENT.—The acute outbursts of inflammatory disturbance occurring during the course of chronic cystitis require the same means for their relief as those already indicated when considering the treatment of acute cystitis—all the prohibition of stimulants, the use of bland mineral waters, demulcent decoctions, infusions, and alkaline draughts. The anodynes, the rest, the heat, the hip-bath, are all indicated here for the acuter symptoms, just as they are in the acute malady, but very much more can be done both in a prophylactic and in a curative way. A milk diet, even an exclusive milk diet, is an element of great value in cases of chronic cystitis. I have two patients, both old men, now under observation, one of whom recovered entirely from cystitis with complete atony, necessitating the constant use of the catheter, by means of an exclusive milk diet. He takes one gallon of milk a day, and nothing else, and lives among his fellow-men at his work and amusements in entire contentment. He has remained absolutely well on this diet during many years. The other patient could not take milk after fair trial, but gradually emerged from the very jaws of death, due to prolonged chronic cystitis and double pyelitis, by the free use of koumiss, which his wife daily prepared for him. Vichy and milk in equal parts, taken cold, is another form of using the milk diet, and the more modern peptonized milk another.
Light white and red wines, or even a little gin or old brandy, are of decided advantage in the majority of enfeebled old men with chronic cystitis. The patient should be clothed with the utmost care. The feet and legs should be clad in wool unless in the very hottest season, and flannel should constantly encase the belly and loins. Nothing is more detrimental to chronic cystitis than chilling the legs.
Another word is necessary in favor of the internal use of alkaline remedies. Even where the urine is alkaline, ammoniacal, putrid, if the stomach will take an alkaline medicine kindly the effect is generally beneficial, for the urine, especially in old men who are prone to these maladies, is quite certain to be acid at the fountain-head. And even if the urine is immediately altered by chronic pyelitis through ammoniacal decomposition before it enters the ureter, yet it will generally irritate the pelvis of the kidney and the ureter and the bladder less if it be secreted in a bland alkaline state than if it be discharged into the irritated area full of uric acid.
Turpentine, copaiba, cubebs, and the muriate of iron are of service in selected cases, but ordinary astringents seem to possess little or no value. Benzoic acid, in ten-grain doses in capsules, sometimes improves the ammoniacal condition of the urine, but the stomach often rejects it. Boracic acid, which has of late been much talked about, in five- to ten-grain doses in water, three or four times a day, is of value occasionally. Quinine is serviceable where the nerve-force is failing. I have been unable to procure any very decided advantage from the use of salicylic acid or the salicylate of sodium by the mouth.
The most important general surgical principle in connection with chronic vesical catarrh is that which concerns emptying the bladder thoroughly and ensuring its cleanliness. In many, perhaps most, conditions of chronic inflammation of the bladder from atony, paralysis, obstruction, or other cause the bladder fails to empty itself entirely. There remains, therefore, a fixed residuum always in the bladder; and although this is diluted and partly evacuated at each act of urination, yet some of the pus, the bacteria, the ammoniacal ferment, remains constantly in the bladder ready to contaminate each new portion of urine as it descends from the kidneys. This must be disposed of, and the bladder washed out, if a permanently satisfactory treatment is to be instituted.
The soft-rubber catheter is to be preferred where it will pass, otherwise the woven silk or the French Mercier instrument, and the bladder should receive attention at least once in the twenty-four hours, and oftener if required. The last drops of urine should be drawn off and the bladder washed with water at about 100° F., in which is dissolved some borax—a heaping teaspoonful to the pint—or other substance capable of disinfecting the contents or mildly stimulating the circulation of the bladder.
Carbolic acid has not yielded good results in my hands. A host of remedies have been employed, but it is doubtful whether anything can do more good than the water mechanically, borax as a disinfectant, dilute nitric acid, minim i-x to the pint, as a stimulant, or, in some cases, nitrate of silver, gr. ½-x to the ounce, used with caution. The injections should be practised through the catheter which withdraws the urine, and repeated according to their effect. For cleansing purposes an injection of simple warm water may be used at each introduction of the catheter. A fountain syringe with two-way stopcock is the most convenient instrument to use for the purpose of simply washing the bladder, because the wash may be repeated indefinitely until it returns clear, without readjusting the nozzle in the catheter.
Very extreme, long-protracted cases of chronic vesical catarrh justify the performance of lateral cystotomy for their relief, or the modification quite recently proposed by Thompson2—a median perineal incision involving only the membranous urethra, through which a large soft-rubber catheter is passed and tied in for a few days or longer.
2 Brit. Med. Journ., Dec. 9, 1882, p. 1131.