Acute Cystitis.

FINLEY ELLINGWOOD, M. D., CHICAGO, ILL.

While not as common as many acute inflammations, an inflammation of the urinary bladder is one of the most trying conditions with which a physician must contend, and acute inflammations dependent upon direct causes are usually more especially trying.

The ordinary form of acute inflammation affects only the mucous membrane which lines the walls of the bladder, but there are cases where from severe cold, or from direct injury, or indirect traumatism, not only the mucous membrane, but the walls of this organ become immediately involved, inducing a condition which demands the most strenuous effort, the utmost skill, and the closest watching on the part of the physician. The larger majority of cases, however, belong to a milder type.

CAUSES.—I am confident that sudden cold, abrupt changes in the atmosphere, prolonged exposure to extreme cold, are among the most common causes of the acute form of this disease. When the body is in this chilled condition, a desire to urinate occurs sooner than normal, and an inclination to hold the urine at that time is strong, and may result in distension of the bladder and stretching of the walls, thus attracting the blood to that organ, and initiating a primary congestion.

Distention of the bladder walls from neglect to pass urine at any time, or in inability to pass urine, which results in decomposition of this fluid, will cause this disease. This is especially true where there is an inclination to prostatic irritation in elderly men, or when that irritation is increased from some immediate local cause, as horseback riding when not accustomed to it, or prolonged walking, or prolonged muscular strain.

A fall, striking upon the perineum, has induced cystitis, or a blow over the abdomen, or over the pubic bone, or other direct injury. It is caused by introduction of the catheter, inducing either direct injury or septic infection, or it may be caused by operations on the urethra, as the dilatation or cutting of a stricture. It follows labor from pressure or injury from the passage of the fetal head, and from subsequent septic infection of the bladder. This latter results from the lack of cleanliness, or from the nurse's carelessness in using the catheter. In one of my patients it resulted from carelessness in removing a small urethral caruncle, in an elderly woman.

The most common, severe and intractable of all septic causes is that of 'gonorrheal infection, especially in men, and specific or non-specific leucorrhea in women. The disease also results from infection during the course of infectious diseases, especially in eruptive fevers, diphtheria and tuberculosis.

Local inflammations, as orchitis, ovaritis, salpingitis, peritonitis, pelvic cellulitis, enteritis, or proctitis, may be extended to and involve the bladder, and, as has been stated, it may readily extend directly from the various forms of kidney disease, and from urethritis, and from specific or non-specific urethritis. Local abscesses or tumors are possible causes also. The use of irritating drugs as medicines, and working among irritating chemicals, may induce the disease.

SYMPTOMATOLOGY.—The symptoms are usually unmistakable. There is a chill, usually quite pronounced, followed by fever, with a temperature of about 102.5° F., the pulse is hard, sharp and quick. There is seldom any vomiting. Immediately with the chill there is a frequent desire to urinate, which is accompanied with tenesmus and irritation, with sharp, cutting and burning pain.

There is soreness also from the bladder, which is localized first above the pubes and also in the perineum. The pain extends to the testicles and to the head of the penis in the male, and in all patients to the back—the loins and sacrum—and into the thighs. It is increased by pressure above the pubes, and when the urine is retained for even a few moments. The urine is passed with increasing irritation, and as the disease progresses the tenesmus extends to the rectum, and strangury occasionally results.

Usually the urine is decreased in quantity, is even quite scanty, and of high specific gravity, and of acid reaction, but this is not invariable. In septic cases I have observed an immediate increase of pale, ammoniacal urine, very acrid and irritating. There may be more or less blood in the urine, and often a considerable quantity of mucus. Occasionally the sediment is heavy, dark and fetid, especially on standing. It is composed of mucus, blood, pus and mucous shreds, with urates and perhaps the triple phosphates.

Later, in the progress of a severe case, there may be septic infection from direct absorption of these products, when exfoliation of the mucous lining of the bladder has taken place, and nephritis with urinary suppression and marked uremic symptoms may appear. This absorption may induce constitutional symptoms resembling those of typhoid fever.

COURSE.—The course of this disease is from ten to fourteen days. It may terminate favorably, it may assume a chronic form, or it may extend to contiguous parts and result in abscess. The acute form of this disease may occasionally appear as an exacerbation during the progress of the chronic form of this disorder.

DIAGNOSIS.—There will be no difficulty in diagnosis. The occurrence of an acute form of symptoms referable directly to the bladder, especially the pain and urinary irritation with frequency of urination and tenesmus, are pathognomonic. The condition is confirmed by the rather abrupt appearance of marked urinary changes, especially if the urine contains mucus in large quantity and some blood. There is but little albumin in the urine, unless from the serum of the blood and pus which may be present.

