Chronic Cystitis.
Synonym:—Chronic inflammation of the bladder.
Definition:—A condition of chronic inflammation of the mucous membrane of the walls of the bladder, involving also in extreme cases, to a greater or less extent, the submucosa and the muscular structures, often making serious inroads on the vitality of the patient.
Etiology:—The disease seldom occurs as a primary disorder. In cases of gravel where there is renal sand in the bladder for a long period, there is constantly increasing irritation, from which this disease slowly develops. This occurs in lithemia also, as well as where there are phosphates or oxalates in the urine, or a single stone may slowly form in the bladder. A common cause in male patients is stricture or other occlusion of the urethra, the prolonged influence of a protracted gonorrhea, prostatic irritation, and ultimate enlargement, especially in aged males. These and other causes prevent complete evacuation of the bladder, and the retained urine—residual urine—becomes decomposed and increasingly irritating and infectious.
The disease results from pressure from external growths or tumors, from the influences of a chronically displaced uterus, from the influence of chronic inflammation in contiguous parts or organs, from neoplasms, or tubercular growths; also, I think, from persistency of an extreme acidity or alkalinity of the urine without necessarily any precipitates. It may follow soon after an acute attack, or there may be marked improvement, at first, in the acute symptoms, with almost entire relief, to be followed later by the gradual development of the symptoms of the chronic disorder. It may develop slowly after acute infectious diseases without an acute attack having occurred.
Symptomatology:—In cases which follow sooner or later after an acute attack, the symptoms are a continuation, in part at least, of those which have been previously observed. They need not be reiterated. In other cases the first symptoms are at first slight urinary irritation, which slowly increases, with failure of the expulsive power of the bladder and urethra. These slowly increase until frequency of urination and tenesmus become very annoying.
At first there are no marked changes in the urine from that which existed for some time subsequently, except a slowly increasing quantity of mucus. Later there is a heavy sediment of blood, pus, mucus and tissue debris. The difficulty and pain of urination slowly increase until the patient, in extreme cases, or where ulceration occurs, is in agony at each urination and is weakened and prostrated by the effort. This causes the patient to resort to catheterization, and if he learns to introduce the catheter himself he soon refuses to endeavor to evacuate the bladder normally, and later evacuation without the catheter becomes impossible. In other cases obstruction from local tumor or greatly enlarged prostate or stricture, make urination impossible and makes the catheter an immediate necessity. From the presence of pus and blood in the urine, and occasionally from the influence of the prolonged disease upon the kidneys, there is usually a much larger quantity of albumin in the urine in chronic than in acute cases.
The impression of this disease upon the constitution is very marked. There is failure of the appetite and of digestion; constipation, and other defective excretion; the skin becomes dry and harsh, and often there are eruptions from imperfect general elimination. There is increasing disinclination to muscular exercise; the patient becomes morose and irritable, and his countenance has a constant appearance of distress. Emaciation and loss of strength are finally pronounced.
Diagnosis:—The urine always contains a heavy sediment, which is increased in turbidity upon boiling or upon the addition of nitric acid. Pus and blood are present, as shown by the tests heretofore described. The persistency and gradual increase of the symptoms of irritation, frequent urination and tenesmus are confirmatory. The urine may be persistently acid. Where decomposition occurs, there is alkalinity, with bacteria in large quantities, which may only persist until the bladder is thoroughly evacuated and irrigated, or alkaline urine may be constantly secreted.
Prognosis:—The prognosis as to complete cure must be guarded. When the cause is persistent, as in foreign growths and in chronic prostatitis, or when the disease follows pyelitis or pyelonephritis, a cure is well nigh impossible, and death is usually the final result. Taken early, many cases are amenable to treatment. Those in which the cause can be permanently removed can usually be cured.
