Cystitis

“ The cases of cystitis in which a suppurative nephritis is likely to be developed are those due to strictures of the urethra, stone in the bladder, operations on the urethra, bladder, and uterus, paraplegia, gonorrhoea, and enlarged prostate.
SYMPTOMS.—When the nephritis occurs with cystitis due to stone in the bladder, strictures, or operations on the genito-urinary tract, the [p. 101] symptoms are much the same. The patient has first the symptoms belonging to the cystitis, then he is attacked with rigors, followed by a febrile movement. The rigors are often repeated ”

“ The diagnosis of cystitis is easily made by proper examination. It should always be remembered that not every woman who complains of painful and frequent urination and vesical tenesmus is necessarily suffering with cystitis. These symptoms are often caused by disease of the urethra, by displacement of the uterus, which drags upon the neck of the bladder, by the pressure of a tumor, or by displacement of the bladder such as may follow laceration of the perineum. ”

“ DISEASES OF THE BLADDER. ACUTE CYSTITIS. Cystitis, or inflammation of the bladder, may be divided into two varieties: simple (acute or chronic) cystitis, and chronic cystitis due to the presence of calculi.
Simple acute cystitis occurs most commonly in the cow, less frequently in the ox, and rarely in the pig or sheep. Female animals are more subject to it than males.
It consists of more or less acute inflammation of the vesical mucous membrane. The inflammation sometimes extends to the muscular coat and the peri-vesical tissues, setting up local or general peritonitis. ”

“ Chronic cystitis is the condition left when the acute symptoms have passed away, but it is liable at any moment to resume the acute condition. If the cystitis is very intractable, refusing to yield to hot irrigations, and to washings with nitrate of silver lotion, it may be advisable to open the bladder from the front, and to explore, treat, drain and rest it. ”

“ The pathology of chronic cystitis is characterized by ulceration and sloughing of the tissues involved. They do not differ materially from the same processes elsewhere, except that the salts of the urine are apt to be deposited upon the shreds of dead tissue the products of destructive inflammation. The hard masses thus formed are passed with great pain. They block up the urethra, and are only expelled by extra strong efforts which cause intense suffering. ”

“ There is probably no pain more intense than that endured by a man with severe general cystitis in its last stages, when the unceasing tenesmus wrings groans from his lips, the sweat from his body, doubles his frame in agony, and converts his facial expression into a distorted tragedy. ”

“ Our efforts must, therefore, be confined to palliating the effects of the presence of the parasite. Practically, the treatment resolves itself into that of chronic cystitis. The diet should be bland but nutritious; stimulants and spices are to be avoided. Excess of all kinds, violent muscular efforts, cold and other causes of catarrh, must also be guarded against. During exacerbations of hæmaturia, or of cystitis, rest should be enjoined and diluents freely partaken of. Milton has obtained good results from gramme doses of extract of male fern three times a day in schistosomum hsematuria. ”

“ 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. ”

“ The prognosis is practically that of a chronic cystitis depending on an irremediable, but not in itself fatal, cause. Much suffering may often be produced, and, as a consequence, anæmia and debility. Possibly calculus may be formed; possibly grave renal disease may ensue; possibly villous or epitheliomatous growths in the bladder. In the milder degrees of infection, which fortunately are the commonest, the patient seems to be in no way inconvenienced by the parasite, and generally escapes all serious consequences. ”

“ When suppurative nephritis complicates the cystitis due to enlarged prostate, the clinical symptoms are somewhat different. The patients are usually men over fifty. They have generally suffered from the symptoms of enlarged prostate—retention of urine, either constant or intermittent, and more or less cystitis, with pus and mucus in the urine in varying amount. Sometimes, however, no such history is obtained; the patients assert that they have had no previous bladder trouble. The first symptom is diminution in the amount of urine passed and the appearance of blood. ”

“ The complication of infective cystitis is frequent, the congestion, redness, ecchymosis, maculation, puckering and thickening of the mucosa, the granular degeneration and desquamation of the epithelium, the exposure of a raw vascular surface, the discoloration of the urine by mucus, pus and blood, and the formation of ammonia and other products of decomposition, becoming marked phenomena. ”

“ More frequently cystitis is the result of inflammation due to continuity of tissue, and forms a complication of urethritis, vaginitis, and the conditions set up by retention of the after-birth. It may also result from ascending infection causing pyelo-nephritis, or ascending infection of any kind which eventually attacks the bladder. It is a very common consequence of the use of unclean catheters, but only in equines and females, as the catheter is not passed in the ox or bull until after urethrotomy. ”

“ The stigmata of maize have a very marked, though not always a favorable, action in all affections of the bladder, whether acute or chronic.
2. In acute traumatic cystitis, and also in gonorrhœal cystitis, they have a very marked diuretic action, but, at the same time, increase the pain; hence they should not be employed in these cases.
3. The best results have been obtained in cases of uric or phosphatic gravel, of chronic cystitis, whether simple or consecutive to gravel, and of mucous or muco-purulent catarrh. ”

“ Benzoic acid and the benzoate of sodium, ammonium, or lithium have been found to be of value in cystitis, and as they can only reach the bladder by previously passing over the pelvic mucous membrane, they should also have a good effect here. It is obvious that constitutional symptoms arising from cystitis and its consequent nephritis may demand the most attention, and should evidently be of a decidedly supporting character, the details of which have no special reference to the disease, but to the general condition. Quinine may be called for as an antipyretic. ”

