Definition.—Chronic inflammation of the mucous membrane of the bladder, attended by more or less structural changes in its walls.
Etiology.—Chronic cystitis may be the result of oft-repeated acute attacks, or it may come on insidiously, following an acute attack which has been neglected. The exciting cause may be a calculus in the bladder, or pressure from the outside, as from a tumor or displaced uterus. It may also arise from a urethral stricture or enlarged prostate, the bladder not being completely emptied, and the urine thus contained becoming acid. Tubercular deposits and neoplasms are among the rarer causes.
Pathology.—In long-standing cases, the mucous membrane becomes very much thickened, affecting its capacity for retaining urine. The surface is not red and velvety, but assumes a purplish or slate color. Its surface is covered with a muco-pus, with here and there an ulcerated patch. There is enlargement of the follicles, and there may be so much obstruction of the ureteral orifices as to cause dilatation of the ureter and pelvis of the kidney, followed by hydronephrosis.
The urine is alkaline, and contains more pus and albumin than in the acute form.
Symptoms.—"Persons suffering from chronic cystitis usually complain of a sense of weight in the hypogastrium and peritoneum, with a dull, dragging pain. There is also tenderness on deep pressure over the hypogastrium. More or less difficulty is experienced in passing urine, sometimes on account of the increased mucous secretion, and at others, from the seeming acridity of the urine. The patient frequently complains of pain in the neck of the bladder, extending the entire length of the urethra, and sometimes of a sensation of scalding or burning referred to the region of the bladder. In severer cases, when complicated with disease of the prostate, or when ulceration has occurred, the pain and heat in the bladder is very severe, the call to urinate urgent and attended by violent tenesmus and straining.
"The general health becomes markedly affected when the disease is severe; the bowels are constipated; the appetite impaired; the skin dry, harsh, and sallow; and there is considerable loss of flesh and strength. The urine varies greatly; in the milder cases it seems nearly natural, but in the more severe cases it contains mucus, pus, and the phosphates. Sometimes it is so thick with the presence of these materials that it is voided with difficulty."
Diagnosis.—"Chronic cystitis is determined by the location of the pain and tenderness, and its association'with difficulty in passing water, and alteration in the urine dependent upon the changed secretions of the bladder. Mucus in the urine may be determined by its action on litmus paper, by its particles coagulating into a thin. semi-opaque membrane, on the addition of nitric acid, and by its soon undergoing putrefactive decomposition, becoming ammoniacal.
"Pus, in urine, generally falls to the bottom when allowed to stand: acetic acid has no effect on it, but if agitated with liquor potassae it forms a dense, translucent, gelatinous mass. If the urine contains phosphatic deposits, it is often very fetid, sometimes pale, at others greenish, and viscid from the abundance of mucus. On placing some of the mucus beneath the microscope, abundant crystals of the triple phosphate are found entangled in it. Dr. Bird remarks that, "One point must be borne in mind in forming a prognosis from the state of the urine; viz., not to regard it as ammoniacal because the odor is offensive, and not to consider the deposit as purulent because it looks so. A piece of litmus paper will often show it to be neutral, and even sometimes acid, while microscopic inspection often proves the puriform appearance of the urine to be an admixture of the phosphates with mucus. For want of these precautions, I have seen some cases regarded as almost hopeless which afterward yielded to judicious treatment. It is quite certain that the mucous membrane of the bladder may, under the influence of chronic inflammation, secrete so much of the earthy phosphates and unhealthy mucus as to render the urine puriform and offensive without having necessarily undergone any structural change."
Prognosis.—"Though persistent in its character, the disease is almost always amenable to treatment. Cases in which there is enlarged prostate with ulceration of the bladder, are the most intractable, and sometimes prove fatal. When associated with chronic disease of the kidneys, it is almost always fatal."
Treatment.—The treatment wilt include internal medication, counter-irritants, and local treatment to the bladder walls. In the milder forms of somewhat acute character, the remedies recommended in acute cystitis will prove beneficial; viz., apis, gelsemium, cantharides, eryngium, etc. In the more chronic forms, and where the urine contains large quantities of mucus, phosphates, etc., we will get better results by the use of additional remedies.
Agrimony.—Where there are large quantities of mucus, or mucus pus, and blood, agrimony will be found to give good results. Agrimony one or two drams, to water four ounces, a teaspoonful every three or four hours.
Colorless Hydrastis and cubebs are also good agents when the same conditions prevail.
Eryngium will be found useful where there is continual uneasiness and the water is scanty and high-colored.
Hydrangia.—Where there is constant backache and the bladder is irritable, hydrangia will give good results.
Elaterium.—This is the remedy so highly praised by Dr. John King, and where the inflammation is at the neck of the bladder, with constant pain, the urine passing spasmodically and leaving unpleasant sensations, the remedy is a good one.
Rhus aromatica will be a good remedy where there is some hemorrhage.
Santonin will prove a good agent where the urine is scanty and passed with difficulty.
Salol.—Where the urine is excessively alkaline, salol in five-grain doses every three or four hours will not prove disappointing.
Injections.—We can not secure the best results, and many times not effect a cure, unless we can secure a clean bladder, and wash out the irritating and decomposing urine. The double catheter may be used, allowing the fluid to escape as rapidly as it flows in; or a soft rubber catheter may be attached to a glass funnel, and the bladder filled, then, by depressing the tube, the water allowed to flow out. Where the deposits are abundant, the bladder should be thoroughly irrigated, one, two, or three times a day. We use plain sterilized water or a normal saline solution, boracic acid solution, or weak solution of potassium chlorate.
Following this treatment, much benefit may be derived by introducing into the bladder a solution of colorless hydrastis and sulphate of zinc; say hydrastis, one dram; zinc sulphate, four grains; water, one ounce. Should this be followed by much pain, it may be washed out with tepid sterile water.
Where there is great pain, morphia may be added to the solution introduced, using one-third or one-half grain to the ounce; or one grain of opium may be used as a rectal suppository.
The older Eclectics obtained good results from counter-irritation over the bladder, and, though rather unpleasant treatment, it will be found to give good results in the more stubborn cases. The old compound tar-plaster may be used to suppuration, or the more modern thapsia plaster.
The bowels should be kept in a soluble condition. Of course, if there be stricture of the urethra or enlarged prostate gland, our attention must be directed to overcoming these difficulties before we can expect much, if any, relief to the cystitis. Where the irritation is persistent and the deposits large, and the treatment has failed to give relief, as a last resort drainage by way of the vagina in the female and the perineum in the male, is to be advised.