Treatment:—The course advised in the treatment of acute cystitis can be adjusted in part to many cases at the onset of this disease, and especially to the mild cases; but the prolonged, deep-seated cases must have an entirely different treatment. A thorough irrigation of the bladder is essential, but this must not be depended upon to the exclusion of specific measures. All causes of the disease must be removed. Gravel must be overcome and any calculi in the bladder must be removed. Any excessive acidity or alkalinity of the urine must be neutralized. The bladder should be thoroughly irrigated sufficiently often to keep it free from any quantity of pus, mucus and blood. In severe cases, at the onset, this may be required once in twelve or eighteen hours, although once in twenty-four hours is usually sufficient; as improvement advances or in milder cases, once in two or three days will be as often as needed. It must be conducted by the physician himself, and every measure adopted to prevent septic infection, as the frequent occurrence of this is one of the serious objections to the use of irrigations. Infection will sometimes occur, even with the utmost care, and will induce acute symptoms difficult of control. A return tube catheter may be used in irrigation, or a silver catheter. A rubber catheter into which a glass tube is tightly inserted is preferable. Over the free end of this glass tube the tip of the rubber tube of a fountain syringe can be readily slipped, while the catheter is in the bladder. The irrigating fluid is passed into the bladder at a temperature slightly above that of the body. When the bladder is filled, the tip of the connecting tube is removed at its attachment to the catheter, allowing the escape of the fluid. The tube is then reattached, and the bladder again filled to be emptied in the same manner, until the fluid returns clear. I positively object to using the tube and fountain or funnel as a syphon, as advised by some writers. The offensive urine flows through the long tube, on lowering the fountain, into the fountain and it is practically impossible to ever perfectly sterilize the apparatus afterward.
The irrigating fluid should be sterile water, or the normal salt solution, or an effective antiseptic solution. I prefer boric acid, potassium permanganate, or hydrogen peroxid. After the, irrigating fluid is withdrawn, a medicated fluid may be introduced. Where the bladder wall is very sensitive the mild applications may be first used, but later, as it becomes accustomed to foreign fluids, stronger ones will be retained without pain. Warm fresh milk one part, to water four parts, is very soothing. As soon as permissible, I would introduce a diluted solution of the hydrochlorate of hydrastin, five grains, sulphate of zinc, one grain, in rose water, one ounce; two drams of this in a pint of warm, sterilized water. If there is distress from its use the rose water may be increased to four times the quantity named, or if there is extreme sensitiveness, a grain of cocain or four grains of morphin may be added to the original formula.
Hydrastis may be introduced in its various forms, and in different strengths. Colorless hydrastis two drams, distilled extract of hamamelis two drams, sulphate of zinc two grains, in four ounces of warm water, may be introduced after the irrigation and retained as long as possible. I have had excellent results, in the extreme cases, especially where there is ulceration, from the introduction of a few drops of thuja, or from half a dram to two drams of echinacea, in four ounces of a mild boric acid solution. I believe thuja exercises a specific beneficial influence. Internal remedies which seem to be indicated will not give prompt results, unless the general conditions of the urine be attended to, and excessive urinary reaction be corrected, as I have stated above. If there is a persistency of the presence of pus, I give gelsemium, one or two drops and echinacea ten drops every two hours from two to three days. I should then add ten drops of pichi, and continue this for a week longer. I have obtained excellent results from a prescription which contains five drops of thuja, and ten or twelve drops of chimaphila, every two or three hours, especially in greatly prolonged cases. I think this prescription will benefit a large proportion of the purulent and ulcerative cases. The milder cases will do well on repeated small doses of urotropin, which should be given every two hours at first, and later four times daily. In cases where there is persistent renal sand which acts as an irritant, xanthium spinosum and red onion are advised in from three to ten minim doses. I have obtained good results from an infusion of triticum in causing an abundant flow of bland urine. This assists materially in washing out the sedimentary irritants. I would emphasize the use of benzoic acid and sodium borate, in the proportions named in acute cystitis, when the urine is strongly alkaline and much mucus is present. I would suspend other remedies until the desired influence of this combination is obtained. Usually not more than five or six days are required to obtain satisfactory results.
Other agents that will be indicated at times, and may be used in full doses, are agrimony, sodium bicarbonate, in extreme acidity, kava kava when there is much relaxation, elaterium when there is a relief from other symptoms but there are little nagging pains on urinating; cantharides in minute doses when there is much straining, and apis when with persistent local irritation, there are mild dropsical effusions, especially edema of the face and eyelids.
I have not obtained good results from counter irritation, and have but little confidence in surgical procedures. I have had many cases brought to me, where septic infection or reinfection had been brought about from operation upon the prostate gland, or upon a urethral stricture, or upon the removal of some foreign growth, as a urethral caruncle, where the subsequent condition was very much worse than the original difficulty for which the operation was performed. While good results have been claimed from permanent drainage, suprapubic or perineal incision, I believe recourse should be had to this measure only in otherwise incurable cases, as it is certainly of doubtful utility.