“ Repeated washing out of the bladder with antiseptic solutions has been recommended, but is open to criticism. Such treatment is difficult in male animals, owing to the special formation of the glans penis and urethra, and in female animals it is by no means easy. In all cases of acute cystitis, in fact, the passage of the catheter is painful, and as a metal, gutta-percha or hard rubber sound is used, the mere contact of the tip of the instrument injures the diseased mucous membrane, makes it bleed, and gives rise to danger of autoinoculation, with the possibility of serious results. ”

“ The most common seem to be forms of paracoli, such as the Bacillus ureæ. Moussu nevertheless believes that Hofflich’s bacillus, which was rediscovered by Porcher, is that which produces typical pyelo-nephritis. It grows in the bladder without producing cystitis, and is succeeded by an ascending infection of the ureters without causing primary ureteritis, the local inflammation occurring chiefly, it would seem, in the pelvis and the kidney. All the other organisms which Moussu has tested have caused lesions of cystitis and of ureteritis, together with those of pyelo-nephritis. ”

“ Vesical epithelium is common. Numerous bacteria are always present (see Fig. 63) .
7. Vesical Calculus, Tumors, and Tuberculosis.—These conditions produce a chronic cystitis, with its characteristic urine. Blood, however, is more frequently present and more abundant than in ordinary cystitis. With neoplasms, especially, considerable hemorrhages are apt to occur. Particles of the tumor are sometimes passed with the urine. No diagnosis can be made from the presence of isolated tumor cells. In tuberculosis tubercle bacilli can generally be detected. ”

“ Earthy phosphates are often mistaken for pus and also seminal fluid. Phosphates are always found in decomposed urine, otherwise they indicate brain affections, acute cystitis, etc. Experience has taught us that the voiding of urine loaded with phosphates is a forerunner of cystitis, or enlargement of the prostate gland, or both. In fact, persons so affected are "prone to serious consequences from mild attacks of almost any and every acute disease." ”

“ There is a rapid change in the general condition of the patient. He becomes much prostrated and emaciated from day to day. The face is drawn and anxious, the tongue dry and brown, the pulse rapid and feeble, and delirium is developed, and the patient finally dies in a condition resembling that of typhoid fever or of pyæmia. The urine is diminished in amount; it may be suppressed. It contains blood, pus, and mucus. The pus and mucus belong to the cystitis; the blood seems to be derived both from the kidneys and the bladder. ”

“ In tuberculous cystitis there is added to the symptoms the discovery of the bacilli of tuberculosis in the urine, and cystoscopic examination may reveal the presence of tubercles of the mucous membrane or even of ulceration. The patient is probably losing weight, and he may present foci of tuberculosis at the back of the testicle, the lung or kidney, or in a joint or bone, or in a lymphatic gland. Treatment is rebellious and unpromising. ”

“ The smallest foci are not visible to the naked eye, but with the microscope we find collections of pus-globules between the tubes, with swelling and degeneration of the epithelium within the tubes. The larger purulent foci look like white streaks or wedges running parallel to the tubes and surrounded by zones of congestion. The larger abscesses replace considerable portions of the kidney.
The ureters in some cases are inflamed, their walls thickened, their inner surface coated with pus or fibrin. The bladder presents regularly the lesions of acute or chronic cystitis. ”

“ Even that small degree of obstruction or hindrance which leads a person to habitually put a little extra strain upon the bladder in order to expel its contents, especially if it be allowed occasionally to become dilated, may gradually lead to dilatation of the ureters, and thus make an easy passage upward for inflammatory and decomposed urine if such should afterward be formed as a consequence of cystitis by retention. ”

“ In cases of prolonged chronic cystitis attending atony of the bladder, notably with hypertrophied prostate, the cavity of the organ is large, its walls seemingly thinned and flabby, its internal coat roughened by the crossing of bundles of muscular fibres or perhaps perfectly smooth. ”

“ The diagnosis is made by finding the ova in the sediment of the centrifuged urine.
Symptoms of cystitis and even pyelitis may follow the early bladder and urethral manifestations. Pain in the back or symptoms suggesting renal colic may be present. Anaemia and physical weakness gradually develop. An important sequel is vesical calculus. It is a question whether the eggs or some other product of the infection form the nucleus of such a stone. Not only can stone be recognized [364] by cystoscopy but rather distinctive are small, glazed yellowish nodules with areas of granulation tissue. ”

“ Women may often be seen who have been treated for weeks for cystitis without avail, and who are immediately relieved of all symptoms by the replacement of a retroverted uterus or the closure of a torn perineum. ”

“ Diagnosis is based on frequent and painful urination in jets, tenderness of the urethra under palpation or catheterization, redness and swelling round the urethral orifice, and the oozing of pus. In the absence of any external injury one should always ascertain if cystitis is present. ”

“ The search for casts must be carefully made. The urine must be fresh, since hyaline casts soon dissolve when it becomes alkaline. It should be thoroughly centrifugalized. When the sediment is abundant, casts, being light structures, will be found near the top. In cystitis, where casts may be entirely hidden by the pus, the bladder should be irrigated to remove as much of the pus as possible and the next urine examined. In order to prevent solution of the casts the urine, if alkaline, must be rendered acid by previous administration of boric acid or other drugs. ”

“ Fortunately, in the majority of cases, the number of parasites is small, though it may increase from repeated infections to 500 or more. In cases of comparatively light infection the disease is reduced to a slight chronic cystitis, with now and then exacerbations, in course of which a slight amount of blood and pus is passed in the urine. The disease may last for years without apparent increase. In the most severe cases death may occur from various causes, rupture of the bladder, ascending pyelo-nephritis, uræmia, albuminuria ”