In acute nephritis there is scanty urine, which is highly albuminous, even when there is no sediment. Where there may be no extreme pain in the back and loins in nephritis with urinary irritation, the extreme local pain and tenesmus of cystitis cannot be mistaken.

PROGNOSIS.—Well-managed cases, without serious complications, will usually terminate favorably in from four to eight days. Severe cases will last from ten days to two or even three weeks. Death seldom results from the disease unless the bladder wall is involved. Kidney complications are serious.

TREATMENT.—Because of the liability to extension of the disease to the kidneys, especially when caused by gonorrheal or other septic infection, and because of the liability to other serious complications and to the possibility of its assuming a sub-acute or chronic form, the treatment must not be conservative. There must be no waiting nor temporizing. Positive, direct and efficient measures must be immediately adopted, and the physician must know that his orders will be executed in detail.

At the onset, the patient should have a hot sitz bath, which should be prolonged as long as no discomfort arises from it. This immediately gives relief to the pain and urinary teasing, as well as encouraging elimination from the skin and serving as a prompt revulsive or derivative. If the bowels are constipated they should be thoroughly flushed with a hot flush, and later a mild saline laxative may be given. The patient should be put to bed and kept in a mild perspiration. Hot applications should be applied over the pubes and kept hot for six or eight hours. The application of libradol to the lower abdomen and to the perineum will be of much service, applied at the onset, but this may well follow the hot applications.

For the fever, aconite should be given, but this should be combined with full doses of gelsemium, for its influence on the nerve distribution in the mucous membrane of the bladder, and consequently upon the irritation and local congestion, both of which it promptly relieves. One of my favorite prescriptions is the following:

Mix. A teaspoonful every hour. When the physiologic ptosis or tightness of breathing occurs from the action of the gelsemium, it may be suspended for one or two doses, or half doses may be given for a few hours, when it can be slowly increased to the full dose. As the symptoms abate, less of this agent may be given. When the fever declines somewhat, the aconite may be replaced by half of a dram of macrotys in the four-ounce mixture with the other constituents

If the urine is concentrated and of acid reaction, mild, soothing diuretic remedies containing a large quantity of water, as infusions of althea, marshmallows or epigea, should be given to reduce the specific gravity of the urine and to retain irritating substances in solution. An occasional dose of twenty grains of sodium bicarbonate may be administered, or the effervescing carbonate or citrate of lithium may be given for neutralization of the acids.

Such a course is usually very prompt in allaying all the symptoms, unless the urine is alkaline and contains a large quantity of mucus. To correct this at first (and there is but little benefit from other specific treatment until this is corrected) I use the following prescription:

Mix. From a dessertspoonful to a table-spoonful every two hours until the acute symptoms of painful urination and tenesmus abate. This is an evidence of the disappearance of the alkalinity and of an abatement in the quantity of the mucus. I know of no combination more prompt and satisfactory in its influence upon this group of symptoms than this.

Our specific remedies will meet many indications promptly, but the conditions of concentrated, irritating urine or of extreme acidity and alkalinity, or of excess of mucus must be considered and may have to be overcome with special measures as suggested. Among the specific remedies are the following:

Hydrangea: Quick, sharp, cutting urethral pain.

Agrimony: Deep-seated, sharp pain, with foul-smelling urine and excessive outpour of mucus.

Cantharides: In minute doses for sharp pain and tenesmus.

Apis: Burning, scalding pain, with tenesmus, especially if there is any local edema.

Pichi: Excess of mucus and pus, with tendency for the disease to assume a chronic form.

Chimaphila and thuja will control the pain and distress in urinating in the sub-acute forms of the disease often more satisfactorily than other remedies.

Eryngium aquaticum will also relieve tenesmus and pain and exercise a soothing influence over the mucous membranes.

Irrigation of the bladder is usually avoided in the acute cases, unless there be a very large quantity of decomposed residuary urine with heavy sediment and much pus in the later stages. Then two or three washings will usually suffice, but they may be repeated, if the sediment persists.

All complications must have immediate treatment; extension of the disease to the kidneys must be anticipated and met with the indicated remedies. Uremic symptoms or septic infection must be treated with echinacea or calcium sulphide and with proper eliminatives.

Morphine should be avoided, as it is apt to increase local conditions. Opium or belladonna in a suppository may be introduced into the rectum for pain, but I have almost invariably succeeded in controlling pain by the specific measures suggested.

Ellingwood's Therapeutist, Vol. 2, 1908, was edited by Finley Ellingwood M.D.